text,label
"LV gram
revealed LVEF of 20%.  On HD3 patient was taken to the cath lab
and had successful stenting of his left circumflex.  He was
continued on plavix and aspirin throughout admission.

# ESRD on HD: Patient receives chronic HD on MWF schedule.
Patient's electrolytes were monitored closely throughout
admission.  Patient was dialyzed on his normal schedule and
pressures tolerated this without issue.  He refused many of his
medications throughout admission.

#Bacteremia: Patient had one blood culture positive for gram
positive cocci, MSSA.  He was treated with IV vancomycin given
penicillin allergy.  Patient will be treated for 10 day course,
last day [**2158-8-15**].",1
"CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS:  [**2158-8-1**] BMS to RCA x 3
3. OTHER PAST MEDICAL HISTORY:
- ESRD [**2-1**] to diabetic nephropathy on HD x7yrs MWF
- Osteomyelitis of the spine with resultant paraplegia
- Hyperparathyroidism
- Left BKA [**2-1**] to gangrene
- Right arm fistula


Social History:
Single Male. Has been on disability in his left BKA. Lives in a
nursing home.
- Tobacco history:  Denies
- ETOH:  Denies
- Illicit drugs:  Denies

Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Significant for diabetes

Physical Exam:
Admission Exam:
GENERAL: Profoundly hard of hearing. NAD.",1
"14. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
Colonial Heights Care and Rehabilitation Center - [**Hospital1 487**]

Discharge Diagnosis:
Primary Diagnosis:
1.  Cardiogenic shock
2.  Left circumflex stenosis

Secondary Diagnosis:
1.  Coronary artery disease
2.  End stage renal disease
3.  Diabetes mellitus type II
4.  Peripheral vascular disease
5.  Chronic right heel ulcer


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Last Name (Titles) 90824**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**].",1
"Admission Date:  [**2181-5-4**]              Discharge Date:   [**2181-5-9**]

Date of Birth:  [**2132-1-15**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Motor vehicle crash

Major Surgical or Invasive Procedure:
ORIF left femur fracture

History of Present Illness:
49M with + EtOH s/p motor vehicle crash; restrained driver vs.
tree. He was transported to [**Hospital1 18**] for further care.

Past Medical History:
Hypothyroidism

Family History:
Noncontributory

Pertinent Results:
[**2181-5-4**] 08:16PM   GLUCOSE-151* LACTATE-5.9*
[**2181-5-4**] 03:09PM   WBC-13.",1
"Disp:*16 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
SAH
hydrocephalus
intracranial hypertension
Pyrexia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
General Instructions
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.

**** Continue Nimodipine as prescribed, if there is an high
co-pay please call our office prior to purchasing.",1
"Discharge Diagnosis:
s/p Motor vehicle crash
Comminuted left femur fracture
Acute blood loss anemia

Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.

Discharge Instructions:
You may touch down weight bear only on your left leg.

You should AVOID drinking alcohol or taking illicit drugs as
these behaviors put you at risk for further injuries.

Followup Instructions:
Follow up in 2 weeks Dr. [**Last Name (STitle) 7376**], Orthopedics Trauma; call
[**Telephone/Fax (1) 1228**] for an appointment.

Follow up after discharge from rehab with your PCP.



Completed by:[**2181-5-8**]",1
"Active Issues:
# Cardiogenic Shock: Patient required pressor support with
dopamine following PCI at OSH and was transferred to [**Hospital1 18**] at a
dose of 8mg/kg/min.  On HD6 patient was successfully weaned from
dopamine and was maintaining a stable blood pressure.  He
maintained pressures through dialysis as well.  He was restarted
on his home anti-hypertensives prior to discharge.

# CAD:  Patient did not have prior history of known CAD, but
recent TTE from [**5-/2158**] revealed anterolateral and apical defects
consistent with CAD. Patient presented on [**8-1**] with RCA infarct
that required BMS x3. Cardiac cath also revealed 90% LCx disease
and completely occluded LAD that was presumed chronic.",1
"[**2181-5-4**] 3:29 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 7**] # [**Clip Number (Radiology) 82593**]
 Reason: 49 year old man s/p MVC w/ hip fracture postop intubated wit
 Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT
 ______________________________________________________________________________
 [**Hospital 2**] MEDICAL CONDITION:
  49 year old man s/p MVC w/ hip fracture postop intubated with massive blood
  loss and metabolic acidosis. Eval for acute lung pathology or trauma.
 REASON FOR THIS EXAMINATION:
  49 year old man s/p MVC w/ hip fracture postop intubated with massive blood
  loss and metabolic acidosis. Eval for acute lung pathology or trauma.
 ______________________________________________________________________________
                                 FINAL REPORT
 PORTABLE CHEST [**2181-5-4**]

 COMPARISON:  Study of earlier the same date.

 INDICATION:  Intubated.

 FINDINGS:  Interval placement of endotracheal tube, with tip terminating 5.8
 cm above carina.  Cardiomediastinal contours are similar in appearance to the
 prior study, and lungs are remarkable for multifocal areas of atelectasis,
 most pronounced at the left lung base and right retrocardiac region.
 Coexisting aspiration is possible.",1
"HCTZ was held in the
setting of hypercalcemia. The home dose of hydralazine was
increased to 75 mg QID and imdur was started at a dose of 30 mg
daily with subsequent improvement in blood pressure control.
Renal ultrasound did not reveal evidence of renal artery
stenosis, consistent with the results of an MRA in [**2195-4-18**].
.
# Hypercalcemia: [**Year (4 digits) 32883**] calcium peaked at 12.7 with a peak
ionized calcium of 1.51. The level improved modestly with
aggressive IVF. [**Name (NI) 32883**] PTH was low. Workup for an underlying
cause was unremarkable, including [**Name (NI) **] cortisol, SPEP/UPEP,
chest x-ray, non-contrast CT of the chest/abdomen/pelvis, and
bone scan.",1
"Per
vascular surgery, the patient should have an ABI checked as an
outpatient.

# Bilateral hearing loss: Patient reported acute hearing deficit
coinciding with his myocardial infarction. No obstructive cause
was apparent on otoscopic examination. Hearing loss appeared to
be symmetric. He was not given otoxic drugs. Ischemia in the
setting of cardiogenic shock is also a possiblity. Symptoms were
not consistent with CVA causing hearing loss, as he had no
associated symptoms of nystagmus, nausea or dizziness as would
be expected.  Patient's hearing improved spontaneously.  He
should have ENT follow-up as an outpatient if he continues to
have further issues.",1
"There is no
evidence of caliber change in the anterior or posterior
circulation to suggest vasospasm. Evaluation for residual
filling of the previously coiled distal left anterior cerebral
artery aneurysm is limited by streak artifact. No additional
aneurysms are identified.

IMPRESSION:
1. Decreased subarachnoid hemorrhage.
2. Redistribution of intraventricular hemorrhage without
evidence of new
hemorrhage. Stable ventricular size without hydrocephalus.
3. No evidence of vasospasm.

CTA Head [**2161-8-27**]:
IMPRESSION:
1. Decrease in extent and density of subarachnoid hemorrhage.
2. No new hemorrhage. Stable ventricular size without
hydrocephalus.
3. The A1 and A2 segments of the left anterior cerebral artery
are minimally decreased in caliber compared to study on [**8-20**], [**2161**].",0
"Left vertebral artery arteriogram shows filling of the left vertebral artery
 with reflux into the right vertebral artery.  Both posterior cerebral arteries
 are seen well.  Both AICA and superior cerebellar artery are seen well.  The
 AICA on the left is an AICA-PICA configuration.  The right PICA is seen
 normally.

 Left internal carotid artery arteriogram status post coil embolization shows
 that the aneurysm is now obliterated.

 Right common femoral artery arteriogram shows widely patent right common
 femoral artery.

 IMPRESSION:  [**Known firstname 12138**] [**Known lastname 39239**] underwent cerebral angiography and coil embolization
 of a 2.2 mm distal anterior cerebral artery aneurysm.  There were no
 complications.",0
"At the time of
discharge, his dose was 300mg po BID.  He will continue this for
11 days, ending [**2158-8-21**].  At that time, he should be
transitioned to amiodarone 200mg po daily.  Despite CHADS2 score
of 3, patient was felt to be a poor candidate for
anticoagulation given poor medication compliance and fall risk.
Patient was in sinus rhythm and hemodynamically stable at the
time of discharge.

# HTN: Patient was in cardiogenic shock at the time of
admission, therefore his home anti-hypertensives were held.
Since BPs were still lowish at discharge norvasc was
discontinued and valsartan was continued but at a much lower
dose (40mg [**Hospital1 **]).",0
"We now catheterized the above-mentioned vessels and AP,
 lateral filming was done.  This revealed a 2 mm aneurysm at the distal
 anterior cerebral artery at the branch point of a frontopolar branch.  The
 aneurysm measured about 2.5 mm in size.

 Therefore we exchanged out the [**Doctor Last Name 586**] 2 catheter in the left internal carotid
 artery for a Neuron 6 French catheter.  The aneurysm itself was catheterized
 with an SL-10 microcatheter and Synchro wire.  The aneurysm was coiled with a
 single coil of 2.2 mm into 3 mm 360 UltraSoft Target coil.  Following this,
 there was very minimal filling at the base of the aneurysm.",0
"The cause of this problem remains unclear despite many tests.
Please stop taking TRIAMTERENE-HYDROCHLOROTHIAZIDE because it
can raise calcium levels. It is imperative that you stay
well-hydrated by drinking plenty of fluids to help keep the
calcium level down.

You had a urinary tract infection which was partially treated
with the antibiotic ciprofloxacin. Please continue taking this
medication through Monday [**1-27**].

The following changes to your blood pressure medications were
recommended:
1) Start taking ISOSORBIDE MONONITRATE (IMDUR) 30 mg daily.
2) Increase HYDRALAZINE to 75 every 6 hours.
3) Discontinue TRIAMTERENE-HYDROCHLOROTHIAZIDE.

Please have repeat blood work done on Monday, [**1-27**].",0
"Pt received some juice prior to
transfer to the ED.
.
VS on arrival to ED: T 97.8 BP 194/90 HR 56 RR 18 Sat 100% on
RA. BS on arrival was noted to be 35, she received a total of
2.5 amps of dextrose, Glucagon, Octreotide 50mcg, 1L of NS and
started on D5 1/2 NS for BS that would transiently come up above
100 and then fall back to 40s. EKGs were essentially unchanged
and CXR was clear. Pt was given Hydralazine 50mg X 1 po for sbp
in 200s, followed by Hydralazine 10mg IV.",0
"_________________________________________________________
                             STAPH AUREUS COAG +
                             |
OXACILLIN-------------       S

   Aerobic Bottle Gram Stain (Final [**2158-8-5**]):
      Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90823**] @ 2232 ON [**8-5**]
-[**Numeric Identifier 28124**].
      GRAM POSITIVE COCCI.
      IN PAIRS AND CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2158-8-5**]):
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.

Imaging:
CXR AP [**2158-8-4**]: Central catheter projects over the lower superior
vena cava. Lung volumes are quite low, making evaluation of the
lungs difficult. There are multiple bilateral rib fractures. I
see no pneumothorax.

TTE [**2158-8-5**]: The left atrium is mildly dilated.",0
"Disp:*44 Tablet(s)* Refills:*2*
9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol) for 4 days: ending
[**2158-8-15**].
Disp:*4 units* Refills:*0*
10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO on non-HD days:
hold for SBP<90, HR<60.
11. Sensipar 60 mg Tablet Sig: Two (2) Tablet PO once a day.
12. Diovan 40 mg Tablet Sig: One (1) Tablet PO twice a day: hold
for SBP<90, HR<60.
13. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.",0
"No evidence of new hemorrhage or
infarction.
2. Interval placement of a right frontal approach ventricular
catheter
terminating in the frontal [**Doctor Last Name 534**] of the right lateral ventricle,
with no change in ventricular size. Small amount of
intraventricular hemorrhage in the occipital horns and fourth
ventricle, unchanged from prior study.
3. Coil pack in the interhemispheric fissure with associated
artifact at that level.

[**2161-8-21**] Femoral (right) Ultrasound:
IMPRESSION: Normal appearance of right common femoral artery and
common
femoral vein with no evidence of pseudoaneurysm.

[**2161-8-23**] CTA Head:
HEAD CTA: The intracranial internal carotid and vertebral
arteries, and their major branches, appear patent.",0
"Compared with the report of the prior study (images unavailable
for review) of [**2193-1-18**], the left ventricle is more
hypertrophied with increased severity of mitral regurgitation.

[**1-15**] Head CT
No evidence of acute intracranial hemorrhage, edema or mass.

[**1-15**] Renal US with dopplers
IMPRESSION: Limited examination. Bilateral brisk systolic
upstrokes in the
main renal arteries at the hilum are present and therefore no
evidence of renal artery stenosis is present. Blunted systolic
upstrokes of intrarenal waveforms could reflect parenchymal
abnormality but cannot be reliably assessed due to limitations
of the examination. If further evaluation is required then non-
gadolinium- enhanced MRA may be attempted.",0
"Name: , D. Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Chief Complaint: New murmur Major Surgical or Invasive Procedure: cardiac catheterization Aortic valve replacement (29mm St. porcine) and removal aortic valve mass AICD History of Present Illness: 51 year old gentleman with newly diagnosed heart murmur.",1
"Echocardiogram notable for aortic insufficiency and a small, mobile echodensity on the LV side of the aortic valve measuring 4x4mm in diameter.",1
Past Medical History: Aortic valve mass with severe aortic insufficiency Hypertension Hyperlipidemia Gout Obesity Psoriasis Social History: Occupation: Works in IT at law firm Lives with: Wife and daughter in Tobacco: Never ETOH: Rare By transesphogeal echo during the surgery the patient had: There are three aortic valve leaflets.,1
There appears to be a mass in the aortic sinus distal to the left coronary cusp.,1
There is a raphe extending from the right coronary cusp to the wall of the aorta.,0
There is no aortic valve stenosis.,1
Severe (4+) aortic regurgitation is seen.,0
"The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet.",0
His aortic valve was considered to be a congenitally abnormal valve.,1
Additionally during his hospital stay he was noted to have an acute kidney injury.,1
"His creatinine on admission was 1.0, during the immediate post-operative period it climbed to 1.6 and quickly resolved to its baseline prior to discharge.",0
Discharge Disposition: Home With Service Facility: All Care VNA of Greater MD Completed by:,0
PATIENT/TEST INFORMATION: Indication: Chest pain.,0
Height: (in) 70 Weight (lb): 260 BSA (m2): 2.34 m2 Status: Inpatient Date/Time: at 10:31 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.,0
Good (>20 cm/s) LAA ejection velocity.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of the RA.,0
"LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%).",0
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
AORTA: Normal aortic diameter at the sinus level.,0
Focal calcifications in aortic arch.,0
Focal calcifications in descending aorta.,0
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).,0
MITRAL VALVE: Mildly thickened mitral valve leaflets.,0
of the mitral chordae (normal variant).,0
Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.,0
GENERAL COMMENTS: A TEE was performed in the location listed above.,0
I certify I was present in compliance with HCFA regulations.,0
The patient was under general anesthesia throughout the procedure.,0
The patient appears to be in sinus rhythm.,0
Results were personally reviewed with the MD caring for the patient.,0
Conclusions: Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage.,0
No spontaneous echo contrast is seen in the body of the right atrium.,0
"Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%).",0
Right ventricular chamber size and free wall motion are normal.,0
There are focal calcifications in the aortic arch.,0
The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present.,0
No aortic regurgitation is seen.,0
The mitral valve leaflets are mildly thickened.,0
Trivial mitral regurgitation is seen.,0
Moderate [2+] tricuspid regurgitation is seen.,0
There is no pericardial effusion.,0
Postbypass The patient is A-paced on an infusion of phenylephrine.,0
Left ventricular systolic function continues to be normal.,0
The mitral regurgitation continues to be trace.,0
Tricuspid regurgitation is now mild.,0
The thoracic aorta is intact post decannulation.,0
Dr. was notified in person of the results at the time of the study.,0
7:17 AM CHEST (PORTABLE AP) Clip # Reason: R/O pneumonia Admitting Diagnosis: HEAD INJURY;SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;PI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with head injury now with fevers and productive cough rule out pnemonia REASON FOR THIS EXAMINATION: R/O pneumonia ______________________________________________________________________________ FINAL REPORT AP CHEST 7:47 .,0
HISTORY: Head injury and fever.,0
IMPRESSION: AP chest compared to through : Moderately severe atelectasis in the lingula is new.,0
No good evidence for pneumonia.,0
No pleural effusion or pneumothorax.,0
Healing posterior left middle rib fracture.,0
Tip of the left subclavian line projects over the SVC.,0
Nasogastric tube ends in the stomach.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: Asked to evaluate this 78 year old white male on Coumadin for sdh s/p fall yesterday.,1
Pt and wife and daughter give history.,0
Pt was at podiatrist yesterday and went to lean on a chair that pushed away from him.,0
He fell striking the back of his head without LOC.,0
He went home and felt wobbly last night but then was unable to get OOB this am.,0
He admits to a frontal headache.,0
"He denies nausea, vomiting, visual changes, additional falls Past Medical History: Atrial fibrillation on Coumadin (but off Coumadin since for endoscopy with biopsy) Diabetes mellitus Hypercholesterolemia Barrett's esophagus Proteinuria s/p appendectomy s/p right hip replacement s/p colecystectomy Social History: He is a former pathologist at .",1
He lives at home with his wife.,0
"smoked occasionally in medical school, but does not currently smoke.",0
"He drank a scotch last night, but does not regularly drink EtOH.",0
He does not use illicit drugs.,0
"Family History: His father had a stroke, and his maternal uncle had DM.",0
"Physical Exam: O: T:AF BP:138 / 70 HR: 79 R 15 O2Sats96 Gen: WD/WN, comfortable, NAD.",0
HEENT: Pupils: bilaterally EOMIs No battles / no raccoon / unable to appreciate hemotympanum Neck: Supple.,0
"Neuro: Mental status: Awake and alert, cooperative with exam, normal affect.",0
"Orientation: Oriented to person, place, and date.",0
Language: Speech fluent with good comprehension and repetition.,0
No dysarthria or paraphasic errors.,0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2 mm bilaterally.",0
Visual fields are full to confrontation.,0
"III, IV, VI: Extraocular movements intact bilaterally without nystagmus.",0
"V, VII: Facial strength and sensation intact and slight left facial.",0
VIII: Hearing intact to voice.,0
"IX, X: Palatal elevation symmetrical.",0
: Sternocleidomastoid and trapezius normal bilaterally.,0
XII: Tongue midline without fasciculations.,0
Motor: Normal bulk and tone bilaterally.,0
Strength full power throughout except left hemiparesis slight throughout.,0
Sensation: Intact to light touch On Discharge: Lethargic.,0
Eyes open minimally to voice.,0
Pertinent Results: ADMISSION LABS: 01:40PM PT-27.6* PTT-35.3* INR(PT)-2.7* 01:40PM PLT COUNT-265# 01:40PM NEUTS-74.1* LYMPHS-16.9* MONOS-7.6 EOS-0.7 BASOS-0.7 01:40PM WBC-7.2 RBC-4.28* HGB-12.8* HCT-38.0* MCV-89 MCH-29.9 MCHC-33.7 RDW-14.2 01:40PM GLUCOSE-104* UREA N-15 CREAT-0.7 SODIUM-133 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-30 ANION GAP-11 09:19PM PT-15.7* PTT-29.7 INR(PT)-1.4* IMAGING: CT Head 1.,0
Acute subdural hematoma measuring 9 mm in widest diameter along the left cerebral convexity extending along the left parasagittal falx and left tentorium with 5-mm rightward shift of normally midline structures and compression of left frontal and temporal horns and dilation of right frontal and temporal horns.,1
No significant interval change since CT scan obtained earlier this a.m. 2.,0
Concern for early left uncal herniation.,0
Sliver of dependent high density in the right occipital is concerning for trace intraventricular hemorrhage.,0
Extensive mucosal thickening is noted in bilateral maxillary sinuses.,0
Interval mild decreased size of the known left-sided subdural hematoma.,0
No new foci of intracranial hemorrhage.,1
Unchanged tiny intraventricular hemorrhage in the right occipital .,0
Unchanged air-fluid levels in the maxillary sinuses.,0
"CXR : Right mid and lower lung opacities, that giving the rapid development since are highly concerning for aspiration, although rapidly developing infection and pneumonia cannot be excluded.",0
There is no pleural effusion or pneumothorax demonstrated.,0
The patient is after cholecystectomy Brief Hospital Course: : Pt admitted to neurosurgery service and the ICU after he was found to have a 9mm acute left sided SDH with 4mm midline shift.,0
Pt was given propylene 9 in the ER upon arrival for an elevated INR of 2.7.,0
He was also treated with FFP and 3 doses of vitamin K to correct to goal INR less than 1.3.,0
In the ICU his systolic blood pressure was controlled to less than 140 and he had q1 neuro checks for continued monitoring.,0
: On the morning of pt found to be more lethargic and following commands less than he previously was.,0
A stat head ct was obtained and showed no significant change from his admission CT.,0
In discussion with the family the patient was made DNR/DNI.,0
Palliative care service was consulted at this point.,0
: Pt remained lethargic with minimal exam.,0
"He was non verbal, not following commands and only moving extremities to noxious stimuli.",0
"After further discussion with the family, comfort measures were instituted.",0
He reamined on Keppra for seizure prophylaxis per palliative care recommendation.,0
The patient's exam remained unchanged on and .,0
"Per palliative care recommendation, the patient was discharged to the Hospice facility on .",0
Medications on Admission: Coumadin 5 daily ASA 325 daily allopurinol 100 daily digoxin .0125 daily Detrol la 4 daily fenofibrate 160 daily fish oil 1000 3 times daily metformin 1000 twice daily Vit B12 Vit d simvastatin 40 ' omeprazole 40 ' Discharge Medications: .,0
Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 1 doses.,0
Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for Pain or fever.,0
Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q1 hour as needed for pain.,0
Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for agitation.,0
Discharge Disposition: Extended Care Facility: Hospice House Discharge Diagnosis: Acute SDH Discharge Condition: Level of Consciousness: Lethargic and not arousable.,0
Discharge Instructions: Comfort Measures Only - recommendations per Hospice Facility Followup Instructions: None Completed by:,0
"10:20 AM CHEST (PORTABLE AP) Clip # Reason: eval infiltrate, effusion Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 61 yo female w/ CAD, s/p tracheostomy on positive pressure vent,w/ARF and shortness of breath, c/o epigastric discomfort with increased wheezing and crackles on exam REASON FOR THIS EXAMINATION: eval infiltrate, effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumonia.",1
PORTABLE SEMIUPRIGHT FRONTAL RADIOGRAPH COMPARISON: .,0
Again are noted a tracheostomy and left-sided pacemaker unchanged in appearance.,0
There is stable cardiomegaly with a persistent congestive heart failure pattern.,1
"There are bilateral pleural effusions, left greater than right unchanged in appearance.",0
In addition there is persistent retrocardiac opacification.,0
"IMPRESSION: Persistent cadiomegaly and congestive heart failure as well as retrocardiac opacification, all unchanged in appearance.",1
Underlying pneumonia in the retrocardiac region cannot be excluded.,0
9:16 PM CHEST (PORTABLE AP) Clip # Reason: NG tube placement ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with IC hemorrhage REASON FOR THIS EXAMINATION: NG tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: NG tube placement.,0
COMPARISON: @ 5:46 A.M. PORTABLE UPRIGHT CHEST @ 9 P.M.: The tip of the NG tube is difficult to visualize but appears to be within the stomach.,0
There is a left PICC with tip in the SVC.,0
There is no evidence of vascular congestion or pleural effusions.,0
There are patchy opacities at the lung bases which probably represent atelectasis vs. aspiration.,0
IMPRESSION: 1) Tip of the NG tube difficult to visualize but appears to be within the stomach.,0
"If clinically indicated, a dedicated abdominal film is suggested to confirm.",0
"2) Patchy bibasilar opacities, probably atelectasis, however, aspiration should also be considered.",0
7:40 AM CHEST (PORTABLE AP) Clip # Reason: Re-evaluate lung fields Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with hypoventilation s/p whipple REASON FOR THIS EXAMINATION: Re-evaluate lung fields ______________________________________________________________________________ FINAL REPORT EXAMINATION: AP chest.,0
A single AP view of the chest is obtained at 0745 hours and compared with the prior morning's radiograph.,0
No significant adverse interval change.,0
Lung volumes remain low with elevation of the right hemidiaphragm.,0
Minimal bibasilar atelectasis is present.,0
Right-sided IJ line is unchanged.,0
"8:40 AM CHEST (PA & LAT) Clip # Reason: REEVAL pna Admitting Diagnosis: CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with DM, PVD REASON FOR THIS EXAMINATION: REEVAL pna ______________________________________________________________________________ FINAL REPORT INDICATIONS: Diabetes, peripheral vascular disease.",1
PA AND LATERAL CHEST: Comparison is made to .,0
Cardiac size remains at the upper limits of normal.,0
There is improvement in bilateral lower lobe opacities with residual predominantly right lower lobe opacity present.,0
"There is blunting of both lateral CP angles, which likely reflects small effusions.",0
IMPRESSION: Resolving bilateral lower lobe opacities.,0
4:13 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line for IV access Admitting Diagnosis: CERVICAL HEMATOMA ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with epidural hematoma REASON FOR THIS EXAMINATION: Please place PICC line for IV access ______________________________________________________________________________ FINAL REPORT INDICATION: IV access needed for intravenous antibiotics.,0
The procedure was explained to the patient.,1
"Dr. , teh Attending Radiologist, was present and supervised the entire procedure.",0
"TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set.",0
Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access.,0
A peel-away sheath was placed over the guidewire and a double-lumen PICC line measuring 39 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
Position of the catheter was confirmed by a fluoroscopic spot film of the chest.,0
The peel-away sheath and guidewire were then removed.,0
"The catheter was secured to the skin, flushed, and a sterile dressing applied.",0
The patient tolerated the procedure well with no immediate complications.,1
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line placement via the right brachial venous approach.,0
Final internal length is 39 cm with the tip positioned in the SVC.,0
The line is ready to use.,0
1:01 PM URIN CATH CHECK Clip # Reason: STUDY: Anterograde Nephrogram.,0
"Please eval Left ureteral obs Admitting Diagnosis: CERVICAL CA/SDA Contrast: OPTIRAY Amt: 50 ********************************* CPT Codes ******************************** * INTRO CATH OR STENT INTO URETH INJ NEPHROSTOMY/PYLOSTOMY * * -51 MULTI-PROCEDURE SAME DAY INTRO CATH OR STENT TO URETHER * * ANTEGRADE UROGRAPHY MOD SEDATION, FIRST 30 MIN.",1
"* * MOD SEDATION, EACH ADDL 15 MIN C1769 GUID WIRES INCL INF * * C1769 GUID WIRES INCL INF C2617 STENT NON-COR,TEMP W/O SYS * **************************************************************************** ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM/CORRECTION PROCEDURE: 1) Left-sided percutaneous nephroureteral stent in exchange for a left-sided percutaneous nephrostomy.",1
Please eval Left ureteral obs Admitting Diagnosis: CERVICAL CA/SDA Contrast: OPTIRAY Amt: 50 ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with L ileoconduit s/p L perc nephrostomy for L hydro.,0
REASON FOR THIS EXAMINATION: STUDY: Anterograde Nephrogram.,0
Please eval Left ureteral obstruction.,0
Eval Feasability of L PCNU stent and Balloon dilation of ureteral stricture.,0
______________________________________________________________________________ FINAL REPORT PROCEDURE: 1.,0
Placement of right nephroureteral stent in exchange for right-sided percutaneous nephrostomy tube.,0
Status post ileal conduit and pelvic exenteration for cervical carcinoma.,0
"INFORMED CONSENT: Informed consent for the procedure of nephrostography, nephroureteral stent placement, possible ureteroplasty, and moderate intravenous sedoanalgesia was obtained from the patient.",1
"Specifically discussed were the indications for the procedure as well as the attendant risk, potential complications, expected outcomes, and alternatives.",1
The patient agreed to have the procedure performed and provided witnessed informed consent signature which in turn was placed in the medical record.,0
"(staff, present and supervising throughout) , M.D.",0
"(fellow) DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the procedures to be performed, the sites of the procedure, appropriate requisition, and appropriate informed consent.",1
"Once the above were verified, the patient was positioned in prone position on a special procedures/angiography table.",0
The left flank and the external segment of the left percutaneous nephrostomy tube were prepped and draped in usual sterile fashion.,0
The skin surrounding the exiting catheter was infiltrated with approximately 5 cc of 1% Xylocaine for local anesthesia.,0
The retention suture was cut.,0
A 0.035-inch guide wire was advanced by way of the nephrostomy tube employed to uncoil the retention pigtail.,0
"The nephrostomy tube was removed over the guide wire, leaving the guide wire in situ.",0
A 6 French vascular sheath was then delivered over this guide wire and positioned with the distal tip in the proximal right ureter.,1
"Nephrostogram was performed and demonstrated no evedince of a stricture or mechanical obstruction, although the contrast material tends to pull in the renal collecting system.",0
"Based on these diagnostic findings, it was decided to proceed with a nephroureteral internal/external drainage placement.",0
"The inner dilator was removed and exchanged for a 5 French Kumpe catheter, which was delivered over the guide (Over) 1:01 PM URIN CATH CHECK Clip # Reason: STUDY: Anterograde Nephrogram.",0
Please eval Left ureteral obs Admitting Diagnosis: CERVICAL CA/SDA Contrast: OPTIRAY Amt: 50 ______________________________________________________________________________ FINAL REPORT (Cont) wire to proximal ureter ureter.,0
"The guide wire was removed and exchanged for a 0.035- inch angled tip Glidewire, which was used to cannulate the course of the ureter extending to the ileal conduit level.",0
The Kumpe catheter was then delivered over the guide wire to the level of the ileal conduit.,0
This was followed with advancement of the 6 French sheath to the mid ureter level.,0
"Nephrostography and ureterography were then performed by way of the 6 French sheath, which delineated no definite mechanical obstruction of the system.",0
The anastomosis with the ileal pouch appears widely patent.,0
"A 0.035-inch, 1.5- mm wire was then advanced by way of the Kumpe catheter and positioned in the ileal conduit pouch.",0
The Kumpe catheter and the 6 French vascular sheath were removed leaving the guide wire in place.,0
An 8 French x 22 cm internal/external nephroureteral stent was delivered over the guide wire with the distal pigtail formed within the ileal pouch and the proximal pigtail formed within the left renal pelvis.,1
"The catheter was secured at the skin using a 0-silk, retention suture and a StatLock device.",0
This all was overlaid with multiple Tegaderm patches.,0
No residual bleeding was encountered.,0
Estimated blood loss was minimal.,0
No immediate complications were encountered.,0
MEDICATIONS: Moderate intravenous sedoanalgesia was provided by administering divided doses of Versed and fentanyl throughout the total interservice time of 45 minutes during which time the patient's hemodynamic parameters were continuously monitored.,0
Fentanyl was given in a total of three divided doses for a total dosage of 75 mcg IV.,0
Versed was given in a total of three divided doses for a total dosage of 1.5 mg IV.,0
Post-procedural orders were entered in POE.,0
Status post placement of left-sided 8 French nephroureteral stent in exchange for a previous 8 French left-sided percutaneous nephrostomy.,0
The patient tolerated the procedure well.,0
The stent was capped externally and left to internal drainage.,0
"11:20 AM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: evaluate lung fields, bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 25 weeks with increasing apnea, on CPAP, softly distended, abd REASON FOR THIS EXAMINATION: evaluate lung fields, bowel gas pattern ______________________________________________________________________________ FINAL REPORT A from at 11:32 a.m. compared to at 7:55 a.m.",1
FINDINGS: Feeding tube overlies the stomach.,0
"The heart is normal in size with a somewhat narrowed mediastinum, suggesting thymic involution.",0
"The infant is now 11 days old, born at 25 weeks with increasing apnea, on CPAP, distended abdomen.",1
"Diffuse granular pattern is noted in both lungs, slightly more prominent than on the prior study.",0
"Abdominal gas pattern shows mildly dilated air-filled loops of bowel, filling the abdomen.",0
There is no evidence of intramural air or free air on this single supine film.,0
No abnormalities are identified within the visualized bones or soft tissues.,0
"IMPRESSION: Granular pattern to both lungs, consistent with hyaline membrane disease or early chronic lung disease.",0
"When compared to the prior study, there has been no significant interval change aside from advancement of the feeding tube and removal of a left femoral line.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Newurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female with no past medical history who had sudden onset of midback pain and severe headache.,0
She said it felt like a bomb while giving a speech in .,0
She finished her speech and vomited once.,0
"She returned to the United States the following day with increased fatigue, headache and backache.",0
"She went to Emergency Department on , where a CTA revealed a large bilobed 1.2 to 2.0 centimeter ACA aneurysm, was transferred to on , for further workup.",0
CTA was repeated confirming the previously mentioned aneurysm.,0
She was transferred to for embolization of the aneurysm.,0
ALLERGIES: No known drug allergies.,0
SOCIAL HISTORY: ETOH and was a thirty pack year smoker.,0
PHYSICAL EXAMINATION: Neurologically she was completely intact.,0
"The pupils were reactive to light and accommodation, 3.0 millimeters and brisk.",0
"Speech was clear and fluent, awake, alert and oriented times three.",0
"Vital signs revealed blood pressure 92 to 106 over 60 to 70s, respiratory rate 14 to 18.",0
HOSPITAL COURSE: The patient was admitted and went directly to the angiography suite where she had her bilobed ACA aneurysm coiled.,0
The coiling was only partially done at that time.,0
"During the actual angiogram and coiling, the patient did complain of chest pain.",0
She was seen by cardiology in the angiography suite and the chest pain resolved on its own.,0
It was felt to be anxiety produced.,0
"Postoperatively, vital signs are temperature 96.0, blood pressure 103/60, pulse 69, respiratory rate 18, oxygen saturation 99%.",0
"The patient was awake, alert and oriented times three.",0
She was unsure of which hospital but was recently transferred.,0
She did know the month and not the day.,0
"The pupils were equal and reactive times light and accommodation, 2.5 to 2.0.",0
She did have some left conjunctival hematoma.,0
Groin was intact with sheath.,0
Her upper and lower extremities revealed motor strength was .,0
"Her white blood cell count was 9.4, hematocrit 32.9.",0
Her preoperative hematocrit was 37.7.,0
"Her prothrombin time was 15.4, partial thromboplastin time 150.",0
"On the first postoperative day, the patient's vital signs were in the 99 to 100 range.",0
She was awake and alert and oriented times three.,0
"She complained of seven out of ten headache, no diplopia.",0
"She remained in the neurologic Intensive Care Unit where she received Nimodipine 30 mg q2hours, normal saline at 150 per hour.",0
Her blood pressure was kept less than 140.,0
Heparin was continued at 600 per hour.,0
"On , the patient was brought back to complete her coiling.",0
"Postoperatively, she was awake, alert and oriented times three.",0
Her right groin sheath remained intact.,0
Her blood pressure was kept in the 100 to 130 range.,0
She needed to remain on Heparin as the apparent vessel was possibly thrombosed and we did not want to wean her off.,0
Heparin was kept at 600 per hour.,0
We did not want the area to thrombose quickly.,0
Her coiling went well and was successful.,0
She remained on Heparin postoperatively.,0
The patient remained in the Intensive Care Unit on Heparin and her partial thromboplastin time was kept between 60 to 80.,0
The sheaths remained in place.,0
"On , the patient was awake, alert and oriented with no complaints and grips were , no drift.",0
"The patient's Heparin drip was reduced on , and she was started on Aspirin 325 mg once daily.",0
"However, the patient did start to complain of blurry vision with peripheral type tunneling of the left eye lasting thirty to forty-five minutes.",0
A retinal fellow was consulted where she was found not to have any evidence of vascular occlusion.,0
"She did have some decreased vision in the left eye, however, the patient claimed it was lasting greater than 1.5 years.",0
It was felt to be an ocular migraine in her left eye.,0
The patient did continue to stay on Heparin.,0
"On , her partial thromboplastin time was at 50.",0
She was seen by the retinal specialist who still felt that it was an ocular migraine and they did sign off and wanted to follow-up as an outpatient.,0
Heparin was stopped on .,0
Aspirin 81 mg was continued.,0
"Her sodium was 136, and had dropped to 134.",0
Those were monitored twice a day.,0
"On , the patient underwent a cerebral angiogram to check the progressive thrombus of the coiled left internal carotid artery.",0
Stable appearance of the coils were noted on that day.,0
She was to start on Plavix at 75 mg once daily and Aspirin 325 mg once daily.,0
She no longer needed Heparin.,0
"Postoperative check, she was awake, alert.",0
"Extraocular movements were full, no drift.",0
"On , she remained awake and alert with no headaches at this time.",0
"Again, her angiogram the previous day showed no spasm.",0
Intravenous fluids were kept at 150 per hour.,0
She did continue on the Nimodipine.,0
"On , we did ask the retinal specialist to reexamine the patient as she complained of decreased vision in her left eye for the last one to two days.",0
Her ophthalmic examination was within normal limits.,0
Her decreased acuity to her left eye was unclear.,0
"Possibilities included mass effect, compression of the aneurysm.",0
"They recommended considering intravenous steroids, also recommended getting an ESR, CRP and then a neurologic ophthalmology consultation.",0
Neurophthalmology did seen the patient and felt that there was some compression of optic neuropathy but they felt that it was related to her ACA aneurysm and mass effect.,0
They did request some steroids.,0
The patient was started on Decadron 4 mg p.o.,0
"On , her vision was improved.",0
"On , the patient underwent status post neuroform stent mediated coiling of her right internal carotid artery aneurysm.",0
"Postoperatively, she did well with no intraoperative complications.",0
"Postoperatively, she was to stay on Plavix and Aspirin.",0
Her sheaths remained in place overnight and she remained on Heparin overnight.,0
"Postoperatively, she was alert without complaints, denied headaches or double vision.",0
Her left groin was oozing around the sheath.,0
"The pupils are equal, round, and reactive to light and accommodation.",0
Visual fields were full to confrontation.,0
They recommended one unit of packed red blood cells.,0
Her blood pressure was kept in the 120 range and continued on Aspirin and Plavix.,0
"Postoperatively, her hematocrit was 28.5 and on , she did receive one unit of packed red blood cells.",0
"On , her vital signs were temperature 98.2, blood pressure 97/49.",0
"White blood cell count was 10.0, hematocrit was now 32.1, platelet count 364,000.",0
The patient was neurologically intact.,0
There was no sign of hematomas.,0
"On , the patient was transferred out of the Neurologic Intensive Care Unit.",0
She was given a physical therapy consultation.,0
Her intravenous fluids were decreased to 100 per hour.,0
Her diet was increased as tolerated.,0
She was given intravenous boluses for her systolic blood pressure less than 100.,0
She remained on the surgical floor.,0
The patient was discharged on .,0
"No strenuous exercise, no driving until cleared by Dr. .",0
"She is to follow-up with Dr. in one week and neurophthalmology, she was given the telephone number to call.",0
Percocet 5/325 one to two tablets p.o.,0
Decadron wean over a week.,0
CONDITION ON DISCHARGE: The patient was discharged neurologically stable on .,0
Dictated By: MEDQUIST36 D: 13:00 T: 10:17 JOB#:,0
"4:21 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with h/o zenker's diverticulum repair, w/ acute desaturation on the floor and possible allergic rxn REASON FOR THIS EXAMINATION: Please eval for interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after Zenker's diverticulum repair with acute desaturation.",0
Portable AP radiograph of the chest was reviewed in comparison to .,0
The ET tube tip is 3 cm above the carina.,0
"The patient continues to be in interstitial pulmonary edema, moderate.",0
"Bilateral, left more than right, opacities are highly concerning for focal areas of consolidation due to aspiration or infection.",0
Bilateral pleural effusion cannot be entirely excluded.,0
", J. NSURG FA11 2:45 PM CT HEAD W/O CONTRAST Clip # Reason: rebleed Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with seizure like activity and L IPH REASON FOR THIS EXAMINATION: rebleed No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Evolution of left frontal intraparenchymal hematoma with small focus of hyperdensity without evidence of new bleeding.",0
Significant vasogenic edema greater than that which would be expected this far from the initial event.,0
Recommend close surveillance of the hematoma and repeat MRI with contrast after resolution of the hematoma to more definitively assess for underlying lesion.,0
"10:30 AM MR ABDOMEN W&W/O CONTRAST; MR RECONSTRUCTION IMAGING Clip # MR DOUBLE DOSE CONTRAST Reason: STAPH BACTEREMIA, LEFT RENAL FAT, ABCESS, HIGH FEVER Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT INDICATION: Staph bacteremia; fever; enlarged left kidney with perinephric stranding on CT of .",1
The patient has a history of medullary sponge kidney.,1
TECHNIQUE: Non-breath-hold renal mass protocol.,0
The patient was unable to hold his breath.,0
His only IV access was through the PICC.,0
20 cc of gadolinium was administered through the PICC via slow hand injection.,0
"MR ABDOMEN WITHIN AND WITHOUT CONTRAST: The visualized portions of the liver, spleen, adrenals, pancreas, and gallbladder are unremarkable.",0
"The right kidney measures 9.4 cm, and has multiple small peripelvic cysts without hydronephrosis.",0
There is an incidental hemangioma in T12 vertebral body.,0
The left kidney measures 11.7 cm.,0
"It has diffuse signal abnormality with poor differentiation of the cortex and medulla, and marked perinephric inflammatory fat stranding and a small amount of adjacent perinephric fluid.",0
"On the CT scan, the patient has bilateral medullary nephrocalcinosis.",0
There is heterogenous contrast enhancement throughout the left kidney with a striated appearance.,0
"Multiple areas of hypo-enhancement throughout the left kidney, more extensive at the upper to mid portions could represent areas of infarction.",0
"There are also multiple cystic areas that do not have a solid nodular enhancing component, with two of the largest cystic areas at the mid- to lower portion measuring 2.7 cm each.",0
There are small left para-aortic lymph nodes adjacent to the left kidney.,0
Multiplanar reconstructions were essential in delineating the anatomy and pathology and confirm the above-stated findings.,0
"Enlarged inflamed left kidney with very heterogenous striated contrast enhancement consistent with infection, and areas of non-enhancement that likely represent infarction.",0
Considerations include xanthogranulomatous pyelonephritis or fulminant pyelonephritis superimposed on underlying medullary sponge kidney.,1
"Multiple cystic areas that correspond to the low- attenuation areas on the recent CT, have the appearance of cysts, and do not have internal heterogeneity or irregular enhancement.",0
"However, infection within cysts cannot be excluded by imaging.",0
Marked perinephric stranding and reactive left para-aortic nodes.,0
"TF (Over) 10:30 AM MR ABDOMEN W&W/O CONTRAST; MR RECONSTRUCTION IMAGING Clip # MR DOUBLE DOSE CONTRAST Reason: STAPH BACTEREMIA, LEFT RENAL FAT, ABCESS, HIGH FEVER Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"9:44 AM ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # Reason: please do PORTABLE stat u/s to do diagnostic paracentesis to Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with hepatoma, hypotension, hypothermia REASON FOR THIS EXAMINATION: please do PORTABLE stat u/s to do diagnostic paracentesis to r/o intraperitoneal bleed and check for subcapsular bleed ______________________________________________________________________________ FINAL REPORT HISTORY: Hepatoma, hypotension, hypothermia, and extreme hematocrit drop.",0
FINDINGS: The liver overall is small and nodular in contour consistent with cirrhosis.,0
This is seen with a background of multiple masses which are most consistent with the multiple hepatomas described in the history.,0
The portal vein is patent with proper direction of flow.,0
The right kidney measures 11.9 cm in length and demonstrates no hydronephrosis.,0
The left kidney measures 10.9 cm in length and demonstrates no hydronephrosis.,0
The spleen is normal in size.,0
"Diffusely throughout the abdomen but predominantly localized in the right upper quadrant, is echogenic material which has consistency and appearance of hemoperitoneum.",0
This has been directly discussed with Dr. from the clinical service while the study was being performed.,0
IMPRESSION: Hemoperitoneum which may be the result of hemorrhage from one of the patient's known hepatomas.,0
"6:32 AM BABYGRAM (CHEST ONLY) Clip # Reason: r/o rds Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with IDM c-section at 26 weeks, now with respiratory distress REASON FOR THIS EXAMINATION: r/o rds ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST HISTORY: New born infant, born prematurely by C-section at 26 weeks.",1
FINDINGS: There are diffuse granular opacities seen bilaterally.,0
The cardiothymic silhouette is normal in appearance.,0
The bony structures are unremarkable.,0
9:59 AM PORTABLE ABDOMEN Clip # Reason: FUP pain Admitting Diagnosis: CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with abdominal pain.,1
"REASON FOR THIS EXAMINATION: FUP pain ______________________________________________________________________________ FINAL REPORT HISTORY: The patient is a 55-year-old male with past medical history of hepatic encephalopathy and HCV cirrhosis, now with abdominal pain, positive sign and gallstones on ultrasound.",1
"COMPARISON: Comparison is made to right upper quadrant ultrasound from , .",0
FINDINGS: Two frontal images of the abdomen show a normal gas pattern and no evidence of free air.,0
Visualized osseous structures are unremarkable and there are no soft tissue calcifications.,0
Lung bases are clear bilaterally.,0
"12:07 PM CHEST (PORTABLE AP) Clip # Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
"Admitting Diagnosis: BENTEL PROCEDURE ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with Bental s/p sternal closure REASON FOR THIS EXAMINATION: pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Bentall procedure, now status post sternal closure.",0
"COMPARISON: at 9:30 a.m. A bedside frontal radiograph of the chest shows an endotracheal tube, which terminates 2.6 cm above the carina.",0
The nasogastric tube courses into the stomach and beyond the field of view.,0
Bilateral pleural drains as well as two mediastinal drains are unchanged.,0
A Swan-Ganz catheter terminates in the outflow tract.,0
Prosthetic valve is also unchanged.,0
"Cardiac, mediastinal and hilar contours are consistent with the postoperative status.",0
"Left retrocardiac opacity is present, indicative of atelectasis and right basilar opacity shows improved aeration from the comparison study.",0
Numerous sternotomy wires are unremarkable.,0
A prominent left sulcus suggest possible small pneumothorax.,0
There is a small left pleural effusion.,0
11:35 AM CHEST (PA & LAT) Clip # Reason: EVAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man S/P FALL REASON FOR THIS EXAMINATION: EVAL EFFUSION ______________________________________________________________________________ FINAL REPORT INDICATION: 76 y/o man status post fall.,0
"CHEST, PA AND LATERAL: Comparison is made to film .",0
The cardiomediastinal silhouette is unremarkable.,0
A right sided pleural effusion is seen along with right lower lobe collapse.,1
There is increased collapse of the right lobe in comparison to one day prior.,0
The left lung appears clear.,0
IMPRESSION: Right pleural effusion with worsened right lower lobe collapse compared to one day prior.,1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 62 year-old gentelman patient of Dr. was referred for outpatient cardiac catheterization.,0
He had symptoms of chest pain that typically occurred after eating.,0
"He had been treating this as a GI symptom, but was referred to his doctor and on he underwent an exercise tolerance test, which showed electrocardiogram changes.",0
Status post vagotomy in the .,0
Status post cholecystectomy in the with two follow up surgeries for abdominal adhesions in the .,0
He had a cardiac catheterization done on .,0
"MEDICATIONS ON ADMISSION: Atenolol 25 mg po q.d., Lipitor 40 mg po q.d., Hydrochlorothiazide 25 mg po q.d., Celebrex 200 mg po b.i.d., Diovan 80 mg po q.d., Zantac 150 mg po b.i.d., Percocet prn and Valium prn.",0
"ADMISSION LABORATORIES: Day prior to catheterization were white count 7.4, hematocrit 35.2, platelet count 274,000 with an INR of 1.1.",0
"His catheterization showed 70% less main lesion, proximal right coronary artery lesion of 90%, right posterolateral ventricular branch 100% lesion, circumflex 80% lesion and mild luminal irregularities of the left anterior descending coronary artery.",1
It also showed an ejection fraction of 51%.,0
Please refer to the cardiac catheterization report on .,0
He was referred to Dr. of cardiac surgery who examined him on the 21st.,0
He also had no history of claudication.,0
PHYSICAL EXAMINATION: He was alert and oriented.,0
His heart was regular rate and rhythm.,0
Preop his BUN was 28 with a creatinine of 1.3 and his hematocrit was 35%.,0
"HOSPITAL COURSE: On , he underwent coronary artery bypass graft times four with a left internal mammary coronary artery to the left anterior descending coronary artery, vein graft to the posterior descending coronary artery, vein graft to the PLV and a vein graft to diagonal one by Dr. .",1
He was transferred to the Coronary Care Unit in stable condition on propofol and nitroglycerin.,0
On postoperative day one he had no events overnight.,0
He remained on a Nipride drip at 0.5 mcg per kilo per minute.,0
He was extubated and sating 96% on 4 liters.,0
He had a cardiac index of 3.2.,0
He was in sinus rhythm in the80s with a good blood pressure.,0
"His white count was 9.4, hematocrit 22.3, platelet count 207,000, sodium 134, K 4.7, chloride 101, CO2 23, BUN 18, creatinine 1.3 with a blood sugar of 149.",0
He started his Lopressor and aspirin.,0
He began his Lasix diuresis.,0
His chest tubes were discontinued as was his Swan-Ganz catheter and he was transferred out to the floor.,0
He was seen by physical therapy there and began his ambulation.,0
On postoperative day two he was sating 94% on 3 liters with a blood pressure of 150/78.,0
He had a temperature max of 102.1.,0
"His incisions were clean, dry and intact with mild bilateral lower extremity edema.",0
His Lopressor was increased for better blood pressure control.,0
On postoperative day three he remained in sinus rhythm.,0
He was readmitted to the Intensive Care Unit for transfusion reaction.,0
His lactic acid was 2.0.,0
He was awake and alert.,0
He had some minimal swelling of his extremities.,0
His abdominal examination was benign.,0
He continued with his rule out protocol.,0
He was on Dopamine at 3 micrograms for improving his urine output.,0
"He got D5W with three amps of bicarb, which had been started overnight and a renal consult was requested and complete urinalysis was done.",0
On postoperative day four he had a temperature max of 100.6 with a good blood pressure.,0
He was sating 94% on 6 liters nasal cannula.,0
"He remained on Dopamine, Lasix.",0
His hematocrit rose to 25.4.,0
His white count rose to 17.8.,0
K was 3.4 with a BUN of 48 and a creatinine of 2.5.,0
"He had decreased breath sounds at bilateral bases of his lungs, but his heart was regular rate and rhythm.",0
The dopamine was to be weaned off and he was transferred back out to the floor.,0
He was seen again by physical therapy.,0
He had good clinical improvement from his transfusion reaction.,0
On postoperative day five his blood pressure was slightly elevated at 157/96.,0
"His incisions were clean, dry and intact.",0
His Foley remained in place as did his pacing wires.,0
His central line was removed.,0
"His hematocrit remained 25.4, which was to be monitored.",0
The patient became agitated in the middle of the night and he took off his O2 and telemetry and gown and the nurses tried to reorient him.,0
Eventually the intern convinced the patient to take some Valium and it was arranged for a sitter to stay with the patient and monitor him closely through the night.,0
He again then wandered from his room and left his room again at 5:30 in the morning on the 29th.,0
Security found him downstairs in the cafeteria drinking coffee.,0
He was reoriented again back to the floor by psychiatry staff who responded to the code purple.,0
His blood pressure was 190/80 when they returned him to his room.,0
He received another dose of Lopressor to help bring his blood pressure down.,0
He was started on Haldol and was again accompanied by a sitter.,0
His hematocrit rose to 26.1 on postoperative day six with a BUN of 52 and a creatinine of 2.4.,0
His K was 5.0 with a magnesium of 2.3.,0
His sternum was stable and his examination was again unimpressive.,0
It was determined that he should have a sitter until his mental status showed clear improvement.,0
He was again combative at 9:00 a.m.,0
He was placed in four point restraints.,0
A full set of laboratories was drawn again.,0
A chest x-ray was done.,0
He was also to be followed by security for a 24 hour period while he continued Haldol therapy on Far Six.,0
His chest x-ray showed a decreased effusion.,0
No localized infection was noted.,0
At 8:00 in the evening on postoperative day six the patient's blood pressure rose to 265/130.,0
"He had a temperature max of 103 and was in sinus tachycardiac, tachypneic in the 30s and was with rigors.",0
Neurologically he was seen again by the CT Surgery fellow that evening.,0
He was neurologically intact with normal speech and following commands.,0
His chest wall sternum were stable.,0
He had no erythema or signs of infection in his wounds.,0
His chest x-ray early in the day had showed no infiltrates.,0
His white count was 12.1 with a hematocrit of 26.,0
His electrocardiogram showed no signs of ischemia.,0
He was given Hydralazine intravenous to manage his acute hypertension and he was transferred back to the Intensive Care Unit.,0
He was seen by psychiatry who recommended again that this was probably delirium and to keep him in restraints with possibly some deep venous thrombosis prophylaxis.,0
The asked that his Serax and Valium be minimized.,0
He was seen by case management.,0
He remained with a security sitter.,0
His transfer to the Intensive Care Unit was canceled after his rigors resolved and his blood pressure responded to the intravenous Hydralazine.,0
On postoperative day seven he remained in a Posey belt for his agitative episodes over the night.,0
He was started on Ciprofloxacin for empiric coverage.,0
The creatinine of 1.7 with a K of 3.5.,0
"His alkaline phosphatase was elevated at 456, otherwise his laboratories were unremarkable.",0
His white count was 12.1 with a hematocrit of 26.2.,0
His physical examination was unremarkable.,0
He continued to be followed by psychiatry and rehab services with physical therapy.,0
On postoperative day eight his BUN came down to 31 with a creatinine of 1.5.,0
His hematocrit remained stable in the mid 20s.,0
He was down one kilogram of weight.,0
"He remained on Hydralazine, Lopresor, Lasix, Valium, Haldol and Ciprofloxacin.",0
Blood cultures were still pending.,0
His Serax was discontinued His Haldol was switched to prn.,0
He remained on a one week course of Ciprofloxacin.,0
His sitter was discontinued as he became more oriented and stated that he did feel much better.,0
He continued to make steady progress with good activity levels and endurance.,0
His pulmonary status was good.,0
He was followed by case management in planning for his discharge and he continued to make dramatic improvement.,0
"On postoperative day nine his blood pressure was 164/92, sating 93% on room air.",0
"His wounds were clean, dry and intact.",0
The plan was to check his culture and sensitivities before discharge and plan for VNA Services at home and to continue his Ciprofloxacin for a total of seven days.,0
On he was discharged to home with instructions for follow up in one week for staple removal and to follow up with his primary care physician in one to two weeks as well as following up with Dr. in three to four weeks.,0
Status post coronary artery bypass graft times four.,1
DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg po b.i.d.,0
"times seven days, Lopressor 75 mg po b.i.d., Hydralazine 15 mg po q.i.d., Zantac 150 mg po b.i.d., Colace 100 mg po b.i.d., Lipitor 40 mg po q.h.s., Valium as needed.",0
Lasix 20 mg po b.i.d.,0
times fourteen days and K-Ciel replacement 20 milliequivalents po q.d.,0
PHYSICAL EXAMINATION ON DISCHARGE: His heart was regular rate and rhythm.,0
His vital signs were stable.,0
His final chest x-ray did show a left lower lobe pneumonia for which he was receiving his antibiotics and again he was discharged on in stable condition to home with VNA Services.,0
Dictated By: MEDQUIST36 D: 11:29 T: 09:39 JOB#:,0
3:47 PM CHEST (PORTABLE AP) Clip # Reason: Lead location?,0
Admitting Diagnosis: INFECTED STENT ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with intermitent CHB.,0
s/p Temp PM screw-in insertion.,0
REASON FOR THIS EXAMINATION: Lead location?,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Temporary pacemaker, to evaluate for lead location and pneumothorax.",0
"FINDINGS: In comparison with study of , there has been insertion of a temporary pacemaker with its tip in the general region of the apex of the right ventricle.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: transfer from NEBH for SOB, possible need for cath given rising troponin Major Surgical or Invasive Procedure: Cardiac Catheterization Coronary Artery Bypass Grafting LIMA-->LAD, SVG-->OM, SVG-->PDA History of Present Illness: 56 y/o male patient of Dr. with HTN, hypercholesterolemia, DM2, current smoking, PVD s/p Left CEA and totally occluded , with chest discomfort begining three weeks ago which he describes as ""stressed out feeing"" right before the holidays.",1
"Denies pain or associated symptomes of SOB, diasphoresis, light headedness, nausea, or leg swelling.",0
"He has been chest dicomfort free for the last several weeks since then, with the exception of increased SOB, mostly at night, and increased leg swelling, cough, and PND.",0
"He presented to Dr. office with SOB, cough, and sputum production, was treated with antibiotics with no resolution of symptomes, and had a CXR suggestive of pulm edema, and so was referred to NEBH ambulatory services for evaluation.",0
"He was admitted to NEBH for r/o MI, troponins 1.82 to 4.16 to 5.35 with CK 173 to 161 to 181.",0
"Started on asa, plavix, lovenox and transferred for possible cath/CABG given rising troponins.",0
Past Medical History: HTN hypercholesterolemia DM2 current smoking PVD s/p Left CEA and totally occluded Hypothyroidism S/P Cholecystectomy S/P Cervical Surgery S/P B/L Knee Surgery Social History: Smoker of 35 years at 2 ppd.,1
"No recent alcohol use, but remote history of frequent use.",0
Family History: Father had MI at 65 years old.,0
Physical Exam: General: Well appearing man in no distress.,0
"Vitals: T 96.2 BP 131/54 HR 61 RR 18 Sat 100% 1L O2 NC FS 58 Wt 110kg HEENT: normal, anicteric sclera Neck: Carotid bruits B/L R>L Chest: Lungs with decreased breath sounds at bases, otherwise clear ABD: Scar over RUQ and above umbilicus, +bowel sounds, soft, NT, ND, no organomegaly EXT: No edema.",0
Good femoral pulses B/L without bruits.,0
"Pertinent Results: INDICATIONS FOR CATHETERIZATION: NSTEMI, low EF, 30 beats of monomorphic VT PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 6 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath.",1
Cardiac output was measured by the Fick method.,0
"Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French angled pigtail catheter, advanced to the left ventricle through a 6 French introducing sheath.",1
"Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 catheter, with manual contrast injections.",0
"Left Ventriculography: was performed in the 30 degrees projection, using 33 ml of contrast injected at 11 ml/sec, through the angled pigtail catheter.",0
Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff.,0
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.21 m2 HEMOGLOBIN: 14 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 15/16/9 RIGHT VENTRICLE {s/ed} 45/15 PULMONARY ARTERY {s/d/m} 45/18/28 PULMONARY WEDGE {a/v/m} 24/25/22 LEFT VENTRICLE {s/ed} 141/24 AORTA {s/d/m} 141/64/71 **CARDIAC OUTPUT HEART RATE {beats/min} 55 RHYTHM SINUS O2 CONS.,1
IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 38 CARD.,0
OP/IND FICK {l/mn/m2} 7.3/3.3 **RESISTANCES SYSTEMIC VASC.,0
RESISTANCE 66 **% SATURATION DATA (NL) SVC LOW 70 PA MAIN 68 AO 88 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.,0
LEFT VENTRICULOGRAPHY: Volumetric data: LV ejection fraction (nl 50%-80%).,0
25 Qualitative wall motion: : 1.,0
Antero basal - hypokinetic 2.,0
Antero lateral - hypokinetic 3.,0
Postero basal - hypokinetic Other findings: Mitral valve was normal.,0
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT.,0
FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 50 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DISCRETE 95 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT.,0
FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DIFFUSELY DISEASED 70 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX DISCRETE 70 13) MID CX DIFFUSELY DISEASED 13A) DISTAL CX DIFFUSELY DISEASED 14) OBTUSE MARGINAL-1 DISCRETE 95 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour41 minutes.,1
Arterial time = 0 hour25 minutes.,0
Fluoro time = 5.6 minutes.,0
"Contrast: Non-ionic low osmolar (isovue, optiray...), vol 83 ml, Indications - Hemodynamic Premedications: ASA 325 mg P.O.",0
"Anticoagulation: Other medication: Fentanyl 25 mcg IV Versed 0.5 mg IV Lasix 20 mg IV Cardiac Cath Supplies Used: 200CC MALLINCRODT, OPTIRAY 200CC 100CC MALLINCRODT, OPTIRAY 100CC COMMENTS: 1.",0
Selective coronary angiography revealed a right dominant system.,0
There was no angiographically apparent CAD in the LMCA.,0
The LAD had a long diffusely diseased segment with a 70% stenosis.,0
The LCX had a 70% proximal stenosis.,0
The OM had a 95% origin stenosis.,0
There was moderate diffuse distal disease in the LCx.,0
The RCA had a 50% mid vessel stenosis and 95% bifurcation disease at the PDA and PL.,0
"Hemodynamics on entry showed elevated filling pressures, mild to moderate pulmonary hypertension, and a normal cardiac output.",1
There was no gradient across the aortic valve on pullback.,0
Left ventriculography showed a dilated ventricle which was globally hypokinetic.,0
Three vessel coronary artery disease.,1
Moderate systolic and mild diastolic ventricular dysfunction.,0
Mild to moderate pulmonary hypertension.,1
"ATTENDING STAFF: , S. Cardiology Report ECG Study Date of 3:51:14 PM Ectopic atrial rhythm.",0
Ventricular premature beat with possible pacemaker fusion.,0
Lone pacemaker spike in the third beat of the rhythm strip.,0
"Read by: , Intervals Axes Rate PR QRS QT/QTc P QRS T 51 /446.86 -53 95 -157 RADIOLOGY Final Report CHEST (PORTABLE AP) 12:47 PM CHEST (PORTABLE AP) Reason: PTX MEDICAL CONDITION: 56 year old man with increasing dyspnea s/p CABG now s/p R-IJ change over wire and d/c CTs REASON FOR THIS EXAMINATION: PTX CHEST, SINGLE AP FILM History of CABG and increasing dyspnea with CV line change.",0
Right jugular CV line is in the SVC.,0
The right costophrenic region is not included on the film.,0
There is opacity at the left base obscuring the left hemidiaphragm consistent with atelectasis in the left lower lobe and associated small left pleural effusion.,0
Status post cervical spine fusion.,0
DR. Approved: 2:55 PM RADIOLOGY Final Report CAROTID SERIES COMPLETE 3:40 PM CAROTID SERIES COMPLETE Reason: please eval for extent of carotid stenosis b/l MEDICAL CONDITION: 56 year old man with h/o PVD s/p left CEA and known occlussion.,0
ON exam with b/l carotid bruits R>L and diminsihed R carotid pulse.,0
REASON FOR THIS EXAMINATION: please eval for extent of carotid stenosis b/l HISTORY: Status post left carotid endarterectomy with right carotid occlusion.,0
"TECHNIQUE: scale ultrasound, color Doppler, and spectral Doppler interrogation of the extracranial carotid arteries were performed.",0
RIGHT: No flow was demonstrated within the right internal carotid artery.,0
"Peak systolic velocity in the right external carotid artery was 193 cm/sec, common carotid artery 43 cm/sec.",0
Blood flow within the right vertebral artery was antegrade.,0
LEFT SIDE: Mild calcified plaques were noted at the origin of the left internal carotid artery.,0
"Peak systolic velocities were as follows: 112 cm/sec ICA, 71 cm/sec CCA, 132 cm/sec ECA.",0
Blood flow direction within the left vertebral artery was antegrade.,0
The ICA-CCA ratio on the left was 1.57.,0
Right internal carotid artery is occluded.,0
Nonhemodynamically significant stenosis of less than 40% was demonstrated in the left internal carotid artery.,0
The study and the report were reviewed by the staff radiologist.,0
"DR. DR. Approved: WED 9:51 AM Brief Hospital Course: 56 y/o male with HTN, hypercholesterolemia, current smoking, DM2, PVD S/P L CEA and occluded presents from outside hospital after completed MI with shortness of breath, was chest pain free and ruled out for active ischemic event.",0
He was started on metoprolol and captopril.,0
His shortness of breath improved with diuresis (40 mg IV lasix QD).,0
He had a 30 second episode of monomorphic VT symptomatic with lightheadedness on .,0
"He went for elective cath on , which showed 3VD, and so he was scheduled for CABG.",0
He was started on amiodarone for VT.,0
"He was continued on his home regimen of 60 units 75/25 QD before breakfast for DM2, but his evening dose of 60 units NPH was halved for morning hypoglycemia.",0
He had a carotid US for his h/o PVD with CEA of left carotid and known totally occluded .,0
It showed 40% Left Stenosis and totally occluded .,0
"He had an abnormally elevated TSH to 25, but his free T4 was normal.",0
We continued his home dose of levothyroxine 300 mcg QD.,0
He may need an EP study for possible ablation of ventricular focus given his episode of monomorphic VT as an Outpatient per Dr. .,1
He may also need an ICD given his low EF an documented episode of symptomatic monomorphic VT. Mr. cardiac catheterization where he was found to have no angiographically apparent CAD in the LMCA.,0
"Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization.",1
He was worked-up in the usual preoperative manner.,0
"On he successfully CABGx (LIMA->LAD, SVG->PDA, SVG->OM).",0
Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake.,0
"He was weaned from ventilator support, extubated, and pressors were weaned.",0
On POD 2 he was then transferred to the cardiac stepdown unit for further recovery.,0
His chest tubes were removed without complication.,0
He was gently diuresed toward his preoperative weight with lasix.,0
"Beta blockade, aspirin, and plavix were resumed.",0
The physical therapy service was consulted to assist with his postoperative strength and mobility.,0
Electrolytes were repleted as needed.,0
On POD 3 his epicardial pacing wires were removed without complication.,0
The Electrophysiology service was consulted regarding history of ventricular tachycardia that occurred preoperatively.,1
"Consideration was given to performing an EP study with ablation however due to his continued tenuous pulmonary status Dr. , Mr. cardiologist elected to continue observation and perform any further work up as an outpatient.",0
Also on POD 3 he began to complain of decreased sensation and flexion to his left calf and shin.,0
"This was attributed to peroneal nerve injury from fluid accumulation or positioning, for which the physical therapy service gave an ankle foot orthotic.",0
We will continue watchful waiting for the return of his left lower extremity function.,0
If indicated further workup will be conducted as an outpatient.,0
He continued to improve his ability to ambulate including climbing stairs without severe respiratory distress or chest pain.,0
"His room air saturations improved to 98% despite continuing to require combivent, albuterol, and advair.",0
"On POD 9 Mr. was at his preop weight with good exercise tolerance, no SOB, or Chest pain.",0
His blood pressure was stable.,0
"His sternotomy and leg incision were clean, dry, and intact, however he was placed on levaquin 500mg for seven days due to sersanquinous drainage at the inferior portion of his sternotomy.",0
"He was discharged to home on POD 9, with cardiac diet, sternal precautions, and instructed to follow up with his PCP and cardiologist in weeks.",0
He will follow up for a wound check on Mon or Tues. at 2.,0
He will follow up with Dr. in four weeks.,0
Medications on Admission: Home Meds: Valium 5 mg TID Humulin N 60 units QD at dinnertime Humalog 75/25 60 units QD before breakfast Levothyroxine 300mcg QD Percocet 5mg/325mg Q4H PRN Additional Meds on transfer: ASA 325 QD Plavix 300 once Nitro Paste 2inches Discharge Medications: 1.,0
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours).,0
"Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours).",0
"Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 4.",0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Aspirin 81 mg Tablet, Delayed Release (E.C.)",0
"Sig: One (1) Tablet, Delayed Release (E.C.)",0
"Disp:*30 Tablet, Delayed Release (E.C.",0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily).,0
Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day.,0
Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation (2 times a day).,0
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours).,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every 4-6 hours.,0
Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous once a day.,0
Humalog Mix 75-25 75-25 unit/mL Suspension Sig: One (1) 60 Subcutaneous qBreakfast.,0
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) 60 Subcutaneous at bedtime.,0
Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed.,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days.,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days.,0
"Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: care group Discharge Diagnosis: CAD, PVD s/p Left CEA, totally occluded , Hypothyroidism, s/p CCY, cervical injury, s/p Bilateral knee replacement with intra-op brady arrest, IDDM, HTN, Hypercholesteremia Discharge Condition: Good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry.",0
"No lotions, creams or powders to incisions.",0
"Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week.",0
No lifting more than 10 pounds for 10 weeks.,0
No driving until follow up with surgeon.,0
Followup Instructions: Dr. in four weeks Dr. in weeks Dr. in weeks Completed by:,0
"6:37 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for int change in ptx Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;FEVER;NEUTROPENIA;R/O TOOTH INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 63 year old with sepsis, low bp and elevated cvp REASON FOR THIS EXAMINATION: eval for int change in ptx ______________________________________________________________________________ FINAL REPORT STUDY: Portable AP chest x-ray.",1
"INDICATION: 63-year-old male with sepsis, low blood pressure, and elevated central venous pressure.",0
Assess for interval change of pneumothorax.,0
"FINDINGS: There is bilateral alveolar pulmonary edema which is significantly worse, compared to the chest x-ray dated .",0
There is no evidence of a right apical pneumothorax.,0
"Left and right central venous catheters remain in unchanged in position, compared to the examination from 12 hours prior.",0
Left lower lobe atelectasis is unchanged.,0
"IMPRESSION: Left lower lobe atelectasis and moderate pulmonary edema, worse compared to the film from 12 hours earlier.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIACICU ADDENDUM: This is a continuation of the prior dictation summary continuing with physical exam.",0
PHYSICAL EXAMINATION: Vital signs: Temperature 98.8; heart rate 79; blood pressure 123/80; respiratory rate 16; oxygen saturation 95% on room air.,0
"In general, the patient is an obese male in no acute distress lying at 30 degrees.",0
"HEENT exam: Normocephalic, atraumatic, anicteric sclerae, pupils are equal, round and reactive to light and accommodation, clear oropharynx, dry mucous membranes.",0
"Neck exam: Elevated jugular venous distention, no lymphadenopathy, supple.",0
Pulmonary exam: Expiratory wheezes predominantly on the right otherwise clear to auscultation with no rales noted.,0
"Cardiovascular exam: Regular rate and rhythm with normal S1, S2, positive S4, no murmurs appreciated.",0
"Abdominal exam: Obese, soft, normoactive bowel sounds, nontender, mildly distended.",0
Extremities: Intra-aortic balloon pump in place with right femoral artery catheter.,0
"No ecchymosis or hematoma noted, 2+ dorsalis pedis and posterior tibial pulses bilaterally, warm and well perfused extremities.",0
LABORATORY AND STUDIES ON ADMISSION: CBC with a white blood cell count of 9.2; hematocrit 38.6; platelets of 284; Chem-7 with a sodium of 140; potassium 4.3; chloride 98; bicarb 32; BUN 12; creatinine 1.1 with glucose of 408; Coags with a PT of 13.2; INR of 1.2 and PTT of 25.5.,0
Initial ABG at the outside hospital with a pH of 7.27; CO2 76; O2 of 341 on a 100% nonrebreather.,0
ABG during cardiac catheterization: PH of 7.28; CO2 65 and O2 of 70 on one liter nasal cannula.,0
"ECHOCARDIOGRAM: On notable for a moderate left atrial dilatation, moderate left ventricular dilatation, moderate dilatation of the aortic route, left ventricular ejection fraction of 45%, and mild pulmonary artery hypertension.",1
"CHEST X-RAY: On admission notable for cardiomegaly with no signs of pulmonary edema, effusion, or infiltrate.",0
"EKG: At the outside hospital notable for a complete heart block with sinus bradycardia and junctional rhythm at 38 to 42, normal axis, ST elevations inferiorly with reciprocal ST depressions in the lateral precordium, leads I and aVL.",1
"Right sided EKG notable for a elevation in lead R, V4 consistent with a right ventricular infarct.",0
"POST CATHETERIZATION EKG: Normal sinus rhythm at 84 with left atrial dilatation, diminished inferior voltage, new T-wave inversions inferiorly with resolution of the ST elevations inferiorly.",0
HOSPITAL COURSE: The patient went for emergent cardiac catheterization.,0
The patient's left heart cardiac catheterization demonstrated proximal right coronary artery total occlusion with acute thrombus and distal right coronary artery clot in a distal stent.,1
The patient underwent Angioject with balloon dilatation of clots in three right coronary artery stents with subsequent stent overlay of the proximal RCA stent in restoration of TIMI three flow.,1
An intra-aortic balloon pump was placed for after load reduction.,0
The patient also underwent a right heart catheterization with demonstration of elevated failing pressures; right atrial pressure 22; right ventricular pressure 61 / 13; pulmonary artery pressure 62 / 36; and pulmonary capillary wedge pressure of 22.,0
A Swan-Ganz catheter remained in place.,0
POST CATHETERIZATION: Continued to monitor the patient's volume status.,0
HOSPITAL COURSE: The patient was started on Integrilin (18 hours); Plavix; and Heparin and was transferred to the Cardiac Intensive Care Unit for further management.,0
"The patient ruled in for an ST elevation myocardial infarction with a peak CK of 1,742.",1
The patient remained chest pain free throughout the remainder of the hospital course.,0
The patient was continued on aspirin and Lipitor and was started on an insulin drip for blood glucose control while in the Critical Care Unit.,0
The patient maintained adequate blood pressure on the intra-aortic balloon pump with mean arterial pressures in the range of 70 to 80.,0
On hospital day #2: The patient was restarted on his home dose of angiotensin receptor blocker for continued after load reduction.,0
Hospital day #3: The intra-aortic balloon pump was removed.,0
The patient was subsequently restarted on a low dose beta blocker with no further evidence of complete heart block.,1
A transthoracic echo was performed which demonstrated mild to moderate decreased left ventricular function with an ejection fraction of 40% secondary to severe hypokinesis of the left ventricular inferior free wall and posterior wall.,0
"The echo also demonstrated severe global right ventricular free wall hypokinesis with contractile dysfunction, mild left atrial dilatation, mild left ventricular symmetric hypertrophy, mild dilatation of the aortic route, and trivial mitral regurgitation.",0
ST elevation myocardial infarction complicated by right ventricular infarction status post percutaneous transluminal coronary angioplasty with overlay stenting at the proximal coronary artery.,1
Coronary artery status post three vessel coronary artery bypass graft in and multiple subsequent cardiac catheterizations.,1
Insulin 75 / 25; 66 units subcutaneous q.,0
AM; 30 units subcutaneous q. PM.,0
Albuterol two puffs MDI q.4 to 6 hours p.r.n.,0
Atrovent MDI two puffs b.i.d.,0
"The patient was discharged to home with instructions to follow up with his primary care physician, .",0
"on , at 9:40 AM.",0
The patient will be contact by a Dr. with a follow up Cardiology appointment.,0
It was recommended that the patient obtain outpatient pulmonary function tests to further evaluate his diagnosis of chronic obstructive pulmonary disease.,0
Dictated By: MEDQUIST36 D: 13:56 T: 09:35 JOB#:,0
"1:21 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with recent extubation, agitation, new fever.",1
REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation for pneumonia.,0
"FINDINGS: As compared to the previous radiograph, the endotracheal tube and the nasogastric tube have been removed.",0
The lungs show normal transparency and structure.,0
There is no evidence of focal parenchymal opacity suggestive of pneumonia.,0
"No pleural effusions, no pneumothorax.",0
The size of the cardiac silhouette is within normal range.,0
"5:29 AM CHEST (PORTABLE AP) Clip # Reason: progression of pseudomonal pna, b/l pleural effusion Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor, cervival adenopathy, PNA, s/p Trach, currently off vent REASON FOR THIS EXAMINATION: progression of pseudomonal pna, b/l pleural effusion ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:01, HISTORY: Severe adenopathy.",1
Pseudomonas pneumonia and pleural effusions.,1
IMPRESSION: AP chest compared to through 23: Pulmonary edema has largely cleared and previous small right pleural effusion continues to decrease.,1
Right middle lobe is still collapsed.,0
Heart size is top normal.,0
Mediastinal widening due to combination of adenopathy and vascular engorgement has improved since .,0
Tracheostomy tube in standard placement.,0
2:51 PM CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.,0
"Clip # Reason: H/O S/O FEM- BYPAS, HTN, A-FIB, NOW INSERTION OF SWAN-GANZ LINE ______________________________________________________________________________ FINAL REPORT A chest fluoro was performed without a Radiologist present.",0
6.9 minutes of fluoro time was used.,0
"10:03 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with recent seizure, NSTEMI, ans asp PNA, now with resp distress REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:18 A.M. HISTORY: Recent seizure and MI.",0
"IMPRESSION: AP chest compared to and : Lung volumes are generally lower, exaggerating the severity of a very mild edema.",0
Consolidation persists in the left lower lobe and small bilateral pleural effusions are probably present.,0
Left subclavian line ends in the upper SVC.,0
3:18 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: reassess Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE ______________________________________________________________________________ MEDICAL CONDITION: mrsa pna REASON FOR THIS EXAMINATION: reassess ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: MRSA pneumonia.,1
Endotracheal tube is 6 cm above carina.,0
Right jugular CV line is in mid SVC.,0
NG tube is in stomach with distal end not included on film.,0
There has been no change in the appearance of the heart or lungs since the previous film obtained on the same date.,0
The bilateral pleural effusions and ill-defined pulmonary opacities predominantly in the right lower zone and left perihilar region are again demonstrated as is the marked bullous emphysema in the right upper lobe and to a lesser extent in the left upper lobe.,0
12:59 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: L>R UE SWELLING PLEASE EVAL FOR DVT Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with L>R UE swelling REASON FOR THIS EXAMINATION: please eval for DVT ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Left greater than right upper extremity swelling.,0
"The left internal jugular, subclavian, axillary, and brachial veins are all easily compressible and fully patent with normal color flow and pulse Doppler waveforms.",0
The basilic and cephalic veins are also identified and patent with easy compressibility.,0
CONCLUSION: No evidence of DVT in the left upper extremity.,0
3:25 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"chf, pna ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with hypotension, ?",0
MI REASON FOR THIS EXAMINATION: ?,0
"chf, pna ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, AT 1530 HOURS.",0
FINDINGS: The lungs are clear without consolidation or edema.,0
Mild aortic tortuosity is again noted and stable.,0
"The cardiac silhouette is borderline enlarged, also stable.",1
No effusion or pneumothorax is noted.,0
Mild degenerative disease is seen throughout the thoracic spine and in the included acromioclavicular joints.,0
IMPRESSION: No acute pulmonary process.,0
PATIENT/TEST INFORMATION: Indication: Shortness of breath.,0
Status: Outpatient Date/Time: at 12:05 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.,0
LEFT VENTRICLE: Left ventricular wall thicknesses are normal.,0
The left ventricular cavity is moderately dilated.,0
There is severe global left ventricular hypokinesis.,0
There is no resting left ventricular outflow tract obstruction.,0
No masses or thrombi are seen in the left ventricle.,0
RIGHT VENTRICLE: Right ventricular chamber size and free wall motion are normal.,0
AORTA: The aortic root is normal in diameter.,0
The ascending aorta is normal in diameter.,0
AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation.,0
MITRAL VALVE: The mitral valve appears structurally normal with trivial mitral regurgitation.,0
There is no mitral valve prolapse.,0
The mitral valve supporting structures are normal.,0
There is no significant mitral stenosis.,0
The left ventricular inflow pattern is normal for age.,0
TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial tricuspid regurgitation.,0
The pulmonary artery systolic pressure could not be determined.,0
PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear structurally normal with physiologic pulmonic regurgitation.,0
The main pulmonary artery and its branches are normal.,0
No color Doppler evidence for a patent ductus arteriosus is visualized.,0
PERICARDIUM: There is no pericardial effusion.,0
GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.,0
Conclusions: The left atrium is normal in size.,0
Left ventricular wall thicknesses are normal.,0
There is severe global left ventricular hypokinesis (ejection fraction 20 percent).,0
The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation.,0
The mitral valve appears structurally normal with trivial mitral regurgitation.,0
"Compared with the findings of the prior study (tape reviewed) of , the left ventricular ejection fraction is markedly reduced.",0
PATIENT/TEST INFORMATION: Indication: Pericardial effusion.,0
Height: (in) 68 Weight (lb): 213 BSA (m2): 2.10 m2 BP (mm Hg): 112/57 HR (bpm): 109 Status: Inpatient Date/Time: at 15:10 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.,0
"LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%).",0
Normal regional LV systolic function.,0
AORTIC VALVE: Moderately thickened aortic valve leaflets.,0
Mild to moderate (+) AR.,0
TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
No echocardiographic signs of tamponade.,0
"Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%).",0
Regional left ventricular wall motion is normal.,0
The aortic valve leaflets are moderately thickened.,0
Mild to moderate (+) aortic regurgitation is seen.,0
There is moderate pulmonary artery systolic hypertension.,0
"There is a moderate sized, circumferential, pericardial effusion with fibrin deposits on the surface of the heart.",0
There are no echocardiographic signs of tamponade.,0
"Compared with the findings of the prior report (tape unavailable for review) of , the pericardial effusion may be smaller.",0
2:59 PM TIB/FIB (AP & LAT) LEFT IN O.R.,0
"; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # Reason: LEFT TIB-FIB CRUSHING INJURY, EX-FIX Admitting Diagnosis: PEDESTRIAN STRUCK ______________________________________________________________________________ FINAL REPORT HISTORY: Crush injury after external fixation.",1
FINDINGS: External fixation device is in place.,0
Multiple images show improved position of the tibial and fibular fractures.,1
"Again, routine nonfluoroscopic images should be obtained when the condition of the patient permits.",0
"10:17 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: Assess for Ludwig's angina, other neck soft tissue infection Admitting Diagnosis: ACUTE PARATITIS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with laryngeal CA, admitted with parodititis, also with L bronchial artery bleed/DAH, now with sepsis, worsening neck swelling REASON FOR THIS EXAMINATION: Assess for Ludwig's angina, other neck soft tissue infection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old male with laryngeal cancer, admitted with parotiditis, left bronchial artery bleed, now with sepsis and neck swelling.",0
Assess for Ludwig angina and soft tissue infection.,0
Comparison was made to the prior chest CT dated .,0
FINDINGS: The patient is status post intubation.,0
There is no definite neck mass.,0
The parotid glands and submandibular glands are symmetric.,0
There is fluid in nasopharyngeal cavity and upper airway due to intubation.,0
"Posterior to the nasopharynx on the left, there is 1-cm area of fluid density, which may be a continuation from the nasopharynx in Rosenmuller fossa, however, the evaluation is somewhat limited.",0
"There are air-fluid levels in bilateral maxillary, sphenoid sinuses representing sinus disease.",0
The visualized portion of mastoid air cells is clear.,0
"At the base of the tongue, note is made of mild increase of subcutaneous fat probably due to edema or third spacing, which was seen diffusely in the other subcutaneous area, however, inflammation in this area cannot be totally excluded.",0
No discrete fluid collection is demonstrated otherwise.,0
"In the visualized portion of lung apices, again note is made of interstitial opacity with alveolar opacities with underlying emphysema seen previously.",0
There is no suspicious lytic or blastic lesion in skeletal structures.,0
Degenerative changes of the cervical spine noted.,0
"IMPRESSION: Limited study, without definite fluid collection.",0
"Fluid in nasopharynx and upper trachea, with fluid density posterior to left nasopharynx, probably a continuation of nasopharyngeal cavity.",0
"Mild diffuse increase of the subcutaneous fat, especially at the level of the tongue base, which can be due to edema, however, inflammation in this area cannot be totally excluded given the clinical setting.",0
Please correlate with physical examination.,0
"(Over) 10:17 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: Assess for Ludwig's angina, other neck soft tissue infection Admitting Diagnosis: ACUTE PARATITIS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont)",0
11:45 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrates ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with interstitial pneumonia REASON FOR THIS EXAMINATION: r/o infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: The patient is a 46-year-old female with interstitial pneumonia.,0
EXAMINATION: Single frontal chest radiograph.,0
COMPARISONS: Comparison is made to reference chest CTs from and and chest radigraph on 1026...,0
"FINDINGS: Severe, diffuse multifocal alveolar airspace opacification, new since chest CTs from and showed a only mild progression of multifocal ground glass pulmonary abnormality diagnosed pathologically as NSIP.",0
"The Chest radiograph on showed progressive opacification compared to the CT just a week earlier, presumably an acute condition such as CHF, less likely pneumonia or hemorrhage because of its uniformly global appearance.",0
The cardiomediastinal and hilar contours are obscured though probably enlarged.,0
IMPRESSION: Interval recurrence or progression of diffuse alveolar opacification in setting of known chronic interstitial lung disease (NSIP/ILD leading diagnostic considerations per OMR).,0
This could be pulmonary edema or widespread pneumonia or hemorrhage.,0
Given the course consideration should also be given to drug or toxin exposure exacerbating a preexisting reaction.,0
1:48 AM CHEST (PORTABLE AP) Clip # Reason: increased oxygen requirment Admitting Diagnosis: MYOCARDIAL INFARCTION;CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with CAD s/p CABG REASON FOR THIS EXAMINATION: increased oxygen requirment ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: CABG.,1
Cordis catheter overlies proximal SVC.,0
There is cardiomegaly with bilateral pleural effusions and associated atelectases in the lower zones.,0
The left hemidiaphragm is obscured.,0
Bilateral pleural effusions and bibasilar atelectases.,0
7:55 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: please r/o focal lesion of liver and evaluate TIPS w/ dopple Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p TIPs REASON FOR THIS EXAMINATION: please r/o focal lesion of liver and evaluate TIPS w/ doppler ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old man status post two days' TIPS.,0
FINDINGS: The liver is heterogeneous with a nodular architecture but no focal liver lesion is identified.,0
There is no biliary dilatation.,0
A trace of ascites is seen in the perihepatic and perisplenic spaces.,0
The spleen is enlarged measuring 16.2 cm.,0
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were obtained.,0
Flow within the main portal vein is hepatopetal with a velocity of 33 cm/sec.,0
"The TIPS shunt is patent with wall-to-wall flow however the velocities are low measuring 51, 44, and 30 cm/sec in the proximal, mid and distal portions respectively.",0
Flow within the anterior right portal vein is hepatopetal and flow within the left portal vein is hepatopetal.,0
Appropriate flow is seen in the hepatic veins.,0
Patent TIPS shunt but with slow flow velocities.,0
Flow within the left portal vein and the anterior right portal vein has not reversed and is not flowing towards the TIPS shunt.,0
A short-term followup ultrasound is recommended.,0
Nodular hepatic architecture with no focal liver lesion identified.,1
Splenomegaly and a trace of ascites.,0
"10:42 AM CHEST (PORTABLE AP) Clip # Reason: eval pna/free air ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with sepsis REASON FOR THIS EXAMINATION: eval pna/free air ______________________________________________________________________________ FINAL REPORT HISTORY: 30-year-old female with sepsis, to rule out cardiopulmonary process.",0
TECHNIQUE: Single portable AP radiograph of the chest was performed.,0
Comparison is made with examination of .,0
FINDINGS: There is a right-sided central venous line with the tip in the right atrium.,0
There is also stable appearance of the dilatation of the main pulmonary trunk indicating chronic pulmonary hypertension.,0
There is stable appearance to the increased interstitial markings in both lungs suggestive of interstitial lung disease.,0
There is stable appearance to a right infrahilar opacity likely infectious or inflammatory.,0
There are multiple surgical clips in the upper abdomen.,0
CONCLUSION: No significant change since the prior examination.,0
Ill-defined right infrahilar opacity likely infectious or inflammatory.,0
Increased interstitial markings in both lungs suggestive of underlying interstitial lung disease.,0
Cardiomegaly and enlarged pulmonary arteries suggestive of pulmonary arterial hypertension.,0
"6:32 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please eval for effusion, infiltrate Admitting Diagnosis: VARICEAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with ascites, NASH, encephalopathy, respiratory failure with worsened oxygenation REASON FOR THIS EXAMINATION: please eval for effusion, infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Encephalopathy, worsening O2 requirements.",1
CHEST: Patient is considerably rotated.,0
"The endotracheal tube, nasogastric tube, and IJ line are unchanged in position.",0
Atelectasis at the left base is seen.,0
The right chest is difficult to evaluate due to rotation.,0
There is probably an effusion present.,0
Right effusion is again probably present.,0
It is probable that there has been an increase in the size of the right effusion since the prior chest x-ray of seven hours previous.,0
IMPRESSION: Probable increasing right effusion in chest.,0
Admission Date: Discharge Date: Date of Birth: Sex: M HISTORY OF PRESENT ILLNESS: The patient is a full-term male newborn transferred from for evaluation of respiratory distress in the setting of trisomy 21.,0
"He was also noted to have a cardiac murmur, hyperbilirubinemia, and He was born to a 33-year-old gravida 4, para 2 (now 3) mother.",0
"PRENATAL SCREENS: Blood type was O positive, antibody negative, rapid plasma reagin nonreactive, Rubella immune, hepatitis B surface antigen negative, group B strep positive.",0
The pregnancy was otherwise uncomplicated.,0
The trisomy 21 status was unknown therefore prenatally.,0
LABOR AND DELIVERY: Mother presented for a scheduled repeat cesarean section.,0
The baby was in the breech position.,0
Artificial rupture of membranes at the time of delivery.,0
There was light meconium stained amniotic fluid.,0
Apgar scores were 8 and 8 at 1 minute and 5 minutes respectively.,0
The infant did receive blow-by oxygen briefly during the resuscitation.,0
NEWBORN COURSE AT : The patient was noted to have dysmorphic features consistent with trisomy 21.,0
He was also noted to have some respiratory distress and required nasal cannula oxygen to be delivered.,0
He was also clinically noted to have jaundice.,0
"Given the respiratory distress and positive maternal group B strep colonization, a sepsis evaluation was performed, and the patient was started on ampicillin and gentamicin.",0
"PERTINENT LABORATORY STUDIES AT : White blood cell count was 24.5 (66 polys, 17 bands), hematocrit was 54, platelets were 163.",0
"Bilirubin at two hours of age was 5.5, and at 22 hours of life was 8.9.",0
"The infant's blood type was O positive, Coombs negative.",0
"RADIOLOGY/IMAGING: A chest x- obtained at showed a large heart; otherwise, clear lung fields.",0
"PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed birth weight was 3842 g, length was 20.5 cm, head circumference was 33.5 cm.",0
"The patient was alert and active, in mild respiratory distress.",0
"He had a anterior fontanel that was soft, open, and flat.",0
He had facial features consistent with trisomy 21.,0
He had a large tongue.,0
He had a redundant nuchal fold.,0
His neck was otherwise unremarkable.,0
His lungs were clear to auscultation bilaterally with only mild subcostal retractions.,0
Cardiovascular examination revealed he had a normal-sounding first heart sound and second heart sound.,0
He had a soft 2/6 systolic murmur along the left sternal border.,0
His pulses were normal; both peripherally and centrally.,0
He was warm and well perfused.,0
"His abdomen was soft, flat, and nontender.",0
His testes were descended bilaterally.,0
He had a normal-shaped penis.,0
His anus was patent and normally placed.,0
His skin was dry and fissured.,0
He had jaundice down to the abdomen.,0
"He had generalized hypotonia but normal strength, suck, and grasp reflex.",0
He had a slightly increased space between the first and second toes.,0
He had simian crease on the left palm.,0
HOSPITAL COURSE BY SYSTEM: 1.,0
"CARDIOVASCULAR SYSTEM: The patient had a repeat chest x-, electrocardiogram, and four-extremity blood pressures performed in our Neonatal Intensive Care Unit.",0
The electrocardiogram showed a normal sinus rhythm with normal intervals and voltages.,0
The chest x- showed a heart that was on the upper limit of normal.,0
The pulmonary vasculature appeared normal.,0
His four-extremity blood pressures were all normal without a gradient.,0
He also had a echocardiogram performed that showed a normally structured heart.,0
RESPIRATORY SYSTEM: The patient had some mild opacity in the lung fields bilaterally.,0
"He briefly required supplemental oxygen by nasal cannula; however, this was weaned overnight, and this morning had transitioned to room air.",0
FLUIDS/ELECTROLYTES/NUTRITION: The patient was initially made n.p.o.,0
"They revealed sodium was 141, potassium was 4.4, chloride was 104, and bicarbonate was 24.",0
These were sent around noon on .,0
Intravenous fluids in the form of D-10-W with 2 mEq of sodium chloride and 1 mEq of potassium chloride per 100 cc were initiated at 80 cc/kg per day.,0
Dipsticks were monitored and remained within normal limits.,0
"On the day of discharge, intravenous fluids were discontinued since the patient was started on oral ad lib feeds of Enfamil-20 which he was taking in excess of 80 cc/kg per day.",0
GASTROINTESTINAL SYSTEM: The patient was tolerating enteral feeds without difficulty.,0
HEMATOLOGY SYSTEM: Bilirubin was sent at our hospital at noon on and was 9.6 for total bilirubin.,0
Single phototherapy was continued here.,0
INFECTIOUS DISEASE SYSTEM: The patient was continued on ampicillin and gentamicin.,0
"However, these were discontinued when we heard that the blood cultures at were sterile for 48 hours.",0
NEUROLOGY SYSTEM: Baseline hypotonia consistent with trisomy 21.,0
TRISOMY 21: A chromosomal analysis was undergoing at .,0
SOCIAL: The parents were updated via telephone.,0
CONDITION AT DISCHARGE: Condition on discharge was stable.,0
DISCHARGE DISPOSITION: Discharged to Special Care Nursery.,0
PRIMARY PEDIATRICIAN: Name of primary pediatrician is Dr. at Active Pediatrics.,0
His telephone number is .,0
Feeds: Feeds on discharge were Enfamil-20 orally ad lib.,0
Screens: State newborn screening status was still pending.,0
The patient received no immunizations thus far.,0
Probable trisomy 21; chromosomal analysis pending.,0
Transient tachypnea of the newborn.,0
Dictated By: MEDQUIST36 D: 12:13 T: 15:22 JOB#:,0
"10:41 AM CHEST (PORTABLE AP) Clip # Reason: please eval lung fields, sudden desaturation Admitting Diagnosis: ISCHEMIA ______________________________________________________________________________ MEDICAL CONDITION: 81 yo woman s/p AKA, mult med prob s/p SBR, acute desat REASON FOR THIS EXAMINATION: please eval lung fields, sudden desaturation ______________________________________________________________________________ FINAL REPORT INDICATION: Status post AKA, acute desaturation.",0
AP chest radiograph shows right sided central line in stable position.,0
Again seen are moderate bilateral pleural effusions as well as mild pulmonary edema that does not appear significantly changed from prior study.,0
"Left retrocardiac opacity is again seen consistent with atelectasis, effusion, and possibly consolidation.",0
IMPRESSION: No significant change from prior study.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: In brief this is a 76-year-old female who presented to Hospital on with acute anterolateral myocardial infarction.,1
"She was treated with nitrates, beta-blockade, aspirin which chemically reversed her symptoms but she started to complain of some recurrent anginal symptoms.",0
Her crit had decreased from 25 to 36 and they had no idea what the reason for her bleed was.,0
Other findings were for hypertension as well as ventricular activity.,0
"She did have a history of hypothyroidism, recurrent urinary tract infection, history of lower gastrointestinal bleeding while on Coumadin.",0
"Additional medications on transfer were intravenous Nitroglycerin, Heparin, Aspirin, Lipitor, Protonics, Captopril, Lopressor.",0
PHYSICAL EXAMINATION: No acute distress.,0
Heart: Tachy 1/6 systolic murmur at the base.,0
"Abdomen soft, nontender, nondistended, bowel sounds present.",0
Alert and oriented times three.,0
"Electrocardiogram on admission shows sinus rhythm at 70, normal axis, poor R-wave progression.",0
Additionally her lateral T-wave changes and inversions noted.,0
The patient was transferred for admission to the where on the EMED service she underwent a coronary artery catheterization that showed significant left main disease warranting a coronary artery bypass.,1
"Her in-hospital course prior to the operation was relatively unremarkable, EF revealing left main disease.",0
"The cardiac catheterization other than remaining elucidating left main disease also showing EF of 15% She was taken to the operating room on where she underwent coronary artery bypass graft times two, left internal mammary artery to left anterior descending, saphenous vein graft to OM2, right saphenous vein endoscopically harvested.",1
"Dr. left pericardium open, there was an arterial line as well as Swann-Ganz catheter, two ventricular leads, one atrial lead, one mediastinal, two left internal mammary artery, two mean arterial pressure 76, right atrial pressure 12.",0
Pulmonary artery diastolic pressures was 16 with a mean of 22 on Propofol for sedation.,0
"She was transferred to the Cardiac Surgical Recovery Unit, she did well, she was extubated on the night of surgery, she had 100.4 for T-max.",0
She started Lasix and Lopressor postop day four.,0
"Her Nipride was weaned off, her lactate was 1.3 and decreasing crit was 26.8, BUN and creatinine was 6.4.",0
"Her Swann-Ganz was removed, her chest tubes were discontinued.",0
"She was transferred to the floor by postop day one, she was working aggressively with physical therapy, she had no complaints.",0
"By postop day 3 she continued to progress however, she did have one episode of nonsustained V-tach times six beats followed by a second episode of 8 and 10 beat run of nonsustained V-tach.",0
Given her relatively normal EF of 50% and the fact she has not been on beta-blockade more than 24 hours at this point her electrolytes were optimized.,0
She was placed on Lopressor 12.5 mg b.i.d.,0
standing dose and she had no recurrence of her symptoms.,0
Foley catheter was removed on postop day three and she was out of bed with assistance and receiving physical therapy and rehabilitation.,0
"By the patient was without any complaints, temperature was 98.2 on exam.",0
"Pulse regular sinus, 140/47 blood pressure, 96% three liters.",0
Airway was recorded as being up however her in's and outs were negative throughout her postop course.,0
Her sternum was stable with no evidence of drainage.,0
She had decreased breath sounds at the basis and throughout.,0
"Right lower extremity was clean, dry and intact.",0
The hybrid insertion points were without cellulitis or drainage.,0
She was out of bed three times a day or q.i.d.,0
She was getting physical therapy.,0
Her lytes were repeated automatically.,0
"DISCHARGE LABS: Significant for crit of 25, BUN and creatinine of 11.5 and 4.",0
"Her chest x-ray showed no evidence of pneumothorax, status post tube removal.",0
She has bilateral pleural effusions.,0
By the patient was deemed stable and appropriate for discharge.,0
q AM time 7 days.,0
q day times 7 days.,0
At home she will receive VNA or she will go to rehabilitation.,0
While at rehabilitation or with VNA services she should receive aggressive physical therapy to anticipated goals preoperative level of functioning.,0
Additionally should have blood pressure monitoring and wound checks as needed.,0
She is instructed to not undergo heavy lifting greater than 10 pounds times 30 days.,0
No driving times 30 days.,0
She may shower with the wound open and water running over it.,0
"Instructions for follow-up include seeing Dr. four weeks, seeing her PCP or cardiologist in three weeks.",0
She can have a wound check if she is discharged from rehabilitation prior to 7 to 10 days either on the floor or if otherwise she is still in rehabilitation they can take care of that matter for her.,0
Left main disease requiring coronary artery bypass graft times two.,1
Left internal mammary artery to Left anterior descending and right saphenous vein graft to the oblique marginal.,0
Dictated By: MEDQUIST36 D: 17:29 T: 20:37 JOB#:,0
"12:26 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate placement of ogt ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with history of drug overdose, charcoal aspiration, intubated, now with ngt changed to ogt.",0
"REASON FOR THIS EXAMINATION: please evaluate placement of ogt ______________________________________________________________________________ FINAL REPORT HISTORY: 38 y/o woman with history of drug overdose, charcoal aspiration, intubated.",0
Please check for NGT placement.,0
"CHEST, PORTABLE: Comparison is made to a prior study from earlier the same day.",0
The lung apices are not depicted on this film.,0
The ETT is seen 1.7 cm from the carina.,0
The consolidation in the left lower lobe is improved.,0
There are no pleural effusions.,0
An NGT is identified with its tip in the stomach.,0
IMPRESSION: 1) Satisfactory position of the NGT.,0
The consolidation in the left lower lobe is somewhat improved.,0
"9:12 PM WRIST, AP & LAT VIEWS RIGHT Clip # Reason: Please evaluate wrist s/p reduction and splinting., Needs to ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with right distal radius fracture s/p fall REASON FOR THIS EXAMINATION: Please evaluate wrist s/p reduction and splinting.",1
Needs to be portable secondary to pt being in MICU with subdural hematoma and MI.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Status post reduction of right radial fracture.,0
"RIGHT WRIST, TWO VIEWS: There is a comminuted intra-articular fracture of the distal radius, with dorsal angulation of the distal radial articular surface.",1
Alignment in the coronal plane is overall anatomic.,0
"However, as noted, there is continued dorsal angulation of the distal surface.",0
The distal radial fracture is better appreciated on the current examination.,0
There is impaction of the more radial component with a non-displaced ulnar styloid fragment.,0
There is resultant ulnar minus variant.,0
IMPRESSION: Improved alignment in the coronal plane.,0
Residual dorsal angulation in the sagittal plane.,0
Admission Date: Discharge Date: Service: HISTORY OF PRESENT ILLNESS: The patient is a 78 year old male known to have a 6 cm abdominal aortic aneurysm who was worked up for surgical repair and had a positive echocardiogram on .,1
"He was transferred from to for coronary artery bypass graft of a 70 to 80% left main disease and three-vessel coronary artery disease with a totally occluded right coronary artery, two plus mitral regurgitation and an ejection fraction of 50%.",1
Questionable myocardial infarction in .,0
Inferior lateral myocardial infarction in .,0
Status percutaneous transluminal coronary angioplasty with two stents.,0
"In , he had a cerebrovascular accident.",0
Recent admission to a hospital for Gram positive pneumonia.,0
Methotrexate which was discontinued pending abdominal aortic aneurysm repair.,1
ALLERGIES: He has no known drug allergies.,0
SOCIAL HISTORY: He lives with family support.,0
"PHYSICAL EXAMINATION: Neurologically, he was alert and oriented.",0
He was regular rate and rhythm on admission.,0
"LABORATORY: CBC of 7.0, 35.4 and 203.",0
"His chemistry preoperatively was 140, 4.0, 107, 22, 24, 1.2 and 101.",0
"Preoperative arterial blood gas of 7.49, 30, 99, 23 and 99.",0
HOSPITAL COURSE: The patient was admitted to the Cardiac Intensive Care Unit where he was optimized for the operation.,0
"He was taken to the Operating Room on , for a coronary artery bypass graft times three by Dr. .",1
"Grafts were to the proximal anterior descending, distal ID and obtuse marginal.",0
"Postoperatively, he was transferred to the Intensive Care Unit and was doing well on .",0
"On , the patient was doing well after his extubation.",0
"During his Intensive Care Unit stay, the patient was not on any drips and he was hemodynamically stable.",0
He was transferred to the Floor on .,0
The patient continued to do well on .,0
"His wires and chest tubes were discontinued without incident as well as his Foley catheter and on postoperative day number four, he was deemed ready for rehabilitation as of .",0
Physical Therapy evaluations concurred that he requires some rehabilitation therapy.,0
"Physical examination upon discharge shows no jugular venous distention, no discharge from his sternal wound.",0
His leg wound was non-erythematous and no discharge from the vein harvest site.,0
The patient is going out on: DISCHARGE MEDICATIONS: 1.,0
12 hours for a week.,0
Potassium chloride 20 mEq p.o.,0
12 hours while on the Lasix.,0
Docusate sodium 100 mg p.o.,0
Percocet tablets one to two q. four hours p.r.n.,0
Albuterol nebulizers q. four hours p.r.n.,0
The patient is doing well upon discharge.,0
Dictated By: MEDQUIST36 D: 21:06 T: 09:32 JOB#:,0
", M. MED 5:20 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with serous ca stage III with new pleural effusion on left.",1
REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ PFI REPORT Interval appearance right pleural and possible pericardial effusions.,1
3:01 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: assess PTX s/p R tube thoracostomy Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with PTX after TBBx REASON FOR THIS EXAMINATION: assess PTX s/p R tube thoracostomy ______________________________________________________________________________ FINAL REPORT HISTORY: PTX post thoracoscopy.,0
This is the third chest radiograph done with interval placement of left chest tube since study two hours earlier.,0
There is an equivocal small residual right apical PTX.,0
The consolidation in the right upper lobe has improved which may relate in part to reexpansion.,0
There is an ill-defined process in the left lower lobe behind the heart consistent with atelectasis or possibly pneumonia.,0
The heart is enlarged with previous CABG and satisfactorily positioned ICD device.,0
Skin staples overlie right axilla.,0
IMPRESSION: Placement right chest tube with diminution in right PTX.,0
3:26 AM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade.,0
Admitting Diagnosis: AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with AS/AI/CAD s/p AVR/CABG REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade.,0
______________________________________________________________________________ FINAL REPORT INDICATION: status-post aortic valve repair and CABG.,1
Portable AP view of the chest dated is compared with the same examination from .,0
The patient is status post median sternotomy.,0
The endotracheal tube is in satisfactory position.,0
The NG tube is coiled in the stomach.,0
"3 chest tubes are present, 1 terminating on the left, one terminating on the right, and one terminating over the mid sternum.",0
There is a right internal jugular Swan-Ganz catheter terminating in the right main pulmonary artery.,0
Again noted is marked cardiomegaly.,0
"The congestive heart failure has markedly improved, but residual interstitial and alveolar opacities particularly in the upper lung lobes remain.",1
There is a small apical pneumothorax seen on this recumbent exam.,0
There is minimal left lower lobe subsegmental atelectasis.,0
"The lucency seen along the left heart border is most likely minimal pneumomediastinum, which would be normal in this postoperative state.",0
IMPRESSION: Aortic valve replacement and CABG.,1
Small apical pneumothorax seen on the recumbent examination.,0
Marked improvement in congestive heart failure.,1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: lisinopril Attending: Chief Complaint: Substernal chest pain and throat tightness with exertion Major Surgical or Invasive Procedure: 1.,0
"Off pump coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, and obtuse marginal arteries.",1
Endoscopic harvesting of the long saphenous vein.,0
History of Present Illness: This is a 57-year-old patient with extensive coronary artery disease history with previous stenting presented again with symptoms and was investigated and found to have a significant lesion in the left anterior descending artery diagonal and the obtuse marginal arteries.,1
Left ventricular function is well preserved and she was electively admitted for off pump coronary artery bypass grafting.,1
"Past Medical History: Coronary artery disease(s/p MI ), BMS to proximal LAD , DES to mid LAD , DES to edge ISR of mid LAD DES and stenosis distal to stent , DES to OM1, ).",1
"diastolic congestive heart failure Hypertension Dyslipidemia Morbid obesity COPD GERD Rt rotator cuff injury/bursitis(outpt PT-2x/wk, Migraines, Depression/Anxiety DJD Hemorrhoids Rosacea Left foot tendion repair Social History: Lives in with her grandchildren.",1
She quit smoking 11 years ago.,0
She does not drink or use drugs.,0
Family History: She was a of the state and does not know her family.,1
"Physical Exam: Physical Exam Pulse: 86 Resp:20 O2 sat:98% B/P Right: 132/68 Left: Height: 5'2 Weight:210 General: AAOx3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x]non-distended [x]non-tender [x]bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT :+2 Left:+2 Radial Right:cath site Left:+2 Carotid Bruit: None Pertinent Results: Echocargiogram LEFT ATRIUM: Normal LA size.",0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.,0
A catheter or pacing wire is seen in the RA and extending into the RV.,0
Left-to-right shunt across the interatrial septum at rest.,0
LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images.,0
"AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.",0
Simple atheroma in ascending aorta.,0
Simple atheroma in descending aorta.,0
AORTIC VALVE: Normal aortic valve leaflets (3).,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.,1
Conclusions Pre operative: The left atrium is normal in size.,0
There is a small PFO with a left-to-right shunt across the interatrial septum.,0
Overall left ventricular systolic function is normal (LVEF>55%).,0
"The diameters of aorta at the sinus, ascending and arch levels are normal.",0
There are simple atheroma in the ascending aorta.,0
There are simple atheroma in the descending thoracic aorta.,0
The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation.,0
Chest X-Ray ; There is mild-to-moderate cardiomegaly.,0
Bilateral pleural effusions are small.,0
"Aside from atelectasis in the left lower lobe, the lungs are grossly clear.",0
Almost complete resolution of atelectasis in the left upper lobe.,0
A small air-fluid level in the retrosternal region suggests the presence of a tiny pneumothorax and small effusion.,0
These are most likely located in the left side.,0
"06:05AM BLOOD WBC-11.7* RBC-3.06* Hgb-10.4* Hct-30.5* MCV-100* MCH-33.9* MCHC-34.0 RDW-13.5 Plt Ct-253 06:15AM BLOOD WBC-11.1* RBC-3.23* Hgb-11.1* Hct-32.1* MCV-99* MCH-34.4* MCHC-34.6 RDW-13.3 Plt Ct-230 08:20AM BLOOD WBC-14.0* RBC-3.26* Hgb-10.8* Hct-32.3* MCV-99* MCH-33.2* MCHC-33.4 RDW-13.3 Plt Ct-192 06:05AM BLOOD Na-137 K-4.1 Cl-97 06:15AM BLOOD Glucose-161* UreaN-19 Creat-1.1 Na-136 K-4.0 Cl-97 HCO3-29 AnGap-14 08:00AM BLOOD Glucose-230* UreaN-14 Creat-0.9 Na-136 K-4.1 Cl-98 HCO3-26 AnGap-16 08:20AM BLOOD Glucose-238* UreaN-16 Creat-1.0 Na-134 K-4.6 Cl-100 HCO3-22 AnGap-17 04:00AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-136 K-4.7 Cl-106 HCO3-23 AnGap-12 Brief Hospital Course: The patient was brought to the Operating Room on where the patient underwent Off pump coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, and obtuse marginal arteries.",1
Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring.,0
She required Nitroglycerin for hypertension her first night post op but was transitioned to oral betablocker and diuretics.,0
"POD 1 found the patient extubated, alert and oriented and breathing comfortably.",0
The patient was neurologically intact and hemodynamically stable.,0
The patient was transferred to the telemetry floor for further recovery.,0
Chest tubes and pacing wires were discontinued without complication.,0
She was started on plavix due to being done off pump and will it need to be continued for six months.,0
Blood sugars were closely monitored and she was restarted on her home regime which have slowly improved.,0
The patient was evaluated by the physical therapy service for assistance with strength and mobility.,0
"By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics.",0
The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions.,0
Medications on Admission: Preadmission medications listed are correct and complete.,0
Information was obtained from webOMR.,0
Atorvastatin 40 mg PO DAILY 2.,0
Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 3.,0
Benzonatate 100 mg PO TID:PRN tos 4.,0
Clopidogrel 75 mg PO DAILY 5.,0
Fluticasone Propionate 110mcg 2 PUFF IH 6.,0
Glargine 80 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7.,0
Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 8.,0
Metoprolol Succinate XL 100 mg PO DAILY 9.,0
Metronidazole Gel 0.75%-Vaginal 1 Appl VG HS 10.,0
Naproxen 500 mg PO Q8H:PRN pain 11.,0
Nitroglycerin SL 0.4 mg SL PRN cp 12.,0
Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 13.,0
Pantoprazole 40 mg PO Q12H 14.,0
Ropinirole 0.25 mg PO QPM 15.,0
Valsartan 80 mg PO DAILY 16.,0
Aspirin 325 mg PO DAILY 17.,0
Vitamin D 400 UNIT PO DAILY Discharge Medications: 1.,0
Aspirin EC 81 mg PO DAILY 2.,0
Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3.,0
Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*1 4.,0
Fluticasone Propionate 110mcg 2 PUFF IH RX *fluticasone [Flovent HFA] 220 mcg 2 puffs twice a day Disp #*1 Inhaler Refills:*0 5.,0
Glargine 50 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6.,0
Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 7.,0
Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8.,0
Ropinirole 0.25 mg PO QPM 9.,0
Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 10.,0
Ibuprofen 600 mg PO Q6H:PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 11.,0
Metoprolol Tartrate 25 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider.,0
*metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 12.,0
Potassium Chloride 20 mEq PO DAILY RX *potassium chloride 20 mEq 1 tablet by mouth daily Disp #*7 Tablet Refills:*0 13.,0
Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing RX *albuterol 2 puffs PRN Q 4 hrs Disp #*1 Inhaler Refills:*0 14.,0
"Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: All Care VNA of Greater Discharge Diagnosis: Coronary artery disease(s/p MI ), BMS to proximal LAD , DES to mid LAD , DES to edge ISR of mid LAD DES and stenosis distal to stent , DES to OM1, ).",1
"Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office on at 10:45a Surgeon Dr. on at 2:15p Cardiologist: Fish at 2:20pm ( office) Please call to schedule the following: Primary Care Dr in weeks **Please call cardiac surgery office with any questions or concerns .",0
Answering service will contact on call person during off hours** MD Completed by:,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: evaluate doboff position Admitting Diagnosis: MENTAL STATUS CHANGES ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with atelectasis/PNA/CHF.,0
REASON FOR THIS EXAMINATION: evaluate doboff position ______________________________________________________________________________ FINAL REPORT AP SUPINE PORTABLE CHEST X-RAY INDICATION: Evaluate Dobbhoff position.,0
COMPARISONS: at 07:51 a.m. An endotracheal tube is positioned approximately 8 cm superior to the carina.,0
A Dobbhoff is seen within the distal esophagus just above the GE junction.,0
A linear band of atelectasis remains in the minor fissure.,0
"Otherwise, the lungs are grossly clear and there is no significant change compared to the film from earlier in the day.",0
IMPRESSION: Dobbhoff positioned within the distal esophagus.,0
"10:38 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for interval changes Admitting Diagnosis: HYPONATREMIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman transferred to ICU for PNA, fluid overload REASON FOR THIS EXAMINATION: Please evaluate for interval changes ______________________________________________________________________________ FINAL REPORT FOLLOWUP EXAMINATION.",0
The left CVL and NGT remain in place.,0
"Less prominent and better defined pulmonary vasculature is noted, suggesting some improvement in fluid status.",0
There are no new consolidations.,0
10:50 PM CHEST (SINGLE VIEW) Clip # Reason: ?PNA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with fever 104.8 rectally and lethargy REASON FOR THIS EXAMINATION: ?PNA ______________________________________________________________________________ FINAL REPORT HISTORY: 51-year-old man with fever of 104.8.,0
COMPARISON: Multiple prior chest radiograph with the latest on .,0
SINGLE SUPINE FRONTAL CHEST RADIOGRAPH: There are no new focal airspace consolidations.,0
The punctate nodular dense opacity seen in the right lateral lung and left mid lung are unchanged.,0
There is no pneumothorax or pleural effusions.,0
There are no airspace consolidations.,0
"The cardiomediastinal silhouette, hilar contour, and pulmonary vasculature are grossly unremarkable.",0
The patient is status post anterior spinal fusion.,0
IMPRESSION: No acute cardiopulmonary process.,0
Height: (in) 60 Weight (lb): 140 BSA (m2): 1.61 m2 BP (mm Hg): 101/44 HR (bpm): 71 Status: Inpatient Date/Time: at 15:31 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.,0
No ASD by 2D or color Doppler.,0
RIGHT VENTRICLE: Normal RV systolic function.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. .,0
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
Mild to moderate [+] TR.,0
PULMONIC VALVE/PULMONARY ARTERY: No PS.,0
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.,0
Conclusions: The left atrium is mildly dilated.,0
No atrial septal defect is seen by 2D or color Doppler.,0
There is no ventricular septal defect.,0
RV with normal free wall contractility.,0
The tricuspid valve leaflets are mildly thickened.,0
There is a trivial/physiologic pericardial effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Ventricular tachycardia Major Surgical or Invasive Procedure: VT-ablation Arterial line placement and removal History of Present Illness: 73 yo M with nonischemic cardiomyopathy, ventricular tachycardia s/p VT ablation and AICD, who was admitted to Hospital for multiple AICD shocks on , now transferred for repeat VT-ablation.",1
"At Hospital, he was started on amiodarone and lidocaine drip, which decreased his heart rate.",0
"He then underwent a right-sided catheterization, which showed muliple vessel disease and had PCI to the LAD/LCx.",0
"This morning, patient again went into sustained monomorphic ventricular tachycardia.",1
He was thus transferred to for repeat VT-ablation.,0
"Patient reports that when he has VT, he experiences palpitations, diaphoresis, and weakness.",0
"Recently, he had these symptoms at the end of and was hospitalized at Hospital from - 11/31, when he was treated with potassium and plan was to consider upgrading his ICD to biventricular pacing.",0
He was discharged home and then had repeated symptoms on .,0
"Of note, patient had his ICD placed approximately 8 years ago, but had recurrent VTs.",0
He underwent VT ablation by Dr. in but continued to have VTs.,0
"He was then succesfully medically managed with amiodarone for 3 years, but had to stop due to hepatic toxicity.",0
"Since then, he has been shocked ""more than 50 times"", including one episode where he had an induced ICD firing, presumably for slow VT. .",0
"On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",0
"He denies recent fevers, chills or rigors.",0
All of the other review of systems were negative.,0
"Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, or syncope.",1
"CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2.",1
CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: with 3 stents placed to LAD and LCx.,1
"- PACING/ICD: VT storm s/p AICD and ablation in - Cardiomyopathy, EF 20% - Myocardial infarction in 3.",1
OTHER PAST MEDICAL HISTORY: - COPD - Hypothyroidism - Abdominal aortic aneurysm repair with stent - Eczema - Multiple hemorrhoidectomies Social History: Patient lives alone.,1
"He is independent for all ADLs, continues to drive.",0
"- Tobacco history: ~75 pack year history, quit 7 years ago - ETOH: Occasional beer but used to drink heavily.",1
"- Illicit drugs: None Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.",1
- Extensive history of cancers.,0
Physical Exam: Physical exam on discharge: VS: <<<<<<<<<< >>>>>>>>> GENERAL: NAD.,0
"Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.",0
"NECK: Supple with JVP of 6 cm CARDIAC: PMI located in 5th intercostal space, midclavicular line.",0
"Soft heart sounds, RR, normal S1, S2.",0
"LUNGS: No chest wall deformities, scoliosis or kyphosis.",0
"Resp were unlabored, no accessory muscle use.",0
"CTAB, no crackles, wheezes or rhonchi.",0
"Right post-cath side no hematoma, no bruits.",0
SKIN: eczematous changes in finger nails and elbows PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: 1.,0
Labs on admission: 01:13AM BLOOD WBC-8.6 RBC-4.06* Hgb-12.3* Hct-35.5* MCV-88 MCH-30.2 MCHC-34.6 RDW-13.5 Plt Ct-262 01:13AM BLOOD PT-12.6 PTT-26.3 INR(PT)-1.1 01:13AM BLOOD Glucose-104* UreaN-23* Creat-0.9 Na-135 K-4.2 Cl-101 HCO3-23 AnGap-15 01:13AM BLOOD ALT-12 AST-22 LD(LDH)-224 AlkPhos-98 TotBili-0.5 01:13AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.3 Mg-2.1 01:13AM BLOOD TSH-0.11* 01:13AM BLOOD Free T4-1.4 .,0
Labs on discharge: <<<<<<<<<<<< >>>>>>>>>> .,0
Imaging/diagnostics: - Echocardiogram (): The left atrium is mildly dilated.,0
There is moderate to severe regional left ventricular systolic dysfunction with near-akinesis of the distal of the left ventricle and global hypokinesis in the remaining segments.,1
A left ventricular mass/thrombus cannot be excluded.,0
Trace aortic regurgitation is seen.,0
Mild (1+) mitral regurgitation is seen.,0
IMPRESSION: Dilated left ventricular cardiomyopathy with near-akinesis of the distal of the left ventricle and global hypokinesis in the remaining segments.,0
"- CXR (): Heart is moderately enlarged, but there is no pulmonary edema or even vascular congestion and the hila are normal size.",0
No pleural effusion or evidence of central adenopathy.,0
Transvenous right atrial pacer lead follows the expected course.,0
A transvenous right ventricular pacer defibrillator lead ends closer to the midline than we generally see but cannot be more carefully localized without a lateral view.,1
- CXR (): ICD leads remain in standard position.,0
Lungs and pleural surfaces are clear.,0
"Brief Hospital Course: 73 yo M with recurrent ventricular tachycardia despite ablation and AICD, cardiomyopathy, CAD s/p PCI, COPD, hypothyroidism, treated with dofetilide and repeat VT-ablation.",1
# Ventricular tachycardia: Pt admitted for initiation of dofetilide ggt which was maintained for 3 days eventually being decreased to 250mcg q12h.,1
"However, on HOD 2 he developed VT into the 140s, with sBP in the 110s-120s.",0
"Received lidocaine bolus, placed on gtt, and ativan.",0
Broke after 5 minutes and did not require firing of ICD.,0
He subsequently went for ventricular substrate ablation the following day (see report).,0
After the procedure his antiarrhythmic therapy was changed to mexilitine 150mg q8h and quinidine was started at 324mg TID.,0
"Of note When arterial sheath was being pulled, he became transiently hypotensive to 60s, got 1 amp of atropine and recovered.",0
"He remained hemodynamically stable for the remainder of admission, but was noted to have occasional runs of 20-40 beats of vtach during which he remained asymptomatic.",0
He was discharged on mexilitine 150 TID and quinidine 324mg TID.,0
# Fever: Febrile to 102 on admission.,0
"Influenza swabs sent, came back positive.",0
Patient remianed on droplet precautions.,0
He remained afebrile throughout admission.,0
"# Cardiomyopathy: Repeat echocardiogram here confirmed EF of 25-30%, with severe regional left ventricular systolic dysfunction, near-akinesis of distal of the LV and global hypokinesis.",1
He diuresed well and remained euvolemic on home dose 20 mg PO Lasix.,0
"# CAD s/p stent: History of MI in with anteriolateral distribution on EKG, consistent with catheterization finding of LAD, LCX stenosis.",0
Patient has been asymptomatic and cardiac enzymes at OSH were not elevated.,0
Underwent uncomplicated catheterization with three stents placed in the LAD and LCX.,0
Discharged on aspirin and plavix.,0
# Hypothyroid: TSH low at 0.11 (0.14 at OSH) and T4 appropriate at 1.4.,0
Just started on new lower dose of levothyroxine 50 mcg three days ago so do not expect TSH to change dramatically.,0
# HTN: Currently normotensive on Carvedilol and Losartan.,0
Increased carvedilol to 6.25 .,0
# HLD: Lipid panel at OSH showed good control on home medication of Cholestipol.,0
Held during admission as was non-formulary.,0
To be continued at discharge.,0
Medications on Admission: -Synthroid 88mcg qd -Carvedilol 3.125 mg -Aspirin 325 mg qd -Losartan 25 mg qd -MAgnesium oxide 400mg -Klonopin 1.0 mg qd -Colestipol 1 mg -Lasix 20 mg po daily -Vitamin D Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Tablet(s) 2. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).,0
5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Disp:*60 Tablet(s)* Refills:*2* 6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day.,0
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*60 Tablet(s)* Refills:*2* 9. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours).,0
Disp:*90 Capsule(s)* Refills:*2* 10. quinidine gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours).,0
Disp:*90 Tablet Sustained Release(s)* Refills:*2* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
12. cholestipol Sig: One (1) tab once a day.,0
Outpatient Lab Work Check Chem-10 for .,0
Please fax results to: Dr. : Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular Arrythmia Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent.,1
Level of Consciousness: Alert and interactive.,0
Activity Status: Ambulatory - Independent.,0
Discharge Instructions: You were seen in the hospital because of a persistent fast rhythm called ventricular tachycardia and because your ICD went off multiple times.,1
You had a procedure called an ablation and the settings on your ICD/pacemaker were adjusted.,0
You also had new stents placed in the arteries supplying blood to your heart.,0
"Because of this, YOU NEED TO TAKE PLAVIX EVERY DAY.",0
DO NOT STOP PLAVIX FOR ANY REASON UNTIL YOU SPEAK WITH YOUR CARDIOLOGIST FIRST.,0
We made the following changes to your medications: STARTED Plavix 75 mg once a day STARTED Quinidine 324 mg 3 times a day STARTED Mexiletine 150 mg three times a day INCREASED Carvedilol to 6.25 mg Please note your follow up appointments below with Dr. and Dr. .,0
We have also include a prescription for bloodwork to be done with the results to be faxed to Dr. .,0
It was a pleasure taking care you during your hospital stay.,0
Followup Instructions: Please make an appointment to see your PCP in the next weeks.,0
"Cardiology appointment with Dr. at 2:15 PM , , RI ( Department: CARDIAC SERVICES When: FRIDAY at 1 PM With: , M.D.",0
Building: SC Clinical Ctr Campus: EAST Best Parking: Garage,0
9:48 AM CHEST (PORTABLE AP) Clip # Reason: change from previous Admitting Diagnosis: PULMONARY EMBULUS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with b/l pulmonary embolism REASON FOR THIS EXAMINATION: change from previous ______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old man with bilateral pulmonary embolism.,1
TECHNIQUE: Portable AP chest radiograph.,0
The comparison is made with the previous chest radiograph dated .,0
FINDINGS: The heart is normal in size.,0
"Again note is made of bilateral prominent pulmonary arteries, which are unchanged compared with the previous study.",0
There is no evidence of parenchymal consolidation or effusion.,0
IMPRESSION: Prominent bilateral pulmonary arteries.,0
9:20 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\THORACOSCOPIC CORONARY ARTERY BYPASS GRAFT VIA MINI THORACOTOMY /SDA ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with s/p cabg REASON FOR THIS EXAMINATION: ?,1
"ptx ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST INDICATION: 34-year-old with CABG, question pneumothorax.",0
"This is compared with prior from , there is a small pneumothorax still seen at the left apex, decreased since the prior study with minimal basal componebt.",0
There is minimal change in bibasilar atelectasis.,0
There is a small pleural effusion on the left.,0
IMPRESSION: Minimal improvement in small left apical pneumothorax.,0
Persistent bibasilar atelectasis with small left pleural effusion.,0
"8:55 PM CHEST (PORTABLE AP) Clip # Reason: fluid overload/infilt Admitting Diagnosis: CENTERAL AIRWAY OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with Med LAD SP stent placements REASON FOR THIS EXAMINATION: fluid overload/infilt ______________________________________________________________________________ FINAL REPORT AP CHEST AT 09:05 P.M. , HISTORY: LAD stent placements.",0
IMPRESSION: AP chest compared to at 9:00 a.m. A left main bronchial stent extends from the carina roughly to the origin of the left upper lobe bronchus.,0
Pulmonary vascular congestion and borderline interstitial edema are new.,0
There is no pneumothorax or pleural effusion.,0
Enlargement of the right hilus is probably due to overlying asscending aorta and distortion due to oblique positioning.,0
No pneumothorax or pleural effusion.,0
"3:11 PM CT HEAD W/O CONTRAST Clip # Reason: 52 year old man with ICH secondary to a L frontal AVM, hydro Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with ICH secondary to a L frontal AVM, hydro, s/p shunt.",0
"REASON FOR THIS EXAMINATION: 52 year old man with ICH secondary to a L frontal AVM, hydro, s/p shunt.",0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc TUE 7:39 PM No evidence of hydrocephalus.,0
Right intraventricular shunt in place.,0
Newly noted subcutaneous emphysema lying along the course of the ventricular shunt in the subcutaneous tissues.,1
New prominence in the left frontal lobe suggestive of CSF or blood.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 52-year-old male with intracranial hemorrhage secondary to left frontal AVM and hydronephrosis status post intraventricular shunt.,1
Please evaluate for shunt malfunction and hydronephrosis.,0
COMPARISONS: Comparison is to non-contrast head CTs from dating back to .,0
TECHNIQUE: Continuous axial non-contrast images of the brain were obtained.,0
FINDINGS: There is again noted to be a 2.2 cm x 3.9 cm left frontal parenchymal hematoma that demonstrates slight interval decrease in size from previous examination from .,0
There is noted to be slight mass effect of this intraparenchymal hematoma with effacement of the left ventricular frontal .,0
There are again noted areas of pneumocephalus that are largely unchanged in both size and appearance from previous examinations.,0
There is an intraventricular catheter in place in coursing through to the third ventricle.,0
There is no evidence of hydrocephalus with the ventricles appearing similar in size from previous study from .,0
There is noted to be a more prominent area of hyperdensity within the region of the left frontal lobe that may represent blood products.,0
"There is subcutaneous emphysema that lies in the course of the shunt tract, which is new from previous exam.",1
The patient is status post left pterional craniotomy.,0
Unchanged left temporal extra-axial hematoma.,0
There is a 5-mm rightward shift of the normally midline structures that is unchanged.,0
There is again noted to be mild mass effect on the left uncus.,0
Stable appearance of the ventricular system with no evidence of interval increase in ventricular size.,0
New subcutaneous emphysema that tracks along the course of the ventricular shunt tract in the subcutaneous tissues.,1
"(Over) 3:11 PM CT HEAD W/O CONTRAST Clip # Reason: 52 year old man with ICH secondary to a L frontal AVM, hydro Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont)",0
"8:04 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate pulmonary processes, post-extubation Admitting Diagnosis: PNEUMONIA;COPD EXAC ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with respiratory failure, extubated today REASON FOR THIS EXAMINATION: Please evaluate pulmonary processes, post-extubation ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Respiratory failure, after extubation.",1
Portable AP chest radiograph was compared to .,0
The patient was extubated in the meantime interval with removal of the NG tube.,0
There is worsening of the left lower lobe opacity which has a triangular shape accompanied by mediastinal shift and is most likely consistent with left lower lobe complete atelectasis accompanied by pleural effusion.,0
Small amount of right pleural effusion is most likely unchanged.,0
Upper lungs are essentially clear and the cardiomediastinal silhouette is unremarkable as much as it can be assessed.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: Cardiac Surgery ADDENDUM: CARDIAC CATHETERIZATION DATA: Catheterization showed an ejection fraction of 55%, 90% ostial left main lesion, 90% ostial left anterior descending artery lesion, 90% proximal left circumflex lesion, 95% right coronary artery lesion, saphenous vein graft to obtuse marginal with an 80% ostial lesion, saphenous vein graft to right coronary artery with a totally occluded saphenous vein graft to left anterior descending artery with a 99% ostial lesion, 1+ mitral regurgitation, and mild global hypokinesis.",1
The patient was referred to Cardiac Surgery for redo coronary artery bypass graft.,1
"The patient was taken to the operating room with Dr. on for a redo coronary artery bypass graft times three with a vein patch to the proximal left anterior descending artery graft, a vein patch to the proximal obtuse marginal graft, and a saphenous vein graft to right coronary artery.",1
Please see the Operative Note for further details.,0
The patient was transferred to the Intensive Care Unit on a dobutamine infusion to maintain adequate cardiac output.,0
The patient required a moderate amount of volume resuscitation for blood pressure and cardiac output.,0
The patient was weaned and extubated from mechanical ventilation on her first postoperative night.,0
The patient had no significant chest tube output.,0
"On postoperative day one, a chest x-ray was obtained which showed a moderate-to-large left-sided pleural effusion.",0
A left-sided chest tube was placed with approximately 300 cc of drainage.,0
The patient tolerated this procedure well with no complications.,0
"On postoperative day two, the patient was noted to have a rising blood urea nitrogen and creatinine and was not responding to diuretics challenges.",0
A Renal consultation was obtained who recommended continued diuretic challenge as they felt that the patient was volume overloaded.,0
"The patient was started on a Lasix infusion which she began to respond to, and the patient's creatinine decreased over the next couple of days back down to her baseline of 1.1 by postoperative day four.",0
"On postoperative day three, the patient was noted to have lateral ST changes on electrocardiogram.",0
It was decided that with the patient's history of early graft occlusion that the patient should go to the cardiac catheterization laboratory for angiography of her grafts.,0
This showed that all of the vein grafts were patent without any flow-limiting stenosis.,0
The patient tolerated this well.,0
The patient continued to diurese and remained in the Intensive Care Unit.,0
She required aggressive pulmonary toilet and had mild hypoxia.,0
"On postoperative day six, the patient had sufficient diuresis, and oxygen requirements had weaned down to nasal cannula.",0
The patient was deemed stable for transfer out of the Intensive Care Unit to the regular floor.,0
"On postoperative day seven, the patient's pacing wires were removed without incident.",0
"On postoperative day eight, the patient was cleared for discharge to rehabilitation.",0
"PHYSICAL EXAMINATION ON DISCHARGE: Temperature maximum was 97, heart rate was 105 (sinus tachycardia), blood pressure was 145/75, respiratory rate was 18, and oxygen saturation was 95% on 3 liters nasal cannula.",0
The patient's weight today was 94 kilograms.,0
The patient weighed 90 kilograms preoperatively.,0
"The patient was alert, awake, and oriented times three.",0
Heart was regular in rate and rhythm.,0
The lungs were clear to auscultation anteriorly/posteriorly with scattered rhonchi at the bases.,0
Lower extremities revealed 2+ pitting edema.,0
"Sternal incision was clean and dry, and Steri-Strips were intact.",0
The left lower extremity vein harvest site revealed Steri-Strips were intact.,0
The very distal portion of the vein harvest site had mild erythema.,0
"PERTINENT LABORATORY DATA ON DISCHARGE: White blood cell count was 10.1, hematocrit was 32.7, and platelet count was 254.",0
"Sodium was 140, potassium was 3.4, chloride was 100, bicarbonate was 34, blood urea nitrogen was 26, creatinine was 1, and blood glucose was 73.",0
PERTINENT RADIOLOGY/IMAGING: A chest x-ray from showed mild pulmonary edema.,0
Elevated left hemidiaphragm; which was consistent with preoperative chest x-ray.,0
Status post redo coronary artery bypass graft.,1
Postoperative electrocardiogram changes with postoperative cardiac catheterization.,0
Lasix 20 mg by mouth twice per day.,0
Colace 100 mg by mouth twice per day.,0
Aspirin 325 mg by mouth once per day.,0
Protonix 40 mg by mouth once per day.,0
Percocet 5/325 one to two tablets by mouth q.4-6h.,0
Norvasc 2.5 mg by mouth once per day.,0
Synthroid 75 mcg by mouth every day.,0
Lipitor 40 mg by mouth once per day.,0
Plavix 75 mg by mouth every day.,0
Lopressor 100 mg by mouth twice per day.,0
Losartan 25 mg by mouth once per day.,0
NPH insulin 20 units subcutaneously q.a.m.,0
and 10 units subcutaneously q.p.m.,0
Regular insulin 6 units subcutaneously q.a.m.,0
and 6 units subcutaneously q.p.m.,0
"Insulin sliding-scale; for a blood sugar of 120 to 140 give 2 units subcutaneously, for a blood sugar of 141 to 160 give 3 units subcutaneously, for a blood sugar of 161 to 180 give 4 units subcutaneously, for a blood sugar of 181 to 200 give 5 units subcutaneously, for a blood sugar of 201 to 220 give 6 units subcutaneously, for a blood sugar of 221 to 240 give 7 units subcutaneously, for a blood sugar of 241 to 260 give 8 units subcutaneously, for a blood sugar of 261 to 280 give 9 units subcutaneously, for a blood sugar of 281 to 300 give 10 units subcutaneously, for a blood sugar of greater than 300 give 12 units subcutaneously.",0
DISCHARGE STATUS: The patient was to be discharged to rehabilitation.,0
The patient was to follow up with Dr. in four weeks.,0
The patient was to follow up with Dr. in two weeks.,0
The patient should be scheduled for a repeat cardiac catheterization in four weeks.,0
Dictated By: MEDQUIST36 D: 11:16 T: 11:19 JOB#:,0
"2:27 AM BABYGRAM AP ABD ONLY Clip # Reason: blood streaked stool, assess abd Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with REASON FOR THIS EXAMINATION: blood streaked stool, assess abd ______________________________________________________________________________ FINAL REPORT ABDOMINAL FILM HISTORY: Blood streaked stool.",1
FINDINGS: Frontal view of the abdomen shows a normal bowel gas pattern.,0
The esophagoenteric catheter reaches the stomach.,0
The bony structures are normal.,0
IMPRESSION: Normal supine view of the abdomen.,0
"2:22 PM BILAT LOWER EXT VEINS Clip # Reason: HYPOXIA ,EVAL DVT Admitting Diagnosis: OBSTRUCTIVE PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man w/ alport's s/p renal transplant a/w post-obstructive PNA and now new dx lung adenoca with hemoptysis, tachycardia, intermittent hypoxia, concern for PE REASON FOR THIS EXAMINATION: r/o dvt ______________________________________________________________________________ WET READ: LLTc SUN 3:06 PM No dvt ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia, concern for PE.",1
TECHNIQUE: Ultrasonography of the lower extremities.,0
"FINDINGS: -scale and color Doppler ultrasonography of the bilateral lower extremities demonstrate normal compressibility, flow, and augmentation of the bilateral common femoral, superficial femoral, and popliteal veins.",0
Patent flow of the bilateral peroneal and posterior tibial veins are also demonstrated.,0
IMPRESSION: No evidence of DVT.,0
10:37 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: pneumothorax Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p whipple with central line-induced pneumothorax s/p L sided chest tube insertion REASON FOR THIS EXAMINATION: pneumothorax ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Followup pneumothorax.,0
Comparison is made to prior study performed four hours earlier.,0
There has been almost resolution of left pneumothorax after placement of a pig-tail catheter.,0
There is atelectasis in the left lower lobe.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: OMED CHIEF COMPLAINT: Fatigue.,0
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male with history of metastatic melanoma with brain metastases who presents with a complaint of fatigue for several days.,0
The patient had a complete response to IL-2- temozolomide based bio-chemotherapy the forth cycle of which caused pancreatitis.,0
He also had pancreatitis on IL-2 and IL-12 therapy.,0
"He recently developed brain metastases and has undergone whole brain XRT, Decadron and was also started on an six weeks course of temozolomide finished on .",0
"Mr. has been seen in the Clinic on , where he complained of fatigue, dysuria and frequency.",0
and patient was started on a five day course of ciprofloxacin for presumptive urinary tract infection.,1
One day after having been seen in the Clinic the patient reported a dramatic increase in sense of fatigue and lack of energy.,0
States he has been inactive since then with decreased p.o.,0
"Denies any fever, chills, nausea, vomiting, abdominal pain, cough, sputum production, flank pain or skin rash but notes persistent dysuria and polyuria.",0
Notes mild abdominal distention but denies any pain and has had regular bowel movements and flatus.,0
Currently notes nausea times one hour prior to admission.,0
In the Emergency Department blood pressure was found to be 81/48 with a heart rate of 78.,0
Blood pressure remained in the high 80's systolic despite three liters of normal saline with no change in the urine output so dopamine was started via peripheral IV with blood pressure climbing to the 95-100 range systolic.,0
PAST MEDICAL HISTORY: Significant for: 1.,0
"Malignant melanoma diagnosed in with metastases to lung and brain status post bio-chemotherapy treatment, status post resection of lung recurrence in the right lower lobe status post IL-2, IL-12, s/p Gleevec trial with observed progression of disease, status post whole brain XRT on Decadron, currently with week six of eight of temozolomide.",1
"MEDICATIONS ON ADMISSION: Atenolol, Decadron, Protonix, ciprofloxacin, Ativan.",0
SOCIAL HISTORY: No alcohol or tobacco use.,0
Married and lives in .,0
"PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5, heart rate 76, blood pressure 94/54, respiratory rate 20, oxygen saturation 96% on room air.",0
"In general, comfortable in no acute distress, chronically ill-appearing.",0
"HEENT: Pupils equal, round and reactive to light and accommodation.",0
Oropharynx erythematous with persistent whitish plaques.,0
Neck: Multiple palpable supraclavicular nodules versus supraclavicular lymph nodes on the right.,0
Cardiovascular examination: Regular rate and rhythm.,0
"No murmurs, rubs or gallops.",0
Lungs clear to auscultation bilaterally.,0
"Abdomen mildly distended, soft, non-tympanitic, non-tender, positive bowel sounds, palpable, subcutaneous nodules.",0
"Extremities: 2+ pitting edema over the lower extremities bilaterally, 1+ pedal pulses.",0
Neurological: Alert and oriented times three.,0
Cranial nerves II through XII intact.,0
Sensation and strength intact in all extremities.,0
"LABS ON ADMISSION: White blood cell count 14.9, hematocrit 30.0, platelets 206,000, neutrophils 94, 4 lymphocytes, 2 macrophages.",0
"Sodium 134, potassium 6.3 which was hemolyzed corrected to 5.1, chloride 99, bicarbonate 20, BUN 80, creatinine 2.4, glucose 189, amylase 59, lipase 43, albumin 2.5, phos 7.0, magnesium 2.0, T-bili 0.7.",0
"UA: Negative nitrites, negative leukocyte esterase, white blood cells, red blood cells, many bacteria.",0
Blood and urine cultures pending at the time of admission.,0
IMPRESSION: Patient is a 59-year-old male with history of malignant metastatic melanoma failed multiple regimens complicated by brain metastases status post XRT and Decadron who presents with complaints of fatigue and subsequently found to be hypotensive and minimally responsive to volume resuscitation.,1
"Hypotension: Given the warm extremities and lack of response to volume resuscitation, the hypotension was felt to be a distributed etiology either due to sepsis or adrenal insufficiency.",0
He was started on stress dose steroids as well as IV vancomycin and IV ceftriaxone and was continued on dopamine and transferred to the Medical Intensive Care Unit for further management.,0
Intravenous fluids were continued as were the stress dose steroids and broad spectrum antibiotics and the dopamine was slowly weaned over the next several days with gradual improvement of urine output as well as pressures.,0
"Infectious Disease: The patient was felt to have likely a urinary source for current presentation; however, abdominal examination was somewhat concerning for possible perforation.",0
He underwent abdominal CT which showed no evidence of fluid collections or free air suggestive of perforation or abscess.,0
He was continued on ceftriaxone and vancomycin for broad spectrum coverage.,0
Antibiotics were continued for the next six days and were discontinued as the goals of care were now felt to be more of comfort care as opposed to active treatment after extensive discussion with the family who now feel that they would not like to pursue aggressive treatment at this point.,0
"Hematology/Oncology: Patient with significant metastatic melanoma with increased tumor burden on abdominal CT underwent echocardiogram on , which showed a mass in the left ventricle consistent with thrombus versus metastatic melanomatous lesion.",0
Pulmonary: Patient had significant oxygen requirement with subjective dyspnea without oxygen by face mask or by nasal cannula.,0
This will be continued as comfort measures.,0
"Code Status: After a lengthy discussion with the family, social worker and palliative care team, it was felt that goals of care would now be for comfort only and would not pursue any active resuscitation or intubation if the patient's condition were to significantly worsen and for this reason he will be listed as a DNR/DNI.",0
Hypotension likely secondary to sepsis.,0
Patient is comfortable and currently without any focal complaints and may be discharged to a hospice facility for further management and end of life care.,0
It is possible he will remain in the hospital for his remaining days.,0
"MEDICATIONS ON DISCHARGE: Morphine IV drip titrate to subjective comfort, Ativan 0.5 mg to 1 mg IV q.",0
"comfort, prednisone 50 mg p.o.",0
"q. day times one day, 30 mg p.o.",0
"q. day times one day, then 10 mg p.o.",0
"q. day times one day, then off.",0
Dictated By: MEDQUIST36 D: 16:23 T: 15:44 JOB#:,0
7:30 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with fever/an sz activity REASON FOR THIS EXAMINATION: r/o pna ______________________________________________________________________________ FINAL REPORT EXAM: Chest single portable AP upright view.,0
CLINICAL INFORMATION: 55-year-old male with history of fever and seizures.,0
FINDINGS: Single AP upright portable view of the chest was obtained.,0
The left costophrenic angle is not fully included on the image.,0
"No focal consolidation, large pleural effusion or pneumothorax is seen.",0
There may be minimal central pulmonary vascular engorgement.,0
The aorta is calcified and tortuous.,0
The cardiac silhouette is not enlarged given technique.,0
Possible mild central vascular engorgement.,0
Left costophrenic angle not fully included on the image.,0
"3:42 PM CT HEAD W/O CONTRAST Clip # Reason: ?Fracture or hemorrhage after fall Admitting Diagnosis: SEIZURE;ETOH WITHDRAWAL ______________________________________________________________________________ MEDICAL CONDITION: 39M admitted for EtOH/opiate withdrawal, fell in shower 11am (), no LOC REASON FOR THIS EXAMINATION: ?Fracture or hemorrhage after fall No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SUN 4:31 PM PFI: Limited study due to motion artifact.",0
No definite large intracranial hemorrhage.,0
"In case of continued clinical concern for subtle intracranial hemorrhage, a repeat examination is recommended.",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Status post fall.,0
COMPARISON: Head CT from .,0
NON-CONTRAST HEAD CT: This exam is limited due to motion artifact.,0
There is no large intracranial hemorrhage or mass effect.,0
The ventricles and extra-axial spaces are appropriate for age.,0
There is no evidence of fracture.,0
There is a stable left frontal subcutaneous hematoma.,0
Imaged paranasal sinuses are grossly clear.,0
IMPRESSION: Limited study due to motion artifact.,0
"NOTE ADDED AT ATTENDING REVIEW: Although I agree there is mild motion artifact, it is not sufficient to obscure any significant amount of hemorrhage.",0
12:26 PM BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # Reason: evaluate bowel ______________________________________________________________________________ MEDICAL CONDITION: Infant with suspicion of bowel obstruction REASON FOR THIS EXAMINATION: evaluate bowel ______________________________________________________________________________ FINAL REPORT ABDOMEN: This is a child with the history of imperforate anus.,0
He had a contrast enema performed several days ago.,0
Our film today continues to demonstrate contrast throughout the large and small bowel.,0
There has been little drainage over the last day.,0
A nasogastric tube is visible within the stomach.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p Gun Shot Wound to head Major Surgical or Invasive Procedure: : Right craniectomy, Right temporal lobectomy, Right MCA clipping : s/p trach/PEG and lumbar drain placement History of Present Illness: 26M sustained GSW to right temple, immediately taken to OR for emergent craniectomy.",1
"Past Medical History: unknown Social History: s/p recent incarceration per hospital/social work records Family History: non-contributory Physical Exam: On Admission: General: lying in bed, unresponsive HEENT: R orbital hematoma, bullet entry site at L temple, no exit site.",0
"Neurological Exam: R pupil fixed and dilated, no spontaneous movements.",0
On Discharge: Spontaneous eye opening on the left; right eye closed.,0
"Left pupil 2.5mm and reactive, left pupil 4mm and minimally(secondary to GSW injury).",0
Spontaneous movement of the RLE and RUE; follows commands with right upper extremity.,0
"Left UE external rotation with noxious stimulation, LLE withdraws with noxious stimulus.",0
Patient is now able to speak with his passimuir valve in place and is oriented to himself and hospital.,0
Right cranial wound is clean dry and intact.,0
The right side of his head is now sunken in as the swelling has resolved and the bone flap is missing.,0
All sutures removed prior to discharge.,0
Pertinent Results: Labs on Admission: 09:05PM BLOOD WBC-10.3 RBC-3.57* Hgb-11.6* Hct-32.7* MCV-92 MCH-32.6* MCHC-35.6* RDW-13.0 Plt Ct-299 09:05PM BLOOD PT-13.4 PTT-30.4 INR(PT)-1.1 09:05PM BLOOD Fibrino-184 09:05PM BLOOD UreaN-14 Creat-1.1 09:05PM BLOOD Lipase-32 01:31AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.9 09:05PM BLOOD ASA-NEG Ethanol-178* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 09:54PM BLOOD Type-ART pO2-480* pCO2-35 pH-7.37 calTCO2-21 Base XS--3 Labs on Discharge : WBC RBC Hgb Hct Plt 10.9 3.39* 11.0* 32.4* 226 Glu BUN Creat Na K Cl HCO3 AnGap 113 15 0.7 139 4.0 102 30 11 Calc Phos Mg 9.3 3.6 1.8 Imaging: CT C-Spine : IMPRESSION: 1.,0
No fracture or dislocation of the cervical spine.,0
Metallic fragments consistent with a gunshot wound are seen.,0
"The squamous part of the temporal bone is shattered, and the head of the mandible is disrupted.",0
"Metallic fragments, pneumocephalus and hemorrhage are seen within the middle cranial fossa (for further details, see the head CT from today).",0
"ATTENDING NOTE: Incidentally noted is somewhat hypolastic odontoid process, a congenital anomaly.",0
No signs of atlanto-axial subluxation seen.,0
"CT Head : FINDINGS: High-density material consistent with metallic fragments are seen adjacent to the right TMJ where there are bone fragments (series 3, image 6).",0
"The lateral wall of the right maxilla is fractured (series 3, image 8), as is the anterior wall (series 3, image 7).",1
High attenuating material within the right maxillary sinus is consistent with blood.,0
Low density material opacifies the other maxillary sinus.,0
"The squamous portion of the temporal bone is shattered (series 3, image 9) and numerous fragments are seen.",0
"There is a fracture of the right zygoma (series 3, image 11).",0
"Metallic fragments and a 1.2 x 1.5 cm intraparenchymal hemorrhage are seen in the right temporal lobe (series 2, image 15).",0
"Locules of air and metallic fragments are seen throughout the brain tracking superiorly to where a significant bullet fragment is seen adjacent to the left frontal bone (series 3, image 27).",0
There is diffuse sulcal effacement indicative of significant cerebral edema.,1
The lateral ventricles appear effaced.,0
The basal cisterns are obliterated indicative of uncal herniation and the cerebellar tonsils are seen in the foramen magnum.,0
Gunshot wound to the head traversing from the right TMJ superiorly to where bullet fragments are seen adjacent to the left frontal bone.,0
"There is associated pneumocephalus, intraparenchymal hemorrhage, uncal, and brainstem herniation.",0
"Significant and complex fractures of the squamous portion of the temporal bone, zygomatic process and anterior and lateral walls of the maxilla as enumerated above.",1
CTA Head : CT ANGIOGRAPHY OF THE HEAD: The CT angiography of the head demonstrates evidence of clipping of the right middle cerebral artery and right supraclinoid internal carotid artery.,1
There is a flow gap identified in the M2 segment of the right middle cerebral artery.,1
The vascular structures in the sylvian region of right middle cerebral artery are visualized which could be secondary to leptomeningeal collaterals.,1
There is no active extravasation identified.,0
The left middle cerebral artery demonstrate normal appearance.,1
Normal vascular appearance is also seen in the posterior circulation with regards to stenosis or occlusion.,0
There appears to be mild vascular spasm.,0
Gunshot wound to the head with multiple bullet fragments in both frontal lobes and left frontal intracerebral hematoma.,1
Evolving right middle cerebral artery infarct.,1
Clips in the region of right middle cerebral artery and supraclinoid internal carotid artery.,1
Right-sided craniectomy with mild bulging of the brain substance through the craniectomy defect.,0
Central herniation and right-sided inferior displacement of the uncus.,0
CT angiography shows occlusion of the right middle cerebral artery secondary to clipping.,1
Collateral circulation is seen in the right sylvian branches of the middle cerebral artery.,1
Mild nonocclusive vasospasm is also identified.,0
Extensive subcutaneous emphysema is seen as well as the emphysema in the right orbit.,0
Better evaluation of the facial bones can be obtained with facial CT if clinically indicated for assessment of fractures.,1
"Head CT : NON-CONTRAST HEAD CT: Compared to one day prior, there is increased edema within the right frontal lobe with increased herniation of the brain parenchyma through the right frontal calvarial defect.",1
"Comparison and exact measurement is difficult, however, the brain extends approximately 2.2 cm beyond the expected location (2:21) compared to 1.5 cm one day prior.",0
"There is slight bowing of the septum pellucidum towards the right, however, no significant midline shift or subfalcine herniation.",0
The ventricles are stable in size and configuration.,0
"The basilar cisterns are difficult to evaluate due to streak artifact from the bullet fragments in the right frontotemporal area, however, appear preserved with no definite evidence of uncal herniation.",0
Left frontal intraparenchymal hemorrhage is stable.,0
Small left-sided subdural hemorrhage is also stable.,0
Multiple fragments and sutures in the right MCA bifurcation are unchanged.,0
Pneumocephalus and blood products in the surgical bed have decreased slightly.,0
No evidence of new hemorrhage.,0
Again there is high-density opacification within the right maxillary sinus and moderately extensive opacification within the ethmoidal air cells and sphenoid sinuses.,0
IMPRESSION: Increasing edema and herniation of the right cerebral hemisphere through the frontoparietal craniectomy defect.,1
No new subfalcine or uncal herniation.,0
"Head CT : FINDINGS: Overall, there is minimal change when compared to the previous examinations.",0
"Again seen is a large amount of brain edema, predominantly at the right frontal lobe with transgaleal herniation through the large right frontoparietal craniectomy site.",1
"The degree of herniation appears increased when compared to the most recent exam, now measuring approximately 26 mm (2:19) as compared with 21 mm previously.",0
The degree of rightward shift of normal midline structures is unchanged.,0
Ventricles are unchanged in size and configuration.,0
The left frontal intraparenchymal hemorrhage is unchanged.,0
There is no new hemorrhage.,0
Numerous bullet fragments are all unchanged and the small amount of pneumocephalus seen on is now resolved.,0
"Numerous facial fractures, soft tissue changes and hyperdense fluid in the right maxillary sinus are all unchanged.",1
IMPRESSION: Slight increase in the degree of trans-galeal herniation and otherwise minimally changed study.,0
Head CT : FINDINGS: Again seen is massive right frontal and temporal and less severe left frontal swelling with edema and mass effect.,0
Unchanged is a left frontal intraparenchymal hematoma.,0
There has been a right frontal and temporal craniectomy with herniation of the brain through the craniectomy defect.,0
There appears to be an extensive infarction of the right middle cerebral artery territory.,1
This appears unchanged since the prior study.,0
There is a small left frontal subdural hematoma that appears slightly larger than on the study of .,0
"However, at its greatest dimension, it measures less than 5 mm and produces only minimal local mass effect.",0
Mild thickening along the posterior falx may represent a small subdural hematoma in this location.,0
There is no evidence of new or increased intraparenchymal hemorrhage.,0
Again seen is a small amount of blood in the occipital of the right lateral ventricle.,0
Extensive shrapnel from gunshot wound is again seen both the intra- and extra-cranially.,0
CONCLUSION: Slight increase in the size of a tiny left frontal subdural hematoma.,0
Status post gunshot wound with extensive right frontal and temporal swelling and right MCA infarction.,1
The left frontal parenchymal hemorrhage with surrounding edema.,0
"Upper Extremity NIS : IMPRESSION: Nonocclusive thrombus in the left basilic and distal cephalic veins, not extending proximally to axillary veins.",0
No deep venous thrombus of the left upper extremity.,0
"Head CT : IMPRESSION: Right frontotemporal edema, evolving right MCA infarct, small left subdural hematoma, and left frontal parenchymal hemorrhage are similar to .",0
"Chest X-Ray : FINDINGS: Since the prior study of one day earlier, multifocal patchy opacities in the perihilar and basilar regions have minimally progressed, and could be due to atelectasis or infection.",0
Indwelling devices remain in standard position.,0
CT Torso : CT CHEST WITH INTRAVENOUS CONTRAST: The tracheostomy tube is in place.,0
The central line via right subclavian access ends in the distal superior vena cava.,0
The airways are patent to the subsegmental levels bilaterally.,1
"Although this study was not optimized for evaluating the vasculature, several filling defects including a segmental branch of the right lower lobar pulmonary artery, compatible with pulmonary embolism.",0
Mild dependent atelectasis seen at the bases bilaterally.,0
"There is a peripheral noncalcified tiny pulmonary nodule in the right upper lobe measuring 3 mm on series 2, image 22.",0
There is no pericardial or pleural effusion.,0
"CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver is homogeneous in attenuation, without focal lesions or biliary ductal dilatation.",0
"The spleen, adrenal glands, pancreas are unremarkable.",0
"Main portal vein, splenic vein, superior mesenteric veins are patent.",0
Kidneys enhance equally and excrete contrast normally.,0
Abdominal loops of large and small bowel are normal.,0
"There is no abdominal fluid collection, free fluid, mesenteric or retroperitoneal lymphadenopathy.",0
CT PELVIS WITH INTRAVENOUS CONTRAST: There is large amount of stool in the rectum and the sigmoid colon.,0
The urinary bladder contains a Foley catheter.,0
Air within the urinary bladder is likely related to recent instrumentation.,0
There is no free pelvic fluid and no pelvic or inguinal lymphadenopathy.,0
BONE WINDOWS: Demonstrate no concerning lytic or sclerotic lesions.,0
"No CT evidence of infection in the chest, abdomen and pelvis.",0
Findings highly concerning for pulmonary embolism.,0
"This study was not optimized for evaluation of pulmonary vasculature, and dedicated CTA chest is recommended to confirm the finding and evaluate extent of pulmonary embolism.",0
Head CT : NON-CONTRAST HEAD CT: Limited exam given streak artifact from multiple metallic fragments.,0
"Compared to the prior exam from , there is decreased herniation of the brain parenchyma through the right parietal osseous defect.",0
"However, there still remains a large portion of brain parenchyma extending beyond the confines of the calvarium.",0
"There is slight decrease in effacement of the left lateral ventricle, suggesting decreased edema.",1
The right lateral ventricle remains relatively dilated compatible with trapping.,0
"There is continued evolution of the right middle cerebral artery territory infarction with multiple gyriform hemorrhagic foci, slightly increased since prior exam.",1
There is persistent diffuse cerebral edema with effacement of the basal cisterns.,1
The sinuses show improved aeration.,0
The right mastoid air cell is completely opacified.,0
The left mastoid tip is opacified.,0
The patient's head is rotated to the left.,0
"Compared to prior exam from , there is minimally decreased edema of the brain parenchyma.",1
Continued evolution of right MCA territory infarct with slightly increased foci of hemorrhage.,0
Brief Hospital Course: The patient was brought to the ER after having sustained gun shot wounds to the head and face.,1
He went to the OR for emergent surgery and had a temporal lobectomy as well as a craniectomy to leave room for swelling.,0
He was transferred to the ICU and remained intubated for several days.,0
The patient had some spontaneous movement initially in the right side of his body.,0
Eventually he was able to follow some commands on the right side.,0
On he had a trach and peg placed in preparation for long term care upon discharge from .,0
On the neurological exam changed.,0
"He was no longer following commands, but was withdrawing all extremities to pain.",0
Stat CT showed increased edema and he was aggressively started on 3% saline and mannitol.,0
"On he was extensor posturing with all 4, had + Babinski bilaterally.",0
There was a family meeting on to explain that the patient's exam was worse.,0
At that time the patient remained full code with a lumbar drain in place.,0
"On his lumbar drain was removed due to concerns of infection, as he continued to be febrile.",0
ID was consulted for concerns of ongoing infection.,0
"Sputum specimen was sent, and grew bacteria requiring the use of Vancomycin and Meropenum for a duration for 14 days.",0
"On , his examination was noticeably improved.",0
"He was again following commands (offering ""thumbs up"") with the right upper extremity, and making attempts to wiggle his right toes to commands.",0
The left side of his body continued to offer withdrawal of the lower extremity and external rotation of the upper extremity.,0
The left pupil was still reactive.,0
"Later in the afternoon, after a episode of coughing, clear fluid was noted to be draining from the right ear.",0
"On the morning of , the staples of his cranial wound were removed, exclusive of the last 2cm over the ear.",0
"It appeared that this was the location of the clear fluid drainage, not the ear canal.",0
"The staples were subsequently removed, and several mattress stitches placed.",0
These stitches are to remain in place until .,0
He also persistently had low dilantin serum levels despite multiple boluses.,0
"Therefore on , he was transition ed to Keppra.",0
", his examination continued to wax and wane (at times would follow commands, and other times not).",0
He also continued to be febrile.,0
"CT Head, Torso, Labs, and LENIS were sent to interrogate for alternate pathologic cause.",0
"CT head, and torso were negative for infectious process.",0
"He was noted to have a mild transaminitis, though clinically unremarkable.",0
"Non-invasive studies of the upper and lower extremities were performed and he was noted to have a non-occlusive basilic vein in the LUE, and occlusive thrombus of the left cephalic vein.",0
"As these are not deep veins, systemic anticoagulation was not indicated, and he was therefore just started on EC ASA(has been on SQH previously).",0
", his examination appeared to be more improved with spontaneous movement of the right upper extremity.",0
He was therefore authorized to transfer to the neurosurgery step-down unit pending bed availability.,0
"He continued to be hospitalized in the stepdown unit, with stable neurological examination.",0
On he completed his Vancomycin and Meropenum course.,0
His sutures were then d/c'd on and he was trnasferred to the floor on .,0
Neurologically he continued to progress and on a passimuir valve was placed by speech/swallow therapist.,0
He was able to speak and verbally interact as well as take in some food by mouth.,0
"He continued on the neurosurgical floor, with daily PT/OT until he was discharged on to rehab facility.",0
Medications on Admission: None Discharge Medications: 1.,0
Acetaminophen 160 mg/5 mL Solution Sig: PO Q6H (every 6 hours) as needed.,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed.,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day).",0
Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day).,0
Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours).,0
Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed).,0
Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day).,0
Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for neck spasm.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.,0
"Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen.",0
"Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day).",0
Insulin Please see attached Insulin Sliding Scale and Fixed Dose Sheet.,0
"Discharge Disposition: Extended Care Facility: Hospital Discharge Diagnosis: Left frontal Intraparenchyml hemorrhage, Left frontal Subdural hemorrhage, Right subfalcine herniation,uncal herniation, diffuse subarachnoid hemorrhage, bullet fragments in Right temporal petrous bone and parenchyma, s/p gun shot wound to head.",0
"Ventilator Acquired Pneumonia Post traumatic optic neuropathy Right posterior globe rupture Right vitreous hemorrhage hyphema Orbital wall fx Nonocclusive thrombus left basilic/ distal cephalic veins Respiratory Failure, s/p tach placement Dysphagia, s/p PEG placement CSF leak Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?",1
?Have your incision checked daily for signs of infection.,0
?Take your pain medicine as prescribed.,0
"?Exercise should be limited to walking; no lifting, straining, or excessive bending.",0
"?All sutures have been removed, and you may wet your head in the shower.",0
"?Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation.",0
"We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication.",0
?You are being discharged on a medication called Keppra(levetiracetam) for seizure prophylaxsis.,0
You will not require blood monitoring for this medication.,0
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?,0
?New onset of tremors or seizures.,0
?Any confusion or change in mental status.,0
"?Any numbness, tingling, weakness in your extremities.",0
"?Pain or headache that is continually increasing, or not relieved by pain medication.",0
"?Any signs of infection at the wound site: redness, swelling, tenderness, or drainage.",0
?Fever greater than or equal to 101??????,0
F. Followup Instructions: Follow-Up Appointment Instructions ?,0
"?Please call ( to schedule an appointment with Dr. , to be seen the week of .",0
?You will need a CT scan of the brain without contrast at that appt.,0
"7:56 AM CT CHEST W/O CONTRAST Clip # Reason: interval change of LLL consolidation, now growing mold on br Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with AML s/p SCT, recent tracheostomy, known LLL consolidation, now growing mold on bronch aspiration REASON FOR THIS EXAMINATION: interval change of LLL consolidation, now growing mold on bronch culture No contraindications for IV contrast ______________________________________________________________________________ WET READ: JMGw TUE 5:37 PM 1.",1
Substantial but incomplete resolution of left lower lobe consolidation and effusion.,0
Rounded opacity within the right breast with adjacent fat stranding.,0
"This could be a seroma or resolving hematoma, and clinical correlation is recommended.",0
Tip of the Dobbhoff catheter is just within the stomach and advancement by several centimeters would lead to more optimal positioning of this catheter.,0
Coronary artery disease with prior bypass grafting.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: AML status post stem cell transplant, recent tracheostomy with known left lower lobe consolidation, with mold on bronch aspiration.",1
CTA CHEST: MDCT imaging was performed from the thoracic inlet to the upper abdomen with IV contrast.,0
Axial 5- and 1.25-mm series were displayed.,0
Sagittal and coronal reformats were performed.,0
"COMPARISON: CT torso of , CT chest performed on outside hospital on , CT chest of .",0
FINDINGS: A left lower lobe consolidation with adjacent pleural effusion has nearly completely resolved with only minimal peribronchovascular consolidation and ground-glass opacity in the left lower lobe (3:25).,0
Only trace pleural fluid is remains on the left side.,0
The left upper lobe and the the right lung is clear.,0
A tracheostomy catheter tip terminates 3.1 cm from the carina.,0
"Otherwise, the airways appear normal.",0
The patient has undergone median sternotomy with prior CABG.,0
There is extensive coronary artery vascular calcification.,0
Aortic valvular calcifications are present.,0
The heart is of normal size and there is no pericardial effusion.,0
"No pathologically enlarged lymph nodes are present within the axilla, hilum, or mediastinum.",0
There is calcification of the left pericardium which is unchanged from an examination dating from .,0
Although not tailored for subdiaphragmatic evaluation.,0
A Dobbhoff catheter tip is just within the stomach and further advancement should be performed.,0
BONE AND SOFT TISSUE WINDOWS: No suspicious bone lesions are present.,0
"Since (Over) 7:56 AM CT CHEST W/O CONTRAST Clip # Reason: interval change of LLL consolidation, now growing mold on br Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ FINAL REPORT (Cont) the examination on , there appears to be a rounded area of increased density in the right breast measuring 3.2 x 2.4 cm with adjacent fat stranding.",1
"5:36 AM CHEST (PORTABLE AP) Clip # Reason: ?interval change Admitting Diagnosis: S/P STABBIMG ______________________________________________________________________________ MEDICAL CONDITION: 33 year old man with stabbing, R Chest tube, apical pneumo REASON FOR THIS EXAMINATION: ?interval change ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Chest tube apical pneumothorax.",0
Lung volumes are quite low.,0
A right apical pneumothorax and volume loss in the right lung are again demonstrated.,0
Its appearance has not changed significantly with a chest tube remains in place at the right base.,0
Second radiopaque tube is projected over the right costophrenic sulcus and may have been inserted in the interval.,0
An endotracheal tube and feeding tube remain in place.,0
IMPRESSION: Suboptimal study demonstrating no definite interval change in appearance of right pneumothorax and volume loss in the right upper lobe.,0
"2:31 PM CHEST (PRE-OP PA & LAT) Clip # Reason: S/P NON Q WAVE MI ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with cad, htn, hi chol, s/p mi in outside hosp.",0
"REASON FOR THIS EXAMINATION: pre op ______________________________________________________________________________ FINAL REPORT HISTORY: S/P MI, pre-op chest x-ray.",0
TECHNIQUE: Chest PA and lateral Comparison with prior study from .,0
Again seen is mild cardiomegaly.,0
The aorta is unfolded and partially calcified.,0
The pulmonary vessels are within normal limits.,0
There is a linear opacity in the left mid-lung.,0
There are no large consolidations.,0
"There are small bilateral pleural effusions, not significantly changed compared to the prior study.",0
There is a thoracic kyphosis.,0
IMPRESSION: Cardiomegaly; no overt CHF.,0
"9:09 AM CHEST (PORTABLE AP) Clip # Reason: evidence of fluid overload Admitting Diagnosis: CONGESTIVE HEART FAILURE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with dyspnea, hypoxia and now tachypenia and respiratory distress, s/p extubation several days ago now with tachypnea REASON FOR THIS EXAMINATION: evidence of fluid overload ______________________________________________________________________________ FINAL REPORT INDICATION: Dyspnea, hypoxia, tachypnea.",1
"SINGLE VIEW CHEST, AP: There is again seen marked cardiomegaly with left ventricular prominence.",0
"When compared to the previous exam, there is improved left ventricular failure.",0
There is improved lung inflation.,0
"There has been reduction in the bilateral pleural effusions, however there is a residual left- sided pleural effusion with atelectasis.",0
The lung fields are clear.,0
IMPRESSION: Improved left ventricular heart failure when compared with to the previous exam.,1
"3:58 PM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate or evidence of CHF Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with SOB, fever and desaturating REASON FOR THIS EXAMINATION: assess for infiltrate or evidence of CHF ______________________________________________________________________________ FINAL REPORT HISTORY: Shortness of breath and fever.",0
"AP SUPINE CHEST: Comparison with shows an interval increase in upper zone redistribution and perihilar haziness, consistent with increased heart failure.",1
"New focal opacity in the right lower lobe with air bronchograms, possibly representing pneumonia versus focal edema.",0
There is persistent opacity within the left lower lobe.,0
"There has been interval removal of a right IJ line, without evidence of pneumothorax.",0
The calcification within the right axilla is unchanged.,0
"New opacity in the right lower lobe, which could represent pneumonia versus focal pulmonary edema.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p PVI c/b post op hypotension and bradycardia Major Surgical or Invasive Procedure: Pulmonary Vein Isolation History of Present Illness: 53 yo male a history of mild Ebstein?????,1
"?s anomaly, atrial tachycardia and recently diagnosed atrial fibrillation.",1
He has had a TEE cardioversion and subsequently discharged.,0
"Then, in he ad palpitations again and had another cardioversion, started on sotalol, but couldn't tolerate due to bradycardia and was referred in for PVI.",0
"Today, the patient underwent successful PVI, but postoperatively he was bradycardic to the high 30s/low 40s, and was hypotensive to the 80s/90s.",0
He was given IVF bolus with improvement of his SBP.,0
"The rhythm appeared to be intermittent junctional bradycardia, thought to be due to sinus dysfunction post PVI.",0
"At the time of transfer to the CCU for monitoring, he was hemodynamically stable and otherwise doing well.",0
He had an ECHO in the PACU which did not show any pericardial effusion.,0
CT abdomen/pelvis without evidence of RP bleed.,0
"On review of systems, he denies deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",0
He denies exertional buttock or calf pain.,0
"Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.",0
"CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (-)Hypertension 2.",0
CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: cardioversion x 2 3.,0
OTHER PAST MEDICAL HISTORY: Atrial fibrillation Atrial tachycardia Ebstein?????,1
"?s anomaly H/O TIA/RIND Abnormal EKG-sinus brady, RBBB, t wave inversion III, avf Dyslipidemia Heart murmur Social History: -Tobacco history: denies -ETOH: 2 drinks/week -Illicit drugs: none Family History: No family history of early MI, otherwise non-contributory.",0
Physical Exam: GENERAL: WDWN in NAD.,0
NECK: Supple with JVP of *** cm.,0
"CARDIAC: PMI located in 5th intercostal space, midclavicular line.",0
Abd aorta not enlarged by palpation.,0
"SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.",0
PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: 04:16AM BLOOD WBC-7.9 RBC-3.81* Hgb-11.9*# Hct-32.3* MCV-85 MCH-31.3 MCHC-36.9* RDW-13.1 Plt Ct-219 07:45AM BLOOD PT-16.2* PTT-25.5 INR(PT)-1.5* 04:16AM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-140 K-3.8 Cl-107 HCO3-28 AnGap-9 .,0
"Two left sided and a single, common right sided pulmonary vein with no evidence of anomalous pulmonary venous return or focal stenosis (dimensions listed above).",0
Dilated right atrium and right ventricle.,0
"Less than 4-mm lung nodules, do not warrant further followup is the patient has no risk factor for malignancy.",0
"If risk factors are present, followup is recommended in 1 year.",0
Signs of small airway disease.,0
Echocardiogram: The left atrium is mildly dilated.,0
The right ventricular cavity is markedly dilated with normal free wall contractility.,0
The aortic root is moderately dilated at the sinus level.,0
The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis.,0
Mild (1+) aortic regurgitation is seen.,0
"The septal insertion of the tricuspid valve is apically displaced, consistent with Ebstein's anomaly.",1
There is borderline pulmonary artery systolic hypertension.,0
IMPRESSION: Mild Ebstein's anomaly with dilated right ventricle and moderate TR.,1
Normal regional and global left ventricular systolic function.,0
Mild aortic and moderate tricuspid regurgitation.,0
No evidence of retroperitoneal hematoma.,0
"Brief Hospital Course: The patient was admitted with difficult to control atrial fibrillation, s/p pulmonary vein isolation with post-operative bradycardia and hypotension.",1
Nodal agents were held and no pressors were needed.,0
Blood pressures on admission were in the 100s systolic with HR in the 60s.,0
The patient did well and was discharged the following day.,0
"He was initially put on a heparin drip, then started on Coumadin and given Lovenox for a bridge.",0
He was discharged with follow-up with Dr. and of Hearts monitor.,0
He remained in sinus rhythm post-procedure.,0
"Medications on Admission: Lipitor 20mg PO qday MVI Lysine 1,000 mg PO qday Discharge Medications: 1.",0
Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily).",0
Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: at 5 PM.,0
"Lysine 1,000 mg Tablet Sig: One (1) Tablet PO once a day.",0
Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous (2 times a day): please use until INR > 2.0.,0
Disp:*14 syringe* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Ebstein's anomaly Dyslipidemia Discharge Condition: VS: stable Groins: stable Labs: stable Discharge Instructions: You were admitted to the hospital to undergo a pulmonary vein isolation procedure to treat atrial fibrillation.,1
You has a short period of low blood pressure and slow heart rate after the procedure.,0
"No changes were made to your medications, except that you should take 5 mg of coumadin daily for now while your INR is subtherapeutic as your coumadin was held for the procedure.",0
"You will need to have your INR checked on Monday, and adjust your dose of coumadin for Monday based on the INR.",0
"Continue the Lovenox until your INR is between 2.0 and 3.0 Go to the emergency room or call your primary doctor if you experience fevers, chills, chest pain, shortness of breath, dizziness, blood in your stool, or black stool.",0
"Followup Instructions: An appointment was made for you to follow up with your cardiologist: 2 weeks - 3 weeks Provider: , M.D.",0
"7:35 AM CT HEAD W/O CONTRAST Clip # Reason: FELL FROM CRIB Admitting Diagnosis: NEWBORN Field of view: 20 ______________________________________________________________________________ MEDICAL CONDITION: Infant with fall from crib REASON FOR THIS EXAMINATION: r/o fracture or bleeding No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: The following is the transcription report generated by , MD at the Medical Center.",0
INDICATION: Fell out of basonnet.,0
TECHNIQUE: Axial images of the brain without contrast.,0
"FINDINGS: The brain appears normally formed, normally myelinated and without structural abnormality, mass lesion or abnormal density.",0
The CSF spaces appear normal.,0
No acute definite hemorrhage is seen.,0
"Within the midline on axial images number 12 of series 2 there are two lucencies within the occipital bone, posteriorly, in the midline that raise the possibiity of a nondisplaced fracture.",0
There is soft tissue swelling of the occipital region and vertex.,0
IMPRESSION: Negative CT of the brain.,0
"Axial bone windows raise the possibility of a midline, nondisplaced occipital skull fracture, which could be confirmed with plain films if clinically indicated.",0
These results were relayed to the referring practitioner Dr. and to from NICU.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: STEMI.,0
"Major Surgical or Invasive Procedure: Cardiac catheterization with angioplasty and stenting (2 x DES to OM1), .",1
History of Present Illness: Ms. is a generally healthy 54-year-old woman who is admitted to the CCU following emergent cardiac catheterization.,1
"On the afternoon prior to admission, the patient had acute onset of a burning substernal CP with a pressure sensation radiating to her left shoulder.",1
"She did not have associated symptoms such as nausea, SOB or diaphoresis.",0
"She thought this might have been indigestion or pain from her neck, and her symptoms did improve with antiacids.",0
The discomfort then waxed and waned over the course of the day; the patient eventually felt well enough to go to sleep.,0
Around 1AM she was awakened from sleep by an acute worsening of her symptoms.,0
"She presented to Hospital where her ECG was notable for STE in I, aVL, V5 and V6 as well as STD in III and V1 through V4.",0
Initial TropI was elevated at 0.51 (initial CK not available).,0
"The patient was treated with ASA, IV heparin and IV NTG, which resulted in transient resolution of her pain.",0
"She was transferred to the ED, where she additionally received Integrillin and 600mg Plavix.",0
"As she was having recurrent discomfort in the ED, she was taken for urgent cardiac cath, performed with radial access, which demonstrated a tight OM lesion.",0
"This lesion was treated with a DES; a small proximal dissection was noted, and this was then treated with a second DES.",0
The was excellent flow post-procedure.,0
"On arrival to the CCU, the patient reports being pain free and feeling entirely well.",0
"On review of systems, she denies any recent fever, chills, change in weight, nausea, vomiting, abdominal pain, change to bowel or bladder habbits, arthalgia, myaglia, dizziness, numbness or weakness.",0
"Upper back pain, s/p spinal fusion Social History: The patient reports being under a moderate amount of psychosocial stress recently.",0
She works in HR for the Social Security Administration.,0
"-Tobacco history: Prior smoker, quit for 14 years, now smoking a few ciggarettes per day.",0
"-ETOH: Rare -Illicit drugs: denies Family History: The patient's mother suffered an MI in her early 40s, but is now in her 80s and doing well.",0
The patient's father required multi-vessle cardiac bypass surgery in his late 60s.,1
"Physical Exam: Gen: Well appearing adult female, no acute distress.",0
"Neck: Supple, without adenopathy or JVD.",0
Chest: Lungs clear to auscultation with normal respiratory effort.,0
"Abdomen: Soft, non-tender and non-distended.",0
Extremity: Small hematoma at right radial access cath site.,0
Motor strength intact in all extremities.,0
"On the day of discharge vital signs were 97.9 F (98.2 F maximum), 93/55 mmHg (range 92/62 to 106/56 mmHg), 56 BPM (range 55 to 72 BPM), RR of 18 and 100 % O2 Sat.",0
"Physical exam findings were unchanged from those above, except for some resolution of hematoma.",0
Pertinent Results: Laboratory Data at Admission: 04:45AM BLOOD WBC-11.5* RBC-4.55 Hgb-14.7 Hct-41.6 MCV-91 MCH-32.3* MCHC-35.4* RDW-12.4 Plt Ct-224 04:45AM BLOOD Neuts-72.8* Bands-0 Lymphs-21.0 Monos-3.7 Eos-1.8 Baso-0.8 04:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL 04:45AM BLOOD PT-12.3 PTT-150* INR(PT)-1.0 04:45AM BLOOD Glucose-117* UreaN-17 Creat-0.7 Na-142 K-4.0 Cl-108 HCO3-23 AnGap-15 04:45AM BLOOD CK(CPK)-176 05:03PM BLOOD CK(CPK)-1690* 04:22AM BLOOD CK(CPK)-1142* 04:45AM BLOOD CK-MB-15* MB Indx-8.5* 04:45AM BLOOD cTropnT-0.12* 05:03PM BLOOD CK-MB-166* MB Indx-9.8* 04:22AM BLOOD CK-MB-65* MB Indx-5.7 04:45AM BLOOD Cholest-69 05:03PM BLOOD %HbA1c-5.7 eAG-117 04:45AM BLOOD Triglyc-53 HDL-45 CHOL/HD-1.5 LDLcalc-13 Laboratory Data at Discharge: 06:40AM BLOOD WBC-7.8 RBC-4.49 Hgb-14.0 Hct-40.1 MCV-89 MCH-31.2 MCHC-35.0 RDW-13.7 Plt Ct-212 06:40AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-143 K-4.5 Cl-105 HCO3-29 AnGap-14 06:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.1 EKG Sinus rhythm.,0
ST-T wave configuration consistent with acute ischemic injury (question posterolateral).,1
No previous tracing available for comparison.,0
Rate PR QRS QT/QTc P QRS T 77 162 84 30 Cardiac Catheterization (radial) BRIEF HISTORY: This 54 year old female with a family history of premature coronary artery disease and current tobacco use presented to Hospital with intermittent resting substernal chest pain that started the day prior.,1
The patient awoke on the day of admission at 2am with recurrent chest discomfort and presented to the hospital where ECG revealed anterolateral ST elevations and an elevated troponin of 0.52.,1
"She was treated with aspirin, heparin, and nitroglycerin with resolution of her pain and ST changes.",0
"Transfer was catheterization was initiated and following arrival to the ED she developed recurrent chest discomfort, was given integrilin and plavix, and taken urgently to the catheterization laboratory.",0
"PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right radial artery, using a 5 French Jacky radial catheter, advanced to the ascending aorta through a 6 French introducing sheath.",1
"Coronary Angiography: was performed in multiple projections using a 5 French JACKY RADIAL catheter, with manual contrast injections.",0
Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s).,0
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.84 m2 HEMOGLOBIN: 14.7 gms % REST **PRESSURES LEFT VENTRICLE {s/ed} 154/25 AORTA {s/d/m} 154/83/113 **CARDIAC OUTPUT HEART RATE {beats/min} 72 RHYTHM SINUS **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT.,0
FROM **RIGHT CORONARY 1) PROXIMAL RCA DIFFUSELY DISEASED 70 2) MID RCA DIFFUSELY DISEASED 70 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA NORMAL 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT.,1
FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 50 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 DISCRETE 100 15) OBTUSE MARGINAL-2 NORMAL **PTCA RESULTS CX PTCA COMMENTS: Initial angiography revealed a 100% occlusion in a large OM branch.,1
We planned to treat this with PTCA and stenting.,0
Heparin and Integrillin were given prophylactically.,0
A 6F XB3.0 guide provided good support.,0
A BMW wire crossed the stenosis without difficulty.,0
We dottered with a 2.0x12mm Sprinter balloon and then predilated at 12 and 14atm.,0
A 2.5x23mm Promus DES was then deployed at 14atm and post-dilated with a 3.0x15mm Quantum Maverick at 20atm and a 3.25x12mm Quantum Maverick at 22atm (mid/distal) and 14atm (proximal).,0
"After the final balloon inflation there was a proximal cap dissection that was covered with a 2.5x8mm Promus DES, deployed at 16atm, and post-dilated to 3.25mm at 20atm.",0
"Final angiography revealed no residual stenosis, TIMI 3 flow, and no apparent dissection.",0
TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 13 minutes.,0
Arterial time = 1 hour 8 minutes.,0
Fluoro time = 26.6 minutes.,0
"Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 270 ml Premedications: Midazolam 1 mg IV Fentanyl 25 mcg IV, 50 mcg IV ASA 325 mg P.O.",0
Clopidogrel 600 mg PO Anesthesia: 1% Lidocaine subq.,0
"Anticoagulation: Heparin 3000 units IV Other medication: Verapamil 2.5 mg IA Integrilin (2mg/ml) 6.8 ml IV bolus, 11.7 ml/hr IV drip Nitroglycerin 200 mcg IC x2 Cardiac Cath Supplies Used: .035IN , MAGIC TORQUE 180CM .014IN , BMW UNIVERSAL 300CM 2.0MM , SPRINTER 12MM 3.0MM , QUANTUM MAVERICK 15MM 3.25MM , QUANTUM MAVERICK 12MM 3.0MM , QUANTUM MAVERICK RX 12MM 3.25MM , QUANTUM MAVERICK RX 08MM 6FR CORDIS, XB 3.0 - ALLEGIANCE, CUSTOM STERILE PACK - , LEFT HEART KIT - , RIGHT HEART KIT 6FR ARROW, TRANSRADIAL ARTERY ACCESS KIT - , PRIORITY PACK 20/30 2.5MM , PROMUS OTW 23MM 2.5MM , PROMUS OTW 08MM - TERUMO, TR BAND LARGE COMMENTS: 1.",1
Coronary angiography in this right dominant system demonstrated three vessel disease.,0
The LMCA was without angiographically apparent disease.,0
The LAD had 50% mid vessel stenosis.,0
The LCx had a 100% occlusion of a large OM1.,0
The RCA had diffuse disease 60-70% in the proximal and mid vessel and was a large caliber artery.,0
Resting hemodynamics revealed mild systemic arterial systolic hypertension with SBP 154 mmHg.,0
The left ventricular filling pressure was elevated at LVEDP 25 mmHg.,0
There was no significant pressure gradient across the aortic valve.,0
Successful PCI of the occluded OM with overlapping 2.5x8mm (prox) and 2.5x23mm (distal) Promus DES.,0
The entire length of stent was post-dilated to 3.25mm.,0
Elevated left ventricular filling pressure.,0
Successful PCI of the LCx with DES.,0
"CARDIOLOGY FELLOW: , A. , M. Echocardiography The left atrium is mildly dilated.",0
The left ventricular cavity size is normal.,0
Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the posterior and lateral walls.,1
There is an anterior space which most likely represents a promient fat pad.,0
PORTABLE UPRIGHT CHEST RADIOGRAPH: There is no focal consolidation and no effusion or pneumothorax.,0
The pleural surfaces are smooth.,0
The hilar and cardiomediastinal contours are normal.,0
Cervical fixation hardware is incompletely visualized.,0
"There is no acute osseous abnormality, and the surrounding soft tissues and upper abdomen are normal.",1
"Non-specific ST-T wave changes, although ischemia or infarction cannot be excluded.",0
Low voltage in the limb leads.,0
Compared to the previous tracing ST-T wave changes are more diffuse and more marked.,0
"Rate PR QRS QT/QTc P QRS T 66 164 78 8 135 Brief Hospital Course: Coronary Artery Disease STEMI, with EKG concerning enough for activation of the cath lab prior to large enzyme and myocardial damage.",1
Enzymes peaked late on the day of admission and were trending down by .,0
PCI with two drug-eluting stents placed in OM1.,0
"Posterolateral hypokinesis was noted on echo, resulting from the present event and associated with a mildly depressed left-ventricular ejection fraction of 50%.",1
"She was monitored with telemetry without any significant events, except for very occasional ectopy.",0
ECG changes progressed slightly (see above).,0
"A1c was not indicative of diabetes as a potential risk factor, nor were lipids particularly abnormal.",0
Smoking is likely the primary indentified inciting factor for this patient.,0
"However, the patient's mother had early coronary disease, in her 40s, suggesting a genetic predisposition that is as yet unidentified in this pedigree, possibly polygenic.",1
"Agressive lipid lowering is indicated, along with antiplatelet agents, particularly after drug-eluting stent placement.",0
"Therefore, her medication regimen includes atorvastatin (80 mg PO QD), Plavix (75 mg PO BID for one week then QD), aspirin (325 mg PO QD).",0
"A beta-blocker, metoprolol succinate (25 mg PO QD) was also added.",0
"Hypertension Mrs. was mildly hypertensive on the first day of admission, with blood pressure range up to 150/89 mmHg.",0
Lisinopril was commenced at an introductory dose (2.5 mg PO QD).,0
"Metoprolol, as above, likely also has a mildly anti-hypertensive effect.",0
Leukocytosis Likely stress demargination in the context of ACS.,0
Resolved spontaneously during the hospital stay.,0
"Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: After 7 days, switch to once daily in the morning.",0
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*5* Discharge Disposition: Home Discharge Diagnosis: ST elevation MI (heart attack) Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You were admitted with chest pain which was found to be due to a heart attack.,0
Your blocked blood vessel was opened using agioplasty and with the placement of two drug coated stents.,0
You are now safe for discharge home.,0
It is very important that you take all of your medications as directed and keep your follow-up appointments.,0
Followup Instructions: Please call to schedule a follow-up appointment with a cardiologist.,0
"In the hospital, you have been cared for by Dr. .",0
Dr. office number is (.,0
"2:12 PM BABYGRAM (CHEST ONLY) Clip # Reason: verify PICC placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity REASON FOR THIS EXAMINATION: verify PICC placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : CLINICAL HISTORY: Verify PICC placement in this premature infant.",1
FINDINGS: A supine portable chest radiograph is compared to the prior chest film dated .,0
There is a right-sided PICC line with its tip in the region of the junction of the brachiocephalic vein with the SVC.,0
"There is an NG tube with its tip in the stomach, an ET tube with its tip at the thoracic inlet, a left-sided ductus clip and two central lines that are superimposed on each other with their position difficult to determine on this oblique film.",0
There is persistent subtotal opacification of both lungs in this patient with hyaline membrane disease.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: transfer for further management of GI Bleed Major Surgical or Invasive Procedure: Upper endoscopy, colonoscopy, capsule endoscopy History of Present Illness: Patient is a 62 year old male with past medical history of atrial fibrillation, alcohol abuse of 1 pint a day, hypertension, and osteoarthritis who presented to on with bright red blood per rectum and black tarry stools for two days.",1
He presented to his PCP and was referred to the ED from there.,0
He had reported about 6 bowel movements with dark red blood mixed in the stool.,0
"At , his initial HCT was 22.8, with BUN 59 and creatinine of 1.12.",0
"He was initially given 2 units PRBCs with IV lasix, IV protonix, and IV ativan for his history of alcohol.",0
"On , he underwent an upper endoscopy which demonstrated a pyloric channel ulcer with healed margins, which were biopsied.",0
Visualization of the colon was limited by copious amounts of blood.,0
"At CT of the abdomen and pelvis was completed that demonstrated incomplete mixing of the oral contrast and gastric contents, with moderate gastric distension.",0
A soft tissue mass in the right inguinal canal was felt to be secondary to prior hernia repair.,0
He underwent a repeat upper endoscopy that again demonstrated no active bleeding.,0
"Repeat colonoscopy demonstrated large amount of old blood, with difficulty getting beyond hepatic flexure due to view obscured by blood.",0
"He underwent a bleeding scan yesterday () that was completed today, which per discussion with providers, was positive for distal dueodenal and proximal jejunal bleed.",0
"Surgery had been following at the hospital and along with the GI team recommended angiography, for which the transfer was requested.",0
"Prior to transfer, he had received a total of 13 units of PRBCs, last one given on morning of transfer for HCT of 25 (lowest was yesterday at 18, received 5 units that day).",0
"There was a question of hypotension during colonoscopy and preparation, down to the 80'-90's systolic.",0
He has a left subclavian cordis in place.,0
"Per sign-out from , his baseline HCT is low 30's.",0
"On morning of transfer, his BP 108/72 (lowest 94/45 at 1 AM) with MAP's of 63-88.",0
He was reported to be in atrial fibrillation with a rate of 80-110's.,1
"He was on an amiodarone drip, protonix drip, thiamine, albumin, and ativan for CIWA.",0
"Upon arrival to the ICU, patient reported he was thirsty, but otherwise had no complaints.",0
"Past Medical History: - Atrial fibrillation, not on coumadin for over a year, stopped due to drinking history and fall risk (stopped after fall).",1
Several cardioversions at - Hypertension - Alcohol abuse: Reports drinking one pint of hard liquor daily.,1
No known history of alcohol withdrawal or seizures - Osteoarthritis - B12 Anemia - COPD - Right hip replacement - Status-post hernia repair - Colon polyp - Status-post tonsillectomy Social History: Patient lives alone.,1
He formerly worked in the office of the Machinist' and is currently retired.,0
He smokes 2 packer per day.,0
He drinks 1 pint of hard liquor daily or 6 beers at a time.,0
Family History: Father died at 70 with diabetes and mother at 89 with hypertension and stroke.,0
He has no brothers or sisters.,0
"Physical Exam: General: Disheveled, in NAD, asking for a drink and internet access.",0
"Slightly pale HEENT: Pale conjunctiva, no scleral icterus.",0
"Cardiac: Irregular, tachycardic, no rubs/murmurs/gallops Abd: Soft, NT, ND, +BS Extr: Warm, no edema, dried blood over hands.",0
"Neuro: Alert, oriented to person, place, month.",0
"Tangential discussion, but fluent speech.",0
Moving all extremities without difficulty.,0
"Psych: Slightly agitated, tangential speech.",0
Pertinent Results: 02:16PM BLOOD WBC-6.4 RBC-2.77* Hgb-8.4* Hct-24.0* MCV-87 MCH-30.2 MCHC-34.9 RDW-15.8* Plt Ct-140* 03:58AM BLOOD WBC-6.2 RBC-2.75* Hgb-8.5* Hct-24.1* MCV-88 MCH-30.8 MCHC-35.1* RDW-16.5* Plt Ct-205 01:43PM BLOOD Hct-24.9* 02:16PM BLOOD Glucose-99 UreaN-28* Creat-0.8 Na-140 K-4.1 Cl-111* HCO3-24 AnGap-9 03:58AM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-140 K-3.5 Cl-109* HCO3-27 AnGap-8 03:58AM BLOOD Albumin-2.2* Calcium-7.3* Phos-3.3 Mg-1.6 .,0
"Angiography IMPRESSION: No active extravasation, pseudoaneurysm or angiodysplasia in the celiac, SMA and territories.",0
Colonoscopy Impression: Ulceration and erythema in the descending colon (thermal therapy) Polyp in the descending colon Diverticulum in the sigmoid colon Otherwise normal colonoscopy to cecum .,1
Recommendations: Routine post procedure orders.,0
Will proceed to capsule endoscopy.,0
Continue PPI for ulceration seen on EGD.,1
Small Bowel Enteroscopy Findings: Esophagus: Normal esophagus.,0
Stomach: Mucosa: Erythema with granularity and erosions with three areas of clean-based ulcerations were seen in the prepyloric region of the lesser curve of the stomach.,1
The ulcerations were provoked and only one oozed with minimal blood.,1
No visible vessel or clot was seen.,0
One endoclip was successfully applied to the ulceration that was oozing at the prepylorus area for the purpose of hemostasis.,1
Duodenum: Contents: Bile was seen throughout the duodenum without any evidence of blood.,0
jejunum: Contents: Bile was seen throughout the jejunum without any evidence of blood.,0
Impression: Erythema and erosion in the pylorus (endoclip) Blood in the duodenum Blood in the jejunum Otherwise normal small bowel enteroscopy to mid to distal jejunum Recommendations: Continue to monitor HCT and provide supportive measures with blood products and fluids as needed.,0
Would proceed to angiography to localize and embolize bleeding source.,0
Please check H.pylori antibody and treat if positive.,0
"Additional notes: The patient's bleeding source is likely distal to the mid-jejunum, as we do not believe the ulcerations in the stomach were the cause of his aggressive GIB given the nature of the lesions.",1
Capsule Endoscopy Report: Procedure info & findings: 1.,0
Multiple Angioectasia (nonbleeding) through the small bowel 2.,0
The capsule did not reach the cecum.,0
Summary & recommendations: Summary: 1.,0
incomplete capsule endoscopy Recommendations: 1.,0
Follow up with referring physician 3.,0
Please obtain KUB prior to an MRI examination.,0
Complete evaluation of the entire small bowel could not be performed as the capsule did not reach the cecum.,0
Enteroscopy to evaluate the angioectasia GENERAL URINE INFORMATION Type Color Appear Sp 01:02PM Yellow Hazy 1.013 Source: CVS DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks 01:02PM NEG NEG TR NEG NEG NEG NEG 7.5 LG Source: CVS MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp 01:02PM 6* 151* MANY NONE 0 1:02 pm URINE Source: CVS.,0
"URINE CULTURE (Pending): Brief Hospital Course: Mr is a 62 year old male with past medical history of atrial fibrillation, alcohol abuse, hypertension, and osteoarthritis, who was transferred from for further management of a GI bleed.",1
#) GI Bleed: push enteroscopy revealed multiple duodenal erosions felt to be the source of his bleeding.,0
Required 17 U blood in total.,0
ASA held - to be resumed in a week if no bleeding.,0
"#) Atrial fibrillation: Difficult to control, required amio gtt, ultimately digoxin and BB controlled rate.",1
"Echo done, no major abnormality.",0
"EP consulted, recommended dig/BB, resumption of full strength asa when able (in one week as above) .",0
"#) Urinary tract infection, bacterial, following catheterization in the ICU.",1
UA with pyuria and bacteria.,0
"Started on CTX IV emperically, transitioned to cefpodoxime PO for planned 10 day course.",0
final speciation and sensitivity will need to be followed up on by MD hospital.,0
Medications on Admission: Medications at home: - 325 mg ASA - Atenolol 100 mg - Lasix 20 mg daily - Albuterol 90 mcg MDI QID PRN Discharge Medications: 1.,0
Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for WHEEZING OR SOB.,0
Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily).,0
"Pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QD AND HS PRN ().,0
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.,0
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days.,0
"Aspirin 325 mg Tablet, Delayed Release (E.C.)",0
PO once a day: Start on only if no evidence of GI bleeding.,0
"Discharge Disposition: Extended Care Facility: Center - Discharge Diagnosis: GI bleeding Atrial fibrillation with rapid ventricular response Urinary tract infection, bacterial Discharge Condition: Stable.",1
Discharge Instructions: Return to Emergency Room for: blood in stools Take all medications as prescribed.,0
Do not take any aspirin for one week.,0
You can then resume the aspirin as long as there is no gastrointestinal bleeding.,0
"Followup Instructions: With your primary doctor within one week of leaving hospital - , B.",0
"8:00 PM CHEST (PORTABLE AP) Clip # Reason: trauma, s/p svc ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with REASON FOR THIS EXAMINATION: trauma s/p svc ______________________________________________________________________________ FINAL REPORT INDICATION: Status post trauma.",0
"SINGLE VIEW CHEST: An endotracheal tube has been placed in the interval, with tip 1.5 cm above the carina.",0
This could be withdrawn by 2-3 cm.,0
The cardiomediastinal and hilar contours are unremarkable.,0
The lungs are clear and there are no pleural effusions.,0
There is a fracture through the right proximal humerus.,1
IMPRESSION: 1) The endotracheal tube is 1.5 cm above the carina and could be withdrawn by 2-3 cm.,0
2) Right proximal humerus fracture.,1
"7:30 AM CHEST (PORTABLE AP) Clip # Reason: EDEMA Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 24 year old woman with combined kidney, liver transplant REASON FOR THIS EXAMINATION: EDEMA ______________________________________________________________________________ FINAL REPORT INDICATION: A 28-year-old woman with kidney and liver transplant.",1
COMPARISON: The comparison is made with a prior chest radiograph dated .,0
"FINDINGS: The endotracheal tube, right IJ line, nasogastric tube are unchanged compared to the prior study.",0
Bilateral drains are noted overlying the abdomen.,0
Cardiac and mediastinal contours are unchanged.,0
Diffuse hyperdensity in skeletal structures are again noted.,0
IMPRESSION: Tubes and lines as described above.,0
"6:06 PM CHEST (PORTABLE AP) Clip # Reason: r/o failure ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with h/o CHF, s/p exp laparotomy,TAH,BSO and omental bx now w/ increased CO2, wheezing REASON FOR THIS EXAMINATION: r/o failure ______________________________________________________________________________ FINAL REPORT INDICATION: H/O CHF, now s/p surgery with increased wheezing.",0
A SINGLE PORTABLE AP CHEST RADIOGRAPH was obtained and compared to the next prior study of .,0
"In the interval since the prior study, the ET tube and NG tube have been removed.",0
"Again seen, is a right central catheter identified with its tip in the distal SVC.",0
The patient's cardiomegaly is stable.,0
There has been no interval change in the position of the dual pacemaker wires.,0
The pulmonary vessels are within normal limits and there is no definite failure.,0
"There continues to be blunting of the right CP angle and there has been slight interval increase in the opacity at the right base, which may be consistent with a developing infiltrate.",0
IMPRESSION: 1) No definite evidence of CHF.,0
2) Interval increase in opacity at right base.,0
A lateral chest radiograph would be helpful for further evaluation.,0
"5:36 PM CT HEAD W/O CONTRAST Clip # Reason: SDH, REASSESS Admitting Diagnosis: SUB ARACHNOID HEMORRHAGE,INTER CRANIAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with R SDH, increasing confusion REASON FOR THIS EXAMINATION: please repeat head ct to assess contusions No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Subdural hemorrhage, reassess, increasing confusion.",0
FINDINGS: There has been no significant change compared with the prior study.,0
Again demonstrated is a large left intraparenchymal hemorrhage extending from the parietal lobe to the temporal lobe with a stable amount of surrounding edema.,0
Again demonstrated is a frontal and left parafalcine subdural hemorrhage.,0
There are bilateral inferofrontal contusions.,0
The ventricular size is not significantly changed compared with the prior study.,0
There is probable subarachnoid blood within the posterior left parietal lobe.,0
There is edema of the left hemisphere with decrease in the size of the sulcations.,0
The visualized paranasal sinuses are unremarkable.,0
IMPRESSION: There has been no significant change compared with the prior study.,0
There is a large left intraparenchymal hemorrhage.,0
There is a small left anterior subdural hemorrhage.,0
There is trace subarachnoid hemorrhage.,0
"There is minimal left uncal herniation, unchanged.",0
7:18 AM CHEST (PORTABLE AP) Clip # Reason: s/p intubation Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man s/p min invasive esophagogastrectomy REASON FOR THIS EXAMINATION: s/p intubation ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation after intubation.,0
Portable AP chest was reviewed and compared to the previous study from .,0
The endotracheal tube tip is in the good position.,0
At least 4.2 cm above the carina.,0
"The right chest tube remains in place, as well as post surgical drain in the left upper mediastinum.",0
There is no change in the bilateral pulmonary opacities.,0
IMPRESSION: Normal position of the ET tube.,0
No changes in comparison to the previous study.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Respiratory distress s/p elective lymph node biopsy Major Surgical or Invasive Procedure: Right internal jugular central line placement Axillary node biopsy Axillary node biopsy Right internal jugular central line placement Endotracheal Intubation X 2 Cardiopulmonary Resuscitation Thoracentesis History of Present Illness: 27 year old gentleman who presented for an elective axillary lymph node biopsy today and subsequently developed respiratory failure and VF and PEA arrests.,1
"Regarding his lymphadenopathy, he reports he began to notice swelling over his left temple about 3 weeks ago that gradually migrated down the left side of his face and behind his jaw into his neck.",0
He reports it is mildly painful over his temple as well as over his jaw while chewing.,0
He also affirms it is tender to palpation.,0
He was in contact with his PCP with these findings and underwent an ultrasound followed by a CT of his head and neck.,0
The scan revealed adenopathy extending from the left ear into the mediastinum and right axilla and the patient was asked to return to the ED for further work up.,0
"He received a CT of chest, abdomen, and pelvis which revealed a mediastinal mass with multiple enlarged nodes in the mediastinum, right axilla, subclavicular and aortocaval nodes near the level of the kidneys.",1
"He was then admitted to , where he underwent VATS and mediastinal mass biopsy, which was nondiagnostic.",0
"He was readmitted from , where he had ENT, thoracics and ACS consults who all felt that there were no clear options for where his repeat biopsy should occur.",0
"It was felt that his lymph nodes could represent reactive lymphadenopathy from his SVC syndrome, but also that a mediastinal mass biopsy could be unrevealing as this was the case in his last VATS.",1
Therefore he had PET CT to identify FDG-avid lymph nodes most appropriate for biopsy which revealed diffuse disease.,1
He was discharged to home with plan for R axillary LN biopsy today.,0
"Today, he was intubated for airway protection given his habitus prior to procedure.",0
Initial intubation was difficult due to habitus.,0
"On extubation, he wasn't ventilating well with elevated end tidal CO2 despite 30-45 min of Ambu ventilation and was reintubated with difficulty.",0
He had no documented episodes of hypotension throughout.,0
"Subsequent to re-intubation, he was found to be in VF and pulseless.",0
Chest compressions were initiated and he was shocked once with ROSC.,0
He subsequently went into PEA arrest and received 2 doses of epinephrine with ROSC.,0
A left femoral a-line and IJ CVL were placed in the setting of the code.,0
"On arrival to the ICU, the patient is intubated and sedated.",0
"Past Medical History: h/o recent lymphadenopathy and a mediastinal mass polysubstance abuse morbid obesity previously difficult intubation s/p VATS Social History: From , currently living in .",1
Smoking pack per day currently; previously was 1ppd x 6 years.,0
Drinks 1 pint of brandy per day x7 months but has cut back to several watermelon nips per night.,0
Smokes blunts of marijuana daily.,0
Has girlfriend x 7 years.,0
"Graduated high school, was previously working as a security guard but has not been working recently.",0
Family History: No history of known malignancy.,0
DISCHARGE LABS 12:27AM BLOOD WBC-6.9 RBC-4.10* Hgb-12.6* Hct-37.9* MCV-93 MCH-30.9 MCHC-33.4 RDW-12.9 Plt Ct-294 12:27AM BLOOD Neuts-94.4* Lymphs-2.7* Monos-1.6* Eos-1.3 Baso-0 12:27AM BLOOD PT-10.9 PTT-27.2 INR(PT)-1.0 12:27AM BLOOD Fibrino-517* 12:27AM BLOOD Glucose-169* UreaN-12 Creat-0.7 Na-141 K-4.2 Cl-105 HCO3-27 AnGap-13 12:27AM BLOOD ALT-28 AST-14 LD(LDH)-227 AlkPhos-46 TotBili-0.3 12:27AM BLOOD Albumin-3.5 Calcium-8.5 Phos-4.0 Mg-2.4 UricAcd-1.7* .,0
MICROBIOLOGY: TISSUE Site: LYMPH NODE RIGHT AXILLARY LYMPH NODE.,0
GRAM STAIN (Final ): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
"TISSUE (Final ): STAPHYLOCOCCUS, COAGULASE NEGATIVE.",0
"Reported to and read back by , (4I) AT 1207.",0
ANAEROBIC CULTURE (Final ): NO ANAEROBES ISOLATED.,0
ACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.,0
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.,0
SPUTUM Site: ENDOTRACHEAL GRAM STAIN (Final ): <10 PMNs and <10 epithelial cells/100X field.,0
QUALITY OF SPECIMEN CANNOT BE ASSESSED.,0
RESPIRATORY CULTURE (Final ): NO GROWTH.,0
PLEURAL FLUID GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
FLUID CULTURE (Final ): NO GROWTH.,0
ANAEROBIC CULTURE (Final ): NO GROWTH.,0
Mini-BAL GRAM STAIN (Final ): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
"RESPIRATORY CULTURE (Final ): NO GROWTH, <1000 CFU/ml.",0
POTASSIUM HYDROXIDE PREPARATION (Final ): Test cancelled by laboratory.,0
This is a low yield procedure based on our in-house studies.,0
"if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306).",0
Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.,0
Path: Anterior mediastinal mass: ATYPICAL LYMPHOID PROLIFERATION HIGHLY SUGGESTIVE OF LYMPHOMA (SEE NOTE).,0
Note: The specimen is composed of fragments of soft tissue with varying histological patterns.,0
"A significant proportion of the biopsy is composed of dense fibrous tissue with scant lymphoid infiltrate, but prominent focal fibroblastic proliferation.",0
"More cellular areas in the biopsy contain a polymorphous cell infiltrate comprised of a spectrum of lymphoid cells, from small to large atypical cells, and inflammatory cells.",0
"Admixed are histiocytes, occasional Langerhans cells, eosinophils and macrophages.",0
Rare -Sternberg-like cell is seen.,0
However classical RS cells are not present.,0
"In small areas of the biopsy clusters of atypical large cells are present, which resemble those seen in primary mediastinal lymphoma, yet they are negative for B cell markers (see below).",0
"Yet in another site in the biopsy, there are numerous epithelioid cells with abundant pink cytoplasm which are positive for cytokeratin and suggestive of reactive mesothelial cells.",0
"By immunohistochemistry the larger cells are negative for CD20, CD3, CD15, LMP and Bcl-6.",0
Most large cells are also negative for CD30 and PAX-5.,0
"However, a small subset of large cells within an area of crush artifact appears positive for PAX5 and are definitively positive for CD30.",0
The same group of cells appears positive for Bcl-6.,0
The same subset of large cells is negative for CD20 and CD79a.,0
"CD45 stains most of the cells given the impression of staining more cells than accounted for by the combined CD20, CD30 and CD3 stained cells.",0
MIB-1 highlights a high proliferation rate within the larger cells.,0
Overall the findings are highly atypical and suggestive of a lymphoma.,0
"However, given the various histological patterns and the atypical immunohistochemistry results, it is not possible to render a definitive diagnosis in this biopsy.",0
"Given the histopathological complexity of this case and the fact that the patient has extensive lymphadenopathy, an excisional lymph node biopsy, i.e.",0
"complete nodal excision, needs to be attempted to maximize that chances of procuring tissue sufficient for a definitive diagnosis.",0
Images: TTE: The left atrium and right atrium are normal in cavity size.,0
Left ventricular wall thicknesses and cavity size are normal.,0
There is mild global left ventricular hypokinesis (LVEF = 40%).,0
Right ventricular chamber size is normal.,0
with borderline normal free wall function.,0
The estimated pulmonary artery systolic pressure is normal.,0
There is an anterior space which most likely represents a prominent fat pad.,0
"IMPRESSION: Mild global left ventricular systoilc dysfunction (most c/w diffuse process, such as toxic, metabolic, post-cardiac arrest stunning, etc.).",1
No clinically-significant valvular disease seen.,0
"CTA CHEST W&W/O C&RECONS, NON-CORONARY: No evidence of pulmonary embolism.",0
"Diffuse mediastinal lymphadenopathy, with epicardial and bronchovascular encasement.",0
"Increased bilateral pulmonary opacities, likely representing post-obstructive pneumonitis/aspiration, atelectasis, infection, and/or hemorrhage.",1
Increased right and new left pleural effusions.,1
Right axillary/subpectoral lymphadenopathy and postoperative changes.,0
CXR: Endotracheal tube ends approximately 2.5 cm above the carina.,0
Consider retracting the ET tube by additional 2 cm .,0
Moderate pulmonary edema has worsened since .,0
Moderately enlarged heart size is unchanged.,0
Left internal jugular line ends at mid SVC.,0
Worsened bilateral moderate pulmonary edema.,0
Moderately enlarged heart is unchanged.,0
Endotracheal tube terminates 2.53 cm above the carina.,0
Consider retracting ET tube by additional 2 cm for more standard position.,0
"PET CT: Extensive FDG-avid disease in the left cervical nodes, mediastinum, right axilla, abdomen, pelvis and bony skeleton.",1
"There is bronchial narrowing, particularly on the right.",0
Vascular compromise is difficult to assess with this non-contrast study - contrast-enhanced CT of the chest is recommended for better assessment of the vascular and bronchial structures in the chest (if clinically indicated).,0
"EKG: Sinus tach 111 bpm, NA, NI, <1mm J point elevation in II, aVF, axis slightly different as compared with prior .",0
"ECHO: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded.",0
Overall left ventricular systolic function is low normal (LVEF 55%).,0
The number of aortic valve leaflets cannot be determined.,0
The mitral valve leaflets are not well seen.,0
No mitral regurgitation is seen.,0
"IMPRESSION: Low normal left ventricular systolic function, improved compared to the prior study on .",0
"CHEST (PORTABLE AP): As compared to the previous radiograph, the patient has been extubated.",0
The left internal jugular vein catheter remains in situ.,0
Unchanged moderate-to-severe cardiomegaly and bilateral enlargement of the mediastinum without evidence of pathologic mediastinal contours.,0
"Brief Hospital Course: 27M with recently discovered diffuse lymphadenopathy/Hodgkin's lymphoma and polysubstance abuse, who presented for elective R axillary LN dissection and subsequently developed respiratory failure and VF and PEA arrests, now with return of spontaneous circulation.",1
# RESPIRATORY FAILURE: Patient was able to be extubated after 2 days in the ICU.,0
The exact trigger was unclear.,0
The patient had bilateral diffuse infiltrates on CXR.,0
This may have been aspiration pneumonia/pneumonitis given multiple intubation attempts.,1
RLL pleural effusion was tapped evening and drained over 1 liter and pigtail catheter was able to be removed .,1
Pleural effusion had LDH of 325 (serum LDH 271) -> exudative likely from pneumonia vs. malignancy.,1
Fluid was sent for cytology and was pending at the time of discharge.,0
"He was initially treated with Zosyn and Vanco for presumed aspiration pneumonia, planned 8 day course started , but was transitioned to levoquin to complete a 7-day course.",0
Sputum culture and blood cultures were negative.,0
"# VT/PEA ARREST: Unclear trigger but could have been compression from large mediastinal mass, aspiration, or from hypercarbia and hypoxia while being bag masked.",1
There was no evidence of PE on CTA.,0
There was very mild troponin elevation that is now resolved with normal CK-MB consistent with cardiac arrest but not ACS.,1
The patients ejection fraction was noted to be depressed to 40% consistent with myocardial stunning from cardiac arrest but later normalized to 55% on repeat echocardiography.,1
Pt was seen by electrophysiology who felt there was no current indication for ICD placement or further investigation.,0
"Patient was informed of danger signs such as palpitations, racing heart beat, light-headedness to call 911 emergently.",0
"# Hodgkin's Lymphoma: Pathology consistent with Hodgkin's Lymphoma, but final pathology will need to be followed-up on.",1
He started modified ABVD (no bleomycin given his recent pulmonary issues) on .,0
He was started on methylprednisolone 100mg IV q24 for 5 days (day 1 = ) and was transitioned to an oral prednisone taper the day of discharge.,0
"He was put on allopurinol for prevention of tumor lysis, adn this was discontinued upon discharge.",0
He will follow-up with Dr. in clinic on Thursday .,0
# PLEURAL EFFUSION: Pleural fluid had LDH of 325 (serum LDH 271) -> exudative likely from pneumonia vs. malignancy.,1
Cytology was still pending at time of discharge.,0
The pigtail removed prior to discharge from the ICU.,0
# LEUKOCYTOSIS: Likely to have been stress response vs aspiration/infection vs malignancy-related.,0
Infectious work-up was negative and WBC soon normalized.,0
# ABNORMAL LFTs: Were initially elevated but later normalized.,0
have been related to arrest and temporary hypoperfusion.,0
TRANSITIONAL ISSUES: ===================== - Outpatient sleep study for possible OSA.,0
Patient had frequent desaturations to 80s at night.,0
- Pt will need follow-up on final pleural fluid cytology - Pt will need follow-up on final LN biopsy pathology Medications on Admission: Home Meds (per recent discharge summary): albuterol sulfate 2 puffs q4h prn wheezing acetaminophen 650 mg qh4 prn pain/fever docusate sodium 100 mg prn constipation oxycodone 10 mg q4h prn pain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation.,0
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing.,0
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for fever or pain.,0
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days: Please take for the next 6 days (through ).,0
"Disp:*6 Tablet(s)* Refills:*0* 5. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day: Please take 4 tablets (total 40mg) on tablets (total 20mg) on , and 1 tablet (total 10mg) on .",0
Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea for 30 doses.,0
Disp:*30 Tablet(s)* Refills:*0* 7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea for 30 doses.,0
Disp:*30 Tablet(s)* Refills:*0* 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain.,0
Discharge Disposition: Home Discharge Diagnosis: Primary - Cardiac Arrest - Respiratory Failure - Hodgkin's Lymphoma - Pleural Effusion Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Dear Mr. , It was a pleasure taking care of you here at .",0
You came in for a biopsy of your lymph node.,0
After the surgery you were having trouble breathing and your heart stopped beating completely.,0
This was most likely because the mass in your chest was putting pressure on your airway and on your heart.,0
Fortunately you were able to be resuscitated and a tube was placed to help you breathe while you recovered.,0
The breathing tube was able to be removed 2 days later.,0
You were then immediately started on treatment for your lymphoma with chemotherapy.,0
"It is important that you follow-up at your appointment scheduled for this Thursday, .",0
"It is EXTREMELY important that if you begin to feel palpitations, racing heart beat, lightheadedness, or if you feel like you are going to pass out, CALL 911.",0
Please make the following changes to your medications.,0
Please START taking: # Levoquin - Take 1 tablet of 750mg for the next 6 days.,0
"Please take this medication through # Prednisone - Please take 4 tablets of 10 mg (total 40mg) on , take 2 tablets of 10 mg (total 20mg) on , and take 1 tablet of 10mg (total 10mg) on .",0
# Zofran - 1 tablet three times a day only as needed for nausea.,0
"If you find that you need to take this medication more than 3 times in one day, call your doctor.",0
# Compazine - 1 tablet every six hours only as needed for nausea.,0
"If you are having to take this more frequently than every 6 hours, call your doctor.",0
Please continue taking your home medications as prescribed.,0
"Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY at 3:30 PM With: , MD Building: Campus: EAST Best Parking: Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY at 3:30 PM With: DR. Building: SC Clinical Ctr Campus: EAST Best Parking: Garage MD Completed by:",0
5:28 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate hydro and shunt placement.,0
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman s/p vps placement REASON FOR THIS EXAMINATION: evaluate hydro and shunt placement.,0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JBRe WED 6:32 AM Only minimal decrease of ventricular size after right frontal lobe _____ shunt placement.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old with intraventricular hemorrhage, status post VPshunt placement.",0
Please evaluate for hydrocephalus and shunt.,0
TECHNIQUE: Axial images of the head were obtained.,0
Coronal and sagittal reformats were acquired.,0
COMPARISON: CT of the head from .,0
"FINDINGS: In the interval, a right frontal approach VP shunt has been placed.",0
"Its tip lies within frontal of the right lateral ventricle, slightly proximal to the foramen of .",0
The catheter tip is surrounded by hyperdense blood clot.,0
"No acute hemorrhage is seen along the parenchymal course of the catheter, which is surrounded by gliosis from a preexisting catheter.",1
A small focus of air is seen in the right frontal .,0
The ventricular size is only minimally decreased; the frontal horns currently measure 57 mm in maximal axial dimension from previously measuring 61.,0
There is unchanged hemorrhage layering in the occipital horns.,0
Artifacts from coils packs in the region of the left posterior communicating artery are again seen.,0
"The mastoid are barely pneumatized, with opacification on the left.",0
IMPRESSION: Only mild decrease of ventricular size status post right frontal approach VP shunt placement.,0
The catheter tip lies within the right frontal and is surrounded by hyperdense blood clot.,0
Unchanged hemorrhage in the occipital horns.,0
LINE PLACEMENT Clip # Reason: r/o PTX/EffusionPLEASE PERFORM AT 1330 (NOT ON ORDER SET).,0
Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with CAD s/p CABG.,1
Please page at with abnormalities.,0
REASON FOR THIS EXAMINATION: r/o PTX/EffusionPLEASE PERFORM AT 1330 (NOT ON ORDER SET).,0
______________________________________________________________________________ FINAL REPORT HISTORY: CABG.,0
"FINDINGS: In comparison with the previous study, there has been a CABG procedure performed.",0
Endotracheal tube is in place with its tip approximately 5 cm above the carina.,0
"Swan-Ganz catheter from the right IJ, which extends well into the right pulmonary artery.",0
Left chest tube is in place with no evidence of pneumothorax.,0
No nasogastric tube is seen.,0
Atelectatic changes are seen at the left base.,0
IMPRESSION: Standard appearance following CABG.,0
4:24 AM CHEST (PORTABLE AP) Clip # Reason: Eval for PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with worsening oxygen requirements.,0
REASON FOR THIS EXAMINATION: Eval for PNA ______________________________________________________________________________ FINAL REPORT AP CHEST 5:01 A.M. HISTORY: Worsening hypoxia.,0
IMPRESSION: AP chest compared to through : Bibasilar consolidation is continuing to clear.,0
There may be residual bronchiectasis.,0
Normal mediastinal and pulmonary vasculature.,0
"11:38 PM BABYGRAM AP ABD ONLY PORT; -77 BY DIFFERENT PHYSICIAN # Reason: evaluate for bowel gas pattern after repogle changed to Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with PIE on CPAP, abd distention REASON FOR THIS EXAMINATION: evaluate for bowel gas pattern after repogle changed to gravity ______________________________________________________________________________ FINAL REPORT SUPINE ABDOMEN: A supine view of the abdomen demonstrates a nasogastric tube within the stomach.",1
Gas is scattered throughout large and a few loops of small bowel.,0
The overall degree of dilatation is somewhat less than the earlier study of .,0
No pneumatosis or gross free air is identified in the supine position.,0
", R. MED 1:43 PM DIALYSIS REMOVE Clip # Reason: Pt w/tunnel HD line placed by IR.",0
"Erythematous and tender, p Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: Pt w/ESRD on HD, metastatic RCC with bacteremia, fever and tender, erythematous HD line on exam.",0
REASON FOR THIS EXAMINATION: Pt w/tunnel HD line placed by IR.,0
"Erythematous and tender, pt bacteremic.",0
"Request line removal and tip culture, after 2pm today.",0
"______________________________________________________________________________ PFI REPORT Removal of tunneled hemodialysis line, right side, without immediate complications.",0
"10:22 PM CHEST (PORTABLE AP) Clip # Reason: intubated patient s/p AMI, febrile transferred from OSH, ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with REASON FOR THIS EXAMINATION: intubated patient s/p AMI, febrile transferred from OSH, check ETT position, r/o infiltrate ______________________________________________________________________________ FINAL REPORT There is no prior study for comparison.",0
FINDINGS: An ETT is demonstrated in satisfactory position above the carina.,0
NG tube is seen although the tip is not well visualized.,0
There is bilateral pulmonary opacities consistent with mild CHF.,0
"Pulmonary infection, however, cannot be entirely excluded in febrile patient.",0
"9:03 AM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MR CONTRAST GADOLIN Reason: eval for infarcts, lesions Admitting Diagnosis: PANCREATIC MASS/SDA Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman w/ visual deficit and occipital lesions on CT REASON FOR THIS EXAMINATION: eval for infarcts, lesions No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: MRI brain and MRA of the head.",0
CLINICAL INFORMATION: Patient with visual deficit for further evaluation.,0
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained.,0
3D time-of-flight MRA of the circle of was acquired.,0
Correlation was made with the head CT of .,0
"FINDINGS: There is evidence of increased T2 signal, in both occipital lobes without evidence of blood products or slow diffusion.",0
No evidence of acute infarct seen on diffusion images.,0
"Following gadolinium, enhancement is seen in both occipital lobes and areas of signal abnormalities.",0
Findings are suggestive of bilateral occipital edema.,0
The appearances are consistent with reversible posterior encephalopathy.,0
Subtle enhancement is also seen in the right cerebellar hemisphere superiorly which could be also related to the reversible encephalopathy syndrome.,0
There is a small area of nonspecific T2 hyperintensity in the left centrum semiovale.,0
"No mass effect, midline shift or hydrocephalus is seen.",0
No evidence of abnormal signal seen within the visualized venous sinuses.,0
Bilateral soft tissue changes are seen in the mastoid air cells.,0
IMPRESSION: Bilateral occipital signal abnormalities with enhancement and subtle enhancement in the right cerebellar hemisphere are consistent with posterior reversible encephalopathy syndrome.,0
No evidence of acute infarct.,0
MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation.,0
IMPRESSION: Normal MRA of the head.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: DOE/Orthopnea Major Surgical or Invasive Procedure: - MV Repair with 36mm Annuloplasty Band History of Present Illness: This is a 70-year-old male patient with a history of shortness of breath with exertion and a new systolic murmur on clinical examination.,0
"Cardiac cath showed mitral valve area of 2.3 sq cm, ejection fraction of 40% and 4+ mitral regurgitation.",1
He was thus transferred from Hospital for surgical revascularization.,0
Past Medical History: HTN Obesity GERD Hyperlipidemia Benign Schwannoma resection Prostate cancer Social History: FOrmer smoker.,1
Family History: Father died at age 85 of MI.,0
"Physical Exam: Admission VS T 98.2 HR 60 BP 102/59 RR18 O2sat 93% RA Ht 70"" Wt 280lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis.",0
"HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM.",0
Pacer pocket in right upper chest.,0
"LUNGS: CTA bilaterally, mild kyphosis.",0
"HEART: RRR, 4/6 systolic murmur ABD: Soft, ND/NT/NABS, obese.",0
"Small umbilical hernia EXT:warm, well perfused, no bruits, no varicosities, mild peripheral edema NEURO: No focal deficits.",0
Discharge Pertinent Results: Carotid Duplex Ultrasound Minimal plaque with bilateral less than 40% carotid stenosis.,0
04:35AM BLOOD WBC-9.9 RBC-4.04* Hgb-12.1* Hct-34.5* MCV-86 MCH-29.9 MCHC-35.0 RDW-14.7 Plt Ct-287 04:35AM BLOOD PT-12.9 PTT-23.9 INR(PT)-1.1 04:35AM BLOOD Glucose-136* UreaN-22* Creat-0.9 Na-141 K-4.1 Cl-101 HCO3-28 AnGap-16 04:35AM BLOOD ALT-22 AST-20 LD(LDH)-166 AlkPhos-47 TotBili-0.7 11:42AM BLOOD Glucose-128* Lactate-1.4 Na-137 K-4.3 Cl-99* CXR PRE-BYPASS: The left atrium is moderately dilated.,0
Overall left ventricular systolic function is low normal (LVEF 50-55%).,0
[Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.],0
The ascending aorta is mildly dilated.,0
There are simple atheroma in the aortic arch.,0
The descending thoracic aorta is mildly dilated.,0
There are complex (>4mm) atheroma in the descending thoracic aorta.,0
The aortic valve leaflets (3) are mildly thickened.,0
There is mitral leaflet flail of the P2 and P3 segments.,0
"An eccentric, anteriorly directed jet of Severe (4+) mitral regurgitation is seen.",0
"POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenyleprhine and was in an intrinsic sinus rhythm.",0
A well-seated mitral annuloplasty ring is seen with normal leaflet motion and gradients (mean gradient = 4 mmHg).,0
There is no valvular systolic anterior motion ().,0
Trivial (normal for prosthesis) mitral regurgitation is seen.,0
Regional and global left ventricular systolic function are normal.,0
Right ventricular systolic function is normal.,0
Aortic contours are intact post-decannulation.,0
"CXR Small bilateral pleural effusion is present new or newly apparent since , but no pneumothorax following removal of left pleural drain.",0
Cardiomediastinal silhouette has a normal post-operative appearance comparable to the size of the heart pre-operatively.,0
Thickening of the left upper posterior costal pleural surface is probably related to prior chest trauma given adjacent healed rib fractures.,0
ospital Course: Mr. was admitted to the on for further management of his mitral valve regurgitation.,1
He was worked-up by the cardiac surgical service in the usual preoperative manner.,0
A dental consult was obtained for oral clearance for surgery.,0
An infected molar was identified and the recommendation was to extract the tooth prior to his surgery.,0
This was performed on without complication and was subsequently cleared for valve surgery.,1
A urine culture showed leukocytes for which ciprofloxacin was started.,0
On Mr. was taken to the operating room where he underwent a mitral valve repair using a 36mm annuloplasty band.,1
Please see operative note for details.,0
Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring.,0
"Within 24 hours, he awoke neurologically intact and was extubated.",0
"Beta blockade, aspirin and a statin were resumed.",0
"On postoperative day one, he was transferred to the step down unit for monitoring.",0
Mr. was gently diuresed towards his preoperative weight.,0
The physical therapy service was consulted for assistance with his postoperative strength and mobility.,0
He continued to make steady progress and was discharged to home on POD #5.,0
He will follow-up with Dr. as an outpatient.,0
Medications on Admission: Flomax 0.4mg QD Gemfibrozil 600mg Metformin 500mg Zocor 10mg QD Metoprolol 100mg QD Lisinopril 20mg QD Omeprazole 20mg QD Discharge Medications: 1.,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain.,0
Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Tamsulosin 0.4 mg Capsule, Sust.",0
"Release 24 hr Sig: One (1) Capsule, Sust.",0
Release 24 hr PO HS (at bedtime).,0
Release 24 hr(s)* Refills:*2* 7.,0
Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Prilosec 20 mg Capsule, Delayed Release(E.C.)",0
"Sig: One (1) Capsule, Delayed Release(E.C.)",0
Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days.,0
"Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 5 days.",0
"Disp:*5 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: Mitral regurgitation Hyperlipidemia GERD Prostate cancer Benign lung tumor HTN Palpitations Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection.",1
"These include redness, drainage or increased pain.",0
"In the event that you have drainage from your sternal wound, please contact the at (.",0
2) Report any fever greater then 100.5.,0
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week.,0
"4) No lotions, creams or powders to incision until it has healed.",0
You may shower and wash incision.,0
Gently pat the wound dry.,0
No bathing or swimming for 1 month.,0
Use sunscreen on incision if exposed to sun.,0
5) No lifting greater then 10 pounds for 10 weeks.,0
6) No driving for 1 month.,0
7) Call with any questions or concerns.,0
Followup Instructions: Please follow-up with Dr. in 1 month.,0
( Please follow-up with Dr. in 2 weeks.,0
Please call all providers for appointments.,0
"11:37 AM CHEST (PORTABLE AP) Clip # Reason: please assess for interval change, pneumothorax Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman s/p right thoracentesis w/removal of 1500 cc fluid REASON FOR THIS EXAMINATION: please assess for interval change, pneumothorax ______________________________________________________________________________ FINAL REPORT HISTORY: Right thoracentesis, to evaluate for pneumothorax.",0
"FINDINGS: In comparison with study of , there has been substantial removal of pleural fluid from the right with no convincing evidence of pneumothorax.",0
Little change in the appearance of the mediastinal silhouette and left lung.,0
2:57 PM FOREARM (AP & LAT) RIGHT; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.,0
"RIGHTClip # Reason: FRACTURE, DEBRIDMENT Admitting Diagnosis: MVA ______________________________________________________________________________ FINAL REPORT INDICATION: Fracture debridement.",0
Fluoroscopic assistance was provided to the surgeon in the O.R.,0
Four spot views were obtained.,0
These demonstrate fixation of mid shaft fractures of the radius and ulna.,1
"7:18 PM CHEST (PA & LAT) Clip # Reason: Please evaluate for infiltrates or consolidations Admitting Diagnosis: UNRESPOSIVE - (FOUND DOWN) ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman admitted with overdose of TCA and other meds with vent associated pneumonia REASON FOR THIS EXAMINATION: Please evaluate for infiltrates or consolidations ______________________________________________________________________________ FINAL REPORT INDICATION: Overdose, vent-acquired pneumonia, followup.",0
COMPARISON: Chest x-ray from 9:53 a.m. the same day.,0
PA AND LATERAL CHEST RADIOGRAPH: There has been interval improvement in the left lower lobe pneumonia.,0
There is some residual interstitial opacity at the bases.,0
The heart is normal in size.,0
There is mediastinal fullness in the area of the aortic knob.,0
Residual mild bibasilar interstitial abnormality with associated small left pleural effusion.,0
Slight fullness of the left superior mediastinum.,0
Comparison to prior films to determine if this is a new finding warranting further investigation.,0
"Alternatively, if there is any clinical concern for mediastinal adenopathy, a CT scan would be definitive.",0
"4:19 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: please evaluate for LUEx thombosis Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with LUEx swelling REASON FOR THIS EXAMINATION: please evaluate for LUEx thombosis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 5:51 PM PFI: Non-visualization of the left cephalic vein; otherwise, no evidence of DVT in the left upper extremity.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 87-year-old male with left upper extremity swelling.,0
COMPARISON: No prior study available for comparison.,0
"LEFT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the left internal jugular, subclavian, axillary, brachial, and basilic veins was performed.",1
Grayscale images are somewhat limited due to patient body habitus.,0
The cephalic vein was not visualized.,0
"There is normal flow, compressibility, and augmentation of the visualized veins.",0
"IMPRESSION: Non-visualization of the left cephalic vein; otherwise, no evidence of DVT in the left upper extremity.",0
PATIENT/TEST INFORMATION: Indication: Left ventricular function.,0
Height: (in) 67 Weight (lb): 180 BSA (m2): 1.94 m2 BP (mm Hg): 124/64 HR (bpm): 96 Status: Inpatient Date/Time: at 13:14 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT ATRIUM: Normal LA and RA cavity sizes.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure (0-5mmHg).,0
"LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%).",0
"Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",0
Estimated cardiac index is normal (>=2.5L/min/m2).,0
Focal calcifications in aortic root.,0
Mild thickening of mitral valve chordae.,0
No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.,0
Conclusions: The left atrium and right atrium are normal in cavity size.,0
The estimated right atrial pressure is 0-5 mmHg.,0
"Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%).",0
"Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded.",0
The estimated cardiac index is normal (>=2.5L/min/m2).,0
"Compared with the prior study (images reviewed) of , the findings are similar.",0
"CLINICAL IMPLICATIONS: Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended.",0
Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data.,0
1:38 PM CHEST (PA & LAT) Clip # Reason: follow -up Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with COPD and pneumonia REASON FOR THIS EXAMINATION: follow -up ______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old female with COPD and pneumonia.,0
COMPARISON: Chest radiograph from .,0
FINDINGS: There is a right central venous catheter with the tip overlying the mid SVC.,0
"There is persistent consolidation of the left lung base, unchanged in appearance compared to prior.",0
No new focal consolidation is appreciated.,0
Fiducial markers are again seen in the posterior basal segment of left lower lobe overlying an area of known bronchogenic carcinoma.,0
The bilateral upper lobes and right lung are clear.,0
The cardiomediastinal and hilar contours are within normal limits.,0
There is no vascular engorgement or pleural effusion.,0
IMPRESSION: Stable appearance of the left lower lobe consolidation.,0
Central venous catheter with the distal tip in the mid SVC.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: Bactrim Attending: Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation/Extubation Ventricular Drain Placement History of Present Illness: Ms is aged 61 year-old and is right-handed.,0
"She has a history of chronic right posterioir tibial osteomyeltitis, hypertension & LUE DVT on coumadin theraphy, presented with acute mental status change upon waking up at 8am this morning.",1
"According to her daughter, she found Ms lying in bed moaning.",0
She openned her eyes and was verbal.,0
There were no complaints of headache or pain.,0
Ms stood up and was unstable.,0
She returned to bed where she vomited once.,0
There was no LOC but she was noted to have blank staring spell which lasted for less than a minute.,0
No convulsive seizure episode was witnessed.,0
"EMS brought Mrs to Hospital, where initial INR was 3.5.",0
Given FFP & Vit K once each.,0
Her Head CT revealed intraventricular bleed (L) with no underlying mass effect on the preliminary read.,0
Vitals were stable at OSH (SBP 130-150's).,0
Patient was stabilized and transferred to for further management (no neurosurgery available at OSH).,0
"At ER, she was noted to be increasing drowsy, lethargic.",0
Vitals were stable (SBP 150-165) with RR between 14-16 on 2 liter nasal canula.,0
"However, due to concern for respiratory support patient was intubated.",0
"She had difficulty speaking, general weakness.",0
"She did not have a headache, and complained of pain in her right leg.",0
Past Medical History: -LUE DVT: Thrombus identified within the left subclavian and left brachial vein.,0
Likely PICC associated from admission.,0
-: I&D Right proximal tibia wound with excision of posterior sinus and removal of antibiotics beads.,0
-Hypertension for ~20 years -s/p GSW in s/p surgical repair Social History: She lives with her daughter and her two grandsons in an apartment in Plain.,1
Moved to area in .,0
"Denies tobacco, EtOH, or other drugs.",0
"Family History: Mother died three months ago of a heart attack in her 70s, she had diabetes.",0
"Father alive, healthy in the DR. 5 siblings, with hypertension, one with diabetes.",0
"Physical Exam: Vitals: T: P:85/min; R:16/min; BP:157/70, SaO2: *prior to intubation General: stuporous, lethargic; arouses to voice and can respond verbally HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated.",0
"No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl.",0
"S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted.",0
"Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally.",0
Skin: no rashes or lesions noted.,0
"Neurologic: -Mental Status: lethargic, oriented to place & person.",0
Decrease arousal but obeys command.,0
"No dysarthria, no spontaneous speech.",0
Responds to verbal command and deep pressure.,0
-Cranial Nerves: Olfaction not tested.,0
PERRL 2 to 1mm sluggishly reactive.,0
Opens and closes eyes spontaneously.,0
Unable to perform funduscopic exam.,0
Conjugated gaze and limited upgaze with no nystagmus.,0
Facial sensation intact to pressure.,0
"No facial droop, facial musculature symmetric.",0
Able to protrude tongue in midline.,0
"-Motor: Decrease bulk UE/LE, normal tone.",0
Unable to test for pronator drift.,0
Unable to perform formal strength testing.,0
"Spontaneous movement of upper extremities against gravity, lower extremities limited to bilateral toe flexion/extension with spontaneous leg movements.",0
Mild RUE weakness on active movement.,0
"-Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout.",0
"-Coordination: No intention tremor, dysdiadochokinesia noted.",0
No dysmetria on FNF or HKS bilaterally.,0
"- Reflex: No clonus, no pathlogic reflexes Tri Bra Pat An Toes C5 C7 C6 L4 S1 CST L2 2 2 2 2 down R2 2 2 2 2 up -Gait and coordination: unable to formally assess.",0
"Prior to discharge, in terms of her neurological examination, her short-term memory was still selective.",0
"However, her motor exam was virtually normal.",0
"Pertinent Results: LABS Hematology CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 5.0 2.64* 8.6* 24.9* 95 32.6* 34.5 14.9 297 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) 05:41AM 297 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 05:41AM 98 20 1.9* 137 3.9 102 29 10 ANTIBIOTICS Vanco 05:41AM 40.8* Import Result IMAGING CT Head Near complete resolution of hemorrhage along the old ventriculostomy tract.",1
Mild decrease in extensive intraventricular hemorrhage with trace increase in size of the ventricular system.,0
CT Head Diffuse intraventricular hemorrhage in the left greater than right lateral ventricles and extending into the third and fourth ventricle.,0
There is no evidence of midline shift.,0
There is global predominantly left sided sulcal effacement with no herniation.,0
There is extensive periventricular and white matter hypodensity which likely represent chronic microvascular infarct.,0
"Brief Hospital Course: The pt is a 61 year-old right-handed, female, with history of chronic right posterioir tibial osteomyeltitis, hypertension & LUE DVT on coumadin theraphy who presented with mental status change.",1
"Head CT from OSH showed large intraventricular blood most of which is in the left lateral, third, and fourth ventricles; hydrocephalus; no evidence of midline shift; no intraparenchymal hemorrhage; 3 mm low attenuation density in the pons which may be a lacunar infarct of indeterminate age; moderate periventricular white matter chane most likely small vessel occlusive disease.",0
"INR up to 3.5 at OSH, given 2 U FFP and Vitamin K 10 mg IV.",0
"Neurologic exam on admission limited but significant for increase lethargy, somnolence.",0
"Neurologic exam on Day 2 of admission: intubated, attends to examiner, not clearly following commands, PERRL, horizontal eye movement but not vertical, gag intact, moves bilateral UE and LE against gravity, localizes pain in all 4 extremities, reflexes brisker on left (4+ in left biceps and brachioradialis), toes downgoing bilaterally.",0
"Her ICU course and treatment plan was as follows: -s/p ventricular drain with neurosurgery, initially on Ancef 2 gm IV q8hr while drain was in place -received intraventricular tPA x2 days.",0
"Increased pressure on to drain 10->15 on , however altered mental status after that so decreased pressure back down to 10, plan now is to clamp drain and remove as tolerated (culture tip upon d/c) -Goal ICP 5-18 -spiked temp to 102.1 on , f/u CXR, blood cx, CSF cx, UA showed neg leuk/neg nitr, 0-2 WBC, no bact, f/u urine cx.",0
"Started Vancomycin 1 gm IV q12, CTX 2 gm IV q12 -continued to spike temp to 102.4 on , f/u LENIs, repeat CXR -BP controlled with SBP goal 140-160, and her home bp meds were restarted: Lisinopril 20 PO daily, Avapro 75 mg daily, Atenolol 50 mg PO increased to , HCTZ 25 mg daily -Coumadin/ASA were held in setting of IVH -Doxycycline, Fluconazole for chronic suppression of osteomyelitis per ID recs -Speech and Swallow: thin liquids and small bites of soft solids, Pills may be given crushed or whole with puree On ID were consulted regarding the growth of multi-resistant Staphylococcus epidermidis from the EVD tip that had been pulled, approximately a week ago.",0
"They recommended that she continue on Vancomycin until , trough between 15-20.",0
"Unfortunately, her creatinine increased, and her Vanc level was supratherapeutic, so the antibiotic was held for several doses.",0
"ID also recommended continuing her Fluconazole and Doxycycline for her chronic osteomyelitis, they will follow her up as an outpatient.",0
"Discussions with Heme Onc and the line services advised the placement of a picc line (Right), as her central line needed changing.",0
Her picc line was taken out prior to her discharge.,0
"Despite holding her Vanc, her Cr trended upwards, so her ACE inhibitor and were stopped, and a renal artery US were requested.",0
Renal ultrasound did not show renal artery stenosis.,0
"she constantly needs encouragement to eat, drink and go to the bathroom.",0
Her course of Vancomycin was also completed prior to discharge.,0
Medications on Admission: -Coumadin 4mg daily (started ) -Atenolol 50 mg Tablet (Daily).,0
-Aspirin 81 mg Tablet (Daily).,0
-Cholecalciferol (Vitamin D3) 400 unit(Daily).,0
-Calcium Carbonate 500 mg (2 times a day).,0
-Alendronate 70 mg QFRI (every friday).,0
-Lisinopril 20 mg daily -Hydrochlorothiazide 12.5 mg DAILY -Lovenox 60 mg = d/c -Avapro 75 mg once a day.,0
Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours).,0
Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours).,0
Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday).,0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
"Disp:*0 Tablet, Chewable(s)* Refills:*0* 5.",0
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to groin as needed for irritation.,0
Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or temp > 100.,0
Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.,0
HydrALAzine 10 mg IV Q6H:PRN SBP >160 page HO if giving 15.,0
Heparin Flush (10 units/ml) 1 mL IV PRN 16.,0
Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Intraventricular hemorrhage Discharge Condition: Problems with short term memory and motivation, needs to be encouraged to eat.",0
"In terms of her strength, she is able to walk and is almost back to her baseline.",0
Discharge Instructions: You have been admitted with bleeding within the ventricles of your brain.,0
"If you have any of the following symptoms: worsening headache, alteration of consciousness, weakness on any one side of your body, or any other change in your function, please go to your nearest emergency department.",0
"Followup Instructions: With Dr in weeks, please call the office to organize a convenient time .",0
"For follow-up with Dr (Infectious Diseases on ), she will need liver function tests drawn prior to this appointment, and FAX'd to .",0
Weight (lb): 147 BP (mm Hg): 104/57 HR (bpm): 55 Status: Inpatient Date/Time: at 10:17 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,1
No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.,0
All four pulmonary veins identified and enter the left atrium.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present.,0
Simple atheroma in aortic arch.,0
No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage.,0
A small patent foramen ovale is present.,0
A left-to-right shunt across the interatrial septum is seen at rest.,0
Post The LV function is preserved Mild Mitral regurgitation similar to preop Aorta is intact,0
"1:04 PM CHEST (PORTABLE AP) Clip # Reason: interval eval PTX, Chest tube Admitting Diagnosis: HEAD BLEED/SPLENIC LACERATION/KIDNEY LACERATION/MVC ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with PTX REASON FOR THIS EXAMINATION: interval eval PTX, Chest tube ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.",0
"FINDINGS: As compared to the previous radiograph, the left chest tube is in unchanged position.",0
The left lung is now almost completely expanded.,0
A minimal pneumothorax is still seen at the left lung apex.,0
Unchanged areas of atelectasis at the left lung bases.,0
Normal aspect of the right lung.,0
"OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: cirrhosis, refractory ascites ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with cirrhosis and large ascites on exam difficult bedside tap REASON FOR THIS EXAMINATION: cirrhosis, refractory ascites ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old with cirrhosis and refractory ascites.",0
Four-quadrant ultrasound demonstrates a large amount of ascites throughout the abdomen.,0
An appropriate spot for paracentesis was identified in the right lower quadrant.,0
A preprocedure timeout was performed.,0
"Signed, written informed consent was obtained, and all the patient's questions were answered prior to the procedure.",0
The patient was prepped and draped in usual sterile fashion.,0
1% lidocaine was used for local anesthesia.,0
A paracentesis catheter was then inserted into the peritoneum and the ascitic fluid collection.,0
Approximately 5.3 liters of slightly cloudy appearing ascitic fluid was removed.,0
The fluid was sent for cell count and differential.,0
"The patient tolerated the procedure well, and there were no immediate post-procedural complications.",0
"Dr. , the attending radiologist, was present and supervising throughout.",0
IMPRESSION: Successful ultrasound-guided paracentesis with removal 5.3 liters of fluid.,0
9:27 AM CHEST (PA & LAT) Clip # Reason: assess ptx Admitting Diagnosis: CORONARY ARTERY BYPASS GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with ct to water seal REASON FOR THIS EXAMINATION: assess ptx ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Pneumothorax.,1
Chest tube placed to waterseal.,0
COMPARISON: Made to recent study of .,0
A right sided chest tube and mediastinal drain remain in place.,0
The patient is status post median sternotomy and aortic valve replacement.,1
Cardiac and mediastinal contours are within normal limits and stable.,0
There are scattered areas of atelectasis within the right lung with a predominantly linear orientation.,0
"Note is also made of more confluent opacity in the left retrocardiac region, also suggestive of atelectasis.",0
There remains mild elevation of the left hemidiaphragm.,0
IMPRESSION: No evidence of pneumothorax.,0
6:43 PM CT HEAD W/O CONTRAST Clip # Reason: r/o change in bleed Admitting Diagnosis: BILATERAL SAH ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with l temporal contussion.,0
REASON FOR THIS EXAMINATION: r/o change in bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: An 81-year-old female with left temporal lobe hemorrhagic contusion.,0
TECHNIQUE: Axial non-contrast CT imaging of the brain.,0
Comparison is made to prior head CTs from and .,0
FINDINGS: There is an unchanged appearance of an area of intraparenchymal hemorrhage within the anterior left temporal lobe with adjacent hypoattenuation/edema within the surrounding cortex and white matter.,0
Effacement of the adjacent sulci is unchanged.,0
A tiny extra-axial collection of blood tracking along the left convexity appears unchanged when compared to the prior examination.,0
The supratentorial ventricular system appears unchanged in size when compared to the prior study.,0
There is a tiny focus of intracranial air present within the region of the right sylvian fissure.,0
No evidence of acute major vascular territorial infarction.,0
Bone windows show no clear evidence of fracture.,0
"Unchanged appearance of left frontotemporal contusions, surrounding mass effect and extra-axial blood.",0
No new areas of hemorrhage identified and unchanged size of the supratentorial ventricular system.,0
Tiny focus of intracranial air in the region of the right sylvian fissure.,0
Please note that prior head CTs described intracranial air.,0
"While no definite skull fracture is identified on these images, intracranial air is suggestive of an occult fracture.",1
PATIENT/TEST INFORMATION: Indication: serial effusion follow-up.,0
Height: (in) 69 Weight (lb): 128 BSA (m2): 1.71 m2 BP (mm Hg): 90/60 HR (bpm): 98 Status: Inpatient Date/Time: at 13:39 Test: Portable TTE (Focused views) Doppler: Limited Doppler and no color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LEFT VENTRICLE: Normal LV wall thickness.,0
PERICARDIUM: Small to moderate pericardial effusion.,0
GENERAL COMMENTS: Left pleural effusion.,0
The left atrium is mildly dilated.,0
Overall left ventricular systolic function is moderately depressed with moderate global hypokinesis.,0
3.There is a small to moderate sized pericardial effusion.,0
"Compared with the findings of the prior study (images reviewed) of , the pericardial effusion appears the same to slightly less while the overall LV function appears unchanged.",0
12:21 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Pls evaluate placement of NG tube.,0
"Admitting Diagnosis: ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with cardiac arrest, right pleural effusion with chest tube, pulled out his NG tube, now replaced.",1
REASON FOR THIS EXAMINATION: Pls evaluate placement of NG tube.,0
______________________________________________________________________________ FINAL REPORT EXAMINATION: AP chest.,0
INDICATION: Status post cardiac arrest.,0
A single AP view of the chest is obtained on at 12:19 hours and compared with the prior study performed the same day at 7:53 hours.,0
The nasogastric tube has been replaced.,0
Its tip is not included on the current examination but is below the diaphragm.,0
The examination is otherwise unchanged since the prior study.,0
The examination is otherwise unchanged with the known right hilar mass and with patchy air space opacity in the right lower lobe.,0
"12:21 PM CT HEAD W/O CONTRAST Clip # Reason: eval for change in bleed, drain, hydrocephalus- less alert Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with REASON FOR THIS EXAMINATION: eval for change in bleed, drain, hydrocephalus- less alert No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Followup hydrocephalus.",1
CONTRAST HEAD CT: Exam compared to the prior study of .,0
FINDINGS: Ventricular dimension is unchanged from the previous examination.,0
Blood remains layered in the posterior aspect of the lateral ventricles.,0
Some blood is still seen in the posterior aspect of the ambiens cistern.,0
Hematoma is still identified in the right thalamus.,0
There is still considerable artifact from the aneurysm coiling.,0
The ventricular catheter is unchanged in position.,0
IMPRESSION: No change in appearance compared to the previous exam.,0
The lateral ventricles remain moderately to markedly dilated.,0
"11:16 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Eval ETT position, eval for infiltrate/pulm edema Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with OLT, s/p sz, ?",0
"aspiration REASON FOR THIS EXAMINATION: Eval ETT position, eval for infiltrate/pulm edema ______________________________________________________________________________ FINAL REPORT HISTORY: Possible aspiration and edema.",0
"FINDINGS: In comparison with the earlier study of this date, the endotracheal tube tip now lies approximately 2.5 cm above the carina.",0
"The diffuse areas of bilateral opacification have cleared to a substantial extent, which most likely reflect some decreased pulmonary edema though resolving aspiration could also be present.",0
Nasogastric tube is now in place and there has been resolution of the dilatation of gas-filled structure in the left upper quadrant.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Heparin Agents Attending: Chief Complaint: Nonhealing ulcer of the left foot.,0
Ischemic rest pain of the right foot.,0
"Major Surgical or Invasive Procedure: Aortobifemoral bypass with 14 x 7 Dacron graft and thrombectomy of right fem- graft Exploratory laparotomy, left colectomy with proctectomy and takedown splenic flexure.",1
History of Present Illness: This 63-year-old gentleman with severe peripheral vascular disease has rest pain of his right foot and a nonhealing ulcer on the left.,1
He has previously had a left-to-right fem-fem bypass with a right femoral-popliteal bypass with saphenous vein many years ago at another institution.,0
This graft was found to be failing and he has undergone a combination of iliac angioplasty and stenting on the left to improve inflow plus surgical revision of the fem- fem bypass.,1
He continues to have poor flow to his extremities and we decided to convert his inflow to an aortobifemoral graft.,1
"Past Medical History: PVD DM2 HTN hyperchol CKD (Cr 1.4) PSH: s/p Left 2nd toe amp, L Angioplasty, CABG '.",0
"L. to R. fem-fem, R. fem-, L iliac stent Social History: Denies tobacco.",0
"Married, lives with his wife.",0
Worked as a computer programmer.,0
This would be consistent with pneumonia in the appropriate clinical setting.,0
The remainder of the lungs is unchanged.,0
Mild increased distension of the pulmonary vasculature suggests slight worsening of fluid status.,0
"IMPRESSION: Evolving left lower lobe consolidation, consistent with pneumonia in the appropriate clinical setting.",1
"DR. Cardiology Report ECG Study Date of 4:21:56 AM Technically difficult study Sinus tachycardia ,Right bundle branch block ST-T wave abnormalities , Since previous tracing of , heart rate faster, ST-T wave abnormalities more marked Read by: , A. Radiology Report PICC W/O PORT Study Date of 2:37 PM Final Report PICC LINE PLACEMENT TECHNIQUE: Using sterile technique and local anesthesia, the left basilic vein was punctured under direct ultrasound guidance using a micropuncture set.",0
A peel-away sheath was then placed over a guide wire and a double lumen PICC line measuring 45 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
The peel-away sheath and guide wire were then removed.,0
There were no immediate complications.,1
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the left basilic venous approach.,0
"Final internal length is 45 cm, with the tip positioned in SVC.",0
DR. DR. Brief Hospital Course: 63 y.o M patient who came in for a scheduled admission on for Aortobifemoral bypass with 14 x 7 Dacron graft and thrombectomy of right fem- graft.,1
"Patient tolerated procedure well, in the PACU patient was noted to have abdominal distention, bladder pressures monitored.",0
"Patient wa hypotensive, started on Neosyniphrine IV drip, transfused with 1 unit PRBC's, decision was made to keep patient intubated, transferred to CVICU.",0
"Patient was fluid rescuscitated, Neo drip was able to be weaned off.",0
"POD1 T maxed 101.1 the rest of vitals stable, remains sedated with Propofol and remains intubated, now acidotic.",0
"Monitored for colon ischemia, abdomen remain distended and tender.",0
Patient became hyperglycemic started with insulin gtt.,0
"POD2 T max 101, hypotensive at times- fluid replaced.",0
"Patient failed vent wean, remains intubated with prn sedation.",0
"Abdomen remains distended, and tympanic.",0
"Hct and Plts down, HIT sent.",0
Started on Zosyn imperically for GNR in sputum.,0
Remains on insulin gtt for glycemic control.,0
POD3 Remains febrile T max 101.3 HR and BP stable.,0
"Patient remains intubated and slightly sedate, able to follow commands.",0
"Reamins on Insulin gtt, started on Protonix IV.",0
"Hct 25<-26<-30, transfused with 1 unit PRBC.",0
"POD4 T max 101.3, HR & BP stable.",0
Remains intubated and slightly sedate.,0
"Abdomen remain distended and firm, bladder pressure 17, kept NPO, genral surgery consulted- recs KUB-showed stomach air filled, abdominal CT with PO contrast-limited study due to PO contrast.",0
"Remains on insulin gtt, Zosyn and added Flagyl IV.",0
PA RIJ converted to TLC CL.,0
"POD5 Increasing melena stools with fever TM 102, general surgery made decision to take to the OR.",0
"Patient underwent Exploratory laparotomy, left colectomy/colostomy with proctectomy and takedown splenic flexure.",0
"Patient tolerated procedure well, returned to for recovery and further observation, J-Tube placement.",0
"POD6/1 VSS, T M 97.7.",0
"Remains intubated, sedated with Versed and Fentanyl.",0
"Zosyn discontinued, started on Vanco and Cipro, kept on Flagyl.",0
"POD7/2 VSS, no acute events.",0
"Remains intubated and sedate, weaning sedation, able to MAE and following commands.",0
Started on Lopressor IV for hypertension.,0
"HCT stable, HIT (-), started on Hep SQ tid for DVT prophylaxis.",0
Remains on Inulin gtt and IV Protonix.,0
Weaning sedation and from vent.,0
"Reamins on Vanco, Cipro, Flagyl, insulin drip, Protonix IV, Fenatnyl.",0
Started to diurese with Lasix.,0
"Diuresing with Lasix, remains on Vanco, Cipro, Flagyl, insulin drip, Protonix IV, Fentanyl.",0
Started tube feeds via J-tube (goal 100cc/h of strength).,0
Converted Insulin gtt to RISS.,0
Endocrine consulted for longterm glycemic control.,0
"Remains on Vanco,insulin drip, Protonix IV, metoprolol IV,Cipro & Flagyl switched to PO.",0
Tube feeds advancing to goal.,0
"POD13/7 VSS, doing well extubated.",0
"PICC line placed in IR, CL d/c'd.",0
"Diuresing with Lasix, Lopressor IV.",0
Remains on Vanc/Cipro/Flagyl and Insulin gtt.,0
Psyc was consulted for delirium ?,0
Out of bed to chair.,0
"Nasal swab came back positive for Oxacillin RESISTANT Staphylococci, placed on respective precaution.",0
"TF at goal, speech and swallow consult to assess ability for PO intake-passed swallowing for soft solids.",0
Continue with out of bed with physical therapy.,0
Psych following-recs Haldol AM and PM.,0
"Tube feeds at goal, change to cycle at night, encourage PO intake.",0
"Started clears PO, continue to cycle tube feeds.",0
POD18/12 Fever spike- blood cultures sent.,0
Continued to work with PT for OOB activities.,0
Continue to cycle tube feeds.,0
"PO's back to clears, patient became distended and nauseous after soft solids.",0
"Caudal portion of wound dressed with wet to dry, DSD .",0
R groin dressed with DSD.,0
L foot ulcer - with Accuzyme then DSD daily.,0
Lydex to the rest of L LE then wrap with kling.,0
"POD19/13 VSS, discharged to extended facility in stable condition.",0
"Medications on Admission: Carvedilol 25'', Lisinopril 40', Bumetanide 1.5', RISS, Lantus 34U qhs, MVI daily, Simvastatin 80', Aspirin 325', Plavix 75', Garlic daily, Losartan 50mg daily, Lutein 6', Ranitidine 150' Discharge Medications: 1.",0
Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical (2 times a day).,0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed.,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): discontinue when patient is fully ambulating.",0
"Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): Hold for diarrhea, excessively soft stool.",0
Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Ongoing for bowel necrosis.,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: On going for bowel necrosis.,0
"Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Drops Ophthalmic PRN (as needed).,0
"Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP < 110, HR < 60.",0
"Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical (2 times a day).",0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed.,0
Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed.,0
Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).,0
Potassium & Sodium Phosphates mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for 3 days: discontinue pending Phosphate and Potassium levels.,0
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: Maximum tylenol 4 g per day.,0
Dextrose 50% in Water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed).,0
Insulin Glargine 100 unit/mL Solution Sig: One (1) 14 units Subcutaneous once a day: 14 units glargine SQ q24h at 0600.,0
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) 40 units Subcutaneous at bedtime: 40 units NPH SQ q24h at 2200. .,0
Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Humalog slidingscale-adm per blood glucose criteria: 5U humalog at starting at 161 mg/dl; increase insulin in increments of 3 units for every 40 mg/dl change in blood glucose eg.,0
161 - 200 5U 201-240 8U 241-280 11U 281-320 14U 320-360 17U > 360 page MD scale as needed.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Nonhealing ulcer of the left foot.,0
"Postoperative colonic ischemia Postoperative delerium Asplenia noted on operation Past Medical History: CAD, Peripheral Vascular disease, Eczema, DM, Chol, HTN, CRI, GERD, Anemia Past Surgical History: s/p RCA stent (bare metal ), Lt 2nd toe amp , CABG, Lt to Rt Fem-fem bypass with Rt fem/ bypass n past, revision Left fem-fem , Lt iliac stent, Lt PTA Discharge Condition: Weak but stable.",1
Keep G limb of GJ tube clamped with q4h residual checks; you may need to return G limb to gravity if his abdomen becomes more distended or he is uncomfortable.,0
Change caudal portion of abdominal wound with wet to dry sterile gauze dressings ; may dress R groin incision with dry sterile dressing 3.,0
"Apply accuzyme ointment to ulcers on left foot, lidex and DSD to calves b/l and change dressings on lower extremities once daily 4.",1
"Check blood glucose ac and hs, administer scale as needed; may need to adjust scale 5.",0
Pt will need to be on long term cipro and flagyl for bowel ischemia.,0
The patient is in need of extensive rehab/PT.,0
Slowly taper down the Haldol at night over the course of weeks.,0
Follow up with Dr on at 2:00 pm.,0
Follow up with Dr in weeks Phone: call to make an appointment 3.,0
"Follow up with your primary care physician, for your chronic renal disease, diabetes, htn, and heart disease Completed by:",1
5:35 AM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: MVC ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with s/p mvc REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT OF THE CERVICAL SPINE WITHOUT CONTRAST: INDICATION: Trauma.,0
TECHNIQUE: CT imaging of the cervical spine from the skull base to the thoracic inlet without IV contrast.,0
Reformatting imaging in the coronal and sagittal plane was performed.,0
There are no studies available for comparison.,0
FINDINGS: There is no evidence of fracture or subluxation.,0
The vertebral bodies are normal in height and alignment.,0
The intervertebral disc spaces are preserved.,0
The central spinal canal is patent.,0
There is no evidence of abnormal prevertebral soft tissue swelling.,0
There is an ETT and orogastric tube in place.,0
Within the right lung apex there is evidence of collapse of the posterior segment of the right upper lobe with an air bronchogram.,0
IMPRESSION: 1) No evidence of fracture or subluxation.,0
2) Collapse of the posterior segment of the right upper lobe.,0
", NMED SICU-A 6:27 AM CT C-SPINE W/O CONTRAST Clip # Reason: fracture Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with fall and c-spine tenderness REASON FOR THIS EXAMINATION: fracture No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: No acute fracture.",1
8:58 AM MR HEAD W & W/O CONTRAST Clip # Reason: s/p tumor resection Admitting Diagnosis: BRAIN MASS Contrast: MAGNEVIST Amt: 12 ______________________________________________________________________________ MEDICAL CONDITION: 44 yo W with PMH of metastatic melanoma s/p radiation and IL-2 tx presented to OSH with HA and confusion.,1
"Pts spouse reporting pt would forget turns in directions while driving, forgets doing the grocery shopping, short term memory loss and personality changes over the past week.",0
"HA is frontal, worse in the evening, responds to ibuprofen.",0
"s/p crani and tumor resection REASON FOR THIS EXAMINATION: s/p tumor resection No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb FRI 3:30 PM There is restricted diffusion lining the resection cavity and within the right caudate, consistent with infarct.",0
Mass effect and ventricular enlargement are again identified.,0
"______________________________________________________________________________ FINAL REPORT MRI OF THE BRAIN WITHOUT AND WITH CONTRAST, INDICATION: 44-year-old with past medical history of metastatic melanoma.",1
Status post resection of right frontal mass.,0
"TECHNIQUE: Axial gradient echo, FLAIR, T2-weighted, and diffusion-weighted sequences were obtained.",0
"Additionally, multiplanar pre- and post-gadolinium T1-weighted sequences were acquired.",0
COMPARISON: Correlation is made with recent pre- and post-operative examinations.,0
"FINDINGS: There is restricted diffusion involving the right caudate nucleus, as well as lining the resection bed, consistent with infarct.",0
Postoperative changes from right frontal craniotomy and resection of a large right frontal mass are noted.,0
There is T1 hyperintense material within and lining the resection cavity on the pre- contrast T1- weighted sequence.,0
"Post contrast, there is no definite hyperintensity beyond that seen on the pre-contrast sequence to suggest presence of residual tumor.",0
"However, the presence of small amounts of residual tumor within hemorrhagic regions described above cannot be completely excluded, and further followup after resolution of postoperative hemorrhage is recommended.",0
There is approximately 10 mm of midline shift.,0
"As before, there is substantial mass effect on the anterior of the right lateral ventricle.",0
Enlargement of the posterior of the right lateral ventricle and of the left lateral ventricle are again noted.,0
There is trans-ependymal CSF flow.,0
There is bilateral uncal herniation.,0
"Overall, these findings of mass effect (Over) 8:58 AM MR HEAD W & W/O CONTRAST Clip # Reason: s/p tumor resection Admitting Diagnosis: BRAIN MASS Contrast: MAGNEVIST Amt: 12 ______________________________________________________________________________ FINAL REPORT (Cont) are similar when compared with the pre- operative examination.",0
Globes and orbits are unremarkable.,0
Osseous and soft tissue structures are notable for postoperative changes from the craniotomy including soft tissue swelling.,0
"Diffusion abnormality within the right caudate and lining the resection cavity, consistent with acute infarct.",0
"Postoperative changes as described above, with associated blood product within and lining the resection cavity.",0
Followup after resolution of hemorrhage is recommended to assess for the presence of residual tumor.,0
"Midline shift and mass effect upon the anterior of right lateral ventricle, with bilateral uncal herniation.",0
"Overall, the extent of these findings is unchanged when compared with the pre-operative examination.",0
2:22 PM CHEST (PORTABLE AP) Clip # Reason: S/P Lt CVL placement.,0
Check line position r/o pneumothorax.,0
"______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with MVA, descending thoracic aortic injury and intraparenchymal liver injury b/l pulm contusion ct to water seal REASON FOR THIS EXAMINATION: S/P Lt CVL placement.",1
______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST RADIOGRAPH.,0
HISTORY: Status post left central venous line placement.,0
Check position and rule out pneumothorax.,0
Comparison is made to the prior study of .,0
FINDINGS: A central line is noted entering from the right side with its tip at the junction of the superior vena cava and the right atrium.,0
The tip of the endotracheal tube is approximately 5 cm superior to the carina.,0
There is a chest tube entering from the right and terminating in the mid-hemithorax on the right.,0
There are bibasilar opacifications which may represent contusion versus atelectasis versus consolidation and these are unchanged from the study of the prior day.,0
The upper lobe opacities seen predominantly on the right are also unchanged.,0
New central line with the tip located at the caval-atrial junction.,0
There is no pneumothorax on the right or the left.,0
Pulmonary opacities unchanged since the prior study yesterday.,0
"1:14 PM HUMERUS (AP & LAT) LEFT; FOREARM (AP & LAT) LEFT Clip # SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT; HAND (AP, LAT & OBLIQUE) LEFT Reason: r/o fracture ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman peds struck by auto REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ FINAL REPORT INDICATION: 42-year-old female pedestrian struck by a car.",1
COMPARISONS: No comparisons are available.,0
"TECHNIQUE: Left humerus, two views/left forearm, one view/left lateral wrist, one view.",0
There is a fracture of the mid shaft of the left humerus with lateral displacement and foreshortening.,1
The fracture is comminuted to at least three fragments.,0
IMPRESSION: Comminuted fracture of the mid shaft of the humerus with lateral displacement and foreshortening.,1
"8:06 AM CT HEAD W/O CONTRAST Clip # Reason: s/p subdural drain removal followup Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with altered mental status found to have Right SDH REASON FOR THIS EXAMINATION: s/p subdural drain removal followup No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NONCONTRAST HEAD CT SCAN: HISTORY: Right-sided subdural, s/p drain removal.",0
TECHNIQUE: Noncontrast head CT scan.,0
"FINDINGS: Since the prior examination of , there has been apparent removal of the right-sided subdural drain.",0
"A small right frontal convexity subdural hemorrhage is still seen, with mixed high and intermediate density material effacing the adjacent cortical sulci of the right frontal lobe with continued 7 to 8 mm contralateral shift of the septum pellucidum and other midline structures.",1
No other significant interval changes are appreciated at this time.,0
CONCLUSION: S/P removal of subdural drainage catheter.,0
7:41 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change.,0
Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man 3 days s/p MIE with right chest tube in place.,0
REASON FOR THIS EXAMINATION: Please eval for interval change.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 7:52 A.M., HISTORY: Minimally invasive esophagectomy three days ago.",0
Right chest tube in place.,0
IMPRESSION: AP chest compared to through 8: Previous bibasilar atelectasis and moderate left pleural effusion have cleared.,0
Right apical pleural tube still in place with no appreciable right pleural abnormality.,0
Mediastinum has a normal postoperative appearance following esophagectomy and gastric pull-up.,0
"Nasogastric tube has been partially withdrawn and now ends 6 cm above the level of the diaphragm, projecting over a midline drain.",0
3:46 PM UNILAT LOWER EXT VEINS Clip # Reason: LT LEG SWELLING EVALUATE FOR DVT Admitting Diagnosis: CONGESTIVE HEART FAILURE;EXACERBATION;HYPOGLYEMIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with swollen left leg REASON FOR THIS EXAMINATION: ?,1
DVT ______________________________________________________________________________ WET READ: KMTd WED 4:42 PM No DVT.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Swollen left leg.,0
FINDINGS: The bilateral common femoral veins have normal flow and appropriate response to Valsalva.,0
The left leg is edematous but there is no evidence of deep vein thrombosis.,0
"The common femoral vein, greater saphenous vein, superficial femoral vein, popliteal vein, peroneal vein, and posterior tibial veins are patent with normal compressibility.",0
There is normal response to augmentation.,0
IMPRESSION: No evidence of left lower extremity deep vein thrombosis.,0
5:06 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man admitted with hypoxic respiratory failure REASON FOR THIS EXAMINATION: please eval for interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST AT 06:16 COMPARISON STUDY: CLINICAL INFORMATION: Hypoxic respiratory failure.,0
FINDINGS: Endotracheal tube terminates at the thoracic inlet.,0
Nasogastric tube courses towards the stomach but the tip is not seen.,0
There are patchy opacities at both lung bases which could be consistent with atelectasis or pneumonia.,0
There are probable bilateral small effusions.,0
Mediastinum is within normal limits.,0
"IMPRESSION: Bilateral bibasilar densities, atelectasis versus pneumonia.",0
5:12 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with SDH REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Assessment of interval change.,0
"FINDINGS: As compared to the previous radiograph, the endotracheal tube, the nasogastric tube and the right-sided central venous access line are unchanged.",0
There is a newly occurred retrocardiac atelectasis and a small left-sided pleural effusion.,0
Focal parenchymal opacities suggestive of pneumonia are not seen.,0
8:34 AM CHEST (PORTABLE AP) Clip # Reason: now with productive cough Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with s/p L CVA REASON FOR THIS EXAMINATION: now with productive cough ______________________________________________________________________________ FINAL REPORT INDICATIONS: Recent stroke and productive cough.,0
"CHEST, AP UPRIGHT: Comparison is made to .",0
The stomach is again rotated.,0
"A nasogastric tube has been placed since the prior study, terminating in the upper portion of the stomach, but with a little purchase.",0
The sidehole is not well visualized and could be above the gastroesophageal junction.,0
There is no upper zone redistribution of the pulmonary vessels.,0
"There are hazy bibasilar opacities which may in part reflect soft tissue attenuation, but the presence of parenchymal airspace disease is suspected.",0
The appearance includes obscuration of the medial right hemidiaphragm and an equivocal focal right lower lobe opacity.,0
"Bibasilar hazy opacities, overall similar to before, although an equivocal focal opacity is now visualized in the right lower lobe.",0
"Differential considerations include atelectasis, dependent edema, aspiration, or in the appropriate clinical setting, pneumonia.",0
"Followup radiographs, preferably with PA and lateral technique, are recommended when clinically feasible.",0
"Relatively proximal positioning of nasogastric tube, which could be advanced further into the stomach to gain better purchase.",0
Findings discussed with Dr. from the SICU on the same day.,0
9:56 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for effusion Admitting Diagnosis: AORTIC VALVE DISEASE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 66 year old male s/p AVR.,1
REASON FOR THIS EXAMINATION: Please assess for effusion ______________________________________________________________________________ FINAL REPORT INDICATION: S/P AVR.,0
"SINGLE VIEW CHEST, AP: There has been interval extubation and removal of right internal jugular Swan-Ganz catheter.",0
The right internal jugular sheath remains in place.,0
With the tip in the distal internal jugular vein.,0
The left sided chest tube and mediastinal drain appear in unchanged position.,0
The cardiac and mediastinal contours are widened and are in stable position.,0
There is persistent atelectasis/effusion at the bilateral bases.,0
IMPRESSION: Small bilateral pleural effusions.,0
"LINE PLACEMENT Clip # Reason: s/p RIJ CVL Admitting Diagnosis: PSEUDOCYST;ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with REASON FOR THIS EXAMINATION: s/p RIJ CVL ______________________________________________________________________________ FINAL REPORT Right IJ line placed, check position.",0
The tip of the right IJ line lies at approximately the junction of the subclavian and internal jugular vein.,0
There is no evidence of pneumothorax.,0
Atelectasis in the right apex is present.,0
Endotracheal tube is present in satisfactory position.,0
Atelectasis at the left base is also present.,0
4:35 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # Reason: Please evaluate effusions further.,0
"Also, presence of infiltr Admitting Diagnosis: SVC SYNDROME Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with h/o plasmacytoma/multiple myeloma s/p autologous stem cell transplant s/p SVC stent and now having daily fevers.",1
Found to have worsening effusions on CXR.,0
REASON FOR THIS EXAMINATION: Please evaluate effusions further.,0
CONTRAINDICATIONS for IV CONTRAST: Cr=1.6 ______________________________________________________________________________ FINAL REPORT INDICATION: 62 year old man with history of multiple myeloma.,1
S/P SVC stent now with daily fevers.,0
TECHNIQUE: Helical axial images of the chest and abdomen were performed without oral and without intravenous contrast.,0
No intravenous contrast was used secondary to the patient's impaired renal function.,0
CHEST CT WITHOUT IV CONTRAST: There is a 2.5 x 4.3 cm mixed attenuation fluid collection in the left upper chest wall.,0
This is at the site of the prior Porta-cath.,0
Minimal surrounding fat stranding is present.,0
There is no axillary or mediastinal lymph node enlargement.,0
A superior vena cava stent is present.,0
There are no infiltrates or consolidations.,0
"There are small bilateral pleural effusions, right greater than left.",0
These are new since the prior study.,0
A subcentimeter nodule is present at the left upper lobe which is stable from prior study of .,0
"ABDOMEN CT WITHOUT IV CONTRAST: The liver, gallbladder, pancreas, spleen, and adrenal glands are unremarkable.",0
Small non-pathologically enlarged retroperitoneal lymph nodes are present.,0
The stomach and visualized portions of the small bowel and large bowel are normal.,0
There is a stable mixed lytic and sclerotic lesion within a lower thoracic vertebral body.,0
This is consistent with the patient's history of multiple myeloma.,1
No new lesions are present.,0
Left anterior chest wall superficial collection at prior port site.,0
"This may be postoperative in nature, representing a hematoma/seroma.",0
An infected collection cannot be ruled out.,0
"Small bilateral pleural effusions, new since the prior study.",0
"Left upper lobe pulmonary nodule, stable from .",0
Stable osseous mixed lytic/sclerotic thoracic vertebral lesion.,0
(Over) 4:35 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # Reason: Please evaluate effusions further.,0
"Also, presence of infiltr Admitting Diagnosis: SVC SYNDROME Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"7:38 AM PORTABLE ABDOMEN Clip # Reason: Benign abdomen on exam, but peg in place.",0
"Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with hx of PE, MS changes w/ fever 101.4, hx of hypoxia looking for source of infection.",0
"REASON FOR THIS EXAMINATION: Benign abdomen on exam, but peg in place.",0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 82-year-old male with history of pulmonary embolus, mental status change with fever to 101.4, and hypoxia.",0
Evaluate for source of infection.,0
SUPINE ABDOMINAL RADIOGRAPH: Bowel gas pattern is non-obstructive.,0
Retained contrast is seen within the colon.,0
Tip of gastrostomy tube is seen overlying the abdomen in the expected region of the stomach.,0
NG tube is partially imaged on the superior margin of the radiograph.,0
Four metallic clips are identified overlying the left lower abdominal quadrant.,0
"8mm density overlies the expected region of the right kideny, most consitent with stone.",0
Tip of gastrostomy tube overlies the stomach.,0
8:25 PM CTA HEAD W&W/O C & RECONS Clip # Reason: eval ICH Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with IVH REASON FOR THIS EXAMINATION: eval ICH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: CTA of the head.,0
"CLINICAL INFORMATION: Patient with intraventricular hemorrhage, for further evaluation.",0
TECHNIQUE: CT of the head was acquired without contrast.,0
"Following this, using departmental protocol, CT angiography of the head acquired.",0
The examination is limited due to delays in acquisition and optimum bolus was not obtained.,0
"FINDINGS: CT HEAD: There is intraventricular hemorrhage identified involving right lateral ventricle, third ventricle, with some extension to the left lateral ventricle.",0
A small area of hyperdensity is also identified in the left sylvian fissure region.,0
CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates a vascular prominence adjacent to the left middle cerebral artery.,0
"However, due to incomplete vascular opacification, it is unclear whether this is due to an aneurysm or due to a prominent venous structure.",0
A repeat CT angiography or a conventional angiography of the head would be helpful for further assessment.,0
The remaining vascular structures appear patent.,0
Intraventricular hemorrhage is identified on CT of the head along with a small area of hypodensity in the left middle cranial fossa.,0
"CT angiography is limited due to delay in acquisition, but demonstrates a small area of contrast enhancement in the left middle cranial fossa adjacent to the sphenoid margin and adjacent to the left middle cerebral artery.",0
It is unclear whether this is due to an MCA aneurysm or due to venous filling.,0
Repeat CT angiography of the head or conventional angiography would be helpful for further assessment.,0
PATIENT/TEST INFORMATION: Indication: Intraop pericardial fluid drainage and pericadiectomy Height: (in) 62 Weight (lb): 121 BSA (m2): 1.55 m2 BP (mm Hg): 120/50 HR (bpm): 105 Status: Inpatient Date/Time: at 16:29 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Mild global RV free wall hypokinesis.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.,0
"Effusion echo dense, c/w blood, inflammation or other cellular elements.",0
Stranding is visualized within the pericardial space c/w organization.,0
Conclusions: Pre pericardial drainage: The left atrium is mildly dilated.,0
A promient/enlarged coronary sinus is seen with a baffle joining.,0
Flow in the baffle is consistent with pulmonary venous flow (this most likely represents the previous correction of partial anamolus pulmonary venous return).,0
The atrial septum is bowed toward the right atrial side No atrial septal defect is seen by 2D or color Doppler.,0
2 distinct right sided pulmonary veins are seen with normal flow profiles.,0
Only one left sided pulmonary vein can be clearly seen.,0
There is mild global right ventricular free wall hypokinesis.,0
There is a large pericardial effusion and an echogenic pericardium..,1
"The effusion appears circumferential, but is loculated and focused mainly posteriorly toward the apex.",0
It is 2.8 cm in diameter at largest.,0
"The effusion is echo dense, consistent with blood, inflammation or other cellular elements.",0
Post drainage and pericardial stripping: The pericardial effusion is now absent/trace.,0
"There is still some thickened/bright pericardium seen posterior to the heart, but the remaining pericardium is no longer seen.",0
RV function appears somewhat improved (borderline normal).,0
The remaining exam is unchanged.,0
All findings discussed with surgeons at the time of the exam.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Shellfish Attending: Chief Complaint: unresponsiveness, respiratory distress Major Surgical or Invasive Procedure: Picc line placement History of Present Illness: Mr. is a 55 year old man with history of COPD on 3L home O2, hypertension, diabetes, history of stroke, hypertension, IV drug use on chronic methadone, history of pancreatitis, history of PE with IVC () who was admitted to on for unresponsiveness and respiratory failure.",1
"He was found minimally responsive at his long-term facility and brought to the ED, where his O2sat was 71% on 3L NC.",0
He was febrile to 101.6F in the ED.,0
He was initially given 2mg Narcan and placed on BiPap with improvement in respiratory status.,0
His respiratory rate increased after the Narcan.,0
CXR was performed which demonstrated a RUL pneumonia.,0
"He received CTX, Flagyl, and Vancomycin.",0
"During his stay in the ED, he became unresponsive at which time ABG was 7.10/168/356/56; he was again given Narcan with improvement.",0
He was then transferred to the MICU after moderate improvement.,0
"In the MICU, he was initially treated with BiPAP and he was continued on vancomycin and zosyn for his RUL pneumonia.",0
He received nebs and prednisone.,0
His Utox was negative except for opiates.,0
"He came off of BiPAP, was stabilized on 3LNC, afebrile, and breathing comfortably, and was called out to the general medical floor.",0
His ABG improved to 7.37/77/153/46 at the time of transfer.,0
"Over the preceding days, patient required between 3-6LNC with O2 sats 89-91%.",0
"On the morning of transfer, his oxygen saturation was noted to be low, between 70-mid 80s.",0
"He was given a nebulizer treatment, after which he transiently improved.",0
At that time he was A+Ox3.,0
A CXR was performed which was showed improvement in RUL infiltrate.,0
He then became more sedated and was given 0.4mg ov Narcan with no improvement.,0
"At that time, ABG showed 7.43/70/64/15.",0
"His saturation increased on a venti mask (up to 96% sat), then trended down to 84%.",0
He was then noted to be increasingly somnolent and transiently unresponsive (with no movement and unrousable to sternal rub); ABG at that time was 7.50/54/83/44.,0
Patient was then transferred to the MICU.,0
"Upon arrival to the MICU, the patient is mentating without difficulty.",0
States he does not understand why he needs to be in intensive care.,0
He does remember having low oxygen this morning but does not remember being unresponsive or frequent attempted arousals.,0
O2 sat is 86-91% on 6L O2.,0
"He denies any chest pain, pleuritic chest discomfort, palpitations, leg pain, cough, shortness of breath, diarrhea, constipation.",0
He does feel like his breathing is somewhat more difficult than at home.,0
He notes that he typically only wears his oxygen at night.,0
"Past Medical History: # Chronic obstructive pulmonary disease: On home O2 # Diabetes: pancreatic surgery # Hypertension # Chronic pancreatitis, s/p Whipple # Hepatitis C # Peptic ulcer disease # Anemia # History of PE with IVC filter () # Possible CVA (): Reports he was comatose for two weeks and has had memory problems since # Seizure disorder # Previous substance abuse # Depression Social History: Lives in retirement home.",1
Brother and sister in area.,0
"Previous alcohol abuse, quit 13 years ago.",0
"Previous smoker 2 pks a day, duration unknown, quit 2-3 years ago.",0
"Previous heroin abuse Family History: Unknown Physical Exam: PE: T: 98.7 BP: 138/79 HR: 93 RR: 14 O2 91% 6LNC Gen: Pleasant, comfortable, no respiratory distress HEENT: No conjunctival pallor.",1
"NECK: Supple, No LAD, No JVD.",0
"No appreciable murmurs, rubs or LUNGS: Decreased breath sounds throughout but symmetric bilat.",0
TTP in epigastrum w/o rebound or guarding.,0
2+ DP pulses BL SKIN: No rashes/lesions.,0
Gait assessment deferred Pertinent Results: STUDIES: .,0
ECG : NSR @ 88.,0
Early repolarization changes in inf leads.,0
"Compared to prior, no change.",0
CXR : writers read: improved consolidation in RUL.,0
CXR : There is interval improvement of the consolidation within the right upper lobe.,0
There is some atelectasis of the right base.,0
The cardiac silhouette and mediastinum is within normal limits.,0
CXR : Right upper lobe pneumonia.,0
Repeat radiography following appropriate therapy recommended to document resolution.,0
ECHO : The left atrium is normal in size.,0
There is mild symmetric left ventricular hypertrophy.,0
There is borderline right ventricular hypertrophy.,0
The pulmonary artery systolic pressure could not be determined (probably at least mildly elevated but Doppler measurements were technically suboptimal).,0
"Brief Hospital Course: Mr. is a 55yoM with history of COPD on 3L home O2, DM, HTN, chronic methadone use admitted with altered MS found to have hypercapnea and pneumonia.",1
"The patient was initially admitted to the MICU, then transferred to the floor.",0
Patient was then transferred back to the MICU.,0
"Upon arrival to the MICU, the patient was mentating without difficulty.",0
"After further improvement in his respiratory status, he was transferred back out the the floor on 3-4L O2.",0
Hospital Course by problem: # altered mental status: waxing and on floor.,0
"Ddx includes med induced, hypercarbia, seizure, infection, toxic-metabolic encephalopathy.",0
Patient was back to MS baseline at time of admission to the MICU.,0
Not clearly related to CO2 and did not have evidence of worsening CO2 rentention from baseline.,0
"Suspect significant contribution of psychoactive medications including methadone, gabapentin, zyprexa, theophylline.",0
Should also consider seizure given question of seizure disorder although no post ictal period and no obvious evidence of seizure clinically.,0
No evidence to suggest active infection either.,0
"Intially methadone, zyprexa, gabapentin were held -> improved MS with holding these medications.",0
These medications have all been resumed at time of discharge.,0
A theophylline level was checked and found to be subtherapeutic.,0
His LFTs and pancreatic enzymes were found to be unremarkable.,0
# hypoxia: pt has a home O2 requirement but significantly increased O2 requirement at presentation.,0
"Ddx includes hypoventilation, PE, mucous plugging, pneumonia, V/Q mismatch from COPD, CHF, cardiac ischemia.",0
Hypoventilation could be explained by altered MS despite improved MS.,0
Pneumonia appears improved on CXR.,0
No evidence of collapse on CXR to suggest mucous plugging.,0
No evidence of CHF on exam or CXR.,0
Pt was ruled out for MI and no ischemic changes on ECG.,0
PE ruled out by CTA.,0
O2 sats were maintained between 88-92% to avoid CO2 retention.,0
"# COPD: Pt has a baseline O2 requirement, ~ 3L O2 via nasal cannula.",0
"Pt was continued on albuterol, spiriva, flovent and theophylline.",0
"Patient was given prednisone and is now on a taper, currently day 2 of prednisone 20mg.",0
He will continue for 3 additional days and then taper to prednisone 10mg qday x 5 days.,0
# RUL Pneumonia - Initially thought to be a possible aspiration PNA given unresponsiveness.,0
Suspect some contribution of pneumonitis given rapid resolution on CXR.,0
No sputum Cx available as dry cough.,0
Afebrile without white count currently.,0
"Treated with vancomycin and zosyn, now day .",0
Patient has a PICC line in place for IV antibiotics.,0
# Diabetes: secondary to pancreatic resection.,0
"NPH was uptitrated while on prednisone, also patient with many dietary indiscretions while in-house resulting in elevated BS.",0
Will discharge patient on NPH 15mg and sliding scale insulin.,0
"As prednisone is tapered and stricter diet is resumed, the patient will likely require less insulin.",0
"# Hypertension: Patient was admitted off antihypertensives but home regimen was supposed to consist of lisinopril 60mg daily, HCTZ 25mg daily, clonidine patch 0.2mg daily, toprol XL 25mg daily.",0
Home regime was slowly re-initiated and patient is discharged on his home regiment.,0
# Chronic abdominal pain: unclear etiology.,0
Likely secondary to abdominal surgery.,0
Seems to be at patients baseline.,0
"# History of PE: Unclear circumstances but had IVC filter placed, reportedly in 2/.",0
IVC filtered confirmed by abdominal CT. Had been on coumadin but was d/c'ed following admission .,0
CTA w/o evidence of new PE.,0
Patient received subq heparin throughout this hospitalization.,0
# Hepatitis C. No active issues.,0
# Seizure disorder: Keppra continued throughout hospitalization.,0
Patient did not have an EEG.,0
# Previous IVDU on methadone - Patient has some nonspecific aches/pains but no clear e/o withdrawal.,0
Home dose Methadone 5 mg PO tid.,0
Patient was restarted on his home dose of methadone the day before discharge.,0
The patient was evaluated by physical therapy and will be discharged to a rehab bed at the with physical therapy.,0
He was discharged on hospital day #7 in stable condition.,0
"Medications on Admission: Albuterol Nebs Q2H PRN Fluticasone 2 puff INH Buproprion 150mg PO BID Citalopram 40mg daily Olanzapine 5mg QHS Levetiracetam 500mg TID Ferrous Sulfate 325mg Gabapentin 300mg , 600mg QHS Memantine 5mg daily Methadone 5mg TID Acetaminophen 325mg Q6H PRN Colace 100mg Dulcolax PRN Amylase-Lipase-Protease 20,000-4,500,25,000 capsule TID with meals Theophylline 80mg/15mL Insulin NPH 10 units QD Tiotropium 18mcg one cap INH daily Ipratropium 0.02% INH Q6H Prilosec 20mg daily Discharge Medications: 1.",0
Fluticasone 110 mcg/Actuation Aerosol : Two (2) Puff Inhalation (2 times a day).,0
Bupropion 75 mg Tablet : Two (2) Tablet PO BID (2 times a day).,0
Citalopram 20 mg Tablet : Two (2) Tablet PO DAILY (Daily).,0
Levetiracetam 500 mg Tablet : One (1) Tablet PO TID (3 times a day).,0
Docusate Sodium 100 mg Capsule : One (1) Capsule PO BID (2 times a day).,0
Senna 8.6 mg Tablet : One (1) Tablet PO BID (2 times a day) as needed.,0
"Bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
": Two (2) Tablet, Delayed Release (E.C.)",0
PO DAILY (Daily) as needed.,0
Ferrous Sulfate 325 (65) mg Tablet : One (1) Tablet PO DAILY (Daily).,0
"Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.)",0
: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
Theophylline 80 mg/15 mL Elixir : One (1) PO BID (2 times a day).,0
"Lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR DAILY (Daily).",0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution : One (1) Inhalation Q4H (every 4 hours).,0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution : One (1) inhalation Inhalation Q2H (every 2 hours) as needed.,0
Hydrochlorothiazide 25 mg Tablet : 0.5 Tablet PO DAILY (Daily).,0
"Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device : One (1) Cap Inhalation DAILY (Daily).",0
"Acetaminophen 325 mg Tablet : One (1) Tablet PO Q6H (every 6 hours) as needed for pain, .",0
Ibuprofen 400 mg Tablet : Two (2) Tablet PO Q8H (every 8 hours) as needed.,0
Ipratropium Bromide 0.02 % Solution : One (1) inhalation Inhalation Q6H (every 6 hours) as needed.,0
Prednisone 20 mg Tablet : One (1) Tablet PO DAILY (Daily) for 3 days.,0
Lisinopril 20 mg Tablet : Two (2) Tablet PO DAILY (Daily).,0
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr : One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Methadone 5 mg Tablet : One (1) Tablet PO TID (3 times a day).,0
Gabapentin 300 mg Capsule : One (1) Capsule PO BID (2 times a day).,0
Gabapentin 300 mg Capsule : Two (2) Capsule PO HS (at bedtime).,0
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 26.,0
Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback : One (1) Intravenous Q8H (every 8 hours) for 7 days.,0
Vancomycin in Dextrose 1 gram/200 mL Piggyback : One (1) Intravenous Q 12H (Every 12 Hours) for 7 days.,0
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 29.,0
Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN.,0
Zyprexa 5 mg Tablet : One (1) Tablet PO qHS.,0
Clonidine 0.2 mg Tablet : One (1) Tablet PO once a day.,0
32. insulin Humalog Insulin Sliding Scale per sliding scale provided.,0
"NPH 15mg (breakfast/dinner) Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary: Pneumonia COPD exacerbation Diabetes Secondary: HTN Chronic pancreatitis HCV PUD Anemia h/o PE with IVC filter Seizure d/o h/o substance abuse Depression Discharge Condition: Stable Discharge Instructions: Please call your doctor > 100.4, shortness of breath, chest pain, inability to tolerate food/liquids.",1
"Follow up with your PCP, .",0
She will see you at your long term care facility.,0
7:19 AM CHEST (PORTABLE AP) Clip # Reason: assess CHF Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 59 yo m w/ bile leak s/p ERCP ARDS leukocytosis REASON FOR THIS EXAMINATION: assess CHF ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY.,0
INDICATION: 59 year old man with bile leak status post ERCP.,0
A single AP portable semi-upright radiograph of the chest was obtained and compared with the next-previous exam dated .,0
There has been no interval change in positioning of a tracheostomy tube nor a left subclavian line.,0
An NG tube is identified with tip passing below the left hemidiaphragm.,0
"Since the previous study, there has been an overall improvement in aeration of the lungs bilaterally, though patchy alveolar opacities persist throughout both lung fields.",0
There are bilateral pleural effusions with fluid seen tracking intothe minor fissure.,0
The overall heart size and mediastinal contours appear stable.,0
IMPRESSION: Interval improvement in aeration of the lungs though some degree of patchy alveolar opacities persists.,0
"Bilateral pleural effusions, probably not significantly changed allowing for differences in patient positioning.",0
LINE PLACEMENT Clip # Reason: ?,0
pneumothorax Admitting Diagnosis: SPINAL CORD TRANSECTION ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p L SCV CVL placement REASON FOR THIS EXAMINATION: ?,0
pneumothorax ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess left subclavian catheter.,0
Comparison is made with prior study performed four hours earlier.,0
New left subclavian vein catheter tip is in the proximal SVC facing the azygos vein.,0
There are no other acute interval changes.,0
"2:10 PM BILAT LOWER EXT VEINS Clip # Reason: Please evaluate for DVT Admitting Diagnosis: MEDIASTINAL MASS ______________________________________________________________________________ MEDICAL CONDITION: 58 year-old female with small cell lung carcinoma, new onset tachycardia with concern for PE REASON FOR THIS EXAMINATION: Please evaluate for DVT ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw SAT 4:17 PM PFI: No DVT in the right or left lower extremity.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 50-year-old woman with small cell lung cancer with new onset tachycardia, evaluate for DVT.",0
"FINDINGS: Grayscale and color son of bilateral common femoral, superficial femoral, popliteal and calf vessels were performed.",0
There is a femoral catheter in the right common femoral vein.,0
"However, an overlying bandage material slightly limits the evaluation of the proximal and mid right superficial femoral veins.",0
"However, normal compressibility, flow and augmentation are observed in all vessels.",0
Arterial vascular calcifications are present.,0
IMPRESSION: No evidence for DVT in the right or left lower extremity.,0
"10:08 AM CHEST (PA & LAT) Clip # Reason: r/o PNA Admitting Diagnosis: CHOLEDOCHOLITHIASIS; GASTRIC ADENOCARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with w/ choledocholithiasis, gastric adenoCA s/p hemigastrectomy w/ B2 loop gastrojej, D2 lymphadenectomy, CCY, CBD exploration, choledochojej REASON FOR THIS EXAMINATION: r/o PNA ______________________________________________________________________________ FINAL REPORT INDICATION: Status post hemigastrectomy, cholecystectomy and choledochoduodenostomy, to rule out pneumonia.",0
COMPARISON: A chest radiograph from .,0
PA AND LATERAL CHEST RADIOGRAPH: In comparison with the recent prior study there has been no significant change in the moderate right pleural effusion and associated right lower lobe opacity which may represent atelectasis or consolidation.,0
Left lung is well expanded and clear.,0
There is no significant change in the small left pleural effusion.,0
The cardiomediastinal and hilar contours are unchanged.,0
"The nasogastric tube terminates 2.5 cm below the diaphragm, should be advanced further for standard positioning.",0
3:26 AM CHEST (PORTABLE AP) Clip # Reason: interval evaluation s/p extubation Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with liver failure REASON FOR THIS EXAMINATION: interval evaluation s/p extubation ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST DATED COMPARISON: Study of .,1
FINDINGS: Indwelling devices are unchanged in position and cardiomediastinal contours are similar allowing for rightward patient rotation.,0
Hazy and reticular opacities in the mid and lower lungs may reflect pulmonary edema in this patient with upper lobe predominant emphysema.,0
5:03 PM CHEST (PORTABLE AP) Clip # Reason: s/p line change.,0
"______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with Hx inf MI, admitted for obstruction, gastrectomy/Bilroth II, now intubated REASON FOR THIS EXAMINATION: s/p line change.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post line change, confirm placement.",0
COMPARISON: Radiograph from one day previously.,0
AP CHEST: The previous exam pulmonary artery catheter has been placed with a central venous line with its tip in the distal SVC.,0
The ET tube tip is unchanged in position.,0
"Again, bibasilar opacities are present within the lungs, not significantly changed.",0
The remainder of the exam is unchanged from the prior.,0
Status post removal of the right IJ pulmonary artery catheter with appropriate placement of the new line.,0
No significant change in the pulmonary parenchyma.,0
12:02 PM CHEST (PA & LAT) Clip # Reason: s/p R thoracotomy Admitting Diagnosis: LUNG CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with REASON FOR THIS EXAMINATION: s/p R thoracotomy ______________________________________________________________________________ FINAL REPORT INDICATION: S/P thoracotomy procedure and left lobectomy.,0
"CHEST, PA AND LATERAL: Two chest tubes remain in place in the left hemithorax.",0
There is a persistent tiny left apical pneumothorax.,0
There is stable postop volume loss in the left hemithorax.,0
Minor atelectatic changes are seen in the left retrocardiac region.,0
The right lung remains clear.,0
"There is extensive subcutaneous emphysema in the left chest wall, markedly increased in the interval.",0
One of the chest tubes appears to be at a slightly lower position in the interval and may have been withdrawn.,0
IMPRESSION: 1) Stable tiny left apical pneumothorax.,0
2) Marked increase in degree of subcutaneous emphysema in the left chest wall.,0
12:29 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ptx?,0
s/p chest tube removal Admitting Diagnosis: UNSTABLE ANGINA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p CABGx4 now w/ acute desaturation REASON FOR THIS EXAMINATION: ptx?,0
"s/p chest tube removal ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: CABG x4, now with acute desaturations status post removal of chest tubes.",0
CHEST: The left chest tube has been removed.,0
Infiltrates are present in the right side particularly in the right upper lobe slightly more pronounced on the previous chest x-ray though this is probably exaggerated due to the low lung volumes.,0
Increased density behind the heart is also present suggesting infiltrates or atelectasis in the left lower lobe as well.,0
IMPRESSION: Infiltrates in right upper lobe and left lower lobe and to a lesser extent right lower lobe.,0
"2:01 PM CHEST (PORTABLE AP) Clip # Reason: eval possible asp -2 PM CXR please Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with R cerebellar bleed, ?aspiration 2PM CXR REASON FOR THIS EXAMINATION: eval possible asp -2 PM CXR please ______________________________________________________________________________ FINAL REPORT AP CHEST 2:07 P.M. ON : HISTORY: Right cerebellar bleed.",0
IMPRESSION: AP chest compared to through 22: Small right pleural effusion is new.,0
Reticular nodular abnormality in the upper lungs has improved since .,0
There are no findings to suggest recent aspiration.,0
I suspect the pulmonary abnormality is due to combination of emphysema and previous mild pulmonary edema.,0
Heart is normal size and the thoracic aorta tortuous but not dilated.,0
"7:17 AM NEONATAL HEAD PORTABLE Clip # Reason: PREMATURE INFANT 1 MONTH AGO ASSESS FOR PVL ______________________________________________________________________________ MEDICAL CONDITION: Infant with 28 4/7 weeks, dol 30 REASON FOR THIS EXAMINATION: R/O PVL, 1 month HUS ______________________________________________________________________________ FINAL REPORT INDICATIONS: One month old former premature infant 28 4/7th weeks.",1
HEAD ULTRASOUND: Comparison is made to previous films from which had been normal aside from slightly asymmetrically thickened left choroid plexus.,0
FINDINGS: Examination of the cranium through the anterior fontanel and mastoid foramen demonstrated no intracranial abnormality.,0
There was no son evidence of periventricular leukomalcia.,0
The choroid plexus is normal on the left side and on the right side as well.,0
"3:01 PM CT ABDOMEN W/O CONTRAST Clip # Reason: ?acute process Admitting Diagnosis: RESPITORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with h/o perforated colon and fevers,pre-op CT scan for IVC filter placement REASON FOR THIS EXAMINATION: ?acute process CONTRAINDICATIONS for IV CONTRAST: crea ______________________________________________________________________________ FINAL REPORT CT ABDOMEN AND PELVIS INDICATION: Query acute intra-abdominal process, history of perforated colon, post-colonoscopy with increased temperature.",1
COMPARISON: No prior CT imaging in this institution for comparison.,0
TECHNIQUE: MDCT axially acquired images from the lung bases to the pubic symphysis displayed with 5-mm slice thickness with oral contrast only.,0
No IV contrast was administered due to abnormal creatinine.,0
Coronal and sagittal reformats have been provided.,0
FINDINGS: CT ABDOMEN WITH IV CONTRAST: There are small bilateral pleural effusions.,0
No lung masses or nodules.,0
"There is mild-to-moderate intra-abdominal ascites and extensive inflammatory stranding of the omentum, greater than expected from previous surgery.",0
The fluid is seen to collect in no-dependent areas of the abdomen.,0
Findings ar worrisome for peritonitis.,0
A sample of fluid could be aspirated and sent for cuture.,0
Anastomotic suture line is identified in the distal transverse colon with an ileostomy identified in the right iliac fossa.,0
NG tube is noted in situ.,0
"Within the confines of non-contrast examination, the liver, gallbladder, spleen, pancreas, adrenals and kidneys are unremarkable.",1
No retroperitoneal masses or adenopathy.,0
The visualized IVC is unremarkable.,0
CT PELVIS WITH IV CONTRAST: Small trace of free fluid is noted in the pelvis.,0
Urinary catheter is noted in the bladder.,0
"The prostate, rectum and sigmoid colon are unremarkable.",0
(Over) 3:01 PM CT ABDOMEN W/O CONTRAST Clip # Reason: ?acute process Admitting Diagnosis: RESPITORY FAILURE ______________________________________________________________________________ FINAL REPORT (Cont) CT OSSEOUS SKELETON: There are degenerative changes with vacuum disc phenomena noted at L5-S1 with no osseous destructive lesions.,1
IMPRESSION: 1.Mild-to-moderate non-dependent intra-abdominal ascites and stranding of the greater omentum more than expected post-surgery concerning for peritonitis.,0
2.Unremarkable ileostomy in the right iliac fossa.,0
Findings discussed by phone with requesting physician MD @ 5:10pm.,0
"3:25 PM CHEST (PA & LAT) Clip # Reason: eval for pnuemothorax on waterseal, PLEASE do at 4 pm tonigh ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with REASON FOR THIS EXAMINATION: eval for pnuemothorax on waterseal, PLEASE do at 4 pm tonight ______________________________________________________________________________ FINAL REPORT INDICATION: Chest tube on water seal, evaluate for pneumothorax.",0
PA AND LATERAL CHEST: Comparison is made to prior study of .,0
The left sided chest tube overlies the left lung apex.,0
There is no evidence for pneumothorax.,0
"There is decreased opacity in the left retrocardiac region, likely representing improving atelectasis.",0
The pulmonary vasculature is unremarkable.,0
The osseous structures are unremarkable.,0
IMPRESSION: 1) No evidence for pneumothorax.,0
2) Atelectasis at the left lung base.,0
3:05 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
ptx after CT removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with CABG REASON FOR THIS EXAMINATION: ?,1
ptx after CT removal ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after CABG.,0
Portable AP chest radiograph was reviewed in comparison to and .,0
The patient was extubated in the meantime interval.,0
"The Swan-Ganz catheter, the NG tube have been removed.",0
There is retrocardiac opacity most likely representing atelectasis.,0
No appreciable pleural effusion has been demonstrated.,0
"12:34 AM CT HEAD W/O CONTRAST Clip # Reason: intrval change in neuro exam Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK (TIA) ______________________________________________________________________________ MEDICAL CONDITION: The patient is a 67 year old right handed woman with a history of CAD s/p MI x2, hypertension, DM, PVD s/p bilateral BKA, and s/p living un-related renal transplant 10 years prior who initially presented to on with a month history of left arm shaking, which on the 2 days prior to admission was associated with left arm weakness and dysarthria, who was subsequently found to have a right MCA infarction.",1
The patient had 2 MRI/MRAs which did not show a right MCA stroke prior to the CT head on showing those findings.,0
"Of note, her second MRI/MRA was within 2 hours of her symptoms of left sided weakness on the morning of , and only showed the small right frontal DWI abnormality.",0
"Regardless, her mental status declined during the day, and a repeat head CT in the evening showed an acute large right MCA infarct.",1
"REASON FOR THIS EXAMINATION: intrval change in neuro exam CONTRAINDICATIONS for IV CONTRAST: s/p renal xplant ______________________________________________________________________________ FINAL REPORT INDICATION: 67-year-old right-handed female with a history of coronary artery disease, myocardial infarction, hypertension and stroke.",1
"NON-CONTRAST HEAD CT: Large area of hypoattenuation in the right frontal, parietal and temporal lobe is consistent with evolving right MCA territory infarct.",0
Degree of mass effect on to the right lateral ventricle secondary to surrounding edema is not significantly changed.,0
"There is no hemorrhage, hydrocephalus, shift of normally midline structure.",0
The -white matter differentiation in the left cerebral hemisphere is preserved.,0
The paranasal sinuses and mastoid air cells are normally aerated.,0
IMPRESSION: Continued evolution of large right MCA territory infarct.,0
10:48 AM CHEST (PORTABLE AP) Clip # Reason: please eval interval change Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCT ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with acute respiratory distress yesterday REASON FOR THIS EXAMINATION: please eval interval change ______________________________________________________________________________ FINAL REPORT CHEST ONE VIEW PORTABLE INDICATION: 62-year-old man with acute respiratory distress.,1
"COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared with the previous study of yesterday.",0
The previously identified mild congestive heart failure has been improving.,1
There is continued cardiomegaly and small pericardial effusion.,0
There is continued left lower lobe opacity indicating pneumonia versus atelectasis.,0
3:52 PM CHEST (PA & LAT) Clip # Reason: abd pain eval for free air ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with REASON FOR THIS EXAMINATION: abd pain eval for free air ______________________________________________________________________________ FINAL REPORT HISTORY: 39-year-old female with abdominal pain.,0
To assess for free intra- abdominal air.,0
TECHNIQUE: AP and lateral radiographs of the chest were performed.,0
Comparison is made with radiographs of .,0
FINDINGS: There is no acute pulmonary process.,0
The cardiomediastinal silhouette is stable.,0
There is no evidence of free air under the diaphragm.,0
CONCLUSION: No acute cardiopulmonary process.,0
No evidence of free air under the diaphragm.,0
"6:51 PM CHEST (PORTABLE AP) Clip # Reason: please assess for PNA Admitting Diagnosis: NON Q MI\CATH ______________________________________________________________________________ MEDICAL CONDITION: 65 yo male w/ NSTEMI, decompensated heart failure, s/p cardiac cath today, and reported PNA at outside hospital REASON FOR THIS EXAMINATION: please assess for PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male with non-ST elevation MI and heart failure, status post catheterization today, assess for pneumonia.",1
"chest, single ap vw The heart is moderately enlarged.",0
The mediastinal and hilar contours are unremarkable.,0
The pulmonary vasculature is upper limits of normal.,0
The lungs are clear without evidence of consolidation or significant pleural effusion.,0
There is no evidence of acute congestive heart failure.,1
There is subtle biapical pleural scarring.,0
"12:56 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: new right CVL Admitting Diagnosis: LEFT RENAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 63M S/P FALL, renal lac,DTs, now post-intubation REASON FOR THIS EXAMINATION: new right CVL ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: Trauma and intubation.",0
Endotracheal tube is 2 cm above the carina.,0
Right subclavian CV line is in distal SVC.,0
Tip of NG tube is in region of distal antrum and pyloroduodenal junction.,0
Allowing for low lung volumes heart size is borderline.,0
"There is opacity at the left base obscuring the medial portion of the left hemidiaphragm consistent with atelectasis/consolidation in the left lower lobe, unchanged since the prior film of the same date.",0
In addition there is atelectasis at the right lung base.,0
"1:33 PM CT CHEST W/O CONTRAST Clip # Reason: please eval size of pleural effusions, placement of catheter Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with b/l pleural effusions with L chest tube and decreased drainage REASON FOR THIS EXAMINATION: please eval size of pleural effusions, placement of catheter No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SUN 6:34 PM Trace right pleural effusion layering posteriorly and in the major fissure.",1
The left pleural effusion has significantly decreased in size compared to .,1
There is a small loculated component posteriorly.,0
The chest tube is within a small loculation of fluid.,0
"Bilateral patchy atelectasis, predominantly at the bases.",0
The pigtail catheter on the left is unchanged in position.,0
Small subcentimeter mediastinal lymph nodes have increased slightly compared to the prior exam.,0
______________________________________________________________________________ FINAL REPORT CT OF THE CHEST: INDICATION: Bilateral pleural effusions and left chest tube and decreased drainage.,1
TECHNIQUE: 5-mm axial images of the chest were obtained from the thoracic inlet to the diaphragm without intravenous contrast.,0
Coronal and sagittal reformations were also obtained.,0
Comparison is made to .,0
FINDINGS: There is a small right pleural effusion layering posteriorly and in the subpulmonic space.,1
"There is a small left pleural effusion, which has decreased in size significantly compared to .",1
There is a pigtail catheter in the lower pleural space posteriorly within a small loculation.,1
There is a second small loculation of fluid just superior to the catheter.,0
"There is bilateral lower lobe atelectasis, greater on the left with mild mediastinal shift to the left.",1
There is patchy lingular atelectasis.,0
There are numerous small subcentimeter mediastinal lymph nodes which have slightly increased in number compared to the prior exam.,0
The heart is borderline in size.,0
There is extensive coronary artery calcification.,0
"Visualized portions of the liver, spleen, pancreas, adrenal glands demonstrate an unremarkable unenhanced appearance.",0
There is an inferior vena cava filter.,0
The visualized portions of the bowel demonstrate no evidence of bowel obstruction or bowel wall thickening.,0
"There is air in the soft tissues overlying the laminectomy site at the thoracolumbar junction, unchanged.",0
"There is no change in the chance (Over) 1:33 PM CT CHEST W/O CONTRAST Clip # Reason: please eval size of pleural effusions, placement of catheter Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ FINAL REPORT (Cont) fracture.",1
"IMPRESSION: Interval decrease in size of the left pleural effusion with a small remaining loculated area posteriorly, separate from the location of the chest tube.",1
BP (mm Hg): 117/89 Status: Outpatient Date/Time: at 11:09 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy.,0
LV systolic function appears depressed.,0
RIGHT VENTRICLE: Right ventricular chamber size is normal.,0
AORTA: The aortic root is moderately dilated.,0
AORTIC VALVE: The number of aortic valve leaflets cannot be determined.,0
The aortic valve leaflets are mildly thickened.,0
There is no significant aortic valve stenosis.,0
Moderate (2+) aortic regurgitation is seen.,0
MITRAL VALVE: The mitral valve leaflets are mildly thickened.,0
TRICUSPID VALVE: The tricuspid valve is not well visualized.,0
PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.,0
"PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded.",0
"Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended).",0
LV systolic function appears at least moderately to severely depressed with probably global hypokinesis (estimated ejection fraction ?30%).,0
The aortic root is moderately dilated.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Altered mental status and CT scan at outside hospital with colonic abcess, right renal artery embolus Major Surgical or Invasive Procedure: PICC line placed RUE History of Present Illness: 74 y/o F with a h/o HTN, RA, hypercholesterolemia who presents from OSH for further w/u of R renal artery embolus and sigmoid diverticulosis with intramural abscess, and slurred speech.",1
is delirious and is unable to relay a history; history is obtained from her daughter and EMS reports.,0
Per report she fell at home 3 days PTA.,0
She does not remember the fall.,0
She says that her friend found her beside the bed yesterday morning and called EMS.,0
She reports L lower back pain since the fall.,0
"She reports that she has felt ""generally down and punk"" for several days, and that her speech has been ""heavy, thick and boozy"" for about 2 weeks.",0
"She denies numbness anywhere, has noticed generalized weakness but no focal weakness, denies dysphagia, word finding difficulties, bowel or bladder incontinence.",0
"She denies fevers, chills, N/V, abd pain, or dysuria at home.",0
Per EMS records they were called to pt's house on at 18:00.,0
was complaining of lower back pain and LUQ abd pain.,0
Family reported to them that pt.,0
"fell 3 days ago, that she has been increasingly confused over the past few days, that her speech has been ""slightly slurred,"" and that she has had generalized weakness for several days.",0
"was brought to an OSH, where head CT showed age-related atrophy but no infarcts.",0
CT abd performed and showed R renal artery embolus and diverticulosis with chronic-appearing intramural abscess.,0
"CEs negative x 1, WBC Ct 18.",0
"received Clindamycin, transferred here for further w/u.",0
"In the ED she underwent evaluation by the neurology, vascular surgery, and general surgery teams.",0
CXR showed a hilar mass.,0
Vascular surgery recommended medical management of renal embolus due to new finding of hilar surgery recommended antibiotics and NPO status to manage diverticular abscess.,1
"She received 1 mg of ativan in the ED, mucomyst, ASA, and levo/flagyl.",0
ROS (per family): Pt is s/p fall 6 mos ago and experienced a vertebral fracture.,0
10 pound weight loss over past 6 months.,0
"Denied headache, cough, chest pain.",0
"Denied nausea, vomiting, diarrhea, or abdominal pain.",0
"Past Medical History: HTN Hypercholesterolemia Rheumatoid arthritis Vertebral fracture Multiple falls per pt., etiology unclear spont pneumothorax - Social History: lives alone in with home health asst several times a week.",1
Tobacco: 1.5 PPD since age 16.,0
"Family History: emphysema - mother glomerulonephritis - son Physical Exam: Vitals: T: 97.8 ax P: 86 BP: 120/60 RR: 18 SaO2: 95% on 2L O2 General: Awake, alert, NAD.",0
"HEENT: NC/AT, PERRL, EOMI, sclera anicteric.",0
"MMM, OP without lesions Neck: supple, no JVD or carotid bruits appreciated Pulm: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl.",0
"S1S2, no M/R/G appreciated Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.",0
Ext: No clubbing cyanosis or edema.,0
Neurologic: -mental status: Alert & Oriented x (occaisionally correctly identifies this as a hospital).,0
-cranial nerves: intact except unable to protrude tongue.,0
Able to hold limbs against gravity but would not resist.,0
-sensory: No deficits to light touch detected.,0
Pertinent Results: CBC: 02:00AM WBC-15.1* RBC-4.35 HGB-10.9* HCT-32.3* MCV-74* MCH-25.0* MCHC-33.7 RDW-16.3* 02:00AM PLT COUNT-364 02:00AM NEUTS-87.9* LYMPHS-9.5* MONOS-2.0 EOS-0.5 BASOS-0.1 .,0
Chemistries: 02:00AM GLUCOSE-112* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 02:00AM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-107 AMYLASE-17 02:00AM LD(LDH)-767* 02:00AM ALBUMIN-2.4* CALCIUM-11.1* PHOSPHATE-2.2* MAGNESIUM-2.4 02:00AM TSH-2.3 09:00PM PTH-13* 09:00PM calTIBC-203* FERRITIN-252* TRF-156* .,0
Serum Tox: 02:00AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG .,0
Coags: 04:25AM PT-13.9* PTT-20.7* INR(PT)-1.2* .,0
Urine studies: 04:40AM URINE COLOR-Straw APPEAR-Clear SP -1.021 04:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG .,0
"CXR : Right hilar mass, with associated airspace opacity within the right upper lobe.",0
"These findings are concerning for malignancy within the right hilum, and secondary post-obstructive pneumonia or consolidation.",0
Further evaluation with a CT scan is recommended.,0
"Tubular filling defect measuring 1.2 cm in proximal right renal artery with hypoperfusion of right kidney, most likely representing right renal artery emboli.",0
Persistent non-perfusion areas seen in the right kidney on delayed images.,0
"Inflammatory changes in sigmoid colon with fat stranding, and 1.3 cm fluid collection versus small abscess.",1
Compression fracture of lower thoracic vertebra.,0
Right hilar mass noted on chest x-ray was not imaged on this abdominal CTA.,0
The renal vein was difficult to assess.,0
The resistive indices are slightly less within the right kidney compared to the left.,0
Further evaluation with a CTA study is recommended.,0
CAROTID U/S : No plaque or wall thickening of either carotid artery.,0
Diffuse low velocity seen b/l suggesting low cardiac output.,0
A very large heterogeneous right hilar mass measuring 7 cm with multiple areas of central necrosis extending to the level of the thyroid with associated mediastinal adenopathy.,0
The mass extends into the SVC as well as the right mainstem bronchus with a short segment demonstrating 50% occlusion.,0
Lack of perfusion of right kidney secondary to previously identified thrombus.,1
"Multiple hypodensities in the liver, the largest representing a simple cyst, the smallest too small to characterize, but may also represent cysts.",0
Compression deformity of T9 of indeterminate age.,0
Echo : The left atrium is normal in size.,0
"No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers.",0
"There a moderate-sized (1.2 cm-thick) echogenic anterior space which most likely represents an epicardial fat pad, though a loculated, organized anterior pericardial effusion cannot be excluded.",0
Chronic-appearing L1 vertebral body compression fracture.,0
Likely small fusiform abdominal aortic aneurysm which was seen on the prior CTA abdomen of .,0
"FNA, Right supraclavicular lymph node : POSITIVE FOR MALIGNANT CELLS consistent with non-small cell carcinoma.",1
CT Head with Contrast : Single focus of low density within the white matter of the right frontal lobe likely representing chronic microvascular infarct.,0
No evidence of enhancing lesions to suggest metastatic disease.,0
Worsening right upper lobe post-obstructive pneumonia secondary to right hilar mass.,0
Increased right lung volume loss.,0
RUQ US : No evidence of acute cholecystitis.,0
"Brief Hospital Course: Ms. is a 74 year old female with a history of HTN, RA, hypercholesterolemia, who presents from OSH for work up of R renal artery embolus and sigmoid diverticulosis with intramural abscess, delirum and slurred speech, now with hypercalcemia and likely nephrogenic DI.",1
Hospital course outlined by problem below: .,0
Right hilar mass - This was concerning for malignancy given history of tobacco and appearance on imaging.,0
The CT scan found a 7cm mass in the right lung which invades into the SVC and right mainstem bronchus.,0
Intervential pulmonology was consulted for possible stenting of right mainstem bronchus.,0
They did not feel it was necessary at the time.,0
Thoracic surgery was consulted for a fine needle aspiration of the supraclavicular node for diagnosis and to see if she was a surgical candidate.,0
The FNA preliminarily showed malignant cells consistent with non-small cell carcinoma.,0
Hematology/oncology and radiation oncology were consulted and treatment options were discussed the with the patient and the family.,0
"A bone scan was to be performed to look for bony mets on day of discharge, but this was discontinued secondary to a change in the patient's treatment goals (see below).",0
"On the last night of admission, the patient had an acute increased need for oxygen therapy (she was on room air prior).",0
A chest x-ray showed pulmonary effusions and a RUL infiltrate suggestive of post-obstructive pneumonia vs lobe collapse.,0
The patient remains afebrile but her WBC was elevated to 20K on discharge from 16K and 18K a fews days prior.,0
"She was already receiving levofloxacin and metronidazole for the diverticular abscess, and she was given furosemide to help with the pleural effusions.",0
"In a family discussion with the medical team, the patient and her daughter decided that no further aggressive treatment was wanted.",0
Hospice consult was placed per Ms. ' request.,0
Extensive conversations had been held with the patient and the daughter throughout her stay regarding her code status and wishes towards treatment and this decision is consistent with those prior conversations.,0
Hypercalcemia - The patient presented with delirium and slurred speech.,0
She was found to have hypercalcemia and hypernatremia which was thought to be a paraneoplastic syndrome.,1
Her PTHrp was found to be elevated at 8.6.,0
Her hypercalcemia was causatively linked to nephrogenic diabetes insipidus.,1
"Renal consult was placed and she was agressively treated with IVF, furosemide, calcitonin, and pamidronate to decrease her calcium levels.",0
She spent one night in the ICU mostly for nursing issues regarding her frequent lab checks and electrolyte monitoring.,0
"Once they were within normal limits, her sodium levels dropped to normal range and she was no longer delirious.",0
Hypernatremia - secondary to nephrogenic diabetes insipidus.,1
Diverticulitis with localized abscess - surgery consult was obtained and they recommened conservative treatment given her comorbidities.,1
She was placed on levofloxacin and metronidazole.,0
"She was initially NPO, but as her delirium resolved, surgery recommended normal diet.",0
She was cleared by a speech and swallow evaluation and placed on soft foods and thin liquids along with Boost supplementation per nutrition recommendations.,0
Right renal emboli - Normal renal function on admission but large renal artery emboli noted.,0
At first this was thought to be likely due to cholesterol emboli per the renal team given h/o hypercholesterolemia and did not require anticoagulation.,0
At discharge it was unclear whether this thrombus is secondary to cholesterol emboli or to her hypercoagulable state secondary to malignancy.,0
Her renal function is still within normal limits.,0
Leukocytosis - The patient's WBC was stable around 16K on levofloxacin and metronidazole for her diverticular abscess.,0
"A few days prior to admission, her WBC rose to 18K, but she remained afebrile.",0
Work up showed no urinary tract infection (patient had foley cath in place for close monitoring of ins/outs for DI treatment) and a RUQ ultrasound showed no cholecystitis (patient had RUQ pain on exam on the day prior to discharge.,0
The chest x-ray the night prior to admission showed possible post-obstructive pneumonia which may account for her increased WBC.,0
She was discharged on oral antibiotics.,0
Anemia - iron studies are consistent with anemia of chronic disease.,0
Her Hct remained stable throughout admission.,0
Rheumatoid arthritis - The patient was not taking medications at admission and treatment was defered.,1
She was given acetaminophen for pain.,0
"During admission, the patient complained of lower back pain and a lumbar spine x-ray showed only an old compression fracture of L1.",0
"A bone scan was to be performed to look for bony mets on day of discharge, but this was discontinued secondary to a change in the patient's treatment goals.",0
*FEN: eating soft foods and thin liquids with boost after cleared by speech and swallow.,0
*Comm: daughter cell home *Code Status: DNR/DNI per HCP (daughter) and per patient Medications on Admission: (not taking any of these medications) atenolol prednisone folic acid fosamax methotraxate Discharge Medications: 1.,0
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed.,0
Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours).,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily) for 6 weeks.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2-3H (every 2-3 hours).,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain.,0
Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed for dyspnea/pain.,0
Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: Lung cancer- cytology consistent with NSCLC Hypercalcemia causing nephrogenic diabetes insipidus Right renal artery embolus Intramural sigmoid abscess .,1
"Secondary diagnosis: Anemia Rheumatoid arthritis Discharge Condition: stable, on 5L oxygen via nasal canual Discharge Instructions: You have been diagnosed with lung cancer and are being discharged to a hospice facility to make you comfortable.",1
You have been prescribed antibiotics for a pneumonia.,0
You have also been given morphine and lorazepam to help with the back pain and shortness of breath.,0
Followup Instructions: none Completed by:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 51-year-old woman with a history of atrial fibrillation, rheumatic heart disease, and status post mitral valve replacement who was transferred for Hospital after being resuscitated for a pulseless ventricular fibrillation arrest that occurred during admission for shortness of breath and abdominal discomfort.",1
"In , the patient had a mitral valve replacement surgery with a bileaflet mechanical valve with a postoperative course significant for new onset atrial fibrillation and an ejection fraction estimated between 35% to 50% (per report).",1
"Since the time prior to admission, the patient experienced the persistence of atrial fibrillation; and, of note, had 1/6 bottles positive for coagulase-negative Staphylococcus in (as per primary care physician).",1
"Prior to admission, the patient complained of a 4-day history of increased dyspnea on exertion, nausea, and vomiting.",0
A transthoracic echocardiogram a her primary care physician's office (Dr. revealed an ejection fraction of 10%.,0
The patient was then sent to Hospital where laboratories were remarkable for a theophylline level of 29 and an INR of 4.3.,0
The patient was also in atrial fibrillation at this time.,1
The patient was then taken to Radiology for a right upper quadrant ultrasound for her abdominal complaints on presentation.,0
"At 2:30 p.m. on , the technician noticed that she was blue, and the patient was in pulseless ventricular fibrillation arrest.",1
"A code was called, and the patient was cardioverted with 300 joules and loaded on 300 mg intravenously of amiodarone, intubated, and was sent to the Intensive Care Unit.",0
"The initial arterial blood gas in the Intensive Care Unit was remarkable for a pH of 7.3, a PCO2 of 32, and a PO2 of 550.",0
"This hospital course was also remarkable for an 8-beat run of nonsustained ventricular tachycardia following the ventricular fibrillation arrest, and the patient was also successfully extubated.",1
The patient was transferred to .,0
"Upon arrival to the Coronary Care Unit, the patient was in atrial fibrillation with a rapid ventricular response of approximately 120 beats per minute to 130 beats per minute.",1
The patient was given a total of 15 mg of Lopressor intravenously with a decrease in heart rate between 100 beats per minute to 110 beats per minute with a stable blood pressure of 104/72.,0
The patient was given 25 mg of oral Lopressor times two doses overnight with good rate control in the 90s.,0
Status post mitral valve replacement in .,0
MEDICATIONS ON ADMISSION: (Medications a home included) 1.,0
Coumadin with alternating doses of 5 mg and 2.5 mg p.o.,0
"ALLERGIES: FLOXIN, 6-MERCAPTOPURINE (with reaction of nausea and vomiting and gastrointestinal intolerance).",0
"MEDICATIONS ON TRANSFER: Amiodarone drip 0.5, Protonix, vancomycin (day one), Combivent, salmeterol, and Phenergan.",0
SOCIAL HISTORY: The patient has approximately a 15-pack-year of smoking.,0
She reports occasional ethanol use.,0
She denies any intravenous drug use.,0
She works in the processing department.,0
"PHYSICAL EXAMINATION ON PRESENTATION: Physical examination upon admission revealed vital signs with a temperature of 98.5, heart rate was 110, blood pressure was 104/78, respiratory was 18, oxygen saturation was 95% on 2 liters nasal cannula.",0
"In general, the patient was resting comfortably, in no acute distress.",0
"Head, eyes, ears, nose, and throat revealed normocephalic and atraumatic.",0
"Pupils were equal, round, and reactive to light.",0
Neck was supple without lymphadenopathy.,0
No jugular venous distention appreciated.,0
"Cardiovascular examination revealed a mechanical first heart sound, second heart sound, tachycardic, irregular rhythm.",0
Chest examination revealed crackles at the left lower base.,0
"The abdomen was obese, soft, mild diffuse tenderness.",0
"Extremities revealed no clubbing, no cyanosis, no edema.",0
"Neurologically, the patient was alert and oriented times three; however, she had some memory deficits.",0
"PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed sodium was 139, potassium was 3.9, chloride was 105, bicarbonate was 20, blood urea nitrogen was 27, creatinine was 2.1, blood glucose was 157.",0
"White blood cell count was 12.1, hematocrit was 34.2, platelets were 255.",0
"PT was 28.1, INR was 5.5, PTT was 34.6.",0
"Amylase was 48, LDH was 395, AST was 21, ALT was 99, albumin was 3.4, bilirubin was 0.6.",0
Blood cultures upon admission were negative.,0
Laboratories from outside hospital revealed creatine kinases that were flat at 73 to 83 to 134; and troponins that remained below 0.4.,0
"RADIOLOGY/IMAGING: Echocardiogram revealed atrial fibrillation at a rate of 101, normal axis, normal intervals, flattened T waves.",1
"A chest x-ray was remarkable for markedly enlarged heart, prosthetic mitral valve.",1
"A catheterization in revealed the following pressures; right atrial pressure of 20, right ventricle was 54/20, pulmonary artery pressure was 54/21, pulmonary capillary wedge pressure was 25 with a V-wave of 45, cardiac index of 3.1.",0
"Also notable for a mitral valve gradient of 12.8, mitral valve area of 1.4, ejection fraction of 45%.",0
No regional wall motion abnormalities.,0
"Mitral regurgitation was 3+, and coronary angiography was normal.",0
"HOSPITAL COURSE BY SYSTEM: The patient was then admitted to the Coronary Care Unit for further observation, status post pulseless ventricular fibrillation arrest; awaiting implantable cardioverter-defibrillator placement.",1
CARDIOVASCULAR: (a) Rhythm/atrial fibrillation: The patient was found to be in atrial fibrillation upon admission and was on an amiodarone drip and a Lopressor 50 mg p.o.,1
Rate well controlled upon admission.,0
"Initially, the patient was switched from an amiodarone drip to oral amiodarone and captopril was added at 6.25 mg p.o.",0
The patient remained in atrial fibrillation with good rate control on amiodarone and Lopressor throughout the majority of the hospital stay and was successfully cardioverted in the Electrophysiology Laboratory on hospital day seven.,1
"Upon discharge, the patient's amiodarone and beta blocker were discontinued; as per Electrophysiology requisition in response to a decreased heart rate, status post cardioversion, as well as interactions with implantable cardioverter-defibrillator capturing.",0
(b) Rhythm/ventricular fibrillation arrest: The patient with a low ejection fraction.,1
The patient was scheduled to be awaiting implantable cardioverter-defibrillator placement throughout the majority of the hospital stay.,0
"Given a questionable history of positive blood cultures in the past, Infectious Disease was asked to consult to elucidate whether or not the patient was at risk for endocarditis and other risks associated with this history of bacteremia.",0
"After an extensive Infectious Disease consultation, the patient was cleared for implantable cardioverter-defibrillator placement.",0
"On hospital day seven, the patient received implantable cardioverter-defibrillator (as per Electrophysiology) with interrogation the following day with procedure notable for no complications and with all parameters stable upon interrogation.",0
The patient was to follow up in the Device Clinic on at 11:30 in Seven.,0
"(c) Pump: Echocardiogram throughout the hospital course was notable for a left ventricular cavity enlargement with severe global diastolic dysfunction, moderate aortic regurgitation, a well-functioning prosthesis with mild mitral regurgitation, with an estimated ejection fraction between 10% to 20%.",0
The patient was continued on a low-dose ACE inhibitor throughout the remainder of her hospital stay as tolerated by the patient's history of chronic renal insufficiency.,0
"(d) Valve/status post mitral valve replacement: Given the patient's questionable history of bacteremia, the patient needed to be ruled out for a possible recent history of endocarditis.",0
Subsequent transthoracic echocardiogram and transesophageal echocardiogram to assess vegetations were negative for vegetations of abscesses.,0
"Of note, transesophageal echocardiogram was also notable for no thrombus in the left atrium, severe left ventricular dysfunction, left cavity dilation, and ventricular free wall hypokinesis.",0
"Given the patient's history of mitral valve repair, the patient remained anticoagulated throughout her hospital stay.",0
"Upon admission, the patient's Coumadin was stopped and heparin was started, with heparin being tapered upon insertion of implantable cardioverter-defibrillator.",0
The patient was then restarted on heparin and Coumadin to achieve a therapeutic goal INR between 2.5 to 3.5 prior to discharge.,0
(e) Coronary artery disease: The patient with no known of coronary artery disease with recent catheterization revealing no coronary artery disease.,0
PULMONARY: The patient has a history of asthma and was continued on her outpatient regimen throughout her hospital stay.,0
"Of note, the patient had one episode of acute shortness of breath with chest pain on hospital day five.",0
The patient reported an epigastric chest pressure without radiation.,0
"No nausea, vomiting, or diaphoresis.",0
"Upon examination, vital signs were stable.",0
The patient was saturating well on room air.,0
The lungs were clear to auscultation bilaterally on examination.,0
There was no jugular venous distention.,0
No electrocardiogram changes were noted.,0
"There were also no events on telemetry, and a chest x-ray showed no evidence of congestive heart failure.",1
"A covering house officer at the time felt that these symptoms were due to ischemia given lack of electrocardiogram findings and clinical scenario, nor was it believed it was due to symptoms of fluid overload.",0
"However, given the patient's anxiety and desire for diuresis, the patient was given 20 mg of intravenous Lasix.",0
The patient experienced no further episodes of chest pain or shortness of breath throughout her hospital stay.,0
"(3) INFECTIOUS DISEASE: The patient was continued on vancomycin upon admission as per outside hospital, and given questionable history of bacteremia in anticipation for possible implantable cardioverter-defibrillator placement.",0
The Infectious Disease consultation service followed the patient to help elucidate the question of possible positive recent history of bacteremia.,0
"As per Infectious Disease, since positive cultures at primary care physician's office were different sensitivities and therefore likely different colonies, it was believed that this culture was most likely either a contaminant or of little clinical significance; and, thus was continued with the management planned and recommended a transesophageal echocardiogram to rule out vegetations.",0
It was also noted that an implantable cardioverter-defibrillator was going to be placed and antibiotics should be given prior to a status post procedure.,0
"Thus, with the results were negative for vegetations, Infectious Disease felt that despite this possible questionable history of positive bacteremia, it was not clinically significant and implantable cardioverter-defibrillator could be placed without any Infectious Disease issues if dosed with vancomycin appropriately prior to and status post procedure.",0
"Of note, on hospital day five, the patient developed a phlebitis and was being treated on vancomycin, as per hospital course of bacteremia.",0
"Within three days, the patient's cellulitis was much improved and remained cleared upon pending discharge.",0
RENAL: The patient has a history of chronic renal insufficiency.,0
Creatinine was followed throughout the hospital stay.,0
ENDOCRINE: The patient had an elevated glucose upon admission.,0
The patient was written for a regular insulin sliding-scale and q.i.d.,0
fingersticks with well-controlled blood glucose levels throughout the remainder of her hospital stay.,0
HEMATOLOGY: The patient was admitted with a supratherapeutic INR level.,0
"As above, Coumadin was held and heparin was started when INR was around 2.",0
"Once INR was around 2, the patient was restarted on heparin and continued on heparin throughout the remainder of her hospital stay.",0
The patient was then re-dosed on Coumadin prior to discharge.,0
CONDITION AT DISCHARGE: Condition on discharge was good.,0
DISCHARGE STATUS: Discharged to home.,0
Status post pulseless ventricular fibrillation arrest.,1
Status post mitral valve replacement.,0
MEDICATIONS ON DISCHARGE: Unknown at the time of this dictation; will be added with an addendum to this Discharge Summary on the patient's discharge date.,0
Dictated By: MEDQUIST36 D: 18:34 T: 16:20 JOB#:,0
"4:09 PM CHEST (PA & LAT) Clip # Reason: r/o chf Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with complicated post op course, now fluid overloaded with significant cardiac history and new complaint of SOB REASON FOR THIS EXAMINATION: r/o chf ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath.",0
"PA and lateral upright chest radiographs were reviewed in comparison to , .",0
"The heart size is top normal, stable.",0
The NG tube tip is in the stomach.,0
The right PICC line tip is at the level of the superior portion of SVC.,0
"Lungs are essentially clear, although slightly hyperinflated with no evidence of pulmonary edema.",0
Small amount of pleural effusion is most likely bilateral.,0
10:03 AM CT PELVIS W/O CONTRAST; CT GUIDANCE DRAINAGE Clip # CT RETROPERITONEAL DRAINAGE Reason: PLEASE HAVE ATTENDING RADIOLOGIST CALL DR PRIOR TO P Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with free air on KUB and CT scan on admission on with continued tenderness to palpation and CT reread demonstrating r pelvic abscess not ovarian cyst REASON FOR THIS EXAMINATION: PLEASE HAVE ATTENDING RADIOLOGIST CALL DR PRIOR TO PROCEDURE TO DISCUSS DRAINAGE OPTIONS.,0
"THANK YOUPlease place a drainage catherer in the previously identified pelvic fluid collection, and send collection for gram stain and culture No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Patient with pelvic abscess with diverticulitis, on antibiotics with continued spiking fevers.",1
"Desire abscess drainage, catheter placement.",0
PROCEDURE: CT guided abscess drainage and drain placement.,0
"TECHNIQUE: Patient was informed of the procedural technique, benefits, and risks (including bleeding, infection, bowel injury, and fistula).",0
Patient gave written consent to proceed.,0
CT scan without additional contrast was performed of the pelvis and appropriate site on the skin was determined for access to the pelvic fluid collection.,0
This area was prepared and draped in usual sterile fashion.,0
Deep anesthesia was provided with a 20-gauge spinal needle.,0
"Then, a TLA catheter with needle in place was inserted using CT Fluoroscopy into the collection and a small amount of fluid aspirated.",0
"Then, a 0.035 Amplatz wire was placed through the TLA catheter and into the collection which was confirmed by CT fluoroscopy.",0
TLA catheter was removed and the tract was serially dilated up to 8 French.,0
"Then, an 8-French drainage catheter was inserted over the wire and into the collection, again confirmed by CT fluoroscopy.",0
Pigtail catheter was engaged and fluid aspirated.,0
The catheter was placed to bag drainage.,0
Catheter was secured to the skin with a StatLock.,0
"Dr. , attending radiologist, was present for the entire procedure.",0
Moderate conscious sedation was administered by a nurse trained in conscious sedation using divided doses of Demerol and Versed.,0
Vitals were monitored throughout the entire procedure.,0
"FINDINGS: Redemonstrated is the complex collection within the right hemipelvis containing fluid and gas, between the right ovary, rectosigmoid bowel, and small bowel.",0
No contrast is within this collection from the recent CT to suggest open fistula from bowel.,0
Final images show the pigtail catheter within the collection and the collection smaller in size.,0
Small amount of (Over) 10:03 AM CT PELVIS W/O CONTRAST; CT GUIDANCE DRAINAGE Clip # CT RETROPERITONEAL DRAINAGE Reason: PLEASE HAVE ATTENDING RADIOLOGIST CALL DR PRIOR TO P Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ FINAL REPORT (Cont) subcutaneous and subgluteal gas is evident from anesthesia.,0
Approximately 20 cc of bloody pus-like fluid was aspirated and sent to the lab for Gram stain and culture.,0
The remainder of the fluid was left in the drainage bag.,0
IMPRESSION: Successful placement of 8-French pigtail catheter drain within the right pelvic fluid collection.,0
"10:00 AM CHEST (PORTABLE AP) Clip # Reason: Secretions/SOB Admitting Diagnosis: LUNG CA LEFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with SCC s/p VATS, LULobectomy; trach.",0
"Now w/ increased wheezing and tight, not responding to bronchodilators, suctioning, lavaging.",0
REASON FOR THIS EXAMINATION: Secretions/SOB ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: Compared to previous study of .,0
INDICATION: History of left upper lobectomy.,0
Tracheostomy tube remains in place.,0
"Of note, the cuff appears over distended.",0
There is volume loss in the left hemithorax consistent with history of prior left upper lobectomy.,0
There remains fullness of both hila with relatively rounded configurations.,0
There is stable left apical pleural fluid and/or thickening.,0
"Since the recent study, there has been interval improved aeration in the left lower lobe with minimal residual linear opacity remaining.",0
No new or worsening areas of opacification are evident.,0
Comparison is made to recent CT torso of which shows a left perihilar mass and right perihilar radiation changes.,0
"Finally, note is made of a left PICC line, the tip of which is not clearly visualized.",0
"IMPRESSION: Stable left hilar mass, concerning for recurrent neoplasm.",0
Overinflation of tracheostomy tube cuff.,0
Improving aeration in left lower lobe with residual linear opacity suggestive of scar or atelectasis.,0
Stable left sided pleural thickening and/or pleural effusion.,0
"7:12 AM CHEST (PORTABLE AP) Clip # Reason: eval for acute process Admitting Diagnosis: RIGHT LUNG CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with recent desaturation on oxygen REASON FOR THIS EXAMINATION: eval for acute process ______________________________________________________________________________ FINAL REPORT HISTORY: Desaturation on oxygen, to assess for acute process.",0
"FINDINGS: In comparison with the study of , there are continued low-lung volumes most likely related to the recent surgery.",0
Right chest tubes remain in place and there is a continued apical pleural capping.,0
Some mild basal pneumothorax is again seen on this side.,0
Bilateral atelectatic changes are seen at the bases.,0
No evidence of acute focal pneumonia.,0
"LINE PLACEMENT Clip # Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
"Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with OP CABG REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
______________________________________________________________________________ FINAL REPORT HISTORY: Post-operative CABG procedure.,0
"FINDINGS: In comparison with the study of , the patient has undergone a CABG procedure with intact sternal wires in place.",0
Endotracheal tube tip lies about 4 cm above the carina.,0
Swan-Ganz catheter lies within the right pulmonary artery and nasogastric tube extends to the upper portion of the stomach.,0
IMPRESSION: Expected appearance following a CABG procedure.,0
"9:14 PM CHEST CTA WITH CONTRAST Clip # Reason: chest pain, SOB, pt became unresponsive , now intubated Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with REASON FOR THIS EXAMINATION: chest pain, SOB, pt became unresponsive , now intubated ______________________________________________________________________________ WET READ: MON 10:38 PM no evidence of pulmonary embolism multifocal ground glass opacities/pneumonia (RUL,RML,RLL,LLL) ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
"CLINICAL INDICATION: Chest pain, shortness of breath, patient became unresponsive and now intubated.",0
TECHNIQUE: CT images were acquired from the lung bases to the thoracic inlet during rapid bolus administration of 100 cc of IV Optiray contrast.,0
Multiplanar reformatted images were performed for further evaluation.,0
CHEST CTA: There is no intraluminal filling defect from the level of the main pulmonary artery to the subsegmental pulmonary arteries.,0
"There are patchy diffuse ground glass opacities, small airways disease, and predominantly peribronchiolar opacities throughout both lungs.",0
"There is partial collapse of the right upper lobe, with probable mucus plugging of the apical segmental bronchus.",0
"An endotracheal tube is present, terminating 3 cm above the carina, with asymmetric position abutting the left wall of the trachea.",0
There is no mediastinal or axillary lymphadenopathy.,0
The partially imaged portions of the liver and spleen are unremarkable.,0
There is marked gastric distension.,0
No evidence of pulmonary embolism.,0
"Multifocal peribronchiolar ground glass opacities and centrilobular nodules, in association with bronchial wall thickening and bronchiolitis.",0
This likely reflects an evolving bronchopneumonia and less likely representing aspiration.,0
Prominent thymus gland which may represent thymic hyperplasia or prominent residual thymus tissue.,0
"Partial atelectasis of right upper lobe, most likely due to mucous plugging.",0
"(Over) 9:14 PM CHEST CTA WITH CONTRAST Clip # Reason: chest pain, SOB, pt became unresponsive , now intubated Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
"2:35 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: fall ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with fall REASON FOR THIS EXAMINATION: fall ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma, s/p seizure and fall TRAUMA AP CHEST X-RAY AND PELVIS: The cardiac, mediastinal and hilar contours are unremarkable.",0
There is an apparent left apical cap.,0
There are numerous left-sided rib fractures which appear to involve the left fourth through 10th ribs.,0
The fourth rib is fractured posteriorly and laterally in two places.,0
No other ribs appear to be fractured in multiple places.,0
The ET tube is approximately 6.4 cm above the carina.,0
The OG tube is seen coursing below the diaphragm.,0
The pelvis shows no evidence of fractures.,0
The SI joints and hips appear normal.,0
The right hip is externally rotated.,0
IMPRESSION: Left-sided rib fractures involving the fourth through 10th ribs.,0
"12:29 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrates Admitting Diagnosis: HYPOGLYCEMIA;DELTA MS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 45 yom with hepatitis, DM1, persistently low BG now hypothermic and with small amount hematemesis - please eval for infiltrates.",0
"REASON FOR THIS EXAMINATION: eval for infiltrates ______________________________________________________________________________ FINAL REPORT HISTORY: Hepatitis, diabetes, and hematemesis.",0
AP PORTABLE CHEST RADIOGRAPH: The diffuse interstitial and alveolar opacities in the perihilar and right upper lung zones are slightly improved from the prior two studies.,0
The heart size is normal.,0
IMPRESSION: Slightly improving patchy pneumonia vs. developing ARDS.,0
8:51 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: ?,0
Infiltrate Admitting Diagnosis: R/O SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman s/p kidney transplant with fever REASON FOR THIS EXAMINATION: ?,0
Infiltrate ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: S/P kidney transplant.,0
FINDINGS: Single AP supine view.,0
"The only prior view is dated , taken preoperatively.",0
There is now evidence of a moderate sized right pleural effusion with blunting of the CP angle and lateral layering extending over the right lung apex.,0
The left lung appears well inflated and no definite left effusion is identified.,0
There appears to be some atelectasis in the right lower lobe behind the cardiac silhouette.,0
No other significant pulmonary abnormality is identified.,0
"Some widening of the superior mediastinum is noted, consistent with the supine position of the patient.",0
IMPRESSION: 1) Moderate sized right pleural effusion.,0
2) Possible atelectatic changes in the right lower lobe.,0
No other cardiopulmonary abnormality is demonstrated.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Altered Mental Status, Hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 81 yo F with h/o Seizure disorder, HTN, ESRD on HD, meningioma s/p resection and DM who initially presented on from were she was found to be nonverbal and unresponsive.",0
In the ED she was hypertensive to the 200's requiring a labatolol gtt and had a K of 7.1 (improved with bicarb and insulin).,0
One day PTA she developed nausea and vomiting.,0
Per report her initial neurologic exam was remarkable for profound encephalopathy with increased RUE tone.,0
She was loaded with IV phenytoin for a subtherapeutic level; she transiently developed complete heart block during the infusion.,1
CT head revealed a lobulated mass in the left ventricular atrium.,0
"She was given empiric ceftriaxone 2g, ampicillin, vanco, and acyclovir for possible meningitis.",0
She was transferred to the for further managment.,0
In the her BP was controlled.,0
She was dialyzed and an LP was performed.,0
Of note she was recently admitted to (discharged 2 wks ago) after a tonic clonic Sz at dialysis.,0
Her Phenytoin level was subtherapeutic at that time.,0
"She had been on phenobarb, which was stopped.",0
Currently she is alert and following verbal commands.,0
She is able to answer some questions with one word response.,0
Social Hx: Denies etoh or tobacco use.,0
Pt was ambulatory and conversant living at home prior to recent admission.,0
Nurse reports that she was ambulatory with a walker and was alert and oriented prior to decompensation.,0
Family Hx: Denies h/o sz disorder.,0
Reports FH of DM and HTN.,0
Past Medical History: PMH: - seizure disorder.,0
Per report she was Sz free on phenobarb and dilantin until 2 weeks ago.,0
- h/o right frontal meningioma in 's s/p resection in - encephalomalacia per her epileptologist (Dr. at 2988) - ESRD on HD 3x/wk - suboptimal given reversed intake and outflow ports - ?clot in L UE AV fistula - DM2 - HTN - hyperlipidemia - ?hyperthyroidism Social History: Social Hx: Denies etoh or tobacco use.,0
Family History: Family Hx: Denies h/o sz disorder.,0
"Physical Exam: Physical Exam: Tc 98.1, 148/62, 70, 18, 98% 2L NC, FS 128 General: appears comfortable lying in bed, NAD HEENT: no scleral icterus, MMM, OP clear, R pupil 4mm, L pupil 3mm, minimally reactive, able to squeeze eyes shut and open mouth on command Neck: Supple, no JVD, right EJ in place Pulmonary: CTAB Cardiac: RRR, nl S1S2, no M/R/G noted Abdomen: soft, NT/ND, nl BS, No HSM.",0
"Extremities: weak DP/PT pulses, no edema Neuro: Following verbal commands, Moving all extremities.",0
Cogwheel rigidity of upper extremities.,0
"Patellar and biceps reflexes brisk and symmetric, Toes upgoing.",0
"Garbled speech, occasionally able to answer question with one word response.",0
Occasionaly myoclonic jerking movements of upper and lower extremities.,0
Pertinent Results: 05:00AM BLOOD WBC-12.3* RBC-3.74* Hgb-12.9 Hct-39.2 MCV-105* MCH-34.4* MCHC-32.8 RDW-16.0* Plt Ct-253 05:00AM BLOOD Neuts-80.7* Lymphs-12.0* Monos-6.3 Eos-0.5 Baso-0.4 07:00AM BLOOD PT-11.8 PTT-22.7 INR(PT)-1.0 04:50AM BLOOD Glucose-148* UreaN-82* Creat-9.2* Na-131* K-7.5* Cl-94* HCO3-15* AnGap-30* 07:00AM BLOOD ALT-81* AST-77* AlkPhos-108 Amylase-117* TotBili-0.1 04:50AM BLOOD CK(CPK)-57 04:39PM BLOOD CK(CPK)-44 07:00AM BLOOD Lipase-29 04:40AM BLOOD Lipase-17 04:50AM BLOOD CK-MB-4 cTropnT-0.07* 04:39PM BLOOD CK-MB-4 cTropnT-0.07* 04:40AM BLOOD VitB12-1387* Folate-GREATER TH 10:35AM BLOOD Ammonia-30 04:39PM BLOOD TSH-1.6 04:50AM BLOOD Phenyto-1.4* 04:40AM BLOOD Phenyto-17.9 Phenyfr-3.7* %Phenyf-21* 02:28PM BLOOD Phenyto-12.8 04:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 08:40AM BLOOD Lactate-1.3 .,0
IMAGING: CT HEAD : Lobulated mass in the left ventricular atrium.,0
No clear evidence of acute hemorrhage or territorial infarction.,0
Atherosclerotic calcification above the aortic knob suggests aberrant right subclavian artery.,0
Tips of dual R supraclavicular catheter project over the SVC and superior cavoatrial junction respectively.,0
"EKG: NSR, rate 54, LAD, TWI in V1 and V2 with j-point elevation and 2mm ST elevation, poor R wave progression, no other st/tw changes.",0
"MRI : Lobulated mass in the left ventricular atrium, which could represent an intraventricular meningioma.",0
There are no signs of recurrent meningioma in the right frontal postoperative region.,0
An additional tiny focus of enhancement and signal abnormality is noted along the right side of the cerebellum.,0
EEG : Prelim - diffuse encephalopathy .,0
"Brief Hospital Course: 81 yo resident with ESRD on HD, meningioma s/p resection/regrowth, HTN, DM, and Sz d/o initially admitted to the intesive care unit with altered MS, hypertension, and hyperkalemia.",0
1) Altered Mental Status likely to hypertensive leukoencephalopathy: The patient presented unresponsive from .,1
At presentation she was found to be hypertensive in the 200s and started on a labetolol drip.,0
Her K was found to be 7.1 and resolved with insulin and bicarb.,0
"A CT head did not show evidence of stroke or hemmorrhage, but a lobulated mass was seen in the left ventricular atrium.",0
"A urine tox screen was found to be negative and TSH, ammonia and LFTs were wnl.",0
"She was given empiric ceftriaxone 2g, ampicillin, vanco, and acyclovir for possible meningitis and transferred to the unit.",0
"The differential included toxic metabolic derangements, leukoencephalopathy secondary to HTN, HSV encephalitis, or post-ictal state as pt had h/o recent seizures.",1
An EEG revealed diffuse encephalopathy without evidence of non-convulsive status epilepticus.,0
"An MRI revealed slight increase in size of her known meningioma since without mass effect, bleed or CVA.",0
"An LP was performed by IR (noted to be difficult to perform) and revealed many RBC's, no WBC's, high protein, and normal glucose.",0
All culture data was negative and cytology was negative as well.,0
Empiric Vanco/Amp/CTX for bacterial meningitis was d/c'ed on given the LP results.,0
Her acyclovir was continued until (started ) when her HSV PCR came back as negative.,0
The patient's mental status started improving during her stay as her blood pressures improved.,0
She was noted to have a significant expressive aphasia.,0
Neurology was consulted and thought the patient's symptoms were related to her hypertension and toxic/metabolic derangements.,1
They though her symptoms would improve over time.,0
Her blood pressures were controlled to a goal of SBPs 140-170 on IV medications and she was then switched to PO medications as her MS improved.,0
"Lisinopril, hydralazine, norvasc and metoprolol were used for BP control.",0
She will need neurosurg to follow up her enlarging meningioma.,0
"She was also instructed to follow-up with her outpatient neurologist, Dr. .",0
2) Seizure disorder: The patient was noted to have a recent recurrence of seizures.,0
"The differential included recent d/c of phenobarbitol, known meningioma acting as foci, and electrolyte disturbances in the setting of ESRD.",0
Patient did have a seizure on in the setting of low calcium after HD.,0
She was initially loaded with Fosphenytoin.,0
Neurology followed the patient and recommended that she start dilantin 200 .,0
Her free and total dilantin levels were followed as well as her LFTs.,0
EEG was done and showed diffuse encephalopathy but no evidence of non-convulsive status.,0
She had no further seizures during her stay.,0
She was discharged on 200 PO BID of dilantin.,0
"Her level was to be checked in one week and she was to follow-up with her outpatient neurologist, Dr. .",0
3) Complete heart block: She had complete heart block during her phenytoin infusion.,1
This was thought to be secondary to phenytoin infusion and after that time the infusion was done slowly.,0
She had no further episodes of heart block.,0
4) HTN: She was initially on labetolol gtt for SBP >200.,0
Her goal SBP was 140-170.,0
"It was noted that her BPs were higher in the right arm than the left, so BPs were taken from the left arm.",0
"When she was transferred to the floor she had been receiving PRN metoprolol, but this was not enough to control her blood pressures.",0
"She was initially started on IV antihypertensives and then changed to PO meds including lisinopril, norvasc, metoprolol and hydralazine.",0
Aggressive blood pressure control was attempted as it was thought her MS changes were due to hypertensive leukoencephalopathy.,1
Her blood pressures were in the 160s on the day of discharge.,0
5) ESRD on HD T/th/Sa: Pt receives dialysis on T/Th/Sa.,0
She was followed by the renal team during her stay.,0
"Initially it was thought her dialysis port was not working well, but she had excellent flows through the port during the second half of her admission.",0
Her electrolytes were followed and she was given phos binders once she could tolerate PO meds.,0
6) ?Hyperthyroidism: Her TSH was drawn and noted to be normal off medications.,0
7) DM2: She was continued on a RISS and qid FS were checked.,0
8) Hypercholesterolemia: She was continued on Lipitor 10 mg qd .,0
9) FEN: She was initially unable to perform a speech and swallow due to her mental status.,0
"As her MS improved she had an evaluation and she was changed to a diet of ground, thin liquids with 1:1 supervision during meals.",0
"She was given liquids by straw with cuing, crushed meds and given with purees.",0
She was continued on a diabetic/renal/low salt diet.,0
"10) Ppx: She was continued on SC heparin, PPI and was kept on aspiration/seizure precautions.",0
11) Code: Full as per chart (discussed with daugther in ) .,0
12) Communication: Daughter - () .,0
13) Access: R groin line removed.,0
R SC HD line in place.,0
"Pt has had fistulas in arms bilat, therefore, unable to place PICC line.",0
R EJ placed 5/10/1/06 and removed on .,0
Medications at Home: - metoprolol 100mg po tid - lisinopril 20mg po daily - ASA 81mg po daily - dilantin 200mg po bid - lipitor 10mg po daily - nephrocaps 1 tab po qam - phoslo 667mg po tid - compazine prn - ?RISS .,0
Transer Meds: - Metoprolol 5 mg IV Q6H:PRN - Acyclovir 300 mg IV Q24H - Pantoprazole 40 mg IV Q24H - Acetaminophen 325-650 mg PO/PR Q4-6H:PRN - Phenytoin 200 mg IV Q12H - Aspirin 300 mg PR DAILY - Prochlorperazine 10 mg IV Q6H:PRN - Heparin 5000 UNIT SC TID - Insulin SS Discharge Medications: 1.,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units Injection TID (3 times a day).",0
Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day).,0
Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed.,0
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily).,0
"Sig: Two (2) Tablet, Delayed Release (E.C.)",0
PO DAILY (Daily) as needed for constipation.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation.,0
Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
PO Q24H (every 24 hours).,0
Prochlorperazine 10 mg IV Q6H:PRN 16. insulin please place patient on a regular insulin sliding scale per the protocol of your institution 17.,0
"Outpatient Lab Work Please have dilantin level checked in one week and send the results to Dr. , in weeks.",0
His phone number is .,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary diagnosis: Toxic metabolic and Hypertensive encephalopathy Seizure disorder .,1
Secondary Diagnosis: Diabetes type 2 Discharge Condition: stable wtih baseline expressive aphasia Discharge Instructions: You are being discharged to a rehabilitiation facility.,1
Please take your medications as prescribed.,0
"Please call your doctor or return to the ER if you become more confused, have very elevated blood pressures, have chest pain, shortness of breath, headaches, dizziness or other concerning symptoms.",0
Followup Instructions: Please follow-up with neurosurgery regarding the meningioma in your brain.,0
Please call ( to make an appointment in the next weks.,0
"Please follow-up with your neurologist, Dr. , in weeks.",0
You should have a dilantin level checked in one week and have the results sent to his office.,0
"Please follow-up with your primary care doctor, Dr. , in weeks.",0
Height: (in) 71 Weight (lb): 165 BSA (m2): 1.95 m2 BP (mm Hg): 119/60 HR (bpm): 77 Status: Inpatient Date/Time: at 10:30 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
"Transmitral Doppler E>A and TDI E/e' <8 suggesting normal diastolic function, and normal LV filling pressure (PCWP<12mmHg).",0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.,0
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
"Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg).",0
No structural heart disease or pathologic flow identified.,0
4:59 AM CHEST (PORTABLE AP) Clip # Reason: acute changes Admitting Diagnosis: RIGHT LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man RU Lobectomy REASON FOR THIS EXAMINATION: acute changes ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP.,0
"HISTORY: Status post right upper lobe lobectomy, evaluate for acute changes.",1
FINDINGS: Evalutation is limited by motion.,0
Tracheostomy is approximately 4.5 cm above the carina.,0
Surgical rib fractures are again identified along the right hemithorax.,1
Right apical pleural fluid collection extending along the right lateral pleural surface is similar in appearance.,0
Subcutaneous air along the right lateral chest wall is unchanged.,1
"Bibasilar opacities, likely atelectasis are similar in appearance.",0
The left costophrenic angle was excluded from the film.,0
"There is mild cardiomegaly, unchanged.",0
IMPRESSION: No significant change when compared to prior exam.,0
", R. MED MICU-7 8:58 AM OTHER EMBO Clip # Reason: embolization of RLL of lung Admitting Diagnosis: PNEUMONIA Contrast: OPTIRAY Amt: 64 ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with metastatic melanoma, persistent bleeding from RLL of lung.",1
"s/p bronch x 3, most recent w/ superior segment of RLL and posterior segment of RLL bleeding controlled w/ argon.",0
REASON FOR THIS EXAMINATION: embolization of RLL of lung ______________________________________________________________________________ PFI REPORT Right bronchial artery embolization with particles and coils with good angiographic results.,0
10:23 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate position of endotracheal tube Admitting Diagnosis: S/P POSTERIOR LAMINECTOMY ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p intubation REASON FOR THIS EXAMINATION: please evaluate position of endotracheal tube ______________________________________________________________________________ FINAL REPORT AP CHEST 10:49 P.M. ON HISTORY: Check endotracheal tube after intubation.,0
IMPRESSION: AP chest compared to : Tip of the endotracheal tube is in standard placement.,0
Left PIC line ends at the junction of brachiocephalic veins and a nasogastric tube passes below the diaphragm and out of view.,0
"In addition two discrete foci of infection in both lungs, there has been progression of more confluent consolidation at the right lung base, and a suggestion of new ground-glass opacification in the left mid lung.",0
"These findings are better assessed by the subsequent chest CT scan, reported separately.",0
Pleural effusion is small if any.,0
", F. MED MICU 11:49 AM CHEST (PORTABLE AP) Clip # Reason: intubation eval placement Admitting Diagnosis: OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with intubation REASON FOR THIS EXAMINATION: intubation eval placement ______________________________________________________________________________ PFI REPORT 1.",0
ET tube 3 cm above carina.,0
NG tube above the GE junction and would recommend advancing 15-17 cm.,0
"Elevated right hemidiaphragm and increased right lung interstitial markings, may represent asymmetric pulmonary edema versus low lung volumes.",0
", MED 1:14 PM CHEST PORT.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: Position of R IJ Admitting Diagnosis: ?,0
UROSEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with sepsis REASON FOR THIS EXAMINATION: Position of R IJ ______________________________________________________________________________ PFI REPORT Right internal jugular catheter ends in the proximal right atrium.,0
"11:45 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: interval post operative changes, MUST BE PERFORMED ONE HOUR Admitting Diagnosis: BRAIN TUMOR ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with s/p stx biopsy REASON FOR THIS EXAMINATION: interval post operative changes, MUST BE PERFORMED ONE HOUR POST OP-1200 noon No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc FRI 2:24 PM Expected post-biopsy changes with a small amount of hemorrhage along the tract status post stereotaxis of a hyperenhancing lesion centered within the right thalamus with associated vasogenic edema.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old female status post stereotactic biopsy.,0
Evaluate for interval post-operative change.,0
COMPARISONS: CT stereotaxis from performed at 7:50 a.m.,0
TECHNIQUE: Contiguous axial images were obtained through the brain.,0
No intravenous contrast was administered.,0
FINDINGS: Since the prior examination the patient has undergone a left frontal burr hole approach CT stereotaxis biopsy of hyperenhancing lesion centered within the left thalamus.,0
There is expected post-operative pneumocephalus adjacent to the right cerebral hemisphere.,0
"There is no significant post-operative hemorrhage, with a small area of high density remaining in the area of biopsy.",0
A linear tract of high density is demonstrated likely related to hemorrhage at the site of biopsy tract.,0
This can be best appreciated on (2:15).,0
There is stable midline shift by approximately 8 mm to the right.,0
There is surrounding vasogenic edema in the region.,0
There is no acute fracture.,0
Visualized portions of the paranasal sinuses and mastoid air cells are well aerated.,0
Ventricles and sulci are stable in size and configuration.,0
IMPRESSION: Expected post-biopsy changes with a small amount of hemorrhage along the tract status post stereotaxis of a hyperenhancing lesion centered within the left thalamus with associated vasogenic edema.,1
5:17 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: SATS DROPPED.PT .,0
"ASSESS FOR PE Admitting Diagnosis: SUBDURAL HEMATOMA;TELEMETRY Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: year old man with REASON FOR THIS EXAMINATION: R/O PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old man with poor oxygen saturation, evaluate for PE.",0
TECHNIQUE: Axial images were performed through the pulmonary vascularity after the administration of intravenous contrast.,0
Multiplanar reformatted images were obtained.,0
Please note the extreme lung apices and bases are not included on the images.,0
CONTRAST: 100 cc of Optiray was administered due to fast bolus rate required for this study.,0
CTA OF THE CHEST: No pulmonary emboli are identified.,0
There is a prominent prevasular lymph node which measures 13 mm in short axis.,0
There are scattered small mediastinal lymph nodes.,0
There are small hilar lymph nodes.,0
There is no axillary lymphadenopathy.,0
There is fluid diffusely throughout the esophagus and an air-fluid level within the upper esophagus.,0
This can predispose to aspiration.,0
There is a heterogeneous nodule within the right lobe of the thyroid gland.,0
There are coarse coronary artery calcifications and cardiomegaly.,1
The thoracic aorta is markedly ectatic with irregularity of its wall.,0
There are tiny bilateral pleural effusions.,0
There is compressive atelectasis at the lung bases.,0
There is respiratory motion limiting the evaluation of the pulmonary parenchyma but no major consolidations are seen.,0
BONE WINDOWS: No suspicious lytic or blastic lesions are seen.,0
Multiplanar reformatted images support the above findings.,0
This increases the patient's risk for aspiration.,0
Nodular density in the right lobe of the thyroid gland.,0
Compressive atelectasis at the lung bases.,0
(Over) 5:17 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: SATS DROPPED.PT .,0
ASSESS FOR PE Admitting Diagnosis: SUBDURAL HEMATOMA;TELEMETRY Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont),0
Low Voltage On EKG Height: (in) 69 Weight (lb): 216 BSA (m2): 2.14 m2 BP (mm Hg): 115/51 HR (bpm): 90 Status: Inpatient Date/Time: at 11:50 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; basal inferolateral - akinetic; RIGHT VENTRICLE: Normal RV chamber size.,0
Borderline normal RV systolic function.,0
"Mild to moderate (+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
"[Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.]",0
PULMONIC VALVE/PULMONARY ARTERY: Mild PR.,1
Conclusions: The left atrium is moderately dilated.,0
The left ventricular cavity is severely dilated.,0
There is severe global left ventricular hypokinesis (LVEF = 15-20%).,0
Mild to moderate (+) mitral regurgitation is seen.,0
"[Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.]",0
IMPRESSION: Severely dilated left ventricle.,0
Severe left ventricular systolic dysfunction - the inferior and inferolateral walls are akinetic.,1
The other walls are hypokinetic with the anterior and lateral walls having relatively better function.,0
The right ventricle is normal in size with borderline function.,0
Mild to moderate mitral regurgitation is seen.,0
At least mild-to-moderate tricuspid regurgitation.,0
"Compared to prior echo of , the left ventricular cavity is slightly more dilated.",0
The degree of mitral regurgitation may have increased.,0
3:19 AM CHEST (PORTABLE AP) Clip # Reason: eval for worsening CHF Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with CHF REASON FOR THIS EXAMINATION: eval for worsening CHF ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient with known congestive heart failure.,1
Portable AP radiograph of the chest was reviewed in comparison to obtained at 12:09 p.m. Tracheostomy is in place.,0
"There is gradual progression of opacification of both lungs, which are completely white -out on the current radiograph.",0
"9:19 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Eval for pneumonia, interval change Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with worsening hypoxia.",1
"REASON FOR THIS EXAMINATION: Eval for pneumonia, interval change ______________________________________________________________________________ WET READ: ENYa WED 10:27 PM Interval complete opacification of the left hemithorax, but without evidence of significant volume changes, as the right caridac border remains similar in possition.",0
DDx consideration includes total left lung collapse or large pleural effusion (simple or hemorrhagic).,0
"If clinically indicated, recommend CT Chest to further assess.",0
EYeh discussed the urgent findings with Dr. at 10:20PM.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old female with worsening hypoxia.,0
TECHNIQUE: Single AP radiograph of the chest was obtained.,0
"FINDINGS: Compared to most recent prior, there has been interval development of complete opacification of the left lung field with slight leftward mediastinal shift, consistent with left lung collapse.",0
"The right lung is well aerated and extends across the midline, consistent with left volume loss.",0
Minimal right basilar linear opacity is likely atelectasis.,0
There is no right pleural effusion or pneumothorax.,0
IMPRESSION: Complete left lung collapse.,0
Preliminary findings were reported by Dr. to Dr. at 10:20 p.m. on .,0
Findings were also reported by wet read in CCC at that time.,0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB IDENTIFICATION: Baby is a 1 week old former 34 week infant being transferred from NICU to Special Care Nursery.,0
"HISTORY OF PRESENT ILLNESS: Baby is a now 1-week-old infant, corrected to 35-6/7 weeks gestation.",1
"This is the former 1.68 kg product of a 34-6/7 week gestation pregnancy, born to a 36-year-old G2 P1, now 2 woman.",0
"PRENATAL SCREENS: Blood type A-positive, antibody negative, Rubella immune, RPR nonreactive, Hepatitis B surface antigen negative, Group beta strep status unknown.",0
Estimated date of delivery was .,0
PRIOR OBSTETRICAL HISTORY: Notable for preeclampsia requiring delivery at 33 weeks gestation.,1
This pregnancy was also complicated by pregnancy induced hypertension as well as oligohydramnios.,0
There was a nonreassuring fetal heart rate tracing noted on the day of delivery and the mother was taken to cesarean section.,1
"The infant emerged with spontaneous cry, required blowby oxygen and routine care in the delivery room Apgar's were 7 at 1 minute and 9 at 5 minutes.",0
He was transferred to the NICU for treatment of prematurity.,0
"ANTHROPOMETRIC MEASUREMENTS: Upon admission to the neonatal intensive care unit weight 1.68 kilograms, 10th %tile; length 43.5 cm, 20th %tile; head circumference 29.5 cm, 10th %tile.",1
PHYSICAL EXAM AT DISCHARGE: Weight 1.59 kilograms reflecting a 5 gram weight increase; length 43 cm; head circumference 30 cm.,0
"GENERAL: Alert, non distressed infant on room air.",0
HEENT: Anterior fontanel open and flat.,0
Sagittal and coronal sutures overriding and movable.,0
CHEST: Breath sounds clear and equal.,0
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: System #1 Respiratory: This infant required treatment with continuous positive airway pressure upon admission to the neonatal intensive care unit.,1
He was able to wean to room air within a few hours after admission.,0
He has continued on room air for the rest of his neonatal intensive care unit admission.,0
"He has had rare episodes of spontaneous apnea and bradycardia, last on requiring stimulatoin.",0
At the time of discharge he is breathing comfortably at a respiratory rate of 30 to 60 breaths per minute.,0
Oxygen saturations are maintained on room air greater than 93%.,0
System #2 Cardiovascular: This infant has maintained normal heart rates and blood pressures.,0
No murmurs have been noted.,0
At the time of discharge baseline heart rate is 140 to 150 beats per minute with a recent blood pressure of 81/53 mmHg.,0
Mean arterial pressure is 53 mmHg.,0
"System #3 Fluids, electrolytes and nutrition: The infant was initially NPO and maintained on intravenous fluids.",0
Enteral feeds were started on day of life 1.,0
The infant has been all ad lib p.o.,0
"feeding, taking between 120 and 160 mL/kg/day.",0
At the time of discharge he is feeding breast milk fortified to 24 calories per ounce with EnfaCare powder.,0
Weight on the day of discharge is 1.59 kilograms.,0
Serum electrolytes were checked on day of life 3 and were within normal limits.,0
"Mildly low dstiks were noted as feedings were advanced, and feedings were changed to a q3hr schedule; dstiks have been normal on this regimen, and feedings can likely be spaced as tolerated.",0
"System #4 Infectious Disease: Due to his respiratory distress and unknown Group beta strep status of his mother, the infant was evaluated for sepsis upon admission to the neonatal intensive care unit.",1
A complete blood count with white blood cell differential was within normal limits and blood culture was obtained prior to starting intravenous ampicillin and gentamicin.,0
The blood culture was no growth at 48 hours and the antibiotics were discontinued.,0
System #5 Hematological: Hematocrit at birth was 54.9%.,0
This infant did not receive any transfusions of blood products.,0
Infant was begun on iron supplementation.,0
System #6 Gastrointestinal: The infant was treated for unconjugated hyperbilirubinemia with phototherapy.,0
Peak serum bilirubin occurred on day of life 2 with a total of 9.4 mg/dl.,0
He was treated with phototherapy for approximately 96 hours.,0
Rebound serum bilirubin on was 4.8 mg/dl.,0
System #7 Neurological: The infant has maintained a normal neurological exam during admission.,0
There were no neurological concerns at the time of discharge.,0
"System #8 Sensory: Audiology, hearing screening has not been performed.",0
It is recommended prior to discharge.,0
DISCHARGE DISPOSITION: Transfer to for continuing level II care.,0
"The primary pediatrician is Dr. , 467R , , , phone number (.",0
CARE AND RECOMMENDATIONS: At the time of discharge: 1.,0
"Feeding, ad lib breast milk fortified to 24 calories/ounce with EnfaCare powder or breast feeding ad lib.",0
"Medications: 1) Ferrous sulfate 25 mg per mL, 0.3 mL p.o.",0
2) Multivitamins of Goldline Baby Vitamins 1 mL p.o.,0
Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birthweight infants until 12 months corrected age.,1
All infants fed predominantly breast milk should receive vitamin D supplementation at 200 IU (may be provided as multivitamin preparation) daily until 12 months corrected age.,0
Car seat position screening has not yet been performed and is recommended prior to discharge.,0
State newborn screen was sent on with no notification of abnormal results to date.,0
"Immunizations, no immunizations administered thus far.",0
Immunizations recommended: Synergis RSV prophylaxis should be considered from through for infants who meet any of the following four criteria: 1) Born at less than 32 weeks.,1
"2) Born between 32 and 35- 0/7 weeks with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings.",0
3) Chronic lung disease or 4) Hemodynamically significant congenital heart disease.,0
Influenza immunizations recommended annually in the Fall for all infants once they reach 6 months of age.,0
"Before this age and for the first 24 months of a child's life, immunization against influenza is recommended for household contacts and out of home caregivers.",0
This infant has not received rotavirus vaccine.,0
"The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age.",1
Prematurity at 34 6/7 weeks gestation.,1
Suspicion for sepsis ruled out.,0
", MD Dictated By: MEDQUIST36 D: 00:40:19 T: 01:46:43 Job#: cc:",0
9:44 AM CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # CT RECONSTRUCTION Reason: pelvis to eval rectal abscess.,1
Needs IV contrast only Admitting Diagnosis: PERI-RECTAL ABSCESS Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with purulent drainage from rectum with fluctuance REASON FOR THIS EXAMINATION: pelvis to eval rectal abscess.,1
Needs IV contrast only No contraindications for IV contrast ______________________________________________________________________________ WET READ: MNIa TUE 11:29 AM 3cm fluid collection with air representing abscess in the left perirectal area.,1
"Small tubular structure with fluid and air extending inferior from the abscess, which may represent skin fistula.",0
Small amount of air in the bladder.,0
WET READ VERSION #1 MNIa TUE 11:28 AM 3cm fluid collection with air representing abscess in the left perirectal area.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old woman with purulent drainage from rectum.,0
TECHNIQUE: Contiguous axial CT images of the pelvis were obtained.,0
"FINDINGS: The patient is status post axillary-bifemoral bypass surgery, with fluid collections in bilateral groin areas, the largest on the right measuring 5.5 x 3.0 cm, decreased in size compared to the prior study.",0
Again note is made of extensive arterial calcification.,0
"Note is made of poor opacification of bilateral femoral veins, probably representing persistent bilateral femoral vein filling defects noted on the prior CT scan.",0
The visualized portion of large and small intestines are within normal limits.,0
Note is made of IUD in the uterus.,0
"Note is made of small amount of air within the urinary bladder, which may be related to recent catheter placement; however, correlation with urine analysis is recommended.",0
"Note is made of irregular shaped 3-cm fluid collection with peripheral enhancement, containing air-fluid level in the left perirectal area, probably representing perirectal abscess in this patient with purulent drainage from the rectum.",1
"Note is made of air-containing tubular structure extending from the above-mentioned abscess, which may represent fistula to the skin.",0
"The abscess is located posterolateralyl , slightly lower than the level of pubic symphysis, and is well away from the bladder.",0
"Note is made of several subcutaneous calcifications, unchanged compared to the prior study.",0
(Over) 9:44 AM CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # CT RECONSTRUCTION Reason: pelvis to eval rectal abscess.,1
"Needs IV contrast only Admitting Diagnosis: PERI-RECTAL ABSCESS Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) BONE WINDOWS: Marked degenerative changes are seen; however, there is no suspicious lytic or blastic lesion.",1
Multiplanar reformation images confirmed the above finding.,0
"3-cm fluid collection with peripheral enhancement containing air and fluid in the left perirectal area, likely representing perirectal abscess in this patient with purulent drainage from rectum.",1
"Air-containing tubular structure extending from the abscess inferiorly, may represent fistula to the skin; however, the most inferior portion of the lesion is not included in the present study.",0
Status post axillary-bifem bypass surgery.,0
"Decrease in size of bilateral inguinal fluid collections, larger on the right, probably representing seroma versus hematoma as described previously.",0
"Small collection of air in the bladder, which may be related to recent catheter placement if there is an appropriate history; however, please correlate with the result of urinalysis.",0
"The information has been communicated with the referring physician, .",0
", by telephone in the morning of , immediately after the interpretation of the study, and the wet read has been provided through CCC.",0
"3:26 PM UNILAT LOWER EXT VEINS Clip # Reason: evaluate for DVT Admitting Diagnosis: HUMERUS FRACTURE;RENAL FAILURE;LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with ESLD a/w left humerus fracture, likely variceal bleed, bacteremia with left leg swelling to the hip and pain REASON FOR THIS EXAMINATION: evaluate for DVT ______________________________________________________________________________ FINAL REPORT HISTORY: 61-year-old male with swelling of the left leg.",1
No prior studies for comparison.,0
"FINDINGS: Grayscale and color Doppler son of the left common femoral, superficial femoral, and popliteal veins were obtained.",0
"There is normal flow, compressibility, and augmentation.",0
Grayscale and color Doppler son of the right common femoral vein was obtained for comparison and is unremarkable.,0
IMPRESSION: No evidence of DVT of the left lower extremity.,0
"9:26 AM CHEST (PA & LAT) Clip # Reason: Please evaluate for aspiration pneumonia, pleural effusions, Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with h/o CAD, MRSA bacteremia, who presents with new O2 requirement.",1
"REASON FOR THIS EXAMINATION: Please evaluate for aspiration pneumonia, pleural effusions, or pulmonary edema ______________________________________________________________________________ FINAL REPORT CHEST X-RAY: INDICATION: MRSA bacteremia with new O2 requirement.",1
"Frontal and lateral views are compared with prior examination dated , .",0
There are median sternotomy wires.,0
There are surgical clips in the mediastinum consistent with coronary artery bypass.,1
There is an increasing right pleural effusion and left pleural effusion.,1
"There is bilateral lower lobe opacity, most likely representing atelectasis.",0
There is a small amount of fluid in the minor fissure.,0
There is plate-like atelectasis in the left upper lobe.,0
There are bilateral vascular congestion.,0
The cardiac silhouette is moderately enlarged.,0
IMPRESSION: Increasing size of pleural effusions with bilateral lower lobe atelectasis.,1
"11:47 AM CHEST (PA & LAT) Clip # Reason: eval for pleural effusions Admitting Diagnosis: AORTIC STENOSIS\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman s/p AVR, CABG REASON FOR THIS EXAMINATION: eval for pleural effusions ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST OF COMPARISON: study.",1
FINDINGS: The patient is status post median sternotomy and coronary artery bypass surgery.,1
Stable postoperative widening of cardiomediastinal contours.,0
Development of mild pulmonary vascular congestion with accompanying interstitial edema.,1
Persistent small pleural effusions and bibasilar atelectasis.,0
PATIENT/TEST INFORMATION: Indication: Congenital heart disease.,0
"Status: Inpatient Date/Time: at 13:00 Test: Portable TTE (Congenital, focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
Report will be generated by .,0
"7:48 AM MR HEAD W/ CONTRAST Clip # Reason: 63 year old woman with Two posterior fossa lesions, wand stu Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: MAGNEVIST Amt: 16 ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with Two posterior fossa lesions, wand study for OR, please place markers poteriorly in occipital region and make sure to image low covering entire posterior fossa.",0
Please perform study and no later.,0
"REASON FOR THIS EXAMINATION: 63 year old woman with Two posterior fossa lesions, wand study for OR, please place markers poteriorly in occipital region and make sure to image low covering entire posterior fossa.",0
"No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa TUE 2:48 PM PFI: Preoperative MR two large heterogeneous lesions within the cerebellar hemispheres, similar in appearance to the MRI of .",0
______________________________________________________________________________ FINAL REPORT INDICATION: Preoperative planning for wand study.,0
TECHNIQUE: Limited post-contrast MR imaging of the brain was performed with fiducial placement for wand study.,0
"COMPARISON: Multiple prior examinations, most recent MR .",0
"FINDINGS: Again seen are two large heterogeneous lesions within the cerebellar hemispheres, one on the left and one on the right with mixed solid and cystic components.",0
"There is mass effect on the fourth ventricle with dilation of the third ventricle and lateral ventricles, similar in appearance to the MR study.",0
No new lesions are seen.,0
"IMPRESSION: Preoperative MR two large heterogeneous lesions within the cerebellar hemispheres, similar in appearance to the MRI of .",0
", M. 2:18 PM CHEST (PRE-OP PA & LAT) Clip # Reason: EVALUATE FOR CARDIOPULMONARY PROCESS Admitting Diagnosis: ANGINA\CATH ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with CAD s/p CABG MV repair , now preop for Redo CABG REASON FOR THIS EXAMINATION: evaluate for cardiopulmonary process ______________________________________________________________________________ PFI REPORT no acute cardiopulmonary process.",0
11:28 AM HIP UNILAT MIN 2 VIEWS IN O.R.,0
RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # Reason: ORIF RIGHT HIP Admitting Diagnosis: (AML) ACUTE MYELOGENOUS LEUKEMIA;HYPOTENSION ______________________________________________________________________________ FINAL REPORT RIGHT HIP CLINICAL INFORMATION: ORIF.,1
FINDINGS: 16 total fluoroscopic spot radiographs demonstrate placement of an intramedullary rod with proximal gamma nail and distal interlocking screw.,0
Please refer to operative note for full details.,0
2:29 PM TIB/FIB (AP & LAT) SOFT TISSUE LEFT Clip # Reason: eval for free air ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with weeping cellulitis of LLE REASON FOR THIS EXAMINATION: eval for free air ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MJMgb FRI 8:26 PM Extensive soft tissue swelling of the left lower extremity without evidence of subcutaneous air.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Weeping cellulitis of the left lower extremity.,0
TECHNIQUE: AP and lateral films of the left lower extremity.,0
FINDINGS: There is extensive soft tissue swelling of the left leg without evidence of subcutaneous air.,0
"No fracture, dislocation, or degenerative change is detected.",0
No soft tissue calcification or foreign body is detected.,0
IMPRESSION: Extensive soft tissue swelling of the left lower extremity without evidence of subcutaneous air.,0
"9:36 PM FEMORAL VASCULAR US RIGHT Clip # Reason: GROIN HEMATOMA R/O PSEUDOANEURYSM Admitting Diagnosis: MYOCARDIAL INFARCT;DIABETIC KETOACIDOSIS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with CAD, NSTEMI c/b afib, now with ARF/CKD 2x2 contrast , s/p femoral catheter placement for HD, with groin hematoma REASON FOR THIS EXAMINATION: r/o psudoaneurism ______________________________________________________________________________ FINAL REPORT INDICATIONS: 79-year-old man with coronary artery disease and acute renal failure, status post placement of femoral hemodialysis catheter.",1
There has been persistent bleeding at this site.,0
"RIGHT FEMORAL VASCULAR ULTRASOUND, LIMITED: There is no evidence of discrete hematoma or pseudoaneurysm.",0
The common femoral artery and vein show normal small color and spectral Doppler flow and waveforms.,0
8:58 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: abnormal kub Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with abnormal kub REASON FOR THIS EXAMINATION: abnormal kub ______________________________________________________________________________ FINAL REPORT HISTORY: Prior studies showing an abnormal bowel gas pattern.,0
"EXAMINATION: Portable babygram, 10:00 A.M., .",0
"Since the study from the previous day, the endotracheal tube has advanced into the lower trachea and is now positioned just above the carina.",0
No change in the PDA clip.,0
There is worsening aeration of the lungs with diffuse opacification of both lungs.,0
There is also new linear lucency that is not clearly within the airways and is concerning for pulmonary interstitial emphysema.,1
No other changes in the chest.,0
"In the abdomen, the stomach remains air-filled and mildly distented.",0
There is also a persistently dilated air-filled loop of bowel seen just under the stomach.,0
It is unclear whether this represents colon of small bowel.,0
"It has changed very little in appearance over the past two days and continued attention to this region is necessary, since this could represent an early manifestation of necrotizing enterocolitis.",0
Worsening aeration with changes concerning for PIE.,0
Abnormal bowel gas pattern with persistently dilated loop in the left upper quadrant which could reflect an early manifestation of NEC.,0
These findings were all discussed with the clinical team.,0
"7:55 AM CHEST (PORTABLE AP) Clip # Reason: interval CXR Admitting Diagnosis: SOB, FEVER ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p L thoacotomy & decortication + REASON FOR THIS EXAMINATION: interval CXR ______________________________________________________________________________ FINAL REPORT INDICATION: Status post left thoracotomy and decortication for empyema.",1
CHEST AP: The three left chest tubes are in place.,0
There is interval removal of the left subclavian line.,0
Mediastinotomy sutures and a prosthetic aortic valve is present.,0
There is slight interval worsening of the opacification of the left hemithorax consistent with the re-accumulation of fluid and atelectasis.,0
The right lung is clear.,0
IMPRESSION: Increasing opacification of the left hemithorax representing increased atelectasis and effusion.,0
"9:19 PM SP,SINGLE FILM IN O.R.",0
Clip # Reason: T2-T5 LAMINECTOMY Admitting Diagnosis: ETOH WITHDRAWAL ______________________________________________________________________________ FINAL REPORT INDICATION: Intraoperative evaluation of patient to evaluate thoracic spinal level.,0
COMPARISON: Chest radiograph from at 2:43.,0
FINDINGS: Two portable intraoperative AP radiographs were obtained of the chest.,0
clamp is visualized at the left T5 vertebral body.,0
A retractor is visualized inferior to the clamp.,0
"An endotracheal tube, an NG tube, and right internal jugular central venous catheter are visualized in stable positions in comparison to prior study.",0
Moderate cardiomegaly is again visualized.,0
There are bibasilar opacities suggestive of pulmonary edema with bilateral pleural effusions.,1
"These findings were discussed by Dr. with Dr. at 10:00 p.m. on , .",0
11:57 AM CHEST (PA & LAT) Clip # Reason: Please evaluate for CHF.,0
Admitting Diagnosis: PNEUMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: year old woman with pneumonia.,0
REASON FOR THIS EXAMINATION: Please evaluate for CHF.,0
______________________________________________________________________________ FINAL REPORT CHEST 2 VIEWS: INDICATION: y/o woman with pneumonia and CHF.,0
"COMMENT: PA & lateral chest is reviewed, and compared with the previous study dated .",0
"Again note is made of marked cardiomegaly with moderate sized ____ pleural effusion, which are not changed.",0
There is continued consolidation in both lower lobes.,0
The lungs are clear otherwise.,0
Again note is made of marked tortuosity of the thoracic aorta with calcification.,0
IMPRESSION: Continued marked cardiomegaly with bilateral pleural effusion and atelectasis in both lower lobes.,0
The pneumonia is not excluded in the lower lobes.,0
"2:03 PM C-SPINE, TRAUMA Clip # Reason: s/p assault, abd pain ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with ?",0
"REASON FOR THIS EXAMINATION: s/p assault, abd pain ______________________________________________________________________________ FINAL REPORT INDICATION: Post assault.",0
"CERVICAL SPINE, LATERAL, SWIMMER'S, AP AND ODONTOID: There is no prevertebral soft tissue swelling.",0
Osteophytes are noted in multiple levels.,0
The lateral view visualizes down to C5-6 and the swimmer's demonstrates normal alignment through C7.,0
The spinous processes are not visualized from C3-C5.,0
Has this patient had surgery in the area?,0
The odontoid process appears intact.,0
The lateral masses of C1 are well aligned to C2.,0
IMPRESSION: Post surgical and degenerative changes.,0
PATIENT/TEST INFORMATION: Indication: Congestive heart failure.,1
BP (mm Hg): 95/49 Status: Inpatient Date/Time: at 09:57 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
There is severe regional left ventricular systolic dysfunction.,0
LV WALL MOTION: The following resting regional left ventricular wall motion abnormalities are seen: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; septal apex- akinetic; RIGHT VENTRICLE: The right ventricle is not well seen.,0
AORTIC VALVE: There are three aortic valve leaflets.,0
There is moderate mitral annular calcification.,0
There is mild thickening of the mitral valve chordae.,0
The tips of the papillary muscles are calcified.,0
Moderate (2+) mitral regurgitation is seen.,0
TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened.,0
There is mild pulmonary artery systolic hypertension.,0
GENERAL COMMENTS: Suboptimal image quality - poor subcostal views.,0
There is severe regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral walls and moderate hypokinesis of the remaining segments.,0
No discrete left ventricular thrombus is seen.,0
The aortic valve leaflets (3) are moderately thickened but not stenotic.,0
The mitral valve leaflets and supporting structures are mildly thickened.,0
There is at least mild pulmonary artery systolic hypertension.,0
IMPRESSION: Left ventricular cavity enlargement with regional and global systolic dysfunction c/w multivessel CAD or other diffuse process.,0
"10:50 AM CHEST (PORTABLE AP) Clip # Reason: aspiration ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with PVD cholangitis REASON FOR THIS EXAMINATION: aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: Cholangitis, aspiration.",0
Comparison is made to the prior study from .,0
Upright AP chest radiograph: The ET tube tip is located at the thoracic outlet.,0
Again demonstrated is a right internal jugular central venous line with the tip in the SVC.,0
There is interval improvement in the amount of congestive heart failure.,1
"Residual right lung opacity remains, consistent with aspiration.",0
There is patchy atelectasis in the left upper lobe.,0
The osseous structures are stable in appearance.,0
ET tube tip at thoracic outlet.,0
Slight improvement in congestive heart failure.,1
Residual opacity from aspiration in right lung.,0
"1:00 AM CHEST (PORTABLE AP) Clip # Reason: assess ET T ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with intox s/p intubation REASON FOR THIS EXAMINATION: assess ET T ______________________________________________________________________________ FINAL REPORT FRONTAL CHEST RADIOGRAPH INDICATION: 24-year-old with intoxication, status post intubation.",0
FINDINGS: The endotracheal tube terminates approximately 2.8 cm above the carina.,0
Nasogastric tube reaches the stomach.,0
"There is no focal consolidation, pleural effusion or pneumothorax.",0
"Imaged osseous structures appear unremarkable, there is no displaced fracture.",0
IMPRESSION: Endotracheal tube in the appropriate position.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafting x2 with a left internal mammary artery graft to the left anterior descending and reverse saphenous vein graft to the ramus intermedius branch.,1
History of Present Illness: Mr. is a 75-year-old male with worsening anginal symptoms who underwent catheterization that showed left main disease and left-sided disease and is presenting for revascularization.,0
"Past Medical History: Coronary Artery Disease, Hypertension, Hyperlipidemia, Post Traumatic Stress Disorder, Prior Knee Replacement, Prior Hernia Repair Social History: Denies tobacco and ETOH.",1
Family History: Denies premature CAD.,0
"Physical Exam: Vitals BP 144/57, HR 54, R 16, SAT 100% on RA General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: 08:15AM BLOOD Hct-31.2* 07:25AM BLOOD WBC-13.2* RBC-3.43* Hgb-10.8* Hct-32.1* MCV-94 MCH-31.4 MCHC-33.6 RDW-14.6 Plt Ct-146* 08:15AM BLOOD UreaN-18 Creat-1.0 K-4.6 07:10AM BLOOD Mg-1.8 Brief Hospital Course: Mr. was admitted and underwent two vessel coronary artery bypass grafting by Dr. .",1
"Intraoperative echocardiogram was notable for depressed LV function with an ejection fraction of 40-45%, and mild mitral regurgitation.",0
"Post bypass, his LV function remain unchanged but his mitral regurgitation improved to trace.",0
"The operation was otherwise uneventful, and he was brought to the CSRU for invasive monitoring.",0
He weaned from intravenous therapy without difficulty.,0
Diuresis was initiated and he transferred to the telemetry floor on postoperative day one.,0
Beta blockade was initially withheld secondary to systolic BP in the 100's and bradycardia.,0
"Over several days, beta blockade was resumed and advanced as tolerated.",0
He remained in a normal sinus rhythm without evidence of atrial or ventricular dysrythmias.,0
He continued to make clinical improvements with diuresis and made steady progress with physical therapy.,0
He was cleared for discharge to home on postoperative day five.,0
"At discharge, his BP was 120-130's/ 60-70 with a HR of 70's(sinus) and room air saturations of 98%.",0
His discharge chest x-ray showed only small bilateral pleural effusions.,0
"Medications on Admission: Toprol XL, Lipitor, Aspirin, Paxil Discharge Medications: 1.",0
Potassium Chloride 20 mEq Tab Sust.Rel.,0
Particle/Crystal Sig: One (1) Tab Sust.Rel.,0
Particle/Crystal PO Q12H (every 12 hours) for 7 days.,0
Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Home Health Visiting RN () Discharge Diagnosis: Coronary Artery Disease - s/p CABG, Hypertension, Hyperlipidemia, Post Traumatic Stress Disorder, Prior Knee Replacement, Prior Hernia Repair Discharge Condition: Good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month Followup Instructions: follow up with Dr. in weeks follow up with Dr. in weeks follow up with Dr. in weeks Completed by:",1
"10:04 AM CHEST (PORTABLE AP) Clip # Reason: Eval for effusion, ETT placement Admitting Diagnosis: BENTEL PROCEDURE ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman s/p Bental REASON FOR THIS EXAMINATION: Eval for effusion, ETT placement ______________________________________________________________________________ FINAL REPORT INDICATION: Dental procedure.",0
"A bedside radiograph of the chest shows numerous support lines and tubes, which are in appropriate position including Swan-Ganz catheter, mediastinal drains, endotracheal tube and nasogastric tube.",0
Dense left basilar atelectasis is also stable.,0
There is a probable small left pleural effusion.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: Assess placement of CVL Admitting Diagnosis: LEFT PLEURAL EFFUSION;STATUS POST LIVER TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 44 M s/p liver txx2, s/p R IJ CVL guidewire exchange REASON FOR THIS EXAMINATION: Assess placement of CVL ______________________________________________________________________________ FINAL REPORT INDICATION: 44-year-old man status post liver transplant x2, status post right internal jugular central venous catheter exchange.",0
COMPARISON: AP supine portable chest x-ray dated at 15:24.,0
AP PORTABLE SEMI-ERECT CHEST X-RAY: A right internal jugular central venous catheter is seen with the tip in the upper superior vena cava.,0
A nasogastric tube descends below the diaphragm with the tip not visualized.,0
An endotracheal tube terminates 6 cm superior to the carina.,0
Two chest tubes terminate within the left lung base.,0
No pneumothorax is seen bilaterally.,0
"The cardiac silhouette, mediastinal and hilar contours are normal and stable.",0
"Again seen is bilateral patchy atelectasis, predominantly within the left lung base, which is stable since the prior exam.",0
No effusions or consolidations are seen.,0
The surrounding soft tissue and osseous structures demonstrate a drain overlying the right upper quadrant and surgical clips in the left lateral thorax.,0
Right internal jugular central venous catheter placement with tip in the upper superior vena cava.,0
Lines and tubes as indicated above.,0
No evidence of pneumothorax bilaterally.,0
"Stable bilateral lung base patchy atelectasis, more prominently on the left.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Zomig Attending: Chief Complaint: Unresponsive.,0
Major Surgical or Invasive Procedure: Intubation.,0
"History of Present Illness: 77 yo F with hx asthma, CHF, PAF, and OSA, found unresponsive at psychiatyric facility with hypercarbic resp failure.",1
She was found with sat of 87% and while asleep 62%.,0
She was recently transfered from to HRI .,0
Pt has had previous desats prior to yesterday.,0
"She was then given 40mg po lasix, 1 mg ativan, and alb nebs.",0
"When arrived in ED, she was given narcan and started on BIPAP.",0
Pt improved on BIPAP in ED and repeat ABG 7.28/85/129/42.,0
Past Medical History: Dementia A-fib HTN OA hypothyroidism Asthma Social History: She has been a resident of nursing homes.,1
"She was most recently at Life center, then HRI, but had previously been at .",0
Her daughter and her son beeper are very involved in her care.,0
She is mostly Portuguese speaking but she does understand some English.,0
Physical Exam: in ED T 99.4 P 80 BP 112/palp Sat 98% on BIPAP Gen - unresponsive except moans HEENT - Pupils 2mm ERRL Chest - CTA B anteriorly with occ upper airway sounds.,0
"Cor - RRR nl s1/s2 no murmurs Abd - soft obese, pos BS Ext - trace edema Neuro - minimally responsive to touch/pain More recent exam: .",0
"Vitals: Tm = 99.6, Tc = 98.1 BP = 120-152/68-78, P = 69-85, RR = 18-20, BS = 102-183, 93-94% on RA.",0
Gen: Obese female laying in bed.,0
Cervical collar not in place.,0
-Chest: CTA B anteriorly and posteriorly with good inspiratory effort.,0
"-Cor: RRR nl s1/s2 -Abd: soft obese, pos BS -Ext: 2+ DPP appreciated bilaterally.",0
Right arm: 2-4 cm friction blister with skin breakdown and serosang ooze covered by duoderm patch.,0
"Pertinent Results: 03:44AM TYPE-ART PO2-129* PCO2-85* PH-7.28* TOTAL CO2-42* BASE XS-9 02:47AM URINE COLOR-Straw APPEAR-Clear SP -1.015 02:47AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG 02:47AM URINE RBC-1 WBC-1 BACTERIA-RARE YEAST-NONE EPI-1 02:47AM URINE HYALINE-1* 02:20AM GLUCOSE-103 UREA N-20 CREAT-0.8 SODIUM-148* POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-36* ANION GAP-11 02:20AM CK(CPK)-35 02:20AM cTropnT-<0.01 02:20AM CK-MB-2 02:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 02:20AM WBC-5.9 RBC-3.93* HGB-11.9* HCT-36.7 MCV-93 MCH-30.3 MCHC-32.4 RDW-13.0 02:20AM NEUTS-51.6 LYMPHS-36.8 MONOS-7.5 EOS-3.2 BASOS-0.9 02:20AM PLT COUNT-121* 02:16AM TYPE-ART PO2-140* PCO2-94* PH-7.24* TOTAL CO2-42* BASE XS-9 02:16AM HGB-12.5 calcHCT-38 06:59AM TYPE-ART RATES-/14 PEEP-8 O2-40 PO2-128* PCO2-105* PH-7.19* TOTAL CO2-42* BASE XS-8 INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-CPAP Admission Chest AP: Allowing for technique, cardiac and mediastinal contours are likely normal.",0
Patchy opacity is seen in the left lower lobe/lingular area.,0
The right lung appears clear.,0
There is slight biapical pleural thickening.,0
Several calcified nodes are seen in the left hilum.,0
"In addition, there appears to be a calcified granuloma in the right upper lobe.",0
There may be a small left pleural effusion.,0
Left lower lobe/lingular patchy consolidation.,0
Calcified nodes/granuloma suggestive of past granulomatous infection.,0
"EKG NSR 78bpm, nl axis, no ST or T wave changes : Chest AP The heart is enlarged but stable.",0
There are calcified lymph nodes in the AP window and left hilum and there are calcified granulomas in the left mid and right upper lung zones.,0
"These findings, as well as an area of right apical thickening are stable.",0
The lungs demonstrate no focal areas of consolidation.,0
No definite pleural effusions are identified on the single projection.,0
"As compared to the recent study, there is improved visualization of the left retrocardiac area.",0
"Brief Hospital Course: 77 yo F with dementia, CHF?",0
who presentedunresponsive at psych facility with hypercarbic respiratory failure.,1
* 1) Respiratory Failure- We thought that her respiratory failure was multifactorial in etiology.,1
The patient is perhaps hypercarbic at baseline.,0
Pt likely hyper carbic at base line.,0
We thought that pnemonia exacerbated her possible COPD/OSA/ obesity hypoventilation to the point where she decompensated.,0
We also found that a pannus in the upper cervical spine which might have contributed to the patient's apnea.,1
The patient was transferred to the MICU where she was intubated then weaned to pressure support and then successfully extubated on .,0
She was then weaned off oxygen onto room air.,0
* 2)Pneumonia exaceCeftriaxone/azith were started on admission which was eventually changed to levofloxacin such that she completed a 10 day course.,0
* 3)Obstructive sleep apnea: She continued to desaturate periodically at night for which she was started on bipap with good effect but the patient refused to wear the bipap mask.,1
She also underwent an inpatient sleep study but this was terminated early secondary to her refusal to wear the bipap mask.,0
* 4)Psych - Pt was originally started on her home psych meds (see meds on admission).,0
However zyprexa and depakote were stopped due to possible respiratory depression.,0
Psychiatry was consulted and they thought that the patient had dementia and resolving delerium.,0
Her standing haldol was discontinued and she was started on zyprexa prn agitation.,0
* 5) Neuro - CT of the head demonstrated basal ganlia lesion and a pannus in the upper cervical spine.,0
"MRI done to further evaluate which demonstrated: a Posterior vertebral pannus formation C1-C2, with compression/stenosis of the spinal cord as it exits the foramen magnum.",0
"There was no evidence of intracranial hemorrhage, or minor or major vascular territorial infarction.",0
Chronic lacunar infarcts were also observed Neurosurg consulted.,0
The spoke to the pts home neurosurgeon at Hospital and found that this was a problem that had already been worked up.,0
Because of her poor baseline functional status the pt was felt to be a poor surgical candidate.,0
She was placed in a cervical collar which she refused to wear.,0
* 6)In light of the continued improvement in her mental status we (the medical team and the patient's family) thought that it would be best if the patient were transferred to a rehab/long term care center where she could prepare for the upcoming surgery should her family decide to procede.,1
At this time the family deferred surgery in light of her condition.,0
Medications on Admission: KCl 10mg qday Lasix 40mg qday Prozac 20mg qday Celebrex 20mg qday Colace 100 mg Ecotrin 81 mg qday Protonix 40mg qday Depakotote 250mg qam/ 500mg qpm Zyprexa 10mg Abilify 10mg qam Discharge Disposition: Extended Care Facility: Care Center Discharge Diagnosis: Primary: 1.,0
Pannus posterior to Odontoid at C2 with compression of the cervicomedullary junction.,0
Degenerative disc disease from C3 through C6 with spinal cord compression.,0
"Able to eat, interactive, at her baseline.",0
"Discharge Instructions: Please return to the emergency room if you experience shortness of breath, difficulty breathing, chest pain, fevers or chills.",0
Please take all of your medications as prescribed.,0
Followup Instructions: Please call Dr. MD at to follow up with regard to potential neck surgery.,0
"LINE PLACEMENT Clip # Reason: eval new line Admitting Diagnosis: ASCITES, HYPOGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with R IJ placed REASON FOR THIS EXAMINATION: eval new line ______________________________________________________________________________ FINAL REPORT INDICATION: 63-year-old man with right internal jugular catheter is placed.",0
SUPINE CHEST X-RAY PERFORMED AT 23:55: There is new right internal jugular catheter with its tip at the superior vena cava.,0
There is no sign of pneumothorax.,0
"Cardiac silhouette is similar to the previous study, is unremarkable.",0
The aortic knob is calcified with the sign of atherosclerotic disease.,0
There is increase in the retrocardiac left lower lobe opacity as compared to the previous study with increase in the left pleural effusion which is currently moderate.,0
Also noted is TIPS at the right upper quadrant of abdomen.,0
New central venous line at the right internal jugular vein.,0
Increase in the retrocardiac left lower lobe opacity with small increase in the left pleural effusion.,0
10:19 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: Please advance to post pyloric.,0
Admitting Diagnosis: HYDROTHORAX Contrast: CONRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with Dobhoff REASON FOR THIS EXAMINATION: Please advance to post pyloric.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 11:35 AM Successful placement of -intestinal tube into third portion of duodenum.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Please advance previously placed Dobbhoff tube to post-pyloric position.,0
-INTESTINAL TUBE PLACEMENT: 2% lidocaine jelly was injected into patient's nostrils prior to procedure for anesthetization purposes.,1
"Under fluoroscopic guidance, a previously placed nasogastric tube was identified; however, a guide wire could not be passed through catheter.",0
Nasogastric tube was pulled and a new -intestinal tube was placed under intermittent fluoroscopic guidance into a post-pyloric position.,0
Contrast was injected to confirm placement in the third portion of the duodenum.,0
The catheter was then flushed with water and taped to patient's nostril.,0
Patient tolerated the procedure well.,1
IMPRESSION: Successful placement of -intestinal tube into third portion of duodenum.,0
"6:18 PM CT PELVIS ORTHO W/O C Clip # Reason: Evaluate acetabulum, femoral head Field of view: 45 ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with L acetabular fx REASON FOR THIS EXAMINATION: Evaluate acetabulum, femoral head No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Left acetabular fracture.",1
TECHNIQUE: Non-contrast CT of the pelvis with coronally and sagittally reformatted images.,0
"FINDINGS: Intraarticular comminuted left acetabular fracture involves the posterior column, roof, and medial wall.",0
"The left femoral head appears to maintain a normal contour, without evidence of fracture.",0
There is associated hematoma within the surrounding soft tissues.,0
"The right hip joint space is slightly narrowed, and moderate osteophyte formations are noted about the right hip.",0
No fracture is seen on the right.,0
The SI joints and pubic symphysis are within normal limits.,0
"Incidentally noted within the soft tissues of the pelvis is a 1 cm calcific density just superior to the bladder, of doubtful significance, which may represent a calcified lymph node.",0
The contents of the pelvis are otherwise unremarkable on this noncontrast examination.,0
IMPRESSION: Intraarticular left acetabular fracture.,0
"12:10 PM CT HEAD W/O CONTRAST Clip # Reason: CTA head/neck with contrast - eval cerebral vessels for AVM, Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: S/P MVC WITH R thalamic bleed REASON FOR THIS EXAMINATION: CTA head/neck with contrast - eval cerebral vessels for AVM, aneurysm No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Right thalamic bleed.",1
TECHNIQUE: Axial images were obtained through the brain without the administration of IV contrast.,0
150 cc of non-ionic Optiray contrast was injected in the attempt to image the intracranial vasculature.,0
"However, the images were obtained before the contrast was seen entering the aorta and carotids.",0
"Therefore, the intracranial vessels are not opacified and incompletely imaged.",0
This problem was discussed with the clinical staff and the patient will not be charged for CT angiogram.,0
A MRA of the circle of is recommended.,0
CT HEAD WITHOUT CONTRAST: The large right thalamic bleed is again identified with intraventricular extension.,0
It has not significantly changed in the interim although there may be a slightly larger amount of intraventricular blood.,0
The ventricles appear slightly larger in size when compared to the previous study.,0
The patient is intubated and there is an NG tube in place.,0
"There has been interval increased opacification in the paranasal sinuses with complete opacification of the left maxillary sinus and partial opacification of the right maxillary sinus, ethmoid and frontal air cells.",0
"IMPRESSION: No significant change in large, right thalamic hemorrhage with intraventricular extension.",0
The ventricles may be slightly increased in size when compared to the previous study.,0
4:01 PM CHEST (PORTABLE AP) Clip # Reason: Desaturation Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with cervical injury now with desaturation.,0
"REASON FOR THIS EXAMINATION: Desaturation ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with cervical injury , now with desaturation.",0
Portable AP chest radiograph was reviewed in comparison to .,0
"There is significant interval progression in right lower lobe opacity already seen on the prior study, consistent with massive aspiration/aspiration pneumonia.",0
No pleural effusion or pneumothorax is seen.,0
"Pneumoperitoneum is redemonstrated, slightly decreased since the prior studies.",0
Findings were discussed with Dr. over the phone by Dr. at 5 p.m. on .,0
Weight (lb): 144 BP (mm Hg): 111/74 HR (bpm): 91 Status: Inpatient Date/Time: at 15:09 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Moderate-severe global left ventricular hypokinesis.,0
"TVI E/e' < 8, suggesting normal PCWP (<12mmHg).",0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; inferior apex - hypo; lateral apex - hypo; RIGHT VENTRICLE: Normal RV wall thickness.,0
AORTA: Normal aortic root diameter.,0
No MR. PERICARDIUM: No pericardial effusion.,0
Conclusions: 1.The left atrium is normal in size.,0
"While the LV function is hard to assess because of the technical difficulty of the study, it does appear that there is mild to moderate global left ventricular hypokinesis with more marked hypokinesis of the inferior, inferolateral and septal walls.",0
Overall left ventricular systolic function is mildly depressed.,0
Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (PCWP<12mmHg).,0
Right ventricular systolic function appears depressed.,0
4.The aortic valve leaflets (3) are mildly thickened.,0
5.The mitral valve leaflets are mildly thickened.,0
6.There is no pericardial effusion.,0
"7:04 PM HIP UNILAT MIN 2 VIEWS RIGHT Clip # Reason: r/o fracture Admitting Diagnosis: MITRAL VALVE DISORDER\MITRAL VALVE REPLACEMENT, ?",1
"TRICUSPID VALVE REPLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 73F POD 4 s/p MVrepair (28mm annuloplasty ring) with R hip pain REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ WET READ: GMSj WED 12:53 AM Uncertain hx - possible fall prior to cardiac surgery per family, pt now guarding right side and not wt bearing.",1
Radiographic findings concerning for an impacted right femoral neck fracture.,0
Cortical disruption along medial margin.,0
Does not involve the greater trochanter.,0
Findings d/w Dr. @ 12:52 am on by telephone.,0
"GSenapati ______________________________________________________________________________ FINAL REPORT HISTORY: Right hip pain, rule out fracture.",1
AP PELVIS AND TWO VIEWS OF THE RIGHT HIP.,0
"Please see wet provided by radiology resident, Dr. .",0
reporting findings concerning for impacted right femoral neck fracture with cortical disruption along the medial margin.,0
This was discussed by Dr. with Dr. at 12:52 a.m. on by telephone.,0
Please see full wet .,0
There is severe diffuse osteopenia.,0
"There is a subcapital fracture of the right proximal femur, with slight lateral offset and anterior apex angulation of the major distal fragment and slight impaction.",1
The hip joint remains congruent.,0
The pelvic girdle remains congruent.,0
Mild degenerative changes of both hips are present.,0
"The lower sacrum is obscured by bowel gas, but visualized portion is grossly unremarkable.",0
Degenerative changes in the lower lumbar spine and lumbosacral junction with scattered vascular calcification noted.,0
"IMPRESSION: Right proximal femur subcapital fracture with impaction, slight offset, and angulation.",1
5:16 PM FEMUR (AP & LAT) RIGHT PORT; PELVIS (AP ONLY) Clip # Reason: cross later ok Admitting Diagnosis: RIGHT HIP PAIN ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with ORIF right femur REASON FOR THIS EXAMINATION: cross later ok ______________________________________________________________________________ WET READ: JXRl FRI 10:15 PM RIght total hip arthroplasty.,0
"On the lateral views, it is difficult to determine whether distal sideplate is flush with .",0
Expected gas in soft tissues.,0
______________________________________________________________________________ FINAL REPORT RIGHT FEMUR.,0
FINDINGS: Right total hip arthroplasty.,0
"Near anatomical alignment, postoperative gas in the soft tissues.",0
Appropriate contact with of the distal side plate cannot safely be confirmed on the basis of the lateral view.,0
"1:31 PM CT HEAD W/O CONTRAST Clip # Reason: r/o old CVA Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: year old woman with deteriorated MS, L facial droop and inability to swallow for last week.",0
REASON FOR THIS EXAMINATION: r/o old CVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT TECHNIQUE: Non-contrast head CT.,0
FINDINGS: There is a 1.3 x 1.9 cm extra-axial calcification adjacent to the left frontal lobe.,0
This appears dural based and likely represents an calcified underlying meningioma.,0
No soft tissue masses are identified.,0
There is no edema within the underlying brain.,0
There is no intracranial hemorrhage.,0
"There is no midline shift, mass effect, or hydrocephalus.",0
There are areas of periventricular white matter hypodensity consistent with chronic microvascular ischemic change.,0
Calcified extraaxial mass adjacent to the left frontal lobe likely represents a calcified meningioma.,0
10:48 AM PORTABLE ABDOMEN Clip # Reason: r/o obstruction/infection ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with alph strep empyema.,0
"Now has very tender, distended abdomen REASON FOR THIS EXAMINATION: r/o obstruction/infection ______________________________________________________________________________ FINAL REPORT INDICATION: Hx of abdominal distention and tenderness.",0
PORTABLE ABDOMEN: Distribution of bowel gas is unremarkable.,0
There is no evidence for intestinal obstruction or ileus.,0
There is a probable calcified abdominal aortic aneurysm-this could be better evaluated by ultrasound or CT if clinically indicated as marked tortuosity of the lower abdominal aorta cannot be ruled out on this single view.,1
IMPRESSION: No evidence of intestinal obstruction.,0
Probable abdominal aortic aneurysm which can be better evaluated by ultrasound or CT exam if clinically indicated.,1
10:23 AM CHEST (PORTABLE AP) Clip # Reason: new NG tube -confirm placement please.,0
"Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with ESRD/HD, CHF, Paroxysmal Afib admitted w/ subdural hematoma, s/p Burr holes s/p CVL REASON FOR THIS EXAMINATION: new NG tube -confirm placement please.",1
______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable.,0
"INDICATION: End-stage renal disease, CHF, paroxysmal atrial fibrillation, admitted with subdural hematoma.",1
"Status post burr holes, status post central venous line and new NG tube, assess position.",0
FINDINGS: AP single view obtained with the patient in supine position is analyzed in direct comparison with a similar previous examination of .,0
Position of left subclavian approach central venous line is unchanged.,0
An NG tube has been placed and can be seen to pass far below the diaphragm.,0
There is no pneumothorax or any other placement related complication.,0
"As before, massive bilateral pleural effusions and marked pulmonary vascular congestion.",0
"7:58 PM MR HEAD W & W/O CONTRAST Clip # Reason: ?ischemia or CVA Admitting Diagnosis: CARDIAC ARREST Contrast: MAGNEVIST Amt: 16 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p Vfib initially arrest initially on arctic sun protocol, on vent and propofol for status epilepticus with ?CVA following V fib arrest given presistent status epilepticus requiring propofol with failed wean.",1
REASON FOR THIS EXAMINATION: ?ischemia or CVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: 53-year-old female status post ventricular fibrillation and status epilepticus.,1
"TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, gradient echo, sagittal MP-RAGE post-contrast images with axial and coronal reformats as well as axial T1 post-contrast and diffusion-weighted images of the brain were obtained.",0
"FINDINGS: Increased FLAIR-T2 signal in the entire cerebral cortex, medial temporal lobe (hippocampus) and basal ganglia and thalamus correspond to areas of decreased diffusion.",0
There is no intracranial hemorrhage or mass effect.,0
The ventricles and extra-axial spaces are within normal limits.,0
Flow void in visualized intracranial arteries is consistent with their patency.,0
Mucosal thickening with probable air-fluid levels in the bilateral sphenoid sinuses are noted.,0
IMPRESSION: Diffuse cerebral anoxic injury.,0
PATIENT/TEST INFORMATION: Indication: Intra-op TEE for CABG Height: (in) 73 Weight (lb): 224 BSA (m2): 2.26 m2 BP (mm Hg): 126/70 HR (bpm): 59 Status: Inpatient Date/Time: at 13:44 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum.,0
LEFT VENTRICLE: Mild symmetric LVH.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex - hypo; septal apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
PULMONIC VALVE/PULMONARY ARTERY: No PR.,0
See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications).,0
The left atrium is moderately dilated.,0
The interatrial septum is aneurysmal.,0
"Mild focal WMAs are seen in the anterior, septal and lateral apical segments.",0
Overall left ventricular systolic function is mildly depressed (LVEF= 45 - 50 %).,0
"POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced 1.",0
Aorta is intact post decannulation.,0
6:32 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: r/o CHF Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with CHF now with 2 respiratory arrests REASON FOR THIS EXAMINATION: r/o CHF ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 18:31.,1
"FINDINGS: Compared to the prior study and multiple prior studies, there does not appear to be a significant interval change.",0
"There is some persistent left retrocardiac density, which could be atelectasis or scarring.",0
Increased interstitial markings are also noted.,0
"No new focal consolidations, and no evidence of worsening fluid status.",0
"Pacemaker hardware and wire remain intact in this patient, status post sternotomy.",1
9:07 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
worsening PNA Admitting Diagnosis: S/P FALL;RIB FRACTURE;PNEUMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with ?,1
worsening PNA REASON FOR THIS EXAMINATION: ?,0
"worsening PNA ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:21 A.M. ON HISTORY: Suspect worsening pneumonia.",0
"IMPRESSION: AP chest compared to : Severe right perihilar consolidation, slightly improved.",0
New consolidation at the base of the left lung could be either atelectasis or second focus of pneumonia.,0
Small left apical pneumothorax has increased.,1
Large collection of subcutaneous air in the left chest wall is stable.,0
"3:14 AM CHEST (PORTABLE AP) Clip # Reason: assess ET tube placement Admitting Diagnosis: COPD/RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with mediastinal mass s/p intubation, s/p moving ETT and placing OGT REASON FOR THIS EXAMINATION: assess ET tube placement ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP.",0
FINDINGS: An ET tube is seen approximately 4 cm above the carina.,0
"There is shift of the trachea towards the right, likely secondary to known thyroid mass.",0
There are low lung volumes.,0
The patient is rotated and has levoscoliosis.,0
A left PICC line is seen at the junction of the subclavian and superior vena cava.,0
There is an NG tube traversing below the diaphragm.,0
There is elevation of the right hemidiaphragm.,0
"There is a retrocardiac opacity, which may represent atelectasis or consolidation.",0
"There is a small left pleural effusion, unchanged.",0
IMPRESSION: ET tube 4 cm above carina.,0
Left PICC line at the junction of SVC and subclavian vein.,0
Persistent retrocardiac opacity concerning for atelectasis or underlying consolidation.,0
These findings are communicated to Dr. at approximately 11:45 a.m.,0
PATIENT/TEST INFORMATION: Indication: Awaiting CABG.,0
Height: (in) 67 Weight (lb): 197 BSA (m2): 2.01 m2 BP (mm Hg): 148/87 HR (bpm): 100 Status: Inpatient Date/Time: at 12:20 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.,1
Moderate (2+) MR. Eccentric MR jet.,0
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR.,1
The left ventricular cavity is mildly dilated.,0
"There is regional left ventricular systolic dysfunction with thinning and akinesis of the infero-lateral wall, hypokinesis of the inferior wall , and hypokinesis of the infero-septum.",0
Overall LV systolic function is mild to moderately depressed (LVEF 35-40%) Right ventricular chamber size and free wall motion are normal.,0
The mitral regurgitation jet is eccentric.,0
IMPRESSION: Regional LV systolic dysfunction with mild to moderately depressed LVEF (35-40%) c/w CAD.,0
7:11 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for ptx s/p ct removal Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p chest tube x2 removal.,0
REASON FOR THIS EXAMINATION: eval for ptx s/p ct removal ______________________________________________________________________________ WET READ: JEKh FRI 9:18 PM 1. no R PTX 2. trace L PTX - no evidence for tension 3. expected B chest wall emphysema ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess for pneumothorax after chest tube removal.,0
There is a very small left pneumothorax.,0
There is no right pneumothorax.,0
Bibasilar opacities left greater than right consistent with atelectasis are grossly unchanged.,0
There are no new lung abnormalities.,0
Left IJ catheter tip is in the SVC.,0
Right IJ catheter tip is in the right atrium.,0
NG tube tip is out of view passing the stomach.,0
Multiple surgical clips projecting the right upper quadrant.,0
There are skin staples in the abdomen.,0
There is small amount of subcutaneous emphysema bilaterally left greater than right.,0
1:45 PM CHEST (PA & LAT) Clip # Reason: r/o infiltrates ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with hx of lingual SCC s/p neck dissection and XRT admitted for sepsis (unknown source).,0
"Now, clinically stable but with low grade fevers on clinda/levo day #10 REASON FOR THIS EXAMINATION: r/o infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: Low-grade fevers and H/O squamous cell CA and neck dissection.",0
PA AND LATERAL CHEST RADIOGRAPH: There is a tracheostomy.,0
The pulmonary vasculature is within normal limits.,0
There are no effusions and there is no pneumothorax.,0
No suspicious lytic or blastic lesions.,0
"4:21 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: PERSISTENT FEVERS Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with MVR, afib, s/b basilar artery occlusion and thalamic/brainstem stroke, s/p tPA.",1
w/ persistent fevers and s/p nasal packings for OP bleeds REASON FOR THIS EXAMINATION: ?,0
sinusitis No contraindications for IV contrast ______________________________________________________________________________ WET READ: AZm MON 6:13 PM Pansinusitis ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
INDICATION: Persistent fevers and S/P nasal packing.,0
TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses.,0
"SINUS CT: There is almost complete opacification of the maxillary, frontal, ethmoid, sphenoid sinuses.",0
The ostiomeatal units are not patent.,0
The cribriform plates are equal in height.,0
The anterior clinoid processes are not pneumatized.,0
The laminal papyracea is intact.,0
The sphenoid sinus septum is mid-line.,0
With the history of nasal packing the significance of this finding is uncertain.,0
"12:32 AM CHEST (PORTABLE AP) Clip # Reason: tachypnia ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with REASON FOR THIS EXAMINATION: tachypnia ______________________________________________________________________________ FINAL REPORT HISTORY: Tachypnea, patient unable to hold still for x-ray.",0
TECHNIQUE: AP view of chest.,0
"Due to technical difficulties the left upper, lateral lung is not included in the present study.",0
There is flattening of both hemidiaphragms.,0
There is a patchy opacity in the right lower lung.,0
A small amount of fluid is seen in the minor fissure and at the right CP angle.,0
"IMPRESSION: Small right pleural effusion, and findings consistent with pneumonia in right lower lobe.",0
"5:46 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with trauma, chest tube x 3, continues on the vent, s/p bronch, s/p ETT advancement, s/p chest tube removal REASON FOR THIS EXAMINATION: please eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:59 A.M., HISTORY: On ventilator after trauma.",1
"IMPRESSION: AP chest compared to through 28: Moderate-sized left pneumothorax unchanged in volume since , two left upper chest pleural tubes still in place.",0
ET tube is in standard placement.,0
"Tip of the left subclavian introducer is at the thoracic inlet, tip of the right subclavian line projects over the junction of brachiocephalic veins.",0
Nasogastric tube ends in the upper stomach and would need to be advanced 4 cm to move all the side ports beyond the gastroesophageal junction.,0
"Residual consolidation in the right upper lobe has improved since , stable since .",0
Lateral aspect of the right chest is excluded from the examination.,0
The remaining right pleural surfaces are unremarkable.,0
Subcutaneous emphysema in the left chest wall and right supraclavicular region has improved.,1
"Patient has long history of stable angina with activity (one flight of stairs), described as a mild chest pressure, non radiating, lasts less than 3 minutes and is relieved by rest.",0
"Last thursday () while emptying the dishwasher, he experienced substernal chest pain, radiating to the left elbow associated with diaphoresis.",0
"No SOB, no dizziness, no nausea/vomiting.",0
The pain was not relieved with rest and was not relieved after taking NTG x2.,0
He called 911 and was transported to Hospital by ambulance.,0
"There is a note that refers to the patient having ST elevations during the amblunace ride, but no EKG demonstrating ST changes were in the chart.",0
"At hospital, he had an EKG that demonstrated ST depressions in anterior leads, and positive troponins (no lab records in transfer chart, note refers to peak troponin I as 3.5) and was taken directly to the cath lab.",0
"Coronary catherization revealed 3 vessel disease, specifically 30% stenosis in LMT, 80% stenosis in mid LAD, 70% stenosis in ramus, 60% in stent stenosis in both RCA stents.",0
Cardiac surgery was consulted and recommended CABG but the patient requested transfer to .,0
"On he had a bleed from his cath site, with SBP in the 90s and HCt 32 -> 29.",0
"Hemostasis was achieved with pressure, heparin and nitro drips were stopped, plavix was stopped (last dose on ) and 2U PRBC were transfused without complication.",0
CT abdomen demonstrated no intraperitoneal or retroperitoneal bleeds.,0
A carotid U/S was negative for carotid stenosis.,0
Patient was transferred to on in stable condition.,0
Dr. was conulted for coronary revascularization.,0
"Past Medical History: Coronary Artery Disease s/p NSTEMI s/p POBA to prox LAD and D1 then repeat PTCA 4 months later for ISR at LAD and D1; DES to RCA x2 Borderline Diabetes Mellitus TIA Gout Dyslipidemia s/p skull fracture as child in setting of trauma Hypertension Past Surgical History: s/p Right cheek basal cell CA excision s/p posterior thorax excision of benign compound nevus s/p RUE atypical nevus/melanoma s/p multiple concussions- as child Social History: Tobacco history: never smoker Retired, used to work at Polaroid doing research.",1
Lives on with his wife.,0
"Family History: No family history of early MI, arrhythmia, or sudden cardiac death; otherwise non-contributory.",1
"Physical Exam: Pulse:69 Resp: 20 O2 sat: 97% RA B/P Right:109/56 Left: Height:5'9 Weight:88KG General: NAD, ALERT AND COOPERATIVE Skin: Dry [X] intact [X] SCAR UPPER MID BACK HEENT: PERRLA [X] EOMI []X Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] NO Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +2 PT : +2 Left: +2 Radial Right: +2 Left:+2 Carotid Bruit Right: NONE Left: NONE Pertinent Results: Echo: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler.",0
There is mild regional left ventricular systolic dysfunction with anterior and anterolateral apical segments.,0
There are three aortic valve leaflets.,0
"POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine.",0
Aortic contours appear intact post decannulation 4.,0
Other findings are unchanged Abd U/S : 1.,0
No intra- or extra-hepatic bile duct dilatation.,0
Cholelithiasis without evidence for acute cholecystitis.,0
Probable hemangioma in the left lobe of the liver.,0
05:15PM BLOOD WBC-10.0 RBC-3.67* Hgb-11.6* Hct-33.4* MCV-91# MCH-31.6 MCHC-34.8 RDW-14.3 Plt Ct-398# 05:15AM BLOOD WBC-10.6 RBC-2.63* Hgb-8.1* Hct-24.1* MCV-92 MCH-30.9 MCHC-33.8 RDW-14.8 Plt Ct-297 05:15PM BLOOD PT-13.0 PTT-26.5 INR(PT)-1.1 12:58PM BLOOD PT-14.3* PTT-36.7* INR(PT)-1.2* 05:15PM BLOOD Glucose-112* UreaN-17 Creat-1.2 Na-134 K-4.9 Cl-98 HCO3-27 AnGap-14 05:15AM BLOOD Glucose-112* UreaN-28* Creat-1.2 Na-134 K-4.3 Cl-100 HCO3-23 AnGap-15 05:15PM BLOOD ALT-94* AST-93* CK(CPK)-24* AlkPhos-258* TotBili-0.6 05:50AM BLOOD ALT-55* AST-34 LD(LDH)-186 AlkPhos-197* Amylase-28 TotBili-0.6 05:15PM BLOOD CK-MB-NotDone cTropnT-0.23* 12:50PM BLOOD %HbA1c-6.3* Brief Hospital Course: On Mr. went to the operating room and underwent Coronary Artery Bypass Grafting x 5(Left internal mammary artery grafted to left anterior descending artery/Saphenous Vein grafted to Diagonal/Obtuse Marginal/Post .,1
Cross clamp time= 78 minutes.,0
Cardiopulmonary Bypass Time= 91 minutes.,0
Please refer to Dr. operative report for further details.,0
"Mr. the procedure well and was transferred to the CVICU in stable but critical condition, requiring pressors to optimize hemodynamic support.",0
He awoke neurologically intact and was extubated without difficulty.,0
All lines and drains were discontinued in a timely fashion.,0
"Beta-Blockers, statin, aspirin and diuresis was initiated.",0
He continued to progress and on POD#2 he was transferred to the step down floor for further monitoring.,0
Physical therapy consulted and evaluated.,0
He had a brief episode of atrial fibrillation on POD#2 which was eventually converted to sinus rhythm with beta-blockers and amiodarone.,1
During his post-op course he worked with physical therapy for strength and mobility.,0
On POD#4 he appeared to be doing well and was cleared by Dr. for discharge to home with VNA.,0
"Of note, he had scant drainage from superior pole on discharge day and was started on a 7 day course of antibiotics.",0
All follow up appointments were advised.,0
"Medications on Admission: HCTZ 12.5mg PO daily ASA 325mg PO daily metoprolol tartrate 50mg PO (Rx is for but patient taking daily) simvastatin 40mg PO daily plavix 75mg PO daily (held for possible cabg, last dose ) Discharge Medications: 1.",0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks.,0
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).,0
Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for sternal drainage for 7 days: first dose given this AM in hospital.,0
Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg x 7 day.,0
Then 200 x 7 days.,0
Finally 200mg QD until stopped by cardiologist.,0
Particle/Crystal PO Q12H (every 12 hours) for 2 weeks.,0
"Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA, Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 Myocardial Infarction (per-op) Borderline Diabetes Mellitus NSTEMI s/p POBA to prox LAD and D1 then repeat PTCA 4 months later for ISR at LAD and D1; DES to RCA x2 TIA Gout Dyslipidemia s/p skull fracture as child in setting of trauma Hypertension Past Surgical History: s/p Right cheek basal cell CA excision s/p posterior thorax excision of benign compound nevus s/p RUE atypical nevus/melanoma s/p multiple concussions- as child Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection.",1
5) No lifting greater then 10 pounds for 10 weeks from date of surgery.,0
6) No driving for 1 month or while taking narcotics for pain.,0
Followup Instructions: Wound check on 6 in 1 week Dr. in 4 weeks Dr. in weeks Dr. in weeks Follow up with your dentist this week regarding dental extractions- should be performed within 2 weeks Completed by:,0
"6:22 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: PULMONARY EMBOLUS;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with influenza and PEs, now being treated for possible ventilator associated pneumonia.",1
"REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old male with influenza and pulmonary embolism, now treated for possible ventilator associated pneumonia, followup chest x-ray.",1
COMPARISON: Chest radiographs available from .,0
SUPINE AP VIEW OF THE CHEST: The endotracheal tube terminates 3.9 cm above the carina.,0
An orogastric tube terminates beyond the scope of this study.,0
"Moderate bilateral pleural effusions, bibasilar atelectasis, and mild pulmonary edema are unchanged since .",1
"IMPRESSION: No interval change of moderate bilateral pleural effusions, bibasal atelectasis, and mild pulmonary edema.",1
"3:01 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: CROHN'S COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with Crohn's Disease and hypotension, now 12L positive over hospital stay REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 3:14 A.M. HISTORY: Crohn's disease and hypotension.",0
IMPRESSION: AP chest compared to through 17: Moderately severe pulmonary edema has changed in distribution since but not in overall severity.,0
"A more focal opacity at the lateral aspect of the left mid lung could represent fissural pleural fluid or focal lung lesion such as pneumonia, better evaluated with an upright view, when feasible.",0
Heart is not appreciably enlarged though the anatomy is distorted by severe scoliosis.,0
Tip of a right subclavian line projects over the superior cavoatrial junction.,0
Small bilateral pleural effusions are present.,1
"8:23 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: 67 yo M w/ pancreatitis, intubated in unit, w/ persistent fe Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with alcoholism, pancreatitis, now with respiratory distress requiring intubation and metabolic acidosis, please evaluate for intrabdominal source of infection, specifically any evidence of necrotizing pancretitis, w/ Crt 1.2, will hold on IV contrast REASON FOR THIS EXAMINATION: 67 yo M w/ pancreatitis, intubated in unit, w/ persistent fevers w/out obvious source->please eval for pseudocyst.",1
"Also, pt has inspisssated barium in colon from last CT-please use gastrograffin ______________________________________________________________________________ FINAL REPORT INDICATION: Pancreatitis, intubated in the Unit with persistent fevers, evaluate for necrotizing pancreatitis.",0
TECHNIQUE: Helically acquired contiguous axial images were obtained from the lung bases to the pubic symphysis without contrast and after the administration of intravenous contrast.,0
FINDINGS: The liver is diffusely of low attenuation consistent with fatty infiltration.,0
There is extensive consolidation posteriorly in both lower lobes with adjacent small pleural effusions which are unchanged compared with .,0
"There are multiple small stones within the gallbladder, however, there is no evidence of cholecystitis.",0
Again a small splenule is noted.,0
There are no peripancreatic fluid collections.,0
There is no evidence of pancreatic necrosis.,0
The adrenal glands are normal.,0
There is a small cyst in the left kidney.,0
There is a small cyst in the lower pole of the right kidney.,0
A NG tube is within the stomach.,0
The small and large bowel are unremarkable.,0
There is a small amount of free fluid throughout the peritoneal cavity.,0
CT OF THE PELVIS: Again noted is a small amount of free fluid within the pelvis.,0
The urinary bladder is collapsed by a Foley catheter.,0
The prostate and rectum are unremarkable.,0
Again noted is an old fracture of the right acetabulum.,0
The bones demonstrate degenerative change and multiple old rib fractures.,0
"IMPRESSION: 1) Extensive pulmonary consolidation bilaterally with small pleural effusions, unchanged.",0
2) Marked fatty infiltration of the liver.,0
3) No evidence of pancreatic pseudocyst or pancreatic necrosis.,0
4) There is a small amount of free peritoneal fluid.,0
"(Over) 8:23 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: 67 yo M w/ pancreatitis, intubated in unit, w/ persistent fe Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont)",0
5:51 PM CHEST (PRE-OP PA & LAT) Clip # Reason: RECURRENT ANGINA;CORONARY ARTERY DISEASE\CARDIAC CATH Admitting Diagnosis: RECURRENT ANGINA;CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man preop cabg REASON FOR THIS EXAMINATION: eval preop ______________________________________________________________________________ FINAL REPORT INDICATION: CABG.,1
PA AND LATERAL VIEWS OF THE CHEST: The heart size is normal.,0
The mediastinal and hilar contours are normal.,0
The pulmonary vascularity is not engorged.,0
No pleural effusion or pneumothorax is identified.,0
No acute osseous finding is seen.,0
IMPRESSION: No acute cardiopulmonary abnormality.,0
1:55 AM CHEST (PORTABLE AP) Clip # Reason: Assess for interval change.,0
Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with COPD and CHF REASON FOR THIS EXAMINATION: Assess for interval change.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old woman with COPD and CHF, assess for interval change.",0
SINGLE FRONTAL RADIOGRAPH: Cardiomegaly persists.,0
There are bilateral effusions left greater than right.,0
There is dense bibasilar atelectasis with air bronchograms.,0
IMPRESSION: Increasing dense basilar opacification left greater than right suggestive of pneumonia.,0
Persistent effusions left greater than right.,0
5:18 PM CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # Reason: 37 year old woman with ?,0
"picc line crossing midline, please Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with ?",0
"picc line crossing midline, please perform oblique view for picc placement.",0
REASON FOR THIS EXAMINATION: 37 year old woman with ?,0
______________________________________________________________________________ WET READ: SHfd FRI 8:34 PM PRIOR FREE AIR NOT WELL SEEN.,0
R PICC IN PROX SVC.,0
WET READ VERSION #1 SHfd FRI 8:33 PM R PICC IN PROX SVC.,0
______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Evaluate PICC placement.,0
Comparison with the previous study done earlier the same day.,0
The heart and mediastinal structures are unchanged.,0
A PICC line is again demonstrated on the right.,0
Its tip is projected in the mid superior vena cava.,0
IMPRESSION: Line placement as described.,0
"11:53 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: POD 4 from pancreas transplant with sudden onset abd pain Field of view: 38 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with abd pain REASON FOR THIS EXAMINATION: POD 4 from pancreas transplant with sudden onset abd pain ______________________________________________________________________________ FINAL REPORT HISTORY: Sudden, severe abdominal pain four days post pancreas transplant.",1
TECHNIQUE: CT imaging of the abdomen and pelvis with 150 mL Optiray.,0
Nonionic contrast was used due to generalized debilitation.,0
"CT ABDOMEN WITH CONTRAST: There are small pleural effusions bilaterally, with adjacent atelectasis.",0
There is a small pericardial effusion.,0
There is a small amount of ascites.,0
The liver and gallbladder are normal in appearance.,0
There is a calcified cyst in the spleen.,0
The native pancreas and native kidneys are atrophic.,1
The tip of the nasogastric tube is in the stomach.,0
There is no evidence of bowel obstruction.,0
CT PELVIS WITH CONTRAST: The renal allograft in the left iliac fossa is normal in appearance.,0
"In the right iliac fossa, the pancreatic allograft enhances poorly, has ill-defined borders, and is surrounded by fluid.",0
There is air within a portion of the fluid collection.,0
There appears to be an abrupt termination of the transplanted artery arising from the right common iliac artery.,1
The transplanted vein cannot be identified.,1
There is air and a foley catheter within the urinary bladder.,0
The skeletal structures are unremarkable.,0
"IMPRESSION: Diminished enhancement of pancreatic transplant, with surrounding fluid collections and poor visualization of transplanted artery and vein.",1
"LINE PLACEMENT Clip # Reason: eval line placement ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with severe abd pain, sob REASON FOR THIS EXAMINATION: eval line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 28-year-old woman with severe abdominal pain, shortness of breath.",0
FRONTAL CHEST RADIOGRAPH: Comparison is made with the prior chest radiograph taken approximately one hour earlier on the same day.,0
Right IJ line is terminating in lower SVC.,0
Cardiac and mediastinal contours are within normal limits.,0
No consolidation or effusion is noted.,0
", MED MICU 2:55 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ASPIRATION PNEUMONIA;C5 CERVICAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: year old man with aspiration PNA, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PFI REPORT Improvement of RLL infiltrate.",1
"OG tube tip is high, at level of diaphragm.",0
10:38 AM MANDIBLE SERIES INCLUD PANOREX Clip # Reason: check placement of plate ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with fractured mandible s/p ORIF REASON FOR THIS EXAMINATION: check placement of plate ______________________________________________________________________________ FINAL REPORT INDICATION: Status post ORIF right mandible fracture.,1
MANDIBLE: Comparison to prior CT maxillofacial scan of .,0
Patient is status post ORIF of the known fracture of the right mandible with side plate and screws.,1
The known fracture through the neck of the left mandible is also noted.,1
9:00 AM CHEST (PORTABLE AP) Clip # Reason: Acute cardiopulmonary processes Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with AML s/p cord blood transplant a/w ARDS now with increasing O2 requirement.,1
Please evaluate for interval change REASON FOR THIS EXAMINATION: Acute cardiopulmonary processes ______________________________________________________________________________ FINAL REPORT HISTORY: Leukemia.,1
Single portable radiograph of the chest demonstrates no interval change in the heart and lungs when compared with .,0
Left subclavian central venous catheter is unchanged.,0
11:13 AM PLEURAL ASP BY RADIOLOGIST; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: Bilateral pleural effusions.,1
"Right effusion drained yesterda Admitting Diagnosis: AMPULLARY CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with s/p whipple, with bilat pl.",1
REASON FOR THIS EXAMINATION: Bilateral pleural effusions.,1
"Right effusion drained yesterday, needs left effusion tapped and drained today.",0
Please send for gram stain/cx/cytology.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old woman status post Whipple with bilateral pleural effusions requiring 02.,1
"ULTRASOUND-GUIDED THORACENTESIS: Written consent was obtained by the patient's physician, .",0
"The patient was placed in the right lateral decubitus position and limited ultrasonic evaluation of the left hemithorax was performed, revealing a moderate pleural effusion.",1
The patient was then prepped and draped using standard sterile technique.,0
Local anesthesia was obtained with 1% lidocaine.,0
Real-time ultrasound documented appropriate positioning.,0
"was then made in the skin and an 18 gauge angiocatheter was inserted into the pleural space and approximately 450 cc of clear, amber fluid was aspirated.",0
"During aspiration, ultrasound was verified appropriate positioning.",0
There are no immediate postprocedure complications.,0
Dr. was present and participating throughout the procedure.,0
"IMPRESSION: Status post ultrasound-guided thoracentesis of approximately 450 cc of clear, amber fluid.",0
"7:24 PM MR HEAD W & W/O CONTRAST; -52 REDUCED SERVICES Clip # Reason: please do DWI and post contrast images for eval of wernickes Admitting Diagnosis: PANCREATITIS Contrast: MAGNEVIST Amt: 11 ______________________________________________________________________________ MEDICAL CONDITION: 59 YOM with DM, HTN, ETOH abuse, presented with pancreatitis / hepatitis.",0
REASON FOR THIS EXAMINATION: please do DWI and post contrast images for eval of wernickes.,0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN MON 10:42 AM PFI: No acute infarct.,0
"Enhancement of mammillary bodies is confirmed, indicating possibility of the diagnosis of Wernicke's encephalopathy.",0
______________________________________________________________________________ FINAL REPORT EXAM: MRI of the brain.,0
CLINICAL INFORMATION: Patient with question of Wernicke's encephalopathy for repeat study with gadolinium.,0
TECHNIQUE: T1 axial and diffusion axial images of the brain were acquired before gadolinium.,0
MP-RAGE sagittal and T1 axial images were obtained following gadolinium.,0
FINDINGS: Comparison was made with the MRI obtained earlier on .,0
There is no acute infarct on diffusion images.,0
The post-gadolinium images demonstrate enhancement of the mamillary bodies consistent with diagnosis of Wernicke's encephalopathy.,0
No abnormal signal is seen within the brainstem or thalami.,0
IMPRESSION: The repeat study confirms the enhancement of the mamillary bodies which is suggestive of Wernicke's encephalopathy.,0
No acute infarct is seen.,0
"10:29 PM CHEST (PA & LAT) Clip # Reason: eval for infiltrate Admitting Diagnosis: ANASARCA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with persistent fever, equivocal portable REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.",0
"As compared to the previous examination, there is no major change.",0
"Slightly different patient rotation, slightly enlarged cardiac silhouette with very mild signs of overhydration, subtle bibasilar hypoventilation, no evidence of pneumonia.",0
10:16 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval infil Admitting Diagnosis: DEEP VEIN THROMBOSIS/ S/P AVR\ REDO HEMI STRENOTOMY ARCH TO DESCENDING STENT ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man s/p Aortic Dissection w/ AVR and Asc.,1
Aorta Replacement in now with increased dissection of desc.,1
thoracic aorta s/p Redo-Sternotomy w/ Endostent of Asc./Arch/Desc.,0
Aorta to Innominate and L Carotid Art.,0
"Bypass REASON FOR THIS EXAMINATION: eval infil ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:30 P.M. ON HISTORY: Aortic dissection and valve replacement.",1
"IMPRESSION: AP chest compared to an earlier postoperative film at 5:55 p.m. today: The cardiac portion of the cardiomediastinal silhouette has increased in caliber, suggesting volume overload or accumulating mediastinal fluid in a paracardiac distribution.",0
Small bilateral pleural effusions have remained stable.,0
The lungs are grossly clear.,0
"ET tube is in standard position, and a Swan-Ganz catheter passes at least as far as the pulmonary outflow tract, though the tip is obscured by cardiac motion.",0
Nasogastric tube ends at the gastroesophageal junction and would need to be advanced at least 10 cm to move all the sideports into the stomach.,0
"A subsequent chest radiograph showed more pronounced postoperative mediastinal widening, raising concern for bleeding, as discussed with physician's assistant caring for that patient at approximately 8 a.m. this morning.",0
10:01 PM MR L SPINE SCAN Clip # Reason: L- SPINE WITH STIR IMAGES.,0
PLEASE INCLUDE LOWER THORACIC SPI Admitting Diagnosis: S/P FALL;CHANGE IN MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with L1 burst fracture REASON FOR THIS EXAMINATION: L- SPINE WITH STIR IMAGES.,1
PLEASE INCLUDE LOWER THORACIC SPINE.,1
"Evaluate for cord compression ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: L1 burst fracture, ?",0
MR of the lumbar and lower thoracic spines with a sagittal STIR sequence.,1
Exam is compared to the patient's CT scan obtained just subsequently.,0
FINDINGS: There is considerable retropulsion of bone fragments at the site of the L1 compression and burst fracture with considerable canal compromise at the level of what is probably the conus or proximal cauda equina.,0
There is an associated epidural hematoma posterior to the vertebral bodies.,0
There is paravertebral hematoma visualized anteriorly as well.,0
The remaining vertebrae are intact.,0
There is no evidence of focal disc protrusion or canal stenosis at any additional level.,0
"There is a considerable presacral fluid collection, raising the question of fracture in the region of the distal sacrum and coccyx, not visualized on either the MR .",1
IMPRESSION: Severe canal compromise as described at the level of the L1 burst fracture.,0
"Increased presacral fluid, raising the question of additional fracture in the region of the sacrum or coccyx.",1
"11:09 AM CHEST (PA & LAT) Clip # Reason: confirm pacemaker lead position ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with pacemaker REASON FOR THIS EXAMINATION: confirm pacemaker lead position ______________________________________________________________________________ FINAL REPORT INDICATION: Pacemaker placement, confirm lead position.",0
Frontal and lateral chest radiographs dated are compared with prior chest radiographs dated .,0
"The pacemaker leads are terminating in right atrium and right ventricle, respectively, unchanged since the prior study.",0
"Again a nodular opacity is noted in the left lower lung zone, likely in the lingula, but not confirmed on the lateral view because the patient is unable to lift the left arm due to recent pacemaker placement.",0
The right upper lung zone ill-defined opacity is not well seen on this study.,0
There is persistent left costophrenic angle blunting.,0
IMPRESSION: 1) Pacemaker leads terminate in expected locations for right atrium and right ventricle.,0
"2) Probable nodule in the lingula, but not confirmed on the lateral view.",0
"Repeat chest radiographs can be performed after the patient can lift the left arm, or a CT study can be performed for further evaluation.",0
3) Small left pleural effusion.,0
"8:25 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: eval ascites, portal venous flow.",1
"______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with cirrhosis, jaundice REASON FOR THIS EXAMINATION: eval ascites, portal venous flow.",1
______________________________________________________________________________ WET READ: 10:21 PM Very limited portable study.,0
"no ascites, mild amount of fluid adjacent to sludge filled GB likely third spacing from adjacent liver disease.",0
Portal veins patent and with normal hepatopedal flow.,0
"______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Cirrhosis, jaundice.",0
PORTABLE RIGHT UPPER QUADRANT ULTRASOUND: No prior for comparison.,0
This study is limited due to portable nature and patient inability to cooperate with examination.,0
The liver is diffusely echogenic.,0
"Gallbladder wall is thickened and edematous, and the gallbladder is moderately distended.",0
Layering sludge is seen within it.,0
No stones or intrahepatic ductal dilatation is seen.,0
Common bile duct is not dilated.,0
Portal venous flow is maintained in the appropriate direction.,0
"Limited study, but no evidence of portal venous thrombosis.",0
Diffusely echogenic liver compatible with cirrhosis.,1
Distended GB with sludge and wall edema.,0
"This may well be related to the underlying acute liver failure, but acute cholecystitis cannot be excluded by this study, and clinical evaluation is necessary.",1
The findings were telephoned to Dr. at 10:30 AM on .,0
9:11 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
effusion Admitting Diagnosis: RUPTURE AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with ruptured AAA and sigmoidectomy REASON FOR THIS EXAMINATION: ?,1
effusion ______________________________________________________________________________ FINAL REPORT CHEST AP PORTABLE SINGLE VIEW.,0
INDICATION: Status post ruptured abdominal aortic aneurysm and sigmoidectomy.,1
Follow up chest examination to evaluate effusion.,0
FINDINGS: AP single view of the chest obtained with patient in supine position is compared with a similar previous examination of .,0
"Position of ETT, left-sided internal jugular approach central venous line with Swan-Ganz catheter and NG tube are all unchanged.",0
Diffuse densities blunt the lateral pleural sinuses and obliterate the diaphragmatic contours.,0
These densities are indicative of bilateral pleural effusion and appear unchanged as seen on these portable examinations.,0
"The pulmonary vasculature does not demonstrate any congestive pattern, nor are there new parenchymal infiltrates and no pneumothorax exists.",0
IMPRESSION: Stable findings on chest examination.,0
7:04 PM CHEST (PA & LAT) Clip # Reason: ?,0
"infectious process ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with metastatic breast, ca w/ L groin pain and tachycardia to 130s REASON FOR THIS EXAMINATION: ?",0
infectious process ______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic breast cancer with left groin pain and tachycardia to 130s.,0
PA AND LATERAL VIEWS OF THE CHEST: A right subclavian central venous catheter tip terminates at the SVC/right atrial junction.,1
The cardiac and mediastinal contours are stable.,0
Blunting of the right costophrenic sulcus may reflect chronic pleural thickening.,0
3-mm right upper lung field nodule is stable.,0
The lungs are otherwise clear without focal consolidation.,0
Posterior spinal fusion hardware within the thoracic spine is redemonstrated as is lateral fusion hardware within the upper lumbar spine with intervertebral body cage device seen.,0
"The osseous structures demonstrate a somewhat mottled appearance, which is better seen on the recent CT torso from , compatible with patient's known osseous metastases.",0
2:27 PM UNILAT UP EXT VEINS US Clip # Reason: eval for dvt Admitting Diagnosis: ACUTE LYMPHOCYTIC LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with recent PICC removal.,1
Now w/ shoulder/bicep pain and a palpable cord in his antecubital fossa.,0
"REASON FOR THIS EXAMINATION: eval for dvt ______________________________________________________________________________ FINAL REPORT ULTRASOUND, UPPER EXTREMITY, LEFT HISTORY: Shoulder and biceps pain.",0
Palpable cord in the antecubital fossa.,0
"In the left cephalic vein starting at the antecubital fossa and extending superiorly up into the upper arm, just short of the shoulder, note is made of a thrombus within the cephalic vein.",0
Ultrasound shows echogenic material in the lumen and lack of compressibility.,0
"Other veins in the left arm including the basilic vein, axillary, and the subclavian vein show normal patent lumen.",0
CONCLUSION: Thrombus in the left cephalic vein extending from the anterior cubital fossa to the upper portion of the left upper arm.,0
Comparison assessment of the right side could not be performed as there is a central line within the corresponding vein in the right arm.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: s/p R CVL placement Admitting Diagnosis: RUPTURED BLEB/SDA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p VATS/Bleb resection REASON FOR THIS EXAMINATION: s/p R CVL placement ______________________________________________________________________________ FINAL REPORT INDICATIONS: Status post bleb section.,0
PORTABLE AP CHEST AT 00:47: Comparison is made to .,0
"The new right subclavian central venous line coils in the region of the internal jugular vein, and the tip is at the level of the clavicular head.",0
Note that a subsequent film from 3 hours and 15 minutes later demonstrates a successfully positioned line .,0
The size of the pneumothorax is unchanged.,0
"Persistent right lung opacity, presumed post-surgical, is stable.",0
There is a small right effusion.,0
There is improved aeration of the left lower lobe.,0
"3:50 PM CHEST (PORTABLE AP) Clip # Reason: eval for PNA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with SOB low sat REASON FOR THIS EXAMINATION: eval for PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old man with shortness of breath, look for pneumonia.",0
Single portable AP chest radiograph is compared to and demonstrates no significant difference.,0
Again demonstrated are healing right-sided rib fractures and a mottled appearance to the right clavicle.,0
"The cardiac silhouette is stable, and the mediastinal contours are stable.",0
Pacemaker leads and sternotomy wires identified.,0
No free air under the diaphragms.,0
No evidence for pulmonary opacification.,0
IMPRESSION: No evidence for acute cardiopulmonary process.,0
PATIENT/TEST INFORMATION: Indication: Aortic valve disease.,1
Pericardial effusion Height: (in) 68 Weight (lb): 210 BSA (m2): 2.09 m2 BP (mm Hg): 102/71 HR (bpm): 125 Status: Inpatient Date/Time: at 15:47 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: The heart rate during this study was 120-140 beats per minute.,1
LEFT VENTRICLE: The left ventricle is not well seen.,0
AORTIC VALVE: A mechanical aortic valve prosthesis is present.,1
"The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients.",0
MITRAL VALVE: A mechanical mitral valve prosthesis is present.,1
"The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients.",0
Conclusions: The left ventricle is not well seen.,0
"However, LV systolic function appears depressed.",0
A mechanical aortic valve prosthesis is present.,1
A mechanical mitral valve prosthesis is present.,1
"8:40 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: assess ng tube status Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with pea arrest today, intubated, ng tube placed REASON FOR THIS EXAMINATION: assess ng tube status ______________________________________________________________________________ FINAL REPORT AP CHEST 8:56 A.M. ON : HISTORY: Cardiac arrest.",1
Check ET and nasogastric tubes.,0
"IMPRESSION: AP chest compared to through at 4:20 p.m.: ET tube, left internal jugular line, and nasogastric tube in standard placements.",0
"Mild pulmonary edema has improved, mild cardiomegaly unchanged, small right pleural effusion increased since 4:20 p.m. No pneumothorax.",0
10:18 PM PORTABLE ABDOMEN Clip # Reason: ?,0
"sbo Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with s/p thoracic aneurysm repair, known retroperitoneal hematoma, now abd distension and emesis REASON FOR THIS EXAMINATION: ?",1
sbo ______________________________________________________________________________ FINAL REPORT INDICATION: Distension and emesis.,0
"SINGLE PORTABLE SUPINE RADIOGRAPH OF THE ABDOMEN: Comparison is made to , .",0
There is new dilatation of several small bowel loops.,0
The colon is air-filled but not dilated.,0
There is a small amount of air in the rectum.,0
Again seen is a contrast-filled gallbladder.,0
Staples are overlying the mid abdomen and right groin area.,0
IMPRESSION: Multiple loops of dilated small bowel.,0
This may be consistent with an ileus in the post-operative setting.,0
An upright film would be helpful to assess for air-fluid levels.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU ADDENDUM: Please note, this is an addendum to the STAT Discharge Summary.",0
Please note changes to the previously listed medications.,0
"On discharge, the patient will be sent to Rehabilitation on: 1.",0
The patient will be off of the Lopressor and Captopril.,0
"She will follow-up with Dr. , Cardiologist in , whose phone number is .",0
Dictated By: MEDQUIST36 D: 11:27 T: 11:38 JOB#: cc:,0
8:56 AM TUNNELLED CATH PLACE SCH Clip # Reason: For dialysis Admitting Diagnosis: CHOLANGITIS ********************************* CPT Codes ******************************** * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with ARF, needs a permanat HD access REASON FOR THIS EXAMINATION: For dialysis ______________________________________________________________________________ FINAL REPORT INDICATION: This is a 48-year-old man with acute renal failure, presents for placement of a tunneled hemodialysis catheter for dialysis.",1
Details of the procedure and possible complications were explained to the patient and informed consent was obtained.,0
"RADIOLOGISTS: , nurse practitioner, performed the procedure supervised by Dr. , attending radiologist.",0
"Using sterile technique, local anesthesia, and conscious sedation, the right internal jugular vein was punctured via just ultrasound guidance using a micropuncture set.",0
Hard copy of ultrasound images were obtained before and immediately after venous access documenting vessel patency.,0
The tract was dilated with serial dilators and a peel-away sheath was then placed.,0
A subcutaneous tunnel was made on the right anterior chest wall and the catheter was introduced through the tunnel and placed through the peel-away sheath with its tip positioned in the right atrium under fluoroscopic guidance.,0
The peel- away sheath was then removed.,0
Position of the catheter was confirmed by chest x-ray in one view.,0
The incision on the neck was closed with Dermabond.,0
The catheter was secured to the skin and a sterile dressing was applied.,0
"Moderate sedation was provided administering divided doses of Versed and fentanyl throughout the total intraservice time of 55 minutes, during which the patient's hemodynamic parameters were continuously monitored.",0
The total dose administered of fentanyl was 100 mcg and of Versed 3 mg.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided tunneled hemodialysis catheter placement via the right internal jugular venous approach with the tip in the right atrium.,0
(Over) 8:56 AM TUNNELLED CATH PLACE SCH Clip # Reason: For dialysis Admitting Diagnosis: CHOLANGITIS ______________________________________________________________________________ FINAL REPORT (Cont),0
"Clip # Reason: ARF, ASSESS FOR HYDRONEPHROSIS Admitting Diagnosis: PNEUMONIA,BLADDER CARCINOMA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with s/p bladder cancer, s/p resection, ARF REASON FOR THIS EXAMINATION: assess for hydronephrosis ______________________________________________________________________________ FINAL REPORT INDICATION: Status post bladder cancer, status post resection, ARF.",1
FINDINGS: The right kidney measures 9.8 cm in length.,0
There is an exophytic cyst measuring 1.3 x 1.8 x 1.1 cm.,0
Left kidney measures 10.9 cm in length.,0
There is mild left hydronephrosis.,0
No ascites or stones visualized.,0
IMPRESSION: Limited evaluation of left kidney.,0
"Within the limits, there is mild left hydronephrosis.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) Attending: Chief Complaint: hardware failure Major Surgical or Invasive Procedure: Revision of thoracic fusion T1-11 History of Present Illness: 78 female who underwent thoracic instrumented fusion for lymphoma presents with hardware eroding through skin.,1
"Past Medical History: Rheumatoid arthritis Rosacea Compression Fractures CHF, EF 30% (cath showed clean arteries Social History: lives alone, never married, no children Family History: no hx of breast or ovarian CA Physical Exam: a and ox3 perrla ht rrr, nl s1,s2 lungs cta abd soft nt neuro: motor full intact LT back: severe kyphosis thoracic with hardware end through skin 8 left exam upon discharge: neuro intact Pertinent Results: 02:11PM HGB-11.1* calcHCT-33 O2 SAT-99 02:11PM GLUCOSE-87 LACTATE-0.9 NA+-140 K+-3.6 CL--109 Brief Hospital Course: Pt was admitted electively to hospital and taken to OR where under general anesthesia she underwent revision/extension of thoracic instrumented fusion.",1
She tolerated this procedure well.,0
Due to long time prone she remained intubated and transferred to ICU post op for close monitoring.,0
her LE motor exam post op showed no focal deficits.,0
She was extubated uneventfully on POD#1.,0
She was transferred out of the ICU to the floor.,0
her diet and activity were advanced.,0
She had JP drain that was monitored and removed on POD#2.,0
She remained on ancef while waitng for OR cultures though there was no evidence of gross infection at time of surgery.,0
She was evaluated by PT and felt suitable for rehab.,0
Medications on Admission: fosamax Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Hardware failure Discharge Condition: neurologically stable Completed by:,0
6:32 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for aneurysm Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with SAH REASON FOR THIS EXAMINATION: eval for aneurysm No contraindications for IV contrast ______________________________________________________________________________ WET READ: JBRe MON 7:41 PM 1.,0
"Extensive SAH hemorrhage involving both cerebral hemispheres, Sylvian fissures, suprasellar, interpeduncular and ambient cisterns, as well as foramen magnum.",1
Extensive intraventricular hemorrhage involving all ventricles.,0
"Severe vasospasm, most pronounced at the anterior circulation.",0
Likely 3 x 3 mm basilar tip aneurysm.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): GJq TUE 4:19 PM IMPRESSION: 1.,0
"Extensive subarachnoid hemorrhage involving both cerebral hemispheres, basal cisterns, and sylvian fissures.",1
Moderate-to-severe vasospasm involving bilateral MCA and ACA branches.,0
"Prominent basilar tip may represent a patulous tip of the basilar with multiple vessels arising from it, possibility of a basilar tip aneurysm can not be excluded.",0
"Given the suboptimal timing of image acquisition following administration of contrast, a repeat CT angiogram or MRA may be considered for detailed evaluation.",0
"Findings discussed by Dr. with on at 11:30 a.m. ______________________________________________________________________________ FINAL REPORT INDICATION: Extensive subarachnoid hemorrhage, to evaluate for aneurysm.",0
COMPARISON: CT cervical spine from outside hospital uploaded to PACS for comparison.,0
TECHNIQUE: Contiguous axial scans of the head were obtained without contrast.,0
"Following intravenous administration of contrast, MDCT angiography of the head and neck was obtained per department protocol.",0
"FINDINGS: CT HEAD: There is a large amount of subarachnoid hemorrhage diffusely filling the basal cisterns, bilateral Sylvian fissures, frontal, temporal and parietal sulci, and the anterior interhemispheric fissure.",0
"A large amount of blood is also seen in bilateral lateral ventricles, third and fourth ventricles.",0
There is no shift of midline structures.,0
There is some degree of cerebral edema.,1
There is no definite large vascular territorial infarction seen.,0
There is mild mucosal thickening of the right inferior maxillary sinus.,0
Rest of the (Over) 6:32 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for aneurysm Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) paranasal sinuses appear unremarkable.,0
There is no fracture identified on the non-dedicated images provided.,0
There is a moderate sized 8.0x1.5cm fat attenuation lesion in the left parietal scalp with some subcutaneous thickening.,0
"CTA HEAD AND NECK: The timing of image acquisition on the CT angiographic images after administration of contrast bolus is not accurate, and enhancement of intracranial arteries is suboptimal.",0
Atherosclerotic calcifications are seen in the aortic arch and visualized descending thoracic aorta.,0
There is a direct origin of the left vertebral artery from the aortic arch.,0
Calcified plaque is seen at the origin of the right vertebral artery from the subclavian.,0
"Bilateral common carotid arteries and internal carotid arteries in the neck appear normal with no evidence of stenosis, occlusion, dissection, or pseudoaneurysm formation.",0
Mild atherosclerotic calcifications are seen at the carotid bifurcation bilaterally.,0
"Both vertebral arteries in the neck are patent with no evidence of stenosis or occlusion; however, the left vertebral artery is diminutive and tortuous in some segments and is inadequately assessed.",1
Atherosclerotic calcifications are seen in bilateral cavernous internal carotid arteries.,0
Assessment for stenosis is limited due to inadequate enhancement.,0
There is moderate-to-severe narrowing of bilateral middle cerebral arterial branches and A2 segment of the anterior cerebral artery and their terminal branches.,1
There is narrowing of bilateral vertebral arteries.,0
"The Basilar artery is narrow in size in the mid and distal segments; however, no significant flow limiation is noted distally.",1
Tip of the basilar artery appears slightly prominent and may relate to the confluence of the arteries rather than an obviosu aneurysm.,0
The superior cerebellar and the posterior cerebral arteries are seen arising from a prominent basilar tip.,0
"Multilevel degenerative changes are noted in the cervical spine with canal and foraminal stenosis, inadequately assessed.",0
"Extensive subarachnoid hemorrhage involving both cerebral hemispheres, basal cisterns, and Sylvian fissures.",1
Moderate-to-severe vasospasm involving bilateral MCA and ACA branches and distal vertebral and Basilar arteries.,0
"Prominent basilar tip may represent a patulous tip of the basilar artery with branch vessels arising from it, possibility of a basilar tip aneurysm can not be excluded.",1
"Given the suboptimal timing of image acquisition following administration of (Over) 6:32 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for aneurysm Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) contrast, a repeat CT angiogram or MRA may be considered for detailed evaluation.",0
Findings discussed by Dr. with on at 11:30 a.m. Pl.,0
see other details on subsequent Conventional angiogram.,0
8:24 PM CT HEAD W/O CONTRAST Clip # Reason: bleed?,0
______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with unwitnessed fall REASON FOR THIS EXAMINATION: bleed?,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: SHfd MON 9:40 PM No ICH ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Status post fall.,0
NON-CONTRAST HEAD CT: This exam is suboptimal due to motion artifact.,0
"There is no intracranial hemorrhage, mass effect or -white matter differentiation abnormality.",0
Mild prominence of the ventricles correspond to sulcal prominence consistent with age-appropriate volume loss.,0
Periventricular and subcortical white matter hypodensities are related to small vessel chronic ischemic disease.,0
Visualized paranasal sinuses demonstrate mucus retention cyst in the right maxillary sinus.,0
The visualized mastoid air cells are clear.,0
IMPRESSION: No acute intracranial abnormality.,0
"10:44 AM CHEST (PORTABLE AP) Clip # Reason: s/p aggressive pulm toilet eval for progression of LLL colla ______________________________________________________________________________ MEDICAL CONDITION: s/p MVA rib fx's mrsa pneumonia REASON FOR THIS EXAMINATION: s/p aggressive pulm toilet eval for progression of LLL collapse ______________________________________________________________________________ FINAL REPORT INDICATIONS: S/P MVA, rib fractures and MRSA pneumonia, evaluate for progression of left lower lobe collapse.",1
SINGLE FRONTAL CHEST: Comparison is made to previous films from .,0
There is no significant interval change in radiographic appearance of the chest.,0
There is persistent opacification of left lower lung zones with the volume loss and a probable small left effusion.,0
"11:08 AM CHEST (PORTABLE AP) Clip # Reason: s/p cabg, s/p ct d/c, r/o ptx Admitting Diagnosis: CONGESTIVE HEART FAILURE EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with CAD s/p CABG.",1
"REASON FOR THIS EXAMINATION: s/p cabg, s/p ct d/c, r/o ptx ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Status post coronary artery bypass surgery.",1
Status post chest tube removal.,0
Comparison is made to a recent study of one day earlier.,0
There has been interval removal of the left-sided chest tube and mediastinal drain.,0
"A Swan-Ganz catheter remains in place, terminating in the right pulmonary artery.",0
The heart is enlarged but stable in size.,0
"There are bibasilar atelectatic changes, stable on the left and slightly worse at the right base.",0
Mild elevation of the left hemidiaphragm is stable.,0
Please note that the periphery of the right mid- and lower lung zones have been excluded from the study and cannot be assessed.,0
"If warranted, this could repeated at no additional charge to the patient.",0
IMPRESSION: No evidence of pneumothorax following chest tube removal.,0
8:42 PM CHEST (PORTABLE AP) Clip # Reason: pre-op.,0
Pt bedrest with log-roll and mildly unstable.,0
"Admitting Diagnosis: BACK PAIN ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with spine fracture, preop.",0
REASON FOR THIS EXAMINATION: pre-op.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Pre-operative radiograph.,0
COMPARISON: No comparison available at the time of dictation.,0
"FINDINGS: The hemidiaphragms are in normal position, there is no pleural effusion.",0
The structure and transparency of the lung parenchyma is unremarkable.,0
"No focal parenchymal opacity suggestive of pneumonia, normal size of the cardiac silhouette, normal hilar and mediastinal appearance.",0
6:29 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: R/O R hemisphere stroke Admitting Diagnosis: CAROTID STENOSIS/SDA Contrast: MAGNEVIST Amt: 12 ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with post op L hemiparesis s/p R CEA REASON FOR THIS EXAMINATION: R/O R hemisphere stroke No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Left hemiparesis.,1
Underwent right carotid endarterectomy on .,0
"EXAMINATION: MRI, MRA head with and without contrast.",0
TECHNIQUE: Multiplanar multisequence MRI of the brain was performed along with time-of-flight MRA of the head.,0
The MRI was performed with and without gadolinium.,0
COMPARISON: CTA head with perfusion imaging.,0
"FINDINGS: There is restricted diffusion in the right cerebral hemisphere along the border of the anterior, middle and posterior cerebral arteries.",0
"This gyriform restricted diffusion shows faint enhancement and increased signal on FLAIR, with mild cortical swelling and effacement of adjacent sulci.",0
"There is a thin rim of susceptibility within the more superior aspect of the infarct compatible with petechial, gyriform hemorrhage.",0
A few tiny foci of restricted diffusion within the right MCA and PCA and left MCA territories are also noted compatible with tiny embolic infarcts.,0
FLAIR sequences otherwise reveal scattered white matter hyperintensities compatible with underlying microvascular changes.,0
There is no evidence of mass.,0
"Findings are otherwise significant for a lipoma within the superior, anterior falx and sequela of bilateral lens surgery.",0
"Time-of-flight MRA of the head reveals a dominant right vertebral artery, fetal origin of the right posterior cerebral artery, and a prominent left posterior communicating artery which is only slightly smaller in caliber than the left P1 segment.",1
Irregularity of the proximal left MCA with a focal moderate to severe stenosis of the distal left M1 segment are similar to the recent CT. No other significant stenosis and no aneurysm is seen.,0
"IMPRESSION: Right hemispheric infarcts, subacute.",0
"The distribution is suspicious for (Over) 6:29 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: R/O R hemisphere stroke Admitting Diagnosis: CAROTID STENOSIS/SDA Contrast: MAGNEVIST Amt: 12 ______________________________________________________________________________ FINAL REPORT (Cont) predominantly watershed infacts, with scattered smaller embolic infarcts.",1
Height: (in) 73 Weight (lb): 220 BSA (m2): 2.24 m2 BP (mm Hg): 130/50 HR (bpm): 106 Status: Inpatient Date/Time: at 14:51 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
RIGHT VENTRICLE: Mildly dilated RV cavity.,0
AORTIC VALVE: Bicuspid aortic valve.,0
Moderately thickened aortic valve leaflets.,0
No masses or vegetations on aortic valve.,0
No mass or vegetation on mitral valve.,0
Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,1
No mass or vegetation on tricuspid valve.,1
Normal tricuspid valve supporting structures.,1
Moderate to severe [3+] TR.,0
No vegetation/mass on pulmonic valve.,0
Conclusions: The left ventricular cavity is mildly dilated.,0
The right ventricular cavity is mildly dilated.,0
The ascending aorta is moderately dilated.,0
The aortic valve is bicuspid.,0
No masses or vegetations are seen on the aortic valve.,0
There is moderate aortic valve stenosis (low gradient due to low output).,0
No mass or vegetation is seen on the mitral valve.,0
Moderate to severe [3+] tricuspid regurgitation is seen.,1
No vegetation/mass is seen on the tricuspid or pulmonic valve.,1
"Compared with the findings of the prior report (tape unavailable for review) of , the overall LVEF may be slightly worse.",0
"If clinically indicated, a a TEE would better characterize the basis of valvular regurgitation and exclude a small vegetation.",0
"11:11 AM UNILAT UP EXT VEINS US RIGHT PORT Clip # Reason: PLEASE EVAL FOR CLOT, SWELLING Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with RUE swelling REASON FOR THIS EXAMINATION: please evaluate for clot ______________________________________________________________________________ FINAL REPORT INDICATION: Right upper extremity swelling.",0
"COMPARISON: Left upper extremity ultrasound, .",0
"FINDINGS: Grayscale and color Doppler son of the right upper extremity including the internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins were performed demonstrating normal flow, augmentation, compressibility, and waveforms except in the cephalic vein that demonstrates echogenic material that is noncompressible and demonstrates no color blood flow.",0
Limited imaging of the left internal jugular vein redemonstrate echogenic material consistent with clot as described on yesterday's examination.,0
Partially visualized clot in the left internal jugular vein.,0
Please see the full left upper extremity study performed for further details.,0
8:50 PM MR CERVICAL SPINE W/O CONTRAST; MRA CERVICAL SPINE Clip # Reason: evalaute for Spinal AVM Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: MAGNEVIST Amt: 30 ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with SAH REASON FOR THIS EXAMINATION: evalaute for Spinal AVM No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 11:55 AM 1.,1
Degenerative changes in the cervical region.,0
No abnormal vascular flow void or abnormal vascular structures on the MRA to indicate arteriovenous malformation in the neck.,0
No abnormal enhancement on the post-gadolinium images.,0
______________________________________________________________________________ FINAL REPORT EXAM: MRI of the neck.,0
"CLINICAL INFORMATION: Patient with subarachnoid hemorrhage, for further evaluation.",1
"TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of cervical spine obtained before gadolinium.",0
Gadolinium-enhanced MRA of the cervical spine was acquired.,0
Post-gadolinium sagittal T1 images of the cervical spine were obtained.,0
FINDINGS: The spinal cord from the skull base to T3 level demonstrates normal signal without focal intrinsic abnormalities.,0
There are no abnormal vascular structures seen within the spinal canal to indicate an arteriovenous malformation.,0
"At C4-5, C5-6, and C6-7, disc bulging is identified with degenerative change.",0
"At C5-6, mild spinal stenosis seen and mild extrinsic indentation on the spinal cord is seen by disc bulging.",0
Moderate bilateral foraminal narrowing is identified.,0
The MRA examination of the neck demonstrates no evidence of abnormal vascular structures in the cervical spinal canal.,0
", P. 9:02 PM CHEST (PRE-OP PA & LAT) Clip # Reason: S/P ARREST Admitting Diagnosis: S/P ARREST ______________________________________________________________________________ MEDICAL CONDITION: 47 year old male with history of hypertension, s/p cardiac arrest and cooling protocol with hospital course complicated by H. flu VAP, seizure, agitation/difficult weaning off vent, HTN urgency, transferred from the MICU to the cardiology floor for further evaluation for cardiac pathology.",1
REASON FOR THIS EXAMINATION: Pre-op ______________________________________________________________________________ PFI REPORT Bilateral lung opacities appear improved since the most recent prior examination.,0
1:51 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"CHF Admitting Diagnosis: DIARRHEA;DEHYDRATION ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with pmh of CAD, CHF, and bandemia, crackles at bases on exam, has received multiple liters of fluid; REASON FOR THIS EXAMINATION: ?",0
CHF ______________________________________________________________________________ FINAL REPORT HISTORY: CHF.,0
Single portable chest radiograph demonstrates no change in the cardiomediastinal contours when compared to .,0
Left subclavian central venous catheter is unchanged in position.,0
There is probable biapical pleural thickening.,0
There may be a small left-sided pleural effusion.,0
"When compared to the previous study, there is no significant interval change.",0
"7:25 AM CHEST (PORTABLE AP) Clip # Reason: please assess for change in effusions, new infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman admitted with pneumonia, now Post extubation, ?",0
"CHF REASON FOR THIS EXAMINATION: please assess for change in effusions, new infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Admitted with pneumonia.",0
"Check for change in effusions, new infiltrates and possible CHF.",0
FINDINGS: A single AP upright view.,0
There has been overall improvement in the appearances of the heart and lungs.,0
The cardiac silhouette is smaller than before.,0
There has been significant partial clearing of the bilateral lower zone and mid zone pulmonary infiltrates.,0
There has also been slight reduction in size of the bilateral pleural effusions.,0
Sternal wire sutures again noted.,0
The superior mediastinal mass is unchanged.,0
The pigtail catheter in the fundus of the stomach is in good position.,0
IMPRESSION: Overall improvement of signs of left heart failure with improved lung ventilation and clearing pulmonary edema.,0
Decreasing size of bilateral effusions.,0
"8:24 PM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, ETT placement Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p cardiac arrest REASON FOR THIS EXAMINATION: assess for infiltrate, ETT placement ______________________________________________________________________________ FINAL REPORT STUDY: Portable AP chest.",1
CLINICAL HISTORY: 50-year-old man status post cardiac arrest.,1
"Assess for infiltrate, endotracheal tube placement.",0
FINDINGS: A single portal AP view of the chest was obtained.,0
No prior studies available for comparison.,0
"There is an endotracheal tube with its tip at the level of the clavicles, approximately 5 cm above the carina.",0
There is a Swan-Ganz catheter in place via an inferior approach with its tip overlying region of the left interlobar artery.,0
There is a nasogastric tube in place with distal end coiled within the stomach and its tip just distal to the gastroesophageal junction.,0
The cardiac silhouette is within normal limits.,0
No focal infiltrates or pleural effusions.,0
IMPRESSION: No evidence of pulmonary infiltrates.,0
"Endotracheal tube in satisfactory position, as clinically questioned.",0
7:58 AM CHEST (PORTABLE AP) Clip # Reason: assess for hemothorax ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p L upper lobectomy REASON FOR THIS EXAMINATION: assess for hemothorax ______________________________________________________________________________ FINAL REPORT INDICATION: Status post left upper lobectomy.,1
Single frontal chest X-ray is compared with prior chest X-ray .,0
There is no significant interval change in position of lines and tubes since the prior study.,0
There is increased opacity in the left hemithorax compared with the prior study probably representing a small layering effusion.,0
There is persistent mild CHF.,0
There is interval decrease in the soft tissue air in the left shoulder.,0
LINE PLACEMENT Clip # Reason: assess line placement Admitting Diagnosis: SUICIDAL IDEATION ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with s/p R IJ TLC REASON FOR THIS EXAMINATION: assess line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 35-year-old man status post right internal jugular venous line placement.,0
AP UPRIGHT CHEST: There has been interval placement of a right internal jugular central venous catheter whose tip extends into the superior vena cava.,0
No pleural effusions are seen.,0
"Cardiac, mediastinal, and hilar contours appear normal.",0
IMPRESSION: Appropriately placed right internal jugular venous catheter.,0
"4:53 AM CHEST CTA WITH CONTRAST Clip # Reason: HYPOXIA, TROUBLE AMBULATING Field of view: 50 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman s/p surgery, poor ambulation for the past week, now with hypoxia.",0
Please w/ any questions or urgent results.,0
REASON FOR THIS EXAMINATION: r/o PE ______________________________________________________________________________ FINAL REPORT INDICATION: 59yr old woman with hypoxia following recent surgery.,0
TECHNIQUE: Contiguous axial images of the chest were obtained with intravenous contrast.,0
Multiplanar reconstruction images were also obtained.,0
CONTRAST: 150cc nonionic intravenous contrast were administered.,0
Contrast administration was done through a central venous line which limited the flow rate to 1cc per second.,0
CHEST CT WITH INTRAVENOUS CONTRAST: The study is severely limited by a poor bolus of contrast and the patient's body habitus.,0
No soft tissue filling defects are seen in the central and lobar pulmonary arteries.,0
"However, the segmental and subsegmental pulmonary arteries cannot be assessed on this study, and small pulmonary emboli cannot be entirely excluded.",0
"The soft tissue windows show no significant axillary, mediastinal or hilar lymph node enlargement.",0
The heart and pericardium are unremarkable.,0
The thoracic aorta has a normal caliber.,0
The lung windows show no pulmonary nodules or areas of parenchymal consolidation.,0
Parenchymal scarring is seen at the right lung base.,0
The airways appear patent to the level of the segmental bronchi bilaterally.,0
Osseous structures show degenerative changes of the spine.,0
Multiplanar reconstruction images confirm the above findings.,0
IMPRESSION: The study is severely limited by the patient's body habitus and the inability to achieve a fast bolus rate through the central venous catheter used for IV contrast administration.,0
No large pulmonary emboli are seen in the central and lobar pulmonary arteries.,0
"However, small pulmonary emboli cannot be excluded from the segmental and subsegmental branches.",0
"LINE PLACEMENT Clip # Reason: eval for ptx, effusions - call cvicu @ with any issues Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH AVR ?",1
"MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with s/p AVR/CABG REASON FOR THIS EXAMINATION: eval for ptx, effusions - call cvicu @ with any issues or concerns - talk with midlevel ______________________________________________________________________________ FINAL REPORT HISTORY: CABG.",1
"FINDINGS: In comparison with the study of , there has been a CABG procedure performed with intact midline sternal wires.",0
The tip of the endotracheal tube is approximately 4 cm above the carina.,0
Right IJ Swan-Ganz catheter tip is in the pulmonary outflow tract.,0
Nasogastric tube extends to the stomach.,0
"Right chest tube is in place, and there is no evidence of pneumothorax.",0
"Mild atelectatic changes are seen at the bases, and there is slight indistinctness of pulmonary vessels that could reflect some mild elevation of pulmonary venous pressure.",0
6:08 AM PORTABLE ABDOMEN Clip # Reason: assess for interval change ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with aspiration PNA and ileus REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE FILM.,0
"History of aspiration, pneumonia and ileus.",0
Distribution of bowel gas is unremarkable and there is no evidence for intestinal obstruction or significant ileus.,0
Status post laminectomies and fusion lower lumbar spine.,0
No change since prior study of .,0
The diaphragms are not included on this film.,0
"3:24 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: FEVER OF UNKNOWN ORIGIN ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with FUO, s/p intubation for pulmonary edema, still intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Fever of unknown allergens status post intubation for pulmonary edema.",0
"CHEST X-RAY, PORTABLE AP: Comparison made to prior study of one day earlier.",0
The tubes and lines are all properly positioned and unchanged from one day prior.,0
The cardiomediastinal silhouette is unchanged.,0
"The appearance of lungs has improved, with decreased vascular engorgement and improved aeration.",0
Persistent left lower lobe atelectasis is present.,0
4:14 PM BILAT LOWER EXT VEINS PORT Clip # Reason: r/o DVT Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with AAA rep. pulm edema REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ FINAL REPORT HISTORY: Lower extremity edema/pulmonary edema.,1
FINDINGS: Duplex and color Doppler demonstrate no evidence of acute or chronic DVT from the common femoral through to the popliteal veins bilaterally.,0
"11:19 AM CHEST (PORTABLE AP) Clip # Reason: difficult intubation, r/o aspiration & pulm edema Admitting Diagnosis: KIDNEY TRANSPLANT REJECTION ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man s/p renal tx, abscess, s/p debridement, now with fever REASON FOR THIS EXAMINATION: difficult intubation, r/o aspiration & pulm edema ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Difficult intubation.",1
"An endotracheal tube is in satisfactory position, and a nasogastric tube terminates within the stomach.",0
Cardiac silhouette is enlarged and there is vascular engorgement as well as increasing perihilar haziness and diffuse interstitial opacities a small patchy opacity in the left retrocardiac region is also noted.,0
Interval development of congestive heart failure with pulmonary edema.,0
Patchy left lower lobe opacity which may relate to atelectasis or focal aspiration.,0
"10:17 PM CHEST (PORTABLE AP) Clip # Reason: failure, infiltrate Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with CHF, new SOB.",1
"REASON FOR THIS EXAMINATION: failure, infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Congestive heart failure with new shortness of breath.",1
Portable AP view of the chest dated is compared with the chest radiograph of and a CT chest of .,0
A dual lead ICD is in stable position with leads terminating in the right atrium and right ventricle.,0
The median sternotomy wires and clips are stable.,0
The heart size is enlarged.,0
The mediastinal and hilar contours are stable.,0
"There is no frank pulmonary vascular engorgement, however, bilateral small pleural effusions are again noted.",0
IMPRESSION: Cardiomegaly with small bilateral pleural effusions are consistent with congestive heart failure.,1
9:47 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate for tube position Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman s/p replacement of Dobhoff REASON FOR THIS EXAMINATION: evaluate for tube position ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST CLINICAL INFORMATION: Replacement of Dobbhoff tube.,0
FINDINGS: Comparison is made to the prior study from the same day at 15:55 hours.,0
Endotracheal tube terminates at the thoracic inlet.,0
Dobbhoff tube is coiled within the stomach.,0
Pigtail catheter is present in the right upper quadrant.,0
There is continued left lower lobe atelectasis and a small left pleural effusion.,0
There is plate-like atelectasis in the lingula as well.,0
Small right pleural effusion and atelectasis at the right lung base.,0
LINE PLACEMENT Clip # Reason: ?dobhoff placement Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with new dobhoff REASON FOR THIS EXAMINATION: ?dobhoff placement ______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old man with new Dobbhoff tube.,1
COMPARISON: Chest radiograph and CT torso .,0
FINDINGS: A frontal upright view of the chest was obtained portably.,0
Low lung volumes result in bronchovascular crowding.,0
The Dobbhoff tube enters the right main stem bronchus.,0
There is no complication of associated opacity or pneumothorax.,0
Cardiac and mediastinal silhouettes are stable.,0
IMPRESSION: Dobbhoff tube enters the right main stem bronchus without complication.,0
Findings were discovered at 10:50 a.m. and discussed with Dr. by phone at 10:51 a.m. .,0
He was already aware at the time of communication.,0
"PERSANTINE MIBI MIBI Clip # Reason: 61 Y/O WOMAN WITH LIKELY DIASTOLIC DYSFUNCTION, WILL NEED STRESS BEFORE CHOLECYSTECTOMY ______________________________________________________________________________ FINAL REPORT HISTORY: 61 yo female with likely diastolic dysfunction and shortness of breath referred for pre-op stress test SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min.",0
"Two minutes after the cessation of infusion, Tc-m sestamibi was administered IV.",0
Baseline EKG demonstrates LBBB with NSSTTW.,0
INTERPRETATION: Image Protocol: Gated SPECT Resting perfusion images were obtained with mibi.,0
Tracer was injected 15 minutes prior to obtaining the resting images.,0
This study was interpreted using the 17-segment myocardial perfusion model.,0
Left ventricular cavity size is normal.,0
The right ventricle appears normal.,0
Resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium.,0
Gated images reveal normal wall motion.,0
The calculated left ventricular ejection fraction is 47%.,0
The ventricular ejection fraction is 47%.,0
Approved: TUE 3:24 PM RADLINE ; A radiology consult service.,0
"To hear preliminary results, prior to transcription, call the Radiology Listen Line .",0
"2:45 PM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: RLE PAIN EVAL FOR DVT Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: year old woman with L. to R. fem-fem bypass now with right knee, popliteal and calf pain.",0
no swelling REASON FOR THIS EXAMINATION: eval for DVT ______________________________________________________________________________ FINAL REPORT STUDY: Right lower extremity venous Doppler ultrasound.,0
"CLINICAL HISTORY: -year-old woman with left to right fem-fem bypass, now with right knee, popliteal and calf pain.",0
Comparison made to prior study dated .,0
FINDINGS: Grayscale and color Doppler ultrasound of the right lower extremity was performed.,0
"The right common femoral, femoral, greater saphenous and popliteal veins are widely patent and demonstrate normal compressibility, augmentation and phasic flow.",0
No evidence of intraluminal thrombus.,0
IMPRESSION: No evidence of right lower extremity deep venous thrombosis.,0
8:03 AM CHEST (PORTABLE AP) Clip # Reason: patient with acute sob.,0
patient with lung ca and baseline le ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with lung ca and abd pain REASON FOR THIS EXAMINATION: patient with acute sob.,0
patient with lung ca and baseline left sided white out on cxr.,0
"thank you ______________________________________________________________________________ FINAL REPORT INDICATION: Lung cancer, with abdominal pain and acute shortness of breath.",0
Baseline white-out on the left side.,0
Comparison is made to chest X-ray .,0
FINDINGS: A single AP upright view of the chest reveals an unchanged obstruction of the proximal left bronchus with corresponding whiteout on the left side.,0
There is no evidence of prior rib resection.,0
There is a corresponding leftward shift of the trachea and heart.,0
There is a decrease in the size of the left sided lateral mid lung zone air pocket previously seen.,0
There are no new pulmonary opacities or pleural effusions present on the right side.,0
There is a right internal jugular catheter in place with the tip in the SVC.,0
IMPRESSION: Persistent left sided white-out with associated leftward shift of the cardiomediastinum.,0
There is a decrease in the left sided air pocket.,0
There is no evidence of new right-sided pulmonary process.,0
8:16 AM CT HEAD W/O CONTRAST Clip # Reason: assess for bleeding Admitting Diagnosis: TRAUMATIC BRAIN INJURY ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman s/p fall on heparin with ?,0
"seizure REASON FOR THIS EXAMINATION: assess for bleeding No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall, trauma, seizure activity.",0
TECHNIQUE: Head CT without contrast.,0
"CT HEAD W/O INTRAVENOUS CONTRAST: There is no evidence of hydrocephalus, shift of normally midline structures, intracranial hemorrhage, or mass lesions.",0
Again seen is the large left sided pontine area of hypoattenuation indicating a large pontine infarction.,0
There is a smaller infarction within the right pons.,0
Infarction is also seen extending into the mid brain.,0
Fluid is seen within the maxillary and sphenoid sinuses.,0
The rest of the surrounding osseous and soft tissue structures are unremarkable.,0
IMPRESSION: Large left sided and smaller right sided pontine infarctions.,0
No evidence of acute intracranial hemorrhage.,0
"8:15 PM CHEST (PORTABLE AP) Clip # Reason: eval mediastinum, pna, ptx ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with chest pain and report of dissection OSH REASON FOR THIS EXAMINATION: eval mediastinum, pna, ptx ______________________________________________________________________________ FINAL REPORT SINGLE VIEW OF THE CHEST.",0
"HISTORY: Chest pain and reported ""dissection"" at OSH; evaluate mediastinum, pneumonia or pneumothorax.",0
"FINDINGS: Single bedside AP examination labeled"" ""supine"" with the prompting OSH examination unavailable.",0
"Allowing for supine positioning, there is some prominence and blurring of the pulmonary vessels and interstitial markings at the lateral aspect of the left lung, raising the possibility of interstitial edema.",0
"The thoracic aorta, and particularly the aortic knob, are indistinct, which may reflect the apparently-known dissection or be related to technique.",1
There is apparent excretion of radiographic contrast material into the renal collecting systems (related to OSH CT).,0
"10:51 AM CT HEAD W/O CONTRAST Clip # Reason: 32 year old man with , temp contusion.",0
"Eval for interval Admitting Diagnosis: INTRACRANIAL HEMORRHAGE; FEMUR FX; S/P ATV CRASH ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with , temp contusion.",1
"Eval for interval changes REASON FOR THIS EXAMINATION: 32 year old man with , temp contusion.",0
Eval for interval changes No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JBRe TUE 3:58 PM 1.,0
Slight decrease in density of the bifrontal diffuse axonal injury hemorrhagic foci.,0
No evidence of infarction or significant mass effect including no evidence of intracranial herniation.,0
Unchanged opacification of the paranasal sinuses consistent with the patient's intubated state.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 32-year-old man with , temporal contusion.",0
TECHNIQUE: Contiguous axial images through the head were performed without administration of intravenous contrast.,0
COMPARISON: CT of the head from and .,0
FINDINGS: The previously seen multifocal hyperdense foci at the -white matter junction of bilateral frontal lobes have decreased in density compared to the prior study and are most likely consistent with diffuse axonal injury.,0
There is only minimal edema surrounding these foci.,0
The -white matter differentiation is well preserved.,0
There is no evidence of definite midline shift.,0
Basal cisterns are well preserved without evidence of intracranial herniation.,0
The ventricles are normal in size and configuration.,0
There is no evidence of infarction.,0
An intracranial pressure probe is visualized entering the skull via a right frontal approach and terminating in the superior right frontal lobe.,0
"There is opacification of bilateral maxillary sinuses, the ethmoid air cells, frontal sinus as well the mastoid air cells, essentially unchanged compared to , likely related to the patient's intubated stage.",0
No definite fractures of the skull are identified.,0
Unchanged opacification of the paranasal sinuses consistent with the patient's intubated stage.,0
"(Over) 10:51 AM CT HEAD W/O CONTRAST Clip # Reason: 32 year old man with , temp contusion.",0
Eval for interval Admitting Diagnosis: INTRACRANIAL HEMORRHAGE; FEMUR FX; S/P ATV CRASH ______________________________________________________________________________ FINAL REPORT (Cont),1
"5:51 AM CHEST (PORTABLE AP) Clip # Reason: please eval for expansion or pnx/ct placement, all profound Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman s/p L pneumonectomy, with attempted SC L placements s/p R chest tube with known small ptx on cxr from now s/p decompression with needle REASON FOR THIS EXAMINATION: please eval for expansion or pnx/ct placement, all profound thoughts appreciated.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 63 year old post-pneumonectomy.,0
"PORTABLE SUPINE FRONTAL RADIOGRAPH: Comparison is made to several films over the past few days, most recently 1:30 p.m. on .",0
There is a persistent small right pneumothorax seen in the right costophrenic angle.,0
A right-sided chest tube remains in place in the upper right hemithorax.,0
There has been a slight improvement in interstitial markings consistent with improving congestive heart failure.,1
Multifocal patchy opacities in the lower lung zones are unchanged.,0
Left pneumonectomy with associated changes of volume loss are stable.,0
IMPRESSION: Persistent small right pneumothorax at the costophrenic angle.,0
Persistent patchy multifocal opacities consistent with multifocal pneumonia.,0
8:54 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"extension of bleed ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with left thalamocapsular hemorrhage, not waking up REASON FOR THIS EXAMINATION: ?",0
"extension of bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Left thalamic hemorrhage, not waking up.",0
Evaluate for extension of hemorrhage.,0
"TECHNIQUE: Non-contrast head CT. CT HEAD W/O CONTRAST: Again noted, is a large left thalamic hemorrhage with intraventricular extension.",0
The appearance of this has not changed in the interval.,0
There are no new areas of hemorrhage.,0
"Again noted, are low attenuation regions within the periventricular white matter, consistent with chronic microvascular infarction, also unchanged.",0
There is no evidence of new infarction.,0
There is minimal rightward mass effect from the left thalamic hemorrhage.,0
"Fluid and mucosal thickening is again noted within the sphenoid sinus, unchanged.",0
IMPRESSION: No evidence of extension of left thalamic hemorrhage.,0
No new areas of hemorrhage seen.,0
"4:06 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: MULTIPLE MYELOMA, AMYLOIDOSIS, ESRD ON HD, NOW WITH FRANKLY BLOODY STOOLS, EVALUATE FOR COLITIS Admitting Diagnosis: PNEUMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with multiple myeloma, amyloidosis, ESRD on HD, now with frankly bloody stools.",1
hemodynamically stable REASON FOR THIS EXAMINATION: please evaluate for colitisNON CONTRAST CT CONTRAINDICATIONS for IV CONTRAST: ESRD ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Frankly bloody stools.,0
TECHNIQUE: 0.625 mm helically acquired images are obtained from the lung bases to the pubic symphysis without intravenous contrast.,0
FINDINGS: Direct comparison is made to prior chest CT dated .,0
"Again, bibasilar atelectasis and moderate effusions are noted.",0
"Persistent hyperattenuation is identified within the pleural space on the right, unchanged since the prior examination.",0
"Again, a large hiatal hernia containing the entirety of the stomach again identified.",0
Evaluation of the bowel reveals no evidence of bowel obstruction.,0
Oral contrast is noted to extend to the level of the rectum.,0
Areas of the colon including the descending colon and much of the sigmoid colon demonstrate mild thickening with the appearance of fat attenuation within the wall.,0
This finding suggests the possibility of chronic colitis.,0
Similar findings are seen within the proximal ascending colon.,0
No definitive evidence of acute inflammation is seen on the current study.,0
The bowel is otherwise grossly unremarkable.,0
"Under the limitations of a non-contrast CT, spleen, adrenal glands, kidneys, pancreas, and gallbladder appear grossly unremarkable.",1
Several punctate calcifications are seen within the liver parenchyma suggesting prior granulomatous infection.,0
An IVC filter is identified.,0
Portions of the filter are noted to extend beyond the confines of the inferior vena cava towards the midline.,0
Calcified uterine fibroids are noted.,0
There appears to be fat attenuation within the wall of the bladder suggesting the possibility of chronic cystitis.,0
Innumerable lytic lesions are seen within the osseous structures consistent with the patient's known history of multiple myeloma.,1
Findings suggestive of the possibility of chronic colitis.,0
"Clinical (Over) 4:06 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: MULTIPLE MYELOMA, AMYLOIDOSIS, ESRD ON HD, NOW WITH FRANKLY BLOODY STOOLS, EVALUATE FOR COLITIS Admitting Diagnosis: PNEUMOTHORAX ______________________________________________________________________________ FINAL REPORT (Cont) correlation is recommended.",1
Findings suggestive of chronic cystitis.,0
Bibasilar atelectasis and pleural effusions.,0
A large hiatal hernia containing the entirety of the stomach as noted above.,0
7:41 AM WRIST(3 + VIEWS) RIGHT Clip # Reason: fracture Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with wrist pain.,0
"REASON FOR THIS EXAMINATION: fracture ______________________________________________________________________________ FINAL REPORT HISTORY: Wrist pain, question fracture.",0
"There is diffuse chondrocalcinosis, which can be seen with calcium pyrophosphate deposition disease (including pseudogout), hyperparathyroidism, or hemachromatosis.",0
"There is severe degenerative change at the first CMC joint, with considerable erosion of the trapezium and small cysts in the adjoining base of the first metacarpal.",0
There is dense vascular calcification.,0
Mild subluxation at the first MCP joint is compatible with laxity of the radial collateral ligament.,0
BP (mm Hg): 140/70 HR (bpm): 74 Status: Inpatient Date/Time: at 14:01 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.,0
A prominent Chiari network is present (normal variant).,0
[Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.],0
RIGHT VENTRICLE: Moderately dilated RV cavity.,0
AORTA: Simple atheroma in aortic arch.,0
Moderate to severe (3+) MR. Eccentric MR jet.,0
The patient was monitored by a nurse throughout the procedure.,0
The patient was sedated for the TEE.,0
Medications and dosages are listed above (see Test Information section).,0
Local anesthesia was provided by benzocaine topical spray.,0
0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion.,0
Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient.,0
Conclusions: The left atrium is dilated.,0
The right atrium is dilated.,0
A large atrial septal defect is present (2.0 -3.0 cm).,1
"It is probably secundum type, however, due to the large size, an ostium primum defect cannot be excluded.",1
The right ventricular cavity is moderately dilated.,0
There is moderate/severe mitral valve prolapse.,1
No definite cleft mitral valve was seen.,1
Moderate to severe (3+) mitral regurgitation is seen.,0
"IMPRESSION: Large ASD (secundum type suggested, cannot exclude primum) with significant left to right shunt.",0
Severe prolapse of the anterior mitral (A2) valve leaflet (no mitral cleft identified) with moderate to severe eccentric mitral regurgitation.,1
10:29 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"PRESS changes Admitting Diagnosis: OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with anuric renal failure after toxic ingestion, persistant hypertension and nausea REASON FOR THIS EXAMINATION: ?",1
PRESS changes CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ FINAL REPORT INDICATION: Persistent hypertension and nausea after toxic ingestion and renal failure.,1
Evaluate for evidence of PRES syndrome.,0
COMPARISONS: CT head of .,0
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of intravenous contrast.,0
"FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction.",0
"Specifically, regions of the posterior occipital lobes are unremarkable.",0
The ventricles and sulci are normal in size and configuration for the patient's age.,0
The basal cisterns are patent.,0
There is preservation of -white matter differentiation.,0
There is a small mucous retention cyst within the right maxillary sinus.,0
"The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities is clear.",0
The previously seen subcutaneous emphysema has resolved.,1
IMPRESSION: No acute intracranial process.,0
"Specifically, no changes in the posterior occipital lobes suggestive of PRES syndrome.",0
", CSURG CSRU 11:43 PM CT HEAD W/O CONTRAST Clip # Reason: r/o CVA, anoxic brain injury, herniation Admitting Diagnosis: ACUTE AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with s/p emergency type a dissection repair REASON FOR THIS EXAMINATION: r/o CVA, anoxic brain injury, herniation No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: No evidence of acute intracranial hemorrhage, herniation, or major territorial infarction.",1
MRI is more sensitive for detection of acute ischemia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Penicillins / Morphine / Biaxin / Sulfa (Sulfonamides) / Ciprofloxacin / Aspirin Attending: Chief Complaint: Abdominal & back pain, nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 73 year-old female with 1 month h/o RUQ pain presented to on with increased RUQ pain, nausea, vomiting, back pain, and temperature of 101.0 degrees F. She was being evaluated for ascending cholangitis, when she had an episode of desaturation to 80s on room air, with observed circum-oral cyanosis, yet immediate return to the 90s when placed on oxygen, 2L via nasal cannula.",0
A D-dimer was sent and returned high (>1000) and she was empirically placed on heparin gtt for presumed pulmonary embolus.,0
"She was given gentamicin 80mg, levaquin 500mg and flagyl 500mg x 2.",0
"A CT scan abdomen / pelvis without contrast revealed abnormal hypodensity in right lobe of liver (2.5cm in diameter), colonic diverticulosis, and mild thinning of wall of colon in LLQ.",1
No intrahepatic or extrahepatic biliary ductal dilatation.,0
"Labs were as follows: WBC 21.7, D-dimer 1050, T.bili 1.6, D.bili 0.8, AP 164, AST 52, ALT 44, Alb 2.2, Trop I 0.11, BUN 34, Cr 1.8.",0
"At this point, a decision was made to transfer to for further evaluation.",0
She was enroute to in the evening on when she became hypotensive (SBP 70s) and reported pleuritic chest pain.,0
She was subsequently diverted to Hospital.,0
"In emergency department, she was resuscitated with fluid and given demerol with improvement in blood pressure and pain.",0
"Once stabilized, she was transported to and admitted to the SICU for further evaluation and management.",0
Past Medical History: PMH: Anxiety Diabetes Mellitus on Glyburide 10mg twice daily GERD on Nexium 40mg daily Depression on Zoloft 50mg daily Hypertension Gastritis H/o paroxysmal A-fib controlled with lopressor Parkinson's Hypothyroidism Rheumatoid Arthritis Fibromyalgia Hyperlipidemia H/o RLE DVT s/p knee replacement COPD Chronic back pain Diverticulitis IBS Esophageal strictures Hiatal hernia .,1
PSH: Cholecystectomy () TAH-BSO () Rotator cuff surgery Bilateral knee replacements(/) Social History: The patient lives with her daughter.,0
"She does not smoke, drink, or use recreational drugs.",0
"Family History: Unremarkable Physical Exam: T 98.2 HR 72 BP 142/83 RR 16 O2 sat 97% on 2L Nc Gen: awake, alert, uncomfortable secondary to pain, pale HEENT: PERRL, EOMI, mucous membranes moist, oropharynx - clear CV: regular rate and rhythm Pulm: CTA, bilaterally.",0
"Chest: Tenderness on palpation of the chest wall and rib cage, bilaterally.",0
Increased pain with deep inspiration.,0
"Abd: soft, non-tender on palpation, obese, positive bowel sounds Ext: warm, well-perfused.",0
no edema Neuro: no focal deficits Pertinent Results: Admission Labs -------------- 10:15PM GLUCOSE-138* UREA N-38* CREAT-1.6* SODIUM-137 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16 10:15PM ALT(SGPT)-62* AST(SGOT)-52* CK(CPK)-36 ALK PHOS-186* AMYLASE-23 TOT BILI-0.9 10:15PM LIPASE-13 10:15PM CK-MB-NotDone cTropnT-0.01 10:15PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.8 10:15PM %HbA1c-6.3* 10:15PM WBC-27.9* RBC-3.44* HGB-9.8* HCT-28.5* MCV-83 MCH-28.5 MCHC-34.5 RDW-13.3 10:15PM PLT COUNT-206 10:15PM PT-13.2* PTT-51.5* INR(PT)-1.2* 10:15PM SED RATE-61* HbA1C 6.3% Radiology Studies ----------------- 12:03 AM ~ CHEST (PORTABLE AP) Reason: eval for acute cardiopulmonary process IMPRESSION: Chest clear.,0
"1:04 AM ~ LIVER OR GALLBLADDER US (SINGL Reason: assess CBD INDICATION: 73-year-old woman with right upper quadrant pain, hypertension, prior cholecystectomy.",1
No intra- or extra-hepatic biliary ductal dilatation.,0
4.5 cm heterogeneous liver lesion with internal flow.,0
"This is concerning for malignancy, further evaluation with CT or MR is recommended.",0
"2:43 PM ~CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST INDICATION: Possible cholangitis, query liver abscess.",1
History of respiratory distress and desaturation with elevated D-dimer.,0
No CT evidence of pulmonary embolism.,0
"Heterogeneous hypodense lesion in segment VIII of the liver associated with a dilated bile duct proximally, and surrounding hyperemia.",0
"Findings may represent a hepatic abscess with associated cholangitis; however, the lesion has not been completely characterized with a multiphasic study.",1
Other considerations include a hepatic tumor although this is considered less likely.,0
Further characterization with MRI is recommended.,0
3:30 PM ~BILAT LOWER EXT VEINS Reason: right femoral DVT noted on CT scan from .,0
8:00 AM ~LIVER OR GALLBLADDER US (SINGL Reason: Interval change in abscess size IMPRESSION: Again seen is a relatively well-defined rounded mass in the right lobe of the liver which measures 5.1 x 4.7 x 4.8 cm today.,1
"On the prior ultrasound the measurements were 4.4 x 4.5 x 4.5 cm, therefore this represents a minimal increase in size.",0
Minimally increased size of right lobe liver mass with interval echogenicity changes that could be consistent with the natural evolution/resolution of an abscess.,1
However underlying mass lesion cannot be excluded.,0
Further followup is recommended to confirm resolution of this lesion.,0
MRI could be performed if further characterization is clinically indicated.,0
9:13 AM ~ LIVER OR GALLBLADDER US (SINGL Reason: Evaluate hepatic abscess.,1
"FINDINGS: son images of the liver reveal interval decrease in the size of the patient's known right hepatic lobe abscess, which is hypoechoic, without demonstrable internal blood flow.",1
"It currently measures 3.7 x 2.8 x 4.1 cm, compared to 5.1 x 4.7 x 4.8 cm.",0
No additional focal hepatic abnormalities are identified.,0
There is no evidence of intrahepatic biliary ductal dilatation.,0
"The common duct is normal at 2.9 mm and the main portal vein is patent, with hepatopetal flow.",0
The patient is status post cholecystectomy.,0
Interval decrease in the size of a known hepatic abscess.,0
"Brief Hospital Course: Patient was admitted to the SICU under the care of Dr. for possible cholangitis, pulmonary embolism and liver abscess.",1
"During that time she was alert and oriented person, place and time,, afebrile with stable vital signs HR 80's, SBP 130-150.",0
"A heparin drip was started upon admission due to elevated D-dimer, complaints of shortness of breath, a CT Scan evaluated no pulmonary embolism.",0
"She had a white count of 27.9, blood cultures and urine cultures were obtained, a dose of gentamicin IV was given and WBC decreased to 20.",0
Patient was transferred to the floor <24 hours from the time of admission.,0
"Abdominal Pain/Hepatic abscess: Right upper quadrant abdominal pain was evaluated initially by CT scan of abdomen and pelvis, patient received IV bicarb pre and post procedure due to impaired renal function.",0
"This demonstrated abnormal hypodensity in right lobe of liver 2.5 cm, 1.5 cm right adrenal adenoma, thinning of left colon wall possibility mild diverticulitis.",1
A liver ultrasound and chest CTA were then obtained to evaluate possible cholangitis and query liver abscess.,1
"The liver ultrasound revealed 4.5 cm heterogeneous liver lesion with internal flow, no biliary ductal dilatation.",0
"The chest CTA revealed Segment VII lesion in liver (abscess with associated cholangitis v. tumor), sigmoid diverticulosis.",1
Patient continued on Gentamycin (started at OSH ) for liver abscess that Dr. felt it would resolve without drainage.,1
Patient was treated with gentamicin IV then Cefpodoxime orally and Flagyl.,0
The hepatic abscess was evaluated with interval ultrasound's measuring 3.7 x 2.8 x 4.1 cm on HD14 compared to 5.1 x 4.7 x 4.8 cm on HD7.,0
Patient was discharged and scheduled for a liver ultrasound on @1:00 pm.,0
Sigmoid diverticulitis: Sigmoid diverticulosis was monitored throughout admission.,0
By HD4 her abdominal pain was improving.,0
"She was started on a low residue 1800 calorie diet, she was passing flatus and having stools.",0
She was started on Neomycin 500 mg orally twice a day and started a bowel regimen of Colace and Psyllium Wafers.,0
"By HD5, the WBC normalized with antibiotic therapy.",0
"On HD6, patient was experiencing ""gas pains"" and received Simethicone and Mylanta with good effect, she was passing flatus and having stools.",0
"On HD7-9, patient was having several episodes of loose stools, C. Diff samples were obtained and three samples were negative.",0
A clostridium difficile toxin B Assay was sent and the results are pending at the time of discharge.,0
Patient was treated with a 14 day course of Vancomycin orally and will complete this course on .,0
"On HD10, the Neomycin, Colace and psyllium were discontinued because of loose stools.",0
Patient was started on lactobacillus therapy and low dose Megace 40 mg daily.,0
"By HD12, patient was having more formed stools with less frequent episodes of bowel movements.",0
She was still experiencing small amounts of pain with eating.,0
"HD13, her abdomen was nontender with no episode of nausea, vomiting and diarrhea.",0
All stool cultures were negative from this admission.,0
Patient was discharged home on a bowel regimen of Colace and Metamucil and to hold if experiencing loose stools.,0
"Nutrition: She was seen by a representative from the nutritional team for education on a low-residue diet 1800 calorie diabetic diet, handouts were provided, a registered Dietitian's phone number was provided to patient and she was referred to outpatient nutritional therapy clinic for follow-up.",0
She was monitored with calorie counts for three days with the initiation of Megace therapy.,0
The intake for HD13 kcal 713/protein 36g and HD14 kcal 1303/P58g.,0
Renal/Elevated Creatinine: Upon admission patient had an elevated creatinine 1.8 that normalized with fluid resuscitation.,0
"On HD10, patient had an elevated creatinine of 1.3, ACE inhibitors and HCTZ were held.",0
Creatinine was 1.1 at the time of discharge.,0
Patient is to follow-up with Dr. about resuming this medications.,0
"Medications on Admission: Metoprolol 50mg po BID Glyburide 10mg po BID Enalapril 80mg every am Zoloft 50', HCTZ 25', Nexium 40', Darvocet prn, Carafrate 1 tablet po four times daily Sinemet 10/100 po twice daily Vitamin E 800mg po daily Colace 100mg po twice daily Lethicin 1325 po daily Discharge Disposition: Home Discharge Diagnosis: Hepatic Abscess _ Right lobe 4cm Mild diverticulitis Discharge Condition: Stable; afebrile, vital signs stable, ambulating at baseline level of functioning, tolerating oral medication and antibiotic regimen, tolerating a low residue diet, completed nutrition education regarding new diet, voiding and passing stool.",1
Discharge Instructions: Please return or contact for: * Nausea and/or vomiting * Fever (>101 F) or chills * Increased or persistent abdominal pain * Inability to pass gas * If you become constipated ** * Increase in shortness of breath or difficulty breathing * Increase in fatigue * Any other concerns Antibiotic regimen: 1) Vancomycin (started ) 250mg orally every 6hours - stop on .,0
This will complete a 14 day course.,0
2) Flagyl (started ) 500mg orally three times a day 3) Fluconazole (started ) 200mg orally daily 4) Cefpodoxime (started ) 200mg orally every 12 hours You will stop the Vancomycin on .,0
"You will continue the Flagyl, Fluconazole and Cefpodoxime until you see Dr. in the clinic.",0
"Diet: Low residue, Low fat , Diabetic/Consistent Carbohydrate Supplement: As recommended by Nutrition, Sugar Free Shake Please avoid products made with whole grain products, bran, seeds, or nuts Bowel Regimen: You should take Colace and Psyllium wafers because of the diverticulitis episode during this hospitalization.",0
These medications can be held if you experience loose stools.,0
Followup Instructions: You are scheduled for a liver ultrasound on @ 1:00pm.,0
"Please report to the Clinical Center, , Radiology Dept.",0
You should have nothing to eat or drink for 6 hours prior to the study.,0
Please take your morning medications with the smallest amount of water possible.,0
This needs to be completed prior to your appointment with Dr. .,0
Your appointment for a hospital follow-up with Dr. is scheduled for @ 215pm.,0
If you are experiencing any difficulty prior to this appointment please call to be seen sooner.,0
Please contact Dr. (Primary Care Physician) and schedule a hospital follow-up appointment.,0
The medications that you were taking prior to hospitalization for your blood presure were changed because of changes in your renal function.,0
This should be followed by Dr. .,0
Dr. has spoken directly with Dr. regarding your hospitalization.,0
"7:22 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx, s/p avr/cabg Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman s/p AVR/cabg x1/root enlargement REASON FOR THIS EXAMINATION: r/o ptx, s/p avr/cabg ______________________________________________________________________________ FINAL REPORT INDICATION: Status post aortic valve replacement and CABG.",1
"SINGLE-VIEW CHEST, AP: In the interval, the patient has been extubated and the NG tube has been removed.",0
"There are again bilateral chest tubes, as well as a mediastinal drain in unchanged positions.",0
"The right IJ SG catheter has been slightly repositioned, with the tip again in the main right pulmonary artery.",1
There is a left subclavian CVL with the tip in the mid SVC.,0
"Patient is status post median sternotomy, CABG and aortic valve replacement.",1
There is patchy bibasilar atelectasis.,0
Interval extubation and NG tube removal.,0
4:39 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with GIB s/p intubation c/b LUL collapse REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with gastroesophageal bleeding after intubation.,1
Portable AP radiograph of the chest was reviewed in comparison to prior studies obtained today earlier.,0
There is currently increased opacification of the left lower lobe which might be consistent with aspiration or progression of infectious process.,0
"The patient is rotated, thus the assessment of the mediastinum is difficult but most likely there is also some minimal degree of left upper lobe atelectasis.",0
The patient is in interstitial pulmonary edema.,0
The ET tube tip is 2.6 cm above the carina.,0
There appears to be a temperature probe in unchanged position.,0
No NG tube is demonstrated.,0
6:10 AM PORTABLE ABDOMEN Clip # Reason: Please assess for retained sponge Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with persistent fever of unknown origin REASON FOR THIS EXAMINATION: Please assess for retained sponge ______________________________________________________________________________ FINAL REPORT INDICATION: Assess for retained sponge in patient with fever of unknown origin.,0
FINDINGS: Diffuse opacification within the visualized portions of both lungs is present suggestive of patchy consolidation.,0
An NG tube passes into the stomach.,0
No radiopaque foreign bodies are present within the abdomen to suggest a retained foreign body.,0
Rounded calcifications are present within the right upper quadrant suggestive of gallstones.,0
Surgical sutures overlie the mid abdomen.,0
No dilated loops of large or small bowel are present to suggest ileus or obstruction.,0
No free air is seen.,0
IMPRESSION: 1) No radiopaque foreign body identified.,0
2) No evidence of ileus or obstruction.,0
3) Patchy consolidation within the visualized portions of both lung bases.,0
4) NG tube in position with its distal side hole near the GE junction.,0
", R. MED MICU 10:44 PM CT CHEST W/O CONTRAST Clip # Reason: Evaluate consolidation Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with increasing oxygen requirement, fevers, leukocytosis REASON FOR THIS EXAMINATION: Evaluate consolidation No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Left upper lobe pneumonia, predominantly within the lingula.",1
5:05 AM PORTABLE ABDOMEN Clip # Reason: ?dilated loops Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with abdominal pain/distension REASON FOR THIS EXAMINATION: ?dilated loops ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Abdominal pain.,0
"Portable AP radiograph of the abdomen was reviewed in comparison to , .",0
The patient is after recent abdominal surgery.,0
IVC filter is in place.,0
Stent in the right iliac artery is in place.,0
Overall unremarkable distribution of bowel in the abdomen is seen.,0
No definitive dilatation of bowel loops is demonstrated.,0
"9:49 PM CHEST (PORTABLE AP) Clip # Reason: evaluate position, low chest Admitting Diagnosis: EMPYEMA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with s/p doboff placement REASON FOR THIS EXAMINATION: evaluate position, low chest ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate position of new Dobhoff tube.",0
COMPARISON: Film 9 hours earlier on the same day.,0
"CHEST, SINGLE AP SUPINE VIEW: The new Dobhoff tube has been inserted inadvertantly into the tracheobronchial tree and its distal end is now in a left lower lobe bronchus.",0
It should be removed and repositioned.,0
"Otherwise, the appearances are unchanged.",0
The cavitary lesion is again noted at the right apex with a pigtail catheter inserted into it.,0
There is also again evidence of cardiomegaly and a small right pleural effusion.,0
IMPRESSION: Dobhoff line inadvertantly inserted into a left lower lobe bronchus.,0
", D. MED MICU-7 3:50 AM CHEST (PORTABLE AP) Clip # Reason: interval change in PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with sepsis, PNA REASON FOR THIS EXAMINATION: interval change in PNA ______________________________________________________________________________ PFI REPORT 1.",1
"Ill-defined, nodular airspace process involving primarily lingula, unchanged.",0
CV catheter in unchanged and satisfactory position.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: eval for new L IJ ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with new IJ REASON FOR THIS EXAMINATION: eval for new L IJ ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON Comparison with a prior study from earlier today.,0
CLINICAL HISTORY: New left IJ central line placement.,0
FINDINGS: Semi-upright portable AP view of the chest is obtained.,0
An endotracheal tube is seen with its tip located approximately 4.7 cm above the carina.,0
An NG tube courses inferiorly below the left hemidiaphragm.,0
"Right IJ dialysis catheter, dual-lead pacer, unchanged.",0
A new left IJ central venous catheter is seen with its tip coursing into the expected location of the superior vena cava.,0
"Bilateral pulmonary opacities are again noted with bilateral pleural effusions, left greater than right.",0
No definite signs of pneumothorax.,0
IMPRESSION: Lines positioned as detailed.,0
"11:29 PM CHEST (PORTABLE AP) Clip # Reason: NGT placement please page with result ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with cerebellar bleed s/p evacuation, MRSA bacteremia, bilat pleural effusions, s/p R thoracentesis and NGT placement and diuresis.",0
REASON FOR THIS EXAMINATION: NGT placement please page with result ______________________________________________________________________________ FINAL REPORT INDICATIONS: Check NG tube placement.,0
Comparison is made to previous films from 15 hours earlier.,0
"AP CHEST: The Dobbhoff tube has been advanced, and the tip is now in the distal stomach.",0
"An endotracheal tube has been placed in the interval, and the tip is located at the thoracic inlet, 5.5 cm above the carina.",0
Again seen is a left subclavian central venous line with the tip in the SVC.,0
There is stable cardiac enlargement.,0
Again seen is a prosthetic aortic valve.,0
Bilateral pleural effusions and bibasilar atelectasis are again seen.,0
"There is increased prominence of the pulmonary vasculature, which likely indicates worsening CHF.",0
Osseous structures are unchanged in appearance.,0
IMPRESSION: Lines and tubes as above.,0
Height: (in) 70 Weight (lb): 222 BSA (m2): 2.18 m2 BP (mm Hg): 119/64 HR (bpm): 69 Status: Inpatient Date/Time: at 11:18 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT ATRIUM: Normal LA size.,0
AORTA: Mildly dilated aortic sinus.,0
There is an inferobasal left ventricular aneurysm.,1
Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %).,1
The aortic root is mildly dilated at the sinus level.,0
"Compared with the prior study (images reviewed) of , the regional dysfunction appears similar.",0
Mild symmetric left ventricular hypertrophy is present.,0
Overall ejfection fraction is difficult to estimate due to suboptimal image quality and frequent ventricular ectopy.,0
10:25 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o aspiration Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with r/o aspiration after self d/c of dobhoff.,0
REASON FOR THIS EXAMINATION: r/o aspiration ______________________________________________________________________________ FINAL REPORT HISTORY: Aspiration.,0
SINGLE PORTABLE RADIOGRAPH OF THE CHEST: Demonstrates interval removal of the nasogastric tube seen on the chest radiograph obtained earlier the same day.,0
Appearance of the heart and lungs is unchanged.,0
LUNG SCAN Clip # Reason: 69 Y/O WOMAN WITH TACHYCARDIA AND DYSPNEA IN SETTING OF BREAST CA.,0
R/O PE ______________________________________________________________________________ FINAL REPORT RADIOPHARMACEUTICAL DATA: 37.8 mCi Tc-m DTPA Aerosol (); HISTORY: 69 year old woman with breast cancer with tachycardia and dyspnea.,1
INTERPRETATION: Please note that the examination was terminated after only the ventilation images were performed.,0
The patient did not want to continue with the perfusion portion of the exam.,0
"Ventilation images obtained with Tc-m aerosol in 8 views demonstrate mild trapping of xenon, especially at the right lung base, which may be due to chronic obstructive pulmonary disease.",0
Chest x-ray shows clear lungs bilaterally with no acute abnormalities.,0
IMPRESSION: Exam terminated after only ventilation portion was performed.,0
The patient would not continue with the perfusion portion and therefore the probability for a pulmonary embolism cannot be determined.,0
Approved: MON 3:33 PM RADLINE ; A radiology consult service.,0
4:51 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for cardiopulmonary process ______________________________________________________________________________ MEDICAL CONDITION: History: 34F with HR 150 REASON FOR THIS EXAMINATION: evaluate for cardiopulmonary process ______________________________________________________________________________ FINAL REPORT HISTORY: 34-year-old female with tachycardia to the 150s COMPARISON: Chest radiograph from and CTA of the chest from PORTABLE AP CHEST RADIOGRAPH: The lungs are clear.,1
No confluent opacity is identified.,0
There is no pulmonary edema or pleural effusions.,0
Cardiomediastinal and hilar contours are within normal limits.,0
IMPRESSION: No acute cardiopulmonary process,0
"8:39 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: persistent hct drops, eval for hematoma, bleeding source Admitting Diagnosis: LIVER FAILURE Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 68F s/p liver transplant, ex lap evacuation of hematoma, small bowel resection REASON FOR THIS EXAMINATION: persistent hct drops, eval for hematoma, bleeding source No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: A 68-year-old female status post liver transplant with ex-lap evacuation of a hematoma and small bowel resection.",0
The patient is having persistent drop in her hematocrit.,0
Evaluate for bleeding source or hematoma.,0
TECHNIQUE: Non-contrast images were performed from the lung bases through the pubic symphysis.,0
Only oral contrast was administered.,0
CT OF THE ABDOMEN WITHOUT CONTRAST: There is a small pneumothorax at the right lung base.,0
There is a chest tube in the lower right lung.,0
This is not significantly changed in size compared to the prior study.,0
"There is a patchy air-space process in the right lower lung, more likely atelectasis.",0
"Additionally, there is a moderate-sized pleural effusion at the left lung base with associated compressive atelectasis.",0
Two J-P drains are seen over the top of the liver.,0
"There is persistent pneumobilia, not significantly changed.",0
The gross pathology of the liver is unchanged.,0
The collection anterior to the liver in the right upper quadrant is slightly smaller in size and measures 10 x 3 cm.,0
"Again, there is a small amount of air in this region.",0
"The spleen, adrenals, kidneys and pancreas are unchanged.",0
There is an NG tube whose tip is in the stomach.,0
There are dilated loops of small bowel extending from the duodenum to the conglomerate small bowel loops in the right lower quadrant that were seen previously.,0
There appears to be a surgical anastomosis in this region.,0
"There is oral contrast distal to this; however, it cannot be ascertained if the oral contrast distal to this is from the prior CT scan versus past contrast from the current study.",0
There is more free fluid in the abdomen.,0
"CT OF THE PELVIS WITH CONTRAST: Again, there is evidence of a small bowel obstruction with a transition point in the right lower quadrant at the site of an anastomotic small bowel.",0
The bowel is collapsed distal to this.,0
The uterus and adnexa are unremarkable.,0
The bladder is collapsed around a Foley catheter.,0
No evidence of retroperitoneal hematoma or bleeding within the abdomen.,0
"(Over) 8:39 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: persistent hct drops, eval for hematoma, bleeding source Admitting Diagnosis: LIVER FAILURE Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont) 2.",0
There is new dilated small bowel loops extending from the duodenum to a transition point in the right lower quadrant near an anastomotic small bowel site.,0
"While oral contrast is seen beyond this, it cannot be ascertained whether this is oral contrast administered from this study or the study from three days prior.",0
Stable appearance to the fluid collection anterior to the liver.,0
These findings were telephoned to Dr. at 9:40 on .,0
LINE PLACEMENT Clip # Reason: s/p RIJ.,0
Please assess line placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with SAH ruptured aneurysm REASON FOR THIS EXAMINATION: s/p RIJ.,1
Please assess line placement ______________________________________________________________________________ WET READ: JEKh SAT 12:12 AM 1.,0
R IJ line tip in low SVC; no pneumothorax.,0
ET tube 4.5 cm above carina.,0
3. endogastric tube courses inferiorly out of view.,0
______________________________________________________________________________ FINAL REPORT PORTABLE SEMI-ERECT CHEST FILM DATED AT .,0
CLINICAL INDICATION: 63-year-old status post a subarachnoid hemorrhage due to a ruptured aneurysm status post right internal jugular placement.,1
Assess line placement and pneumothorax.,0
Please note that comparison to old films would be helpful to assess for interval change.,0
A single portable semi-erect chest film dated at is submitted.,0
Right internal jugular central line with its tip in the superior vena cava.,0
Nasogastric tube courses below the diaphragm with the tip not identified on the current study.,0
Endotracheal tube has its tip at the thoracic inlet.,0
"Lungs appear well inflated without evidence of focal airspace consolidation, pleural effusion, or pneumothorax.",0
Height: (in) 67 Weight (lb): 158 BSA (m2): 1.83 m2 BP (mm Hg): 116/65 HR (bpm): 78 Status: Inpatient Date/Time: at 11:45 Test: TTE (Focused views) Doppler: Color Doppler only Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%).,0
Cannot assess RV systolic function.,0
Paradoxic septal motion consistent with prior cardiac surgery.,0
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).,1
MITRAL VALVE: Normal mitral valve leaflets.,0
TRICUSPID VALVE: Tricuspid valve not well visualized.,0
"Suboptimal image quality - bandages, defibrillator pads or electrodes.",0
Emergency study performed by the cardiology fellow on call.,0
Conclusions: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%).,0
The right ventricular cavity is mildly dilated Free wall motion could not be assessed.,0
A bioprosthetic aortic valve prosthesis is present.,1
The mitral valve leaflets are grossly normal.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Bacteremia/sepsis s/p Left PCN replacement Major Surgical or Invasive Procedure: nephrostomy tube (left) replaced History of Present Illness: This is 61 year-old male with a history of obstructing left renal stone, suprapubic catheter, numerous UTIs who presents from day care center with fever, tachycardia.",1
Pt was scheduled for an appointment with Dr. for treatment of his obstructing left stone.,0
Day of admission at the nursing home his left perc nephrostomy was noted to have migrated out and he was brought to where IR replaced his tube ~1:30pm.,0
"In the day care unit he was noted to be ill appearing, spiked a temperature to 102.6 and began vomiting.",0
"Pt c/o pain, given oxycodone, urology called said urostomy outpt fine.",0
Pt became tachy to 130's.,0
Pt given dose of cefepime.,0
"Currently, pt reports LLQ pain, s/p vomiting, chronic b/l foot pain.",0
"Denies headache/LH/CP/SOB/diarrhea, melena, brbpr, dysuria, rash.",0
"Past Medical History: s/p CVA Neurogenic bladder s/p suprapubic cath Recurrent UTIs with Klebsiella/Pseudomonas Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p R-CHOP x 6 cycles) Bells Palsy BPH Hypertension Partial Bowel obstruction s/p colostomy Hepatitis C Cryoglobulinemia SLE with transverse myelitis, anti-dsDNA Ab+ Insulin Dependant Diabetic Fungal Esophagitis Stage IV?",1
Urinary Tract Infections-pseudomonas & enterococcus Social History: Lives in a nursing home since .,1
"Denies smoking, ETOH, drug use.",0
Has sister close by () who he is close to.,0
Is a Jehova's Witness and does not agree to blood transfusions.,0
"Family History: Non-Contributory Physical Exam: on discharge Vitals: Tm 99.7 Tc 98.9 130/70 94 18 95%RA Pain: b/l LE Access: R PICC Gen: nad, lying in bed HEENT: mm dry CV: RRR, no m appreciated Resp: CTAB, no crackles or wheezing Abd; soft, nontender, +colostomy prolapse with brown/green stool, +BS, L PCN yellow urine, SPT in place Ext; no edema, hyperpig changes, onychomycosis, b/l shins ttp Neuro: A&OX3, slow to respond, stable mild L facial droop psych: flat skin: new erythematous rash over R abdomen to upper thigh with numerous very small white pustules (white heads), no skin breakdown, no bullae Pertinent Results: Chem panel BUN/creat 4/1.0 (baseline 0.8), Phos 3.5, Mag 1.8 WBC 9s INR 1.3 hgb 9s .",1
"UA large LE, SPT 227 wbc, PCN 672 wbc, mod bacteria UCx negative X2 UCx in past pseudomonas and providencia.",1
"suprapubic UCx wth 3,000-5,000 GNR (suggestive of pseudomonas) Blood Cx 1 of 3 sets with corneybacterium (contaminant) Blood cx X2 NTD, X1 , X2 NTD C-diff pos, neg .",0
Imaging/results: LENI bilateral LE: negative.,1
CXR : L pleural effusion improving.,0
"CT a/p noncontrast : No significant interval change compared with : No abscess, stable subcapsular left renal hematoma, stable bilateral non- obstructing renal calculi, persistent cholelithiasis, likely AVN of the right femoral head, fat stranding in the sigmoid area and bilateral pleural effusions.",1
CT a/p noncontrast : Study limited due to lack of IV contrast administration.,0
There is no obvious evidence of abscess.,0
There is no obvious evidence of acute colitis.,0
"No significant interval change compared to , with some mild decrease in fluid collection in the abdominal cavity and pelvic tracking of the left perirenal space.",0
Stable subcapsular left renal hematoma.,0
"Status post left nephrostomy tube in placement, stable since .",0
Stable dilatation of the left ureter compared to .,0
"Small bilateral pleural effusion, unchanged, with some dependent atelectasis.",0
"Stable bilateral renal calculi, nonobstructing.",0
Cholelithiasis without evidence of acute cholecystitis.,1
"Fatty liver infiltration, diffuse, stable.",0
"Presumable AVN of the right femoral head, unchanged.",0
Minimal wall thickening and fat stranding in the sigmoid area unchanged since .,0
Large subcapsular renal hematoma with acute hemorrhage expanding the perinephric space and extending into the anterior perirenal space and likely in the pelvis.,1
"Status post left nehrostomy tube exchange, which terminates in the left renal pelvis.",0
No evidence of hydroureter or hydronephrosis.,0
"Focal area of hyperdensity in the pelvis surrounding sigmoid colon, likely related to bleedin from the renal hematoma.",0
"Although less likely, a focal colonic process cannot be excluded.",0
Cholelithiasis without evidence of cholecystitis.,0
Slight interval increase in fluid collection in the right lower quadrant and pelvis tracking from the left pararenal space consistent with small amount of intraperitoneal hemorrhage.,1
Status post left nephrostomy tube exchange which demonstrates stable position in the left renal pelvis compared to .,0
Stable dilation of the left ureter compared to .,0
"Bilateral pleural effusions, unchanged from .",0
Stable bilateral renal calculi that are nonobstructing.,0
"Probable early AVN of the right femoral head, unchanged from .",0
Brief Hospital Course: Brief hospital course: Per report the patient's nephrostomy tube fell out at nursing home and replaced on by IR.,0
"Pt was intially admitted to MICU with ever, tachycardia, LLQ pain and ?pus at perc tube site later that day.",0
"given h/o Pseudomonas UTI's, recurrent urosepsis, nephrolithiasis, suspected source of sepsis and fevers were the urinary tract.",1
He was initially started on Cefepime (later switched to Ceftaz) and Vanco ( d/c'd).,0
The pt continued to have LLQ pain.,0
"Initially thought was possible C-diff and he was empirically started on PO flagyl (c-diff toxin subsequently positive, continued diarrhea, changed to PO vanc, plan to continue until 1week post Abx around ).",0
Pt continued to c/o LLQ pain and thus underwent a CT Abd showing a subcapsular hematoma without focal abcess.,0
This was rechecked after a drop in Hct and found to be stable and has been stable with repeat CTs during hospital stay.,0
CT scans were also negative for abcess to explain persistant fevers.,0
"Urinary Cultures finally came back with Pseudomonas and Providenci Stuartii and pt remained febrile-->ID consulted, Abx changed to meropenem, and plan is for 2weeks (until ).",1
"Definitive treatment would be removal of kidney stones that are likely infected (UA persistantly dirty, though may be colonization).",0
Urology was following and did not want to remove stones while pt was still having fevers.,0
Decision made to f/u urology after 2weeks of Abx and he has f/u arranged with Dr. .,0
"Initially was afebrile for 3days after a couple days on meropenem, then again started having fevers.",0
"Blood Cx with , old PICC removed () and vanc restarted, planned until .",0
"Pt has not had temp spike for 2days now, though continues to have low grade temps to 100.",0
His latest cultures are all negative and he is on vanc/meropenem/PO vanc.,0
"His appetite is very poor and he is started on sugar free shakes TID, PO hydration is encouraged to prevent volume depletion.",0
"He has chronic b/l LE pain from neuropathy and PAD, his neurontin was increased.",0
"If his issues become stable, he should follow up with vascular to see if anything can be down with blood flow to the area.",0
He is stable and being transfered back to with plans for urology f/u.,0
Please see progress note below for details: .,0
"61 year old male with MMP including DM, CVAs, SLE with myelopathy, neurogenic bladder s/p SPT, recurrent nephrolithiasis/urosepsis s/p L PCN admitted for dislogded PCN, replaced, post-procedure urosepsis, now on meropenem unitl .",1
Post procedure also developed a subcapsular hemmorhage/anemia (stable).,1
"Hospital course complicated by c-diff on PO vanc, PICC associated bacteremia on IV vanc.",0
"Continues to have intermittent low grade temps, likely infected stones.",0
Overall stable and plan to discharge back to today.,0
"Fevers: recurrent/intermittent: initially on vanc/ceftaz, then meropeneum since for presumed urosepsis (ESBL, pseudomonas, etc).",1
Again started IV Vanc for bacteremia ( PICC).,0
"CT scan repeat stable hemmorhage, no abcess.",0
"Most likley poss is infected stone that remains as repeat UAs still very dirty -blood cx (PICC removed , last temp spike).",0
"New R PICC placed -cont Vanc (started ) for bacteremia, plan till -cont meropenem for total 2weeks (until ) for urosepsis.",0
"However, concern is that stone is infected (repeat UA SPT and PCN dirty) and removal is only definitive treatment as patient is having persistant intermittent fevers.",0
"has appt with Dr. on , so continue Abx till this.",0
"-C-diff, plan to cont PO vanc for 1-2weeks after above Abx (approx ) per ID recs.",0
"-tylenol q6 prn -appreciate ID reccommendations, signed off.",0
R Abdominal wall rash: benign appearing.,0
"?fungal vs contact dermatitis -antifungal powder, keep area dry and clean .",0
Acute blood loss anemia: subcapsular hemmorhage.,1
-hgb stable around 9s .,0
"c mild CKD: creat up to 1.7, now back to baseline, monitor closely as creat 0.8->1.0, not much PO hydration.",0
"Recurrent nephrolithiasis, obstructing L stone s/p L PCN, recurrent urosepsis.",0
dirty UAs ( catheter vs infected stones).,0
"-again urology would like to wait for 2weeks, has appt with Dr. , keep on Abx till then (2weeks total) -Note, repeat CT (and ) with stable hematoma and fluid collection w/o mention of abcess (fevers).",1
DM: lantus and lispro 4U tid and SSI -chronic b/l LE pain neurolpathy and likely PAD.,0
"increased neurontin to 600mg TID, consider vascular follow up to eval blood flow.",0
"C-diff: PO vanco (for 1-2weeks after completion of ABx), decreased ostomy output so plan till .",0
bowel regimen if constipation on narcotics .,0
LLQ Abd Pain- CT Abd on and revealed subcapsular left renal hematoma and a slight interval increase in fluid collection in the right lower quadrant and pelvis tracking from the left pararenal space consistent with small amount of intraperitoneal hemorrhage.,1
In addition there was stable dilation of the left ureter and stable bilateral renal calculi.,0
Repeat CTs duing hospitalization showed stable hematoma and his pain improved throughout his stay with tylenol and oxycodone prn.,1
"Depression: celexa (dose increased), ambien prn .",0
"FEN/proph: HLIV, encourage PO hydration, monitor lytes, diabetic diet as tolerated with ensure tid, TEDs/SCDs, no AC, PPI, bowel regimen as needed with pain meds, pt refusing PT, OOB to chair TID .",0
"Pt is stable, plan in place for course of Abx, continues to have low temps.",0
Plan to send to ( health care) today with urology f/u with Dr. .,0
"Medications on Admission: Insulin 18units QHS, lispro 8 units breakfast, lunch, dinner MVI Citalopram 10mg daily folic acid 1mg daily gabapentin 300mg TId oxycodone 5mg Q6hr simvastatin 10mg daily acetaminophen bisacodyl calcium 600+D iron mag citrate prn prilosec 20mg daily senna simethicone thiamine Discharge Medications: 1.",0
Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation.,0
Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): end date: 7 days after completion of other antibiotics.,0
Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day).,0
"Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed.",0
"Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): for oral thrush.",0
Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed.,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever.,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain.,0
Lantus 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime.,0
Insulin Lispro 100 unit/mL Insulin Pen Sig: Four (4) Units Subcutaneous TID before meals: Also sliding scale.,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day).,0
Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every six (6) hours: until .,0
"Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours: until .",0
"CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO at bedtime.",0
Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day.,0
Discharge Disposition: Extended Care Facility: Healthcare- Discharge Diagnosis: 1.,0
"UTI/sepsis (pseudomonas, providencia), bacteremia (PICC) 2.",1
"Clostridium difficile colitis 3. left renal capsule hematoma 4. bilateral nephrolithiasis, s/p nephrostomy tube placement 5.",1
DM with chronic neuropathy (b/l LE) 6. colostomy with prolapse 7.,1
SLE with myelopathy 8. history of stroke with late effects Discharge Condition: STABLE Discharge Instructions: You were admitted after nephrostomy tube replacement with fevers and hypotension.,0
"The kidney stones must be removed, so please assure you follow up with Dr. as scheduled on .",0
You will be on IV meropenem until .,0
"You also have c.difficile colitis, and should continue to take the vancomycin until at least 7 days beyond finishing your other antibiotics ( or so) .",0
"You also had bleeding around the kidney where the nephrostomy tube was placed, but did not have any blood transfusions.",0
"You also had an infection associated with the PICC, you will be on IV vanc for 5days .",0
You have a new rash over your Rside of abdomen and upper thigh.,0
"It looks like you skin is irritated but nothing too serious, keep the area dry and clean, and use topical powder that is ordered.",0
"If your skin starts to open up with big blisters, please tell the doctors at the nursing home.",0
Please call your primary care physician with any concerns or questions.,0
"Please return to the hospital if you have persistant fever greater than 101, increased abdominal pain, worsened diarrhea, low blood pressure or any other concerns.",0
"Followup Instructions: PCP: , .",0
"Provider: , MD Phone: Date/Time: 3:40 Provider: RM 2 -PREADMISSION TESTING Date/Time: 11:00 Provider: ,ONE Date/Time: 7:00",0
"7:29 AM CHEST (PORTABLE AP) Clip # Reason: acute cardiopulmonary process Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man admitted with pericarditis, now with increasing O2 requirement, and cough.",0
REASON FOR THIS EXAMINATION: acute cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: Pericarditis with increasing oxygen requirement and cough.,0
COMPARISONS: Chest radiograph dated .,0
FINDINGS: A single AP portable view of the chest was obtained.,0
Bilateral pleural effusions are new (small on the left and moderate on the right).,1
"The cardiac silhouette remains enlarged, compatible with known pericardial effusion.",1
Prominence of the interstitial markings is suggestive of interstitial edema.,0
Indistinct right heart border may reflect right middle lobe atelectasis and/or consolidation; this could be further evaluated with a lateral radiograph.,0
"New bilateral pleural effusions, mild interstitial edema and stable enlarged cardiac silhouette, compatible with known pericardial effusion.",1
Possible consolidation and/or atelectasis of the right middle lobe.,0
"5:50 AM PORTABLE ABDOMEN Clip # Reason: ileus Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with pancreatitis, s/p dobhoff removal, please eval for ileus REASON FOR THIS EXAMINATION: ileus ______________________________________________________________________________ FINAL REPORT STUDY: Single view of abdomen, .",1
HISTORY: 42-year-old male with pancreatitis and status post Dobhoff tube removal.,0
FINDINGS: Comparison is made to previous study from .,0
The Dobbhoff tube has been removed.,0
There is a nasogastric tube whose tip is in the pylorus.,0
There is a relative paucity of bowel gas throughout the abdomen.,0
There is an air-filled viscous seen in the mid abdomen which is unclear if this is small or large bowel.,0
Air is also seen within the stomach.,0
IMPRESSION: Nonspecific bowel gas pattern.,0
There is a general paucity of bowel gas throughout the abdomen with a nonspecific air-filled loop in the mid abdomen.,0
Bowel obstruction is not excluded on this study as the small bowel loops may be fluid filled.,0
"7:49 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: CONGESTIVE HEART FAILUE, PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with fever, multifocal PNA REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old male with fever and known multifocal pneumonia.",1
COMPARISONS: dating back to .,0
FINDINGS: Multifocal diffuse airspace opacities have slightly changed with increase involving the left upper lobe likely representing a change in distribution of mild interstitial pulmonary edema with stable known superimposed multifocal pneumonia.,1
A left pleural effusion is increased and now moderate in size and a small right new effusion is newly developed.,0
Stable moderate cardiomegaly and atherosclerotic calcification involving the thoracic aorta.,0
"Technically limited evaluation, though PPM/AICD leads in stable position.",0
"Left lower lobe opacification is unchanged and can represent combination of atelectasis, effusion and superimposed consolidation.",0
"IMPRESSION: Increased now moderate-sized right effusion and small left pleural effusion since one day prior, though with no associated change in extent of mild interstitial pulmonary edema.",0
Stable moderate left lower lobe consolidation.,0
1:25 PM CHEST (PORTABLE AP) Clip # Reason: PTX Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH AVR ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p CABg REASON FOR THIS EXAMINATION: PTX ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Status post CABG.,1
CHEST: The endotracheal tube and left chest tube have been removed and the tip of the Swan-Ganz catheter withdrawn to the right ventricle.,0
"Right effusion is seen and some opacities in the left base are present, probably representing atelectasis.",0
Tip of Swan-Ganz catheter lies in right ventricle.,0
LINE PLACEMENT Clip # Reason: pls assess tip of LUE 44cm PICC; call w/ wet read Admitting Diagnosis: HEPATACELLULAR CARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with new left picc REASON FOR THIS EXAMINATION: pls assess tip of LUE 44cm PICC; call w/ wet read thanks ______________________________________________________________________________ FINAL REPORT INDICATION: New left PICC.,0
FINDINGS: The distal tip of left PICC rolls back on itself for 1.9 cm suggesting it might terminate in another vessel such as azygos vein.,0
The cardiomediastinal silhouette and hilar contours are normal.,0
"Lungs are clear with no focal consolidation, pleural effusion, or pneumothorax.",0
There has been interval removal of NG tube.,0
The drainage catheter of the right upper quadrant is unchanged.,0
Findings were discussed with Callory by at the time of dictation.,0
"12:30 AM MR HEAD W/ CONTRAST Clip # Reason: patient with Lt. frontal lesion, please do VueScope Wand stu Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with new L frontal mass, please do VueScope Wand study tonight as patient is scheduled for surgery On Tuesday (tomorrow) morning.",0
"REASON FOR THIS EXAMINATION: patient with Lt. frontal lesion, please do VueScope Wand study tonight as patient is scheduled for surgery tomorrow morning ______________________________________________________________________________ FINAL REPORT INDICATIONS: Preop surgery for left frontal mass.",0
Contiguous axial images following the administration of 10 ml of Magnivist according to the protocol.,0
Exam was compared to prior study of in particular to the sequence from that examination.,0
Again is noted a large heterogenous enhancing mass involving the left frontal lobe and extending to the corpus callosum into the right frontal lobe with surrounding vasogenic edema.,0
The distal small lesion in the anterior parafalcine region of the left frontal lobe is also identified and is unchanged from the prior study.,0
The degree of mass effect is similar to the prior study.,0
The ventricular size remains unchanged.,0
Distal lesions are not identified.,0
IMPRESSION: Stable appearance of two enhancing masses involving the frontal lobes as described.,0
7:35 PM CHEST (PRE-OP PA & LAT) Clip # Reason: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with suspected pancreatic necrosis REASON FOR THIS EXAMINATION: Preop for pancreatic debridement ______________________________________________________________________________ FINAL REPORT HISTORY: Preop pancreatic necrosis.,0
Subclavian CV line is in distal SVC.,0
"Allowing for this, heart size is normal.",0
There are small bilateral pleural effusions and atelectasis/consolidation in the left lower lobe.,1
No previous films for comparison.,0
There is moderate distension of the stomach with fluid and air.,0
"IMPRESSION: Atelectasis/consolidation left lower lobe with small bilateral pleural effusions, left greater than right.",1
"LINE PLACEMENT Clip # Reason: 47 cm sl Picc placed in left brachial vein, need Picc tip pl Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with new picc REASON FOR THIS EXAMINATION: 47 cm sl Picc placed in left brachial vein, need Picc tip placement ______________________________________________________________________________ WET READ: ARHb WED 5:50 PM L PICC terminates in upper SVC.",1
Right upper lung consolidation not significantly changed.,0
Left CP angle not completely viewed but perhaps mild improvement in left effusion with persistent associated atelectasis.,0
Discussed PICC w/ IV nurse () ______________________________________________________________________________ FINAL REPORT HISTORY: PICC placement.,0
"Single portable radiograph of the chest demonstrates a left-sided PICC, new when compared to .",0
The PICC tip is in the SVC.,0
"A right-sided central venous catheter, likely right subclavian vein, remains unchanged with its tip in the right atrium.",0
"The left costophrenic angle is excluded, but a moderate left-sided pleural effusion persists.",1
There is left basilar atelectasis.,0
The right lung is similar in appearance to that seen on the previous study.,0
", MED 9:17 AM PICC LINE PLACMENT SCH Clip # Reason: unsuccessful bedside attempt left side Admitting Diagnosis: ETOH WITHDRAWAL ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with need for double picc REASON FOR THIS EXAMINATION: unsuccessful bedside attempt left side ______________________________________________________________________________ PFI REPORT PFI: Successful placement of a 5-French dual-lumen PICC via the left brachial vein.",0
The tip is positioned in the SVC.,0
12:56 AM BABYGRAM (CHEST ONLY) Clip # Reason: eval lung Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with acute decompensation REASON FOR THIS EXAMINATION: eval lung ______________________________________________________________________________ FINAL REPORT CHEST: The study is compared with the examination of .,0
Endotracheal tube is 1 cm above the carina.,0
An umbilical venous catheter now terminates near the junction of the SVC and right atrium.,0
Increasing opacity is noted on the left consistent with atelectasis.,0
Diffuse changes of RDS are again seen.,0
"2:21 PM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with ARDS, pneumonia, weakness REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: ARDS.",1
"Single portable radiograph of the chest again demonstrates patchy, bilateral, airspace opacities.",0
Findings are similar to that seen on .,0
There is a small left-sided effusion.,0
There may be a small right-sided pleural effusion.,1
Severe degenerative change of the right glenohumeral joint is again noted.,0
No shift of the mediastinal structures.,0
"IMPRESSION: Patchy bilateral airspace opacities, unchanged.",0
Diagnostic considerations again include pneumonia.,0
"Severe degenerative change of the right glenohumeral joint, similar in appearance.",0
"10:43 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ?retroperitoneal bleed Admitting Diagnosis: S T ELEVATION MYOCARDIAL INFARCTION\LEFT HEART CATHETERIZATION ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p ORIF with anterior wall MI, now with falling Hct.",1
"CT pelvis without contrast REASON FOR THIS EXAMINATION: ?retroperitoneal bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Total left hip arthroplasty at outside hospital, now with falling hematocrit.",0
TECHNIQUE: MDCT images were obtained from the lung bases to the proximal femur without intravenous contrast.,0
Coronal and sagittal reformats were obtained.,0
FINDINGS: There is mild dependent atelectasis.,0
The lung bases are otherwise clear.,0
Coronary atherosclerotic calcifications are noted.,0
"The cardiac are low-attenuation, consistent with anemia.",1
No focal liver lesions are identified.,0
"A significant amount of dependent hyperdense material is noted in the gallbladder, likely representing vicarious excretion of contrast material.",0
"The pancreas, spleen, and adrenal glands are unremarkable.",0
There is no nephrolithiasis seen on this non-contrast CT.,0
The stomach and small bowel are unremarkable.,0
There is no retroperitoneal hematoma.,0
"There is no portacaval, mesenteric, or retroperitoneal lymphadenopathy.",0
There is no free air or free fluid.,0
CT OF THE PELVIS: Evaluation of the total left hip arthroplasty is limited due to beam hardening artifact.,0
"However, there is expected soft tissue edema as well as subcutaneous air that tracks along the iliacus.",0
The appendix is normal (103b:31).,0
"The colon, rectum, and prostate are unremarkable.",0
"A Foley catheter is in the bladder, which is collapsed.",0
Bilateral inguinal hernias are noted.,0
There is no pelvic lymphadenopathy.,0
There is a small amount of pelvic free fluid in the presacral space.,0
OSSEOUS STRUCTURES: Left total hip arthroplasty is noted.,0
There are no osseous lytic or blastic lesions suspicious for malignancy.,0
"Expected soft tissue edema and subcutaneous air, consistent with post-surgical changes from left total hip arthroplasty.",0
MJMgb (Over) 10:43 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ?retroperitoneal bleed Admitting Diagnosis: S T ELEVATION MYOCARDIAL INFARCTION\LEFT HEART CATHETERIZATION ______________________________________________________________________________ FINAL REPORT (Cont),1
"7:27 AM CHEST (PORTABLE AP) Clip # Reason: Assess for pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with severe ARDS, pulm fibrosis s/p bronch yesterday.",1
Spiking temps despite several courses abx.,0
REASON FOR THIS EXAMINATION: Assess for pneumonia ______________________________________________________________________________ FINAL REPORT CHEST SINGLE FILM: HISTORY: Respiratory failure with bronchoscopy and fever unresponsive to antibiotics.,0
Tracheostomy tube is ____ cm above carina.,0
PICC line is in mid SVC.,0
Chest tube is present in left lower hemithorax.,0
There is diffuse bilateral interstitial disease as previously demonstrated.,0
No change in heart size or mediastinal width.,0
IMPRESSION: No change since prior film.,0
"Specifically no evidence for new pulmonary edema, pneumonia or pneumothorax.",1
6:06 AM CHEST (PORTABLE AP) Clip # Reason: pleural effusions Admitting Diagnosis: OVARIAN CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman s/p BSO for primary ovarian vs peritoneal mass.,0
"REASON FOR THIS EXAMINATION: pleural effusions ______________________________________________________________________________ FINAL REPORT INDICATION: Status post bilateral salpingo-oophorectomy for primary ovarian versus peritoneal mass, pleural effusions.",0
"BEDSIDE SUPINE RADIOGRAPH OF THE CHEST: Bilateral pleural effusions, moderate-sized are unchanged.",0
"There is a bibasilar consolidation, left more than right, also unchanged.",0
A new rounded opacity is seen in the left mid lung.,0
"Given rapid development, this could be a focus of rounded atelectasis, however infection/aspiration is not excluded.",0
The morphology is very atypical for the latter.,0
ET tube is 5.1 cm above the carina.,0
NG tube is in standard location.,0
A left IJ catheter is terminating in the mid to distal SVC with a slight kink above the clavicle.,0
"Bulging contour of the right superior cardiac border, at the cavoatrial junction could be vascular and explained by rotational asymmetry.",1
Moderate sized bilateral pleural effusions and bibasilar atelectasis.,0
"A new rounded left mid lung opacity, given rapid development could represent rounded atelectasis.",0
Kink in the left IJ just above the clavicle.,0
11:51 AM CHEST (PORTABLE AP) Clip # Reason: interval change of effusion Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman s/p fluid resuscitation REASON FOR THIS EXAMINATION: interval change of effusion ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP single view.,0
"INDICATION: 61-year-old female patient status post fluid resuscitation, interval change of effusion.",0
"FINDINGS: AP single view of the chest obtained with patient in semi-upright position, is analyzed in direct comparison with the next preceding similar study dated .",0
Previously existing marked pulmonary congestive pattern almost reaching edema has markedly improved.,0
"Presently, there are no signs of new acute parenchymal infiltrates and the lateral pleural sinuses remain free.",0
"There is moderate degree of right-sided diaphragm elevation, cause unknown.",0
"IMPRESSION: Improvement of congestive pattern, new pulmonary abnormalities.",0
"2:22 PM CYSTOGRAM (, ) Clip # Reason: Please evaluate for vesiculoureteral reflux as patient may r Admitting Diagnosis: PNEUMONIA;DEEP VEIN THROMBOSIS;ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with bladder cancer, had cystoscopy 1 week ago.",1
REASON FOR THIS EXAMINATION: Please evaluate for vesiculoureteral reflux as patient may require cystoscopy with infusion of formalin to stop hematuria.,0
______________________________________________________________________________ WET READ: MDAg 4:54 PM no evidence of vesiculouretral reflux.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Bladder cancer status post cystoscopy, evaluate for vesicoureteral reflux.",0
CYSTOGRAM: The patient had a Foley catheter in place.,0
Approximately 150cc of contrast was instilled via gravity before the patient felt the need to urinate.,0
No reflux was demonstrated with a full bladder.,0
The patient began to void with the Foley catheter in place and again no reflux was demonstrated.,0
A tiny bladder diverticulum is seen.,0
IMPRESSION: No evidence of vesicoureteral reflux.,0
"3:42 PM CTA CHEST W&W/O C &RECONS Clip # Reason: ?PE Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA Contrast: OPTIRAY Amt: 95 ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man POD from AAA repair & ex-lap n/w acute hypoxia and change in ability to ventilate REASON FOR THIS EXAMINATION: ?PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CTA OF THE CHEST INDICATION: 76-year-old man, postop day from AAA repair and exploratory laparotomy, now with acute hypoxia and difficulty ventilating.",1
TECHNIQUE: Continuous MDCT acquired axial images were obtained from the thoracic inlet to the upper abdomen before and after the administration of 130 cc Optiray intravenous contrast via bolus CT-PA technique.,0
Multiplanar reformatted images were obtained and reviewed.,0
"CTA CHEST: There are bilateral pleural effusions, greater on the right than on the left.",0
"There is adjacent compressive atelectasis bilaterally, also more prominent at the right base.",0
"There is a diffuse, mild hazy ground glass opacity throughout the lung parenchyma, but no focal airspace opacities are appreciated.",0
The central airways are patent bilaterally.,0
No evidence of mucus plug or other obstructive lesion is seen.,0
"An endotracheal tube is seen, with its tip approximately 6.5 cm above the carina.",0
There is no evidence of pulmonary embolism.,0
"A nasogastric tube is seen, coursing below the diaphragm.",0
A left subclavian central venous catheter is seen with its tip in the superior vena cava.,0
"A second, larger catheter, presumably the PA line is seen coursing from the right internal jugular, and also terminating with its tip at the junction of the superior vena cava and right atrium.",0
"In the posterior left upper lobe, there is a pleurally based soft tissue density measuring 1.8 x 0.8 cm, which may represent a focal area of pleural thickening, but a focal infectious process cannot be entirely excluded, and attention should be paid to this area on followup examination.",0
"There is extensive atherosclerotic disease of the thoracic aorta, with extensive calcification, but no evidence of dilatation or aneurysm.",1
Limited views of the upper abdomen demonstrate an incompletely evaluated low- attenuation lesion within the left lobe of the liver measuring roughly 5 x 4.5 cm.,0
"It is unclear whether this represents an area of heterogeneous perfusion or a focal low attenuation mass lesion, or postoperative change.",0
Further evaluation is recommended when the patient's condition stabilizes.,0
(Over) 3:42 PM CTA CHEST W&W/O C &RECONS Clip # Reason: ?PE Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA Contrast: OPTIRAY Amt: 95 ______________________________________________________________________________ FINAL REPORT (Cont) Osseous structures are unremarkable.,1
Surgical clips are seen in the anterior abdominal wall.,0
"Bilateral pleural effusions with compressive atelectasis, greater on the right than on the left.",0
Bilateral increased mild ground glass haziness with mild cardiomegaly may be indicative of congestive failure.,0
Low attenuation area within the liver is incompletely evaluated on the CT of the chest.,0
"1.8 cm left upper lobe pleurally based nodular soft tissue density most likely represents pleural reaction, but attention on followup is recommended.",0
"6:53 AM NEONATAL HEAD PORTABLE Clip # Reason: EVALUATE BRAIN AND VENTRICLES Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: INFANT BORN AT 27 WEEKS GESTATION, NORMAL SCAN AT 3 DAYS OF LIFE REASON FOR THIS EXAMINATION: EVALUATE BRAIN AND VENTRICLES ______________________________________________________________________________ FINAL REPORT A NEONATAL PORTABLE HEAD ULTRASOUND.",1
"COMPARISON: , a normal study.",0
FINDINGS: Examination of the cranium through the anterior fontanelle and the right mastoid foramen demonstrated no structural abnormality and no evidence of intracranial hemorrhage.,0
"When compared to the prior study, there has been no significant interval change.",0
"IMPRESSION: Stable, normal head ultrasound.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Shellfish Attending: Chief Complaint: Fall Major Surgical or Invasive Procedure: : Exploratory laparotomy with duodenal patch, Hepatorrhaphy, Placement of jejunal feeding tube, Temporary abdominal closure.",0
": Abdominal washout, temporary closure.",0
": Exploratory laparotomy, washout, and closure of abdomen with internal drainage.",0
"History of Present Illness: Ms. is an 85F with chronic CLL, bladder cancer s/p TURB, and retroperitoneal non-hodgkins lymphoma who presents with abdominal pain s/p fall this afternoon.",1
"Patient was recently admitted in early may with hyponatremia and dehydration related to poor po intake, diuretic use, and possible RLL pneumonia.",0
"At that time, CT showed interval increase in her RP mass and she was started on rituximab.",0
Recent CT from showed a decrease in the size of her mass and increased pleural effusions.,0
"Since her CT, she has been at her baseline with continued poor po intake.",0
"Today, she attempted to rise from a chair and fell over, striking her abdomen on the coffee table.",0
She did not hit her head and denies LOC.,0
She complained of severe abdominal pain therafter with 2 episodes of emesis.,0
"Since arrival in the ED, she has had increasing tachypnea and hypoxia.",0
A non-rebreather mask and foley were placed.,0
"Her pain has worsened and she reports feeling confused and overwhelmed Past Medical History: -Transitional cell bladder CA s/p TURB (), anticipating radiation -Non-hogkins retroperitoneal lymphoma on rituximab -Chronic CLL -Depression -Anxiety -Hypothyroidism -Dyspepsia -Herpes zoster -Right bundle-branch block.",1
"-HTN -Hyperlipidemia Past Surgical History: -Lobular breast CA s/p resection -Mechanical fall requiring R arm hardware -Two spinal surgeries for scoliosis, s/p hysterectomy for fibroid Social History: The patient is a widow from her first husband back in the and married to her second husband for about 24 years.",1
Denies any illicit drug use.,0
"Family History: Denies any known family history of any blood disorders or cancer that she is aware of Physical Exam: On admission: Vital Signs: 97.8 90 154/69 16 98% 2L Nasal Cannula General Appearance: Cahectic, appears uncomfortable with labored breathing Cardiovascular: RRR Respiratory: Diminished breath sounds bilaterally, L>R, crackles at b/l bases, wheezes intermittently, using accessory muscles for breathing Abdomen: Soft, markedly distended, severely tender to palpation and percussion throughout with rebound tenderness and guarding/ Extremities: Warm, thin, no edema On discharge: Vital Signs: T 98.0 BP 130/78 P 68 R 20 O2sat 97% RA GEN: A&O, NAD CV: RRR PULM: Crackles to bilateral lung bases on auscultation, no use of accessory muscles.",1
"GI: Soft, appropriately tender at incision site, minimally distended.",0
"Abdominal midline surgical incision well-approximated with staples intact, no drainage, minimal errythema.",0
RLQ old drain sites with small amount serosang drainage.,0
EXTR: 2+ edema to all 4 extremties.,0
Pertinent Results: 02:00PM BLOOD WBC-12.3* RBC-3.87* Hgb-11.9* Hct-38.3 MCV-99* MCH-30.7 MCHC-31.0 RDW-18.8* Plt Ct-668* 02:00PM BLOOD Glucose-146* UreaN-36* Creat-1.0 Na-138 K-4.0 Cl-100 HCO3-29 AnGap-13 CT abdomen/pelvis: 1.,0
New pneumoperitoneum and complex free fluid.,0
"In the absence of recent intervention, findings are highly concerning for a bowel perforation, and given the distribution and mechanism of injury, a duodenal perforation is suspected.",0
New heterogeneous hepatic hypodensities within segment IVb of the liver concerning for hepatic lacerations and hematoma.,1
Ill-defined pancreatic head hypodensity is concerning for additional injury.,0
Cholelithiasis with gallbladder wall edema likely secondary to the intra-abdominal fluid.,1
Flattened IVC suggest a degree of volume depletion.,0
Unchanged appearance of extensive retroperitoneal mass compatible with lymphoma.,0
Bladder mass at the right UVJ is not well delineated on the current exam.,1
"Labs at discharge: 06:17AM BLOOD WBC-11.7* RBC-4.21 Hgb-12.7 Hct-40.9 MCV-97 MCH-30.1 MCHC-31.0 RDW-17.3* Plt Ct-391 06:17AM BLOOD Glucose-149* UreaN-30* Creat-0.6 Na-144 K-4.1 Cl-104 HCO3-28 AnGap-16 06:17AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 Brief Hospital Course: After long discussions with the patient, her husband, her son, her PCP, her oncologist, the consensus was to proceed with surgery.",0
Patient was taken emergently to the OR on .,0
"Due to severe bowel distension, her abdomen could not be closed and she was brought to the ICU intubated and sedated.",0
ICU Course: Patient was initially hypotensive and required neosinephrine for pressor support.,0
She was resuscitated with crystalloid and PRBC with improvement.,0
"She was taken back to the OR on for wash out and attempted closure, however her colon was still too distended and came back to ICU intubated and sedated.",0
A rectal tube was placed for decompression with good effect.,0
Tube feeds were started via her Jtube.,0
"She was treated with vanco, cipro, and flagyl for 48 hours postop.",0
"Once improved, she was diuresed with a lasix drip.",0
"On , she returned to the OR for definitive closure which she tolerated well.",0
"On the night of , she developed afib with RVR requiring an amio drip for rate control.",0
She converted to sinus rhythym within 12 hours.,0
Her tube feeds were advanced to goal and her amiodarone converted to po.,0
She was transferred to the floor on .,0
Floor course: On the floor her vital signs were routinely monitored and remained stable.,0
She was monitored on telemetry and remained in NSR with occasional PVC's on the PO amiodarone.,0
Diuresis was continued with intermittent IV lasix.,0
Her electrolytes were monitored and repleted as needed.,0
Tube feeds were continued at goal via the J tube.,0
She was kept NPO with an NG tube in place until when the NG tube was removed.,0
Speech and swallow was consulted on to evaluate for dysphagia.,0
She had difficulty swallowing but ultimately the decision was made to keep her NPO with tubefeeds for 10 more days after discharge to allow the site of perforation time to heal.,0
Plan was to re-evaluate swallowing at rehab 10 days from discharge and advance diet if appropriate at that time.,0
A foley catheter had been placed on admission and was removed on at which time she was able to void adequate amounts of urine without difficulty.,0
She remained on SC heparin for DVT prophylaxis.,0
Physical therapy was consulted to evaluate the patient's mobility who recommended rehab when patient was medically cleared.,0
The patient's oncologist Dr. was notified of her hospitalization.,0
The oncology service evaluated the patient and agreed with the plan of care.,0
Plan was to hold off on any radiotherapeutic treatment of her bladder cancer until she has recovered and reevaluate after the patient has recovered.,0
On she remains afebrile and hemodynamically stable.,0
She is tolerating tube feeds at goal via J tube and diuresing appropriately with lasix prn.,0
She is being discharged to acute rehab to continue her recovery.,0
"Medications on Admission: Acyclovir 400 mg TID, Amlodipine 5mg daily, Atorvastatin 10 mg daily, Duloxetine 60 mg daily, Levothyroxine 100 mcg daily, Lorazepam prn, Mirtazapine 7.5 mg qhs, Olmesartan 20mg daily, Sertraline 20mg daily, Spironolocatone-HCTZ 25 mg daily, Aspirin 81mg daily, Calcium 250 mg daily, Vitamine D3 1000 U daily, Colace 100 mg TID, Multivitamin Discharge Medications: 1. mirtazapine 15 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO HS (at bedtime).",0
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).,0
3. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours).,0
"4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day).",0
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).,0
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
8. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
9. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily ().,0
"10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
11. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).,0
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
13. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day).,0
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
15. sertraline 20 mg/mL Concentrate Sig: Five (5) mL PO DAILY (Daily).,0
Discharge Disposition: Extended Care Facility: Newbridge on the - Discharge Diagnosis: s/p fall 1.,0
3. sepsis Discharge Condition: Mental Status: Clear and coherent.,0
Activity Status: Ambulatory - requires assistance or aid (walker or cane).,0
Discharge Instructions: You were admitted to the hospital after a fall and a perforation in a portion of your gastrointestinal tract called your duodenum.,0
Your required an operation to fix the area of perforation and a feeding tube was placed into the portion of your small bowel below the area of perforation called the jejunum.,0
You are now receiving tubefeeds through the tube.,0
You should not eat or drink anything by mouth until your swallowing has been re-evaluated at the rehab facility 10-14 days from now.,0
Please follow up in the Acute Care Surgery clinic at the appointment scheduled for you below.,0
"Because of the surgery, plans for any radiotherapeutic treatment of your bladder cancer have been put on hold for now.",0
Please follow up with Dr. after you have left rehab to discuss future treatment.,0
Followup Instructions: Department: GENERAL SURGERY/ With Dr.,0
When: TUESDAY at 1:30 PM With: ACUTE CARE CLINIC Building: LM Bldg () Campus: WEST Best Parking: Garage Completed by:,0
"LINE PLACEMENT Clip # Reason: s/p CVL placement Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with bilateral arm fractures REASON FOR THIS EXAMINATION: s/p CVL placement ______________________________________________________________________________ WET READ: MNIa WED 6:18 PM rt ij line with tip in rt atrium, no ptx.",1
increased atelectasis in the left lower lobe.,0
ETT tipe just below thoracic inlet.,0
Dr. was informed at 6:20 PM.,0
______________________________________________________________________________ FINAL REPORT SINGLE VIEW OF THE CHEST DATED .,0
HISTORY: A 54-year-old man with bilateral arm fractures; status post CVL placement.,1
"FINDINGS: Single bedside AP examination labeled ""semierect at 5:40 p.m."" is compared with the study exposed on the trauma board, obtained the previous day.",0
The tip of the new ET tube lies 6.5 cm proximal to the carina and the right IJ central venous catheter terminates in the low right atrium.,0
There is no evidence of pneumothorax in this position.,0
The lung volumes remain low with basilar patchy subsegmental atelectasis and small left pleural effusion; a retrocardiac consolidation cannot be excluded.,0
No fracture of the thoracic cage is identified.,0
"COMMENT: Findings, including the low-lying right IJ central venous catheter, were discussed with Dr. by Dr. (6:20 p.m., ).",0
Height: (in) 67 Weight (lb): 176 BSA (m2): 1.92 m2 BP (mm Hg): 110/71 Status: Inpatient Date/Time: at 13:36 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT ATRIUM: The left atrium is elongated.,0
LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with normal cavity size.,0
The aortic arch is normal in diameter.,0
No 2D echo or Doppler evidence of coarctation of the distal aortic arch.,0
MITRAL VALVE: The mitral valve leaflets are structurally normal.,0
GENERAL COMMENTS: The patient is bradycardic (HR<60bpm).,0
The echocardiographic results were reviewed by telephone with the houseofficer caring for the patient.,0
Conclusions: The left atrium is elongated.,0
There is symmetric left ventricular hypertrophy with normal cavity size.,0
The mitral valve leaflets are structurally normal.,0
"Compared with the prior study of , the LV systolic function is not as vigorous (may be related to the lower heart rate).",0
A dilated ascending aorta is now identified.,0
7:39 PM CT STEREOTAXIS W/ CONTRAST Clip # Reason: pre-op head CT with frame for stereotactic brain biopsy.,0
pre Admitting Diagnosis: ALTERED MENTAL STATUS;TELEMETRY Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with R frontal mass s/p status epilepticus REASON FOR THIS EXAMINATION: pre-op head CT with frame for stereotactic brain biopsy.,1
pre-op will call 30 mins before procedure No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old man with right frontal mass.,0
"Comparison is made to the prior study done on , and MR of the head done on .",0
TECHNIQUE: Contrast-enhanced head CT performed for stereotaxis localization.,0
FINDINGS:The hypodense right frontal mass measures 33 x 45 mm which appears relatively unchanged compared to the recent MR.,0
There is no discernible enhancement.,0
No other focal brain lesion was identified.,0
"No shift of normally midline structures, hydrocephalus or major or minor vascular territorial infarct is detected.",0
No intracranial hemorrhage is identified.,0
The bone windows does not demonstrate any fracture.,0
"There is prominent bilateral mastoid sinus opacification, as well as fluid in the sphenoid sinus, likely inflammatory in origin, or related to intubated status of the patient.",0
Unchanged appearance of the right frontal hypodense lesion which most likely represents a primary brain neoplasm based on the recent MRI.,1
See above report for additional findings.,0
8:06 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate/edema Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with increasing secretions REASON FOR THIS EXAMINATION: Evaluate for infiltrate/edema ______________________________________________________________________________ FINAL REPORT INDICATION: Increasing secretions.,1
COMPARISON: and CT torso of .,0
"SEMI-UPRIGHT AP CHEST: Since the prior study, the nasogastric tube has been advanced into the stomach.",0
The endotracheal tube is in unchanged position.,0
Cardiac and mediastinal contours are stable.,0
"The lungs are clear, with unchanged mild elevation of the left hemidiaphragm.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Confirmed with microbiology laboratory that Group B strep from blood culture is sensitive to levofloxacin.",0
Discharge Disposition: Home MD Completed by:,0
11:15 AM CHEST (PA & LAT) Clip # Reason: r/o chf Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with s/p cabg REASON FOR THIS EXAMINATION: r/o chf ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG.,1
PA AND LATERAL CHEST: Compared to .,0
Multiple lines and tubes have been removed.,0
There is no evidence of congestive heart failure.,0
IMPRESSION: Stable cardiomegaly with small bilateral effusions; no evidence of congestive heart failure.,0
4:06 PM CT HEAD W/O CONTRAST Clip # Reason: Evaluate for progression of the ICH.,0
Please do the CT scan Admitting Diagnosis: AMC;FEVER ______________________________________________________________________________ MEDICAL CONDITION: 68 year old female with refractory AML and history of B-cell lymphoma admitted with fever now with ICH in the setting of severe thrombocytopenia.,1
REASON FOR THIS EXAMINATION: Evaluate for progression of the ICH.,0
Please do the CT scan at 1600 (per neurosurg recs for continuing monitoring).,0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): KCLd WED 6:30 PM No significant change compared to prior studies.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Follow up intracranial hemorrhage.,0
COMPARISON: Comparison is made to two prior studies performed earlier the same day at 8:00 a.m. and 4:00 p.m.,0
TECHNIQUE: Non-contrast head CT scan.,0
FINDINGS: No significant change seen compared to prior studies.,0
"Again seen is hemorrhage within the left thalamus, lentiform nucleus, extending to the caudate head.",0
No increase in intraventricular component of hemorrhage is identified.,0
"Mass effect is similar, with dilation of the temporal of the left lateral ventricle, also unchanged from prior studies.",0
Visualized paranasal sinuses are normally aerated.,0
IMPRESSION: No significant change seen compared to two recent prior studies.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Influenza Virus Vaccine Attending: Chief Complaint: sternal wound dehiscence Major Surgical or Invasive Procedure: sternal debridement sternal debridement/omental flap History of Present Illness: 65 yo F with severe MR s/p Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending artery, Saphenous vein graft to posterior descending artery), Mitral valve repair.",1
Readmitted w/ falls at home and head CT revealed new frontal lobe meningioma.,0
"Past Medical History: - Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending artery, Saphenous vein graft to posterior descending artery), Mitral valve repair -Severe Mitral regurgitation -Coronary artery disease s/p prior RCA stenting c/b ISR x 2, most recently with Cypher stenting in for NSTEMI -Hypertension -Dyslipidemia -': post cath large retroperitoneal hematoma extending from the right groin superiorly to the level of the lower pole of the right kidney-->required 7 units PRBCs -Non sustained polymorphic VT s/p ICD -Depression -History of panic attacks/anxiety, prior psychiatric admission within the past several years -Gastroesophageal reflux disease -Osteopenia -History of pulmonary nodules, followed by serial imaging -Glucose intolerance -History of H. pylori Social History: Retired, worked as hairdresser.",1
Husband died in from MI.,0
Lives at home with 18 yo son.,0
"Pt smoked cigarettes x many years, reports on-off history most recently in setting of CABG quit.",0
"Family History: Father died at age 50 of an MI and ""enlarged heart.""",0
Mother had depression and panic attacks Physical Exam: Pulse: Resp: O2 sat: B/P Right: Left: Height: Weight: General: Skin: Dry [] intact []- moist yeast under both breasts.,0
"open draining sternal wound HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: +2 Left:+2 PT : +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: 06:10AM BLOOD WBC-15.0* RBC-3.50* Hgb-10.3* Hct-31.1* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.7 Plt Ct-215 05:09AM BLOOD Glucose-172* UreaN-32* Creat-0.8 Na-137 K-4.3 Cl-99 HCO3-27 AnGap-15 04:00AM BLOOD ALT-47* AST-26 LD(LDH)-563* AlkPhos-75 Amylase-155* TotBili-0.4 Brief Hospital Course: Ms. was admitted on to cardiac surgery.",1
"Infectious disease was consulted and she was started on Vancomycin, ciprofloxacin, and diflucan.",0
On she underwent a sternal debridement in the operating room.,0
No gross pus was detected intra-operatively.,0
She then returned to the operating room on for a second sternal debridement and closure with an omental flap.,0
She tolerated both procedures well and was transferred to the surgical intensive care unit post-operatively on both occasions.,0
She was extubated and weaned from drips.,0
Her diet was advanced as tolerated.,0
Cornebacterium grew from her operative cultures.,0
Neurosurgery was consulted regarding weaning her steroids.,0
Her JP drains were continued per the plastics surgery service.,0
A PICC was placed for her antibiotics.,0
"By post-operative day 11 and 8 she was ready for discharge to rehab with continued JP drain care, IV Vancomcin, and neurosurgery follow-up.",0
Medications on Admission: Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 3.,0
Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily).,0
Disp:*30 Patch 24 hr(s)* Refills:*0* 4.,0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.,0
Citalopram 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO Q8H (every 8 hours) as needed for anxiety.,0
Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)).,0
Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)).,0
Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours).,0
Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.,0
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day).",0
"Disp:*90 Tablet, Chewable(s)* Refills:*0* 18.",0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain.,0
Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1.,0
"Outpatient Lab Work Weekly CBC with differential, BUN/Creatinine, LFTs, Vanco trough with results sent to the Infectious disease nurses or to on MD is closed at (.",0
Vancomycin 500 mg Recon Soln Sig: Seven y (750) mg Intravenous Q 12H (Every 12 Hours): until .,0
JP drain care Please record and dispose of daily JP output.,0
Bring these records to your plastic surgery appointment 6.,0
Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day).,0
Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days: evaluate for need for further lasix at end of course.,0
Particle/Crystal PO once a day for 10 days.,0
Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Hydrocortisone 20 mg Tablet Sig: 2.5 Tablets PO Q12H (every 12 hours): wean by halving the dose every other day.,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day).",0
White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for eye care.,0
Disp:*qs Patch 24 hr(s)* Refills:*2* 15.,0
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Drops Ophthalmic PRN (as needed) as needed for eye care.,0
Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical (2 times a day): apply under breasts for yeast infection.,0
"Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: - - Discharge Diagnosis: sternal wound infection Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Provider: , MD Phone: Date/Time: 9:00 Dr. (plastic surgery) in weeks (.",1
please call for an appointment Please record and dispose of daily JP drain output.,0
Bring these records to your plastic surgery appointment.,0
Dr. (neurosurgery) ( in 4 weeks.,0
Please call for an appointment.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service:NEONATOLOGY PRIMARY DIAGNOSIS: Prematurity.,1
"SECONDARY DIAGNOSIS: Respiratory distress, resolved.",0
"Twin Number 1 is a 1370 gram female born at 30 1/7 weeks by cesarean section due to preterm labor and transfer maternal infection to a 33 year-old gravida I, para now II mother.",1
Pregnancy complicated by presentation to on in preterm labor and possible urinary tract infection.,0
"Transferred to the and was treated with ampicillin, magnesium and betamethasone.",0
She remained inpatient on and off magnesium for preterm labor.,0
The day before delivery developed shaking chills and fever.,0
Culture grew gram negative rods.,0
Urine appears infected as well.,0
With concerns for pyelonephritis versus chorioamnionitis.,0
Mom was treated with ceftriaxone.,0
Given concern of possible chorioamnionitis and preterm labor was delivered via cesarean section.,1
"In the delivery room the infant emerged with good cry, given blow by oxygen and Apgars were 8 and 8.",0
"Prenatal screens were B positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, normal fetal survey.",0
"Initial examination on admission to Neonatal Intensive Care Unit was notable for inspiratory cracking, grunting, flaring and retracting.",0
HOSPITAL COURSE BY SYSTEMS: Respiratory.,1
Patient was intubated given the respiratory distress and was given one dose of Surfactant on day of life one.,0
She was extubated by day of life 2 to CPAP.,0
She remained on CPAP 21 percent FIO2 until day of life 15.,0
She has been on room air for 24 hours at time of dictation.,0
She was started on caffeine on day of life two.,0
She currently remains on 10 mg p.o.,0
She has between three to six spells per day.,0
Cardiovascular: She received one normal saline bolus on day of life one for poor perfusion.,0
She has always had stable blood pressures and otherwise remained hemodynamically stable.,0
She has not had any murmurs.,0
"Fluid, electrolytes and nutrition: She was started on 80 cc per kilo per day of 10 percent dextrose fluid.",0
Her total fluids were increased to a total of 160 per kilo per day by day of life eight.,0
Fluids were reduced on day of life 14 to 130 cc per kilo per day for concerns of reflux and feeding intolerance.,0
She was started on Premature Enfamil 20 calorie per ounce formula on day of life three and had volumes increased to full volume by day of life nine.,0
Calories have been supplemented to a total of 28 calories per ounce with ProMod.,0
She received all of that via nasogastric tube.,0
Dextrostix have always remained stable.,0
Electrolytes have always remained stable.,0
Heme: Phototherapy was initiated on day of life two for a bilirubin of 6.1.,0
She had a peak bilirubin on day of life four at 7.4.,0
She had a rebound bilirubin level of day of life eight at 3.9 and a direct component of 0.2.,0
Hematocrit on day of life one was 47 and on day of life two it was 52.,0
Platelets were 264 and 261 respectively.,0
Infectious disease: was started on Ampicillin and Gentamicin.,0
She had initial white count of 9.6 with 18 percent polys and 2 percent bands.,0
"Repeat white count due to concerns of neutropenia was 9.9, with 61 percent polys and no bands.",0
She was continued on antibiotics for seven days given concern for respiratory distress.,0
Neurologic: Head ultrasound on day of life 9 was negative.,0
She has not yet had an eye examination and is due to two weeks.,0
Routine Health Care Management: has not yet received hepatitis B vaccine.,0
MEDICATIONS ON DISCHARGE: Potassium citrate 10 mg p.o.,0
"daily, ferrous sulfate .1 cc daily, vitamin E 5 units daily.",0
EXAMINATION ON DISCHARGE: Discharge weight on day of life 16 is 1360 grams.,0
"Anterior fontanelle is soft, open and flat.",0
"Equal air entry bilaterally with no grunting, flaring and retracting with breath sounds.",0
"Regular rhythm with normal rate, no murmur appreciated.",0
Abdomen soft with no distention.,0
"Normal active bowel sounds, 2+ femoral pulses, normal female genitalia, patent anus.",0
"Warm and pink, normal tone.",0
Dictated By: MEDQUIST36 D: 14:30 T: 14:53 JOB#:,0
3:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change Admitting Diagnosis: TYPE B DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with recent aortic dissection and intubated in setting of mental status changes REASON FOR THIS EXAMINATION: evaluate for interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 10:27 AM PFI: Status post extubation.,0
"No significant interval change in mild pulmonary edema, moderate left effusion and small right effusion.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old with recent aortic dissection.,0
SINGLE AP SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPH: The ET tube has been removed.,0
Otherwise no significant interval change in moderate left and small right pleural effusions.,0
NG tube terminates in the stomach.,0
The heart remains mildly enlarged and the aorta is tortuous.,0
No change in mild pulmonary edema.,0
"IMPRESSION: Unchanged mild pulmonary edema, moderate left and smaller right pleural effusions.",1
10:53 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate/edema ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with wheezing and altered mental status REASON FOR THIS EXAMINATION: Evaluate for infiltrate/edema ______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old male with wheezing and altered mental status with concern for pneumonia or edema.,1
"COMPARISON: , , , and .",0
AP PORTABLE CHEST: A right-sided PICC terminates in the SVC.,0
Heart size and mediastinal contours are stable.,0
There are relatively low inspiratory lung volumes.,0
Redemonstrated is the non-calcified pleural plaque of the left base.,0
Small pulmonary nodules seen on chest CT are not well appreciated on this single frontal view.,0
There is no pleural effusion or pneumothorax.,0
There is no overt congestive failure.,0
Redemonstration of calcified pleural plaque at the left lung base.,0
No overt congestive failure or focal consolidation identified.,0
"9:05 PM CT HEAD W/O CONTRAST Clip # Reason: LT SIDED WEAKNESS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with new onset L sided weakness REASON FOR THIS EXAMINATION: eval ich, mass effect No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EMERGENCY HEAD CT SCAN HISTORY: Sudden onset of left-sided weakness.",0
Evaluate for intracranial hemorrhage or mass effect.,0
FINDINGS: There is a 2 mm chronic lacunar infarct within the right lentiform nucleus.,0
"There is no evidence for intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus.",0
There is partial demonstration of what is likely a small left maxillary antral mucus-retention cyst.,0
CONCLUSION: No evidence for acute intracranial hemorrhage.,0
Right lentiform nucleus chronic lacunar infarct.,0
CT ANGIOGRAPHY OF THE NECK AND HEAD: TECHNIQUE: Bolus intravenously enhanced imaging.,0
Only non-processed sagittal and coronal reconstructions of this data are available at this time as well as the source images for review.,0
FINDINGS: There is no definite contour abnormality involving the cervical carotid system on either side.,0
No hemodynamically significant stenosis or ulceration is seen in this locale.,0
There is demonstration of a nearly 4 x 6 cm right thyroid lobe mass with speckled calcifications.,0
"When the patient's condition permits, further evaluation of this lesion by son is recommended to more precisely characterize the abnormality.",0
The left vertebral artery appears hypoplastic throughout its course.,0
"Intracranially, no definite sign of a hemodynamically significant stenosis or vascular occlusion is detected, again allowing for the limited analysis available at the time of this emergency study.",0
Also noted on the sagittal reconstructions is moderate degenerative change of the atlanto-dental interval superiorly.,0
"CONCLUSION: No definitive demonstration for vascular pathology accounting for the patient's marked, acute neurologic deficit.",0
"In that regard, following emergent discussion with the attending physician, .",0
", it was decided that a followup MR study is warranted.",0
(Over) 9:05 PM CT HEAD W/O CONTRAST Clip # Reason: LT SIDED WEAKNESS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont),0
4:42 PM CT HEAD W/O CONTRAST Clip # Reason: eval for ICH ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with right sided weakness REASON FOR THIS EXAMINATION: eval for ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: PBec SAT 5:22 PM no acute process.,0
"PBishop WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Right-sided weakness, please evaluate for intracranial hemorrhage.",0
COMPARISON: No prior studies available for comparison.,0
TECHNIQUE: Non-contrast axial images were obtained through the brain.,0
Coronal and sagittal reformations were provided.,0
"FINDINGS: There is no evidence of hemorrhage, edema, large masses, mass effect, or acute infarct.",1
Encephalomalacia related to prior infarct noted in left frontoparietal lobe.,0
Hypodensity in the left thalamus suggestive of prior ischemic disease.,0
Basal ganglia calcification demonstrated on the left.,0
"Periventricular and subcortical white matter hypodensities are seen, likely due to small vessel ischemic disease.",0
"Ventricles and sulci are prominent, consistent with age-related parenchymal involution.",0
Extensive vascular calcifications noted in bilateral carotid siphons.,1
"The mastoid air cells, middle ear cavities, and paranasal sinuses are clear.",0
No soft tissue swelling evident.,0
Prior infarction in left frontoparietal lobe and evidence of chronic microvascular infarction.,0
"6:26 AM CHEST (PORTABLE AP) Clip # Reason: please eval for acute infectious process ______________________________________________________________________________ MEDICAL CONDITION: History: 31M w/ hx seizures, recent cough and fever REASON FOR THIS EXAMINATION: please eval for acute infectious process No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of seizures and recent cough and fever, evaluate for acute infectious process.",0
COMPARISONS: Reference chest radiograph .,0
"SINGLE AP VIEW OF THE CHEST: There is diffuse ground glass and nodular opacity within the left lung which spares the apex, concerning for pneumonia or aspiration.",0
"Allowing for low lung volumes, the right lung is clear.",0
"Allowing for differences in technique, the heart size is unchanged.",0
IMPRESSION: Left lung nodular and ground-glass opacity concerning for aspiration or pneumonia.,0
4:02 AM CT HEAD W/O CONTRAST Clip # Reason: 39 year old man with known SAH - eval for hydrocephalus.,0
PLE Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with known SAH - eval for hydrocephalus.,1
PLEASE PERFORM SCAN ON REASON FOR THIS EXAMINATION: 39 year old man with known SAH - eval for hydrocephalus.,0
PLEASE PERFORM SCAN ON No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl SAT 6:10 AM Interval decrease in the amount of subarachnoid blood in comparison to one day prior.,0
Similar to slightly-decreased size of the ventricles in comparison to one day prior.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 39-year-old male with subarachnoid hemorrhage.,1
"COMPARISON: CT of the head, .",0
TECHNIQUE: Non-contrast head CT was obtained.,0
FINDINGS: The amount of subarachnoid hemorrhage has decreased in comparison to one day prior.,1
The basal cisterns are now essentially patent.,0
There may be a small amount of residual subarachnoid blood in the suprasellar cistern.,0
The ventricles are similar to slightly decreased in size in comparison to the prior study.,0
-white matter differentiation remains preserved.,0
"No new areas of intracranial hemorrhage are identified, and there is no intraparenchymal hemorrhage.",0
The visualized paranasal sinuses demonstrate mucosal thickening of the sphenoid air cells.,0
Mastoid air cells are normally pneumatized and aerated.,0
IMPRESSION: Interval decrease in the amount of subarachnoid blood in comparison to one day prior.,0
Similar to decreased size of ventricles.,0
8:14 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: ?,0
"ligamentous injury Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED: No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MR CERVICAL SPINE HISTORY: Seizures and traumatic brain injury, question ligamentous injury.",1
"Sagittal imaging was performed with long TR, long TE fast spin echo, short TR, short TE spin echo, and STIR technique.",0
Axial imaging was performed with gradient echo technique.,0
Comparison to a cervical spine CT of .,0
FINDINGS: Alignment of the cervical spine is normal.,0
Vertebral body signal intensity appears normal.,0
The spinal cord appears normal.,0
Axial images at C2-3 and C3-4 appear normal.,0
"At C4-5, there appears to be a small protrusion of the intervertebral disc into the left neural foramen.",0
The right foramen and the spinal canal appear normal.,0
There are no significant abnormalities noted on axial images at other levels down to T1.,0
The patient is intubated and there is fluid in the pharynx.,0
CONCLUSION: Mild degenerative disc disease.,0
Otherwise normal examination with no evidence of fracture or ligamentous injury.,0
", H. 2:35 PM CHEST (PORTABLE AP) Clip # Reason: r/o intrathoracic process Admitting Diagnosis: S/P VF ARREST ______________________________________________________________________________ MEDICAL CONDITION: 64 yo male s/p cardiac arrest REASON FOR THIS EXAMINATION: r/o intrathoracic process ______________________________________________________________________________ PFI REPORT There is mild vascular congestion.",0
There is a small left pleural effusion and moderate cardiomegaly.,0
"PORT Clip # Reason: r/o obstruction - please do dopplers - is intubated Admitting Diagnosis: ATHEROSCLEROSIS W/ CLAUDICATION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with L CFA to peroneal bypass with ISSVG REASON FOR THIS EXAMINATION: r/o obstruction - please do dopplers - is intubated will need portable ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 87-year-old woman with vascular surgery, now with rising creatinine.",1
RENAL ULTRASOUND: The right kidney measures 9.8 cm.,0
The left kidney measures 10.5 cm.,0
There is a simple left renal cyst measuring 1.2 x 1.7 x 1.2 mm.,0
"There is no evidence of hydronephrosis, stones, or mass.",0
Incidentally noted is a collapsed gallbladder with edema in the wall.,0
Bladder is seen collapsed with a Foley.,0
IMPRESSION: No evidence of hydronephrosis.,0
3:44 PM C-SPINE (PORTABLE) IN O.R.,0
"Clip # Reason: H/O DISC HERNIATION, NOW FOR C4-C6 DISCECTOMY..FUSION ______________________________________________________________________________ FINAL REPORT C SPINE IN OR: Single lateral view in the OR reveals anterior fusion of the C4 and 5 vertebral bodies.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Metronidazole / Tetracycline Attending: Chief Complaint: Chest Pain, Nausea, Vomiting Major Surgical or Invasive Procedure: Cardiac Catheterization w/ Stent Placement History of Present Illness: Ms. is a 64 yo female with a h/o NIDDM, HTN who presents with acute onset of substernal chest pain which occurred while getting ready for bed at approximately 11 p.m. She describes the pain as a stabbing, soreness in her mid-chest.",0
She states that she ate for dinner and subsequently experienced nausea and multiple episodes of vomiting.,0
"She took Motrin 800 mg PO x 2, but vomited up both doses.",0
Her husband states that she became diaphoretic.,0
EMS was called approximately 4 hours after onset of symptoms.,0
"EKG on arrival revealed ST elevations in inferio-lateral leads, and code stemi was called in ED.",0
"In cath lab, 2 DES were deployed to proximal RCA.",0
"Procedure was complicated by atrial fibrillation, with complete lost of p-waves and concomitant SBP's to 90's.",1
Temporary pacing wire was placed in coronary sinus with immediate restoration of AV synchrony and improvement of BP.,0
"TTE was performed during procedure with concern for vessel perforation, but there was no evidence of pericardial effusion.",0
Patient was pain-free throughout procedure.,0
"She had short runs of VT in cath lab, and she received Amiodarone 150 mg IV x 2. .",0
ROS is notable for episodes of substernal chest pain which occurred with exertion for approximately the past year.,0
"Review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.",0
"On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",0
"She denies recent fevers, chills or rigors.",0
She denies exertional buttock or calf pain.,0
Past Medical History: Hypertension NIDDM Dyslipidemia Angina Social History: Social history is significant for the absence of prior or current tobacco use.,0
There is no history of alcohol abuse.,0
Patient is originally from .,0
Family History: There is no family history of premature coronary artery disease or sudden death.,1
"Physical Exam: VS: T 96.9 , BP 174/89 , HR 76, RR 19, O2 99% on 2L NC Gen: WDWN middle aged black female in NAD, resp or otherwise.",0
Neck: Supple with JVP of 8 cm.,0
"CV: PMI located in 5th intercostal space, midclavicular line.",0
"Chest: No chest wall deformities, scoliosis or kyphosis.",0
"Abd: soft, NTND, No HSM or tenderness.",0
"Skin: No stasis dermatitis, ulcers, scars, or xanthomas.",0
Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: 02:45AM FIBRINOGE-438* WBC-11.4* RBC-4.74 HGB-12.8 HCT-37.6 MCV-79* MCH-27.0 MCHC-34.1 RDW-14.0 CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-2.0 CHOLEST-220* cTropnT-<0.01 CK-MB-3 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG TRIGLYCER-86 HDL CHOL-63 CHOL/HDL-3.5 LDL(CALC)-140* 02:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG COLOR-Straw APPEAR-Clear SP -1.006 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG 02:53AM GLUCOSE-201* LACTATE-2.4* NA+-144 K+-3.3* CL--98* TCO2-29 %HbA1c-7.0* LACTATE-1.0 NA+-142 K+-2.9* 12:26PM CK-MB-86* MB INDX-12.1* cTropnT-1.64* 12:26PM CK(CPK)-709* 05:35PM CK-MB-92* MB INDX-9.5* cTropnT-2.33* 05:35PM CK(CPK)-965* .,0
Cardiac Catheterization : COMMENTS: 1.,0
Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease.,1
The proximal RCA was totally occluded.,0
The LAD had serial 80% stenoses.,0
The LCx had mild disease.,0
Resting hemodyanmic measurement demonstrated elevated filling pressures with an RVEDP 22 mmHg and PCWP 24 mmHg.,0
This near equalization was suggestive of an RVMI (Pseudoconstriction).,0
The mean PAP was 26 mmHg.,0
was depressed at 2.05 l/min/m2.,0
Successful PTCA and stenting of the proximal RCA with a 3.5 x 18 mm XIENCE DES which was post dilated to 3. at high pressure and a 3.5 x 23 mm XIENCE DES in the distal RCA.,0
"Final angiography revealed no resisual stenosis in the stents, no dissection and near normal flow.",0
Shock with AV dysynchrony requiring CS pacing FINAL DIAGNOSIS: 1.,0
Two vessel coronary artery disease.,1
Elevated left and right sided filling pressures.,0
"Acute inferior myocardial infarction, managed by acute ptca.",1
PTCA of the RCA vessel.,0
ECHOCARDIOGRAM : The left ventricular cavity size is normal.,0
There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the basal half of the inferior and inferolateral walls.,1
The remaining segments contract normally (LVEF = 40 %).,0
The aortic valve leaflets (3) appear structurally normal with good leaflet excursion.,0
IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD.,0
ECHOCARDIOGRAM : The left atrium is normal in size.,0
The estimated right atrial pressure is 0-10mmHg.,0
There is mild regional left ventricular systolic dysfunction with mild basal to mid inferior wall hypokinesis.,0
Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg).,0
The aortic arch is mildly dilated.,0
"IMPRESSION: Compared with the prior study (images reviewed) of , the focal left ventricular dysfunction and overall systolic function have much improved.",0
"Brief Hospital Course: Ms. is a 64 yo woman with HTN, NIDDM, dyslipidemia who presented with a chief complaint of chest pain, nausea, vomiting due to inferior/Right ventricular STEMI # STEMI: The patient underwent cardiac catheterization with x 2 to proximal RCA.",0
Cardiac enzymes were cycled with a peak CK of ~900 at 48 hours.,0
"She was started on ASA, Plavix, high-dose Statin as well as metoprolol and lisinopril.",0
Echo post MI showed preserved LVEF (>55%).,0
"While the patient presented in atrial fibrillation in the setting of STEMI, she returned to a sinus rhythm post MI and there was no indication for pacemaker evaluation.",1
The importance of medication compliance was discussed with the patient and she was scheduled for follow-up with the cardiology clinic.,0
"# DM: The patient had a history of DM which she treated with a home remedy of ""bitter bark"".",0
Her hemoglobin A1c on admission was 7.,0
Her blood sugars during hospitalization ranged from 80's to 230.,0
She was treated in house with sliding scale insulin.,0
Metformin therapy was initiated prior to discharge and fasting blood sugars on this regimen were in the 120-130 range.,0
The patient was instructed to follow-up with her PCP regarding further DM management.,0
Medications on Admission: Bitter bark for diabetes control Coenzyme Q10 ?,0
Vitamin D ASA PRN NTG PRN Discharge Medications: 1.,0
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO HS (at bedtime).,0
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6.,0
"Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain.",0
"Coenzyme Q10 Oral Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ST elevation mycardial infarction Coronary artery disease Diabetes Hypertension Discharge Condition: The patient was hemodynamically stable, afebrile and without pain at the time of discharge.",1
Discharge Instructions: You were admitted for evaluation of chest pain and our studies indicated that you had a heart attack.,0
You underwent a cardiac catheterization and 2 stents were placed in the blood vessels of your heart.,0
"Because of these sents, it is very important for you take a new medication called Plavix.",0
This medication thins your blood and helps to keep your stents open.,0
"In addition to the Plavix, we have started several other medications which will protect your heart from further damage.",0
"These medications include two blood pressure medications (Toprolol and Lisinopril), a medication for your cholesterol (Simvastatin), and a full strength aspirin (325mg daily).",0
"We have also started a medication for your diabetes (Metformin), which you will need to take twice a day.",0
You should take all of these medications as directed.,0
You should not stop any of these medications unless directed by your physician.,0
"In the next few weeks, you will need to follow-up with your primary care doctor as well as with our cardiology department.",0
We have scheduled appointments for you.,0
Please be sure to attend these appointments as scheduled.,0
"In the meantime, please call your doctor or return to the emergency room if your chest pain returns or if you develop shortness of breath, nausea, vomiting, fatigue, weakness, fever chills or any other symptoms of concern.",0
"Cardiology: , MD Phone: Date/Time: 1:00 Completed by:",0
5:53 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?,0
tube placement ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with tube reposition to 22 cm at lip REASON FOR THIS EXAMINATION: ?,0
tube placement ______________________________________________________________________________ FINAL REPORT STUDY: Single portable AP chest radiograph.,0
INDICATION: 41-year-old male with endotracheal tube repositioning.,0
"FINDINGS: The endotracheal tube is in acceptable position, approximately 4 cm from the carina.",0
Nasogastric tube remains in good position.,0
The cardiomediastinal silhouette is within normal limits.,0
IMPRESSION: Acceptable positioning of lines and tubes.,0
"5:55 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ETT tube placement Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with h/o pl eff and SOB, now post-op s/p VATS procedure and intubated REASON FOR THIS EXAMINATION: ETT tube placement ______________________________________________________________________________ FINAL REPORT INDICATIONS: 74-year-old man with history of pleural effusion and shortness of breath, now postoperative status post VATS procedure and intubated.",1
"CHEST, PORTABLE AP VIEW: Comparison is made to earlier the same day.",0
The patient has been intubated.,0
"The tip of the endotracheal tube lies below the thoracic inlet, approximately 5 cm above the carina.",0
A right internal jugular central venous catheter is unchanged.,0
There are multiple chest tubes overlying the left lower hemithorax.,0
The patient is status post aortic valve replacement.,1
The medistinal and hilar contours are unchanged.,0
"There is a hydropneumothorax, with a small left- sided effusion but new air projecting over the left lung base in the costophrenic sulcus.",0
Laterally there is also persistent pleural thickening and or fluid.,0
"IMPRESSION: Status post endotracheal intubation, with the tip lying 5 cm above the carina.",1
"11:09 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval ett placement ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with sob, s/p intubation REASON FOR THIS EXAMINATION: eval ett placement ______________________________________________________________________________ FINAL REPORT INDICATIONS: Intubation.",0
PORTABLE SUPINE AP CHEST: Comparison is made to the study from one hour earlier.,0
The newly inserted endotracheal tube tip is in satisfactory position in the mid trachea.,0
The NG tube tip is below the diaphragm.,0
Note is made of diffuse gaseous distention of multiple bowel loops.,0
Heart size and appearance of the lungs are unchanged in the short interval since the prior study.,0
"4:43 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o post-ERCP bleed, RP bleed Admitting Diagnosis: LOWER GI BLEED Field of view: 47 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man s/p recent GI bleed with distal ileocolic artery embolization, s/p ERCP with sphincterotomy on with continued decresing Hct.",0
"REASON FOR THIS EXAMINATION: r/o post-ERCP bleed, RP bleed CONTRAINDICATIONS for IV CONTRAST: ARF;ARF ______________________________________________________________________________ FINAL REPORT INDICATION: Recent GI bleed.",0
"Distal ileocolic artery embolization, recent ERCP and sphincterotomy.",0
"Continued hematocrit drop, assess for post-ERCP hemorrhage.",0
TECHNIQUE: Volumetric CT imaging of the abdomen and pelvis was performed without oral or IV contrast.,0
"COMPARISON: DVT ultrasound from , and abdominal CT scan from .",0
CT OF THE ABDOMEN WITHOUT CONTRAST: There is bilateral lower lobe atelectasis.,0
Assessment of the solid abdominal organs is limited without IV contrast.,0
"Allowing for limitations, the liver and spleen are unchanged.",0
"The gallbladder contains internal high-density material, indicating vicarious excretion of previously administered IV contrast.",0
"Given that the contrast fills the gallbladder, the cystic duct is patent.",0
There is no biliary ductal dilatation.,0
There is questionable mild stranding beneath the pancreatic neck.,0
"Dense contrast in the colon causes streak artifact, which limits assessment somewhat.",0
There is no evidence of retroperitoneal hemorrhage.,0
There are no renal stones or evidence of hydronephrosis.,0
A tiny nonobstructing 2 mm stone is present in the mid pole of the left kidney.,0
"Redemonstration of non- pathologically enlarged mesenteric and retroperitoneal lymph nodes, unchanged.",0
CT OF THE PELVIS WITHOUT CONTRAST: The bladder is collapsed about a Foley catheter.,0
There is no free fluid in the pelvis or evidence of pelvic hematoma.,0
Note is made of asymmetrical soft tissue edema in the right leg compared to the left.,0
"Furthermore, the right common femoral vein and SFA appear distended compared to the left SFA, with higher density internal material.",0
No evidence of retroperitoneal hematoma following ERCP.,0
Questionable areas of inflammatory stranding immediately beneath the pancreatic neck.,0
"The assessment is limited by dense contrast in the hepatic flexure, causing beam hardening artifact.",0
Findings could indicate mild post- ERCP pancreatitis.,0
Potential DVT in right common and superficial femoral veins.,0
"Compared to the ultrasound from , this would be a new finding.",0
An IVC filter is already present.,0
"If determining whether there is DVT in the right lower (Over) 4:43 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o post-ERCP bleed, RP bleed Admitting Diagnosis: LOWER GI BLEED Field of view: 47 ______________________________________________________________________________ FINAL REPORT (Cont) extremity is of clinical significance, this could be confirmed with Doppler son.",1
"Nonobstructing 2-mm stone in mid pole, left kidney.",0
Unchanged non-pathologically enlarged mesenteric and retroperitoneal lymph nodes.,0
Findings concerning the potential right DVT were called to Dr. at 5:30 pm on .,0
"2:40 PM CT HEAD W/O CONTRAST Clip # Reason: r/o ICH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with weakness, increased confusion after fall with head strike REASON FOR THIS EXAMINATION: r/o ICH CONTRAINDICATIONS for IV CONTRAST: cr ______________________________________________________________________________ WET READ: SJBj FRI 3:14 PM No acute intra-cranial process.",0
Diffuse chronic small vessel ischemic changes.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old woman with weakness, increased confusion after fall with head strike.",0
TECHNIQUE: MDCT data were acquired through the head without intravenous contrast.,0
Images were displayed in multiple planes.,0
COMPARISON: None at this institution.,0
"FINDINGS: No hemorrhage, large territorial infarction, edema, mass, or shift of normally midline structures is present.",0
Diffuse periventricular and subcortical white matter hypodensities are consistent with small vessel ischemic changes.,0
The ventricles and sulci are mildly prominent consistent with cortical atrophy.,0
The basal cisterns are widely patent.,0
The mastoid air cells and paranasal sinuses are well aerated.,0
No fractures or scalp hematoma is present.,0
IMPRESSION: Small vessel ischemic changes.,0
"4:36 PM CHEST (PORTABLE AP) Clip # Reason: r/o PNA, effusion Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with hypotension, intraabdominal fluid collection REASON FOR THIS EXAMINATION: r/o PNA, effusion ______________________________________________________________________________ FINAL REPORT DATE: .",0
TYPE OF EXAMINATION: Chest AP portable single view.,0
"INDICATION: 89-year-old male patient with hypotension, intra-abdominal fluid collection, evaluate for pneumonia or effusion.",0
FINDINGS: AP single view with patient in sitting semi-upright position is obtained and the images are analyzed in direct comparison with the next preceding AP and lateral chest examination obtained with the patient in sitting position.,1
Again noted is moderate cardiac enlargement and a mildly widened and elongated thoracic aorta.,0
"The latter follows with its descendent portion, the scoliotic shape of the thoracic spine.",0
Significant asymmetric appearance of the chest is again noted on the frontal view related to the scoliotic deformity with more narrow intercostal spaces in the left hemithorax compared to the right.,0
There are some hazy diffuse densities on the right base which appear to have progressed mildly in comparison to the next preceding study.,0
"These densities raise again concern for infectious process in the right lower lobe parenchyma and is recommended to treat these findings, assuming they represent acute infection in the appropriate clinical setting.",1
"Mild blunting of the lateral pleural sinuses is again noted, but this has not progressed.",0
IMPRESSION: Right lower lobe hazy infiltrates most likely representing pneumonia.,0
", M. MED 4:57 AM CHEST (PORTABLE AP) Clip # Reason: please eval interval change Admitting Diagnosis: GASTROINTESTINAL BLEED;CHEST PAIN;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: year old man with known lung masses, admitted for chest pain and GI bleed, rhonchi on exam REASON FOR THIS EXAMINATION: please eval interval change ______________________________________________________________________________ PFI REPORT PFI: No acute process including no evidence of pulmonary edema or pneumonia.",0
11:24 AM CHEST (PA & LAT) Clip # Reason: Recent changes in effusion?,0
"Admitting Diagnosis: SEPSIS,PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man s/p strep sepsis, bacteremia and pna with loculated right pleural effusion, please eval for change.",1
REASON FOR THIS EXAMINATION: Recent changes in effusion?,0
______________________________________________________________________________ FINAL REPORT HISTORY: Sepsis and pleural effusion.,1
"PA AND LATERAL CHEST: Compared to , there is interval clearing of the right upper lobe density, consistent with consolidation.",0
There is minor residual opacification within this region.,0
There are small bilateral pleural effusions with fluid in the right minor fissure.,1
There is atelectasis at the left lung base.,0
No other new focal areas of consolidation or pulmonary vascular congestion.,0
IMPRESSION: Interval clearing of the right upper lobe consolidation.,0
"6:50 PM CHEST (PORTABLE AP) Clip # Reason: eval L subclavian line placement, trach positioning, HD cath ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with CHF, CRF, and amyloidosis.",0
"REASON FOR THIS EXAMINATION: eval L subclavian line placement, trach positioning, HD cath positioning.",0
______________________________________________________________________________ FINAL REPORT PROCEDURE: AP portable chest.,0
INDICATION: Status post trache and HD catheter placement.,0
Comparison is made to the prior examination of the same day at 6:11 hours.,0
FINDINGS: There has been interval removal of an ET tube and placement of a tracheostomy tube in good position.,0
There has been interval placement of a right-sided Hickman catheter with its tip in the SVC/RA junction.,0
An NG tube is seen with its tip in the fundus of the stomach.,0
A left-sided subclavian central venous line is in stable position.,0
Bilateral chest tubes are again seen in stable position.,0
The cardiomediastinal borders are unchanged.,0
There is interval improvement in the appearance of the pulmonary vasculature.,0
"Bilateral pleural effusions likely remain, although the right costophrenic angle is excluded from view.",0
"A right lower lobe opacity is again seen, unchanged in appearance.",0
IMPRESSION: 1) Satisfactory placement of a right-sided Hickman catheter and tracheostomy tube.,0
2) Continued appearance of right lower lobe opacity.,0
3)Iinterval improvement in mild cardiac failure.,0
Continued appearance of bilateral pleural effusions.,0
8:41 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Eval position of ETT.,0
Admitting Diagnosis: INCARCERATED HERNIA ______________________________________________________________________________ MEDICAL CONDITION: year old man with COPD intubated and Right mainstem ETT position pulled back REASON FOR THIS EXAMINATION: Eval position of ETT.,0
______________________________________________________________________________ FINAL REPORT CHEST ON AT 08:50 HISTORY: Check ET tube.,0
"FINDINGS: The ET tube has been pulled back, but is still slightly low.",0
It is now 1.9 cm above the carina.,0
There has been some interval partial re-expansion of the left lower lung.,0
There continues to be volume loss in the left lower lung with low lung volumes bilaterally.,0
NG tube tip is in the stomach.,0
5:35 PM CHEST (PA & LAT) Clip # Reason: pneumonia?,0
"Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with leukocytosis, hypotension, fevers.",1
REASON FOR THIS EXAMINATION: pneumonia?,0
______________________________________________________________________________ WET READ: FBr FRI 5:49 PM NO ACUTE INTRATHORACIC PATHOLOGY INCLUDING NO PNEUMONIA.,0
______________________________________________________________________________ FINAL REPORT CHEST TWO VIEWS CLINICAL INFORMATION: Leukocytosis and hypotension.,1
"FINDINGS: Since the prior study, there has been development of very subtle bibasilar opacities which could represent developing pneumonia or atelectasis.",0
Upper lung zones are clear.,0
"IMPRESSION: Faint developing bibasilar infiltrates, atelectasis versus pneumonia.",0
9:02 AM CHEST (PORTABLE AP) Clip # Reason: follow PTX Admitting Diagnosis: PNEUMONIA;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with CHF and ESRD with b/l pleural effusions w/ bilateral pneumothorax after thoracentesis REASON FOR THIS EXAMINATION: follow PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumothorax follow up.,0
COMPARISONS: FRONTAL CHEST RADIOGRAPH: The left apical and basilar pneumothorax and bibasilar effusions are not significantly changed.,0
There is continued slight patchy opacity at both lung bases.,0
A right internal jugular dialysis catheter remains in position.,0
IMPRESSION: No significant change in size of left sided pneumothorax and bilateral pleural effusions.,0
7:34 AM CHEST (PORTABLE AP) Clip # Reason: assess for ETT placement Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with melena.,0
REASON FOR THIS EXAMINATION: assess for ETT placement ______________________________________________________________________________ FINAL REPORT INDICATION: 67-year-old man with melena status post intubation.,0
"PORTABLE AP CHEST RADIOGRAPH: There has been interval placement of an ET tube, with the tip approximately 4 cm above the carina.",0
There is a right subclavian central venous line with the tip in the mid SVC.,0
The defibrillator device is seen overlying the left chest wall.,0
There are scattered areas of patchy opacity in the left retrocardiac region and in the right lower lobe which may represent areas of atelectasis and/or consolidation.,0
There are no pleural effusions or pneumothorax seen but the pulmonary vasculature is stable in appearance.,0
"IMPRESSION: Interval placement of an ET tube, with the tip in the mid trachea.",0
No other significant interval change.,0
Height: (in) 70 Weight (lb): 165 BSA (m2): 1.93 m2 BP (mm Hg): 116/34 HR (bpm): 61 Status: Inpatient Date/Time: at 10:14 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
AORTIC VALVE: Three aortic valve leaflets.,0
Mnimally increased gradient c/w minimal AS.,0
Calcified tips of papillary muscles.,0
Mild (1+) MR. Normal LV inflow pattern for age.,0
Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion.,0
GENERAL COMMENTS: The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested.,0
Overall left ventricular systolic function is normal (LVEF 60-70%).,0
There is a minimally increased gradient consistent with minimal aortic valve stenosis.,0
"However, the absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Hypotension, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 59 year old male with stage III (Tx N2 M0) GE junction adenocarcinoma s/p 2 cycles of cisplatin and flurouracil ( and ) and recent PE ( on lovenox) who presents with poor PO intake, nausea, vomiting x 2 weeks, now with hypotension to the 80s and a-fib with RVR 130s-150s.",1
He has been being seen by a visiting nurse him today and found him to be tachycardic and hypotensive and referred him to the ED.,0
He has been asymptomatic with the exception of nausea and vomiting and right elbow tenderness and erythema.,0
He denies fever and chills.,0
"He denies SOB, CP, palps, myalgias, cough, dysuria, sore throat or diarrhea.",0
"He denies feeling dehydrated, and he says that he's been urinating a few times a day without difficulty.",0
"In the ED, initial vitals were 97.8 72 (not real) 94/65 16 100% RA.",0
He was given 5L of NS.,0
Pt was in a-fib with RVR and a rate of 130s-150s.,0
"Due to hypotension, no medications were given for rate control.",0
"Due to recent PE, CT was obtained and showed decreased clot burden and stable infarct.",0
"Out of concern for possible infectious etiology, vancomycin 1g and 2g cefepime were given.",0
"Due to refractory hypotension, peripheral neosynephrine was started.",0
"On the floor, he's lying in bed comfortable.",0
"Past Medical History: Past Oncologic History: Stage III (Tx N2 M0) GE junction adenocarcinoma, s/p 2 cycles of Fluorouracil - Cisplatin.",0
Also actively receiving XRT with plans for surgery in the fall.,0
"Other Past Medical History: Severe rheumatoid arthritis, previously on enbrel.",1
History of multiple joint surgeries related to RA as well.,0
"History of pericarditis, thought secondary to RA.",0
Pulmonary Embolism Social History: He lives with his wife of 34 years.,1
"He has been on disability for the past ten years, formerly was a manager at a bottling plant and .",0
"- Tobacco: He quit smoking in , previously smoked 30-35 years, 1-1.5 PPD - Alcohol: He has drinks per week previously.",0
- Illicits: Denies Family History: His mother and sister have .,0
There is no family history of cancers.,0
No family history of dvt or pulmonary embolism.,1
"Physical Exam: ADMISSION PHYSICAL EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally scan basilar crackles, no wheezes, rales, ronchi CV: Irregularly irregular, tachycardic, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; ulnar deviation of his fingers bilaterally; warm raised erythematous alecranon bursa on right forearm.",0
"Mild TTP Neuro: CN2-12 grossly in tact, no focal deficits DISCHARGE PHYSICAL EXAM Vitals: T: 96.4 102/62 79 20 94%RA 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, ronchi CV: RRR, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; ulnar deviation of his fingers bilaterally; R arm > L arm, with loose edema.",0
"No swelling, erythema around port site.",0
Compared to the previous tracing of atrial fibrillation is new.,1
CHEST PORTABLE (): IMPRESSION: No acute intrathoracic process.,0
Interval decrease in clot burden involving subsegmental branches of posterior basal segment of right lower lobe since .,0
"2.3 x 1.3 cm enlarging subpleural perifissural right lower lobe nodule, concerning for metastatic pleural disease.",0
Additional scattered sub 4 mm bilateral pulmonary nodules appear stable since at least .,0
Minimal upper zone interlobular septal thickening may reflect volume status.,0
"Stable distal esophageal thickening, compatible with esophageal carcinoma.",0
"New perifissural hepatic hypodensity, incompletely assessed on current examination.",0
"Although this may represent focal fatty infiltration, given history of malignancy, dedicated hepatic imaging is recommended to exclude metastasis.",0
Likely right axillary vein thrombosis.,1
Recommend DVT study for confirmation ECHO (): The left atrium is normal in size.,0
Left ventricular regional function is probably normal though views are technically suboptimal.,0
US ELBOW R (): IMPRESSION: 1.,0
No fluid collection seen at the right elbow within the superficial tissues.,0
Indeterminate soft tissue density adjacent to the right humerus.,0
If there is clinical concern an MRI could further characterize this area UE DOPPLER (): IMPRESSION: Acute right axillary vein thrombosis XR R ELBOW (): IMPRESSION: 1.,1
If there is clinical concern an MRI could further characterize this area.,0
CXR (): FINDINGS: There is new faint opacity in the left lower lobe which could represent early pneumonia.,0
There are trace bilateral pleural effusions.,0
Emphysematous changes including increased AP diameter and flattening of the diaphragms are seen.,0
A right-sided central line is in place with tip near the cavoatrial junction.,0
"IMPRESSION: Faint left lower lobe opacity could represent early pneumonia Brief Hospital Course: ==== BRIEF HOSPITALIZATION SUMMARY ==== 59 year old male with esophageal cancer presenting with FTT and hypotension and a-fib with RVR, given 5L of IVF now on neosynephrine, pt already anticoagulated without interruption on lovenox, transferred to ICU for cardioversion.",0
ICU Course: Patient was transferred with persistent afib with RVR to 150s for cardioversion.,0
Continued digoxin which was started on the floor.,0
HR did not increase above 120s and patient was not started on a Diliazem ggt.,0
Patient was successfully cardioverted on in normal sinus rhythm.,0
"Per cardiology recs, he was started on Metoprolol 25mg PO q8h and digoxin was continued.",0
Patient remained in normal sinus rhythm and was transferred to the floor.,0
Imaging notable for potential lung and liver involvement of primary tumor.,0
Primary oncologist notified and will f/u as outpt.,0
Will likely change trajectory of care plan.,0
"=== ACTIVE ISSUES ==== Hypotension: Likely multifactorial with dehydration from vomiting and poor PO intake contributing, as well as his new a-fib with RVR causing decreased atrial kick.",1
Infection given his abnormal substrate (esophageal cancer) was of concern.,0
He was resuscitated with 5L NS prior to coming to the ICU and was started on neosynephrine.,0
He was treated with vancomycin and cipro for potential infectious causes while awaiting culture data.,0
"He did have a red, warm elbow that he thought was consistent with an RA flare, though it warrants monitoring.",0
He was afebrile without a leukocytosis.,0
His pressors were weaned off and his blood pressure was stable in the 90s-100s prior to transfer to the floor.,0
A-fib with RVR: New a-fib.,0
He has had a history of PAF in the setting of pericarditis related to his RA in his 20s.,0
He was volume resuscitated in the ED with 5L.,0
"He remained in a-fib, though his rate was controlled in the 100s.",0
"He was dig loaded, and a potential infectious precipitant was treated as above.",0
"A CT was done given his recent PE, and it showed a decreased clot burden.",0
Echo was normal with a non-dilated LA.,0
"Cardiac enzymes were negative, and a TSH was elevated (free T4 nl).",0
"Pt was cardioverted with sedation in the MICU, and returned to NSR.",0
Continued lovenox and metoprolol 25mg tid.,0
Transitioned to outpt toprol xl 75mg qd.,0
Pt was monitored on tele for24 hrs before d/c to .,0
"PNA: Pt w/ e/o PNA on CXR, w/ cough for one week.",0
Treating for CAP considering hx of productive cough one week.,0
levofloxacin initiated (through ) Esophageal CA: Had 2 cycles of flurouracil and cisplatin.,0
"Nausea has been improved, no vomiting during this hospitalization.",0
Will continue to w/u as outpt.,0
"Likely metastatic progression, which would make him a non-surgical candidate.",0
outpatient appointment on w/ oncologist and surgeon Esophageal CA: Had 2 cycles of flurouracil and cisplatin.,0
He has had nausea and vomiting multiple times a day without relief with compazine and zofran.,0
"Denies feeling dehydrated, though he has been receiving intermittent infusions of NS in the outpatient clinic.",0
"RA: Possible involvement of his right elbow, however, edema in that arm is most likely axillary vein thrombosis.",1
us and xray unrevealing === TRANSITIONAL ISSUES === 1. f/u on w/surgeron and onc to discuss treatment plan 2 Pt to arrange for cardiology f/u in weeks.,0
"if onc appt first, should draw dig level 3 MEDICATION CHANGES: STOP taking relafen 2 tabs twice per day (500mg), as you have noted that you have not been taking START taking digoxin 250 mcg.",0
One (1) Tablet by mouth DAILY (Daily).,0
START taking metoprolol succinate extended release 75 mg by mouth every day (one 50 mg tablet and one 25mg Tablet per day) START taking levofloxacin 750 mg Tablet.,0
"Take One Tablet by mouth once a day for 5 days: Take through Medications on Admission: albuterol sulfate 90 mcg Two puffs inh Q6H prn enoxaparin 80 mg/0.8 mL Syringe Subq lorazepam 1 mg Q4-6h prn nausea, vomiting ondansetron HCl 8 mg PO Q8H prn nausea/vomiting prochlorperazine maleate 10 mg PO Q6 hours prn nausea/vomiting relafen 2 tabs (500mg), not taking, has not needed acetaminophen 500 mg by mouth every four hours as needed omeprazole 20 mg PO once a day Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for sob wheeze.",0
"2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for nausea, anxiety.",0
3. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours).,0
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*0* 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day.,0
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: Take a total of 75mg per day in the morning (one 50mg and one 25mg tablet).,0
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Take through .,0
"Disp:*5 Tablet(s)* Refills:*0* 8. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea.",0
"Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 9. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea.,0
Discharge Disposition: Home With Service Facility: Angels at home Discharge Diagnosis: Primary Diagnosis: atrial fibrillation with rapid ventricular response Secondary Diagnosis: hypotension GE junction adenocarcinoma Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Dear Mr. , It was a pleasure taking care of you.",0
You were admitted to the hospital because you had an abnormal heart rhythm (atrial fibrillation) with a rapid heart rate.,1
"Also, you had a low blood pressure.",0
Your low blood pressure was most likely from a combination of dehydration and the abnormal heart rhythm.,0
"While in the Intensive Care Unit, we gave your heart an electrical impulse to return it to a normal rhythm.",0
"Fortunately, your heart returned to a normal rate and a normal rhythm.",0
You should follow-up with the division of cardiology so that they can follow your heart rhythm.,0
"Also, you had a pneumonia when you were admitted.",0
You should continue the antibiotic (levofloxacin) through .,0
"You also have close follow-up with your primary oncologist, on , to discuss your oncological issues.",0
At this time he will also evaluate the swelling in your right arm.,0
You should continue taking the lovenox as directed.,0
"Also, you should be sure to drink plenty of fluids to keep from becoming dehydrated.",0
"MEDICATION CHANGES: STOP taking relafen 2 tabs twice per day (500mg), as you have noted that you have not been taking START taking digoxin 250 mcg.",0
Take One Tablet by mouth once a day for 5 days: Take through .,0
"Followup Instructions: It is important for you to call the , Division of Cardiology to schedule an appointment within the next two weeks with Dr. : .",0
They will follow up your heart rate and rhythm.,0
"Department: HEMATOLOGY/ONCOLOGY When: THURSDAY at 9:00 AM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY at 9:30 AM With: , LPN Building: Campus: EAST Best Parking: Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY at 10:00 AM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage",0
", R. TSICU 1:59 AM MR THORACIC SPINE W/O CONTRAST Clip # Reason: please do MRI T-spine to further characterize fractures Admitting Diagnosis: POLYTAUMA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with fall with thoracic spine fractures REASON FOR THIS EXAMINATION: please do MRI T-spine to further characterize fractures No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",1
Mild compression deformity of L1 with additional levels of potential trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.,1
Multilevel degenerative changes with moderate canal narrowing at T10-11 with cord deformity and no abnormal cord signal.,0
"Extensive edema throughout the paraspinal soft tissues, predominantly posteriorly within the interspinous ligaments.",0
Incompletely evaluated cervical spine demonstrates severe canal narrowing at C4-5 with cord deformity and no abnormal cord signal.,0
"12:14 PM CHEST (PORTABLE AP) Clip # Reason: check et tube placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with trauma, sdh w/ large pleural effusion, right upper lobe and middle lobe pna.",0
REASON FOR THIS EXAMINATION: check et tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Assess endotracheal tube position.,0
Comparison is made to study of eight hours prior.,0
There has been interval placement of an endotracheal tube which terminates several cm above the carina and is in satisfactory position.,0
Other lines and tubes are unchanged.,0
There is continued worsening of multifocal patchy opacifications in the right upper and left upper lobes.,0
Left lower lobe retrocardiac opacification and right lower lobe patchy opacifications are unchanged.,0
IMPRESSION: ET tube in satisfactory position.,0
Worsening multifocal infiltrates in bilateral upper lobes.,0
PATIENT/TEST INFORMATION: Indication: R/O Tamponade.,0
Height: (in) 66 Weight (lb): 152 BSA (m2): 1.78 m2 BP (mm Hg): 140/70 HR (bpm): 60 Status: Inpatient Date/Time: at 14:51 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is moderately dilated.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.,0
LEFT VENTRICLE: The left ventricular cavity size is normal.,0
There is paradoxic septal motion consistent with prior cardiac surgery.,0
AORTIC VALVE: A bioprosthetic aortic valve prosthesis is present.,0
PERICARDIUM: There is a small pericardial effusion.,0
There is no significant respiratory variation in mitral/tricuspid valve flows.,0
GENERAL COMMENTS: A left pleural effusion is present.,0
The right atrium is moderately dilated.,0
"Compared with the findings of the prior report (tape unavailable for review) of , the AVR is new.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM TO DISCHARGE SUMMARY: The patient has a past medical history of: 1.",0
Peripheral vascular disease status post left above the knee amputation.,0
Effexor 112.5 a.m. and q. h.s.,0
Depakote 125 twice a day.,0
Metformin 850 twice a day.,0
Erythromycin Ophthalmologic solution three times a day.,0
Colace 100 twice a day.,0
APAP one gram via drip three times a day.,0
Levofloxacin 500 q. day; this was started on .,0
Xalatan Ophthalmologic solution q. day.,0
Trusopt 2% Ophthalmologic solution twice a day.,0
ALLERGIES: The patient has no known drug allergies.,0
SOCIAL HISTORY: He lives in a nursing home.,0
His health care proxy is his niece.,0
"Of note, his discharge medications also include: 1.",0
Effexor 112.5 a.m. and 187.5 q. h.s.,0
Dictated By: MEDQUIST36 D: 16:18 T: 19:40 JOB#:,0
PATIENT/TEST INFORMATION: Indication: Coronary artery disease.,1
Height: (in) 63 Weight (lb): 185 BSA (m2): 1.87 m2 BP (mm Hg): 123/54 HR (bpm): 72 Status: Inpatient Date/Time: at 09:06 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter with >50% decrease during respiration (estimated RAP 5-10 mmHg).,0
Mild regional LV systolic dysfunction.,0
No 2D or Doppler evidence of distal arch coarctation.,0
Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
The estimated right atrial pressure is mmHg.,0
"There is regional left ventricular systolic dysfunction with hypokinesis of the inferior and posterior walls; however, the overall left ventricular ejection fraction is well-preserved (on intraaortic balloon counterpulsation).",0
There is mild aortic valve stenosis (area 1.2-1.9cm2).,0
"3:34 PM MRI ABDOMEN W/O CONTRAST; MRI PELVIS W/O CONTRAST Clip # Reason: evaluate for liver abscess, pancreatitis/pancreas fcollectio Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with elevated lft's REASON FOR THIS EXAMINATION: evaluate for liver abscess, pancreatitis/pancreas fcollectionducts for occlusion CONTRAINDICATIONS for IV CONTRAST: cr Yes to Choyke questions.",1
"______________________________________________________________________________ FINAL REPORT MRI ABDOMEN AND PELVIS INDICATION: Evaluate for liver abscess, pancreatitis or pelvic collection.",0
TECHNIQUE: Multiplanar T1- and T2-weighted imaging was acquired on a 1.5 Tesla magnet.,0
Intravenous contrast was not administered because of low GFR.,0
"COMPARISON: , MRI abdomen and ERCP and CT abdomen .",0
FINDINGS: MRI ABDOMEN: There is extensive hemoperitoneum.,0
There is extensive perihepatic hematoma.,1
There is subcapsular hematoma overlying the right lobe of liver.,1
There is a 5 cm diameter area of high signal intensity on non- contrast axial T1-weighted sequence within segment VIII of the liver compatible with intrahepatic hematoma/hemorrhage.,1
A smaller area of similar signal intensity is also seen more centrally in the right lobe of liver (series 5 image 14).,0
There is moderate dilation of the intrahepatic biliary tree.,0
The common bile duct is dilated and measures 1.5 cm in maximum diameter.,0
There are two biliary stents within the common bile duct.,0
"The diameter of the common bile duct is slightly reduced compared to previous MRCP on ; however, the signal characteristics of the contents of the common bile duct are more complex and lower signal intensity on T2-weighted sequence suggesting debris versus clot, though there is no T1 hyperintensity within the common bile duct to confirm that this is clot.",0
There is increased dilation of the left intrahepatic bile duct.,0
This now measures 6 mm in diameter and is increased compared to previous examination.,0
There is intermediate signal intensity material within the distal left hepatic duct adjacent to the confluence with the right hepatic duct.,0
This is compatible with debris versus hematoma obstructing the left hepatic duct.,1
"Of note, the biliary stents are not seen to traverse this area of obstruction of the left hepatic duct.",1
There is air in the gallbladder.,0
"(Over) 3:34 PM MRI ABDOMEN W/O CONTRAST; MRI PELVIS W/O CONTRAST Clip # Reason: evaluate for liver abscess, pancreatitis/pancreas fcollectio Admitting Diagnosis: FEVER ______________________________________________________________________________ FINAL REPORT (Cont) No focal pancreatic lesion is seen.",0
Evaluation is somewhat limited by the absence of intravenous contrast administration.,0
"The background liver, spleen and vertebral marrow are of low signal intensity compatible with iron deposition.",0
There is a moderate left pleural effusion.,0
There is a large right pleural effusion with right lower lobe volume loss.,0
The native kidneys are atrophic.,0
There is no adrenal mass.,0
The intrahepatic vascularity is not well assessed in the absence of intravenous contrast.,1
"In particular, flow void is not clearly seen to the left portal vein and patency is not adequately assessed.",0
"MRI PELVIS: The right lower quadrant transplanted kidney is normal in signal intensity, apart from a tiny high signal interpolar cyst measuring 5 mm in diameter.",1
There is extensive hematoma in the pelvis.,0
There is a hematoma anterior to the rectum measuring 7.3 cm (craniocaudad) x 7.2 cm (anteroposterior) x 7.5 cm (transverse diameter).,0
"Multiple areas of fluid- fluid levels with dependent hyperintensity on pre-contrast T1-weighted sequence, compatible with hematomas are seen within the pelvis.",0
There is a right lower quadrant anterior abdominal wall hernia with evidence of hematoma extending into the hernial sac.,0
This is anterior to the right renal transplant.,1
There is a septated cystic structure posterior to the right lower quadrant renal transplant measuring 6 x 3.4 x 4.6 cm in diameter.,1
This was present on previous CT and most likely represents a small lymphocele.,0
There is generalized subcutaneous edema.,0
There is a small right hip joint effusion.,0
Right lobe liver intrahepatic hematoma.,1
Dilated biliary tree with focally increased caliber of the left hepatic duct with evidence of debris versus hematoma obstructing the left hepatic duct.,1
Probable lymphocele posterior to the transplanted kidney in the right lower quadrant.,1
Hematoma anterior to the rectum.,0
The intrahepatic vascularity in particular left portal vein has not been well assessed and ultrasound with doppler could be performed to further assess.,1
Report discussed with on after initial discussion by Dr. with the referring team on .,0
"(Over) 3:34 PM MRI ABDOMEN W/O CONTRAST; MRI PELVIS W/O CONTRAST Clip # Reason: evaluate for liver abscess, pancreatitis/pancreas fcollectio Admitting Diagnosis: FEVER ______________________________________________________________________________ FINAL REPORT (Cont)",0
"10:59 AM CT HEAD W/O CONTRAST Clip # Reason: please evaluate for any acute process to contribute to patie Admitting Diagnosis: STAGE III RECTAL CANCER;PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with PMHx rectal cancer with metastatic peritoneal carcinomatosis, now with worsening somnolence REASON FOR THIS EXAMINATION: please evaluate for any acute process to contribute to patient's somnolence CONTRAINDICATIONS for IV CONTRAST: renal insufficiency ______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT CONTRAST.",1
"HISTORY: Rectal cancer, metastatic peritoneal carcinomatosis with worsening somnolence, evaluate for acute process.",1
TECHNIQUE: MDCT axially acquired images through the brain were obtained.,0
No IV contrast was administered.,0
FINDINGS: Exam is slightly limited due to patient motion.,0
"Within this limitation, there is no evidence of acute hemorrhage or shift of normally midline structures.",0
The ventricles and sulci are normal in appearance.,0
There is no evidence of hydrocephalus.,0
The basal cisterns are preserved.,0
The visualized paranasal sinuses are clear.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Non healing ulcer of left great hallux Major Surgical or Invasive Procedure: : Left common femoral artery to below the knee popliteal bypass graft (saphenous vein) : PEG History of Present Illness: Mrs is an 86-year-old female previously hospitalized from - with persistent ulceration and infection of the left great toe.,1
An angiogram during that hospitalization identifying a long occlusion of the left superficial femoral artery with sole distal runoff constituted by the peroneal artery which was unable to be open percutaneously.,1
She was discharge to home on IV antibiotics and readmitted on for a left common femoral to below-knee popliteal artery bypass graft with nonreverse saphenous vein in hope of increasing blood flow to the left foot for wound healing.,0
"Past Medical History: -Peripheral Arterial Disease -Moderate AS, LVH -Chronic LE edema -Chronic diastolic CHF -s/p PPM for sick sinus syndrome -IDDM c/b neuropathy, CHF, dysphagia, afib on coumadin, h/o Sublingual CA s/p sublingual sx CA, Dysphagia cervical/thoracic vertebrae sx for -Spinal stenosis -On warfarin for afib and PE/DVT for left subclavian DVT due to PPM wire -Diabetes -Laminectomy -Stage III CKD, baseline 1.4 -RML nodule Social History: Lives with husband.",1
Prior smoking history of 1ppd/30 years.,0
Pertinent Results: 04:35AM BLOOD WBC-11.8* RBC-3.07* Hgb-9.1* Hct-33.5* MCV-109* MCH-29.8 MCHC-27.3* RDW-20.2* Plt Ct-243 04:35AM BLOOD PT-34.4* PTT-38.4* INR(PT)-3.3* 04:35AM BLOOD Glucose-175* UreaN-82* Creat-5.1* Na-139 K-5.6* Cl-100 HCO3-28 AnGap-17 Brief Hospital Course: The patient is an 86-year-old female previously hospitalized from - with persistent ulceration and infection of the left great toe.,1
An angiogram during the hospitalization identified a long occlusion of the left superficial femoral artery with sole distal runoff constituted by the peroneal artery which was unable to be open percutaneously.,1
She was discharge to home briefly on IV antibiotics and readmitted on for a left common femoral to below-knee popliteal artery bypass graft with nonreversed saphenous vein in hope of increasing blood flow to the left foot for wound healing.,0
Peripheral Arterial Disease Peripheral pulses were dopperable.,1
Left 1st toe had dry gangrene.,0
"Respiratory Failure She had a presumed aspiration pneumonia on requiring ICU admission and intubation for 2 days, treated with vancomycin and cefepime.",1
She again required transfer to the ICU on for hypercarbia with somnolence requiring BIPAP briefly.,0
She was maintained on 4L O2 via nasal cannula.,0
3.Chronic Kidney Disease/Acute Kidney Injury Baseline creatine was 1.3-1.6 prior to surgery.,1
"After surgery, the patient was oliguric with no response to lasix.",0
She eventually became anuric secondary to an acute kidney injury and hemodialysis was starting on .,1
4.Dysphagia/Aspiration She had a history of sublingual cancer ~20 years ago and received oral resection.,1
Bedside swallowing evaluation showed aspiration.,0
A Doboff feeding tube was placed and tube feeding were begun.,0
A PEG tube was placed on .,0
Wounds Leg thigh incision was opened secondary to nonhealing and packed with normal saline damp gauze.,0
6.DVT Left axillary DVT was found on felt to be secondary to PICC which was pulled.,0
She was already fully anticoagulated for her atrial fibrillation.,1
"7.Goals of Care After last transfer to ICU for hypercapnia on , the family met with the medical staff to redefine the goals of care.",0
Mrs. code status was changed to DNR/DNI and they decided they did not want to continue dialysis.,0
"As arrangements where being made to transfer to hospice care, Mrs. cardiac arrested.",0
She died at 8:02PM on .,0
"Discharge Disposition: Expired Discharge Diagnosis: Peripheral Arterial Disease, sp L CFA endarterectomy, L CFA to BK bypass .",1
"Chronic Kidney Disease, on dialysis Aortic Stenosis Dysphagia Discharge Condition: Expired Completed by:",1
6:30 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"improvement in PNA Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION\LEFT HEART CATH ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man who p/w chest pain, developed sepsis and determined to have a pna.",0
REASON FOR THIS EXAMINATION: ?,0
improvement in PNA ______________________________________________________________________________ FINAL REPORT AP CHEST 6:58 A.M. : HISTORY: Previous chest pain.,0
IMPRESSION: AP chest compared to 4 a.m. on and intervening torso CT: Right upper lobe cavity demonstrated by yesterday's torso CT has not been visible on conventional radiographs.,0
"Since yesterday, the major change has been increase in small bilateral pleural effusions, greater on the left, new opacification at the base of the left lung, accompanied by leftward mediastinal shift, suggesting this is largely, if not entirely atelectasis, and a small region of hazy opacity in the left midlung conceivably early pneumonia.",0
"The small region of consolidation at the base of the right lung could be pneumonia, and is comparable in size with the appearance on the CT, probably increased since earlier in the day yesterday.",0
"There is no pulmonary edema, but in the setting of severe emphysema, cardiac decompensation can be manifested as pleural effusions alone.",1
"The right apical lesion could be acute pneumonia, but might also be either a cavitated lung mass or reactivation tuberculosis.",1
Dr and I discussed these findings by telephone at the time of dictation.,0
11:58 AM CHEST (PA & LAT) Clip # Reason: r/o PTX please do after 11 AM Admitting Diagnosis: S/P MOTOR VEHICKE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with chest tubes to water seal REASON FOR THIS EXAMINATION: r/o PTX please do after 11 AM ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 3:14 PM PFI: No evidence of pneumothorax after placement of chest tube to water seal.,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient with chest tube on water seal.,0
PA and lateral upright chest radiographs were compared to .,0
The current study demonstrates no evidence of right pneumothorax.,0
The chest tube is in unchanged position.,0
There are again noted healed fractures of the right upper ribs.,1
Pleural effusion is most likely bilateral.,0
There is no change in the appearance of the left lower lung retrocardiac opacity most likely consistent with atelectasis.,0
10:27 AM LUMBO-SACRAL SPINE (AP & LAT) Clip # Reason: please do in standing position to evaluate alignment Admitting Diagnosis: L2 METASTOSIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p L2 vertebrectomy REASON FOR THIS EXAMINATION: please do in standing position to evaluate alignment ______________________________________________________________________________ FINAL REPORT LUMBOSACRAL SPINE CLINICAL INFORMATION: Pain status post L2 vertebrectomy.,0
FINDINGS: Two views of the lumbar spine are submitted.,0
Patient is status post L2 vertebrectomy.,0
Fixation rods and screws traverse the L1 and L3 vertebral bodies.,0
An L2 vertebral cage spans the L2-L3 region.,0
Remainder of the vertebral body heights are maintained.,0
IMPRESSION: Status post L2 vertebrectomy with placement of vertebral cage and hardware spanning the L1-L3 region.,0
"8:46 AM CHEST (PORTABLE AP) Clip # Reason: assess ballon pump placement Admitting Diagnosis: CHEST PAIN\CATH ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with CAD post cath, post intubation and has IABP REASON FOR THIS EXAMINATION: assess ballon pump placement ______________________________________________________________________________ FINAL REPORT HISTORY: Intraaortic balloon pump.",0
FINDINGS: This is a markedly lordotic film.,0
"The radiopaque marker of the intraaortic balloon pump is visualized in the region of the aortic arch, but because of the lordosis the exact position cannot be determined.",0
Endotracheal tube is 3 cm above the carina.,0
The NG tube is in the stomach.,0
There is a femoral Swan- Ganz catheter with tip in the pulmonary outflow tract.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: Right PICC reposition.,0
Admitting Diagnosis: ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with right PICC reposition.,0
REASON FOR THIS EXAMINATION: Right PICC reposition.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY INDICATION: Patient with PICC line re-positioned.,0
FINDINGS: Right-sided PICC line has been pulled back and is now in cavoatrial junction.,0
The rest of the exam is unchanged.,0
Left subclavian line ends in upper SVC.,0
There is no pneumothorax and bilateral pleural effusions are small.,0
CONCLUSION: Right-sided PICC line is in adequate position at cavoatrial junction.,0
", J. FA10 9:57 AM BILAT LOWER EXT VEINS Clip # Reason: PAIN AND SWELLING BLE // ASSESS FOR DVT Admitting Diagnosis: FEVERS ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with LUPUS, ESRD on HD admitted with infected former RUE avg site/bacteremia now with complaints of bilateral leg pain R >L.",1
s/p R BKA REASON FOR THIS EXAMINATION: assess for DVT ______________________________________________________________________________ PFI REPORT No evidence of DVT seen in either lower extremity.,0
PATIENT/TEST INFORMATION: Indication: Atrial fibrillation.,1
Height: (in) 69 Weight (lb): 270 BSA (m2): 2.35 m2 BP (mm Hg): 173/52 HR (bpm): 67 Status: Inpatient Date/Time: at 12:09 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
LEFT VENTRICLE: Moderate symmetric LVH.,0
Normal mitral valve supporting structures.,0
LV inflow pattern c/w impaired relaxation.,0
GENERAL COMMENTS: Suboptimal image quality - ventilator.,0
There is moderate symmetric left ventricular hypertrophy.,0
Left ventricular systolic function is hyperdynamic (EF>75%).,0
There is a moderate resting left ventricular outflow tract obstruction.,0
The left ventricular inflow pattern suggests impaired relaxation.,0
IMPRESSION: Moderate symmetric LVH with hyperdynamic LV systolic function and a moderate resting LVOT gradient.,0
The Valsalva maneuver could not be performed as the patient was intubated.,0
", MED MICU-7 1:55 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: epidural hematoma Admitting Diagnosis: EPIDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with hemophilia and epidural hematoma REASON FOR THIS EXAMINATION: epidural hematoma No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT IMPRESSION: Since the previous MRI, the epidural hematoma seen in the lower cervical upper thoracic region has slightly extended inferiorly to T2-T3 level with a small inferior extent now visualized, minimally indenting the thecal sac.",1
"Overall, the mass effect from the hematoma from C6-T2 level, which was previously noted, has not significantly changed.",0
Previously noted degenerative changes are again identified.,0
"9:53 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate SAH s/p ventriculostomy ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with high grade SAH, PLease perform in ED prior to transport to ICU REASON FOR THIS EXAMINATION: evaluate SAH s/p ventriculostomy No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: High-grade subarachnoid hemorrhage status post ventriculostomy.",1
FINDINGS: There is massive subarachnoid hemorrhage.,1
Blood fills the lateral ventricles and third and fourth ventricles.,0
The temporal horns of the lateral ventricles are dilated.,0
There is no shift of the normally midline structures.,0
The normal sulcal pattern is obliterated.,0
The - white matter differentiation is preserved.,0
Blood fills the suprasellar cisterns.,0
A ventriculostomy drain enters from the right frontal lobe and terminates in the third ventricle.,0
A small amount of subcutaneous air is noted at the entrance site of the ventriculostomy drain.,0
There is a small amount of fluid within the sphenoid sinus.,0
There is a large amount of fluid within the visualized portions of the maxillary sinus.,0
There is minimal mucosal thickening in the ethmoid air cells.,0
IMPRESSION: There is a high-grade subarachnoid hemorrhage with blood filling the subarachnoid space.,1
"Blood fills the lateral ventricles, third ventricle and fourth ventricle.",0
The ventriculostomy drain is in satisfactory position within the third ventricle.,0
Note is made of a small amount of air along the ventriculostomy tract.,0
The hemorrhage appears to be more prominent in the region of Anterior Communicating artery suggesting possible rupture of a Anterior communicating artery aneurysm.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Amoxicillin / Codeine Attending: Chief Complaint: Upper GI Bleed Major Surgical or Invasive Procedure: Intubation Femoral Cordis A-line EGD History of Present Illness: This is a 42 year-old male with a history of HCV cirrhosis s/p TIPS for variceal bleeding who presents from prison to with hematuria, dysuria, back pain, abdominal pain, jaundice x 2 months.",1
"He underwent a CT-scan that reportly showed evidence of varices of the spleen & esophagus, cirrhosis with question of a mass, and soft tissue density in the bladder in .",1
He had 3-4 visits to the hospital secondary to abdominal pain and was being treated with Motrin and tylenol for pain.,0
"He was going to have an outpatient cystoscopy on , but was postponed due to abdominal pain.",0
"He was admitted on 2/5s admitted to the ICU with worsening lethargy, tachypnea, low grade fevers and question hepatic encephalopathy.",0
"He was also being treated for possible cholecystitis with meropenem and underwent an MRCP, read still pending at .",0
He had a NGT placed for unclear reasons that caused nose bleeding and coughing up blood.,0
Today the patient developed hematemesis with a large amount of frank blood (~2L).,0
He was intubated in the ICU and transferred to ED.,0
"In the ED, blood pressures remained SBP 120's, tachycardic ranging 110-120.",0
"Ventilator settings were AC Vt 500, PEEP 5, RR: 20 and FiO2 100%.",0
CXR initially showed R main stem and tube was pulled back with proper position on repeat CXR.,0
"Patient's labs were significant for INR: 1.8, fibrinogen 93, Hct 28.5, plt 82, lactate 2.8.",0
He was started on an IV Protonix 80mg followed by a gtt and octreotide 50mcg followed by a gtt.,0
He was also given Cipro 400mg IV.,0
A cordis was placed in the ED.,0
"He was transfused 2U pRBC, 2U FFP and was completing liters 3 and 4 on arrival.",0
U/S was performed in the ED and showed patent TIPS.,0
He was evaluated by hepatology and surgery.,0
Pt with continued bleeding via his left nare that was packed in the ED and evaluated by ENT and a balloon was placed in the left nostril.,0
Past Medical History: HCV dx Cirrhosis s/p TIPS for variceal bleed Bladder mass Psoriasis Social History: History of EtOH (reportly 25 yr ago) and smoking (quit 5 years ago after 25 yr history).,0
H/o cocaine and marijuana use 25 yrs ago.,0
Family History: Unable to obtain Physical Exam: Admission: GEN: intubted and sedated.,0
Pt with bright red blood from oropharynx.,0
Pt with epistaxsis balloon in place.,0
Labs 07:42AM BLOOD WBC-2.9* RBC-2.77* Hgb-8.8* Hct-25.7* MCV-93 MCH-31.6 MCHC-34.2 RDW-20.8* Plt Ct-27* 07:42AM BLOOD PT-16.6* PTT-26.3 INR(PT)-1.5* 07:42AM BLOOD Glucose-106* UreaN-26* Creat-0.5 Na-148* K-3.4 Cl-116* HCO3-25 AnGap-10 07:42AM BLOOD ALT-82* AST-170* LD(LDH)-263* AlkPhos-80 TotBili-15.4* 07:42AM BLOOD Calcium-7.5* Phos-1.8* Mg-2.2 .,0
"GI Bleeding Study: IMPRESSION: No evidence of active bleed in the face, chest, abdomen, or pelvis.",0
U/S: IMPRESSION: Patent TIPS with wall-to-wall flow.,0
Evaluation was limited given patient's clinical status and was focused towards detection of TIPS patency.,0
"Patent TIPS, however Doppler interrogation is limited.",0
Cirrhotic liver with sequelae of portal hypertension including trace ascites and large epigastric varices.,1
"Multiple right lobe hepatic nodules, suspicious for possible HCC, warrant further evaluation with cross-sectional imaging (i.e.",0
MRI) on a nonurgent basis to evaluate for hepatoma in this cirrhotic patient.,0
EGD Impression: Varices at the middle third of the esophagus and lower third of the esophagus Blood in the stomach Duodenal ulcer (injection) Otherwise normal EGD to second part of the duodenum Recommendations: Extensive fresh bleeding proximally from nares and oropharynx.,1
Grade II-III varices without evidence of active bleeding.,1
Duodenal ulcer with epinephrine injection given potential contributor to bleeding.,1
"Please continue abx, octreotide gtt, PPI gtt, PRBC, FFP.",0
Contact ENT potential embolization and full assessment of oropharynx.,0
Will need re assessment with EGD and re assessment of TIPS as course continues.,0
EGD Impression: Varices at the middle third of the esophagus and lower third of the esophagus Visualization to antrum.,0
NG successfully placed via endoscopy.,0
Otherwise normal EGD to Antrum Recommendations: Successful placement of -gastric tube.,0
CXR IMPRESSION: Interval development of mild CHF.,0
Brief Hospital Course: Assesment: This is a 42 year-old man with a history of HCV cirrhosis s/p TIPS who presented with an upper GI bleed.,0
Upper GI Bleed: Mr. had a history of HCV cirrhosis s/p TIPS for prior variceal bleed in .,0
He developed hematemsis at the OSH and was intubated for airway protection.,0
He had continued bleeding in the ED.,0
He also had continued bleeding via the left nare.,0
ENT evaluated him and placed an epistaxsis balloon.,0
He was admitted to the ICU and underwent EGD by GI.,0
There was no evidence of active variceal bleeding.,0
There was a duodenal ulcer that was injected.,1
"Mr. received 7U pRBC, 3U FFP and 1U plts.",0
He was continued on a IV PPI gtt and octreotide gtt.,0
He was treated with meropenem.,0
His hematocrit continued to trend down.,0
He had a repeat EGD on that again did not show any active bleeding.,0
A RUQ ultrasound was performed and showed a patent TIPS and large liver nodules.,0
"Of note, he had an MRCP performed at that showed large liver lesions consistent with HCC.",0
He was evaluated by both Oncology and Hepatology who reviewed the films and gave a prognosis of days to weeks.,0
A family discussion was held.,0
After several meetings the family wanted to extubate the patient and pursue CMO.,0
He was placed on a morphine gtt.,0
He was transferred to the floor on .,0
He died at 1830 on with family at his bedside.,0
Respiratory Failure: Pt intubated for airway protection.,1
He was terminally extubated on .,0
Medications on Admission: Transfer Medications: Lactulose enema Benadryl 50mg q8 Zofran 4mg q6 prn Dilaudid 4mg q4 prn MS contin 15mg Tylenol 500mg q12 prn Albuterol nevs q2: prn lactulose 30ml q8 Colace 100mg Clobetasol cream Meropenem 1g q8 Ativan 0.5mg q8 prn Prilosec 20mg daily Trazadone 25mg qhs Senna daily ducolax daily Ensure Sarna lotion Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Hepatitis C Cirrhosis Hepatic Encephalopathy Variceal GI bleed Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired,1
Height: (in) 69 Weight (lb): 178 BSA (m2): 1.97 m2 BP (mm Hg): 118/53 HR (bpm): 69 Status: Inpatient Date/Time: at 13:30 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.,0
Overall left ventricular systolic function is mildly depressed with infero-lateral akenisis.,0
The apex is not well seen but appears hypokinetic.,0
There is an anterior space which most likely represents a fat pad.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Medicine, Firm NOTE: Day of discharge unknown.",0
This Discharge Summary is dictated for his hospitalization course through .,0
"HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old gentleman with a past medical history significant for terminal cirrhosis of the liver due to alcohol, pancytopenia, hepatitis C virus, and history of gastrointestinal bleed who presented in with a rash and hypotension.",1
The patient initially presented to the outside hospital due to his rash on his hands and feet for two days that was painful and itchy.,0
He also noted that his hands and feet were swelling and that they were cold.,0
The patient was found to be hypotensive in the Emergency Department at the outside hospital and was given two liters of fluid and was started on a dopamine drip.,0
"On arrival to , the dopamine was weaned with blood pressures in the mid 80s to low 90s.",0
"He denied any fevers, chills, neck stiffness, mental status changes, sore throat, shortness of breath, chest pain, melena, bright red blood per rectum, hematemesis, abdominal pain, or increased abdominal girth.",0
"The patient received 2 grams of ceftriaxone as well as Flagyl, and 2 million units of penicillin for a question of syphilis.",0
Terminal cirrhosis of the liver due to alcohol.,1
History of a gastrointestinal bleed.,0
Lasix 80 mg by mouth in the morning and 40 mg by mouth in the evening.,0
Spironolactone 40 mg by mouth every other day.,0
Folic acid 1 mg by mouth once per day.,0
Nadolol 20 mg by mouth once per day.,0
Iron sulfate 325 mg by mouth once per day.,0
Thiamine 100 mg by mouth once per day.,0
Vitamin C. ALLERGIES: No known drug allergies.,0
FAMILY HISTORY: Family history significant for alcoholism in his father.,0
SOCIAL HISTORY: The patient is single and lives with his mother and sister.,0
works as a part-time contractor.,0
He does have a history of alcohol and denied alcohol use in the past three months.,0
He denied any tobacco use or intravenous drug abuse.,0
"PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 96.1 degrees Fahrenheit, his blood pressure was 71/29, his heart rate was 76, his respiratory rate was 16, and his oxygen saturation was 96% on room air.",0
"In general, a thin Caucasian male, shivering under covers, but no diaphoresis.",0
"Head, eyes, ears, nose, and throat examination the pupils were equal, round, and reactive to light.",0
The mucous membranes were dry.,0
Neck examination revealed there was no lymphadenopathy.,0
Cardiovascular examination revealed a regular rate and rhythm.,0
"There were no murmurs, rubs, or gallops.",0
Pulmonary examination revealed clear to auscultation bilaterally.,0
"The abdomen was soft, distended, and nontender.",0
There were normal active bowel sounds.,0
"Extremity examination revealed no clubbing, cyanosis, or edema.",0
No axillary or other lymphadenopathy.,0
"Skin revealed petechial rash with purpuric regions on the feet, 0.5-cm lesions on the Achilles tendon.",0
No rash on the legs or thighs.,0
Positive palmar on the dorsum of the hand.,0
Skins and recurs on the elbows.,0
"Neurologically, the patient was alert and oriented times three.",0
Cranial nerves II through XII were grossly intact.,0
"PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 23.1 (with 90% neutrophils and 3 bands), his hematocrit was 31.1, and his platelets were 269.",0
"His sodium was 127, potassium was 4.4, chloride was 102, bicarbonate was 15, blood urea nitrogen was 64, creatinine was 2.3, and his blood glucose was 105.",0
"His calcium was 7.9, his magnesium was 1.8, and his phosphorous was 5.9.",0
"His alanine-aminotransferase was 19, his aspartate aminotransferase was 35, his alkaline phosphatase was 367, his total bilirubin was 4, his albumin was 2.4, his lipase was 22, and his amylase was 94.",0
"Prothrombin time was 17.6, his partial thromboplastin time was 43.3, and his INR was 2.",0
"Urinalysis showed trace blood, but negative protein and otherwise negative.",0
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed atelectasis at the right base; otherwise was clear.,0
"IMPRESSION: The patient is a 49-year-old gentleman with a history of hepatitis C virus, cirrhosis, hepatic encephalopathy, alcohol abuse, and a history of gastrointestinal bleed who presented with a petechial rash on the hands, both his feet, elbows, and associated malaise.",1
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1.,0
"FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL ISSUES: the patient had a paracentesis performed which revealed white blood cells, 425 red blood cells, 57% neutrophils, no microorganisms, 2+ polymorphonuclear leukocytes.",0
The serum ascites albumin gradient was greater than 1; consistent with portal hypertension.,0
"Based on these results, even though the cultures were negative to date, the patient was diagnosed with having spontaneous bacterial peritonitis due to his history of chronic liver disease.",1
"For this reason, he was started initially on vancomycin, levofloxacin, and ceftriaxone for broad antibiotic coverage.",0
"However, the vancomycin and levofloxacin were discontinued on hospital day two, and he was just continued on the ceftriaxone 1 gram intravenously q.24h.",0
An abdominal ultrasound revealed a main portal vein that was patent with thready anterior grade flow.,0
"No definite thrombus, and a large amount of ascites.",0
"No hydronephrosis, and a cirrhotic liver without a focal mass.",0
The patient was continued on thiamine and folic acid supplements.,0
"He was on a low protein diet, and lactulose was given for prevention/aiding in treatment of hepatic encephalopathy.",0
"His Lasix, spironolactone, and nadolol were initially held due to his hypotension but were restarted on hospital day three without incident.",0
The patient initially presented with hyponatremia which improved on 2 liters of free water restriction.,0
DERMATOLOGIC ISSUES: Dermatology was consulted for the patient's diffuse rash.,0
"A biopsy was performed which revealed no microorganisms, and the cultures were pending to date.",0
This showed evidence of leukocytoclastic vasculitis; consistent with cryoglobulinemia.,0
The cryoglobulinemia was in relation to his hepatitis C viral cirrhosis.,1
"The patient was treated symptomatically with betamethasone, Usaryn, and Bacitracin topical creams.",0
CARDIOVASCULAR ISSUES: The patient initially presented with hypotension.,0
He was started on dopamine pressors which were discontinued on hospital day two.,0
"His heart rate and blood pressure stabilized, and he was thought stable to be restarted on his Lasix, spironolactone, and nadolol.",0
"A transthoracic echocardiogram was performed which revealed an ejection fraction of greater than 50%, and trivial mitral regurgitation.",0
"No effusion, no aortic regurgitation, and no vegetations.",0
Poor visualization of the tricuspid and pulmonary valves.,0
GENITOURINARY ISSUES: The patient had a negative urine culture.,0
He was found to be in acute renal failure; likely due to his dehydration.,1
"However, his creatinine had returned almost to baseline at the time of this dictation.",0
"HEMATOLOGIC ISSUES: On hospital day three, the patient was found to have a hematocrit of 21.2.",0
"For this reason, he was consented and transfused 2 units of packed red blood cells in order to keep his hematocrit above 27.",0
Iron studies were pending at the time of this dictation.,0
INFECTIOUS DISEASE ISSUES: Blood cultures times two were pending at the time of this dictation and were negative to date.,0
The patient had a rise in white blood cell count but remained afebrile.,0
He was continued on the ceftriaxone 1 gram intravenously q.12h.,0
to be continued for a total of 10 days; to be discontinued on .,0
The patient will need chronic ciprofloxacin for spontaneous bacterial peritonitis prophylaxis.,0
DISCHARGE STATUS: To a rehabilitation facility.,0
Multivitamin one tablet by mouth every day.,0
Usaryn cream apply topically twice per day.,0
Bacitracin 500 U/g ointment one application topically twice per day.,0
Betamethasone 0.05% cream one application topically twice per day.,0
Lactulose 30 mL by mouth three times per day.,0
Spironolactone 25 mg by mouth every other day.,0
Furosemide 80 mg by mouth in the morning and 40 mg by mouth in the evening.,0
Ceftriaxone 2 grams intravenously q.12h.,0
(to be stopped on ).,0
Cirrhosis of the liver; end-stage liver disease.,1
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to call his primary care physician (Dr. in one to two weeks (telephone number ) for a follow-up appointment.,0
NOTE: Another dictation is to follow for the patient's hospitalization course beyond .,0
Dictated By: MEDQUIST36 D: 17:30 T: 01:46 JOB#:,0
8:42 PM CT HEAD W/O CONTRAST Clip # Reason: POST-ANGIO Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with SAH.,1
REASON FOR THIS EXAMINATION: Developing hydrocephalus No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb FRI 11:05 PM 1.,0
Interval placement of right-sided vascular coil.,0
Very minimal increase in ventricular size compared to most recent prior exam.,0
Extensive subarachnoid hemorrhage with blood layering in the occipital horns bilaterally.,1
PFI VERSION #1 EHAb FRI 11:03 PM 1.,0
Interval placement of right-sided embolization coil.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 88-year-old female with subarachnoid hemorrhage.,1
COMPARISON: at approximately 4 p.m.,0
TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast.,0
"FINDINGS: Compared to most recent prior exam, the ventricles are measuring approximately 5 mm larger than before.",0
There has been interval placement of a metallic coil in the region of the right posterior communicating artery.,0
"Otherwise, there has been no significant interval change.",0
Extensive subarachnoid hemorrhage is again seen with blood layering within the occipital horns bilaterally.,1
There is preservation of -white differentiation without CT evidence for large territorial infarct.,0
White matter hypodensity suggests sequela of chronic small vessel ischemic disease.,0
Visualized bones and soft tissues are within normal limits.,0
The visualized portions of the paranasal sinuses and mastoid air cells are well aerated.,0
These findings were discussed with Dr. by Dr. by telephone at 22:12 on .,0
(Over) 8:42 PM CT HEAD W/O CONTRAST Clip # Reason: POST-ANGIO Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont),1
7:57 PM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: TRANSFER ______________________________________________________________________________ FINAL REPORT HISTORY: Trauma.,0
FINDINGS: The followup study had already been performed at the time that this was wet read by the resident.,0
"Large left pneumothorax is seen with some rightward mediastinal shift, consistent with tension pneumothorax.",1
Extensive subcutaneous emphysema greatly obscures detail.,0
Endotracheal tube tip lies well above the carina and nasogastric tube extends to the stomach.,0
"11:03 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: EVALUATE HEART AND LUNGS, CONFIRM ETT, UAC/UVC POSITIONS Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant BORN AT 25 WEEKS GESTATION, RDS REASON FOR THIS EXAMINATION: EVALUATE HEART AND LUNGS CONFIRM ETT, UAC/UVC POSITIONS ______________________________________________________________________________ FINAL REPORT No comparisons.",1
FINDINGS: The endotracheal tube is above the thoracic inlet.,0
The UVC has tip entering the pulmonary trunk.,0
The UAC is appropriately positioned at the T7 level.,0
The clinicians were aware of this.,0
Hyaline membrane disease is evident.,0
There is no effusion or pneumothorax.,0
The abdominal bowel gas pattern is unremarkable.,0
"6:35 PM US EXTREMITY NONVASCULAR RIGHT Clip # Reason: SOFT TISSUE LUMP AT ANTECUB FOSSA, R/O ABCESS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man s/p cabg, now with thrombophlebitis and rising WBC in light of receiving abx and anti-coagulation for a fib.",0
REASON FOR THIS EXAMINATION: r/o abcess ______________________________________________________________________________ FINAL REPORT INDICATION: Hx of thrombophlebitis and increasing white count.,0
"RIGHT UPPER EXT DOPPLER: Ulstrasound of the right upper extremity was performed, which demonstrates no evidence of abscess collection.",0
There is normal flow within the brachial vein and the brachial artery.,0
Height: (in) 73 Weight (lb): 188 BSA (m2): 2.10 m2 BP (mm Hg): 158/90 HR (bpm): 98 Status: Inpatient Date/Time: at 16:22 Test: Portable TTE (Focused views) Doppler: Limited Doppler and no color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Conclusions: Left ventricular wall thicknesses and cavity size are normal.,0
There is a very small pericardial effusion.,0
"Compared with the prior study (images reviewed) of , the left ventricle is slightly less vigorous, but without regional dysfunction.",0
The pericardial effusion is similar.,0
"1:54 PM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrates/effusions Admitting Diagnosis: MITRAL VALVE DISORDER, CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH MVR ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man s/p mvr/cabg REASON FOR THIS EXAMINATION: assess for infiltrates/effusions ______________________________________________________________________________ FINAL REPORT HISTORY: MVR/CABG.",1
"FINDINGS: In comparison with the study of , there is little overall change.",0
Opacification at the left base is again consistent with some combination of atelectasis and effusion.,0
Monitoring and support devices remain in place.,0
"There is some indistinctness of pulmonary vessels, raising the possibility of some overhydration.",0
"In addition, the opacification at the right costophrenic angle extending upward along the chest wall, consistent with a developing pleural fluid collection on the right.",0
"6:39 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOP ABD/PEL LIMITEDClip # Reason: Please evaluate with dopplar for eval hepatic arteries, port Admitting Diagnosis: ACUTE LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man acute alcoholic hepatitis with continues hyperbilirubinemia, please evaluate with dopplar for eval hepatic arteries.",1
Also for evidence of mass or other liver lesions (as previously noted).,0
"REASON FOR THIS EXAMINATION: Please evaluate with dopplar for eval hepatic arteries, portal system and biliary system.",0
Also for evidence of mass or other liver lesions (as previously questioned).,0
______________________________________________________________________________ FINAL REPORT INDICATION: 55-year-old man with acute alcoholic hepatitis with continuous hyperbilirubinemia.,1
Please evaluate for Doppler for evaluation of hepatic arteries.,0
Also evaluation of mass or other liver lesions.,0
"COMPARISON: Ultrasound of the abdomen from , CT of the abdomen from .",0
FINDINGS: Evaluation of the intra-abdominal organs was limited due to patient's compliance and body habitus.,0
Within these limitations the liver appears diffusely echogenic although no discrete focal lesions are definitely visualized.,0
There is a small amount of simple fluid ascites.,0
The hepatic artery is patent.,0
The portal vein is patent with reversal of flow.,0
The hepatic veins were not definitely visualized.,0
The anterior and posterior right portal veins were noted but the left portal vein was not imaged.,0
The spleen measures 10.6 cm and is normal.,0
The left portal vein was not definitely visualized.,0
No mass lesions were noted.,0
"However, evaluation for these lesions is limited due to the factors described above.",0
A CT or MR is recommended for further evaluation of the hepatic vessels as well as for focal lesions.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: 53 yo female who six weeks ago was a pedestrian struck by a truck on the left side resulting in multiple fractures including clavicle and 13 ribs.,0
She was left with a pleural effusion on the left which was documented during an emergency room visit on at .,1
She has been using an incentive spirometer at home reportedly faithfully.,0
"Over the past 2-3 days she has noticed dramatically increased orthopnea such that she is now sleeping sitting up but no significant increase in dyspnea on exertion, fever, sputum production.",0
"Physical exam: Looks relatively Past Medical History: Osteopenia OCD Anxiety Social History: Married Works as a social worker Family History: Non contributory Pertinent Results: Upon admission: 11:49PM GLUCOSE-166* UREA N-10 CREAT-0.6 SODIUM-135 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14 11:49PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.9 11:49PM WBC-13.2*# RBC-3.64* HGB-10.2* HCT-31.1* MCV-85 MCH-28.1 MCHC-32.9 RDW-13.8 11:49PM PLT SMR-HIGH PLT COUNT-536* 11:49PM PT-14.2* PTT-33.5 INR(PT)-1.2* CHEST (PORTABLE AP) 8:57 PM IMPRESSION: AP chest compared to , 6:57 p.m.: There has been no increase in left pleural effusion but consolidation in the left mid and lower lung has increased substantially, an unusual pattern for first reexpansion pulmonary edema suggesting instead pulmonary hemorrhage.",1
Right lung is clear and heart size is normal.,0
"Minimally displaced fracture of the left seventh rib is unchanged and may be a second fracture, of the left tenth rib laterally, chronicity indeterminate.",0
Cytology Report PLEURAL FLUID Procedure Date of REPORT APPROVED DATE: SPECIMEN RECEIVED: PLEURAL FLUID SPECIMEN DESCRIPTION: Received 5ml bloody fluid.,0
PREVIOUS BIOPSIES: THIN LAYER PREP PAP SMEAR WITH IMAGING THIN LAYER PREP PAP SMEAR WITH IMAGING 05- THIN LAYER PREP PAP SMEAR 96- PAP 95- PAP DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS.,0
CHEST (PA & LAT) 10:36 AM IMPRESSION: PA and lateral chest compared to : Previously severe left lung consolidation has improved.,0
A smaller volume of consolidation remains in the right apex and perihilar right mid lung.,0
Small bilateral pleural effusions are probably unchanged over the past several days.,1
Brief Hospital Course: She was admitted to the Trauma Service.,0
She underwent chest xray which revealed no increase in left pleural effusion but consolidation in the left mid and lower lung which had increased substantially since last chest radiograph in early but no pneumothorax.,1
She was transferred to the ICU where she was monitored closely; she was placed on supplemental oxygen.,0
Serial chest xrays were followed.,0
Interventional Pulmonology was consulted for Thoracentesis; 2.5 liters was drained from the left chest.,0
A bronchoscopy was done 2 days later which revealed patent airways with minimal to no secretions.,0
She was started on Levaquin for presumed pneumonia.,0
She is being discharged to home with skilled nursing from visiting nurses.,0
She will follow up in Surgery clinic in 1 week; an xray will be prior to this appointment.,0
"Medications on Admission: MS Contin 30bid, Klonopin 0.25""', Prozac 60' Discharge Medications: 1.",0
Morphine 15 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO every twelve (12) hours.,0
Disp:*120 Tablet Sustained Release(s)* Refills:*0* 2.,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain.,0
Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia.,0
Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 10 days.,0
"Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical every twenty-four(24) hours: Apply to affected area.",0
"Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VISITING NURSE AND COMMUNITY HEALTH Discharge Diagnosis: Left pleural effusion Pneumonia Discharge Condition: Good Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headache, dizziness, chest pain, shortness of breath, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you.",1
Continue with the antibiotics for another 10 days.,0
You may resume your usual home medications as prescribed.,0
"Followup Instructions: Follow up next week with Dr. in Surgery Clinic, call for an appointment.",0
You will need to have an xray prior to this appointment.,0
"You also have an appointment with Provider: , MD Phone: Date/Time: 8:30 you will need to have an xray prior to this appointment on Date/Time: 8:10 MD, Completed by:",0
9:40 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Is NGT in good position?,0
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with SAH and nausea REASON FOR THIS EXAMINATION: Is NGT in good position?,1
"______________________________________________________________________________ FINAL REPORT INDICATION: Subarachnoid hemorrhage, nasogastric tube location.",1
FINDINGS: The course of the nasogastric tube is unremarkable.,0
The side port of the nasogastric tube appears to be positioned in the middle parts of the stomach.,0
"There is no evidence of complications, notably no pneumothorax.",0
"Otherwise, the appearance of the lung and thorax is similar to the CT examination from , 4:11 p.m. No characteristic areas of scarring and atelectasis at both the right and left lung bases.",0
No other focal parenchymal opacities.,0
Borderline size of the cardiac silhouette without relevant pleural effusions.,0
"3:56 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: eval for possible left ptx Admitting Diagnosis: AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with s/p asc aorta replacement REASON FOR THIS EXAMINATION: eval for possible left ptx ______________________________________________________________________________ FINAL REPORT HISTORY: Ascending aorta replacement, to assess for left pneumothorax.",1
"FINDINGS: In comparison with the earlier study of this date, there is still a tiny apical pneumothorax.",0
"The effusions and basilar atelectasis, as well as enlargement of the cardiac silhouette, are essentially unchanged.",1
", R. CSURG CSRU 2:22 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess for ischemia Admitting Diagnosis: STEMI\CARDIAC CATHERIZATION ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p MI and RVAD placement REASON FOR THIS EXAMINATION: assess for ischemia CONTRAINDICATIONS for IV CONTRAST: ARF;ARF ______________________________________________________________________________ PFI REPORT Anasarca.",1
Bilateral pleural effusions and atelectasis.,0
No evidence of bowel obstruction or ischemia.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CCU CHIEF COMPLAINT: ICD firing.,0
"HISTORY OF PRESENT ILLNESS: This is a 70 year old male with a history of coronary artery disease, status post myocardial infarction times two, coronary artery bypass graft complicated by congestive heart failure (ejection fraction 15%), left ventricular thrombus, on Coumadin in the past, and recurrent ventricular tachycardia, status post ablation/ICD placement , now on Mexiletine and Sotalol, who presented to outside hospital Emergency Department after repeated ICD firing this a.m.",1
The patient stated that the ICD had not fired since .,0
"This incident occurred while he was in bed, waking up in the morning.",0
"He had no chest pain or palpitations with these episodes, however, he reported for the last two weeks feeling nauseated, lightheaded with decreased exercise tolerance and appetite.",0
He states that his weight has been decreasing since he started Zaroxolyn two weeks ago and that he is constantly thirsty.,0
"In the outside hospital Emergency Department, he was started on Lidocaine and Amiodarone drips after noting recurrent runs of ventricular tachycardia.",1
His potassium was noted to be 1.8.,0
He was given 60 mEq of Potassium Chloride and transferred to .,0
"On another review of systems, the patient denies palpitations, fevers, chills, cough, shortness of breath, vomiting, abdominal pain, changes in urinary symptoms.",0
"Coronary artery disease, status post coronary artery bypass graft in , status post myocardial infarction times two.",0
"Congestive heart failure, ejection fraction 15 to 20%.",1
"Ventricular tachycardia, status post ablation and ICD placement .",1
"Diabetes mellitus type 2, insulin dependent.",0
Obstructive sleep apnea on CPAP.,0
Aspirin 81 mg once daily.,0
Univasc 15 mg once daily.,0
Toprol XL 25 mg p.o.,0
Potassium Chloride 20 mEq p.o.,0
SOCIAL HISTORY: Past tobacco and quit thirty years ago.,0
No current ETOH or other drugs.,0
The patient lives with wife in .,0
Exercises on treadmill thirty minutes a day.,0
"PHYSICAL EXAMINATION: On admission, vital signs revealed temperature 94.3, blood pressure 102/52, pulse 60, respiratory rate 21, oxygen saturation 100% on one liter nasal cannula.",0
"In general, a pleasant male in no acute distress.",0
"Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation.",0
Neck - jugular venous pressure seven centimeters.,0
"Cardiovascular shows regular rate and rhythm, soft S1 and S2, no murmurs, rubs or gallops.",0
Pulmonary is clear to auscultation bilaterally.,0
"Abdomen is soft, nontender, nondistended, normoactive bowel sounds.",0
"Extremities showed no edema, bilaterally 1+ dorsalis pedis and 2+ radial pulses bilaterally.",0
"LABORATORY DATA: On admission, from outside hospital, white blood cell count 18.5, hematocrit 42.5, platelet count 178,000.",0
"Chemistries notable for sodium 120, potassium 1.8, chloride 80, bicarbonate 30, blood urea nitrogen 19, creatinine 1.2, glucose 153, CK 52, MB 2.0, troponin I 0.29.",0
Electrocardiogram at outside hospital showed wide complex tachycardia with right bundle branch block pattern.,0
Here electrocardiogram showed AV paced right bundle branch block pattern with wider QRS to 60 milliseconds.,0
Ventricular tachycardia - The patient was weaned off Amiodarone and Lidocaine drips.,1
"Liver function tests were checked as previously had history of rising enzymes in the setting of Amiodarone use, however, these were normal.",0
The patient was taken to the Electrophysiology Laboratory for mapping of ventricular tachycardia foci and had three monomorphic ventricular tachycardia foci ablated.,1
"Afterward, telemetry showed occasional runs of atrial tachycardia up to nine beats and he was restarted on lower dose of Sotalol 80 mg p.o.",0
He was not restarted on Mexiletine.,0
He will return at a future date for biventricular pacer upgrade by Electrophysiology service.,0
His ICD was also adjusted to fire and pace for slow rate ventricular tachycardia in the 140s.,1
"Coronary artery disease - The patient continued on Aspirin, beta blocker which was titrated up to Toprol 50 mg and low dose ace inhibitor which was limited by blood pressure.",0
He had no evidence of ischemia.,0
"Congestive heart failure - As the patient was very dry, he was initially bolused with normal saline which improved his clinical condition.",1
He had a repeat transthoracic echocardiogram which showed ejection fraction of 10 to 15%.,0
"He was started on Aldactone and his home dose of Lasix which resulted in large amounts of diuresis ranging from one to 3.5 liters per day, which resulted in overdiuresis.",0
"Thus, on discharge, he will be instructed to check daily weight and take Aldactone/Lasix if his weight increases beyond that of his dry weight which is 213 pounds.",0
Right groin pseudoaneurysm - The patient had development of right groin hematoma and pseudoaneurysm documented by ultrasound after his electrophysiology procedure.,1
Vascular surgery was consulted and the patient had pseudoaneurysm injected with thrombin.,0
His groin examination improved and his hematocrit remained stable.,0
Left lower extremity cellulitis - The patient had leukocytosis initially with 8% bands and 73% neutrophils suggestive of infection.,1
Blood cultures and urine cultures were negative but we did note the development of erythema and edema of the left lower extremity which was outlined by pen.,0
He was ruled out for left lower extremity deep vein thrombosis by ultrasound and started on Unasyn for broad coverage.,0
"By hospital discharge, he was day 4.5 of antibiotics.",0
He was switched to Zosyn near discharge as his cellulitis had only minimally improved.,0
"However, an infectious disease consultation assured the team that it was responsive to antibiotics and that he will be discharged on two week course of Augmentin.",0
His left third and fourth toes were also noted to have purulent discharge which was debrided by podiatry prior to discharge.,0
The infectious disease team took swabs which were sent for culture and are pending though gram stain has been negative.,0
He will need to follow-up with podiatry as an outpatient to continue following the toe ulcers so will have VNA set up to do dressing changes daily.,1
He was instructed to be only partial weight-bearing to the left lower extremity with touchdown weight-bearing to heel only.,0
Insulin dependent diabetes mellitus - Fingerstick was noted to be in high 100s to low 200s and Lantus was increased to 62 units q.d.,0
The patient seemed to have elevated blood sugar mostly in the evenings around 9:00 to 10:00 p.m.,0
This may further need to be adjusted as an outpatient.,0
He will also continue on Humalog sliding scale p.r.n.,0
"Fluids, electrolytes and nutrition - The patient initially admitted with extremely low potassium of 1.8 at outside hospital and 2.1 on arrival here.",0
He required large doses of Potassium repletion as he was totally body potassium depleted.,0
"However, after hydration and repletion of electrolytes, his potassium remained stable on Aldactone and Lasix.",0
"He was initially noted to be hyponatremic and hypochloremic as well, but this all improved after adequate hydration.",0
He will be continued on cardiac diet.,0
DISCHARGE STATUS: The patient was discharged to home with services.,0
Status post left ventricular mapping and ablation of ventricular tachycardia foci.,1
"Pseudoaneurysm of right groin, status post thrombin injection.",0
Atorvastatin 10 mg once daily.,0
Toprol XL 50 mg p.o.,0
once daily for weight equal or greater than 213 pounds.,0
Augmentin 500/125 mg one tablet p.o.,0
three times a day times fourteen days.,0
Insulin Glargine 62 units subcutaneously once daily.,0
Vitamin C 500 mg p.o.,0
Collagenase Ointment to toes daily.,0
"FOLLOW-UP PLANS: The patient has appointment made for nurse practitioner at Dr. office on , at 3:00 p.m. for follow-up of potassium and lower extremity cellulitis/ulcers.",1
Dr. is away on vacation this week but information regarding the hospital course briefly given to receptionist.,0
The patient will call Dr. for appointment as well.,0
He will call podiatry for appointment in the next one to two weeks.,0
"After full resolution of cellulitis, electrophysiology will telephone the patient for return for biventricular pacer placement.",1
Dictated By: MEDQUIST36 D: 11:14 T: 19:00 JOB#:,0
"9:35 AM CHEST (PORTABLE AP) Clip # Reason: please confirm PICC line placement ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman slow vent wean after post-surgical ARDS REASON FOR THIS EXAMINATION: please confirm PICC line placement ______________________________________________________________________________ FINAL REPORT HISTORY: 61 y/o woman with post surgical ARDS, status post PICC line placement.",0
PORTABLE CHEST: Compared to the left subclavian line has been removed.,0
There is a right sided PICC with tip in the superior vena cava.,0
There has been no change in the tracheostomy.,0
The tip of the feeding tube is seen in the stomach.,0
The cardiac silhouette is mildly enlarged however the pulmonary vasculature is normal.,0
The costophrenic angles are sharp.,0
The visualized bones are unremarkable.,0
The patient is status post cholecystostomy.,0
"PORT Clip # Reason: DUPLEX, eval renal perfusion Admitting Diagnosis: HYPERTENSIVE URGENCY ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with HTN and type B aortic dissection, worsening renal function REASON FOR THIS EXAMINATION: DUPLEX, eval renal perfusion ______________________________________________________________________________ FINAL REPORT HISTORY: 34-year-old male with hypertension, type B aortic dissection, worsening renal function.",1
COMPARISON: CT abdomen and pelvis .,0
FINDINGS: The left kidney measures 10.4 cm.,0
The right kidney measures 10.9 cm.,0
"There is no mass, hydronephrosis, or stones.",0
There is wall-to-wall color flow of the right and left main renal arteries.,0
"The resistive indices of the right main renal artery ranges from 0.77 to 0.86, with resistive indices in the lower and upper poles of 0.76.",0
The resistive indices in the left main renal artery is 0.79.,0
Resistive indices in the upper left and lower poles of the left kidney are 0.79 and 0.62 respectively.,0
Appropriate flow within the main renal arteries with symmetric resistive indices bilaterally.,0
"12:28 PM PORTABLE ABDOMEN Clip # Reason: r/o NEC, colitis ______________________________________________________________________________ MEDICAL CONDITION: Infant with long term antibiotic course and now with recent bloody stools.",0
"REASON FOR THIS EXAMINATION: r/o NEC, colitis ______________________________________________________________________________ FINAL REPORT TIME: 11:40 hours.",0
INDICATION: Infant with long-term antibiotic course and now with recent bloody stools; evaluate for colitis.,0
FINDINGS: A single supine view of the abdomen is compared with .,0
"Today's study is slightly limited, in that the diaphragms are clipped off the image.",0
An NG tube is again noted to reach the stomach.,0
"The bowel gas pattern is minimally irregular within the right lower quadrant, with no dilated bowel loops and no specific signs of necrotizing enterocolitis, such as pneumatosis, free intraperitoneal air, and portal venous gas.",0
No obvious bowel wall thickening is detected.,0
"LINE PLACEMENT Clip # Reason: NG placement Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with stroke REASON FOR THIS EXAMINATION: NG placement ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: Patient with nasogastric tube placement.,0
FINDINGS: The tip and side port of the nasogastric tube is in the distal esophagus and needs to be advanced several centimeters 10-15 cm for more optimal placement so that it is beyond the gastroesophageal junction.,0
Cardiac silhouette and mediastinum are within normal limits.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Aneurysm Major Surgical or Invasive Procedure: : Cerebral Angiogram and stent/coiling of aneusyrm History of Present Illness: Ms. is a 59-year-old female with a history of an incidental left MC aneurysm that was detected as part of workup for moyamoya disease.,1
She had a diagnostic angiogram.,0
She has had significant disease of the right hemisphere and she agreed to proceed for stent assisted coiling of treatment of the left middle cerebral artery aneurysm.,1
Past Medical History: Past Medical History: 1. hypertension 2. hypercholesterolemia 3. vertigo Past Surgical History 1. tubal ligation.,1
"Social History: No smoking, etoh or illicit use.",0
"She has two children, she lives with her daughter.",0
"Family History: Non contributory Physical Exam: At discharge:nonfocal groin soft and no hematoma, dorsalis pedis pulses 2+ bilaterally Pertinent Results: 09:40AM GLUCOSE-104* UREA N-13 CREAT-0.6 SODIUM-144 POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-27 ANION GAP-12 09:40AM estGFR-Using this 09:40AM HCT-40.6 09:40AM PLT COUNT-283 09:40AM PT-13.1* PTT-31.3 INR(PT)-1.2* Angiogram: successful stent assisted coiling of brain aneurysm Brief Hospital Course: Ms. was taken to the IR suite with Dr. and underwent a stent assisted coiling without complication under GETA.",0
She was extubated and taken to the SICU and was neurologically intact post-op.,0
She was on Aspirin and Plavix.,0
"Overnight, her HOB and diet was advanced.",0
"On , patient was nonfocal on exam and groin soft with no hematoma.",0
She was discharged home in stable condition.,0
"Medications on Admission: metoprolol and nifedipine, omeprazole, oxybutynin, simvastatin, ASA 81, Plavix Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",0
Disp:*60 Tablet(s)* Refills:*2* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months.,0
Disp:*QS Tablet(s)* Refills:*0* 3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).,0
4. nifedipine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily).,0
"5. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
8. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: MCA aneurysm Discharge Condition: Mental Status: Clear and coherent.,0
Take Aspirin 325mg (enteric coated) once daily.,0
Take Plavix (Clopidogrel) 75mg once daily.,0
"Continue all other medications you were taking before surgery, unless otherwise directed ?",0
You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort.,0
What activities you can and cannot do: ?,0
"When you go home, you may walk and go up and down stairs.",0
"You may shower (let the soapy water run over groin incision, rinse and pat dry) ?",0
"Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?",0
"No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal).",0
"After 1 week, you may resume sexual activity.",0
"After 1 week, gradually increase your activities and distance walked as you can tolerate.",0
No driving until you are no longer taking pain medications Followup Instructions: Please call for follow up with Dr. in in 6 months with MRI/A of the head.,0
"8:37 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: tube placement Admitting Diagnosis: METASTATIC HCC ______________________________________________________________________________ MEDICAL CONDITION: 20 year old woman with Met HCC, s/p intubation REASON FOR THIS EXAMINATION: tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: Intubation.",0
Single portable chest radiograph demonstrates interval placement of nasogastric tube.,0
The NGT tip is located within the stomach.,0
There is a new endotracheal tube with its tip at the clavicular heads.,0
The left subclavian central venous catheter tip is unchanged in position.,0
"The previously seen right-sided pleural effusion has again increased in size, now extending around the right lung apex.",1
There is associated passive atelectasis of the right lung.,0
The left costophrenic angle is sharp.,0
Innumerable nodular pulmonary opacities are again noted.,0
IMPRESSION: Support lines as described.,0
"Innumerable nodular pulmonary densities, better assessed on recent CT examination.",0
"5:02 PM CHEST (PORTABLE AP) Clip # Reason: r ptx, ARDS ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with pneumococcal sepsis/ pneumonia ARDS, DIC, subcutaneous emphysema.",1
"REASON FOR THIS EXAMINATION: r ptx, ARDS ______________________________________________________________________________ FINAL REPORT INDICATION: ARDS, right pneumothorax.",0
"The two right-sided chest tubes are in little changed position, with unchanged appearance of the small apical and basilar pneumothoraces.",0
ET and NG tubes remain in satisfactory position.,0
Again seen are multiple small round calcifications overlying both lungs.,0
"There is slightly improved left retrocadiac opacity, but worsening right mid lung zone opacity.",0
There is continued right lateral chest wall subcutaneous emphysema.,0
"ARDS, with continued right-sided pneumonia and pulmonary edema.",0
"Multiple small calcific densities overlying both lungs, most likely related to a prior granulomatous infection, such as histoplasmosis.",0
Persistent small apical and loculated basilar pneumothorax.,0
", F. CC6A 1:45 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: RUQ u/s.",0
Please assess for sources of cholestasis Admitting Diagnosis: GASTRIC CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman s/p gastrectomy for gastric CA c/b anastomotic leak now with elevated LFTs and Tbili REASON FOR THIS EXAMINATION: RUQ u/s.,0
"Please assess for sources of cholestasis ______________________________________________________________________________ PFI REPORT Gallbladder contains sludge, which may not be unexpected in this patient who has been fasting.",0
"Otherwise, no specific signs of cholecystitis.",0
"No biliary dilatation, gallbladder wall edema, or pericholecystic fluid seen.",0
The patient is diffusely tender.,0
Complex collection surrounding the liver is as seen on CT and likely represents subhepatic hematoma.,0
"No definite focal abnormality is seen in the liver, although assessment is slightly limited due to patient discomfort.",1
4:23 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate interval change Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with respiratory failure and intubation.,1
"REASON FOR THIS EXAMINATION: Evaluate interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:18 A.M., HISTORY: Respiratory failure and intubation.",1
"IMPRESSION: AP chest compared to through 21: Previous bibasilar consolidation, left greater than right, has substantially improved over so short a time that this is more likely due to atelectasis than pneumonia.",0
"No endotracheal tube is seen below T1, the upper margin of this film.",0
"Heart size top normal, unchanged.",0
Left PIC catheter ends in the SVC.,0
"Pleural effusion, if any, is minimal and there is no pneumothorax.",0
"7:10 AM CHEST (PORTABLE AP) Clip # Reason: r/o pulm process Admitting Diagnosis: STEMI ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with productive cough, fevers, s/p extubation REASON FOR THIS EXAMINATION: r/o pulm process ______________________________________________________________________________ FINAL REPORT AP CHEST 8:02 HISTORY: Productive cough and fever, following extubation.",0
"IMPRESSION: AP chest compared to : ET tube has been removed, responsible for subglottic edema.",0
Minimal left pleural effusion may be present.,0
Cardiomediastinal and hilar silhouettes are normal.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Septic shock with PEA arrest Major Surgical or Invasive Procedure: : Cardiac arrest resuscitation : PICC line placement : s/p removal sternotomy wires History of Present Illness: 61M well known to the West 1 service.,1
He has an extensive surgical history with the most recent operation being an ileostomy take down and Hartmann's reversal on .,1
He was doing well post-operatively.,0
"His wife states that 2 days ago he ""passed out"" for 2 minutes at the table.",0
"She states that he became very ""ashen"".",0
The next day he had a temperature to 104 but they did not seek medical attention at that time.,0
They are here now (the next day) for evaluation.,0
"Upon questioning, the patient appeared to sneeze and then have a vasovagal response, this happened a second time and he became bradycardic and then had no rhythm on the monitor.",0
ACLS was initiated and chest compressions were begun.,0
He appeared to be coming to so CPR was stopped and he had a rhythm on the monitor but now he had no palpable pulse.,0
He was in PEA arrest.,0
He receieved 1mg of atropine and 1mg of epinephrine and then proceeded to develop V-tach which then converted to sinus tachycardia.,0
He was then intubated for airway protection.,0
A Right IJ central venous catheter was inserted.,0
His BP then began to rise and he began to fight the ventilator.,0
Sedation was administered in the form of propofol.,0
His blood pressure subsequently dropped to a low of 50 and Levophed was started.,0
The propofol was stopped but his BP still remained low.,0
He was then taken to the CT for a noncon CT of his head and torso.,0
He was then taken to the SICU for close monitoring.,0
A full history was unable to be obtained.,0
"Past Medical History: Coronary artery disease Bypass surgery to two vessels ~11y ago (at ) Peptic ulcer disease - H.Pylori (no operative intervention, no massive hemorrhage) Hypertension Hyperlipidemia .",1
"Hartmanns reversal, component separation CCY, ileost, closure of abdomen subtotal colectomy Chest closure R colectomy R-->L Fem-Fem bpg AVR - CABG x 2 Social History: Current smoker.",0
"Family History: non contributory Physical Exam: T- 103.4 C BP- 113/52 HR- 92 RR- 16 O2Sat 100% intubated Gen: Lying in bed, intubated, sedated HEENT: NC/AT, moist oral mucosa CV: RRR Lung: CTA b/l Abd: dressed with gauze ext: no edema, venodynes on Pertinent Results: On Admission: WBC-9.3 RBC-3.71* Hgb-10.2* Hct-31.5* MCV-85 MCH-27.4 MCHC-32.3 RDW-13.0 Plt Ct-321 PT-15.5* PTT-31.4 INR(PT)-1.4* Glucose-144* UreaN-26* Creat-1.5* Na-136 K-4.5 Cl-101 HCO3-24 AnGap-16 ALT-24 AST-23 CK(CPK)-37* AlkPhos-125 TotBili-0.5 Lipase-19 Calcium-7.5* Phos-3.6 Mg-1.4* On Discharge WBC-6.1 RBC-3.43* Hgb-9.5* Hct-29.3* MCV-85 MCH-27.8 MCHC-32.6 RDW-14.5 Plt Ct-191 PT-13.3 PTT-23.7 INR(PT)-1.1 Glucose-108* UreaN-33* Creat-3.2* Na-143 K-3.7 Cl-104 HCO3-29 AnGap-14 ALT-1 AST-13 AlkPhos-157* TotBili-0.3 Brief Hospital Course: 62 y/o male well known to surgical service who went into PEA arrest after fever and probable septic shock at home.",1
He was successfully resuscitated and was transferred to the SICU for further management.,0
He was seen in consult by neurology who felt that the patient was improving and he actually returned to his baseline by the time of discharge.,0
Infectious disease was consulted for antibiotic management for staph bacteremia (MSSA) in patient with history of aortic bioprosthetic valve.,0
He still has sternal wires in place.,0
A TTE was performed on showing a severe global free wall hypokinesis.,0
The bioprosthetic aortic valve was noted and the gradient was normal.,0
Compared with previous studies the biventricular systolic function is globally worsened.,0
Another TTE was performed on showing an improvement but still depressed systolic function.,0
Due to his worsening renal function a renal consult was obtained.,0
His creatinine continued to rise and his highest level was 9.4 on .,0
Over the course of the next few days his was down to 3.2 with daily improvements.,0
His urine output was always 2 liters or more and it was felt to be ATN from the time of the PEA arrest.,0
The patient did not require hemodialysis.,0
His weights continued to fall daily and his edema resolved with intermittent lasix.,0
He will be followed as an outpatient by the renal fellow who saw him during this hospitalization.,0
"After his initial fever in the ER, he never had another fever throughout the hospitalization.",0
"He had initially been placed on Vanco, Zosyn and Flagyl which was switched to Cefazolin due to IDs' concern for an osteomyelitis of the sternum.",0
The sternal wires were removed on in the OR and a bone biopsy was taken at that time.,0
"Due to these continued concerns, the patient had a PICC line placed and he will have 6 weeks of Cefazolin with labs and follow up with the infectious disease department.",0
- one Capsule(s) by mouth daily OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth Q4-6hr as needed for pain ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - one Tablet(s) by mouth HS as needed for sleep Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1 Tablet(s) by mouth once a day DIMENHYDRINATE [DRAMAMINE] - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once a day as needed for car rides LOPERAMIDE [IMODIUM A-D] - 2 mg Tablet - 1 Tablet(s) by mouth once a day as needed for diarrhea MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1.,0
Oxycodone-Acetaminophen 5-325 mg Tablet : 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
": One (1) Capsule, Delayed Release(E.C.)",0
Lorazepam 0.5 mg Tablet : One (1) Tablet PO Q 8H (Every 8 Hours) as needed for anxiety.,0
Metoprolol Tartrate 50 mg Tablet : One (1) Tablet PO BID (2 times a day).,0
Cefazolin 1 gram Recon Soln : Two (2) grams Intravenous twice a day for 6 weeks.,0
"Heparin, Porcine (PF) 10 unit/mL Syringe : Two (2) ML Intravenous PRN (as needed) as needed for line flush.",0
Lipitor 10 mg Tablet : One (1) Tablet PO once a day.,0
Zyrtec 10 mg Tablet : One (1) Tablet PO once a day.,0
Citalopram 20 mg Tablet : One (1) Tablet PO once a day.,0
Gabapentin 300 mg Capsule : One (1) Capsule PO three times a day.,0
Combivent 18-103 mcg/Actuation Aerosol : One (1) puff Inhalation once a day.,0
Lisinopril 10 mg Tablet : One (1) Tablet PO once a day.,0
Ambien 5 mg Tablet : One (1) Tablet PO at bedtime.,0
Aspirin 81 mg Tablet : One (1) Tablet PO once a day.,0
Loperamide 2 mg Capsule : One (1) Capsule PO four times a day as needed for diarrhea/loose stool.,0
Multivitamin Tablet : One (1) Tablet PO once a day.,0
"Outpatient Lab Work CBC/diff, BUN, creatinine, AST, ALT, ALk Phos, T bili.",0
PLease fax to clinic ATTN: Please draw weekly starting Discharge Disposition: Home With Service Facility: All Care VNA of Greater Discharge Diagnosis: s/p PEA arrest Bioprosthetic aortic valve prosthesis with biventricular systolic dysfunction acute renal failure: resolving ATN sepsis ?,1
"osteomyelitis of sternum, awaiting biopsy results taken Discharge Condition: Good A+Ox3 Ambulatory with assist (patient legally blind) Discharge Instructions: Please call Dr office at for fever, chills, nausea, vomiting, diarrhea, increased pain, drainage from the wound, redness or purulence at the wound sites or other concerning symptoms.",0
Dressings may be changed once daily.,0
"Please call if the appearance changes or there are concerns regarding either the sternotomy or midline abdominal wound Cefazolin to be continued through via PICC line Labs to be sent to outpatient ID (see orders) and he will have appointments with them and Dr Followup Instructions: , MD Phone: Date/Time: 11:00 (Weekly labs ordered for ID) , MD Phone: Date/Time: 11:00 Please call Dr office at for follow up appointment week of Kidney disease follow up appointment.",1
Please call ( for appointment the week of Completed by:,0
"2:47 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for esophageal balloon placemnt Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with hypoxic resp failure multifocal PNA REASON FOR THIS EXAMINATION: eval for esophageal balloon placemnt ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON HISTORY: Evaluate esophageal balloon placement, hypoxic respiratory failure, multifocal pneumonia.",1
FINDINGS: The endotracheal tube tip is 4 cm above the carina.,0
"There is an NG tube with tip in the stomach, off the film.",0
There is a second esophageal tube with the tip just below the gastroesophageal junction.,0
There is a right IJ line with tip in the right atrium.,0
There has been some slight improvement in the aeration bilaterally but there continued to be fluffy alveolar infiltrates left greater than right.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Ivp Dye, Iodine Containing Attending: Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Cardiac catheterization, no intervention performed Esophagogastroduodenography (EGD) Foley cath placement History of Present Illness: This is a 70 y/o male from , h/o HTN, HL, DM, s/p recent ACA infarct, on the neuro service at from , who now presents from with coffee-ground emesis + some blood x 1 this AM.",1
Patient not able to provide history.,0
"Per patient's son and records, patient was having intermittent nausea/vomiting since his discharge from in .",0
He has not been doing well from a rehab perspective and has been very weak with decreased po intake.,0
"Today, he had sudden onset of n/v with abdominal pain and a low-grade fever.",0
Abdominal u/s done at without any pathology preliminary.,0
U/A + with large amount of WBC's.,0
He was noted to then have emesis with coffee-ground material around 6pm and was transferred to ED for further evaluation.,0
"Per patient's son, the patient is not coversant and it is not clear whether this is to his recent CVA (which left residual right hemiparesis and a non-fluent aphasia) or depression.",0
"In the ED, VS were Tm 103.4, BP 120/71, HR 115, RR 20, SaO2 97%/2L NC.",0
"Exam significant for grossly positive NGL, no clearance after 1 L of fluid.",0
"He was given PPI 40 mg IV, Levofloxacin 500 mg IV, Flagyl 500 mg IV, and Tylenol 650 mg. Also received 2 L NS for transient hypotension to SBP's 80, with improvement to low 100's.",0
"GI made aware of patient, plan for EGD in AM.",0
"Incidentally noted to have new ST depressions inferiorly on telemetry, cards consulted and per ED, no intervention possible.",0
Patient admitted to MICU for further management.,0
Hyperlipidemia 4. s/p cholecystectomy 5. s/p recent left ACA infarct with residual right hemi-paresis and nonfluent aphasia Social History: SH: quit smoking 3yrs ago.,1
"No etoh/drugs Family History: FH: brother with cardiac disease Physical Exam: VS: Tc 101.8, Tm 103, BP 143/72, HR 120, RR 22, SaO2 96%/40% FiO2 General: Elderly male, non-conversant, appears ill. HEENT: NC/AT, PERRL, EOMI.",0
"Neck: supple, no LAD Chest: few bibasilar crackles CV: RR tachy s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS, no HSM Ext: no c/c/e, wwp Neuro: Non-conversant.",0
Patient not cooperative with rest of the exam.,0
Pertinent Results: 06:55PM BLOOD WBC-16.9*# RBC-4.19* Hgb-11.9* Hct-34.3* MCV-82 MCH-28.4 MCHC-34.7 RDW-14.1 Plt Ct-180 05:30AM BLOOD WBC-8.9 RBC-4.08* Hgb-11.7* Hct-33.1* MCV-81* MCH-28.6 MCHC-35.2* RDW-14.3 Plt Ct-164 06:55PM BLOOD Neuts-91.7* Bands-0 Lymphs-4.4* Monos-3.4 Eos-0.4 Baso-0.1 05:30AM BLOOD PT-14.6* PTT-31.8 INR(PT)-1.3* 06:55PM BLOOD Glucose-191* UreaN-24* Creat-1.7* Na-135 K-4.7 Cl-101 HCO3-23 AnGap-16 05:30AM BLOOD Glucose-94 UreaN-18 Creat-1.3* Na-140 K-3.9 Cl-107 HCO3-22 AnGap-15 06:55PM BLOOD ALT-41* AST-27 CK(CPK)-21* AlkPhos-36* Amylase-109* TotBili-0.5 03:43AM BLOOD CK(CPK)-293* 09:09AM BLOOD CK(CPK)-377* 03:42AM BLOOD CK(CPK)-376* 04:57PM BLOOD CK(CPK)-164 06:55PM BLOOD CK-MB-NotDone cTropnT-<0.01 09:09AM BLOOD CK-MB-34* MB Indx-9.0* cTropnT-1.26* 03:42AM BLOOD CK-MB-46* MB Indx-12.2* cTropnT-1.90* 04:57PM BLOOD CK-MB-26* MB Indx-15.9* cTropnT-1.68* 05:30AM BLOOD cTropnT-1.96* 05:04AM BLOOD Type-ART Temp-39.3 pO2-95 pCO2-37 pH-7.41 calTCO2-24 Base XS-0 05:04AM BLOOD Lactate-0.9 .,0
CXR: IMPRESSION: No definite consolidation or CHF.,0
NG tube coiled in the gastric body; its tip is out of the field of view.,0
Compared to the previous tracing of heart rate is now faster.,0
"Marked inferolateral ST segment depression with T wave inversions, consider an acute ischemic process.",0
Compared to the previous tracing of heart rate is now faster with marked ischemic type repolarization abnormalities.,0
LE U/S: IMPRESSION: No DVT.,0
ECHO: The left atrium is normal in size.,0
Overall left ventricular systolic function is normal (LVEF>55%).There may be mild focal basal inferolateral hypokinesis (views suboptimal).,0
"Compared with the prior study (images reviewed) of , views are technically suboptimal for comparison of regional wall motion.",0
": Cardiac cath: - LMCA short but patent - LAD origin 40-50% stenosis with mild diffuse dz - LCX origin 70-80% followed by diffuse dz up to 80% involving origins of both mod large OMs - RCA mid 60% - No intervention performed to LCX due to risk of jailing LAD because part of stent would need to be in left main Brief Hospital Course: This is a 70 y/o male with HTN, HL, DM, s/p recent CVA, now p/w hematemesis, tachycardia, fever, and leukocytosis.",1
"# Sepsis - patient fit sepsis criteria on admission, with fever, leukocytosis, tachycardia and positive u/a and urine culture.",1
"He was initially hypotensive in the ED with response to 2 L NS and upon arrival to the MICU, had no further hypotensive episodes.",1
"He was bolused with IVF for his tachycardia, which improved and resolved within 12 hours.",0
"He was started broadly on ciprofloxacin, flagyl, zosyn, and vancomycin initially, which was tapered to zosyn, ciprofloxacin, and vancomycin as urine cx returned as >100,000 GNR, and then to just cipro after his UCx came back as E coli sensative to all but ampicillin.",1
CXR was without infiltrates and blood cx x 2 have been NGTD.,0
He has been hemodynamically stable x 24+ hours and has never required pressors or further fluid boluses since initial admission.,0
"# Urinary retention - since his CVA, the patient has suffered from bladder distention which was not a problem for him beforehand, suggesting a neurogenic bladder.",1
"Urology evaluated the patient in house, and felt that this was the most likely cause of his distention, not his BPH.",0
"They recommend that he keep his Foley in place indefinitely, and that he follow up with them in resident clinic on a Wednesday AM sometime in 6 weeks from his discharge.",0
"He will likely require the Foley on a continuing basis, but they can re-evaluate him at that time in clinic.",0
"# Renal insufficiency - Baseline Cr 1.3-1.6, within baseline; possible contribution from retention as above.",0
"# Elevated biomarkers - patient had concerning EKG changes on admission, notably deep ST depressions in the inferior and lateral leads.",0
"He also had a positive troponin and CK, which has since trended upwards.",0
"This was initially thought to be secondary to demand ischemia as the EKG changes occured while he was tachycardic to the 120's; however, given the continued rise of the biomarkers, there was concern for an NSTEMI.",0
Management was limited given the GI bleed.,0
He was started on BB and underwent EGD for evaluation of bleed.,0
He was found to have Barretts esophagus and erosions from NGT trauma.,1
"He underwent cardiac cath the following day that showed: -- LMCA short but patent - LAD origin 40-50% stenosis with mild diffuse dz - LCX origin 70-80% followed by diffuse dz up to 80% involving origins of both mod large OMs - RCA mid 60% - No intervention performed to LCX due to risk of jailing LAD because part of stent would need to be in left main Medical management was optimized with increase of BB and he was continued on aspirin, statin.",0
"# Hematemesis - concerning for UGIB source, such as PUD vs gastritis vs AVM's.",0
"LGIB also possible, but less likely.",0
He received only 1 U PRBCs on admission and since then his Hct have remained stable and there has not been anymore active bleeding.,0
"He was continued on IV PPI and had a NGT to suction, which was d/c'd today.",0
"GI performed EGD which showed Barrett's and erosions from NGT, and he was cleared for catheterization.",0
He will be dischaged on PPI .,0
"# Diarrhea - patient had diarrhea intermittently during his hospitalization, and he has a C diff toxin pending at the time of his discharge.",0
"He has not had any abd discomfort, and his WBC has come down since admission though is still elevated.",0
"Pt will need to have his C diff toxin result followed up on at the , , and if positive will need to start a course of metronidazole.",0
"# s/p recent CVA - ASA initially held, but restarted after EGD.",0
"Continued on beta blocker, diabetes control, lipid control.",0
"# HTN - Beta blocker, uptitrate as needed.",0
# Hyperlipidemia - continued lipitor .,0
Atorvastatin 10 mg qd 3.,0
Protonix 40 mg qd 4.,0
Lisinopril 10 mg qd 5.,0
Aspirin 325 mg qd 6.,0
Bisacodyl 10 mg qd prn 7.,0
Senna 8.6 mg prn 8.,0
Tamsulosin 0.4 mg qd 9.,0
Vitamin D 400 mg qd 11.,0
Lactulose 20 gm qd 12.,0
Reglan 10 mg tid 13.,0
Remeron 7.5 mg qhs .,0
Atorvastatin 80 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
Pantoprazole 40 mg IV Q12H 3.,0
Aspirin 325 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
Bisacodyl 5 mg Tablet : Two (2) Tablet PO once a day.,0
Senna 8.6 mg Capsule : One (1) Capsule PO twice a day as needed.,0
Vitamin D 400 unit Tablet : One (1) Tablet PO once a day.,0
Lactulose 20 g Packet : One (1) PO once a day.,0
Reglan 5 mg Tablet : One (1) Tablet PO three times a day.,0
Remeron 15 mg Tablet : 0.5 Tablet PO at bedtime.,0
Ciprofloxacin 500 mg Tablet : One (1) Tablet PO Q12H (every 12 hours) for 5 days.,0
Metoprolol Tartrate 25 mg Tablet : One (1) Tablet PO TID (3 times a day).,0
Insulin Regular Human 100 unit/mL Solution : per sliding scale Injection three times a day.,0
"Discharge Disposition: Extended Care Discharge Diagnosis: Sepsis from urinary source Chronic urinary retention, likely neurogenic bladder Myocardial infarction S/P Stroke with residual hemiparesis Hematemesis Renal insufficiency Discharge Condition: Stable.",1
Patient at baseline function with right sided hemiparesis.,0
Discharge Instructions: Please take all of your medications as prescribed.,0
"Please call your PCP or return to the ED if you have chest pain, shortness of breath, nausea, bloody emesis, or other symptoms that are of concern to you.",0
"Followup Instructions: You have the following Cardiology appt set up: Provider: , MD Phone: Date/Time: 10:30 Please call to arrange follow up in the Wednesday AM clinic in 6 weeks (.",0
"Keep your Foley in place until that appointment, otherwise you will continue to retain urine.",0
"You have had diarrhea recently, and given your recent antibiotic use, this is concerning for C difficile infection.",0
A test for C diff toxin was sent and is pending at the time of your discharge.,0
Please have your healthcare provider at call the on Sunday to find out the results of your C diff test.,0
4:49 PM CHEST (PORTABLE AP) Clip # Reason: R arm picc line for long term IV abx.,0
"Please page with ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with febrile neutropenia, hypoxia, cough, Left middle lung zone crackles.",0
REASON FOR THIS EXAMINATION: R arm picc line for long term IV abx.,0
Please page with wet read when available.,0
Thanks ______________________________________________________________________________ FINAL REPORT INDICATION: PICC line placement for longterm antibiotics.,0
Comparison is made to the study from approximately two hours and 40 minutes earlier.,0
AP CHEST RADIOGRAPH: A right sided PICC line catheter is demonstrated with the tip in the superior vena cava.,0
The appearance of the left lung is unchanged.,0
"The right lung demonstrates a slight increase in opacity, indicative of worsening pulmonary edema.",0
The osseous structures are unchanged.,0
IMPRESSION: PICC line in superior vena cava.,0
"These results were discussed with the IV team at the time of interpretation, as requested.",0
"10:50 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lungs and heart Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant intubated, septic, CO2 retention REASON FOR THIS EXAMINATION: evaluate lungs and heart ______________________________________________________________________________ FINAL REPORT CHEST CLINICAL INDICATION: Sepsis.",0
FINDINGS: A single frontal portable view of the chest is performed on at 11:00 PM.,0
"There is diffuse hazy opacification throughout both lungs, possibly at least partially related to slightly low lung volumes and portable technique.",0
"However, slightly more patchy opacifications in the left upper lobe are suspicious for a focal parenchymal process as was seen on the most recent prior study from at 6:15 AM.",0
There is perihilar vascular prominence suggesting some pulmonary vascular congestion as well.,0
The heart and mediastinal contours are within normal limits for a portable study.,0
ET tube tip terminates at the thoracic inlet.,0
Nasogastric tube coils in the stomach.,0
Visualized bowel gas is unremarkable.,0
"8:50 AM CHEST (PORTABLE AP) Clip # Reason: 23 yo s/p picc placement ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man with n/v, diarrhea, progressive sensory/motor neuropathy now with decr O2.",0
"REASON FOR THIS EXAMINATION: 23 yo s/p picc placement ______________________________________________________________________________ FINAL REPORT INDICATION: Nausea, vomiting, and diarrhea s/p PICC placement.",0
FINDINGS: Single view of chest with comparison to .,0
There is right internal jugular central line catheter with tip in the lower superior vena cava.,0
A left approach PICC additionally resides within the lower superior vena cava in the region of the junction with the right atrium.,0
There is area of linear opacification in the left perihilar region which may represent a focal area of atelectasis vs. developing consolidation.,0
There is contrast seen within the colon.,0
IMPRESSION: 1) Satisfactory placement of lines.,0
2) No evidence of pneumothorax.,0
3) Linear area of opacification in the left perihilar region.,0
This may represent a focal area of atelectasis vs. developing consolidation.,0
Follow up chest radiograph may be performed to evaluate for any progression.,0
", MED MICU-7 8:48 AM CT HEAD W/O CONTRAST Clip # Reason: eval for acute bleed Admitting Diagnosis: ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with cirrhosis, elevated INR,new altered mental status requiring intubation REASON FOR THIS EXAMINATION: eval for acute bleed No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No evidence of hemorrhage.",1
Possible partial collapse of the superior endplate of the C5 vertebral body.,0
"If not previously evaluated, recommend radiographs of the cervical spine.",0
10:12 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: central line placement.,0
______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman who is code sepsis REASON FOR THIS EXAMINATION: central line placement.,0
______________________________________________________________________________ FINAL REPORT COMPARISON: Previous study of earlier the same date.,0
"A right internal jugular vascular catheter has been placed, terminating at the junction of the superior vena cava and right atrium.",0
"There is no evidence of pneumothorax, and there has otherwise been no significant change since the previous study of earlier the same date.",0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Cardizem / Lisinopril Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 89 year old female with PMH CHF, Afib, CAD, DM2 chief complaint of tachypnea, hypoxia.",0
"Family reports that over two weeks she has had increased fatigue, lethargy as well as cough.",0
Starting one day prior to admission she was noted to have significantly worsened dyspnea and tachypnea to 30's-40's.,0
MD recomended she go to the ED however yesterday pt refused.,0
In clinic today she denied any pain or other concerns.,0
"She was tachypnic with RR 34, BP 146/80 T98.4 91% on 2L NC at rest with desat to 86% with moving to exam table and lying down for EKG.",0
"She also was found to have diffuse wheezing and bilateral crackles on lung ausculation, and be in Afib with RVR at 105-120.",0
"Per family ROS is negative for any fevers, vomiting, diarrhea, chest pain, palpitations.",0
"Her weight is stable, without lower extremity edema.",0
In clinic she was suspected to have CHF exacerbation due to worsened Left sided heart failure.,1
Atrial fibrillation anticoagulated on coumadin.,1
Social History: Pt lives with her son and daughter in law.,0
"Former smoker (20 pack year hx, quit 30 yrs ago).",0
"Family History: Noncontributory Physical Exam: VS: 99.5 139/77 HR 80 92% 3L w RR 26 Gen: elderly, fatigued, somnulent HEENT: MM dry, sclera anicteric.",0
NECK: JVP at angle of jaw CARDS: Irreg irreg.,0
Rales throughout with course crackles bilat bases.,0
"SKIN: dry, No stasis dermatitis, ulcers, scars, or xanthomas.",0
"PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ NEURO: AAO to person, place, but fatigues easily.",0
Blood cultures x2 pending Brief Hospital Course: On the floor she was treated for presumed PNA with levaquin and diuresed with torsemide (maintained even) given clinical exam and elevated BNP (6900).,0
She developed acute renal failure w Cr bump to 1.7.,1
Triggered on at 9am for tachynpea and hypoxia.,0
O2 sat 87% 4L w RR 32-36.,0
ABG 7.3/90/61 w HCO3 46.,0
She was transferred to the CCU.,0
"In the CCU, the patient was started on an esmolol gtt for rate control.",0
ABG did not improve despite BiPap.,0
She was diuresed with a lasix drip.,0
However her blood pressure dropped into the 80s -responsive to fluid bolus.,0
the CCU team had a family meeting and it was agreed to make the patient CMO.,0
That evening at 9:30pm the patient died.,0
Not arousable to sternal rub.,0
"The family was notified, and declined autopsy.",0
Medications on Admission: Atorvastatin 10mg po daily Digoxin 125mcg po daily Donepezil 10mg po qhs Metoprolol 62.5mg po daily Omeprazole 20mg po daily Spironolactone 25mg po daily Torsemide 20mg twice a week.,0
30mg the other days Coumadin 1-1.5mg po daily Calcium 500mg po daily Ferrous gluconate 240mg po daily Senna Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1.,0
Acute on chronic diastolic congestive heart failure secondary to mitral stenosis Discharge Condition: -- Discharge Instructions: None Followup Instructions: None MD Completed by:,1
12:22 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: following chronic lung dx.,0
"would like film @ 12 noon Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, chronic lung dx REASON FOR THIS EXAMINATION: following chronic lung dx.",1
"would like film @ 12 noon ______________________________________________________________________________ FINAL REPORT CHEST, AT 1223 PM: HISTORY: Chronic lung disease.",1
"There is an endotracheal tube, which terminates 2 cm above the carina.",0
A feeding tube extends into the stomach.,0
A PDA clip is in place.,0
Lung volumes are lower than previously.,0
"There is diffuse bilateral airspace opacification, consistent with severe chronic lung disease, with atelectasis in all lobes.",1
The possibility of superimposed pulmonary edema cannot be excluded.,0
S/p VT arrest Height: (in) 68 Weight (lb): 185 BSA (m2): 1.98 m2 BP (mm Hg): 143/81 HR (bpm): 100 Status: Inpatient Date/Time: at 10:18 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,1
"Compared with the findings of the prior report (tape unavailable for review) of , there is probably no change.",0
4:41 PM MRA NECK W&W/O CONTRAST Clip # Reason: r/o vertebral artery dissection Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman s/p MVC REASON FOR THIS EXAMINATION: r/o vertebral artery dissection No contraindications for IV contrast ______________________________________________________________________________ WET READ: CXWc WED 11:39 PM No vertebral artery dissection.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old status post MVC with C2 pedicle fractures seen on outside hospital cervical spine CT.,1
Evaluate for vertebral artery dissection.,0
"COMPARISON: Non-contrast head CT, .",0
The outside hospital CT of the cervical spine is not available for comparison.,0
"TECHNIQUE: MRA of the neck was performed including T1 axial fat sat, 2D time- of-flight, and T1 post-contrast images of the neck.",0
MRA OF THE NECK: The cervical courses of the common carotid arteries and vertebral arteries are normal with no evidence of stenosis or occlusion.,1
"There is no high T1 signal on the fat-saturated images to suggest an intramural hematoma, and no irregularity of the vessel to suggest dissection.",0
The vertebral arteries are noted to be tortuous bilaterally.,0
The known C2 fracture is not well appreciated and correlation should be made with outside hospital CT of the cervical spine.,1
IMPRESSION: No evidence of vertebral artery dissection or occlusion.,0
Please correlate with OSH CT of the cervical spine.,0
"5:13 PM CHEST (PORTABLE AP) Clip # Reason: 1815 Admitting Diagnosis: CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with trach REASON FOR THIS EXAMINATION: any signs of PNA or effusions ______________________________________________________________________________ WET READ: RSRc 9:18 PM Possible small right effusion, but positioning and low lung volumes somewhat limit evaluation.",1
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH: INDICATION: Evaluation for pneumonia.,0
"FINDINGS: As compared to the previous radiograph, there is no major change.",0
Unchanged findings of the feeding tube.,0
The other monitoring and support devices are also unchanged.,0
Moderate right-sided pleural effusion with subsequent atelectasis.,1
Minimal left-sided pleural effusion with retrocardiac atelectasis.,1
Mild enlargement of the cardiac silhouette.,0
10:22 AM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung expansion ______________________________________________________________________________ MEDICAL CONDITION: Infant on hifi REASON FOR THIS EXAMINATION: evaluate lung expansion ______________________________________________________________________________ FINAL REPORT HISTORY: Infant on HIFI.,0
FINDINGS: The current study is compared to the preceeding film of .,0
Tip of the ETT is in satisfactory position below the thoracic inlet and above the level of the carina.,0
The left sided central venous catheter tip is located left axilla.,0
"As compared with the prior study, there has been a significant improvement in bilateral lung aeration compared to the prior examination.",0
There are persistent bilateral moderate air space opacities.,0
The heart size appears to be mildly enlarged.,0
4:39 PM FEMUR (AP & LAT) BILAT Clip # Reason: following bil femur fx.,0
Want exam @ 4pm today ______________________________________________________________________________ MEDICAL CONDITION: Infant with bil femur fx REASON FOR THIS EXAMINATION: following bil femur fx.,0
Want exam @ 4pm today ______________________________________________________________________________ FINAL REPORT HISTORY: Infant with bilateral femoral fractures.,0
FINDINGS: The current study is compared to a prior film of the lower extremities dated .,0
"Note is once again made of fractures of the proximal femora with demineralization and fraying of the metaphyseal regions of the proximal and distal femora, tibias and fibulas in keeping with the diagnosis of rickets.",0
There is no gross change since the prior study.,0
The proximal left femur is somewhat better imaged and there is some suggestion of anterior displacement of the distal femoral fracture fragment.,0
"8:21 PM PORTABLE ABDOMEN Clip # Reason: r/o obstruction, Please do xray at 8:00 PM ______________________________________________________________________________ MEDICAL CONDITION: Infant with abdominal cyst, delayed gastric emptying, intestinal narrowing.",1
"REASON FOR THIS EXAMINATION: r/o obstruction Please do xray at 8:00 PM ______________________________________________________________________________ FINAL REPORT ABDOMEN: The study is a continuation of an Upper GI, small bowel follow through performed this weekend and demonstrates contrast in a nondilated colon.",1
There is no small bowel distention.,0
3:15 PM CHEST (PORTABLE AP) Clip # Reason: NG tube placement Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: hx as above 63F intubated for respiratory failure.,1
REASON FOR THIS EXAMINATION: NG tube placement ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Respiratory failure.,1
Check for position of nasogastric tube.,0
The tip of the nasogastric tube lies in the cardiac region of the stomach.,0
side port is also within the stomach.,0
There has been no other change since the prior film.,0
IMPRESSION: Nasogastric tube in satisfactory position.,0
"9:19 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with trauma REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: AGLc SUN 11:04 PM subacute (callus seen but fracture line still visible) and acute right rib fractures, no pneumothorax.",1
"patchy opacities in Rt lung, possible aspiration or contusions.",0
bullet in posterior Rt chest (paraspinal region).,0
old trauma to left femur.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 48-year-old male status post assault with strangling, with complaints of neck swelling, change in voice, and back pain.",0
"CT head, C-spine, and CTA neck were performed concurrently.",0
"TECHNIQUE: MDCT axial imaging was performed through the chest, abdomen and pelvis after administration of 130 mL of IV Optiray.",0
Multiplanar reformatted images were then obtained.,0
"CT CHEST WITH IV CONTRAST: There are acute right rib fractures, posteriorly in the fifth rib and anterolaterally involving the fourth and fifth ribs.",1
"Subacute fractures are also noted involving the lateral eighth, ninth and tenth ribs, where bony callus formation can be seen, but the fracture line remains evident.",1
"As further evidence of prior trauma, there is a bullet fragment noted in the right paraspinal region adjacent to T7.",0
"The patient is intubated, with tip 4.1 cm above the .",0
Secretions are noted layering within the distal trachea and the bronchi.,0
Peripheral patchy airspace opacities in the right lower lobe (superior segment) could represent foci of aspiration or contusion.,0
Dependent atelectatic changes are also noted.,0
"Additionally, there is area of consolidation with what appears to be a dilated bronchiole in the right middle lobe adjacent to the fissure, possibly representing scarring.",0
Mild mural calcifications are noted along the ascending aorta.,0
"Otherwise, the heart and aorta appear unremarkable.",0
No pericardial effusion is noted.,0
Incidental note is made of common origin of the right innominate artery and the left common carotid artery from the aortic arch.,0
"No mediastinal, hilar or axillary adenopathy is noted.",0
"CT ABDOMEN WITH IV CONTRAST: The liver, gallbladder, spleen, pancreas, and adrenal glands are unremarkable except to note what appears to be pancreatic (Over) 9:19 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma ______________________________________________________________________________ FINAL REPORT (Cont) divisum (2:69).",0
The common duct is mildly dilated at 8 mm.,0
There is also mild dilation of the intrahepatic ducts centrally.,0
The common bile duct tapers normally and the gallbladder is nondistended.,0
"Other than for two tiny subcentimeter hypodensity in the right kidney which are too small to accurately characterize, the kidneys and ureters appear unremarkable.",0
The bowel are suboptimally assessed due to relative lack of intraperitoneal fat and lack of oral contrast opacification of the bowels.,0
No definite free fluid or free air is noted within the abdomen.,0
The abdominal aorta is of normal caliber.,0
No definite adenopathy is noted although again this assessment is limited.,0
"CT PELVIS WITH IV CONTRAST: The urinary bladder is empty, with Foley catheter in place.",0
Coarse calcifications are noted within the prostate.,0
The rectosigmoid colon and pelvic loops of bowel are suboptimally assessed but without definite abnormality.,0
"No pelvic free air, free fluid or definite adenopathy is noted.",0
"OSSEOUS STRUCTURES: Other than for the rib fractures noted above, no other acute fracture is seen.",1
Degenerative changes are noted at the lumbosacral junction.,0
"There is also heterotopic bone formation at the greater trochanter of the left femur, probably due to old trauma.",0
"Acute right rib fractures as delineated above, without pneumothorax or pleural effusion.",1
Patchy peripheral airspace opacities in the right lower lobe could represent aspiration or contusion.,0
No definite intra-abdominal injury seen.,0
"Evidence of old trauma manifest as subacute right rib fractures, bullet fragment in the right paraspinal region in the chest, and heterotopic bone formation along the proximal left femur.",1
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CORRECTION: The date of discharge for this patient was on , not .",0
Dictated By: MEDQUIST36 D: 19:47 T: 13:30 JOB#:,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby girl delivered at 33-6/7 weeks gestation weighing 2545 grams and was admitted to the Intensive Care Nursery from Labor and Delivery for management of respiratory distress and prematurity.,1
"Mother is a 31-year-old gravida 2, para 0, now 1, mother with estimated date of delivery .",0
"Prenatal screens included blood type A+, antibody screen negative, RPR nonreactive, hepatitis B surface antigen negative, Rubella immune and group B Strep unknown.",0
The pregnancy was uncomplicated until the day prior to delivery when the mother presented with preterm labor and premature rupture of delivery.,1
The membranes were ruptured about 18-1/2 hours prior to delivery.,0
The mother received intrapartum antibiotics about 14-1/2 hours prior to delivery.,0
The infant emerged with a good cry.,0
Received free flow oxygen in the Delivery Room and then was transported to the Intensive Care Nursery.,0
Apgars scores were 8 and 8 at one and five minutes respectively.,0
PHYSICAL EXAMINATION ON ADMISSION: Weight 2545 grams (75-90th percentile).,0
Length 46 cm (50-75th percentile).,0
Head circumference 29.75 cm (25th percentile).,0
"In general, a nondysmorphic, pink infant.",0
Skin without rashes or petechiae.,0
"Head: Anterior fontanelle, soft, flat.",0
Eyes: Red reflex present bilaterally.,0
"Lungs: Inspiratory crackles with grunting, flaring and retracting.",0
"Heart: Normal sinus rhythm, no murmur.",0
Reflexes appropriate for gestational age.,0
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1.,0
Respiratory: Was intubated and received one dose of surfactant for respiratory distress syndrome.,1
"Maximum ventilator support pressures 25/5, rate of 24, 35% oxygen.",0
Responded well to the surfactant and was extubated on day of life one.,0
Required supplemental oxygen by nasal cannula until day of life seven.,0
Has remained on room air since with comfortable work of breathing with respiratory rate in the 30's to 50's.,0
Had mild apnea of prematurity but did not require methylxanthine therapy.,0
The last episode was on .,0
Cardiovascular: Has remained hemodynamically stable throughout hospitalization.,0
Recent blood pressure 68/33 with a mean of 46.,0
"Fluids, electrolytes and nutrition: Initially maintained on peripheral intravenous fluid of D10W.",0
Enteral feeds were started on day of life one and reached full volume feeds on day of life four.,0
At discharge is taking expressed breast milk or breast feeding well with weight gain.,0
Gastroenterology: Was treated with phototherapy for indirect hyperbilirubinemia.,0
"Peak bilirubin total 14.5, direct 0.5.",0
Hematology: Hematocrit on admission 53%.,0
Did not require any blood products during this admission.,0
Infectious Disease: A CBC and blood culture was drawn on admission.,0
Was treated with 48 hours with ampicillin and gentamicin.,0
Neurology: Examination is age appropriate.,0
Sensory: Hearing screening was performed with automated auditory brain stem responses.,0
Orthopedic: Noted to have an eversion of the right foot due to positioning in utero.,0
Was seen by Occupational Therapy who noted the right foot was everted was minimal plantar flexion.,0
The parents were taught exercises to promote active plantar flexion and some inversion plus some gentle stretching exercises.,0
The infant has improved during this hospitalization and follow up is not needed at this time.,0
CONDITION AT DISCHARGE: A 17-day-old now 36-2/7 weeks corrected age preterm infant who is feeding and gaining weight.,1
DISCHARGE DISPOSITION: Discharge home with parents.,0
"PRIMARY PEDIATRICIAN: , M.D., .",0
Medications: Fer-in- 0.25 cc p.o.,0
Car seat position screening pending.,0
State newborn screen sent on and .,0
Immunizations received: Received hepatitis B immunization on .,0
"Immunizations recommended: Synagis RSV prophylaxis should be considered from through for infants meeting the following three criteria: (a) Born at less than 32 weeks; (b) Born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with pre-school sibslings; or (c) with chronic lung disease.",0
Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age.,1
Before this age the family and other caregivers should be considered for immunization against influenza to protect the infant.,0
FOLLOW-UP APPOINTMENTS RECOMMENDED: Appointment with pediatrician recommended week of discharge.,0
AGA 33-6/7 week preterm female.,0
Dictated By: MEDQUIST36 D: 13:48 T: 13:09 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Oxycodone Attending: Chief Complaint: S/p fall, Right subdural hematoma Major Surgical or Invasive Procedure: Right craniotomy for subdural evacuation History of Present Illness: This is a 85 year old female on Aspirin/Coumadin for atrial fibrillation who is status post presumed mechanical fall on .",1
She attempted to stand from a seated position and fell onto her right side.,0
She presents from Hospital where she had a Head CT that was consistent with subdural hematoma with midline shift.,0
The patient was given 1 unit of fresh frozen plasma and transferred here for further evaluation and treatment.,0
"While in the ED, the patient became nauseous with increasing headache and a repeat Head Ct was performed.",0
"The patient was given an additional unit of FFP/profiline 9, and vitamin K. The patient was loaded with Dilantin.",0
"The patient's son was present and stated that his mother refused to go to the hospital yesterday, but this morning she was lethargic and confused so he brought her to Hospital.",0
He also stated the she was a Full Code.,0
The patient proceeded to become lethargic and stopped following commands while in the Emergency Department.,0
"Past Medical History: Afib on coumadin CHF CAD Vertigo HTN Left hip ORIF Social History: Lives at home, has son named who is the HCP.",0
"Family History: Unknown Physical Exam: On admission: Gen: eyes open spontaneously, smiling, sitting up in bed comfortable, NAD.",0
HEENT: Pupils: EOMs: intact Neck: Supple.,0
"Orientation: Oriented to person, not place or date Language: Speech fluent with good comprehension and repetition.",0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally.",0
"V, VII: Facial strength and sensation intact and symmetric.",0
Strength full power throughout except right deltoid- - difficult mobility.,0
Pronator drift- patient unable to perform given decreased mobility Sensation: Intact to light touch bilaterally.,0
"Toes downgoing bilaterally On Discharge: AOx3 to person, place, month and year Follows commands easily.",0
"Left Upper and Lower extremities 4+/5 Right Sensation intact to Light touch Pertinent Results: 12:00PM PT-13.7* PTT-25.7 INR(PT)-1.3* 04:31PM PT-11.9 INR(PT)-1.1 07:31PM PT-11.2 PTT-24.8* INR(PT)-1.0 03:04AM BLOOD PT-10.5 PTT-23.4* INR(PT)-1.0 12:00PM cTropnT-<0.01 05:46PM CK(CPK)-193 05:46PM CK-MB-5 cTropnT-<0.01 03:04AM BLOOD CK(CPK)-612* 03:04AM BLOOD CK-MB-18* MB Indx-2.9 cTropnT-<0.01 Head CT FINDINGS: Again visualized is a hyperdensity along the inner table of the skull on the right ranging from anterior to the right frontal lobe to the right parietal lobe, consistent with an acute subdural hematoma.",0
This hemorrhage measures 14 mm in maximal dimension from the inner table of the skull and demonstrates mass effect on adjacent sulci and the right frontal and parietal lobe with stable leftward shift of normally midline structures by 8 mm.,0
No new foci of hemorrhage are identified.,0
"A hypodensity region is again noted in the right frontal lobe, and may represent an infarction of indeterminate age.",0
Confluence of periventricular white matter hypodensities.,0
Bilateral basal ganglia calcifications are again identified.,0
No acute fractures are noted.,0
There is mild sphenoidal mucosal thickening as well as mild opacification of the right maxillary air cells.,0
"Otherwise, the remainder of the visualized paranasal sinuses and mastoid air cells are clear.",0
"Stable appearance of acute right subdural hematoma, ranging from anterior to the right frontal lobe to posterior to the right occipital lobe measuring approximately 14 mm in maximal dimension from the inner table of the skull.",0
There is continued stable leftward shift of normally midline structures by 8 mm.,0
New foci of hemorrhage is identified.,0
"Hypodense region in the right frontal lobe is again noted and may represent an infarction of indeterminate age, versus a confluence of periventricular white matter hypodensity.",0
Chest Xray FINDINGS: Frontal and lateral views of the chest were obtained.,0
There is no focal consolidation or pneumothorax.,0
Blunting of the left posterior costophrenic sulcus may represent a tiny pleural effusion or scarring.,0
Prominent diffuse interstitial markings suggest underlying chronic lung disease.,0
The heart is mildly enlarged.,0
Mediastinal silhouette and hilar contours are within normal limits.,0
Degenerative changes seen in the shoulders bilaterally.,0
No displaced rib fracture is identified.,0
A wedge compression deformity in the lower thoracic/upper lumbar spine is of unknown chronicity.,0
Aortic calcifications are better seen on the prior study.,0
Wedge compression deformity in the lower thoracic/upper lumbar spine of unknown chronicity.,0
Head CT FINDINGS: The patient is status post right craniectomy with interval evacuation of the right subdural hemorrhage.,1
The subdural cavity has been replaced by air.,0
There is persistent 8 mm leftward shift of normally midline structures.,0
A small left parafalcine hemorrhage layering along the left tentorium is more apparent than prior studies.,0
No new intraparenchymal hemorrhage is identified.,0
Hypodensity in the right frontal lobe is unchanged and may represent an infarction of indeterminate age versus confluence of periventricular white matter hypodensity.,0
Mild mucosal thickening is seen in the right sphenoid sinus.,0
The mastoid air cells and middle ear cavities are clear.,0
Post-surgical changes after right craniectomy with stable 8 mm leftward shift of normally midline structures.,0
Small left parafalcine subdural hemorrhage.,1
Pelvis Xray FINDINGS: There are no old films available for comparison.,0
This is a single AP view of the pelvis.,0
"There is diffuse osteopenia, which somewhat limits evaluation.",0
There is an old healed left hip fracture with an intramedullary rod and screw with associated deformity of the left femoral head and new bone formation extending into the soft tissues.,0
"No new fracture is identified, but osteopenia limits this assessment.",0
CT head There is reaccumulation of fresh subdural hematoma along the right convexity.,0
New right parietal lobe intraparenchymal hemorrhage surrounded by edema : CXR: FINDINGS: Tip of the nasogastric tube is in the mid-to-lower stomach with the side hole just distal to the esophagogastric junction.,1
Little change in the heart and lungs when compared to the study of this date.,0
: Video Swallow evaluation: TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division.,0
Multiple consistencies of barium were administered.,0
FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction.,0
"There was, however, deep penetration and aspiration with nectar and honey-thick barium.",0
"There was residual barium with all thicknesses, most pronounced with pudding thickness barium.",0
IMPRESSION: Penetration and aspiration with nectar and honey-thick barium.,0
Residual barium with all thicknesses.,0
"For details of the examination as well as recommendations, please refer to speech and swallow division note in online medical record.",0
"DR. Brief Hospital Course: 85F who presented to an OSH after a fall, on Coumadin, CT showed a R SDH and she was transferred to .",0
"On initial examination, her exam was stable, however, she decompensated while in the ER and required to go to the OR emergently.",0
"Intraoperatively, the patient did well, and post-operatively was taken to the ICU where she was later extubated.",0
Post-op imaging was stable with expected post-op changes.,0
There were no issues overnight.,0
The patient remained in Afib.,0
"On , the patient was more awake and alert.",0
Her exam was improved from the day prior.,0
She remained in the ICU for monitoring.,0
Her Dilantin level corrected was 19.1 and one dose was held.,0
On she remained neurologically stable.,0
"Her Dilantin level was high again, two doses of Dilantin were held.",0
She was ready for transfer to the floor so that she can work more aggressivly with PT and OT.,0
On her mental status continued to improve.,0
Dilantin level remained high and so she was switched to Keppra for seizure prophylaxis.,0
She was seen and evaluated by physical therapy and occupational therapy who felt that she would benefit from acute rehab.,0
Overnight on into she became tachycardic to the 130s.,0
Metoprolol dosing was increased to 50 and then to 75 on .,0
"On this day she was noted to have decreased strength on the left and had pupil asymmetry, L>R.",0
CT head showed a new Right SDH and new right IPH but improvement in MLS.,0
Stroke Neurology was consulted and did not feel that this was a hemorrhagic conversion of ischemic stroke.,0
She continued to aspirate on repeat Speach and Swallow evaluation on .,0
We discussed the need for NGT or Dobhoff placement.,0
She wishes tohold off until Monday.,0
"On , she was tolerating water and taking meds without issues.",0
"On , patient was seen to have more overall generalized weakness.",0
She was also seen to desat with O2 at 89%.,0
Respiratory was called and patient was placed on 2L O2 and saturation was improved.,0
A CXR was ordered to evaluate for PNA and a NGT was placed for medication and food administration.,0
She was started on Ciprofloxacin for a UTI on .,0
"Video swallow evaluation was performed on and demonstrated moderate-severe pharyngeal dysphagia primarily characterized by risk of aspiration with all PO intake due to swallow initiation delay, reduced laryngeal valve closure, and residue mixing with secretions.",1
She was maintained on strict NPO status.,0
"At the time of discharge on she was tolerating a regular diet, afebrile with stable vital signs.",0
Information was obtained from Family/Caregiver.,0
Warfarin 5 mg PO DAILY16 2.,0
Aspirin 81 mg PO DAILY 3.,0
Furosemide 20 mg PO DAILY 4.,0
Calcium Carbonate 500 mg PO BID 5.,0
Digoxin 0.125 mg PO DAILY 6.,0
FoLIC Acid 1 mg PO DAILY 7.,0
Metoprolol Tartrate 25 mg PO BID 8.,0
Omeprazole 20 mg PO DAILY 9.,0
Meclizine 12.5 mg PO DAILY:PRN vertigo Discharge Medications: 1.,0
Calcium Carbonate 500 mg PO BID 2.,0
Digoxin 0.125 mg PO DAILY 3.,0
FoLIC Acid 1 mg PO DAILY 4.,0
Metoprolol Tartrate 25 mg PO BID 5.,0
Warfarin 5 mg PO DAILY16 6.,0
Acetaminophen 325-650 mg PO Q6H:PRN pain headache 7.,0
Free 1-2 DROP BOTH EYES PRN dry eye 8.,0
Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days 9.,0
Heparin 5000 UNIT SC TID 10.,0
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 11.,0
LeVETiracetam 1000 mg PO BID 12.,0
Multivitamins 1 TAB PO DAILY 13.,0
Potassium Chloride 40 mEq PO BID Duration: 24 Doses Hold for K > 4.5 14.,0
Phosphorus 500 mg PO BID 15.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Subdural hematoma with compression Cerebral edema Intraparenchymal Hemorrhage Dysphagia Delirium Urinary Tract Infection Discharge Condition: Mental Status: Confused - sometimes.,1
Activity Status: Out of Bed with assistance to chair or wheelchair.,0
Discharge Instructions: Craniotomy for Subdural Hematoma Dr.,0
Have a friend/family member check your incision daily for signs of infection.,0
Take your pain medicine as prescribed.,0
"Exercise should be limited to walking; no lifting, straining, or excessive bending.",0
"Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation.",0
"Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc.",0
"You were on a medication such as Coumadin (Warfarin) and Aspirin 81 mg qd, prior to your injury, you may safely resume taking this on .",0
"Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to.",0
New onset of tremors or seizures.,0
Any confusion or change in mental status.,0
"Any numbness, tingling, weakness in your extremities.",0
"Pain or headache that is continually increasing, or not relieved by pain medication.",0
"Any signs of infection at the wound site: redness, swelling, tenderness, or drainage.",1
Fever greater than or equal to 101??????,0
"Please call ( to schedule an appointment with Dr. , to be seen in 4 weeks.",0
You will need a CT scan of the brain without contrast.,0
4:48 PM CAROTID SERIES COMPLETE PORT Clip # Reason: PREOP CABG Admitting Diagnosis: CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with CAD 3VD REASON FOR THIS EXAMINATION: please assess for evidence of carotid stenosis ______________________________________________________________________________ FINAL REPORT CAROTID STUDY HISTORY: Coronary artery disease.,1
9:00 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate L effusion Admitting Diagnosis: S/P BOATING ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with L decortication / rib resection REASON FOR THIS EXAMINATION: evaluate L effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Follow up.,1
"As compared to the previous radiograph, surgical clips are now seen in the left lateral thoracic wall.",1
The old chest tube has been removed and two new chest tubes have been inserted.,0
"Obviously, as a consequence, substantial parts of the pre-existing left-sided fluid is drained, the overall amount of fluid has markedly decreased and parts of the retrocardiac lung parenchyma are again aerated.",0
"The morphology of the right lung, with moderate pleural effusion and basal opacities is unchanged.",0
"The endotracheal tube is in unchanged position, the nasogastric tube has been removed.",0
"7:10 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for interval change, position of lines Admitting Diagnosis: CARDIAC CATH, S/P MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman s/p STEMI, intubated, s/p cardiac cath w/out intervention REASON FOR THIS EXAMINATION: Please assess for interval change, position of lines ______________________________________________________________________________ FINAL REPORT INDICATION: Myocardial infarction, status post diagnostic cardiac catheterization.",1
Assess for interval change and position of lines.,0
COMPARISON: Prior chest radiograph from the day before.,0
TECHNIQUE AND FINDINGS: A single view frontal chest radiograph was obtained in semi-erect position at the bedside.,0
Lines and tubes are unchanged.,0
"As before, there is stable cardiomegaly and widening of the cardiomediastinal silhouette, known retrocardiac opacity and persisting improvement in bilateral pulmonary edema.",0
CONCLUSION: No significant change as compared to previous study from yesterday.,0
"3:58 AM CHEST (PORTABLE AP) Clip # Reason: intervel progression on pulm edema Admitting Diagnosis: ISCHEMIC BOWEL ______________________________________________________________________________ MEDICAL CONDITION: 74 with afib on predexa, dialated cardiomyopathy, HLD, HTN, s/p PE, s/p recent stroke who is transffered from the medical floor due to uncontrolled Afib/RVR, dehydration and renal failure which developed in the context of recieving in-patient colonoscopy prep as part of work-up for a subacute diarrheal illness.",1
REASON FOR THIS EXAMINATION: intervel progression on pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: AFib with RVR and renal failure.,0
FINDINGS: The tip of the NG tube is just past the gastroesophageal junction.,0
A left PICC ends at the confluence of the brachiocephalic veins.,0
A right subclavian central line ends in the mid SVC.,0
The mild-to-moderate pulmonary edema has resolved.,0
"New right lower lobe collapse is shifting the mediastinum rightward, despite a small right pleural effusion.",0
Moderate enlargement of the cardiomediastinal silhouette is stable.,0
New right lower lobe collapse and possible small right pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: confusion Major Surgical or Invasive Procedure: Intubation with mechanical ventilation, now extubated History of Present Illness: 18 yo M who was to ED by friends when confused and .",0
Per his friends the patient was completely normal earlier in the day (He is visiting from ).,0
They happened upon him tonight and he was alternating between confusion (laughing inappropriately) and combative.,0
Friends reported that had smoked MJ before but unknown if any other substances.,0
Also found to have large hematoma over left frontal skull.,0
Patient unable to give history.,0
"Patient presented to ED afebrile 98.2, tachy 130's, hypertensive > 180's, blood sugar 149, oxygenating well on room air.",0
Patient intubated to allow for head imaging.,0
Head CT neg for bleed.,0
"Once intubated, on propafol, HR to 90's, SBP to 120's.",0
"Discussed with tox who were concerned for anticholinergic syndrome, PCP, , or dextromethorphan.",0
Past Medical History: None Social History: Student at College of Art.,0
"Was smoking Marijuana just prior to admission, but denies other illicit drug use.",0
- CT C-spine **preliminary report** Endotracheal tube and nasogastric tubes are viewed respectively.,0
There is no malalignment or acute fracture of the cervical spine.,0
There is no prevertebral soft tissue swelling.,0
"Please note, CT is unable to provide intrathecal detail comparable to MRI.",0
The visualized portions of the lung apices are unremarkable.,0
IMPRESSION: No evidence of acute fracture or malalignment of the cervical spine .,0
"- CT head **preliminary report** FINDINGS: There is no evidence of acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major or minor vascular territorial infarction.",0
The density values of the brain parenchyma are within normal limits.,0
There is a large subcutaneous hematoma over the left frontal area measuring at least 9 cm in diameter with areas of hyperdensity suggestive of ongoing bleeding.,0
No underlying skull fracture or foreign body is detected.,0
The visualized portions of the paranasal sinuses and the mastoid air cells are unremarkable.,0
"No evidence of acute intracranial pathology, including no sign of intracranial hemorrhage.",0
Large left frontal subcutaneous hematoma with foci of hyperdensity reflective of ongoing bleeding.,0
- pCXR: FINDINGS: An endotracheal tube is present with the distal tip approximately 3.7 cm from the carina.,0
A nasogastric tube is evident coiled within the gastric body.,0
The lung volumes are low.,0
The lungs otherwise are clear.,0
The cardiac silhouette is within normal limits accounting for patient and technical factors.,0
No pleural effusion or pneumothorax is evident.,0
IMPRESSION: Endotracheal tube in satisfactory position.,0
"Low lung volumes, but otherwise, lungs are clear.",0
Brief Hospital Course: 18 yo M who was brought to ED by friends when confused and .,0
# Altered Mental Status: 18 y.o.,0
patient with no past medical history brought in by friends to .,0
"Reportedly, he smoked Marijuana and had a panic attack, causing him to run his head into a wall.",0
"Afterward he was intermittently confused and , ambulance called.",0
"Tox screen negative for both drugs of abuse and ASA, triCyc, and tylenol.",0
He was intubated and sedated in order to obtain head and neck CTs.,0
No fractures noted of the skull or C-spine.,0
"Physicial exam and CT head revealed a large subcutaneous hematoma, but no parenchemal or other internal bleeding by imaging.",0
"Toxicology was consulted and felt possible agents included PCP, , or dextromethorphan.",0
His mental status improved quickly and he was extubated within 12 hours.,0
Most likely his mental status changes were secondary to head trauma given hematoma.,0
His repeat neuro exam was normal.,0
The patient was scheduled on a flight home to on the day of discharge.,0
"It was felt he was safe to fly, and was instructed to follow up with his primary care physician (Dr. in days to be sure he did not have concussive symptoms.",0
"The patient's sister, , was contact and updated.",0
A message was left for the patient's PCP.,0
# Leukocytosis: No localizing sign of infection.,0
"Level was trending down, and likely to trauma/acute inflammation.",0
"# FEN - NPO while intubated, then regular diet.",0
"# PPX - hep sc, PPI .",0
Full Code Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: 1.,0
Respiratory failure secondary to intoxication 2.,0
"Hypertension -- resolved Discharge Condition: Stable, neurologic exam normal Discharge Instructions: You were admitted with altered mental status, now improved back to your baseline.",0
Please follow up with your doctor in days.,0
"Call your doctor or return to the Emergency Room immediately if you have confusion, severe or worsening head pain, blurred vision, or any other symptom that concerns you.",0
Followup Instructions: Call your doctor when you get home; Set up a follow up appointment in days to be sure you do not develop symptoms of a concussion.,0
9:41 AM PORTABLE ABDOMEN Clip # Reason: ileus Admitting Diagnosis: ACUTE CORONARY SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with s/p CABG REASON FOR THIS EXAMINATION: ileus ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw 1:30 PM No bowel obstruction or ileus.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Status post CABG with ileus.,0
FINDINGS: There is nonspecific bowel gas pattern with non-dilated loops of bowel.,0
There is an irregularity to the right iliac crest likely related to prior bone harvest.,0
Extensive vascular calcifications are present.,0
Extensive degenerative change as well as scoliosis deformity of the lumbar spine is present.,0
There is a radiopaque ovoid structure projecting over the right lower pelvis as well as an ovoid radiodense object projecting in the area of the patient's penis likely related to a penile prosthesis and pump reservoir.,1
IMPRESSION: No evidence for bowel obstruction or ileus.,0
"3:54 AM CHEST (PORTABLE AP) Clip # Reason: per team request Admitting Diagnosis: ASPIRATION; FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: 80 year with increasing O2 requirements possibly seconday to aspiration from previous small bowel follow through REASON FOR THIS EXAMINATION: per team request ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest, AP portable, single view.",0
"INDICATION: Increasing oxygen requirements, possibly secondary to aspiration.",0
Compare with the next previous examination.,0
FINDINGS: AP single view of the chest obtained with the patient in semi-upright position is analyzed in direct comparison with the next previous similar study of .,0
The previously described extensive bilateral pulmonary parenchymal densities persist.,0
"They may have increased somewhat, but technical differences in exposure may account for this.",0
Previously described central venous lines in unchanged position.,1
IMPRESSION: Persistent advanced pulmonary densities representing pulmonary infiltrates and CHF.,0
Clip # Reason: BILAT HYDRO ?,0
"UTI HEMATURIA Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 20 year old woman with hematuria, dysuria REASON FOR THIS EXAMINATION: bilateral hydro?",0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg MON 12:38 AM PFI: No evidence of hydronephrosis.,0
Marked asymmetric right posterior bladder wall thickening with hyperemia.,0
"Findings may represent UTI, however, given the history of lupus, interstitial cystitis is also a consideration and urology consultation is recommended.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 20-year-old female with hematuria and dysuria.,0
RENAL ULTRASOUND: The right kidney measures 10.2 cm and the left kidney measures 10.8 cm.,0
"There is no evidence of hydronephrosis, mass or stones.",0
"The bladder is markedly abnormal with asymmetric frond-like thickening of the bladder wall, particularly in the right posterior wall.",0
There is hyperemia of the bladder wall without identifiable debris in the bladder lumen.,0
"IMPRESSION: Asymmetric right posterior bladder wall thickening and hyperemia may be related to urinary tract infection; however, given the history of lupus, interstitial cystitis is also a consideration and urology consultation is recommended.",1
"Given the asymmetry of the findings, a cystoscopy may be needed (if findings persist after appropriate treatment) with biopsy to exclude malignancy.",0
"12:02 AM CHEST (PORTABLE AP) Clip # Reason: placement of NGT Admitting Diagnosis: MYOCARDIAL INFARCTION;S/P ARREST ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with new NGT placed REASON FOR THIS EXAMINATION: placement of NGT ______________________________________________________________________________ FINAL REPORT AP CHEST, 12:21 A.M. ON HISTORY: New nasogastric tube.",1
IMPRESSION: AP chest compared to : Nasogastric tube passes into the stomach and out of view.,0
Intra-aortic balloon pump in standard placement.,0
Slight increase in interstitial abnormality right lung base could be early edema.,0
There is no pleural effusion.,0
ET tube in standard placement.,0
5:04 PM CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: r/o spinal abscess Admitting Diagnosis: HEMATOCHEZIA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old femal s/p I&D w/ weakness REASON FOR THIS EXAMINATION: r/o spinal abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post I&D with weakness.,0
TECHNIQUE: Helically-acquired contiguous axial images of the thoracic spine were obtained following the administration of 150 cc of IV Optiray.,0
Nonionic contrast was administered secondary to the patient's debility.,0
Coronal and sagittal reconstructions were performed.,0
CT OF THE THORACIC SPINE WITH IV CONTRAST: No fracture or malalignment of the thoracic spine is identified.,0
Multilevel degenerative changes are noted with anterior osteophyte formation and endplate sclerotic changes.,0
The outline of the thecal sac appears unremarkable.,0
No paraspinal fluid collections are identified suggestive of an abscess.,0
Bilateral pleural effusions and bibasilar atelectasis are noted.,0
IMPRESSION: Multilevel degenerative changes without evidence of malalignment or fracture.,0
No focal fluid collections identified suggestive of an abscess.,0
Spinal canal detail is limited and an epidural abscess cannot be fully excluded on the basis of this study.,0
"If the patient is able to tolerate it, an MR study with gadolinium is a more sensitive study.",0
8:07 PM CHEST (PORTABLE AP) Clip # Reason: s/p NG placement after pt pulled out previous one.,0
Now repla ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with SDH REASON FOR THIS EXAMINATION: s/p NG placement after pt pulled out previous one.,0
Now replaced ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: NG tube replaced after being pulled out.,0
The tip of the NG tube lies within the stomach.,0
No gross failure is seen.,0
Bibasilar atelectasis is still present.,0
IMPRESSION: Tip of NG tube lies in stomach.,0
"4:31 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: RIGHT PROXIMAL TIBIA SARCOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with CAD, COPD, s/p osteosarcoma resection, now extubated REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb SAT 9:46 AM Opacity in right lung base is unchanged.",0
Slight improvement of left lung base patchy consolidation.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old male with coronary artery disease, COPD, status post osteosarcoma resection, now extubated.",1
COMPARISON: Most recent chest radiograph in .,0
PORTABLE AP CHEST RADIOGRAPH: Patient is status post sternotomy with intact wires.,1
Patient is status post CABG surgery.,1
Epidural catheter is in place.,0
Severe emphysema predominantly in upper lobes are unchanged.,0
Unchanged appearance of consolidation in the right lung base.,0
Improvement of the left lung base consolidation.,0
Unchanged small right pleural effusion.,0
Heart size is within normal limits.,0
"9:31 AM CHEST (PORTABLE AP) Clip # Reason: please eval for infiltrates ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with possible sz intubated in field and vomited a lot while intubated REASON FOR THIS EXAMINATION: please eval for infiltrates ______________________________________________________________________________ FINAL REPORT CHEST, : INDICATION: Patient vomited during intubation procedure in the field.",0
The ETT and the NGT have now been removed.,0
There is now evidence of some patchy atelectasis in the right lower lobe and some linear atelectasis in the left lower zone as well.,0
Slight blunting of the left costophrenic angle is noted.,0
The heart again shows some left ventricular enlargement.,0
However the pulmonary vessels do not indicate cardiac failure at this time.,0
No other significant cardiopulmonary abnormality is identified.,0
"IMPRESSION: Right lower lobe and to a lesser extent left lower zone atelectasis, consistent with the history of aspiration.",0
No other acute cardiopulmonary abnormality.,0
8:13 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: evalaute for infiltrate Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with s/p evar REASON FOR THIS EXAMINATION: evalaute for infiltrate ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 9:56 AM ET tube tip is 5.9 cm above the carina.,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Assess ET tube s/p endovascular AAA repair.,0
ET tube now is 5.9 cm above the carina.,0
Vascular fluid overload has improved as are bibasilar atelectasis.,0
Left pleural effusion is still small.,0
NG tube tip is coiled in the stomach and should be repositioned.,0
No other interval change from 6 hours earlier.,0
"10:12 AM CHEST (PA & LAT) Clip # Reason: S/P CABG ON FRIDAY INTERVAL CHANGE Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with s/p CABG with HCT drop REASON FOR THIS EXAMINATION: bleed ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, .",1
HISTORY: Status post CABG with hematocrit drop.,0
"IMPRESSION: PA and lateral chest compared to and 9: Lung volumes are lower following extubation, postoperatively.",0
"Two left pleural drains in place, but only a small residual left pleural effusion is present.",0
"Lateral view shows retrosternal air and fluid collection, common postoperative finding.",0
"Cardiomediastinal silhouette is essentially normal postoperatively, and aside from plate-like areas of atelectasis in the lower lungs, the lungs are clear.",0
"7:46 AM MR KNEE W&W/O CONTRAST RIGHT; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please eval for possible osteomyelitis, septic joints, or ab Admitting Diagnosis: ENDOCARDITIS Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with MSSA endocarditis with L hip and thigh pain and spacer in R knee REASON FOR THIS EXAMINATION: Please eval for possible osteomyelitis, septic joints, or abscesses in pelvis, hips, and knees No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: MSSA endocarditis, left hip and thigh pain, spacer in the right knee.",1
"Evaluate for osteomyelitis, septic joints, or abscess.",0
COMPARISON: Right knee radiographs from (images scanned into PACS).,0
"TECHNIQUE: Following sequences of the right knee were obtained on a 1.5 Tesla magnet: Axial T1, axial STIR, axial T2, sagittal T1, sagittal STIR, axial 5 pre- and post-contrast, sagittal T1 VIBE post-contrast, axial T1 with fat saturation post-contrast.",0
20 mL of 0.1 mmol/kg of gadolinium-DTPA was injected by hand without adverse effect.,0
MRI OF THE RIGHT KNEE WITH AND WITHOUT INTRAVENOUS CONTRAST: Patient demonstrates evidence of a previous total knee replacement with complete removal of the hardware.,0
"Multiple small foci of low signal on T1- and T2- weighted imaging are identified within the knee, compatible with susceptibility artifact from previous surgery, most pronounced within the anterior aspect of the knee.",0
The inferior patella demonstrates extensive osseous remodeling.,0
"Low signal material on T1- and T2-weighted imaging is demonstrated within the removed hardware beds, consistent with methyl methacrylate.",0
"Specifically, methyl methacrylate is identified within the shaft of the distal femur, the suprapatellar region, proximal tibial shaft, and knee joint.",0
A small amount of fluid within the joint space is uniformly high in signal on both STIR sequences and pre- contrast T1- weighted fat- suppressed sequences.,0
The latter finding is unusual and suggests that residual gadolinium administered from a previous MR examination has been excreted into the joint.,0
"This joint fluid is in direct communication with the periprosthetic beds, as joint fluid is noted to extend superior to the suprapatellar methyl methacrylate component, and also circumferentially around the methyl methacrylate stems within the distal femur and proximal tibia.",0
"As intra-articular gadolinium is demonstrated prior to the administration of intraveneous gadolinium on the current exam, these findings suggest that the contrast received from the patient's previous MR has been retained and excreted into the intra-articular space.",0
"Post- contrast administration on this examination, no areas of additional enhancement are (Over) 7:46 AM MR KNEE W&W/O CONTRAST RIGHT; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please eval for possible osteomyelitis, septic joints, or ab Admitting Diagnosis: ENDOCARDITIS Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) demonstrated.",1
"There is diffuse reticular abnormal signal within the subcutaneous tissues surrounding the knee, which is intermediate in signal on T1-weighted images, and high in signal on T2-weighted images, compatible with subcutaneous edema.",0
The regional muscle groups are all atrophied and the majority of the images muscles demonstrate diffuse heterogeneous high signal on T2- weighted imaging compatible with edema.,0
Patency of the vessels is not well assessed on this examination.,0
"The patient's reported above-knee popliteal to dorsalis pedis bypass graft is not well visualized, possibly obscured by surrounding susceptibility artifact.",0
Presence of intra-articular gadolinium on the pre-contrast sequences indicates retention and excretion of contrast which was administered for a previous MR examination on .,0
"Please note that the patient has had three MRIs with intravenous gadolinium in the span of three days (at 2 different institutions), and the presence of intra- articular gadolinium on the current study (and in the urinary bladder on the pre-contrast images from the previous study) suggests renal impairment and decreased clearance of gadolinium.",0
Correlation with patient's creatinine levels and consideration of dialysis is recommended.,0
No further MR examinations with gadolinium is recommended in the near future until the patient's renal function has been evaluated.,0
Findings discussed with Dr. on .,0
Status post removal of total knee replacement with methyl methacrylate in the removed hardware beds.,0
"Periprosthetic fluid is seen surrounding the methyl methacrylate components, which is in continuity with the joint space, a nonspecific finding.",0
MRI cannot distinguish between edema related to post-surgical changes and edema related to infection.,0
No discrete abcess is identified.,0
Diffuse edema within the subcutaneous tissues of the knee.,0
10:01 AM PICC LINE PLACMENT SCH Clip # Reason: Placed L. arm PICC Won't advance last 10cm.,0
Admitting Diagnosis: PNEUMONIA Contrast: OPTIRAY Amt: 15 ********************************* CPT Codes ******************************** * EXCH PERPHERAL W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION * * FLUORO GUID PLCT/REPLCT/REMOVE FEE ADJUSTED IN SPECIFIC SITUATION * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with REASON FOR THIS EXAMINATION: Placed L. arm PICC Won't advance last 10cm.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): FBCa FRI 5:26 PM Uncomplicated PICC exchange.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Malposition of indwelling PICC line.,0
RADIOLOGISTS: Dr. and performed the procedure.,0
"TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling left arm PICC line and subsequently into the SVC under fluoroscopic guidance.",0
The old PICC line was then removed and a peel-away sheath was placed over the guidewire.,0
Attempts to advance the catheter over the wire into the SVC were unsuccessful.,0
"The catheter and the guidewire were removed and injection of a small amount of contrast material through the peel-away sheath demonstrated patent cephalic, brachial and brachiocephalic veins.",0
A 0.018 Glidewire was advanced through the peel-away sheath into the SVC under fluoroscopic guidance.,0
A new single-lumen PICC line measuring 49 cm in length was then placed over the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
The peel-away sheath and guidewire were removed.,0
The patient tolerated the procedure well without immediate complications.,0
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new single-lumen PICC line.,0
Final internal length is 49 cm with the tip positioned in the proximal SVC.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Minimal Invasive Off-Pump Coronary Artery Bypass Graft x 1 w/ Thorascopic LIMA Harvest History of Present Illness: 41 y/o male with h/o HIV and +FH c/o chest pain.,1
Had an abnormal stress test and was then referred for a cardiac cath.,0
There was an attempt at stenting the LAD but failed.,0
Now will undergo surgical revascularization.,0
"Past Medical History: HIV, Hyperlipidemia, Asthma, Peripheral Neuropathy, Gastroesophageal Reflux Disease, s/p Tonsillectomy, s/p cochlear implant Social History: Quit smoking 2 weeks ago after ppd x 28yrs.",1
Social ETOH drinker w/ approx.,0
Family History: 2 sisters with in there 30's.,1
"Physical Exam: VS: 60 18 132/71 5'"" 172# Gen: WDWN male in NAD Skin: unremarkable HEENT: EOMI, PERRL, poor dentitian Neck: Supple, FROM, -JVD, -bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft NT/ND +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: Echo: The left atrium is moderately dilated.",0
The left atrium is elongated.,0
The right ventricular cavity is dilated.,0
"After completion of the grafting, there is no significant change in the echocardiographic examination.",0
CXR: Small left apical pneumothorax as well as multiple loculated left hydropneumothoraces appear unchanged.,0
Subcutaneous emphysema persists in the left chest wall.,0
"Heart size, mediastinal and hilar contours are within normal limits.",0
Multifocal atelectasis in the left lung is unchanged as well as a small right pleural effusion.,0
04:34PM BLOOD WBC-16.9*# RBC-3.87* Hgb-12.0* Hct-34.0* MCV-88 MCH-31.0 MCHC-35.2* RDW-14.7 Plt Ct-219 09:00AM BLOOD WBC-7.3 RBC-3.38* Hgb-10.2* Hct-29.7* MCV-88 MCH-30.3 MCHC-34.5 RDW-14.7 Plt Ct-291# 06:40PM BLOOD PT-12.9 PTT-27.3 INR(PT)-1.1 06:40PM BLOOD UreaN-14 Creat-0.9 Cl-106 HCO3-24 09:00AM BLOOD Glucose-135* UreaN-19 Creat-1.1 Na-136 K-4.8 Cl-99 HCO3-28 AnGap-14 Brief Hospital Course: Mr. was a same day admit and on was brought to the operating room where he underwent a minimal invasive off-pump coronary artery bypass graft x 1.,1
Please see operative report for details.,0
Following surgery he was transferred to the CSRU for invasive monitoring in stable condition.,0
"Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated.",0
On post-op day one beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight.,0
On post-op day two he was transferred to the SDU for further care.,0
Initial chest x-ray during post-op period revealed a small apical pneumothorax.,0
"Despite chest tubes remaining in place, pneumothorax was still evident through post-op day four.",0
Therefore chest tubes were removed on post-op day four.,0
Post chest x-ray still revealed pneumothorax but with no increase in size.,0
He remained stable during these days while receiving physical therapy for strength and mobility.,0
On post-op day 5 he was doing well and was discharged home with VNA services and the appropriate follow-up appointments.,0
"Medications on Admission: Albuterol Neb q6hr, Albuterol INH, Aspirin 325mg qd, Atenolol 25mg qd, Chantix 1mg , Flovent INH, Lexiva 700mg , Lipitor 20mg qd, Marinol 10mg , Norvir 100mg , Omeprazole 20mg qd, Videx EC 250mg qd, Viread 300mg qd Discharge Medications: 1.",0
LEXIVA 700 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Marinol 10 mg Capsule Sig: One (1) Capsule PO twice a day.,0
Norvir 100 mg Capsule Sig: One (1) Capsule PO twice a day.,0
"Videx EC 250 mg Capsule, Delayed Release(E.C.)",0
Viread 300 mg Tablet Sig: One (1) Tablet PO once a day.,0
"7:29 AM CHEMOEMBO LIVER Clip # Reason: growing tumor, needs CE Contrast: OPTIRAY Amt: 251 ********************************* CPT Codes ******************************** * TRANSCATHETER INFUSION NOT LYS INITAL 3RD ORDER ABD/PEL/LOWER * * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO * * TRANSCATHETER INFUSION F/U STATUS INFUSION/EMBO * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE * * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with HCC REASON FOR THIS EXAMINATION: growing tumor, needs CE ______________________________________________________________________________ FINAL REPORT HISTORY: 62-year-old man with hepatocellular carcinoma requiring chemoembolization.",0
PROCEDURE AND FINDINGS: The procedure was performed by Drs.,0
"and , who was present and supervising throughout.",0
Informed consent was obtained and preprocedure timeout was performed.,0
The patient's right groin was then prepped and draped in standard sterile fashion.,0
"Due to the patient's body habitus, ultrasonographic guidance was used to access the right common femoral artery with a 19 gauge needle after administration of 1% lidocaine.",0
wire was advanced into the abdominal aorta and the needle was exchanged for a 6 Fr bright-tipped sheath.,0
The sheath was attached to continuous flush.,0
A 5 Fr C2 Cobra catheter was then advanced over the wire into the abdominal aorta.,0
Selective access into the superior mesenteric artery was gained and SMA arteriogram was performed.,0
This demonstrated a patent SMA with filling of large venous collaterals.,0
Slight opacification of the portal vein was observed.,0
"Using the catheter and a glide wire, selective access into the splenic vein was obtained.",0
Splenic arteriogram was performed which demonstrated a patent splenic artery with filling of a large splenorenal shunt.,0
Filling of an additional large collateral was seen which may have been a gonadal vein.,0
The catheter was then repositioned into the SMA and 30 mg of Papaverine was injected through the catheter.,0
Repeat SMA arteriogram was performed which redemonstrated large venous collaterals and slight opacification of the portal vein.,0
"Using the catheter and glide wire, selective access was then obtained into the right hepatic artery.",0
"Right hepatic arteriogram demonstrated at least five right hepatic masses, the largest located inferiorly.",0
Splaying of hepatic arteries was observed as well as invasion of portal branches by the tumors.,0
Contrast was also observed passing in a hepatofugal fashion in the portal vein.,0
"Based on these diagnostic findings, it was decided that the patient would benefit from chemoembolization.",0
"With the catheter in the right hepatic artery, an emulsified combination of 60 mgm doxorubicin in 20ml of ethiodol were infused.",0
"(Over) 7:29 AM CHEMOEMBO LIVER Clip # Reason: growing tumor, needs CE Contrast: OPTIRAY Amt: 251 ______________________________________________________________________________ FINAL REPORT (Cont) Intermittent 2 cc of lidocaine was administered as well.",0
"Following completion of the chemotherapy, a Gelfoam slurry was infused into the right hepatic artery until stagnant flow was seen.",0
Postembolization arteriogram demonstrated cessation of flow through the right hepatic artery and retrograde contrast filling the left hepatic artery and gastroduodenal artery.,0
The catheter and sheath were then removed.,0
Pressure was held until hemostasis was achieved.,0
The patient tolerated the procedure well and there were no immediate postprocedure complications.,0
Multiple right hepatic masses consistent with the patient's known hepatocellular carcinoma.,0
Invasion into the portal vein is seen with hepatofugal flow in the portal vein on injection of the right hepatic artery.,0
Successful chemoembolization of the right hepatic lobe.,0
Large splenic and mesenteric collaterals including a splenorenal shunt.,0
Dr. held pressur on the arteriotomy site for 15minutes after the catheter was removed.,0
"1:50 PM CHEST (PORTABLE AP) Clip # Reason: s/p CABG and AVR w/^PIP-r/o ptx ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with cad and as REASON FOR THIS EXAMINATION: s/p CABG and AVR w/^PIP-r/o ptx ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : Compared to one day earlier.",0
CLINICAL INDICATION: S/P coronary artery bypass surgery and valve replacement.,1
"An ETT, Swan-Ganz catheter, mediastinal drain, and two left-sided chest tubes are in place as well as NGT.",0
"Of note, the NGT is coiled in the upper stomach.",0
Other lines and tubes are all in satisfactory position.,0
The cardiac and mediastinal contours are within normal limits for technique and recent post operative status of the patient.,0
"Note is made of a subtle bilateral interstitial pattern, new in the interval.",0
"There are also atelectatic changes at both lung bases, left greater than right.",0
"There is some haziness in the region of the left costophrenic sulcus, possibly due to a small effusion.",0
IMPRESSION: 1) Bilateral basilar atelectasis and probable small left pleural effusion.,0
"2) Subtle interstitial pattern, likely representing interstitial pulmonary edema.",0
"11:36 PM CHEST (PORTABLE AP) Clip # Reason: new infiltrate, edema??",0
"Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with h/o COPD and CHF with sudden onset SOB REASON FOR THIS EXAMINATION: new infiltrate, edema??",1
______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST: INDICATION: Sudden onset shortness of breath.,0
FINDINGS: ETT tip is less than 2 cm above the carina and should be pulled back slightly.,0
There is marked thoracic scoliosis.,0
There are no focal infiltrates.,0
IMPRESSION: ETT should be withdrawn 1-2 cm.,0
"1:23 PM UNILAT UP EXT VEINS US Clip # Reason: Please reassess known IJ clot Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with HIT, GBS, enterococcus bacteremia REASON FOR THIS EXAMINATION: Please reassess known IJ clot ______________________________________________________________________________ FINAL REPORT INDICATION: Please reassess known IJ clot.",0
"The right jugular vein, right subclavian vein, right axillary vein, right brachial vein (proximal, mid and distal) and the right basilic vein are patent and demonstrate normal augmentation and flow direction.",0
There is no evidence of thrombosis at the above-described vessels of the right upper extremity.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Briefly, the patient is a 64-year-old male who is an unrestrained driver of a car that was T-boned on the passenger side and then rolled over to the driver side.",0
The patient was found unresponsive and caught under the dashboard.,0
He had a long extrication time.,0
"He is intubated by EMS at the scene, later becoming agitated and localizing.",0
His only obvious injury at the time was a head laceration.,0
He as Life Flighted to .,0
"PHYSICAL EXAMINATION: Temperature was 97 rectal, heart rate 72, pressure of 170/133, respiratory rate 18, pulse oximetry 100% The patient was intubated and sedated.",0
"Pupils were 2 mm, fixed and equal.",0
The patient was in a hard collar.,0
There was an abrasion over the left forehead and scalp.,0
Chest and lungs are clear to auscultation bilaterally.,0
Cardiac is regular rate and rhythm.,0
Neck is supple in hard collar.,0
"The abdomen was soft, nontender, nondistended.",0
Back: He had no stepoff or obvious deformities.,0
Extremities are warm without edema.,0
His peripheral pulses were intact.,0
Neurological exam: He was sedated.,0
"LABORATORY: On admission included a hematocrit of 37.7, white count 8.7, BUN and creatinine 18.8, and amylase of 68, lipase 2.1.",0
"Blood gas was 7.51, 29, 434, 24 and 1.",0
Urinalysis showed 11 to 20 red blood cells.,0
His urine tox is negative.,0
Initial trauma workup and imaging included a chest x-ray demonstrated adequate position of the endotracheal tube and orogastric tube with tip in the esophagus.,0
Pelvic x-ray which was without fracture.,0
A Head CT which was negative.,0
A C-spine CT with reconstructions that was negative.,0
An abdominal pelvis CT which is also read as negative initially.,0
HOSPITAL COURSE: Following his initial resuscitation imaging workup the patient was transferred to the Trauma Intensive Care Unit under the care of Dr. .,0
Overnight from hospital day 0 to hospital day one the patient remained intubated and sedated.,0
On hospital day two the patient was extubated in the Intensive Care Unit without any difficulty.,0
Following extubation the patient remained somewhat somnolent but with a nonfocal neurologic exam otherwise the sedation was held.,0
"Hospital day two the patient remained in the Intensive Care Unit, was transferred to the floor on hospital day three.",0
On the floor the patient again had somewhat decreased verbal output per the patient's wife.,0
"Also appeared somnolent, at times confused but otherwise a nonfocal neurologic exam.",0
"Given that the patient was somewhat somnolent he had a repeat head CT performed, this head CT demonstrated one small area of intraparenchymal bleed consistent with diffuse axonal injury verses artifact.",0
"Given the nonspecific findings on CT it was decided to obtain an Magnetic resonance scan, performed on Friday evening and this magnetic resonance scan was significant for diffuse spinal injury.",0
"For this the neurology service was consulted, felt that the patient's exam was significant for decreased processing speed.",0
"Attention, concentration and poor short-term verbal recall.",0
"The patient was felt to have relatively preserved procedural and remote memory but impaired frontal executive function including fluency, some word finding difficulty and impaired abstract reasoning and comprehension of complex commands.",0
I felt this exam once again consistent with verses an acute concussional syndrome.,0
"They recommended an EEG, neuropsych testing and assessment for neurology rehabilitation.",0
"The Rehabilitation service was consulted and they recommended an acute rehabilitation for vertigo associated ataxia, cognitive therapy.",0
Additionally they recommended he remain out of work for at least three weeks and restart part time.,0
They felt there was no neurologic event that caused a seizure or stroke and wanted the patient to return to clinic on at approximately 12 noon.,0
"On the patient tolerating a regular diet, pain well controlled and adequate neurologic rehabilitation, plan in place and decided to discharge the patient to rehabilitation.",0
"FOLLOW-UP for Mr. should be with Behavioral Neurology, Dr. or Dr. , .",0
On the at 12 o'clock.,0
Dictated By: MEDQUIST36 D: 15:25 T: 17:31 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ibuprofen Attending: Chief Complaint: hypoxemia/hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo with h/o afib, gib, ischemic colitis, CHF just discharged from MICU to Rehab MACU on readmitted with hypoxemiz and hypotension.",0
This is the third admission this month for Ms. .,0
"Please review past discharge summary for details, but briefly she had GI bleed from AVMs, dabigatran stopped, readmitted with ischemic colitis, managed conservatively.",0
She was relatively hypotensive during her last admission.,0
She was always very clear about her wishes to avoid invasive measures including central lines.,0
"At rehab, she was noted to be hypoxemic.",0
Also had right calf pain and dvt ruled out by ultrasound.,0
She was admitted here for work-up.,0
"In emergency department, was started on dopamine for hypotension.",0
"On arrival, discussed with patient and niece at bedside.",0
She stated she wanted to be made comfortable.,0
She stated that she did not want medicine to raise her blood pressure and was made CMO.,0
"Patient was transferred to 7 from the MICU accompanied by her niece, and palliative care physicians (Dr. from , Dr. ) were consulted.",0
"Per palliative care recommendations, was placed given intravenous and sublingual morphine, 5% lidocaine patch, acetaminophen, scopolamine patch and SL Levsin for comfort.",0
Vital signs were held for comfort.,0
"She was monitored regularly for pain and shortness of breath, which were treated with the above medications.",0
She was declared deceased at 13:47 on .,0
"Primary cause of death was CHF secondary to sepsis, with incident causes of GIB, mesenteric ischemia, ischemic colitis, CAD, atrial fibrillation, thyroid cancer.",1
Primary care physician (Dr. was notified of admission.,0
"Past Medical History: * Coronary artery disease with MIs (?X3 in ) * Hypertension * Atrial fibrillation: on digoxin in the past, now on dabigatran started ~ * Hyperlipidemia * Osteoarthritis * Cholecystectomy + ERCP in * Partial hysterectomy * Thyroid cancer s/p thyroidectomy and parathyroidectomy Social History: Worked at Hospital as nursing aide in the Alcoholics Unit for years.",1
"Retired, lives in retirement community.",0
"glasses of wine/month (social), denies illicits.",0
Remote history of tobacco (quit over 40 years ago).,0
Has refused to ever have colonoscopy.,0
Family History: Father had an MI in his 50s and died of renal cancer.,0
Mother had an MI in her 40s.,0
No family history of sudden cardiac death.,0
"Daughter died at 54 years old of liver cancer, brother died at 77 years old (4 years ago) of gastric cancer.",0
"No other family history of malignancies, IBD, celiac disease, blood dyscrasias.",0
"Physical Exam: VS: Not recorded GENERAL: Obese elderly woman in no acute distress, drowsy but responsive, unable to state why in hospital, says she's at , cannot recall date.",0
"HEENT: NC/AT, sclerae anicteric, MMM, OP clear.",0
"HEART: RRR, no MRG, nl S1-S2.",0
"LUNGS: Diffuse rhonchi, no r/wh, good air movement, resp unlabored.",0
"ABDOMEN: Soft/NT/ND, obese, no masses or HSM, no rebound/guarding.",0
"EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.",0
SKIN: No rashes or lesions.,0
Pertinent Results: ADMISSION LABS: .,0
"03:45PM BLOOD WBC-9.0 RBC-4.29 Hgb-13.0 Hct-40.0 MCV-93 MCH-30.2 MCHC-32.4 RDW-16.5* Plt Ct-281 03:45PM BLOOD Neuts-78* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 03:45PM BLOOD Glucose-132* UreaN-35* Creat-1.6* Na-142 K-5.1 Cl-109* HCO3-26 AnGap-12 03:45PM BLOOD proBNP-7656* Brief Hospital Course: 87 year-old woman with history of gastrointestinal bleed, atrial fibrillation, heart failure, ischemic colitis admitted from rehab with heart failure and hypotension.",1
She has consistently expressed a desire to avoid invasive measures and states clearly that she would like to be made comfortable and is okay with the possibility of death.,0
Her niece is at bedside and confirms that this is consistent with her wishes throughout.,0
"She was made comfort measures only and transferred to the floor with her niece (health care proxy), where palliative care was consulted.",0
"She was made comfortable with intravenous and sublingual morphine, 5% lidocaine patch, scopolamine patch, acetaminophen, and sublingual levsin.",0
"She was monitored regularly for pain and shortness of breath, with the above medications titrated to effect.",0
She was declared deceased at 13:47 .,0
"Her primary care physician, .",0
Autopsy was declined as patient is donating her body to medical science.,0
Medications on Admission: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).,0
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO twice a day.,0
3. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 6 days: Course to be complete .,0
4. ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400) mg Intravenous once a day for 6 days: Course to be complete .,0
"5. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
6. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia.,0
"7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual PRN as needed for chest pain: Please take 1 tab as needed for chest pain.",0
"1 tab every 5 minutes, for up to 3 tabs in 15 min.",0
Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain.,0
Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis Congestive Heart Failure Sepsis Mesenteric Ischemia Discharge Condition: Deceased.,1
Discharge Instructions: You were admitted with low oxygen levels and hypotension.,0
You were made comfortable and passed away Followup Instructions: None.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: HIV antibody test was checked and was negative.",0
"Discharge Disposition: Home With Service Facility: All Care VNA of Greater MD, Completed by:",0
", W. TSICU 12:27 AM MR HEAD W/O CONTRAST; MRV HEAD W/O CONTRAST Clip # Reason: eval patency of transverse sinus Admitting Diagnosis: EPIDURAL ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man w/comminuted depressed fracture of the occipital bone extending inferiorly s/p washout REASON FOR THIS EXAMINATION: eval patency of transverse sinus No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Hemorrhagic contusions in the cerebellum involving the left cerebellar hemisphere and both tonsils with inferior herniation of cerebellar tonsils below foramen magnum.",1
Blood within the lateral ventricles without hydrocephalus.,0
MRV shows slightly narrowed mid portion of the left transverse sinus at the site of fracture and contusion with continuous flow signal indicating patency.,1
Superior sagittal and right transverse sinuses are normal.,0
PATIENT/TEST INFORMATION: Indication: Pulmonary hypertension.,0
Height: (in) 64 Weight (lb): 105 BSA (m2): 1.49 m2 BP (mm Hg): 101/50 HR (bpm): 110 Status: Inpatient Date/Time: at 14:54 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.,0
Doppler parameters are indeterminate for LV diastolic function.,0
GENERAL COMMENTS: Suboptimal image quality as the patient was difficult to position.,0
Suboptimal image quality - body habitus.,0
Suboptimal image quality - ventilator.,0
Suboptimal image quality - patient unable to cooperate.,0
The rhythm appears to be atrial fibrillation.,1
Doppler parameters are indeterminate for left ventricular diastolic function.,0
The right ventricular cavity is moderately dilated with normal free wall contractility.,0
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).,0
There is (at least) moderate pulmonary artery systolic hypertension.,0
Normal overall left ventricular systolic function.,0
Moderate right ventricular dilation with preserved systolic function.,0
Mild calcific degenerative aortic stenosis.,0
At least moderate pulmonary hypertension.,0
"9:56 AM CT HEAD W/O CONTRAST Clip # Reason: 32 year old woman s/p L craniectomy for evacuation of LSDH, Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman s/p L craniectomy for evacuation of LSDH, please evaluate for interval changes REASON FOR THIS EXAMINATION: 32 year old woman s/p L craniectomy for evacuation of LSDH, please evaluate for interval changes No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 11:28 AM PFI: Interval increase in two foci of intraparenchymal hemorrhage in the left frontal cortex.",0
Two newly apparent foci of subarachnoid hemorrhage adjacent to the anterior margin of the left craniectomy.,1
Interval decrease in bifrontal subdural hematomas and parafalcine hematoma.,0
Expected evolution of vasogenic edema with slight decrease in the perimesencephalic and suprasellar cistern effacement.,0
No evidence of subfalcine herniation.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 32-year-old female status post left craniectomy for evacuation of left subdural hematoma.,0
"FINDINGS: The patient is status post left frontal craniectomy with a large amount of parenchymal tissue herniating through the craniectomy defect, but not significantly changed from prior.",0
There has been interval increase in two foci of intraparenchymal hemorrhage with associated edema.,1
"The first is more superior, measuring 2.0 x 1.0 cm (2:26) compared to 1.0 x 0.5 cm previously.",0
"The second, more inferior intraparenchymal measures 4.5 x 1.2 cm compared to 3.2 x 1.2 cm previously.",0
Bilateral trace subdural frontal hematomas are less conspicuous than the prior exam measuring up to 2 mm on the right and 1.5 mm on the left.,0
Overall there is decreased conspicuity of hemorrhagic products along the cerebral falx.,0
There are two newly apparent foci of subarachnoid hemorrhage along the anterior margin of the craniectomy defect (2:23).,1
There has been otherwise expected evolution of multiple foci of subarachnoid hemorrhage in the bifrontal lobes compared to the prior study.,1
There has been expected evolution of vasogenic edema.,0
There is slightly decreased effacement of the perimesencephalic and suprasellar cisterns; the latter is now more apparent than on the previous studies.,0
"Multiple basilar skull fractures are again noted, and better-characterized on the admission study.",1
"Air- fluid levels are noted in the left maxillary and bilateral sphenoid sinuses with aerosolized secretions, likely related to intubation.",0
"IMPRESSION: (Over) 9:56 AM CT HEAD W/O CONTRAST Clip # Reason: 32 year old woman s/p L craniectomy for evacuation of LSDH, Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ FINAL REPORT (Cont) 1.",0
Status post left temporal craniectomy and evacuation of left subdural hematoma with slight interval enlargement of the two dominant foci of parenchymal hemorrhage in the left frontal lobe.,1
"Two newly-apparent foci of subarachnoid hemorrhage adjacent to the anterior margin of the left craniectomy defect, with otherwise expected evolution of multiple foci of bifrontal subarachnoid hemorrhage.",1
Interval decrease in the bifrontal subdural hematomas.,0
"Evolution of cerebral edema with slight decrease in the degree of effacement of the suprasellar more than the perimesencephalic cisterns, which are still largely obliterated.",1
COMMENT: Findings were discussed with Dr. at 10:45 a.m. on .,0
"3:55 PM CHEST (PORTABLE AP) Clip # Reason: eval ETT placement, sp reintubation.",0
______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with extubation and reintubation now.,0
"low EF, VT, ?asp PNA.",0
"REASON FOR THIS EXAMINATION: eval ETT placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post extubation, now reintubated.",0
SINGLE VIEW CHEST: The endotracheal tube ends 5 cm above the carina.,0
The right internal jugular catheter is again identified in the mid SVC.,0
The NG tube appears to have been removed in the interval.,0
"Again noted is a diffuse interstitial, alveolar pattern.",0
"There are also multiple focal alveolar coalescing opacities, predominantly at the periphery.",0
Left lower lobe consolidation is also present.,0
There are bilateral pleural effusions.,0
IMPRESSION: Endotracheal tube 5 cm above the carina.,0
No other significant change in the interval.,0
9:47 AM CT HEAD W/O CONTRAST Clip # Reason: interval change *****Please do by 8a***** Admitting Diagnosis: EPILEPSY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 46M s/p L temporal lobectomy REASON FOR THIS EXAMINATION: interval change *****Please do by 8a***** No contraindications for IV contrast ______________________________________________________________________________ WET READ: 10:48 AM little change since prior study except for slight improvement in pneumocephalus.,0
______________________________________________________________________________ FINAL REPORT INDICATION: A 46-year-old man status post left temporal lobectomy.,0
"COMPARISON: Multiple head CTs, most recent of .",0
TECHNIQUE: Axially acquired images were obtained through the head without contrast.,0
FINDINGS: The patient is status post left temporal craniotomy and left temporal lobe resection.,0
Again seen is an area of extra-axial hemorrhage in the surgical bed which is unchanged in size and appearance.,0
Pneumocephalus is seen overlying the left frontal lobe and temporal lobe resection cavity.,0
There is mild mass effect from the pneumocephalus although the extent of pneumocephalus has slightly decreased since prior study.,0
Encephalomalacic changes of the left frontal lobe remain.,0
No new hemorrhage is noted.,0
The ventricles are stable in size.,0
IMPRESSION: Stable appearance of extra-axial hemorrhage in the left temporal lobectomy bed.,0
Expected postoperative changes including improved pneumocephalus.,0
No new areas of hemorrhage.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. is a 63 yo M with history of COPD (2L home O2 at night), schizophrenia, pulmonary hypertension admitted with progressively worsening dyspnea and hypoxia.",0
Of note he was recently admitted for COPD exacerbation and pneumonia for which he was treated with levofloxacin x5 days and prednisone taper decreasing by 10mg q2 days.,1
"He has been followed by VNA daily since his recent discharge and was sent in for O2 of 86% on RA, normally 90-92%.",0
"Per report from VNA he was taking steroids at home, antibiotic course was completed on the day following discharge.",0
He report that he has had increasing dypnea and chest tightness for the past 4-5 days although it is difficult to elicit details about how he has been feeling.,0
"He denies fever, nausea, vomiting, light headedness, syncope, diarrhea, abdominal discomfort.",0
On arrival in the ED T99.4 BP 102/61 HR 109 99% on NRB.,0
"He was given albuterol/atrovent nebs and noted to be more somnolent in the ED, was changed from NRB to 2L NC with improvement in mental status.",0
ABG was drawn which was similar to baseline 7.37/58/73 on 2LNC.,0
He did have period of hypotension with BP 95/p.,0
"He was given 1.5L NS, vancomycin 1g IV, zosyn 4.5g IV and prednisone 60g po.",0
He was also sent for CTA given hypotension and mild tachycardia.,0
He was also started on BIPAP.,0
On arrival to the ICU he appears well and reports that he is feeling significantly better than when he first got to the ED.,0
He was changed over from BIPAP to 2L NC upon arrival.,0
"Past Medical History: 1) COPD: FEV/FVC 60% in (no recent PFTs available), on home 1.5-2L O2 at night only 2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO ) 3) Schizophrenia 4) Hx GI bleeding 5) Mental Retardation Social History: Lives in with brother and brother-in-law.",0
On disability since for mental health issues.,0
Has home nurse visit every morning and evening.,0
Reports ~50 pack-year smoking history with abstinence for the past 9 days since recent d/c.,0
Patient denies alcohol use and drug use.,0
"CXR Opacity seen within the right lower lobe may represent resolving pneumonia; however, a recurrence cannot be excluded.",0
"However, this is less likely given incongruity with clinical findings.",0
No new areas of consolidation seen.,0
CXR: Previously reported right basilar opacities are improving with minimal residual infrahilar opacities remaining with associated bronchial wall thickening and mild volume loss.,0
"New peribronchiolar opacities have developed in the left retrocardiac region and may represent acute aspiration, atelectasis, or an early focus of pneumonia.",1
"Prominence of the hila appear unchanged, possibly due to prominent pulmonary vasculature, but standard PA and lateral radiographs would be helpful prior to discharge for more complete assessment when the patient's condition permits.",0
"CHEST (PA & LAT) Study Date of 9:13 AM The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD.",0
The heart is not enlarged.,0
There is mild unfolding of the ascending aorta.,0
There is patchy opacity in the right infrahilar region and to a lesser extent in the lingula.,0
There is minimal blunting of the right costophrenic angle.,0
"IMPRESSION: Patchy opacity right infrahilar region worse than on , consistent with pneumonia.",0
"Patchy opacity also in the left lingular region, probably unchanged allowing for technique.",0
Please note that followup to resolution is recommended to exclude a neoplastic or other chronic infiltrate.,0
"Brief Hospital Course: Mr. is a 63 yo M with history of COPD (2L home O2 at night), schizophrenia, pulmonary hypertension admitted to MICU with progressively worsening dyspnea.",0
His MICU course was uncomplicated and he was transfered to the floor for further management.,0
On the floor he remained hypoxic but reporting he was at baseline.,0
Ultimately he was discharged with followup with pulmonary medicine on a steroid taper and abx for concern of PNA.,0
VNA is scheduled to see him and do home pulmonary PT.,0
He may eventually need inpatient pulm.,0
PT if he can tolerate it.,0
"# Respiratory distress: Most likely COPD exacerbation; initial ABG relatively similar to his baseline, second overnight with slight worsening.",0
CXR equivocal for worsening pneumonia.,0
Significant worsening of leukocytosis on admission which is improving off ABx.,0
Steroids: prednisone 60 for a total of 5 days and taper by 10mg daily every other day.,0
"So 60mg to , 11/30-12/0 50mg, and so forth.",0
"With the help of pulmonary consult he was discharged on anticholinergics, inhaled steroids, and beta agonists.",0
Was on azithromycin initially but switching to levofloxacin 750mg PO daily D1 for worsening R perihilar opacity on interval CXR concerning for PNA.,0
Goal O2 sats were 90-93% given COPD and baseline retention.,0
Desat to 77% with ambulation which is worse than baseline by report.,0
ABG at rest on room air was 7.38/62/56.,0
Discharged with 24hr O2 at home.,0
# Leukocytosis - significantly elevated to 38.4 on admission from 15 on at time of discharge.,0
"Possibly to steroids, also consider infection with most likely sources being recurrence of pneumonia vs C.diff given recent antibiotics.",0
Given CXR on concerning for PNA switched to levofloxacin.,0
This is a good explanation for his leukocytosis.,0
# Tobacco abuse - readressed importance of tobacco cessation in preventing progression of COPD and helping to decrease future infections/hospitalizations.,0
Was discharged on continuous O2 and warned about the risks of oxygen and smoking.,0
Given nicotine patch Medications on Admission: Olanzapine 5 mg Tablet qd Fluticasone-Salmeterol 250-50 mcg/Dose one INH Tiotropium Bromide 18 mcg one INH daily Aspirin 81 mg Tablet qd Pantoprazole 40 mg qday Nicotine 14 mg/24 hr Patch Prednisone 20mg daily Albuterol 90 mcg 2 puffs q4 hours prn Discharge Medications: 1.,0
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation (2 times a day).,0
Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Prednisone 10 mg Tablet Sig: 1-6 Tablets PO as directed: 60mg = 6 pills 50mg = 5 pills 50mg = 5 pills 40mg = 4 pills 40mg = 4 pills 30mg = 3 pills 30mg = 3 pills 20mg = 2 pills 20mg = 2 pills 10mg = 1 pill 10mg = 1 pill.,0
Disp:*30 Patch 24 hr(s)* Refills:*0* 6.,0
"Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day.",0
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) inhalation Inhalation every four (4) hours as needed.,0
Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days.,0
Continuous home oxygen 11. ambulatory oxygen 12.,0
"Outpatient Physical Therapy Pulmonary physical therapy Discharge Disposition: Home With Service Facility: Health Systems Discharge Diagnosis: Primary diagnosis: COPD exacerbation, pulmonary hypertension .",1
"Secondary diagnosis: Schizophrenia, mental retardation Discharge Condition: Good, stable vital signs, tolerating moderate exertion on continuous oxygen Discharge Instructions: You were admitted for shortness of breath related to your underlying lung disease.",0
We are sending you home on a continuous oxygen therapy.,0
You must not smoke with your oxygen.,0
We are giving you a prescription for nicotine patches to help you not smoke.,0
Your visiting nurse will help you with this.,0
The nurse will also provide pulmonary physical therapy for your breathing.,0
Please attend your follow up appointments .,0
"Please call your doctor or go to the nearest emergency department if you experience worsening shortness of breath, chest pain, weakness, trouble waking up or staying awake, diarrhea, vomiting, or other concerning symptoms.",0
"Followup Instructions: Provider: , M.D.",0
Please schedule an appointment with the lung doctors in the Pulmonary Clinic within 2 weeks of discharge.,0
"The telephone number is MD, Completed by:",0
"9:41 AM CHEST (PORTABLE AP) Clip # Reason: EVAL PNA ______________________________________________________________________________ MEDICAL CONDITION: History: 69F with tachycardia, hypotensionClinical Question: eval PNA REASON FOR THIS EXAMINATION: {See Clinical Indication Field} No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: CHEST SEMI-ERECT AP PORTABLE VIEW CLINICAL INFORMATION: 69-year-old female with history of tachycardia, hypotension, evaluate for pneumonia.",1
FINDINGS: Single frontal view of the chest was obtained.,0
"There are low lung volumes, accentuate the bronchovascular markings.",0
Fullness of the hila and mild perihilar opacities may relate to mild fluid overload and/or crowding of vessels.,0
No definite focal consolidation is seen.,0
No large pleural effusion or pneumothorax.,0
Cardiac and mediastinal silhouettes are grossly stable.,0
IMPRESSION: Low lung volumes with possible mild fluid overload.,0
Consider repeat with better inspiration when patient able.,0
4:49 AM CHEST (PORTABLE AP) Clip # Reason: intubated SICU.,0
please eval postop Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with REASON FOR THIS EXAMINATION: intubated SICU.,0
please eval postop ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 11:43 AM NG tube tip is at the expected area of gastroesophageal junction.,0
No change in the position of tubes and lines.,0
Slightly improved aeration of the right lung.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Post-operative evaluation.,0
The NG tube tip is at the expected level of the gastroesophageal junction.,0
"No change in the position of the tubes and lines is demonstrated compared to the prior study from , obtained at 05:11.",0
Left retrocardiac atelectasis is unchanged.,0
There is slightly improved aeration of the right lung.,0
"3:12 PM MR L SPINE SCAN Clip # Reason: spinal cord injury/soft tissue injury ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with wave injury, initial numbness/paralysis x 4 extremities, now Bilat upper extr weakness/tingling REASON FOR THIS EXAMINATION: spinal cord injury/soft tissue injury ______________________________________________________________________________ FINAL REPORT MRI OF LUMBAR SPINE CLINICAL INFORMATION: Status post trauma.",0
"TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were obtained.",0
"FINDINGS: From T12-L1 to L3-4, no abnormalities are seen.",0
"At L4-L5 and L5-S1 level, disc and facet degenerative changes are seen with mild disc bulging without spinal stenosis.",0
"From L1-S3 level, the visualized bony structures demonstrate no evidence of abnormal marrow signal to indicate marrow edema or fracture.",1
There is no evidence of intraspinal hematoma or thecal sac compression seen.,0
The conus is located at normal level.,0
The paraspinal soft tissues are unremarkable.,0
"IMPRESSION: Disc and facet degenerative changes at L4-5 and L5-S1 levels, otherwise unremarkable study.",0
No evidence of fracture or marrow edema seen.,0
"4:34 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with CLD, increased O2 and vent support REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT A portable chest taken on at 1644 hours and compared to at 2238 hours.",0
FINDINGS: There has been no change in position of lines or tubes.,0
Again noted are diffuse parenchymal densities in the lungs bilaterally consistent with chronic lung disease.,1
"6:17 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with 3 VCAD, now with unstable angina.",1
Preop CABG REASON FOR THIS EXAMINATION: pre-op CABG ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST INDICATION: Coronary artery disease and unstable angina.,1
FINDINGS: The heart is top normal in size and the aorta is unfolded.,0
There is increased AP diameter of the chest with slight flattening of the hemidiaphragm.,0
"There is no pulmonary vascular congestion, pleural effusion, focal infiltrate or pneumothorax.",0
Chronic interstitial markings are evident.,0
There is anterior wedge deformity within a single vertebral body in the lower thoracic spine.,0
IMPRESSION: Hyperinflation and chronic-appearing interstitial changes.,0
Wedge deformity within the lower thoracic spine.,0
", J. SICU-A 9:57 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: with duplex - assess vasculature, ?hepatic hematoma Admitting Diagnosis: SPONTANEOUS BACTERIAL PERTONITIS ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with s/p OTL on now with GI bleed REASON FOR THIS EXAMINATION: with duplex - assess vasculature, ?hepatic hematoma ______________________________________________________________________________ PFI REPORT PFI: 1.",1
Normal Doppler evaluation of the transplanted liver vasculature.,0
"No intrahepatic biliary ductal dilatation, however, apparent slight increase in common hepatic duct from 4-5 mm to now 7-8 mm, of indeterminate significance.",0
"Small perihepatic post-surgical fluid collection, similar to prior.",1
"11:16 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: eval for acute traumatic injury Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with fall from height REASON FOR THIS EXAMINATION: eval for acute traumatic injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: JWK WED 2:11 PM No acute findings appreciated ______________________________________________________________________________ FINAL REPORT INDICATION: 45-year-old man with fall from height.",0
TECHNIQUE: MDCT axial images of the abdomen were obtained without IV contrast.,0
"Following the administration of IV Optiray contrast, images of the chest, abdomen and pelvis were obtained.",0
Multiplanar images were then reformatted.,0
CT CHEST WITH IV CONTRAST: The heart and great vessels are unremarkable.,0
There are no pathologically enlarged axillary or mediastinal lymph nodes.,0
The lungs are clear without pulmonary nodules or pleural effusions.,0
There are two small bullae within the left lower lobe.,0
CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a small hiatal hernia.,0
"The liver, gallbladder, spleen, adrenal glands, pancreas, kidneys, stomach, and abdominal loops of small and large bowel are unremarkable.",0
There is no free air or free fluid within the abdomen.,0
CT PELVIS WITH IV CONTRAST: A Foley catheter is seen within the bladder.,0
The rectum and sigmoid colon are unremarkable.,0
There is a coarse prostatic calcification.,0
There are no pathologically enlarged pelvic or inguinal lymph nodes and no free fluid within the pelvis.,0
OSSEOUS STRUCTURES: Demonstrate degenerative changes of the L5/S1 disc interspace.,0
Heterotopic ossification is seen off the left iliac .,0
Well corticated osseous fragments off the greater trochanter are likely a sequela of prior trauma.,0
IMPRESSION: 1) No acute abnormality appreciated.,0
3) Small left lower lobe bullae.,0
"(Over) 11:16 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: eval for acute traumatic injury Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"2:28 PM CHEST (PA & LAT) Clip # Reason: please eval for infiltrate, chf ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman w/ lupus,esrd p/w progressive sob x 1 month.",0
"REASON FOR THIS EXAMINATION: please eval for infiltrate, chf ______________________________________________________________________________ FINAL REPORT INDICATION: Lupus with end-stage renal disease and progressive shortness of breath for one month.",0
COMPARISON is made to prior cxr of .,0
FINDINGS: There is stable cardiomegaly with again evidence of median sternotomy wires.,0
There is again demonstrated prominence of the central pulmonary vascularity.,0
"There has been interval increased perihilar, interstitial and alveolar opacities consistent with edema.",0
A dialysis catheter is again noted overlying the right hemithorax.,0
There is blunting of the left CP angle possibly representing a small effusion.,0
IMPRESSION: Development of insterstitial and alveolar edema,0
11:13 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
pulm edema ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with REASON FOR THIS EXAMINATION: ?,0
pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for pulmonary edema.,0
PORTABLE AP CHEST: The heart size is difficult to assess due to patient rotation and lordotic positioning.,0
There is slight prominence of the pulmonary vascularity without overt pulmonary edema.,0
"In the right lung base there was previous patchy opacity; however, now there is a focal rounded density in the right lung base.",0
"This could represent partial resolution of the previous process, however, an underlying mass should be considered.",0
Osseous structures are within normal limits.,0
IMPRESSION: 1) No overt pulmonary edema.,0
2) Rounded opacity within the right lung base.,0
A corresponding structure was not present on a chest CT from .,0
A chest CT is recommended to exclude an underlying mass.,0
"3:00 PM BABYGRAM (CHEST ONLY); BABYGRAM (CHEST ONLY) Clip # Reason: PAIN ______________________________________________________________________________ FINAL REPORT CHEST, HISTORY: Pneumothorax.",0
FINDINGS: Right pneumothorax has occurred since prior studies.,0
It is moderate to large in size.,0
Basilar medial pneumothorax on the left persists.,0
NG tube is no longer seen.,0
Umbilical venous catheter reaches low right atrium and UAC reaches T8.,0
5:48 PM CHEST (PORTABLE AP) Clip # Reason: check PA line placement Admitting Diagnosis: AORTIC VALVE STENOSIS\AORTIC VALVE REPLACEMENT; MINIMILLAY INVASIVE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with aortic stenosis s/p minimally invasive AVR.,1
"REASON FOR THIS EXAMINATION: check PA line placement ______________________________________________________________________________ FINAL REPORT INDICATIONS: Aortic stenosis, status post aortic valve replacement with PA line placement.",1
PORTABLE AP CHEST: Comparison is made to previous films from one hour previously.,0
An endotracheal tube is seen with tip at the thoracic inlet.,0
There is a Swan-Ganz catheter with the tip in the right pulmonary artery.,0
A nasogastric tube is present with tip in the stomach.,0
"The left lung is clear, without infiltrates or consolidations.",0
There is a layering right sided pleural effusion.,0
IMPRESSION: Repositioned Swan-Ganz catheter with the tip in the right pulmonary artery.,0
"6:02 PM BILAT UP EXT VEINS US Clip # Reason: 70 year old man with fever, evaluate for clot Admitting Diagnosis: HYDROCEPHALUS ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with fever, evaluate for clot REASON FOR THIS EXAMINATION: 70 year old man with fever, evaluate for clot ______________________________________________________________________________ WET READ: ASpf SAT 11:28 AM The right axillary clot has resolved.",1
The right basilic clot is smaller.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old male with fever, known upper extremity venous thrombosis.",0
COMPARISON: Ultrasound of the upper extremities from .,0
"FINDINGS: -scale and Doppler images of the right and left subclavian, internal jugular, brachial, basilic and cephalic veins were obtained.",0
There was wall-to-wall flow with normal response to compression in all visible veins except the right basilic vein where a small amount of residual clot remains.,0
The right axillary clot has resolved.,0
Interval resolution of previously noted right axillary DVT.,0
The right basilic clot is intervally diminished in size.,0
"6:02 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG with desaturation ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with cad, htn, dm, copd with severe L main and 3vd pre-oped for CABG.",0
"REASON FOR THIS EXAMINATION: s/p CABG with desaturation ______________________________________________________________________________ FINAL REPORT INDICATION: 68 y/o woman with CAD, hypertension, COPD with pre-operative chest radiograph for CABG, with increased hypoxia.",0
"CHEST, SINGLE VIEW: There is stable cardiomegaly in patient recently post-op CABG.",0
There is consolidation of the left retrocardiac space associated with a small left pleural effusion.,0
There is slight pulmonary vascular redistribution.,0
The right lung is otherwise unremarkable.,0
A Swan-Ganz catheter is seen with tip in the proximal right main pulmonary artery.,0
Two chest tubes are seen overlying the medial and lateral aspects of the left middle lung zone.,0
Surgical clips are seen overlying the soft tissues on the left side of the neck.,0
IMPRESSION: 1) Left lower lobe consolidation/collapse associated with a small pleural effusion.,0
2) Slight pulmonary vascular redistribution consistent with mild left ventricular decompensation.,0
"3) Swan-Ganz catheter tip in proximal right pulmonary artery, without evidence of pneumothorax.",0
"4:03 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH;ACUTE RENAL FAILURE;HCT DROP ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with 1 week of increasing sob/doe, fluid overload and intubated REASON FOR THIS EXAMINATION: Please eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST AT 4:58 A.M. HISTORY: One week of increasing shortness of breath.",1
IMPRESSION: AP chest compared to through 3: Mild interstitial edema as seen in the left lung has improved since and this may account for slight improvement in the extent of very severe consolidation in the mid and right lower lung.,0
Small pleural effusions are unchanged.,0
"Tip of the ET tube is at least 2 cm above the upper margin of the clavicles, 3-4 cm above optimal placement.",0
Right jugular line tip projects over the internal jugular vein and a left supraclavicular dual channel catheter ends in the low SVC.,0
Findings were discussed by telephone with Dr. at the time of dictation.,0
", M. MED FA9A 3:19 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: NG tube insertion attempted twice and failed.",0
"Kindly to fix Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: year old man with yo M, DM, HTN, Afib (not on anticoagulation), BPH, urine retention on chronic foley after stroke on , prostate Ca (mets to pelvic bone) was transferred to for evaluation of his very recent seizure on and chronic bilateral subdural hematomas.",1
REASON FOR THIS EXAMINATION: NG tube insertion attempted twice and failed.,0
Kindly to fix an NG tube under flouroscope guidance please ______________________________________________________________________________ PFI REPORT Successful placement of - tube into the stomach.,0
The tube is ready to use.,0
4:02 PM CHEST (PA & LAT) Clip # Reason: Evaluate for pulmonary process.,0
"Admitting Diagnosis: PNEUMOMEDIASTINUM;RHABDO;GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with shortness of breath, fever.",0
REASON FOR THIS EXAMINATION: Evaluate for pulmonary process.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 7:51 PM No evidence of pneumonia.,0
No evidence of mediastinal air within the limitations of the chest radiograph.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath and fever.,0
COMPARISON: Chest CT from and several chest radiographs from to .,0
The heart size is top normal.,0
"Mediastinal position, contour and width are unremarkable.",0
The current study does not demonstrate evidence of pneumomediastinum.,0
Bibasilar linear opacities most likely consistent with atelectasis.,0
No pneumoperitoneum has been shown.,0
3:26 AM CHEST (PORTABLE AP) Clip # Reason: interval change?,0
"Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 88F mediastinal mass, h.influenza PNA REASON FOR THIS EXAMINATION: interval change?",1
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Mediastinal mass, pneumonia, questionable interval change.",0
"FINDINGS: As compared to the previous radiograph, there is no relevant change.",0
The bases of the right lung are minimally better ventilated than before.,0
"The monitoring and support devices are constant, constant size of the cardiac silhouette, constant appearance of the left lung.",0
"12:11 PM BABYGRAM AP ABD ONLY PORT Clip # Reason: Newborn, grossly bloody stools.",0
"Eval for bowel obstruction/p Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with bloody stools REASON FOR THIS EXAMINATION: Newborn, grossly bloody stools.",0
______________________________________________________________________________ FINAL REPORT STUDY: Abdomen.,0
CLINICAL HISTORY: This is a 2-day-old preterm infant with grossly bloody stools.,0
FINDINGS: A single portable view of the abdomen was obtained.,0
I have no prior films available for comparison.,0
Air is seen within the rectosigmoid.,0
There are a few lucencies overlying the right abdomen that probably represent a cast of stool.,0
The bowel gas pattern is otherwise within range of normal limits.,0
The visualized bony structures are normal.,0
"2:22 PM CHOLANGIOGRAM,IN OR W FILMS Clip # Reason: GALLBLADDER STONES Admitting Diagnosis: CHOLECYSTITIS ______________________________________________________________________________ FINAL REPORT INDICATION: Intraoperative cholangiogram.",1
FINDINGS: Single fluoroscopic spot image is submitted for review from an open cholecystectomy.,0
A radiologist was not present during the procedure.,0
"The image demonstrate opacification of the common bile duct, the intrahepatic ducts, and a portion of the duodenum.",0
"There are what appear to be small filling defects in the distal aspect of the common bile duct, and the common bile duct itself is prominent.",0
Multiple rounded densities arising off of one of the right intrahepatic bile ducts could represent small bilomas.,0
"Please refer to the operative note from , for details regarding the procedure.",0
Possible filling defects in the distal aspect of the common bile duct.,0
Multiple rounded densities arising off of a right intrahepatic duct could represent small bilomas.,0
6:06 PM CHEST (PA & LAT) Clip # Reason: year old male c dyspnea and low sats.,0
______________________________________________________________________________ MEDICAL CONDITION: year old man with above.,0
REASON FOR THIS EXAMINATION: year old male c dyspnea and low sats.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Dyspnea, low oxygen saturation.",0
There are opacities within the bilateral lower lobes.,0
"The heart size, mediastinal, and hilar contours are normal.",0
The pulmonary vascularity appears normal.,0
Soft tissue and osseous structures are unremarkable.,0
"IMPRESSION: Bibasilar opacities, probably representing multifocal pneumonia.",0
"12:05 AM CHEST (PORTABLE AP) Clip # Reason: S/p INTUBATION,pl evall ETT POSITION.",0
"______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with ESOPHAGECTOMY REASON FOR THIS EXAMINATION: S/p INTUBATION,pl evall ETT POSITION.",0
______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: Esophagectomy and intubation.,0
ETT is 3 cm above carina.,0
Distal end of NG tube is in mid portion of intrathoracic stomach at level just below carina.,0
Overlying monitor pad obscures detail on the right but there is persistent right pleural effusion and associated atelectasis/consolidation in the right mid and lower zones with fluid extending over the right lung apex.,0
Linear atelectases are present in the left lower zone.,0
"11:24 AM CHEST (PORTABLE AP) Clip # Reason: eval for pleural effusion, pulmonary edema Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with CABG s/p stent with CP and hypoxia REASON FOR THIS EXAMINATION: eval for pleural effusion, pulmonary edema ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old man with CABG, status post stenting on with chest pain and hypoxia.",0
Evaluate for pleural effusion or pulmonary edema.,0
FINDINGS: Frontal view of the chest.,0
Sternotomy wires are aligned and intact.,0
The heart is of normal size with an expected postoperative appearance of the mediastinum.,0
"A small left pleural effusion is slightly increased from , with associated adjacent atelectasis.",0
"No pulmonary vascular congestion, pulmonary edema, pneumothorax, or focal consolidation concerning for pneumonia.",0
Slight increase in small left pleural effusion with adjacent atelectasis.,0
Stable postoperative appearance of heart and mediastinum.,0
Clip # Reason: Any evidence of pyelonephritis or renal abscess?,0
Admitting Diagnosis: HYPERKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with culture-proven UTI who continues to have leukocytosis.,0
REASON FOR THIS EXAMINATION: Any evidence of pyelonephritis or renal abscess?,0
"______________________________________________________________________________ FINAL REPORT Renal ultrasound INDICATION: 84-year-old female with culture proving urinary tract infection, continues to have leukocytosis.",1
Concern for pyelonephritis or abscess.,0
COMPARISONS: CT abdomen and pelvis .,0
"FINDINGS: The right kidney measures 8.5 cm and the left kidney is symmetric in size, measuring 8.7 cm.",0
"Both are atrophic with cortical thinning, compatible with medical renal disease.",0
Echogenic linear foci in the hilar fat is likely atherosclerotic calcification.,0
No hydronephrosis or renal calculi.,0
No perinephric fluid collections are present.,0
The urinary bladder is partially collapsed with a Foley catheter.,0
"Mildly atrophic kidneys with thin cortices bilaterally, compatible with medical renal disease.",0
No hydronephrosis or calculi are present.,0
Probable atherosclerotic vascular calcific foci in the hilar fat.,0
Urinary bladder partially contracted with Foley catheter placement.,1
"10:57 PM FOREARM (AP & LAT) LEFT; HAND (AP, LAT & OBLIQUE) LEFT Clip # Reason: ?FX Admitting Diagnosis: SP MVC;TENSION PTX ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate for fracture following trauma.",0
FINDINGS: Left forearm two views and three views of the left wrist demonstrate fractures involving the base of the proximal phalanx of the ring finger and to the third metacarpal head.,1
There is also a small fracture off the ulnar styloid.,0
"There is irregularity of the radial styloid with suggestion of the small nondisplaced fracture which exits out the lateral articular surface, best seen on the oblique view.",0
Degenerative changes of the first CMC and triscaphe joint are noted.,0
Images of the forearm demonstrate no fractures in the region of the ulnar radial shaft or in the region of the elbow.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CCU ADDENDUM: This is a discharge summary addendum detailing the events from to .",0
CARDIAC: The patient was started on Cozaar as well as Coreg and doses were titrated to the discharge dose of 25 mg p.o.q.d.,0
Cozaar and 12.5 mg p.o.b.i.d.,0
"As far as the patient's atrial fibrillation, the patient's Amiodarone drip was switched to a p.o.",1
dose of 400 mg p.o.,0
"In addition, electrophysiology took the patient to the laboratory and performed a direct-current cardioversion.",0
At the time of discharge the patient was in sinus rhythm in the mid 80s.,0
Further plan was for continued loading with Amiodarone with subsequent followup with the EP team and placement of an ICD in approximately one month.,0
PULMONARY: The patient was continued on a steroid taper with switch from IV Solu-Medrol to p.o.,0
"At the time of discharge, the patient was on a dose of 50 mg p.o.",0
q.d and a long taper was planned.,0
"In addition, the patient was receiving Atrovent and Albuterol nebulizer, which was switched to MDI at the time of discharge.",0
The patient then completed a ten-day course of Levofloxacin and Flagyl for a questionable community-acquired pneumonia/aspiration pneumonia.,0
"FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was noted to have decreased p.o.",0
intake secondary to decreased appetite.,0
The patient was encouraged to maintain adequate p.o.,0
"intake, the patient's creatinine remained stable.",0
"However, BUN was noted to rise gradually.",0
"The rise in the latter was thought to be secondary to once again, poor p.o.",0
intake and the patient was encouraged to maintain adequate hydration.,0
The patient is to be discharged to rehabilitation.,0
Dilated cardiomegaly with an ejection fraction of 20%.,0
Paroxysmal atrial fibrillation status post direct-current cardioversion on .,1
"times one week, then 300 mg p.o.",0
times two weeks; then 400 mg q.d.,0
"times one day then 40 mg times three days, then 30 mg times three days, then 20 mg times three days, then 10 mg times three days, then 5 mg times three days, then taper to off.",0
Lovenox 100 mg subcutaneously b.i.d.,0
Albuterol MDI 2 puffs q.i.d.p.r.n.,0
Atrovent MDI 2 puffs q.i.d.p.r.n.,0
FOLLOW-UP CARE: The patient is to followup with the Department of Electrophysiology in approximately one month for ICD placement.,0
"DR., 11-398 Dictated By: MEDQUIST36 D: 10:59 T: 11:10 JOB#:",0
Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: mental status change Major Surgical or Invasive Procedure: None History of Present Illness: This is an 89 year-old woman who has been living at with her sister for the past month with multiple medical problems who presented on with mental status change.,0
"Pt awoke at 7 am on the morning of admission ""not feeling well"" and was noted to have a change in mental status.",0
At 8:40 am the patient was noted to have a right facial droop in the setting of hypotension.,0
Pt was evaluated by the stroke service who determined that the reported deficits had resolved following correction of her hypotension.,0
A CT of the head did not reveal any infarcts or acute changes.,0
"On arrival in ER, patient noted to be hypotensive to high 60's and hypoxic to 80's on room air.",0
"She was admitted to the with septic physiology of unknown source, but given history of UTI's and few localizing symptoms, felt secondary to urosepsis.",1
Initially started on vanc/levo/flagyl in ED.,0
"Patient given 5 liters of normal saline in , Zosyn/vancomycin maintained and patient's blood pressure improved to systolics in 120's overnight.",0
"Patient less hypoxic, satting well on 4 liters.",0
Patient transferred to the floor on .,0
"At this time, her mental status is improved and appears to be at baseline.",0
She has dementia at baseline.,0
She denies localizing complaints ongoing prior to admission or at this time.,0
Says she just felt sleepy before coming in.,0
"Denies cough, sputum production, chest pain.",0
"Denies abdominal pain, nausea, vomiting, diarrhea.",0
No recent change in bowel habits.,0
"Denies hematochezia, melena, hemoptysis, hematemesis.",0
NSAID-induced gastropathy with an upper GI bleed in .,0
"Prior studies: colonoscopy: diverticulus in sigmoid colon, polpy in rectum, otherwise normal.",0
"EGD: no evidence of old or active bleeding in gastric body EGD: hiatal hernia, barretts, NSAID induced gastropathy, duodenitis.)",0
2L O2 via NC at baseline.,0
Atrial fibrillation not currently anticoagulated secondary to fall risk.,0
Dementia Social History: Lives in .,0
Ex-marine in World War II.,0
Pt lives on the of the .,0
Sister lives there as well.,0
No significant changes are noted.,0
"Motion artifact is again present, limiting the evaluation.",0
"No intracranial masses, nor hemorrhages are identified.",0
Midline structures are normal in position.,0
Ventricles and subarachnoid spaces are within normal limits for age.,0
Decreased attenuation is again visualized in the left posterior frontal white matter consistent with a chronic infarction.,0
"Patchy areas of low density is seen in the periventricular and deep white matter of both cerebral hemispheres, consistent with chronic microvascular ischemic changes.",0
No acute major vascular territorial infarctions are identified.,0
INTERPRETATION: Chronic infarct in the posterior left frontal lobe.,0
MRI is more sensitive in detecting acute infarction.,0
Chest x-ray: INDICATION: Right facial droop.,0
"Examination is limited due to kyphoscoliosis and flexed position of the patient's neck, partially obscuring the superior mediastinum and lung apices.",0
There is a new patchy area of consolidation within the right lower lobe as well as an area of ill-defined opacity in the left perihilar region.,0
The latter finding is best visualized on the second of two images in this series.,0
"Cardiac and mediastinal contours are stable with a hiatal hernia noted, although this was previously better visualized on prior studies.",0
"IMPRESSION: Patchy right lower lobe and left perihilar opacities, which may be due to aspiration or pneumonia.",0
Followup radiographs are suggested to document resolution.,0
chest x-ray: INDICATION: 89-year-old woman with pneumonia.,0
COMPARISON: Chest x-ray dated .,0
FINDINGS: Note is made of marked kyphosis and tortuosity of thoracic aorta and trachea.,0
The patient head is partially overlying the upper lung fields.,0
Cardiac and mediastinal contours are overall unchanged compared to the prior study.,0
Note is made of CHF.,0
Note is made of increased bilateral pleural effusion with atelectasis versus consolidation.,0
Healed fracture of the right humerus is noted.,0
"IMPRESSION: Worsening CHF, bilateral pleural effusion and bibasilar consolidation versus atelectasis, which can represent worsening pneumonia.",0
EKG on admit : nl sinus ryhthm @ 88 bpm with a PAC.,0
"elevated ST segments in V2-V4 (no change from ), no T wave inversions.",0
"Brief Hospital Course: This is an 89 year-old woman who presented with acute mental status change, hypotension, noted to have urinary tract infection and possible pneumonia.",1
She had a very short intensive care unit stay.,0
"The following issues were addressed on this admission: ID: Patient admitted with septic shock, hypotension requiring brief dopamine and 5 liters of IVF.",1
"Suspected source was urine given pyuria, many bacteria but urine culture returned negative.",0
"Also with possible pneumonia by chest x-ray but poor films, possibly just atelectasis and does not report history of cough, trouble breathing, chest pain.",0
Unclear if sick contacts at .,0
"No other sources identified, no localizing symtoms.",0
Blood cultures remained negative throughout admission.,0
The patient's altered mental status quickly returned to baseline and septic physiology resolved on broad spectrum vanco/zosyn.,1
Concern for possible aspiration but swallowing study done identified patient as not increased aspiration risk.,0
No bacteremia by blood cultures of .,0
Patient was maintained on zosyn/vancomycin until .,0
At that time switched to levoquin/flagyl to cover possible urinary tract infection and possible aspiration pneumonia.,1
Repeat chest x-rays on and were more concerning for consolidation/possible aspiration.,0
and thus antibiotics were continued.,0
Plan is for 14 day course of levoquin/flagyl (total gram negative and anaerobe coverage including zosyn dosing).,0
"Cardiovascular: ischemia: Patient with no known history of CAD, although was on aspirin on admit.",0
Decision made to stop aspirin given history of previous GI bleeds and decreased crit on admit from baseline.,0
Beta-blockade intially held with hypotension.,0
Once stabilized beta-blockade was re-instituted at previous outpatient dosing.,0
Pump: Patient was mildy volume overloaded after aggressive IVF's for sepsis.,0
"She has a history of hyperdynamic ventricle, ef 70-80%, likely diastolic dysfunction.",0
She was diuresed over her hospital course a few liters.,0
Also maintained on beta-blockade and ace inhibition at outpatient dosing without adjustments.,0
Rhythm: history of PAF: not on anticoagulation given hx of GIB.,0
Patient was in normal sinus rhythm throughout admission including by EKG on .,0
Acute renal failure: Patient with Creatinine baseline <1.0.,1
"Elevation on admission likely secondary to hypoperfusion of kidneys (prerenal) given BUN/Cr and hypotension, responded to fluids.",0
After fluids and through diuresis creatinine stable at 0.7. .,0
"Heme: a)Anemia: Hct drop 29 to 22 after 5L IVF, likely secondary to hemodilution.",0
"However, does have history of GIB.",0
Has been guiaic negative here.,0
She received one unit of blood in ICU and another on floor.,0
"Responded well both times, maintained crit >28 given COPD.",0
Has been in low to mid 30's since transfusions.,0
b)Coagulopathy on admit: PTT: 40.6 INR: 1.5.,0
"Pt not on any anticoagulant, unclear etiology.",0
Corrected with vitamin K: monitor for now.,0
"Normal platelets, do not think it is DIC.",0
"Hyponatremia: On admission, felt to be hypovolemic hyponatremia, responded to fluids.",0
Baseline in very low 130's for years now.,0
"Pulmonary/History of COPD: on home oxygen 2l, ""order a tank when I need it.""",0
"As per previous notes, patient with baseline oxygen saturations in 80's on 2 liters at home.",0
"Multi-factorial pulmonary etiologies including habitus, COPD.",0
"Maintain oxygen, saturations generally mid to high 80's on liters but no acute explanations for low oxygen saturation.",0
"Depression: Maintained on Remeron Osteoporosis: Maintained on raloxifene, vitamin D and calcium.",0
"Maintained on protonix for GI prophylaxis, subcu heparin for DVT prophylaxis.",0
Patient's CODE status was DNR/DNI throughout.,0
Medications on Admission: atenolol 25 lisinopril 20 lasix 40 protonix 40 flovent atrovent albuterol evista 60 accolate 20 mirtazapine aricept 10 colace senna calcium vitamin D multi-vitamin Discharge Medications: 1.,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed.,0
"Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)",0
PO Q12H (every 12 hours).,0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO QD ().",0
Evista 60 mg Tablet Sig: One (1) Tablet PO once a day.,0
Donepezil Hydrochloride 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation (2 times a day).,0
Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day).",0
Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days.,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours).,0
"Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheeze.",0
Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: pneumonia, urinary tract infection, sepsis, copd, dementia, depression Discharge Condition: stable Discharge Instructions: Contact MD if you have chest pain, shortness of breath or if you develop any pain or concerning symptoms.",1
Followup Instructions: Should contact Dr. at this week to make an appointment.,0
"4:54 AM CT HEAD W/O CONTRAST Clip # Reason: eval interval change Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with hypertensive IPH REASON FOR THIS EXAMINATION: eval interval change CONTRAINDICATIONS for IV CONTRAST: not needed ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old man with hypertensive intraparenchymal hemorrhage, evaluate for interval change.",0
TECHNIQUE: MDCT images were acquired through the head without contrast.,0
Multiplanar reformations were obtained and reviewed.,0
FINDINGS: Again noted is a right basal ganglia intraparenchymal hemorrhage that measures 35 x 19 mm today versus 31 x 17 mm on the prior examination.,0
This is associated with minimal leftward shift of the normally midline structures.,0
No new areas of hemorrhage are noted.,0
The ventricles and sulci are normal in size and configuration.,0
The visible paranasal sinuses show an increase in sphenoid sinus fluid since the study of .,0
The visible mastoid air cells are well aerated.,0
IMPRESSION: Essentially unchanged right basal ganglia intraparenchymal hemorrhage.,1
"3:49 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please check ETT placement (pulled back 3 cm) Admitting Diagnosis: METASTATIC LUNG CANCER, DIARRHEA, NEUTRUPENIA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with 68 year old man with SC Lung CA, known lung nodules, hypoxia, fevers REASON FOR THIS EXAMINATION: please check ETT placement (pulled back 3 cm) ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP 8:24 PM Proper adjustment of ETT position.",0
Now again increasing pulmonary edema.,0
______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
"INDICATION: Small cell lung cancer, no lung nodules.",0
Check ETT placement now after being pulled back by 3 cm.,0
AP single view of the chest obtained with patient in supine position is analyzed in direct comparison with a preceding similar study obtained six hours earlier during the same date.,0
The ETT has been retracted by approximately 3 cm and is now safely above the bifurcation.,0
Previously described right internal jugular approach central venous line and NG tube in unchanged position.,0
The patient is in slightly right-sided rotation.,0
Comparison of the lung fields clearly indicates increased diffuse densities in both lung fields most likely representing increasing pulmonary edema.,0
IMPRESSION: Proper adjustment of ETT.,0
Again increasing pulmonary edema pattern following temporary improvement two examinations earlier on the same date.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Tetanus Toxoid,Adsorbed Attending: Chief Complaint: severe aortic stenosis, systolic CHF Major Surgical or Invasive Procedure: TAVI AVR Corevalve (26 mm porcine)via mini sternotomy History of Present Illness: 86F with PMHx significant for severe aortic stenosis, HTN, CAD s/p ?stent vs PCI in LAD, systolic CHF with LVEF 20% and paroxysmal afib who presented to Hospital last month with dyspnea on exertion and chest tightness with walking.",1
"Denies peripheral edema, PND or orthopnea.",0
"There, she ruled in for acute on chronic systolic congestive heart failure and NSTEMI, with peak troponin of 5.3.",1
"Transferred to , underwent cardiac cath revealing 2v disease (OM2 95%, RCA 100% likely chronic).",1
She underwent successful PCI to the 90% lesion in the proximal segment of the OM2 with 2.5x12mm Integrity bare metal stent on .,0
She was evaluated by cardiac surgery and was deemed to be of high risk for conventional surgical AVR.,1
"After informed consent, she was screened for the High Risk arm of the Corevalve/TAVI trial and was randomized to Corevalve/TAVI.",1
"Past Medical History: CHF, Dyspnea on exertion Dyslipidemia, Hypertension, coronary artery disease, P A Fib, s/p PCI to LAD in , patient states she has a stent, Hearing loss, Iron deficiency, anemia, Osteoporosis ?",1
"(pt on sinemet but no documentation of diagnosis),osteoarthritis(chronic nightly R leg pain) Social History: -Tobacco history: none -ETOH: 3 cocktails/week -Illicit drugs: none Lives with her husband, who is her caregiver.",0
"Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.",0
"Physical Exam: PHYSICAL EXAMINATION 62.8 kgs Vitals: T: 97.6 degrees Farenheit, BP: 105/32 mmHg supine, HR 73 bpm, RR 18 bpm, O2: 94 % on O2FM.",0
THYROID: No thyromegaly or thyroid nodules.,0
Grossly normal without any significant focal deficits PSYCH: Mood and affect were appropriate.,0
Pertinent Results: 09:35AM BLOOD WBC-8.8 RBC-3.63* Hgb-10.5* Hct-30.5* MCV-84 MCH-28.8 MCHC-34.3 RDW-14.9 Plt Ct-272 09:35AM BLOOD PT-30.1* INR(PT)-2.9* 06:39AM BLOOD Glucose-87 UreaN-27* Creat-1.1 Na-140 K-4.4 Cl-102 HCO3-34* AnGap-8 06:39AM BLOOD proBNP-* 06:39AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.1 01:00PM BLOOD %HbA1c-5.9 eAG-123 TTE :Conclusions The left atrium is moderately dilated.,0
There is mild symmetric left ventricular hypertrophy with normal cavity size.,0
There is mild regional left ventricular systolic dysfunction with inferior akinesis and inferoseptal hypokinesis.,0
The right ventricular cavity is mildly dilated with borderline normal free wall function.,0
An aortic CoreValve prosthesis is present.,1
The transaortic gradient is normal for this prosthesis.,0
IMPRESSION: Focal LV systolic dysfunction consistent with prior inferior infarction.,1
Mildly dilated right ventricle with borderline systolic function.,0
"Compared with the prior study (images reviewed) of , a CoreValve prosthesis is present.",0
The function of the lateral wall has improved.,0
The right ventricle was probably mildly hypokinetic/dilated on the prior study also.,0
"Electronically signed by , MD, Interpreting physician 16:59 Intra-op TEE preliminary report: Conclusions Pre implant No spontaneous echo contrast is seen in the left atrial appendage.",1
A small secundum atrial septal defect is present.,1
"There is mild to moderate regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anterior wall and the mid inferior wall..",0
Overall left ventricular systolic function is mildly depressed (LVEF= 40 %).,0
The aortic valve leaflets are severely thickened/deformed.,1
There is critical aortic valve stenosis (valve area <0.8cm2).,1
Dr. was notified in person of the results on at 900 am Post implant Corevalve seen in the aortic position.,1
There is trivial aortic insufficiency.,0
There is mild mitral regurgitation.,0
I certify that I was present for this procedure in compliance with HCFA regulations.,0
"Interpretation assigned to , MD, Interpreting physician Brief Hospital Course: Admitted on for preadmission testing.",0
Workup was uneventful and she was cleared for .,0
"Underwent a TAVI AVR Corevalve via mini sternotomy by Dr. , and transferred to the CVICU.",0
She was extubated POD # 2.,0
She had sinus bradycardia and intermittent AFib.,0
"No malignant arrhythmias noted on telemetry thus far, and her baseline ECG is unchanged from her pre-op LBBB.",0
Titrated her Coreg as tolerated by her BP and HR.,0
Transferred to the floor on POD #2 and she continued to progress well.,0
Pacing wires and CT were discontinued without incident.,0
Gently diuresed toward her preop weight.,0
Coumadin restarted for A Fib.,0
Cleared for discharge to rehab on POD #6.,0
All questions and concerns addressed.,0
"- one Tablet(s) by mouth daily Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.)",0
- one Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 400 unit Capsule - two Capsule(s) by mouth twice daily SENNOSIDES [SENNA] - (OTC) - 8.6 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime as needed VIT C-VIT E-LUTEIN-MIN-OM-3 [OCUVITE] - 150 mg-30 unit- mg-150 mg Capsule - one Capsule(s) by mouth twice daily Discharge Medications: 1. multivitamin Tablet : One (1) Tablet PO DAILY (Daily).,0
2. brimonidine 0.15 % Drops : One (1) Drop Ophthalmic twice a day: one drop both eyes.,0
3. carbidopa-levodopa 25-100 mg Tablet : One (1) Tablet PO TID (3 times a day).,0
"4. aspirin 81 mg Tablet, Delayed Release (E.C.)",0
": One (1) Tablet, Delayed Release (E.C.)",0
5. docusate sodium 100 mg Capsule : One (1) Capsule PO BID (2 times a day) for 1 months.,0
6. oxycodone-acetaminophen 5-325 mg Tablet : 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
"7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR DAILY (Daily).",0
9. potassium chloride 10 mEq Tablet Extended Release : One (1) Tablet Extended Release PO once a day for 5 days.,0
10. atorvastatin 40 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
11. carvedilol 25 mg Tablet : One (1) Tablet PO twice a day: hold for BP < 90 or HR < 55.,0
12. acetaminophen 325 mg Tablet : Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp.,0
13. digoxin 125 mcg Tablet : one-half Tablet PO DAILY (Daily): 0.0625 mg daily.,0
14. warfarin 1 mg Tablet : One (1) Tablet PO today only @ 4PM: dose today is 1 mg; all further daily dosing per rehab provider; target INR 2.0-2.5 for A Fib.,0
INSULIN SS per attached insulin sliding scale 16. furosemide 20 mg Tablet : One (1) Tablet PO once a day for 5 days.,0
"Discharge Disposition: Extended Care Facility: Nursing & Retirement Home - Discharge Diagnosis: CHF, Dyspnea on exertion Dyslipidemia, Hypertension, coronary artery disease, P A Fib, s/p PCI to LAD in , patient states she has a stent, Hearing loss, Iron deficiency, anemia, Osteoporosis ?",1
"(pt on sinemet but no documentation of diagnosis),osteoarthritis(chronic nightly R leg pain) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance, gait steady Sternal pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Discharge Instructions: ) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon.",0
Look at your incisions daily for redness or drainage.,0
"2) Please NO lotions, cream, powder, or ointments to incisions.",0
"3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided.",0
4) No driving for approximately one month and while taking narcotics.,0
Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive.,0
5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns **Please call cardiac surgery office with any questions or concerns .,0
"Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for these appts: Surgeon Dr. @ 12:00, 2A Cardiologist Dr. @ 12:00, 2A Please call cardiac surgery if need arises for evaluation or readmission to hospital ;Answering service will contact on call person during off hours** Please call to schedule appt with PCP .",0
in weeks Labs: PT/INR for Coumadin ?,0
indication A Fib Goal INR 2.0-2.5 First draw tomorrow ***Please arramge for coumadin/INR f/u prior to discharge from rehab Completed by:,0
7:43 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line placement Admitting Diagnosis: MITRAL REGURGITATION Contrast: OPTIRAY Amt: 20 ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with CAD, BPH s/p TURP here with CHF exacerbation.",0
Has femoral line that needs to be pulled.,0
PICC nurse unable to get bedside PICC or peripherals.,0
REASON FOR THIS EXAMINATION: PICC line placement ______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for heparin.,0
"Dr. , the Attending Radiologist, supervised the exam.",0
"TECHNIQUE: Using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set.",0
A peel-away sheath was then placed over a guidewire and a 5 French double-lumen PICC line measuring 19 cm in length was then placed through the peel-away sheath with its tip positioned in the mid axillary vein under fluoroscopic guidance.,0
Position of the catheter was confirmed by fluoroscopic spot film of the chest.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the left brachial venous approach.,0
"Final internal length is 19 cm, with the tip positioned in the mid axillary vein due to occlusion through which the wire could not be passed.",0
"Please note that due to occlusion of the venous system, the wire could not be passed beyond the level of the mid axillary vein into the more central venous system.",0
A similar phenomena had been seen on the right arm.,0
"Therefore, a decision was made to place midline terminating in the mid axillary vein from the left brachial vein.",0
(Over) 7:43 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line placement Admitting Diagnosis: MITRAL REGURGITATION Contrast: OPTIRAY Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont),0
7:42 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for pneumothorax resolution after Chest Xray Admitting Diagnosis: MVA;CLOSED HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with unrestrained MVC thrown from car L hemopneumothorax REASON FOR THIS EXAMINATION: evaluate for pneumothorax resolution after Chest Xray ______________________________________________________________________________ FINAL REPORT INDICATION: COMPARISON is made to prior study of 3 hours earlier.,1
SUPINE AP PORTABLE CHEST: There has been insertion of a left-sided chest tube.,0
"ET tube and NG tube remain unchanged in position, with the NG tube again coiled in the stomach.",0
No definite pneumothorax is seen.,0
There is thickening along the left lateral thoracic side wall which is either pleural effusion or possibly hematoma from the multiple left-sided rib fractures.,0
There is collapse/consolidation of the left lower lobe.,0
The extreme left lateral structures are not included.,0
12:55 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with new fever.,0
"REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT AP CHEST, 1:06 PM ON HISTORY: 52-year-old man with new fever, suspect pneumonia.",1
"IMPRESSION: AP chest compared to : Aside from small areas of linear atelectasis, lungs are clear.",0
Cardiomediastinal and hilar silhouettes and pleural surfaces are normal.,0
Multichannel right supraclavicular central venous line ends in the right atrium.,0
1:31 PM CHEST (PORTABLE AP) Clip # Reason: assess for effusion/pneumothorax Admitting Diagnosis: WOUND DEHISCENCE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with chronic sternal wound now s/p instrumentation/closure REASON FOR THIS EXAMINATION: assess for effusion/pneumothorax ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf FRI 4:04 PM Moderate left effusion with slight improvement in basal atelectasis after sternal closure without evidence of pneumothorax on this limited evaluation.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Chronic sternal wound status post closure.,1
Assess for pneumothorax or effusion.,0
TECHNIQUE: Portable slightly upright radiograph of the chest.,0
"FINDINGS: Endotracheal tube, right IJ catheter, and nasogastric tube are unchanged in appearance.",0
"There has been interval placement of sternal fusion plates, left chest tube, and right mediastinal drain.",0
Left-sided atelectasis slightly improved with moderate left pleural effusion and atelectasis again seen.,1
"The study is limited by both underpenetration and rotation but within these limitations, no definite pneumothorax is seen.",0
Right lung is well aerated without effusion.,0
IMPRESSION: Moderate left effusion with slight improvement in basal atelectasis after sternal closure without evidence of pneumothorax on this limited evaluation.,0
"Status: Inpatient Date/Time: at 13:30 Test: Portable TTE (Congenital, focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
12:55 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: Please image + pelvis.,0
"for fluid collection/absce Admitting Diagnosis: BACTERIAL ENDOCARDITIS;TELEMETRY Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man s/p median sternotomy for pericardial abscess, now with inc. WBC REASON FOR THIS EXAMINATION: Please image + pelvis.",1
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATIONS: Recent median sternotomy for pericardial abscess.,0
TECHNIQUE: MDCT imaging of the torso was performed following administration of oral and 130 cc of Optiray IV contrast.,0
Coronal and sagittal reformatted images were made.,0
COMPARISON: Abdominal CT scan from .,0
CT OF THE CHEST WITH IV CONTRAST: There is a large pericardial effusion which appears multiloculated and contains internal air bubbles.,0
There has been aortic valve replacement and changes from prior median sternotomy with multiple mediastinal clips.,1
The collection insinuates itself about the aorta and great vessels in the superior pericardial recesses.,0
The largest single axial dimension in the transverse dimension is approximately 9 cm.,0
There is a large right and small left pleural effusion.,1
These demonstrate intermediate Hounsfield units.,0
There is associated atelectasis of both lower lobes.,0
The right pleural effusion appears loculated with a large loculated component superiorly.,1
Patchy areas of ground-glass opacity are present anterior to atelectatic lung as well as along the mediastinal surface adjacent to the collection.,0
This could be additional atelectasis or focal pneumonia.,0
The ascending and descending aorta are normal in caliber.,0
There is no evidence of active extravasation.,0
"Multiple enlarged mediastinal and bilateral hilar lymph nodes are identified, the largest being a 12 x 18 mm pretracheal node.",0
CT OF THE ABDOMEN WITH IV CONTRAST: Beam hardening artifact from the patient's pacemaker obscures evaluation of the inferior liver.,0
"A rounded low- density focus is seen just medial to the right anterior portal vein in segment V which measures 6 mm, and it is most likely a cyst.",0
The lesion is unchanged since .,0
The gallbladder is mildly distended.,0
The spleen is at the upper limits of normal in size.,0
"The adrenal glands, kidneys, stomach, and small and large bowel loops are unremarkable.",0
There is no ascites or pathological mesenteric or retroperitoneal lymphadenopathy.,0
CT OF THE PELVIS WITH IV CONTRAST: The distal ureters are unremarkable.,0
Multiple air bubbles are present in the bladder.,0
There is a large amount of stool throughout the colon.,0
There is a trace amount of pelvic fluid.,0
No enlarged inguinal or pelvic nodes are present.,0
(Over) 12:55 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: Please image + pelvis.,0
for fluid collection/absce Admitting Diagnosis: BACTERIAL ENDOCARDITIS;TELEMETRY Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) BONE WINDOWS: There are changes from prior median sternotomy.,1
Sternal osteomyelitis cannot be excluded.,0
No suspicious lytic or sclerotic osseous lesions are identified.,0
Large pericardial fluid collection with air bubbles.,0
Whether the fluid is infected cannot be determined.,0
Large loculated right pleural effusion.,1
No evidence of intra-abdominal abscess.,0
Bilateral lower lobe atelectasis versus pneumonia.,0
This could be due to previous foley catheter placement or cystitis.,0
Results were discussed with at 1:45 p.m. on .,0
5:26 PM CT HEAD W/O CONTRAST Clip # Reason: bleed?,0
Admitting Diagnosis: STAB WOUND TO NECK ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with HIV and suicide attempt with mental status changes REASON FOR THIS EXAMINATION: bleed?,1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: HIV, suicide attempt with mental status changes.",1
"FINDINGS: There is no evidence of intracranial hemorrhage, shift of normally midline structures, mass effect, or hydrocephalus.",0
There is no major vascular territorial infarct.,0
The -white matter differentiation remains intact.,0
There is mild motion artifact.,0
There are no acute fractures.,0
There is mild mucosal thickening within the sphenoid sinus.,0
IMPRESSION: No intracranial hemorrhage or mass effect.,0
6:05 PM BILAT LOWER EXT VEINS PORT Clip # Reason: EVAL FOR DVT.,0
"TACHYCARDIA AND TACHYPNEA Admitting Diagnosis: PSEUDOARTHROSIS, C5-C6/SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with tachycardia, tachypnea, several days post op REASON FOR THIS EXAMINATION: eval for dvt ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl FRI 8:35 PM no left or right lower extremity DVT ______________________________________________________________________________ FINAL REPORT HISTORY: 65-year-old male with tachycardia and tachypnea several days postoperative.",0
"BILATERAL LOWER EXTREMITY DVT STUDY: Grayscale and Doppler son of the right and left common femoral, superficial femoral, and popliteal veins demonstrate normal venous flow, compressibility, and augmentation.",0
No intraluminal thrombus is identified.,0
IMPRESSION: No evidence of right or left lower extremity deep vein thrombosis.,0
"7:37 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please eval for NGT position Admitting Diagnosis: OGILVE'S SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with colonic pseudoobstruction, NGT pulled out s/p re-positioning REASON FOR THIS EXAMINATION: please eval for NGT position ______________________________________________________________________________ WET READ: 10:26 PM NGT terminated in lower esophagus.",0
Repeat exam already order at time of initial interpretation.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of NG tube position.,0
Portable AP chest radiograph was compared to obtained at 10:28.,0
The NG tube tip is above the gastroesophageal junction at the level of the T10.,0
The cardiomediastinal contour is stable.,0
"The lungs are unremarkable, and there is no pleural effusion or pneumothorax.",0
Height: (in) 70 Weight (lb): 187 BSA (m2): 2.03 m2 BP (mm Hg): 150/65 HR (bpm): 94 Status: Inpatient Date/Time: at 15:06 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.,0
LEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy.,0
AORTIC VALVE: The aortic valve leaflets are mildly thickened.,1
There is moderate aortic valve stenosis.,1
MITRAL VALVE: There is moderate mitral annular calcification.,0
"There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded.",0
PATIENT/TEST INFORMATION: Indication: ?Diastolic function.,0
Height: (in) 68 Weight (lb): 152 BSA (m2): 1.82 m2 BP (mm Hg): 113/72 HR (bpm): 60 Status: Inpatient Date/Time: at 09:42 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT ATRIUM: Mild LA enlargement.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.,0
A mass/thrombus associated with a catheter/pacing wire in the RA or RV.,0
Normal IVC diameter (>2.1cm) with <50% decrease with sniff (estimated RA pressure (>=15 mmHg).,0
Mild-moderate regional LV systolic dysfunction.,0
"TDI E/e' >15, suggesting PCWP>18mmHg.",0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - hypo; basal inferolateral - akinetic; mid inferolateral - hypo; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Mild global RV free wall hypokinesis.,0
Mild to moderate (+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
The right atrium is markedly dilated.,0
A 4-6mm mobile echodensity is seen in the right atrium (clip ) in close association with RV pacing lead and c/w a thrombus (cannot exclude vegetation if clinically suggested).,0
The estimated right atrial pressure is at least 15 mmHg.,0
There is mild-moderate regional dysfunction with thinning/near akinesis of the basal half of the inferolateral wall and inferior walls.,0
The remaining segments are mildly hypokineti (LVEF =30-35 %).,0
No intraventricular thrombi are identified.,0
Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).,0
The right ventricular cavity is mildly dilated with mild global free wall hypokinesis.,0
Mild-moderate (1=2+) mitral regurgitation is seen.,0
CONCLUSION: Dilated left ventricular cavity with regional and global systolic dysfunction c/w multivessel CAD or other diffuse process.,0
Mobile right atrial echodensity associated with the pacing wire as described above most c/w thrombus.,0
Compared with the prior study (images reviewed) of a mobile echodensity on the atrial pacing wire is now seen.,0
The heart rate is now slower.,1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CCU CHIEF COMPLAINT: Respiratory failure.,1
"HISTORY OF PRESENT ILLNESS: Mr. is a 69-year-old previously healthy male who was transferred from an outside hospital for admission into the Medical Intensive Care Unit with the following primary problems; respiratory alkalosis, anion gap, metabolic acidosis, respiratory failure requiring intubation secondary to ventilatory fatigue, acute liver failure, and acute renal failure of unclear etiology.",1
The history was obtained from two daughters; the patient was comatose at the time of presentation.,0
"One month ago, the patient was well walking roughly five miles per day.",0
At that time he started complaining of exertional dyspnea and insomnia.,0
His daughters described frequent weakness secondary to dyspnea and palpitations.,0
"He was seen at ""urgent care"" and diagnosed with anxiety.",0
"He was started on amitriptyline, lorazepam, and Tylenol PM.",0
He also complained of coughing at that time and had a chest x-ray that was notable for a large heart and fluid.,0
He was subsequently treated for pneumonia with a 10-day course of antibiotics and Combivent for one week.,0
"Three weeks prior to presentation, he returned to urgent care with a chief complaint of ""thrush,"" but he was told he did not have pneumonia (per radiologist read of a chest x-ray), but he did have cardiomegaly; and, again ""fluid in his lungs.""",0
"At that time, Lasix was started.",0
He saw Pulmonary on where he had abnormal pulmonary function tests and an arterial blood gas as follows: 7.44/32/76 on room air.,0
The patient was felt to have idiopathy pulmonary fibrosis.,0
"His daughters noted some slurred speech and tremors subsequent to that, and he was seen by his primary care physician four days prior to the current admission for an evaluation for profound exertional dyspnea.",0
He was unable to go from chair to bed.,0
"His Lasix dose was increased, and over the past two to three days he has had continued worsening exertional dyspnea, increasing confusion, and disorientation.",0
He coughed up some sputum.,0
"He was nauseated and had dry heaves for three, and he developed watery diarrhea and was started on p.r.n.",0
His daughters felt he was yellow three days ago and somewhat ashen-appearing today.,0
The review of systems was also notable for an 18-pounds weight loss over the last four weeks.,0
"There is no history of intravenous drug use, recent travel, and the patient denies any sexual activity.",0
"Esophageal stricture, status post multiple dilatations.",0
SOCIAL HISTORY: The patient lives alone.,0
He is a widower since .,0
One of his daughters died approximately one year after cocaine ingestion.,0
She was the patient's primary care giver.,0
The patient had a son who died in from human immunodeficiency virus/acquired immunodeficiency syndrome.,0
The patient smokes one pack per day for the last 40 years.,0
He is a former heavy alcohol drinker 30 years ago.,0
He has been sober for the last 20 years.,0
For the past 10 years he has had one drink per day.,0
"FAMILY HISTORY: The patient's family denies a family history of diabetes, hypertension, coronary artery disease, and cancer.",0
Both of the patient's parents died in their 80s.,0
HOSPITAL COURSE: (From ) The patient presented intermittently apneic and tachypneic.,0
An arterial blood gas there was as follows: 7.52/16/212 on 55% face mask.,0
"Subsequently, he went to 7.38/19/105.",0
The patient was intubated for worsening ventilatory fatigue.,0
"His laboratories demonstrated acute renal failure with a creatinine of 2.2 (when it had been normal two weeks prior), and hepatitis transaminases in the 400s (climbing to greater than 1000 prior to transfer).",1
"A lactate level was 3.5, and TCA level was 550.",0
An electrocardiogram demonstrated a wide QRS.,0
"On arrival here, he was hemodynamically stable, over-breathing the ventilatory, and unresponsive.",0
"PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a blood pressure of 87/63, pulse of 77, oxygen saturation of 98%.",0
"Ventilator settings the patient was on were assist control, 14 X 700, with a positive end-expiratory pressure of 10, an FIO2 of 60, and arterial blood gas was 7.39/26/191.",0
"In general, intubated and comatose.",0
"Head, eyes, ears, nose, and throat revealed left pupil was 4 mm (down to 3 mm with light), the right was 3.5 mm (down to 3 mm).",0
"There was no blinking to threat, and there were absent corneal reflexes.",0
Chest had coarse breath sounds bilaterally.,0
The cardiovascular examination was notable for distant heart sounds.,1
"The abdomen was soft, distended.",0
There was flank dullness to percussion.,0
The liver edge was 2 cm below the costal margin.,0
The extremities showed 2+ pitting lower extremity edema and palmar erythema.,0
The neurologic examination was as follows: the patient was comatose.,0
The pupils were minimally reactive.,0
There was no corneal reflex.,0
There was withdraw to pain on the right but not on the left.,0
The patellar reflexes were absent bilaterally.,0
"PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data evaluated a white blood cell count of 11.6, hematocrit of 42, platelets of 185.",0
"The urinalysis showed large blood, negative nitrites, 30 protein, greater than 50 red blood cells, 6 to 10 white blood cells, many bacteria, and 6 to 10 hyaline casts.",0
"SMA-7 revealed a sodium of 133, potassium of 5.4, chloride of 99, bicarbonate of 18, blood urea nitrogen of 89, creatinine of 2.9, and glucose of 141.",0
The creatine kinase was 375 (it had been 158 and then 221).,0
"Alkaline phosphatase was 122, magnesium of 3.1, total bilirubin of 2.8, albumin of 3.8, calcium of 8.7, phosphorous of 9.",0
Troponin was less than 0.4.,0
"The serum toxicology screen was negative except for TCA, and the urine toxicology screen was negative.",0
The TCA level at was 550.,0
"The ALT was 1784, and the AST was 3065.",0
RADIOLOGY/IMAGING: A CT of the head was suggestive of pontine stroke.,0
"HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for management of multiple medical problems including comatose state of unclear etiology, worsening exertional dyspnea requiring intubation, evolving acute liver failure, and new acute renal failure of unclear etiology.",1
"In the Intensive Care Unit, the patient underwent a magnetic resonance imaging after the head CT suggested a pontine stroke.",0
The magnetic resonance imaging was unremarkable.,0
"The patient was started on an acetylcysteine for possible Tylenol toxicity; although, a level was low/undetectable.",0
He was extubated without difficulty on hospital day two.,0
He was afebrile and hemodynamically stable throughout the rest of his acute course.,0
"His acute renal failure improved with gentle diuresis, and his liver function tests began trending down of their own .",1
It was felt that the elevated transaminases may have been secondary to shocked liver versus TCA toxicity versus Tylenol toxicity.,0
The patient's mental status was also noted to improve to the point where he was interactive.,0
"The patient was transferred to the floor on , and the Congestive Heart Failure Service was consulted.",1
"It was felt that the patient's course of worsening dyspnea, cardiomegaly, and fluid overload on chest x-ray were all consistent with the development of new congestive heart failure.",1
The patient was on captopril which was titrated up and switched to Zestril.,0
"Aldactone was added, and diuresis was attempted first with oral Lasix and then with increasing amounts of intravenous Lasix.",0
"From a pulmonary standpoint, the patient grew out Escherichia coli from his sputum and was started on Levaquin after his white blood cell count became to trend up and the patient started developing low-grade temperatures.",0
"In terms of gastrointestinal, the patient's transaminases continued to trend down for a peak AST of 3000 and a peak ALT of 1700, but the alkaline phosphatase and total bilirubin remained elevated.",0
A right upper quadrant ultrasound was subsequently obtained that was consistent with congestive hepatopathy.,0
"From a renal standpoint, the patient's creatinine trended down to 1.4 to 1.5 with volume repletion.",0
"From a hematologic standpoint, the patient's platelets were noted to be decreasing on a daily basis, and heparin antibodies were eventually sent which came back positive for antiplatelet Factor IV antibody.",0
"The patient was on subcutaneous heparin at the time, which was discontinued.",0
"On the day of transfer to the Coronary Care Unit, the patient underwent a cardiac catheterization, and the right heart catheterization revealed the following pressures, right atrial mean of 15, right ventricular 60/18, pulmonary artery of 60/30, wedge 30, cardiac output of 3, with an index of 1.5 measured by sic, superior vena cava oxygen saturation of 48%, and a pulmonary artery saturation of 52%.",0
"These numbers improved with milrinone with his pulmonary artery diastolic pressure dropping from 30 to 18, and the wedge dropping from 30 to 15, cardiac output improving from 3 to 5.8, with an index improving from 1.5 to 2.9.",0
"Coronary angiography revealed 40% to 50% left main stenosis, a mild proximal circumflex lesion, and minimal luminal irregularities in the left anterior descending artery.",0
The patient was brought to the Coronary Care Unit on for the management of Swan-/milrinone therapy to aid in diuresis.,0
"While in the Coronary Care Unit, the patient responded well to diuresis with milrinone.",0
"He was also maintained on Lasix, Zestril, and Aldactone to manage his heart failure.",1
"On , the patient's milrinone was discontinued, but he became tachycardic and dyspneic and developed elevated right-sided pressures.",0
"The central venous pressure went up from 12 to 23, and the mean pulmonary artery pressure rose from 30 to 65.",0
"At that time, the patient also spiked a temperature to 103.4.",0
It was felt that the patient failed to come off the milrinone in the setting of a new infection.,0
Blood cultures obtained at the time of the temperature spike revealed 4/4 bottles positive for methicillin-resistant Staphylococcus aureus.,0
"The patient was empirically started on vancomycin, and then gentamicin was added 24 hours later.",0
"Over the next 48 hours, the patient's milrinone was slowly weaned off without difficulty.",0
"On the day prior to discharge from the Coronary Care Unit, the patient was noted to put out 3600 cc of urine with 500 cc of intake reported on 0.188 mcg/kg per minute of milrinone and a standing Lasix of 80 mg intravenously b.i.d.",0
"On , the patient's PA catheter was removed and the line tip was cultured.",0
It grew out greater than 15 CFU/mL of Staphylococcus aureus which has yet to be further speciated.,0
"Given the clinical setting, it was felt that the patient's bacteremia was secondary to line-related infection, tunnel site more so than endoluminal.",1
"At the time of discharge from the Coronary Care Unit, the patient was also noted to have two other mild laboratory abnormalities: (1) The patient's platelet count drifted down over a course of 48 hours from 104 to 83 in the setting of having all heparin held.",0
A further workup is currently pending including DIC panel and repeat liver biochemistries.,0
"(2) The patient also had mild hyponatremia to 127 with a serum osmolality of 272, and a urine osmolality of 325.",0
"The hyponatremia was felt the be multifactorial including the patient's congestive heart failure, use of milrinone and Lasix, and possible excessive unsupervised free water intake.",1
"ACTIVE DISCHARGE PROBLEMS: At the time of discharge from the Coronary Care Unit, the patient's active problems remained as follows: 1.",0
Congestive heart failure with a low ejection fraction (an ejection fraction of 10% by a prior echocardiogram) complicated by congestive hepatopathy.,1
Line-related methicillin-resistant high-grade Staphylococcus aureus bacteremia.,0
Dictated By: MEDQUIST36 D: 12:28 T: 18:35 JOB#:,0
"Admission Date: Discharge Date: Service: HISTORY OF PRESENT ILLNESS: The patient is an 85 year old female with a past medical history of bilateral carotid stenosis, coronary artery disease, status post left anterior descending percutaneous intervention, hypertension, hypercholesterolemia, who was admitted to the CCU for monitoring following elective right internal carotid artery percutaneous intervention.",1
"The patient has initially been evaluated in , for word finding difficulty and a left facial droop and was found to have bilateral internal carotid artery stenosis.",1
"The patient has a history of significant coronary artery disease, multiple medical problems and her age.",1
She was referred for elective stent intervention of her carotids as opposed to endarterectomy.,0
"She had a magnetic resonance scan - MRA of head and neck on , which showed a two right hemispheric microhemorrhages and right subcortical small vessel ischemic disease.",0
"During the stent procedure, the patient required a Neo-Synephrine drip for decreased blood pressure and Atropine times two for decreased heart rate.",0
"During the procedure, the patient was noted to have an right posterior carotid AV fistula.",0
"Carotid stenosis bilaterally, ultrasound , bilateral internal carotid artery stenosis of 70 to 90%.",1
Cerebrovascular accident with small vessel disease.,1
"Known facial droop, right hemispheric microhemorrhages.",0
"Coronary artery disease, , catheterization with a left main 20% ostial stenosis, left anterior descending 80% midstenosis, status post stent, diagonal 90% stenosis status post stent, left circumflex 40% lesion at the OM1.",1
"Ejection fraction estimated to be 67% on a MUGA, ETT MIBI, that she had in .",0
"There was no nuclear defect, perfusion defects, during the test.",0
Status post Zenker's diverticular repair.,0
ALLERGIES: Intravenous pyelogram dye causes her to have anaphylaxis.,0
Univasc 7.5 mg one once daily and 15 mg q.p.m.,0
Dyazide 12.5 mg once daily.,0
Lipitor 10 mg once daily.,0
Plavix 75 mg once daily.,0
SOCIAL HISTORY: She lives alone.,0
No tobacco use and rare ETOH use.,0
"PHYSICAL EXAMINATION: At the time of presentation, she was afebrile with a heart rate of 63, blood pressure 120/50 to 160/60, respiratory rate 16, oxygen saturation 99% on two liters.",0
She is in no acute distress lying in bed.,0
No bruit or jugular venous distention appreciated.,0
"Heart is regular rate and rhythm, S1 and S2, no murmurs, rubs or gallops.",0
Her lungs are clear to auscultation bilaterally posteriorly.,0
"Abdomen with normoactive bowel sounds, soft, nontender, nondistended.",0
"Extremities - no cyanosis, clubbing or edema.",0
Her dorsalis pedis were .,0
Her neurologic examination revealed cranial nerves with the exception of her facial nerve were intact.,0
She has flat nasolabial fold on the left side.,0
Normal upper and lower extremity strength.,0
"LABORATORY DATA: On the day of admission, white blood cell count 6.6, hematocrit 32.6, platelet count 291,000.",0
"Total cholesterol was 173, HDL 45, LDL 109.",0
"ASSESSMENT: This is an 81 year old female with a history of coronary artery disease, peripheral vascular disease, carotid artery stenosis, bilaterally, hypertension, hypercholesterolemia, admitted to the CCU status post right internal carotid artery stent.",1
"Neurology - The patient had stent, status post right internal carotid artery stent.",1
She initially was on Neo-Synephrine to maintain a blood pressure goal between 110 and 150.,0
She had q1hour neurological checks and then q2hour neurological checks.,0
"Initially, her Neo-Synephrine was weaned off and the patient's blood pressure gradually rose to approximately 160 to 170.",0
"As a result, some very low dose Nitroglycerin drip was started to try to keep her blood pressure between 150 and 110.",0
The patient had hypotension with blood pressure down to 70.,0
The Nitroglycerin drip was stopped and Neo-Synephrine drip was started with blood pressure up to as high as 200s.,0
"When all drips were stopped, her blood pressure gradually came down to 120 to 130 systolic.",0
This was fairly soon after the stent had been placed and the patient arriving in the CCU.,0
"Overnight the first hospital night, the patient was placed on a low dose of Neo-Synephrine 0.1 to maintain her blood pressure between 110 to 120 with gradually being able to be weaned off the drip and on the second hospital day, the Neo-Synephrine drip was turned off.",0
"The patient did not require any Atropine in the CCU, however, she did have a symptomatic bradycardia going down to mid 30s while she is sleeping, coming up to mid 40s to 50s when being awakened.",0
"On the neurologic examination, there was no focality or any change in her examination from her baseline which had the left nasolabial fold flattening.",0
"However, the patient did seem to be confused the evening status post the procedure and on day two on the , the patient had a CT of the head without contrast which showed no definite hemorrhage.",0
"The results were reviewed with the neurologist following along with the team, Dr. .",0
"On the second day postprocedure, the patient was acting more oriented and less confused.",0
Her confusion seemed to coincide with the onset of night fall and possible disturbance of her sleep/wake cycle.,0
The rest of her stay the patient had blood pressure near goal being consistently in the 120s to 130s.,0
She was transferred to the floor and Step-Down Unit on Two for further monitoring.,0
The patient was seen by physical therapy who felt the patient was a fall risk and recommended for both feet physical therapy and occupational therapy and a short term rehabilitation to optimize her functional capacity before returning to living alone at home.,0
Hematology - The night after the procedure the patient had a right arterial and venous sheath in place for her arterial line that was monitoring her blood pressure.,0
"The patient, despite having a leg immobilizer and numerous discussions and explanations and exhortations to stay in bed, attempted to get out of bed on the first night of her admission, and was seen by house staff.",0
House staff and nursing staff got the patient into bed.,0
"Her groin examination was stable with no bruit or hematoma, however, on the next day, her hematocrit dropped to 26.3.",0
The patient had two units of packed red blood cells transfused with her hematocrit being 34.9 on the day of discharge.,0
Her CT of her abdomen and pelvis showed no retroperitoneal hematoma.,0
This examination was done on .,0
Blood pressure control - The patient will be discharged on Univasc 7.5 mg twice a day and will follow-up with Dr. in four to six weeks to have her blood pressure medications adjusted possibly placing her back on her beta blocker as well.,0
Coronary artery disease - The patient was continued on her Aspirin and now will be on Plavix for life long therapy.,1
Infectious disease - The patient had a low grade temperature maximizing at 100.5 on the day prior to discharge.,0
"She had urine and blood cultures sent, all of which are no growth at the time of discharge.",0
"As well, her urinalysis was unremarkable.",0
She had no localizing symptoms of temperature or fever.,0
Her temperature is 100 temperature maximum on the day of discharge.,0
"Bilateral carotid artery stenosis, status post right internal carotid artery stenting.",1
"Significant coronary artery disease, status post left anterior descending stenting.",1
Right facial droop seemingly due to an old stroke.,0
PROCEDURE: Right internal carotid artery stent.,0
Artificial Tears one to two drops O.U.,0
FOLLOW-UP: The patient is to see Dr. in approximately four weeks in follow-up appointment for this procedure and at the same time to see her primary care physician.,0
Dictated By: MEDQUIST36 D: 12:07 T: 13:27 JOB#:,0
"2:00 AM MR L SPINE SCAN Clip # Reason: 25 Y/O MALE W/ L2 FX ON CT, PARESTHESIA OF LT. LEG.",0
"Admitting Diagnosis: L2 FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with L2 fx on CT, paresthesia of left leg REASON FOR THIS EXAMINATION: r/out cord compression, ligamentous injury need STIR images No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: MRI of the lumbar spine.",1
CLINICAL INFORMATION: The patient with compression fracture of L2 for further evaluation.,0
TECHNIQUE: T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were acquired.,0
The axial images are somewhat limited by motion.,0
FINDINGS: There is abnormal signal and compression of L1 vertebra visualized with retropulsion.,0
"There is high-grade spinal stenosis seen at this level, which is high, between 75/100 percent of the spinal canal width.",1
There is also indentation on the conus by the retropulse vertebra.,0
Increased signal is seen in the region of conus indicating edema.,0
There is no evidence of disruption of the intraspinous ligaments.,0
There is no evidence of intraspinal hematoma identified below the level of the fracture.,1
"At L4-5, disc bulging and degenerative disc disease is seen without spinal stenosis.",0
"At L5-S1 level, there is a rudimentary disc indicating transitional vertebra.",1
There is increased signal seen within the superior endplates of T11 and T12 vertebra indicating mild acute compression.,1
IMPRESSION: Acute fracture of L1 vertebra with retropulsion and high-grade spinal stenosis at L1 level.,1
Extrinsic compression of the conus with increased signal within the distal spinal cord indicating edema.,0
Mild acute compressions of T11 and T12 vertebrae.,1
Disc degenerative change and mild bulging of L4-5 disc.,0
Transitional vertebra at lumbosacral junction with a rudimentary disc between L5 and S1.,0
"10:20 AM N-G TUBE PLACEMENT (W/ FLUORO) Clip # Reason: please place post-pyloric feeding tube (dobhoff) ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with poor po intake REASON FOR THIS EXAMINATION: please place post-pyloric feeding tube (dobhoff) ______________________________________________________________________________ FINAL REPORT INDICATION: Poor PO intake, needs post-pyloric feeding tube.",0
FEEDING TUBE PLACEMENT: A nasojejunal - feeding tube was placed under fluoroscopy past the pylorus and into the fourth portion of the duodenum.,0
10 cc of contrast was injected to confirm tip placement.,0
IMPRESSION: Status post post-pyloric feeding tube placement.,0
4:42 PM C-SPINE NON-TRAUMA VIEWS IN O.R.,0
Clip # Reason: C3-T1 Admitting Diagnosis: BACK PAIN R/O CORD COMPRESSION ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MH TUE 8:39 AM Three intraoperative films of the cervical spine related to posterior fusion procedure.,0
"______________________________________________________________________________ FINAL REPORT On view #1, C1 through lower portion C4 is demonstrated and a surgical marker overlies the spinous process of the C4 vertebral body.",0
Multiple support devices are in place.,0
"On the AP view, bilateral pedicle screws are in place from C4 through T1.",0
"On the unlabelled lateral view, the pedicle screws are seen posteriorly, nominal in position, with evidence of laminectomy.",0
"Correlation with real- time findings and when appropriate, conventional radiographs are recommended for full assessment.",0
", C. NSURG SICU-B 11:37 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: post-op Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with s/p crani REASON FOR THIS EXAMINATION: post-op No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Patient is status post left frontoparietal craniotomy with expected postoperative changes for large area of intraparenchymal hemorrhage seen essentially within the left frontal lobe with still a large component of high mixed attenuation hemorrhage seen within the left frontal lobe.",1
Significant decrease in size in AP dimension since prior examination where now it measures approximately 56 mm from prior extended through to the left parietal region measuring 79 mm.,0
"An underlying mass or vascular malformation remains in the differential, an MR can be obtained for further characterization.",0
", M. NSURG SICU-B 6:26 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: Interval change in intracranial bleed since 3pm scan?",0
Admitting Diagnosis: MENINGIOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with brain tumor resected today.,0
Please perform scan at 7pm.,0
REASON FOR THIS EXAMINATION: Interval change in intracranial bleed since 3pm scan?,0
"No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Status post left frontal craniotomy for left frontal mass resection, with stable appearance of left frontal hemorrhage in the resection bed.",0
4:30 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"atelectasis Admitting Diagnosis: FEVER-R/O TB ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man trach, PNA, who destatted REASON FOR THIS EXAMINATION: ?",0
atelectasis ______________________________________________________________________________ FINAL REPORT HISTORY: Hypoxia.,0
"Single portable chest radiograph again demonstrates severe bilateral emphysematous change, worse in the right upper lung.",0
Support lines are unchanged when compared to .,0
Cardiomediastinal contours are similar in appearance.,0
I doubt the presence of a pleural effusion and the appearance of the costophrenic angles is likely attributable to flattening of the bilateral hemidiaphragms.,0
IMPRESSION: No significant change when compared to .,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: SOB Major Surgical or Invasive Procedure: intubation History of Present Illness: Pt is a 85 y/o man w/ Parkinsons dz, COPD, and CHF who presented to from his nursing home w/ complaints of a low grade temperature and SOB this AM.",0
He complained additionally of a dry cough but denied leg pain/swelling/rash.,0
He has had no recent medication changes or diet changes.,0
"At the outside hospital, he was found to be tachycardic to 118, hypertensive to the 160s and hypoxic to the high 80s on a NRB.",0
He developed rapid atrial fibrillation requiring cardioconversion and was noted to have precordial ST elevations with CKs in the 500s.,1
His CMO code status was reversed so that the son in could come up to see his father and he was intubated for respiratory distress.,0
He was transferred to for further evaluation and possible cath.,0
"Her in the CCU, his ST elevations had resolved although he was still tachycardic in a. fib and febrile.",0
"CHF Social History: Lives in a chronic care facility Family History: NC Physical Exam: Gen: Intubated, sedated, diaphoretic HEENT: Pupils slowly reactive, MMM Neck: -LAD/JVD appreciated CV: Irregular rhythm, S1/S2, -M/R/G ascultated Lungs: coarse inspiratory breath sounds.",0
ECHO : The left atrium is moderately dilated.,0
Brief Hospital Course: A/P: Pt is an 85 y/o man w/ a PMH of parkinsons and COPD who presented w/ SOB and ekg changes along with enzyme elevations.,0
Cardiac - patient had CE elevations w/out EKG changes when transferred to .,0
His family deferred catheterization due to his poor condition and previous DNR/DNI status.,0
He was initially hypotensive necessitating pressors upon admission.,0
He did not appear to be in CHF and responded well to fluid boluses.,0
His pressors were weaned off and he remained pressor free for the remainder of his stay.,0
His initially had afib when evaluated at the outside hospital and was cardioconverted to NSR.,0
He was monitored on tele throughout his admission.,0
He occassionally reverted to afib during his admission and was rate controlled with metoprolol for these tachyarrhythmias.,0
Respiratory distress - the patient has a hx of copd and chf.,0
He was transferred to us intubated although he had previously been DNR/DNI.,0
He tolerated a wean of his ventillator and was successfully extubated during his stay.,0
His family discussed the options with the covering team and decided that he should be DNI if he ever again decompenstated from a respiratory standpoint.,0
He was maintained on stress dose steroids for 5d and received nebs.,0
His sputum cx grew MRSA which was treated w/ vancomycin.,0
He was diuresed later on in his hospital course and responded well to 40mg lasix IV.,0
CRI - the patient's creatinine on arrival was 1.3 but quickly normalized .,0
ID - the patient was never febrile during his admission and mostly was hypothermic to the 95-96 range.,0
He had a persistently elevated WBC count and a hemodynamic picture c/w sepsis on admission.,0
"He was treated w/ IVF and empirically started on vancomycin, ceftazidime, and flagyl.",0
Blood and urine cultures grew nothing but his sputum cx grew MRSA.,0
He was underwent a 10d course of vancomycin.,0
The patient continued to have poor functional status and was transfered from the CCU to step down floor for continued care.,0
"Discussion were held with the patient's family and they decided to have him made CMO, with antibiotics and morphine drip for comfort care.",0
The patient expired on .,0
Medications on Admission: protonix metoprolol albuterol carbidopa aricept Discharge Medications: None-Deceased Discharge Disposition: Expired Discharge Diagnosis: NSTEMI Discharge Condition: Patient Expired Discharge Instructions: None Followup Instructions: None Completed by:,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Cardiothoracic Surgery.,0
CHIEF COMPLAINT: Ventricular fibrillation arrest.,1
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old woman who was dancing at a wedding when she suddenly collapsed.,0
"Bystanders commenced cardiopulmonary resuscitation and emergency medical technicians placed an AAD and shocked her at 200 joules, which converted her to a normal rhythm.",0
She was down for approximately five minutes and subsequently transferred to an outside hospital.,0
"The patient was stabilized at the outside hospital and transferred on Lopressor, Lidocaine drip, nitroglycerin paste, morphine, Ativan and levofloxacin.",0
"She was then taken for a cardiac catheterization on , which revealed global hypokinesis with a left ventricular ejection fraction of about 40%.",1
"The left main coronary artery was diffusely diseased with 80% ostial stenosis, left anterior descending artery 70% origin, and the mid and distal left anterior descending artery were small and diffusely diseased.",1
"The left circumflex had 95% origin stenosis, and right coronary artery had 60% ostial and 60% mid-stenosis.",1
An intra-aortic balloon pump was correctly placed.,0
"After stabilization, the patient was subsequently evaluated for cardiac surgery.",0
"Borderline diabetes mellitus, recently discovered.",0
SOCIAL HISTORY: The patient quit smoking about 15 to 20 years ago after a 15 pack year history.,0
She is a social drinker.,0
FAMILY HISTORY: The patient's mother had three myocardial infarctions.,0
She has a family history of diabetes mellitus on the paternal side.,0
"OUTPATIENT MEDICATIONS: Lipitor, dose unknown.",0
REVIEW OF SYSTEMS: The patient has had an intentional 20 pound weight loss over the last several months.,0
She had had recent episodes of dyspnea on exertion while walking stairs.,0
"She has no complaints of nausea, vomiting, diarrhea, night sweats or chest pain.",0
"PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 99.1, heart rate 72, blood pressure 110/38, respiratory rate 16 and oxygen saturation 100%.",0
She was ventilated with SIMV 600-17-0.7 with a PEEP/pressure support .,0
General: Intubated and sedated but responded to voice.,0
"Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation, conjunctivae injected, anicteric sclerae.",0
Neck: Supple with no discernable jugular venous distention or bruits.,0
"Cardiovascular: Regular rate and rhythm, normal S1 and S2, II/VI systolic ejection murmur.",0
"Abdomen: Soft, nontender, nondistended, positive bowel sounds.",0
"Extremities: No cyanosis, clubbing or edema.",0
HOSPITAL COURSE: The patient was taken to the Operating Room on for coronary artery bypass grafting times three.,1
"Grafts included left internal mammary artery to the left anterior descending artery, saphenous vein graft to obtuse marginal and saphenous vein graft to the posterior descending coronary artery.",1
The procedure was performed without complication and the patient was subsequently transferred to the Cardiothoracic Intensive Care Unit.,0
The intra-aortic balloon pump was discontinued on postoperative day number one and the patient was successfully weaned from drips and extubated.,0
She was adequately fluid resuscitated and hemodynamically stabilized in the Intensive Care Unit.,0
The patient continued to do well and was subsequently transferred to the floor on postoperative day number three.,0
"On the floor, the patient had several episodes of atrial fibrillation.",1
She was converted to sinus rhythm with intravenous Lopressor.,0
Oral doses of Lopressor and amiodarone were progressively increased.,0
These episodes of atrial fibrillation soon ceased without any further episodes.,1
The patient's course was also complicated somewhat by periods of confusion.,0
"She was followed closely by her family and staff and, eventually, this confusion diminished and she was at her baseline mental status.",0
Her stay on the floor was also remarkable for some small amounts of drainage from her incision site.,0
The fluid was nonpurulent looking and there was no erythema around her incision.,0
Clindamycin was started for a two week course for treatment of this possible infection.,0
The patient continued to improve daily.,0
She was tolerating an oral diet and her pain was under good control.,0
"By postoperative day number nine, the patient continued to do well and was felt to be stable to be discharged home.",0
"Physical examination on discharge: Vital signs: Temperature 99.3, pulse 68, blood pressure 169/53, respiratory rate 18 and oxygen saturation 93% on two liters.",0
Cardiovascular: Regular rate and rhythm.,0
Lungs: Clear to auscultation bilaterally.,0
"Incision: Draining slightly, with no erythema or purulent material.",0
DISCHARGE STATUS: The patient was discharged to home with VNA assistance.,0
DISCHARGE MEDICATIONS: Metoprolol 50 mg p.o.b.i.d.,0
Enteric coated aspirin 325 mg p.o.q.d.,0
Potassium chloride 20 mEq p.o.q.d.,0
FOLLOW-UP: The patient was instructed to follow up with Dr. in four weeks and to follow up with Dr. in three to four weeks.,0
DISCHARGE DIAGNOSIS: Status post coronary artery bypass grafting times three following ventricular fibrillation arrest.,1
Dictated By: MEDQUIST36 D: 11:52 T: 12:37 JOB#:,0
3:27 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO); 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # Reason: pls re-position dobhoff (displaced during transesophageal ec Admitting Diagnosis: BILE DUCT STRICTURE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p hapatic lobectomy REASON FOR THIS EXAMINATION: pls re-position dobhoff (displaced during transesophageal echo this am) ______________________________________________________________________________ FINAL REPORT HISTORY: 48-year-old man status post hepatic lobectomy with feeding tube displaced during transesophageal echocardiogram.,0
PROCEDURE & FINDINGS: Fluoroscopic examination of the existing feeding tube demonstrated it coiled within the patient's pharynx and the tip in the esophagus.,0
The tube appeared damaged and was subsequently removed.,0
A new weighted feeding tube was obtained and coated in Lidocaine jelly.,0
It was advanced through the nostril into the stomach.,0
Air and 5 cc of Conray were infused through the tube to opacify the gastric anatomy.,0
The tube was subsequently advanced past the pylorus and into the third portion of the duodenum.,0
Post-placement injection of contrast demonstrated appropriate positioning of the tube tip within the third portion of the duodenum.,0
The catheter was secured with tape.,0
The patient tolerated the procedure well and there are no immediate postprocedure complications.,1
IMPRESSION: Successful placement of postpyloric feeding tube.,0
"7:55 AM CHEST (PORTABLE AP) Clip # Reason: Pna?, Ards?",0
"Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with necrotizing fasciitis, s/p R-side chest tube pulled back 4 cm REASON FOR THIS EXAMINATION: Pna?, Ards?",1
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST.,0
REASON FOR EXAM: Assess for pneumonia or ARDS the patient with necrotizing fasciitis.,1
Comparison is made with prior study performed a day earlier.,0
FINDINGS: Tracheostomy tube is in place.,0
Right subclavian vein catheter tip is in unchanged position in the SVC.,0
"Less radiolucency of the right hemithorax is consistent with decrease in the amount of pneumothorax, though a pleural line cannot be assessed.",0
Right chest tube remains in place.,0
There is mild improvement in the aeration of the left lower lobe.,0
There is also progressive improvement in the bilateral parenchymal opacities and radiolucent areas due to mild pulmonary edema and pneumatoceles IMPRESSION: Persistent small to moderate right pneumothorax,0
7:16 AM CHEST (PORTABLE AP) Clip # Reason: r/o RLL collapse Admitting Diagnosis: CHF;AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with AS s/p AVR s/p bronchoscopy yesterday REASON FOR THIS EXAMINATION: r/o RLL collapse ______________________________________________________________________________ FINAL REPORT INDICATION: Status post AVR with bronchoscopy yesterday.,0
Rule out right lower lobe collapse.,0
FINDINGS: Portable radiograph of the chest.,0
Stable position of right internal jugular line and left dual-lumen subclavian catheter.,0
Both appear to terminate near the atriocaval junction.,0
Endotracheal tube is approximately 3.5 cm from the carina.,0
NG tube is identified with its side port below the level of the diaphragm.,0
Multiple midline sternotomy wires are unchanged.,0
Mediastinal and cardiac silhouettes are stable.,0
Stable left-sided pleural effusion and left retrocardiac density representing airspace disease versus atelectasis.,0
Mild stable pulmonary vascular congestion is noted.,0
Right lung is clear without pleural effusion or evidence of collapse.,0
IMPRESSION: No evidence of right lower lobe collapse.,0
Stable left-sided pleural effusion and retrocardiac density representing atelectasis versus airspace disease.,0
2:35 AM CHEST (PORTABLE AP) Clip # Reason: PTX?,0
"Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with end stage liver disease complicated by hemothorax recurrent effusions, s/p chest tube.",1
REASON FOR THIS EXAMINATION: PTX?,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube in place, to assess for pneumothorax.",0
"FINDINGS: In comparison with the study of , the right chest tube remains in place and there is no evidence of pneumothorax.",0
"There may be some increasing opacification at the right base, suggestive of worsening pneumonia.",0
Increasing prominence of pulmonary vasculature suggests overhydration.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Pegasys ProClick / Penicillins Attending: Chief Complaint: Elective resection of L temporal mass.,0
Major Surgical or Invasive Procedure: Left temporal craniotomy for mass resection.,0
Right inguinal lymph node biopsy.,0
"History of Present Illness: 52 yo Right handed man diagnosed with a left temporal lesion in , found on workup of right sided arm and leg numbness, speech arrest, episodes of disorientation, memory difficulties and involuntary movements of his righ hand.",0
He was started on Keppra and the dose has been titrated up by Dr. for control of these symptoms with good effect.,0
"Since the increase in Keppra to 1000mg the patient has not experienced any numbness, tingling, difficulies with speech or episodes of disorientation.",0
He presents with his wife today for surgical consultation.,0
He reports Headaches in the form of pressure at the back of his head.,0
"Histocytosis X, dx by CT imaging, no biopsy.",0
"Positive PPD due to BCG vaccination, TB exposure from mother.",0
"Social History: Married, children, from , works as an engineer.",0
His wife is a psychiatrist.,0
Family History: Mother had disseminated TB.,0
"Physical Exam: ADMISSION EXAM: AF VSS Gen: WD/WN, comfortable, NAD.",0
HEENT: Pupils: EOMs Neck: Supple.,0
"Abd: Soft, NT, BS+ Extrem: Warm and well-perfused.",0
Recall: objects at 5 minutes.,0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally.",0
"No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally.",0
"Reflexes: B T Br Pa Ac Right Left Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: ADMISSION LABS: 01:01AM BLOOD WBC-9.1# RBC-4.04* Hgb-12.8* Hct-35.3* MCV-87 MCH-31.5 MCHC-36.1* RDW-12.1 Plt Ct-258 01:01AM BLOOD PT-11.9 INR(PT)-1.1 06:39PM BLOOD Na-126* K-4.0 Cl-96 01:01AM BLOOD Glucose-156* UreaN-7 Creat-0.8 Na-125* K-4.5 Cl-95* HCO3-20* AnGap-15 01:01AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8 .",0
Biapical reticular and cystic changes consistent with patient's known history of histiocytosis X.,0
Subcentimeter subpleural pulmonary nodules for which a follow up CT chest in 12 months or attention on follow up imaging is recommended.,0
Bilateral axillary adenopathy which is stable since .,0
Multiple enlarged retroperitoneal and pelvic lymph nodes.,1
A right external iliac lymph node may be amenable to ultrasound-guided biopsy if required.,0
MRI HEAD: IMPRESSION: Surgical planning study demonstrates increase in size (3cm) in irregular pattern of enhancement of left temporal and periatrial mass.,0
The mass has considerably increased in size compared with the MRI .,0
"Given the rapid change in size, an aggressive neoplasm such as glioma is suspected.",0
ECHO: IMPRESSION: Normal global and regional biventricular systolic function.,0
"Post-contrast images are motion degraded, limiting evaluation for pulmonary embolism in segmental and subsegmental branches.",0
No central pulmonary embolism identified.,0
Chronic reticular and cystic changes within the upper lungs in this patient with history of Langerhans' cell histiocytosis.,0
No new focal consolidation within the lungs.,0
"DISCHARGE LABS: 12:54AM BLOOD WBC-5.7 RBC-3.68* Hgb-12.1* Hct-33.9* MCV-92 MCH-32.9* MCHC-35.7* RDW-12.1 Plt Ct-309 05:18AM BLOOD PT-11.6 PTT-27.3 INR(PT)-1.1 12:54AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-127* K-4.1 Cl-95* HCO3-25 AnGap-11 12:54AM BLOOD ALT-51* AST-16 LD(LDH)-162 AlkPhos-45 TotBili-0.7 04:00AM BLOOD CK(CPK)-407* 05:18AM BLOOD ALT-43* AST-14 LD(LDH)-152 CK(CPK)-248 AlkPhos-51 TotBili-0.8 04:00AM BLOOD CK-MB-2 cTropnT-<0.01 12:54AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.3 UricAcd-2.8* 01:08PM BLOOD Osmolal-273* 05:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE 05:00AM BLOOD HIV Ab-NEGATIVE 05:00AM BLOOD HCV Ab-NEGATIVE 05:21PM BLOOD mthotrx-0.43 12:54AM BLOOD mthotrx-0.10 Brief Hospital Course: 52yo man with histiocytosis and diabetes insipidus admitted for left temporal mass resection, preliminary pathology suspicious for lymphoma.",1
"He was having right ear fullness, headaches, numbness on the right side, and involuntary RUE movements (?seizure) x3 months.",0
Seen in Brain Clinic and scheduled for resection .,0
MRI prior to rescetion showed increase in size compared to .,0
CT torso significant for enlarged retroperitoenal and iliac LNs.,0
He was admitted to the Neurosurgery service for elective bx and resection of temporal mass.,0
He was transferred to the ICU for SBP control and q1 neurochecks.,0
"He tolerated the procedure well, but post-operatively he showed marked word finding difficulty.",0
A head CT showed no hemorrhage or hydrocephalus.,0
He was given NaCl tabs for hyponatremia.,0
Neuro-oncology was consulted for further management and he was then transferred to the Oncology service.,0
# Left temporal lesion: Craniotomy confirmed high-grade B-cell lymphoma.,0
High-dose methotrexate delayed for iliac lymph node biopsy and bone marrow biopsy to exclude systemic lymphoma.,0
"Pelvic LN biopsy done , results pending, but early review showed abundance of lymphocytes, not appearing aggressive like CNS lesion.",0
Case discussed at HemePath Conference.,0
Cycle #1 high-dose methotrexate 6g/m2 (dose reduced for 1st cycle with plan to increase dose if tolerated) given .,0
Sodium bicarb by IV and PO to aid excretion of MTX.,0
Followed MTX levels daily starting 24hrs after MTX.,0
Leucovorin (or levoleucovorin) rescue started 24hrs post-chemo.,0
He tolerated chemotherapy very well and the expressive aphasia resolved over days.,0
- PENDING final pathology of pelvic LN and bone marrow.,0
# Seizures: Continued levetiracetam 1000 mg .,0
# Anxiety and sleep disorder: Added clonazepam 0.5mg qNOON for anxiety.,1
Continued clonazepam 1mg QHS for insomnia.,0
# Aphasia: Speech therapy following with services at discharge.,0
# Hyponatremia: Likely SIADH + HCTZ.,0
"HCTZ stopped and NaCl tabs were given in ICU, then stopped.",0
"Hyponatremia resolved, so DDAVP restarted .",0
# Diabetes insipidus: Controlled on DDAVP.,1
"Restarted DDAVP, initially held due to hyponatremia/SIADH.",0
"Followed daily urine Na, osm, and specific gravity.",0
# Chronic hepatitis B: Hepatitis serologies negative.,1
Hep B viral load negative; lamivudine not given.,0
"# Chest pain: Troponin negative, CTA negative.",0
"Tender right upper chest wall suggested musculoskeletal cause, no resolved.",0
HCTZ stopped due to hyponatremia.,0
"# FEN: Regular MTX diet (no citrate, vitamin C, or carbonated beverages).",0
"# PPX: Heparin SC, H2 blocker, bowel regimen.",0
# Access: Triple lumen central line from craniotomy d/c'd at discharge.,0
"Medications on Admission: CLONAZEPAM 1 mg PO at bedtime DESMOPRESSIN [DDAVP] 2 sprays times a day HYDROCHLOROTHIAZIDE 25 mg PO once a day LEVETIRACETAM 1,000 mg PO BID LISINOPRIL 10 mg PO once a day ASPIRIN 81 mg PO once a day DIPHENHYDRAMINE-ACETAMINOPHEN [TYLENOL PM] Discharge Medications: 1. clonazepam 1 mg PO QHS.",0
2. clonazepam 0.5 mg PO NOON.,0
Disp:*30 Tablet(s)* Refills:*0* 3. levetiracetam 1000 mg PO BID.,0
Disp:*120 Tablet(s)* Refills:*2* 4. lisinopril 10 mg PO HS.,0
5. dexamethasone 4 mg PO Q6H.,0
Disp:*120 Tablet(s)* Refills:*1* 6. famotidine 20 mg PO Q12H.,0
"Disp:*60 Tablet(s)* Refills:*2* 7. desmopressin 10 mcg/spray Aerosol, Spray Sig: Two (2) Spray Nasal : Take at 6:00AM and qHS.",0
"8. desmopressin 10 mcg/spray Aerosol, Spray Sig: One (1) Spray Nasal NOON.",0
9. acetaminophen 325-650 mg PO Q6H PRN Pain.,0
10. oxycodone 5-10 mg PO Q4H Pain.,0
Disp:*20 Tablet(s)* Refills:*0* 11. docusate sodium 100 mg PO BID.,0
12. senna 8.6 mg PO BID PRN constipation.,0
13. leucovorin calcium 5 mg Tablet Sig: 4 Tablets PO Q6H x1 days.,0
Disp:*16 Tablet(s)* Refills:*0* 14. sodium bicarbonate 1300 mg PO Q6H x1 days.,0
Disp:*8 Tablet(s)* Refills:*0* 15. prochlorperazine maleate 5-10mg PO Q6H PRN Nausea.,0
Outpatient Speech/Swallowing Therapy Speech therapy for resolving expressive aphasia post-craniotomy.,0
Discharge Disposition: Home Discharge Diagnosis: 1.,0
CNS (central nervous system) lymphoma.,0
Pelvic adenopathy (enlarge lymph nodes).,1
Cycle #1 high-dose methotrexate chemotherapy.,0
SIADH (syndrome of inappropriate anti-diuretic hormone) makes sodium levels low.,0
Diabetes insipidus - makes sodium levels high.,1
Discharge Condition: Activity as tolerated.,0
No lifting greater than 10 pounds.,0
Mental Status: Clear and coherent.,0
Discharge Instructions: You were admitted to the hospital for a craniotomy and resection of a brain mass in the left temporal region.,0
"Pathology showed this to be an aggressive lymphoma, so you were transferred to the Oncology service to start chemotherapy.",0
"The surgery was complicated by a severe word finding difficulty, which markedly improved over several days.",0
"Before you were given chemotherapy, a pelvic lymph node biopsy was done because a CT scan had shown enlarged lymph nodes in the pelvis and abdomen.",1
A bone marrow biopsy was also done to complete staging.,0
"High-dose methotrexate chemotherapy was given and you tolerated this well, but will need to take an additional day of sodium bicarbonate and leucovorin to help the kidneys continue excreting the chemotherapy.",0
You were also followed by Endocrinology for diabetes insipidus and SIADH (syndrome of inappropriate antidiuretic hormone) causing high and low sodium levels.,1
This was treated with DDAVP and careful monitoring of sodium levels.,0
Your wound was closed with dissolvable sutures; you can wash your hair since three days after surgery.,0
"We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication.",0
"If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation.",0
"Make sure to take your steroid medication with meals, or a glass of milk.",0
Clearance to drive and return to work will be addressed at your post-operative office visit.,0
Make sure to continue to use your incentive spirometer while at home.,0
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?,0
"Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage.",0
Dexamethasone 4mg every six hours.,0
Sodium bicarbonate 1300mg every six hours for one day.,0
Leucovorin every six hours for one day.,0
"Followup Instructions: RETURN TO 11-, , , ON WEDNESDAY, FOR CYCLE #2 HIGH-DOSE METHOTREXATE CHEMOTHERAPY.",0
THIS WEEK TO ARRANGE FOLLOW-UP.,0
Please return to the office in days (from your date of surgery) for removal of your staples/sutures and/or a wound check.,0
This appointment can be made with the Nurse Practitioner.,0
Please make this appointment by calling .,0
"If you live quite a distance from our office, please make arrangements for the same, with your PCP.",0
"The Brain Clinic is located on the of , in the Building, .",0
Their phone number is .,0
"Please call to make an appointment, or require additional directions.",0
"Department: HEMATOLOGY/BMT When: WEDNESDAY at 2:00 PM With: , NP Building: SC Clinical Ctr Campus: EAST Best Parking: Garage .",0
"Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY at 2:00 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage",0
Fevers with positive blood cultures with VRE.,0
Height: (in) 67 Weight (lb): 161 BSA (m2): 1.85 m2 BP (mm Hg): 110/70 HR (bpm): 77 Status: Outpatient Date/Time: at 11:07 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<=2.1cm) with >50% decrease with sniff (estimated RA pressure (0-5 mmHg).,0
Mild to moderate (+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
PERICARDIUM: Very small pericardial effusion.,0
GENERAL COMMENTS: Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient.,0
An inferolaterally directed jet of mild to moderate (+) mitral regurgitation is seen.,0
IMPRESSION: Mild-moderate mitral regurgitation without evidence of discrete vegetation.,0
Preserved global and regional biventricular systolic function.,0
"Compared with the prior study (images reviewed) of , the severity of mitral regurgitation and estimated PA systolic pressure are increased If the clinical suspicion for endocarditis is moderate or high, a TEE would be better able to define the mitral valve morphology for possible vegetation.",0
PATIENT/TEST INFORMATION: Indication: cabg Status: Inpatient Date/Time: at 09:53 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.,0
LEFT VENTRICLE: Mildly depressed LVEF.,0
LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
AORTA: Normal ascending aorta diameter.,0
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.,0
The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope.,0
Conclusions: Pre-bypass: No spontaneous echo contrast is seen in the left atrial appendage.,0
Overall left ventricular systolic function is mildly depressed (LVEF=40-45 %).,0
Post-CPB: Good RV and LV systolic fxn.,0
"9:11 PM UNILAT UP EXT VEINS US LEFT PORT Clip # Reason: eval LUE AV graft for evidence of abscess, fluid collection, Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with ESRD on HD, recently converted AV fistula to graft due to clot which could not be removed now w/ pain at site of AVG and 4 days of fatigue.",0
"REASON FOR THIS EXAMINATION: eval LUE AV graft for evidence of abscess, fluid collection, other evidence of infxn ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb FRI 11:13 PM 1.9 cm hypoechoic fluid collection subcutaneously at site of pain is felt more likely to represent postoperative fluid collection than abscess though an infection of fluid cannot be excluded.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old male with end-stage renal disease on hemodialysis with left upper extremity AV graft with erythema and pain at site.,1
FINDINGS: Focal son over the area of erythema and tenderness near the left axilla was performed.,0
A 1.9 x 1.2 x 0.9 cm fluid collection is identified subcutaneously.,0
No significant surrounding hypervascularity is associated with this lesion.,0
The underlying AV graft demonstrates normal flow and waveforms.,0
"IMPRESSION: Son characteristics of the 1.9 cm subcutaneous fluid collection are more consistent with postoperative seroma than abscess, though infection cannot be completely excluded.",0
12:15 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Any bleeding or colitis?,0
"Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman s/p cardiac arrest with RUQ pain, diarrhea, transaminitis REASON FOR THIS EXAMINATION: Any bleeding or colitis?",1
"CONTRAINDICATIONS for IV CONTRAST: Will need catheterization, trying to reduce dye load ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE 6:21 PM 1.",0
Bilateral pleural effusions with mild pulmonary edema.,0
Markedly thickened gallbladder wall without secondary signs of acute cholecystitis; may represent a more chronic process versus more acute hepatic dysfunction.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 56-year-old female status post cardiac arrest, now with right upper quadrant pain, diarrhea, and transaminitis.",1
STUDY: CT of the abdomen and pelvis without IV contrast; MDCT images were generated through the abdomen and pelvis without IV contrast but with oral contrast.,0
Coronal and sagittal reformatted images were also generated.,0
COMPARISON: Abdominal radiograph from .,0
"FINDINGS: ABDOMEN: Within the visualized portion of the chest, there are moderate bilateral pleural effusions, consisting of simple fluid, with associated atelectasis.",0
"Additionally, there is subtle hazy ground-glass opacity throughout the lungs, and most prounounced in the right middle lobe which may represent mild pulmonary edema.",0
"Within the limits of a non-contrast study, the liver shows no focal lesion; mild periportal edema is seen.",0
The gallbladder shows marked wall thickening but no pericholecystic fluid; subtle density along its lumen may represent sludge or tiny stones.,0
"In the anterior of the spleen, a lentiform hypodensity is seen that measures 31 x 12 mm in the axial dimension; it has a dependently layering appearance, and may represent sequelae of prior trauma.",0
The pancreas and adrenal glands show no overt evidence of masses.,0
The kidneys show no stones or hydronephrosis.,0
The small and large intestine show no signs of obstruction.,0
PELVIS: Foley catheter is noted in the bladder.,0
A rectal Foley is seen within the rectum.,0
The sigmoid colon is decompressed.,0
The appendix is visualized and fills with oral contrast.,0
BONES: There are no aggressive-appearing lytic or sclerotic lesions.,0
Mild degenerative disc disease is seen at L4-L5 primarily in the form of subtle disc space narrowing and endplate sclerosis.,0
(Over) 12:15 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Any bleeding or colitis?,0
Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,1
Markedly thickened gallbladder wall without secondary signs of acute cholecystitis likely from acute hepatic dysfunction.,0
12:52 PM CHEST (PORTABLE AP) Clip # Reason: Confirmation of NG tube placement.,0
"Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with CAD, CHF, now s/p CVA NG tube placed.",1
REASON FOR THIS EXAMINATION: Confirmation of NG tube placement.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, is compared with study from earlier same date.",0
"An NG tube is in place, the distal aspect coils in the proximal stomach.",0
"The examination is otherwise, unchanged with persistent cardiac enlargement and congestive heart failure and associated pleural effusion.",1
IMPRESSION; NG tube terminates in proximal stomach.,0
"9:54 PM CHEST (PORTABLE AP) Clip # Reason: r/o chf, infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with lt basal ganglia bleed, tachypneic, leukocytosis, high o2 req REASON FOR THIS EXAMINATION: r/o chf, infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 79 YEAR OLD WOMAN WITH LEFT BASILAR GANGLIA BLEED, TACHYPNEA, LEUKOCYTOSIS, AND HYPOXIA.",0
EVALUATE FOR CHF OR INFILTRATE.,0
A single portable radiograph of chest dated compared with prior AP portable on .,0
There is a stable appearance of the cardiomediastinal and hilar contours.,0
There has been a slight interval increase in the right upper lobe opacity and new dense opacification of the left lower lobe.,0
A right IJ line is seen with its tip in the mid SVC.,0
A nasogastric tube is seen with its tip in the region of the fundus of the stomach.,0
The soft tissues and osseous structures are unremarkable.,0
Increasing right upper lobe and left lower lobe opacities.,0
Rapidly progressive pneumonia and asymmetric edema are considered less likely.,0
Lines and tubes in satisfactory position.,0
2:17 AM CHEST (PORTABLE AP) Clip # Reason: acute onset sob.,0
"r/o infiltrate, pneumothorax ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with ESRD, ARDS, intubated, with decreased sats and becoming increasingly difficult to provide adequate tidal volumes on pressure controlled ventilation.",0
REASON FOR THIS EXAMINATION: acute onset sob.,0
"r/o infiltrate, pneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: ESRD, ARDS, intubated, decreased saturations, worsening ventilation.",0
COMPARISON: AP SUPINE CHEST: The heart is enlarged with pulmonary venous engorgement and there is considerable opacification posterior to the heart which is not significantly changed.,0
"Positions of ETT, NGT and right IJ line remain the same.",0
An aortic valve is present.,0
IMPRESSION: CHF with left lower lobe opacification.,0
There is no significant change since .,0
"5:09 AM CHEST (PORTABLE AP) Clip # Reason: Intubated, pls eval for interval change Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with sigmoid synovial fistula REASON FOR THIS EXAMINATION: Intubated, pls eval for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Post-surgery.",1
"FINDINGS: In comparison with the study of , the monitoring and support devices remain in place.",0
Continued enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure.,0
"Overall, little change from the prior study.",0
8:08 AM ABDOMEN (SUPINE ONLY) PORT Clip # Reason: Please assess Dobhoff with high abdominal film Admitting Diagnosis: ASCITIS ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with Dobhoff not in view on CXR REASON FOR THIS EXAMINATION: Please assess Dobhoff with high abdominal film ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa WED 5:49 PM PFI: Dobbhoff tube coiled within the stomach with tip at the level of the pylorus.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of Dobbhoff position.,0
Single view of the abdomen demonstrates Dobbhoff tube coiled within the stomach with tip at the region of the pylorus.,0
A central venous line is in place with tip within the right atrium.,0
Surgical staples are noted in the upper abdomen.,0
There is a small right pleural effusion.,0
IMPRESSION: Dobbhoff tube coiled within the stomach with tip at the level of the pylorus.,0
"7:16 AM ABDOMEN U.S. (PORTABLE) Clip # Reason: ELEVATED BILIRUBIN, EVALUATE LIVER AND GALLBLADDER Admitting Diagnosis: PREMATURITY/S/P SURGERY ______________________________________________________________________________ MEDICAL CONDITION: Infant with ELEVATED DIRECT BILIRUBIN AND TRANSAMINASES HISTORY OF FEEDING INTOLERANCE REASON FOR THIS EXAMINATION: EVALUATE LIVER AND GALL BLADDER ______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMINAL ULTRASOUND HISTORY: Three-month-old infant with elevated direct bilirubin and transaminase, history of feeding intolerance.",1
"FINDINGS: Examination of the abdomen demonstrated a normal liver, spleen, gallbladder, and pancreas.",0
There was no evidence of biliary duct dilatation.,0
"The kidneys were of normal size but both appeared somewhat echogenic, there are no prior similar studies.",0
There is no evidence of ascites.,0
"IMPRESSION: Aside from slightly echogenic kidneys, this study was normal.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Left and right heart catheterization from right femeral artery Drug eluting stent placement to RCA History of Present Illness: 73 y/o F w/ no previous PMH, on no home meds.",1
"Was shopping w/ daughter when developed acute onset of CP, assoc w/ SOB & diaphoresis.",0
Described CP as band-like tightness.,0
"Presented to OSH, found to have inferior STE on EKG and positive troponins.",0
"She was started on ASA, plavix, lopressor, and aggrestat.",0
She was placed on a nitro gtt for SBP in 200s.,0
She was then transferred to for intervention.,0
"Of note, daughter won $10,000 scratch lottery on Monday.",0
"ROS: Active, cares for grandchild.",0
"Past Medical History: s/p vaginal hysterectomy Social History: Retired, previously worked in housekeeping at Hospital.",0
"Husband was murdered 30+ years ago, so she raised her 7 children on her own.",0
"She is a prior smoker, though she quit around age 60.",0
She has a 60 pack-year history.,0
Is very active and takes care of her grandchildren.,0
"Of note, her daughter won $10,000 on a scratch ticket earlier in the week (?",0
"cause of her excitement/surprise/stress) Family History: 7 grown children, all healthy.",0
Brother had first MI at age 40.,0
"Physical Exam: PE (post-cath): VS - T 97.5, HR 61, BP 129/74, RR 20, O2 sat 100% 3L NC general - in bed, comfortable, NAD HEENT - OP clr, MMM, JVP difficult to assess supine CV - RRR, nl s1 s2, no m/r/g chest - CTAB abd - NABS, soft, NT, no g/r ext - no edema, 1+ DP/PT pulses R groin - dressing intact, small hematoma, no bruit, R femoral venous catheter intact Pertinent Results: Labs on admission: WBC 8.7, Hgb 12.2, Hct 36.1, MCV 90, Plt 316 PT 13.9*, PTT 138.6*, INR(PT) 1.2* Na 137, K 4.1, Cl 105, HCO3 21, BUN 17, Cr 0.6, Glu 118 Ca 8.6, Phos 3.8, Mg 1.9, ALT 11, AST 35 ABG: pO2-138* pCO2-39 pH-7.41 calHCO3-26 .",0
07:23PM BLOOD CK(CPK)-153* CK-MB-18* MB Indx-11.8* cTropnT-0.68* 03:16AM BLOOD CK(CPK)-143* CK-MB-17* MB Indx-11.9* .,0
"05:30AM BLOOD Chol 179, TG 90, HDL 56, CHOL/HD 3.2, LDLcalc 105 .",0
"Labs on discharge: WBC 7.7, Hgb 11.6*, Hct 34.5*, MCV 88, Plt 284 Na 142, K 4.3, Cl 106, HCO3 27, BUN 18, Cr 0.7, Glu 86, Mg 2.1 .",0
Imaging: CARDIAC CATH : 1.,0
Coronary angiography revelaed a right dominant system.,0
The LMCA showed no significant stenoses.,0
The LAD showed a smooth 60% midsegment stenosis and a smooth 50% distal segment stenosis.,0
The LCX showed no significant stenoses with minimal luminal irregularities.,0
The RCA showed serial 60% mid and 60% distal stenoses which appeared irregular and potentially consistent with resolution of previously ruptured plaques.,0
"Hemodynamic studies demonstrated normal filling pressures with severely reduced cardiac index initially measured at 1.6 L/min/m2, which was likely altered by falsely elevated initial hemoglobin measurement.",0
"Left ventriculography was notable for symmetric anterolateral, apical, and inferior wall akinesis suggestive of apical ballooning syndrome.",0
The anterobasal and inferobasal regions were hyperkinetic with estimated ejection fraction of 40-50%.,0
There was no evidence of mitral regurgitation.,0
Successful placement of two overlapping Cypher drug-eluting stents (3.5 x 28 mm proximally with 3.5 x 23 mm distally) in the mid-RCA.,0
"Final angiography demonstrated minimal residual stenosis in the proximal stent, moderate disease in the jailed acute marginal, no angiographically apparent dissection, and normal flow (See PTCA Comments).",0
Two vessel coronary artery disease in setting of possible RCA plaque rupture.,1
Normal filling pressures suggestive of normal diastolic function.,0
Severely abnormal systolic function suggestive of apical ballooning syndrome.,0
Successful placement of drug-eluting stents in mid-RCA.,0
"The left ventricle appears hyperdynamic in all segments except for the apex, which is hypokinetic (but not akinetic or dyskinetic) relative to the rest of the left ventricle.",0
The overall left ventricular ejection fraction is approximately 70 percent.,0
No left ventricular aneurysm is seen.,0
Impression: apex is hypokinetic relatiive to the rest of the left ventricle (hyperdynamic).,0
"Brief Hospital Course: 73 yo F, with no previously known CAD, here for CP, ECG changes, and troponin leak - ?",0
"# Ischemia - Mrs. was taken straight to the cath lab and her cath showed RCA & LAD lesions, but nothing that looked suspicious for the cause of her acute chest pain.",0
"A DES was placed in her RCA, but then hemodynamic measurements were taken and were significant for a depressed cardiac index.",0
A subsequent LV-gram showed apical akinesis consistent with Takotsubo cardiomyopathy.,0
The PA catheter was left in overnight so that her PA pressures could be monitored.,0
She was continued on aggrestat until the morning after her catheterization.,0
"She did well overnight, her PA catheter was pulled the next morning, and she was transferred out to the floor.",0
Daily ECGs were checked and Mrs. had resolution of inferior ECG changes but persistent lateral ST elevations and deepening T wave inversions.,0
"She was started on ASA, plavix, bblocker, ACE-i and a statin.",0
Her lipid panel was checked and was significant for an LDL of 105 so she was kept on high dose lipitor.,0
Her cardiac enzymes were cycled x2 after her catheterization and were trending down.,0
"On arrival to the OSH, she already had a troponin leak so it was unclear if her infarction happened earlier than the actual onset of her pain.",0
"She had no further episodes of chest pain during her admission, but it was recommended that she have a stress test as an outpatient to look for other areas of ischemia.",0
"# Pump - Mrs. had a depressed EF and CO by LV-gram, with apical akinesis being the most prominent finding.",0
"This was felt to be more consistent with Takotsubo cardiomyopathy than MI, but an exact etiology was not able to be determined.",0
"By exam, she remained euvolemic and her cardiac function improved.",0
"Prior to discharge, an ECHO revealed a restored EF (LV was hyperdynamic w/ EF of 70% and only hypokinetic apex).",0
"She will continue the bblocker and ACE-i until she follows up with her new outpatient cardiologist, Dr. , at Medical on .",0
# Rhythm - She was monitored on telemetry throughout her hospital stay and remained in NSR.,0
Her daily EKGs showed persistent ST elevations in the lateral leads with deepening T wave inversions but she remained chest pain free.,0
"# Glycemic control - She was started on HISS on admission for tight glycemic control during her acute coronary syndrome, but since she has no h/o DM and her cardiac function was improving, the HISS and fingersticks were discontinued after 48 hours.",1
She only had one elevated serum glu throughout her stay (glu was 118 on admission).,0
"# FEN - She was given a regular, low sodium, cardiac, heart healthy diet.",0
Her electrolytes were checked daily and were repleted prn to keep K >4 and Mg >2.,0
"# PPX - Heparin SC for DVT ppx, no need for PPI, bowel regimen.",0
# Code - Presumed full .,0
"# Dispo - To home, with f/u appts scheduled with her PCP and new outpt cardiologist, Dr. .",0
Medications on Admission: Tylenol prn Discharge Medications: 1.,0
Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).,0
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 5.,0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute coronary syndrome Takotsubo cardiomyopathy Discharge Condition: Good.,1
"Afebrile, BP 109/59, HR 93.",0
EKG shows persistent ST elevations in lateral leads with deepening T wave inversions.,0
She is chest pain free.,0
"Please call your PCP or go to the ER if you develop any of the following symptoms: fever, chills, dizziness, headaches, chest pain, chest pressure, shortness of breath, nausea, vomiting, leg numbness, tingling or swelling, or any other worrisome symptoms.",0
Please take all your new medications as prescribed.,0
It is very important that you take plavix and aspirin EVERY DAY because they will help keep your stent open.,0
Do not stop these medications unless your cardiologist instructs you to.,0
Please follow-up with your PCP and your new cardiologist as directed below.,0
"You have an appointment with Dr. , your PCP, at 3:45pm.",0
Please call her office at if you have any questions or need to reschedule.,0
"You have an appointment with Dr. , your new cardiologist, on Friday at 1:45 pm.",0
"His office is located at Medical, , , MA.",0
His phone number is (.,0
Please call his office with any questions or re-scheduling needs.,0
You should have a stress test performed as an outpatient and Dr. will be able to help you set this up.,0
5:38 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
pneumo Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p liver transplant acute desat REASON FOR THIS EXAMINATION: ?,1
"pneumo ______________________________________________________________________________ FINAL REPORT INDICATION: Status post liver transplant, to evaluate for pneumothorax.",0
PORTABLE AP CHEST COMPARISON: .,0
The left subclavian catheter terminates in the SVC.,0
The Swan-Ganz catheter is in the main pulmonary artery.,0
The ET tube is unchanged and in good position.,0
There is a moderate right and a small left pleural effusion.,0
The left lower lobe atelectasis has improved.,0
Moderate right and small left pleural effusion.,0
No pneumothorax evident on this supine projection.,0
Improving right lower lobe atelectasis.,0
LINE PLACEMENT Clip # Reason: Please evaluate for acute cardio/pulmonary process.,0
Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p colectomy with hypotension.,0
REASON FOR THIS EXAMINATION: Please evaluate for acute cardio/pulmonary process.,0
______________________________________________________________________________ WET READ: EAGg TUE 7:15 PM Limited study due to patient position.,0
Distal end of new right subclavian central line appears to be in the right atrium and could be pulled back 2.5 to 3 cm.,0
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Evaluate line.,0
This is a limited study.,0
The left lateral hemithorax was not included on the film.,0
A new right subclavian catheter tip is in the right atrium and could be pulled back 2-3 cm to standard position.,0
Height: (in) 67 Weight (lb): 182 BSA (m2): 1.94 m2 BP (mm Hg): 115/1 HR (bpm): 70 Status: Inpatient Date/Time: at 09:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT ATRIUM: Marked LA enlargement.,0
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.,0
Paradoxic septal motion consistent with conduction abnormality/ventricular pacing.,0
Conclusions: The left and right atria are markedly dilated.,0
"Overall left ventricular systolic function is moderately depressed, with moderate global hypokinesis (EF 35%).",0
An eccentric jet of moderate (2+) mitral regurgitation is seen.,0
"A pacemaker lead is seen entering the right atrium, then traversing the interatrial septum and the mitral valve, with the lead tip positioned in the trabeculations of the left ventricular apex.",1
IMPRESSION: Pacemaker lead at the left ventricular apex.,0
Moderate global left ventricular systolic dysfunction.,0
Mild right ventricular systolic dysfunction.,0
"Compared with the prior study (images reviewed) of , pacemaker lead is new.",0
The other findings appear similar.,0
Dr. was notified of these results by phone at 9:40a on the day of the study.,0
"5:13 AM CHEST (PORTABLE AP) Clip # Reason: please assess for atelectasis, change from prior Admitting Diagnosis: MULTI TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with multiple rib fractures REASON FOR THIS EXAMINATION: please assess for atelectasis, change from prior ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Multiple rib fractures and left hydropneumothorax.",1
Comparison is made with prior study performed 10 hours earlier.,0
Mild-to-moderate pulmonary edema has minimally improved.,0
Worsening right upper lobe opacity at the periphery is worrisome for aspiration.,0
Left lower lobe atelectasis has improved.,0
A small left pleural effusion with loculation in the apex is unchanged.,0
Cardiomediastinal contours are within normal limits.,0
"ET tube tip is 7.3 cm above the carina, can be advanced couple of centimeters for more standard position.",0
"Admission Date: Discharge Date: Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) / Codeine / Motrin Attending: Chief Complaint: Hip and back pain Major Surgical or Invasive Procedure: Cardiac catheterization Aortic Valve Replacement (19mm CE Magna Pericardial Tissue Valve) on History of Present Illness: 83yo F with a hx of AS (valve area of 0.8 cm2) and hx of hypoglycemia presented to emergency department with syncope x 2 and falls, initially c/o hip and back pain.",1
"Past Medical History: Aortic Stenosis, Hypertension, Breast Cancer s/p lumpectomy and XRT, Gastroesophageal Reflux Disease, Hiatal Hernia, Diverticulosis, Sciatica, Osteoarthritis, Carpal Tunnel Syndrome, Rotator Cuff tendonitis, Hypoglycemia, s/p B knee arthroscopy, s/p R TKR, s/p Cholecystectomy, s/p Rotator repair, s/p B Cataract surgery, s/p Tonsillectomy Social History: Lives alone.",1
"No kids, but many family and friends in the area.",0
Sister: CA with liver mets.,0
"Physical Exam: VS: T: 96.8, HR: 57, BP: 130/90, RR: 20, SaO2: 99% RA, 5'1"", 64.4kg GEN: Very pleasant elderly female in NAD Skin: R Shoulder scar, RUQ abd scar, R knee scar (all well healed) HEENT: NC/AT, EOMI, anicteric, mmm NECK: Supple, full ROM, -JVD CV: RRR, S1, S2, +3/6 systolic crescendo/decrescendo murmur appreciated most loudly in RUSB with ?radiation to carotids.",0
"LUNGS: CTA bilaterally, tenderness to palpation over left flank but no obvious bruising.",0
"ABD: Soft, NT, ND, +BS, obese EXT: BLE, mult.",0
"varicosities and spider veins NEURO: A+Ox3, CN II-XII grossly intact, gait grossly normal Pertinent Results: Carotid U/S: Mild plaque in the left internal carotid artery, with an estimated percentage of stenosis less than 40%.",0
No evidence of stenosis in the extra-cranial right internal carotid artery.,0
"Echo: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%).",0
There is severe aortic valve stenosis.,1
"Compared with the prior study (images reviewed) of , the severity of aortic stenosis and mitral regurgitation have progressed.",0
CARDIAC CATH: Selective coronary angiography showed a right dominant system with no flow limiting stenoses.,0
Limited hemodynamics showed a normal pulmonary pressure (PA mean 18mmHg).,0
"The right and left sided filling pressures were normal (RVEDP 9mmHg, LVEDP 13 mmHg).",0
"The cardiac output was preserved (CO 4.1 l/min, CI 2.5 l/min/m2).",0
The peak-to-peak gradient across the aortic valve was 65 mmHg.,1
The mean gradient was 49 mmHg.,0
The calculated aortic valve area was 0.5 cm2 (assumed O2 consumption).,1
Echo: There is mild symmetric left ventricular hypertrophy with normal cavity size.,0
Global mild to moderate LV systolic dysfunction.,0
"Area by continuity is 0.5, with a peak gradient of 45 mmHg.",0
Ascending aorta is not dilated.,0
The mitral valve leaflets are moderately thickened.,0
Moderate to severe (3+)mitral regurgitation is seen.,0
Post-CPB: Well-seated and functioning aortic valve prosthesis.,1
12:00PM BLOOD WBC-8.2 RBC-3.98* Hgb-13.2 Hct-37.8 MCV-95 MCH-33.1* MCHC-34.9 RDW-13.0 Plt Ct-169 06:40AM BLOOD WBC-4.7 RBC-3.77* Hgb-12.0 Hct-35.8* MCV-95 MCH-32.0 MCHC-33.7 RDW-12.8 Plt Ct-186 12:00PM BLOOD PT-12.7 PTT-22.1 INR(PT)-1.1 06:20AM BLOOD PT-13.2* PTT-24.7 INR(PT)-1.2* 12:00PM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-139 K-5.4* Cl-100 HCO3-28 AnGap-16 06:40AM BLOOD Glucose-86 UreaN-18 Creat-0.6 Na-138 K-4.1 Cl-105 HCO3-23 AnGap-14 02:30PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR 12:00PM URINE Color-Straw Appear-Clear Sp -1.006 12:00PM URINE RBC-0 WBC- Bacteri-MANY Yeast-NONE Epi-0-2 : Urine culture + for E. Coli Brief Hospital Course: Ms. was admitted for syncope most likely secondary to her worsening aortic stenosis.,1
Underwent x-rays to r/o any fractures.,0
She had an ECHO on that proved that her AS was worsening.,0
CT surgery was consulted for evaluation of the patient's candidacy for AVR.,0
She underwent several studies prior to sugery.,0
Carotid duplex was negative for any evidence of carotid stenosis.,0
Cardiac catheterization revealed no CAD.,0
"During her admission labwork, she was found to have a UTI.",0
Initially started on Ciprofloxacin and cultures came back postive for E. Coli.,0
She was switched to Nitrofurantoin.,0
The patient was scheduled for AVR after having completed 7 days of antibiotics for a UTI.,0
"Urinalysis from and were both negative and cultures each grew <10,000 organisms.",0
Dental clearance provided from her home dentist.,0
She was finally brought to the operating room on where she underwent a aortic valve replacement.,1
Please see operative report for surgical details.,0
She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition.,0
"Later on op day she was weaned from sedation, awoke neurologically intact and extubated.",0
On post-operative day one her chest tubes were removed and she was started on beta blockers and diuretics.,0
Throughout the rest of her post-op course she was gently diuresed towards her pre-op weight.,0
Later on this day she was tranferred to the cardiac surgery step down floor.,0
"She continued to do well, tolerate diet, pain controlled on oral medications, and participated with physical therapy until ready for discharge.",0
"Medications on Admission: At home: Diovan/HCTZ 25mg qd, Lipitor 10mg qd Discharge Medications: 1.",0
Particle/Crystal PO twice a day for 10 days.,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed.,0
Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation.,0
Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation.,0
Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: Tablets PO Q4-6H (every 4 to 6 hours) as needed.,0
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed.,0
Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days.,0
"Discharge Disposition: Extended Care Facility: for the Aged - Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Hypertension, Breast Cancer s/p lumpectomy and XRT, Gastroesophageal Reflux Disease, Hiatal Hernia, Diverticulosis, Sciatica, Osteoarthritis, Carpal Tunnel Syndrome, Rotator Cuff tendonitis, Hypoglycemia, s/p B knee arthroscopy, s/p R TKR, s/p Cholecystectomy, s/p Rotator repair, s/p B Cataract surgery, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: take shower.",1
Wash incision and gently pat dry.,0
"Do not apply lotions, creams, ointments or powders to incision.",0
Do not lift more than 10 pounds for 2 months.,0
Do not drive for 1 month.,0
"If you develop a fever, notice sternal drainage or redness around incision, please contact office immediately.",0
p Instructions: Dr. in 4 weeks Dr. in 2 weeks,0
"5:34 AM CHEST (PORTABLE AP) Clip # Reason: Eval for interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with PNA and h/o CVA, CHF.",0
"REASON FOR THIS EXAMINATION: Eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 5:49 A.M. ON HISTORY: Pneumonia, CVA, CHF.",0
IMPRESSION: AP chest compared to and 5th: Borderline pulmonary edema and small bilateral pleural effusions are unchanged since .,0
Tip of the left subclavian line projects over the junction of the brachiocephalic veins.,0
ET tube in standard replacement.,0
", M. TSURG SICU-A 4:36 AM CHEST (PORTABLE AP) Clip # Reason: interval change, ?ptx Admitting Diagnosis: T8 SPINAL CORD COMPRESSION AND CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with s/p spine surgery, IVC filter, B/L CT palcements REASON FOR THIS EXAMINATION: interval change, ?ptx ______________________________________________________________________________ PFI REPORT Left lower lobe atelectasis and small left pleural effusion worsened.",1
ET tube approximately 3 cm too high.,0
10:28 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ET tube placement Admitting Diagnosis: COPD EXCERBATION ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with COPD exacerbation.,0
"REASON FOR THIS EXAMINATION: ET tube placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: COPD, exacerbation, status post ET placement.",0
"FINDINGS: As compared to the previous radiograph, there is unchanged position and course of the monitoring and support devices, in particular of the endotracheal tube.",0
"Again, the caudal parts of the hemithoraces are not included on the image.",0
Unchanged size of the cardiac silhouette.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CHIEF COMPLAINT: Disabling claudication of the right lower extremity for approximately six months to a year.,0
HISTORY OF PRESENT ILLNESS: Mrs. is a 64-year-old white female with a past medical history significant for hypertension and hyperlipidemia who presented to Dr. office with a complaint of disabling claudication in her right lower extremity thigh and calf that occurred after walking approximately one block.,0
It was relieved by resting one to two minutes and recurred after she resumed ambulation.,0
She had an magnetic resonance scan of her back as well as x-rays which failed to reveal any kind of degenerative joint disease.,0
She is evaluated by Dr. who felt that it was secondary to aortoiliac disease and arterial insufficiency.,0
She was sent for an angiogram which revealed diffuse disease of the lower abdominal aorta especially just above the iliac bifurcation with complete occlusion of the right common iliac artery.,0
"Stenosis of the proximal left iliac artery, proximal left external iliac artery and at the ostium of the left internal iliac artery.",0
No evidence of disease in the femoral arteries on either side was noted.,0
There was patency of the three distal vessel run offs in the right lower leg with the exception of the distal few cm of the anterior tibial arteries with no complaint of the dorsalis pedis on that side and focal stenosis in the distal peroneal artery.,0
Due to these findings it was decided by Dr. that she would require an aortobifemoral bypass and she was subsequently admitted for this procedure.,0
PAST MEDICAL HISTORY: Significant for hypertension and hyperlipidemia that is managed with oral medication.,0
She has a history of proteinuria with workup pending at this time.,0
Also of note with that is mild hyponatremia and hypokalemia that is managed with oral medications.,0
She also has a history of urinary tract infection with questionable pyelonephritis in the past managed with antibiotics.,1
PAST SURGICAL HISTORY: Significant for bladder suspension as well as left shoulder surgery for a bursitis and a left ganglion cyst.,0
She also admits to a history of having tonsillectomy and adenoidectomy performed as well as a hysterectomy.,0
SOCIAL HISTORY: Remarkable for her being married and living with her husband at this time.,0
She has a significant history of nicotine abuse with an over 100 pack year history that continues today.,0
She denies any history of alcohol abuse.,0
HOSPITAL COURSE: The patient was admitted to where she underwent an aorto-bifemoral bypass on .,0
Details of this procedure are dictated in a separate operative note.,0
"On the way to surgery she had become lightheaded and had a pre-syncopal episode, was initially taken to the Emergency Room prior to admission.",0
This was felt to be secondary to mild hypovolemia and hypokalemia.,0
She subsequently was taken to the pre-op holding area where she was hydrated adequately and her electrolytes were repleted.,0
"She felt better, back to her baseline and it was decided they would continue with surgery.",0
Postoperatively she did quite well and was transferred up to the Vascular Intensive Care Unit.,0
She was monitored with a Swann-Ganz catheter for any fluid shifts as well as cardiac events.,0
Initially postoperatively she was maintained on renal dose Dopamine as well as Neo-Synephrine for a low blood pressure and low SVR and low urine output.,0
She subsequently improved with two units of packed red blood cells and some mild gentle hydration.,0
On postoperative day one she was subsequently weaned off of both medications and had adequate urine output.,0
She continued to do well and was maintained on NPO until her bowel function returned.,0
Her electrolytes were repleted adequately and she continued to progress well without any hemodynamically significant events.,0
"On postop day four her Swann-Ganz catheter was removed and she was now making good urine, passing flatus and was having a clear lung exam.",0
She was gotten out of bed and evaluated by physical therapy.,0
They felt she would need several days of acute rehabilitation while in hospital and would benefit from another two days.,0
Currently she is doing quite well and she is tolerating an oral diet without any difficulty.,0
She is afebrile with vital signs stable.,0
She has been restarted on all of her usual medications.,0
Her physical examination at this time reveals a well developed female appearing older than her standard age of 64.,0
Her neck is supple without evidence of jugular venous distention and there is a left carotid bruits.,0
Her heart is regular rate and rhythm.,0
"Lungs are clear to auscultation bilaterally without wheezes, rales or rhonchi.",0
"Abdomen is soft, nontender, nondistended with positive bowel sounds present.",0
"Her incisions are clean, dry and intact with staples present in the midline and in both groins.",0
There is no drainage from these incisions or erythema noted.,0
Her pulse exam is remarkable for palpable femoral pulses bilaterally as well as posterior tibial pulses bilaterally.,0
"Her disposition at this time is stable, progressing well.",0
She will be discharged when she is cleared by physical therapy and wishes to be discharged home to go to a rehabilitation facility.,0
Her staples are to remain in until she follows up with Dr. in approximately 10 days to two weeks.,0
A nurse will be arranged for routine vitals and monitoring.,0
At this point home physical therapy is not necessary.,0
DISCHARGE MEDICATIONS: Same as admission medication list without changes.,0
Disabling claudication secondary to severe aortoiliac disease and right common iliac artery occlusion.,0
"Low urine output, currently resolved.",0
Anemia postoperatively resolved with blood transfusion.,0
"LABORATORY VALUES: At the time of discharge are significant for glucose of 111, BUN 10, creatinine 0.5, potassium 3.7, calcium 8.2, phosphorus 3.0, magnesium 1.4, hematocrit 31.3.",0
White blood count was within normal range.,0
Her electrocardiogram is without change from her admission which revealed mildly prolonged QT interval without evidence of ischemic changes.,0
A chest x-ray revealed resolving congestive heart failure as well as bibasilar atelectasis.,1
She is being treated with her daily doses of diuretics.,0
Dictated By: MEDQUIST36 D: 14:15 T: 13:29 JOB#:,0
11:19 AM CHEST (PORTABLE AP) Clip # Reason: ETT placement Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with CAD & Pulm.,1
edema REASON FOR THIS EXAMINATION: ETT placement ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON .,0
FINDINGS: There are no old films available for comparison.,0
"There is an ET tube with tip slightly low, 1.6 cm above the carina.",0
The NG tube tip is in the stomach with the proximal port just below the GE junction.,0
"There are bilateral patchy alveolar infiltrates, right greater than left and upper lobe greater than lower lobe that could represent an infectious infiltrate versus pulmonary edema.",0
There is a right IJ line with tip in the SVC.,0
"5:15 PM CT HEAD W/O CONTRAST Clip # Reason: please evaluate for post-op hemorrhage Admitting Diagnosis: NEW BRAIN MASS, CONFUSION, SEIZURES ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p crani for tumor resection REASON FOR THIS EXAMINATION: please evaluate for post-op hemorrhage No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 6:14 PM Minimal post-surgical hemorrohage, with expected post-operative findings after right parietal craniectomy.",1
"Otherwise unchanged; no development of hydrocephalus, severe mass effect or herniation.",0
Low density at resection site = combination of mild edema and encephalomalacia.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 62-year-old male status post craniectomy for tumor resection.,1
COMPARISON: Non-contrast head CT .,0
TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial vertex without IV contrast.,0
"HEAD CT WITHOUT IV CONTRAST: There has been interval right parietal craniectomy, with excision of a mass centered in the right parietal bone.",0
"There is a combination of edema and encephalomalacia involving the right parietal lobe adjacent to the resection site, as well as extending into the temporal and occipital lobes.",0
"There is expected pneumocephalus, and only minimal linear hyperdensity at the site of resection, some of which may represent venous sinus, but there is likely a small amount of expected postoperative hemorrhage.",0
"There is no interval development of hydrocephalus, there is no transtentorial, subfalcine, or uncal herniation.",0
"No other site of hemorrhage, edema, mass effect, or shift of normally midline structures is identified.",1
There is a pattern of periventricular hypodensity consistent with chronic small vessel ischemic disease.,0
"There is partial opacification of the right mastoid air cells, but this was seen also on the prior study.",0
The paranasal sinuses and remainder of soft tissues appear normal.,0
Expected postoperative change at the site of right parietal craniectomy for tumor resection.,0
"Combination of edema and encephalomalacia in right parietal, temporal, and occipital lobes.",0
"(Over) 5:15 PM CT HEAD W/O CONTRAST Clip # Reason: please evaluate for post-op hemorrhage Admitting Diagnosis: NEW BRAIN MASS, CONFUSION, SEIZURES ______________________________________________________________________________ FINAL REPORT (Cont)",1
Left ventricular function Weight (lb): 200 BP (mm Hg): 101/50 HR (bpm): 128 Status: Inpatient Date/Time: at 13:44 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Saline Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
"No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.",0
Beat-to-beat variability on LVEF due to irregular rhythm/premature beats.,0
Focal calcifications in ascending aorta.,0
"GENERAL COMMENTS: Contrast study was performed with 2 iv injections of 8 ccs of agitated normal saline, at rest, and post-Valsalva.",0
Patient was unable to cooperate with maneuvers.,0
Suboptimal image quality - poor echo windows.,0
There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm.,0
"1:27 AM CT HEAD W/O CONTRAST Clip # Reason: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: year old woman with fall at OSH, findings intracranial hemorrhage detailed above.",0
"REASON FOR THIS EXAMINATION: assess for change in intraventricular hemorrhage, IPH, SAH, No contraindications for IV contrast ______________________________________________________________________________ WET READ: EAGg SUN 3:50 AM Little overall change in known intraventricular, bifrontal and right temporal parenchymal and SAH hemorrhage.",0
______________________________________________________________________________ FINAL REPORT INDICATION: -year-old female status post fall transferred from outside hospital with intracranial hemorrhage.,1
COMPARISON: CT of at 23:15 at .,0
TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast.,0
Coronal and sagittal reformats were displayed.,0
"FINDINGS: Compared to the prior study, there is little interval change.",0
Large right intraventricular hemorrhage demonstrates some redistribution with increased blood products in the right frontal and third ventricle.,0
There is newly apparent hyperdense material layering within the left lateral ventricle.,0
Blood products are also noted within the cerebral aqueduct and fourth ventricle.,0
"Two foci of intraparenchymal hemorrhage in the right frontal lobe are similar to prior, the largest measuring 10 x 6 mm compared to 11 x 8 mm previously.",0
A third focus of intraparenchymal hemorrhage in the right temporal lobe is also similar to prior.,0
Scattered foci of probable subarachnoid hemorrhage are noted in the bifrontal region.,1
No shift of the normally midline structures.,0
No major vascular territory infarction.,0
Large right frontal subgaleal hematoma and laceration are noted without underlying osseous injury.,0
Periventricular white matter hypodensity is most consistent with chronic small vessel ischemic disease.,0
Age-appropriate prominence of ventricles and sulci is consistent with diffuse parenchymal volume loss.,0
There has been bilateral lens surgery.,0
The visualized paranasal sinuses and mastoid air cells are well aerated.,0
Little overall change in known right lateral intraventricular hemorrhage.,0
Similar appearance of multiple foci of intraparenchymal and subarachnoid hemorrhage.,1
Large right frontal subgaleal hematoma.,0
(Over) 1:27 AM CT HEAD W/O CONTRAST Clip # Reason: S/P FALL ______________________________________________________________________________ FINAL REPORT (Cont) FOllow up as clinically indicated if no intervention is contemplated.,0
"12:06 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: ?process in liver/spleen/gall bladder Admitting Diagnosis: ACUTE LEUKEMIA Field of view: 31 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with ALL, on chemo, with new elevated LFTs REASON FOR THIS EXAMINATION: ?process in liver/spleen/gall bladder CONTRAINDICATIONS for IV CONTRAST: on nephrotoxic antibiotics, with mild renal insufficiency ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: History of ALL on chemotherapy with new elevated LFTs.",1
"Evaluate for an abnormality within the liver, spleen and gallbladder.",0
TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung bases to the pubic symphysis in a multiphasic fashion.,0
CONTRAST: 150 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study.,0
CT OF THE ABDOMEN WITH IV CONTRAST: Minimal bibasilar atelectasis is noted at the lung bases bilaterally.,0
"Within the right lower lung zone, there is a filling defect seen on the arterial phase within a segmental branch of the right pulmonary artery (while this cannot be traced back to the main pulmonary artery on this study, this corresponds to a branch of the pulmonary artery on the prior exam).",0
This is concerning for a pulmonary embolism.,1
No pulmonary nodules or parenchymal consolidation is seen at the lung bases.,0
There has been interval resolution of the previously seen small bilateral pleural effusions.,0
"There are focal areas of relatively increased density adjacent to the gallbladder, which likely represents focal fatty sparing.",0
"Additionally, the left lobe of the liver is enlarged, suggesting chronic liver disease.",0
No focal abnormalities are identified within the liver.,0
"The pancreas, kidneys, adrenal glands, spleen and gallbladder are normal in appearance.",0
"The renal artery contours have a beaded appearance bilaterally, greater on the right, which is suggestive of changes from underlying fibromuscular dysplasia.",0
"The bowel is normal in appearance, without any evidence of bowel wall thickening or dilatation.",0
No free fluid or free air is seen.,0
No pathologically enlarged retroperitoneal or mesenteric lymphadenopathy is seen.,0
"Several scattered retroperitoneal lymph nodes are noted, which are not enlarged by CT criteria.",0
CT OF THE PELVIS WITH IV CONTRAST: The patient is status post hysterectomy.,0
No free fluid is seen.,0
"Within the deep pelvis, there is a soft tissue density nodule between the vagina and right pubic ramus which ilkely represents a lymph node which is enlarged and appears to have increased in size compared to the last CT scan, now measuring 15 X 12 mm vs 12 X 11 mm on the last exam.",0
The (Over) 12:06 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: ?process in liver/spleen/gall bladder Admitting Diagnosis: ACUTE LEUKEMIA Field of view: 31 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) bladder is normal in appearance.,1
Several scattered diverticula are seen arising off the sigmoid colon.,0
BONE WINDOWS: No suspicious lytic or sclerotic lesion identified.,0
Fatty infiltration of the liver.,0
Enlargement of the left lobe of the liver suggests chronic underlying liver disease.,0
"There is a focal filling defect within a segmental branch of the right main pulmonary artery in the right lower lung zone, which represents a segmental pulmonary embolism.",1
This was discussed with Dr. at 2:00 pm on /5.,0
"There is a soft tissue density lesion, likely representing an enlarged lymph node, within the deep right hemipelvis which appears to have increased since the prior exam (now measuring 15 X 12 mm vs 12 X 11 mm).",0
"Given the patient's history of CLL, attention should be paid to this on subsequent follow-up 4.",0
"There is a beaded appearance to the renal arteries bilaterally, greater on the right, which likely represents fibromuscular dysplasia.",0
Clip # Reason: please evaluate for renal obstruction and please evaluate bl Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with ARF and bladder scan with ?hyperechoic mass REASON FOR THIS EXAMINATION: please evaluate for renal obstruction and please evaluate bladder for mass ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old man with ARF and bladder scan with hyperechoic mass.,0
Evaluate for renal obstruction and please evaluate bladder for mass.,0
There is no evidence of hydronephrosis.,0
The right kidney measures 11.8 cm.,0
The left kidney measures 11.8 cm.,0
No focal renal lesions are identified.,0
The bladder is partially distended and demonstrates internal echoes suggestive of clots.,0
There is no son evidence of bladder mass.,0
"No evidence of bladder mass, partially distended bladder with internal clots.",0
6:32 PM CHEST (PORTABLE AP) Clip # Reason: S/p line placement.,0
Admitting Diagnosis: S/P MVC;HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with MVC REASON FOR THIS EXAMINATION: S/p line placement.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: MVC, status post line placement.",0
AP PORTABLE CHEST: There is now a left subclavian line which terminates in the lower SVC.,0
The endotracheal tube and NG tube remain in appropriate position.,0
IMPRESSION: Satisfactory positioning of the left subclavian catheter.,0
8:21 AM CHEST (PORTABLE AP) Clip # Reason: shortness of breath-- ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with sob fever REASON FOR THIS EXAMINATION: shortness of breath-- ______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old man with shortness of breath and fever.,0
AP UPRIGHT PORTABLE CHEST X-RAY: Previous chest x-ray .,0
The patient is slightly rotated to the left.,0
The cardiac silhouette is normal in size.,0
The mediastinal and hilar contours appear normal.,0
"Within the right upper lung, there is a decreased opacity of interstitial markings, consistent with emphysema.",0
The pulmonary vessels appear normal.,0
A faint opacity within the left lower lung appears new since prior exam.,0
The left costophrenic angle is poorly visualized.,0
The surrounding soft tissue and osseous structures appear normal.,0
IMPRESSION: Probable left lower lobe opacity.,0
Please obtain lateral view for complete evaluation.,0
"Admission Date: Discharge Date: Service: Allergies: Penicillins / Shellfish Derived Attending: Chief Complaint: shortness of breath, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: 86 year old female with a past medical history of occipital stroke with memory difficulties, atrial fibrillation, Cdiff, dCHF on 2L at home, severe AS, presented with SOB increasing x 4-5 days.",1
"In the ED, initial VS: 98.4 94 85/46 36 100 on NRB.",0
They thought CHF on home O2 but did not give lasix because worried about low SBPs.,0
Got levo/flaygl and IV vanco for recurrence of Cdiff.,0
"On NRB 99% 29, 99, 95/30.",0
Niece had preferred no ICU admission.,0
Patient refused central line downstairs.,0
BCx not done prior to antibiotics.,0
Patient only had 20G IV.,0
"Of note, patient has had multiple hospitalizations since , at first for new atrial flutter as well as signs of posterior cardioembolic strokes.",1
"She was started on aspirin/clopidogrel anticoagulation, rate controlled, and diuresed before being discharged to rehab.",0
"Unfortunately, her rehab course was complicated by two hospitalizations at an outside hospital.",0
One of these hospitalizations was for hospital associated pneumonia but the cause of the other was unknown.,0
She is now status post a hospitalization for C diff colitis sepsis complicated by exacerbation of her diastolic CHF and delirium.,0
She subsequently completed a course of PO Vancomycin.,0
"Currently, patient complaining of ""feeling ill"" but does not go into detail about what is bothering her.",0
She seems confused and keeps referring to her niece as her roommate.,0
"She denied, CP, cough, fever, chills, abdominal pain or diarrhea.",0
Her niece endorsed worsening DOE and at rest.,0
She also reported diarrhea that was large and foul-smelling at home X3 days for which she gave her immodium.,0
Her niece endorsed that the patient is not aggitated at home so she stopped the Zyprexa from a previous admission which she had been prescribed for delirum.,0
A discussion was had about her goals upon admission given her low blood pressure and limited IV access.,0
The patient and the niece were perfectly clear about refusing central lines even if that could be a way to give pressure support and antibiotics that could be potentially life saving.,0
They understood that were not giving her standard of care and understood that the risks include potentially death.,0
"ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria.",0
History of left occipital infarction in with associated naming difficulties previously anticoagulated but now on plavix 2.,0
Asthma in childhood - Currently using 2L nasal canula but no documented underlying lung disease and no pulmonary function tests 5.,1
Cdiff Social History: She never married and worked as a social worker.,0
Currently living with her .,0
two brothers who do not live locally.,0
She quit smoking 20 years ago and cannot recall how much she used to smoke.,0
She does not drink alcohol or use illicit drugs.,0
"Per family, she was first woman to run for governor of .",0
Family History: Notable for depression in a grandmother.,0
She has two brothers in their 80s who are alive and healthy.,0
Physical Exam: Tcurrent: 36.8 ?,0
Suboptimal evaluation of the peripheral pulmonary arterial branches due to patient respiratory motion.,0
No evidence of pulmonary embolism in the central or segmental pulmonary arterial branches.,0
Pulmonary edema and increased moderate right pleural effusion with overlying atelectasis.,0
"Indeterminant right renal cystic lesion, suboptimally evaluated on recent renal ultrasound.",0
Recommend renal MRI for further evaluation since ultrasound findings were non-conclusive.,0
ECHO: Left atrium is mildly dilated.,0
Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%).,0
The right ventricular free wall is hypertrophied.,0
The right ventricular cavity is mildly dilated with normal free wall contractility.,0
There is abnormal septal motion/position.,0
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).,1
There is severe pulmonary artery systolic hypertension.,0
"Compared with the prior study (images reviewed) of , the RV appears slightly larger with RVH present (probably present on the prior study).",0
The degree of pulmonary hypertension detected has increased.,0
CXR: Moderately severe pulmonary edema collecting at the lung bases and small right pleural effusion has increased.,0
Heart size is normal despite the extremely heavily calcified mitral annulus.,0
"Prior imaging has shown severe aortic valvular calcification, heavy atherosclerotic calcification, and severe emphysema.",0
"Brief Hospital Course: 86 year old female with a past medical history of occipital stroke with memory difficulties, atrial fibrillation, Cdiff, dCHF on 2L at home, severe AS, presented with SOB increasing x 4-5 days .",1
Hypotension: Patient was admitted to MICU for hypotension in the setting of diarrhea.,0
She refused central line placement and treatment with pressors in the emergency room.,0
"In the MICU, dilt and lasix were held, and patient was initially treated with IVFs and albumin with good response.",0
"Subsequently, patient became dyspneic with O2 requirement.",0
While in the MICU she did have further episode of hypotension after receiving lasix for presumed CHF exacerbation with CXR significant for pulmonary edema (see below).,0
"Upon transfer to the wards, patients systolic blood pressure remained 90s-low 100s, and lasix and diltiazam were held and not restarted on discharge given low blood pressures.",0
C Diff: The patient was initially admitted to the medical ICU for hypotension.,0
Patient had frequent episodes of diarrhea and stool cultures tested positive for c. diff.,0
"Given her presentation of leukocytosis, tachycardia, hypotension (see below) there was a concern for SIRS, and blood cx were drawn which were negative.",0
She was started on vanc and flagyl for c diff treatment.,0
"On transfer to the wards, leukocytosis resolved and patient was maintained on her antibiotic regimen.",0
Upon discharge she continued on vancomycin course for treatment of recurrent c. diff.,0
"dCHF exacerbation: While in the MICU, patient became short of breath with an increased O2 requirement.",0
A CXR sig for pulm edema and CTA negative for PE.,0
Patient was given Lasix which lead to an episode of hypotension to sBP 70s.,0
Subsequently she was resuscitated with albumin and was continued on nebs and nasal cannula.,0
A TTE was ordered to assess progression of known Aortic Stenosis.,0
"TTE results showed: moderate aortic valve stenosis (valve area 1.0-1.2cm2), and compared to previous TTE slightly larger RV and increased pulmonary hypertension.",1
"Upon transfer to the wards, the patient blood pressure remained hypotensive with sbp in the 90s-low 100s and so lasix was held and not restarted on discharge.",0
"End of life care was discussed with the , , who indicated that the patient did not was any invasive interventions.",0
Social work was consulted and the agreed with plan to speak w/ PCP (who has good relationship with the patient) to have end of life discussion with patient as an outpatient.,0
# Afib: Patient declined anticoagulation with coumadin.,0
"She was continued on aspirin and plavix, but diltiazam was held given her labile blood pressures and not restarted upon discharge.",0
# Hyponatremia: While in the MICU patient was hyponatremia (Na 129) thought to be secondary to CHF exacerbation.,0
"Upon transfer to the wards, hyponatremia resolved.",0
Na on discharge 135. .,0
# Depression: Patient was continued on her outpatient regimen of antidepressent (zoloft).,0
Diltiazem CD 120 mg p.o.,0
Iron sulfate 325 mg p.o.,0
Multivitamin Capsule Sig: One (1) Capsule PO once a day.,0
FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day.,0
Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days.,0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
"Disp:*1 inhaler* Refills:*0* Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: Primary: -Recurrent C. Diff -Decompensated diastolic CHF Secondary: -Atrial Fibrillation -Aortic Stenosis Discharge Condition: Breathing 98% on 2L, SBP 98-100 Discharge Instructions: You were seen in the hospital because of your difficulty breathing and diarrhea.",1
You were admitted in the intensive care unit because of your breathing and low blood pressure.,0
"You refused central line placement, inorder to give you medicines to keep your blood pressure up.",0
"We gave you lasix but this made your blood pressure drop, so we did not restart your lasix.",0
In order to improve your breathing we treated you with nebulizers and oxygen.,0
A stool test showed that you have recurrent c. diff.,0
We treated this with antibiotics.,0
"We made the following changes to your home medications: (1) Please do not take lasix, diltiazam, potassium chloride.",0
Lasix and diltiazam can reduce your blood pressure.,0
You will need to follow up with Dr. who will decide when to restart these medications.,0
(2) Please continue Vancomycin for 10 days.,0
"If you experience any worsening shortness of breath, worsening diarrhea or abdominal pain, fevers >101, lightheadedness or any other concerning symptoms please call your PCP or return to the emergency room.",0
"Followup Instructions: Please follow up with a nurse practitioner, on at 3:20 in the Atrium Suite .",0
She will assess your breathing as we have held your lasix.,0
If you need to reschedule this appointment please call .,0
Please follow up with Dr. on 1:45pm the North Suite 6th florr.,0
"Dr. will decide when to restart your lasix, diltiazam, potassium chloride.",0
"12:28 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with severe AS, 2VD s/p cardiac cath today now w/ word finding difficulties and left facial drooping.",0
New R sided weakness REASON FOR THIS EXAMINATION: r/o bleed ______________________________________________________________________________ FINAL REPORT INDICATION: Left facial droop.,0
Axial noncontrast CT scans of the brain were obtained.,0
Comparison is made to the previous MRI of .,0
"FINDINGS: As noted on the previous MR examination, there is evidence of microvascular infarction throughout the white matter.",0
The focal left internal capsule infarction is not clearly identifiable on the background of white matter hypodensity.,0
There are no areas of cortical attenuation abnormality or gyral edema to suggest acute cortical infarction.,0
There is no hyperdensity within the brain or in the extra-axial spaces to indicate acute hemorrhage.,0
The ventricles are not dilated.,0
There is no shift of structures.,0
The visualized paranasal sinuses and mastoids are clear.,0
IMPRESSION: There is no evidence of acute intracranial hemorrhage.,0
There are no major vascular territorial infarctions identified.,0
"8:58 PM CHEST (PORTABLE AP) Clip # Reason: eval for pna ______________________________________________________________________________ MEDICAL CONDITION: year old man with altered mental status REASON FOR THIS EXAMINATION: eval for pna ______________________________________________________________________________ WET READ: RBLd 10:31 PM nondisplaced distal left clav fx, indetermin age, but may be acute.",1
ac jt intact on this single image.,0
"RLL consol, pna vs asp ______________________________________________________________________________ FINAL REPORT EXAM: Chest, single semi-upright portable view.",0
CLINICAL INFORMATION: -year-old male with history of altered mental status.,1
FINDINGS: Single AP frontal view of the chest was obtained.,0
"Patchy right base opacity raises concern for consolidation, which could be due to pneumonia and/or aspiration.",0
"The cardiac silhouette is mildly enlarged, likely accentuated by AP technique.",0
"There is a non-displaced fracture through the left distal clavicle of indeterminate age, but could be acute.",1
The left acromioclavicular joint appears intact on this single image.,0
Left costophrenic angle not fully included.,0
"Right base opacity raises concern for consolidation, such as pneumonia or aspiration.",0
PA and lateral views would be helpful when/if patient able.,1
"Non-displaced distal left clavicle fracture of indeterminate age, but which may be acute.",1
"4:25 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ACUTE PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with acute pancreatitis, resp failure, ards, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 4:54 A.M. HISTORY: Pancreatitis, respiratory failure and ARDS.",1
"IMPRESSION: AP chest compared to through : Severe bilateral lower lobe and right middle lobe atelectasis, worsened on the left, stable on the right, since .",1
"Upper lungs clear, hyperlucent suggesting emphysema.",0
Small to moderate left pleural effusion increased slightly.,0
"ET tube, right internal jugular line, left PIC catheter, in standard placements, and nasogastric tube traceable only to the upper stomach.",0
"2:25 PM US ABD LIMIT, SINGLE ORGAN Clip # Reason: ABNORMAL CT, R/O ACUTE CHOLECYSTITIS, Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with REASON FOR THIS EXAMINATION: r/o acute choleycystitis, RUQ US ______________________________________________________________________________ FINAL REPORT INDICATION: Acute right upper quadrant pain.",1
COMPARISON: CT torso of .,0
RIGHT UPPER QUADRANT ULTRASOUND: The visualized portion of the liver echotexture is normal.,0
There is no intrahepatic biliary dilation.,0
The gallbladder is contracted and contains a gallstone.,0
There is no gallbladder wall edema or pericholecystic fluid.,0
IMPRESSION: Contracted gallbladder with a gallstone.,0
No evidence of acute cholecystitis.,0
Height: (in) 63 Weight (lb): 111 BSA (m2): 1.51 m2 BP (mm Hg): 143/85 HR (bpm): 129 Status: Inpatient Date/Time: at 12:32 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<=2.1cm) with <50% decrease with sniff (estimated RA pressure (5-10 mmHg).,0
LEFT VENTRICLE: Overall normal LVEF (>55%).,0
Conclusions: The estimated right atrial pressure is 5-10 mmHg.,0
"There is a very small to small, circumferential pericardial effusion measuring up to 1 centimeter in greatest dimension.",0
"Very small to small, circumferential pericardial effusion without echocardiographic evidence of tamponade.",0
Bubble Study R/O PFO Height: (in) 68 Weight (lb): 310 BSA (m2): 2.46 m2 BP (mm Hg): 108/59 HR (bpm): 84 Status: Inpatient Date/Time: at 11:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Saline Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT VENTRICLE: Normal LV wall thickness and cavity size.,0
RIGHT VENTRICLE: RV not well seen.,0
IMPRESSION: Very poor technical quality due to patient's body habitus.,0
"Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded.",0
The right ventricle is not well seen.,0
No pathologic valvular abnormality seen.,0
The inter-atrial septum was not well seen.,0
"The poor technical quality of the study means that the presence of an ASD/PFO could not be confirmed or refuted, even after the injection of agitated saline.",0
"Compared with the prior study (images reviewed) of , the findings are similar although the technically suboptimal nature of both studies does not allow for definitive comparison.",0
", H. 6:31 AM CHEST (PORTABLE AP) Clip # Reason: Any acute cardiopulmonary process?",1
"Admitting Diagnosis: STEMI ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with CAD, with hypoxia.",0
REASON FOR THIS EXAMINATION: Any acute cardiopulmonary process?,1
"Bilateral airspace opacities, right greater than left is worse compared to , is concerning for worsening pulmonary edema, however, pneumonia cannot be completely excluded in the _____ clinical setting.",1
5:04 PM BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: PICC line placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity on ventilator REASON FOR THIS EXAMINATION: PICC line placement ______________________________________________________________________________ FINAL REPORT Infant with prematurity on ventilator PICC line placement.,1
Examination is compared to the exam earlier the same day showing repositioning of the right- sided PICC line now terminating at the level of the SVC.,0
ET tube terminates just below the thoracic inlet.,0
The umbilical venous catheter terminates at the level of the RA-IVC junction.,0
The heart size may be mildly enlarged.,0
There are granular opacities bilaterally which do appear improved from prior examination.,0
An opacity overlying the right mid abdomen likely represents a skin dressing.,0
"IMPRESSION: PICC line repositioned, now terminating at the SVC.",0
"Apparent mild cardiac enlargement, which may in part be due to the rotation of the infant.",0
Height: (in) 66 Weight (lb): 160 BSA (m2): 1.82 m2 BP (mm Hg): 95/60 HR (bpm): 66 Status: Inpatient Date/Time: at 19:13 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,1
RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.,0
AORTIC VALVE: ?# aortic valve leaflets.,0
Trivial MR. TRICUSPID VALVE: Mild [1+] TR.,0
Suboptimal image quality - poor subcostal views.,0
"While the right atrium cannot adequately visualized, there is a concern for a localized clot that may compress slightly on the right atrial wall.",0
"The right ventricle is not well seen, but its function is probably normal.",0
IMPRESSION: Normal left ventricular systolic function.,0
6:28 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: FKh WED 9:03 AM No obvious c-spine fracture severe degenerative changes with multilevel listhisis.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 85 year old woman status post trauma.,0
COMPARISON: No comparisons are available.,0
TECHNIQUE: Initially contiguous axial images were obtained throughout the cervical spine.,0
FINDINGS: There is again noted the linear nondisplaced fracture in the base of the skull.,0
"There is also a fracture of the right mastoid, though it is not well delineated.",0
"Severe degenerative changes of the cervical spine are identified, with multilevel listhesis.",0
"Degenerative changes are most prominent at the levels of C1/2, C5/6 and C6/7 and C7/T1.",0
There is calcification and thickening of the transverse ligament.,0
The odontoid appears to be intact.,0
There is a disc bulge at the level of C2/C3 causing mild-to-moderate stenosis of the spinal canal.,0
There is severe disc space narrowing at the level of C3/C4 but no stenosis of the spinal canal.,0
There is mild grade 1 anterolisthesis of C4 over C5.,0
At this level there is also mild disc bulge.,0
There is retrolisthesis of C5 over C6 which is causing moderate to severe narrowing of the spinal canal.,0
At this level the vertebral bodies are almost fused.,0
At the level of C6/C7 there is also narrowing of the spinal canal.,0
At the level of C7/T1 there is marked anterolisthesis of C7 over T1.,0
"There is also stenosis of the spinal canal at this level, with thickening of the ligamentum flavum.",0
No definite fractures were identified.,0
"However, correlation with physical exam and if point tenderness exists MRI could be performed to evaliuate the cord and soft tissues for injury in the setting of these severe degenerative changes.",0
The visualized outline of the thecal sac is intact.,0
CT does not provide any intrathecal detail.,0
The lung apicies are clear.,0
Severe degenerative changes of the cervical spine with multilevel disc space narrowing and listhesis.,0
"Although no definite fractures were identified and there is no prevertebral soft tissue swelling, recommend clinical (Over) 6:28 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: trauma ______________________________________________________________________________ FINAL REPORT (Cont) correlation and MRI for further evaluation, if indicated.",0
Linear nondisplaced fracture of the occipital bone in the base of the skull.,0
"If clinically indicated, further evaluation with a dedicated CT could be performed.",0
"7:13 AM NEONATAL HEAD PORTABLE Clip # Reason: PREMATURITY, ASSESS FOR PVL ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 30 weeks gestation, now 1 month old REASON FOR THIS EXAMINATION: r/o PVL ______________________________________________________________________________ FINAL REPORT HISTORY: Infant born at 30 weeks gestation.",1
"FINDINGS: Since the exam dated , there is now visualization of tiny choroid plexus cysts bilaterally.",0
"Specifically, there are two choroid plexus cysts on the right and one choroid plexus cyst on the left.",0
The largest choroid plexus cyst is on the right and measures 3.6 mm.,0
"There is a prominent echogenicity in the left caudothalamic groove, which raises the possibility of a left germinal matrix hemorrhage.",0
"A follow up ultrasound should be obtained to exclude this possibility, and recommendation was discussed with the ICU team.",0
The ventricular system size is normal.,0
The sulci and gyri of the cerebrum and cerebellum have a normal appearance and are consistent with patient's prematurity.,0
No extraaxial fluid collection is seen.,0
IMPRESSION: Tiny bilateral choroid plexus cysts (dominant cyst on the right measures 3.6 mm).,0
Prominent echogenicity in the left caudotalamic groove raises the possibility for a germinal matrix hemorrhage.,0
Follow up ultrasound is recommended.,0
"1:20 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for infection ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with chest pain, some shortness of breath, low grade fevers REASON FOR THIS EXAMINATION: evaluate for infection ______________________________________________________________________________ FINAL REPORT INDICATION: Chest pain.",0
SINGLE FRONTAL UPRIGHT RADIOGRAPH OF THE CHEST: The LLL demonstrates a calcified granuloma measuring 7 mm.,0
"The lungs are otherwise clear without focal consolidations, pleural effusions, or pneumothorax.",0
There is no pulmonary edema.,0
Surgical clips are present in the epigastric region.,0
4:20 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval changes Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with tachypnea ?,0
due to central malignancy invasion vs pulm edema vs infection REASON FOR THIS EXAMINATION: please eval for interval changes ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Tachypnea.,0
COMPARISON: Chest radiograph from obtained at 1:28 p.m.,0
The left subclavian line tip is in proximal right atrium/cavoatrial junction.,0
Mild vascular engorgement is unchanged.,0
Left basal opacity is most likely consistent with atelectasis with no change since the prior study as well.,0
1:43 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man w/ esophageal ca with bronchus extension p/w respiratory failure.,1
"REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Esophageal carcinoma with extension to bronchus, respiratory failure.",1
CHEST: There has been no significant change since the prior chest x-ray of .,0
The position of the various lines and tubes are unchanged.,0
Complete opacification of left hemithorax is again noted and multiple patchy opacities are seen throughout the right lung.,0
Height: (in) 61 Weight (lb): 108 BSA (m2): 1.46 m2 BP (mm Hg): 140/80 HR (bpm): 109 Status: Inpatient Date/Time: at 11:18 Test: TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
"LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",0
PERICARDIUM: Moderate to large pericardial effusion.,0
"RV diastolic collapse, c/w impaired fillling/tamponade physiology.",0
There is a moderate to large sized pericardial effusion.,0
"There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology.",0
"Status: Inpatient Date/Time: at 10:30 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
5:19 AM CHEST (PORTABLE AP) Clip # Reason: Please assess interval change.,0
Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with respiratory failure.,1
REASON FOR THIS EXAMINATION: Please assess interval change.,0
______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 66-year-old man with respiratory failure.,1
Please assess for interval change.,0
"Comparison exam: Findings: A right-sided PICC line in place, position unchanged.",0
"Endotracheal tube in place, position unchanged.",0
There is unchanged mild cardiomegaly.,0
There are bilateral small pleural effusions.,0
"There is increased ill defined, hazy opacity in the lungs bilaterally, which may be related to layering pleural effusions.",0
"8:09 AM CHEST (PORTABLE AP) Clip # Reason: progressive lung disease Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with CHF s/p extubation with progressive respiratory failure, MRSA PNA, previously volume overloaded REASON FOR THIS EXAMINATION: progressive lung disease ______________________________________________________________________________ FINAL REPORT HISTORY: CHF, s/p extubation with progressive respiratory failure, MRSA pneumonia, previously volume overloaded.",1
PORTABLE SEMI-SUPINE CHEST: ICD with an atrial lead is unchanged in position.,0
There is improved but persistent CHF.,0
The patient is post CABG with a large heart.,0
"3:41 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ET tube now pulled back, please assess for position of ET tu Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: year old woman with fevers, hypoxia.",0
prior CXR showed ET tube was advanced to far.,0
"REASON FOR THIS EXAMINATION: ET tube now pulled back, please assess for position of ET tube ______________________________________________________________________________ FINAL REPORT CXR, SINGLE PORTABLE FILM HISTORY: Check for ET tube placement which has been repositioned.",0
"CXR, SINGLE SEMI-UPRIGHT PORTABLE FILM ET tube tip is just 1 cm above the carina.",0
This should be withdrawn another 2-3 cm.,0
"The right subclavian line and the NG tube appear satisfactory, although the NG tube is coiled with its tip lying in the gastric fundus.",0
Note is made of left lower lobe atelectasis/infiltrate as on film done earlier today as well as yesterday.,0
CONCLUSION: ET tube should be withdrawn another 2-3 cm.,0
Findings discussed with Dr. .,0
PATIENT/TEST INFORMATION: Indication: Intra OP TEE during CABG procedure Height: (in) 68 Weight (lb): 242 BSA (m2): 2.22 m2 BP (mm Hg): 134/78 HR (bpm): 76 Status: Inpatient Date/Time: at 14:52 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.,0
Moderate-severe regional left ventricular systolic dysfunction.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Complex (>4mm) atheroma in the ascending aorta.,0
Mildly thickened aortic valve leaflets.,0
2.There is moderate symmetric left ventricular hypertrophy.,0
There is moderate to severe regional left ventricular systolic dysfunction.,0
Overall left ventricular systolic function is moderately depressed.,0
"Resting regional wall motion abnormalities include moderately depressed anterior wall, anterior septum, septum, inferior septum, anterolateral and lateral wall.",0
Inferior wall and inferolateral walls contract normally.,0
5.The ascending aorta is mildly dilated.,0
There are complex (>4mm) atheroma in the ascending aorta.,0
There are complex (10 mm) atheroma in the aortic arch.,0
6.There are three aortic valve leaflets.,0
7.The mitral valve leaflets are mildly thickened.,0
8.The tricuspid valve leaflets are mildly thickened.,0
9.There is a trivial/physiologic pericardial effusion.,0
Post Bypass 1.Patient is receiving infusions of epinephrine and milrinone.,0
Left ventricular systolic function is somewhat improved.,0
Right ventricular systolic function is preserved.,0
PATIENT/TEST INFORMATION: Indication: Cerebrovascular event/TIA.,0
Height: (in) 68 Weight (lb): 222 BSA (m2): 2.14 m2 BP (mm Hg): 130/70 HR (bpm): 55 Status: Inpatient Date/Time: at 09:07 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; inferior apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
"There is mild to moderate regional left ventricular systolic dysfunction with with severe hypokinesis of the inferior septum, basal half of the inferolateral wall, and distal inferior wall.",1
IMPRESSION: Normal biventricular cavity sizes with regional left ventricular systolic dysfunction c/w multivessel CAD.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: EMERGENCY Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim / Cozaar / Captopril Attending: Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Mechanical ventilation Blood transfusion History of Present Illness: 77 y/o lady with CHF, AF, HTN was discharged from Trauma service yesterday after she was admitted here with C7 fracure secondary to fall.",1
She initially presented to an outside hospital prior to the recent admission and was intubated for ?,0
respiratory distress vs glottic swelling.,0
Her course here was complicated by unable to wean her off of vent and she eventually underwent a trach/PEG placement on .,0
Patient was discharged to .,0
Patient states that she has felt tired and sleepy in the last two days.,0
Patient has had episodes of tachycardia to 150s at rehab facility yesterday.,0
CXR this morning there was concerning for CHF.,0
"She recieved 40 mg of furosemide IVP, cardizem 30 mg PGT (1444) and 1 mg of ativan (1255).",0
Her BP dropped to 60s/40s.,0
She received some fluid boluses.,0
"Her vent setting there was ACMV PEEP 5, rate 12, Volume 500 FiO2 40%.",0
She was taken to .,0
She recieved 500 mg of levofloxacin.,0
She was transfered here given recent hospitalization.,0
In ED her vitals were T 99.5 HR 79 BP 84/50 RR 18 100% O2sat.,0
"Patient received 1.5 L NS, 1 gram IV vancomycin and started on 1 u PRBC.",0
"She denies any chest pain, shortness of breath, fever, chills, nightsweats, abdominal pain, headache, acute change in vision, hearing, new weakness, change in sensation.",0
"No diarrhea, constipation, hematuria, dysuria, or blood in stool.",0
"Past Medical History: - CHF, unclear history - AF - HTN - NHL - ?",0
"radiation treatment to thyroid, ?",0
"hypothyroidism - anxiety - intermittent diarrhea - trach/PEG - C7 fx 2/4/009 s/p fall - vent dependent respiratory failure - multiple pleural taps; right-sided thoracentesis , left-sided thoracentesis , ?",1
"R PTX, s/p right chest tube placement - s/p trach/PEG Social History: Patient is coming from rehab.",0
Denies ever using tobacco/ETOH/street drugs.,0
"Family History: HTN, CAD Physical Exam: Gen: alert and awake, pleasant lady in NAD, following commands HEENT: EOM-I, MMM, OP clear, trach in place Heart: S1S2 holosystolic murmur audible throughout precordial area best heard at apex radiating to axilla Lungs: wheezes R>L Abdomen: BS present, soft NTND Ext: WWP, no edema Neuro: strenght in R ext and 3+/5 in L ext Guaic negative in ED Pertinent Results: 05:20AM BLOOD PT-40.8* PTT-30.8 INR(PT)-4.5* .",1
05:20AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 .,0
08:16AM BLOOD WBC-9.8 RBC-2.94* Hgb-9.3* Hct-26.6* MCV-91 MCH-31.7 MCHC-35.0 RDW-14.5 Plt Ct-296 05:00PM BLOOD Hct-28.3* .,0
MICROBIOLOGY: 9:33 am SPUTUM Source: Endotracheal.,0
GRAM STAIN (Final ): >25 PMNs and <10 epithelial cells/100X field.,0
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.,0
RESPIRATORY CULTURE (Final ): OROPHARYNGEAL FLORA ABSENT.,0
CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S .,0
RADIOLOGY: CT C-SPINE: The alignment is normal.,0
There is a depressed fracture of the endplate of the C7 vertebra.,1
There is no significant canal stenosis at this level.,0
"There is a posterior endplate fracture of the T2 vertebral body, without significant canal stenosis at this level.",1
There is again multilevel degenerative disc and facet disease on the left at C2-3.,0
There is scarring at the lung apex.,0
The right pleural effusion is again noted.,1
No significant canal stenosis at these levels.,0
Multilevel degenerative change is similar to prior.,0
IMPRESSION: No change in the appearances of C7 and T2 fractures.,0
CXR: In the interval the amount of hazy opacity projecting over the right hemithorax with regions of lucency within it has significantly increased causing obscuration of the right hemidiaphragm.,0
Mild blunting of the left costophrenic angle persists.,0
The pulmonary vasculature appears distinct without any significant Kerley B lines noted.,0
There is continued opacity in the retrocardiac region.,0
"Right-sided PICC, tracheostomy, and calcifications within the aorta are unchanged.",0
"IMPRESSION: Increased effusions, moderate-to-large on right and small-to- moderate on left.",0
"Persistent adjacent opacities, probably compressive atelectasis, although infection cannot be excluded within these regions.",0
CT HEAD: CONCLUSION: No definite new intracranial abnormality.,0
"Bilateral mastoid and right middle ear abnormality, raising question of an ongoing inflammatory process, also involving the right sphenoid sinus air cell.",0
NOTE: Please note that the present study was obtained only with a soft tissue algorithm.,0
"Therefore, maximum bone detail was not depicted at this time.",0
"Finally, MR scanning of the brain, if feasible, offers far greater sensitivity in the detection of acute brain ischemia, compared with the present CT scan .",0
KUB : FINDINGS: Unchanged position of the access line.,0
No gastric or intestinal distention.,0
No evidence of pathological air-fluid levels.,0
"CXR : Since , there is no overall change.",0
"Tubes and catheters are in unchanged position, including a right PICC ending in the right brachiocephalic vein.",0
"Moderate-to-large right pleural effusion, small left pleural effusion and moderate-to-large bibasilar atelectasis are unchanged.",1
There are no signs of volume overload.,0
"EKG : Atrial fibrillation Low limb lead QRS voltages Delayed R wave progression with late precordial QRS transition Modest low amplitude lateral T wave changes Findings are nonspecific Since previous tracing of , T wave abnormalities decreased and Q-Tc interval appears shorter .",1
Low voltage in the standard leads.,0
Decreased R wave and T wave inversion in leads V2-V3.,0
T wave inversion in leads V4-V6.,0
Consider anterior wall myocardial infarction of undetermined age.,0
"Compared to the previous tracing of , when there was left and right arm lead reversal, the precordial T wave inversions are new and may represent acute ischemia.",0
"In addition, anterior voltage is decreased which may be related to lead placement.",0
"Brief Hospital Course: 77 y/o lady with CHF, AF, HTN was discharged from Trauma service yesterday after she was admitted here with C7 fracure secondary to fall now presents with hypotension.",0
# Hypotension: Initial differential was that this was secondary hypovolemia in the setting of aggressive diuresis and diastolic heart failure vs. autonomic instability vs. medication effect.,1
"Patient underwent an infectious work-up which revealed only MSSA in sputum, presumed colonization given lack of fevers and leukocytosis.",0
"Patient was noted to have episodes of low systolic BP's (high 60's), but BP improved after discontinuing clonidine as there was no clear indication for her to be on this medication.",0
"She continues to have episodes of hypotension while sleeping, but no changes in mentation.",0
"She was started on Coreg for management of her heart failure, which BP tolerated.",1
Midodrine administration was changed to 10 mg qHS.,0
Patient should not return to hospital for low BP's unless accompanied by alteration in mental status.,0
# Chronic vent dependence: Patient was trached on during previous admission following 3 failed extubation attempts.,0
"Her son at that time gave the Surgical team a vague history of a possible prior tracheostomy, and radiation to her neck -- perhaps causing some tracheal stenosis.",1
"On bronchoscopy, close evaluation demonstrated upper airway edema, with no leak when the cuff was down.",0
"She was placed on steroids, but given these findings, the decision was made to proceed with a trach/peg for ?",0
Vent settings at time of this ICU were AC 15/5/50%.,0
"Of note, a thoracentesis was also performed during previous admission for evaluation of her pleural effusion, with results consistent with a transudative process.",1
Her PCP was by the ICU team and confirmed that her pleural effusions were chronic.,1
Patient also appears to have weakened diaphragm as indicated by low NIF.,0
"She was gently diuresed during this hospitalization, with vent settings successfully reduced to Pressure Support ventilation at .",0
"Scarce MSSA was cultured from sputum, but given radio in the absence of leukocytosis, fever, radiographic changes, or hemodynamic instability, antibiotic therapy was deferred.",0
CXR on the morning of discharge showed a chronic right pleural effusion but overall improvement.,1
# Diastolic heart failure: Has chronic transudative right pleural effusion.,1
She has a documented AceI and allergy.,0
She was started on beta-blockade with Coreg 6.5 mg .,0
She was discharged on a standing dose of Lasix 40 mg PO daily.,0
She also responds to PRN dosing of Lasix 40 mg IV PRN.,0
"# Atrial fibrillation: Patient had episodes of rapid afib with HR 150's - 180's, triggered by suctioning, manipulations in the bed, and interactions with the healthcare team.",1
"She received Lopressor 5 mg IV for these epidodes, with resolution.",0
She was started on Carvedilol for rate control.,0
She is anticoagulated on Coumadin with a target INR .,0
Her coumadin dose was adjusted for both supratherapeutic INR and subtherapeutic INR.,0
INR on the morning of discharge was 1.8.,0
Coumadin dose was readjusted to 2 mg daily.,0
"# Anemia: Normocytic, most likely secondary to recent admission and frequent phlebotomy.",0
She received 1 unit PRBC's on arrival to for hematocrit of 24 in the setting of hypotension.,0
Hct 29.7 on day of discharge following diuresis and 1 unit PRBC's.,0
Normal Vit B12 nd folate in .,0
# Thyroid disease: Thyroid CA s/p surgery and radiation.,0
TFT's previously consistent with sick thyroid with elevated TSH but normal free T4.,0
She was continued on thyroid replacement therapy with Levothyroxine 200 mcg daily.,0
TFT's should be rechecked in one month following resolution of acute illness.,0
# C7-T2 fractures: No clear history of stroke after comparing PCP?????,1
"CT of her c-spine was repeated during this hospitalization at the request of the Ortho Spine service, demonstrating no interval changes of C7/T2 fractures.",0
"Per Ortho, she was scheduled for follow-up with Dr. in late .",0
She has been instructed to continue wearing the c-collar for a total of 8 weeks (end date ).,0
# Low-grade fever: On patient was documented to have a low-grade fever to 100.3.,0
Her PICC line was discontinued.,0
Patient had no subsequent fevers and WBC on morning of discharge was 6K.,0
Her only positive culture data from this hospitalization revealed scarce MSSA in sputum culture from sample collected on .,0
# FEN: Continued tube feeds via PEG tube with Replete with fiber at goal 60 ml/hour.,0
# Code status: Full Code.,0
Medications on Admission: Warfarin 2.5 mg PG daily Docusate Sodium 50mg Liquid PGT Albuterol Sulfate 90 mcg 6 Puffs Inhalation Q4H prn Bisacodyl 10 mg PR daily prn Insulin sliding scale Camphor-Menthol 0.5-0.5 % Lotion TID prn Acetaminophen 325 mg PG Q4H prn Senna 8.6 mg PO BID prn Lansoprazole 30 mg PG DAILY Clonidine 0.1 mg PG TID Midodrine 10 mg PG TID Quetiapine 50 mg PG QHS Levothyroxine 200mcg PG daily Chlorhexidine mouthwash Discharge Medications: 1.,0
Levothyroxine 200 mcg Tablet : One (1) Tablet PO once a day.,0
Ipratropium Bromide 17 mcg/Actuation Aerosol : Two (2) Puff Inhalation QID (4 times a day).,0
Chlorhexidine Gluconate 0.12 % Mouthwash : One (1) ea Mucous membrane (2 times a day).,0
Midodrine 10 mg Tablet : One (1) Tablet PO at bedtime.,0
Quetiapine 50 mg Tablet : One (1) Tablet PO at bedtime.,0
Guaifenesin 100 mg/5 mL Syrup : Fifteen (15) ML PO Q6H (every 6 hours).,0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler : Six (6) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing.,0
Docusate Sodium 50 mg/5 mL Liquid : One (1) PO BID (2 times a day).,0
Senna 8.6 mg Tablet : One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
Coreg 6.25 mg Tablet : One (1) Tablet PO twice a day.,0
Coumadin 2 mg Tablet : One (1) Tablet PO once a day: Goal INR .,0
Lasix 40 mg Tablet : One (1) Tablet PO once a day.,0
"Discharge Disposition: Extended Care Facility: Medical Center - Discharge Diagnosis: Hypotension Anemia C7 fracture Atrial fibrillation Respiratory failure Discharge Condition: BP 117/50, HR 90-100 (afib), SpO2 94% on Pressure Support 10/5/50% INR 1.8 Discharge Instructions: You were admitted to the hospital with hypotension.",1
"You were evaluated for infection, but none was identified.",0
"You were noted to have episodes of hypotension while sleeping, during which you were asymptomatic.",0
Your Clonidine was discontinued with improvement.,0
You were started on Coreg for heart rate control.,0
"You should return to the hospital for fevers, persistent hypotension with altered mental status, or other concerning symptoms.",1
Followup Instructions: You have been advised to wear your c-collar for a total of 8 weeks (start date was ).,0
You are scheduled to follow-up with Dr. in the Department of Orthopaedics on at 11 AM.,0
His office is located on of the Building on .,0
Please call if you need to reschedule.,0
You should follow-up with your primary care physician .,0
following your discharge from rehabilitation.,0
12:10 PM CHEST (PA & LAT) Clip # Reason: hemothorax?,1
pneumothorax Admitting Diagnosis: HEMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman s/p R vats and evacuation of hemothorax with possible intraop tear of carina.,1
CT on right to water seal.,0
REASON FOR THIS EXAMINATION: hemothorax?,1
pneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: 83-year-old post-VATS and evacuation of hemothorax.,1
Comparison Previously seen small right basilar pneumothorax is no longer evident.,0
There are persistent bilateral pleural effusions with bibasilar atelectatic changes.,0
There has been a decrease in the prominence of the pulmonary vasculature.,0
Cardiac and mediastinal contours are unchanged with stable cardiomegaly.,0
The left hemidiaphragm remains elevated.,0
The osseous structures demonstrate a marked kyphosis with degenerative changes seen throughout the thoracic spine.,0
A right apical chest tube is unchanged in position.,0
IMPRESSION: Resolution of small right basilar pneuomothorax.,0
Unchanged appearance of bibasilar pleural effusions with associated atelectasis.,0
"5:03 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: evaluate lung fields, et-tube placement, and UAC placement Admitting Diagnosis: PREMATURITY;POOR RESPIRATORY EFFORT ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 41 3/7wks intubated on vent REASON FOR THIS EXAMINATION: evaluate lung fields, et-tube placement, and UAC placement ______________________________________________________________________________ FINAL REPORT Film of the chest and abdomen, on week plus infant who has respiratory distress.",1
The infant has been intubated.,0
The tip of the endotracheal tube is at T3 level.,0
Umbilical artery catheter is at T5 level.,0
Both lungs are large in volume.,0
"On the right side, there is opacity affecting right upper lobe and, to a lesser extent right lower lobe.",0
The appearance is that of retained fetal fluid on the right.,0
This implies some obstruction to egress of lung fluid via the tracheobronchial tree.,0
Any information from prenatal scans would be helpful in this regard.,0
"10:52 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrates, consolidation ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with ALS, admitted here for w/u of lower Gi bleed REASON FOR THIS EXAMINATION: r/o infiltrates, consolidation ______________________________________________________________________________ FINAL REPORT INDICATION: ALS, lower GI bleed.",0
Reference Exam: FINDINGS: Tracheostomy tube is unchanged.,0
There is hazy increased opacity over the left lung consistent with an effusion.,0
There is retrocardiac increased opacity consistent with volume loss/infiltrate.,0
The appearance to the right lower lobe has slightly improved but there continues to be some volume loss in that region.,0
6:08 AM CHEST (PORTABLE AP) Clip # Reason: r/o chf/infiltrate Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: year old woman with CHF presents with intertrochanteric fx s/p left hip hemiarthroplasty.,0
"REASON FOR THIS EXAMINATION: r/o chf/infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: CHF, status post left hip hemiarthroplasty.",0
COMPARISON: Chest x-ray from .,0
SINGLE PORTABLE AP SUPINE CHEST RADIOGRAPH: The endotracheal tube is 5.1 cm above the carina.,0
There is a stable appearance to the cardiac and mediastinal contours.,0
There is prominence of the pulmonary vasculature without any evidence of overt congestive heart failure.,1
There are small bilateral pleural effusions.,0
There is no evidence of consolidation.,0
IMPRESSION: Pulmonary vasculature prominence without any evidence of overt congestive heart failure.,1
"Admission Date: Discharge Date: Service: MED Allergies: Sulfa (Sulfonamides) / Codeine / Lasix Attending: Chief Complaint: Bradycardia/ hyppotension Left foot pain Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo F with DMII, CHF with EF 55-60, CAD, PVD s/p bilat fem-pops, RAS, chronic Afib who was discharged yesterday from medicine service after CHF exacerbation.",0
Patient prsents to ED with hypoxia (88% on RA).,0
Her chest x-ray showed improved CHF but persistent blt opacities and cardiomegaly.,0
She was 20 mg IV lasix with minimal uop but then noted to be hypotensive (80s) with bradycardia to lower 40s.,0
She was dced on dilt 120 once a day and Toprol XL 100 once a day.,0
She was given 1 mg Atropine with HR in 50s and then given calcium gluconate 2 g with glucagon 1 mg IV x 2.,0
"EKG with AFIB and low voltage (old), vent rate in 150s.",0
Patient denies any chest pain / SOB currently.,0
Complaining of left leg pain.,0
"Per son, patient is a bit more confused than usual.",0
"Past Medical History: PMX: chronic afib, CAD s/p NSTEMI ', CHF with EF 55-60, DMII, legally blind, hx of mesenteric ischemia, uterine CA hx, DM c/b neuropathy, PVD s/p bifem- bypass.",0
FINDINGS: Portable AP upright chest radiograph demonstrates a left pleural effusion which has increased in size.,0
There is a persistent left retrocardiac opacity.,0
There is a new focal opacity in the right middle lobe which obscures the right heart border.,0
"While this was not present on the most recent prior examination, enhancement seen on other prior studies and is most likely an area of recurrent atelectasis, however, a developing pneumonia cannot be excluded at this site.",0
The cardiac and mediastinal contours are unchanged.,0
New right middle lobe opacity either representing atelectasis versus developing pneumonia.,0
Left pleural effusion which appears to have increased in size and associated persistent left retrocardiac density.,0
"RADIOLOGY Final Report UNILAT UP EXT VEINS US RIGHT 10:59 AM UNILAT UP EXT VEINS US RIGHT Reason: PT WITH RUE SWELLING, R/O DVT MEDICAL CONDITION: 83 year old woman with R arm swelling, in DIC REASON FOR THIS EXAMINATION: ?DVT Please do at bedside, pt critically ill RIGHT UPPER EXTREMITY VENOUS ULTRASOUND.",0
"FINDINGS: scale and color doppler examination of the right jugular, subclavian, axillary, brachial, basilic, and cephalic veins demonstrates normal compressibility, color flow, respiratory variation, and augmentation.",0
There is no sign of intraluminal thrombus.,0
IMPRESSION: No evidence of venous thrombosis.,0
"CT ABDOMEN W/O CONTRAST 11:37 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: ABD PAIN Field of view: 36 MEDICAL CONDITION: 83 year old F with ischemic left foot, severe PVD, CHF, DIC who initially complained of abdominal pain with elevated lactate, now stable for CT. REASON FOR THIS EXAMINATION: ?PLEASE R/O MESENTERIC ISCHEMIANO IV CONTRAST PLEASE - ARF CONTRAINDICATIONS for IV CONTRAST: acute renal failure INDICATION: 83 year old with severe peripheral vascular disease, CHF, who initially complained of abdominal pain with elevated lactate.",1
Please do not administer IV contrast.,0
TECHNIQUE: Contiguous axial images were obtained through the abdomen and pelvis following the administration of oral contrast only.,0
IV contrast was not administered secondary to the ordering physician's request.,0
Multiplanar reformatted images were also obtained.,0
COMPARISON: CT abdomen/pelvis of .,0
"CT OF ABDOMEN W/O IV CONTRAST: The imaged portions of the lung bases demonstrate an interval increase in the size of bilateral pleural effusions, now large on the right and moderate on the left.",0
"There is also increased opacification of the right middle lobe, with intervening air bronchograms.",0
There is stable cardiomegaly with prominence of the right atrium.,0
"The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys are not significantly changed in appearance, allowing for the noncontrast aspect of this exam.",0
There is a new small amount of perihepatic ascites and increased subcutaneous edema within the soft tissues of the posterior abdomen.,0
There is diffuse wall calcification of the intra-abdominal aorta.,0
Bilateral renal artery stents are in place.,0
The opacified loops of large/small bowel are unremarkable in appearance.,0
"There is no evidence of bowel obstruction, wall thickening, or air within the bowel walls.",0
Noted are scattered colonic diverticulae.,0
CT OF PELVIS W/O IV CONTRAST: There is increased fatty stranding/fluid density within the presacral space.,0
"The rectum, distal loops of bowel and adnexal regions are unremarkable.",0
A Foley catheter is seen within a nondistended urinary bladder.,0
Bone windows again show diffuse degenerative changes of the visualized spine.,0
There are no suspicious lytic or sclerotic lesions.,0
Multiplanar reformatted images were helpful in confirming the above findings.,0
These images also show no secondary signs of acute mesenteric ischemia.,0
IMPRESSION: 1) Limited noncontrast exam of the abdomen.,0
"Allowing for this limitation, there are no secondary signs of acute/chronic mesenteric ischemia.",0
No evidence of bowel obstruction.,0
2) Interval increase in the size of bilateral pleural effusions.,0
3) Right middle lobe pneumonia.,0
4) New small amount of perihepatic ascites and evidence of third spacing of fluids within the dependent subcutaneous soft tissues and presacral space.,0
"CT HEAD W/O CONTRAST 11:39 AM CT HEAD W/O CONTRAST Reason: ?CVA ?cause of altered mental status MEDICAL CONDITION: 83 year old woman with ischemic left foot, CHF, DIC who has been having mental status changes, now stable for CT. REASON FOR THIS EXAMINATION: ?CVA ?cause of altered mental status CONTRAINDICATIONS for IV CONTRAST: None.",0
"INDICATION: Ischemic left foot, CHF, DIC, who has now been having mental status changes, evaluate for CVA or intracranial bleed.",0
TECHNIQUE: Axial images of the brain were obtained without IV contrast.,0
"NONCONTRAST HEAD CT: There are multiple chronic lacunar infarcts, most prominent in the lentiform nuclei and internal capsules bilaterally.",0
"Additionally, there is evidence of periventricular hypodensity in the white matter of the cerebrum, consistent with chronic small vessel ischemia.",0
There is no obvious blurring of the -white interface or sulcal effacement to suggest acute infarction.,1
"Additionally, there is no mass effect or shift of normally midline structures.",0
The ventricles are not abnormally enlarged.,0
There is mild sulcal prominence consistent with age related atrophic changes.,0
No evidence to suggest acute infarction.,1
Multiple chronic lacunar infarcts and changes consistent with chronic small vessel ischemia as described above.,0
PORT 11:40 PM RENAL U.S.,0
"PORT Reason: ?hydro, renal infarct, cz of decreased uop MEDICAL CONDITION: 83 year old woman with history of renal artery stenosis s/p stent now with acute renal failure REASON FOR THIS EXAMINATION: ?hydro, renal infarct, cz of decreased uop INDICATION: Renal artery stenosis status post stenting.",1
The right kidney measures 9.3 cm.,0
The left kidney measures 9.1 cm.,0
"No nephrolithiasis, hydronephrosis or renal mass is detected.",0
A small amount of pericholecystic fluid is noted.,0
"Brief Hospital Course: - EF 55-60% mild symm LVH, RV mildly dilated, 1+ AR, 1+MR Altered mental status had an initial unclear etiology.",0
Patient had an elevated lactate with a gas consistent with metabolic acidosis.,0
Patient also has abdominal pain and there was some concern for bowel ischemia.,0
Patient had a negative head CT.,0
Patient also was initially anuric and bladder scan indicated no urine in the bladder.,0
Renal us was negative for masses and hydronephrosis.,0
5 mL of urine was obtained and spinning the urine revealed questionable muddy brown casts.,0
Patient produced 30 cc of urine after a small fluid bolus and urine lytes indicates ATN most likly secondary to hypotension.,1
"(Cr: 1.9) Patient had elevated lactate (9.6), increased INR (3.4), low-normal fibrinogen, elevated white count (14), FDP- 80-160, D Dimer- 6569 and patient was thought to be in DIC.",0
Question of whether this was urosepsis vs sequelae of ischemic foot.,0
Urine cultures grew E.Coli and patient was placed on ceftriaxone.,0
Vascular was consulted regarding patient left lowere extrimity.,0
"Initially she was not a surgical candidate secondary to DIC, but once this resolved, vascular surgery felt patient was not a candidate for thrombectomy, and would need BKA.",0
"Long discussion with patient and family, and it was decided that patient did not want BKA and would be convered to CMO.",0
Patient understood that not having BKA would result ultimately in death.,0
"In addition, while in hospital, patients BP and HR were very elevated most likely secondary to foot pain.",0
Patients CK continued to rise - at dc was 1544.,0
She was dced home on hospice with palliative medication.,0
Medications on Admission: patient said she is not sure what she was taking Discharge Medications: 1.,0
Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours).,0
Disp:*10 Patch 72HR(s)* Refills:*2* 3.,0
Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q4-6H (every 4 to 6 hours): concentration: 20mg/ml.,0
Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q2-4H (every 2 to 4 hours) as needed.,0
Haloperidol Lactate 2 mg/mL Concentrate Sig: 0.5-5 mg PO BID (2 times a day): concentration 2mg/ml.,0
"Disp:*qs mg* Refills:*2* Discharge Disposition: Home With Service Facility: Discharge Diagnosis: CMO DIC left lower extremity necrosis A fib Discharge Condition: stable Discharge Instructions: Please follow hospice nurse instructions Followup Instructions: CMO follow up hospice nurse recs MD, Completed by:",0
3:47 AM WRIST(3 + VIEWS) LEFT Clip # Reason: eval for fx ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man hit by car with left elbow lac REASON FOR THIS EXAMINATION: eval for fx ______________________________________________________________________________ FINAL REPORT INDICATION: 53-year-old male pedestrian hit by car with left elbow laceration.,1
No prior examinations for comparison.,0
"LEFT WRIST, AP, OBLIQUE, AND LATERAL: The bones are diffusely demineralized.",0
There are no acute fractures or dislocations.,0
Mild degenerative changes are noted at the first carpometacarpal joint and triscaphe joint.,0
Probable old fracture deformity of the lunate.,0
The pronator fat pad is preserved.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: RIGHT BASILIC 47cm PICC Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with new picc REASON FOR THIS EXAMINATION: RIGHT BASILIC 47cm PICC ______________________________________________________________________________ WET READ: DLrc MON 9:32 PM New right approach PICC with tip at the cavoatrial junction.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: PICC line placement.,0
FINDINGS: Newly inserted PICC line over the right upper extremity.,0
Tip of the line projects over the cavoatrial junction.,0
"The course of the line is unremarkable, there is no evidence of pneumothorax or other complication.",0
"Otherwise, the radiograph is unchanged.",0
PATIENT/TEST INFORMATION: Indication: Hypertrophic cardiomyopathy.,0
Cath lab evaluation of gradient and coronary anatomy prior to ethanol ablation.,0
Height: (in) 74 Weight (lb): 230 BSA (m2): 2.31 m2 BP (mm Hg): 124/60 HR (bpm): 103 Status: Inpatient Date/Time: at 10:00 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: Optison Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.,0
MITRAL VALVE: Valvular systolic anterior motion of mitral valve leaflets.,0
Conclusions: Baseline studies obtained on Dobutamine 5mcg/kg/min.,0
There is symmetric left ventricular hypertrophy with normal cavity size and hyperdynamic systolic function (EF>75%).,0
There is valvular with a severe (peak 90mmHg) resting left ventricular outflow tract obstruction.,0
"After injection of diluted (3:7) Optison and injection in the second septal, there is prompt opacification/hyperenhancement of the RV side of the mid-portion of the interventricular septum.",0
The catheter was then withdrawn and advanced in to the proximal brance of the second septal.,0
"Following injection of diluted Optison, there was opacification of the distal portion of the basal third of the septum.",0
No RV free wall enhancement is seen.,0
8:24 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
atelectasis Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with diminished breath sounds bilaterally and desaturation w/ low tidal volumes REASON FOR THIS EXAMINATION: ?,1
"atelectasis ______________________________________________________________________________ FINAL REPORT HISTORY: Diminished breath sounds bilaterally and desaturation, low tidal volumes, question atelectasis.",0
"CHEST, SINGLE AP PORTABLE VIEW.",0
Assessment of fine detail is considerably limited by patient body habitus and underpenetration.,0
"Allowing for this, compared with at 23:11 p.m., no significant change is detected.",0
Again seen is a very large cardiomediastinal silhouette and opacity over the mid and lower zones of the right base with obscuration of the right hemidiaphragm.,0
"Left hemidiaphragm remains visible, though there is some increased retrocardiac density, also grossly unchanged.",0
"Probable slight upper zone redistribution, without overt CHF.",0
"Tubing extends through the mediastinum, presumably related to an NG- or Dobbhoff-type tube, but due to body habitus and technical factors, the tubing can only be visualized to the level of the mid cardiac silhouette.",0
"Right IJ central or PICC line tip not well seen, but likely overlies the IMPRESSION: Right base collapse and/or consolidation, probably with a moderate-sized effusion.",0
"Increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation.",0
No significant change is detected compared with .,0
"However, the opacity at the right base is entirely new compared with and the opacity at the left base may be slightly worse.",0
9:07 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna or chf ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p cabg and avr who presents with acute sob REASON FOR THIS EXAMINATION: r/o pna or chf ______________________________________________________________________________ FINAL REPORT INDICATION: 61 year old male status post CABG and AVR with shortness of breath.,0
AP single view of the chest is compared to .,0
FINDINGS: Patient is status post median sternotomy and AVR.,0
"In the interval, there is apparent increase in the cardiac silhouette which is markedly enlarged.",0
This could represent pericardial effusion.,0
There is also a new left retrocardiac opacity that could represent atelectasis or pneumonia.,0
There is no evidence of CHF.,0
IMPRESSION: 1) Interval apparent increase in the cardiac silhouette could represent pericardial effusion.,0
"2) Left lower lobe opacity most likely represents atelectasis, but in the right clinical setting could represent consolidation.",0
", H. MED FA2 2:43 PM MESSENERTIC Clip # Reason: Please perform mesenteric arteriogram and possible embolizat Admitting Diagnosis: LOWER GI BLEED Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with h/o diverticulosis presenting with BRPBR found to have diverticular bleed in colonoscopy today in need of embolization.",1
REASON FOR THIS EXAMINATION: Please perform mesenteric arteriogram and possible embolization for active ascending colon bleed.,0
"______________________________________________________________________________ PFI REPORT Mesenteric arteriography including selective arteriograms of SMA, , ileocolic, right colic, middle colic arteries were performed and no active contrast extravasation was noted concerning for bleeding.",0
Therefore no intervention was performed.,0
11:40 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"tube placememnt, aspiration ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with intubated, ICH REASON FOR THIS EXAMINATION: ?",0
"tube placememnt, aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old male with intracranial hemorrhage status post intubation.",1
Evaluate tube placement and for aspiration.,0
SUPINE AP VIEW OF THE CHEST: The endotracheal tube terminates 5.5 cm above the carina.,0
"The nasogastric tube follows a normal course within the stomach, with tip projecting off the inferior borders of the film.",0
Linear opacity in the left lung base is compatible with subsegmental atelectasis.,0
There is no appreciable pleural effusion or pneumothorax.,0
"Mediastinal silhouette, hilar contours and pulmonary vasculature are within normal limits.",0
Large endplate osteophytes are noted in the thoracolumbar spine.,0
"10:22 PM CHEST (PA & LAT) Clip # Reason: source of fever Admitting Diagnosis: MESENTERIC ISCHEMIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with fever REASON FOR THIS EXAMINATION: source of fever ______________________________________________________________________________ FINAL REPORT INDICATION: Fever, evaluate source.",0
TECHNIQUE: PA and lateral chest.,0
FINDINGS: Heart size and mediastinal contours are normal.,0
A right-sided PICC terminates overlying the upper SVC.,0
"Since the previous examination, the endotracheal tube, nasogastric tube and left subclavian venous access catheter have been removed.",0
There is interval marked improvement in diffuse bilateral pulmonary opacities and probable improvement in bilateral pleural effusions allowing for differences in patient positioning.,0
Bilateral pulmonary hyperinflation is consistent with patient's underlying emphysema.,0
Surgical clips are seen in the upper abdomen.,0
Right-sided PICC in satisfactory position.,0
Marked improvement in bilateral pulmonary consolidation likely representing improved pneumonia superimposed upon emphysema.,1
"10:41 AM CHEST (PORTABLE AP) Clip # Reason: place of NGT, please make sure to get below diaphragm in vie Admitting Diagnosis: SEIZURES ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with AMS,unable to protect airway ,place NGT for meds REASON FOR THIS EXAMINATION: place of NGT, please make sure to get below diaphragm in view ______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old female.",0
FRONTAL CHEST RADIOGRAPH: The nasogastric tube is appropriately positioned 2.7 cm above the carina.,0
The right internal jugular central venous line tip overlies the SVC.,0
The nasogastric tube has been appropriately advanced.,0
There are small bilateral pleural effusions and increased retrocardiac opacity likely representing atelectasis.,0
4:02 PM FOREARM (AP & LAT) LEFT Clip # Reason: eval for fx Admitting Diagnosis: STATUS EPILEPTICUS ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with left arm pain s/p fall REASON FOR THIS EXAMINATION: eval for fx ______________________________________________________________________________ FINAL REPORT HISTORY: Pain after fall.,0
FINDINGS: Two views of the forearm show no evidence of acute fracture or dislocation.,0
The elbow and wrist are not adequately assessed to exclude fracture in this region.,0
"11:29 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: eval for cause of sepsis, worsening hypoxia on ventilator Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with FUO, hypotension, altered MS REASON FOR THIS EXAMINATION: eval for cause of sepsis, worsening hypoxia on ventilator CONTRAINDICATIONS for IV CONTRAST: renal failure;renal failure ______________________________________________________________________________ FINAL REPORT HISTORY: 60-year-old male with fever of unknown origin, hypotension, altered mental status and worsening hypoxia on ventilator.",1
"COMPARISON: CT torso from , CT abdomen/pelvis of and .",0
"TECHNIQUE: MDCT axial imaging was performed through the chest, abdomen and pelvis with oral contrast only.",0
"CT CHEST WITHOUT IV CONTRAST: ET tube, dual-lumen right IJ central venous catheter, and right subclavian central venous catheter are in place.",0
The patient is status post CABG and aortic valve replacement.,0
Native coronary arteries are heavily calcified and mitral annulus calcifications are again noted.,0
"Compared to the prior CT studies, there are new bilateral small pleural effusions, slightly greater on the right.",0
"There is new lung consolidation with air bronchograms involving the posterior right upper lobe, as well as collapse of the right middle and lower lobes.",0
Atelectasis/consolidation is also noted along the dependent portions of the left lower lobe.,0
No lymph node enlargement is seen meeting size criteria for adenopathy.,0
CT ABDOMEN: There is new ascites surrounding the liver and the spleen.,0
"The non-enhanced liver, spleen, pancreas, and adrenal glands appear unremarkable.",0
A post- pyloric feeding tube is in place.,0
"The non-enhanced stomach, small bowel, and colon appear unremarkable.",0
Mild stranding surrounding the atrophic native kidneys is unchanged.,0
"Vascular calcifications are again noted in the aorta, splenic artery, and iliac arteries.",0
There is no free air within the abdomen.,0
CT PELVIS: A Foley catheter and a rectal tube are in place.,0
The left pelvic renal transplant appears unchanged from most recent prior studies; air is no longer seen within the collecting system.,0
Small amount of free fluid is noted within the pelvis.,0
"Otherwise, the rectosigmoid colon and pelvic loops of bowel appear unremarkable.",0
A fat- and fluid-containing left inguinal hernia is noted.,0
"New stranding in the subcutaneous fat, particularly along the lower abdomen (Over) 11:29 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: eval for cause of sepsis, worsening hypoxia on ventilator Admitting Diagnosis: FEVER ______________________________________________________________________________ FINAL REPORT (Cont) and pelvis, is consistent with anasarca.",0
No region of bony destruction is seen concerning for metastasis or osteomyelitis.,0
New right upper lobe consolidation and right middle and lower lobe collapse.,0
Atelectasis/consolidation in depedent portions of left lower lobe.,0
"5:29 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: assess for cord compression Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with ESRD on HD, and NSCLC s/p vertebroplasty on with proximal left arm weakness REASON FOR THIS EXAMINATION: assess for cord compression No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MR CERVICAL SPINE, .",0
HISTORY: Proximal left arm weakness in a patient on hemodialysis with non-small cell lung cancer.,0
"Sagittal imaging was performed with long TR, long TE fast spin-echo, short TR, short TE spin-echo, and STIR technique.",0
"Axial imaging was performed with long TR, long TE fast spin-echo and with gradient-echo technique.",0
Comparison to cervical spine plain radiographs of and as well as a cervical spine CT of and the cervical spine MR of .,0
FINDINGS: Again identified is hardware related to the cervical fusion previously described.,0
This hardware creates artifacts that are most severe at the C2 level compromising evaluation of the contents of the spinal canal.,0
There appears to be a large mass destroying the C2 vertebral body with extensive spread of the mass beyond the confines of the body and apparent vertebral distribution.,0
"There is relatively little encroachment on the spinal canal, however.",0
"Compared to the prior MR, there is angulation and kyphosis with its apex at the C2 level.",0
There is more encroachment on the spinal canal on the current study than was present on the MR.,0
There is also extensive prevertebral soft tissue swelling.,0
This is new since the prior MR examination and appears approximately comparable to the prevertebral swelling seen on the plain radiographs.,0
"It is unclear to what extent this prevertebral swelling may be postoperative, since the surgery appears to have been posterior only.",0
There is an extensive soft tissue mass that surrounds the C2 vertebral body.,0
The nerve roots will be required to pass through this as they exit the spinal column.,0
It is possible this might be responsible for some of the patient's pain.,0
"Without contrast-enhanced studies, evaluation is limited for defining the full extent of tumor involvement of the vertebral bodies.",0
"However, there appear to be several levels that are compromised by tumor extension.",0
"In particular, there appears to be tumor at the C4-C5 level in the distal portion of the neural foramen.",0
"This is incompletely characterized, but apparently represents a second metastatic deposit.",0
CONCLUSION: Limited study due to the lack of intravenous contrast and due to artifacts arising from the fusion hardware.,0
There is angulation and kyphosis with its apex at C2.,0
"This, in addition to tumor breaking through the posterior margin of the vertebral body produces narrowing of the spinal canal, but not spinal cord compression.",0
There is extensive paravertebral tumor (Over) 5:29 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: assess for cord compression Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ FINAL REPORT (Cont) spread at the C2 level.,0
There appears to be a second tumor deposit in the C3-C4 neural foramen.,0
"4:16 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change Admitting Diagnosis: HEPATIC ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with multifocal pneumnonia REASON FOR THIS EXAMINATION: evaluate for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:43 A.M. HISTORY: Multifocal pneumonia.",1
IMPRESSION: AP chest compared to .,0
"Multifocal pulmonary consolidation has changed in distribution, but not in severity in the left lung, slightly worse in the right lower lung.",1
Azygous distention suggests increased intravascular pressure or volume.,0
Feeding tube ends in the upper stomach.,0
10:16 AM HIP UNILAT MIN 2 VIEWS LEFT; PELVIS (AP ONLY) Clip # Reason: evaluate for fracture ______________________________________________________________________________ MEDICAL CONDITION: History: 59M with fall onto L hip REASON FOR THIS EXAMINATION: evaluate for fracture ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old male with fall onto left hip.,1
FINDINGS: Single frontal view of the pelvis and three views of the left hip were obtained.,0
a complete fracture of the left femoral neck is present with mild varus angulation.,0
Vague lucencies of the left femoral shaft is suggestive of osteopenia.,0
Left femoral neck fracture with mild varus angulation.,0
Left femoral shaft lucencies suggestive of osteopenia in the setting of decreased weght bearing from prior stroke.,0
"8:30 PM BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # Reason: r/o pneumotosis, abnormal bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with rds, guiac + stools, aspirates.",1
Would like exam @ 2100.,0
"REASON FOR THIS EXAMINATION: r/o pneumotosis, abnormal bowel gas pattern ______________________________________________________________________________ FINAL REPORT HISTORY: Premature infant with hyaline membrane disease with guaiac+ stools.",0
When compared to the exam on there is now a more featureless appearance to the bowel gas pattern.,0
There is no definite evidence of pneumatosis.,0
There is no portal venous gas or free air.,0
Feeding tube is in the stomach.,0
"10:57 AM CHEST (PORTABLE AP) Clip # Reason: Please compare to prior film for progression of PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with pneumonia REASON FOR THIS EXAMINATION: Please compare to prior film for progression of PNA ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW ON HISTORY: Followup pneumonia.",0
FINDINGS: There is dense opacification and volume loss in the right lower lobe with complete obscuration of the right hemidiaphragm.,0
There is some plate-like atelectasis in the left lower lobe.,0
The right IJ line tip is in the SVC/RA.,0
IMPRESSION: New complete volume loss and opacification in the right lower lobe consistent with both consolidation and atelectasis.,0
"5:27 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: SPINAL CORD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with fever, secretions, pna REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Fever.",1
Cardiomegaly is accentuated by the projection.,0
Tracheostomy tube is in standard position.,0
Left subclavian catheter tip is in the mid SVC.,0
Moderate left pleural effusion and probably small right pleural effusion have increased in amount with increasing bibasilar opacities left greater than right consistent with atelectasis.,0
4:27 PM CHEST (PORTABLE AP) Clip # Reason: Please verify correct placement of RIJ central line.,0
"Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 58 year old obese man s/p cardiac cath, with long history of CHF, p/w cardiac stent thrombosis.",1
REASON FOR THIS EXAMINATION: Please verify correct placement of RIJ central line.,0
______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Line placement.,0
"A right IJ vascular catheter has been placed, and is in satisfactory position within the SVC.",0
"No pneumothorax is identified, but the right is only incompletel imaged on this study, and a basilar pneumothorax may not be detectable for this reason.",0
Repeat imaging of the right lung to include its entirety could be obtained at no additional charge to the patient.,0
"A tracheostomy tube and permanent pacemaker remain in place, as well as a feeding tube.",0
"The heart remains enlarged, and there is a persistent CHF pattern.",0
"IMPRESSION: Central venous catheter in satisfactory position, with no pneumothorax.",0
"However, incomplete imaging of the right lung precludes assessment for basilar pneumothorax.",0
"12:19 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: RETROCARDIAC OPACITY ON CXR,LEUKOCYTOSIS Admitting Diagnosis: PERITONITIS Field of view: 40 ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with treated PNA and peritonitis during admission, now with new leukocytosis and ?retrocardiac opacity on CXR REASON FOR THIS EXAMINATION: r/o acute process No contraindications for IV contrast ______________________________________________________________________________ WET READ: AGLc 2:36 AM tiny bilat pleural effusions.",0
peritoneal dialysis catheter in RUQ.,0
transplant kidney with calcifications in RLQ.,1
"large wide- based RLQ ventral wall hernia containing multiple loops of bowel, w/o obstruction.",0
3.7 x 6.0 x 7.4 cm likely fluid containing structure rim calcifications posterior lateral to right hip prosthesis ?chronic seroma or other chronic fluid collection.,0
fluid in soft tissues of right hip.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Leukocytosis, question of retrocardiac opacity on chest x-ray.",0
"COMPARISON: Chest radiographs available from , through , CTA chest from , and hip radiograph available from .",0
"TECHNIQUE: MDCT-acquired axial images of the chest, abdomen, and pelvis were obtained without the use of IV contrast.",0
Coronal and sagittal reformations were performed.,0
CT OF THE CHEST WITHOUT IV CONTRAST: The heart is enlarged.,0
There is a moderate amount of coronary and aortic calcifications.,0
"The main pulmonary artery is enlarged, measuring 32 mm in diameter.",0
Scattered mediastinal lymph nodes do not meet CT criteria for lymphadenopathy.,0
"A focal area of consolidation is present within the right lower lobe (2:31), with neighboring atelectasis.",0
These findings are compatible with pneumonia.,0
Left basilar atelectasis and scarring are present at the left base.,0
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Examination of the abdominal solid organs is limited due to the lack of IV contrast.,0
"The liver, spleen, gallbladder, pancreas, and adrenal glands appear normal.",0
"The kidneys are severely atrophic, with multiple large fluid-density lesions.",0
The stomach and intra-abdominal loops of small and large bowel demonstrate no obstruction.,0
There is no free air.,0
A large right lower quadrant ventral hernia is present.,0
"Multiple loops of (Over) 12:19 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: RETROCARDIAC OPACITY ON CXR,LEUKOCYTOSIS Admitting Diagnosis: PERITONITIS Field of view: 40 ______________________________________________________________________________ FINAL REPORT (Cont) small bowel protrude through a fascial defect measuring up to 8 cm across.",0
An old renal transplant lies inferiorly to this.,1
"No distinct tissue is visualized, and there are multiple internal calcifications.",0
"Areas of hypodensity (2:80), are nonspecific.",0
No drainable fluid collection is detected.,0
A peritoneal catheter clip is coiled between this region and the inferior aspect of the liver.,0
"CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon, intrapelvic loops of small and large bowel appear normal.",0
Trace free fluid is present.,0
There is no pelvic or inguinal lymphadenopathy.,0
The patient is status post right total hip arthroplasty.,0
"Lucent areas around the acetabular cup, concerning for possible hardware loosening, also seen on the prior radiograph from .",0
"Lateral to the prosthesis, there is a circumscribed 60 x 37 mm mass recollection with dependent high density particles (2:86).",0
This most likely represents a chronic fluid collection.,0
OSSEUS STRUCTURES: No acute fractures are detected.,0
There is moderate dextroscoliosis and severe kyphosis of the thoracic spine.,0
Multiple thoracic vertebrae demonstrate anterior wedge compression defects and loss of vertebral disc spaces.,0
Trabecular demineralization within the vertebral bodies is compatible with longstanding renal osteodystrophy.,1
"Right lower lobe consolidation, likely a focus of pneumonia.",0
Small bilateral pleural effusions and bibasilar atelectasis.,0
"Large right lower quadrant ventral hernia with protruding loops of small bowel, with no evidence of obstruction.",0
Lucency surrounding the acetabular component of a right total hip arthroplasty concerning for hardware loosening and/or particle disease.,0
Fluid collection lateral to the right hip prosthesis is most likely a chronic fluid collection.,0
"Mixed attenuating soft tissue mass with internal calcifications at the failed renal transplant site, but nonspecific.",1
No drainable fluid collection is seen.,0
Trace free fluid within the pelvis.,0
"WET READ by , G on 2:36 AM.",0
"(Over) 12:19 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: RETROCARDIAC OPACITY ON CXR,LEUKOCYTOSIS Admitting Diagnosis: PERITONITIS Field of view: 40 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"5:07 AM CHEST (PORTABLE AP) Clip # Reason: eval for fluid/infiltrate Admitting Diagnosis: ANEURYSM;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with fever REASON FOR THIS EXAMINATION: eval for fluid/infiltrate ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:41 A.M., HISTORY: Fever.",0
"Pulmonary vasculature is mildly engorged, but there is no edema and no consolidation.",0
Moderate cardiomegaly and enlarged pulmonary arteries remain chronically enlarged.,0
Feeding tube ends in the stomach.,0
", R. CSURG CSRU 4:23 PM CHEST PORT.",0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion Admitting Diagnosis: ATRIAL SEPTAL DEFECT ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with ASD s/p ASD Closure.,1
"REASON FOR THIS EXAMINATION: r/o PTX/Effusion ______________________________________________________________________________ PFI REPORT Volume overload, new since the prior study.",0
Position of tubes and lines as expected.,0
"3:45 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with resp failure REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:28 A.M. HISTORY: Respiratory failure.",1
"IMPRESSION: AP chest compared to chest radiographs through at 5:48 a.m. Moderately-severe diffuse infiltrative pulmonary abnormality is slightly more pronounced today than the past several days, probably representing mild pulmonary edema superimposed on the fibro-organizing stage of ARDS.",1
"Heart is mildly enlarged, exaggerated by extremely-low lung volumes.",0
"Tracheostomy tube unchanged in position, tip no less than 6 cm above the carina.",0
"Right internal jugular line tip projects over the superior cavoatrial junction, feeding tube passes into the stomach and out of view.",0
Dr. and I discussed the findings by telephone.,0
PATIENT/TEST INFORMATION: Indication: CABG Status: Inpatient Date/Time: at 12:42 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.,0
: Mildly dilated ascending .,0
Trivial MR. TRICUSPID VALVE: Physiologic TR.,0
Conclusions: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.,0
with normal free wall contractility.,0
The ascending is mildly dilated (3.5 - 3.7 cm) and free of atherosclerotic plaque.,0
Post-CPB: Preserved biventricular systolic fxn.,0
"No AI, no MR. .",0
"2:57 PM CHEST (PA & LAT) Clip # Reason: eval for PNA ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with hypoxia, cough, rhonci REASON FOR THIS EXAMINATION: eval for PNA ______________________________________________________________________________ FINAL REPORT HISTORY: 21-year-old man with hypoxia, cough, and rhonchi.",0
PA AND LATERAL CHEST RADIOGRAPHS The lungs display diffusely increased bilateral reticular opacities with slightly increased more focal consolidation noted in the region of the lingula obscuring the left heart border and outer upper left lung.,0
Slight widening of the right paratracheal stripe is likely related to mild reactive lymphadenopathy within the mediastinum with prominence of the hila likely within normal limits.,0
"Heart size is within the normal limits and there is no evidence of pneumothorax, pulmonary edema, or pleural effusions.",0
IMPRESSION: Diffusely increased reticular opacities bilaterally with more focal region of consolidation noted within the lingula and peripheral left upper lobe.,0
Findings may relate to a bacterial or atypical pneumonia (ie.,0
"mycoplasma or viral, including CMV or even varicella); etiologies such as Pneumocystis jiroveci should be considered, if patient is immunocompromised.",0
These findings were discussed with Dr. shortly after exam acquisition at 3:20 p.m.,0
"3:13 PM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # Reason: r/o fracture s/p fall Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p stroke/fall REASON FOR THIS EXAMINATION: r/o fracture s/p fall ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.",0
"FINDINGS: Three views of the left shoulder show no evidence of fracture, dislocation, bone destruction, or bone erosion.",0
A bone island is seen within the proximal left humerus.,0
Degenerative change is seen within the AC joint with no evidence of separation.,0
IMPRESSION: No evidence of fracture or dislocation within the left shoulder.,0
"11:39 PM CHEST (PORTABLE AP) Clip # Reason: eval R-SC cordis and r/o PTX ______________________________________________________________________________ MEDICAL CONDITION: year old woman with sepsis, intubated s/p multiple line attempts (L subclaviand and L IJ).",0
Please assess for pneumothorax REASON FOR THIS EXAMINATION: eval R-SC cordis and r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Assess line placement.,0
PORTABLE SUPINE FRONTAL RADIOGRAPH: Comparison-30 minutes prior.,0
There has been interval placement of a right subclavian central venous catheter which terminates in the distal SVC/cavo-atrial junction.,0
There is no pneumothorax seen on this supine radiograph.,0
No other changes compared to 30 minutes prior.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Thoracentesis, Left side History of Present Illness: Mr. is a 75 yo M w/ metastatic papillary thyroid cancer s/p XRT 19 sessions who presented on with 2 days of worsening dysphagia for solids, poor oral intake, weight loss 20 pounds over last several weeks and some lethargy.",0
"On admission, in the ED T 96.7, Hr 133, BP 102/73 and RR 20 sats 93% on RA.",0
"His WBC was 26.5, with 87% Neutrophils.",0
"His chest x ray was read as multifocal pneumonia, predominately affecting the lingula and left lower lobe.",0
He was transfer to the floor.,0
"On the floor, he was started on Levofloxacine/Flagyl.",0
He was also given Zoledonic Acid and IV fluids to treat his hypercalcemia.,0
GI was also consulted but they have not seen him until he recovers from his multifocal pneumonia.,0
He had an esophageal x ray that showed no evidence of esophageal perforation but aspiration of contrast material into the airway.,0
he was also evaluated by Speech and swallow who recommended an esophageal video swallow to assess him better.,0
Overnight his O2 saturation started to drop.,0
"this morning he was on 6 L NC sats into the 88%, increased work of breathing.",0
i/o over 24 H 3 L positive.,0
"He received 40 Iv lasix, and had 600 cc urine out.",0
Chest x ray revealed worsening Left pleural effusion.,0
"ABG 7.49,27, 68 compatible with acute repiratory alcalosys and hypoxemia.",0
"Past Medical History: Papillary thyroid cancer dx fall right neck mass --s/p neck mass resection ; unable to perform thyroidectomy high bleed risk, proximity to trachea and recurrent laryngeal nerve and large tumor size --s/p XRT to neck --s/p RAI ablation --Metastatic to lymph nodes and adrenal glands * s/p hernia repair * s/p tonsillectomy Social History: Remote tobacco use, smoked 1.5 packs/week x 20 years.",1
"Family History: Son with Grave's disease Physical Exam: HR 135, Bp 115/68, HR 79, Sats 95% on 10L Gen: Thin elderly, in moderate distress HEENT: moist oral mucose Neck: surgical scar, skin changes secondary to radiation.",0
small tumors in the anterior part of his neck.,0
"Hrt: Regular rate S1 S2 no m/r/g Chest vesicular cluster erhthematous rash over R anterior hemithorax Lungs: decrease BS and dullness to percussion over left hemithorax Abd: Soft, nontender +bowel sounds Ext: Warm, well perfused Neuro: Alert, interactive Pertinent Results: 10:20AM BLOOD WBC-33.5* RBC-4.64 Hgb-13.5* Hct-40.8 MCV-88 MCH-29.1 MCHC-33.0 RDW-16.3* Plt Ct-264 10:20AM BLOOD Glucose-99 UreaN-23* Creat-0.9 Na-152* K-3.1* Cl-114* HCO3-19* AnGap-22* 10:55AM BLOOD ALT-57* AST-30 AlkPhos-147* TotBili-0.5 10:20AM BLOOD LD(LDH)-296* CK(CPK)-70 10:20AM BLOOD TotProt-5.5* Albumin-2.7* Globuln-2.8 Calcium-11.7* Phos-2.4* Mg-2.1 11:30AM BLOOD Type-ART pO2-68* pCO2-27* pH-7.49* calTCO2-21 Base XS-0 .",0
"RADS chest x ray: IMPRESSION: New multifocal pneumonia, predominately affecting the lingula and left lower lobe.",0
Stable widened mediastinum consistent with known right thyroid mass with tracheal deviation to the left.,1
Abdomen: IMPRESSION: No evidence of obstruction .,0
No evidence of esophageal perforation.,0
Aspiration of contrast material into the airway.,0
": Chest x ray MARKED INTERVAL INCREASE IN LT EFFUSION, NOW MODERATE TO LARGE RESULTING IN INCREASE OPACIFICATION OF LESS AERATED LT HEMITHORAX.",0
INTERVAL INCREASE IN mULTIFOCAL RT OPACITIES.,0
D/W Brief Hospital Course: Mr. is a 75 yo M w/PMHx sx for metastatic papillary thyroid cancer with local invasion and tracheal deviation who presents with worsening o2 requirment and chest x ray showed worsening left pleural effusion #.,1
"Respiratory distress: patient admitted 3 days ago, with leukocytosis, no fevers and x ray that showed multifocal pneumonia.",0
X ray this morning showed worsening pleural effusion that could definitely explain his shortness of breath.,0
"He has not spike fevers but his WBC continues to trend up despite a/b which is concerning for underlying infection either viral, bacterial.",0
Other posibilites will include PE given tachycardia and underlying malignancy.,0
"On the other hand, he was definitely positive in fluid balance given hydration for hypercalcemia.",0
Patient underwent thoracentesis for diagnosis.,0
Palliative care was consulted and eventually it was decided to make the patient CMO.,0
He expired on of respiratory arrest.,0
# Leukocytosis: no documented fever.,0
likely secondary to his pulmonary process.,0
He also has his zoster lesions with no clear evidence of superinfection.,0
There was no evident source of his infection.,0
# Hypernatremia: patient presented with normal sodium on admission.,0
He received about 5 L last 24 hours.,0
"ddx includes DI which might be due to his hypercalcemia, or given high cloride and low bicarb it could also be due to NS hydration.",0
"# hypercalcemia: patient with prior normal calcium, likely hypercalcemia of malignancy.",0
"Patient was initially full code, but his respiratory status continued to worsen.",0
"He eventually was seen by palliative care, and was made CMO.",0
He expired secondary to respiratory arrest likely from complications of his malignancy.,0
Wife HCP Medications on Admission: Levoxyl 88 mcg PO daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Expired Metastatic Papillary Carcinoma Respiratory failure Pleural Effusion Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Captopril Attending: Addendum: Pls see results section Pertinent Results: CT Chest CT OF THE CHEST WITHOUT CONTRAST: There is diffuse ground-glass opacity and patchy areas of consolidation within the right upper lobe as well as consolidation in the right lower lobe.",0
Relative increased ground-glass opacity is also seen in the left upper lobe.,0
"There are bilateral pleural effusions, moderate on the right and small on the left.",0
"Mediastinal lipomatosis is present, accounting for wide appearance of the mediastinum on plain film x-ray.",0
ET tube is in good position.,0
There are multiple mediastinal but non-enlarged lymph nodes.,0
Anasarca within the right thoracic subcutaneous soft tissues is noted.,0
NG tube is seen coiled within the stomach.,0
Imaged upper abdomen is otherwise normal.,0
No suspicious bone lesions are seen.,0
Right internal jugular central venous line has its tip in the distal SVC.,0
Findings consistent with background pulmonary edema.,0
"Partial consolidations in the right upper and lower lobes, and increased ground-glass in the left upper lobe.",0
Findings most likely relate to multifocal pneumonia.,0
"Bilateral pleural effusions, moderate on the right and small on the left.",0
CT Chest FINDINGS: There is interval decrease in bilateral pleural effusions.,0
There is also improvement in the right upper lobe atelectasis.,0
There are persistent partial atelectasis of the lower lobes likely due to associated pleural effusion.,0
There is also interval improvement in the ground-glass opacities likely due to pulmonary edema.,0
Pleural effusions are now small-to-moderate.,0
Mediastinal lipomatosis and multiple small mediastinal lymph nodes are not changed when compared to the prior study and do not meet CT criteria for pathology.,0
The heart and great vessels are unchanged when compared to prior study.,0
Again noted calcifications of the right coronary artery.,0
The ET tube is in good position.,0
Limited images of the upper abdomen reveal a small amount of ascites around the liver and spleen.,0
There is a left subclavian central line with the tip in the distal left brachiocephalic vein.,0
The heart remains slightly enlarged.,0
There is a G-tube within the stomach.,0
Bone windows demonstrate no suspicious lytic or blastic lesions.,0
"Interval improvement in pulmonary edema, pleural effusions, and atelectasis.",0
Calcifications of the right coronary artery.,0
Ct Sinus NON-CONTRAST SINUS CT: The frontal sinuses are clear.,0
Mild mucosal thickening is present in both maxillary sinuses.,0
A small mucosal retention cyst is present within the floor of the left maxillary sinus.,0
Polypoid area of mucosal thickening is present within a left sphenoid air cell.,0
The remainder of the sphenoid air cells and ethmoid air cells are clear.,0
"The reconstructed images are of limited resolution, precluding assessment of the ostiomeatal complexes.",0
The ethmoid roofs and cribriform plates are level.,0
The main sphenoid septum inserts just to the left of midline.,0
There is pneumatization of the left optic strut but no pneumatization of the anterior clinoid processes.,0
Lamina papyracea appears intact bilaterally.,0
The nasal septum is unremarkable.,0
Note is made of scattered opacification in the mastoid air cells.,0
IMPRESSION: Mild mucosal thickening in the maxillary sinuses and sphenoid sinus.,0
Partial opacification in the mastoid air cells bilaterally.,0
Regional left ventricular wall motion is normal .,0
ECHO The left atrium is moderately dilated.,0
The aortic valve leaflets appear structurally normal with good leaflet excursion.,0
"Compared with the prior study (tape reviewed) of , the findiings are similar.",0
PASSY-MUIR VALVE trial : SUMMARY:Pt tolerated the valve in line on the vent for approximately 10 minutes today prior to fatiguing and experiencing respiratory discomfort.,0
"However, the pt was able to verbally communicate and tolerate the valve although for a short period of time.",0
Would suggest continued trials with the valve with respirtory therapy.,0
ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!,0
Monitor O2 Sats / respiration while valve is in place.,0
Do not allow the patient to sleep with the valve in place.,0
PMV wear schedule is up to the discretion of the nurse and/or respiratory therapist.,0
Discharge Disposition: Extended Care Facility: - MD Completed by:,0
"8:05 AM IVC GRAM/FILTER Clip # Reason: Please evaluate for IVC filter placement for DVT Contrast: OPTIRAY Amt: 90 ********************************* CPT Codes ******************************** * INTERUP IVC INTRO CATH SVC/IVC * * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER * * IVC GRAM NON-IONIC 50 CC * * NON-IONIC 30 CC * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with bipolar d/o s/p VPA overdose now with R psoas bleed after anti-coagulation for DVT REASON FOR THIS EXAMINATION: Please evaluate for IVC filter placement for DVT ______________________________________________________________________________ FINAL REPORT INDICATION: IVC filter placement, status post DVT with right psoas bleed.",0
"Consent was obtained from the health care proxy, .",0
The patient was prepped and draped in a standard sterile fashion.,0
and performed the procedure with Dr. supervising and present throughout.,0
A 4 French multiside lobed catheter was introduced through the left common iliac vein and the tip was placed into the IVC.,0
An IVC run of contrast demonstrates a single IVC with little reflux into the right iliac vein and normal reflux into the left iliac vein.,0
The renal veins were identified.,0
The 4 French multiside holdeded catheter was replaced with a 7 French sheath.,0
Through this sheath - IVC filter was placed.,0
90 cc of optiray was used.,0
IMPRESSION: Satisfactory placement of a IVC filter without immediate complication.,0
"5:49 PM CT CHEST W/O CONTRAST Clip # Reason: anatomic location, size of cavitary lesions; effusion, infil Admitting Diagnosis: FUNGAL PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with necrotizing pna, spont ptx, coccidomycosis with cavitary lesions, worsening sob, arf likely prerenal REASON FOR THIS EXAMINATION: anatomic location, size of cavitary lesions; effusion, infiltrate, pericardial effusion No contraindications for IV contrast ______________________________________________________________________________ WET READ: AZm MON 10:21 PM Extensive lung consolidations and a milary pattern of lung invlovement c/w fungal infection.",0
"INDICATION: Necrotizing pneumonia with coccidioidomycosis with cavitary lesions, worsening shortness of breath.",0
Evaluate size of cavitary lesions and effusions.,0
TECHNIQUE: Helically aquired contiguous axial images were obtained from the lung apices through the upper abdomen.,0
CONTRAST: Neither oral nor IV contrast were administered.,0
CT CHEST W/O IV CONTRAST: The soft tissue window images reveal no significant axillary lymphadenopathy.,0
A few scattered mediastinal lymph nodes are visualized which do not meet CT criteria for lymphadenopathy.,0
"There are small bilateral pleural effusions, left greater than right.",0
Coronary artery calcification is noted.,0
The lung window images reveal a mild to moderate right pneumothorax.,0
There is extensive consolidation of the right lung with multiple small lung nodules in a miliary pattern throughout both lungs.,0
The right lung consolidation mainly involves the right middle lobe.,0
Consolidations are also visualized in the right lower lobes bilaterally.,0
A cavitary lesion is visualized in the right middle lobe measuring 3.5 x 1.4 cm.,0
A chest tube is visualized in the right hemithorax.,0
There is extensive subcutaneous emphysema over the right hemithorax.,0
There are no suspicious lytic or blastic lesions in the osseous structures.,0
"In the imaged portion of the upper abdomen, the visualized portion of the liver, gallbladder, spleen appear unremarkable.",0
There is calcification of the right adrenal gland.,0
"IMPRESSION: 1) Large right middle lobe consolidation, small consolidations at the bases bilaterall, many of whoch are cavitating.",0
Miliary pattern of lung involvement consistent with given history of coccidomycosis.,0
"2) Extensive subcutaneous emphysema over the right hemithorax with mild to (Over) 5:49 PM CT CHEST W/O CONTRAST Clip # Reason: anatomic location, size of cavitary lesions; effusion, infil Admitting Diagnosis: FUNGAL PNEUMONIA ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
(Cont) moderate pneumothorax on the right side.,0
A chest tube is in place.,0
"8:36 AM CAROTID SERIES COMPLETE Clip # Reason: PREOP CABG, HX CAD , HX BILAT CEA AND CVA Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with cad for cabg.",0
hx bilat cea and cva REASON FOR THIS EXAMINATION: assess for stenosis ______________________________________________________________________________ FINAL REPORT STUDY: CAROTID SERIES COMPLETE.,1
"REASON: Preop CABG, history of stroke, and status post bilateral carotid endarterectomy.",1
FINDINGS: Duplex evaluation was performed of bilateral carotid arteries.,0
"On the right, there is echogenic material filling the ICA lumen with no flow by pulse wave or color Doppler.",0
This is consistent with ICA occlusion.,0
There is also heterogeneous plaque in the common carotid and external carotid.,0
"These vessels are patent with peak velocities of 65 and 121 cm/sec, respectively.",0
There is no flow seen in the right vertebral artery.,1
"On the left, the common carotid, internal carotid, and external carotid all show echogenic material and no flow by pulse wave or color Doppler, consistent with occlusion of the common carotid, external carotid and internal carotid arteries.",1
The left vertebral artery is patent with peak velocity of 89.,1
"Left ICA, CCA, and ECA occlusion.",0
"10:29 PM PORTABLE ABDOMEN Clip # Reason: evaluate for ileus Admitting Diagnosis: FEVER; NEUTROPENIA ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with febrile neutropenia, hypotension, n/v.",0
"REASON FOR THIS EXAMINATION: evaluate for ileus ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE FILM HISTORY: Hypertension, nausea and vomiting.",0
There are a few gas-filled loops of non-dilated small bowel with gas present throughout the colon.,0
No evidence of intestinal obstruction or ileus.,0
", F. MED SICU-B 3:41 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with cirrhosis, intubation for aspiration REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ PFI REPORT Endotracheal and nasogastric tubes in good position.",0
"PATIENT/TEST INFORMATION: Indication: R/O PDA Status: Inpatient Date/Time: at 15:41 Test: Portable TTE(Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
10:36 AM CHEST (PA & LAT) Clip # Reason: effusion or infiltrate?,0
"Admitting Diagnosis: HYPERKALEMIA, ANEMIA, NAUSEA, ARF ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with renal failure, HD initiation REASON FOR THIS EXAMINATION: effusion or infiltrate?",1
______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST HISTORY: Renal failure.,1
IMPRESSION: PA and lateral chest compared to : Mild hyperinflation of the chest suggests obstructive airways disease.,0
Dual-channel right-sided central venous line ends in the low SVC and upper right atrium.,0
No pneumothorax or mediastinal widening.,0
Height: (in) 58 Weight (lb): 108 BSA (m2): 1.40 m2 BP (mm Hg): 118/50 HR (bpm): 61 Status: Inpatient Date/Time: at 13:33 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
There are focal calcifications in the aortic root.,0
There are focal calcifications in the ascending aorta.,0
There is mild aortic valve stenosis.,0
TRICUSPID VALVE: The tricuspid valve leaflets are normal.,0
The tricuspid valve supporting structures are normal.,0
There is no triscupid stenosis.,0
PERICARDIUM: There is a trivial/physiologic pericardial effusion.,0
Overall left ventricular systolic function is normal (LVEF 60%).,0
"Compared with the findings of the prior study (tape reviewed) of , the left ventricular ejection fraction is increased, mainly due to improvement of contractile function of the interventricular septum.",0
1:34 AM CHEST (PORTABLE AP) Clip # Reason: assess for PNA and/or other abn.,0
"Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;CHEMOTHERAPY ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with AML , on chemo, now nuetropenic with fever, cough.",1
REASON FOR THIS EXAMINATION: assess for PNA and/or other abn.,0
______________________________________________________________________________ FINAL REPORT INDICATIONS: 46 y/o male with AML on chemotherapy.,0
"TECHNIQUE: Single, AP view of the chest is provided.",0
"FINDINGS: Again noted are multiple consolidations in both lung fields, particularly in the mid right lung and left upper lobe.",0
These are unchanged compared to prior film from .,0
The cardiac silhouette and mediastinum are within normal limits.,0
IV lines remain in place and correctly positioned.,0
There is blunting of the left lateral costophrenic recess consistent with a small effusion.,0
Bones and soft tissues are unremarkable.,0
IMPRESSION: Unchanged appearance of the chest compared to film from .,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: Pt had a malpositioned picc that was repositioned and needs Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with PICC REASON FOR THIS EXAMINATION: Pt had a malpositioned picc that was repositioned and needs repeat cxry to confirm tip location please page at .,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 82-year-old man with PICC, the patient had a malpositioned PICC which has been repositioned, evaluate for placement.",0
COMPARISON: at 2:05 p.m. (earlier today).,0
TECHNIQUE: Portable upright chest radiograph.,0
"FINDINGS: Right PICC line has been pulled back, but still remains in the right internal jugular vein.",0
Cardiomediastinal silhouette is unchanged compared to the prior study.,0
"As before, extensive scattered bilateral air space opacities are present with now development of small central lucencies suggesting central cavitation.",0
This likely represents multifocal pneumonia.,0
"Left hilus appears enlarged possibly reflecting lymphadenopathy, however, possiblility of malignancy cannot be excluded.",0
Increased atelectasis within the right base.,0
The right-sided PICC line still terminates in the internal jugular vein.,0
"If pulled back 6 cm, the tip should be at the origin of the right brachiocephalic vein, then it should be advanced to the level of mid SVC.",0
Persistent extensive scattered bilateral opacities consistent with multifocal penumonia.,0
"In the context of right hilar enlargement, CT scan with contrast is recommended for further evaluation and to rule out an underlying malignancy.",0
Note: Above findings were communicated in the Critical Results dashboard on .,0
"11:06 AM L-SPINE (AP & LAT) Clip # Reason: New-onset loss of L5 motor function, please assess for compr Admitting Diagnosis: FOOT ULCERS ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with REASON FOR THIS EXAMINATION: New-onset loss of L5 motor function, please assess for compression fx.",0
______________________________________________________________________________ FINAL REPORT INDICATIONS: Recent onset of loss of L5 motor function.,0
AP and lateral views of the lumbar spine are submitted for interpretation.,0
Comparison is made to a prior AP supine abdomen radiograph.,0
The bones are diffusely demineralized.,0
There is a mild compression deformity at the L4 vertebral body level.,0
Very minimal loss of height is noted at L5 as well.,0
The remaining lumbar vertebral bodies show preservation of normal height.,0
The disk spaces are relatively well preserved with some mild narrowing noted at L3-L4.,0
Degenerative changes are noted posteriorly in the facet joints.,0
Extensive vascular calcifications are seen throughout the abdominal aorta and its branches.,0
"Regarding the decreased height at L4, it was likely present at the time of the recent abdominal radiograph as well, but difficult to compare due to lack of the lateral view at that time.",0
"Within the abdomen, note is made of multiple air filled loops of dilated bowel, which were also present on a recent CT of the abdomen of , which described a small-bowel obstruction.",0
There is also a suggestion of ascites.,0
IMPRESSION: 1) Compression deformity at L4 and very minimal compression at L5.,0
"2) Dilated loops of small bowel, concerning for small-bowel obstruction.",0
Please note that recent abdominal CT of described a small-bowel obstruction.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEONATOLOG HISTORY: Baby girl was born on at full term to a 33-year-old gravida 2, para 1 mother with unremarkable prenatal labs and unremarkable pregnancy.",0
Delivery was spontaneous and vaginal after rupture of membranes for appropriate 12 hours prior to delivery.,0
Maternal group B strep status was negative.,0
Amniotic fluid was meconium stained; infant emerged vigorous and did not require resuscitation in the delivery room.,0
Apgar scores were 7 and 8.,0
Birth weight was 3305 grams.,0
"Infant was initially admitted to the well-baby nursery, where jitteriness was noted at the three hours of age; DC at that time was 36, which did increase to 60 at feeding, but fell again to 41 two hours after feeding.",0
"Infant's temperature was 97 degrees at two hours of age, 97.3 at four hours of age.",0
The infant was then transferred to the Newborn Intensive Care Unit for further evaluation of the hypoglycemia and hypothermia.,1
PHYSICAL EXAMINATION: Examination on admission revealed the following: The infant was well appearing and vigorous.,0
"Weight was 3,305 grams which is approximately the 50th to 75th percentile.",0
"Head circumference is 34.5 cm, which is also the 75th percentile.",0
Vital signs were stable in room air.,0
The infant was nondysmorphic appearing.,0
Fontanelles were soft and flat; palate intact; nares and ears were normal.,0
Red reflex was present bilaterally.,0
Chest was clear without increased work of breathing.,0
Heart was regular rate and rhythm without murmur of gallop.,0
Abdomen was soft without hepatosplenomegaly.,0
Genitalia were that of a normal female.,0
Infant was mildly jittery with appropriate tone and moving all extremities.,0
HOSPITAL COURSE: Infant was admitted to the newborn Intensive Care Unit for evaluation and treatment of the hypoglycemia and hypothermia.,1
RESPIRATORY: The infant remained stable from a respiratory standpoint throughout admission.,0
"Mild desaturations were noted on day #1 of life, which had resolved by day #2.",0
CARDIOVASCULAR: The infant remained hemodynamically stable with normal blood pressure and heart rate throughout the admission.,0
"FLUIDS, ELECTROLYTES, AND NUTRITION: The infant was initially begun on IV fluids of D10 in response to the hypoglycemia, as well as allowed to feed p.o.ad lib.",0
"Over the two days of admission, the IV fluids were able to be gradually weaned to off with stable blood sugars as feeding improved.",0
"By day of life #2, the infant was feeding well on an ad lib basis, breasting feeding and bottle with blood sugars stable, 58 to 66 off IV fluids.",0
Birth weight of 3305 was followed by weight of 3340 grams on day of life #2.,0
Urine and sugar level were normal.,0
"Electrolytes were checked on day #1 and were within normal limits, including a calcium level of 8.7.",0
GASTROINTESTINAL: The infant had normal stools throughout admission.,0
Bilirubin of 24 hours of life was 5.3/0.3.,0
"INFECTIOUS DISEASE: Initial CBC revealed a white count of 19.7, hematocrit of 45, platelet count of 277 with a differential of 66 polys, 0 bands.",0
Ampicillin and Gentamicin were begun given the hypoglycemia and hypothermia pending cultures; these are discontinued after 48 hours with a benign clinical course and negative cultures.,1
SENSORY: The infant passed hearing screen with automated auditory brain stem responses.,0
DISPOSITION: The infant is being transferred to the Well Baby Nursery for further monitoring.,0
If the infant does well it is anticipated that the infant will be able to be discharged to home in 24 hours.,0
"PEDIATRICIAN: Primary pediatrician is Dr. at Missing Pediatrics in , .",0
CARE RECOMMENDATIONS: Breast feed with bottle supplements on an ad lib basis.,0
IMMUNIZATIONS RECEIVED: Hepatitis B vaccination is pending.,1
Dictated By: MEDQUIST36 D: 12:46 T: 12:50 JOB#:,0
5:48 PM CHEST FLUORO WITHOUT RADIOLOGIST Clip # Reason: VAD INSERT Admitting Diagnosis: FEBRILE NEUTROPENIA ______________________________________________________________________________ FINAL REPORT Chest fluoro was performed without radiologist present.,0
11 seconds of fluoro time was used.,0
7:26 AM CHEST (PORTABLE AP) Clip # Reason: r/o pul edema ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with acute MI now with hypoxia REASON FOR THIS EXAMINATION: r/o pul edema ______________________________________________________________________________ FINAL REPORT INDICATION: Acute MI now with hypoxia.,0
Increased opacification is seen at the hilar area consistent with pulmonary vascular congestion.,0
There is a combined interstitial edema and focal pulmonary edema pattern seen throughout both lung fields.,0
Bilateral pleural effusions are seen.,0
A small area of focal density is visualized in the left lower lobe.,0
This could represent pulmonary edema vs. a early pneumonia.,0
All these findings are consistent with congestive heart failure.,1
"Focal consolidation left lower lung, could be either focal area of pulmonary edema or early consolidation from other etiology.",0
"2:49 PM CHEST (PORTABLE AP) Clip # Reason: question of acute change Admitting Diagnosis: ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with Hep C cirrhosis c/b resp distress, now s/p extubation.",1
with acute temp spike REASON FOR THIS EXAMINATION: question of acute change ______________________________________________________________________________ FINAL REPORT INDICATION: Hepatitis C cirrhosis with respiratory distress.,1
SUPINE AP CHEST: The nasogastric tube and left internal jugular central venous catheter are unchanged in position.,0
No pneumothorax is detected on the supine radiograph.,0
There are very low lung volumes on today's exam.,0
The patchy opacities previously described in both lung fields are somewhat increased on today's exam.,0
The findings may represent early asymmetric pulmonary edema versus an infectious process.,0
The possibility of bowel gas visualized within the abdomen indicates ascites.,0
"IMPRESSION: Interval worsening of bilateral patchy opacities, which could be consistent with early asymmetric pulmonary edema versus an infectious process.",0
"2:53 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change after diuresis Admitting Diagnosis: CHF VS PNA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with dyspnea and orthopnea REASON FOR THIS EXAMINATION: please evaluate for interval change after diuresis ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:27 A.M. ON HISTORY: 61-year-old man with dyspnea and orthopnea.",0
Evaluate for interval change after diuresis.,0
IMPRESSION: AP chest compared to : What was previously moderately severe interstitial pulmonary edema has progressed to severe pulmonary edema with a perihilar distribution.,0
Moderate cardiomegaly may be slightly larger and small bilateral pleural effusions are larger as well.,0
"8:55 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with CAD REASON FOR THIS EXAMINATION: pre op for CABG ______________________________________________________________________________ FINAL REPORT INDICATION: 84-year-old man with coronary artery disease, preop for CABG.",1
PA AND LATERAL CHEST RADIOGRAPH: There is no comparison.,0
Thoracic aorta is tortuous and calcified.,0
There is mild apical pleural thickening.,0
There is no consolidation or effusion or CHF.,0
There are degenerative changes of thoracolumbar spine.,0
2:04 PM CHEST (PORTABLE AP) Clip # Reason: s/p rll lobectomy ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with CAD s/p CABG s/p recent PTCA c/b LAD perforation REASON FOR THIS EXAMINATION: s/p rll lobectomy ______________________________________________________________________________ FINAL REPORT INDICATION: S/P right lower lobe lobectomy.,0
S/P CABG and recent PTCA.,0
"CHEST, SINGLE VIEW: There is a right IJ line with its tip extending into the right axillary vein.",0
There is some subcutaneous emphysema in the right neck and right superior hemithorax.,0
There is a tiny right lateral basilar pneumothorax.,0
The patient is S/P right lower lobe lobectomy and right lung volume loss is identified.,0
"There are two chest tubes on the right, one with its side port external to the chest cavity and the other with its side port within the right chest cavity.",0
There are no areas of pulmonary parenchymal consolidation.,0
There is a left apical calcified granuloma and a left hilar calcified lymph node.,0
"IMPRESSION: 1) A right IJ line is malpositioned, extending into the right axillary vein.",0
This was discussed with Dr. on the day of the exam.,0
2) Tiny right lateral basilar pneumothorax.,0
One of the right chest tubes has its side port external to the chest cavity.,0
9:26 PM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate for acute intracranial process.,0
"Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with new word finding problem, left sided paresis, non-reactive left pupil.",0
REASON FOR THIS EXAMINATION: Please evaluate for acute intracranial process.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 89-year-old woman with new word finding problem, left-sided paresis, nonreactive left pupil.",0
Evaluate for acute intracranial process.,0
"CT HEAD WITHOUT CONTRAST: There is a dense right MCA sign (M1 segment), highly concerning for acute occlusion.",0
No CT evidence of major territorial infarct or hemorrhage is apparent.,0
There is no mass effect or shift of normally midline structures.,0
Prominence of the sulci and ventricles is consistent with age- related atrophic changes.,0
There is minimal mucosal thickening in the left maxillary sinus.,0
Surrounding soft tissue structures appear unremarkable.,0
"IMPRESSION: Dense MCA sign on the right (M1 segment), highly suspicious for acute occlusion.",0
CTA or MRI/MRA should be performed for confirmation.,0
This has been communicated to Dr. immediately after review of the study.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: UROLOGY Allergies: Amoxicillin Attending: Chief Complaint: Bladder and Prostate Cancer Major Surgical or Invasive Procedure: Cystoprostatectomy and Neobladder creation History of Present Illness: 64 yoM seen in Multidisciplinary Prostate Cancer Clinic with newly diagnosed 7 (3+4) prostate cancer found on w/u of PSA 7.68 and nodule on R. Prostate MRI revealed suspicious bladder lesion, worrisome for invasion.",1
Cystoscopic bx of bladder lesion revealed 5cm mass with path revealing high grade TCC.,0
"PMH: The patient has ahistory of factor V deficiency, which leads to hypercoagulability.",0
"Meds: simvastatin, Lisin/HCTZ All: amox Brief Hospital Course: Mr was admitted to Urology after undergoing cystoprostatectomy and neobladder creation.",1
No concerning intraoperative events occurred; please see dictated operative note for details.,0
"He initially progressed along as expected tolerating a house diet by POD4, but then developed an ileus.",0
A CT scan POD 7 revealed a fascial dehiscence and he was taken for emergent repair.,0
Intra-operatively a small bowel anastomotic leak was discovered.,0
General Surgery was called and assisted in the anastomotic revision.,0
Please see dictated operative notes separately.,0
He was taken to the ICU post-op for aggressive IVF hydration due to Creatinine elevation.,0
This elevation resolved with hydration and returned to baseline.,0
He was transferred to the floor.,0
Throughout his hospitalization he received SQ heparin and pneumoboot prophylaxis.,0
"However, he developed a PE diagnosedby VQ scan.",0
"A hematology consult was called, IV heparinization was performed and a L common femoral DVT was discaovered.",0
Since the time of revision he was unable to advance his diet due to profound ileus and abdominal distension.,0
He received TPN beginning POD3 from his revision until the day before discharge.,0
A GI consult was called and found no definitive cause or therapy for his ileus.,0
He developed gout in his Left Ankle and Right Knee.,0
A rheumatology consult was obtained and a steriod taper performed.,0
He transitioned to PO coumadinization and became therapeutic.,0
"However, as diet advanced his INR fell again to 1.6.",0
His coumadin dose was adjusted.,0
"Prior to discharge, a cystogram showed an intact neobladder.",0
He time-voided without significant residuals.,0
He was discharged to home to follow up with Dr. and hematology.,0
"His primary care doctor, Dr. , agreed to manage his post-op INR monitoring/coumadin management.",0
Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever.,0
Psyllium Packet Sig: One (1) Packet PO DAILY (Daily): Over the Counter.,0
Warfarin 4 mg Tablet Sig: Two (2) Tablet PO at dinner: Follow up INR with Dr. .,0
"Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a day as needed for constipation, bloating, or cramps: Over the Counter.",0
Urocit-K 10 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: Take with breakfast and dinner until seen by Dr. .,0
Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Prostate and Bladder cancer Discharge Condition: Stable Discharge Instructions: -Perform scheduled voiding- void every 3 hours during the day and every 5 hours at night during sleep.,1
We want your bladder to hold no more than 400 mL of urine.,0
-Follow up for an INR check related to Coumadin monitoring Monday with Dr. .,0
Call her office early monday morning to be seen.,0
"-You may shower, but do not tub bathe, swim, or soak.",0
-No strenuous excercise or heavy lifting until you follow up with Dr. .,0
"If it hurts, stop doing it.",0
"medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath.",0
Followup Instructions: Follow up with Dr. in clinic in weeks.,0
"1:58 PM CHEST (PORTABLE AP) Clip # Reason: Eval position of ET tube, eval evidence of PNA Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with STEMI c/b cardiogenic shock and PNA.",1
S/p intubation at OSH prior to transfer.,0
"REASON FOR THIS EXAMINATION: Eval position of ET tube, eval evidence of PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old man with STEMI, complicated by cardiogenic shock and pneumonia.",1
COMPARISONS: No prior imaging available at this institution.,0
FINDINGS: A single portable chest radiograph was obtained.,0
An endotracheal tube terminates in the clavicular heads.,0
An enteric catheter sidehole projects over the stomach.,0
A right internal jugular catheter terminates in the upper SVC.,0
Bilateral lower lobe opacities do not obscure the heart border.,1
"Lobular septal thickening is seen at both bases, suggesting a component of pulmonary edema.",0
A retrocardiac opacity obscures the left hemidiaphragm.,0
IMPRESSION: Endotracheal tube in appropriate position.,0
Bilateral lower lobe pulmonary opacities are mostly attributable to edema and effusions.,1
An additional compenent of infection in the right lower lobe is possible.,0
"5:24 PM CHEST (PORTABLE AP) Clip # Reason: Pt had a right sided picc line and needs tip confirmation, p Admitting Diagnosis: SEPSIS;PILONIDAL ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with MRSA sacral abcess and bacteremia who needs picc for IV vancomycin.",0
"REASON FOR THIS EXAMINATION: Pt had a right sided picc line and needs tip confirmation, please page at with wet read, thanks.",0
______________________________________________________________________________ FINAL REPORT INDICATION: MRSA sacral abscess and bacteremia.,0
Needs a PICC line for antibiotic treatment.,0
FINDINGS: A single AP upright image is provided.,0
The new PICC line tip appears in satisfactory position at the SVC/RA junction.,0
The multinodular lung opacities noted previously are unchanged bilaterally.,0
"There is again evidence of patchy atelectasis in the right lower lobe, associated with elevation of the right hemidiaphragm.",0
A small right-sided pleural effusion is also again noted.,1
The heart and pulmonary vessels are otherwise unremarkable.,0
IMPRESSION: Satisfactory placement of new PICC line.,0
The previously described pulmonary nodules and right basilar atelectasis are unchanged.,0
"Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with CABG REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
Page Mark Courtneu with issues.,0
Pt in OR 4 and will be in CSRU in 90 mins.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Status post CABG.,0
"FINDINGS: In comparison with study of , there is an endotracheal tube in place approximately 4 cm above the carina.",0
Left IJ Swan-Ganz catheter extends to the right pulmonary artery.,0
Nasogastric tube extends to the upper stomach.,0
Left chest tube is in place with no pneumothorax.,0
Atelectatic changes seen at both bases.,0
IMPRESSION: Standard appearance following cardiac surgery.,0
"6:19 PM MR HEAD W & W/O CONTRAST Clip # Reason: ?neurosarcoid Admitting Diagnosis: GASTROINTESTINAL BLEED;TELEMETRY Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with seizures, REASON FOR THIS EXAMINATION: ?neurosarcoid ______________________________________________________________________________ FINAL REPORT Gadolinium hand sprain imaging.",0
TECHNIQUE: Multiplanar T1 and T2-weighted gadolinium enhanced brain imaging was obtained.,0
FINDINGS: No significant interval change is seen since the prior study of .,0
There is no new area of pathological enhancement seen within the brain parenchyma.,0
"There are no new areas of abnormal signal seen within the brain, either.",0
The principal vascular flow patterns are again seen.,0
There is redemonstration of what is likely a large mucous retention cyst within the left maxillary antrum.,0
CONCLUSION: No significant interval change from the prior study of .,0
PATIENT/TEST INFORMATION: Indication: Abnormal ECG.,0
Status: Inpatient Date/Time: at 09:21 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
No spontaneous echo contrast is seen in the LAA.,0
Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA.,0
No spontaneous echo contrast in the body of the RA or RAA.,0
Simple atheroma in aortic root.,0
Complex (>4mm) atheroma in the descending thoracic aorta.,0
Mildly thickened aortic valve leaflets (3).,0
Pulmonic valve not well seen.,0
The patient received antibiotic prophylaxis.,0
The left atrium is normal in size.,0
No spontaneous echo contrast is seen in the left atrial appendage.,0
The left atrial appendage emptying velocity is depressed (<0.2m/s).,0
No thrombus is seen in the left atrial appendage.,0
No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage.,0
There are simple atheroma in the aortic root.,0
Dr. was notified in person of the results.,0
POST-CPB: On infusion of phenylephrine.,0
Preserved biventricular systolic function post CPB.,0
Aortic contour is normal post decannulation.,0
4:55 AM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: GSW ______________________________________________________________________________ FINAL REPORT HISTORY: 22-year-old male found at home with gunshot wound through right scapula and left thigh gunshot wound.,1
Chest tube with a large amount of bloody output initially transferred from outside hospital.,0
No prior comparison exams are available.,0
TRAUMA SERIES PORTABLE CHEST: A right-sided chest tube is noted to be in place with a probable small residual right hydropneumothorax identified.,1
Diffuse opacity projecting over predominantly the right upper lobe likely represents extensive pulmonary contusion versus reexpansion edema.,1
The left lung appears grossly clear.,0
The metallic bullet with a small metallic fragment is noted to lie over the midline at the T2-T3 interspace.,0
Cardiomediastinal silhouette is within normal limits as is the hilar contours.,0
No significant mediastinal widening is identified.,0
Endotracheal tube terminates approximately 6 cm from the carina and nasogastric tube terminates beneath the diaphragm with the side port likely at the GE junction.,0
Subcutaneous emphysema is noted adjacent to the rt scapula.,1
AP PELVIS: No acute fractures or dislocations are identified.,0
SI joints and pubic symphysis appear intact.,0
Please note overall examination is limited by overlying trauma board.,0
Probable mild residual right hydropneumothorax.,1
Diffuse consolidation projecting over the right upper lobe likely represents pulmonary hemorrhage versus reexpansion edema.,0
Sideport of NGT likely at GE junction.,0
"8:01 PM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: MRI/MRA r/o vascular anomaly as source of bleed, known Lt th ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with REASON FOR THIS EXAMINATION: MRI/MRA r/o vascular anomaly as source of bleed, known Lt thalamic hemorrhage with intraventricular blood clot ______________________________________________________________________________ FINAL REPORT MRI OF THE BRAIN WITH MRA OF THE CIRCLE OF INDICATION: Left thalamic bleed and intraventricular clot.",0
"Multiplanar, T1 and T2 weighted images of the brain are obtained.",0
3D TOF MRA of the intracranial circulation was performed.,0
Comparison is made to the prior head CT exam from .,0
"MRI of the brain reveals a large area of intraventricular hemorrhage, larger on the left side with minimal midline shift.",0
"There is also an acute hemorrhage within the left thalamus, unchanged from the head CT exam.",0
Small areas of subarachnoid hemorrhage are seen along the left parietal sulci.,0
A right sided ventriculostomy catheter is seen in position.,0
There is also smaller amounts of hemorrhage seen within the aquaducts and the fourth ventricle.,0
There are no new areas of hemorrhage detected since the prior head CT. MRA of the intracranial circulation was partially degraded by motion artifact.,0
"The major intracranial vessels remain patent.There is enlargement of the left PCA, which could represent the feeder to a posterior temporal AVM.",0
There is a large vessel probably representing posterior draining veins to the suspected AVM draining into the internal cerebral veins.An intranentricular component of the AVM cannot be excluded.,0
IMPRESSION: Suboptimal examination due to motion artifact.,0
"Extensive intraventricular hemorrhage ,left thalamic and parietal bleed as noted on the prior head CT with SAH.",0
Ventriculostomy catheter in place without hydrocephalus.,0
"MRA reveals an AVM in the left posterior temporal lobe, probably supplied by the left PCA, and a large draining vein in the left occipital lobe.Correlation with conventional angiography would be recommended.",0
7:02 PM ABDOMEN (SUPINE ONLY) PORT; -76 BY SAME PHYSICIAN # Reason: evaluate placement of NGT Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with respiratory failure REASON FOR THIS EXAMINATION: evaluate placement of NGT ______________________________________________________________________________ WET READ: JMGw SAT 7:48 PM unchanged appearance to NGT position despited reported atempted advancement ______________________________________________________________________________ FINAL REPORT ABDOMEN INDICATION: Evaluation of nasogastric tube placement.,1
"Unchanged appearance of the nasogastric tube position, despite the reported tube advancement.",0
7:17 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrates Admitting Diagnosis: BACK PAIN ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p asc ao replacement ^wbc REASON FOR THIS EXAMINATION: assess for infiltrates ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 10:01 AM No relevant change.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.,0
"FINDINGS: As compared to the previous examination from , there is no relevant change.",0
The monitoring and support devices are in unchanged position.,0
The extent and distribution of the moderate bilateral pleural effusions is constant.,1
No newly occurred parenchymal opacities.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: elevated INR Major Surgical or Invasive Procedure: None History of Present Illness: 68 F with ESRD on HD, CHF with EF 15%, CAD s/p CABG, Afib on coumadin, admit from ED with significantly elevated INR now s/p 4 units FFP.",0
Patient reports being in her usual state of health with exception of mild diarrhea starting yesterday.,0
Patient reports daughter gave her a medication for this.,0
"On , INR checked and noted to be 8.6.",0
"During HD today, INR rechecked and greater than assay.",0
"Initial BP 81/36, post BP 93/50 (range 73-93).",0
"Other than diarrhea, patient has been feeling well.",0
"No abdominal pain, fever, chest pain, bloody stools, epistaxis, hematemesis or other e/o bleeding; no dyspnea, though feels ""wheezy"" following FFP, feels like she got too much fluid.",0
"No dysuria though has had ""dark urine"".",0
"In ED, vitals 98.4, HR 72, BP initially 76/40, R20, 100% on 4L.",0
"Started on 4 units FFP, received 5 vit D SQ and 5 IV.",0
Ace and B-blocker have been held.,0
Hospital course: s/p 4 U FFP.,0
Hct stable w/o source of bleed.,0
"CHF with EF of 15% s/p BiV pacer on coumadin, recently admitted for CHF exacerbation in 2.",0
"ESRD - on HD since , *EDW 64.4 kg* 3.",0
CAD s/p MI & CABG x 2 ( and revised in ) 4.,0
DMII x 4yrs on insulin 5. s/p L AKA 6.,0
Hypothyroidism 7. a-fib on coumadin 8. home oxygen (needed at night when sleeping) Social History: Lives at home with daughter.,1
"Remote smoking history less than 2-3yrs total, pt has not smoked in over 30yrs.",0
There is no history of alcohol abuse or IVDU.,0
"Family History: non-contributory Physical Exam: Vitals: T 97 (afeb), BP 105/55 (80-100/40-50), HR 78 (paced), R 16, 100% 2L.",0
"wt 69 kg; I/O 170/anuric General: Pleasant female, NAD HEENT: NC/AT, PERRL, sclera anicteric, MM slightly dry Neck: Supple, no adenopathy.",0
"L EJ in place Chest: +bilateral rhonchi with few wheezes, no crackles appreciated Heart: RRR S1 S2, SM at LUSB Abdomen: soft, NTND, no HSM, +BS Extrem: s/p L AKA, RLE without edema.",0
Pertinent Results: Labs: 03:00PM BLOOD WBC-4.4# RBC-3.49* Hgb-10.0* Hct-32.5* MCV-93 MCH-28.7 MCHC-30.9* RDW-20.8* Plt Ct-158 07:15AM BLOOD WBC-5.0 RBC-3.21* Hgb-9.1* Hct-31.7* MCV-99* MCH-28.4 MCHC-28.8* RDW-21.4* Plt Ct-189 03:00PM BLOOD Glucose-104 UreaN-14 Creat-1.4* Na-139 K-7.4* Cl-100 HCO3-34* AnGap-12 07:15AM BLOOD Glucose-148* UreaN-37* Creat-1.9* Na-141 K-4.2 Cl-101 HCO3-34* AnGap-10 04:42AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.5 Mg-1.6 07:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1 04:42AM BLOOD ALT-16 AST-32 LD(LDH)-242 AlkPhos-234* TotBili-0.3 04:42AM BLOOD TSH-5.2* 01:10PM BLOOD Free T4-1.3 03:00PM BLOOD Vanco-13.2 04:23PM BLOOD Lactate-1.2 .,0
INR 04:15PM BLOOD PT-150* PTT-150* INR(PT)->22.8* 04:00PM BLOOD PT-17.7* INR(PT)-1.6* .,0
Blood cx- no growth .,0
CXR : IMPRESSION: Persistent small bilateral pleural effusions.,0
Marked interval improvement in right-sided pleural effusion.,0
"Increased airspace opacity involving both lungs may simply reflect low lung volumes, but mild pulmonary edema is not excluded.",0
"Brief Hospital Course: ASSESSMENT AND PLAN: 68 F with ESRD on HD, CHF, Afib on coumadin; admit to MICU with supratherapeutic INR now s/p 4 units FFP and IV vit K. .",0
The patient had an elevated INR which was greater than assay at one point early on in her admission.,0
"Of note, the patient took a bowel regimen for constipation and reports significant diarrhea prior to admission.",0
The patient was not taking excess coumadin doses.,0
In addition the patient was on vancomycin for a previous HD catheter infection which could have contributed to the increased INR.,0
The patient had no signs of bleeding at the time of admission or during her hospitalization.,0
Her INR normalized with giving IV vit K and 4 units of FFP.,0
The patient was restarted on coumadin prior to discharge.,0
She was discharged on 4mg of coumadin daily with a follow up INR check at hemodialysis.,0
The patient became hypotensive with SBPs in the 70s in ED and at HD.,0
She was admitted to the MICU for monitoring and her home BP medications were stopped.,0
She had a negative blood cx and a negative CXR.,0
She was receiving vancomycin with HD for a previous line infection.,0
Her SBP on the day of discharge ranged from 100-110s and she was not restarted on her BP meds prior to discharge.,0
#Hypothyroidism: She had and elevated TSH at 5.2 and a normal free T4.,0
Her dose of levothyroxine was increased from 125 to 150mcg daily.,0
# Systolic CHF: The patient has systolic CHF with an EF of 15%.,0
She received 4 units FFP plus additional IVF while in the MICU.,0
She did not require early HD as she was not volume overloaded.,0
Her carvedilol and ACEI were held due to her hypotension and not restarted prior to discharge.,0
# Diabetes type II: The patient was continued on her home Lantus and ISS.,0
# ESRD on HD: The patient received HD while at the hospital as per her normal schedule.,0
She finished her doses of vancomycin for her previous line infection.,0
The patient has a history of CAD and CABG x2 with CHF.,0
She was continued on ASA while in the hospital.,0
The patient was not able to tell me the name of her new PCP so could not find out why she was no longer on a statin.,0
I did confirm her medications with her pharmacy and she was not receiving a statin.,0
Her ACE and beta-blocker were held due to her hypotension.,0
These medications should be restarted as an out-patient after follow up with her PCP.,0
#Lesions on back of calf and bleeding of R big toe secondary to nail clipping.,0
The lesion of the back of her calf is surrounded by erythematous tissue suggesting adequate blood flow to heal the lesion.,0
The patient felt her ultram was not helping her.,0
She uses a lidocaine patch on her left leg which provides some relief.,0
I started gabapentin which the patient requested to be discharged on.,0
"# Full code: discussed with patient PGY-1, Medications on Admission: Carvedilol 3.125 mg daily Lantus 12 units at HS Senna 1 tab Humalog sliding scale ASA 325 mg daily lorazepam 0.5 mg HS prn albuterol neb QID prn wheeze lisinopril 5 mg daily Percocet 5-325, 1-2 tabs QID prn pain tramadol 50 mg Q6H prn colace 100 levothyroxine 125 daily warfarin 5 mg daily Flovent MDI vanco with HD zolpidem 5mg qHS Bisocodyl 5mg 1-2 tabs daily enulose 90ml, 15ml q4hrs vicadin 5 tabs 5/500 q4hrs lidoderm patch 5% 1 daily PRN limb pain Discharge Medications: 1.",0
Sevelamer HCl 400 PO TID W/MEALS 2.,0
Levothyroxine 150 mcg PO once a day.,0
Aspirin 325 mg PO DAILY 4.,0
Docusate Sodium 100 mg PO BID: PRN as needed for constipation.,0
Senna 8.6 mg PO BID:PRN as needed for constipation.,0
Acetaminophen 500 mg Two Tablet PO q6hrs: PRN pain as needed for pain.,0
Zolpidem 5 mg PO HS (at bedtime) as needed for insomnia.,0
Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation.,0
Lactulose 10 gram/15 mL Solution Fifteen ml PO every four (4) hours as needed for severe constipation.,0
Lorazepam 0.5 mg PO qHS as needed for anxiety.,0
Lidocaine 5 %(700 mg/patch) One Adhesive Patch DAILY 12.,0
Oxycodone 5 mg PO every four (4) hours as needed for pain.,0
Guaifenesin 600 mg Tablet PO twice a day as needed for cough.,0
14. insulin glargine continue home dose of 12units subcut qHS 15. humalog continue previous home sliding scale 16.,0
Warfarin 4 mg PO once a day.,0
Fluticasone 110 mcg/Actuation Aerosol Two Puff Inhalation 18.,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) One Inhalation every six (6) hours as needed for wheeze.,0
Gabapentin 300 mg One Capsule PO Q24H as needed for limb pain.,0
Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary 1.,0
End Stage Renal Disease on hemodialysis .,1
Chronic Congestive Heart Failure with EF 15% 2.,1
Coronary artery disease s/p myocardial infarction 3.,1
Left above the knee amputation 4.,1
Atrial fib Discharge Condition: Blood pressure stable and INR no longer supratherapeutic Discharge Instructions: You were admitted with a supratherapeutic INR and with decreased blood pressure.,1
Your supratherapeutic INR was treated with fresh frozen plasma and vitamin K. Your blood pressures have improved and you have been put back on coumadin with a goal INR of .,0
The doses of the following medications were changed: -warfarin -levothyroxine .,0
The following medications were discontinued: -carvedilol -lisinopril -dextromethorphan-guaifenesin .,0
The following meds were started: gabapentin .,0
Adhere to 2 gm sodium diet Fluid Restriction to 2L .,0
"Please return to the hospital if you develop dizziness, difficulty breathing, chest pain, blood in stool, vomiting blood, blood in urine, any sign of bleeding, or any new medical condition.",0
Please check INR with dialysis Followup Instructions: Please follow up with your PCP 1-2 weeks and discuss restarting your blood pressure medications.,0
PATIENT/TEST INFORMATION: Indication: Rheumatic heart disease.,0
Height: (in) 63 Weight (lb): 131 BSA (m2): 1.62 m2 BP (mm Hg): 132/65 HR (bpm): 54 Status: Inpatient Date/Time: at 13:08 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,0
Moderate to severe spontaneous echo contrast in the body of the LA.,0
Moderate to severe spontaneous echo contrast in the LAA.,0
No spontaneous echo contrast or thrombus in the body of the RA or RAA.,0
RIGHT VENTRICLE: Normal RV chamber size.,0
MITRAL VALVE: Moderately thickened mitral valve leaflets.,0
Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion.,0
Mild valvular MS (MVA 1.5-2.0cm2).,0
The posterior pharynx was anesthetized with 2% viscous lidocaine.,0
Moderate to severe spontaneous echo contrast is seen in the body of the left atrium and sludge is present in the left atrial appendage.,0
No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage.,0
with mild global free wall hypokinesis.,0
The mitral valve leaflets are moderately thickened with calcified leaflet tips and mild thickening of the subvalvular apparatus.,0
There is mild mitral annular calcification.,0
"The mitral valve shows characteristic rheumatic deformity and mild mitral stenosis (MVA 2.4 cm2, mean gradient 7 mmHg at 100 bpm).",1
IMPRESSION: Mild rheumatic mitral stenosis.,1
Left atrial appendage sludge without formed thrombus.,0
2:00 PM CT C-SPINE W/O CONTRAST Clip # Reason: eval for injury ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with fall yesterday and report of headstrike.,0
REASON FOR THIS EXAMINATION: eval for injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: MXAk TUE 2:43 PM No acute cervical spine fracture or prevertebral soft tissue swelling.,1
"Significant spinal canal narrowing, particularly at C4 and C5 due to posterior osteophytes.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Status post head trauma.,0
TECHNIQUE: MDCT-acquired axial images were obtained through the cervical spine without intravenous contrast.,0
FINDINGS: There is no evidence of acute cervical spine fracture or prevertebral soft tissue swelling.,1
The cervical spine is normally aligned.,0
"There are severe degenerative disc disease throughout the cervical spine with several very large protuberant posterior osteophytes with significant AP narrowing of the canal, most prominently at C3-C4, C4-C5, and to a lesser degree at C5-C6.",0
There is significant canal stenosis at these levels and cord compression cannot be excluded.,0
CT is not able to provide intrathecal detail compared to MRI.,0
There is also severe multilevel neural foraminal narrowing.,0
Evidence of left carotid surgery.,0
No acute cervical spine fracture or prevertebral soft tissue swelling.,1
"Severe degenerative disc disease with very large protruding posterior osteophytes at C3-C4, C4-C5, and C5-C6.",0
"If clinical suspicion for cord compression is high, MR is the recommended study of choice.",0
9:58 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: r/o fluid collection and re-evaluation of gallbladder.,0
"if po Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 72 year old critically ill woman, intubated, sedated, febrile, intermittently hypotensive, leukocytosis, rising total bilirubin REASON FOR THIS EXAMINATION: r/o fluid collection and re-evaluation of gallbladder.",0
"if possible r/o any abscess ______________________________________________________________________________ FINAL REPORT INDICATION: Critically ill patient, with persistent fevers and leukocytosis, rising bilirubin.",0
Please reassess gallbladder for any fluid collections.,0
COMPARISON: Right upper quadrant ultrasound of .,0
LIMITED RIGHT UPPER QUADRANT ULTRASOUND: Today's exam was technically limited secondary to a significant amount of bowel gas overlying the midline.,0
"Allowing for this limitation, the gallbladder has an improved appearance since yesterday's exam.",0
"There is still likely sludge within the lumen, but the previously described increased wall edema is not apparent on today's exam.",0
No pericholecystic fluid collections are identified.,0
"The common duct is not dilated, measuring 5 mm in diameter.",0
Limited scale views of the liver are unremarkable.,0
"Again, noted is a small amount of perihepatic ascites.",0
IMPRESSION: Improved son appearance of the gallbladder compared to the exam of .,0
2:35 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Position of PICC tipCharlene # Admitting Diagnosis: SEIZURES ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with tip seen in RA per Radiology.Advised to pull back 5cm and re-xray.,0
REASON FOR THIS EXAMINATION: Position of PICC tipCharlene # ______________________________________________________________________________ FINAL REPORT INDICATION: Slightly repositioned left PICC.,0
"COMPARISON: Chest radiograph from earlier the same day, at 03:31.",0
FINDINGS: Bedside AP radiograph of the chest demonstrates that the left PICC has been retracted and now lies in the upper segment of the SVC.,0
"The study is otherwise unchanged, including atelectasis of the right lower lobe and left lingula, as well as chronic left lower lobe collapse.",0
There is no pneumothorax or effusion.,0
IMPRESSION: Repositioned left PICC now terminates in the upper SVC.,0
The study is otherwise unchanged.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Paper tape Attending: Chief Complaint: L ICA aneurysm Major Surgical or Invasive Procedure: Angiogram with coiling of L ICA aneurysm History of Present Illness: 64 y/o F presents for elective coiling of L ICA aneurysm Past Medical History: Depression Hypertension Hyperthyroidism with multinodular goiter PSurgHx: Thoracic surgery on as above Previous excision of breast cysts Social History: Single lives alone.,1
Tobacco: 45 pack-year quit 1/.,0
ETOH none Family History: Father: pancreatic cancer Siblings: Brother in good health Physical Exam: On Discharge: Gen: comfortable appearing HEENT: Pupils: 3-2mm bilat EOMs slightly jerky with bilateral partial ptosis ?,0
thyroid disease Neck: Supple without carotid bruits and has thyroidectomy scar Lungs: CTAB Cardiac: RRR.,0
"Abd: Soft, NT, BS+ Extrem: Warm but toes purple.",0
Good PTs bilaterally with reduced DPs.,0
Good femoral pulses bilat without bruits.,0
Mild edema to ankles bilat.,0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally.",0
"III, IV, VI: Extraocular movements intact bilaterally without nystagmus with somewhat jerky saccades.",0
"V, VII: Facial strength and sensation intact and symmetric but bilateral mild ptosis.",0
Limb exam: Normal tone throughout.,0
"Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally in UE.",0
Normal sensation in LE save decreased vibration to ankle on left.,0
Reflexes: B T Br Pa Ac Very brisk reflexes throught with spread and pectorals/finger jerks in the negative and adductors in both LE.,0
Cerebellar: No finger/nose or heel-shin ataxia.,0
Pertinent Results: 01:26AM BLOOD WBC-8.9 RBC-3.12* Hgb-9.3*# Hct-27.8*# MCV-89 MCH-29.7 MCHC-33.3 RDW-13.5 Plt Ct-507*# 01:26AM BLOOD PT-12.9 PTT-30.3 INR(PT)-1.1 01:26AM BLOOD Glucose-121* UreaN-13 Creat-0.6 Na-138 K-3.9 Cl-109* HCO3-20* AnGap-13 Brief Hospital Course: 64 y/o F with bilateral ICA aneurysms presents for elective coiling of L ICA aneurysm.,0
At the beginning of the case patient SBP was elevated to the 200s.,0
Aneurysm was coiled sucessfully and patient was transferred to the PACU until and ICU bed is available.,0
She was placed on a heparin gtt at 700u/hr and on aspirin.,0
"Postoperatively she had some visual disturbances (""shimmering light on right visual field"", like ""optical migraine""), but resolved.",0
"She tolerated PO's was ambulating without difficulty, bowel and bladder function were normal.",0
She is discharged home in stable condition.,0
"Medications on Admission: Amlodipine 2.5 mg qd, Atenolol 50 mg qd, Fluoxetine 40 mg qd Methimazole 5mg qd Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).",0
"2. bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache.,0
6. atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety.,0
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.,0
9. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation (2 times a day).,0
10. methimazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
11. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).,0
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for back spasm.,0
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
15. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Discharge Disposition: Home Discharge Diagnosis: L ICA aneurysm Discharge Condition: Mental Status: Clear and coherent.,0
No driving until you are no longer taking pain medications What to report to office: ?,0
"Changes in vision (loss of vision, blurring, double vision, half vision) ?",0
Slurring of speech or difficulty finding correct words to use ?,0
Severe headache or worsening headache not controlled by pain medication ?,0
A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?,0
"Trouble swallowing, breathing, or talking ?",0
"Numbness, coldness or pain in lower extremities ?",0
Temperature greater than 101.5F for 24 hours ?,0
"New or increased drainage from incision or white, yellow or green drainage from incisions ?",0
"Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes.",0
"If bleeding stops, call our office.",0
"If bleeding does not stop, call 911 for transfer to closest Emergency Room!",0
Followup Instructions: Please follow up with Dr. in 6 weeks with a MRI/MRA.,0
Please call ( to schedule.,0
9:24 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: Please place post-pyloric Dobhoff feeding tube.,0
Place / Admitting Diagnosis: AORTIC ANEURYSM\ BENTAL PROCEDURE VS VALVE SPARING AORTIC ROOT REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with REASON FOR THIS EXAMINATION: Please place post-pyloric Dobhoff feeding tube.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Post pyloric feeding tube placement.,0
The scout radiograph demonstrates a Dobbhoff catheter overlying the stomach.,0
The Dobbhoff catheter was removed.,0
Under fluoroscopic guidance a nasojejunal feeding tube was advanced into the proximal jejunum.,0
A small amount of contrast was injected to confirm placement.,0
IMPRESSION: Satisfactory placement of the nasojejunal feeding tube.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: s/p new L SC CVL, please eval line placement and for PTX Admitting Diagnosis: ANEURYSM;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with SAH s/p L subclavian CVL placement REASON FOR THIS EXAMINATION: s/p new L SC CVL, please eval line placement and for PTX ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb TUE 12:32 PM New left subclavian venous catheter tip in the SVC.",0
Note is made that the tubing is kinked at the inferior margin of the clavicle near the insertion site.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Central line placement.,0
AP PORTABLE CHEST: Compared to the study at 5:41 a.m. this morning there has been placement of a new left subclavian venous catheter which terminates in the mid SVC.,0
At the insertion site along the inferior margin of the clavicle the tube is slightly kinked but does not appear occluded.,0
Tip of the n asogastric tube remains in the stomach.,0
"2:23 PM CHEST (PORTABLE AP) Clip # Reason: decreased o2 sats please repeat cxr, previous film inadequat ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with copd, decreased o2 sats REASON FOR THIS EXAMINATION: decreased o2 sats please repeat cxr, previous film inadequate ______________________________________________________________________________ FINAL REPORT HISTORY: Decreasing O2 sats.",0
A single AP upright chest radiograph demonstrates an ET tube in appropriate position.,0
There is tortuosity of the aorta.,0
The heart is unremarkable in size.,0
"There is perihilar prominence, as well as bibasilar interstitial prominence.",0
The lung bases are spared.,0
"IMPRESSION: There is perihilar and basilar interstitial prominence, which may represent pulmonary edema (with the heart normal in size, this is probably non-cadiogenic).",0
Another possibility is aspiration pneumonia.,0
"4:54 AM CHEST (PORTABLE AP) Clip # Reason: Eval for infiltrate, overload, interval change Admitting Diagnosis: MENINGITIS; INTRACRANIAL ABCESS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with ETT & persistent fevers REASON FOR THIS EXAMINATION: Eval for infiltrate, overload, interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: ETT, evaluation for interval change.",1
Slightly decreased lung volumes and change in patient position.,0
No newly appeared focal parenchymal opacity.,0
"10:22 AM CT HEAD W/O CONTRAST Clip # Reason: RESPIRATORY FAILURE, BOOP, ALTERED MENTAL STATUS, R/O BLEED ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with above REASON FOR THIS EXAMINATION: 47 yo wf with hiv, boop here with resp failure.",1
noted to have altered mental status.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: HIV, BOOP, respiratory failure and altered mental status.",1
TECHNIQUE: Axial non-contrast CT scans of the brain were performed.,0
There are no previous studies for comparison.,0
There are no focal areas of abnormal attenuation within the brain parenchyma.,0
Grey white matter differentiation is preserved.,0
"On a few images, there is motion artifact.",0
There is no clear evidence of acute intracranial hemorrhage.,0
"There is a cystic 1 cm mass in the region of the pineal, probably a pineal cyst.",0
There are no abnormal extra-axial collections.,0
Bone window images demonstrate opacification of the mastoid air cells bilaterally and fluid within the right middle ear cavity.,0
There is minimal sphenoid mucosal thickening.,0
The visualized ethmoid and maxillary sinuses are clear.,0
No calvarial abnormalities are seen.,0
IMPRESSION: There is no evidence of acute intracranial hemorrhage or mass effect.,0
There is fluid in the mastoids bilaterally and the right middle ear.,0
4:42 PM PICC LINE PLACMENT SCH Clip # Reason: please place PICC Admitting Diagnosis: RIGHT HIP OSTEOARTHRITIS/SDA ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man s/p V fib arrest, s/p right THR with need for PICC for hydration REASON FOR THIS EXAMINATION: please place PICC ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc TUE 11:23 PM PFI: Uncomplicated placement of a dual-lumen catheter of a 36 cm line from right basilic approach, with the catheter tip terminating in the lower SVC.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 81-year-old man status post VFib arrest, status post right total hip replacement with need for peripherally inserted central catheter for hydration.",0
RADIOLOGISTS: The procedure was performed by Drs.,0
"and with Dr. , the Attending Radiologist, being present and supervising.",0
PROCEDURE: The right arm was prepped and draped in the standard sterile fashion.,0
"Following a preprocedure timeout, theone of the right-sided brachial veins was punctured under ultrasound guidance, using the Seldinger technique.",0
Hard copy ultrasound images were obtained before and after venous access documenting vessel patency.,0
A 0.018 Nitinol guidewire was then advanced into the SVC under fluoroscopic guidance.,0
"Following removal of the needle, a 4.5 French peel-away introducer set was advanced over the Nitinol guidewire, and the guidewire was removed.",0
"A 36 cm 5-French double- lumen catheter was then advanced through the peel- away introducer set under fluoroscopic guidance, with the tip terminating in the lower SVC.",0
"The peel- away sheath was then removed, and the catheter was securely fastened to the skin with two StatLock devices.",0
"A Tegaderm dressing was then applied over the StatLock devices, and a sterile dressing was fastened to the Tegaderm.",0
The catheter ports were flushed and capped.,0
Hemodynamic parameters were monitored throughout the procedure.,0
"IMPRESSION: Successful placement of a 36 cm dual-lumen catheter, with right basilic approach, with the catheter tip terminating in the lower SVC.",0
(Over) 4:42 PM PICC LINE PLACMENT SCH Clip # Reason: please place PICC Admitting Diagnosis: RIGHT HIP OSTEOARTHRITIS/SDA ______________________________________________________________________________ FINAL REPORT (Cont),0
"4:48 AM CHEST (PORTABLE AP) Clip # Reason: Fevers - eval for PNA/Pleural effusion - please perform ~060 Admitting Diagnosis: PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p peds-struck REASON FOR THIS EXAMINATION: Fevers - eval for PNA/Pleural effusion - please perform ~0600 (pt going to OR in AM) ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:05 A.M., HISTORY: Fever following motor vehicle pedestrian accident.",1
Evaluate pleural effusion or pneumonia.,0
"IMPRESSION: AP chest compared to consolidation at the left lung base has improved slightly since , small right pleural effusion is stable and there is some consolidation at the right lung base, which has changed in distribution, but not in overall severity.",0
"11:23 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: SP LIVER TRANSPLANT ILEUS WBC 20 R/O OBSTRUCTIONVS ABCESS\ Admitting Diagnosis: END STAGE LIVER DISEASE Field of view: 38 Contrast: VISAPAQUE Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p liver transplant, c/b bile leak, s/p Roux-en-Y hepaticojej, now with ileus and WBC 20.",1
REASON FOR THIS EXAMINATION: Please assess for obstruction or abscess.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old status post liver transplant complicated by bile leak and status post Roux-en-Y hepaticojejunostomy, now with ileus, leukocytosis, and positive C. diff titer.",1
COMPARISONS: CT of and .,0
TECHNIQUE: Axial MDCT images of the abdomen and pelvis with oral and 100 cc of nonionic Visipaque contrast.,0
"CT ABDOMEN WITH IV CONTRAST: There remain moderately-sized bilateral effusions with passive atelectasis at the lung bases, unchanged from the prior CT. Visualized portion of the heart and pericardium are unremarkable.",0
Transplant liver enhances homogeneously with patency of the hepatic and portal venous system.,1
"The proper hepatic artery is not optimally visualized, as this is not a dedicated CT angiogram study, however, the proximal portion appears patent.",0
"Overall, there is increase in the amount of intra-abdominal and pelvic ascites, most notable in the lesser sac and subhepatic regions.",0
"This fluid, however, appears simple, without evidence of organizing or pockets of air to suggest developing abscess.",0
"Kidneys, adrenal glands, spleen, stomach, and post-surgical small bowel are unremarkable.",0
The patient is status post hepaticojejunostomy due to bile leak after liver transplant.,1
There is an indwelling tube within the Roux limb.,0
There is no evidence to suggest bowel obstruction.,0
CT PELVIS WITH IV CONTRAST: The distal small bowel is borderline in size but demonstrates no transition point or decompressed distal portions to suggest bowel obstruction.,0
"The majority of the bowel is decompressed and difficult to evaluate with adjacent ascites, however, there appears to be mild thickening of the splenic flexure, which may be artifactual due to decompression and adjacent ascites.",0
There is diffuse mild subcutaneous edema.,0
"There is a stable soft tissue nodule involving the subcutaneous tissue posterior to the left buttock, unchanged from the prior study.",0
Increase in the amount of free pelvic ascitic fluid.,0
The bladder and distal ureters are unremarkable.,0
No abnormal lymph nodes are seen in the pelvis.,0
BONE WINDOWS: No suspicious lytic or blastic lesions are appreciated.,0
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images were helpful (Over) 11:23 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: SP LIVER TRANSPLANT ILEUS WBC 20 R/O OBSTRUCTIONVS ABCESS\ Admitting Diagnosis: END STAGE LIVER DISEASE Field of view: 38 Contrast: VISAPAQUE Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) in evaluating the descending colon.,1
"IMPRESSION: 1) Status post liver transplant and hepaticojejunostomy; unremarkable appearance of the transplant liver, without evidence of abscess or bowel obstruction.",1
"2) Overall increase in the amount of intra-abdominal and pelvic ascites, most prominent within the lesser sac, left abdomen, and pelvis.",0
"3) Possible mild wall thickening of the splenic flexure, though this may be artifactual due to adjacent ascites and decompression; correlate clinically.",0
4) Moderate bilateral pleural effusions.,0
5) Stable subcutaneous soft tissue nodule posterior to the left buttock.,0
7:34 AM CHEST (PORTABLE AP) Clip # Reason: assess interval change Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man intubated REASON FOR THIS EXAMINATION: assess interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST : COMPARISON: .,1
Endotracheal tube and nasogastric tube have been removed.,0
Cardiomediastinal contours are stable in appearance.,0
Improving atelectasis is present at the left lung base.,0
The examination is otherwise unchanged.,0
11:37 AM CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # Reason: liver vessels Admitting Diagnosis: END STAGE LIVER DISEASE Field of view: 46 ______________________________________________________________________________ MEDICAL CONDITION: 50M w with HIV/chronic hep C cirrhosis w HCC s/p liver transplant now with abdominal pain REASON FOR THIS EXAMINATION: liver vessels No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 50-year-old man with HIV and chronic hepatitis cirrhosis with HCC status post liver transplant with abdominal pain.,1
"Following the administration of IV Optiray contrast, images of the abdomen and pelvis were obtained in the arterial and venous phase.",0
CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There are small bilateral pleural effusions with associated compressive atelectasis which has increased at the left lung base.,0
Extensive heterogeneous perfusion throughout the liver has decreased.,0
The spleen is enlarged and there is now a new peripheral wedge- shaped hypodensity consistent with infarction.,0
The organizing hematoma posterior to the liver has decreased in size.,1
"The adrenal glands, kidneys, pancreas, stomach, and abdominal loops of small and large bowel are unremarkable.",0
"There are numerous paraesophageal, splenic, and gastric varices.",0
A single surgical drain remains with tip within the porta hepatic region.,1
Abdominal ascites has increased and is now moderate in amount.,0
"CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, bladder, and prostate gland are unremarkable.",0
There is a fat and fluid-containing right inguinal hernia.,0
There are no enlarged mesenteric or retroperitoneal lymph nodes.,0
There is moderate body wall edema.,0
CTA ABDOMEN: The patient is status post liver transplant.,1
Two areas of narrowing are again present within the graft hepatic artery.,0
"These are present at the origin of the graft hepatic artery and at the graft hepatic artery native proper hepatic artery anastomotic site (series 3A, images 48 and 51).",0
"The celiac axis, superior mesenteric artery, and are patent.",0
The right and left main portal veins are patent.,0
The donor main portal vein is completely occluded to the iliac vein conduit.,0
Collateral vessels in the porta hepatis suggest cavernous transformation.,0
The iliac vein conduit is also thrombosed to the level of the SMV anastomosis.,0
The native splenic vein drains extensive collaterals likely into the right renal vein.,0
"A tiny focus of clot is seen within the IVC (Series 6, Image 52).",0
(Over) 11:37 AM CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # Reason: liver vessels Admitting Diagnosis: END STAGE LIVER DISEASE Field of view: 46 ______________________________________________________________________________ FINAL REPORT (Cont) Osseous structures demonstrate no suspicious lytic or sclerotic foci.,0
Thrombosis of the donor portal vein extending to the iliac vein anastomosis.,1
The iliac vein graft is also thrombosed to the level of the SMV anastomosis.,0
Two presumed areas of arterial narrowing within graft common hepatic artery as previously described.,0
Resolving heterogeneous perfusion of the liver.,0
"Multiple enlarged gastric, perisplenic, and retroperitoneal varices.",0
Increasing moderate amount of ascites within the stomach.,0
Large fluid-containing right inguinal hernia.,0
Tiny focus of clot within the IVC.,0
Findings were discussed with Dr. on .,0
"8:29 AM CT HEAD W/O CONTRAST Clip # Reason: eval for reaccumulation SDH Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with L SDH evacuation and recent multiple seizures REASON FOR THIS EXAMINATION: eval for reaccumulation SDH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: SDH, recent evacuation, multiple seizures, to evaluate for re-accumulation.",1
COMPARISON: CT head done on .,0
FINDINGS: Status post left frontal and temporal craniotomy.,0
"There is left-sided subdural hemorrhage along the convexity and along the falx with a maximum transverse dimension of 1.7 cm at the vertex, series 2, image 25.",1
There is mild indentation on the left cerebral hemisphere.Comparison of this with the prior study is somewhat difficult given the differences in positioning- may be stable/ minimal increase.,0
"There is also subdural hemorrhage in the left middle cranial fossa in the left inferior frontal region, is mildly decreased compared to the prior study.",1
"Otherwise, there is no new acute intracranial hemorrhage.",1
The ventricles and extra-axial CSF spaces elsewhere are unremarkable with mild prominence.,0
Assessment is somewhat limited due to motion-related artifacts and artifacts from the EEG leads.,0
Study somewhat limited due to motion and EEG leads related artifacts.,0
"Within this limitation, there is re-demonstration of left-sided subdural hemorrhage along the convexity and along the falx, with a maximum transverse dimension of 1.7 cm at the vertex.",1
Comparison with the recent study somewhat difficult given the differences in positioning.,0
Attention on close followup to be considered.,0
Mild decrease in the subdural hemorrhage in the left middle cranial fossa and in the left inferior frontal region.,1
No new hemorrhage otherwise allowing for the limitations.,0
(Over) 8:29 AM CT HEAD W/O CONTRAST Clip # Reason: eval for reaccumulation SDH Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ FINAL REPORT (Cont),1
9:22 AM CT HEAD W/O CONTRAST Clip # Reason: s/p fall-r/o bleed Admitting Diagnosis: TRICUSPID REGURGITATION\TRICUSPID VALVE REPLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with REASON FOR THIS EXAMINATION: s/p fall-r/o bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Fell and hit the right front portion of her head on a chair.,1
"FINDINGS: There is no sign of intracranial hemorrhage, mass effect, shift of the normally midline structures, hydrocephalus, or major vascular territorial infarction.",0
/white matter differentiation is preserved.,0
There is no sign of fracture or bone destruction.,0
The paranasal sinuses and the orbits are unremarkable.,0
IMPRESSION: No acute intracranial hemorrhage or mass effect.,1
"7:05 AM CHEST (PORTABLE AP) Clip # Reason: r/o pulm effusion Admitting Diagnosis: MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: year old woman with hypoxia in setting of recent anterior STEMI, LAD stent .",1
"REASON FOR THIS EXAMINATION: r/o pulm effusion ______________________________________________________________________________ FINAL REPORT AP CHEST: INDICATION: Hypoxia, recent anterior MI.",0
Comparison is made with the prior chest x-ray on .,0
FINDINGS: There is left ventricular enlargement.,0
There is slight perihilar haziness and upper zone vascular redistribution.,0
Mild left ventricular failure cannot be excluded.,0
"The lungs demonstrate small bilateral effusions, greater on the left side.",0
There are decreased lung volumes.,0
There is left lower lobe collapse/consolidation.,0
IMPRESSION: 1) Increased bilateral pleural effusions.,0
2) Left lower lobe collapse/consolidation.,0
3) Cannot exclude mild left ventricular failure.,0
"9:52 AM CHEST (PORTABLE AP) Clip # Reason: effusions Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 61 yo female w/ CAD, s/p tracheostomy on positive pressure vent, w/ PNA, CHF.",1
REASON FOR THIS EXAMINATION: effusions ______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary artery disease.,0
"Status post tracheostomy, on positive pressure ventilation.",0
"Rule out pneumonia, CHF, effusions.",0
"There appears to be slight worsening of bilateral pulmonary infiltrates, particularly in the lower zones.",0
This is associated with some slight increase in bilateral pleural effusions.,0
Lung inflation is slightly reduced.,0
There is again evidence of some left lower lobe collapse/consolidation behind the heart.,0
The heart shows slight left ventricular enlargement.,0
There is evidence of a prior CABG procedure.,0
A tracheostomy tube and right IJ central line remain in good positions.,0
Pacemaker electrodes remain well positioned in the right atrium and right ventricle respectively.,0
IMPRESSION: Findings are suggestive of slightly worsening left heart failure with increasing bibasilar infiltrates and effusions.,1
"7:29 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: ACUTE MYELOID LEUKEMIA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with AML here for allo-SCT REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ WET READ: JMGw WED 9:17 PM left basilar atlectesis, but no consolidations.",1
left subclavian central line tip may abut wall of SVC.,0
right sided catheter tip in the low SVC.,0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: AML, evaluation for pneumonia.",0
"FINDINGS: As compared to the previous radiograph, the patient has received a right-sided central venous access line.",0
The tip of this line projects over the lower SVC.,0
Unchanged left-sided central venous access.,0
Borderline size of the cardiac silhouette.,0
Minimal atelectasis projecting over the left costophrenic sinus.,0
No focal parenchymal opacity suggesting pneumonia.,0
"10:02 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: PAIN, R/O GALLSTONES Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with pancreatitis REASON FOR THIS EXAMINATION: gallstones ______________________________________________________________________________ FINAL REPORT LIVER AND GALLBLADDER ULTRASOUND INDICATION: 42-year-old man with pancreatitis.",1
"Note made of CT abdomen and pelvis dated , .",0
"FINDINGS: The bedside ultrasound examination is markedly limited by patient body habitus, and inability to cooperate due to pain and respiratory distress.",0
"Limited images of the liver demonstrate increased echogenicity, likely representing fatty liver.",0
Gallbladder was unable to be identified.,0
IMPRESSION: Markedly limited portable study.,0
", F. MED SICU-B 1:11 PM CT CHEST W/O CONTRAST Clip # Reason: Please eval for worsening emphysema, signs of atypical infec Admitting Diagnosis: S/P CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with COPD, s/p cardiac arrest.",1
Now with tachypnea and difficulty off the vent.,0
"REASON FOR THIS EXAMINATION: Please eval for worsening emphysema, signs of atypical infections.",0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Moderate upper lobe predominant emphysema and diffuse bronchial wall thickening suggesting chronic airway disease.,0
"LINE PLACEMENT Clip # Reason: eval for position of R IJ Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with h/o MI, panctransplant now with renal failure admitted for hypoxemia related to CHF vs pna with worsening dyspnea, s/p R IJ placement REASON FOR THIS EXAMINATION: eval for position of R IJ ______________________________________________________________________________ FINAL REPORT INDICATION: New right internal jugular line placement.",1
COMPARISON: Two studies from .,0
AP SEMI-UPRIGHT CHEST: There has been interval placement of a right internal jugular central venous catheter with its tip projecting over the cavoatrial junction.,0
A nasogastric tube tip is not visualized but remains below the diaphragm.,0
"An endotracheal tube tip is at the thoracic inlet, 7.2 cm above the carina.",0
The bilateral extensive interstitial lung consolidative opacities have improved since yesterday.,0
Please note that the left costophrenic angle is excluded from this film.,0
IMPRESSION: Right internal jugular central venous catheter tip projects over the cavoatrial junction.,0
Improvement in the extensive interstitial and consolidative abnormalities.,0
"3:42 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: OVARIAN CANCER ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with multiple ex-laps for pelvic mass, repair of enterotomies, and delayed abdominal wound closure REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
CLINICAL HISTORY: 89-year-old woman with multiple exploratory laparotomies for pelvic mass.,0
Status post repair of enterotomies and delayed abdominal wound closure.,0
FINDINGS: Comparison is made to prior study from .,0
"The endotracheal tube, IJ and subclavian central venous lines are unchanged in position.",0
"There are persistent bilateral pleural effusions and a left retrocardiac opacity as well as moderate pulmonary edema, stable.",0
8:52 PM CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # Reason: stroke?,0
Contrast: OPTIRAY Amt: 80 ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with new onset seizures and old CVA.,0
REASON FOR THIS EXAMINATION: stroke?,0
"No contraindications for IV contrast ______________________________________________________________________________ WET READ: RSRc WED 9:47 PM No evidence of thrombus in vertebral arteries, common carotid arteries, or intracranial arteries.",0
Proximal left vertebral artery plaque/narrowing again seen.,0
"- ______________________________________________________________________________ FINAL REPORT HISTORY: 73-year-old man with new onset seizures and old CVA, on Coumadin.",0
TECHNIQUE head and neck CTA.,0
Contiguous axial images were obtained through the brain without contrast material.,0
"Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of Omnipaque intravenous contrast material.",0
"Images were processed on a separate workstation with display of curved reformats, volume-rendered images, and maximum intensity projection images.",0
COMPARISON: Head CT from at 6:24 p.m.and CTA done on .,0
The head CT is unchanged in appearance compared to dedicated head CT from three hours before this study.,0
"Again, there is a large area of hypodensity within the left temporal, parietal, occipital lobes consistent with evolution of a chronic infarction.",0
"There is no acute hemorrhage, no masses and no shift of midline.",0
There is significant prominence of the ventricles and sulci consistent with age-related diffuse parenchymal volume loss.,0
The patient is intubated with an orogastric tube.,0
"There is mild mucosal thickening of the bilateral maxillary, bilateral ethmoid, and bilateral sphenoid sinuses.",0
The frontal and mastoid air cells are clear.,0
NECK CTA: Significant atherosclerotic calcifications are noted.,0
There is calcification at the bifurcation of the left and right common carotid arteries causing mild-moderate stenosis at the bifurcation.,0
"The atherosclerotic plaques with some calcifications are also seen extending intot he proximal internal carotid artery causing less than 30% stenosis in the ICA, left mroe than right.",0
Overall the appearance is unchanged..,0
There is no flow- limitation.,0
"At the origin of the left vertebral artery, there is small amount of calcification.",0
"The left vertebral artery is diminutive compared to the right, but there is no flow- limiting stenosis.",0
(Over) 8:52 PM CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # Reason: stroke?,0
"Contrast: OPTIRAY Amt: 80 ______________________________________________________________________________ FINAL REPORT (Cont) CTA HEAD: There is extensive calcification of the left and right internal carotid arteries within the carotid siphons, unchanged.",0
Full evaluation of the intracranial vessels is limited due to suboptimal arterial enhancement due to delayed phase imaging.,0
There is no evidence for aneurysm or occlusion of the intracranial vessels.,0
Within the inferior division of M2 branch of the left MCA there is redemonstration of the previously noted moderate-severe stensosis.,0
There is some flow noted distally.,0
"There is a common ICA/PICA trunk on the right side, which was seen supplying the right cerebellar hemisphere.",0
There is a small caliber left.,0
There is a small left PCA with a prominent PICA.,0
The thyroid is diffusely heterogeneous with low-density nodules and we would recommend ultrasound for further evaluation.,0
There is thickening of the left lung apical fissure.,0
"There are degenerative changes within the cervical spine, not adequately assessed ont he present study.",0
No areas of acute intracranial hemorrhage or acute infarction identified.,0
Unchanged moderte-severe stenosis of the inferior division of left M2 branch with some flow noted and decreased caliber distally.,0
"Atheroslcerotic disease invovling the common carotid arteries at bifurcation causing moderate stenoses and mild at proximal cervical itnernalc arotid arteries, not significantly changed compared to CTA of .",0
Heterogeneous thyroid with multiple areas of low density and we would recommend ultrasound for further evaluation.,0
PATIENT/TEST INFORMATION: Indication: Myocardial infarction.,1
Height: (in) 63 Weight (lb): 118 BSA (m2): 1.55 m2 BP (mm Hg): 126/75 HR (bpm): 72 Status: Inpatient Date/Time: at 10:32 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LEFT VENTRICLE: Normal LV cavity size.,0
"TVI E/e' >15, suggesting PCWP>18mmHg.",0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - akinetic; basal anteroseptal - akinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg).,0
"Resting regional wall motion abnormalities include mid to distal anterior, anteroseptal and apical akinesis/hypokinesis .",0
10:57 AM HIP UNILAT MIN 2 VIEWS RIGHT; FEMUR (AP & LAT) RIGHT Clip # Reason: alignment Admitting Diagnosis: HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p ORIF R hip REASON FOR THIS EXAMINATION: alignment ______________________________________________________________________________ FINAL REPORT HISTORY: Fracture fixation.,1
FIVE VIEWS OF THE RIGHT HIP AND RIGHT FEMUR: There is a comminuted intertrochanteric fracture with considerable displacement and rotation of the lesser trochanter.,1
This fracture has been fixated by a long intramedullary rod with interlocking rod extending into the femoral head and two distal interlocking screws.,0
Appearances unchanged from intraoperative radiographs (one day ago).,0
The left hip and SI joints are normal.,0
"3:51 PM RENAL U.S.; DUPLEX DOPP ABD/PEL Clip # Reason: please do with doppler to assess patency of vasculature thx Admitting Diagnosis: HEPATIC ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with urinary retention also presenting with acute kidney injury REASON FOR THIS EXAMINATION: please do with doppler to assess patency of vasculature thx ______________________________________________________________________________ FINAL REPORT RENAL ULTRASOUND HISTORY: 46-year-old woman with urinary retention, acute kidney injury, please evaluate kidneys and patency of vasculature.",1
"FINDINGS: Normal appearance of bilateral kidneys without evidence of hydronephrosis, nephrolithiasis, or renal mass.",0
The right kidney measures 10.5 cm in length.,0
The left kidney measures 10.7 cm in length.,0
"Normal Doppler flow with normal waveforms are seen in the bilateral main renal arteries and renal veins, with normal flow and waveforms in the upper, mid, and lower pole inter-lobar arteries bilaterally.",0
Moderate amount of intraperitoneal ascites noted.,0
IMPRESSION: Normal appearance of bilateral kidneys with normal Doppler evaluation of bilateral renal vessels.,0
"8:04 PM HAND (AP, LAT & OBLIQUE) BILAT Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p MVC - assess for fracture REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 74-year-old male status post MVC.",0
"AP, LATERAL AND OBLIQUE VIEWS OF BILATERAL HANDS: No fracture or dislocation is identified in the left hand.",0
Nondisplaced right radial styloid fracture is present with intra-articular extension of fracture into the radiocarpal joint.,1
Incidental note is made of an expansile 10 x 8mm lucent lesion in the right distal ulnar epiphysis.,0
"The lesion has benign features, including no periosteal reaction or cortical breakthrough and most suggestive of aneurysmal bone cyst.",0
Non-displaced right radial styloid process fracture with intra- articular extension.,1
"2-mm geometric radiodensity in the dorsum of the left hand near an apparent soft tissue defect, which may represent retained foreign body.",0
"Incidental note is made of expansile lucent lesion in the right distal ulnar epiphysis, likely an aneurysmal bone cyst.",0
"9:09 AM MRI ABDOMEN W/O CONTRAST; FOLLOW-UP,REQUEST BY RAD.",0
"Clip # Reason: CALL BACK BY RADIOLOGIST COR AND AXIAL SSFSE(HASTE) WITH RESP GATING, Admitting Diagnosis: EXCESSIVE LOSS ______________________________________________________________________________ FINAL REPORT CLIP #: This clip was performed as the continuation of the MRCP performed , with clip #.",0
The images included in this clip are described in the dictated report of the examination.,0
7:36 AM CHEST (PORTABLE AP) Clip # Reason: Assess for interval changes.,0
"Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: year old man with cough, ?",0
pneumonia and hypoxia REASON FOR THIS EXAMINATION: Assess for interval changes.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST Patient with cough, question pneumonia.",0
This is compared to the prior study from .,0
There is no significant interval change.,0
There is evidence of bilateral pleural effusions.,1
The cardiac silhouette is mildly enlarged.,0
The opacification throughout the right hemithorax may represent asymmetric pulmonary edema.,0
No evidence of a focal pneumonia.,0
IMPRESSION: Minimal change with persistent pleural effusions and prominent opacification of the right lung.,1
4:54 PM CHEST (PORTABLE AP) Clip # Reason: dobhoff placement Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with new dobhoff REASON FOR THIS EXAMINATION: dobhoff placement ______________________________________________________________________________ WET READ: FRI 6:33 PM R PICC line ends in lower SVC.,0
Tracheostomy ends 5.7 cm above carina.,0
Left jugular line appears to have been removed in the interval since the prior exam.,0
Removal of old feeding tube with new dobhoff placement with weighted tip in teh fundus and may be advanced into the stomach.,0
Findings discussed with Dr. at 6pm on via tel.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Dobbhoff placement.,0
"FINDINGS: In comparison with the study of , there has been placement of a Dobbhoff tube that straddles the esophagogastric junction.",0
It should be pushed forward several cm.,0
Other monitoring and support devices remain in place.,0
Suggestion of some poor definition of the left hemidiaphragm that could represent some atelectatic changes or even small effusion.,0
GI BLEEDING STUDY Clip # Reason: MELENA.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Fifty-six year old woman with h/o coronary artery disease, PVD, ESRD, on dialysis, diabetes, cirrhosis, now with melena and decreasing hematocrit.",1
"DECISION: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-m, blood flow and delayed images of the abdomen for 85 minutes were obtained.",0
Blood flow images were unremarkable.,0
"Delayed blood pool images show expected activity in the heart, spleen and vessels.",0
There is no evidence of increasing tracer activity in bowel loops to suggest active bleed.,0
IMPRESSION: No evidence of active GI bleed.,0
Approved: 2:42 PM West RADLINE ; A radiology consult service.,0
4:52 AM CHEST (SINGLE VIEW) Clip # Reason: ?,0
PNA interval assessment Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with ?,0
PNA REASON FOR THIS EXAMINATION: ?,0
PNA interval assessment ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Interval assessment for pneumonia.,0
Single AP view of the chest was compared to .,0
There is pleural thickening along the left chest that might be chronic due to the multiple rib fractures present along the lateral aspect of the reached.,0
"No interval development of consolidation worrisome for infection, no interval development of pulmonary edema was noted, although minimal vascular engorgement is more obvious on the current study than on the prior examination.",1
12:03 PM CHEST (PA & LAT) Clip # Reason: Eval pacer leads s/p implant.,0
______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p cabg and mv repair now s/p pacemaker implant.,0
REASON FOR THIS EXAMINATION: Eval pacer leads s/p implant.,0
"______________________________________________________________________________ FINAL REPORT TWO VIEW CHEST, : CLINICAL INDICATION: Assess pacemaker leads.",0
Comparison is made to previous study dated one day earlier.,0
"A permanent pacemaker is present, with leads terminating in the right atrium and right ventricle, not significantly changed since the previous study.",0
"There is a tiny left apical pneumothorax present, which has decreased in size in the interval.",0
"Additionally, there is a similar-sized pneumothorax at the right lung apex which has also been present previously and is not significantly changed.",0
There are small to moderate bilateral pleural effusions.,0
Adjacent atelectatic changes are observed in both lung bases.,0
IMPRESSION: 1) Permanent pacemaker with leads terminating in right atrium and right ventricle.,0
"2) Small biapical pneumothoraces, with interval improvement in the left side in the interval.",0
"3) Small to moderate pleural effusions, not significantly changed.",0
7:10 AM CHEST (PORTABLE AP) Clip # Reason: Changes from prior X ray?,0
Admitting Diagnosis: RULE OUT MYOCARDIAL INFARCTION PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: year old man with s/p thoracentesis and pneumothorax in previous xray.,1
"Per CT , pneumothorax ex vacuo.",0
REASON FOR THIS EXAMINATION: Changes from prior X ray?,0
______________________________________________________________________________ FINAL REPORT INDICATION: -year-old male status post thoracentesis with resulting pneumothorax.,0
Evaluate for changes from prior films.,0
"COMMENTS: Single AP portable chest radiograph was reviewed and compared with serial chest radiographs from , to the most recent of , .",0
The tip of a right IJ catheter projects over the mid SVC.,0
"Compared to the film of , a very small right apical pneumothorax is unchanged.",0
Interval increase in a large right pleural effusion with adjacent atelectasis is noted.,1
A small left pleural effusion is stable.,1
A left-sided catheter shard overlies the left hemidiaphragm.,0
Degenerative changes of the spine are noted.,0
Stable small right apical pneumothorax.,0
Increasing large right pleural effusion with associated atelectasis.,1
"Left lower lobe consolidation, which could be atelectasis or developing pneumonia alone or in combination.",0
", M. MED 5:21 AM CHEST (PORTABLE AP) Clip # Reason: evaluate left pleural effusion Admitting Diagnosis: HL;R/O SEPSIS; MENTAL STATUS CHANGES ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with increased ICP 2/2 metastatic lymphoma s/p intubation and ?",0
left pleural effusion REASON FOR THIS EXAMINATION: evaluate left pleural effusion ______________________________________________________________________________ PFI REPORT Increasing opacity of LLL and heart shift to the left side could represent area of atelectasis and pneumonia/ aspiration and/or pleural effusion.,0
"9:28 AM CHEST (PRE-OP PA & LAT) Clip # Reason: NEW ONSET AFIB;SOB ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with severe MR, for MVR on .",0
REASON FOR THIS EXAMINATION: baseline pre-op ______________________________________________________________________________ FINAL REPORT INDICATION: MR.,0
FINDINGS: Linear scarring or atelectasis is visualized at both lung bases.,0
There is no focal consolidation or evidence of pulmonary edema.,0
The cardiac silhouette is not enlarged.,0
IMPRESSION: No acute cardiopulmonary disease.,0
4:29 PM CT HEAD W/O CONTRAST Clip # Reason: r/o intracranial head ______________________________________________________________________________ MEDICAL CONDITION: year old woman with reported vfib arresst on coumadin - ?head REASON FOR THIS EXAMINATION: r/o intracranial head No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKXa FRI 4:56 PM No acute intracranial hemorrhage or shift of midline structures.,0
Fullness of nasopharyngeal soft tissues which may be related to intubation.,0
INDICATION: -year-old woman with reported ventricular fibrillation arrest on Coumadin.,1
"Possible head trauma, evaluate for intracranial bleed.",0
FINDINGS: There is no evidence of acute intracranial hemorrhage or mass effect.,0
There is no shift of normally midline structures.,0
The ventricles and cisterns are normal.,0
The density values of the brain parenchyma are normal.,0
"There is fullness of the nasal pharyngeal soft tissues, which may be related to intubation.",0
There is fluid within the maxillary sinuses bilaterally.,0
The osseous structures of the head appear unremarkable.,0
IMPRESSION: No acute intracranial hemorrhage.,0
Nasopharyngeal fullness may be related to intubation.,0
Fluid within the maxillary sinuses.,0
", W. MED MICU-7 4:53 PM BILAT LOWER EXT VEINS Clip # Reason: R/O DVT, SWELLING Admitting Diagnosis: CHOLECYSTITIS ______________________________________________________________________________ MEDICAL CONDITION: year old woman with tachypnea and sinus tachycardia REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ PFI REPORT No DVT",0
4:45 PM CT CHEST W/O CONTRAST Clip # Reason: SOB ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with a h/o ANCA pos vasculitis who was treated with cytoxan and prednisone x3 mo who presented with SOB and an absolute neutrophil count of 0 but has failed to improve on 1 wk of broad spectrum ABx / G-CSF and requires further w/u of the diffuse interstitial and airspace findings on CXR REASON FOR THIS EXAMINATION: evaluate for ?,0
infiltrate ______________________________________________________________________________ FINAL REPORT No prior CT scans for comparison.,0
"CLINICAL INDICATION: History of vasculitis, treated with cytoxin and Prednisone, with shortness of breath and neutropenia.",0
Failure to improve on broad spectrum antibiotics.,0
Helical CT of the thorax is performed without intravenous or oral contrast administration.,0
"Images were initially obtained with 8 mm collimation and 8 mm reconstruction intervals, but additional limited high resolution CT images were also performed with 1 mm collimation at selected intervals in the supine position.",0
Prone images were not obtained due to patient's intubated status.,0
"Assessment of the lungs reveals severe diffuse emphysema, which affects the upper lobes to a greater degree than the remainder of the lungs and affect the left lung to a greater degree than the right.",0
"There are multifocal areas of alveolar consolidation, including the left upper lobe posteriorly, lingula posteriorly, and the lower lobes posteriorly.",0
There is also some patchy consolidation within the right middle lobe.,0
The left upper lobe also demonstrates an area of increased opacity in the perihilar region which contains air bronchograms and probably corresponds to the apparent lung nodule on recent chest radiograph.,0
"There are interstitial abnormalities present at the lung bases, with small cystic spaces as well as larger areas of bullous disease.",0
Reticular opacities are also noted.,0
These findings are mostly localized to the lung bases.,0
An endotracheal tube is in satisfactory position.,0
The central airways appear patent to the segmental level bilaterally.,0
Review of the soft tissue structures of the thorax demonstrate small mediastinal nodes which are probably reactive given diffuse lung disease.,0
"There is an area of apparent lymph node enlargement in the left hilum, which is difficult to separate from adjacent consolidative changes and pulmonary vessels on this non contrast study.",0
There are small dependent pleural effusions bilaterally.,0
Incidentally noted are small calcified granulomas within the right lower lobe consolidation.,0
"Imaging of the upper portion of the abdomen demonstrate no significant abnormality in the imaged portion of the liver or spleen, but these organs are incompletely imaged on this study.",0
There is non specific mesenteric stranding (Over) 4:45 PM CT CHEST W/O CONTRAST Clip # Reason: SOB ______________________________________________________________________________ FINAL REPORT (Cont) in the imaged portion of the abdomen.,0
Review of the osseous structures of the thorax reveals degenerative changes within the spine.,0
Note is also made of focal lucencies within the lower thoracic spine.,0
A nasogastric tube is coiled within the stomach.,0
"IMPRESSION: 1) Multifocal alveolar consolidation, with a predominantly dependent distribution.",0
The findings are most suggestive of a multifocal pneumonia.,0
Aspiration pneumonia should be considered given predominant dependent distribution.,0
Vasculitis is an additional consideration given the provided clinical history.,0
"2) Apparent nodular opacity in the left lung on recent chest radiograph likely corresponds to an area of focal consolidation, with evidence of air bronchograms visualized in this region and contiguity with adjacent areas of consolidation.",0
"3) Enlarged left hilar lymph nodes, probably reactive given extensive consolidative changes.",0
4) Small bilateral pleural effusions.,0
"6) Findings suggestive of interstitial fibrosis at the lung bases, difficult to fully characterize due to overlying consolidative changes.",0
"7) It would be helpful to perform a follow-up chest CT after conventional radiographic resolution of consolidation, in order to document resolution of left hilar lymph node enlargement, nodular opacity in the left lung, and to better characterize the interstitial lung disease.",0
"9:30 AM CHEST (PORTABLE AP) Clip # Reason: r/o new pleural effusion, worsening consolidation Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with CAP on 3L of O2, on vanc/levo/aztreonam x2d.",1
"REASON FOR THIS EXAMINATION: r/o new pleural effusion, worsening consolidation ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Consideration for effusion and consolidation.",1
"FINDINGS: As compared to the previous examination of , bilateral pleural effusions have developed.",1
These effusions are slightly more severe on the right than on the left side.,0
"As a consequence, both the left and the right lower lung areas have become atelectatic, which is best seen in the retrocardiac lung areas.",0
"The visible parts of the lung parenchyma are unchanged, including the predescribed parenchymal opacities.",0
No evidence of newly occurred parenchymal opacities.,0
The size of the cardiac silhouette is unchanged.,0
"6:59 PM CT HEAD W/O CONTRAST Clip # Reason: eval for obvious brain mass, ICH ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with cancer, need for anticoagulation REASON FOR THIS EXAMINATION: eval for obvious brain mass, ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: KYg TUE 8:16 PM no hemorrhage.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old male with cancer, needs anticoagulation.",0
"Evaluate for brain mass, intracerebral hemorrhage.",0
"NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus, shift of normally midline structure, or evidence of major vascular territorial infarct.",0
The -white matter differentiation is preserved.,0
"Hypodensities in the periventricular and subcortical white matter reflect chronic microvascular ischemic change, not significantly changed from .",0
The visualized paranasal sinuses and mastoid air cells remain normally aerated.,0
The surrounding soft tissues and osseous structures are normal.,0
"If there is concern regarding metastases, an MRI with gadolinium is more sensitive.",0
4:34 PM CHEST (PORTABLE AP) Clip # Reason: eval failure ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with resp distress REASON FOR THIS EXAMINATION: eval failure ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress.,1
TECHNIQUE: Single frontal radiograph of the chest.,0
FINDINGS: There are low lung volumes.,0
Cephalization and prominence of the vasculature is present however no overt pulmonary edema is seen.,0
"Denser consolidation at the bases likely represents atelectasis; however, infection/consolidation cannot be excluded.",0
Trace pleural effusion on the right may be present.,0
"7:26 AM NEONATAL HEAD PORTABLE Clip # Reason: INFANT WITH PREMATURITY AT 32 WEEKS INTRAUTERINE GROWTH RESTRICTION, NOW 25 DAYS OLD, R/O PVL Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity at 32 weeks intrauterine growth restriction, now 25 days old REASON FOR THIS EXAMINATION: r/o pvl ______________________________________________________________________________ FINAL REPORT CRANIAL ULTRASOUND: Study is compared with the prior examination of .",1
Images were obtained in coronal and sagittal planes through the anterior fontanelle and in the axial plane through a mastoid approach.,0
The ventricles are of normal size.,0
The anterior portion of the choroid plexus on the right is somewhat more prominent than expected which is a finding which was evident on the earlier examination.,0
The 2-mm choroid plexus cyst noted at that time is not clearly visible on current study.,0
There is no evidence of appendimal or intraventricular hemorrhage.,0
There is no evidence of periventricular leukomalacia.,0
The extra-axial spaces are normal.,0
IMPRESSION: Slight prominence of the choroid plexus on the right cyst evident on earlier study is no longer seen.,0
The findings are felt to be within normal limits.,0
1:24 PM CHEST (PORTABLE AP) Clip # Reason: eval for pna ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with AMS REASON FOR THIS EXAMINATION: eval for pna ______________________________________________________________________________ FINAL REPORT INDICATION: Acute altered mental status.,0
FINDINGS: The endotracheal tube projects 4.3 cm above the carina.,0
The NG tube distal tip projects at the expected location of the stomach.,0
The pacemaker tips project at the right atrium and expected position of right atrium and right ventricle.,0
Aorta is tortuous and calcified.,0
Small left pleural effusion is noted.,0
Mild left basilar atelectasis is also noted.,0
"3:02 PM PORTABLE ABDOMEN Clip # Reason: eval for contrast in kidneys Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with ARF, concern for contrast nephropathy.",0
"REASON FOR THIS EXAMINATION: eval for contrast in kidneys ______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN, SINGLE VIEW, AT 1529 HOURS.",0
HISTORY: Acute renal failure with concern for contrast nephropathy.,1
FINDINGS: Single portable view of the abdomen is compromised secondary to body habitus.,0
There is loss of the properitoneal fat stripes and central clumping of the gas distended loops of bowel consistent with ascites.,0
No contrast is noted overlying the expected locations of the kidneys or ureters.,0
Oral contrast is noted in the distal colon including the rectum and therefore obscures the bladder.,0
IMPRESSION: Ascites with retained oral contrast in the distal colon and rectum.,0
No contrast seen corresponding to renal fossae or course of ureters.,0
"7:25 AM CHEST (PORTABLE AP) Clip # Reason: eval PNA, ET tube placement, pulm edema Admitting Diagnosis: CARDIOGENIC SHOCK ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with arrest, MI, CVA, pneumonia REASON FOR THIS EXAMINATION: eval PNA, ET tube placement, pulm edema ______________________________________________________________________________ FINAL REPORT HISTORY: MI with CVA and tube placement.",1
There is continued extensive opacification at the left base consistent with volume loss in the left lower lobe and associated pleural effusion.,1
Indistinctness of pulmonary markings suggests superimposed elevation of pulmonary venous pressure.,0
"2:43 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: pls evaluate for PE Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with chronic hypercarbia, COPF, CHF with acute respiratory failure REASON FOR THIS EXAMINATION: pls evaluate for PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old man with chronic hypercarbia and acute respiratory failure.",1
Please evaluate for pulmonary embolism.,0
TECHNIQUE: Axial MDCT images were obtained from thoracic inlet to upper abdomen after administration of Optiray intravenously.,0
No oral contrast was used.,0
Sagittal and coronal reformatted images were obtained.,0
CT OF CHEST WITH IV CONTRAST: No filling defect is noted within the main pulmonary artery and its branches to suggest pulmonary embolism.,0
No pathologically enlarged mediastinal or hilar nodes are identified.,0
The largest mediastinal node measures 7 mm in the short axis.,0
No pathologically enlarged axillary node is noted.,0
The heart and great vessels appear unremarkable except for calcification of the descending thoracic aorta and part of coronary arteries.,1
A small amount of left-sided pleural effusion and dependent atelectasis is noted.,0
Lung windows do not demonstrate bilateral upper lobe parenchymal consolidation.,0
No pulmonary nodule is seen.,0
Note is made of centrilobular emphysema scattered throughout both lungs.,0
Patient is status post endotracheal tube placement and NG tube placement in proper position.,0
"The visualized portion of the upper abdomen demonstrates normal-appearing liver, spleen and adrenal glands, and kidneys.",0
BONE WINDOWS: No concerning lytic or sclerotic lesion is identified.,0
A bone island is noted within the twelfth thoracic vertebra.,0
No pulmonary embolism is identified.,0
Upper lobe parenchymal reticulonodular infiltrate.,0
Centrilobular emphysema scattered throughout both lungs.,0
Small amount of left-sided pleural effusion and dependent atelectatic changes are noted within the left lung base.,0
"(Over) 2:43 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: pls evaluate for PE Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ FINAL REPORT (Cont)",1
"6:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ?obstruction ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with hx CVA, non-communicative now with apparent abd pain and repeated vomiting REASON FOR THIS EXAMINATION: ?obstruction No contraindications for IV contrast ______________________________________________________________________________ WET READ: SESHa WED 8:25 PM Bilateral airspace opacities worrisome for aspiration.",0
"Left renal vague parenchymal hypodensity, cannot exclude infection or infarct.",0
Small focus of air in the subcu tissues overlying the left upper thigh - correlate with history.,0
WET READ VERSION #1 DMFj WED 7:55 PM Bilateral airspace opacities worrisome for aspiration.,0
______________________________________________________________________________ FINAL REPORT CT OF THE ABDOMEN AND PELVIS PERFORMED ON Compared with a prior study from .,0
"CLINICAL HISTORY: 69-year-old man with history of right MCA distribution, CVA, noncommunicative, now with apparent abdominal pain and vomiting.",0
TECHNIQUE: MDCT was used to obtain contiguous axial images through the abdomen and pelvis following the uneventful administration of 130 cc Optiray IV contrast.,0
No oral contrast was administered.,0
FINDINGS: LUNG BASES: There is extensive bibasilar tree-in- nodular opacities which raise concern for aspiration.,0
Right lower lobe dependent atelectasis is also noted.,0
The heart appears normal in size and shape.,0
ABDOMEN: An NG tube is seen with its tip coiled in the stomach.,0
There is evidence of prior cholecystectomy with clips noted in the gallbladder fossa.,0
"The spleen, pancreas are unremarkable aside from pancreatic atrophy.",0
The adrenal glands have a normal appearance bilaterally.,0
"There is heterogeneous enhancement of the left kidney with areas of hypoperfusion noted in the interpolar region, which were not seen on a prior contrast-enhanced CT from .",0
Findings are somewhat concerning for infarct or infection.,0
"There is a hypodensity in the lower pole of the right kidney, which likely represents a (Over) 6:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ?obstruction ______________________________________________________________________________ FINAL REPORT (Cont) small cyst though too small to adequately characterize.",0
The right kidney is otherwise unremarkable.,0
The abdominal aorta and major branch vessels are widely patent.,0
There is no retroperitoneal lymphadenopathy.,0
The stomach and duodenum have an unremarkable appearance.,0
PELVIS: Loops of small and large bowel are suboptimally assessed given that no enteric contrast was administered.,0
"There is, however, no evidence of ileus or obstruction.",0
A shunt catheter is seen in the right hemiabdomen with its tip along the inferior edge of the liver.,0
No abnormal fluid collections are seen within the abdomen or pelvis.,1
OSSEOUS STRUCTURES: No suspicious lytic or blastic osseous lesion is seen.,0
Evidence of prior laminectomy in the lower thoracic spine is noted.,0
Facet arthropathy is noted at the lumbosacral junction.,0
Subcutaneous gas in the left upper thigh is likely iatrogenic.,0
Additional areas of nodular density in the anterior subcutaneous fat along the lower abdomen wall likely reflect medication injections.,0
Extensive tree-in- opacities at the lung bases are suggestive of aspiration.,0
Poorly defined areas of hypodensity in the left kidney are new from a prior study from and raise concern for infectious or ischemic process.,0
No evidence of acute bowel process.,0
VP shunt catheter tip in the right hemiabdomen appearing unremarkable.,0
"1:46 PM CT CHEST W/CONTRAST Clip # Reason: pneumonia or left chest wall abscess Admitting Diagnosis: MYOCARDIAL INFARCTION/CATH ______________________________________________________________________________ MEDICAL CONDITION: 34 year old woman with low grade fever, leukocytosis, s/p pericardial window pain at left breast REASON FOR THIS EXAMINATION: pneumonia or left chest wall abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest CT with contrast on .",1
TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to subdiaphragmatic area after the administration of 75 cc of IV contrast.,0
Thinner slice 5-mm and 1.25-mm contiguous images in the axial plane were obtained.,0
Sagittal/coronal reformatted images were obtained as well.,0
"HISTORY: 34-year-old woman with low-grade fever, leukocytosis, status post pericardial window with pain at the left breast, pneumonia or left chest wall abscess.",1
FINDINGS: A large triangular non-enhancing consolidation with superimposed partial cavitation centrally is seen in the right upper lobe.,0
Another non- enhancing triangular wedge- shaped opacity is seen in the left lower lobe.,0
Bibasilar atelectasis adjacent to small right more than left pleural effusion are noted.,0
Scattered areas of ground-glass opacities are seen in both lungs along with thickened interlobular septa indicative of underlying pulmonary edema.,0
"The heart is enlarged; specifically the left atrium.Multiple grossly enlarged lymph nodes; 2.2-cm subcarinal lymph node, 2.2-cm right lower paratracheal lymph node, a 1.6-cm right upper paratracheal lymph node, a 1.5- cm left prevascular lymph node, 1-cm and 9 mm right hilar lymph nodes, and a 9-mm left hilar lymph node in the short axis dimension.",0
The bones do not show any lesions suspicious for malignancy or infection.,0
The liver appears slightly hyperdense than expected likely secondary to transfusion.,0
"A hyperattenuating material is seen in the dependent most portion of the gallbladder, likely sludge or debris .",0
"Mild cardiogenic pulmonary edema characterized by the presence of scattered ground-glass opacities, septal thickening, and cardiomegaly, particularly the left atrium.",0
Bibasilar atelectasis with adjacent small right more than left pleural effusion.,0
A right upper lobe consolidation with cavitation worrisome for pneumonia.,0
(Over) 1:46 PM CT CHEST W/CONTRAST Clip # Reason: pneumonia or left chest wall abscess Admitting Diagnosis: MYOCARDIAL INFARCTION/CATH ______________________________________________________________________________ FINAL REPORT (Cont) 4.,1
A left upper lobe wedge-shaped non-enhancing opacity worrisome for pulmonary infarct secondary to a coexistent pulmonary embolism.,1
Further evaluation to exclude or confirm coexistent pulmonary embolism is recommended.,1
Information was telephoned to Dr. at approximately 4:30 p.m. 5.The lymph nodes are rather enlarged for a cardiogenic cause like heart failure.Other causes including neoplam should be investigated.,1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Keflex / Paper Tape Attending: Chief Complaint: Headache Major Surgical or Invasive Procedure: Cereberal angiography History of Present Illness: Pt with left frontal and prepontine cisternal hemorrhages (new onset headache,neurologically intact).",1
S/P left ICA stent placemtn at an outside hospital.,0
Transferred to for further treatment.,0
Past Medical History: R leg sciatica hypothyroid Parkinson's TAH/BSO GERD CAD 60-69% L ICA stenosis CABGx4 S/P Appendectomy Social History: Lives with husband Present tobacco use Family History: Noncontributory Physical Exam: VSS per Medical record.,1
Headaches are controlled on present therapies.,0
Pertinent Results: CBC ()-11.4* 4.18* 10.2* 32.7* 78* 24.5* 31.3 18.7* 411 Brief Hospital Course: Pt underwent cerebral angiography by Dr. on .No post procedure complications.,0
Progressing as expected in the immediate post procedure phase.,0
Headaches controlled on present regimen.,0
"Medications on Admission: albuterol inhaler and nebulizers twice a day prn, atorvastatin 20 mg daily, carbidopa-levodopa 50/200 twice daily, Plavix 75 mg daily, diltiazem 240 mg daily, Advair 100/50 twice daily, omeprazole 40 mg twice daily, glyburide 5 mg twice daily, HCTZ 12.5 mg daily, lisinopril 10 mg daily, metoprolol 100 mg twice daily, Effexor 150 mg daily, oxycodone 5 mg qid prn, ASA 325 mg daily.",0
Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily).",0
Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed.,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4hrs; prn as needed.,0
Disp:*28 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: Subarachnoid hemorrhage Discharge Condition: Stable Discharge Instructions: Angiogram Medications: ?,1
Take Aspirin 325mg (enteric coated) once daily ?,0
Take Plavix (Clopidogrel) 75mg once daily ?,0
You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What activities you can and cannot do: ?,0
"When you go home, you may walk and go up and down stairs ?",0
"No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?",0
"After 1 week, you may resume sexual activity ?",0
"After 1 week, gradually increase your activities and distance walked as you can tolerate ?",0
"If bleeding does not stop, call 911 for transfer to closest Emergency Room Followup Instructions: Please call Dr. for appointment.",0
He would like to see you next week.,0
2:45 PM CHEST (PORTABLE AP) Clip # Reason: DOE Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with CAD s/p CABG.,1
"REASON FOR THIS EXAMINATION: DOE ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM: History of CABG.",0
7:08 AM CHEST (PORTABLE AP) Clip # Reason: r/o edema Admitting Diagnosis: PVD\LEFT LEG ANGIO ______________________________________________________________________________ MEDICAL CONDITION: year old woman with pulmonary edema REASON FOR THIS EXAMINATION: r/o edema ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old woman with pulmonary edema.,0
"Single AP view of the chest dated , at 8:16, is compared with the AP view of the chest from , at 21:41.",0
The endotracheal tube terminates 2.4 cm above the carina.,0
The NG tube tip terminates in the body of the stomach.,0
"There is continued left retrocardiac opacity, which may represent consolidation.",0
No other definite opacities are identified.,0
The pulmonary vasculature is normal.,0
The heart and mediastinal contours are unchanged.,0
IMPRESSION: 1) Lines and tubes as described above.,0
"2) Persistent left lower lobe opacity, which may represent consolidation.",0
"3:25 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE;RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with PNA, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia with intubation.",1
"FINDINGS: In comparison with study of , there is again globular enlargement of the cardiac silhouette with evidence of increased pulmonary venous pressure and right upper lung consolidation.",0
"12:57 PM CHEST (PORTABLE AP) Clip # Reason: eval for pneumothorax s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube removal, to assess for pneumothorax.",1
"FINDINGS: In comparison with study of , all of the monitoring and support devices have been removed.",0
Continued enlargement of the cardiac silhouette with engorgement of pulmonary vessels and bilateral pleural effusions with compressive atelectasis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 58 year old white male with a history of noninsulin dependent diabetes mellitus, hypercholesterolemia and hypertension had an abnormal electrocardiogram on a routine physical examination.",1
"He had a positive stress test which showed anterior, anteroseptal, anterolateral, apical and inferoapical myocardial infarction and ischemia.",0
"He then had a cardiac catheterization on , which revealed a 40 to 50 percent left main lesion, 95 percent left anterior descending coronary artery lesion, a 75 percent left circumflex lesion with an ejection fraction of 35 to 40 percent.",1
He is now admitted for elective coronary artery bypass graft.,1
PAST MEDICAL HISTORY: History of noninsulin dependent diabetes mellitus.,1
Status post hand and wrist surgery.,0
Glucovan 5/500 one in the a.m. and two in the p.m. 4.,0
ALLERGIES: He has no known allergies.,0
FAMILY HISTORY: Significant for coronary artery disease.,1
"SOCIAL HISTORY: He lives with his wife, quit smoking fifteen years ago and has not had alcohol for ten years.",0
He does smoke three cigars per day.,0
"REVIEW OF SYMPTOMS: Significant for recent fatigue, question of arthritis in his shoulders.",0
"PHYSICAL EXAMINATION: On physical examination, he is a well- developed, well-nourished white male in no apparent distress.",0
Vital signs are stable and afebrile.,0
"Head, eyes, ears, nose and throat examination is normocephalic and atraumatic.",0
"The neck was supple with full range of motion, no lymphadenopathy or thyromegaly.",0
Carotids are two plus and equal bilaterally without bruits.,0
The lungs are clear to auscultation and percussion.,0
"Cardiovascular examination is regular rate and rhythm, normal S1 and S2, with no murmurs, rubs or gallops.",0
"The abdomen was soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly.",0
"Extremities were without cyanosis, clubbing or edema.",0
Pulses were two plus bilaterally throughout with the exception of dorsalis pedis which was one plus bilaterally.,0
"HOSPITAL COURSE: He was admitted and on , he underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending coronary artery with an extension endarterectomy of the left anterior descending coronary artery and reversed saphenous vein graft to the posterior descending coronary artery and ramus.",1
Cross clamp time was 97 minutes; total bypass time was 143 minutes.,0
He was transferred to the CSRU on Neo- Synephrine and Propofol and had a stable postoperative night.,0
He was extubated postoperative day number one.,0
He was transferred to the floor postoperative day number two and had his chest tubes discontinued.,0
"Postoperative day number three, his epicardial pacing wires were discontinued and, postoperative day number four, he was discharged to home in stable condition.",0
twice a day for seven days.,0
Percocet one to two tablets p.o.,0
Glucovan 5/500 one tablet in the morning and two tablets at night.,0
"His laboratories on discharge revealed white blood cell count 8.2, hematocrit 27.1, platelet count 215,000.",0
"Sodium 141, potassium 4.1, chloride 106, CO2 29, blood urea nitrogen 18, creatinine 0.6, blood sugar 89.",0
FOP: He will be followed in one to two weeks by Dr. and in four weeks by Dr. .,0
Dictated By: MEDQUIST36 D: 14:52:33 T: 15:38:39 Job#:,0
"5:38 AM CHEST (PORTABLE AP) Clip # Reason: ARDS, R ptx ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with pneumococcal sepsis/ pneumonia ARDS, DIC, significant subcutaneous emphysema, right ptx.",1
"REASON FOR THIS EXAMINATION: ARDS, R ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumococcal sepsis, ARDS.",0
PORTABLE SUPINE CHEST: The ETT and right IJ line remain in satisfactory position.,0
"Three chest tubes are in place on the right, terminating in the region of the right upper lobe.",0
There has been significant interval improvement in the degree of subcutaneous emphysema.,0
"There are persistent bilateral patchy opacities, with slightly more confluent areas in the right upper lobe.",0
"When compared to more remote examinations, the parenchymal opacities have improved.",0
Again seen are multiple calcified granulomas bilaterally.,0
"Persistent multifocal patchy opacities, improved when compared to the patient's admission chest radiograph.",0
This is consistent with the given the history of pneumococcal sepsis and ARDS.,0
"Diffuse calcified granulomas, perhaps reflective of previous histoplasmosis.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: OME The patient's date of discharge is pending.,0
"This dictation covers the hospital course from admission, until .",0
The remainder of the hospital course will be dictated by the next intern taking over care for this patient.,0
CHIEF COMPLAINT: AML with increased blasts on a CBC.,0
"HISTORY OF PRESENT ILLNESS: This is a 46 year old male who developed dyspnea on exertion, palpitations and left abdominal pain and was diagnosed with pancytopenia in .",0
"Bone marrow aspirate was consistent with myelodysplastic syndrome, MDS.",0
He was started on Procrit at the time and Aranesp and treated with arsenic which was discontinued in .,0
"White blood cell count increased to 300,000 with 87 percent myeloblasts and he was treated with leukophoresis followed by induction chemotherapy 7 Plus 3, in , without infectious complications.",0
"A repeat bone marrow biopsy on , showed hypercellular marrow with myeloid maturation and diffuse reticular fibrosis.",0
"He was given another course of chemotherapy in , and went home on .",0
He received platelets and blood transfusions during this time.,0
"On , he saw Dr. in Clinic where he was noted to have increasing blast count.",0
He was asked to come into the hospital for admission of chemotherapy.,0
His appetite has been good and he has had improving energy recently.,0
"He denies fevers, chills, nausea, vomiting, shortness of breath, cough, chest pain, diarrhea or dysuria and his weight has increased by five pounds in the past week.",0
PAST MEDICAL HISTORY: AML as described above with induction chemotherapy 7 plus 3 in .,0
Vocal cord polyps removed in .,0
"History of optic disc elevation, right greater than left.",0
Neumega 7 cc subcutaneously q.,0
FAMILY HISTORY: Father with alcoholic cirrhosis.,0
SOCIAL HISTORY: He is married and lives with his wife in .,0
Quit alcohol at 28 years old.,0
Quit tobacco approximately five months ago.,0
Quit marijuana approximately one year ago.,0
Exposure to barium and lead in the past.,0
"PHYSICAL EXAMINATION: In general, well dressed, well nourished man in no apparent distress appearing slightly fatigued.",0
Vital signs are temperature of 98.3 F.; heart rate 95; blood pressure 160/80; respiratory rate 20; saturation of 100 percent on room air.,0
"HEENT: Pupils equal, round and reactive to light.",0
"Chest is clear to auscultation bilaterally with no wheezes, rales or rhonchi.",0
"Heart is regular rate and rhythm, normal S1, S2, II/VI systolic murmur, question flow murmur.",0
"Abdomen soft, nontender, nondistended, positive bowel sounds, positive hepatosplenomegaly.",0
"Extremities with no clubbing, cyanosis; one plus pitting edema bilateral lower extremities.",0
Neurological: Five out of five strength in all extremities.,0
Back tender over the bone marrow biopsy sites.,0
"PERTINENT LABORATORY DATA: Hematocrit is 24.0; white blood cell count is 4.7 with 51 percent polys, 2 bands, 34 lymphs, 19 monos, one eo, 29 percent blasts.",0
"INR is 1.3, fibrinogen 297, LDH 393, uric acid 6.8, creatinine 0.8, potassium 3.9, ANC is 959, ALT 73, AST 30, alkaline phosphatase 86.",0
ONCOLOGY: The patient presented with AML with increasing blasts on smear.,0
"The patient underwent chemotherapy with the FLAG protocol, which included Fludarabine, Ara-C and GCSF.",0
The patient had an echocardiogram on presentation which was normal.,0
He had an uncomplicated course during his hospitalization stay.,0
He got GCSF continual and his hematocrit continued to drop during the hospitalization course.,0
HEMATOLOGY: The patient's transfusion hematocrit threshold was 25.0.,0
He was given blood transfusions in- house to maintain a hematocrit of greater than 25 as well as platelet transfusions to be greater than 10.,0
"He had an episode where he required steroids, Decadron times one, prior to platelet transfusion as this had been occurring during his previous hospitalization stay at an outside hospital.",0
"INFECTIOUS DISEASE: The patient was maintained on Bactrim, Diflucan and Acyclovir for prophylaxis.",0
Levaquin was added once his ANC was less than 500.,0
"DIET, FLUID, ELECTROLYTES AND NUTRITION: The patient was maintained on a neutropenic diet.",0
"When counts decreased, then he was maintained on intravenous fluids.",0
"Once his hydration reached an equilibrium after chemotherapy, he was switched to KVO during the day and maintenance fluids at night times one liter.",0
ACCESS: The patient had a left Portacath already in place on admission.,0
He received a right triple lumen catheter at the Interventional Radiology in the right subclavian.,0
He had some pain associated at the site and got Oxycodone as needed.,0
VERTIGO: The patient experienced a one time episode of vertigo while getting blood and while getting high dose ARA-C. Otoscopic examination was unremarkable.,0
He had an MRI with gadolinium which was negative for any abnormalities except for mastoid and sphenoid fluid.,0
OPHTHALMOLOGY: The patient had a history of a visual field cut defect and optic disc swelling right greater than left.,0
The patient had Ophthalmology consulted in- house.,0
They recommended an orbital MRI to rule out leukemic infiltrate.,0
The patient had a fine cut MRI of the orbits which was negative for a leukemic infiltrate or mass effect.,0
Followup of a lumbar puncture that was performed in the patient prior to admission was obtained from the outside hospital and was negative for malignant cells or any infectious process.,0
The remainder of the hospital course will be dictated in a future discharge addendum summary by the next intern taking care of this patient.,0
Dictated By: MEDQUIST36 D: 14:31:07 T: 19:02:19 Job#:,0
"4:25 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: Eval for acute pathology Admitting Diagnosis: SEPSIS Field of view: 44 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with h/o cirrhosis and new abd pain, LLQ.",1
Also with fever and elevated creatinine.,0
"REASON FOR THIS EXAMINATION: Eval for acute pathology CONTRAINDICATIONS for IV CONTRAST: no urine output;elevated Cr ______________________________________________________________________________ FINAL REPORT HISTORY: 60-year-old man with history of cirrhosis, now with new abdominal pain, left lower quadrant.",0
TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained with oral and IV contrast.,0
Coronal and sagittal reformatted images were obtained.,0
CT ABDOMEN: There is mild dependent atelectasis.,0
The liver is somewhat shrunken and nodular in contour.,0
Adrenal glands and kidneys are within normal limits.,0
Prominent venous collaterals are observed around the spleen.,0
"Note is made of dilatation of small bowel loops, however contrast is seen passing into the colon.",0
There is diffuse colonic diverticulosis.,1
The wall of the colon is also diffusely thickened throughout its entire course.,0
Stranding in the right lower and left lower quadrants is observed.,0
Small flecks of free air are observed.,0
Note is made of prominent mesenteric and retroperitoneal lymph nodes.,0
CT PELVIS: Foley catheter is seen in the bladder.,0
Sigmoid diverticulosis is seen as is diffuse thickening of the wall.,0
There is a small amount of pelvic free fluid.,0
No pelvic or inguinal lymphadenopathy is identified.,0
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.,0
Diffuse thickening of the colon more consistent with ischemia from venous hypertension or a low flow state.,1
A less likely possibility is infectious colitis.,0
Small amount of intraperitoneal free air is consistent with perforation.,0
Associated portal hypertension as demonstrated by the large perisplenic varices and the splenomegaly.,1
The Micu was notified of these findings at the time of interpretation.,0
(Over) 4:25 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: Eval for acute pathology Admitting Diagnosis: SEPSIS Field of view: 44 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont),0
"4:48 PM CHEST (PORTABLE AP) Clip # Reason: new brady Admitting Diagnosis: RENAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with brady, new O2 requirement REASON FOR THIS EXAMINATION: new brady ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .",0
INDICATION: New oxygen requirement and bradycardia.,0
FINDINGS: Exam is limited by marked leftward patient rotation.,0
This limits assessment of cardiomediastinal contours.,0
Diffuse hazy opacity overlies the right hemithorax and probably reflects a moderate-to-large layering effusion on the supine radiograph.,0
There is also a suggestion of consolidation in the right mid and lower lung as well as in the left retrocardiac region.,0
"This could potentially represent multifocal aspiration, pneumonia, and less likely pulmonary edema.",0
There is also suggestion of a small-to-moderate left pleural effusion.,1
Initial further evaluation with repeat non-rotated radiograph would be helpful for more complete assessment.,0
8:51 AM CT HEAD W/O CONTRAST Clip # Reason: eval progression Admitting Diagnosis: LUNG CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with metastatic lung ca with intracranial bleed s/p brain mass resection and hematoma evacuation.,0
"REASON FOR THIS EXAMINATION: eval progression ______________________________________________________________________________ FINAL REPORT HISTORY: 43 y/o woman with metastatic lung CA to the brain, status post evacuation of intracranial hematoma.",1
"FINDINGS: Again seen is edema in the right parietal and superior temporal area, with a few hyperdense foci representing residual blood.",0
"Except for resolution of pneumocephalus seen on the prior study, this area of the evacuated hematoma is unchanged.",0
There is minimal residual shift of the septum pellucidum to the right.,0
The right occipital is still not well seen.,0
The remainder of the ventricular system appears within normal limits.,0
"Again noted are postsurgical changes, including the right parietal, left frontal and left parietal craniotomies.",0
"Otherwise, there is no interval change.",0
9:05 AM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: evaluate for source of bleed Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with dropping HCt on heparin gtt REASON FOR THIS EXAMINATION: evaluate for source of bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: JXKc TUE 10:57 AM No hemorrhage identified in the neck.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 65-year-old male with dropping hematocrit, on heparin drip, evaluate for source of bleed.",0
CA esophagus with s/p surgery.,0
No prior studies are available for comparison.,0
TECHNIQUE: NONCONTRAST MDCT axial images of the neck were obtained.,0
Coronal and sagittal reformations were obtained.,0
FINDINGS: No areas of acute hemorrhage are identified within the neck.,1
"Few scattered lymph nodes within the posterior cervical triangles are not pathologically enlarged by CT size criteria.There are atherosclerotic calcifications of the bilateral internal carotid arteries immediately distal to the bifurcation, left more severe compared to the right, with additional atherosclerotic calcifications of the aortic arch.",0
Evaluation for any lesions is limited due to the lack of IV contrast.,0
"Within the visualized paranasal sinuses and brain, small air-fluid levels are evident within the sphenoid sinus as well as a tiny amount of layering hemorrhage within the occipital of the left lateral ventricle.",0
These findings are better assessed on concurrent head CT.,0
"Within the visualized lung apices, there is a right central venous catheter, partially imaged.",0
"Left pleural thickening, with coarse calcifications along the pleura bilaterally are better assessed on concurrent CT of the torso.",0
"Multilevel degenerative changes are noted, most severe at C5-6 with a grade 1 retrolisthesis of C5 on C6 and posterior disc-osteophyte complexes noted.",0
No evidence of acute hemorrhage within the neck.,1
"Partially visualized small amount of layering hemorrhage within the occipital of the left lateral ventricle, better assessed on concurrent head CT. 3.",1
"MArked atherosclerotic calcifications in the carotid and vertebral arteries, inadequately assessed.",0
Dedicated vascular imaging can be considered for better assessment (Over) 9:05 AM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: evaluate for source of bleed Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont) LIMITED EVALUATION OF NECK FOR OTHER ABNORMALITIES GIVEN THE LACK OF IV CONTRAST.,0
"Multilevel degenrative changes in the cervical spine, as above.",0
see the report on Torso CT performed concurrently.,0
"3:42 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: patient with microperf in retroperitonium, eval for increase ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with above REASON FOR THIS EXAMINATION: patient with microperf in retroperitonium, eval for increase No contraindications for IV contrast ______________________________________________________________________________ WET READ: CCqc TUE 4:29 PM no change in bowel thickening ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Hypotension.",0
Question of free retroperitoneal air seen on CT from .,0
TECHNIQUE: Non-contrast images were obtained through the abdomen and pelvis.,0
No oral contrast was provided because the emergency room physician desired rapid scan to exclude free intra-abdominal air.,0
Comparison is made to a study of .,0
CT ABDOMEN WITHOUT IV CONTRAST: The previously administered oral contrast has passed to the large intestine.,0
"There is continued thickening of the wall of the descending colon, sigmoid colon and rectum.",0
A sliver of air is again seen posterior to the right common and internal iliac arteries.,0
On the current study this crescent of air appears is surrounded by a wall and can be connected with a loop of small bowel.,0
The size of this air collection is decreased compared to the study of .,0
There is no free air within the peritoneum.,0
There is no free fluid within the abdomen or pelvis.,0
Gallstones are again seen within the gallbladder.,0
Extensive vascular calcifications are unchanged.,0
"Non-contrast views of the liver, spleen, pancreas, and adrenal glands are normal.",0
There is no bowel obstruction.,0
CT PELVIS WITHOUT IV CONTRAST: The bladder is collapsed and the patient has a Foley catheter.,0
Continued colitis involving the descending colon and sigmoid colon.,0
"Air previously thought to be extraluminal is decreased in size, and represents small bowel.",0
This finding may represent a small internal hernia.,0
There is no evidence of associated obstruction.,0
The findings were discussed with Dr. of the surgical team.,0
"(Over) 3:42 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: patient with microperf in retroperitonium, eval for increase ______________________________________________________________________________ FINAL REPORT (Cont)",0
11:59 PM CHEST (PORTABLE AP) Clip # Reason: subcut emphysema- ?,0
lt pneumothx Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p CABG REASON FOR THIS EXAMINATION: subcut emphysema- ?,0
"lt pneumothx ______________________________________________________________________________ FINAL REPORT AP CHEST, 12:32 P.M., HISTORY: Status post CABG.",0
"IMPRESSION: AP chest compared to at 4:02 p.m. Moderate-sized bilateral pleural effusions and mild pulmonary edema largely dependent are new, obscuring the cardiac silhouette which may have enlarged slightly in the interim following extubation.",0
Tip of the Swan-Ganz catheter projects over the right pulmonary artery.,0
Left pleural and midline drains are still in place.,0
These findings were discussed with a house officer caring for this patient at the time of dictation.,0
9:51 AM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: S/P MVA ASSESS FOR FX ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man s/p motorcycle accident REASON FOR THIS EXAMINATION: Asses for fx No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: Motorcycle accident.,1
Evaluate for fracture of the spine.,0
TECHNIQUE: Non-contrast helical scanning of the cervical spine with sagittal and coronal reconstructions.,0
FINDINGS: There is a probable vascular groove traversing the junction of the right hemilamina of C1 adjoining the articular mass.,0
The remainder of the atlas is intact.,0
The remainder of the cervical spine appears normally aligned with no discontinuity present to suggest other fractures.,0
There is presumed incidental demonstration of fairly prominent calcification within the right lateral oropharyngeal wall.,0
Presumably this is dystrophic calcification within a tonsillar crypt.,0
CONCLUSION: No definite sign of fracture- see above report.,0
"9:51 PM CHEST (PA & LAT) Clip # Reason: r/p CHF r/o infiltrate Admitting Diagnosis: FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with h/o CHF and s/p 2 liver transplants now with fever, increased WBC, rhonchi, and change in mental status REASON FOR THIS EXAMINATION: r/p CHF r/o infiltrate ______________________________________________________________________________ FINAL REPORT CHEST 2 VIEWS: CLINICAL INDICATION: Fever and elevated white blood cell count.",0
Comparison is made to prior chest radiograph of .,0
There has been interval removal of a left subclavian catheter.,0
The heart size and mediastinal contours are within normal limits and stable.,0
There is a moderate to large right pleural effusion.,1
"Allowing for semi-erect positioning on the previous study, this is probably not changed.",0
The medial border of the right pleural effusion is somewhat unusual and is difficult to exclude a loculated component.,1
There remains adjacent increased opacity within the right mid and lower lung zones.,0
The left lung is clear and there is no evidence of left pleural effusion.,1
IMPRESSION: Persistent moderate to large right pleural effusion.,1
Correlative lateral decubitus radiograph may be helpful to exclude a significant loculated component.,0
Underlying infectious process in the right middle and lower lobes cannot be excluded.,0
"8:42 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; CT 100CC NON IONIC CONTRAST Reason: DIFFUSE ABD.PAIN,FEVERS.",0
"?ABSCESS?PERF Admitting Diagnosis: FEVER, ABDOMINAL PAIN Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with diffuse abdominal pain, fevers, chills, on peritoneal dialysis with peritonitis REASON FOR THIS EXAMINATION: r/o abscess, perf No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old woman with diffuse abdominal pain and fevers.",1
The patient is on peritoneal dialysis and presents with peritonitis.,1
COMPARISONS: Comparison is made to .,0
TECHNIQUE: 64-MDCT axial images of the abdomen and pelvis were obtained with oral and IV contrast.,0
Nonionic IV contrast was used due to patient's request.,0
CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: Multiple small nodules in the lung bases.,0
Some of the nodules are calcified and consistent with granulomas.,0
Most of the nodules are unchanged when compared to .,0
"There is one nodule seen in the last image (series 2, image 1) that measures 4 mm and it was not previously imaged.",0
There is bibasilar atelectasis that are new when compared to prior study.,0
The heart is in the upper limits of normal size.,0
There are no focal lesions in the liver.,0
The spleen and pancreas are within normal limits.,0
There is no evidence of small bowel obstruction.,0
The opacified loops of small bowel and stomach appear to be unremarkable.,0
"There are two hypodense areas in the midpole of the right kidney, the largest one measures 14 mm.",0
They most likely represent simple cysts.,0
"However, they were not well characterized in this study.",0
The ureters are not dilated.,0
There is a peritoneal dialysis catheter entering the anterior abdominal wall.,1
There are postoperative changes in the abdominal wall from prior hernia repair.,0
There is stranding of the mesentery and a small amount of peritoneal fluid in the abdomen and pelvis.,0
These findings are nonspecific and may be related to the peritoneal dialysis.,1
No discrete abscess is identified.,0
"There are multiple retroperitoneal paraaortic lymph nodes, but none of them meet CT criteria for pathology.",0
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There is a Foley catheter in the urinary bladder.,0
A small amount of free fluid in the pelvis and stranding of the mesentery as described above.,0
No free air in the pelvis is identified.,0
There is mild atherosclerotic changes of the aorta.,0
"There are small inguinal (Over) 8:42 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; CT 100CC NON IONIC CONTRAST Reason: DIFFUSE ABD.PAIN,FEVERS.",0
"?ABSCESS?PERF Admitting Diagnosis: FEVER, ABDOMINAL PAIN Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) lymph nodes that do not meet CT criteria for pathology.",0
BONE WINDOWS: There are no suspicious lytic or blastic lesions.,0
CT reformations were important to confirm the above-mentioned findings.,0
Diffuse stranding of the mesentery and small amount of free fluid in the abdomen.,0
These findings could be secondary to peritoneal dialysis and peritonitis.,1
"However, no discrete abscess or focal bowel abnormality to account for this process can be identified.",0
Multiple small nodules in the right lung base.,0
Most of them are unchanged since .,0
One of these nodules was not imaged before and measures 4 mm.,0
Hypodense areas in the right kidney as described above most likely represent simple cysts.,0
The larger one was seen in .,0
"9:23 AM CHEST (PORTABLE AP) Clip # Reason: evaluate PNA ______________________________________________________________________________ MEDICAL CONDITION: 20 year old woman with mvc, head trauma REASON FOR THIS EXAMINATION: evaluate PNA ______________________________________________________________________________ FINAL REPORT HISTORY: Motor vehicle accident, head trauma, evaluate for pneumonia.",1
TECHNIQUE: AP view of the chest.,0
Comparison with prior study from .,0
FINDINGS: The extreme right CP angle is not included in the present exam.,0
"Again seen is a Swan-Ganz catheter, an NG tube and an ETT in satisfactory and unchanged position.",0
The heart and mediastinum are normal.,0
"There are no consolidations, pleural effusions or pneumothorax.",0
"There are linear opacities in the left lung base, the atelectases in the right lung base have increased in the interval.",0
IMPRESSION: Improvement of bibasilar atelectases.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Please note patient's tracheostomy was NOT decannulated and a number 6 french tracheostomy remains in place.",0
"Please also note that patient is chronically in atrial fibrillation, however, he has adequate rate control and is anticoagulated.",1
Also note that tube feeds are being changed to full strength Impact with fiber given at 100cc/hour cycled over 18 hours.,0
5:36 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for progression of PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 45 y/o with treated multifocal pneumonia.,0
"REASON FOR THIS EXAMINATION: please evaluate for progression of PNA ______________________________________________________________________________ FINAL REPORT INDICATION: Multifocal pneumonia, now with new fevers.",0
Please evaluate for progression of pneumonia.,0
"PORTABLE AP SEMI-ERECT RADIOGRAPH OF THE CHEST: ET tube, nasogastric tube, and left subclavian central line in satisfactory position.",0
A right-sided PICC line has been removed in the interval.,0
There is increase in right-sided layering pleural effusion.,0
"There appears worsening of the left-sided opacity with air bronchograms now, also involving the left upper lung.",0
There appears to be some improvement in the opacity in the left lower lung.,0
The left-sided consolidation obscures the left mediastinal border.,0
The heart silhouette appears unchanged.,0
"8:19 AM PORTABLE ABDOMEN Clip # Reason: assess for free air/illeus Admitting Diagnosis: AORTIC STENOSIS\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with s/p AVR REASON FOR THIS EXAMINATION: assess for free air/illeus ______________________________________________________________________________ FINAL REPORT HISTORY: Status post AVR, assess for free air or ileus.",1
PORTABLE SUPINE ABDOMINAL RADIOGRAPH No priors are available.,0
There is a nondilated bowel gas pattern with mild gaseous prominence without evidence of pneumoperitoneum.,0
An oval radiopaque object noted in the right upper quadrant may correspond to a gallstone or intraluminal fecal content.,0
Radiopaque mediastinal drains project over the mid abdomen.,0
Nonspecific bowel gas pattern without evidence of obstruction or ileus.,0
No pneumoperitoneum on this limited view.,0
PATIENT/TEST INFORMATION: Indication: Chronic lung disease.,1
Height: (in) 67 Weight (lb): 339 BSA (m2): 2.53 m2 BP (mm Hg): 104/33 HR (bpm): 102 Status: Inpatient Date/Time: at 09:44 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
Lipomatous hypertrophy of the interatrial septum.,0
Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
Conclusions: The left atrium is markedly dilated.,0
"Global left ventricular function is probably normal, but a focal wall motion abnormality cannot be fully excluded.",0
Mild right ventricular dilation with normal systolic function.,0
Small pericardial effusion without echocardiographic signs of tamponade.,0
"2:46 PM CHEST (PA & LAT) Clip # Reason: eval pna ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with increased seizures REASON FOR THIS EXAMINATION: eval pna ______________________________________________________________________________ FINAL REPORT INDICATION: Increased seizures, evaluate for pneumonia.",0
"FINDINGS: The lungs are well expanded and clear without focal consolidation, pleural effusion or pneumothorax.",0
Cardiac and mediastinal silhouettes and hilar contours are normal.,0
Increased retrosternal clear space is unchanged.,0
The ventriculoperitoneal shunt is unchanged in position with the tip in the right upper quadrant.,0
"IMPRESSION: No pneumonia, edema or effusion.",0
"LINE PLACEMENT Clip # Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o Admitting Diagnosis: AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man s/p Redo-sternotomy, AVR.",1
"REASON FOR THIS EXAMINATION: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: radiograph.",0
FINDINGS: Patient is status post recent median sternotomy and coronary artery bypass surgery.,1
"Tip of endotracheal tube terminates 3.5 cm above the carina, Swan-Ganz catheter terminates in right ventricular outflow tract, and nasogastric tube courses below the diaphragm.",0
Midline drain and low lying right chest tube are also evident.,0
"Widening of cardiomediastinal contours probably reflects a combination of postoperative change, accentuation by portable supine technique, and increased volume status of the patient, but attention to this area on short-term followup radiograph would be helpful to exclude mediastinal hematoma as communicated to by telephone on at 4:06 p.m. at the time of discovery.",0
Mild perihilar edema is present as well as multifocal patchy atelectasis in the mid and lower lungs centrally.,0
Small left pleural effusion is noted but there is no evidence of a pneumothorax.,0
"5:02 PM CHEST (PORTABLE AP) Clip # Reason: acute process Admitting Diagnosis: METASTATIC RENAL CELL CARCINOMA\INTERLEUKIN (HD-IL2) ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with metastaic renal CA on IL-2 therapy, afib w/ RVR and HTN REASON FOR THIS EXAMINATION: acute process ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Metastatic renal cancer with AFib and hypertension.",1
Comparison is made with prior study of .,0
Right supraclavicular catheter tip is in the lower SVC.,0
The cardiac size is top normal.,0
"Aside from minimal atelectasis in the left lower lobe, the lungs are clear.",0
Previously seen lung nodules in CT of are below the resolution of this radiograph.,0
PATIENT/TEST INFORMATION: Indication: Right MCA stroke.,0
Height: (in) 71 Weight (lb): 200 BSA (m2): 2.11 m2 BP (mm Hg): 164/84 HR (bpm): 96 Status: Inpatient Date/Time: at 11:57 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,0
"Left ventricular wall thickness, cavity size and global systolic function are normal (LVEF >55%).",0
A small (4mm) focal mobile echodensity is suggested on the posterior leaflet (clip # only) that could not be confirmed in other views.,0
"IMPRESSION: Mildly thickened mitral leaflets with possible echodensity on the posterior leaflet as described, but without pathologic mitral regurgitation.",0
Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function.,0
"Compared with the prior study (images reviewed) of , comparative views were not acquired, but the possible mitral leaflet abnormality was not seen.",0
10:58 PM BABYGRAM (CHEST ONLY) Clip # Reason: ?,0
ETT position; evaluate lungs ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress; electively intubated REASON FOR THIS EXAMINATION: ?,1
ETT position; evaluate lungs ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Status post intubation.,0
Single view of the chest from is submitted for interpretation on .,0
Single view of the chest shows an endotracheal tube reaching the mid trachea.,0
"Air bronchograms are demonstrated and there is very little change in diffuse hazy opacity seen throughout both lungs, when compared to the study obtained 5 hours previously.",0
Bowel gas pattern remains normal.,0
IMPRESSION: ET tube in satifactory position.,0
Findings consistent with hyaline membrane disease.,0
PATIENT/TEST INFORMATION: Indication: Tachycardia/abnormal ekg (h/o CLL s/p allogenic stem cell transplant/MRSA sepsis/increased hypoxia.,1
Height: (in) 66 Weight (lb): 190 BSA (m2): 1.96 m2 BP (mm Hg): 108/62 HR (bpm): 104 Status: Inpatient Date/Time: at 11:10 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT VENTRICLE: Mildly dilated LV cavity.,0
AORTA: Mildy dilated aortic root.,0
Left ventricular dysnchrony is present.,0
IMPRESSION: Mild global biventricular systolic dysfunction.,0
1:42 PM CHEST (PORTABLE AP) Clip # Reason: central line placement ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with vomiting REASON FOR THIS EXAMINATION: central line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 39-year-old female with vomiting and central line placement.,0
SINGLE PORTABLE RADIOGRAPH: Patient is slightly rotated to the left.,0
A left internal jugular central venous catheter has its tip terminating at the cavoatrial junction.,0
Trace retrocardiac linear atelectasis is present.,0
Mild right upper lobe volume loss appears similar as compared to .,0
The lungs are otherwise clear.,0
An IVC filter is in stable position.,0
IMPRESSION: Left internal jugular central venous catheter with tip at cavoatrial junction without pneumothorax.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: 45cm right picc.,0
Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with new picc REASON FOR THIS EXAMINATION: 45cm right picc.,0
"______________________________________________________________________________ WET READ: NATg MON 8:31 PM Tip in RA, pull back 4cm.",0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 5:34 P.M., HISTORY: 55-year-old man with a new PICC line.",0
IMPRESSION: AP chest compared to : Right PIC line ends in the right atrium approximately 2 cm beyond the estimated location of the superior cavoatrial junction.,0
Lungs low in volume but clear.,0
"Nasogastric tube can be traced as far as the upper stomach, but the tip is indistinct.",0
Height: (in) 65 Weight (lb): 139 BSA (m2): 1.70 m2 BP (mm Hg): 111/46 HR (bpm): 62 Status: Inpatient Date/Time: at 10:14 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid inferior - hypo; septal apex - hypo; inferior apex - hypo; remaining LV segments contract normally.,0
Mild to moderate (+) MR. LV inflow pattern c/w impaired relaxation.,0
There is mild regional left ventricular systolic dysfunction with focal severe hypokinesis of the inferior wall and inferior septum.,0
The remaining segments contract normally (LVEF = 40-45 %).,0
Right ventricular chamber size is mildly dilated with normal free wall motion are normal.,0
IMPRESSION: Moderate concentric left ventricular hypertrophy.,0
Mild regional dysfunction c/w CAD.,0
Mild to moderate mitral regurgitation.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: r dl picc 47cm Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with REASON FOR THIS EXAMINATION: r dl picc 47cm ______________________________________________________________________________ WET READ: JXKc FRI 9:15 PM Right PICC line terminates in mid SVC.,0
NG tube terminates in proximal stomach and should be advanced for better positioning.,0
No PTX or acute process identified.,0
-jkang ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Assess right PICC.,0
Right PICC tip is in the mid SVC.,0
NG tube terminates in proximal stomach and should be advanced for standard positioning.,0
No pneumothorax or enlarging pleural effusions.,0
12:18 PM CHEST (PORTABLE AP) Clip # Reason: status-post left arm double-lumen picc placement.,0
please ch ______________________________________________________________________________ MEDICAL CONDITION: ds REASON FOR THIS EXAMINATION: status-post left arm double-lumen picc placement.,0
______________________________________________________________________________ FINAL REPORT HISTORY: S/P left double lumen PICC placement check position.,0
CHEST PORTABLE: Comparison is made to a prior study of .,0
Heart position and mediastinum are difficult to evaluate.,0
There is persistent opacification at both lung bases.,0
A tracheal stoma is identified and is in satisfactory position.,0
A left PICC is seen in the axilla.,0
The tip is not visualized in the mediastinum.,0
IMPRESSION: Tip of the left PICC cannot be visualized within the mediastinum due to overlying soft tissues.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: Mr. is a 50 year-old man who was an unrestrained passenger in a high speed motor vehicle accident against a telephone pole, question of loss of consciousness.",1
He was hemodynamically stable in the field.,0
There was a crushed steering wheel.,0
The patient is complaining of left sided chest pain.,0
He is transferred to the for further management.,0
He was given tetanus and Clindamycin.,0
PAST MEDICAL HISTORY: No known past medical history.,0
"PHYSICAL EXAMINATION ON ADMISSION: Significant for temperature of 101.4, heart rate of 80, blood pressure 140/palp, respirations 97% on nasal cannula.",0
Pupils are equal 4 to 3 bilaterally.,0
There is a through and through lower lip laceration through the Vermilion border.,0
There is intrusion of the four lower front teeth with chipped teeth.,0
Lungs are clear to auscultation.,0
Left chest wall has tenderness.,0
Area of tenderness at T3 in the back without step offs or obvious deformity.,0
Extremities are his right hand swelling with superficial laceration.,0
Gross motor and sensation is intact times four.,0
There is a superficial laceration of the left knee.,0
"LABORATORY: White blood cell count 7.5, hematocrit 36.7, normal platelets.",0
Electrocardiogram was normal sinus rhythm.,0
Radiologic workup included a trauma series that had a normal C spine.,0
"A note was made of a left third, fourth and fifth rib fractures with a small left apical pneumothorax.",0
Hand films at the time showed no fractures or dislocations of the right hand.,0
"Chest, abdomen and pelvic CT showed a minimal left pneumothorax, pneumocele and lung contusion on the left.",0
Rib fractures again of the left third through six ribs.,0
Negative abdomen pelvis CT and no evidence of thoracic lumbar spinal fractures.,0
CT of the sinuses and facial bones showed normal sinuses.,1
Posterior displacement of the four anterior mandibular teeth.,0
CT of the C spine showed no evidence of fracture or malalignment.,0
Completion C spine films again showed no fractures or malalignment.,0
Follow up chest x-ray showed an unchanged pneumothorax and rib fractures.,0
"Views of the thoracic and lumbar spine showed no lumbar thoracic spinal fractures, but a question of an inferior lower sternal fracture.",0
MRI of the thoracic spine was normal and films of the right shoulder showed no significant abnormalities.,0
HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit for monitoring given his pneumothorax and likely myocardial contusions.,0
The oral surgery team evaluated the patient and closed his lip laceration and used arch bars to stabilize his four lower front teeth.,0
He is started on Clindamycin and Peridex rinses.,0
He subsequently ruled out by enzymes and had no electrocardiogram changes.,0
He was transferred to the floor on hospital day number two on telemetry.,0
He persisted with thoracic spinal tenderness and TLS films and CTs were followed up with an MRI scan that was negative.,0
"He was started on a soft diet, which he tolerated well.",0
His antibiotics and pain medications were changed over to po and he was discharged to home without further complications.,0
He is to follow up with the oral surgery clinic and trauma clinic.,0
Dictated By: MEDQUIST36 D: 12:20 T: 07:41 JOB#:,0
12:33 PM CHEST (PORTABLE AP) Clip # Reason: r/o free air Admitting Diagnosis: PNEUMONIA;TELEMETRY;METHICILLIN RESISTANT STAPH AUREUS;VANCOMYCIN RESISTANT ENTEROCOCCUS ______________________________________________________________________________ MEDICAL CONDITION: year old man with distended abdomen s/p EGD today REASON FOR THIS EXAMINATION: r/o free air ______________________________________________________________________________ FINAL REPORT INDICATION: y/o man with distended abdomen.,0
"COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of yesterday.",0
There is continued mild congestive heart failure with cardiomegaly and small bilateral pleural effusions.,1
There is continued left lower lobe atelectasis.,0
No evidence of pneumothorax is identified.,0
There is no evidence of free intraperitoneal air seen.,0
The tip of the left sided PICC line is identified in the superior vena cava.,0
The right jugular IV catheter remains in place.,0
The NG tube terminates in the gastric body.,0
IMPRESSION: Continued mild congestive heart failure with cardiomegaly and small bilateral pleural effusions.,1
Continued left lower lobe atelectasis.,0
3) No evidence of free intraperitoneal air identified.,0
"3:00 PM CHEST (PORTABLE AP) Clip # Reason: eval for infection or other acute change ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with syncope and ams REASON FOR THIS EXAMINATION: eval for infection or other acute change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH CLINICAL HISTORY: Syncope, acute mental status change.",1
COMPARISON: Chest radiographs and .,0
TECHNIQUE: Single frontal supine portable chest radiograph.,0
FINDINGS: The study is limited due to position and low lung volumes.,0
Also note that the left costophrenic angle is not included in the study.,0
There has been interval removal of the endotracheal tube.,0
Interval development of mild- to- moderate right pleural effusion is seen.,0
Right lower lobe opacity can't be excluded.,0
"The heart is enlarged, associated with pulmonary vascular congestion and Kerley B lines consistent with pulmonary edema.",1
Median sternotomy changes are again identified.,0
Interval removal of right- sided venous catheters are noted.,0
There is an old fracture deformity of the right humeral neck.,0
Limited portable chest radiograph demonstrates interval development of mild-to-moderate right-sided pleural effusion.,0
Right lower lobe infiltrate can't be excluded.,0
"Cardiomegaly and pulmonary vascular congestion, findings compatible with mild-to-moderate congestive heart failure.",1
Further evaluation with dedicated PA and lateral chest radiographs can be performed.,0
12:49 PM CHEST (PORTABLE AP) Clip # Reason: eval for pleural effusions Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Status post AVF.,1
There are persistent low lung volume.,0
Mild right pleural effusion is probably unchanged allowing the difference in position of the patient.,1
Small left pleural effusion is also unchanged.,1
"Bilateral atelectases, larger on the right side, have increased on the right.",0
"The cardiac size cannot be evaluated, is obscured by the pleural parenchymal abnormalities.",1
Left PICC tip can be followed to the mid SVC.,0
7:52 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: partial sbo?,0
"Admitting Diagnosis: PULMONARY EMBOLIS Field of view: 45 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with pancreatic CA, one month s/p whipple in , s/p MICU stay with spontaneous bacterial peritonitis, now with partial sbo vs. ileus.",1
REASON FOR THIS EXAMINATION: partial sbo?,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old man with pancreatic cancer, status post Whipple, with spontaneous bacterial peritonitis, evaluate for partial small-bowel obstruction or ileus.",1
TECHNIQUE: MDCT-acquired contiguous axial images were obtained from the lung bases to the pubic symphysis.,0
"CONTRAST: Oral contrast, 150 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study.",0
"CT OF THE ABDOMEN WITH IV CONTRAST: At the lung bases, there are moderate sized bilateral pleural effusions with associated atelectasis.",0
"There is a large mass within the head of the pancreas, corresponding to the patient's known pancreatic cancer.",0
This measures approximately 4.7 x 5.0 cm.,0
There is no distal pancreatic ductal dilatation.,0
"Additionally, there are extensive small nodularities within the mesentery, suggesting mesenteric metastases.",0
There appears to be infiltration of this pancreatic mass into the adjacent duodenum.,0
The portal vein is patent.,0
"The SMV is patent, and travels adjacent to the mass.",0
"Splenic vein is patent; however, there appears to be narrowing of the splenic vein at its junction with the SMV.",0
The celiac axis and the SMA are widely patent.,0
"The liver demonstrates multiple hypoattenuating areas, which likely correspond to metastatic foci.",0
"Additionally, there are large wedge-shaped areas of difference in attenuation involving portions of the left and right lobes which suggest a perfusion difference or areas of fatty infiltration The spleen is normal in appearance.",0
"There is a 4.2 x 2.6 cm heterogeneous nodule within the left adrenal gland, which also may represent a metastatic focus.",0
The right adrenal gland and right kidney are normal in appearance.,0
Several hypodensities are seen within the left kidney which are too small to characterize.,0
"There is an extensive amount of ascites extending around the liver, the spleen, and within the intraperitoneal cavity to the pelvis.",0
The patient is status post Whipple procedure.,0
"Anastomosis can be seen of small-bowel to the stomach, to the gallbladder, and more distally, a (Over) 7:52 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: partial sbo?",0
Admitting Diagnosis: PULMONARY EMBOLIS Field of view: 45 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) jejunoileostomy can be identified.,0
"There is air and contrast within the gallbladder, likely from the bowel loops.",0
"Additionally, there is pneumobilia within the extra- and intra-hepatic biliary system, also relating to surgery.",0
Two small rounded foci of air can be seen adjacent to the liver beneath the diaphragm.,0
"This may be a result of recent intervention, suggest paracentesis.",0
No oral contrast extravasation is identified.,0
No other areas of free air identified.,0
There is no dilatation of small and large bowel loops.,0
There is extensive soft tissue anasarca.,0
CT OF THE PELVIS WITH IV CONTRAST: Foley catheter seen within the bladder.,0
The rectum is normal in appearance.,0
There is extensive amount of ascitic fluid within the pelvis.,0
BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified.,0
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology.,0
"A 5.0 x 4.7 cm mass in the pancreatic head, corresponding to the patient's known pancreatic cancer.",0
"There is extension of this into the adjacent duodenum, and extensive hepatic, mesenteric, and left adrenal metastases.",0
The main venous and arterial vasculature appears to be widely patent.,0
"The patient is status post Whipple for this, and changes relating to surgery can be identified.",0
"Additionally, there are two small foci of air adjacent to the liver, which may be from recent intervention such as paracentesis.",0
No other foci of air or oral contrast extravasation can be identified.,0
There is no evidence of small or large bowel obstruction.,0
Focal hypodensities within the kidneys which are too small to characterize.,0
Bilateral moderate sized pleural effusions with associated atelectasis.,0
There are wedge-shaped areas of different attenuation within the liver which may represent focal fatty infiltration or perfusion abnormalities.,0
Results were discussed with Dr. at 1:30 a.m. on .,0
"3:47 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval progression Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with aspiration pneumonia, intubated REASON FOR THIS EXAMINATION: evaluate for interval progression ______________________________________________________________________________ FINAL REPORT INDICATION: 86-year-old man with aspiration pneumonia who was intubated.",0
FRONTAL CHEST RADIOGRAPH: The endotracheal tube and right-sided subclavian central venous line are in unchanged positions.,0
Again identified is mild overinflation of the endotracheal balloon.,0
"Bilateral parenchymal opacities, worse at the bases have not changed in appearance.",0
IMPRESSION: No significant change in appearance of bilateral parenchymal opacities.,0
"4:25 AM CHEST (PORTABLE AP) Clip # Reason: for changes Admitting Diagnosis: ASCITES;LIVER AND RENAL DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with ESLD, resp distress, intubation REASON FOR THIS EXAMINATION: for changes ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for interval changes.",1
"FINDINGS: As compared to the previous radiograph, the pre-existing right basal opacity shows minimal signs of regression.",0
The lung volumes are slightly improved as compared to the previous image.,0
"Unchanged aspect of the left hemithorax, no focal parenchymal opacities have newly occurred.",0
Unchanged aspect of the cardiac silhouette.,0
Height: (in) 70 Weight (lb): 200 BSA (m2): 2.09 m2 BP (mm Hg): 119/53 HR (bpm): 78 Status: Inpatient Date/Time: at 11:41 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
AORTA: Moderately dilated aortic sinus.,0
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR).,1
"AVR well seated, normal leaflet/disc motion and transvalvular gradients.",0
[The amount of AR is normal for this AVR.],0
A bileaflet aortic valve prosthesis is present.,1
"The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients.",1
[The amount of regurgitation present is normal for this prosthetic aortic valve.],1
IMPRESSION: Trivial residual pericardial effusion.,0
Borderline-normal left ventricular systolic function.,0
Normally-functioning bileaflet aortic valve prosthesis.,1
"Compared with the prior study (images reviewed) of , left ventricular systolic function has slightly improved.",0
The other findings are stable.,0
Weight (lb): 294 BP (mm Hg): 140/68 HR (bpm): 100 Status: Inpatient Date/Time: at 11:49 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Moderate regional LV systolic dysfunction.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; remaining LV segments contract normally.,0
AORTIC VALVE: Mildly thickened aortic valve leaflets.,0
No MR. TRICUSPID VALVE: Tricuspid valve not well visualized.,0
GENERAL COMMENTS: Resting tachycardia (HR>100bpm).,0
There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal of the left ventricle.,0
The remaining segments contract normally (LVEF = 30-35 %).,0
No masses or thrombi are seen in the left ventricle but cannot be fully excluded.,0
The remaining left ventricular segments contract normally.,0
The aortic valve leaflets are mildly thickened (?#).,0
Extensive apical hypokinesis with depressed left ventricular function.,0
"Compared with the prior study (images reviewed) of , mitral regurgitation is not visualized (but image quality is worse).",0
Estimated pulmonary artery pressures could not be assessed.,0
11:35 AM CHEST (PORTABLE AP) Clip # Reason: please check for interval changes ______________________________________________________________________________ MEDICAL CONDITION: s/p ngt placment..pt with aspiration admitted for group a strep sepsis with intubation/extubation REASON FOR THIS EXAMINATION: please check for interval changes ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: Intubation and NG tube placement in patient with aspiration.,0
There is cardiomegaly with slight pulmonary vascular engorgement.,0
"There is opacity at the left base obscuring the left hemidiaphragm, consistent with consolidation in the left lower lobe.",0
There is biapical pleural thickening.,0
Cannot rule out small pleural effusions in this single view.,0
J tube overlies upper abdomen.,0
IMPRESSION: Probable left lower lobe pneumonia.,0
Cardiomegaly with possible CHF but no overt pulmonary edema or significant change in heart size since the prior study.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE CCU HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old female with past medical history of pulmonary embolism and pulmonary hypertension status post thromboendarterectomy at UCSD three weeks ago, who had been started on Coumadin prior to her discharge, who for the past week had been complaining of increasing shortness of breath with exertion and at rest, and substernal chest pain x1 week.",1
"The morning of admission she had complained of orthopnea, no PND, so she went to the Pulmonary Clinic, where Dr. had a CT of the chest done, which showed that she had a pericardial effusion.",0
She was sent to the Emergency Room.,0
An echocardiogram done in the Emergency Room showed a 3-4 cm circumferential pericardial effusion with right atrial and right ventricular collapse.,0
The patient was sent to the Catheterization Laboratory for pericardial centesis after having been given a unit of fresh-frozen plasma.,0
No vitamin K was given secondary to the patient's anticoagulation needs.,0
850 cc of fluid were drained.,0
The patient's hemodynamics and symptoms improved.,0
"REVIEW OF SYSTEMS: The patient had chest pain, dyspnea on exertion, orthopnea, shortness of breath, presyncope, no PND, no edema, no palpitations, or syncope.",0
She had a pulmonary embolus which was diagnosed in in the distal left main with extension to the upper and lower bronchi and right main bronchi.,0
She had been starting on Coumadin in .,0
Status post thromboendarterectomy at UCSD.,0
"Coumadin 10 mg , Wednesday, Friday, 15 mg Tuesdays, Thursdays, Saturdays, Sundays.",0
SOCIAL HISTORY: She is married.,0
"She has no history of tobacco use, social alcohol use.",0
FAMILY HISTORY: Her mother had a pulmonary embolus.,0
Her father had a DVT.,0
She has an aunt with lupus.,0
"EXAM ON ADMISSION: Vital signs in the Emergency Room: 97.2, 121/74, heart rate of 99, respiratory rate of 18, and sats 100% on room air.",0
"In general, she was alert and oriented times three, a thin white female in no apparent distress.",0
"HEENT: Pupils are equal, round, and reactive to light and accommodation.",0
"Mucous membranes moist, oropharynx clear.",0
"Cardiovascular: Regular, rate, and rhythm, normal S1, S2.",0
"She had a three-component friction rub, no murmurs.",0
She had jugular venous distention to 9 cm.,0
Respiratory: Clear to auscultation bilaterally.,0
"Abdomen is soft, nontender, nondistended, bowel sounds present.",0
"Extremities: No clubbing, cyanosis, or edema.",0
Her pulses were 2+ bilaterally.,0
Groin: She had postcatheterization left femoral A-V sheath.,0
"LABORATORIES ON ADMISSION: White count was 10, hematocrit was 33.7, platelets of 502.",0
Her complete blood count within normal limits.,0
Her LFTs were within normal limits.,0
Hypercoagulable workup in the past had been negative.,0
"STUDIES IN THE EMERGENCY ROOM: CTA of the chest showed no pulmonary embolus, large pericardial effusion.",0
The last echocardiogram in showed an ejection fraction of 55% with right ventricular hypertrophy.,0
"The transthoracic echocardiogram on the day of admission showed a 3-4 cm circumferential pericardial effusion with RA and RV collapse, and respiratory variations consistent with tamponade.",0
"ELECTROCARDIOGRAM: Normal sinus rhythm, heart rate of 100, it was normal voltage.",0
She had T-wave inversions in V3 to V5 which were old and questionable pulsus alternans.,0
"The patient was admitted to the CCU after having gone to the Catheterization Laboratory, where they drained 850 cc of bloody fluid.",0
HOSPITAL COURSE BY SYSTEMS: Cardiovascularly: The patient's drain was left in place.,0
"The plan was not to discontinue the drain until the output had fallen to almost 0, but with the plan of restarting the Coumadin prior to pulling the drains to make sure that no further accumulation of fluid would happen.",0
Her hematocrit after the drain was placed were checked q3h until they stabilized.,0
"Even though the patient's hematocrit dropped to 33 to 27, she was not transfused as she was a healthy female with no coronary artery disease.",0
"On the evening of admission, followup chest x-ray showed pneumopericardium.",0
They felt that this was not significant.,0
"It was probably likely due to having drain the pericardial effusion, and her pericardium having been stiff from being expanded for so long.",0
"Thus, no action was taken.",0
"Of note, the pericardial drain significant amounts of fluid and air were drained from the patient and the pneumopericardium had resolved as of the 9th.",0
"The patient on the 9th, had drained 875 cc of fluid.",0
Her pain was being controlled.,0
Pulmonary wise: She was being weaned off oxygen.,0
She had been on 3 liters of oxygen prior to going to pericardial drainage.,0
Her Coumadin had been held as her INR was 4.0 on admission.,0
Echocardiogram done on the 9th showed an ejection fraction of 55%.,0
"On the 10th, the pericardial drain drained 150 cc.",0
Her Coumadin was restarted that evening and Heparin was started as well as the patient's INR had become subtherapeutic.,0
Her pain was still being controlled.,0
"On the 11th, the patient had a small nosebleed likely due to the oxygen.",0
She was given humidified air to breathe.,0
Her sats had remained stable throughout.,0
The pericardial drain was discontinued on the 11th as it had put out less than a half a cc in 24 hours.,0
"On the 12th, the patient had been stable overnight.",0
"Her INR was 2.5, and her pain has been controlled.",0
"As she had no other acute needs, she was discharged home.",0
"DISCHARGE INSTRUCTIONS: If she experiences any chest pain, felt short of breath, or increasing fatigue, to please her M.D.",0
or go to the Emergency Room.,0
She is being discharged on Coumadin 10 mg tablet to be taken every evening.,0
Her Coumadin level was currently therapeutic.,0
She needs to have her INR level checked by her PCP later that week.,0
History of pulmonary embolism status post thromboendarterectomy.,0
"RECOMMENDED FOLLOWUP: She was to followup with Dr. on , at 1:45 pm.",0
"She was to have a follow-up echocardiogram, , at 11 am.",0
She was to followup with Dr. on at 11:30 am.,0
"MAJOR SURGICAL OR INVASIVE PROCEDURES: Cardiac catheterization, repair of pericardial effusion drainage.",0
Ibuprofen 600 mg take one q8h prn for seven days.,0
Coumadin 10 mg po q hs at bedtime.,0
This would be dosed by her primary care physician.,0
Dictated By: MEDQUIST36 D: 19:07 T: 09:53 JOB#: cc:,0
"Admitting Diagnosis: AORTIC INSUFFICIENCY\AORTIC AND MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with AVR/MVR REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
Pt in OR 3 and will be in CSRU in 180 mins.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: Radiograph of INDICATION: Status post cardiovascular surgery.",0
FINDINGS: There has been interval median sternotomy and aortic and mitral valve replacement procedures.,1
"New widening of cardiomediastinal contours is present and could reflect a combination of postoperative change, increased volume status of the patient, and accentuation by technique, clinical correlation and careful radiographic followup is recommended to exclude mediastinal hematoma.",0
"Note is made of pneumopericardium, but there is no evidence of pneumothorax.",0
Indwelling monitoring and support devices are in standard position.,0
Patchy perihilar and left retrocardiac opacities are likely due to atelectasis.,0
Small amount of subcutaneous emphysema is present in the left neck.,0
3:14 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for PNA Admitting Diagnosis: LARYNGEAL CANCER ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with emergent trach for resp distress in the setting of stridor and larygeal ca and crackles on left REASON FOR THIS EXAMINATION: Please eval for PNA ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW.,0
HISTORY: Emergent trach for respiratory distress.,1
"FINDINGS: The patient is status post tracheostomy, which is not significantly changed compared to the film from earlier the same day.",1
The cardiac and mediastinal silhouettes are normal.,0
The lungs are clear without infiltrate or effusion.,0
3:15 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval ETT position Admitting Diagnosis: LUNG CANCER;TRACHEAL ESOPHAGEAL FISTULA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with TEF and intermittent cuff leak.,0
"REASON FOR THIS EXAMINATION: eval ETT position ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: Evaluate position of the endotracheal tube.,0
FINDINGS: Comparison is made to the previous study performed nine hours earlier.,0
There is an endotracheal tube whose distal tip is 3 cm above the carina.,0
There is again seen some hyperinflation of the ETT cuff.,0
A left-sided bronchial stent is again seen in unchanged position.,0
There is opacification of the right lung with unchanged volume loss.,0
There is mproved aeration of the left base since the previous study.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Dilaudid / Colchicine Attending: Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Redo-Sternotomy, Drainage of old pericardial effusion and partial pricardectomy History of Present Illness: 65 y/o male who underwent coronary artery bypass graft x 3 on .",0
Re-admitted with tamponade and underwent pericardiocentesis.,0
During that admission had recurrent effusion and he then underwent right VATS/window on .,0
Went home shortly after and was readmitted again on with recurrent effusion.,0
Underwent subxiphoid window and discharged several days later.,0
Patient recently completed 3 months of Prednisone and still c/o SOB/DOE.,0
Echo on shows pericardial clot at mid RV level.,0
"Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 , Pericardial Effusion s/p Percardiocentesis and R VATS/window 7/15/006 and s/p Subxiphoid window , Hypertension, Hyperlipidemia, Gastroesophageal Reflux Disease, Depression Social History: Lives with wife, works as a carpenter.",1
Cigs: quit in ETOH: 1-2 drinks/day Family History: Unremarkable.,0
"Physical Exam: VS: 74 20 130/80 5'7"" 215# Gen: Well-appearing male in NAD HEENT: EOMI, PERLL, NC/AT Neck: Supple, FROM, -JVD, -bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft-, NT/ND, +BS and obese Ext: Warm, well-perfused, -edema, -varicosities Neuro: MAE, non-focal, A&O x 3 Pertinent Results: CXR: Decreased right-sided pulmonary edema with improved right lower lobe atelectasis and stable left lower lobe atelectasis.",1
"Echo: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded.",0
IMPRESSION: Mildly dilated right ventricle with preserved global biventricular systolic function.,0
"Compared with the prior study (images reviewed) of , the right ventricle is slightly more dilated.",0
Chest CT: Pulmonary embolism through the right upper and right lower lobes.,1
Stable left lower lobe partial collapse.,0
Findings in the right lung are most likely due to asymmetric pulmonary edema.,0
Small stable left pleural effusion.,0
LE U/S: No evidence of DVT in either lower extremity.,0
Extensive small pulmonary emboli to the right upper and right lower lobes.,0
Relative sparing of the right middle lobe.,0
Some of these are chronic in appearance.,0
Associated airspace abnormalities can represent infarction or pneumonia or both.,0
Left lower lobe partial collapse.,0
Echo: PRE PERICARDIECTOMY: Overall left ventricular systolic function is normal (LVEF>55%).,0
The left ventricular cavity is small.,0
"There is a large pericardial effusion which appears loculated, compressing on the inferior wall of the left ventricle .",0
Mild to moderate mitral regurgitation present.,0
POST PERICARDIECTOMY: The loculated effusion is no longer present with resolution of the inferior wall compression.,0
The mitral regurgitation is somewhat improved and appears to be mild now.,0
The rest of the exam is unchanged from pre periocardiectomy.,0
01:38PM BLOOD WBC-11.0 RBC-3.85* Hgb-10.7* Hct-32.2* MCV-84 MCH-27.8 MCHC-33.2 RDW-15.1 Plt Ct-196 03:15AM BLOOD WBC-7.9 RBC-3.50* Hgb-9.5* Hct-29.4* MCV-84 MCH-27.0 MCHC-32.2 RDW-15.4 Plt Ct-196 06:20AM BLOOD WBC-14.6* RBC-5.17 Hgb-14.1 Hct-44.4 MCV-86 MCH-27.3 MCHC-31.8 RDW-15.2 Plt Ct-636* 01:38PM BLOOD PT-14.5* PTT-24.2 INR(PT)-1.3* 06:20AM BLOOD PT-35.1* PTT-36.1* INR(PT)-3.8* 01:38PM BLOOD UreaN-19 Creat-0.9 Cl-106 HCO3-29 01:38PM BLOOD UreaN-19 Creat-0.9 Cl-106 HCO3-29 06:20AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-144 K-4.0 Cl-102 HCO3-33* AnGap-13 Brief Hospital Course: Mr. was a same day admit after undergoing all pre-operative work-up as an outpatient.,0
On he was brought to the operating room where he underwent a redo-sternotomy with drainage of old pericardial effusion and partial pericardectomy.,0
"Later on op day he was weaned from sedation, awoke neurologically intact and extubated.",0
His pre-op meds were restarted and was started on beta blockers and diuretics as well.,0
He was gently diuresed towards his pre-op weight.,0
Later on post-op day one he was transferred to the telemetry floor.,0
On post-op day two his chest tubes were removed.,0
On post-op day two and three he was c/o of some shortness of breath and required additional oxygen support via nasal canula secondary to room oxygen sats of 87-91%.,0
Mr. shortness of breath progressively worsened and on post-op day four a chest CT revealed a pulmonary embolism.,1
He was transferred back to the CSRU and early on post-op day six he re-intubated for worsening hypoxia.,0
A bronchoscopy was performed and he was started on IV heparin.,0
Pulmonary and hematology were consulted on this day as well.,0
His WBC was also elevated and blood cultures were taken and he was started on broad spectrum antibiotics.,0
Infectious disease and Rheumatology were consulted on post-op day six.,0
He remained intubated for several more days while recovering from the pulmonary embolism.,1
Antibiotics were stopped after blood cultures came back negative.,0
"On post-operative day nine he was weaned from sedation, awoke neurologically intact ant extubated.",0
Over next couple of days he received aggressive pulmonary toilet and required hi- O2.,0
Coumadin was started and was titrated during his hospital until his INR was therapeutic.,0
His respiratory condition slowly improved and was doing well on post-op day fourteen and transferred back to the telemetry floor.,0
While on the floor he worked with physical therapy to regain his strength and mobility.,0
Cleared for discharge to rehab on POD ........... Target INR is 2.0- 3.0.,0
"Medications on Admission: Lipitor 80mg qd, Lisinorpil 20mg qd, Prilosec 20mg qd, Aspirin 81mg qd, MVI, Fluoxetine 40mg qd, Felodipine 10mg qd, Zetia 10mg qd, Chlorthalidone 25mg qd, Bisoprolol 5mg qd, Advil 200mg Discharge Disposition: Extended Care Facility: Long Term Health - Discharge Diagnosis: Recurrent Pericardial Effusion s/p Drainage of old pericardial effusion and partial pricardectomy PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 , Pericardial Effusion s/p Percardiocentesis and R VATS/window 7/15/006 and s/p Subxiphoid window , Hypertension, Hyperlipidemia, Gastroesophageal Reflux Disease, Depression Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection.",1
5)No lifting greater then 10 pounds for 10 weeks.,0
6)No driving for 1 month.,0
Followup Instructions: Dr. in 4 weeks Dr. in weeks Dr. in weeks PT/INR goal 2.0-3.0 for pulmonary embolism MD,1
"11:40 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate lympadenopathy Admitting Diagnosis: FAILURE TO THRIVE Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with panc head mass, lympadenopathy REASON FOR THIS EXAMINATION: please evaluate lympadenopathy No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old male with pancreatic head mass and lymphadenopathy.",0
COMPARISON: CT abdomen and pelvis.,0
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were performed without IV contrast.,0
Multiphasic scans were then obtained of the abdomen and pelvis.,0
CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Bibasilar dependent atelectasis.,0
No focal liver lesions identified.,0
Pneumobilia is again seen and stable.,0
Hyperemic gallbladder wall with small amount of surrounding low-attenuation density likely representing fluid is also unchanged.,0
A stent is seen extending from the distal common bile duct into the duodenum.,0
"The head, body, tail of the pancreas are unremarkable.",0
Spleen is within normal size limits and contains multiple punctate low-attenuation lesions too small to characterize.,0
The right kidney contains multiple low attenuation lesions too small to characterize.,0
The previously seen hypovascular left kidney lesion is decreased in size likely secondary to interval core biopsy.,0
As previously described there is extensive lymphadenopathy seen surrounding the pancreatic head and extending retroperitoneal in the periaortic region extending to the bifurcation of the iliacs.,0
"A representative node is seen on series 4, image 48.",0
"It is left periaortic, measures 21 mm and is unchanged compared to previously measuring 20 mm.",0
No free air or free fluid.,0
"Multiple scattered, nonpathologically enlarged mesenteric nodes.",0
Small bowel and large bowel are unremarkable.,0
"CT PELVIS WITH IV CONTRAST: The urinary bladder, rectum are unremarkable.",0
There are multiple pathologically enlarged nodes bilaterally within the inguinal region.,0
"A representative node seen on series 4, image 76 measures 17 mm and node is located lateral to the left external iliac artery.",0
"Large prostate again noted, unchanged with periureteric edema/filling defect on the right upon insertion into the right hemitrigone.",0
As mentioned previously these raise possibility of a possible bladder base lesion and recommend correlation with cystoscopy.,0
Unchanged bilateral fat containing inguinal hernias and extensive iliac nodal lymphadenopathy unchanged.,0
(Over) 11:40 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate lympadenopathy Admitting Diagnosis: FAILURE TO THRIVE Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) BONE WINDOWS: No suspicious lytic or sclerotic bony lesions.,0
Extensive lymphadenopathy unchanged compared to prior study from three weeks ago.,0
Findings consistent with systemic process such as lymphoma.,0
Less likely to represent diffuse metastatic disease.,0
Percutaneous biopsy can easily be achieved in various locations including retroperitoneum and external iliac chain specifically within the left external iliac region as marked on scan and indicated above.,0
"Left renal lesion significantly decreased in size, likely secondary to prior biopsy.",0
Lymphoma still a strong consideration within differential.,0
"Multiple low attenuation lesions within right kidney, too small to characterize.",0
As previously described recommend cystoscopy for further evaluation.,0
Multiple unchanged splenic lesions too small to characterize.,0
"Liver lesions too small to characterize on prior study, not definitely seen on todays scan.",0
"3:40 AM CHEST (PORTABLE AP) Clip # Reason: assess any interval change Admitting Diagnosis: RESPIRATORY ARREST ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man intubated after hypoxic resp distress, ?",0
"asp PNA, REASON FOR THIS EXAMINATION: assess any interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxic respiratory distress.",0
PORTABLE AP CHEST: Comparison is made to study performed one day prior.,0
"Endotracheal tube, left IJ central venous catheter, and nasogastric tube remain in stable position.",0
The patient has undergone median sternotomy.,0
There is stable cardiomegaly and mild interstitial edema.,0
"In the interval, there is slightly improved aeration of the left lower lobe.",0
IMPRESSION: Improved aeration of the left lower lobe.,0
10:15 AM MR ABDOMEN W/O CONTRAST Clip # Reason: 71 yo female with complicated pmh with adrenal insuff by co ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with see above REASON FOR THIS EXAMINATION: 71 yo female with complicated pmh with adrenal insuff by stim test and is symptomatic with low bp's--now on stress dose steroids.,0
please page with any questions.,0
thanks ______________________________________________________________________________ FINAL REPORT INDICATION: 71 YEAR OLD WITH SEIZURE DISORDER.,0
"ADMITTED WITH HYPOTENSION, MENINGITIS, PSEUDOMONAS PNEUMONIA, AND GI BLEED, AND SEIZURES.",0
NOW WITH STATUS POST TRACHEOSTOMY AND PEG TUBE PLACEMENT.,0
"HYPERTHERMIC AND HYPOTENSIVE, EPIGASTRIC PAIN.",0
This is a markedly limited exam due to patient motion and body habitus.,0
Body habitus prevents the utilization of the phase coil array and thus the images have markedly decreased signal noise.,0
The three non-breath hold sequences utilized for interpretation are the axial and coronal T1 weighted images and the coronal STIR weighted images.,0
MRI ABDOMEN WITHOUT CONTRAST: There is a right adrenal mass which measures approximately 1.2 x 0.8 cm.,0
This cannot be characterized due to the poor signal to noise.,0
"Review of the recent CT of the abdomen dated reveals that this lesion does not attenuation features on CT, but wash-out curves on CT could be used to attempt to establish diagnosis of an adrenal adenoma.",0
The left adrenal is unremarkable.,0
"The spleen, kidneys, and pancreas as well as liver are unremarkable but this is a markedly limited examination.",0
Noted are bilateral pleural effusions and associated dependent atelectasis.,0
Right adrenal mass as described above which cannot be characterized due to poor signal to noise.,0
"This lesion does not attenuation features on CT, but a wash-out curve on CT could be performed to attempt to establish of diagnosis of an adrenal adenoma.",0
7:31 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: lung collapse?,0
Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with ptx s/p chest tube REASON FOR THIS EXAMINATION: lung collapse?,1
______________________________________________________________________________ FINAL REPORT INDICATION: Status post chest tube.,0
FINDINGS: A chest tube is in place in unchanged position compared to at 5:00 a.m. A very small apical pneumothorax is still present.,1
Multiple right rib fractures are again identified.,0
Perihilar haze and increased opacification of the lungs indicates fluid overloaded status.,0
The cardiac and mediastinal silhouettes are stable.,0
Slight right residual pneumothorax with chest tube in place.,1
"8:50 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate pneumothorax Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with severe asthma p/w COPD exacerbation, ?PNA, intubated for resp failure, s/p PTX with CT to suction.",1
REASON FOR THIS EXAMINATION: Evaluate pneumothorax ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumothorax.,0
"AP CHEST: Comparison with one day prior, there is a tiny right apical pneumothorax with a small-bore right chest tube in place.",0
There is subcutaneous emphysema on the right.,0
"The ET tube, right central line and NG tube are in satisfactory position.",0
"No pleural effusions, focal consolidations, or vascular congestion.",0
IMPRESSION: Persistent subcutaneous emphysema and tiny right apical pneumothorax.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY INTERIM DISCHARGE SUMMARY: HISTORY OF PRESENT ILLNESS: This is a 60 year old right handed woman with a past medical history of coronary artery disease, hypertension, history of aneurysm clip seven years ago at , who at 4:00 p.m. on the day of admission had sudden onset vertigo, right facial weakness, and dysarthria.",1
"The week prior she had had one minute episodes of a ""dizzy"" sensation while she was sitting and watching television and noted some heaviness in the left leg only.",0
"Transport services reported that the patient had had headache in the right temporal region, now resolved per the patient.",0
"Systolic blood pressure was in the 160s on arrival, heart rate in the 80s, and she is in sinus rhythm.",0
Temperature at the outside hospital was 96.1.,0
Daughter-in-law and son report very severe right facial droop and dysarthria that is very difficult to understand her.,0
"It improved in the Emergency Department at the outside hospital, but she is not still at baseline.",0
"The patient also reports ""dizziness"".",0
"Coronary artery disease, status post coronary artery bypass grafting.",1
History of transient ischemic attack with speech slurring one year ago and hot flashes.,0
"Gastrointestinal, loose stools, dark stools, incontinence of urine and feces with coughing.",0
Suspect gastrointestinal problems but she has not been scoped.,0
"There are no liver, kidney, cancer history and no history of diabetes mellitus.",1
"Fracture of the arm, status post pin in , pins out three days prior to admission.",0
"Aneurysm clip at in , incidental finding.",0
"History of coronary artery bypass graft, two vessel at in .",1
MEDICATIONS ON ADMISSION: (At home) 1.,0
SOCIAL HISTORY: Tobacco quit .,0
No alcohol and no drugs.,0
Nurse comes three times per week.,0
Son lives down the street.,0
FAMILY HISTORY: Mother with history of myocardial infarction.,1
Aneurysms run in the family.,0
"PHYSICAL EXAMINATION: On admission, vital signs revealed temperature 96.1, heart rate 92, blood pressure 140/110, respiratory rate 18, oxygen saturation 92% in room air.",0
"Head, eyes, ears, nose and throat examination - sclera clear.",0
Mucous membranes are moist although dry around the mouth.,0
The heart is regular rate and rhythm.,0
Chest - Lungs clear to auscultation bilaterally anteriorly.,0
"The abdomen is obese, soft.",0
Neurologic examination - mental status - alert and oriented.,0
There is dysarthria although she follows commands and speech is fluent.,0
"Upgaze, right more than left.",0
She looks to the right and left.,0
Right eye did not look laterally.,0
"Right pupil 4.0 millimeters, left pupil is 6.0 millimeters.",0
"Ptosis in the right eye, torsional upbeating nystagmus in primary gaze.",0
Decreased sensation in right V1 through V3.,0
There is tongue midline but slightly deviated to the left.,0
Hearing is intact bilaterally to finger rub.,0
"Over the course of hospitalization, the nystagmus has improved significantly as well as the facial droop although she does continue to have somewhat of a facial droop.",0
Motor - bilateral grasp is .,0
Tibialis anterior and gastrocnemius .,0
The patient did continue to have full strength throughout.,0
Sensation intact bilaterally to light touch throughout.,0
Coordination - fine finger movements intact bilaterally in hands.,0
"She moves very ataxic on initial examination, however, this improved significantly and she has much less ataxia on .",0
"LABORATORY DATA: On , white blood count 10.3, hematocrit 30.7, and she was transfused throughout the hospital course to attempt to keep the hematocrit above 30.0.",0
"However, stool guaiac was negative.",0
"INR on , was 1.4.",0
Partial thromboplastin time was 63.8.,0
Protein B 121 which is normal.,0
"Urinalysis on , was positive.",0
"Repeat urinalysis after treatment on , is now negative.",0
"Glucose 120, blood urea nitrogen 10, creatinine 0.7, sodium 140, potassium 4.4, chloride 107, bicarbonate 27 on .",0
"ALT 19, AST 15, LDH 154, alkaline phosphatase 58, amylase 11, total bilirubin 0.5.",0
She ruled out for myocardial infarction by enzymes twice.,1
"Calcium 8.9, phosphate 4.3, magnesium 2.4.",0
"Iron 34, total cholesterol 178, TIBC 224, Vitamin B12 315, folate 12.7, haptoglobin 238, ferritin 41, transferrin 172.",0
"Triglycerides 103, HDL 54, LDL 103, homocysteine 5.9.",0
"Urine culture was growing Klebsiella oxytoca and Enterococcus species, both of which are pansensitive.",0
Sputum culture was no growth.,0
Protein S 68 which is within normal range.,0
"Angiocardiolipin antibodies IgG and IgM normal at 3.0 and 3.1, respectively.",0
Lipoprotein A is high at 60 on .,0
"Initial magnetic resonance scan of the head showed bilateral pica infarcts, also an aneurysm clip causing loss of signal, inability to evaluate in distal right internal carotid artery M1 and A1 segments.",0
"Angiogram on , showed multiple areas of thrombosis including right vertebral artery thrombosis, left pica thrombosis, stenosis at the origin of the right anterior inferior cerebellar artery as well as stenosis of the left vertebral artery in both its proximal segment above the level of C5 vertebral body as well as the level of C1 vertebral body, approximately 50%, as well as distal intracranial left vertebral artery stenosis greater than 60% but with a patent basilar artery and collateral flow as described in the results.",1
Serial head CT proved stable.,0
There is hypoattenuation in the cerebellar cortex consistent with pica infarction bilaterally.,0
"There is some surrounding edema, however, no midline shift or evidence of tonsillar herniation.",0
There was some distortion of the fourth ventricle and flattening of the quadrigeminal plate cistern which was unchanged as well as a hypodensity in the left basal ganglia consistent with an old infarct.,0
"There was never any herniation or change in the CT. CT of the abdomen and pelvis on , showed no evidence of retroperitoneal hemorrhage.",0
"This was obtained because of the patient's hematocrit, however, there was no retroperitoneal hemorrhage.",0
There was bilateral mild to moderate atelectasis in the lungs.,0
There was no free air and no lymphadenopathy.,0
There was a large left sided paraesophageal hernia.,0
This hernia required placement of nasogastric tube with the help of interventional radiology initially.,0
"Transthoracic echocardiogram revealed ejection fraction of 40%, left and right atrium normal in size, left ventricular wall thickness normal with mild regional left ventricular systolic dysfunction.",0
There is a moderate size thrombus in the left ventricle.,0
"Left ventricular wall motion abnormalities show at the anterior apex akinetic, septal apex akinetic, lateral apex akinetic and the apex akinetic.",0
Right ventricle and right ventricular chamber size and free wall motion normal.,0
Aortic root normal in diameter.,0
"Aortic valve leaflets mildly thickened, no aortic regurgitation.",0
Mitral valve showed trivial mitral regurgitation seen.,0
"HOSPITAL COURSE: The patient was admitted, initially transferred, and underwent angiogram revealing occluded right vertebral artery and stenosis in the left vertebral artery in addition to her pica infarcts bilaterally.",1
Transthoracic echocardiogram showed incidental clot in the heart although the infarcts were thought to be due to artery-artery emboli from the vertebrals.,1
"Hypercoagulable workup was originally sent because initially the clot in the heart was found, though likely this clot formed because of the akinetic apex.",0
The hypercoagulable workup revealed elevated lipoprotein A.,0
This will be repeated this week and will be treated with Niacin should it still be high.,0
The patient was started on Heparin on the day of admission especially given this clot in the heart and she was continued on Labetalol drip to control her blood pressure to keep it in the systolic range of 120 to 160.,0
"On , the day after admission, the patient was transiently transferred to the floor, however, she became agitated.",0
She self discontinued her femoral line which was her only access and later had some episode of desaturating to the mid 80s.,0
"The repeat head CT showed signs of cerebellar edema, but no herniation.",0
She was transferred back to the Intensive Care Unit.,0
"She did remain stable in the Intensive Care Unit and was started on Coumadin initially, however, was requiring frequent suctioning for her sputum.",0
Feeding tube was placed and she was started on tube feeds.,0
"She did become somnolent around the date of , however, she was found at that time to have a urinary tract infection and was started on Levaquin.",1
"On , was day six of the Levaquin.",0
The patient was transfused for her anemia.,0
Anemia workup was sent and her stool guaiac was negative.,0
"Later on that evening, she desaturated while being suctioned.",0
She had transient respiratory arrest and became very bradycardic.,0
Chest compressions were given for about one minute when the patient became asystolic and the patient was intubated.,0
"At the time of the code, the patient was at her baseline neurologic status and then after intubation she was moving all four extremities.",0
Head CT at that time was unchanged.,0
Heparin drip was temporarily stopped and a central line was placed.,0
The patient was placed on Propofol at that time.,0
The following day the patient was taken off the Propofol and she did awaken and was able to follow commands well.,0
"She was intubated for the next couple of days for stabilization of her respiratory status and was extubated on , and did well after that.",0
"By , the frequency of suctioning decreased and the patient was on nasal cannula.",0
"Her issues neurologically, the patient suffered bilateral pica strokes.",0
She is on Lipitor for future stroke prevention and also continues on Heparin drip until she has a therapeutic INR on her Coumadin.,0
"As for the elevated lipoprotein A, that will be repeated and then Niacin will be started if it does indeed remain elevated.",0
"Respiratory wise, she has been extubated and is stable, status post extubation.",0
"It is unclear as to whether some of her somnolence may have been due to CO2 narcosis and so today she has been maintaining oxygen saturation in the low to mid 90s and has become more awake, is doing well on oxygen by nasal cannula.",0
"Cardiovascularly, she is now on Metoprolol, Enalapril and p.r.n.",0
Hydralazine for her blood pressure and is off the Labetalol drip.,0
Gastrointestinal - She has a large hiatal hernia and nasogastric tubes are very difficult to place.,0
"She will receive a percutaneous endoscopic gastrostomy tube tomorrow , as she cannot swallow, has failed her swallowing evaluation and likely will not be able to swallow for some time.",0
Infectious disease - She ahs remained afebrile throughout her hospital course.,0
"She was found to have a urinary tract infection on , and is now on day six of the Levaquin.",1
This will likely be continued for seven days and stopped.,0
"Hematologically, her hematocrit remained stable.",0
Currently she is being transfused for hematocrit less than 30.0.,0
She has not had any retroperitoneal bleed and no guaiac positive stools.,0
"Renally, she is stable and there are no issues.",0
"Endocrine wise, she does have evidence of diabetes mellitus with a hemoglobin A1C of 6.0.",1
She is on four times a day fingerstick and her regular insulin sliding scale.,0
She will need outpatient follow-up for this.,0
Code Status - Her code status has been full code.,0
"She has improved as far as having no further double vision, less vertigo and less dysarthria at this point than on admission.",0
She is being currently stabilized for transfer to the floor at some point in the very near future.,0
"The oncoming resident will dictate the rest of the hospital course, discharge instructions, medications and follow-up.",0
Dictated By: MEDQUIST36 D: 20:04 T: 20:12 JOB#:,0
"3:14 PM PERC NEPHROSTO Clip # Reason: please place left percutaneous nephrostomy Admitting Diagnosis: SEPSIS;TELEMETRY ********************************* CPT Codes ******************************** * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN * * ANTEGRADE UROGRAPHY MOD SEDATION, FIRST 30 MIN.",0
"* **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with candidema, evidence of stone with obstruction on CT REASON FOR THIS EXAMINATION: please place left percutaneous nephrostomy ______________________________________________________________________________ FINAL REPORT INDICATION FOR THE EXAM: 88-year-old woman with ureteral stone on CT. RADIOLOGISTS: The procedure was performed by Drs.",0
", , and , the attending radiologist, who was present and supervising throughout the entire procedure.",0
PROCEDURE AND FINDINGS: The risks and benefits of the procedure were explained and written informed consent was obtained.,0
"The patient was placed in prone position on angiographic table, and the left flank was prepped and draped in usual sterile fashion.",0
Timeout was performed to confirm patient identity and the type of the procedure to be performed.,0
Ultrasound demonstrates mild hydronephrosis of the left kidney.,1
"Using 1% lidocaine and ultrasound guidance, left renal pelvis was punctured with a 20-gauge Chiba needle which was advanced into the renal parenchyma at the level of the inferior calix.",0
"The stylet was removed, and a small amount of contrast was injected and the nephrostogram demonstrated mildly dilated renal pelvis and ureter.",0
A 0.018 guidewire was advanced through the needle up to the level of the renal pelvis under fluoroscopic guidance.,0
"The needle was exchanged for an Accustick sheath system (sheath and dilator/cannula assembly), which was advanced up to the level of renal pelvis.",0
The stiffening cannula was unlocked and only the sheath and inner dilator was advanced into the ureter.,0
"The inner dilator of the Accustick sheath and the wire were then removed, and a 0.035 wire was advanced and coiled in the renal pelvis.",0
The Accustick sheath was removed over the wire and exchanged for an 8 French percutaneous nephrostomy tube that was advanced over the wire.,0
The wire was removed and the pigtail of nephrostomy tube was coiled within the renal pelvis.,0
Injection of small amount of contrast demonstrates good positioning of the catheter within the renal pelvis.,0
The pigtail was locked and the catheter was secured to the skin with 2-0 silk sutures and connected to nephrostomy bag for external drainage.,0
"Moderate sedation was provided by administering divided doses of 50 mcg of fentanyl throughout the total intraservice time of 30 minutes, during which the patient's hemodynamic parameters were continuously monitored.",0
IMPRESSION: (Over) 3:14 PM PERC NEPHROSTO Clip # Reason: please place left percutaneous nephrostomy Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ FINAL REPORT (Cont) 1.,0
Mildly dilated left renal pelvis and left ureter.,0
"Successful placement of an 8 French APD percutaneous nephrostomy tube under ultrassonographic and fluoroscopic guidance, with pigtail coiled in the left renal pelvis.",0
Tube is connected to an external bag.,0
7:53 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx Admitting Diagnosis: ATRIAL SEPTAL DEFECT\REPAIR ATRIAL SEPTAL DEFECT ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man s/p min.,1
ASD repair CT on water seal REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT INDICATION FOR STUDY: Ruling out pneumothorax in a 38-year-old man with ASD repair.,0
TECHNIQUE: Chest x-ray is done in a portable AP semi-erect manner.,0
There is interval removal of the endotracheal tube and NG tube.,0
Left internal jugular CV line in proximal SVC.,0
No pneumothorax on either right or left side.,0
There is a right-sided chest tube with its tip at the apex of the right lung.,0
There is atelectasis at left lower lobe.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Codeine / Codeine Anhydrous / Ambien Attending: Chief Complaint: Code Stroke/Altered mental status Major Surgical or Invasive Procedure: MRI EEG History of Present Illness: The pt is a 67 year-old gentleman who presented with alteration in mental status.,0
The pt was unable to offer a history at the time of my encounter.,0
"Therefore, the following history is per the primary team, EMS and the medical record.",0
"Per EMS, the pt was last seen well by his wife at 1am before going to bed last night (i.e.",0
8 hours prior to presentation).,0
"This morning at approximately 8am, his wife found him in bed not responding to her and ""thrashing around.""",0
"On their arrival, they found the pt to be unresponsive with eyes deviated to the right and ""pinpoint"".",0
"Given history of diabetes mellitus, fingersticks were performed and were 84 and 106.",1
He was given 2mg of IV ativan without effect.,0
He was subsequently brought to the ED for further evaluation.,0
"At the time of my initial encounter, the pt was in the midst of intubation.",0
"Therefore, a detailed NIHSS could not be performed (see brief examination below).",0
"He was subsequently sedated and paralyzed, unfortunately further obscuring the examination.",0
The pt was unable to offer a review of systems.,0
"Past Medical History: - Hypertension - Diabetes mellitus, on insulin (insulin regimen NPH 40 q am + SS) with HgA1C 5.",1
"- Chronic renal failure (Baseline creatinine 1.7 - 3.1) - Peripheral neuropathy - Glaucoma - Hepatitis B: SAg neg, SAb+, CAb+ - Hepatitis C: HCV VL 86K , genotype IB - Anemia - Baseline Hct 26-32 - H/O Chest pain, no CAD on angiography - Substance abuse (none since ') - H/O Osteomyelitis - H/O Back pain - Legally blind - H/O PPD conversion - Erectile dysfunction - H/O MVA with extensive injuries requiring skin graft Social History: Social history is significant for the absence of current tobacco use (quit in , 2 packs/week for ~50 yrs).",1
There is no H/O of alcohol abuse.,0
"No IVDU, although crack abuse till 's.",0
"Patient is married with 3 children, lives with wife.",0
"Family History: No CAD in family; h/o cancer Physical Exam: Vitals: T: 98.5F P: 80 R: 16 BP: 253/140 SaO2: 98% General: Lying in bed with eyes closed, intubated.",0
"HEENT: NC/AT, MMM Neck: No carotid bruits appreciated.",0
"No nuchal rigidity Pulmonary: Lungs with transmitted sounds bilaterally Cardiac: RRR, nl.",0
"S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally.",0
"Skin: no rashes noted, multiple healed scars over abdomen and legs.",0
Neurologic (initial examination just prior to intubation and sedation): -mental status: Does not open eyes to verbal or noxious stimuli.,0
-cranial nerves: PERRL 1.5 to 1mm and briskly reactive.,0
"Eyes were initially deviated to the right, on reexamination approximately 10 minutes later, EOMI to oculocephalic maneuver.",0
Corneal reflex and nasal tickle present bilaterally.,0
Was seen to move all extremities antigravity in a semi-purposeful manner during line placement before he was chemically paralyzed.,0
No overt adventitious movements were noted.,0
"-sensory: Could not assess prior to intubation, sedation and administration of paralytics.",0
"-DTRs: Could not assess prior to intubation, sedation and administration of paralytics.",0
Plantar response was mute bilaterally.,0
Pertinent Results: 09:50AM WBC-7.4 RBC-3.29* HGB-10.3* HCT-32.9* MCV-100* MCH-31.3 MCHC-31.3 RDW-14.8 09:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG 09:50AM cTropnT-<0.01 09:50AM CK-MB-6 09:50AM ALT(SGPT)-44* AST(SGOT)-76* CK(CPK)-134 ALK PHOS-77 AMYLASE-156* TOT BILI-0.3 11:57AM PHENYTOIN-15.6 Brief Hospital Course: Neurologic: Patient was initially admitted to the neuro-intensive care unit for close observation.,0
"Considerations for patient's etiology of mental status change were multiple and included seizure, hypertensive encephalopathy, metabolic, infectious, toxic, medication/substance withdrawl, stroke.",1
A head CT scan did not demonstrate evidence of bleed or evolving infarct.,0
MRI was negative for infarct but showed extensive small vessel disease presumably from poorly controlled hypertension.,0
As seizure was high on the differential patient had bedside EEG monitoring which showed moderate enceohpalopathy on and .,0
On a 15 second seizure was witnessed and captured with EEG showing no epileptiform acitivity and relatively normal background.,0
"In the emergency room he received 1.5 grams of IV phenytoin (in addition to total of 4mg IV lorazepam) in ED, and was continued on Dilantin 100/100/130, then increased to 100/100/230.",0
"LFTs were slightly elevated on , but normal on and again very mildly elevated .",0
Ammonia level was withing normal limits and then repeated for continued encephalopathy but continued to be normal .,0
CSF studies were sent to r/o CNS infection and patient had normal results with no growth and negative HSV PCR.,0
"A second set of MRI/CTs was obtained to make sure that patient had not developed any interval neurological process that could be affecting his mental status, and these studies were normal.",0
The pateint's delerium began to clear some after he was placed in a windowside bed and forced into a more regular day/night sleep schedule with daytime stimulation.,0
Cardiac wise he was followed on telemetry.,0
"Hypertension was previously poorly controlled at home on lisinopril, catapress, amlodipine and hydralazine.",0
"Lisinopril was increased from 20 to 40, amlodipine continued at 10 daily, hydralazine continued at 75 Q6hrs, catapress increased from 1 to 3.",0
Lopressor was started and eventually titrated up to 150mg TID.,0
Cardiac enzymes were negative at admission.,0
Pulmonary: patient self-extubated and tolerated well.,0
Endocrine: Patient's home doses of NPH insulin initially held as he was intubated and not receiving nutrition.,0
Was maintained on a regular insulin sliding scale.,0
"When tube feeds started, he had home dose of NPH (24 qAM, 20 qPM) restarted.",0
NPH titrated up as patient's blood sugars continued to be elevated.,0
consult called and patient was started on Lantus 15 with Humalogue sliding scale.,0
Renal: Has history of chronic renal insufficiency.,0
Creatinine was 2.3 on admission and corrected to baseline level of 1.8 within 24 hours.,0
The patient was found to be retaining urine during the admission.,0
"At discharge, he was being treated for a UTI and Foley was discharged.",0
He will need a post-void residual checked after transfer to assure that he is not retaining urine.,0
"Should he become aggitated or in pain, urinary retention needs to be ruled out.",0
Inectious Disease: CXR was negative for pneumonia.,0
UA was negative but urine cultures grew beta strep.,0
Was started on Bactrim initially and then changed to clindamycin based on sensitivities.,0
Stool studies showed no Cdiff.,0
CSF studies also sent and negative cultures and HSV PCR.,0
He had one UTI treated with Ciprofolxacin and then a second UTI developed before discharge.,0
He was started on Cipro and Vanc to which the organisms were sensitive.,0
"GI: LFTs slightly elevated , then normal .",0
Again mildly elevated with AST less elevated than prior but Lipase again similarly elevated with no clear reason.,0
Patient's abnominal exam at this time normal with no tenderness and normal bowel sounds.,0
"Patient had normal bowel movements and no diarrhea or tube feeding residuals, then passed swallow eval and started diabetic diet.",0
"FEN: was Hypernatremic so replenishing free water deficit of 3.4 L (plus insensible losses) with 100cc/hr of D51/2NS for total of 4 L Prophyllactically received SC heparin, pneumoboots, PPI.",0
Medications on Admission: (Per recent discharge summary): 1.,0
Clonidine 0.2 mg/24 hr Weekly 2.,0
Omeprazole 20 mg PO once a day.,0
Lisinopril 20 mg PO DAILY 5.,0
Amlodipine 10 mg PO DAILY 6.,0
"Insulin: NPH insulin 24 units in the morning, 20 units qhs 7.",0
Atorvastatin 10 mg PO DAILY 8.,0
Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed.,0
Pilocarpine HCl 4% Drops One Drop Ophthalmic Q8H 10.,0
Dorzolamide-Timolol 2-0.5 % One Drop Ophthalmic DAILY 11.,0
Latanoprost 0.005 % Drops One Drop Ophthalmic HS 12.,0
Hydralazine 75 mg PO Q6H 13.,0
Isosorbide Dinitrate 20 mg PO TID Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Hypertensive encephalopathy.,1
Patient becoming more oriented daily.,0
Discharge Instructions: FOllow up as below.,0
Do not drink or use drugs.,0
REHAB: Please note that the patient has history of urinary retention.,0
Please check a post-void residual tonight to assure that the patient is not retaining.,0
"If in the future, there is aggitation or pain, please consider that he may be retaining urine.",0
Please also place the patient in a window-adjacent bed.,0
His delerium seems to improve significantly if he is forced into a regular wake/sleep schedule by daytime stimulation.,0
"Followup Instructions: AFter discharge from rehabiliation, please call your : : , M. to arrange Neurologist: Provider: , MD Phone: Date/Time: 11:30. , of Building.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins / Fluconazole Attending: Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: Ms. is a 60F with severe chest wall deformity from polio as a child (scoliosis); she uses CPAP at home (unclear if also on home oxygen).,1
"C/o dyspnea x 1 week, worse in the last two days; no cough, no CP, no f/c.",0
In the ED she was placed on NRB satting 90% when she was found to be satting in the mid70's on 2LNC (initial triage assessment says she was 98% on RA).,0
She was then attempted on BiPAP with subjective improvement in symptoms and improvement in sats to 97%.,0
"Over the course of 15-20 minutes, she maintained her sats but ED notes report ""pt is not tolerating BiPAP well.""",0
VBG showed 7.14/132/110 on the BiPAP.,0
Ms. MS worsened with increasing lethargy; she was subsequently intubated by Anesthesia with propofol (later changed to versed).,0
Boluses of fentanyl 50 mcg were given.,0
She was given doses of levfloxacin and vancomycin for presumed PNA based on CXR findings.,0
Past Medical History: * Quadriplegia-- from polio as child; has some movement of hands (L > R) and lateral movement of legs; wheelchair bound * Chronic resp insufficiency restrictive lung disease from kyphoscoliosis from polio; weekly chest PT * Uses CPAP at night * H/o bed sores * h/o shingles * ?,1
"on albuterol Social History: SOCIAL HISTORY: -- has two brothers who are involved in her care -- lives at home with home aides Family History: Non-contributory Physical Exam: VS in the ED: (no temp documented), HR 98, BP 122/54, 22, 98% RA initially VS on arrival to the MICU: 95.7, 100/57, 67, 14, 88% on AC 350x12/5/0.4 General: small, frail woman; chronci contractures of legs and arms; sedated on vent; with OG tube Lungs/Chest: per nursing, with mild amount of thick secretions; rhonchorous; good air movement throughout; chest wall deformity thoguh padded in bed and difficult to assess fully Cardio: RRR, no m.r.g.",0
The cardiac and mediastinal contours are relatively unchanged compared to the previous examination.,0
"Consolidation is demonstrated within the retrocardiac region, which obscures the medial contour of the left hemidiaphragm, and is concerning for pneumonia.",0
No sizeable pleural effusions or pneumothorax.,0
Brief Hospital Course: Ms. is a 60 yoF with childhood post-polio changes of kyphoscoliosis and long-standing restrictive chest wall disease.,1
She is normally on nasal mask BiPAP at night on settings of 24/7 at home.,0
"She presented with one week of progressive shortness of breath and was found to be hypoxic and hypercarbic in the ED, requiring intubation.",0
"She was initially treated for a pneumonia, although sputum cultures were negative and there was questionable radiographic evidence of an infiltrate.",0
Rapid respiratory panel was negative for viral infections.,0
"She was placed on nebulizers, though it was felt that her respiratory failure was not largely due to an obstructive process.",1
"Ultimately, no cause to her progressive respiratory failure was identified, but she was able to be weaned from the ventilator to BiPAP on settings of 20/6 with a full face mask.",1
She was unable to tolerate being off the BiPAP machine for any amount of time because she would rapidly become hypoxic.,0
She chose to change her code status to DNR/DNI.,0
She expressed multiple times that she did not wish to have any further invasive therapies to prolong her life (including tracheostomy) and understood that without these measures she would be unable to breathe on her own.,0
The patient expressed that she would like to have her BiPAP mask removed while in the hospital and to be made comfortable and allowed to pass without further interventions.,0
She was moved out to the medicine floor where she visited with her family.,0
On the morning of her BiPAP was removed.,0
She was given ativan and morphine for comfort and at 12:30pm the patient expired in the presence of her two brothers.,0
Medications on Admission: Nizoral cream to rash daily Centrum Protopic 0.1% ointment Saline nasal spray Nystatin powder Albuterol nebs Prax lotion Sudafed 30 mg Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Acute on chronic respiratory failure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A,1
9:20 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: assess for change - pt with discordant chest movement and ta Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\INJURIES;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with hypoxia and tachypnea REASON FOR THIS EXAMINATION: assess for change - pt with discordant chest movement and tachypnea ______________________________________________________________________________ FINAL REPORT INDICATION: 78-year-old female with hypoxia and tachypnea.,1
"COMPARISONS: Comparison is made to AP chest radiograph from 31, .",0
Endotracheal tube is located in a standard position.,0
The tip of a left subclavian catheter terminates in the mid SVC.,0
A nasogastric tube is seen with its tip in the body of the stomach.,0
"There is a small right apical pneumothorax, unchanged in size.",1
Multiple left-sided rib fractures are stable.,1
There is a mild increase in left lower lobe atelectasis and associated moderate pleural effusion.,0
"Bilateral patchy opacities, which may reflect lung contusions are unchanged.",0
"Left retrocardiac opacification representing possible atelectasis, dependent edema, and/or pneumonia is unchanged.",0
"Left lower lobe consolidation could be atelectasis, dependent edema, and/or pneumonia.",0
Previously seen bilateral patchy opacities are unchanged in size.,0
"10:26 AM US ABD LIMIT, SINGLE ORGAN Clip # Reason: Please perform diagnostic and therapeutic tap.",0
"Admitting Diagnosis: LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with CLL s/p transformation, allo SCT in , now with AMS and tense/distended abdomen.",0
REASON FOR THIS EXAMINATION: Please perform diagnostic and therapeutic tap.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Request for ultrasound-guided therapeutic paracentesis.,0
FINDINGS: Moderate amount of ascites is noted in all four quadrants.,0
Due to patient's agitation and altered mental status the procedure was not attempted.,0
"This was discussed with referring physician, .",0
at the time of the study.,0
It was decided to reevaluate the patient after administration of anxiolytics on the floor with the intention of re-attempting the procedure after stabilization of the mental status changes.,0
IMPRESSION: Sufficient quantity ascites for paracentesis.,0
Paracentesis not performed due to patient agitation; see above.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: DISCHARGE SUMMARY ADDENDUM: DISCHARGE MEDICATIONS: The patient will be discharged on all preoperative medications.",0
Additionally Ms. will go home on 1.,0
MS Contin 15 milligrams po bid.,0
Percocet one to two tablets po q three to six hours prn pain.,0
"Vioxx 50 milligrams po q day times five days, then 25 milligrams po q day.",0
DISCHARGE FOLLOW UP: The patient will call Dr. office today to arrange for follow up.,0
Dictated By: MEDQUIST36 D: 09:58 T: 09:58 JOB#:,0
PATIENT/TEST INFORMATION: Indication: Atrial fibrillation/flutter.,1
BP (mm Hg): 136/60 Status: Inpatient Date/Time: at 11:35 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
LEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.,0
There is moderate global left ventricular hypokinesis.,0
There is moderate global right ventricular free wall hypokinesis.,0
TRICUSPID VALVE: The pulmonary artery systolic pressure could not be determined.,0
"Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended).",0
The aortic valve leaflets are mildly thickened with a minimally increased gradient consistent with minimal aortic valve stenosis.,0
"IMPRESSION: Biventricular hypokinesis c/w diffuse process (toxin, metabolic, tachycardia induced, etc.",0
"- cannot exclude multivessel CAD, though less likely given lack of regionality to dysfunction).",0
7:32 AM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
FINDINGS: The two studies include an AP view of the chest and an AP view of the pelvis.,0
"CHEST: The right clavicular fracture, right rib fractures, and left scapular fractures seen on the CT scan are not well seen on this limited AP chest x-ray due to overlying trauma board and incomplete visualization of the osseous structures.",0
There is an ET tube with the tip approximately at the carina and could be pulled back.,0
An NG tube is seen with the tip in the stomach.,0
There is also a left-sided chest tube with the tip in the left apex.,0
"There is subcutaneous air on the left, outlining the pectoralis major muscle.",0
The mediastinal and cardiac silhouette appear within normal limits.,0
There is no definite sign of pneumothorax on these limited views.,1
"IMPRESSION: Right clavicular, right rib, and left scapular fracture that were seen on the CT are not clearly visualized on this AP view.",0
HIP: There are no fractures seen in the pelvis.,0
There is a left femoral shaft fracture with proximal and medial displacement of the distal fracture fragment.,1
The sacroiliac and pubic symphysis joints are intact.,0
IMPRESSION: Displaced and overriding left proximal femoral shaft fracture.,1
"3:32 PM CAROTID SERIES COMPLETE PORT; VENOUS DUP EXT UNI (MAP/DVT) PORT LEFTClip # 424-5784 Reason: PREOP CABG ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with severe 3 vessel CAD including significant LMCA lesion, to OR in AM () for CABG.",0
Pt on bedrest until 3PM.,0
"REASON FOR THIS EXAMINATION: r/o carotid stenosis ______________________________________________________________________________ FINAL REPORT HISTORY: 83-year-old woman with severe coronary artery disease, in planning for coronary artery bypass graft.",1
RADIOLOGIST: This study was read by Dr. .,0
"Evaluation of the extracranial carotid arteries was performed with B-mode, color and spectral Doppler ultrasound.",0
"FINDINGS: With B-mode ultrasound, a small amount of plaque was seen in the left internal carotid artery.",0
"On the right side, peak systolic velocities were 58 cm/sec for the internal carotid artery, 72 cm/sec for the common carotid artery and 58 cm/sec for the external carotid artery.",0
The right ICA/CCA ratio was 0.80.,0
"On the left side, peak systolic velocities were 68 cm/sec for the ICA, 67 cm/sec for the CCA and 50 cm/sec for the ECA.",0
The left ICA/CCA ratio was 1.01.,0
Both vertebral arteries presented antegrade flow.,0
IMPRESSION: Less than 40% stenosis of the bilateral internal carotid arteries.,0
"VENOUS MAPPING HISTORY: 83-year-old woman with severe coronary artery disease, scheduled for CABG.",1
"TECHNIQUE: Venous mapping in the lower extremities was performed with B-mode, color and spectral Doppler ultrasound.",0
"FINDINGS: No superficial veins were seen in the right lower extremity, consistent with a history of previous stripping.",0
"In the left lower extremity, the greater saphenous vein presented patent and compressible with diameters ranging between 0.26 and 0.73 cm.",0
(Over) 3:32 PM CAROTID SERIES COMPLETE PORT; VENOUS DUP EXT UNI (MAP/DVT) PORT LEFTClip # 424-5784 Reason: PREOP CABG ______________________________________________________________________________ FINAL REPORT (Cont) COMPARISON: None available.,0
IMPRESSION: Venous mapping of the lower extremities shows evidence of a patent left greater saphenous vein.,0
PATIENT/TEST INFORMATION: Indication: Aortic valve endocarditis with regurgitation Height: (in) 68 Weight (lb): 196 BSA (m2): 2.03 m2 BP (mm Hg): 124/59 HR (bpm): 73 Status: Inpatient Date/Time: at 14:25 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Brief endotracheal intubation during attempt at esophageal intubation.,1
AORTA: No atheroma in aortic arch.,0
No atheroma in descending aorta.,0
Small vegetation on aortic valve.,1
GENERAL COMMENTS: Written informed consent was obtained from the patient.,0
A TEE was performed in the location listed above.,0
The patient was monitored by a nurse e throughout the procedure.,0
A TEE procedure related complication occurred (see comments for details).,0
No thoracic aortic dissection is seen.,0
There is a small vegetation on the right cusp of the aortic valve.,1
IMPRESSION: Small aortic valve vegetation with severe aortic regurgitation.,1
Dr. was notified by telephone on at 1400.,0
"7:29 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: R/O dissection Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with AMS s/p fall, hypertensive bradycardic, now with cp.",0
"REASON FOR THIS EXAMINATION: R/O dissection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old man with MS, status post fall, hypertensive, bradycardic, now with chest pain.",0
"COMPARISON: Multiple studies, the most recent dated .",0
"TECHNIQUE: MDCT axial images through the chest, abdomen, and pelvis with IV contrast.",0
Coronal and sagittal reformatted views were displayed.,0
"CT OF THE CHEST WITH IV CONTRAST: The central airways are patent to the segmental levels, bilaterally.",1
The heart is at the upper limits of normal.,0
"There is a rounded opacity in the left lower lobe, likely represents a rounded atelectasis.",0
"Scattered areas of ground glass opacity are noted, bilaterally, probably due to breathing.",0
"The aorta is tortuous, at the upper limits of normal without evidence of dissection.",0
Coronary artery calcifications are noted.,0
No evidence of pleural or pericardial effusions.,0
"No evidence of mediastinal, hilar, or axillary lymphadenopathy.",0
"The pulmonary artery is enlarged, suggestive of pulmonary hypertension.",1
CT OF THE ABDOMEN WITH IV CONTRAST: Streak artifact is noted due to patient's arms.,0
"The liver, pancreas, gallbladder, and adrenal glands are normal.",0
"The spleen is enlarged, and unchanged when compared to prior study.",0
"No oral contrast was administered which limits the evaluation of the bowel; however, no gross abnormality is detected.",0
Stool throughout the colon is noted.,0
There is a infrarenal IVC filter in place.,0
The IVC caudal to the filter is distended which a low attenuation lumen suspicious of thrombosis.,0
There is no evidence of free air or free fluid within the abdomen.,0
"Small mesenteric and retroperitoneal lymph nodes are noted, not pathologically enlarged by CT criteria.",0
"CT OF THE PELVIS WITH IV CONTRAST: The bladder, distal ureters, and prostate are unremarkable.",0
No evidence of free fluid within the pelvis.,0
No evidence of pelvic or inguinal lymphadenopathy.,0
"Again noted, extensive degenerative changes involving the thoracic and lumbar spine with chronic compression fracture of L1.",0
No evidence of aortic dissection.,0
"Rounded opacity in the left lung base likely represents rounded (Over) 7:29 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: R/O dissection Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) atelectasis.",0
"If clinically indicated, a repeat scan in prone position could be performed for further evaluation and to exclude underlying mass lesion.",0
Pulmonary artery dilatation suggestive of pulmonary artery hypertension.,1
IVC filter with slight increased density in its lumen suspicious for occlusion.,0
"(Over) 7:29 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: R/O dissection Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) (Over) 7:29 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: R/O dissection Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) (Over) 7:29 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: R/O dissection Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont)",0
", F. MED MICU 8:59 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: please eval for extent of disease, pls assess temporal bones Admitting Diagnosis: FACIAL SWELLING ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with preseptal cellulitis extending down to neck, face and R eye REASON FOR THIS EXAMINATION: please eval for extent of disease, pls assess temporal bones (fluid aspirated from R this AM), sinuses, deep tissue infection CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ PFI REPORT PFI: Interval decrease in right frontoparietal temporal subgaleal hypodense fluid collection compared to .",1
No subcutaneus edema or gas is identified.,0
"8:26 PM CT HEAD W/O CONTRAST Clip # Reason: r/o ICH STAT Admitting Diagnosis: CLOT ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with unresponsive event, dilated pupils REASON FOR THIS EXAMINATION: r/o ICH STAT No contraindications for IV contrast ______________________________________________________________________________ WET READ: RJab SAT 11:56 PM No acute process.",0
No hemorrhage or acute infarct.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old woman with unresponsive and dilated pupils, rule out intracranial hemorrhage.",0
COMPARISON: CTA head from .,0
TECHNIQUE: MDCT axial imaging was obtained through the brain without the administration of intravenous contrast material.,0
Coronal and sagittal reformats were completed.,0
FINDINGS: Old left frontal lobe infarction with associated ex vacuo dilatation of the left lateral ventricle is unchanged.,1
"There is no evidence of acute hemorrhage, edema, mass effect, or territorial infarction.",1
"There is periventricular white matter hypodensity, likely from chronic small vessel ischemic disease.",1
The ventricles and sulci are prominent consistent with atrophy.,0
"The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear.",0
There are cavernous carotid artery calcifications.,0
"No acute intracranial process, including hemorrhage or acute infarction.",1
Old left frontal lobe infarct.,0
"2:38 PM CT C-SPINE W/O CONTRAST; CT,CORONAL,SAGITAL,OBL RECONSTRUCTION Clip # Reason: LT ARM WEAKNESS, ABN MRI, C4-C7 SIGNAL ENHANCEMENT, ?",0
"MASS, BLEEDING ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with L arm weakness after heavy lifting, abnormal C-Spine signal intensity on MRI REASON FOR THIS EXAMINATION: 89 y/o female with c4-c-7 signal enhancement on MRI.",0
"if with/w/o contrast) to assess for mass, calcium deposition, bleeding.",0
______________________________________________________________________________ FINAL REPORT INDICATION: year old woman with left arm weakness.,0
Follow-up for abnormal spinal mass following MRI.,0
TECHNIQUE: Contiguous helical images of the cervical spine were obtained without IV contrast.,0
"CT C-SPINE WITHOUT CONTRAST: Again identified within an extramedullary, likely intradural location, is a well-circumscribed, approximately 13 mm, high-attenuation mass lesion at approximately the C5-6 level, exerting mass effect upon the cord with cord displacement towards the right.",0
There is some subarachnoid hemorrhage surrounding the cervical cord superior to the lesion.,0
There is cervical spondylosis at the C5-6 level.,0
Extensive degenerative changes are present manifested by anterior osteophytes and joint space narrowing.,0
Note is made of a multinodular goiter.,0
Scattered vascular calcifications within the carotid artery are identified.,0
There are no paraspinal masses.,0
Limited views of the lung apices do not reveal any abnormalities.,0
"Limited evaluation of the occipital lobe of the brain reveals high attenuation foci within the region of the dentate nucleus, likely representing calcifications.",0
IMPRESSION: 1) Approximately 13 mm hyperattenuating lesion within the cervical canal exerting mass effect upon the cord at the C5-6 level.,0
This likely is within an intradural and extramedullary location.,0
"Again, as with the previous MR C- spine, a broad differential exists, including ependymoma, meningioma, and AVM.",0
"The presence of subarachnoid blood raises the likelihood of ependymoma, as opposed to being related to a simple hematoma.",0
Correlation with a gadolinium- enhanced MR C- spine is suggested.,0
"(Over) 2:38 PM CT C-SPINE W/O CONTRAST; CT,CORONAL,SAGITAL,OBL RECONSTRUCTION Clip # Reason: LT ARM WEAKNESS, ABN MRI, C4-C7 SIGNAL ENHANCEMENT, ?",0
"MASS, BLEEDING ______________________________________________________________________________ FINAL REPORT (Cont)",0
", E. TSICU 5:54 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: Postop evaluation Admitting Diagnosis: GUNSHOT WOUND TO FACE ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with comminuted right mandible fracture REASON FOR THIS EXAMINATION: Postop evaluation No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Persistent right mandibular ramus fracture, comminuted, with less overlapping of fracture fragments compared to the preoperative study.",1
Decrease in number of radiodense bullet fragment adjacent to the fracture site.,0
Persistent swelling/hematoma around the fracture site.,0
"6:05 AM CHEST (PORTABLE AP) Clip # Reason: Intubated with LLL collapse ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with , resp failure.",1
REASON FOR THIS EXAMINATION: Intubated with LLL collapse ______________________________________________________________________________ FINAL REPORT HISTORY: Myasthenia with intubation and left lower lobe collapse.,0
ET tube is 3 cm above the carina.,0
Right jugular CV line is in proximal SVC.,0
"There is persistent opacity at the left base obscuring the left hemidiaphragm consistent with atelectasis/consolidation in the left lower lobe, unchanged since prior study of .",0
Cannot r/o associated small left pleural effusion.,0
"7:01 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with hypotension, cardiogenic shock, intubated s/p balloon pump insertion .",1
REASON FOR THIS EXAMINATION: please evaluate for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Hypotension.,0
Single portable radiograph of the chest demonstrates a similar cardiomediastinal contour to that seen on .,0
The left costophrenic angle is excluded.,0
"There are likely persistent bilateral, small, pleural effusions.",0
There is a nasogastric tube present with its tip in the stomach.,0
The proximal NGT side port is at the level of the gastroesophageal junction and the NGT should be advanced.,0
The remaining support lines are unchanged.,0
IMPRESSION: Nasogastric tube with its tip in the stomach.,0
The proximal side port is at the level of the gastroesophageal junction.,0
The NGT should be advanced.,0
7:38 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: ?,0
effusion Admitting Diagnosis: BILATERAL PNEUMONIA;SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with hx of IVDA s/p R VATS decortication cyanotic with decreased SpO2 87% REASON FOR THIS EXAMINATION: ?,0
"effusion ______________________________________________________________________________ FINAL REPORT AP CHEST, 8:28 A.M. ON HISTORY: Right VATS decortication.",0
"IMPRESSION: AP chest compared to , and 25.",0
"The extent of right pleural thickening is unchanged over the past several days including apical, basal and small fissural component.",0
Tip of left PIC catheter projects over the superior cavoatrial junction or upper right atrium.,0
Right pleural tube in place.,0
"9:45 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate facial fractures & look for intracranial hemorrhage ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with fall, suspected nasal fracture REASON FOR THIS EXAMINATION: evaluate facial fractures & look for intracranial hemorrhage No contraindications for IV contrast ______________________________________________________________________________ WET READ: DCsc WED 11:02 PM NO INTRACRANIAL HEMORRHAGE MULTIPLE FACIAL FRACTURES NO PNEUMOCEPHALUS NO DEPRESSED SKULL FRACTURE ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
CT HEAD WITHOUT CONTRAST INDICATION: Facial trauma.,0
Noncontrast axial images through the brain.,0
There is no intraaxial or extraaxial hemorrhage.,0
There is preservation of the -white matter interfaces.,0
There is a small amount of periventricular white matter hypoattenuation.,0
"The ventricles and sulci are mildly prominent, consistent with atrophy.",0
"There is high density fluid within the nasal cavity and both maxillary sinuses, layering within the sphenoid sinus, and also within the frontal air cells.",0
The mastoids and inner ear canals are areated.,0
No fractures are seen at the base of the skull.,0
"IMPRESSION: 1) No intracranial hemorrhage, areas of mass effect, or evidence of acute infarction.",0
"2) Multiple facial fractures will be described under a separate clip (, which is a CT of the sinuses).",0
"11:06 PM PORTABLE ABDOMEN Clip # Reason: rule out bowel perforation Admitting Diagnosis: CONGESTIVE HEART FAILURE;ATRIAL FIBRILLATION;+ TROPONIN\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with ESRD, CAD, GI bleed, rising white count, now unresponsive REASON FOR THIS EXAMINATION: rule out bowel perforation ______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old female with GI bleed, rising white count, now unresponsive.",1
Please evaluate for bowel perforation.,0
COMPARISON: CT abdomen and pelvis from five hours prior.,0
SINGLE PORTABLE SUPINE VIEW OF THE ABDOMEN: There is no supine evidence of pneumoperitoneum.,0
An abdominal aortic aneurysm is identified.,0
A left hip unipolar replacement as well as several injection granulomas are also identified.,0
There are mild degenerative changes of the spine.,0
IMPRESSION: No supine evidence for pneumoperitoneum.,0
"If bowel perforation is highly suspected, upright radiograph is more useful.",0
3:14 PM ART DUP EXT LO UNI;F/U LEFT Clip # Reason: 80s female s/p multiple vascular operations including axilla ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with hx of severe PVD.,0
"REASON FOR THIS EXAMINATION: 80s female s/p multiple vascular operations including axillary-femoral graft, fem-fem graft, and fem graft.",1
recently complaining of left foot pain and a colder left foot.,0
PLEASE ASSESS FOLLOWING: Is the left profunda femoris open??,0
Is the left popliteal open?,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Ax-fem, fem-fem, and fem- grafts, now with left foot pain.",0
FINDINGS: There is complete occlusion of the patient's cross femoral graft.,0
"The left profunda is patent however, velocities are low (approximately 20 cm/sec.)",0
"and as expected, the wave form is monophasic.",0
The left superficial femoral artery appears to be patent with similar low velocities and monophasic flow.,0
The left popliteal artery is widely patent also with similar flow patterns.,0
"IMPRESSION: Patent left-sided profunda, SFA and popliteal arteries.",0
All with low velocities (10 to 20 cm/sec.),0
and expected monophasic wave forms.,0
", G. MED CC7A 12:34 AM CHEST (PORTABLE AP) Clip # Reason: assess for acute processes Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with emphysema, CAD, with SOB, cough, fever REASON FOR THIS EXAMINATION: assess for acute processes ______________________________________________________________________________ PFI REPORT Worsening of bibasal focal consolidations worrisome for worsening pneumonia.",1
"12:26 AM CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: re-check placement, required for TFs Admitting Diagnosis: LEFT SUBCLAVIAN DEEP VEIN THROMBOSIS ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with new Dobhoff REASON FOR THIS EXAMINATION: re-check placement, required for TFs ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Dobbhoff catheter, evaluation.",1
"FINDINGS: Compared to the previous radiograph, the Dobbhoff catheter has been advanced by approximately 5 cm.",0
The tip now projects over the proximal parts of the stomach.,0
There is no evidence of complications.,0
"The other monitoring and support devices, and the general appearance of the lung and heart are unchanged.",0
9:40 AM CHEST (PA & LAT) Clip # Reason: Please check at 10AM.,0
"eval ptx Admitting Diagnosis: GUN SHOT WOUND ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man s/p GSW, s/p ex-lap.",0
"s/p CT placement , now clamped REASON FOR THIS EXAMINATION: Please check at 10AM.",0
"eval ptx ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, AT 09:44 HOURS HISTORY: Status post gunshot wound.",1
FINDINGS: There has been slight interval increase in size of the right-sided pneumothorax.,1
There is now approximately 15 mm of maximal visceral and parietal pleural separation at the apex.,0
"The right-sided chest tube is intrafissural, likely reducing its functionality.",0
Linear opacity emanating from the right hilum is likely atelectasis or contusion related to chest tube placement.,0
Again seen are retained bullet fragments in the chest as previously described.,0
Skin staples are seen at the presumed entry site along the lateral right lower chest.,0
Again seen is a mid epigastric JP drain.,0
A biliary stent is noted.,0
Midline staples from presumed exploratory laparotomy are also noted.,0
"Please note, there is a small fluid component in the right pleural space.",0
IMPRESSION: Interval enlargement of right pneumothorax with no radiographic evidence of tension physiology.,1
The indwelling chest tube is intrafissural which likely may play a role in reduced functionality for evacuating the pneumothorax.,1
The finding and impression was discussed with the referring surgical team shortly after dictation.,0
3:24 AM CHEST (PA & LAT) Clip # Reason: infiltrate Admitting Diagnosis: ALTERED MENTAL STATUS-HYPOTHERMIA ______________________________________________________________________________ MEDICAL CONDITION: year old woman with new onset lethargy and hypothermia x 2 days.,0
Unable to get hx now.,0
REASON FOR THIS EXAMINATION: infiltrate ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: New onset of lethargy and hyponatremia for last two days.,0
PA and lateral upright chest radiograph compared to .,0
"The heart size is mildly enlarged, unchanged.",0
The mediastinal contours are unremarkable.,0
The right middle lobe consolidation and possibly right lower lobe opacity _____ on the lateral view.,0
"In addition, the patient is in pulmonary edema.",0
No sizable pleural effusion is demonstrated.,0
Right middle and lower lobe consolidation.,0
"4:59 PM FOOT 2 VIEWS LEFT Clip # Reason: LT FOOT INFECTION, LT FOOT DEBRIVEMENT Admitting Diagnosis: NECROTIZING FASCIITIS ______________________________________________________________________________ FINAL REPORT HISTORY: Per doctor.",1
"LEFT FOOT, TWO VIEWS There is a large skin defect overlying the posteroinferior calcaneus.",0
"However, the calcaneus is within normal limits, without evidence of osteomyelitis.",0
A small inferior calcaneal spur is noted.,0
"Probable diffuse osteopenia, but no focal bone destruction.",0
"4:25 AM CHEST (PORTABLE AP) Clip # Reason: evalaute NG tube placement Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with vent dependence, hypothermia REASON FOR THIS EXAMINATION: evalaute NG tube placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 04:28 A.M., HISTORY: Vent dependent.",0
IMPRESSION: AP chest compared to : Nasogastric tube ends in the upper stomach.,0
Left subclavian transvenous pacemaker lead follows the expected course through the floor of the right ventricular apex.,0
Mild interstitial pulmonary edema is present.,0
Vascular is tortuous but unchanged.,0
No appreciable pleural effusion or indication of pneumothorax.,0
"11:19 AM PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # Reason: please drain large anterior abdominal fluid collection, plea Admitting Diagnosis: STATUS POST COLECTOMY;ANASTOMOSIS LEAK ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with multiple abdominal abscesses on CT Scan REASON FOR THIS EXAMINATION: please drain large anterior abdominal fluid collection, please leave catheter is place after drainage?",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Abdominal abscess identified on recent CT scan.,0
PROCEDURE: Informed written consent was obtained from the patient after explaining the risks and benefits of the procedure.,0
Pre-procedure timeout was completed using two patient identifiers.,0
2% lidocaine was used as local analgesia.,0
Sterile technique was employed throughout.,0
"Under CT guidance, an 18-gauge spinal needle was advanced into the patient's abdominal fluid collection located within the anterior peritoneal cavity along the midline.",0
Approximately 15 cc of purulent fluid drained.,0
"Following this, a 19-gauge catheter was advanced into the fluid collection under direct CT guidance and another 15 cc of purulent fluid were obtained.",0
The fluid was sent for Gram stain and culture.,0
The patient remained stable throughout his stay in the CT suite.,0
IMPRESSION: Successful CT-guided aspiration of abdominal fluid collection.,0
"12:56 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o PE, infiltrates, r/o intra-abdominal infection Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with sepsis, hypotension, hypoxic and hypercarbic resp failure REASON FOR THIS EXAMINATION: r/o PE, infiltrates, r/o intra-abdominal infection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Sepsis, hypotension, hypoxia and respiratory failure, evaluate for PE or infiltrates.",1
TECHNIQUE: Helically acquired contiguous axial images were obtained from the lung bases to the lung apices after the administration of 100 cc of intravenous Optiray through a slow injection rate through a central line.,0
The technique is the best possible given the patient's conditions.,0
CT OF THE CHEST: No pulmonary emboli are identified.,0
The small subsegmental vessels are not well visualized.,0
There are numerous mediastinal lymph nodes.,0
These were not present on the prior study.,0
Small hilar lymph nodes are also present.,0
There is bilateral pleural effusions right greater than left.,0
There is compressive atelectasis within both lung bases.,0
On lung windows there are patchy opacities throughout both lung fields.,0
These could be due in part to respiratory motion.,0
Another consideration is atypical infection or pulmonary edema.,1
There is diffuse anasarca of the soft tissues.,0
These were not present on prior exam.,0
Bilateral pleural effusions and compressive atelectasis of the lung bases.,0
Nonspecific subtle infiltrates within both lungs.,0
These are difficult to evaluate due to respiratory motion.,0
These could represent atypical infection or pulmonary edema.,1
"10:10 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W&W/O CONTRAST Reason: Infarct versus mass versus evidence of infection versus vasc Contrast: MAGNEVIST Amt: 18 ______________________________________________________________________________ MEDICAL CONDITION: 51F status post CVA in , went to outside hospital this morning, complaints of worsened dysarthria and right-sided weakness of the arm and leg since she awoke this morning.",0
Also complained of generalized weakness since yesterday.,0
"He head CT is outside hospital negative for bleed, concerning for possible subacute infarct, transferred to for neurologic evaluation.",0
REASON FOR THIS EXAMINATION: Infarct versus mass versus evidence of infection versus vasculitis No contraindications for IV contrast ______________________________________________________________________________ WET READ: SAT 3:07 AM 1.,0
No enhancement of distal bilateral V4 segments and basilar artery presumably secondary to distal vertebral and basilar artery thrombosis.,0
"The right P1 segment is vaguely seen, but the remaining portions of the PCAs bilaterally are not visualized.",0
Small PCOMMs are seen bilaterally.,0
"Left A1 segment is narrowed, could be due to hypoplasia and/or atherosclerosis.",0
"Scattered small acute infarcts in the left occipital lobe, right cerebellum, right pons, and possibly left pons.",0
Complete opacification of the left maxillary sinus.,0
______________________________________________________________________________ FINAL REPORT MRI AND MRA BRAIN AND NECK WITHOUT AND WITH CONTRAST HISTORY: Prior infarction.,1
Now with worsening dysarthria and right-sided weakness.,0
"Sagittal short TR, short TE spin echo imaging was performed through the brain.",0
"Axial imaging was performed with , TR, long TE fast spin echo, gradient echo, diffusion, and 3D time-of-flight MRA technique.",0
Gadolinium-enhanced MRA was performed through the neck.,0
Comparison to a brain MR .,0
FINDINGS: There are multiple areas of new infarction since the prior study.,1
"These are most prominent in the pons, predominantly on the left, where there is associated hemorrhage.",0
"There are also small infarctions in the right cerebellar hemisphere of the left occipital lobe, and the right cerebral peduncle.",1
These all implicate posterior circulation abnormalities.,0
The brain MRA demonstrates very poor signal arising from the basilar artery and its branches.,0
The distal vertebral arteries are visualized on the non-contrast MRA but the vertebrobasilar junction is not.,0
The axial T2-weighted images demonstrate a loss of the normal flow void in the basilar artery.,0
"The gadolinium-enhanced neck MRA source images demonstrate the distal vertebral arteries, the vertebrobasilar junction, and the distal basilar artery.",0
"This suggests that these vessels are patent but experiencing extremely slow flow, responsible for the poor visualization on the non-contrast time-of-flight images.",0
"However, the mid basilar is not opacified on the gadolinium MRA.",0
"(Over) 10:10 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W&W/O CONTRAST Reason: Infarct versus mass versus evidence of infection versus vasc Contrast: MAGNEVIST Amt: 18 ______________________________________________________________________________ FINAL REPORT (Cont) Overall, these findings suggest a focal area of severe stenosis or thrombosis in the mid basilar artery with poor runoff for the vertebral arteries and reduced flow through the superior cerebellar and posterior cerebral arteries.",1
This would explain the distribution of infarction seen on the diffusion images.,0
"The MRA also demonstrates loss of the A1 segment of the left anterior cerebral artery, which was present on the MR examination of .",0
There is no evidence of infarction in the A1 distribution.,0
Images of the remainder of the brain demonstrate no other areas of hemorrhage or infarction.,0
The remainder of the intracranial branches appear normal.,0
"A preliminary report was issued that read ""no enhancement of distal bilateral V4 segments and basilar artery presumably secondary to distal vertebral and basilar artery thrombosis.",0
"The right P1 segment is vaguely seen, but remaining portions of the PCAs bilaterally are not well visualized.",0
Small posterior communicating arteries are seen bilaterally.,1
"Left A1 segment is narrowed, could be due to hypoplasia or atherosclerosis.",0
"discussed with Dr. at 3:03 a.m. via telephone on .""",0
CONCLUSION: Apparent mid basilar severe stenosis or occlusion with multiple posterior circulation infarctions.,1
There is a small amount of hemorrhage in the pons associated with these infarctions.,0
6:42 AM CHEST (PORTABLE AP) Clip # Reason: ?fluid overload.,0
"______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with hx of pulm fibrosis, Afib, CHF, pharyngocutaneous fistula with tracheostomy s/p laryngectomy.",0
REASON FOR THIS EXAMINATION: ?fluid overload.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST - compared to previous study of 2 days earlier.,0
Clinical suspicion for fluid overload.,0
"A tracheostomy tube remains in place, in satisfactory position.",0
The pulmonary vascularity appears engorged.,0
"There is interval worsening perihilar haziness and vascular indinstinctness, superimposed upon a background of chronic interstitial lung disease.",0
"There are bilateral small pleural effusions, with interval slight increase on the right side in the interval.",0
IMPRESSION: Congestive heart failure pattern superimposed upon underlying changes of interstitial fibrosis.,1
"6:23 AM CHEST (PORTABLE AP) Clip # Reason: volume status, infiltrates, post vap Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with vap, improving REASON FOR THIS EXAMINATION: volume status, infiltrates, post vap ______________________________________________________________________________ FINAL REPORT HISTORY: Respiratory failure with pneumonia.",1
"FINDINGS: In comparison with the study of , there is little change in the appearance of the multifocal areas of airspace consolidation.",0
"12:45 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: pt w/ persistent hypoxia, right heart strain on echo - would Admitting Diagnosis: ACUTE RENAL FAILURE; A FIB Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 55 y/o male w/ h/o afib, etohism, multi-organ failure/sepsis now improving aftre 2nd micu stay but still mild hypoxia, w evidence of r. ventricular failure on echo - would like repeat cta to eval for pe REASON FOR THIS EXAMINATION: pt w/ persistent hypoxia, right heart strain on echo - would like to eval for pulmonary embolism.",1
Please page with wet read tonight.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia and left ventricular failure by echo.,0
TECHNIQUE: Contiguous axia images through the chest were obtained using the CT angiogram protocol.,0
INTRAVENOUS CONTRAST: 150 cc of Optiray due to patient debility.,0
"CT ANGIOGRAM CHEST: This is a technically better study than the previous one, with less patient motion and better bolus.",0
There is no sign of intraluminal filling defect within the pulmonary arteries to suggest pulmonary embolism.,0
"Bilateral pleural effusions are again noted, not substantially changed in the interval.",0
"Several prevascular lymph nodes are noted, the largest measuring 11 mm in greatest short axis dimension.",0
Other nodes are noted in the paratracheal region and the subcarinal region.,0
The subcarinal node measures 2.4 cm in greatest short axis dimension.,0
Atelectatic changes are noted at both lung bases.,0
There is no evidence of lobar consolidation.,0
BONE WINDOWS: Degenerative changes are present throughout the spine.,0
There are no suspicious lytic or sclerotic bony lesions.,0
CT RECONSTRUCTIONS: These images do not demonstrate pulmonary embolism.,0
"Bilateral pleural effusions, unchanged since the previous exam.",0
"(Over) 12:45 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: pt w/ persistent hypoxia, right heart strain on echo - would Admitting Diagnosis: ACUTE RENAL FAILURE; A FIB Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont)",1
"3:56 AM CHEST (PORTABLE AP) Clip # Reason: assess cordis position and swan position - unable to move sw Admitting Diagnosis: ADENOMA CECUM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man s/p ileocolectomy, known COPD; assess L subclavian line status REASON FOR THIS EXAMINATION: assess cordis position and swan position - unable to move swan into good position and cordis appears kinked in subcu ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Line placement.",0
Comparison is made to previous studies of and .,0
"A Swan-Ganz catheter remains in place, terminating in the proximal right pulmonary artery.",0
There is a focal kink in the catheter near the skin insertion site at the level of the second posterior rib.,0
An endotracheal tube is in satisfactory position and a feeding tube and nasogastric tube terminate below the diaphragm.,0
"There is persistent vascular engorgement, there has been interval worsening of a pattern of pulmonary edema, most prominent in the perihilar regions.",0
IMPRESSION: 1) Worsening congestive heart failure pattern.,0
2) Focal kink in left subclavian catheter at skin insertion site region.,0
Correlation with physical exam findings at catheter site suggested.,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: eval right IJ placement Admitting Diagnosis: PEA ARREST ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with PEA arrest - just placed R IJ REASON FOR THIS EXAMINATION: eval right IJ placement ______________________________________________________________________________ FINAL REPORT HISTORY: PE at rest, status post right IJ placement.",0
"Compared with earlier the same day, a right IJ central line has been placed, tip over mid/distal SVC.",0
There is upper zone redistribution and mild increased interstitial edema.,0
There is left lower lobe collapse and/or consolidation.,0
Small right greater than left pleural effusions are again noted.,0
IMPRESSION: Interval placement of right IJ line with tip over mid/distal SVC.,0
Some interval improvement in the degree of CHF.,0
Height: (in) 69 Weight (lb): 210 BSA (m2): 2.11 m2 BP (mm Hg): 132/71 HR (bpm): 73 Status: Inpatient Date/Time: at 16:16 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
IMPRESSION: Mild left ventricular hypertrophy with overall normal systolic function.,0
"11:51 PM CLAVICLE LEFT Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with mcc vr suv REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT INDICATION: Motorcycle versus SUV, assess for clavicular fracture.",1
"LEFT CLAVICLE, TWO VIEWS: There is a minimally displaced fracture of the one-third of the left clavicle.",1
No other fracture is identified.,0
There is cervical spinal hardware seen.,0
The visualized lung appears clear.,0
IMPRESSION: Minimally displaced fracture of the mid third of the left clavicle.,1
3:39 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
VAP Admitting Diagnosis: SEIZURES ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with ?,0
"VAP, new trach REASON FOR THIS EXAMINATION: ?",0
"VAP ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH Indication; VAP, endotracheal tube.",0
"TECHNIQUE: Supine portable chest view was reviewed in comparison with prior chest radiographs through with the most recent from , .",0
FINDINGS: Bilateral lung volumes are low.,0
Endotracheal tube ends approximately 3.2 cm above the carina.,0
"A feeding tube terminates into the stomach; however, the distal end is off radiographic view.",0
Right subclavian line ends at approximately at the cavoatrial junction.,0
"Since prior radiograph from , there are no relevant changes in the lungs.",0
Mild bibasal atelectasis is similar.,0
Cardiomediastinal silhouette is stable with normal heart size.,0
", G. SICU-A 4:49 AM CHEST (PORTABLE AP) Clip # Reason: Fluid status Admitting Diagnosis: PARASTOMAL HERNIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man S/P ventral hernia repair REASON FOR THIS EXAMINATION: Fluid status ______________________________________________________________________________ PFI REPORT PORTABLE CHEST Some shifts in plate-like atelectasis and somewhat improved fluid status.",1
3:40 PM CT C-SPINE W/O CONTRAST Clip # Reason: Please do not give contrast as s/p renal transplant.,0
"Reasses Admitting Diagnosis: UNABLE TO WALK/WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with Type 1 DM, s/p renal transplant, s/p cervical discectomy c/b aspiration PNA, NSTEMI with increased WBC and fever REASON FOR THIS EXAMINATION: Please do not give contrast as s/p renal transplant.",1
"Reassess surgical site CONTRAINDICATIONS for IV CONTRAST: renal transplant ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Diabetes status post renal transplant and cervical discectomy, increased white cell count and fever.",1
"NON-CONTRAST CT OF THE CERVICAL SPINE WITH MULTIPLANAR REFORMATTED IMAGES: FINDINGS: Since prior MRI study of , there has occurred an anterior cervical fusion and anterior plate fixation at C4-C5.",0
"At the level of the disc itself especially on the left side there has been reduction in the posterior epidural mass, presumably disc herniation, previously noted.",0
There is persistence of this posterior epidural component at the level of the inferior body of C4 and the superior body of C5.,0
A small left paracentral disc protrusion is present at C3-C4 unchanged from previous examination.,0
Disc space narrowing is again identified at C5-C6.,0
Disc space is somewhat widened attributable to the graft material at C4-C5.,0
There is no evidence of retropulsion of disc material into the spinal canal.,0
IMPRESSION: Status post cervical discectomy with features as discussed above.,0
7:05 AM BILAT LOWER EXT VEINS PORT Clip # Reason: eval for DVT Admitting Diagnosis: HYPERCALCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with HIT and hypoxemic resp failure REASON FOR THIS EXAMINATION: eval for DVT ______________________________________________________________________________ FINAL REPORT BILATERAL LOWER EXTREMITY VEIN ULTRASOUND PORTABLE: INDICATION: 66-year-old man with history of respiratory failure.,1
"FINDINGS: scale and Doppler son of bilateral common femoral, superficial femoral, and popliteal veins were performed.",0
"There is normal compressibility, flow and augmentation.",0
Subcutaneous edema is noted bilaterally.,0
IMPRESSION: No evidence of DVT bilaterally in the lower extremities.,0
"4:48 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for infiltrate Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with weakness and hypoxia REASON FOR THIS EXAMINATION: Please evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT AP CHEST 5:22 A.M., : HISTORY: Weakness and hypoxia.",0
IMPRESSION: AP chest compared to : Right jugular line ends in the lower SVC.,0
Severe enlargement of the cardiac silhouette has worsened since .,0
"In the absence of pulmonary edema, this raises the possibility of some pericardial effusion.",0
"Aside from mild right basal atelectasis, lungs are clear.",0
There is no appreciable pleural effusion.,0
"Chest CT scan underway will assess the presence of pericardial effusion, if any.",0
10:20 AM CHEST (PORTABLE AP) Clip # Reason: eval for cardiopulmonary process ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with resp distress REASON FOR THIS EXAMINATION: eval for cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old woman with respiratory distress.,0
AP PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The evaluation of the radiograph is limited due to severe patient rotation.,0
"The right subclavian central line is seen in the superior vena cava, but the tip of the line is not well visualized.",0
The tracheostomy tube is seen.,0
There are bilateral opacities predominantly in the lower lung fields.,0
The mediastinal and hilar contours are difficult to assess due to rotation.,0
"IMPRESSION: Bilateral lung opacities predominantly at lower lung fields, which are concerning for pneumonia.",0
"A PA and lateral radiograph would be helpful for more complete assessment, when the patient's condition permits.",0
Similar findings have been seen on prior radiographs.,0
"Although possibly due to recurrent aspiration pneumonia, a more chronic process such as bronchoalveolar cell carcinoma cannot be excluded.",1
"If infectious symptoms are absent, or, if this fails to resolve following antibiotics, CT would be recommended.",0
Right central venous catheter whose tip is not well visualized.,0
", S. 9:02 AM CHEST (PORTABLE AP) Clip # Reason: interval status Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 30 year old man with mesothelioma, pulm edema, LLL PNA REASON FOR THIS EXAMINATION: interval status ______________________________________________________________________________ PFI REPORT Right PICC is in the mid SVC.",1
Left pleural thickening is unchanged.,0
Left pleural effusion slightly decreased.,0
11:59 CT C-SPINE W/O CONTRAST Clip # Reason: MVC ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with reported SDH per oSH REASON FOR THIS EXAMINATION: ?frx No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Subdural hematoma at outside hospital.,0
TECHNIQUE: CT axial images from the skull base through the thoracic inlet without IV contrast.,0
CT OF THE SPINE WITHOUT IV CONTRAST: No prevertebral soft tissue swelling is seen.,0
No acute fracture is identified.,0
There is a 2-mm retrolisthesis of C5 over C6.,0
"Multilevel degenerative changes, worse at the level of C4-5 with moderate-to-severe narrowing of the left neural foramina and mild-to-moderate C5-6 right neural foramina.",0
The visualized lung apices are unremarkable.,0
Bilateral carotid calcifications are seen.,0
No evidence of acute fracture.,0
Multilevel degenerative changes as described above.,0
NOTE ADDED AT ATTENDING REVIEW: I agree that there is no evidence of fracture or subluxation.,0
"However, the images at C4-5 suggest a large hyperdense intraspinal lesion, perhaps a disk protrusion.",0
"Although this may represent an artifact, if real this would cause substantial cord compresssion.",0
The appearance is worrisome enough to merit a spine MR.,0
This finding was discussed with Dr. at 1 pm on .,0
"5:18 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?CHF Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with HIV, ESLD Hep B xferred from OSH intubated w. worsening hypoxia REASON FOR THIS EXAMINATION: ?CHF ______________________________________________________________________________ FINAL REPORT INDICATION: HIV, end-stage liver disease, transferred from outside hospital, intubated with worsening hypoxia.",1
Comparison is made to study performed earlier the same day.,0
SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The radiograph is virtually unchanged.,0
"Heart size, mediastinal and hilar contours are stable.",0
A moderately left- sided pleural effusion layers posteriorly.,0
There is stable atelectasis in the right upper lobe with elevation of the minor fissure.,0
"ET tube, nasogastric tube, right supraclavicular central venous line tip, and left internal jugular central venous line are in unchanged position.",0
1:22 PM CT HEAD W/O CONTRAST Clip # Reason: Evaluate for cause of neurologic decifits.,0
"Admitting Diagnosis: ACUTE LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with episode of PEA, now with neurologic deficits.",1
REASON FOR THIS EXAMINATION: Evaluate for cause of neurologic decifits.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old man with PA arrest, now with neurologic deficits.",0
There are no prior studies for comparison.,0
"FINDINGS: There is no evidence of hemorrhage, mass effect, shift of the normally midline structures, or infarction.",0
"There is mucosal thickening and aerosolized secretions of the ethmoid, sphenoid, and maxillary sinuses which is likely secondary to patient's endotracheal intubation.",0
No hemorrhage or mass effect.,0
"7:04 PM CHEST (PA & LAT) Clip # Reason: assess for PNA versus CHF Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN\CATH ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with transferred from OSH with shortness of breath,RLL PNA, ?",0
"MI REASON FOR THIS EXAMINATION: assess for PNA versus CHF ______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old man with transfer from outside hospital with shortness of breath, right lower lobe pneumonia.",0
FINDINGS: PA and lateral views of the chest demonstrate the patient to be status post median sternotomy and aortic valve replacement.,1
The cardiac silhouette is enlarged.,0
There is marked pleural thickening along the left side of the chest.,0
There is an ovoid- shaped opacities along the right major fissure.,0
"In addition, opacities in the right lung base are noted.",0
There is no evidence of pleural effusions.,0
Degenerative changes of the thoracic spine are noted.,0
Left-sided pleural thickening may represent malignant or nonmalignant (loculated effusion) pleural based disease and not fully characterized.,0
Ovoid opacity along the major fissure likely represents fluid.,0
Right lung base opacities not fully characterized.,0
Comparison with prior studies (chest radiographs or CTs) is recommended and/or a baseline CT scan with IV contrast for further characterization.,0
Status post CABG and aortic valve replacement.,1
Findings were discussed with Dr. at the time of dictation.,0
3:04 PM PICC LINE PLACMENT SCH Clip # Reason: Please evaluate for midline check/change for a PICC vs. plac Admitting Diagnosis: PLEURAL EFFUSION Contrast: OPTIRAY Amt: 10 ********************************* CPT Codes ******************************** * INTRO NEEDL/CATH VEIN -59 DISTINCT PROCEDURAL SERVICE * * FLUORO 1 HR W/RADIOLOGIST * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with poor access.,0
"Has left midline in, does not draw.",0
REASON FOR THIS EXAMINATION: Please evaluate for midline check/change for a PICC vs. placement of central venous line.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 46-year-old man with poor access.,0
Has left midline in which does not aspitate.,0
PROCEDURE: Exchange of 5 French double-lumen pre-existing catheter for 4 French single-lumen.,0
ANESTHESIA: 1% lidocaine was administered at the venotomy site.,0
RADIOLOGISTS: Dr. (fellow) and Dr. (attending interventional radiologist) who supervised the entire procedure.,0
TECHNIQUE AND FINDINGS: Verbal consent was obtained from the patient who was brought to the angiography suite and placed supine on the imaging table.,0
A preprocedure timeout and huddle were performed as per protocol.,0
The left upper arm and pre-existing catheter were prepped and draped in the usual sterile fashion.,0
A scout image confirmed the location of the double- lumen PICC line with tip terminating in the mid left axillary vein.,0
Both lumens failed to aspirate but did flush.,0
Contrast injection indicated collaterals in the chest wall.,0
Flow in the subclavian artery was not demonstrated.,0
The kit 0.018 wire and a 0.018 nitinol wire could not pass through either lumen of the catheter.,0
A 0.018 angled Glidewire passed through one lumen into the distal subclavian artery.,0
"The catheter was removed, a sheath inserted, inner dilator removed and new 30 cm 4 French single-lumen PICC line advanced into the axillary vein.",0
"Upon retraction, some 4-cm this new line aspirated and flushed easily.",0
The catheter was secured and a sterile dressing was applied.,0
IMPRESSION: Exchange of left midline for new 30 cm 5 French single lumen catheter (with 4 cm out on the skin).,0
The catheter tip is in the left axillary vein.,0
The line is ready for use.,0
(Over) 3:04 PM PICC LINE PLACMENT SCH Clip # Reason: Please evaluate for midline check/change for a PICC vs. plac Admitting Diagnosis: PLEURAL EFFUSION Contrast: OPTIRAY Amt: 10 ______________________________________________________________________________ FINAL REPORT (Cont),0
4:32 PM HIP UNILAT MIN 2 VIEWS Clip # Reason: please evaluate for rt hip fx.,0
"Admitting Diagnosis: LEFT TIBIA AND FIBULA FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with rt hip pain post fall, s/p Lf tib/fib ORIF.",1
REASON FOR THIS EXAMINATION: please evaluate for rt hip fx.,0
______________________________________________________________________________ FINAL REPORT INDICATIONS: 80 y/o woman status post left tib/fib open reduction and internal fixation.,0
Please evaluate for right hip fracture.,0
AP PELVIS AND CONE DOWN VIEWS OF THE RIGHT HIP: These are markedly limited due to overlying soft tissue.,0
The most superior portion of the pelvis is cut off the film.,0
No definite right hip fracture is noted.,0
", J. TSICU 12:31 PM CHEST (PORTABLE AP) Clip # Reason: confirm ETT position Admitting Diagnosis: CHOLANGIO CARCINOMA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with upper GI bleed, scheduled for endoscopy REASON FOR THIS EXAMINATION: confirm ETT position ______________________________________________________________________________ PFI REPORT Endotracheal tube terminates 6.8 cm above carina and could be advanced for standard positioning.",0
4:36 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: r/o obstruction Admitting Diagnosis: MITRAL REGURGITATION ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with vomiting REASON FOR THIS EXAMINATION: r/o obstruction ______________________________________________________________________________ WET READ: FBr MON 6:32 PM no evidence of obstruction or free intraperitoneal air.,0
Interval development of the right middlle lobe and basilar portion RLL atelectasis.,0
"______________________________________________________________________________ FINAL REPORT ABDOMINAL RADIOGRAPH INDICATION: 48-year-old man with vomiting, rule out obstruction.",0
FINDINGS: There is no evidence of free intraperitoneal air.,0
There are no dilated loops of small bowel or air fluid levels.,0
Gas and stool noted in the colon.,0
Surgical clips are noted in the right and the left inguinal regions.,0
There is a large right paracardiac opacity which is better assessed on subsequently performed CT scan and is compatible with hematoma.,1
Compressive atelectasis is noted in the adjacent right lower lung.,0
Pleural fluid is also noted tracking along the lateral right hemithorax.,0
Patient is status post median sternotomy and mitral valve replacement.,1
A left lateral rib defect is noted.,0
"Right paracardiac density, compatible with large hematoma seen on subsequently performed chest CT.",1
Please refer to this CT scan for further detail.,0
"2:26 PM KNEE (2 VIEWS) LEFT Clip # Reason: eval hardware Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman s/p left knee I&D and left polyliner exchange REASON FOR THIS EXAMINATION: eval hardware ______________________________________________________________________________ FINAL REPORT STUDY: Two views of the left knee, portable, .",0
"INDICATION: Evaluate hardware, status post left knee, I and D and left poly liner exchange.",0
FINDINGS: Interval removal of skin staples.,0
"Subcutaneous edema and emphysema, post-surgical.",0
A surgical drain is seen within the left knee joint.,1
The visualized hardware from left total hip arthroplasty is intact.,0
No evidence for hardware loosening or osteolysis.,0
No definite fracture or dislocation.,0
IMPRESSION: Post-surgical changes of the left knee.,0
Status post I and D. Intact hardware.,0
5:28 AM CHEST (PORTABLE AP) Clip # Reason: 77 yo female admitted for hypertensive urgency.,0
"please asses ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with hx of htn, temporal arteritis, cad.",0
REASON FOR THIS EXAMINATION: 77 yo female admitted for hypertensive urgency.,0
please assess for pulmonary vascular congestion.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Temporal arteritis with hypertensive urgency.,0
FINDINGS: Single frontal view of the chest.,0
There is a mild thoracic scoliosis concave to the left.,0
"There are no consolidations, pleural effusions, or evidence of congestive heart failure.",0
There is minor bibasilar atelectasis.,0
IMPRESSION: No evidence of congestive heart failure.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: Patient is a previously healthy 24 year-old male who moved to the United States from five months prior.,0
He presented to the with history of two weeks of illness with jaundice and drowsiness that is progressively getting worse.,0
No significant family history of liver disease.,0
The patient was found to have significantly elevated LFTs.,0
He was emergently evaluated for a liver transplantation and was found to be a suitable candidate.,0
He was admitted to for further evaluation and management.,0
PHYSICAL EXAMINATION: Patient is drowsy and very hard to arouse.,0
"LABORATORY DATA ON ADMISSION: Included ALT 727, AST 377, alkaline phosphatase 108, amylase 84, total bilirubin 41.9.",0
"HOSPITAL COURSE: Due to patient's increased neurological distress, he was emergently transferred to the Intensive Care Unit, paralyzed and intubated.",0
"On surveillance chest x-ray after intubation, he was found to have a right pneumothorax and the chest tube was placed.",0
"He had an ultrasound which showed a small liver surrounded by hyperechoic fibrous fatty tissue, suggestive of perihepatitis, patent portal and hepatic venous system, minimal ascites, splenomegaly.",0
A catheter was placed for fluid management.,0
Patient was transfused two units for falling hematocrit.,0
"On hospital day #2 and 3, the patient remained afebrile.",0
He is on prophylactic antibiotics.,0
His LFTs are slowly going down.,0
He is still intubated and sedated.,0
Transfused with packed red blood cells and FFPs p.r.n.,0
for correction of anemia and coagulopathy.,0
"On , a liver became available.",0
"The patient was taken to an operating room where involving cadaveric liver transplant, Roux-en-Y hepaticojejunostomy was performed.",0
The operation when without complications.,0
Please see operation note for details.,0
The patient was transferred to the Surgical Intensive Care Unit in stable condition.,0
"On postoperative day #1, the patient is on Zosyn, Vancomycin, Bactrim and Acyclovir for antibacterial and antiviral prophylaxis.",0
"He was started on CellCept, Cyclosporin, Simulect IV for immunosuppression.",0
Patient is afebrile requiring Nitric Oxide for IPA pressure.,0
He had an ultrasound of his liver performed which showed normal flow characteristics in the lower vessels without evidence of focal abnormalities.,0
"He was transfused with platelets, FFPs and RBCs for coagulopathy and anemia p.r.n.",0
He was started on TPN.,0
He is also on SVHD.,0
"On postoperative day #2, the patient spiked a fever up to 101.5 F. His Propofol started to get withdrawn.",0
"He remains unresponsive, intubated and ventilated.",0
He had a repeat ultrasound which was read as no flow through hepatic artery.,0
The patient had a CTA which showed normal flow and perihepatic changes consistent with postoperative changes.,0
His ICP drain was removed.,0
"On postoperative day #3, the patient remains afebrile up to 103.3 F. He was pan cultured with source still unknown.",0
"Off sedation, but still unresponsive.",0
"His PA pressures are improving, but still require Nitric Oxide.",0
"On postoperative day #4, the patient is still febrile weaning off NO2.",0
"Opening eyes, but not following command.",0
His blood cultures grew gram negative rods.,0
He had duel cholangiogram done on postoperative day #6 which showed no strictures and normal ducts.,0
He had a fluoro guided NG tube placement for tube feeds.,0
"On postoperative day #7, the patient continued to be febrile.",0
Continued on antibiotic prophylaxis including Imipramine for fevers.,0
His Nitric Oxide was discontinued.,0
He is slowing becoming alert and starting to follow commands.,0
One of his JPs was removed.,0
He had a CT Scan of his head which showed two small foci of hemorrhage in the right frontal lobe immediately adjacent to calvarial defect.,0
CT Scan of his abdomen showed small left lower lobe consolidation.,0
"On postoperative day #8, the fevers are going down.",0
"He had a MRI of the head done which showed recent left insula cortical infarction, normal flow through a circle of in the major branches.",0
"On postoperative day #9, the patient is afebrile.",0
There was a question new right middle lobe infiltrate on chest x-ray.,0
"On hospital stay #11, the patient had repeat MRI of the head which was unchanged.",0
He had a swallow study performed which is normal.,0
"Patient is responsive, moving all extremities and following commands.",0
He is starting to move with help.,0
"He had a liver biopsy performed that showed evidence of preservation injury, otherwise normal.",0
"The patient continued on tube feeds, through post-pyloric Dobbhoff tube.",0
He is also starting to take regular food.,0
His medication was switched to p.o.,0
He was transferred to the floor on postoperative day #14 in stable condition.,0
"On postoperative day #15, the patient had an increase in LFTs.",0
He had an ultrasound performed which showed no hepatic artery flow.,0
"He had an emergency CTA performed which showed normal flow through hepatic artery, however there was a stricture of common hepatic.",1
Neurology Service was reconsulted and patient was started on aspirin.,0
The patient has remained afebrile.,0
His LFTs are going down.,0
He is on oral medications.,0
Calorie count was performed and showed that the patient is taking one half of his required calories p.o.,0
and he was switched on nighttime tube feeds.,0
The patient has trouble feeding himself and OT was consulted who found the patient has a lot of trouble with fine motor movements.,0
was consulted and was managing the patient's blood sugars.,0
He was started on Norvasc which brought his blood pressure under control.,0
"On postoperative day #17, the patient was found to have good p.o.",0
His tube feeds were stopped and Dobbhoff was removed without complication.,0
He is still whispering while talking so Speech and ENT consults were obtained which both indicated the patient has edematous erythematous vocal cords consistent with intubation injury.,0
Suggested that the patient will be based on humidified air with voice rest.,0
Continue to work with Respiratory and OT.,0
The patient is feeding himself.,0
Continued immunosuppression with new oral modified daily by levels.,0
Blood sugar controlled and improved.,0
"On postoperative day #5, the patient is afebrile.",0
He is ambulating without assistance.,0
Can feed and dress himself.,0
"His wound is clean, dry and intact.",0
His G tube is in place.,0
He will undergo G tube cholangiogram today.,0
"DISCHARGE STATUS: Patient is discharged home with VNA for medication supervision, wound check, PT and OT.",0
FOLLOW UP: Outpatient follow up schedule and lab schedule will be set up with the transplant center.,0
"Acute fulminant hepatic failure status post liver transplant, status post encephalopathy, status post ICV monitoring.",1
"G tube placement, PA monitoring.",0
Small hemorrhagic infarcts frontal temporal region.,0
Nutritional failure requiring TPN and tube feeds.,0
02-366 Dictated By: MEDQUIST36 D: 10:22 T: 10:40 JOB#:,0
"2:31 PM CHEST (PORTABLE AP) Clip # Reason: please eval for effusions infiltrate Admitting Diagnosis: FEVER, ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 28yo F s/p allograft removal, complicated postop course with sepsis, cont fevers REASON FOR THIS EXAMINATION: please eval for effusions infiltrate ______________________________________________________________________________ FINAL REPORT STUDY: AP chest performed on .",1
HISTORY: 28-year-old female with sepsis and continued fevers.,0
Evaluate for effusions and infiltrates.,0
FINDINGS: Compared to previous study from .,0
There is a tracheostomy tube and median sternotomy wires which are unchanged.,0
"The nasoenteric tube tip is not seen, but is likely within the stomach.",0
The cardiac silhouette is enlarged but unchanged.,0
There is again noted diffuse bilateral airspace opacities that appear more confluent when compared to the previous studies.,0
This is most likely secondary to pulmonary edema.,0
"However, superimposed multifocal pneumonia cannot be excluded.",0
"11:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please eval for retroperitoneal bleed/expansion of AAA Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH Field of view: 50 ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with groin hematoma, with marginal hct.",1
Also with known AAA of approx 5cm REASON FOR THIS EXAMINATION: Please eval for retroperitoneal bleed/expansion of AAA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for groin hematoma retroperitoneal bleed.,0
History of known abdominal aortic aneurysm.,1
TECHNIQUE: MDCT acquired contiguous axial images were obtained from lung bases to the level of the mid thigh.,0
CONTRAST: No contrast was administered.,0
CT OF THE ABDOMEN: A small left pleural effusion is noted with associated atelectasis.,0
"Two small nodules are seen at the right lung base, the largest measuring 4 mm in diameter.",0
"There are multiple foci of mediastinal air anterior to the pericardium, and immediately posterior to the sternum, with associated mediastinal wires, compatible with known recent history of coronary arterial bypass surgery.",0
Calcification is seen within the coronary vessels.,0
"The liver, gallbladder, spleen, adrenal glands and kidneys appear normal on this limited non-contrast enhanced CT scan.",0
"Limited evaluation of bowel, though there is no abnormal dilatation or evidence of wall thickening or inflammatory stranding.",0
Vascular calcification is seen within the aorta.,0
"Within the infrarenal portion of the aorta, immediately above the aortic bifurcation, there is aneurysmal dilatation of the aorta, which measures 5.3 x 4.4 cm in maximum diameter.",0
CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid colon are normal.,0
The bladder is normal in appearance.,0
A Foley catheter is seen within the bladder and the balloon appears to be within the prostatic portion of the urethra.,0
No free fluid or pelvic lymphadenopathy is seen.,0
"Within the right groin, there is high-density material, consistent with a hematoma, seen extending into the medial aspect of the proximal right thigh.",0
"In largest transverse diameter, this measures 11 x 4.2 cm.",0
There is no extension of this into the rectus sheath or retroperitoneum.,0
BONE WINDOWS: No sclerotic or lytic lesions are identified.,0
"Large hematoma within the right groin, measuring 11 x 4.2 cm in maximum (Over) 11:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please eval for retroperitoneal bleed/expansion of AAA Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) transverse diameter.",1
"Aneurysmal dilatation of the abdominal aorta, immediately above the aortic bifurcation measuring 5.3 x 4.4 cm in maximum diameter.",1
Small left pleural effusion with associated atelectasis.,0
"Two pulmonary nodules at the right lung base, largest of which measures 4 mm in diameter.",0
"In the absence of a known primary malignancy, followup evaluation of these can be performed in one year's time.",0
Post-surgical changes including pneumomediastinum from the patient's recent CABG.,0
"Foley catheter within the bladder, which appears to be low line, and the balloon is positioned within the prostatic portion of the urethra.",0
Results were discussed with Dr. at 11:50 a.m. on .,0
Height: (in) 68 Weight (lb): 255 BSA (m2): 2.27 m2 BP (mm Hg): 108/35 HR (bpm): 73 Status: Inpatient Date/Time: at 11:38 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Mild (1+) MR. TRICUSPID VALVE: Moderate [2+] TR.,0
1.The left atrium is mildly dilated.,0
2.The left ventricular cavity size is normal.,0
Overall left ventricular systolic function is hard to assess given the limited views but the basal portion of the inferior wall appears dyskinetic.,0
Right ventricular systolic function is hard to assess but is probably normal.,0
4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion.,0
Very mild (TR- 1+) mitral regurgitation is seen.,0
7.There is no pericardial effusion.,0
3:18 AM CHEST (PORTABLE AP) Clip # Reason: ETT in proper place?,0
"Admitting Diagnosis: INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man s/p PEA arrest, intubated REASON FOR THIS EXAMINATION: ETT in proper place?",1
"______________________________________________________________________________ FINAL REPORT PORTABLE AP SEMI-ERECT CHEST FILM AT 3:35 CLINICAL INDICATION: 79-year-old status post PEA arrest, intubated, question of location.",1
Comparison to prior study dated at 8:32.,0
"Endotracheal tube has its tip just below the thoracic inlet, unchanged.",0
"Right subclavian central line with its tip in the distal SVC, unchanged.",0
"Lungs appear relatively well inflated, although the right hemidiaphragm is mildly elevated.",0
"No focal airspace consolidation, pulmonary edema or pneumothorax.",0
The left costophrenic angle is not entirely included on the study.,0
Degenerative changes are seen in the thoracic spine.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Rituximab / Vincristine / Penicillins Attending: Chief Complaint: Rituximab desensitization.,0
"Major Surgical or Invasive Procedure: Blood transfusion, Platelet transfusion History of Present Illness: For complete H&P please see initial BMT note.",0
Briefly this is a 65 y.o.,0
Female w/ refractory follicular lymphoma who recently established care w/ Dr. and Dr. .,0
Given the level of thrombocytopenia her treatment regimen is limited to Rituximab.,0
Pt has history of complement mediated anaphylaxis reaction to Rituximab hence the elective admission for desensitization.,0
She was admitted to the ICU for closer observation whilst undergoing desensitization.,0
She has had 3 reactions to rituximab in the past.,0
"Specifically she received her first dose in and she was noted to have chills, HTN, rigors, sense of doom within an hour of infusion which was relived when the infusion was stopped.",0
"She underwent a retrial of Rituximab in with a slower rate of infusion, unfortunately she had the sensation of throat tightening and itching and the infusion was stopped.",0
"She underwent another retrial several weeks ago with pretreatment of steroids, Benadryl and unfortunately she was noted to have rigors, chills, HTN, throat itching and ?swelling within an hour of infusion.",0
Per allergy their consensus is this is a complement mediated reaction and they recommend 48hours of IV Methylprednisolone 40mg IV q6hours.,0
On review of his history it appears he also has had significant fatigue over the past few weeks that was attributed to her pancytopenia.,0
Past Medical History: ONCOLOGY HISTORY: Diagnosed at 65 y.o.,0
with Follicular lymphoma in during work up of BOOP.,0
"BM bx showed 40-50% celluarity, of which approximately 50% was lymphoma.",0
"She was started on R-CHOP but given her aforementioned reactions she received 6 cycles of CHOP, completing in and achieving a complete remission as documented by PET-CT on .",0
She relapsed by CT scan in and received one cycle of fludarabine 50mg daily on days .,0
This treatment was complicated by febrile neutropenia and was discontinued.,0
"She then underwent six cycles of CVP, complicated by neuropathy.",0
"She achieved a partial remission based on CT in , with a stable scan in , , and .",0
She underwent a bone marrow bx on given persistent thrombocytopenia.,0
BM bx showed increased celluarity with 70% of cellular material lymphoma cells consistent with her follicular lymphoma.,0
She was started on chlorambucil 4mg daily on approximately which was complicated by leukopenia and admission for anemia two weeks later.,0
Follicular Lymphoma (diagnosed -refractory) Bronchiolitis obliterans organizing pneumonia Social History: The patient has three sons and three grandchildren.,1
She is a former sales clerk for an electronics company and now enjoys cooking in her free time.,0
She does not drive due to peripheral neuropathy.,0
She is a former light smoker and quit 6 years ago.,0
"Family History: NC Physical Exam: GENERAL: Pleasant, well appearing Caucasian Female walking to bed from wheelchair in NAD HEENT: No scleral icterus.",0
"CARDIAC: Regular rhythm, normal rate.",0
III/VI SEM noted in upper rt sternal border.,0
"LUNGS: CTAB, good air movement biaterally.",0
"No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses.",0
"CN II-, , XII intact.",0
"Peripheral neuropathy noted b/l LE to level of knee, b/l fingertips.",0
woman with follicular lymphoma and pancytopenia admitted to ICU for Rituximab desensitization.,1
"Rituximab desenitization: Several weeks ago pt endorsed fatigue, lightheadedness.",0
She underwent bone marrow biopsy which showed a recurrence of her follicular lymphoma.,0
Given her thrombocytopenia and adverse effects on other regimens pt was admitted for Rituximab desensitization.,0
"She was originally admitted to the BMT floor and then transferred to the for close airway monitoring given her prior reactions to Rituximab of throat itchiness, HTN, rigors.",0
"She was seen by Allergy who recommended a desensitization protocol of 48hrs of Methylprednisolone 40mg q6hr followed by H2 blocker, Benadryl with desensitization goal dose of 600mg.",0
During and after desensitization pt did not experience any adverse reactions.,0
She was then discharged home after the oncology team had seen her.,0
Her oncologist's office will call her for an appointment to initiate Rituximab.,0
Pancytopenia: Pt has been pancytopenic over the past few weeks likely lymphoma given her recent BM biopsy results.,0
Pt underwent bone marrow biopsy on with cytogenetics for MDS work-up which was still pending at time of discharge.,0
On the BMT floor she received 2u of PRBC and 1u plts.,0
Her Hct remained stable albeit at a level of 22.,0
Prior to discharge pt was given another unit of PRBCs.,0
She will need to follow up with her oncologist for her bone marrow biopsy results for MDS.,0
BOOP: She was continued on her home regimen of Symbicort.,0
"Peripheral Neuropathy: Attributed to Vincristine exposure, she was continued on her home regimen of Gabapentin.",0
Hyperlipidemia: She was continued on home regimen of Simvastatin.,0
Hypothyroidism: She was continued on home regimen of levothyroxine.,0
"Medications on Admission: BUDESONIDE-FORMOTEROL [SYMBICORT] - (Prescribed by Other Provider) - Dosage uncertain EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider) - 40,000 unit/mL Solution - 60,000 units q7d GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 2 Capsule(s) by mouth twice a day LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth once a day LORAZEPAM - (Prescribed by Other Provider) - Dosage uncertain SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CALCIUM - (Prescribed by Other Provider) - Dosage uncertain DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1.",0
Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day).,0
Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation ().,0
"Epogen 20,000 unit/mL Solution Sig: 60,000 units Injection once a week.",0
Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Discharge Disposition: Home Discharge Diagnosis: Primary: Rituximab desensitization Secondary: Pancytopenia, Anemia requiring blood transfusion, Neutropenia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital for the initiation of the Rituximab medication for your Follicular Lyphoma.",1
"As you have a history of allergic reactions to this medication you underwent a 2 day protocol to be desensitized to this medication, you were able to tolerate a full dose without any allergic reactions.",0
As your blood and platelet counts were low you were also given blood and platelet transfusions.,0
We made on changes to your medication.,0
"If you experience any fevers, chills, extreme shivering, throat itching, swelling or difficulty breathing please return to the ED or call your doctor.",0
Followup Instructions: Your oncologist will call you for an appointment to start your Rituximab.,0
Height: (in) 70 Weight (lb): 180 BSA (m2): 2.00 m2 Status: Inpatient Date/Time: at 19:24 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,0
LEFT VENTRICLE: Normal regional LV systolic function.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Physiologic TR.,0
Conclusions: PRE-BYPASS: The left atrium and right atrium are normal in cavity size.,0
POST-BYPASS: The patient is A paced.,0
The remainder of the examination is unchanged.,0
Dr. was notified in person of the results in the operating room.,0
"2:21 PM CT CHEST W/O CONTRAST Clip # Reason: please eval for pna Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with ALL s/p HIDAC w/ neutropenic fevers REASON FOR THIS EXAMINATION: please eval for pna No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc WED 5:29 PM Since , there is no new focal area of consolidation.",0
Bilateral pleural effusion is cleared.,0
Tiny dependent atelectasis is seen.,0
No signs of acute cardiopulmonary process.,0
"______________________________________________________________________________ FINAL REPORT CT CHEST WITHOUT CONTRAST REASON FOR EXAM: 38-year-old woman with ALL, status post HIDAC, with neutropenic fevers.",0
TECHNIQUE: Chest MDCT was performed without contrast using 5mm and 1.25mm axial slice thickness.,0
"FINDINGS: Since , there is no area of consolidation.",0
Right central venous line is in unchanged position.,0
Right lower lobe bulla is stable.,0
Lungs are otherwise clear except to note tiny dependent atelectasis.,0
There is no lymph node enlargement using CT criteria.,0
Heart and great vessels are normal.,0
Airways are patent to the subsegmental level.,0
The upper abdomen is unremarkable except to note prior cholecystectomy.,0
"1:33 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for pneumonia, atelectasis.",0
"Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with CVA, aspiration pna.",0
Thickened secretions; afebrile and WBC wnl.,0
"REASON FOR THIS EXAMINATION: Please eval for pneumonia, atelectasis.",0
"______________________________________________________________________________ FINAL REPORT CHEST ONE VIEW, PORTABLE INDICATION: 87-year-old man with CVA, aspiration pneumonia.",0
"COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and compared with previous study of .",0
The patient has been extubated.,0
The previously identified opacity in both lower lobes has been improving.,0
There is also improvement of the pulmonary edema compared with previous study.,0
A nasogastric tube terminates in the gastric body.,0
Note is made of contrast within the colon.,0
The radiograph is suboptimal in technique.,0
"Admission Date: Discharge Date: Service: NEUROLOGY Allergies: Codeine Attending: Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: Intubation MRI Echo History of Present Illness: This is an 82 yo woman with PAF, stroke in past, high chol, cad, as well as dementia and hx breast ca past s/p L mastectomy, who presents from facility as ""code stroke"" when friends noticed she was not talking around 12:30PM.",1
"Initially, unable to identify last well time - spoke with (SW in facility) who saw her at 1PM and said that pt's friends reported that pt could not talk and was drooling between 12:30 and 1PM - she had apparently showed up to lunch that way.",0
"She was seen well at dinner night prior; when staff went to room today, there was another shirt ""with drool on it"" thus staff thinks drooling may have started earlier in day.",0
Was apparently able to walk normally with no signs of weakness anywhere.,0
"Pt brought to ED where NIHSS score was 9 for LOC questions, Visual field cut (L SIDE), Sensory neglect (R SIDE), aphasia (could comprehend commands and y/n questions but nearly no output), and likely decreased sensation on R. As code stroke called at 2PM and last well was unknown, she was considered out of window for IV and IA TPA.",0
"Eventually met another staff member who gave her meds at 8:30AM and says that pt was completely at baseline at time - at this point, because she was in 9hr window, she was considered for protocol.",0
"Past Medical History: 1) CAD, recent anterior MI- LAD 30% proximal stenosis with diffuse severe disease, large DI with 70% occlusion.",0
"2) CHF- diastolic dysfunction dx 3 yrs ago 3) History of atrial fibrillation- Previously on coumadin for many years, but self d/c'd.",1
"4) CVA- age 30's, sensory loss in 1 hand 5) dementia- progressing in past 3 years per daughter 6) breast CA s/p mastectomy Family History: noncontributory Physical Exam: T 97.4 HR 81 BP 187/47 (last checked: 156 systolic); 98%RA; RR 14 General appearance: elderly white female, NAD, some drooling HEENT: moist mucus membranes, clear oropharynx Neck: supple, no bruits, no jvd Heart: regular rate and rhythm, no murmurs Lungs: crackles at bases bilaterally Abdomen: soft, nontender +bs Extremities: warm, well-perfused .",1
"Mental Status: The patient is alert and awake, seemed to comprehend commands and questions (answered with head nods, or showing number of fingers); however, she could not produce spontaneous speech besides quite dysarthric ""Ahh laa"" for """" when asked her name.",0
"When asked to repeat initially, she was unable to say anything; later, she could repeat slowly and with significant dysarthria ""My Name Is "" and said ""Today Sunny Day"" for ""today is a sunny day.""",0
"She could not name or read, but could sign her name.",0
Cranial Nerves: The visual fields are significant for a left sided field cut with or without hemineglect.,0
The optic discs are difficult to visualize (bilateral cataract).,0
"Eye movements are normal, with no nystagmus.",0
"Pupils react equally to light, both directly and consensually.",0
"Sensation on the face is intact to light touch, pin prick; could not assess ext to DSS on face.",0
Facial movements are normal and symmetrical.,0
Hearing is intact to finger rub.,0
The palate elevates in the midline.,0
The tongue protrudes in the midline and is of normal appearance.,0
"Motor System: With the exception of subtle triceps weakness bilat, and elevated tone in the legs, the appearance, tone, power are normal in all 4 limbs, including shoulder abductors, and extensors and flexors of the arms, wrists, fingers, hips, knees, feet and toes.",0
"There is no tremor, drift, or abnormal movements.",0
"Reflexes: The tendon reflexes are present, symmetric and normal.",0
The plantar reflexes are mute bilaterally.,0
"Sensory: Pt agrees with ""normal sensation"" on limbs to LT, PP, but there is extinction to DSS over the right hemi-body.",0
Could not fully participate with ?proprioception testing.,0
Coordination: There is no ataxia.,0
The finger/nose test and finger tapping were normal.,0
Gait: could not be assessed Pertinent Results: 02:23PM cTropnT-0.45* 10:00PM CK-MB-17* MB INDX-10.1* cTropnT-0.50* 02:22PM PT-12.1 PTT-24.6 INR(PT)-1.0 02:22PM PLT COUNT-410 02:22PM NEUTS-77.6* LYMPHS-14.9* MONOS-6.1 EOS-1.1 BASOS-0.4 02:22PM WBC-8.3 RBC-4.01* HGB-10.3* HCT-32.2* MCV-80* MCH-25.7* MCHC-32.0 RDW-15.9* .,0
MRI/MRA: Small right middle and posterior cerebral artery territory acute infarctions.,1
"Given the multivessel distribution and the history of prior left cerebral hemispheric infarct, the findings are most consistent with an embolic event.MRA CIRCLE OF : The major tributaries of the circle of are patent.",1
Irregularity along the intracranial portions of bilateral carotid arteries is consistent with moderate atherosclerosis.,0
IMPRESSION: No evidence of significant stenosis.,0
"ADDENDUM: Perfusion images confirm reduced flow in the areas of acute infarction, somewhat more extensive than the areas of restricted diffusion.",1
"The diffusion/perfusion mismatch is consistent with the presence of an ""ischemic penumbra.""",0
Carotid US: There is no appreciable plaque or wall thickening involving either carotid system.,0
The peak systolic velocities bilaterally are normal as are the ICA to CCA ratios.,0
There is normal antegrade flow involving both vertebral arteries.,0
No evidence of pulmonary embolism 2.,0
Right upper lobe consolidation consistent with pneumonia.,0
Compressive right and left lower lobe atelectasis.,0
"Cardiomegaly, atherosclerotic disease, and a small pericardial effusion.",0
Persistent large bilateral pleural effusions.,0
New left upper lobe consolidation consistent with pneumonia versus aspiration.,0
Improved aeration of the right upper lobe.,0
"Cardiomegaly, atherosclerotic disease and small pericardial effusion.",0
"Brief Hospital Course: Floor and ICU Course: Neuro: Patient was diagnosed with new right temporal lobe infarct, suspected to be embolic based on the patient's history of Afib without being anticoagulated.",0
Patient was initially considered for study as she was not a candidate for TPA based on her time window of greater than 3 hrs.,0
"However, the patient was turned down by the study center based on her troponin leak.",0
"Was managed with supportive care, and started immediately on Heparin Drip, as well as for the developing MI.",0
"Sustained profound bulbar weakness thought to be as a result of her bilateral cortical infarcts, vs involvement of some corticobulbar fibers.",0
On repeat speech and swallow eval continued to be unable to swallow bulbar weakness so PEG placed.,0
CVS: Patient was seen Day 1 by cardiologist Dr .,0
"MI (peaked , and again on to 0.85).",0
Beta Blocker and ACE inhibitor started per cards recs.,0
Developed some degree of CHF with pneumonia on and was found to have EF down from 55% to 35 % also with worsening MR.,0
"Initially received Lasix drip to diurese, then Lasix IV BID.",0
Intubated emergently and transferred to ICU.,0
RUL PNA and possible LLL PNA on CXR.,0
Bilateral effusions found on CT which were shrinking after Lasix drip for 72 hrs.,0
Continued to have respiratory distress on the floor which was felt to be pleural effusions and pneumonia.,1
GI: on TF and protonix.,0
"h/o GI bleed with recent guiac + (), melanotic stools and Hct trending down over weekend ().",0
Seen by GI but too unstable to tolerate scope.,0
"Got two units blood then hct stablized, but stool still melanotic.",0
PEG placed on without incident.,0
Heme: Hct trended down 30->25 and on Heparin Gtt with goal 50-70.,0
PTTs in low 50s Sunday Started on FE supplements for FE defficiency anemia.,0
"As patient normocytic, checked B12 and FA to see if there was combination of microcytic and macrocytic anemia, but FA and B12 normal.",0
Had to give two units PRBC to keep Hct >30 (recent MI) and stopped Heparin Gtt 12/112 secondary to continued melena.,0
Completed 7 days Cipro/flagyl for PNA.,0
End of Life course: Pt.,0
developed worsening respiratory distress on (see Respiratory section above).,0
"Her care was discussed with her family as reintubation was felt to be possible, and they felt that she would not want this and would want her care to focus on comfort.",0
Palliative care was therefore involved and non-comfort medications were stopped.,0
was kept comfortable with Ativan PRN anxiety and Morphine PRN pain.,0
She expired with family at the bedside on .,0
"Discharge Disposition: Expired Discharge Diagnosis: Bilateral Ischemic infarcts Aspiration Pneumonia Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None MD, Completed by:",0
4:40 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: NECROTIZING PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with necrotizing pancreatitis, intubated REASON FOR THIS EXAMINATION: ?",0
interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Necrotizing pancreatitis.,0
"FRONTAL CHEST RADIOGRAPH: An endotracheal tube, nasogastric tube and left subclavian central venous lines are in unchanged and appropriate positions.",0
The heart size is within normal limits.,0
A small left-sided layering pleural effusion is slightly more prominent.,1
Left retrocardiac atelectasis and a small right-sided pleural effusion are unchanged.,1
There is a moderate degree of scarring at the lung bases.,0
Mild increased size of small left-sided pleural effusion.,1
Stable small right-sided pleural effusion and left retrocardiac atelectasis.,1
", CSURG FA6A 11:46 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: PTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man post-pull CT-s/p OPCAB REASON FOR THIS EXAMINATION: PTX ______________________________________________________________________________ PFI REPORT PFI: No pneumothorax after chest tube removal.",1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 46 year-old male admitted on from the Emergency Department after the patient was brought in by EMS for being stabbed in the back three times.,0
"The patient does not recall how the event occurred entirely, but reportedly was attacked.",0
"The patient was alert, awake, without any respiratory distress in route to the hospital without any other complaints.",0
PAST MEDICAL HISTORY: History of hepatitis C status post interferon and ribavirin treatment and a history of a prior stab wound in .,1
Status post IVDU and current alcoholism.,0
100% O2 saturations on nonrebreather.,0
The patient was alert and oriented times three with a small abrasion to the right neck.,0
The neck had a C collar in place.,0
Cardiac examination was a regular rate and rhythm without any murmurs.,0
Lungs were clear to auscultation on both sides.,0
"Abdomen was soft, nontender with bowel sounds present.",0
The back showed there was a 2 cm stab wound to the left paraspinal region at T6 and a 2 separate 1.5 cm stab wounds at the level of T5 T6 just medial to the scapula border.,0
Extremities were warm without any edema and well perfuse.,0
All distal pulses were intact.,0
There was no obvious deformity.,0
The neurological examination was grossly intact to motor function and sensation bilaterally.,0
"INITIAL LABORATORIES: Normal CBC, normal coags, lactate of 3.2, creatinine 0.9 and otherwise normal electrolytes and an alcohol level of 95.",0
INITIAL RADIOLOGY: Chest and pelvic x-rays were normal.,0
Abdominal CT was within normal limits.,0
Chest CT showed a right pneumothorax.,1
"HOSPITAL COURSE: The patient was diagnosed with a right pneumothorax by CT and admitted for placement of right sided chest tube, which was performed without complications and serial hematocrits were monitored.",1
The C spine was cleared once the patient was sober.,0
Chest tube was removed without incident with a small residual less then 5% pneumothorax remaining.,1
Repeat chest x-ray the following day demonstrated the pneumothorax was decreasing in size.,1
The patient is discharged home.,0
Status post stab wounds to the back.,0
Methadone 5 mg po b.i.d.,0
for five days only with Ibuprofen 400 mg t.i.d.,0
Pantoprazole 40 mg po q.d.,0
Dilaudid 2 mg po q 6 hours prn for five days.,0
RECOMMENDED FOLLOW UP: The patient can follow up at the Trauma Clinic if there are any new developments with the wounds or problems relating to this injury.,0
Otherwise he is to obtain a primary care physician for long term healthcare.,0
Dictated By: MEDQUIST36 D: 11:47 T: 12:08 JOB#:,0
"4:12 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please confirm central line placement, r/o free air in the s Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with c.diff colitis, hypotension s/p RIJ REASON FOR THIS EXAMINATION: please confirm central line placement, r/o free air in the setting of colitis on upright film ______________________________________________________________________________ FINAL REPORT SEMI-UPRIGHT PORTABLE CHEST of COMPARISON: Previous study of earlier the same date.",0
"Right internal jugular vascular catheter terminates within the mid to lower superior vena cava, with no pneumothorax.",0
Subtle interstitial opacities have developed and likely represent mild interstitial edema.,0
"No free intraperitoneal air is identified, but semi-upright position of the radiograph is relatively insensitive for detecting this entity.",0
Standard upright chest radiograph or left lateral decubitus abdominal view would be recommended for more complete assessment.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: morphine Attending: Chief Complaint: hematemesis Major Surgical or Invasive Procedure: endoscopy History of Present Illness: Ms. is a 66 year-old woman with a past medical history of prior lung cancer s/p left pneumonectomy, COPD, history of breast cancer s/p radiation/lumpectomy, multiple recent hospitalizations for pneumonia, initially presented to on with shortness of breath and persistent cough.",1
"She had a recent admission at the beginning of for a CAP, COPD exacerbation during which she had a CTA of her chest which showed a new lobulated right upper lobe mass invasive into the airways, with possible postobstructive pneumonitis, highly suspicious for malignancy.",0
"She was apparently supposed to have an outpatient bronchoscopy, but this never happened.",0
"When she presented to with SOB, she had a troponin of .28/.24, diffuse deep TWI, BNP of 1,000.",0
"TTE was done which showed apical hypokinesis, EF 60%.",0
"Cardiology was consulted and per notes, thought she had stable CAD, not acute coronary syndrome, recommended statin/aspirin, held off beta blocker secondary to wheezing.",0
"In terms of her SOB, it was felt that she was having another COPD exacerbation with possible postobstructive pneumonia.",0
"She was initially admitted to the floor and improved on PO steroids with nebulizers, then her respiratory status worsened, she became tachcyardic and she was tranferred to the MICU and started on Vancomycin and Zosyn.",1
"According to the notes, vanco had been dc'ed, however was given earlier today prior to transfer.",0
"It was determined that she needed another CTA of the chest, however, she declined.",0
"After speaking with IP here, the patient was intuabted on , had a bronch at , and is being transferred post - procedure to for further management and evaluation for possible stenting procedure.",0
"At the time of transfer, the results of the bronch were unknown, but tissue biopsies were taken.",0
"On arrival to the MICU, patient is intubated and sedtaed, comfortable on vent.",0
"Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain.",0
"Denies headache, sinus tenderness, rhinorrhea or congestion.",0
"Denies cough, shortness of breath, or wheezing.",0
"Denies chest pain, chest pressure, palpitations, or weakness.",0
"Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits.",0
"Denies dysuria, frequency, or urgency.",0
Denies rashes or skin changes.,0
Past Medical History: - Prior right lung pneumonectomy for lung cancer - COPD - prior community acquired pneumonias - breast cancer with lumpectomy: lumpectomy followed by radiation therapy - anxiety - positional vertigo - stress fracture both ankles - Cesarean section - reported history of a right adrenal mass - insomnia - GERD - diaphragmatic hernia.,1
"Social History: ( records): She was a moderate cigarette smoker, smoking about less than a pack of cigarettes a day for 35-40 years until 4 years ago when lung cancer was diagnosed.",0
No smoking since then and no exposure to secondhand cigarette smoke.,0
"She does not drink alcohol, does not use drugs.",0
She does not work right now.,0
"She is married, lives with her husband.",0
She is physically quite active.,0
"Family History: NC Physical Exam: Admission Exam Vitals: 98.4 95 158/81 18 100% gen: intubated and sedated, not responding to commands CV: tachycardic, no appreciable murmurs over vent Resp: transmitted breath sounds on left, coarse breath sounds on right Abd: +BS, soft Neuro: pupils equal Pertinent Results: Chest Xray Left lung is airless and mediastinum occupies the left hemithorax suggesting prior left pneumonectomy.",0
"Right upper lobe is densely consolidated, and at its periphery is a 5 x 12 cm homogeneous opacity with lobulated margins along the lung interface which certainly could be a mass involving lung and pleura.",0
The right lower lung is free of consolidation but there are septal lines suggesting mild edema.,0
Nasogastric tube ends in the upper stomach.,0
Right jugular line tip projects over the middle third of the leftward displaced SVC.,0
ECG Sinus rhythm with premature atrial contractions.,0
"Possible lateral infarction, age undetermined.",0
Brief Hospital Course: Ms. is a 66 year old woman with a history of non small cell lung cancer s/p left pneumonectomy and COPD who presented with a new right lung mass and post - obstructive pneumonia.,1
She was initially admitted to with symptoms of shortness of breath.,0
She was transferred for possible stenting.,0
She had been intubated at .,0
On arrival to she was placed on broad spectrum antibiotics given concern for a possible post-obstructive picture.,0
She was seen by the interventional pulmonary team shortly after arrival to .,0
"They performed a bronchoscopy, but were unable to perform any intervention given the location of the tumor compressing her airway.",0
Multiple discussions were held with the patient's family and her outside providers were contact.,0
We discussed her overall poor prognosis.,0
Ms. family expressed that she would not want any more invasive procedures or further treatments.,0
Her care was transitioned to comfort focused measures.,0
She was extubated on and passed away on .,0
Her sons and were both contact.,0
Medications on Admission: albuterol 2 puffs q.i.d.,0
vitamin D 1000 units a day Tylenol 1000 mg q.6h.,0
zolpidem 12.5 mg at bedtime fluticasone 110 mcg 2 sprays b.i.d Meds on transfer: Vancomycin HCl 1000 mg DAILY Zosyn 3.375 g q6 Propofol Fentanyl Prednisone 60 mg PO daily Lorazepam 1 mg TID:PRN anxiety Escitalopram Oxalate 10 mg DAILY Buspar 5 mg Xopenex nebs PRN Omeprazole 40 mg Singulair 10 mg once a day Aspirin 81 mg daily Simvastatin 10 mg daily Ambien 10 mg:PRN Lovenox 40 mg daily Fluticasone Mucinex Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired MD,0
"10:14 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for progression of ARDS, fluid overload, or ptx Admitting Diagnosis: RESP FAILURE-RENAL FAILURE-CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 77 yo M with COPD/CHF s/p trach now with hypoxemia and likely ARDS and renal failure leading to volume overload and high pressure ventilation REASON FOR THIS EXAMINATION: evaluate for progression of ARDS, fluid overload, or ptx ______________________________________________________________________________ FINAL REPORT INDICATION: 77-year-old woman with COPD, CHF, questionable ARDS.",1
SEMIUPRIGHT AP CHEST RADIOGRAPH: Tracheostomy tube and a right-sided subclavian central venous line are in appropriate positions.,0
There is moderate congestive heart failure and moderate cardiomegaly.,1
The left costophrenic angle cannot be evaluated secondary to technical factors.,0
Bilateral pleural effusions are unchanged.,0
Unchanged retrocardiac opacity representing atelectasis/consolidation.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MICU ADDENDUM: It is recommended that the patient continue on Lovenox 60 mg subcutaneously b.i.d.,0
for a known clot in her PICC line.,0
"The line does infuse, however.",0
"Also, follow-up as needed is suggested for Guaiac positive stool.",0
This note is intended to accompany the full discharge summary.,0
Dictated By: MEDQUIST36 D: 04:30 T: 16:36 JOB#:,0
"2:17 PM CT CHEST W/CONTRAST Clip # Reason: PAPILLARY THYROID CA, EVALUTATE FOR STAGING, POTENTIAL WORSENING OF METASTATIC DISEASE Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ MEDICAL CONDITION: 36 yo M w/ thyroid papillary CA w/ mets to chest LN and bone REASON FOR THIS EXAMINATION: pls eval for staging; potential worsening of metastatic disease, compared to prior chest CT No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd SUN 6:39 PM 1. marked interval increase in size of mediastinal and hilar lymphadenopathy.",1
2. stable to increased size of multiple periaortic/periesophageal lymph nodes.,1
3. marked interval increase in size of paratracheal soft tissue masses/lymph nodes at the level of the thoracic inlet.,1
"4. small bilateral pleural effusions, new.",1
"5. small pericardial effusion, worse.",0
"6. new mixed sclerotic and lucent bony lesions at T1, T3 and T11, concerning for mets.",0
"Increase in size of left axillary lymph node, up to 9mm short axis diameter, previously barely visible.",0
7. no lung nodules seen.,0
WET READ VERSION #1 JKSd SUN 5:18 PM 1. marked interval increase in size of mediastinal and hilar lymphadenopathy.,0
"6. new mixed sclerotic and lucent bony lesions at T4 and T11, concerning for mets.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 36-year-old man with thyroid papillary cancer with metastatic (Over) 2:17 PM CT CHEST W/CONTRAST Clip # Reason: PAPILLARY THYROID CA, EVALUTATE FOR STAGING, POTENTIAL WORSENING OF METASTATIC DISEASE Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ FINAL REPORT (Cont) disease to the chest, lymph nodes and bones.",1
COMPARISON: Head CT and CT torso of .,0
TECHNIQUE: Axially acquired images were obtained through the chest after the administration of 75 cc of Optiray intravenous contrast.,0
Coronal and sagittal reformatted images were also displayed.,0
FINDINGS: Bilateral paratracheal nodules are located at the level of the thoracic inlet are markedly enlarged since the previous study of .,0
"The right measures 2.8 x 2.5 cm, previously 1.1 x 0.9 cm.",0
"The left now measures 2.4 cm x 1.5 cm, previously measuring 1.7 x 1.0 cm.",0
Surgical clips are noted from prior thyroidectomy.,0
There has also been marked interval increase in mediastinal and bilateral hilar lymphadenopathy.,1
"The largest node/nodal conglomerate is subcarinal (2:28) and now measures 2.9 x 4.4 cm, previously 2.5 x 3.2 cm.",0
"The largest hilar nodal conglomerate is on the right (2:26) and now measures 3.4 cm x 2.1 cm, previously 2.1 cm x 1.8 cm.",0
A small pericardial effusion has increased in size.,0
"There are small bilateral pleural effusions, new since the previous study.",1
There is adjacent bibasilar atelectasis.,0
No lung nodules are identified.,0
"Multiple paraortic and paraesophageal lymph nodes are also again seen, stable to slightly increased in size.",1
"Visualized upper aspect of the abdomen demonstrates a 1.2 cm portahepatis lymph node, slightly increased in size from 1.0 cm.",1
"BONE WINDOWS: Since the previous study, there are new areas of mixed sclerosis and lucency at the anterior aspect of vertebral body T11, at the right superior posterior aspect of the T3 vertebral body, and the majority of vertebral body T1.",0
"Vague areas of sclerosis in the left scapula, left 5th and 6th ribs, and right 6th, 7th and 8th ribs may also represent areas of bony metastases.",0
Interval increase in size of mediastinal and hilar lymphadenopathy as described above.,0
Stable to increase in size of multiple lymph nodes surrounding the esophagus and aorta.,1
Marked interval increase in size of paratracheal soft tissue nodules/lymph nodes at the level of the thoracic inlet.,1
"Small bilateral pleural effusions are (Over) 2:17 PM CT CHEST W/CONTRAST Clip # Reason: PAPILLARY THYROID CA, EVALUTATE FOR STAGING, POTENTIAL WORSENING OF METASTATIC DISEASE Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ FINAL REPORT (Cont) new since the previous study.",1
"Small pericardial effusion, increased in size since the previous study.",0
"New mixed lucent and sclerotic lesions in vertebral bodies T1, T3 and T11, concerning for metastasis.",0
"PET-CT of , demonstrates FDG-avid disease in T3, T6, and T12.",0
"3:43 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ACUTE RESPIRATORY FAILURE;SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with mucous plugging, PNA, intubated.",1
REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for interval change.,0
"FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position.",0
Also unchanged is the moderate retrocardiac atelectasis and the potential for a mild to moderate left-sided pleural effusion.,0
"4:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: Evaluate for obstruction, abscess, pancreatic pathology, bow Admitting Diagnosis: PANCREATITIS Field of view: 36 Contrast: OPTIRAY Amt: 150CC ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with recurrent abdominal pain of unclear etiology.",1
"REASON FOR THIS EXAMINATION: Evaluate for obstruction, abscess, pancreatic pathology, bowel wall inflammation or edema, fluid in abdomen, etc.",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Recurrent abdominal pain of unclear etiology.,0
Prior workup for question of pancreas abnormalities.,0
Unable to complete MRI on due to claustrophobia.,0
TECHNIQUE: Axial multidetector CT was performed through the abdomen and pelvis after the uneventful intravenous administration of 150 cc Optiray and ingestion of oral contrast.,0
Coronal and sagittal reformats were made.,0
COMPARISONS: CT and prior MRI.,0
"CT ABDOMEN WITH CONTRAST: As before, the common bile duct is dilated, similar to , though slightly more than .",0
It currently measures 11 mm within the pancreatic head.,0
The common hepatic duct is also mildly dilated at 9 mm as is the cystic duct remnant.,0
There is mild central intrahepatic biliary ductal dilatation.,0
This likely reflects progressive sphincter of Oddi dysfunction.,0
Patient is status post cholecystectomy.,0
The liver is without abnormality.,0
"As before, there is low attenuation within the ventral pancreas which on prior MRI was shown to be fatty infiltration.",0
Main pancreatic duct is normal in caliber.,0
Pancreas divisum seen on prior MRI is not well-depicted on this study.,0
No focal pancreatic abnormality of concern.,0
"There is a normal CT-enhanced appearance of the spleen, bilateral adrenal glands, and small bowel within the abdomen.",0
Focal defect within the right kidney in the area of a prior simple cyst on MRI likely reflects involuted cyst.,0
"Patient is status post cecal resection and reanastomosis, with a normal appearance.",0
"CT PELVIS WITH CONTRAST: As seen on the prior CT, there is small bowel with mesentery that forms the dome of the urinary bladder.",1
Gas within some of these loops of small bowel and a small amount of contrast within the inferior aspect of these loops of small bowel suggest that this was a bladder augmentation.,0
Foley catheter is in place.,0
No wall thickening or other definite abnormality with the bladder.,0
Bilateral adnexa are within normal limits.,0
"The uterus is nonapparent, and was likely surgically resected.",0
There are multiple sigmoid diverticula.,0
"There is (Over) 4:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: Evaluate for obstruction, abscess, pancreatic pathology, bow Admitting Diagnosis: PANCREATITIS Field of view: 36 Contrast: OPTIRAY Amt: 150CC ______________________________________________________________________________ FINAL REPORT (Cont) a small rectal diverticula Vs. a perirectal partially calcified node.",1
No concerning lymph nodes within the pelvis.,0
BONE WINDOWS: No concerning lytic or sclerotic bone lesions.,0
Distinct extrahepatic and mild central intrahepatic biliary ductal dilatation likely reflects sphincter of Oddi dysfunction.,0
"Fatty infiltration of the ventral portion of the pancreas, as before.",0
No concerning pancreatic abnormality and no duct dilation.,0
Pancreatic divisum seen better on prior MRI.,0
Bladder augmentation with small bowel has the expected appearance.,0
"12:09 PM PICC LINE PLACMENT SCH Clip # Reason: picc Admitting Diagnosis: CORONARY ARTERY DISEASE ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with HIV and CAD s/p LAD stent REASON FOR THIS EXAMINATION: picc ______________________________________________________________________________ FINAL REPORT HISTORY: 46-year-old male with HIV, CAD, needs intravenous access for fluids, medications.",1
"PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr. with Dr. , the Attending Radiologist, supervising the entire procedure.",0
Patient was placed supine on the angiographic table.,0
The right upper arm was prepped and draped in standard sterile fashion.,0
The right brachial vein was accessed under ultrasound guidance after local administration of 1% lidocaine with a 21 gauge micropuncture needle.,0
An .018 guide wire was advanced through the needle into the superior vena cava under fluoroscopy.,0
A small was made with a #11 blade scalpel at the insertion site.,0
The needle was exchanged for a 4.5 Fr micropuncture sheath with inner dilator.,0
The inner dilator was removed.,0
The PICC line was cut to a length of 35 cm and advanced over the wire under fluoroscopic guidance.,0
The wire and peel-away sheath were removed.,0
Final fluoroscopic chest ray demonstrates the tip of the PICC line to be in the superior vena cava.,0
"The line was flushed, capped and heplocked, and secured to the skin using StatLock and OpSite.",0
"CONCLUSION: Successful placement of 35 cm dual-lumen right brachial PICC line with tip in the superior vena cava, OK to use.",0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Prilosec / Morphine Attending: Addendum: see discharge information--it has been updated Discharge Disposition: Home Followup Instructions: Call the Clinic at for a follow up appointment in weeks.,0
"Provider: , MD Phone: Date/Time: 1:45 Provider: , RD Phone: Date/Time: 9:30 Provider: , MD Phone: Date/Time: 10:00 Follow up with Dr. (Gastroenterology) in 2 weeks.",0
"Call for an appointment ( MD, Completed by:",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: please check picc tip position.,0
"#5f,50cm picc for multiple m Admitting Diagnosis: RESPIRATORY FAILURE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with pneumonia REASON FOR THIS EXAMINATION: please check picc tip position.",1
"#5f,50cm picc for multiple meds.",0
______________________________________________________________________________ WET READ: KKgc SAT 10:15 PM New LUE PICC takes an abnormal course.,0
Review of prior CT did not demonstrate a left SVC.,0
Possibly coiled within the left internal mammary vein.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with pneumonia after PICC line placement.,0
Portable AP chest radiograph was compared to prior study from the same day obtained earlier.,0
"The left PICC line goes through the left subclavian vein and then takes a sharp caudal turn and running parallel to and to the left of the spine, with the portion of the catheter being distal to the subclavian vein at least 18 cm in length.",0
"The position of the catheter is unclear, it might be in the internal mammary vein or alternatively in the arterial structure, correlation with the output of the catheter is suggested with immediate re-position.",0
The prior CT did not demonstrate left superior vena cava thus the location of the catheter cannot be in the left superior vena cava.,0
The findings were discussed with IV access team ( over the phone by Dr. ).,0
Intersegmental artery to the inferior pole of the left kidney.,0
Segmental artery to the interpolar aspect of the left kidney.,0
"CATHETERS: 4.0 French Cobra 2, 4.0 French , 2.4 French high-flow microcatheter.",0
CONTRAST MATERIAL: 150 mL of Optiray-320.,0
Informed consent for the procedure was obtained after risks and potential complications of the procedure had been discussed.,1
"Prior to the procedure, a huddle and timeout protocol was carried out according to the hospital policy.",0
APPROACH: Right common femoral artery.,0
The patient was placed on the angiographic table in usual supine position and skin of the bilateral inguinal regions was prepped and draped in a sterile manner.,1
Local anesthesia was effected by 1% lidocaine.,0
Dr. punctured the right common femoral artery using 19-gauge single-wall needle followed by insertion of a 6-French endovascular sheath in the right common (Over) 4:02 PM RENAL Clip # Reason: if bleeding present please embolize Admitting Diagnosis: HEMOPTYSIS Contrast: OPTIRAY Amt: 185 ______________________________________________________________________________ FINAL REPORT (Cont) femoral artery.,0
A 5.0 French Cobra catheter was advanced into the abdominal aorta followed by successful selective catheterization of the left renal artery.,0
LEFT RENAL ARTERIOGRAM: Selective injections of the left renal artery in multiple projections demonstrated normal anatomy of the segmental and subsegmental arteries with homogeneous capillary blush.,0
"Further segmental catheterizations of the interpolar and inferior polar arteries were carried out by 2.4 French microcatheter followed by multiple subselective injections, which demonstrated no evidence of extravasation and no evidence of pseudoaneurysm or arteriovenous fistula.",0
"After completion of the left renal arteriogram with superselective injections, selective catheterizations of the left-sided L2, L3 and L4 lumbar arteries was accomplished.",0
"L2, L3 and L4 lumbar arteriograms demonstrated no extravasation, AV fistula or pseudoaneurysm.",0
"SUMMARY: No appropriate target for therapeutic embolization was identified, but possibly secondary to tamponading effect of the retroperitoneal hematoma in addition to the intermittent nature of hemorrhage.",1
No evidence of active bleeding on left renal arteriogram including segmental selective injections to the interpolar branch and inferior polar branch.,0
"No evidence of pseudoaneurysm, AV fistula, or free extravasation on left-sided lumbar arteriograms with selective injections of L2, L3 and L4 lumbar arteries.",0
Status: Inpatient Date/Time: at 14:05 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.,0
LEFT VENTRICLE: Severely dilated LV cavity.,0
Severe global RV free wall hypokinesis.,0
AORTA: Normal aortic arch diameter.,0
Moderate (2+) MR. TRICUSPID VALVE: Mild [1+] TR.,0
The patient was scheduled fo rcardiac surgery and was extremely hypotensive and hemodynamically untable.,0
TEE images showed severe biventricular systolic dysfunction and moderate mitral regurgitation.,1
ECMO Cannulae were inserted and the procedure (CABG) was cancelled.,0
Patient condition imporved with inotropic support biventricular systolic function improved.,0
Overall left ventricular systolic function is severely depressed.,0
There is severe global right ventricular free wall hypokinesis.,0
Status: Inpatient Date/Time: at 09:03 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
No spontaneous echo contrast in the body of the LAA.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - hypo; inferior apex - hypo; lateral apex - normal; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,1
Complex (mobile) atheroma in the descending aorta.,0
Image quality was suboptimald - poor esophageal contact.,0
Conclusions: PRE-BYPASS: The left atrium is normal in size.,0
No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage.,0
A patent foramen ovale is present.,0
There are complex (mobile) atheroma in the descending aorta.,0
Post_Bypass: Normal RV systolic function.,0
5:45 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with likely pna REASON FOR THIS EXAMINATION: please eval for interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST CLINICAL INFORMATION: Evaluate for interval change.,1
FINDINGS: Single portable chest radiograph is compared to the prior study from .,0
Endotracheal tube remains at thoracic inlet.,0
Nasogastric tube courses below the diaphragm but the tip is not seen.,0
There is mild atelectasis at both lung bases.,0
There is continued retrocardiac consolidation.,0
Heart and mediastinum are within normal limits.,0
", S. TSICU 10:09 AM MR W& W/O CONTRAST Clip # Reason: Integrity of C4/5 disc Admitting Diagnosis: BLUNT TRAUMA Contrast: MAGNEVIST Amt: 18 ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with C4/5 fracture dislocation, s/p PSF C4-5 REASON FOR THIS EXAMINATION: Integrity of C4/5 disc No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",0
"Intramedullary cord signal abnormality spanning the levels of C2-C6, most compatible with cord edema and with a more focal heterogeneous component which extends the cord at the level C4-C5 that raises the possibility of underlying intramedullary focal hemorrhage/hematoma.",1
Status post C4-C5 posterior fusion with improvement in previously noted acute malalignment.,0
Strongly suspected disruption of the posterior longitudinal ligament.,0
C4-C5 disc herniation/protrusion with extrusion of contents demonstrated immediately superiorly posterior to the C4 vertebral body which at this point results in elevation of the posterior longitudinal ligament and abuts the ventral aspect of the spinal cord.,0
6:03 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"chf, pna, ptx, acute pulmonary process Admitting Diagnosis: ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY;BILIARY OBSTRUCTION;RESPIRATORY OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with acute cholangitis, S/P IR wire placement in sphincter, p/w acute abdominal pain.",1
"ERCP attempted, aborted because acutely de-sat'd.",0
"chf, pna, ptx, acute pulmonary process ______________________________________________________________________________ FINAL REPORT HISTORY: Acute hypoxia during ERCP attempt.",0
FINDINGS: AP portable semiupright view.,0
The endotracheal tube terminates 1 cm below the thoracic inlet.,0
"The heart, mediastinum and pulmonary vessels are within normal limits, accounting for positioning.",0
"There are linear opacities at both lung bases, consistent with atelectasis.",0
A dual-lead pacemaker is again noted within the left chest wall.,0
IMPRESSION: No acute cardiopulmonary pathology.,0
"10:58 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: abscess Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with rising WBC, fever, s/p retroperitoneal AAA, splenectomy, re-exlap REASON FOR THIS EXAMINATION: abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT TORSO ON .",1
CLINICAL HISTORY: Complicated postoperative course following open AAA repair.,0
TECHNIQUE: Non-contrast acquisition of helical imaging was performed from the thoracic inlet through the ischial tuberosities with coronal and sagittal reformatted images provided.,0
"Comparison made to multiple prior studies, most recently .",0
FINDINGS: CHEST: Orogastric tube courses through the esophagus to terminate in the proximal duodenum.,1
"There are diffuse ground-glass opacities throughout the upper lobes and less notably within the lower lobes, thorough evaluation is somewhat limited due to respiratory motion.",1
"However, these have the appearance of pulmonary edema without focal airspace consolidation.",0
There are large pleural effusions.,0
"Stable large mediastinal nodes are seen, the largest in the right paratracheal station measuring approximately 2.5 x 1.7 cm increasing in size when compared to prior study of , however, likely reactive in nature.",0
"Thoracic aorta is normal in course and caliber with extensive mural calcifications, unchanged.",0
Trachea and main airways remain patent.,0
"ABDOMEN: The excluded aneurysm sac is unchanged in size measuring approximately 4.6 x 4.4 cm, within an infrarenal location.",0
"Central Dacron graft appears intact, however, without contrast, thorough evaluation cannot be made.",0
"There is persistent heterogeneous fluid within the retroperitoneum along the left paravertebral region as well as a small fluid collection in the splenectomy bed, which measures approximately 5 x 3 cm.",0
"The retroperitoneal fluid does track into the pelvis along the left pelvic side wall, markedly decreased when compared to most recent prior study, however, it is understood the patient has undergone interval evacuation of this hematoma.",1
Non-contrast enhanced solid organs are unchanged.,0
Kidneys are symmetric in size and attenuation.,0
PELVIS: Pelvic bowel loops are normal in appearance.,0
Contrast does extend all the way to the rectum.,0
There is a Foley catheter within a nondistended bladder.,0
There is trace of pelvic free (Over) 10:58 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: abscess Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA ______________________________________________________________________________ FINAL REPORT (Cont) fluid.,1
There is intramuscular hematoma seen within the left obturator internus muscle as well as the adductors of the right thigh just inferior to a femoral venous catheter.,0
Left lower quadrant skin staples are seen along the skin.,0
"Non-contrast evaluation of the aorta incompletely evaluates the integrity of the Dacron graft, however, no definite evidence of extravasation or continuing leak.",0
"Persistent hematoma, which is much smaller in size within the left retroperitoneum, either residual or recurrent in nature, as well as small fluid collection in the splenectomy bed, none of which contain locules of gas to suggest infection.",0
Bilateral pleural effusions with extensive ground-glass opacities within the upper lobes.,0
Intramuscular hematoma left obturator and right adductor musculature.,0
A contrast enhanced CT examination would be of assistance in thorough evaluation.,0
3:45 PM KNEE (2 VIEWS) BILAT PORT; TIB/FIB (AP & LAT) BILAT PORT Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: year old man with s/p mvc REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT HISTORY: S/P MVA.,0
"RIGHT LOWER LEG, 2 VIEWS.",0
"LEFT LOWER LEG, 2 VIEWS.",0
Please note that oblique views are recommended for optimal assessment of fracture about the joint.,0
"RIGHT KNEE: There are marked degenerative changes, with varus angulation of the knee.",0
Staples are seen in soft tissues anterior to the patella raising the question of a foreign body or prior surgical procedure.,0
A tube overlies the knee.,0
There is diffuse soft tissue edema.,0
"There are moderately severe degenerative change, with straightening of usual valgus angulation.",0
"Allowing for positioning, no fracture is detected.",0
RIGHT LOWER LEG: There is a fracture of the mid shaft of the right fibula.,1
No tibial fracture is detected.,0
"Soft tissue swelling, no fracture detected about the left lower leg.",0
"1:41 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for chf Admitting Diagnosis: GALLSTONE;PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with history of diastolic dysfunction, s/p A. fib with RVR.",1
"REASON FOR THIS EXAMINATION: evaluate for chf ______________________________________________________________________________ FINAL REPORT HISTORY: Diastolic dysfunction, to evaluate for congestive failure.",1
"FINDINGS: In comparison with the study of from an outside hospital, there is still huge enlargement of the cardiac silhouette.",0
The pulmonary vasculature is essentially within normal limits.,0
This discordancy raises the possibility of pericardial effusion or cardiomyopathy.,0
Substantial displacement of the upper thoracic trachea to the right is again seen.,0
"Although this could be a manifestation of substantial dilatation of the aorta, the possibility of another mediastinal process causing this must be considered.",0
"8:04 AM CHEST (PORTABLE AP) Clip # Reason: compare R pleural effusion, eval degree of CHF Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 74 yo male transferred SICU for CHF, recurrent episode of CHF decomp and re-intubated.",1
"now s/p thoracentesis REASON FOR THIS EXAMINATION: compare R pleural effusion, eval degree of CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Recurrent episodes of CHF, decompensation, status post thoracentesis, evaluate right pleural effusion and congestive heart failure.",1
TECHNIQUE: Single AP portable supine chest.,0
"FINDINGS: Since the previous examination of , an endotracheal tube, right internal jugular venous access catheter, nasogastric tube, and dual electrodes with left-sided pacemaker appear in unchanged configuration.",0
A metallic stent is again seen within the left superior mediastinum.,0
"There is stable cardiomegaly and interval increase in asymmetric bilateral air space opacities, more prominent on the right.",0
There is interval decrease in right-sided pleural effusion.,0
"A left pleural effusion is probably unchanged, allowing for differences in patient positioning.",0
Increased opacity within the left lower lobe with obscuration of the left hemidiaphragm is consistent with atelectasis versus consolidation.,0
Sternal suture wires and mediastinal clips in unchanged configuration.,0
Lines and tubes in unchanged position.,0
"Increase in pulmonary edema, more prominent on the right.",0
"In the setting of right-sided thoracentesis, this could possibly represent reexpansion pulmonary edema.",0
Decrease in right pleural effusion.,0
Left pleural effusion is probably stable.,0
"4:10 AM CHEST (PORTABLE AP) Clip # Reason: resolution of collapse, pulmonary edema Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 74 F RML & RLL PNA, bilat effusions, now extubated.",0
"CXR on showed new edema, continued RML,RLL, LLL collapse.",0
now s/p lasix and chest pt.,0
"REASON FOR THIS EXAMINATION: resolution of collapse, pulmonary edema ______________________________________________________________________________ FINAL REPORT AP CHEST 6:17 A.M., : HISTORY: Right lower lobe pneumonia, bilateral pleural effusions.",1
IMPRESSION: AP chest compared to through 20: Moderate right pleural effusion changed in distribution reflecting supine positioning but may have increased.,0
Mild pulmonary edema has developed.,0
Left lower lobe collapse is unchanged.,0
ET tube and right subclavian line are in standard positions.,0
Nasogastric tube passes into the stomach and out of view.,0
3:40 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"collapse Admitting Diagnosis: PLEURAL EFFUSION;LEFT LOWER LOBE MASS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman s/p flex bronc, intubated with pulmonary edema, fever.",1
"Bronch t/d shows 75% occulsvive l main bronchus NSCLCA , pulmonary edema with decreased O2 sat.",1
collapse ______________________________________________________________________________ FINAL REPORT HISTORY: Decreasing O2 sats.,0
"AP UPRIGHT CHEST: Compared with several hours prior, there is no significant change in the left lower lobe collapse.",1
There is a moderate left pleural effusion and a small right pleural effusion.,0
The endotracheal and NG tubes are unchanged in position.,0
No change in the left central venous catheter.,0
"IMPRESSION: No significant change in bilateral pleural effusions, cardiac failure and left lower lobe collapse.",1
2:37 PM CHEST (PORTABLE AP) Clip # Reason: Elevated WBC count.,0
"Admitting Diagnosis: MYASTHENIA CRISIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with myasthenia , increased weakness s/p intubation.",0
REASON FOR THIS EXAMINATION: Elevated WBC count.,0
"______________________________________________________________________________ FINAL REPORT INDICATIONS: Myasthenia, status post intubation, elevated white count.",0
PORTABLE AP CHEST: Comparison is made to previous films from .,0
FINDINGS: There is a left subclavian central venous line with the tip in the superior vena cava.,0
The aorta is partially calcified.,0
There is a small right sided pleural effusion.,0
The left CP angle is not included in the present study.,0
There is better aeration of the lower lobes.,0
There is a patchy atelectasis in the right lung base.,0
IMPRESSION: Small right sided pleural effusion and patchy atelectasis in the right lung base.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: check CVL position, ?",0
"pneumothorax Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p CVL placement REASON FOR THIS EXAMINATION: check CVL position, ?",0
"pneumothorax ______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old man, status post CVL placement.",0
Assess for position and pneumothorax.,0
COMPARISON: Multiple prior chest radiographs with the latest on at 1318 hours.,0
SINGLE PORTABLE CHEST RADIOGRAPH: The right IJ CVL terminating in the lower SVC.,0
The endotracheal tube terminates approximately 4.3 cm above the carina.,0
Bilateral hazy opacities are compatible with mild interstitial edema.,0
"Bibasilar atelectasis is left greater than right, with possibly a small left pleural effusion.",0
Median sternotomy wires are intact.,0
The underlying osseous structures are grossly unremarkable.,0
Right IJ CVL terminates in the lower SVC.,0
"9:54 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: PO contrast study , eval for evidence of bowel injury.",0
"ARF Admitting Diagnosis: HYPOTENSION;AAA REPAIR Field of view: 50 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with large retroperitoneal abscess , bfrag bacteremia with question of bowel injury REASON FOR THIS EXAMINATION: PO contrast study , eval for evidence of bowel injury.",1
ARF so cannot use IV contrast yet CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ WET READ: 12:37 AM interval placement of pigtail drainage catheter with the right retroperintoneal abscess.,0
"size has decreased accordingly, though there is still a large amount of air tracking from the right posterior pararenal space all the way inferiorly to the femoral vessels.",0
"of note, while this more posterior fluid/air collection has decreased in size, there has been no appreciable change in the component centered anterior/inferior to the graft bifurcation, which is also the component that appears contiguous with the previsouly described air interposed between the diastatic native wrap and graft material.",0
additional fluid and air seen anterior in the extraperitoneal space on the right actually appears increased from prior study.,0
"regarding the question of bowel injury/contrast leak, while no extraluminal contrast is seen, orally administered contrast has passed only as far as the prox ileum.",0
"given retroperitoneal location the abscess, right colon injury would be of greatest concern, and rescanning following distal passage of contrast may be helpful.",1
"additional findings, including bilateral effusions, atelectasis, small ascites, anddystrophic lilver calcification are not significantly changed.",0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Patient with recent aortobifemoral bypass graft with large retroperitoneal abscess, bacteremia, status post retroperitoneal abscess drainage.",1
Please assess for source of abscess.,0
STUDY: CT abdomen and pelvis without contrast.,0
TECHNIQUE: Axial multidetector CT was obtained from above the diaphragm to below the pubic symphysis after the ingestion of water-soluble contrast orally but no administration of intravenous contrast.,0
PRELIMINARY REPORT: Interval placement of pigtail catheter within the right retroperitoneal abscess.,1
"Size is decreased accordingly, though there is still a large amount of air tracking from the right posterior pararenal space inferiorly to the femoral vessels.",0
"Of note, while this more posterior fluid/air collection has decreased in size there has been no appreciable change in the component centered anterior/inferior to the graft bifurcation, which is also the component that appears contiguous with the previously (Over) 9:54 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: PO contrast study , eval for evidence of bowel injury.",0
ARF Admitting Diagnosis: HYPOTENSION;AAA REPAIR Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) described air interposed between the diastatic native graft and graft material.,0
"Additional fluid and air is seen anteriorly in the extraperitoneal space on the right, actually appears increased from prior study.",0
"No extraluminal contrast is seen, however orally-administered contrast has passed only as far as the proximal ileum.",0
"Given the retroperitoneal location of the abscess, right colon injury would be of greatest concern and rescanning following distal passage of contrast may be helpful.",1
"Additional findings including bilateral effusions, atelectasis, small ascites, and dystrophic liver calcification are not significantly changed.",0
Dr. discussed with Dr. of surgery.,0
"FINDINGS: There has been slight increase in bilateral pleural effusions, which remain small and dependent.",1
Dependent atelectasis has also increased bilaterally in the lower lobes.,0
"As before, there are coronary artery calcifications and aortic atherosclerosis.",0
"CT ABDOMEN WITHOUT CONTRAST: As before, the liver looks somewhat nodular in appearance, which does raise the question of cirrhosis or fibrosis.",0
"The coarse calcification within segment VIII of the liver is again likely from prior infection, trauma, or calcified cystic lesion and is almost certainly benign.",0
"No liver lesion is seen, though evaluation is limited without intravenous contrast.",0
"The gallbladder is mildly distended and there is a suggestion of dense material dependently near the gallbladder neck, which could represent gallstones, however, this is uncertain.",0
There is no pericholecystic stranding.,0
The bile ducts are normal in appearance.,0
"Fluid is seen within the lesser sac and along the stomach, which is unusual.",0
There is also fluid seen around the spleen and about the tip of the right lobe of the liver and in Morison's pouch.,0
The pancreas is grossly normal with a single calcification within the body but is poorly assessed without intravenous contrast.,0
The spleen is enlarged measuring 15.6 cm in greatest span.,0
"There is contrast seen within the right renal collecting system, which is very slightly dilated, likely secondary to partial obstruction from the lower retroperitoneal abscess and inflammation.",1
"Hypodense, round 1.8-cm lesion in the right upper pole is likely a cyst but incompletely characterized on this non-contrast study.",0
The right retroperitoneal collection tracking from the superior most aspect of the posterior pararenal space into the pelvis has decreased in size markedly after the percutaneous pigtail drainage catheter placement.,0
There is mostly gas within this collection except within the most dependent portion where there is still some fluid and debris which measures 7.5 x 3.0 x 4.4 cm roughly.,0
"The more medial aspect of this collection that extends anterior to the right common iliac artery and into the pelvis below the aortic bifurcation as well as anterior to the proximal left common iliac portion of the graft has (Over) 9:54 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: PO contrast study , eval for evidence of bowel injury.",0
"ARF Admitting Diagnosis: HYPOTENSION;AAA REPAIR Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) decreased very slightly in size, now measuring 5.7 x 9.8 x 9.0 cm, whereas on prior it measured 11.2 x 5.7 x 9.8 cm.",0
This is very heterogeneous with some locules of gas suggesting it is multiloculated.,0
Again it surrounds the anterior portions of the common iliac portions of the aortobifemoral bypass graft.,0
"Also as before, gas is seen between the graft and the native aortic wall both anteriorly and posteriorly.",0
No gas is actually seen within the bypass graft.,0
"The extension of the fluid collection along the right flank anteriorly that is likely extraperitoneal has increased slightly in size, now measuring 18.4 x 3.3 x 5.1 cm roughly.",0
"This now contains a fairly large locule of gas in its nondependent portion, suggesting it has been partially in communication with other portions of the collection, most likely.",0
"Since this collection did not contain gas on the prior study of , it may have temporarily had communication with the collection after the drain placement went in, but has become loculated, however, this is uncertain.",0
"Between this collection and the ascending colon, there is interposed heterogeneous gas and some fluid that more likely represents insinuating extraluminal gas from the retroperitoneal collection than a diverticulum.",0
"Small diverticula are seen within the ascending colon, as seen on the CT.",0
"The tip of the appendix immediately abuts the more medial collection on today's study and on the study, raising the question of a ruptured tip appendicitis as the cause of the retroperitoneal abscess, though this is uncertain.",1
"The appendix did appear completely normal on CT. As stated in the preliminary report, contrast did only make it to the distal ileum and remains entirely within the bowel.",0
No extravasation of oral contrast.,0
CT PELVIS WITHOUT CONTRAST: Much of the information about the pelvic fluid collections is contained above.,0
Free fluid within the peritoneal cavity is seen tracking into the pelvis.,0
The distal large bowel is normal in appearance except for some small sigmoid colonic diverticula.,0
"The aortobifemoral bypass graft in its more distal component on the right has the expected appearance, losing contact with the gas and retroperitoneal collection in its external iliac portion.",0
There is a small amount of fluid inferiorly just at the anastomosis of the graft of the common femoral artery that is likely postoperative on the right.,0
"On the left, fluid collection is seen just inferior to and at the anastomosis of the graft of the common femoral artery, which measures simple-fluid in attenuation and has an imperceptibly thin wall and likely represents a seroma.",0
Skin staples are still seen along the groin bilaterally.,0
There is anasarca evident within the soft tissues of the hips and flank.,0
A Foley catheter is seen within the urinary bladder which is decompressed.,0
"BONE WINDOWS: (Over) 9:54 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: PO contrast study , eval for evidence of bowel injury.",0
ARF Admitting Diagnosis: HYPOTENSION;AAA REPAIR Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) Extensive degenerative changes are seen within the lower thoracic and lumbar spine.,0
"The abscess collection does abut the right psoas muscle and essentially surround it, but the medial aspect of the psoas is normal in appearance.",1
The collection does not appear to abut the bone or disc spaces.,0
Degenerative changes are also seen to a mild degree in bilateral hips and within the sacroiliac joints bilaterally.,0
IMPRESSION: Decreased size of right retroperitoneal abscess after pigtail catheter drainage placement with only minimal decrease in size in the abscess component about the aortic bifurcation that touches the bypass graft iliac components.,1
Increased size of right flank fluid collection that may be loculated intraperitoneal or extraperitoneal.,0
Persistant gas between the native aorta and the aortobifemoral bypass graft.,0
"The appendiceal tip abuts the largest collection within the central pelvis about the bifurcation, and it is possible that ruptured appendicitis was the cause of this collection.",0
"The appendix did appear normal on CT, however,, and appears normal now.",0
"The patient also did have a right colonic diverticula, and while there is not definite evidence for diverticular rupture or right colon injury, extraluminal gas and heterogeneous collection does abut the proximal ascending colon.",0
Contrast did not make it into the colon to assess for leak.,0
Poor assessment of the bypass graft without intravenous contrast.,0
Small fluid collections about the distal anastomosis of the graft are likely benign as they are simple in attenuation.,0
Cirrhotic-appearing liver and splenomegaly which raises question of portal hypertension.,0
These findings were discussed with multiple members of the surgical team the morning of .,0
4:53 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for consolidation Admitting Diagnosis: HYDRATION; PAIN MANAGEMENT; INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with rapid atrial fibrillation REASON FOR THIS EXAMINATION: Evaluate for consolidation ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF COMPARISON: .,1
FINDINGS: Persistent cardiomegaly and mild congestive heart failure pattern with interstitial edema.,0
No confluent areas of consolidation.,0
9:10 PM CHEST (PORTABLE AP) Clip # Reason: pt has hemorrhage from trach.,0
Please eval for source of ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p CABG c/b resp failure s/p trach.,0
now acute hypotensive episode REASON FOR THIS EXAMINATION: pt has hemorrhage from trach.,0
"Please eval for source of bleed ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory failure, acutely hypotensive, hemorrhage from trach.",0
COMPARISON is made to the prior study from 15 hours earlier.,0
"Supine AP chest radiograph: Again demonstrated is a tracheostomy tube, right subclavian central venous line and sternal wires.",0
The heart size and mediastinal contours are stable in appearance.,0
There are worsening bilateral lung opacities consistent with worsening left ventricular failure with or without ARDS.,0
Some of the increased opacity may be due to aspirated blood.,0
There is further atelectasis/consolidation of the left lower lobe.,0
IMPRESSION: Worsening congestive heart failure and/or ARDS.,1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Gadolinium-Containing Agents Attending: Chief Complaint: Severe abdominal pain Major Surgical or Invasive Procedure: CT guided drainage of LLQ intra-abdominal abcess History of Present Illness: 72F Vascular Surgery patient four days s/p thrombectomy, arterioplasty and stenting of her L Ax-BiFem jump graft presents 8 hrs after acute exacerbation of her post-op abdominal pain.",1
scars LLQ incision (+)tenderness (-)pus (-)erythema Ano: guaiac(-) per Vascular resident Pertinent Results: 4:57 PM CT PELVIS/ABDOMEN WITH AND WITHOUT CONTAST IMPRESSION: 1.,0
Thickening and fatty stranding adjacent to the sigmoid colon which is associated with two large extraluminal gas locules suggesting perforated diverticulitis.,1
There is also free intraperitoneal air.,0
These findings are consistent with the perforated diverticulitis.,0
Stable intra- and extra-hepatic bile duct dilatation.,0
Status post axillobifemoral and superficial femoral artery bypass grafting.,0
CT ABDOMEN WITH AND WITHOUT CONTRAST IMPRESSION: 1.,0
Sigmoid and descending colonic diverticulitis with new gas and possibly oral contrast containing abscess in the left lower quadrant measuring 4.3 cm.,1
1:00 AM CT ABDOMEN/PELVIS W/CONTRAST IMPRESSION: 1.,0
"Increase in size of extraluminal collection of the left pericolic gutter, consistent with abscess.",0
Pigtail catheter appears in good position.,0
Local inflammatory change has worsened at this site.,0
"Persistent sigmoid and descending colonic wall thickening, not appreciably changed.",1
"Small low-density peripherally enhancing fluid collection of the deep pelvis, slightly smaller in size.",0
Redemonstration of distal abdominal aortic occlusion.,0
Extra anatomic bypass graft remains patent.,0
04:20AM BLOOD WBC-9.3 RBC-3.76* Hgb-11.2* Hct-32.1* MCV-85 MCH-29.7 MCHC-34.7 RDW-14.0 Plt Ct-314 12:06PM URINE Color-Yellow Appear-Clear Sp -1.010 6:06 pm ABSCESS Source: pigtail drain.,1
GRAM STAIN (Final ): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
FLUID CULTURE (Preliminary): ESCHERICHIA COLI.,0
Daptomycin AND MINOCYCLINE REQUESTED BY DR.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP.,0
| | AMPICILLIN------------ 16 I =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R LINEZOLID------------- 1 S MEROPENEM-------------<=0.25 S PENICILLIN------------ =>64 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final ): NO ANAEROBES ISOLATED.,0
"FUNGAL CULTURE (Preliminary): ALBICANS, PRESUMPTIVE IDENTIFICATION.",0
"03:00AM BLOOD PT-15.9* PTT-32.5 INR(PT)-1.4* Brief Hospital Course: Briefly, Mrs. is a 72 F with recent thrombectomy of jump graft from L. ax -fem to SFA and stenting of distal anastamosis, who presented to on with severe abdominal pain and was found to have perforated sigmoid diverticulitis by CT. She was admitted to the Vascular Surgery Service.",1
"She was followed by Cardiac Surgery, Blue/General Surgery, and during this hospital course.",0
"Her hospital course is broken down by systems as follows: Neuro Her pain was controlled by fentanyl and lidocaine patches and a PCA; when appropriate, she was transitioned to po pain medications.",0
"CV The patient was put on telemetry during her hospital course, and was taken off when appropriate.",0
"She was anticoagulated with aspirin, plavix, and was put on lovenox as bridge therapy while she was made therapeutic on coumadin Pulm No issues; the patient worked with physical therapy to get out of bed and ambulate every day, and pulmonary toilet was encouraged.",0
GI Initially her perforated diverticulitis was managed by bowel rest.,0
Her diet was slowly advanced and changed based on her clinical symptoms.,0
TPN was initiated to supplement her caloric requirements.,0
"When the patient's nausea and abdominal pain were severe, her diet was held, and the patient was made NPO.",0
Her diet was advanced when appropriate to a low residue diet with good effect.,0
"She had several days of loose bowel movements which were c.diff negative, which also resolved.",0
She received intravenous fluids to compensate for her losses.,0
GU She continued to void spontaneously after foley d/c'd on .,0
"Her volume status and urinary output were routinely monitored for changes, and the patient's intravenous fluids were adjusted accordingly.",0
Heme Her INR was elevated on admission.,0
"She was placed on a heparin gtt on , which was stopped when the patient was able to take oral medications, and coumadin could be started.",0
"At that time, the patient was also put on a bridge therapy of lovenox until she was therapeutic.",0
"THe patient's hematocrit was carefully monitored, and she was transfused 1u for hct 27.8, which increased to 30.4; she was also transfused on with good result.",0
"She will continue lovenox injections 60mg SC bid on discharge, and Dr. , her oncologist will follow up her CBC and coagulation profile on discharge.",1
"ID Pt was placed on iv abx including ampicillin, levofloxacin, and flagyl.",0
"During her stay, she also briefly received gentamycin and vancomycin for added coverage, and also received gentamycin flushes into her pigtail catheter.",0
"These were tailored over the course of her hospital stay, and she was discharged on linezolid and Bactrim.",0
"On hospital day 10, the patient had a PICC placed in order for her to received the multiple antibiotics in addition to TPN (through her Port-a-cath) IR placed a pigtail catheter to drain her pelvic collection on HD3.",0
"This pelvic collection grew VRE, E. Coli and staph aureus.",0
Please see the results section for more details.,0
"Endo The patient was put on an insulin sliding scale, and her blood sugars were carefully monitored especially while on TPN.",0
The remainder of her hospital course was unremarkable with her vital signs and laboratory values within normal limits.,0
She is being discharged home in stable condition.,0
She will have home PT and services to assist her.,0
"Medications on Admission: ASA 81, doxepin 25', lipitor 40', meclizine 125', pregabalon 50""', fentanyl patch, lidocaine patch, omeprazole 20', pyridoxine 100', plavix 75', coumadin 2', atenolol 12.5', lasix 20 QOD Discharge Medications: 1.",0
Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours).,0
Disp:*10 Patch 72 hr(s)* Refills:*0* 4.,0
Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Pyridoxine 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).,0
"Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily).",0
Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 weeks.,0
Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous (2 times a day) for 4 weeks.,0
"Outpatient Lab Work CBC, INR on Wednesday or Thursday Please fax results to Dr. at 14.",0
Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 4 weeks.,0
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea for 4 weeks.,0
"Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Perforated diverticulitis LLQ abdominal abcess s/p CT guided drainage rheumatoid arthritis CAD s/p MI osteoarthritis lung ca s/p chemo and XRT GERD HTN AFib PVD R. CIA-bifem BPG w/ dacron , L. ax.",1
"fem-fem bypass w/ PTFE , revision L. ax-fem w/ jump graft 5/07 L axillary angioplasty and jump graft from L. ax fem to SFA S/P hrombectomy of jump graft with stenting of distal anastamosis Discharge Condition: Stable Discharge Instructions: NUTRITION: - You will continue a low residue diet - Call the General Surgery team for worsening abdominal pain, vomiting or nausea/diarhea and high fever.",0
FOLLOW-UP: - Keep your follow-up appointments Followup Instructions: Please follow up with Dr. in weeks; call ( to schedule an appointment.,0
"Please call Dr. assistant, , at for Date & Time for follow-up in weeks Provider: , MD (Primary Care Physician) Phone: call for a post hospitalization follow-up Please call to schedule an appointment with Dr. at or in weeks.",0
Dr. will follow your INR for your coumadin dosing as well as blood counts.,0
"11:46 AM CT PELVIS ORTHO W/O C Clip # Reason: s/p pelvic pinning after pelvic fracture Admitting Diagnosis: MULTIPLE TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with pelvic fracture s/p pinning REASON FOR THIS EXAMINATION: s/p pelvic pinning after pelvic fracture No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Pelvic fracture, status post pinning.",1
TECHNIQUE: Axial CT images of the bony pelvis were obtained without intravenous contrast.,0
Sagittal and coronal reformations were created.,0
CT OF THE PELVIS: Comparison is made to pre-operative study dated .,0
"Again seen is a complex fracture of the right sacral ala extending to the S2 and S3 right neural foramina and articular surface of the right sacroiliac joint, There has been interval placement of a large transverse sacral screw which traverses both sacroiliac joints.",0
"The patient has undergone bone graft harvest and packing in the right posterior iliac bone, with interval resolution of previously evident gas in the soft tissues.",0
Comminuted fracture of the right inferior pubic ramus extending to the articular surface of the acetabulum is unchanged.,0
Previously noted hemorrhage within the retroperitoneum and pelvis has decreased in size and extent.,0
IMPRESSION: Interval pinning of complex sacral fracture across SI joints.,0
9:39 PM CHEST (PORTABLE AP) Clip # Reason: eval swan placement ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with REASON FOR THIS EXAMINATION: eval swan placement ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate for swan placement.,0
SINGLE VIEW OF THE CHEST Comparison to prior exam from same day at 1655.,0
This exam is extremely limited.,0
ET tube identified in satisfactory position.,0
NG tube identified coursing towards the stomach.,0
Swan ganz catheter identified with tip in the distal right interlobar artery.,0
There is no visualized pneumothorax.,0
The inferior portions of the hemithoraces bilaterally are not visualized.,0
IMPRESSION: Swan ganz catheter identified with tip in the right distal interlobar artery without pneumothorax.,0
9:24 AM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: Evaluate for gallstones and spleen.,0
"(ok to be done on Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with h/o pancreatitis, diffuse gastritis, splenic infarct and thrombocytopenia.",1
REASON FOR THIS EXAMINATION: Evaluate for gallstones and spleen.,0
(ok to be done on ) ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): YGd TUE 10:38 AM 1.,0
Small segment V liver hemangioma.,0
Trace ascites seen on CT two days prior not evident on ultrasound.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 40-year-old male with history of pancreatitis with diffuse gastritis as well as splenic infarct and thrombocytopenia, here for evaluation of gallstone and the spleen.",1
COMPARISON: Recent CT dated .,0
FINDINGS: The liver demonstrates overall normal echotexture.,0
"Within segment V adjacent to the gallbladder fossa is a 1.4 x 1.2 cm circumscribed echogenic low flow lesion, compatible with a hemangioma.",0
There is no appreciable intrahepatic biliary dilatation.,0
"The common duct is prominent, measuring up to 7 mm.",0
"The gallbladder is moderately distended, with a large amount of sludge but no shadowing stones.",0
There is no gallbladder wall thickening or pericholecystic fluid.,0
The main portal vein demonstrates normal hepatopetal flow.,0
"The spleen is heterogeneous, with hypoechotexture of the lower pole, compatible with known infarct.",0
"Also seen is a 4.9 x 3.4 x 5.4 cm hypoechoic structure near the pancreatic tail, compatible with known pseudocyst.",0
Previously demonstrated small ascites on CT dated is not evident on current exam.,0
Kidneys are not evaluated on this exam.,0
"8:30 PM MR ABDOMEN W/O CONTRAST Clip # Reason: 45 yo F POD#3 s/p TAH now with progressive R leg weakness an ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with Hep C, asthma, cervical radiculopathy REASON FOR THIS EXAMINATION: 45 yo F POD#3 s/p TAH now with progressive R leg weakness and falling Hct concerning for retroperitoneal hematoma ______________________________________________________________________________ FINAL REPORT MRI OF THE PELVIS, , 19:54 INDICATION: Status post surgery (TAH) with progressive right leg weakness.",0
Falling hematocrit - possible retroperitoneal hematoma.,0
TECHNIQUE: High-resolution coronal T1 and STIR imaging was performed followed by axial T1 with and without fat suppression and axial T2 images.,0
3D sequence was also performed - no intravenous contrast was administered.,0
FINDINGS: Both ovaries are in place and are normal in size with small follicles and/or cysts.,0
The patient is status post hysterectomy.,0
"Free fluid is seen in the presacral space, as well as within the pelvis and just anterior to the bladder.",0
There is is consistent with post-surgical findings.,0
The fluid does not show featurs of hemorrhagic material on the T1-weighted images.,0
The psoas muscles are symmetrical bilaterally with no evidence for hematoma.,0
Oblique coronal images show exiting nerve roots from the sacral plexus to be normal.,0
The sacroiliac joints are normal.,0
The sciatic nerves are symmetrical bilaterally without evidence for abnormal signal or morphology.,0
No osseous lesions are seen.,0
Incidental note is made of subcutaneous edema consistent with an element of third spacing.,0
Status post hysterectomy without evidence for mass effect upon the sacral nerve roots.,0
Postoperative fluid in the pelvis.,0
7:29 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o PTX/EffusionPlease note chest open along with 2 mosquito Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman s/p Mediastinal exploration for bleeding s/p RVAD placement.,0
REASON FOR THIS EXAMINATION: r/o PTX/EffusionPlease note chest open along with 2 mosquito's left in pt.,0
______________________________________________________________________________ WET READ: 9:57 PM 1.,0
External scissors obscurating the tip of ETT.,0
NGT coiled in the oropharynx.,0
Slightly improved right patchy opacities.,0
"EYeh called the primary team at 9:50PM, and discussed in particular the malpositioned NGT.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Mediastinal exploration for bleeding.,0
"FINDINGS: In comparison with the earlier study of this date, there is a nasogastric tube that is coiled in the mouth and pharynx.",0
Bilateral chest tubes are in place with no evidence of pneumothorax.,0
The opacification involving much of the right lung has decreased.,0
Little change in the retrocardiac opacification consistent with atelectasis and effusion and possible supervening pneumonia.,0
"11:27 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for interval change Admitting Diagnosis: FEVER-MANTLE CELL LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with mantle cell lymphoma with probable DAH, s/p extubation, worsening x ray yesterday in the pm, feeling better today but still requiring high FIO2.",0
REASON FOR THIS EXAMINATION: Evaluate for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 10:45 A.M. HISTORY: Mantle cell lymphoma.,0
"IMPRESSION: AP chest compared to chest radiographs through 20: The extensive ground-glass and consolidative abnormality that developed in the lower lungs between and 19, worsened on the 20 and has improved substantially today.",0
"_____ changes are consistent with diffuse alveolar hemorrhage or drug reaction, not with infection.",0
"While the time course is consistent with pulmonary edema there is no evidence that it is volume related, since there is no coordinated change in heart size or the caliber of mediastinal or pulmonary vessels.",0
Tip of the left subclavian infusion port projects over the SVC.,0
9:57 AM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: EVAL C SPINE ?,0
"FX, INCREASE IN EXTREMITY WEAKNESS Admitting Diagnosis: SYNCOPE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with ?",0
cspine fx REASON FOR THIS EXAMINATION: please eval c spine CONTRAINDICATIONS for IV CONTRAST: HD pt ______________________________________________________________________________ FINAL REPORT TECHNIQUE: Non-contrast CT through the cervical spine with sagittal and coronal reformatted images.,0
FINDINGS: There is no evidence of acute fracture.,0
"At C5-6 and C6-7, there are degenerative disc changes with posterior disc osteophyte complexes which do not significantly narrow the spinal canal.",0
There is no significant neural foraminal narrowing.,0
Incidental note is made of significant carotid artery calcifications as well as some fluid at both lung apices.,1
IMPRESSION: No fractures or dislocations.,0
"4:33 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: DIVERTICULITIS ______________________________________________________________________________ MEDICAL CONDITION: year old man with pna REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: -year-old man, within pneumonia, assess for interval change.",1
COMPARISON: Multiple prior chest radiographs with the latest on .,0
"SINGLE PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: The lung volumes are slightly improved, but bibasilar opacities persist, representing a combination of focal airspace consolidations, atelectasis, and pleural effusions.",0
Hazy opacities are compatible with pulmonary edema.,0
The cardiomediastinal silhouette is incompletely evaluated secondary to obscuration from the underlying opacities but grossly unchanged.,0
The right chest dual-chamber pacemaker sends leads to the expected location of the right ventricle and right atrium.,0
IMPRESSION: No significant interval changes besides slightly improved lung volumes.,0
"Persistent bilateral opacities compatible with combination of pulmonary edema, focal airspace consolidation and pleural effusions.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old woman with a history of coil aneurysm two months ago at .,0
"The patient had a myocardial infarction perioperatively, had a routine angiogram done on the 12th at the for re-evaluation of the aneurysm.",1
The follow-up angiogram showed the presence of recanalization of the previously coiled aneurysm and therefore the patient underwent recoiling of the remnant using Bioactive Matrix GDC coils.,0
"The patient had no bleeding prior to or postcoiling, and patient had a normal neurological examination prior coiling.",0
The patient was admitted to the Intensive Care Unit postprocedure for monitoring.,0
Vitamin E. ALLERGIES: Morphine which causes nausea and vomiting.,0
"PHYSICAL EXAMINATION: On physical exam, temperature was 97.6, heart rate 60, blood pressure 158/67, respiratory rate 16, and sat is 97% on face mask.",0
"In general, the patient was in no acute distress responding appropriately.",0
"HEENT: Pupils are equal, round, and reactive to light.",0
"Extraocular movements are full, no jugular venous distention.",0
"Heart regular, rate, and rhythm, no murmurs, rubs, or gallops.",0
"Abdomen: Positive bowel sounds, soft, nontender, nondistended.",0
Extremities are warm and well perfused.,0
Neurologically: Cranial nerves II through XII intact.,0
Strength was in all extremities.,0
"She was awake, alert, and oriented times three.",0
"She was monitored in the Intensive Care Unit overnight, transferred to the regular floor.",0
"On postprocedure day #1, she also had a MRA which shows good coiling of the aneurysm.",0
She tolerated the procedure well.,0
She was discharged home on with followup with Dr. in six months for a repeat angiogram.,0
Simvastatin 40 mg po q day.,0
Atenolol 25 po q day.,0
Protonix 40 mg po q day.,0
Folic acid 1 mg po q day.,0
Aspirin 81 mg po q day.,0
Percocet 1-2 tablets po q4h prn for pain.,0
Dictated By: MEDQUIST36 D: 10:13 T: 10:26 JOB#:,0
LINE PLACEMENT Clip # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY.,0
Pleural effusio Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with CABG REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY.,1
"Pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG, extubation.",0
FINDINGS: An endotracheal tube projects 5 cm above the carina with its tip.,0
"Swan-Ganz catheter, nasogastric tube and pleural and mediastinal drains are in expected position.",0
Borderline size of the cardiac silhouette without evidence of pulmonary edema.,0
", W. MED 11:10 AM CHEST (PORTABLE AP) Clip # Reason: evalate for chest process Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with GI bleed, evaluate for chest process REASON FOR THIS EXAMINATION: evalate for chest process ______________________________________________________________________________ PFI REPORT PFI: Mild cardiomegaly.",0
9:38 AM CHEST (PORTABLE AP) Clip # Reason: please reeval rul Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with mva vs. tree.,1
"REASON FOR THIS EXAMINATION: please reeval rul ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, at 952 hours.",0
HISTORY: Postop motor vehicle collision status post tracheostomy.,1
"COMPARISON: Multiple priors, the most recent dated .",0
FINDINGS: Pneumoperitoneum is again evident likely related to recent surgery.,0
"There is a consolidation of the left lobe, suspicious for pneumonia.",0
There has been interval improvement in the subsegmental atelectasis of the right upper lobe with complete resolution.,0
The endotracheal tube distal tip is approximately 5.4 cm from the carina.,0
The distal tip of cervical spine hardware is noted.,0
There is no pneumothorax or superimposed edema.,0
The mediastinum is otherwise unremarkable.,0
IMPRESSION: Left lower lobe consolidation seen better on the current radiograph due to improved positioning.,0
Pneumoperitoneum is likely of recent surgery.,0
"8:24 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate for infiltrate, CHF Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with HCV, HBV, s/p liver transplant, now with tachypnea, hypoxia and tachycardia, aggressive IVF hydration yesterday REASON FOR THIS EXAMINATION: evaluate for infiltrate, CHF ______________________________________________________________________________ WET READ: 8:46 PM no significant interval change.",1
- ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Hypoxia and tachycardia in a patient after aggressive intravenous fluid hydration.,0
"PORTABLE AP CHEST RADIOGRAPH COMPARED TO , OBTAINED AT 10:33 A.M.",0
The heart size is mildly enlarged but stable.,0
Mediastinal contours are unchanged including dilatation of the azygous vein.,0
"Vascular engorgement in the perihilar area is demonstrated, slightly more pronounced compared to the previous prior study, but with no evidence of overt failure.",0
"Bibasilar atelectasis is noted, unchanged including the right middle lobe atelectasis.",0
IMPRESSION: Mild vascular engorgement with no overt failure.,0
"3:11 PM CHEST (SINGLE VIEW); -76 BY SAME PHYSICIAN # Reason: please eval for cardiopulmonary process ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with white count, DKA, recent pneumonia REASON FOR THIS EXAMINATION: please eval for cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: White count, diabetic ketoacidosis, recent pneumonia.",0
COMPARISON: at 1301 and .,0
"FINDINGS: Single lateral view of the chest was obtained, and the study was read in conjunction with the AP view of the chest performed earlier in the day.",0
"Previously noted bilateral upper lobe predominantly interstitial opacities seen on have improved somewhat, but still persist.",0
"The cardiac, mediastinal and hilar contours appear relatively unchanged.",0
"Minimal blunting of the costophrenic angle posteriorly on the left is re-demonstrated, compatible with a small effusion, similar to the prior exam.",0
Pulmonary vascularity is not engorged.,0
Mild degenerative changes are noted in the thoracic spine.,0
Innumerable punctate calcifications are noted in the spleen.,0
IMPRESSION: Persistent but improved interstitial opacities in the upper lobes bilaterally suggestive of resolving infectious process.,0
No new focal consolidation demonstrated.,0
12:55 PM CHEST (PORTABLE AP) Clip # Reason: fevers with recent PNA.,0
"Eval for worsening PNA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with fevers, trached REASON FOR THIS EXAMINATION: fevers with recent PNA.",0
Eval for worsening PNA ______________________________________________________________________________ FINAL REPORT HISTORY: 50-year-old male with fevers and tracheostomy with recent pneumonia.,1
"COMPARISON: Multiple prior chest radiographs, most recently .",0
"CHEST, SEMI-UPRIGHT PORTABLE AP VIEW: Bilateral lung opacities have increased in comparison to seven days prior.",0
The cardiac silhouette remains enlarged.,0
Retrocardiac opacity appears increased from seven days prior.,0
The cardiac silhouette remains markedly enlarged.,0
"Progressive airspace opacities right greater than left, which may reflect atelectasis or infection.",0
The patient will be undergoing CT for further evaluation.,0
", C. NMED SICU-A 3:28 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate interval change Admitting Diagnosis: ANEMIA;RENAL FAILURE;ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with IPH, brain masses, seizure REASON FOR THIS EXAMINATION: evaluate interval change No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Stable right temporoparietal intraparenchymal hematoma with extension to lateral ventricles.",1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Demerol Attending: Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: CT guided Drainage left upper quadrant catheter placement into a large abdominal and pelvic pancreatic fluid collection, with drainage of 2250 cc.",0
"8 French catheter into a perisplenic fluid collection and exchange of a second catheter into the left paracolic fluid collection, with no significant residual fluid identified on post-procedure images .",0
Successful repositioning of peripancreatic catheter to a position more closely approximating the pancreatic tail History of Present Illness: This is a 65 year old male transferred from .,0
He underwent a left laparoscopic nephrectomy on for renal cell carcinoma.,0
"His post-op course was complicated by acute tubular necrosis, gastritis/bleeding peptic ulcer, LLL pneumonia, and pancreatitis.",1
The patient received 2 units of PRBCs on POD 8 for low HCT.,0
Abd CT on POD 9 revealed peripancreatic fluid collection concerning for possible disruption of the pancreatic duct.,0
"On transfer, he complained of sharp abdominal pain in bilat.",0
"Past Medical History: recently diagnosed L RCC, depression, HTN, herniated disc, spinal stenosis, chronic back pain, nephrolithiasis, R knee DJD PSH: L nephrectomy & adrenalectomy (), 2 R knee surgeries, L knee surgery Social History: Divorced Lives with daughter in Smokes 1-1.5 ppd x 50 years No EtOH No DOA Family History: NC Physical Exam: 97.8, 81, 136/70, 20, 94% RA Gen: Anxious, NAD, uncomfortable secondary to abdominal pain.",0
"CV: RRR, no M/R/G Chest: decreased breath sounds bilat.",0
"Abd: soft, distended, tender on palpation to bilat.",0
lower quadrants and left flank.,0
6 cm midline abd incision intact with steri strips.,0
"3 intact lap site incisions on let abd covered with steri strips, +typany, no rebound, no guarding.",0
"Ext: warm, 1+ EDEMA, stage 1 sore on coccyx Pertinent Results: 10:22PM BLOOD WBC-21.0* RBC-4.38* Hgb-10.7* Hct-32.6* MCV-74* MCH-24.4* MCHC-32.8 RDW-15.9* Plt Ct-387 05:04AM BLOOD WBC-14.6* RBC-3.94* Hgb-9.6* Hct-29.0* MCV-74* MCH-24.3* MCHC-33.0 RDW-16.5* Plt Ct-341 05:42AM BLOOD WBC-8.3 RBC-4.10* Hgb-10.1* Hct-30.2* MCV-74* MCH-24.7* MCHC-33.5 RDW-16.5* Plt Ct-373 04:12AM BLOOD Glucose-143* UreaN-21* Creat-1.2 Na-134 K-4.5 Cl-98 HCO3-32 AnGap-9 11:05AM BLOOD ALT-25 AST-37 AlkPhos-191* Amylase-170* TotBili-1.6* 05:42AM BLOOD ALT-16 AST-16 AlkPhos-151* Amylase-171* TotBili-0.6 10:22PM BLOOD Lipase-220* 11:05AM BLOOD Lipase-288* 05:42AM BLOOD Lipase-184* .",0
CT GUIDANCE DRAINAGE 1:43 PM IMPRESSION: 1.,0
"Patient is status post left upper quadrant catheter placement into a large abdominal and pelvic pancreatic fluid collection, with drainage of 2250 cc.",0
CT PELVIS W/CONTRAST 8:07 AM IMPRESSION: 1.,0
"Interval increase in volume of fluid, which extends from the pancreatic tail into the left renal fossa and along the left pericolic gutter.",0
Inflammatory changes around the pancreatic tail causes thrombosis of the splenic vein in this region.,0
Poor enhancement of the pancreatic tail could reflect parenchymal necrosis.,0
"No change in bilateral pleural effusions, left greater than right.",0
2 mm right middle lobe pulmonary nodule redemonstrated for which no additional followup is needed in a patient without history of malignancy or risk factors for lung cancer.,0
ERCP Cannulation: Cannulation of the pancreatic duct was performed with a sphincterotome using a free-hand technique.,0
Pancreas: The pancreatic duct appeared normal in the area of the head and body.,0
A post surgical leak was noted in the area of the tail.,0
Procedures: A 8 mc by 7 Fr Zimmon single pigtail pancreatic stent was placed successfully to resolve the leak.,0
Cannulation of the pancreatic duct was performed with a sphincterotome using a free-hand technique.,0
The pancreatic duct appeared normal in the area of the head and body.,0
A 8 mc by 7 Fr Zimmon single pigtail pancreatic stent was placed successfully to resolve the leak.,0
Return to Surgery service/ Dr 2.,0
NPO till recovery then start clears and advance as tolerated 3.,0
ERCP in 3 weeks to remove the PD stent.,0
CT CHANGE PERCUTANEOUS TUBE 10:10 AM IMPRESSION: 1.,0
"Patient status post placement of a new 8 French catheter into a perisplenic fluid collection and exchange of a second catheter into the left paracolic fluid collection, with no significant residual fluid identified on post-procedure images.",0
Unchanged bilateral pleural effusions with adjacent atelectasis.,0
Multiple non-obstructing right renal calculi measuring up to 9 mm.,0
CT ABDOMEN W/CONTRAST 9:43 AM IMPRESSION: 1.,0
Two drainage catheters in the left mid abdomen as described.,0
"The paraspinal catheter is draining the pancreatic tail collection, which has decreased in size since its placement on .",0
The left flank catheter is situated within a nearly completely obliterated fluid collection.,0
No new drainable fluid collections identified.,0
"Otherwise, unchanged internal pancreatic drain, and distended gallbladder with a focal area of hyperattenuation.",0
"Improved pleural effusions, right more so than left.",0
CT PERITINEAL DRAIN EXCLUDING APPENDICEAL 6:20 PM IMPRESSION: Successful CT-guided placement of an 8 French catheter into a recurrent perisplenic fluid collection.,0
Approximately 100 cc were aspirated and a sample was submitted for chemistry and microbiology analysis.,0
CT FISTULOGRAM S&I 4:34 PM IMPRESSION: Successful repositioning of peripancreatic catheter to a position more closely approximating the pancreatic tail.,0
"Brief Hospital Course: This is a 65 year old male with pancreatitis and peripancreatic fluid collection on CT, s/p left nephrectomy for transferred from .",0
"Peripancratic fluid collection: A CT showed a large fluid collection and on had CT guided drainage placement into a large abdominal and pelvic pancreatic fluid collection, with drainage of 2250 cc.",0
His drain was accidently self D/C'd and he required a new drain on .,0
"Thereafter, a 10 French pigtail catheter was inserted directly into the collection utilizing a trocar technique.",0
Approximately 350 cc of opaque beige colored fluid was aspirated and sent for Gram stain and culture.,0
He went for ERCP on and the pancreatic duct appeared normal in the area of the head and body.,0
"Then on he had placement of a new 8 French catheter into a perisplenic fluid collection and exchange of a second catheter into the left paracolic fluid collection, with no significant residual fluid identified on post-procedure images.",0
The drains continued to put out thick brown/maroon fluid.,0
The output decreased with time.,0
A CT was obtained on .,0
FEN: HE was NPO with IVFs.,0
A PICC line was placed and TPN was initiated.,0
"After the CT on , we advanced his diet and monitored his drain output.",0
"He was tolerating a diet, not complaining of increasing abdominal pain.",0
We monitored his drain output and then the more superior drain was removed on .,0
"On , he became hypotensive and septic due to an increase in the fluid collection and went for CT-guided placement of an 8 French catheter into a recurrent perisplenic fluid collection.",0
On he went for successful repositioning of peripancreatic catheter to a position more closely approximating the pancreatic tail.,0
"Cultures grew ALBICANS, PRESUMPTIVE IDENTIFICATION.",0
He was treated with Imipenem and Fluconazole IV.,0
He will go home with Levofloxacin for 1 week.,0
He will return to clinic in 2 weeks for a CT scan.,0
"Medications on Admission: trazodone, celebrex, lorazepam Discharge Medications: 1.",0
PT Device Bilateral neoprene knee sleeve.,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks.,0
Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 1 months.,0
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for inability to sleep.,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed.,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed.,0
Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety.,0
Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months.,0
"Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health & Hospice Services, Inc.",0
"Discharge Diagnosis: Pancreatitis Peripancreatic fluid collection Malnutrition Sepsis Hypotension Discharge Condition: Good Tolerating a diet Pain well controlled Drains in place Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness.",1
* New or worsening cough or wheezing.,0
* If you are vomiting and cannot keep in fluids or your medications.,0
"* You are getting dehydrated due to continued vomiting, diarrhea or other reasons.",0
"Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing.",0
* You see blood or dark/black material when you vomit or have a bowel movement.,0
"* Your skin, or the whites of your eyes become yellow.",0
* Your pain is not improving within 8-12 hours or not gone within 24 hours.,0
Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back.,0
"* You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees.",0
"* Any serious change in your symptoms, or any new symptoms that concern you.",0
* Please take any new meds as ordered.,0
* Continue to amubulate several times per day.,0
"* Continue to eat several, small meals through-out the day.",0
* You are going home with your drains in place.,0
"Continue with drain care, including flushing drains 3-4x/day.",0
"Followup Instructions: Please follow-up with Dr. , ERCP, for stent removal.",0
Call ( to schedule this appointment.,0
Please follow-up with Dr. in 2 weeks.,0
Call with questions or concerns.,0
"Provider: , MD Phone: Date/Time: 11:15 Completed by:",0
1:08 AM CHEST (PORTABLE AP) Clip # Reason: s/p re-intubation Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with perc cecum s/p colectomy REASON FOR THIS EXAMINATION: s/p re-intubation ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd MON 12:14 PM Endotracheal tube ends 5.2 cm above the carina.,1
"Otherwise, no significant changes since prior study.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Reintubation after colectomy.,0
"IMPRESSION: AP chest submitted for review on , compared to : Tip of the new endotracheal tube is in standard placement, feeding tube ends in the very upper stomach and should probably be advanced several centimeters to move all the side ports beyond the gastroesophageal junction.",0
Right subclavian line tip projects over the mid SVC.,0
"Mild residual interstitial abnormality left lower lobe, not appreciably changed since , though improved since .",0
"Small bilateral pleural effusions are new since , stable since .",0
Patient has had right thoracotomy and upper posterior rib resection as well as median sternotomy.,0
"1:10 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for source of infection: abscess, diverticulitis Admitting Diagnosis: FEVER Field of view: 41 ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with enterococcus bacteremia, unknown source REASON FOR THIS EXAMINATION: eval for source of infection: abscess, diverticulitis No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Enterococcus bacteremia of unknown source.",1
COMPARISON: No direct studies available for comparison.,0
TECHNIQUE: Axial CT images were acquired from the lung bases to the ischial tuberosities following administration of oral and 130 cc of intravenous Optiray 350 contrast.,0
Coronal and sagittal reformatted images were also reviewed.,0
ABDOMINAL FINDINGS: The visualized portions of the lung bases are notable for a small left pleural effusion.,0
Hazy bilateral pulmonary opacities are only partially visualized at the upper portion of the study.,0
The visualized portion of the heart apex is unremarkable.,0
"The stomach, small bowel, pancreas, spleen, adrenal glands, kidneys, liver and gallbladder are unremarkable.",0
There is no free gas or free fluid.,0
"Scattered mesenteric and retroperitoneal lymph nodes are visualized, none of which meet CT criteria for pathologic enlargement.",0
"PELVIC FINDINGS: The urinary bladder, distal ureters, seminal vesicles, rectum are unremarkable.",0
The colon is notable for sigmoid diverticulosis with no evidence of diverticulitis.,0
Dystrophic calcification is noted within the prostate.,0
There is no inguinal or pelvic lymphadenopathy.,0
There is no free fluid in the pelvis.,0
SOFT TISSUE AND OSSEOUS FINDINGS: There are no suspicious sclerotic or lytic osseous lesions.,0
"Note is made of two calcified injection granulomas, one in the subcutaneous fat overlying the left gluteus musculature and the second within the left gluteus musculature.",0
"Left pleural effusion and only partially visualized pulmonary opacity, in the appropriate clinical context an infectious source in the lungs should be considered.",0
Injection granulomas in the left buttock.,0
"(Over) 1:10 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for source of infection: abscess, diverticulitis Admitting Diagnosis: FEVER Field of view: 41 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"5:40 PM FINGER(S),2+VIEWS RIGHT Clip # Reason: R 5th digit.",0
r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 66F s/p fall REASON FOR THIS EXAMINATION: R 5th digit.,0
r/o fx ______________________________________________________________________________ FINAL REPORT HISTORY: 66-year-old female status post fall and pain at the right fifth digit.,0
STUDY: Three views of the right fifth digit.,0
FINDINGS: At the base of the fifth proximal phalanx is a minimally displaced transverse fracture.,1
The fracture does not involve the articular surface.,0
The distal fragment is minimally displaced in a dorsal fashion.,0
Marked soft tissue swelling is noted about this area.,0
There is no radiopaque foreign body or subcutaneous gas.,0
IMPRESSION: Minimally displaced fracture of the base of the fifth digit proximal phalanx without evidence of intra-articular extension.,1
Findings were discussed with Dr. at 18:33 on .,0
"3:05 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: please insert post-pyloric tube Admitting Diagnosis: GASTROINTESTINAL BLEED Contrast: CONRAY Amt: 50 ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with ESLD, respiratory failure, high resideuals of tube feeds in stomach.",1
needs post-pyloric tube for tube feeds.,0
REASON FOR THIS EXAMINATION: please insert post-pyloric tube ______________________________________________________________________________ FINAL REPORT STUDY: Post-pyloric -intestinal tube placement.,0
INDICATION: This is a 48-year-old gentleman with a history of end-stage liver disease and respiratory failure.,1
Patient with recent high residuals of nasogastric tube feeds.,0
Request for post-pyloric tube placement.,0
"TECHNIQUE: Under fluoroscopic guidance, a 12-French - feeding tube was inserted through the right naris into the esophagus, stomach and upper portion of the duodenum.",0
Position within the duodenum was confirmed with injection of approximately 5-10 cc of water-soluble contrast.,0
IMPRESSION: Successful -intestinal tube placement.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU CHIEF COMPLAINT: Chest pain.,0
"HISTORY OF PRESENT ILLNESS: This is a 51-year-old female with hyperlipidemia and a family history of coronary artery disease who was awoken at 3 a.m. on the day of admission with chest tightness radiating down her left arm and with tingling, nausea, and diaphoresis worsened by exertion.",1
She described it as in intensity.,0
"At 9:30 a.m., she was seen by her primary care physician who saw absent R waves in V1 through V4 on electrocardiogram and ST elevations in V2 through V6 and sent the patient to Emergency Department.",0
"While at Emergency Room, she was given sublingual nitroglycerin, Retavase times one dose, a heparin drip, Lopressor intravenously, a nitroglycerin drip and med-flighted to for catheterization.",0
"At , her vital signs were stable.",0
"On arrival at , Ms. was taken to the Catheterization Laboratory and found to 3-vessel disease with total occlusion of the left anterior descending artery after the second diagonal which was successfully angioplastied.",0
There was total occlusion of the right coronary artery with prominent left-to-right collateral from the left circumflex.,1
There was mild left circumflex disease with a 50% stenosis of the mid vessel.,0
"She was also noted to have increased right and left heart filling pressures, with mean pulmonary capillary wedge pressure of 22, with a left ventricular ejection fraction of 30%, and anterolateral, and apical, as well as anterolateral akinesis.",0
"REVIEW OF SYSTEMS: No fevers, chills, cough, shortness of breath, chest pain, or lightheadedness.",0
No bright red blood per rectum.,0
She had left knee repaired arthroscopically.,0
History of bursitis and arthritis.,0
Gastroesophageal reflux disease (with a Schatzki's ring).,1
ALLERGIES: She is allergic to CORTISPORIN EAR DROPS (she reports swelling of the ear to this medication).,0
MEDICATIONS ON ADMISSION: She is on Centrum once per day.,0
Protonix which she discontinued about one week ago.,0
She denies any over-the-counter or herbal medications.,0
"Her physician had suggested starting Lipitor for her high cholesterol, but she had refused earlier.",0
FAMILY HISTORY: She has a family history of coronary artery disease.,1
Her father had a heart attack around the age of 50.,0
Her mother had diabetes and had a myocardial infarction at the age of 78.,1
"SOCIAL HISTORY: She had a 10-pack-year history of tobacco, but she quit 30 years ago.",0
She denies any alcohol use.,0
"She has two children who live nearby, but she lives alone in .",0
"PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, her temperature was 97, blood pressure was 130/56, heart rate was 64, pulmonary artery pressures were 29 and 14 (with 21 as a mean), respiratory rate was 18, and she was saturating 100% on 2 liters nasal cannula.",0
"She was in no acute distress, pleasant.",0
Jugular venous pressure was about 7 cm.,0
Her lungs were clear to auscultation bilaterally.,0
She had some breath sounds in the left lower chest.,0
A crescendo-decrescendo systolic murmur at the base radiating to her neck.,0
"No gallops, and no rubs.",0
The abdomen was soft and nontender.,0
She had 2+ dorsalis pedis and posterior tibialis pulses.,0
"There was no clubbing, cyanosis, or edema.",0
There was active bleeding and oozing from the left catheter site.,0
She was alert and oriented times three.,0
"PERTINENT LABORATORY VALUES ON PRESENTATION: Her laboratory data revealed white blood cell count was 10.2, hematocrit was 35, and platelets were 295.",0
Differential with 85% neutrophils and 11% lymphocytes.,0
INR was 1.4 and partial thromboplastin time was 95.7.,0
"Sodium was 140, potassium was 3.9, chloride was 106, bicarbonate was 24, blood urea nitrogen was 9, creatinine was 0.6, and blood glucose was 118.",0
"Total cholesterol was 233, triglycerides were 45, high-density lipoprotein was 67, and low-density lipoprotein was 157.",0
Her creatine kinase peaked at 2795 and decreased throughout the rest of the hospital stay.,0
Troponin was greater than 50.,0
Her CK/MB peaked at 449 and decreased to 5.,0
The MB index peaked at 16.1 and decreased to 4.3.,0
Her hemoglobin A1c was 5.5.,0
"PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus rhythm at 60, with 1-mm ST elevations in leads V2 through V5, with Q waves in V1 through V3 and V5.",0
An echocardiogram showed a left ventricular ejection fraction of 40% with a mildly dilated left atrium.,0
"Distal anterior, septal, apical, and distal lateral hypokinesis to akinesis was present.",0
"There was trace mitral regurgitation, but no aortic stenosis.",0
HOSPITAL COURSE: The patient finished her 18-hour course of Integrilin status post catheterization.,0
"She was treated with aspirin, Lipitor, Plavix, metoprolol, and an ACE inhibitor.",0
The patient did well and remained stable throughout the hospital stay.,0
"Due to her anteroapical hypokinesis and akinesis with a 30% to 40% ejection fraction, she was started on anticoagulation.",0
She was started on a heparin drip while waiting for her Coumadin become therapeutic.,0
The patient did well and was evaluated by Physical Therapy who felt that the patient was safe to go home.,0
The patient was kept in house while waiting for her INR to be therapeutic.,0
Her Plavix was essentially discontinued since the patient did not receive a stent.,0
"She had initially been started on Plavix for a more aggressive regimen for her diffuse coronary artery disease, but given that the patient was also on Coumadin it was felt that the aspirin and Coumadin would be sufficient.",1
DISCHARGE STATUS: Discharge status was to home.,0
"Native coronary artery disease, status post intervention.",1
"The patient was to see her primary care physician on Tuesday, .",0
Her primary care physician was and updated as to her hospital course.,0
The patient was to follow up with her cardiologist within two weeks.,0
once per day (this dose to be adjusted as per her primary care physician based on her INR for a goal INR of 2 to 3).,0
Dictated By: MEDQUIST36 D: 14:57 T: 07:52 JOB#:,0
6:49 AM CHEST (PORTABLE AP) Clip # Reason: eval for acute process Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman pedestrian struck with fever now w/ tachypnea on vent REASON FOR THIS EXAMINATION: eval for acute process ______________________________________________________________________________ FINAL REPORT AP CHEST 6:40 A.M. HISTORY: Fever and tachypnea.,0
IMPRESSION: AP chest compared to through 15.,0
", T. NMED SICU-B 3:53 AM ABDOMEN (SUPINE ONLY) Clip # Reason: interval eval Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with SBO REASON FOR THIS EXAMINATION: interval eval ______________________________________________________________________________ PFI REPORT Ileus unchanged from AXR and CT .",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Bronchoscopy PICC placement History of Present Illness: Mr. is a 66 year old man with PMH notable for POEMS s/p autoSCT , therapy-related MDS (no MDS therapy), recently hospitalized for F/N and diagnosed with recurrence of POEMS syndrome, CKD on HD presenting with 2 day h/o worsening BUE motor fasciculations and depressed level of consciousness.",1
Patient recently admitted with neutropenic fever and hypotension initially requiring intubation.,0
Work-up notable for B+glucan and regimen tailored to voriconazole and cipro at time of discharge.,0
Pt admitted yesterday fasciculations and altered mental status.,0
"Had been doing well on the floors except for complaints of penile/bladder pain that was challenging to control with methadone, morphine, percocet and dilaudid.",0
Foley catheter was placed to help with symptom relief (helped in previous admissions).,0
This evening pt was noted to be febrile to 101.3 with SBP 60s-70s.,0
Pt was transferred to for further management.,0
"On arrival to the MICU, patient's VS were T101.2, HR106, BP73/53, R20, 88%RA -> 96%2LNC.",0
Pt was moaning in pain.,0
"Past Medical History: ONCOLOGIC HISTORY: POEMS syndrome manifested by polycythemia, polyneuropathy, organomegaly, endocrinopathies including hypocalcemia, hypothyroidism, hypogonadism and elevated PTH (diagnosed in ).",1
"In anasarca that eventually progressed to respiratory failure, treated with plasmapheresis and prednisone followed by 18 months of cyclophosphamide.",0
"/: Bortezomib (1.3 mg/m2 days 1,4,8,11 and dexamethasone (20 mg days 1,2,4,5,8,9, 11, and 12) x three cycles discontinued due to painful lower extremity neuropathy.",0
high dose cytoxan for stem cell mobilization () high dose melphalan with stem cell rescue () In remission since than.,0
": bone marrow aspirate and biopsy showed dysplastic basophilic and polychromatophilic erythroblasts, a marked left shift and dysplastic myelopoiesis and abundant hyperchromic megakaryocytes, which initially were felt to be consistent with colchicine toxicity; however, chromosome studies performed on that bone marrow material revealed an abnormal karyotype 15/16 studied cells showed a complex clone with the following anomalies.",1
"He had deletion in the long arm of chromosome 5 between band 5q13 and 5q33, otherwise known as 5q minus.",0
"He had monosomy 13, monosomy 17, monosomy 20, and addition of an unidentified marker chromosome and double minute chromosomes.",0
These were all consistent with a myeloid abnormality since there were not an increased number of blasts much more consistent with MDS.,0
OTHER PAST MEDICAL HISTORY: 1.,0
POEMS syndrome: First diagnosed in with treatment described above.,0
His manifestations have been as follows: A. Polyneuropathy - CIDP in ; Painful lower extremity sensory neuropathy and proprioception defects.,0
"B. Organomegaly - Splenomegaly C. Endocrinopathy - Hypothyroidism, hypogonadism, hypocalcemia related to hypoparathyroidism D. Monoclonal gammopathy E. Skin and nail changes - now resolving.",1
F. Pulmonary hypertension and restrictive lung disease.,1
"G. Chronic renal insufficiency (which has now resolved with therapy) H. Anasarca, now resolved.",0
I. Hyperuricemia and gout - now resolved J. Polycythemia and thrombocythemia - now resolved 2.,0
S/p tracheostomy 5. prostate cancer s/p brachytherapy 6. gout 7. pulmonary HTN and restrictive lung disease 8. chronic kidney disease 9.,1
Acute angle glaucoma () Social History: Pt is a Ukrainian refugee who immigrated to the US in .,0
He lives with his wife and they have two sons.,0
He works as a paint salesman for -.,0
He is also a veteran.,0
"Exposed to , which he believes is the etiology of his POEMS.",0
"Family History: Mother is alive and has SLE, fibromyalgia.",0
His father's medical history is unknown.,0
"Physical Exam: ADMISSION EXAM General: Awake, groaning in pain.",0
12:23 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
POTASSIUM HYDROXIDE PREPARATION (Final ): NO FUNGAL ELEMENTS SEEN.,0
Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final ): YEAST.,0
Respiratory Viral Antigen Screen (Final ): negative 4:34 am URINE: NO GROWTH.,0
3:23 pm BLOOD CULTURE: NO GROWTH.,0
4:46 am STOOL: C. difficile DNA amplification assay Negative for toxigenic C. difficile 3:46 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
RESPIRATORY CULTURE (Final ): ~1000/ML Commensal Respiratory Flora.,0
NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.,0
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated.,0
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ): Negative for Cytomegalovirus early antigen by immunofluorescence.,0
IMAGING: Chest Ct IMPRESSION: 1.,0
"Compared with prior exam, there has been interval resolution of scattered bilateral consolidations, with interval appearance of new areas of discrete consolidation and ground-glass opacities in the left upper, right lower and right middle lobes suggesting multifocal pneumonia.",1
"Interval worsening of bibasilar atelectasis, right worse than left, with nearly total collapse of the right lower lobe.",0
No radiologic signs to explain pelvic pain.,0
"Significant interval improvement of anasarca, with almost complete resolution of pleural effusion and ascites.",0
Mild perinephric stranding and cardiomegaly not significantly changed compared with prior exam.,0
Supporting devices are in expected positions.,0
"CT HEAD W/O CONTRAST Study Date of FINDINGS: There is no evidence of intracranial hemorrhage, edema, mass effect, or infarction.",0
There is swelling and a small scalp hematoma overlying the left forehead.,0
Prominent ventricles and sulci suggest age-related involutional changes.,0
"The basal cisterns appear patent, and there is preservation of -white differentiation.",0
"The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear.",0
The globes are intact bilaterally.,0
"IMPRESSION: No evidence of hemorrhage, mass effect, edema, or infarction.",0
Small left frontal scalp hematoma.,0
Chronic changes as described above.,0
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of IMPRESSION: Normal right upper quadrant ultrasound.,0
Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS.,0
Pulmonary macrophages and rare bronchial cells.,1
"CHEST (PORTABLE AP) Study Date of Transient improvement in the diffuse severe consolidative pulmonary abnormality which recurred between and have reversed slightly, although to some extent the greater opacification in both lungs could be due to lower lung volumes.",1
"Nevertheless, this raises possibility of superimposition of a component of hydrostatic edema or a developing diffuse alveolar damage.",0
The global nature of the abnormality argues against worsening of concurrent pneumonia or pulmonary hemorrhage.,1
Small bilateral pleural effusions are unchanged.,0
Feeding tube passes into the stomach and out of view.,0
Right subclavian line ends close if not beyond the superior cavoatrial junction.,0
Right PIC line can be traced as far as the lower margin of the clavicle.,0
Brief Hospital Course: 66 yo M w/POEMS syndrome and MDS a/w worsening motor fasciculations and decreased level of consciousness at rehab facility admitted for febrile neutropenia and hypotension with multifocal pneumonia.,1
"During the course of his admisssion, he had multiple issues, as detailed below.",0
"However, he and his family made a decision to change goals of care to focus on comfort measures only, and he expressed a desire to return home with hospice care.",0
"Hospital issues prior to patient changing goals of care to comfort measures: # Hypotension / Septic shock: On admission, Pt met SIRS criteria with enterococcus from urine culture, coag-neg staphlococcus in blood cx from , and radiologic evidence for multifocal pneumonia.",1
"He was treated with vancomycin, cefepime for pneumonia.",0
"Given his h/o aspergillus pneumonia and that he was neutropenic upon admission, ambisome was added to cover for fungal etiologies.",0
He intermittently required IV fluids and Levophed to maintain his MAP > 65.,0
He required stress dose hydrocortisone.,0
CXR and chest CT revealed multifocal lobar pneumonia.,0
Blood Cx was positive for coagulase negative staphlococcus.,0
Bronchoalveolar lavage on and showed no organisms on culture.,0
# Respiratory failure: The patient was intubated on for hypoxic respiratory failure and airway protection secondary to pneumonia complicated by diffuse alveolar hemorrhage.,1
"CT chest showed new focal opacities in the left upper, and right lower and right middle lung lobes consistent with pneumonia.",1
The infectious disease team followed the patient and provided recommendations.,0
"He was initially treated with vancomycin, cefepime, and ambisome.",0
BAL showed no organisms on culture.,0
The patient was extubated on .,0
Ambisome was later switched to voriconazole due to persistent low potassium while on ambisome and an 8 day course of vancomycin and meropenem was completed for gram positive cocci in blood cultures.,0
The patient was actively diursed with IV lasix and electrolytes were repleated as needed for component of fluid overload.,1
He remained on a face tent to maintain oxygen saturation.,0
"On the final days of hospitalization, family family refused nasal cannula.",0
His O2 sats remained in the mid to low 90s on room air.,0
# POEMS/MDS: Patient has a history of myelodysplastic syndrome and POEMS.,1
He was followed by the hematology service during his admission.,0
His Hct was in the low 20s throughout this admission.,0
He received transfusions of packed red blood cells as need to maintain hematocrit about 21.,0
He also received platelet transfusions as need with a goal platelet of 40 given diffuse alveolar hemorrohage.,0
He was further treated with neupogen and prednisone; lenolidomide was held due to concern for neurotoxicity.,0
"# Pain management: He has chronic pain throughout, including bladder spasms, and was treated with oxybutynin, dilaudid PRN, and fentanyl patches.",1
Fentanyl patches were intermittently discontinued when he had fevers.,0
Pain management was difficult with higher doses causing altered mental status.,0
The pain was most responsive to the IV steroids.,0
Dilaudid was discontinued toward the end of hospitalization.,0
"Once the decision was made to start hospice, patient's pain needs were met with IV hydrocortisone and morphine.",0
He was discharged with presciptions for hydrocortisone and oral morphine solution.,0
# Urine with enterococcus - A urine cx growing vancomycin-resistant enterococcus.,0
The patient was treated with antibiotics as described above.,0
"# Muscle fasciculations- Per neurology, this represents multifocal myoclonus and asterixis, which are fairly non-specific and likely cortical irritation.",0
"Etiology unclear, but most likely toxic/metabolic effect or underlying infection.",1
#Dysphagia: Patient had trouble swallowing medications and failed his speech and swallow evaluation regurgitation/aspiration.,0
"Patient was receiving tube feeds through an NG tube, which became clogged.",0
"Upon removal of the NG tube, patient began having nosebleeds and a discussion of replacing the tube vs. TPN vs. PEG was had with the family.",0
"At this point, the family decided that conservative management with comfort goals would be best.",0
Hospice was consulted and made the necessary arrangements for the patient to go home with hospice care.,0
TRANSITIONAL ISSUES Patient will be going home with hospice services.,0
The company is Hospice of Greater and Greater ().,0
The appropriate prescriptions were provided.,0
Patient's family was provided with official DNR/DNI form to present on encounters with EMS.,0
Levothyroxine Sodium 112 mcg PO DAILY 2.,0
Acyclovir 400 mg PO Q8H 3.,0
Cyanocobalamin mcg PO DAILY 4.,0
Thiamine 100 mg PO DAILY 5.,0
Calcium Carbonate 500 mg PO BID 6.,0
Citalopram 20 mg PO DAILY 7.,0
Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8.,0
Gabapentin 600 mg PO BID 9.,0
Midodrine 2.5 mg PO TID 10.,0
Dexamethasone 3 mg PO Q12H 11.,0
Methadone 2.5 mg PO QAM 12.,0
Methadone 5 mg PO QHS 13.,0
OxycoDONE (Immediate Release) 5 mg PO Q2H:PRN severe pain 14.,0
Phenazopyridine 100 mg PO TID Duration: 3 Days 15.,0
Oxybutynin 5 mg PO TID 16.,0
Lidocaine Jelly 2% 1 Appl TP TID:PRN penile pain 17.,0
Terazosin 1 mg PO HS 18.,0
Lenalidomide 10 mg PO DAILY 19.,0
Voriconazole 200 mg PO Q12H 20.,0
Docusate Sodium 100 mg PO BID 21.,0
Senna 1 TAB PO BID:PRN constipation 22.,0
Pantoprazole 40 mg PO Q24H 23.,0
Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR DAILY 24.,0
Ondansetron 8 mg PO Q4-6HRS:PRN nausea 25.,0
Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1.,0
Morphine Sulfate (Concentrated Oral Soln) 5-15 mg PO Q2H:PRN pain RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5-15 mg by mouth every 2 hour Disp #*30 Milliliter Refills:*0 2.,0
50 mg IV Q8H RX *Solu-Cortef (PF) 100 mg/2 mL 50 mg hydrocortisone every 8 hours Disp #*21 Unit Refills:*0 Discharge Disposition: Home With Service Facility: Hospice of Greater Discharge Diagnosis: Primary: POEMS Syndrome Secondary: Fungal pneumonia Respiratory failure Diffuse Alveolar Hemorrhage VRE UTI Discharge Condition: Mental Status: Confused - sometimes.,1
Level of Consciousness: Lethargic but arousable.,0
"Discharge Instructions: Dear Mr. , You were admitted to the hospital because of worsening of your POEMS syndrome.",0
"During your hospitalization, you and your family decided to focus primarily on your comfort, and you are being discharged home with hospice care.",0
We have stopped all medications except those to help treat your pain and discomfort.,0
The medications that we recommend you continue are morphine solution and intravenous hydrocortisone.,0
Please contact Hospice of Greater and Greater with any new concerns at .,0
Followup Instructions: None Completed by:,0
7:13 AM CHEST (PORTABLE AP) Clip # Reason: New pleural effusion?,0
Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with Inferior MI s/p PCI with BMS REASON FOR THIS EXAMINATION: New pleural effusion?,1
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for pleural effusions.,0
Unchanged moderate cardiomegaly with signs of minimal fluid overload and bilateral areas of atelectasis.,0
Unchanged venous introduction sheath in the right internal jugular vein.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Altered mental status.,0
"Major Surgical or Invasive Procedure: Femoral CVL PICC placed Blood transfusion History of Present Illness: 42 year old woman with history of alcohol abuse, anemia of chronic disease, depression/anxiety, gastric bypass who presents with encephalopathy.",1
"The patient was found by her family in her bathtub, covered in urine and stool with an empty bottle of vodka nearby.",0
The patient was also jaundiced and lethargic and brought in by her EMS for further evaluation.,0
"In the ED, initial vs were: T96.8 HR 51 BP 136/96 RR16 95% on RA.",0
"CXR was negative for pneumonia, ultrasound without ascites, CT head negative for intracranial processes.",0
"Labs were notable for WBC 13.3 with left shift and 3% bands, ammonia was elevated at 68, INR 2.1 transaminitis (ALT 57, AST 272, TBili 19.7, Albumin 3.3 and AlkPhos 196).",0
"Urine and serum tox were negative, including for tylenol and alcohol levels.",0
"Lactate was 9.1, 4.6 after aggressive volume resuscitation with ~7L normal saline.",0
The patient received vancomycin and ceftriaxone and a femoral line was placed.,0
"Given question of a seizure episode (per family) with mild shaking in the ED, patient received valium 10mg IV X1.",0
The patient reports a history of withdrawal seizures.,0
The patient also received sedation with antoher 10mg IV Valium for the femoral line placement (inability to get access anywhere else).,0
Hepatology was called who felt this could be consistent with alcoholic hepatitis.,1
The patient was able to tolerate lactulose PO and thiamine 100mg IV in the ED but was in four point restraints for some time.,0
"On the arrival to the MICU, the patient was agitated but verbally responsive.",0
"Denies any pain, shortness of breath, chest pain, diarrhea, recent trauma.",0
"States her last alcohol consumption was two days ago, unclear the quantity.",0
"Review of systems: (+) Per HPI (-) Denies fever, chills, cough, shortness of breath.",0
"Denies chest pain, nausea, vomiting, diarrhea, dysuria, rashes or skin changes.",0
"Past Medical History: * Anemia of chronic disease * Depression - two suicide attempts in past (one an overdose), followed by counselor (unsure location) * Anxiety * Recent memory loss/black out spells * Roux-en-Y gastric bypass * Small bowel obstruction, lysis of adhesions * Urinary incontinence * Open cholecystectomy * Tubovarian abscess * Left hip plate s/p fall as child Social History: Separated from her husband, lives alone.",1
Brother and boyfriend help her out.,0
Patient denies tobacco and illicits.,0
"Heavy alcohol use, last drink ""two days ago"" per patient.",0
Family History: Mother and father with diabetes mellitus.,0
"Ext: Warm, well perfused, 2+ pulses, 2+ tender edema, L>R, left calf tender, moving all four extremities Neuro: Oriented to place and time, DOWb intact.",0
"The cardiac size is moderately enlarged, unchanged.",0
IMPRESSION: Stable cardiomegaly with no acute cardiopulmonary abnormality.,0
"LENI: Color and grayscale son of bilateral common femoral, left-sided superficial femoral, popliteal and calf veins were performed.",0
Flow was seen within the calf veins.,0
"Remaining vessels demonstrated normal flow, augmentation, and compressibility.",0
There is edema within the superficial tissues of the calf.,0
"RUQ: The liver is diffusely echogenic, consistent with fatty infiltration or cirrhosis.",0
The main portal vein is patent with hepatopetal flow.,0
This study is severely limited due to body habitus and liver echogenicity.,0
The common duct is not identified.,0
"IMPRESSION: Limited study with echogenic liver, consistent with fatty infiltration or cirrhosis; advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study.",1
Portal vein is grossly patent.,0
CXR: The previously noted right upper extremity approach PICC line has been removed in the interval.,0
Lung volumes are markedly diminished.,0
There is resultant bronchovascular crowding at the lung bases and linear opacity at the right lung base in particular.,0
No focal consolidation or superimposed edema is noted.,0
The mediastinum is grossly unremarkable.,0
"The cardiac silhouette, though accentuated by low lung volumes is stable in size.",0
The visualized osseous structures are unremarkable.,0
"Low lung volumes, with bronchovascular crowding.",0
No definite acute pulmonary process identified.,0
CT head: No acute intracranial process.,0
Again note is made of nonspecific low density bilaterally within internal capsules.,0
"As previously, we would recommend a nonurgent MRI to follow up this finding.",0
"Brief Hospital Course: 42 year old female with history of EtOH abuse, depression, anxiety, and prior Reux-en-Y gastric bypass surgery admitted with encephalopathy and jaundice found to have alcoholic hepatitis, whose course has been c/b UTI, encephalopathy, and EtOH withdrawal.",1
"# Alcoholic hepatitis: The patient presented with jaundice, AST>>ALT, and markedly elevated Tbili.",1
Steroids were initially held due to concern about possible infection.,0
"Then, prednisone was started on .",0
Viral hepatitis serologies were negative.,0
"Bilirubin trended down to nadir of 13.9, but then stabilized around 14-15.",0
All hepatically cleared medications were held during this time.,0
"She was given pantoprazole, vitamin D, and calcium given high dose steroids.",0
"Her sugars were monitorred on high dose steroids but she did not require any insulin administration, likely a result of impaired gluconeogenesis.",0
Prednisone was stopped on given new leukocytosis and fevers.,0
Pantoprazole and calcium were subsequently stopped.,0
Vitamin D therapy was continued given documented history of vitamin D deficiency.,1
She was given oxycodone for her pain.,0
She will follow up with liver as an outpatient.,0
She was told to abstain from alcohol or risk permanent liver damage from alcohol.,1
"# Urinary tract infection: Initially a source of infection was unclear, so the patient was started on empiric vancomycin and ceftriaxone, broadened to vanc/cefepime upon admission to the ICU.",1
Urine culture grew E. coli.,0
Antibiotics were narrowed to ceftriaxone when urine culture data/sensitivies became available.,0
She was continued ceftriaxone for a total 7 day course.,0
# Encephalopathy: Likely secondary to hepatic encephalopathy in the setting of alcoholic hepatitis and UTI.,1
No ascites on ultrasound for SBP.,0
The patient was treated with antibiotics as above.,0
"She was also given lactulose 30mL QID, titrated to to bowel movements daily.",0
"At the time of discharge, her mental status was back to her baseline with attention intact.",0
# Elevated lactate: Patient with initial lactate 9 --> 2.8 with aggressive volume resuscitation.,0
She also initially had an anion gap lactic acidosis.,0
This was most likely secondary to alcoholic hepatitis and UTI.,1
# Alcohol withdrawal: Patient and family states she has had seizures in the past.,1
Reportedly last drink two days ago and patient's alcohol level was negative on tox screen.,0
She was maintained Ativan 1-2mg IV q2 hours with CIWA >10.,0
"She was given a banana bag overnight, then continued on IV thiamine and given PO folate/MVI.",0
Social work was involved and set her up with community health center where there is individual counseling and a structured relapse prevention program.,0
The patient began to withdraw on and was treated with IV lorazepam intially every one hour per CIWA >10.,0
This was gradually broadened back to every 2-4 hours.,0
Her CIWA scale was discontinued four days prior to discharge.,0
"She was continued on oral thiamine, MVI, and folate.",0
She was given Ensure supplementation.,0
# Fever and leukocytosis: The patient developed fever and leukocytosis after alcoholic hepatitis was improving.,1
She was hemodynamically stable with the exception of persistent tachycardia.,0
She had no localizing signs or symptoms of infection.,0
"LENI of the left leg was negative for DVT, with CXR without infiltrate.",0
UA was within normal limits.,0
Blood cultures are pending at the time of discharge.,0
Fever has resolved and leukocytosis is trending down now that steroids have been stopped.,0
"# Megaloblastic Anemia: Possibly multifactorial with chronic liver disease, with poor marrow response and poor nutrition contributing.",1
"The patient was guaiac positive, with INR 2.1 in the setting of decompensated liver disease and alcohol abuse.",1
The patient was also hemodiluted with ~7L normal saline given in the emergency room.,0
The patient's hematocrit has intermittently been this low in the past.,0
She received 2 unit of PRBCs and bumped hct appropriately.,0
This also was used as colloid resuscitation which improved her BP.,0
Iron studies were done but are unrelieable after blood transfusion.,0
B12 and folate were within normal limits.,0
Her hematocrit was stable around 25 for the week prior to discharge.,0
She will need iron studies performed as an outpatient.,0
"# Thrombocytopenia: Likely in the setting of splenic sequestration from portal hypertension, liver disease.",1
Pneumoboots were used for DVT prophylaxis.,0
"# Depression/Anxiety: Stable, med rec was performed with pharmacy and the patient is not on antidepressants at home.",0
"All sedating medications were held given hepatotoxicity or hepatic clearance including trazodone, zolpidem, and gabapentin.",0
Gabapentin was re-started on .,0
# Urinary incontinence: Stable during admission.,1
The patient is followed by urology as outpatient.,0
Solifenacin was held during admission.,0
"# Depression: Emotionally labile, currently not on antidepressants.",0
Improved mood and affect towards the end of admission.,0
Psychiatry followed along inpatient and recommended Celexa once LFT's improved.,0
"# Left Leg Weakness: This is most likely secondary to alcohol, prolonged immobility, and deconditioning.",1
There was also an element of functional weakness as the patient was able to hold her leg up upon exam.,0
TSH slightly elevated but free T4 within normal limits.,0
A PT consult was obtained who recommended rehabilitation.,0
"Medications on Admission: * Gabapentin 300mg three times daily * Hydroxyzine ?25mg three times daily * Lidocaine 5% patch * Solifenacin 5mg daily (antispasmodic, antimuscarinic) * Trazodone 100mg qHS * Zolpidem 10mg twice daily * Docusate 100mg twice daily * Ferrous sulfate 325mg daily * Multivitamin daily Discharge Medications: 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours).",0
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for groin/perineal irritation .,0
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Only during rehab stay for alcoholic hepatitis.,1
Not to be discharged home on this medication.,0
"9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily).",0
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Discharge Disposition: Extended Care Facility: Hospital at Hospital Discharge Diagnosis: Primary Diagnosis: Alcoholic Hepatitis, Depression, Urinary Tract Infection Secondary Diagnosis: Alcohol Abuse Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: Dear Ms. , It was a pleasure taking care of you at .",0
You were admitted to the hospital with inflammation of your liver secondary to heavy alcohol use.,1
This is known as alcoholic hepatitis.,1
This is extremely detrimental to your health.,0
You should not drink alcohol or risk permanent damage to your liver.,1
Please work with the services at so that they may help you avoid alcohol in the future.,0
You had a urinary tract infection.,1
This was treated with IV antibiotics for seven days.,0
"The following changes have been made to your medication record: START lasix 40mg daily START spironolactone 50mg daily START folic acid START thiamine START miconazole START oxycodone 10mg every 6 hours as need for pain related to alcoholic hepatitis, not to be continued after rehab stay HOLD Vesicare STOP Trazodone STOP Ambien STOP Hydroxyzine Followup Instructions: The following appointments were made for you: Department: LIVER CENTER When: MONDAY at 11:30 AM With: , MD Building: LM Campus: WEST Best Parking: Garage",1
12:27 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"resolution of effusion s/p left CT removal Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 49F pancreatitis, left effusion s/p thoracentesis.",1
s/p drainage of pancreatic pseudocyst.,0
s/p Left CT removal REASON FOR THIS EXAMINATION: ?,0
resolution of effusion s/p left CT removal ______________________________________________________________________________ FINAL REPORT SINGLE AP FILM: History of pancreatitis with thoracentesis of left pleural effusion and chest tube removal.,1
Status post removal of left pleural catheter.,0
There is a persistent small left pleural effusion and bibasilar atelectases.,1
The PICC line overlies proximal SVC.,0
Tip of Left jugular CV line is in region of junction of left brachiocephalic vein and SVC.,0
These catheters overlie upper abdomen.,0
10:10 AM CHEST (PA & LAT) Clip # Reason: r/o ptx Admitting Diagnosis: MVP\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man s/p MVR and ct removal REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVR and CT removal.,1
"PA AND LATERAL CHEST: There has been interval removal of the endotracheal tube, NG tube, Swan-Ganz catheter, and chest tubes.",0
Interval increase in bilateral effusions (right greater than left).,0
Persisting subcutaneous emphysema on the right.,0
Unremarkable mediastinal and hilar contours.,0
Visualized osseous structures demonstrate no abnormality.,0
IMPRESSION: 1) No pneumothorax identified.,0
2) Interval increased in bilateral pleural effusions and atelectasis.,0
"2:42 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for CHF, pneumonia, effusions ______________________________________________________________________________ MEDICAL CONDITION: year old man with hip fracture, s/p surgery REASON FOR THIS EXAMINATION: evaluate for CHF, pneumonia, effusions ______________________________________________________________________________ FINAL REPORT INDICATION: STATUS POST HIP FRACTURE AND SURGERY.",0
CHEST AP: Comparison is made to the prior film dated .,0
"Again noted is evidence of LV enlargement, with slight upper zone redistribution.",0
"Also noted are bilateral pleural effusions, left worse than right.",0
"However, compared to the prior exam, the above pleural effusions demonstrate significant improvement.",0
The above findings are consistent with mild CHF.,0
IMPRESSION: LV enlargement with mild CHF.,0
Improvement over the prior exam dated .,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: line placement Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with altered mental status, CVL placed in left IJ.",0
REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT HISTORY: 69-year-old female with altered mental status.,0
STUDY: Supine portable chest radiograph.,0
"FINDINGS: The heart size is enlarged, similar to prior study.",0
Mediastinal contours demonstrate a mildly tortuous aorta.,0
"There continues to be prominence of the central pulmonary vasculature, compatible with congestion.",0
There is no large pleural effusion or pneumothorax.,0
There has been interval placement of a left-sided central venous catheter with its tip abutting the right lateral aspect of mid SVC; the catheter may be advanced 2-3 cm if there is difficulty withdrawing or giving fluids through it.,0
These findings were discussed with shortly after midnight on by over the phone.,0
"8:50 AM CT HEAD W/O CONTRAST Clip # Reason: please eval r/o acute traumatic injury ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man etoh abuse, s/p fall, reports head trauma REASON FOR THIS EXAMINATION: please eval r/o acute traumatic injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: SZm TUE 9:37 AM No acute intracranial process.",0
Mucosal thickening of the sinuses worse than prior.,0
Clinical correlation for acute sinusitis.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 38-year-old male with alcohol abuse, status post fall, trauma.",1
Evaluate for acute traumatic injury.,0
TECHNIQUE: Contiguous nonaxial and axial images were acquired through the brain with multiplanar reformations.,0
"FINDINGS: No intracranial hemorrhage, mass effect, edema or shift of the normally midline structures.",0
-white matter differentiation is observed.,0
Again noted is a prominence of the cerebral and cerebellar sulci compatible with atrophy.,0
"Prominent right extra-axial space with associated right cerebellar mass effect, possibly due to an arachnoid cyst.",0
"There is mucosal thickening of the sphenoid sinuses, worse on the left than the right as well as mucosal thickening the ethmoid sinuses.",0
There is no evidence of any skull fracture.,0
There is superficial swelling of the frontal scalp.,0
No evidence of acute intracranial process.,0
Sinus disease with mucosal thickening predominantly in the sphenoid sinuses.,0
6:11 AM CHEST (PORTABLE AP) Clip # Reason: Resp Failure.,0
"______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with cerebral aneurysm s/p angio, now in CHF s/p diuresis REASON FOR THIS EXAMINATION: Resp Failure.",1
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : Compared to two days earlier.",0
CLINICAL INDICATION: Congestive heart failure.,1
"A right sided chest tube remains in place, terminating at the right lung apex.",0
There is an unusual kink in the chest tube which remains unchanged.,0
"The heart is enlarged, and there is a persistent congestive heart failure pattern.",1
This appears slightly worse in the interval.,0
"Bilateral pleural effusions are present, moderate on the right and small on the left.",1
The right effusion has slightly increased in the interval.,0
"A Swan-Ganz catheter remains in place, with the tip terminating in the proximal right pulmonary artery.",0
An endotracheal tube has been removed in the interval as well as the nasogastric tube.,0
IMPRESSION: Interval worsening of congestive heart failure pattern with associated increase in right pleural effusion.,1
Height: (in) 72 Weight (lb): 248 BSA (m2): 2.34 m2 BP (mm Hg): 144/86 HR (bpm): 73 Status: Inpatient Date/Time: at 15:56 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Propofol IV was administered for sedation by Anesthesia.,0
LEFT ATRIUM: No spontaneous echo contrast in the body of the LA.,0
No mass/thrombus in the LAA.,0
Mild spontaneous echo contrast in the LAA.,0
Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of the RA.,0
MD caring for the patient was notified of the echocardiographic results by e-mail.,0
Conclusions: No spontaneous echo contrast is seen in the body of the left atrium.,0
No mass/thrombus is seen in the left atrium or left atrial appendage.,0
Mild spontaneous echo contrast is present in the left atrium.,0
The left atrial appendage emptying velocity is borderline depressed (0.2m/s).,0
There are simple atheroma in the descending thoracic aorta to 40 cm from the incisors.,0
The TEE probe was not advanced across the gastro-esophageal junction due to history of prior gastric bypass.,1
IMPRESSION: No intra-atrial thrombus noted.,0
Minimal spontaneous echo contrast in left atrium.,0
8:47 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: new doboff placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with new doboff placement REASON FOR THIS EXAMINATION: new doboff placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation of Dobbhoff catheter.,0
"As compared to the previous examination of , at 10:35 a.m., the tip of the Dobbhoff catheter has been advanced by approximately 10 cm.",0
The tip is still located in the stomach.,0
"2:07 AM CHEST (PORTABLE AP) Clip # Reason: ET-tube position Admitting Diagnosis: TACCHYCARDIA/BRADYCARDIA;ATRIAL FLUTTER\A-FLUTTER ABLATION;BV PACER ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with REASON FOR THIS EXAMINATION: ET-tube position ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: .",1
"Endotracheal tube terminates about 1.5 cm above the carina, and a feeding tube has been withdrawn, with tip now projecting above the diaphragm level.",0
These findings have been communicated by telephone to Dr. on .,0
Pulmonary edema has slightly improved in the interval.,0
There are no other substantial changes.,0
7:15 AM NEONATAL HEAD PORTABLE Clip # Reason: Is there PVL?,0
"Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 26 weeks, now term (40 weeks PCA) REASON FOR THIS EXAMINATION: Is there PVL?",1
"______________________________________________________________________________ FINAL REPORT SCANS OF THE BRAIN, CRANIAL ULTRASONOGRAPHY ON These scans show normal intracranial anatomy and no evidence of recent or prior intracranial hemorrhage.",0
The ventricular system is normal for this age and gestation infant.,0
"The subarachnoid space at the level of the foramen of is 4 mm, which is within normal range.",0
", MED 2:55 PM CT CHEST W/O CONTRAST Clip # Reason: Evaluate parenchymal process for suggestion of etiology and/ Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with diffuse alveolar hemmorhage and hypoxic respiratory failure.",1
REASON FOR THIS EXAMINATION: Evaluate parenchymal process for suggestion of etiology and/or focality with high res CT CONTRAINDICATIONS for IV CONTRAST: ______________________________________________________________________________ PFI REPORT Diffuse alveolar ground-glass opacities might be consistent with diffuse pulmonary hemorrhage or pulmonary edema.,0
6:40 AM CHEST (PORTABLE AP) Clip # Reason: S/P BRONCH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman s/p LUL w/ resp failure s/p intubation REASON FOR THIS EXAMINATION: S/P BRONCH ______________________________________________________________________________ FINAL REPORT AP portable chest radiograph .,0
HISTORY: 74 year old woman status post bronch for respiratory failure.,1
PORTABLE AP CHEST RADIOGRAPH: Comparison is made to study from .,0
An endotracheal tube is located 4 cm above the carina.,0
Right-sided subclavian central venous catheter is seen with tip in the SVC.,0
There are two left-sided chest tubes.,0
The heart and mediastinal contours are stable.,0
Opacities at the right base obscure the right hemidiaphragm.,0
There is a left retrocardiac density.,0
There is volume loss of the left lung and the mediastinal contents are slightly shifted to the left.,0
Left rib fractures are again noted.,0
IMPRESSION: 1) Removal of left-sided central line catheter.,0
Left lower lobe consolidation vs. collapse and associated bilateral pleural effusions.,0
9:54 AM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: Patient with new aphasia.,0
assess for recent stroke Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with Hx ICH REASON FOR THIS EXAMINATION: Patient with new aphasia.,1
assess for recent stroke ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: A patient with new aphasia and status post clipping and coiling of aneurysm.,0
"TECHNIQUE: T1 sagittal and T2, susceptability and diffusion axial images of the brain were obtained.",0
3D TOF of the circle of was acquired.,0
FINDINGS: There are postoperative changes with left frontal crainiotomy and incrased signal on T2 weighted images in this region indicative of edema from postoperative changes.,0
No evidence of restricted diffusion is seen in this region or in other parts of the brain to indicate acute infarct.,0
A small bilateral occipital subdural collections are noted as seen on the CT of .,0
No evidence of hydrocephalus or midline shift is seen.,0
A right frontal ventricular drainage catheter is visualized with mild increased sounding signal on T2 weighted images.,0
No evidence of an intraparenchymal hematoma is seen in the visualized brain.,0
"Artifacts obscur evaluation of the anterior, inferior frontal lobe region.",0
IMPRESSION; No evidence of acute infarct.,0
Small bilateral occipital subdural collections.,0
Findings discussed with Dr. at the time of interpretation of this study on .,0
MRA OF THE HEAD: The MRA of the head is limited for evaluation of the anterior cerebral arteries due to obscurration of the flow signal detail from artifacts from clip.,0
Normal flow signal is identified in the visualized middle cerebral internal carotid and anterior carotid arteries in the interior circulation and in the arteries of posterior circulation.,0
IMPRESSION: No significant abnormalities detected on the MRA of the head with the exception of the anterior cerebral arteries which are not visualized secondary to clip artifacts.,0
"3:02 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: ASSESS FOR PE.SEVERE ARDS,DECREASED HCT.ASSESS FOR RETROPERITONEAL BLEED.",0
"Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with severe pul HTN, ARDS, asp pneumonitis currently intubated and on pressors.",0
"- # REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Severe pulmonary hypertension, ARDS, aspiration pneumonitis with hypoxia.",0
Patient with decreased hematocrit and thrombocytopenia.,0
"TECHNIQUE: CT imaging of the chest, abdomen and pelvis with 150cc of Optiray.",0
Non-ionic contrast was used due to patient's debility.,0
COMPARISON is made to prior chest CT from .,0
CT CHEST W&W/O CONTRAST: please note that there was suboptimal contrast administration as the contrast bolus was administered via a femoral line.,0
There is no evidence of a large central pulmonary embolus.,0
"There is diffuse alveolar airspace opacification with minimal sparing of the anterior portions of the lungs, which is consistent with the patient's suspected ARDS/Aspiration pneumonitis.",0
There is atelectasis at the dependent portions of the lung bases bilaterally.,0
There are tiny pleural effusions bilaterally.,0
There are bullae present at the right lung base.,0
"The heart, pericardium, and great vessels are unremarkable.",0
There is an NG tube in place which passes into the stomach.,0
There is an SG catheter in position with its distal tip in the left pulmonary artery.,0
"There is evidence of diffuse anasarca, within the soft tissues of the chest, abdomen and pelvis.",0
CT ABDOMEN W/CONTRAST: The liver is normal in contour and attenuation with no hepatic mass or biliary ductal dilatation.,0
"The gallbladder is distended, but is otherwise, unremarkable.",0
The spleen is not enlarged.,0
There is no evidence of splenic infarct.,0
Within the kidneys there are bilateral wedge-shaped areas of non-perfusion within the peripheral renal cortex.,0
There are at least two areas of suspected small infarcts within the right renal cortex and at least one area of suspected renal infarct within the left renal cortex.,0
This finding was not present on the prior exam of .,0
The adrenal glands are unremarkable.,0
There is no pathologic retroperitoneal lymphadenopathy.,0
There is diffuse distension of the colon with no evidence of a transition point to suggest mechanical obstruction.,0
There is no evidence of wall thickening within the small bowel or colon.,0
There is no evidence of a retroperitoneal hematoma within the abdomen or pelvis.,0
"(Over) 3:02 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: ASSESS FOR PE.SEVERE ARDS,DECREASED HCT.ASSESS FOR RETROPERITONEAL BLEED.",0
Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) CT PELVIS W/CONTRAST: The urinary bladder is unremarkable.,0
There is evidence of low attenuation material within the uterine cavity.,0
This finding should be evaluated on subsequent exams.,0
There are injection granulomas present within the buttocks bilaterally.,0
Bone windows show no suspicious lytic or sclerotic lesions.,0
IMPRESSION: 1) No evidence of large central pulmonary embolus.,0
2) Diffuse air-space opacification which is consistent with patient's suspected aspiration pneumonitis/ARDS.,0
This finding has significantly worsened when compared to the prior study of .,0
3) No evidence of retroperitoneal hematoma.,0
4) Bilateral small wedge-shaped areas of non-perfusion within the peripheral renal cortex bilaterally.,0
These infarcts are new when compared to the prior exam.,0
5) Diffuse distension of the colon without evidence of transition point to suggest mechanical obstruction.,0
6) Low density material within the uterine cavity.,0
This finding should be followed on subsequent exams.,0
"10:04 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with pleural effusions s/p VATS, talc pleuradesis.",1
REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 82-year-old female with pleural effusions status post VATS and talc pleurodesis.,0
COMPARISON: AP semi-upright portable chest x-ray dated .,0
"AP UPRIGHT PORTABLE CHEST X-RAY: Compared with prior exam, a left pleural effusion has slightly decreased, with persistent left lower lobe consolidation.",0
"Right lung parenchymal opacities, pleural thickening and effusion are not significantly changed in this patient status post VATS.",0
"The cardiac mediastinal silhouette is upper limits of normal, stable.",0
Mild pulmonary vascular congestion and borderline interstitial edema are unchanged.,0
Dense arthrosclerotic calcifications line the thoracic aorta.,0
Slight interval decrease in size of left pleural effusion.,0
Stable postoperative changes in the right hemithorax.,0
A tiny loculated pneumothorax seen on prior CTA dated is not readily appreciated on this upright film.,0
6:27 PM CHEST (PORTABLE AP) Clip # Reason: assess Trach position Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with CAD s/p CABG with left chest bleed post-op.,1
REASON FOR THIS EXAMINATION: assess Trach position ______________________________________________________________________________ FINAL REPORT HISTORY: 75-year-old man with coronary artery disease status post CABG with left chest bleed postop.,1
Now status post tracheostomy placement.,0
CHEST AP: The tracheostomy tube appears in satisfactory position.,0
The ETT and NGT have been removed.,0
Left subclavian CVL and left chest tube are unchanged in appearance.,0
"Cardiac, mediastinal and hilar contours are stable.",0
The patient is status post median sternotomy and CABG.,1
There is slight interval increased lucency of the left lung field consistent with decreased pleural fluid.,0
Patchy right-sided pulmonary opacities are stable.,0
Osseous and soft tissue structures are stable.,0
Satisfactory position of tracheostomy tube.,0
Slight decrease in amount of left pleural fluid.,0
Stable patchy right pulmonary opacities.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Prozac / Haldol Attending: Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. is a 25 year-old man with a history of alcoholism and seizure disorder who presents with alcohol withdrawal and is admitted to the for management of tachycardia, hypertension, and significant diazepam requirement.",1
He was last admitted for alcohol withdrawal in / and was cocaine positive at that time.,1
He was discharged with a plan to follow-up at outpatient substance abuse program.,0
"He continued drinking, however, and notes that he has been drinking approximately a quart of alcohol daily and two 40 oz beers.",0
He has also not been taking his seizure medications for several days to weeks.,0
He had his last drink yesterday morning and states that he had a generalized seizure a few hours later.,0
"It was witnessed by his boyfriend who states that he lost consciousness for five to ten minutes, with tonic-clonic motion and loss of bladder continence.",0
He has not had a seizure since that time.,0
"This morning, he presented to the ED for evaluation, as he felt chest pain, general malaise, was tremulous, and had visual hallucinations of seeing rats and bugs.",0
"In the ED, initial vs were: 98.6 120 150/100 18 99%ra.",0
"He was given valium 10 mg IV x 9, a banana bag, multivitamin, and aspirin 325 mg.",0
"He was tachy to the 120s and hypertensive to SBPs of 160, and there was concern for potential hemodynamic instability, so ICU admission was requested.",0
Serum EtOH 19 and tox screen otherwise negative.,0
"On the floor, he is anxious and tremulous but denies hallucinations.",0
"Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion.",0
"Denies chest pressure, palpitations, or weakness.",0
Past Medical History: - Alcoholism - Hx.,1
seizures (GTC) related to hx.,0
of head injury (hit by bat per pt.,0
"); was on tegretol and neurontin for ppx, as well as clonazepam for anxiety, but stopped all of these when he began drinking again - ?Hepatitis C Social History: He drinks approximately a quart of vodka daily and two 40 oz beers daily and smokes.",1
He reports using cocaine on a single ocassion (last use ) though some OMR notes report regular cocaine use.,0
He has no contact with his family and he works at Subway.,0
He lives with his boyfriend.,0
Family History: He has no contact with his family and he works at Subway.,0
He rents a room with his friend.,0
# Alcoholism/withdrawal: History of alcoholism with multiple admissions for withdrawal.,1
Has attempted detox in past but unsuccessful.,0
Also has history of seizures in setting of withdrawal.,1
Pt was put on CIWA scale w/diazepam 10mg q1hr.,0
Tox screen came back with positive serum alcohol and urine benzos.,0
Pt unwilling to enter detox program at this time.,0
"However, pt did establish contact with clinic and set up appointment for clinic intake and physician f/u at that clinc.",0
Requiring Q3 diazepam into morning of but none throughout morning.,0
Pt not significantly symptomatic with resolution of tachycardia.,0
Somewhat anxious without home clonazepam which had been held since giving diazepam but eager to go home and stating ready to go home.,0
Pt d/ced home with instructions not to drink and f/u with as he had scheduled.,0
# Seizure disorder: No evidence of seizure activity while in hospital.,0
Was on gabapentin in past but has not been taking medications for days to weeks.,0
At time of discharge was given 20 day scripts for clonazepam and gabapentin to get him to his appointments.,0
"# ?Hepatitis C: No history of documented hepatitis in OMR but patient states he is hep C positive, contracted from tattoo, no history of IVDU.",1
Hepatitis serologies showed HCV Ab positing and HBV ab negative to surface and core.,0
# Rash: unclear etiology - likely tinea corpis although Cculd represent autoimmune condition.,0
Boyfriend does not have similar symptoms.,0
Pt given script for ketoconazole cream at time of d/c.,0
Instructed that if he wanted he could find shampoo with ketoconazole in it and use this instead of the cream if he wished.,0
Medications on Admission: Acetaminophen 650 mg PO/NG Q6H:PRN pain Clonazepam 2 mg PO/NG QAM Clonazepam 1 mg PO/NG QPM Gabapentin 600 mg PO/NG Q8H Multivitamins 1 TAB PO/NG DAILY Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cessation Thiamine 100 mg PO/NG DAILY Discharge Medications: 1.,0
Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a day for 20 days.,0
"Clonazepam 1 mg Tablet Sig: 1-2 Tablets PO 2 tablets in the AM, 1 tablet in the PM for 20 days: Please take as you were previously: -2 tablets in AM -1 tablet in PM.",0
Ketoconazole 2 % Cream Sig: One (1) Topical once a day for 7 days.,0
Disp:*1 1* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1) Alcohol Withdrawal Secondary Diagnosis: 1) Seizure disorder Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Mr. , you were admitted to the hospital due to alcohol withdrawal and were monitored in the ICU with medications to treat your withdrawal.",1
"When you showed improvement, had scheduled clinic follow-up at clinic, and felt able to go home safely, you were discharged to home.",0
You were discharged with prescriptions for 20 days for the following medications: -Clonazepam 2mg by mouth every morning and 1mg by mouth every evening -Gabapentin 600mg by mouth three times each day -Ketoconazole Cream 2% apply to your rash once each day for 7 days (as an alternative you can find a shampoo that contains 2% Ketoconazole and apply this to the rash for 7 days).,0
You should keep your follow-up intake appointments with clinic on and your follow-up with a physician that is scheduled for 2 weeks afterward.,0
You should refrain from alcohol use upon discharge.,0
"Because of your history of becoming sick from withdrawal, and because you have a history of seizures that increase your risk for withdrawal seizures, it would be best for your current and long-term health to refrain from alcohol use.",1
Followup Instructions: Follow up with clinic as you have already scheduled.,0
It is very important for your health that you keep these appointments as the clinic at will be able to offer you resources and care that will greatly improve your long-term health.,0
"1:36 AM CHEST (PORTABLE AP) Clip # Reason: 53 year old woman with new onset stroke, r/o concomitant inf Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with new onset stroke, r/o concomitant infection (ie pna) REASON FOR THIS EXAMINATION: 53 year old woman with new onset stroke, r/o concomitant infection (ie pna) ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Fever.",0
Portable AP chest radiograph was reviewed.,0
"Mediastinum has normal position, contour and width.",0
The pleural surfaces are smooth with no pleural effusion.,0
6:01 PM CT HEAD W/O CONTRAST Clip # Reason: head bleed?,0
Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: History: 53F with lethargy REASON FOR THIS EXAMINATION: head bleed?,1
No contraindications for IV contrast ______________________________________________________________________________ WET READ: 6:47 PM Study severely limited by motion.,0
No large acute intracranial process.,0
The left mastoid air cells are opacified.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Lethargy.,0
TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without the use of IV contrast.,0
"FINDINGS: Three attempts were made at imaging; however, this study is severely limited by patient motion.",0
"There is no evidence of an acute large intracranial hemorrhage, mass effect, or territorial infarction.",0
"The ventricles and sulci are mildly prominent, reflective of diffuse cortical atrophy.",0
"The mastoid air cells are underdeveloped, and there is moderate opacification of the left air cells (2:9).",0
The middle ear cavities are clear.,0
Included views of the paranasal sinuses are clear.,0
"Severely limited study due to patient motion; however, no large acute intracranial process detected.",0
Opacified left mastoid air cells.,0
"5:48 AM CHEST (PORTABLE AP) Clip # Reason: please eval for PNA vs CHF, PTX, other interval change Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with sob, trach s/p new trach placed and s/p several line attempts in R subclavian, with line in L subclavian, hypotensive REASON FOR THIS EXAMINATION: please eval for PNA vs CHF, PTX, other interval change ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of tracheostomy and CV line placement.",1
The intratracheal tube is approximately 1 cm above the carina.,0
The left subclavian CV line overlies the proximal SVC.,0
No pneumothorax or other change since the prior study of .,0
There is a marked thoracic scoliosis convex to the right.,0
3:29 PM CT CHEST W/O CONTRAST Clip # Reason: please evaluate for interval change in mass Admitting Diagnosis: MULTIPLE MYELOMA;SHORTNESS OF BREATH;MEDIASTINAL MASS ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with multiple myeloma and newly diagnosedmediastinal mass.,0
S/P pericardiocentesis and balloon pericardiotomy due to pericardial effusion and early tamponade.,0
REASON FOR THIS EXAMINATION: please evaluate for interval change in mass No contraindications for IV contrast ______________________________________________________________________________ WET READ: JMBu TUE 4:54 PM NO CHANGE IN MASS FROM .,0
LARGE LEFT PLEURAL EFFUSION PERSISTS.,1
______________________________________________________________________________ FINAL REPORT HISTORY: Question interval change in mass.,0
Multiple myeloma with new mediastinal mass.,0
Responsive mass to short term therapy will determine discharge management plans regarding whether or not the patient should receive out patient chemotherapy.,0
TECHNIQUE: Non contrast chest CT.,0
FINDINGS: The size of the dominant mediastinal mass and the other mediastinal adenopathy is unchanged over the short interval compared to the prior study.,0
Unchanged also is pericardial and pleural effusion.,1
The appearance of the lungs is stable.,0
Please refer to the prior report for detailed description of the pertinent findings.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Valium / Morphine / Penicillins / Ace Inhibitors Attending: Chief Complaint: Shortness of breath/Chest pain Major Surgical or Invasive Procedure: - CABGx1 (Saphenous vein graft->Obtuse marginal artery) History of Present Illness: 82 year old who presented to Hospital with SOB on .,1
He was found to be in CHF with a troponin leak of 0.1.,0
Transferred to in where a cardiac cath revealed complicated single vessel disease.,0
He was thus referred for surgical revascularization.,0
Past Medical History: Diabetes type II Hyperlipidemia Ischemic cardiomyopathy EF 45% secondary to old inferior MI Advanced COPD/Asthma BPH Shoulder surgery h/o DVT GERD DJD s/p L hip replacement s/p C1 laminectomy and suboccipital craniectomy s/p colostomy and colectomy for colon cancer in h/o benign tumor at base of spine -removed Social History: Patient is widowed.,1
"Non smoker since , no etoh.",0
Two daughters who are actively involved in his care.,0
Family History: Non-contributory Physical Exam: Admission VS - BP 144/44 (122-140)/(44-86) HR 86-90 RR 20 O2 99% Gen: WDWN elderly male in NAD.,0
Neck: Supple with no evidence of JVD.,0
Good femoral and distal pulses.,0
"Discharge VS T 98 BP 104/60 HR 63SR RR 18 O2sat 96%-RA Gen NAD Neuro A&Ox3, MAE, nonfocal exam CV RRR, no M/R/G.",0
"Sternum stable, incision CDI Pulm clear but diminished in bases bilat Abdm soft, NT/ND/+BS Ext warm, trace pedal edema bilat Pertinent Results: 12:18PM GLUCOSE-90 NA+-134* K+-3.8 12:12PM UREA N-32* CREAT-1.1 CHLORIDE-102 TOTAL CO2-28 12:12PM WBC-4.4# RBC-2.72* HGB-9.2* HCT-25.0* MCV-92 MCH-33.9* MCHC-36.9* RDW-13.7 12:12PM PLT COUNT-257 12:12PM PT-13.8* PTT-37.9* INR(PT)-1.2* 07:10AM BLOOD WBC-6.2 RBC-3.00* Hgb-10.0* Hct-27.6* MCV-92 MCH-33.4* MCHC-36.3* RDW-13.7 Plt Ct-226 05:30AM BLOOD PT-12.4 INR(PT)-1.0 07:10AM BLOOD Plt Ct-226 07:10AM BLOOD Glucose-159* UreaN-22* Creat-1.1 Na-131* K-4.1 Cl-97 HCO3-27 AnGap-11 ECHO Pre Bypass: The left atrium and right atrium are normal in cavity size.",0
There is moderate to severe global left ventricular hypokinesis.,0
Overall left ventricular systolic function is severely depressed (LVEF=20 %).,0
There are simple atheroma in the ascending and descending aorta.,0
Post Bypass: Left ventricular function is improved.,0
The EF is now around 30%.,0
The motion of the lateral and anterolateral walls is improved.,0
Mild MR and mild AI remain.,0
The calculated aortic valve area is similar.,0
", M 82 Radiology Report CHEST (PA & LAT) Study Date of 3:18 PM , FA6A SCHED CHEST (PA & LAT) Clip # Reason: f/u MEDICAL CONDITION: 82 year old man with s/p cabg Final Report STUDY: PA and lateral chest .",0
HISTORY: 82-year-old man status post CABG.,1
FINDINGS: The cardiac silhouette is enlarged but stable.,0
There has been removal of the right IJ central venous catheter.,0
Median sternotomy wires are seen.,0
There is no focal consolidation or pulmonary edema.,0
Small bilateral pleural effusions are seen best on the lateral view.,0
DR. Approved: SUN 7:44 PM Brief Hospital Course: Mr. was admitted to the on for elective surgical management of his coronary artery disease.,1
He was taken directly to the operating room where he underwent coronary artery bypass grafting to one vessel (SVG-OM).,1
Please see OR report for details.,0
He tolerated the operation well and postoperatively he was taken to the intenisve care unit.,0
Within 24 hours he had awoke neurologically intact and was extubated.,0
On POD 1 he was transferred to the step down floor for continuing post-operative management.,0
"His heart failure regime was reinstituted, as was his diabetes medications with the addition of sliding scale insulin.",1
On the floor he had an uneventful post-operative course with the exception of intermittent atrial fibrillation for which anticoagulation was started.,1
On POD 4 it was decided he was ready for discharge to rehabilitation at Snai in .,0
"Medications on Admission: Theophylline 300'', Singulair 10', Advair 500"", Metformin 500"", ASA 160', Flomax 0.4', Proscar 5', Protonix 40', Glyburide 2.5', Simvastatin 20', Fosamax 70 q week, MVI', Januvia 100'.",0
"Allergies: Codeine/Valium/Morphine/oxycodone-N&V, PCN-rash, ACE-^K+, Vicryl sutures, Mycins-rash.",0
Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours).,0
Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: Tablets PO every 4-6 hours as needed.,0
Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous QAC&HS.,0
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Theophylline 100 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO BID (2 times a day).,0
Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation (2 times a day).,0
Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
Amiodarone 200 mg Tablet Sig: as directed below Tablet PO BID (2 times a day): 400mg x5 days then 400mg QD x1 wk then 200mg QD.,0
Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: target INR 2.0 Patient to receive 5mg Coumadin on .,0
Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: dose.,0
Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: CAD s/p CABGx1(Saphenous vein graft->Obtuse marginal artery) HTN Colon Cancer Diabetes Asthma BPH DVT GERD CKD Ischemic cardiomyopathy Chronicsystolic HF LVEF 30% Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection.,1
Please follow-up with Dr. 2 weeks after released from rehab.,0
4:24 PM CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.,0
Clip # Reason: LINE PLACEMENT Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ FINAL REPORT A chest fluoro was performed without a radiologist present.,1
5 seconds of fluoro time was used.,0
12:13 PM CHEST (PORTABLE AP) Clip # Reason: rule out acute Cp process ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with shortness of breath REASON FOR THIS EXAMINATION: rule out acute Cp process ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: 72-year-old man with shortness of breath.,0
Rule out acute cardiopulmonary process.,0
Only report available for review.,0
"SINGLE AP UPRIGHT VIEW OF THE CHEST: Ill- defined patchy right lower lobe opacity, may reflect focal atelectasis exaggerated by overlying soft tissue, however an early pneumonia can not be excluded.",0
No definite pleural effusions are evident.,0
The heart is moderately enlarged.,0
Pulmonary vasculature is within normal limits.,0
Osseous and soft tissue structures are grossly unremarkable.,0
"IMPRESSION: Right lower lobe patchy opacity may indicate, focal atelectasis, exaggerated by overlying soft tissues, however an early pneumonia can not be excluded.",0
Height: (in) 68 Weight (lb): 240 BSA (m2): 2.21 m2 BP (mm Hg): 108/57 HR (bpm): 101 Status: Inpatient Date/Time: at 12:12 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
A catheter or pacing wire is seen in the RA.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior - akinetic; mid inferior - dyskinetic; basal inferolateral - akinetic; mid inferolateral - hypo; mid anterolateral - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Cannot assess regional RV systolic function.,0
The rhythm appears to be A-V paced.,0
The left ventricular cavity is dilated.,0
LV systolic function appears depressed (?30%) but images are suboptimal for assessment of wall motion.,0
The right ventricular cavity is mildly dilated with grossly preserved contractility but views are suboptimal.,0
"Compared with the prior study (images reviewed) of , left ventricular systolic function appears more vigorous in the setting of tachycardia.",0
"11:38 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval NGT&ETT positions Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p right pneumonectomy w/ left chylothorax, s/p VATS.",0
"Eval for tube placement, lung expansion REASON FOR THIS EXAMINATION: eval NGT&ETT positions ______________________________________________________________________________ FINAL REPORT Portable chest compared to previous study of earlier the same date.",0
INDICATION: Nasogastric tube and endotracheal tube position.,0
"An endotracheal tube is in place, terminating approximately 5 cm above the carina.",0
No nasogastric tube is identified.,0
"With the exception of endotracheal tube placement, there has been otherwise no significant change since the recent study of earlier the same date.",0
11:09 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"pna Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with fever, in c-collar and tachycardia REASON FOR THIS EXAMINATION: ?",1
pna ______________________________________________________________________________ FINAL REPORT AP CHEST 11:28 A.M. HISTORY: Fever and tachycardia.,0
IMPRESSION: AP chest compared to and 13: Heterogeneous opacification in the infrahilar left lung has been present without appreciable change since at least .,0
Whether this is pneumonia or atelectasis is radiographically indeterminant.,0
Thickening along side a minimally displaced rib fractures is unchanged and there is no layering effusion or pneumothorax.,1
"Moderate cardiomegaly, accompanied by mediastinal vascular engorgement suggests borderline cardiac decompensation, but there is no pulmonary edema.",0
8:41 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: C spine ligament injuty Admitting Diagnosis: POLYTRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 16F unrestrained passenger pickup truck.,0
REASON FOR THIS EXAMINATION: C spine ligament injuty No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 16-year-old female with unrestrained MVA.,0
Assess for ligamentous injury in the setting of cervical tenderness.,0
COMPARISON: None available for comparison.,0
"TECHNIQUE: Sagittal STIR, diffusion-weighted images, T1 and T2 images as well as axial gradient echo and T2 sequences were obtained without contrast.",0
FINDINGS: The cervical spine is slightly straightened.,0
"Vertebral body height, bone marrow signal, and alignment are unremarkable.",0
The intervertebral discs demonstrate preservation of height and T2 signal.,0
There is no abnormal signal involving the para- and inter-spinous ligaments.,0
"At C5/C6, there is a minimal central disc protrusion, contacting the anterior cord surface.",0
"At C6/C7, an annular tear is associated with mild central disc protrusion, contacting and minimally deforming the anterior cord surface.",0
There is no evidence of disc herniation or neural foraminal narrowing.,0
The craniocervical junction is normal.,0
"Besides the above-mentioned areas of mild cord remodeling, the cervical cord has normal morphology and preserved intrinsic T2 signal.",0
There is no diffusion abnormality.,0
Incidental note is made of prominent adenoid tissue.,0
No evidence of fracture or ligamentous injury.,1
Relatively mild degenerative changes involving C5/C6 and C6/C7 segments with small central disc protrusions and minimal cord remodeling.,0
"5:27 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for pneumothorax (s/p thoracentesis) Admitting Diagnosis: ABD PAIN ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with cirrhosis, resolving SBP, now with incr WBC.",0
"s/p thoracentesis REASON FOR THIS EXAMINATION: Please eval for pneumothorax (s/p thoracentesis) ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Cirrhosis, status post thoracentesis, evaluate for pneumothorax.",0
Neither side shows a pneumothorax.,0
11:16 AM CHEST (PORTABLE AP) Clip # Reason: eval for pneumothorax s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP.,1
FINDINGS: Patient has been extubated and the NG tube has been removed.,0
There has been interval removal of left-sided chest tube.,0
There has been interval development of left lower lobe collapse with small left pleural effusion.,1
This is new when compared to prior exam.,0
Vague right upper lobe opacity is stable.,0
New left lower lobe collapse and small left pleural effusion.,1
Persistent right upper lobe opacity concerning for pneumonia.,0
Findings were discussed with Dr. via telephone at 11:50 a.m.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with stent placement Laparoscopic converted to open cholecystectomy History of Present Illness: Pt is a 66 yo F with PMHx sig.,1
for GERD who presents to Hospital for 2 weeks of epigastric pain and transferred here for emergent ERCP.,0
"Pt reported that for the past 2 weeks she has had worsening GERD symptoms, describing intermittent sharp epigastric pain, no radiation, improved with prevacid.",0
"She also reports 1 episode of N/V, nonbloody 2 weeks ago.",0
She reports that she has always alternated between diarrhea and constipation; no changes in bowel habits.,0
She denies BRBPR and melena.,0
She also reports shaking chills the past week.,0
Pt reports she has been feeling very weak as well.,0
She had fallen last night.,0
She feel again this morning while waking to the bathroom.,0
She reports that she suddenly became very weak and slumped to the ground.,0
She was there from about 3 AM to 8AM until her sister-in-law came to help.,0
"She denied LOC, but reports hitting her head.",0
"At Hospital, initial VS were: T98, 94/59, 72, 16, 96% on RA.",0
"Her VS trended toward sepsis with tachycardia to 112, BP to 90/51.",0
A Rt femoral line was placed and pt was started on levophed.,0
"for WBC 18 (33% bands), HCT 38, plt 239, Cr 1, K 2.5, SGO 67, SGP 132, TB 8.4, DB 5.1, alk phos 408, CK 503, CKMB 7.3, Trop I 0.26 (<0.10).",0
US showed thickened GB wtih multiple stones and biliary dilitation wtih CBD of 14 mm.,0
"CT abd showed dialted intrahepatic biliary ducts, CBD of 14 mm, a soft tissue density at the intrahepatic biliary duct bifurcation of the R and L main CBD, thickened gb with stones, nonspecific mesenteric LAD.",0
CXR showed mild bibasilar atelectasis.,0
Pt received zosyn and ?3 L of NS.,0
Pt was transferred for emergent ERCP.,0
"On the , SBPs dipped to 70s transiently.",0
"In the ED, initial vs were: 97.5, 111/54 on 0.30 mcg/kg levophed, 115, 96% on 4L.",0
"for lactate 3.8, WBC 26 (37% bands), HCT 28.9, TB 5.9, 438, lip , ap 310, alt 112, ast 103.",0
Pt was continued on levophed.,0
ERCP has been consulted and perform the procedure tonight.,0
Surgery had no further recs.,0
"Current vs are: 95/47 on Levophed 0.28, 113, 39, 98% on 4L.",0
"Past Medical History: Depression, Hyperlipidemia, GERD, Osteoarthritis, s/p TAH Social History: Lives alone, works as a secretary.",0
"Denies tobacco use, usually drinks a glass of wine per evening.",0
Has not had any alcohol in 1 week.,0
"Family History: Father died of colon cancer at age 78; mother had dementia, died at age 84.",0
Has one brother whose health is unknown.,0
Physical Exam: On Admission: .,0
"97.4 111-117 102/50-111/59 16-26 97% 4lNC Gen: dyspneic female, appears younger than stated age, NAD, mild scleral icterus, diaphoretic HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD Cor: RRR without m/g/r, no JVD, no bruits Lungs: CTA bilat.",0
"Marked CBD dilatation, with moderate intrahepatic biliary ductal dilatation, but no pancreatic ductal dilatation.",0
"No radiopaque obstructing stone is identified, but findings are concerning for obstruction.",0
Inflammatory changes surrounding the head of the pancreas concerning for acute pancreatitis.,1
"Gallbladder wall thickening and pericholecystic stranding, with relatively gallbladder.",0
"This may be reactive, associated with biliary obstruction.",0
"If there is concern for acute cholecystitis, a nuclear medicine hepatobiliary scan may be helpful.",1
GI ERCP: Pus was seen in the stomach.,0
There was pus discharge in the major papilla.,0
There was an impacted stone stone in the major papilla.,0
There was a filling defect that appeared like sludge/stone in the lower third of the common bile duct.Minimal amount of contrast was injected considering risk of bacteremia.,0
4 ml pus material has been suctioned from the bile duct and sent for culture.,0
A 7cm by 10FR Cotton biliary stent was placed successfully in the lower third of the common bile duct using a Microvasive 10FR stent introducer kit.,0
Sphincterotomy was not perfromed considering her underlying coagulopathy.,0
Brief Hospital Course: Ms. is a 66F who was transferred to from hospital with a diagnosis of cholangitis.,0
When she arrived she was in septic shock and requiring a Levophed drip to maintain adequate perfusion pressures.,1
She was transferred to the ICU and electively intubated and underwent an emergent ERCP on .,0
The ERCP showed purulent material in the stomach and coming from the major papilla.,0
There was an impacted stone in the major papilla and another stone in the lower third of the CBD.,0
A stent was placed in the distal CBD.,0
"She was placed on empiric Vanc, Zosyn, and Flagyl.",0
Blood cultures from hospital grew E.coli that was pan sensitive.,0
Bile cultures also grew E.coli that was pan sensitive.,0
Repeat blood cultures drawn here at were negative.,0
She recovered from her initial septic episode after decompression of her biliary tree and Levophed was quickly weaned off.,0
Once stable she was transferred to the surgical floor.,0
On she was taken to the operating room for cholecystectomy.,0
"A laparoscopic attempt was made, but due to extensive adhesions a conversion to open cholecystectomy was made for the safety of the patient.",0
Post-operatively she did quite well.,0
She was given a PCA for pain control and started on her home medications.,0
Her diet was slowly advanced and she was converted to oral pain medications.,0
A PICC line was placed early in her hospital stay due to difficult access and the need for multiple antibiotics and IVF but was removed prior to discharge.,0
Physical therapy evaluated her and recommended rehabilitation for improving ambulation therefore she was transferred to rehab for a less than 30 day stay.,0
"Medications on Admission: Abilify 5 mg daily , Pristiq ?100 mg daily , Liptor 20 mg daily, Prevacid 30mg PO daily, Motrin 800 mg Discharge Medications: 1.",0
Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain.,0
Discharge Disposition: Extended Care Facility: Senior Healthcare - Discharge Diagnosis: Cholangitis Choledocholithiasis Cholecystitis Discharge Condition: Good Discharge Instructions: Call your surgeon if you develop: - fever > 101 or chills - inability to eat or drink - persistent abdominal pain not relieved by your medication - persistent nausea or vomiting - increasing redness or drainage from your incision - or any other concerns you may have .,1
Do not take a tub bath or submerge your incision in water for the next 3-4 weeks.,0
Resume all of your home medications.,0
You will be given a prescription for narcotic pain medication.,0
Do not drive while taking this medication as it may make you drowsy.,0
You will also be given a prescription for a stool softener.,0
Followup Instructions: The Gastroenterologist will contact you and schedule an appointment for a repeat ERCP to remove the stent that they placed on the first ERCP.,0
"Provider: , MD Phone: Date/Time: 10:15 Call Dr. () for an appointment in 2 weeks Provider: , MD Phone: Date/Time: 10:15 Call Dr. () for an appointment in 2 weeks Completed by:",0
11:09 PM CHEST (PA & LAT) Clip # Reason: Please eval r/o acute process ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with neutropenia REASON FOR THIS EXAMINATION: Please eval r/o acute process ______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old female with neutropenia.,1
"CHEST, PA AND LATERAL: Examination is suboptimal due to underpenetration.",0
Streaky left lower lobe opacities may represent atelectasis or early pneumonia.,0
Heart size is at the upper limits of normal.,0
The aorta is mildly tortuous.,0
There are no pleural effusions or pneumothorax.,0
IMPRESSION: Left lower lobe atelectasis or consolidation.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: 46 yo F with witnessed fall down 10 stairs today at 1pm was knocked unconscious after hitting her head in multiple places and was taken to an outside hospital.,0
This was viewed by her neighbor who gave the report.,0
"She was temporarily unconscious but then awoke and was noted to be confused, lethargic and then vomited several times.",0
"In the ED at the OSH she was awake on arrival but began to have nausea, vomiting and increased lethargy -> she was then intubated.",0
"Her head CT there showed a fresh 6mm L SDH with approximately 4mm of midline shift, there was no identified intracerebral contusion or hemorrhage.",0
A C-spine CT was also performed which was read as negative for recent fracture or dislocation.,0
"She was sent emergently to by ambulance, intubated, for neurosurgical consultation and evaluation for possible drainage.",0
"In the ED here she is intubated, off sedation and visibly agitated, moving all extremities.",0
"Past Medical History: L knee surgery yrs ago Hx of DVT at time of knee surgery, never on anticoagulation Social History: occasional etoh to tobacco works at a fish market with her husband Family History: Non-contributory Physical Exam: PHYSICAL EXAM: O: BP:132/80 HR:103 R18 O2Sats:100% -> CMV 1.0/400x18/PEEP 5 Gen: Intubated and agitated, moving all extremities to voice HEENT: Pupils: 4->3.5 equal but slow EOMs: unable to assess Pt has blood in R external auditory canal.",0
"Neck: In hard collar, immobilized Lungs: clear b/l Back: No palpable stepoffs Cardiac: tachycardic, regular Abd: Soft, non-distended Extrem: Warm and well-perfused, no gross deformities Neuro: GCS: 11 (alert but intubated) Mental status: Intubated - able to respond to simple commands.",0
II: Pupils equally round and reactive to light 4->3.5 Motor: Able to lift arms and legs off bed b/l.,0
Squeezes hand and moves foot to command.,0
Sensation: unable to assess Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Pertinent Results: ADMISSION LABS: 04:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 04:00PM WBC-20.9* RBC-4.14* HGB-12.6 HCT-36.5 MCV-88 MCH-30.4 MCHC-34.4 RDW-13.0 04:00PM GLUCOSE-136* UREA N-17 CREAT-0.7 SODIUM-138 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18 DISCHARGE LABS: 05:15AM BLOOD WBC-6.3 RBC-3.38* Hgb-9.7* Hct-28.7* MCV-85 MCH-28.6 MCHC-33.7 RDW-13.7 Plt Ct-281 04:00PM BLOOD Neuts-85.9* Bands-0 Lymphs-9.4* Monos-4.0 Eos-0.3 Baso-0.5 05:15AM BLOOD PT-12.4 PTT-26.4 INR(PT)-1.0 05:15AM BLOOD Glucose-80 UreaN-7 Creat-0.5 Na-137 K-3.6 Cl-106 HCO3-21* AnGap-14 IMAGING: CT Head in ED : IMPRESSION: 1.,0
"No change in left subdural hematoma (from OSH) with mass effect, effacement of sulci, and 3-mm rightward shift of midline structures.",0
Non-displaced oblique right temporal bone fracture with associated mastoid air cell opacification.,1
Right frontal bone fracture involving right orbital roof and lateral orbital wall.,0
No evidence of traumatic injury.,0
"Multiple findings worrisome for metastatic disease, as noted on the very recent prior study.",0
CT Head evening: IMPRESSION: 1.,0
No significant interval change in left subdural hematoma with stable 3-mm left-to-right midline shift.,0
Unchanged right temporal and frontal bone fractures.,0
"CT Head : Left holohemispheric subdural hematoma, not significantly changed from the prior study with approximately 2.5 mm of left to right midline shift.",0
Decrease in size of the left convexity subdural hematoma as well as decrease of the midline shift to the right.,0
Brief Hospital Course: The patient was seen at an OSH ED for a 6 mm SDH.,0
She was transferred to the for management.,0
She arrived to our EW intubated.,0
Examination revealed that she was awake and following commnads consistently.,0
Repeat head CT revealed no interval progression in the SDH.,0
She was weaned to extubation the evening of her admission.,0
The patient remained neurologically intact post-extubation and for the remainder of the hospital stay.,0
Subsequent examination revealed a right hemotypamiun for which the patient was seen by the ENT service.,0
Ophthalmology was also consulted for right orbit fracture (no surgery was indicated and outpatient clinic follow up was recommended).,0
The patient was slow to mobilize in the ensuing days.,0
"Ultimately, physical therapy evaluated her and recommended home with services.",0
She was discharged on with follow up recommendations and contact information.,0
Medications on Admission: none Discharge Medications: 1.,0
Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: No driving while on this medication.,0
Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).,0
Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache: This contains Tylenol.,0
Do not take more than 3grams of Tylenol in 24 hours.,0
Ciprofloxacin 0.3 % Drops Sig: Two (2) Drop Ophthalmic (2 times a day) for 1 weeks.,0
Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for prn dizziness.,0
Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: -Left Subdural Hematoma -Right temporal bone fracture -Right frontal bone fracture involving right orbital roof and lateral orbital wall Discharge Condition: Neurologically stable Mental Status: Clear and coherent.,1
Discharge Instructions: General Instructions ?,0
"Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc.",0
"You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring.",0
**You are also being discharged on ear drops to prevent an infection from developing.,0
"You must continue these drops until you are seen in follow up by the Ear, Nose and Throat doctors 1-3 weeks.",0
"Any confusion, lethargy or change in mental status.",0
"New onset of the loss of function, or decrease of function on one whole side of your body.",0
Followup Instructions: Follow-Up Appointment Instructions ?,0
"?Please call ( to schedule an appointment with Dr. , to be seen in 2 weeks.",0
?You will need a CT scan of the brain without contrast prior to your appointment.,0
This can be scheduled when you call to make your office visit appointment.,0
You will need to make an appointment to follow up with opthomology.,0
This appointment can be obtained by calling .,0
You should make this appointment within 1 week.,0
You will need to make an appointment to follow up with ENT.,0
You can make this appointment by calling (.,0
"This appointment should also be within 1-3 weeks, and can be coordinated with your eye appointment.",0
Please continue your ear drops until you are seen and evaluated by them.,0
"5:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change in infiltrate Admitting Diagnosis: OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with apparent narcotic, tylenol od now hypotensive and respiratory acidosis REASON FOR THIS EXAMINATION: evaluate for interval change in infiltrate ______________________________________________________________________________ FINAL REPORT AP CHEST ON 5:38 A.M. .",0
"IMPRESSION: AP chest compared to : Right lung base is markedly elevated conceivably due to a paralyzed, severely eventrated, or traumatized right hemidiaphragm, given multiple healed right rib fractures.",0
ET tube is in standard placement and a nasogastric tube passes below the diaphragm and out of view.,0
"3:58 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: s/p aneurysm coiling Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with REASON FOR THIS EXAMINATION: s/p aneurysm coiling No contraindications for IV contrast ______________________________________________________________________________ WET READ: DLrc WED 5:25 PM Patient is status post new anterior communicating coiling, also status post bilateral MCA coiling.",1
Evolution of intraventricular hemorrhage with bilateral ventriculostomy shunts still in place.,1
"No worsening hydrocephalus, new hemorrhage, infarction, or mass effect.",1
______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 53-year-old male status post aneurysm coiling.,0
COMPARISONS: Comparison to CTA of the head from done at 9 a.m.,0
TECHNIQUE: Contiguous axial images of the brain were obtained.,0
FINDINGS: The patient is status post new anterior communicating artery ANEURYSM coiling.,0
The patient is status post bilateral MCA ANEURYSM coiling.,0
"There is extensive intraventricular hemorrhage in the bilateral lateral ventricles, the third ventricle, the fourth ventricle, extending into cistern of the lamina terminalis and also adjacent parenchyma adjacent to the previously noted anterior communicating artery aneurysm.",1
The hemorrhage appears to have greater attenuation than prior examination and appears slightly decreased in size consistent with expected evolutional changes.,0
There is hyperattenuation of the falx cerebri and the cerebellar falx that is consistent with recent contrast administration from angiogram procedure.,0
"There are bilateral ventriculostomy shunts, the left one which terminates in the third ventricle and the right which terminates at the septum pellucidum.",0
There are tiny focal areas of hyperattenuation along the sulci consistent with tiny areas of subarachnoid hemorrhage that is unchanged from prior examination from 9 a.m. on .,1
There is no evidence of mass effect or shift of midline structures.,0
The ventricles demonstrate a similar size and appearance from prior examination from at 9 a.m.,0
There is no evidence for worsening hydrocephalus.,0
"IMPRESSION: The patient is status post ACOM aneurysm coiling with extensive residual intraventricular hemorrhage in the bilateral lateral, third, and fourth ventricles as described above.",1
There is no worsening hydrocephalus or worsening hemorrhage.,1
(Over) 3:58 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: s/p aneurysm coiling Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont),1
3:08 PM BILAT LOWER EXT VEINS PORT Clip # Reason: please assess for clot Admitting Diagnosis: ASPIRATION PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with Wolfram syndrome admit for asp PNA persistent fevers despite coverage for appropriate bacterial infxn.,0
"REASON FOR THIS EXAMINATION: please assess for clot ______________________________________________________________________________ FINAL REPORT INDICATIONS: 24-year-old man with Wolfram syndrome and aspiration pneumonia, with persistent fever.",0
TECHNIQUE: Bilateral lower extremity venous ultrasound and Doppler examinations.,0
"FINDINGS: Bilateral grayscale and Doppler son of the bilateral common femoral, superficial femoral, and popliteal veins were performed.",0
"These show normal compressibility, augmentation, and Doppler flow and waveforms.",0
IMPRESSION: No evidence of deep vein thrombosis.,0
"7:18 AM CHEST (PORTABLE AP) Clip # Reason: assess pulm edema Admitting Diagnosis: LUNG MASS RIGHT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman s/p vats wedge resection REASON FOR THIS EXAMINATION: assess pulm edema ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, AT 8:36: INDICATION: Follow up of congestive heart failure.",1
FINDINGS: The pulmonary vasculature appears less distended and the heart size is decreased slightly.,0
Blunting of the right costophrenic sulcus is consistent with some effusion.,0
No new foci of air space disease are detected.,0
right CVL remains in place - no pneumothorax.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Upper GI bleed.,0
Major Surgical or Invasive Procedure: PICC line placement.,0
"History of Present Illness: A 58 yo female with MMP including recently diagnosed AV endocarditis and recent left parietal infarct (), HTN, CAD s/p CABG, DM2, GIB on anticoagulation,recent sepsis who is transferred from OSH with new CNS lesions.",0
Ms has had 2 recent admissions to OSH; first on for parietal infarct.,0
Stroke w/u only revealed aortic plaque so she was started on coumadin and eventually discharged.,0
She had another admission on for chest pain and was found to have + bld cx for strep viridans and an eccho which revealed AV endocarditis.,0
She was started on penicillin.,0
She was note to have altered mental status at that time but no CNS imaging was pursued.,0
She was transferred to Hospital on on penicillin.,0
"Per report, has ""seizure activity"" on ""left arm spastic, eyes rolled back.""",0
Loaded with dilantin and has been on 100 mg po tid since then.,0
"She got CT wet read ""1.7 cm high density focus in left cerebral whiet matter vs. cortex.",0
"Could be primary hemorrhage or hemorrghaic tumor.""",0
"She was taken back to , then tx to .",0
She was seen by neurology and neurosurgery; on examination she was encephalopathic with evidence of right hemiparesis/ prior stroke.,0
"In the ED, VS on arrival were: T: 97.9; Hr: 80; BP: 116/60; RR: 16; O2 100 4L NC.",0
"She was given ASA 325 mg po x 1, protonix 40 mg IV, 1 L of NS.",0
"at 10 am, found to have large maroon/black stool.",0
HCT 22 from 29 on admission (27 at OSH).,0
INR was 1.2 with normal platelets.,0
NG lavage showed bright red blood.,0
Pt was hemodyanamically stable in the ED.,0
Per report she was oriented x 2.,0
Coronary artery disease s/p CABG 2.,0
"Left parietal infarct, early .",0
Chronic non healing right heel ulcer 6.,0
History of gastrointestinal bleeding on anticoagulation 9.,0
History of recent ARF requiring temporary dialysis 10.,0
"History of colonic resection with colostomy 5-6 years ago, reversed.",0
This was complicated by prolonged intubation with trach and eventual decannulation.,0
Social History: Lives with her son-wheelchair bound few years (due to open wound on heal of foot).,0
"Physical Exam: VS: T: 96.6; HR: 87; BP: 103/53; RR: 15; O2: 100 2L Gen: Can arouse with touch, though speaking one-two words, not always sensicle HEENT: Dilated but minimally responsive 4-->3 mm, OP dry, unable to fully assess Neck: No LAD.",0
"Lungs: CTA b/l anteriorly Abd: Obese, distended slightly.",0
Back: unable to assess Ext: b/l surgeries with multiple scares in LE (likely bypasses for PVD).,0
"Missing left great toe, other toes.",0
Left heal ulcer small with granulation.,0
There is bandage over right heal Neuro: Could not assess CN as pt was non-cooperative with exam and lethargic.,0
"Thought we were in """" that it was 1900.",0
Unable to move right side.,0
Left side: hand grip .,0
Other though limited by inattention and lethargy.,0
Pertinent Results: LAB DATA: CBC: 07:30PM WBC-10.3 RBC-3.90* HGB-9.5* HCT-29.9* MCV-77* MCH-24.5* MCHC-31.9 RDW-25.5* 07:30PM NEUTS-71.4* LYMPHS-19.0 MONOS-7.0 EOS-2.3 BASOS-0.3 LFTS: 07:30PM ALT(SGPT)-11 AST(SGOT)-27 CK(CPK)-66 ALK PHOS-126* AMYLASE-23 TOT BILI-0.4 07:30PM LIPASE-10 CHEMISTRIES: 07:30PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.3* 07:30PM GLUCOSE-107* UREA N-6 CREAT-0.7 SODIUM-128* POTASSIUM-3.8 CHLORIDE-87* TOTAL CO2-30 ANION GAP-15 CULTURE DATA: : Blood cultures with e.coli (sensitive to meropenem; zosyn) : Urine culture with pseudomonas (sensitive to zosyn; I sensitivity to meropenum) EKG: Afib in 100s.,0
"Seems to be in and out of afib on tele MRI head (): Signal abnormalities in left frontal and parietal lobes on the left, with anatomic distribution and imaging characteristics consistent with subacute infarctions of embolic etiology.",1
RUE Ultrasound: (): No evidence of DVT in the right upper extremity TTE (): The left atrium is elongated.,0
Left ventricular systolic function appears grossly preserved in suboptimal views.,0
Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction.,0
There is mild aortic valve stenosis (area 1.2-1.9cm2) Trace aortic regurgitation is seen.,0
There is a trivial pericardial effusion.,0
"Probable bibasilar atelectasis, although consolidation cannot be excluded.",0
"8-mm hypodensity in the right kidney, which is too small to characterize.",0
Status post subtotal colectomy with a diastasis in the anterior pelvic wall containing small bowel loops.,0
"While some of the distal small bowel loops are distended with air/fluid levels, oral contrast reaches the rectum without evidence of bowel obstruction.",0
No free fluid and no drainable fluid collection in the abdomen or pelvis.,0
CXR (): Bilateral lower lobe atelectasis or consolidation with interval worsening at the right base.,0
Bilateral foot x-ray (): 1.,0
Diffuse osteopenia limiting fine the bony detail to diagnose nondispaced fractures and osteomyelitis changes.,0
No definite evidence of lytic or sclerotic changes underlying areas of soft tissue defects within the heels bilaterally.,0
A tiny cortical defect seen along the base of the fifth metatarsal on the left.,0
Recommend correlating clinically to determine if there is point tenderness or an ulcer underlying this lesion.,0
Endocarditis: Ms has AV endocarditis (strep viridans) with resultant CNS and splenic embolism.,1
Ms was continued on penicillin 3million U IV q4 hrs.,0
Surveillance blood cultures were negative for strep viridans; however she was found to have ecoli bacteremia which was sensitive to meropenem.,0
"Therefore, she was changed to meropenem at the advice of the infectious diseases service.",0
Repeat echocardiogram at did not show evidence of endocartidis.,0
The plan at the time of discharge included the following: --Meropenum 500 mg IV Q6H through --Penicilllin 3 million units IV Q4H to start after completion of Meropenum and to be used until 2.,0
Cerebral emboli: These likely represented septic emboli in the setting of endocarditis.,1
Ms was loaded on dilantin and was given IV decadron to decreased cerebral edema.,0
This was tapered with resolving lethargy/headache.,0
Her antibiotics were dosed for CNS infection.,0
"Regarding steroids, plan was for a swift taper with 4 additional days of prednisone, 10mg daily to be finished after discharge.",0
"Dilantin was continued at 100mg TID, per neurology recommendations.",0
Ms is expected to have a persistant R hemiparisis but may regain some other functions.,0
Her mental status greatly improved from stuporus on admission to conversant at the time of discharge.,0
Ecoli bacteremia: Ms was noted on to have + bld cx for Ecoli.,0
This is suspected to be from translocation through esophagus or gut.,0
She was started on meropenem.,0
Repeat surveillance cultures were negative.,0
"CT abdomen was negative, urine did not reveal E coli; abd/pelvis CT scan was negative; podiatry felt her heel ulcers were not the source.",0
"Pseudomonas UTI: Although the organism had intermediate to meropenem, ID service wanted to continue meropenem alone with the idea that meropenem is concentrated in the Urine.",0
Upper GIB: Ms had a massive upper GIB on admission; she was intubated for airway protection and urgently scoped which showed multiple severe ulcers.,0
"She was transfused several units blood and started on sucralfate, PPI, with stabilization of her.",0
"At the time of discharge, she was continued to remain OFF aspirin and coumadin.",0
The decision for future anticoagulation in the setting of atrial fibrillation was to be made in the future in consultation with the patient's PCP.,1
Chronic pain: The patient's pain was felt to be secondary to her diabetic neurpathy.,0
She presented on a fentanyl patch at 50mcg every 72 hours.,0
This appeared in adequate and the dose was subsequently increased to 75mcg every 72 hours with improved effect.,0
PO narcotic PRN was used for breakthrough pain.,0
"The pain states that she had previously been on gabapentin, but that she did not tolerate this medication.",0
7. b/l heal ulcers: Patient presented with a history of chronic non-healing ulcers.,0
X-rays with no evidence of osteomyelitis.,0
Podiatry did not feel there was any need for debridement.,0
Daily wound care was used.,0
Hypothyroidism: The patient did not present on thyroid medication.,0
"Upon review of her discharge summaries from her OSH courses, it appeared that she had a history of hypothyroidism; as such, a TSH was checked and found to be elevated.",0
"She was started on levothyroxine, 50mcg daily.",0
Plan was for repeat TFTs in weeks to determine the need for increased dosing.,0
"Diabetes mellitus: The patient presented with type II diabetes, on insulin.",0
"While an inpatient, she was continued on insulin with, initially, lantus and a HISS; this later changed to lantus, regular insulin with meals and a HISS.",0
Part of her hyperglycemia was felt to be secondary to steroids.,0
"As such, she may require less insulin upon discharge and thereafter, as her steroids are tapered and stopped.",0
"Her regimen at the time of discharge included: --Lantus 15units QHS --Regular 5units with meals --Humalog slidind scale As above, her also has a diabetic neuropathy treated with fentanyl patch.",0
"Coronary artery disease: The patient had been on a beta-, ACEI and ASA.",0
The first two medications were held initially as she was hypotensive.,0
"The beta- was restarted later in her course, then changed to a CCB given her hyperkalemia.",0
The ACEI was held throughout the admission.,0
The ASA was held in the setting of her GI bleed.,0
Future decisions regarding resumption of this medication were left to her primary care.,0
"Atrial fibrillation: During the admission, the patient was intermittantly in atrial fibrillation; at times were rate would increase to the 120s so, once her blood pressure stabilized, she was rate controlled with a beta-.",1
On she was switched to a CCB given possibility that her hyperkalemia was BB induced.,0
Right upper extremity edema: The patient had persistent RUE edema.,0
An ultrasound was performed on and did not show any evidence of DVT.,0
The edema remained at the time of discharge.,0
"Hypertension: The patient presented with a diagnosis of hypertension, on a BB and an ACEI.",0
"During most of her admission, her blood pressures were in the low 100s.",0
"As above, a BB (and later a CCB) were used for rate control.",0
Her BP remained stable thereafter.,0
Mental status change: The etiology of this was unclear.,0
"It may have been secondary to septic emboli, but it may also have been associated with her untreated hypothyroidism.",0
"At the time of discharge, the patient was oriented to person, ""; "" and "" "".",0
She was repeatedly reminded that it was .,0
"Her short-term memory was poor, although she did recall the name of her resident physician after repeated reminders.",0
"Initially, the patient would become agitated at times; haldol and/or olanzapine were used.",0
The patient did not require these medications over hte final 4 days of her admission.,0
Anxiety: The patient complained of intermittant anxiety during her hospitalization.,0
Low dose lorazepam was used with good effect and no apparent paradoxical agitation.,0
"Medications on Admission: -NPH insulin 20units qam, 20 units qpm -regular insulin sliding scale starting at 200 at 2 units, by 2 units every 50 -zinc sulfate 220mg po daily -ASA 325mg po daily -heparin sc 5000 units sc tid -nitrobid 1 inch q6 hour topical -MVI 1tab po daily -vitamin C 500mg po bid -lasix 20mg po daily -fentanyl patch 50mcg/h q72h -protonix 40mg po daily -lisinopril 10mg po daily -lopressor 25mg po bid -tylenol prn -percocet prn -advair 1puff -dilantin 100mg po tid -PCN 3million units IV q4h Discharge Medications: 1.",0
Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day.,0
Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane PRN (as needed).,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation.,0
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety.,0
Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours).,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed.,0
Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days.,0
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 5 days: Please continue through .,0
Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime.,0
Insulin Regular Human 100 unit/mL Solution Sig: Five (5) units Injection with meals.,0
Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day.,0
Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: Primary: 1.,0
Upper GI bleed 5. s/p parietal stroke 6.,0
Right upper extremity edema 13.,0
Anxiety Discharge Condition: Improved; off oxygen.,0
Discharge Instructions: You are being discharged to an extended care facility where you will continue to have ongoing care for your active medical issues.,0
You have appointments scheduled with a new Primary Care Doctor (Dr. at .,0
"Followup Instructions: You have the following appointment scheduled: PRIMARY CARE FOLLOW-UP: , M.D.",0
"Phone: Date/Time: 8:00 - This is located on the , Building, CLINIC: , MD Phone: Date/Time: 9:00 - This is located on the , Building, .",0
"PCP: , MD Phone: Date/Time: 8:30 - This is located on the , Building,",0
"8:23 PM FOOT AP,LAT & OBL RIGHT Clip # Reason: r/o osteo Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with charcot foot and chronic right foot wound with GPC bacteremia.",1
REASON FOR THIS EXAMINATION: r/o osteo ______________________________________________________________________________ FINAL REPORT THREE VIEWS OF THE RIGHT FOOT INDICATION: Charcot foot and chronic right wound with TPC bacteremia.,1
"COMPARISON: Radiographs of the right foot, .",0
"FINDINGS: Soft tissue indentation is seen at the plantar aspect of the foot, compatible with a soft tissue defect or ulcer.",0
There are postoperative changes at the hindfoot with evidence of prior destruction or debridement at the region of the anterior subtalar joint with an ovoid methyl methacrylate presumably antibiotic impregnated spacer in this region.,0
A similar spacer is also visualized in the region of the fifth tarsometatarsal joint.,0
Extensive chronic arthropathy is seen involving the intertarsal and tarsometatarsal joints in addition to the first metatarsophalangeal joint.,1
"IMPRESSION: The overall appearance is similar to prior examination and while osteomyelitis is not excluded, no clear new area of bone destruction is seen.",0
8:05 AM CT HEAD W/O CONTRAST Clip # Reason: interval change from .,0
Please scan at 0600 on Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man pulled out his ventricular drain REASON FOR THIS EXAMINATION: interval change from .,1
Please scan at 0600 on No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post removal of ventricular drain for followup.,0
TECHNIQUE: Non-contrast axial images of the head are obtained with 5 mm section thickness.,0
"CT HEAD WITHOUT CONTRAST: Compared to a day prior, there is no significant interval change.",0
The right ventricular catheter has been removed with residual tract seen.,0
No change in ventricular size is apparent.,0
"Again, note is made of diffuse subarachnoid hemorrhage bilaterally with intraventricular hemorrhage layering in the occipital horns, not significantly changed compared to the prior study.",1
Patient is status post aneurysmal coiling of the left distal anterior cerebral artery.,0
There is no shift of normally midline structures and the ventricles are unchanged in caliber.,0
Note is made of an unchanged prior lacunar infarct in the left centrum semiovale.,0
"A right frontal burr hole is noted; otherwise, surrounding osseous structures unremarkable.",0
Imaged portions of the paranasal sinuses and mastoid air cells appear well aerated.,0
"IMPRESSION: Post right lateral ventricular catheter removal with unchanged appearance of subarachnoid and intraventricular hemorrhage, as well as ventricular size.",1
Height: (in) 63 Weight (lb): 179 BSA (m2): 1.85 m2 BP (mm Hg): 118/73 HR (bpm): 135 Status: Inpatient Date/Time: at 15:29 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
"2:43 AM ACUTE ABD SERIES ( VIEWS OF ABD & SGL CHEST VIEW) Clip # Reason: please also do cross table lateral view, evaluate for obstru Admitting Diagnosis: CONSTIPATION ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with constipation x 3d, abdominal distention s/p disimpaction REASON FOR THIS EXAMINATION: please also do cross table lateral view, evaluate for obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN RADIOGRAPHS HISTORY: Constipation.",0
"COMPARISON: Abdomen radiographs dated , performed at 12:36 a.m.",0
"TECHNIQUE: Two views of the abdomen, frontal and supine projections.",0
"FINDINGS: Again demonstrated are multiple severely dilated small and large bowel, grossly unchanged from prior study.",0
"Again seen is the large amount of stool in the rectal vault, unchanged.",0
No evidence for free air is noted.,0
"IMPRESSION: No significant change from prior study, with mechanical obstruction due to fecal impaction.",0
Height: (in) 63 Weight (lb): 145 BSA (m2): 1.69 m2 BP (mm Hg): 95/41 HR (bpm): 80 Status: Inpatient Date/Time: at 15:52 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
LEFT ATRIUM: Moderate LA enlargement.,0
Mild symmetric LVH with normal cavity size.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - akinetic; mid inferoseptal - hypo; basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; inferior apex - hypo; RIGHT VENTRICLE: Mildly dilated RV cavity.,1
There is moderate regional left ventricular systolic dysfunction with inferior and inferolateral .,1
The remaining segments contract normally (LVEF = 35%).,0
"IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.",1
Moderate to severe tricuspid regurgitation.,1
"Compared with the prior study (images reviewed) of , tricuspid regurgitation is more prominent and pulmonary pressures are higher.",0
Left ventricular function and the other findings are similar,0
10:34 AM CT HEAD W/O CONTRAST Clip # Reason: Eval.,0
for acute injury/CVA Admitting Diagnosis: CIRRHOSIS;RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p liver-kidney txplant with AMS REASON FOR THIS EXAMINATION: Eval.,1
for acute injury/CVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old man status post liver and kidney transplant with altered mental status.,1
"FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, shift of normally midline structures, or change in ventricular size.",0
Mild ventricular and focal prominence is consistent with age-related involutional change.,0
There remains mineralization of the basal ganglia bilaterally.,0
The visualized paranasal sinuses and mastoid air cells are clear.,0
"For the evaluation of acute brain ischemia, an MRI with diffusion weighting is more sensitive than CT.",0
LINE PLACEMENT Clip # Reason: please evaluate line placement and r/o PTX Admitting Diagnosis: CARDIAC ARREST;GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with GI bleed s/p central line placement REASON FOR THIS EXAMINATION: please evaluate line placement and r/o PTX ______________________________________________________________________________ WET READ: JKPe WED 7:32 PM rt ij tip in upper right atrium.,0
"HISTORY: 70-year-old woman with GI bleed, status post central line placement; rule out pneumothorax.",0
"TECHNIQUE: Single bedside AP examination labeled ""upright at 1745"" is compared with study dated .",0
"The new right IJ central venous catheter reaches the high right atrium, with no pneumothorax.",0
Tandem common bile duct stents are redemonstrated in the right upper abdomen.,0
The lungs are well- inflated and clear.,0
The cardiomediastinal silhouette and pulmonary vessels are within normal limits with no pleural effusion.,0
New central venous catheter tip in the high right atrium with no pneumothorax.,0
A preliminary interpretation was furnished to Dr. by Dr. .,0
"10:05 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: s/p mvc ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman s/p MVA rollover, restrained REASON FOR THIS EXAMINATION: s/p mvc ______________________________________________________________________________ FINAL REPORT INDICATION: MVA rollover restrained.",0
AP CHEST AND AP PELVIS: The cardiac and mediastinal contours are normal.,0
There is slight increased opacity within the right lung.,0
The left lung is clear.,0
There are probable trace bilateral pleural effusions.,0
There is a small right pneumothorax.,1
"There are rib fractures involving the right third, fourth, fifth, and sixth ribs.",1
These fractures involve both the posterior and lateral ribs.,0
The bilateral hips and SI joints are normal.,0
No pelvic fractures are identified.,0
Note fine osseous detail is obscured due to overlying trauma board.,0
IMPRESSION: Multiple contiguous right rib fractures.,0
Probable right pulmonary parenchymal contusion.,0
"2:26 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: please eval for microperforation, source of GIB Admitting Diagnosis: GASTROINTESTINAL BLEED Field of view: 48 ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with R sided abdominal pain and rebound, LGIB HCT unchanged after 7 units PRBCs s/p r colectomy REASON FOR THIS EXAMINATION: please eval for microperforation, source of GIB CONTRAINDICATIONS for IV CONTRAST: renal failure;; failure ______________________________________________________________________________ WET READ: DLrc WED 6:00 AM Limited scan without intravenous contrast.",1
"Since prior examination, interval development of stranding surrounding the ascending colon from the prior colectomy site to the level of the hepatic flexure with bowel thickening most compatible with a colitis, either infectious or ischemic in etiology.",0
In addition increase in amount of simple perisplenic simple ascites and ascites tracking along right para colic gutter.,0
Bibasilar consolidation is improved since prior examination though with persistent bibasilar atelectasis.,0
______________________________________________________________________________ FINAL REPORT CT ABDOMEN AND PELVIS WITHOUT CONTRAST COMPARISON: .,0
HISTORY: Right-sided abdominal pain and rebound with lower GI bleed.,0
Evaluate for source of GI bleed.,0
TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were obtained.,0
Coronal and sagittal reformats were performed.,0
FINDINGS: CT ABDOMEN: There are small bilateral pleural effusions.,0
These have slightly increased when compared to prior exam.,0
There is no pericardial effusion identified.,0
"Within the limitations of a non-contrast exam, the spleen, pancreas, adrenal glands, kidneys and liver are unremarkable.",0
"The gallbladder is mildly distended, unchanged.",0
Hyperdensity layering within the gallbladder may represent small amount of stones or sludge.,0
"There has been interval increase in perisplenic fluid (2, 31) as well as fluid within the right paracolic gutter.",0
Patient is status post partial colectomy.,0
"Small amount of hyperdensity layering within the ascending colon (2, 44) is identified and is of unclear etiology.",0
There is mild wall thickening of the right colon.,0
Increased thickness of the retroperitoneal fascia may represent edema.,0
There is no evidence of retroperitoneal bleeding or hematoma.,0
The psoas muscles are symmetric.,0
There is no evidence of free air.,0
Extensive calcifications of the descending aorta and its branches are noted and consistent with atherosclerotic disease.,0
"(Over) 2:26 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: please eval for microperforation, source of GIB Admitting Diagnosis: GASTROINTESTINAL BLEED Field of view: 48 ______________________________________________________________________________ FINAL REPORT (Cont) CT OF THE PELVIS: Small amount of fluid within the right paracolic gutter is increased (2, 78).",0
"The rectum, sigmoid colon, bladder and prostate are unremarkable.",0
Patient is status post left fem- bypass.,1
There is bilateral inguinal fat-containing hernias.,0
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.,0
Multilevel degenerative changes of thoracic and lumbar spine are noted.,0
Calcified injection granulomas are seen in the posterior subcutaneous soft tissues.,0
No evidence of retroperitoneal bleeding.,0
Slight interval increase in perisplenic and right paracolic gutter free fluid.,0
Minimal hyperdensity within the ascending colon near the suture line.,0
"While this may represent ingested material, high-density material such as blood products cannot be excluded.",0
Mild right colonic wall thickening.,0
"Differential diagnosis includes ischemia, infectious or inflammatory causes.",0
Patient is status post left fem- bypass with bilateral inguinal fat-containing hernias.,1
"5:56 AM PORTABLE ABDOMEN Clip # Reason: eval for ileus vs. SBO ______________________________________________________________________________ MEDICAL CONDITION: 29 year old woman with mytochondrial myopathy, trach/vent, s/p PEG yesterday, also firm RLQ mass likely impacted stool, now w/abd distension, tympanitic.",0
"REASON FOR THIS EXAMINATION: eval for ileus vs. SBO ______________________________________________________________________________ FINAL REPORT ABDOMEN, SINGLE FILM.",0
HISTORY: Abdominal distension and tympany.,0
G tube overlies left upper quadrant.,0
There is free intraperitoneal gas likely secondary to the interventional procedure.,0
Retained contrast is present in the right colon.,0
There are gas-filled loops of small bowel with gas present throughout the colon.,0
No evidence for intestinal obstruction.,0
The cecum is not unduly dilated.,0
5:16 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: One more assessment of feeding tube position.,0
Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 71M s/p Dobhoff feeding tube placement.,0
REASON FOR THIS EXAMINATION: One more assessment of feeding tube position.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Position of Dobbhoff tube.,0
"FINDINGS: In comparison with earlier study of this date, the Dobbhoff tube has been extended to the distal stomach.",0
5:49 PM CHEST (PORTABLE AP) Clip # Reason: Please assess PICC line placement.,0
Admitting Diagnosis: ANKLE FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with PICC line which appears to have changed position.,0
REASON FOR THIS EXAMINATION: Please assess PICC line placement.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .,0
"Right PICC has been withdrawn, and now terminates at the medial aspect of the right clavicle within the expected location of the right subclavian vein.",0
Nasogastric tube has been removed in the interval.,0
"Slight increase in degree of gas-filled loops of bowel in the imaged upper abdomen, with persistent mild elevation of left hemidiaphragm.",0
2:05 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Diverticulitis?,0
"vs SBO ______________________________________________________________________________ MEDICAL CONDITION: History: 54M with abdominal pain, n/v REASON FOR THIS EXAMINATION: Diverticulitis?",0
vs SBO No contraindications for IV contrast ______________________________________________________________________________ WET READ: PBec WED 3:11 PM L inguinal canal hernia containing bowel and fat with upstream large bowel dilatation to 4.9 cm (not including cecum).,1
"Beyond hernia, bowel is collapsed.",0
minimimal inflammatory changes in fat in hernia but not bowel wall enhancement abnormality to suggest ischemia.,0
trace free fluid noted in abdomen.,0
"no free air WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Abdominal pain, nausea, vomiting; evaluate for diverticulitis versus small bowel obstruction.",0
TECHNIQUE: Contrast-enhanced axial images were obtained from lung bases to the pelvic outlet.,0
Coronal and sagittal reformations are provided.,0
FINDINGS: Minimal atelectasis noted in the lung bases.,0
Heart size is normal and without pericardial effusion.,0
Extensive coronary calcifications are identified.,0
The liver is homogeneous in attenuation without discrete masses or lesions.,0
"The pancreas contains interdigitating fat, but is without mass or pancreatic duct dilatation.",0
The spleen and bilateral adrenal glands are normal.,0
"The bilateral kidneys are without masses, stones, or hydronephrosis.",0
A large portion of the small bowel is decompressed.,0
"However, the entire large bowel is dilated up to the level of sigmoid bowel herniation through the left inguinal canal at which point there is a high grade transition to collapsed bowel.",1
There is a small amount of inflammatory change in the surrounding herniated fat.,0
No abnormal bowel wall enhancement to suggest ischemia at this point.,0
"However, there is a trace amount of free fluid noted within the paracolic gutters, left greater than right, as well as within the dependent portions of the abdomen.",0
Atherosclerotic changes noted within the abdominal aorta and splenic artery without aneurysmal dilatation or dissection.,0
The ostia of the celiac and superior mesenteric arteries are widely patent.,0
Incidental note is made of (Over) 2:05 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Diverticulitis?,0
vs SBO ______________________________________________________________________________ FINAL REPORT (Cont) two left renal arteries.,0
Single right renal artery identified.,0
"The hepatic, left, right, main portal veins and their major tributaries are unremarkable.",0
No suspicious lytic or blastic lesions identified.,0
There is multilevel degenerative change noted in the thoracic spine with exaggerated kyphosis.,0
IMPRESSION: Left inguinal hernia containing sigmoid colon and causing large bowel obstruction.,1
"No bowel wall enhancement abnormalities to suggest ischemia, though trace fluid is identified within the abdomen.",0
"8:22 AM CT CHEST W/CONTRAST Clip # Reason: check l chest, s/p lobectomy, radiation Admitting Diagnosis: CORONARY ARTERY DISEASE Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with cad REASON FOR THIS EXAMINATION: check l chest, s/p lobectomy, radiation No contraindications for IV contrast ______________________________________________________________________________ WET READ: JBRe SAT 10:21 AM 1.",1
Moderate aortic arch atherosclerotic calcifications.,0
Possible Saber-sheath trachea which might be related to prior radiation surgery.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old man status post lobectomy, radiation.",0
TECHNIQUE: Contiguous MDCT images through the chest were obtained after administration of intravenous contrast.,0
"Axial, coronal and sagittal reformats were acquired.",0
"FINDINGS: CT OF THE CHEST: The patient is status post left upper lobectomy and thoracotomy of the fourth through seventh left ribs with mild left lung base scarring (series 2, image 31).",0
"The right seventh, eighth and ninth ribs show chronic thoracotomy changes.",0
"No evidence of suspicious pulmonary nodules, lung consolidation or pneumothorax.",0
"No axillary, mediastinal or hilar lymphadenopathy.",0
There are moderate calcifications at the aortic arch.,0
The ascending aorta shows no calcifications.,0
There are no calcifications of the coronary arteries.,0
Partially visualized upper abdomen demonstrates cholelithiasis without cholecystitis.,0
The patient is status post right nephrectomy.,0
"There is a 17 x 14 mm right adrenal gland nodule, incompletely characterized on this CT scan.",0
Multiple surgical clips are seen in the left upper quadrant at the splenic hilum and at the GE junction of the esophagus.,0
"There is a 21 x 23 mm pathologically enlarged celiac axis lymph node (series 2, image 58) and a 30 mm porta hepatis lymph node, nonspecific.",0
"(Over) 8:22 AM CT CHEST W/CONTRAST Clip # Reason: check l chest, s/p lobectomy, radiation Admitting Diagnosis: CORONARY ARTERY DISEASE Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ FINAL REPORT (Cont) There are exophytic mid pole left renal cysts Hounsfield unit measurements of 10, likely representing simple cysts.",1
BONES: There is DISH of the thoracic spine.,0
No concerning suspicious lytic or sclerotic bony lesions.,0
Moderate calcifications of the aortic arch.,0
No calcification of the ascending aorta.,0
"1.7 cm right adrenal gland nodule, incompletely characterized on this CT and MR is recommended for further workup.",0
Pathologically enlarged celiac axis lymph node which can be further assessed with MRI.,0
5:15 AM CHEST (PORTABLE AP) Clip # Reason: worsening pneumonia?,0
"Admitting Diagnosis: EXPLORATORY LAP ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with s/p small bowel resection () complicated by leak of primary anastomosis (), now s/p ex-lap w/ ileocecectomy, ileostomy & mucus fistula.",0
REASON FOR THIS EXAMINATION: worsening pneumonia?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 40-year-old man status post small bowel resection complicated by leak of primary anastomosis, now status post exploratory laparotomy.",0
COMPARISON: Multiple chest radiographs with latest from .,0
ONE VIEW OF THE CHEST: The lungs are low in volume and show diffuse bilateral airspace opacities which are essentially unchanged compared to the prior examination.,0
"The cardiac silhouette is enlarged, unchanged.",0
The mediastinal silhouette is normal.,0
The hilar contours are normal as well.,0
An ET tube terminates 3 cm above the carina.,0
An NG tube passes out of view with its tip below the diaphragm.,0
A right-sided IJ catheter terminates with its tip in the distal SVC appropriately.,0
IMPRESSION: Diffuse bilateral airspace opacities appear unchanged over multiple prior examinations.,0
These could relate to worsening pneumonia or ARDS.,0
11:23 PM CHEST (PORTABLE AP) Clip # Reason: please eval NG tube placement ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with morbid obesity intubated with failure to wean now planned for trach.,1
REASON FOR THIS EXAMINATION: please eval NG tube placement ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST is compared with previous study of earlier same day.,0
The examination is technically suboptimal.,0
"The patient is markedly rotated towards the left, and the examination is under penetrated.",0
A tracheostomy tube is new in the interval and is in satisfactory position.,0
"A vascular catheter appears unchanged in position, allowing for markedly leftward patient rotation.",0
"An NG tube identified and can be visualized coursing below the diaphragm, but the distal tip is not clearly seen.",0
A right pleural effusion persists.,0
There is chronic pleural thickening and volume loss within the left hemithorax.,0
IMPRESSION: NG tube coursing below the diaphragm.,0
Tracheostomy tube in satisfactory position.,0
1:38 PM CHEST (PORTABLE AP) Clip # Reason: s/p AVR repair.,0
Please do stat CXR in ICU.,0
______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with REASON FOR THIS EXAMINATION: s/p AVR repair.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Aortic valve replacement.,1
Status post swan ganz catheter insertion and intubation.,0
"CHEST, SINGLE VIEW: The heart size is stable.",0
Linear atelectasis is noted in the right lung zone.,0
No other focal pulmonary opacities or effusions are noted.,0
The endotracheal tube tip is approximately 3 cm above the carina.,0
A nasogastric tube tip terminates in the stomach.,0
A right IJ pulmonary artery catheter is noted with tip in the proximal left main pulmonary artery.,0
IMPRESSION: 1) Right IJ catheter tip in proximal left main pulmonary artery.,0
2) Satisfactory positioning of endotracheal tube and nasogastric tube.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval for line placement Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with new R IJ REASON FOR THIS EXAMINATION: eval for line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 87-year-old man with new right IJ placement.,0
TECHNIQUE: Single portable AP view of the chest was acquired.,0
"COMPARISON: Portable chest radiograph from and 9, and CT of the chest from .",0
"FINDINGS: In the interval, a right internal jugular central line was placed terminating in the right atrium.",0
A left IJ ends at the mid SVC.,0
Unchanged left basilar atelectasis and new right lower lobe atelectasis.,0
A Dobbhoff feeding tube ends in the horizontal portion of the duodenum.,0
Cardiomediastinal silhouette and hila are normal.,0
Right IJ line should be retracted by about 4 cm.,0
New right lower lobe atelectasis.,0
Dr. was notified about this finding on .,0
"2:23 PM DUP EXTEXT BIL (MAP/DVT) Clip # Reason: FEVER Admitting Diagnosis: HEAD BLEED;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 17 year old woman with ICH basal ganglia AVM, persistent fever REASON FOR THIS EXAMINATION: ?DVT ______________________________________________________________________________ FINAL REPORT STUDY: Bilateral lower extremity venous duplex.",0
"REASON: Intracerebral hemorrhage and AVM with persistent fever, question DVT.",1
FINDINGS: Duplex evaluation was performed of bilateral lower extremity veins.,0
"There is normal compression, augmentation and phasicity of the common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins bilaterally.",0
IMPRESSION: No evidence of lower extremity deep vein thrombosis bilaterally.,0
"3:06 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumonia, CHF ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with s/p CABG, NIDDM, HTN, diastolic dysfunction, s/p sternal debridement and flap closure.",0
"REASON FOR THIS EXAMINATION: r/o pneumonia, CHF ______________________________________________________________________________ FINAL REPORT History of diabetes CABG sternal debridemal with flap closure and tracheostomy with fever.",0
NG tube extends below diaphragm.,0
There is flattening of the diaphragms consistent with COPD.,0
Small bilateral pleural effusions with some upper zone redistribution consistent with CHF superadded to COPD.,0
In addition there is ill-defined opacity in the right upper lobe which could be due to area of consolidation.,0
There is obscuration of the left hemidiaphragm likely due to a combination of left pleural effusion and atelectasis and/or consolidation in the left lower lobe.,0
Overall appearances are unchanged since the prior study of .,0
"IMPRESSION: COPD with probable CHF, small bilateral pleural effusions and consolidation in the right upper and left lower lobes, as described.",0
"11:58 CHEST (PORTABLE AP) Clip # Reason: 59 yo man w/renal cell ca, met to lung w/hemoptosis, intubat ______________________________________________________________________________ MEDICAL CONDITION: \59 year old man with above REASON FOR THIS EXAMINATION: 59 yo man w/renal cell ca, met to lung w/hemoptosis, intubated, s/p line change please check placement ______________________________________________________________________________ FINAL REPORT HISTORY: 59 y/o renal cell carcinoma.",0
CHEST: Tip of right jugular line lies in the proximal SVC or possibly upper portion of right atrium.,0
consolidation of right lower lobe persists.,0
11:17 AM CHEST (PA & LAT) Clip # Reason: PTX on previous CXR after chest tube removal.,0
"Is ther a PTX ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with multi-vessel CAD, s/p CABG.",0
REASON FOR THIS EXAMINATION: PTX on previous CXR after chest tube removal.,0
Is ther a PTX; has it increased or decreased in size?,0
______________________________________________________________________________ FINAL REPORT 2 VIEWS CHEST: INDICATION: Pneumothorax.,0
Comparison made to previous study from 1 day earlier.,0
"There is a small left apical pneumothorax which has decreased in size in the interval, with the visceral pleural line now at the third posterior rib level.",0
"There are multifocal lung opacities, most prominent in the right perihilar region and left retrocardiac area.",0
The left retrocardiac opacities appear worse in the interval.,0
"There are persistent small bilateral pleural effusions, left greater than right, and the left hemidiaphragm remains mildly elevated.",1
IMPRESSION: 1) Slight decrease in size of the left apical pneumothorax with small pneumothorax remaining.,0
2) Multifocal lung opacities with interval progression in left retrocardiac region.,0
"This probably reflects atelectasis in this recently postoperative patient, but infectious process in the left lower lobe is not excluded.",0
3) Persistent small bilateral pleural effusions.,1
"8:16 AM CHEST (PORTABLE AP) Clip # Reason: S/P FALL, HEAD INJ; CHECK ET PLACEMENT ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, .",0
The examination is centered at the thoracoabdominal junction and excludes the portion of the chest above the level of the carina.,0
"Subsequently, dictated chest radiograph performed less than one hour later allows for complete imaging of the chest.",0
Please see that separately dictated report under clip .,0
"5:49 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval ETT placement Admitting Diagnosis: PNEMONIA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with hypoxic resp failure, s/p MI REASON FOR THIS EXAMINATION: eval ETT placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation of tube placement.",0
"FINDINGS: As compared to the previous radiograph, an endotracheal tube has been placed.",0
The tip of the tube projects 4 cm above the carina.,0
"There is no evidence of complications, no pneumothorax.",1
"Minimal perihilar opacities, potentially suggestive of mild fluid overload.",0
"LINE PLACEMENT Clip # Reason: R IJ placed Admitting Diagnosis: GASTROINTESTINAL BLEED;R/O COLON CANCER\COLONOSCOPY ______________________________________________________________________________ MEDICAL CONDITION: year old woman with guaiac positive stools, here for GI prep and colonscopy; now with severe abd pain REASON FOR THIS EXAMINATION: R IJ placed ______________________________________________________________________________ FINAL REPORT INDICATION: Guiac +stools.",0
Now with severe abdominal pain.,0
Status post right IJ line placement.,0
SEMI-ERECT RADIOGRAPH OF THE CHEST: The patient is status post placement of a right internal jugular central venous catheter.,0
The tip is obscured by overlying pacemaker wires but likely terminates in the mid SVC.,0
There has been removal of the NG tube.,0
"Again noted is fracture of one of the right ventricular pacemaker leads, which is age indeterminate.",0
Prominent bilateral hilar vasculature and more prominent peripheral pulmonary vasculature is noted.,0
Fuzziness at both costophrenic angles may represent new small pleural effusions.,0
There also is a new left lower lobe atelectasis.,0
"IMPRESSION: 1) Status post right IJ line placement, tip not definitely seen but likely in mid SVC.",0
2) Evidence of volume overload.,0
3) New left lower lobe atelectasis.,0
1:30 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: r/o aspir Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\AORTIC VALVE REPLACEMENT; REPAIR ASCENDING AORTIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with REASON FOR THIS EXAMINATION: r/o aspir ______________________________________________________________________________ FINAL REPORT INDICATION: Aspiration.,1
OROPHARYNGEAL VIDEO FLUROSCOPIC SWALLOWING EVALUATION.,0
FINDINGS: An oropharyngeal swallowing video fluoroscopy was performed today in collaboration with speech pathology.,0
Barium of varying consistencies as barium with solids was administered.,0
In the oral phase there was premature spillover of liquid into the valleculae.,0
In the pharyngeal phase there was mild delay in swallow initiation.,0
Mild amount of residua in the valleculae was cleared with repeat swallows or sips of thin liquid.,0
IMPRESSION: Mild amount of residua in the valleculae which cleared with repeat swallows or sips of thin liquid.,0
Mild amount of penetration with no episodes of aspiration.,0
"2:43 PM CHEST (PORTABLE AP) Clip # Reason: assess infiltrates/effusions Admitting Diagnosis: CORONARY ARTERY DISEASE;CHF ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with s/p MVR/ Rt sided Dual chamber pacemaker, rt axillary vein approach s/p CT removal REASON FOR THIS EXAMINATION: assess infiltrates/effusions ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, AT 3:11 P.M.",1
COMPARISON: Previous study of one day earlier.,0
A previously reported tiny left apical pneumothorax is faintly visualized and not significantly changed allowing for technical differences between the two studies.,0
Cardiac and mediastinal contours are stable compared to a similarly positioned radiograph from at 8:20 a.m.,0
"There has been interval improvement in atelectatic changes within the left retrocardiac region, and note is made of small bilateral pleural effusions.",0
"9:31 AM CHEST (PORTABLE AP) Clip # Reason: please eval for failure Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with recent STEMI, LE swelling REASON FOR THIS EXAMINATION: please eval for failure ______________________________________________________________________________ FINAL REPORT INDICATIONS: Status post myocardial infarction.",0
COMPARISON: No prior studies in PAX.,0
"FINDINGS: AP portable, supine view.",0
There is slight left ventricular enlargement.,0
The lung parenchyma are clear.,0
The visualized osseous structures are grossly unremarkable.,0
IMPRESSION: Slight cardiomegaly without evidence of congestive heart failure.,0
"11:35 PM CT HEAD W/O CONTRAST Clip # Reason: 87 yo female with CHF, a-fib, falls who presents with head c ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with above PMH REASON FOR THIS EXAMINATION: 87 yo female with CHF, a-fib, falls who presents with head contusion and severe anemia.",0
Please eval for head bleed.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 86yr old woman s/p fall with head contusion.,0
CT HEAD: COMPARISON: TECHNIQUE: Axial noncontrast images were performed from the skull base through the vertex.,0
CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage or shift of normally midline structures.,0
There is mild prominence of the ventricles and sulci consistent with age related brain atrophy.,0
There is no evidence of major vascular territorial infarct.,0
No mass lesions are identified.,0
"12:56 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: R/O biliary obstruction, PLEASE DOPPLER HEPATIC ARTERY Admitting Diagnosis: RIGHT KNEE OA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p R TKA with past liver transplant with rising LFTs REASON FOR THIS EXAMINATION: R/O biliary obstruction, PLEASE DOPPLER HEPATIC ARTERY ______________________________________________________________________________ FINAL REPORT TECHNIQUE: Abdominal ultrasound (complete study).",1
HISTORY: 60-year-old man status post right TKA with past liver transplant with rising LFTs.,1
REASON FOR EXAM: Please evaluate for biliary obstruction and flow in hepatic artery.,0
FINDINGS: Grayscale and color ultrasound imaging of the liver and vascular structures were performed and comparison made to prior ultrasound of and a CT of .,0
The liver parenchyma remains free of focal lesions.,0
No perihepatic fluid is seen.,0
No biliary dilatation and obstruction was seen today.,0
Spleen is enlarging measuring 16 cm.,0
Visualization of the pancreas is limited due to overlying bowel gas.,0
"DOPPLER: The portal vein demonstrates high velocity of flow (100 cm/sec), that could be secondary to upstream stenosis and is slightly faster than the prior study.",0
Hepatic arteries remain patent with appropriate waveforms.,0
Hepatic veins also are patent with normal flow.,0
Splenic vein presents normal flow.,0
There is no significant change when compared to previous exams.,0
Portal vein with high velocities that could be secondary to upstream stenosis.,0
Normal hepatic evaluation of hepatic arteries and veins.,0
"Admission Date: Discharge Date: Service: ADDENDUM HOSPITAL COURSE: The patient became more agitated throughout the hospital course, and so she was started on Seroquel 12.5 mg b.i.d.",0
She then required another 12.5 mg b.i.d.,0
"Urinalysis showed greater than 1000 white cells, and urine culture showed greater than 100,000 E. coli with susceptibility to Levaquin.",0
She was then given a three-day course of Levaquin.,0
A urinalysis should be repeated at the end of .,0
"The patient continued to have elevated blood pressure with systolic in the 150s, so her Metoprolol was increased from 25 b.i.d.",0
DISCHARGE MEDICATIONS CHANGES: Metoprolol 37.5 mg p.o.,0
"b.i.d., Seroquel 12.5 mg p.o.",0
ADDITIONAL DISCHARGE DIAGNOSIS: Urinary tract infection.,1
"DR.,MADGY 13-282 Dictated By: MEDQUIST36 D: 19:36 T: 19:35 JOB#:",0
"6:09 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for pneumonia, chf, pneumo.",0
"______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with h/o etoh use s/p intubation for airway protection, now with oxygen desaturations.",0
"REASON FOR THIS EXAMINATION: evaluate for pneumonia, chf, pneumo.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: ETOH, desaturation.",0
AP radiograph dated is compared with the AP radiograph dated .,0
The ETT is in proper position.,0
The right subclavian catheter tip is in proper position.,0
The NGT is in the stomach.,0
There are bilateral lower lobe patchy infiltrates worse on the left.,0
There are no large pleural effusions.,0
IMPRESSION: Bilateral lower lobe infiltrates consistent with aspiration.,0
"4:50 PM CHEST (PORTABLE AP) Clip # Reason: pneumonia Admitting Diagnosis: MULTISYSTEM TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with fever spike to 103, please evaluate for interval change, ?",0
"consolidation REASON FOR THIS EXAMINATION: pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old female patient with fever spike to 103, evaluate for interval change.",1
FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position.,0
Analysis is performed in direct comparison with the next preceding similar study obtained 10 hours earlier during the same day.,0
"The patient remains intubated, the ETT terminating in the trachea 4 cm above the level of the carina.",0
Comparison with the next previous study is the ETT has been withdrawn by approximately 2 cm.,0
It remains still in adequate position.,0
"NG tube as before, reaching far below diaphragm.",0
"Right subclavian central venous line terminating overlying the SVC at the level 2 cm below the carina, unchanged.",0
No evidence of new parenchymal infiltrates.,0
Left-sided retrocardiac atelectasis obliterating the central portion of the diaphragm as before.,0
No evidence of new pulmonary infiltrates and no increased pulmonary vascular congestion.,0
"A diffuse haze over the lung bases, slightly more on the left than the right, is suggestive of pleural effusions layering in the posterior portions of the pleural spaces.",0
"If quantitation and documentation of such event is required, a chest lateral view could be helpful.",1
IMPRESSION: No significant interval change in comparison with the next previous chest examination obtained ten hours earlier.,0
Height: (in) 69 Weight (lb): 166 BSA (m2): 1.91 m2 BP (mm Hg): 84/52 HR (bpm): 66 Status: Inpatient Date/Time: at 13:28 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - akinetic; basal inferoseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
"There is moderate regional left ventricular systolic dysfunction with septal, apical and inferior akinesis.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. was admitted to the hospital on - the day prior to our evaluation - with a known history of coronary artery disease since when he had a myocardial infarction with intermittent angina since then over that decade.,1
It had increased over the past few months.,0
"On the Thursday prior to admission he had prolonged chest pain that did not resolve and became worse Friday, at which time he presented to .",0
He ruled in for a myocardial infarction.,0
His stress test was positive.,0
He was transferred to for cath.,0
"Cardiac catheterization revealed a left main 70% to 80% lesion, LAD 70% lesion, circumflex 80% lesion, a totally occluded right coronary artery, and an ejection fraction of 35%.",1
"Intraaortic balloon pump was placed in the cath laboratory, and the patient was referred to Dr. for surgery.",0
PAST SURGICAL HISTORY: Bilateral inguinal herniorrhaphies.,0
MEDICATIONS ON ADMISSION: Toprol XL 25 mg p.o.,0
"once daily, Zetia 10 mg p.o.",0
"once daily, lisinopril 10 mg p.o.",0
"once daily, Prilosec 20 mg p.o.",0
"once daily, and Crestor 40 mg p.o.",0
SOCIAL HISTORY: The patient admits to 4 to 5 drinks on the weekend.,0
He quit smoking 12 years ago with a 36-pack-year history.,0
"PREOPERATIVE LABORATORY DATA: Sodium of 136, K of 4.5, chloride of 105, bicarbonate of 23, BUN of 13, creatinine of 0.9, and blood sugar of 121.",0
"White count of 13.3, hematocrit of 43.3, and platelet count of 252,000.",0
"PT of 13, PTT of 34, and INR of 1.1.",0
"Initial preoperative labs also showed a calcium of 9.7, phosphorous of 4.4, magnesium of 1.9.",0
RADIOLOGIC STUDIES: His EKG showed a sinus rhythm at 54 with Q wave in lead III.,0
"His chest x-ray showed no infiltrates, consolidations, or effusions.",0
"PHYSICAL EXAMINATION ON ADMISSION: He is 5 feet 9 inches tall, weighing 207 pounds.",0
"He was in sinus rhythm at 50, with a blood pressure of 133/82, respiratory rate of 14, saturating 98% on 2 liters.",0
He was in no apparent distress.,0
He had no carotid bruits.,0
His lungs were clear bilaterally on the anterior portions.,0
Heart was regular in rate and rhythm with S1 and S2.,0
"No murmurs, rubs, or gallops.",0
"The abdomen was soft, nontender, and nondistended with no hepatosplenomegaly and positive bowel sounds.",0
"His extremities were warm and well perfused with no cyanosis, clubbing, or edema.",0
The patient did have psoriasis on both lower extremities; knees and shins.,0
An IVP was present in his right groin.,0
HOSPITAL COURSE: He was seen and evaluated by Dr. .,0
The patient transferred back to CCU after his balloon placement and cardiac catheterization.,0
"He had some disorientation to his Ambien overnight, and the following morning was taken to the operating room by Dr. .",0
"He underwent coronary artery bypass grafting x 3 with a LIMA to the LAD, a vein graft to the OM1, and a vein graft to the ramus.",1
"He was transferred to the cardiothoracic ICU in stable condition on an epinephrine drip at 0.01 mcg/kg/min, a Neo- Synephrine drip at 0.6 mcg/kg/min, and a propofol drip at 40 mcg/kg/min.",0
The patient was extubated successfully overnight.,0
"On postoperative day 1, he was hemodynamically stable with a blood pressure of 111/56 with a cardiac index of 2.1.",0
He had decreased breath sounds in the left base.,0
He was alert and oriented.,0
His balloon pump remained in his right groin with palpable DP and dopplerable PT pulses.,0
His balloon was pulled later in the day as was his Swan-Ganz catheter.,0
His repeat chest x-ray postoperatively showed a left pleural effusion.,0
"His chest tubes remained in place, and he began the weaning of epinephrine and the Neo-Synephrine.",0
"He was also seen and evaluated by case management, and later that afternoon his balloon pump was removed from his right femoral artery.",0
"On postoperative day 2, his Swan had also been discontinued.",0
His chest tubes were pulled.,0
He began aspirin and Lasix diuresis.,0
"His creatinine remained stable at 0.9, and he was hemodynamically stable.",0
Later that day he was transferred out to the floor.,0
He was seen and evaluated by physical therapy and began working to ambulate with the nurses and therapist.,0
"On postoperative day 3, he was already anxious to leave the hospital.",0
He complained of feeling a click in his chest.,0
Continued beta blockade of Lopressor and IV Lasix for diuresis.,0
His creatinine remained stable at 0.9 with a hematocrit of 29.4 and a white count of 7.4.,0
He had a small amount of serous drainage on the distal part of his chest dressing.,0
It was unclear whether or not this was from his sternum or from his chest tubes.,0
His Lasix was switched to p.o.,0
His pacing wires were removed.,0
He continued to make excellent progress.,0
He was doing very well with ambulating.,0
DISCHARGE STATUS: On the 30th he was discharged to home with VNA services with the following discharge diagnoses.,0
Status post coronary artery bypass grafting x 3.,1
Status post stent of left circumflex.,0
twice a day (for 7 days).,0
Percocet 5/325 1 to 2 tablets p.o.,0
Enteric coated aspirin 81 mg p.o.,0
"DISCHARGE INSTRUCTIONS: He was instructed also to follow up with Dr. (his cardiologist) 1 to 2 weeks after discharge, and to make an appointment to see Dr. in the office for his postoperative surgical visit in 4 weeks.",0
DISCHARGE DISPOSITION: He was discharged to home with VNA services on .,0
Dictated By: MEDQUIST36 D: 14:09:22 T: 16:49:01 Job#:,0
"9:08 PM CT CHEST W/O CONTRAST Clip # Reason: evaluate for progression/resolution of consolidation, ?evide Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with CRI, IDDM, CAD, normal pressure hydrocephalus w/VP shunt, s/p rx for severe b/l PNA, CXR diffuse process c/w ARDS, but oxygenating well, pressures low.",0
"thanks, REASON FOR THIS EXAMINATION: evaluate for progression/resolution of consolidation, ?evidence of CHF, effusions ______________________________________________________________________________ FINAL REPORT CT OF THE CHEST .",0
"CLINICAL INDICATION: Severe bilateral pneumonia, ARDS, evaluate for progression.",0
TECHNIQUE: CT images acquired from the thoracic inlet through the lung bases without IV contrast.,0
"CT OF THE CHEST WITHOUT IV CONTRAST: Compared to , the left pleural effusion has increased in size, now with moderate sized bilateral pleural effusions.",0
"There is little changed appearance of diffuse bilateral consolidations and ground glass opacities, which are most prominent within the mid and upper lung zones.",0
The airway is patent to the level of the subsegmental bronchi.,0
Also again seen are several mildly enlarged mediastinal lymph nodes.,0
There are scattered calcifications within the thoracic aorta.,0
An NG tube is present and terminates within the stomach.,0
An endotracheal tube is present terminating at the level of the carina.,0
The patient is status post CABG.,0
A Swan-Ganz catheter is present terminating within the right main pulmonary artery.,0
A VP shunt is present.,0
Limited images of the upper abdomen demonstrate diffuse arterial vascular calcifications.,0
"The visualized portions of the liver, pancreas, left kidney, spleen, and adrenal glands are unremarkable.",0
Little changed appearance of extensive bilateral alveolar and ground glass opacities which are most prominent within the mid and upper lung zones bilaterally.,0
"Moderate bilateral pleural effusions, with an increased size of the left pleural effusion.",0
Somewhat distal positioning of the endotracheal tube which could be withdrawn 1-2 cm.,0
"(Over) 9:08 PM CT CHEST W/O CONTRAST Clip # Reason: evaluate for progression/resolution of consolidation, ?evide Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) These findings were immediately discussed with Dr. .",0
"7:19 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: AORTIC STENOSIS\Transcatheter Aortic Valve Implant (TAVI) with Pump Stand-by (CoreValve) ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman s/p corevalve REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post surgery, evaluation for interval change.",1
"FINDINGS: As compared to the previous radiograph, the lung volumes have minimally increased, potentially reflecting improved ventilation or higher ventilatory pressures.",0
"The pre-existing parenchymal opacities, left more than right, however, are unchanged in extent and severity.",0
"Unchanged monitoring and support devices, unchanged stent graft position.",1
No newly appeared focal parenchymal opacities.,0
Unchanged left healed rib fractures.,0
", CSURG FA6A 7:41 AM CHEST (PORTABLE AP) Clip # Reason: ptx Admitting Diagnosis: CHEST TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man s/p traumatic chest injury REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ PFI REPORT 1.",0
Small right apical pneumothorax is new or newly apparent.,0
"Persistent right middle and lower lobe atelectasis with small effusion as well as apparent elevation of the right lung base which may be secondary to small subpulmonic effusion, although phrenic nerve injury should be considered.",0
"5:01 AM CHEST (PORTABLE AP) Clip # Reason: eval for ptx, pna, edema Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 74 yo f w/ sepsis and now intubated, persistent hypotension of 3 pressors.",1
"REASON FOR THIS EXAMINATION: eval for ptx, pna, edema ______________________________________________________________________________ FINAL REPORT PORTABLE SEMIERECT CHEST 5:00 A.M.",0
There is a large left pneumothorax with radiographic signs suggestive of tension.,0
This has increased in size considerably since the earlier chest x-ray of .,0
"An endotracheal tube is difficult to assess due to patient body habitus and positioning, but appears to terminate approximately a cm above the carina.",0
A permanent pacemaker lead terminates in the right ventricle.,0
The heart size is stable.,0
The left lung is collapsed in the setting of pneumothorax.,0
There remains a moderate-to-large right pleural effusion and small left pleural effusion.,0
IMPRESSION: Large left pneumothorax with radiographic signs suggestive of tension.,0
"At the time of this dictation, additional chest radiographs have been obtained and are dictated separately.",0
The clinical house staff caring for the patient was alerted to this finding on the date of the study.,0
7:14 PM CT HEAD W/O CONTRAST Clip # Reason: eval known subarachniod ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: The recommendation for CTA or MRA was discussed with Dr. on the afternoon of .,0
7:14 PM CT HEAD W/O CONTRAST Clip # Reason: eval known subarachniod ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p fall from OSH with subarachnoid bleed on CT REASON FOR THIS EXAMINATION: eval known subarachniod No contraindications for IV contrast ______________________________________________________________________________ WET READ: 8:11 PM Bilateral subarachnoid hemorrhage.,1
"Most likely traumatic given history, though underlying aneurysm not entirely excluded.",0
______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Patient status post fall with subarachnoid hemorrhage on outside hospital scan.,1
COMPARISON: There are no prior studies for comparison.,0
"NON-CONTRAST HEAD CT SCAN: There are several areas of hyperdensity involving bilateral frontal and parietal gyri, consistent with subarachnoid hemorrhage.",1
Blood is also seen within both sylvian fissures.,0
No subdural hematoma is visualized.,0
"The ventricles and sulci are mildly prominent, consistent with involutional change.",0
"There is hypodensity of the cerebral periventricular white matter, consistent with chronic microvascular infarction.",0
There are calcifications of the cavernous carotid arteries.,0
No soft tissue abnormality is identified.,0
"IMPRESSION: Subarachnoid hemorrhage, greatest in the areas of the sylvian fissures bilaterally.",1
"Though the etiology is likely traumatic, an underlying aneurysm is not excluded.",0
Findings were discussed with Dr. at the conclusion of the exam.,0
"NOTE ADDED AT ATTENDING REVIEW: The extensive nature of the hemorrhage, and the apparent spherical area of high density in the left sylvian fissure (seires 2 image 15) raise a concern of aneurysmal bleeding.",0
"Recommend CTA, MRA, or catheter arteriography for further evaluation.",0
"6:28 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?NGT placement after adjustment Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with GBM, severe dysphagia REASON FOR THIS EXAMINATION: ?NGT placement after adjustment ______________________________________________________________________________ FINAL REPORT AP CHEST 6:34 P.M. HISTORY: Brain tumor.",0
IMPRESSION: AP chest compared to 5:50 p.m.: Nasogastric tube still loops in the stomach and passes retrograde into the distal esophagus.,0
These findings were discussed with the clinical house officer caring for this patient at the time of dictation of the proceeding examination.,0
7:55 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man s/p AAA repair.,0
Bilat pleural effusions with reaccumulation after thoracentesis L and R. s/p L thoracentesis and pigtail.,0
REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 75 year old status post AAA repair.,0
FINDINGS: The right pleural effusion is somewhat smaller.,0
The left side remains clear.,0
Upper zone redistribution is seen.,0
Increased opacification in the area above the minor fissure is seen.,0
This could represent either posterior fluid or consolidation in the right upper lobe anteriorly.,0
Possible right upper lobe infiltrate.,0
", C. NMED FA11 12:13 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: evaluate for infarct, ALSO DO CT PERFUSION Admitting Diagnosis: LEFT ARM SPASMS ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with right MCA aneurysm s/p coiling, presented with left hand spasms, but now with left hand/arm numbness and weakness.",0
"REASON FOR THIS EXAMINATION: evaluate for infarct, ALSO DO CT PERFUSION No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No evidence of infarction on CT perfusion, but limited by artifacts from the coil mass.",0
No evidence of occlusion or stenosis.,0
3:43 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: able to swallow Admitting Diagnosis: MULTIPLE SCLEROSIS FLARE ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with MS progressive.,1
please eval for ability to swallow.,0
REASON FOR THIS EXAMINATION: able to swallow ______________________________________________________________________________ FINAL REPORT STUDY: Video swallow.,0
INDICATION: This is a 35-year-old female with history of progressive multiple sclerosis.,1
COMPARISONS: Comparison is made to the prior swallow examination dated .,0
VIDEO FLUOROSCOPIC OROPHARYNGEAL SWALLOWING STUDY: This study is performed in conjunction with the Rehabilitative Services staff.,0
Barium of various consistencies was administered to the patient and video fluoroscopic images obtained.,0
ORAL PHASE: Notable for mildly prolonged bolus formation and mastication.,0
Bolus control noted to be mildly reduced with premature spillover prior to swallow with both thin and nectar-thick liquids.,0
AP tongue movement noted to be mildly-to-moderately reduced.,0
Mild amount of residue in the oral cavity.,0
"PHARYNGEAL PHASE: Mild delay in followup initiation, but improved compared to the previous exam.",0
The delay increased over the course of the study as the patient grew more fatigued.,0
"Palatal elevation, laryngeal elevation, laryngeal valve closure, and epiglottic deflection were within normal limits.",0
Bolus propulsion was within normal limits.,0
A mild amount of residue was seen in the valleculae and on the posterior pharyngeal wall.,0
There is a mild amount of residue within the piriform sinuses following thin liquid administration.,0
"ASPIRATION/PENETRATION: The patient was noted to aspirate on thin liquids, however, in contrast from the previous day, the patient was able to spontaneously cough.",0
"The patient was noted to penetrate with nectar-thick liquids, but was able to clear during the swallow.",0
IMPRESSION: Mild-to-moderate dysphagia with poor bolus control and swallow delay.,0
At risk for aspiration on thin liquids.,0
Recommendation for patient to remain n.p.o.,0
with only small sips of nectar-thick liquids with medication.,0
Please refer to the speech pathology report of the same day for further details.,0
(Over) 3:43 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: able to swallow Admitting Diagnosis: MULTIPLE SCLEROSIS FLARE ______________________________________________________________________________ FINAL REPORT (Cont),1
"3:21 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: please advance DHT post-pyloric, to jejunum if possible Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 50 ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with necrotizing pancreatitis REASON FOR THIS EXAMINATION: please advance DHT post-pyloric, to jejunum if possible ______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old male with necrotizing pancreatitis.",0
Please advance Dobbhoff tube into post-pyloric position.,0
TECHNIQUE: Fluoroscopic guided placement of a nasointestinal tube.,0
PROCEDURE: The Dobbhoff tube in place was curling in the stomach and its tip was located in the mid esophagus.,0
For such reason it was removed and a new - 8 French tube was advanced.,0
"The tube was placed in the stomach without difficulty, but the patient became agitated after a few unsuccesful attempts to advance the tube into a post-pyloric position.",0
"Due to agitation, large amounts of secretion and oxygen desaturation to the 88%, I decided to abort the procedure.",0
The tube was left in the stomach in case a further attempt to advance to a post-pyloric position is requested.,0
IMPRESSION: Unsuccessful attempts to place a nasointestinal tube.,0
12:30 PM CT CHEST W/O CONTRAST Clip # Reason: interval change Admitting Diagnosis: HEMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with hemothorax REASON FOR THIS EXAMINATION: interval change No contraindications for IV contrast ______________________________________________________________________________ WET READ: JXRl TUE 3:50 PM overall decrease in the amount of pleural fluid.,1
high density component inferiorly c/w clotted blood is unchanged.,0
the chest tube is superior to the majority of pleural fluid/blood.,0
aneurysmal enlargement of ascending aorta (4.5cm) should be followed with CT in 1 year.,0
aortic valve and coronary artery calcifications.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old male with hemothorax.,1
COMPARISON: Non-contrast chest CT .,0
TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed without intravenous or oral contrast.,0
Images are presented for display in the axial plane as 1.25-mm and 5-mm collimation.,0
A series of multiplanar reformation images were also submitted for review.,0
NON-CONTRAST CHEST CT: Right hemothorax is again identified.,1
The amount of pleural fluid in the mid to upper right hemithorax has decreased.,0
"More inferiorly, the amount of higher density pleural material, consistent with clotted blood products, is unchanged.",0
"A chest tube is in place, with the tip located posteriorly at the level of the aortic arch.",0
The chest tube is located superior to the majority of pleural fluid.,0
There is a small pneumothorax.,0
Aeration of the right lung has improved.,0
Leftward shift of mediastinal structures due to the pleural fluid has decreased.,0
"The right lower lobe basal segmental bronchi are essentially collapsed, with surrounding collapsed lung.",0
Low density within the ventricles that is consistent with anemia.,0
Calcifications involve the aortic valve and coronary arteries.,0
The ascending aorta is dilated to maximal dimension of 4.5 cm.,0
"There is no mediastinal, hilar, or axillary lymphadenopathy.",0
(Over) 12:30 PM CT CHEST W/O CONTRAST Clip # Reason: interval change Admitting Diagnosis: HEMOTHORAX ______________________________________________________________________________ FINAL REPORT (Cont) Right rib fractures are unchanged.,1
"Imaging of the upper abdomen demonstrates splenomegaly, unchanged.",0
Overall decrease in amount of pleural fluid with unchanged amount of clotted blood consistent with hemothorax.,1
The chest tube lies superior to the majority of the pleural fluid.,0
Right lower lobe basal segmental bronchi collapse with surrounding right lower lobe atelectasis.,0
4.5-cm ascending aneurysmal dilation of the thoracic aorta.,0
This should be reassessed in one year with a chest CT. 5.,0
Findings regarding the follow-up CT were entered into the radiology critical results reporting system on .,0
"6:24 AM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields, heart size ______________________________________________________________________________ MEDICAL CONDITION: Infant with increased CO2 REASON FOR THIS EXAMINATION: evaluate lung fields, heart size ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate lungs and heart in baby in NICU.",0
FINDINGS: Frontal view of the chest shows that the umbilical venous catheter reaches right atrium.,0
Endotracheal tube tip is about T1.,0
"The lungs are slightly better aerated than on Film #6, but there is still diffuse haziness, right greater than left.",0
The stomach is less distended than it was on the two prior films.,0
9:19 AM CT HEAD W/O CONTRAST Clip # Reason: EVALUATE CEREBELLAR BLEED S/P EVACUATION ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with Cerebellar bleed.,0
REASON FOR THIS EXAMINATION: S/P evacuation of cerebellar bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NONCONTRAST HEAD CT INDICATION: 77 year old male with cerebellar bleed.,0
Patient with recent evacuation of cerebellar bleed.,0
TECHNIQUE: CT imaging of the brain without contrast enhancement.,0
There are no prior studies available for comparison.,0
CT HEAD W/O CONTRAST: There is evidence of an intraventricular drainage catheter with its distal tip located within the right lateral ventricle.,0
There is evidence of intraventricular and subarachnoid blood.,0
There is evidence of air within the anterior of the left lateral ventricle as well as anterior to the frontal lobes bilaterally.,0
There is evidence of extensive recent surgical change within the posterior fossa with air and extensive hemorrhage.,0
"The upper portion of the fourth ventricle is patent; however, the distal aspect of the fourth ventricle is not well seen secondary to hemorrhage and extensive artifact from surrounding bone.",0
The ventricles and sulci are mildly enlarged consistent with age appropriate involutional change.,0
Bone windows demonstrate extensive surgical change within the occiput with extensive soft tissue swelling noted over the occipital region as well.,0
The visualized portions of paranasal sinsues are clear.,0
"IMPRESSION: 1) Extensive surgical change within the posterior fossa with pneumocephalus, intraventricular and subarachnoid hemorrhage, and placement of a drainage catheter within the right of the lateral ventricle.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: 1.,0
Aspiration pneumonia required intubation 2.,1
CBD injury status post open cholecystectomy Major Surgical or Invasive Procedure: : ERCP .,0
: Successful placement of 8 French external Amplatz anchor drain into the distal right hepatic duct with external drainage to the bag.,0
"History of Present Illness: 60M PMH stage 1 bladder cancer s/p radiation Rx in , with two years of intermittent RUQ pain 6 hours after fatty meals and presumed to be cholecystitis, with partial intermittent cystic duct obstruction confirmed by HIDA scan.",1
He also had a RUQ ultrasound that showed a contracted gallbladder with small stones and a thickened wall.,1
"He was scheduled for laparscopic cholecystectomy on , however after 30 minutes of attempting to strip dense adhesions between the gallbladder and the omentum, the procedure was converted to open.",1
"A challenging and lengthy dissection ensued, requiring extensive stripping of omental adhesions as well as adhesions between the gallbladder and liver bed.",1
"An accessory bile duct was identified and ligated, and clipped again later when it was noted to be leaking.",0
"A high ligation near the gallbladder neck was undertaken given the gallbladder neck was edematous and friable, and so it was also oversewn.",1
"On , transaminases were noted to be elevated with AST 148, ALT 245, Tbili 1.4, Dbili 0.3.",0
"Later that day, the patient underwent ERCP which showed multiple filling defects in the CBD.",0
A sphincterotomy was performed and several stones were extricated.,0
Cholangiogram did not demonstrate filling of the right and left hepatic ducts and subsequently there was extraluminal contrast outside of the CBD and intestine concern for bile leak.,0
"During the ERCP the patient had an aspiration event, requiring intubation.",1
"Given concern for possible bile duct injury, the patient was transferred to Surgical ICU.",0
On presentation the patient was noted to be febrile to 101.9.,0
RLQ JP drain to bulb suction and site c/d/i.,0
"Right flank with IR drain to gravity drainage, site c/d/i.",0
"EXTR: Warm, no c/c/e Pertinent Results: 06:20AM BLOOD WBC-8.8 RBC-3.39* Hgb-11.1* Hct-32.9* MCV-97 MCH-32.6* MCHC-33.6 RDW-13.8 Plt Ct-202 06:45AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-148* K-3.3 Cl-106 HCO3-32 AnGap-13 06:45AM BLOOD ALT-103* AST-70* AlkPhos-68 TotBili-1.2 06:45AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 10:17 pm BLOOD CULTURE Source: Venipuncture #1.",0
"**FINAL REPORT ** Blood Culture, Routine (Final ): NO GROWTH.",0
3:47 am URINE Source: Catheter.,0
**FINAL REPORT ** URINE CULTURE (Final ): NO GROWTH.,0
Multifocal aspiration in the lower lungs.,0
Post-cholecystectomy changes with drain and surrounding stranding without focal fluid collection to suggest biliary leak or hematoma; however the right hepatic artery is not well seen and interruption/occlusion cannot be excluded with slightly decreased right hepatic enhancement on the arterial phase imaging.,1
ERCP: Impression: Evidence of a previous sphincterotomy was noted in the major papilla.,0
Cannulation of the biliary duct was successful and deep with a balloon catheter using a free-hand technique.,0
Contrast medium was injected resulting in complete opacification of the distal common bile duct.,0
Filling of contrast was noted in the distal bile duct.,0
Wire could not be passed into the proximal bile duct.,0
Common hepatic duct and intrahepatics could not be opacified.,1
This is concerning for complete bile duct transection.,0
There was extravassation of bile consistent with a post operative bile leak.,0
Examination is limited due to non-breathhold sequence acquisition and no dynamic imaging was performed secondary to same.,0
Diffuse fatty deposition within the liver.,0
Decompression of the right posterior intrahepatic bile ducts from the PTBD drain.,1
"There is, however, intrahepatic dilatation of the right anterior and left intrahepatic biliary tree.",1
The common hepatic duct is not identified throughout its length.,0
The distal common bile duct is nondilated.,0
Preferential hyperenhancement noted of the left lobe of the liver which is transient and equilibrates on more delayed phase of imaging.,0
"Findings most likely reflect the findings on prior CTA from , where the right hepatic artery was not identified on that study.",1
Brief Hospital Course: The patient was transferred from OSH and admitted to the General Surgical Service for evaluation.,0
He was admitted in SICU intubated s/t aspiration pneumonia and started empirically on Unasyn.,1
"On , the patient underwent abdominal CTA, which demonstrated post-cholecystectomy changes with drain and surrounding stranding without focal fluid collection to suggest biliary leak or hematoma; the right hepatic artery is not well seen and interruption/occlusion was suspected.",1
On the patient underwent ERCP which was concerning for complete bile duct transection with surgical clip.,0
"At the same day, patient underwent PTBD drain placement into right posterior intrahepatic bile ducts for decompression.",1
"After procedure patient was extubated and kept in SICU for observation, the patient's LFTs were stable.",0
"On patient underwent MRCP, during which common hepatic duct was not identified throughout its length.",1
The MRCP was limited secondary to non-breathhold sequence acquisition and claustrophobia.,0
"On , patient was hemodynamically stable, his respiratory status improved and he was transferred on the floor tolerating clears IV fluids and antibiotics, with a foley catheter, and Dilaudid PCA for pain control.",0
The patient was hemodynamically stable.,0
Neuro: The patient received Dilaudid PCA on the floor with good effect and adequate pain control.,0
"When tolerating oral intake, the patient was transitioned to oral pain medications.",0
CV: The patient was found to have mild hypertension and was started on Metoprolol with good effect.,0
The patient was discharged home on PO Lopressor 25 mg with instruction to follow up with PCP within next 1-2 weeks.,0
Pulmonary: The patient was treated empirically with IV Unasyn for possible aspiration pneumonia.,1
"ON HD # 2, patient was extubated and his supplemental O2 was weaned off on HD # 7.",0
The patient's pulmonary function was continued to improve; vital signs were routinely monitored.,0
"Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization.",0
"GI/GU/FEN: On admission, patient's JP drain output was positive for bile leak.",0
PTBD catheter was placed on HD # 2 and has an average daily output around 500-600 cc.,0
The patient's electrolytes were checked daily and repleted when necessary.,0
"Diet was advanced when appropriate, which was well tolerated.",0
"Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary.",0
The patient's LFTs were stable and he was discharged home on regular low fat diet.,0
ID: The patient's white blood count and fever curves were closely watched for signs of infection.,0
Blood and urine cultures were negative.,0
The patient was treated with Unasyn x 7 days for possible aspirational pneumonia.,1
He was discharged home on PO Ciprofloxacin for empirical treatment of possible cholangitis.,0
"Endocrine: The patient doesn't have a history of diabetes, however his serum glucose was slightly elevated during hospitalization.",1
The patient advised to follow up with his PCP for additional work up of possible borderline diabetes.,0
Hematology: The patient's complete blood count was examined routinely; no transfusions were required.,0
Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible.,0
"At the time of discharge, the patient was doing well, afebrile with stable vital signs.",0
"The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled.",0
The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.,0
"Medications on Admission: ASA81, vicodin Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).",0
Disp:*60 Tablet(s)* Refills:*0* 2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
"Disp:*80 Tablet(s)* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
)(s)* Refills:*2* 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 weeks.,0
"Disp:*42 Tablet(s)* Refills:*0* 5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks.",0
"Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours).",0
Discharge Disposition: Home With Service Facility: Discharge Diagnosis: 1.,0
Transection of common hepatic duct with surgical clip .,0
Biliary leak s/p open cholecystectomy 3.,0
Aspiration pneumonia Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication.",0
"Also, please take any new medications as prescribed.",0
"Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids.",0
"Avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions.",0
Avoid driving or operating heavy machinery while taking pain medications.,0
Please follow-up with your surgeon and Primary Care Provider (PCP) as advised.,0
"Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site.",0
*Avoid swimming and baths until your follow-up appointment.,0
"*You may shower, and wash surgical incisions with a mild soap and warm water.",0
Gently pat the area dry.,0
"*If you have staples, they will be removed at your follow-up appointment.",0
"*If you have steri-strips, they will fall off on their own.",0
Please remove any remaining strips 7-10 days after surgery.,0
"PTBD Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever).",0
"*If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain.",0
"Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character.",0
Be sure to empty the drain frequently.,0
"Record the output, if instructed to do so.",0
"*Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge.",0
Change daily and as needed.,0
*Keep the insertion site clean and dry otherwise.,0
"*Avoid swimming, baths, hot tubs; do not submerge yourself in water.",0
*Make sure to keep the drain attached securely to your body to prevent pulling or dislocation.,0
"JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever).",0
*Maintain suction of the bulb.,0
"*Note color, consistency, and amount of fluid in the drain.",0
*Be sure to empty the drain frequently.,0
"*You may shower; wash the area gently with warm, soapy water.",0
"Followup Instructions: Department: SURGICAL SPECIALTIES When: FRIDAY at 1:15 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage .",0
Please follow up with Dr. (PCP) in weeks to discuss you blood pressure medication and possible borderline diabetes.,0
"9:32 AM BILAT LOWER EXT VEINS Clip # Reason: please eval for DVT Admitting Diagnosis: CIRRHOSIS;LOWER EXTREMITY DYSPNEA;EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with fever REASON FOR THIS EXAMINATION: please eval for DVT ______________________________________________________________________________ FINAL REPORT INDICATION: Fever, evaluate for DVT.",0
FINDINGS: Exam is somewhat limited by edema and body habitus.,0
"The common femoral, popliteal and calf veins were fully compressible with normal augmentation and pulsed-Doppler waveforms.",0
IMPRESSION: No evidence of DVT bilaterally on this limited study.,0
"5:25 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PNEUMONIA;HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 77yo woman with pneumonia, ARDS, pleural effusion, mitral regurg.",0
REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT EXAMINATION: AP chest.,0
"INDICATION: Pneumonia, IRDS, pleural effusion.",0
Single AP view of the chest is obtained at 05:50 hours and is compared with the prior morning's radiograph.,0
"Allowing for technical differences, there likely has been no major change in the appearance of the bilateral interstitial and alveolar opacities.",0
No large pleural effusion is seen.,0
Tubes and lines are unchanged.,0
Right apical pleural thickening may represent some loculated fluid.,0
Note that the lateral half of the right hemithorax is not included on the current image.,0
"IMPRESSION: Persistent bilateral interstitial and alveolar opacities, more marked on the right side which do not appear to have significantly changed since the prior day's radiograph.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Tape / Lipitor Attending: Chief Complaint: lightheadedness & weakness Major Surgical or Invasive Procedure: blood transfusions History of Present Illness: 71yo man with a history of CAD s/p CABG, s/p mechanical on coumadin, s/p ICD for VT/CHB/afib, CHF w/ EF 25-30%, Lupus (in remission), CKD, chronic anemia on Aranesp, h/o recurrent GIB, who presents with lightheadedness & generalized wkness over days.",1
The hx comes from both pt and his wife.,0
"Pt had been in his USOH, until about 3 days ago, when his wife noted the patient to be more fatigued & sleeping more than usual.",0
The patient reports that he began feeling lightheaded w/ standing (though no syncope) and generally weak during that time.,0
"He notes that he has had some dark/""black"" stools over the past days, though reports no abd pain, N/V/D.",0
"(Of note, his hct had been 34 on routine check 5 days ago.",0
His INR was supratherapeutic at that time at 4.29; his coumadin was dose reduced from 3mg MWF/2mg TTHS to 2mg daily.),0
He reports baseline SOB is stable.,0
"Pt did have an episode of SSCP the day PTA, which occurred at rest & resolved with nitro.",0
The pain was similar to that which he has on a nearly daily basis.,0
"The patient's symptoms of LH & generalized wkness/fatigue continued to progress, so he asked his wife to bring him to the for eval.",0
"In ED: VS T 98, 112, 116/69, 19, 100% on NRB.",0
His HR dropped into the 60-70s after triage.,0
He had one BP of 76/30 & improved to 117/66 w/o intervention.,0
"ASA, nitro, and fentanyl were give.",0
EKG reportedly stable & not evolving.,0
CE w/ trop 0.07 & CK 44.,0
Other labs notable for drop in hct from 33.9-->28 over ~6 days.,0
"Stool was ""dark"" & guaiac +.",0
Crt 2.9 increased from baseline 1.5-1.7.,0
Glucose 33 on chem 7 & Recheck 130s.,0
Pt being admitted to ICU for mgt & eval of possible GIB & ARF.,0
"ROS: He reports no fevers, chills.",0
?wt loss (unsure am't) Chronic SOB.,0
+ chronic angina uses 2SL mult days a wk.,0
Pain occurs at rest usually.,0
"No change in vision, hearing.",0
"No hematuria, dysuria, LE swelling.",0
Past Medical History: 1) Coronary artery disease status post coronary artery bypass graft (CABG).,1
"The last catheterization was in , currently being medically managed, followed by Dr. .",0
(2) Status post St. aortic valve replacement and then a redo in and in .,1
"(3) He has CHB, afib, ventricular tachycardia status post pacemaker implantable cardioverter-defibrillator (ICD) implantation.",0
"(4) He has a history of GI bleeds, has had gastritis and duodenal noted in the past.",0
(5) He has CHF with an ejection fraction of 25-30% (6) Hypertension.,0
(8) Lupus with a history of lupus nephritis.,1
(11) He also has thrombocytopenia and a mildly reduced white count for which he is being followed in Hem/ Clinic.,0
"(12) H/o abnl chest CT: 1.5 cm precarinal lymph node, as well as a few of lung nodules.",0
Seen by Dr. in pulm clinic.,0
(13) Emphysema: Pulmonary function tests done in the office today were reviewed.,0
"He has an FEV1 of 2.1 liters, which is 78% of predicted and an FVC of 3.24 liters, which is 84% of predicted, and an FEV1/FVC ratio of 62%.",0
This is consistent with a very mild obstructive deficit.--per pulm note in OMR Social History: He lives with his wife.,0
is a retired truck driver.,0
He smoked 1.5 packs a day for 28 years and quit in .,0
He has been exposed to asbestos in the past.,0
He reports that he worked in shipyards and was spraying asbestos paint.,0
"Family History: His mother, father and sister all died of liver failure.",1
"His father was an alcoholic, his sister had lupus.",0
There is no family history of lung disease.,1
Physical Exam: VS: 97.2 128/72 72 20 100% RA GEN: Well-appearing man who appears younger than his stated age.,0
"Multiple ecchymoses on hands, arms.",0
"HEENT: NC/AT, EOMs intact, PERRLA.",0
Oral mucosa pink and moist.,0
"CARD: Normal rate, regular rhythm.",0
II/VI systolic murmur at the RUSB with mechanical closing sound.,0
"No wheezes, rales, or rhonchi.",0
"EXT: Warm, 2+ pulses, 1+ edema R>L.",0
"5/5 strength, light touch, temperature sensation intact throughout.",0
Pertinent Results: Admission Labs: WBC-8.5# RBC-3.29* HGB-9.2* HCT-28.0* MCV-85 MCH-27.8 MCHC-32.6 RDW-17.4* NEUTS-69.0 LYMPHS-23.4 MONOS-6.6 EOS-0.7 BASOS-0.4 GLUCOSE-105 UREA N-130* CREAT-2.2* SODIUM-139 POTASSIUM-5.8* CHLORIDE-107 TOTAL CO2-17* ANION GAP-21* .,0
07:35AM BLOOD CK-MB-NotDone proBNP-3394* 12:22PM BLOOD CK-MB-NotDone cTropnT-0.10* 11:38AM BLOOD CK-MB-NotDone cTropnT-0.22* 07:03PM BLOOD CK-MB-6 cTropnT-0.14* .,0
Admission CXR: No acute cardiopulmonary process identified.,0
Echo () The left atrium is mildly dilated.,0
There is symmetric left ventricular hypertrophy.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %); no definite regional wall motion abnormality is identified although views are technically suboptimal.,1
The right ventricular cavity is dilated with normal free wall contractility.,0
The transaortic gradient is upper normal for this prosthesis.,0
There is severe mitral annular calcification.,0
The motion of the tricuspid prosthetic leaflets appears normal.,0
"Discharge Labs: 08:12PM BLOOD WBC-3.4* RBC-3.42* Hgb-9.8* Hct-29.8* MCV-87 MCH-28.7 MCHC-32.9 RDW-17.1* Plt Ct-107* 08:12PM BLOOD PT-21.5* PTT-110.7* INR(PT)-2.0* 08:12PM BLOOD Glucose-93 UreaN-57* Creat-1.7* Na-133 K-4.6 Cl-101 HCO3-21* AnGap-16 08:12PM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8 Brief Hospital Course: 71 yo man w/ CAD s/p CABG, s/p mechanical , afib, EF 25-30%, h/o GIB, chronic anemia, CKD second to lupus nephritis, who presents with lightheadedness and fatigue in the setting of a drop in his hematocrit and acute renal failure found to have guiac positive stools.",1
"# Acute on chronic anemia, acute blood loss: The pt was felt to have a slow UGIB.",1
"He was transfused a total of six units pRBCs with a Hct goal of approximately 30; although his HCT initially failed to bump appropriately, it did stabilize.",0
"The GI service was consulted and, based on the pt's comorbidities and prior negative endoscopies, conservative medical managment was pursued with IV PPI x 72 hours.",0
The pt's home anticoagulation was reversed with vitamin K; when his INR dropped below 1.5 he was started on a heparin gtt given his mechanical valve.,1
"On transfer out of the MICU to the medicine floor, the pt's Hct was stable in the 30s and his INR was 1.5.",0
He was continued on his heparin to coumadin bridge.,0
Patient's hematocrit remained stable and required no further transfusions on the medical .,0
His stools lightened and patient was switched to po protonix .,0
Coumadin was restarted and INR of 2 acheived on the day prior to discharge.,0
It is recommended by the GI team that he undergo a capsule enteroscopy as an outpatient to complete the workup of GIB.,0
# Status post mechanical aortic valve replacement: The pt's home INR goal is 2.0-3.0 He was supratherepeutic at the time admission (5.3) and his anticoagulation was reversed as above.,1
"When INR was below 1.5, the pt was treated with a heparin gtt.",0
He continued on a heparin gtt while receiving 2mg of coumadin daily until INR >2.,0
Patient was discharged home with a plan for repeat INR check on and appropriate follow up with his PCP who manages his INR.,0
"# Acute on chronic renal failure: At the time of admission, the pt was thought to be pre-renal due to GIB/poor PO intake.",1
His Cr improved with IVF and pRBCs.,0
The pt's home Lasix and were held at the time of admission but added back at the time of discharge.,0
His dose was decrease by half due to persistent borderling hypotension while on the floor.,0
Patient's creatinine was at baseline of 1.7 at the time of discharge.,0
"# CAD: The pt complained of CP several times during admission, however this was similar to his baseline.",0
His home BB was continued; his ASA was briefly held in the setting of his GIB.,0
Cardiac biomarkers were checked and were flat; no ECG changes were ever noted.,0
Patient was discharged home on aspirin and BB.,0
#Hyponatremia: Pt with mild hyponatremia at the time of admission.,0
This was thought to have occured in the setting of probably decreased blood volume/relative hypovolemia.,0
This corrected with fluid administration and improved PO intake.,0
"# Hypertension: The pt's home anti-hypertensives were initially held in the setting of acute bleeding, but were restarted by the time of discharge as above.",1
Home levothyroxine continued during his stay.,0
Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed).",0
"Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheeze.",0
Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM.,0
Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please use as directed.,0
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day.,0
"Protonix 40 mg Tablet, Delayed Release (E.C.)",0
"Disp:*60 Tablet, Delayed Release (E.C.",0
Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.,0
Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms.,0
Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
Outpatient Work Please draw INR on and fax results to: Dr. FAX# 16.,0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper Gastrointestinal Bleed Acute blood loss anemia Chronic kidney failure stage IV Iatrogenic Coagulopathy .,1
"Secondary diagnosis: Coronary artery disease St. aortic valve replacement Complete heart block History of GI bleeds Congestive heart failure Hypertension Gout Lupus with a history of lupus nephritis Hypothyroidism Thrombocytopenia Leukopenia Emphysema Discharge Condition: Hemodynamically stable, hematocrit stable at baseline, creatinine stable at baseline, therapeutic INR Discharge Instructions: You have been admitted for lightheadedness and dizziness.",1
"Prior to admission, your INR had been supratherapeutic at 4.29.",0
"You had also noticed dark, black stools prior to admission.",0
We believe your dizziness and lightheadedness was due to an upper GI bleed.,0
You were medically managed in the medical ICU for your upper GI bleed.,0
"Coumadin, aspirin, lasix, and valsartan were held and you were transfused 5 units of packed red blood cells.",0
Your hematocrit or blood level was stabilized after initiation of protonix and you were started on a heparin to coumadin bridge for anticoagulation for your mechanical heart valve.,1
It is recommended that you continue on twice daily oral protonix to prevent further gastrointestinal bleeding.,0
It is also recommended that you undergo an outpatient capsule study to look for sources of bleeding in your small bowel.,0
Please continue your coumadin at 2 mg PO daily with an INR check next week on at your usual facility.,0
Please continue all other medications with the exception of aspirin and oxycodone which have been discontinued and valsartan which has been cut in half.,0
Please discuss resuming aspirin with Dr. at follow up.,0
"Also, please discuss referral for outpatient capsule study with Dr. .",0
"If you develop any chest pain, shortness of breath, dizziness, lightheadedness, or any other general worsening of condition, please call your PCP or come directly to the ED.",0
Followup Instructions: Please have your INR checked on and have the results faxed to Dr. .,0
You have an appointment with radiology for a CT scan on at 3 PM.,0
"If you are unable to keep this appointment, please call to reschedule.",0
You have an appointment with Dr. on at 9:15 AM.,0
You have an appointment at the Pulmonary Function on at 1 PM.,0
"9:54 AM DUP EXTEXT BIL (MAP/DVT) Clip # Reason: eval for LE DVT Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with esophagogastrectomy pod#9 REASON FOR THIS EXAMINATION: eval for LE DVT ______________________________________________________________________________ FINAL REPORT INDICATION: Status post esophagogastrectomy, postoperative day nine.",1
"FINDINGS: Grayscale and Doppler son of the bilateral common femoral, superficial femoral, and popliteal veins was performed.",0
"Normal flow, compressibility, augmentation and waveforms were demonstrated.",0
"3:13 AM KNEE (AP, LAT & OBLIQUE) LEFT Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with mvc REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 37-year-old female status post MVC.",0
FINDINGS: Two views of the left knee demonstrate no fracture or dislocation.,0
"Status: Inpatient Date/Time: at 14:36 Test: Portable TTE(Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
Report to be generated at .,0
6:16 PM CHEST (PORTABLE AP) Clip # Reason: upright chest look for infiltrate/ pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with REASON FOR THIS EXAMINATION: upright chest look for infiltrate/ pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Suspected pneumonia.,0
"CHEST, PORTABLE AP: Comparison is made to the prior study obtained on .",0
The heart is of normal size.,0
The hila and mediastinal contours appear stable.,0
The aorta is again noted to be unfolded.,0
A Port-A-Cath device is noted with its tip in the distal SVC.,0
There are no focal consolidations or pleural effusion.,0
IMPRESSION: No evidence of acute pneumonia or CHF.,0
", F. MED MICU 12:14 PM CT HEAD W/O CONTRAST Clip # Reason: eval for hemorrhage or stroke Admitting Diagnosis: PNEUMONIA;SEVERE AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with new R sided weakness REASON FOR THIS EXAMINATION: eval for hemorrhage or stroke CONTRAINDICATIONS for IV CONTRAST: CRI ______________________________________________________________________________ PFI REPORT There is a small 4.5 mm focus of high attenuation in the left parieto-occipital region which could represent a small punctate hemorrhagic focus.",1
"There is no mass effect, edema or herniation.",0
"There is no evidence of acute major vascular territorial infarcts; however, CT is a limited study for evaluation of acute infarct.",0
Other areas of punctate high attenuation could reflect dural calcifications given well-circumscribed appearance.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Ativan / Prochlorperazine Attending: Chief Complaint: DLBCL, inability to keep up with transfusion requirements Major Surgical or Invasive Procedure: None History of Present Illness: Mr. is a 61-year-old man with a history of diffuse large B-cell lymphoma status post six cycles of R-CHOP between and , status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate, and s/p 3 cycles of ESHAP chemotherapy and two doses of intra-thecal ARA-C. His last cycle of ESHAP was .",0
"Mr. is well known to the service, his last admission being from to and complicated by fever and neutropenia secondary to clostridium difficile infection (stool C. diff negative prior to discharge), typhlitis, VRE urosepsis, upper and lower extremity DVTs, and atrial fibrillation with rapid ventricular rate.",1
He was discharged to and returns because of a falling platelet count and inability to keep up with his transfusion needs while maintaining anticoagulation with lovenox.,0
Since discharge the patient reports that he has had difficulties with episodes of dry heaves and was started on marinol the day prior to transfer.,0
He has also had some mild abdominal discomfort intermittantly that improves somewhat with eating.,0
He has had a few episodes of diarrhea as well.,0
"He has not had any frank fevers, however, his wife notes that his temperature has been rising somewhat.",0
"He has had variable PO intake, at times eating well and at times eating little to nothing at mealtimes.",0
The swelling in his upper and lower extremities has decreased remarkably and he has lost nearly 30 pounds of weight.,0
"He states he was placed on oxygen 2 days ago, but has not had any shortness of breath.",0
"He has been working with physical therapy at , but is not up walking yet.",0
"In addition, he notes no upper respiratory symptoms (runny nose, sore throat), cough, reflux, shortness of breath, chest pain, blood per rectum, dysuria, rashes, arthralgias.",0
Past Medical History: Oncologic History: Mr. initially presented to an outside hospital in with a 30-pound weight loss over the prior 6 months.,0
He was worked up and found to have a soft tissue mass in the cardiac ventricles involving the myocardium and extending into the interatrial septum.,0
"He was also noted to have multiple pulmonary nodules, bilateral pleural effusions, a pericardial effusion, large bilateral adrenal masses, and diffuse soft tissue masses involving both kidneys.",1
"The hospital course was complicated by the development of tamponade physiology, and the patient ultimately underwent a pericardial window.",0
"A renal biopsy on confirmed diffuse large B-cell lymphoma (Stage 4B), and a pericardial biopsy on also was consistent with large B-cell lymphoma.",0
He was diffusely immunoreactive for CD20 and co-expressed Bcl-2 and Bcl-6.,0
"CD43, CD5, TdT, Bcl-1, S100 were negative.",0
LMP for EBV was negative.,0
CD10 and CD30 were weekly expressed.,0
"In addition, a bone marrow biopsy demonstrated bone marrow involvement by lymphoma.",0
The patient was initiated on R-CHOP on and received six cycles between and and is also status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate.,0
CT abdomen on showed evidence of new liver lesion concerning for disease recurrence.,0
"CT guided liver biopsy on was positive and on further evaluation was found to have involvement in his heart, chest wall and retropharyngeal space.",0
"He also was assumed to have it in his CSF, even though the first LP had only one aytpical cell.",0
He received a total of 3 cycles of ESHAP chemotherapy and two doses of intra-thecal ARA-C. His last cycle of ESHAP was .,0
No discrete hepatic lesions were noted on CT abdomen on .,0
Flow cytometry showed indefinite evidence of lymphomatous involvement of the CSF.,0
"He was followed by neuro-oncology in-house who recommended no further IT ARA-C and to follow his neurologic symptoms clinically, and to re-refer him back to his outpatient neuro-oncologist (Dr. if he had any worsening confusion or neurologic symptoms.",0
"Given that he had received 3 x IT chemo and 3 cycles of high-dose Ara-C, it was felt to be sufficient for CNS prophylaxis.",0
"Other Medical History: # Large B Cell lymphoma as above # Recent C Diff Colitis # Hx of DVTs, upper & lower extremities, on Lovenox # Strep viridans bacteremia (1 bottle; PICC-associated?",0
"treated w/ ceftriaxone/PCN/ceftriaxone x4 weeks total) # Erythema nodosum, right forearm () # Intermittant atrial fibrillation with RVR # Cardiogenic Syncope # History of febrile neutropenia # Typhlitis # VRE Urosepsis # Nephrolithiasis # Anemia # Gerd Past Surgical History: # Amputation of right 2nd digit after electrical accident Social History: Social History: (Per OMR) The patient is married and has one son.",1
"+ 60 pk year history of tobacco, but quit in of , just prior to his diagnosis of lymphoma due to symptoms of profound weakness.",0
"Drinks socially, ~ 2 drinks per month.",0
"One son is alive and healthy, and is also a physician.",0
"has been able to accomplish basic ADLs with minimal assistance, but is dependent on advanced ADLs.",0
"Family History: FHx: Family History: (per OMR) Father - died of Mother - SLE, DM, CAD; died age 75 Brother - cardiac arrythmias Brother - prostate CA Son - healthy Physical Exam: V/S: T 99.0, BP 112/78, HR 78, RR 18, 97% on 2L NC GEN: Thin, pale, male in NAD HEENT: Sclera anicteric, left pupil 4 mm, right pupil 3 mm, both pupils reactive to light.",0
"NECK: No lymphadenopathy, left IJ central line with dried blood under the dressing CHEST: Decreased BS bilaterally without wheezes, rhonchi, or crackles.",0
"CV: RRR, normal s1 and s2, no murmurs or extra heart sounds appreciated ABD: +BS, soft, non-tender, no hepatosmplenolmegaly EXT: Warm, well perfused.",0
2+ edema in the left LE and 1+ edema in the right upper extremity.,0
"2+ DP pulse on right, not appreciable on left secondary to edema.",0
"SKIN: sacral ulcer, no rashes noted NEURO: A&O x 3, decreased strength throughout.",0
Unable to dorsiflex ankles bilaterally.,0
Pertinent Results: Admission Labs: 03:34PM BLOOD WBC-0.5*# RBC-3.04* Hgb-9.8*# Hct-27.1* MCV-89 MCH-32.3* MCHC-36.2* RDW-16.3* Plt Ct-38* 03:34PM BLOOD Neuts-24* Bands-2 Lymphs-62* Monos-8 Eos-0 Baso-2 Atyps-0 Metas-2* Myelos-0 03:34PM BLOOD PT-13.4 PTT-26.7 INR(PT)-1.1 03:34PM BLOOD Gran Ct-129* 03:34PM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-140 K-4.8 Cl-103 HCO3-31 03:34PM BLOOD ALT-9 AST-15 LD(LDH)-265* AlkPhos-82 TotBili-0.6 03:34PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.3* Mg-1.7 Microbiology: 4:45 pm STOOL CONSISTENCY: SOFT Source: Stool.,0
**FINAL REPORT ** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ): Feces negative for C.difficile toxin A & B by EIA.,1
Imaging: CXR - The left internal jugular line tip is at the cavoatrial junction.,0
There is interval development of bilateral pleural effusions and bibasal atelectasis.,1
There is also increased opacity in the right upper lung that is seen in addition to the known cavity demonstrated on chest CT. No pneumothorax is demonstrated.,0
Small bilateral pleural effusions are present that appears to be increased since the prior study.,1
RUE ultrasound - IMPRESSION: 1.,0
"Overall unchanged appearance of right upper extremity DVT extending through the subclavian, axillary, and brachial veins.",0
Peripheral flow in the subclavian and brachial veins indicates nonocclusive thrombus in these vessels.,0
"However, thrombus remains occlusive in the axillary vein.",0
"Occlusive thrombus in the basilic vein, not well visualized previously, but likely unchanged.",0
"Persistent respiratory variability of the left subclavian vein indicates the SVC remains patent, without occlusive central propagation of right subclavian thrombus.",0
ECG - Normal sinus rhythm.,0
Axis is minus 40 degrees.,0
Poor R wave progression in leads V1-V4.,0
Non-specific ST-T wave changes diffusely.,0
Compared to the previous tracing of there is no diagnostic interval change.,0
CXR - The left central venous line tip is at the cavoatrial junction.,1
Cardiomediastinal silhouette is unchanged including left ventriculomegaly.,0
"The lung volumes are unchanged, slightly decreased compared to more remote prior studies.",0
"The known severe emphysema with bibasilar opacities, pleural effusion and known right upper lung consolidation appears to be unchanged as well.",1
There is no evidence of interval development of pulmonary edema.,0
"CXR - FINDINGS: In comparison with the study of , there is again evidence of chronic pulmonary disease with bilateral pleural effusions and atelectatic changes at the bases.",1
The retrocardiac opacification is somewhat more prominent than on the previous study.,0
Central catheter remains in place.,0
CT Torso with contrast - IMPRESSION: 1.,0
New moderate bilateral pleural effusions with associated atelectasis.,1
There is no new consolidation within the lung parenchyma to suggest presence of pneumonia.,0
Unchanged appearance of right upper lobe consolidation with central cavitation.,0
"Previously identified left chest wall mass and cardiac masses are not visualized on the current study, consistent with continued interval improvement in lymphoma.",0
Resolution of wall thickening involving the cecum and ascending colon.,0
"Cholelithiasis within the gallbladder neck, but no CT evidence of acute cholecystitis.",0
"Bilateral renal cortical thinning, most consistent with scarring.",0
"Extensive atherosclerotic disease of the distal aorta, with unchanged bilateral common iliac artery aneurysms and significant intramural clot on the right.",0
ECHO - The left atrium is mildly dilated.,0
"Compared with the prior study (images reviewed) of , no change.",0
CXR - IMPRESSION: Regression of previously identified bilateral pleural effusion.,1
"Unfortunately, no lateral view has been obtained which could identify the presence or absence of remaining pleural effusion accumulating in the posterior sinuses in this patient in standing position.",1
"Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study SPIROMETRY 11:03 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 4.74 4.52 105 4.36 96 -8 FEV1 3.10 3.18 98 2.76 87 -11 MMF 2.24 3.03 74 1.90 63 -15 FEV1/FVC 65 70 93 63 90 -3 LUNG VOLUMES 11:03 AM Pre drug Post drug Actual Pred %Pred TLC 7.24 6.88 105 FRC 4.65 3.88 120 RV 2.59 2.36 110 VC 4.83 4.52 107 IC 2.59 3.00 86 ERV 2.06 1.52 136 RV/TLC 36 34 104 He Mix Time 2.50 DLCO 11:03 AM Actual Pred %Pred DSB 9.31 26.50 35 VA(sb) 6.22 6.88 90 HB 9.50 DSB(HB 11.36 26.50 43 DL/VA 1.83 3.85 47 CT Torso with contrast - IMPRESSION: 1.",0
Significant interval decrease of bilateral pleural effusions.,1
"Multiple small focal nodularities, consistent with tree-in- appearance, predominantly in the right lung but also seen in the left lung, concerning for infectious process.",0
Unchanged surgical sutures and apical scar in the right lung.,0
No acute changes in the abdomen compared to the CT torso performed 10 days ago.,0
Unchanged left-sided common femoral/iliac DVT.,0
Unchanged gallstones without evidence of acute cholecystitis.,0
"Brief Hospital Course: Mr. is a 61 year old male with diffuse large B cell lymphoma, s/p multiple cycles of treatment, most recently his third cycle of ESHAP chemotherapy with a history of upper and lower extremity DVTs, atrial fibrillation with RVR, and recent C. difficile colitis who was admitted with neutropenia and thrombocytopenia and inability to keep up with his transfusion requirements.",1
"Diffuse large B cell lymphoma - The patient is s/p multiple cycles of chemotherapy, including several cycles of intrathecal chemotherapy that were felt sufficient for CNS prophylaxis.",0
The patient had a CT scan on that demonstrated a dramatic remission of his formerly bulky disease.,0
Repeat CT scan on failed to identify recurrent lymphoma.,0
"However, when the patient developed hypercalcemia and delerium it was felt that his Diffuse large B cell lymphoma had likely recurred.",0
"His hypercalcemia eventually responded to pamidronate, fluids and calcitonin.",0
"However, his delerium did not fully resolve.",0
"Given the patient's likely disease recurrence despite multiple rounds of chemotherapy, it was felt that the patient was unlikely to benefit from additional chemotherapy.",1
"In discussion, with the patient and his family, it was decided not to pursue additional diagnostic studies such as a lumbar puncture or a bone marrow biopsy.",0
The patient's care was shifted towards comfort measures and he passed aways peacefully on with his family at his side.,0
# The patient had multiple other medical issues that required treatment during this admission.,0
He was neutropenic secondary to his most recent ESHAP therapy.,0
His is ANC nadired at 37.,0
He was placed on neutropenic precautions while he remained neutropenic.,0
The patient required multiple transfusions of platelets during this admission.,0
His platelet levels eventually recovered as his neutropenia resolved.,0
The patient had a history of RUE DVT and was noted to have a thrombus in his right iliac artery aneurysm.,0
His dose of lovenox had to be lowered in order to continue anticoagulation while the patient's platelets were so low.,0
"During this hospitalization, he completed treatment for his previously documented Afib and his symptoms resolved.",0
"Atrial fibrillation with RVR - The patient has a history of intermittant afib with RVR, particularly in response to lasix.",1
The patient was initially kept on the metoprolol regimen that he came from on.,0
After a couple of days in the hospital the patient had a rising oxygen requirement and was given several small doses of lasix to remove extra fluid from his multiple transfusions.,0
He over went into afib with rvr in the middle of the night and usually responded to 25-50 mg PO of metoprolol tartrate.,0
"On the patient was in afib with rvr, assymptomatic and hemodynamically stable, for multiple hours and did not respond to 50 mg PO metoprolol.",0
Cardiology was informally consulted and they recommended returning to the patient's prior regimen of metoprolol succinate 200 mg daily and metoprolol tartrate 50 mg Q midnight and stopping diuresis.,0
The patient responded very well to this regimen initially.,0
"However, after the patient had difficulties with hypercaclemia, he became more delerious and stopped eating and drinking.",0
The patient became more hypotensive despite fluid and electrolyte repletion.,0
Pt had sustained afib with RVR and required transfer to ICU on .,0
He required Neo gtt to maintain his MAP >60.,0
"Digoxin loading was attempted; however, his hr did not respond.",0
He was then tried on amiodarone.,0
"During this time, a family discussion was held and it was decided to transition goals of care to comfort.",0
"He actually converted into NSR upon transfer back to service, off neo, on .",0
"Hypoxia - The patient did not require oxygen during his previous admission, however, he was on 2L NC when trasfered from the OSH.",0
"The patient was noted to become hypoxic, particularly at night, requiring increased amounts of oxygen (up to 4L NC) to keep his O2 sats greater than 90%.",0
"Chest x-rays and CT-chest showed no evidence of infection, but did show new bilateral pleural effusions compared to imaging from his prior admission in addition to his previously known lung disease.",1
"Interventional pulmonology was , however, they did not feel that the effusions were large enough to drain.",0
"Lasix was used to try to remove some of the extra fluid and the patient's oxygen requirement did decrease such that his O2 sats were 95% or greater sitting up during the day, however, he continued to require oxygen while lying in bed and sleeping.",0
"A repeat ECHO was performed, however, it showed no change from his prior study appoximately a month earlier.",0
"Pulmonology was consulted Repeat x-ray showed improvement in the patient's effusions, and his oxygen requirement resolved on its own, likely a delayed effect of diuresis, requiring several days for fluid shifts to transpire.",0
The patient also underwent pulmonary function testing due to concern for emphysema based on CT scan and prior smoking history and need for such testing if stem cell transplant were to be considereed.,0
The patient was noted to have a very low DLCO.,0
"It was felt that this was most likely multifactorial, arising from emphysema, underlying lung disease and scar from his prior pneumonia, and possibly chronic thromboembolic disease given his known DVTs.",1
"Medications on Admission: Neutraphos 2 grams TID Metoprolol tartrate 100 mg Reglan 10 mg PO QIDACHS Reglan 10 mg IV BID prn nausea Protonix 40 mg daily Acyclovir 400 mg PO Q8H Fluconazole 200 mg PO daily Multivitamin, 1 tab daily Flagyl 500 mg IV Q8H Zofran 8 mg Q6H prn nausea Simethicone Mylanta 80 mg, 1 tab QID prn Marinol 5 mg Q4H prn nausea Magnesium sulfate 1g IV Q6H Methadone 2.5 mg TID KCl 40 mEq TID Lidoderm patch 5% to back 12 hours on and 12 hours off Filgrastin 300 mcg sc daily for ANC < Lovenox 60 mg Q12H (held on morning of admission) Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: 1.",0
Diffuse large B cell lymphoma s/p 3rd cycle of ESHAP chemotherapy 2.,0
Thrombocytopenia secondary to chemotherapy 3.,0
Neutropenia secondary to chemotherapy 4.,0
Hypoxia secondary to pleural effusions 5.,1
Atrial fibrillation with rapid ventricular rate 6.,1
C. difficile colitis Discharge Condition: expired Discharge Instructions: NONE Followup Instructions: none MD Completed by:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Sulfasalazine / Tape ""X10YD / Lactose / Optiray 350 Attending: Chief Complaint: ESLD Major Surgical or Invasive Procedure: liver transplant4/29/11 Exploratory laparotomy, takedown jejunojejunostomy and liver biopsy History of Present Illness: 40 yoM who was seen this morning for reposition of his NJ tube which had 'fallen out.'",1
His laboratory values at that time happened to notice that his bilirubin and creatinine were acutely elevated.,0
He was referred to the ED for further work up.,0
"Per report from the ED, when he arrived he was hypotensive and minimally repsonsive.",0
He was immediately placed on Dopamine and gievne Normal saline boluses.,0
He was then consented for and a Right sided central venous access was obtained via Internal jugular vein.,0
He stabilized and at that point transplant surgery was consulted approximately 2.5 hours after admission to the ED.,0
"When I arrived to see this patient, he was awake, alert and in no apparent distress.",0
He complained only of suprapubic pain.,0
He was jaundiced and lethargic.,0
He denies fevers or chills.,0
He denies dysuria or decreased frequency or volume.,0
He denies abnormal bowel movements.,0
He denies changes in mental status (confirmed by his family) and denies vision changes or dizziness.,0
No acute musculoskeletal weakness or instability although he is cachectic and has difficulty ambulating at times.,0
Ulcerative colitis s/p subtotal cholectomy 2.,1
Esophageal varices s/p banding Social History: He is single and heterosexual; He is currently not working and is on disability.,1
He lives at home with parents.,0
Family History: His father has disease.,0
There is no known family history of colon cancer.,0
He does not smoke cigarettes or use NSAIDs.,0
He is not certain whether stress makes his condition worse.,0
"Physical Exam: Afebrile, VSS AAO x3, NAD, depressed affect RRR no MRG appreciated CTA soft, protuberant, mild to moderate supraumbilical pain, scar c/w prior surgery.",0
JP drain in place to splenic bed + 1 edema of LE's Pertinent Results: On Admission: WBC-17.1*# RBC-3.74*# Hgb-13.4*# Hct-40.1# MCV-107*# MCH-35.8* MCHC-33.3 RDW-21.1* Plt Ct-244# PT-24.2* INR(PT)-2.3* UreaN-157* Creat-6.0*# Na-135 K-5.4* Cl-100 HCO3-9* AnGap-31* Glucose-84 ALT-286* AST-285* AlkPhos-217* TotBili-50.0* Albumin-3.0* Calcium-7.8* Phos-10.6*# Mg-2.6 HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE At Discharge WBC-10.5 RBC-3.19* Hgb-9.9* Hct-29.9* MCV-94 MCH-31.1 MCHC-33.2 RDW-18.2* Plt Ct-868* PT-12.1 PTT-22.2 INR(PT)-1.0 Glucose-96 UreaN-39* Creat-0.8 Na-139 K-4.6 Cl-108 HCO3-24 AnGap-12 ALT-29 AST-24 AlkPhos-107 TotBili-0.4 Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-1.8 tacroFK-9.1 Brief Hospital Course: 40 yoM with liver failure secondary to PSC cirrhosis was admitted to the Transplant service under Dr. .,1
He was started on IVF resuscitation.,0
Vanc and Zosyn were started for broad coverage after pan-culturing.,0
H Bedside R-sided thoracentesis for 1L fluid.,0
He was sent to the SICU on for management of acidosis and hyperkalemia.,0
HD line placed was placed and CVVH started.,0
"BP was low requiring Levo, vasopressin and dobutamine-->weaned to levophed and dobutamine overnight.",0
"Increased large right and new small left pleural effusions, with new multifocal pneumonia and continued right lower lobe collapse was seen on CXR .",0
On a R chest tube was placed by IP with large outputs (4.5L).,0
Vancomycin was started for GPCs in pleural fluid.Pleural fluid culture was negative.,0
He did have a positive blood culture on isolating VRE.,0
Antibiotics were adjusted and subsequent blood cultures remained negative.,0
On a donor liver was available.,0
A TTE was done showing mildly dilated LA and RA.,0
"LV wall thickness, cavity size and regional/global systolic function normal (LVEF 75%).",0
RV chamber size & free wall motion normal.,0
AV leaflets (3) structurally normal w/good leaflet excursion--no stenosis or regurge.,0
MV leaflets mildly thickened & myxomatous & borderline/mild post leaflet MV prolapse.,0
Liver transplant was cancelled for positive blood cultures.,0
He was treated with daptomycin ()] then was cleared for liver transplant.,0
"On , a liver donor offer was available.",0
On he underwent liver transplant with splenectomy given B incompatible status (patient blood type O).,1
He received one pheresis treatment prior to OR.,0
"Intraop, 3 JPs were placed (2 around the liver) and 1 in the splenic bed.",0
Please refer to operative notes for details.,0
Postop hepatic duplex revealed patent hepatic vasculature.,0
"However, there was slight reversal of flow in diastole and then absence of flow in end diastole.",0
"A small subhepatic collection seen inferior to the left lobe of the liver Postop, he was sent to the SICU for management and required many blood products per protocol to keep hemodynamically stable.",1
Daily anti B antibodies were check daily for 2 weeks.,0
He did not require additional pheresis treatments.,0
He experinnced increasing depression with psychotic features including hallucinations and delusions of people intending to harm him.,0
transferred to SICU for mangagement and monitoring.,0
He still required multiple transfusions.,0
"On , an abdominal CT was done for continued drop in HCT despite numerous blood transfusion and blood products.",0
No active extravasation was identified.,0
along the hepaticojejunostomy limb suggestive of bleeding was noted.,1
Thrombosis of right portal vein was noted.,1
"Delayed and decreased renal parenchymal enhancement, compatible with ARF He then underwent CT angio without bleeding source seen.",0
"On , a bleeding scan was performed noting acute GI bleeding from splenic flexure.",1
"On , he required take back to the OR for revision of the J-J anastomosis for bleeding after significant bloody stools and decrease in HCT from 38-->15.7 over 36 hours.",1
"On , RUQ US showed occlusive thrombus seen within the right anterior and right posterior portal veins.",1
Hepatopetal flow was seen within the main and left portal veins.,1
"The hepatic arteries, hepatic veins, and IVC were patent.",1
"Postop, he was doing well and had been started on a heparin gtt for his portal vein thrombosis.",1
He was transferred to the floor .,0
"The thrombosis had resolved on US, but his heparin drip was continued and he was started on coumadin .",0
"In the early AM on , however, he was noted to have melena.",0
"His hct had dropped from 27-20, though he was HDS.",0
"He was then transferred to the SICU, where he received 3u PRBC and 2u FFP.",0
Hct stablized and he eventually transferred out of the SICU to the med unit.,0
"US showed resolution of PV clot Neurologically/psychologically, he had metabolic encephalopathy and severe depression with paranoia and self-deprecating behavior.",1
"Psych saw the pt and he was given Haldol for hallucinations, but he became flaccid and min responsive after receiving.",0
Haldol and trazadone were held also for long QT (calculated on ECG ).,0
A post pyloric feeding tube was placed on .,0
Brain MRI on was notable hyperintensity within the basal ganglia extending into the superior mid brain.,0
"This was too focal for leukencephalopathy, rather it was c/w hepatic encephalopathy.",1
On he was readmitted to the SICU for an episode of melena with a hct drop from 27-20.,0
"Gave 4u PRBC, 2u FFP.",0
Repeat duplex of liver was without clot.,0
Heparin drip and coumadin were stopped on for 2nd bleed and resolution of PV clot.,0
Hyperkalemia was treated with kayexalate once then with standing lasix and florinef.,0
Psyche recommended starting Remeron and Ritalin .,0
Mental status improved with brighter affect and near resolution of paranoia.,0
PT recommended rehab for significant deconditioning.,0
This was evaluated with US noting a non- occlusive thrombus in left subclavian and occlusive thrombus in left basilic.,0
"Patient was to be discharged to rehab on , immediately prior to discharge the patient had a fall, discharge was cancelled.",0
Head CT was performed and negative for fracture or intracranial process.,0
"Hip, arm and leg x-rays were also obtained and negative for fracture.",0
The patient felt fine overnight and was cleared for discharge to rehab the following day.,0
"Tube feeds still running, clips have been removed from incision, splenic drain remains in place.",0
"Medications on Admission: CIPROFLOXACIN 500', ERGOCALCIFEROL 50,000 q week, FUROSEMIDE (held), LOPERAMIDE 2"""", NADOLOL 20', NYSTATIN QID, OMEPRAZOLE 20', MEPHYTON 5', SPIRONOLACTONE (hold), URSODIOL 600"", CALCIUM CARBONATE-VITAMIN D3 600 mg-400 unit Tablet"", FERROUSUL 325"", MAGNESIUM OXIDE 400', MULTIVITAMIN', VITAMIN A 8000 TIW Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: follow printed sliding scale Injection ASDIR (AS DIRECTED).",0
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol.,0
"3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day).",0
"4. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): see printed taper schedule.,0
8. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours).,0
9. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): give at 7am and 1200 noon .,0
10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
11. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hyperkalemia: for hyperkalemia.,0
12. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as needed for hyperkalemia: for hyperkalemia prevention.,0
13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours): give at 6pm and 6am must have trough level on Monday and Thursdays Do not adjust dose without checking with Transplant.,0
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 15.,0
"Outpatient Lab Work Every Monday and Thursday cbc,chem 10, ast, alt, alk phos, t.bili, albumin, trough prograf level and UA fax results to Transplant Office Discharge Disposition: Extended Care Facility: Discharge Diagnosis: UC/PSC ESLD s/p liver transplant Depression/paranoia J-J anastomosis bleed at splenic flexure Left subclavian non-occlusive thrombus, occlusive left basilic thrombus Discharge Condition: Mental Status: Clear and coherent.",1
Withdrawn at times/flat affect Activity Status: Ambulatory - requires assistance or aid (walker or cane).,0
"Discharge Instructions: You will be transferring to Rehab in Please call the Transplant Office if you experience the following fever, chills, nausea, vomiting,inability to take any of your medications, jaundice, increased abdominal pain, abdominal distension, incision redness/bleeding/drainage, feeding tube clogs Followup Instructions: Provider: , MD Phone: Date/Time: 1:40 Provider: , MD Phone: Date/Time: 1:20 Provider: , MD Phone: Date/Time: 1:00 Completed by:",0
11:03 AM PORTABLE ABDOMEN Clip # Reason: look for obstruction ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman intubated for respiratory distress REASON FOR THIS EXAMINATION: look for obstruction ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress.,0
Firm abdomen on physical exam.,0
SUPINE PORTABLE ABDOMEN: A nasogastric tube descends into the left abdomen.,0
"There is a paucity of visible bowel gas, possibly representing ascites or fluid filled bowel loops.",0
A large soft tissue mass might also give this appearance.,0
Small amount of air is noted in the left lower quadrant.,0
The aorta is densely calcified but not aneurysmally dilated.,0
The visible osseous detail is limited.,0
Findings were discussed with Dr. on the day of this study at 1220 hours.,0
"IMPRESSION: Paucity of bowel gas, as above.",0
4:39 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Eval for ET tube position Admitting Diagnosis: TRACHEAL BRONCHEAL MALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman s/p thoracotomy s/p re-intubation REASON FOR THIS EXAMINATION: Eval for ET tube position ______________________________________________________________________________ FINAL REPORT INDICATION: Status post thoracotomy and reintubation.,0
"PORTABLE CHEST AT 4:40 P.M.: Compared with the film earlier at 3:10 p.m., an ETT is now present with its tip at the level of the medial clavicles roughly 5 cm above the carina.",0
"There has been interval partial reexpansion of the atelectatic changes at the right base and in the left mid lung field, but new atelectasis is now seen in the retrocardiac left lower lobe.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old male with a history of severe depression and prior suicide attempt found unresponsive at restaurant and brought in by ambulance to Hospital where he had a witnessed generalized tonic clonic seizure and was given Ativan and Dilantin and intubated for airway protection and then transferred to for further management.,0
"Major depressive disorder, prior suicide attempts with ethylene glycol requiring dialysis with some residual renal injury.",0
"History of use of Paxil, Risperdal, Wellbutrin, Effexor, though current medications and doses are unknown.",0
SOCIAL HISTORY: Lives with sister.,0
"Not married, no children, unemployed.",0
"Positive history of tobacco use, but none currently.",0
"Occasional alcohol approximately two drinks per day, recently broke up with girlfriend.",0
"PHYSICAL EXAMINATION: General, sedated, intubated.",0
"HEENT pupils are equal, round and reactive to light 6 mm to 4 mm.",0
Cardiovascular regular rate and rhythm.,0
"Pulmonary decreased breath sounds at bilateral bases, clear to auscultation bilaterally otherwise.",0
"No clubbing, cyanosis or edema.",0
Neurological withdraws from pain in extremities times four.,0
"LABORATORY: White blood cell count 15.0, hematocrit 38.1, platelets 240.",0
"Chemistries sodium 138, potassium 3.7, chloride 104, bicarb 24, BUN 18, creatinine 1.2, glucose 96.",0
"Liver function tests within normal limits, albumin 4.7, serum osms 291, magnesium 2.0, calcium 9.2.",0
"Arterial blood gas on pressure support 15 to 5, 7.35, 44, 438.",0
"Electrocardiogram sinus tachycardiac at 127, no acute ST or T wave changes.",0
Normal QT interval and normal QRS interval.,0
Chest x-ray right lower lobe opacity.,0
"Overdose: The patient ingested an unknown substance, however, upon waking up he states that it was a large number of pills, which he states were his own.",0
There is no evidence of ethylene glycol ingestion as the patient never had an anion gap.,0
"A toxicology consult was obtained and the patient demonstrated evidence of anticholinergic __________ and with dilated pupils and somnolence, which resolved after two to three days.",0
The patient was extubated on and had slow mental status improvement and was at baseline mental status on discharge.,0
He had no medical sequela from his ingestion beside the seizure at the outside hospital.,0
He was observed with a one on one sitter with no significant events and continued supportive care.,0
A psychiatric consult was obtained and they were following throughout his hospital course.,0
"The patient does admit that this was a suicide attempt, however, upon being extubated he denied that he currently had suicidal ideation throughout his hospital course.",0
"Seizure: This is the first time that the patient has had a seizure likely secondary to the ingestion of the large number of psychiatric medications, which could lower his seizure threshold.",0
Initially loaded with Dilantin and kept at a therapeutic level with po Dilantin.,0
His head CT was negative.,0
"His B-12, TSH and RPR were normal.",0
He had an MRI and an esophagogastroduodenoscopy both of which were negative for a possible focus of seizure.,0
Neurology was following throughout his hospital course and determined that there was no indication for him to be on anticonvulsants as this likely does not represent epilepsy.,0
"Pulmonary: After extubation he had a chest x-ray, which showed bilateral _________ infiltrates, which was consistent with aspiration pneumonia versus pneumonitis.",0
"He initially had an elevated white blood cell count and fever and was started on Levo and Flagyl, however, never became symptomatic and he maintained his O2 sats on room air.",0
He did not have a cough and was not short of breath and the Levofloxacin and Flagyl were discontinued prior to discharge.,0
Psychiatric: The Psychiatry Service was following the patient after extubation.,0
"They were unable to determine, which medications he was on prior to his suicide attempt.",0
All psychiatric medications were held until further information was obtained and the patient was observed at his baseline state and was continued on a one on one sitter with suicide precautions and will be transferred to Hospital for inpatient psychiatric hospitalization for further management.,0
DISPOSITION: The patient was transferred from the Intensive Care Unit on and was observed on the medical floor for two days.,0
The patient had no further events and no sequela from his ingestion.,0
He was deemed medically and neurologically stable for transfer and the patient was transferred for inpatient psychiatric management.,0
Psychiatric follow up as arranged post inpatient hospitalization.,0
Follow up with primary care physician in one to two weeks.,0
Hydrochlorothiazide 25 mg po q.d.,0
CONDITION ON DISCHARGE: Medically and neurologically stable.,0
Needs inpatient psychiatric care with suicide precautions.,0
Dictated By: MEDQUIST36 D: 09:52 T: 09:55 JOB#:,0
"3:42 PM CT HEAD W/O CONTRAST Clip # Reason: eval for trauma ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with s/p ped struck REASON FOR THIS EXAMINATION: eval for trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: DCsc SAT 4:41 PM LEFT EXTRA AXIAL BLEED, LEFT OCCIPITAL INTRAPARYENCHMAL BLEED MIN MASS EFFECT ______________________________________________________________________________ FINAL REPORT (REVISED) *ABNORMAL!",0
TECHNIQUE: Noncontrast axial acquired images of the brain.,0
No prior study for comparison.,0
FINDINGS: A high density extra-axial fluid collection is seen along the left lateral convexity.,0
This regions measures approximately 4 mm thick at its thickest point.,0
A 2nd region of increased attenuation is seen within the left posterior occipital lobe (series 2-b image 39).,0
This region is surrounded with a rim of low density.,0
There is a region of encephalomalacia just lateral to the anterior of the left lateral ventricle in the left frontal lobe.,0
Periventricular white matter hypodensity densities likely relate to chronic microvascular infarction.,0
The ventricles and sulci are prominent.,0
There is preservation of the /white matter interface.,0
Some fluid is seen within the left maxillary sinus.,0
There is a superifical laceration/hematoma above the right orbit.,0
No other extracranial abnormality is identiifed.,0
No skull fracture is seen on the axial images or on the lateral scout.,0
"Acute extra-axial hemorrhage along the lateral left convexity, at the level of the temporal lobe.",0
This has the appearance of a epidural hematoma but subdural hematoma cannot be excluded.,0
Left occipital hemorrhage that appears intraparenchymal.,0
There is a small rim of edema surrounding this hemorrhage but there is minimal mass affect.,0
These results were discussed with the surgical team at the time the study was performed.,0
Possible fracture involving the anterior wall and lateral wall of the right maxillary sinus and right orbital roof.,0
This must be further evaluated with dedicated orbital CT studies.,0
(Over) 3:42 PM CT HEAD W/O CONTRAST Clip # Reason: eval for trauma ______________________________________________________________________________ FINAL REPORT (REVISED) *ABNORMAL!,0
"6:11 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: check et tube placment and aeration of R lung Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with pancreatitis/DT's, reintubated REASON FOR THIS EXAMINATION: check et tube placment and aeration of R lung ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the lung aeration.",1
Portable AP chest radiograph compared to obtained at 11:17 p.m.,0
"The ET tube tip is just below the level of the clavicle heads, 6 cm above the carina.",0
The right internal jugular line tip projects at the level of cavoatrial junction.,0
There is markedly improved aeration of the right lung with minimal opacity projecting at the perihilar area.,0
There is no evidence of sizable right pleural effusion.,0
Minimal retrocardiac consolidation is demonstrated on the left which can be retrospectively seen on the previous study.,0
No sizable left pleural effusion is demonstrated.,0
IMPRESSION: Marked improvement of the aeration of the right lung suggesting atelectasis as a cause for the previously demonstrated abnormality.,0
Left retrocardiac consolidation may represent either atelectasis or infectious process.,0
2:42 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: year old woman with fall REASON FOR THIS EXAMINATION: trauma ______________________________________________________________________________ FINAL REPORT HISTORY: Fall.,0
FINDINGS: Single frontal radiograph of the chest is obtained with patient positioned on a trauma board.,0
"The lungs are notable for left greater than right basilar opacities, possibly atelectatic or aspiration in this post-traumatic patient.",0
"Cardiomediastinal and hilar contours are notable for widening, likely positional though incompletely evaluated.",0
"Large trace of curvilinear lines extending from the left mid abdomen into the lower chest are nonspecific, and these may represent skin folds.",0
This should be correlated to the patient positioning at time of image acquisition.,0
A single frontal view of the pelvis is obtained showing a normal bowel gas pattern and no radiopaque foreign bodies.,0
The included osseous structures reveal extensive degenerative changes throughout the included visualized spine as well as involving the hip joints bilaterally.,0
The sacrum is obscured by overlying bowel gas.,0
IMPRESSION: No radiographically apparent traumatic sequelae in the chest and pelvis.,0
"Apparent widening of the superior mediastinum is likely due to technique and position, but incompletely assessed.",0
Recommend upright PA and lateral radiographs for better assessment.,0
Results were communicated to on,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Pump-assisted, beating-heart coronary artery bypass grafting x3 -- left internal mammary artery to left anterior descending artery and saphenous vein sequential grafting to posterior descending artery and posterior left ventricular branch History of Present Illness: 55 year old Cantonese speaking male with a history of Cardiomyopathy EF 10-15%, Hypertension, and pulmonary artery hypertension who has been experiencing chest pain for the past year.",1
He complains of chest discomfort for the past year that occurs with rapid exertion.,0
He denies chest discomfort at rest; he denies shortness of breath and leg swelling.,0
He was referred for cardiac catheterization on which revealed multiple coronary artery disease.,1
Mild spontaneous echo contrast is seen in the body of the left atrium.,0
No thrombus/mass is seen in the body of the left atrium.,0
No mass or thrombus is seen in the right atrium or right atrial appendage.,0
"Overall left ventricular systolic function is severely depressed, with akinetic inferior wall and apex(LVEF= 20 %).",0
The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis.,0
"The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients.",0
Improved -ventricular systiolic function with persistent wall m otion abnmormalities (EF =30%) (Background epinephrine infusion) 2.,0
No change in valve structuer and function.,0
Head CT: There is no evidence of acute intracranial pathology.,0
"Mucosal thickening is noted in the sphenoid and left maxillary sinus, focal defect is noted on the left lamina papyracea, of uncertain chronicity.",0
Punctate calcifications are visualized in the vertebral arteries and both carotid siphons.,0
Echo: The left atrium is elongated.,0
The right ventricular cavity is dilated with depressed free wall contractility.,0
Significant pulmonic regurgitation is seen.,0
CXR: Severe cardiomegaly is stable postoperatively and comparable to the preoperative appearance.,0
There is no appreciable atelectasis and no pleural effusion or pulmonary edema.,0
Prominent nipple shadow should not be mistaken for lung nodules.,0
Right PIC line ends in the region of the superior cavoatrial junction.,0
Brief Hospital Course: This 55-year-old patient with ischemic cardiomyopathy who presented with exertional symptoms and was investigated and found to have a very low ejection fraction of 10%-15%.,1
"The coronary angiogram showed significant disease in the left anterior descending artery, the right coronary artery, and the distal circumflex artery.",1
A perfusion scan demonstrated reversible ischemic areas.,0
He was admitted for elective coronary artery bypass grafting.,1
"In view of the low ejection fraction, the plan was to proceed with pump-assisted, beating-heart coronary artery bypass grafting.",1
"He was brought to the operating room on where the he underwent pump-assisted, beating-heart coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and saphenous vein sequential grafting to posterior descending artery and posterior left ventricular branch.",1
The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support.,0
Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight.,0
On POD 2 he was walking to the bathroom and became unresponsive upon return to the chair.,0
He was found to be in PEA and code blue was called.,0
Compressions were initiated and he was coded with a return of blood pressure and spontaneous rhythm after epinephrine and atropine.,0
He was intubated for airway protection and transferred to the CVICU.,0
He remained hemodynamically stable on no inotropic support but was slow to wake.,0
Head CT was done which was negative for any acute event.,1
On he was consistently following commands and was extubated without incident.,0
He was hypertensive after extubation and medications were titrated up for goal SBP <130.,0
Coreg and Ace-I were initiated with low EF.,0
He had a swallow evaluation which he passed for regular diet with thin liquids.,0
He did have some confusion and agitation which improved with Haldol.,0
On he was transferred again to the step down unit.,0
Echocardiogram was done to reassess EF which showed LVEF of 30%.,0
EP evaluated patient on for his PEA arrest and recommendations for follow-up in future.,1
They recommended an outpatient AICD evaluation in 1 month.,0
The patient was evaluated by the physical and occupational therapy services for assistance with strength and mobility.,0
"By the time of discharge on POD 18 the patient was ambulating with assistance (with a left drift), the wound was healing well and pain was controlled with Tylenol.",0
The patient was discharged to in in good condition with appropriate follow up instructions.,0
"Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth daily FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sub lingually 1 tablet under the tongue.",0
as needed for when you get chest pain.,0
"Take sitting down POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Capsule, Sustained Release - 1 Capsule(s) by mouth daily PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.)",0
- 1 Tablet(s) by mouth daily Discharge Medications: 1. isosorbide mononitrate 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Disp:*60 Tablet(s)* Refills:*2* 2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Disp:*120 Tablet(s)* Refills:*2* 3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Disp:*120 Tablet(s)* Refills:*2* 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Disp:*30 Tablet(s)* Refills:*2* 5. aspirin 81 mg Tablet, Delayed Release (E.C.)",0
)(s)* Refills:*2* 6. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 8. potassium chloride 20 mEq Tab Sust.Rel.,0
Particle/Crystal PO Q12H (every 12 hours).,0
Particle/Crystal(s)* Refills:*2* 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Puffs Inhalation Q6H (every 6 hours) as needed for wheezes.,0
"Disp:*qs * Refills:*0* 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever.",0
"Disp:*30 Tablet(s)* Refills:*0* 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day).",0
Disp:*qs * Refills:*2* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
"Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x 3 postop cardiac arrest Past medical history: Dilated Cardiomyopathy (EF 10-15%) Hypertension Hyperlipidemia Pulmonary Artery hypertension Mitral Regurgitation TIA per patient () Discharge Condition: Alert and oriented x2 nonfocal Ambulating with assistance (left drift) Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage.",1
"No Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon.",0
"Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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 Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns .",0
Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. on at 2:00pm Cardiologist: Dr. on at 8:20am Please call to schedule appointments with your Primary Care Dr. in weeks **Please call cardiac surgery office with any questions or concerns .,1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Tetracycline / Dilaudid (PF) / Pravastatin Attending: Chief Complaint: Diarrea, nausea, vomiting, blood in ostomy bag Major Surgical or Invasive Procedure: - R IJ catheter placed History of Present Illness: 54F w Crohn's (on Humira) b/c colitis now s/p sigmoidectomy w end colostomy, ventral hernia repair, & abdominal wall reconstruction c/b complete SBO due to adhesive disease & porta1 vein thrombosis, AFib on coumadin presents with 1-2 wks of abd pain, emesis, fever to 100.7, diarrhea with small amt of BRB (sml amt BRB she thinks from irritation of the ostomy itself).",1
Pt states that all the members of her family had a GI illness in the past several weeks; her symptoms were similar to what her family experienced.,0
"However, over the past week, she developed crampy abdominal pain that is more consistent with a Crohn's flare, as well as bloody diarrhea.",0
She states that this diarrhea is far more watery that her usual IBD flares.,0
She has been unable to keep anything down due to nausea and vomiting.,0
She has felt progressively more weak with dizziness on standing as well as palptitations.,0
"Today, the patient became so severe that she decided to present to an emergency department for evaluation.",0
Vital signs in the ED: 97.6 88 83/44 16 99 RA .,0
"In the , pt's abdomen was noted to be diffusely tender, especially around ostomy site.",0
The patient was noted to be persistently hypotensive in the sBP 80s after 4 L NS resuscitation and she developed BRB in her ostomy bag.,0
"In total she received 5L NS, a R IJ was placed and she was ultimately started on levophed at 10 mcg/min.",0
ED labs were significant for INR 8.3; the patient received 10 mg IV vitamin K. Lactate 3.4 on admission with improved to 1.3 s/p IVF administration.,0
She was also started on Zosyn.,0
"- EKG: atrial fibrillation with HR 101, LAD, IVCD, STD V4-V6 - CXR: no acute process - CT abdomen with PO & IV contrast was obtained which showed ?",1
air near colostomy site as well as stranding .,0
The patient was discussed with GI; they felt that no steroids were needed at the moment.,0
"Last set of ED vital signs: 114/50, 77, 25, 95% 2L nc .",0
"ROS: (+): As above (-): Chest pain, cough, sputum production, dysuria, urinary frequency/urgency, syncope, myalgias, arthralgias, headache, wheeze, focal numbness or weakness.",0
"Past Medical History: - Crohn's Disease (diagnosed ) c/b fistulas, sigmoidectomy, SBOs - Atrial fibrillation since ---> DCCV x3 at ---> Cardioversion at - Nonsustained Ventricular Tachycardia - Benign Multinodular Goiter (followed by Dr. - s/p Cervical cancer - GERD - Paraspinal cyst (followed by Dr. - Pulmonary lesions - Mediastinal mass (stable on MRI) - Portal vein clot - Arthritis - Anxiety Social History: - Married, living with her family in - Previously worked as physical therapist - Tobacco: Smoked intermittently in college, but no recent use - EtOH: Denies - Illicit Drug Use: Nil.",1
"Family History: - Father: UC, esophageal cancer --- Paternal aunt with - Mother: Basal & squamous cell carcinoma - Grandmother developed afib at 80 years of age - Maternal grandmother: lung cancer - diagnosed with IBD at age 14 Physical Exam: ON ADMISSION: GEN: Obese, pallid, NAD HEENT: NCAT.",1
NECK: R IJ in place PULM: Diminished BS bilaterally with faint expiratory wheeze at bases.,0
"COR: Irregular, +S1S2 : Hypoactive BS.",0
"Diffusely TTP, worse surrounding ostomy site.",0
Ostomy bag with green liquid stool.,0
"Slightly more tender in RUQ as well, with rebound but no guarding.",0
Nontender to percussion & bed shake.,0
"EXT: WWP, unable to palpate pulses.",0
1+ LE edema NEURO: AAOx3.,0
"MAEE Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: CXR no acute process.",0
Frontal and lateral views of the chest are compared to previous exam from .,0
Again seen is elevation of the right hemidiaphragm.,0
The lungs remain clear of consolidation or effusion.,0
Osseous and soft tissue structures are unchanged.,0
Diffuse colonic wall thickening of the remaining colon.,0
"Differential considerations include changes from patients known Crohn's disease, infectious or inflammatory causes, or even hemorrhage given elevated INR and possible high density of the wall in certain areas.",0
Parastomal hernia with a focus of air within the soft tissues which is not clearly intraluminal and may be may be extraluminal.,0
Close clinical followup suggested and repeat can be performed if desired.,0
CMV VIRAL LOAD: NEGATIVE 3:36 pm STOOL CONSISTENCY: WATERY Source: Stool R/O K.OXY & LISTERIA PER DR. # .,0
FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Final ): NO CAMPYLOBACTER FOUND.,0
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ): NO E.COLI 0157:H7 FOUND.,0
FECAL CULTURE - R/O VIBRIO (Final ): NO VIBRIO FOUND.,0
FECAL CULTURE - R/O YERSINIA (Final ): NO YERSINIA FOUND.,0
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ): Feces negative for C.difficile toxin A & B by EIA.,0
"Brief Hospital Course: REASON FOR HOSPITAL ADMISSION: 54 F with Crohn's c/b multiple surgeries & prior SBO presents with fever, diarrhea, hypotension, BRB per ostomy bag.",0
"HOSPITAL COURSE # HYPOTENSION/SEPTIC SHOCK: Pt met multiple SIRS criteria (hypotension, fever, tachycardia, leukocytosis) with suspected GI source given her abdominal pain & diarrhea.",1
"Pulmonary source was considered but no signs or symptoms of PNA, clear CXR.",0
Low suspicion for urosepsis as pt without dysuria and urinalysis not c/w infection.,1
Initially c/f gram negative bacteremia as she was at high risk for GI translocation.,0
She states that she has had multiple family members who have had symptoms consistent with viral GE recently.,0
Concern also that she could have prolonged course of norovirus given that she is on Humira.,0
She was initially treated with aggressive IVF resuscitations which failed in the ED and she required levophed in the ICU.,0
zosyn and cipro were started for source control and double coverage.,0
Levophed was able to be weaned.,0
Home anti-hypertensives were held and electrolytes aggressively repleted.,0
This resolved with treatment .,0
"# Acute Gastroenteritis: The patient presented with BRB via her ostomy site (see GIB below) and abdominal pain, c/f infection vs chrohns flare vs ostomy trauma.",1
Some purulent drainage around the ostomy site which was sent for culture.,0
Surgery examined the site and felt that the ostomy looked fine.,0
GI was consulted and they felt most likely this was an infectious etiology.,0
No scope was felt to be necessary at this point.,0
"Stool cultures for yersinia, vibrio, e.coli, C.diff, and CMV viral load were NEGATIVE.",0
All cx were no growth to date.,0
"She completed a 5 day course of Cipro/Flagyl, though this was likely an acute viral illness.",0
- C. diff PCR and Norovirus serology PENDING at discharge .,0
#GI bleeding: pt presented with BRB per ostomy site.,0
HCT was slightly decreased from baseline on admission and dropped further with aggressive IV hydration.,0
HCT was trended and remained stable.,0
There was no further evidence of bleeding .,0
"# COAGULOPATHY: Pt with INR 8.3 on admission despite taking regular warfarin dose, likely due to her acute infectious process.",0
Repeat INR 2.1 s/p IV vitamin K. INR 1.6 on hospital day two.,0
Warfarin was initially due to concern for GIB.,0
"However, when this issue was excluded her Warfarin was resumed at home dose.",0
"She was bridged with heparin gtt and transitioned to Lovenox bridge 1mg/kg q12 until her INR is >1.9 - Repeat INR in days, goal INR .",0
# Acute Kidney Injury: Creatinine 2.1 on admission from baseline of approximately 0.6.,1
FeNa 0.21% Felt to be likely prerenal or possibly ATN in setting of hypotension.,0
Pt was aggressively rehydrated with IVF as above with improvement in creatinine.,0
# Atrial Fibrillation: Diltiazem and metoprolol initially held in setting of sepsis with hypotension.,1
Digoxin was continued for positive effect on cardiac output.,0
"Prior to leaving the ICU, hypotension had resolved and metoprolol was restarted.",0
Dilt was also restarted at a lower dose (30mg daily vs home dose of 360mg daily) - Her home regimen was resumed on discharge.,0
"# Asthma: No evidence for acute exacerbation, although slight expiratory wheeze at bases.",1
Maintained on albuterol nebs prn.,0
"# HTN: hypotensive on admission and home antihypertensives were held and then restarted at lower doses, see Afib above.",0
"Medications on Admission: MEDICATIONS: (confirmed with patient - HCTZ 12.5 mg QD - Simvastatin 10 mg QD - Warfarin 4 mg QD - Lisinopril 20 mg QD - Diltiazem 360 mg QD - Digoxin 250 mcg QD - Lantus 38 units QAM - Humalog 8 units before meals - Humira - Advair 250/50 - Metformin 500 mg - Proair 2 puffs Q3-4H PRN SOB, wheeze - Omeprazole 20 mg - Cyclobenzaprine 14 mg TID PRN - Metoprolol 50 mg - Nystatin powder - Codeine sulfate 30 mg PRN diarrhea - Lorazepam 2 mg TID PRN anxiety - Tylenol PRN - Vitamin D - Vitamin B12 - Ferrous sulfate Discharge Medications: 1. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day.",0
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM.,0
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
"5. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day.",0
6. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lantus 100 unit/mL Solution Sig: Thirty Eight (38) units Subcutaneous once a day.,0
Humalog 100 unit/mL Solution Sig: Eight (8) units Subcutaneous qAC: resume home dosing based on blood sugars.,0
Humira Please resume at usual dose 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation (2 times a day).,0
11. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.,0
ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing.,0
"13. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
PO BID (2 times a day).,0
14. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for spasm.,0
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
16. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for anxiety.,0
17. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
18. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day.,0
"19. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day.",0
"20. enoxaparin 100 mg/mL Syringe Sig: One (1) injection Subcutaneous every twelve (12) hours for 7 days: continue until INR >1.9, then STOP.",0
"Outpatient Work PT/INR, CBC within 2-3 days.",0
Location: MEDICAL GROUP Fax: 22. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain : avoid with alcohol or driving.,0
Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Sepsis due to gastroenteritis Hypotension Coagulopathy Atrial Fibrillation Parastomal hernia Crohn's disease Hypertension Type 2 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted with an acute diarrheal illness which caused low blood pressure.,0
"Because of this, you spent time in the ICU.",0
"With IV fluids and antibiotics, you improved.",0
The GI service evaluated you and felt this was most consistent with a viral gastroenteritis and NOT due to Crohn's.,0
You were also found to have a hernia around your ostomy.,0
Please follow up with your surgeon for this.,0
"Finally, your INR was found to be high on admission, likely due to your acute illness.",0
Your Warfarin was reversed and then restarted.,0
Please continue your home Warfarin dose.,0
"Until your INR is 2, please take the Lovenox (Enoxaparin) shots.",0
Resume all your home medications.,0
New medications include Lovenox and Percocet.,0
Do NOT use Percocet with alcohol or driving.,0
"- please call for an appointment within the next 7-10 days Department: ENDO SUITES When: MONDAY at 10:30 AM Department: DIGESTIVE DISEASE CENTER When: MONDAY at 10:30 AM With: ,MD Building: Building (/ Complex) Campus: EAST Best Parking: Main Garage Department: DIV.",0
OF GASTROENTEROLOGY When: MONDAY at 2:00 PM With: Building: Ra (/ Complex) Campus: EAST Best Parking: Main Garage,0
BP (mm Hg): 179/109 Status: Inpatient Date/Time: at 10:53 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
LV WALL MOTION: The following regional left ventricular wall motion abnormalities are seen: basal anteroseptal - akinetic; mid anteroseptal - thin/scarred/akinetic; basal inferior - akinetic; mid inferior - akinetic; apex - akinetic; the remaining left ventricular segments are hypokinetic.,0
RIGHT VENTRICLE: The right ventricular wall thickness is normal.,0
The following regional left ventricular wall motion abnormalities are seen: basal anteroseptal - akinetic; mid anteroseptal - thin/scarred/akinetic; basal inferior - akinetic; mid inferior - akinetic; apex - akinetic; the remaining left ventricular segments are hypokinetic with the lateral wall relatively preserved.,0
"Compared to the report of , the wall motion abnormalities, LV dysfunction and MR are new.",0
Height: (in) 70 Weight (lb): 250 BSA (m2): 2.30 m2 BP (mm Hg): 107/52 HR (bpm): 101 Status: Inpatient Date/Time: at 12:19 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Physiologic MR (within normal limits).,0
There is mild regional left ventricular systolic dysfunction with moderate anterior septal hypokinesis and mild inferior septal hypokinesis.,0
Physiologic mitral regurgitation is seen (within normal limits).,0
"IMPRESSION: Moderate hypokinesis of the anterior septum, mild hypokinesis of the inferior septum.",0
No significant valvular abnormality seen.,0
9:08 AM CHEST (PORTABLE AP) Clip # Reason: evaluate effusion Admitting Diagnosis: TACCHYCARDIA/BRADYCARDIA;ATRIAL FLUTTER\A-FLUTTER ABLATION;BV PACER ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with s/p avr REASON FOR THIS EXAMINATION: evaluate effusion ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient after aortic valve replacement.,1
Portable AP chest radiograph compared to .,0
The right internal jugular line tip is in superior SVC.,0
There is no change in the mediastinal contour as well as insignificant left chest wall emphysema.,0
There is also no change in relatively low lung volumes and the mild vascular engorgement.,0
"Status: Inpatient Date/Time: at 17:00 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
"2:43 PM CT CHEST W/O CONTRAST Clip # Reason: evaluation of RLL persistent pneumonia that required intubat ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with COPD, CAD, s.p.",0
"intubation secondary to PNA here for further evaluation of RLL process with chest CT, a tracheostomy, and a PEG procedure.",0
REASON FOR THIS EXAMINATION: evaluation of RLL persistent pneumonia that required intubation.,0
Pt will be going for tracheostomy around 11AM this morning and a PEG tube around 3-4PM this afternoon.,0
Please schedule non-contrast chest CT around that schedule if possible.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 79 YEAR OLD FEMALE WITH HISTORY OF RIGHT LOWER PERSISTENT PNEUMONIA THAT REQUIRED INTUBATION.,0
CT IS REQUESTED FOR FURTHER ASSESSMENT.,0
Helical CT was performed without intravenous or oral contrast administration with 8 mm collimation and 8 mm reconstruction intervals.,0
No prior chest CT scans are available for comparison.,0
"A tracheostomy tube is in place, in satisfactory position.",0
Assessment of the soft tissue structures of the thorax demonstrates an enlarged precarinal lymph node measuring approximately 1.4 cm in greatest short axis dimension.,0
"No definite hilar lymph node enlargement is evident, but the assessment of the hilar is limited due to absence of intravenous contrast.",0
There is large amount of fat in the intra-atrial septum suggestive of lipomatous hypertrophy of the intra-atrial septum.,0
Coronary artery calcification is evident.,1
A very small pericardial effusion is noted.,0
Note is made of enlargement of the main pulmonary artery suggesting the possibility of pulmonary artery hypertension.,1
There is a moderate-sized right pleural effusion and a small left pleural effusion.,0
There are very subtle areas of ground-glass opacity in the upper lobes and there are scattered tiny centrilobular nodules predominantly in the left upper lobe and lingula.,0
Patchy ill-defined areas of ground-glass opacity are noted in the left lower lobe as well patchy foci of consolidation and some focal atelectasis adjacent to the pleural effusion.,0
"Within the right lower lobe, there is passive atelectasis related to the pleural effusion; there may also be a component of pneumonia in the right lower lobe particularly given the provided clinical history.",0
There is partial atelectasis of the right middle lobe which is likely due to passive atelectasis related to the adjacent effusion.,0
No definite centrally obstructing mass is identified on this non-contrast study.,0
Imaging of the upper portion of the abdomen demonstrates a percutaneous gastrostomy tube.,0
The imaged portion of the liver demonstrates a small low density lesion near the gallbladder measuring less than 1 cm in diameter.,0
"Imaged portions of the kidneys reveal no focal abnormalities, but the kidneys and liver are incompletely imaged on this study.",0
The right kidney appears slightly smaller and may be atrophic.,0
The adrenal glands reveal no suspicious masses.,0
There is a small amount of ascites present.,0
Fluid is noted within the chest wall probably reflecting anasarca.,0
The imaged portion of the pancreas reveals no suspicious abnormalities on this non-contrast study.,0
(Over) 2:43 PM CT CHEST W/O CONTRAST Clip # Reason: evaluation of RLL persistent pneumonia that required intubat ______________________________________________________________________________ FINAL REPORT (Cont) Review of the osseous structures of the thorax reveals no suspicious lytic or blastic lesions.,0
"A nasogastric tube is noted, coursing into the stomach and towards the duodenum with the tip not included on this study.",0
A right PICC line is seen with the tip terminating in the region of the right subclavian vein proximally.,0
"Dense right lower lobe opacification with air bronchograms, surrounded by pleural fluid, likely due to a combination of passive atelectasis and provided history of pneumonia.",0
There is partial atelectasis of the right lower lobe and left lower lobe posteriorly adjacent to pleural fluid.,0
"Additionally, there are subtle areas of ground-glass opacity throughout both lungs with associated small centrilobular nodules, likely due to bronchiolitis/bronchopneumonia.",0
Followup radiographs to document resolution of the right lower lobe process after appropriate antibiotic therapy and resolution of the effusion may be helpful.,0
Moderate right and small left pleural effusions.,0
Enlarged precarinal lymph node likely hyperplastic in this patient with history of pneumonia.,0
Prominent fat in the intra-atrial septum is suggestive of lipomatous hypertrophy of the intra-atrial septum.,0
Enlarged pulmonary artery suggesting pulmonary artery hypertension.,1
2:01 AM MR LIMITED Clip # Reason: L4 LEVEL DEFICITS S/P MULTI TRAUMA.,0
Admitting Diagnosis: MULTIPLE TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with bilateral L4 level deficits s/p multitrauma REASON FOR THIS EXAMINATION: eval for cord injury ______________________________________________________________________________ FINAL REPORT INDICATION: 27 year old trauma patient with bilateral L4 deficits.,0
"TECHNIQUE: Sagittal T1, T2, and inversion recovery images of the cervical and thoracic spine were obtained.",0
Sagittal T1 and T2 weighted images of the lumbosacral spine were included.,0
The study was terminated prior to completion secondary to patient's inability to tolerate the examination.,0
MRI CERVICAL AND THORACIC SPINE: Normal vertebral body alignment and height are preserved throughout.,0
The intervertebral discs are normal in height and signal and density.,0
"appears widely patent, and the cord is of normal signal throughout.",0
There is no increased signal in the inversion recovery images to indicate acute traumatic injury.,0
MRI LUMBOSARCAL SPINE: Normal vertebral body height and alignment are preserved.,0
There is normal marrow signal throughout.,0
There is loss of signal of the L5-S1 intervertebral disc with a small annular tear along the posterior aspect.,0
"On the sagittal view, there may be disc bulge or protrusion, although evaluation is limited due to the lack of axial images.",0
This disc does not extend into any of the neural foramina on the sagittal views.,0
There is no evident neural foraminal narrowing.,0
IMPRESSION: 1) Normal appearance of the cervical and thoracic spine without evidence of cord compression or acute traumatic injury.,0
2) Limited examination of the lumbosacral spine demonstrates an L5-S1 disc bulge or protrusion with a posterior annular tear but no evidence of stenosis or neural foraminal narrowing.,0
Please note that this is a limited examination due to the lack of axial images.,0
These can be repeated when the patient is better able to tolerate the exam.,0
9:20 AM CHEST (PORTABLE AP) Clip # Reason: change in cardiopulm process?,0
"Admitting Diagnosis: CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p cardiac arrest, intubated in field, s/p cardiac cath, with femoral SG in place, now febrile s/p witnessed aspiration.",1
REASON FOR THIS EXAMINATION: change in cardiopulm process?,0
______________________________________________________________________________ FINAL REPORT HISTORY: Cardiac arrest ?line placement or change in cardiopulmonary process.,0
"CHEST, SINGLE AP PORTABLE SUPINE VIEW.",0
"An ETT is present, tip at level of clavicle approximately 6.4 cm above the carina.",0
"A femoral approach Swan-Ganz catheter is present, tip over main pulmonary artery.",0
The aorta is calcified and unfolded.,0
"Allowing for supine positioning, no definite CHF.",0
No focal consolidation or effusion.,0
No supine film evidence of pneumothorax identified.,0
"Compared with 1 day earlier and allowing for differences in positioning, doubt interval change.",0
"2:50 AM CHEST (PORTABLE AP) Clip # Reason: evaluate interval change Admitting Diagnosis: SEPSIS;ACUTE PANCREATITIS;RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with pancreatitis, intubated REASON FOR THIS EXAMINATION: evaluate interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for interval change.",1
"COMPARISON: , 4:14 p.m. As compared to the previous examination, the lung volumes have slightly decreased.",0
"The size of the cardiac silhouette has slightly increased, the right aspects of the mediastinum are wider than on the previous radiograph.",0
"Also, increased have the small bilateral pleural effusions that lead to homogeneous opacities and marking of the two hemidiaphragms.",0
There is retrocardiac and right basilar atelectasis.,0
No newly occurred focal parenchymal opacities.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo woman with no significant transferred from OSH after a seizure earlier this am.,0
History is provided per the OSH records and the patient's husband and son.,0
"By routine, she woke up around 3am, checked on the house.",0
"However, the patient did not return to bed for 15 to 20 minutes, and her concerned husband went to look for her.",0
"She was found on the floor of the kitchen, unresponsive.",0
He called EMS and did not note any seizure activity while awaiting their arrival.,0
"EMS found her to be having a ""full seizure grand mal"" for ~30 seconds,associated with ""snoring respirations, unresponsive.""",0
She had left eye deviation and a left facial droop.,0
"She was brought to Hospital, still noted as unresponsive, with left gaze deviation but no facial droop, moving the right arm and leg.",0
"At ~ 4 am, she was given ativan 2mg, then pavulon 10mg IV, thiamine, and cerebyx 1gm.",0
"She had a head CT, which showed bilateral frontal intracerebral hemorrhages.",0
She was given an additional 10mg pavulon IV and then transferred here.,0
She was given an additional 2mg IV fentanyl prior to neurology consult.,0
Somehat more irritable in recent days after attending funeral; otherwise no complaints and at normal functioning baseline.,0
Past Medical History: No significant past medical history per family.,0
Patient visited physician for regular .,0
Social History: Active woman who lived at home with her husband.,0
"There are large bilateral frontoparietal intraparenchymal hemorrhages with associated surrounding edema, but without significant shift and no evidence of herniation.",0
There is evidence of a fluid-fluid level within the left frontoparietal hemorrhagic region.,0
There is no prior exam available at this time with which to compare and to evaluate the evolution of the hemorrhage.,0
"CTA of the head and neck reveals no evidence of aneurysm, stenosis, occlusion or vascular malformations.",0
"The venous system also appears patent, with no evidence of thrombosis.",0
A followup scan after the resolution of the hematoma is recommended in order to better evaluate the etiology of the hemorrhage.,0
CT head (): The appearance of the left frontal intraparenchymal hemorrhage is not significantly changed from the prior study.,0
There is slight increase in the intraventricular hemorrhage in the occipital of the left lateral ventricle and there is minimal decrease in the rightward shift of the normally midline structures.,0
Otherwise there are no other interval changes noted.,0
There is no evidence of hydrocephalus or uncal herniation.,0
MRI/A of head (): 1.,0
"Similar overall appearance of large recent bilateral lobar hemorrhages, as well as intraventicular and subarachnoid hemorrhages.",0
"Although subarachnoid hemorrhage appears more diffuse, this could relate to the greater sensitivity of MR or to redistribution of blood products.",0
No evidence of abnormal enhancement or vascular malformation.,0
Numerous punctate foci of prior hemorrhage throughout the cerebral hemispheres.,0
This appearance supports the possibility of amyloid angiopathy.,0
"However, follow-up examination in approximately six weeks is recommended, to be performed with gadolinium, to better exclude the possibility of an underlying mass lesion.",0
NG tube can be advanced further as the sideport is likely in the esophagus.,0
"EKG (): Atrial fibrillation, mean ventricular rate 122.",1
Compared to previous tracing cardiac rhythm is now atrial fibrillation.,1
"EKG (815/07, later): Sinus rhythm.",0
Compared to previous tracing cardiac rhythm is now sinus mechanism.,0
Brief Hospital Course: was admitted to the Neuro-ICU for further evaluation and management.,0
"A CTA of the head and neck on admission showed large bilateral frontoparietal intraparenchymal hemorrhages with associated surrounding edema, but without significant shift and no evidence of herniation.",0
There was evidence of a fluid level within the left frontoparietal hemorrhagic region.,0
"However, there was no evidence of aneurysm or other vascular malformation.",0
"The venous system also appeared patent, with no evidence of thrombosis.",0
"A follow up MRI/MRA of the head on the following day revealed a similar overall appearance of the bilateral lobar hemorrhages, as well as intraventicular and subarachnoid hemorrhages.",0
There was no evidence of abnormal enhancement or vascular malformation.,0
"Interestingly, there were numerous punctate foci of prior hemorrhage throughout the cerebral hemispheres, an appearance suggestive of the possibility of amyloid angiopathy.",0
The patient showed little improvement clinically in the ensuing days.,0
Although she did exhibit occassional eye opening but otherwise remained obtunded.,0
"Her course was complicated by runs of tachycardia (including an episode of atrial fibrillation on EKG), associated with troponin leakage.",1
Cardiology was consulted and it was thought that these phenomena were likely related to the intracranial hemorrhage.,1
"As her QT was prolonged, beta-blockers were not recommended at standing doses for concern of degenerative arrhythmias.",0
"Given the hemorrhage, anti-coagulation was not indicated.",0
She was also treated for a UTI with bactrim.,0
"After extensive discussion with the family regarding the patient's wishes, her poor prognosis given her lesions/deficits, and limited chance of meaningful recovery, the patient's husband and sons decided to place her on comfort measures only.",0
"Extubation was carried out and comfort care enacted on , and the patient expired later that afternoon.",0
"Medications on Admission: None Discharge Medications: Not applicable (N/A) Discharge Disposition: Expired Discharge Diagnosis: Bilateral intraparenchymal lobar hemorrhages, likely secondary to amyloid angiopathy.",0
Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A MD,0
"1:44 PM PERC G/G-J TUBE PLMT Clip # Reason: Need G-Tube Admitting Diagnosis: CHEST PAIN-R/O MYOCARDIAL INFARCTION Contrast: CONRAY Amt: 30 ********************************* CPT Codes ******************************** * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE * * CATHETER, DRAINAGE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with AMI, A Fib, CHF, now with mental status changes with difficulty swallowing.",1
"REASON FOR THIS EXAMINATION: Need G-Tube ______________________________________________________________________________ FINAL REPORT INDICATION: Acute MI, afib, CHF, mental status changes, failed swallowing study, requires feeding tube.",0
RADIOLOGISTS: Procedure performed by Drs.,0
"and , radiologist present supervising procedure.",0
MEDICATION AND CONTRAST: 50 mcg Fentanyl were administered intravenously in divided doses under constant hemodynamic monitoring.,0
Total of 5 cc 1% subcutaneous lidocaine was administered.,0
Total of 20 cc ionic contrast was administered.,0
PROCEDURE/TECHNIQUE: Patient's family were informed of details and associated risks of the procedure and written consent was obtained.,0
Patient was placed supine on angiographic table and the abdomen was sterile prepped in the usual fashion.,0
Rectal air was administered to opacify the colon.,0
Ultrasonography was performed to demonstrate the anatomic relationship between the liver and stomach.,0
The stomach was insufflated via previously placed OGT.,0
Under fluoroscopic observation a 21 gauge Acustik needle was advanced into the body of the stomach and placement within the stomach confirmed with administration of contrast.,0
Two additional T-fasteners were deployed under fluoroscopic observation in the same manner each time demonstrating presence of needle within the stomach with contrast administration.,0
Once the stomach wall was tacked to the abdominal wall cavity with T-fasteners a third pass with a 21 gauge Acustik needle was made under fluoroscopic observation and the body of the stomach entered between three T- fasteners.,0
Again this is confirmed with contrast administration.,0
An 0.35 inch Bentson guidewire is advanced throught this Acustik needle and coiled within the antrum of the stomach.,0
The needle was then exchanged for a 5 Fr sheath.,0
An MP catheter was advanced over the guidewire and through the sheath and used to direct the guidewire into the pylorus and duodenum.,0
The .035 inch Bentson guidewire was advanced into the proximal jejunum and the MP catheter then advanced into the proximal jejunum.,0
The .035 inch Bentson guidewire was exchanged for an .035 Amplatz wire.,0
The sheath and catheter are then removed and a 9 and 12 Fr dilator serially placed over the Amplatz wire through a skin incision between the three T-fasteners.,0
A 14 Fr peelaway sheath is then advanced with tip positioned within the antrum of the stomach.,0
The 14 Fr (Over) 1:44 PM PERC G/G-J TUBE PLMT Clip # Reason: Need G-Tube Admitting Diagnosis: CHEST PAIN-R/O MYOCARDIAL INFARCTION Contrast: CONRAY Amt: 30 ______________________________________________________________________________ FINAL REPORT (Cont) feeding tube was then advanced over the Amplatz wire and positioned with distal tip within the proximal jejunum and the pigtail is formed within the second portion of the duodenum.,1
Contrast administration demonstrates proper positioning within the jejunum without evidence of extravasation of contrast.,0
The percutaneous jejunostomy tube is then secured with a StatLock device.,0
IMPRESSION: Successful placement of percutaneous gastrojejunostomy tube under fluoroscopic guidance with tip positioned in the proximal jejunum.,0
The T- fasteners should be removed on days.,0
OGT should remain overnight and percutenous gastrojejunostomy tube can be used beginning tomorrow as ordered.,0
"11:05 AM N-G TUBE PLACEMENT (W/ FLUORO) Clip # Reason: Please place POST-PYLORIC feeding tube, LEAVE NG in stomach ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with REASON FOR THIS EXAMINATION: Please place POST-PYLORIC feeding tube, LEAVE NG in stomach ______________________________________________________________________________ FINAL REPORT INDICATION: Post pyloric feeding tube for enteral nutrition.",0
FEEDING TUBE PLACEMENT WITH FLUOROSCOPIC GUIDANCE: A post-pyloric feeding tube was advanced through the nasal cavity through the esophagus into the stomach without difficulty.,0
An indwelling NGT was noted to have its tip in the region of the pyloric channel.,0
The post-pyloric type feeding tube was unable to be advanced beyond the pylorus despite retracting the indwelling NGT away from the region of the pylorus.,0
"In discussion with the clinical team, the post pyloric type feeding tube was left in situ with slack coiling in the stomach.",0
IMPRESSION: Feeding tube placed coiled in stomach with tip in region of the pylorus.,0
Unable to advance beyond the pylorus effectively.,0
Follow up abdominal plain films at appropriate intervals are recommended to assess for position of feeding tube tip.,0
"7:48 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: PULMONARY EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with htn admitted with pneumonia, nstemi and pulmonary edema now s/p intubation REASON FOR THIS EXAMINATION: please eval for interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Pneumonia, pulmonary edema, status post intubation, evaluation for interval change.",1
"FINDINGS: As compared to the previous examination, the monitoring and support devices are in unchanged position.",0
"The extent and distribution of the pre-existing parenchymal opacities are nearly unchanged, neither clear increases nor decreases are observed.",0
Also unchanged is the retrocardiac atelectasis and the size of the cardiac silhouette.,0
There is no evidence of newly occurred focal opacities in the lung parenchyma.,0
No radiological evidence of pneumothorax.,0
8:00 AM BABYGRAM (ABD ANY SGL VIEW) () Clip # Reason: evaluate bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with blood streaks in stool REASON FOR THIS EXAMINATION: evaluate bowel gas pattern ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE VIEW BABYGRAM HISTORY: Infant with blood streaks in stool.,1
FINDINGS: There is slightly more gaseous distention than on the study of .,0
"There is no evidence of obstruction, pneumatosis or pneumoperitoneum.",0
5:44 PM CT EMERGENCY HEAD W/O CONTRAST Clip # Reason: found lethargic.,0
"______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with above PMH cad, copd, chf REASON FOR THIS EXAMINATION: found lethargic.",0
______________________________________________________________________________ FINAL REPORT CT HEAD.,0
TECHNIQUE: Contiguous axial imaging was obtained from the foramen magnum to the cranial vertex.,0
CT SCAN OF THE HEAD WITHOUT CONTRAST: There is no intra- or extraaxial hemorrhage.,0
"There is no mass, mass effect or shift of the normally midline structures.",0
A lacune is identified within the right basal ganglia.,0
There is moderate symmetrical enlargement of the ventricles and sulci compatible with age-related atrophy.,0
There is a mild amount of periventricular low attenuation compatible with chronic white matter microvascular infarction.,0
No major vascular territorial infarction is identified.,0
No fracture is seen and the visualized paranasal sinuses are clear.,0
There is no pneumatization of the mastoid air cells.,0
"3:57 PM CHEST (PORTABLE AP) Clip # Reason: for reintubation to confirm tube position ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, CLD, pseudomonas pneumonia REASON FOR THIS EXAMINATION: for reintubation to confirm tube position ______________________________________________________________________________ FINAL REPORT INDICATIONS: CHEST: Comparison is made to previous films from .",1
FINDINGS: Endotracheal tube is at the carina.,0
"There is a ductus clip in place, unchanged.",0
The lungs are low in volume and there is a coarse reticular interstitial pattern present most marked in the upper lobes bilaterally.,0
There is periosteal new bone formation surrounding the left humerus that suggests some degree of metabolic deficit.,0
Periosteal new bone can also be seen in premature infant simply from routine movements of the extremities.,0
Consideration of a full evaluation of the extremities is suggested.,0
"BP (mm Hg): 153/79 HR (bpm): 53 Status: Inpatient Date/Time: at 21:05 Test: Portable TTE (Complete) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",0
Conclusions: There is probably mild left ventricular hypertrophy.,0
Left ventricular chamber size is normal and systolic function appears grossly preserved (EF probably >50%).,0
Right ventricular chamber size is normal and systolic function appears normal.,0
8:36 AM CHEST (PORTABLE AP) Clip # Reason: LLL collapse?,0
Admitting Diagnosis: LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with l lingula resection pulmonary edema respiratory ARDS and ILD REASON FOR THIS EXAMINATION: LLL collapse?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Left lingular resection, pulmonary edema and ARDS.",0
Assess for left lower lobe collapse.,0
PORTABLE AP VIEW OF CHEST: Comparison is made to an exam of .,0
There has been near complete resolution of the previously described opacification of the left lower lobe.,0
There has also been an overall decrease in the amount of prominent interstitial markings and perihilar haziness since the previous exam.,0
There are no new focal consolidations or increased pleural effusions.,0
"There remains diffuse prominence of the lungs, consistent with the patient's above-stated ARDS.",0
Visualized soft tissues and osseous structures are stable.,0
"IMPRESSION: No evidence of left lower lobe collapse/consolidation on today's exam, improved since the radiograph of .",0
Overall improvement in diffuse pulmonary edema.,0
"8:06 AM PICC LINE PLACMENT SCH Clip # Reason: requesting SECOND PICC to provide TPN plus additional access Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * REPOSITION CENTRAL VENOUS CATH FLUORO 1 HR W/RADIOLOGIST * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with AICD pacer pocket infection from MSSA, C. dif colitis, and fungal bacteremia, with poor apetite and intake of PO foods REASON FOR THIS EXAMINATION: requesting SECOND PICC to provide TPN plus additional access for medications ______________________________________________________________________________ FINAL REPORT INDICATION: AICD pacer pocket infection, C. diff.",1
Poor appetite and intake of PO foods.,0
Please convert the single- lumen PICC to a double-lumen PICC for TPN.,0
PROCEDURE: This procedure was performed by Drs.,0
"and , with Dr. present and supervising.",0
The right upper arm was prepped in the region of the previously placed basilic vein PICC.,0
The catheter was cut and a 0.018 guide wire was advanced under fluoroscopy into the superior vena cava.,0
The catheter was removed and replaced with a 5-French sheath.,0
A 43-cm double- lumen PICC was then advanced under fluoroscopic guidance into the superior vena cava.,0
A final chest x-ray was obtained.,0
The film demonstrates the tip to be in the superior vena cava just above the atrium.,0
Also noted is a pulmonary artery catheter from a right-sided approach.,0
A Stat-Lock was applied and the line was heplocked.,0
"IMPRESSION: Successful replacement of the 4-French single-lumen PICC with a 5-French dual-lumen PICC via the right basilic vein (43 cm total length), ready for use.",0
1:39 PM CAROTID SERIES COMPLETE PORT Clip # Reason: PARIETAL EMBOLI Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with new diffuse parietal emboli REASON FOR THIS EXAMINATION: r/o carotid emboli source ______________________________________________________________________________ FINAL REPORT CAROTID STUDY HISTORY: Diffuse parietal emboli.,0
FINDINGS: No appreciable plaque or wall thickening involving either carotid system.,0
The peak systolic velocities bilaterally are normal as are the ICA/CCA ratios.,0
"1:18 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: LUE PAIN AND SWELLING ?DVT Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p subdural hematom evacuation, left sided hemiplegia.",1
Pain with left upper ext movement.,0
dvt ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JBRe SAT 3:51 PM PFI: Nonocclusive thrombosis of the left cephalic vein.,0
No evidence of deep venous thrombosis.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old man status post subdural hematoma evacuation, left-sided hemiplegia.",1
Please assess for DVT of the left upper extremity.,1
TECHNIQUE: Grayscale and color Doppler ultrasound images of the left upper extremity were performed.,1
COMPARISON: There are no comparison studies available.,0
"FINDINGS: There is normal compressibility, flow and augmentation of the left internal jugular, subclavian, axillary, brachial, and cephalic veins.",0
"There is a non-occlusive thrombosis of the left cephalic vein, with residual flow.",0
IMPRESSION: Nonocclusive thrombosis of the left cephalic vein.,0
1:18 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: S/P FALL ON HEAD ______________________________________________________________________________ MEDICAL CONDITION: 17 year old man s/p fall to head REASON FOR THIS EXAMINATION: r/o intraabdominal injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: AHPb SAT 1:52 AM URGENT: cord compression at c4/c5 with likely retropulsed disc and possible hemorrhage.,0
"urgent MR necessary ______________________________________________________________________________ FINAL REPORT TECHNIQUE: Contrast-enhanced axial CT imaging of the chest, abdomen and pelvis with coronal and sagittal reformats was reviewed without comparison.",0
INDICATION: 17-year-old man with fall on head from jumping on trampoline.,0
"CT CHEST WITH CONTRAST: The lungs are clear, and the pleura are normal.",0
The heart and great vessels of the mediastinum are unremarkable.,0
The airways are patent to the subsegmental level.,0
The soft tissues are unremarkable.,0
"CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, spleen, adrenal glands, small bowel loops are normal without evidence for injury.",0
The kidneys contain small hypodense lesions on both sides.,0
"The right cyst is likely normal, but the attenuation is too high for strict CT criteria, perhaps artifact, but an ultrasound in the outpatient setting can be performed for further evaluation.",0
There is no free air or free fluid in the abdomen.,0
CT PELVIS WITH CONTRAST: There is trace free fluid in the pelvis.,0
"The rectum, sigmoid, and large bowel are normal caliber.",0
The distal ureters and bladder are normal.,0
A Foley is present within the bladder.,0
The aorta and major branches are patent without evidence for extravasation.,0
BONE WINDOWS: There is no evidence for fracture within the thoracic or lumbar spine.,0
"Evaluation of the intercanal elements is limited by CT, but there are no significant compressive abnormalities identified.",0
"No evidence for traumatic injury in the chest, abdomen, or pelvis.",0
Ultrasound can be performed in an outpatient setting to ascertain simple nature.,0
"5:06 AM CHEST (PORTABLE AP) Clip # Reason: assess pulm edema, for infiltrates Admitting Diagnosis: TRACHEAL BRONCHIAL MALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with chest tube to water seal s/p extubation, now s/p open trach.",0
"REASON FOR THIS EXAMINATION: assess pulm edema, for infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary edema.",0
Tracheostomy tube and enteric tube remain in stable position.,0
"Again seen is moderate to severe diffuse pulmonary edema, unchanged.",0
Small bilateral pleural effusions are noted.,0
Dense left retrocardiac density is consistent with atelectasis.,0
IMPRESSION: No significant interval change in pulmonary edema and left lower lobe atelectasis.,0
PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for ascending aortic replacement Height: (in) 78 Weight (lb): 210 BSA (m2): 2.31 m2 BP (mm Hg): 110/67 HR (bpm): 64 Status: Inpatient Date/Time: at 15:02 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.,0
Bidirectional shunt across the interatrial septum at rest.,0
"Normal LV wall thickness, cavity size, and systolic function (LVEF>55%).",0
AORTA: Moderately dilated aortic root.,0
Conclusions: Prebypass 1.No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
There is a bidirectional shunt across the interatrial septum at rest.,0
"2.Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%).",0
3.Right ventricular chamber size and free wall motion are normal.,0
4.The aortic root is moderately dilated.,0
The sinuses of Valsalva are dilated.,0
5.The mitral valve leaflets are structurally normal.,1
Biventricular systolic function is unchanged.,0
Trace to mild mitral regurgitation present.,0
Graft material seen in the ascending aorta.,0
2:20 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: S/P FALL ON COUMADIN BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man s/p bicyclist struck with head bleed REASON FOR THIS EXAMINATION: eval: inj No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT 75-year-old male found down after a bicycle accident.,1
"TECHNIQUE: MDCT continuously acquired axial images of the chest, abdomen and pelvis were obtained after 130 mL Optiray IV contrast.",0
CT OF THE CHEST WITH IV CONTRAST: There is no evidence of aortic aneurysm or dissection.,0
The great vessels of the chest opacify well and are unremarkable.,0
There are extensive coronary artery calcifications as well as calcifications of the aortic arch.,0
"There is no pathologic mediastinal, axillary or hilar lymphadenopathy.",0
Lung windows demonstrate a small left pleural effusion with associated left basilar atelectasis.,0
Two noncalcified pulmonary nodules of the left upper lobe and one of the right upper lobe measure up to 4 mm in size.,0
There are mild bullous emphysematous changes.,0
No focal consolidation or pneumothorax is identified.,0
There is a small hiatal hernia.,0
"CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, pancreas, adrenal glands, stomach, duodenum, and intra-abdominal loops of large and small bowel are unremarkable.",0
There is sludge within the gallbladder but no evidence of acute cholecystitis.,0
Both kidneys demonstrate tiny hypodensities too small to definitively characterize.,0
Also noted is an 18 mm simple cyst at the mid pole of the left kidney with associated mild nonspecific perineprhic stranding.,0
Both kidneys enhance and excrete contrast symmetrically and the ureters are well opacified and are of normal caliber.,0
There is no free intra-abdominal air or fluid.,0
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the urinary bladder.,0
The rectum and pelvic loops of bowel are unremarkable.,0
The prostate gland is markedly enlarged.,0
There is no free pelvic fluid or lymphadenopathy.,0
BONE WINDOWS: There are degenerative changes of the spine including bridging osteophytes of the thoracic spine.,0
No fracture or spinal malalignment is identified.,0
There are no suspicious lytic or sclerotic osseous lesions.,0
No evidence of traumatic intra-abdominal injury.,0
Small left pleural effusion with left basilar atelectasis.,0
(Over) 2:20 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: S/P FALL ON COUMADIN BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 3.,0
A few small pulmonary nodules measuring up to 4 mm in size.,0
CT followup at six months is suggested to ensure stability.,0
"18 mm left renal cyst and bilateral hypodense foci of the kidneys, too small to definitively characterize but probably cysts.",0
12:09 AM MR W & W/O CONTRAST Clip # Reason: please evaluate for lower thoracic-lumbar demyelinating dise Admitting Diagnosis: BRAIN MASS Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with acute disseminated encephalomyelitis who has new lower thoracic lesion on mri that is not completely visualized on prior spine film.,0
REASON FOR THIS EXAMINATION: please evaluate for lower thoracic-lumbar demyelinating disease ______________________________________________________________________________ FINAL REPORT Further evaluation of presumed demyelinating lesions.,0
Multiplanar T1 and T2 weighted sequences before and after the administration of gadolinium.,0
The exam was compared to the prior study of .,0
FINDINGS: A focus of contrast enhancement in the distal aspect of the cord seen on the previous examination is again identified.,0
No evidence of focal disc protrusion in the lumbar region.,0
There is no evidence of canal or foraminal stenosis.,0
IMPRESSION: Contrast enhancement in the conus region of the cord consistent with a demyelinating process and similar to exam of .,0
"4:24 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: advance Dobhoff to post-pyloric position Admitting Diagnosis: HYDROTHORAX Contrast: CONRAY Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with ESLD, intubated, needs feeds REASON FOR THIS EXAMINATION: advance Dobhoff to post-pyloric position ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old male, intubated, who needs feeds.",0
Advance Dobbhoff to post-pyloric position.,0
FINDINGS: Initial film was taken of the Dobbhoff which showed the distal tip within the proximal stomach.,0
Numerous attempts were made to advance Dobbhoff under fluoroscopy.,0
The stomach was severely distended with fluid.,0
"After insufflation of air, the Dobbhoff tube could be advanced to the region of the pylorus.",0
The pylorus was very tight and the Dobbhoff tube could not be advanced into the duodenum.,0
Contrast was injected and only a scant amount was able to trickle through the pylorus.,0
"At this point, the original wire within the Dobbhoff was removed.",0
The patient had approximately 200 mL of residual removed from the stomach.,0
A new wire was advanced within the Dobbhoff.,0
"Again, attempts were made to advance the tip to a post-pyloric position.",0
"After 10 minutes of fluoroscopy, we failed to advance it to a post-pyloric position.",0
"At this point, contrast was injected confirming the tip was at the location of the pylorus.",0
The Dobbhoff tube was left in place with its tip at the entrance of the pylorus.,0
Patient tolerated this procedure well.,1
IMPRESSION: Failure to advance the Dobbhoff tube to a post-pyloric position.,1
Tube advanced with its tip to the entrance of the pylorus.,0
"4:54 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with severe pancreatitis and pleural effusions REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Severe pancreatitis and pleural effusions, to evaluate for change.",0
"Substantial bilateral pleural effusions persist, worse on the left.",0
Cardiac size is essentially within normal limits.,0
The midline structures are not substantially shifted to the left on this study.,0
This may have reflected some obliquity of the previous study or some expectoration of a mucous plug causing previous atelectatic change.,0
7:15 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with CHF decompensation.,1
REASON FOR THIS EXAMINATION: please evaluate for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: 88-year-old man with CHF decompensation.,0
"SINGLE UPRIGHT VIEW OF THE CHEST AT 7:41 A.M.: A dual-lead pacemaker generator overlies the left upper hemithorax, with intact leads terminating in the right atrium and right ventricle.",0
Minimal haziness of the pulmonary vasculature persists.,0
There is no new consolidation or pleural effusion.,0
Retrocardiac opacity has minimally increased.,0
"IMPRESSION: Unchanged mild pulmonary edema with increase in retrocardiac opacity, likely atelectasis.",0
", P. FA9A 8:24 AM CHEST PORT.",0
LINE PLACEMENT Clip # Reason: 46cm left picc.,0
Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with REASON FOR THIS EXAMINATION: 46cm left picc.,0
______________________________________________________________________________ PFI REPORT Left PICC line tip is in cavoatrial junction.,0
Post recent Whipple abdominal drain is in the upper abdomen.,0
Right mid lung atelectasis is unchanged.,0
Left small pleural effusion is unchanged.,0
"Left retrocardiac consolidation is slightly increased, could be atelectasis or pneumonia.",0
"7:43 AM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: EVALUATE RLE FOR DVT, S/P RLE LINE Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with broviac catheter in place, inserted through right leg, , now with thrombocytopenia REASON FOR THIS EXAMINATION: evaluate for thrombosis ______________________________________________________________________________ FINAL REPORT ULTRASOUND OF THE RIGHT THIGH, RIGHT ILIAC VEINS, AND IVC FOR DVT HISTORY: Almost 2-month-old girl with a history of prior Broviac catheter inserted via the right leg on .",1
"FINDINGS: Real time son of the deep veins of the right thigh, right iliac region, and IVC performed portably in the NICU.",0
The superior aspect of the superficial femoral vein in the proximal thigh has a normal appearance.,0
It is easily compressible without evidence for intraluminal thrombus.,0
A similar finding is identified in the right common femoral vein.,0
The right external iliac vein and portions of the right common iliac vein opacify completely with signal on color Doppler imaging and show no evidence for intraluminal thrombus.,0
"However, the more proximal portions of the common femoral vein and the distal IVC are not identified due to extensive bowel gas shadowing.",0
The proximal and mid aspect of the IVC shows normal flow on color Doppler imaging without evidence for intraluminal thrombus.,0
"IMPRESSION: No evidence for DVT involving the deep veins of the proximal right thigh, the right external iliac vein, and visualized portions of the right common iliac vein as well as the proximal and mid IVC.",0
The distal IVC and the proximal right common iliac vein were obscured by extensive overlying bowel gas shadowing.,0
"6:42 AM CHEST (PORTABLE AP) Clip # Reason: assess effusions, s/p diuresis ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with short of breath ?",0
"emphysema vs chf vs. pneumonia; please do in AM REASON FOR THIS EXAMINATION: assess effusions, s/p diuresis ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath, emphysema ?CHF, pneumonia.",1
Comparison is made with prior radiograph .,0
There are bilateral effusions right greater than left with associated collapse/consolidation at the bases.,1
The heart size is difficult to assess due to overlying effusions.,1
This appearance is not significantly changed from the prior study.,0
The visualized associated osseous structures appear normal.,0
IMPRESSION: No significant change in bilateral pleural effusions with associated collapse/consolidation.,1
12:50 PM CHEST (PORTABLE AP) Clip # Reason: r/o ptx s/p ct's d/c'd ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with s/p avr/homograft REASON FOR THIS EXAMINATION: r/o ptx s/p ct's d/c'd ______________________________________________________________________________ FINAL REPORT INDICATION: Status post AVR.,0
"There is evidence of multiple sternal wires, suggestive of prior surgical intervention.",0
The heart is within normal limits.,0
No evidence of upper zone redistribution.,0
Hilar and mediastinal contours are unremarkable.,0
There is evidence of atelectasis at middle lung zone.,0
"The left CP angle is blunted, suggestive of a small left-sided pleural effusion.",0
Note is also made left lower lobe collapse/consolidation.,0
Visualized osseous structures are unremarkable.,0
IMPRESSION: No definite evidence of CHF or pneumonia.,0
"RENAL SCAN Clip # Reason: 58 YR OLD MAN WITH S/P ACUTE DISSECTION AND RENAL FAILURE, EVAL FOR FLOW/SPLIT ______________________________________________________________________________ FINAL REPORT RADIOPHARMACEUTICAL DATA: 5.4 mCi Tc-m MAG3 (); HISTORY: 58 y/o male s/p acute type A dissection extending to common iliac bifurcation and left common iliac artery.",1
Involvement of renal arteries is unknown.,0
Patient is presenting for evaluation of renal failure.,0
INTERPRETATION: Flow and dynamic images were obtained after intravenous administration of tracer.,0
Blood flow images show symmetric perfusion to both kidneys.,0
Renogram images show delayed excretion of tracer bilaterally.,0
The differential function obtained by analysis of tracer concentration in the parenchyma from 2 to 3 minutes post tracer injection shows the left kidney to be performing 47 % of the total renal function and the right kidney performing 53 %.,0
Markedly delayed tracer excretion bilaterally.,0
Findings consistent with poor parenchymal function which may reflect acute tubular necrosis in the setting of recent hypotensive insult or chronic medical renal disease.,1
Repeat assessment could be performed as clinically indicated.,0
Findings discussed with Dr. on the afternoon of by Dr. over the telephone.,0
Approved: FRI 3:18 PM RADLINE ; A radiology consult service.,0
"4:39 PM CHEST (PORTABLE AP) Clip # Reason: check for right lung re-expansion/pneumothorax, s/p right th Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with heart failure, bilateral pleural effusions, s/p right thoracentesis REASON FOR THIS EXAMINATION: check for right lung re-expansion/pneumothorax, s/p right thoracentesis ______________________________________________________________________________ FINAL REPORT HISTORY: Right thoracentesis, to evaluate for re-expansion and pneumothorax.",1
"FINDINGS: In comparison with study of , there has been a thoracentesis with removal of a substantial amount of pleural fluid.",0
There is no evidence of pneumothorax and could reexpansion of the lower right lung.,0
No evidence of reexpansion pulmonary edema.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NOTE: This is a Discharge Summary Addendum to the previous Addendum from .,0
HOSPITAL COURSE CONTINUED: The patient had a question of a right middle lobe infiltrate on chest x-ray noted on .,0
The patient was started on ceftazidime for presumed Medical Intensive Care Unit associated pneumonia.,0
"On , the patient underwent a bronchoscopy to further elucidate the question of a right middle lobe infiltrate.",0
It was noted that there was no purulent discharge or tracheoesophageal fistula on bronchoscopy.,0
The patient has remained clinically without pneumonia since his bronchoscopy.,0
"On , it was decided that the patient most likely did not have pneumonia and ceftazidime was stopped.",0
The patient had also been on vancomycin for presumed tracheal cuff cellulitis.,0
"The area around the cuff was erythematous; however, it was not warm nor was it indurated.",0
It most likely was a result of inflammatory and/or irritative changes to the skin.,0
The patient did not have clinical cellulitis around the tracheal pallor.,0
The patient's vancomycin was stopped.,0
The patient has been weaned off CPAP to a tracheal mask for durations of up to 16 hours on and on .,0
The patient has been tolerating these weanings appropriately.,0
The patient was started on Mucomyst for secretion to help decrease the thickness of his secretions.,0
The patient was tolerating his current respiratory support well.,0
The patient was ready for discharge to rehabilitation when rehabilitation is available.,0
Dictated By: MEDQUIST36 D: 14:14 T: 14:28 JOB#:,0
", M. NSURG FA11 9:34 PM MR HEAD W & W/O CONTRAST Clip # Reason: please evaluate for residual tumor burden; please do within Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with REASON FOR THIS EXAMINATION: please evaluate for residual tumor burden; please do within 36hrs post-op No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Postoperative changes are identified in the cerebellum with no definite residual enhancement.",0
Right frontal small area of blood products as on the recent CT.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Lisinopril Attending: Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Cath History of Present Illness: Ms is an 84 year old woman with history of labile hypertension, coronary artery disase (per report with 40% RCA lesion seen in cath), CLL, h/o breast cancer s/p left mastectomy and ischemic cardiomyopathy, presenting with new episode of chest pain this evening.",1
History is obtained via russian interpreter; patient reports she was at home resting when she started having severe chest pain localized to the left chest and which radiated to the left arm.,1
Patient took imdur and diovan and pain resolved in approximately 5 minutes.,0
"Denies any dizziness, syncope or pre-syncope, nausea, vomiting, diarrhea, diaphoresis, but did feel some difficulty breathing.",0
"Patient denies any recent joint pains, cough, hemoptysis, black stools or red stools.",0
"Patient believes this pain is more of a ""pressure"" than the pain she has been experiencing for the last few months.",0
"Denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.",0
"In the ED, 181/94, 70, 26 200% RA.",0
"Given 5mg IV lopressor, aspirin, plavix and heparin drip after discussion of ECG with cardiology fellow.",0
Patient admitted for further evaluation.,0
"Past Medical History: Hypertension Diet-controlled diabetes Congestive heart failure Breast cancer diagnosed 15 years ago, s/p left mastectomy CLL Social History: No smoking history.",1
Denies EtOH or illicit drugs.,0
"Family History: No family history of early MI, otherwise non-contributory.",0
Physical Exam: VS: 97.9 140/55 71 20 99% RA GENERAL: Well appearing elderly femaly in no distress.,0
NECK: Supple with JVP of 16 cm.,0
"EXTREMITIES: trace bilateral pedal edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.",0
PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: 09:00PM BLOOD WBC-8.8 RBC-4.14* Hgb-12.7 Hct-36.1 MCV-87 MCH-30.7 MCHC-35.2* RDW-13.9 Plt Ct-221 09:00PM BLOOD PT-12.5 PTT-23.8 INR(PT)-1.1 09:00PM BLOOD Glucose-148* UreaN-13 Creat-0.7 Na-139 K-3.6 Cl-100 HCO3-26 AnGap-17 09:00PM BLOOD CK(CPK)-79 05:40AM BLOOD ALT-20 AST-34 CK(CPK)-200* 01:10PM BLOOD CK(CPK)-173* 05:35AM BLOOD CK(CPK)-102 05:30AM BLOOD CK(CPK)-62 05:25AM BLOOD CK(CPK)-51 09:00PM BLOOD CK-MB-4 proBNP-255 09:00PM BLOOD cTropnT-0.03* 05:40AM BLOOD CK-MB-19* MB Indx-9.5* cTropnT-0.38* 01:10PM BLOOD CK-MB-14* MB Indx-8.1* cTropnT-0.25* 12:05AM BLOOD CK-MB-7 cTropnT-0.16* 05:35AM BLOOD CK-MB-6 cTropnT-0.15* 05:30AM BLOOD CK-MB-NotDone cTropnT-0.11* 05:25AM BLOOD CK-MB-NotDone cTropnT-0.15* 05:40AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.3 Iron-71 05:40AM BLOOD calTIBC-347 Ferritn-58 TRF-267 Cardiology Report ECG Study Date of 8:54:32 PM Sinus rhythm.,0
Inferolateral T wave abnormalities are non-specific but cannot exclude ischemia.,1
Since the previous tracing of sinus bradycardia is absent.,0
CXR IMPRESSION: No evidence of pneumonia.,0
Probable trace right pleural effusion.,0
TTE The left atrium and right atrium are normal in cavity size.,0
There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferolateral wall.,1
The remaining segments contract normally (LVEF = 50 %).,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction c/w CAD.,0
Mild pulmonary artery systolic hypertension.,1
.. CARDIAC CATHETERIZATION: COMMENTS: 1.,0
Selective coronary angiography of this right dominant system revealed one vessel CAD.,0
"The LMCA, LAD and LCX had no angiographically apparent flow limiting disease.",0
The RCA had a calcified ostial 95% lesion with left to right collaterals to the distal RCA.,0
"Successful rotational atheretomy, PTCA and stenting of the ostial RCA with two overlapping Cypher (3x18mm distal; 3.5x13mm) drug eluting stents postdilated distally with a 3.25mm balloon and 3.5mm balloon proximally.",0
"Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments).",0
Successful closure of the right femoral arteriotomy site with a Mynx closure device.,0
"Limited resting hemodynamics demonstrated systemic arterial hypertension, with BP of 180/72 mmHg.",0
One vessel coronary artery disease.,1
"Successful rotational atheretomy, PTCA and stenting of the ostial RCA with two overlapping Cypher drug eluting stents.",0
"Brief Hospital Course: Ms is an 84 year old woman with history of CAD, systolic heart failure, presenting with complaint of chest pain.",1
# NSTEMI: Patient with complaints of chest pain the day of admission.,0
She was chest pain free after SL nitro.,0
She ruled in for NSTEMI with a peak Trop of 0.38.,0
She was started on heparin and integrelin gtt.,0
"She was also given ASA 325, plavix loaded with 600mg and continued on 75mg daily, and continued her BB.",0
She remained chest pain free thoughout her admission.,0
She underwent cardiac cath on and showed One vessel coronary artery disease with 95 % occluded proximal RCA.,1
"She then underwent successful rotational atheretomy, PTCA and stenting of the ostial RCA with two overlapping Cypher drug eluting stents as well as successful closure of the right femoral arteriotomy site with a Mynx closure device.",0
She will plan on long-term Plavix therapy.,0
# CHRONIC SYSTOLIC HEART FAILURE: The patient underwent ECHO on and showed an EF 50%.,1
She was continued on her BB and therapy.,0
# HYPERTENSION: Pt with labile blood pressures during her stay.,0
Her BP would be elevated into SBP 150's later in the evening.,0
Her valsartan was changed to noon time dosing to improve evening pressures.,0
Her BP improved with the adjustment.,0
"She was continued on Diltiazem, Isosorbide, Metoprolol, and valsartan.",0
# Diabetes: She is diet controlled.,0
Her AM glucose has been elevated with a high of 148.,0
She was monitored with QACHS FS and covered with an ISS.,0
She should have outpatient follow-up regarding further management.,0
# Glaucoma: She was continued on her outpatient regimen .,1
# FEN: Cardiac/ Diabetic diet was continued and her electrolytes were monitored daily and repleted as needed.,0
# PROPHYLAXIS: Heparin drip .,0
# CODE: The patient was maintained as a full code status for the entirety of her hospital course and this was confirmed with family .,0
# CONTACT: -daughter ( / ( Medications on Admission: -- Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"-- Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily).",0
-- Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"-- Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
-- Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime).,0
Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed).,0
Betimol 0.5 % Drops Sig: One (1) Ophthalmic once a day Discharge Medications: 1.,0
Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day.,0
Timolol Maleate 0.5 % Drops Sig: One (1) Ophthalmic Daily ().,0
Polyvinyl Alcohol 1.4 % Drops Sig: Ophthalmic prn.,0
"Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily).",0
"Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 7.",0
Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.,0
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 8.,0
"Sig: Two (2) Capsule, Delayed Release(E.C.)",0
")(s)* Refills:*2* Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Primary: NSTEMI Hypertension Diet-controlled diabetes Diastolic Congestive heart failure Discharge Condition: stable, chest pain free, ambulating, O2 sat >95% on RA Discharge Instructions: It was a pleasure taking care of you while you were in the hospital.",1
You were admitted to because of a heart attack.,0
You underwent cardiac catheterization that showed a blockage of one of the arteries of your heart and you had a stent placed.,0
Please take all your medications as prescribed.,0
The following changes were made to your medication regimen.,0
Please take aspirin 325 mg daily instead of 81 mg daily 2.,0
Please take plavix 75 mg daily.,0
It is very important that you take this medication every day.,0
Do not stop this medication until you are told to do so by your cardiologist.,0
You will start taking Toprol XL 150mg daily 4.,0
Your Diltiazem was decreased to 180mg daily 5.,0
You were started on omeprazole 40mg daily 6.,0
You will start Lipitor 80mg daily Please follow up with the appointments below.,0
"Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms.",0
"Weigh yourself every morning, MD if weight > 3 lbs.",0
Adhere to 2 gm sodium diet Followup Instructions: You have an appointment with your primary care physician .,0
If this is not convenient you can call and reschedule.,0
The office number is .,0
"Provider: , MD Phone: Date/Time: 2:20 Completed by:",0
"7:07 PM ABDOMEN U.S. (PORTABLE) Clip # Reason: PT W/ DECREASED BP, R/O AAA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with back pain + hypotension REASON FOR THIS EXAMINATION: r/o AAA ______________________________________________________________________________ FINAL REPORT INDICATION: Hypotension and ?",0
ABDOMEN US: Limited scale ultrasound images of the abdomen demonstrate normal aoritc caliber from the proximal abdominal aorta through to the bifurcation.,0
No free fluid is seen within the abdomen.,0
IMPRESSION: No evidence of AAA.,0
"3:54 PM SHOULDER (AP, NEUTRAL & AXILLARY) SOFT TISSUE BILAT Clip # Reason: ?",0
"of DJD, effusions Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with severe shoulder pain REASON FOR THIS EXAMINATION: ?",1
"of DJD, effusions ______________________________________________________________________________ FINAL REPORT INDICATION: 79 year old man with severe shoulder pain.",0
"BILATERAL SHOULDER VIEWS, TWO AP VIEWS OF EACH WITH INTERNAL/EXTERNAL ROTATION: No axillary views were performed.",0
"There is a probable left internal jugular venous catheter, whose intrathoracic course cannot be characterized on these views.",0
A biventricular pacemaker overlies the left hemithorax.,0
"There is no evidence for fracture, dislocation, or bony destruction on either side.",0
"It is not possible to evaluate for a shoulder effusion on these views, although no significant downward displacement of the humeral heads is seen.",0
The adjacent lung apices appear clear.,0
IMPRESSION: No evidence of significant degenerative change.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) / Fentanyl / Morphine Attending: Chief Complaint: s/p Assault Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo male s/p assault after reportedly initiating an attack on the other individiual.,0
He was intubated for combativeness and transported to for continued trauma care.,0
Past Medical History: Hepatitis C Anxiety Family History: Noncontributory Pertinent Results: 10:49PM TYPE-ART PO2-87 PCO2-52* PH-7.31* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA 01:53PM GLUCOSE-102 UREA N-13 CREAT-0.8 SODIUM-142 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-24 ANION GAP-11 01:53PM ALT(SGPT)-75* AST(SGOT)-107* ALK PHOS-146* AMYLASE-93 TOT BILI-3.1* 01:53PM LIPASE-19 01:53PM ALBUMIN-3.2* CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.9 01:53PM WBC-4.5 RBC-3.67* HGB-12.3* HCT-36.1* MCV-98 MCH-33.4* MCHC-34.0 RDW-14.7 01:53PM PLT COUNT-43* 01:35AM PT-16.3* PTT-29.1 INR(PT)-1.5* 01:35AM FIBRINOGE-110* CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST 1:45 AM CT SINUS/MANDIBLE/MAXILLOFACIA Reason: r/o fx MEDICAL CONDITION: 45 year old man with assault REASON FOR THIS EXAMINATION: r/o fx CONTRAINDICATIONS for IV CONTRAST: None.,1
"The additional finding of a minimally displaced left zygomatic arch fracture, prompting report revision, was communicated to , Quality Assurance Nurse, via her voice mail on at 11:30AM.",0
"INDICATION: Status post assault, rule out fracture.",1
MDCT acquired axial images of the paranasal sinuses and facial bones were obtained with coronal reformatted images.,1
"FINDINGS: There is a fracture of the posterior wall of the left maxillary sinus, a left nasal bone fracture, and a minimally displaced fracture of the left lateral orbital wall.",1
There also appears to be a slightly displaced fracture of the left inferior orbital wall posteriorly without entrapment of the extraocular muscles.,0
There is layering hemorrhage in the left maxillary sinus.,1
There is overlying soft tissue swelling.,0
No other fractures are seen.,0
IMPRESSION: Multiple facial fractures as above.,1
ADDENDUM: There is a minimally displaced fracture of the left zygomatic arch.,0
CT HEAD W/O CONTRAST 1:44 AM CT HEAD W/O CONTRAST Reason: r/o bleed MEDICAL CONDITION: 45 year old man with assault REASON FOR THIS EXAMINATION: r/o bleed CONTRAINDICATIONS for IV CONTRAST: None.,0
"INDICATION: Status post assault, rule out bleed.",0
TECHNIQUE: MDCT acquired images of the head were obtained without contrast.,0
FINDINGS: There is no evidence of acute intra- or extra-axial hemorrhage.,1
-white matter differentiation appears preserved.,0
There is no hydrocephalus or shift of normally midline structures.,0
"Bone windows reveal fractures of the left nasal bone, the posterior wall of the left maxillary sinus, and a minimally displaced fracture of the lateral left orbital wall.",1
A large air fluid level is noted in the left maxillary sinus.,0
Multiple facial fractures as above.,1
Please also refer to the report from the CT sinus maxillofacial bones study that is dictated separately.,1
"CHEST (PA & LAT) 3:42 PM CHEST (PA & LAT) Reason: eval pna, effusion, edema, ptx MEDICAL CONDITION: 45 year old man with fever, cough, desats REASON FOR THIS EXAMINATION: eval pna, effusion, edema, ptx CHEST, TWO VIEWS.",0
"INDICATION: 45-year-old man with fever and cough, evaluate for pneumonia, effusion, edema.",0
"CHEST, TWO VIEWS: Comparison is made to prior study from earlier the same day.",0
There is platelike atelectases in the right and left lower lobe.,0
This has improved in comparison to the prior study from 5:07 a.m.,0
IMPRESSION: Improved atelectasis in the lower lobes bilaterally.,0
Brief Hospital Course: Patient admitted to the trauma service.,0
Plastic Surgery and Ophthalmology were immediately consulted because of his injuries.,0
"Non operative intervention; Plastics recommended Levofloxacin, he initially received IV which was later changed to oral.",0
This will continue for an additional 3 days after discharge to complete a 10 day course.,0
He will follow up with Plastics in 1 month after discharge.,0
Ophthalmology found no entrapment and recommended eye drops with follow up in their clinic as necessary.,0
"He continued to have midline bony tenderness posterior cervical region despite negative imaging for any fractures, dislocations of his cervical spine.",0
He is being discharged with a soft collar for comfort.,0
Pain control was an issue with patient during his hospitalization; he is being discharged with oral Dilaudid.,0
Medications on Admission: Wellbutrin Ativan Lactulose Dilaudid Discharge Medications: 1.,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: maximum: 12 pills in 24 hours.,0
Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday).,0
Disp:*3 Patch Weekly(s)* Refills:*2* 3.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 7 days.,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days.,0
Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day).,0
Disp:*60 Tablet Sustained Release(s)* Refills:*2* 8.,0
Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) drops Ophthalmic four times a day.,0
Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO Q6H:PRN as needed for nausea.,0
Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Discharge Diagnosis: s/p Assault Left facial fractures (maxillary) Discharge Condition: Stable Discharge Instructions: Discharge directly to prison per authorities.,1
Continue the levofloxacin (antibiotic) until the medicine is gone.,0
You may wear soft cervical for comfort.,0
Use the eye drops as directed to avoid irritation.,0
Followup Instructions: Call the plastic surgery clinic within a few days at for a follow up appoinment in 1 month for your facial fractures.,1
"You do not require follow up with the eye doctors unless have worsening vision, pain with eye movement, or anything else that concerns you.",0
The clinic number is .,0
10:12 AM CHEST (PA & LAT) Clip # Reason: Eval PNA or other acute intrathoracic process Admitting Diagnosis: FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man s/p distal gastrectomy REASON FOR THIS EXAMINATION: Eval PNA or other acute intrathoracic process ______________________________________________________________________________ FINAL REPORT Extensive consolidation in both lower lungs and moderate bilateral pleural effusions are new.,1
"Heart is normal in size, though increased slightly since yesterday's examination.",0
Right jugular line ends in the mid SVC.,0
Nasogastric tube has been removed.,0
Dr. and I discussed these findings.,0
", E. TSICU 3:59 AM CT HEAD W/O CONTRAST Clip # Reason: int changes ***please take at 04:00 *** Admitting Diagnosis: S/P FALL;HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with IPH s/p fall on coumadin REASON FOR THIS EXAMINATION: int changes ***please take at 04:00 *** No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",0
Again continued interval increase in size of parenchymal hemorrhage within the infarcted tissues of the left temporo-occipital lobe.,0
No new focus of intracranial hemorrhage nor intraventricular extension.,1
Unchanged appearance of multiple foci of hypodensities corresponding to prior infarcts.,0
Redemonstration of depressed anterior wall of right frontal sinus fracture.,0
PATIENT/TEST INFORMATION: Indication: cardiac arrest / ?effusion Height: (in) 71 Weight (lb): 180 BSA (m2): 2.02 m2 BP (mm Hg): 128/80 HR (bpm): 75 Status: Inpatient Date/Time: at 15:05 Test: Portable TTE (Focused views) Doppler: Color Doppler only Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness.,1
AORTIC VALVE: Aortic valve not well seen.,0
Conclusions: Left ventricular wall thicknesses are normal.,0
There is mild regional left ventricular systolic dysfunction with akinesis of the basal to mid inferolateral segments.,0
The aortic valve is not well seen.,0
Mild focal LV systolic dysfunction.,0
The RV is not well seen but it may be mildly dilated and hypokinetic.There is no pericardial effusion.,0
8:44 PM CHEST (PORTABLE AP) Clip # Reason: eval chest tube Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with s/p aaa repair with MOS failure REASON FOR THIS EXAMINATION: eval chest tube ______________________________________________________________________________ FINAL REPORT HISTORY: S/P AAA repair.,1
"CHEST, AP PORTABLE: The position of the NG tube and the subclavian line remains unaltered.",0
The position of the left chest tube is not significantly altered with the final of the chest tube lying within the soft tissues.,0
Atelectasis at the left base is present.,0
"There is some probable pulmonary plethora, consistent with mild failure.",0
IMPRESSION: No significant change in position of any of the lines or tubes.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Amoxicillin / bees / CT scan dye Attending: Chief Complaint: wheezing s/p bronchial thermoplasty Major Surgical or Invasive Procedure: bronchial thermoplasty History of Present Illness: 36 yo F with h/o severe persistent asthma, pericarditis, heart murmur, ovarian cysts, C-section x2, enrolled in the PAS study, s/p bronchiothermoplasty of RLL with wheezing post procedure.",1
"She has had severe asthma since her first pregnancy leading to several hospitalizations at , the last in she was admitted for 2 weeks despite being on maximal inhaled steroids and bronchodilators.",1
"She has completed several prednisone tapers after hospital admission, with which she feels jittery and gains weight.",0
"On the floor, patient is wheezing and feels very tight.",0
Patient underwent her procedure today and postoperatively in the PACU she had chest pain and shortness of breath.,1
Chest pain was in severity.,0
She got albuterol and 1g IV tylenol and morphine (total 5 mg) for pain with some relief.,0
Glycopyrole to reduce secretions and prednisone preoperatively.,0
PFTs preop were performed and her 4 hour postop PFTs were 60% of her preop PFTs.,0
"Per protocol, if PFTs less than 80% of preoperative values, then the patient requires admission for further evaluation.",0
"Past Medical History: Asthma (since childhood) Heart murmur Pericarditis Ovarian cysts C-section X 2 Social History: single mom, lives with her 2 children.",1
Occupation: nanny and administrative director.,0
Alcohol: occasional <1 per week.,0
These findings are concerning for multifocal infection and less likely pulmonary edema.,0
Small amount of pleural effusion cannot be excluded.,0
Current study reveals no evidence of pneumothorax or pneumomediastinum within the limitations of this portable AP radiograph.,0
No evidence of deep vein thrombosis in either leg.,0
Superficial thrombophlebitis seen in the left calf at the site of the patient's tenderness.,0
"CXR As compared to the previous radiograph, there is no relevant change.",0
"Relatively low lung volumes with parenchymal opacities at both lung bases, right more than left.",0
The extent of the opacity is stable since the previous examination.,0
Moderate cardiomegaly without evidence of pulmonary edema.,0
Brief Hospital Course: This is a 36 yo F with hx of severe asthma who was admitted s/p bronchial thermoplasty for shortness of breath and wheezing.,1
# Shortness of breath: Patient admitted s/p bronchial themoplasty for shortness of breath and wheezing.,1
"She was managed with IV steroids, frequent nebulizers, and oxycodone and morphine for pain.",0
Her chest pain was evaluated with ECG and troponins which were negative for ischemic.,0
Overnight she became tachypneic and tachycardic prompting transfer to the MICU for close monitoring.,0
She was given heliox and ativan with improvement of her symptoms.,0
She had a LENI for calf pain which was negative for DVT.,0
She was transferred back to the floor however returned to the MICU due to persistent dyspnea and tachycardia.,0
She was evaluated by ENT who found the patient to have paradoxical vocal fold motion which could be contributing to her symptoms.,0
It was recommended that she start a reflux regimen and follow up with ENT in weeks.,0
She should also undergo respiratory retraining therapy.,0
She was transitioned to a po prednisone taper regimen and repeat bedside spirometry showed improvement in her respiratory function.,0
She was transferred back to the floor and remained stable overnight.,0
She was discharged with plans to follow up with interventional pulmonary and ENT.,0
# Anxiety: Respiratory distress responded to ativan in MICU.,0
Psychosocial triggers believed to be a significant contributor to vocal cord malfunction and episodes of dyspnea.,0
TRANSITIONAL ISSUES: - no labs pending at time of discharge - Follow up for PVFM evaluation and respiratory retraining - Follow up with interventional pulmonology as scheduled - patient full code during admission Medications on Admission: Preadmission medications listed are correct and complete.,0
Information was obtained from Patient.,0
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 2. albuterol sulfate *NF* 90 mcg/actuation Inhalation 2 puffs 3.,0
Fluticasone Propionate NASAL 1 SPRY NU DAILY 4.,0
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH 5.,0
Ipratropium Bromide MDI 1 PUFF IH Q6H 6.,0
Montelukast Sodium 10 mg PO DAILY 7.,0
ValACYclovir 500 mg PO PRN ulcers 8.,0
NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr Vaginal monthly Discharge Medications: 1.,0
Montelukast Sodium 10 mg PO DAILY 2.,0
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH 3.,0
Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 5.,0
PredniSONE 10 mg PO DAILY Duration: 65 Doses Start: After 20 mg tapered dose.,0
Take 60mg (six 10mg tabs) once per for 3 .,0
Then take 50mg (five 10mg tabs) once per for 3 .,0
Then take 40mg (four 10mg tabs) once per for 3 .,0
Then take 30mg (three 10mg tabs) once per for 3 .,0
Then take 20mg (two 10mg tabs) once per for 3 .,0
Then take 10mg (one 10mg tab) once per for 3 .,0
Tapered dose - DOWN RX *prednisone 10 mg tablet(s) by mouth daily as directed Disp #*65 Tablet Refills:*0 6.,0
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 7.,0
Ipratropium Bromide MDI 1 PUFF IH Q6H 8.,0
NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr Vaginal monthly 9.,0
ValACYclovir 500 mg PO PRN ulcers 10.,0
"Albuterol Inhaler PUFF IH Q6H:PRN shortness of breath RX *albuterol sulfate [ProAir HFA] 90 mcg 1-2 puffs inhaled every 4-6 hours Disp #*1 Each Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Asthma, Paradoxical vocal cord movement Secondary diagnosis: Anxiety Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: Dear Ms. , It was a pleasure taking care of your at Medical Center.",0
You were admitted after your lung procedure because of persistent wheezing and shortness of breath.,1
You were managed with inhalers and medications but required two nights in the ICU for increased monitoring.,0
"You were evaluated by the ear, nose and throat experts who found that you have spasms of your vocal cords contributing to your shortness of breath.",1
You improved with continued inhalers and breathing therapy.,0
You should follow up with your pulmonologist as scheduled for futher management of your asthma.,0
You will need to schedule an appointment to see ENT for further evaluation of your vocal cords.,1
Please START taking: - Omeprazole 20mg PO BID - Prednisone taper as follows: 60 mg (6 tablets) for 3 () 50 mg (5 tablets) for 3 () 40 mg (4 tablets) for 3 () Your pulmonologist can discuss how they want to complete your taper at your follow up appointment on .,0
Please continue taking you home medications as directed.,0
Followup Instructions: Please call ENT at to schedule a follow up appointment with Dr. within 1-2 weeks.,0
"Department: PFT When: TUESDAY at 8:00 AM Department: PULMONARY FUNCTION LAB When: TUESDAY at 8:00 AM With: PULMONARY FUNCTION LAB Building: GZ BUILDING (FELBEERG/ COMPLEX) Campus: EAST Best Parking: Main Garage Department: WEST CLINIC When: TUESDAY at 9:00 AM With: , MD Building: De Building ( Complex) Campus: WEST Best Parking: Garage Completed by:",0
"3:03 AM CHEST (PORTABLE AP) Clip # Reason: eval ETT, lung fields Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE;RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with multifocal PNA, CHF intubated in MICU REASON FOR THIS EXAMINATION: eval ETT, lung fields ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP view on .",1
"HISTORY: 74-year-old woman with multifocal pneumonia and congestive heart failure, intubated in MICU, evaluate ETT and lung fields.",1
"FINDINGS: In the interim, a newly placed left subclavian central line has been placed with distal tip still in the left brachiocephalic vein.",0
An endotracheal tube projects approximately 2.5 cm above the carina bifurcation.,0
There is persistent multifocal airspace disease in both lungs which has not significantly resolved from the previous examination.,0
"There is also persistent bilateral pleural effusion with consistent atelectasis, left more than right.",0
The osseous structures do not show any abnormalities suspicious for any aggressive lesion.,0
Newly placed left subclavian venous catheter with distal tip projected over the course of the left brachiocephalic vein.,0
Persistent multifocal airspace disease consistent with history of pneumonia.,0
Unchanged bilateral bibasilar pleural effusion.,0
"8:03 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOP ABD/PEL LIMITED Reason: SP LIVER TRISEGMENTECTOMY ,EVAL LIVER FLOW Admitting Diagnosis: METASTASIS OCCULAR MELANOMA TO LIVER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 42-year-old female who underwent proton beam therapy for an ocular melanoma in .",1
"She had a recurrence in and once again received proton beam radiation, on she was noted tohave an elevated alkaline phosphatase at 189.",0
"A CT scan was performed on which demonstrated a 4-cm mass in the domeof the liver in the right lobe (Segment VII, VIII) and a second5-cm lesion in Segment IVb (medial segment of the left lobe.",0
"Now s/pright hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy REASON FOR THIS EXAMINATION: s/p portal vein thrombosis, eval the the flow ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 9:23 AM Expected post-multisegmentectomy appearance with normal left portal vein/hepatic artery waveforms.",1
______________________________________________________________________________ FINAL REPORT HISTORY: 42-year-old female with right hepatic lobectomy following metastatic melanoma.,0
DUPLEX DOPPLER LIVER ULTRASOUND: There has been trisegmentectomy of the liver.,0
"The left lobe of the liver appears unremarkable, without focal liver lesion identified.",0
"Appropriate waveforms are identified in the left portal vein, which is patent.",0
Limited waveforms of the left hepatic artery appear normal.,0
There is no fluid collection or ascites.,0
IMPRESSION: Expected post-trisegmentectomy appearance of the left lobe of the liver.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: Baby is the 2.180 gram product of a 34-2/7 week twin gestation born to a 32-year-old, G2, P1, now 3 mother.",1
"Prenatal screens - A positive, antibody negative, hepatitis surface antigen negative, rubella immune, RPR nonreactive, GBS unknown.",0
Mother presented with rupture of membranes in preterm labor.,0
Infants were delivered by cesarean section for twin gestation and repeat C-section.,1
Twin A emerged vigorous with good cry.,0
"Apgars were 8 and 9 at 1 and 5 minutes, respectively.",0
"PHYSICAL EXAM ON ADMISSION: Weight 2.18 kg, length 45.5 cm, head circumference 31.25 cm.",0
Anterior fontanel open and flat.,0
Clear breath sounds with fair aeration.,0
"Abdomen soft, nondistended, no masses.",0
HISTORY OF HOSPITAL COURSE BY SYSTEMS: 1.,0
RESPIRATORY: has been stable in room air throughout hospital course with no episodes of apnea or bradycardia.,0
FLUID AND ELECTROLYTE: Birthweight was 2.18 kg.,0
Discharge weight is 2355 grams.,0
Infant has been in excess of 100 per kg over the last 24 hours of breast milk or Enfamil 24 calorie.,0
GI: Peak bilirubin was on day of life #4 of 6.5/0.2.,0
He has not required any intervention.,0
HEMATOLOGY: Hematocrit on admission was 49.7.,0
Has not required any blood transfusions.,0
INFECTIOUS DISEASE: CBC and blood culture obtained on admission.,0
"CBC was benign, and blood cultures remain negative at 48 hours.",0
NEURO: Infant has been appropriate for gestational age.,0
"SENSORY: Hearing screen was performed with automated auditory brain stem responses, and the infant passed.",0
NAME OF PRIMARY PEDIATRICIAN: CARE RECOMMENDATIONS: 1.,0
Feeding: Continue ad lib feeding breast milk or Enfamil 24 calorie.,0
Car seat position screening has been performed and infant passed the 90-minute screening.,0
Immunizations received: Infant received hepatitis B vaccine on .,0
"DISCHARGE DIAGNOSES: Premature twin #1, rule out sepsis, mild hyperbilirubinemia.",0
", Dictated By: MEDQUIST36 D: 20:26:42 T: 21:27:01 Job#:",0
11:04 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval ET tube placement.,0
Admitting Diagnosis: ACUTE RESPIRATORY FAILURE;SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with resp failure.,1
REASON FOR THIS EXAMINATION: eval ET tube placement.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after reintubation.,0
The right central venous line catheter distal tip is at the cavoatrial junction.,0
"Bibasal atelectasis and pleural effusions are at least moderate, and unchanged.",0
The nodular opacities known since the chest CT from are at least in part seen on the prior radiograph.,0
There is slight interval improvement in pulmonary edema.,0
There is no change in the right basal consolidation since .,0
8:13 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
endotracheal tube placement and migrated esophageal stent ______________________________________________________________________________ MEDICAL CONDITION: 72F s/p transhiatal esophagogastrectomy s/p complication of esophageal stenting procedure now intubated.,0
endotracheal tube placement and migrated esophageal stent parts ______________________________________________________________________________ WET READ: 9:49 PM ET in proper position.,0
bilateral patchy alveolar opacities most likely secondary to aspiration are slightly more prominnet compared to the prior studies.,0
Esophageal stent has migrated to the pharynx and upper esophagus.The presence of stent within airways can not be assessed on this Ap radiograph.,0
Left effusion and basilar atelectasis have increased.,0
Hyperdense area projecting over the heart represents retained barium?.,0
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Trans-hiatal esophagogastrectomy with esophageal stenting post-procedure.,0
Now intubated with concern for migrated stent.,0
STUDY: Portable frontal chest x-ray.,0
PRELIMINARY REPORT: Endotracheal tube in proper position.,0
Bilateral patchy alveolar opacities most likely secondary to aspiration or slightly more prominent compared to the prior studies.,0
The esophageal stent has migrated to the pharynx and upper esophagus.,0
Presence of stent within the airways cannot be assessed on this AP radiograph.,0
Left effusion and bilateral atelectasis have increased.,0
Hyperdense area projecting over the heart represents retained barium?,0
"FINDINGS: Compared to , the esophageal stent has migrated cephalad with its distal most portion now at the thoracic inlet roughly 10.0 cm cephalad to where it was on the prior study.",0
The more superior portion may be just below the upper esophageal sphincter.,0
Endotracheal tube is in expected position roughly 6.0 cm above the carina.,0
There is no gas seen within the stomach in the mediastinum.,0
Left basilar consolidation persists and there is high- density material overlying the left lung base which could represent retained barium if there has been administered since .,0
Consolidation in the left mid lung and right apex are unchanged and may represent slow resolving aspiration versus scarring.,0
"There is likely a small left pleural effusion, however, the right pleural effusion appears to have resolved.",0
Total left shoulder arthroplasty and right chronic rotator cuff tendinopathy changes and post- surgical suture anchors are unchanged.,0
Migration of esophageal stent into the cervical esophagus.,0
Persistent pulmonary opacities with new high-density material overlying (Over) 8:13 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
endotracheal tube placement and migrated esophageal stent ______________________________________________________________________________ FINAL REPORT (Cont) the left lung base which could be barium within the stomach or within the lung.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF THE PRESENT ILLNESS: Mrs. is a 67-year-old female with a history of severe mitral regurgitation, who recently underwent mitral valve replacement two weeks prior to admission, complicated only by a brief episode of postoperative bradycardia.",0
"The patient for a visit on the day of admission due to worsening shortness of breath, cough, and paroxysmal nocturnal dyspnea with orthopnea since she went home.",0
She was sent to the Emergency department from Clinic via ambulance.,0
"On further questioning through the translator, the patient reported that she was feeling ill on her day of discharge, discharge she had developed worsening cough, producing white phlegm and occasional blood-tinged sputum, but never yellow or green.",0
"She reported that she had not been able to sleep, and she has not been able to lie flat, and she has been sitting in a chair at night.",0
"She denied any fever, chills, or any chest pain.",0
"She denied any nausea or vomiting, but she had one episode of frequent loose stools.",0
She denied any melena or hematochezia.,0
"In the emergency department, the patient was found to have bibasilar crackles and an elevated jugular vein at 10 cm to 12 cm.",0
A portable chest x-ray result was reported to show congestive heart failure and right sided pleural effusion.,1
The patient was given 40 mg IV Lasix with good output.,0
The patient was given Levofloxacin for questionable UTI by urine dipstick.,0
Blood cultures were not obtained.,0
The patient was transferred to 3.,0
"Mitral regurgitation, mitral valve prolapse status post mitral valve replacement in .",0
Colace 100 mg one tablet b.i.d.,0
Potassium chloride 20 mEq p.o.b.i.d.,0
Lasix 20 mg p.o.one tablet b.i.d.,0
Percocet 5/325 one to two tablets q.4h.,0
"SOCIAL HISTORY: The patient smoked in the past, no alcohol history.",0
She lives with her sister.,0
"PHYSICAL EXAMINATION: Examination revealed the following: Heart rate 96 and irregular, blood pressure 124/70, respiratory rate 22, oxygen saturation 99% on three liters nasal cannula.",0
"GENERAL: The patient is an alert, awake female looking slightly tremulous and short of breath upon speaking.",0
"Head, eyes, ears, nose, throat: Examination demonstrated mucous membranes mildly dry, no icterus.",0
"CARDIOVASCULAR: S1 metalic, soft 1/6 systolic murmur, irregular rhythm.",0
"PULMONARY: Right decreased air entry in the lower chest, crackles and rubs in mid chest left basilar crackles, no wheezing, postoperative wound well approximated, no apparent drainage, no pain over the chest wound.",0
"ABDOMEN: Nondistended, nontender, positive bowel sounds, no mass, right flank changes with local skin breakdown extending into the right hip, back, and buttock regions.",0
"RECTAL: Rectal examination revealed no obstipation, guaiac-negative stool.",0
EXTREMITIES: No lower extremity edema.,0
"NEUROLOGICAL: The patient is alert, awake, oriented times three; appears to answer appropriately to questions, moving all four extremities, asymmetric.",0
"LABORATORY DATA: Labs upon admission revealed the following: White count 18.2, hematocrit 27.8, platelet count 781,000, PT 21.6, PTT 39.5, INR 3.2.",0
"Sodium 128, potassium 5.3, chloride 92, bicarbonate 25, BUN 17, creatinine 0.8, glucose 165, CK 222, troponin less than 0.3.",0
Urinalysis showed 3 to 5 white cells plus nitrites.,0
"Catheterization results on revealed the coronary arteries normal, moderate-to-several mitral regurgitation plus severe mitral annular calcification and normal ventricular function with a EF of 64%.",0
HOSPITAL COURSE: CARDIOVASCULAR: The patient was maintained on telemetry and service.,0
"By ECHO, she was subsequently found to have an approximately 500 cc pericardial effusion, which was drained percutaneously without any complications.",0
Coumadin was held prior to procedure and ordered to decrease the INR to less than two.,0
"Also, after the patient's pericardiocentesis she was cardioverted secondary to her atrial fibrillation; it was successful.",1
The patient was maintained in normal sinus rhythm throughout the course of her stay.,0
"RESPIRATORY: The patient also was found to have a right phrenic nerve paresis, likely temporary as the nerve was not transected, apparently irritated during the mitral valve replacement procedure.",0
"She was found to have a left-sided pleural effusion, which was successfully drained by the pulmonary fellow.",1
Fluid was sent off for analysis and no infection or malignancy was found.,0
"She has a baseline shortness of breath when she lies down, however, she had no worsening of shortness of breath, cough, or chest pain throughout the course of stay.",0
"HEMATOLOGY: The patient was restarted on her Coumadin with a Coumadin load secondary to her atrial fibrillation history, as well as prosthetic valve.",1
It was considered crucial that her INR is at least 2.5 before she is discharged.,0
She was to follow-up with the Clinic.,0
"Pericardial effusion, status post pericardiocentesis.",0
Left pleural effusion status post right thoracocentesis.,1
until and then 200 mg p.o.q.d.,0
Iron sulfate 325 mg p.o.q.d.,0
Calcium carbonate 500 mg p.o.t.i.d.,0
"DISCHARGE INSTRUCTIONS: The patient is to followup with her primary care physician, .",0
"She is to followup with Dr. , her cardiologist on , 4:15 and Dr. , her CT surgeon at 10 a.m. She was also to call the Clinic at for follow up care.",0
Dictated By: MEDQUIST36 D: 15:16 T: 15:40 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby girl twin 2 was the 1125 gram product of a 28 and week gestation, twin gestation born go a 40-year-old G1 P0 now 2 mom.",1
"Pregnancy complicated by preterm labor and cervical shortening, which required admission to the .",0
Treatment with tocolysis and betamethasone.,0
"Rupture of membranes on other twin occurred on , delivery , due to onset of labor with breech breech presentation.",0
"Prenatal screens, A positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, Rubella immune.",0
Infant emerged with good heart rate and respiratory effort.,0
Apgars were 5 and 8.,0
"Required blow by O2 and CPAP in delivery room, brought to the newborn intensive care unit for further management of prematurity.",1
PHYSICAL EXAMINATION: On admission birth weight was 1.125 kilograms.,1
"Head circumference was 26.5 cm, L=38.5 cm.",0
Lungs with coarse crackles bilaterally.,0
"Abd: soft, no masses, no hepatosplenomegaly.",0
Hips held in breech presentation.,0
"Normal neuro exam, nonfocal and age appropriate.",0
"admitted to the newborn intensive care unit with increasing respiratory distress, intubate to manage respiratory distress syndrome.",1
"Received surfactant x 2 doses; CPAP 10/5 through ; RA to ; NC to ; RA to ; NC 200 cc/min O2 from to , weaned to RA.",0
NC O2 primarily for Rx of bradycardi.,0
"Currently Rx caffeine citrate(8 mg/kg/day)po since / 3, .",0
Has had no cardiovascular issues throughout her hospital course.,0
Birth weight was 1.125 kilograms.,1
Head circumference was 26.5 cm.,0
She was initially started on 80 cc per kilo per day of D10W.,0
Enteral feedings were initiated on day of life #2.,0
She achieved full enteral feedings by (day 9); currently tolerating 150 cc/kg/day Special Care 26 calories.,0
Peak bilirubin was on day of life #2 of 4.1/0.2.,0
Last bili = 3.7 This issue has resolved.,0
Last Hct =41% day 2.,0
No blood transfusion during this hospital course.,0
A CBC and blood culture obtained on admission.,0
"CBC had a white count of 7.7K, 8 polys and 1 band.",0
"Repeat CBC improved WBC= 8.2k, 40 neutrophils, 0 bands, 47 lymphs, platelet count of 229.",0
"She received ampicillin, gentamycin for a total of 48 hours at which time blood cultures remained negative and antibiotics were discontinued.",0
She has been appropriate for gestational age.,0
Head ultrasound on day of life #8 was within normal limits.,0
"Ophthalmology ROP screen, hearing screen not performed at , should performed prior to discharge.",0
NAME OF PRIMARY PEDIATRICIAN: Dr. .,0
"CARE AND RECOMMENDATIONS: Feeds at discharge continue 150 cc per kilo per day of breast milk 26 calorie, advancing caloric density as required.",0
"Medications, caffeine citrate 8 mg po every day, ferrous sulfate of 0.15 milliliters po every day (25 mg per milliliter), vitamin E 5 units po every day.",0
Car seat screening to be conducted at .,0
State newborn screens initially sent : increased amino acids likely due to parenteral nutrition.,0
repeat screen sent on .,0
Will receive prior to discharge.,0
DISCHARGE DIAGNOSES: Premature infant twin #2.,0
Respiratory distress syndrome Negative sepsis evaluation Rx antibiotics x 48 hr.,1
Apnea and bradycardia of prematurity.,1
", MD Dictated By: MEDQUIST36 D: 00:29:51 T: 07:05:32 Job#:",0
3:37 PM CHEST (PORTABLE AP) Clip # Reason: eval for PTX ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman w/ tracheal stenosis and TBM.,0
tracheal stent removed REASON FOR THIS EXAMINATION: eval for PTX ______________________________________________________________________________ FINAL REPORT History of tracheal stenosis and tracheobronchomalacia.,0
"Evaluate for pneumothorax, status post stent removal.",0
PORTABLE AP CHEST RADIOGRAPH: Comparison made to prior radiograph from .,0
"Since then, the patient demonstrates decreased lung volumes, increased interstitial markings, and upper zone redistribution of pulmonary blood flow which is likely secondary to worsening CHF.",0
"Heart size remains mildly enlarged, but stable.",0
IMPRESSION: Increasing interstitial edema concerning for worsening CHF.,0
"Dr. , pager , notified of findings at the time of dictation.",0
"6:43 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for consolidation, pneumothorax Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with metastatic thyroid cancer now with acute SOB REASON FOR THIS EXAMINATION: evaluate for consolidation, pneumothorax ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF WITH COMPARISON TO : FINDINGS: Apparent removal of endotracheal tube and nasogastric tube.",1
"Improving aeration in left lower lobe, but worsening diffuse hazy opacity throughout the left hemithorax.",0
It is uncertain whether this is due to technical artifact from lack of centering or if there is a layering pleural effusion on this side.,1
Interstitial opacities persist in the mid and lower lungs and could reflect atypical infection or edema.,0
"3:04 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate the OGT position- we are anticipating the st Admitting Diagnosis: MOTORCYCLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with polytrauma, hemodynamic instability, L pneumothorax with chest tube.",1
"Now with Desats s/p rolling for epidural REASON FOR THIS EXAMINATION: please evaluate the OGT position- we are anticipating the start of Tube Feeds and want to varify the position of the current tube since he has moved, etc ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Orogastric tube placed.",0
Left pneumothorax with chest tube.,0
CHEST: The tip of the orogastric tube lies in the lower esophagus and should be advanced.,0
Left chest tube is present.,0
Extensive subcutaneous emphysema is noted.,1
There has been decrease in the size of the bilateral effusions since the prior chest x-ray of .,0
The position of the other lines and tubes is unchanged.,0
IMPRESSION: Tip of nasogastric tube lies in lower esophagus and should be advanced..,0
"4:31 AM CHEST (PORTABLE AP) Clip # Reason: Evolution of pneumonia, ET location Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with multifocal pneumonia REASON FOR THIS EXAMINATION: Evolution of pneumonia, ET location ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Multifocal pneumonia and intubated patient.",0
ET tube tip is 3.9 cm above the carina.,0
Small bilateral pleural effusions are larger on the right side.,0
Multifocal areas of consolidation worse in the right lung have increased in the left lower lobe.,0
PATIENT/TEST INFORMATION: Indication: s/p repeat pericardiocentesis and subsequent baloon pericardiostomy.,0
Height: (in) 65 Weight (lb): 165 BSA (m2): 1.82 m2 BP (mm Hg): 112/77 HR (bpm): 90 Status: Inpatient Date/Time: at 13:39 Test: Portable TTE (Focused views) Doppler: No doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
RIGHT VENTRICLE: Markedly dilated RV cavity.,0
Abnormal septal motion/position consistent with RV pressure/volume overload.,0
The right ventricular cavity is markedly dilated.,0
There is abnormal septal motion/position consistent with right ventricular pressure/volume overload.,0
"Compared with the findings of the prior study (tape reviewed) of , the size of the pericardial effusion has decreased.",0
4:45 PM BABYGRAM (CHEST ONLY) Clip # Reason: r/o RDS/pneumonia Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with resp distress REASON FOR THIS EXAMINATION: r/o RDS/pneumonia ______________________________________________________________________________ FINAL REPORT at 16:46.,1
CLINICAL HISTORY: This is a newborn infant on day of life #1 with respiratory distress.,0
FINDINGS: A single portable view of the chest was obtained.,0
The heart size and pulmonary vascularity are within range of normal limits.,0
"There is a fine, ground-glass opacification of the lungs suggesting the diagnosis of hyaline membrane disease.",0
There is no focal lung opacification.,0
Abdominal situs is normal and the visualized bony structures are normal.,0
"8:15 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for acute intraabdominal process Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man intubated for resp failure after presenting with fever, vomiting, and diarrhea REASON FOR THIS EXAMINATION: eval for acute intraabdominal process CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 56-year-old man, intubated for respiratory failure after presenting with fevers, vomiting and diarrhea.",1
Please evaluate for acute intra-abdominal process.,0
TECHNIQUE: Abdomen and pelvis CT without contrast.,0
"MDCT images from the thoracic inlet through the pubic symphysis were obtained after administration of oral contrast, without administration of IV contrast.",0
"Multiplanar reformation images (axial, coronal, sagittal) were generated.",0
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Partially visualized airway is patent to the segmental level bilaterally.,0
"There is bilateral pleural effusion and atelectasis/consolidation, more marked in the left lower lobe , that could be consistent with pneumonia.",0
Partially visualized heart shows coronary calcification.,0
There is no lymphadenopathy visualized.,0
"With the limitation of a noncontrast study, the liver, pancreas, and spleen appear unremarkable.",0
There is no evidence of intra- or extra-hepatic biliary dilatation.,0
"The gallbladder is distended measuring up to 13 cm in length, but without evidence of stranding or fluid to suggest inflammation.",0
"A small region of fat stranding and numerous but nonpathologically enlarged nodes is present in the mesentery in the mid abdomen, just inferior to the duodenum.",0
Although evaluation of the bowel is limited by noncontrast technique there is no evidence of bowel obstruction.,0
"The distal terminal ileum shows circumferential mural hypodensity consistent with circumferential fat infiltration, which is a nonspecific finding that can be seen in the setting of chronic or prior inflammatory process.",0
"Hypodense mass in right adrenal gland measuring 10.3 mm (2:29) with , has a density consistent with adrenal adenoma.",0
Regions of punctate and linear calcification are seen in the adjacent adrenal limbs and possibly in the nodule itself.,0
Gastroduodenal and foley catheters visualized.,0
The kidneys appear symmetric in size without evidence of hydronephrosis or masses.,0
"Small amount of fat stranding around the kidneys, greater on the right, a nonspecific finding.",0
"CT OF THE PELVIS WITHOUT IV CONTRAST: The bladder, distal ureters, prostate, seminal vesicles, appendix, sigmoid colon and rectum appear unremarkable.Small (Over) 8:15 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for acute intraabdominal process Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ FINAL REPORT (Cont) bilateral fat-containing inguinal hernias.",1
OSSEOUS STRUCTURES: No suspicious lytic or blastic lesions.,0
"Coronal and sagittal reformatted images were reviewed, confirmed the axial findings.",0
"Bilateral pleural effusion and bibisilar consolidation/atelectasis , more marked on the left, consistent with pneumonia.",0
"Gallbladder distention, without specific signs for acute cholecystitis.",0
HIDA scan is recommended if there is clinical concern for cholecystitis.,0
"Mesenteric stranding, a nonspecific finding that could be consistent with mesenteritis or enteritis.",0
Right adrenal lesion consistent with an adrenal adenoma.,0
Calcifications in right adrenal gland also noted and considerations might include prior adrenal hemorrhage; adrenal cyst would be an alternate consideration for the low density adrenal nodule and could be confirmed with MRI or contrast enhanced CT protocol if clinically indicated.,0
"Distal terminal ileum with circumferential fatty infiltration of the wall, a nonspecific finding that can be seen in setting of prior or chronic inflammation process.",0
"6:38 PM UNILAT UP EXT VEINS US RIGHT Clip # Reason: RIGHT ARM SWELLING R/O DVT Admitting Diagnosis: CHRONIC RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with esrd s/p renal transplant REASON FOR THIS EXAMINATION: r/o dvt ______________________________________________________________________________ FINAL REPORT INDICATION: Right upper extremity swelling after renal transplant, line placement, history of graft.",1
RIGHT UPPER EXTREMITY ULTRASOUND: Normal compressibility and color flow are seen in the right internal jugular vein.,0
Normal color flow and Doppler waveforms in the right subclavian vein.,0
Normal compressibility and color flow in the axial and brachial veins.,0
Cephalic vein is not identified.,0
Graft is seen; there is normal arterial waveforms in the arterial site of the anastomosis.,0
No flow is seen in the venous portion of the anastomosis.,0
IMPRESSION: No evidence of DVT in the right upper extremity.,0
"Arterio-venous graft seen with probable thrombus in venous aspect, however, this should be confirmed by fistulogram in interventional radiology.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: Aspirin / Tape II Disposable Liner Adhes / Coumadin / Vancomycin Attending: Chief Complaint: seizure Major Surgical or Invasive Procedure: Intubation History of Present Illness: is a 72 year-old woman sent over from after she was found seizing in her bed this morning at her nursing home.,1
"She has a history of severe disease with a complete occlusion of the left carotid and a left hemispheric stroke, as well as b/l AKAs secondary to peripheral disease.",1
Her daughter who was present in the stated that she had recovered much of her speech but still had some difficulty getting words out.,0
She reportedly moved both her arms well at baseline.,0
"She has not been by her nursing home in the last few days but had not heard any report of illness, cough, cold, or GI problems.",0
She has never had a seizure.,0
By report she was found this morning with her right arm shaking and nonresposive.,0
She was given ativan and valium (unknown dose) and intubated for airway protection.,0
She arrived at and was on propofol and very sedated.,0
"ROS unobtainable given intubation Past Medical History: 1.Atrial fibrillation diagnosed 2.CVA 2/02, with residual expressive aphasia 3.Type 2 DM since age 50,with neuropathy,retinopathy-s/p laser ou 4.Left DVT treated with coumadin 5.Thyroid nodule 6.Osteoporosis 7.VRE left 8.Immature cataracts 9.PVD 10. sacral decubitus PSH 1.Subtotal thyroidectomy for nodule 2.Vitrectomy left eye 3.Amputation right first toe 4.Left AKpop-peroneal NRSVG 5.Left TMA 6.Right AKpop-peroneal NRSVG 7.Left 8.Revision left 9.Right SFA-AT composite bilateral NRSVG 10.Amputation right toes 2->5 Social History: worked as a bus driver.",1
Lives at nursing home in .,0
"Family History: daughter does not know family history Physical Exam: Physical Exam on Admission: Vitals: 97 80 90/70 14 99% vent General: intubated and sedated HEENT: NC/AT, ET tube Neck: no meningismus Pulmonary: coarse breath sounds Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: b/l AKA Skin: no rashes or lesions noted.",0
Neurologic: -Mental Status: intubated and sedated.,0
"no response to sternal rub -Cranial Nerves: left pupil 2.5 and reactive, right is 1.5 and reactive, +VOR, + corneals, gag intact -Motor: flaccid tone throughout.",0
No definite acute intracranial hemorrhage EEG : IMPRESSION: This is an abnormal routine EEG in the awake and asleep states due to the presence of intermittent right mid-temporal epileptiform discharges.,1
These findings are indicative of an active epileptogenic focus in the right temporal region.,0
"In addition, the background activity is diffusely slow indicative of a moderate encephalopathy which suggests widespread cerebral dysfunction but is non-specific as to etiology.",1
No electrographic seizures are present.,0
Note is made of an irregularly irregular cardiac rhythm consistent with atrial fibrillation.,1
EEG : IMPRESSION: This telemetry captured two pushbutton activations.,0
It showed no evidence of seizures.,0
"Throughout the recording, the background rhythm remains slow and indicative of an encephalopathy.",0
There were no prominent focal abnormalities but encephalopathies may obscure focal findings.,0
There were no epileptiform features or electrographic seizures.,0
MRI head : IMPRESSION: 1.,0
Acute infarction of the right basal ganglia with very slight mass effect on the adjacent right lateral ventricle and evidence of recent hemorrhagic conversion.,1
Acute infarction of the right posterior temporal and right medial parietal lobe.,0
"Absence of the flow void in the left internal carotid artery indicating probable occlusion, likely chronic.",1
"Stable encephalomalacia in the left temporal and left cerebellum, suggestive of prior infarctions.",0
CXR : Lung volumes are appreciably lower.,0
"Increase in opacification in the left lung is attributable to very mild edema, but on the right the change is more pronounced with a more nodular component which suggests developing aspiration pneumonia.",0
"The endotracheal tube ends above the upper margin of the clavicles, no less than 7 cm from the carina and it should be advanced cm for more secured seating.",0
Nasogastric tube is coiled in the stomach.,0
There is no pneumothorax or appreciable pleural effusion.,0
"CXR : Patient is rightward shifted which projects the large heart over the right lower lung, but nevertheless, there is clearly progressive opacification of the right lung and decrease in volume of the right hemithorax suggesting a large component of atelectasis, conceivably obscuring pneumonia, but not necessarily.",1
Left lung is grossly clear.,0
"As before, the endotracheal tube is too high, 2 cm above the upper margin of the clavicles and no less than 6 cm above the carina.",0
It should be advanced at least 3 cm for more secured seating and improved aeration.,0
"At least a small right pleural effusion, new or increased since , is presumed.",0
Nasogastric tube is looped in the stomach.,0
Right PIC line ends at the junction of brachiocephalic veins.,0
"A new lead runs parallel to the left clavicle ending in the midline, but I do not recognize it.",0
There is no left pleural effusion or pneumothorax.,0
EEG : IMPRESSION: This telemetry captured no pushbutton activations.,0
The background remained markedly suppressed throughout.,0
"Nevertheless, there were no clearly epileptiform features or electrographic seizures.",0
"Brief Hospital Course: 72 year-old woman with a history of hemispheric L MCA stroke, L carotid occlusion, severe PVD s/p b/l AKA's who presented after being found seizing in bed at her nursing facility.",1
She has no prior history of seizures.,0
She was given ativan and valium (unknown doses) at an OSH and intubated prior to transfer to .,0
Upon arrival here she was intubated and sedated with no further signs of seizure activity.,0
Initial exam revealed intact brainstem reflexes but was otherwise very limited due to her sedation.,0
"CT showed encephalomalacia of the left hemisphere, and UA was grossly positive.",0
She was loaded with Keppra and started on Ceftriaxone IV and admitted to the neuro ICU.,0
Neuro: She remained quite obtunded and was unable to be weaned from ventilatory support.,0
"On exam she was noted to be moving her right side more than left, inconsistent with her prior large L hemispheric stroke.",0
Routine EEG on also showed R temporal spikes without clinical correlate.,0
"She was continued on Keppra and connected to LTM, which showed an encephalopathic background in delta-theta frequences without further evidence of epileptiform activity.",0
An MRI was performed on which showed multiple new strokes in R MCA distribution with hemorrhagic conversion in R basal ganglia.,0
"Most likely source was presumed to be embolic from atrial fibrillation, but may also be related to stenosis/occlusion given hx of L carotid occlusion and severe PVD.",1
Aggrenox was discontinued in the setting of hemorrhage and she was switched to aspirin.,0
She was continued on simvastatin.,0
Vessel imaging and TTE were considered for further work-up but were deferred after discussion with family regarding goals of care when patient was made CMO.,0
CV: She was maintained on telemetry monitoring during her admission which revealed atrial fibrillation.,1
She was continued on Metoprolol 25mg and Simvastatin 10mg daily.,0
Aggrenox was switched to aspirin after she was found to have hemorrhagic conversion of new infarct.,0
This was stopped when she was made CMO.,0
Endo: She was maintained on fingersticks and sliding scale insulin for blood glucose control.,0
"TSH was found to be high at 6.1, T3 56, T4 5.3.",0
Her FSs and ISS were stopped when she was made CMO.,0
ID: She continued to have intermittent fevers throughout her admission.,0
UA was positive upon admission and she was initially started on ceftriaxone for empiric treatment.,0
CXR subsequently began to show evidence of aspiration pneumonia vs. VAP and her antibiotic coverage was broadened to linezolid/cefepime.,0
Sputum culture showed GPC in pairs and clusters.,0
Her ABx were stopped when she was made CMO.,0
Pulm: She was maintained on mechanical ventilation and was unable to be weaned due to her poor mental status and lack of gag reflex.,0
She was terminally extubated and passed away on .,0
"Prophylaxis: She was maintained on SC heparin and a bowel regimen, which were stopped when pt was made CMO.",0
Code status: Ms. was initially full code upon admission as confirmed with her husband and son.,0
"After she was found to have new R sided strokes and continued to deteriorate, a family meeting was held on .",0
They acknowledged her poor prognosis agreed that she would not want to live with the deficits she would be left with.,0
She was made DNR/DNI on and subsequently her family decided to transition her care to CMO on .,0
She was extubated and passed away on .,0
"Medications on Admission: Aggrenox Insulin Metoprolol Zoloft Zocor Trazadone MVI Vitamin D Discharge Medications: N/A, pt expired Discharge Disposition: Expired Discharge Diagnosis: R MCA infarcts Seizures Pneumonia Discharge Condition: Expired Discharge Instructions: Ms. was admitted to on after being found seizing at home.",0
She was taken to an outside hospital and given medications to stop her seizures.,0
A breathing tube was placed to protect her airway.,0
She was then transferred to .,0
Her seizures stopped with medication but she was still not waking up appropriately.,0
"An MRI of her brain was then performed which showed multiple strokes in the right side of her brain, in addition to her previous large area of stroke in the left side of her brain.",0
She also developed a severe pneumonia which was treated with antibiotics.,0
"Given her poor prognosis and low likelihood of recovery, her family decided to make her care focused on comfort measures only.",0
The breathing tube was removed and she passed away peacefully on .,0
Admission Date: Discharge Date: Service: Allergies: Sulfonamides / Ticlid / Persantine / Aspirin / Benadryl / Xylocaine / Prevacid Attending: Chief Complaint: Pt.,0
was short of breath and desaturating into the low 80's on RA at Rehab facility.,0
Major Surgical or Invasive Procedure: Central line with cordis placement for SGC in the Rt.,0
femoral vein History of Present Illness: Pt.,0
"is an 86 yo male with h/o chronic afib, cad, recently discharged from () s/p pericardial window for tamponade.",0
was discharged to the Rehab.,0
facility where after spending less then 24 hours at the facility he began experiencing increasing SOB with oxygen sats dropping into the 80's on room air.,0
required NRB and at the ED his oxygen sats improved on BIPAP.,0
"CXR showed mild failure, B/L effusions R>L, and no ischemic ECG changes.",0
He got 50 mg IV ethacrynic acid in ED.,0
He spiked a fever of 102 and levofloxacin was started in the ED.,0
Repeat ECHO in ED was unchanged from the one at discharge.,0
Admitted to CCU for diuresis and close monitoring.,0
"Past Medical History: Pericardial effusion (s/p pericardial window, unknown etiology) Afib(on warfarin) CHF (EF 30-40%) CAD(s/p AMI ') PVD PUD Pulm.",0
HTN asthma gout CEA(') CVA(') Partial thyroidectomy Social History: no tobacco or EtOH.,0
Family History: + CAD Physical Exam: Vitals: Temp: 99.5/102 BP: 160/64 HR 92 RR 18 O2 sat.,0
": 96% on Bipap 15/5/100% Gen: Awake, alert, moderate respiratory distress HEENT: +JVD to the ear Cardiac: Irregularly irregular, II/IV holosystolic murmur heard best at the apex Resp: tachypnic, poor inspiratory effort, use of accessory muscles, decreased breath sounds with crackles at bases bilaterally R>L, no wheezes Abd: + large abd.",0
"hernia on right side, + bowel sounds, nontender Ext: cyanotic fingers, erythematus, warm, indurated area on left antecubital region (10cmx7cm), 2+ pitting sacral edema, 2+ pitting edema raight ankle, 3+ pitting edema left ankle to mid-calf.",0
Unable to palpate DP's or PT's Neuro: Alert and oriented X 3 Pertinent Results: 06:16AM PT-22.6* PTT-40.5* INR(PT)-3.4 PLT COUNT-184 WBC-7.9 RBC-3.96* HGB-12.3* HCT-39.1* MCV-99* MCH-31.1 MCHC-31.4 RDW-14.1 MAGNESIUM-2.5 GLUCOSE-91 UREA N-84* CREAT-1.8* SODIUM-142 POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-35* ANION GAP-14 11:00AM NEUTS-86* BANDS-1 LYMPHS-5* MONOS-7 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 WBC-14.0*# RBC-4.17* HGB-12.8* HCT-41.1 MCV-99* MCH-30.8 MCHC-31.2 RDW-14.0 CK(CPK)-33* LACTATE-1.9 URINE BLOOD-LG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR 09:30PM CK(CPK)-21* CXR 1) Congestive heart failure with bilateral pleural effusions.,1
ECHO The left atrium is markedly dilated.,0
"Overall left ventricular systolic function is moderately depressed (ejection fraction 30-40 percent) secondary to extensive severe apical hypokinesis, and at least mild hypokinesis of the rest of the left ventricle.",0
The supporting structures of the tricuspid valve are thickened/fibrotic.,0
"There is a small posterolateral pericardial effusion, as well as a moderate sized loculated pericardial effusion subtending the right atrial free wall.",0
No right atrial or right ventricular diastolic collapse is seen.,0
Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures.,0
"Compared with the findings of the prior study (tape reviewed) of , no major change is evident.",0
was admitted to the CCU for diuresis and close monitoring.,0
"was started on Ceftriaxone and Azithromycin, and the levofloxacin was d/c'ed.",0
Blood cultures came back positive for coag.,0
Vanco was started and then switched to nafcillin + levo after sensitivities and ID consulted.,0
"Also initially treated for CHF exacerbation w/ natrecor, ethacrynic acid.",0
"became lethargic, had inc. in creatinine, metabolic alk.",0
"secondary to diuresis, and was hypoventilating.",0
Began fluid boluses to inc. volume status .,0
"Attempted SGC, however was unable to pass tricuspid valve secondary to severe TR.",0
"Renal fxn continued to deteriorate, and the pt.",0
had worsening of the pleural effusions.,0
The patient also developed black melanotic stools and was given 1 unit of PRBC's.,0
"The team had a discussion with Mr. and his family, and it was decided to no longer persue aggressive invasive procedures.",0
Mr. continued to have worsening acute renal failure and respiratory distress and it was decided after further discussion with the family to make Mr. DNR/DNI with comfort measures only.,1
"All his medications/treatments were stopped except for morphine prn pain and comfort, oxygen, and foley.",0
Mr. passed away at 0200 on Medications on Admission: 1.,0
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every other day).,0
Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).,0
Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO QD (once a day).,0
PO QD (once a day) as needed.,0
Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for please give until bm.,0
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Puffs Inhalation Q6H (every 6 hours).,0
"Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO qam ().",0
"Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO qhs ().",0
Ethacrynic Acid 25 mg Tablet Sig: Four (4) Tablet PO QD (once a day).,0
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed.,0
Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day).,0
Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QD EXCEPT MONDAY AND THURSDAY (): please hold until INR stabilizes.,0
Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO MONDAY AND THURSDAY ONLY (): please hold until INR stabilizes.,0
"Discharge Medications: none Discharge Disposition: Home Facility: Deceased Discharge Diagnosis: Pericardial effusion, CHF, ARF Discharge Condition: Pt.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: EGD History of Present Illness: 64 yo F with h/o DM1 now admitted with hypertensive crisis.,0
Pt states she has had bouts of chest pain with her hiatal hernia in the past that have lasted for several days.,0
States 4 days PTA at she awoke with chest pain and nausea and vomiting that was typical of her nml hiatal hernia pain only was more severe in nature.,0
"Also had some chills but no fevers, no SOB, cough.",0
Went to a hospital in NH and states she was diagnosed with pna and started on an antibiotic.,0
States she was told that her chest pain was the hiatal hernia.,0
She continued to have vomiting and states she was only able to tolerate sips of clears.,0
She did tolerate jello before being discharged 1 day PTA.,0
States she was given all of her regular BP meds at the OSH but was told that her sBP was persistently in the 190's.,0
"States she went home and continued to have nausea, vomiting, and was unable to tolerate any po's so came to the following day.",0
On day of admission she states she was able to take the Diovan 160mg but no other BP meds.,0
"On admission in the ED, BP 211/90, HR 82.",0
Initial ECG showed 1mm ST depressions V5-6.,0
"She was started on heparin gtt, nitro gtt, 5mg IV metoprolol x 3 and morphine 10mg IV.",0
CTA negative for dissection and PE.,0
Nitro gtt was titrated up to 300mcg and a CCU bed was requested because the pt was still experiencing some chest discomfort.,0
Has some DOE with walking but attributes this to deconditioning given that she is unable to exercise b/c of her sciatica.,0
With regards to BP states that Diovan was recently decreased from 320 to 160mg daily due to hyperkalemia.,0
States had a black stool this a.m. that was formed and soft.,0
Had a cscope 1 month ago which showed only grade 1 internal hemorrhoids.,0
"DM1 for 36 years, on insulin pump 3.",0
"Hypercholesterolemia 4. h/o CP in , cardiac cath clean - sx's felt to be ?spasms.",0
"Hiatal hernia 7. s/p hysterectomy Social History: Married, lives with husband, has 4 children, smokes 10 cig/day, occassional EtOH, no illicit drug use.",1
"Family History: Mother MI 's Father MI 's Physical Exam: PE: VS: 99.0, 69, 142/65, 11, 100% on 2L NC.",0
"Gen: alert, oriented, cooperative female in NAD HEENT: MM dry, OP clear, PERRL Neck: no lymphadenopathy, no thyromegally, no JVD Lungs: clear to ausculatation bilaterally CV: RRR, nl S1S2, II/VI systolic murmer at LLSB Abd: soft, non-tender, non-distended, positive BS, insulin pump in place with no erythema or tenderness surrounding insertion site.",0
"Ext: no edema Neuro: strength 5/5 UE and LE, no slurred speech, CN II-XII intact.",0
Pertinent Results: 11:48PM GLUCOSE-100 UREA N-16 CREAT-1.0 SODIUM-137 POTASSIUM-3.0* 11:48PM PHOSPHATE-1.7* MAGNESIUM-1.5* 11:48PM PT-14.8* PTT-68.5* INR(PT)-1.3* 05:15PM URINE COLOR-Straw APPEAR-Clear SP -1.012 05:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 05:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 04:15PM GLUCOSE-122* UREA N-15 CREAT-1.0 SODIUM-137 POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-28 ANION GAP-15 04:15PM ALT(SGPT)-32 AST(SGOT)-40 LD(LDH)-301* CK(CPK)-270* ALK PHOS-86 AMYLASE-88 TOT BILI-0.7 04:15PM LIPASE-63* 04:15PM CK-MB-3 cTropnT-<0.01 04:15PM PHOSPHATE-1.8* MAGNESIUM-1.6 04:15PM WBC-8.2 RBC-3.34* HGB-10.9* HCT-30.5* MCV-91 MCH-32.6* MCHC-35.8* RDW-13.8 04:15PM NEUTS-73.6* LYMPHS-17.9* MONOS-7.8 EOS-0.5 BASOS-0.2 04:15PM PLT COUNT-184 04:15PM PT-12.5 PTT-27.1 INR(PT)-1.1 CTA : 1) No PE or aortic dissection.,0
"2) Small bilateral pleural effusions, without CT evidence of congestive heart failure.",0
3) Left renal calculus with small amount of nonspecific fluid and stranding lateral to the left kidney.,0
CTU could be performed if concerned about obstructing ureteral stone.,0
CXR : no acute cardiopulmonary abnmlity.,0
No masses or thrombi are seen in the LV.,0
RV chamber size and free wall motion are normal.,0
Aortic valve leaflets mildly thickened but aortic stenosis is not present.,0
Stress : Exercised for 6 minutes of protocol.,0
"The test was stopped at the patient's request due to neck discomfort, lower back discomfort and fatigue.",0
This represents a limited physical working capacity.,0
"She reported a progressive discomfort in the back of her neck beginning at 3.75 minutes of exercise, progressing to at 4 minutes of exercise, subsiding to at peak exercise and resolving completely with rest by 5 minutes of recovery.",0
No ST segment changes were noted during exercise or recovery periods.,0
The rhythm was sinus with no ectopy.,0
"Blood pressure response to exercise was appropriate, heart rate response was blunted.",0
IMPRESSION: Possible atypical anginal type symptoms with no ischemic EKG changes at the achieved workload.,0
pMIBI : Resting perfusion images were obtained with thallium.,0
Exercise images were obtained with MIBI.,0
Stress images show no perfusion defects.,0
Resting perfusion images show no abnormality.,0
LVEF calculated from gated wall motion images obtained after exercise shows a LVEF that is visually estimated at 50%.,0
The wall motion is normal.,0
IMPRESSION: No perfusion defects at the level of exercise achieved.,0
EGD (): Grade 2 esphagitis in distal of esophagus.,0
Brief Hospital Course: 64 yo F with h/o DM1 admitted with hypertensive urgency and chest pain.,0
# Hypertensive crisis: Ms was admitted with SBP >200 despite having taken her regular BP meds at home; she reports her SBP was similarly elevated throughout her recent admission to OSH.,0
She has not been able to take her medication regularly recently however due to persistant nausea and vomiting.,0
"Her HTN is likely secondary to a) lack of BP meds, b) pain and n/v causing increased sympathetic stimulation.",0
She was initially started on a nitro gtt in the ED; upon admission to the CCU she was transitioned to PO labetolol overnight.,0
"She was restarted on her outpatient medications with the addition of carvedilol, which was titrated to 25 .",0
"The patient continued to have elevated BP, so Amlodipine was added.",0
The patient will follow up with her PCP 1 week; as she recovers from this acute illness her PCP may be able to wean her BP regimen.,0
She may need an outpatient renal artery MRA to evaluate for secondary hypertension.,0
# Chest pain: Ms reports that this episode of chest pain is similar to pain she has had with her hiatal hernia/gastritis in the past.,1
Cardiac ischemia was thought to be very unlikely given ECG relatively unchanged and 2 sets of negative cardiac enzymes.,0
"Her pain was treated with standing reglan, PPI, , dPRN morphine.",0
"She was continued on her , statin.",0
We recommend an outpatient follow up stress test.,0
# N/V: The patient reports that her symptoms were consistent with her hiatal hernia/gastroparesis/gastritis in the past.,1
"She may have had a viral syndrome (had chills previously), though she did not have diarrhea.",0
Obstruction was thought to be very unlikely as the patient had regular BM's with active bowel sounds.,0
"GI was consulted, and an EGD was performed, which showed mild antral gastritis and Grade 2 distal esophagitis.",1
"She was treated with anzemet prn and ativan PRN as well as reglan, , and PPI .",0
She was also given IVF hydration.,0
She will follow up with GI as an outpatient.,0
"# h/o black stools with anemia: had cscope 1 month ago which was negative, and EGD this admission did not show active bleed.",0
"Now likely has anemia of inflammation; anemia labs were sent (including B12, folate and iron studies) and were pending at discharge.",0
She did not require transfusion.,0
She will follow up with her PCP.,0
# FEN: her electrolytes were followed and repleted as needed.,0
# Endocrine: She was continued on her insulin pump for her type 1 DM; however on she ran out of insulin cartridges (though she did not tell her doctors) and she developed DKA.,0
"She was treated with IVF, IV insulin and started on NPH/ISS with rapid correction of the DKA.",0
was consulted; she was discharged on her insulin pump.,0
She will follow up with .,0
She was continued on levothyroxine for her hypothyroidism.,0
"# h/o pna diagnosed at OSH: The patient had no signos or symptoms of pneumonia throughout her admission, therefore no antibiotices were given.",0
# h/o depression: continue citalopram.,0
# h/o sciatica: cont and neurontin.,0
"Medications on Admission: Diovan 160mg daily Lisinopril 40 daily HCTZ 25 daily 325 Citalopram 20mg po daily Levoxyl 75mcg daily Lorazepam 0.5mg po prn Neurontin 800 qam, 800mg qpm, and 1600 qhs 30mg qam, 10 qpm Ranitidine 300mg daily Reglan 10mg before meals and at bedtime Rocaltrol 0.25mcg qam Zocor 40mg po qhs Discharge Medications: 1.",0
Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime).,0
Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO QAM (once a day (in the morning)).,0
Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QPM (once a day (in the evening)).,0
Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day).,0
Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO bid ().,0
Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)).,0
Insulin Continue your insulin pump regimen as prescribed by your doctors at .,0
Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency.,0
"Antral gastritis Discharge Condition: Good- blood pressure controlled, tolerating PO diet.",0
"Discharge Instructions: During this admission you have been treated for hypertension, esophagitis and gastritis.",1
Please continue to take all medications as prescribed.,0
Please follow up with your PCP and the clinic as listed below.,0
Please discuss the following at your follow up visit with Dr : 1.,0
Blood pressure medication regimen 2.,0
"Workup for secondary causes of hypertension (specifically, MRA of renal arteries) 3.",0
Status of your abdominal pain/nausea 5.,0
"Anemia If you develop headache, dizziness or lightheadedness, chest pain, increased nausea/vomiting, difficulty controling your blood sugars or any other symptom that is concerning to you, please seek immediate medical care.",0
"You have been started on the following new medications: Carvedilol, amlodipine, , pantoprazole Followup Instructions: DR , MD Date/Time: 3:50 Phone: DR (GI) Date/Time: 12:30 Phone:",0
"11:09 PM CT C-SPINE W/O CONTRAST; CT C-SPINE W/O CONTRAST Clip # CT RECONSTRUCTION Reason: MVC ______________________________________________________________________________ WET READ: SMLe FRI 3:50 AM neg ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATIONS: 20 y/o woman status post MVA, restrained, transferred from an outside hospital.",0
TECHNIQUE: Multiple axial images of the cervical spine were obtained without IV contrast.,0
"In addition, reformatted images in the coronal and sagittal plains were obtained and reviewed.",0
"Note that due to a failure of the PACS archive, this study was not queued for final review until .",0
FINDINGS: No fracture or dislocation is identified.,0
The patient is intubated and there is an NG tube also present.,0
No prevertebral soft tissue swelling is seen.,0
"However, the thyroid gland is somewhat diffusely prominent- clinical correlation is advised, regarding this finding.",0
IMPRESSION: No fracture or dislocation.,0
"5:31 PM CT CYSTOGRAM (PEL) W/CONTRAST Clip # Reason: question evidence of colovesicular fistula Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Contrast: OMNIPAQUE Amt: 40 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with multiple sclerosis, chronic indwelling Foley and recurrent UTIs, here with urosepsis and multi organisms in urine cx.",1
REASON FOR THIS EXAMINATION: question evidence of colovesicular fistula No contraindications for IV contrast ______________________________________________________________________________ WET READ: EHAb FRI 10:06 PM No definitive colovesicular fistula detected on this study.,0
"Contrast seen in the right seminal vesicle, of indeterminate etiology, possibly secondary to retrograde flow.",0
Preliminary findings discussed with Xiaoming by phone at 10:05 p.m. on .,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 53-year-old male with multiple sclerosis, chronic indwelling Foley catheter, recurrent urinary tract infections, now with urosepsis and clinical concern for colovesicular fistula.",1
TECHNIQUE: Axial CT images through the pelvis were acquired after instillation of 400 cc of contrast into the urinary bladder.,1
Coronal and sagittal reformatted images were reviewed.,0
FINDINGS: Intravenous contrast fills the bladder without evidence of leak.,0
No contrast is seen within the rectum.,0
"Contrast is seen in the right seminal vesicle, possibly secondary to retrograde flow.",0
The fat plane between the bladder and rectum is obscured.,1
A Foley catheter is seen within the bladder.,1
"The bladder wall is trabeculated, likely secondary to neurogenic bladder.",1
Air layering anteriorly within the bladder is likely due to instrumentation.,0
Residual enteric contrast is seen within the cecum.,0
"Visualized portion of the colon is distended with air, as seen yesterday.",0
Evaluation of intrapelvic organs is limited in the absence of intravenous contrast.,0
IMPRESSION: No definitive colovesicular fistula detected on this study.,0
(Over) 5:31 PM CT CYSTOGRAM (PEL) W/CONTRAST Clip # Reason: question evidence of colovesicular fistula Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Contrast: OMNIPAQUE Amt: 40 ______________________________________________________________________________ FINAL REPORT (Cont),1
"3:06 PM CHEST (PA & LAT) Clip # Reason: eval for infiltrate Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman with pseudomonal pna, s/p 3 weeks IV abx.",0
"REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Pseudomonal pneumonia, status post three weeks of IV antibiotics.",0
"CHEST, PA AND LATERAL: There has been interval resolution of the multiple patchy opacities within both lungs.",0
"There is residual scarring/atelectasis, most markedly in the right lung zone.",0
"The cardiac, mediastinal and hilar contours are unremarkable.",0
The left-sided PICC terminating within the mid SVC is again identified.,0
IMPRESSION: Interval resolution of pulmonary opacities with residual scarring/atelectasis.,0
"2:12 PM CHEST (PORTABLE AP) Clip # Reason: interval evaluation Admitting Diagnosis: ASTHMA, COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman s/p chest tube placement x 2 for recurrent PTX REASON FOR THIS EXAMINATION: interval evaluation ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: COMPARISON: .",0
A tracheostomy tube and two left-sided chest tubes remain in place.,0
"Extensive subcutaneous emphysema is noted, which obscures underlying fine detail.",1
"Allowing for this factor, there is no definite pneumothorax.",0
Heterogeneous lung opacities are identified bilaterally with an area of more confluent opacification developing in the left lower lobe as compared to the prior study.,0
The possibility of developing pneumonia in this region should be considered in the appropriate clinical setting.,0
PATIENT/TEST INFORMATION: Indication: L Main CAD s/p CABG.,0
"Eval LV function, valves Height: (in) 67 Weight (lb): 162 BSA (m2): 1.85 m2 BP (mm Hg): 95/43 HR (bpm): 89 Status: Inpatient Date/Time: at 12:10 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.",1
Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
"Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%).",0
4:28 AM PORTABLE ABDOMEN Clip # Reason: eval small bowel distention Admitting Diagnosis: SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man h/o GBS with AIDP REASON FOR THIS EXAMINATION: eval small bowel distention ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 54-year-old male with history of with AIDP.,0
Evaluate for small bowel distention.,0
Again seen are multiple stack dilated loops of small bowel measuring up to 5.7 cm.,0
Surgical clips projects over the right upper quadrant.,0
Stool and gas is seen within the colon and rectum.,0
No evidence for intraperitoneal free air.,0
IMPRESSION: Findings consistent with partial obstruction versus ileus.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 50 year old man with hypercholesterolemia, hypertension, cigarette smoking, FHx of early MI presented with CP to OSH; found to have inferior STEMI, was transferred to for emergent cardiac catheterization.",1
"Patient developed SSCP while working on his motorcycle, assoc w/ diaphoresis and right arm numbness.",0
His wife called EMS and he was brought to where he received NTG and ASA.,0
"He was found to have inferior ST elevations on EKG was started on Plavix, a Heparin gtt, and Integrillin gtt.",0
"Next, patient was transferred to for cath.",0
Cardiac cath showed a RCA and LCX dz with 80% OM1 and 100% OM2 lesions.,0
"His OM2 was stented with a DES, resulting in resolution of his chest pain.",0
He is now admitted to the CCU for monitoring.,0
"Currently, he feels well w/ only mild lingering chest pressure.",0
"No chest pain, dyspnea, palpitations, abd pain, leg pain, or leg weakness or numbness.",0
"Past Medical History: - HTN - hyperlipidemia - depression Social History: significant for tobacco use, > 20 pack-years, currently ppd.",0
"Family History: - CAD: father died of MI at 61, brother had MI at 40.",0
"Physical Exam: VS: T , BP 120/77, HR 79, RR 12, O2 sat 99% RA Gen: healthy appearing man lying flat in bed, pleasant and conversational, NAD HEENT: NCAT.",0
Neck: Supple with no JVD.,0
"CV: reg s1/s2, no s3/s4/m/r Pulm: CTA b/l, no crackles or wheezes.",0
"Abd: obese, +BS, soft, NT.",0
"Left fem puncture site w/ no oozing, tenderness, or bruit.",0
"Ext: warm; 2+ DP b/l, no edema, no femoral bruits.",0
Neuro: a/o x 3 Pertinent Results: 11:37PM WBC-13.8* RBC-4.54* HGB-14.0 HCT-40.3 MCV-89 MCH-30.7 MCHC-34.7 RDW-13.9 .,0
"EKG - demonstrated ST elevations in II, III, aVF, V5, V6 and ST depressions in aVR, AvL and V1, V2.",0
Actue inferolateral ST segment elevation myocardial infarction with reciprocal depressions in lead aVL and V1-V2.,1
"CARDIAC CATH performed on demonstrated: 40% mid, 80% distal RCA, LCX with 80% OM1 and 100% OM2, as well as 30% LMCA lesion RA 11, RV 46/7, PA 49/19/32, PCWP 20 CI 2.26, CO 4.52 .",0
Cardiac ECHO performed Conclusions: The left atrium is normal in size.,0
The estimated right atrial pressure is 11-15mmHg.,0
There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferolateral wall and basal inferior wall.,1
There is no mitral valve prolapse.The pulmonary artery systolic pressure could not be determined.,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD.,0
"Brief Hospital Course: Patient is a 50 year old man with multiple cardiac risk factors admitted to CCU for monitoring after inferior ST-elevation myocardial infarction, treated with a drug eluting stent to the second obtuse marginal branch off of the left circumflex artery.",1
"1) Coronary artery disease: He has multiple risk factors including hyperlipidemia, hypertension, smoking and family history.",1
Cath showed significant RCA disease and distal LCX disease.,0
"After placement of the OM2 stent (Taxus) the patient was treated with ASA 325 daily, plavix 75 daily, atenolol 50BID, Lisinopril 5 daily, and lipitor 80 daily.",0
The patient was on an integrillin gtt for 18 hours after stent placement.,0
He had several asymptomatic 10 beat runs of ventricular tachycardia after catheterization.,1
These had completely resolved for over 24 hours prior to discharge.,0
An ECHO demonstrated left ventricular ejection fraction of 45% to 50%.,0
2) HTN: managed with atenolol and lisinopril as above.,0
3) Hyperlipidemia: start lipitor 80 mg as above.,0
4) Tobacco use: We started a nicotine patch and the patient was counseled regarding the need for smoking cessation.,0
Medications on Admission: - ASA 81mg qd - Lisinopril/HCTZ 10/12.5mg daily - Lipitor 10mg daily - Prozac 40mg/80mg alternating daily Discharge Medications: 1.,0
Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Patch 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: STEMI Hypertension Smoking Hyperlipidemia Coronary artery disease Discharge Condition: Vital signs stable.,1
No longer short of breath.,0
Discharge Instructions: Please take your medications as prescribed.,0
Please follow up with the appointments as documented below.,0
"Again, we understand that quitting smoking is very difficult, but we also must emphasize that with your hypertension, high cholesterol and family history, smoking has the propensity of worsening your heart disease and increasing the likelyhood of another heart attack.",0
Followup Instructions: Provider: Phone: Date/Time: 10:00 Please followup with Dr. at 10:00 am on .,0
His office can be reached at ( Please call your primary care physician to make follow up appointment in the next two weeks.,0
1:04 PM CHEST (PA & LAT) Clip # Reason: evaluate for PNA: ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with fever to 103.3; evalaute for infiltrate REASON FOR THIS EXAMINATION: evaluate for PNA: ______________________________________________________________________________ FINAL REPORT INDICATION: 63 y/o man with fever to 103.,0
A left sided venous line is seen with tip at the superior vena cava/right atrial border.,0
"There is opacity in the left lower lobe which likely represents atelectasis, but could be secondary to an infectious process.",0
No new infiltrate in comparison to film .,0
There is once again seen mild prominence of the pulmonary vasculature.,0
"IMPRESSION: Left lower lobe opacity, atelectasis vs. infectious process.",0
Exam overall unchanged from .,0
PATIENT/TEST INFORMATION: Indication: AS CAD Pre - OP CABG Height: (in) 65 Weight (lb): 155 BSA (m2): 1.78 m2 BP (mm Hg): 113/65 HR (bpm): 72 Status: Inpatient Date/Time: at 09:36 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.,1
Trivial MR. LV inflow pattern c/w impaired relaxation.,0
5:13 PM BABYGRAM AP ABD ONLY PORT Clip # Reason: PICC adjust Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: PICC right leg REASON FOR THIS EXAMINATION: PICC adjust ______________________________________________________________________________ FINAL REPORT _____ AT 1724 HOURS HISTORY: PICC line right leg.,1
FINDINGS: The infant is rotated to the left.,0
Endotracheal tube remains high at C7-T1.,0
"Feeding tube tip overlies the stomach, unchanged.",0
There is a left femoral PICC line in place which has been pulled back from its previous position overlying the right atrium to its current position approximately three vertebral bodies below the level of the hemidiaphragm.,0
There has been some increase in aeration of the left lung though left upper lobe and entire right lung remain opacified.,0
Abdominal gas pattern is unchanged and without evidence of intramural or free air.,0
No abnormalities are noted within the visualized bones or soft tissues.,0
"2:46 PM CHEST (PA & LAT) Clip # Reason: eval for silent aspiration Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with s/p intracerebral hemorrhage REASON FOR THIS EXAMINATION: eval for silent aspiration ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Intracerebral hemorrhage, possible aspiration.",1
Comparison with the previous study done .,0
The lungs appear otherwise clear.,0
There is no focal consolidation.,0
The aorta is mildly tortuous and calcified as before.,0
Feeding tube has been removed.,0
IMPRESSION: No evidence of aspiration post-feeding tube removal.,0
Prominence of the pulmonary interstitium which may reflect interstitial lung disease.,0
6:36 AM CHEST (PORTABLE AP) Clip # Reason: assess for collapse Admitting Diagnosis: RESP.,0
"FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with Wolfram's syndrome (blind/deaf/DM/DI), intubated at OSH after seizure w/aspiration pneumonia on , unable to wean off ventilator, txf'd to .",1
"Acute desat this am REASON FOR THIS EXAMINATION: assess for collapse ______________________________________________________________________________ FINAL REPORT HISTORY: Aspiration pneumonia, acute desaturation.",1
PORTABLE AP UPRIGHT CHEST RADIOGRAPH.,0
"FINDINGS: No change in position of the NG tube, right IJ line, or ETT.",0
Interval clearing of the left retrocardiac density.,0
There is some residual patchy infiltrate of the left lower lobe.,0
No new infiltrates or pleural effusions.,0
Persistent linear atelectasis at the right base.,0
IMPRESSION: Resolving left lower lobe consolidation/atelectasis.,0
2:08 PM CT LOW EXT W/O C RIGHT Clip # Reason: eval for fx/abnormality?,0
Admitting Diagnosis: EXPLORATORY LAPAROTOMY ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with R toe and ankle dislocation REASON FOR THIS EXAMINATION: eval for fx/abnormality?,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 32-year-old man with right toe, ankle dislocation.",0
TECHNIQUE: MDCT axial images through the right foot were obtained without intravenous contrast and displayed in multiplanar reformats.,0
FINDINGS: There is an oblique comminuted intra-articular fracture extending through the base of the second metatarsal (series 803B: image 31).,1
Distraction of the fracture fragments is minimal and measures approximately 2 mm.,0
A tiny ossific fragment is interposed between the base of the second metatarsal and middle cuneiform/first metatarsal base.,0
There is minimal 1.5 mm lateral offset of the second metatarsal upon the middle cuneiform.,0
No additional fractures are seen.,0
There is expected soft tissue swelling.,0
IMPRESSION: Oblique intra-articular fracture extending through the base of the second metatarsal in the region of the Lisfranc ligament with slight lateral offset of the second metatarsal.,1
These findings are concerning for Lisfranc injury.,0
Findings were conveyed to Dr. on at 5:45 p.m.,0
"1:18 PM CHEST (PORTABLE AP) Clip # Reason: please eval for new infiltrate or effusion Admitting Diagnosis: ESOPHAGEAL CANCER;CROHNS DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with metastatic esophageal CA to lung, presents with leukocytosis to 45 REASON FOR THIS EXAMINATION: please eval for new infiltrate or effusion ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.",0
"INDICATION: 59-year-old female patient with metastatic esophageal carcinoma to lung, presents with leukocytosis.",0
Evaluate for new infiltrate or effusion.,0
FINDINGS: AP single view of the chest has been obtained with patient in sitting upright position.,0
Available for comparison is the next preceding similar study of .,0
Previously described central venous line advanced via right internal jugular approach appears in unchanged position seen to terminate in the low SVC but safe of the entrance into the right atrium.,0
On previous examination identified round and rather well-delineated approximately 3 cm diameter mass has increased markedly in sinus.,0
The lesion is now less well delineated but has a diameter of almost 5 cm.,0
No other new parenchymal pulmonary abnormalities are identified on this single AP portable chest view.,0
Heart size remains unchanged and within normal limits and there is no evidence of pulmonary vascular congestion.,0
Lateral pleural sinuses remain free from any fluid accumulation.,0
IMPRESSION: Progression of previously identified nodular density in right lower lung.,0
", W. TSICU 12:30 PM CHEST (PORTABLE AP) Clip # Reason: evaluation of ETT Admitting Diagnosis: SPLENIC RUPTURE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p splenectomy REASON FOR THIS EXAMINATION: evaluation of ETT ______________________________________________________________________________ PFI REPORT PFI: Uncomplicated intubation, no pneumothorax.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MICU- ADDENDUM Please note that this discharge summary is an addendum/continuation of the discharge summary that was done by Dr. .................. on .,0
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old white female with a long history of pulmonary issues who is well known to the and i a patient of Dr. who was admitted on for weaning off her ventilator.,0
"Her ventilator on admission was CPAP with an FIO2 of 40%, PEEP of 5, and a pressure support of 30.",0
She was transferred from the / Facility because two weaning trials were attempted which were unsuccessful.,0
"Hence, it was decided that a weaning would be carried out in the Medical Intensive Care Unit under the supervision of her attending Dr. .",0
PAST MEDICAL HISTORY: Please see Dr. ................... initial part of the discharge summary from .,0
MEDICATIONS: Please see Dr. ................. discharge summary from .,0
SOCIAL HISTORY: She smoked tobacco for five years while in college.,0
She currently resides at the Kindres/ Facility.,0
"HOSPITAL COURSE: Please see Dr. .................. discharge summary from , as it describes her hospital course from the day of admission on , through .",0
The remainder of the hospital course is as follows: 1.,0
Pulmonary: The patient has a long history of severe lung disease.,0
"She has a history of Hodgkin's disease and is status post CHOP and radiation therapy complicated by histoplasmosis, adult respiratory distress syndrome, and she is status post left pneumonectomy for Aspergillus.",1
She was recently admitted in the spring for pneumonia.,0
She had been on pressure support of 30 with a PEEP of 5 and an FIO2 of 40% on her admission.,0
Two attempts were made at the / Facility to wean her which were both unsuccessful.,0
"Her baseline PACO2 is in the 80s, and a renal compensation brings her bicarbonate in the range of 40-50.",0
She has tolerated this well and was able to wean from her vent.,0
She was kept on a ................... while she received her pressure support via tracheostomy at night.,0
"She had a tracheostomy revision on , and was found to have a posterior tracheal ulcer which was a very early TE fistula.",0
She had a temporary tracheostomy which was changed to permanent on .,0
A bronchoscopy after that showed that the ulcer had healed.,0
"The patient is currently using a TP with an FIO2 of 50% during the day time, and at night she uses a BIPAP with an EPAP of 6 and an IPAP of 12.",0
The plan is to send her back to her rehabilitation center where she will remain on her The patient during the day with blow-by oxygen and will remain on the BIPAP at night on her home ventilator.,0
Cardiac: The patient has a history of biventricular congestive heart failure and cardiomyopathy and is known to have an ejection fraction close to 20%.,1
"Her left-sided heart failure is thought to be secondary to tachycardia inducing cardiomyopathy, and her right heart failure is thought to be secondary to cor pulmonale.",1
"Her resting pulse ranges anywhere between 100-120s and is sinus tachycardia, and based on previous experience, it has shown that any decrease or increase from this resting heart rate, can send her into respiratory distress and cause decompensation.",1
"She is also very volume sensitive, and given that she has biventricular heart failure, our goal is to keep her weight between 150-120 lbs.",1
"In addition, she is on a regimen of Lasix, Metolazone, and Aldactone to help control her volume status.",0
"She remains at her baseline goal weight between 150-120 lbs on this diuresis regimen, and she does not appear to have any respiratory distress.",0
The patient is also on Digoxin 0.125 mg every other day and 0.25 mg every other day.,0
She does have her Digoxin level checked and should be checked on a regular basis.,0
"Fluids, electrolytes, and nutrition: The patient is known to have a volatile/fluctuating potassium level.",0
She has a history of constipation and sometimes develops hyperkalemia from her inability to excrete her potassium to her GI tract.,0
"In addition, with her large diuresis, she also is known to drop her potassium level significantly in the range of 2.4-2.5.",0
"To help maintain her potassium at a reasonable level since she is on Digoxin, she is taking 40 mEq Potassium Chloride t.i.d., and her potassium level has remained relatively stable in that we had been checking it twice a day, and it ranges from 3.1 to 4.0 with this current regimen in addition to the Lasix, Metolazone, and Aldactone she is taking.",0
Her nutrition is delivered to her via her G-tube with a .................. tube feeds.,0
The patient also has a baseline metabolic alkalosis as mentioned early on with bicarbs of 40-50 to compensate for her severely impaired and decreased ventilation.,0
She has a significant amount of large dead space and a VD/VT ratio of 0.8.,0
She is tolerating this metabolic alkalosis well.,0
"Gastrointestinal: As mentioned, the patient has a history of constipation, especially when she uses narcotic analgesics.",0
She had been on Percocet for pain experienced from her tracheostomy site.,0
"She has had some bowel movements since Dr. ................. discharge summary of , and her potassium levels have been relatively stable in the range of 3.0-4.0.",0
"In addition, she is getting Colace 100 mg p.o.",0
"b.i.d., and she is getting Senna tabs and Simethicone.",0
We are being very aggressive with her bowel regimen to help maintain and regulate bowel movements.,0
"Infectious disease: Given the patient's significant pulmonary history, she was taking inhaled Tobramycin for pseudomonas prophylaxis.",0
"She was taking this for 28 days and then tried off for 21 days in which it was found that her white blood count was increasing, and the Tobramycin was restarted.",0
"She does have a history of chronic leukocytosis from , but no specific signs of infection from her baseline was noted.",0
"On , she was found to have 15 bands on her CBC, and she was found to have a positive urinalysis, and she was started on Levaquin 500 mg p.o.",0
"In addition on , she grew coag-negative staph from her PICC line and was started on Vancomycin because it was sensitive to that.",0
"On , her urine culture came back negative, and so the Levaquin was discontinued, but she continued to receive Vancomycin 1 g q.12 hours for a total of seven days; on the day of discharge, it will be day #5 of 7.",0
Psychiatry: The patient has a history of anxiety attacks with complicated respiratory failure.,1
It was thought that the anxiety was a large component of this failure.,0
She was relying on multiple pain medications which had been discontinued due to her constipation and other problems.,0
"She seems to be doing well on a regimen of Amitriptyline 75 mg q.h.s., Zyprexa 5 mg q.h.s., and she occasionally gets Ativan p.r.n.",0
"Tubes, lines, and drains: A central line was placed due to the PICC line infection; however, since she is a very difficult stick and she need to get her blood checked on a regular basis, a right PICC line is going to be placed by Interventional Radiology, and the subclavian is going to be removed prior to her discharge.",0
"She also has a tracheostomy and G-tube, and all of these sites are clean, dry, and intact.",0
Prophylaxis: The patient is able to get out of bed with physical therapy and Occupational Therapy.,0
She is also getting a PPI per her G-tube.,0
DISCHARGE STATUS: The patient is stable.,0
DISPOSITION: The patient is being discharged to either facility or the / Facility depending on bed availability.,0
Dictated By: MEDQUIST36 D: 18:55 T: 19:06 JOB#:,0
3:15 AM CHEST (PORTABLE AP) Clip # Reason: eval change Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with sepsis REASON FOR THIS EXAMINATION: eval change ______________________________________________________________________________ FINAL REPORT HISTORY: 87-year-old man with sepsis.,0
"CHEST AP: Cardiac, mediastinal, and hilar contours are unchanged.",0
Right subclavian line is again noted.,0
"There continued to be right upper, mid, and lower lung opacities.",0
"There is a new left lower lung opacity, which obscures the left hemidiaphragm.",0
"Unchanged right lung opacities, most consistent with pneumonia.",0
"New left lower lobe opacity, which could represent atelectasis, aspiration, or pneumonia.",0
"7:14 AM NEONATAL HEAD PORTABLE Clip # Reason: INFANT BORN AT 29 5/7 WEEKS, R/O IVH Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 29 5/7 weeks REASON FOR THIS EXAMINATION: r/o IVH ______________________________________________________________________________ FINAL REPORT HISTORY: Premature infant born at 29 weeks gestation.",1
CRANIAL ULTRASOUND: Live scanning was performed through the anterior and mastoid fontanelles.,0
The brain is normal in echogenicity and morphology.,0
The overall appearance of the brain parenchyma is consistent with the patient's prematurity.,0
The ventricles are normal in size and there is no evidence of intraparenchymal or intraventricular hemorrhage.,0
The extra-axial fluid spaces are unremarkable.,0
No evidence of intraventricular hemorrhage.,0
Height: (in) 62 Weight (lb): 125 BSA (m2): 1.57 m2 BP (mm Hg): 108/88 HR (bpm): 110 Status: Outpatient Date/Time: at 10:21 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
Moderate global RV free wall hypokinesis.,0
There is severe global left ventricular hypokinesis (LVEF = 15-20 %).,0
IMPRESSION: Severe global left ventricular hypokinesis.,0
Moderate right ventricular systolic dysfunction.,0
Mild to moderate aortic and mild mitral regurgitation.,0
7:14 AM CHEST (PORTABLE AP) Clip # Reason: s/p EVAR w/worsening hypoxia r/o effusion/PTX Admitting Diagnosis: AORTA THORACIC ABDOMINAL ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with as above REASON FOR THIS EXAMINATION: s/p EVAR w/worsening hypoxia r/o effusion/PTX ______________________________________________________________________________ FINAL REPORT HISTORY: EVAR with worsening hypoxia.,1
"FINDINGS: In comparison with the study of , there is slight decrease in the opacification at the left base, suggesting improving aeration of the left lower lobe and decreasing effusion.",0
Continued atelectatic changes on the right base.,0
"Central catheter remains in place, and the endovascular prosthesis is again seen.",0
1:37 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * PICC W/O PORT -51 MULTI-PROCEDURE SAME DAY * * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE * * US GUID FOR VAS.,0
"ACCESS C1751 CATH ,/CENT/MID(NOT D * * C1769 GUID WIRES INCL INF * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line that needs removal infection.",1
Needs second line for chronic Abx.,0
REASON FOR THIS EXAMINATION: Please place PICC line ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old female with numerous infections requiring chronic antibiotics.,1
"Dr. , the attending radiologist was present and supervising throughout the procedure.",0
PROCEDURE/FINDINGS: The patient was brought to the radiology suite and placed supine on the angiography table.,0
"Following a preprocedure timeout including the patient's name and two patient identifiers, the right arm was sterilely prepped and draped.",0
"As no suitable veins were visible, ultrasound was used to identify the right brachial vein which was patent and compressible.",0
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.,0
A 21-gauge needle was used to access the right brachial vein.,0
Hard copy ultrasound images were obtained before and after venipuncture.,0
A 0.018-inch guide wire was threaded through the needle into the vein.,0
Then the needle was exchanged for a 4 French micropuncture sheath.,0
"The guide wire was advanced into the SVC and based on the markings on the wire, a PICC line was trimmed to a length of 40 cm.",0
The PICC was then advanced over the wire and into the SVC under fluoroscopic guidance.,0
"The catheter was flushed, capped, and heplocked.",0
"Finally, the catheter was statlocked into place and a sterile transparent dressing was applied.",0
A final fluoroscopic image was taken demonstrating the tip of the PICC in the distal SVC.,0
IMPRESSION: Successful placement of a 4 French single-lumen 40-cm PICC by way of the right brachial vein with the tip in the distal SVC.,0
7:47 AM CHEST (PORTABLE AP) Clip # Reason: s/p AVR redo Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with REASON FOR THIS EXAMINATION: s/p AVR redo ______________________________________________________________________________ FINAL REPORT EXAMINATION: AP chest.,0
Single AP view of the chest is obtained on at 0750 hours and compared with the prior morning's radiograph.,0
"Allowing for technical differences, there does not appear to have been any significant change.",0
There is increased retrocardiac density on the left side consistent with atelectasis/airspace disease at the left base.,0
Patchy opacity at the right base likely represents subsegmental atelectasis.,0
There is no evidence of frank failure.,0
No large pneumothorax is seen.,0
"The nasogastric tube seen previously below the diaphragm is not seen on the current examination, but there does appear still to be a nasogastric tube in the proximal esophagus.",0
Dr. was paged at hours to discuss without response.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Levaquin / Azithromycin / Bactrim Attending: Chief Complaint: Fever Major Surgical or Invasive Procedure: Bone marrow biopsy Transfusion of 2 units of blood History of Present Illness: is a 40 year old woman with metastatic non-small cell lung cancer, admitted with febrile neutropenia.",1
"Ms. was first diagnosed with squamous cell NSCLC in when she presented with chest pain, shortness of breath, and back pain, and was found to have a malignant pleural effusion.",1
She underwent pleural biopsy on at OSH that showed metastatic nonsmall carcinoma of pulmonary origin with suggestion of squamous differentiation.,0
She was treated with carboplatin/gemcitabine from to .,0
In disease progressed and she was treated with two additional cycles carboplatin/gemcitabine.,0
"In she developed neurologic symptoms of headache, dysarthria, and difficulty with fine motor skills, and brain imaging diagnosed multiple brain metastases.",0
She completed whole brain radiation as of and was then treated with two cycles Navelbine.,0
She then developed LFT abnormalities.,0
"Keppra and dexamethasone were held, adn she then had a seizure.",0
She was admitted to Neuro-oncology service /09.,0
Keppra and dexamethasone were restarted.,0
She was hospitalized again /09 with pulmonary embolism and was started on enoxaparin.,0
"CT raised concern for progressive disease in her liver, and on she began treatment on erlotinib.",1
She was last seen in clinic on at which time she was noted to be neutropenic.,0
Bactrim was discontinued out of concern this was marrow suppression from drug effect.,0
Ms. presented to the ED today with fever 102.8.,0
In the ED T 98.0 HR 108 BP 99/69 RR 20 98%RA.,0
Past Medical History: * Non-small cell lung cancer diagnosed via biopsy in with known metastasis to T11.,0
"She underwent chemotherapy with gemcitabine and carboplatin from to , again to .",0
She presented in to with brain metastases.,0
No neurosurgery intervention deemed appropriate and was set up for whole brain XRT by radiation oncology at from /09.,0
"She also had ~2 weeks of vinorelbine on , stopped for elevated LFTs.",0
"Started erlotinib * Malignant L pleural effusion, s/p multiple thoracenteses.",1
"s/p chest tube, talc pleurodesis * Seizures secondary to brain mets.",1
"Occurred , while off keppra due to elevated LFTs.",0
"* Bilateral PEs - lobar PE in RUL, segmental PE in LLL * Steroid myopathy Social History: She lives with her husband and 3 children (girl 15, boys 12 and 7 all healthy).",0
"She denies smoking, alcohol or drug use.",0
"She did not have recent travel, or change in diet.",0
She used to work in a medical office in the medical records depparment.,0
"Family History: There is no family history of cancer including lung, ovary, colon and breast.",0
Her father is alive at age 77 with hypertension.,0
Her mother is alive at age 68 healthy.,0
She has 2 healthy sisters.,0
There is no history of premature CAD or stroke or diabetes.,0
The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation.,0
IMPRESSION: Normal global and regional biventricular systolic function.,0
"CXR (): PORTABLE UPRIGHT CHEST RADIOGRAPH: Cardiomediastinal contours are unchanged, with prominent left mediastinal fat pad.",0
Left-sided pleural thickening or tiny fluid in the fissure is not changed.,0
Known multiple lung masses are not as well seen.,0
"However, no new consolidation or pulmonary edema is seen.",0
"The rounded sclerotic focus in T10 is redemonstrated, consistent with known metastasis.",0
IMPRESSION: No acute findings such as pneumonia or pulmonary edema seen.,0
"MICRO: Blood cx : NGTD Urine cx : >100K lactobacillus Legionella Ag : negative Sputum: viral neg Bone Marrow Biopsy pending Brief Hospital Course: 40 yo female with metastatic NSCLC on dexamethasone for brain mets, and recent admission for PE returned with febrile neutropenia.",1
"# Febrile neutropenia: She was admitted to the MICU due to a borderline BP initially, which improved with fluids.",0
BP settled in 95-105 systolic.,0
She did not require pressors/CVL in the MICU.,0
She was given stress dose steroids x24hrs before returning back to her normal deacron dose.,0
No clear infectious source found on history or culture data.,0
"The suddent onset could be compatible with influenza, however her urine cx showed >100K lactobacillus which is likely cotamination.",0
Her CXR showed no evidence of infection.,0
She was was broadly covered with cefepime and vanco while she remained neutropenic.,0
Once her counts rose with an ANC > 500 these were stopped and she was started on cefpodoxime to complete a 7-day course.,0
She will follow up with Dr. later this week.,0
# Neutropenia: Patient found to become neutropenic in mid-.,0
Differential for her neutropenia included marrow suppression/infiltration from her disease vs medication effect vs infection affecting her bone marrow.,1
Patient's bactrim was stopped on and her counts were found to be depressed on the next lab check she had after starting the bactrim.,0
During her hospitalization her keppra was stopped and she was started on topamax instead as keppra was also suspected of causing marrow suppression.,0
She underwent a bone marrow biopsy and these results were pending at the time of discharged.,0
By time of discharge her ANC had rose to 1216 and WBC was 1.9.,0
"As her counts recovered so quickly, her neuropenia was likely secondary to medication-effect, likely bactrim as this was temporally related to the onset of neutropenia.",1
Bactrim was added as an allergy to OMR and she was instructed not to take bactrim again.,0
"# Anemia: Hct was 19.5 on admission, though no obvious signs of bleeding.",0
"Though there was abnormalities on her differential, there was otherwise no obvious sign of hemolysis.",0
She was given 2 units PRBCs with mostly appropriate bump in her Hct.,0
Iron studies showed anemia of chronic disease and vitamin B12 and folate have recently been normal.,1
Her Hct prior to discharge remained in the mid-20's.,0
# Metastatic NSCLC with brain mets: Patient has known brain mets s/p XRT which have resulted in seizures.,0
She was continued on gabapentin 300 mg PO Q8H.,0
As above her keppra was stopped and she was started on Topiramate 100 mg PO BID for seizure prevention.,0
A topiramate level was sent on and was pending at time of discharge.,0
She was asked to follow up with Dr. in weeks.,0
She is on dexamethasone to decrease cerebral edema.,1
After the day of stress dose steroids as above she was continued on the dexamethasone taper as outlined by Dr. : On will decrease to 0.5 mg every other morning and on with stop.,0
She was being treated with erlotinib prior to admission.,0
This was held on admission (even though it is not known to cause marrow suppression).,0
Upon discharge she was asked to restart it at her home regimen as an outpatient.,0
"# EKG with inf/lateral TWI: Admission EKG showed TWI, but she had no clinical evidence of ischemia.",0
She was ruled out for MI with 3 sets of negative cardiac enzymes.,0
An echo was without evidence of wall motion abnormalities.,0
# Recent PE: Patient was recently diagnosed with bilateral PEs on and is on lovenox.,0
She was continued on lovenox 90 mg SC Q12H.,0
# Lower extremity leg weakness: Patient has a known steroid myopathy.,0
She was discharged with home PT.,0
"# Transminitis: Patient at basline has had a transaminitis, this remained stable/improved during this hospitalization.",0
# CODE: FULL CODE Medications on Admission: Lovenox 90mg Dexamethasone 1mg daily Erlotinib 100mg daily Neurontin 300mg TID Levetiracetam 500mg Ibuprofen prn Tylenol prn Discharge Medications: 1.,0
Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours).,0
"Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take 1 tablet daily until , then take 1 tablet every other day until .",0
Stop taking dexamethasone on .,0
Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours).,0
Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days.,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Do not drive while taking this medication.,0
Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea.,0
Tarceva 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Primary - Febrile neutropenia Acute on chronic anemia Secondary - Metastatic non-small cell lung carcinoma History of seziures Recent pulmonary emboli Steroid myopathy Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital due to fevers.",1
Your blood counts were found to be low so you were monitored closely and treated with broad spectrum antibiotics.,0
You underwent a bone marrow biopsy to examine your bone marrow; these results are pending.,0
You were also given blood transfusions due to low blood counts.,0
Your counts improved and you were changed to oral antibiotics and remained without evidence of infection.,0
It is thought that your low counts were due to an uncommon side effect of the antibiotic bactrim.,0
You should not take bactrim in the future and it has been added to your drug allergy list in our records.,0
You will need to finish 4 days of cefpodoxime 200 mg twice daily.,0
"Your dexamethasone is being tapered: Take 1 tablet daily until , then take 1 tablet every other day until .",0
Your keppra was stopped and you were started on topomax 100 mg twice daily.,0
You should restart your tarceva as prescribed upon discharge.,0
For pain you can take 1 percocet every 4 hours as needed.,0
Do not drive while taking this medication.,0
For nausea you can take 10 mg of compazine every 6 hours as needed.,0
Continue to take your outpatient medications as prescribed.,0
"Call your primary doctor, or go to the emergency room if you experience fevers, chills, dizziniess, shortness of breath, inability to tolerate oral intake, blood in your stool, black stool, or other concerns.",0
"Followup Instructions: You will be called by Dr. office () tomorrow with an appointment to be scheduled sometime for Thursday, .",0
Please call if you don't hear from his office by tomorrow afternoon.,0
You will need to follow up with Dr. () within the next 1-2 weeks.,0
"Please keep your previously scheduled appointment: Provider: , Phone: Date/Time: 12:00 MD Completed by:",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Lipitor / Sotalol / Amiodarone Attending: Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: Mr. is a 75 yo Male with history of HTN, Hyperlipidemia, Afib on Coumadin, patient was in his normal state of health until the evening of Sunday () when he rose from sitting and felt lightheaded /Dizzy.",0
"Later that evening he patient woke from sleep with an episode of dark black diarrhea, with specs of red mixed in.",0
"Through the night and prior to presentation today the patient had, similar episodes.",0
"During this time patient notes some dizziness, lightheadness.",0
Patient notes no associated chest pain or shortness of breath.,0
He reports no prior episode of dark black/bloody bowel movements/emesis in the past.,0
He notes no history of liver disease and endorses only one drink a week.,0
He notes no epigastric pain or indigestion in the past.,0
Notes no changes in bowel habits or weight loss.,0
Unable to have colonoscopy secondary to coumadin.,0
He notes no change in diet and has not had undercooked/raw meet recently.,0
"In the ED, initial vs were: Afebrile P70-80s BP systolics 90-105.",0
Patient was given Vitamin K 10mg IV.,0
Two 18 guage IVs placed.,0
Repeated labs two point HCT drop 35 ->33.,0
NG lavage 500cc totally clear.,0
Rectal with Dark Brown/Reddish heme positive stool.,0
Vitals prior to transfer 89 117/72 15 97% RA.,0
Past Medical History: 1)Hyperthyroidism secondary to amiodarone use 2)Atrial fibrillation: s/p cardioversion x 4 3)Coronary artery disease: s/p cardiac cath 4)Hyperlipidemia.,1
"7)Status-post left hip replacement , successful.",0
"8)""Pinched nerve"" resulting in right leg pain and numbness.",0
Worked as a truck driver for 20years then for for 23 years.,0
Social history is significant for the absence of tobacco use for the last 35 years.,0
Pt reports drinking alcoholic beverages per week.,0
Family History: Brother: Rectal 60s.,0
Mother: Died in 60s secondary to Father: Medical Hx unknown to patient.,0
"Physical Exam: Admission: Vitals: BP: 124/43 P:85 R:19 O2: 99% General: Very Pleasant, Talkative, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, Conjunctiva slightly pale.",0
"Recommendations: Fair prep, need to have repeat colonoscopy in 3 yrs Brief Hospital Course: 75 yo male with history of chronic atrial fibrillation on coumadin, hypertension, hyperlipidemia, CAD, who presents with one day history of dark black/red stools and lightheadedness.",1
"Upper GI Bleed Pyloric Ulcer: Required total 2 units PRBC, 2 FFP.",0
Remained HD stable throughout entire course of hospitalization.,0
GI performed EGD while patient in MICU and noted non-bleeding ulcer.,0
"Recommended continued high dose PPI and testing for H. pylori serologies, which returned negative.",0
No history of liver disease or alcohol abuse.,0
"NG lavage negative in ED, however history consistent with upper GI bleed.",0
"Colonoscopy was normal, though repeat colonoscopy should be done in 3 years.",0
Hematocrit stabilized x 48 hours prior to discharge.,0
Protonix 40mg should be continued and patient will f/u with GI as outpatient.,0
Advised to avoid ALL NSAIDS and to return to ED if melanotic/bloody stools.,0
Hypotension: In ED patient reported to be slightly more hypotensive than during previous admission.,0
In the MICU blood pressure appears to be back to baseline.,0
"Lisinopril and Atenolol initially held, restarted when hematocrit stabilized.",0
"Thrombocytopenia: No clear etiology while inhouse, but platelets noted to trend down (see above lab values) prior to discharge.",0
Not on heparin while inhouse.,0
Repeat CBC will need to be followed up by PCP.,0
Hyperthyroidism secondary to Amiodarone Toxicity: Previously on Methimazole.,0
Stopped recently by Dr. his outpatient endocrinologist when found to be euthyroid.,0
Hyperlipidemia: Continued Zetia 10mg Daily.,0
Has had myalgias with statin.,0
Chronic Atrial Fibrillation: Failed Cardioversion x4.,1
Goal rate Control to 80s while resting; Coumadin/Atenolol held while in MICU given GIB.,0
"Was on metoprolol while on medical floor, and home atenolol restarted on discharge.",0
"Coumadin held during entire hospitalization in anticipation for colonoscopy, though no biopsies were ultimately taken.",0
"Coumadin restarted upon discharge starting at 5mg QHS, with INR to be followed up on by PCP.",0
CAD: Two vessel coronary artery disease (LCx and LAD).,1
No change in the coronary anatomy compared to the cath in .,0
Mild left ventricular diastolic dysfunction.,0
Normal systolic left ventricular function.,0
Allopurinol 300 mg Tablet Daily 2.,0
Ezetimibe 10 mg Daily 3.,0
Atenolol 100 mg One tablet twice daily 4.,0
Lisinopril 20 mg Once Daily 5.,0
"Coumadin 2.5 mg Tablet One Tablet, once a day: take 2.5mg every day for 4 days and 5mg on the fifth day.",0
Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).,0
Atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Outpatient Lab Work Please have a CBC and INR checked on with results reported to , H. MD.",0
Phone: Fax: Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1.,0
Upper GI bleed secondary to ulcer 2.,1
Atrial fibrillation with rapid ventricular response SECONDARY DIAGNOSIS: 1)Hyperthyroidism secondary to amiodarone use 2)Coronary artery disease 3)Hyperlipidemia.,1
Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital on with a GI bleed.,0
"We did a colonoscopy and endoscopy, which showed that this bleed most likely came from an ulcer in your stomach.",0
"For this reason, you were started on a medicine called pantoprazole.",0
"Take this medicine twice a day, and follow-up with the gastroenterologist as listed below.",0
"Should you have any black or bloody stools, it is IMPERATIVE that you call your doctor or come back into the hospital as your ulcer can bleed again.",1
The following changes have been made to your medicines: 1.,0
START taking protonix twice a day 2.,0
START taking 5mg coumadin a day.,0
It will take a few days for your INR to increase to the appropriate level.,0
"Have bloodwork checked on Monday morning and reported to your PCP, you can alter your coumadin dose as needed.",0
"Followup Instructions: Please follow up with your PCP, .",0
", on Monday, at 10:30 am.",0
"Have your bloodwork done on the morning of prior to your appointment, so Dr. can have the results and adjust your coumadin as needed.",0
"Provider: XRAY (SCC 2) Phone: Date/Time: 1:10 Provider: , MD Phone: Date/Time: 1:30",0
8:30 AM ABDOMEN (SUPINE ONLY) PORT PORT Clip # Reason: evaluate for lap pads/ instruments left in abdomen ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with REASON FOR THIS EXAMINATION: evaluate for lap pads/ instruments left in abdomen ______________________________________________________________________________ FINAL REPORT HISTORY: 82 y/o woman.,0
Evaluate for lab pads or instruments left in the abdomen.,0
"SUPINE, PORTABLE AP ABDOMINAL FILM: There is an NG tube in place.",0
There is a linear opacity in the right upper quadrant that may represent a marker on a lap pad; its exact location and etiology is unclear.,0
"linear density is present in the region of the right hemidiaphragm, etiology and location unknown.",0
It would be helpful if a repeat study were done with overlying tubes and wires removed.,0
"11:38 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: pulmonary embolism Admitting Diagnosis: MALAISE Contrast: OMNIPAQUE Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with h/o colon adenoca, s/p open sigmoidectomy for colonic adenoca , COPD, DM, EtOH cirrhosis, who was admitted with hypotension.",1
REASON FOR THIS EXAMINATION: pulmonary embolism No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old man with colonic adenocarcinoma status post open sigmoidectomy for colonic adenocarcinoma .,1
TECHNIQUE: MDCT data were acquired through the chest after administering intravenous contrast.,0
Images were displayed in multiple planes and slice thicknesses.,0
COMPARISON: Chest radiographs through .,0
FINDINGS: CTA: Contrast bolus timing is adequate for assessment of the pulmonary vasculature to the subsegmental level.,0
There are acute pulmonary emboli to the right upper anterior lobe (4:46) and lateral right middle lobe (4:80) subsegmental pulmonary arteries.,1
CHEST CT: Moderate right and small left pleural effusions are present.,1
Right basilar atelectasis is mild.,0
No focal nodule is identified.,0
Left basal atelectasis is mild.,0
"The right lower lobe bronchus is narrowed by indeterminate intraluminal material, possibly mucous (4:103, 106A:50).",0
A 9-mm hypodense nodule is present in the left lobe of the thyroid gland.,0
A 4cm fluid pocket between the coronary sinus and esophagus is likely a pericardial recess.,0
A small anterior pericardial effusion is noted.,0
Coronary artery calcifications are noted in the distal circumflex and proximal LAD distributions.,0
"No mediastinal, hilar, or axillary adenopathy is present.",0
This study was not designed for evaluation of subdiaphragmatic organs.,0
The liver has a nodular contour.,0
Visualized portions of the spleen and adrenal glands are unremarkable.,0
A small hiatal hernia is present.,0
There are no concerning lytic or sclerotic bone lesions.,0
Loss of disc height is moderate at multiple levels.,0
Acute pulmonary emboli to the right upper and lower lobes.,1
"(Over) 11:38 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: pulmonary embolism Admitting Diagnosis: MALAISE Contrast: OMNIPAQUE Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) 2.",1
Right greater than left moderate and small pleural effusions.,1
Right greater than left atelectasis.,0
Findings were discussed with Dr. by telephone after discovery of the imaging finding at 2 p.m. on .,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MED Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending: Chief Complaint: 1.",0
Bacteremia of unknown etiology 2.,0
"Diarrhea Major Surgical or Invasive Procedure: Intubation Central Line placement History of Present Illness: Pt is a 70 yo woman with multiple medical problems, with the most pertinent to current admission being CHF, A Fib, CAD, pulmonary HTN, COPD, myoclonic tremor presented to the ED on with altered mental status, increased tremor, and confusion.",0
"Pt was hypotensive, febrile, with no response IV fluids.",0
"MUST protocol was inforced, pt was intubated.",0
"WBC 12.6, INR 2.9, Cr 2.3 from 1.5.",0
Neurology saw patient and felt increase in increase in severity of tremor was in setting of sepsis.,0
Unlikely a CNS infection so antibiotics d/c'd.,0
"CXR showed + CHF secondary to volume rescusitation, Pt started on lasix and metroprolol.",0
: Pt vomited and aspirated and had to be intubated.,0
"Later pt spiked to 102.1, with rapid A fib.",0
Lasix dc'd once rate controlled (very tenous fluid status at this point).,0
Pt started on levo/clinda for aspiration pneumonia after blood was + for pseudomonas.,0
Pt extubated and brought to the floor.,0
"Past Medical History: CHF DM on insulin AFib Anemia CAD Pulmonary HTN Hypercholesterolemia COPD/BOOP on home O2 Thyroid CA s/p resection/now hypothryoid Myoclonic tremors H/O PE OSA on CPAP Depression/Anxiety MRSA/VRE Social History: Divorced, with 3 children Accountant VNA assistant at home Physical Exam: General: lethargic but alert, in no acute distress HEENT: most mucous membranes, oral mucosa normal, OP normal, PERRLA, EOMI CVS: +JVD, irregularly irregular rhythm, quiet heart sounds Lungs: crackles diffusely, most at bases, bilaterally Abdomen: obsese, tender to palpation on RU/RL quadrant.",1
Blood Cx done showed gram negative rods/pseudomonas that was not sensitive to levo.,0
Pt eLevo was dc'd and started on aztreonam per ID for pseudomonal bacteremia.,0
"Surveillance blood cx were done, and at 48 hours, were negative to date.",0
Pt evaluated for PICC line for long term antibiotics upon dispo.,0
"2) Chest Pain/CHF transfer to floor, pt started on lasix again (overloaded) and Cardiology consulted regarding chest pain.",0
"Enzymes were negative, and chest pain resolved.",0
"Since patient has diastolic dysfunction, diltiazem was started to further decrease rate along with BBlocker.",0
She was slowly diuresed and lasix prn was changed to lasix mf/hr drip due to her positive response of decreasing fluid overload in the past with this regimen.,0
"While on the floor, pt received O2 via nasal canulae, and nebs prn for wheezing/SOB due to COPD.",0
At d/c Pt continues to be under a diuresis regimen of Lasix 80 po BID/spironolactone.,0
"Blood pressures can fluctuate with overdiuresis, however, so dosing must be watched carefully.",0
decrease/increase this regimen slowly with follow up as an outpatient.,0
on amiodarone and beta blocker for rate control.,0
3) Endocarditis - WBC after dropping was up from 11 to 14.,0
"Pt cxed again, but remained afebrile.",0
WBC decreased back down to 10 in the next draw.,0
"On , pt's blood cx (done due to increase in WBC on ) grew back gram + staph aureus most likely secondary from an infected central line vs occipital ulcer.",0
"Dermatology saw patient and cultured the occipital site, which grew back staph aureus.",0
the line was pulled and a peripheral line was placed for access.,0
Pt got a tte and tee to evaluate for endocarditis.,0
": TEE showed small vegetation on aortic valve, with mild to moderate regurgitation at the aortic valve; mild regurgitation at tricuspid and mitral valves; no abscesses.",0
The presence of vegetations in the presence of staph aureus bacteremia is c/w endocarditis.,0
Pt had negative blood cx to date of discharge from -onward.,0
"on Vancomycin 1 gm q 24 ours via the picc, however, Vanc trough elevated out of therapeutic range on , so pt has since been getting Vanc troughs checked daily to determine whether Vanc dose will be given for the day/goal Vanc level: .",0
"Current trough is 11 (), pt should be given her vanc dose this evening () 4) DM -Blood sugars fluctuated x 2 days, came to see pt and dc'd the NPH and started lantus with ssi.",0
"Pt continued to c/o leg pain, so gabapentin increased to 600 TID.",0
Current regimen is SSI with Lantus 20 U at night.,0
5) C Diff- : stool + for C diff.,0
Started on flagyl for longterm management (6 weeks).,0
Stool Cx negative on .,0
on flagyl as an outpatient (start date x 6 weeks for recurrence of cdiff x 2).,0
6) Afib - Current INR 2.1.,0
"Being given coumadin, which is dosed daily based on INR.",0
"Will get 5 mg coumadin this evening, but can be changed daily based on INR.",0
"Crit has decreased mildly, but remains stable.",0
"7)Prophylaxis: As an outpatient, she is to get good bowel regimen to be used prn, good pain management, PPI, vitamins, and diabetic heart healthy diet.",0
Inspect site every shift Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: 1. sepsis 2.,0
Pulmonary HTN 7.Hypercholesteremia 8. h/o BOOP 9.,0
COPD on home O2 10.,0
"Thyroid CA s/p resection, now hypothyroid 11. myoclonic tremors 12.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: assess for pneumothorax s/p line placement Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with recent esophageal rupture, bronchomalacia, now with respiratory distress and re-intubation, s/p L subclavian line REASON FOR THIS EXAMINATION: assess for pneumothorax s/p line placement ______________________________________________________________________________ FINAL REPORT REASON FOR THE STUDY: Assessment for pneumothorax and the patient is status post line placement.",1
TECHNIQUE: Portable semi-upright view of the chest and the study is compared to the same day study done seven hours earlier.,0
FINDINGS: The new left subclavian port line has its tip at the junction of subclavian vein and brachiocephalic vein.,0
Endotracheal tube is 5.6 cm above trachea.,0
The endotracheal tube cuff is overinflated and is bulging and putting pressure on the tracheal lumen and it needs to be partially deinflated.,0
Right subclavian PICC line has its tip in superior SVC.,0
There is an NG tube with its tip in the stomach.,0
There is improvement of reticular opacity at right and left lung suggesting improvement of pulmonary edema.,0
There are bilateral massive pleural plaques suggesting asbestos exposure.,0
The heart size is normal and mediastinal and hilar contours are normal.,0
Small pleural effusion on the right is stable.,0
Slightly overinflated cuff of ETT,0
3:09 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for interval change Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with sepsis from pancreatitis who continues to be febrile REASON FOR THIS EXAMINATION: Evaluate for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Pancreatitis with sepsis and continued fever.,1
"FINDINGS: In comparison with the study of , the tip of the endotracheal tube is above the clavicular level, approximately 6.3 cm above the carina.",0
The nasogastric tube extends well into the stomach.,0
"Another apparent orogastric tube has its tip only in the distal esophagus, unchanged from the previous study.",0
Opacification at the right base is consistent with pleural fluid and associated atelectasis.,0
"Some widening of the superior mediastinum is again noted, most likely reflecting the size of the patient.",0
4:19 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
increased intracranial edema/hemmorhage - increasing intra ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman s/p trauma REASON FOR THIS EXAMINATION: ?,1
increased intracranial edema/hemmorhage - increasing intracranial pressure CONTRAINDICATIONS for IV CONTRAST: look for blood ______________________________________________________________________________ FINAL REPORT INDICATION: 62 year old woman status post trauma with intracranial hemorrhage and increasing intracranial pressure.,1
CT HEAD WITHOUT CONTRAST COMPARISON: TECHNIQUE: CT head without contrast.,0
FINDINGS: An intraventricular catheter is again noted terminating in the region of the foramen of .,0
The previously identified catheter terminating in the region of the caudate nucleus has been removed in the interval.,0
Extensive areas of intraparenchymal hemorrhage are again noted within the right temporal lobe and to a lesser extent the posterior left temporal lobe.,1
Overall quantity of hemorrhage appears to be approximately unchanged however there is increaseing mass effect and edema with increasing right-to-left shift.,0
There is new obliteration of the frontal horns of the lateral ventricles and third ventricle.,0
There has been slight interval increase in the extensive multifocal areas of subarachnoid hemorrhage.,1
There is partial obliteration of the basal cisterns.,0
The prepontine cistern is not effaced.,0
"There is opacification of the maxillary, ethmoid, sphenoid and frontal sinuses.",0
Fluid is present within the dependent portions of the mastoid air cells bilaterally.,0
"Hematoma adjacent to the right orbit is again noted, unchanged.",0
IMPRESSION: There is interval increase in mass effect associated with the right frontal and bilateral temporal intraparenchymal hemorrhages.,1
There is slight interval increase in subarachnoid blood.,0
There is new obliteration of the frontal horns of the lateral ventricles.,0
There is partial obliteration of the basilar cisterns.,0
Appearance is worrisome for impending herniation.,0
(Over) 4:19 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
increased intracranial edema/hemmorhage - increasing intra ______________________________________________________________________________ FINAL REPORT (Cont),1
"2:58 PM MRCP (MR ABD W&W/OC) Clip # Reason: for evaluation of cause of hepatitis, including obstruction, Admitting Diagnosis: HYPOXIA Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man h/o oral lichen planis with acute hepatitis (1000s) of unclear origin (viral and autoimmune panels negative, though liver biopsy notable for immune mediated cause (drug vs autoimmune), on steroids but LFTs continuing to rise.",1
Please perform MRCP and MRV.,0
"ALT: 1313 AP: 320 Tbili: 0.6 AST: 591 LDH: 203 REASON FOR THIS EXAMINATION: for evaluation of cause of hepatitis, including obstruction, thrombosis, infiltrative disease, biliary disease, or any other cause.",1
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MR LIVER INDICATION: Acute hepatitis with oral lichen planus infection.,1
Prior autoimmune screen negative for elevated LFTs.,0
COMPARISON: CT and ultrasound .,0
"TECHNIQUE: Multiplanar T1- and T2-weighted imaging were acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during, and after the uneventful intravenous administration of 15 mL of Magnevist.",0
"In addition, 5 cc of Magnevist was administered orally with 75 cc of VoLumen.",0
"FINDINGS: In the right lower lobe, 11 x 13 mm nodule is identified arising from the posterior aspect of the right pleural surface (series 1601, image 6).",0
This was not appreciated on prior CT abdomen from owing to slice selection.,0
"However, when compared with prior CT chest , indeed it may correspond to a 3-mm nodule, which was seen at that time.",0
Further evaluation with a chest CT is recommended.,0
The liver is not enlarged.,0
There is normal hepatic parenchymal signal intensity.,0
"A 3-mm simple cyst is noted in segment III of the liver which is hyperintense relative to hepatic parenchyma on imaging (series 1602, image 55) and does not demonstrate enhancement post-contrast (series 6, image 29).",0
"There is evidence for mild periportal edema (series 6, image 29 and series 1602, image 63) which can be seen in the setting of acute hepatitis.",1
There is a replaced right hepatic artery arising from the superior mesenteric artery.,0
The visualized hepatic and portal veins are patent.,0
No gallstones are evident within the gallbladder and there is no intra- or extra-hepatic biliary dilatation.,0
The pancreas is homogeneous in signal intensity and enhances uniformly.,0
There are two sub-5-mm cystic lesions distributed throughout the body and tail of the pancreas.,0
"The first is seen within the body measuring 5 mm (series 6, (Over) 2:58 PM MRCP (MR ABD W&W/OC) Clip # Reason: for evaluation of cause of hepatitis, including obstruction, Admitting Diagnosis: HYPOXIA Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ FINAL REPORT (Cont) image 29) and the other lesion is seen within the tail of the pancreas measuring 3 mm (series 6, image 24).",0
These are hyperintense relative to pancreatic parenchyma on imaging and do not demonstrate enhancement post-contrast.,0
Findings are consistent with either side branch IPMN versus other cystic lesion of the pancreas.,0
Interval followup MRI in one year is recommended to confirm stability.,0
Pancreatic duct is normal in caliber and demonstrates no irregularity.,0
The spleen measures 12 cm.,0
Both adrenal glands are unremarkable.,0
"There are bilateral simple renal cysts identified in relation to both kidneys, the largest in the right kidney is identified in the lower pole measuring 4.9 x 4.6 cm (series 6, image 13) and in the upper pole of the left kidney measuring 2.0 x 2.8 cm (series 6, image 33).",0
These are all hyperintense relative to parenchyma on imaging and not demonstrate enhancement post-contrast.,0
There are no retroperitoneal masses or adenopathy.,0
No abnormally dilated or thickened small or large bowel loop in the visualized abdomen.,0
There is no free fluid.,0
Bone marrow signal is normal and there are no osseous lesions.,0
"Indeterminate 15 x 11 mm nodule noted in the right lower lobe, which is new when compared with prior CT from and further evaluation with CT is recommended.",0
"Mild periportal edema noted within the liver, which can be seen in the setting of acute hepatitis without focal liver lesion or intra- hepatic abscess identified.",1
Two sub-5-mm pancreatic cystic lesions in the body and tail of the pancreas as described with differential diagnosis including side branch IPMN versus other cystic lesion of the pancreas.,0
Interval follow-up in one year is recommended with MRCP to ensure stability.,0
2:23 PM CAROTID SERIES COMPLETE Clip # Reason: ?,0
stenosis Admitting Diagnosis: ACITIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with AS REASON FOR THIS EXAMINATION: ?,0
stenosis ______________________________________________________________________________ FINAL REPORT HISTORY: 75-year-old woman with aortic stenosis.,0
RADIOLOGISTS: This study was read by Dr. .,0
"TECHNIQUE: Evaluation of the extra-cranial carotid arteries was performed with B-mode, color and spectral Doppler ultrasound.",0
"FINDINGS: With B-mode, a mild-to-moderate amount of plaque was seen in the bilateral common and internal carotid arteries.",0
"On the right side, peak systolic velocities were 64 cm/sec for the internal carotid artery, and 58 cm/sec for the common carotid artery.",0
The right ICA/CCA ratio was 1.10.,0
"On the left side, peak systolic velocities were 117 cm/sec for the ICA and 44 cm/sec for the CCA.",0
The left ICA/CCA ratio was 2.65.,0
Less than 40% stenosis of the right internal carotid artery.,0
40% to 59% stenosis of the left internal carotid artery.,0
Admission Date: Discharge Date: Service: SURGERY Allergies: Aspirin Attending: Chief Complaint: bilateral foot pain with weight bearing and bloody drainage rt.,0
toe #2 Major Surgical or Invasive Procedure: angiogram diagnostic Right Fem-peroneal bypass Right 2nd toe amputation History of Present Illness: bilateral foot pain with weight bearing and bloody drainage rt.,1
toe #2 HPI: y/o male with multiple medical problems to his gerntologist with c/o right foot pain.,0
Foot exam demonstrated calicies and smal ulceration of right plantar heel.,0
Recommendation at that time was to followup with his podiatrist for shoe fitting and possible new shoes prior to leaving to for vacation.,0
Did well in but upon return to noted increasing foot pain bilaterally.,0
Wife noted yesterday when changing his socks bleeding on the sock.,0
Saw his podiatrist today who did a foot film per wife which showed osteo.,0
Patient refered to Dr. .,0
Seen in office and now admitted for antibiotics and vascular evaluation.,0
Of note patient previously underwent left SFA-peroneal bpg with right arm vein by Dr. .,0
Patient has also had right CEA staged with his CABG's.,1
Ultrasound at the time of CEA showed bilateral carotid stenosis right > left.,0
DM2 -latest A1C 6.1% 2.,0
"CAD s/p CABG x4 in , SVG to post and lat circ, svg to OM, LIMA to LAD 3. s/p MI (15 years ago) 4. chronic systolic CHF, EF 20% 9/08 5. h/o afib -per chart.",1
CKD -baseline Cr 2.3 7.,0
PVD s/p fem- bypass in 10.,0
Left intertrochanteric fracture s/p ORIF 15.,0
"Recent PE in early , on coumadin 16.",0
History of R CEA Social History: Lives at home with wife of 60 years.,0
"Import Social History Family History: non-contributory Physical Exam: VS: 98.8 98.2 67 183/80 18 99%RA Gen : oriented x 3, no acute distress HEENT: no JVD, carotid 1+palp bilat.",0
"no bruits Lungs: CTA Heart: RRR, no mumur,gallop or rub ABD.",0
"soft nontender, bs active no bruits or masses EXT: left foot cool rubrous , no ulcers rt.",0
"foot cool, #2 tore with abraded tip to bone and cynotic toe Pulses: RIGHT: fem//dp/pt: palp/palp/dopp-mono,/dopp-mono LEFT: fem//dp/pt :palp/0/dopp-mono/palp Neuro:AAOx3, nonfocal Pertinent Results: 09:14PM URINE COLOR-Straw APPEAR-Clear SP -1.011 09:14PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG 09:14PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 08:00PM GLUCOSE-182* UREA N-69* CREAT-3.3* SODIUM-135 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-22 ANION GAP-18 08:00PM estGFR-Using this 08:00PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-1.9 08:00PM TSH-76* 08:00PM T4-2.2* FREE T4-0.35* 08:00PM WBC-12.4*# RBC-3.76* HGB-11.4* HCT-32.5* MCV-86 MCH-30.3 MCHC-35.1* RDW-14.3 08:00PM PLT COUNT-339 CXR:Moderate to severe cardiomegaly unchanged.",0
"No pulmonary edema or appreciable pulmonary vascular abnormality, no pleural effusion.",0
The patient has had median sternotomy and coronary bypass grafting.,1
08:00PM PT-27.2* PTT-35.2* (PT)-2.7* Brief Hospital Course: Admitted.,0
"c/s sent of rt.#2 toe,Renally dose ATBX began and Vanco levels monetered.",0
Vein mapping and arterial studies completed.,0
"Scheduled for Monday thydroid function studies demonstrate thypothyroidism.discussed with patient geritrician, will began low dose of syntyhroid 25mcg daily.",0
"1/24-25/09 No acute events, scheduled for lower extremity angiogram .",0
Underwent Ultrasound-guided puncture of left common femoral artery.,0
Contralateral third-order catheterization of right superficial femoral artery.,0
Abdominal aortogram with pelvic angiogram.,0
"Unable to revascularize, scheduled for right fem-peroneal bypass on .",0
"No acute events, angio access benign.",0
Pre-op and consented for lower extremity bypass in am.,0
"Taken to OR and underwent right fem-peroneal bypass and transfered to PACU intubated secondary to intraoperative hypotension, patient was not extubated and transfered to CTICU for vent support.",1
serial troponins were done inital 0.56 peaked 0.66.,0
POD#1 CTICU D2 Remains intubated on vent.,0
POD #2 CTICU D3 possible vent wean and extubate today if ABG's satifactory and mental status continues to improve.,0
"Creatinine rising, admission 3.3-> 3.8 today, ruled in for NSTEMI.",0
Continue to cycle cardiac enzymes.,0
"Cardiology following- recs BP control-on Nitro gtt and Hydralazine IV prn, beta blocker.",0
Remains on Nitro drip and Hydralazine prn for BP control.,0
Trop today .75 from <-.66<-.56.,0
"POD#4 Transferred to 5/VICU, oral meds resumed.",0
"Vanco trough elevated 24.2, Vanco d/c'd.",0
Remains on Cipro and Flagyl.,0
Checking daily Vanco random levels.,0
Pre-op and consented for right 2nd toe amputation.,0
"POD #6 Taken to OR, underwent right 2nd toe amputation, tolerated procedure well, recovered in PACU, then transferred back to 5.",0
Physical therapy consult for discharge planning- out of bed w/ 2 person assit.,0
"vanco level 17.4, creatinine slowly coming down today 3.5 (admission 3.2).",0
"Remains on Heparin drip- Coumadin bridge, 1.3.",0
"Physical therapy strongly recommends short term rehab, patient and family amenable.",0
POD# Patient screened for rehab.,0
"Heparin drip continued, nearly to at 1.9 ( ).",0
Plan to d/c to rehab when bed available and d/c heparin drip at that time.,0
"Discharged to Hospital in stable condition, will FU w/ Dr. in 2 weeks.",0
Staples will come out at rehab in 1 week.,0
"today is 1.9, will continue w/ daily dosing of Coumadin till is reached and stable.",0
Medications on Admission: coreg 3.125 mg aricept 10 mg qd lasix 40 mg qd hydralazine 10 mg imdur 30 mg qd omeprazole 20 mg qd simvastatin 10 mg qd aldactone 12.5 mg flomax 0.4 mg qd effexor xr 75 mg qd coumadin 2 mg qd (held since ) colace 100 mg Novolin MVI .,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed.,0
Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).,0
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).,0
"Venlafaxine 75 mg Capsule, Sust.",0
Release 24 hr PO DAILY (Daily).,0
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Four (24) Units Subcutaneous qAM.,0
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) Units Subcutaneous at bedtime.,0
Insulin Regular Human 100 unit/mL Solution Sig: Two (2) Units Injection with meals: REGULAR INSULIN SLIDING SCALE AS FOLLOWS: 121-160 2Units 161-200 4Units 201-241 6Units 241-280 8Units >280 Notify MD.,0
Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Please have checked and adjust coumadin dose as per protocol.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: rt.,0
"# 2 toe ischemic changes, gangrene history of DM2, insuin dependant with neuropathy history of perpheral vascular disease s/p left fem-peroneal BPG history of c6-7 radiculopathy with C4-5 spinal canal stenosis history of CVA,s/p rt.CEA history of coriinary disease s/p CABG""s x4, MI 96w CHF,NSTEMI GI bleed history of AF, anticoagulated history of DVT, recurrent PEx2, anticoagulated history of dyslipdemia history of macular degeneration history of dyslipdemia history of GI bleed, transfused history of cardiac arrest SVT w aberancy with GI bleed history of ileus narcotics.",1
"postoperative NSTEMI acute on chronic renal failure Discharge Condition: stable Discharge Instructions: Lower Extremity Bypass Discharge Instructions Have checked as arranged by your rehab facility, adjust coumadin dose as directed by your doctor.",1
Adhere to <2 gm sodium diet.,0
"- ambulate essential distances untill FU with Dr. - Ace wrap leg from foot-knee when ambulating - Elevate leg when sitting - may shower, no tub baths - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Continue all medications as directed - Keep all follow-up appointments - You have an appointment with Dr. scheduled at 9:30AM on WEDNESDAY, .",0
"Followup Instructions: You have an appointment with Dr. scheduled at 9:30AM on WEDNESDAY, .",0
2:50 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: please evaluate for prostate ca and metastasis.,0
"Admitting Diagnosis: CHEST PAIN Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with ESRD on HD, elevated PSA, presenting with low back pain, found to have bilateral pleural effusions.",1
REASON FOR THIS EXAMINATION: please evaluate for prostate ca and metastasis.,0
"CONTRAINDICATIONS for IV CONTRAST: renal failure on hd ______________________________________________________________________________ FINAL REPORT CT CHEST, ABDOMEN AND PELVIS WITH CONTRAST HISTORY: Elevated PSA, multifocal pain, evaluate for metastatic disease.",1
"TECHNIQUE: Non-contrast helical acquisition obtained through chest, abdomen, and pelvis.",0
"CHEST: There is a large right pleural effusion and a smaller left pleural effusion with associated airspace opacities, most consistent with atelectasis.",1
"There is dense atherosclerotic calcification of coronary arteries, aorta, and branch vessels.",0
Post-surgical changes of coronary artery bypass grafting are noted.,0
ICD device is in place.,0
"There is diffuse body wall edema, consistent with anasarca.",0
A left brachiocephalic venous stent is in place.,0
ABDOMEN: Moderate ascites is present.,0
"The non- contrast liver, spleen, pancreas, and adrenal glands are unremarkable.",0
There is atrophy of the kidneys bilaterally.,0
Dense atherosclerotic vascular calcification of aorta and branch vessels is noted.,0
There is a 3.3 cm infrarenal abdominal aortic aneurysm.,0
Visualized bowel loops are normal in caliber.,0
PELVIS: The prostate is enlarged.,0
Bowel loops are normal in caliber.,0
"Review of bone windows demonstrates innumerable sclerotic lesions involving the lower cervical spine, thoracic spine, lumbar spine, sacrum, bilateral iliac bones, bilateral hips, and sternum.",0
"Given the findings of an enlarged prostate and elevated PSA, findings most likely represent metastatic disease from prostate carcinoma.",0
There are no pathologic compression fractures identified.,0
"IMPRESSION: Multifocal sclerotic bone lesions, most consistent with metastatic disease from prostate cancer in the setting of elevated PSA and enlarged prostate gland.",0
(Over) 2:50 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: please evaluate for prostate ca and metastasis.,0
Admitting Diagnosis: CHEST PAIN Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) Large right pleural effusion.,1
Small infrarenal abdominal aortic aneurysm.,0
3:09 AM CHEST (PORTABLE AP) Clip # Reason: r/o pneumonia.,0
"Admitting Diagnosis: SYRINGOMYELIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with fever, low bp post op.",0
REASON FOR THIS EXAMINATION: r/o pneumonia.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Fever and low blood pressure post operatively.,0
PORTABLE AP CHEST: Orthopedic hardware is noted in the thoracolumbar region.,0
Skin staples are noted overlying the left mid lung and are aligned vertically over the left medial lung.,0
Stable position of coiled tubes and wires overlying the mediastinum.,0
The cardiomediastial and hilar contours are unremarkable.,0
There is minimal discoid atelectasis at the right lung base.,0
Otherwise the lungs are clear.,0
There are no pleural effusions or pneumothoraces.,0
IMPRESSION: Stable chest radiograph with no evidence of pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Neonatology HISTORY: , boy #2 was at 35 weeks gestation by primary cesarean section for twin gestation and concerns for growth of this twin.",1
"The mother is a 31-year-old gravida 1, para 0 now 2 woman.",0
"Her prenatal screens are blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B Strep unknown.",0
This pregnancy was remarkable for monochorionic/diamniotic twins.,0
"During the pregnancy, there were concerns for pulmonary stenosis in Twin A and fetal growth restriction in this Twin B.",0
Both infants had normal amniotic fluid volume and normal biophysical profiles.,0
"At the time of delivery, this infant emerged vigorous.",0
Apgars were 8 at 1 minute and 9 at 5 minutes.,0
Rupture of membranes occurred at the time of delivery and there were no sepsis risk factors.,0
"Birth weight is 1,515 grams (less than the 10th percentile).",1
Birth length is 41 cm (less than the 10th percentile) and head circumference 30 cm (10-25th percentile).,0
"PHYSICAL EXAMINATION: The admission physical exam reveals a vigorous nondysmorphic, small for gestational age preterm infant.",1
Anterior fontanel is soft and flat.,0
"Heart was regular, rate, and rhythm, no murmur.",0
Stable hip examination and symmetric tone and reflexes.,0
HOSPITAL COURSE BY SYSTEMS: Respiratory status: has always remained in room air and he has no apnea of prematurity.,0
He has had only bradycardia and desaturations associated with feeding discoordination.,0
"On exam, his respirations are comfortable.",0
His lung sounds are clear and equal.,0
Cardiovascular status: has remained normotensive throughout his NICU stay.,0
"On exam, he has a normal S1, S2 heart sound and no murmur.",0
There are no cardiovascular issues.,0
"Fluids, electrolytes, and nutrition status: At the time of discharge, his weight is 2,150 grams.",0
His length is 45 cm and his head circumference is 31.5 cm.,0
Enteral feeds were begun shortly after admission to the NICU and has always been well tolerated.,0
He had some initial hypoglycemia that was resolved with feedings.,0
"At the time of discharge, he is eating NeoSure 24 calories/ounce.",0
Gastrointestinal status: was treated with phototherapy for hyperbilirubinemia of prematurity from day of life #4 to day of life #5.,0
"His peak bilirubin occurred on day of life #4 and was total 8.3, direct 0.5.",0
Genitourinary: was circumcised on and the area has healed well.,0
Hematological status: The infant has received no blood product transfusions during his NICU stay.,0
Infectious disease status: Infant has received no antibiotics during his NICU stay.,0
Neurological: Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears.,0
Psychosocial: Parents have been very involved in the infant's care throughout his NICU stay.,0
CONDITION ON DISCHARGE: The infant is discharged in good condition.,0
DISPOSITION: The infant is discharged home with his parents.,0
"PRIMARY PEDIATRICIAN: Primary pediatric care will be provided by Dr. of in , , telephone number .",0
CARE AND RECOMMENDATIONS AFTER DISCHARGE: Feedings: NeoSure 24 calories/ounce made by concentration with the NeoSure powder.,0
Recommended to continue supervised consistent weight gain.,0
Medications: Iron sulfate (25 mg/mL) 0.2 cc p.o.,0
The infant has passed the car seat position screening test.,0
The last state newborn screen was sent on and was within normal limits.,0
The infant received his first hepatitis B vaccine on .,0
"Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria: 1) at less than 32 weeks, 2) between 32 and 35 weeks with two of three of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or with preschool siblings, or 3) with chronic lung disease.",1
"Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant.",0
"FOLLOWUP: Visiting Nurses Association of , telephone number .",0
Status post prematurity 35 weeks gestation.,1
Status post intrauterine growth restriction.,0
Status post hyperbilirubinemia of prematurity.,0
Dictated By: MEDQUIST36 D: 13:22 T: 06:21 JOB#:,0
"2:49 PM CHEST (PORTABLE AP) Clip # Reason: please r/o infiltrates, fluids Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p left MCA stroke, with fever, respiratory distress, tachycardic to 150's (likely afib).",0
"REASON FOR THIS EXAMINATION: please r/o infiltrates, fluids ______________________________________________________________________________ FINAL REPORT INDICATION: A 48-year-old male with fever, respiratory distress.",0
The comparison is made to the prior chest radiograph dated .,0
"FINDINGS: The patient is status post tracheostomy, with the tracheostomy tube terminating in the trachea, approximately 3 cm above the carina.",0
No evidence of pneumothorax is noted.,0
The heart is enlarged in size.,0
The mediastinal and hilar contours are unchanged compared to the prior study.,0
Previously noted pleural effusion is decreased.,0
Right costophrenic angle is not included on the present study.,0
Right subclavian venous line is removed.,0
"2:07 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval ETT placement Admitting Diagnosis: UROSEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with resp failure REASON FOR THIS EXAMINATION: eval ETT placement ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST FILM, AT 13:59 CLINICAL INDICATION: History of respiratory failure with endotracheal tube placement, check location.",1
Comparison is made to the patient's previous study dated at 9:21.,0
"Portable semi-erect chest film, at 13:59, is submitted.",0
IMPRESSION: Endotracheal tube and right internal jugular central line are unchanged in position.,0
The nasogastric tube has been advanced and now the tip is within the stomach and the side port is probably just beneath the gastroesophageal junction.,1
There has been interval improvement in mild pulmonary edema.,0
"More focal patchy opacity at the left base persists which could reflect a combination of compressive atelectasis and/or pleural effusion, although pneumonia cannot be entirely excluded.",0
Overall cardiac and mediastinal contours are difficult to assess due to the airspace process.,0
"4:25 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman on vent, ?",1
aspiration REASON FOR THIS EXAMINATION: please evaluate ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Suspected aspiration.,0
The ET tube tip is 5.3 cm above the carina.,0
"The cardiomediastinal silhouette is unchanged, grossly within normal limits with minimal questionable left cardiac enlargement.",0
There is interval decrease in the left perihilar opacity consistent with resolution of aspiration with no new consolidations demonstrated on the current study.,0
: (in) 74 Weight (lb): 187 BSA (m2): 2.11 m2 BP (mm Hg): 122/44 Status: Inpatient Date/Time: at 11:52 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the right atrium and/or right ventricle.,0
[Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.],0
Mild tricuspid [1+] regurgitation is seen.,0
"Overall left ventricular systolic function is severely depressed with inferior and inferolateral akinesis, septal hypokinesis/akinesis and apical hypokinesis/akinesis with mild to moderate hypokinesis elsewhere.",0
"Compared with the findings of the prior report (tape unavailable for review) of , the findings are similar.",0
"4:58 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for acute abdominal source of sepsis Admitting Diagnosis: R/O BILIARY OBSTRUCTION Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with cholangitis, was improving, now w/ sudden rigors, hypotension, abdominal pain, rising fever and lactate.",1
"REASON FOR THIS EXAMINATION: eval for acute abdominal source of sepsis No contraindications for IV contrast ______________________________________________________________________________ WET READ: IPf SAT 7:07 PM Perforated loculated gallbladder, loculated in the right liver lobe.",1
D/ at 6:20 pm by Dr. .,0
"______________________________________________________________________________ FINAL REPORT HISTORY: An 84-year-old woman with cholangitis, with improving and now with sudden rigors, hypotension, abdominal pain, rising fever and lactate.",1
Evaluate for acute abdominal source of sepsis.,1
TECHNIQUE: CT abdomen and pelvis with IV and oral contrast.,0
Coronal and sagittal reformatted images are provided.,0
"IV contrast was hand injected through a central line by (Dr., radiology fellow).",0
"COMPARISON: Compared to ultrasound from , and CT abdomen and pelvis .",0
FINDINGS: There are bilateral basilar atelectases at the lung bases.,0
There are minimal bilateral pleural effusions at the lung bases.,0
"There is gap in the wall of the gallbladder, (2:27), with a lobulated collection with minimal enhancement in the right lobe of the liver, and surrounding fat stranding, concerning for perforated loculated gallbladder.",0
"There is a biliary stent in place with tip at the right biliary duct, (2:19).",0
"Air is seen within the intrahepatic biliary ducts, likely from a recent ERCP procedure.",0
"Gallstones are seen again, (2:28).",0
"The kidneys enhance symmetrically, and excrete contrast symmetrically.",0
There is nonspecific stranding and minimal perinephric fluid around the right kidney.,0
"Left kidney appears smaller than the right kidney, and there is some central hypoattenuation, which could be due to atrophy.",0
"There are aterosclerotic vascular changes seen on the left renal artery, not well assessed on this non-angiographic study.",0
"Several hypodensities are seen in the right kidney, too small to characterize.",0
No pathologically enlarged lymph nodes are seen in the retroperitoneum or mesentery.,0
There are significant atherosclerotic changes in the vessels of the abdomen.,0
CT PELVIS: The urinary bladder is collapsed and there is a Foley catheter within.,0
"There is air within the urinary bladder, likely from low placement of a Foley catheter.",0
Calcified fibroid in the uterus are seen.,0
(Over) 4:58 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for acute abdominal source of sepsis Admitting Diagnosis: R/O BILIARY OBSTRUCTION Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are seen.,1
Multiple degenerative changes in the lumbar spine.,0
Contained gallbladder perforation into the right lobe of the liver.,1
Atrophy of the interpolar left kidney.,0
"Atherosclerotic changes of the left renal artery, not well assessed on this non-angiographic study.",0
"Findings were discussed with Dr. at 6:20 p.m. on , by Dr. .",0
"9:45 AM CHEST (PORTABLE AP) Clip # Reason: asses interval change Admitting Diagnosis: C-SPINE INJURY ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man with c5 fx w/ spo2 REASON FOR THIS EXAMINATION: asses interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 29-year-old man with decreasing SpO2, to assess for interval change.",0
"CHEST X-RAY, AP PORTABLE VIEW COMPARISON: .",0
FINDINGS: The ET tube again is 8 cm above the carina and should be advanced at least 3-4 cm.,0
These findings were communicated to Dr. .,0
The tip of the NG tube is in good position in the gastric body.,0
"8:12 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: SMALL BOWEL RESECTION, EVALUATE - TACHY - ?",0
"PE Admitting Diagnosis: UTERINE MALIGNANCY/SDA Field of view: 38 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman POD#9 s/p TAH-BSO, small bowel resection and reanastomosis, sigmoid colectomy (intraabd stool spillage in OR) for uterine adenocaricnoma, postop course complicated by ICU stay, now with mental status changes, fever, tachycardia.",1
"REASON FOR THIS EXAMINATION: eval pulmonary embolism No contraindications for IV contrast ______________________________________________________________________________ WET READ: 11:15 PM 1. no PE or acute aortic syndrome 2. small B pleural effusions, L > R, w/ associated atelectasis 3. remnant retroperitoneal mass that encases aorta, IVC, and R ureter 4. dilated R renal pelvis and mass-encased R ureter w/ stent in place; delayed excretion of R kidney, suggesting some component of obstruction 5. descending colostomy, no evidence of obstruction 6. perihepatic, perisplenic, B paracolic gutter, and pelvic free fluid - cannot rule out anastomotic leak; no organized fluid collection or free air 7.",1
R lower ventral abdominal wall locules of gas may represent fistula or drain tract 8. extensive soft tissue edema 9.,1
"L PICC tip in low SVC d/ @ 23:00 WET READ VERSION #1 11:07 PM 1. no PE or acute aortic syndrome 2. small B pleural effusions, L > R, w/ associated atelectasis 3. remnant retroperitoneal mass that encases aorta, IVC, and R ureter 4. dilated R renal pelvis and mass-encased R ureter w/ stent in place; delayed excretion of R kidney, suggesting some component of obstruction 5. descending colostomy, no evidence of obstruction 6. perihepatic, perisplenic, B paracolic gutter, and pelvic free fluid - cannot rule out anastomotic leak; no organized fluid collection or free air 7.",1
R lower ventral abdominal wall locules of gas suggest enterocutaneous fistulous tract 8. extensive soft tissue edema 9.,0
"L PICC tip in low SVC d/ @ 23:00 ______________________________________________________________________________ FINAL REPORT CTA CHEST AND ABDOMEN INDICATION: 70-year-old woman post-op day 9, mental status change, fever, tachycardia.",0
TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the symphysis pubis before and after the administration of intravenous contrast.,0
"(Over) 8:12 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: SMALL BOWEL RESECTION, EVALUATE - TACHY - ?",0
PE Admitting Diagnosis: UTERINE MALIGNANCY/SDA Field of view: 38 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) Coronal and sagittal reformats were produced and reviewed.,0
CT CHEST WITH AND WITHOUT IV CONTRAST: No axillary or mediastinal lymph nodes which measure greater than 1 cm in short axis.,0
Small left axillary nodes which do not meet size criteria for pathologic enlargement.,1
"Small bilateral pleural effusions, larger on the left with associated compressive atelectasis.",1
"4-mm indeterminate pulmonary nodule in the right middle lobe (3A:41), tiny indeterminate pulmonary nodule more inferiorly (3A:51).",0
No other pulmonary nodules seen.,0
The heart and great vessels are unremarkable in appearance.,0
No convincing evidence of a pulmonary embolus in the segmental and subsegmental pulmonary arteries.,0
CT ABDOMEN WITH IV CONTRAST: Small amount of ascites.,0
No biliary duct dilatation seen.,0
"There is a small amount of dependent high-attenuation material within the gallbladder, most likely due to biliary sludge.",0
The portal vein and hepatic veins are patent.,0
"The spleen, both adrenal glands and pancreas are unremarkable in appearance.",0
The left kidney is unremarkable in appearance.,0
"The right kidney shows moderate hydronephrosis, a JJ stent is in situ with the proximal loop seen within the renal pelvis.",1
Hydronephrosis is evident down to the level of the large necrotic retroperitoneal nodal mass.,1
"At L4/L5 level, there is a 5 x 3.7-cm necrotic soft tissue mass that lies to the right side of the aorta.",0
This attenuates the IVC significantly.,0
"Because of the phase of contrast of this study, it is not possible to assess whether the IVC remains patent or not.",0
Second necrotic nodule seen anteriorly measuring 1.7 x 1.7 cm.,0
This is also seen on the pre-operative MR. fluid seen in both paracolic gutters.,0
Anastomotic suture line seen in the right lower quadrant.,0
Pockets of air in the subcutaneous tissues overlying the right lower quadrant are thought to be related to the recent surgical intervention.,0
"CT PELVIS WITH IV CONTRAST: Anterior to L5/S1, there is a 3.7 x 5.6-cm fluid collection with a peripheral enhancing wall consistent with an intra-abdominal collection.",0
"The appearance is, however, similar to the necrotic node seen just superiorly; however, no nodal mass was identified on the pre-operative MRI in this region.",0
The distal end of the right-sided JJ stent is seen within the bladder.,0
The rectum is unremarkable in appearance.,0
No pelvic lymphadenopathy is seen.,0
BONY STRUCTURES: No concerning lytic or sclerotic bony lesion seen.,0
Persistent necrotic retroperitoneal nodal mass which attenuates the IVC.,0
The IVC cannot be assessed on the current study.,0
PE Admitting Diagnosis: UTERINE MALIGNANCY/SDA Field of view: 38 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 3.,0
Possible necrotic nodal mass in the pelvis versus a small post-operative fluid collection.,0
"Subcutaneous air in the right lower abdomen most likely related to recent surgery, an enterocutaneous fistula is considered less likely however clinical correlation is advised.",0
"2:26 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: CTA chest to assess for pulmonary embolism Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 59 year-old male with COPD, unspecified heart failure with acute onset hypoxia REASON FOR THIS EXAMINATION: CTA chest to assess for pulmonary embolism No contraindications for IV contrast ______________________________________________________________________________ WET READ: MPtb SAT 4:34 PM 1.",1
Atelectasis at base of left lower lobe.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: A 59-year-old male with emphysema, heart failure, and acute onset hypoxia; concern for pulmonary embolism.",1
COMPARISON: Portable chest radiograph today at 7:00 a.m.,0
TECHNIQUE: MDCT axial images of the chest obtained using a low-dose technique at full inspiration without contrast followed by axial images at shallow inspiration after rapid bolus of 100 mL Optiray IV contrast.,0
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are several small blebs along the pleural surfaces of the upper lobes.,0
Mild background centrilobular emphysema is noted.,0
There is atelectasis at the base of the left lung.,0
A small high-density nodule of the right lower lobe (3:50) is consistent with a granuloma.,0
There is no pleural or pericardial effusion.,0
Atherosclerotic calcifications are noted of the aortic arch and coronary arteries.,0
The thoracic aorta is normal in caliber without dissection or aneurysm.,0
There are no pathologically enlarged mediastinal or hilar lymph nodes.,0
The pulmonary arteries opacify well and there is no evidence of pulmonary embolism.,0
Limited evaluation of the upper abdomen shows no abnormality.,0
There is an old fracture with surrounding callus of posterior left rib #5.,0
Atelectasis at the base of the left lower lobe.,0
"3:48 PM RETROPERITONEAL LIMITED US; Clip # Reason: please place perc choley tube Admitting Diagnosis: CHOLECYSITIS ********************************* CPT Codes ******************************** * RETROPERITONEAL LIMITED US * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with acute abdmonial pain REASON FOR THIS EXAMINATION: please place perc choley tube No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 81-year-old woman with acute abdominal pain, for perc chole tube.",0
FINDINGS: The patient was brought to the department with the intention of performing a percutaneous cholecystostomy.,0
An initial ultrasound confirmed the presence of diffuse gallbladder wall thickening.,0
"In addition, the patient has a son sign.",0
"Prior to proceeding to a percutaneous cholecystostomy, the patient's airway was assessed to allow the administration of conscious sedation.",0
"Unfortunately, the patient's airway was such that it was not deemed safe to give her conscious sedation in the ultrasound department.",0
She was reviewed by anesthesia who agreed with our assessment.,0
"Therefore, we will plan to perform percutaneous cholecystostomy tomorrow under anesthesia care.",0
The patient was returned to the .,0
IMPRESSION: Thick-walled gallbladder with a son sign consistent with acute cholecystitis.,1
"Planned percutaneous cholecystostomy not performed in view of the patient's airway, the procedure has been re-scheduled for tomorrow under anaesthesia care.",0
", R. MED SICU-A 2:20 PM CHEST PORT.",0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: 57cm left picc.,0
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with REASON FOR THIS EXAMINATION: 57cm left picc.,0
"______________________________________________________________________________ PFI REPORT Left PICC ends in the mid superior vena cava; otherwise, no significant change from the prior study performed one hour earlier.",0
"4:18 PM CHEST (PRE-OP PA & LAT) Clip # Reason: AORTIC REGURGITATION\AORTIC VALVE REPLACEMENT REDO; BENTAL PROCEDURE; CORONARY ARTERY BYPASS GRAFT WITH MVR Admitting Diagnosis: AORTIC REGURGITATION\AORTIC VALVE REPLACEMENT REDO; BENTAL PROCEDURE; CORONARY ARTERY BYPASS GRAFT WITH MVR ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p AVRX5 for preop eval of AVR and CABG REASON FOR THIS EXAMINATION: pre-op ______________________________________________________________________________ FINAL REPORT CHEST TWO VIEWS, AT 16:19 HOURS.",1
"CLINICAL INFORMATION: Pre-op for aortic valve replacement, re-do.",1
"FINDINGS: Since the prior study, there has been interval development of cardiomegaly.",0
"In addition, there has been interval development of fluid within the minor fissure.",0
The remainder of the lungs are clear.,0
IMPRESSION: Interval development of cardiomegaly with loculated fluid in the minor fissure.,0
"7:19 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: consolidations, pulm edema Admitting Diagnosis: CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with hx of CHF, transferred urgently to the MICU for resp distress REASON FOR THIS EXAMINATION: consolidations, pulm edema ______________________________________________________________________________ WET READ: GMSj SUN 9:13 PM Right-sided large bore central line in unchanged position - RA/RV.",0
Mild to moderate interstitial pulmonary edema - slightly increased since prior.,0
Stable bibasilar consolidations - likely atelectasis.,0
Increasing bilateral pleural effusions - though both small.,0
"GSenapati ______________________________________________________________________________ FINAL REPORT AP CHEST, 7:13 P.M., ON HISTORY: CHF.",0
"IMPRESSION: AP chest compared to through , 1:17 p.m.: Moderately severe pulmonary edema has not worsened since earlier in the day, though moderate right and small left pleural effusions have increased.",0
"Moderate cardiomegaly has remained stable over the past several days, but has progressed substantially since and could be due to cardiomegaly and/or pericardial effusion.",0
"Dual-channel catheter, presumably for hemodialysis ends in the right atrium.",0
Height: (in) 64 Weight (lb): 160 BSA (m2): 1.78 m2 BP (mm Hg): 13/755 HR (bpm): 69 Status: Inpatient Date/Time: at 13:00 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
The end-diastolic PR velocity is increased c/w PA diastolic hypertension.,0
The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension.,1
IMPRESSION: Mild right ventricular cavity enlargement with low normal systolic function.,0
Normal left ventricular cavity size and regiona/global systolic function.,0
"This constellation of findings is suggestive of a primary acute pulmonary process (e.g., pulmonary embolism, pneumonia, bronchospasm, etc.)",1
10:25 AM CT CHEST W/O CONTRAST Clip # Reason: amiodarone toxicity.,0
"Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with SOB x 18 months s/p CABG in ', on amiodarone since that time w/ worsening SOB.",1
Pt unable to perform adequately for PFT evaluation.,0
REASON FOR THIS EXAMINATION: amiodarone toxicity.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old female with shortness of breath x18 months status post coronary artery bypass graft in .,1
"Patient is on amiodarone since the CABG, with worsening shortness of breath.",0
COMPARISON: PA and lateral chest x-ray dated .,0
TECHNIQUE: MDCT imaging of the chest was performed without intravenous contrast.,0
Inspiratory and expiratory images were obtained.,0
CT CHEST WITHOUT INTRAVENOUS CONTRAST: A right internal jugular central venous catheter terminates in the distal SVC.,0
A left-sided pacemaker is seen with leads adjacent to the right atrium and right ventricle.,0
The patient is status post coronary artery bypass graft with sternal wires and sutures.,1
"The ascending aorta is slightly ectatic, without aneurysmal dilatation, and measures 2.8 cm at widest diameter.",0
There are diffuse coronary artery and aortic calcifications.,1
Small bilateral pleural effusions are seen bilaterally.,0
"There is no axillary, mediastinal, or hilar lymphadenopathy.",0
"On lung windows, mild scarring is seen within bilateral lung bases.",0
There is no interstitial thickening or areas of consolidation.,0
Pleural-based calcifications are seen within the right lung anteriorly.,0
No intraparenchymal nodules or masses are identified.,0
"Limited imaging of the upper abdomen reveals a hyperdense liver with a few scattered low-attenuation lesions within the right liver lobe, which likely represent simple cysts.",0
"The gallbladder is enlarged with a moderate amount of intraluminal sludge, but no visualized stones.",0
Again noted is diffuse atherosclerosis.,0
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous abnormalities.,0
No definite evidence to support pulmonary amiodarone toxicity.,0
Hyperdense liver consistent with patient's known history of amiodarone toxicity.,0
A few scattered hypodense lesions within the liver are not adequately characterized on this non-contrast study.,0
Ultrasound or MRI is recommended for further evaluation.,0
(Over) 10:25 AM CT CHEST W/O CONTRAST Clip # Reason: amiodarone toxicity.,0
Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH ______________________________________________________________________________ FINAL REPORT (Cont) 4.,1
Moderate amount of intraluminal sludge.,0
Pleural-based calcification in right anterior lung consistent with prior asbestos exposure.,0
Status: Inpatient Date/Time: at 12:07 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
No spontaneous echo contrast or thrombus in the body of the LAA.,0
All four pulmonary veins not identified.,0
Normal LV wall thickness and cavity size.,0
Severely thickened/deformed aortic valve leaflets.,1
Moderate to severe (3+) AR.,0
Moderate thickening of mitral valve chordae.,1
Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
There is severe aortic valve stenosis (valve area 0.8-1.0cm2).,1
Moderate to severe (3+) aortic regurgitation is seen.,0
There is moderate thickening of the mitral valve chordae.,1
Preserved LV systolci function 2.,0
Bioprosthetic valve in aortic positiion.,1
Well seated and mechanically stable.,0
9:22 AM CHEST (PORTABLE AP) Clip # Reason: Pt pre-op for renal transplant with new onset desaturation i ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with ARF REASON FOR THIS EXAMINATION: Pt pre-op for renal transplant with new onset desaturation in setting of acute renal failure upon chronic.,1
r/o pul edema ______________________________________________________________________________ FINAL REPORT HISTORY: Preop for renal transplant.,0
"PORTABLE AP UPRIGHT CHEST: Compared with 5/11, the patient has developed diffuse patchy infiltrates involving all areas of the right lung.",0
There is persistent patchy atelectasis or infiltrate in the retrocardiac region.,0
"7:31 PM CHEST (PORTABLE AP) Clip # Reason: please eval for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with fevers REASON FOR THIS EXAMINATION: please eval for infiltrate ______________________________________________________________________________ WET READ: PXDb MON 10:53 PM LEFT MID LUNG OPACITY, COULD REFLECT ATELECTASIS GIVEN LOW LUNG VOLUMES, OR A DEVLOPING PNEUMONIA IN RIGHT CLINICAL SETTING WET READ VERSION #1 PXDb MON 10:52 PM LEFT MID LING OPACITY, COULD REFLECT ATELECTASIS GIVEN LOW LUNG VOLUMES, OR A DEVLOPING PNEUMONIA IN RIGHT CLINICAL SETTING ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old man with fevers, evaluate for infiltrate.",0
"SINGLE AP BEDSIDE RADIOGRAPH OF THE CHEST: There is left mid lung faint consolidation, which could reflect pneumonia or atelectasis.",0
The right costophrenic angle is excluded from the field of view.,0
The heart size is normal and the pulmonary vasculature is within normal limits.,0
Moderate dextroconvex thoracic scoliosis is noted.,0
IMPRESSION: Left mid lung faint consolidation could reflect pneumonia or atelectasis.,0
", C. NMED SICU-B 2:42 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: eval for interval change in bleed Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with cerebellar hemorrhage REASON FOR THIS EXAMINATION: eval for interval change in bleed No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No interval change in cerebellar intraparenchymal hemorrhage with dissection into the ventricular system and associated hydrocephalus.",1
"Scattered foci of subarachnoid hemorrhage, likely due to redistribution.",0
1:55 PM PICC LINE PLACMENT SCH Clip # Reason: Placement for use Admitting Diagnosis: GUN SHOT WOUND ********************************* CPT Codes ******************************** * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with need for prolonged antibiotic therapy.,1
PICC line unable to be placed by RN REASON FOR THIS EXAMINATION: Placement for use ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc FRI 5:22 PM Uncomplicated fluoroscopic-guided PICC line exchange for a new single lumen PICC line.,0
"Final internal length is 51.5 cm, with the tip positioned in SVC.",0
______________________________________________________________________________ FINAL REPORT PICC LINE EXCHANGE/REPOSITIONING INDICATION: Malposition of indwelling PICC line.,0
RADIOLOGIST: Dr. performed the procedure.,0
Dr. was the attending physcian who was present and supervising.,0
"TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling right arm PICC line, and subsequently into the SVC under fluoroscopic guidance.",0
The old PICC line was then removed and a peel-away sheath was then placed over the guidewire.,0
A new single lumen PICC line measuring 52 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new single lumen PICC line.,0
"Final internal length is 52 cm, with the tip positioned in the SVC.",0
(Over) 1:55 PM PICC LINE PLACMENT SCH Clip # Reason: Placement for use Admitting Diagnosis: GUN SHOT WOUND ______________________________________________________________________________ FINAL REPORT (Cont),0
LINE PLACEMENT Clip # Reason: ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with AVR/CABG - please with results if there is concern REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ FINAL REPORT HISTORY: Cardiac surgery.,1
"FINDINGS: In comparison with study of , there is now an endotracheal tube in place with its tip approximately 7 cm above the carina.",0
Right IJ Swan-Ganz catheter extends to the pulmonary artery.,0
The nasogastric tube extends to the stomach with the side hole at the level of the esophagogastric junction.,0
Left chest tube is in place without pneumothorax.,0
Mild atelectatic changes at the left base.,0
", G. MED FA2 5:06 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please eval for phlegmon vs abscess and interval change from Admitting Diagnosis: INFLAMMATORY BOWEL DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with chrons disease and known phlegmon, now with fevers and abd pain REASON FOR THIS EXAMINATION: please eval for phlegmon vs abscess and interval change from scan from (in our system) No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Two small abscesses up to 2 cm in size in midline lower pelvis.",1
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: R IJ placement Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with septic shock REASON FOR THIS EXAMINATION: R IJ placement ______________________________________________________________________________ WET READ: TXCf SUN 7:50 PM Rt IJ line projects over mid svc.,1
"heterogeneous right lung base opacity, unchanged.",0
"right upper lobe and left lung base opacities appear more conspicuous from prior exam, may represent additional areas of infection.",0
"chadashvili ______________________________________________________________________________ FINAL REPORT AP CHEST, 7:23 P.M., 12, .",0
New right IJ line placement.,0
IMPRESSION: AP chest compared to : Tip of the new right internal jugular line projects over the mid SVC.,0
"No pneumothorax, mediastinal widening or appreciable pleural effusion.",0
"Large scale consolidation in the lower lungs, right greater than left, is unchanged.",0
"Pleural effusion, minimal if any.",0
4:52 AM CHEST (PORTABLE AP) Clip # Reason: mew doboff Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with s/p new doboff placement (again. ),0
REASON FOR THIS EXAMINATION: mew doboff ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.,0
FINDINGS: Slightly more distal but still normal position of the nasogastric tube.,0
"Otherwise, no relevant change, no pleural effusions, subtle retrocardiac opacity suggestive of atelectasis.",0
Normal size of the cardiac silhouette.,0
4:37 PM PICC LINE PLACMENT SCH Clip # Reason: **power PICC- double lumen placement Admitting Diagnosis: STERNAL WOUND INFECTION This is a power pick ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with PPM (L)/IV team unsuccessful REASON FOR THIS EXAMINATION: **power PICC- double lumen placement ______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for antibiotics.,1
RADIOLOGIST: Dr. and performed the procedure.,0
"The study was reviewed by the staff radiologist, Dr. .",0
"TECHNIQUE: Using sterile technique and local anesthesia, the right basilic vein was punctured under direct ultrasound guidance using a micropuncture set.",0
A peel-away sheath was then placed over a guidewire and a double lumen Power PICC line measuring 40 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen Power PICC line placement via the right basilic venous approach.,0
"Final internal length is 40 cm, with the tip positioned in SVC.",0
1:06 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"ptx, htx, pna ______________________________________________________________________________ MEDICAL CONDITION: History: 81F with cp after REASON FOR THIS EXAMINATION: ?",0
"ptx, htx, pna No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old female with chest pain postoperatively.",0
TECHNIQUE: Single frontal chest radiograph was obtained with the patient in an upright position with AP technique.,0
FINDINGS: There has been interval removal of the right central venous catheter.,0
"Bibasilar pulmonary opacities, left greater than right, appear similar compared to prior and likely represent a combination of effusion and atelectasis, although left lower lobe pneumonia cannot be excluded.",0
Mild pulmonary edema appears slightly worse in the interval.,0
No pneumothorax is detected on this view.,0
Median sternotomy wires and mediastinal clips likely reflect prior CABG.,0
"IMPRESSION: Persistent left greater than right basilar opacities which may represent pleural effusion and atelectasis, but left lower lobe pneumonia cannot be excluded.",0
Mild pulmonary edema appears slightly worse.,0
10:02 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE;TELEMETRY Admitting Diagnosis: CORONARY ARTERY DISEASE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with coronary artery disease.,1
REASON FOR THIS EXAMINATION: Please assess for infiltrate or effusion ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Coronary artery disease.,1
CHEST: The heart and mediastinum are normal.,0
5:36 PM CHEST (PRE-OP PA & LAT) Clip # Reason: pre-op CABG Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CAD REASON FOR THIS EXAMINATION: pre-op CABG ______________________________________________________________________________ FINAL REPORT INDICATION: 77 y/o pre-op for CABG.,1
PA AND LATERAL CHEST: No prior studies.,0
FINDINGS: The heart demonstrates a left ventricular configuration.,0
The mediastinal contours are normal.,0
The lung volumes are reduced.,0
There is slight blunting of the left costophrenic angle.,0
There is evidence of prior surgery in the left lung with surgical chain sutures seen at the left lung base.,0
IMPRESSION: Blunting of the left costophrenic angle and evidence of prior surgery at the left lung base.,0
"10:48 AM CHEST (PORTABLE AP) Clip # Reason: ?fx, PTX or effusions ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with traumatic fall REASON FOR THIS EXAMINATION: ?fx, PTX or effusions ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH PERFORMED ON COMPARISON: None.",0
"CLINICAL HISTORY: Status post fall with subarachnoid hemorrhage, question acute injury in the chest.",1
FINDINGS: AP portable supine view of the chest is obtained.,0
"No focal consolidation, effusion, or pneumothorax is seen.",0
Heart and cardiomediastinal silhouette appears normal.,0
IMPRESSION: No acute injury in the chest.,0
", W. SICU-A 8:33 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for PBA, atelectasis, effusion Admitting Diagnosis: CIRRHOSIS;ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with crackles left base REASON FOR THIS EXAMINATION: Please eval for PBA, atelectasis, effusion ______________________________________________________________________________ PFI REPORT Interstitial edema increased.",1
"Left retrocardiac opacity is unchanged, could be atelectasis or pneumonia.",0
2:37 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval eval Admitting Diagnosis: PLEURAL CUT FISTULA PE ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with bilateral cavitating lung lesions s/p extubation REASON FOR THIS EXAMINATION: ?,1
"interval eval ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Bilateral cavitating lung lesion, followup of the patient after extubation.",1
Portable AP radiograph of the chest was compared to .,0
"As compared to the prior study, the right internal jugular line has been removed.",0
The right PICC line tip is at the level of cavoatrial junction.,0
Right lung consolidation and cavitary lesions are unchanged.,0
"Left mid lung consolidation is unchanged, although minimal progression of the left pleural effusion after discontinuation of the left chest tube cannot be excluded.",0
"1:28 PM CHEST (PORTABLE AP) Clip # Reason: eval for CHF Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with multiple ortho injuries REASON FOR THIS EXAMINATION: eval for CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Multiple orthopedic injuries, evaluate for CHF.",0
PORTABLE CHEST RADIOGRAPH: Right-sided central venous sheath seen with tip projecting over the SVC.,0
Cardiac and mediastinal contours are unremarkable.,0
Small right pleural effusion is noted.,0
Left retrocardiac opacity and basilar atelectasis is noted.,0
Likely emphysematous changes also noted.,0
There is no evidence of definite CHF.,0
IMPRESSION: Small right pleural effusion.,0
"Retrocardiac opacity also seen, possibly representing atelectasis although focal consolidation cannot be excluded.",0
"9:33 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p AVR and ct removal REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP PORTABLE VIEW HISTORY: 56-year-old man, S/P AVR and CT removal, rule out pneumothorax.",0
Comparison is made with prior study performed day before.,0
FINDINGS: There has been interval improvement of hazy opacities located in the left upper lobe.,0
There has been mild interval increase in the opacity located in the left lower lobe.,0
Stable widening of the cardiomediastinal silhouette consistent with patient's post-operative state.,0
There is no evidence of pneumothorax or pleural effusion.,1
"The endotracheal tube, nasogastric tube, chest tube, and right internal jugular venous access sheath have been removed.",0
Patient is S/P median sternotomy and aortic valve prosthesis.,0
Interval improvement of the pulmonary edema.,0
Increase in the atelectasis/consolidation in the left lower lobe and continued opacity in the retrocardiac area.,0
Chest CT is recommended for further assessment.,0
10:01 AM CHEST (PORTABLE AP) Clip # Reason: R/O PTX ______________________________________________________________________________ CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED: ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: INDICATION: Evaluate for pneumothorax s/p thoracotomy.,0
Comparison is made to previous study of 1 day earlier.,0
This is a repeat dictation for previously lost report.,0
"An ETT, Swan-Ganz catheter, NG tube, and bilateral chest tubes remain in place.",0
Cardiac and mediastinal contours are stable in the interval.,0
"There remain bilateral pleural effusions, with loculation of the left pleural effusion.",1
Note is also made of nonspecific opacity peripherally in the left lung base adjacent to the area of pleural fluid.,0
IMPRESSION: No significant interval change allowing for differences in technique.,0
"7:15 AM CHEST (PORTABLE AP) Clip # Reason: r/o reaccumulation of pleural effusion Admitting Diagnosis: CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 68M s/p SBR for mesenteric ischemia, s/p OLTx c/b small bowel anastomosis leak s/p takeback for repair , s/p trach , s/p hep art stent REASON FOR THIS EXAMINATION: r/o reaccumulation of pleural effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 10:46 AM No interval change in moderate to severe bilateral pleural effusion and moderate bibasilar atelectasis.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old man with multiple recent abdominal surgeries.,0
"FINDINGS: Comparison is made to the prior chest radiograph of , and a CT of chest of .",0
"There has been no interval change in the position of the PICC, NG tube and the tracheostomy tube.",0
The latter projects approximately 6.7 cm above the carina.,0
Moderate to severe bilateral pleural effusion and moderate bibasilar atelectasis are unchanged.,1
IMPRESSION: No interval change in moderately severe bilateral pleural effusions and moderate bibasilar atelectasis.,1
10:29 AM CHEST (PA & LAT) Clip # Reason: s/p CABG w/post op fever-r/o effusion Admitting Diagnosis: CHEST PAIN\CATH ______________________________________________________________________________ MEDICAL CONDITION: s/p CABG REASON FOR THIS EXAMINATION: s/p CABG w/post op fever-r/o effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG.,0
PA AND LATERAL CHEST: There are new sternotomy wires and mediastinal medical clips consistent with status post CABG.,0
The hilar contours and pulmonary vascularity are unremarkable.,0
Patchy bibasilar opacities are consistent with atelectasis.,0
LINE PLACEMENT Clip # Reason: check placement of IJ.,0
"had to withdraw 6 cm because sitting Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with HIV, HCC.",1
REASON FOR THIS EXAMINATION: check placement of IJ.,0
had to withdraw 6 cm because sitting in ventricle.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 51-year-old female with HIV, bacteremia.",0
Single AP chest radiograph compared to show re-positioning of the right IJ central venous catheter which terminates in the right atrium.,0
8mm nodule in the right upper lobe is better evaluated on CT.,0
Elevation of the left hemidiaphragm is unchanged and related to underlying splenomegaly.,0
9:55 AM BILAT UP EXT VEINS US Clip # Reason: r/o dvt Admitting Diagnosis: INTRACRANIAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with AVM status post craniotomy on bed rest for five days now with upper extremity swelling REASON FOR THIS EXAMINATION: r/o dvt ______________________________________________________________________________ FINAL REPORT INDICATION: AVN.,0
S/P craniotomy with upper extremity swelling.,0
"BILATERAL UPPER EXTREMITY ULTRASOUND: scale and doppler son of the bilateral internal jugular, subclavian, axillary, brachial and cephalic veins were performed.",0
"There is normal flow, compressibility and wave forms demonstrated.",0
There is no intraluminal thrombus.,0
"3:30 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate necrotizing pancreatitis with po and iv cont Admitting Diagnosis: ACUTE PANCREATITIS;GI BLEED Field of view: 38 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with pancreatitis REASON FOR THIS EXAMINATION: please evaluate necrotizing pancreatitis with po and iv contrast, full pancreatic protocol not necessary No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Pancreatitis, sepsis.",1
TECHNIQUE: A CT pancreatitis protocol was used.,0
Helically acquired axial images were obtained through the abdomen before and after the administration of 150 cc of nionionic Optiray contrast.,0
Images were also obtained through the pelvis after the administration of IV contrast.,0
"CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: There are small, bilateral pleural effusions with reactive atelectasis.",0
A Swan-Ganz catheter is seen entering the right atrium and right ventricle.,0
An NG tube is seen coursing below the diaphragm into the stomach.,0
The pancreas appears to enhance homogenously within the body and tail.,0
There is some heterogeneous enhancement of the head of the pancreas.,0
There is a significant amount of peripancreatic stranding and fluid which is extending into the transverse mesocolon and lesser sac.,0
There are also areas of more localized fluid collections posterior to the gastroesophageal junction.,0
The fluid/fat stranding is also extending into the left pericolic gutter.,0
"The liver, spleen and adrenal glands are unremarkable.",0
"There are hypoattenuating areas within both kidneys consistent with simple cysts, the largest within the lower pole of the left kidney.",0
"All the major vessels appear patent including the splenic, superior mesenteric and portal veins .",0
The intraabdominal loops of large and small bowel are unremarkable.,0
CT OF THE PELVIS WITH IV CONTRAST: There is free-fluid within the pelvis.,0
A Foley catheter with air was seen within the bladder.,0
"Small, bilateral pleural effusions with reactive atelectasis.",0
Large amount of peripancreatic inflammation which extends from the transverse mesocolon to the left pericolic gutter.,0
No distinct localized collections are seen.,0
The body and tail of the pancreas appeared to enhance homogeneously.,0
There is heterogeneous enhancement of the head of the pancreas.,0
Ascites and free-fluid within the pelvis.,0
(Over) 3:30 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate necrotizing pancreatitis with po and iv cont Admitting Diagnosis: ACUTE PANCREATITIS;GI BLEED Field of view: 38 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) These findings were discussed with Drs.,1
and from the surgery team.,0
4:57 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with CAD preop CABG REASON FOR THIS EXAMINATION: evaluate for acute process ______________________________________________________________________________ FINAL REPORT EXAM: Chest frontal and lateral views.,1
"CLINICAL INFORMATION: 73-year-old male with history of coronary artery disease, pre-op CABG.",1
FINDINGS: Frontal and lateral views of the chest are obtained.,0
"Prominent pleural calcification is seen overlying the left lateral hemithorax, suggesting prior asbestos exposure.",0
There is overlying left pleural thickening versus less likely a small left effusion.,0
No right pleural effusion is seen.,0
The cardiac silhouette is top normal to mildly enlarged.,0
There are mild degenerative changes along the spine.,0
"IMPRESSIONS: Prominent left-sided lateral pleural plaques, suggest prior asbestos exposure.",0
Adjacent mild left pleural thickening versus less likely pleural effusion.,0
6:07 PM CHEST (PORTABLE AP) Clip # Reason: fever ?pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman s/p thoracentesis REASON FOR THIS EXAMINATION: fever ?pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: S/P thoracentesis.,0
CHEST AP: There has been interval withdrawal of the ET tube.,0
"Again noted is a VP shunt, extending below the diaphragm.",0
"Again noted is a moderate sized right pleural effusion, which demonstrates interval decrease in size compared to the prior study.",1
Also noted is a small left pleural effusion.,1
There is patchy atelectasis at both lung bases.,0
"Also noted is a retrievable Tulip IVC filter, which remains stable in position since the prior study.",0
IMPRESSION: Interval decrease in the size of previously noted right pleural effusion.,1
Interval development of a small left-sided pleural effusion.,1
12:22 PM CHEST (PORTABLE AP) Clip # Reason: tachypnea Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with increased respiratory rate REASON FOR THIS EXAMINATION: tachypnea ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with increase respiratory rate.,1
The patient continues to be in moderate interstitial pulmonary edema accompanied by bilateral moderate pleural effusions and bibasilar areas of atelectasis.,0
"Overall, no significant change since was noted.",0
"4:17 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: disease progression, pneumonia Admitting Diagnosis: METASTATIC LYMPHOMA Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with metastatic lymphoma, cxr demonstrates increase in nodules, also concern for pneumonia REASON FOR THIS EXAMINATION: disease progression, pneumonia No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic lymphoma with increase of nodules on chest x-ray.",1
Evaluate disease progression or evidence of pneumonia.,0
TECHNIQUE: Helical CT of the chest was performed with 5 mm slice collimation after the administration of IV contrast.,0
100 cc of Optiray nonionic contrast was given for the patient's debility.,0
"Comparison is made to prior outside study of the chest dated , as well as CT of the abdomen of .",0
"FINDINGS: Examination of lung windows demonstrates innumerable solid pulmonary nodules diffusely distributed across all bronchopulmonary segments, the largest of which is 24 x 38 mm in a subpleural location of the inferior portion of the right upper lobe.",0
"There is postobstructive collapse of the right middle lobe, and there is a 14 mm nodule posterior to the right bronchus, which is causing compression of the bronchus.",0
Other central airways remain patent.,0
"Due to differences in technique, it is difficult to assess interval change in size of the pulmonary nodules seen on the prior abdominal CT, but innumerable new ones are present.",0
There is minimal bibasilar atelectasis.,0
"Examination of the soft tissue windows demonstrates a large left axillary mass, which appears to be the confluence of two adjacent masses.",0
"Together, this measures 34 x 58 mm in size.",0
"While this extends adjacent to the ribs, there is no definite destructive changes of the adjacent ribs.",0
There is a 1 cm precarinal lymph node.,0
The heart and pericardium are within normal limits.,0
Multiple centimeter-sized soft tissue densities are seen in the subcutaneous tissues behind the left shoulder.,0
"Limited examination of the upper abdomen again demonstrates multiple unchanged hypodense lesions within the spleen, with an unremarkable appearance of the visualized portion of the liver.",0
"There is a cystic-appearing structure adjacent to the liver and pancreatic head, which is incompletely characterized.",0
It has a similar appearance to dilated cystic duct on the prior study.,0
"The kidneys appear slightly atrophic on this study, and adrenal glands appear to be within normal limits.",0
"However, there are new retroperitoneal lymph nodes, with a 26 mm lymph node adjacent to the splenic hilum and a 23 mm lymph node anterior to the left kidney.",0
"(Over) 4:17 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: disease progression, pneumonia Admitting Diagnosis: METASTATIC LYMPHOMA Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) Examination of the osseous structures demonstrates osteopenia and degenerative change, without suspicious lytic or blastic lesions.",1
"Significant interval progression of lymphoma, with diffuse and innumerable lesions within both lungs.",0
Postobstructive collapse of the right middle lobe.,0
Nonobstructive compression of the right main stem bronchus.,0
New retroperitoneal lymph nodes and subcutaneous lesions in the posterior region of the left shoulder.,0
Cystic-appearing structure adjacent to the pancreatic head may represent dilated cystic duct but is incompletely characterized on today's study.,0
10:40 AM HIP UNILAT MIN 2 VIEWS RIGHT; FEMUR (AP & LAT) RIGHT Clip # KNEE (2 VIEWS) RIGHT Reason: ?,0
fracture Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman s/p fall and stroke w/ pain & bruising REASON FOR THIS EXAMINATION: ?,0
fracture ______________________________________________________________________________ FINAL REPORT STUDY: Two views of the femurs and two views of the right knee performed on .,0
HISTORY: 65-year-old woman status post fall with stroke and pain.,0
FINDINGS: There are no signs for acute fractures or dislocations.,0
Normal osseous mineralization is identified.,0
There is no joint effusion.,0
Mild degenerative changes are seen in the lower lumbar spine and the sacroiliac joints bilaterally.,0
Valvular heart disease Height: (in) 71 Weight (lb): 270 BSA (m2): 2.40 m2 BP (mm Hg): 104/49 HR (bpm): 92 Status: Inpatient Date/Time: at 15:52 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: septum to posterior wall delay by M-mode is 320 msec LEFT ATRIUM: Moderate LA enlargement.,0
TSI demonstrates significant LV dyssynchrony with significant inferolateral wall contraction delay (vs. anterior septum wall).,0
"Patient meets at least modified CARE-HF criteria for ventricular dyssynchrony, and may benefit from resynchronization therapy.",0
Complex (mobile) atheroma in aortic root.,0
Significant AS is present (not quantified) Mild (1+) AR.,0
Minimally increased gradient consistent with trivial MS.,0
Thickened/fibrotic tricuspid valve supporting structures.,0
"Overall left ventricular ejection fraction is severely depressed (LVEF= 20-30 %), primarily secondary to marked intraventricular mechanical dyssynchrony.",0
"Tissue synchronization imaging demonstrates significant left ventricular dyssynchrony, with the inferolateral wall contracting 320 ms later than the anterior septum.",0
"The patient meets at least modified CARE-HF criteria for ventricular dyssynchrony, and may benefit from resynchronization therapy.",0
The right ventricular cavity is markedly dilated with depressed free wall contractility.,0
There are complex (mobile) atheroma in the aortic root The aortic valve leaflets are severely thickened/deformed.,1
Significant aortic stenosis is present (not quantified).,0
The mitral valve shows characteristic rheumatic deformity.,0
There is a minimally increased gradient consistent with trivial mitral stenosis.,0
"Compared with the findings of the prior study (images reviewed) of , the pressure gradient across the aortic valve is reduced, with similarly depressed overall left ventricular ejection fraction.",0
"The current study demonstrates marked intraventricular contractile dyssynchrony with markedly delayed activation of the posterior wall relative to the interventricular septum, resulting in markedly reduced systolic ejection as well as diastolic filling.",1
2:00 PM PORTABLE ABDOMEN Clip # Reason: ?,0
SBO Admitting Diagnosis: AORTIC VALVE VEGETATION ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with s/p CABG/vomiting/Diarrhea REASON FOR THIS EXAMINATION: ?,0
"SBO ______________________________________________________________________________ FINAL REPORT HISTORY: CABG with vomiting and diarrhea, to assess for small-bowel obstruction.",0
"There is dilatation of what appears to be both large and small bowel, presenting a nonspecific adynamic ileus pattern.",0
The relative paucity of distal colonic gas raises the possibility of a partial obstruction.,0
"If this is a serious clinical concern, CT would be the next imaging procedure.",0
9:22 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: ?,0
"etiology of pain/fever, r/o perforation Admitting Diagnosis: MELENA Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with HCV/cirrhosis p/w diffuse abd pain, melena, hematemesis, fever to 101.6 REASON FOR THIS EXAMINATION: ?",1
"etiology of pain/fever, r/o perforation No contraindications for IV contrast ______________________________________________________________________________ WET READ: FKh SAT 12:50 AM Extravasation of oral contrast to the retroperitoneum or lesser sac.",0
Large amount of air in the retroperitoneum.,0
Mild dilatation of the CBD.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old male with HCV/cirrhosis.,0
"Now, presenting with diffuse abdominal pain, melena, hematemesis and fever.",0
Rule out etiology of fever.,0
TECHNIQUE: 64-MDCT axial images of the abdomen and pelvis were performed with oral and IV contrast.,0
Nonionic IV contrast was used due to the rapid bolus necessary for this study.,0
150 cc of Optiray 350 were used.,0
CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are atelectatic changes in the lung bases.,0
There are no pleural effusions or focal consolidations.,0
There is no evidence of pericardial effusion.,0
There is a large amount of air in the retroperitoneum.,0
There is evidence of oral contrast extravasation in the retroperitoneum.,0
These findings are consistent with perforation of a viscus.,0
"Considering the history of upper GI bleeding and the location of the retroperitoneal air, it is most likely due to posterior duodenal ulcer perforation.",1
There is a moderate amount of ascites in the abdomen.,0
"The liver is irregular, which is consistent with the patient's history of cirrhosis.",1
The hepatic arteries are patent.,0
The hepatic veins are patent.,0
The spleen is enlarged and measures 14 cm.,0
There is a 1.6 cm cyst in the lower pole of the right kidney.,0
There are at least 2 small hypodense areas in the left kidney that are too small to characterize.,0
There is no evidence of hydronephrosis or masses.,0
Suspicious liver lesion in the dome of the liver seen in the prior study is not seen today due to the different technique of the study.,0
"The major mesenteric vessels are patent including the , celiac, SMA, SMV and IMV.",0
The common bile duct is (Over) 9:22 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: ?,0
"etiology of pain/fever, r/o perforation Admitting Diagnosis: MELENA Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) prominent, measuring 10 mm but no obstructive lesion is seen.",0
The opacified loops of small bowel are unremarkable.,0
There is marked thickening of the entire colon which could be due to low albumin state versus colitis.,0
This finding is new when compared to .,0
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There is thickening of the sigmoid colon.,0
"The urinary bladder, seminal vesicles and prostate are unremarkable.",0
CT RECONSTRUCTIONS: Were important to evaluate the air in the retroperitoneum.,0
IMPRESSION: 1) Large amount of air in the retroperitoneum.,0
There is also extravasation of oral contrast into the retroperitoneum.,0
"These findings are suspicious for a perforation of the duodenum posteriorly, especially considering the patient's history of upper GI bleeding.",0
2) Edema of the colon may be related to hypoalbuminemic state versus colitis.,0
3) Findings consistent with cirrhosis and portal hypertension (splenomegaly / varices).,0
4) Small amount of free fluid in the abdomen.,0
5) The liver lesion seen in the dome of the liver is not identified on this study due to different phase of contrast.,0
6) Small bilateral pleural effusions.,0
12:35 AM CHEST (SINGLE VIEW) Clip # Reason: eval ETT position ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with s/p R hand stab wound REASON FOR THIS EXAMINATION: eval ETT position ______________________________________________________________________________ FINAL REPORT INDICATION: Right hand stab wound.,0
AP SUPINE CHEST: ET tube projects between the clavicles.,0
Trauma board limits complete evaluation of the thoracic structures.,0
There is no evident effusion.,0
Heart size is normal and the mediastinal and hilar contours are within normal limits.,0
There are no evident fractures.,0
There are no signs specific for pneumothorax on the supine film.,0
IMPRESSION: ET tube in adequate position.,0
10:00 PM CHEST (PORTABLE AP) Clip # Reason: Admission CXR Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with EtOH Cirrhosis and cellulitis with upper GI Bleed.,1
Has port-a-cath REASON FOR THIS EXAMINATION: Admission CXR ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST at 22:09 INDICATION: Upper GI bleed.,0
FINDINGS: The Port-A-Cath is seen with the access port overlying the right lateral ribs and the tip of the tubing in the SVC with no PTX.,0
"Thin basilar atelectatic changes seen in the left costophrenic sulcus, but there is no evidence of a patchy consolidation and there are no features of CHF.",0
", J. TSICU 12:04 PM CT CHEST W/O CONTRAST Clip # Reason: eval for pna or acute intrathoracic process Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with TBI and ?",0
pna with breakthrough fevers REASON FOR THIS EXAMINATION: eval for pna or acute intrathoracic process No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Small left pneumothorax is clear.,1
"Nonhemorrhagic bilateral pleural effusions are new, small on the right, moderate on the left.",0
"Dependent opacity increased, more marked on the left, could be atelectasis or pneumonia.",0
Tracheostomy and gastrostomy in place.,0
"No rib fractures, slightly displaced on the left.",0
Minimal pericardial effusion is still physiological.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Cardiomyopathy Major Surgical or Invasive Procedure: Thoracoscopic placement biventricular epicardial leads History of Present Illness: Pt is a 55 year old male with a history of severe cardiomyopathy and EF of 15% who presented with increased shortness of breath on exertion.,0
"Past Medical History: Smoker, cardiomyopathy, EF 15%, CHF, HTN, hypercholesterolemia, dermatomyositis, psoriasis, GERD, h/o heavy alcohol use, Right 5th digit amputation Social History: smoking history, h/o heavy EtOH Physical Exam: 97.8 HR 70 RR 20 O2 sat 97% RA NAD CTAB RRR Soft NTND No edema Psoriasis on extremities Pertinent Results: 10:35PM GLUCOSE-161* UREA N-21* CREAT-0.7 SODIUM-135 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-29 ANION GAP-12 10:35PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-74 TOT BILI-0.5 10:35PM %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE 10:35PM WBC-10.5 RBC-4.31* HGB-13.5* HCT-37.3* MCV-87 MCH-31.4 MCHC-36.2* RDW-13.3 10:35PM PLT COUNT-240 10:35PM PT-12.9 PTT-27.3 INR(PT)-1.1 Brief Hospital Course: Patient had attempted lead placement by Cardiology on .",1
"Procedure unsuccessful, so patient went to the operating room for thoracoscopic biventricular lead placement on .",0
He was transferred intubated in stable condition to the CSRU and extubated later that day.,0
His chest tube was removed on POD 1.,0
"Patient ambulated, progressed to a regular diet, and was discharged home on POD 2 in good condition.",0
"Medications on Admission: Lasix 60, Lisinopril 20, KCl 20, Protonix 40, Coreg 6.25"", MVI Discharge Medications: 1.",0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO q6h prn as needed for pain.,0
Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day.,0
Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.,0
Discharge Disposition: Home Discharge Diagnosis: Cardiomyopathy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection.,0
Your chest tube stitches should be removed in 10 days.,0
"This can be done at your doctor's office, or you can come to clinic (call to schedule).",0
2) Report any fever greater then 100.5 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week.,0
"Followup Instructions: Please follow up with Dr. in 4 weeks, .",0
Please follow up with Cardiology (in the Electrophysiology Clinic) as directed.,0
They will call you to schedule an appointment.,0
"If you do not hear from them within a few days, call the Cardiology department at -8800 to schedule an appointment.",0
Call to make all appointments.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Pt.",0
was also sent on Coumadon 5 mg PO daily for INR goal of .5.,0
will have INR daily until INR goal is reached.,0
Discharge Disposition: Extended Care Facility: mapleleaf MD Completed by:,0
EXERCISE MIBI Clip # Reason: Patient with a 4-week history of chest pain with exertion.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Patient with a 4-week history of chest pain with exertion for evaluation.,0
SUMMARY OF PRELIMINARY PROTOCOL FROM THE EXERCISE LAB: EXERCISE STOPPED SECONDARY TO MARKED ST ELEVATIONS.,0
"Resting heart rate: 75, on metoprolol.",0
Percent maximum predicted heart rate: 81%.,0
Symptoms during exercise: chest pressure.,0
Reason exercise terminated: ST elevation.,0
ECG findings: 3.5- elevations in V2-V5 and 1.5- depressions inferolaterally.,0
INTERPRETATION: Imaging Protocol: Gated SPECT.,0
Resting perfusion images were obtained with Tl-201.,0
Exercise images were obtained with Tc-m sestamibi.,0
The image quality is adequate.,0
Left ventricular cavity size is dilated at stress.,0
Resting and stress perfusion images reveal reversible anterior wall defects extending from the apex to the mid chamber.,0
"There is also a moderate, reversible inferior wall defect most notable in the mid chamber.",0
Gated images reveal hypokinesis and apical akinesis.,0
The calculated left ventricular ejection fraction is 33%.,0
"Markedly abnormal exercise MIBI study stopped for marked STE's; severe and reversible anterior wall defects extending from the apex to the mid chamber and a moderate, reversible defect in the inferior wall, most notable in the mid chamber.",0
Global hypokinesis with apical akinesis.,0
Ischemic dilatation with an end-diastolic volume of 177 ml.,0
Left ventricular ejection fraction of 33%.,0
Approved: WED 3:19 PM RADLINE ; A radiology consult service.,0
"5:18 PM CHEST (PORTABLE AP) Clip # Reason: r/o ptx, pna, chf Admitting Diagnosis: RESPIRATORY INSUFFICIENCY; COPD ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with severe copd s/p extubation yesterday now with acute desat, rising PCo2 REASON FOR THIS EXAMINATION: r/o ptx, pna, chf ______________________________________________________________________________ FINAL REPORT HISTORY: Severe COPD.",1
Acute hypoxia after recent extubation.,0
The lung apices are not fully included on the image.,0
The nasogastric tube terminates just below the left hemidiaphragm.,0
The right internal jugular venous catheter remains in stable position.,0
There is a chest tube at the right apex.,0
The heart and mediastinum are unchanged.,0
"There are diffuse bilateral interstitial opacities, as well as small areas of more patchy opacity in both mid lung zones.",0
These findings may represent pulmonary edema or multifocal pneumonia.,0
IMPRESSION: Pulmonary edema vs multifocal pneumonia.,0
8:23 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: ?,0
"Portable, pt on HD, in CVICU and unable to travel Admitting Diagnosis: ATHEROSCLEROSIS W/ CLAUDICATION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with AVF LUE, arm swollen REASON FOR THIS EXAMINATION: ?",1
"Portable, pt on HD, in CVICU and unable to travel ______________________________________________________________________________ FINAL REPORT INDICATION: 87-year-old female with left upper extremity swelling, evaluate for DVT.",0
COMPARISON: No previous exam for comparison.,0
"FINDINGS: Grayscale, color and Doppler images were obtained of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins.",0
"Normal flow, compression, and augmentation is seen in all of the deep veins and within the left basilic vein.",0
The left cephalic vein does not compress and does not demonstrate vascular flow.,0
IMPRESSION: Occlusive thrombus seen within the left cephalic vein which is a superficial vein.,0
No deep vein thrombosis identified.,0
"9:46 AM PELVIS U.S., TRANSVAGINAL; PELVIS LIMITED Clip # Reason: Unusually lg uterus size for patient's age.",0
"Please assess f ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman admitted for multiple medical problems such as a 4-month hx of weakness, failure to thrive, change in mental status with negative neuro, ID, and pulmonary work-up.",0
Unusually large uterus size on CT scan prompts pelvic US.,0
REASON FOR THIS EXAMINATION: Unusually lg uterus size for patient's age.,0
Please assess for endometrial abnormalities.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 72-year-old woman with large uterus noted on recent CT scan.,0
PELVIC ULTRASOUND: Transabdominal and transvaginal examination demonstrate a retroverted uterus measuring 6.1 x 3.3 x 5.0 cm.,0
The endometrium is measured at 2.2 mm.,0
There is a 1.9 x 2.2 x 1.3 cm fibroid within the fundus of the uterus.,0
Also noted is a calcified smaller fibroid in the midbody.,0
There is no pelvic free fluid.,0
The ovaries are not well visualized.,0
IMPRESSION: There is a 1.9 x 2.2 x 1.3 cm fibroid in the fundus of a retroverted uterus.,0
"6:01 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for ards, failure ______________________________________________________________________________ MEDICAL CONDITION: 26 y.o.",0
"female intubated for resp distress aspiration, now with ARDS.",0
Continues to have episodes of decreased O2 sats.,0
"REASON FOR THIS EXAMINATION: please evaluate for ards, failure ______________________________________________________________________________ FINAL REPORT HISTORY: Aspiration pneumonia, ARDS.",0
Single portable AP view of chest compared to study of .,0
IMPRESSION: Diffuse bilateral air space opacities are persistent.,0
Opacities have increased in density in the right perihilar region and along the right cardiac border.,0
Tiny left apical pneumothorax is unchanged.,0
Support lines and tubes are in stable positions.,0
9:06 AM PORTABLE ABDOMEN Clip # Reason: Please assess for any interval change.Please perform around Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with syndrome.,1
REASON FOR THIS EXAMINATION: Please assess for any interval change.Please perform around 0900 ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of patient with history of ileus for interval change.,0
TECHNIQUE: Two portable supine abdominal radiographs were obtained.,0
FINDINGS: Again visualized are stable-appearing dilated air-filled loops of small and large bowel consistent with stable ileus.,0
A previously dilated loop of sigmoid colon appears less distended.,0
IVC filter is again visualized in mid abdomen.,0
Osseous structures remain grossly unremarkable.,0
An overlying drain consistent with a possible Foley catheter is again visualized from the midline to the left lower quadrant.,0
IMPRESSION: Distended air-filled small and large bowel loops consistent with stable ileus.,0
4:11 PM CHEST (PORTABLE AP) Clip # Reason: Please eval PNA for progression and for effusions.,0
Pt not t Admitting Diagnosis: CORONARY ARTERY DISEASE;VENTRICULAR ARREST\CATH ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with distended abd.,1
"He has been intubated with aspiration PNA for 3 days until this am, now extubated REASON FOR THIS EXAMINATION: Please eval PNA for progression and for effusions.",0
Pt not tolerating extubation without Bipap.,0
"______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of aspiration pneumonia and extubation.",0
NG tube is in body of stomach.,0
Endotracheal tube has been removed.,0
"Compared with prior study of , there has been partial re-aeration of the left lower lobe with persistent opacities at both lung bases consistent with atelectases/consolidation.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending: Chief Complaint: S/P fall with IPH Major Surgical or Invasive Procedure: None History of Present Illness: 50 year old woman who slipped and fell on ice (possibly twice) with no recollection of events.,0
Later complained of a headaches and memory problems was brought to the hospital and found to have right sided IPH.,0
A CT the following day showed a stable right sided IPH.,0
She had some short term memory lapses.,0
On her second hospital she was transferred to the surgical floor.,0
"On her third hospital day she was awake, alert and orientated X3, follows commands, she remembered objects at 5 minutes.",0
Her pain medication was changed to Diladid to help her headache.,0
She was tolerating a regular diet and voiding.,0
Her dilantin level was therapeutic.,0
Physical therapy saw the patient and felt she did not require physical therapy.,0
"On her fifth hospital day, the pt was discharged home in stable condition.",0
The patient remained neurologically intact throughout her hospitalization.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Use with Dilaudid.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q 3 hours as needed: No driving while on this medication.,0
Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 30 days.,0
Disp:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: IPH Discharge Condition: Neurologically stable Discharge Instructions: ?,0
"You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week.",0
This can be drawn at your PCP?????,0
"?s office, but please have the results faxed to .",0
?Please call ( to schedule an appointment with Dr. to be seen in 4 weeks.,0
* Call to have your sutures removed at your primary care physician's office on Monday.,0
3:22 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"interval change Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with ACOM aneurysm, s/p coiling REASON FOR THIS EXAMINATION: ?",1
interval change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT CONTRAST INDICATION: 50-year-old man with Acom aneurysm status post coiling.,0
"NON-CONTRAST HEAD CT: Patient is post coiling of the Acom aneurysm, with streak artifact limiting evaluation of immediately adjacent area.",0
"Within the limitation, the extent of diffuse subarachnoid hemorrhage in the basal severe forms, sylvian fissure, interhemispheric fissure, sulci of the frontal lobes have decreased in extent.",1
The amount of intraventricular hemorrhage has not appreciably changed.,0
"There is no shift of normally midline structures, hydrocephalus, or evidence of new hemorrhage.",0
The osseous structures and extracalvarial soft tissues are unremarkable.,0
Imaged paranasal sinuses demonstrate new mucosal thickening in maxillary sinus.,0
IMPRESSION: Interval improvement in extent of diffuse subarachnoid hemorrhage.,1
Status post coiling of the anterior communicating artery aneurysm.,0
ATTENDING NOTE: Less apparent SAH could be due to redistribution.,0
No loss of GW differentiation.,0
Ventricles slightly prominent but unchanged.,0
"Decrease in extent of diffuse subarachnoid hemorrhage, no new hemorrhage.",1
Status post coiling of the Acom aneurysm.,0
10:55 PM CHEST (PORTABLE AP) Clip # Reason: eval for line placement ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with sepsis REASON FOR THIS EXAMINATION: eval for line placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post line placement.,0
COMPARISON: X-ray done earlier today approximately 3 hours ago.,0
SUPINE SINGLE VIEW OF THE CHEST: There is interval placement of right IJ central line which is kinked in the right brachiocephalic vein.,0
Recommend repositioning of the central line.,0
Otherwise unchanged when compared to the previous study done three hours ago.,0
7:23 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG w/dropping HCT-r/o effusion Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with CAD s/p CABG REASON FOR THIS EXAMINATION: s/p CABG w/dropping HCT-r/o effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG with dropping hematocrit.,1
UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy and CABG.,0
The patient has been extubated and the feeding tube has been removed.,0
Mediastinal drain and left basilar pleural chest tube remain unchanged.,0
There is slight interval worsening of left basilar opacity likely representing worsening atelectasis.,0
The pulmonary vascularity is within normal limits.,0
Mild worsening in left lower lobe atelectasis.,0
"4:03 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: HYPERCARBIA;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with OSA hypercarbic respiratory failure REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 04:50 A.M., ON HISTORY: Hypercarbic respiratory failure.",1
IMPRESSION: AP chest compared to : ET tube in standard placement.,0
Nasogastric tube would need to be advanced 4 cm to move all the side ports into the stomach.,0
Mild left basal atelectasis is improving.,0
Lateral aspect left lower hemithorax is excluded from the examination.,0
No signs elsewhere of pneumothorax or appreciable pleural effusion.,0
"4:18 PM PICC LINE PLACMENT SCH Clip # Reason: ?please replace PICC Admitting Diagnosis: FEVER ********************************* CPT Codes ******************************** * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF * * C1769 GUID WIRES INCL INF * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with MRSA bacteremia, rx w/ vanco but persistently + blood cultures, replace current PICC w/ new line.",0
REASON FOR THIS EXAMINATION: ?please replace PICC ______________________________________________________________________________ FINAL REPORT INDICATION: 40-year-old male with MRSA bacteremia.,0
", , and , the attending radiologist, present throughout the procedure.",0
PROCEDURE AND FINDINGS: The patient was brought to angiography table.,0
Left upper arm was prepped and draped in usual sterile fashion.,0
1% lidocane was applied for local anesthesia.,0
0.018 wire is inserted through the previousely placed single lumen 4 French catheter and exchanged with a 5 Fr sheath.,0
"The wire is removed, and the double lumen 5 French catheter was inserted, with the tip terminating in left brachiocephalic vein, with a length 1 cm longer than the previous PICC line.",0
"The line was flushed, capped, and StatLocked.",0
The patient tolerated the procedure without acute immediate complication.,0
IMPRESSION: Successful exchange and upsize of the catheter (5 French double lumen) with the tip terminating in left brachiocephalic vein.,0
"LINE PLACEMENT Clip # Reason: line change Admitting Diagnosis: PANCREATIC PSEUDOCYST ______________________________________________________________________________ MEDICAL CONDITION: 55F respiratory distress, low urine output/receiving fluids now acutely desating REASON FOR THIS EXAMINATION: line change ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE SUPINE.",1
FINDINGS: There has been interval ET tube placement.,0
The tip terminates at approximately 4 cm above the carina.,0
There has been placement of a right IJ catheter in the right atrium/cavoatrial junction.,0
There is an unchanged appearance of AICD device with metallic leads.,0
There are bilateral interstitial markings and opacities consistent with pulmonary edema.,0
Lines and tubes as described above.,0
"Diffuse bilateral interstitial edema, minimally changed since previous exam.",0
"7:53 PM CHEST (PORTABLE AP) Clip # Reason: ett placement Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: year old man with swan left cordis line, rule out pneumo or effusion.",0
"REASON FOR THIS EXAMINATION: ett placement ______________________________________________________________________________ FINAL REPORT This is a portable chest of , compared to previous study earlier the same date.",0
CLINICAL INDICATION: Endotracheal tube assessment.,0
A Swan-Ganz catheter has been repositioned in the interval and is now in the right main pulmonary artery.,0
An endotracheal tube is in satisfactory position terminating about 3 cm above the carina and a nasogastric tube terminates below the diaphragm.,0
The cardiac silhouette is upper limits of normal in size.,0
There is vascular engorgement and there has been interval worsening of pulmonary opacities with confluent alveolar opacities now noted in the lungs diffusely superimposed upon a preexisting interstitial pattern.,0
Previously noted more asymmetrical focal opacity in the right upper lobe appears less prominent than before.,0
IMPRESSION: 1) Successful repositioning of Swan-Ganz catheter.,0
2) Worsening diffuse pulmonary opacities consistent with diffuse pulmonary edema.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafting times three(left internal mammary to left anterior descending with vein grafts to diagonal and PDA) History of Present Illness: This is a 51 year old male with CAD s/p PCI at in .,1
"Recently presented with a few months of chest pain, slowly getting worse.",0
"Catheterization on revealed an occluded RCA, significant stenoses proximal and distal to a previously placed proximal LAD stent and moderate disease otherwise.",0
He underwent preoperative evaluation and was cleared for surgery.,0
Past Medical History: Coronary Artery Disease s/p stents Hyperlipidemia Hypertension Social History: He workes in the deli department at the Stop and Shop.,1
-Tobacco history: denies any smoking.,0
-ETOH: denies any alcohol use.,0
-Illicit drugs: denies any drug use.,0
Family History: He states his father died at the age of 54 of an MI.,0
Denies any other family history.,0
"Physical Exam: General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema- none Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 1+ PT : 2+ Left: NP Radial Right: 2+ Left: 2+ Carotid Bruit: none Pertinent Results: Intraop TEE: PREBYPASS No atrial septal defect is seen by 2D or color Doppler.",0
POSTBYPASS LV systolic function is normal EF-55%.,0
RV systolic function remains normal.,0
The study is otherwise unchanged from the prebypass period.,0
Brief Hospital Course: Admitted and underwent coronary artery bypass grafting surgery by Dr. .,1
"For surgical details, please see operative note.",0
"Following the operation, he was brought to the CVICU for invasive monitoring.",0
"On postoperative day one, he showed signs of ETOH withdrawal.",0
"He became increasingly tachypneic, tachycardic and hypertensive.",0
He concomitantly became more impulsive and confused/agitated requiring Ativan and Haldol prn.,0
"Due to delirium tremens and agitation, he was reintubated for safety on postoperative day three.",0
"On postoperative day four, patient self extubated.",0
His mental status seemed improved on Valium three times daily.,0
"On postoperative day five, he transferred to the cardiac SDU.",0
Valium was titrated down accordingly.,0
Mental status and signs of ETOH withdrawal improved dramatically.,1
He remained in a normal sinus rhythm.,0
Beta blockade was advanced as tolerated and ACEI was added for hypertension.,0
"Over several days, he continued to make clinical improvements and was eventually cleared for discharge to for the Aged - MACU Medications on Admission: Aspirin Discharge Medications: 1.",0
Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.,0
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days.,0
"4. potassium chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 5 days.",0
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.,0
"6. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a day.",0
7. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Transdermal qsunday .,0
Lopressor 100 mg Tablet Sig: One (1) Tablet PO three times a day.,0
Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.,0
Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day.,0
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.,0
Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Coronary artery disease, s/p CABG Postop ETOH Withdrawal, Altered Mental Status Hyperlipidemia Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain well controlled Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon.",1
"Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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 .",0
Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. @ 1 PM Cardiologist: Dr. @ 140 PM Primary Care Dr. on @ 145 PM **Please call cardiac surgery office with any questions or concerns .,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MICU CHIEF COMPLAINT: Increased secretions.,0
"HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male with severe restrictive lung disease secondary to polio and severe right kyphoscoliosis and paraplegia, COPD on chronic steroids, status post trach, who presents with a chief complaint of increased secretions.",1
The patient reports that within the last few days he has been experiencing some shortness of breath and increased secretions and requested assistance by calling EMS.,0
The patient has a home vent which is set at pressure support of 15 by 5 and FIO2 of 21% by EMTs.,0
He was brought to the Emergency Room where chest x-ray was performed which was unremarkable for infiltrate.,0
The patient was suctioned with medium amount of white sputum.,0
While in the Emergency Room the patient was noted to have increased congestion and transient saturation to 90%.,0
The patient's saturation improved while being bagged.,0
He was suctioned and his blood pressure elevated to 200/100.,0
He was given Hydralazine and transferred to medical ICU for further evaluation.,0
"PAST MEDICAL HISTORY: 1) Restrictive lung disease secondary to kyphosis, polio.",0
No pulmonary function tests available.,0
2) Chronic obstructive pulmonary disease.,1
3) Bronchiectasis status post multiple pneumonias.,0
Patient reports he is vented at night and is able to tolerate trach mask during the day.,0
6) History of DVT in 11/92.,0
7) History of C. diff in 7/94.,0
10) Recent admission to with treatment with high dose steroids tapered and Levaquin.,0
"MEDICATIONS: On admission, Methyldopa 250 mg , Nexium 300 mg q d, KCL, Lasix 40 mg po q d, Singular 10 mg q d, Prednisone 10 mg being tapered down per script, Levaquin 500 mg, Slo- 300 mg q d, Tylenol #3 for back pain prn, Bactrim q d. REVIEW OF SYSTEMS: Significant for back pain, cough with sputum that is yellowish, reported low grade fevers, no chills or shakes, no abdominal pain, diarrhea, constipation or dysuria.",0
SOCIAL HISTORY: Patient lives at home and has VNA services provided 8 hours per day.,0
VNA phone number is .,0
His stent is serviced by .,0
PHYSICAL EXAMINATION: Generally patient is a chronically ill appearing man with trach.,0
"Marked obesity, especially of the neck.",0
"Vital signs, temperature 100.5, pulse 96, blood pressure 171/68, respiratory rate 16, O2 saturation 98% on 21% FIO2, set at pressure support of 15 and PEEP of 5.",0
"HEENT: Pupils round and reactive to light, JVD unable to assess secondary to neck obesity, mucus membranes moist.",0
"Heart, regular rate and rhythm, no murmur, rub or gallop, hyperdynamic PMI.",0
Lungs rhonchorus bilaterally without wheezes.,0
"Abdomen soft, nontender, non distended with well healed midline scar.",0
Extremities with 1+ bilateral edema.,0
"Neuro, alert and oriented times three, bilateral hand grip with normal strength, 1+ strength in lower extremities, deep tendon reflexes 0-1+ throughout.",0
"LABORATORY DATA: On admission revealed white count of 10.2 with differential of 68 neutrophils, 20 lymphs, 9 monos, hematocrit 42.5, and platelet count 316,000.",0
"His sodium was 141, potassium 2.6, chloride 105, CO2 24, BUN 10 and creatinine 0.2, glucose 87.",0
"EKG showed normal sinus rhythm at 97 beats per minute, normal intervals, axis 97 degrees, right atrial enlargement, poor R wave progression, 1 PAC, T wave flattening and T wave inversion in V1 to V3, right bundle branch block appearing.",0
This was the EKG in the Emergency Room.,0
On arrival to the floor the patient was also noted to have ST depression of 1 mm in 3 and F with heart rate at 116 and blood pressure of 213/89.,0
"Chest x-ray showed severe right kyphoscoliosis, no effusion, no infiltrate, difficult to assess heart size.",0
"HOSPITAL COURSE: In summary, the patient is a 51-year-old man with chronic restrictive lung disease secondary to polio and musculoskeletal abnormalities, COPD, on chronic ventilation through a trach, presenting with increased congestion and low grade fevers.",0
His issues during this hospitalization included: 1.,0
Cardiovascular: The patient was noted to be hypertensive to 200/100.,0
"At the time of admission he was not symptomatic, however, his EKG showed ST depressions in leads 3 and F. For his hypertensive emergency the patient was started on Labetalol with normal elevation of his blood pressure to 120's and reversal of EKG changes to baseline.",0
"In addition, patient was ruled out for myocardial ischemia with serial CKs and troponin which were normal.",0
Pulmonary: The patient did present with congestion and shortness of breath.,0
He did not appear to be in congestive heart failure and there was no evidence of pneumonia on his chest x-ray.,0
"However, patient was started on Zithromycin for possible bronchitis.",0
He completed the course of antibiotics while in the hospital.,0
"After initial low grade fever recorded on admission, the patient remained afebrile.",0
The patient did not appear to be in COPD exacerbation so there was no indication for high dose steroids.,0
"Fluids, Electrolytes & Nutrition: On presentation the patient was hyperkalemic and hypermagnesemic.",0
It was thought to be due to the diuretic use without potassium replacement.,0
The patient's potassium was repleted by mouth within a few days.,0
The delay was caused by patient's refusal to take medication.,0
The patient was maintained on subcu Heparin and Protonix.,0
"Social issues: Per patient report, he lives independently in Apartments with daily VNA services.",0
Social work was involved in patient's management in addition to the case manager to clarify the services he obtains.,0
"There was an issue of vent cleaning-apparently patient prohibited the VNA to clean his vent, partially leading to his difficulties ventilating.",0
The patient appears to be more compliant with his care at present time.,0
On admission patient's VNA was notified of patient's hospitalization and promptly reassigned his services.,0
His discharge was delayed due to the lack of staff to provide VNA services for him.,0
"FOLLOW-UP: The patient has a follow-up appointment with his primary care physician, .",0
", at on at 3:30 p.m.",0
"In addition he was scheduled to see a pulmonologist, Dr. on Thursday, at 9:15 a.m. on the of Building.",0
On the care of this patient was transferred to Dr. who will dictate an addendum to this discharge summary that will include the discharge medications.,0
Dictated By: MEDQUIST36 D: 22:56 T: 20:23 JOB#:,0
9:35 PM HIP UNILAT MIN 2 VIEWS RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # Reason: FEMUR RODING Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT RIGHT FEMUR 14 VIEWS CLINICAL INFORMATION: ORIF.,0
FINDINGS: 14 fluoroscopic intraoperative spot radiographs are submitted for interpretation.,0
An intermedullary rod traverses a severely comminuted segmental fracture of the proximal femoral shaft.,0
The rod is transfixed by two proximal screws through the femoral neck and two distal interlocking screws through the distal metadiaphysis of the femur.,0
The fracture fragments are in near anatomic alignment.,0
Please refer to the operative note for full details.,0
"4:11 PM CT CHEST W/O CONTRAST Clip # Reason: interval progression, question cavitating lesions?",0
"Admitting Diagnosis: MYELODYSPLASTIC SYNDROME;FEVER;LOW BLOOD COUNT ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with h/o MDS, neutropenia, now with GNR bacteremia, fever continues to spike fevers.",0
"REASON FOR THIS EXAMINATION: interval progression, question cavitating lesions?",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Myelodysplastic syndrome, neutropenia, gram-negative rod bacteremia, continued fever.",0
TECHNIQUE: Helically acquired contiguous axial images were obtained from the lung apices to the lung bases without IV contrast.,0
"CT OF THE CHEST WITHOUT IV CONTRAST: Again seen are multiple enlarged lymph nodes within the paratracheal, pretracheal, subcarinal, and prevascular space.",0
The size of these lymph nodes is stable since the prior study.,0
No new lymphadenopathy is present.,0
No pathologically enlarged hilar or axillary lymphadenopathy is seen.,0
"The heart, pericardium, and great vessels are within normal limits.",0
A central venous catheter is seen with the tip terminating in the distal superior vena cava.,0
Small bilateral pleural effusions persist which have slightly decreased in size since the prior study.,0
"Lung window images again demonstrate extensive, diffuse, bilateral, ill- defined nodular and patchy opacities, predominantly distributed within the upper lobes.",0
There has been no significant interval change in the appearance of the lungs since the prior study.,0
Airways are patent to the level of segmental bronchi bilaterally.,0
"In the imaged portion of the upper abdomen, there is a small axial hiatal hernia.",0
Tiny non-obstructing 3-mm renal calculus is identified within the upper pole of the right kidney.,0
"The visualized portion of the liver, gallbladder, pancreas, spleen, adrenal glands, and left kidney are within normal limits.",0
BONE WINDOWS: No suspicious lytic or sclerotic lesions are present.,0
"IMPRESSION: 1) No significant interval change in extensive, ill-defined, diffuse nodular and patchy opacities which are predominantly distributed within both upper lobes.",0
These findings in this neutropenic patient are most suggestive of an infectious etiology with invasive aspergillosis high on the differential.,0
"The radiographic differential diagnosis also includes other fungal infections, PCP, emboli, cryptogenic organizing pneumonitis, and less likely, vasculitis.",0
"(Over) 4:11 PM CT CHEST W/O CONTRAST Clip # Reason: interval progression, question cavitating lesions?",0
Admitting Diagnosis: MYELODYSPLASTIC SYNDROME;FEVER;LOW BLOOD COUNT ______________________________________________________________________________ FINAL REPORT (Cont) 2) Stable mediastinal lymphadenopathy.,0
"3) Small bilateral pleural effusions, slightly decreased in size since the prior study.",0
4) Tiny non-obstructing right renal calculus.,0
9:17 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: eval for aspiration Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with dysphagia / lethargy s/p IPH with dobhoff in place REASON FOR THIS EXAMINATION: eval for aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: 86-year-old man with dysphagia and lethargy status post intraparenchymal hemorrhage.,1
TECHNIQUE: Oropharyngeal videofluoroscopic swallowing evaluation.,0
FINDINGS: A videofluoroscopic swallowing evaluation was performed today in conjunction with speech and swallow pathology.,0
The oral phase demonstrated severely impaired bolus formation with significant anterior spill.,0
Residue remained under the tongue and lateral sulci.,0
A moderate amount of oral cavity residue remained following all boluses which were intermittently suctioned.,0
The pharyngeal phase was significant for near-absent epiglottic deflection and reduced bolus propulsion.,0
"Vallecular, piriform sinus and posterior pharyngeal wall residue was demonstrated with all consistencies.",0
There was one episode of mild laryngeal penetration with thin liquids during the swallow with a straw.,0
Aspiration did eventually follow penetration after swallowing and was not fully cleared with spontaneous or cued throat clearing or coughing.,0
IMPRESSION: Severe oropharyngeal dysphagia with significant oral and pharyngeal residue.,0
Episode of aspiration after penetration.,0
"For further details, please refer to the speech and swallow pathologist's note of the same day.",0
"10:07 AM CHEST (PORTABLE AP) Clip # Reason: R/O CHF versus pneumonia Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with subdural hematoma REASON FOR THIS EXAMINATION: R/O CHF versus pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Subdural hematoma, to evaluate CHF versus pneumonia.",0
"FINDINGS: In comparison with the study of , there is extensive _____ patient in respiratory motion greatly limiting the quality of the image.",0
"Areas of increased opacification at both bases are consistent with atelectasis, though supervening pneumonia cannot be excluded.",0
The tip of the Dobbhoff tube now appears to be in the upper thoracic esophagus.,0
This information has been telephoned to Dr. .,0
"LINE PLACEMENT Clip # Reason: please check PICC tip left basilic 47cm Admitting Diagnosis: EXPLORATORY LAPAROTOMY ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with new line placement REASON FOR THIS EXAMINATION: please check PICC tip left basilic 47cm ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest, port line placement.",0
REASON FOR EXAM: Please check PICC position in left basilic vein.,0
"Findings: Since the previous chest radiograph, the new PICC line passes along the basilic vein and into the left internal jugular vein and requires repositioning.",0
The NG tube is unchanged.,0
"There is bibasilar atelectasis with no acute consolidation, mass, pleural effusion, or pneumothorax.",0
IMPRESSION: New left-sided PICC line which passes into the left internal jugular vein should be repositioned.,0
"4:50 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: eval signs of obstruction ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with HIV, abdominal distension, vomitting REASON FOR THIS EXAMINATION: eval signs of obstruction ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: HIV, abdominal distention and vomiting.",0
ABDOMEN: Air-filled loops of large and small bowel are present and _____ some air-fluid levels also seen.,0
Gas does extend to the rectum and appearances therefore more consistent with an ileus rather than obstruction.,1
3:27 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with hemorrhagic stroke s/p intubation REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Hemorrhagic stroke.,0
CHEST: The right-sided pneumothorax persists.,0
"Allowing for differences in position and lung volume, there has probably been no significant change.",0
Extensive subcutaneous emphysema is again seen.,0
"IMPRESSION: Allowing for differences in technique, little change, pneumothorax persists.",0
"4:47 AM CHEST (PORTABLE AP) Clip # Reason: eval: PTX ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with COPD, found down, +chest pain REASON FOR THIS EXAMINATION: eval: PTX ______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old woman with COPD, found down with chest pain.",0
CHEST AP: There is marked cardiomegaly.,0
"There are bilateral pleural effusions, greater on the right and bibasilar opacities.",0
Osseous and soft tissue structures are unremarkable.,0
"IMPRESSION: Bibasilar opacities which could represent atelectasis, pneumonia, or aspiration.",0
"Bilateral pleural effusions, larger on the right.",0
"Name: , G. Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Mr. remained in the hospital due to post-operative atrial fibrillation.",1
"He was started on heparin and coumadin for anticoagulation, and awaiting his INR to become therapeutic.",0
"His lopressor was increased, and he has had only two more self limiting episodes in the past 48 hours.",0
He was also noted to have an increasing WBC.,0
"He has no fever, a U/ yesterday was negative, and his chest x-ray from tody revealed some mild pulmonary edema, small bilateral effusions (decreased from previous film), and no infiltrate.",0
He does have some redness at the upper aspect of his sternal incision (left > right side).,0
"He will be discharged on a 7-day course of Keflex, with a follow-up wound evaluation and WBC check on .",0
"He was instructed to call for any fever, wound drainage, or increased erythema.",0
Major Surgical or Invasive Procedure: Aortic valve replacement with 25 mm Perimount pericardial valve.,0
History of Present Illness: see prior Past Medical History: see prior Social History: see prior Family History: see prior Physical Exam: n/a Pertinent Results: 05:30AM BLOOD WBC-16.8* RBC-3.99* Hgb-11.1* Hct-34.4* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.3 Plt Ct-681* 05:30AM BLOOD Plt Smr-VERY HIGH Plt Ct-681* 05:40AM BLOOD Mg-2.0 05:30AM BLOOD PT-18.8* PTT-43.8* INR(PT)-2.4 Brief Hospital Course: see prior Medications on Admission: see prior Discharge Medications: 1.,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: .,0
"Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days.",0
"Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3.",0
Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Ramipril 5 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily).,0
Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days.,0
"Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: then check INR Monday, and call Dr. office for dosing for target INR 2.0-2.5.",0
"Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: AS, s/p AVR #25 CE pericardial post-op AFib PMH: Htn, ^chol Discharge Condition: good Discharge Instructions: keep wounds clean and dry.",0
"OK to shower, no bathing or swimming.",0
Take all medications as prescribed.,0
"Call for any fever, increased redness or drainage from wounds Follow up on Monday for wound check p Instructions: clinic in 2 weeks Dr in weeks Dr in 4 weeks MD Completed by:",0
5:24 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: S/P TRAUMA ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
SUPINE AP VIEW OF THE CHEST: The right lateral chest wall has been excluded from the field of view.,0
The aorta is markedly unfolded with aortic knob calcifications present.,0
"Patchy opacity within the left lung base may reflect atelectasis, but pulmonary contusion is not excluded.",0
Blunting of the left costophrenic angle likely reflects a small effusion.,0
No large pneumothorax is seen on this supine study.,0
Multiple left-sided rib fractures are visualized.,0
A comminuted distal left clavicular fracture is present.,0
"Additionally, partially imaged is a fracture of the right proximal humerus.",1
AP VIEW OF THE PELVIS: Overlying trauma board limits evaluation.,0
"There is mild cortical irregularity of the right superior and inferior pubic rami, compatible with fractures.",0
No other fractures definitively noted.,0
"There are degenerative changes in both hips, severe on the left and moderate on the right with joint space narrowing, subchondral cystic and sclerotic changes, and osteophyte formation.",0
The pubic symphysis and sacroiliac joints are not diastatic.,0
Ill-defined sclerotic region projecting over the right iliac bone may represent overlying fecal contents.,0
Patchy opacity in the left lung base may reflect atelectasis or pulmonary contusion.,0
Distal left clavicular fracture and left proximal humeral fracture.,0
Right superior and inferior pubic rami fractures.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NICU/Neurology DIAGNOSIS: 1.,0
Small intracerebral hemorrhages on right frontotemporal and 3.,0
Aortic graft infection Procedures: 1.,1
PICC line placement HISTORY OF PRESENT ILLNESS: Mr is a 26 year old right-handed man who was recently hospitalized at from through for multiple injuries sustained after a motor vehicle accident.,0
For the details please refer to previous discharge summary.,0
"In summary, on , the patient sustained an unrestrained 28 feet ejection.",0
He sustained a severe head injury with a reported Coma Scale of 14 at the scene.,0
The patient developed a retrograde amnesia of the events preeceding the accident of about one hour and post traumatic amnesia for about two months.,0
"He also developed traumatic aortic dissection, liver laceration, severe pulmonary contusion.",0
He was intubated for two and a half months due to recurrent pneumonias.,0
"Other Injuries included bilateral orbital fractures, pelvic fracture, left radial fracture, pneumo and hemothorax.",0
"After a prolonged hospital stay, the patient underwent rehabilitation at Hospital.",0
"On while at Hospital, he had a generalized tonic-clonic seizure.",0
"At that time, it was decided to transfer him to for further management.",0
He had a second seizure en- route and a third in Emergency Room.,0
"In the ER he was treated with a total of 8 mg of Ativan, 1 gm of Dilantin.",0
His magnesioum level was 1.1 mg/dl.,0
He was intubated in the Emergency Room and treated with 20 mg/kg/dose of Phenobarbital.,0
His head CT was normal.,0
"A CSF sample obtained by lumbar puncture showed three white blood cells, 1500 red blood cells.",0
A second tube was clear and colorless.,0
Blood cultures from showed coagulase negative Staphylococcus as well as coagulase negative Staphylococcus which was resistant to Cephalin.,0
He was extubated on and tranferred to the Neurology Service for further management.,0
MEDICATIONS ON TRANSFER TO FLOOR: 1.,0
"8, hold for systolic blood pressure of less than 110 3.",0
Lovenox 13 mg subcutaneously b.i.d.,0
Protonix 40 mg q. day 6.,0
Clonidine patch 0.1 mg q.d.,0
Fentanyl patch 25 mcg q.d.,0
"Tube feeds at 50 cc/hr ALLERGIES: Penicillin PHYSICAL EXAMINATION: Physical examination on admission on , general examination revealed temperature 101.2, his temperature reached maximum of 104.1.",0
"Blood pressure was 130/64, heart rate 131, respirations 18.",0
"The patient appeared agitated and restless, moving all extremities.",0
Lungs with coarse breathsounds bilaterally.,0
"Cardiac examination was notable for regular rate and rhythm, tachycardiac to auscultation.",0
"Abdomen was soft, no tenderness to palpation.",0
No cyanosis or edema of extremities.,0
"Neurological examination: On mental status examination the patient was drowsy, but arousable, moved eyes to name, grunting, could not tell the examiner where he was, his name or the date.",0
He did not follow any commands.,0
"On cranial nerves examination, discs were normal, pupils were 8 mm and reactive.",0
Visual fields were full grossly to threat.,0
Face was symmetric with palatal elevation of tongue.,0
"Motor, moving all extremities, withdraws to pain times four.",0
"Reflexes, reflexes were 2+ bilaterally at biceps, triceps and brachioradialis, patella, ankle and toes downgoing on both sides.",0
"LABORATORY DATA: Laboratory values showed an INR of 1.5, chest x-ray showed a questionable left lower lobe atelectasis or infiltrate.",0
Computerized tomography scan did not show any obvious infarct or hemorrhage.,0
"HOSPITAL COURSE: The patient was initially managed in the Neurological Intensive Care Unit where he remained intubated until , the morning of which he was extubated as his condition improved and he was transferred to the floor for further management.",0
"Generalized tonic clonic seizure assessment and management: -The patient was initially treated with 350 mg/die of Dilantin however, his PTN levels were repeatedly below the expected range.",0
"On , he had a PTN level of 4.9 ug/dl and therfore he received an additional 600 mg bolus.",0
His daily Dilantin dose was also increased to 250 mg .,0
"Due to his history of liver damage, there was concern that the amount of free PTN would be higher as expected by the total serum PTN level.",0
"Therefore, a free PTN level was obtained and it is pending at the time of the present dictation.",0
During the present hospital course the patient did not have any other seizures.,0
A MRI scan showed very small hemorrhages in the right frontotemporal and left parietal lobes consistent with his history of head injury.,0
"Aortic graft/repair -Because of the central lines infection with coagulase negative Staphylococcus and his initial fevers, the patient was started on Vancomycin and the Infectious Disease service was consulted.",1
"On , his Vancomycin peak was elevated.",0
The dose of Vancomycin was then decreased from 1 gm q.,0
12 to 7 and 15 mg q.,0
He needs to complete a 10 day course of Vancomycin for prophylactic reasons until .,0
"As per Infectious Disease recommendation, he needs to get three independent sets of blood cultures after he finishes his course of Vancomycin and will need close follow-ups because of the possibility of the aortic graft being infected is real and is of concern.",0
The patient is to continue to meet a target systolic blood pressure of less than 150 systolic.,0
"He is to follow up with Dr. , from the cardiothoracic surgery service.",0
He will also remain on sternal precautions of lifting no more than 5 pounds until .,0
"Infectious disease -As mentioned above, the patient will need to complete a course of Vancomycin 150 mg q.",0
"Until then, the dose of Vancomycin will be adjusted according to his blood levels.",0
The patient did very well after extubation.,0
"On neurological examination, he was alert and appropriate.",0
"His motor exam showed Deltoids 4- on the left, 4 on the right; biceps 4 bilaterally; triceps 4 bilaterally; wrist extensors 4 bilaterally; finger extensors were 4 bilaterally; iliopsoas was 4+ bilaterally; hamstring 4 bilaterally; quadriceps 4 bilaterally; anterior tibialis was 3+ on left, none on the right; gastrocnemius was 4- on the left, none on the right; EM could not be elicited bilaterally.",0
Laboratory data at time of dictation: His magnesium was 1.8.,0
All of his blood cultures subsequent to the intial positive ones are pending at this time.,0
"His PT was 13.2, PTT was 39.0, INR was 1.2.",0
"Reticulocyte count 0.2, haptoglobin 266, ferritin was pending, transferrin was 171, LDH was 201, total bilirubin 0.3, iron 49.",0
Trough was still pending at time of dictation.,0
The Hematology Team concluded that he may have a thalassemic trait that is clinically irrelevant at the present time.,0
They do no reccomend further workup at the present time.,0
He will continue on subcutaneous Heparin until he can ambulate on his own.,0
"12, this may have to be adjusted depending on the peak and trough level after third dose tomorrow evening 2.",0
"8, hold for systolic blood pressure less than 110 3.",0
"Dilantin 250 mg q. day, this may have to be adjusted after tomorrows value 4.",0
Heparin subcutaneous 5000 units b.i.d.,0
Protonix 14 mg q. day 6.,0
"Clonidine 0.1 mg q. week, patch 7.",0
Tube feed at 50 cc/hr goal 9.,0
prn to keep blood pressure less than 150 systolic FOLLOW UP: 1.,0
The patient is to follow up with Dr. in Cardiothoracic Surgery as mentioned above.,0
"He is to be on strict blood pressure control regimen, or systolic less than 150 as mentioned above.",0
He should get three sets of independent blood draws after Vancomycin is stopped to make sure that he doesn't have any nidus infectious that could potentially seed aortic graft.,0
He is to continue receiving subcutaneous Heparin until he is fully ambulatory.,0
He is to follow up with his primary care provider as soon as he leaves the rehabilitation facility.,0
He is to arrange visit with a neurologist as needed.,0
Dictated By: MEDQUIST36 D: 18:04 T: 18:12 JOB#:,0
Height: (in) 64 Weight (lb): 122 BSA (m2): 1.59 m2 BP (mm Hg): 86/43 HR (bpm): 110 Status: Inpatient Date/Time: at 11:01 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
The IVC is normal in diameter with appropriate phasic respirator variation.,0
TVI e'<0.08m/s c/w elevated LV filling pressures.,0
"Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction.,0
Overall left ventricular systolic function is normal (LVEF 70%).,0
Tissue velocity imaging demonstrates an e' of <0.08m/s c/w an elevated left ventricular filling pressure (>12mmHg).,0
Transmitral Doppler and tissue velocity imaging are consistent with Grade II (modearte) left ventricular diastolic dysfunction.,0
6:20 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"pna vs fluid overload Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with and adenocarcinoma, w/ new L MCA CVA.",0
now w/ respiratory distress REASON FOR THIS EXAMINATION: ?,0
pna vs fluid overload ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath in a patient with CVA.,0
The comparison was obtained with .,0
There is again demonstrated right hilar and right mediastinal enlargement due to known metastatic lymphadenopathy.,0
The lungs are grossly clear with no sizeable pleural effusion demonstrated.,0
4:29 AM CHEST (PORTABLE AP) Clip # Reason: interval exam Admitting Diagnosis: ETOH CIRRHOSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p trach and NGT placement.,0
"REASON FOR THIS EXAMINATION: interval exam ______________________________________________________________________________ FINAL REPORT CHEST, ONE VIEW PORTABLE: INDICATION: 50-year-old man status post tracheostomy.",0
"COMMENTS: A portable supine AP radiograph of the chest is reviewed, and compared with the previous study of yesterday.",0
"The tracheostomy tube, right jugular IV catheter, and nasogastric tube remain in place.",0
There is continued left lower lobe consolidation indicating pneumonia versus atelectasis.,0
There is continued mild congestive heart failure with cardiomegaly and small bilateral pleural effusion.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: CC: Major Surgical or Invasive Procedure: none History of Present Illness: This is a 56 year-old male with a history of ETOH cirrhosis with esophageal varices s/p TIPS as well as active EtOH use who presents with hematemesis x2 yesterday per VNA report.,1
"He was brought in by his cousin for concern for GIB, and currently denies that he had any hematemesis but instead endorses hematochezia.",1
"He Denies abdominal pain, diarrhea, melena or hematochezia.",0
Per report has been eating/drinking OK w/o aspiration/N/V.,0
"In the ED, they did not gastric lavage due to varices and risk of bleed.",0
He was hemodynamically stable w/ HR 74 BP 117/74 O2sat 98%RA.,0
GI was consulted and pt was started on an octreotide gtt; received cipro IV and IV PPI.,0
"ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes.",0
Past Medical History: - Alcoholic cirrhosis - hx of esophageal variceal bleed and hepatic encephalopathy.,1
He has had 2 TIPS procedures with stent placement in and again in .,0
Underwent TIPS revision in and .,0
"- EGD : Grade esophageal varices, Esophagitis, Portal hypertensive gastropathy - Chronic pancreatitis complicated by a parapancreatic cyst that was infected with enteroccocus and coagulase negative staph.",1
"On vancomycin from , then linezolid .",0
- Type 2 DM on insulin - Anemia of chronic disease - Thrombocytopenia - Depression - Umbilical Hernia - History of delerium tremens .,1
Social History: Pt lives alone with sisters in area and friends in the building.,0
"Last used ETOH ""in "" - per other reports, still actively drinking and removed from list.",0
No h/o IVDU or other drug use.,0
"Says he smokes ""5 packs a day"".",0
"Family History: father - cirrhosis Physical Exam: On Presentation to ICU: Vitals: T: 98.4 BP: HR: 83 RR: 19 O2Sat: 100% RA GEN: jaundiced, disheveled, no acute distress HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea, dryMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: distended, no peripheral dullness to percussion, Soft, NT, +BS, + HSM, no masses Rectal: guiac (-) EXT: No C/C/E, no palpable cords NEURO: + asterixis, alert, oriented to place, unable to reidentify people, not oriented to time.",0
Strength 5/5 in upper and lower extremities.,0
"SKIN: +jaundice, cyanosis, or gross dermatitis.",0
Pertinent Results: 07:00PM WBC-6.8 RBC-3.58*# HGB-13.2*# HCT-35.1* MCV-98# MCH-36.9* MCHC-37.6* RDW-14.4 07:00PM NEUTS-72.7* LYMPHS-12.0* MONOS-6.9 EOS-7.1* BASOS-1.2 07:00PM PLT COUNT-49* .,0
07:00PM PT-16.7* PTT-32.9 INR(PT)-1.5* .,0
07:00PM GLUCOSE-293* UREA N-20 CREAT-1.0 SODIUM-128* POTASSIUM-2.4* CHLORIDE-90* TOTAL CO2-24 ANION GAP-16 07:00PM ALT(SGPT)-43* AST(SGOT)-94* ALK PHOS-379* TOT BILI-12.7* 07:00PM LIPASE-138* .,0
11:03PM BLOOD Hct-34.2* Plt Ct-51* 04:12AM BLOOD Hct-30.3* Plt Ct-47* 11:39AM BLOOD Hct-30.7* .,0
CXR: IMPRESSION: Interval improvement in right basilar opacity with persistent small right pleural effusion.,0
Findings are suggestive of resolving pneumonia.,0
No new areas of abnormality otherwise identified.,0
Liver U/S with Doppler: 1.,0
"Unchanged occluded anterior TIPS and unchanged patent posterior TIPS with normal flow in the proximal, mid and distal portions of the stent.",0
Cholelithiasis with no evidence of cholecystitis.,0
"Brief Hospital Course: 56 yo male with EtOH cirrhosis and esophageal varices s/p 2 TIPS with multiple revisions, as well as active EtOH use who presents with hematemesis x2, without further episodes and a stable Hct.",1
# Hematemesis: Patient had two episodes of hematemesis by report has a history of grade I-III varices.,1
"He initially received an octreotide drip, IV PPI, and IV cipro, however this was stopped on the day after admission as his Hct was stable and he did not appear to have an active GI bleed.",0
He had no further episodes of hematemesis while hospitalized and has been guaiac negative here.,0
"As his story changes depending who speaks with him, it is unclear if he actually had hematemesis, however he is not currently bleeding and his Hct has been stable.",1
He was continued on a PPI daily and nadolol 20 mg daily for variceal ppx.,0
His diet was advanced and he was tolerating a regular diet without problem the night prior to discharge.,0
"# EtOH cirrhosis: The patient has alcoholic cirrhosis and is not on the list due to recent alcohol use (the patient denies using alcohol in the past 3 years, however he recently received a letter in from the board stating he was being inactivated from the list due to recent alcohol use).",1
He was continued on rifaximin and lactulose (titrating for bowel movements) for ppx of encephalopathy.,0
He was continued on nadolol and a PPI as above.,0
At discharge he was restarted on his aldactone.,0
"# Type 2 DM: The patient's lantus was initally held as he was NPO, however it was added back as he began to eat.",0
His finger sticks were checked qid and he was covered with sliding scale insulin.,0
He was discharged on his home dose of 38 units of lantus qpm.,0
"# EtOH abuse: The patient denies recent alcohol use, but has a history of DT's.",0
Teh patient was monitored closely for withdrawal and placed on a CIWA scale.,0
He required no diazepam during this admission.,0
"He was continued on folic acid, thiamine, and a MVI.",0
He was counceled to avoid alcohol use due to his liver disease.,1
# History of depression: The patient was continued on his home dose of amitriptyline.,0
"# Thrombocytopenia: The patient has chronic thrombocytopenia, likely secondary to liver disease.",1
His platlets remained stable during this admission.,0
Medications on Admission: Per d/c Summary.,0
Nadolol 20 mg Daily 3.,0
Rifaximin 200 mg Tablet three tabs 4.,0
Lactulose Thirty (30) ML PO QID 5.,0
Amitriptyline 10 mg QHS 8.,0
Thiamine HCl 100 mg Daily 9.,0
Folic Acid 1 mg Daily 10.,0
Insulin Glargine 100 unit/mL Solution Sig: 38U Subcutaneous at bedtime.,0
Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO twice a day.,0
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO four times a day: Titrate to bowel movements per day.,0
"Omeprazole 40 mg Capsule, Delayed Release(E.C.)",0
Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38) units Subcutaneous at bedtime.,0
Aldactone 100 mg Tablet Sig: 1.5 Tablets PO once a day.,0
"Discharge Disposition: Home Discharge Diagnosis: Primary- Hematemeis Secondary- Alcoholic cirrhosis Diabetes Depression Discharge Condition: Stable, no signs of bleeding and tolerating a regular diet.",1
Discharge Instructions: You were admitted to the hospital due to two episodes of hematemesis (vomiting of blood).,0
You were monitored in the ICU overnight and you had no signs of active bleeding and your blood counts were stable.,0
Your diet was slowly advanced and you had no difficulty tolerating a regular diet.,0
Your blood counts remained stable throughout your hospitalization.,0
No changes were made to your medications.,0
"Call your primary doctor or go to the emergency room if you experience fevers, chills, dizzines, shortness of breath, vomiting of blood, blood in your stool, or black stool.",0
Followup Instructions: Please keep your previously scheduled appointments: Provider: Phone: Date/Time: 9:15 Provider: CLINIC Phone: Date/Time: 8:40 Completed by:,0
Height: (in) 70 Weight (lb): 262 BSA (m2): 2.34 m2 BP (mm Hg): 110/65 HR (bpm): 53 Status: Inpatient Date/Time: at 15:35 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%).,0
Conclusions: There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%).,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function.,0
"7:10 PM CT HEAD W/O CONTRAST Clip # Reason: UNRESPONSIVENESS,R/O CVA Admitting Diagnosis: MITRAL REGURGITATION ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with REASON FOR THIS EXAMINATION: r/o cva No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 68-year-old man with unresponsiveness.",0
FINDINGS: The study is limited by motion artifact.,0
"There is no evidence of hemorrhage, mass effect, hydrocephalus, shift of normally midline structures, or infarction.",0
"There is sphenoid, ethmoid and maxillary sinus mucosal thickening.",0
Nasogastric and endotracheal tubes are noted.,0
IMPRESSION: Limited study with no abnormalities detected.,0
No evidence of hemorrhage or mass effect.,0
"9:53 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval interval change Admitting Diagnosis: ESOPHAGEAL DIVERTICULUM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 75M s/p open zenker's diverticulum repair , esophageal injury s/p layered closure, alloderm reinforcement s/p neck exploration REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Esophageal injury status post neck exploration, question interval change.",1
"FINDINGS: There is volume loss and opacity in both lower lobes, obscuring both hemidiaphragms.",0
Some of this is due to volume loss but some is likely due to effusion and underlying infiltrate cannot be excluded.,0
There is some mild pulmonary vascular redistribution.,0
The endotracheal tube tip is 5 cm above the carina.,0
"The NG tube tip is off the film, at least in the stomach.",0
11:25 PM CHEST (PORTABLE AP) Clip # Reason: r/o mediastinal bleed Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman s/p pacemaker placement- pt became hyptonesive after temp pacemaker removed REASON FOR THIS EXAMINATION: r/o mediastinal bleed ______________________________________________________________________________ FINAL REPORT HISTORY: 87 year old woman status post pacemaker placement.,0
Became hypotensive after removal of temporary pacemaker.,0
CHEST AP: There is stable LV enlargement.,0
The hilar and mediastinal contours are within normal limits.,0
There has been interval removal of temporary pacer wire.,0
There is a new dual-lead permanent pacer with leads appropriately positioned.,0
Osseous and soft-tissue structures are unremarkable.,0
IMPRESSION: No evidence of mediastinal hematoma.,0
Interval removal of pacer wire and placement of permanent pacer with right atrial and ventricular leads appropriately positioned.,0
"4:36 PM BILAT UP EXT VEINS US; -59 DISTINCT PROCEDURAL SERVICE Clip # -76 BY SAME PHYSICIAN : r/o DVT for source of embolic stroke Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with R MCA stroke REASON FOR THIS EXAMINATION: r/o DVT for source of embolic stroke ______________________________________________________________________________ FINAL REPORT INDICATION: 46-year-old man status post stroke, evaluate for embolic source.",0
"FINDINGS: Grayscale and Doppler son of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed.",0
"These demonstrate normal compressibility, augmentation, waveforms and flow.",0
IMPRESSION: No evidence of upper extremity DVT.,0
LINE PLACEMENT Clip # Reason: ETT and CVL in OR Admitting Diagnosis: S/P FALL/MULTIPLE FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with REASON FOR THIS EXAMINATION: ETT and CVL in OR ______________________________________________________________________________ FINAL REPORT CHEST port line placement.,0
INDICATION: 47-year-old woman with ETT.,0
LAST MENSTRUAL PERIOD: ET tube is 4 cm above the carina.,0
FINDINGS: Right subclavian line tip projects over the SVC.,0
"Otherwise, the lungs are clear.",0
There is cardiac enlargement with engorgement of the mediastinal vessels.,0
IMPRESSION: No evidence for failure.,0
No pneumothorax or pleural effusions.,0
11:20 AM CHEST (PA & LAT) Clip # Reason: improvement in effusion?,0
"Admitting Diagnosis: LEFT EFFUSION;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with exudative left pleural effusion, chest tube, and pigtail, likely secondary to trauma.",1
REASON FOR THIS EXAMINATION: improvement in effusion?,0
"______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Exudative left pleural effusion, chest tube placement and pigtail, follow up.",0
Left PICC line tip is at the level of mid SVC.,0
Left pigtail catheter is in place.,0
Left chest tube is in place.,0
There is overall no substantial change in the appearance of the left pleural effusion including loculation at the apex and at the base.,0
No appreciable pneumothorax is seen.,0
"Overall, the amount of the effusion is moderate.",0
There is also substantial subpulmonic component most likely represent.,0
Right lung is essentially clear except for minimal right lower lung linear atelectasis.,0
2:06 PM CHEST (PORTABLE AP) Clip # Reason: PTX?,0
______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with fall this morning and SDH and AMS REASON FOR THIS EXAMINATION: PTX?,0
"______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST INDICATION: 79-year-old man with fall this morning, with subdural hemorrhage and mental status change, question pneumothorax.",0
"FINDINGS: The visualized lungs are clear, although the left costophrenic angle has been cut off.",0
The cardiomediastinal silhouette is normal.,0
There is no evidence of effusion.,0
"The known collapsed T12 vertebral body is not well seen on today's exam, as there is no lateral view.",0
"LINE PLACEMENT Clip # Reason: evaluate lines, ptx, effusion Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with s/p CABG REASON FOR THIS EXAMINATION: evaluate lines, ptx, effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Patient status post CABG, evaluate for line, pneumothorax, effusion.",1
SUPINE FRONTAL RADIOGRAPH OF THE CHEST: The right costophrenic angle is excluded from the field of view.,0
There is a right IJ terminating in the distal SVC.,0
"The ET tube is slightly high, above the level of the clavicle, terminating 5.6 cm above the carina.",0
"There is bibasilar consolidation, likely atelectasis.",0
Mild postoperative widening of the mediastinum.,0
"NG tube is in the stomach, the side port is at the gastroesophageal junction.",0
External pacer leads are noted.,0
There is a left basilar chest tube without evidence of a pneumothorax.,0
ET tube is slightly high terminating above the clavicles and could be advnanced slightly for more optimal positioning.,0
"NG tube slightly high with the side port at the gastroesophageal junction, further advancement by 5 cm is recommended.",0
Small left pleural effusion and bibasilar atelectasis.,0
"12:15 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: eval for trauma, fx ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with HTN, DM, s/p mechanical fall, landed on R.side of face, large ecchymoses/pain REASON FOR THIS EXAMINATION: eval for trauma, fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: FXKd FRI 12:58 PM Soft tissue swelling over the right orbit.",0
Soft tissue in the left external auditory canal likely cerumen and warrants direct inspection.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old male with recent fall and large ecchymosis on the right eye, to assess for a fracture.",0
TECHNIQUE: CT of the facial bones was performed.,0
Correlation is made with CT brain of .,0
FINDINGS: The large left subdural hematoma is better assessed on today's CT brain.,1
There is soft tissue swelling seen over the right orbit.,0
There is soft tissue also seen in the left external auditory meatus likely cerumen.,0
There is mild mucosal thickening in the maxillary sinuses.,0
There is no acute facial bone fracture.,0
Soft tissue swelling seen over the right orbit.,0
There is no acute facial fracture.,0
Soft tissue seen in the left external auditory meatus most likely represents cerumen though warrants clinical correlation with direct inspection.,0
7:22 AM NEONATAL HEAD PORTABLE Clip # Reason: follow-up previous study; rule out PVL Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 29 weeks now 1 month old REASON FOR THIS EXAMINATION: follow-up previous study; rule out PVL ______________________________________________________________________________ FINAL REPORT This is a baby boy at 29 week gestation now about a month old.,1
Exam performed on was normal as is today's exam.,0
"There is no evidence of intraventricular hemorrhage, ventriculomegaly or parenchymal disease.",0
"3:23 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: HEMORRHAGIC STROKE ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man on ventilator REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: On ventilator, to assess for change.",0
"FINDINGS: In comparison with the study of , the left subclavian catheter has been removed.",0
The right subclavian catheter has been pulled back to the mid portion of the SVC.,0
Continued low lung volumes with minimal bibasilar atelectatic change.,0
"2:30 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: dobhoff placement Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 52M w/necrotizing pancreatitis s/p ERCP, presents to SICU after new fevers, worsening abdominal distension, low UOP and worsening respiratory status.",1
"REASON FOR THIS EXAMINATION: dobhoff placement ______________________________________________________________________________ FINAL REPORT HISTORY: 52-year-old male with necrotizing pancreatitis status post ERCP, in need of post-pyloric Dobbhoff placement.",0
TECHNIQUE: The patient was brought to the fluoroscopic suite and placed supine on the table.,0
Sedation was provided by the ICU nurse boluses.,0
"Under fluoroscopic guidance, a Dobbhoff tube was advanced through the left naris and into the stomach.",0
"For improved purchase, the wire was then inserted, and the tube was advanced into the third portion of the duodenum.",0
A small amount of iodinated contrast was then injected confirming a duodenal position.,0
The tube was then bridled in place and the patient was returned to the ICU in stable condition.,0
"FINDINGS: Two spot fluoroscopic images demonstrate a Dobbhoff tube with its tip in the third portion of the duodenum, which is then confirmed by contrast injection, which refluxes up the second portion of the duodenum.",0
IMPRESSION: Successful post-pyloric Dobbhoff tube placement.,0
This was bridled in place.,0
"4:34 PM CHEST (PORTABLE AP) Clip # Reason: Acute decompensation Admitting Diagnosis: METASTATIC SARCOMA;SUPERIOR VENAL CAV SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with metastatic sarcoma with pulm mets/SVC syndrome s/p bronchus stent/svc stent, just extubated, with cough, LLL opacity, now with sudden onset decrease BS on R side and dropping O2 sat REASON FOR THIS EXAMINATION: Acute decompensation ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Acute desaturation in a patient with metastatic sarcoma.",0
Markedly increased bilateral basal consolidations are accompanied by bilateral increase in pleural effusion.,1
This consolidations might be either due to bibasilar atelectasis or massive aspiration.,0
Mild pulmonary edema is unchanged.,0
"There is no change in the position of the right central venous line ,central venous stent.",0
Findings were communicated to Dr. .,0
"10:50 AM CHEST (PORTABLE AP) Clip # Reason: fever, sob low sao2 ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with REASON FOR THIS EXAMINATION: fever, sob low sao2 ______________________________________________________________________________ FINAL REPORT INDICATION: Low oxygen saturation, fever, and shortness of breath.",0
AP SUPINE PORTABLE CHEST: The examination is limited by positioning.,0
"The patient's chin overlaps the lung apices, and the left CP angle is excluded.",0
The mediastinal and cardiac contours appear unchanged allowing for this.,0
Air bronchograms are noted on the right in a peri-hilar distribution.,0
"There is persistent pleural thickening in the right mid-lung zone, laterally.",0
There is marked gastric distention.,0
IMPRESSION: Very limited radiographs demonstrating air bronchograms in the right peri-hilar region.,0
Pneumonia or aspiration should be considered.,0
"1:01 PM CT CHEST W/CONTRAST; CT RECONSTRUCTION Clip # 200CC NON IONIC CONTRAST SUPPLY Reason: SOB, CHEST PAIN Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman s/p ccy, complicated by biliary leak, with persistent hypoxia and ekg concerning for pe.",0
REASON FOR THIS EXAMINATION: r/o pe No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: CT scan of the thorax.,0
CLINICAL HISTORY: 44 year old woman status post cholecystectomy complicated by biliary leak with persistent hypoxia.,0
Comparison made to chest x-ray dated .,0
TECHNIQUE: Contiguous helical slices were acquired through the thorax post administration of 175 ml of Optiray.,0
Optiray was used as the patient is in the ICU.,0
The images were reformatted and viewed on a workstation.,0
FINDINGS: This is a suboptimal study despite two attempts.,0
"However, no large central pulmonary embolism is seen.",0
"No embolism is seen in the posterior segmental branches of the right lower lobe or in the right middle lobe, as well as in the left lower lobe.",0
Both upper lobes and the anterior segments of the right lower lobe are not well visualized due to technique factors and therefore small segment pulmonary emboli cannot be excluded.,0
The pulmonary parenchyma is markedly abnormal with diffuse ground-glass opacity in association with interlobular septal thickening predominantly in the upper lobe regions and more predominantly peripherally.,0
There is relative sparing of the lung bases.,0
No significant left ventricular or left atrial enlargement is seen.,0
The hepatic veins are within normal limits.,0
"Small, less than 1 cm, prevascular and paratracheal lymph nodes are seen.",0
BONE WINDOWS: No significant bony abnormalities are seen.,0
Reconstructed images confirm the above findings.,0
IMPRESSION: 1) Suboptimal study but no definite evidence of large central pulmonary embolus.,0
"The segmental branches are only partially assessed, as described above.",0
"(Over) 1:01 PM CT CHEST W/CONTRAST; CT RECONSTRUCTION Clip # 200CC NON IONIC CONTRAST SUPPLY Reason: SOB, CHEST PAIN Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (Cont) 2) Diffuse ground glass and interlobular septal thickening, as described above.",0
This is nonspecific in nature and could be related to pulmonary edema with upper lobe predominance due to the patient's supine position.,0
"However, it could also be due to an infectious or inflammatory process of multiple etiologies.",0
ARDS is also a consideration.,0
These results were discussed with the referring clinician.,0
"Unit No: Admission Date: Discharge Date: Sex: F Service: HISTORY OF PRESENT ILLNESS: This is an 83-year-old female with type 2 diabetes, peripheral vascular disease status post bilateral femoral distal bypass in and with a history of atrial fibrillation who presents to the emergency room complaining of abdominal pain.",1
"She states that she had some dyspepsia for several weeks, but on the Friday prior to admission, she developed severe abdominal pain.",0
"The pain she described as non-radiating, constant, but feels better when she rocks to and fro.",0
The patient also states she had some nausea and one episode of bilious emesis.,0
The patient denies fevers or chills or bright red blood per rectum or melena.,0
She denies discolored stools or dark urine.,0
PAST MEDICAL HISTORY: As above.,0
"MEDICATIONS AT HOME: Amiodarone, Coumadin, Lipitor, Mavik and Avandia.",0
"PHYSICAL EXAMINATION: Temperature is 96.5, heart rate 97, blood pressure 128/77, respiratory rate 16, saturating 97% on room air.",0
General - elderly lady in no acute distress.,0
"Cardiovascular - 2/4 systolic murmur noted, irregular heart rate.",1
Pulmonary exam - clear to auscultation bilaterally.,0
"Abdomen was soft, nondistended, positive tenderness in the right upper quadrant and epigastrium with sign positive, positive periumbilical hernia with reducible hernial sac.",1
Extremities - bilateral lower extremity edema with 2+ pedal pulses bilaterally.,0
"LABORATORY: CBC - white blood cells 8, hematocrit 33.2, platelets 172 with 85% neutrophils.",0
"Chem-7 - 132, 4.5, 106, 23, 25, 0.9 and glucose of 210.",0
"LFTs - 118, 209, 159, 1.4, alkaline phosphatase 36.",0
"Ultrasound shows a thickened gallbladder wall with the common bile duct 4 mm in diameter, no stones seen.",0
PROCEDURES PERFORMED: Laparoscopic cholecystectomy and periumbilical hernia repair.,1
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted on hospital day 1 for IV hydration and preop preparations.,0
She was started on IV fluids and Levo-Flagyl.,0
"The following morning, she underwent a laparoscopic cholecystectomy and a repair of umbilical hernia.",1
Her postoperative course was complicated by difficult intravascular fluid management.,1
Her cardiac ejection fraction had previously been documented at 30% and the patient quickly became oliguric while at the same time bilateral crackles were noted in the lung fields.,0
Her urine output was maintained with fluid boluses and her pulse oximetry was noted to be satisfactory in the upper 90s on nasal cannula oxygen.,0
The patient's cardiovascular and urine output status continued to deteriorate until postop day 6 at which time she was transferred to the surgical intensive care unit for better hemodynamic monitoring and fluid status maintenance.,1
"At that time, her urine output had been 180 cc for the previous 24 hours despite multiple fluid boluses and IV fluid hydration.",0
The patient's creatinine had increased to 1.7 from 0.7 preoperatively.,0
"At that time, due to fluid overload, the patient developed respiratory distress and was transferred to the SICU.",0
"Under more intensive monitoring, the patient's hemodynamic status and urine output improved and she was transferred back to the floor on postop day 9.",0
"At that time, her creatinine had lowered back down to 0.6.",0
The patient continued to slowly improve until postop day 9 when it was noted that her umbilical hernia repair wound was draining some serous fluid.,1
"On investigation of this, it was noted that her umbilical wound repair had failed so on postop day 9, the patient was taken back to the operating room where an open repair of a complex umbilical hernia repair was performed.",1
"Postoperatively, the patient was maintained in the PACU for better hemodynamic monitoring for the 1st postop day.",0
She was then transferred to the floor where she continued to have low urine output and was difficult to manage hemodynamically.,0
She was able to be managed though this time by increasing her beta blockade which kept her heart in a sinus rhythm as opposed to reverting to atrial fibrillation as it had multiple times throughout her hospital stay.,1
"Throughout this hospital stay, she also complained of multiple episodes of chest pain for which she was ruled out for MI multiple times.",0
Her EKG varied between atrial fibrillation with moderate to fast ventricular response to normal sinus rhythm.,1
The tendency to enter atrial fibrillation was secondary most probably to either electrolyte imbalance which was corrected daily or to fluid overload.,1
"On postoperative day 9, the patient was also noted at the time of her periumbilical wound investigation and re- repair to have some erythema surrounding the wound.",1
"For this, she was placed on vancomycin which was continued for the 5 postop days after the 2nd surgery in the hospital and will be continued with linezolid x7 more days in rehab.",0
"The patient was discharged to rehab on postop day 5 and 16, stable.",0
Periumbilical hernia with subsequent re-repair of complex periumbilical hernia.,1
Congestive heart failure with an ejection fraction of 30%.,1
Amiodarone 200 mg tablets - take 1 p.o.,0
Albuterol inhaler metered dose MDI - 1-2 puffs p.o.,0
Guaiphenesin 100 mg/5ml syrup - please take ml p.o.,0
Atrovent metered dose inhaler - take 1-2 puffs q.6 p.r.n.,0
Rosiglitazone 2 mg tablets - take 1 p.o.,0
Atorvastatin 40 mg - take 1 p.o.,0
Trandolapril 4 mg 1 p.o.,0
Lopressor 25 mg 1 p.o.,0
Miconazole 2% powder - apply topically to perineal area b.i.d.,0
Hydromorphone 2 mg tablets p.o.,0
Warfarin 1 mg 1 p.o.,0
Linezolid for 7 days at a dose of 500 mg p.o.,0
FOLLOW-UP PLANS: The patient is to follow up with Dr. in 2 weeks' time.,0
The patient will be given the phone number of Dr. which is .,0
"The patient also has pre- existing appointments with Dr. in the far building on at 9:40 in the morning and she has an appointment for an echocardiogram at Center on at 10:00 a.m. She also has an appointment with at the Building on at 11:00 a.m. , MD Dictated By: MEDQUIST36 D: 09:32:10 T: 10:31:43 Job#: cc: , MD",0
3:41 AM CHEST (PORTABLE AP) Clip # Reason: Eval pulmonary edema Admitting Diagnosis: BILATERAL URETERAL OBSTRUCTION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man h.o.,0
"transitional carcinoma s/p neobladder takedown, ileal condiot placement.",0
"Admitted for A. fib with RVR, hypotension s/p 9L NS, 2u PRBC.",0
"REASON FOR THIS EXAMINATION: Eval pulmonary edema ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Afib, evaluate pulmonary edema.",0
FINDINGS: The heart size continues to be mildly enlarged.,0
There is volume loss in both lower lungs.,0
"An early infiltrate, particularly on the right cannot be excluded.",0
There is some mild pulmonary vascular re-distribution and possible small left effusion.,0
"IMPRESSION: Overall, worsened appearance of the lungs compared to the film from a month ago, there could be an element of CHF.",0
An early infiltrate in the lower lobes cannot be excluded.,0
", C. NMED SICU-A 8:13 PM CT HEAD W/O CONTRAST Clip # Reason: ?",0
Extension of hemorrhagic component of stroke as was given Admitting Diagnosis: STROKE/TIA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with ischemic stroke s/p TPA REASON FOR THIS EXAMINATION: ?,0
Extension of hemorrhagic component of stroke as was given TPA 24 hrs prior.,0
Please do at 8pm on .,0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Stable petechial blood in the left frontal ACA territory.,0
"10:21 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: U/S of liver to evaluate TIPS Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p Roux-en-Y hepatojejunostomy for Mirizzi's sdm, h/o GIB from hepatic pseudoaneurysm (coiled),h/o esophageal varices and ascites.",0
REASON FOR THIS EXAMINATION: U/S of liver to evaluate TIPS ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of TIPS.,0
LIVER DOPPLER ULTRASOUND: This study is compared to and .,0
The portal vein is patent with hepatopetal flow.,0
"Compared to the prior ultrasound, it is difficult to appreciate any flow direction change.",0
"Flow velocities were measured and were 30-60 cm per second in the proximal portion of the TIPS, 60 cm per second in the mid-portion of the TIPS, and 130 cm per second in the distal portion of the TIPS.",0
Main portal vein velocity was 30 cm/sec.,0
Intra-TIPS increase of velocity from 30 to 130 cm per second.,0
"The distal TIPS velocity has increased compared to the previous studies, but this may be due to technical difficulties with the prior exam.",0
The current study suggests good TIPS function.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Crestor Attending: Chief Complaint: RUQ pain after a fall, transfer from OSH for management of sepsis and respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy with BAL CT-guided placement of catheter in intra-abdominal abscess History of Present Illness: 68 year old gentleman retired judge past medical history of DM, AFlutter s/p ablation on pradaxa, EtOH abuse was transferred from to on after right mid quadrant abdominal pain from a recent fall a week prior.",1
"At that time, he had ""resistant"" E coli UTI (to cipro, levo, bactrim, augmentin), complicated by acute renal failure (Cr 2, BUN 17), mild sepsis/SIRS associated with hypotension and lactic acidosis.",1
Initially treated at with flouroquinolone transitioned to ertapenem at NEBH.,0
His initial presentation improved and EtOH withdrawal was managed by ativan however this was followed by progressive somnolence and SOB.,0
There was concern for aspiration pneumonia and acute respiratory failure given bilateral parenchymal infiltrates andworsening hypoxemia on ABG requiring intubation.,1
He was placed on ertapenam and levaquin to cover atypical organisms given his recent admission from community.,0
"Given improvement in leukocytosis (initially WBC 19 PMN 72 BAND 15), but persistence of fever, levaquin was discontinued.",0
"Multiple cultures including blood, urine , stool, sputum cultures were unrevealing except for albicans on sputum.",0
Multiple attempts of us guided thoracocentesis failed due to minimal amount of fluid.,0
This eventually ended up a thoracic surgeon placing a left chest tube on with VATS procedure (CT guided failed as well).,0
It was noted that the pleural surface was reddened and consistent with exudative but cultures and cytology were unremarkable.,0
Bronchoscopy on was unrevealing in terms of cultures.,0
PICC line was changed with persistently non-significant blood cultures.,0
Had elevated lipase in the pleural fluid consistent with elevation in blood lipase up to 5000's.,0
"Five CT were done and did not reveal pancreatic inflammation, necrosis or pseudocyst.",0
"After 18 day of antibiotics, they were discontinued since no source of infection identified (staph epi on one of the cultures and Ecoli as noted previously).",0
"Holding tube feeds, psych meds and diuretic didn't help to stop fever.",0
Multiphasic CT showed lesion at the lower pole of the liver with exophytic cyst off the right kidney concern for possible undrained infection or underlying HCC (AFP 97.7) with MR abdomen more consistent with solid tumor than hemangioma.,1
"Eventually, tumor fever was concerning renal cyst biopsy was discussed.",0
"on prior to preparation to transfer to , pt had fever, tachypnic with tube feeds emanating from around the trach.",0
Vancomycin and zosyn were started.,0
Transitioned from pressure support to assist control.,0
"During his stay, he had complete lower lobe collapse in his lower lobes with surrounding effusion in the setting of hypoalbuminemic state and a chest tube was placed as above with right lower lobe re-expansion but still was unable to wean.",1
Bronchoscopy was performed which showed tracheobroncomalacia possibly more than 80% of the lumen was narrowed by positive pressure ventilation.,0
"Due to this, tracheostomy and PEG tube was placed .",0
"Prior to presentation to OSH, he had a fall with abdominal pain, found to have rectal muscle hematomta, pradaxa was held.",0
He remained in sinus per dc summary with diltaizem 30 mg q 6 hour and lopressor 25 mg twice daily.,0
He received DVT prophylaxis throughout his stay per dc summary (was on lovenox 40 mg sc daily per dc summary).,0
His last few days of stay was notable for higher insulin requirements which was somehow concerning for underlying infection however tube feeds were increased as well to meet his caloric needs.,0
"Prior to transfer, T 98.3, SBP 140/80.",0
Admission weight at OSH noted to be 111 kg.,0
"FiO2 40%, PEEP 5, RR 26, TV 400, PH 7.55, PCo2 27, PO2 81, total CO2 24.4 O2sat 97% On arrival to the MICU, patient's VS. HR 84bpm, BP 140/70, Sat 98% Mechanical Ventilation: Assist control (Volume Targeted), Tidal volume: 450 cc Respiratory rate: 18 PEEP: 5 cm/h2o FIO2: 50 % Past Medical History: DM-2 HYPERTENSION ATRIAL FLUTTER s/p ablation on pradaxa HYPOTHYROIDISM MIXED HYPERLIPIDEMIA colonic polyp removal CYST OF KIDNEY, ACQUIRED CALCULUS OF KIDNEY PROTEINURIA BLADDER NEOPLASM OBESITY CARDIOMEGALY OSA Social History: Patient is single without children.",1
He is semi-retired as an attorney/judge.,0
Tobacco: Remote cigarettes in the 's.,0
Strong history for cigar use and alcoholism.,1
"Family History: non-contributory Physical Exam: On Admission: General: arousable, moves all limbs, follows commands, nods yes or no HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: insp and exp rhonchi.",0
"air entry reduced at bases on both sides Abdomen: soft, bowel sounds present, no organomegaly appreciated, no tenderness to palpation, no rebound or guarding.",0
"GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.",0
mild trace pitting edema at the feet.,0
"Neuro: moving all extremities, following commands On Discharge: T 97.6 T max 98.9 HR 72 BP 144/76 RR 18 100% RA with trach abdominal drain with 10 cc of output in 24 hours yesterday General: A and O x 3, although intermittently confused at times (sometimes forgets place) HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated.",0
"trach in place, minimal erythema, signficantly improved from earlier this week CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: rare rhonchi.",0
"Abdomen: soft, bowel sounds present, no organomegaly appreciated, no tenderness to palpation, no rebound or guarding.",0
"PEG tube and intra-abdominal drain in place, no erythema around either GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.",0
An Index >=0.5 is considered to be positive.,0
"Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL blood cultures: 3:03 pm BLOOD CULTURE Source: Venipuncture.",0
"Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE.",0
Isolated from only one set in the previous five days -> suspected contaminant blood cultures from and still pending as of 4:23 pm ABSCESS Source: R peri-nephric abscess.,0
GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).,0
FLUID CULTURE (Final ): ESCHERICHIA COLI.,0
Piperacillin/tazobactam sensitivity testing available on request.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final ): NO ANAEROBES ISOLATED.,0
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.,0
4:31 pm BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE BRONCHUS.,0
RESPIRATORY CULTURE (Final ): Commensal Respiratory Flora Absent.,0
ACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.,0
C. difficile DNA amplification assay (Final ): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay.,0
7:44 pm URINE Source: Catheter.,0
**FINAL REPORT ** URINE CULTURE (Final ): ESCHERICHIA COLI.,0
sensitivity testing confirmed by Microscan.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 32 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Imaging: ECGL: Sinus rhythm.,0
Compared to the previous tracing of the P-R interval is less prolonged and the ventricular rate is faster.,0
CT ABD & PELVIS WITH CONTRAST Study Date of IMPRESSION: 1.,0
Bilobed retroperitoneal collection of fluid.,0
This fluid may be related to the right kidney where a small non-specific irregular hypodensity is present.,0
Additional intraperitoneal fluid is seen in perihepatic and perisplenic regions.,0
The perihepatic fluid appears to be contiguous with a not fully characterized hypodensity in segment VI of the liver.,0
"Mildly thickened bladder wall, nonspecific in the setting of bladder collapse, though thickening due to infectious or inflammatory process cannot be excluded.",0
CT CHEST W/CONTRAST Study Date of IMPRESSION: 1.,0
CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of IMPRESSION: Secretions at the tracheostomy site and extending into the subglottic region with no mass or abscess.,1
"US HEMATOMA SUBCUT DRAIN INCISION Study Date of IMPRESSION: Technically successful ultrasound-guided percutaneous drain placement of right flank hematoma, possibly infected.",0
"Culture grew E. coli sensitive to ceftriaxone as noted above Repeat CT abdomen/pelvis on showed resolving right peri-nephric abscess, only 2 cm x 2 cm, compared to 6 x 4 cm, final read pending at time of discharge, but did discuss findings and improvements with attending radiologist.",0
"The drain remains in place, with intent to remove in coming days when output is scant.",0
Brief Hospital Course: # Respiratory failure: The patient was transferred here with tracheostomy on mechanical ventilation for presumed HCAP and aspiration pneumonia.,1
The patient had a bronchoscopy here which did not show evidence of tracheobronchomalacia.,0
A bronchoalveolar lavage was done; results consistent with respiratory flora.,0
Antibiotics were subsequently tailored to ceftriaxone and flagyl from Vancomycin and zosyn.,0
The patient was diuresed with IV lasix for pulmonary edema and b/l pleural effusions.,1
The patient improved and was able to be transitioned to trach mask.,0
Patient was tolerating trach mask well when he was transferred to the floor.,0
"Periodic diuresis was continued with Lasix 60 mg IV daily to , with lyte repletion.",0
"Trach site cellulitis improving, vancomycin and fluconazole for trach site cellulitis should finish on .",0
# Fever: The patient was having fevers at the outside hospital and continued to have fevers here.,0
"A CT showed a perihepatic abscess that was drained, however there were multiple pockets and all may not be adequately drained.",0
The fluid grew 2+ GNRs that speciated to E coli sensitive to ceftriaxone.,0
He also had an E coli UTI that is pan-sensitive based on OSH biogram and our sensitivities here.,0
Antibiotics were transitioned from Vancomycin and Zosyn to ceftriaxone and flagyl based on sensitivities.,0
"The patient continued to spike fever, however the fever curve improved, and this is not suprising given perihepatic abscess that is still draining.",0
"Additionally, the patient had some erythema around the site of his trach.",0
"He was started on Fluconazole, IP was consulted who determined it was not necessary to change the trach.",0
Vanc and fluconazole as noted above.,0
"Regarding abdominal drain, patient has been afebrile for over 5 days, with abscess improving, and only scant output over 24 hours on .",0
Patient will continue on ceftriaxone and Flagyl.,0
Expect the drain can be removed in coming days after outpt approaches zero for 24 hours.,0
"Ceftriaxone and Flagyl should be continued, and consideration given to repeat CT abdomen/pelvis to ensure continued resolution of right peri-nephric abscess.",0
"# Altered mental status: On arrival, the patient was arousable but very sedated.",0
"This was likely multifactorial and a combination of toxic/metabolic, delirium and sedation.",0
Patient had been on heavy benzos for possible EtOH withdrawal at outside hospital.,0
Sedating medications were discontinued and the patient's mental status improved.,0
"On the floor, the patient continued to improve, and was A and O x 3 with occasional confusion, and is a very pleasant man.",0
# Coagulopathy: Patient had INR of 1.4 on admission.,0
This was thought to be to alcoholic liver disease vs. malnutrition.,1
Patient's anticoagulation was held due to rectus sheath hematoma that developed after his initial fall.,0
"INR 1.3 at discharge, should continue to improve as nutrition status improves.",0
# Aflutter s/p ablation: Patient has history of atrial flutter s/p ablation.,1
He was intermittently in atrial fibrillation with rapid ventricular response which was treated with IV diltiazem.,1
His oral medications were tailored to cardizem 60mg PO QID and Lopressor 50mg .,0
He remained in sinus rhythm with occasional ventricular ectopy.,0
Anticoagulation was held in the setting of rectus sheath hematoma at the OSH.,0
"Anticoagulation was discussed with his PCP, given his recent fall, hematoma, infection, and long hospital course, decision was made to defer restarting anti-coagulation at this time.",1
# Hyperglycemia: Patient has known Type II Diabetes.,0
"Per records, it was difficult controlling his blood sugar at OSH requiring twice daily lantus regimen in addition to ISS.",0
Patient was treated with insulin sliding scale.,0
# Hypertension: Patient was intermittently hypertensive with pressures running 160s-180s systolic.,0
His medications were tailored as above to cardizem 60mg PO QID and Lopressor 50mg .,0
Acetaminophen 500 mg PO Q6H:PRN fever please inform HO if fever thanks.,0
max daily dose 2 gram 2.,0
Albuterol-Ipratropium PUFF IH Q6H:PRN SOB/wheeze through ET tube 3.,0
CeftriaXONE 1 gm IV Q24H 4.,0
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5.,0
Diltiazem 60 mg PO QID please hold for SBP < 100 or HR < 60 6.,0
1 DROP BOTH EYES 7.,0
Fluconazole 400 mg PO Q24H Duration: 3 Days 8.,0
FoLIC Acid 1 mg PO DAILY 9.,0
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 10.,0
Heparin 5000 UNIT SC TID 11.,0
"Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen.",0
Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 13.,0
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14.,0
Metoprolol Tartrate 50 mg PO BID please hold for SBP < 100 or HR < 60 15.,0
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 16.,0
Multivitamins 1 TAB PO DAILY 17.,0
Ondansetron 4 mg IV Q8H:PRN nausea 18.,0
Thiamine 100 mg PO DAILY 21.,0
Vancomycin 1000 mg IV Q 12H 22.,0
Venlafaxine 100 mg PO TID 23.,0
"Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary diagnosis: Sepsis from UTI complicated by peri-nephric and peri-hepatic abscess Delerium Tremens (at OSH, fully resolved) Respiratory failure, likely due to sepsis s/p tracheostomy Malnutrition ICU delerium Secondary diagnosis: alcohol dependence a. flutter s/p ablation, in sinus rhythm throughout Discharge Condition: Mental Status: Confused - sometimes.",1
"Usually A and O x 3, but occasionally confused in the evening and morning Level of Consciousness: Alert and interactive.",0
Discharge Instructions: You were transferred from another hospital for management of fever.,0
You underwent a bronchoscopy that did not show any lung infection.,0
CT scan of your abdomen showed fluid abscesses around your kidney and liver.,1
"A drain was placed, and you were placed on antibiotics.",0
You also had a tracheostomy and stomach tube placed because of the length of time you were on the ventilator and to help improve your nutrition.,0
You also received antibiotics to treat a skin infection around you tract site.,1
"You will continue your recovery from your long hospitaliztion at , acute rehab facility.",0
Followup Instructions: You will follow up with your PCP after discharge from rehab.,0
"7:52 AM CHEST (PORTABLE AP) Clip # Reason: PTX Admitting Diagnosis: MITRAL REGURGITATION\MITRAL VALVE REPLACEMENT CORONARY ARTERY BYPASS GRAFT REDO ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man Redo MVrepair / CABG REASON FOR THIS EXAMINATION: PTX ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW AT 7:54 HISTORY: Status post CABG, question pneumothorax.",1
"REFERENCE EXAM: Again seen is the small right apical pneumothorax, is slightly smaller than on the film from the prior day.",0
Two left chest tubes are unchanged.,0
There is volume loss in both lower lobes but no definite infiltrate.,0
"There is feeding tube with tip off the film, at least in the stomach.",0
This patient is status post sternotomy with mediastinal clips.,1
There is a right IJ Cordis with tip in the SVC.,0
5:46 AM CHEST (PORTABLE AP) Clip # Reason: r/o acute lung process Admitting Diagnosis: HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: MVC s/p multiple fractures with possible pneumonia REASON FOR THIS EXAMINATION: r/o acute lung process ______________________________________________________________________________ FINAL REPORT HISTORY: Multiple fractures and possible pneumonia.,1
"FINDINGS: In comparison with the study of , central catheter again extends to the mid-to-lower portion of the SVC.",0
Previously described kink at the skin entrance is not definitely appreciated.,0
Low lung volumes may account for much of the prominence of the transverse diameter of the heart.,0
No evidence of vascular congestion.,0
There has been placement of a nasogastric tube that extends to the stomach.,0
"However, the side hole appears to lie just above the esophagogastric junction.",0
Height: (in) 62 Weight (lb): 200 BSA (m2): 1.91 m2 BP (mm Hg): 119/71 HR (bpm): 89 Status: Inpatient Date/Time: at 09:40 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
RIGHT VENTRICLE: Normal RV wall thickness.,0
No MS. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
LV systolic function appears moderately depressed (ejection fraction 30-40 percent) secondary to hypokinesis of the anterior septum and apex; the inferior and posterior walls may also be hypokinetic.,0
The right ventricular cavity is unusually small.,0
"Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction appears increased.",0
"10:37 PM CHEST (PORTABLE AP) Clip # Reason: pt w/ 2 episodes of seizures, and high fevers, r/o aspiratio Admitting Diagnosis: SEIZURES ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with sz REASON FOR THIS EXAMINATION: pt w/ 2 episodes of seizures, and high fevers, r/o aspiration ______________________________________________________________________________ FINAL REPORT HISTORY: Seizures, high fever, rule out aspiration.",0
"CHEST, SINGLE AP SUPINE PORTABLE VIEW: An EG tube is present, tip in satisfactory position approximately 4.7 cm above the carina.",0
"An NG tube is present, tip extending beneath diaphragm, off film.",0
"A portion of the tube is coiled in the fundus, but the tip continues distal to that.",0
"There is no CHF, focal infiltrate, or effusion.",0
Multiple devices overlying the chest.,0
IMPRESSION: No focal infiltrate to suggest aspiration.,0
1:00 PM ABDOMEN (SUPINE ONLY) IN O.R.,0
; -77 BY DIFFERENT PHYSICIANClip # ABDOMINAL FLUORO WITHOUT RADIOLOGIST Reason: IVC FILTER Admitting Diagnosis: OPEN ABDOMEN ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation for IVC filter placement.,0
TECHNIQUE: Single fluoroscopic view was obtained.,0
FINDINGS: Single fluoroscopic view demonstrates an IVC filter along with instruments over the presumed L2 level.,0
Multiple overlying staples are visualized.,0
IMPRESSION: Visualized IVC filter and instrumentation over the presumed L2 level.,0
"8:53 PM BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: r/o pneumothorax Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with right pneumothorax, chest tube to water seal REASON FOR THIS EXAMINATION: r/o pneumothorax ______________________________________________________________________________ FINAL REPORT BABYGRAM CHEST .",1
HISTORY: Infant with right pneumothorax.,0
FINDINGS: The endotracheal tube and right sided chest tube are only minimally changed in position since the study of earlier the same day.,0
"The right sided pneumothorax has decreased and there may only be a minimal residual amount of pneumothorax, if any.",0
There is no definite evidence for a left pneumothorax.,0
The amount of pneumomediastinum has decreased.,0
A pleural effusion is not seen.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Mr. is a 45-year-old man who presented to the Trauma Service following injury to his right eye.,1
The patient was operating a nail gun when a nail ricocheted and penetrated into his right face.,0
"It apparently went through his right maxilla, through his orbit and his eye, and into his brain.",0
He sustained a loss of consciousness and no further injury.,1
His Coma Scale on presentation was 15.,0
MEDICATIONS ON ADMISSION: He takes no medications on a daily basis.,0
ALLERGIES: He is allergic only to PENICILLIN.,0
"PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, his blood pressure was 148/82, oxygen saturation was 98%.",0
"In general, he was an adult male in no acute distress.",0
His Coma Scale was 15.,0
"His head, ears, nose, eyes and throat were notable for an entry wound just inferior to the right maxilla penetrating into the orbit.",0
There was ecchymosis to the right eye.,0
His right pupil was 3 mm and reactive.,0
"His median gaze was greater than his lateral gaze, and he had no up or down gaze.",0
His left pupil was reactive 4 mm to 3 mm.,0
There was no other facial injury or bony injury noted.,0
"His neck was supple, all structures midline with no tenderness.",0
Chest was clear to auscultation bilaterally.,0
Heart had a regular rate and rhythm.,0
"The abdomen was flat, soft, nontender, and nondistended.",0
Extremities were noted to be neurovascularly intact.,0
His motor strength was throughout as was his sensorium.,0
HOSPITAL COURSE: The patient was evaluated by both the Ophthalmology and Neurosurgery teams.,0
"On further evaluation it was found that the nail penetrated through the right orbit and into the right frontal lobe of the patient's brain, by approximately 1.2 cm.",0
"In addition, there was only a small amount of blood found in his sylvian fissure with no mass effect or shift noted.",0
"The following morning, the patient was taken to the operating room for removal of the nail.",0
"Operative findings were notable for a galvanized nail piercing the right orbital roof, through the dura, into the right frontal lobe.",0
They did note subarachnoid blood and a small hematoma along the path of the nail.,0
"The intracranial aspect of the nail was removed, and the tract was debrided and irrigated, after which time the dural defect was repaired.",0
The Ophthalmology Service then removed the remainder of the foreign body and repaired his right globe.,0
The patient's postoperative course was relatively unremarkable.,0
The patient was given intravenous clindamycin pending results of cultures taken intraoperatively.,0
"In addition, he was started on Tobradex eyedrops q.i.d.",0
"In addition, the patient was started on Dilantin 100 mg p.o.",0
to continue for approximately one month following his injury.,1
"By the second postoperative day, the patient was noted to be awake, alert, complaining only of a mild headache.",0
"From a neurosurgical standpoint, he was otherwise stable.",0
"He was also evaluated by Ophthalmology on his second postoperative day, noting that he was also stable following his ruptured globe repair with vitreous hemorrhage.",1
They did note that he had a subconjunctival hemorrhage and a question of retinal detachment in the right eye.,1
"They recommended that he be followed very closely as an outpatient, and to be continued on the Tobradex, and keep a shield to his right eye.",0
"DISCHARGE STATUS: On , the patient was discharged home.",0
CONDITION AT DISCHARGE: In stable condition.,0
"DISCHARGE INSTRUCTIONS: He was instructed to follow up with Ophthalmology on the day following his discharge; namely, at 11 a.m. in the Clinic in Five.",0
"In addition, he was instructed to follow up with Dr. at in approximately one month.",0
His appointment was set for at 1:15 p.m.,0
The patient was also instructed to please return to Five at in approximately seven days for staple removal and wound check.,0
The patient verbalized an understanding of all discharge instructions and was discharged to home without incident.,0
MEDICATIONS ON DISCHARGE: (The patient was discharged home on the following medications) 1.,0
Tobradex eyedrops 1 drop to the right eye q.i.d.,0
to continue a 30-day course.,0
"DISCHARGE DIAGNOSES: Foreign body to the right eye and right frontal lobe; now, status post removal of foreign body and surgical repair.",0
Dictated By: MEDQUIST36 D: 11:52 T: 18:23 JOB#: (cclist),0
1:23 PM CT HEAD W/O CONTRAST Clip # Reason: Eval for head injury s/p stab wounds to face.,1
Admitting Diagnosis: STABBING VICTIM ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man s/p multiple stab wounds.,0
REASON FOR THIS EXAMINATION: Eval for head injury s/p stab wounds to face.,1
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Multiple stab wounds.,0
TECHNIQUE: MDCT acquired axial images of the head were obtained without IV contrast.,0
FINDINGS: There is no acute intra- or extra-axial hemorrhage.,0
The basilar cisterns are patent.,0
"Partial opacification of the maxillary sinuses, ethmoid sinuses, and sphenoid sinuses is noted.",0
No displaced skull fracture is identified.,0
IMPRESSION: No evidence of acute intracranial pathology.,0
Sinus changes may be secondary to intubation.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Transfer for liver transplant eval Major Surgical or Invasive Procedure: Intubation Thoracentesis Chest tube removal Dobhoff placement x2 History of Present Illness: This is a 62 year-old female with a history of breast cancer, hemochromatosis, hepatic encephalopathy, s/p TIPS , hepatic hydrothorax who is transferred for transplant evaluation.",1
The patient was recently discharged on after a prolonged hospitalization for ascites and pleural effusions.,1
The patient underwent TIPS proceudre on and was discharged home.,0
"However, she became very confused secondary to hepatic encephalopathy and admitted on .",1
The patient was found unresponsive for 8 minutes and transferred to the MICU (no medications and was not intubated).,0
"The patient hepatic encephalopathy was improving, but she had worsening hypoxia secondary to pleural effusions.",1
She eventually required intubation and right chest tube was placed.,0
She had good drainage from her tube and also diuresed via lasix gtt.,0
She was able to be extubated on .,0
Her chest tube continues to drain 500cc per day.,0
"Additionally, the hospital course was complicated by c. diff colitis for which she was treated with a 16 day course of po vancomycin.",0
"Additionally, her blood cultures grew VRE and was treated with linezolid that was changed to daptomycin that was d/c on .",0
"The patient also had several episodes of atrial tachycardia that was initially treated with propanolol, but was stopped secondary to hypotension.",0
The patient was also found to have an left axillary DVT and has been on heparin gtt since .,0
The patient was transferred for further workup of the hydrothorax and liver transplant eval.,0
On arrival the paient had no complaints and doing well.,0
"She denied abdominal pain, fevers, chills, nausea, vomiting, bloody stools, SOB or other complaints.",0
"ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes.",0
Past Medical History: 1) Breast Cancer Stage I (Dx ) s/p lumpectomy & radiation.,1
"Currently on tamoxifen 2) Hemochromatosis heterozygous type 2A, A/H63D (liver biopsy ) 3) HTN 4) Esophagus 5) Prior admission on with pleural effusions s/p thoracentesis (~5L) and paracentesis x2 (5L and 3.5L) Social History: Pt is a teacher and widowed for last couple of years.",1
"Denied EtOH, smoking or other drug abuse Family History: No family history of hemochromatosis or liver disease.",0
Moderate left-sided pleural effusion with air-fluid level.,0
Moderate cardiomegaly with increased interstitial markings.,0
Right PICC line in standard position.,0
Right basal areas of atelectasis.,0
Obviously atelectatic increase in lung density around the left hilus.,0
Bronchial washings Atypical epithelial cells in a background of pulmonary macrophages and bronchial cells.,0
TTE The left atrium is mildly dilated.,0
Left ventricular systolic function is hyperdynamic (EF 70-80%).,0
Patent and appropriate TIPS and portal veins.,0
Small amount of sludge within the gallbladder with some tiny stones.,0
Pleural fluid cytology NEGATIVE FOR MALIGNANT CELLS.,0
Lymphocytes and monocytes (see note).,0
"Evidence of iron deposition in the liver and pancreas, consistent with primary chemochromatosis.",0
No evidence of iron deposition in the heart on limited images presented.,0
No imaging stigmata of cirrhosis.,0
"Patchy increased signal at the lung bases, trace right pleural effusion.",0
LUE Doppler U/S No deep vein thrombosis seen in the left arm.,0
Reactive mesothelial cells and macrophages.,0
"CXR There is blunting of both CP angles, but there is no large effusion as was present previously.",0
Right-sided PICC line tip is in the right atrium.,0
Feeding tube tip is off the film.,0
There are areas of opacity in the left lower lung and right mid lung.,0
The left lower lung opacity has a rounded configuration and measures 2.6 cm.,0
"This has not been visualized on the prior film, some of which could have been due to technique, volume loss, infiltrate, and overlying effusion.",0
"The mass lesion in this region cannot be totally excluded and if cross-sectional imaging has been obtained at an outside institution would be helpful to ensure that no lesion is present, this could just be a loculated area of fluid.",0
The heart is upper limits normal in size.,0
IMPRESSION: Patchy areas of opacity in the left mid lung and the right mid lung.,0
It is unclear if these represent focal infiltrates.,0
Repeat CXR Compared to the film from earlier the same day there is a small right pneumothorax.,0
This was present on the earlier film but was not commented upon.,0
There is volume loss in both lower lungs and a more confluent appearance to the opacity previously mentioned in the left mid lung.,0
There continues to be hazy right mid lung alveolar infiltrate.,0
"CXR There is a small right pneumothorax, unchanged compared with .",0
Otherwise no significant change is detected.,0
Proximal left humeral fracture again noted.,0
"Increased right basilar opacity likely represents worsening pleural effusion, worsening atelectasis or consolidation in the correct clinical setting.",0
Increased left basilar and lingula opacities likely reprsent atelectases.,0
"However, pneumonia can't be excluded in the correct clinical setting.",0
"DISCHARGE LABS: WBC 24.5 HCT 23.6 Plt 183 Na 131 K 4.2 Cl 95 HCO3 32 BUN 30 Cr 0.7 Glc 101 Ca 7.9 Mg 1.8 Ph 3.2 AP 166 Tbili 1.1 Alb 2.3 PT 12.6 PTT 36.7 INR 1.1 Brief Hospital Course: Ms. is a 62 F with history of breast cancer s/p radiation and chemotherapy, hemochromatosis, hepatic encephalopathy, s/p TIPS , hepatic hydrothorax who was transferred from an OSH for transplant evaluation.",1
"Had episode of hypoxia and hypotension in MICU, requiring intubation and pressors.",0
Now extubated and stable off pressors.,0
Currently on Vanc/Zosyn for HAP.,0
# RESPIRATORY FAILURE: On admission the patient's respiratory status was stable with O2 sats >95% on 2L NC.,1
She had a left pleural effusion and right sided effusion that was being drained by a chest tube secondary to sympathetic effusion from ascites.,1
The patient went into acute respiratory distress on the morning of secondary to hypoxia.,1
She was initially placed on a NRB without resolution and became more hypoxic to the 60-70 and tachypneic.,0
She was also hypotensive and started on levophed and given IVF.,0
She was urgently intubated for hypoxemic respiratory failure.,1
The patient was initially treated broadly with vanco/cefepime and then changed to linezolid/cefepime/flagyl given her prior history of VRE and C. diff.,0
Her CXR did not show evidence of pneumothorax.,0
"The patient underwent bronch on that showed small airways, but no evidence of infection or aspiration of foreign body.",0
The patient had been maintained on a heparin gtt for axillary DVT prior to the event making PE less likely.,0
The patient respiratory status improved and was able to be extubated on .,0
"Likely multifactorial in setting of hydrothorax, secretions placing her at risk for mucous plugging, pre-existing axillary DVT leading to PE, re-expansion edema, possibly hepatopulmonary syndrome with orthodeoxia, aspiration etc.",0
Given rapid improvement however most likely aspiration event and/or plugging.,0
"On the floor, the patient maintained a stable respiratory status.",0
"She had a L thoracentesis performed on , which drained 1.5L.",0
Chest tube was pulled on and there has been no reaccumulation of fluid.,0
The patient is currently satting 96% on RA.,0
Bronchial washings were negative for malignant cells.,0
She is being treated with Vanc/Zosyn/Levaquin for HAP - 14 day course to end .,0
"# SHOCK: The patient became hypotensive after her acute respiratory failure requiring initiation of levophed, vasopressin and neosynephrine.",1
"She was also covered with broad spectrum antibiotics including linezolid given her history of VRE, flagyl given her history of c. diff and cefepime.",0
"Her initial UA was positive, but cultures grew yeast likely colonization.",0
Her C. diff was negative.,0
The patient had an elevated WBC of 27 after her respiratory failure that resolved the following day.,1
The patient had a cortstim and did not respond appropriately.,0
She was started on stress dose sterodis.,0
An ECHO was performed and showed hyperdynamic without clear constriction from infiltration.,0
She was able to be weaned off all pressors by at midnight.,0
"She finished a 7 day course of Linezolid, Cefepime, and Flagyl.",0
She was transitioned from Hydrcortisone to oral Prednisone and started on a taper.,0
"She has maintained SBP>95 and has not had any lightheadedness, SOB, or CP.",0
Anemia: Pt with HCT 26 on admission in the setting of hypotension and shock - was transfused 3 units pRBCs in the ICU.,1
"HCT increased to the mid30s during the hospitalization - likely hemoconcentrated, as she was being aggressively diuresed.",0
"HCT decreased as diuresis has been titrated down, currently 23.6, near baseline ~25.",0
Had guaiac positive stool x2.,0
"EGD with esophagitis, colonoscopy with e/o diverticula in sigmoid.",0
Vitamin B12 and folate WNL.,0
"- continue to monitor HCT # Leukocytosis: Pt with WBC up to 27 early in admission, likely to stress dose steroids in the ICU.",0
"Resolved to 7, but the started to rise slowly.",0
"Stable at ~18 for several days, increased WBC to 28.7, now decreasing to 24.5 on discharge.",0
Pt on Vanc/Zosyn/Levaquin for HAP.,0
Pt has been afebrile and has remained hemodynamically stable.,0
"Continues to have loose stool, but Cdiff negative x5 since last treatment at OSH in ; loose stool correlates with tube feeding, added bananas to diet to help bulk stool.",0
"Attempted to obtain induced sputum, but was not able to retrieve sample.",0
"Pt has been on steroids for adrenal insufficiency, which could also be influencing the increased WBC count - currently on Hydrocortisone.",0
Pt had repeat UA/UCx and BCx sent prior to discharge.,0
"Repeat CXR with ?infiltrate vs atelectasis, but pt is already on Vanc/zosyn/Levaquin for HAP, end .",0
"Pt had video swallow eval to r/o aspiration - no overt aspiration, able to tolerate nectar thickened liquids and regular diet.",0
# Hemochromatosis: Pt with MELD score of 6.,0
She was diagnosed with hemochromatosis in and has been stable.,0
"However, her course has recently been complicated by recurrent ascites, pleural effusions and hepatic encephalopathy following TIPS procedure.",1
She has started her liver transplant eval.,0
Currently no evidence of encephalopathy or asterixis.,0
Pt required blood transfusions for oncotic pressure support in the ICU and therefore receiving futher iron load.,0
RUQ was performed that showed patent TIPS.,0
- Please start Ciprofloxacin 250mg PO daily (or 500mg PO daily if she is on continuous tube feeds) for SBP prophylaxis after she finishes the course of Vanc/Zosyn/Levquin #.,0
Axially DVT: Pt with axillary DVT at OSH.,0
She was continued on a heparin gtt and transitioned to Lovenox.,0
Repeat U/S showed resolution of clot.,0
She is on Heparin SC BID for prophylaxis (TID dosing resulted in increased PTT).,0
"# FEN: nectar thick liquids, regular solid, low Na diet, TF.",0
Medications on Admission: Omeprazole 20mg dailu Lidocaine/Maalox Albuterol neb Ipratropium neb Losderm patch docusate 100mg Heparin gtt 1400U/hr Discharge Medications: 1.,0
"Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every twelve (12) hours for 7 days.",0
Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 g Intravenous Q8H (every 8 hours) for 7 days.,0
Pantoprazole 40 mg IV Q24H 5.,0
Ondansetron 4 mg IV Q8H:PRN nausea 6.,0
"Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 (): 12 hours on, 12 hours off.",0
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day).,0
Tamoxifen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED).,0
Promethazine 6.25 mg IV Q6H:PRN nausea 16.,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical (2 times a day) as needed for itching.,0
Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)).,0
Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)).,0
Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): end .,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection (2 times a day).",0
Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough.,0
"Discharge Disposition: Extended Care Facility: Medical Center - Discharge Diagnosis: Primary Diagnosis: Hepatic hydrothorax Pneumonia Adrenal insufficiency Anemia Secondary Diagnosis: Hemochromatosis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Dear Ms. , You were admitted to the hospital with fluid in your lungs.",1
"You were intubated and in the process, one of your vocal cords was paralyzed.",0
You can follow up with ENT for further evaluation of your vocal cord.,0
"You had fluid removed from your left lung, and the chest tube that was in place on the right has been removed.",0
You are being treated with intravenous antibiotics for a pneumonia - you will need to continue these medications for 7 more days.,1
The rest of your liver transplant evaluation can be completed as an outpatient.,0
You still need to have a cardiac MRI and pulmonary function tests.,0
"Followup Instructions: MD: Specialty: Otolaryngology/ ENT Date/ Time: Tuesday, :30am Location: 2 Center Dr., MA Phone number: Please follow up with the transplant center: Provider: , MD Phone: Date/Time: 2:00 Provider: , TRANSPLANT SOCIAL WORK Date/Time: 3:00",0
5:23 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
PNA Admitting Diagnosis: MANDIBLE FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with difficulty weaning from vent REASON FOR THIS EXAMINATION: ?,1
PNA ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Questionable pneumonia.,0
"Unchanged size of the cardiac silhouette, unchanged retrocardiac atelectasis.",0
The pre-existing signs suggesting pulmonary edema are unchanged.,0
There is no evidence of newly occurred focal parenchymal opacities suggesting pneumonia.,0
Also unchanged is the extent of bilateral pleural effusions.,0
"3:51 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: infiltrate, effusion ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with AMS REASON FOR THIS EXAMINATION: infiltrate, effusion ______________________________________________________________________________ FINAL REPORT INDICATION: 77-year-old female with altered mental status.",0
Evaluate for infiltrate or effusion.,0
COMPARISON: Multiple studies including most recent of .,0
UPRIGHT AP VIEW OF THE CHEST: Lung volumes are low.,0
Heart size is not significantly changed from prior.,0
There is hilar fullness and central vascular engorgement with probable small bilateral pleural effusions suggestive of volume overload but there is no overt pulmonary edema.,0
Tortuosity of thoracic aorta otherwise unremarkable mediastinum.,0
Old left distal clavicular fracture is noted.,0
IMPRESSION: Probable trace bilateral effusions and central vascular engorgement suggestive of volume overload.,0
"6:24 AM BABYGRAM (ABD ANY SGL VIEW) () Clip # Reason: serial surveillance for concerning bowel gas pattern, R/O NE ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity REASON FOR THIS EXAMINATION: serial surveillance for concerning bowel gas pattern, R/O NEC ______________________________________________________________________________ FINAL REPORT CLINICAL DATA: 24 week premature infant, with medical necrotizing entero- colitis.",0
COMMENT: Comparison is made to a prior study from .,0
"There is improvement in the appearance of the bowel gas pattern, with resolution of the previously noted tubular featureless loops of bowel in the lower quadrants bilaterally.",0
The appearance is more normal today.,0
Kinking of the nasogastric tube within the gastric body is noted.,0
Its recommended that the tube be pulled back about 3 cm.,0
The appearances of the lungs is consistent with mild pulmonary edema superimposed on chronic lung disease.,1
12:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Evidence bleeding in abdomen?,0
Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: The findings regarding possible metastatic disease in the lumbar spine and pelvis were discussed with the patient's nurse on at 9:30 a.m. 12:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Evidence bleeding in abdomen?,1
"Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with elevated INR on warfarin, acute/chronic SDH s/p fall, falling HCT REASON FOR THIS EXAMINATION: Evidence bleeding in abdomen?",1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old woman with elevated INR, on warfarin.",0
Known acute- on-chronic subdural hematoma.,1
TECHNIQUE: Non-contrast CT of the abdomen and pelvis.,0
CT OF THE ABDOMEN: The lung bases demonstrate bilateral lower lobe atelectasis as well as small bilateral pleural effusions of simple fluid attenuation.,0
The visualized heart and pericardium are unremarkable apart from coronary artery calcifications.,1
The study is markedly limited by lack of intravenous contrast.,0
"The liver, adrenal glands, spleen, and pancreas appear unremarkable.",0
The kidneys demonstrate no hydronephrosis.,0
A punctate calcification in the right kidney may reflect a nonobstructing stone.,0
The loops of small and large bowel are normal in caliber.,0
"There is nonspecific mild mesenteric stranding, particularly in the upper abdomen.",0
The caliber of the abdominal aorta is within normal limits though it is heavily calcified in the infrarenal portion.,0
CT OF THE PELVIS: A Foley catheter is within the bladder lumen.,0
There is no evidence of retroperitoneal hematoma.,0
OSSEOUS STRUCTURES: There are extensive degenerative changes of the spine.,0
There is a patchy appearance to the iliac bones bilaterally and spine which likely reflects diffuse demineralization.,0
There is a compression deformity of T12.,0
There are multiple sclerotic foci throughout the spine.,0
No evidence of acute hemorrhage in the abdomen or pelvis.,1
Small bilateral pleural effusions with associated atelectasis.,0
Probable nonobstructing right renal stone.,0
Diffuse small sclerotic foci throughout the lumbar spine raise the possibility of metastatic disease.,0
(Over) 12:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Evidence bleeding in abdomen?,0
Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ FINAL REPORT (Cont),1
12:05 AM PORTABLE ABDOMEN Clip # Reason: Evaluate NG tube placement Admitting Diagnosis: VENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with VT s/p cardioversion with AICD REASON FOR THIS EXAMINATION: Evaluate NG tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate NG tube placement.,1
ABDOMEN: Single frontal portable supine abdomen radiograph was compared to .,0
"The NG tube tip is likely in the distal esophagus, slightly proximally displaced since prior.",0
Moderate-to-large right pleural effusion and small left pleural effusion are present.,0
NG tube tip likely in the lower esophagus.,0
Moderate-to-large right and small left pleural effusions with cardiomegaly and retrocardiac opacity.,0
"10:36 AM CHEST (PORTABLE AP) Clip # Reason: s/p rigid bronch, tumor debulking, assess for lung reexpansi Admitting Diagnosis: LEFT HEMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 80F s/p fall, with right lung whiteout, s/p chest tube placement REASON FOR THIS EXAMINATION: s/p rigid bronch, tumor debulking, assess for lung reexpansion ______________________________________________________________________________ FINAL REPORT HISTORY: An 80-year-old status post fall with right lung white out status post chest tube placement.",1
COMPARISON: This study was obtained at 11:02 hours.,0
Comparison is made to prior study of earlier the same day at 7:16.,0
FINDINGS: The right chest tube remains in place.,0
"Since the prior study, there has been resolution of the right pneumothorax with partial reexpansion of the right lung.",0
The right lower lobe remains atelectatic.,0
Right upper lobe has reexpanded.,0
"Also, noted is interval placement of an ET tube, which is 4 cm above the carina.",0
"Cardiomegaly, left pleural effusion, and compression partial atelectasis of the left lower lobe are again noted.",0
IMPRESSION: 1) Interval placement of an endotracheal.,0
2) Resolution of the right pneumothorax and reexpansion of the right upper lobe.,0
"Right lower lobe, however, remains atelectatic.",0
3) Soft tissue emphysema along the right lateral aspect of the chest.,0
9:44 AM BABYGRAM AP ABD ONLY PORT Clip # Reason: evaluate bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: bloody stool REASON FOR THIS EXAMINATION: evaluate bowel gas pattern ______________________________________________________________________________ FINAL REPORT BABYGRAM ABDOMEN AT 9:46 HISTORY: Bloody stool.,0
FINDINGS: Comparison is made to the examination of the abdomen performed .,0
The bowel gas pattern is non-obstructive.,0
There is no evidence of pneumatosis or pneumoperitoneum.,0
The lung bases show findings of chronic lung disease.,0
A nasogastric tube tip projects over the gastric bubble.,0
"8:16 PM CT HEAD W/O CONTRAST Clip # Reason: eval bleed ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with fall from 9 feet, txf osh, report of SAH REASON FOR THIS EXAMINATION: eval bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Fall from 9 feet, report of subarachnoid hemorrhage from outside hospital.",0
"TECHNIQUE: Noncontrast CT of the head was obtained, compared with the study performed at at , 17:15 PM.",0
This exam was not seen by the cosigning attending.,0
"FINDINGS: There is slight thickening of the tentorium on the left, which probably represents a small peritentorial subdural hematoma.",0
No other evidence of hemorrhage is seen.,0
There is no shift of normally midline structures or mass effect.,0
Extra- axial spaces and ventricles appear age appropriate.,0
No significant soft tissue abnormalities are appreciated.,0
Periapical lucency is seen along the left superior alveolar plate at the left first upper molar.,0
IMPRESSION: Slightly thickened appearance of the tentorium on the left probably represents a small peritentorial subdural hematoma.,0
This appears unchanged since the prior CT from .,0
No subarachnoid hemorrhage is identified.,0
Note that this examination is slightly motion limited.,0
"4:09 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for interval development of pulm edema, infilt Admitting Diagnosis: GASTROINTESTINAL BLEED;DUODENAL ULCER;DOWN SYNDOME;URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 49F tetralogy fallot, Massive GI bleed, intubated for airway, has central line.",1
"s/p aggressive colloid and IVF REASON FOR THIS EXAMINATION: Please assess for interval development of pulm edema, infiltrates ______________________________________________________________________________ FINAL REPORT HISTORY: Status post GI bleed with aggressive fluid resuscitation.",0
"Since the prior study, there has been an increase in bilateral pleural effusions, right slightly greater than left.",0
There is dense focal opacity behind the left side of the heart consistent with atelectasis or infiltrate.,0
Tip of the endotracheal tube is approximately 11 mm above the carina and could be pulled back 1-2 cm.,0
Tip of the NG tube is in the stomach and tip of the right IJ line is in the junction of the SVC and right atrium.,0
Tip of the endotracheal tube could be pulled back 1-2 cm.,0
Left lower lobe opacity consistent with atelectasis or infiltrate.,0
"8:29 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with COPD, PNA REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: COPD, assessment for interval change.",0
"FINDINGS: As compared to the previous examination, the transparency of the right basal lung parenchyma has increased, the extent of right-sided pleural effusion has decreased.",1
"The radiographic appearance of the left basal lung, with pleural effusion and subsequent atelectasis is unchanged.",1
Also unchanged is the size of the cardiac silhouette.,0
No evidence of newly appeared parenchymal opacity suggestive of pneumonia.,0
Unchanged position of the right-sided central venous access line.,0
"6:03 PM CHEST (PA & LAT) Clip # Reason: pls eval ro acute proc ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with fever, cough REASON FOR THIS EXAMINATION: pls eval ro acute proc ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON Comparison with a CT chest from as well as a chest radiograph from .",0
"HISTORY: Fever and cough, question acute process.",0
FINDINGS: AP upright and lateral views of the chest were obtained.,0
A dialysis catheter is in unchanged position with tip located in the expected location of the distal superior vena cava.,0
"There is no significant change from the recent CT with persistent bilateral pleural effusions, left greater than right and left lower lobe consolidation which could represent compressive atelectasis versus pneumonia.",1
The mid and upper lungs remain well aerated.,0
Cardiomediastinal silhouette appears grossly stable.,0
"IMPRESSION: Stable bilateral pleural effusions with left lower lobe consolidation likely compressive atelectasis, though cannot exclude pneumonia.",1
3:54 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT COMPARISON: None.,0
CLINICAL HISTORY: Status post hit by train.,0
FINDINGS: Portable supine chest and pelvis radiograph obtained.,0
Underlying trauma board limits evaluation.,0
"The lungs are poorly ventilated though no definite airspace consolidation, effusion, or pneumothorax is seen.",0
Heart size cannot be assessed due to supine technique.,0
Bony structures appear grossly intact.,0
PELVIS: There is marked distraction of the pubic symphysis measuring approximately 4.3 cm.,0
Right sacroiliac joint widening is better assessed on subsequent CT torso.,0
"Also, right sacral alar fracture is suboptimally assessed due to external overlapping structures.",0
Please refer to subsequently performed CT torso for additional details.,0
Marked diastasis of the pubic symphysis with right sacral ala fracture and apparent widening of the right SI joint.,0
Findings are better appreciated on CT torso performed subsequently.,0
"3:25 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for pulmonary emboli Admitting Diagnosis: STERNAL WOUND INFECTION Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man s/p mvr/cabg now with increasing hypoxia and hyotensive REASON FOR THIS EXAMINATION: eval for pulmonary emboli No contraindications for IV contrast ______________________________________________________________________________ WET READ: MPtb MON 4:38 AM No pulmonary embolism.",1
Bilateral pleural effusions and dependent atelectasis.,0
Discussed with Dr. at 4:30AM .,0
"MPOWELL ______________________________________________________________________________ FINAL REPORT HISTORY: 83-year-old male status post coronary artery bypass graft, presenting with increasing hypoxia and hypotension for evaluation of pulmonary embolism.",0
"TECHNIQUE: CT of the chest was performed pre- and post-administration of intravenous contrast, reconstructions were performed in the axial, sagittal, and coronal planes.",0
COMPARISON: With examination of .,0
FINDINGS: CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There has been an interval increase in the bibasilar effusions and pulmonary vascular congestion since the prior examination.,0
There are ill-defined patchy opacities present in both lungs which may represent a combination of fluid overload and infection.,0
There has been an interval increase in the bibasilar effusions and atelectasis of the lower lobes.,0
There is a new consolidative opacity in the right middle lobe.,0
There is a small pericardial effusion present.,0
There are stable scattered mediastinal lymph nodes with the largest measuring 14.1 x 14.1 mm in a pretracheal location.,0
Extensive atherosclerosis is present in the coronary arteries.,0
The coronary arteries arise from the normal expected anatomical location.,0
There is no pulmonary embolism or aortic dissection.,0
"The endotracheal tube, NG tube, and central venous line are seen in situ.",0
The central venous line ends in the SVC.,0
The endotracheal tube and NG tube are in satisfactory locations.,0
Evidence of prior granulomatous disease is noted.,0
"(Over) 3:25 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for pulmonary emboli Admitting Diagnosis: STERNAL WOUND INFECTION Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) MUSCULOSKELETAL: There has been a recent sternotomy and there are multiple sternal fixators noted.",1
"There is a linear soft tissue density present in the subcutaneous tissues of the left chest, this may represent sequelae of recent surgical intervention or a chest drain on this side.",0
There is wedge compression of the T11 veretbral body.,0
Increased bibasal effusions along with infiltrates / atelectasis of the lower lobes and ill-defined patchy infiltrates in other lobes as well bilaterally.,0
No convincing evidence of a pulmonary embolism or aortic dissection.,0
Moderate centrilobular emphysema and evidence of prior granulomatous disease.,0
"6:46 PM PORTABLE ABDOMEN Clip # Reason: Verify UAC/UVC placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematruity, RDS REASON FOR THIS EXAMINATION: Verify UAC/UVC placement ______________________________________________________________________________ FINAL REPORT INDICATION: NEWBORN PREMATURE TWIN AT 27 WEEKS.",0
"Since the prior film, the UAC and UVC have been pulled back and are now in satisfactory position with the UVC in the right atrium and the UAC projected at T7-8.",0
"8:45 AM CHEST (PORTABLE AP) Clip # Reason: assess effusion and rt sided markings Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p CABG, s/p AICD, with AV endocarditis, ao root abscess REASON FOR THIS EXAMINATION: assess effusion and rt sided markings ______________________________________________________________________________ FINAL REPORT REASON FOR THE EXAMINATION: Assessment for effusion and right-sided marking.",0
This patient is status post CABG and AICD placement and aortic valve endocarditis and root abscess.,0
This study was done for assessment of effusion.,0
"TECHNIQUE: AP Chest, compared to .",0
FINDINGS: A moderate left pleural effusion is stable while a small to moderate right pleural effusion has increased .,0
"Mediastinal widening to the right of midline in the region of the ascending aorta, is stable in comparison to , but significantly enlarged compared to , due to hematoma or other mediastinal fluid collection, or acute aortic dilatation or pseudoaneurysm.",1
The position of the prosthetic aortic valve is unchanged.,0
The tip of a right internal jugular catheter sheath projects over thoracic inlet.,0
The feeding orogastric tube passes into the stomach and out of view.,0
Bilateral basilar opacification of the lungs consistent with atelectasis.,0
IMPRESSION: Stable moderate left pleural effusion.,0
Mild-to-moderate right pleural effusion is increased.,0
"Recently developed mediastinal hematoma, fluid loculation, aortic dilatation, or pseudoaneurysm.",0
"5:25 AM CHEST (PORTABLE AP) Clip # Reason: progression of lung disease Admitting Diagnosis: HYPERKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with wegener's granulomatous now with worsening renal function REASON FOR THIS EXAMINATION: progression of lung disease ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 1:38 PM Overall, no significant change from the study of .",1
______________________________________________________________________________ FINAL REPORT STUDY: Portable upright AP chest radiograph.,0
HISTORY: 60-year-old man with Wegener's granulomatosis and new worsening renal function.,1
Question progression of lung disease.,0
COMPARISON: Comparison is made to chest radiograph from and CT of the chest from .,0
"FINDINGS: Overall, there is no significant change compared to the study from .",0
"There are moderate, bilateral pleural effusions.",0
"These are new since , though unchanged from .",0
There are unchanged bilateral mid lung opacities and a focus of right apical fibrosis.,0
There are diffusely prominent interstitial markings.,0
The cardiomediastinal contour is unremarkable.,0
IMPRESSION: Unchanged bilateral pleural effusions and mid-lung zone consolidations.,0
3:34 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: ability to swallow Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with dysphagia REASON FOR THIS EXAMINATION: ability to swallow ______________________________________________________________________________ FINAL REPORT HISTORY: 85-year-old male with dementia with history of aspiration and choking while swallowing.,1
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with speech and swallow division.,0
FINDINGS: Patient aspirated thin liquids and nectar-thickened liquids.,0
Penetration was seen while swallowing honey-thick liquids.,0
"With puree and solids, there is no gross aspiration or penetration.",0
The multiple consistencies of barium passed freely through the oropharynx without evidence of obstruction.,0
"For more details, please refer to the speech and swallow division note in OMR.",0
IMPRESSION: Abnormal oropharyngeal swallowing videofluoroscopy with aspiration of thin liquids and nectar-thickened liquids.,0
There was penetration of honey-thickened liquids.,0
Patient was able to swallow puree and soft solids without aspiration or penetration.,0
"9:25 AM CHEST (PA & LAT) Clip # Reason: please evaluate for change Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with PNA, prior CXR recommended repeat to evaluate bases REASON FOR THIS EXAMINATION: please evaluate for change ______________________________________________________________________________ FINAL REPORT INDICATION: Diastolic heart failure admitted with pneumonia, evaluate change.",1
COMPARISON: at 0508 hours and .,0
FINDINGS: Frontal and lateral views of the chest again demonstrate bilateral consolidations consistent with multifocal pneumonia.,0
"Within the largest consolidation of the left lower lobe there is a suggestion of cavity formation demonstrated by a rounded opacification with lucent center, follow up is recommended.",0
"Compared to prior, there has been a decrease in the degree of opacification suggesting interval diuresis of pulmonary edema.",0
There is no pneumothorax or new consolidation.,0
IMPRESSION: Persistent bilateral multifocal pneumonia with interval improvement of pulmonary edema.,0
Close attention on follow up should be paid to the left lower lobe consolidation for evaluation of cavity formation.,0
10:37 AM CHEST (PORTABLE AP) Clip # Reason: s/p CT d/c Admitting Diagnosis: MITRAL DISORDER\MITRAL VALVE REPLACEMENT ?,1
CORONARY ARTERY BYPASS GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with s/p MV repair REASON FOR THIS EXAMINATION: s/p CT d/c ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair and discontinuation of the chest tube.,1
Portable AP chest radiograph was compared to obtained at 06:12 a.m.,0
The Swan-Ganz catheter was removed.,0
The replaced valve is in place.,0
"There is minimal apical pneumothorax that can be retrospectively seen on the prior study, on the right, and appears to be slightly decreased since the prior study.",0
Attention with subsequent radiograph is recommended.,0
"Left basal opacity is unchanged, consistent with atelectasis.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old female with a history of breast cancer with known brain mets, history of PE, recent radiation therapy and steroids who presented in with myopathy presumed secondary to sterids, which have been given for her brain mets.",1
"She was later sent to rehab, but returned early in with increased cough with exertion with fever to 101.",0
"She was treated with Levaquin given her temperatures and differential diagnosis of increased PE burden load, infections or pneumonia and questionable lymphangitic spread of her cancer.",1
The patient did not experience improvement in her symptoms and was readmitted on with continued dyspnea and fevers.,0
"Review of CTA showed no PE, but there was ground glass opacities on CT, so PCP was considered highly unlikely given her recent history of steroid use.",0
Her induced sputum was negative and BOL was done and also negative.,0
She was given Bactrim and she had improvement in the shortness of breath after her Bactrim was started and improved room air sats and was sent home on Bactrim.,0
She then continued to do poorly and then returned on .,0
She presented on clinic on with hypotension for which she was given intravenous fluids.,0
She spiked a fever to 103 with blood pressures hypertensive into the systolic 80s and with rigors.,0
Chest x-ray showed a question of left lung opacity.,0
The patient was given Vancomycin and a gram of intravenous fluids.,0
"Today, the patient was found in the bathroom and became hypoxic with saturations in the 80s and was responsive to oxygen, but was still tachypneic without improvement and was placed on nonrebreather.",0
Currently the patient is admitted to the Intensive Care Unit for further medical care.,0
Currently the patient is short of breath without chest pain or dysphagia.,0
Breast cancer left side diagnosed in status post mastectomy with 5 out of 9 positive lymph nodes.,1
She was treated with chemotherapy and bone marrow transplant and then later with Tamoxifen from to .,0
In she had mediastinal lymphadenopathy treated with Taxol and changed to Navelbine on .,0
"She had diagnosed brain mets in right side cerebella and parietal for which she was treated with chemotherapy, radiation therapy and Decadron.",0
History of pulmonary embolism in treated with only aspirin secondary to brain mets.,1
Protonix 40 mg q day.,0
SOCIAL HISTORY: She is an emergency room physician at the .,0
She is married with three children.,0
"PHYSICAL EXAMINATION: On examination on transfer to the Intensive Care Unit she is febrile with a low grade temperature of 100.1, tachycardic to 110, hypotensive 85/49, tachypneic into the 50s and 60s, 95% on nonrebreather.",0
"In general, she is extremely tachypneic, difficulty in speaking words.",0
"Her heart is regular without murmurs, rubs or gallops, slightly tachycardic.",0
Her pulmonary examination shows she has bronchial breath sounds with dry crackles at the bases.,0
"Extremities no clubbing, cyanosis or edema.",0
She is alert and following commands.,0
"LABORATORY: White blood cell count 3.2, hematocrit 26.6, platelets 130, chemistry is 131, potassium 3.0, chloride 105, bicarb 17, BUN 10, creatinine 0.5, glucose 105.",0
"Calcium 7.3, phos 1.8, magnesium 1.5.",0
"She had a gas showing 7.36, 31, 96.",0
She had a CT from the 29th of her abdomen and pelvis showing marked increased consolidations at the left lung base and question of new left sided pleural effusion.,0
Pulmonary: The patient was transferred to the Intensive Care Unit for respiratory distress and febrile hypotension with a question of a new infiltrate on her chest x-ray.,0
The exact etiology of the patient's respiratory distress was presumed to be questionable multifactorial.,0
There was concern about possible pneumonia.,0
Also she had a history of PE and also there was concern about possible lymphangitic spread of her breast CA.,0
"Given her fevers and shortness of breath the patient was treated with broad spectrum antibiotics initially started on Ceptaz, Levaquin and __________ and Clindamycin.",0
Lab two antibiotics were added considering the patient was thought to be a relatively high risk for PCP .,0
"The patient was initially trialed on BiPAP, but the patient was increasingly dyspneic, increased respiratory stress and ultimately needed to be intubated on .",0
"Earlier during her Intensive Care Unit course she underwent bronchoscopy, which was sent for cytology and multiple bacterial pathogens all of which were negative.",0
Ultimately her Intensive Care Unit course continued and she began to defervesce and her bacterial studies particulaly from BAL lavage were found to be negative.,0
The patient had multiple antibiotics withdrawn.,0
Clindamycin and _______________ was discontinued early in hospital course.,0
Her PCP was thought to be negative.,0
"In addition, Vancomycin, Levaquin were also discontinued.",0
She was later continued on Ceftazidine and Clindamycin for possible gram negative infection and also for possible post obstructive picture that she would be at risk for given her pulmonary anatomy.,0
As the hospital course went on the patient's respiratory did not show mild improvement on the ventilator.,0
She was able to oxygenate originally.,0
Unfortunately her mental status failed to improve despite having been off all sedative medications for several days.,0
Later in her Intensive Care Unit course family meetings took place and given the patient's overall poor prognosis with decreased mental status it was decided that the patient would become CMO.,0
Subsequently she was extubated on .,0
The patient continues to actually ventilate well off of the respiratory.,0
"However, she is CMO and will not be intubated for respiratory distress.",0
"Cardiovascular: The patient was initially transferred to the Intensive Care Unit thought to be exhibiting septic physiology, respiratory distress and hypotensive.",0
She required aggressive intravenous fluids and later required pressor support with neo-synephrine.,0
Later during her Intensive Care Unit course she was felt to be somewhat overloaded and intravenous fluids were cut back.,0
It was quite difficult weaning her off of neo-synephrine.,0
She was also given stress dose steroids.,0
Later in her hospital course she also had an echocardiogram for question of new ECG findings in her inferior leads.,0
"Her echocardiogram, however, was essentially normal with an ejection fraction of 55% without any gross wall motion abnormalities or valvular pathology.",0
As mentioned above the patient's hemodynamic status was tenuous throughout her hospital course as it was difficult to wean the patient off of neo-synephrine.,0
"By , however, the patient had been off of neo-synephrine, but at this time as mentioned above the patient was deemed to be CMO per discussion with physicians and her husband/health care proxy.",0
Hematology: Patient with a history of known malignancy and also a history of pulmonary embolisms from .,0
Earlier in her Intensive Care Unit course the team was concerned about possible pulmonary embolisms as a possible source of the patient's respiratory decompensation.,0
"However, the patient also had brain metastasis and at this point anticoagulation was thought to be a contraindication given risk for hemorrhage into these tumors.",0
"She did have lower extremity doppler ultrasounds, which were negative.",0
"Infectious disease: As mentioned above patient initially hypotension, febrile and in respiratory distress presumed to be septic source likely pulmonary.",0
"Initially the patient was treated with broad spectrum antibiotics including Vancomycin, Ceptaz, Levaquin, Clindamycin and _________.",0
All of her cultures are negative to date.,0
She was negative for PCP and subsequently _____________ was continued and Clindamycin was changed for anaerobic coverage.,0
In addition her Vancomycin and Levaquin were also discontinued.,0
The patient remained afebrile during the majority of her hospital course.,0
By virtue of discussions on the patient was deemed to be CMO and all antibiotics were withdrawn at this point.,0
"Gastroenterology: The patient had an abdominal CT earlier in her Intensive Care Unit course, which was essentially negative for an intraabdominal pathology.",0
"She was initially supported with tube feeds during her Intensive Care Unit course, but at this point the patient is CMO and tube feeds have been subsequently discontinued.",0
DISPOSITION: The patient's attending physician was in constant communication with the health care proxy her husband.,0
"As her Intensive Care Unit course continued and the patient showed minimal signs of meaningful improvement, continued discussions were had with the family about possibly changing code status.",0
"Ultimately it was decided by that the patient had shown minimal improvement and minimal evidence of improvement status, it was decided at this point for the patient to be extubated and to move toward CMO care.",0
"Subsequently all antibiotics, blood draws and supportive blood pressure medications were withdrawn.",0
Currently she is comfortable with morphine and Ativan prn.,0
Currently plans are in the making for arranging for the patient to have home hospice care.,0
Please see discharge addendum for further developments in the patient's care.,0
Metastatic breast cancer end stage.,0
"Respiratory failure unclear etiology, presumed secondary to possible pneumonia, questionable lymphangitic spread.",1
Albuterol and Atrovent nebs prn.,0
Dictated By: MEDQUIST36 D: 01:15 T: 05:47 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: Neonatology HISTORY: Baby Girl is a 37-6/7 weeks female infant born by spontaneous vaginal delivery to a 31-year-old gravida 1, para 0, now one woman.",0
"Prenatal screens: Blood type B positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta Strep positive.",0
Labor was induced with Cytotec and Augmentin with pitocin after spontaneous rupture of membranes 22.5 hours prior to delivery.,0
Maternal interpartum temperature spiked to 101.3.,0
Mother received antibiotics beginning 10 hours prior to delivery.,0
There was persistent fetal tachycardia present (greater than three hours) with a fetal heart rate in the 170s and 180s.,0
The Newborn Intensive Care Unit team was in attendance at the delivery at the request of Obstetrics.,0
The infant emerged with decreased tone and without spontaneous respiratory effort.,0
"She was dried, bulb suctioned, and given positive pressure ventilation for 30 seconds with excellent response.",0
Heart rate is always greater than 80.,0
Apgars were six at one minute of age and eight at five minutes of age.,0
The infant was admitted to the Newborn Intensive Care Unit for evaluation for sepsis.,0
"PHYSICAL EXAM ON ADMISSION: Birth weight 3,625 grams (greater than 90th percentile), length 51.5 (90th percentile), head circumference 34.5 cm (75th-90th percentile).",0
Infant vigorous nondysmorphic term appearing female infant.,0
"Anterior fontanel is open and flat, mild caput, positive bilateral red reflex, lips, gums, and palate intact, neck is supple and without masses, clavicles intact.",0
"Heart: Regular, rate, and rhythm, no murmur.",0
"Pink and well perfused, +2 femoral pulses.",0
Abdomen is soft and nontender and without masses.,0
"Three vessel umbilical cord, liver edge at right costal margin.",0
"Respiratory: Shortly after admission to the Newborn Intensive Care Unit, the infant was noted to have several desaturations to the 80s associated with a color change requiring nasal cannula oxygen for the first 24 hours of age and then weaned on room air on day of life two without further desaturations.",0
She is currently on room air with O2 saturations greater than 95%.,0
Cardiovascular: A murmur was noted shortly after admission to the Newborn Intensive Care Unit.,0
An echocardiogram on revealed a small muscular VSD.,0
Her blood pressure has been stable throughout her NICU course not requiring any fluid boluses or pressors.,0
"Fluids, electrolytes, and nutrition: Hypoglycemic episodes within first 24 hours of age with several D sticks in the 30-40 range requiring two boluses of D10W and initiation of IV fluids.",0
"Intravenous fluids were successfully weaned on , and infant maintaining blood glucose in 70 range.",0
Infant breast and bottle feeding well.,0
"Discharge weight is 3,580 grams, discharge length 51.5 cm, discharge head circumference 34.5 cm.",0
GI: Total bilirubin on day of life one was 5.7 with a direct bilirubin of 0.2.,0
Heme: Hematocrit upon admission was 54.1.,0
The infant did not receive any blood products in the Newborn Intensive Care Unit.,0
"ID: Upon admission to the Newborn Intensive Care Unit, a complete blood count with differential and a blood culture was drawn.",0
"Complete blood count revealed a white count of 27,000, hematocrit of 54, platelet count of 288,000 with 67% neutrophils, and 1% bands.",0
The blood culture was negative at 48 hours of age.,0
The infant received 48 hours of ampicillin and gentamicin.,0
Neurology: Head ultrasound not indicated.,0
The infant did not pass in either ear both right and left ears were deferred.,0
Follow up testing is recommended with the Department of Public Health.,0
The parents received information regarding locations available for resting.,0
Psychosocial: Social Work has been involved with the family.,0
The contact social worker can be reached at .,0
"CONDITION ON DISCHARGE: Infant stable, feeding well, resolved hypoglycemia, resolved oxygen requirement.",1
DISCHARGE DISPOSITION: To home with parents.,0
"NAME OF PRIMARY PEDIATRICIAN: Dr. of , phone #.",0
CARE RECOMMENDATIONS: Feeds at discharge: Breast or bottle feeding.,0
CAR SEAT POSITION SCREENING: Not indicated.,0
STATE NEWBORN SCREEN: The first newborn screening will be drawn at 72 hours of age on .,0
"IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) with chronic lung disease.",0
FOLLOW-UP APPOINTMENT: Follow up with Cardiology at recommended for muscular VSD and follow up for hearing screen at Department for Public Health recommended.,0
Dictated By: MEDQUIST36 D: 01:58 T: 06:20 JOB#:,0
"9:02 AM MRI PELVIS W/O CONTRAST; -52 REDUCED SERVICES Clip # Reason: evaluate soft tissues around osteomyelitis Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with osteomyelitis of the lumbar-sacral spine and psoas muscle abscesses REASON FOR THIS EXAMINATION: evaluate soft tissues around osteomyelitis No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 89-year-old with prior lumbar discitis osteomyelitis, now with fevers of unknown origin, question abscess.",1
COMPARISONS: CT abdomen/pelvis of .,0
"TECHNIQUE: Due to patient discomfort, the patient could not tolerate more than the coronal T1 and STIR sequences.",0
the latter very motion limited.,0
"FINDINGS: Very limited study, terminated before completion per patient request due to extreme discomfort and agitation.",0
Coronal T1- weighted images demonstrate avascular necrosis in both femoral heads with edema throughout the right femoral neck and extensive osteoarthritic changes involving both hips.,0
"There is destruction at L2-3, the site of prior discitis osteomyelitis.",0
A motion limited coronal STIR sequence was obtained which in addition to the femoral head shows edema tracking throughout the adductor muscles bilaterally and extensive subcutaneous edema about the thighs bilaterally.,0
Coronal STIR sequence does not image the L2-3 spinal level to assess for active edema or inflammation.,0
The images are essentially nondiagnostic in evaluating the pelvic viscera and osseous structures to a better extent.,1
IMPRESSION: 1) Severely limited study for reasons stated above.,0
2) Bilateral femoral avascular necrosis with severe underlying osteoarthritis.,0
3) Prominent bilateral subcutaneous edema and edema tracking along the adductor musculature bilaterally.,0
4) Study not of diagnostic quality to assess the psoas muscles or exclude deep abscess.,0
"11:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: trach tube placement, after removal by pt Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach REASON FOR THIS EXAMINATION: trach tube placement, after removal by pt ______________________________________________________________________________ FINAL REPORT INDICATION: Supraglottic squamous cell carcinoma, pneumonia, status post trach tube placement after removal by patient.",1
"COMPARISON: AP semi-upright view of the chest from 5:50, the same day.",0
"UPRIGHT AP VIEW OF THE CHEST: Tracheostomy tube is present with tip in standard position, 7.3 cm from the carina.",0
Study is limited by respiratory motion artifact.,0
"Allowing for this, the diffuse opacity involving the right lung has progressed, appearing more consolidative in nature, with increased loss of aeration.",0
A large right pleural effusion has also increased in the interval.,1
Continued heterogeneous opacity primarily involving the left upper and mid lung is not significantly changed in the interval.,0
Small left pleural effusion is likely present.,1
Standard positioning of tracheostomy tube.,0
Worsening diffuse opacification of the right lung with increased size of large right pleural effusion.,1
Unchanged heterogeneous opacity in the left upper and mid lung and small left pleural effusion.,1
8:06 AM CT L-SPINE W/O CONTRAST Clip # Reason: eval for injury Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man s/p trauma REASON FOR THIS EXAMINATION: eval for injury No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc SAT 3:30 PM No evidence of fracture or malalignment alignment.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 21-year-old male status post trauma, evaluate for injury.",0
TECHNIQUE: Contiguous axial images of the lumbar spine were obtained without IV contrast.,0
FINDINGS: Lumbar lordosis is preserved.,0
There is no fracture or malalignment.,0
The spinal canal appears grossly patent without evidence for an epidural hematoma.,0
"Limited views of the abdomen reveal periportal edema, likely related to IV fluid hydration.",0
"Otherwise, limited views are unremarkable.",0
IMPRESSION: No fracture or malalignment.,0
12:14 AM CHEST (PORTABLE AP) Clip # Reason: check tube placement ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man s/p cardiac arrest REASON FOR THIS EXAMINATION: check tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post cardiac arrest.,0
"SUPINE AP CHEST: An endotracheal tube is in place, with the tip approximately 3.1 cm from the carina.",0
A trauma board obscures detail.,0
"There is a nasogastric tube in place, with the tip overlying the stomach.",0
The right lateral chest is excluded from the image.,1
Right lateral chest was excluded from the image.,1
A repeat radiograph was obtained.,0
"3:02 PM CHEST (PORTABLE AP) Clip # Reason: s/p R IJ PA cath, r/o ptx, eval positionUPRIGHT CXR PLEASE Admitting Diagnosis: ABDOMINAL PAIN;STENT PLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with S/P SUBTOTAL COLECTOMY REASON FOR THIS EXAMINATION: s/p R IJ PA cath, r/o ptx, eval positionUPRIGHT CXR PLEASE ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM.",0
History of subtotal colectomy with Swan-Ganz catheter placement.,0
Endotracheal tube is approximately 2 cm above the carina.,0
Tip of Swan-Ganz catheter is in right main pulmonary artery.,0
"There is subsegmental atelectasis at the right lung base, new since the prior study of .",0
"Correlate clinically and with further follow-up, if indicated, to re-evaluate for evolving consolidation in this region.",0
IMPRESSION: Right basilar atelectasis and/or evolving consolidation.,0
9:40 AM BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # Reason: following contrast from UGI.,0
"Need exam @ 4am ______________________________________________________________________________ MEDICAL CONDITION: Infant with BILIOUS SPITTING, ABDOMINAL DISTENSION REASON FOR THIS EXAMINATION: following contrast from UGI.",0
Need exam @ 4am ______________________________________________________________________________ FINAL REPORT INDICATION: Infant with bilious spitting.,0
Please perform study following upper GI series.,0
FINDINGS: This film was made available for interpretation on .,0
"Single frontal portable view of the abdomen demonstrates barium within the descending colon and rectum, suggesting no evidence of focal bowel obstruction.",0
Upper GI series was performed at on .,0
"Several uniformly distened gas-filled loops of bowel are seen throughout the abdomen, without evidence for a focal obstruction.",0
NG tube tip terminates in the expected location of the stomach.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Bactrim Attending: Chief Complaint: transfer from micu for altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is a 45 year-old male with history of HIV/AIDS( CD4 53, VL < 50), HCC (w/ cirrhosis) who was found to have mental status changes after taking tincture of opium.",1
"The patient says he has had diarrhea for 2 years, but has been worse over past couple of days.",0
"Usually this is relieved with loperamide, though over last 2 days diarrhea worse and took opium.",0
The morning of the admission the patient took an unknown amount of opium and mother noted patient was somnolent and difficult to arouse.,0
"The patient said with the recent diarrhea he had some abdominal pain, nausea, fever to 101 and some streaks of blood in his stool.",0
Based on his somnolence he was brought to ED.,0
"In the ED, patient received naloxone 0.8mg with intermittent improvement in mental status followed by relapse to original state.",0
He also complained of headache at this time.,0
"Due to headache and concern for meningitis, patient received head CT and also 1 dose of acyclovir, ceftriaxone, and vancomycin.",0
Blood cultures were sent prior to this.,0
He was also given lactulose for possible hepatic encephalopathy.,0
"Due to concern for naloxone requirement and periods of apnea, patient was transferred to MICU for further respiratory monitoring.",0
"His micu course was uncomplicated, he had some meds (trazodone, mirtazapine, percocet and clonazepam) held to prevent further somnolene and he was given lactulose for high ammonia.",0
"Initially treated for presumed meningitis given fevers, given ceftriaxone, azithromycin and vancomycin His mental status improved and he was transferred to medicine.",0
"Currently patient feels well, had formed, non-bloody stool today.",0
"AIDS by CD4 (CD4 128, HIV VL<50, , on abacavir, atazanavir, lamivudine, reports missing 1 dose/week typically) 2.",0
HCV (Genotype hybrid) not currently treated due to his polysubstance abuse and depression.,0
Invasive Anal Carcinoma treated with chemo/XRT; recent high grade lesion found and treated; followed in Anal dysplasia clinic 4.,0
"Substance abuse, cocaine and ETOH 5.",0
"L arm amputee secondary to compression injury and ischemia after drug overdose, 6.",0
Depression with multiple suicide attempts 7.,0
Bone marrow toxicity secondary to Bactrim/AZT 8.,0
MRSA scrotal abscess x2 .,0
"COPD (FEV1 83% of predicted on ) 12. erosive gastritis on EGD, 14. s/p multiple sexual and physical trauma Social History: lives alone, social support from mother in .",0
"h/o polysubstance abuse, although denies current drug use or EtOH use, 10 pack year smoking hx, Pt has been in multiple fights, where he has been severely beaten and injured.",0
The patient dropped out of high school while in the tenth grade secondary to being bullied on the basis of being gay.,0
He later obtained his GED.,0
"Family History: -His family psychiatric history is significant for his mother diagnosed with depression and alcoholism, currently in remission, -His biological father has a history of depression.",1
-His sister died at the age of 24 in a fire while intoxicated with alcohol.,0
-His brother was addicted to heroin and prescription opioids and he had died from an overdose.,0
"Physical Exam: Vitals: BP: 103/59, P 94, T 98.6, 98%RA, RR 15 GEN: sitting in bed, NAD, pleasant male HEENT: EOMI, sclera anicteric, no mucosal ulcerations of thrush, MM slightly dry COR: regular rhythm, no M/G/R PULM: slight crackles at bases bilateral ABD: Soft, mildly distended, non-tender, +BS EXT: No cyanosis, clubbing or edema, warm, well-perfused, +2 DP pulses, LUE amputation at forearm.",0
"NEURO: aaox3, conversant, appropriate, cn intact, strength intact, non-focal exam Pertinent Results: 11:43PM GLUCOSE-123* UREA N-25* CREAT-1.3* SODIUM-133 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-13 06:12PM AMMONIA-83* 05:25PM GLUCOSE-125* UREA N-26* CREAT-1.3* SODIUM-136 POTASSIUM-5.6* CHLORIDE-109* TOTAL CO2-20* ANION GAP-13 05:25PM WBC-5.4 RBC-3.78* HGB-13.5* HCT-41.4 MCV-110*# MCH-35.7* MCHC-32.6 RDW-16.2* .",0
"ct head: IMPRESSION: No acute intracranial pathology, including no sign of intracranial hemorrhage .",0
cxr: FINDINGS: Single frontal view of the chest demonstrates normal heart size and mediastinal contours.,0
There are linear markings at the left base consistent with scar or small areas of atelectasis.,0
"There is no parenchymal consolidation, pleural effusion, or pneumothorax.",0
IMPRESSION: Left basilar atelectasis or scar .,0
doppler abd: IMPRESSION: 1) Heterogeneous cirrhotic appearing liver normal Doppler waveforms and no focal lesions.,0
3) Trace amount of ascites insufficient for paracentesis.,0
Brief Hospital Course: 45 y.o.,0
"male with history of AIDS, HCV cirrhosis, polysubstance abuse, diarrhea, admitted for mental status changes and respiratory monitoring.",1
"His micu course was uncomplicated, he had some meds (trazodone, mirtazapine, percocet and clonazepam) held to prevent further somnolence and he was given lactulose for high ammonia.",0
"Initially treated for presumed meningitis given fevers, he was given ceftriaxone, azithromycin and vancomycin.",0
His mental status improved and he was transferred to medicine.,0
"#) Mental status changes - The patient's mental status changes were likely related to his overdose of opium, as his mental status improved through his course.",1
"Given his elevated ammonia a concern for encephalopathy was raised, but this was unlikely.",0
"Given this concern the patient was initially treated with lactulose, and rifaximin.",0
"With the history of fever and headache in ED, he was initially treated for meningitis, though on the floor he was afebrile with no meningismus, so concern for meningitis was low and he was not treated any further.",0
"On the floor, his mental status improved and this was again related to opium overdose.",1
Given this his lactulose and rifaximin were stopped.,0
"He was doing well prior to discharge, and as blood cultures were sent in the ED, and should be followed as an outpatient.",0
"#) Cirrhosis: The patient had improved mental status on the floor, and while he had elevated ammonia it was unlikley he had encephalopathy, so his lactulose and rifaximin (given in the ED and MICU) were stopped.",0
"He did not appear to have a large amount of ascites, though given his delicate fluid balance he had an US which showed minimal ascites.",0
"As he had Acute renal failure, his lasix and spironolactone were held, and his fluid balance was closely followed.",1
"His renal function improved prior to discharge, so to prevent fluid overload his diuretics were restarted at a lower dose, and he will be followed closely by ID and the coinfection clinic as an outpatient, so he is maintained on the appropriate dose of diuretics to prevent reacummulation of ascites.",0
"#) HIV - The patient is followed by Dr. , and he is on appropriate medications.",0
"He was followed by ID and was continued on PCP and MAC prophylaxis with and azithromycin respectively, and also continued on his antiretroviral regimen (Emtricitabine, tenofovir, abacavir, ritonavir, atazanavir).",0
He will be closely followed by ID and the coinfection clinic as an outpatient.,0
"#) Diarrhea - The patient has chronic diarrhea, and the acute worsening was likely due to the lactulose he was given.",1
"ID did not feel this was infectious, though stool cultures were sent and should be followed as an outpatient.",0
"With the discontinuation of his lactulose and rifaximin, and with starting imodium, the patient's diarrhea improved and he was at baseline for discharge.",0
#) Chronic thrombocytopenia: The patient has a history of bone marrow toxicity secondary to Bactrim/AZT.,1
His thrombocytopenia appears stable during this admission and was not an active issue.,0
"#) Acute renal failure - The patient has a baseline creatinine that appears to be around 0.9-1.0, and this was elevated to 1.3.",1
This was likely due to dehydration in setting of diarrhea for this patient.,0
His lasix and spironolactone were held and with IVF his renal function returned to baseline.,0
"He was restarted on a lower dose of his diuretics prior to discharge, and will need his dose of diuretics readjusted as an outpatient and should have his creatinine closely monitored as well.",0
Medications on Admission: Transfer meds: Sarna Lotion 1 Appl TP QID:PRN Clonazepam 1 mg PO QHS traZODONE HCl 100 mg PO HS:PRN Mirtazapine 30 mg PO HS Oxycodone-Acetaminophen 1 TAB PO Q4-6H:PRN Emtricitabine 200 mg PO Q24H Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Rifaximin 200 mg PO TID Lactulose 15 ml PO BID Multivitamins 1 CAP PO DAILY Azithromycin 1200 mg PO 1X/WEEK (TH) Suspension 1500 mg PO DAILY Heparin 5000 UNIT SC TID Ritonavir 100 mg PO DAILY Tenofovir Disoproxil Fum.,0
300 mg PO DAILY Atazanavir 300 mg PO DAILY Abacavir *NF* 20 mg/mL Oral 10mL .,0
Oxycodone/Acetaminophen 5-325mg 1 tablet PO Q4-6H PRN 2.,0
Furosemide 80 mg PO DAILY 3.,0
Spironolactone 200 mg PO DAILY 4.,0
Mirtazapine 30 mg PO QHS 5.,0
Trazodone 100 mg PO HS 6.,0
Clonazepam 1 mg PO QHS 8.,0
Azithromycin 1200mg PO 1X/WEEK (TH).,0
Abacavir 200mg PO BID 10.,0
Atazanavir 300mg PO DAILY 11.,0
Truvada 1 pill daily 12.,0
Ritonavir 100 mg PO DAILY 13.,0
Hexavitamin PO DAILY Discharge Medications: 1.,0
Abacavir 20 mg/mL Solution Sig: Ten (10) ML PO 10mL (): 200 mg .,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed.,0
Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed.,0
750 mg/5 mL Suspension Sig: 1500 mg PO DAILY (Daily): 10 ml daily.,0
Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).,0
Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (TH).,0
Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).,0
Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day.,0
Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).,0
Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed.,0
Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1.,0
Altered mental status related to drug overdose 2.,0
"Acute renal failure Discharge Condition: stable, tolerating medications Discharge Instructions: 1.",1
"You were admitted with altered mental status, likely due to opium use.",0
You should avoid opium in the future.,0
"All of your medications are the same, except we are decreasing your lasix and spironolactone.",0
You should have these readjusted by Dr. .,0
"Return for fevers, chills, weight gain, shortness of breath, vomiting, worsened diarrhea and inability to take medications.",0
Please attend all follow-up appointments.,0
Follow new medication list Followup Instructions: 1.,0
"You need to attend your infectious disease appointment as follows: Provider: , MD Phone: Date/Time: 1:00.",0
This is the urgent care clinic .,0
Please attend the following appointment: Provider: CLINIC Phone: Date/Time: 1:00 .,0
Provider: MRI Phone: Date/Time: 2:15,0
2:00 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: SOB Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with SOB REASON FOR THIS EXAMINATION: SOB ______________________________________________________________________________ FINAL REPORT STUDY: AP chest .,0
HISTORY: 67-year-old man with shortness of breath.,0
The left-sided central venous catheter and nasogastric tube are again seen.,0
The lower lung fields have been cut off from the study.,0
There is again seen an aortic valve replacement and median sternotomy wires.,1
There is prominence of the pulmonary vascular markings superiorly.,0
The lung bases again cannot be evaluated.,0
"3:23 PM CHEST (PORTABLE AP) Clip # Reason: please eval cardiopulm status ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with h/o bmt and gvhd on immunosuppressive therapy presents febrile with chills and a cough, no hypoxic.",0
"REASON FOR THIS EXAMINATION: please eval cardiopulm status ______________________________________________________________________________ FINAL REPORT INDICATION: History of bone marrow transplantation graft-versus-host disease on immunosuppressive therapy with fever, chills and cough.",1
UPRIGHT AP VIEW OF THE CHEST: The right PICC has been removed.,0
Cervical fusion hardware is present.,0
"Cardiac, mediastinal and hilar contours are unchanged and within normal limits.",0
There is no pulmonary vascular congestion.,0
No pleural effusions or pneumothorax.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Addendum: Final pathology foot biopsy: DIAGNOSIS: Soft tissue, right foot, biopsy (A): Fragments of mature bone with remodeling and features suggestive of chronic osteomyelitis and fibrovascular tissue with chronic inflammation and fibrin deposition.",1
11:11 AM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o hemothorax Admitting Diagnosis: BILATERAL PNEUMONIA;SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with PNA and large pleural effusion s/p attempted thoracentesis.,0
"REASON FOR THIS EXAMINATION: r/o hemothorax No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT CHEST WITH CONTRAST INDICATION: History of pneumonia enlarged pleural effusion, status post attempted thoracentesis, rule out hemithorax.",0
Comparison is made to prior CT scan dated .,0
TECHNIQUE: Multidetector CT scanning of the chest was performed following intravenous administration of 100 cc of Optiray contrast.,0
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There has been interval placement of two right-sided chest tubes.,0
The more inferiorly placed right-sided chest tube terminates near the right lung base.,0
A larger caliber chest tube inserted slightly superiorly terminates near the right lung apex posteriorly.,0
There has been an overall decrease in the previously identified large right- sided pleural effusion.,0
"There are residual more loculated appearing right- sided effusions, the largest of which is seen anteriorly at best appreciated on series 2, image 25 at the level of the pulmonary artery bifurcation, which appears low density measuring approximately 13.5 x 6.3 cm extending anteriorly along the right hemithorax.",0
"Superiorly, there are smaller more high attenuation collections at the right lung apex, some of which may contain hemorrhage given elevated Hounsfield units.",0
"Several scattered foci of air are also noted throughout the right hemithorax, which could represent minimal areas of pneumothorax.",0
"There is dense significant reexpansion of the right lung, best appreciated in the right lower lobe.",0
The left lung demonstrates interval resolution of a previously seen small pleural effusion.,0
Note is made of a 2.5 x 1.6 cm oval shaped area of consolidation medially in the left lung base which could represent a rounded area of atelectasis or a developing infiltrate.,0
"The heart, pericardium, and great vessels appear within normal limits.",0
No pathologically enlarged areas of adenopathy are identified.,0
The visualized portions of the upper abdomen are unremarkable.,0
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions.,0
"Interval placement of two right-sided chest tubes, as detailed above, with decrease in size of massive right-sided effusion.",0
"Residual loculated fluid collections within the right hemithorax as detailed above with higher attenuation collections near the right lung apex, (Over) 11:11 AM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o hemothorax Admitting Diagnosis: BILATERAL PNEUMONIA;SHORTNESS OF BREATH ______________________________________________________________________________ FINAL REPORT (Cont) which could represent areas of hemothorax.",0
"Small focal area of consolidation in the left lung base medially, which could represent an area of rounded atelectasis or small developing infiltrate.",0
8:57 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: ?,0
"P-cvl tip position ______________________________________________________________________________ MEDICAL CONDITION: former 28 week gestation infant, on bowel rest P-CVL originating left antecubital vein REASON FOR THIS EXAMINATION: ?",0
P-cvl tip position ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Former 28-week gestational age infant with recent placement of CVL.,0
This CVL is identified which has been placed in the left arm and is in the right atrium.,0
Lung opacities are identified compatible with BPD given the infant's age.,0
IMPRESSION: CVL with end in right atrium.,0
10:12 PM CHEST (PORTABLE AP) Clip # Reason: r/o CHF/pneumonia.,0
"______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with dyspnea, low sats and sounds like crap.",0
REASON FOR THIS EXAMINATION: r/o CHF/pneumonia.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 79 year old with shortness of breath and hypoxia.,0
"FINDINGS: Allowing for technique, cardiac and mediastinal contours are normal.",0
There is a minimal amount of atelectasis seen at the left lung base.,0
There are no focal consolidations.,0
There is slight prominence of the perihilar vessels.,0
No definite effusions are seen.,0
IMPRESSION: Slight prominence of the perihilar pulmonary vessels without definite evidence of CHF.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: GENERAL SURGERY/PURPLE TEAM.,0
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old female with a known gastric ulcer on EGD presenting initially to the Medical Intensive Care Unit with bleeding per rectum.,0
"The patient was in the usual state of health until the day prior to admission, when she developed gradual weakness.",0
She also had several loose stools of unusual collar and poor PO intake.,0
The daughter reported noticing bright red blood in the patient's bowel movements and brought the patient to the emergency room for evaluation.,0
The patient was managed medically by the MICU team during which time she received approximately 10 units of blood over a three-day period.,0
"On hospital day #2, the patient was taken for EGD, which demonstrated old clotted blood in the entire stomach.",0
No apparent bleeding within the stomach itself.,0
"After excavation and area of active bleeding was sitting in the pyloric channel, similar to that described on 8/.",0
Hemostasis was achieved with epinephrine injections.,0
"After the procedure, she was discharged back to the Intensive Care Unit for continued medical management.",0
"On , the Department of General Surgery was consulted.",0
"At that time, recommendations were made.",0
"Medical management was recommended, as well as discontinuing any nonsteroidals or aspirin products with request for surgery to be consulted if bleeding continued to be a problem.",0
"On , the patient was noted to become profoundly hypotensive with blood pressure in the 80s/50s.",0
"Hematocrit measured at that time was 26, down from a previous of 30.",0
It was determined at that time that the patient would require an operation to repair her bleeding ulcer.,0
The patient was taken to the operating room for a subtotal gastrectomy with Billroth II anastomosis.,0
Please see operative note from Dr. for details of this operation.,0
"The patient, after the operation, was transferred to the Intensive Care Unit, where she was given aggressive volume rehydration.",0
The patient had received two units of packed red blood cells in the MICU.,0
"On , she received an additional two units in the operating room.",0
The patient did well within the Intensive Care Unit.,0
She was gradually weaned from her FIO2 to room air.,0
She was transferred to the floor.,0
"On postoperative day #3, she was gradually advanced from clear sips to full clears to general diet.",0
"Due to the patient's poor ambulatory status, rehabilitation was considered appropriate, intermediate move from the hospital to home.",0
"At the time of discharge, the patient was tolerating a post- gastrectomy diet without difficulty.",0
She was quite requiring any rehydration to maintain adequate fluid.,0
She was voiding and stooling normally.,0
"Stools did demonstrate old clot within them, consistent with the amount of bleeding that she had had previously in her upper GI tract.",0
This was not considered worrisome due to the fact that the hematocrit had remained stable at or above 30 during this entire period.,0
DISCHARGE STATUS: The patient was discharged to a rehabilitation facility.,0
"DISCHARGE DIAGNOSES: Bleeding pyloric ulcer, status post subtotal gastrectomy and Billroth II anastomosis.",0
Percocet one to two tablets PO q.3h.,0
"Fluticasone 110 mcg, two puffs IH b.i.d.",0
Subcutaneous heparin 5000 units q.8h.,0
"Fentanyl patch 75 mcg per hour, TP q.72h.",0
"Metoprolol 25 mg PO b.i.d., hold for systolic less than 100, heart rate less than 60.",0
Protonix 40 mg PO q.24h.,0
Mirtazapine 15 mg PO q.h.s.,0
FOLLOWUP PLAN: The patient will see Dr. in approximately two weeks.,0
Dictated By: MEDQUIST36 D: 09:43 T: 10:23 JOB#:,0
"5:51 AM CHEST (PORTABLE AP) Clip # Reason: eval s/p bronch/thoracotomy Admitting Diagnosis: STAB WOUND ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with recent L-chest stab wound now s/p Lt thoracotomy; post-op RUL collapse now s/p bronch REASON FOR THIS EXAMINATION: eval s/p bronch/thoracotomy ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: 41-year-old man with recent left-sided stab wound.,0
There has been improvement of the opacity at the right mid and suprahilar region since the previous study.,0
There are chest tubes seen on the left side with no residual pneumothorax seen.,0
"There is a vascular catheter on the left side which was kinked at entry site of the skin, unchanged.",0
A ET tube is seen with distal tip at the aortic knob.,0
There is a persistent left retrocardiac opacity which is not significantly changed.,0
", N. MED CC7A 11:09 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: N/A, just want tube placed post-pylorically Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 5 ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with prior NGT placement that she vomited out.",0
"REASON FOR THIS EXAMINATION: N/A, just want tube placed post-pylorically ______________________________________________________________________________ PFI REPORT Successful advancement of Dobbhoff tube into the duodenum",0
"7:50 AM MR HEAD W & W/O CONTRAST Clip # Reason: 46 y/o woman with metastatic adenocarcinoma unknown primary Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 16CC ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman s/p seizure, w/know metastatic adenocarcinoma REASON FOR THIS EXAMINATION: 46 y/o woman with metastatic adenocarcinoma unknown primary source...r/o mets to brain No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Metastatic adenocarcinoma of unknown primary without known intracranial metastases.",0
"History of right temporal/parietal cerebral hemorrhage in while on anticoagulation therapy for pulmonary embolism, status post craniotomy.",0
"COMPARISON: Non-contrast head CT of , is available for correlation.",0
"TECHNIQUE: Sagittal T1-weighted and axial T1-weighted, T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained.",0
"Following intravenous gadolinium administration, multiplanar T1-weighted images of the brain were obtained.",0
FINDINGS: There is a large area of encephalomalacia in the right parietal lobe.,0
There is a focus of subacute and chronic blood products within the encephalomalacia.,0
A right parietal craniotomy is seen.,0
These findings likely represent the sequela of the hematoma described in the history.,0
Associated ex vacuo dilatation of the atrium of the right lateral ventricle is noted.,0
Other ventricles are normal in size.,0
There is no evidence of edema or acute infarction in the brain parenchyma.,0
"High signal throughout the sulci on postcontrast images appears related to venous hyperemia, which may be seen following a seizure.",0
High signal throughout the sulci is also present on the FLAIR images.,0
"While this finding may be seen in venous hyperemia, meningitis cannot be excluded.",0
"In the absence of sulcal hyperdensity on the preceding head CT, subarachnoid hemorrhage is unlikely.",0
The major vascular flow voids appear unremarkable.,0
High signal throughout the sulci on postcontrast T1-weighted and FLAIR images may be related to venous hyperemia following a seizure.,0
"According to Dr. , the patient has been on propofol, and propofol use is also associated with high signal in the sulci on FLAIR images.",0
"However, meningitis cannot be excluded by imaging, and clinical correlation is recommended.",0
The pattern of enhancement is not typical for leptomeningeal metastatic disease.,0
"Right parietal encephalomalacia with a small focus of subacute and chronic blood products, consistent with history of a previous hematoma.",0
(Over) 7:50 AM MR HEAD W & W/O CONTRAST Clip # Reason: 46 y/o woman with metastatic adenocarcinoma unknown primary Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 16CC ______________________________________________________________________________ FINAL REPORT (Cont) Findings discussed with Dr. at 4:20 p.m. on .,0
11:05 AM CHEST (PA & LAT) Clip # Reason: assess effusions Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p CABG REASON FOR THIS EXAMINATION: assess effusions ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old male status post CABG.,0
TECHNIQUE: AP semi-upright single view of the chest.,0
FINDINGS: There are skin staples and sternal wires.,0
There is a left subclavian central line with the tip in the superior SVC in unchanged position.,0
"Again, noted bilateral pleural effusions, which are not significantly changed when compared to the prior study.",0
There is associated left retrocardiac opacity that most likely represents atelectasis.,0
Stable bilateral apical pleural thickening.,0
"1:15 AM CHEST (PORTABLE AP) Clip # Reason: assess for worsening infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with recent admit for LLL PNA, p/w fever, dyspnea REASON FOR THIS EXAMINATION: assess for worsening infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 76-year-old male with recent admission for left lower lobe pneumonia presenting with fever, dyspnea.",1
AP chest radiograph compared to show diffuse increased bilateral opacities which is most suggestive of pulmonary edema.,0
"Retrocardiac opacity is unchanged and likely represents atelectasis, although consolidation cannot be excluded.",0
The cardiomediastinal contour is unchanged.,0
"10:53 AM BABYGRAM (CHEST ONLY) PORT Clip # Reason: 3 do ex 25 w with PIE, on HIFI.",0
"Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with PIE, on HIFI.",0
"REASON FOR THIS EXAMINATION: 3 do ex 25 w with PIE, on HIFI.",0
______________________________________________________________________________ FINAL REPORT Comparison is made with the exam done on the 20th.,0
"Since that time, there is more evident pulmonary interstitial emphysema on the left side.",1
There is probably a small pneumothorax on the left side as well.,0
"The right side remains nearly oblique, not changed since prior exam.",0
The endotracheal tube ends above the carina.,0
Umbilical venous line continues to be in the right atrium and the umbilical artery line continues to be at about the level of T7.,0
LINE PLACEMENT Clip # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p CABG REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY ______________________________________________________________________________ WET READ: 8:29 PM RIJ cath tip in right atrium.,1
ETT tip 4.5 cm above carina.,0
Small left effusion and left basal atelectasis.,0
Bilateral chest tubes in place.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: radiograph.,0
FINDINGS: Right internal jugular vascular catheter terminates near the expected location of junction of superior vena cava and right atrium.,0
"Endotracheal tube and nasogastric tube are in standard position, and low lying chest tubes are also in place.",0
The patient is status post recent median sternotomy and coronary bypass surgery.,1
Expected slight increase in width of cardiomediastinal contours in the postoperative period.,0
No evidence of pulmonary edema.,0
Mild bibasilar atelectasis and small pleural effusions.,0
Probable mild pneumomediastinum extending into the soft tissues of the neck.,0
"7:59 PM CHEST (PA & LAT) Clip # Reason: r/o infiltrate Admitting Diagnosis: CIRRHOSIS,FEVER ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with HIV (cd4 236 in ), HBV, new onset cough and fever REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT Chest two views PA and lateral.",1
History of HIV with new onset cough and fever.,0
Feeding tube is present in stomach with distal end not included on the film.,0
No definite pulmonary consolidation or pleural effusions.,1
There is some crowding of vascular markings at the right base.,0
IMPRESSION: No evidence for pneumonia.,0
"No change since prior study of , .",0
12:34 PM CHEST (PORTABLE AP) Clip # Reason: Evidence of pneumonia Admitting Diagnosis: FEBRILE NEUTROPENIA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with factor VIIIi presented with neutropenia and fever.,1
Spiked temp to 101.5 this AM.,0
"REASON FOR THIS EXAMINATION: Evidence of pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Fever, to evaluate for pneumonia.",0
"FINDINGS: In comparison with study of , there are lower lung volumes that may be partially responsible for the enlarged transverse diameter of the heart.",0
No vascular congestion or pleural effusion.,0
Left PICC line again extends to the lower portion of the SVC.,0
"Specifically, no evidence of acute pneumonia.",0
7:40 AM US EXTREMITY NONVASCULAR LEFT PORT Clip # Reason: Asses for fluid collection around recently placed intra femo ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman s/p total abdominal colectomy with end ileostomy.,0
S/P ORIF of L femur fx with IM rod.,0
Pt was c/o pain on that side and hasd elevated WBC despite ABX.,0
REASON FOR THIS EXAMINATION: Asses for fluid collection around recently placed intra femoral rod.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Left hip pain and elevated white blood count after hip repair.,0
"FINDINGS: The proximal portion of the left lower extremity adjacent to the proximal femoral diaphysis contains an irregular, multiloculated fluid collection; the largest component measures approximately 4 x 5 cm.",0
The collection appears removed from the acetabular joint.,0
It appears to lie adjacent to cortex.,0
IMPRESSION: Proximal left lower extremity fluid collection described above probably reflects a post operative collection.,0
"9:52 PM CHEST (PORTABLE AP) Clip # Reason: PLEASE EVAL FOR MIGRATION OF PICC LINE PLACED ON Admitting Diagnosis: CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 27M with Hajdu- syndrome, known R elbow osteomyelitis, here with worsening R elbow ulcer on Daptomycin.",1
REASON FOR THIS EXAMINATION: Location of PICC line ______________________________________________________________________________ WET READ: KKgc TUE 1:05 AM Left Picc seen upto the level of left brachicephalic vein.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 10:10 P.M. ON HISTORY: Right elbow osteomyelitis.",1
IMPRESSION: AP chest compared to : The previous left PIC line is not visible.,0
Right upper lobe collapse is chronic.,1
There is no pulmonary edema or appreciable pleural effusion.,0
A tracheostomy tube is in place and abuts the left tracheal wall.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: Please evaluate Left subclavian line placement Admitting Diagnosis: PAINLESS JAUNDICE ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with UGIB with new left subclavian line placement REASON FOR THIS EXAMINATION: Please evaluate Left subclavian line placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess line.,0
Comparison is made with prior study performed 11 a.m. Left subclavian catheter tip is in the mid SVC.,0
ET tube is in standard position.,0
Right PICC tip is in the upper right atrium.,0
Cardiomediastinal contours are unchanged with enlarged main pulmonary arteries and tortuous aorta.,0
Bibasilar atelectasis have increased on the left.,0
"IN-111 WHITE BLOOD CELL STUDY Clip # Reason: INFECTION IN THROMBUS AND L LUNG ______________________________________________________________________________ FINAL REPORT HISTORY: Seventy-nine year old man with a loculated left apical effusion and an ascending aortic thrombus and sepsis, also he has an aortic conduit, evaluate for infection.",1
"INTERPRETATION: Following the injection of autologous white blood cells labeled with Indium-111, images of the whole body and static images of the chest and abdomen were obtained at 24 hours.",0
These images show normal uptake within the liver and spleen.,0
There are no abnormal areas of white blood cell uptake.,0
The above finings are consistent with no active infection.,0
IMPRESSION: No evidence of active infection.,0
Approved: 9:25 AM West RADLINE ; A radiology consult service.,0
PATIENT/TEST INFORMATION: Indication: Right ventricular function.,0
Height: (in) 68 Weight (lb): 173 BSA (m2): 1.92 m2 BP (mm Hg): 118/49 HR (bpm): 70 Status: Inpatient Date/Time: at 11:08 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
RIGHT VENTRICLE: Dilated RV cavity.,0
Moderate to severe (3+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
There is partial posterior mitral leaflet flail.,0
"An eccentric, anteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen.",0
"IMPRESSION: Probable partial flail of the posterior mitral leaflet with consequent moderate-to-severe, anteriorly directed, mitral regurgitation.",0
Left ventricular systolic function is probably normal.,0
The right ventricle is not well seen but is probably mildly dilated with normal systolic function.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Cortisone / Lisinopril Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Coronary artery bypass graft x5 (Left internal mammary artery > left anterior descending, saphenous vein graft > RAMUS, saphenous vein graft > obtuse marginal > obtuse marginal 2, saphenous vein graft > posterior descending artery) History of Present Illness: 80 year old male, who was swimming and acutely short of breath with shoulder and neck pain.",1
Was transported to outside hospital via ambulance and underwent cardiac catherization that revealed coronary artery disease.,1
"referred for surgical evaluation Past Medical History: Coronary artery disease Hypertension Elevated lipids Diabetes mellitus type 2 Chronic renal insufficiency Shoulder arthritis Social History: Retired chemist smoked cigars ~ 35years (3cigars/day) lives alone ETOH 2 drinks per week Family History: none Physical Exam: General HR 86, 124/83 Skin unremarkable HEENT unremarkable Neck supple Full ROM Chest lung clear bilat anteriorly Heart RRR Abdomen soft, NT, ND, +BS Ext warm well perfused no edema Pulses +2 Pertinent Results: CHEST (PORTABLE AP) 8:01 AM CHEST (PORTABLE AP) Reason: hct MEDICAL CONDITION: 80 year old man with s/p cabg REASON FOR THIS EXAMINATION: hct AP CHEST 8:33 A.M. HISTORY: CABG.",1
IMPRESSION: AP chest compared to and 18: Mediastinal vascular engorgement has improved and small left pleural effusion decreased substantially.,0
Left lower lobe atelectasis is better.,0
Moderate (2+) MR. TRICUSPID VALVE: Physiologic TR.,0
"REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 1.",0
The left atrium and right atrium are normal in cavity size.,0
"There is moderate regional left ventricular systolic dysfunction with anterior, antero septal, anterolateral mid to apical hypokinesis.",0
Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %).,0
"POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including epinephrine and phenylephrine.",1
MR is mild to moderate with further improvement on after load reduction.,0
"Other findings are unchanged Brief Hospital Course: Transferred in from outside hospital for surgical evaluation, and underwent preoperative workup.",0
On was taken to the operating room for coronary artery bypass graft surgery; see operative report for further details.,1
He was treated with vancomycin for peri operative antibiotics since he was in the hospital greater than twenty four hours prior to surgery.,0
He was transferred to the intensive care unit for further hemodynamic monitoring.,0
"He was weaned from sedation, awoke neurologically intact and was extubated in the first twenty four hours.",0
He continued to progress and on post operative day 1 transferred to the floor.,0
"He creatinine rose from baseline of 1.9 to 2.5, and then slowly improved.",0
Chest tubes and pacing wires removed without incident.He was transfused.,0
He was started on coumadin and amiodarone for atrial fibrillation.,1
Cleared for discharge to rehab on POD #4.,0
is to make all followup appts.,0
Medications on Admission: ASA 162 daily Nifedipine 30 daily metformin 850 folic acid 1 daily Slow MAg 64 daily lasix 40 daily Tricor 145 daily Citracal Glucosamine Chondroitin Glipizide 10 Lisinopril 40 daily Vytorin 80/10 daily Discharge Medications: 1.,0
Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily ().,0
Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months.,0
Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 weeks: 400 mg for one week, then 200 mg for one week, then 200 mg daily ongoing.",0
Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: dose for today only;all further dosing by rehab provider.,0
Discharge Disposition: Extended Care Facility: Long Term Health - Discharge Diagnosis: Coronary artery disease s/p cabg x5 Hypertension Elevated lipids Diabetes mellitus type 2 Chronic renal insufficiency arthritis postop A fib Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions and pat dry.,1
"Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 100.5 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns p Instructions: Dr in 4 weeks () please call for appointment Dr in 1 week () please call for appointment Dr in weeks -please call for appointment Wound check appointment 2 as instructed by nurse () Completed by:",0
"10:41 AM CHEST (PORTABLE AP) Clip # Reason: evaluate pleural effusions ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with dm1, cap, sp ards, reintubated REASON FOR THIS EXAMINATION: evaluate pleural effusions ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: Diabetes s/p ARDS.",1
FINDINGS: A single AP supine view.,0
A tracheostomy tube has replaced the previous ETT.,0
The left IJ central line remains in satisfactory position with its tip in the upper SVC.,0
The heart is at the upper limits of normal in size.,0
There is again evidence of diffuse interstitial and alveolar infiltrates in both lungs.,0
Probable bilateral posterior layering pleural effusions noted.,1
There is also evidence of collapse/consolidation of the left lower lobe behind the heart.,0
These findings are not significantly changed since the prior study.,0
IMPRESSION: Essentially unchanged findings consistent with ARDS and bilateral pleural effusions.,1
", C. CSURG FA6A 10:07 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: Eval for ileus Admitting Diagnosis: NON ISCHEMIC CARDIOMYOPATHY\IMPLANTABLE CARDIOVERTER DEFIBRILLATOR UPGRADE TO BIVENTRICULAR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with post op ileus REASON FOR THIS EXAMINATION: Eval for ileus ______________________________________________________________________________ PFI REPORT PFI: Findings again most suggestive of postoperative ileus with loops of bowel measuring up to 9 cm on the supine views.",1
9:39 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: Aspiration risk?,0
Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with CAP versus aspiration pna.,0
REASON FOR THIS EXAMINATION: Aspiration risk?,0
______________________________________________________________________________ FINAL REPORT INDICATION: 84-year-old female with possible aspiration pneumonia.,0
VIDEO OROPHARYNGEAL SWALLOW: This examination was performed in conjunction with the speech and language pathologist.,0
Multiple consistencies of barium were administered under constant fluoroscopic observation.,0
ORAL PHASE: There is mild impairment with piecemeal bolus formation and prolonged mastication of all textures.,0
Mild-to-moderate reduction in bolus control was noted.,0
Some premature spillover was noted as well.,0
"Overall, oral transit times were mildly to moderately reduced.",0
PHARYNGEAL PHASE: There is incomplete epiglottic deflection with normal pharyngeal elevation and laryngeal valve closure.,0
There is adequate opening of the upper esophageal sphincter.,0
No significant residue was noted within the valleculae and piriform sinuses.,0
ASPIRATION/PENETRATION: Intermittent penetration was noted secondary to premature spillover and swallow delay.,0
There were no episodes of aspiration.,0
Mild esophageal reflux was noted.,1
IMPRESSION: Mild-to-moderate oral and mild pharyngeal dysphagia.,0
Episodes of penetration with no evidence of aspiration.,0
"For further details, please refer to the speech and pathology report on the same day.",0
", S. MED FA10 10:19 AM ESOPHAGUS Clip # Reason: like to get barium swallow to evaluate signs of esophagus dy Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old male with a h/o AAA repair (EVAR) in with multiple complications (athero-emboli, psoas abscesses, vertebral osteomyelitis s/p posterior fixation) with failure to thrive and regurgitation of food particles.",1
REASON FOR THIS EXAMINATION: like to get barium swallow to evaluate signs of esophagus dysmotility.,0
______________________________________________________________________________ PFI REPORT PFI: Normal primary peristalsis with occasional tertiary contractions.,0
Moderately sized hiatal hernia with _____ delay in transit through diaphragmatic hiatus.,1
"11:47 AM CHEST (PORTABLE AP) Clip # Reason: s/p chest tube removal Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with s/p RUL lobectomy ; now w/ 'd O2 sat, r/o PE REASON FOR THIS EXAMINATION: s/p chest tube removal ______________________________________________________________________________ FINAL REPORT INDICATION: Removal of chest tubes.",0
"CHEST PORTABLE, AP UPRIGHT: Comparison study .",0
There has been removal of the two right-sided chest tubes.,0
There is a small inferior pneumothorax seen at the right lung base.,0
Bullous disease is noted at the right apex.,0
There is a persistent left pleural effusion.,0
The left lung is unchanged.,0
"Again, noted is a left central line, which has its tip in the SVC.",0
Pulmonary sutures are noted along the right superior mediastinum.,0
There is postoperative shift of the mediastinum from left to right.,0
IMPRESSION: Removal of the right chest tubes with small inferior pneumothorax.,0
"5:06 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CHEST PAIN;\CATH Admitting Diagnosis: CHEST PAIN;\CATH ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man, no significant past medical history, found to have LM disease on angiogram today, awaiting CABG REASON FOR THIS EXAMINATION: pre-op CXR ______________________________________________________________________________ FINAL REPORT INDICATION: 48-year-old man with no significant past medical history with left main disease, awaiting CABG.",0
PA AND LATERAL CHEST RADIOGRAPHS: Heart size and mediastinal contours are within normal limits.,0
"The lungs are clear without evidence of consolidation, pneumothorax, or effusion.",0
There is a congenital left 7th rib anomaly.,0
2:19 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: assess ETT placement Admitting Diagnosis: COPD FLARE;SHORTNESS OF BREATH;RULE OUT MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with worsening SOB and COPD flare s/p ETT adjustment REASON FOR THIS EXAMINATION: assess ETT placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post endotracheal tube adjustment.,0
Semi-upright AP chest at 14:34: The endotracheal tube tip now terminates approximately 6 cm from the carina.,0
"It is not as obvious on the current study, but there may be overinflation of the endotracheal tube cuff.",0
The nasogastric tube is unchanged.,0
The heart and lungs are unchanged in appearance from one hour ago.,0
IMPRESSION: Repositioning of the endotracheal tube.,0
"Though it is not clear, the endotracheal tube cuff may be over inflated, and clinical correlation is requested.",0
"8:18 AM CT HEAD W/O CONTRAST Clip # Reason: 25 female s/p mva intubated altered loc ______________________________________________________________________________ MEDICAL CONDITION: 19 year old woman with REASON FOR THIS EXAMINATION: 25 female s/p mva intubated altered loc ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 25-year-old female status post MVA, loss of consciousness.",1
Multiple axial CT images of the head were performed without administration of contrast.,0
FINDINGS: There is extensive internal hemorrhage noted.,0
There is subdural hemorrhage noted along the tentorium.,0
"Subarachnoid hemorrhage is noted along the sylvian fissure on the right, along the falx, and along the convexity.",0
"Intraparenchymal hemorrhage is noted in the left frontal region and along the corpus callosum, suggesting shear injuries.",0
There is an air-fluid level noted in the right maxillary sinus.,0
There is a fracture noted involving the right mandibular ramus.,1
Air-fluid level is also noted in the left maxillary sinus.,0
Soft tissue scalp filling noted in the right posteroparietal region.,0
"Extensive intracranial hemorrhage, as described above.",1
Fracture noted in the right mandibular ramus.,0
Air-fluid level noted in the maxillary sinuses bilaterally.,0
"These findings were immediately discussed with Dr. , the Trauma resident in charge of this patient.",0
"6:12 AM BABYGRAM (CHEST ONLY) Clip # Reason: r/o atelectasis/ confirm ETT placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with recent re-intubation, elevation in vent support REASON FOR THIS EXAMINATION: r/o atelectasis/ confirm ETT placement ______________________________________________________________________________ FINAL REPORT CHEST CLINICAL INDICATION: Infant with recurrent reintubation.",0
FINDINGS: Single frontal portable view of the chest was performed on .,0
"Since , ET tube has been withdrawn, and now terminates in the upper thoracic trachea, at or just below the thoracic inlet.",0
"There is improved aeration of both lungs, most likely related to repositioning of the ET tube.",0
Some hazy opacification persists throughout both lungs suggesting surfactant deficiency.,0
No focal pulmonary parenchymal abnormalities.,0
"There has been placement of a new nasogastric tube, whose distal tip projects over the stomach.",0
Left PICC tip probably terminates in the left innominate vein.,0
"9:15 AM CHEST (PORTABLE AP) Clip # Reason: fever, r/o PNA Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with fever, r/o PNA REASON FOR THIS EXAMINATION: fever, r/o PNA ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: .",0
FINDINGS: Removal of endotracheal tube and feeding tube.,0
Widespread bilateral calcified pleural plaques consistent with prior asbestos exposure.,0
"Previously reported opacities within the lingula have markedly improved, and opacification in left retrocardiac region is also improving.",0
These findings are likely related to improving atelectasis.,0
Additional minor atelectatic changes in the right lower lobe are also improving.,0
"IMPRESSION: No new or worsening areas of abnormality to suggest a site of developing pneumonia, but standard PA and lateral chest radiograph may be considered for more complete assessment of the lungs if clinical suspicion persists.",0
PATIENT/TEST INFORMATION: Indication: Evaluate for tamponade during EP procedure Height: (in) 72 Weight (lb): 185 BSA (m2): 2.06 m2 BP (mm Hg): 84/59 HR (bpm): 86 Status: Inpatient Date/Time: at 11:30 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: imaging done with agitatied saline injection into pericardial space to verify needle position for pericardiocentesis.,1
Conclusions: Pre-pericardiocentesis: There is a moderate sized pericardial effusion.,0
The right ventricle is small but no definite chamber collapse is seen.,0
Post pericardiocentesis: no residual pericardial effusion.,0
"6:30 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: foreign body in esophagus?, AGAIN Admitting Diagnosis: GLASS INGESTION;GI SCOPE ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with hx of swallowing glass reporting crushing beer bottle and swallowing, no hematemesis REASON FOR THIS EXAMINATION: foreign body in esophagus?, AGAIN ______________________________________________________________________________ WET READ: ARHb WED 8:37 PM No radioopaque foreign body seen on chest radiograph.",0
Oral contrast in large bowel.,0
"______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST, , AT 18:54 REASON FOR EXAM: Hematemesis, swallowing foreign body.",0
Cardiac size is top normal.,0
There is no radiopaque foreign body in the chest.,0
"11:40 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o retroperitoneal hematoma ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman s/p cardiac cath with acute drop in HCT REASON FOR THIS EXAMINATION: r/o retroperitoneal hematoma No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: S/P cardiac catheterization, acute drop in hematocrit, r/o retroperitoneal hematoma.",0
TECHNIQUE: Contiguous axial images were obtained from the lung bases to the femoral heads without intravenous contrast.,0
CT ABDOMEN WITHOUT CONTRAST: There is minimal atelectasis at both lung bases.,0
"The unenhanced liver, gallbladder, spleen, pancreas, and adrenals appear normal.",0
"Contrast material is identified in the collecting systems of both kidneys and both ureters, from the recent cardiac catheterization.",0
The kidneys have an unremarkable appearance.,0
There is no significant mesenteric or retroperitoneal lymphadenopathy.,0
There is no evidence for a retroperitoneal hematoma.,0
Heavy vascular calcifications are noted.,0
CT PELVIS WITHOUT CONTRAST: There is diverticulosis without evidence for diverticulitis.,0
"Contrast material is identified within numerous diverticula, likey from a recent contrast enhanced study.",0
A left femoral vein catheter is identified.,0
No focal fluid collections are identified.,0
There is a 2.3 x 2.0 cm mass in the right adnexa.,0
There is also a possible left adnexal mass.,0
A Foley catheter is in place.,0
No evidence for retroperitoneal hematoma.,0
Diverticulosis without evidence for acute diverticulitis.,0
"2.3 x 2.0 cm mass in the right adnexa, and possible left adnexal mass.",0
This should be further evaluated by ultrasound.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: ADDENDUM: Patient's discharge was delayed until secondary to lack of rehabilitation bed.",0
The patient's condition was stable at the time of discharge and she will follow up with Dr. on at 3 PM for staple removal.,0
Dictated By: MEDQUIST36 D: 09:52 T: 10:10 JOB#:,0
7:29 AM CHEST (PORTABLE AP) Clip # Reason: Pulm edema?,0
"Admitting Diagnosis: ACUTE CORONARY SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with STEMI, new MR, new cardiomyopathy REASON FOR THIS EXAMINATION: Pulm edema?",1
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: STEMI, cardiomyopathy, questionable pulmonary edema.",1
Minimal atelectasis at the left lung bases with retrocardiac atelectasis and a potential small left pleural effusion.,0
No signs of overt pulmonary edema.,1
"2:33 PM PLEURAL ASP BY RADIOLOGIST; GUIDANCE FOR /ABD/PARA CENTESIS USClip # CHEST U.S. Reason: LT EMPYEMA LT LUNG, PIGTAIL INSTERTION AND DRAINAGE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with REASON FOR THIS EXAMINATION: 55M s/p Pancoast resection and LUL wedge resection now with two left sided fluid collections seen on Chest CT. We have requested CT guided drainage, however the CT scan is not working today.",0
Please perform U?S guided placement of pigtail catheters in both fluid collections.,0
"______________________________________________________________________________ FINAL REPORT INDICATIONS: 55 y/o man s/p pancreas resection and left upper lobe wedge resection, now with left fluid collection, worrisome for empyema on chest CT. ULTRASOUND GUIDED PLEURAL DRAINAGE: The advantages and complications of the procedure were explained to the patient and informed consent was obtained.",0
The patient was prepped and draped in the usual sterile fashion.,0
Local anesthesia in the lateral inferior chest wall was performed using 10 cc of Lidocaine 1%.,0
An 8 French pigtail catheter was inserted into the pleural space on the second attempt and cloudy fluid could be aspirated.,0
The sample was sent for gram stain and culture.,0
The catheter was then secured in place.,0
The patient tolerated the procedure satisfactorily.,0
Ultrasound exam of the fluid collection over the left apex was unable to demonstrate a safe route of access to the collection and the procedure was therefore terminated.,0
IMPRESSION: Ultrasound guided placement of an 8 French pigtail catheter into the inferior pleural collection.,0
Access to the collection over the lung apex could not be obtained using ultrasound.,0
Findings were discussed with Dr. and the patient is scheduled for a CT guided pleural drainage on at 8 a.m..,0
7:50 PM CHEST (PORTABLE AP) Clip # Reason: Effusion?,0
"Admitting Diagnosis: LOWER EXTREMITY REST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with cool Left leg, s/p lower extremity bypass, respiratory distress REASON FOR THIS EXAMINATION: Effusion?",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Cool left leg, status post lower extremity bypass and respiratory distress.",1
Evaluate for effusion or edema.,0
"FINDINGS: Again, the patient is intubated, with the tip of the endotracheal tube approximately 5 cm above carina.",0
"Right IJ central venous catheter is present, with the tip in the mid SVC.",0
Bilateral calcified breast prostheses seen.,0
"Evaluation of the pulmonary parenchyma again shows bilateral alveolar opacities, probably with slight improvement of the aeration at the right lung base when compared to the prior.",0
"However, the left base demonstrates slightly more linear opacity than on the comparison, probably atelectasis.",0
No significant pleural effusions are seen.,0
"There is a right-convex scoliosis of the thoracolumbar spine, centered at approximately the thoracolumbar junction.",0
"Slight improvement in the aeration at the right base, although minimal change overall.",0
"11:08 PM ORBITS (WATERS, & LAT) Clip # Reason: metal fragment in orbits Admitting Diagnosis: L2 FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man needing MRI, hx of cutting pipes REASON FOR THIS EXAMINATION: metal fragment in orbits ______________________________________________________________________________ FINAL REPORT INDICATIONS: 25-year-old man needing MRI, with history of pipe cutting and question of exposure to metal fragments.",0
"SKULL, TWO VIEWS: These views demonstrate no evidence of radiopaque foreign body.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY OF PRESENT ILLNESS: NO DICTATION (MUSIC) , MD Dictated By: MEDQUIST36 D: 10:19:26 T: 10:27:03 Job#:",0
2:45 PM CHEST (PORTABLE AP) Clip # Reason: Eval for PNA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with lethargy REASON FOR THIS EXAMINATION: Eval for PNA ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 85-year-old male with lethargy.,0
"Single AP chest radiograph compared to , shows moderate-sized bilateral pleural effusions, which allowing for difference in technique is not significantly changed in size.",1
Bilateral lower lobe opacity may represent atelectasis although airspace consolidation cannot be entirely excluded.,0
The extent of pulmonary vascular engorement is slightly improved.,0
Right IJ hemodialysis catheter terminates in the right atrium.,0
Dual leads of a left chest wall pacemaker terminate in the right atrium and ventricle.,0
7:11 AM CHEST (PORTABLE AP) Clip # Reason: IABP position; ?,0
edema Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with STEMI s/p cath today with stent to his LAD and respiratory failure requiring intubation.,1
REASON FOR THIS EXAMINATION: IABP position; ?,0
"edema ______________________________________________________________________________ FINAL REPORT AP CHEST, 7:36 A.M., .",0
"IMPRESSION: AP chest compared to and 21: Tip of the intraaortic balloon pump is at the apex of mildly aneurysmal aortic knob, 2-4 cm above standard placement.",0
Tip of an ascending Swan-Ganz catheter projects over the main pulmonary artery.,0
"ET tube tip at the thoracic inlet is at least 6 cm from the carina, 2-3 cm above optimal placement.",0
Nasogastric tube ends in the stomach which is not distended.,0
"Aside from mild atelectasis at the right base, lungs are clear.",0
"There is no pulmonary edema, pleural effusion or pneumothorax.",0
6:11 AM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with trauma REASON FOR THIS EXAMINATION: r/o pneumothorax ______________________________________________________________________________ FINAL REPORT CHEST: CLINICAL HISTORY: (*40 y/o woman with trauma*).,1
COMPARISON: Made to previous study dated .,0
There has been some mild interval increase in the right sided pulmonary opacity most likely representing pulmonary contusion.,0
There is some mild increased left sided opacity also noted.,0
"The multiple lines and tubes remain unchanged including an endotracheal tube, right sided chest tube, left sided Swan-Ganz catheter and left chest tube.",0
The left sided chest tube continues to extend far medially.,0
A nasogastric tube is also in place with the tip in the proximal stomach.,0
There has been reduction in the amount of subcutaneous emphysema.,0
IMPRESSION: Interval increase in bilateral air space disease likely representing pulmonary contusion.,0
", C. NMED FA11 10:14 AM UNILAT UP EXT VEINS US RIGHT Clip # Reason: ?DVT Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with old stroke here with first seizure activity now with swollen and painful R arm concerning for thrombus REASON FOR THIS EXAMINATION: ?DVT ______________________________________________________________________________ PFI REPORT Occlusive thrombus throughout the length of the cephalic vein, a superficial vein.",1
No deep venous thrombosis demonstrated.,0
12:02 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate.,0
"Admitting Diagnosis: GI BLEED/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with reversal of and diverting ileostomy, ventral hernia repair REASON FOR THIS EXAMINATION: r/o infiltrate.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative, to evaluate for aspiration.",0
"FINDINGS: In comparison with study of , there is little change.",0
"Again, there are low lung volumes with bibasilar subsegmental atelectatic change.",0
No evidence of acute pneumonia in this patient with intact midline sternal sutures.,0
", C. MED CC7A 8:47 PM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: RLL LUNG MASS Admitting Diagnosis: RIGHT LOWER LOBE;LARGE VOCAL CORD MASSES Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with new RLL mass REASON FOR THIS EXAMINATION: Staging CT No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",1
Known heterogeneous 5.3 cm x 5.1 cm cystic and solid mass predominantly centered within the posterior basal segment of the right lower lobe.,0
Associated mediastinal lymph nodes as detailed above with the largest being a subcarinal lymph node measuring up to 12 mm in short axis.,1
"Suspicious arterial rim-enhancing foci in the spleen, the largest of which measures 13 mm and a second focus which measures 8 mm as detailed above.",0
"Bilateral small pleural effusions, also with fluid tracking along the right major fissure.",1
"5:03 AM CHEST (PORTABLE AP) Clip # Reason: now intubated, with new pulmonary process on , thick sec Admitting Diagnosis: PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman with multi trauma REASON FOR THIS EXAMINATION: now intubated, with new pulmonary process on , thick secretions ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Multi-trauma, intubated with new pulmonary process.",1
The ET tube tip is 5.5 cm above the carina.,0
The left subclavian line tip is at the level of mid SVC.,0
"Heart size and mediastinal appear to be unchanged, but there is interval improvement of left upper lobe atelectasis as well as mid left lung atelectasis with more central position of the mediastinum but with still present minimal left basal atelectasis.",0
Surgical clips are projecting over the recently placed internal fixator of the right humerus.,1
No interval development of substantial pleural effusion is demonstrated.,0
9:20 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate doboff tube placement Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with s/p burr holes for SDH REASON FOR THIS EXAMINATION: please evaluate doboff tube placement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 11:45 AM The Dobbhoff tube terminates in the proximal stomach.,0
"There is some retrocardiac atelectasis, however, the previously seen left lower lobe opacity is not appreciated on this study.",0
There is no evidence for ___.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 82-year-old male with subdural hematoma, status post burr holes.",0
Evaluate for Dobbhoff tube placement.,0
COMPARISON: Comparison is made to portable chest radiograph from .,0
FINDINGS: The Dobbhoff tube is seen extending into the proximal stomach.,0
The lungs appear clear without consolidation or effusion.,0
"The previously seen left lower lobe opacity is less apparent, although there is likely some retrocardiac atelectasis.",0
The hilar and cardiomediastinal contours are unchanged.,0
There is no evidence for vascular engorgement or pulmonary edema.,0
IMPRESSION: Dobbhoff tube extends to the proximal stomach.,0
Retrocardiac atelectasis without focal left lower lobe opacity.,0
"1:21 PM CT THORACENTESIS DRAINAGE; CT GUIDED NEEDLE PLACTMENT Clip # Reason: Please tap left effusion and obtain fluid for analysis Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION;ATRIAL FIBRILLATION;HYPOTENSION\CARDIAC CATH ********************************* CPT Codes ******************************** * CT THORACENTESIS DRAINAGE CT GUIDED NEEDLE PLACTMENT * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with VAP s/pNSTEMI REASON FOR THIS EXAMINATION: Please tap left effusion and obtain fluid for analysis ______________________________________________________________________________ FINAL REPORT HISTORY: 86-year-old man with VAP status post NSTEMI, please tap left effusion and obtained for analysis.",0
TECHNIQUE: After discussion of the risks and benefits of the left thoracentesis under ultrasound guidance.,0
"The patient and his health care proxy , informed consent was obtained.",0
A timeout procedure was performed using three patient identifiers.,1
The preliminary ultrasound of the posterior thorax demonstrates a left greater than right pleural effusion.,0
A site was chosen along the left posterior thorax.,0
The left posterior thorax was then prepped and draped in the usual sterile fashion.,0
1% buffered lidocaine was used for local anesthesia.,0
A 5 French catheter was advanced into the left pleural effusion and 1 liter of clear amber fluid was drained.,0
Samples were sent to the laboratory.,0
The patient tolerated the procedure well without immediate post-procedure complication.,1
"Radiology attending, Dr. , was present and actively participated throughout the duration of the procedure.",0
IMPRESSION: Successful ultrasound-guided left thoracentesis.,0
One liter of clear amber fluid was drained.,0
Samples were sent to the laboratory as requested by the referring service.,0
12:36 PM CT T-SPINE W/O CONTRAST Clip # Reason: PLEASE DO T1-T9 WITH RECONSTRUCTION PLEASE .....,0
Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDEMT ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with S/P T2-8 FUSION / T3-4 COMMINUTED FRACTURES REASON FOR THIS EXAMINATION: PLEASE DO T1-T9 WITH RECONSTRUCTION PLEASE ..... No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Thoracic spine fracture status post fusion.,1
"COMPARISON: Thoracic spine MRI, dated , and torso CT, dated , .",0
TECHNIQUE: Axial multidetector CT images of the thoracic spine were obtained.,0
Sagittal and coronal reformatted images were generated.,0
"FINDINGS: Correlation with a preceding torso CT reveals that there are 13 rib-bearing vertebrae, numbered T1 through T13 in this report, 4 lumbar-type vertebrae, and a partially sacralized L5.",0
There is evidence of laminectomies from T2 through T6.,0
It is not clear whether there is a laminotomy at T7.,0
There is posterior fusion from T1 through T7.,0
"There are pedicle screws at T1, T2, T5, and T7, which appear well positioned without evidence of loosening.",0
"Fractures of the posterior and anterior elements of T3 and T4 are again seen, as described previously.",0
"Due to extensive hardware- related artifacts, evaluation of the spinal canal is limited.",0
A drain is present in the laminectomy beds.,0
"There is a partially visualized right pneumothorax, new compared to .",1
"There are partially visualized dependent pulmonary opacities, which were present previously.",0
A left pleural effusion is also again seen.,0
"Thirteen thoracic-type vertebrae, labelled T1 through T13 in this report.",0
"Status post posterior fusion as described above, with anatomic alignment.",0
Comminuted fractures of T3 and T4 as described previously.,0
Evaluation of spinal canal is markedly limited due to artifacts.,0
"Partially visualized right pneumothorax, better seen on a chest radiograph performed earlier today.",1
"10:33 PM CHEST (PORTABLE AP) Clip # Reason: r/o PNA or acute pathology Admitting Diagnosis: COPD,PNEUMONIA,PULMONARY EMBOLUS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with COPD, HTN, hypothyroidism transferred from OSH for PE and PNA REASON FOR THIS EXAMINATION: r/o PNA or acute pathology ______________________________________________________________________________ FINAL REPORT AP CHEST HISTORY: COPD, hypertension and hypothyroidism.",1
"IMPRESSION: AP chest reviewed in the absence of any prior chest radiographs: Consolidation in the right upper lobe marginates in the interlobar fissure, probably pneumonia.",0
There is no pleural effusion or evidence of central adenopathy.,0
The heart is normal size.,0
Mediastinal fullness and leftward tracheal deviation suggests enlargement of at least the right lobe of the thyroid gland.,0
"Dr. and I discussed these findings, at the time of dictation.",0
"2:07 PM CHEST (PORTABLE AP) Clip # Reason: fever, and hypotension--eval for PNA ______________________________________________________________________________ MEDICAL CONDITION: 49M s/p liver tx with saddle thrombus on heparin.",0
"REASON FOR THIS EXAMINATION: fever, and hypotension--eval for PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 49-year-old with a history of prior liver transplant and pulmonary embolus.",0
Now with fever and hypotension.,0
"Comparison is made to several studies dating back to , most recently .",0
FINDINGS: Cardiac and mediastinal contours are normal.,0
The previously seen right pleural effusion has decreased.,1
"There is improved aeration at the right lung base, but some atelectasis still persists.",0
A pigtail catheter is again seen within the right upper quadrant at the edge of the film.,0
IMPRESSION: Slight improvement in previously seen small right pleural effusion with improved aeration at the right lung base.,1
1:04 PM CHEST (PORTABLE AP) Clip # Reason: postop film Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT; W/AVR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman s/p AVR/cabg x1 REASON FOR THIS EXAMINATION: postop film ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old woman status post AVR.,1
"SINGLE AP VIEW OF THE CHEST: Endotracheal tube, mediastinal and chest drains, and a Swan-Ganz catheter are in position.",0
There is widening of the mediastinum and increased pulmonary vascular markings consistent with postoperative changes.,0
"Also, noted are new midline sternotomy wires and staples as well as aortic valve prosthesis.",1
Soft tissues and osseous structures are unchanged.,0
IMPRESSION: Changes consistent with recent thoracic surgery.,0
"LINE PLACEMENT Clip # Reason: please evaluate for acute process; please evaluate CVL place Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with cirrhosis, hypotension; also with increased O2 requirement; now, s/p RIJ CVL placement REASON FOR THIS EXAMINATION: please evaluate for acute process; please evaluate CVL placement ______________________________________________________________________________ WET READ: 8:41 PM Tip of R IJ CVL in RA.",1
"Bibasilar atelectasis, L > R. Cannot rule out superimposed PNA.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Catheter placement.,0
"FINDINGS: In comparison with study of , there has been placement of a right IJ catheter that extends to the right atrium.",0
There are lower lung volumes that may account for the apparent increase in the transverse diameter of the heart.,0
Indistinctness of pulmonary vessels suggests elevated pulmonary venous pressure.,0
Opacification at the right base with silhouetting of the hemidiaphragm is consistent with atelectasis and effusion.,0
"In the appropriate clinical setting, the possibility of pneumonia would have to be considered.",0
Minimal atelectatic changes are seen on the right.,0
"5:12 PM CT CHEST W/O CONTRAST Clip # Reason: s/p pnuemothorax times two eval for airway disease, Pt S/P a Admitting Diagnosis: S/P FALL, S/P R/O MI ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with REASON FOR THIS EXAMINATION: s/p pnuemothorax times two eval for airway disease, Pt S/P ascending aneurysym repair No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumothorax x 2 after ascending aortic aneurysm repair.",0
"TECHNIQUE: Non-contrast chest CT with reconstructions and lung algorithm, and at 1.25 mm intervals.",0
COMPARISON: Chest radiographs from earlier the same day.,0
NONCONTRAST CHEST CT: There are sternal wires and post-surgical changes within the mediastinum from ascending aortic repair.,0
"Note is made of a residual large amount of likely loculated pericardial fluid adjacent to the ascending aorta, which contains several air bubbles.",0
The fluid does not demonstrate Hounsfield units consistent with blood (approximately 15).,0
There is no pericardial effusion about the apex or inferior aspect of the heart.,0
A right chest tube is in place.,0
"There is a small to moderate sized right pneumothorax, most pronounced at the right lung base anteriorly.",0
"There is a smaller posterior component at the level of the bronchus intermedius, and a tiny right apical component.",0
There is a moderate left pleural effusion with associated atelectasis of the left lower lobe.,1
No suspicious consolidations are seen.,0
There is minor right lower lobe atelectasis as well.,0
"Note is made of high attenuation material within the atelectasis (not present on the prior CT, ).",0
Limited evaluation of the upper abdomen again demonstrates gallstones without evidence of acute cholecystitis.,0
"The visualized portions of the spleen, liver, and kidneys are unchanged since the abdominal CT scan from .",0
"Evaluation of osseous structures shows osseous changes from prior median sternotomy and, with multiple posterior right rib fractures.",0
"IMPRESSION: 1) Moderate residual right pneumothorax, most pronounced in the right lung base anteriorly, but with additional pneumothorax pockets posteromedially and in the right apex.",0
2) Moderate amount of pericardial fluid adjacent to ascending aorta with post-operative air bubbles.,0
"3) Moderate left pleural effusion with associated atelectasis of the left (Over) 5:12 PM CT CHEST W/O CONTRAST Clip # Reason: s/p pnuemothorax times two eval for airway disease, Pt S/P a Admitting Diagnosis: S/P FALL, S/P R/O MI ______________________________________________________________________________ FINAL REPORT (Cont) lower lobe.",1
4) High attenuation right lower lobe atelectasis.,0
"Given oral contrast seen in the bowel (new since ), findings are likely due to aspirated barium.",0
"5:12 PM FOOT AP,LAT & OBL LEFT PORT; HEEL (AXIAL & LATERAL) LEFT PORT Clip # Reason: s/p screw tightening.",0
evaluate interval change since pre-op.,0
Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p screw tightening.,0
REASON FOR THIS EXAMINATION: s/p screw tightening.,0
______________________________________________________________________________ WET READ: 9:51 PM Evaluation of bony detail limited by splint material.,0
Screws again seen transfixing the distal tibia/fibula as well as extending through the hindfoot into the distal tibia.,0
Mildly displace fracture of the distal fibula does not appear significantly changed.,0
Changes associated with Charcot foot again noted.,0
______________________________________________________________________________ FINAL REPORT STUDY: Five images of the left foot and ankle .,0
"INDICATION: Status post screw tightening, evaluate for interval change since preop.",0
FINDINGS: A posterior plaster splint is present and obscures the bony detail.,0
Again seen is the distal fibular fracture without change in alignment.,0
Unchanged periostitis along the fibula.,0
Status post ORIF of the high syndesmosis and subtalar and tibiotalar arthrodesis.,0
The syndesmotic screws are intact.,0
The arthrodesis screws are intact and unchanged in position.,0
Unchanged perihardware lucency around the distal anterior screw.,0
Unchanged findings of Charcot arthropathy within the midfoot and hindfoot.,0
No hardware complication of the high syndesmotic screws.,0
Unchanged perihardware lucency around the anterior arthrodesis screw.,0
"3:11 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please eval for plugging or other path Admitting Diagnosis: FOURNIER'S GANGRENE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with new desats and paradoxical breathing REASON FOR THIS EXAMINATION: please eval for plugging or other path ______________________________________________________________________________ FINAL REPORT HISTORY: New desaturation, to assess for plugging.",0
"FINDINGS: In comparison with the earlier study of this date, diffuse bilateral pulmonary opacifications persist.",0
There is no evidence to suggest a substantial lobar collapse.,0
12:56 PM CAROT/CEREB Clip # Reason: ?,0
BLEED Contrast: OPTIRAY Amt: 220 ********************************* CPT Codes ******************************** * 3ED ORDER /BRACHIOCEPHALIC 2ND ORDER /BRACHIOCEPHALIC * * -59 DISTINCT PROCEDURAL SERVICE 1SR ORDER /BRACHIOCEPHALIC * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD OR> /BRACHIO * * CAROTID/CERVICAL/BILAT A-GRAM CAROTID/CEREBRAL BILAT A-GRAM * * VERT/CAROTID/CEREBRAL A-GRAM VERT/CAROTID/CEREBRAL A-GRAM * * EXT BILAT A-GRAM -52 REDUCED SERVICES * * IV CONSCIOUTIOUS SEDATION PRO * **************************************************************************** ______________________________________________________________________________ FINAL REPORT (REVISED) PREOPERATIVE DIAGNOSIS: Rule out basilar stenosis.,0
INDICATIONS: This patient presented with a cerebellar hemorrhage and a previous suggestion of a basilar stenosis.,0
This angiogram is being performed to determine whether the basilar artery is completely occluded or whether it is stenosed and ammenable to treatment.,0
"CONSENT: The patient was given a complete explanation of procedure including the risks, benefits and possible complications both to himself and the family.",0
The family agreed to proceed with the operation.,0
ANESTHESIA: Conscious sedation followed by department of nursing with divided doses of Versed and Fentanyl with continuous hemodynamic monitoring throughout the procedure.,0
10 cc of 1% lidocaine was also infused into the right common femoral region.,0
PROCEDURE: The patient was brought into the endovascular suite and placed in stable and supine position.,0
The right and left groin areas were prepped and draped in the usual sterile fashion.,0
At this point a 19 gauge single wlal needle was used to puncture the right common femoral artery after performingin small skin incision with a #11 blade.,0
Upon the return of brisk arterial blood a guidewire was inserted into the right common femoral and over the wire a 5 French vascular sheath was inserted into the right common femoral artery and secured in position with a cutaneous 0 silk suture.,0
The sheath was kept under continuous heparinized saline drip irrigation.,0
5 French vascular sheath was used over a hydrofoley guidewire to introduce the catheter in the left subclavian artery.,0
With the catheter in the left subclavian artery angiographic run was performed in the AP projection.,0
The catheter was then placed into the innominant artery with the catheter in the innominant artery angiographic run was obtained of the chest in the AP projection.,0
The catheter was then advanced into the right common carotid artery with the catheter in the right common carotid artery angiograhphic run was obtained in AP projection of the neck.,0
The catheter was then placed into the right internal carotid artery and a biplane angiographic run was obtained of the whole head.,0
The catheter was then placed into the right suclavian artery where an AP projection of the right subclavian artery.,0
The catheter was then placed into (Over) 12:56 PM CAROT/CEREB Clip # Reason: ?,0
BLEED Contrast: OPTIRAY Amt: 220 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) the left common carotid artery where an angiographic run was obtained of the left common carotid artery in single plane projection of the neck.,0
The catheter was then inserted into the left internal carotid artery where a biplane angiographic run was obtained of the head in AP and lateral projections.,0
Catheter was then removed from the patient and a right common femoral artery run was obtained using injection of the vascular sheath with 10 cc of non-ionic contrast and accquisition of approximately 15 digital images.,0
At this point a wire was introduced back into the vascular sheath and the vascular sheath was removed and arteriotomy was closed using a Perclose device.,0
Patient tolerated the procedure well and was transferred back to the Recovery Room having sufferred no neurological sequallae as a result of the procedure.,0
Injection of the left subclavian artery demonstrates a number of atherosclerotic changes of the arch and of the proximal subclavian artery other than then irregular atherosclerotic changes in the wall there appears to be no frank stenosis of the left subclavian artery.,0
Injection of the left subclavian artery also reveals a slow flow into the dimminutive left vertebral artery.,0
"Injection of the left subclavian artery with the cuff elevated reveals the course of the left vertebral artery to be hypoblastic in the neck and free of any focal stenosis in the cervical region, however, there is scant filling of the vertebral artery beyond its supply to the PICA.",0
Injection of the innominate artery reveals minimal atherosclerotic changes in the wall and no evidence of focal stenosis or dissection.,0
"The origin of the right common carotid artery and the right subclavian artery are free of disease, as is the origin of the right vertebral artery.",0
Injection of the right common carotid artery reveals no evidence of stenosis or disease.,0
There is a minimal bump on the outer edge of the right internal carotid artery origin which is not hemodynamically significant and constitutes less than 10% stenosis.,0
Visualization of the intracranial vessels of the right internal carotid artery injection reveal no evidence of intracranial aneurysm or arteriovenous shunting.,0
They also reveal significant perfusion of the upper basilar artery by retrograde flow down the posterior communicating artery.,0
This finding suggests that the proximal basilar artery is indeed occluded.,0
"Injection of the right subclavian artery with the calf elevated reveals a somewhat tortuous anatomy of the right vertebral artery which is the dominant of the two vertebral arteries in addition, the flow is slow and ends in PICA with evidence of occlusion of the proximal basilar trunk.",0
(Over) 12:56 PM CAROT/CEREB Clip # Reason: ?,0
BLEED Contrast: OPTIRAY Amt: 220 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) 5.,0
Injection of the left common carotid artery reveals again minimal shelf changes on the origin of the left internal carotid artery which are not hemodynamically significant and are not significantly ulcerated.,0
Injection of the left internal carotid artery in the intracranial portion reveals it to no intracranial aneurysm but shows a left posterior communicating artery and infundibulum.,0
"There is less perfusion of the upper basilar trunk from the left internal carotid artery, when compared to the right internal carotid artery.",0
Injection of the right common femoral artery reveals it to be free of stenosis or disease.,0
IMPRESSION: Proximal basilar artery occlusion with retrograde perfusion of the upper basilar trunk from the right posterior communicating artery in retrograde fashion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Protamine / Lovenox Attending: Chief Complaint: hip pain Major Surgical or Invasive Procedure: Dialysis History of Present Illness: The patient is an 81 year old female with past medical history of coronary artery disease, aortic stenosis status post Aortic valve repair, diastolic congestive heart failure, End stage renal disease on hemodialysis (MWF ), diabetes , and hypertension who presented to the ED with left thigh pain after a fall in the afternoon.",1
The patient states she went to the refrigerator using her walker when her knee gave out and she fell on her butt.,0
Her legs were twisted under her.,0
She denies LOC or head injury.,0
She was unable to weight bear on her left leg and after one of pain day decided to come to the ED.,0
Past Medical History: 1. repeated Hx of gastrointestinal bleeding (most recent ) 2.,0
Left hemicolectomy with transverse colostomy for GIB 3.,0
Diastolic CHF (EF 65-75%) on 2L O2 4.,0
Status post tracheostomy placement after prolonged intubation in ICU (at time of colectomy) - removed 5.,0
"Severe AS s/p mechanical AVR, , goal INR 6.",0
End-stage renal disease on HD MWF (via LUE AVF) 10.,1
Bilateral total knee replacment 11.,0
Multiple skin lesions removed by general and plastic surgery 12.,0
"Presumptive history of atrial fibrillation; on amiodarone 14. revision of LUE AVF -->functioning and started HD Social History: Lives at home with husband, and son.",1
"Is a non-smoker, no alcohol use, no history of illicit drug use.",0
"Retired, former manager Her son lives her on the of their two family home.",0
Family History: She is an only child.,0
Grandfather died of cancer but son is not sure of what type.,0
"Physical Exam: VS: Afebrile BP 115/46 HR 52 100% on 2L NC GEN: African American female in NAD, sitting up in bed HEENT: EOMI, PERRL, oropharynx clear NECK: Supple, no CHEST: CTABL, no w/r/r CV: Bradycardic, S1S2, no m/r/g ABD: Soft/NT/ND; colostomy with associated herniation at site EXT: no c/c/e SKIN: no rashes NEURO: AAOx 3; no focal deficits; gait deferred; answers questions appropriately .",0
Pertinent Results: Admission labs- 10:44PM BLOOD WBC-3.7* RBC-3.90* Hgb-12.4 Hct-37.7# MCV-97 MCH-31.7 MCHC-32.8 RDW-15.1 Plt Ct-169 10:44PM BLOOD Neuts-59.4 Lymphs-31.0 Monos-5.8 Eos-3.2 Baso-0.6 10:44PM BLOOD PT-26.5* PTT-30.9 INR(PT)-2.6* 10:44PM BLOOD Glucose-86 UreaN-44* Creat-6.3*# Na-139 K-4.5 Cl-99 HCO3-29 AnGap-16 06:15AM BLOOD Calcium-6.9* Phos-5.7*# Mg-1.9 Images- xray RIGHT FEMUR: Diffuse osteopenia.,0
Suboptimal radiograph for evaluation of a fracture.,0
No definite fracture or dislocation seen; however subtle fracture could be missed.,0
"On one of the images, there is overlapping hand with ring, which is limiting the evaluation of that area.",0
RIGHT KNEE: Status post total knee arthroplasty.,0
No evidence of lucency at the total hip prosthesis.,0
No evidence of fracture or dislocation.,0
There is a large calcified fibroid.,0
"Suboptimal radiograph; however, no definite fracture or dislocation seen.",0
CT pelvis IMPRESSION: No evidence of free fluid or hematoma.,0
CT lower ext PRELIMINARY READ- non displaced fracture of the left lesser trochanter.,0
"Brief Hospital Course: The patient is an 81 year old female with past medical history of coronary artery disease, aortic stenosis status post Aortic valve repair, diastolic congestive heart failure, End stage renal disease on hemodialysis (MWF ), diabetes , and hypertension who presents with left hip pain.",1
"In the ED, VS were : T98.4 BP 104/48 HR 58 RR18 100%RA.",0
She received tramadol and toradol for pain but was still unable to ambulate given severe pain.,0
The next morning in the ED her blood pressure was found to be in the 84/31 -> 78/32.,0
She also had a Hct drop from 37 to 31 and there was concern that she was bleeding.,0
She was given 2L NS while in the ED with some improvement in pressure and her AM BP meds were held.,0
Hip films showed osteopenia but no fractures.,0
CT abdomen and CT thigh were done to further evaluate her hypotension and the CT thigh showed nondisplaced fracture of her left lesser trochanter.,1
Ortho was consulted and felt she did not need surgery and recommended PT consult and partial weight bearing as tolerated.,0
She was transferred to the ICU for further management of her hypotension.,0
# Hypotension: Her BP improved with 2L of fluid bolus.,0
The hypotension was thought to be realated to fluid depletion initially.,0
Her BP meds were stopped.,0
"She had several low BPs into the 80s while asleep, and was given small fluid boluses without great effect.",0
"She went for HD the day after admisison, she was 7kg above her dry wt, had 1.5 liters removed and BP actually improved.",0
"Therefore, she was likely not fluid depleted, but more likely was fluid overloaded.",0
Her hct was stable and a CT of the extremity and abd/pelvis showed no evidence of bleeding as an explaination.,0
Her amiodarone was restarted but her metoprolol and hydralazine were held.,0
"When she was transfered to the medicine floor, her BP meds continued to be held and her blood pressure remained in the low 100s.",0
"She should continue to not take her metoprolol as long as her blood pressures remains low, but this medication can be restarted as an outpatient if her BP increases.",0
"# Trochanteric fracture: She had a new stable, non-displaced fracture.",1
"Pt was seen by ortho who recommended partial weight bearing as tolerated and PT, and surgical repair was not needed at this time.",0
She was treated for her pain with tylenol and IV morphine with her turning.,0
She continued to improve and did well on tylenol alone.,0
# ESRD: Continued on HD M/W/F.,0
Continued on nephrocaps and sevelamir.,0
Renal followed the pt while admited.,0
She should be discharged on a new medication: Sevelamer Carbonate 2400 mg three times a day with meals.,0
"# Anemia of chronic disease: Iron studdies showed ferretin 1295, TIBC 161, trasnferin 124.",1
Pt received EPO at hemodialysis.,0
TSH = 3.5 # Atrial fibrillation: She was in sinus rhythm and her metoprolol was initially was held due to low BP.,1
She was continued on her amiodarone.,0
She was continued on anticoagulation.,0
# Hyperlipidemia: She was continued on her statin Medications on Admission: Nexium 40mg PO daily Fluticasone/salmeterol 250/50mcg 1 INH Senna Aranes ASA 81mg PO daily Hydralazine 25mg PO q6hours (hold on dialysis days) Simvastatin 20mg PO daily Amiodarone 200mg PO daily Ambien 5mg qHS PRN Metoprolol 50mg PO bid.,0
(hold on dialysis days) Lactulose PRN Colace 50mg PRN Levthyroxine 88mcg tab PO daily Warfarin Nephrocaps 1mg PO daily Sevelamer 2400 mg PO TID W/MEALS Discharge Medications: 1.,0
"Nexium 40 mg Capsule, Delayed Release(E.C.)",0
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Lactulose 10 gram/15 mL Solution Oral 8.,0
Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation.,0
Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM.,0
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for fever/pain.,0
Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
Discharge Disposition: Extended Care Facility: Hospital Discharge Diagnosis: Primary diagnosis: Trochanteric fracture Hypotension End stage renal disease Secondary diagnosis: hypothyroidism atrial fibrillation anemia of chronic disease Discharge Condition: Good.,1
Discharge Instructions: You came to the hospital because you fell and hurt your leg.,0
You had a CT scan which showed you have a nondisplaced fracture of your thigh bone and the orthopedic surgeons thought that you did not need surgery.,0
They said that you can bear weight on your leg as tollerated.,0
You were transfered to the ICU because you were found to have low blood pressure.,0
There you received IV fluids and pain medications.,0
You did well and were transfered back to the medicine floor.,0
During your hospitalization you continued to have your hemodialysis.,0
You were also evaluated by the physical therapists who recommended that you go to rehab until your leg heals a little more.,0
"The following changes have been made to your medications: Start: Sevelamer Carbonate 2400 mg three times a day with meals Stop: metoprolol Stop: hydralazine Please go to all follow up appointments (see below) Please call your doctor or return to the hosptial if you have fever above 103, chest pain, shortness of breath, increased weight gain over 5 lbs, increased pain in your leg, or any other symptoms of concern.",0
"Followup Instructions: Please go to the following appointments: You have an appointment in Orthopedics with , NP on at 9:20 am.",0
"The phone number is You will need to go the of the building at 9 am the day of your appointment () so that you can have an x ray done You should also make an appointment with your nurse practitioner, .",0
Her phone number is (.,0
She has asked that you call her as soon as you are discharged from rehab so that she can make a house call to check on you.,0
"Provider , AV CARE AV CARE (NHB) Phone: Date/Time: 8:00",0
"1:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Pls eval for infiltrate, pulmonary edema Admitting Diagnosis: HEMATURIA ______________________________________________________________________________ MEDICAL CONDITION: year old man with UTI and hypotension, s/p IV fluids now with hypoxia; EF 25% REASON FOR THIS EXAMINATION: Pls eval for infiltrate, pulmonary edema ______________________________________________________________________________ FINAL REPORT AP CHEST, 1:10 P.M. HISTORY: -year-old man with UTI and hypotension, hypoxia.",1
IMPRESSION: AP chest compared to at 2:30 a.m.,0
Previously questioned left lower lobe consolidation is actually due to overlying vasculature and chronic bronchial wall thickening.,0
There is no pulmonary edema or congestion of either pulmonary or mediastinal vessels.,0
"Given the history of hypoxia and hypotension, pulmonary embolism should be considered, though there is nothing to suggest it on this study.",1
Transvenous right atrial and right ventricular pacer leads follow their expected courses.,0
Mild widening of the upper mediastinum is longstanding due to tortuous head and neck vessels.,0
PATIENT/TEST INFORMATION: Indication: Preoperative assessment.,0
CABG Height: (in) 62 Weight (lb): 148 BSA (m2): 1.68 m2 BP (mm Hg): 115/60 HR (bpm): 59 Status: Inpatient Date/Time: at 11:27 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
Normal IVC diameter with <50% decrease during respiration (estimated RAP 11-15mmHg).,0
There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%).,0
Trace to mild (1+) mitral regurgitation is seen.,0
Height: (in) 67 Weight (lb): 380 BSA (m2): 2.66 m2 BP (mm Hg): 130/87 HR (bpm): 101 Status: Inpatient Date/Time: at 11:13 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Suboptimal image quality as the patient was difficult to position.,0
The aortic arch is moderately dilated.,0
"9:27 PM CHEST (PORTABLE AP) Clip # Reason: trach location, fluid status Admitting Diagnosis: CHRONIC RESPIRATORY FAILURE;AIRWAY OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with ESRD, chronic resp failure on vent.",1
"REASON FOR THIS EXAMINATION: trach location, fluid status ______________________________________________________________________________ FINAL REPORT HISTORY: Renal and respiratory failure, to assess tracheostomy tube.",1
"FINDINGS: In comparison with study of , there is little change in the appearance of the tracheostomy tube.",0
"Dobbhoff tube is in place, though the image ends above the diaphragm so the tip cannot be seen.",0
Central catheter tip similarly is difficult to evaluate and appears to be in the right atrium.,0
Prominence of interstitial markings persists and there are probable bilateral pleural effusions.,0
3:16 PM CHEST (PORTABLE AP) Clip # Reason: check ET tube position Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with respiratory failure s/p reintubation REASON FOR THIS EXAMINATION: check ET tube position ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory failure.,1
FINDINGS: Comparison made to a prior radiograph from earlier the same day.,0
A limited portable chest radiograph demonstrates an endotracheal tube that terminates 5 cm above the carina.,0
A right-sided central venous line terminates in the lower SVC.,0
The right hemithorax is largely excluded from this examination.,0
"The left lung is clear with no evidence of pneumothorax, pleural effusion, or pulmonary parenchymal consolidation.",0
The heart size and mediastinal contours are unchanged compared to prior studies from the same day.,0
IMPRESSION: An endotracheal tube terminates 5 cm from the carina.,0
Otherwise unchanged limited portable chest radiograph.,0
6:26 PM CT HEAD W/O CONTRAST Clip # Reason: ischemic event Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH ?,1
MVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with altered mental status/delerium REASON FOR THIS EXAMINATION: ischemic event No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc TUE 8:01 PM No acute intracranial process seen.,0
"Atrophy, small vessel ischemic disease, and bilateral basal ganglia lacunar infarcts noted.",0
"If there is concern for acute infarction, MRI with diffusion-weighted imaging would be recommended for more sensitive evaluation.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old male with altered mental status and delirium concerning for ischemic event.,0
COMPARISON: MR head from .,0
TECHNIQUE: MDCT-axial imaging was performed through the brain without administration of IV contrast.,0
NON-CONTRAST HEAD CT: Slight tilting of the patient's head during imaging limits evaluation for symmetry somewhat.,0
"Allowing for this, no evidence of acute intracranial hemorrhage, edema, mass effect, hydrocephalus, or large vascular territory infarction is seen.",0
"Study is also limited due to patient motion, particularly the imaging through the skull base.",0
Again prominence of the sulci and ventricles is consistent with age-related involutional change.,0
Periventricular white matter hypodensities are likely due to chronic small vessel ischemic disease.,1
Note is also made of likely chronic small lacunar infarcts in bilateral basal ganglia.,0
"The soft tissues, orbits, and skull appear intact.",0
The visualized paranasal sinuses and mastoid air cells are normally aerated.,0
Vascular calcifications are noted along the cavernous carotid arteries.,0
IMPRESSION: No acute intracranial process seen.,0
"There is evidence of chronic microvascular as well as old lacunar infarction, as on the previous MR.",0
"If there is persistent concern for acute infarction, MRI with diffusion-weighted imaging would be recommended for more sensitive evaluation.",0
Height: (in) 68 Weight (lb): 181 BSA (m2): 1.96 m2 BP (mm Hg): 120/60 HR (bpm): 75 Status: Inpatient Date/Time: at 12:14 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
The aortic root is moderately dilated athe sinus level.,0
IMPRESSION: Symmetric left ventricular hypertrophy with preserved global and regional systolic function.,0
2:26 PM L-SPINE (AP & LAT) IN O.R.,0
Clip # Reason: FUSION Admitting Diagnosis: LUMBAR STENOSIS\FUSION LAMINECTOMY LUMBAR L3-L5 ______________________________________________________________________________ FINAL REPORT HISTORY: Fusion.,1
Two lateral views of the lumbar spine were obtained portably in the OR.,0
"One view shows two surgical markers, one posterior to the presumptive L4 vertebral body and one posterior to the presumptive L5 vertebral body.",0
There is grade 1 anterolisthesis of L3/4 and L4/5.,0
"On view #2, pedicle screws are present overlying the L3, L4, and L5 vertebral bodies, in nominal alignment.",0
Correlation with real time findings is recommended for full assessment.,0
"1:40 PM PICC LINE PLACMENT SCH Clip # Reason: please adjust PICC (loops around) Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME ********************************* CPT Codes ******************************** * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with bacteremia on IV abx, PICC placed in IR has now coiled on itself REASON FOR THIS EXAMINATION: please adjust PICC (loops around) ______________________________________________________________________________ FINAL REPORT HISTORY: Malpositioned PICC.",0
"RADIOLOGISTS: and , with Dr. (the Attending Radiologist), being present and supervising the procedure.",0
The left arm and in situ PICC were prepped and draped in standard sterile fashion.,0
"A 0.018-inch guidewire was advanced through the red lumen of the PICC and the tip was repositioned into the superior vena cava from the left brachiocephalic vein, under fluoroscopic guidance.",0
"Both lumens of the catheter flushed and aspirated well, were capped and heplocked.",0
The catheter was fixed in place with a StatLock device and a sterile transparent dressing was applied.,0
Final limited chest radiograph confirmed catheter tip position in the superior vena cava.,0
The catheter can be used immediately.,0
IMPRESSION: Successful repositioning of the left-sided PICC from the subclavian vein to the superior vena cava.,0
8:26 AM CT HEAD W/O CONTRAST Clip # Reason: assess interval change.,0
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with IPH REASON FOR THIS EXAMINATION: assess interval change.,1
"No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): GWp FRI 10:07 AM Similar-to-slightly increased appearance of left occipitotemporal intraparenchymal hemorrhage, similar appearance of intraventricular hemorrhage, stable appearance of right frontal approach ventriculostomy catheter with tip terminating in the region of the foramen of .",0
More prominent appearance of subarachnoid blood at the right vertex.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Assess interval change in intraparenchymal hemorrhage.,0
FINDINGS: There is a stable appearance to the right frontal approach ventriculostomy catheter with its tip terminating in the region of the foramen of .,0
The ventricular system is stable in size and configuration to the prior study.,0
"Left occipitotemporal intraparenchymal hemorrhage now measures 6.7 x 3.4 cm, previously 6.4 x 3.2 cm with associated stable edema and intraventricular dissection where hemorrhage is seen in the bilateral lateral ventricles, third and fourth ventricle.",0
Subarachnoid blood at the right vertex is more conspicuous on today's study.,0
There is no new focus of hemorrhage.,0
There is mild ethmoidal sinus thickening and a retention cyst.,0
"Retention cyst versus polyp is seen in the left maxillary sinus, mastoid air cells are clear.",0
Similar-to-slightly increased size of left occipitotemporal intraparenchymal hemorrhage.,0
Stable appearance of intraventricular hemorrhage and ventriculostomy catheter.,0
Increased conspicuity of small amount of subarachnoid blood at the right vertex.,0
3:10 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO); -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # Reason: ** please place POST-PYLORIC DOBHOFF tube in IR ** Admitting Diagnosis: BACTEREMIA Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 78F s/p hepatojejunostomy who is intubated.,1
"REASON FOR THIS EXAMINATION: ** please place POST-PYLORIC DOBHOFF tube in IR ** Per Attg request, given this a transplant pt, would prefer attempt via fluoroscopy.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old woman presents for positioning of nasointestinal tube into the duodenum.,0
TECHNIQUE: Fluoroscopic-guided nasointestinal tube placement.,0
FINDINGS: An 8 French - nasointestinal tube was inserted through the left nostril.,1
"Under fluoroscopic guidance, the tube was advanced through the pharynx into the stomach with the tip seen ending at the ligament of Treitz.",0
"Placement was confirmed with the use of contrast medium, which demonstrated the tip of the tube in the distal duodenum.",0
IMPRESSION: Successful placement of nasointestinal tube to the ligament of Treitz.,0
PATIENT/TEST INFORMATION: Indication: Hypotension with EKG changes Height: (in) 66 Weight (lb): 200 BSA (m2): 2.00 m2 BP (mm Hg): 100/47 HR (bpm): 78 Status: Inpatient Date/Time: at 16:29 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%).,0
There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%).,0
IMPRESSION: Mild left ventricular hypertrophy with normal global and regional biventricular systolic function.,0
Normally-functioning mechanical aortic valve prosthesis.,0
At least mild mitral regurgitation.,0
"Compared with the prior study (images reviewed) of , the findings are similar, however pulmonary pressures and severity of tricuspid regurgitation have both increased since the time of a more comprehensive study of .",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: Baby is a 3.015 kilogram product of a 34 week gestation, born to a 37 year old G-5, P-3, now 4, black female.",0
"Prenatal screens: A positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS negative.",0
"Maternal history remarkable for morbid obesity, chronic hypertension treated with nifedipine, type 2 diabetes mellitus on insulin, asthma on albuterol, sleep apnea treated with CPAP, recurrent UTIs, sickle cell trait.",0
There is a history of preeclampsia with previous pregnancies.,0
"This pregnancy complicated by advanced maternal age, no amniocentesis, normal fetal survey at 16 weeks, preeclampsia with hypertension, headache, blurred vision, nonstress test nonreassuring, biophysical profile 8 out of 8, ultrasound reveals breech positioning, betamethasone complete on .",0
"Under epidural anesthesia, the infant was delivered by cesarean section secondary to breech positioning and preeclampsia.",1
Mother given Fentanyl approximately 5 minutes prior to delivery.,0
"Breech extraction, depressed infant with poor respiratory effort, variable heart rate intermittently above and below 100 requiring vigorous stimulation, bag mask ventilation and finally Narcan before significant and sustained improvement in respiratory effort and heart rate.",0
"Apgar 4, 6 and 7.",0
"PHYSICAL EXAMINATION: On admission, an LGA 34 week male with mild retractions, weight 3.015 kilograms, length 49 cm, head circumference 33 cm, all greater than 90th percentile.",0
"Anterior fontanelle soft, flat, nondysmorphic, intact palate, mild retractions, fair aeration, wet breath sounds, no murmur, normal pulses, soft abdomen, 3 vessel cord, no hepatosplenomegaly, normal male genitalia, testes descended into scrotum.",0
No hip click but wax hips.,0
"Patent anus, no sacral dimple.",0
Positive mongolian spots on buttocks.,0
Bruising on abdomen and legs.,0
"Decreased tone, moved all extremities well.",0
HISTORY OF HOSPITAL COURSE: By systems: Respiratory: was initially on nasal prong CPAP for 48 hours at which time he was transitioned to nasal cannula O2.,0
and then to RA on the morning of transfer with O2 sats 90-97% Cardiovascular: No issues.,0
Fluid and electrolytes: Birth weight was 3.015 kilograms.,0
The infant was initially started on 60 cc/kg/day of D10W.,0
IV fluids were weaned slowly with the addition of enteral feedings.,0
The infant has now weaned off of all IVF and is tolerating 140 cc/kg/day enteral feedings of PE/MM 20 cal/oz.,0
The infant has been euglycemic throughout hospital stay.,0
GI: Peak bilirubin was on day of life #3 at 7.6/0.4.,0
He has not required any intervention at this time.,0
Hematology: Hematocrit on admission was 50.,0
He has not required any blood transfusions.,0
"Infectious disease: CBC and blood culture obtained at admission, CBC was benign and blood cultures remain negative.",0
The infant started on ampicillin and gentamicin at 24 hours of age for continued respiratory support needs.,0
"X-ray at that time was consistent with pneumonia so the infant will be treated with a total of 7 days total of ampicillin and gentamicin, of which he still needs one more dose of gentamicin and 2 more doses of ampilllin.",0
Neurology: He has been appropriate for gestational age.,0
Audiology: Hearing screen has not been performed but should be done prior to discharge.,0
Psychosocial: Social worker has been involved with family due to difficulties with transprotation.,0
Social worker can be reached at ( if any questions arise.,0
"DISCHARGE DISPOSITION: To Hospital, a level II nursery, telephone number is .",0
"Name of primary pediatrician is Dr. , telephone number if .",0
Continue 140 mL/kg/day of Enfamil or breast milk at 20 calories/oz.,0
Medications: Continue ampicillin at 150 mg/kg q.12hours and gentamicin 4 mg/kg daily to complete the total of 7 days.,0
Car seat position screening not yet performed.,0
State Newborn screens have been sent per protocol and have been within normal limits.,0
The infant has not received any immunizations to date.,0
"Immunizations recommended: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following 3 criteria: 1, born at less than 32 weeks, 2, born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or 3, with chronic lung disease.",1
Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age.,0
"Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers.",0
"Premature infant born at 34 weeks, large for gestational age.",1
", Dictated By: MEDQUIST36 D: 20:26:29 T: 21:15:35 Job#:",0
LINE PLACEMENT Clip # Reason: R picc pulled back 9cm Admitting Diagnosis: BILATERAL KNEE OSTEOARTHRITIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man s/p b/l knee replacement now with hypercarbic respiratory failure - s/p IJ placement.,0
REASON FOR THIS EXAMINATION: R picc pulled back 9cm ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the right PICC line.,0
Portable chest radiograph was compared to .,0
The PICC line can be visualized up to the mid portion of SVC.,0
"No continuation is demonstrated below this point, but this chest radiograph is suboptimal for visualization of the wire.",0
"For precise evaluation of the wire placement, a PA and lateral chest radiograph should be obtained.",0
"The heart size, the mediastinum and the lungs are unremarkable.",0
No pleural effusion is identified.,0
"3:12 PM SHOULDER VIEWS NON TRAUMA LEFT Clip # Reason: ?osteomyelitis Admitting Diagnosis: INFECTED ICD WIRE;BACTEREMIA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with recurrent MSSA bacteremia, bone scan showing uptake in L shoulder (, and OSH scan ) REASON FOR THIS EXAMINATION: ?osteomyelitis ______________________________________________________________________________ FINAL REPORT LEFT SHOULDER VIEWS AP AND LATERAL Y VIEW.",0
Comparison made to previous film of .,0
Abnormal uptake in left shoulder on preceding outside bone scan.,0
FINDINGS: There is narrowing of the leftglenohumeral joint in keeping with background of degenerative change.,0
This is very similar in appearance to the previous plain film of .,0
There is no evidence of bone destruction or periosteal reaction to strongly suggest osteomyelitis on plain film.,0
Some increased uptake of isotope would be expected in the setting of degenerative change.,0
Pacemaker wire box projected over the left pectoral area.,0
Moderate degenerative change in the left shoulder joint.,0
Plain film unchanged compared to previous film of .,0
PATIENT/TEST INFORMATION: Indication: Interval progression of Pericardial effusion.,0
Height: (in) 70 Weight (lb): 180 BSA (m2): 2.00 m2 BP (mm Hg): 96/61 HR (bpm): 94 Status: Inpatient Date/Time: at 14:51 Test: Portable TTE (Focused views) Doppler: Limited doppler and no color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
The effusion appears loculated anteriorly.,0
"Compared with the findings of the prior study (tape reviewed) of , no change.",0
"4:52 PM CHEST (PORTABLE AP) Clip # Reason: eval infiltrate/effusion Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with cystic lung dz, renal tx, here with fever, sob, crackles now at L base REASON FOR THIS EXAMINATION: eval infiltrate/effusion ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
HISTORY: 57-year-old woman with cystic lung disease.,0
Patient with fever and shortness of breath.,0
There is a right-sided central venous catheter with distal tip in the mid SVC.,0
The cardiac silhouette is markedly enlarged.,0
There is again noted marked interstitial prominence.,0
"However, this is slightly improved since the previous study, consistent with improve pulmonary edema in a patient with chronic interstitial changes.",0
Chain sutures are seen within the right middle lung zone.,0
The opacities seen at the left lung bases have improved since the prior study.,0
3:15 PM CTA ABD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # CTA PELVIS W&W/O C & RECONS Reason: EVAL FOR AAA - POST ANGIO COILING Admitting Diagnosis: SAH Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with REASON FOR THIS EXAMINATION: R/O AAA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CTA OF THE AORTA.,0
CLINICAL HISTORY: Status post neuro aneurysm coiling.,0
CTA OF THE AORTA: There is scattered calcification throughout the entire abdominal aorta.,0
The aorta enhances homogeneously without evidence of focal aneurysm.,0
There is ectasia of the infrarenal aorta measuring up to 2.8 x 2.8 cm.,0
The common iliac arteries are normal in caliber.,0
There are three left renal arteries.,0
There is a single right-sided renal artery.,0
"CT OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The liver is normal in size, intensity.",0
No focal hepatic lesion is identified.,0
There is contrast material within the gallbladder from vicarious excretion.,0
"The pancreas, spleen, adrenal glands and kidneys are unremarkable.",0
Unopacified small and large bowel are normal in appearance.,0
CT OF THE PELVIS WITHOUT AND WITH CONTRAST: The bladder is unremarkable.,0
There is a balloon Foley catheter within the bladder.,0
No lymphadenopathy is present within the pelvis.,0
There is stranding of the right groin from recent intervention.,0
BONE WINDOWS: There are degenerative changes of the right hip and lumbar spine.,0
IMPRESSION: 1) Ectasia of the infrarenal aorta without focal aneurysm.,0
2) Three left renal arteries.,0
9:22 AM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed hx stroke s/p cabg Admitting Diagnosis: DEHYDRATION ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with cabg REASON FOR THIS EXAMINATION: r/o bleed hx stroke s/p cabg CONTRAINDICATIONS for IV CONTRAST: r/o bleed ______________________________________________________________________________ WET READ: ARHb TUE 10:51 AM No intracranial hemorrhage or edema.,0
Sequela of prior remote L MCA terriotry infarct again noted.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old male status post CABG.,0
Evaluate for intracranial hemorrhage with history of stroke.,0
TECHNIQUE: Non-contrast axial images of the head are obtained at 5-mm section thickness.,0
"FINDINGS: There is no intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarction.",1
"Left temporal encephalomalacia and ex vacuo dilatation of the left lateral ventricular trigone is consistent with remote left MCA territory infarct, with hypodensity along the left internal capsule, also apparent.",0
Minimal periventricular white matter hypodensity is consistent with chronic small vessel ischemic changes.,0
"Overall, ventricular and sulcal size and configuration appears not significantly changed.",0
"Minimal bilateral maxillary sinus mucosal thickening, bilateral ethmoid air cell mucosal thickening and opacification and sphenoid sinus mucosal thickening is noted.",0
The imaged portions of the mastoid air cells are well aerated.,0
Atherosclerotic calcifications involve the cavernous carotid bilaterally.,0
"IMPRESSION: No acute intracranial hemorrhage or edema, sequelae of remote left MCA territory infarct again noted.",0
"4:06 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for tube placement Admitting Diagnosis: ASCITIES ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with cirrhosis, hiv, hcv now s/p intbuation REASON FOR THIS EXAMINATION: eval for tube placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post intubation, evaluation for tube placement.",1
FINDINGS: An endotracheal tube has been placed.,0
The tube is malpositioned in the right main bronchus.,0
"As a consequence, a complete collapse of the left lung is observed.",0
No evidence of other complications.,0
Normal appearance of the right lung.,0
was paged and notified by the time of dictation.,0
"11:19 PM PORTABLE ABDOMEN Clip # Reason: r/o SBO, ileus Admitting Diagnosis: CORD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 47 y/o male s/p diving accident w/ C3 cord injury, with abdominal distention REASON FOR THIS EXAMINATION: r/o SBO, ileus ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old male, status post diving accident with C3 cord injury, with abdominal distention, rule out small bowel obstruction, ileus.",1
FINDINGS: One portable supine abdominal radiograph was reviewed.,0
Significant dilation of the stomach is noted with interval removal of NG tube.,0
A small amount of air along with a considerable amount of stool is seen throughout the colon.,0
There is a mildly dilated loop of air-filled small bowel in the mid abdomen.,0
The overall bowel gas pattern is nonspecific.,0
The imaged osseous structures are unremarkable.,0
An IVC filter is seen.,0
There is a tube and ring structure overlying the mid abdomen extending toward the thorax.,0
No definitive evidence of obstruction or ileus.,1
Markedly distended stomach with interval removal of NG tube.,0
"3:13 PM CHEST (PA & LAT) Clip # Reason: Assess for pneumo, s/p CT pull ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p CABG REASON FOR THIS EXAMINATION: Assess for pneumo, s/p CT pull ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG with removal of chest tube, assess for pneumothorax.",0
COMPARISON: PA AND LATERAL CHEST: The endotracheal tube and right internal jugular catheter have been removed in the interval.,0
There are bibasilar areas of increased opacity with air bronchograms present.,0
These findings are consistent with bilateral lower lobe atelectasis.,0
"In the appropriate clinical setting, pneumonia cannot be excluded.",0
There is no evidence for congestive heart failure.,0
There is no widening of the mediastinum.,0
IMPRESSION: No evidence for pneumothorax.,0
Bibasilar areas of opacity which likely relate to atelectasis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Cephalosporins / Morphine / Fentanyl Attending: Chief Complaint: Lethargy, txf from OSH with presumed urosepsis Major Surgical or Invasive Procedure: Left femoral line foley catheter changed History of Present Illness: Mr. is a 46 year old male with multiple medical problems pertinently including DM2 and morbid obesity, being transferred from OSH with presumed urosepsis.",1
He presented to on the morning of transfer c/o 3 days of increasing lethargy and AMS.,0
"By his report he has been feeling ""out of it"" for the last 3 days, but can't quite articulate why.",0
"He says he's been very weak and actually fell once, however on further questioning and review of the notes this has been going on for months.",0
"He denies any headache, photophobia, neck stiffness.",0
"ROS positive for cough over the last week or so, occasionally productive of sputum, as well as shortness of breath, however he says this is also a chronic problem.",0
"Denies any fevers, chills, abdominal pain.",0
Has a chronic foley in place for about a year and denies any pain at the foley site or change in urine color.,1
His colostomy output has not changed in consistency or quantity.,0
"He is unsure if he has had any recent medication changes, and mentions that he takes a lot of anti-anxiety medications.",0
"At the OSH he was found to be virtually unresponsive, hypotensive to the 80s systolic.",0
"WBC was 10, with a positive UA (+nitrite, +LE, 20-50 WBC, mod bact).",0
"He received 2L NS, vanco/zosyn and was transported to .",0
"On arrival in the ED here, systolics were 80-90 but improved with 2 L IVF.",0
"He had a central line placed in R groin, however has not required pressors.",0
"On arrival to the the patient's vitals were 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC.",0
"He was responsive, albeit sluggish.",0
"Of note, patient has been treated for numerous UTIs in the past, most recently had proteus UTI in , sensitive to Augmentin and cefuroxime.",0
Has also had pseudomonal and klebsiella UTIs in the last 1-2 years.,0
"Past Medical History: 1) DM2 diagnosed with triopathy: Creatinine has been as low as 0.8 in the last couple of years, however widely fluctuant, as high as 2 in the recent past.",0
"2) COPD, on home O2.",0
Multiple episodes of respiratory failure requiring intubation in recent years.,0
"Most recently, was admitted in with a perforated transverse colon requiring partial colectomy and transverse colostomy.",0
"This course c/b anticipated respiratory failure and anticipatory tracheostomy, pseudomonal and MRSA PNA.",1
Also with acalculous cholecystitis requiring cholecystostomy tube.,0
"3) OSA on CPAP 3) VRE 4) s/p tracheostomy, as above in 5) HTN 6) CHF: During hospitalization in it was thought that failure contributed to his respiratory failure.",1
"Last echo was in at which time LVEF thought to be roughly normal, however very poor study and RV not visualized.",0
"7) Anemia of chronic disease, multiple transfusions in the past 8) s/p BKA for chronic LE ulcer 9) TIA in .",1
10) Difficult intubation; fiberoptic guidance in of .,0
14) C. Difficile in .,0
Bilateral carpal tunnel release in .,0
Quadriceps tendon repair in .,0
"Status post partial resection of transverse colon, end transverse colostomy, mucus fistula, jejunostomy tube and percutaneous tracheostomy on .",1
Social History: Lives home alone with VNA.,0
"Remote cigar smoking, no cigarettes.",0
"Family History: Non-contributory Physical Exam: 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC Gen: Morbidly obese caucasian male appearing slightly dyspneic but otherwise comfortable.",1
"MS: AAO x 3, responds to questions appropriately however very slow to respond.",0
"Neck: JVP unable to evaluate Cor: RR, normal rate, distant HS Lungs: Scattered expiratory wheezes anteriorly Abd: NABS, soft, colostomy bag with brown stool, appears C/D/I, second ostomy with gauze C/D/I.",0
"Extr: RLE with erythematous plaque/patch circumferentially around distal tibia (patient reports chronic), 2+ pitting and weeping edema with a couple of vesicles.",0
"LLE s/p BKA, stump covered with dressing.",0
"There is blunting of both costophrenic angles, right greater than left, consistent with pleural effusions.",0
There is no evidence for overt pulmonary edema or focal consolidation.,0
"Brief Hospital Course: 46 year old male with DM2, morbid obesity, p/w hypotension, positive UA, and presumed narcotics abuse.",1
These issues resolved w/ decreased pain meds and fluid resuscitation.,0
New finding of growing in blood cx taken and proteus miribilis in urine - hemodynamically stable.,1
"#) UTI: Has history of recurrent UTIs, resistant to multiple antibiotics.",1
UA collected on grew mixed flora - likely fecal contaminants.,0
Repeat U/A after changing foley showed proteus miribilis.,0
Started abx to treat given hx multiple UTIs in this pt w/ diabetes and indwelling catheter.,1
Gave 5 days of 14 day course of cefpodoxime.,0
Discussed whether pt needed to have foley in place - pt feels that he can't make it to the bathroom in time and does not want to use urinal.,0
Risk of recurrent infection was explained but pt wants to keep foley.,1
Condom cath not possible due to retracted penis.,0
He will need a repeat U/A after completion of abx.,0
#) in blood cx: growing in 1 bottle from ; uncertain whether cultures were taken prior to fem line placement or after.,0
Repeat mycolytic cx sent and LFTs normal - fluconazole started w/ 7 of 14 days remaining.,0
Ophtho consult to eval for chorioretinitis - no evidence of fungemia.,0
Pt clinically stable at discharge and subsequent cultures unrevealing thusfar.,0
"#) pain control: pt was taking MS contin 100mg tid at home, but unclear why he has been taking this - possibly for multiple chronic joint pain.",0
He was restarted on MS contin 15mg tid; dose changed to and required only few additional doses of MS IR.,0
He exhibited no signs of withdrawal during this admission.,0
He gave permission to contact Dr. who prescribes his pain meds.,0
"Also, SW spoke w/ his brother who is concerned that pt is overmedicating himself at home.",0
"Now, all his providers - psychiatrist, pain MD all made aware of his pain regimen and of each other.",0
Will send copy of discharge summary to his providers; request that his address issue of narcotics contract.,0
#) HTN: Intially hypotensive but responded w/ IVF resuscitation.,0
Metoprolol was restarted at 25mg po bid - home dose is 100mg po bid.,0
Titrated up to 75mg for persistently elevated BP but dose limited by HR in 30s to 50s.,0
Also restarted clonidine 0.6mg po bid and added lisinopril.,0
BP was better controlled on lisinopril 40mg but creatinine increasing so decreased dose to 30.,0
"Considered MRA of renal arteries given resistance to multiple hypertensive regimen, but unable to perform this study due to pt's habitus.",0
We decided to continue medical management at this time.,0
Added on amlodipine 10mg qd w/ BP ranging in 130s to 140s prior to discharge.,0
#) ?hip dislocation: pt c/o persistent L hip pain and requesting X-ray.,0
"On exam, pt had full ROM and not tender at joint insertion site.",0
Imaged both L hip and R shoulder - these did not show evidence of fracture or dislocation.,0
Likely that pt is deconditioned from prolonged hospitalization - he has not been out of bed since admission.,0
Would work more aggressively w/ PT to get him out of bed.,0
"#) Confusion/lethargy: Patient clearly slow to respond to questions, but is much more alert at discharge; reports sluggishness at home.",0
Mental status clearer with time and reduced narcotic dose.,0
"#) Hypotension: Did not meet criteria for SIRS as WBC < , no fever, HR < 90, RR < 20, however did have mild leukocytosis with positive UA, therefore presumed urosepsis at intial presentation.",0
However additioal history was obtained from pt's brother of large amount of narcotics use to explain hypotension and lethargy.,1
Initially treated with broad spectrum ABX but then held awaiting culture results.,0
Hypotension resolved quickly with IV fluids.,0
"#) ARF: 1.4, up from 0.9 1 year ago.",0
"BUN also elevated, most likely pre-renal in the setting of hypotension.",1
Back to baseline after IVF.,0
"#) Anemia: Baseline appears to be around 29, currently 27, however was 30 at OSH prior to fluids.",1
No signs of active bleeding.,0
"#) DM2: Good control w/ outpatient regimen of lantus 44 units , plus RISS.",0
#) Access: PIV; fem line in .,0
#) Code status: full - discussed w/ pt.,0
"HCP is , his brother.",0
Medications on Admission: Paxil 40 mg Neurontin 600 mg QID Flonase 1 spray Flovent 1 puff Protonix 40 mg daily Combivent 2 puffs Reglan 10 mg TID Lantus 44 units Clonidine (Catapres) 6 mg ?,0
Metoprolol 100 mg Klonopin 2 mg TID Lorazepam 2 mg daily Xanax 1 mg TID Astelin 1 spray Lasix 40 mg Discharge Medications: 1.,0
"Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal (2 times a day).",0
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours).,0
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed.,0
Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Alprazolam 1 mg Tablet Sig: One (1) Tablet PO tid prn.,0
Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed.,0
Loratadine 10 mg Tablet Sig: One (1) Tablet PO qd ().,0
Clonidine 0.2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
"Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed.",0
Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous sliding scale: Please refer to insulin sliding scale.,0
Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours).,0
Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed.,0
Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).,0
Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days.,0
Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 7 days.,0
Discharge Disposition: Extended Care Facility: Healthcare Center - Discharge Diagnosis: Primary: somnolence secondary to narcotics overuse recurrent UTIs hypertension in blood culture acute renal failure .,1
"DM2 COPD OSA on CPAP VRE s/p tracheostomy, as above in CHF Anemia of chronic disease s/p BKA for chronic LE ulcer Urinary retention Depression Morbid obesity Discharge Condition: stable Discharge Instructions: Please return for further care if you have fevers, chills, dizziness, weakness, shortness of breath, chest pain, fainting, sleepiness, or any other symptoms that are concerning to you.",1
Take all your medications only as directed.,0
Make sure to work with your physical therapist to make sure you regain your former strength and mobility.,0
Keep you appointments as listed for you below.,0
Followup Instructions: Eye clinic appointment at or eye clinic Completed by:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: OTOLARYNGOLOGY Allergies: Cardizem / Quinidine Attending: Chief Complaint: Odynophagia due to hypopharyngeal cancer Major Surgical or Invasive Procedure: Radical neck dissection, total laryngectomy, partial pharyngectomy with RFFP, open G-tube and skin flap; History of Present Illness: 73yo w/ sore throat and jaw discomfort.",1
W/up revealed left pyriform sinus lesion.,1
Admitted to after undergoing direct laryngoscopy and pyriform sinus biopsy.,1
Past Medical History: PMH: 1.,0
"On screening colonoscopy, a single semi-pedunculated 16mm non-bleeding polyp was found in the proximal ascending colon.",0
"Polypectomy was performed with complete retrieval of the polyp using a hot snare, pathology revealed an adenoma.",0
"Atrial fibrillation/Atrial flutter, diagnosed in .",1
"Pericardial effusion, found in on chest CT. Pericardiocentesis performed.",0
"Vocal cord squamous cell carcinoma, .",0
"Social History: Drinks 2 glasses of scotch per day, reports a more significant drinking history in the past of several cocktails/day.",0
He lives at home with his wife and reports no limitations in ADLs.,0
He is retired from working in the petroleum industry and now plays golf 3 times per week.,0
Family History: Family history: (patient was unsure of some details).,0
Father died at age 84.,0
Mother died at age 78 with a stroke.,0
"Has 5 siblings, 1 reportedly diagnosed with heart disease.",0
"Has 4 children, 1 diagnosed with valvular disease and a son with NIDDM.",0
"Significant medical events include: - Neck: swelling and small hematoma in post op; followed by plastic surgery which recommended no specific treatment; - Cariovascular: - BP: patient presents with elevated BP, requiring medication adjustment (see medication list) - Dysrythmias: monitored by telemetry, patient presents multiple episodes of ~2 sec.",0
"pauses, acceptable given his condition accoring to his cardiologist, prompting reduction of his Metoprolol dosage (125 tid -> 100 tid) and halt of Digoxin.",0
He also presented one episode of ventricular tachycardia (4 systoles) on post op day 12.,0
An echocardiography did not show any change compared to his prior status (see attached report).,0
- Endocrinology: high blood glucose titers have required the initiation of insulin-based therapy: Fixed dose: Glargine 15 Units at bedtime Sliding scale: See attached sliding scale (dated ) - Electrolyte: patient presented with hypernatremia corrected after several days of q4h free water flush via PEG-tube; hypomagnesiemia treated with Mg supplement.,0
"On date of transfer: Na 140, Mg 1.8 - Warfarin treatment was started on with initial dose of 5 mg; INR on : 1.2; needs to be adjusted with the goal of INR .",0
- Nutrition: patient fed via PEG-tube; diet changed to night-only cycle as he started PO pureed food on ; Promote w/fiber full strength 100 ml/hr between 6pm and 6 am.,0
"- Earlier in his hospitalization, patient developed decubitus ulcers necessitating wound care.",0
"Overall, positive patient evolution prior to his discharge to a rehabilitation center for further improvement of his physical capabilities while under adequate monitoring.",0
Medications on Admission: (same as discharge) 1.,0
Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).,0
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
"Nitroglycerin 6.5 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO bid () as needed for Anti-anginal.",0
Discharge Medications: Aspirin 162 mg PO daily Heparin 5000 Unit sc tid Warfarin per PT/INR (started ; INR on : 1.2) Hydralazine HCl 25 mg PO q6h Captopril 25 mg PO bid Metoprolol 100 mg PO tid Docusate sodium (liquid) 100 mg PO bid Latanoprost 0.005% Ophtal.,0
"1 drop OU HS Dolasetron mesylate 12.5 mg IV q8h PRN nausea Oxycodone-Acetaminophen Elixir ml PO q4-6h PRN Morphine sulfate 2-4 mg IV q3-4h PRN Haloperidol 0.5-1.0 mg IV q4h PRN anxiety, agitation Insulin SC: Glargine 15 U at bed time + sliding scale.",0
"Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: Status post resection of hypopharyngeal squamous cell carcinoma with bilateral modified radical neck dissection, R hemithyroidectomy, total laryngectomy, L radical forearm free flap ro R facial artery, STSG to R arm, #8 trach, PEG; Discharge Condition: Patient in good condition, awake and cooperative; ambulates with help; Neuro: oriented, no focal neurological deficit excepted speech/swallow due to surgical excision/reconstruction;Cardio: chronic atrial fib/flutter; HR irregular, between 60-100; BP: tendency to high BP ~160/60; occasional 2 sec.",0
"pauses; 1 episode of v. tach (4 systoles), bilat.",0
"mild ankle edema on ; Resp: via tracheal stoma, NAD, 02 sat.",0
"96-100%, occasional expectorations, ausculation: occasional rhonchi; recent CXR: small left pleural effusion w/basal atelectasis, no infiltrate; : G-tube, bowel mvmt ok; GU: urinates ok; Neck: skin flap well vascularized (check w/doppler); no erythema, tenderness, heat; left hand: occasioanl pain and tingling in fingers (no specific periph.",0
refill ok; temperature: similar to very slightly colder than right hand; no compartment syndrome but needs to be checked; Endocrine: elevated blood glucose: high blood glucose titers have required the instauration of insulin-based therapy: Fixed dose: Glargine 15 Units at bedtime Sliding scale: See attached sliding scale (dated ) BP: tendency to high blood pressure requiring adjustment of medication; Arrythmias: reccurent episodes of ~2 sec.,0
pauses; 1 episode of 4-systole v.,0
"; patient supervised by telemetry; Discharge Instructions: Physical therapy, respiratory PT, Speech therapy (electrolarynx), swallowing PT, Cardiac monitoring, telemetry Airway care, G-tube care Followup Instructions: Please contact Dr at to arrange f.up appointment Completed by:",0
9:16 AM CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # Reason: evaluate increased swelling of neck mass Field of view: 26 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with large left posterior neck swelling.,0
"Had CT neck on , chest CT .",0
Please evaluate for extension of neck swelling and involvement of adjacent structures.,0
"REASON FOR THIS EXAMINATION: evaluate increased swelling of neck mass ______________________________________________________________________________ FINAL REPORT INDICATION: 24 YEAR OLD MAN WITH LARGE LEFT POSTERIOR NECK SWELLING, INDURATED.",0
EVALUATE FOR INVOLVEMENT OF ADJACENT STRUCTURES.,0
TECHNIQUE: Axial images of the neck were obtained at 5 mm collimation with IV contrast.,0
CONTRAST: 100 cc of Optiray intravenous contrast was given secondary to the patient's diabetic status.,0
CT OF NECK WITH IV CONTRAST: There is a soft tissue attenuation large mass in the right posterior neck with indiscrete margins.,0
It extends from the last mastoid to the C6 vertebral body.,0
"There is considerable irregular density attenuation which might represent fluid, however, there is no definite abscess seen.",0
There is blurring of fat planes which suggest inflammation.,0
"Also is noted thick cervical fascia that extends anteriorly, but does not cross the midline.",0
"Compared to the prior study, this region has a similar appearance.",0
Again associated lymphadenopathy is present.,0
"The lung apices do not have scarring, infiltrates, or effusion.",0
"There is no definite spinal involvement seen, however, CT is not sensitive for evaluating this region.",0
IMPRESSION: Unchanged appearance of the right posterior neck musculature myositis and cellulitis.,0
"If there is clinical concern for spinal cord involvement, recommend MR myelogram.",0
3:12 PM CT HEAD W/O CONTRAST Clip # Reason: check progression of sdh s/p drain Admitting Diagnosis: CHF;SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with sdh.,0
REASON FOR THIS EXAMINATION: check progression of sdh s/p drain No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 62 year-old woman with subdural hemorrhage status post drain placement.,1
FINDINGS: Patient is now status post subdural drainage catheter placement.,0
There has been interval decrease in the size of the subdural hematoma.,0
Left inferior temporal bone fracture is unchanged in appearance.,0
Slight shift of midline structures to the right is stable.,0
"The ventricles and sulci are prominent, consistent with atrophy.",0
IMPRESSION: Interval decrease in size of left subdural hemorrhage status post drainage catheter placement.,1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: ADMITTING DIAGNOSIS: C. difficile colitis.,0
"HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female with a past medical history of ""diastolic dysfunction"", left ventricular hypertrophy, hypertension, hypothyroidism, who presented from with a temperature of 99, white blood cells of 26 and complaints of weakness.",0
"The patient denied any cough, dysuria, headache, photophobia, stiff neck, or diarrhea.",0
"However, the patient reported decreased p.o.",0
"intake over the four weeks prior to admission, though she takes 40 of p.o.",0
In the patient was recently treated for pneumonia with levofloxacin x 1 week and a urinary tract infection with Macrodantin.,0
She was admitted to and noted right foot pain.,0
Osteomyelitis was not evidence on x-ray of her foot.,0
"The patient was treated for gout with prednisone, and urinary retention with straight catheterization.",0
In the Emergency Department she had blood pressure of 75/38.,0
The patient received four liters of normal saline and blood pressure increased to 105-110 systolic.,0
A urine culture was drawn and she was admitted to the .,0
Calcitonin nasal spray 200 q. day.,0
"PHYSICAL EXAMINATION: On admission heart rate was 62, blood pressure 108/75, temperature maximum 96.3, 98% on room air.",0
"General: No apparent distress, sitting.",0
"Neck: Jugular venous distension 4 cm, supple.",0
"Cardiovascular: Regular rate and rhythm, S1 and S2, 2/6 systolic ejection murmur at the left lower sternal border.",0
"Chest: Crackles at the bilateral bases, 1/5 up.",0
"Abdomen: Soft, mildly tender, nondistended.",0
"Neurologic: Awake, alert, oriented x 3.",0
Cranial nerves II-XII were intact.,0
"Musculoskeletal: Left heel dressing, painful bilateral knees and ankles, left knee full and warm, pain with motion.",0
LABORATORY DATA: CBC showed WBC of 26.3.,0
"Chest x-ray showed no congestive heart failure, no infiltrates.",1
"EKG showed sinus rhythm at 66 with a normal axis, and left ventricular hypertrophy.",0
Leukocytosis: The patient was found to have C. difficile colitis.,0
The patient throughout hospitalization had decreasing abdominal pain until on discharge was able to tolerate a p.o.,0
diet and had no abdominal pain.,0
The patient's white blood cells decreased throughout the hospitalization.,0
The patient was sent home with metronidazole 500 mg t.i.d.,0
The patient was also kept on C. difficile precautions throughout the hospitalization.,0
Urinary retention: The patient has had several trials in the in which the patient's Foley catheter was discontinued and the patient was not able to urinate.,0
She failed several voiding trials.,0
The patient was also not on any anticholinergics.,0
Urology was consulted and stated to follow up with Dr. in one to two weeks for a voiding trial as an outpatient.,0
"Knee pain: The patient was status post two attempted knee taps, failed by rheumatology.",0
The patient's pain was well controlled with scheduled Tylenol and Ultram p.r.n.,0
This was felt to be most likely secondary to osteoarthritis.,0
The patient had no increasing warmth or swelling during the last few days of hospitalization.,0
Hypothyroidism: The patient was stable throughout the hospitalization on her thyroid replacement regimen.,0
"Anemia: Her hematocrit was stable throughout the hospitalization, will need outpatient iron studies.",0
Hypotension: The patient's blood pressures were stable over the last few days of hospitalization.,0
The patient's atenolol was increased slowly throughout hospitalization to 25 mg q. day.,0
The patient was on atenolol 100 q. day as an outpatient.,0
Will need follow up for titrating blood pressure medications.,0
Coronary artery disease: The patient was started on Plavix and stopped aspirin secondary to increased troponin levels and recommendation of staff.,1
A beta blocker was increased as tolerated.,0
The patient was also ruled out for an myocardial infarction during this hospitalization.,0
DISCHARGE STATUS: The patient may be discharged to rehabilitation.,0
DISCHARGE STATUS: The patient remained DNR/DNI throughout the hospitalization.,0
Calcitonin 200 units q. day.,0
Vitamin D 400 units p.o.,0
Calcium carbonate 500 mg t.i.d.,0
The patient is to follow up with primary care physician in one to two weeks.,0
The patient is to follow up with urology in one to two weeks.,0
Dictated By: MEDQUIST36 D: 09:20 T: 09:47 JOB#:,0
LINE PLACEMENT Clip # Reason: left sc cvl placement Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with REASON FOR THIS EXAMINATION: left sc cvl placement ______________________________________________________________________________ FINAL REPORT HISTORY: Central catheter placement.,1
"FINDINGS: In comparison with the study of , there has been placement of the second left subclavian catheter that has its tip at virtually the same level as the initial catheter in the mid portion of the SVC.",0
Little change in the appearance of the heart and lungs.,0
5:42 PM CHEST (PORTABLE AP) Clip # Reason: eval placement of NGT; recent KUB does not reveal position o Admitting Diagnosis: COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with c. difficile colitis.,0
"REASON FOR THIS EXAMINATION: eval placement of NGT; recent KUB does not reveal position of tube ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate placement of NG tube, patient with C. difficile colitis.",0
"VIEWS: AP upright chest at 18:03 hours, comparison dated at 11:49 hours.",0
FINDINGS: A left subclavian line is in satisfactory position with the tip in the mid SVC.,0
An NG tube is seen with tip in the fundus of the stomach.,0
"There is no other significant change in the examination, with the exception of improvement in small bilateral pleural effusions.",0
There is no acute cardiac failure.,1
The elevated right hemidiaphragm previously noted is unchanged and may represent posterior diaphragmatic eventration.,0
The dilation of the transverse colon is once again noted and is unchanged.,0
"IMPRESSION: 1) Satisfactory position of subclavian line, with NG tube tip located in gastric fundus.",0
2) Slight improvement in pleural effusions.,0
Height: (in) 73 Weight (lb): 120 BSA (m2): 1.73 m2 Status: Inpatient Date/Time: at 10:20 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Only parasternal long axis views available.,0
Images on video tape only.,0
No digital images stored due to arrest situation.,0
LEFT VENTRICLE: Dilated LV cavity.,0
Conclusions: The left ventricular cavity is dilated.,0
The right ventricular cavity size is grossly normal.,0
There is near akinesis of the left and right ventricular cavities.,0
No gross pericardial effusion is identified.,0
12:10 PM CT C-SPINE W/O CONTRAST Clip # Reason: C-spine injury.,0
______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p MVC.,0
REASON FOR THIS EXAMINATION: C-spine injury.,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: ENYa SAT 12:41 PM No acute cervical fx or malalignment.,0
Evidence of aspiration in the bilateral lung apice.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 51-year-old man, status post MVC.",0
TECHNIQUE: Non-contrast MDCT images were acquired from the skull base to the cervicothoracic junction.,0
Multiplanar reformatted images were obtained for evaluation.,0
FINDINGS: There is no acute cervical fracture or malalignment.,0
There is an NG tube traversing the esophagus.,0
"Multilevel degenerative changes are noted, with a prominent anterior osteophyte at C4.",0
The prevertebral soft tissues are normal.,0
"In the visualized lung apices, there are bilateral dependent consolidative densities, concerning for aspiration in the acute setting of trauma.",0
There is a 1.1 cm mucus retention cyst in the right maxillary sinus.,0
The remaining paranasal sinuses are clear.,0
No acute cervical fracture or malalignment.,0
Moderate multilevel degenerative disease with osteophytes may increase risk of spinal cord injury.,0
Aspiration in the bilateral lung apices.,0
3:08 PM PERC G/J TUBE CHECK/REPLACE Clip # Reason: Convert G-tube to J-tube.,0
"Admitting Diagnosis: PNEUMONIA Contrast: OMNIPAQUE Amt: 25 ********************************* CPT Codes ******************************** * CONVERT G TO GJ, ALL INCL.",0
* **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with metastatic renal cell CA admitted for recurrent aspiration pneumonia/sepsis.,1
REASON FOR THIS EXAMINATION: Convert G-tube to J-tube.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old man with metastatic renal cell, admitted for recurrent aspiration pneumonia and sepsis.",1
Please convert G-tube to J-tube.,0
RADIOLOGISTS: Dr. (fellow) and Dr. (attending) performed the procedure.,0
The attending physician was present and supervised throughout the procedure.,0
"ANESTHESIA: Moderate sedation was provided by administering divided doses of 1.5 mg of Versed throughout the total intraservice time of 39 minutes, during which the patient's hemodynamic parameters were continuously monitored.",0
"Flouroscopy time : 8 min 15 Sec PROCEDURE: Written informed consent was obtained from the patient after explaining the risks, benefits, and alternatives to the procedure.",0
The patient was brought to the angiographic suite and laid supine on the table.,0
The indwelling tube and surrounding abdomen were prepped and draped in a sterile fashion.,0
A preprocedure huddle and timeout were performed per protocol.,0
Contrast was injected through the indwelling tube to confirm the presence in the stomach and wire was advanced and coiled in the stomach.,0
The indwelling endoscopically placed G-tube was pulled out over the wire and a 9 French -Tip sheath was placed.,0
"Leaving the in place as a safety wire, a Kumpe and Glidewire were utilized to position the tip of the Glidewire into the jejunum.",0
The Kumpe was then advanced into the jejunum and Glidewire was exchanged for an Amplatz.,0
"18 French MIC GJ-tube was placed over the Amplatz and once the tube was in place, the Amplatz wire was removed.",0
Contrast injection confirmed the presence of the tube in the jejunum.,0
The safety wire was also removed.,0
The retention balloon was inflated with 8 mL of sterile water mixed with contrast.,0
IMPRESSION: Successful uncomplicated conversion of an endoscopically placed G-tube to a GJ-tube with the tip in the jejunum.,0
(Over) 3:08 PM PERC G/J TUBE CHECK/REPLACE Clip # Reason: Convert G-tube to J-tube.,0
Admitting Diagnosis: PNEUMONIA Contrast: OMNIPAQUE Amt: 25 ______________________________________________________________________________ FINAL REPORT (Cont),0
"3:04 AM CHEST (PORTABLE AP) Clip # Reason: evolving pna Admitting Diagnosis: DEEP VEIN THROMBOSIS ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with multifocal PNA REASON FOR THIS EXAMINATION: evolving pna ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:02 A.M. ON HISTORY: Multifocal pneumonia evolving.",1
"IMPRESSION: AP chest compared to and chest CT scanning on : Areas of consolidation, some quite nodular seen on the abdomen CT are not as readily evident on the subsequent chest radiograph on .",0
"There does appear to be some clearing of the middle lobe component of earlier consolidation, the lower lobe remains severely consolidated.",0
"Pleural effusion is minimal, on the right, if any.",1
9:11 AM CT HEAD W/O CONTRAST Clip # Reason: post-op eval s/p left cranioplasty / return of bone flap Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p trauma .,0
now with return of bone flap to left cranium.,0
REASON FOR THIS EXAMINATION: post-op eval s/p left cranioplasty / return of bone flap No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: The patient is status post left cranioplasty with return of bone flap.,0
FINDINGS: The patient is status post bone flap placement over the left frontoparietal lobe region.,0
There is a large 10.0 x 2.7 cm fluid collection situated between the bone graft and calcified dural membrane.,0
There are air bubbles within this collection.,0
Air is seen in the adjacent subcutaneous tissues less likely post- surgical in nature.,0
There is moderate subfalcial herniation with compression of the right lateral ventricle.,0
"Again, noted is hypodensity within the right frontal and left occipital lobes.",0
There is a small focus of increased attenuation seen within the right frontal lobe as previously described.,0
Stables are seen in the overlying soft tissues.,0
Large epidural fluid collection adjacent to the site of previous bone graft with associated subfalcine herniation.,0
Infarcts in the right frontal and left occipital lobes.,0
Increased attenuation seen in the right frontal lobe is consistent with small areas of hemorrhage and is unchanged compared to the prior exam.,0
1:05 PM CT HEAD W/O CONTRAST Clip # Reason: ich?,0
______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with seizure REASON FOR THIS EXAMINATION: ich?,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: 2:29 PM No acute process.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old man with seizure, evaluate for intracranial hemorrhage.",0
"NON-CONTRAST CT HEAD: There is no intra- or extra-axial hemorrhage, shift of normally midline structures, mass effect, or evidence of acute infarct.",0
The bony calvarium is intact.,0
"Deformity of the left lamina papyracea is present with fat herniating into the defect, likely representing old injury.",0
There is mild mucosal thickening of the maxillary sinuses.,0
"8:42 AM VENOUS DUP EXT UNI (MAP/DVT) LEFT Clip # Reason: assess flow in AV graft/fistula and mark anantomy on skin fo ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with ESRD need for HD access, s/p L UE AV fistulas/grafts REASON FOR THIS EXAMINATION: assess flow in AV graft/fistula and mark anantomy on skin for subsequent fistulogram and possible revision in OR ______________________________________________________________________________ FINAL REPORT HISTORY: Revised left upper extremity AV fistula at an outside hospital, please assess anatomy and assess for obstruction.",0
FINDINGS: Doppler evaluation of the brachial artery demonstrates no significant calcification.,0
"At the brachial artery - interposed gortex graft anastomosis, the peak systolic velocity is 411 cm/sec., indicating a moderate to high grade stenosis.",1
The gortex graft joins to the basilic vein.,0
"At the graft-vein anastomosis, there is a pseudoaneurysm.",0
Adjacent to this is a hypoechoic area measuring about 1.5 cm in diameter.,0
This shows no flow and likely represents either hematoma or a thrombosed portion of this patient's pseudoaneurysm.,0
There is no definite fluid around the interposed gortex graft to suggest infection.,0
The draining basilic vein is markedly dilated.,0
IMPRESSION: 1) Brachial artery to basilic AV fistula created via an interposed gortex graft.,1
No evidence of graft infection.,0
2) Moderate to high grade stenosis at the arterial-graft anastomosis.,0
3) Pseudoaneurysm at the graft-venous anastomosis.,0
"4) 1.5 cm hypoechoic area next to the pseudoaneurysm, likely representing a hematoma.",0
"12:45 PM T-SPINE Clip # Reason: T4 FX Admitting Diagnosis: BACK PAIN ______________________________________________________________________________ WET READ: MH MON 3:37 PM A wet WAS REQUESTED ON AN AP VIEW OF THE TSPINE OBTAINED INTRA- OPERATIVELY, RE THE LEVEL OF THE SURGEON'S MARKER.",0
tHE INITIAL VIEW WAS CONCSIDERED INDETERMINATE AND A REPEAT VIEW TO THE INCLUDE THE CSPINE AND THE LEVEL OF INTEREST WAS REQUESTED.,0
"AT THE TIME THE SECOND TSPINE FILM WAS REQUESTED, DR.",0
"REVIEWED THE TSPINE FILM WITH THE SURGEON IN THE OR AS FOLLOWS: THE NUMBER OF THE LEVEL REMAINS DIFFICULT TO ACCURATELY DETERMINE, GIVEN THE DEGREE OF DISTORION ON THE FILM AND ABSENCE OF THE C1/2 LEVEL.",0
"HOWEVER, WE AGREE WITH THE SURGEON THAT THE SURGICAL MARKER OVERLIES THE LOWER EDGE OF THE TSPINE VERTEBRAL BODY THAT LIES IMMEDIATELY ABOVE THE LEVEL OF THE FLATTENED VERTBERAL BODY, AS DEMONSTRATED ON THE TSPINE CT.",0
"THE FLATTENED VB LEVEL WAS DESIGNATED T4 ON THAT PREVIOUS CT, COUNTING FROM L5 ON THE SCOUT.",0
"HOWEVER, THE NUMBER LEVEL BASED ON THIS CURRENT INTRA- OPERATIVE FILM REMAINS INDETERMINATE.",0
THE CLIP NUMBER INCLUDING THESE STUDIES IS STILL IN ARRIVED STATUS.,0
A FULL REPORT WILL BE ISSUED AFTER THE EXAM CLIP NUMBER IS VERIFIED.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 45-year-old female with a reported T4 fracture.,1
For intraoperative evaluation of position.,0
EXAMINATION: Six portable radiographs were obtained intraoperatively over time centered about the upper thoracic spine.,0
COMPARISONS: Comparison to CT examination of the thoracic spine from .,0
"FINDINGS: View #1 - Lateral view, centered low, does not include the area of interest.",0
View #2 - AP shows a marker to the right of the upper thoracic spine.,0
The level is uncertain and a repeat film to include the cspine and allow more accurate assignment of levels was requested.,0
"ET tube and additional overlying suppoert tubes and lines, as well as surgical instrumentation noted.",0
Lucency of right lung thought to reflect pneumothorax.,0
Area of interest is obscured by surgical intruments.,0
A new surgical marker has been placed.,0
"The numerical vertebral body level remains difficult to conclusively assign, in part due to inevitable distortion related to patient positioning.",0
It is noted that the tip of the surgical instrument projects over the inferior aspect of the vertebral body that lies immediately above the level of the known markedly compressed thoracic vertebnral body.,1
"Note is made that the compression deformity was localized to T4 on recent CT examination by counting from the L5 vertebral body, but, it is not clear on the current film, whether the compression level (Over) 12:45 PM T-SPINE Clip # Reason: T4 FX Admitting Diagnosis: BACK PAIN ______________________________________________________________________________ FINAL REPORT (Cont) would be considered T4.",0
These findings were discussed with surgeon in the OR - - please see wet issued at that time.,0
Plate and screws overlies the upper thoracic spine in the midline.,0
Area of interest lies at upper edge of film.,0
Postion of anterior plate and screws noted.,0
IMPRESSION: Multiple intra-operative views related to stabilization procedure for upper thoracic spine compression fracture.,1
"Surgical instrument seen overlying an upper thoracic vertebral body, followed by placement of anterior plate and screws.",1
Please see detailed discussion above.,0
"7:02 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Evaluate placement of ET tube, OG tube Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman re-intubated for pna REASON FOR THIS EXAMINATION: Evaluate placement of ET tube, OG tube ______________________________________________________________________________ WET READ: JEKh MON 9:14 PM 1.",0
ET tube 3.5 cm above carina 2. two endogastric tubes course below GE junction & out of view 3.,0
R PICC tip in low SVC 4.,0
R pleural effusion w/ atelectasis - underlying infection cannot be ruled out ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Reintubation for pneumonia.,1
"FINDINGS: As compared to the previous radiograph, the tip of the endotracheal tube now projects 3.5 cm above the carina.",0
The course of the nasogastric tubes is unremarkable.,0
The right PICC line is in unchanged position.,0
"There is slight improvement in ventilation of the lungs, notably at the right mid and right basal lung level.",0
"However, relatively extensive partly atelectatic consolidations are seen in both lung bases and an extensive right pleural effusion is still visualized.",0
Moderate enlargement of the cardiac silhouette.,0
1:13 PM CT HEAD W/O CONTRAST Clip # Reason: r/o cva Admitting Diagnosis: MITRAL REGURGITATION\MITRAL VALVE REPLACEMENT CORONARY ARTERY BYPASS GRAFT REDO ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with REASON FOR THIS EXAMINATION: r/o cva No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 77-year-old male after cardiac surgery with concern for infarction.,1
COMPARISON: No prior study available.,0
FINDINGS: Well-defined hypodensity is noted of the parasagittal right frontal cortex and subcortical white matter consistent with acute infarction.,0
A smaller area of hypodensity of the left parietal cortex and subcortical white matter is also consistent with acute infarction.,0
There is no evidence of intracranial hemorrhage or mass effect.,0
The cerebral sulci and ventricles are symmetric and age appropriate.,0
The paranasal sinuses and mastoid air cells are clear.,0
No osseous or surrounding soft tissue abnormality is seen.,0
IMPRESSION: Acute infarction of the right frontal and left parietal lobes.,0
Well-defined appearance of the areas of infarction suggest that infarction is over 24 hours old and not hyperacute.,0
"Findings discussed with , PA of cardiac surgery at 2 p.m. on .",0
"11:10 AM CHEST (PA & LAT) Clip # Reason: assess for interval change Admitting Diagnosis: LEFT LOWER LOBE COLLAPSE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with history of L lung collapse s/p L main bronchus stent; s/p bronch, stent removal REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Left main stem bronchus stent removal.",1
"CHEST, TWO VIEWS: Comparison with .",0
Complete collapse of the left lung with leftward mediastinal shift is again seen.,0
Low lung volumes are present.,0
"Cardiovascular status is difficult to assess, however, pulmonary vascular engorgement is probably present.",0
Minor atelectasis in the mid lung zone is again noted.,0
Persistent completely collapsed left lung.,0
"12:39 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX, eval consolidation.",0
"Admitting Diagnosis: THORACIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with s/p stent graft of descending aortic aneurysm, with RLL PNA.",1
"REASON FOR THIS EXAMINATION: r/o PTX, eval consolidation.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Status post stent graft of the descending aortic aneurysm.,0
FINDINGS: The right internal jugular catheter is in stable position.,0
Post- surgical changes and aortic stent graft are again noted.,0
There is slight improvement in the previously described right lower lobe pneumonia.,0
There is also slight improvement in previously identified pattern of failure.,0
Background emphysema is again noted.,0
The right-sided pleural effusion is not significantly changed.,1
IMPRESSION: Slight interval improvement in right lower lobe pneumonia and failure.,1
"Name: , J Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM: DISCHARGE MEDICATIONS: Neurontin 800 mg per G tube tid, Ativan .5 mg IV q 8 hours prn, Clozaril 200 mg per G tube q h.s., Percocet 1-2 tabs per G tube q 4-6 hours prn, Reglan 10 mg IV q 8 hours, G tube replacement ?",0
"cc per 1 cc loss, replaced with ?",0
Dictated By: MEDQUIST36 D: 09:14 T: 12:51 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: hypotension Major Surgical or Invasive Procedure: Left femoral line History of Present Illness: 76 yo M with ESRD on HD, CAD, AAA repair, Aflutter, AVR, COPD, transferred from hospital with sepsis.",1
He was dialysed 5 times in the past 1 week as patient had gained around 9 kg.,0
"He also noted to have diarrhea, decreased PO intake.",0
He also complained of left flank pain for the last 1-2 weeks.,0
"On the morning od admission, he felt really weak and slumped to the ground.",0
His daughter checked his BP which was SBP of 30's.,0
He was immediately taken to .,0
"In the EMS, his SBP was in 60's.",0
"At , he got Fluid boluses and was started on pressors.",0
They tried SCL but were not successful.,0
He was then transferred to for further management.,0
"In the ED, he got a fem line (under sterile precautions) and was started intially on Neo and then switched to Levo.",0
"His UA was dirty, he had leukocytosis and elevated CKs.",0
"He also received Vanc, Cefepime.",0
Past Medical History: atrial fibrillation/atrial flutter CAD s/p CABG thoracic ascending aortic aneurysm s/p AVR HTN CKD - on HD MWF s/p pacer s/p AAA repair ?,1
?03 COPD hypothyroid carotid stenosis possible renal artery stenosis kyphosis asthma asbestosis restless leg Social History: Patient lives with his wife and one of his 3 children.,1
"He quit smoking 40 years ago (), smoked for 18 years.",0
Asbestos exposure in submarines 50 yrs ago.,0
"Denies any EtOH, no IVDU.",0
"Family History: no h/o DM, HTN, no Cancer Mother died of heart disease at 90 Physical Exam: Vitals: 97.8, 91/71, 66, 14, 100%/3L NC Gen: alert, oriented, in no acute distress HEENT: furrowed tongue, mild glossitis Neck: thick neck, no JVD appreciable Heart: S1/S2, many ectopic beats, 3/6 SEM at LUSB Lungs: bilateral wheezes, no crackles Abdomen: tense, no tenderness/guarding/rigidity, normoactive BS Flank: no tenderness Ext: no edema Neuro: no focal deficits Pertinent Results: 05:20PM BLOOD CK(CPK)-1598* 02:18AM BLOOD CK(CPK)-1143* 05:57PM BLOOD CK(CPK)-696* 02:18AM BLOOD CK-MB-24* MB Indx-2.1 cTropnT-0.30* 05:20PM BLOOD Cortsol-29.1* 12:25AM BLOOD Cortsol-39.1* 01:00AM BLOOD Cortsol-44.5* 05:20PM WBC-19.5* RBC-3.34* HGB-11.2* HCT-33.6* MCV-101* MCH-33.5* MCHC-33.3 RDW-17.9* 05:20PM GLUCOSE-76 UREA N-41* CREAT-5.1*# SODIUM-138 POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-24 ANION GAP-18 .",1
"EKG: Aflutter with 4:1 block, no acute ST-T wave changes .",0
Chest Xray: Overall improvement in the congestive heart failure seen in early .,1
Likely there is still a mild degree of pulmonary edema.,0
Stable appearance to the mediastinum.,0
"Nonvisualization of left upper extremity veins with multiple collateral vessels identified, suggestive of a chronic obstruction.",1
This can be further evaluated with an MR examination.,0
No evidence of deep venous thrombosis in the right upper extremity.,0
"Fistula graft within the left forearm which is widely patent, however, it appears to be anastomosed to arterial vessels.",0
No venous flow is noted within the region of the fistula graft anastomoses.,0
Echo : 1.The left atrium is mildly dilated.,0
2.There is mild symmetric left ventricular hypertrophy.,0
4.A bioprosthetic aortic valve prosthesis is present.,0
Severe [4+] tricuspid regurgitation is seen.,0
"Compared with the findings of the prior report (images unavailable for review) of , the MR significantly.",0
An accurate assessment of the aorta could not be made on the present study.,0
Fistulography L arm: Angiography of the arterialized L brachial vein showed an occluded L subclavian vein.,0
The L subclavian vein was occluded.,0
The procedure was abandoned in favor of surgical intervention.,0
FINAL DIAGNOSIS: 1. thrombosed L AV fistula 2. occluded L subclavian vein .,0
"HD catheter exchange by IR: Uneventful exchange of right IJ dialysis catheter, as above.",0
"The tip of the catheter, which was removed, was sent for cultures.",0
Left fistula ligation without any major complications.,0
"Brief Hospital Course: 76 yo M with ESRD on HD, CAD, AAA repair, Aflutter, AVR, COPD with hypotension from urosepsis vs overdialyzing, requiring MICU stay.",1
He was transiently on pressors.,0
"Broad spectrum antibiotics were started in the ICU, as well as a Heparin gtt for Aflutter and L UE clot.",0
"He was transferred to the floor with stable BP, off pressors, on Vancomycin and Cefepime.",0
line sepsis vs. pneumonia vs hypovolemia aggressive HD and decreased PO intake.,0
Cortstim test was negative for adrenal insufficiency.,0
"Likely sources of infection are HD catheter, PNA, less likely urine.",0
"Off Levophed gtt after 24h, BP was stable, then transferred to floor.",0
Patient received IV fluids as needed.,0
Vancomycin (started ) and Cefepime (started ) were continued.,0
A total course of 21 days should be given.,0
Multiple blood and urine cultures from through came back negative.,0
HD catheter cultures were sent off on and also came back negative.,0
Pt was hemodynamically stable on discharge and afebrile.,0
"2) CAD s/ CABG: Pt developed elevation of troponin to 0.3 (from 0.14 from ), CPK elevated to 1598 although no elevation of CK-MD index.",0
EKG no evidence of any acute ST-T wave changes.,0
"This could represent demand ischemia in the setting of sepsis, hypotension.",0
Cardiac enzymes were cycled x3 and remained stable.,0
Pt was continued on Lipitor.,0
ASA was held on Heparin gtt.,0
Pt was continued on toprol XL with holding parameters once his blood pressure was stable after transfer from the ICU.,0
"An Echo from to assess LV function showed EF of 75%, but MR. p appointment with cardiologist Dr. should be scheduled for 1-2 weeks after discharge.",0
3) Atrial flutter: His rate was controlled in 4:1 bloc.,1
It was therefore unlikely that this was contributing to the hypotension.,0
Pt was continued on his BB.,0
A heparin gtt was initiated which was discontinued shortly pior discharge since he went for an AV fistula ligation.,0
He also developed guaiac positive stools on two occasions during his hospital stay.,0
"The first time, the heparin gtt has been held transiently (see below).",0
"The second time, Coumadin was just started at 3mg qHS and was held as well for guaiac positive stools.",0
A hematocrit should be checked at rehab.,0
It should be decided after further Hematocrits whether anticoagulation with Coumadin is being continued as an outpatient.,0
4) L UE clot: Present since fistula operation in .,0
The patient was on a heparin gtt for the majority of his hospital stay.,0
"However, the drip has been discontinued shortly prior discharge.",0
A fistulogram on was performed and showed a large clot that could not be cleared during the procedure.,0
Transplant surgery ligated the fistula on without any major complications.,1
Swelling of his arm improved soon thereafter.,0
An outpatient followup appointment has been scheduled by transplant surgery in order to follow up on his ligated AV fistula.,0
5) ESRD: Pt received routine HD on M/W/F or as needed.,0
Pt was continued on Nephrocaps and PhosLo.,0
HD catheter was exchanged over wire on by IR.,0
HD catheter tip was sent for culture and came back negative.,0
He should resume his regular outpatient HD.,0
Vancomycin should be given with hemodialysis.,1
Levels should be checked prior each Vanco dose.,0
6) Anemia: Likely secondary ESRD.,0
Iron studies consistant with ACD.,0
Hct was trending down to 31.,0
Pt received Epo with HD and dose was increased on .,0
7) Guaiac positive stools: Pt had Guaiac pos stool on .,0
"Heparin gtt was transiently held and pt was briefly on PPI IV BID, but repeat hct remained stable at a lower baseline.",0
One unit of PRBC were transfused on .,0
The heparin drip was restarted but discontinued shortly prior discharge for an AV fistula ligation.,0
Coumadin was started after the procedure at 3mg qHS but was held as well because of another guaiac positive stool.,0
It is recommended that the patient is undergoing an outpatient GI workup for this GI bleed.,0
"8) Dizziness: The patient developed intermittent, mild dizziness when moving.",0
These symptoms appeared shortly prior discharge.,0
"One likely diagnosis would be BPPV among others, and should be further worked up as an outpatient.",0
9) HTN: Continued BB after transfer to the floor.,0
Xopenex (Levalbuterol) to be considered if tachycardic.,0
11) Hypothyroid: Continued levothyroxine; initial elevated CK could be from hypothyroidism.,0
"TSH was 64, Free T4 was 0.57 while patient was still in the ICU.",0
Synthroid dose was increased from 75 mcg to 100 mcg daily.,0
Patient was discharge on this higher dose.,0
"12) PPX: heparin gtt (for majority of hosptial stay), one dose of Coumadin, held after guaiac positive stools, Heparin sc for the remainder, pneumoboots, protonix, HOB elevation .",0
13) FEN: heart healthy diet .,0
"13) Access: L Femoral line discontinued on , HD catheter, PICC, PIV .",0
15) Code: DNR/I Medications on Admission: ASA 81 mg Carbidopa-Levodopa 10-100 mg Tablet TID Atorvastatin 40 mg QD Morphine 15 mg Fluticasone-Salmeterol 250-50 mcg/Dose Metoprolol Succinate 25 mg Tablet SR QD Pantoprazole 40 mg Ipratropium Bromide Q6H Docusate Sodium 100 mg Ropinirole 1 mg Nephrocaps QD Levothyroxine 75 mcg QD Discharge Medications: 1.,0
Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
"Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing.",0
Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
Ropinirole 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous QHD (each hemodialysis) for 10 days: Started .,1
Check Vanco level prior each HD.,0
Cefepime 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 8 days: Started .,0
Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary Diagnosis: 1. ?,0
L Upper extremity clot .,0
"Discharge Instructions: Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms.",0
Please take all your medications as directed.,0
Your coumadin has been held.,0
Please keep you follow up appointments as below.,0
"Followup Instructions: Please follow up with your primary care doctor (, M. ) as needed.",0
Please schedule a followup appointment with Dr. () in weeks from now.,0
from transplant surgery has scheduled an oupatient appointment for you.,0
Her phone number is .,0
"The appointment is: Provider: , MD Phone: Date/Time: 9:10 .",0
Vancomycin and Cefepime to be continued until 21 day course is completed or for one week after discharge.,0
Vancomycin levels should be checked prior each Hemodialysis.,1
*******Patient had guaiac positive stools during hospitalization.,0
Outpatient GI workup is necessary.,0
********His Hematocrit should be checked at rehab.,0
His last Hct at discharge was 26.5.,0
********* Coumadin (3mg qHS) was started during the hospitalization but has been held prior discharge.,0
It should be decided as an outpatient when to restart.,0
"7:31 AM CHEST (PORTABLE AP) Clip # Reason: assess for pna Admitting Diagnosis: PEDISTRIAN STRUCK;SUBARACHNOID HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p ped struck with new onset fever and + sputum, REASON FOR THIS EXAMINATION: assess for pna ______________________________________________________________________________ FINAL REPORT HISTORY: Fever and post-trauma patient.",1
Multiple moderately displaced left rib fractures.,0
Probable left pleural effusion layering in semi-erect position with associated left lower lobe atelectasis.,0
Small vague patchy opacities right lung.,0
Heart normal size with tortuous aorta.,0
I doubt the presence of PTX.,0
This is seventh consecutive daily chest radiograph with no change from exam .,0
"IMPRESSION: No short interval change, left rib fractures and effusion.",0
Flash pulm edema Height: (in) 64 Weight (lb): 150 BSA (m2): 1.73 m2 BP (mm Hg): 99/51 HR (bpm): 70 Status: Inpatient Date/Time: at 09:59 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
The left atrial volume is increased.,0
There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the mid to distal anterior septum and anterior wall.. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).,0
Moderate pulmonary artery systolic hypertension.,0
"Compared with the prior study (images reviewed) of , the estimated pulmonary artery systolic pressure is slightly higher.",0
The other findings are similar.,0
"9:33 PM SKULL (AP, & LAT) TRAUMA; C-SPINE NON-TRAUMA VIEWS Clip # Reason: pls shoot only skull and c-spine ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with intubated.",0
Plan for MRI REASON FOR THIS EXAMINATION: pls shoot only skull and c-spine ______________________________________________________________________________ FINAL REPORT INDICATION: Screening for MRI.,0
TWO VIEWS OF THE SKULL.,0
No embedded metallic objects are detected.,0
A left ear ring is present.,0
There is an endotracheal tube and ventilation hardware overlying the oral cavity.,0
No acute fracture or dislocation is seen.,1
No sclerotic or lytic lesions are detected.,0
TWO VIEWS OF THE C-SPINE.,0
An endotracheal tube terminates approximately 5 cm above the level of the carina.,0
There is a right-sided PICC terminating at the upper SVC.,0
Included views of the lung apices are unremarkable.,0
No embedded metallic objects are seen.,0
There is no acute fracture or traumatic malalignment of the cervical spine.,1
IMPRESSION: No evidence of embedded metallic objects seen.,0
There is a left ear ring which is external to the patient.,0
Admission Date: Discharge Date: Service: NEUROSURG HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old retired cardiologist who presented to his primary care physician earlier this week with complaints of three day episode of mild ataxia.,0
He also had complaints of word finding difficulty which began on and this has progressed and is associated with mild difficulty with comprehension and problem solving as well as short term memory.,0
He also report an episode of left eye viral conjunctivitis.,0
Malignant melanoma resected from his right forearm 10 years ago with no recurrence.,1
Bladder cancer in and seen on cystoscopies which was low grade and followed with serial follow up.,0
"Cystoscopies are always negative, most recently in .",0
Premalignant colon polyp in .,0
Herpes simplex of the left eye and hypertension.,0
Probenecid 500 milligrams po q day.,0
Trazodone 50 to 100 milligrams po q HS.,0
Ambien 5 milligrams po q HS.,0
Prevacid 30 milligrams po q day.,0
Lovastatin 20 milligrams po q day.,0
Enalapril 5 milligrams po bid.,0
Paxil 20 milligrams tabs 1.5 tab po q A.M. 8.,0
Donnatal 1 po q HS.,0
"PHYSICAL EXAMINATION: He is awake and alert, oriented times three but with some word finding difficulties in naming watch and clearly frustrated by this.",0
"Pupils are equal, round and reactive to light.",0
Peripheral vision intact to gross exam.,0
"Cranial nerves II through XII intact, no clonus, no drift.",0
Finger to nose within normal limits.,0
Strength is in all muscle groups.,0
Sensation intact to light touch throughout.,0
Deep tendon reflexes diminished but equally and symmetric.,0
"Lungs - dry, broncho .................... breath sounds with deep rales in the right posterior.",0
Heart - regular rate and rhythm.,0
Abdomen - positive bowel sounds.,0
Femoral and distal pulses 2+ bilaterally.,0
MRI shows a 2.5 by 2.5 cm posterior left temporal lesion with surrounding temporal edema and minimal effacement of the left temporal and posterior of the lateral ventricle.,0
The patient is admitted and underwent a left craniotomy for resection of tumor on without intraoperative complication.,0
Postoperative vital signs were stable.,0
"He was awake, alert and oriented times 3, following commands.",0
"He had a slight right facial droop, sensation is intact.",0
He was transferred to the regular floor after spending the night in Intensive Care Unit.,0
He is in stable condition and ready for discharge to home on .,0
The patient will be discharged to home with follow up in the Brain Clinic in two weeks.,0
He will return to 45 for staple removal in ten days.,0
Dilantin 100 milligrams po tid will wean to 2 milligrams po bid of Decadron over one week's time.,0
Zantac 150 milligrams po bid.,0
Percocet one to two tablets po q four hours prn for pain.,0
In addition to all of his pre-hospital medications.,0
DISCHARGE CONDITION: The patient was in stable condition at the time of discharge.,0
Dictated By: MEDQUIST36 D: 10:23 T: 14:34 JOB#:,0
"9:21 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: 60 y/ with hx of pancreatitis with severe epigastric pai Field of view: 44 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with REASON FOR THIS EXAMINATION: 60 y/ with hx of pancreatitis with severe epigastric pain, tenderness, and rlq tenderness ______________________________________________________________________________ FINAL REPORT INDICATION: 64 y/o man with history of pancreatitis and currently with severe epigastric pain.",0
TECHNIQUE: CT abdomen and pelvis with and without IV contrast and with oral contrast.,0
150 cc of optiray contrast was used.,0
Non ionic contrast was used secondary to patient's debility.,0
COMPARISON: CT ABDOMEN WITH AND WITHOUT IV CONTRAST: The lung bases demonstrate bilateral small pleural effusions.,0
There liver has diffuse fatty infiltration.,0
The pancreas is well visualized and demonstrates peripancreatic inflammation.,0
The degree of inflammation is consistent with severe pancreatitis.,0
There is no evidence of pancreatic cyst.,0
There is once again noted is a left adrenal mass.,0
This is unchanged in size.,0
Both kidneys enhance and excrete contrast symmetrically and uniformely.,0
There is a right renal cyst.,0
"The stomach, small bowel, and large bowel are all unremarkable.",0
There is no significant retroperitoneal lymph node enlargement.,0
"CT PELVIS WITH IV CONTRAST: The distal ureters, bladder and rectum are all unremarkable.",0
"There is no free fluid, no free air, and no abnormal lymph node enlargement within the pelvis.",0
The bones demonstrate no suspicious lytic or sclerotic lesions.,0
"No evidence of cyst, mass, or pancreatic necrosis.",0
"3) Adrenal mass on the left, unchanged since prior exam.",0
5:38 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with resp failure REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory failure.,1
FINDINGS: Endotracheal tube seen with tip in the right main stem bronchus.,0
"Increasing bilateral airspace opacities identified, consistent with worsening pulmonary edema.",0
Possible layering effusions also identified bilaterally.,0
IMPRESSION: Endotracheal tube with tip in the right main stem bronchus.,0
Discussed with Dr. on .,0
", F. MED MICU-7 3:41 AM CHEST (PORTABLE AP) Clip # Reason: interval changes Admitting Diagnosis: HEPATIC ENCEPHALOPAHTY ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with hepatic encephalopathy, s/p 4L IVF.",1
REASON FOR THIS EXAMINATION: interval changes ______________________________________________________________________________ PFI REPORT Nasogastric tube now in expected position.,0
Height: (in) 68 Weight (lb): 220 BSA (m2): 2.13 m2 BP (mm Hg): 98/84 HR (bpm): 82 Status: Inpatient Date/Time: at 10:05 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.,0
TRICUSPID VALVE: Mild PA systolic hypertension.,1
Conclusions: Left ventricular wall thickness and cavity size are normal.,0
There is a small partially echo filled inferolateral pericardial effusion.,0
IMPRESSION: Small localized inferolateral partially echo-filled pericardial effusion possibly representing a hematoma.,0
No evidence for tamponade physiology.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Multiple facial fractures, skull fractures s/p MVC Major Surgical or Invasive Procedure: Bilateral Craniotomy for repair of skull fracture, pericranial flap, extraction of frontal sinus and skull base repair Evacuation of bifrontal cranitomy for evacutaion of hematoma History of Present Illness: 41 yo s/p high speed MVC, intoxicated, brief LOC, GCS 15 at scene.",1
"CT of the head reveals multiple face fractures, R frontal sinuses fracture, depressed skull fractures.",1
Transferred to with Med flight for further evaluation and treatment.,0
"Past Medical History: None Social History: Unmarried, carpenter, 4-5 beers/day x 20 years, no tobacco Family History: N/C Physical Exam: O: T:101.4-> 98.1 Orally BP:145/90 HR:84 R:16 O2Sats:100%RA Gen: Lying in stretcher, NAD, multiple facial lacerations HEENT: Remains in C-collor, Midfrontal stures in OSH intact, dry blood in mouth/nose.",1
Right orbital ecchymotic with mild peri-orbital edema.,0
Laceration inside into the mouht(down the lips).,0
"ABD: Soft, NT, BS+ Extrem: Warm and well-perfused.",0
VIII: Hearing intact to finger rub bilaterally.,0
No pronator drift Sensation: Intact to light touch bilaterally.,0
Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger.,0
Pertinent Results: 01:57PM PHENYTOIN-12.5 01:57PM HCT-38.2* 03:00AM GLUCOSE-114* UREA N-8 CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-19 03:00AM CALCIUM-8.2* PHOSPHATE-3.5 MAGNESIUM-1.5* 03:00AM WBC-16.1* RBC-4.19* HGB-13.4* HCT-39.6* MCV-95 MCH-32.0 MCHC-33.8 RDW-12.4 03:00AM PLT COUNT-372 01:24AM URINE HOURS-RANDOM 01:24AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG 01:24AM URINE COLOR-Straw APPEAR-Clear SP -1.004 01:24AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 01:22AM GLUCOSE-107* LACTATE-2.5* NA+-146 K+-4.1 CL--104 TCO2-24 01:21AM GLUCOSE-106* UREA N-8 CREAT-0.8 SODIUM-140 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-20* ANION GAP-22* 01:21AM AMYLASE-63 01:21AM ASA-NEG ETHANOL-193* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 01:21AM WBC-16.3* RBC-4.70 HGB-15.2 HCT-43.8 MCV-93 MCH-32.3* MCHC-34.7 RDW-12.4 01:21AM PLT COUNT-376 01:21AM PT-11.9 PTT-21.7* INR(PT)-1.0 01:21AM FIBRINOGE-281 .,0
CT C-spine: IMPRESSION: No evidence of cervical spine fracture.,0
"CT head: There is redemonstration of the comminuted fracture of the frontal sinus involving both the anterior and posterior bony walls, with contiguous pneumocephalus.",0
The present study also demonstrates a linear fracture to the left of midline involving the planum sphenoidale and extending into the sphenoid sinus along its left lateral wall.,0
The bifrontal hemorrhagic contusions are redemonstrated and do not appear to have altered substantially in extent.,0
"However, there also appears to be a small area of hemorrhage within the left occipital lobe, which was also demonstrated, in retrospect, on the prior study.",0
Presumably this is a contrecoup injury.,0
"TLS: Anterior wedging of the mid thoracic vertebral body anteriorly, likely T8 or T9.",0
Age of this finding is indeterminate.,0
Comparison to old films if available would be helpful to establish stability.,0
CT face: There is a depressed comminuted fracture through the right frontal sinus involving the posterior table with resultant pneumocephalus.,0
Multiple osseous fragments are seen in the area of the right frontal sinus.,0
There appears to be involvement of the superior aspect of the right orbit.,0
There is concern for involvement of the right cribriform plate.,0
Fracture line is seen traversing through the ethmoid air spaces.,0
"No displaced fractures are seen in the left maxillary sinus, however, there is fluid level with gas likely representing blood.",0
Again noted is large amount of pneumocephalus.,0
There is soft tissue swelling seen in the frontal scalp.,0
There is a fracture of the planum sphenoidale.,0
There is a fracture of the right ethmoid roof.,0
There is a fracture of the anterior maxillary spine.,0
There are foreign bodies anterior to the mandible.,0
"Brief Hospital Course: The patient was admitted to the Trauma Service, initially to the T-SICU.",0
Plastic Surgery and Neurosurgery were consulted.,0
A lip laceration was repaired by Plastics.,0
He was loaded with Dilantin and then started on maintenance dosing for seizure prophylaxis.,0
He was started on Vanco/Flagyl/Gentamicin for broad antimicrobial coverage.,0
Ortho-Spine was consulted and cleared the spine.,0
He remained hemodynamically stable throughout his course.,0
He tolerated a PO diet well.,0
He spent 2 days in the trauma SICU where his CT scans were followed and his brain contusions remained stable he was neurologically intact.,0
"On he underwent a Bicoronal, bifrontal craniotomy for complex repair with elevation of frontal lobes, repair of skull base fragmentation, exenteration of frontal sinus, repair of orbital roof, orbital rim, ethmoidal cells, frontal cells, closure of CSF leak, pericranial graft, dural graft,cranioplasty.",0
In conjunction with Neurosurgery and Plastic surgery.,0
"He was monitored overnight in the PACU overnight and was neurologically intact, he had a CT scan with no sign of intracranial hemorrhage.",0
He had a lumbar drain in place draining 10-15cc/hr working well.,0
"This afternoon, the patient was on the floor and the lumbar drain got disconnected.",0
An unclear amount of CSF was drained.,0
The patient then became somnolent and was found to be drowsy.,0
"A repeat CAT scan was performed which showed a bifrontal hematoma in the resection cavity, extending from subgaleal into the portion just underneath the bifrontal bone flap.",0
The patient was therefore urgently taken back to the operating room for urgent re-exploration.,0
"Post operatively he was transferred to the Trauma SICU, he was awake, alert and orientated X3 no cranial nerve deficits, with good motor strength.",0
Post op CT had no reaccumulation of hemorrhage.,0
On he was transferred to the neurostep down unit for q2 hour vital signs and monitoring.,0
He reamined on flat bed rest to prevent CSF leak.,0
A repeat CT on showed pneumocephlus with no reaccumulation of blood.,0
His nasal stures removed on Labial-madibular juction laceration sutures are disolvable by plastic surgery there does not require removal.,0
Patient discharged home with follow up and discharge instruction in stable condition.,0
Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed.,0
Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1.,0
Right frontal and left frontal contusions 5.,0
Right frontal comminuted right sinus fracture with posterior table fracture 6.,0
"Facial lacerations/abrasions Discharge Condition: Good Discharge Instructions: 1.Keep insicion site dry and clean, do not wet.",0
"Report any drainage, swelling or redness or fever greater tahn 101.5.",0
Follow up with Neurosurgery/Plastic Surgery as below.,0
"Call your doctor or go to the ER for: uncontrollable pain, nausea/vomiting, headache, weakness, dizziness, or other troubling concerns.",0
Followup Instructions: * Neurosurgery: follow up with Dr on Friday for staple removal call for appointment at .,0
"* Plastic Surgery: Follow up with Dr , in plastic surgery clinic 1-2 weeks after discharge, call for an appointment at Completed by:",0
", S. TSURG SICU-A 8:39 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?ptx, effusion Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p R thoracotomy REASON FOR THIS EXAMINATION: ?ptx, effusion ______________________________________________________________________________ PFI REPORT There is bibasilar atelectasis.",0
There is no pneumothorax or large pleural effusion.,0
Right chest tube is in place.,0
NG tube is in unchanged position.,0
7:44 PM CHEST (PORTABLE AP) Clip # Reason: s/p intubation ______________________________________________________________________________ MEDICAL CONDITION: 25 year old woman with OD s/p intubation REASON FOR THIS EXAMINATION: s/p intubation ______________________________________________________________________________ FINAL REPORT INDICATION: Status post intubation.,0
CHEST AP: There is no prior films available for comparison.,0
There is placement of ET tube with the tip about 2 cm above the carina.,0
Hilar and the mediastinal contours are unremarkable.,0
"There is no pleural effusion, focal consolidation or pulmonary edema.",0
IMPRESSION: The tip of ET tube is 2 cm above the carina.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Levofloxacin / Allopurinol Attending: Chief Complaint: Bilateral hip pain Major Surgical or Invasive Procedure: Left hip hemiarthroplasty Right hip ORIF Intubation PICC placement History of Present Illness: 81 yo woman with PMH signficant for SLE, gout, CHF and MVR, severe osteoporosis who was admitted on to from NH, c/o bilateral hip pain.",1
"She denied trauma but had an overlying hematoma on the right side, however she does not ""recall anything"" at this point.",0
"Plain x-rays showed bilateral hip fractures, intratrochanteric on one side and femoral neck on other.",1
The patient was initially hypotensive to the 80s but then responded to fluids.,0
She was admitted to Medicine due to medical comorbidity.,0
"Surgery was initally planned for but on that day, she developed hypoxemia and cyanosis and CXR showed pulmonary edema, so she was diuresed with Lasix and Bumex and she did well though her O2 sats remained in the high 90?????",1
Cardiology and Pulmonary were consulted.,0
"Pulmonary felt, that she likely has interstitial underlying lung disease as well that is contributing to her hypoxemia.",1
She was continued on betablockers for rate control but Coumadin was held.,0
She was not on any other form of DVT prophylaxis or anticoagulation.,0
She was also found to have a UTI from ESBL-E.coli and was treated with Zosyn.,0
"The patient was also noted to be thrombocytopenic, chronically around 65K which was attributed to SLE.",1
Her anemia was ranging around a Hgb 8.3-8.5.,0
She was transfused 1 Unit PRBC?????,0
"?s, Hct 27.9 prior to transfer.",0
The patient also has ARF with an unclear baseline (last 1.0 in ) now Creatinine 1.2 per last report.,0
She was admitted to on .,0
She was evaluated by orthopaedics for operative repair of her hips.,0
She was assessed to be fluid overloaded as part of her hypoxia.,0
"There was concern about a PE, so a CTA was done on which showed no PE, but did show bilateral pleural effusions with patchy ground glass opacities, apical interlobular septal thickening and peripheral reticulation.",0
There was mediastinal and hilar adenopathy.,0
"The decision was made to diurese further, and her oxygen requirement was decreased from 3L to 1L nc.",0
"She had a repeat UA which showed E.coli that was sensitive to bactrim, so the zosyn was changed to bactrim.",0
On she was felt stable to go to the OR the following day for possible surgical repair of both hips.,0
On she was taken to the OR and the left hip repair was started.,0
"She was noted to have a large amount of bleeding, and an intraopeartive hct was 21% (from 30% the previous day).",0
She was given 3u PRBC intraoperatively.,0
She was noted to have an arrhythmia vs ST depressions on telemetry during this time.,0
The decision was made to not proceed with the right hip at this time.,0
"There was a postoperative attempt at extubation, which per report she failed due to rising CO2.",0
"At this time she is intubated, on a propofol gtt.",0
"NH, no evidence of trauma.",0
Past Medical History: 1) Rheumatic heart disease - h/o rheumatic fever at age 11; s/p porcine MVR .,1
"S/p pacemaker insertion, also .",0
2) PAF 3) SLE - reportedly associated with pneumonitis and pancytopenia.,0
"4) s/p R total knee replacement - , c/b septic arthritis in MSSA 5) Hypothyroidism 6) Old R hip surgery 7) Gout 8) Osteoporosis Social History: She is a widow.",1
She has family in the area.,0
Daughter and husband live nearby.,0
"Previous tobacco use, she quit 30 years ago.",0
She uses alcohol very infrequently.,0
"Functional status is poor, she ambulates very little at baseline in a wheelchair.",0
She lives in a NH.,0
Family History: Brother status post CABG at age 69.,0
"Physical Exam: On Admission to MICU: Physical exam: VS T 99.0 BP 110/50 HR 70 RR 12 O2Sat 100% on AC 500x12 RR 12 40% Ge: Intubated, sedated HEENT: NC/AT, PERRLA, anicteric NECK: no LAD, JVD at 8cm, no carotid bruit, left EJ in place COR: S1S2, regular rhythm, no r/g, split 2, III/VI holosystolic murmur over apex.",0
PULM: crackles about 1/3 up both lung fields anteriorlly.,0
"ABD: + bowel sounds, soft, nd, nt Skin: warm extremities, large hematoma over R knee, back not examined.",0
"EXT: 1+ DP, 2+ edema, swelling of b/l hip.",0
Left hip bandaged with soft tissue swelling of thigh.,0
RLE shortened and externally rotated.,0
GU: Perineal bruising / hematoma with swelling of left labia > right labia.,0
"Pertinent Results: ECHO at OSH: Preserved LV function, R pulm HTN, RV enlargement, TV 51mmHg .",0
ECHO here: The left atrium is moderately dilated.,0
Right ventricular systolic function is borderline normal.,0
[Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.],0
A bioprosthetic mitral valve prosthesis is present.,0
The transmitral gradient is normal for this prosthesis.,0
"Compared with the prior study (images reviewed) of , left ventricular systolic function appears preserved.",0
Tricuspid regurgitation is now more prominent and pulmonary artery systolic pressure is now higher.,0
"Bilateral pleural effusions with patchy ground-glass opacity, apical interlobular septal thickening, and peripheral reticulation.",0
"Findings likely, at least in part, reflect a degree of hydrostatic pulmonary edema.",0
It is unclear what component of these changes are chronic in nature.,0
"If indicated, followup CT after the patient's acute clinical findings have been treated may be performed.",1
"Numerous thoracic compression fractures, age indeterminate.",0
Coronary artery and other vascular calcifications consistent with atherosclerosis.,0
Displaced right femur intratrochanteric fracture with pins in situ.,1
CT HEAD: No acute intracranial pathology including no sign of intracranial hemorrhage.,0
R Elbow: 2views: Radial head fracture .,0
BNP: 9000 at OSH .,0
"Admission EKG: Afib, V-paced, HR 70, ST scooping in I; throughout three sequential EKG on / patient is developing a TWI in isolated V2 Brief Hospital Course: # B/l hip fractures osteoporosis s/p repair: The patient was originally admitted with bilateral hip fractures, the left newer than the right, of unclear origin as there was no known trauma or fall.",1
"However, there was no suspicion of abuse and social work confirmed this.",0
"After some respiratory optimization, described below, and reversal of her INR with vitamin K and FFP, the patient underwent a left hemiarthroplasty on .",1
"Intraoperatively, some abnormal appearing changes, possible ST depressions, appeared on her telemetry and the operation limited to only the left side at that time.",1
She was a difficult ween from the ventilator and was transferred to the MICU for rule out ACS and vent ween.,0
She was ruled out by a normal EKG and 3 sets of negative cardiac biomarkers.,0
She also required several units of PRBCs for postoperative anemia.,0
She was extubated shortly thereafter.,0
She returned to the OR for a right ORIF and removal of the preexisting hardware on .,0
"Again, post operatively she developed respiratory distress and had to be reintubated and transferred to the MICU.",0
"During her time in the MICU, there was noted to be soft tissue swelling of her R knee and thigh but an ultrasound showed no DVT and no gross hematoma.",0
After stabilization the patient returned to the floor and began working with physical therapy.,0
She was WBAT with anterolateral hip precautions.,0
Her pain was controlled initially with IV morphine and PO oxycodone but she was eventually transitioned to Percocet with good effect.,0
She was also begun on calcium and vitamin D supplementation to augment her Actonel usage.,0
She was maintained on enoxaparin prophylaxis until her coumadin level returned to a therapuetic range.,0
She will continue physical therapy at her rehabilitation center with a follow up with Dr. in orthopedics.,0
"# Respiratory distress: Upon transfer from the OSH, the patient had a new oxygen requirement of unknown etiology.",1
After an initial concern of PE a CTA was done that showed no PE but chronic interstitial lung disease with possible acute pulmonary edema overlying it.,1
A repeat echocardiogram showed a preserved LVEF but moderate to severe pulmonary hypertension.,0
She carries a diagnosis of CHF but discussions with the PCP could not further clarify its cause or current status.,0
"Based on clinical status, it is likely diastolic dysfunction.",0
"Prior to her first operation, the patient was diuresed with IV Lasix with improvement in her oxygen requirement.",1
"After the operation, she was not able to intially extubated but was extubated within 24 hours and did well subsequently.",0
"She returned to the OR on and developed postoperative respiratory distress and hypercarbia (ABG 7.0/99/84), likely from fluid overload and sedation.",0
"She was reintubated, diuresed with IV lasix and extubated sucessfully the next day.",0
The patient was weened from her O2 to room air and placed back on her outpatient regimen of 40mg Lasix PO BID and Spironolactone 25mg PO daily to maintain her current fluid balance.,0
She remained stable on room air with minimal subjective shortness of breath.,0
"# Anemia: Over the course of her admission, the patient has required a total of 9 units of PRBCs to be transfused for intra and postoperative blood loss, including a small amount of bleeding into her bilateral thighs.",1
The last transfusion was on and her hematocrit has remained stable since with no further signs of bleeding.,0
# Afib: Initially her INR was reversed with vitamin K and FFP.,0
She was maintained on good rate control using her metoprolol.,0
"After completion of her surgeries, her coumadin was restarted.",0
Her INR will need to be checked 2-3x/week until it is therapeutic with a goal INR of .,0
Her digoxin was also restarted after the completion of her surgeries.,0
"# Hyperkalemia: Pt noted to be hyperkalemic post-op, with no peaked T waves on EKG (in setting of baseline intraventricular conduction delay).",0
"Hyperkalemia resolved after administration of calcium, insulin, and D50; this issue has remained stable.",0
# Prosthetic (porcine) valve/MVR: No need for continued anticoagulation for this reason.,0
Valve function appears to be good based on echocardiogram.,0
"# ARF: Cr was noted to be 1.2 on admission and 1.7 at the OSH, with no recent recorded baseline (last Cr ).",0
"Currently, this issue is resolved after blood transfusion with recent Cr of 0.9 - 1.0.",0
The etiology was likely prerenal with poor forward flow from CHF.,0
"# UTI: E.Coli UTI here, noted on admission.",0
"Reported as ESBL at OSH and initially got Zosyn, however then found to be bactrim sensitive, which was treated with 7 day course of Bactrim which finished .",0
No further signs of infection.,0
# Depression: Patient continued on home regimen of citalopram 20mg PO daily.,0
# Hypothyroidism: Patient continued on home regimen of levothyroxine 88mcg daily.,1
# FEN: Regular as tolerated.,0
"Patient not hungry, so have added Ensure TID to supplement .",0
"# Prophylaxis: Enoxaparin 40mg SC daily, pneumoboots, PPI PO (home regimen), bowel regimen.",0
"# Code: DNR, not DNI (form in chart), confirmed with daughter.",0
"# Comm: Daughter , also HCP Medications on Admission: Medications at home: Actonel 35mg po Daily MVI Daily Protonix 40mg po Daily MOM 30cc po prn BIsacodyl supp one rectal prn Mylanta 20cc po Daily prn Peptobismol 2 TSP po Duonebs Q6h prn Citalopram 20mg po Daily Spironolactone 25mg Daily Digoxin 0.125mg Daily Vitamin C Daily 500mg Colchicine 0.3mg Daily Furosemide 40mg Metoprolol 50mg Tylenol Loperamide 2mg po Daily prn Levoxyl 88mcg Daily Coumadin 5mg Daily Discharge Medications: 1.",0
Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): Continue until INR >2.,0
Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed.,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed.,0
Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice a day: Hold for SBP<100 or HR<60.,0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO BID (2 times a day).",0
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).,0
Actonel 35 mg Tablet Sig: One (1) Tablet PO once a day.,0
DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
Colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO once a day.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Bilateral Hip Fractures s/p L hemiarthroplasty () and R ORIF () Diastolic Congestive Heart Failure Lupus with interstitial lung disease.,1
"Discharge Condition: All vitals signs stable, off oxygen.",0
Discharge Instructions: You were admitted with fractures of both hips.,0
"You also had some trouble breathing, requiring oxygen.",0
"This was likely from fluid build up in your lungs, backing up from your heart.",0
This is called congestive heart failure.,1
This fluid was removed using IV Lasix and then will be kept off using the oral form of Lasix you were previously on.,0
"Your hip fractures were repaired surgically, however after each surgery, you had increased trouble breathing, requiring intubation and stays in the medical ICU.",1
"However, you quickly recovered after more fluid was taken off with Lasix.",0
"You also had a drop in your blood count after the operations, from blood loss during the operation and some bleeding into the legs after the operation.",1
You received a number of blood transfusions to correct this.,0
"However, your blood count is now stable and you have no further signs of bleeding.",0
"You also had a small and temporary decrease in your kidney function upon admission, likely due to some dehydration.",0
This improved and was normal by the time of discharge.,0
"You also had a urinary tract infection treated with a course of antibiotics, finished in the hospital.",1
"During your first operation, there was a concern about your heart based on the EKG taken during the operation.",1
"However, subsequent labs tests showed no damage to the heart and no heart attack.",0
You were also given some pain medications to control your pain.,0
These will continue at the rehab facility.,0
You will also continue Followup Instructions: Please call Dr. office at ( to schedule a follow up appointment in the next 1-2 weeks.,0
Please call Dr. office at to schedule a follow up appointment in the next few weeks.,0
Provider: CLINIC Phone: Date/Time: 11:30,0
"8:21 AM CHEST (PORTABLE AP) Clip # Reason: r/o aspiration pneumonia Admitting Diagnosis: CEREBRAL ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with feeding tube, s/p L MCA REASON FOR THIS EXAMINATION: r/o aspiration pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Status post left MCA.",1
"VIEWS: Single AP portable upright view, comparison dated .",0
FINDINGS: NG tube is again seen extending below the diaphragm with tip terminating below the borders of the radiograph.,0
"The heart size, mediastinal contours, and pulmonary vasculature are unchanged without cardiac failure.",0
No pleural effusions or areas of focal consolidation.,0
"The examination is otherwise unchanged with stable elevation of the right hemidiaphragm, prior CABG and surgical clips overlying the right upper quadrant of the abdomen and the right upper lobe.",0
IMPRESSION: Unchanged position of nasogastric tube and no acute cardiopulmonary abnormality.,0
No radiographic evidence of aspiration pneumonia.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: placement of CVL Admitting Diagnosis: GASTROINTESTINAL BLEED,SPONTANEOUS BACTERIAL PERITONITIS ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with peritonitis REASON FOR THIS EXAMINATION: placement of CVL ______________________________________________________________________________ WET READ: JXRl WED 8:42 PM right IJ catheter terminates in SVC.",1
"bilateral effusions, right greater than left, underlying atelectasis similar to 12 hours prior.",0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Placement of central venous access line.,0
"FINDINGS: As compared to the previous radiograph, a new central venous access line has been inserted over the left internal jugular vein.",0
"The course of the line is unremarkable, the tip of the line projects over the mid SVC.",0
The pre-existing right-sided pleural effusion has minimally increased in extent.,1
"Otherwise, the radiographic appearance is unchanged.",0
"IMPRESSION: Normal course and position of central venous access line, no complications.",0
", D. 6:04 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE\CARDIAC CATH Admitting Diagnosis: CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with known 3VD awaiting CABG REASON FOR THIS EXAMINATION: preop CXR ______________________________________________________________________________ PFI REPORT No evidence of acute pulmonary process.",1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: erythromycin / Penicillins Attending: Chief Complaint: chest pain Major Surgical or Invasive Procedure: Percutaneous coronary intervention with BMS placement x 2 Intubation Central Line Arterial Line History of Present Illness: 85 yr old female patient of Dr. with hx of CAD, CABG and stenting in as well as left leg angioplasty , s/p right leg stents , also has a left common femoral aneurysm (still present after thrombin injection), on coumadin for PAF, who presents for elective cardiac catheterization tomorrow.",1
Patient has experienced recent increased exertional angina.,0
"Symptoms occur often at nighttime, where she has noticed that she develops chest discomfort when she moves pillows around on her bed.",0
She notes relief of the pain with one nitroglycerin or rest.,0
"She has had an abnormal stress test on , which showed a fixed inferior defect but a reversible antero-apical defect.. EF is noted to be 41%.",0
Dr. has requested Mucomyst administration prior and after cath.,0
"Currently, patient reports no chest pain, shortness of breath, nausea or vomiting.",1
She is without any pain at the current time.,0
She reports no recent fevers or chills.,0
"On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",1
She denies exertional buttock pain.,0
"Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope.",0
"CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension.",0
CARDIAC HISTORY: -CAD s/p CABG in .,0
"-PERCUTANEOUS CORONARY INTERVENTIONS: RCA, LAD ostial vein graft in ; left SFA angioplasty in 8/99.",1
"OTHER PAST MEDICAL HISTORY: CHF EF 41% on stress test Paroxysmal atrial fibrillation COPD DJD Peripheral vascular disease (s/p PTCA stent R SFA , PTCA stent L SFA ) spinal stenosis Social History: SOCIAL HISTORY: Lives in in facility.",1
"Has daughter (daughter-HCP): (cell), (home) -Tobacco history: Denies currently, significant past history, 2 pks/day for many years -ETOH: Denies currently, social drinker previously -Illicit drugs: none Family History: Father who died of coronary artery disease.",1
"Physical Exam: On presentation: VS: T=96.3 BP=146/58 HR=76 RR=18 O2 sat=92%RA GENERAL: AAOx3, NAD.",0
NECK: Supple with JVP of 3 cm above clavicle.,0
"CARDIAC: RR, normal S1, S2.",0
2/6 SEM loudest at LUSB.,0
No S3 or S4 noted.,0
"LUNGS: Resp were unlabored, no accessory muscle use.",0
EXTREMITIES: 2+ pitting edema present up to knees bilaterally.,0
Venous stasis changes present bilaterally.,1
"SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted.",0
PULSES: Right: 2+ DP 2+ PT 2+ Left: 2+ DP 2+ PT 2+ Pertinent Results: On presentation: 07:45PM BLOOD WBC-4.5 RBC-2.90* Hgb-8.5* Hct-26.2* MCV-90 MCH-29.1 MCHC-32.3 RDW-15.3 Plt Ct-218 07:45PM BLOOD PT-12.4 PTT-25.5 INR(PT)-1.0 07:45PM BLOOD Glucose-132* UreaN-59* Creat-1.8* Na-139 K-4.1 Cl-107 HCO3-24 AnGap-12 07:45PM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2 .,0
"On discharge: wbc: 6.8 hgb: 7.3 hct: 22.4 plt: 420 Na: 136, K: 4.1 CL: 104 bicarb; 24 BUN: 31 Cr: 1.1 ca: 8.9 P: 3.1 Mg: 1.9 .",0
Microbiology: URINE CULTURE (Final ): ESCHERICHIA COLI.,0
">100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Blood cultures - all negative except for 2 sets pending on d/c C. diff toxins - neg x 2 Respiratory cx - yeast and mold .",0
Coronary angiography in this right dominant system demonstrated a 50% lesion in the LMCA.,1
The LAD was totally occluded and filled via vein graft.,1
The Lcx had a mid 50-60% discrete lesion.,0
The RCA had a mid 60-70% discrete instent restenosis.,0
"Graft angiography demonstrated a svg to the mid LAD witha 70% proximal lesion, instent restenosis with evidence of thrombus.",1
Resting hemodynamics revealed elevated right and left sided filling pressures with a pcwp of 25mmHG and RVEDP of 20mm Hg.,0
Moderate pulmonary hypertension was present with a PAP of 63mm Hg.,0
Cardiac output was normal at 4L/min.,0
There was severe systolic hypertension at 163mmHg while on a nitroglycerine drip.,0
Three vessel coronary artery disease of the native arteries.,1
"Left main disease, and instent restenosis of SVG-LAD graft.",1
Severe systolic hypertension with evidence of diastolic dysfunction.,0
TTE: The left atrium and right atrium are normal in cavity size.,0
Overall left ventricular systolic function is low normal (LVEF 50%) secondary to inferior posterior hypokinesis.,0
with depressed free wall contractility.,0
"CXR: As compared to the previous radiograph, the inferior vena cava catheter has been removed.",0
The remaining monitoring and support devices are in unchanged position.,0
"Minimal retrocardiac atelectasis, the presence of a small left pleural effusion cannot be excluded.",0
Unchanged borderline size of the cardiac silhouette without evidence of overt pulmonary edema.,0
"CXR: As compared to the previous examination, there is no relevant change.",0
Moderate cardiomegaly without signs of overt pulmonary edema.,0
Moderate tortuosity of the thoracic aorta.,0
: UE venous US: IMPRESSION: Non-occlusive thrombus seen adherent to the PICC line within the left basilic vein extending into the left subclavian vein.,0
No renal abscess or son signs of pyelonephritis.,0
Please note that a normal ultrasound does not exclude the diagnosis of pyelonephritis.,0
Benign simple-appearing right renal cyst.,0
Bilateral renal calcifications likely representing vascular calcifications and tiny crystals with no evidence of obstructing stones or hydronephrosis.,1
"Brief Hospital Course: 85 yr old female patient of Dr. with hx of CAD, CABG and stenting in as well as left leg angioplasty , s/p right leg stents , also has a left common femoral aneurysm (still present after thrombin injection), on coumadin for PAF, who presents for elective cardiac catheterization after worsening angina.",1
# Coronary artery disease and catheterization complications - Patient admitted for pre-hydration prior to catheterization.,1
Taken to the cardiac cath lab on .,0
There was total occlusion of her LAD with 70% in-stent restenosis and evidence of thrombus in her proximal SVG-LAD.,1
PTCA/stenting of her LAD venous graft was complicated by graft perforation into the thorax without evidence of tamponade after the procedure.,1
She was intubated and remained stable enough to deliver 2 overlapping DES to the venous graft with occlusion of the perforation.,1
"She was transfused 4 units pRBC in total, with stable pressures on dopamine gtt and transferred to the CCU for post-procedure monitoring.",1
Post-procedure TTE did not show evidence of pericardial effusion.,0
"She was continued on home dose clopidigrel 75mg, which should be continued for 12 months.",0
She should be instructed aspirin 325mg indefinitely.,0
B-blocker and to be restarted (as described below).,0
# Ventilator Associated Pneumonia: She developed fevers while being intubated.,1
She was pan-cultured and given meropenem + vancomycin for a 7 day course.,0
"Sputum grew sparse mold, without any pathogens.",0
"After initial difficulty weaning her from the ventilator, she was succesfully extubated on .",0
She is now on room air.,0
"Urinary tract infection: Weeks into the hospitalization, while on the regular medical floor, the patient became acutely lethargic and cultures were taken.",1
Urinalysis was highly suggestive of infection and she was empirically started on Cipro.,0
"Her urine culture grew E.coli, resistant to Cipro, and her antibiotic regimen was changed to Cefpodoxime for a course of 3 more days (total of 7).",0
Renal ultrasound was obtained to r/o abcess which was negative for abscess or pylo .,0
"Left wrist and hand cellulitis with LUE DVT: Her wrist and thenar eminence became quite swollen, erythematous, and painful on movement.",0
"She was empirically started on vancomycin for coverage, which was changed to dicloxacillin/bactrim.",0
A LUE ultrasound revealed a non-occlusive thrombus in the basilic vein with extension in the subclavian.,0
"This was associated with the PICC line in this location, so it was removed promptly.",0
She was not started on heparin due to ongoing melenotic stools as well as a hematocrit in the low 20s.,0
Wrist cellulitis improved on discharge .,0
# Hypernatremia: Na+ rose in setting of poor PO intake.,0
"While she was refusing to take anything by mouth, she was given D5W.",0
"When she began to eat small amounts again, her Na+ normalized to the normal range at discharge.",0
"# Nutrition: After extubation, PO intake was markedly decreased, as patient refused to eat.",0
"In discussions with the daughter, she strongly refused feeding tube and states this is against patient's wishes.",0
"She has continued to need a lot of encouragement to eat and drink, stating that if she had food she liked, she would eat more.",0
"Her mental status continued to improve with mild increases in PO intake, so the decision was made to monitor her nutritional status as an outpatient.",1
# Delirium: Patient developed worsening MS delirium following extubation.,1
This continued despite correction of her hypernatremia and treatment of her VAP.,0
She was treated with haldol with little effect and modifications.,0
"She gradually became more conversant, but continued to be intermittently confused.",0
She should have Olanzipine if needed in the evenings to prevent any agitation.,0
Aprazolam and gabapentin have been discontinued upon discharge.,0
"Though her nutritional status remains poor, we have decided (in conjunction with the family) to avoid NG or PEG tube feedings and allow her to increased her diet as tolerated.",0
"Her UTI and left hand cellulitis caused another acute change in her mental status, which improved with proper treatment of these infections.",1
"# Acute Kidney Injury - Patient's renal function initially deteriorated following catherization, likley secondary to contrast nephropathy.",1
Baseline Cr thought to be 1.6 or so.,0
"She was extensively diuresed with lasix and metolazone, and her kidney function eventually improved and she had good urine output.",0
"She was started on her home dose of lasix, but her creatinine bumped once again and her losartan and lasix were held.",0
"# Scleral/conjunctival hemorrhages: She developed sigificant bilateral eye hemorrhages during admission, likely related to anticoagulation + coughing while intubated.",1
She gradually improved without issue.,0
# Paroxysmal atrial fibrillation: Now in sinus consistently.,1
"Her CHADS2 = 3, and given her risk of bleeding is relatively low and she is a potential fall risk, we decided to hold off on coumadin.",0
She will continue on ASA and plavix as above.,0
# COPD: She was intubated s/p catheterization.,0
"When she was extubated, she was continued on Spiriva per home dose.",0
"# Hyperlipidemia: Crestor was initially held given , but then restarted once patient was extubated and able to tolerates POs, and her renal function improved.",1
# Hypertension: Losartan and and metoprolol (increased to 100mg daily) continued on discharge.,0
She was also started on low-dose Amlodipine 5mg.,0
Her home dose of Lasix was also restarted when kidney function improved.,0
"# GERD: While intubated and s/p intubation, her PPI was changed to Lansoprazole which she should continue.",0
Medications on Admission: Aspirin 81 mg PO daily Plavix 75 mg daily Crestor 5 mg daily 000 Toprol XL 25 mg daily Losartan 25 mg PO daily Lasix 40 mg daily Nitroglycerin 0.4 mg PO PRN Spiriva 18 mcg PO daily Omeprazole 20 mg daily Gabapentin 200 mg TID Folic acid 1 mg daily Xalatan 0.005% daily Celebrex 200 mg PO daily Alprazolam 0.5 mg PO BID Premarin 0.625 mg daily Discharge Medications: 1. aspirin 325 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
2. clopidogrel 75 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
3. rosuvastatin 5 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
4. metoprolol succinate 100 mg Tablet Sustained Release 24 hr : One (1) Tablet Sustained Release 24 hr PO once a day.,0
"5. nitroglycerin 0.4 mg Tablet, Sublingual : One (1) tablet Sublingual every 5 min for total of 2 tabs as needed for chest pain.",0
"6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device : One (1) Cap Inhalation DAILY (Daily).",0
7. folic acid 1 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
8. latanoprost 0.005 % Drops : One (1) Drop Ophthalmic HS (at bedtime): both eyes.,0
9. white petrolatum-mineral oil 56.8-42.5 % Ointment : One (1) Appl Ophthalmic PRN (as needed) as needed for eye irritation: both eyes.,0
10. docusate sodium 100 mg Capsule : One (1) Capsule PO BID (2 times a day) as needed for constipation.,0
11. senna 8.6 mg Tablet : One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
12. amlodipine 5 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
"13. heparin (porcine) 5,000 unit/mL Solution : One (1) syringe Injection twice a day.",0
14. acetaminophen 325 mg Tablet : 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
15. mirtazapine 15 mg Tablet : One (1) Tablet PO HS (at bedtime).,0
16. losartan 25 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
17. ascorbic acid 500 mg Tablet : One (1) Tablet PO BID (2 times a day).,0
18. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid : Five (5) ml PO BID (2 times a day).,0
19. polyethylene glycol 3350 17 gram/dose Powder : One (1) packet PO DAILY (Daily).,0
20. cefpodoxime 100 mg Tablet : Two (2) Tablet PO Q24H (every 24 hours) for 3 days.,0
"Disp:*6 Tablet(s)* Refills:*0* 21. lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR DAILY (Daily).",0
Discharge Disposition: Extended Care Facility: Nursing & Rehabilitation Center - Discharge Diagnosis: Coronary Artery Disease Paroxysmal Atrial fibrillation diabetes mellitus type 2 Hypertension Chronic Obstructive pulmonary disease Peripheral Vascular disease Hypernatremia conjunctival Hemorrhage Discharge Condition: Mental Status: Confused - sometimes.,1
Discharge Instructions: You had chest pain and a complicated cardiac catheterization to find out the cause of your chest pain.,1
The vein graft to a heart artery was opened using a bare metal stent but a small perforation developed and was closed with two Grafmaster covered stents.,1
You required a breathing machine for low oxygen and medicine to keep your blood pressure up.,0
"Antibiotics were given for pneumonia, a urinary tract infection, and a skin infection involved your left hand and wrist.",1
You have slowly recovered and need rehabilitation to get stronger.,0
It is very important that you eat as much as possible.,0
We made the following changes to your medicine: 1.,0
Increase aspirin to 325 mg daily 2.,0
Increase Metoprolol to 100 mg daily 3.,0
"Start colace, miralax and senna to prevent constipation 4.",0
Start amlodipine to lower your blood pressure 5.,0
Start Heparin injections to prevent blood clots 6.,0
Start tylenol as needed for pain 7.,0
"Stop taking Gabapentin, Celebrex, Aprazolam and Premarin 8.",0
Start an eye ointment for dry eyes 9 change Omeprazole to Lansoprazole to protect your stomach 10.,0
Start Mirtazipine to help your appetite 12.,0
Start vitamin c and Iron to help your anemia 13. finish a 7 day course of Cefpodoxime to treat your urinary infection and the cellulitis on your left arm.,1
"Followup Instructions: Name: , Location: ASSOCIATES IN INTERNAL MEDICINE Address: , , , Phone: Appt: at 2:45pm",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: is a 41-year-old female with past medical history of questionable chronic obstructive pulmonary disease and asthma with two recent hospitalization for asthma / chronic obstructive pulmonary disease flares complicated by pneumonia.,1
"Patient presents with five days of URI symptoms, sore throat and fatigue, three days of shortness of breath with inhaler use with moderate relief, two day history of cough, dry and nonproductive and subjective fevers and chills.",0
"Patient denies myalgias, headache, chest pain, rash, diarrhea, abdominal discomfort, or hemoptysis.",0
Current symptoms are identical to prior admission.,0
Patient's last admission was on .,0
Patient has one lifetime history of intubation.,0
"Patient had a lung biopsy in , past reports suggestive of interstitial pulmonary fibrosis.",1
"On presentation to the Emergency Department, patient had a temperature of 101.9 F, heart rate of 126, blood pressure 156/85, breathing rate of 28, saturating at 83% on room air.",0
Patient was put on oxygen.,0
Patient received a chest x-ray which showed questionable early left lower lobe infiltrate with atelectasis.,0
"EKG showed patient in sinus tach with poor R wave progression, left axis deviation, no signs of ischemia.",0
"Patient was started on antibiotics, steroids, nebs and admitted.",0
"Adult onset asthma with one lifetime intubation, multiple hospitalizations.",0
History of VRE and MRSA.,0
History of positive PPD status post six month treatment with INH and Rifampin.,0
History of TDs in the setting of ETOH withdraw.,0
Exploratory laparotomy for abdominal mass versus uterine cyst.,0
Patient has insensitivity to Codeine which gives her GI upset.,0
True allergy to Penicillin for which she gets a rash.,0
Erythromycin for which she also gets a rash.,0
"AM, 400 mg q. PM.",0
SOCIAL HISTORY: Patient smokes one to two packs of cigarettes per day and has a history of medical noncompliance and poor follow up.,0
Patient has been sober for greater than 10 years.,0
"Also prior use of LSD, cocaine and heroin use, but none in the recent past.",0
"PHYSICAL EXAMINATION: On arrival to the medical floor, the patient had a temperature of 98.3 F, blood pressure 120/68, pulse of 100, respirations 22, saturating 94% on 10 liter mask.",0
"In general patient is an obese white female in mild distress, able to speak in full sentences.",0
"Pupils equal, round and reactive to light.",0
Neck was supple without tenderness or rigidity.,0
No jugular venous distention was appreciated.,0
Lungs: Decreased breath sounds in the right base with mild wheezing.,0
"Cardiovascularly: Patient was tachycardic, S1, S2, no murmurs.",0
"Abdomen was obese, soft, nontender, nondistended with normoactive bowel sounds.",0
Extremities: 1+ pitting edema lower extremities to the knee.,0
"Normal strength and sensation, equal bilateral extremities.",0
No clubbing or cyanosis with minimal pitting lower extremity edema.,0
"LABORATORY: White count 21.4, hematocrit 40.3, platelets 322.",0
"Sodium 137, potassium 4.0, chloride 102, bicarbonate 24, BUN 10, creatinine 0.7, glucose of 197.",0
HOSPITAL COURSE: Patient was admitted to the Medical Floor.,0
Patient received oxygen via face mask to keep saturations greater than 92%.,0
Patient received q. three hour standing Albuterol and Atrovent neb treatments.,0
Patient was started on Levofloxacin 500 mg p.o.,0
q. day and patient was also started on Solu-Medrol 80 mg IV q. eight hours.,0
Patient was managed on this course until the second hospital day when patient was found to be increasingly somnolent.,0
"ABG was performed at this time that showed a pH of 7.35, pCO2 of 58, pO2 of 132.",0
"Because of this, the patient was taken to the ICU for observation.",0
"In the ICU, the patient continued to slowly improve.",0
"Steroids, nebulizer treatments and antibiotics were continued as on the floor.",0
Patient received cardiac echo for evaluation of possible congestive heart failure.,0
Patient had left ventricular wall thickness.,0
Cavity size and systolic function were all normal with a left ventricular ejection fraction of greater than 55% and normal left ventricular region wall motion unchanged in the interval from previous echo of .,0
The patient returned to the floor after two days of observation in the ICU in improved condition.,0
Patient had chest x-ray at this time which showed interval resolution of patient's pulmonary opacities.,0
Pulmonary consult was obtained for more input on patient's worsening respiratory status who advised patient receive chest CT Scan.,0
The chest CT Scan was consistent with worsening interstitial lung disease.,0
Patient's sedation is a possible contribution of patient's psychiatric regimen was considered and psych consult was obtained.,0
"They recommended it was reasonable to hold sedating psychiatric medications, but continuing patient on low dose Clozaril.",0
All other psychiatric medications were stopped.,0
"Throughout this time, the patient slowly continued to improve in respiratory status requiring less frequent nebs and decreased O2.",0
The patient was transitioned from mask to nasal cannula where she continued to improve.,0
The patient was also started on Bactrim for PCP prophylaxis and other follow up chest x-ray showed no evidence of focal consolidation.,0
Patient completed a course of Levofloxacin which was stopped prior to discharge.,0
Fingersticks were checked on patient during the hospital stay and slowly started to trend upward.,0
Patient was put on sliding scale insulin.,0
"At time of discharge, the patient is saturating about 92% on two liters nasal cannula.",0
The patient will be discharged to pulmonary rehab prior to discharge home.,0
CONDITION ON DISCHARGE: Stable and improved.,0
DISCHARGE DIAGNOSIS: As per admission in addition to recent admission for asthma exacerbation with questionable pneumonia in the setting of interstitial lung disease and likely steroid induced hyperglycemia.,1
"NPH insulin 8 units at breakfast, five units at dinner.",0
Fluticasone 112 micrograms two puffs b.i.d.,0
"Prednisone 60 mg q. day times 30 days then 15 mg q. day for three days than 40 mg q. day times three days, 30 mg q. day for three days, 20 mg q. day for three days, 10 mg q. day for three days then stop.",0
Guaifenesin 5 to 10 ml p.o.,0
Albuterol and Atrovent nebs q. four hours p.r.n.,0
Calcium Carbonate 500 mg p.o.,0
"Bactrim single strength tabs, one tab p.o.",0
Heparin 5000 units subcutaneous q.,0
Patient advised to follow up with Dr. from Pulmonary Service in four weeks.,0
Patient advised to see primary care provider in one week for follow up and especially to discuss smoking cessation which is imperative in this patient with underlying lung disease.,0
Patient also advised to see psychiatrist in one week for follow up.,0
Dictated By: MEDQUIST36 D: 14:22 T: 15:57 JOB#:,0
"2:00 PM CHEST (PORTABLE AP) Clip # Reason: PTX, improvement in right pleural effusion Admitting Diagnosis: DIABETIC KETOACIDOSIS ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman s/p right pleuracentesis REASON FOR THIS EXAMINATION: PTX, improvement in right pleural effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 4:59 PM 1.",1
Status post right thoracentesis with markedly improved aeration of the right lung.,0
"HISTORY: 60-year-old woman, status post right thoracentesis; ?",0
improvement in right pleural effusion.,1
"FINDINGS: Single bedside AP examination labeled ""upright at 13.45"" is compared with bedside study obtained some eight hours earlier, as well as on from the previous day.",0
"There has been significant improvement in the right pleural effusion, status post thoracentesis, with the right CP angle relatively sharp, and no pneumothorax.",1
There is persistent left pleural effusion with basilar atelectasis and pulmonary vascular congestion; the tracheostomy is unchanged.,1
Status post right thoracentesis with significant improvement in the appearance of the right hemithorax and no pneumothorax.,0
Persistent left pleural effusion with associated basilar atelectasis.,1
"9:12 AM CHEST (PORTABLE AP) Clip # Reason: eval for pneumonia Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with new hypoxia and fever, cough REASON FOR THIS EXAMINATION: eval for pneumonia ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:25 A.M., HISTORY: New hypoxia and fever with cough.",0
"IMPRESSION: AP chest compared to :08 p.m.: Lungs are essentially clear, heart size is normal, and there is no pleural abnormality.",0
8:38 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # Reason: PLease obtain a CT urogram +/- contrast with delayed imaging Admitting Diagnosis: SEPSIS Field of view: 42 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with hematuria and urosepsis.,0
REASON FOR THIS EXAMINATION: PLease obtain a CT urogram +/- contrast with delayed imaging.,0
Question of bladder mass vs. blood No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: CT chest and abdomen dated .,0
CLINICAL HISTORY: 81-year-old woman with hematuria and urosepsis.,0
Question of bladder mass versus blood.,0
"Comparison made to prior studies, including CTA chest dated .",0
"TECHNIQUE: Multiple transaxial images of the abdomen and pelvis were obtained with and without intravenous contrast, after the administration of oral contrast.",0
Coronally and sagittally reformatted images were also obtained.,0
CT ABDOMEN: Evaluation is somewhat limited secondary to streak artifacts from the patient's arms being at her side.,0
"There are patchy opacities of the visualized lung bases, most likely representing atelectasis.",0
No pleural or pericardial effusions.,0
"There are multiple, subcentimeter hypoattenuating lesions throughout the liver that are too small to characterize but most likely represent hepatic cysts.",0
"The gallbladder, pancreas, spleen, and adrenal glands are normal.",0
"There is a fused, horseshoe-configuration kidney at the right lower abdomen.",0
"Multiple hypoattenuating lesions are in the fused kidney, the largest on the left measuring up to 3.9 cm.",0
No definite enhancing renal masses are identified.,0
There is at least one hyperdense cyst in the right portion of the kidney.,0
"There are small, nonobstructing renal calculi, the largest on the right measuring up to 9 mm (sequence 2, image #60).",0
No filling defects are seen in the ureters.,0
There has been interval decrease in the degree of hydronephrosis.,0
There is a Foley catheter in the urinary bladder.,1
There is diffuse thickening of the urinary bladder wall that may represent cystitis.,1
"The spine is markedly deformed, with fusion of L2-3.",0
A lipoma is in the left gluteal musculature measuring up to 4.5 cm.,0
"No evidence of bladder mass, as clinically questioned.",0
Diffuse bladder wall thickening that may represent cystitis.,0
(Over) 8:38 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # Reason: PLease obtain a CT urogram +/- contrast with delayed imaging Admitting Diagnosis: SEPSIS Field of view: 42 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
"Interval, partial decompression of the collecting system.",0
"Horseshoe kidneys with multiple hypoattenuating lesions, many of which are too small to characterize but most likely represent cysts.",0
"Multiple hypoattenuating lesions in the liver, likely cysts.",0
Diffuse osteopenia and deformity and ankylosis of lumbar spine.,0
", F. MED MICU-7 12:06 AM CHEST (PORTABLE AP) Clip # Reason: please eval for pneumonia Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with SOB and hypotension REASON FOR THIS EXAMINATION: please eval for pneumonia ______________________________________________________________________________ PFI REPORT No pneumonia.",1
8:43 AM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W&W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS Reason: amnesia ?,0
infarction short term memory loss Admitting Diagnosis: CHEST PAIN;TELEMETRY Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with s/p asc aorta replacement avr REASON FOR THIS EXAMINATION: amnesia ?,0
"infarction short term memory loss No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe WED 5:43 PM PFI: Multiple punctate deep white matter regions of infarction, which are likely subacute within the right and left frontal lobe and left precentral gyrus.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Amnesia status post ascending aortic replacement/AVR.,0
TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the brain without and with intravenous gadolinium.,0
"In addition, 3D time-of- flight MR arteriography was performed of circle of .",0
Two-dimensional time-of-flight MRA was performed of the carotid and vertebral arteries.,0
Coronal VIBE imaging was performed during the infusion of intravenous contrast.,0
Rotational reformatted images were prepared.,0
"MRI/MRA OF THE BRAIN: There are three punctate regions of restricted diffusion, one within the paramedian right frontal lobe, one within the paramedian/subcortical left frontal lobe, and one within the left precentral gyrus in a subcortical location.",0
"The two more superior lesions appear to display some T2/FLAIR abnormality of which the lesion on the right may also have a corresponding defect noted on the ADC map, which is slightly misregistered.",0
The additional two foci display no definite ADC map correlate suggesting a subacute time frame.,0
No other regions of acute infarction are identified.,0
There are few scattered additional T2/FLAIR hyperintensities which likely related to chronic small vessel disease.,0
"No abnormal enhancement, mass lesions, intracranial hemorrhage, shift of midline structures, hydrocephalus, or mass effect is present.",0
There are bilateral large mucus retention cysts noted within the maxillary sinuses.,0
The MRA of the circle of displays no flow-limiting stenosis within the circulation with no aneurysm or AV malformation.,0
The posterior circulation is noted to be right dominant.,0
"MRA OF THE NECK: There is no flow-limiting stenosis involving the common carotid, internal carotid, or vertebral arteries bilaterally.",0
The origins of the common carotid and vertebral arteries are patent with no regions of (Over) 8:43 AM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W&W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS Reason: amnesia ?,0
infarction short term memory loss Admitting Diagnosis: CHEST PAIN;TELEMETRY Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) stenosis.,0
The visualized portion of the aortic arch is unremarkable.,0
IMPRESSION: Subacute to acute punctate likely watershed-type bifrontal infarctions.,0
"While they are not at the -white junction, the multifocal vascular territory may also suggest an underlying embolic cause (especially given recent aortic surgery).",0
Findings were discussed with PA by Dr. on date of exam at approximately 3 p.m.,0
5:06 PM FACIAL BONE (WATERS & LAT) Clip # Reason: INTRA-OPERATIVE FILM ______________________________________________________________________________ FINAL REPORT INTRAOPERATIVE RADIOGRAPH LISTED AS FACIAL BONES: A single lateral intraoperative radiograph of the skull is submitted for interpretation.,1
Numerous surgical clips are identified as well as a ventriculoperitoneal shunt.,0
An opaque device overlies the precervical soft tissue structures and appears to represent a surgical clamping device.,0
Height: (in) 69 Weight (lb): 198 BSA (m2): 2.06 m2 BP (mm Hg): 103/50 HR (bpm): 53 Status: Inpatient Date/Time: at 23:43 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Patient with severe ARDS now with new T-wave changes on ECG LEFT ATRIUM: Mild LA enlargement.,1
MITRAL VALVE: Mild to moderate (+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
GENERAL COMMENTS: The patient appears to be in sinus rhythm.,0
Echocardiographic results were reviewed with the houseofficer caring for the patient.,0
Transmitral and tissue Doppler imaging suggests normal left ventricular filling pressure (PCWP<12mmHg).,0
IMPRESSION: Preserved -ventricular systolic function.,0
"Compared with the findings of the prior study (images reviewed) of , left ventricular systolic function has improved and is now normal.",0
Dr. was notified in person of the results at the conclusion of the study.,0
"1:03 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: FALL DOWN STAIRS Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with fall down stairs REASON FOR THIS EXAMINATION: eval acute process No contraindications for IV contrast ______________________________________________________________________________ WET READ: AKSb SUN 2:50 AM No acute injury in chest, abdomen or pelvis.",1
"Thoracic aortic aneurysm, up to 4.5 cm.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 82-year-old with subarachnoid hemorrhage after fall.,1
"TECHNIQUE: Multidetector helical scanning of the chest, abdomen, and pelvis was performed following the administration of oral and 130 cc IV Optiray contrast.",0
"CT OF THE CHEST: There is dependent atelectasis, however, no evidence of acute lung injury.",0
"The aorta is tortuous and enlarged, measuring up to 4.5 cm.",0
There is no evidence of acute aortic injury.,0
There is no mediastinal fluid or adenopathy.,0
Extensive vascular calcifications are seen within the LAD and aortic valve.,0
The heart is enlarged particularly in the right atrium.,0
CT OF THE ABDOMEN: The stomach is moderately distended with fluid and air and an NGT is recommended.,0
"The liver, spleen, adrenal glands, pancreas, kidneys, and intra- abdominal small and large bowel loops are normal.",0
"There is no free fluid, free air, or lymphadenopathy.",0
CT OF THE PELVIS: There is a Foley catheter and air within the bladder.,0
No pelvic free fluid or lymphadenopathy.,0
Old fractures of the left inferior and superior pubic rami and bilateral ribs are noted.,1
Total left hip arthroplasty is positioned slightly posteriorly in reference to the acetabulum.,0
There is grade 1 anterolisthesis of L4 on L5.,0
"No evidence of acute traumatic injury within the chest, abdomen or pelvis.",0
Old fractures involving the left hemipelvis.,1
Findings were discussed with Dr. at the time of the exam.,0
(Over) 1:03 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: FALL DOWN STAIRS Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont),0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: perforated near obstructing colon cancer secondary to neoplasm Major Surgical or Invasive Procedure: Exploratory laparotomy, low anterior resection with Hartmann's pouch and colostomy, left colectomy, appendectomy, colonic lavage, splenectomy, LUQ and pelvic drain placement.",1
History of Present Illness: 71-year-old gentleman with a history of a colonoscopy that showed a lesion in the colon that was biopsied and showed high grade dysplasia.,0
He underwent a staging CT scan as an outpatient of the torso which showed free air without significant symptoms.,0
He was sent emergently to the ER.,0
"He was admitted to the surgical service, put on broad-spectrum antibiotics.",0
"Due to the nature of the findings on the CT scan and a near-obstructing lesion in the pelvis, surgical intervention was offered.",0
Past Medical History: None Social History: Smokes cigarettes per day and drinks one beer per day.,0
Wife is schizophrenic and they have no children.,0
"Pt has family in , niece and nephew.",0
"Family History: Unknown Physical Exam: On admission: 98.7 83 134/79 24 97% RA NAD RRR CTAB soft non-distended, LLQ tenderness, no peritoneal signs.",0
"Rectal guiaic negative no edema Pertinent Results: 06:15PM BLOOD WBC-6.7 RBC-4.64 Hgb-15.0 Hct-41.8 MCV-90 MCH-32.3* MCHC-35.9* RDW-14.7 Plt Ct-260 09:19AM BLOOD WBC-8.1 RBC-4.27* Hgb-13.1* Hct-37.9* MCV-89 MCH-30.8 MCHC-34.7 RDW-14.8 Plt Ct-241 06:15PM BLOOD Plt Ct-260 07:27PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2 09:19AM BLOOD Plt Ct-241 09:51AM BLOOD Glucose-91 UreaN-22* Creat-1.1 Na-148* K-3.1* Cl-97 HCO3-33* AnGap-21* 06:15PM BLOOD Glucose-98 UreaN-13 Creat-1.2 Na-143 K-3.3 Cl-100 HCO3-28 AnGap-18 05:43PM BLOOD CK(CPK)-477* 01:12AM BLOOD LD(LDH)-129 11:15PM BLOOD Lipase-24 06:59AM BLOOD Lipase-24 05:43PM BLOOD CK-MB-2 10:59AM BLOOD CK-MB-2 02:11AM BLOOD CK-MB-2 cTropnT-<0.01 09:51AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 01:12AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6 Brief Hospital Course: Pt was admitted to surgery, given levoflox and flagyl.",0
He was taken to OR for emergent operation on .,0
"In OR patient was given 11000cc of IVF, 8 units pRBC, 4 units FFP, 1 unit cryo and had an EBL of 3000cc.",0
"He was stable and transferred to SICU, intubated post-op for CV resusitation.",0
"He was transfused 2 Units pRBC, POD2 Hct 31.1.",0
"Ampicillin was added, and TPN started, stoma was found to be intact.",0
POD5 pt transferred to surgical floor started on PO diet and advanced as tolerated.,0
"Pathology shows stage 4 disease, with 4/15 LN positive and invasion of small bowel.",0
Pt discharged POD9 to rehab in good condition with good ostomy function for stoma teaching and PT.,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain.,0
Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day for 1 months.,0
Disp:*90 Capsule(s)* Refills:*3* Discharge Disposition: Extended Care Facility: Discharge Diagnosis: 1.,0
"Diverticular disease Discharge Condition: Good Discharge Instructions: Please call doctor greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain or pain around ostomy not controlled by pain medications or any other concerns you have.",0
Please resume taking all medications as taken prior to this surgery and pain medications and stool softener as prescribed.,0
"You may resume your regular diet, but avoid food high in fiber.",0
A visiting nurse will come to your home to help with the care of your ostomy.,0
No heavy lifting for 4-6 weeks or until directed otherwise.,0
"leave wound open to air, please leave steri-strips intact until they fall off.",0
"Followup Instructions: Please follow up at already arrangd appointments: Dr. ,LMOB-3A (NHB) Date/Time: 4:00 ( , MD Date/Time: 3:00 (",0
Height: (in) 61 Weight (lb): 160 BSA (m2): 1.72 m2 BP (mm Hg): 105/50 HR (bpm): 64 Status: Inpatient Date/Time: at 11:39 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
LV WALL MOTION: The following resting regional left ventricular wall motion abnormalities are seen: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - hypokinetic; mid inferolateral - hypokinetic; inferior apex - hypokinetic; lateral apex - hypokinetic; RIGHT VENTRICLE: The right ventricular cavity is dilated.,1
Mild to moderate [+] tricuspid regurgitation is seen.,0
Resting regional wall motion abnormalities include inferior akinesis and inferolateral hypokinesis.,0
Right ventricular free wall is not fully visualized but systolic function appears depressed.,0
"Compared with the findings of the prior study (tape reviewed) of , regional wall motion abnormality is new and estimated pulmonary artery systolic pressure is now higher.",0
Family History: nc Brief Hospital Course: Brief Hospital Course: Patient was admitted to the Urology service after undergoing radical cystectomy and ileal conduct.,0
Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin.,0
"With the passage of flatus, patient's diet was advanced.",0
The patient was ambulating with assistance from physical therapy and pain was controlled on oral medications by this time.,0
The ostomy nurse saw the patient for ostomy teaching.,0
He was seen by rheumatology for his gout and recommendations were followed.,0
"At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage.",0
The ostomy was perfused and patent.,0
Patient is scheduled to follow up in one weeks time with in clinic for wound check.,0
He was discharged to a rehab facility for physical therapy.,0
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Disk with Devices Inhalation (2 times a day).,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Inhalation Q6H (every 6 hours) as needed.,0
Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED).,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed.,0
Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day).",0
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day).,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: bladder cancer Discharge Condition: stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone.,0
"Please take Tylenol in addition to oxycodone, and transition to Tylenol as pain improves.",0
"-You may shower, but do not immerse incision, no tub baths/swimming.",0
"-Small white steri-strips bandages will fall off in days, you may remove at that time if irritating.",0
"-Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5.",0
-Please refer to visiting nurses (VNA) for management of the ileal conduct.,0
Rheumatology in 4 weeks- call to schedule appointment Followup Instructions: 1-2 weeks with Dr. Rheumatology in 4 weeks- call to schedule appointment MD Completed by:,0
1:37 PM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: Please review ERCP images from Admitting Diagnosis: CHOLEDOCHOLITHIASIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman who presented with 5 days history of RUQ pain with nausea and vomiting.,0
"Afebrile, hypotensive in ED, required pressors.Improved with BP 100/60 off inotropic support.",0
"suspected cholangitis REASON FOR THIS EXAMINATION: Please review ERCP images from ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Right upper quadrant pain, nausea and vomiting, suspected cholangitis.",0
FINDINGS: Twelve spot fluoroscopic images were obtained without a radiologist present.,0
Contrast within the colon is from prior CT. Cholecystectomy clips are in place.,0
"Filling defects within a mildly dilated common duct are stones, extracted by basket sweep.",0
A small amount of contrast refluxes into the duodenum.,0
Mild intrahepatic biliary dilatation with and slight irregularity ducts is noted.,0
A plastic stent was placed.,0
IMPRESSION: Common duct stones extracted by basket sweep.,0
Mild intrahepatic biliary duct dilatation.,0
Please see ERCP report in OMR for full procedure details and recommendations.,0
12:00 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: eval trauma ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with s/p ped struck w/ loc REASON FOR THIS EXAMINATION: eval trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: JK WED 2:50 PM Severe cerv.,0
Grade 1 degenerative subluxation of C7 upon T1.,0
WET READ VERSION #1 JK WED 2:49 PM Severe cerv.,0
Grade 1 degenerative subluxagtion of C7 upon T1.,0
TECHNIQUE: Axial noncontrast helical scanning of the cervical spine was performed without IV contrast.,0
Sagittal and coronal reconstructions were obtained.,0
FINDINGS: There is severe spondylosis from C4 to C7 level.,0
"At the C2-3 level, there is moderate bilateral facet joint degeneration with moderate left neural foraminal narrowing.",0
"At the C3-4 level, there is moderately severe facet joint degeneration on the left side with mild left foraminal narrowing.",0
Some osteophytosis is also seen on the posterior-inferior surface of the C3 vertebra.,0
There is mild to moderate disc space narrowing at this level as well.,0
There is severe disc space narrowing at C4-5 level.,0
There is moderate neural foramina narrowing bilaterally.,0
Osteophytic reaction is seen both anteriorly and posteriorly.,0
There is mild to moderate cord compression at this level.,0
"At the C5-6 level, again there is severe disc space narrowing with anterior and posterior osteophytosis of the vertebral bodies and moderate right-sided neural foraminal narrowing.",0
Mild cord compression is present at this level as well.,0
Moderate disc space narrowing is also seen at the C6-7 level with osteophytosis.,0
"There is grade 1 anterolisthesis of C7 over T1, likely degenerative in origin.",0
Moderate atherosclerotic calcification of left and right carotid bifurcations is present.,0
There is no sign of fracture.,0
CT is not able to provide any intrathecal detail.,0
The visualized outline of the thecal sac appears unremarkable.,0
IMPRESSION: Severe spondylosis involving C4 to C7 region of the cervical spine.,0
(Over) 12:00 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: eval trauma ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
Height: (in) 64 Weight (lb): 106 BSA (m2): 1.49 m2 BP (mm Hg): 130/56 HR (bpm): 60 Status: Inpatient Date/Time: at 13:30 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; inferior apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
"Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 55-60%).",0
"There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid inferoseptum, inferior, and inferolateral walls and distal septum and inferior wall.",0
The remaining segments contract normally.,0
The aortic valve leaflets (3) are mildly thickened without aortic stenosis is not present.,0
IMPRESSION: Normal biventricular cavity sizes with preserved global biventricular systolic function with LV regional wall motion abnormalities as above.,0
"Admission Date: Discharge Date: Service: SURGERY Allergies: Amoxicillin / Percocet Attending: Chief Complaint: Colocutaneous fistula, panniculitis, cellulitis Major Surgical or Invasive Procedure: EXPLORATORY LAPAROTOMY, COLOCUTANEOUS FISTULA TAKEDOWN, EXTENDED RIGHT COLECTOMY, LYSIS OF ADHESIONS, ILEOCOLOSTOMY, PERCUTANEOUS GASTROSTOMY TUBE, SOFT TISSUE DEBRIDEMENT & VENTRAL HERNIA REPAIR Wound exploration, VAC removal, skin and deep soft tissue debridement and VAC replacement History of Present Illness: F with history of Afib, CAD, CHF and colocutaneous fistula presents with cellulitis, leukocytosis and colocutaneous fistula.",1
"History is unclear, but pt does report having a history of an incisional hernia in the past(possibly from a hysterectomy) which became complicated with a colocutaneous fistula.",1
It is unclear how many surgical procedures she has undergone however she did present with an outside hospital operative report from .,1
On pt underwent resection of infected mesh and closure of colocutaneous fistula.,0
The mesh was resected and a 2 cm defect was found on the anterior abdominal wall.,0
The defect was closed with a 2-0 Prolene in running fashion and 3-0 silk interrupted seromuscular closure was performed to re-enforce this defect.,0
The fascia was closed with 1 nylon interrupted sutures and the sink was left open for packing.,0
At some unclear point the hernia re-occurred.,0
Per her daughter the patient started leaking feculent material this morning from her wound (similar to prior colocutaneous fistula) and she went to .,1
At it was noted that in addition to this feculent material draining from her abdomen she had cellulitis and panniculitis.,1
CT scan was obtained and she was transferred to for further care.,0
"She denies fevers, chills, nausea, emesis, diarrhea, constipation.",0
"Past Medical History: A. fib, vertigo, CAD, CHF PSH: hysterectomy, incisional hernia repair ~ 30 years ago c/b colocutaneous fistula, s/p resection of infected mesh and closure of colocutaneous fistula Family History: Noncontributory Physical Exam: Upon presentation to : VS: 98.2 70 89/41 36 97% Gen: NAD, alert and oriented though does become easily confused CVS: irreg Pulm: no resp distress Abd: Soft but distended.",1
Feculent material draining from R mid/lower abdomen from what appears to be a necrotic (dusky) colocutaneous fistula.,0
There are 3 distinct opening in the skin.,0
There is surrounding erythema overlying most of her pannus extending >30 cm in diameter across her abdomen consistent with cellulitis.,0
The pannus is firm and tender.,0
"Pertinent Results: 08:58PM GLUCOSE-168* UREA N-26* CREAT-0.9 SODIUM-133 POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-18* ANION GAP-12 08:58PM CALCIUM-7.6* PHOSPHATE-2.4* MAGNESIUM-1.5* 08:58PM WBC-10.9# RBC-3.26* HGB-9.6* HCT-29.3* MCV-90 MCH-29.6 MCHC-32.9 RDW-14.4 08:58PM PLT COUNT-215 08:58PM PT-15.6* PTT-30.5 INR(PT)-1.4* 12:45PM NEUTS-88* BANDS-6* LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 05:14 11.2* 2.66* 7.8* 25.0* 94 29.3 31.1 15.4 170 IMAGING: - CT A/P (OSH): (wet read) large incisional hernia w/colocutaneous fistula, small bowel is also within the hernia, no evidence of obstruction or clear evidence of compromised bowel (pneumatosis or wall thickening), soft tissue inflammation surrounding consistent with panniculitis, also a phlegmonous collection w/in ant abdominal wall.",1
- CXR: Heart size is enlarged.,0
Bilateral small amount of pleural effusion as well as left lower lobe atelectasis are new as compared to the prior study.,0
- CXR: The appearance of the cardiomediastinal silhouette as well as bibasal atelectasis and bilateral small pleural effusion is unchanged.,0
No new consolidations or pneumothorax have been demonstrated.,0
"Brief Hospital Course: She was admitted to the ACS service and taken to the operating room on for exploratory laparotomy, colocutaneous fistula takedown, extended right colectomy, lysis of adhesions, ileocolostomy, percutaneous gastrostomy tube, soft tissue debridement and ventral hernia repair.",1
Postoperatively she was taken to the ICU where she was noted to be in rapid atrial fibrillation.,1
She was treated with Amiodarone drip and prior to transfer to floor she was ordered for oral amiodarone and given IV Lopressor.,0
Upon transfer to floor her heart rate remained in the high 130's-140's range.,0
She received additional IV Lopressor doses; Digoxin was recommended by Cardiology and a loading dose was given.,0
Once her rate was controlled she was started on daily Digoxin but was noted with episodes of bradycardia; her Digoxin was changed to every other day dosing.,0
Her Atenolol was restarted at 12.5 mg daily.,0
Tube feedings via her gastrostomy tube were started early on; Nutrition was consulted for recommendations and changes made accordingly.,0
She was also given an oral diet for which she is currently tolerating.,0
"On she was taken back to the operating room for wound exploration, VAC removal, skin and deep soft tissue debridement and VAC replacement.",0
"The antibiotics that she had been started on postoperatively continued until , these were administered via a PICC that was removed prior to discharge.",0
She was evaluated by Physical therapy and is being recommended for rehab after her acute hospital stay.,0
She will be discharged with plans for continuing VAC dressing therapy.,0
"Medications on Admission: (per OSH records) Meclizine 12.5''', Levothyroxine 50', Allopurinol 150', atenolol 25', ASA 81', Ferrous sulfate 325', isosorbide 20' Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection (2 times a day).",0
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): hold for HR <65.,0
4. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): hold for HR <65 and/or SBP <110.,0
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
6. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain.,0
"7. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation.,0
Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation.,0
"Dulcolax 5 mg Tablet, Delayed Release (E.C.)",0
"Sig: Tablet, Delayed Release (E.C.",0
)s PO once a day as needed for constipation.,0
Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: Colocutaneous fistula Ventral hernia Wound cellulitis Rapid atrial fibrillation Bradycardia Discharge Condition: Mental Status: Clear and coherent; hear of hearing.,1
Discharge Instructions: You were hospitalized with an infection along your colon which required an operation and also repair of your ventral hernia.,1
A large dressing called a VAC dressing has been applied to your abdominal wound to help with healing and closure.,0
This dressing will be changed every 2 days.,0
It is expected that your wound will heal in time; it is very important that you maintain adequate nutrition.,0
You are receiving nutrition through a feeding tube and also are on a regular diet.,0
You have completed a course of antibiotics for the infection.,0
"Followup Instructions: Follow up next week in clinic, call for an appointment.",0
Follow up with your PCP after discharge from rehab; you or your family will need to call for an appointment.,0
10:05 PM BABYGRAM (CHEST ONLY) Clip # Reason: ASSESS EXPANSION ON LOWER MEAN AIRWAY PRESSURE ON HFOV Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with PREMATURITY REASON FOR THIS EXAMINATION: ASSESS EXPANSION ON LOWER MEAN AIRWAY PRESSURE ON HFOV ______________________________________________________________________________ FINAL REPORT CHEST: HISTORY: Infant born prematurely.,1
FINDINGS: Frontal view of the chest shows that the ETT tip is at carina.,0
There is still diffuse haziness of the lungs.,0
"The lungs are, however, slightly better aerated than on the most recent prior examination.",0
"11:35 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for free air Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with COPD, now with acute abdomen.",0
"REASON FOR THIS EXAMINATION: Please evaluate for free air ______________________________________________________________________________ FINAL REPORT INDICATIONS: 73 year old woman with COPD, now with acute abdomen.",0
Evaluation for free air requested.,0
COMPARISON: Upright AP portable chest x-ray.,0
TECHNIQUE: Upright AP portable chest x-ray.,0
FINDINGS: The upright view shows no evidence of free intraperitoneal air.,0
The tip of the pulmonary artery catheter is in an unchanged position.,0
The degree of cardiomegaly is stable with some bilateral upper zone redistribution of the pulmonary vascularity.,0
Again seen is bibasilar atelectasis with pleural effusions.,0
IMPRESSION: No free intraperitoneal air.,0
"Otherwise, essentially unchanged findings of bibasilar atelectasis, bilateral pleural effusions, and increased pulmonary vascularity.",0
12:16 AM RENAL TRANSPLANT U.S.,0
"PORT Clip # Reason: eval hydro, perinephric fluid, vasculature (RIs) Admitting Diagnosis: CRF/SDA ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with s/p LURT with decreased UOP REASON FOR THIS EXAMINATION: eval hydro, perinephric fluid, vasculature (RIs) ______________________________________________________________________________ FINAL REPORT HISTORY: Postop day 1 from renal transplant.",0
RENAL TRANSPLANT ULTRASOUND: scale and Doppler ultrasound: The transplant kidney is in the left lower quadrant and measures 10 cm.,1
No evidence of perinephric fluid collections or hydronephrosis.,0
There is flow in the main renal artery and vein.,0
"There is no detectable diastolic flow within the upper, mid, or lower poles.",0
IMPRESSION: No detectable diastolic flow within the transplant kidney.,0
These findings are concerning for increased arterial resistance in such conditions as ATN or acute rejection.,0
These findings were discussed with Dr. at 1 a.m. on .,0
"6:12 PM CHEST (PORTABLE AP) Clip # Reason: Pt with advancement of ETT, please evaluate Admitting Diagnosis: SPONTANEOUS BACTERIAL PERITONITIS ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with h/o CHF w/ leaking R IJ central line.",0
"REASON FOR THIS EXAMINATION: Pt with advancement of ETT, please evaluate ______________________________________________________________________________ FINAL REPORT INDICATION: Patient with CHF.",0
Leaking of fluid around the right IJ central line.,0
COMPARISON: Radiograph performed one hour earlier.,0
FINDINGS: The ET tube has been advanced a few mm and is located at the level of the thoracic inlet.,0
The right IJ central line is unchanged in position.,0
"It's unclear in which vessel it is located, since it crosses the airway on the prior chest radiograph.",0
The heart and lung fields are unchanged.,0
Height: (in) 64 Weight (lb): 158 BSA (m2): 1.77 m2 BP (mm Hg): 134/68 HR (bpm): 55 Status: Inpatient Date/Time: at 09:00 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
Top normal/borderline dilated LV cavity size.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - hypo; mid inferolateral - akinetic; basal anterolateral - hypo; mid anterolateral - hypo; inferior apex - hypo; lateral apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
"Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
GENERAL COMMENTS: Suboptimal image quality - poor parasternal views.,0
The left atrial volume is severely increased.,0
The left ventricular cavity size is top normal/borderline dilated.,0
There is moderate regional left ventricular systolic dysfunction with inferior akinesis and inferolateral hypokinesis.,0
Overall left ventricular systolic function is moderately depressed (LVEF= 35%).,0
IMPRESSION: Moderate left ventricular hypertrophy with moderate regional left ventricular systolic dysfunction consistent with coronary artery disease.,1
At least moderate mitral regurgitation.,0
2:25 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade.,0
"still in OR, please perform Admitting Diagnosis: SEVERE MR\MITRAL VALVE REPLACEMENT; W/ ?",0
RVAD BACKUP/SDA ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with severe MR s/p MV repair.,0
REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade.,0
"still in OR, please perform when in CSRU.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 21 y/o s/p mitral valve repair.,0
An AP study of the chest shows an ETT and NG tube and a Swan-Ganz catheter and left chest tube and mediastinal chest tubes in place.the Tip of the ETT is about 5 cm above the carina.,0
The tip of the right jugular vein Swan-Ganz catheter is in the main pulmonary artery.,0
The tip of the NG tube is in the mid gastric body.,0
Post sternotomy changes are also noted.,0
The suggestion of a small right apical pneumothorax.,0
Minimal degree of soft tissue emphysema is also noted in the left lower neck.,0
IMPRESSION: Small left apical pneumothorax?.,0
Postoperative changes and multiple lines and tubes in place.,0
Minimal degree of left lower lobe partial atelectasis.,0
Height: (in) 68 Weight (lb): 160 BSA (m2): 1.86 m2 BP (mm Hg): 109/55 HR (bpm): 107 Status: Inpatient Date/Time: at 19:37 Test: Portable TTE (Focused views) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness.,0
"MITRAL VALVE: Trivial MR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded.",0
IMPRESSION: Dynamic left ventricular function with small chamber size.,0
Hypovolumia should be considered in the setting of hypotension.,0
"3:25 PM CHEST (SINGLE VIEW) Clip # Reason: NEW PAIN POST NG TUBE PLACEMENT Admitting Diagnosis: DEHYDRATION ______________________________________________________________________________ FINAL REPORT INDICATION: 80-year-old, assess NG tube position.",0
Portable semi-upright frontal radiograph compared to .,0
The patient was unable to cooperate with positioning and is markedly rotated and slumping towards the right side.,0
"The aorta is tortuous and unfolded and appears widened, likely due to positioning.",0
An NG tube is seen with its tip probably in the proximal portion of the duodenum.,0
There is a right-sided PICC with its tip in the mid SVC.,0
Repeat frontal radiographs are recommended to evaluate the mediastinum when the patient is able to cooperate.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Trauma ADMISSION DIAGNOSES: 1.,0
Thoracic spine T4-5 transverse process fractures.,1
Right second and third rib fractures.,0
Status post open reduction internal fixation right mandible.,0
ADMISSION HISTORY AND PHYSICAL: This is a 28-year-old male status post motor vehicle crash.,1
"He was T-boned on the driver's side, unrestrained, questionable loss of consciousness.",0
Patient was intubated at an outside hospital for neck swelling.,0
Right chest tube was placed for clinical suspicion for pneumothorax.,1
Endotracheal tube was dislodged en route to .,0
Chest x-ray on arrival showed right lower lobe and right upper lobe collapse despite chest tube.,0
Bronch was performed in the Emergency Room.,0
PAST MEDICAL HISTORY: Unknown other than IV drug use.,0
PHYSICAL EXAM ON ARRIVAL: 98.0/80/104/46/31/100% intubated on SIMV.,0
"Pupils are equal, round, and reactive to light and accommodation.",0
Patient has a chin laceration.,0
C collar is in place.,0
Lungs are clear to auscultation bilaterally.,0
There is a right chest tube in place.,0
Abdomen is flat and soft.,0
"No obvious extremity fractures, 2+ pulses distally.",0
Track marks in bilateral upper extremities.,0
ADMISSION LABORATORIES: CBC is 15.4/35.8/408.,0
Tox screen is negative for alcohol and opiates.,0
"FILMS: CT of head shows no intracranial hemorrhage, small anterior encephalomalacia of the left anterior frontal lobe, bilateral displaced mandibular condyles.",0
"CT of the chest showed right second and third rib fractures, right clavicle fracture, right subcutaneous emphysema, right chest tube, small right pneumothorax, right upper lobe and right lower lobe collapse, left base atelectasis, no pleural or pericardial effusions.",1
Normal heart and great vessels.,0
CT of the chest also shows C5-6 transverse process fractures.,0
Facial CT shows multiple mandibular fractures with anterior displacement bilaterally.,1
Probable small avulsion in the right maxilla.,0
CT of the abdomen is normal.,0
CT of pelvis is normal.,0
CT of C spine reveals no fracture.,0
Chest x-ray after bronch shows right upper lobe and right lower lobe reinflated.,0
TLS shows no obvious fractures.,0
BRIEF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit.,0
One of the first interventions was placement of a right subclavian cordis.,0
"He also underwent bronchoscopy in which thick mucus plugs were taken out, and a tooth was removed from one of the right lower lobe bronchi.",0
Plastic Surgery was consulted for the mandible.,0
Orthopedics was consulted for the clavicle and transverse process fractures.,0
Patient had his right subclavian line removed and a left subclavian cordis placed.,0
"On , the patient underwent tracheostomy by Dr. .",0
He tolerated the procedure well and the tracheostomy tube was left in throughout his stay.,0
"On , the patient underwent open reduction internal fixation of the mandible.",0
This was performed by Dr. .,0
Intermandibular fixation was placed during that time.,0
Patient remained with stable vital signs throughout his course in the ICU.,0
He was postoperatively placed on Vancomycin and Zosyn.,0
Vancomycin was started as the patient had positive MRSA growth from his A-line site and he had positive MRSA in his sputum and on a rectal swab.,0
Vancomycin was continued for a total of 14 days while the patient was in the hospital.,0
Zosyn was also started postoperatively for the open mandibular fracture.,1
Zosyn was left in place for approximately eight days.,0
"Regarding patient's respiratory status, the trache was left in place throughout his stay.",0
"Patient was able to suction by himself and had one-way talking valve placed, which he tolerated well.",0
"He was educated on suctioning by respiratory care, and it was determined that he would be able to take care of this at home with the help of VNA.",0
"Regarding the patient's mandibular fracture, patient had a fracture which appeared to be healing well.",0
"He had a small area of draining wound on the left angle of the jaw, which was thought to be due to a possible small submandibular gland fistula with slight saliva draining.",1
That wound was treated with wet-to-dry dressings b.i.d.,0
and was healing well previous to discharge.,0
There is no indication that the patient had an infection at this spot.,0
Patient did receive 1 unit of packed red blood cells while he was in the ICU.,0
"Regarding the patient's right clavicle, patient was seen by Orthopedics.",0
A figure-of-eight brace was placed and a sling was used for comfort.,0
Physical Therapy saw him regarding this and signed off on it.,0
He will be following up with Ortho Trauma Clinic for this.,0
"Regarding patient's mandibular fracture, the IMF was continued and it will be removed at Dental School by the Oral and Maxillofacial fellow after discharge.",0
"Patient's right chest tube was discontinued without event, and there is no residual pneumothorax.",1
Patient was eventually transferred to the floor.,0
He was eventually able to take p.o.,0
pain medication and he was eventually able to take a p.o.,0
He was treated with tube feeds up until that point.,0
Controlling his pain was a difficult task.,0
Acute Pain service was consulted.,0
"As the patient had a history of IV drug abuse, he required a large amount of pain medications including Fentanyl patch, methadone, and Dilaudid, along with clonidine and Vioxx.",0
Physical therapists were involved throughout his care.,0
"Patient was ambulating well, tolerating his Boost diet, and urinating on his own, and having normal bowel movements prior to discharge.",0
"Vancomycin was discontinued prior to D/C, and he will not need linezolid as an outpatient.",0
Patient remained afebrile with stable vital signs while on the floor.,0
Repeat hematocrit showed stable hematocrit in the low 30s.,0
"Patient remained in-house so he would be able to receive home nursing care, and home nursing care was arranged for tracheostomy care and for dressing changes to his left jaw.",0
DISCHARGE INSTRUCTIONS: Wear the figure-of-eight brace at all times with a sling for comfort.,0
Care for the tracheostomy site as instructed.,0
Perform wound care as instructed.,0
PROCEDURES WHILE IN HOSPITAL: 1.,0
Chest tube placement and removal.,0
Tracheostomy removal will be arranged by the Trauma Clinic.,0
Clonidine 0.1 mg twice a day.,0
Nicotine patch 14 mg every 24 hours.,0
Fentanyl patch 50 mcg/hour patch/72 hours.,0
Dictated By: MEDQUIST36 D: 14:09 T: 08:31 JOB#:,0
5:44 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Reason: ?intraabdominal injuries Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with xfer intubated w/ significant poly trauma REASON FOR THIS EXAMINATION: ?intraabdominal injuries No contraindications for IV contrast ______________________________________________________________________________ WET READ: ASpf SUN 7:36 PM Right 1st-7th rib fractures.,1
Left 1st-7th and 12th rib fractures.,1
Left vertebral body transverse process fractures.,1
2 left and 1 right pleural space pneumothorax.,1
Non displaced posterior sternal fracture with anterior mediastinal hematoma (enlarged compared to previous exam).,1
"Fluid in the upper mid retroperitoneum, likely pancreatic head laceration.",0
Left renal lower pole contusion.,0
Pubic symphysis and bilateral SI joint diastasis with craniocaudal disruption.,0
Small focus of perineal arterial extravasation was more apparent on the outside hospital CT.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old woman with transfer and significant polytrauma.,0
COMPARISON: Outside hospital CT torso from at 3:00 p.m.,0
"TECHNIQUE: MDCT images were acquired through the chest, abdomen, and pelvis and lower extremities with IV contrast.",0
CT OF THE CHEST WITH IV CONTRAST: The thyroid gland is unremarkable.,0
There is no axillary or mediastinal lymphadenopathy by CT size criteria.,0
"There is subcutaneous emphysema in the left axilla and tracking down the left chest wall, likely related to multiple rib fractures.",1
There is also left chest wall hematoma.,0
The heart and great vessels are unremarkable.,0
The aorta is normal in caliber throughout.,0
There is an anterior mediastinal hematoma related to a minimally displaced posterior sternal fracture in the lower sternal body.,1
Bilateral dependent consolidations likely represent a combination of atelectasis and aspiration.,0
The esophagus is filled with fluid and distended.,0
There are small bilateral pneumothoraces with one right and two left-sided chest tubes ending in appropriate position within the pleural cavity.,0
"CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, both adrenals, right kidney and gallbladder are unremarkable.",1
There is fluid adjacent to the pancreas with significant soft tissue stranding and fluid anterior to the portal vein concerning for a pancreatic injury.,1
Also noted is a small amount of fluid in the (Over) 5:44 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Reason: ?intraabdominal injuries Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) retroperitoneum adjacent to the pancreas.,0
The left kidney shows an area of hypoattenuation along its lower pole (2A:64) that is concerning for a contusion.,0
There is a moderate amount of retroperitoneal fluid tracking along the right flank that may represent urine from a bladder rupture.,1
Apparent thickening of the left descending colon may be related to under-distention.,0
"Mesenteric haziness could be related to motion, but mesenteric injury cannot be excluded.",0
CT OF THE PELVIS WITH IV CONTRAST: An extraperitoneal bladder rupture is seen with extraluminal contrast present from outside hospital prior CT and extending along the medial right thigh.,1
Evaluation for an arterial extravasation is limited due to confounding factors from the extraperitoneal bladder rupture.,1
A Foley catheter is within the bladder.,0
"The patient has a fibroid uterus, unchanged.",0
"Bilateral, right greater than left, flank subcutaneous contusions are seen.",0
LOWER EXTREMITIES: Contrast from the extraperitoneal bladder rupture tracks down the right adductor compartment.,1
Also noted is possible focus of extravasation in the right popliteal fossa likely related to damage from the patient's replaced knee dislocation.,1
No other areas of extravasation are noted in the lower extremities.,0
The popliteal arteries are patent.,0
"OSSEOUS STRUCTURES: Fractures of the right clavicle, right first through seventh and tenth ribs, left first through eighth and twelfth ribs, left first to fifth lumbar vertebral transverse processes are present.",1
"Also noted is a severe pelvic fracture with a comminuted fracture of the right iliac crest with extension to the right sacroliac joint as well as severe diastasis with craniocaudad dissociation of the pubic symphysis as well as a fracture pubic bone fragment within the deep pelvis, possibly involving the bladder.",1
Nondisplaced fracture at the left pubic symphysis is also noted.,0
Severe pubic symphysis diastasis as above and right iliac diastased fracture extending to the right sacroiliac joint.,0
Nondisplaced left pubic bone fracture.,0
(Over) 5:44 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Reason: ?intraabdominal injuries Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
A perineal arterial extravasation was noted on the initial hospital study but cannot be assessed on the current examination due to extraluminal contrast from the bladder rupture.,1
Sternal fracture with substernal/anterior mediastinal hematoma increased in size compared to prior.,1
Bilateral consolidations likely related to a combination of atelectasis and aspiration.,0
Findings concerning for left renal lower pole contusion.,0
Peripancreatic fluid with fluid anterior to the portal vein concerning for pancreatic injury.,0
"Haziness of the mesentery could be related to motion, but mesenteric injury cannot be excluded.",0
Multiple right one through seventh and tenth and left first through eighth and twelfth rib fractures.,1
Left one through five lumbar vertebral transverse process fractures.,1
Possible small focus of right popliteal artery extravasation.,1
"7:03 PM BABYGRAM CHEST & ABD (2 FILMS STANDARD) PORT Clip # Reason: Retained fetal lung fluid vs surfactant deficiency, Exclude Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with antenatal polyhydramnios, and postnatal abdominal distention and respiratory distress REASON FOR THIS EXAMINATION: Retained fetal lung fluid vs surfactant deficiency Exclude bowel obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN.",1
Comparison is made with the examination done earlier in the day.,0
There has been no change.,0
The lungs are mildly edematous as is the body wall.,0
"There is intense calcification in the abdomen, compatible with meconium peritonitis.",0
"Air was present only in the stomach and the duodenal bulb, suggesting duodenal atresia.",0
"Though the abdomen is otherwise gasless, there could be a more distal obstruction with air present in the stomach only because of relative ileus.",0
1:44 PM PELVIS (AP ONLY) PORT Clip # Reason: ?,0
"fxr ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with found down, head bleed REASON FOR THIS EXAMINATION: ?",0
fxr ______________________________________________________________________________ FINAL REPORT INDICATION: Found down with intracranial hemorrhage.,1
SUPINE AP VIEW OF THE PELVIS: No fracture or dislocation is present.,0
Mild degenerative changes are seen in the hips.,0
The sacroiliac joints and the pubic symphysis are not diastatic.,0
No focal lytic or sclerotic osseous abnormality is seen.,0
6:11 PM CT CHEST W/O CONTRAST Clip # Reason: rib fractures- respiratory distress - ?,0
lung collapse vs hem Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with hx of fall down stairs REASON FOR THIS EXAMINATION: rib fractures- respiratory distress - ?,1
"lung collapse vs hemothorax No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of fall down stairs, evaluate for rib fractures, respiratory distress lung collapse, or hemothorax.",1
TECHNIQUE: Axial MDCT images were obtained through the chest without intravenous contrast.,0
Additional thin-section reformatted images are provided.,0
"CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: Since the previous examination, the small anterior mediastinal hematoma associated with the patient's sternal and right first rib fractures, has decreased in size.",0
There is no pathologic- appearing mediastinal or hilar lymphadenopathy.,0
A small amount of pericardial fluid is unchanged.,0
The central airways are patent.,0
Atelectasis within the lung bases posteriorly has improved in the interval.,0
"Small area of focal ground-glass opacity at the left lung apex appears more prominent than at the time of the previous examination, possibly due to slice selection differences, although new focal area of consolidation is not excluded.",0
There is no evidence of hemothorax or pneumothorax.,0
"Limited images of the liver, spleen, pancreas, and adrenal glands appear unremarkable.",0
Contrast within the gallbladder is consistent with vicarious excretion.,0
BONE WINDOWS: Bone windows again demonstrate fractures of the sternal manubrium and right first rib.,0
Decreased size of small localized anterior mediastinal hematoma since .,0
Fractures of sternum and right first rib.,1
No evidence of hemothorax or pneumothorax.,0
Increased prominence of left apical opacity may reflect technical differences or new focus of consolidation.,0
(Over) 6:11 PM CT CHEST W/O CONTRAST Clip # Reason: rib fractures- respiratory distress - ?,0
lung collapse vs hem Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont),1
11:48 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: s/p MVR w/fevers-r/o cholecystitis.,0
Continues w/ increased ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with REASON FOR THIS EXAMINATION: s/p MVR w/fevers-r/o cholecystitis.,0
Needs to be evaluated tonight.,0
______________________________________________________________________________ FINAL REPORT RIGHT UPPER QUADRANT ULTRASOUND: INDICATION: 75 y/o male s/p MVR with fevers.,0
"FINDINGS: The gallbladder is distended with dependent tumefactive sludge, and measures 9.3 by 5.6 by 5.8 cm.",0
Pericholecystic fluid is identified but there is no thickening of the gallbladder wall.,0
There is no intrahepatic or extrahepatic ductal dilatation.,0
The common bile duct measures 5-6 mm in greatest diameter.,0
IMPRESSION: Distended gallbladder with sludge and pericholecystic fluid.,0
"Given these findings, the patient may benefit from percutaneous drainage.",0
"10:08 AM CHEST (PA & LAT) Clip # Reason: sternal drainage, r/o dehiscence Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with s/p cabg REASON FOR THIS EXAMINATION: sternal drainage, r/o dehiscence ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST: CLINICAL INDICATION: Status post coronary artery bypass surgery.",1
The patient is slightly rotated towards the right which somewhat limits assessment of the sternal wires.,0
"However, even allowing for rotation, there appears to a be a change in orientation of the most inferiorly located sternal wire.",0
Cardiac and mediastinal contours are stable in the post-operative.,0
"There are atelectatic changes within both lower lobes and note is made of small pleural effusions, left greater than right.",0
"IMPRESSION: Alteration in orientation of lower sternal wire, concerning for sternal dehiscence.",0
Correlation with physical exam findings is suggested.,0
CT may also be considered for more complete assessment if warranted clinically.,0
"11:54 AM CHEST (PA & LAT) Clip # Reason: r/o widened mediastinum ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with cp, ?dissection by sx at OSH REASON FOR THIS EXAMINATION: r/o widened mediastinum ______________________________________________________________________________ FINAL REPORT HISTORY: Chest pain.",0
Possible dissection at outside hospital.,0
"CHEST, 3 views: Comparison is made with 4 hours prior.",0
A pacer electrode remains unchanged in position.,0
"The left costophrenic angle is incompletely imaged, but there is no right pleural effusion.",0
There appears to be unfolding of the tortuous aorta.,0
No focal infiltrates or vascular redistribution.,0
IMPRESSION: No significant change from 4 hours prior.,0
Stable mediastinal contour with tortuous and possibly dilated aorta.,0
"Given clinical concern for dissection, a CTA can be obtained.",0
5:29 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
central line location Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with alt MS. R IJ pulled back 3 cm after noting to be in RA.,0
central line location ______________________________________________________________________________ FINAL REPORT INDICATION: Positioning of right IJ central line.,0
There is interval traction of the central line as its tip is located now in the caval-atrial junction.,0
The chest x-ray is otherwise unchanged.,0
"10:29 AM CHEST (PORTABLE AP) Clip # Reason: Progression of pneumonia vs pulmonary hemorrhage Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man h/o Downs, Alzheimers, presenting with HCAP, now hemoptysis.",0
"REASON FOR THIS EXAMINATION: Progression of pneumonia vs pulmonary hemorrhage ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: History of Down syndrome, Alzheimer's disease, hemoptysis, evaluation.",1
"FINDINGS: As compared to the previous radiograph, the current image is taken in a highly rotated patient position.",0
"As a result, hyperlucency of the left lung apex without definite signs of pneumothorax is seen.",0
The pre-existing opacity at the right lung apex is unchanged.,0
"Lung volumes have minimally decreased, but the pre-existing signs suggesting fluid overload have decreased.",0
"No evidence of pleural effusions, interposition of colon between the liver and the abdominal wall.",0
Unchanged position of the right internal jugular vein catheter.,0
Unchanged appearance of the cardiac silhouette.,0
"4:22 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p ct insertion rt Admitting Diagnosis: CHEST MASS\ATRIAL MYXOMA REMOVAL, SEPTAL MYOMECTOMY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with s/p REASON FOR THIS EXAMINATION: s/p ct insertion rt ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: Previous study of earlier the same date.",0
"Following right-sided chest tube replacement, a right pneumothorax has markedly decreased in size with only a small residual pneumothorax remaining.",0
Subcutaneous emphysema has developed adjacent to the chest tube insertion site.,0
"With the exception of these findings and slight advancement of the nasogastric tube, there are no other relevant changes since the recent chest radiograph.",0
"9:08 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: S/P CARDIAC CATH, ABD PAIN, RT GROIN HEMATOMA Admitting Diagnosis: STE MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p cardiac catheterization over weekend; with increasing hematoma in right groin as well as bandlike LQ abd pain.",1
Please evaluate for RP bleed and groin hematoma.,0
REASON FOR THIS EXAMINATION: 58 year old man s/p cardiac catheterization over weekend; with increasing hematoma in right groin as well as bandlike LQ abd pain.,1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post cardiac catheterization over the weekend with increasing hematoma in right groin as well as band-like lower quadrant abdominal pain, please evaluate for retroperitoneal bleed and groin hematoma.",1
COMPARISON: Right groin ultrasound of .,0
TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic symphysis without intravenous or oral contrast.,0
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: A 1-mm nodule is seen in the right middle lobe (2:2).,0
Linear opacities in the lower lobes bilaterally in dependent location are consistent with atelectasis.,0
There are coronary artery calcifications and probable coronary artery stent in place.,1
There is a moderate hiatal hernia.,0
"In the right lobe of the liver, a 5-mm hypodense lesion (2:27) is too small to accurately characterize.",0
"Allowing for non- contrast technique, the liver, spleen, gallbladder, pancreas, and adrenal glands appear otherwise unremarkable.",0
"In the interpolar region of the left kidney, a 6-mm hyperdense exophytic lesion could represent a hyperdense cyst.",0
A small amount of contrast is present in the collecting systems and medullary pyramids.,0
"Multiple non-pathologically enlarged, but numerous, lymph nodes are present in the mesentery and retroperitoneum.",0
The large and small bowel loops are normal in caliber.,0
"There is diverticulosis of the colon with inspissated high-density material in multiple diverticulae, but no evidence of inflammatory change.",0
There is no ascites or free intraperitoneal air.,0
There is no evidence of intra-abdominal hematoma and the psoas muscles are symmetric bilaterally.,1
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Marked asymmetric stranding in the right groin is consistent with patient's described hematoma after catheterization.,1
"While there is no large organized hematoma, a 2.3 x 3.4 cm confluent area of hemorrhage just adjacent to the femoral artery and vein (2:84) is present consistent with a small hematoma, and there is high-density material tracking along the iliopsoas musculature in the right pelvic side wall consistent with extension of hematoma (2:77).",1
"The bladder contains contrast consistent with previous administration, possibly from the prior cardiac catheterization.",1
"The prostate and seminal vesicles and rectum appear (Over) 9:08 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: S/P CARDIAC CATH, ABD PAIN, RT GROIN HEMATOMA Admitting Diagnosis: STE MYOCARDIAL INFARCTION ______________________________________________________________________________ FINAL REPORT (Cont) unremarkable.",1
Multiple diverticula are present in the sigmoid colon without evidence of inflammatory change.,0
BONE WINDOWS: No lesions worrisome for osseous metastatic disease are identified.,0
Right groin stranding and hematoma extending into the right pelvic side wall without evidence of large retroperitoneal bleed or hemoperitoneum.,0
"5-mm hypodensity in the right lobe of the liver, too small to characterize.",0
1-mm right middle lobe pulmonary nodule.,0
"If there is no history of risk factors for lung cancer, no further followup is required.",0
6-mm exophytic lesion arising from the left kidney is incompletely characterized.,0
A wet read was provided to on by Dr. describing local stranding and hematoma in the right groin without evidence of retroperitoneal bleed or other acute abdominal or pelvic pathology.,1
3:08 PM CHEST (PORTABLE AP) Clip # Reason: interval change after treatment Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with plasma cell leukemia and PNA REASON FOR THIS EXAMINATION: interval change after treatment ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Followup pneumonia.,1
"Comparison is made with prior studies, CT , chest x-ray .",0
Right upper lobe pneumonic consolidation is stable.,0
"Bilateral lower lobe multifocal smaller consolidations are also stable from , but everything has improved since .",0
Right PICC is no longer visualized.,0
"There are no new lung abnormalities, pneumothorax or enlarging pleural effusions.",0
10:52 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for new consolidation/pna.,0
"______________________________________________________________________________ MEDICAL CONDITION: 46M with necrotizing pancreatitis, s/p tracheostomy, tenacious secretions.",0
REASON FOR THIS EXAMINATION: Please eval for new consolidation/pna.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: INDICATION: Necrotizing pancreatitis.,0
Tenaceous respiratory secretions and respiratory difficulties.,0
Comparison is made to previous radiograph of .,0
"Tracheostomy tube, central venous catheter, and NG tube remain in place.",0
The distal tip of the NG tube is not well demonstrated.,0
There remains increased opacity in the left retrocardiac region as well as a left pleural effusion.,1
Perihilar haziness is without interval change.,0
"IMPRESSION: 1) Persistent perihilar haziness, which may represent a component of pulmonary edema.",0
2) Persistent left pleural effusion.,1
"Adjacent left retrocardiac opacity, which may represent atelectasis associated with effusion.",0
Underlying infectious process is not excluded.,0
"Admission Date: Discharge Date: Service: HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old female with a past medical history asthma, questionable congestive heart failure, valvular heart disease presents with cough, chills, anorexia and back pain times one week.",1
The patient comes to Emergency Department from primary care physician's office where she was found to be hypoxic on room air to a saturation of about 90%.,0
"The patient complained of positive yellow to white sputum times ten days, diffuse back pain, right chest pain that radiates to under her right arm, decreased po intake times one week, chills and sweats.",0
"The patient denies nausea, vomiting, fever, neck stiffness, diarrhea, shortness of breath, palpitations, headache and abdominal pain.",0
The patient was diagnosed with pneumonia at an outside hospital and given Levaquin.,0
The patient's primary care physician .,0
History is limited due to the patient's family not being around and the patient being an okay historian.,0
The patient has had positive sick contacts within her family recently.,0
"REVIEW OF SYSTEMS: See history of present illness above, positive chronic constipation, positive chronic pruritus.",0
Asthma (on inhaled steroids and MDIs).,0
The patient has been off medication for awhile.,0
Questionable congestive heart failure (patient found to be edematous.,1
Unclear if hypoalbumin versus congestive heart failure).,1
Valvular heart disease (tricuspid regurgitation).,1
ALLERGIES: Unknown reaction to sulfa and cephalosporins.,0
SOCIAL HISTORY: The patient lives with her husband.,0
Family is involved and lives nearby.,0
She ahs a son and a daughter.,0
"She denies tobacco use, alcohol or drug use.",0
The patient's husband smokes two packs per day.,0
The patient is currently retired.,0
HEENT mucous membranes are dry.,0
"No murmurs, rubs or gallops noted.",0
"Pulmonary decreased breath sounds at the right base, mild dullness to percussion at the right base, crackles one half to 2/3 up in the posterior right lung field, crackles at the left base.",0
Back no costovertebral angle tenderness.,0
"Extremities, warm, no clubbing, cyanosis or edema, dry.",0
Neurological alert and oriented times three.,0
"LABORATORY: White blood cell count 16.7, hematocrit 37.8, platelets 352, sodium 138, K 4.8, chloride 103, bicarbonate 16, BUN 41, creatinine 2.1 changing to 2.3.",0
"Glucose 61, anion gap of 19.",0
"CPK 33, MB not done and troponin T less then .01.",0
Chest x-ray showed right middle lobe and left lower lobe pneumonia (chest x-ray from outside facility read by in house radiologist).,0
"In the Emergency Room the patient was given Azithromycin 500 mg, Levofloxacin 500 mg and 1 liter of normal saline.",0
Blood cultures were drawn times one.,0
Pneumonia: The patient initially given Levofloxacin and Azithromycin in the Emergency Department.,0
This was changed to Levofloxacin and Vancomycin when blood cultures showed gram positive cocci in pairs and clusters.,0
One set of blood cultures came back positive in both anaerobic and aerobic bottles for strep pneumococcus and therefore Ceftriaxone was added on for double coverage and Flagyl added on for questionable aspiration pneumonia.,0
Strep pneumo was sensitive to Levofloxacin.,0
On the patient required an increase in oxygen need from 3 liters to nasal cannula to 5 liters of nasal cannula to keep saturations in the 90s.,0
"An arterial blood gas on that day was right fem stick showed 7.37, 29, 61 on 5 liters nasal cannula.",0
Lactate at that time was normal.,0
The patient received a CT scan that showed moderate right pleural effusion and right sided pneumonia.,1
"Interventional pulmonary was called to assist in a thoracentesis, however, by ultrasound minimal fluid was seen and no thoracentesis was performed.",0
On the patient had increased oxygen requirement and needed to be on 10 liters face mask to keep her oxygen saturation in the 90s.,0
She desated to the 80s when she was off the face mask.,0
"The patient continued on triple antibiotic, however, oxygen need continued to increase.",0
Overnight on the patient desated to the 70s and needed to be on 10 liters of nonrebreathers to get her oxygen saturations in the 90s.,0
"On the morning of the patient is much more somnolent then baseline and an arterial blood gas was obtained from the right femoral artery and it was 7.27, 46, 131 on 10 liters nonrebreather.",0
Lactate is pending from that.,0
MICU consult was called and she is probably going to be transferred to the MICU for closer monitoring.,0
"Repeat CT scan with contrast showed no PE, showed diffuse ground glass opacities in bilateral lung fields with no change in pneumonia of the right upper lobe, right lower lobe and right middle lobe.",0
"Patient with probable ARDS given that her PAO2/FIO2 on day of transfer equals 131, which is less then 200.",0
Until the patient was transferred to the MICU respiratory was called to put the patient on a BiPAP machine.,0
"Elevated INR: Possibly due to poor po intake and malnutrition, therefore the patient was given vitamin K replacement.",0
Hypothyroidism: The patient's TSH was 1.1 and her T4 was found to be low at 0.4 so her Levoxyl dose was increased from 60 to 75.,0
Asthma: Patient with occasional wheezes and was started on nebulizer treatments and maintained on Fluticasone.,0
Alzheimer's disease: Fomepizole was continued.,0
Hypertension: The patient is not on medication.,0
Her blood pressure has been within normal limits.,0
"Questionable congestive heart failure: Patient with crackles on examination, however on admission no edema, and no JVD.",1
"On the day of transfer patient with increase in jugulovenous pulsation, mild nonpitting edema on examination.",0
Lasix 20 intravenously was ordered along with a Foley catheter to monitor instructions and out.,0
Increased creatinine/renal failure: The patient came in with a high BUN to creatinine ratio.,0
"Creatinine on admission was 2.3, with intravenous fluids it came down to 1.0.",0
Appeared to be prerenal acute renal failure.,1
"The patient was given 1 liter of intravenous fluids the day prior to transfer, because she was getting contrast for her CT scan.",0
Arrhythmia: The patient found to be tachycardic on in the 140s.,0
On electrocardiogram she had no T waves and appeared to be in possible atrial fibrillation.,1
The patient's nebulizers were changed to Ipratropium with Albuterol only for prn.,0
The patient had recently received her Albuterol medication prior to her tachycardia.,0
Lopressor 5 intravenously was pushed and she was started on 12.5 b.i.d.,0
The patient was maintained on telemetry.,0
A repeat electrocardiogram was normal.,0
"The patient had an episode on telemetry that appeared to be nonsustained ventricular tachycardia and the patient received an echocardiogram, which showed an elongated left atrium, EF of 50 to 60, moderate dilated ascending aorta, mild thickening of AV valve that are not stenotic, 1+ aortic regurgitation, mild thickening of mitral valve, 1 to 2+ mitral regurgitation, mild thickened tricuspid valve thickening and fibrotic, 3+ tricuspid regurgitation (no change since prior study on ).",1
"Leukocytosis: Patient with right upper, middle and lower lobe infiltrate and strep pneumococcus bacteremia.",0
Repeat blood cultures are still pending.,0
White blood cell count is still climbing to a value of 24.7 today up from 18.5.,0
Chest pain on admission: The patient ruled out for myocardial infarction with cardiac enzymes times three and maintained on aspirin.,0
"Anemia: The patient is anemic on admission with a hematocrit of 38.8 down to a low in the 20s, now on transfer.",0
Hematocrit is stable at 30.3.,0
The patient with guaiac positive stools.,0
Diarrhea: Patient with a few episodes of diarrhea.,0
"FEN: Patient found to have low albumin levels 1.9, total protein 4.7.",0
Given probable ARDS status hypercatabolic and may account for low albumin and edema.,0
Boost supplementation was added and a nutrition consult was called.,0
A nutrition consult has not come prior to transfer.,0
"The patient is sating in the 90s on 10 liters nonrebreather, appears more somnolent then normal.",0
She is being transferred to the MICU.,0
Hydroxizine 10 mg three times a day.,0
Fomepizole 10 mg at night.,0
Haldol .5 mg po t.i.d.,0
Gemfibrozil 600 mg twice a day.,0
Paroxetine 20 mg once a day.,0
Fluticasone 110 mcg two puffs inhaled b.i.d.,0
Tocopheryl 400 units twice a day.,0
Folate 1 mg a day.,0
Heparin 5000 units subq q 12.,0
Metoprolol 12.5 mg po b.i.d.,0
Levofloxacin 250 mg po q day.,0
Ferrous sulfate 325 mg a day.,0
Metronidazole 500 mg three times a day.,0
Levothyroxine 75 mcg po q day.,0
Ceftriaxone 1 gram intravenously q 24 hours.,0
Pantoprazole 40 mg once a day.,0
Dictated By: MEDQUIST36 D: 10:56 T: 11:12 JOB#:,0
"9:05 AM DUP EXTEXT BIL (MAP/DVT) Clip # Reason: assess for available CABG conduit, bilateral upper and lower Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with CAD REASON FOR THIS EXAMINATION: assess for available CABG conduit, bilateral upper and lower extremities ______________________________________________________________________________ FINAL REPORT VEIN MAPPING.",1
"FINDINGS: RIGHT LEG: The greater saphenous vein is unremarkable, measuring 6 mm in diameter in the groin, 3 mm in diameter at the level of mid thigh, 2 mm in diameter at the level of the knee and at the level of the mid calf.",0
The right lesser saphenous vein is not clearly identified.,0
"LEFT SIDE: The greater saphenous vein is patent and unremarkable in appearance, measuring 3 mm in diameter in the groin, 2 mm in diameter at the level of the mid thigh and knee, and 1 mm in diameter at the level of the upper calf.",0
"The lesser saphenous vein is also unremarkable, measuring 2 mm in diameter in the popliteal fossa and at the level of mid calf, and slightly over 2 mm in diameter at the level of the distal calf.",0
IMPRESSION: Vein mapping as above.,0
Nonvisualization of the right lesser saphenous vein.,0
10:33 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: PLEASE DO FILM AT 10PM .,0
"evaluate for expansion of pneu Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man s/p AVR, chest tube pulled, r pneumo REASON FOR THIS EXAMINATION: PLEASE DO FILM AT 10PM .",1
evaluate for expansion of pneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: S/P AVR with removal of chest tube.,0
PORTABLE AP CHEST X RAY: Comparison made to study from at 18:27.,0
S/P AVR with median sternotomy.,0
Right apical pneumothorax is again seen and unchanged.,0
Left ventricular enlargement is also again seen and unchanged.,0
No pleural effusions or new opacities are seen.,0
IMPRESSION: Right apical pneumothorax again seen and unchanged.,0
LINE PLACEMENT Clip # Reason: pls confirm tube and assess interval change in lungs Admitting Diagnosis: UNRESPONSIVE ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman reintubated.,0
"pls confirm position REASON FOR THIS EXAMINATION: pls confirm tube and assess interval change in lungs ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ONE VIEW AT 23:03 HOURS CLINICAL INFORMATION: 39-year-old female re-intubated, assess ET tube.",0
"FINDINGS: Endotracheal tube terminates at the thoracic inlet approximately 4.3 cm above the carina, in satisfactory position.",0
"Heart is enlarged, mediastinum within normal limits.",0
"Since prior study, there is no substantial difference in appearance of the chest.",0
There is continued consolidation of the left lower lobe with infiltrate extending into the left upper lobe.,0
There is continued airspace opacity within the right lower lobe.,0
There are probable perihilar infiltrates on the right as well.,0
There is severe dextroscoliosis of the upper thoacic spine.,0
Endotracheal tube in satisfactory position.,0
No appreciable change in bilateral pulmonary infiltrates.,0
Weight (lb): 135 BP (mm Hg): 122/68 HR (bpm): 68 Status: Outpatient Date/Time: at 15:48 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
IMPRESSION: No vegetations seen (reasonable-quality study).,0
Normal global and regional biventricular systolic function.,0
"In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis.",0
"Compared with the prior study (images reviewed) of , severity of tricuspid regurgitation has decreased.",0
"1:15 AM BABYGRAM AP ABD ONLY PORT Clip # Reason: EVALUATE BOWEL GAS PATTERN Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with bacteremia and increased aspirates, full belly, emesis REASON FOR THIS EXAMINATION: EVALUATE BOWEL GAS PATTERN ______________________________________________________________________________ FINAL REPORT Infant with bacteremia, increased aspirates and emesis.",1
Compare to prior exam dated .,0
The NGT is coiled on itself and probably terminates in the esophagus.,0
The bowel gas pattern hasn't changed much from the prior examination.,0
There are still multiple distended loops of bowel.,0
Air and fecal material are seen dowt to in the rectum.,0
Height: (in) 56 Weight (lb): 154 BSA (m2): 1.59 m2 BP (mm Hg): 89/45 HR (bpm): 102 Status: Inpatient Date/Time: at 16:05 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) left ventricular diastolic dysfunction.,0
IMPRESSION: Symmetric LVH with preserved global and regional biventricular systolic function.,0
"Compared with the prior study (images reviewed) of , the findings appear similar.",0
"9:39 AM US ABD LIMIT, SINGLE ORGAN Clip # Reason: Please obtain peritoneal fluid for diagnosis Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with metastatic renal cell carcinoma, known pancreatic and duodenal mets, increasing abdominal distention, mild ascites REASON FOR THIS EXAMINATION: Please obtain peritoneal fluid for diagnosis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): KKXa MON 10:49 AM Very small amount of ascites adjacent to the liver dome.",1
"Given the small amount of fluid and resolution of patient's symptoms, no paracentesis was performed at this time.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic renal cell carcinoma with known pancreatic and duodenal metastases.,0
Mild ascites and increasing abdominal distention.,0
Please obtain peritoneal fluid for diagnosis.,0
COMPARISON: CT abdomen of and abdomen ultrasound of .,0
"FINDINGS: A limited four quadrant examination was performed, revealing a minimal amount of ascites adjacent to the dome of the liver.",0
No fluid was seen in the left upper quadrant or in either lower quadrant.,0
"The patient noted that he was feeling much better today, in terms of his abdominal distention.",0
The amount of ascites fluid was discussed with Drs.,0
No paracentesis was performed at this time given resolution of symptoms and decreased amount of ascites.,0
Findings were also discussed with the patient at the conclusion of the exam.,0
"6:01 PM BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # Reason: presence of glomerulonephritis Admitting Diagnosis: CONGESTIVE HEART FAILURE;RESPIRATORY DISTRESS ********************************* CPT Codes ******************************** * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with NSTEMI, embolic stroke developed acute renal failure, urine sediment showed red caell casts.",1
REASON FOR THIS EXAMINATION: presence of glomerulonephritis ______________________________________________________________________________ FINAL REPORT INTERVENTIONAL PROCEDURE UNDER ULTRASOUND GUIDANCE.,0
A portable ultrasound exam was performed to evaluate the left kidney prior to providing guidance for renal biopsy.,0
A site was marked over the lower pole of the right kidney with the patient placed in the prone position and the skin prepped and draped in standard manner.,1
A preprocedure timeout was completed by all members of the team following the nephrology group obtaining consent from the patient's daughter.,1
Ultrasound guidance was provided during the obtaining of four cores from the lower pole of the right kidney.,0
No immediate complications were noted.,0
IMPRESSION: Ultrasound guidance provided to facilitate core biopsies from the lower pole of the right kidney.,0
8:06 AM PORTABLE ABDOMEN Clip # Reason: evalaute for follow up of dilatation ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with abdominal distension.,0
REASON FOR THIS EXAMINATION: evalaute for follow up of dilatation ______________________________________________________________________________ FINAL REPORT INDICATIONS: History of abdominal distention.,0
PORTABLE ABDOMEN: Colostomy tube overlies right lower quadrant.,0
Gas and retained contrast are persistent throughout the colon.,0
There has been no change since the prior study of .,0
IMPRESSION: No significant change since the prior film.,0
The cecum remains decompressed following the cecostomy.,0
10:08 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval mediastinum and pulm edema Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT MAZE; ?,1
"PATENT FORAMEN OVALE CLOSURE /SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p cabg x4/PFO closure/MV repair/ cryo Maze now w/ hypotension and decr hct REASON FOR THIS EXAMINATION: eval mediastinum and pulm edema ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Status post CABG, postoperative day 4, hypertensive chest.",0
Mitral valve prosthesis is present.,1
The degree of failure has decreased since the prior chest x-ray of .,0
The mediastinal widening is also decreased in size.,0
"Mediastinal tubes, chest tube and endotracheal tube remain in satisfactory positions.",0
IMPRESSION: Slight improvement since prior chest x-ray of four hours prior.,0
9:37 PM PORTABLE ABDOMEN Clip # Reason: r/o recurrence Admitting Diagnosis: UTI/PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with h/o staghorn calculi REASON FOR THIS EXAMINATION: r/o recurrence ______________________________________________________________________________ FINAL REPORT INDICATION: History of staghorn calculi.,0
"FINDINGS: Single view of the abdomen in supine position demonstrates bilateral calcific densities within the renal pelvis, right greater than left.",0
The bowel gas pattern is unremarkable.,0
Degenerative changes of the lower lumbar spine are noted.,0
"3:05 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST Reason: nausea, and vomiting, hx of pancreatitis--eval for pseudocys Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with REASON FOR THIS EXAMINATION: nausea, and vomiting, hx of pancreatitis--eval for pseudocyst No contraindications for IV contrast ______________________________________________________________________________ WET READ: MMBn SUN 4:46 AM 31 x 23 mm pancreatic tail lesion.",1
"Small amount of surrounding inflammation is consistent with residual or recurrent pancreatitis, ______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old man with nausea and vomiting and history of pancreatitis.",0
COMPARISON: CT abdomen and pelvis dated .,0
TECHNIQUE: MDCT noncontrast imaging of the abdomen and pelvis was performed.,0
"Following the administration of 150 cc of intravenous Optiray, MDCT imaging of the abdomen and pelvis was performed.",0
"CT ABDOMEN WITH ORAL, WITH INTRAVENOUS CONTRAST: Multiple cysts are seen primarily within the right lung base.",0
There are no areas of consolidation or pleural effusions.,0
The liver is low in attenuation consistent with fatty infiltration.,0
No focal nodules or masses are detected.,0
A calcified 8 mm stone is seen within the gallbladder neck.,0
There is no pericholecystic fluid or surrounding inflammation.,0
"The spleen, bilateral adrenal glands, and right kidney are normal.",0
"Multiple hypodensities are seen within the left kidney, the largest of which measures 23 x 16 mm.",0
"While these most likely represent simple cysts, they are not fully characterized.",0
The abdominal loops of large and small bowel are normal in caliber and contour.,0
There is no mesenteric or retroperitoneal lymphadenopathy.,0
There is no free air and no free fluid.,0
"The pancreas enhances normally to the tail, where there is a 31 x 23 mm hyperdense, slightly rim-enhancing lesion that extends superiorly off the pancreatic tail.",0
Mild surrounding soft tissue stranding could be consistent with residual or recurrent pancreatitis.,0
"CT PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: The distal ureters, bladder, sigmoid, rectum and prostate are unremarkable.",0
"New 31 x 23 mm soft tissue density rim-enhancing mass extending superiorly (Over) 3:05 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST Reason: nausea, and vomiting, hx of pancreatitis--eval for pseudocys Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) off the pancreatic tail.",0
This most likley represents a hemorrhagic pancreatic pseudocyst given the patient's history of pancreatitis.,1
Mild surrounding soft tissue stranding consistent with residual or recurrent inflammation.,0
3:49 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT CHEST AND PELVIS RADIOGRAPH.,0
FINDINGS: CHEST RADIOGRAPH: There is a markedly widened mediastinum.,0
"There is no definite focal consolidation, large pleural effusion or pneumothorax.",0
Overlying trauma board and cervical spine collar limits evaluation.,0
Multiple old healed rib fractures are identified.,1
Acute left fourth rib fracture is identified.,0
TRAUMA RADIOGRAPH: Overlying trauma board limits evaluation.,0
Stool in the rectum identified.,0
Widened mediastinum for which further evaluation with chest CTA is recommended.,0
Acute left fourth rib fracture.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: assess line placement Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with new RIJ insertion REASON FOR THIS EXAMINATION: assess line placement ______________________________________________________________________________ FINAL REPORT HISTORY: 44-year-old woman with new right internal jugular catheter placement.,0
COMPARISON: Chest radiograph approximately five hours earlier.,0
SINGLE SUPINE VIEW OF THE CHEST AT 1341 HOURS: The patient is markedly rotated.,0
The endotracheal tube terminates 2.7 cm from the carina.,0
A new right internal jugular catheter terminates in the mid SVC.,0
"An enteric tube terminates in the stomach, with the side port at or above the GE junction.",0
Surgical clips project over the right upper quadrant.,0
"Allowing for the change in patient positioning, there has been little interval change in diffuse, bilateral, severe parenchymal opacities, with probable underlying cardiomegaly.",1
"There is no superimposed consolidation, new large pleural effusion or pneumothorax.",0
IMPRESSIONS: Right internal jugular catheter terminates in the mid SVC.,0
"No short interval change in severe, bilateral parenchymal opacities.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: lethargy, weakness Major Surgical or Invasive Procedure: none History of Present Illness: 71 yo male w known multifocal hepatoma (non-operable and no chemoembo), w/ recent h/o GIB (no varices, but friable mucosa), and w/ 12U PRBC transfusion/MICU stay for likely intraperitoneal bleed who was noted by family to be lethargic with c/o sudden onset of abd pain on DOA, EMS called lethargy/weakness.",0
"Of note, pt recently finished 2wk chemo tx of Xeloda 1000 mg b.i.d.",0
"In ED, BP 57/43 L fem line placed, amp levo/flagyl given, started dopa/IVF, c/o CP in ER and improved with increased BP.",0
"Levophed added to dopa 15. became tachy, therefore dopa d/c'd and neo added.",0
"Had CP in ED while hypotensive, rec'd ASA 81 x 4.",0
Hepatocellular carcinoma diagnosed by biopsy in of .,0
Seen on CT scan in .,0
"Since the liver is cirrhotic and has multiple lesions, the patient is not a candidate for surgical resection.",0
Hepatitis C contracted by blood transfusion during CABG.,0
"Chronic atrial fibrillation, but not on Coumadin.",1
Coronary artery disease status post CABG x4 30 years ago.,0
CHF with an EF of 25% with hospitalizations for CHF exacerbation.,0
Blood loss anemia from chronic GI bleed status post recent endoscopy showing no varices.,0
Diet controlled diabetes mellitus type 2.,0
1. hypoTN: likely combination of bleeding and sepsis.,0
"Pt was originally started with amp/levo and flagyl with continued hypotension and intermittent fever, abx changed to vanco/levo and flagyl.",0
"Despite being on broad spectrum of abx, pt remain hypotensive and developed DIC with high d-dimer and increased FDP and coagulopathy, and required neosyn and levophed for BP suppor till expired.",0
"Bleed from hepatoma lesions s/p embolization, hct relatively stable throughout hospital stay.",0
"Discussion with pt's family, has decided to change code status from DNI/DNR to CMO with BP support on .",0
"2: tachy afib with CP: s/p amiodarone and digoxin loading, ECHO showed global hypokinesis with EF 10%, likely had a MI.",0
"3. acute on chronic renal failure: initially improved with rehydration and transfusion, likely pre-renal, urine Na<10, UreaN521 Cr84 osm364 FENa=0.2% but later increased again from 1.7 to 2.2 to 3 to >7, likely combination of hepatorenal and ATN from the dye loading and hypotension.",1
"Pt expired on , intern was called for asystole, pt with rare sporadic respirations which ceased w/in approx 10 min.",0
"Pupils were fixed and dilated, no carotid pulse, no visible/audible respirations, pt pronounced at 11:57pm, admitting notified.",0
Family were around when pt passed away.,0
Diltiazem 240 mg sustained release p.o.,0
"Xeloda 1000mg po bid Discharge Medications: none, pt expired Discharge Disposition: Extended Care Facility: pt expired Discharge Diagnosis: 1.",0
15. multi-organ failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:,0
"5:27 PM CHEST (PORTABLE AP) Clip # Reason: compare w/ prior, poor resp status Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man s/p MVA with Ptx s/p CT pulled REASON FOR THIS EXAMINATION: compare w/ prior, poor resp status ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVA with pneumothorax, chest tube removed, evaluate for pneumothorax.",1
TECHNIQUE: Single AP portable upright chest.,0
FINDINGS: A nasogastric tube is in place with the tip terminating below the borders of the radiograph.,0
Endotracheal tube terminates in the upper trachea.,0
"Right subclavian venous access catheter with tip terminating in distal SVC, unchanged.",0
"Spinal fixation rod hardware and surgical staples, unchanged.",0
The heart size and mediastinal contours are within normal limits.,0
"In comparison with the previous examination, the nodular opacity in the right upper lobe medially appears less prominent.",0
There is persistent opacity in the right lower lobe with small right pleural effusion.,0
Decrease in left pleural effusion.,0
Slight decrease in pulmonary opacification in the right mid-lung.,0
Stable right lower lobe opacity.,0
"Decreased left pleural effusion, stable small right pleural effusion.",0
7:38 AM KNEE (PORTABLE) RIGHT Clip # Reason: fracture or dislocation ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p fall from stairs REASON FOR THIS EXAMINATION: fracture or dislocation ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old status-post fall from stairs.,0
Evaluate for fracture or dislocation.,0
"KNEE, RIGHT, TWO VIEWS: Soft tissue swelling is identified in the region of the knee joint.",0
"There is a possible knee joint effusion, but the lateral view is slightly oblique.",0
"If clinically indicated, the possibility of effusion could be further evaluated with a shoot-through lateral view of the right knee.",0
IMPRESSION: No fracture is identified.,0
There may be an effusion.,0
"If clinically indicated, the knee could be further evaluated with a shoot-through lateral view to further assess for this possibility.",0
8:18 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please evaluate chest tube placement and resolution of ptx Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with right ptx REASON FOR THIS EXAMINATION: please evaluate chest tube placement and resolution of ptx ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of patient with known pneumothorax.,1
AP radiograph of the chest was compared to prior study obtained at 7:32 p.m. Left chest tube has been inserted with subsequent substantial improvement of currently minimal pneumothorax.,1
The NG tube tip remains too proximal.,0
"8:42 AM BABYGRAM (CHEST ONLY) PORT Clip # Reason: poor oxygenation, chronic lung disease Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with increasing oxygen needs REASON FOR THIS EXAMINATION: poor oxygenation, chronic lung disease ______________________________________________________________________________ FINAL REPORT Comparison is made with exam done on the 6th.",1
"Since that time the lung volumes have become even lower, resulting in nearly complete lungs bilaterally (?).",0
Patient has severe chronic lung disease.,1
With the current film I cannot exclude any superimposed edema or pneumonia.,0
Endotracheal tube ends above the carina.,0
There is evidence of ligation of the ductus arteriosis.,0
6:59 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: *Please do exam at 7pm tonight.,0
Thanks!Assess for change in Admitting Diagnosis: MULTIPLE ICD CHARGES ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with large right pleural effusion and new right basilar pneumothorax s/p thoracentesis.,1
REASON FOR THIS EXAMINATION: *Please do exam at 7pm tonight.,0
Thanks!Assess for change in pneumothorax.,0
"______________________________________________________________________________ FINAL REPORT Portable chest, at 7:31 p.m. compared to previous study of 2:33 p.m. the same date.",0
Moderate-to-large right basilar pneumothorax is slightly increased in size compared to the recent examination.,0
There is otherwise no substantial change in the appearance of the chest.,0
"8:04 AM CT CHEST W/CONTRAST Clip # Reason: evaluate L lung, + dedicated airway CT w/ exp/inspiratory vi Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with left upper lobe mass lobectomy for lung ca w/ recurrent pneumoniae, failure to wean, increased secretions & recurrent L lung collapse & likely dynamic tracheomalacia.",1
(to be done in addition to chest CT w/ contrast).,0
x if you have questions.,0
"thank you REASON FOR THIS EXAMINATION: evaluate L lung, + dedicated airway CT w/ exp/inspiratory views to evaluate for tracheomalacia.",0
"______________________________________________________________________________ FINAL REPORT CT THORAX, : Compared to recent CT chest of .",0
"CLINICAL INDICATION: The patient is a 74 year old female who is s/p left upper lobectomy for lung cancer, and presents with recurrent pneumonias in the left lower lobe and recurrent collapse.",0
There is clinical suspicion for tracheobronchomalacia.,0
"The patient was imaged according to the CT airway protocol, which involves a standard dose CT of the chest during end inspiration and a subsequent low dose CT of the chest during dynamic exhalation.",0
"Unfortunately, the patient was unable to cooperate with standard breath-holding instructions, and the examination is technically suboptimal for that reason.",0
"For the initial inspiratory scan, 100 cc of Optiray was administered intravenously.",0
Nonionic contrast was chosen due to the patient's debilitated status and respiratory difficulties.,1
"A tracheostomy tube is in place, and terminates several cm above the carina.",0
The distal tip of the tube abuts the posterior wall of the trachea with the patient in a supine position.,0
The left main stem bronchus appears patent.,0
The left lower lobe bronchus appears occluded just beyond the takeoff of the superior segment bronchus.,0
The superior segment bronchus appears patent but narrowed.,0
"With regard to the assessment of the trachea between inspiratory and expiratory phases of respiration, at the level of the aortic arch, the trachea measures approximately 330 mm squared.",0
"During dynamic exhalation, the tracheal lumen decreases to 117 mm squared.",0
This meets radiographic criteria for tracheomalacia.,0
"Excessive narrowing of the bronchus intermedius and origin of right middle lobe bronchus is also observed during dynamic breathing, as well as within the right upper lobe bronchus.",0
No definite excessive collapse is observed in the left main stem bronchus during dynamic breathing.,1
"Assessment of the lungs reveals numerous thickened septal lines within the right lung, as well as multifocal patchy areas of ground-glass attenuation.",0
Many of the patchy ground-glass opacities are new since the prior study.,0
"With regard to the left lung, there is near complete collapse of the left lower lobe with only very minimal residual aerated lung remaining, mostly at the apex, presumably corresponding to the superior segment of the left lower lobe.",0
"(Over) 8:04 AM CT CHEST W/CONTRAST Clip # Reason: evaluate L lung, + dedicated airway CT w/ exp/inspiratory vi Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) Overall, the degree of aerated lung in the left lower lobe has decreased since the prior study.",0
Review of the soft tissue structures of the thorax demonstrates a moderate- sized dependent right pleural effusion which has increased in size since the previous examination.,1
There is also a moderate-sized left pleural effusion which is partially loculated and stable in appearance as compared to the previous examination.,1
"Note is also made of a low density structure superiorly within the left atrium, concerning for a focus of left atrial thrombus.",0
"Numerous mediastinal lymph nodes are identified, measuring up to 12 mm in greatest short axis dimension in the precarinal region and up to 13 mm in diameter in the pretracheal region.",0
Only the upper most portion of the abdomen is included on the study.,0
"No significant abnormality is seen in the imaged portion of the liver, spleen, or adrenal glands but these organs are incompletely imaged on this study.",0
IMPRESSION: 1) Suboptimal dynamiic airway CT due to patient's limited ability to cooperate with breath-holding instructions.,0
"Nonetheless, there is evidence of excessive airway collapse during dynamic breathing within the intrathoracic trachea, bronchus intermedius and right upper lobe bronchi, consistent with tracheobronchomalacia.",1
No excessive collapse is observed within the left main stem bronchus.,1
The left lower lobe bronchus is occluded beyond the origin of the superior segment bronchus and cannot be assessed for malacia.,0
"2) Occlusion of left lower lobe bronchus, which may be due to retained secretions but tumor involvement is not excluded and correlation with bronchoscopy is advised.",0
"3) Near complete collapse of left lower lobe, which is less well aerated than on the previous study with only a very minimal amount of aerated lung in the superior segment.",0
4) Moderate-sized bilateral pleural effusions with interval increase in size of right effusion in the interval.,1
5) Thickened septal lines in the right lung with multifocal patchy ground- glass opacities.,0
This may be due to interstitial edema and/or infection.,0
9:00 AM PELVIS WITH JUDET VIEWS Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with trauma REASON FOR THIS EXAMINATION: trauma ______________________________________________________________________________ FINAL REPORT HISTORY: 59 year old woman with trauma.,0
AP PELVIS WITH JUDET VIEWS: No acute fracture or dislocation identified.,0
The hip joints and SI joints are well visualized and are normal in appearance.,0
Small phleboliths are identified in the pelvis.,0
There is a left femoral vein catheter identified IMPRESSION: No acute fracture or dislocation.,0
"12:58 PM ART DUP EXT LO UNI;F/U Clip # Reason: please eval right popliteal and sfa for occlusion, please ev Admitting Diagnosis: RIGHT FOOT PAIN ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with PVD and R foot pain REASON FOR THIS EXAMINATION: please eval right popliteal and sfa for occlusion, please eval velocities ______________________________________________________________________________ FINAL REPORT STUDY: Arterial duplex of the lower extremities.",0
REASON: The patient is status post bypass with continued foot pain.,0
FINDINGS: Duplex evaluation performed from the right SFA to popliteal stent.,0
"From proximal to distal, the velocities are 75, 93, 83, 76, 319, 53, 65, and 71.",0
"At the level of the distal SFA above the knee, there is a peak velocity ratio of 4 and dampened velocities.",0
This is consistent with a greater than 75% stenosis at this location.,0
IMPRESSION: Patent right SFA/popliteal segment status post stent/angioplasty.,0
"However, there appears to be 75% stenosis in the distal SFA above the knee.",0
"3:26 AM CHEST (PORTABLE AP) Clip # Reason: assess progression pulm disease Admitting Diagnosis: END STAGE RENAL DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with cirrhosis, systolic CHF p/w sepsis REASON FOR THIS EXAMINATION: assess progression pulm disease ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
HISTORY: 80-year-old woman with cirrhosis and systolic CHF.,1
The lines and tubes are unchanged in position.,0
There remains cardiomegaly which is stable.,0
There are also bilateral pleural effusions and a left retrocardiac opacity which is stable.,0
LINE PLACEMENT Clip # Reason: l dl power picc 51cm iv Admitting Diagnosis: TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with picc REASON FOR THIS EXAMINATION: l dl power picc 51cm iv ______________________________________________________________________________ FINAL REPORT INDICATION: Left PICC positioning.,0
COMPARISONS: Chest radiograph from .,0
FINDINGS: A beside AP radiograph of the chest demonstrates a new left PICC terminating within the mid portion of the superior vena cava.,0
"Aside from trace left lower lobe atelectasis, the lungs are clear and the hilar and cardiomediastinal contours are normal.",0
There is no pneumothorax or pleural effusion and the pulmonary vascularity is normal.,0
Old right posterior 8th and 9th rib fractures are noted.,0
IMPRESSION: New left PICC terminates in the mid SVC.,0
"NOTE: Findings were communicated to , the PICC nurse, by Dr. via telephone on at 9:15 a.m.",0
"6:28 PM CT C-SPINE W/O CONTRAST Clip # Reason: OSH films reported as L-sided transverse process fracture no Admitting Diagnosis: BLUNT TRAUMA Field of view: 25 ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with MVC and T1 fracture REASON FOR THIS EXAMINATION: OSH films reported as L-sided transverse process fracture non-displaced of T1 SO WE ONLY NEED IMAGING AROUND T1, NO NEED TO DO ENTIRE THORACIC SPINE.",1
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT OF THE C-SPINE.,0
INDICATION: 37-year-old male status post MVC.,0
COMPARISONS: There are no prior images available for comparison.,0
TECHNIQUE: MDCT axial images of the cervical spine were acquired.,0
Coronal and sagittal reformatted images were then obtained.,0
FINDINGS: There is a minimally displaced fracture involving the left transverse process of the T1 vertebral body.,1
There is also a minimally displaced fracture involving the posterior first rib which is minimally displaced as well.,0
No other fractures are present.,0
There is no subluxation of the cervical spine.,0
The visualized outline of the thecal sac is unremarkable.,0
There is a small left apical pneumothorax.,1
A hazy opacity posteriorly could represent a focal pulmonary contusion.,0
There may be a small nondisplaced fracture involving the posterior aspect of the sternum (2:82).,0
Minimally displaced fractures involving the left transverse process of T1 and the posterior first rib as described.,0
Small associated left apical pneumothorax.,1
Possible nondisplaced fracture involving the posterior aspect of the sternum on the left.,0
Correlation with outside hospital CT images is recommended.,0
These findings were discussed with Dr. by Dr. over the telephone at 8:00 p.m. on .,0
8:24 PM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"strok, bleed, progression ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with stroke L frontal parietal and ?",0
uncal herniation REASON FOR THIS EXAMINATION: ?,0
"strok, bleed, progression No contraindications for IV contrast ______________________________________________________________________________ WET READ: PXDb WED 8:49 PM large left cerrebral intraparenchymal hemorrhage with large perihemorrhagic edema and signifcant mass effect worse than prior outisde study, there is subfalcine, uncal and beginning downward transtentorial herniation with effacement of quadrigeminal plate cisterns.",0
"______________________________________________________________________________ FINAL REPORT NON-CONTRAST HEAD CT PERFORMED ON CLINICAL HISTORY: 74-year-old woman with large left cerebral hemorrhage, transferred from outside hospital.",0
Comparison is made with outside hospital head CT performed today at 5:47 p.m. (three hours ago).,0
FINDINGS: Non-contrast head CT. A large acute left cerebral intraparenchymal hemorrhage is again noted measuring approximately 5.7 x 4.5 cm.,0
"This is similar to that seen previously; however, there is increased surrounding edema which causes effacement of the left lateral ventricle and subfalcine herniation of approximately 10 mm.",0
There is diffuse effacement of the left cerebral sulci.,0
There is partial (left) effacement of the suprasellar cistern and the quadrigeminal cistern which is worrisome for impending downward transtentorial herniation.,0
There is no evidence of ventricular obstruction.,0
Osseous structures appear grossly intact.,0
IMPRESSION: Large left cerebral parenchymal hemorrhage with surrounding edema and increasing mass effect causing 1-cm rightward subfalcine herniation and mild effacement of the suprasellar and quadrigeminal cisterns on the left worrisome for early downward transtentorial herniation.,0
These findings were discussed with Dr. at approximately 8:35 p.m. on .,0
5:18 AM CHEST (PORTABLE AP) Clip # Reason: Please assess interval change.,0
"Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with pancreatitis, respiratory failure.",1
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH CLINICAL INDICATION: 27-year-old man with pancreatitis and respiratory failure.,1
Please assess for interval changes.,0
FINDINGS: There is a right-sided internal jugular line with the proximal SVC.,0
Interval removal of the endotracheal tube.,0
Nasogastric tube in place with distal tip in the stomach.,0
Cardiac silhouette is within normal limits.,0
No focal airspace consolidation or evidence of CHF.,0
There is mild interval decrease in degree of left lower lobe atelectasis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending: Chief Complaint: Weakness Major Surgical or Invasive Procedure: LEFT OCCIPITAL CRANI FOR MASS History of Present Illness: Mr. is a 58 year old male with a PMH significant for HTN, HLD, DM 2, and 40+ pack year smoking history admitted for weakness found to have lung and brain masses.",0
"The patient reports that he was in his usual state of health until 1 day prior to admission, at which point he had acute onset of weakness while walking with his wife.",0
"describes this an an inability to stay standing last for several minutes, after which he felt unsteady but was able to walk home independently.",0
"Per the patient's wife, he did not exhibit any difficulty with walking or gait imbalance.",0
"He denies any vertigo, headache, lightheadedness, dysarthria, vision changes, tinnitus, CP/SOB, or nausea.",0
"This morning, the patient reports that while walking his dogs he experienced a similar episode requiring him to sit down.",0
"After approximately 5-10 minutes, he was able to walk back home.",0
"Over the course of the day, the patient felt fatigued and stayed in bed, and this evening the patient was brought to by his family for further evaluation.",0
"In the ED, intial VS 95.8 62 138/84 16 100%RA.",0
"The patient was had a CXR that demonsrated a right perihilar spiculated mass, and a CTH that demonstrated extensive left parietal lobe vasogenic edema.",0
"The patient was seen by Neurology and Neurosurgery, with the recommendation for MRI, and he was admitted to Medicine for further management.",0
"Currently, the patient is resting comfortably.",0
States that he has a right sided headache described as right temple pressure.,0
"Denies weight loss, night sweats, hematochezia/melena, cough, hemoptysis, dysuria, hematuria, N/V/D, abd pain.",0
"ROS is notable for several months of fatigue, unchanged dyspnea on exertion, and a stutter that is worse than baseline over the past several months.",0
"Past Medical History: - Normal MIBI in , though echo shows small area of akinesis - HTN - HLD - DM 2 - COPD (emphysema) - GERD/Barrett's esophagus - Elevated PSA s/p normal biopsy in - Childhood seizure disorder - last event at 11 or 12 years of age - Anxiety/trouble with anger management, on Risperdal - Learning disability - Multiple hernias - Glaucoma bilaterally - Strabismus - Tonsillectomy - Umbilical hernia repair - Right inguinal hernia repair - ""Eye operation"" at 6-8 years of age because ""I was seeing double"" Social History: Married.",0
Works in bottle redemption center.,0
"Tobacco - Quit , 1ppdx40+years.",0
"Denies IV, illicit, or herbal drug use.",0
"Family History: Very strong family history of lung cancer in mother, grandparents, and multiple aunts&uncles.",0
Physical Exam: VS: 97.4 119/81 60 18 96%RA Gen: Age appropriate male in NAD.,0
"HEENT: PERRL, eomi, sclerae anicteric.",0
"MMM, OP clear without lesions, exudate, or erythema.",0
"CV: Nl S1+S2 Pulm: CTAB, no wheezes Abd: S/NT/ND +bs Rectal: OB brown negative (per ED) Ext: No c/c/e.",0
"LAD: No cervical, submental, posterior auricular, supraclavicular or axillary lymphadenopathy.",0
"Neuro: Oriented to person, place, and time.",0
"Speech notable for stutter, no slurring.",0
"CN II-XII intact, visual fields intact.",0
5/5 Strength bilaterally upper and lower extremities.,0
"-Babinski, 1+ patellar bilaterally, sensation intact to light touch in all extremities.",0
"ON DISCHARGE: Awake, Alert and Oriented x3 denies h/a, N/V PERRL 3mm, Left lateral gaze MAE's with good strengths following all commmands + dysmetria R>L Pertinent Results: Admission lab results: 02:45PM WBC-3.7* RBC-4.59* HGB-13.5* HCT-40.0 MCV-87 MCH-29.3 MCHC-33.6 RDW-14.2 02:45PM NEUTS-50.4 LYMPHS-39.4 MONOS-8.0 EOS-1.9 BASOS-0.3 02:45PM PLT COUNT-137* 02:45PM ALT(SGPT)-22 AST(SGOT)-19 LD(LDH)-146 ALK PHOS-48 TOT BILI-0.5 02:45PM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-4.2 MAGNESIUM-1.9 02:45PM GLUCOSE-72 UREA N-15 CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 05:15PM URINE COLOR-Yellow APPEAR-Clear SP -1.021 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 05:15PM URINE RBC-0-2 WBC- BACTERIA-FEW YEAST-NONE EPI-0-2 MRI Head PRE OP: IMPRESSION: 1.",0
"Heterogeneous enhancing lesions in the left parasagittal parieto-occipital lobe and the left cerebellum, with susceptibility artifacts and extensive left parietal parenchymal edema.",0
The constellation of findings is compatible with hemorrhagic brain metastasis with vasogenic edema.,1
"In the clinical context of a spiculated pulmonary mass, this is highly suggestive of squamous cell carcinoma metastasis with hemorrhagic components.",0
No hydrocephalus or significant midline shift.,0
Right lower lobe mass consistent with primary bronchogenic neoplasm.,0
Lymphadenopathy is identified in the ipsilateral hilum and the subcarina.,0
Equivocal lymph nodes are identified in the contralateral mediastinum.,0
No evidence of hepatic metastases.,0
A tiny right adrenal nodule is too small to characterize.,0
CT Head (Post-op); expected post-operative changes.,0
"Post-surgical changes, with hemorrhage in the resection cavity, but no definite evidence of residual or recurrent neoplasm.",0
"Small punctate focus of decreased diffusion in the posterior left parietal lobe, and deep to the resection cavity, may represent a tiny infarct versus cytotoxic edema.",0
"Stable enhancement and intrinsic T1 hyperintense foci in the left cerebellar hemisphere, also likely representing metastatic disease, and unchanged since the prior study.",0
"Brief Hospital Course: Mr. is a 58 year old male with a PMH significant for HTN, HLD, DM 2, and 40+ pack year smoking history admitted for weakness found to have lung and brain masses.",0
# Weakness: Almost definitely due to malignancy and brain masses.,0
"Given the patient's significant tobacco/smoking history, right perihilar mass concerning for primary lung neoplasm, specifically squamous cell lung cancer, with brain metastasis, although cannot rule out another primary at this time.",1
Chief complaint of weakness in the setting of subtle neurologic findings as detailed by Neurology also concerning in setting of left parietal vasogenic edema.,0
He was started on dexamethasone 4mg IV Q6H and got Q4H neuro checks.,0
"Given his history of a Dilantin as a child, he was started on Keppra for seizure prophylaxis.",0
"His neurologic exam remained stable, but given the size of the brain mass, he was taken by neurosurgery for surgical resection .",0
# DM 2: His Glipizide and Actos/Metformin forumulation were held.,0
He was covered with a Humalog sliding scale QACHS.,0
# COPD: Respiratory status stable without hypoxemia.,0
"He was initially on an ipratropium inhaler QID, but was then changed back to his home tiotropium daily.",0
Did not require an albuterol rescue.,0
# Learning disability/anger management: He was continued on his Risperdal.,0
"After speaking with the patient and his outpatient case manager, it was felt that he was competent to make his own medical decisions.",0
He was able to articulate understanding of the need for surgery and the potential risks involved.,0
"He signed papers to have his uncle, , as his health care proxy.",0
"On , Mr. was transferred from the medicine team, to neurosurgery team following open craniotomy for resection of brain mass.",0
He was taken to the ICU for frequent neurological examinations and systolic blood pressure control.,0
"He was kept in the ICU until the morning of , when he was transferred to the floor.",0
His pain was well controlled and his neurological exam remained unchanged.,0
His dexamethasone taper began on .,0
On he was seen by physical therapy and occupational therapy.,0
His neurological exam remained unchanged.,0
He continued to work with PT on and was cleared for discharge home with PT and VNA.,0
He remained inhouse until discharge plans could be coordinated with the hospital social worker and his personal social worker.,0
He was discharged to home on with physical therapy and VNA.,0
Medications on Admission: Risperidone 0.5mg Crestor 40mg daily Glipizide ER 5mg daily Actos/metformin 15/850 Tiotropium 1 puff daily Alendronate 75mg weekly Omeprazole 20mg Ca+Vit D ASA 81 daily Timolol 1 drop OU QHS Alendronate weekly Finasteride 5mg daily Discharge Medications: 1.,0
Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily).,0
"Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, headache.",0
Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for Wheezing, SOB.",0
"Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily).",0
Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)).,0
"Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Left Occipital mass, left cerebellar masses x2 Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?",0
You or a family member should inspect your wound every day and report any of the following problems to your physician.,0
Keep your incision clean and dry.,0
You may wash your hair with a mild shampoo 24 hours after your sutures are removed.,0
"Do NOT apply any lotions, ointments or other products to your incision.",0
DO NOT DRIVE until you are seen at the first follow up appointment.,0
Do not lift objects over 10 pounds until approved by your physician.,0
DIET Usually no special diet is prescribed after a craniotomy.,0
"A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery.",0
"Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation.",0
Take all of your medications as ordered.,0
You do not have to take pain medication unless it is needed.,0
"It is important that you are able to cough, breathe deeply, and is comfortable enough to walk.",0
Do not use alcohol while taking pain medication.,0
Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone).,0
-An over the counter stool softener for constipation (Colace or Docusate).,0
"If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed).",0
"Often times, pain medication and anesthesia can cause constipation.",0
"You were on Aspirin, prior to your surgery, you may safely resume taking this at one month after surgery.",0
"Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding.",0
"You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation.",0
ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued.,0
You should become a little stronger every day.,0
Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again.,0
Follow the activity instructions given to you by your doctor and therapist.,0
Increase your activity slowly; do not do too much because you are feeling good.,0
You may resume sexual activity as your tolerance allows.,0
"If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly.",0
DO NOT DRIVE until you speak with your physician.,0
"Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool.",0
Do your breathing exercises every two hours.,0
"Use your incentive spirometer 10 times every hour, that you are awake.",0
WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications.,0
"Although your surgery is over, there is the possibility of some of these complications developing.",0
"These complications include: infection, blood clots, or neurological changes.",0
Call your Physician Immediately if you Experience: ?,0
"Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking.",0
"Loss of vision, either partial or total.",0
"Numbness, tingling, or weakness in your extremities or face.",0
"Stiff neck, and/or a fever of 101.5F or more.",0
Severe headache or change in headache.,0
Problems controlling your bowels or bladder.,0
Productive cough with yellow or green sputum.,0
"Swelling, redness, or tenderness in your calf or thigh.",0
Call 911 or go to the Nearest Emergency Room if you Experience: ?,0
"New onset of seizure or change in seizure, or seizure from which you wake up confused.",0
A seizure that lasts more than 5 minutes.,0
Important Instructions Regarding Emergencies and After-Hour Calls ?,0
"If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed.",0
"Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone.",0
"Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed.",0
Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ?,0
?Please return to the office in days (from your date of surgery) for removal of your sutures and a wound check.,0
?You will be set up for Whole Brain radiation in .,0
"One month following the radiation, you will be seen in the Brain Clinic.",0
"If you are not contact with an appointment time, please call to set up this appointment.",0
?You will not need an MRI of the brain as this was done during your hospitalization.,0
5:19 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for feeding tube - not seen on abd x-ray ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with hanging s/p insertion of feeding tube REASON FOR THIS EXAMINATION: evaluate for feeding tube - not seen on abd x-ray ______________________________________________________________________________ FINAL REPORT INDICATION: 52 year old man status post hanging and status post insertion of feeding tube.,0
Please assess feeding tube placement.,0
"CHEST X-RAY, PORTABLE AP: A Dobbhoff feeding tube is seen with tip in the stomach.",0
There has been interval removal of a right subclavian central venous line and endotracheal tube.,0
"Slight opacity seen in the right lower lobe, not significantly changed from prior exam.",0
The right hemithorax is incompletely visualized.,0
IMPRESSION: Dobbhoff tube tip in stomach.,0
"3:27 AM CHEST (PORTABLE AP) Clip # Reason: see below Admitting Diagnosis: RIGHT HIP HARDWARE DISLOCATION ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with ""vegetative state"" s/p trache/peg assess for interval change REASON FOR THIS EXAMINATION: see below ______________________________________________________________________________ FINAL REPORT HISTORY: Vegetative state with tracheostomy and PEG.",1
"FINDINGS: In comparison with study of , the monitoring and support devices are essentially unchanged.",0
Continued enlargement of the cardiac silhouette with evidence of elevated pulmonary venous pressure.,1
Opacification at the left base is consistent with pleural effusion and volume loss in the left lower lobe.,0
"In the appropriate clinical setting, superimposed pneumonia would have to be considered.",0
", M. TSICU 5:27 AM CHEST (PORTABLE AP) Clip # Reason: ?",0
pulm status and ETT placement Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with respiratory distress and pancreatitis or splenic hematoma REASON FOR THIS EXAMINATION: ?,1
pulm status and ETT placement ______________________________________________________________________________ PFI REPORT ET tube is 2.2 cm above the carina.,0
Moderate-to-large bilateral pleural effusions larger on the left side are unchanged and associated with adjacent atelectasis.,0
"7:35 PM ABDOMEN (SUPINE ONLY) PORT Clip # Reason: confirm NGT placement Admitting Diagnosis: RESPIRATORY FAILURE,UROSEPSIS ______________________________________________________________________________ MEDICAL CONDITION: year old woman with poor po intake - NGT for TF REASON FOR THIS EXAMINATION: confirm NGT placement ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old woman with poor p.o.",1
"intake, NG tube for tube feeds.",0
COMPARISON: Chest x-ray performed two days prior.,0
FINDINGS: There has been interval placement of a nasogastric tube with the tip just entering the fundus of the stomach.,0
The bowel gas pattern demonstrates no evidence of obstruction.,0
There is no evidence of free intraperitoneal air on this supine only study.,0
Bilateral pleural effusions and left greater than right consolidations are again noted.,0
Scattered likely vascular calcifications are demonstrated throughout the abdomen.,0
"IMPRESSION: Status post NG tube placement with the tip just reaching the fundus of the stomach, which should likely be advanced further for tube feedings.",0
"7:19 AM CHEST (PORTABLE AP) Clip # Reason: please compare with previous scans for resolution of pneumon Admitting Diagnosis: INTERCRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with intracranial hemorrhage, NGT, chest-tube now D/C'd REASON FOR THIS EXAMINATION: please compare with previous scans for resolution of pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Discontinuation of chest tube.",0
"SINGLE VIEW OF THE CHEST: Comparison with , shows no significant change.",0
There is minimal atelectasis at the left lung base.,0
The Dobhoff tube remains in satisfactory position.,0
"The lungs are otherwise clear, without effusions, infiltrates or vascular congestion.",0
Stable cardiac and mediastinal contour.,0
"5:14 AM CHEST (PORTABLE AP) Clip # Reason: evaluate process Admitting Diagnosis: BILATERAL ANKLE FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with recent pneumonia REASON FOR THIS EXAMINATION: evaluate process ______________________________________________________________________________ FINAL REPORT HISTORY: Recent pneumonia, evaluate.",1
A tracheostomy tube is in place.,0
"There is dense retrocardiac density, with obscuration of left hemidiaphragm, consistent with left lower lobe collapse and/or consolidation.",0
"There is vascular plethora, vascular blurring, and interstitial edema, consistent with CHF.",0
Equivocal minimal blunting of the right costophrenic angle.,0
"Compared with at 5:41 a.m., the overall appearance is similar.",0
Possible very slight interval improvement in the CHF findings.,0
"4:14 PM MR HEAD W & W/O CONTRAST Clip # Reason: AML,ALTERED MENTAL STATUS Admitting Diagnosis: ACUTE LEUKEMIA Contrast: MAGNEVIST Amt: ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with with AML s/p tx, now with persistent AMS REASON FOR THIS EXAMINATION: ro leptomeningeal disease or masses No contraindications for IV contrast ______________________________________________________________________________ WET READ: ASpf TUE 8:50 PM Normal head MRI.",1
d/w Swati at 8:50 pm on .,0
"______________________________________________________________________________ FINAL REPORT HISTORY: AML status 146 days post transplant in remission, now with persistent AMS.",1
Rule out leptomeningeal disease or masses.,0
The patient is s/p double cord allogeneic transplant in c/b GVHD and EGD c/w GVHD in gastric fundus.,1
Currently the patient is intubated for multifocal pneumonia and respiratory failure.,1
"TECHNIQUE: MRI of the brain was performed utilizing sagittal T1, axial T1, axial gradient, axial FLAIR, axial T2, and diffusion with ADC map sequences without contrast.",0
"After the administration of intravenous contrast, coronal, axial and sagittal T1-weighted sequences were performed.",0
COMPARISON: MRI of the brain .,0
"FINDINGS: Within the right cerebellar hemisphere, a new enhancing 8 mm x 3 mm focus of FLAIR hyperintensity is present without associated slow diffusion, surrounding edema or mass effect.",0
The ventricles and sulci are normal in caliber and configuration.,0
"Stable minimal periventricular confluent T2 prolongation is present predominantly surrounding the frontal horns of the lateral ventricles, most likely representing sequela of chronic small vessel ischemic disease.",0
No diffusion abnormalities are detected.,0
Interval development of fluid filling bilateral mastoid air cells and paranasal sinuses as follows: Fluid fills the bilateral mastoid air cells without abnormal surrounding diffusion signal.,1
There is near complete fluid filling of multiple anterior ethmoid air cells.,0
Moderate layering fluid is also present within the nasopharynx.,0
The frontal sinuses demonstrate minimal mucosal thickening.,0
New solitary 8-mm focus of FLAIR-hyperintensity and enhancement in the right cerebellar hemisphere without significant surrounding edema or mass effect.,0
"Given the immunocompromise, multifocal pneumonia and GVHD, the most likely etiology is infection, likely opportunistic and/or septic embolic, possibly related to the patient's pulmonary disease or possibly an indwelling catheter.",1
"Another more remote possibility is a focus of small vessel (Over) 4:14 PM MR HEAD W & W/O CONTRAST Clip # Reason: AML,ALTERED MENTAL STATUS Admitting Diagnosis: ACUTE LEUKEMIA Contrast: MAGNEVIST Amt: ______________________________________________________________________________ FINAL REPORT (Cont) involvement related to GVHD.",1
The absence of surrounding edema or mass effect may relate to the immunosupression.,0
"Mild periventricular white matter disease, stable, without enhancement and likely representing sequelae of chronic small vessel ischemic disease.",0
"New fluid-opacification of bilateral mastoid air cells and multiple anterior ethmoid air cells, as well as layering fluid within the nasopharynx.",1
"Though this likely is ""passive,"" related to intubation and supine positioning, superimposed infection cannot be excluded completely.",0
"COMMENT: The above impression was discussed in detail with Dr at 10 am and then again, at 1:30 pm, on .",0
9:50 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"R ptx Admitting Diagnosis: POST OPERATIVE BLEEDING ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with shortness of breath, s/p attempted R thoracentesis REASON FOR THIS EXAMINATION: ?",0
"R ptx ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY, COMPARISON: .",0
"Moderate right pleural effusion is without change as well as adjacent right middle and lower lobe opacities, likely atelectasis.",0
Increasing linear opacities are present in the left lower lung suggestive of discoid atelectasis.,0
Mild perihilar haziness has developed consistent with mild fluid overload or early CHF.,0
IMPRESSION: No pneumothorax following thoracentesis attempt.,0
Persistent moderate right pleural effusion.,0
8:33 AM CHEST (PORTABLE AP) Clip # Reason: Please check placement of right basilic PICC line.,0
"Please pa Admitting Diagnosis: ASPERGILLOSIS\BRONCHOSCOPY RIGID; FLEXIBLE ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with fresh trach,aspergillosis REASON FOR THIS EXAMINATION: Please check placement of right basilic PICC line.",0
Please page IV nurse wet thanks # ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: Tracheal aspergillosis.,0
FINDINGS: A single AP semi-upright view.,0
The new right upper extremity PICC line tip is well positioned in the mid SVC.,0
No significant complications can be identified.,0
The appearances of the heart and pulmonary vessels are unremarkable.,0
No pulmonary infiltrates are identified.,0
There is no evidence of any effusion.,0
A tracheostomy tube remains in good position.,0
IMPRESSION: Satisfactory placement of PICC line.,0
Tracheostomy remains in good position.,0
7:31 AM CHEST (PORTABLE AP) Clip # Reason: r/o inf Admitting Diagnosis: MR\MITRAL VALVE REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with MR s/p MVR.,1
"REASON FOR THIS EXAMINATION: r/o inf ______________________________________________________________________________ FINAL REPORT CHEST, ONE VIEW, PORTABLE INDICATION: 65-year-old woman status post MVR.",0
"COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with previous study of yesterday.",0
The patient is status post MVR and median sternotomy.,0
The tip of the endotracheal tube is identified at thoracic inlet.,0
Bilateral chest tubes and mediastinal drain remain in place.,0
The right jugular Swan-Ganz catheter terminates in the right main PA. No pneumothorax is seen.,0
There is also slight improvement of the atelectasis in both lower lobes.,0
A nasogastric tube remains in place.,0
"4:32 AM CHEST (PORTABLE AP) Clip # Reason: r/o acute intrathoracic process ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with myasthenia , temp to 103, altered MS REASON FOR THIS EXAMINATION: r/o acute intrathoracic process ______________________________________________________________________________ FINAL REPORT INDICATION: History of myasthenia with fevers to 103 degrees and altered mental status.",1
Evaluate for acute intrathoracic process.,0
COMPARISON: CT chest from .,0
"FINDINGS: Retrocardiac opacification could be due to atelectasis, although an infectious process cannot be excluded.",0
There is minimal right basilar atelectasis.,0
Pulmonary vascular congestion is seen without evidence of interstitial pulmonary edema.,0
A small left pleural effusion is possible.,0
There is no right pleural effusion.,0
Left retrocardiac opacification could be atelectasis or infection.,0
Pulmonary vascular congestion without evidence of interstitial edema.,0
Possible small left pleural effusion.,0
"11:29 PM CHEST (PORTABLE AP) Clip # Reason: 88 yo female, s/p intubation in field for copd flare assess ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with copd REASON FOR THIS EXAMINATION: 88 yo female s/p intubation in field for copd flare assess placement ______________________________________________________________________________ FINAL REPORT HISTORY: 88 year old woman with COPD flare.",0
PORTABLE CHEST: The tip of an endotracheal tube is seen at the level of the carina.,0
The tube should be pulled back approximately 4 cm.,0
There is a left subclavian line with its tip in the superior vena cava.,0
There is no pneumothorax seen.,0
"The cardiac, hilar and mediastinal silhouettes are within normal limits for size.",0
Endotracheal tube in unsatisfactory position and should be pulled back approximately 4 cm.,0
11:10 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
CHF ______________________________________________________________________________ MEDICAL CONDITION: History: 70M with chest pain REASON FOR THIS EXAMINATION: ?,0
"CHF No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old man with chest pain, assess for CHF.",0
PORTABLE CHEST RADIOGRAPH: Persistent left greater than right basal streaky opacities likely reflect atelectasis which cleared to some degree on the subsequent study.,0
No focal consolidation is seen with mild vascular congestion less pronounced than on the previous examination.,0
No pleural effusion or pneumothorax is identified on this portable AP view.,0
The heart is likely top normal in size with intact median sternotomy wires and otherwise normal cardiomediastinal silhouette.,0
Slight right sided indentation of the trachea may reflect thyroid goiter.,0
IMPRESSION: Mild vascular congestion without overt edema.,0
"2:59 PM CAROTID SERIES COMPLETE Clip # Reason: Please assess for carotid disease Admitting Diagnosis: LUNG MASS, DIVERTICULAR ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with MS changes REASON FOR THIS EXAMINATION: Please assess for carotid disease ______________________________________________________________________________ FINAL REPORT CAROTID STUDY DATED .",0
FINDINGS: There is no appreciable plaque or wall thickening involving either carotid system.,0
The peak systolic velocities fall within the lower arrange.,0
There is antegrade flow involving both vertebral arteries.,0
"IMPRESSION: No appreciable plaque or wall thickening, diffuse low velocities throughout suggesting cardiac dysfunction.",0
4:22 PM BABYGRAM (CHEST ONLY); -77 BY DIFFERENT PHYSICIAN # Reason: PICC line placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with PICC line REASON FOR THIS EXAMINATION: PICC line placement ______________________________________________________________________________ FINAL REPORT EXAMINATION: Babygram.,0
CLINICAL HISTORY: The patient is two-day old baby who is here for evaluation of PICC line placement.,0
"COMPARISON: Comparison is made to prior examination dated , time 15:35.",0
FINDINGS: Again noted is PICC line with its tip located in the right atrium at T5 level.,0
"The patient is rotated to the right side, somewhat limiting evaluation of lungs.",0
"However, there is a mild ground-glass opacity, perhaps representing mild degree of Hyaline Membrane Disease.",0
"No focal consolidation, pleural effusion, or pneumothorax is seen.",0
Endotracheal tube with its tip located at the level of thoracic inlet is seen.,0
Heart size and mediastinal contours are difficult to assess but most likely stable from prior examination.,0
"Bowel gas pattern in the visualized abdomen is nonobstructive without evidence of pneumatosis, portal venous gas, abnormal calcification, or focal dilatation of small bowel loops.",0
PICC line with its tip located at T5 level.,0
The findings were discussed with the clinician taking care of this patient at the time of dictation.,0
"Mild opacity in both lungs, which may represent mild hyaline membrane disease.",0
"9:07 AM CHEST (PORTABLE AP) Clip # Reason: et tube placement Admitting Diagnosis: H/O DVT, LEG SWELLING ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with hypotension/sepsis, GI bleed, and renal failure.",0
Now s/p insertion of R IJ line for dialysis.,0
"REASON FOR THIS EXAMINATION: et tube placement ______________________________________________________________________________ FINAL REPORT CHEST 1 VIEW PORTABLE: INDICATION: 62 y/o man with hypotension, GI bleeding.",0
"COMMENTS: Portable semi-erect AP radiographs of the chest is reviewed, and compared with the previous study of yesterday.",0
The tip of the ETT is identified at thoracic inlet.,0
Bilateral jugular IV catheters remain in place.,0
There is continued moderate pulmonary edema with bilateral small pleural effusions.,0
An NG tube terminates in the gastric body.,0
2:07 AM CT HEAD W/O CONTRAST Clip # Reason: S/P FALL WITH LOC - ?,0
SDH ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with REASON FOR THIS EXAMINATION: s/p mechanical fall No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Mechanical fall.,0
TECHNIQUE: Noncontrast axial images were obtained from the skull base to the vertex.,0
"CT OF THE HEAD WITHOUT IV CONTRAST: There is a large cisterna magna, and possible inferior hypoplasia, suggestive of a Dandy Walker malformation.",0
"In addition there is mild ventricualr dilatation, with a somewhat dysmorphic appearance of the cerebral hemispheres, possibly due to callosal dysgenesis.",0
"There is no mass effect, shift of the normally midline structures, intra-axial or extra- axial hemorrhage, or hydrocephalus.",0
"The osseous structures, paranasal sinuses and soft tissues are unremarkable.",0
No evidence of acute intracranial hemorrhage or edema.,0
"Dandy-Walker malformation/variant, with possible additional brain anomalies, as noted above.",0
MRI would be an ideal follow-up study to more clearly assess these issues.,0
Height: (in) 62 Weight (lb): 192 BSA (m2): 1.88 m2 BP (mm Hg): 148/88 HR (bpm): 75 Status: Inpatient Date/Time: at 15:42 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.,0
TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.,0
"By report, compared to the study of , there is no significant change.",0
Clip # Reason: UTI RULE OUT HYDRONEPHROSIS Admitting Diagnosis: URINARY TRACT INFECTION;CELLULITIS;HYPERGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with UTI REASON FOR THIS EXAMINATION: rule out hydronephrosis ______________________________________________________________________________ FINAL REPORT RENAL ULTRASOUND CLINICAL INDICATION: Urinary tract infection.,1
The right kidney measures 10.7 cm in length and the left kidney 10.3 cm.,0
There are no stones or signs of hydronephrosis or any perinephric fluid collections seen.,0
"Both kidneys, however, show increased echogenicity in the cortical tissues.",0
This was also noted on the prior scan in and the appearance is essentially unchanged.,0
The bladder is emptied via a Foley catheter.,0
CONCLUSION: No evidence of stones or fluid collections.,0
"Normal-sized kidneys, but increased echogenicity consistent with some form of diffuse parenchymal disease, unchanged since .",1
"3:35 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: interval progression Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with tracheostomy, with acute onset SOB and wheeziness REASON FOR THIS EXAMINATION: interval progression ______________________________________________________________________________ FINAL REPORT CHEST ON .",0
"HISTORY: Tracheostomy, acute-onset shortness of breath.",0
"FINDINGS: Compared to the film from earlier the same day, there is no significant interval change in the appearance of the lungs or tracheostomy tube.",0
The gastric bubble appears slightly distended.,0
"5:33 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with L chest tube, s/p esophagectomy REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:41 A.M., .",0
HISTORY: Left chest tube following esophagectomy.,0
"IMPRESSION: AP chest compared to , 5:55 p.m.: Previous atelectasis simulating thickening of the minor fissure has substantially improved.",0
Fullness in the adjacent mediastinum is probably a combination of mediastinal vascular engorgement and distention of the gastric pull-up.,0
Cardiac portion of the mediastinum is mildly enlarged and unchanged.,0
Atelectasis in the left lung is relatively mild.,0
The pleural sulci are excluded from the examination but pleural effusion if any is not relatively small.,0
There is no indication of pneumothorax.,0
"Location of the tip of the right subclavian infusion port is still uncertain, and may not be in a central vein.",0
Nasogastric tube passes below the diaphragm and out of view.,0
"Left pleural tube unchanged in position, still impinging on the mediastinum.",0
PATIENT/TEST INFORMATION: Indication: Intra-op TEE for LAA excision and PVI Height: (in) 73 Weight (lb): 180 BSA (m2): 2.06 m2 BP (mm Hg): 100/60 HR (bpm): 85 Status: Inpatient Date/Time: at 15:10 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.,0
No thrombus in the LAA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.,0
MITRAL VALVE: Elongated mitral valve leaflets.,1
No MS. Physiologic MR (within normal limits).,0
The mitral valve leaflets are elongated.,1
"POST LAA Excision: No significant residual LAA is detected by 2D, 3D or by color flow doppler.",0
Non turbulent flow seen in Pulmonary veins.,0
", J. NSURG TSICU 8:40 AM CT HEAD W/O CONTRAST Clip # Reason: eval interval change in subdural hematoma and cerebellar int Admitting Diagnosis: S/P PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 17 year old man s/p pedestrian struck by motor vehicle REASON FOR THIS EXAMINATION: eval interval change in subdural hematoma and cerebellar intraparenchymal hemorrhage; please do around 6-7am No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No interval change.",1
"4:48 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please assess for ET tube placement and other abnromalities Admitting Diagnosis: VFIB ARREST ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p vfib arrest, now intubated.",0
REASON FOR THIS EXAMINATION: please assess for ET tube placement and other abnromalities ______________________________________________________________________________ WET READ: GMSj TUE 11:33 PM ET 4.6 cm from carina.,0
Rt IJ ending at mid SVC.,0
Reticular opacities in the lung bases persist and may reflect ongoing pulmonary edema as central venous congestion is still evident.,0
Other possibilities include chronic interstial lung disease.,1
Stable small bilateral pleural effusions and bibasilar atelectasis.,0
GSenapati ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Assessment for endotracheal tube placement and other abnormalities.,0
FINDINGS: The tip of the endotracheal tube projects 4.6 cm from the carina.,0
The nasogastric tube is in the stomach.,0
Right internal jugular vein catheter ends in the mid SVC.,0
"There is no pneumothorax, reticular opacities in the lung bases persist and may reflect ongoing pulmonary edema as central venous fluid overload is still evident.",0
Stable small bilateral pleural effusions and bilateral areas of atelectasis.,0
"6:10 PM CHEST (PORTABLE AP) Clip # Reason: Eval ETT placement - Thanks Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man s/p Fall w/ head injury REASON FOR THIS EXAMINATION: Eval ETT placement - Thanks ______________________________________________________________________________ FINAL REPORT INDICATION: 29-year-old status post fall with head injury, evaluate endotracheal tube placement.",0
PORTABLE AP SUPINE CHEST: No priors for comparison.,0
"Endotracheal tube identified, with its tip 4.5 cm above the carina.",0
The aortic arch is sharp.,0
"The lungs are clear without evidence of consolidation, effusion, or contusion.",0
Visualized osseous structures demonstrate no evidence of fracture.,0
IMPRESSION: 1) Endotracheal tube with its tip 4.5cm above the carina.,0
2) No evidence of acute traumatic injury.,0
3:45 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: clamping trial Admitting Diagnosis: RIGHT LUNG LESION\RADIO FREQUENCY ABLATION RIGHT LUNG W/BIOPSY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with REASON FOR THIS EXAMINATION: clamping trial ______________________________________________________________________________ FINAL REPORT HISTORY: Clamping trial.,0
"FINDINGS: In comparison with the earlier study of this date, there is no interval change following tube clamping.",0
"12:22 PM CHEST (PORTABLE AP) Clip # Reason: please eval for pneumothorax, pericardial effusion, and inte Admitting Diagnosis: GROSS HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with bilateral masses, pleural effusions, and fluid-filled cysts on imaging s/p removal of R pleural catheter.",1
"REASON FOR THIS EXAMINATION: please eval for pneumothorax, pericardial effusion, and interval change ______________________________________________________________________________ FINAL REPORT HISTORY: 87-year-old male with bilateral masses, pleural effusions, and fluid filled cysts, now status post removal of right pleural catheter.",1
COMPARISON: Chest radiograph of .,0
UPRIGHT PORTABLE CHEST X-RAY: The patient is status post removal of a right pleural drain and a right PICC.,0
"Since four days prior, there is now re- accumulation of a large left pleural effusion.",1
The left cyst now contains air and appears smaller but this may be due to patient positioning.,0
Small right pleural effusion is present and the large left basilar cyst is now fluid- filled.,1
The upper lungs are clear with no pneumothorax.,0
"Although the left heart border is obscured by pleural effusion, the heart size is enlarged and likely unchanged.",1
"8:05 AM CHEST (PORTABLE AP) Clip # Reason: pna, aspiration Admitting Diagnosis: C SPINE FRACTURE,FRONTAL SINUS FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p motor scooter accident rising WBC, thick sputum, on vent REASON FOR THIS EXAMINATION: pna, aspiration ______________________________________________________________________________ FINAL REPORT STUDY: Chest radiograph.",1
INDICATION: Patient with pneumonia status post vascular accident.,1
REPORT: The patient has a tracheostomy tube in situ with its tip approximately 5 cm above the carina.,0
A nasogastric feeding tube lies with its tip point towards the pylorus in good position.,0
A left-sided subclavian line is in situ.,0
The patient's cervical spine fixation hardware is poorly visualized on current study.,0
The heart is within normal limits of size.,0
"Persistent changes are identified in the left costophrenic sulcus, where there is increased opacification likely representing underlying effusions.",0
This has not changed in the interval from previous examination.,0
Satisfactory placement of tubes and lines.,0
"7:49 AM CHEST (PORTABLE AP) Clip # Reason: 20 yo with severe sepsis; intubated, sedated with swan; plea ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man with NO PRIOR MEDICAL HISTORY, pneumonia, ARDS, high fiO2, follow up film REASON FOR THIS EXAMINATION: 20 yo with severe sepsis; intubated, sedated with swan; please evaluate change in infiltrates and position of swan ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARED TO ONE DAY EARLIER.",0
An endotracheal tube and nasogastric tube are in satisfactory position.,0
A Swan-Ganz catheter terminates in the right ventricular outflow tract region.,0
The cardiac and mediastinal contours are normal.,0
"The lungs reveal multifocal alveolar opacities, diffuse and patchy in the right lung and confluent within the left perihilar and retrocardiac regions.",0
"Overall, the opacities appear slightly worse in the right lung.",0
"There remains asymmetric apical thickening left greater than right which may be due to associated pleural fluid, particularly at the left apex.",0
"IMPRESSION: Bilateral asymmetric alveolar pattern, slightly worse in the interval in the right lung.",0
This may be due to pneumonia complicated by ARDS.,0
"9:58 PM UNILAT UP EXT VEINS US LEFT PORT Clip # Reason: LEFT Admitting Diagnosis: OVERDOSE,ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with swelling of left upper extremity, with recently placed left subclavian line REASON FOR THIS EXAMINATION: Clot in left subclavian vein ______________________________________________________________________________ FINAL REPORT INDICATION: Swelling of the left upper extremity with recently placed left subclavian line.",0
"Grayscale and Doppler son of the left internal jugular, subclavian, axillary and brachial veins were performed.",0
The cephalic and basilic veins were not visualized.,0
"Normal flow, waveforms and compression where appropriate are demonstrated within the examined vessels.",0
The patient's central venous catheter is seen within the left subclavian vein medially.,0
There is no evidence of thrombus where the catheter is visualized.,0
IMPRESSION: No evidence of DVT in the left upper extremity.,0
Please note that the superficial veins including the cephalic vein and basilic vein were not visualized.,0
"3:51 AM CHEST (PORTABLE AP) Clip # Reason: interval change, confirm placement of Dubhoff Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man s/p liver transplant, extubated REASON FOR THIS EXAMINATION: interval change, confirm placement of Dubhoff ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Assessment of the patient after liver transplantation.",1
The major change since the prior study is progression of vascular engorgement/currently mild to moderate interstitial edema.,1
Bibasal linear atelectasis are unchanged.,0
The patient was extubated with removal of the NG tube and the Dobbhoff tube.,0
The left internal jugular line tip is at the level of superior SVC.,1
Right internal jugular has been removed.,1
Height: (in) 68 Weight (lb): 210 BSA (m2): 2.09 m2 BP (mm Hg): 115/65 HR (bpm): 83 Status: Inpatient Date/Time: at 16:07 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
No MR. Normal LV inflow pattern for age.,0
"5:40 AM T-SPINE; L-SPINE (AP & LAT) Clip # Reason: S/P MVA ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man s/p trauma REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ FINAL REPORT HISTORY: Trauma, MVA.",1
"THORACIC SPINE, TWO VIEWS: There is an anterior wedging deformity of the T12 vertebral body.",1
"LUMBAR SPINE, TWO VIEWS: The anterior wedging deformity and fracture of T12 is again noted.",1
There is no spondylolisthesis in the lumbar spine.,0
9:40 AM PICC LINE PLACMENT SCH Clip # Reason: Requesting IR guided PICC placement.,0
PICC nurse unsuccessful Admitting Diagnosis: PNEUMONIA This is a power pick ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with Downs, Alzheimers, pneumonia requiring long term IV antibiotics.",0
REASON FOR THIS EXAMINATION: Requesting IR guided PICC placement.,0
PICC nurse unsuccessful in R arm.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old male with Down's syndrome and Alzheimer's, with pneumonia requiring long-term intravenous antibiotics.",1
"RADIOLOGISTS: Dr. , nurse , Dr. (present and supervising).",0
PROCEDURE/FINDINGS: The patient was brought to the angiography suite and placed supine on the table.,0
A preprocedure huddle and timeout were performed as per protocol.,0
The patient's right upper extremity was prepped and draped in the usual sterile fashion.,0
The chosen puncture site was anesthetized with a 1% lidocaine solution.,0
"Under ultrasound guidance, with hard copy images on file, the right basilic vein was accessed with a micropuncture needle, following which a guidewire was threaded through the needle and into the axillary vein.",0
"The needle was then exchanged for a micropuncture sheath, following which the guidewire was removed and a 110-cm nitinol wire was threaded through the sheath until its tip was within the distal SVC.",0
Appropriate measurements were taken and a double-lumen PowerPICC was cut to the appropriate length of 33 cm.,0
The PICC was then advanced over the wire until its tip was within the distal SVC.,0
The wire was removed and confirmation of the PICC tip position was made with a fluoroscopic spot view of the chest.,0
Both ports were aspirated and flushed with sterile saline.,0
The PICC was secured to the patient's arm with a StatLock device and sterile dressing.,0
"The patient tolerated the procedure well, with no immediate post-procedural complications.",0
The total fluoroscopy time was 7.6 minutes and the radiation dose was 80 mGy.,0
IMPRESSION: Successful placement of a 33-cm double-lumen PowerPICC via a right basilic vein approach.,0
The tip of the catheter is in the distal SVC.,0
"7:20 AM CHEST (PORTABLE AP) Clip # Reason: evaluate lung fields Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION/CATH ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man s/p STEMI c/b cardiogencic shock now with swan, productive sputum.",1
REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT AP CHEST 7:57 A.M.: HISTORY: Cardiogenic shock after MI.,1
"IMPRESSION: AP chest compared to chest films since , most recently : Lung volumes are lower compared to , moderate bilateral pleural effusions and severe enlargement of the cardiac silhouette are stable.",0
Mild edema and atelectasis are confined to the lower lobes.,0
The upper lobes are largely clear.,0
Tip of the Swan-Ganz catheter which traverses a left subclavian introducer projects over the main pulmonary artery.,0
4:15 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate placement of RIJ.,0
"Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with h.o BMT for CLL a/w F/N, ?",0
"infiltrate, now with acute SOB and desat with hemoptysis.",0
REASON FOR THIS EXAMINATION: Evaluate placement of RIJ.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Bone marrow transplant with fever and neutropenia, shortness of breath and hemoptysis, evaluate placement of right internal jugular line.",0
VIEWS: AP semierect view compared with AP supine views taken approximately two hours earlier.,0
FINDINGS: There has been interval removal of the right internal jugular line.,0
There is interval placement of a left internal jugular central venous line with tip terminating in the proximal superior vena cava.,0
"The cardiac, mediastinal, and hilar contours remain unchanged.",0
The diffuse bilateral reticular-nodular opacities appear more diffuse on this current study suggesting slight worsening.,0
There is persistent left lower lobe collapse and consolidation.,0
Satisfactoy placement of left internal jugular central venous line.,0
More diffuse appearance of bilateral diffuse reticulonodular opacities suggesting slight worsening of pulmonary edema or alveolar hemorrhage.,0
Persistent left lower lobe collapse/consolidation.,0
"5:53 AM MR HEAD W/ CONTRAST Clip # Reason: pre-surgical mapping for bilateral craniotomy and cranioplas Contrast: MAGNEVIST Amt: 14 ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man with small frontal tumor REASON FOR THIS EXAMINATION: pre-surgical mapping for bilateral craniotomy and cranioplasty No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Small frontal tumor, surgical mapping for bilateral craniotomy and cranioplasty.",0
COMPARISON: MR head done on .,0
TECHNIQUE: Limited MR of the head with post-contrast images.,0
"FINDINGS: Previously noted focal lesion in the right parietal bone at the vertex, approx.",0
"1.4x3.0cm (series 5002, image 104) is redemonstrated for surgical planning.",0
Assessment and cahracterization on the present study is limited due to lack of pre-contrast routine sequences.,0
IMPRESSION: Redemonstration of the lesion in the right parietal bone at the vertex for surgical planning.,0
see prior MR study and report for details reg.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: headache and weakness Major Surgical or Invasive Procedure: EVD placement History of Present Illness: 78 yo RHM with history of left parietal stroke in , aflutter s/p ablation, on coumadin, pacer, HTN, DM, OSA, presenting with one day history of headache and generalized weakness.",1
"As per patient's wife, he was in his usual state of health yesterday until bedtime, around 10 PM when he had a mild bifrontal headache and had difficulty getting in and out of bed.",0
"Neither he nor his wife noted any lateralizing weakness, and he went to bed and again had difficulty, requiring assistance when going to use the bathroom, needing to hold onto the wall, but did not fall.",0
He had a mild headache this AM and felt diffusely weak and went to and there he was recommended to go to ED for further evaluation.,0
"Upon arrival, he was mildly drowsy and with a mild bifrontal headache.",0
"A CT head revealed an acute right basal ganglia, anterior thalamus, choroid plexus and intraventricular hemorrhage with layering in the occipital horns with mild ventricular dilatation, and a neurological consult was requested after the imaging study was performed.",1
"Since returning from CT, the wife notes the patient has been more drowsy and confused, frequently falling off to sleep and appearing more disoriented.",0
His blood pressure has been more elevated as well (140s-160s systolic prior to CT and since has been 180s-200s despite 10 mg hydralazine).,0
"ROS negative for visual changes, dizziness, speech changes, lateralizing weakness or sensory changes, bowel or bladder changes.",0
"No recent fevers, chills, cough, chest pain, shortness of breath, diaphoresis, nausea, vomiting, diarrhea, or constipation.",0
"Past Medical History: PMHx; -left parietal stroke in with resulting cognitive changes such as difficulty with numbers, word retrieval, and occasional stuttering as well as right lower quadrantsonopia.",0
Patient had small bleed upon initiation of anticoagulation after stroke.,0
-seizures in and presumed to be secondary to stroke- one GTC and one with unilateral shaking and speech arrest followed by weakness (wife unaware of which side).,0
"Second seizure occurred in setting of AED wean and none since resumed at prior dose -aflutter s/p ablation, on coumadin -pacemaker -DM -HTN -GERD -OSA on CPAP -glaucoma Social History: Social History; -catholic priest, had been a social worker, quit after stroke in .",1
No history of tobacco or etoh.,0
"Lives with wife, , or Family History: Family History; -brother with stroke in late 60s, father with disease Physical Exam: Physical Examination; VS; BP 202/154 P 67 RR 21 96% on 2L General: Awake, cooperative, NAD.",0
"HEENT: NC/AT, MMM, oropharynx clear Neck: No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl.",1
"S1S2 Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted.",0
"Neurologic: -Mental Status: Drowsy, requiring frequent stimulation to remain awake, and repeatedly closing eyes.",0
States date is is ED.,0
Can do DOY forward but not backwards.,0
Speech mildly slurred but able to repeat a sentence.,0
Occasional paraphasic errors and names objects correctly.,0
Unable to state which holiday occurred last week.,0
-Cranial Nerves: I: Olfaction not tested.,0
II: PERRL 3 to 2mm and brisk.,0
Blinks to threat in all quadrants.,0
"III, IV, VI: EOMI without nystagmus.",0
V: Facial sensation intact to light touch.,0
VII: L NLF flattening and decreased activation on L with smile VIII: Hearing intact to finger-rub bilaterally.,0
"IX, X: Palate elevates symmetrically.",0
: 5/5 strength in trapezii and SCM bilaterally.,0
XII: Tongue protrudes in midline.,0
"-Motor: Normal bulk, tone throughout.",0
Uncooperative with formal strength testing but able to maintain all extremities antigravity against resistance.,0
-Sensory: Intact to light touch and pinprick throughout.,0
"-DTRs: Tri Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was extensor on left, mute on right.",0
-Coordination: No dysmetria on FNF b/l.,0
"-Gait: deferred Pertinent Results: 03:02PM PLT COUNT-190 03:02PM NEUTS-53.6 LYMPHS-37.7 MONOS-5.8 EOS-2.5 BASOS-0.4 03:02PM WBC-6.0 RBC-4.48* HGB-13.8* HCT-39.0* MCV-87 MCH-30.8 MCHC-35.4* RDW-13.6 03:02PM cTropnT-<0.01 03:02PM CK(CPK)-87 11:39PM PT-20.3* PTT-23.9 INR(PT)-1.9* 11:44PM LACTATE-2.3* 11:44PM TYPE-ART PO2-187* PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 Brief Hospital Course: 78 yo RHM with history of left parietal stroke in , aflutter s/p ablation, on coumadin, pacer, HTN, DM, OSA, presenting with one day history of headache and generalized weakness, and found to have acute right basal ganglia hemorrhage on CT head with IVH in 3rd ventricle, layering of occipital horns, and moderate ventricular dilitation.",1
The hemorrhage may have been secondary to hypertension in setting of anti-coagulation.,1
INR was reversed with 2 units FFP and 10 mg vit K in ED.,0
"Shortly after initial CT head, he was found to become more drowsy, requiring frequent stimulation to maintain arousal, and hypertensive (>200 systolic), requiring nicardipine drip.",0
"Repeat CT head did not show significant change, with mild improvmeent in alertness after blood pressure control, however constellation of symptoms as well as CT head were concerning for possible obstructive hydrocephalus; patient had an EVD placed and removed; his repeat head CT showed hydrocephalus which neurosurgery decided not to further intervene on as patient was clinically stable; hydrocephalus remained stable.",1
HOSPITAL COURSE BY SYSTEM: Neurologic: Patient's CT consistent with R basal ganglia hemorrhage on CT head s/p EVD placement.,0
Patient was kept on q 1 neuro checks then q 2 hour.,0
Patient was started on keppra for seizure with past seizure history.,0
Repeat NCHCT was stable initially; .,0
Transferred to floor on .,0
Head CT showed hydrocephalus which neurosurgery decided not to further intervene on as patient was clinically stable; hydrocephalus remained stable.,0
"Cardiovascular: h/o atrial flutter, hypertension.",1
Started on On PO digoxin and PO cardizem for rate control.,0
Dig level 0.7 on .,0
"His BP should not be higher than 170; may give IV hydralizine PRN Pulmonary: Initially intubated for worsening mental status, extubated on .",0
Requiring lasix gtt for a short period.,0
"Gastrointestinal / Abdomen: no acute issues, was extubated on .",0
S/S evaluated that he needed nectar thickened liquids.,0
"Renal: Lasix gtt d/c'd, goal to stay euvolemic, may restart if needed.",0
Hematology: INR 2.5 s/p 2U FFP and vitamin K in the emergency room.,0
He was started on aspirin days after admission.,0
"RISS for now, adjust for goal FS<150 ID: MRSA+.",0
"He spiked to 101.3 while in ICU, he was on vanc/ceftaz for 5 day course (started ); complete.",0
He has been afebrile for several days.,0
Medications on Admission: -keppra 750 mg -diltiazem CD 180 daily -coumadin 5 mg daily -metformin 500 mg -gabapentin 100 mg qhs -omeprazole 20 mg daily -zoloft 100 mg daily -cosopt both eyes in AM -xalatan both eyes in PM Discharge Medications: 1. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)).,0
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime).,0
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever.,0
6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day).,0
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
9. diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
12. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
13. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: right basal ganglia hemorrhage with intraventricular extension Discharge Condition: awake, sometimes not oriented to time, left arm and leg weakness Discharge Instructions: You were presented to the hospital with headaches.",1
Your head images showed an acute right basal ganglia hemorrhage with intraventricular extension that was thought to have been secondary to hypertension in setting of anti-coagulation.,1
You had a ventricular shunt temporarily placed.,0
You were in ICU for a few days before being transferred to the floor.,0
"Followup Instructions: Provider: , .D.",0
"Phone: Date/Time: 4:00 MD, Completed by:",0
"1:29 PM G/GJ TUBE CHECK Clip # Reason: correct placement of G tube (changed AM) Admitting Diagnosis: PELVIC ABSCESS WITH PERFORATED VISCUS;FISTULA Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman s/p sigmoid colectomy, enterotomy repair REASON FOR THIS EXAMINATION: correct placement of G tube (changed AM) ______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old woman status post sigmoid colectomy, enterotomy repair, G-tube placement, assess for correct placement of G-tube.",0
G-TUBE CHECK: Water-soluble contrast (Optiray) was dripped into the recently placed G-tube.,0
Multiple spot images were obtained demonstrating the G-tube in the antrum.,0
There was no extraluminal leak of contrast.,0
There was prompt emptying of contrast into the duodenum.,0
Scout images revealed surgical drains overlying the pelvic cavity as well as the right side of the abdomen.,0
Also noted was an additional catheter overlying the pelvic cavity.,0
There was residual contrast noted in the colon.,0
IMPRESSION: G-tube in place in the antrum of the stomach without evidence of extraluminal leak of contrast.,0
"LINE PLACEMENT Clip # Reason: New left subclavian line, evaluate line placement.",0
Admitting Diagnosis: MALIGNANT VERTIBRAL NEOPLASM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with RCC c/b mets to c-spine s/p fusion.,1
"REASON FOR THIS EXAMINATION: New left subclavian line, evaluate line placement.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic renal cell carcinoma, status post cervical spine fusion.",0
Evaluate new left subclavian line placement.,0
PORTABLE CHEST: Left subclavian central venous catheter terminates in the mid superior vena cava.,0
An endotracheal tube terminates 7 cm above the carina.,0
"An endogastric tube courses below the diaphragm, terminating within the stomach.",0
"Retrocardiac consolidation is new, as is consolidation at the right lung base.",0
No definite pleural effusion or pneumothorax is seen.,0
Pulmonary vasculature has not significantly changed in the short interval.,0
Cervical spine hardware is partially imaged.,0
Gaseous distention of colonic loops are partially imaged in the abdomen.,0
"No pneumothorax, status post left subclavian central venous catheter placement.",0
New multifocal consolidations may represent aspiration or pneumonia.,0
11:07 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for pneumothorax and lead placement Admitting Diagnosis: VENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with VT s/p AICD revision procedure REASON FOR THIS EXAMINATION: Evaluate for pneumothorax and lead placement ______________________________________________________________________________ FINAL REPORT AP CHEST 11:51 A.M : HISTORY: V-tach after ICD revision.,1
Evaluate for pneumothorax or other complication.,0
IMPRESSION: AP chest compared to : Mild relative elevation of the left hemidiaphragm most likely due to basal atelectasis.,0
"No pneumothorax, pleural effusion, or mediastinal widening.",0
The cardiac apex is excluded from the study.,0
The course of right atrial lead is standard.,0
The ventricular lead passes beyond the plane of the tricuspid valve and out of view.,0
The proximal electrode spans the superior cavoatrial junction.,0
Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Hip fracture Major Surgical or Invasive Procedure: OPERATIVE PROCEDURE: 1.,0
"Closed reduction of right hip with open placement of dynamic hip screw, right hip.",0
"Examination under anesthesia with placement of splint, right elbow.",0
Exploratory laparotomy with drainage of intra-abdominal abscess and peritonitis with gross soilage with bile and gastric contents.,0
Exposure and wide drainage of perforated posterior duodenal ulcer with internal and external drainage.,1
Placement of a right femoral arterial line.,0
History of Present Illness: yo F with MMP (see below) who sustained a mechanical fall down stairs resulting in a hip and arm fracture.,1
Fall was witnessed by daughter.,0
"seizures, no LOC, no head or neck trauma.",0
"Patient denies CP, SOB, light headedness, or dizziness prior to of after the fall.",0
She fell on her R side and had a great deal of pain in her R arm and hip.,0
Presented to and found to have R humerus and R hip fx.,0
"Ct of head and neck neg for fx, bleed, and dislocation.",0
"Coronary artery disease status post non-ST-elevation myocardial infarction in , status post cardiac catheterization with left anterior descending artery stent placement in 05/.",1
CHF with an ejection fraction of 40-45% 3.,0
"Anemia, transfusion dependent every three months.",0
Chronic renal insufficiency with a b/l creatinine of 1.4.,0
History of syncope and first degree A-V heart block with beta blocker therapy.,0
History of lower gastrointestinal bleed in .,0
"Pacemaker- DDD dual chamber rate response pacemaker for symptomatic bradycardia Social History: Lives alone in , a daughter in the area, two children and exercises two times a week by walking and stretching.",0
"no, tob, no etoh, no drugs Family History: Noncontributory Physical Exam: at admission T 96.0 BP 177/61 P 70 R 18 O2 97 on RA Gen - somnolent, confused HEENT - PERRL, OP clear, EOMI Cor - rrr, no m/r/g Chest - CTAB anteriorly Abd - s/nt/nd +BS Ext - 2+ edema to knees, warm 2+ pulses, pain in R arm and R hip Pertinent Results: 06:00PM GLUCOSE-188* UREA N-48* CREAT-1.3* SODIUM-138 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 06:00PM CK(CPK)-32 06:00PM CK-MB-NotDone 06:00PM WBC-14.9*# RBC-2.91* HGB-8.5* HCT-24.7* MCV-85 MCH-29.3 MCHC-34.5 RDW-14.6 06:00PM NEUTS-87.9* BANDS-0 LYMPHS-6.3* MONOS-5.7 EOS-0.1 BASOS-0 06:00PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL 06:00PM PLT SMR-NORMAL PLT COUNT-216 06:00PM PT-13.3 PTT-26.4 INR(PT)-1.2 .",0
"EKG - NSR 64, 1st deg block, LAD, new TWI inf/lat leads, new ST depressions V4-6 .",0
The left ventricular wall thicknesses are normal.,0
There is mild regional left ventricular systolic dysfunction.,0
"Resting regional wall motion abnormalities include inferolateral , inferior and mid septal hypokinesis.",0
6.There is moderate pulmonary artery systolic hypertension.,1
"Compared with the findings of the prior study (tape reviewed) of , the LV function has improved with an improvementt in function of the apex, septal and anterior walls.",0
New inferior and inferolateral wall motion abnormalities with more severe mitral regurgitation present.,0
Coronary angiography demonstrated single vessel disease in a right dominant system.,0
The left main was normal.,0
"The LAD had serial 90% lesions proximally, involving the origin of the first diagonal, which was occluded and filled via left to left collaterals.",0
The mid-distal LAD was underfilled initially but was without obstructive disease.,0
The non-dominant circumflex system had no hemodynamically significant stenoses.,0
The dominant RCA was a large vessel with no significant disease.,0
Resting hemodynamics revealed elevated right and left sided filling pressures with a mean RA pressure of 12 mm Hg and a mean wedge pressure 24 mm Hg.,0
Moderate pulmonary hypertension was present with a PA of 52/28.,0
The cardiac index was preserved at 3.0 L/min/m2.,0
Left ventriculography was not performed due to the presence of moderate renal insufficiency (creatinine 1.6).,0
Successful PTCA and stenting of the proximal LAD with overlapping 2.25x13mm and 2.25x18mm Hepacoat stents with no residual stenosis or dissection and normal flow (see PTCA comments).,0
Moderately elevated right and left sided filling pressures.,0
Successful stenting of the proximal LAD.,0
TECHNIQUE: A multidetector scanner was used to obtain contiguous axial images from the lung bases to the pubic symphysis.,0
Neither IV nor oral contrast were used.,0
"CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are bilateral pleural effusions, right greater the left; there is compressive atelectasis at the left lung base.",0
There are coronary vascular calcifications.,0
A nasogastric tube is seen coiling in the stomach.,0
A dual chamber pacemaker is seen with leads terminating in the right atrium and right ventricle.,0
"Nasogastric tube is seen coiling in the stomach, with its tip at the pylorus.",0
"Allowing for the limitations of this noncontrast study, the liver, pancreas, adrenals, stomach are unremarkable.",0
A 1.8 cm exophytic renal cyst is seen on the left.,0
"A similar lesion is seen on the right, measuring 2.2 cm.",0
"The aorta is normal in caliber, with vascular calcifications.",0
"A small amount of free fluid is seen tracking around the liver, right pericolic gutter, along the mesentery and surrounding the right colon, which is collapsed.",0
A small amount of nondependent free air is seen in the anterior aspect of the abdomen.,0
"The remainder of the bowel loops are fluid filled, and nondilated.",0
"CT OF THE PELVIS WITHOUT IV CONTRAST: As previously noted, there is a small amount of free fluid surrounding the right colon, tracking along the mesentery and into the pelvis.",0
A small amount of free air is seen in the nondependent portion of the pelvis.,0
Vascular calcifications are seen in the abdominal aorta and iliac arteries.,0
Subcutaneous edema is noted in the lower abdomen and pelvis.,0
"A catheter is seen entering the left inguinal region and coursing along the iliac vessels, terminating in the left pelvis.",0
"Osseous structures are remarkable for degenerative changes of the spine, and a fracture of the proximal right humerus, with orthopedic hardware causing beam hardening artifact.",1
"A small amount of free air and free fluid in the pelvis and abdomen, mostly along the right pericolic gutter and surrounding the ascending colon, concerning for perforation.",0
Other bowel loops are unremarkable on this limited study.,0
"This was discussed with Dr. at approximately 6:30 p.m., .",0
"Bilateral pleural effusions, right greater than left, with left-sided compressive atelectasis.",0
Right proximal humeral fracture status post fixation.,1
DR. DR. Approved: FRI 4:01 PM Brief Hospital Course: yo F with MMP who sustained a mechanical fall down stairs resulting in a hip and arm fracture.,1
1) s/p Fall - unlikely to be mechanical in nature.,0
Patient has injuries to her shoulder and hip.,0
2) CV - Patient has CAD and CHF with a low hct and major trauma.,0
She also has new changes on EKG.On pressor to hold mean 60. .,0
3) Anemia - patient transfusion dependant with a baseline of 28.,0
"- transfuse 2 units today, with lasix .",0
4) GERD - PPI .,0
"5) DM- glipizide, ISS .",0
6) PMR - cont prednisone .,0
"7) GI:Ms. is an unfortunate year old woman, status post a recent fall necessitating right ORIF of the hip and right wrist fracture ORIF, who was in the hospital for this event, when it was noted that she had abdominal pain, distention and coffee ground emesis with worsening mental status and renal failure.",1
CT scan was obtained and this revealed free air and massive ascites.Pt underwent surgery on 1.,0
Continue to deteriorate spiking fevers with ventilatory support on pressors to hold the bp.,0
with no improvement in mental staus was made CMO 5/20/5.,0
Expired at 5pm Medications on Admission: lasix alt 40mg and 20mg qday levothyrox 50mcg qday lisinopril 5mg qday famotidine 20 mg qday fe so4 325mg qday asa 325mg qday toprol xl 25mg qday glipizide 5mg qday imdur 60mg qdau prednisone 5mg qday tylenol Discharge Disposition: Expired Discharge Diagnosis: MULTIORGAN FAILURE DUODENAL PERFORATION MULTIPLE TRAUMA Discharge Condition: deceased Followup Instructions: none Completed by:,1
"LINE PLACEMENT Clip # Reason: confirm placement of line, post-op Admitting Diagnosis: C6 FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: year old man with s/p fall REASON FOR THIS EXAMINATION: confirm placement of line, post-op ______________________________________________________________________________ FINAL REPORT STUDY: AP chest .",0
"CLINICAL HISTORY: -year-old man status post fall, for placement of line.",0
There has been placement of a right-sided subclavian catheter with distal lead tip in the mid SVC.,0
There is a cervical spinal hardware.,0
There is atelectasis of the lung bases.,0
There are no signs for overt pulmonary edema.,0
There is a feeding tube whose distal tip and side port are not well seen distally.,0
6:28 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with tachypnea REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE UPRIGHT CHEST AT 18:29 HOURS.,0
"FINDINGS: Relative to the prior exam, the lung volumes are diminished.",0
No consolidation or edema is evident.,0
Aortic tortuosity is again present and slightly exaggerated due to low lung volumes.,0
The cardiac silhouette is within normal limits for size.,0
The bones are profoundly and diffusely osteopenic but otherwise unremarkable.,0
IMPRESSION: Limited study due to low lung volumes with no definite pneumonia or edema appreciated.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: S/p arrest Major Surgical or Invasive Procedure: intubation and mechanical ventilation History of Present Illness: 68yo M no known signifigant PMH (no regular medical care) presents s/p arrest at son's house.,0
"History was obtained via son, since patient was intubated and unresponsive at time of arrival.",0
Patient was sitting in son's den watching TV today.,0
Son noted that he had to remind his father three times of the names of the teams playing in the game they were watching (MS very strong at baseline).,0
"Son left room and then returned to find patient ""blue"" and unresponsive, upright in chair.",0
to floor and began CPR.,0
rec'd CPR for 5 min.,0
"before EMS arrived, at which time he was found by EMS apnic and pulseless and in VFib.",0
Shocked at 200J x 1 --> asystole --> shock 200J times one --> narrow complex tach with pulses.,0
100mg Lidocaine bolus given followed by Lido drip.,0
"Taken to , where he recd Etomidate drip, Succinilcholine, Ativan, Nitro drip, rectal ASA.",0
Pt intubated after multiple attempts (failed intubation in field).,0
"On arrival to the ED, HR 107 BP 154/90 RR16 100%, intubated.",0
"ECG showed no ST segment elevations but atrial fibrillation, LVH and diffuse non-specific ST segment depressions.",1
CXR showed on prelim read wide mediastinum with BL basilar infiltrates and left sided air bronchogram.,0
"Pt was given 20.5mg Integrilin bolus followed by 113.6mcg/min, Heparin drip, Lidocaine 2mg/min drip, Plavix 600mg and Metoprolol 10mg IV.",0
"Of note, family reports that patient earlier complained of chest pain this afternoon.",0
"Medical history is otherwise unknown, since pt did not seek regular care.",0
"S/he denies recent fevers, chills or rigors.",0
S/he denies exertional buttock or calf pain.,0
CARDIAC RISK FACTORS: None known 2.,0
CARDIAC HISTORY: None -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3.,0
OTHER PAST MEDICAL HISTORY: Per family no signifigant PMH.,0
"Social History: -Tobacco history: per family, did smoke ""over 20 years ago"" -ETOH: None -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.",0
"Physical Exam: Admission: VS: T= 36.9 BP= 132/79 HR= 100 II RR= Intubated GENERAL: Obese, intubated, dusky, + barehugger.",0
"NECK: No bruits, no jvp.",0
PULSES: Weak radial pulses BL.,0
Pertinent Results: 08:44PM BLOOD WBC-14.1* RBC-4.95 Hgb-14.8 Hct-43.7 MCV-88 MCH-29.9 MCHC-34.0 RDW-15.6* Plt Ct-300 03:30AM BLOOD PT-14.5* PTT-146.0* INR(PT)-1.3* 12:35AM BLOOD Glucose-144* UreaN-19 Creat-1.4* Na-141 K-4.1 Cl-108 HCO3-17* AnGap-20 12:35AM BLOOD CK(CPK)-470* 09:05AM BLOOD CK(CPK)-609* 06:15PM BLOOD CK(CPK)-486* 05:28AM BLOOD CK(CPK)-300* 09:05AM BLOOD CK-MB-82* MB Indx-13.5* cTropnT-0.76* 06:15PM BLOOD CK-MB-82* MB Indx-16.9* 12:35AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 08:51PM BLOOD Comment-QNS FOR IO 03:54PM URINE Color-Yellow Appear-Clear Sp -1.014 03:54PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG 03:54PM URINE RBC-* WBC-* Bacteri-MOD Yeast-NONE Epi-0 03:54PM URINE CastGr-0-2 CastHy-* 9:00 pm SPUTUM Source: Endotracheal.,0
**FINAL REPORT ** GRAM STAIN (Final ): >25 PMNs and <10 epithelial cells/100X field.,0
2+ (1-5 per 1000X FIELD): BUDDING YEAST.,0
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.,0
RESPIRATORY CULTURE (Final ): MODERATE GROWTH OROPHARYNGEAL FLORA.,0
URINE CULTURE (Final ): NO GROWTH.,0
Blood Cx : Pending CXR: CONCLUSION: 1.,0
The NG tube appears to be folded on itself within the esophagus and should be repositioned.,0
The ET tube has its tip approximately 90 mm from the carina and needs repositioning.,0
Heart is enlarged and the mediastinum is widened.,0
"If there is clinical suspicion of mediastinal vascular injury, cross-sectional imaging is recommended.",0
Indistinct pulmonary vasculature may represent pulmonary edema.,0
Other possibilities like infection or aspiration are not excluded.,0
ECHO: The left and right atria are moderately dilated.,0
There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40 %).,0
Mild symmetric left ventricular hypertrophy with global biventricular hypokinesis.,0
"CT_Head: IMPRESSION: Very limited study without evidence for intracranial hemorrhage, loss of -white matter junction differentiation (where visualized), and demonstrating patent foramen magnum.",0
Recommend MR for more detailed evaluation of possible hypoxic injury.,0
EEG: Pending Brief Hospital Course: /: passed at 5:15am Family notified and decline autopsy : Pt made CMO Extubated and morphine gtt : -Neuro deciding whether need repeat Head CT -Running even -Re: asp pneumonia holding off on starting ABX unless he spikes (would start Levoflox) -Holding TF due to high residuals - Maintenance fluids initiated - IV Heparin stopped - Social work c/s for end of life coping issues - Having elev BP's 170's-190's likely response to inc intra-cranial pressure -Neuro Recs: No repeat Head CT unless he has a blown pupil -Fam will be here at 11am tomorrow for mtg .,0
"Cardiac Arrest: The patient was found ""blue"" and unresponsive by son.",1
CPR was initiated and EMS arrived within 5 minutes.,0
Patient was found by EMS apneic and pulseless and in VFib.,0
"Patient was intubated after multiple attempts, failed intubation in field.",0
He was transferred to the CCU and continued on heparin gtt and integrilin.,0
Je was initated on the hypothermia protocol to gaurd against cerebral reperfusion injusry for 24hrs.,0
The patient eventually converted to sinus rhythm and HR slowed to 40s.,0
"Per review of literature, this is normal for patient's undergoing cooling.",0
The patient was evaluated by neurology who initatied continuous EEG monitoring.,0
He also had a CT-head that showed no intracranial hemorrhage.,0
The patient completed 24hrs of cooling.,0
The EEG showed no cortical activity and neuro exam revealed little/no brainstem relfexes.,0
A family meeting was arranged and given his poor prognosis for meaningful recovery the family made the patient CMO.,0
He was extubated and placed on a morphine gtt.,0
The patient passed on at 5:15am.,0
"Medications on Admission: none Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Cardiac Arrest Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a MD, Completed by:",1
"4:15 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for pleural effusions Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with pneumonia, on HD REASON FOR THIS EXAMINATION: Evaluate for pleural effusions ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST CLINICAL INFORMATION: Pleural effusions, question pneumonia.",0
FINDINGS: Portable chest radiograph demonstrates a large-bore catheter on the right extending into the cavoatrial junction.,0
The left IJ catheter has been removed.,0
The left costophrenic angle has been omitted from the study.,0
There is patchy atelectasis at the left lung base.,0
"There is also mild patchy airspace opacity in both lungs which could represent a combination of atelectasis or aspiration, possibly infiltrate.",0
There is mild congestive failure.,1
Heart is top normal in size.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Bactrim Attending: Chief Complaint: Fevers, tachycardia, tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. is a 65 year old man with a history of CLL and pulmonary embolus.",1
He has been off of treatment for his CLL secondary to complications from the chemotherapy.,0
He has required frequent transfusions for his anemia (last transfusion of 2 units of pRBC's on ).,0
"He is neutropenic and has been on valacyclovir, pentamidine, and voriconazole.",0
He reports a dry cough starting about one month ago.,0
Two weeks ago he began having a cough slightly productive of whitish sputum.,0
The cough was at night and would occasionally wake him up.,0
He did not take any medication for the cough and it was not made better or worse by anything that he noticed.,0
At his oncology appointment on he reported worsening of this cough.,0
A chest xray showed a right sided infiltrate with concern for a fungal process.,0
He was started on Augmentin and azithromycin.,0
"He felt febrile last evening, but did not have a thermometer.",0
He took Motrin and drove back from to his regular home.,0
His temperature this AM was 98.7.,0
By noon his temperature was 102.5.,0
He called his oncologist and was sent to the ED for further evaluation and workup of his fevers.,0
"In the ED, initial vs were: 102.5 130 113/58 26 100 on 4L.",0
He was given a total of 2 L of normal saline and 1000 mg of acetaminophen.,0
His blood pressures were in the low 90's during most of his stay in the ED.,0
"His respiratory rate increased to the 30's, but improved after treatment with a nebulizer.",0
His heart rate improved to the 110's after fluids.,0
He also received 100 mg of hydrocortisone.,0
"After discussion with the onc fellow, the patient was started on vancomycin and cefepime.",0
His antifungal coverage was not increased.,0
Vital signs on transfer were: 102.8 98/43 112 22 99 on 4L.,0
"Initially on presentation to the , he reported being relatively comfortable, but tachypneic.",0
Afterwards he developed on ongoing cough that was improved with guafenesin and a nebulizer.,0
He stated that his breathing felt more comfortable than yesterday.,0
"Review of sytems: Reports recent constipation, but now having regular bowel movements.",0
He reports having a few episodes at home where he will not be able to get to the bathroom quick enough.,0
"He had some incontinence of urine last night, but denied dysuria or hematuria.",0
He reports last night using the urinal and having a bowel movement at the same time on the floor.,0
"He reports being able to sense the bowel movement, but not being able to get to the toilet quick enough.",0
Reports little appetite over the last day.,0
"Denied chest pain or tightness, palpitations.",0
"Denied nausea, vomiting, diarrhea, constipation or abdominal pain.",0
"Past Medical History: Oncology History: SUMMARY OF CLL HISTORY: 1) He developed herpes zoster of the right cheek in , treated with Valtrex.",0
"In , he had recurrence of a cutaneous eruption involving the right cheek, but evaluation was felt inconsistent with recurrent herpes zoster and biopsies supported a clonal low-grade B-cell lymphoproliferation, perhaps ""marginal zone B-cell lymphoma,"" reviewed by dermatologist Dr. at .",0
"(2) This right face cutaneous eruption waxed and waned in early , extending to involve the right nostril and skin to the left of midline underneath the nose.",0
"In follow-up evaluation a CBC showed leukocytosis (WBC = 22.7K), but differential was not obtained.",0
He saw Dr. in follow-up who performed skin lesional punch biopsy of the superior nasolabial crease on .,0
"This showed skin involvement by CLL, without evidence of transformation.",0
"(3) Subsequently, he saw Dr. at , and flow cytometry of peripheral blood on confirmed a lymphocyte predominance by CLL; 3% of cells were positive for CD38.",0
"On , torso CT scan at showed extensive lymphadenopathy at multiple sites throughout the upper neck, chest, abdomen and pelvis, as summarized in my note.",0
(4) Repeat CBCs in again showed leukocytosis with lymphocyte predominance on differential.,0
He saw hematologist Dr. for a second opinion.,0
"At , WBCs = 13.6 and 17.9K with 76% and 66% lymphocytes on and , respectively.",0
"Flow cytometry at again confirmed CLL; however, 50% of B cells were CD38 positive.",0
"(5) In , he developed fevers and constitutional symptoms with marked fatigue and weight loss.",0
"On evaluation by Dr. at , concern was raised regarding transformation of his CLL, and repeat torso CT scan was obtained on , showing interval increase in some but not all areas of lymphadenopathy, as summarized in my note.",0
"However, subsequent evaluation by infectious disease specialist Dr. at disclosed erlichiosis, and therapy with doxycycline was begun.",0
"By , he had noted marked improvement in his constitutional symptoms with resolution of fevers and stabilization of his weight, having had a 15-pound weight loss during his summer illness.",1
"(6) In , he developed bilateral otitis media, worse on the right, complicated by tympanic membrane perforation.",0
Throughtout and he noted progressive DOE.,0
"He saw Dr. at on who noted 2 cm submandibular and inguinal lymph nodes, in addition to small anterior and posterior cervical and bilateral axillary lymph nodes.",0
"WBC was now 60K, representing a tripling in WBC over 4 months.",0
"Peripheral blood FISH analysis on CLL cells was obtained showing abnormalities for the D13S319 13q14.3 and P53 17p13.1 probes in 4/100 and 70/100 nuclei, respectively.",0
"(7) In , he met pulmonologist Dr. and cardiologist Dr. , who diagnosed and managed CHF.",0
"On lasix, he felt improved shortness of breath.",0
"However, on and he experienced ""crashing"" fevers and sweats.",0
"With progressive dyspnea, he was found to have markedly increased left pleural effusion and posterior pericardial effusion with RV collapse.",1
"Admitted to hospital on , he ultimately underwent placement of a pericardial window, with drainage of left pleural and pericardial fluid, both showing CLL cells.",0
"However, evaluation of pericardial tissue showed organizing fibrinous material with entrapped mixed inflammatory cells, including numerous small lymphocytes consistent with CLL cells.",0
"However, there was no evidence of transformation or otherwise, and CLL cells were regarded as ""bystanders.""",0
"The overall findings were those of an ""organizing pericarditis, the cause of which is unclear.""",0
"Of note, multiple specimens for various infectious diseases (see OMR) were negative except for B4 and B5 antibodies which were ""8"" rather than ""less than 8.""",0
"(8) On , he was admitted to hospital from to with progressive dyspnea related to worsening bilateral pleural effusions.",1
Left thorascopic pleural biospy and talc pleurodesis were performed on .,0
"Pleural biopsy showed: ""Extensive granulation tissue along with mesothelial proliferation and hemosiderin-laden macrophages are seen, consistent with the chronicity of the effusive process is present.",1
No morphological evidence of large cell transformation or infection is seen.,0
"The morphology, supported by the concurrent flow cytometry immunophenotyping (: CD20 dim, CD5-positive, CD23-positive, lambda light chain expression) is consistent with a diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma.""",1
"Again, CLL was felt to be a ""bystander"" and not the cause of the pleural effusion.",1
"Of note, convalescent serum samples subsequently returned showing a rise in B5 antibody to a level of 32.",0
Molecular analyses for Erlichia were negative on pleural tissue.,0
He felt improved after talc pleurodesis.,0
"(9) With progressive symptomatic anemia and thrombocytopenia, he began his first chemotherapy for CLL on , receiving cycle #1 of fludarabine/Cytoxan (without rituximab).",0
"On , when peripheral blood lymphocytes declined below 50K, he received his first dose of Rituxin, given over 2 days.",0
Further therapy with Fludara/Cytoxan was held due to persistent thrombocytopenia.,0
"On , with persistent thrombocytopenia, he began weekly Rituxin X 4 with vincristine and prednisone 100 mg daily x5 added to Rituxin on , followed by prednisone taper for presumed ITP.",0
"With subsequent improvement in platelet counts, he received R-CVP from to .",0
"On , with substantial recovery in all blood counts, he received FCR, with FC administered on days 1 and 2, not day 3.",0
Full-dose cycle 3 FCR was administered on days 1 through 3 beginning .,0
"(10)Due to worsening anemia and thrombocytopenia thought to be secondary to ITP as well as bone marrow involvement with CLL, he received a pulse of high-dose dexamethasone at the beginning of with 4 doses of weekly rituximab and weekly vincristine on weeks 2 through 4 ( through ).",0
"On , he began daily prednisone instead of dexamethasone pulsing.",0
Thrombocytopenia improved but anemia persisted.,0
"(11) On , he began Campath subcutaneously in an attempt to further unload CLL from bone marrow.",0
"On , after five Campath doses, Campath was held secondary to WBC 0.4 with ANC 297 and increased anemia and thrombocytopenia.",0
He received one week of weekly rituximab on .,0
(12) Hospitalized to with febrile neutropenia attributed to viral infection.,0
"Blood cultures, urine culture, CMV viral load, adenovirus PCR, EBV PCR, Parvo 19 DNA negative and HHV-8 PCR and respiratory viral screen and cultures were all negative.",0
Received Cefime and Neupogen with resolution of fever.,0
"(13) On , with worsened severe thrombocytopenia attributed to ITP complicating progressive CLL, he resumed prednisone 1 mg/kg = 80 mg daily.",0
"14) From to , he recieved cycle 1 cyclophosphamide plus 7 days dexamethasone (in lieu of prednisone).",0
"Cycle 1 was complicated by H1N1 infection with presumed superimposed aspergillosis, and he was in hospital with prolonged neutropenia.",0
"With persistent neutropenia, he received 4 weekly doses of rituximab in and again in , ending on .",0
"Prednisone was resumed for ITP following hi-dose pulsed dexamethasone, and prednisone dosing has been tapered slowly.",0
"On , we administered IVIg for hypogammaglobulinemia in the setting of his infection.",0
"On , repeat chest CT showed marked improvement with near complete resolution of ground glass lung opacities, prompting infectious disease specialist Dr. to discontinue voriconazole therapy for aspergillosis.",0
"(15) Began RCD chemotherapy on for progressive thrombocytopenia, anemia, lymphadenopathy and neutropenia.",0
"(16) After four cycles of RCD chemotherapy, anemia and thrombocytopenia improved, and lymphadenopathy resolved.",0
Decision made to hold off on further cycles due to prolonged leukopenia and increasing fatigue.,0
OTHER PMH: (1) History of basal cell carcinoma of skin.,0
(3) Urinary frequency with BPH.,1
(4) Hyperplastic colonic polyp resected in colonoscopy.,0
(5) Ankle fracture in early complicated by DVT requiring coumadin anticoagulationx Social History: Retired banking lawyer.,0
"Lives on the , but spends the summers on .",0
"Family History: Father had bladder cancer Physical Exam: Admission Exam: General: Alert, oriented HEENT: sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: crackles at bases, rhonchorous breath sounds over right middle and upper lobes CV: Tachycardic Abdomen: soft, non-tender, slightly-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ DP/PT pulses, 2+ LE edema.",0
Aerobic Bottle Gram Stain (Final ): GRAM NEGATIVE ROD(S).,0
Reported to and read back by AT 14:40PM ON .,0
"Urine Culture : pending Imaging: CXR :Large opacity is identified within the right upper to mid lung zone, corresponding to the region of abnormality on prior chest radiograph, though significantly increased in size/severity compared to prior.",0
No significant vascular congestion or pulmonary edema is identified.,0
Mild blunting of the right costophrenic angle is unchanged from prior and likely represents a stable small effusion.,0
A trace left effusion may also be present.,0
"Large consolidation within the right upper lung zone, significantly increased in size since prior, probable pneumonia given the clinical history and increase in severity compared to prior.",1
Stable small right pleural effusion.,1
Possible trace left pleural effusion.,1
Brief Hospital Course: Mr. is a 65 year old man with advanced CLL which left him neutropenic for an extended period of time.,0
"He met SIRS criteria on admission with tachycardia, fevers and leukopenia.",0
His CXR revealed a RUL consolidation concerning for pneumonia.,0
He was broadly covered for bacterial pathogens with vancomycin and cefepime.,0
He had been on voriconazole prophylaxis prior to admission which was expanded to ambisome for fungal coverage.,0
He had a history of erlichia and was started empirically on doxycycline as he had spent time on this season.,0
"His blood and urine was cultured, and beta glucan and galactomanan were assayed.",0
Blood cultures would later show GNR.,0
"Despite treatment, he had persistent respiratory distress with increased work of breathing and hypoxia.",0
He was clear that he did not want to be intubated and maintained a DNR/DNI order.,0
"He briefly tried non-invasive BiPAP mask ventilation for comfort the morning after his arrival, though this measure was poorly tolerated.",0
"After discussing with his family, he elected to focus his goals of care on comfort only.",0
He was placed on a morphine drip and his respiratory distress was alleviated.,0
He died several hours later at 14:30 on in the company of his family.,0
"Medications on Admission: ENOXAPARIN 80 mg LORAZEPAM - 0.5-1 mg Tablet QHS prn sleepiness METOPROLOL SUCCINATE - 25 mg PANTOPRAZOLE - 40 mg PENTAMIDINE [NEBUPENT] 300 mg(s) inhaled via nebulizer every 4 weeks PREDNISONE - 5 mg Tablet qAM, 2.5 mg qPM TAMSULOSIN - 0.4 mg Capsule VALACYCLOVIR - 500 mg Tablet VORICONAZOLE [VFEND] - 200 mg Tablet DIPHENHYDRAMINE HCL [BENADRYL] 25 mg QHS prn MULTIVITAMIN Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired",0
"3:33 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for pleural effusion left lower lobe Admitting Diagnosis: DYSPNEA-RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with elevated WBC, mild hypoxia on RA REASON FOR THIS EXAMINATION: please evaluate for pleural effusion left lower lobe ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:34 A.M., HISTORY: Elevated white count and hypoxia.",1
IMPRESSION: AP chest compared to and : Mild pulmonary edema has worsened while mild cardiomegaly is stable but small bilateral pleural effusion and mediastinal vascular engorgement have increased reflecting cardiac decompensation and/or volume overload.,1
Dr. was paged to discuss these findings at the time of dictation.,0
"3:30 PM CHEST (PORTABLE AP) Clip # Reason: s/p ETT repositioning; eval for change in pulmonary edema ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with acute hepatic failure, hypoxia REASON FOR THIS EXAMINATION: s/p ETT repositioning; eval for change in pulmonary edema ______________________________________________________________________________ FINAL REPORT INDICATION: ETT repositioning.",1
PORTABLE SUPINE CHEST AT 3:50 PM: The endotracheal tube is approximately 4.6 cm above the carina.,0
There is an NG tube coiled within the stomach.,0
The right IJ Swan-Ganz catheter tip is in the region of the main pulmonary artery.,0
There is an area of increased lucency at the right lung base on this supine film which suggests the presence of a right-sided pneumothorax.,0
"In addition, there is evidence of pneumomediastinum, evidenced by a linear area of lucency along the left superior mediastinum.",0
Linear areas of lucency are seen tracking into the neck.,0
Subcutaneous emphysema is also seen in the right side of the neck.,0
There continues to be diffuse bilateral patchy alveolar opacities.,0
"There is a more confluent area of opacity in the left retrocardiac region, increased since the previous examination.",0
Possible right-sided pneumothorax with an area of increased lucency at the right lung base on this supine film.,0
"A left lateral decubitus film, centered on the right lung would help to confirm this diagnosis.",0
"Pneumomediastinum with air tracking into the neck, and right neck subcutaneous emphysema.",0
"Diffuse pulmonary opacities which could represent pulmonary edema, ARDS, versus multifocal pneumonia.",0
There is worsening consolidation in the left retrocardiac region.,0
Findings called to the MICU and discussed with the MICU resident caring for the patient.,0
(Over) 3:30 PM CHEST (PORTABLE AP) Clip # Reason: s/p ETT repositioning; eval for change in pulmonary edema ______________________________________________________________________________ FINAL REPORT (Cont),0
11:19 AM CHEST (PA & LAT) Clip # Reason: s/p chest tube pull.,0
s/p cabg ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with as a above REASON FOR THIS EXAMINATION: s/p chest tube pull.,0
s/p cabg ______________________________________________________________________________ FINAL REPORT INDICATION: S/P chest tube removal.,0
AP CHEST: Comparison film from the previous day demonstrates interval removal of the left sided chest tube.,0
Sternal wires and surgical clips are present.,0
There are patchy opacities that likely represent atelectasis.,0
The remainder of the exam is unchanged.,0
IMPRESSION: 1) S/P chest tube removal.,0
"2) Bilateral patchy vague opacities likely representing atelectasis, but a component of perihilar edema is also possible.",0
"5:30 AM CHEST (PORTABLE AP) Clip # Reason: eval for effusion/consolidation/atelectasis Admitting Diagnosis: FEVER,ORIGIN UNKNOWN ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman s/p liver and renal tx now with right sided pleural effusion.",1
Eval for progression REASON FOR THIS EXAMINATION: eval for effusion/consolidation/atelectasis ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.,0
REASON FOR EXAM: Post-liver and renal transplant with right-sided pleural effusion.,1
FINDINGS: A large right pleural effusion has increased in size with layering in the right apex giving a hazy appearance.,1
There is also new left lower lobe atelectasis with a small left pleural effusion.,1
Slight worsening in the extent of pulmonary edema and vascular re-distribution is noted since the previous study with stable moderate cardiomegaly.,0
IMPRESSION: Increased size of the right pleural effusion which is large with worsening mild to moderate pulmonary edema and new left lower lobe atelectasis and pleural effusion.,1
"6:15 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate infiltrate and effusion ______________________________________________________________________________ MEDICAL CONDITION: 75 yo man with recent CVA and NQWMI, now with resolving septic shock, presumably R pneumonia.",1
"Continued fevers, postivive sputum, blood cultures.",0
REASON FOR THIS EXAMINATION: Please evaluate infiltrate and effusion ______________________________________________________________________________ FINAL REPORT AP BEDSIDE CHEST RADIOGRAPH: INDICATION: 75 y/o male with CVA and MI with resolving septic shock.,0
Patient with history of right sided pneumonia and continued fevers.,0
FINDINGS: Comparison is made to a prior study from ___/21/02.,0
The heart size and mediastinal contours are stable.,0
There is an ETT in good position.,0
There is an NG tube in place that passes beneath the diaphragm.,0
The distal tip of the NG tube overlies the fundus of the stomach.,0
There has been interval removal of a right sided IJ CVC.,0
There are surgical clips overlying the right upper quadrant of the abdomen.,0
The patient is in a supine position which prevents accurate assessment of the pulmonary vasculature.,0
Some element of left ventricular failure cannot be excluded.,0
There is increased hazy diffuse opacification of the right lung consistent with a layering right sided pleural effusion or diffuse infiltrate within the right lung.,0
IMPRESSION: Worsening diffuse opacification of the right lung which may be secondary to a layering pleural effusion as well as some element of pulmonary infiltrate most prominent at the right lung base.,0
7:02 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: C1 C2 not clearly seen on C spine.,0
"______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with dementia, s/p unwitnessed fall, unable to see C1 C2 on c spine (contrast may or may not be needed) REASON FOR THIS EXAMINATION: C1 C2 not clearly seen on C spine.",0
______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: Status post unwitnessed fall.,0
Unable to see C1-2 on the plain radiographs.,0
TECHNIQUE: Contiguous axial images were obtained through the C1-C4 vertebral bodies.,0
"FINDINGS: There is no evidence of acute fractures, mal-alignment, areas of bone destruction, or prevertebral soft tissue swelling.",1
The visualized paravertebral soft tissues are unremarkable.,0
Multiplanar reformatted images confirm the above findings.,0
IMPRESSION: No evidence of acute fractures or mal-alignment of the C1-C3 vertebral bodies.,1
"NOTE: The head is slightly rotated, (a few degrees to the right), relative to visualized upper cervical spine, presumably positional in nature.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: angina Major Surgical or Invasive Procedure: CABG x3 (LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 64 yo male with CAD and prior PTCA years ago.",1
Transferred in from OSH with unstable angina and + MIBI for infero-septal ischemia.,0
Cardiac enzymes were negative x 2.,0
"Went home for plavix washout, to return for CABG in a few days.",0
Past Medical History: HTN Hyperlipidemia CAD /PTCA ~15 yrs ago - balloon angioplasty Social History: Social history is significant for the absence of current tobacco use- quit 20 yrs ago.,0
"Family History: Father died 69 with cerebral hemorrhage, mother died at 80 ""old age"".",0
There is no family history of premature coronary artery disease or sudden death.,1
"Physical Exam: 5'9 "" 212 # skin HEENT unremarkable neck supple , full ROM, no carotid bruits appreciated CTAB anteriorly RRR no murmur soft, NT, ND + BS warm, well-perfused with no edema or varicosities noted neruo grossly intact 2 + bil.",0
fem/DP/PT/radials Pertinent Results: Conclusions PREBYPASS 1.,0
No atrial septal defect or PFO is seen by 2D or color Doppler.,0
Dr. was notified in person of the results on at 928.,0
POST CPB: Preserved -ventricular systolic function.,0
No change in valve structure or function.,0
"Electronically signed by , MD, Interpreting physician 11:03 , J M 64 Radiology Report CHEST (PORTABLE AP) Study Date of 8:14 AM , R. CSURG CSRU SCHED CHEST (PORTABLE AP) Clip # Reason: ?",0
PTX s/p CT removal MEDICAL CONDITION: 64 year old man s/p CABG REASON FOR THIS EXAMINATION: ?,0
PTX s/p CT removal Provisional Findings Impression: SP 4:01 PM No pneumothorax after instrument removal.,0
Final Report TYPE OF EXAMINATION: Chest AP portable single view.,0
INDICATION: Status post bypass surgery.,0
Now extubated and tube removal.,0
"The patient is extubated and the previously described central venous line, pulmonary catheter, mediastinal and chest tubes have been removed.",0
There is no pneumothorax and no significant pulmonary vascular congestion.,0
"When comparison is extended to the pre-operative single view study of , postoperative findings include moderate enlargement of the heart silhouette and some retrocardiac density consistent with atelectasis.",0
No new acute parenchymal infiltrates are identified.,0
DR. Approved: 5:26 PM ?,0
08:40AM BLOOD WBC-7.9 RBC-3.14* Hgb-10.3* Hct-28.4* MCV-91 MCH-32.8* MCHC-36.2* RDW-11.9 Plt Ct-187 12:15PM BLOOD WBC-19.3*# RBC-3.69* Hgb-12.1* Hct-32.9* MCV-89 MCH-32.6* MCHC-36.6* RDW-12.6 Plt Ct-168 08:40AM BLOOD Glucose-112* UreaN-13 Creat-0.8 Na-136 K-4.5 Cl-103 HCO3-26 AnGap-12 02:59AM BLOOD Glucose-130* UreaN-13 Creat-0.7 Na-137 K-4.1 Cl-107 HCO3-26 AnGap-8 Brief Hospital Course: Admitted and underwent CABG x3 with Dr. .,0
Please refer to Dr operative report for further details.,0
Transferred to the CVICU in stable condition on phenyleprine and propofol drips.,0
Gently diuresed toward his preop weight.,0
Beta blockade titrated.Tubes and drains were discontinued in a timely fashion.,0
POD#1 he was transfered to SDU for further telemetry monitoring and recovery.,0
The remainder of his postoperative course was essentially uneventful.,0
He continued to progress and on POD#4 he was discharged to home with VNA.,0
Medications on Admission: HCTZ 25 mg daily atenolol 75 mg lipitor 80 mg daily imdur 60 mg daily norvasc 2.5 mg daily folic acid Discharge Medications: 1.,0
Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days.,0
Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed.,0
Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: .,0
VNA Discharge Diagnosis: CAD s/p cabg x3 HTN elev.,0
"lipids Discharge Condition: good Discharge Instructions: no lotions, creams or powders to any incision no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, or drainage no driving for one month AND until off all narcotics shower daily and pat incisions dry Followup Instructions: see Dr. in weeks see Dr. in weeks see Dr. in 4 weeks Completed by:",0
Height: (in) 66 Weight (lb): 162 BSA (m2): 1.83 m2 BP (mm Hg): 103/68 HR (bpm): 120 Status: Inpatient Date/Time: at 14:10 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is elongated.,0
"LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%).",0
Physiologic tricuspid regurgitation is seen.,0
GENERAL COMMENTS: The patient is tachycardic (HR>100bpm).,0
There is a focal echogenic 0.6 cm mass atttched to the anterior mitral valve leaflet.,0
Patient tachycardic during the exam.,0
"Impression, focal echogenic 0.6 cm mass is attatched to the anterior mitral valve leaflet.",0
"This may represent a focal area of calcification, however, because an old echocardiogram is not availble for comparison a vegetation cannot be excluded.",0
"8:55 AM CHEST (PORTABLE AP) Clip # Reason: (L)infiltrate Admitting Diagnosis: THORACIC AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with left carotid-SC stent/seroma REASON FOR THIS EXAMINATION: (L)infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, CLINICAL INFORMATION: Stent.",1
FINDINGS: Comparison is made to the study of the day before.,0
Again noted is an aortic stent graft.,0
"Request states left carotid subclavian stent, although this is not quite visible on the radiograph.",0
Surgical clips are present in the left axilla/chest wall.,0
"Nasogastric tube courses below the diaphragm, but the tip is not seen.",0
Right IJ catheter terminates in the superior vena cava.,0
Heart and mediastinal are otherwise within normal limits given recent surgery.,0
There is a persistent left pleural effusion and left lower lobe atelectasis.,0
Small right pleural effusion and right atelectasis.,0
Little change in the appearance of the chest since the prior study.,0
7:15 AM NEONATAL HEAD PORTABLE Clip # Reason: rule out intracranial hemorrhage or other abnormality Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 28 weeks gestation REASON FOR THIS EXAMINATION: rule out intracranial hemorrhage or other abnormality ______________________________________________________________________________ FINAL REPORT This is a dictation of a study performed on .,1
Images are reviewed on .,0
Today's review does not reveal any evidence of ventriculomegaly or other abnormality.,0
"9:57 PM MR KNEE W/O CONTRAST LEFT Clip # Reason: TRAUMA TO KNEE,FRACTURE Admitting Diagnosis: MULTIPLE TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with REASON FOR THIS EXAMINATION: reconstruction planned left tib /plateau fx ______________________________________________________________________________ FINAL REPORT INDICATION: Tibial plateau fracture for pre-operative evaluation prior to reconstruction.",1
"TECHNIQUE: Utilizing the extremity coil at 1.5 Tesla, fast spin echo axial, coronal, and sagittal PD and T2; sagittal STIR.",0
COMPARISON: CT of MR LEFT KNEE: Medial tibial plateau fracture is present extending from the tibial plateau mid- line inferiorly and medially to exit the proximal tibial diametaphysis 5.1 cm below the tibial plateau margin.,1
The medial plateau fragment is displaced medially approximately 9 mm.,0
There is marked comminution in the mid-line of the tibial plateau.,0
The anterior cruciate ligament appears intact and taught with partial avulsion of an ossific fragment at the lateral aspect of its insertion.,0
There is abnormal increased signal within the posterior cruciate ligament compatible with disruption of fibers.,0
"There is a 1.4 cm fragment of tibial plateau attached to the posterior cruciate ligament which is displaced approximately 1.5 cm posteriorly with surrounding osseous comminution, edema and hemorrhage.",0
The medial meniscus is intact with preserved cartilage in the medial compartment.,0
The patellofemoral compartment cartilage is preserved.,0
In the lateral compartment there is complex tear of the anterior which is irregular and attenuated.,0
The body and posterior of the lateral meniscus are intact.,0
The lateral compartment cartilage appears preserved.,0
There is a large lipohemarthrosis present.,0
"There is bone marrow edema involving the entire medial tibial plateau, predominantly the anterior aspect of the lateral tibial plateau, the lateral aspect of the lateral femoral condyle and the anterior aspect of the medial femoral condyle.",0
These are all compatible with bone contusions.,0
The medial collateral ligaments appears intact and there is surrounding edema deep and superficial to its proximal aspect compatible with grade 2 sprain.,0
The fibular collateral ligament also appears intact with edema deep and superficial compatible with grade 2 sprain.,0
There is marked edema of the popliteus muscle compatible with grade 2 strain with the myotendinous junction and popliteus tendon intact.,0
There is no significant edema in the posterolateral corner to suggest capsula/arcuate ligament injury.,0
"There is edema and enlargement of the proximal (Over) 9:57 PM MR KNEE W/O CONTRAST LEFT Clip # Reason: TRAUMA TO KNEE,FRACTURE Admitting Diagnosis: MULTIPLE TRAUMA ______________________________________________________________________________ FINAL REPORT (Cont) anterior tibialis and extensor digitorum muscles compatible with at least a grade 2 strain.",1
There is edema in the proximal peroneus longus muscle/tendon with focal 13 cm fluid collection just below the fibular head compatible with at least partial tear.,0
There is mild associated edema in the lateral aspect of the fibular head.,0
IMPRESSION: 1) Disrupted PCL with attached 1.4 cm avulsed fragment at its tibial insertion site.,0
2) Taught ACL with partial osseous avulsion at the lateral aspect of its insert site.,0
3) Medially distracted medial tibial plateau fracture with marked comminution in the tibial plateau mid-line.,1
4) Anterior lateral meniscus tear.,0
5) Grade 2 sprains of the medial collateral ligament and fibular collateral ligament.,0
6) Grade 2 injury of the popliteus muscle.,0
7) At least grade 2 injuries of the proximal anterior tibialis and extensor digitorum tendon/muscles.,0
8) At least high grade partial tear of the proximal peroneus longus muscle/tendon.,0
10) Bone contusions as described.,0
"12:05 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o intra-abdominal/post-surcigal abscess, colitis Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 30F DM1, ESRD on HD p/w N/V, HA, A/P since last night.",1
"REASON FOR THIS EXAMINATION: r/o intra-abdominal/post-surcigal abscess, colitis No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd SAT 4:06 AM No evidence of colitis.",0
small area of soft tissue density overlying the previous site of ventral hernia most likely postsurgical changes.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 30-year-old woman with end-stage renal disease on hemodialysis who presents with nausea, vomiting and headache and abdominal pain since last night.",1
"COMPARISON: Multiple CTs of the abdomen and pelvis, most recent of .",0
TECHNIQUE: Axially acquired images were obtained from the lung bases to the pubic symphysis after the administration of oral contrast only.,0
FINDINGS: This examination is limited by noncontrast technique.,0
CT OF THE ABDOMEN: There is minimal bibasilar atelectasis.,0
At the right lung base a more focal area of ground glass opacity is new.,0
Tip of dialysis catheter seen in right atrium.,0
Imaged portion of heart and pericardium otherwise unremarkable.,0
"Non-contrast appearance of the spleen, adrenal glands, pancreas, gallbladder, and liver are within normal limits.",0
Kidneys are small and atrophic bilaterally.,0
There is some apparent high density within the renal collecting systems of uncertain significance that could reflect recent or small administration of contrast.,0
Again seen is extensive calcification of the mesenteric and pelvic vessels.,0
Status post umbilical/ventral hernia repair.,0
"Soft tissue density is noted in the subcutaneous fat overlying the site of ventral defect, likely post-surgical changes without definite fluid collection identified.",0
"Oral contrast has progressed to the distal small bowel, although the colon is not yet opacified.",0
"CT OF THE PELVIS: The non-contrast appearance of the uterus, rectum, and bladder are within normal limits apart from bladder distention.",0
"There is a (Over) 12:05 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o intra-abdominal/post-surcigal abscess, colitis Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ FINAL REPORT (Cont) small amount of free fluid in the pelvis that is intermediate in density, but not significantly different from prior CT of .",1
No concerning osseous lesions are identified.,0
"IMPRESSION: 1.Small soft tissue density noted within the subcutaneous fat overlying the previous site of ventral hernia, likely post-surgical changes.",0
No evidence of abscess or colitis.,0
"Focal ground glass opacity in right lower lobe could be due to edema, infectious or inflammatory change.",0
"Small amount of intermediate density free fluid in the pelvis, a nonspecific finding.",0
If there are symptoms referable to the pelvis then pelvic ultrasound would further evaluate.,0
", A. MED MICU-7 3:25 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with PNA, s/p intubation.",0
REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PFI REPORT No interval change in the diffuse consolidation of the right lower lobe and the position of the endotracheal tube.,0
"9:53 PM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: PT WITH WORSENING EDEMA VS NEW INFARCT ON CT Admitting Diagnosis: SAH;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with ICH, worsening edema vs new infarct on CT. REASON FOR THIS EXAMINATION: DWI only ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma, intracranial hemorrhage.",1
"COMPARISON: CT of head, .",0
"TECHNIQUE: Multiplanar T1W, T2W, FLAIR and diffusion-weighted imaging was performed.",0
3D TOF imaging with multiplanar reconstructions was also performed of the circle of .,0
"MRI OF THE BRAIN: FLAIR images show increased signal within the large left temporal lobe hemorrhage, as well as multiple areas of increased signal within the left internal capsule, right insular cortex and right frontal lobe.",0
"There is accompanying bright signal on the diffusion-weighted images in these areas, which is concerning for these areas of infarction being recent.",0
There is no major vascular territorial infarct seen.,0
The amount of rightward subfalcine herniation is unchanged from the previous study.,0
No evidence of hydrocephalus is noted.,0
"There is fluid and mucosal thickening in the sphenoid, mastoid and maxillary air cells.",0
MRA OF CIRCLE OF : The major tributaries of the circle of are patent.,0
There is no overt area of significant stenosis or aneurysmal dilatation.,0
"IMPRESSION: Multiple areas of elevated signal on both FLAIR with accompanying positive diffusion-weighted imaging signal within the right insular cortex, right temporal lobe and left internal capsule.",0
These areas are concerning for additional areas of evolving infarction.,0
There are no major vascular territorial infarcts.,0
7:32 AM CHEST (PORTABLE AP) Clip # Reason: changes in CHF/ effusion?,0
______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with s/p avr/mvr REASON FOR THIS EXAMINATION: changes in CHF/ effusion?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: S/P AVR and MVR, evaluate for changes in CHF/effusion.",0
Single frontal chest radiograph dated is compared with prior chest radiograph dated .,0
There is no significant interval change in position of lines and tubes.,0
"Again, the side port of the NG tube is at the GE junction.",0
There is interval improvement in the mild CHF.,0
There is persistent left lower lobe pneumonia with pleural effusion.,1
"9:06 AM T-SPINE; L-SPINE (AP & LAT) Clip # C-SPINE SGL 1 VIEW; -59 DISTINCT PROCEDURAL SERVICE Reason: eval injury, eval injury ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with s/p mvc REASON FOR THIS EXAMINATION: eval injury ______________________________________________________________________________ FINAL REPORT HISTORY: Trauma.",0
"THORACIC & LUMBAR SPINE, MULTIPLE VIEWS: There is no evidence of acute fracture or dislocation of the thoracic or lumbar spine.",0
There is normal alignment of the thoracic and lumbar spine.,0
Vertebral body height and disc space are well preserved.,0
Visualized soft tissues appear unremarkable.,0
Residual contrast is noted in the renal collecting system.,0
"C SPINE, OPEN MOUTH VIEW: Extremely limited study due to patient's position and the known C2 fracture is not well visualized.",0
IMPRESSION: Unremarkable T and L spine.,0
"OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: diagnostic paracentesis, fluid for gm stain/culture Admitting Diagnosis: ACUTE ABDOMINAL PAIN;COLECTOMY;HYPOTENSION ********************************* CPT Codes ******************************** * PARACENTESIS DIAG.",0
"OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p colectomy for toxic megacolon, now with persistent fevers without source, ascites on CT scan REASON FOR THIS EXAMINATION: diagnostic paracentesis, fluid for gm stain/culture ______________________________________________________________________________ FINAL REPORT HISTORY: A 56-year old man status post-colectomy for toxic megacolon, and now with persistent fevers without source, ascites on CT scan.",1
"REASON FOR EXAM: Diagnostic paracentesis, exclude for Gram stain culture.",0
PROCEDURE: The general ICU consent was used for this procedure.,0
A preprocedure timeout was performed using three patient identifiers.,0
"Using ultrasound guidance, an appropriate site for the paracentesis was chosen in the left lower quadrant.",0
"The skin was sterily prepped, and using a 5-French catheter, 50 mL of serous fluid was aspirated, and sent for Gram stain and culture, and cell count.",0
"The attending, Dr. , was present for the procedure.",0
"CONCLUSION: Successful bedside ultrasound-guided paracentesis (diagnostic), with no immediate complications.",0
Admission Date: Discharge Date: Date of Birth: Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old man with a sudden onset of loss of consciousness on the morning of admission.,0
His wife witnessed shaking and frothing activities for about 2-3 minutes.,0
The patient awoke with memory of the fall or syncope and never had signs or symptoms before like this.,0
"Now feels woozy, lightheaded but not confused or disoriented.",0
CT at the outside hospital shows a colloid cyst of the third ventricle.,0
He was transferred to for further management.,0
"PAST MEDICAL HISTORY: Includes hypercholesterolemia, MVR in on Coumadin, status post ablation and cardioversion, hypertension, GERD, CHF, Dressler's syndrome and hepatitis C. PHYSICAL EXAMINATION: He is in no acute distress.",1
His vital signs are stable.,0
"His pupils are equal, round and reactive to light.",0
"Bilateral upper and lower extremities are , reflexes are 2+ throughout.",0
His EKG was normal on admission.,0
"His Chem 7, sodium 141, potassium 3.8, chloride 104, CO2 27, BUN 11, creatinine .9, glucose 99.",0
"Coags on admission, PT 25, INR 4.1 and his PTT was 33.",0
HOSPITAL COURSE: The patient was started on Heparin.,0
His INR was allowed to drift down to the 2.5 range and then he was started on Heparin.,0
"Cardiology assessed him and felt that it was important to continue the Heparin and that once he was able to start back on Coumadin, that his INR be 2.5 to 3.0.",0
On the patient underwent transcollossal resection of colloid cyst.,0
The patient was monitored on the surgical Intensive Care Unit post-op.,0
"His blood pressure was 120/50, heart rate 95, sats 95% on two liters.",0
"Neurologically the patient was awake and alert, oriented times two, following commands with a decreased affect and decreased motor strength of the left upper extremity.",0
On postoperative day #1 the patient underwent head CT which revealed a venous infarct on the right frontal lobe.,0
The patient remained in the Intensive Care Unit with close neurologic evaluation.,0
He had a slight interval increase in the size of the right frontal lobe bleed and infarct.,0
On the patient had a repeat head CT which showed slight interval increase in the size of the infarct and edema.,0
"The patient was continued to be monitored in the surgical Intensive Care Unit, neurologically remained awake and alert, oriented times , and continued to have some decreased strength in the left upper extremity.",0
The patient was restarted on Heparin on and remained stable neurologically on IV Heparin.,0
He was started on po Coumadin .,0
He was transferred to the regular floor on in stable and neurologic condition.,0
His left upper extremity weakness improved.,0
"He was out of bed ambulating, tolerating regular diet, voiding spontaneously and became therapeutic on his Coumadin on .",0
He was discharged home in stable condition with follow-up with Dr. in one month time.,0
"His incision was clean, dry and intact at the time of discharge and his vital signs remained stable.",0
He will follow-up with his primary care physician for his Coumadin treatment.,0
Dictated By: MEDQUIST36 D: 11:04 T: 11:16 JOB#:,0
3:37 PM US EXTREMITY NONVASCULAR LEFT Clip # Reason: left groin evalaute fluid collection Admitting Diagnosis: AORTIC VALVE STENOSIS\AORTIC VALVE / ASCENDING AORTA REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with s/p asc aorta replacement REASON FOR THIS EXAMINATION: left groin evalaute fluid collection ______________________________________________________________________________ FINAL REPORT STUDY: Left femoral non-vascular ultrasound.,1
INDICATION: 53-year-old male status post aortic replacement with fevers.,0
Please evaluate left groin fluid collection noted on CT.,0
FINDINGS: Patient is status post left femoral puncture prior to the examination.,0
"There is a tiny 2 x 1 cm fluid collection adjacent to the left femoral vessels, noted on previous CT, which is heterogenous containing more solid than fluid components with an appearance most consistent with a hematoma.",0
This collection is tiny and not amenable to drainage.,0
11:10 AM UPPER EXTREM VEINS US RIGHT Clip # Reason: pt.,0
"with decreasing anasarca revealing R>L upper ext edema, ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man s/p colectomy pod 14, complicated post op course REASON FOR THIS EXAMINATION: pt.",0
"with decreasing anasarca revealing R>L upper ext edema, h/o R sided CVL, concern for thrombosis please eval.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Complicated postop course, postop day 14.",0
Decreasing anasarca revealing right greater than left upper extremity swelling.,0
"RIGHT UPPER EXTREMITY ULTRASOUND: Color doppler and -scale images were obtained of the right internal jugular, subclavian, cephalic, axillary and brachial veins.",0
There is normal flow and wave forms.,0
IMPRESSION: No DVT in the right upper extremity.,0
"11:21 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p L sub clav line placement plse check position, pneumotho Admitting Diagnosis: ACUTE ABDOMEN ______________________________________________________________________________ MEDICAL CONDITION: 86 yo F w/ hx duodenitis s/ patch for perforated duodenal ulcer REASON FOR THIS EXAMINATION: s/p L sub clav line placement plse check position, pneumothorax ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Subclavian line placement.",1
Diffuse bilateral pulmonary infiltrates consistent with edema and bilateral pleural effusions persist.,0
A feeding tube has been withdrawn.,0
A left subclavian catheter has been inserted and terminates at the level of the superior vena cava.,0
There is no other significant change.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Acute pancreatitis with symptomatic pancreatic pseudocyst Major Surgical or Invasive Procedure: : Revision of cyst gastrostomy, pancreatic debridement, and subtotal cholecystectomy.",1
: Uncomplicated placement of 8.5 French internal-external drain in the right posterior ductal system and attached to an external drainage bag.,0
: Successful uncomplicated upsize of the existing 8 French biliary drain to a 10 French biliary drain with the pigtail in the duodenum.,0
": Uncomplicated exchange of 10 French biliary drainage catheter for another 10 French biliary drain, with pigtail in duodenum.",0
: Successful uncomplicated exchange of an indwelling 10 French internal-external biliary drain with a 12 French internal-external biliary drain with free flow of contrast demonstrated in the small bowel.,0
"History of Present Illness: Ms. is a 51 year old female a history of acute pancreatitis in , possibly alcohol induced, which was complicated by symptomatic pseudocyst requiring recent hospitalization.",1
She underwent endoscopic transgastric cystgastrostomy and stent placement with Dr. on .,0
"Her symptoms were relieved for approximately two days post-procedure but nausea, bilious emesis and early satiety with associated weight loss gradually returned.",1
She believes that she has lost approximately 50 lbs since her initial bout of pancreatitis.,0
"Past Medical History: Acute pancreatitis () c/b intubation, prolonged ICU stay, IJ thrombosis, and VAP ARF requiring HD (now off of HD) IJ thrombosis (as above); coumadin held this week pre-procedure HTN (pt denies) DM2 (pt denies) EtOH abuse (no current) RA Social History: Lives with mother; no stairs in the house.",1
"Cigs - formerly 1ppd; now only ppd EtOH - h/o abuse, none current No IVDU Family History: No neoplasm Physical Exam: On Admission: Vitals: 97.0 120 113/84 18 98 RA Gen: NAD, AOX3, non-toxic appearing CV: sinus tachycardic, nl s1 and s2, normotensive Resp: CTAB Abd: mildly distended, tender to palpation over epigastrium Extremities: 2+ dp, no edema On Discharge: VS: 98.6, 73, 148/82, 16, 100 % RA GEN: NAD CV: RRR, no m/r/g PULM: Diminished on LLL ABD: Midline incision well healed, Right frank with PTC drain capped.",0
"Abdomen tender to palpation throughout, mildly distended.",0
"EXTR: Warm, no c/c/e Pertinent Results: 04:38AM BLOOD WBC-6.6 RBC-3.04* Hgb-8.6* Hct-26.3* MCV-86 MCH-28.3 MCHC-32.7 RDW-16.4* Plt Ct-340 04:18AM BLOOD Glucose-134* UreaN-40* Creat-1.0 Na-140 K-4.1 Cl-115* HCO3-21* AnGap-8 04:18AM BLOOD ALT-49* AST-45* AlkPhos-451* TotBili-0.4 04:18AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.7 MICRO: PANCREATIC TISSUE: **FINAL REPORT ** GRAM STAIN (Final ): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.",0
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).,0
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).,0
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.,0
1+ (<1 per 1000X FIELD): BUDDING YEAST.,0
Reported to and read back by DR. PAGER# @ 0224 ON .,0
"TISSUE (Final ): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep.",0
Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ENTEROCOCCUS SP..,0
11:11 am URINE Source: CVS.,0
Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R 5:57 pm BILE GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.,0
"IN PAIRS, CHAINS, AND CLUSTERS.",0
1+ (<1 per 1000X FIELD): YEAST(S).,0
"FLUID CULTURE (Final ): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep.",0
Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPH AUREUS COAG +.,0
"Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations.",0
Rifampin should not be used alone for therapy.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.,0
Interval decrease in size of large peripancreatic collection s/p placement of pseudocyst gastrostomy catheter.,0
Presence of gas within this collection likely due to drain however superinfection cannot be excluded.,0
Lower lung opacity concerning for pneumonia.,0
CXR: FINDINGS: There are low lung volumes.,0
Bibasilar atelectasis have minimally improved.,0
Mild vascular congestion has minimally improved.,0
There are no new lung abnormalities or pneumothorax.,0
Right PICC tip is at the cavoatrial junction.,0
SBFT: IMPRESSION: Cyst-gastrostomy without evidence for leak.,0
Brief Hospital Course: The patient with history of acute pancreatitis with pancreatic pseudocyst s/p endoscopic cystgastrostomy and stent placement was admitted to the General Surgical Service for evaluation of nausea and vomiting.,1
"On , the patient underwent revision of cyst gastrostomy, pancreatic debridement, and subtotal cholecystectomy, which went well without complication (reader referred to the Operative Note for details).",1
"Prior operation, patient received 2 units of FFP for INR > 1.5.",0
"After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a foley catheter, and Dilaudid PCA catheter for pain control.",0
"On POD # 1, patient underwent CT-guided placement of the internal/external drain in R posterior ductal system s/t rising T-bili.",1
"The patient's postoperative hospital course was complicated by prolong PO intolerance, nausea/vomiting required multiple NGT placement, episodes of severe anemia which required multiple RBC transfusions and ICU observation, MRSA cholangitis and UTI.",1
Neuro: The patient received Dilaudid PCA with good effect and adequate pain control.,0
"When tolerating oral intake, the patient was transitioned to oral pain medications with IV for breakthrough pain.",1
The patient is unable to tolerate PO medication and was transitioned back to IV Dilaudid.,0
CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored.,0
Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored.,0
She received 2 doses of Lasix postoperatively for fluid overload.,0
"GI: Post-operatively, the patient was made NPO with IV fluids.",0
Several attempts were made to advance patient's diet and failed.,0
The patient experienced severe nausea with emeses and NG tube was replaced total 5 times.,0
The patient was started on TPN on POD # 5 and she was continued on TPN throughout hospitalization.,1
Small bowel follow through was done on POD # 16 and was negative for obstruction or leak.,1
"Patient's enteric, PTBD and JP output were replaced with IV fluids 1 cc to 1 cc.",0
"On POD # 23, patient was started on IV Octreotide and her secretions subsided.",0
"NG tube was removed on POD # 24, patient diet was advanced to sips of clear.",0
The patient continue to have intermittent nausea and her diet was not advanced prior discharge.,0
She may be advanced to clears in Rehab if tolerated.,0
"Electrolytes were followed daily, and aggressively repleted during hospitalization.",0
Biliary: PTBD was placed on POD # 1 and was capped on POD # 3.,0
On POD # 6 PTBD was upsized s/t persistent leak around the tube.,0
"On POD # 17, patient underwent tube cholangiogram which demonstrated patent PTBD, catheter was replaced during the study.",0
"On patient spiked fever to 102, her drain was open to garavity and bile was sent for cultures.",0
On patient's PTBD was upsized to 12 French and bile was resent for microbiology.,0
Both bile samples were positive for MRSA and patient was started on Unasyn on and Vancomycin on .,0
"Currently PTBD is capped, patient remains afebrile since antibiotics were started.",0
LFTs were routinely followed during hospitalization and increase of LFTs indicated PTBD cholangiogram/exchange.,0
Patient will require continue LFTs follow up in Rehab.,0
The patient underwent 10 days course with IV Cipro/Flagyl for infected pseudocyst.,1
"On patient spiked fever, she was pancultured and started on IV Unasyn.",0
Bile cultures were positive for MRSA and urine was positive for E-coli.,0
"The patient was started on IV Vancomycin x 2 weeks total, treatment for UTI wasn't indicated s/t patient is assymptomatic.",0
Patient's WBC was within normal limits during hospitalization.,0
Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly in TPN.,1
Hematology/Anemia: The patient's complete blood count was examined routinely and her HCT was stable low.,1
On POD # 12 patient's HCT was 12.7 and her NG output was tinged with blood.,0
The patient was asymptomatic except mild tachycardia.,1
"Patient was transferred in ICU for observation, she received 4 units of RBC total and Lovenox (treatment for IJ thrombus) was discontinued.",0
Post transfusion HCT improved to 23.8.,0
The patient received 2 more units of RBC on for HCT 21.9.,0
Her HCT improved and remianed stable low until discharge.,0
The patient was started on Pantoprazole 40 mg for 7 days and continued on 40 mg .,0
"The HCT drop most likely was cause by upper GI bleed, which stopped, the following NG output was gastric without any blood.",0
"The patient has a history of IJ vein thrombosis and was on Lovenox , her anticoagulation therapy was discontinued after event.",1
She completed 1 month treatment with Coumadin prior operation and treatment with anticoagulation medication is no longer required.,0
"The patient was tolerating a sips of clears, ambulating, voiding without assistance, and pain was well controlled.",0
"Medications on Admission: Warfarin 5mg daily, albuterol, pantoprazole 40mg daily, Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day).",0
Pantoprazole 40 mg IV Q24H 4.,0
Metoclopramide 10 mg IV Q6H 5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching.,0
6. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).,0
7. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: Drops Ophthalmic PRN (as needed) as needed for eye irritation.,0
"8. bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain.,0
DiphenhydrAMINE 25 mg IV Q6H:PRN itch 11.,0
Pantoprazole 40 mg IV Q12H 12.,0
Ampicillin-Sulbactam 3 g IV Q6H cholangitis Start: Stat 13. ampicillin-sulbactam 3 gram Piggyback Sig: One (1) dose Intravenous every six (6) hours for 5 days.,1
14. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 12 days.,0
Ondansetron 4 mg IV Q6H:PRN nausea 16.,0
HYDROmorphone (Dilaudid) 0.2-0.4 mg IV Q2H:PRN pain 17. insulin regular human 100 unit/mL Solution Sig: 2-10 units Injection four times a day: please follow the sliding scale.,0
Discharge Disposition: Extended Care Facility: Northeast - Discharge Diagnosis: 1.,0
"Recurrent pancreatic pseudocyst/abscess, following endoscopic drainage.",0
Prolonged PO intolerance Discharge Condition: Mental Status: Clear and coherent.,0
"PICC Line: *Please monitor the site regularly, and your MD, nurse practitioner, or Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site.",0
"* your MD to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely.",0
DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry.,0
Contact your Nurse if the dressing comes undone or is significantly soiled for further instructions.,0
"*Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever).",0
Followup Instructions: Please follow up with Dr. in days for a follow up visit.,0
The number to call and make this appointment is (.,0
", C. NMED TSICU 4:41 AM MR HEAD W/O CONTRAST Clip # Reason: please eval for acute infarct territory as pt needs to be st Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with left sided neglect REASON FOR THIS EXAMINATION: please eval for acute infarct territory as pt needs to be started on heparin for afib.",0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Infarct along the insular cortex and temporal and frontal operculum.,0
This is in MCA distribution.,0
"No large hematoma, mass effect or midline shift seen.",0
"9:47 AM CT HEAD W/O CONTRAST Clip # Reason: Interval change, residual blood.",0
Planning for EVD level Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with Intraventricular hemorrage s/p drainage.,0
"REASON FOR THIS EXAMINATION: Interval change, residual blood.",0
"Planning for EVD level change No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc TUE 5:58 PM Overall, minimally changed study from that done one day prior.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Intraventricular hemorrhage status post drain.,0
COMPARISON: Comparison is made to CT of the head from .,0
"TECHNIQUE: Contiguous, axial CT images were acquired through the brain in the absence of intravenous contrast.",0
"FINDINGS: Overall, this study is minimally changed from that done one day prior.",0
A burr hole at the left frontal bone with ventricular drain terminating near the third ventricle is unchanged.,0
Also unchanged is left intraventricular hemorrhage with mild amount of surrounding vasogenic edema.,0
1-2 mm right shift of normal midline structures is also unchanged.,0
There is no new area of hemorrhage.,0
Mucosal thickening at the maxillary sinuses bilaterally as well as in the ethmoid air cells is also unchanged.,0
"IMPRESSION: Overall, minimally changed study from that done one day prior.",0
LINE PLACEMENT Clip # Reason: post-placement of right TLC Admitting Diagnosis: CORONARY ARTERY DISEASE; ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with CABG REASON FOR THIS EXAMINATION: post-placement of right TLC ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with CABG.,1
"The patient was extubated in the meantime interval with removal of the NG tube, Swan-Ganz catheter replacement by the right internal jugular line.",0
The mediastinal drain is in place.,0
The left chest tube is in unchanged position.,0
The right internal jugular line tip is in the proximal right atrium and to secure its position in the distal SVC might be pulled back for about 3 cm.,0
There is minimal left apical pneumothorax with no right pneumothorax.,0
"The left retrocardiac opacity has increased in the interim, most likely consistent with atelectasis due to termination of mechanical ventilation.",0
Small amount of left pleural effusion is unchanged.,0
", J. NSURG SICU-B 10:46 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: extent of infarct?",0
"Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with stroke, s/p IA tPA REASON FOR THIS EXAMINATION: extent of infarct?",0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Area of infarct and subsequent hemorrhagic transformation in the region of the right putamen and globus pallidus with small amount of surrounding edema and mass effect on the right lateral ventricle without significant midline shift.,0
Diffusion-weighted images hard to interpret due to large amount of blood.,0
8:51 AM CHEST (PORTABLE AP) Clip # Reason: Recurrent fever spikes ______________________________________________________________________________ MEDICAL CONDITION: 49 yo man with persistent fevers.,0
"need to check placement of ngt for po contast for ct. REASON FOR THIS EXAMINATION: Recurrent fever spikes ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : CLINICAL INDICATION: Recurrent fever spikes.",0
Comparison is made to previous study of one day earlier.,0
The examination is limited as the patient was unable to cooperate with standard radiographic positioning.,0
This resulted in incomplete imaging of the right lung.,0
A NGT is no longer visualized.,0
The right PICC line remains in place terminating near the junction of the SVC and right atrium.,0
The cardiac and mediastinal contours are stable allowing for rightward rotation of the patient.,0
"The imaged portion of the right lung demonstrates some persistent patchy areas of increased opacity, but this is difficult to compare due to differences in positioning.",0
IMPRESSION: 1) No NGT is visualized.,0
"If one is indeed present, it may be coiled within the oropharynx.",0
2) Limited assessment of the lungs due to incomplete imaging of the right lung.,0
Repeat radiograph is suggested to allow better comparison to the previous study.,0
9:59 PM GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) PORT Clip # Reason: Please perform US for paracentesis guidance.,0
"______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with ovarian hyperstimulation syndrome markedly enlarged ovaries, ascites.",0
REASON FOR THIS EXAMINATION: Please perform US for paracentesis guidance.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Ascites.,0
Ultrasound localization for paracentesis without a radiologist: Large pocket of free fluid was identified in the left abdomen.,0
The skin was marked over this pocket of fluid in the left mid axillary line of mid abdomen.,0
The MICU physicians were present during imaging.,0
Paracentesis was performed in the absence of a radiologist.,0
"8:46 AM CT HEAD W/O CONTRAST Clip # Reason: eval for interval changes in AM Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 62M known subdural, increased in size today's CT. asymptomatic REASON FOR THIS EXAMINATION: eval for interval changes in AM No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: Followup study to assess subdural hemorrhage.",1
"FINDINGS: Comparison with the prior head CT scan of the previous day reveals, if anything, slightly less prominence of the extremely tiny posterior superior interhemispheric subdural hemorrhage.",1
There are no new areas of intracranial hemorrhage identified.,0
There is no change in ventricular size.,0
"The surrounding osseous and soft tissue structures show no overt interval changes, although it is to be emphasized that this study does not completely and optimally evaluate the facial skeleton and orbits.",0
CONCLUSION: Minimal to negligible change in tiny interhemispheric subdural hemorrhage.,1
Results were discussed with the housestaff taking care of the patient at 9:20 a.m. on .,0
"5:41 PM CHEST (PORTABLE AP) Clip # Reason: assess pna, effusion Admitting Diagnosis: SEPSIS;THROMBOCYTOPENIA;MENTAL STATUS CHANGES ______________________________________________________________________________ MEDICAL CONDITION: 33F w/ septic shock, probable pna REASON FOR THIS EXAMINATION: assess pna, effusion ______________________________________________________________________________ FINAL REPORT INDICATION: A 33-year-old with septic shock and probable pneumonia.",1
AP UPRIGHT CHEST: No priors for comparison.,0
A right IJ line is seen with its tip in the caval-atrial junction.,0
NG tube seen coursing up the screen.,0
"At the left base, there is likely effusion and consolidation, which given the clinical history is consistent with pneumonia.",1
Atelectasis at the right base.,0
The upper lung zones are clear.,0
The heart is within normal limits of size and the mediastinal and hilar contours are unremarkable.,0
IMPRESSION: 1) Probable left lower lobe pneumonia and effusion.,0
2) Right basilar opacity likely representing atelectasis.,0
3) Satisfactory central line placement; no pneumothorax.,0
"REASON FOR THIS EXAMINATION: r/o stenosis or thrombosis, please do ANGIOPLASTY if needed BUT NO STENTING please.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: A 64-year-old male with bacteremia, end stage renal disease, on hemodialysis with left arm AV fistula, with left arm swelling.",1
"PROCEDURE/FINDINGS The procedure was performed by , M.D.",0
"with Dr. , attending radiologist, present and supervising.",0
"After explaining the risks and benefits of the procedure to the patient, a written and informed consent was obtained.",0
The patient was placed supine on the angiographic table.,0
The pre-procedure timeout was performed.,0
Ultrasound was used to access the fistula after local administration of 1% lidocaine with a 21-gauge micropuncture needle.,0
An 0.18 glidewire was advanced through the needle into the vein.,0
The needle was exchanged for a 5- French micropuncture sheath within a dilator.,0
The inner dilator and wire were removed.,0
A venogram was then performed through this sheath.,0
"This demonstrated a small cephalic vein, multiple collaterals are seen in the area of the axillary vein, and subclavian vein.",0
A tight stenosis is seen in the left brachial cephalic vein at this junction with the superior vena cava with a filling defect within it.,0
"A blood pressure cuff was then inflated in the upper arm, in order to identify the arterial anastomosis.",0
"However, the arterial anastomosis could not be identified.",0
"wire was then advanced through the micropuncture sheath, and the sheath exchanged for a 6- French broad-tipped sheath within a dilator.",0
A C2 Cobra catheter was then advanced over the wire up to the left axillary region.,0
The wire was exchanged for an 0.35 stiff glidewire which was maneuvered into the superior vena cava.,0
"The C2 catheter was advanced further adjacent to the left brachial cephalic vein, and a venogram performed, which again demonstrated the previously visualized tight stenosis.",0
"Based on these (Over) 10:46 AM AV FISTULOGRAM SCH Clip # Reason: r/o stenosis or thrombosis, please do ANGIOPLASTY if needed Admitting Diagnosis: CIRRHOSIS BACTEREMIA;VANCOMYCIN RESISTANT ENTEROCOCCUS;METHICILLIN RESISTANT STAPH AUREUS Contrast: OPTIRAY Amt: 315 ______________________________________________________________________________ FINAL REPORT (Cont) diagnostic findings, it was decided that the patient would benefit from and was a good candidate for angioplasty.",0
The C2 catheter was removed.,0
The 6- French sheath was exchanged for a 7- French bright tip sheath within a dilator.,0
A 10 mm x 4 cm balloon was advanced across the area of stenosis and angioplasty performed.,0
This was followed by a 12 mm x 4 cm balloon across the area of stenosis.,0
A subsequent venogram demonstrated only partial response.,0
"We then advanced an 8 mm x 2 cm cutting balloon over a V-18 0.18 guidewire across the area of stenosis, followed by 10 mm x 4 cm balloon.",0
"A final venogram again demonstrated partial response with dilated subclavian vein, aneurysmal dilation of the proximal fistula.",0
An ultrasound examination of the left upper extremity venous system would be beneficial to evaluate both the inflow and outflow of the fistula.,0
The patient was then transferred to the recovery area where the vascular sheath was removed and manual pressure applied until adequate hemostasis was achieved.,0
"IMPRESSION: Small cephalic vein, multiple central collaterals with tight stenosis and filling defect in the left brachial cephalic vein dilated with 8-12 mm balloons demonstrating partial response.",0
Balloon angioplasty of the left subclavian vein.,0
Aneurysmal dilatation of the proximal fistula.,0
Arterial anastomosis not clearly seen.,0
3:04 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 80 yo F with R cerebellar hemorrhage REASON FOR THIS EXAMINATION: interval change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 80-year-old female with right cerebellar hemorrhage.,0
FINDINGS: There has been overall no change in the right cerebellar hemorrhage measuring 4.1 x 3.1 cm compared to 4.1 x 3.1 cm previously.,0
"There is persistent extension of blood products at the left cerebellar hemisphere, third and fourth ventricles, and interpeduncular fossa.",0
Blood products are also again noted layering in the left occipital .,0
There is decreased conspicuity of blood products within the right frontal .,0
A ventricular drainage catheter is again noted from a left frontal approach terminating in the region of the foramen of .,0
The caliber of the lateral ventricles is similar to the prior study.,0
"There is a linear hyperdense focus in the right frontal convexity (2:22) which could represent contrast within a vessel from the recent CTA, however, a new focus of hemorrhage is not excluded.",0
A punctate focus of pneumocephalus is again noted along the left frontal convexity.,0
Confluent periventricular white matter hypodensity is compatible with chronic small vessel ischemic disease.,0
Visualized paranasal sinuses and mastoid air cells are well aerated.,0
"Stable appearance of right cerebellar intraparenchymal hemorrhage with extension into the third and fourth ventricles, interpeduncular fossa and lateral ventricle.",0
"Linear radiodense focus in the right frontal region may be related to recent contrast administration; however, a new or evolving focus of subarachnoid hemorrhage is not excluded and attention is recommended on followup.",0
"Unchanged position of intraventricular catheter from a left frontal approach, with stable size of the lateral ventricles.",0
(Over) 3:04 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont),0
"5:13 PM CHEST (PORTABLE AP) Clip # Reason: r/o ptx, confirm line position Admitting Diagnosis: VAGINAL BLEEDING ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman s/p subclavian line placement; please do not come until we call thanks REASON FOR THIS EXAMINATION: r/o ptx, confirm line position ______________________________________________________________________________ FINAL REPORT History of subclavian CV line placement.",0
Subclavian Cordis catheter is in left subclavian vein.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: NG tube Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with stroke s/p NGT REASON FOR THIS EXAMINATION: NG tube ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: NG tube placement.,0
Portable AP chest radiograph was compared to obtained at 6:37 p.m.,0
Cardiomediastinal silhouette is unchanged including cardiomegaly.,0
10:03 PM MR THORACIC SPINE W/O CONTRAST Clip # Reason: please evaluate 2 levels above T12 and 2 below for further c ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with T12 fracture w/ retropulsed fragment seen on CT at OSH REASON FOR THIS EXAMINATION: please evaluate 2 levels above T12 and 2 below for further characterization and ?,1
"cord involvement ______________________________________________________________________________ WET READ: DJD SUN 11:40 PM There is, in fact, posterior retropulsion of T12 into the epidural space.",0
"The fragmant impresses on the anterior margin of the conus, R>L and extends into the R lateral recess of T12 MD ______________________________________________________________________________ FINAL REPORT INDICATION: 32-year-old with T12 fracture and retropulsed fracture fragment, assess for cord edema.",0
TECHNIQUE: Multiplanar T1- and T2-weighted images of the thoracic spine without the administration of IV contrast.,0
Comparison is made to thoracic spine CT performed 15 minutes earlier.,0
FINDINGS: There is a burst fracture of the T12 vertebral body with retropulsion of fracture fragments into the left aspect of the spinal canal with resultant cord compression.,1
Increased signal intensity is seen in the spinal cord at this level extending superiorly posterior to the T11 vertebral body.,1
"Increased signal intensity is seen in the soft tissues posteriorly at the level of T12, suggestive of ligamentous injury.",0
"On the sagittal T1- weighted images, there is a convex rim of slightly increased T1 signal intensity posterior to the T12 vertebral body extending superiorly to the T11-12 disc interspace and inferiorly along the L1 vertebral body, which may represent a small epidural hematoma.",0
Visualized intra-abdominal contents appear normal.,0
Burst fracture of the T12 vertebral body with retropulsed fracture fragment causing spinal cord compression and edema at this level.,1
"Probable small epidural hematoma at the T12 level extending superiorly to the T11-12 interspace and inferiorly, posterior to the L1 vertebral body.",0
Findings were discussed with Dr. at 4:00 p.m. on .,0
"1:57 AM CHEST (PORTABLE AP) Clip # Reason: eval CXR Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man s/p exlap, anastamotic leak, bronch REASON FOR THIS EXAMINATION: eval CXR ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Status post exploratory laparotomy anastomotic leak.",0
ET tube tip is 7cm above the carina.,0
Right IJ catheter tip is in the SVC.,0
There is no evident pneumothorax.,0
Left lower lobe retrocardiac atelectasis is unchanged.,0
Left pleural effusion is unchanged.,1
The right lung is grossly clear.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: /INTERNAL MEDICINE HISTORY OF THE PRESENT ILLNESS: Mr. was a 50-year-old gentleman with a history of hepatopulmonary syndrome, hypoxemia, end-stage liver disease, and DIC who was transferred from an outside hospital after being found down and apneic.",1
HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit at the and aggressive measures were made to support the patient's respiratory status.,0
"Unfortunately, however, the patient succumbed to his hepatopulmonary syndrome and continued active bleeding to his lungs and gastrointestinal tract from fistulae in his lungs and from his DIC.",0
"He expired on after being made comfort measures only by his family, specifically his brother.",0
Dictated By: MEDQUIST36 D: 02:00 T: 16:03 JOB#:,0
4:27 PM CT CHEST W&W/O C ; CT ABD & PELVIS WITH CONTRAST Clip # Reason: evidence of abscesses?,0
please c Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with endocartis and septic emboli.,0
REASON FOR THIS EXAMINATION: evidence of abscesses?,0
please consider CT torso both with and without contrast.,0
Please do at least CT torso with contrast.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old female with endocarditis and septic emboli.,1
COMPARISON: MRI brain dated and abdominal ultrasound dated .,0
TECHNIQUE: MDCT images were acquired from the thoracic inlet through the pubic symphysis prior to and following administration of intravenous and oral contrast with multiplanar reformations.,0
CT CHEST: The tracheostomy tube terminates 2.6 cm above the carina.,0
There is a left-sided PICC with tip terminating in the cavoatrial junction.,1
"The tracheostomy tube appears to enter the airway from the right, displacing what appears to be fluid filled proximal trachea to the left (5, 1).",0
The heart is normal in size without pericardial effusion.,0
There are bilateral small pleural effusions with compressive atelectasis.,0
"Allowing for significant respiratory motion, there is likely a component of interstitial edema.",0
Assessment for focal lesion is highly limited.,0
CT ABDOMEN: There is a large non-hemorrhagic abdominal ascites.,0
"The liver appears small and nodular in contour, suggestive of cirrhosis.",1
"The gallbladder demonstrates mild redundancy towards the fundus, compatible with a Phrygian cap.",0
"The spleen is top normal in size measuring up to 12 cm, with confluent hypodensity involving much of the anterior superior aspect of the spleen (5, 41), as well as additional scattered foci of wedge-shaped peripheral hypoattenuation, consistent with multi-focal splenic infarction.",0
The pancreas and adrenal glands appear within normal limits.,0
"Bilateral kidneys also demonstrate areas of wedge-like infarcts (for example 5, 69).",0
There is no hydronephrosis or hydroureter.,0
Small and large bowel loops appear normal in caliber.,0
Assessment for lymphadenopathy is limited due to presence of ascites.,0
"CT PELVIS: The bladder dome contains air, presumably post-instrumentation.",0
A Foley catheter and a rectal tube are in place.,0
The uterus and adnexa appear within normal limits.,0
"There are bilateral adnexal cysts, measuring 2.7 x 2.6 cm on the left and 2.8 x 2.4 cm on the right, which would be within normal limits in a menstruating patient.",0
"If patient is postmenopausal, these should be assessed by ultrasound.",0
(Over) 4:27 PM CT CHEST W&W/O C ; CT ABD & PELVIS WITH CONTRAST Clip # Reason: evidence of abscesses?,0
please c Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) There is marked anasarca.,0
BONE WINDOW: No focal concerning lesion.,0
Small bilateral pleural effusions with compressive atelectasis.,0
Nodular liver contour suggestive of cirrhosis.,1
"Large volume splenic infarct and bilateral renal infarcts, compatible with history of endocarditis and septic emboli.",1
Findings reported to Dr. via phone at 5:50 pm on .,0
11:55 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: 27 week infant with HMD s/p line placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with above REASON FOR THIS EXAMINATION: 27 week infant with HMD s/p line placement ______________________________________________________________________________ FINAL REPORT HISTORY: Line placement for hyaline membrane disease.,1
Umbilical venous catheter present with its tip in the region of the ductus venosus.,0
ET tube present with tip overlying C7-T1.,0
Diffuse hazy opacification and hypoinflation of the lungs consistent with hyaline membrane disease.,0
Normal bowel gas pattern for age.,0
IMPRESSION: ET tube high in position.,0
Changes consistent with hyaline membrane disease.,0
", CSURG FA6A 9:54 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: ?",0
"gastric dilatation, bowel obstruction Admitting Diagnosis: CHF ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman s/p redo sternotomy/AVR w/ nausea and emesis REASON FOR THIS EXAMINATION: ?",0
"gastric dilatation, bowel obstruction ______________________________________________________________________________ PFI REPORT No evidence of distended bowel.",0
"7:53 AM CHEST (PORTABLE AP) Clip # Reason: s/p craniotomy POD 0, CXR eval ETT Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 71 yo M with mild head trauma , s/p bilateralevacuation of acute on chronic subdural hematomas , returnswith worsening headaches with left-sidedsubdural now s/p Left craniotomy with evacuation of SDH X 2 REASON FOR THIS EXAMINATION: s/p craniotomy POD 0, CXR eval ETT ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.",0
REASON FOR EXAM: Chronic subdural hematoma.,0
"FINDINGS: Since the previous study, the patient has been intubated with its tip at the thoracic inlet and 7.3 cm above the carina.",0
Bilateral infrahilar airspace opacities are new and could be due to aspiration or evolving infection.,0
"The lungs are otherwise clear, with no pneumothorax or pleural effusion.",0
IMPRESSION: Bilateral infrahilar airspace opacities could be due to aspiration or evolving infection.,0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: Neonatology INTERIM HISTORY: Baby is a 1370 gram male boy who was born on at 31-4/7 weeks of gestation.,1
He has trisomy-21 and was admitted to the Neonatal Intensive Care Unit for prematurity and respiratory distress.,1
"Mother is a 29 year-old female, gravida I, para 0, I. Prenatal screens were O positive, antibody negative, hepatitis B negative, Rubella immune, RPR nonreactive and HSV negative.",0
Prenatal son did not show any structural heart disease.,0
Fetal ultrasounds did have indication for echogenicities in the bowel that resolved on subsequent ultrasounds.,0
Mother received a full course of betamethasone in mid-.,0
was delivered by cesarean section for worsening uteroplacental insufficiency with absence of end diastolic flow on the ultrasound.,1
Rupture of membranes was at delivery with clear fluid.,0
Apgars were 7 and 9 at one and five minutes respectively.,0
"He was vigorous, active with spontaneous respirations at delivery.",0
"Upon admission to the Neonatal Intensive Care Unit his weight was 1370 grams (75%), length 41.5 cm (50%) and head circumference 28 cm (50%).",1
"Vital signs: Heart rate 122, temperature 97.9, respiratory rate 50s, blood pressure 77/43 and mean of 55.",1
"In general: Infant was a dysmorphic, premature baby in mild respiratory distress.",0
"Anterior fontanelle open and flat, wide set eyes, low -set ears and upslanting palpebral fessures, flat occiput.",0
"S1 and S2, full femoral pulses.",0
"No flaring, grunting or tachypnea on room air.",0
Coarse breath sound decreased but equal bilaterally.,0
"Extremities warm, pink, well perfused.",0
"Positive simian crease on upper extremities, spacing between first and toes on lower extremities.",0
"Genitourinary: Normal male genitalia, testes descended bilaterally.",0
HOSPITAL COURSE BY SYSTEM: Respiratory: He was placed initially on nasal CPAP with 21% of FIO2 for 1 day and then was gradually weaned and changed to room air.,1
"Initially he had some apnea, then bradycardia especially with feeding but gradually resolved and currently he is breathing room air and his respirations are between 40 to 60 breaths per minute.",1
His last documented apnea or bradycardia of prematurity was .,1
Cardiology: Initially there was no murmur but during the hospital stay he has had an intermittent soft systolic murmur heard at the left sternal border.,0
The femoral pulses are full and positive bilaterally.,0
His blood pressure is in the range of 77/44 with a mean of 50 and his heart rate is between 140 to 150s.,0
"An electrocardiogram was done which showed slight left axis deviation and an echocardiogram was revelaed a small atrial septal defect versus patent foramen of ovale, qualitatively normal left ventricular systolic function and no pericardial effusion.",1
"Fluids, Electrolytes and Nutrition: He was kept NPO for the first day and given IV fluids.",0
Feedings were gradually started on the second day of life and IV fluids were weaned.,0
"Currently, he is feeding Breast Milk at the breast or expressed breast milk with 24 calories per ounce supplemented with Similac Powder.",0
He is also being sent home on Goldline baby multivitamins.,0
Discharge weight is 2555 grams.,0
During the hospital course he had hyperbilirubinemia and was placed on phototherapy.,0
The maximum bilirubin was 8.7 with a direct of .3 on day of life 5.,0
His last bilirubin was 7.0/0.3 on day of life 11 ().,0
Hematology: His last hematocrit was on which revelaed a count of 42 with a reticulocyte count of 3.7.,0
He is being sent home on supplemental iron.,0
Infectious disease: He received oxacillin and gentamicin for 2 days.,0
GI: He has a small umbilical hernia on exam.,1
Neurology: He had two head ultrasounds.,0
The first on did not reveal any abnormlities.,0
The second on revealed a small resolving subependymal bleed on the left.,0
Audiology: Hearing screen was performed on and he passed in both ears.,0
Ophthalmology: The initial ophthalmology screen which was done on revelaed immature retina to zone 3.,0
The repeat screen on showed mature retina.,0
Follow-up is recommended at 9 months of age.,0
Genetics: A chromosome study on confirmed the diagnosis of trisomy 21.,0
Social: The family was consulted by the social worker.,0
The social worker can be reached at .,0
"PRIMARY PEDIATRICIAN: Dr. and , NNP at the House.",0
Feeding: Breast Nilk and/or Similac 24 po ad lib.,0
Medications: (a) Goldline baby multivitamins 1 ml po qday.,0
(b) Ferrous Sulfate (concentration 25 mg/ml) 0.4 ml po qday.,0
Car seat position screen: Passed.,0
State newborn screening status: Samples sent and .,0
No abnormal results have been reported.,0
Immunizations received: Hepatitis B vaccine on .,0
Synagis RSV prophylaxis should be considered from through for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks.,1
"2) born between 32 and 35 weeks with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings, or 3) with chronic lung disease.",1
Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers.,0
Pediatrician within 2 days of discharge.,0
Gentics/Down Syndrome Clinic at ().,0
Ophthamology at 9 months of age.,0
"Bay Cove Early Intervention Program, .",0
Prematurity at 31 weeks of gestation.,1
Atrial Septal Defect versus Patent Foramen Ovale.,1
", Dictated By: MEDQUIST36 D: 14:18:42 T: 15:06:12 Job#:",0
4:16 PM CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: mass?,0
"Admitting Diagnosis: SHORTNESS OF BREATH Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man admitted for aspiration pna with cognitive decline, trouble swallowing.",0
hx of tougue cancer REASON FOR THIS EXAMINATION: mass?,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Cognitive decline and difficulty swallowing.,0
Contiguous axial images were obtained through the brain.,0
Imaging was performed before and during intravenous administration of 100 cc of Optiray contrast.,0
Comparison to a neck CT of .,0
"FINDINGS: Images of the brain demonstrate no evidence of mass, mass effect, edema, hemorrhage, or infarction.",0
There is no abnormal enhancement after contrast administration.,0
The brain imaging appears normal.,0
"Again identified is opacification of the right mastoid air cells, unchanged since the study of .",0
CONCLUSION: The brain appears normal.,0
Again identified is right mastoid opacification.,0
"9:09 AM CHEST (PORTABLE AP) Clip # Reason: please assess location of ngt Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with cad, bronchitis, and severe AS s/p AVR.",0
"REASON FOR THIS EXAMINATION: please assess location of ngt ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, AT 10:27: INDICATION: Check NGT.",0
FINDINGS: The NGT is seen with the tip coiled in the fundus of the stomach.,0
The current study shows a shallow level of inspiration which could be partially responsible for the increased overall density to the lungs with crowded vessels.,0
In addition this is less penetrated compared to the prior.,0
Of note I do not clearly visualize a pneumothorax.,0
The heart size is unchanged.,0
IMPRESSION: NGT with tip coiled in fundus of the stomach.,0
"2:07 PM CHEST (PORTABLE AP) Clip # Reason: infiltrate Admitting Diagnosis: CHEST PAIN;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man s/p AVR/annular repair REASON FOR THIS EXAMINATION: infiltrate ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: 35-year-old man status post AVR annual repair.,0
FINDINGS: Swan-Ganz catheter has been removed.,0
There remains a left IJ central venous catheter with tip at the cavoatrial junction.,0
Tip of the endotracheal tube is 3.5 cm above the carina and appropriately sited.,0
The lung fields are unchanged with a left retrocardiac opacity and small bilateral pleural effusions.,1
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM: On the patient continued to be febrile with temperatures up to 104.6.",0
On further evaluation it was discovered that he had a large decubitus ulcer.,0
Plastic surgery was contact and evaluated the patient and felt convinced that the ulcer was rather shallow and they recommended normal saline wet to dry dressings tid and also continued antibiotic coverage for 21 days.,0
"The patient was started on Vanco, Levo and Flagyl on and to complete a course of 21 days.",0
Ongoing discussions occurred regarding a gallium scan that was obtained on the 21st after 48 hours of injection.,0
The gallium scan is reported preliminarily as negative with no evidence of infection.,0
The patient continues to have fevers though the fever curve is down.,0
"Over the last 24 hours has been around 100 to 101, was 104-105 before.",0
The patient was seen by neurology on and they felt that the patient's generalized weakness was from deconditioning and a toxic metabolic picture from his general medical condition.,0
"The patient had occasional tachypnea while in the unit, prompting his pressure support to be increased to 25 and his PEEP to 5.",0
"Over the last two days, the 20th and the 21st the patient's pressure support was decreased, most recently to 10.",0
The patient is very anxious at baseline and becomes tachypneic during those episodes.,0
His amylase and lipase have normalized.,0
"His LFTs continue to show total bilirubin is mildly elevated, last check was 2.5 on with a normal amylase.",0
I have discussed patient's T tube with surgery who recommend keeping the tube in for more weeks for discontinuation at some point in mid .,0
Would continue to follow LFTs.,0
The patient also had a Dobbhoff tube placed at bedside for feedings and his feedings were also changed to Ultracal with a goal rate of 100 cc per hour.,0
The other important addended issue is that the patient has a CD4 count of 217 with the infectious disease doctors against PCP.,1
patient is allergic to Sulfa and Dapsone.,0
Please see page 1 for further details about decision regarding recommendations for PCP .,0
Dictated By: MEDQUIST36 D: 16:03 T: 17:22 JOB#:,0
"8:37 PM CHEST (PORTABLE AP) Clip # Reason: evaluate tip of ETT, evaluate for PNA Admitting Diagnosis: SEIZURE DISORDER ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with seizures, recent aspiration PNA (LLL) and left pleural effusion, intubated REASON FOR THIS EXAMINATION: evaluate tip of ETT, evaluate for PNA ______________________________________________________________________________ FINAL REPORT HISTORY: ET tube placement.",0
Endotracheal tube tip lies approximately 4 cm above the carina.,0
Right IJ catheter extends to the upper portion of the SVC.,0
Nasogastric tube is coiled within the upper stomach.,0
"Cardiac silhouette is within normal limits, and there is no vascular congestion or acute pneumonia.",0
"There may be minimal atelectatic changes at the left base, though a lateral view would be helpful to further evaluate this region.",0
PATIENT/TEST INFORMATION: Indication: Intraop CABG ?AVR.,0
"Evaluate valves, wall motion, aortic contours Height: (in) 69 Weight (lb): 160 BSA (m2): 1.88 m2 Status: Inpatient Date/Time: at 10:31 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness and cavity size.",1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; anterior apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
The MR vena contracta is <0.3cm.,0
"Mild (1+) MR. to the eccentric MR jet, its severity may be underestimated (Coanda effect).",0
Conclusions: Pre Bypass: Left ventricular wall thicknesses and cavity size are normal.,0
There is mild regional left ventricular systolic dysfunction with mild to moderate anterior hypokinesis.,0
"An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen.",0
"Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect).",0
Post Bypass: Preserved biventricular function with some interval improvement in anterior wall motion.,0
"2:43 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: f/u small RT ptx Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEVERE MITRAL REGURGITATION;COPD\CATH ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with MVrepair REASON FOR THIS EXAMINATION: f/u small RT ptx ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 6:38 PM Right pneumothorax increased, now moderate.",1
Pneumomediastinum and bilateral subcutaneous emphysema are new.,0
______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP REASON FOR EXAM: 76-year-old woman with MV repair.,0
"Since earlier today at 11:22, right pneumothorax increased, now moderate.",0
"Pneumopericardium also increased, still small.",0
"Retrocardiac opacity persists, could be atelectasis.",0
There is no other change.,0
Results were paged immediately to Dr. at the time of dictation.,0
"7:11 PM CHEST (PORTABLE AP) Clip # Reason: S/P RT IJ TLC PLACEMENT; R/O PNEUMO, ASSESS POSITION; ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with stroke, gi bleed s/p NGT tube placement REASON FOR THIS EXAMINATION: S/P RT IJ TLC PLACEMENT; R/O PNEUMO, ASSESS POSITION; ______________________________________________________________________________ FINAL REPORT INDICATION: Stroke and GI bleeds.",0
Status post NG tube and right IJ CVL placement.,0
PORTABLE AP CHEST: NG tube has tip in the stomach.,0
"There is interval repositioning of right IJ CVL, now with tip in upper SVC.",0
Lucency along the right apical pleura is unlikely to represent a pneumothorax in the absence of additional instrumentations since the prior study.,0
"Lungs are hyperinflated with flattening of the hemidiaphragms, suggestive of background emphysema.",0
"Biapical linear opacities are likely unchanged, allowing for differences in technique.",0
Soft tissues and osseous structures are unremarkable.,0
IMPRESSION: Right IJ CVL with tip in upper SVC following repositioning.,0
11:09 AM CHEST (PA & LAT) Clip # Reason: ?,0
reaccumulation of fluid Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with follicular lymphoma and malignant pleural effusions s/p thoracentesis earlier in course REASON FOR THIS EXAMINATION: ?,1
reaccumulation of fluid ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST RADIOGRAPH OF COMPARISON: chest radiograph.,0
FINDINGS: Left pleural effusion has increased in size and is now moderate.,1
Small right pleural effusion is not appreciably changed.,1
Bibasilar lung opacities adjacent to pleural effusions probably reflect atelectasis.,1
IMPRESSION: Increasing left pleural effusion.,1
", T. NMED FA11 3:21 PM MR HEAD W & W/O CONTRAST Clip # Reason: tumor recurrence?",0
Please perform brain tumor protocol and a Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 13 ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with oligodendroglioma resection s/p surgery and seizuresPlease do after the EEG leads are off REASON FOR THIS EXAMINATION: tumor recurrence?,0
Please perform brain tumor protocol and arterial spin labelling No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Right frontal postoperative changes.,0
Unchanged FLAIR abnormalities with unchanged or slightly decreased enhancement in the right frontal region.,0
No new areas of enhancement.,0
"5:52 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate left lung collapse vs infiltrate Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with large cell Ca & tumor burden encasing left main stem bronchus, resolving resp distress and s/p treatment for obstructive PNA REASON FOR THIS EXAMINATION: please evaluate left lung collapse vs infiltrate ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP on .",1
HISTORY: Please evaluate left lung collapse versus infiltrate for a 64-year- old woman with large cell cancer tumor burden encasing left mainstem bronchus status post treatment for obstructive disease.,1
"FINDINGS: In the interim, the left upper lung has reexpanded indicating almost complete resolution of atelectasis, most likely secondary to an endobronchial mucous plug.",0
The left heart border is actually visualized on today's examination indicating a lingular reexpansion.,0
There is persistent silhouetting of the left hemidiaphragm indicative of basilar atelectasis with a coexistent left pleural effusion.,0
"Bulky mediastinal masses are still seen in both right and left hilar regions, with significant narrowing of the left main bronchus.",0
The right lung is relatively clear.,0
The patient is status post cardiothoracic surgery with sternotomy wires.,1
"Significant improvement in aeration of the left upper lung as well as the lingular region, most likely secondary to resolution of an intrabronchial mucous plug.",0
Persistent mediastinal and hilar masses encasing and narrowing the left main bronchus.,0
Bilateral small pleural effusion with persistent left lower lobe collapse.,0
The report was telephoned to the doctors taking of the patient.,0
Height: (in) 67 BP (mm Hg): 153/63 HR (bpm): 89 Status: Inpatient Date/Time: at 14:04 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Patient reportedly has a 21 mm porcine aortic valve.,0
This study was compared to the prior study of .,0
No resting or Valsalva inducible LVOT gradient.,0
Mild functional MS due to MAC.,0
There is no left ventricular outflow obstruction at rest or with Valsalva.,0
The transaortic gradient is higher than expected for this type of prosthesis (expected upper limit is <23 mmHg).,0
There is a mild mitral inflow gradient due to mitral annular calcification.,0
Mild (1+) mitral regurgitation is seen (but may be underestimated).,0
"Compared with the prior study (images reviewed) of , findings are similar.",0
", M. NSURG SICU-A 10:18 AM CTA HEAD W&W/O C & RECONS Clip # Reason: please evaluate for arterial blood supply to right sided mas Admitting Diagnosis: BRAIN MASS Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with huge right frontoparietal mass REASON FOR THIS EXAMINATION: please evaluate for arterial blood supply to right sided mass.",0
"No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Extremely large partially calcified, probably extra-axial mass in the right temporal lobe.",0
"There is minimal if any supply from the middle cerebral artery, which appears to be predominantly lifted up and displaced by the mass, rule out it is not encased by it.",1
Recommend evaluation with dedicated diagnostic cerebral angiogram to delineate the vascular supply for this lesion.,0
No definite aneurysm is seen.,0
"There is a soft tissue thickening in the left frontal scalp, recommend correlation with direct visualization and palpation.",0
"5:12 AM CHEST (PORTABLE AP) Clip # Reason: ?interval change Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p esophagectomy REASON FOR THIS EXAMINATION: ?interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old man status post esophagectomy, query interval change.",0
SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: There is stable cardiomegaly.,0
The mediastinal and hilar contours are unchanged.,0
Chest tubes are seen on the right.,0
There is an OG tube with its tip projecting below the diaphragm.,0
A Left IV catheter tip projects over the lower SVC.,0
There is an increased left pleural effusion and right effusion with associated bibasilar atelectasis.,0
Postoperative changes are seen on the right including mediastinal clips.,0
"IMPRESSION: Increase in bibasilar effusions and associated atelectasis, worst on the left, and postoperative changes.",0
1:46 PM CHEST (PORTABLE AP) Clip # Reason: LINE PLACEMENT Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with REASON FOR THIS EXAMINATION: LINE PLACEMENT ______________________________________________________________________________ FINAL REPORT INDICATION: Line placement.,0
"The examination is technically limited, as the lateral aspect of the left mid and lower lung zones have been excluded from the radiograph.",0
The ordering physician requested that the film not be repeated if the indication was line placement and the line placement was on the right side.,0
"A right subclavian vascular catheter is present, with the distal tip terminating within the superior vena cava.",0
There is no evidence of pneumothorax on the supine radiograph.,0
Endotracheal tube and nasogastric tube are in satisfactory position.,0
"There are bilateral layering pleural effusions, and there is also atelectasis in the left lower lobe.",0
Bilateral perihilar haziness is also noted and may reflect a component of edema from fluid overload.,0
3:37 PM CT GUIDANCE DRAINAGE; CT PERITINEAL DRAIN EXCLUDING APPENDICEAL Clip # CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: for CT-guided drainage Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man s/p hepatic resection for cholangiocarcinoma complicated by persistent intra-abd fluid collections.,0
REASON FOR THIS EXAMINATION: for CT-guided drainage No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT GUIDED DRAINAGE OF INTRAABDOMINAL COLLECTIONS CLINICAL DETAILS: Post-partial hepatic resection for cholangiocarcinoma.,0
Postoperative pancreatitis and multiloculated intraabdominal collections.,1
"PROCEDURE: Following preprocedure written consent and confirmation of patient identity and nature of procedure, two separate CT-guided drainage procedures were performed.",0
"The patient was prepped and draped in the usual sterile fashion, given local and intravenous (a total of 100 mcg of fentanyl and 2 mg of midazolam IV in titrated boluses).",0
"Following CT localization and intra- procedure CT fluoroscopy, a 12-gauge pigtail catheter was placed into the largest collection in the right upper quadrant mesentry using a coaxial technique over a 22-gauge Chiba needle .",0
"Aspiration yielded up to 60 cc of initially purulent material, which later became slightly sanguinous.",0
A sample of this has been sent for culture.,0
Post- procedure CT confirmed the formed tip at the posterior inferior aspect of this collection.,0
"Some contrast was injected into the cavity post- procedure, and the cavity was irrigated using sterile saline.",0
A second 10 French pigtail catheter was inserted into the most posterior collection in the left lower quadrant just anterior to the inferior aspect of the left psoas muscle.,0
Again a coaxial technique over a 22-gauge Chiba needle was used following aseptic preparation of this area local and IV analgesia.,0
Initial aspiration yielded up to 30 cc of similar purulent material.,0
The cavity was irrigated with sterile saline and post-procedure noncontrast CT confirms the tip within the posterior collection.,0
There is an adjacent collection measuring up to 5.5 cm transverse located directly anterior to the drained collection.,0
"For the moment, we plan to perform irrigation of the drained components and a follow up CT after a few days hoping that these collections may intercommunicate and drain further.",0
There is still a multiloculated collection in the posterior lower retroperitoneum measuring up to 6.5 cm transverse x 5 cm AP.,0
Successful percutaneous pigtail catheter insertions into the largest collection in the right upper quadrant (12 French) and 10 French pigtail (Over) 3:37 PM CT GUIDANCE DRAINAGE; CT PERITINEAL DRAIN EXCLUDING APPENDICEAL Clip # CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: for CT-guided drainage Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ FINAL REPORT (Cont) catheter insertion into the posterior left retroperitoneal collection.,0
Dr. was present for procedure.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Found down/altered mental status Major Surgical or Invasive Procedure: RIJ Endotracheal intubation Right femoral temporary dialysis catheter placement and removal LUE fasciotomy status post skin graft placement R subclavian tunneled dialysis catheter placement and removal History of Present Illness: Mr. is a 50M with a PMH of polysubstance abuse, Hepatitis C, and depression who was found down by his family with altered mental status on the evening of .",1
"Per the patient's family, he had been on a week-long binge with multile substances, those of which are known to the family include: ETOH, benzodiazapines, heroin, trazodone, and crack.",0
He was discovered asleep in his car outside of his family's house on the evening of .,0
"The next morning, he was not fully arousable.",0
He was taken to Hospital on the morning of for altered mental status.,0
The work-up at included: 1.,0
Left arm skin breakdown with compartment syndrome.,1
MRI of the head showing multiple embolic CVA's 6.,0
Rhabdomyolysis He was transferrd to the for further management.,0
"In our ED, he presented with the following vital signs: 190/95, 104, 97%RA.",0
"Clinically he was somnolent, following simple commands, hypertensive, and tachycardic.",0
"He was given valium for presumed alcohol withdrawl, and was then intubated for airway protection.",0
Serum/urine tox confirmed the presence of benzodiazapines and cocaine.,0
He was found to be in fulminant liver failure with a transaminitis and coagulopathy.,1
"It was unclear if this was due to tylenol toxicity vs. shock picture, so the ED administered N-acetyl cysteine with the toxicology service consulting, despite negative tylenol on his tox screen.",0
"He received a 150mg/kg bolus over 60 minutes Neurology was consulted for the acute mental status changes with embolic strokes- they had no further recommendations, as anticoagulating him would not be possible given his coagulopathy.",0
"Orthopedics was consulted for his left arm compartment syndrome, and plan for a faciotomy.",1
"His rhabdomyolysis was managed with saline diuresis, with approximately 6-7L of NS.",0
"He was also found to be in acute renal failure, with a Cr of 3.7.",1
"His CK-MB and troponin were elevated, cardiology was notified of the admision, but had no current recommendations.",0
"Labs were otherwise notable for a positive UA, a normal lactate level, hyponatremia, hypocalcemia, hypomagnesemia.",0
Our ED ordered a CT torso and cervical spine.,0
"Past Medical History: Depression Hepatitis C Polysubstance abuse Social History: Works as a truck driver, just left a substance abuse rehabilitation facility on Sunday.",1
"No tobacco, polysubstance abuse as detailed above.",0
Supportive family including 3 daughters.,0
"Legally divorced from wife; primary decision maker is oldest , .",0
"Family History: NC Physical Exam: Admission Day exam- T=afebrile... BP=187/117... HR=94... RR=... O2=100% AC 600x20, FiO2 40%, PEEP5 GENERAL: Intubated, sedated HEENT: Pupils sluggish bilaterally.",0
RIJ in place with minimal bleeding at the sige.,0
"No murmurs, rubs or .",0
LUNGS: Course bilateral breath sounds ABDOMEN: NABS.,0
"No HSM EXTREMITIES: RUE s/p fasciotomy, wound vac in place.",0
"Cool extremities with 1-2+ pulses SKIN: Multiple areas of skin break down and ecchymosis NEURO: Sedated, babinskis down-going bilaterally At discharge his exam was: GEN: NAD, confused HEENT: OP clear, no SI, MMM NECK: no JVD, supple, no LAD, no masses CV: RRR, no Murmur, S1 S2, pulses 2+ bilaterally CHEST: CTA B ABD: NABS, soft, NT, ND, no HSM EXT: graft site on Lt forearm with 4cm necrotic area, dry, stable; rest of graft is eythematous and without change; left hand contracted; left trochanter ulcer, skin wounds on both LE, knee, dressings c/d/i, limbs with no edema, warm and well perfused.",1
"**FINAL REPORT ** Blood Culture, Routine (Final ): STAPH AUREUS COAG +.",1
Staphylococcus species may develop resistance during prolonged therapy with quinolones.,0
"Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy.",1
Testing of repeat isolates may be warranted.,0
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final ): REPORTED BY PHONE TO @ 0645 ON .,0
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS 5:09 am URINE Source: Catheter.,0
"**FINAL REPORT ** URINE CULTURE (Final ): STAPHYLOCOCCUS, COAGULASE NEGATIVE.",0
"SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R NITROFURANTOIN-------- <=16 S OXACILLIN-------------<=0.25 S PENICILLIN G---------- 0.12 R 3:54 am SPUTUM Source: Endotracheal.",0
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.,0
Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site.,0
Please contact the Microbiology Laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate.,0
"Note: For treatment of menigitis, penicillin G MIC breakpoints are <=0.06 ug/ml (S) and >=0.12 ug/ml (R) Note: For treatment of meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R) For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).",0
"SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STREPTOCOCCUS PNEUMONIAE | | CEFTRIAXONE----------- =>4 R ERYTHROMYCIN---------- =>8 R =>1 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S 1 S OXACILLIN-------------<=0.25 S PENICILLIN G----------<=0.03 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R VANCOMYCIN------------ <=1 S HCV VIRAL LOAD (Final ): 6,340,000 IU/mL.",1
5:37 pm SPUTUM Source: Endotracheal.,0
**FINAL REPORT ** GRAM STAIN (Final ): PMNs and <10 epithelial cells/100X field.,0
MODERATE GROWTH ** AMIKACIN SUSCEPTIBILITY REQUESTED BY DR. (#) .,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS | AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S 4:36 am URINE Source: Catheter.,0
**FINAL REPORT ** URINE CULTURE (Final ): PSEUDOMONAS AERUGINOSA.,0
">100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by .",0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 4 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I 3:49 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool.,0
"CT without contrast of chest, abd, pelvis IMPRESSION: 1.",0
"Diffusely decreased hepatic attenuation, which is commonly seen in liver steatosis, less common etiologies include hepatitis, toxic hepatic injury, or metabolic disorders.",1
ECHO The left atrium and right atrium are normal in cavity size.,0
There is mild to moderate global left ventricular hypokinesis (LVEF = 40-45 %).,0
Systolic function of apical segments is relatively preserved.,0
Right ventricular chamber size is normal with mild free wall hypokinesis.,0
IMPRESSION: No valvular pathology or pathologic flow identified.,0
"Mild symmetric left ventricular hypertrophy with mild biventricular global hypokinesis c/w diffuse process (toxin, metabolic, tachycardiac, etc.).",0
Patent hepatic vasculature with appropriate waveforms.,0
No liver masses and no biliary dilatation.,0
Carotid U/S IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis.,0
HEAD MRI without contrast IMPRESSION: Acute bilateral globus pallidus infarcts and acute to subacute infarcts in both cerebellar hemispheres.,1
-------------------- Brief Hospital Course: is a 50 year-old male with a history of polysubstance abuse who presented with altered mental status after being found down by family members.,0
"Extended hospital course was as follows, by problem: #.",0
"Rhabdomyolysis and acute renal failure: Patient presented with CK ~40,000 in the setting of ARF, compartment syndrome, and hypocalcemia.",1
This was likely secondary to immobilization after polysubstance intoxication.,0
Patient was hydrated and received approximately 24 liters.,0
"The decision was made to start HD and his CK slowly began trending down; initially, temporary HD catheter was placed in femoral artery.",0
Later IR placed a tunneled catheter in the right subclavian artery which had to be replaced after patient pulled it out.,1
Over his hospitalization his Cr and urine output improved.,0
"Patient received last hemodialysis treatment on , .",0
"On , hemodialysis catheter was removed by interventional radiology.",0
Cr at discharge was 1.1.,0
Altered mental status: Patient was obtunded and comatose at presentation - intubated for airway protection.,0
"MRI showed multiple embolic strokes, and toxicology showed alcohol, heroin, and crack/cocaine.",1
"Differential included multiple CVAs, substance abuse, hepatic encephalopathy (stage II-III), infection, and delirium.",1
"On the medicine floor, patient was oriented only to himself initially and required a sitter.",1
Haldol used PRN for agitation and confusion.,0
Poor mental status had a component secondary to the strokes with superimposed delirium.,1
"On discharge, mental status was improved, but patient still having confusion and memory problems.",0
clear source was found for the strokes.,0
Patient had a repeat echocardiogram which was negative for a PFO.,0
"Possibly due to arrythmia and/or transient wall motion abnormality during drug intoxication that produced thrombi in the heart, which then embolized to brain.",0
"At , neurology involved and decision was made not to anticoagulate given severe coagulopathy on admission.",0
Carotid ultrasound was done and 40% stenosis bilaterally.,0
Blood cultures grew staph aureus in bottles from arterial line and he was placed on vancomycin dosed by HD with a plan for 14 day course.,1
"Subsequent blood cultures were negative, and vancomycin was discontinued.",0
"Following closure of left upper extremity fasciotomy and resolution of acute liver failure, patient was placed on aspirin and Statin.",1
"On floor begin rehab with PT, OT.",0
Will need these services at rehab.,0
Fulminant liver failure: Unclear etiology.,1
"At level of transaminitis at presentation, the differential was narrowed to toxin-induced, shock state, and viral hepatitis.",1
have been transaminitis secondary to rhabdomyolysis.,1
"The patient has known hepatitis C, viral load 6.3 million.",1
"Serum was negative for acetaminophen, although he was started on NAC in the ED.",0
Doppler study of the portal and hepatic veins was done and showed patent vessels.,0
Albumin on presentation was 2.8.,0
AST and ALT peaked at 3739 and 9036.,0
Trended to normal over his admission.,0
Consider Ribavirin and interferon after resolution of acute illness and depression.,0
Left upper extremity compartment syndrome: Unclear if the patient suffered a crush injury versus bleed into the arm from coagulopathy.,1
"On presentation, patient was taken for emergent fasciotomy in the operating room.",0
"A wound vac was placed, and plastics involved for grafting area.",0
Wound vac was removed on .,0
Patient had limited movement of left digits.,0
Physical therapy and occupational therapy were also involved.,0
"Per plastics recommendations, patient is to follow up with plastics clinic during the week of discharge.",0
"Post op a 4cm area of necrosis in the center of his graft developed, was stable, did not appear infected.",1
Plastics thought it was a region of failed graft tissue recommended close observation.,0
OT recommended placing splint (over padding) on left hand to prevent contracture.,0
Alcohol withdrawal - Placed on CIWA protocol with lorazepam prn >10 given hepatic failure.,1
Did not have withdraw sx.,0
"After several days, patient was discharged off of CIWA protocol.",0
Social work became involved for substance abuse counseling.,0
"NSTEMI: On admission, cardiac biomarkers were elevated.",0
Likely demand during multi-organ system failure.,0
EKG did not show ischemic changes.,0
"Cardiology was involved; given coagulopathy, fasciotomy, and liver failure, aspirin and Statin were not started initially.",1
"Later, patient was started on low-dose aspirin and Statin.",1
"Diarrhea: In ICU and on medicine floor, patient continued to have loose stools.",0
C. diff toxin was sent and was found to be negative.,0
Stool cultures were also sent and showed no organisms.,0
"Fever - On , the patient had a witnessed aspiration event.",0
CXR showed possible aspiration pneumonia; this cleared on subsequent x-rays.,0
"On , had fevers to 101.7 and developed a leukocytosis to 14.7 with left shift.",0
"Due to possible aspiration PNA, started on Unasyn and kept on Vancomycin.",0
"As he continued spiking fevers, the concern for HAP/VAP was raised.",0
"Unasyn changed to Zosyn and levofloxacin, continued on Vancomycin on .",0
Sputum cultures were obtained showing pan-sensitive serratia.,0
Urine Culture on grew pseudomonas only sensitive to amikacin.,0
Vanc and Zosyn were discontinued on as there was no MRSA and as serratia was pansensitive.,0
"On , amikacin was started.",0
ID consultant thought that Pseudomonas in urine was not clinically significant (as urine had cleared) and that Serratia in sputum was not likely pathologic in this patient's case; antibiotics were discontinued .,0
Right leg bone infarct - Patient was found to have pain in right knee.,0
Plain film was done and showed right bone infarct.,0
Orthopedics was consulted and felt that no further imaging/intervention was necessary.,0
Patient may required knee replacement in future.,0
Source for infarct was believed to be from embolic strokes.,0
"Depression - Reports a history of depression, formerly on Paxil and trazodone.",0
During long hospitalization expressed worsening of depression symptoms.,0
On Paxil and trazodone were restarted.,0
These doses may need to be adjusted.,0
Social work consult to discuss current situation.,0
"Anemia - Likely multifactorial, including bone marrow suppression from substance abuse, bleeding from LUE.",1
Iron studies not consistent with iron-deficiency anemia or anemia of chronic disease.,1
Threshold for transfusion hematocrit <= 21.,0
Will need to be monitored.,0
FEN - Diet changed to thin liquids and soft foods.,0
"Skin wounds- several skin wounds, graft site on left forearm.",0
"Also, pressure ulcers on lower extremities.",1
Will need daily dressing changes and monitoring for infection.,0
Patient will be discharged to rehab to improve strength and mobility and will need follow up care with plastic surgery and his PCP.,0
Medications on Admission: Famotidine 20 mg IV Q24H Heparin 5000 UNIT SC TID Labetalol 100 mg PO TID Alteplase (Catheter Clearance) 2 mg IV 2X Lorazepam 2 mg IV Q6H:PRN Albuterol MDI PUFF IH Q4H:PRN Artificial Tear Ointment 1 Appl BOTH EYES PRN Discharge Medications: 1.,0
Artificial Tear with Lanolin Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eye.,0
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): pt may refuse.,0
Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing.,0
Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours).,0
Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<110.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Rhabdomyolysis Acute compartment syndrome s/p fascitomies on left arm Multifocal embolic strokes Fulminant liver failure Acute renal insufficeny requiring hemodialysis Non-ST elevation myocardial infarction Polysubstance abuse Hepatitis C Urinary tract infection Bacteremia Pneumonia Depression Right leg bone infarct Pressure ulcers Discharge Condition: Hemodynamically stable, afebrile, poor orientation, weakness on left side.",1
Discharge Instructions: You were transfered to for further treatment of your multiple medical problems after being found unreponsive in your car.,0
"Initally you had liver failure, kidney problems, a heart attack, and multiple strokes.",1
You required temporary dialysis for your kidney.,0
You also had a fasciotomies of your left forearm that required a skin grafts.,0
You had a stroke resulting in weakness on the left side of your body.,0
You spent part of your admission in the ICU for these problems.,0
will require physical therapy at the rehab center.,0
Please keep your follow up appointments.,0
"Please do not use IV or street drugs or drink alcohol, they are harmful for your health.",0
Take your medications as instructed.,0
Changes were made to your home medications.,0
"If you have chest pain, shortness of breath, fever, drainage from your wounds, or any other concerning symptom please seek medical attention or go to the ER.",0
"Followup Instructions: Plastic Surgery clinic, Please Call ( to schedule a follow up appointment.",0
Please make an appointment to see your PCP as soon as you leave the hospital.,0
"4:44 PM CHEST (PA & LAT) Clip # Reason: eval for occult PNA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with improved now returned nausea s/p head injury REASON FOR THIS EXAMINATION: eval for occult PNA ______________________________________________________________________________ FINAL REPORT TWO VIEWS OF THE CHEST HISTORY: 65-year-old man has returned for nausea, status post head injury; evaluate for occult pneumonia.",0
"FINDINGS: Two views are compared with the limited bedside AP examination labeled ""trauma"" dated .",0
"There is linear atelectasis at the left lung base with slight elevation of that hemidiaphragm, new.",0
"However, no evidence of focal consolidation is seen.",0
"The cardiomediastinal silhouette and pulmonary vessels are within normal limits, with no evidence of CHF.",0
There are atherosclerotic changes involving the thoracic aorta.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: ?placement Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with s/p L subclavian CVL REASON FOR THIS EXAMINATION: ?placement ______________________________________________________________________________ FINAL REPORT HISTORY: Left subclavian line.,0
FINDINGS: There is a new left subclavian line with tip in the distal SVC.,0
"Again seen are patchy bilateral alveolar infiltrates, greatest in the left lower lobe and right upper lobe.",0
These have shown some partial clearing compared to the study from earlier the same day.,0
The ET tube is 6.5 cm above the carina.,0
"11:29 AM CHEST (PORTABLE AP) Clip # Reason: eval ptx Admitting Diagnosis: PRE-OP LIVER TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 65yo male s/p kidney/liver transplant on , for failed OLT and stage 3CKD.",1
REASON FOR THIS EXAMINATION: eval ptx ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Status post kidney and liver transplant.,1
Moderate right pneumothorax has increased from the prior study performed 12 hours earlier.,0
Swan-Ganz catheter tip is in the right main pulmonary artery.,0
Bibasilar atelectases are larger on the right side.,0
"There is a small right pleural effusion, probably new.",0
Findings were discussed with clinical team by phone early afternoon on .,0
"11:50 AM CT HEAD W/O CONTRAST Clip # Reason: interval change, subarachnoid hemorrhage Admitting Diagnosis: MOTORCYCLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with REASON FOR THIS EXAMINATION: interval change, subarachnoid hemorrhage No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HEAD CT HISTORY: 58-year-old man with subarachnoid hemorrhage after a motor vehicle accident.",1
TECHNIQUE: Contiguous 5-mm axial images were obtained from the skull base to the vertex.,0
FINDINGS: Comparison is made to .,0
"Again seen is extensive left-sided subarachnoid hemorrhage along the sulci of the left frontal, parietal and temporal lobes.",1
Again seen are two small hemorrhagic contusions with surrounding vasogenic edema of the left temporal lobe peripherally which are not significantly changed compared to the prior study.,0
The previously described left-sided subdural hematoma is again seen and remains tiny on today's study.,0
There are no new intracranial hemorrhages.,1
The ventricles are unchanged in size.,0
Again seen is a large area of scalp hemorrhage and edema on the left.,0
Also again seen is high-density material with air-fluid levels in the maxillary sinuses bilaterally consistent with blood.,0
There is also blood and fluid within the nasal cavity and nasopharynx as before.,0
Scout images show an endotracheal tube and orogastric tube.,0
Left-sided subcutaneous emphysema is again seen.,1
Fracture of the left lateral orbital wall is noted.,0
"There is mucosal thickening involving the ethmoid, sphenoid, and left frontal sinus.",0
"IMPRESSION: Since , no significant change in the two small hemorrhagic contusions of the left temporal lobe with surrounding left-sided subarachnoid hemorrhage.",1
The previously described left subdural hematoma is not well seen on today's study.,0
Hemorrhage within the maxillary sinuses and the nasal cavity and nasopharynx as before.,1
"(Over) 11:50 AM CT HEAD W/O CONTRAST Clip # Reason: interval change, subarachnoid hemorrhage Admitting Diagnosis: MOTORCYCLE ACCIDENT ______________________________________________________________________________ FINAL REPORT (Cont) Left lateral orbital wall fracture as before.",1
"9:33 PM MR L SPINE W/O CONTRAST Clip # Reason: please eval compression deformity involving the L3 vertebral Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with h/o VISA, ESRD on HD, HIV/AIDS, presents with compression deformity of L3 REASON FOR THIS EXAMINATION: please eval compression deformity involving the L3 vertebral body with retropulsion of bony fragments incompletely characterized seen on CT CONTRAINDICATIONS for IV CONTRAST: ESRD Yes to Choyke questions.",1
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JK SAT 9:42 AM PFI: Unusual deformity of L3 and L4 vertebral bodies.,0
Minimal amount of edema in adjacent discs.,0
"Low-grade infection cannot be completely excluded, vs. mechanical instability.",0
"______________________________________________________________________________ FINAL REPORT LUMBAR SPINE MRI SCAN HISTORY: End-stage renal disease, on hemodialysis.",1
"HIV/AIDS, presents with compression deformity of L3.",0
"Evaluate compression deformity, incompletely characterized on CT scan.",0
"TECHNIQUE: Sagittal T1, T2 and STIR images were obtained.",0
There are no axial images available at this time.,0
"COMPARISON STUDIES ON PACS ARCHIVE: CT scan noted in your report is not available on PACS, either.",0
"FINDINGS: There is an unusual L-shaped deformity of the L3 vertebral body, and a corresponding deformity of the L4 vertebral body.",0
The intervening disc space also has an L-shaped configuration.,0
Arising from the posterior aspect of the L3-4 disc space remnant is a moderate posterior spondylitic ridge which appears to cause moderate central canal stenosis.,0
"While there are no axial images available, there does appear to be prominent L3-4 foraminal stenosis due to the abnormal morphology of the L3 and L4 vertebrae.",0
"On the STIR images, there is very slight edema within these vertebral bodies, with more linear areas of edema in what are presumably the L2-3 and L4-5 discs.",0
"Despite these findings, there does not appear to be bone destruction to suggest an ongoing inflammatory process nor is there prevertebral soft tissue swelling.",0
"Nevertheless, given the immunocompromised state of this patient, it is conceivable that a low-grade infectious process could be present.",0
The L2-3 disc is also mildly desiccated.,0
"The imaged distal spinal cord, conus medullaris and remainder of the uncompressed cauda equina are normal.",0
CONCLUSION: Unusual deformity of the L3 and L4 vertebral bodies.,0
Some edema (Over) 9:33 PM MR L SPINE W/O CONTRAST Clip # Reason: please eval compression deformity involving the L3 vertebral Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ FINAL REPORT (Cont) in this locale.,1
A low-grade infection cannot be excluded.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Medicine, Firm HISTORY OF PRESENT ILLNESS: Mr. is a 49-year-old male with a history of Crohn's disease, status post multiple surgeries and ileostomy at 19 years of age, on chronic total parenteral nutrition, with steroid-induced osteomyelitis with a history of frequent peripherally inserted central catheter line infections.",1
"The patient has also had a recent diagnosis of C4-C5 epidural abscess and osteomyelitis with coagulase-negative Staphylococcus aureus, status post 10 weeks of intravenous oxacillin treatment.",0
He was recently switched to doxycycline two weeks ago by mouth.,0
The patient was in his usual state of health until the morning of when he had a temperature of 100.6 which was a high temperature for the patient.,0
"His home care nurse was concerned given his history of multiple line infections, but Mr. was asymptomatic at that time with no complaints.",0
"Later on the same day, the patient developed rigors and another temperature spike during total parenteral nutrition infusion.",0
He was subsequently brought to the Emergency Department for evaluation.,0
"REVIEW OF SYSTEMS: On review of systems, the patient denied nausea, vomiting, hematemesis or any change in his ostomy output.",0
"He had no headache, no cough, no shortness of breath, and no chest pain.",0
"He had fevers and chills, but no dysuria.",0
"On arrival in the Emergency Department, the patient was found to have a systolic blood pressure in the 60s.",0
"He was also noted to be anemic with a hematocrit of 22 (down from his usual of 25), and an increase in his serum creatinine to 2.9 (up from a baseline of 1.4 to 2.1 in ).",0
The patient was started on intravenous fluid resuscitation and dopamine for hypotension.,0
He was given a dose of ceftazidime and vancomycin.,0
The patient also received 100 mg of hydrocortisone given his chronic steroid use for his Crohn's disease.,0
He was transferred the Medical Intensive Care Unit.,0
"Crohn's disease, status post multiple abdominal surgeries with ileostomy since the age of 19.",1
The patient is followed by Dr. at the .,0
He is currently on prednisone.,0
"Short bowel syndrome, on chronic total parenteral nutrition.",0
A recent history of C4-C5 epidural abscess and osteomyelitis secondary to line infection.,0
"The patient is status post surgical decompression by Dr. , treated with 10 weeks of intravenous oxacillin and recently changed to p.o.",0
doxycycline two weeks prior to admission.,0
Cultures from this infection grew coagulase-negative Staphylococcus aureus.,0
The patient has history of multiple polymicrobial line sepsis from his indwelling peripherally inserted central catheter lines.,0
The patient has a history of chronic renal insufficiency with a baseline creatinine of 1.9.,0
MEDICATIONS ON ADMISSION: Medications on admission included prednisone 3 mg p.o.,0
"PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on arrival to the Medical Intensive Care Unit revealed a blood pressure of 95/60, heart rate of 80, respiratory rate of 18, and a temperature of 100.1.",0
General examination revealed a cachectic male who was diaphoretic.,0
Cardiovascular examination revealed a regular rate and rhythm with normal first heart sound and second heart sound.,0
A holosystolic murmur at the left sternal border with no third heart sound or fourth heart sound.,0
The patient's jugular venous pulsation was measured to be 6 cm.,0
"Lung examination revealed bibasilar crackles; otherwise, clear to auscultation.",0
The abdominal examination revealed a healed old multiple surgical scars.,0
The patient had an ileostomy bag.,0
"He had normal bowel sounds, and his abdomen was nontender and nondistended.",0
Extremity examination revealed warm extremities with no edema and palpable pedal pulses.,0
"PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory studies on admission revealed a hematocrit of 22, white blood cell count of 7, and a platelet count of 109.",0
"Serum chemistry revealed a sodium of 140, potassium of 3.1, chloride of 108, bicarbonate of 20, blood urea nitrogen of 56, and creatinine of 2.4, and a serum glucose of 53.",0
RADIOLOGY/IMAGING: Chest x-ray on admission revealed bibasilar atelectasis with no focal consolidation.,0
HOSPITAL COURSE: The patient was transferred to the Medical Intensive Care Unit after stabilization in the Emergency Department.,0
"In the Medical Intensive Care Unit, his peripherally inserted central catheter line was removed for a suspicion of line sepsis.",0
A right internal jugular central line was placed.,0
"After removal of his peripherally inserted central catheter line, the patient was able to be weaned off dopamine in one to two hours after his arrival to the Medical Intensive Care Unit.",0
The patient was continued on ceftazidime and vancomycin intravenously as well as stress-dose steroids.,0
"During his stay in the Medical Intensive Care Unit, the patient continued to spike temperatures of up to 102.2.",0
"However, he remained hemodynamically stable throughout his entire course.",0
He was transferred out to the Medicine Service on after stabilization.,0
"At the time of transfer, the patient was only on vancomycin intravenously.",0
The patient remained afebrile during his entire course on the Medicine Service with his temperature maximum being 100.4 on .,0
All of his blood cultures obtained since his admission remained negative.,0
"The tip of his peripherally inserted central catheter line that was removed was cultured and was found to grow methicillin-resistant Staphylococcus aureus, for which the patient was kept on intravenous vancomycin.",0
"The patient continued to defervesce, and his stress-dose steroids were discontinued.",0
His blood pressure remained stable after discontinuation of his steroids.,0
The patient was maintained on 3 mg of prednisone q.d.,0
A transthoracic echocardiogram was obtained for evaluation of possible endocarditis.,0
"On echocardiogram, on , the patient was found to have no echocardiographic evidence of endocarditis.",0
His left ventricular ejection fraction was normal at greater than 55%.,0
"The patient was found to have moderate-to-severe 3+ mitral regurgitation, and 2+ tricuspid regurgitation was also seen.",0
His left atrium was mildly dilated.,0
There was mild pulmonary systolic hypertension.,0
There was no pericardial effusion.,0
The patient's acute renal failure resolved during his stay on the Medicine Service.,1
He was thought to have acute tubular necrosis secondary to transient hypotension when he presented to the Emergency Department.,0
"After hydration and blood pressure resuscitation, the patient's acute renal failure resolved.",1
"After being afebrile for over 48 hours, the patient received a peripherally inserted central catheter line placement on and was discharged to home on intravenous vancomycin.",0
The patient has a follow-up appointment with Dr. in the Infectious Disease Clinic on .,0
The patient was to be discharged on intravenous vancomycin (finishing a 2-week course) and then restarted on dicloxacillin by mouth until he sees Dr. .,0
DISCHARGE DIAGNOSES: Peripherally inserted central catheter line sepsis.,0
Fentanyl patch 50 mcg transdermally every three days.,0
Vancomycin 1 g intravenous q.24h.,0
Ativan 0.5 mg to 1 mg p.o.,0
(to start after finishing nine days of intravenous vancomycin).,0
Dictated By: MEDQUIST36 D: 19:01 T: 10:28 JOB#:,0
"PATIENT/TEST INFORMATION: Indication: H/O MVR, CHF Height: (in) 64 Weight (lb): 142 BSA (m2): 1.69 m2 BP (mm Hg): 130/75 HR (bpm): 87 Status: Inpatient Date/Time: at 08:43 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .",0
Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RA pressure (10-20mmHg).,0
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).,1
"Moderate valvular MS (MVA 1.0-1.5cm2) Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
The estimated right atrial pressure is 10-20mmHg.,0
The right ventricular cavity is moderately dilated with mild global free wall hypokinesis.,0
The prosthetic mitral valve leaflets are thickened.,1
The gradients are higher than expected for this type of prosthesis.,0
There is moderate valvular mitral stenosis (area 1.0-1.5cm2).,1
"Compared with the prior study (images reviewed) of , the severity of bioprosthetic mitral stenosis has decreased.",1
The detected pulmonary artery sytolic hypertension has increased to severe.,1
There is a left to right shunt across the atrial septum post mitral valvuloplasty.,1
"4:45 PM PORTABLE ABDOMEN Clip # Reason: SEE WHERE GASTROGRAFFIN HAS TRAVELED THAT WAS PLACED DOWN NG Admitting Diagnosis: ETOH INDUCED CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with new elevated wbc, history of abdominal surgery.",0
REASON FOR THIS EXAMINATION: SEE WHERE GASTROGRAFFIN HAS TRAVELED THAT WAS PLACED DOWN NGT.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: History of abdominal surgery, evaluate Gastrograffin placed down NG tube.",0
PORTABLE SUPINE ABDOMINAL FILM: Comparison is made to previous abdominal film from approximately 50 minutes prior.,0
NG tube is seen with tip within the fundus of the stomach.,0
Surgical clips are again identified within the left upper quadrant.,0
"Compared to the prior study, there appears to be decreased amount of high density material within the stomach.",0
"LINE PLACEMENT Clip # Reason: please check placement r bas dl picc for hep & abx, has l sc Admitting Diagnosis: DISSECTING THORACIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man s/p dissection repair REASON FOR THIS EXAMINATION: please check placement r bas dl picc for hep & abx, has l sc TLC call beeper with wet read asap thanks ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM.",1
Tracheostomy tube is 4 cm above carina.,0
Chest tube is in left upper thorax.,0
Left subclavian CV line overlies proximal SVC.,0
There are bilateral pleural effusions and associated bibasilar atelectases.,1
Height: (in) 69 Weight (lb): 260 BSA (m2): 2.31 m2 Status: Inpatient Date/Time: at 09:48 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
There is mild global left ventricular hypokinesis.,0
Overall left ventricular systolic function is difficult to assess but is probably mildly depressed.,0
"LINE PLACEMENT Clip # Reason: location of 46 cm right basilic picc tip Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with head injury REASON FOR THIS EXAMINATION: location of 46 cm right basilic picc tip ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Head injury, assess right PICC.",0
"Right PICC tip is in the right atrium, can be withdrawn approximately 4 cm to a standard position.",0
Bibasilar opacities consistent with atelectasis have almost completely resolved.,0
The right lateral CP angle is not included on the film.,0
Cardiomediastinal contours are normal with cardiac size top normal.,0
There are no enlarging pleural effusions.,0
7:09 PM CT HEAD W/O CONTRAST Clip # Reason: assess for new changes.,0
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with L SDH with recent mental status changes.,0
REASON FOR THIS EXAMINATION: assess for new changes.,0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 9:41 PM No change in left temporal contusion.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 37-year-old male with left temporal contusion and mental status changes.,0
COMPARISON: Head CT without IV contrast .,0
TECHNIQUE: Axial imaging was performed from the cranial vertex to the foramen magnum without IV contrast.,0
HEAD CT WITHOUT IV CONTRAST: A hemorrhagic contusion in the left temporal lobe and surrounding hypodensity consistent with edema are unchanged.,0
There is no evidence of new hemorrhage or expansion of resolving left subdural hematoma.,0
There has been no interval development of shift of midline structures or hydrocephalus.,0
A soft tissue retention cyst in the sphenoid sinus is unchanged in appearance.,0
IMPRESSION: No change in left temporal lobe contusion or development of shift of midline structures.,0
There is no change in the tiny left subdural hematoma.,0
"9:29 AM CHEST (PORTABLE AP) Clip # Reason: r/o pna Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with REASON FOR THIS EXAMINATION: r/o pna ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:15 A.M., HISTORY: Fever and cough, rule out pneumonia.",1
IMPRESSION: AP chest compared to through 21: Mild infrahilar opacification is most commonly atelectasis.,0
"If patient can tolerate conventional radiographs, lateral view would be helpful to assess the severity of basal abnormality.",0
Transvenous right atrial and right ventricular pacer leads are unchanged in standard placements.,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: r/o ptx, assess line placement Admitting Diagnosis: AORTIC INJURY ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman s/p aortic repair REASON FOR THIS EXAMINATION: r/o ptx, assess line placement ______________________________________________________________________________ WET READ: GWp MON 9:56 PM Swan Ganz otherwise CT/ETT increase airspace opacification d/ 9:55p GWilliams ______________________________________________________________________________ FINAL REPORT AP CHEST, , 8:19 p.m. HISTORY: Rule out pneumothorax and check line placements after aortic repair.",1
"IMPRESSION: AP chest compared to the only prior chest radiograph, 7:35 p.m. on : Tip of the new Swan-Ganz line projects over the right descending pulmonary artery.",0
There is no pneumothorax or mediastinal widening.,0
"Severe global pulmonary consolidation, presumably edema, unchanged since earlier in the day.",0
Postoperative cardiomediastinal silhouette is unremarkable.,0
"ET tube, two right apical and one midline drain are unchanged in their respective positions.",0
"Subcutaneous emphysema, unchanged on both sides of the chest and in the left neck.",0
1:57 PM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE;HYPERTENSION ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with fevers and pneumonia REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Fever and pneumonia.,1
"FINDINGS: Compared to the film from the prior day, there is no significant interval change.",0
11:32 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: ?,0
anoxic brain injury Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with ?,1
global anoxic brain injury per ct REASON FOR THIS EXAMINATION: ?,1
anoxic brain injury ______________________________________________________________________________ FINAL REPORT MR HEAD INDICATION: 71-year-old male with question of global anoxic brain injury.,1
MR HEAD: TECHNIQUE: Sagittal T1.,0
"Axial T1, T2, FLAIR, gradient echo, diffusion.",0
No prior MRI is available for comparison.,0
"FINDINGS: On the diffusion-weighted images, there is restricted diffusion in the cortical regions involving all lobes of the brain in a rather symmetric fashion, most notably in the posterior temporal/occipital region, correlating with the recent CT scan .",0
"On the conventional sequences (T2, FLAIR), there is very little, if any, signal abnormality identified in the regions of diffusion abnormality.",0
"These findings are consistent with diffuse brain injury, such as from anoxia.",0
"However, given the lack of signal abnormality on the conventional sequences, the possibility of reversible abnormality is to be considered, and continued followup, as well as vigorous ventilatory/circulatory support is recommended.",0
"These findings were discussed with , M.D.",0
"There are several small areas of T2 hyperintensity within the cerebral periventricular white matter, which are probably related to chronic small vessel ischemic changes, also noted on the prior CT scan.",0
There is no evidence of intracranial hemorrhage.,0
There is no mass effect or shift of the normally midline structures.,0
"Mucosal thickening is seen in all of the paranasal sinuses, possibly due to intubation or inflammatory processes.",0
IMPRESSION: Restricted diffusion involving the cortical regions of all the lobes of the brain bilaterally in a symmetric fashion.,1
"However, given the relative lack of signal abnormality on the conventional images, this may suggest some degree of reversibility of this diffuse brain injury, and therefore, continued followup and vigorous ventilatory/circulatory support is suggested.",1
Findings were discussed with Dr. on at 2:55 p.m. MR ANGIOGRAPHY OF THE BRAIN: TECHNIQUE: 3D time-of-flight MRA imaging of the brain was performed.,0
No prior study is available for comparison.,0
(Over) 11:32 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: ?,0
"anoxic brain injury Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ FINAL REPORT (Cont) FINDINGS: The anterior and posterior circulations are grossly unremarkable, without evidence of significant stenosis or aneurysm greater than 3 mm.",1
All of the included intracranial vessels are patent.,0
IMPRESSION: Normal MR angiography of the brain.,0
", C. CSURG FA6A 3:12 PM SHOULDER VIEWS NON TRAUMA RIGHT Clip # Reason: r/o fracture Admitting Diagnosis: NON STE MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with s/p cabg- right shoulder pain with abduction REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ PFI REPORT PFI: No fracture or dislocation detected involving the right shoulder.",1
"8:11 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate lung parenchyma and position of ET tube ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with UGIB, EtOH withdrawal, new lung mass and brain masses REASON FOR THIS EXAMINATION: please evaluate lung parenchyma and position of ET tube ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: INDICATION: Upper GI bleed.",1
"An ETT is in satisfactory position, terminating approximately 4.5 cm above the carina.",0
"There is prominence of the right mediastinal contour, possibly due to accentuation by rotation.",0
"There is homogeneous area of opacification in the right upper lobe, bordered inferiorly by the minor fissure.",0
Relative sparing of the right apex appears to be due to underlying bullous emphysema in this region.,0
The remaining portions of the lungs are grossly clear.,0
IMPRESSION: 1) ETT in satisfactory position.,0
"2) Right upper lobe consolidation, which may be due to aspiration or an evolving area of infectious pneumonia.",0
3) Prominence of right mediastinal contour possibly due to accentuation by rotation.,0
Repeat non-rotated film would be helpful to allow more complete assessment and to exclude the possibility of right paratracheal lymphadenopathy.,0
"3:45 AM CHEST (PORTABLE AP) Clip # Reason: evaluate right pneumothorax Admitting Diagnosis: S/P STABBING ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with stab wounds to right chest, had tracheostomy, now with desaturations.",0
REASON FOR THIS EXAMINATION: evaluate right pneumothorax ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Stab wound to the right chest tracheostomy.,0
There is a previous from at 2:53 p.m.,0
FINDINGS: Cardiac silhouette is unchanged.,0
The superior mediastinum remains to be prominent.,0
"There remains to be a right chest tube, which is unchanged in position.Vague infiltrate around chest tube.",0
Again noted is subcutaneous emphysema along the lateral right hemithorax.,0
There is a tracheostomy in place.,0
There is an NG tube in place in with the tip seen in the right upper quadrant.,0
IMPRESSION: New vague infiltrate around chest tube in the right lower lobe.,0
"10:08 PM CHEST (PORTABLE AP) Clip # Reason: pls evaluate lung fields and ET placement Admitting Diagnosis: COAGULOPATHIC ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with respiratory distress at OSH, now intubated REASON FOR THIS EXAMINATION: pls evaluate lung fields and ET placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:30 P.M. ON HISTORY: Respiratory distress.",0
IMPRESSION: AP chest compared to : Moderate-to-large right pleural effusion and small left pleural effusion have increased substantially.,0
Mild-to-moderate cardiomegaly has increased slightly and there is mild pulmonary vascular congestion but no edema.,0
Opacification at the lung bases is probably atelectasis.,0
"ET tube tip is at the upper margin of the clavicles, right jugular line ends at the junction of brachiocephalic veins.",0
Right PIC catheter ends in the mid SVC.,0
5:03 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # CT BRAIN PERFUSION Reason: eval for cva Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with L sided facial droop and L arm weakness since approx 12-1am REASON FOR THIS EXAMINATION: eval for cva No contraindications for IV contrast ______________________________________________________________________________ WET READ: SHfd MON 6:47 AM Please note that wet read for non-con CT was entered at about 5:25 am.,0
AREA OF DECREASED BLOOD VOL IS SMALLER THAN mtt AND bLOOD FLOW COMPATIBLE WITH PRESENCE OF PNUMBRA.,0
WET READ VERSION #1 SHfd MON 5:33 AM No ICH.,0
right insular ribbon sign likely R MCA acute infarct.,0
WET READ VERSION #2 SHfd MON 6:46 AM NO ICH.,0
______________________________________________________________________________ FINAL REPORT EXAMINATION: Head CTA with perfusion.,0
HISTORY: A 77-year-old female presents with left-sided facial droop and left arm weakness for approximately five hours.,0
COMPARISON: MRI on this date.,0
TECHNIQUE: Non-contrast images through the brain were obtained followed by angiographic phase images through the head and neck after administration of intravenous contrast.,0
FINDINGS: Initial non-contrast images through the brain demonstrate a subtle region of hypoattenuation with loss of the cortical ribbon involving the right insular cortex extending more superiorly into the right frontal lobe.,0
"There are additional extensive confluent T2 regions of low attenuation throughout the supratentorial white matter, with focal changes within the right lentiform nucleus, likely reflecting sequela of chronic microvascular disease.",1
CTA: There is a three-vessel aortic arch.,0
There is moderate atherosclerotic disease involving the arch and origins of the great vessels.,0
"There is marked tortuosity of the right subclavian artery, as well as of the common and cervical internal carotid arteries bilaterally.",0
There is mild atherosclerotic disease at the carotid bifurcations without high-grade stenosis.,0
Transverse luminal dimension of the internal carotid arteries are 4 mm bilaterally.,0
There is fullness of the cavernous segment of the left internal carotid artery (Over) 5:03 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # CT BRAIN PERFUSION Reason: eval for cva Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ FINAL REPORT (Cont) without a discrete aneurysm.,0
The remainder of the internal carotid arteries are normal.,0
There is a small infundibulum at the origin of the right ophthalmic artery.,0
There is abrupt cut-off of the distal M1 segment of the right middle cerebral artery.,0
There is enhancement throughout the MCA branches distally.,0
There is prominent infundibulum at the origin of the large right posterior communicating artery with fetal type formation of the right posterior cerebral artery and an associated hypoplastic right P1 segment.,0
The left posterior cerebral artery is normal.,0
The left middle cerebral artery and anterior cerebral arteries are normal.,0
PERFUSION: There is asymmetrically elevated mean transit time throughout approximately 50% of the right middle cerebral artery territory.,0
"There is a small region of asymmetrically diminished blood volume within the right MCA distribution, involving the anterior right frontal lobe.",0
The changes are slightly evident on the cerebral blood flow map.,0
"Evaluation of the soft tissues of the neck demonstrates a 3.4 x 2.6 cm right neck mass within the submandibular space, displacing the submandibular gland anteriorly and inferiorly.",0
Several other smaller lymph nodes are present.,0
"There is associated asymmetric soft tissue fullness and enhancement at the tongue base on the right extending posteriorly along the oropharynx, and extending inferiorly into the hypopharynx where there appears to be asymmetric thickening of the right aryepiglottic fold.",0
There is biapical scarring with several nodular densities which may represent consolidation though are concerning for possible metastatic disease in this context.,0
"The findings suggest an acute embolus within the distal M1 segment of the right middle cerebral artery, associated with a small infarct within the anterior right frontal lobe and a much broader area of tissue at risk encompassing just under 50% of the right middle cerebral artery territory.",0
"3.4 cm right submandibular space mass, which may represent a pathologic lymph node.",0
There is associated asymmetric thickening of the tongue base on the right and the findings are concerning for an oropharyngeal tumor such as squamous cell carcinoma with an adjacent metastatic node.,0
ENT consultation and direct inspection are recommended.,0
"Biapical scarring with what may represent nodular consolidation within the visualized lung apices, which should be correlated with a dedicated chest CT. (Over) 5:03 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # CT BRAIN PERFUSION Reason: eval for cva Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ FINAL REPORT (Cont) Perfusion findings were appropriately identified by the on-call radiology resident and communicated to the clinical service at the time of study, and the additional findings of the right neck mass were discussed with the managing neurology service, Dr. , at the time of dictation at 10:30 hours on .",0
"9:11 AM CHEST (PORTABLE AP) Clip # Reason: sever SOB, dyspnoea ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with s/p right pneumonectomy for lung CA, drainage for empyema with fistula, multiple complications.",1
"REASON FOR THIS EXAMINATION: sever SOB, dyspnoea ______________________________________________________________________________ FINAL REPORT FRONTAL CHEST RADIOGRAPH: HISTORY: Severe shortness of breath and dyspnea in patient who is s/p right pneumonectomy for lung cancer.",0
COMPARISON: FINDINGS: Evidence of right pneumonectomy with peristent air fluid level which is unchanged.,0
"The pleura surrounding the aerated portion of the right chest is thickened, which is not new.",0
"Within the right-sided air space there is inhomogeneous, fine textured opacification which could represent funcal superinfection or blood-clot.",0
This finding is somewhat more pronounded than in the studies obtained yesterday.,0
"In addition, there are ill-defined infiltrates in the left base which are new since the prior study.",0
The cardiac contour reveals left ventricular enlargement and there appears to be some upward redistribution of the pulmonary vasculature which may represent early heart failure.,0
A tracheobronchial stent is again seen and unchanged in appearance since the prior study.,0
IMPRESSION: 1) Opacification within aerated space in right chest cavity which could represent a fungal superinfection or a blood-clot.,0
2) Left lower lobe infiltrates which could represent pneumonic process vs. atelectasis.,0
3) Possible slight left-sided heart failure.,0
"Name: , H Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiac Surgery The patient was to go home on , but his INR was subtherapeutic and he went home on with an INR of 2.7.",0
"He will receive 3 mg of Coumadin tonight and then followup with his doctor, Dr. and have him regulate the Coumadin.",0
Dictated By: MEDQUIST36 D: 08:55 T: 09:04 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: Service: CARDIOTHORACIC SURGERY ADDENDUM Note: This is an addendum to the discharge summary which was dictated on , covering through , the day of discharge.",0
"HOSPITAL COURSE: On , on postoperative day #37, which was day 17 of a 19 day course of Vancomycin, the patient's T-max was 99.3?????",0
"?, blood pressure 114/44, oxygen saturation 100%, in sinus rhythm in the 70s.",0
"The patient remained on CPAP with pressure support at 40%, white count 9.8, hematocrit 30.",0
"Heart was regular, rate and rhythm.",0
The patient had slightly coarse breath sounds.,0
The patient continued to have trach trials and a swallowing study to determine where should would be for her rehabilitation placement.,0
She continued on Vancomycin as we awaited a bed.,0
She was seen again on the 12th by the Clinic.,0
The Clinic did a consult again on to reevaluate the Insulin protocol that the patient was using.,0
They recommended a new protocol for the patient with changing to Humalog.,0
They recommended that the patient follow-up with as an outpatient.,0
"The patient was also seen by cardiologist Dr. who noted that she was stable over night, maintaining good blood pressure and normal sinus rhythm at 80.",0
Her swallow study was successful.,0
"The plan was made to continue with her ventilatory care and continue her beta-blocker, ACE inhibitor, and await the rehabilitation bed.",0
"On on postoperative day #38, the patient on the trach ventilator all night.",0
She did pass her swallowing study.,0
Her breath sounds continued to clear a bit.,0
Her trach site was intact.,0
She appeared to be doing well.,0
"She continued on her Plavix and Aspirin, as well as Lopressor and day 18 of 19 of her Vancomycin.",0
"She also continued to be covered by the sliding scale Insulin, subcue Heparin, in addition to her Captopril and her Insulin protocol .",0
They saw her again on the 13th.,0
She continued to be seen by Physical Therapy and Case Management again on the 13th.,0
She was accepted at .,0
The patient was transferred over for need of CSRU bed to the SICU on the 13th.,0
Please refer to the transfer note.,0
"Her PICC line and arterial line had been discontinued at that point, she only had peripheral IVs.",0
She continued on oxygen via ............... in the morning with additional support in the evening.,0
"On , the day of discharge, the patient completed 19 of 19 days of Vancomycin therapy.",0
She was rested over night.,0
"Her discharge labs consisted of a sodium of 138, potassium 4.7, chloride 103, CO2 26, BUN 42, creatinine 1.2.",0
Her chest film showed improved aeration.,0
She had a T-max of 100.2?????,0
"?, blood pressure 120/49, oxygen saturation 96% on 2 L. Heart was regular, rate and rhythm.",0
Her extremities were warm and well perfused.,0
The plan was to continue her tracheostomy trial and ventilatory weaning at the rehabilitation facility.,0
The patient was discharged to on .,0
Peripheral vascular disease status post right femoral to popliteal bypass.,0
Status post coronary artery bypass grafting times three on .,0
Status post right lower extremity ulcer.,0
Status post PICC line placement.,0
DISCHARGE MEDICATIONS: Atenolol ............. 0.25% 1 drop O.S.,0
"b.i.d., Lorazepam 2 mg q.4 hours p.r.n., Percocet 1 tab p.o.",0
"q.4 hours pain, Colace 100 mg p.o.",0
"b.i.d., Reglan 5 mg IV q.6 hours p.r.n., Plavix 75 mg p.o.",0
"q.d., Aspirin 325 mg p.o.",0
"q.d., Zantac 150 mg p.o.",0
"q.d., Albuterol nebs 1 q.4 hours p.r.n., Zolpidem 5 mg q.h.s.",0
"p.r.n., Vancomycin 750 mg IV on , day of discharge, then discontinue, Lopressor 25 mg p.o.",0
"b.i.d., Heparin 5000 U subcue b.i.d., Captopril 6.25 mg p.o.",0
"t.i.d., NPH 15 U q.a.m.",0
"and q.p.m., regular Insulin sliding scale as noted on the discharge form protocol, Robitussin 5 cc q.6 hours p.r.n.",0
"DISCHARGE INSTRUCTIONS: Intensive chest physical therapy and suctioning, vent wean, and tracheostomy trials as specified.",0
Follow-up blood sugars q.4 hours with Insulin sliding scale adjustments.,0
Specific instructions were given also not to pull the tracheostomy without either ENT or Surgery evaluation prior to doing so.,0
"FOLLOW-UP: The patient was instructed to follow-up with the attending surgeon in the office, Dr. in approximately one month after discharge.",0
DISPOSITION: The patient was discharged to rehabilitation on .,0
Dictated By: MEDQUIST36 D: 14:35 T: 13:50 JOB#:,0
"10:50 AM ABDOMEN U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # DUPLEX DOPP ABD/PEL Reason: liver, portal vein patency, extent of ascites: PLEASE DO DUP Admitting Diagnosis: FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: year old man with ascites of unclear etiology REASON FOR THIS EXAMINATION: liver, portal vein patency, extent of ascites: PLEASE DO DUPLEX IMAGING OF PORTAL VEIN/LIVER VASCULATURE ______________________________________________________________________________ FINAL REPORT STUDY: Doppler ultrasound of liver and ultrasound of abdomen.",1
INDICATION: Patient with possible ascites.,0
"TECHNIQUE: Grayscale, color flow and pulse wave Doppler insonation of the liver and the liver vasculature was performed.",0
Formal abdominal son was also performed.,0
COMPARISON: No examination available for comparison.,0
Reference is made to previous chest radiographs and plain films of the abdomen.,0
REPORT: Examination was performed portably and this somewhat limits the quality of the examination.,0
The left kidney measures 10.3 cm.,0
The right kidney measures 10.8 cm.,0
"Both kidneys are normal size, shape, and echogenicity.",0
A simple cyst is identified in the left lobe measuring 1.8 cm.,0
"Color flow and pulse wave Doppler insonation of the liver vasculature shows patent hepatic veins, portal veins and arteries, with normal hepatopetal flow identified in the portal vein and its branches, as well as a widely patent main hepatic artery.",0
"The gallbladder contains sludge, but is otherwise unremarkable without evidence of gallbladder wall thickening.",0
No intra- or extra-hepatic biliary dilatation is identified.,0
The midline pancreas and retroperitoneal organs appear normal.,0
There is an intra-abdominal catheter or tube in situ on the left flank lying superior to the liver- probably a gastrostomy-It is difficult to determine whether this lies in an intraluminal location on the provided images.,0
A trace left-sided pleural effusion is seen.,0
"Normal liver and Doppler liver ultrasound, duplex liver ultrasound.",0
Left-sided intra-abdominal catheter whose location is indeterminate.,0
"(Over) 10:50 AM ABDOMEN U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # DUPLEX DOPP ABD/PEL Reason: liver, portal vein patency, extent of ascites: PLEASE DO DUP Admitting Diagnosis: FAILURE TO THRIVE ______________________________________________________________________________ FINAL REPORT (Cont) 4.",1
PATIENT/TEST INFORMATION: Indication: Evaluate for clot.,0
Height: (in) 66 Weight (lb): 215 BSA (m2): 2.06 m2 BP (mm Hg): 88/41 HR (bpm): 108 Status: Inpatient Date/Time: at 11:12 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
AORTIC VALVE: The aortic valve is not well seen.,0
Overall left ventricular systolic function is difficult to assess but is probably normal (LVEF>55%).,0
No obvious mass or thrombus in this technically difficult study.,0
"4:24 PM CT ABDOMEN W/O CONTRAST Clip # Reason: Please drain perisplenic phlegmon for culture Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with high fevers s/p adrenalectomy with a 1.5cm splenic phlegmon, concern as source of infx REASON FOR THIS EXAMINATION: Please drain perisplenic phlegmon for culture No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Perisplenic phlegmon for drainage and culture.",0
TECHNIQUE: Multidetector contiguous axial images of the abdomen were obtained without intravenous contrast.,0
The study was initially scheduled as a possible procedure.,0
However and consent was obtained via telephone from the patient's daughter.,0
"However, a preprocedure CT was performed and based on those results, no drainage catheter was placed.",0
CT ABDOMEN WITHOUT IV CONTRAST: The patient is status post left adrenalectomy and splenectomy.,0
"Compared to the prior study, no drainable fluid collections are seen.",0
"There is stranding of the fat in the anterior pararenal fossa, as well as in the region surrounding the tail of the pancreas.",0
"The surrounding subcutaneous soft tissues demonstrate inflammatory changes, there are surgical clips seen in this region.",0
"Again seen within the liver are multiple low-density lesions, unchanged.",0
"The gallbladder, right adrenal gland, and kidneys are unchanged.",1
There is a feeding tube terminating in the jejunum.,0
The stomach and loops of unvisualized loops of small bowel are not dilated.,0
"Few images through the upper abdomen demonstrate bibasilar atelectasis, right greater than left, and a small left-sided pleural effusion is seen.",0
Again seen is metallic streak artifact in the left lower lobe from the patient's known pulmonary arteriovenous malformation embolization.,0
BONE WINDOWS: No suspicious lytic or blastic lesions.,0
IMPRESSION: No drainable fluid collection seen in the splenectomy bed.,0
"As such, a drainage catheter was not placed.",0
8:52 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for vascular abnormality Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with recent CVA and abnormal head CT REASON FOR THIS EXAMINATION: eval for vascular abnormality No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Recent CVA and abnormal head CT.,1
TECHNIQUE: Contiguous axial images were obtained from the aortic arch through the brain during infusion of 75 cc of intravenous contrast material.,0
COMPARISON: CTA and MRA and MRI .,0
FINDINGS: CT HEAD: Non-contrast MDCT images were acquired earlier at 7:58 a.m. ().,0
"CTA HEAD: No contrast is noted in the right vertebral artery in the distal V2, V3, and V4 segments up to the basilar artery.",1
"These findings likely represent near completely occlusion from a thrombus, which has worsened from when the thrombosis was noted in segments V3 and V4.",0
"There is extensive calcified atherosclerosis at the segment V4 of the right vertebral artery, similar in appearance to prior CTA of .",1
"The left vertebral artery is patent up to the takeoff of the left PICA, as seen on prior study, which may represent hypoplastic distal left vertebral artery, but occlusion cannot be excluded.",1
The left PICA is patent.,0
The right PICA is not seen.,0
The bilateral PCAs are patent.,0
Right PCOM is patent and the left PCOM is not visualized.,0
"The right ICA is patent with calcified atherosclerosis and minimal narrowing at the proximal supraclinoid segment, with no aneurysm formation or evidence of dissection, unchanged when compared to prior study.",0
"The left ICA is widely patent with minimal calcified atherosclerosis and no significant stenosis, aneurysm formation or dissection.",1
"The distal right and left internal carotid arteries measure 6 and 7 mm in diameters, unchanged.",0
"Near complete thrombosis of the right vertebral artery has worsened from prior CTA and MRI ( in the distal V2 segement, stable in the V3 and V4 segements) 2.",1
"Left vertebral artery is patent up to the left PICA,but non visualised (Over) 8:52 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for vascular abnormality Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) after the take off of the PICA which may represent congenital hypoplastic left vertebral artery, but an occlusion of this segment cannot be excluded.",1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: GERD and small hiatal hernia Major Surgical or Invasive Procedure: Laparoscopic converted to open, redo Nissen fundoplication, and repair of hiatal hernia.",1
Reopening of abdomen and washout of intraperitoneal hematoma.,0
Endoscopy CT guided pigtail placement left pleural space CT guided drain placed in perisplenic fluid collection History of Present Illness: 41-year-old black gentleman status post Nissen fundoplication five years ago.,0
He did great during this time with no reflux or difficulty swallowing at all.,0
"He had previously undergone endoscopic approaches to relieve his heartburn, which had failed.",0
"However, for the last two months, he has had difficulty with some reflux as well as swallowing water.",0
Endoscopy revealed a small hiatal hernia and gastritis.,0
A barium swallow showed a small herniation of the GE junction possibly above the diaphragm.,0
He complains of these problems with swallowing and also notes more frequent burping.,0
Past Medical History: Episcleritis bilaterally: Followed by Dr. .,1
GERD s/p Nissen Fundoplication Obesity Hypercholesterolemia: Borderline in the past.,1
Chronically elevated liver function tests: Normal evaluation in the past.,0
Chronic low back pain Hypertension.,0
s/p distal biceps tear and repair on by Dr. .,0
Social History: The patient states that he drinks beer occasionally on the weekends.,0
"He smokes occasional cigars, but is exposed to secondhand smoke at home.",0
The patient smoked while he was in military but quit over 10 years ago.,0
Family History: Mother has a history of migraine headaches.,0
His mother has a history of diabetes.,0
Uncle has a history of lung cancer.,0
He has four children who are all healthy.,0
"Physical Exam: Vital signs Temperature of 97.2, blood pressure 143/92, O2 sat 99%, pulse 84, Resp 20, weight 236 pounds.",0
Pertinent Results: UGI : No evidence of leak.,0
"Slow passage of contrast from the esophagus into the stomach, likely from edema, with residual barium within the distal esophagus.",0
CT Abd/pelvis/CTA chest : 1.,0
Dense right lower lobe consolidation consistent with pneumonia.,0
Large left pleural effusion with pleural enhancement; infection cannot be excluded.,1
Patchy consolidation at lung apices suggests aspiration or infection.,0
"Fluid collection in the surgical bed, extending along the stomach and pancreatic tail, with marked stranding in left upper quadrant.",0
Extraluminal hyperdense material at the GE junction may represent surgical pledgets or extravasated contrast.,0
"Notably, however, there is no intraperitoneal free air (endoscopy with insufflation was performed prior to this examination to assess for leak).",0
"Limited evaluation for pulmonary embolus due to timing of contrast, but no evidence of large pulmonary embolus.",0
"Peripancreatic fluid may be tracking from surgical bed, but recommend obtaining pancreatic enzymes for clinical correlation to exclude pancreatitis as a cause of left upper quadrant inflammatory change.",0
ETT terminates 1.4 cm above the carina.,0
TTE : Mild symmetric left ventricular hypertrophy with normal systolic function.,0
"Right ventricular dilation, hypertrophy, mild hypokinesis, and severe estimated pulmonary artery systolic hypertension.",1
These findings are consistent with a primary chronic pulmonary process.,0
Esophagus : No evidence of leak at the gastric fundus to correlate with the findings on previous CT.,0
"While it remains possible that the density at the GE junction seen on the previous CT represents leaked barium, given the inability to demonstrate leak on the present examination, these densities are felt more likely to represent hyperdense pledgets which were reportedly used in the surgery.",0
Stable size and configuration of peri-GE junction low-density fluid.,0
"Unchanged extraluminal hyperdense material, may represent extraluminal contrast versus surgical pledgets.",0
"New small-bowel obstruction with transition point in the mid abdomen (2, 66), most likely due to adhesion.",0
Improved bilateral pleural effusions status post left chest tube placement.,1
Improved but persistent bibasilar atelectasis.,0
"Trace pneumomediastinum, likely expected post-surgical change.",0
"Interval placement of multiple intra-abdominal drains, with persistent multiple low-density collections within the lesser sac and peripancreatic location, gastrohepatic space, and perisplenic regions.",0
"Though one of the drains situated in the gastrohepatic space appears centered within a fluid collection, the remainder of the drains do not.",0
"Moderate left pleural effusion, larger in size, that is slightly hyperattenuating, may contain hemorrhagic or proteinacious components.",1
Left subclavian line tip not central in location and should be adjusted.,0
"Trace free fluid in the pelvis, nonspecific, and may reflect sequela of recent surgery.",0
"Interval decrease in size of perisplenic fluid collection which contains a pigtail catheter; decreased although persistent smaller loculations including lesser sac, peripancreatic and gastrohepatic collection.",0
Near-resolution of a left pleural effusion which contains a pigtail catheter.,1
"Stranding and low density within the abdominal wall musculature, developing collection not entirely excluded.",0
Correlation with physical examination and consideration of ultrasound is suggested if an infection is suspected in the area.,0
The CT findings are non-specific and may be post-operative or due to serous or infected fluid.,0
Few subtle wedge-shaped hypodensities within the renal parenchyma.,0
"main differential considerations include infarction versus infection, other etiologies are considered less likely.",0
Correlation with urinalysis and other clinical factors is suggested.,0
"The areas of relative hypoperfusion are in the upper poles only, so possibly the appearance is secondary to nearby peripancreatic inflammation and might not be significant in itself.",0
"Blood Culture, Routine (Final ): STAPHYLOCOCCUS, COAGULASE NEGATIVE.",0
ISOLATED FROM ONE SET ONLY.,0
SENSITIVITIES PERFORMED ON REQUEST.. Peritoneal fluid GRAM STAIN (Final ): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
WOUND CULTURE (Final ): A swab is not the optimal specimen collection to evaluate body fluids.,0
Brief Hospital Course: Mr. presented to on for a laparoscopic Redo Nissen which was converted to open Nissen redo and hiatal hernia repair.,1
"Postoperatively, he was transferred from the PACU to the floor where over the next few days experienced an increase in oxygen requirements with saturations in the 90s% despite vigorous pulmonary toilet.",1
His chest xray revealed a new large left pleural effusion and a small right pleural effusion.,1
This prompted an upper GI which ruled out a leak.,0
His pain was controlled with an epidural and PCA and his stomach remained decompressed with a nasogastric tube.,0
On he was transferred to the SICU as he had more respiratory distress and was electively intubated for airway control and subsequent imaging.,0
"He had a CT scan of the chest, abdomen and pelvis.",0
"This imaging study showed a large left pleural effusion and RLL consolidation c/w pneumonia, peri-GE junction fluid.",1
His WBC 25K at that time and vancomycin was started.,0
"The thoracic surgery service was consulted for left chest tube placement and subsequent endoscopy which revealed normal mucosa, an intact wrap and no leaks.",0
His chest tube drained about 850 cc and his PO2 gradually improved.,0
"His sputum culture was MSSA positive, BAL were both negative.",0
He also developed rapid atrial fibrillation and was seen by the Cardiology service.,1
Part of their work up included an ECHO which showed moderate-severe RV dysfunction demonstrated by PASP 62.,0
his atrial fibrillation converted to NSR with amiodarone.,1
"On , he was trialed for extubation, but reintubated for increased work of breathing.",0
On he had a follow up CT scan which showed fluid at GE junction.,0
Due to an increasing WBC and no significant improvement he had an exploratory lap and washout of intraperitoneal hematoma which showed no evidence of leak.,0
He was started Zosyn and continued on vancomycin empirically.,0
His left chest tube was removed without difficulty.,0
"From , Mr. continued to be intubated with a mucus plug removed by bronchoscopy on , and a failed trial of extubation on .",0
He had a follow up CT torso on which a large L pleural effusion and subdiaphragmatic/perisplenic collection.,1
Both the left pleural effusion and perisplenic abscess were drained by IR on with pig tail catheters.,1
These collections both drained dark fluid which were culture negative.,0
Mr. WBC count began trending down from 17 to 12 following drainage.,0
"Additionally, after the IR guided drainage of the left pleural effusion and perisplenic fluid, Mr. respiratory status improved and he was extubated on .",1
"After extubation, he improved rapidly and on his tube feeds, nasogastric tube, foley, and central venous line were all discontinued and his diet was advanced to full liquids.",0
"On the floor, Mr. continued to improve dramatically while his WBC decreased to 10.3.",0
He was seen by physical therapy for deconditioning but after a few treatments he was up and walking independently.,0
A followup CT scan on showed that the left pleural effusion had mostly resolved and the perisplenic collection had decreased to 13 mm.,1
His drains were then sequentially discontinued.,0
"On the last drain was removed, his WBC was 6K and his antibiotics were discontinued.",0
His abdominal wound drained some serosanguinous fluid from the lower 1/3rd and was partially opened on .,0
There was no cellulitis and the base of the wound was clean.,0
He underwent dressing changes with saline moist to dry gauze.,0
He did have some minor skin tears which were treated with non adherent dressings.,0
His appetite was slowly improving and he was also started on Ensure for supplementation.,0
"After a long, protracted hospital course he was discharged to home on and will follow up with Dr. in 2 weeks.",0
"ECONAZOLE - 1 % Cream - apply to groin and bottom and sides of feet twice a day Use for at least 3 months, then once a week thereafter.",0
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth three times a day.,0
"OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.)",0
- 1 Capsule(s) by mouth twice a day Discharge Medications: 1.,0
Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain.,0
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take this if you are requiring Percocet to prevent constipation.,0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation four times a day as needed for wheezes.,0
Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: 1.,0
Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness.",0
"*New or worsening cough, shortness of breath, or wheeze.",0
*If you are vomiting and cannot keep down fluids or your medications.,0
"*You are getting dehydrated due to continued vomiting, diarrhea, or other reasons.",0
"Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing.",0
*You see blood or dark/black material when you vomit or have a bowel movement.,0
"*You experience burning when you urinate, have blood in your urine, or experience a discharge.",0
*Your pain in not improving within 8-12 hours or is not gone within 24 hours.,0
Call or return immediately if your pain is getting worse or changes location or moving to your chest or back.,0
"*You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius.",0
"*Any change in your symptoms, or any new symptoms that concern you.",0
"Please resume all regular home medications , unless specifically advised not to take a particular medication.",0
Avoid lifting weights greater than lbs until you follow-up with your surgeon.,0
Incision Care: * Your abdominal wound needs to be packed twice daily with saline moistened gauze and covered with a dry dressing.,0
The VNA will helpou with that.,0
"*Please call Dr. if you have increased pain, swelling, redness, or drainage from the incision site.",0
Followup Instructions: Please have followup CT scan in 6 mo for evaluation of peripancreatic fluid which has the potential to develop into a pseudocyst.,0
"Provider: , MD Phone: Date/Time: 8:30 Provider: , MD Phone: Date/Time: 1:00 call Dr. for a follow up appointment in weeks.",0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Aspiration Major Surgical or Invasive Procedure: PEG tube placement, trach tube replacement History of Present Illness: yo M w/ h/o endstage alzheimer's, afib, esophageal stricture s/p 3 diliataions, and recurrent aspiration who presented from nursing home for lethargy, and cough w/sputum over last couple days.",1
"Wife says 1 wk ago pt (?partially)pulled out his g-tube, and nurse put back in place.",0
"Pt was looking more emaciated and his feeds were increased from 12h to continuous over 24h, which is when she thinks pt started to decline, and may have been aspirating.",0
Over the last couple days pt became more unresponsive and also developed a cough w/ sputum.,0
Pt was on levoflox for pna as outpt.,0
"Of note pt was discharged on with asp pna, treated with vanco/cipro/zosyn.",0
During that admission pt failed extubation twice due to mucous pluging and tracheostomy was placed.,0
J-tube and G-tube were placed to prevent aspiration.,0
"(Also had C5-6 fusion then) Required bag masking at NH, hemodynamically stable, then transported to , cxr showed pna, no ivf, then transferred to .",0
"In ED, t99.8, 136/91, 104, 22, 99%ra, cachectic, non-responsive, rhonchi at R base, suctioning pus from lungs, abd soft, IVF initiated - given 1.5L, ceftaz, vanco, and azithro initiated.",0
"HR 88, sats 50% 15L, rr26, 149/94, T 100.8 on transfer.",0
Past Medical History: Esophageal stricture ?,0
"s/p Hiatal hernia Hypertension S/p aortic valve replacement 3 years ago bovine per wife Hip fracture s/p repair H/o aspiration pneumonia, ?",1
recurrent aspiration H pylori gastritis Dementia Social History: Patient is a retired ENT surgeon per out side hospital report.,0
"Independent ADLs until last summer Family History: non contributory Physical Exam: GENERAL: late-stage alzheimer's - nonresponsive HEENT: Normocephalic, atraumatic.",0
"Neck Supple, No LAD, No thyromegaly.",0
"JVP=flat LUNGS: course rhonchi, and rales throughout ABDOMEN: +BS Soft, NT, ND.",0
NEURO: Pt non-responsive to commands.,0
Pertinent Results: 04:06AM BLOOD WBC-7.6 RBC-3.87* Hgb-11.3* Hct-33.5* MCV-87 MCH-29.3 MCHC-33.8 RDW-15.8* Plt Ct-373 02:30PM BLOOD Neuts-85.0* Lymphs-10.6* Monos-4.0 Eos-0.2 Baso-0.2 04:00PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2* 04:06AM BLOOD Glucose-115* UreaN-19 Creat-0.7 Na-141 K-3.8 Cl-106 HCO3-28 AnGap-11 02:30PM BLOOD CK(CPK)-16* 02:30PM BLOOD cTropnT-0.01 04:06AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.2 03:30PM BLOOD Lactate-1.9 04:49AM URINE Color-Pink Appear-Hazy Sp -1.013 04:49AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG 04:49AM URINE RBC-756* WBC-87* Bacteri-FEW Yeast-NONE Epi-0 Sputum culture: MRSA Urine and blood cultures: neg CXR: 1.,0
Patchy opacity in the right lower lobe concerning for pneumonia.,0
"Dense retrocardiac opacity, which could represent second area of pneumonia or atelectasis.",0
Replacement of G/J tube: Uncomplicated placement of gastrojejunostomy tube through the patient's existing tract.,0
The tube may be used immediately.,0
"Brief Hospital Course: yoM htn, afib, esophageal stricture transferred from nursing home with lethary and fever, diagnosed at OSH ED with pna, transferred to , diagnosed with pna, admitted to for tx of aspiration pna/HAP.",0
# Pt has had recurrent pneumonia.,0
Pt had aspiration pneumonia on this admission.,0
It is possible that pt had aspiration with increasing his feeds from 12h to continuous 24h.,0
His trach was also replaced with one with a cuff to further prevent aspiration risk.,0
He was treated w/ Vancomycin and Zosyn.,0
Cipro was not started during this admission as there is no recorded Pseudomonas infection on cultures.,0
"Pt required frequent suctioning initially q1h, which is now improved.",0
Pt is now afebrile and wbc is coming down.,0
"He showed moderate growth of STAPH AUREUS COAG +, and his zosyn was discontinued.",0
Pt needs Vanc 1g IV q24 (as only coag + SA on cx data) x8 days () for two more days.,0
"# Hypernatremia - Pt's Na was 158, and improved with free water replacement.",0
"# 1st degree AV block - overnight once, now resolved in sinus 60-80s HR #.",0
"H/o Atrial Fibrillation - currently not in afib, but rate controlled.",1
"Hypertension- currently controlled, will moniter #.",0
"UTI- UA with neg nitrates but pos leukocytes, few bacteria, WBC 21-50, 90 on repeat, Urine Culture with minimal yeast and GNR.",0
Treated while pt was on Zosyn #.,0
"Hiatal hernia- gave home omezprazole Medications on Admission: Lasix 40 Aricept 10 QD ASA 81 Omep 40 QD KCl suspension 20 Levaquin 250 x9d Ativan 0.5mg q6 prn Twocal HN continuous @ 50ml/h via g-tube Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Primary: Aspiration Pneumonia, MRSA Secondary: Alzheimers dementia Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted with fevers, increased secretions thought to be due to an aspiration pneumonia.",1
We treated you with antibiotics to cover the bacteria which grew from your cultures.,0
Followup Instructions: please follow up with your PCP as necessary MD Completed by:,0
5:40 AM PORTABLE ABDOMEN Clip # Reason: evaluate bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with feeding intolerance REASON FOR THIS EXAMINATION: evaluate bowel gas pattern ______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN ON AT 5:55 A.M. HISTORY: Feeding intolerance.,1
"The comparison view is at 7:44 p.m. Bowel loops are slightly more distended and featureless in comparison to the prior study, but there is no pneumatosis or evidence for free air or portal venous gas.",0
"The stomach is distended, but the nasogastric tube only extends to the GE junction.",0
"4:44 PM CHEST (PA & LAT) Clip # Reason: f/u effusions, atx Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with s/p CABG REASON FOR THIS EXAMINATION: f/u effusions, atx ______________________________________________________________________________ FINAL REPORT HISTORY: CABG.",1
"FINDINGS: In comparison with the earlier study of this date, there is little overall change.",0
"Increased opacification persists at the left base, most likely related to atelectasis and effusion.",0
"In the appropriate clinical setting, supervening pneumonia would have to be considered.",0
Right IJ catheter again extends to the mid-to-lower SVC.,0
3:03 PM CHEST (PORTABLE AP) Clip # Reason: swan ganz placement Admitting Diagnosis: HEMATURIA;RENAL MASS ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p R partial nephrectomy REASON FOR THIS EXAMINATION: swan ganz placement ______________________________________________________________________________ FINAL REPORT Portable chest of compared to .,0
CLINICAL INDICATION: Swan-Ganz catheter placement.,0
Swan-Ganz catheter terminates in the proximal right pulmonary artery.,0
An endotracheal tube is in satisfactory position but the cuff appears over-distended.,0
A nasogastric tube terminates below the diaphragm.,0
The patient is S/P median sternotomy and valvular surgery.,0
Cardiac and mediastinal contours are within normal limits for post-operative status of the patient.,1
A right-sided chest tube is present with no pneumothorax.,0
There is no evidence of focal consolidation.,0
"There is hazy increased opacity adjacent to the left costophrenic sulcus, suggestive of a small pleural effusion.",0
IMPRESSION: 1) Lines and tubes in satisfactory position but note is made of slight over-distention of endotracheal tube cuff.,0
2) Probable small left pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: vaginal bleeding, fever/chills Major Surgical or Invasive Procedure: None History of Present Illness: Ms. is a 28 year old G2P1 s/p LTCS on with postpartum course complicated by vaginal bleeding requiring blood transfusion immediately post-op, with subsequent identification of pelvic hematoma requiring readmission for additional blood transfusion, who presents to ED today with recurrent heavy vaginal bleeding, fatigue and shaking chills.",1
"From , the patient was amditted to the hospital with acute vaginal bleeding and sympotmatic anemia requiring transfusion.",0
Her hematocrit went from 32->19.,0
Following transufsion Hct increased to 27.,0
She was also treated for ?,0
endometritis given fundal tenderness noted on examination.,0
"Since her discharge from the hospital on , she reports that she has had continued vaginal bleeding which waxes and wanes with periods of heavy flow and light flow.",0
"However, today she experienced very heavy vaginal bleeding when she went to the bathroom with passage of large clots.",0
"In addition, she has experienced fatigue, chills, vomiting and diarrhea today.",0
"She states that she has felt feverish today, but has not taken her temperature.",0
"She denies any intercourse since delivery, dysuria or urinary frequency.",0
"Past Medical History: OB/Gyn Hx: G2P1 SAB @ 7 weeks in LTCS for NRFHT Pap ASCUS, negative HR HPV PMH: *) Seizures *) Low body weight PSH: LTCS as noted Social History: lives with fiancee and child, denies T/E/D Family History: Non-contributory Physical Exam: on admission: T 96.8 BP: 102/70->77/52->104/53 HR: 183-> 127->97 RR: 14 O2: 100% RA General: Fatigued, appears dry CV: Tachycardic with regular rhythm Pulm: CTAB Abd: Thin, soft, + BS, diffusely TTP, but exquisitely TTP over suprapubic region, no guarding and no rebound SSE: ~100-150 cc clot evacuated from vagina and os, no active bleeding from cervix Bimanual: Exquisitely tender on exam with inserion of finger and throughout exam.",0
"+ CMT and + TTP over suprapubic area, no masses appreciated in adnexa, but limited discomfort.",0
"Ext: NT, NE on discharge ______________ Brief Hospital Course: Ms. is a 28 year old s/p c-section c/b blood loss anemia requiring blood transfusion, with readmission for heavy vaginal bleeding and identification of pelvic hematoma requiring additional blood transfusion, who presents to the ED again with vaginal bleeding and fever/chills.",1
"In the ED, she was tachycardia and hypotensive, concerning for sepsis vs blood loss anemia.",0
She was initially admitted to the ICU for close monitoring but did not require pressors and vitals improved to normal range.,0
"Her hematocrit was 25.2 (from 27.9 @ discharge ) and she was transfused 2 units PRBCs with an increase to 28.6, and was subsequently stable.",0
"Her WBC was 18.2, without bands and trended down to 9.2.",0
A urine culture was negative and blood cultures had no growth to date at time of discharge.,0
She was started on vancomycin & zosyn as her initial presentation was concerning for sepsis.,0
Flagyl was added on HD 1.,0
She was seen by the ID service who recommended discontinuation of antibiotics unless chronic endometritis was suspected.,0
"However, given her course concerning for sepsis, antibiotics were continued until discharge.",0
"On admission, a CT scan showed a persistent 5.9 x .8 cm hematoma between the posterior uterine wall and the bladder, slightly decreased in size as compared to preceding exam dated , with faint peripheral enhancement.",0
Superinfection of the hematoma could not be excluded.,0
There was a small amount of complex fluid in the pelvis.,0
No retained products of conception were identified.,0
She remained stable in the ICU and was transferred to the floor on HD 2.,0
She was started on methergine for control of vaginal bleeding.,0
"As there was suspicion for chronic endometritis prompting lower uterine segment atony, Ms. was discharged home with a course of flagyl and levofloxacin per ID recommendations.",0
"On day of discharge, Ms. heavy vaginal bleeding, dizziness, and abdominal pain.",0
"Medications on Admission: - Keppra 1000mg - Vitamin D 50,000 units every 2wks - Folic acid daily - Prenatal vit + iron daily Discharge Medications: 1. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days.",0
Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 1 weeks.,0
Methergine 0.2 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 2 days.,0
"Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pelvic hematoma, vaginal bleeding, possible endometritis Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: Ms. , you were admitted for further evaluation and management of vaginal bleeding and concern for infection.",0
Please take the two antibiotics (levofloxacin and metronidazole) as prescribed for the next 1 week.,0
You have also been prescribed methergine to help with vaginal bleeding.,0
"Followup Instructions: Provider: , MD Phone: Date/Time: 1:00 , Clinical Center Completed by:",0
"The patient underwent CTA prior to angiography, demonstrating no definite active extravasation or pseudoaneurysm.",0
"However, given continued bleeding, presents for angiography and possible embolization.",0
"PHYSICIANS: Dr. , the attending radiologist, performed the procedure.",0
Right common femoral artery access.,0
Replaced right hepatic artery and inferior pancreaticoduodenal artery angiography.,0
MEDICATIONS: The patient has not been n.p.o.,0
"for six hours, the procedure was performed with local lidocaine and a single (Versed 2 mg administered in divided doses by a trained radiology nurse, during which continuous hemodynamic monitoring was performed).",0
"PROCEDURE: Prior to initiation of the procedure, written informed consent was (Over) 5:29 PM MESSENERTIC Clip # Reason: Evaluate for source of bleed Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ FINAL REPORT (Cont) obtained and a preprocedure timeout was performed.",0
The patient was placed supine on angiography table and the right groin was prepped and draped in a sterile manner.,0
"Under ultrasound and fluoroscopic guidance, micropuncture needle access was obtained at the right common femoral artery over the mid femoral head, and a 5 French sheath was placed.",0
"Next, a C2 catheter was used to select one of the SMA, and angiography was performed; however, the catheter retracted back into the aorta.",0
"This was exchanged for a 5 French catheter was used to perform sequential angiography of the celiac artery, SMA, replaced right hepatic artery.",0
"Additionally, a 3 French microcatheter and Transcend wire were used to access the stump and angiography was performed followed by coil embolization (using several 4 mm x 2 cm and 2 mm x 2 cm coils).",0
"Post-stump and embolization, angiography demonstrated no further filling of the embolized portion of the stump.",0
"Additionally, microwire and catheter access to the inferior pancreaticoduodenal artery arising from replaced right hepatic artery was obtained and angiography demonstrated a slightly irregular vessel, however, no evidence of active extravasation or pseudoaneurysm.",0
The patient tolerated the procedure well and the sheath was removed and manual compression applied to hemostasis.,1
Again seen is variant anatomy.,0
"Specifically, there is a replaced right hepatic artery arising from the SMA.",0
Angiography demonstrates collateral filling into a segment IV branch which previously was supplied by the proper hepatic artery (not seen on the post-surgical CT in its proximal portion).,1
"Additionally, an inferior pancreaticoduodenal branch arises from the proximal portion of a replaced right hepatic artery.",0
"Finally, filling of the left gastric artery and a replaced left hepatic artery was also noted.",0
Slow filling of a long GDA stump was seen without definite extravasation of the stump.,0
"However, this was prophylactically coiled, and no further filling of the embolized portion of the stump was seen.",0
SMA angiography and replaced right hepatic angiography demonstrated no evidence of contrast extravasation within the mesenteric vessels or within vessels in the right upper quadrant supplying the pancreatic bed.,0
"Fluoroscopy of the JP drain at the end of procedure demonstrated some evidence of contrast material within this, which could be contrast from the prior CT scan or angiogram from venous or delayed sources of bleeding.",0
Successful prophylactic coil embolization of the GDA stump.,0
Findings were discussed with the surgical service upon completion of the procedure by Dr. on at 8:00 p.m. (Over) 5:29 PM MESSENERTIC Clip # Reason: Evaluate for source of bleed Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ FINAL REPORT (Cont),1
9:49 AM CHEST (PA & LAT) Clip # Reason: r/o ptx s/p right cgest tube removed Admitting Diagnosis: MITRAL STENOSIS\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman s/p min.,1
MV repair ^CT drainage REASON FOR THIS EXAMINATION: r/o ptx s/p right cgest tube removed ______________________________________________________________________________ FINAL REPORT INDICATION: Mitral valvular repair and chest tube removal.,0
"PA AND LATERAL CHEST: As compared to , right chest tube has been removed.",0
There is no visible pneumothorax.,0
Mild interstitial edema and small bilateral pleural effusions with a background of underlying emphysema are unchanged.,0
2:55 PM HIP UNILAT MIN 2 VIEWS LEFT Clip # Reason: s/p fall now c/o pain in left hip ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with left hip pain REASON FOR THIS EXAMINATION: s/p fall now c/o pain in left hip ______________________________________________________________________________ FINAL REPORT INDICATION: Left hip pain following fall.,0
COMPARISONS: Trauma series dated .,0
"LEFT HIP, TWO VIEWS: Again seen is a slightly displaced fracture of the left inferior pubic ramus.",0
No other fractures or dislocations are seen.,0
Enteric contrast is likely related to the abdomen/pelvis CT from .,0
Radiopaque material of uncertain significance projects over the soft tissues of the upper thigh.,0
"11:09 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: trauma Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man rollover mvc trauma REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: SGA TUE 12:07 PM shattered spleen with hemoperitoneum, hlium appears intact, fractures of the left posterior 8th, 9th, 10th, ribs with small adjacent contusion, tiny pnuemothorax anteriorly, non-displaced fractures of pelvis (L sacrum and symphisis pubis) ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",1
INDICATION: Rollover motor vehicle accident.,1
TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis following the administration of 150 cc of nonionic Optiray contrast.,0
CT ABDOMEN WITH CONTRAST: There is a small pulmonary contusion within the left lung base.,0
There is also a tiny pneumothorax anteriorly overlying the left lung and apex of the heart.,1
The superior part of the spleen has been shattered into multiple fragments.,0
"There is a moderate amount of blood seen around the spleen which is also tracking along the left paracolic gutter, right paracolic gutter and settling within the pelvis consistent with hemoperitoneum.",0
The splenic hilum appears intact.,0
There is no active contrast extravasation seen.,0
"The liver, gallbladder, adrenals, kidneys are unremarkable.",0
The kidneys enhance and excrete contrast symmetrically.,0
The intra abdominal loops of small and large bowel are unremarkable.,0
CT PELVIS WITH CONTRAST: There is again fluid within the pelvis which is most likely blood indicating hemoperitoneum.,0
The intrapelvic loops of small and large bowel are unremarkable.,0
"BONE WINDOWS: There are fractures of the left 8th, 9th, and 10th ribs posteriorly.",0
This is adjacent to the pulmonary contusion within the left lung base.,0
There are also fractures of the pelvis on the left.,0
The left sacral ala and left symphysis pubis contain nondisplaced fractures.,1
There is an adjacent hematoma within the musculature.,0
IMPRESSION: 1) Shattered spleen with hemoperitoneum.,0
The splenic hilum appears intact with no active contrast extravasation.,0
"2) Left posterior 8th, 9th, and 10th rib fractures with adjacent pulmonary (Over) 11:09 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: trauma Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
There is also a tiny pneumothorax on the left.,1
3) Left sided pelvic fractures of the sacrum and superior pubic ramus with adjacent intramuscular hematoma.,0
4) Findings were called to the intern on the trauma surgery service at the time of the .,0
"4:41 PM MRHAND W/O&W/CONTRAST LEFT; MR CONTRAST GADOLIN Clip # Reason: Please assess for soft tissue infection Admitting Diagnosis: CELLULITIS,MENTAL STATUS CHANGE Contrast: MAGNEVIST Amt: 14 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with sepsis and high grade bacterimia, s/p sugical debridement of left A-V fistula.",0
REASON FOR THIS EXAMINATION: Please assess for soft tissue infection ______________________________________________________________________________ FINAL REPORT MRI OF THE LEFT HAND WITH GADOLINIUM: CLINICAL HISTORY: Sepsis and high-grade bacteremia.,0
Status post surgical debridement of left AV fistula.,0
Assess for soft tissue infection.,0
FINDINGS: MR of the left hand was obtained wit multiplanar multisequence imaging without and with contrast.,0
FINDINGS: There is extensive subcutaneous edema involving the dorsal and volar aspects of the hand.,0
The bones are normal in signal.,0
There is no bone marrow edema or abnormal enhancement.,0
A small 5 MM fluid collection is identified adjacent the radial aspect of the 2nd metacarpal superior to the interosseous muscle.,0
No other fluid collection is identified.,0
"The extensor and flexor tendons are normal in course, caliber, and signal.",0
Marked dorsal and volar subcutaneous edema.,0
5 mm fluid collection adjacent to the radial aspect of the 2nd metacarpal.,0
No evidence to suggest osteomyelitis.,0
", E. 2:17 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W&W/O C Reason: ?",0
"evidence of dissection, subclavian stenosis Admitting Diagnosis: AORTIC STENOSIS;CORONARY ARTERY DISEASE Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with h/o AAA stented, s/p aortic valvuloplasty yesterday now with upper back pain.",1
BP different in upper arms REASON FOR THIS EXAMINATION: ?,0
"evidence of dissection, subclavian stenosis No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No aortic dissection.",0
No significant narrowings at origin or proximal portions of left subclavian artery.,0
Findings communicated over the phone to Dr. at around 15:20 on .,0
"8:21 AM PORTABLE ABDOMEN Clip # Reason: 45 YO WOMAN, pod#4 S/P tah SECONDARY TO UTERINE FIBROIDS WIT ______________________________________________________________________________ MEDICAL CONDITION: fibroid uterus, s/p TAH REASON FOR THIS EXAMINATION: 45 YO WOMAN, pod#4 S/P tah SECONDARY TO UTERINE FIBROIDS WITH POST-OP NAUSEA VOMITING.",0
"______________________________________________________________________________ FINAL REPORT ABDOMEN, SINGLE FILM: History of abdominal pain and recent hysterectomy.",0
Gas is present throughout the colon.,0
There are gas-filled nondilated loops of small bowel.,0
No evidence for intestinal obstruction or significant post-op ileus.,0
", C. MED 12R 5:45 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: r/o cirrhotic changes Admitting Diagnosis: ALCOHOL WITHDRAWAL ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man with transaminitis, thrombocytopenia REASON FOR THIS EXAMINATION: r/o cirrhotic changes ______________________________________________________________________________ PFI REPORT Neck liver consistent with fatty infiltration.",1
"However, other forms of liver disease including advanced liver disease and/or cirrhosis cannot be completely excluded based on this study.",0
There is no intrahepatic biliary dilatation.,0
LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: 54cm left picc.,0
Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with REASON FOR THIS EXAMINATION: 54cm left picc.,0
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 61-year-old male with left PICC.,0
Single AP chest radiograph compared to shows interval placement of a left PICC terminating at the superior cavoatrial junction.,0
The lung volumes remain low.,0
Patchy bibasilar atelectasis is slightly increased on the left.,0
"6:32 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o worsenign aortic dissection Admitting Diagnosis: CHEST PAIN Contrast: OPTIRAY Amt: 160 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with known type B aortic dissection with tearing dissection REASON FOR THIS EXAMINATION: r/o worsenign aortic dissection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Known type B aortic dissection with tearing chest pain, evaluate for worsening aortic dissection.",0
COMPARISON: Chest CT without contrast of and MRA chest of .,0
"TECHNIQUE: Axial MDCT images were obtained through the chest prior to and following the administration of 100 cc of intravenous Optiray, with delayed images obtained through the pubic symphysis.",0
"Subsequently, a second bolus contrast was administered and axial MDCT images were obtained from the lung bases to the pubic symphysis with an additional set of delayed images from the lung apices to the pubic symphysis.",0
CONTRAST: Intravenous nonionic contrast was administered.,0
"CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: Again seen is an aortic dissection involving the descending aorta originating just distal to the left subclavian artery, with evidence of previous repair of the ascending aorta.",1
"The partially thrombosed false lumen extends along the medial aspect of the superior portion of the descending aorta, and along the anterior and posterior aspects of the more distal descending aorta, in an approximately unchanged configuration from the MR .",0
"However, a crescentic area of irregular hyperdensity is seen just anterior and medial to the aortic wall at the level of the carina (3:52) which displays progressive enhancement following the administration of intravenous contrast.",0
This measures approximately 4.1 x 1.7 cm and has slightly increased from the previous examination allowing for differences in technique.,0
"Additional, subsequent, delayed images show progressive enhancement of a region posterior to the esophagus (9:23), and taken together these features are concerning for extravasated intravenous contrast within a mediastinal hematoma.",0
Diffuse stranding throughout the mediastinum and a pretracheal lymph node appear otherwise unchanged.,0
"Bilateral pleural effusions do not show definitive evidence of increasing density with delayed imaging to suggest the presence of extravasated contrast, and although a left pleural effusion is intermediate in density, its size is little changed from .",0
The ascending aorta is unchanged in caliber at 3.4 cm in diameter.,0
"The descending aorta measures up to 5.5 x 5.0 cm in diameter (3:46), probably not significantly changed allowing for differences in technique between the present study and the previous MRI.",0
"Hyperdensity within the wall of the descending aorta on pre- (Over) 6:32 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o worsenign aortic dissection Admitting Diagnosis: CHEST PAIN Contrast: OPTIRAY Amt: 160 ______________________________________________________________________________ FINAL REPORT (Cont) contrast images is consistent with either intramural hematoma or thrombosed false lumen, and there is progressive opacification of the false lumen on delayed images.",1
There is unchanged cardiomegaly and an aortic valve replacement.,0
There are coronary artery calcifications and sternal suture wires.,0
"There is bilateral atelectasis, unchanged.",0
"CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: The liver is hypodense suggestive of fatty infiltration, and prominence of the hepatic veins likely relates to patient's cardiomegaly.",0
"The spleen, pancreas, and adrenal glands appear unremarkable.",0
Multiple bilateral hypodense renal lesions are too small to accurately characterize and measure up to 8 mm in diameter.,0
The abdominal aorta measures 2.7 cm in diameter and is tortuous.,0
"The descending thoracic aortic dissection appears to terminate approximately at the level of the diaphragmatic hiatus, without evidence of extension of the dissection to the infrarenal aorta.",1
Mural calcification is consistent with atheromatous disease.,0
"The celiac trunk, superior mesenteric artery, and inferior mesenteric arteries are patent.",0
"The gallbladder contains hyperdense material consistent with sludge, stone, or vicarious excretion of contrast.",0
There are multiple non-pathologically enlarged mesenteric and retroperitoneal lymph nodes.,0
There is a small amount of free fluid in the abdomen.,0
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The prostate is enlarged and there are probable bladder diverticulae.,0
There is a small amount of free fluid in the pelvis.,0
"In the left inguinal region, a 1.1 cm oval structure (7:62) could represent a small pocket of loculated fluid or postsurgical change.",0
There are no pathologically enlarged pelvic or inguinal lymph nodes.,0
Surgical clips are seen in the left and right groin.,0
Bone windows show degenerative change of the thoracic and lumbar spine without evidence of suspicious lytic or sclerotic osseous lesions.,1
MULTIPLANAR REFORMATIONS: Coronal and sagittal reformations are helpful in delineating the area of extravasated contrast about the descending thoracic aorta.,1
Descending thoracic aortic dissection with peri-aortic extravasated contrast consistent with rupture.,1
These findings were discussed immediately at the time of the examination with (7:30 p.m. ).,0
"(Over) 6:32 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o worsenign aortic dissection Admitting Diagnosis: CHEST PAIN Contrast: OPTIRAY Amt: 160 ______________________________________________________________________________ FINAL REPORT (Cont) 2.",0
Mediastinal hematoma with progressive enhancement consistent with extravasated blood products.,0
"Bilateral pleural effusions, however, do not show definite evidence of enlargement or of extravasated blood.",0
"Cardiomegaly, aortic valve replacement and prior ascending aortic repair.",0
"Bilateral hypodense renal lesions, too small to accurately characterize.",0
Height: (in) 64 Weight (lb): 130 BSA (m2): 1.63 m2 BP (mm Hg): 109/46 Status: Inpatient Date/Time: at 14:44 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
LV WALL MOTION: The following resting regional left ventricular wall motion abnormalities are seen: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; RIGHT VENTRICLE: Right ventricular chamber size is normal.,0
Resting regional wall motion abnormalities include inferior and inferolateral akinesis with hypokinesis elsewhere.,0
There is a small left to right shunt across the interatrial septum identified by color Doppler consistent with a small (secundum-type) atrial septal defect.,0
12:33 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for thoracic pathology ______________________________________________________________________________ MEDICAL CONDITION: 24 year old woman with chest pain REASON FOR THIS EXAMINATION: evaluate for thoracic pathology ______________________________________________________________________________ FINAL REPORT INDICATION: 24-year-old female with chest pain.,0
"SINGLE PORTABLE CHEST RADIOGRAPH: The lungs remain clear with no consolidation, effusion, or pneumothorax.",0
Osseous structures and surrounding soft tissues are unremarkable.,0
2:21 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval interval change Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman sp thoracoplasty REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 14:22.,0
"INDICATION: Thoracoplasty, check for interval change.",0
FINDINGS: Progressive opacification of the limited right lower lobe airspace is identified with further volume loss.,0
"Findings are consistent with progressive atelectasis, perhaps due to mucous plugging.",0
No other significant interval changes are noted with the left lung remaining clear.,0
BP (mm Hg): 123/70 HR (bpm): 47 Status: Inpatient Date/Time: at 12:15 Test: Portable TTE (Focused views) Doppler: Limited doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
False LV tendon (normal variant).,0
Overall left ventricular systolic function is normal (LVEF>55%) without regional wall motion abnormalities.,0
The LV apex is heavly trabeculated.,0
There is an LV false chord.,0
PATIENT/TEST INFORMATION: Indication: Intra-op TEE for MV repair/replacement Height: (in) 61 Weight (lb): 110 BSA (m2): 1.47 m2 BP (mm Hg): 124/64 HR (bpm): 84 Status: Inpatient Date/Time: at 15:20 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.,0
No MS. Eccentric MR jet.,0
Severe (4+) MR. TRICUSPID VALVE: Mild [1+] TR.,0
There is moderate/severe mitral valve prolapse of posterio leaflet and mild prolapse of anterior leaflet is seen.,1
"An eccentric, anterior directed jet of Severe (4+) mitral regurgitation is seen.",0
"POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including Phenylephrine 1.",0
A well seated mitral annuloplasty ring is seen.,0
Mean gradient across the valve is 6 mm of Hg.,0
CABG Status: Inpatient Date/Time: at 11:11 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
Conclusions: Pre-CPB: The left atrium is normal in size.,0
"Post-CPB: Patient is AV-Paced, on low dose Neo.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Fever, AMS Major Surgical or Invasive Procedure: right femoral line placement left tunneled catheter removal left arterial line placed History of Present Illness: 61 male with history of seizure disorder, nonischemic cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session on saturday), hepatitis B, CAD, CVA, recent admission for line bacteremia given vanco for 2 week course, who was at his rehab center and found to be febrile with altered mental status and hypoglycemia.",1
His sugars there were in the 30s and he was given oral glucose which improved his finger stick to 156.,0
His baseline mental status is A+0x3 but today he was A+O x2.,0
"Pt had recent admission in for staph epidermidis and CONS bacteremia, thought to be from tunnel line (tunnel tip grew CONS).",0
"At that time, tunnel line was changed (, fluro guided tunnel line, exchanged over wire).",0
"Pt was given vancomycin for 2 week course, dosed per HD protocol.",0
"In the ED inital vitals were, T 102.2 HR 105 BP 94/44 RR 18 pOx 98% 2L.",0
Pt noted to have pus coming out of his tunnel line on left.,0
"His temp spiked at 104, SBP initialy 160s.",0
Tunnel line culture was sent off.,0
"Patient was given 4L NS, MAPs dropped to the low 60s, placed femoral line (goal was to preserve other sites sinec pt likely currently bactermic and will likely need new line), started levophed infusion 0.06 (BP 94/45).",0
"For fever of 104, given rectal tylenol 650mg, linezolid 600mg, zosyn 4.5 (not given vanco bc history of VRE).",0
"Cultures were obtained including blood, urine, HD catheter swab.",0
"Labs were significant for CBC WBC 11.9, Hgb 9.4, HCT 31, PLT 366.",0
"Phos low at 1.6, Mg 2, Ca 9.7.",0
"Lytes revealed UA: large euks, blood, 300+ protein, sh 1013, pH 6.5.",0
"Na 135, K 5.1, Cl 94, Bicarb 25, BUN 33, Cr 8.2, Gluc 107.",0
"ABG: pH 7.43, CO2 41, O2 58, HCO3 28 CXR showed: no signs of pneumonia, mildly increased pulm vascular pressures.",0
Access includes 18G right and left forearm and right neck.,0
Femoral line and tunnel line.,0
Most Recent Vitals: 101 80/44 18 82 96% 2LNC .,0
"On arrival to the ICU, pt is A+O x3, states he has a doctorate in history and music.",0
"He is at times sleepy, and at times very sharp and able to answer questions such as the details of his PhD.",0
"Denies any pain anywhere, no cough, no abd pain, last bm yesterday, no diarrhea, states he has been admitted several times for recurrent tunnel line infections.",0
Review of systems: (+) Per HPI (-) Denies recent weight loss or gain.,0
"Past Medical History: - Seizure disorder since mid 's after starting dialysis - MSSA HD line infection with septic lung emboli with left pleural effusion - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 20-30% - MI per pt - CVA per pt (?residual LE weakness) - ESRD on hemodialysis HTN.",1
EDW 80 kg as of .,0
- Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement - Admission to MICU in for seizure and hypotension - Swab positive for MRSA and VRE at left groin site in and MRSA positive from same site - admission for staph epidermidis bacteremia and CONS bacteremia sp vanco x 2 weeks -: MSSA and VRE bacteremia -MSSA and Social History: Retired piano and organ teacher.,1
"Has 2 PhDs (history and music) and prefers to be called ""Dr.",0
Walks with a walker at baseline.,0
"Never smoker, no other drug use.",0
"Has 2 sisters that live out of state, son died few years ago (""was shot to death"").",0
"Family History: Father with DM, mother died at age 41 of renal failure Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: anterior lungs are clear bilaterally CV: Regular rate and rhythm, normal S1 + S2, systolic murmur left sternal border, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with scant dark urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.",1
"Right knee with warm patellar joint, ballotable.",0
"Neuro: CN 2-12 intact, sensation throughout, stregnth throughout, small pinpoint pupils, EOM intact, A+O x3.",0
"Pertinent Results: LABS: On admission: 09:00AM BLOOD WBC-11.9*# RBC-3.63* Hgb-9.4* Hct-30.9* MCV-85 MCH-25.8* MCHC-30.4* RDW-16.0* Plt Ct-366 09:00AM BLOOD Neuts-88.0* Lymphs-6.1* Monos-3.1 Eos-2.7 Baso-0.1 09:00AM BLOOD PT-14.0* PTT-34.0 INR(PT)-1.3* 09:00AM BLOOD Glucose-107* UreaN-33* Creat-8.2*# Na-135 K-5.1 Cl-94* HCO3-25 AnGap-21* 09:00AM BLOOD Calcium-9.7 Phos-1.6*# Mg-2.0 02:59PM BLOOD TSH-0.45 02:59PM BLOOD Cortsol-40.3* 02:58AM BLOOD Cortsol-25.6* 09:00AM BLOOD Digoxin-1.5 09:11AM BLOOD pO2-58* pCO2-41 pH-7.43 calTCO2-28 Base XS-2 09:11AM BLOOD Glucose-102 Lactate-2.3* K-5.1 calHCO3-27 Micro: Blood Cx , 25, 26, 29: no growth to date Blood Cx : MRSA Femoral CVL tip : no growth to date HD catheter tip : MRSA Joint fluid: 12:00; culture showed no growth.",1
WBC RBC Polys Lymphs Monos 81 17 2 Wound swab (from prior HD cath site): MRSA Urine cx: : no growth Studies: Radiology CHEST (PORTABLE AP) Mild cephalization which could reflect mild pulmonary venous congestion.,0
Cardiovascular ECHO The left atrium is mildly dilated.,0
Overall left ventricular systolic function is low normal (LVEF 55%) with subtle basal inferior hypokinesis.,0
No vegetation/mass is seen on the pulmonic valve.,0
"Compared with the prior study (images reviewed) of , the LVEF has improved.",0
Radiology KNEE 2 VIEW PORTABLE RI There are degenerative changes with narrowing of the lateral compartment which causes valgus angulation at the knee.,1
There is spurring at the inferior pole of the patella.,0
There are no focal lytic or blastic lesions.,0
There is some soft tissue swelling.,0
Radiology CHEST (PORTABLE AP) HD catheter has been removed.,0
If any there is a small right pleural effusion.,0
The chin of the patient obscures the right apex.,0
There is mild vascular congestion.,0
There are no new abnormalities from .,0
Widened mediastinum and deviation of the trachea towards the right is due to enlarged thyroid gland.,0
Multiple left rib fractures are noted.,0
"Brief Hospital Course: BRIEF HOSPITAL COURSE: This is 61 male with history of seizure disorder, nonischemic cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session saturday), hepatitis B, CAD, CVA, several admissions in the past for tunnel associated MSSA/CONS/VRE bacteremia, recent admission 1 month ago for Staph epidermidis and CONS line bacteremia given vanco for 2 week course, who presented with MRSA bacteremia likely due to an infected tunnel line.",0
"ACTIVE ISSUES SEPTIC SHOCK: The patient persented with Fever (Tm 104), Leukocytosis (WBC 12), Tachycardia (HR 100s), lactate 2.3, mental status change, and BP 94/44 on low dose Levophed and after 4L, consistent with septic shock.",1
"Methicillin resistant staph aureus grew from the blood culture bottles, swab of the catheter and culture of the tip of the catheter line.",1
Pus was noted surrounding the catheter site which was evaluated by general surgery and no I/D indicated.,0
His urine culture revealed no growth despite large amount of leukocytes.,0
His presenting chest xray was clear and joint fluid analysis of his right knee was not consistent with septic arthritis.,1
A TTE demonstrated no evidence of vegetations.,0
A TEE was deferred given it would not change antibiotic duration.,0
He briefly required pressor support with levophed via a femoral line placed in the ED.,0
He was initially started on linezolid which was discontinued in favor of vancomycin and zosyn in the intensive care unit which were narrowed to vancomycin alone when culture data was available.,0
His HD was line was removed and he HD was deferred for 1 week before a temporary femoral line was placed.,0
Surveillance blood cultures were all negative following his admission cultures on .,0
Duration of therapy 6 weeks () with vancomycin to be given with HD.,0
A tunneled right subclavian line was placed prior to discharge.,0
"Last HD prior to admission was 2 days PTA, on Saturday.",0
"HD was deferred for as long as possible, to allow for a line holiday given segnificant bacteremia and sepsis.",0
"Patient was monitored on telemetry, electrolytes checked daily, small boluses of fluid given for hypotension.",0
"line was replaced on , w/ HD on , now back on prior Tu/Th/Sat schedule.",0
ALTERED MENTAL STATUS: Patient is significantly altered from baseline.,1
"Initially, AMS felt to be due to hypoglycemia.",0
"Likely multifactorial-- septic shock, uremia.",1
"?s family, his mental status has been declining for >1 year.",0
"Patient had one witnessed seizure on the day of HD (5 days into admission), and it was discovered that he had been under dosed on his keppra during the admission.",0
"It is possible that he has been having seizures during this time that have been affecting his MS, however, his postictal state is not similar to his mental status throughout the admission.",1
Mental status continued to improved.,0
Head CT in demonstrated expected expected age-related changes.,0
consider neurocognitive testing in the outpatient setting.,0
HYPOGLYCEMIA: Likely acute infectious state.,0
"Can also see in renal failure (because insulin cleared by kidneys), hypopit (pt has known pituitary mass), adrenal insuf (had normal cortisol Am level check on prior admission), insulinoma.",1
Most likely etiology is sepsis.,0
Patient's blood glucose WNL after 1 day into admission.,0
SEIZURE DISORDER: Patient is on oxcarbazepine and keppra as an outpatient.,0
Patient was underdosed Keppra during his HD vacation this admission.,0
He experienced a brief localized seizure consisting of 1 minute of facial twitching 5 days into admission.,0
"Pt was apparently on the incorrect seizure medication, which was per his prior d/c summary and outside facility list (was ~ of his appropriate dose neuro note).",0
"?s prior seizures were more generalized, last documented in , attributed to medication non-compliance.",0
"Neurology was consulted and Pt was restarted on Keppra 500 tid plus 500 mg dose after HD, and oxcarbazepine 300 mg tid plus 300 mg dose after HD.",0
Pt apparently tends to have seizures after HD.,0
Pt states that he typically has a small facial seizure every few months.,0
Pt did not have any further seizures during his hospitalization.,0
ANION GAP METABOLIC ACID: Likely lactic acidosis and renal failure.,1
Gap closed as patient restarted on HD 5 days into admission.,0
"CAD/CHF: Mild pulm edema on CXR, however on exam pt appears mildly volume down with some decreased skin turgor.",0
Pt given several liters of IVF in setting of septic shock.,1
He is at risk for pulmonary edema so will trend his O2 requirement and exam closely.,0
"HD was restarted 5 days into admission, which will manage volume status.",0
"Continued home simvastatin and ASA, and digoxin dosed according to HD.",0
"HCT currently 31, at baseline.",0
Likely multifactorial: anemia ESRD and anemia of chronic disease.,1
He was given epoeitin in dialysis.,0
"INR 1.3: Likely poor nutrition, recent antibiotics.",0
He was given vitamin K prior to discharge .,0
"HYPOPHOSPHOTEMIA: Phos 1.9 on admission (repleted), lower then expected given renal failure.",1
"Differential includes poor nutrition, osetomalacia, diuretics, hyper-parathyropidism, hyperthyroidism, recovery from starvation, steroids.",0
Baseline phos is usualy .,0
Repeat Phos levels remained WNL.,0
"Pt was complaining about knee effusion, which felt warm and was tapped by orthopedic service.",0
"Fluid showed 200 WBC, 1625 RBC, 81% Polys 17% Lymphs, no organisms on gram stain, no crystals.",0
Pt was treated with analgesics with improvement in his pain.,0
TRANSITIONAL ISSUES - vancomycin for 6 weeks (last date ) - consider neurocognitive testing Medications on Admission: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
2. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).,0
"6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA): extra dose to be given on dialysis days after dialysis.",0
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
"8. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
9. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three times a day.,0
"10. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three times a week (Tues, Thurs, Sat): extra dose to be given on dialysis days after dialysis.",0
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not exceed 4 grams in 24 hours.,0
"14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day.,0
16. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation.,0
17. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime: hold for loose stools; pt may refuse.,0
18. chlorhexidine gluconate 4 % Liquid Sig: One (1) Topical times each week.,0
"Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical once a day: APPLY LIBERALLY TO SKIN ON HANDS, FEET 20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed Intravenous HD PROTOCOL (HD Protochol): To be dosed based on trough and given on hemodialysis; continue until .",1
21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain.,0
Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day.,0
5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD DAYS ().,0
"7. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO ON HD DAY ().,0
10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever.",0
"12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
13. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation.,0
14. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation.,0
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily).,0
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous with HD for 1 doses: To be dosed based on trough and given on hemodialysis days.,1
"(Duration 6 weeks, last day ).",0
Disp:*qS * Refills:*0* 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain.,0
Discharge Disposition: Extended Care Facility: Senior Healthcare of Discharge Diagnosis: 1.,0
Methicillin Resistant Staphylococcus Aureus Bactermia 2.,1
End Stage Renal Disease Discharge Condition: Mental Status: Confused - sometimes.,1
"Discharge Instructions: Dear Mr. , .",0
You were admitted for a fever and found to have another infection in your blood likely related to your hemodialysis line.,1
Your tunneled catheter was removed and dialysis was stopped for 1 week.,1
A temporary catheter was then placed in your groin before a new tunneled catheter could be placed in your right subclavian site.,0
You will need to continue antibiotics for a total of 6 weeks.,0
The following changes were made to your medication list: 1.,0
CONTINUE Vancomycin with hemodialysis for 6 weeks (last day ) 2.,0
HOLD Sevelamer until otherwise directed 4.,0
HOLD Calcium acetate until otherwise directed .,0
"Weigh yourself every morning, MD if weight goes up more than 3 lbs.",0
Followup Instructions: Please follow-up with the physicians at your facility and your outpatient nephrologists.,0
"3:52 PM UNILAT UP EXT VEINS US LEFT PORT Clip # Reason: PLEASE EVAL FOR CLOT IN LT ARM/SWELLING/LINE IN Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED;SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with significant edema of left arm on side of central line REASON FOR THIS EXAMINATION: please evaluate for clot ______________________________________________________________________________ WET READ: DXAe WED 5:45 PM Extensive occlusive DVT involves the left jugular, subclavian, one brachial vein and the basillic and cephallic veins proxially.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 82 year-old woman with left arm edema on site of central line placement.,0
LEFT UPPER EXTREMITY ULTRASOUND: The right subclavian demonstrates normal flow and waveforms.,1
"The left internal jugular, subclavian, axillary, as well as one of the two brachial veins and the proximal left cephalic and basilic veins demonstrate occlusive thrombus with no evidence of flow.",0
Flow is seen in the distal basilic and cephalic veins as well as one brachial vein.,0
IMPRESSION: Extensive deep vein thrombosis involving the left upper extremity as above.,1
Findings were discussed in person Dr. by ultrasound technologist at 5:30 p.m. on .,0
"11:11 AM CT HEAD W/O CONTRAST Clip # Reason: eval for bleed Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man off sedation x 36 hours, thrombocytopenia, minimal mental status activity REASON FOR THIS EXAMINATION: eval for bleed CONTRAINDICATIONS for IV CONTRAST: acute renal failure ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old gentleman off sedation for 36 hours, with AML, thrombocytopenia and minimal mental status activity.",1
COMPARISON: CT of the head .,0
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage or major vascular territorial infarct.,0
-white matter differentiation is preserved.,0
A tiny linear hyperdensity within the left basal ganglia is likely a focus of calcification.,0
The osseous structures and soft tissues are unremarkable.,0
"There is moderate opacification of the visualized maxillary sinuses, near complete opacification of the sphenoid sinuses, (pt.",0
is intubated) and near complete opacification of the mastoid air cells.,0
The frontal sinuses are clear.,0
No acute intracranial hemorrhage or major vascular territorial infarct.,0
NOTE ON ATTENDING REVIEW: THIS STUDY WAS AVAILABLE FOR INTERPRETATION ON .,0
"7:23 AM CHEST (PORTABLE AP) Clip # Reason: eval for pneumonia/effusions Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFTWITH AVR ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with severe AS, s/p AVR asc arch replacement REASON FOR THIS EXAMINATION: eval for pneumonia/effusions ______________________________________________________________________________ FINAL REPORT INDICATION: Severe aortic stenosis, status post aortic valve replacement and ascending arch replacement.",1
"SINGLE VIEW CHEST, AP: There is no change when compared to previous exam with small bilateral pleural effusions, cardiomegaly, and a right IJ CVL sheath.",0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: yo M w/ CAD s/p CABG, AF s/p ppm on coumadin, presents with fevers, productive cough (brown sputum) and worsening SOB over day.",0
"In the ED: he presented in respitory distress with initial vitals: T 102.2, BP 140/70, HR 72, RR 40's 02sat 78RA->93% on NRB.",0
A CXR showed evidence of a LLL infiltrate.,0
"His labs were significant for a WBC count of 11.6 (16 bands), bun/crt 50/2.",0
"He was started on BIPAP with good effect (PS 12, PEEP 8, 100%, 99% 02sats with RR of 20's), he was given fluids 1L NS, azithro, ceftrioxone, tylenol.",0
Admited to the ICU for BIPAP and treatment of his PNA.,0
"ROS: significant for productive cough, SOB, decreased appetite over past 2 days.",0
(a) Status post acute myocardial infarction in .,1
(b) Status post coronary artery bypass graft in .,1
Prostate cancer; status post radiation therapy.,0
Status post permanent pacemaker placement.,1
Status post left total hip replacement surgery.,0
"Social History: accountant and retired lawyer, .",0
Family History: Family History: A daughter died of unknown CA at the age of 54.,0
"No other family history of cancer, diabetes, HTN, stroke, or heart disease.",0
"Physical Exam: VS: Temp: 97.3 BP: / HR: 63 RR: O2sat GEN: venti mask in place, NAD, pleasant elderly M HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: JVD approx 8-10cm RESP: rales throughout CV: heart sounds obscured by rales.",0
"ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3.",0
Pertinent Results: 11:48PM WBC-11.6* RBC-4.22* HGB-12.8* HCT-36.6* MCV-87 MCH-30.3 MCHC-35.0 RDW-14.0 11:48PM NEUTS-69 BANDS-16* LYMPHS-13* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 11:48PM PLT COUNT-213 11:48PM CK-MB-2 cTropnT-<0.01 proBNP-7359* 11:48PM GLUCOSE-165* UREA N-50* CREAT-2.0* SODIUM-139 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17 11:54PM LACTATE-2.9* 12:07AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 05:58AM CK-MB-3 cTropnT-<0.01 .,0
"CXR: LLL infiltrate, mild CHF Brief Hospital Course: Pneumonia: Pt admitted to ICU and respiratory distress resolved with BIPAP.",0
"LLL infiltrate on CXR, prominent vasculature.",0
Improved with coverage with ceftrioxone/azithro for CAP.,0
"A.fib: Stable, h/o afib, followed closely by cardiology.",0
Bacteremia: Patient was admitted to ICU on presentation.,0
"Blood cultures with strep pneumonia, thought secondary to pneumonia, sensitive to levofloxacin.",0
"On hospital day 3, pt had normal O2 sat, looked and felt well.",0
WBC count normalized and pt was afebrile.,0
"He asked to be discharged home, and was discharged to complete a 10 day course of levofloxacin.",0
Medications on Admission: Amlodipine 2.5mg qdaily simvastatin 80mg qdaily toprol XL 50mg qdaily coumadin 2mg/1mg/1mg triamterene 37.5 qdaily ocutabs qdaily Discharge Medications: 1.,0
Continue all home medications 2.,0
Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 days.,0
Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pneumonia Discharge Condition: stable Discharge Instructions: Please take your antiobiotic every other day until the pills are completed.,0
Followup Instructions: Please follow up with Dr. within 2 weeks.,0
10:10 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for acute infectious process ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with ams + ffall REASON FOR THIS EXAMINATION: Please eval for acute infectious process ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH PERFORMED ON .,0
CLINICAL HISTORY: Status post fall with altered mental status.,1
FINDINGS: Portable supine AP view of the chest is obtained.,0
Right CP angle is excluded.,0
Low lung volumes limit evaluation.,0
"The lungs appear well inflated without focal consolidation, large effusion, or pneumothorax.",0
Cardiomediastinal silhouette appears grossly unremarkable.,0
Multiple left rib fractures appear old and fully healed.,0
No acute fractures are seen.,0
IMPRESSION: No acute findings in the chest.,0
"7:42 AM PORTAL VENOGRAPHY Clip # Reason: has portal vein thrombus on CTA, needs thrombolysis.",0
"Admitting Diagnosis: PORTAL VEIN THROMBOSIS/S/P LIVER TX Contrast: OPTIRAY Amt: 175 ********************************* CPT Codes ******************************** * TRANSCATHETER INFUSION FOR LYS PERC PORTAL VEIN CATH * * -51 MULTI-PROCEDURE SAME DAY 2ND ORDER OR> VENOUS SYSTEM * * -51 MULTI-PROCEDURE SAME DAY 1SR ORDER BRANCH VENOUS SYSTEM * * -59 DISTINCT PROCEDURAL SERVICE TRANSCATHETER INFUSION * * PERC TRANHEP PORTOGRAPHY NO PR -59 DISTINCT PROCEDURAL SERVICE * * MOD SEDATION, FIRST 30 MIN.",1
"MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF * * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF * * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF * * C1887 CATHETER GUIDING INF/PERF C1894 INT.SHTH NOT/GUID,EP,NONLASER * * C1894 INT.SHTH NOT/GUID,EP,NONLASER C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p liver transplant for Laennec's cirrhosis.",1
Had liver duplex today to eval for HA thrombosis prior to rapamune conversion.,1
No portal flow seen on U/S.,0
"REASON FOR THIS EXAMINATION: has portal vein thrombus on CTA, needs thrombolysis.",0
Initiation of TPA transcatheter thrombolysis of portal vein and superior mesenteric vein thrombosis with intervascular ultrasound.,1
CLINICAL INDICATION: Portal vein thrombosis.,1
"(staff, present and supervising throughout).",0
INFORMED CONSENT: Procedural informed consent was obtained from the patient.,0
"The patient acknowledged understanding of the indications for the procedure, the attended risks, including but not limited to that of bleeding and infection were explained to the patient.",0
Also explained were the possible surgical alternatives.,0
"DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the procedure to be performed, the site of the procedure, appropriate requisition, and appropriate informed consent.",0
"Once the above were verified, the patient was positioned in supine fashion on a special procedure/angiography table.",0
Right upper quadrant and right flank were prepped and draped in usual sterile fashion.,0
"Ultrasound was employed to assess the hepatic vasculature and guide (Over) 7:42 AM PORTAL VENOGRAPHY Clip # Reason: has portal vein thrombus on CTA, needs thrombolysis.",0
Admitting Diagnosis: PORTAL VEIN THROMBOSIS/S/P LIVER TX Contrast: OPTIRAY Amt: 175 ______________________________________________________________________________ FINAL REPORT (Cont) venipuncture of a peripheral right hepatic venule.,1
"A suitable venule space was selected, using _____ fluoroscopic guidance and digital palpation.",0
The skin and subcutaneous tissues were infiltrated with approximately 15 cc of 1% Xylocaine.,0
"After several passes using a 22-gauge Chiba skinny needle, a suitable right portal venule was accessed.",0
Hand injection of contrast was employed to outline the portal vasculature to guide the advancement of a 0.018 angled Glidewire to the main portal vein and into the inferior mesenteric vein.,0
"Once satisfactory position was determined, an end-hole catheter was advanced over the guide wire and positioned in the inferior mesenteric vein.",0
"Venographic injection performed therein demonstrated large amount of intraluminal thrombus within the superior mesenteric vein, main portal vein at the confluence above the superior mesenteric vein and the inferior mesenteric vein and a right lobar branch of the portal vein.",0
"Based on the diagnostic findings, it was decided that the patient would benefit from and was a good candidate for infusion therapy.",0
The portal vein and the superior mesenteric vein were ventrally traversed with a 0.035- inch Glidewire followed with delivery of an infusion catheter extending from the right hepatic vein to the superior mesenteric vein.,1
The patient was begun on TPA infusion.,0
The infusion catheter was secured at the skin interface as was the 6 French access sheath.,0
The 6 French access sheath was connected to continuous heparinized saline flush infusion.,0
TPA infusion was administered by way of the infusion catheter.,0
Saline flush was administered by way of the cooling port of the infusion catheter.,0
The patient tolerated the procedure both well.,0
All catheters were secured and the patient was transferred from the department and admitted to the intensive care unit for monitoring.,0
"MEDICATIONS: Moderate intravenous sedoanalgesia was provided by administering divided doses of both fentanyl and Versed throughout the total intraservice time of 1 hour 55 minutes, during which time the patient's hemodynamic parameters were continuously monitored.",0
Fentanyl was given in total of three doses for a total dosage of 150 mcg IV.,0
Versed was given in two doses for a total dosage of 2 mg IV.,0
Total intraservice time was 1 hour and 55 minutes.,0
"Large amount of thrombus seen within the superior mesenteric vein, main portal vein, a right lobar branch of the portal vein.",0
Status post placement of an infusion catheter across the thrombus described above and initiation of ultrasound-assisted thrombolysis with TPA.,0
"(Over) 7:42 AM PORTAL VENOGRAPHY Clip # Reason: has portal vein thrombus on CTA, needs thrombolysis.",0
Admitting Diagnosis: PORTAL VEIN THROMBOSIS/S/P LIVER TX Contrast: OPTIRAY Amt: 175 ______________________________________________________________________________ FINAL REPORT (Cont),1
5:43 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for injury Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man s/p MVC REASON FOR THIS EXAMINATION: eval for injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: FBr SUN 6:42 AM no acute pathology in chest/abd/p.,0
Old avulsive injury adjacent to symphisis pubis.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 19-year-old man with motor vehicle accident.,1
"TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis were obtained after administration of IV contrast.",0
Sagittal and coronal reformatted images were then obtained.,0
CT OF THE CHEST: No mediastinal hematoma or aortic pathology is identified.,0
No pleural or pericardial effusion is seen.,0
"No pulmonary nodule, parenchymal opacification, or pleural effusion is seen.",0
"CT OF THE ABDOMEN WITH CONTRAST: The liver, spleen, adrenal glands, kidneys, pancreas, gallbladder, common bile duct, stomach, duodenum, loops of small bowel and large bowel have normal appearance.",0
No free air or fluid is noted within the abdomen.,0
No pathologically enlarged nodes are seen.,0
Incidental note is made of extrarenal pelvis on the left side.,0
CT OF THE PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter.,0
"The prostate, seminal vesicles, and the rectum and sigmoid colon are normal.",0
No free fluid is noted in the pelvis.,0
BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.,0
Old avulsive injury of parasymphyseal region of symphysis pubis is noted bilaterally.,1
Hemangioma of T11 vertebral body is noted.,0
"No acute pathology in the chest, abdomen, and pelvis.",0
Old avulsive injury of parasymphyseal region of the symphysis pubis.,0
(Over) 5:43 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for injury Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont),0
"8:08 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval changes Admitting Diagnosis: ACUTE LEUKEMIA;NEUTROPENIA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with AML, febrile neutropenia please eval for evidence of pneumonia/CHF.",1
"REASON FOR THIS EXAMINATION: evaluate for interval changes ______________________________________________________________________________ FINAL REPORT INDICATION: Neutropenia, fever.",0
PORTABLE CHEST: Comparison is made to film from 2 days earlier.,0
"There is interval worsening of aeration diffusely, with increased interstitial markings and perihilar infiltrates, likely reflecting pulmonary edema.",0
There are persistent bilateral pleural effusions.,0
"Abnormal density persists in the left base silhouetting the diaphragm, without significant interval change.",0
"IMPRESSION: 1) Worsened aeration, consistent with worsening pulmonary edema.",0
2) Persistent bilateral pleural effusions.,0
2:35 PM TIB/FIB (AP & LAT) RIGHT IN O.R.,0
; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # Reason: R/O FX Admitting Diagnosis: POLY TRAUMA ______________________________________________________________________________ FINAL REPORT TIB/FIB RIGHT REASON FOR EXAM: Assess for fracture.,0
5 Fluoroscopic images were obtained in the OR without the presence of a radiologist.,0
Minimal degenerative changes are in the knee joint.,0
Small calcaneal spur is noted.,0
"12:53 PM N-G TUBE PLACEMENT Clip # Reason: request IR placed dobhoff Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 5 ********************************* CPT Codes ******************************** * NASAL/OROGASTRC TUBE PLMT, PRO EXCH PERPHERAL W/O PORT * * FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with CVA REASON FOR THIS EXAMINATION: request IR placed dobhoff ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 4:04 PM PFI: 1.",0
"Successful exchange of malpositioned right PICC for a new 41-cm double lumen Bard Power PICC, tip positioned in the superior vena cava.",0
Successful placement of post-pyloric small bore feeding tube with tip in the proximal jejunum.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 78-year-old male with CVA.,0
"The patient presents for repositioning of a malpositioned right PICC line, as well as placement of a post-pyloric feeding tube.",0
"OPERATORS: Dr. (resident) and Dr. (attending radiologist), who was present for the procedure.",0
"Procedure was explained to the patient, and the patient was brought to the angiography suite.",0
PROCEDURE: Attention was first turned towards the patient's indwelling malpositioned right PICC line.,0
"A scout image was obtained, demonstrating the PICC coiled within the subclavian vein.",0
"The PICC was cut, and a 0.018 wire was advanced through the catheter.",0
"The catheter was removed over the wire, and a peel-away sheath was placed.",0
The wire was then used to measure the appropriate catheter length.,0
A 41-cm double lumen Bard Power PICC was then placed through the sheath and positioned in the superior vena cava under fluoroscopic guidance.,0
Wire and peel-away sheath were removed.,0
The catheter position was confirmed with a single spot fluoroscopic image of the chest.,0
"Catheter aspirated and flushed, and secured to the skin with a StatLock device.",0
A sterile dressing was applied.,0
Attention was then turned towards placing a post-pyloric feeding tube.,0
"The patient's existing NG tube was removed, and a new small bore feeding tube was placed via the right naris into the stomach.",0
"Under fluoroscopic guidance, the tube was then maneuvered into a post-pyloric position with the tip terminating in the proximal jejunum.",0
Position was confirmed with a small contrast (Over) 12:53 PM N-G TUBE PLACEMENT Clip # Reason: request IR placed dobhoff Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 5 ______________________________________________________________________________ FINAL REPORT (Cont) injection.,0
The patient tolerated these procedures well.,0
10:09 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: NGT in correct position?,0
Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman s/p NGT REASON FOR THIS EXAMINATION: NGT in correct position?,1
______________________________________________________________________________ FINAL REPORT INDICATION: NG tube placement.,0
COMPARISON: Radiograph available from .,0
"FRONTAL CHEST RADIOGRAPH: Moderate cardiomegaly, large bilateral pleural effusions, and mild pulmonary edema are unchanged since the 1:59 a.m. study.",0
The mediastinal contour is normal.,0
A nasogastric tube terminates within the stomach.,0
IMPRESSION: NG tube terminating within the stomach.,0
Unchanged bilateral pleural effusions and mild interstitial edema.,0
Height: (in) 69 Weight (lb): 195 BSA (m2): 2.05 m2 BP (mm Hg): 91/66 HR (bpm): 86 Status: Inpatient Date/Time: at 16:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal - akinetic; mid inferoseptal - akinetic; anterior apex - hypo; septal apex- akinetic; inferior apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
"There is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis of the septum and anterior walls, apex, and distal inferior wall.",1
The remaining segments contract normally (LVEF = 25 %).,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with mild cavity enlargement and extensive regional systolic dysfunction c/w CAD.,1
Right ventricular cavity enlargement/free wall hypokinesis.,0
"Compared with the prior study (images reviewed) of , regional left ventricular systolic dysfunction is more extensive (LAD distribution); right ventricular dysfunction and a small pericardial effusion are now apparent.",1
Is there a history to suggest myocarditis?,0
"CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or .",0
"Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Vicodin / Adhesive Tape / Lisinopril Attending: Chief Complaint: fever and abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. is a 62F with h/o breast cancer, DM, and diverticulitis recently treated with ciprofloxacin and flagyl who presents with fever to 101.3 and LLQ abdominal pain.",1
She was evaluated in clinic for complaints of chronic diarrhea.,0
A colonoscopy was performed showing diverticulitis with EGD showing gastritis.,1
She was started on 2 weeks of cipro/flagyl which she completed on .,0
She called GI on with complaints of increased LLQ pain.,0
"She had a CT scan at an OSH that showed diverticulitis, and was advised to continue her antibiotics and low residue diet.",0
She recently left on a trip for on and developed a fever to 101.3 and was advised to seek evaluation in the ED.,0
"Since starting ciprofloxacin and flagyl she describes ""explosive"" diarrhea with approximatley 8 bowel movements daily; she has had diarrhea associated with flagyl in the past per her report.",0
"Stools have been rust-colored, without melena or hematochezia.",0
She has abdominal discomfort sharp in quality worse in LLQ radiating to RLQ.,0
"She has bloating and nausea, without vomiting.",0
Review of systems is notable for chronic abdominal discomfort and alternating constipation and diarrhea with current symptoms more severe than her baseline.,0
"Denies lightheadedness, dizziness, foreign travel, sick contacts, ingesting undercooked food.",0
"Has mild SOB without CP, no h/o CAD, has heartburn, no coughing, dysuria.",0
"In the ED, vitals were T99.4 P 101 BP 113/69, RR 16, O2 100% on RA.",0
"She was treated with IVF, Unasyn, and tylenol.",0
Blood cultures were sent prior to antibiotics.,0
"CT abdomen showed uncomplicated diverticulitis, and she was admitted to medicine for further management.",0
"Past Medical History: * Breast cancer, stage II hormone positive - status post lumpectomy, adjuvent chemotherapy and XRT - - : Adriamycin, Cytoxan and Taxol - radiation therapy -, thirty-three visits.",1
"* PAF * htn * DM * hyperlipidemia * depression * anxiety * severe AS and MR s/p bioprosthetic AVR, MVR * migraines * complex sleep disordered breathing - doesn't use CPAP * BPPV * Diverticulosis * Hypothyroidism * Hiatal hernia * GERD * s/p appy Social History: Lives on with her husband.",1
Former 1.5 ppd smoker x 17 yrs.,0
Family History: Father w/ DM and died of MI at 57.,0
Mother with COPD and lung ca.,0
"Sister with DM, ESRD on HD, and CAD s/p bypass.",0
"Physical Exam: T 99.6 P 101 BP 119/53 RR 20 O2 96% RA General Pleasant somewhat uncomfortable appearing woman HEENT dry MM, sclera white, conjunctiva pale Neck no JVD Pulm few crackles at bases persisting post cough, no wheeze Back no CVA tenderness CV regular rate S1 S2 III/VI systolic murmur at base Abd soft, +bowel sounds, no rigidity or guarding, tender to palpation LLQ Extrem warm tr edema Neuro alert and interactive Pertinent Results: CBC WBC 9.9, Hb/Hct 7.4/25.9, plts 454 Chem 140/4.2/107/25/7/0.6<86 Mg 1.9 lactate 2.4, ALT 17 AST 18 ALKP 93 Tbil 0.3 40 lip 23 Alb 4 .",0
"EKG NSR 84bpm, normal axis and intervals, no acute ischemia .",0
CXR PA AND LATERAL CHEST: Heart size is at the normal limits.,1
The patient is status post midline sternotomy and aortic and mitral valve replacements.,1
"There is stable haziness around the left heart border, likely stable post-surgical changes.",0
No consolidations to suggest pneumonia are identified.,0
No effusions or evidence of CHF is identified.,0
CT abd IMPRESSION: Acute uncomplicated sigmoid diverticulitis with focal area of sigmoid bowel wall thickening.,1
Follow up CT or colonoscopy after treatment is recommended to ensure resolution as an underlying mass lesion cannot be completely excluded.,0
"Brief Hospital Course: This 62F with h/o breast cancer, DM, and recent diverticulitis s/p ciprofloxacin and flagyl presents with fever and increased LLQ pain.",1
LLQ pain: Diverticulitis is cause in this patient.,1
"No adnexal pathology seen on CT. --Managed with IVF rehydration, NPO advancing to sips as tolerated, morphine prn pain --Unasyn started --GI consulted, and agreed with plan of care.",0
Primary care of this patient transferred to Dr. .,0
Surgical intervention no indicated at this time.,0
Follow-up scheduled in 1 week.,0
Patient will complete 9 day oral course of Augmentin.,0
"Anemia: Given gastritis on EGD and diverticular disease, suspect GI source.",0
Decrease in Hct may also be dilutational in part in setting of IVF resuscitation.,0
Given h/o breast cancer concern also for malignant marrow process.,1
"--Type and screen, transfuse Hb>7, follow Hct -no transfusion required with this admission.",0
Follow-up with continue with PCP and Oncologist.,0
"Fever: Likely due to GI source, agree that C. diff important consideration in this patient recently treated with antibiotics (would be less commonly associated with flagyl, though not impossible).",0
No pulmonary or GU symptoms to suggest pna or UTI.,0
"--Blood, urine, and stool cultures are all negative.",0
"During this admission, patient was maintained on home medication regimen once tolerating oral intake: -h/o breast cancer: continue arimidex -atrial fibrillation: continue beta blocker -DM: hold avandia, cover with sliding scale insulin -HTN: continue metoprolol -hypothyroidism: continue levothyroxine -hyperlipidemia: continue statin -depression and anxiety: continue home psych meds -GERD: continue PPI .",1
The patient was managed conservatively.,0
"Once her abdominal tenderness subsided, and normal bowel function resumed, her diet was advanced.",0
She has been tolerating a regular diet.,0
"Vital signs have remained stable, and WBC normal.",0
She responded well to IV antibiotics and re-hydration.,0
"She was advised to make a follow-up appointment with Dr. next, and to continue the oral Augmentin.",0
Medications on Admission: cipro/flagyl completed aspirin 81 mg daily Toprol XL 50 mg daily Arimidex 1 mg daily Claritin 10 mg daily Cymbalta 150 mg daily Lasix 20 mg daily levothyroxine 150 mctg daily simvastatin 40 mg daily Singulair 10 mg daily trazodone 175 mg qhs desipramine 50 mg lorazepam 2.5 mg daily Prilosec 20 mg Mirapex 0.125 mg qhs avandia 4 mg daily ca/vit D MVI Discharge Medications: 1.,0
Anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily).",0
"Duloxetine 30 mg Capsule, Delayed Release(E.C.)",0
"Sig: Five (5) Capsule, Delayed Release(E.C.)",0
Desipramine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).,0
Ativan 1 mg Tablet Sig: 2.5 Tablets PO every 6-8 hours as needed for anxiety.,0
Calcium 600 + D 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day.,0
Vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a day.,0
Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.,0
Mirapex 0.125 mg Tablet Sig: 0.5-1 Tablet PO once a day.,0
Particle/Crystal PO once a day.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months.,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 2 weeks.,0
Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 2 weeks.,0
Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 9 days.,0
Disp:*18 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Diverticultitis .,0
"Secondary: breast cancer s/p lumpectomy and chemoradiation, severe AS and MR s/p bioprosthetic AVR and MVR, PAF, HTN, DM, hyperlipidemia, diverticulosis, GERD, hiatal hernia, migraines, complex sleep disordered breathing, BPPV, hypothyroidism, depression, anxiety, appy Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness.",1
*Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon.,0
*Avoid driving or operating heavy machinery while taking pain medications.,0
* Please resume all regular home medications and take any new meds as ordered.,0
* Continue to ambulate several times per day.,0
Adhere to 2 gm sodium diet.,0
Please make a follow-up appointment with Dr. ( for next week.,0
"Provider: , MD Phone: Date/Time: 10:30 3.",0
"Provider: , MD Phone: Date/Time: 12:30 4.",0
"Provider: , MD Phone: Date/Time: 11:45 Completed by:",0
5:44 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"acute process Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 21M with mental retardation, extensive pulm hx p/w worsening resp failure pneumonia.",1
acute process ______________________________________________________________________________ FINAL REPORT AP CHEST 5:54 A.M. ON .,0
IMPRESSION: AP chest compared to and : The chest cage is markedly deformed.,0
There is a concave to the left and a relatively small right hemithorax.,0
Spinal stabilization rods in place are intact but precise location is not assessed by this examination.,0
The proximal portion of a left bronchial stent is obscured by the rods.,0
The distal portion is proximal to the lobar branching of the left main bronchus.,0
Left lung is severely consolidated and heterogeneous opacification of the right lung has progressed since .,0
"Findings could be due to pulmonary edema alone, or widespread pneumonia.",1
"Given the chest deformity, heart size is difficult to assess but it appears larger on today's examination than in .",0
5:04 PM BABYGRAM (CHEST ONLY) Clip # Reason: pneumothorax Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress REASON FOR THIS EXAMINATION: pneumothorax ______________________________________________________________________________ FINAL REPORT FILM OF THE CHEST ON .,1
"By appearance, this is likely a full term infant.",0
Clinical concern is for pneumothorax.,0
"There is diffuse hazy opacity throughout the lungs, central vascular prominence, and mild cardiomegaly.",0
Resorbing fetal fluid is the most likely cause.,0
"Because of the prominent cardiac size, close evaluation for presence of murmur or other abnormalities referable to the cardiovascular system would be helpful information.",0
The abdominal situs is normal.,0
I believe the aortic arch is left-sided.,0
"12:26 PM CHEST (PORTABLE AP) Clip # Reason: Please evalute for acute process Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man s/p sepsis, extubated a few days ago, now desating REASON FOR THIS EXAMINATION: Please evalute for acute process ______________________________________________________________________________ FINAL REPORT INDICATION: Sepsis, to evaluate for any acute process.",1
TECHNIQUE: Single portable radiograph of chest.,0
"Comparison was made with multiple prior radiographs, with the most recent study from .",0
FINDINGS: The tip of the right internal jugular catheter is in the upper SVC and the tip of a right PICC line is terminating in the lower SVC.,0
"Since , there are no new pulmonary abnormalities identified.",0
Atelectatic changes in the bilateral lung bases are stable and lung volumes are low.,0
Cardiac size is mildly prominent and unchanged.,0
3:41 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Please evaluate pancreas for possible infected psuedocyst/pa Admitting Diagnosis: ACUTE RENAL FAILURE;CHOLECYSTITIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man recent gallstone pancreatitis s/p lap chole admitted for sepsis found to have pancreatic fluid collection/debris on prior imaging.,1
Sepsis is now resolved but patient with new intermittent fevers without clear source.,0
"Urine, blood and thoracentesis cultures have all been negative.",0
"Given patient history an intra-abdominal process, in particular given pancreatic debris and ?fluid collection is most likely nidus.",0
"Given his history of a prior lap chole there was concern for possible infection in gallbladder fossa, this may be another nidus.",0
He may require srugical intervention if complicated pancreatitis or inttra-abdominal collection can be found.,0
REASON FOR THIS EXAMINATION: Please evaluate pancreas for possible infected psuedocyst/pancreatic debris.,0
Please also evaluate gallbladder fossa for possible infection No contraindications for IV contrast ______________________________________________________________________________ WET READ: MON 5:04 PM 1.,0
"Increased rim-enhancing pancreatic fluid collection, measuring 21.5 x 11.3 x 10.7 cm compared to 18.9 x 9.4 x 9.9 cm on prior CT.",0
Adjacent small rim- enhancing collection is unchanged.,0
There are two new rim-enhancing fluid collections surrounding the left hepatic lobe and adjacent to the spleen.,0
"All of these collections are likely pseudocysts, although infection of these collections is possible.",0
Unchanged infarction involving the inferior aspect of the spleen.,0
New wedge shaped region of hypoenhancement in the superior aspect of the spleen is likely ischemia or evolving infarction.,0
Persistent occlusion of the splenic vein.,0
New small to moderate left pleural effusion and associated compressive atelectasis.,1
Small quantity of air in the bladder should be correlated with recent catheterization.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Recent gallstone pancreatitis status post laparoscopic cholecystectomy, admitted for sepsis and found to have pancreatic fluid collection/debris on prior imaging.",1
Sepsis is now resolved but patient continues to have intermittent fevers without clear source.,0
Please evaluate for source of persistent fevers.,0
TECHNIQUE: MDCT axial images were acquired from the lung bases through the lesser trochanters following administration of both oral and intravenous contrast material.,0
COMPARISON: Multiple prior studies including a CT abdomen/pelvis from and abdominal ultrasound from .,0
"ABDOMEN CT: Compared to CT from , there is a new small-to- moderate left pleural effusion with associated left basilar compressive atelectasis.",1
The visualized portion of the right lung base is clear aside from minimal dependent atelectasis.,0
Minimal pericardial fluid is slightly increased (2:4).,0
(Over) 3:41 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Please evaluate pancreas for possible infected psuedocyst/pa Admitting Diagnosis: ACUTE RENAL FAILURE;CHOLECYSTITIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) The liver is grossly unremarkable.,1
Minimal fluid and air within the resection bed is decreased compared to CT from .,0
A wedge-shaped region of hypoenhancement within the inferior aspect of the spleen is consistent with infarction and not significantly changed compared to the prior study.,0
"There is a new wedge-shaped region of hypoenhancement within the more superior aspect of the spleen, concerning for ischemia/infarction (2:20-26).",0
The adrenal glands are normal appearing bilaterally.,0
"An 8-mm hypodensity in the lower pole of the right kidney is too small to characterize but is likely a simple cyst, not significantly changed compared to the prior study.",1
The kidneys are otherwise normal-appearing bilaterally with symmetric excretion of contrast material.,0
The stomach and small bowel are grossly unremarkable.,0
"There is colonic diverticulosis without evidence of diverticulitis, predominantly involving the sigmoid colon.",0
The large bowel is otherwise unremarkable.,0
"The previously seen large pancreatic walled-off collection has increased in size, measuring 21.5 x 11.3 x 10.7 cm, compared to 18.9 x 9.4 x 9.9 cm on CT from .",0
An adjacent walled-off collection measuring 4.4 x 3.3 cm and is not significantly changed in size (2:45).,0
"There is a new collection with a thin enhancing rim, measuring up to 13.4 x 7.3 cm in axial/oblique plane, surrounding a portion of the left hepatic lobe (2:15-27).",0
A second new rim-enhancing collection measuring 8.1 x 2.6 cm is seen adjacent to the spleen (2:15).,0
The remaining portion of the visualized pancreatic parenchyma enhances normally.,0
"As before, the splenic vein is occluded.",0
The superior mesenteric vein and portal vein remain patent.,0
The splenic artery is normal in caliber.,0
A small quantity of fluid is seen within the paracolic gutters bilaterally.,0
"Multiple prominent/enlarged portacaval and celiac axis lymph nodes are again seen (2:20, 25).",0
There is no free air in the abdomen.,0
The abdominal aorta is normal in caliber.,0
Calcifications are seen throughout both the abdominal aorta and bilateral iliac arteries.,0
"PELVIS CT: A small quantity of air is seen within the bladder (2:83), possibly secondary to recent catheterization.",0
The bladder is otherwise unremarkable.,0
Small bilateral iliac chain and inguinal lymph nodes do not meet CT size criteria.,0
There is a small fat-containing left inguinal hernia.,0
BONE WINDOW: No suspicious lytic or blastic lesions are identified.,0
Mild multilevel degenerative changes of the thoracolumbar spine are seen.,0
IMPRESSION: (Over) 3:41 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Please evaluate pancreas for possible infected psuedocyst/pa Admitting Diagnosis: ACUTE RENAL FAILURE;CHOLECYSTITIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
"Increased size of large pancreatic walled-off fluid collection, measuring up to 21.5 cm and unchanged adjacent smaller fluid collection measuring up to 4.4 cm.",0
New collection measuring up to 13.4 cm surrounds a portion of the left hepatic lobe.,0
Additional new collection measuring is seen adjacent to the spleen.,0
All of these collections are consistent with pseudocysts 2.,0
"Unchanged hypoenhancement of the inferior portion of the spleen, likely secondary to infarction.",0
A new infarction in the upper pole of the spleen 3.,0
"Occlusion of the splenic vein, as before.",0
"Decreased fluid and air within the gallbladder resection bed, consistent with Surgicel.",0
"Small-to-moderate left pleural effusion with associated left basilar compressive atelectasis, new compared to CT from .",1
Tiny foci of air within the bladder should be correlated with recent catheterization.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MICU CHIEF COMPLAINT: Dyspnea.,0
"HISTORY OF PRESENT ILLNESS: This is an 80 year old female with severe chronic obstructive pulmonary disease with an FEV1 of 0.59 and continued tobacco use, on two liters of home O2.",1
"The patient has had multiple admissions for chronic obstructive pulmonary disease (, ).",1
She has been steroid dependent for several years and is currently on 15 mg of Prednisone q. day.,0
The patient is well usually at rest and requires oxygen when ambulating.,0
She was at her baseline until five days prior to admission when she began experiencing increased shortness of breath at rest with increased respiratory rate and exhaustion.,0
"In addition, she has been nauseated and anorexic with abdominal pain.",0
She says that symptoms correlate with the hot weather and the air conditioner use.,0
"REVIEW OF SYSTEMS: Positive chronic cough with yellow sputum, positive chronic back pain.",0
"Denies fevers, chills, chest pain or sick contacts.",0
Chronic obstructive pulmonary disease with FEV1 equal to 0.59.,1
Positive PPD with three negative sputum.,0
Echocardiogram in with an ejection fraction of 50% and decreased right ventricular function.,0
SOCIAL HISTORY: The patient is married with three children.,0
Tobacco use greater than two packs per day.,0
The patient uses wheelchair at home.,0
The patient rarely ambulates at home.,0
Prednisone 15 mg q. day.,0
Navane 4 mg q. h.s.,0
Serax 10 mg four times a day.,0
Tegretol 200 mg four times a day.,0
Albuterol two puffs q. three to four hours.,0
Atrovent two puffs q. two to four hours.,0
Nebulizer at home with mask two liters.,0
Flovent 220 micrograms twice a day.,0
Zantac 150 mg twice a day.,0
Volmax 4 mg q. day.,0
Centrum vitamin one q. day.,0
PHYSICAL EXAMINATION: Vital signs were temperature 101.7 f.; heart rate 92; blood pressure 101/53; respiratory rate of 35; oxygen saturation 87% on two liters.,1
"In general, the patient was a thin ill appearing woman in some respiratory distress, breathing at a fast respiratory rate and with clear discomfort.",0
"HEENT: Her pupils are equal, round, and reactive to light and accommodation.",0
She had dry mucous membranes.,0
Her lungs had decreased breath sounds at the bases bilaterally with wheezes on the right lung and some coarse breath sounds at the left lung base.,0
"Cardiac examination: The patient was tachycardic with a regular rhythm; no murmurs, rubs or gallops were appreciated.",0
Abdomen was tender to palpation diffusely with positive bowel sounds.,0
"Extremities showed no cyanosis, clubbing or edema.",0
Neurological examination showed the patient to be alert and oriented times three with normal and symmetric strength in the upper and lower extremities.,0
Skin showed no rashes on examination.,0
LABORATORY: An EKG showed sinus rhythm at a rate of 93 beats per minute with normal intervals.,0
"No T wave inversions, however, ST changes were noted.",0
"Her labs on admission were a sodium of 138, potassium of 4.2, chloride of 101, bicarbonate of 25, BUN of 8.0, creatinine of 1.9, glucose of 145.",0
"Blood gas with a pH of 7.32, a pCO2 of 54 and a pAO2 of 74.",0
"White blood cell count of 18.6, with 67% neutrophils, 5% bands, a hematocrit of 44.2, and platelets of 278.",1
The patient's blood gas was taken on two liters of oxygen.,0
"Past spirometry has shown an FEV1 of 0.59 which is 33% of predicted, vital capacity of 1.24 which is 49% predicted, and an FEV1/FEC of 67% predicted.",0
These were done in .,0
Chest x-ray on admission showed hyperinflated lungs with flattened diaphragms bilaterally.,0
No signs of congestive heart failure.,1
There was a question of a right lower lobe pneumonia.,0
"SUMMARY: In summary, the patient is a 67 year old female with severe chronic obstructive pulmonary disease with an FEV1 of 0.59, bipolar disorder, hypertension, with multiple admissions to this hospital for chronic obstructive pulmonary disease exacerbations.",1
"She presents now with a chronic obstructive pulmonary disease exacerbation of unclear etiology, a question of a right lower lobe pneumonia versus the heat versus a viral upper respiratory infection.",1
"The patient presented with a temperature of 101.2 F, small opacity in the right lower lobe on chest x-ray and some yellow sputum that she states is at her baseline.",0
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE: In the Emergency Room, the patient required Bi-PAP mask in order to properly oxygenate and increase her oxygen saturation greater than 90%.",1
She was placed on a Bi-PAP nasal mask with pressure support of 8 and a PEEP of 5 and it was titrated to patient comfort to keep her respiratory rate less than 30.,0
The patient was continued on her Albuterol and Atrovent nebulizers q. two hours.,0
The patient was started on Solu-Medrol 80 mg intravenously three times a day.,0
"On day two of admission, the patient was switched to p.o.",0
Prednisone but that afternoon was noted to have worsening oxygenation on Bi-PAP.,0
She was then switched to a full face mask with improvement in her oxygenation and her coordination with the ventilator.,0
"However, the patient was found to be quite somnolent on day three of admission and blood bases a that time showed a pH of 7.31, a pCO2 of 56, and a pO2 of 63, which is probably very close to the patient's baseline.",0
It was therefore decided that she was not hypercarbic but that her mental status changes were due to her increased ativan and morphine use for anxiety and back pain while in the Medical Intensive Care Unit.,0
The patient continued to require Bi-PAP at a pressure support of 8 and a PEEP of 5 with decreased oxygen saturations throughout the day.,0
"The patient, in addition, had increased agitation requiring Ativan.",0
"On the night prior to discharge, the patient was aggressively suctioned with normal saline which yielded several brown and bloody clots.",0
"After aggressive suctioning, the patient improved her saturation markedly with an oxygen saturation of 98% on three liters nasal cannula.",0
The patient continued to saturate well on three liters nasal cannula overnight and throughout the day and she became much more alert and conversant.,0
"By the time of discharge, the patient was saturating in the high 90s on three liters nasal cannula.",0
"MENTAL STATUS CHANGES: On admission to the Medical Intensive Care Unit, the patient was extremely anxious with a very high respiratory rate which calmed down with 2 mg of Ativan.",0
"On the second day of admission, the patient was requiring ativan q. two and morphine q. two for back pain, and was found to be quite lethargic, so the Ativan and morphine were stopped.",0
"The patient began to wake up at 8 p.m. on the third day of admission and by the next morning, her mental status was back to baseline.",0
"PNEUMONIA: The patient was admitted with a fever of 101.7 F., and increased white blood cell count of 18 with 5% bands and a right lower lobe opacity was noted on the chest x-ray.",1
The patient was therefore started on Levofloxacin and continued on that coverage for assumed community acquired pneumonia.,0
"On the day of discharge, the patient was on day four of a seven day course.",0
This is addendum to problem number one.,0
The patient was transitioned to oral Prednisone 60 mg q. day with an aggressive taper to 15 mg q. day over the course of two weeks and she will need to have continued aggressive pulmonary toilet.,0
"RENAL FUNCTION: The patient was initially admitted with a high creatinine of 1.7, up from her baseline of 1.2.",0
It was assumed that the patient had prerenal insufficiency due to hypovolemia with a sodium of 138.,0
The patient was hydrated at 100 cc per hour of normal saline.,0
Nephrotoxic drugs were avoided and the patient's renal function returned to baseline on day two of admission and continued to stay at baseline throughout her admission.,0
CARDIAC STATUS: The patient was complaining of chest pain on the second day of admission.,0
She complained of chest pain 10 out of 10 radiating to her left arm which improved with sublingual Nitroglycerin and morphine times two.,0
The cardiac enzymes were cycled and remained negative.,0
The patient's chest pain resolved and was assumed to be secondary to her pneumonia.,0
"In addition, the patient was found to be hypertensive on the second day of admission, with a blood pressure of 170/80.",0
"Hypertension seemed to be secondary to her decreased oxygen saturation and increased respiratory rate in addition to some pain that she was having, and her hypertension improved considerably once her ventilation was improved.",1
The patient did not need any hypertensive medications during this admission.,0
RENAL: The patient was initially admitted with a creatinine of 1.7 which was up from her baseline of 1.2 to 1.3.,0
Her prerenal insufficiency was considered to be secondary to hypovolemia and prerenal failure.,0
The patient was hydrated with 100 cc per hour of normal saline and by discharge her creatinine had returned to its baseline of 1.3.,0
PROPHYLAXIS: The patient was maintained on subcutaneous heparin and ranitidine.,0
"CODE STATUS: The patient was ""Do Not Resuscitate"", ""Do Not Intubate"".",0
Communication was maintained with the husband.,0
Several family meetings were arranged to discuss the long term care of the patient.,0
"In addition, Palliative Care was involved with the patient's care.",0
The patient lives with her husband.,0
"PAIN CONTROL: The patient was complaining of considerable back pain during this hospitalization, requesting morphine.",0
"On the day of discharge, the patient was transitioned from morphine intravenously p.r.n.",0
to MS-Contin for longer acting pain control with MSIR for breakthrough pain.,0
DISPOSITION: The patient will be transferred to the Medical Floor today.,0
Pulmonary consultation is to follow the patient on the floor.,0
"In addition, the patient should have aggressive pulmonary toilet done by Respiratory Therapy.",0
"Albuterol nebulizer solution, one nebulizer q. two hours p.r.n.. 2.",0
Ipratropium bromide one nebulizer q. two hours p.r.n.,0
Heparin 5000 units subcutaneously q.,0
q. four to six hours p.r.n.,0
Nicotine 14 mg transdermal patch q. day.,0
Nitroglycerin sublingual 0.3 mg p.r.n.,0
"Albuterol nebulizer solution, one nebulizer q. four hours.",0
"Ipratoprium bromide nebulizer solution, one nebulizer q. six hours.",0
Morphine sulfate IR 50 mg p.o.,0
Morphine sulfate SR 50 mg p.o.,0
Prednisone taper to go as follows: Prednisone 40 mg p.o.,0
"q. day times two doses, then Prednisone 30 mg p.o.",0
"q. day times two doses, then Prednisone 15 mg p.o.",0
CONDITION ON DISCHARGE: Condition on discharge to the floor was stable.,0
Chronic obstructive pulmonary disease exacerbation with pneumonia.,1
Dictated By: MEDQUIST36 D: 11:48 T: 15:04 JOB#:,0
"10:22 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for new pneumonia Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with new blood culture positivity and thick secretions REASON FOR THIS EXAMINATION: Evaluate for new pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: New blood culture positivity and thick secretions, evaluate for new pneumonia.",1
COMPARISON: Radiographs dating back to and most recently .,0
FINDINGS: Hazy opacities in both lower lobes appear to have worsened since the radiograph performed on and may represent edema with possible concomitant pneumonia or atelectasis.,0
The position of the tracheostomy tube in unchanged.,0
The tip of the left upper extremity peripherally inserted central venous catheter is projected over the expected location of the upper right atrium.,1
"The nasogastric tube tip may have migrated proximally, and is projected over the body of the stomach approximately 6 cm below the expected location of the gastroesophageal junction.",0
The cardiac size is normal.,0
Possible proximal migration of nasogastric tube whose tip now lies approximately 6 cm below the expected location of the gastroesophageal junction.,0
Result telephoned to Dr at approximately 09.00 .,0
5:07 AM CHEST (PORTABLE AP) Clip # Reason: please check ETT placement s/p change of tube air leak Admitting Diagnosis: PANCREATITIS; SPLENOMEGALY ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with acute pancreatitis REASON FOR THIS EXAMINATION: please check ETT placement s/p change of tube air leak ______________________________________________________________________________ FINAL REPORT INDICATION: Please check endotracheal tube placement.,1
"VIEWS: Single AP portable supine view dated at 4:15 am, comparison dated at 1:46 am.",0
FINDINGS: The endotracheal tube is seen with the tip approximaely 0.5 cm above the carina.,0
The right IJ line is in stable position with tip in mid SVC.,0
"The remainder of the examination is unchanged, with left lower lobe collapse and consolidation and bilateral pleural effusions.",0
IMPRESSION: 1) Endotracheal tube with tip 0.5 cm above the carina.,0
"2) Lines remain in stable position, remainder of examination unchanged.",0
This result was communicated to the covering resident on the day of the exam.,0
10:23 AM CHEST (PA & LAT) Clip # Reason: evaluate sternum given new click and drainage Admitting Diagnosis: CHEST PAIN;CORONARY ARTERY DISEASE;RENAL INSUFFICIENCY\CATH ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man s/p CABG.,1
REASON FOR THIS EXAMINATION: evaluate sternum given new click and drainage ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG with new sternal click and drainage.,0
Three views of the chest were compared to and demonstrate a vertical lucency along the sternum.,0
"The alignment of the sternal wires is unchanged, but there is a fractured inferior sternal wire.",0
Skin staples are present and there is marked swelling of the subcutaneous tissues of the sternum.,0
The lungs are clear and small bilateral pleural effusions are stable.,0
IMPRESSION: Sternal lucency can be normal post recent sternotomy but can also represent sternal dehiscence.,0
Height: (in) 68 Weight (lb): 176 BSA (m2): 1.94 m2 BP (mm Hg): 98/45 HR (bpm): 97 Status: Inpatient Date/Time: at 11:49 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Estimated cardiac index is high (>4.0L/min/m2).,0
"The estimated cardiac index is high (>4.0L/min/m2), likely secondary to chronic liver disease.",1
IMPRESSION: Vigorous biventricular systolic function.,0
"Compared with the prior study (images reviewed) of , the echocardiographic findings are similar, although the patient is now more tachycardic.",0
2:52 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: ?,0
aspiration Admitting Diagnosis: GUN SHOT WOUND ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man s/p GSW REASON FOR THIS EXAMINATION: ?,0
aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: 27-year-old with gunshot wound.,0
FINDINGS: A video swallow examination was performed under fluoroscopic guidance in collaboration with speech pathology.,0
"Barium of varying consistencies including barium mixed with solids, and a barium tablet was administered.",0
"There was no evidence of residual, penetration, or aspiration.",0
No evidence of penetration or aspiration.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: vancomycin Attending: Addendum: Anemia in the post operative pperiod requiring 2 PRBC - this was caused from acute blood loss from the surgical procedure.",1
Pt also had blood stream infection secondary to infected prosthetic arterial graft.,1
Admission Date: Discharge Date: Service: ORTHOPAEDICS Allergies: Bactrim Attending: Chief Complaint: Ms. presents for definitive treatment to her right hip.,0
Major Surgical or Invasive Procedure: Right hip revision Past Medical History: -CAD with CABG*4 in -Hypertension -Diabetes -Hypothyroidism -Osteoarthritis -Status post choleycystectomy -Status post hysterectomy for unclear reasons -Status post right hip arthroplasty in Social History: Does not use tabacco or ETOH.,1
She currently lives with her daughter.,0
Family History: Patient reports both her parents died of pneumonia in middle age.,0
She is otherwise unable to give much family history.,0
"Pre-operatively, she was consented, prepped, and brought to the operating room.",0
"Intra-operatively, she was closely monitored and remained hemodynamically stable.",0
She tolerated the procedure well without any complication.,0
"Post-operatively, she was transferred to the PACU/SICU and floor for further recovery.",0
"On the floor,she was consulted by geriatric services due to some confusion/agitation whose recommendations were appreciated and followed.",0
"On hct was 24.5 and received 2 units prbc, chest xray normal no consolodation, u/a normal.",0
hct 28.7 bun 52/1.9 geriatric services aware.,0
Sh progressed with physical therapy to improve her strength and mobility.,0
Sh was discharged today in stable condition.,0
"Medications on Admission: clopidograel 75mg', Levothyroxine 88mcg', ASA 325mg', Furosemide 40mg', Gliburide 10mg'', Allergies: Bactrim Discharge Disposition: Extended Care Facility: Baypointe - Discharge Diagnosis: OA right hip Discharge Condition: Stable Discharge Instructions: If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation.",0
You may not bear weight on your right leg.,0
Please use your crutches for ambulation.,0
You may resume all of the medications you took prior to your hospital admission.,0
Take all medication as prescribed by your doctor.,0
You have been prescribed a narcotic pain medication.,0
Please do not drive or operate any machinery while taking this medication.,0
* Continue your warfarin as prescribed to help prevent blood clots.,0
You need to have weekly blood draws while taking this medication.,0
We may change your medication dose depending upon your INR level.,0
"Followup Instructions: Provider: , ORTHOPEDIC PRIVATE PRACTICE Phone: Date/Time: 2:30 Completed by:",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending: Chief Complaint: Exertional chest pain and shortness of breath Major Surgical or Invasive Procedure: - CABGx3 (left internal mammary artery->left anterior descending artery, Saphenous vein graft->Diagonal artery and Saphenous vein graft->Right coronary artery).",1
History of Present Illness: Mr. is a 62-year-old gentleman with a history of coronary artery disease following ST elevation myocardial infarction in .,1
He underwent PCI stenting to his left anterior descending artery and diagonal.,0
In of the same year he underwent repeat cardiac catheterization for recurrent complaints of chest pain.,0
This catheterization revealed an 80% in- re-stenosis of the bare metal in his pyramidal in his mid LAD.,0
He underwent restenting with a drug-eluding which was placed inside his bare metal .,0
"Despite PCI standing and medical therapy, he continued to complain of exertional angina and he was then referred for surgical revascularization.",0
Past Medical History: Hypertension Hyperlipidemia STEMI in s/p diagonal PTCA and LAD stenting Gout s/p surgical removal of foot deposits Psoriasis History of sciatica from damaged disc Spontaneous PTX as a teenager Social History: Social history is significant for the the absence of current tobacco use (the patient quit 30 years ago).,1
There is no history of alcohol abuse (patient drinks 1 glass of red wine a night).,0
Works as a market communications manager at a tech firm in .,0
"Divorced, lives alone in and works in .",0
Family History: There is a family history of premature coronary artery disease or sudden death (father had an MI in his 50s and brother had sudden death while mowing the lawn in his early 60s.),1
Physical Exam: Admission VS BP 135/84 HR 77 RR 16 O2sat 100% on RA Gen: WDWN middle aged male in NAD.,0
Neck: Supple with no significant JVP.,0
"LUNGS: CLear Abd: Soft, NTND.",0
Ext: Trace lower extremity edema.,0
"DPs, PTs 2 + BL.",0
"Discharge VS T 99 BP 116/76 HR 88 SR RR 20 O2sat 96%-RA Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA bilat CV RRR, sternum stable.",0
"Incision CDI Abdm soft, NT/+BS Ext warm, well perfused.",0
Trace edema bilat Pertinent Results: 11:14AM HGB-13.0* calcHCT-39 11:14AM GLUCOSE-112* LACTATE-1.4 NA+-140 K+-4.0 CL--108 02:28PM FIBRINOGE-137* 02:28PM PT-15.0* PTT-25.4 INR(PT)-1.3* 02:28PM PLT COUNT-129* 02:28PM WBC-10.4# RBC-2.38*# HGB-8.6*# HCT-23.3*# MCV-98 MCH-36.0* MCHC-36.8* RDW-13.5 04:16PM UREA N-15 CREAT-0.9 CHLORIDE-113* TOTAL CO2-26 06:04AM BLOOD WBC-8.0 RBC-2.58* Hgb-9.2* Hct-25.2* MCV-98 MCH-35.7* MCHC-36.5* RDW-15.8* Plt Ct-188 06:04AM BLOOD Plt Ct-188 04:16PM BLOOD PT-14.0* PTT-30.6 INR(PT)-1.2* 06:04AM BLOOD UreaN-21* Creat-1.2 Na-141 K-3.9 ========================================================= ECHO Pre Bypass: The left atrium is normal in size.,0
There are complex (>4mm) atheroma in the aortic arch.,0
Post Bypass: Preserved biventricular function.,0
"============================================================= , M M 62 Radiology Report CHEST (PA & LAT) Study Date of 12:56 PM MEDICAL CONDITION: 62 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax No pneumothorax.",0
Stable appearance of the chest.,0
Final Report REASON FOR EXAMINATION: Followup of a patient after CABG.,0
PA and lateral upright chest radiograph was compared to prior study obtained the same day earlier at 09:58 a.m.,0
The right internal jugular line tip is in the mid low SVC.,0
The post-sternotomy wires are stable.,0
There is no interval change in the small left pleural effusion and right middle lobe atelectasis.,0
There is no evidence of failure.,0
DR. Approved: 3:11 PM = ================================================================ Brief Hospital Course: Mr. was admitted to the on for surgical management of his coronary artery disease.,1
He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels.,1
Postoperatively he was taken to the intensive care unit for monitoring.,0
"Within 4-5 hours, Mr. neurologically intact and was extubated.",0
"On postoperative day one, Mr. was transferred to the step down unit for further recovery.",0
He was gently diuresed towards his preoperative weight.,0
"Mr. developed rapid atrial fibrillation which was treated with amiodarone and an increase in his beta blockade, he converted back to sinus rhythm.",0
The remainder of his post-operative course was uneventful.,0
On POD 4 he was discharged home with visiting nurses.,0
Medications on Admission: Toprol 100mg daily Pravachol 80mg daily Allopurinol 100mg daily Lisinopril 10mg daily Norvasc 5mg daily Enbrel weekly Plavix 75mg daily Aspirin 325mg daily Discharge Medications: 1.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed.,0
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.,0
Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg x5 days then 400mg QD x5 days then 200mg QD.,0
Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed.,0
Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days.,0
Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: CAD s/p CABGx3 h/o STEMI h/o Angioplasty and stenting HTN Hyperlipidemia Gout Psoriasis Sciatica Spontaneous pneumothorax in past Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection.,1
Followup Instructions: clinic in 2 weeks Please follow-up with Dr. in 1 month.,0
( Please follow-up with Dr. on at 11:20AM.,0
Please follow-up with Dr. in weeks.,0
Call all providers for appointments.,0
Phone: Date/Time: 11:20 Completed by:,0
5:26 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: Is there evidence of 1) leak from gastric or duodenal repair Admitting Diagnosis: S/P STABBING Field of view: 38 ______________________________________________________________________________ FINAL ADDENDUM Findings discussed with Dr. .,0
"5:26 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: Is there evidence of 1) leak from gastric or duodenal repair Admitting Diagnosis: S/P STABBING Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with s/p ex lap repair of gastric and duodenal injury after stab wound (POD 6), s/p takeback for abdominal compartment syndrome (POD 3), now with persistent hypotension, volume requirement.",1
Please perform with IV and NGT contrast - we are most interested in proximal bowel.,0
REASON FOR THIS EXAMINATION: Is there evidence of 1) leak from gastric or duodenal repair 2) missed bowel injury 3) abscess 4) missed pancreatic injury?,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 26-year-old male status post ex-lap repair of gastric and duodenal injury after stab wound, postop day 6.",1
Postop day 3 for reoperation for abdominal compartment syndrome.,1
"TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the chest, abdomen, and pelvis from the thoracic inlet to the pubic symphysis.",0
"CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral dependent lower lobe consolidation vs atelectasis, right greater than left.",0
Small left pleural effusion is present.,0
"Note is made of a tiny air bubble within a small focal colleciton of pleural fluid along the left mid lateral chest, which may relate to a small traumatic pneumatocele.",1
ET tube and NG tube are identified.,0
The heart and great vessels are normal.,0
The thoracic aorta maintains a normal contour.,0
"No mediastinal, axillary or hilar lymphadenopathy.",0
"CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: No focal hepatic lesion is identified, however streak artifact limits sensitivity.",1
"The adrenal glands spleen, gallbladder and pancreas are within normal limits.",0
Fluid is seen surrounding the head of the pancreas.,0
Pigtail drain via a left subcostal approach terminates anterior to the stomach and left lobe of the liver.,0
JP drain is seen within the subcutaneous tissues of the mid abdomen.,0
"Contrast opacifies the small bowel, however yet to reach the cecum and distal ileum.",0
"There is a tiny focus of high density material along the anterior abdominal wall (series 2 image 90), which is of uncertain etiology and may relate to suture material although extraluminal contrast cannot be excluded .",0
There is no evidence of intraperitoneal extravasation of oral contrast.,0
Suture material is identified in the stomach and proximal small bowel.,1
"(Over) 5:26 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: Is there evidence of 1) leak from gastric or duodenal repair Admitting Diagnosis: S/P STABBING Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont) Intermesenteric fat stranding and small amount of free fluid seen within the abdomen, however, no evidence of free intra- abdominal air.",1
The abdominal aorta maintains a normal contour.,0
"The celiac, proximal SMA, are normally opacified.",0
"CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon are within normal limits.",0
Bladder is decompressed and contains a Foley with tiny bubbles of air.,0
"Free fluid with a hematocrit level is seen within the pelvis, likely blood.",0
A left fat-containing inguinal hernia is identified.,0
BONE WINDOWS: No suspicious lytic or sclerotic lesion is detected.,0
Note is made of diffuse subcutaneous tissue strading and edema.,0
"More focal tissue asymetry is identified overlying the right illiac bone, which may represent contusion, edema, IM hematoma (though atypical).",0
Right lower lobe consolidation vs atelctasis.,0
Postoperative changes within the stomach and proximal duodenum.,1
No evidence of intrperitoneal extravasation of oral contrast.,0
Extensive intermesenteric stranding and small amount of free fluid.,0
Free fluid within the pelvis with a hematocrit level consistent with blood.,0
"Slight asymmetry of the muscles overlying the right iliac crest which may represent contusion, edema or Intramuscular hematoma.",0
"Tiny focus of high density material along the anterior abdominal wall (series 2 image 90), which is of uncertain etiology and may relate to suture material although extraluminal contrast cannot be excluded.",0
Recommend correlation with exam and CT can be repeated if indicated.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: garbled speech, transfered from OSH hospital Major Surgical or Invasive Procedure: Left carotid Stent and MERCI procedure History of Present Illness: 48 yo RHM who works as a paver and trucker and has a medical history of untreated hyperlipidemia, at noon today, was found to have garbled speech by his boss, when talking to him on the phone.",1
EMS was called and he was sent to .,0
"On examination, he was found to have a right hemiplegia, left gaze deviation, and aphasia.",1
"He was found by CT head scan to have a left MCA stroke, and he was given IVtPA (13:41 h 6.8 cc, 13:44 h rest of the infusion).",0
"According to his wife, he had been complaining of numbness in his right arm for 2-3 days, otherwise no other symptoms such as problems with his vision, or speech problems, or weakness were noted by his wife.",0
"The neurologist from discussed the patient with Dr , and a decision was made to transfer the patient, for possible a neuro interventional radiological procedure.",0
"Past Medical History: Untreated hyperlipidemia, not under a PCP, other MH according to his wife.",0
"Social History: He does not smoke cigarettes, but occasionally smokes marijuana, dose not drink alcohol Family History: Sister had an intracranial aneurysm which has resulted in a hemiparesis.",0
"Physical Exam: T-afebrile in the OSH, whisked to CT and then angio before temp could be checked BP-132/87 HR-80 RR-18 O2Sat-99% Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, left carotid bruit, but no vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: NIHSS: 19 Mental status: Awake and alert, cooperative with exam, normal affect.",1
"Aphasic, dense right hemiparesis, was able to do a thumbs up with the left hand.",0
"Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally.",0
"Eyes cross midline, may have a visual field deficit, which was not mapped.",0
"Tone flaccid in the right arm, and slightly increased in the right leg.",0
"No observed myoclonus or tremor No pronator drift Tri WF WE FE FF IP H Q DF PF TE TF L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 No movement in the right arm or leg Sensation: Moves away from noxious stimulus on the left but not on the right Reflexes: 2 on the left, and +2 and symmetric throughout.",0
"Left toe downgoing, right toe mute Coordination/Gait not assessed as the angio suite were waiting for the patient.",0
"Occlusion of the left cervical internal carotid artery, with partial reformation at the carotid canal at the proximal carotid canal and thombitc in etiology related to atherosclerotic disease.",1
"2.Occlusion of the distal M1 and proximal M2 of the left middle cerebral artery, likely embolic/ denovo thrombosis, with dense clot within.",1
"Acute infarct in the left parietal and insular region, in the MCA territory, with a larger area of reversible ischemia surrounding.",0
"Both the areas of infarction and reversible ischemia are incompletely imaged on the present study, with upper limits not being included.",0
"MR can be considered for better assessment of the extent of infarction, and also the basal ganglia, if encessary.",0
"Atherosclerotic disease, in the right common carotid artery bifurcation, extending into the proximal cervical internal carotid artery, resulting in approximate less than 50% stenosis.",1
"Multilevel degenerative changes in the cervical spine mild-to-moderate, incompletely characterized on the present study.",0
CT head/ neck w and w/o contrast 1.,0
Procedure note- underwent cerebral angiography and emergent stenting and angioplasty of his left internal carotid artery and mechanical thrombectomy of the left middle cerebral artery without any complications.,1
"Study Date of 1:54 PM, MRA brain In comparison with the most recent examination, again areas of subacute ischemia are redemonstrated involving the left caudate and lentiform nuclei without evidence of hemorrhagic transformation, the areas of ischemia also involve the left insular and temporal lobe extending the convexity, vascular territories of the left anterior cerebral and middle cerebral arteries.",0
"The MRA of the head demonstrates vascular flow in both internal carotids as well as the vertebrobasilar system, apparently the left medial cerebral artery is patent including the M1 and M2 segments, no evidence of flow stenotic lesions are identified in the posterior circulation or right internal carotid artery.",1
Both anterior cerebral arteries are patent.,0
"IMPRESSION: There is evidence of vascular flow in the left middle cerebral artery, including the M1 and M2 segments as well as the M2 bifurcation.",1
"No flow stenotic lesions are demonstrated, the right internal carotid and the vertebrobasilar system arteries are patent.",0
TEE The left atrium is normal in size.,0
"No thrombus is seen in the right atrial appendage No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest (patient unable to cooperate with maneuvers).",0
IMPRESSION: No evidence of intracardiac thrombus.,0
Good left atrial emptying velocities.,0
"Dr. was notified by telephone on at 12:15 p.m.. Brief Hospital Course: 48 yo RHM who has a history of untreated dyslipidemia, who was treated at with IVtPA, was transfered to .",0
He was admitted to ICU.,0
He underwent CTA and emergent stenting of and MERCI procedure for clot removal by neurosurgery team.,0
"Although the procedure was technically successful, his deficits were unchanged.",0
He was started on Clopidogrel and continued on aspirin.,0
Normoglycemia and normothermia was achieved using sliding scale and tylenol prn.,0
"His Lipid profile was abnormal, and he was started on 80 mg of atorvastatin.",0
It was felt that his carotid occlusive disease was atherosclerotic in nature.,0
He underwent OT/PT/speech eval and was transfered to rehab facility for further care.,0
"Disp:*30 Tablet, Chewable(s)* Refills:*2* 3.",0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain .,0
"Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Discharge Diagnosis: Acute infarct in the left parietal and insular region, in the MCA territory with, Left ICA occlusion s/p IV t PA, s/p Stent, MERCI retrieval Untreated hyperlipidemia Discharge Condition: Stable Discharge Instructions: Please call your doctor or 911 if you develop any alarming symptoms.",1
Please take medications as prescribed.,0
"Please continue with Pneumoboots for DVT prophylaxis, sliding scale of insulin depending on his blood sugars.",0
"Followup Instructions: Please call Dr office , for scheduling an appointment in weeks for follow up.",0
Please follow up with PCP 1-2 weeks.,0
Syncope Height: (in) 72 Weight (lb): 195 BSA (m2): 2.11 m2 BP (mm Hg): 127/79 HR (bpm): 91 Status: Inpatient Date/Time: at 09:18 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Trivial MR. TRICUSPID VALVE: TVP.,0
Normal main PA. No Doppler evidence for PDA PERICARDIUM: Moderate pericardial effusion.,0
No RA or RV diastolic collapse.,0
"Significant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.",0
"Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 60%).",0
Tricuspid valve prolapse is present.,0
There is a moderate sized pericardial effusion.,0
"There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling, although frank cardiac tamponade is not present.",0
"Compared with the findings of the prior study (images reviewed) of , the findings are similar.",0
1:34 PM BABYGRAM (CHEST & ABDOMEN) PORT Clip # Reason: line placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity @ 25 weeks gestation REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT HISTORY: Premature infant.,0
FINDINGS: The ETT tip is at the carina and pointing toward the origin of the right main stem bronchus.,0
The UVC tip is in the right atrium and has been pulled back slightly since the prior examination.,0
The UAC tip is at T7.,0
The lungs remain moderately hyperinflated.,0
There is a mild to moderate ground glass appearance of the lung parenchyma bilaterally in keeping with RDS.,0
9:21 AM CHEST (PORTABLE AP) Clip # Reason: ASSESS FOR PNEUMO ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with Tb s/p thoracentesis RIGHT REASON FOR THIS EXAMINATION: ASSESS FOR PNEUMO ______________________________________________________________________________ FINAL REPORT INDICATION: 86 y/o female with history of tuberculosis s/p right thoracentesis.,0
AP PORTABLE ERECT CHEST RADIOGRAPH dated is compared to the prior study performed on as well as the oldest available study dated .,0
"FINDINGS: There is cardiomegaly associated with bilateral diffuse interstitial opacities and bilateral pleural effusions, right greater than left.",1
The appearance of the somewhat loculated right lower lobe effusion does not appear to be significantly changed.,0
Comparison with the oldest available study dated reveals a pleural effusion and pleural thickening present in the right at that time.,1
There is no evidence of pneumothorax s/p thoracentesis.,0
Note is again made of a left apical cavitation.,0
IMPRESSION: 1) Cardiomegaly associated with bilateral diffuse interstitial opacities.,0
These findings are consistent with congestive heart failure.,0
"2) Persistence of a loculated right lower lobe effusion, likely with an element of pleural scarring.",1
This finding is not significantly changed as compared to the prior study.,0
3) No evidence of pneumothorax.,0
PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for off pump CABG Status: Inpatient Date/Time: at 15:00 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
AORTA: Focal calcifications in aortic root.,0
Complex (mobile) atheroma in the aortic arch.,0
Conclusions: Limited study due to poor acoustic windows.,0
The left atrium is markedly dilated.,0
Overall left ventricular systolic function appears normal (LVEF>55%).,0
There are complex (mobile) atheroma in the aortic arch.,0
The interatrial septum is poorly seen and an ASD/PFO can not be completely ruled out.,0
"After completion of bypass grafting, the echo windows were even more limited.",0
The right ventricle appeared somewhat underfilled but with normal free wall function.,0
Only limited left ventricular segments could be seen but there appeared to be mild global hypokinesis with somewhat more septal hypokinesis.,0
Overall function is probably mildly decreased.,0
7:54 AM CHEST (PORTABLE AP) Clip # Reason: pulm status Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with CAD s/p CABG.,1
REASON FOR THIS EXAMINATION: pulm status ______________________________________________________________________________ FINAL REPORT CHEST 1 VIEW PORTABLE: INDICATION: 76 y/o man with CAD s/p CABG.,0
COMMENTS: Portable AP radiograph of the chest is reviewed and compared to the previous study of yesterday.,0
There is continued congestive heart failure with cardiomegaly and bilateral pleural effusions.,1
There is continued bibasilar patchy atelectasis.,0
The tip of the ETT is identified at the thoracic inlet.,0
The patient is s/p CABG and median sternotomy.,0
An NG tube courses towards the stomach.,0
The previously identified right jugular temporary pacer remains in place.,0
IMPRESSION: Congestive heart failure with cardiomegaly and bilateral pleural effusions.,1
"9:23 AM CHEST (PORTABLE AP) Clip # Reason: Increased Oxygen requirement, eval for interval change.",0
"Admitting Diagnosis: CORNARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CAD s/p CABG REASON FOR THIS EXAMINATION: Increased Oxygen requirement, eval for interval change.",1
______________________________________________________________________________ FINAL REPORT CHEST HISTORY: CABG.,0
There is streaky density at the lung bases consistent with subsegmental atelectasis.,0
"There is increased density in the retrocardiac area as before, unchanged.",0
"Left chest tubes, a mediastinal drain and a right internal jugular catheter remain in place.",0
"Increased density in the retrocardiac area consistent with atelectasis or consolidation, unchanged.",0
"Tubes and line remain in place, unchanged.",0
"11:35 PM CHEST (PRE-OP PA & LAT) Clip # Reason: r/o chf, infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with LM disease, to be admitted, currently in cath lab holding area 4. please do after 9 pm REASON FOR THIS EXAMINATION: r/o chf, infiltrate ______________________________________________________________________________ FINAL REPORT CHEST 2 VIEWS PA & LATERAL: Preop CABG.",0
No previous films are available on PACS for direct comparison at this time.,0
There is a mild thoracic scoliosis convex to the right.,0
There is slight cardiomegaly with LV predominance but no evidence for CHF.,0
"A dual chamber right sided pacemaker is present with atrial and ventricular leads in situ, in good location.",1
There is minimal blunting of posterior costophrenic angle.,0
Degenerative changes are present in the thoracic spine and there are surgical clips in the right upper abdomen presumed s/p cholecystectomy.,0
IMPRESSION: No evidence for CHF.,0
"4:13 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: DELIRIUM;TREMORS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with resp failure REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:40 A.M. ON HISTORY: 54-year-old man with respiratory failure and possibility of interval change.",1
IMPRESSION: AP chest compared to through at 4:44 a.m.: Previous mild pulmonary edema has worsened slightly as has the volume of the moderate-to-large right pleural effusion.,1
The extent of overlying abnormality makes it difficult to exclude pulmonary infection.,1
The heart is top normal in size.,0
"ET tube ends at the upper margin of the clavicles, no less than 5.5 cm from the carina.",0
Right PIC line ends in the right brachiocephalic vein.,0
2:17 AM CHEST (PORTABLE AP) Clip # Reason: interval progress Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with legionella and ARDS REASON FOR THIS EXAMINATION: interval progress ______________________________________________________________________________ FINAL REPORT HISTORY: Legionella and ARDS.,0
"FINDINGS: In comparison with the study of , there may be even further diffuse opacification with air bronchograms involving much of the left hemithorax.",0
The areas of consolidation in the right mid and lower lung zones have also increased in prominence.,0
8:00 AM CHEST (PORTABLE AP) Clip # Reason: 82 y/o bilary sepsis ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with as above REASON FOR THIS EXAMINATION: 82 y/o bilary sepsis ______________________________________________________________________________ FINAL REPORT HISTORY: Biliary sepsis.,0
COMPARISON: Outside portable chest x-ray dated from .,0
UPRIGHT PORTABLE CHEST: Low lung volumes are again noted.,0
There is an NG tube which coils twice in the region of the neck and once in the vicinity of the lower esophagus with its tip pointing cephalad within the mid esophagus.,0
There is also density in the retrocardiac region on the left.,0
The patient has a known hiatal hernia seen on an upper GI study from done in .,0
The NG tube may in fact coil within the hernia sac.,0
IMPRESSION: NG tube coils possibly in the hypopharynx and also coiled either in the distal esophagus or within hiatal hernia.,0
8:41 PM CHEST (PA & LAT) Clip # Reason: ?,0
"infectious process ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with abd, ?",0
"thickened gallbladder on outpatient US, +TTP diffusely, REASON FOR THIS EXAMINATION: ?",0
"infectious process ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, , AT 2041 HOURS HISTORY: Abdominal pain with question of thickened gallbladder on outpatient ultrasound.",0
FINDINGS: The previously noted mild interstitial edema has resolved in the interval.,0
No consolidation or failure noted.,0
"Pleural plaques are identified, particularly in the left hemithorax.",0
There are likely small bilateral pleural effusions.,0
Atelectasis is seen in the retrocardiac left lower lobe and medially in the right lung base.,0
Again seen is a markedly tortuous and severely atherosclerotic aorta.,0
"The cardiac silhouette remains enlarged, but stable.",0
A dual-chamber pacemaker is in stable course and position from a right subclavian approach.,0
Degenerative changes are noted throughout the thoracic spine.,0
IMPRESSION: Improved lung aeration with no acute pulmonary process.,0
There are likely small pleural effusions or chronic scarring.,0
"6:08 AM CHEST (PORTABLE AP) Clip # Reason: hypoxia, pna, access for progression ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p trach, failure to wean, pnuemonia REASON FOR THIS EXAMINATION: hypoxia, pna, access for progression ______________________________________________________________________________ FINAL REPORT INDICATION: Prior tracheostomy with failure to wean.",1
FINDINGS: Sternal wires are again demonstrated along with a tracheostomy tube.,0
"The heart size, mediastinal contours and pulmonary vasculature are unchanged in appearance.",0
"There has been further reduction in the right lower lung zone volumes, representing atelectasis/collapse, with concommitant elevation of the right lung base.",0
There is also enlargement of the right sided pleural effusion.,0
No focal opacities suggestive of pneumonia are present.,0
"IMPRESSION: Progression of right lower and right middle lobe atelectasis/collapse, increased size of right sided pleural effusion.",0
"12:50 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: with abdominal contrast, please; eval for obstruction Admitting Diagnosis: PERICARDIAL EFFUSION\CATH Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with esophageal ca, s/p surgery and XRT admitted with pericardial effusion.",0
now s/p tap with reaccumulation of pleural effusion/ptx.,0
Also ?aspiration on CXR and ?,0
gastric outlet/GI obstruction as increased NGT output.,0
Please perform with PO contrast only.,0
"REASON FOR THIS EXAMINATION: with abdominal contrast, please; eval for obstruction No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Esophageal cancer status post surgery and XRT admitted with pericardial effusion.",0
Now status post tap with reaccumulation of pleural effusion and pneumothorax.,0
gastric outlet or GI obstruction as NG tube output is increased.,0
COMPARISON: CT chest dated .,0
"TECHNIQUE: MDCT acquired images of the chest, abdomen, and pelvis obtained without IV contrast as per physician .",0
CT OF THE CHEST WITH IV CONTRAST: There is interval decrease in size of a right-sided pleural effusion.,0
A right-sided pneumothorax appears larger compared to the prior study.,0
A left-sided pleural effusion is unchanged.,0
There is interval decrease in size of the pericardial effusion with slight thickening of the pericardial stripe still identified.,0
Patient is status post gastric pull through.,0
There is atherosclerotic disease of the aorta and coronary arteries.,0
There is evidence of prior radiation therapy.,0
There is a plastic tube that extends from the right chest wall into the lung parenchyma on the right.,0
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a calcified gallstone within the gallbladder.,0
"Limited noncontrast evaluation of the liver, pancreas, spleen, and adrenal glands is unremarkable.",0
"There is a low-density lesion in the left kidney at the interpolar region that likely represents a cyst, although it is not fully characterized on this noncontrast study.",0
There is a small non-obstructing stone in the upper pole of the right kidney that measures several cm in diameter.,0
A second small focus of calcification is also seen at the inferior pole of the right kidney.,0
There is a J-tube in place.,0
Small and large bowel are of normal caliber.,0
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the bladder.,0
No pelvic or inguinal lymphadenopathy.,0
Bone windows demonstrate no suspicious lytic or sclerotic lesions.,0
"(Over) 12:50 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: with abdominal contrast, please; eval for obstruction Admitting Diagnosis: PERICARDIAL EFFUSION\CATH Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.",0
"Interval decrease in pericardial effusion and right-sided pleural effusion with left-sided pleural effusion, not significantly changed.",0
Interval increase in size of right-sided pneumothorax compared to prior chest CT. 3.,0
Compressive atelectasis in both lungs with no specific evidence for aspiration.,0
No evidence of GI or bowel obstruction.,0
Small nonobstructing stones in the right kidney.,0
"Low attenuation lesion in the left kidney that likely represents a cyst, that is not fully characterized on this noncontrast study.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Aspirin / Advil Attending: Chief Complaint: Variceal Bleed Major Surgical or Invasive Procedure: Endoscopy: 3 cords of grade II varices were seen in the lower third of the esophagus and gastroesophageal junction.,1
4 bands were successfully placed.,0
"History of Present Illness: This is a 61 year-old male with a history of hepatitis C cirrhosis, Interstial Lung Disease, and Celiac Sprue who presents with upper GI bleed.",1
"The patient reports that since Saturaday, 5 days prior to admission, we developed melena.",0
"His stools were loose, black and tarry.",0
The frequency was upto every 15minutes.,0
"He stated that it was improving and ""clearing"" by last night.",0
"He reported some dry heaves, but no emesis or hematemesis.",0
He also denied any bright red blood per rectum.,0
The patient has also been having low grade temperatures 99F and feeling extremely fatigued.,0
He reports that he has been having difficulty sleeping.,0
"The patient was scheduled for an outpatient endoscopy today (Wed, ) and called the Liver Center with his symptoms on .",0
"He was advised to go to the ED, but declined because he wanted Dr. to do the procedure and his diarrhea was improving.",0
He decided to wait until today to proceed with the endoscopy.,0
"He denied any current NSAID/ASA use, although does report a prior episode of melena 1 year prior after advil use.",0
"At the endoscopy today, they found coffee grounds and active bleeding.",0
Three cords of grade II varices in the lower third of the esophagus and gastroesophageal junction.,1
The varices were actively bleeding.,1
They were able to sucessfully place 4 bands during the procedure and bleeding was stopped were successfully placed.,0
"They also saw erythema, congestion in the fundus compatible with gastropathy.",0
"His blood pressures ranged 120-130's/70-80's, HR was 110's and 98% on 3L.",0
He was also given 500cc of IVF.,0
"Currently, the patient states he is fatigued.",0
"No abdominal pain, fevers or chills.",0
States his breathing is comfortable.,0
No chest pain and baseline SOB.,0
"ROS: (+) SOB at baseline, slightly worsened from baseline (no cough) The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough.",0
"Past Medical History: 1) Hepatitis C with cirrhosis dx - never treated for HepC - thought to be transmitted through dental procedure 2) Interstial Lung Disease dx 10yrs ago - on home O2 3L (uses intermittently, but always at night) - Dr. at is Pulm doctor - previously treated with prednisone in the past, but not currently being treated 3) Celiac Sprue Social History: Disabled, previously worked as a court reporter.",1
Married and lives with his wife in .,0
Quit smoking in (smoked for 25-30yrs ~5cigs/day).,0
"No current EtOH use in over 20yrs, no h/o abuse.",0
"Family History: Mother and Father with HTN Celiac on maternal side No h/o liver disease Physical Exam: GEN: thin, frail gentleman.",1
"Extremely fatigued appearing, pale, but NAD.",0
Communicating and answering questions appropriately.,0
"HEENT: EOMI, PERRL, sclera anicteric, pale conjuctiva, MMM, OP Clear NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2 PULM: dry crackles diffusely, increased at the bases, no W/R ABD: Soft, NT, ND, +BS, no HSM, +umbilical hernia.",0
"No evidence of asictes EXT: No C/C/E NEURO: alert, oriented to person, place, and time.",0
"SKIN: No jaundice, cyanosis, or gross dermatitis.",0
Pertinent Results: 10:07AM BLOOD Hct-27.4* 04:25AM BLOOD WBC-2.8* RBC-3.29* Hgb-8.4* Hct-26.3* MCV-80* MCH-25.7* MCHC-32.0 RDW-20.8* Plt Ct-44* 04:35AM BLOOD WBC-2.4* RBC-3.09* Hgb-8.0* Hct-24.2* MCV-78* MCH-25.8* MCHC-33.0 RDW-21.1* Plt Ct-36* 09:19PM BLOOD Hct-27.1* 10:05AM BLOOD WBC-3.9* RBC-2.92*# Hgb-7.0*# Hct-22.9*# MCV-78* MCH-24.1* MCHC-30.7* RDW-22.2* Plt Ct-46* 10:05AM BLOOD Neuts-75.8* Lymphs-17.6* Monos-5.4 Eos-1.1 Baso-0.2 04:35AM BLOOD PT-15.5* PTT-35.7* INR(PT)-1.4* 10:05AM BLOOD PT-15.6* PTT-34.2 INR(PT)-1.4* 04:35AM BLOOD Glucose-121* UreaN-19 Creat-0.7 Na-138 K-3.7 Cl-110* HCO3-21* AnGap-11 10:05AM BLOOD Glucose-174* UreaN-23* Creat-0.7 Na-135 K-3.6 Cl-105 HCO3-22 AnGap-12 04:35AM BLOOD ALT-17 AST-28 LD(LDH)-188 AlkPhos-79 TotBili-1.9* DirBili-0.6* IndBili-1.3 10:05AM BLOOD ALT-21 AST-33 LD(LDH)-185 CK(CPK)-42 AlkPhos-83 Amylase-50 TotBili-1.0 04:35AM BLOOD Albumin-3.1* Calcium-7.4* Phos-3.3 Mg-1.7 10:05AM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.0 Mg-1.9 04:35AM BLOOD Hapto-<20* .,0
"Final Report AP CHEST, 10:26 A.M., HISTORY: Cirrhosis and variceal bleed.",0
"IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lung volumes are quite low, due in part to severely distended stomach.",0
Opacification at both lung bases is probably secondary relaxation atelectasis.,0
"Fullness in the upper mediastinum is probably vascular engorgement, but these areas should be reexamined when lung volumes are greater.",0
No pneumothorax or appreciable pleural effusion.,0
Dr. was paged to report these findings at the time of dictation.,0
DR. Approved: WED 3:56 PM .,0
Final Report STUDY: Liver and gallbladder ultrasound: -scale and Doppler evaluation.,0
"INDICATION: Hepatitis C cirrhosis with variceal bleed, please evaluate.",1
COMPARISONS: None available on PACS at the time of dictation.,0
FINDINGS: The liver is diffusely coarsened and echogenic consistent with known cirrhosis.,1
"No focal liver lesion is identified, although coarse in echotexture limits optimal evaluation for small lesions.",0
The pancreas is not well visualized given overlying bowel gas.,0
No abdominal aortic aneurysm is identified.,0
There is an umbilical hernia.,0
Moderate to marked ascites is present within the abdomen.,0
The right kidney measures 10 cm.,0
The left kidney measures 12.8 cm.,0
There is no intra- or extra-hepatic biliary ductal dilatation with the common duct measuring 5 mm.,0
There is marked splenomegaly with the spleen measuring 21.1 cm.,0
The gallbladder is filled with intraluminal stones.,0
No wall thickening is demonstrated in the portion of the wall adjacent to the liver with the remainder of the gallbladder not well evaluated given shadowing from stones.,0
There are prominent cysts within the left kidney upper pole measuring 5 cm and lower pole measuring 3.4 cm.,0
DOPPLER EVALUATION: The main portal vein is patent with normal hepatopetal flow.,0
The hepatic veins are patent with expected triphasic waveforms.,0
"The hepatic artery is patent with normal directional flow, brisk upstroke and forward diastolic flow.",0
The splenic vein is patent yet prominent with small surrounding vessels consistent with varices.,0
Patent hepatic vasculature with normal directional flow.,0
Diffusely coarsened echogenic liver consistent with known cirrhosis.,1
No focal mass lesion is identified although evaluation is limited for small lesions secondary to the coarsened echotexture.,0
Marked splenomegaly with the spleen measuring 21 cm.,0
Cholelithiasis with near complete filling with intraluminal stones.,0
"DR. DR. Approved: 10:01 PM Brief Hospital Course: This is a 61 year-old male with a history of HepC cirrhosis Grade II varices, Interstial Lung Disease, Celiac Sprue who presents with upper GI bleed s/p 4 bands in endoscopy today.",1
Pt transferred to for close monitoring.,0
"# Variceal Bleeding: Pt with 5 day history of melena, but no hemetamesis.",0
Known history of HepC cirrhosis since .,0
Pt underwent EGD that showed active bleeding from grade II varices.,1
Successfully placed 4 bands and bleeding stopped.,0
Prior labs show Hct of 31.8 with driop to 22.9 after procedure.,0
Pt with low BP after procedure SBP 90-100.,0
"Pt mentating appropriately, but extremeley fatigued upon arrival to floor.",0
"Was given 3U pRBCs during his time in the ICU (2U upon arrival on floor for HCT 22.9 which increased to 27, and 1U on morning of for HCT 24.2), given goal HCT>28.",0
He was also started on an octreotide drip and protonix drip post-procedurally as well as ciprofloxacin 500 IV BID for prophylaxis s/p banding.,0
"Aside from the HCT drops mentioned above, he was hemodynamically stable and tolerating POs in the and was decided in conjunction with GI that he was fit to be discharged home.",0
He was discharged with PO protonix and PO cipro (for 5 more days).,0
He will also have a repeat EGD in 2 weeks which the patient has been instructed to schedule with Dr. .,0
Hepatitis C Cirrhosis: see above.,1
Pt followed by Dr. in Liver Center.,0
Pt not on diuretics or lactulose.,0
"He had a RUQ U/S with dopplers that did not show any acute process, but the patient has been intructed to f/u with Dr. as an outpatient for further evaluation of his Hep C/cirrhosis.",1
Interstial Lung Disease: Pt dx 10 years prior.,0
"Was previously on prednisone, but stopped 6 years prior.",0
"Respiratory status currently stable on 3L O2 in the , which is his home requirement.",0
"Celiac Sprue: stable, currently NPO, but we were able to advance his diet slowly to regular gluten free.",0
# FEN: the patient tolerated a regular gluten free diet.,0
Medications on Admission: Home Oxygen 3L NC Discharge Medications: 1.,0
PO every twelve (12) hours.,0
Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 5 days.,0
Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Esophageal variceal bleed secondary to hepatitis C cirrhosis .,1
"Secondary: 1) Hepatitis C with cirrhosis dx 2) Interstial Lung Disease dx 10yrs ago 3) Celiac Sprue Discharge Condition: afebrile, stable vitals, tolerating POs, ambulatory Discharge Instructions: You were admitted for severe blood loss through your stools, which was found to be from bleeding in your esophagus.",1
"You were treated with an endoscopy which showed bleeding veins in your esophagus, 4 of which were banded.",0
"After your procedure, you were monitored in the ICU where you were given 3 units of blood.",0
Your blood counts ultimately stabilized and you were doing well for >24 hours before you were sent home.,0
You were also treated with medications to help stop the bleeding from your esophagus.,0
"Importantly, you should call Dr. office to schedule a repeat endoscopy in 2 weeks to reassess your esophageal varices and ensure there is bleeding.",1
"Finally, you had an ultrasound of your abdomen which did not show any acute findings, but will reviewed with you by your outpatient hepatologist (liver doctor).",1
You will be sent home with new medications.,0
One is called protonix which is to help protect you from bleeding.,0
"The other is an antibiotic, ciprofloxacin, which you will take for 5 more days at home.",0
Please take all medications as prescribed.,0
Please attend all appointments listed below.,0
"Please do not hesitate to return to the hospital for bleeding through your stools, black stools, chest pain, dizziness, or any other concerning symptoms at all.",0
Followup Instructions: Please call Dr. () to schedule an appointment to followup for your repeat endoscopy in 2 weeks and your hepatitis C liver ultrasound.,1
", MD Phone: Date/Time: 11:00",0
"1:08 PM CAROTID SERIES COMPLETE Clip # Reason: pre-op for CABG Admitting Diagnosis: CHEST PAIN;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with CAD, s/p cath yesterday which showed left main disease, to get CABG tomorrow REASON FOR THIS EXAMINATION: pre-op for CABG ______________________________________________________________________________ FINAL REPORT Department of Radiology Standard Report Carotid US Study: Carotid Series Complete Reason:72 year old woman with left main disease, pre op CABG.",0
Findings: Duplex evaluation was performed of bilateral carotid arteries.,0
On the right there is a small heterogeneous plaque in the ICA.,0
On the left there is a small heterogeneous plaque seen in the ECA.,0
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 123/20, 96/18, 101/26, cm/sec.",0
CCA peak systolic velocity is 84 cm/sec.,0
ECA peak systolic velocity is 138 cm/sec.,0
The ICA/CCA ratio is 1.4.,0
These findings are consistent with 40-59% stenosis.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 83/21, 88/29, 105/28, cm/sec.",0
CCA peak systolic velocity is 88 cm/sec.,0
ECA peak systolic velocity is 123 cm/sec.,0
The ICA/CCA ratio is 1.1 .,0
These findings are consistent with no stenosis.,0
Right antegrade vertebral artery flow.,0
Left antegrade vertebral artery flow.,0
Impression: Right ICA 40-59% stenosis.,0
8:46 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please evaluate ET tube position Admitting Diagnosis: DIARRHEA;ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with AML in s/p ET tube placement REASON FOR THIS EXAMINATION: Please evaluate ET tube position ______________________________________________________________________________ FINAL REPORT INDICATION: Status post endotracheal tube placement.,1
FRONTAL CHEST RADIOGRAPH The endotracheal tube has been withdrawn and now lies approximately 3 cm above the carina.,0
Nasogastric tube and right-sided PICC line are unchanged.,0
Opacities in both upper lobes are unchanged.,0
"3:03 PM CHEST (PA & LAT); -76 BY SAME PHYSICIAN # Reason: ?PTX Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p R VATS decortication w/2 remaining chest tubes, CT's to water seal at noon; please eval at 1600 for interval change, PTX REASON FOR THIS EXAMINATION: ?PTX ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON .",0
"HISTORY: Chest tubes to waterseal, question interval change.",0
FINDINGS: Two right chest tubes are again seen.,0
There is a probable tiny right apical pneumothorax.,0
Again seen is a right effusion layering laterally with volume loss in the right lower lobe and a small left effusion with volume loss in the left lower lobe.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Fall: closed scalp laceration C1-C3 fracture R rib fracture R pleural effusion L1 burst fracture L humeral fracture T3 vertebral body fracture T2-4 compression fracture Major Surgical or Invasive Procedure: None none History of Present Illness: 51M admitted as a trauma transfer s/p fall from window, GCS 15 on scene.",1
"Taken to OSH where he was awake, alert, moving all extremities.",0
"After undergoing CT scan, associated with altered mental status and respiratory distress, and so was intubated.",1
"(Required 3 attempts, hypoxic to 60s during this.)",0
"CT showed C1 bilateral arch fxs, C2 type 3 dens fx, C3 burst fx, L1 burst fx as well as R rib fractures, R pleural effusion.",1
Also had a large scalp laceration with significant bleeding.,0
"During transfer via , became hypotensive and received 3L IVF and got hypoxic to low 90s on vent.",0
"In the ED, got pRBC x1.",0
Scalp lac closed with staples by ED.,1
Requiring neo for BP management and O2 sats sustained in the high 80's in EDC.,0
Patient was admitted to the TSICU for further management.,0
There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%).,0
The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion.,0
"MR Fractures of the C1, type 3 odontoid fracture, and fracture of the C3 vertebral body and the posterior elements on the left with associated disruption of the anterior longitudinal ligament at C2-C3.",1
Increased fluid signal within the interspinous ligament at C1-C2 without disruption compatible with ligamentous sprain.,0
There is no spinal cord abnormality and no compromise of the spinal canal.,1
"Mild compressions of T1, T2 and T3 vertebrae.",0
Increased fluid signal within the upper thoracic vertebral bodies at T1 through T3 compatible with compression fractures.,1
8:13 pm SPUTUM Source: Endotracheal.,0
**FINAL REPORT ** GRAM STAIN (Final ): THIS IS A CORRECTED REPORT .,0
Reported to and read back by RINNE @10AM .,0
>25 PMNs and <10 epithelial cells/100X field.,0
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).,0
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
4+ (>10 per 1000X FIELD): 4+ (>10 per 1000X FIELD): .,0
RESPIRATORY CULTURE (Final ): MODERATE GROWTH Commensal Respiratory Flora.,0
"BETA STREPTOCOCCI, NOT GROUP A.",0
"L humerus plain film Acute comminuted, impacted fracture of the surgical neck of the humerus with mild posterior subluxation of the humeral head.",1
"The moderate right pleural effusion, likely serosanguineous in nature.",1
"Multiples rib fractures with chest wall hematoma, thoracic vertebral fracture with stable prevertebral hematoma, and comminuted fracture of the left humeral head.",1
"A focus of ground-glass opacity in the left upper lobe, of unclear etiology.",0
"If the patient develops symptoms of pneumonia, this should be reassessed.",1
No acute large or central pulmonary embolism in a study limited by respiratory motion.,1
Small to moderate right pleural effusion with collapse of the right lower lobe and increased collapse of the right middle lobe.,1
"Fracture through the T3 vertebral body, multiple rib fractures and vertebral body T2-T4 compression fractures as previously seen.",1
9:46 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT ** GRAM STAIN (Final ): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
5:04 am URINE Source: Catheter.,0
**FINAL REPORT ** URINE CULTURE (Final ): ENTEROBACTER AEROGENES.,0
">100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request.",0
This organism may develop resistance to third generation cephalosporins during prolonged therapy.,0
"For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used.",1
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER AEROGENES | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.,0
"RESPIRATORY CULTURE (Final ): 10,000-100,000 ORGANISMS/ML.",1
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER AEROGENES | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: The patient was admitted to the acute care service after a fall from a window.,1
He was admitted to the intensive care unit as a transfer from an outside hospital intubated and sedated secondary to respiratory distress.,1
"On imaging, he was initially found to have multiple rib fractures (R2-7) and, C1-C3 and L1 fractures, 15 cm scalp laceration and left proximal humeral fracture.",1
Patient was transfused 2u PRBC in the emergency room likely secondary to scalp bleeding which was stapled closed.,1
Staples were removed and delayed primary closure was obtained with interrupted prolene on HD# 2.,0
HD #3 Vanc/Zosyn was started to sputum findings and inabiltiy to wean from vent.,0
Aggressive diuresis was maintained in attempt to extubate the patient.,0
Neurospine recommendations called for non-operative management of all vertebral fractures.,1
Patient was fitted for TLSO brace on HD3.,0
Hyperglycemia remained an issue during ICU course with increasing insulin gtt requirements up to 10U/hr.,0
"On HD5, was consulted for further management of the patients blood sugars.",0
A insulin regimen was started and blood sugars were closely monitored.,0
He was placed on sliding scale and long acting insulin.,0
"His blood sugars have been labile at 115-230. REVIEW OF SYSTEMS: Neuro: Initially intubated and sedated on arrival, he was arousable after sedation was weaned and he was interactive by HD 5.",0
An epidural was placed by the acute pain service on for better pain control related to rib fractures.,1
He was changed from propofol to precedex and was then successfully extubated on with much improvement in his mental status.,0
"TLSO brace and logroll precautions, in addition to a hard cervical collar were maintained for nonoperative management of his C1-3, and L1 spinal fractures according to recommendations from the spine service.",1
He was able to work with physical therapy on .,0
"Following transfer back to the TSICU on , the epidural catheter was removed.",0
"He was then given intermittent dilaudid and tylenol for pain control, and sedated with propofol after reintubation for bronchoscopy.",0
He was switched to precedex on in order to facilitate ventilator weaning.,0
"CV: In the ED, he was transfused 2U PRBC for anemia likely related to scalp bleeding which was repaired.",1
His hemodynamics and hematocrit were monitored carefully.,0
Echocardiography on admission revealed no significant pericardial fluid.,0
Mr. had some tachycardia on the floor on and was transferred back to the ICU.,0
"He had been demonstrating low grade sinus tachycardia throughout his ICU stay, blood pressures remaining stable, treated with metoprolol as needed.",0
"Resp: Initially admitted s/p intubation for declining mental status, Mr. was found to have ventilator dependent respiratory failure, concern for aspiration, and pleural effusions, and required a prolonged wean from the vent.",1
"He was initially placed on ARDS protocol, and attempts were made to wean him as this resolved.",0
"As of HD 8, he was still intubated and requiring CPAP, and was not tolerating significant weaning of PEEP or PSV.",0
"On his pain control was much improved after epidural placement, and he was subsequently successfully extubated.",0
His oxygen requirement continued to wean.,0
"Following transfer to the surgical floor on , Mr. experienced new onset tachycardia with fever and respiratory distress, and was transferred back to the TSICU.",1
Bronchoscopy was performed without significant intraluminal findings.,0
"CT of the chest was obtained, and although negative for PE, a previously unseen T3 vertebral body fracture was identified, and ongoing RML/RLL collapse seen with small surrounding effusion.",1
"BAL gram stain was positive for GNR/GPC, started on VAP protocol, vancomycin, cipro, cefepime.",0
"On , the patient underwent ventilator recruitment maneuvers on CMV which were quite successful in improving his RML/RLL collapse.",1
Repeat CXR on was much improved.,0
"Final BAL cx grew enterobacter, and antibiotics were tailored on to ciprofloxacin therapy.",0
He was successfully weaned back to minimal pressure support settings and extubated on .,0
"GI: Although he was NPO immediately following admission, an OGT was placed and tube feeds were started on .",0
"This was transitioned to a Dobhoff feeding tube on , which was self-d/c'd later that night.",0
"After extubation, Mr. was evaluated by the Speech and Swallow team, and advanced to ground solids and thin liquids on , which he tolerated well.",0
"After reintubation on , tube feeds were restarted again and advanced to goal.",0
"After extubation , a repeat speech and swallow evaluation was obtained.",0
The patient was cleared for a regular diet.,0
"GU: Mr. urine output, electrolyte, and volume status were carefully monitored throughout his ICU stay.",0
"He was successfully diuresed several liters prior to transfer, which he tolerated well.",0
"In order to facilitate extubation and ongoing diuresis, the patient was started on a lasix drip on with the goal of 1-2L negative over a 24 hour period.",1
"During the post-operative course, he has been voiding without difficulty.",0
"ID: Concern arose for aspiration versus ventilator associated pneumonia in the setting of difficulty weaing from the vent, and when cultures returned with beta strep, GPCs, GPRs, and GNRs, he was covered with vancomycin and zosyn from .",1
"On after returning to the TSICU, a bronchoscopy was performed with GNR/GPCs on gram stain and VAP protocol was initiated, vancomycin, ciprofloxacin, and cefepime were started.",0
Antibiotics were tailored to ciprofloxacin monotherapy on after cultures finalized with enterobacter aerogenes.,0
"His urine culture also grew >100,000 enterobacter which was covered by the ciprofloxacin as well.",0
"Endo: Mr. was found to be significantly hyperglycemic on admission, and required an insulin drip for glycemic control.",0
"was consulted for recommendations, and he was transitioned to a basal/bolus regimen on .",0
He was restarted on the insulin drip on after hyperglycemia with goal TF.,0
"The drip was weaned on , and lantus 15 units was started for the evening.",0
His regimen will likely require ongoing aggressive titration as a diet is reintroduced.,0
"MSK: He was seen by ortho trauma for a left humerus fracture, which was treated conservatively with a sling.",1
"As per neuro, for C1-C3 fracture, L1 burst fracture, T2-T4 compression fractures, T3 vertebral body fracture.",1
"He also has right rib fractures which were treated with supportive care, pain control, and aggressive pulmonary toilet.",1
He has been evaluated by physical and occupational therapy and recommendations made for discharge to an extended care facility where he can further regain his strength and mobility.,0
"As he became progressively more awake, he was evaluated by Psychiatry to determine if the fall was a suicide attempt.",0
He was cleared by psychiarty for discharge without restrictions.,0
"He has follow-up appointments scheduled with the acute care service, orthopedics, and neurology.",0
"Medications on Admission: glipizide 5', metformin 500'', lisinopril 10' Discharge Medications: 1.",0
Acetaminophen 650 mg PO Q6H:PRN pain or fever 2.,0
Albuterol Inhaler PUFF IH Q6H:PRN wheezing 3.,0
Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4.,0
Heparin 5000 UNIT SC TID 5.,0
Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing 6.,0
MetFORMIN (Glucophage) 1000 mg PO BID Please give with breakfast and dinner.,0
"Metoprolol Tartrate 25 mg PO BID hold for sbp<100, hr<60 8.",0
OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain 9.,0
Quetiapine Fumarate 25 mg PO HS 10.,0
Senna 1 TAB PO BID:PRN constipation 11.,0
Glargine 28 Units Dinner Insulin SC Sliding Scale using HUM Insulin 12.,0
Docusate Sodium 100 mg PO BID 13.,0
Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days last dose 9/19 14.,0
"GlipiZIDE 5 mg PO DAILY pleaes monitor blood sugars: risk of hypoglycemia while on ciprofloxacin Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: fall, polytrauma injuries -> Right rib fractures, C1-C3 fractures, T2-T4 compression fractures, T3 fracture, L1 burst fracture, left humeral fracture Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: You have C1-C3, T3, L1 fractures.",0
You will need to wear a TLSO brace when out of bed or greater than 30 degrees and a hard collar at all times x 2-3 months.,0
You will follow up with Dr. in 6 weeks with AP/lateral XRAYs of thoracic spine to determine the next steps.,1
You have a left humeral fracture.,0
You will wear a sling for comfort and continue pendulum exercises with PT/OT.,0
You should be nonweightbearing on the left until otherwise directed.,0
You will follow up with Dr. in orthopedic clinic in 2 weeks to discuss the next steps.,0
You sugars were high during your stay.,0
You should follow up with your primary care provider to adjust your blood sugar regimen.,0
You should also discuss your blood pressure medications.,0
We are sending you home on metoprolol and holding your lisinopril.,0
You can discuss this regimen with your outpatient physician.,0
You will complete a one week course of ciprofloxacin which was started on and switched to pills on .,0
"Followup Instructions: Department: GENERAL SURGERY/ When: THURSDAY at 2:30 PM With: Dr. in the ACUTE CARE CLINIC Phone: Building: LM Bldg () Campus: WEST Best Parking: Garage Department: ORTHOPEDICS When: THURSDAY at 8:00 AM With: ORTHO XRAY (SCC 2) Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: ORTHOPEDICS When: THURSDAY at 8:20 AM With: , NP Building: Campus: EAST Best Parking: Garage Department: NEUROSURGERY When: FRIDAY at 11:00 AM With: , MD Building: LM Bldg () Campus: WEST Best Parking: Garage Notes: Spine X-ray at 10:00 AM Completed by:",1
"11:01 AM CHEST (PORTABLE AP) Clip # Reason: assess for CHF and line placement Admitting Diagnosis: VENTRICULAR FIBRILLATION ARREST\CATH ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with vfib arrest xfer from OSH with central lines REASON FOR THIS EXAMINATION: assess for CHF and line placement ______________________________________________________________________________ FINAL REPORT HISTORY: Ventricular fibrillation and arrest, transferred from outside hospital.",1
To assess for congestive failure and line placement.,1
There are intact sternal sutures in a patient with previous CABG and a prosthetic valve.,0
There is substantial enlargement of the cardiac silhouette with a plethora of ill-defined pulmonary vessels consistent with vascular congestion.,0
"Some areas of increased opacification at the bases could reflect atelectasis, though the possibility of supervening infection cannot be excluded.",0
Right IJ catheter which could be a lead with a metallic tip extends to the region of the apex of the right ventricle.,0
A left subclavian catheter does not appear to cross the midline.,0
Of incidental note are surgical clips overlying the right axillary region.,0
", F. MED 10:35 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for interval change.",0
"Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with intubation, respiratory distresss.",1
REASON FOR THIS EXAMINATION: Evaluate for interval change.,0
"______________________________________________________________________________ PFI REPORT Persistent focal consolidation of the lower lobes concerning for pneumonia, particularly on the right.",0
Improvement in alveolar opacity in the upper lobes suggests improvement in superimposed pulmonary edema.,0
3:24 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for evolution of possible PNA.,0
"Admitting Diagnosis: ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with h/o PEA arrest x2, necrotizing pancreatitis, who presents with cyclic fevers REASON FOR THIS EXAMINATION: Please evaluate for evolution of possible PNA.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: 28-year-old man with history of PEA arrest x2, necrotizing pancreatitis who presents with cyclic fevers.",0
Please evaluate for evolution of possible pneumonia.,0
TECHNIQUE: AP semi-upright portable chest x-ray.,0
COMPARISON: Portable chest x-ray from .,0
"FINDINGS: Unchanged bilateral basilar right and left lower lobe opacities, consistent with pneumonia or atelectasis.",0
Cardiomediastinal silhouette and hilar unchanged.,0
There is no pneumothorax and there is no significant pleural effusion.,0
"IMPRESSION: Bilateral basilar opacities, consistent with pneumonia or atelectasis.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Prochlorperazine / Heparin Agents Attending: Chief Complaint: Fevers Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Ms. is a 38yo F ALL s/p double cord blood SCT c/b GVHD, severe left ventricular systolic dysfunction attributed to chemotherapy for ALL as well as XRT for (EF 15-20%), embolic CVA now on coumadin, asthma, hypertension and chronic kidney disease, well-known to the service who was just discharged yesterday () after a prolonged hospital course for acute on chronic CHF thought be be due to cardiac GVHD and acute on chronic renal failure.",1
She was discharged home with daily infusions of IV torsamide and methylprednisolone.,0
She came to clinic today fopr follow-up where she was found to be febrile to 102 and up 0.5lbs from her discharge weight.,0
"CXR was done and cardiac silloette was increased, concerning for pleural effusion.",0
"Blood (PICC and peripheral) and urine cultures were sent, and she was started on empiric meropenem.",0
"On arrival to the floor, pt has no complaints.",0
She spent an hour outside yesterday and was otherwise at home resting.,0
She does nto recal any bug bites.,0
She did not feel subjectively febrile.,0
"She has some cough, but no different or worse than prior to discharge.",0
"She has some pedal ,a put attributes this to being up and walking around today.",0
"Per her sister, the pt got her torsemide and methyprednisolone in clinic today.",0
"outpatient NP, pt's weight was 137# today, up slightly from 136.5# on the day of discharge.",0
Past Medical History: ALL: - initially presented in right chest and right upper extremity pain and paresthesias and visual blurriness.,0
"WBC 149,000; received leukapheresis, started on hydroxyurea.",0
Diagnosed with precursor B-cell ALL.,0
"- underwent phase I induction with daunorubicin, vincristine, dexamethasone, L-asparaginase, MTX; phase II with cyclophosphamide, cytarabine, mercaptopurine, MTX - Bone Marrow Aspirate/Biopsy on showed no morphologic evidence of residual leukemia - underwent allo double cord blood SCT , course complicated by neutropenic fever and acute skin GVHD - subsequent course has been complicated by pseudomonas pneumonia in , empiric treatment of CMV pericarditis in , chronic nausea and vomiting which has been treated as GVHD with steroids though colonoscopies in and were negative for GVHD.",1
"OTHER MEDICAL HISTORY: - Embolic stroke in on coumadin - Asthma - Hypertension - Cervical Intraepithelial Neoplasia - C-section in - Cardiomyopathy due to early anthracycline-related cardiotoxicity - Chronic kidney disease stage III/IV, baseline creatinine ~2.0 - Chronic abdominal pain: Her workup so far has included EGD , with mild signs of gastritis, no GVHD.",1
"Colonoscopy , unremarkable with biospy negative for GVHD, CMV.",0
UGI and SBFT was mostly unremarkable.,0
"She has had multiple CT scans which have demonstrated moderate ascites with interval increase, no drainable fluid collection, diverticulosis, small fat-containing umbilical hernia with mild fat stranding, no bowel obstruction.",0
"RUQ ultrasound revealed ascites, gallbladder wall edema presumably from third spacing, and no biliary duct dilatation.",0
Social History: She is single with a daughter and a son.,0
Previously employed at though has not worked since her diagnosis.,0
"Lifelong nonsmoker, but not currently.",0
"Family History: Mother with history of gastric cancer, died at age 40.",0
"Physical Exam: Physical Exam on Admission: VS: T97.9/Tm 102, BP 110/67, HR 86, RR 18, 94% on 2L GEN: AOx3, NAD HEENT: Pupil equal and round.",0
No oral lesions or exudates.,0
"Pulm: Bibasilar crackles Abd: soft, NT, ND Extremities: wwp, edema of the feet and distal ankles B/L Skin: no rashes or bruising Neuro: nonfocal Pulsus paradoxus 2mmHg .",0
Physical Exam on Discharge: Patient expired.,0
Pertinent Results: 02:07PM UREA N-82* CREAT-2.7* SODIUM-129* POTASSIUM-4.4 CHLORIDE-90* TOTAL CO2-27 ANION GAP-16 02:07PM ALT(SGPT)-23 AST(SGOT)-75* LD(LDH)-1186* ALK PHOS-540* TOT BILI-1.9* DIR BILI-1.4* INDIR BIL-0.5 02:07PM ALBUMIN-3.6 CALCIUM-8.3* PHOSPHATE-4.2 MAGNESIUM-1.9 02:07PM WBC-4.1 RBC-2.62* HGB-8.8* HCT-24.4* MCV-93 MCH-33.7* MCHC-36.3* RDW-23.7* 02:07PM NEUTS-86* BANDS-0 LYMPHS-6* MONOS-7 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-5* 02:07PM PLT SMR-VERY LOW PLT COUNT-24* 02:07PM GRAN CT-3543 .,0
IMAGING: CXR (): AP single view of the chest has been obtained with patient in upright position.,0
Comparison is made with the next preceding PA and lateral chest examination of .,0
The heart size has increased further in size.,0
There is no typical configurational abnormality.,0
The rather general increase of the heart shadow is suggestive of pericardial effusion.,0
Previously described right-sided PICC line remains in unchanged position.,0
"Pulmonary vascular congestive pattern has not changed significantly; however, the previously described patchy and partially confluenting parenchymal densities persist and apparently have progressed further.",1
They are most marked in the mid lung field on the right side and the lateral upper lobe area on the left.,0
Lateral pleural sinuses are partially concealed by the described parenchymal densities.,0
"Conclusive evidence of pleural effusion is not present, and major pleural effusion is unlikely as it did not exist on the lateral view on the preceding chest examination.",0
Progression of bilateral pulmonary infiltrates in this patient on stem cell transplant therapy.,1
Echo (): Moderate ?partially loculated pericardial effusion without definite evidence for tamponade physiology.,0
Normal biventricular cavity sizes with preserved global and regional biventricular systolic function.,0
"Compared with the prior study (images reviewed) of , the pericardial effusion is larger.",0
Echo (): There is mild symmetric left ventricular hypertrophy.,0
Overall left ventricular systolic function is normal (LVEF 65%).,0
There is a small to moderate sized pericardial effusion.,0
"Echo (): The left atrium appears extrinsically compressed (mildly) posteriorly, possibly by a consolidated posterior pericardial effusion.",0
The left ventricular cavity is unusually small.,0
Overall left ventricular systolic function is low normal (LVEF 50%).,0
The epicardial surface of the right ventricle as well as atria appears to be encased in a layer of echodense material (epicardial fat vs consolidated effusive material).,0
No evidence of cardiac tamponade seen.,1
"No evidence of acute cholecystitis, as clinically queried.",0
"Reversed flow in the main portal vein, could be secondary to cardiac tamponade or tricuspid regurgitation.",1
Redemonstration of FNH in the right hepatic lobe.,0
Moderate-sized bilateral pleural effusions and a small amount of ascites Brief Hospital Course: 38 year old female with ALL s/p cord blood transplant complicated by multi-organ GVHD admitted directly to the ICU for recurrent fever and increased pulmonary infiltrates on CXR.,1
#Sepsis: Patient presented to the clinic with fevers to 102; CXR showed increased pulmonary infiltrates and heart size.,1
"She received a dose of meropenem, blood and urine cultures were sent, and she was admitted directly to the ICU.",0
"After transfer to the ICU she was given IV fluids and continued on broad-spectrum antibiotics (vancomycin, cefepime), antifungal (voriconazole) and antiviral (gancyclovir).",0
"Bronchoscopy lavage fluid was sent for pan-culture, pneumocystis smear, and CMV screen.",0
CMV pneumonitis was suspected given previous BAL CMV+.,0
Hypoxia and work of breathing worsening and she required intubation for ventilation (see below).,0
"Microbiology revealed parainfluenza 3, but no other pathogens: sputum bacterial and fungal cultures + BAL cultures/stains/labs were all negative, including negative PCRs for PCP and CMV.",0
"She received vancomycin, cefepime, ganciclovir, voriconazole, and amphotericin B for broad anti-bacterial, anti-fungal, and anti-viral coverage.",0
She also received four doses of IVIG.,0
# Hypoxia: Serial CXRs showed diffuse bilateral infiltrates.,0
Patient arrived in the ICU unintubated but was intubated on the day after transfer for increasing respiratory effort and somnolence.,1
She was sedated on fentanyl and versed due to agitation and discomfort on the vent.,0
She was difficult to wean from 80% Fi02 and 14 PEEP.,0
She required mechanical ventilation at an Fi02 of 100% O2 until the time of expiration.,0
"In addition to infection, there was concern for ARDS.",0
The patient expired on the ventilator.,0
"#Pericardial Effusion: Admission CXR showed increased heart size, and the echo done on showed increase in pericardial effusion without evidence of tamponade.",1
"Patient's primary cardiologist, Dr. was alerted and recommended follow up with echo on .",0
"Follow-up echo showed worsening moderate-to-large pericardial effusion, which was drained by bedside pericardiocentesis.",0
"Pericardial fluid included 30% lymphocytes and 60% macrocytes, cultures negative.",0
"Although she does not carry a diagnosis of cardiac GVHD, this was suspected.",0
A third follow-up echo showed normal LVEF.,0
"#Congestive heart failure with systolic dysfunction: Patient has known CHF with systolic dysfunction from chemo, XRT and suspected cardiac GVHD.",1
Considered whether patient's recent CHF lability might contribute to current respiratory acuity.,1
She was euvolemic to slightly volume up on exam with lower extremity pitting edema.,0
Daily weights showed her to be under her recent discharge weight of 136.5 lb.,0
"She was on torsemide on arrival, but this was held in the context of hypovolemia (see below).",0
NiCOM maneuvers were performed and a transesophageal Balloon was placed for pleural pressure monitoring.,0
"Following pericardiocentesis her cardiac output improved, repeat Echo was performed, and congestive heart failure was thought not to be the cause of her declining clinical picture.",1
A repeat ECHO did show worsening right ventricular function.,0
"Despite being on three pressors, the patient's clinical picture declined and she developed hypotension.",0
#Chronic Kidney Disease: Patient baseline creatinine 2.5 - 3.0 with admission Cr of 2.7.,1
Creatinine continued to rise from 3.0 to 3.7 despite IVF.,0
"Pt was hypocalcemic to 5.9 (requiring standing supplementation) and hyperphosphatemic, both likely secondary to renal failure.",1
She became anuric and was started on CVVHD.,0
CVVHD was discontinued as the patient developed hypotension despite being on three pressors.,0
"#ALL: Pt is s/p double cord blood SCT complicated by GVHD on immunosuppression, recently discharged on mycophenolate, IV solumedrol and bactrim/acyclovir for prophylaxis.",0
Her mycophenolate dose was changed to 500 mg PO BID and she was continued on this plus 60 mg IV solumedrol daily.,0
"She was on Bactrim prophylaxis prior to admission, and this was increased to therapeutic dosing while in the ICU.",0
She was transiently IV fluid and pressor-dependent with hypotension to 85/45 but maintained BP through most of her ICU stay.,0
Home nifedipine and lopressor were held.,0
Transfused 1U PRBC for Hct 22 on ICU day 2; post-transfusion Hct 27.,0
"She was hyponatremic, likely due to diuresis (which was stopped).",0
No mental status changes prior to intubation.,0
"Stable transaminases, with normal ALT and AST mildly elevated.",0
"Unclear etiology, likely secondary to hypoxia and end-organ underperfusion.",0
Platelet count remained low but patient did not show signs of coagulopathy.,0
Medications on Admission: -acyclovir 400 mg Tablet One (1) Tablet by mouth every twelve (12) hours.,0
"-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization One (1) Neb Inhalation every six (6) hours as needed for SOB, wheezing -digoxin 125 mcg Tablet One (1) Tablet by mouth EVERY OTHER DAY.",0
"-ergocalciferol (vitamin D2)50,000 unit Capsule One (1) Capsule by mouth 1X/week -lorazepam 0.5 mg Tablet One (1) Tablet by mouth every six (6) hours as needed for anxiety/nausea.",0
-methylprednisolone sodium succ Sixty (60) mg Intravenous once a day.,0
"-metoprolol succinate 50 mg Tablet Extended Release 24 hr, One (1) Tablet Extended Release 24 hr by mouth once a day -morphine [MS Contin]15 mg Tablet Extended Release One (1) Tablet Extended Release by mouth twice a day.",0
-mycophenolate mofetil 500 mg Tablet Two (2) Tablet by mouth twice a day.,0
-nifedipine 60 mg Tablet Extended Release One (1) Tablet Extended Release by mouth once a day in the evening.,0
-NPH insulin human recomb Ten (10) units Subcutaneous twice a day: Please administer 10 units before breakfast and 10 units before dinner.,0
"-omeprazole 40 mg Capsule, Delayed Release(E.C.)",0
"One (1) Capsule, Delayed Release(E.C.)",0
by mouth once a day.,0
"-ondansetron 4 mg Tablet, Rapid Dissolve Tablet, Rapid Dissolves by mouth three times a day as needed for nausea.",0
-oxycodone 5 mg Tablet One (1) Tablet by mouth every 4-6 hours as needed for pain.,0
-sildenafil 20 mg Tablet Four (4) Tablet by mouth three times a day.,0
-sulfamethoxazole-trimethoprim 400-80 mg Tablet One (1) Tablet by mouth DAILY (Daily).,0
-torsemide 20 mg/2 mL (10 mg/mL) Solution Forty (40) mg Intravenous once a day.,0
-voriconazole 200 mg Tablet One (1) Tablet by mouth every twelve (12) hours.,0
Discharge Medications: Deceased Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased,0
Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: new left sided neck mass Major Surgical or Invasive Procedure: Excision of deep left neck mass Novo7 infusion History of Present Illness: 83-year-old male with 20-year history of Waldenstrom's macroglobulinemia and acquired disease.,1
"In , he developed new onset left anterior cervical lymphadenopathy.",0
MRI scan confirmed the presence of a single 2.8 cm Left Level II JD lymph node.,0
"He denies odynophagia, dysphagia, hemoptysis, voice changes, fevers, chills, or night sweats.",0
He has had no recent URIs or other significant ENT complaints.,0
Past Medical History: Type II diabetes: diet controlled Waldenstrom's macrogammaglobulinemia acquired disease Hypertension Gout BPH Social History: Wife diet three months ago.,1
"Smoked pipe for about thirty years, occasional cigar, occasional EtOH, no drugs Family History: Mother with diverticulosis, father with stroke, brother had MI at age 36 yrs.",0
"Physical Exam: Gen: elderly male, NAD HEENT: anicteric, pale conjunctiva, OMM slightly dry, OP clear, neck supple, left neck incision with overlying steri strips, No evidence of active bleeding Cardiac: RRR, no M/R/T appreciated Pulm: CTA bilaterally Abd: NABS, soft NT/ND, no masses Ext: No C/C/E, warm with 2+ DP bilaterally Pertinent Results: GLUCOSE-140 UREA N-26 CREAT-1.3 SODIUM-142 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-29 CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-1.4 WBC-6.8 RBC-2.92 HGB-10.4 HCT-30.4 MCV-104 MCH-35.7 MCHC-34.4 RDW-17.4 PLT COUNT-81 PT-9.4 PTT-40.8 INR(PT)-0.6 DIAGNOSIS: 1.",0
"Left neck mass, excisional biopsy (A-D): Metastatic poorly-differentiated squamous cell carcinoma.",0
"Left neck mass #2, excisional biopsy (E-I): Metastatic poorly-differentiated squamous cell carcinoma.",0
"Note: The tumor cells are negative for CK-7, CK-20 and TT-1, consistent with squamous cell carcinoma.",0
Brief Hospital Course: 84 year old male with acquired disease in the setting of Waldenstrom's macroglobulinemia admitted for excisional cervical lymph node biopsy.,1
1) Excisional lymph node biopsy/Post-op bleeding: The patient underwent excisional biopsy of 2.8 cm left lymph node on .,0
"He received 90 mcg/kg novo7 pre-op, followed by 20 mcg/kg over 5 hours in PACU.",0
"However, ~ 3 minutes after infusion, bleeding recurred at the incision site.",0
He was admitted tho the MICU for closer monitoring and intravenous 7.,0
"He also received desmopressin X1, and thrombin impregnated surgicel pads were placed on the wound.",0
His JP drain was removed on following bolus of 7.,0
"The 7 infusion was stopped without recurrence of bleeding, and he was transferred to the general medical floor.",0
"2) Squamous Cell Carcinoma: The pathology of the lymph node was consistent with metastatic squamous cell carcinoma, unknown primary.",0
"Hematology-oncology was consulted, who recommended an outpatient PET scan.",0
"Per ENT, the risk of blind biopsies of the nasopharynx in the setting of acquired deficiency is unacceptably high.",0
"The patient will be discharged to follow-up with oncology as an outpatient 3) Hypertension: Once the patient was transferred to the general medical floor and there was no further evidence of active bleeding, his home anti-hypertensives were resumed.",0
4) Type II diabetes: The patient was maintained on an insulin sliding scale while in-house.,0
His diabetes is diet-controlled at home.,0
5) Code: Full Code Medications on Admission: Cardura 4 mg PO daily Proscar 5 mg PO daily Atenolol 25 mg PO daily Folic acid 1 mg PO daily Allopurinol 300 mg PO daily Dyazide 37.5/25 PO daily Lisinopril 40 mg PO daily Discharge Medications: 1.,0
Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 days.,0
Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed.,0
Cardura 4 mg Tablet Sig: One (1) Tablet PO once a day.,0
Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day.,0
Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.,0
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.,0
Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Discharge Disposition: Home Discharge Diagnosis: Primary: s/p excisional biopsy of left neck mass Secondary: Waldenstrom's macrogammaglobulinemia, acquired disease, hypertension, gout, benign prostate hypertrophy, metastatic small cell carcinoma Discharge Condition: stable Discharge Instructions: 1.",1
"Please call if fever greater than 101.5, if increased redness around wound, if discharge from wound, if increased bleeding from wound or fullness in neck.",0
"Please do not immerse wound in bath, swimming, or sauna for 2 weeks.",0
Please do not drive while taking narcotics.,0
Please follow up with primary care provider concerning hospitalization.,0
Followup Instructions: 1) Oncology Please follow-up with your primary oncologist on as previously scheduled.,0
"- if you wish to transition your care to oncology, please call to make an appointment with thoracic oncology clinic via () - your oncologist should schedule you for an outpatient PET scan - your oncologist will likely schedule you for follow-up with radiation oncology 2) ENT Provider: , .D.",0
Where: LM (ENT) Phone: Date/Time: 2:00 3) Hematology: Please call to make an appointment with your outpatient hematologist (Dr. ) to be seen within 2 weeks following discharge.,0
"4) Primary care Please follow-up with your primary care physician (Dr. ) within 1 week following discharge - you should have your hematocrit (red blood cell) and platelet count checked at that time to ensure stability (HCT 32.2, platelets 102 at time of discharge) MD, Completed by:",0
"11:38 PM KNEE (AP, LAT & OBLIQUE) BILAT; FEMUR (AP & LAT) BILAT Clip # ANKLE (AP, MORTISE & LAT) BILAT Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with REASON FOR THIS EXAMINATION: trauma ______________________________________________________________________________ FINAL REPORT INDICATION: 25-year-old man with trauma, evaluate for fracture.",1
"BILATERAL LOWER EXTREMITIES, NINE RADIOGRAPHS: There is a comminuted fracture of the right mid femur.",1
There are two separate fracture sites within the proximal and mid right femur.,1
"There is medial angulation of the middle fracture fragment, and lateral angulation of the distal fracture fragment.",0
There is no evidence of hip dislocation.,0
There is also bayonetting and slight posterior dislocation of the distal fracture fragment.,0
There is associated soft tissue swelling within the thigh.,0
No definite joint effusion is seen around the right knee joint.,0
There is no evidence of dislocation around the right knee joint.,0
"There is a comminuted fracture of the distal right tibia and fibula, extending to the articular surface of the right ankle joint.",1
The ankle mortise itself appears relatively intact.,0
There is limited evaluation of the ankle joint on this single view.,0
There is fracture of the left femur at two locations.,1
"There is a comminuted fracture through the intertrochanteric region, with slight medial angulation of the mid fracture fragment.",0
"Additionally, there is an oblique fracture through the mid to distal left femur, with medial displacement and bayonetting of the distal fracture fragment.",1
"On these limited views around the left knee joint, there is no definite joint effusion or fracture around the left knee.",0
"On the two views of the left ankle, no fracture is identified within the distal tibia or fibula.",1
"There is a probable fracture of the left talus, with cortical irregularity and lucency on the anterior and superior aspects of the left talus.",0
There is a left ankle joint effusion.,0
Comminuted fracture of the right proximal femur in two locations.,1
"Fracture of the proximal left femur in two locations, as described above.",1
Comminuted fractures of the right distal tibia and fibula.,1
This could be further evaluated with dedicated radiographs of the left ankle.,0
"4:22 PM BABYGRAM (CHEST ONLY) Clip # Reason: Term newborn, s/p CPR at delivery.",0
UVL and UAL line placeme ______________________________________________________________________________ MEDICAL CONDITION: Infant with above.,0
"REASON FOR THIS EXAMINATION: Term newborn, s/p CPR at delivery.",0
"UVL and UAL line placement, and verify ETT position.",0
______________________________________________________________________________ FINAL REPORT CHEST: HISTORY: Infant born at term.,0
FINDINGS: Endotracheal tube is seen with tip at C6.,0
Umbilical venous catheter reaches right atrium.,0
Umbilical arterial catheter reaches T9.,0
The heart size is normal and the lungs are clear.,0
There is gas in the stomach and the remainder of the abdomen is gasless at this time.,0
11:13 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
encephalitis Admitting Diagnosis: TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 68 yo M w/ hypoxic respiratory failure and possible encephalitis.,1
"encephalitis No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 5:21 PM No acute intracranial hemorrhage, edema, or mass.",0
"If acute infarction or encephalitis is a consideration, please consider obtaining MRI.",0
______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT INTRAVENOUS CONTRAST INDICATION: 68-year-old man with hypoxic respiratory failure and possible encephalitis.,1
COMPARISON: CT head dated and MRI dated .,0
"FINDINGS: There is no acute intracranial hemorrhage, edema, shift of normally midline structures, or hydrocephalus.",0
The extracalvarial soft tissues and surrounding osseous structures are unremarkable.,0
Imaged paranasal sinuses and mastoid air cells are well aerated.,0
Small lucencies in the squamous temporal bones on both sides () relate to arachnoid granulations.,0
Please consider MR for acute infarction or encephalitis is needed.,0
"4:55 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: MULTIPLE TRAUMA,PLANE CRASH ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman s/p L-CVL c/b PTX, now s/p L CT removal decreasing PTX; s/p extubation REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:19 A.M., .",0
HISTORY: Left central venous line placement.,0
IMPRESSION: AP chest compared to through 11: Small bilateral pleural effusion unchanged.,0
Atelectasis at left base is worsened.,0
"Pulmonary vascular congestion is stable and there may be new mild pulmonary edema, although heart size is normal and unchanged.",0
Tip of left subclavian line projects over the junction of the brachiocephalic veins.,0
"9:09 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ATRIAL FIBRILLATION ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with pleural edema, shortness of breath REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.",1
REASON FOR EXAM: Pulmonary edema and shortness of breath.,0
"FINDINGS: In comparison to the previous chest radiographs, diffuse, relatively uniform opacification of the lungs has much improved due to resolving pulmonary edema which is now mild.",0
"Small bilateral pleural effusions are probably unchanged, although the assessment of the left pleural effusion is difficult due to severe thoracolumbar scoliosis.",1
IMPRESSION: Significant improvement in pulmonary edema which is now mild with a stable small right pleural effusion.,1
"9:42 AM CHEST (PORTABLE AP) Clip # Reason: eval for pulm edema Admitting Diagnosis: HYPOTENSION-HEPATORENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with encephalopathy, hypotension, increasing hypoxia REASON FOR THIS EXAMINATION: eval for pulm edema ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
HISTORY: 45-year-old woman with encephalopathy and hypotension.,0
There has been placement of a nasogastric tube whose distal tip and side port are below the gastroesophageal junction.,0
There are low lung volumes which limit evaluation.,0
"Allowing for this, however, there is no focal consolidation.",0
"There is some minimal prominence of the interstitial markings, however, I doubt the presence of significant pulmonary edema.",0
"There has been improvement of the linear atelectasis at the right base, however, there has been development of linear atelectasis at the left base in the interim.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Augmentin Attending: Chief Complaint: chest/neck pain Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: 38 yo f with PMH of ASD and pulmonary vein anolmous circulation (LL pulm vein drained into coronary sinus) s/p repair in (coronary sinus into LA), asthma, migraines presents with dry cough and chest pain/ neck pain exacerbated by deep breathing.",1
"Initially, PCP felt pain was musculoskelatal and was given flexeril, ibuprofen w/ little relief.",0
She also reports N/V x2 days.,0
CXR shows a left pleural effusion with associated opacity and a small right pleural effusion.,1
She was initially hemodynamicallyt stable but then pressure dropped to 70's/50.,0
She was started on dopamine.,0
Echo showed large circumferential pericardial effusion with stranding and clotted appearance.,0
"She was given 4L of fluid in ED with little UO, morphine 4mg, ketorolac, ASA, tylenol, levetiracetam, dopamine, promethazine, zofran.",0
"Upon arrival to CCU she was afebrile, BP 90/60 on dopamine 5, RR 14, HR 100.",0
Cardiac and thoracic surgery saw her in CCU and plan was for thoracentesis and probable surgery tomorrow.,0
"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.",0
"Denies recent fevers, chills or rigors.",0
Denies exertional buttock or calf pain.,0
"Cardiac review of systems is notable for chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, presyncope.",0
She denies syncope or lower extremity edema.,0
"Past Medical History: ASD, Migraines, asthma, endometriosis Past surgical hx: ASD repair in (repair of an ASD and baffle of ananomalous pulmonary vein using the pericardium - so that coronary sinus drains in left atrium), lipoma resection from lower back, cystic ovary s/p resection, tubal ligation.",1
Social History: Significant for the absence of tobacco use.,0
No history of alcohol abuse or drug abuse.,0
Family History: Father died of MI at 72 years.,0
No history of sudden death.,0
"PHYSICAL EXAMINATION: VS: T 96.8 BP 90/60 HR 100 RR 16 O2 97% 3L NC, pulses 5 Gen: well appearing, oriented x3.",0
Neck: no elevation of JVP appreciated.,0
"RR, slightly distant S1, S2.",0
"+wheezes on R scattered, +bronchial breath sounds on L side up to half way.",0
Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ .,0
Pertinent Results: 2D-ECHOCARDIOGRAM performed on demonstrated: LA is mildly dilated.,0
A relatively immobile outpocketing is along the mid-interatrial septum (coronary sinus baffle) with both systolic an diastolic flow.,0
No intracardiac flow is identified with saline injection at rest or with maneuvers.,0
Estimated RA pressure is 11-15mmHg.,0
Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%).,0
Regional systolic function is normal.,0
Abnormal septal motion/position (?post op vs. constriction - less likely).,0
RV chamber size is normal.,0
RV systolic function appears depressed.,0
AV leaflets appear structurally normal with good leaflet excursion.,0
MV structurally normal with trivial MR.,0
"Moderate sized (~1.5cm) circumferential, echo-filled pericardial effusion with some stranding c/w organization.",0
"Tamponade physiology is not suggested on transmitral Doppler, but this can be absent with pulmonary artery systolic hypertension.",0
"ETT performed on normal perfusion CARDIAC CATH performed on showed moderate left to right intracardiac shunt, Secundum-type atrial septal defect, Anomalous pulmonary vein to coronary sinus drainage.",0
"RADIOLOGY Preliminary Report CHEST (PORTABLE AP) 4:02 PM CHEST (PORTABLE AP) Reason: evaluate for pneumo s/p chest tube removal MEDICAL CONDITION: 38 year old woman with ASD, chest pain, pericardial effusion and pneumonia/pleural effusion s/p Pericardiectomy REASON FOR THIS EXAMINATION: evaluate for pneumo s/p chest tube removal CLINICAL HISTORY: ASD, chest pain, pericardial effusion.",1
"CHEST Since the prior chest x-ray of , the right chest tube has been removed.",0
There is no pneumothorax on this side and only a small area of basilar atelectasis is now present.,0
The left chest tube is still present.,0
Some atelectasis is seen on this side but no infiltrates are present.,0
IMPRESSION: Right chest tube removed.,0
No failure or pneumonia seen.,0
"Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 07:10AM 8.3 3.99* 9.7* 29.7* 75* 24.3* 32.7 18.2* 545* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 07:10AM 90 8 0.6 140 4.5 103 29 13 Brief Hospital Course: This is a 38 yo F with h.o ASD and anolmous pulmonary vein to coronary sinus s/p repair in , she presented with chest pain, neck pain, worse with deep breathing.",0
She was found to have a organized pericardial effusion and pleural effusion and pneumonia.,1
Thoracic was consulted as was Dr. from cardiac surgery.,0
She had a thoracentesis in the ED and 550 cc was obtained.,0
She had a CT scan which revealed enhancement of the pericardium and was concerning for infection.,0
On she underwent redo sternotomy and drainage of pericardial and L pleural effusion.,1
She tolerated the procedure well and was transferred to the CSRU in stable condition.,0
She was extubated on the post op night and was transferred to the floor on POD#1.,0
She was treated with Vanco and Cipro until all of the cultures came back and upon dishcarge they were all negative.,0
"On POD#3, the chest tubes were d/c'd and she was discharged on POD#4 in stable condition.",0
Medications on Admission: Flovent Albuterol ASA 325 mg daily Discharge Medications: 1.,0
Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 weeks.,0
PO Q24H (every 24 hours) for 2 months.,0
Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day.,0
Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.,0
Atenolol 25 mg PO daily.,0
"Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: s/p redo sternotomy, draiage of pericardial and left pleural effusion PMH: ASD s/p repair ', Migranes, Asthma, Endometriosis, lypoma resection, cystic ovary resection, tubal ligation Discharge Condition: good Discharge Instructions: Keep wounds clean and dry.",1
"Call for any fever>100.5, and for redness or drainage from wound Followup Instructions: clinic in 2 weeks.",0
Dr in 4 weeks Dr in weeks Completed by:,0
"1:27 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: NGT placement Admitting Diagnosis: FACIAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 87F s/p fall, LeFort II REASON FOR THIS EXAMINATION: NGT placement ______________________________________________________________________________ FINAL REPORT INDICATION: An 87-year-old woman status post fall and NG tube placement.",0
Single AP view of the chest dated shows NG tube coursing under the diaphragm.,0
The tip cannot be evaluated as it terminates below the image margin.,0
The endotracheal tube is 2-3 cm above the carina.,0
A left upper lobe opacity may represent pneumonia.,0
"Additionally, there is an ill-defined opacity at the left base.",0
A short-term interval follow up is recommended to document resolution.,0
Comparison with prior films or chest CT may be indicated however.,0
"IMPRESSION: Left upper lobe and left base opacities, which may represent pneumonia.",0
Short- term interval follow up is recommended to document resolution.,0
"Nasogastric tube tip courses below the diaphragm, however, its distal position cannot be confirmed as it extends off the film.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Norvasc Attending: Chief Complaint: HA, word-finding difficulties Major Surgical or Invasive Procedure: angiogram History of Present Illness: Mr. is a 50-year-old right-handed male with history of hypertension, presenting with headache and word-finding difficulties.",0
"Patiet reports last evening while watching television, he developed a left temporo-parietal headache in severity.",0
It appeared to wax and wane in intensity and he cannot say if it was of particular sudden onset.,0
"He went to bed and awoke this morning with persistent headache, but went to work anyway.",0
"He reports upon arriving to work, he had difficulty concentrating and occasional difficulty getting words out.",0
"He stated he could understand what people were saying to him, and generally could speak fluently, but occasionally would have word-finding difficulties, and felt generally ""confused.""",0
He went home and took a nap.,0
"Later in the afternoon, he went to his PCP.",0
arrival his BP was 142/110 and he was taken to the ED for further evaluation.,0
Upon arrival he reports persistent headache.,0
"No neck pain, diplopia, visual changes, weakness, numbness, paresthesias, bowel or bladder changes.",0
"No recent fevers, chills, nausea, vomiting, chest pain, or shortness of breath.",0
He does report not taking his antihypertensive medication over the past two days.,0
No similar episodes in past and no history of headache.,0
Past Medical History: HTN Social History: works as a maintenace worker.,0
"No tobacco, social etoh, no drugs Family History: mother with stroke at age 89 and HTN Physical Exam: Physical Exam; VS; T 98.1 P 66 BP 148/98 RR 16 99% RA General: Awake, cooperative, NAD.",0
"HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated.",0
"Neurologic: -Mental Status: Alert, oriented x 3.",0
Able to relate history without difficulty.,0
"Able to name DOY forward, but unable to name backwards.",0
Occasional word finding difficulties and paraphasic errors.,0
"Says ""finger"" when asked to name thumb.",0
Unable to name 5th digit or knuckles.,0
"Difficulty , unable to read right half of sentences and makes paraphasic errors on left side of text.",0
"When asked to write, he writes ""y my (scribble) mo.""",0
Difficulty with R vs. L discrimination.,0
Describes photo only with activity on left side of picture.,0
Bisects lines to the left of midline and omits line in bottom left corner of page.,0
Unable to calculate quarters in $1.75.,0
"VII: No facial droop, facial musculature symmetric.",0
VIII: Hearing intact to finger-rub bilaterally.,0
"No adventitious movements, such as tremor, noted.",0
"Delt Bic Tri WrE FFl FE IO IP Quad Ham TA EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout.",0
-DTRs: Tri Pat Ach L 2 2 2 2+ 1 R 2 2 2 2+ 1 Plantar response was mute bilaterally.,0
"-Coordination: No intention tremor, no dysdiadochokinesia noted.",0
"No dysmetria on FNF or HKS bilaterally, but misses target, appears to be secondary to visual difficulties.",0
-Gait: deferred Exam on Discharge: Patient alert and oriented to self and year PERRL 3-2mm bilaterally EOMs intact Face symmetrical Tongue midline Motor: D B T IP Q H AT R 5- 5- 5- 5- 5- 5- 5- 5- 5- L 5 5 5 5 5 5 5 5 5 Incision: c/d/i with staples Some moderate dysarthria Pertinent Results: CT HEAD W/O CONTRAST: Left parietotemporal intraparenchymal hemorrhage.,0
CTA HEAD W&W/O C & RECONS: 1.,0
"Stable appearance of a left parietotemporal hemorrhage with expected minimal increase in surrounding vasogenic edema, causing effacement of sulci.",0
There is no midline shift or herniation.,0
Unremarkable intracranial vasculature without evidence of AVM.,0
"If underlying etiology for hemorrhage remains unclarified, followup is recommended to further elucidate cause.",0
Mild paranasal sinus disease MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST: Left temporal hematoma with surrounding edema.,0
Minimal peripheral enhancement is compatible with reaction to the bleeding itself.,0
The possibility of underlying neoplasm or vascular malformation cannot be excluded.,0
CT HEAD W/O CONTRAST 1.,0
No evidence of new large intracranial hemorrhage after surgery.,0
"Left temporoparietal hemorrhage is not larger, and demonstrates decreasing density, consistent with evolving blood products.",0
Surrounding vasogenic edema which causes diffuse effacement of the cerebral sulci is unchanged.,0
"Brief Hospital Course: Mr. is a 50-year-old right-handed male with history of hypertension, presenting with onset of headache last evening, followed by word-finding difficulties and ""confusion"" while at work on day of admission.",0
"His examination was notable for occasional word-finding difficulties, paraphasic errors, difficulty with repetition, finger agnosia, acalculia, R/L discrimination difficulties, and R inferior quadrantsonopsia.",0
He was found to have a 3.0 x 2.7 cm left parietotemporal intraparehchymal hemorrhage on CT head.,0
He was admitted to the neurology service he continued to have halting but fluent speech and severe anomia.,0
"His studies included head CT, CTA head/neck, MRI brain, MRA head/neck, and angiogram.",0
Head CT and brain MRI was significant for left parietotemporal intraparenchymal hemorrhage.,0
CTA and MRA did not show an AVM but it could not be excluded.,0
"To further investigate for an AVM, a conventional angiogram was performed.",0
The angiogram showed an AVM in the left parietotemporal area.,0
"Given the fact that the patient had a previous hemorrhage from this AVM, he was recommended to have a craniotomy to remove the AVM which occurred on without complications.",0
He was monitored overnight his BP was kept less than 140 then he was transferred to the floor.,0
He was noted to have increase BP for which additonal agents were added with good effect.,0
He tolerated a regular and voiding.,0
A follow up angiogram on showed no residual avm.,0
His exam was still altered particulary with his speech.,0
"He will be discharged on home with 24 hour supervision and will have out patient, speech, occupational, and physical therapy.",0
He will follow up in 4 weeks with Dr. with NCHCT.,0
Medications on Admission: lisinopril 10 mg daily Discharge Medications: 1.,0
Outpatient Speech/Swallowing Therapy Outpatient speech therapy to follow-up for aphasia 2.,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: Use while taking Dilaudid.,0
Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).,0
"Outpatient Occupational Therapy Please eval and treat has agnosia, dyscalculia, dysgraphia, possible poor insight.",0
Outpatient Physical Therapy Please evaluate and treat Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: 1.,0
"Intracerebral (intraparenchymal) hemorrhage, left parietotemporal 2.",0
Arteriovenous malformation (AVM) Seconday: 1. hypertension Discharge Condition: Mental Status: Mild transcortical motor aphasia (impaired naming and fluency with retained comprehension and repetition).,1
Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent The remainder of the neurologic exam is normal.,0
"Discharge Instructions: You were admitted with headache, confusion, and word-finding difficulties.",0
Brain imaging showed that you had bleeding in the left side of your brain called a left parietotemporal intraparenchymal hemorrhage.,0
This was found by angiogram to be due to an abnormality of the blood vessels known as an arteriovenous malformation (AVM).,0
GENERAL INSTRUCTIONS WOUND CARE ?,0
Usually no special is prescribed after a craniotomy.,0
"A normal well balanced is recommended for recovery, and you should resume any specially prescribed you were eating before your surgery.",0
Use your incentive spirometer 10 times every hour that you are awake.,0
Neurology: to be arranged through your primary care physician.,0
Your primary care physician for BP management.,0
?Please return to the office on to have your sutures removed make an appointment by calling .,0
?Please call ( to schedule an appointment with Dr. to be seen in weeks.,0
You will need either CT scan of the brain or an MRI of the brain and this will be scheduled along with your appt.,0
"1:59 PM BABYGRAM (CHEST ONLY) Clip # Reason: Tachypnoea, CPAP.",0
"______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, clinical HMD.",0
"REASON FOR THIS EXAMINATION: Tachypnoea, CPAP.",0
"______________________________________________________________________________ FINAL REPORT CHEST, : CLINICAL INDICATION: Premature infant of twins.",0
FINDINGS: A single frontal portable view of the chest was performed on .,0
The heart and mediastinal contours are within normal limits.,0
"There is subtle hazy opacification throughout both lungs, which would be in keeping with some degree of surfactant deficiency.",0
No focal pulmonary parenchymal process is identified.,0
The demonstrated osseous structures are unremarkable.,0
"4:17 AM CHEST (PORTABLE AP) Clip # Reason: ptx, assess for change Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with severe MR, AVR, intubated with difficulty ventilating REASON FOR THIS EXAMINATION: ptx, assess for change ______________________________________________________________________________ FINAL REPORT CHEST, PORTABLE AP ON COMPARISON: .",1
"HISTORY: 49-year-old man with severe mitral regurgitation treated, AVR, intubated with difficulty ventilating, evaluate for pneumothorax.",0
FINDINGS: Persistent mild-to-moderate cardiomegaly with worsening pulmonary vascular congestion and diffuse airspace opacities along with worsening bilateral small pleural effusions are again seen.,1
"Bilateral right middle lobe and left lower lobe collapse is noted, essentially unchanged.",1
Endotracheal tube distal tip projects 3.5 cm above the carina.,0
"In the interim, inferior to the IVC, a Swan-Ganz catheter has been introduced with distal tip in the left pulmonary artery.",1
An intraaortic balloon pump distal tip terminates approximately 3.7 cm above the left mainstem bronchus.,0
Persistent right middle lobe and left lower lobe atelectasis.,0
Swan-Ganz catheter in left pulmonary artery.,1
4:06 PM CHEST (PORTABLE AP) Clip # Reason: assess for pna ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with hepatic encephalopathy REASON FOR THIS EXAMINATION: assess for pna ______________________________________________________________________________ FINAL REPORT INDICATION: Hepatic encephalopathy.,1
"CHEST, AP PORTABLE: Comparison is made to .",0
The mediastinal and hilar contours appear unremarkable.,0
The lungs are clear without evidence of pleural effusion or focal consolidation.,0
Visualized osseous structures appear unremarkable.,0
"1:10 AM CHEST (PORTABLE AP) Clip # Reason: r/o increasing effusion, consolidation, pneumothorax Admitting Diagnosis: /LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with cirrhosis, h/o pleural effusions s/p R thoracentesis 1400cc serous fluid off today.",1
Now desated to 86% 5L.,0
"REASON FOR THIS EXAMINATION: r/o increasing effusion, consolidation, pneumothorax ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: S/P right thoracentesis.",0
"COMPARED TO PRIOR STUDY PERFORMED AT 18:25: Small to moderate right pleural effusion is stable, no evidence of pneumothorax.",1
Left cardiac border is obscured by parenchymal and pleural abnormality.,0
"Allowing difference in position of the patient, small to moderate left pleural effusion is unchanged.",1
Bibasilar relaxation atelectasis is present.,0
Mild interstitial pulmonary edema is new.,0
Left supraclavicular catheter remains in place.,0
"Status: Inpatient Date/Time: at 21:00 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
"11:47 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: CHF Admitting Diagnosis: CHANGE IN MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with hx of SI admitted for suspected seroquel overdose REASON FOR THIS EXAMINATION: CHF ______________________________________________________________________________ FINAL REPORT INDICATION: 42-year-old man with drug overdose, CHF.",0
"COMPARISON: Chest x-ray obtained 5 hours earlier on the same day, .",0
FINDINGS: The cardiac and mediastinal contours are unchanged compared to the prior study.,0
"Again note is made of patchy opacity in left lower lobe, which may represent aspiration versus atelectasis.",0
"IMPRESSION: Left lower lobe opacity, which may represent atelectasis versus aspiration.",0
"Admission Date: Discharge Date: Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: mechanical fall Major Surgical or Invasive Procedure: none History of Present Illness: yo F s/p mechanical fall, she remembers she tripped in the bathroom and fell from standing position, did not lose consciousness.",0
Patient was taken to outside hospital where CT head showed SDH.,0
Patient was transferred to .,0
"On arrival to patient is alert and oriented, denies confusion, headache, dizziness and vertigo.",0
She complains of left sided body pain.,0
Denies chest pain and shortness of breath.,0
"Patient had a recent syncopal episode, patient was hospitalized recently.",0
"EEG negative, per family report work up for syncope was negative.",0
Patient was recently discharge from rehab.,0
CHF with LVEF 20% PSH: 1.,0
Bilateral cataract surgery Social History: She is widowed.,0
She lives at home with nursing care from daughters.,0
She is using a walker for ambulation.,0
She does not smoke nor consume alcohol.,0
Family History: Her family history is noted for a sister who died of breast cancer.,0
Another sister died of ruptured aortic aneurysm.,0
Her mother died at age .,0
"Physical Exam: On arrival to : Vitals: 98.3 84 139/66 17 94% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR's PULM: Decrease basilar respiratory sounds.",0
"ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused.",0
No bone deformities Strength 4/5 Bilateral upper and lower extremities.,0
"On discharge: Vitals: 96.6 61 144/70 18 100% RA GEN: A&O, NAD CV: RRR, normal S1S2 Pulm: Breath sounds dimished bilaterally Abd: Soft, nontender, nondistended Extr: No LE edema, warm, pink and well perfused.",0
"Neuro: A&O X , +MAE and follows commands, PERRLA, speech clear and coherent Pertinent Results: Labs on admission: 09:51PM WBC-10.8 RBC-3.57* HGB-11.4* HCT-33.8* MCV-95 MCH-31.9 MCHC-33.8 RDW-12.6 09:51PM NEUTS-87.3* LYMPHS-8.5* MONOS-3.5 EOS-0.4 BASOS-0.4 09:51PM PLT COUNT-202 09:51PM PT-12.2 PTT-24.6* INR(PT)-1.1 09:51PM GLUCOSE-125* UREA N-68* CREAT-1.7* SODIUM-138 POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-31 ANION GAP-14 09:51PM cTropnT-0.02* 10:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 10:08PM URINE COLOR-Straw APPEAR-Clear SP -1.006 Labs at discharge: 05:02AM BLOOD WBC-8.1 RBC-3.20* Hgb-10.2* Hct-30.1* MCV-94 MCH-31.8 MCHC-33.8 RDW-12.6 Plt Ct-171 04:55AM BLOOD Glucose-84 UreaN-69* Creat-1.9* Na-133 K-5.0 Cl-97 HCO3-29 AnGap-12 04:55AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.9 04:55AM BLOOD cTropnT-0.04* CT head w/out contrast: IMPRESSION: 1.",0
"Left subdural collection of uniform low density, likely represents a subdural hygroma or chronic subdural hematoma with mild rightward shift of midline structures.",1
Prominent extra-axial space overlying the right frontal lobe mixed density between intermediate and lower density suggesting a subdural hematoma which is likely either subacute or older.,0
CT spine w/out contrast: IMPRESSION: No acute fracture or malalignment.,0
"Dilated esophagus and small left pleural effusion, also better evaluated on chest CT. CT chest/abd/pelvis w/out contrast: IMPRESSION: 1.",0
"Multiple displaced comminuted left-sided rib fractures with a left-sided pleural effusion and small foci of air which are loculated in the pleural or extrapleural space near the fractures and also along the outer chest wall, although there is no substantial pneumothorax at this time.",0
Dilated esophagus suggesting an abnormality of motility.,0
"Mildly prominent left supraclavicular lymph node, probably reactive.",0
"Left femur xray (AP & LAT), pelvis xray (AP only): IMPRESSION: Findings suggesting prior injury.",0
"Bilateral total hip replacements, which appear intact.",0
"HUMERUS (AP & LAT) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT; SHOULDER 1 VIEW LEFT FINDINGS: The bones appear demineralized.",0
Left-sided rib fractures are better characterized on CT torso examination from the same day.,0
"There is no evidence for fracture, dislocation, or bone destruction involving the shoulder, humeral shaft or elbow.",0
"At the elbow, there is prominent calcified enthesiopathy along both the medial and lateral epicondyles.",0
"IMPRESSION: Left-sided rib fractures, better characterized on CT imaging of the same day.",0
ECG Normal sinus rhythm with marked intra-atrial conduction abnormality.,0
Left ventricular hypertrophy with secondary repolarization abnormality.,0
"Intervals Axes Rate PR QRS QT/QTc P QRS T 69 166 160 458/473 80 -59 130 SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT: Mild glenohumeral DJD.",0
Partially visualized lateral rib fracture.,0
Brief Hospital Course: Ms. was admitted initially to the ICU under the acute care service for monitoring.,0
Her imaging was reviewed and neurosurgey was consulted for her SDH.,0
"It was determined that her head CT findings were not acute, and that findings were consistent with L frontal lobe SDH vs. hygroma without mass effect and R chronic SDH.",0
"She remained without neurologic defecits, and no intervention was needed.",0
It was determined she was safe to start on DVT prophylaxis with SC heparin.,0
She was scheduled for neurosurgery follow up and a repeat head CT prior to discharge.,0
"Of note, cardiac enzymes were cycled on admission given the fall and patient's cardiac history.",0
"Troponins were slightly elevated at 0.02, 0.02 and 0.04; however this was in the setting of chronic renal insufficiency and elevated creatinine (1.7-1.9).",0
ECG was obtained as well which showed normal sinus rhythm with marked intra-atrial conduction abnormality but no evidence of acute myocardial infarction or ischemia.,0
"She remained without chest pain, palpitations, shortness of breath, or syncopal symptoms.",0
She was admitted on a regular diet.,0
She was also started on a bowel regimen given her decreased mobility and administration of narcotics.,0
She was noted to have no repsiratory issues.,0
She has a known EF of 20% so her fluid status was watched closely.,0
After being monitored overnight in the ICU wihtout any issues she was transferred to the floor on HD #1.,0
On the floor her vital signs were routinely monitored and she remained afebrile and hemodynamically stable.,0
Her oxygen saturations remained within normal limits on room air.,0
"Her home cardiac medications were restarted including her plavix, metoprolol, aspirin, and lasix; however, her spironolactone was held due to persisent mild hyperkalemia 5.5 on admission (5.0 at discharge).",0
Her pain medications were adjusted to adequately control her pain level and ensure her ability to use incentive spirometry.,0
She was also started on standing nebulizer treatments to optimize her respiratory function.,0
Her neuro status remained unchanged.,0
"Physical therapy and occupational therapy were consulted to assess her mobility and safety given her injuries and history of falls, who recommended to discharge a rehab facility when medically cleared.",0
On she is afebrile and hemodynamically stable.,0
Her pain is well controlled and she is tolerating a regular diet and making adequate amounts of urine.,0
She is being discharged to a rehab facility to continue her recovery.,0
Patient's anticipated length of stay at rehab is less than 30 days.,0
Medications on Admission: 1 Lopressor 100mg 2 Lasix 10 mg daily 3 Spironolactone 12.5 mg daily 4 Plavix 75 mg daily 5 Calcium 1500 mg daily 6 Vit D 1000 IU daily 7 Vit B 12 1000 dialy 8 Sertraline 12.5 mg daily 9 MVI 10 Imodium prn 11 Tylenol prn Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
2. sertraline 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
5. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain.,0
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation.,0
"11. bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
"12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day).",0
"13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing.",0
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours).,0
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
Discharge Disposition: Extended Care Facility: Newbridge on the - Discharge Diagnosis: Primary: s/p fall Injuries: Left rib fractures Secondary: Chronic left frontal lobe subdural hematoma vs. hygroma Chronic right subdural hematoma Hyperkalemia Discharge Condition: Level of Consciousness: Alert and interactive.,1
Mental Status: Confused - sometimes.,0
Discharge Instructions: You were admitted to the hospital after suffering a fall.,0
You sustained broken ribs on your left side from the fall.,0
"There was a small amount of blood noted on the CT scan of your head, but upon review it was determined that this was old blood and you have no acute injury to your head.",0
It is recommended that your follow up with neurosurgery in 1 month for a repeat head CT scan to re-evaluate this chronic bleed in your brain.,0
You sustained rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain.,0
You should take your pain medicine as as directed to stay ahead of the pain otherwise you won't be able to take deep breaths.,0
"If the pain medication is too sedation, take half the dose and notify your physician.",0
is a complication of rib fractures.,0
In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake.,0
This will help expand the samll airways in your lungs and assist in coughing up secretions that pool in the lungs.,0
You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing.,0
Symptomatic relief with ice packs or heating pads for short periods may ease the pain.,0
"Return to the ED right away for any acute shortness of breath, increased pain or crackling sensation around your rips (crepitus).",0
Narcotic pain medication can cause constipation.,0
Thefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible.,0
Please resume all of your regular home medications EXCEPT your spironolactone.,0
This medication has been held because you had elevated potassium levels while in the hospital.,0
Your potassium levels will be rechecked at rehab.,0
"Followup Instructions: Name: ,MD Specialty: Primary CAre Location: Address: , , Phone: When:Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.",0
Department: GENERAL SURGERY/ When: THURSDAY at 1 PM With: ACUTE CARE CLINIC Building: LM Bldg () Campus: WEST Best Parking: Garage You will need a chest x-ray prior to this appointment.,0
"Please go to , Clinical Center, Radiology 30 minutes prior to your appointment.",0
We are working on a follow up appointment in the Neurosurgery Department with Dr. in the next month.,0
The Rehab will be called with the appointment.,0
"If you have not heard or have questions, please call .",0
Height: (in) 65 Weight (lb): 198 BSA (m2): 1.97 m2 BP (mm Hg): 98/66 HR (bpm): 115 Status: Inpatient Date/Time: at 14:08 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
A catheter or pacing wire is seen in the right atrium and/or right ventricle.,0
Tricuspid regurgitation is present but cannot be quantified.,0
"Overall left ventricular systolic function is severely depressed (ejection fraction 20-30 percent) secondary to severe hypokinesis of the basal and midventricular segments of all wall, with focal dyskinesis of the basal posterior wall; the apex contracts normally.",0
12:24 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: premie infant s/p UA and UV line placement and s/p intubatio Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with above.,1
REASON FOR THIS EXAMINATION: premie infant s/p UA and UV line placement and s/p intubation.,0
______________________________________________________________________________ FINAL REPORT EXAMINATION: Chest and abdomen.,0
This is our initial exam on this child born prematurely.,0
The patient is intubated with the endotracheal tube above the carina.,0
An umbilical artery line reaches T7.,0
An umbilical venous line is malpositioned in the right portal vein.,0
There is evidence of moderately severe hyaline membrane disease.,0
"11:05 AM PORTABLE ABDOMEN Clip # Reason: evaluate for residual barium in GI tract that would limit CT Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man s/p barium swallow, awaiting abdominal CT, but postponed due to residual barium REASON FOR THIS EXAMINATION: evaluate for residual barium in GI tract that would limit CT ______________________________________________________________________________ FINAL REPORT INDICATION: 39-year-old man status post barium swallow.",0
"Awaiting abdominal CT, not possible secondary to residual barium.",0
TECHNIQUE: Supine radiograph of the abdomen.,0
COMPARISON: Supine portable KUB of the abdomen from .,0
"FINDINGS: Compared to , there is overal decrease of the residual barium in the colon.",0
"However, there is still significant residual barium in the descending colon and rectum.",0
There is no evidence of large or small bowel obstruction.,0
"9:38 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP Admitting Diagnosis: AORTIC STENOSIS\RIGHT HEART CATH;LEFT HEART CATH ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with aortic stenosis REASON FOR THIS EXAMINATION: please evaluate from axillary arteries to common femoral.",1
This is a pre-op exam.,0
Please conduct study at 0800 so that her pretreatment schedule is correct CONTRAINDICATIONS for IV CONTRAST: allergy: Preteated !,0
"______________________________________________________________________________ WET READ: SPfc 11:26 AM Extensive atherosclerotic disease with ectasia of the ascending aorta, similar to that seen in .",0
"Otherwise, incidental note is made of a nodule in the left lower lobe of the lungs, appearing slightly larger since .",0
This could be followed with a dedicated high-res Chest ct in ~3months ______________________________________________________________________________ FINAL REPORT INDICATION: Preoperative evaluation in a patient with aortic stenosis.,0
TECHNIQUE: Axial CT images were acquired through the torso prior to and thereafter following the administration of 100 cc of intravenous Optiray 350 contrast.,0
CT CHEST WITH AND WITHOUT CONTRAST: The airways are patent to segmental levels bilaterally.,0
Heterogeneous attenuation throughout the lungs is likely related to air-trapping.,0
There is a small amount of dependent atelectasis bilaterally.,0
A nodular opacity posterolaterally in the left lower lobe is 13 x 9 mm.,0
"This correlates to a small nodular opacity, which was described on a CT from , and has now grown minimally in size.",0
"A hypodense pretracheal node is borderline in size, measuring 10mm in shortest diameter.",0
The heart and great vessels are notable for coronary arterial calcification as well as aortic valvular calcification.,1
"In addition, calcification is visualized along the length of the aorta, which is ectatic, unchanged from the previous studies, measuring approximately 37 x 38 mm in the ascending aorta.",0
Dense calcification is also prominent at the origin of the left subclavian artery.,0
"The main as well as right pulmonary arteries are prominent in size measuring ~29 mm, suggesting pulmonary hypertension.",1
"Note is made of cardiomegaly, in particular with left atrium appears enlarged.",0
"CT ABDOMEN WITH AND WITHOUT CONTRAST: The stomach, duodenum, spleen, pancreas, adrenal glands, right kidney, and gallbladder are unremarkable.",0
The left kidney contains an 18x18mm hypodensity which is hypodense (~27H.U.),0
"and does not enhance, though is new or enlarged.",0
"The liver is notable for three hypodensities, two in the right lobe and one in the left, all of which are too small to characterize though appear unchanged from .",0
There is no free gas or free fluid in the abdomen.,0
There is no retroperitoneal or mesenteric lymphadenopathy.,0
"(Over) 9:38 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP Admitting Diagnosis: AORTIC STENOSIS\RIGHT HEART CATH;LEFT HEART CATH ______________________________________________________________________________ FINAL REPORT (Cont) Vascular structures are notable for extensive atherosclerotic calcification along the length of the aorta in the absence of aneurysmal dilation.",1
Calcification is noted at the origin of the renal arteries bilaterally as well as at the origin of the superior mesenteric artery.,0
The celiac trunk is notable for a separate origin of the left gastric artery.,0
CT PELVIS WITH AND WITHOUT CONTRAST: The urinary bladder contains a small amount of gas and a Foley catheter.,0
"The uterus, right adnexa, and rectum are unremarkable.",0
A punctate calcification in the left adnexa is unchanged.,0
"There is no free gas or fluid in the pelvis, and there is no pelvic sidewall or inguinal lymphadenopathy.",0
Regional vascular structures opacify normally.,0
Note is made of scattered injection granulomas in the right buttocks region.,0
OSSEOUS FINDINGS: The patient is status post median sternotomy.,0
"There is a wedge compression deformity in the mid thoracic spine at the T5 vertebral body, which is unchanged since .",0
There is a grade 1 anterolisthesis of L4 over L5.,0
Degenerative disc disease at that same level with endplate sclerosis has progressed since .,0
"Extensive atherosclerotic disease as well as ectatic dilation of the ascending aorta, similar to that seen in .",0
"Left lower lobe pulmonary nodular opacity, appearing minimally enlarged from .",0
"Given the size of this lesion, followup with a PET study or dedicated CT of the chest within three months, is recommended.",0
"While this is likely a cyst, it is new/enlarged from the previous study and could be correlated to U/S for further characterization.",0
Stable hepatic hypodensities too small to characterize but likely cysts.,0
Wedge compression deformity in the mid thoracic spine and degenerative changes in the remainder of the spine as cataloged above.,0
5:11 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with probable metastatic lung cancer, h/o CHF admitted with sepsis and LLL pneumonia REASON FOR THIS EXAMINATION: ?",0
interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Probable metastatic lung cancer with CHF and sepsis and possible left basilar pneumonia.,0
"FINDINGS: In comparison with the study of , there are persistent bilateral engorgement of the pulmonary vessels consistent with elevated pulmonary venous pressure.",1
More coalescent areas of opacification at the left base and the mid zones are somewhat worrisome for supervening pneumonia.,0
Enlargement of the cardiac silhouette persists.,0
"Left costophrenic angle is not well seen, suggesting some pleural effusion.",1
IMPRESSION: Vascular congestion with findings concerning for left lower lung pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Talc Pleurodesis () History of Present Illness: Ms. is a 61 year old woman with a history of metastatic breast cancer to the lung and brain on weekly Taxol, cycle 3 on , who presents to the emergency room from Hospital with shortness of breath.",1
She recently was found to have a right sided pleural effusion s/p thoracentesis with 2100 ml of fluid removed on .,1
Her week 3 Taxol dose was held this day due to the pleural effusion.,1
She initially improved; however felt more shortness of breath in the past 2 days.,0
She initially presented to Hospital where a CXR showed reaccumulation of pleural effusion on the right.,1
She was then transferred to the ER.,0
"In the emergency department, initial vitals: 97.5 112 111/78 98% 2L NC.",0
"ECG showed sinus tachycardia with ST depressions V4 to V6 which were new, thought to be rate-related.",0
"On the floor, she reports dyspnea on exertion with taking 17 steps.",0
She has a cough productive of clear/white sputum which has been present for the past few weeks.,0
She reports minimal improvement in her dyspnea after the thoracentesis.,0
"She has occasional headaches, no vision changes, no numbness or tingling.",0
She has no chest pain but has a some palpitations when walking 17 steps.,0
She denies fevers or chills.,0
No recent change in bowel or bladder habits.,0
"Past Medical History: - Metastatic breast cancer (1) a right frontal craniotomy for resection of the metastasis by , M.D.",1
"on (2) Cyberknife radiosurgery to the 1-right frontal lobe resection cavity to 2400 cGy (800 cGy x 3 fractions) at 84% isodose line from to (3) lumbar puncture on showed 0 WBC, 31 protein, and negative cytology for malignant cells (4) status post Cyberknife radiosurgery on at 2-right frontal metastasis to cGy at 70% isodose line and 3-left frontal metastasis to 2200 cGy at 77% isodose line.",1
Her FDG-PET from did not show FDG uptake.,0
She underwent a thallium-SPECT today and the official result is pending.,0
"She reports some evidence of word-finding difficulty intermittently, particuarly when she is fatigued.",0
"She does not have headache, nausea, vomiting, seizure, imbalance, or fall.",0
Dr. will change her navelbine treatment to possibly Doxil.,0
Her oncological problem began in when she palpated a mass in the left breast.,0
A mammogram showed suspicious breast tumor.,0
She underwent a left mastectomy with none of 11 lymph nodes positive for tumor.,0
The pathology showed ER positive infiltrating ductal carcinoma.,0
"She received CAF chemotherapy, followed by chest irradiation, and 5 years of tamoxifen.",0
She was well until when she developed a cough and a chest X-ray showed a shadow.,0
A work up at another institution revealed metastatic breast cancer to her subcarinal lymph node.,0
"Biopsy showed adenocarcinoma that was ER positive, PR negative, HER-2 negative by FISH.",0
She was then treated with Faslodex from to .,0
Subsequent work up revealed an esophageal metastasis.,0
"A right upper lobe transbronchial biopsy on showed adenocarcinoma, and her treatment was switched to Xeloda on .",0
"She the received external beam mediastinum irradiation on to to 5,000 cGy.",0
She started weekly navelbine on .,0
"Her neurological problem began in later and early , with pounding -frontal headaches that radiated to the occiput.",0
These headaches were worse with motion but improved with Aleve.,0
She did not have night-time headache.,0
"She also had positional nausea and imbalance, but no vomiting.",0
"A gadolinium-enhanced head MRI on showed a right frontal enhancing mass with surrounding cerebral edema, mass effect, and 2 mm of midline shift.",0
"She had a craniotomy by , M.D.",0
on for resection of the right frontal mass.,0
The pathology was ER positive metastatic breast carcinoma.,1
This was followed by Cyberknife radiosurgery to the right frontal lobe resection cavity to 2400 cGy (800 cGy x 3 fractions) at 84% isodose line from to .,0
She then had another session of Cyberknife radiosurgery on at 2-right frontal metastasis to cGy at 70% isodose line and 3-left frontal metastasis to 2200 cGy at 77% isodose line.,0
"Other Past Medical History: - Diabetes - h/o seizures Social History: married, two grown children in the area.",1
Family History: Grandmother died of stomach cancer at age 76.,0
"No breast, ovarian, uterine, or colon cancers in the family.",0
Father- stroke and coronary artery disease.,0
"Physical Exam: ON ADMISSION: PHYSICAL EXAM: VS: T97 BP 118/60 HR 123 RR 22 96% 2L GENERAL: alert and oriented, NAD HEENT: No scleral icterus.",0
"LUNGS: Decreased breath sounds on the right side, dullness to percussion through entire right lung field.",0
"No HSM EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses.",0
"AT DISCHARGE: PHYSICAL EXAMINATION: VS: T 96.9 BP98-122/56-70s HR90-108 RR16-18 FSG 140-180s Gen: NAD, resting comfortably HEENT: MMM, O/P clear, sclera anicteric.",0
Calcified prevascular lymph node is redemonstrated.,0
"A moderate-to-large right pleural effusion appears similar when compared to the prior reference chest radiograph, and has increased when compared to the prior chest radiograph of .",1
"Previously noted right upper lobe consolidation persists, and may be slightly improved when compared to the prior study.",0
Left basilar atelectatic changes are present.,0
"The mediastinal contours appear unchanged, and assessment of the cardiac silhouette size is difficult given the presence of the moderate-to-large right pleural effusion.",1
No acute osseous abnormality is seen.,0
"IMPRESSION: Moderate-to-large right pleural effusion, increased when compared to prior radiograph from .",1
CXR : The Port-A-Cath catheter tip is at the cavoatrial junction.,0
Right chest tube has been inserted in the interim after pleuroscopy with interval decrease in the right pleural effusion.,1
Partial atelectasis of right lower lung is still present as well as apical accumulation of pleural effusion on the right.,1
The left lung is essentially clear.,0
No change in the mediastinal silhouette overall has been demonstrated including the left hilar calcified lymph nodes.,0
CXR : FINDINGS: One portable upright AP view of the chest.,0
A moderate right pleural effusion with fluid layering along the lateral right lung and apex as well as medially adjacent to the mediastinum is unchanged.,1
Mild right lower lobe atelectasis is unchanged.,0
"The cardiac, mediastinal and hilar contours are stable.",0
Calcified lymph node in the aortopulmonary window is unchanged.,0
IMPRESSION: No significant change in moderate right pleural effusion.,1
Normal global biventricular systolic function.,0
Technically suboptimal to exclude focal wall motion abnormality.,0
"Pathology: Pleura, biopsy (A): Poorly differentiated adenocarcinoma, morphologically consistent with metastatic breast carcinoma.",1
Rare atypical but degenerated epithelioid cells (see note).,0
"Right pleural fluid, cell block: Non-diagnostic; the specimen did not survive processing.",1
"Discharge Labs: 04:29AM BLOOD WBC-10.9 RBC-2.70* Hgb-7.3* Hct-23.9* MCV-89 MCH-26.9* MCHC-30.4* RDW-20.6* Plt Ct-250 04:29AM BLOOD Glucose-101* UreaN-12 Creat-0.5 Na-136 K-4.0 Cl-106 HCO3-24 AnGap-10 05:32AM BLOOD PT-16.2* PTT-32.0 INR(PT)-1.4* 04:19AM BLOOD LD(LDH)-263* CK(CPK)-53 04:29AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7 01:13AM BLOOD Cortsol-24.8* Brief Hospital Course: The patient is a 61 year old female with a history of metastatic breast cancer to the brain, lungs and adrenal glands who presents with shortness of breath and was found to have a recurrent pleural effusion which was drained at OSH with transfer for pleurodesis.",1
"# Shortness of Breath: She presented to OSH with SOB likely related to her recurrent pleural effusion, and had 2100 ml removed before transfer to .",1
Her effusion is most likely malignant in etiology and related to her metastatic breast cancer.,1
Talc pleurodesis was performed on by the IP service.,0
"She was drained daily, however got to the point where her drain was not removing fluid on 3 consecutive days so her PleurX catheter was removed by the IP service on .",0
A stitch was placed that needs to be removed in 2 weeks.,0
"# Hypotension: Following the procedure, the patient was still sedated and hypotensive and started on neo drip.",0
Her pressures did not respond to fluids.,0
"Was thought that low pressures were most likely due to sedative effect, however, took a few days to wean patient off neo.",0
Antibiotics were not started given lack of fever and no localizing symptoms.,0
The patient was volume resuscitated while being maintained on pressors.,0
"Because of her prolonged pressor requirement and use of steroids as an outpatient, she was also started on hydrocort in the event of adrenal insufficiency despite normal AM cortisol.",0
The patient's blood pressures stabilized and we were able to wean off neo.,0
The patient's blood pressures were stable on the Oncology floor off of hydrocortisone and a random cortisol was 25 - it was felt it would be very unlikely for her to have adrenal insufficiency in that setting.,0
"# Oliguria: Upon transfer to the MICU, the patient had some oliguria.",0
She was volume resucitated and her urine output ultimately improved.,0
"On transfer out of the unit, she was making good urine.",0
She required periodic fluid boluses to keep adequate urine output.,0
# pleural effusion: The patient was found to have exudative pleural effusion based on Light's criteria.,1
Cytology of pleural fluid was positive.,1
"Pleural fluid was negative for fungus, AFB, anaerobes, and culture did not grow out anything.",1
"The patient was hypoxic post procedure, and initially needed supplemental O2.",0
"However, the O2 was soon weaned, and on transfer out of the MICU, the patient was breathing comfortably and satting well on RA, where she remained.",0
# Stool in Vagina: The patient was noted to have stool coming from her vagina.,0
Gynecology was consulted for concern of a rectovaginal fistula.,1
"Their exam revealed no fistula, but an atrophic perineum, thought trauma from childbirth and poor nutritional status.",0
Stool was getting to the vagina because it was loose and this thin tissue did not prevent back passage of stool.,1
She tested negative for C dificile infection twice.,0
"They felt she was not a surgical candidate and recommended stool bulking to help prevent stool from flowing into the vagina, and follow up in clinic as needed.",0
"# Delirium - The patient was intermittently confused, not knowing where she was or why she was in the hospital.",0
She was easily redirectable and was not agitated.,0
It was felt this was most likely secondary to a prolonged stay in the hospital and ICU on top of poor substrate given her past CNS metastatic disease and surgeries.,0
This improved throughout her stay on the Oncology floor.,0
She was set up with follow up with her Neuro-Oncologist.,0
#Dysphagia - on pt began to have some trouble swallowing pills and food.,0
"She stated that she had a sensation of something being ""stuck"" in her upper chest, but denied pain.",0
There was concern for radiation encephalopathy as this coincided with some confusion/altered mental status.,0
Speech and swallow evaluated her on and felt that her swallowing was fine with the following recs: 1.,0
Continue PO diet of thin liquids and regular consistency solids.,0
Pills whole or crushed as tolerated.,0
Alternate bites and sips as needed to clear mild oral residue.,0
Assistance with meal set up as needed.,0
As the pt's mental status and alertness was improving somewhat along with her ability to swallow food and pills we felt that the dysphagia had been in the setting of needing to swallow a significant quantity of pills quickly and that she would be able to swallow pills over more extended periods of time.,1
"# ECG changes: She was thought to have subtle lateral ST depressions on her initial EKG in the ED, thought to be rate related.",0
She denied any chest pain.,0
"Troponins were negative, and repeat ECG the next morning was unchanged from prior.",0
# Diabetes Mellitus / Hypoglycemia: She was hypoglycemic the morning after admission with glucose 48 on her AM labs and FBG 65.,0
This was likely related to her poor PO intake and continued use of Glimepiride at home.,0
Her Glimepiride was held during her stay and she was placed on a Humalog insulin sliding scale.,0
Her Glimepiride was stopped on discharge pending PCP .,0
Her blood sugars the day of discharge were all > 90. .,0
"# Seizure History: She was continued on Levetiracetam 1000 mg QAM, 500 mg at noon, and 1000 mg QPM.",0
She did not have any apparent seizure episodes during her stay.,0
# Depression / Insomnia: She was continued on her home Sertraline 150 mg PO daily and Lorazepam 0.5 mg PO Q6H PRN.,0
# Breast Cancer: Not an active issue during this admission.,0
# DVT Prophylaxis: Heparin 5000 units SC TID .,0
"Transitional Issues: - follow up with Dr. and Dr. of Oncology and Neuro-Oncology - follow up with Urogynecology as needed - number provided in discharge instructions - Will need suture over right flank removed in 2 weeks - Bulking of stool to prevent overflow to vagina Medications on Admission: Glimepiride 2mg PO daily Levetiracetam 1000 mg in the AM, 500 mg midday, 1000 mg PM Lorazepam 0.5 mg PO PRN insomnia Nystatin 500,000 units QID Sertraline 150 mg PO daily Acetaminophen 500 mg PO q4H PRN pain Omeprazole 20 mg PO daily Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 1000 mg in the morning, 500 mg at lunch, 1000 mg in the evening.",1
"2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO NOON (At Noon): 1000 mg in the morning, 500 mg at lunch, 1000 mg in the evening.",0
"3. nystatin 500,000 unit Tablet Sig: One (1) Tablet PO QID (4 times a day).",0
4. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
"6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea, anxiety, insomnia.",0
7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
8. sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).,0
"9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea, anxiety, insomnia.",0
"10. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
11. psyllium Packet Sig: One (1) Packet PO TID (3 times a day).,0
"12. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO q8prn as needed for nausea.",0
13. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stool.,0
14. miconazole nitrate 2 % Powder Sig: One (1) application Topical QID;prn as needed for rash or vaginal dryness/itching.,0
Discharge Disposition: Extended Care Facility: Care nad Rehabilitation Center Discharge Diagnosis: Primary Diagnoses: Recurrent Pleural Effusion Loss of perineal body Delirium Secondary Diagnoses: Metastatic Breast Cancer Diabetes Mellitus Seizures Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted to the hospital for shortness of breath from a recurrent pleural effusion related to your breast cancer.,1
The effusion was drained and talc pleurodesis was performed to help prevent the fluid from reaccumulating.,0
"After the procedure, your blood pressure was persistently low, so you were monitored in the ICU.",0
Your blood pressure improved and you were cared for on the general medicine floor.,0
Your chest tube stopped draining fluid so it was removed.,0
You were noted to have stool coming from your vagina while in the hospital.,0
You were seen by our gynecologists who felt you did not have a fistula.,0
They felt this was most likely due to thinning of the skin between your vagina and rectum.,0
"As you are not a candidate for surgery at this time, they felt that stool bulking agents such as fiber and loperamide are the best options at this time.",0
"While in the hospital, you were found to have low blood sugar.",0
This was likely related to your poor recent appetite and continued use of Glimepiride.,0
This medication can cause low blood sugars if taken without adequate food intake.,0
You should stop taking this medication for now and discuss the various options for your diabetes control with your PCP and Oncologist.,0
You were also seen by our Speech and Swallow specialists who felt that your swallowing was normal and you could tolerate regular foods.,0
You will leave on a new medication regimen that will be provided by your rehabilitation facility.,0
"Acetaminophen mg PO Q6H:PRN pain Heparin 5000 UNIT SC TID LeVETiracetam 1000 mg PO BID give total of 1000 mg in the morning, 500 mg at lunch, 1000 mg in the evening Lorazepam 0.5 mg PO Q6H:PRN nausea, anxiety, insomnia Loperamide 2 mg PO QID titrated to solid, formed bowel movement Miconazole Powder 2% 1 Appl TP :PRN candidal infxn Nystatin 500,000 UNIT PO QID Ondansetron 8 mg PO Q8H:PRN nausea Omeprazole 20 mg PO DAILY Psyllium 1 PKT PO TID Sertraline 100 mg PO DAILY Followup Instructions: Name: E., MD Location: -DIVISION OF HEMATOLOGY/ONCOLOGY Address: , 9, , Phone: When: You will be called at home tomorrow with a follow up appointment.",0
"If you do not hear, please call the above number.",0
"Department: NEUROLOGY When: THURSDAY at 11:00 AM With: , M.D.",0
Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Please call to schedule an appointment with the Urogynecology department - either Dr. Dr. .,0
"6:52 PM CHEST (PORTABLE AP) Clip # Reason: respiratory distress, eval pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with immunocompromised, multilobar pneumonia, in resp distress REASON FOR THIS EXAMINATION: respiratory distress, eval pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress, evaluate pneumonia, immunocompromised.",1
AP CHEST: There are no prior studies for comparison.,0
"There is near complete consolidation of the left lower lobe with an air bronchogram and alveolar opacities in the left upper lobe, right upper lobe, and faintly in the remainder of the right lung.",0
The cardiac size cannot accurately be assessed due to the left lower lobe opacity.,0
The mediastinal contours are within normal limits.,0
A left pleural effusion is probably present.,1
The osseous structures are within normal limits.,0
IMPRESSION: Mutifocal pneumonia most severe in the left lower lobe.,0
A left effusion cannot be excluded.,0
7:07 AM CHEST (PORTABLE AP) Clip # Reason: please perform between AM to eval for interval change Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p esophagectomy REASON FOR THIS EXAMINATION: please perform between AM to eval for interval change ______________________________________________________________________________ FINAL REPORT EXAMINATION: Portable chest x-ray.,0
"CLINICAL HISTORY: 69-year-old male status post esophagectomy, please assess for interval change.",0
FINDINGS: A single portable image of the chest is compared to the prior examination dated .,0
There is improved aeration of the lungs.,0
There is a persistent left pleural effusion as well.,0
The cardiomediastinal silhouette is grossly unchanged.,0
"An esophageal stent is again noted that extends to the level of the superior aspect of the manubrium, and it is difficult to ascertain if this is change in position, for the patient's positioning varies on this exam.",0
A right-sided PICC catheter terminates within the expected region of the superior vena cava.,0
"Two catheters project over the mediastinum right of midline, one is likely a chest tube.",0
Improved aeration of the lungs bilaterally.,0
Persistent bibasilar opacities likely reflect underlying atelectasis.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: new line placement, infiltrates Admitting Diagnosis: CHOLANGITIS;RENAL FAILURE;CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with ascending cholangitis now s/p intubation, ?",1
"tube placement REASON FOR THIS EXAMINATION: new line placement, infiltrates ______________________________________________________________________________ FINAL REPORT PORTABLE FILM OF THE CHEST SUPINE AT HOURS ON The nasogastric tube is in place with the tip in the body of the stomach.",0
Left subclavian line in the superior vena cava and the airway is in good position approximately 4-5 cm above the bifurcation of the trachea.,0
The pulmonary edema has diminished and the vessels are more linearly normal sized.,0
However there is still large bilateral pleural effusions and there appears to be a segment of atelectasis of the left lower lobe and probable lingula air bronchogram present in this area.,1
This is not changed since the previous study.,0
CONCLUSION: No significant change in the appearance of the chest noted there also appears to be a sheath in the right axilla which ends before entering the thorax.,0
"3:46 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement, effusion, infiltrate Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with respiratory failure REASON FOR THIS EXAMINATION: ET tube placement, effusion, infiltrate ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 9:21 AM Malposition of ET tube.",1
"Bilateral pleural effusions, small to moderate.",0
Left retrocardiac opacity consistent with atelectasis that appears to be worse compared to .,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation and tubes and lines placement.,0
The ET tube tip is 6 cm above the carina.,0
The right internal jugular line tip is at the cavoatrial junction (approximately).,0
"Left retrocardiac opacity is unchanged, most likely representing combination of atelectasis and fluid.",0
Bilateral pleural effusions are small to moderate and unchanged as well.,0
No evidence of a failure is present.,0
Several rounded opacities are projecting over the right upper lung and most likely represent granulomas.,0
"10:56 AM CT HEAD W/O CONTRAST Clip # Reason: eval for interval change Admitting Diagnosis: RASH ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with ICH s/p fall, still lethargic and altered REASON FOR THIS EXAMINATION: eval for interval change CONTRAINDICATIONS for IV CONTRAST: ESRD ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Persistent lethargy and altered mental status, Followup intracranial hemorrhage.",1
Exam compared to prior study of .,0
A septal hematoma is unchanged in appearance from the previous examination.,0
There is some reduction in the amount of hemorrhage layering in the right occipital since the previous study.,0
A small focal density in the right posterior frontal white matter is unchanged.,0
There is a new area of high density in the anterior interhemispheric fissure extending on both sides of the anterior falx cerebri.,0
"Some of this may be subdural in nature, but it appears to largely represent subarachnoid blood.",0
It is layering along the right A1 portion of the anterior cerebral artery.,0
IMPRESSION: New anterior interhemispheric hemorrhage with features as discussed above.,0
"This hemorrhage may be in continuity with the septal hematoma superiorly, but this is indefinite.",0
", C. CSURG FA6A 2:59 PM FEMORAL VASCULAR US RIGHT Clip # Reason: eval for right iliac and right femoral artery flow, leak or Admitting Diagnosis: CHEST PAIN;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with right iliac artery dissection during cardiac cath at OSH REASON FOR THIS EXAMINATION: eval for right iliac and right femoral artery flow, leak or thrombus ______________________________________________________________________________ PFI REPORT PFI: No evidence of right groin pseudoaneurysm or hematoma.",1
Normal color and Doppler flow within the common femoral vein and artery.,0
10:09 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
ptx s/p ct removal page with concerns thanks Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with CAD s/p Off-Pump CABG.,1
"ptx s/p ct removal page with concerns thanks ______________________________________________________________________________ FINAL REPORT PORTABLE UPRIGHT CHEST, 10:41 A.M., INDICATION: Evaluate for pneumothorax status post chest tube removal.",0
"FINDINGS: Compared with , multiple lines, tubes, and catheters have been removed.",0
A left chest tube remains in place.,0
The atelectasis at the right base has cleared.,0
Mild retrocardiac linear atelectasis is now present.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB ID: Baby is an almost 2 week old former 35+ wk premature infant being discharged from the NICU.,0
"HISTORY: Baby was born as the 2.053 kg product of a 35-2/7 week gestation pregnancy to a 29-year-old G1, P0, now 1 mother.",0
"Maternal type is O positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown.",0
Pregnancy was complicated by HELLP.,0
The infant was delivered by C-section for progressive HELLP symptoms.,1
"He emerged slightly stunned, but responded to suction and stimulation.",0
Apgars were 8 and 9 at 1 and 5 minutes respectively.,0
"PHYSICAL EXAMINATION ON ADMISSION: Weight was 2.053 kg, length 45 cm, head circumference 32 cm.",0
"Anterior fontanelle were open and flat, positive red reflex.",0
Clavicles and palate were intact.,0
"Mild grunting, regular rate and rhythm, no murmur.",0
"Abdomen was soft and nondistended, pink and well perfused.",0
"Tone and activity appropriate, normal male genitalia and patent anus.",0
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: was admitted to the newborn intensive care unit and has been stable in room air throughout hospital course with occasional apnea and bradycardic episodes.,1
"The most recent documented episode was on , and he was spell-free for 5 days at the time of discharge.",0
CARDIOVASCULAR: Status has been stable throughout the hospital course.,0
FLUIDS AND ELECTROLYTES: Birth weight was 2.053 kg.,0
"The infant was begun on ad lib PO feedings at admission, and did not require IVF.",0
"He did require gavage feedings briefly, but has been all PO feeding since .",0
"At discharge, he is feeding BM24 with breast-feeding ad lib, with a discharge weight of 2190 grams.",0
GASTROINTESTINAL: Peak bilirubin was 9.7/0.2 on day of life #6 and did not require any intervention.,0
HEMATOLOGY: Hematocrit has not been checked.,0
INFECTIOUS DISEASE: The infant has had no sepsis risk factors.,0
NEUROLOGY: Has been appropriate for gestational age.,0
SENSORY: Audiology - a hearing screen was performed with automated auditory brainstem responses and the infant passed.,0
"NAME OF PRIMARY PEDIATRICIAN: Pediatrics, telephone .",0
"FEEDS AT DISCHARGE: Continue ad lib feedings, Similac or breast milk 24 calorie concentrated with 4 calories of NeoSure.",0
CAR SEAT POSITION SCREENING: Performed for a 90 minute screening and the infant passed.,0
STATE NEWBORN SCREENS: Sent per protocol and have been within normal limits.,0
IMMUNIZATIONS RECEIVED: The infant received hepatitis B vaccine on .,0
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following 3 criteria: 1.,0
Born at less than 32 weeks.,0
"Born between 32 and 35 weeks with 2 of the following - day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings.",0
"Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers.",0
"Prematurity, born at 35-2/7 weeks gestation 2.",1
", MD Dictated By: MEDQUIST36 D: 00:46:24 T: 09:26:49 Job#:",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Procardia / Aliskiren Attending: Chief Complaint: Altered mental status.,1
Major Surgical or Invasive Procedure: None.,0
"History of Present Illness: 72 yo m with hx GBM and ICH around mass, who presents to ER via EMS due to lethargy at facilty today.",0
"Per the daughter and son, the pt was agitated and was complaining of abdominal pain yeserterday.",0
He did not want to eat and was throwing objects.,0
He had 3 large BMs.,0
"Today pt was more unresponsive, destated to 88% on 6liters NC.",0
EMS found pt to have FS of 80 at sceen.,0
"In the ER, VS on arrival were HR 63, SBP 80-90, RR 14, 100%, rectal temp 100.",0
Pt had a FS of 34 and was given 1 Amp D50.,0
He was lethargic and minimally responsive and did not improve with dextrose.,0
Pt was intubated after about 20 min for airway protection.,0
Prior to this he had intermitent apnea and a wet sounding cough.,0
"CXR showed a possible bilaterally PNA, and CT head with no new head bleed.",0
Hct was found to be 26 from 32 and pt was ordered for 1 unit of blood.,0
Trop was elevated to 0.26 with EKG changes concerning for new twave inversions in lateral leads.,0
EKGs were sent to cards.,0
Pt was trace guaiac positive on exam.,0
SBP dropped to 77 and pt was started on levophed after at 2.5 liters IVF had been given.,0
"Pt was given vanco, ctx, and levo.",0
Pt given dexamethasone 10mg for stress steriods.,0
"On transfer VS were- HR 61, BP 118/58 (levophed 0.12), RR 14, Fio2 100%, peep 10, TV 500, sat 100%.",0
"Past Medical History: -Right frontotemporal glioblastoma multiforme WHO Grade IV, status post biopsy on , on protocol using hypofractionated involved-field radiotherapy with temozolomide followed by Cyberknife boost -Ischemic stroke -Malignant HTN -CAD s/p IMI -Chronic diastolic CHF -PAF (ED visit ) -Type II diabetes mellitus -Anxiety/Depression Social History: He is a resident of & Nursing Center in , MA.",1
He is a retired rocket scientist from .,0
He worked for USSR space program and NASA.,0
"A former pipe smoker, he quit in .",0
He is a social drinker and he does not abuse illicit drugs.,0
Family History: Father: Type diabetes and hypertension.,1
CT head w/o contrast : IMPRESSION: No acute change from prior study.,0
Right cerebral hypodensity is consistent with known GBM.,0
Dystrophic calcification in the right temporal lobe and right basal ganglia reflects either post-treatment change or prior hemorrhage.,0
There is no acute hemorrhage identified.,0
Encephalomalacia from prior right parietal and right occipital infarcts is noted.,0
Global prominence of the sulci and ventricles is compatible with encephalomalacia.,0
CT C/A/P : IMPRESSION: 1.,0
"Abdominal pneumoperitoneum, which may be due to jejunal ischemia and infarct given abnormal-appearing jejunal loops with wall thickening, possible pneumatosis and mesenteric fat stranding and fluid.",0
"Evaluation, however, is limited by lack of IV contrast.",0
"Bibasilar consolidations which may be atelectasis, although pneumonia is not excluded.",0
Atherosclerotic disease of the aorta and coronary vessels.,1
Echo : The right atrium is moderately dilated.,0
Borderline pulmonary artery systolic hypertension.,1
There is evidence of diastolic dysfunction.,0
KUB : IMPRESSION: Small amount of free air visualized in the left lateral decubitus abdominal radiograph and consistent with persistant pneumoperitoneum.,0
"DISCHARGE LABS: 09:20AM BLOOD WBC-10.9 RBC-3.00* Hgb-9.5* Hct-29.5* MCV-98 MCH-31.8 MCHC-32.4 RDW-15.5 Plt Ct-266 09:20AM BLOOD Glucose-177* UreaN-25* Creat-0.8 Na-143 K-3.6 Cl-105 HCO3-28 AnGap-14 04:56AM BLOOD ALT-20 AST-18 AlkPhos-71 TotBili-0.2 05:12AM BLOOD ALT-22 AST-14 LD(LDH)-468* AlkPhos-74 TotBili-0.1 06:36AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.7 Brief Hospital Course: 72 yo m with hx of Ischemic stroke, HTN , CAD s/p IMI, diastolic CHF, PAF, Type II diabetes mellitus, rec UTI?????",1
"?s and GBM with recent intracranial hemorrhage , who presented with altered mental status with concern for pneumonia, intubated in ER due to altered mental status and airway protection.",1
He was admitted to ICU where an abdominal CT was obtained for abdominal distention and pneumoperitoneum was found.,0
Hypotension due to sepsis was treated with pressors and IVF.,0
"He was not a surgical candidate, so the bowel perforation was treated with vanco, 7 days ceftiaxone, and metronidazole (started ).",0
"Abx changed to cipro with metronidazole for a planned 14 day course, finishing .",0
Ceftriaxone also covered a Proteus and Klebsiella UTI.,0
# Pneumoperitoneum with sepsis: Managed medically due to poor surgical candidacy.,1
The repeated normal lactate spoke against bowel ischemia as the underlying process.,0
Bowel perforation may have been promoted by chronic steroid therapy.,1
Hypotension required IV fluids and pressors.,0
Patient was intially kept NPO than gradually advanced to full diet and tolerated this well.,0
Plan is to continue cipro and metronidazole to complete a 14 day course finishing .,0
# Altered mental status: Continued delirium.,1
He needed one arm restraint to maintain IV access while getting IV antibiotics.,0
"Once changed to PO, he no longer required IV access or restraints.",0
His family is opposed to any use of anti-psychotics.,0
"# HTN: Intially off his home , BB, and diuretic as he was strictly NPO and hypotensive.",0
"After initial hypotension, he developed HTN with SBP's to the 180's.",0
He was treated with IV Labetolol gtt + clonidine patch.,0
"Most outpatient meds were re-established: eplerenone, torsemide, labetalol, clonidine, and amlodipine.",0
Valsartan 160mg will be added back as an outpatient.,0
# UTI: Proteus and Klebsiella UTI treated with ceftriaxone.,0
# DMII: Volatile blood sugars.,0
Insulin glargine and sliding scale increased per.,0
Plan to taper dexamethasone to 2mg and further after discharge as discussed with Neuro-Oncology.,0
# Acute Renal Failure: Resolved.,1
"Originally Cr 1.6 from baseline 1.0, BUN was elevated.",0
FeNa = 0.25% indicating pre-renal azotemia.,0
"In the setting of almost normal BNP, this was likely to hypovolemia/distributive shock rather than CHF exacerbation with poor forward flow.",0
"Subsequently after IV fluid and improving renal functions, he started to diurese.",0
He was restarted on his home dose of torsamide 30mg daily as well as eplerenone 50mg daily.,0
# GBM/Intracranial hemorrhage: Continued outpatient levetiracetam.,0
"# Asymmetrical leg edema: Considering inability to anticoagulate given recent ICH and family's wish for no filter, further work-up was not be pursued.",0
"# Anemia: Stable without transfusions, though was trace guaiac positive in ED.",0
# Cough: Controlled with PRN benzonatate and ipratropium nebs.,0
# Tinea pedis: Continued miconazole cream .,0
# EKG changes/Troponin elevation: Due to demand ischemia.,0
Continued statin and beta blocker therapy.,0
# Pain/headache: Palliative care consulted.,0
# FEN: Regular diabetic diet with thiamine supplement.,0
No heparin due to ICH history.,0
"# Code: DNR, but okay to intubate.",0
Patient and family are anticipating additional Palliative consultation at skilled nursing facility.,0
Medications on Admission: Amlodipine 10mg PO daily Clonidine 0.3mg/24hr patch qwk Labetaolol 400mg PO BID Epleranone 50mg PO daily Torsemide 30mg PO daily Valsartan 160mg PO BID Simvastatin 40mg PO daily Levetiractam 500mg PO q8hr Dexamethasone 3mg PO BID Omeprazole 20mg PO daily Docusate 100mg PO BID Senna 8.6mg PO BID Buspirone 5mg PO daily Citalopram 20mg PO daily Clonazepam 0.5mg PO qHS Trazadone 25mg q2PM and 12.5mg TID prn agitation Insulin Glyburide Timolol 0.5% 1 gtt OU Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
2. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday).,0
3. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
4. eplerenone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
6. torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day.,0
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours).,0
"8. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Continue x3 days, then taper to 1mg PO BID x3 days, then taper to 0.5mg PO BID.",0
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days: Finishes .,0
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Finishes .,0
"11. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day.,0
13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation.,0
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain not relieved by tylenol.,0
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
16. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic (2 times a day).,0
17. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical (2 times a day) as needed for rash on heal.,0
18. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough.,0
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
20. insulin glargine 100 unit/mL Cartridge Sig: Sixty Five (65) Units Subcutaneous once a day.,0
"21. insulin aspart 100 unit/mL Cartridge Sig: As directed Units Subcutaneous QACHS: Insulin sliding scale, see sheet.",0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: 1.,0
Discharge Condition: Mental Status: Confused - sometimes.,1
"Discharge Instructions: You were admitted for altered mental status (delirium, confusion) and required intubation (breathing machine) in order to protect your airway and keep breathing.",1
"While in the ICU, CT scan showed a bowel perforation.",0
"You were not well enough for surgery, so this was treated with antibiotics.",0
"In addition, for very low blood pressure, you needed IV fluids and pressors (medications that increase blood pressure.",0
"Once your blood pressure returned, you needed blood pressure medication for hypertension.",0
Acute kidney failure resolved with IV fluids.,1
You were also treated for a Proteus and Klebsiella urinary tract infection.,1
Your diabetes was difficult to control and the insuline doses were adjusted by the Endocrinologist (diabetes doctor).,0
"To help manage the very high blood sugar levels, the dexamethasone for the glioblastoma multiforme (brain cancer) was decreased.",0
"Valsartan 160mg 2x a day was held for hypotension, but this can be restarted as the blood pressure increases.",0
Dexamethasone dose was decreased from 3mg to 2mg two times a day.,0
"After three days, this dose can be tapered further to 1mg two times a day x3 days, then to 0.5mg two times a day.",0
Insulin glargine (Lantus) dose was changed to 65 Units daily.,0
Insulin sliding scale was adjusted (see sheet).,0
"Buspirone 5mg daily was not given during this hospitalization, but can be restarted.",0
"Citalopram 20mg daily was not given during this hospitalization, but can be restarted.",0
"Trazadone 25mg q2PM and 12.5mg TID PRN agitation was not given during this hospitalization, but can be restarted.",0
Acetaminophen 650mg PO 3x a day (scheduled) was added for chronic pain.,0
Followup Instructions: PLEASE CALL YOUR ONCOLOGIST DR.,0
THIS WEEK FOR A FOLLOW-UP APPOINTMENT.,0
"Department: CARDIAC SERVICES When: WEDNESDAY at 10:30 AM With: , NP Building: SC Clinical Ctr Campus: EAST Best Parking: Garage",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Bee Pollens Attending: Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization x2 PCI to LAD and L-Cx History of Present Illness: 53 year old male with hypertension p/w anterior STEMI and new RBBB now s/p proximal LAD stent.,1
"Pt was in his USOH, working at home in the morning.",0
"He was sitting at his desk when he started to feel ""uncomfortable"" without specific complaints.",0
Pt lied on the sofa for about 15minutes without relief.,0
He went upstairs from his basement where he was working and started to c/o severe Chest pain and significant SOB.,0
"Per pt's mother, pt lied on the couch then lied on the floor as he could not get comfortable.",0
mother called 911 and EMS arrived within 30minutes of onset of severe CP.,0
Pt did not take any medications for his pain.,0
Per EMS EKG strip noted ST elevations and brought to ED.,0
"In ED found to have new RBBB, ST elevations in V1-V6, ST depressions in II, III, aVF.",0
"Pt c/o CP in ED, received ASA, NTG x2 and dropped his BP to 90/P, received 500cc IVF bolus with improvement in BP to 138/102.",0
"He was started on Hep gtt, loaded with Plavix 600mg and 4mg Morphine IV with symptomatic relief.",0
Pt was taken to the cath lab for immediate intervention.,0
"In cath lab, pt found to have 90% thrombotic LAD lesion, had 3.0x18 cypher stent.",0
Also with 80% mid-circumflex lesion which was not stented.,0
"Wedge of 31, RA 11, PA 51/30 mean 39.",0
"O2 sats dropped to 76% on 6 liters, got lasix 20mg IV.",0
"Sats improved, but htn, started on ntg gttp.",0
"Vagaled with foley placement, became hypotensive, ntg d/c'd and given atropine.",0
"He responded, and then became htn again, started back on low-dose ntg.",0
Pt with one prior h/o CP about 2.5 years ago while visiting .,0
CP at that time was very minimal compared to current presentation.,0
"Per physicians in work up no CAD, negative EKG.",0
Pt has not had CP since then until current presentation.,0
Pt has a very sedentary lifestyle with minimal ambulation/activity.,0
"He denies any DOE/SOB at rest, no orthopnea, no PND.",0
"Past Medical History: - borderline hypercholesterolemia - hypothyroidism - hypertension Social History: Social History: Married, lives at home with wife and .",1
Works at home as financial analyst.,0
"No tobacco, occasional EtOH 1-2 drinks per week.",0
Denies any other drug use.,0
"Family History: Family History: uncles with CAD -MIs at age 50 & age 75 with CABG; with DM, HTN; aunt- breast ca Physical Exam: Physical Exam: VS- P=93 BP= 103/70 R= 19 97% on 2l Gen- in NAD HEENT- EOMI, o/p clear CV- RR, no m/r/g Pulm- CTA=bil Abd- S/NT/ND Ext- W&D, 2+ radial/DP pulses Neuro- non-focal Pertinent Results: ECG: Sinus rhythm with ventricular premature depolarizations.",0
Selective coronary angiography revealed a codominant system.,0
The LMCA was angiographically normal.,0
The LAD had a proximal 95% thrombotic lesion with slow flow.,0
The LCX had a 80% lesion at the takeoff of a large OM1.,0
The small nondominant RCA was angiographically normal.,0
Hemodynamics post intervention showed elevated left sided filling pressure (PCWP mean 35 mm Hg with V waves to 46 mm Hg).,0
There was moderate pulmonary arteriolar hypertension (PASP 55 mm Hg) in the setting of an elevated PCWP.,1
The cardiac index was depressed at 1.9.,0
"Patient was hemodynamically stable throughout the procedure, but was hypoxic to an O2 sat of 84% on a nonrebreather.",0
He was given 40 mg IV lasix and started on IV nitroglycerine and his sat improved to 100% with a couple of deep breaths.,0
Successful placement of 3.0 x 18 mm Cypher drug-eluting stent postdilated with a 3.5 mm balloon in the proximal LAD for this acute ST elevation myocardial infarction.,1
"Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow .",0
No evidence of retroperitoneal hemorrhage.,0
"Patchy bilateral lower lobe opacities, worrisome for aspiration.",0
Atelectasis is a less likely possibility.,0
ECHO: EF 40% Conclusions: 1.,0
"Anterior, distal septal and apical hypokinesis to akinesis is present.",0
CXR PA&L: The heart is upper limits of normal in size.,0
There is upper zone vascular redistribution and worsening perihilar haziness.,0
"Additionally, there is an asymmetrical opacity at the right apex at the level of the first anterior right rib and right clavicle.",0
"On the lateral view, there is increased opacity overlying the lower thoracic spine, corresponding to the posterior basilar segments of the lower lobes.",0
"Additionally, the lungs appear overinflated with flattening of the hemidiaphragms.",0
"Widespread pulmonary ground glass opacities, scattered foci of consolidation and diffuse septal thickening.",0
These findings may represent pulmonary hemorrhage and/or pulmonary edema.,0
"Small pericardial effusion, slightly enlarged in comparison to the previous film.",0
Bilateral small nonobstructing renal stones .,0
"C. Cath: COMMENTS: 1.The lesion was predilated with a 2.5 X 12mm Voyager balloon, stented with a 3.5 X 18mm Cypher stent and post dilated with a 3.5 X 13mm High sail balloon with lesion reduction from 80% to 0%.",0
"The final angiogram showed TIMI III flow with no residual stenosis, no dissection and no embolisation.",0
The patient left the lab in a stable condition.,0
2. left ventriculogram was performed in projection with 36 ml of contrast at 12ml/sec.,0
"The entire anterior wall and the apex, except for a small area in the anterior basal segment was akinetic.",0
"Bivalirudin 45 mg bolus, 110 mg hr drip post cath .",0
Right bundle-branch block with left anterior fascicular block.,0
Q waves in the inferior leads with minimal ST segment elevation and terminal T wave inversion consistent with acute evolving myocardial infarction.,1
Diffuse non-specific ST-T wave changes.,0
Compared to the previous tracing of there is probably no significant change.,0
LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 04:45AM 36.7* 361 04:55AM 10.2 3.67* 11.9* 34.3* 93 32.4* 34.7 14.4 287 08:08PM 13.2* 36.7* 207 12:20PM 9.4 5.04 16.5 45.6 91 32.7* 36.1* 13.9 300 .,0
UreaN Creat Na K Cl HCO3 AnGap 04:45AM 21* 1.2 4.3 09:21PM 4.2 04:55AM 121* 25* 1.2 141 4.2 104 27 14 .,0
CE: CK(CPK) 12:45PM 362 04:45AM 348 09:21PM 189 08:50AM 355 06:40AM 507 04:58AM 1849 07:24PM 2437 04:00AM 4580 08:08PM 6445 12:20PM 135 .,0
CK-MB MB Indx cTropnT 12:45PM 21* 5.8 2.85* 04:45AM 24* 6.9* 09:21PM 7 08:50AM 4 5.59* 06:40AM 5 5.94* 04:58AM 21* 1.1 5.49* 07:24PM 57* 2.3 04:00AM 259* 5.7 14.32* 08:08PM 496* 7.7* 23.07* 12:20PM <0.01 .,0
Cholest Triglyc HDL CHOL/HD LDLcalc 04:00AM 121 901 40 3.0 63 .,0
Brief Hospital Course: Assessment/Plan: 53 year old male with p/w anterior wall STEMI s/p proximal LAD stent and L-Cx stent.,0
"CV - Ischemia - Pt p/w STEMI, found to have 90% LAD lesion and 80% occlusion of circumflex.",0
CE were cycled and peaked on day of admission with peak CK 6445 and Tn-T 23.07.,0
On day of admission underwent stenting of proximal LAD.,0
Pt was hypotensive post cath and required IABP for 24hrs.,0
"IABP weaned off, maintained own BP will low range 80s-90s SBP.",0
"He was not started on pressors, his SBP responded to IVF.",0
"He was started on ASA, Plavix, high dose statin immediately post cath.",0
He also underwent an Abdomen/Pelvic CT which ruled out an RP bleed.,0
His HCT had a small drop but did not require blood transfusions throughout his hospitalization.,0
"In setting of hypotension immediately following C. Cath, pt was not started on BB until .",0
He was started on a low dose 12.5mg and tolerated well with persistent SPB in 90s-low 100s.,0
"Pt underwent 2nd C. Cath on to revascularize Cx lesion without complications, he recieved Bivalirudin 45 mg bolus, 110 mg hr drip.",1
He did have elevated MBI post 2nd cath-periprocedure NSTEMI.,0
"He remained CP free since his first cath, his CE trended down and was discharge on ASA, Plavix, Statin, BB.",0
CV - Pump - Wedge of 30 in cath lab.,0
"Got lasix, and also ntg gttp, weaned off when arrived to CCU.",0
Low cardiac index of 1.9.,0
"He had no evidence of cardiogenic shock, perfusing well with good urine output.",0
"Hypotension most likely hypovolemia, no evidence of bleed.",1
Pt had Abdominal/Pelvic CT which ruled out an RP bleed.,0
IVF given with good response in BP.,0
ECHO with moderately depressed LVsys function.,0
EF of 40% with overall left ventricular systolic function is moderately depressed.,0
"He was started on Hep gtt for anticoagulation while awaiting 2nd cath, however hemoptysis hep gtt was turned off.",0
He was subsequently diuresed with low dose of lasix 10mg daily for pulm edema.,0
"He was maintained on 10mg lasix daily, however he was autodiuresing making ~1L UOP daily.",0
His lasix was d/c'd as BP was somewhat tenuous while optimizing cardiac meds.,0
"On 2nd cath ventriculography notable for entire anterior wall and the apex, except for a small area in the anterior basal segment was akinetic, with an EF of 30-35%.",0
He was started on Lovenox and transitioned to Coumadin.,0
He was not started on an ACE-I since his BP remained in the low 100s.,0
"He was scheduled to f/u with Dr. on Tuesday, to have INR drawn.",0
Will need to start ACE-I as outpatient.,0
CV - Rhythm - Pt remained in NSR throughout his hospital course.,0
Hemoptysis: Pt started to have hemoptysis on after having started hep gtt.,0
Hep gtt was turned off for hemoptysis.,0
High resolution Chest CT c/w dependent ground glass opacities most likely pulmonary edema vs. pulm hemorrhage.,0
He was diuresed w/low dose of lasix daily with improvement in O2 sats.,0
"He was r/o'd for TB with a negative PPD formally read on after 48hours, no sign of induration.",0
Induced sputum x3 was sent for AFB which were all negative.,0
Will need f/u Chest CT as outpatient.,0
Hyperglycemia: Pt had persistent hyperglycemia requiring Insulin.,0
"He had no known dx of DM, however, both are diabetics.",0
Formal consult was obtained for new diagnosis of DM and further management.,0
His Hgb AIC was 5.9%.,0
"He was sent home with a glucometer, started on glipizide and was set up with follow up with a Nurse educator as well as physician.",0
Hypothyroidism - continued on home dose of levoxyl.,0
Htn - on hyzaar as outpt.,0
"Had transient episode of hypotension following C. Cath, without evidence of cardiogenic shock or bleed.",1
Abd/Pelvic CT r/o'd RP bleed.,0
He remained normotensive following STEMI.,0
"Started low dose BB for cardioprotective effect, tolerated well, did not start ACE-I during hospitalization as BP remained low 100s.",0
CODE: FULL Medications on Admission: Medications (home): - lipitor 5 mg QD - levoxyl 100 mcg QD - hyzaar QD .,0
Allergies: - sulfa (rash as a child) - bee stings-->anaphylaxis Discharge Medications: 1.,0
Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Glucometer Elite Classic Kit Sig: One (1) Miscell.,0
Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).,0
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7.,0
Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 10 days.,0
Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Glipizide 5 mg Tablet Sig: 0.5 Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: STEMI CAD HTN DM-diagnosed during this admission Hypercholesterolemia Discharge Condition: Stable Discharge Instructions: Please take all your medications as directed and keep all your follow up appointments.,0
"If you have chest pain, shortness of breath, palpitations, are lighthead or have other worisome symptoms please call your physician and go to the emergency room.",0
"Please note you were started on the following medications: -Toprol XL 50mg daily, Aspirin 325mg daily, Plavix 75mg daily, Atorvastatin 80mg daily, Lovenox and Coumadin for your heart -Your were started on glipizide for your diabetes Followup Instructions: You have an appointment with Cardiologist, Dr. , next week: Provider: , .D.",1
You have an appointment at on with a Nurse Educator at 2pm and with Dr. at 10am on the same day at .,0
Please call if you have any questions prior to your appointment.,0
"You have a new PCP : Provider: , MD Phone: Date/Time: 2:00, you must call to register prior to your appointment to update your insurance information.",0
"Please have your blood drawn in the Center on the on Wednesday, .",0
"The lab is open from 7:30am-4pm, if you have questions you may call .",0
LINE PLACEMENT Clip # Reason: Evaluate PICC placement - Left Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man s/p trach and Dobhoff tube.,1
REASON FOR THIS EXAMINATION: Evaluate PICC placement - Left ______________________________________________________________________________ FINAL REPORT INDICATION: Left-sided PICC placement.,0
AP supine chest radiograph of is compared to the prior study of .,0
FINDINGS: This study is technically limited.,0
A left-sided PICC line is seen with its tip likely overlying the SVC.,0
"This finding is not definitive, and a repeat chest radiograph was advised.",0
"The heart size is enlarged, and there is mild congestive heart failure.",1
Left-sided PICC likely overlying the SVC.,0
A repeat chest radiograph was advised.,0
Mild cardiomegaly with mild CHF.,0
2:05 PM G/GJ TUBE CHECK PORT Clip # Reason: Eval for leak.,0
PLEASE BE SURE TO DO J STUDY BEFORE G STUDY.,0
"Admitting Diagnosis: INTRA CRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 25 year old woman with fever, apparaent leak around J tube.",0
REASON FOR THIS EXAMINATION: Eval for leak.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 25 year old woman with fever and apparent leak around J-tube site.,0
FINDINGS: Fluoroscopic imaging was obtained after injection of approximately 40 cc of Conray 60 into the patient's J tube and G-tube.,0
No extravasation of contrast was noted.,0
There are no dilated loops of small bowel.,0
Significant gastroesophageal reflux was noted on the exam.,0
Surgical clips are noted in the right upper abdominal region.,0
There are no obvious osseous abnormalities seen.,0
IMPRESSION: No extravasation of contrast from the patient's G-tube and J- tube.,0
"1:35 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: ?area of mesenteric ischemia Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIS STENOSIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with a past medical history significant for critical aortic stenosis, systolic congestive heart failure, and question of recent ischemic colitis (2 wks ago) who is being worked up for possible aortic valve repair.",1
REASON FOR THIS EXAMINATION: ?area of mesenteric ischemia No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 83-year-old female with past medical history significant for critical aortic stenosis and questionable ischemic colitis.,0
EXAMINATION: CTA of the abdomen and pelvis with and without intravenous contrast.,0
COMPARISONS: CT examination from .,0
TECHNIQUE: Helically-acquired axial images were obtained from the lung bases to the pubic symphysis initially without and subsequently after the uneventful administration of 130 cc of Optiray intravenous contrast.,0
Coronal and sagittal reformations are provided for review.,0
Images were obtained in arterial phase and portal venous phase imaging.,0
FINDINGS: CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: There are moderate bilateral simple layering pleural effusions.,0
The lung bases are otherwise clear with no pulmonary nodules or areas of focal parenchymal opacification.,0
Partially imaged is a pacing lead demonstrated within the right ventricle.,0
"The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys, and visualized portions of intra-abdominal small and large bowel are unremarkable.",0
There is no intra-abdominal free air or free fluid.,0
"CT OF THE PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid colon with an area of relative narrowing, and bladder are unremarkable.",0
"Incidentally noted are two heavily calcified pelvic masses, one demonstrated anterior to the bladder measuring 4.3 x 3.1 cm and the other demonstrated within the left adnexa measuring 2.5 x 2.0 cm.",0
CTA EXAMINATION: There is extensive atherosclerotic calcification demonstrated within the abdominal aorta and its major branches.,0
The SMA and celiac axis are widely patent at their origins.,0
Note is made of an accessory left hepatic artery.,0
"There is extensive atherosclerotic plaque at the origin (Over) 1:35 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: ?area of mesenteric ischemia Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIS STENOSIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) of the , though it is patent beyond this point.",1
The remainder of the hepatic vasculature is conventional.,0
Note is made of a heavily calcified rounded region within the expected region of the splenic artery measuring up to 4 mm.,0
"The main portal vein, splenic vein and SMV are patent.",0
BONE WINDOWS: The patient is status post left femoral fixation.,0
There are no suspicious lytic or sclerotic lesions identified.,0
"Patent abdominal vasculature with widely patent origins of the celiac axis, SMA and and no evidence of mesenteric ischemia.",0
No bowel wall thickening to indicate ischemic colitis.,0
"Heavily calcified masses within the pelvis, one anterior to the bladder and one within the left adnexa which show short-term interval stability since that are presumed to be related to adnexal structures such as a calcified ovary and intrapelvic fibroid, and though are of uncertain etiology, coarse calcifications indicate a benign origin.",0
Moderate bilateral simple layering pleural effusions.,0
Variant anatomy with an accessory left hepatic artery.,0
"4:08 PM ART DUP EXT LO UNI;F/U RIGHT Clip # Reason: eval for stenosis/dissection Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with VT s/p previous ablation now with ablation and arterial access accompanied by pain and resistence advancing wire REASON FOR THIS EXAMINATION: eval for stenosis/dissection ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old woman with an arterial right groin access, now with pain.",0
Evaluation for stenosis or dissection.,0
No studies available for comparison.,0
TECHNIQUE: Grayscale and Doppler ultrasound images of the right lower extremity arterial system were obtained.,0
"FINDINGS: Right common femoral artery, superficial femoral artery, popliteal artery, profunda artery, anterior tibial and posterior tibial artery demonstrate normal triphasic flow throughout.",0
IMPRESSION: Normal arterial waveforms throughout.,0
There is no evidence of pseudoaneurysm or AV fistula or dissection in the right lower extremity.,0
"9:06 AM CHEST (PORTABLE AP) Clip # Reason: R/O CHF, PNA ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with TACHYCARDIA POST SURGERY REASON FOR THIS EXAMINATION: R/O CHF, PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 36 y/o man with tachycardia.",0
Evaluate for heart failure or pneumonia.,0
FINDINGS: Comparison is made to a prior study dated .,0
"Given the supine nature of the film, the mediastinal and hilar contours are unremarkable.",0
There are low lung volumes present bilaterally.,0
There is atelectasis at the lung bases bilaterally.,0
There are no areas of focal infiltrates.,0
There is no evidence of heart failure.,0
Low lung volumes with bilateral atelectasis at the bases.,0
6:13 PM CT HEAD W/O CONTRAST Clip # Reason: 82 year old woman ?,0
"L parietal acute stroke, R SDH/SAH Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman ?",1
"acute stroke, R SDH/SAH REASON FOR THIS EXAMINATION: 82 year old woman ?",0
"L parietal acute stroke, R SDH/SAH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post acute stroke with right subdural and subarachnoid bleed.",1
TECHNIQUE: Routine noncontrast head CT.,0
FINDINGS: Examination is extremely limited secondary to patient motion.,0
There is an unchanged small subdural hematoma extending from the right parafalcine region along the superior falx and the mid-convexity.,0
"Additionally, there is a small amount of hyperdensity in the left parietooccipital region with a hyperdense calcified focus in this region as well.",0
There is a small amount of hematoma seen in the left lateral ventricle posteriorly.,0
There is no evidence of significant mass effect or midline shift.,0
The surrounding osseous and soft tissue structures are grossly unremarkable.,0
The visualized paranasal sinuses show mucosal thickening in the left ethmoid air cells.,0
"IMPRESSION: Examination extremely limited secondary to patient motion, however, identification of a right subdural hematoma as described as well as a focus of subarachnoid hemorrhage in the left parietooccipital region is seen.",1
No significant mass effect or midline shift.,0
No definite change from .,0
This examination should be repeated once the patient has stabilized.,0
"2:28 AM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields, r/o pneumothorax Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress REASON FOR THIS EXAMINATION: evaluate lung fields, r/o pneumothorax ______________________________________________________________________________ FINAL REPORT EXAMINATION: Portable chest, one view.",1
"COMPARISON: Comparison is made to prior examination dated , time 17:27.",0
"FINDINGS: Again noted is mild diffuse underlying hazy opacity with mildly prominent interstitium, which may represent mild hyaline membrane disease without significant interval change from prior examination.",0
Heart size and mediastinal contours are within normal limit.,0
The visualized osseous structures are normal.,0
"IMPRESSION: Stable chest study demonstrating mild diffuse hazy opacities, which may represent mild hyaline membrane disease.",0
5:50 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # Reason: extent of thymoma mets to abdomen.,0
"PLEASE USE PO AND IV cont Admitting Diagnosis: WEAKNESS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with myasthenia , malignant thymoma s/p thymectomy, chemo and radiation with known mets to left lung and below diaphragm REASON FOR THIS EXAMINATION: extent of thymoma mets to abdomen.",1
PLEASE USE PO AND IV contrast (per thoracic surgery reccs).,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Malignant thymoma, chemo and radiation with known mets to left lung and below diaphragm.",0
"COMPARISON: CT scan and MR abdomen, .",0
TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging of the abdomen and pelvis was reviewed.,0
"CT ABDOMEN WITH CONTRAST: Multiple pulmonary nodules are present in the visualized portions of the left lung, insignificantly changed from , .",0
Again seen are multiple large masses along the left chest wall that are not markedly different from .,0
"The largest such mass measures 8.4 x 3.3 cm, previously measuring 7.9 x 3.4 cm, perhaps slightly larger versus differences in slice selection.",0
There is no free air or fluid in the abdomen.,0
A small irregular hypodensity along the falciform ligament is likely focal fat.,0
No suspicious lesions are identified in the liver.,0
"The gallbladder, pancreas, spleen, and stomach is unremarkable.",0
"There is a single thickened jejunal loop (3:27) that is nonspecific, perhaps focal enteritis or less likely secondary to radiation.",0
The adrenal glands and kidneys are unremarkable.,0
Small stranding in the anterior subcutaneous tissues is secondary to injection sites.,1
"CT PELVIS WITH CONTRAST: The rectum, sigmoid, and large bowel are unremarkable.",0
The uterus and adnexa are remarkable for apparent thickening of the endometrium at 22mm though this may be secondary to contrast phase.,0
Distal ureters and bladder are normal.,0
No pathologic adenopathy is identified in the pelvis.,0
BONE WINDOWS: Patient is status post median sternotomy.,0
Multiple bone islands are identified.,0
No suspicious lesions are identified.,0
"No marked interval change in multiple large left anterior, lateral, and posterior chest wall masses and multiple pulmonary nodules.",0
Possible thickening of the endometrium at 22mm.,0
Ultrasound in 6 weeks is (Over) 5:50 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # Reason: extent of thymoma mets to abdomen.,0
PLEASE USE PO AND IV cont Admitting Diagnosis: WEAKNESS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) standard recommendation if clinically indicated.,0
Nonspecific single small bowel loop thickening.,0
"2:43 PM CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # Reason: acute process Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with hemoptysis, lung mass and sudden decrease in O2 sats REASON FOR THIS EXAMINATION: acute process ______________________________________________________________________________ FINAL REPORT CHEST, AP PORTABLE SINGLE VIEW INDICATION: Hemoptysis, lung mass, and sudden decrease in oxygen saturation.",1
FINDINGS: AP single view of the chest obtained with patient in sitting semi- upright position is analyzed in direct comparison with a preceding similar study obtained approximately 11 hours earlier during the same date.,0
Typical central pulmonary edema has developed during the interval.,0
"The previously described right lower lung field density, apparently the site of a mailgnant mass, appears unchanged.",0
Telephone report was rendered to referring physician.,0
8:39 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CEREBROVASCULAR ACCIDENT Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman preop for cranioplasty REASON FOR THIS EXAMINATION: acute CP process ______________________________________________________________________________ FINAL REPORT HISTORY: Preoperative radiograph.,0
"TECHNIQUE: Chest radiograph, two views.",0
FINDINGS: There is no pneumonia.,0
"There is no pleural effusion, or pneumothorax.",0
Cardiac silhouette is top normal in size.,0
Hilar and mediastinal silhouette within normal limits.,0
Height: (in) 63 Weight (lb): 195 BSA (m2): 1.91 m2 BP (mm Hg): 164/89 HR (bpm): 100 Status: Inpatient Date/Time: at 15:22 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,1
Aortic valve not well seen.,0
"No masses or vegetations on mitral valve, but cannot be fully excluded due to suboptimal image quality.",0
Mild (1+) MR. LV inflow uninterpretable due to tachycardia and/or fusion of spectral Doppler E and A waves TRICUSPID VALVE: Tricuspid valve not well visualized.,0
"No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality.",0
"If clinically indicated, a TEE is recommended.",0
"Compared with the prior study (images reviewed) of , there is no significant change.",0
"7:17 AM CHEST (PORTABLE AP) Clip # Reason: eval for hemothorax Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p cabg REASON FOR THIS EXAMINATION: eval for hemothorax ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG, evaluate for hemothorax.",1
FRONTAL CHEST RADIOGRAPH Again seen is a right internal jugular central venous catheter sheath and mediastinal drain.,0
There are small bilateral pleural effusions and linear lingular atelectasis.,0
There is no significant change.,0
"1:55 PM UNILAT LOWER EXT VEINS LEFT Clip # Reason: r/o dvt Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with LLE swelling, pain and hx metastatic CA REASON FOR THIS EXAMINATION: r/o dvt ______________________________________________________________________________ FINAL REPORT INDICATION: Lower extremity swelling.",1
"Grayscale and Doppler son of the left common femoral, superficial femoral and popliteal veins were performed.",0
"Normal flow, augmentation, compressibility and wave forms are demonstrated.",0
Intraluminal thrombus is not identified.,0
", MED 8:43 PM CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # CT PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Reason: please eval for evidence of SBO with ORAL CONTRAST ONLY, NO Admitting Diagnosis: SEPTIC SHOCK ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with CAD, presented to OSH with possible cholecystitis and septic shock.",1
POD #2 s/p lap chole.,0
"Transferred from OSH overnight to for ERCP, no evidence of cholangitis.",0
"CT torso this morning showed possible SBO REASON FOR THIS EXAMINATION: please eval for evidence of SBO with ORAL CONTRAST ONLY, NO IV CONTRAST CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ PFI REPORT 1.",0
"Dilated loops of small bowel measuring up to 3.6 cm, with slight decompression since the examination performed eight hours prior, with more distal decompressed cecum, ascending, transverse and descending colon and small bowel that is most compatible with early small bowel obstruction, though focal ileus also remains a possibility.",0
Oral contrast has only reached to the point of proximal to mid jejunum with no discrete transition point identified as of yet.,0
"No associated bowel wall thickening, pneumatosis, or intra-abdominal ascites.",0
"To further delineate transition point, a repeat examination can be performed, or serial radiographs can be obtained.",0
"There is a sharp area of margination of the bowel, best seen on (2:55), though the bowel distal to this point is not entirely decompressed and no fecalization is seen preceding this point.",0
"Bilateral simple pleural effusions stable since recent examination, left lower lobe collapse with superimposed underlying aspiration/infection.",1
"3:08 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for pneumothorax s/p chest tube removal Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE / ASCENDING AORTA REPLACEMENT CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman s/p AVR, CABG REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY DATED Compared to previous study of earlier the same date.",1
"FINDINGS: Following removal of bilateral chest tubes and mediastinal drains, there is no visible pneumothorax.",0
There has otherwise been little change in the appearance of the chest except for improving atelectasis at the right base.,0
3:43 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: eval swallow Admitting Diagnosis: MYASTHENIA ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman with myasthenia .,0
REASON FOR THIS EXAMINATION: eval swallow ______________________________________________________________________________ FINAL REPORT INDICATION: 36 year old woman with myasthenia .,0
VIDEO OROPHARYNGEAL SWALLOW: This examination was performed in conjunction with a speech therapist.,0
"Barium was administered to the patient in multiple consistencies, including thin, thick, barium-soaked cookie, pudding, bagel and tablet.",0
There was premature spillover of the liquid consistencies into the valleculae and piriform sinuses.,0
The spillover into the piriform sinuses was not eliminated with a chin tuck.,0
"There was no penetration or aspiration, however.",0
There was minimal residue in the valleculae and piriform sinuses.,0
"The patient was able to swallow the barium tablet, which was held up mom at the level of the aortic arch.",0
The barium tablet easily passed into the stomach with the administration of pudding.,0
IMPRESSION: No evidence of aspiration.,0
The patient swallowed each of the consistencies without difficulty.,0
The barium tablet passed into the stomach with administration of pudding.,0
"10:59 AM CHEST (PA & LAT) Clip # Reason: s/p CABG w/chest tube-r/o PTX Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with REASON FOR THIS EXAMINATION: s/p CABG w/chest tube-r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG, rule out pneumothorax.",1
PA AND LATERAL CHEST RADIOGRAPH: A left-sided chest tube is seen in unchanged position.,0
Note is made of bibasilar atelectasis.,0
Again note is made of a possible metallic foreign body overlying the cardiac silhouette and located posteriorly on the lateral chest radiograph overlying one of the lower thoracic vertebrae.,0
"4, Please correlate for posterior metallic foreign body overlying cardiac silhouette.",0
Height: (in) 64 Weight (lb): 91 BSA (m2): 1.40 m2 BP (mm Hg): 132/58 HR (bpm): 102 Status: Inpatient Date/Time: at 14:07 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
GENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of agitated normal saline at rest.,0
No atrial septal defect is seen by 2D or color Doppler or saline injection at rest (patient unable to cooperate with maneuvers).,0
IMPRESSION: Moderate global left ventricular hypokinesis.,0
No definite cardiac source of embolism identified.,0
"If clinically indicated, a TEE may be better able to identify a potential cardiac source of embolism.",0
"7:08 AM CHEST (PORTABLE AP) Clip # Reason: s/p ct removal Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with s/p cabg POD 1 REASON FOR THIS EXAMINATION: s/p ct removal ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient after CABG, one day after surgery after chest tube removal.",0
Portable AP chest radiograph was compared to obtained at 2:37 p.m.,0
The Swan-Ganz catheter tip is at the level of the right ventricle outflow tract.,0
After removal of the left chest tube there is questionable minimal apical pneumothorax although it may represent calcification within the subclavian artery and should be followed.,0
The bibasilar retrocardiac opacities are unchanged consistent with atelectasis.,0
No large amount of pleural effusion is present but small pleural effusion in both pleural spaces cannot be excluded.,0
12:21 PM CAROTID SERIES COMPLETE Clip # Reason: PREOP Admitting Diagnosis: AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with aortic stenosis and possible carotid stenosis.,0
REASON FOR THIS EXAMINATION: Please evaluate for carotid stenosis.,0
______________________________________________________________________________ FINAL REPORT INDICATIONS: Patient is an 84-year-old female with aortic stenosis and possible carotid stenosis.,0
Please rule out significant carotid disease.,0
FINDINGS: RIGHT: B-mode images demonstrate mild calcific plaque in the right carotid bifurcation.,0
The right common carotid artery waveform is within normal limits and has a peak systolic velocity of 69 cm/sec.,0
The internal velocities are 72/19.,0
The external velocity is 86.,0
The ICA/CCA ratio is 1.0.,0
"By velocity criteria, this would correlate with a 1-39% stenosis.",0
LEFT: B-mode images on the left demonstrate mild luminal plaque.,0
The common carotid artery waveform is within normal limits and has a peak velocity of 73 cm/sec.,0
The internal velocities are 91/23.,0
The ICA/CCA ratio is 1.2.,0
"By velocity criteria, this would correlate with a 1-39% ICA stenosis.",0
"Both vertebral arteries have antegrade, monophasic flow.",0
IMPRESSION: Bilateral 1-39% ICA stenosis with mild calcific plaque.,0
"11:44 AM CT ABD W&W/O C Clip # Reason: Please evaluate for continued pseudocyst hemorrhage or other Admitting Diagnosis: PANCREATITIS, BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 60M with recent pancreatitis and RLL PE, now with hemorrhagic pancreatic pseudocyst on CT s/p IVC filter placement and now with persistent abdominal pain REASON FOR THIS EXAMINATION: Please evaluate for continued pseudocyst hemorrhage or other intra-abdominal pathology that may account for continued abdominal pain, low Hct, and elevated WBC count.",1
"Please perform with both IV and PO contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Recent pancreatitis and right lower lobe PE, now with hemorrhagic pancreatic pseudocyst on CT of , status post IVC filter placement and with persistent abdominal pain.",1
Please evaluate for continued pseudocyst hemorrhage or other intra-abdominal pathology.,0
"TECHNIQUE: Helically acquired axial MDCT images were obtained through the abdomen without intravenous contrast and were followed by helically acquired MDCT images through the abdomen after the intravenous administration of contrast in a split bolus, dual-energy technique.",0
CONTRAST: Oral and intravenous nonionic contrast.,0
"CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Imaged portion of lung bases are notable for small bilateral pleural effusions, slightly increased on the right compared to , and mild adjacent bibasilar atelectasis.",0
The imaged portion of heart and pericardium appear unremarkable.,0
A complex network of peripancreatic pseudocysts is again seen.,0
"A bilobed collection adjacent to the pancreatic body which measures 5.4 x 10.4 cm (4:57), is not significantly changed.",0
"A collection along the greater curvature of the stomach and pancreatic tail which measures 5.1 x 9.4 cm (4:59), is slightly increased having measured previously 4.1 x 7.9 cm.",0
"A larger collection which extends inferiorly along the anterior pararenal fascia and measures 15.9 x 7.4 x at least 16.2 cm, previously measured 11.2 x 5.0 x 12.6 cm, having increased in size in the interval.",0
This shows continued hyperdensity on pre-contrast images consistent with hemorrhage.,0
"Although markedly compressed by the numerous pseudocysts, there is diffuse enhancement of the pancreatic parenchyma without definite areas of focal necrosis appreciated.",0
A rounded enhancing structure adjacent to the pancreatic tail (4:67) most likely represents a splenule.,0
There is no evidence of aneurysm or thrombosis of peripancreatic vessels.,1
"The splenic vein is narrowed focally (4:69), but remains patent.",0
The superior mesenteric and portal veins are patent.,0
There is no biliary dilation and the gallbladder is nondistended.,0
"Bilateral adrenal glands appear unremarkable although the left adrenal gland (Over) 11:44 AM CT ABD W&W/O C Clip # Reason: Please evaluate for continued pseudocyst hemorrhage or other Admitting Diagnosis: PANCREATITIS, BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) is slightly displaced by a pseudocyst collection.",1
There is a small amount of perihepatic ascites.,0
Small amount of free fluid surrounds the spleen.,0
Mild pelvic caliectasis is present on the left.,0
Right kidney shows no evidence of hydronephrosis.,0
"An IVC filter is in place and due to the phase of contrast administration, assessment for thrombus within the IVC is limited.",0
The descending and transverse colon show wall thickening consistent with colitis and likely reactive.,0
The focus of active extravasation of contrast which was seen previously on the second scan of is not clearly visualized.,0
Stranding in the subcutaneous tissues of the left flank is again noted.,0
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are identified.,0
"Increase in size of a component of a complex pseudocyst, with increased internal density, findings that are consistent with continued interval hemorrhage within a pseudocyst.",0
"However, the previously demonstrated active extravasation is no longer visualized.",0
"This finding discussed with Dr. on via telephone at the time of dictation, approximately 4:30 PM.",0
Findings consistent with post-pancreatitis change including multiple peripancreatic pseudocysts.,1
No evidence of definitive pancreatic necrosis.,0
"Findings consistent with colitis, likely reactive.",0
Phase of contrast administration limits assessment for patency of the IVC.,0
"Bilateral pleural effusions, slightly increased on the right.",0
"11:57 AM CT C-SPINE W/O CONTRAST Clip # Reason: IPH- fall, ?",0
"FX ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with REASON FOR THIS EXAMINATION: IPH- fall, ?",0
FX No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT OF THE CERVICAL SPINE INDICATION: 78-year-old male with intraparenchymal hemorrhage status post fall.,0
TECHNIQUE: Axial non-contrast scanning was performed through the cervical spine.,0
FINDINGS: There is no fracture or alignment abnormality within the cervical spine.,0
"Linear hypodensity within the cortex of the uncovertebral joint at C2/3 likely representing a vascular groove, with well-corticated margins.",0
"There is moderate multilevel spondylotic change, worst at C5/6, where there is moderate narrowing of the spinal canal.",0
Please note that CT cannot provide intrathecal detail comparable to MRI.,0
IMPRESSION: No fracture or alignment abnormality within the cervical spine.,0
6:45 PM CHEST (PORTABLE AP) Clip # Reason: eval for chf ______________________________________________________________________________ MEDICAL CONDITION: 87yo M with SOB REASON FOR THIS EXAMINATION: eval for chf ______________________________________________________________________________ FINAL REPORT STUDY: Chest x-ray portable AP.,0
INDICATION: 87-year-old male with shortness of breath.,0
FINDINGS: Film detail is limited secondary to patient motion.,0
A biventricular pacemaker/AICD with leads within the coronary sinus and right ventricle is unchanged in position compared to the previous examination.,0
Evidence of prior median sternotomy for CABG is again noted.,0
The heart is markedly enlarged which does not appear to be significantly changed compared to the previous examination.,0
There is minimal bilateral pulmonary edema with associated small-to-moderate pleural effusions.,0
Increased opacity is again noted over the lingular segment of the left lung which obscures the left heart border.,0
IMPRESSION: Examination very limited secondary to patient motion.,0
Mild pulmonary edema with associated pleural effusions is likely present and reflective of congestive heart failure.,1
Unchanged appearance of opacity within the lingula.,0
Repeat radiography may be helpful.,0
12:54 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/effusion/tamponade.,0
"pt still in OR, please perform Admitting Diagnosis: ACUTE CORONARY SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with CP, increased O2 requirement, and CAD s/p off pump CABG.",0
REASON FOR THIS EXAMINATION: r/o PTX/effusion/tamponade.,0
"pt still in OR, please perform CXR when pt arrives CSRU.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Increased 02 requirement.,0
The patient is status post CABG with multiple sternal wires noted.,0
"ET tube, NG tube, left IJ swan ganz catheter, mediastinal drain, left and right chest tubes are noted to be in satisfactory position.",0
There is patchy atelectasis noted at the right and left mid lung zone.,0
Also noted is left lower lobe collapse/consolidation associated with a small left pleural effusion.,0
\ IMPRESSION: Postsurgical changes compatible with patient's recent CABG.,0
"6:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: placement of NG tube Admitting Diagnosis: FALL/PELVIC FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with hypothermia, somnolence persistent bacteremia.",1
"REASON FOR THIS EXAMINATION: placement of NG tube ______________________________________________________________________________ FINAL REPORT INDICATION: 83-year-old woman with hypothermia, somnolence, bacteremia.",0
Please assess position of nasogastric tube.,0
PORTABLE CHEST: Examination is compared to the prior from three hours earlier.,0
"There has been interval placement of a nasoenteric tube, which terminates at least one hand width below the diaphragm, however, the tip is not seen on this chest film.",0
The cardiomediastinal silhouette is stable given the change in positioning.,0
"Again seen is pulmonary fibrosis, most pronounced on the right and the perihilar region.",0
There is likely superimposed pulmonary vascular engorgement.,0
There is obscuration of the right hemidiaphragm suggesting pleural effusion.,0
"The trachea shows marked deviation to the right, which is stable.",0
IMPRESSION: Fibrosis with possible superimposed vascular engorgement.,0
"Nasogastric tube terminates below the diaphragm, however, the tip is not imaged on this chest film.",0
5:51 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: tamponade Admitting Diagnosis: CORONARY ARTERY DISEASE\OFF PUMP CORONARY ARTERY BYPASS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man s/p OPCABG REASON FOR THIS EXAMINATION: tamponade ______________________________________________________________________________ WET READ: FRI 7:02 PM Repeated CXR.,1
ETT terminates 7.6 cm above the carina.,0
Swan-Ganz tip in the main pulmonary artery.,0
Persistent left lower lung opacity.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, CLINICAL INFORMATION: Tamponade.",0
FINDINGS: Portable chest radiograph is compared to prior study of the same date from 17:31 hours.,0
A Swan-Ganz catheter is in place.,0
There is continued left lower lobe consolidation and a small left-sided pleural effusion.,0
There is no congestive failure.,0
ET tube terminates at the thoracic inlet.,0
"Nasogastric tube courses below the diaphragm, but the tip is not well seen.",0
It is unclear as to whether the nasogastric tube is looped within the esophagus.,0
A repeat radiograph centered on the abdomen would be helpful.,0
1:21 PM CHEST (PORTABLE AP) Clip # Reason: please eval for consolidation / effusions Admitting Diagnosis: THIGH HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with fever post-op REASON FOR THIS EXAMINATION: please eval for consolidation / effusions ______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative fever.,0
"FINDINGS: In comparison with the study of , there is again no evidence of pneumonia.",0
Elevation of the right hemidiaphragm is stable.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Medical Intensive Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 76 year old man with a history of chronic obstructive pulmonary disease, coronary artery disease, status post four vessel coronary artery bypass graft, mitral valve replacement, left ventricle pseudoaneurysm with thrombus who was admitted to the Medical Intensive Care Unit with respiratory distress and hypercarbic respiratory failure.",1
Four days prior to admission the patient began to have progressively worsening shortness of breath with increasing oxygen requirement and orthopnea.,0
The patient went to the Emergency Room where he was found to be afebrile and had diffuse wheezes.,0
He was admitted to the hospital with a presumptive diagnosis of chronic obstructive pulmonary disease exacerbation.,1
"On the medical floor he was treated with Solu-Medrol 60 mg intravenously for five doses and Albuterol, Atrovent nebulizers without significant improvement for two days.",0
"His oxygen saturation was decreased to 86% with exertion, so he was started on empiric Levofloxacin given his slow improvement.",0
"On the morning of , the patient began to have chest pain and shortness of breath.",0
"The chest pain was 4 out of 10, typical for his angina and had desaturations into the 70s on 2 liters by nasal cannula, increased to 6 liters, improved to 84% oxygen saturation and 90% on 100% nonrebreather.",0
An electrocardiogram showed questionable MATs with heart rate in the 120s and possible ST depressions in V3.,0
He received sublingual nitroglycerin with resolution of chest pain.,0
Chest x-ray was obtained that showed a right lower lobe consolidation that was initially thought to be fluid overload.,0
He was subsequently given a total of 160 mg of intravenous Lasix but continued to desaturate with fluctuating oxygen requirement and arterial blood gases.,0
"Arterial blood gases was obtained with values of pH 7.33, pCO2 57 and pO2 of 64 on 6 liters by nasal cannula.",0
He was then transferred to the Medical Intensive Care Unit for further management of his respiratory failure.,1
"Coronary artery disease, status post four vessel coronary artery bypass graft, porcine mitral valve replacement in , complicated by mediastinitis.",0
"Left ventricular pseudoaneurysm with thrombus diagnosed by transesophageal echocardiogram, .",0
"Chronic obstructive pulmonary disease on home oxygen at 2 liters, baseline carbon dioxide in the 48 to 52 range.",1
"Multiple hospital admissions, last in .",0
"Pulmonary function tests in revealed an FVC of 1.84 (41 percent), FEV1 0.94 (32 percent), FEV/FVC 51 (77%).",0
"Bilateral carotid stenosis, status post stent placement in the left carotid in .",0
"Gastrointestinal bleed in , large lower gastrointestinal bleed with angiectasias in the cecum, also found to have internal hemorrhoids and diverticuli.",0
"Esophagogastroduodenoscopy showing hiatal hernia and gastritis, the patient has had multiple bleeds on Plavix in and resulting in melena.",0
"Chronic renal insufficiency, baseline creatinine 1.3 to 1.5.",0
Status post polypectomy and cholecystectomy.,0
"ALLERGIES: Penicillin, Ancef, Vancomycin, question of anaphylaxis, Procainamide.",0
MEDICATIONS ON TRANSFER: Levofloxacin 250 mg p.o.,0
"day #2, Prednisone 60 mg q.d., Lasix 40 mg q.d., Albuterol, Atrovent nebulizers q.",0
"6 hours, subcutaneous heparin, Protonix 40 mg q.d., Fluticasone 110 mcg 2 puffs b.i.d., Salmeterol 50 mcg b.i.d.",0
"SOCIAL HISTORY: The patient lives with his wife, remote smoking history, 40 pack years and no alcohol use.",0
He is a retired firefighter with possible asbestos exposure in the past.,0
"PHYSICAL EXAMINATION: On transfer to medicine Intensive Care Unit - Temperature 98.1, blood pressure 144/75, heart rate 87, respiratory rate 20 to 30.",1
Oxygen saturation 92% on 50% facemask.,0
"Head, eyes, ears, nose and throat showed equal pupils, round and reactive to light.",0
Neck was supple with no jugulovenous distension.,0
Jugulovenous pressure was approximately 6 cm.,0
The patient was tachycardiac with a III/VI holosystolic murmur heard at the left upper sternal border radiating to the axilla.,0
Lungs had diffuse expiratory wheezes with decreased air movement.,0
"Abdomen was soft, normal bowel sounds, well healed scar.",0
"Extremities had 2+ pitting edema, left greater than right, but were warm with strong pulses.",0
"Neurologically, he was oriented to self and date.",0
He was minimally cooperative with the examination but was able to follow simple commands.,0
"LABORATORY DATA: Pertinent laboratory values on transfer to the Medicine Intensive Care Unit showed laboratory data notable for a white count of 23.1 and arterial blood gases with a pH of 7.31, pCO2 59, pO2 of 62 on 10 liters, saturating 93%.",0
"Pertinent imaging - Chest x-ray showed bilateral pleural effusions, left greater than right, hyperinflation with cardiomegaly and pleural thickening with a possible left lower lobe consolidation with no evidence of pulmonary edema.",0
"An electrocardiogram showed inconsistent P wave morphology with right bundle branch block, depression in V3 and minimal T wave inversion in V1 and V2.",0
HOSPITAL COURSE: (In the medical Intensive Care Unit by issue) 1.,0
"Respiratory failure - On arrival in the Medicine Intensive Care Unit, the patient was placed on BiPAP and continued to have relatively good arterial blood gases.",1
The patient continued to improve and was on antibiotics and continued steroid treatment and was returned to the Medical Floor on .,0
Later that night the patient began to desaturate again on the medical floor to the 90s.,0
"A blood gas was drawn that showed a pH of 7.25, pCO2 of 76 and pO2 of 90.",0
The patient appeared to be tiring and was intubated.,0
An earlier sputum culture grew out Methicillin-resistant Staphylococcus aureus and the patient was started on Linezolid due to his Vancomycin allergy.,1
He continued to improve and was extubated on .,0
He remained on BiPAP for a short period of time and was soon transitioned oxygen by facemask and subsequently nasal cannula.,0
The patient was initially on intravenous steroids for chronic obstructive pulmonary disease exacerbation which was changed to Prednisone and slowly tapered over his hospital course.,1
Atrial fibrillation/atrial flutter - The patient had brief episodes of atrial fibrillation upon arrival into the Medical Intensive Care Unit with pressure drops to systolics of 80s.,0
The rate was controlled with a Diltiazem drip at this time.,0
"Upon returning to the floor on , he again went into atrial fibrillation with difficulty in controlling his rate despite being on the Diltiazem drip.",0
He became hypotensive and was transferred back to the Medicine Intensive Care Unit.,0
He continued to have a high heart rate in the 140s with hypertension.,0
Electrophysiology was consulted and it was decided that the patient should be cardioverted.,0
"He was placed on Amiodarone and remained in normal sinus rhythm until , when he was transferred back to the Medical Floor.",0
Shortly thereafter the patient again went into atrial fibrillation with heart rate in the 140s and systolics in the 70s.,0
Cardiology was again consulted and it was decided to transfer the patient back to the Medicine Intensive Care Unit for possible cardioversion.,0
"Upon arrival in the Medicine Intensive Care Unit the patient's blood pressure had improved and he was placed on a Diltiazem drip, but again became hypotensive, so the Diltiazem drip was discontinued.",0
The patient was then placed on Digoxin the following day when electrophysiology was consulted.,0
"The patient was cardioverted, remained on Amiodarone and Digoxin.",0
Following this he remained in normal sinus rhythm until he was transferred back to the Medical Floor.,0
"Thrombocytopenia - The patient's platelets continued to dwindle down to a level of 53,000.",0
Proton pump inhibitor was held briefly.,0
The patient developed melena so it was restarted.,0
Hematology was consulted and thought that the Linezolid might be the leading candidate for thrombocytopenia.,0
Since the patient had finished a ten day course of Linezolid the antibiotic was discontinued.,0
Gastrointestinal bleed/anemia - The patient had multiple episodes of melena with guaiac positive stools and received multiple transfusions with a goal of hematocrit above 30%.,0
The patient remained on his home regimen of Nexium.,0
Gastroenterology was initially consulted and deferred doing an esophagogastroduodenoscopy unless the patient began to have a brisker bleed.,0
By the end of the Medicine Intensive Care Unit stay the hematocrit was remaining stable.,0
Chronic obstructive pulmonary disease - The patient received frequent Albuterol/Atrovent nebulizers and was treated with steroids initially intravenous that was changed to Prednisone and tapered.,1
Left superficial femoral vein thrombosis - The patient had very edematous lower extremities.,0
Ultrasound was obtained which showed a new left superficial femoral vein thrombosis.,0
"Although the patient had three indications for anticoagulation with atrial fibrillation, thrombosis in the left ventricle thrombus, the patient could not be anticoagulated prior and continued with gastrointestinal bleed.",0
"On , an inferior vena cava filter was placed by Dr. , left ventricular pseudoaneurysm.",0
Thoracic surgery and Dr. followed the patient while in the Medicine Intensive Care Unit.,0
Repair of mitral valve leak and pseudoaneurysm was deferred until after recovery from current illness.,0
"For the remainder of this discharge summary, please see the addendum on , dictated by .",0
Dictated By: MEDQUIST36 D: 19:58 T: 20:18 JOB#:,0
"6:01 PM CT HEAD W/O CONTRAST Clip # Reason: eval for interval change-bleed/shift Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with diffuse large B cell lymphoma with CNS involvement, s/p Cycle 1 methotrexate (today) newly hypertensive, bradycardic and complains of ha/blurry vision REASON FOR THIS EXAMINATION: eval for interval change-bleed/shift No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SUN 8:20 PM No change when compared to prior exam.",0
3 mm leftward shift of midline structures is slightly decreased when compared to prior exam.,0
"Multiple hyperdense lesions, stable in appearance.",0
______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT CONTRAST.,0
HISTORY: 74-year-old male with CNS involvement of large B-cell lymphoma.,0
"Complaining of headache and blurry vision, evaluate for interval change or bleed.",0
"FINDINGS: There is a 2.5 x 2.4 cm hyperattenuating lesion in the right thalamic/internal capsule region, unchanged in size.",0
"There is a 3-mm shift of normally midline structures toward the left, decreased when compared to prior exam.",0
The amount of surrounding edema adjacent to this lesion is unchanged.,0
"Hyperdense lesions in the medial right frontal lobe, right temporal lobe and left cerebellum are stable in appearance.",0
Patient is status post right frontal craniotomy.,0
There is no evidence of extra-axial hemorrhage.,0
"IMPRESSION: Hyperdense and hemorrhagic right thalamic lesion, unchanged.",0
Minimally decreased leftward shift of normally midline structures as described above.,0
12:37 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: eval for fluid collection.,0
"PO & IV contrast Admitting Diagnosis: SEPSIS Field of view: 50 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 55F s/p ex lap, multiple washouts, now w/ hct drop today REASON FOR THIS EXAMINATION: eval for fluid collection.",0
PO & IV contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 55-year-old female status post surgery for acute perforated diverticulitis status post multiple washouts.,1
Today the patient had a hematocrit drop.,0
Rule out intracranial hemorrhage or abscess.,1
150 cc of Optiray 250 were used.,0
Nonionic IV contrast was used due to the patient's clinical condition.,0
CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There is no pericardial effusion.,0
The visualized portions of the heart are unremarkable.,0
There are bilateral small pleural effusions with associated atelectasis.,0
There is interval increase in patchy opacities in the left lung base which could represent atelectasis versus aspiration.,0
The study is slightly limited due to the presence of artifact coming from the arms since the patient could not elevate them.,0
There is an NG tube with the tip in the duodenum (third portion).,0
There is again noted nonocclusive thrombus in the main portal vein and left portal vein which appears to be unchanged when compared to the prior study.,0
The pancreas and kidneys are unremarkable.,0
The patient's abdomen is open with multiple drains placed superficially.,0
There is diffuse mesenteric stranding due to surgical manipulation.,0
The patient is status post Hartmann procedure and colostomy in the left lower quadrant.,0
The gallbladder is unremarkable and not distended.,0
There is no free fluid in the abdomen.,0
There are no fluid collections in the abdomen.,0
"CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There is still oral contrast in the Hartmann's pouch, probably from the prior study.",0
There is no free fluid or free air in the pelvis.,0
There is a right common femoral central line with the tip in the right external iliac vein.,0
No obvious fluid collections are seen in the abdomen or in the pelvis.,0
BONE WINDOWS: The bone structures are stable when compared to the prior study.,0
There is scoliosis of the thoracolumbar spine.,0
IMPRESSION: (Over) 12:37 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: eval for fluid collection.,0
PO & IV contrast Admitting Diagnosis: SEPSIS Field of view: 50 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,0
There is no evidence of intraabdominal hemorrhage.,0
Stable appearance of thrombus in the portal veins.,0
MR : (in) 67 Weight (lb): 162 BSA (m2): 1.85 m2 BP (mm Hg): 154/74 HR (bpm): 107 Status: Inpatient Date/Time: at 14:06 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Normal aortic valve leaflets (3).,0
GENERAL COMMENTS: Suboptimal image quality - patient unable to cooperate.,0
There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%).,0
IMPRESSION: Mild LVH with mild to moderate global systolic dysfunction.,0
Mild right ventricular systolic function.,0
"Compared with the prior study (images reviewed) of , right ventricle is larger and pulmonary pressures are higher.",0
"5:03 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with aspiration pneumonitis REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH FINDINGS: As compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed.",1
"The widespread bilateral parenchymal opacities, right more than left, the moderate cardiomegaly and the bilateral areas of atelectasis at the lung bases are unchanged.",0
No newly appeared parenchymal changes.,0
12:22 AM MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: ?,0
met Contrast: MAGNEVIST Amt: 10CC ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Left temporal/occipital bleed.,0
"TECHNIQUE: Multiplanar T1, T2, susceptibility, FLAIR, and diffusion weighted images were obtained through the brain.",0
T1 weighted images were obtained after administration of 10 cc of gadolinium.,0
3D time of flight MRA of the circle of was performed with multiplanar reformations.,0
COMPARISONS: CT of the brain from .,0
"MR BRAIN WITH AND W/O CONTRAST: There is a region of susceptibility defect in the left parieto-occipital region, which corresponds to the previously identified hemorrhage.",0
This area is somewhat heterogeneous on multiple images.,0
The images are degraded by patient motion.,0
There is edema surrounding the area of hemorrhage.,0
There is no significant mass effect or shift of normally midline structures.,0
There is no evidence for an acute infarct on the diffusion weighted images.,0
No enhancing lesions are identified after administration of gadolinium.,0
CIRCLE OF MRA: There is imaging just to the cephalad level of the hemorrhage.,0
The major tributaries of the circle of are patent.,0
There is no area of significant stenosis or aneurysmal dilatation.,0
"There is no evidence for an arteriovenous malformation, given the limits of coverage of this study.",0
IMPRESSION: 1) The area of hemorrhage in the left parieto-occiptal region is again identified.,0
2) No findings to suggest metastatic disease.,0
3) Normal circle of MRA.,0
9:46 AM CT HEAD W/O CONTRAST Clip # Reason: post op SDH evacuation Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with crani for SDH evacuation must eval REASON FOR THIS EXAMINATION: post op SDH evacuation No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old female status post craniotomy for evacuation of subdural hemorrhage.,1
COMPARISON: NECTs on and .,0
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast.,0
"FINDINGS: Again are seen post-craniotomy changes in the left frontoparietal bones, with skin staples and a drain placed in the subdural space of the left frontoparietal convexity.",0
There is persistence of locules of gas and scattered areas of blood products which appear similar in extent to the prior exam.,0
There is a 6.3 mm left to right shift in the midline structures which is not significantly changed compared with prior exam.,0
There continues to be sulcal and left lateral ventricle effacement in the left.,0
There is no evidence of ventricular entrapment.,0
"IMPRESSION: Post-surgical changes along the left convexity with small amount of blood products and pneumocephalus, similar to prior study.",0
"6:59 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please eval lung fields Admitting Diagnosis: HYPERGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with shock REASON FOR THIS EXAMINATION: please eval lung fields ______________________________________________________________________________ WET READ: DMFj TUE 9:59 PM ETT, RIJ and NG lines/tubes in good position.",0
Low lung volumes with bibasilar atelectasis.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Shock.,0
"FINDINGS: In comparison with the earlier study of this date, the endotracheal tube, nasogastric tube and right IJ catheters remain in position.",0
No evidence of acute focal pneumonia or vascular congestion.,1
LINE PLACEMENT Clip # Reason: 53 cm picc tip with 17 out Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with hydration needs REASON FOR THIS EXAMINATION: 53 cm picc tip with 17 out ______________________________________________________________________________ WET READ: 9:11 PM left PICC tip in left subclavian.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 8:52 P.M., HISTORY: New PICC line.",0
"IMPRESSION: AP chest compared to : Left PIC line ends at the underside of the left clavicle, outside the chest.",0
"ET tube is in standard placement, nasogastric tube passes below the diaphragm and out of view and a shunt catheter which traverses the right neck, chest and upper abdomen.",0
"Mild pulmonary vascular engorgement persists, but there is no longer pulmonary edema.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Hip trauma Major Surgical or Invasive Procedure: None History of Present Illness: 49 year old female patient status post hitting a tree while riding a horse, transfer from outside hospital with comminuted fracture of right illiac crest.",0
"Past Medical History: Intersticial Cystitis Social History: Non contributory Family History: Non Contributory Physical Exam: Alert, oriented x3, non appereant distress.",0
"Resp: clear to auscultation bilateral CV: regular rate and rythm Abdomen: soft, non tender, non distended.",0
"Rectal exam good tone, guiac negative Right Pelvis with large non expandind hematoma/ecchymosis Extrem: no deformities, no edema Pertinent Results: 09:00PM GLUCOSE-118* UREA N-11 CREAT-0.7 SODIUM-139 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13 09:00PM CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-1.5* 09:00PM WBC-10.5 RBC-3.92* HGB-12.9 HCT-36.8 MCV-94 MCH-32.9* MCHC-35.1* RDW-13.6 09:00PM NEUTS-82.9* BANDS-0 LYMPHS-13.9* MONOS-2.5 EOS-0.6 BASOS-0.2 09:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL 09:00PM PLT SMR-NORMAL PLT COUNT-234 09:00PM PT-12.9 PTT-24.9 INR(PT)-1.1 C-SPINE, TRAUMA 9:53 PM TECHNIQUE: Cervical spine, three views.",0
FINDINGS: There is no prevertebral soft tissue swelling.,0
"There are degenerative changes involving predominantly C4/C5, C5/C6 and C6/C7 with anterior osteophytes.",0
"Allowing for this, the vertebral bodies are of normal height, and there is no evidence of fracture or listhesis.",0
There is straightening of the cervical lordosis with a minimal kyphosis centered at the level of C4/C5.,0
IMPRESSION: Degenerative changes and straightening of the cervical lordosis.,0
"However, no fracture is seen.",0
CT 100CC NON IONIC CONTRAST 10:54 PM CT OF THE ABDOMEN WITH CONTRAST: The visualized lung bases show dependent changes bilaterally.,0
The visualized heart and pericardium are unremarkable.,0
The patient has bilateral breast implants.,0
"The liver, gallbladder, pancreas, spleen, and adrenal glands are unremarkable.",0
"The right kidney contains multiple low-attenuation, rounded foci, which are too small to characterize but likely represent simple renal cysts.",0
Both kidneys enhance symmetrically and excrete contrast normally.,0
There is no evidence of hydronephrosis or hydroureter.,0
"There is no evidence for visceral laceration, free air, or free fluid.",0
"The nonopacified stomach, and intra-abdominal loops of small and large bowel are unremarkable.",1
There is no pathologically enlarged mesenteric or retroperitoneal lymphadenopathy.,0
"CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, and intrapelvic loops of small and large bowel are unremarkable.",0
"The uterus is enlarged and contains multiple masses, which may represent a fibroid uterus.",0
"The right ovary contains a 3.5 x 4.2 cm rounded, low-attenuation likely cyst.",0
The left adnexa is not well visualized.,0
There is no free intrapelvic fluid.,0
There is no pathologically enlarged inguinal or pelvic lymphadenopathy.,0
The distal ureters are unremarkable.,0
The bladder is collapsed around the Foley catheter.,0
"BONE WINDOWS: There is a minimally displaced, comminuted fracture of the right iliac .",0
"There is expansion of the right iliopsoas muscle, indicating an intramuscular hematoma.",0
"Additionally, there is subcutaneous soft tissue hematoma overlying the right hip and lower flank.",0
"The fracture does not extend into the acetabulum, and there is no fracture or dislocation seen within the right hip.",0
"Minimally displaced, comminuted fracture of the right iliac with adjacent expansion of the iliopsoas muscle, likely secondary to hemorrhage.",0
Additional hematoma within the subcutaneous soft tissues overlying the right hip and lower flank.,0
"Bulky uterus, most likely secondary to fibroids, however when clinically stable a pelvic ultrasound should be performed for definitive characterization.",0
"3.5 x 4.2 cm rounded, low-density structure involving the right adnexa, likely a cyst.",0
"Again, when clinically stabe, a pelvic ultrasound is recommended for definitive characterization.",0
"Brief Hospital Course: Patient was admited to the regular floor, pain was well controled with a PCA and later PO meds.",0
Serial Hct controled with no sing of expanding hematoma.,0
The patient was also follow by the Orthopedic Surgeons and no surgical intervention was necesary.,0
The patient had a favorable course and was discharge home with physical therapy and follow up by her primary care physician.,0
Medications on Admission: Uristat Discharge Medications: 1.,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain for 2 weeks.,0
Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for 2 weeks.,0
"Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right iliac crest fracture Discharge Condition: Good Discharge Instructions: -Weight bearing as tolerated -Please contact your PCP ( , fax ) to arrange Orthopedic and GYN follow up Followup Instructions: 1. clinic in 2 weeks with previous X-ray (AP&Lat) 2.",0
Call Dr for follow up appointment Completed by:,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Tylenol overdose Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: 20 y.o.,0
male with h/o polysubstance abuse and depression presents s/p tylenol O.D.,0
He was in his USOH until the evening of when he felt depressed and drank a 6-pack of beer.,0
He then began superficially cutting his left wrist and then took #20 tabs of 500 mg tylenol.,0
"He passed out and awoke at 10 AM on with mild ABD pain, nausea, vomiting (brown material) and had mild ataxia.",0
He continued to vomit and then presented to Hospital.,0
"There he was noted to have transaminitis, coagulopathy and thrombocytopenia and was transferred to .",0
"During ICU stay, patient was started on mucomyst for elevated INR (peak 14.1 and transaminitis (ALT , AST 7208) and ARF.",0
Received 4 days of NAC.,0
Hepatology and transplant surgery following for possible OLT.,0
"On HD#4, LFTs peaked and both coagulopathy and ARF resolved.",0
Was seen by psyched and 1:1 sitter was d/c'd by HD#4.,0
Now transfered to medical team for monitoring and transition to outpatient psych facility.,0
"Past Medical History: -Childhood heart murmur -Polysubstance abuse (cocaine, marijuana, EtOH with h/o rehab) Social History: SH: Lives with girlfriend.",0
Family History: FH: Grandfather with EtOH abuse.,0
"Physical Exam: T 98.6 HR 100 BP 127/54 RR 26 O2Sat 98%ra GEN: pale, diaphoretic, many tatoos HEENT: PERRL, EOMI CV: regular, no mrg LUNGS: clear ABD: RUQ tenderness, no rebound, +BS EXT: no edema NEURO: mild asterixis PSYCH: denies SI Pertinent Results: CT Abd : 1) Markedly fatty infiltrated liver, with no focal lesions.",0
"2) No variant hepatic arterial, portal venous, or hepatic venous anatomy.",0
"CT Chest : There is a large pleural effusion on the right, with right lower lobe collapse and consolidation ECHO: 1.",1
"CXR IMPRESSION: New bilateral pleural effusions (right>left), Given the clinical history, underlying pneumonia at the right base and/or aspiration not excluded; correlate clinically.",1
Post Thoracentesis CXR IMPRESSION: Status post thoracentesis with resolution of right-sided pleural effusion; no pneumothorax identified.,1
Pleural Fluid Analysis 12:52PM PLEURAL WBC-1225* RBC-1000* Polys-61* Lymphs-8* Monos-14* Meso-3* Macro-14* 12:52PM PLEURAL TotProt-2.5 Glucose-125 LD(LDH)-230 12:52 pm PLEURAL FLUID GRAM STAIN (Final ): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
FLUID CULTURE (Preliminary): NO GROWTH.,0
ANAEROBIC CULTURE (Pending) Other Microbiology: EBV/CMV neg.,0
Neg MRSA and VRE screens : (aerobic bottle) GRAM POSITIVE RODS.,0
CONSISTENT WITH CORYNEBACTERIUM ANDPROPIONIBACTERIUM SPECIES.,0
FURTHER IDENTIFICATION TO FOLLOW Brief Hospital Course: Tylenol Overdose The patient was admitted after ingesting a significant amount of tylenol in a suicide gesture with grossly abnormal liver function tests and coagulation profile.,1
He was hospitalized and supported for acute liver failure.,1
"Transplant surgery was following but in light of improving clinical picture and labs during hospitalization, there was ultimately no indication for liver transplant.",0
"He was followed by the transplant service, the liver service, and the toxicology service.",0
The patient was aggressively hydrated and received a course of mucomyst.,0
His labs improved on this regimen.,0
His pain was controlled with morphine as needed.,0
Depression/Suicide attempt The psychiatry service followed the patient while admitted and he expressed regret over the suicide attempt and no suicidal ideation; he reported multiple stressors at home including the deaths of friends.,0
"was felt to be stable for non-inpatient psychiatry treatment for his depression, and will follow up with his local crisis team.",0
Acute Renal Failure The patient had mild transient renal failure (peak Cr 1.0) that resolved during hospitalization.,0
These values normalized over the course of his hospitalization.,0
"Hepatitis C Incidentally, the patient was found to be hepatitis C antibody positive.",0
"He reported that he had been HCV negative two years ago and since that time had not had unprotected sex or injected drugs, but had had tatoos done since then.",0
A HCV viral load was pending on discharge.,0
A U/A showed only trace protein.,0
He was given the Hepatitis A vaccine while hospitalized.,0
He will follow up with the liver service on discharge.,0
SW provided support for this new diagnosis.,0
?Pneumonia The patient was found to have a right lower lobe infiltrate on imaging and was mildly hypoxic on transfer to the medicine service.,0
He had developed a mild leukocytosis and had been started on levofloxacin and flagyl for a question of aspiration pneumonia (the patient initially had an NGT in place though he was never intubated).,0
He had an associated right-sided pleural effusion for which he underwent a thoracentesis which showed an exudative effusion without evidence of empyema and with a negative culture.,1
His hypoxia resolved and his CXR post procedure showed no evidence of a pneumothorax and showed impressive resolution of the opacification in the right lower lobe.,0
His leukocytosis resolved and he was discharged to finish a 7 day course of antibiotics.,0
EtOH abuse The patient also has a history of alcohol abuse and was kept on thiamine and folate.,1
This issue was also addressed by the social work and psychiatric teams.,0
"Thrombocytopenia Nadir of 26 and likely multifactorial: EtOH abuse, poor nutritional status and acute liver failure.",1
Platelets on discharge were 175.,0
Hypophosphatemia The patient was aggressively repleted.,0
?GIB Patient had a history of coffee ground emesis.,0
An NG lavage showed coffee grounds with clearing.,0
"His HCT dropped with hydration but remained thereafter stable and he had no further episodes of coffee ground emesis, BRBPR, melena or any other symptoms concerning for GI bleed.",0
The patient was discharged home to follow up with the crisis team in his area for possible placement.,0
Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days.,0
"Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute liver failure secondary to alcohol and tylenol overdose Hepatitis C Depression, suicide attempt Discharge Condition: Stable, tolerating an oral diet, afebrile, no suicidal ideation Discharge Instructions: 1.",1
You were admitted for acute liver faiure and are improving.,1
You should follow up in the liver clinic (see below) to follow up for hepatitis C. 2.,1
"Please call the ""crisis team"" tomorrow () and they will help arrange further follow up.",0
Where: LM CENTER Phone: Date/Time: 10:20 Call the crisis team at tomorrow.,0
", MED 9:49 AM CHEST PORT.",0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: please assess placement of new right IJ central line, rule o Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman s/p intubation, s/p right IJ placement REASON FOR THIS EXAMINATION: please assess placement of new right IJ central line, rule out pneumothorax ______________________________________________________________________________ PFI REPORT Right internal jugular catheter ends in mid SVC.",0
PORT Clip # Reason: ?,0
"obstruction, hydronephrosis Admitting Diagnosis: MYELOFIBROSIS\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with myelofibrosis s/p allo SCT, now with acute renal failure REASON FOR THIS EXAMINATION: ?",1
"obstruction, hydronephrosis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc SAT 2:26 PM 1.",0
Symmetric bilateral mild hydronephrosis without associated obstruction.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 54-year-old male with myelofibrosis status post stem cell transplant, now with acute renal failure.",1
Evaluate for obstruction or hydronephrosis.,0
COMPARISONS: Comparison is made to abdominal ultrasound from and CT from .,0
FINDINGS: The left kidney measures 10.3 cm.,0
"Since prior examination, there is increased prominence of the medullary pyramids likely secondary to increased cortical echogenicity.",0
"There is no hydronephrosis, nephrolithiasis or new discrete masses.",0
Pre-void images of the bladder are unremarkable with bilateral ureteral jets demonstrated.,0
IMPRESSION: No evidence of hydronephrosis or nephrolithiasis.,0
Increased prominence of the medullary pyramids likely secondary to increased cortical echogenicity that can be seen in a wide range of renal cortical parenchymal diseases.,0
These findings were discussed with at 7:10PM.,0
"3:00 PM DIALYSIS REMOVE Clip # Reason: **this is for removal** please remove HD catheter that had b Admitting Diagnosis: ACUTE RENAL FAILURE ********************************* CPT Codes ******************************** * REMOVAL IMPLANT PORT * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with ARF now resolved, htn.",1
REASON FOR THIS EXAMINATION: **this is for removal** please remove HD catheter that had been previously placed.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 38 year old gentleman with tunneled right IJ hemodialysis catheter.,0
Presents for catheter removal as he no longer requires dialysis.,0
and with Dr. being present and supervising for the entire procedure.,0
The catheter site was anesthetized with 1% lidocaine.,0
clamp was utilized to free the catheter cuff from the surrounding tissue.,0
The catheter was removed and pressure was held at the right internal jugular puncture site until hemostasis was achieved.,0
The catheter exit site was dressed.,0
The patient tolerated the procedure well and there were no immediate post procedure complications.,0
IMPRESSION: Successful removal of tunneled right IJ hemodialysis catheter.,0
9:32 PM MR HEAD W/O CONTRAST Clip # Reason: ?,0
"anoxic brain injury Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with left CVA, now unresponsive post PEA arrest, ?",0
anoxic injury REASON FOR THIS EXAMINATION: ?,0
"anoxic brain injury CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old male with known left watershed infarct, now unresponsive status post PEA arrest.",1
"TECHNIQUE: Axial T2, FLAIR, susceptibility, and diffusion-weighted imaging as well as sagittal T1-weighted imaging was performed without administration of IV contrast.",0
"MRI BRAIN: Compared to the MR head of , where small foci of acute infarct were seen in the left centrum semiovale consistent with watershed infarct, there is new large superimposed region of infarct in the left MCA vascular distribution.",0
Corresponding increased FLAIR signal is seen within these regions.,0
"No new hemorrhage, shift of normally midline structures, loss of the basal cisterns or hydrocephalus is seen.",0
Old infarcts involving the left frontal region and the pons is unchanged.,0
Periventricular T2 and FLAIR hyperintensities again likely relate to chronic small vessel ischemic disease.,1
The patient is status post right lens replacement.,0
Mucosal thickening is again noted in the maxillary sinuses.,0
"There is interval resolution of fluid that was seen layering in the sphenoid sinuses, however, there is increased fluid seen within the right mastoid air cells.",0
"The normal intravascular flow voids are demonstrated, although this is not an adequate evaluation of the intracranial vessels.",0
"New large vascular territory infarct involving left MCA territory, superimposed on previously seen left centrum semiovale watershed infarct.",0
This could be embolic or thrombolic in etiology.,0
No hemorrhage or shift of normally midline structures is seen.,0
"Although this is not an adequate evaluation of intracranial vessels, the normal vascular flow voids are demonstrated.",0
These findings were discussed with Dr. at the time of this dictation.,0
(Over) 9:32 PM MR HEAD W/O CONTRAST Clip # Reason: ?,0
anoxic brain injury Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ FINAL REPORT (Cont),0
", J. MED SICU-A 1:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: FOR OG PLACEMENT PER FLOOR Admitting Diagnosis: PNEMONIA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man post-cardiac cath with stent to LCx and ?aspiration PNA on ventilator with worsening O2 requirement.",0
REASON FOR THIS EXAMINATION: ?infiltrate ______________________________________________________________________________ PFI REPORT 1.,0
"Nasogastric tube ends in the proximal stomach, side ports at the level of GE junction, recommend advancement.",0
"Blunting of the right costophrenic angle, with vague opacity projecting over, may be due to layering pleural effusion, presence of superimposed opacity due to aspiration not excluded.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Sudden onset headache and Right sided weakness Major Surgical or Invasive Procedure: : Placement of External Ventricular Drain / right side : Angiogram and embolization of a-comm aneurysm : Re-Placed EVD right side evd removal on right/evd placed on left /cerebral angioplsty and cerebral angiogram History of Present Illness: HPI:Pt.,0
"is a 31 year old male, who per his mother has been having occipital headaches for the past few weeks.",0
per outside ED report pt.,0
was shoveling manure today when he developed a sudden onset headache and right sided weakness.,0
"He was taken to an outside facility where his headache was accompanied by sever N/V and questionable seizure activity and decerebrate posturing, pt.",0
"was intubated there after CT scan showed diffuse SAH greatest in the region of the ACOM, and he was transferred to .",0
Past Medical History: PMHx: none Social History: Social Hx: + tobacco ( approx.,0
"rolls own No ETOH Family History: Family Hx:NC Physical Exam: PHYSICAL EXAM: O: T: BP: 133 /70 HR: 50's R: vented 16 O2Sats 100% Gen: Intubated and sedated IN ICU HEENT: Pupils: 2mm, minimally reactive EOMs: unable to eval.",0
"Neuro: + cough and gag Mental status:intubated sedated, not following commands Cranial Nerves: I: Not tested Motor: slight decerebrate posturing seen in ED Dishcarge Exam: AOx2-3, MAE with full strength.",0
"No prontator drift Pertinent Results: 12:22AM WBC-22.0* RBC-4.34* HGB-13.9* HCT-39.9* MCV-92 MCH-32.0 MCHC-34.8 RDW-13.9 03:16AM PT-13.4 PTT-24.1 INR(PT)-1.2* 12:22AM GLUCOSE-160* UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 06:29PM CEREBROSPINAL FLUID (CSF) WBC-1500 HCT,Fl-6.0* Polys-88 Lymphs-2 Monos-8 Macroph-2 CTA IMPRESSION: 1.",0
"Anterior communicating artery aneurysm, 9 x 5 mm.",0
Massive intraparenchymal and intraventricular hemorrhage with hydrocephalus.,1
Small amount of subarachnoid hemorrhage.,1
"Relatively unchanged appearance of diffuse subarachnoid, predominantly right frontal intraparenchymal and extensive intraventricular hemorrhage.",1
"Persistent perihemorrhagic edema around the right frontal hematoma causing mild subfalcine herniation measuring up to 7 mm, unchanged.",0
Interval clippage of the anterior communicating artery aneurysm with no signifacnt residual within limits of the sreak artifact from the coils.,0
CTA : CONCLUSION: No change in ventricular calibers since study of .,0
Status post coiling of anterior communicating artery aneurysm with residual intraparenchymal and intraventricular hemorrhage.,0
The CT perfusion study demonstrates an avascular area corresponding to the right frontal lobe hematoma but no evidence of cerebral ischemia elsewhere.,0
The CTA suggests generalized reduction in caliber of the intracranial arteries with no focal narrowings to suggest vasospasm.,0
"Brief Hospital Course: 31M admitted to the ICU on with no eye opening(attempted however), follows commands in UEs & LLE.",0
"PERRL, and EVD in place.",0
He was extubated on and ICPs were WNL.,0
He had a CTA/Perfusion study which showed no vasospasm or ischemia.,0
He then pulled out his EVD on the night of .,0
He had a Head CT which showed no worsening hydrocephalus.,0
He did become more lethargic on the and the EVD was replaced and emperic treatment antibiotics were started for elevated WBCs in the CSF.,0
ICPs WNL however remained bloody.,0
"On he began to become more alert and arousable, following commands although only oriented to self.",0
On he show improved alertness and orientation.,0
decreased mental status in the afternoon- CTA+P sugestive of vasospasm began triple H therapy with goal bp 180 pt scheduled for diagnostic angio showed ACA territory vasospasm.,0
He required continued with a EVD at 10.,0
"He remained neurologically orientated x1, followed commands difficult with 2 step commands, motor strength full throughout.",0
"He had continuous hyponatremia, he was treated with salt tabs with good effect.",0
On and a diagnositic angio showed vasospasm for which he received verapamil.,0
He remained neurologically with some short term memory issues remembering the date and the name of the hospital.,0
On his EVD was removed and he was transferred to the neurostep down unit.,0
"He progressed well once he was on the floor, he orientated X3, eating well, voiding and having bowel movements.",0
PT and OT were concerned with cognitive abilities and felt he would need 24 hour care.,0
He is being sent home with his parents for 24 hours supervision they have agreed to providing this care.,0
Tylenol 325 mg Tablet Sig: Three (3) Tablet PO every hours.,0
"Keppra 1,000 mg Tablet Sig: Two (2) Tablet PO twice a day.",0
Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: A-comm aneurysm rupture subarachnoid hemorrage(atraumatic) vasospasm / cerebral Discharge Condition: stable Discharge Instructions: General Instructions ?,1
"You may wash your hair, as your staples have been removed.",0
?Please return to the office on for a wound check.,0
"?Please call ( to schedule an appointment with Dr. , to be seen in 4 weeks.",0
?You will need a CT scan of the brain without contrast.,0
7:52 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate hydrocephalus Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with removal of ventriculostomy drain REASON FOR THIS EXAMINATION: evaluate hydrocephalus No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): ENYa WED 11:15 AM No new intracranial hemorrhage.,1
Minimal increase in right subdural fluid.,0
Mass effect on right lateral ventricle.,0
Minimal increase in the leftward shift.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 62-year-old man, status post fall, status post placement of ventriculostomy drain for hydrocephalus, now status post removal of drain.",1
"COMPARISON: Series of head CT without contrast, with the latest on , .",0
FINDINGS: There is an interval removal of the left ventriculostomy drain.,0
There is an interval decrease of pneumocephalus.,0
"The right subdural fluid is again seen, measuring 16 mm, compared to 14 mm, representing a minimal interval increase.",0
There is persistent mass effect on the right lateral ventricle.,0
"There is also a slight increase of leftward shift of midline structures, now 8 mm compared to the previous 7 mm.",0
There is no evidence of new intracranial hemorrhage.,0
Interval removal of the left ventriculostomy drain.,0
Minimal increase in the right subdural fluid collection and minimal increase of the rightward midline shift and mass effect on the right lateral ventricle.,0
No evidence of new intracranial hemorrhage.,0
"The findings of this study have been discussed with the primary team, Dr. with resident Dr. by phone at 11:30 on the day of study.",0
(Over) 7:52 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate hydrocephalus Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ FINAL REPORT (Cont),1
"7:28 PM BILAT LOWER EXT VEINS Clip # Reason: please asess for DVT Admitting Diagnosis: CHOLEDOCHOLITHIASIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 68F s/p open cholecystectomy 2 days ago with known history of COPD, CABG,angina, with new desaturations while ambulating today on the floor.",0
This was with associated tachycardia to the 90s.,0
ABG with paO2 of 64%.,0
REASON FOR THIS EXAMINATION: please asess for DVT ______________________________________________________________________________ WET READ: KKgc FRI 9:07 PM No DVT in both lower extremities.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old woman status post open cholecystectomy, now with new desaturation.",0
"FINDINGS: Grayscale and Doppler son of bilateral common femoral, superficial femoral, deep femoral, popliteal, and proximal calf veins were performed.",0
"There is normal compressibility, flow and augmentation throughout.",0
Large calcified plaque is seen in the right common femoral artery.,0
IMPRESSION: No DVT in both lower extremities.,0
"3:33 PM CTA ABD W&W/O C & RECONS Clip # Reason: please eval pancreatic mass for surgery Admitting Diagnosis: PANCREATIC HEAD CANCER Field of view: 45 Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with newly diagnosed pancreatic head adenoCA REASON FOR THIS EXAMINATION: please eval pancreatic mass for surgery No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Newly diagnosed pancreatic head adenocarcinoma, evaluate pancreatic mass for surgery.",0
TECHNIQUE: MDCT-acquired axial images from the lung bases to the L4 vertebral body were displayed with 2.5-mm slice thickness without contrast and subsequently with intravenous contrast in the arterial and venous phases.,0
Coronal and sagittally reformatted images were displayed with 5-mm slice thickness.,0
CT ABDOMEN: Bilateral pleural effusions are seen with associated compressive atelectasis.,0
The partially imaged heart and pericardium are unremarkable.,0
A few hypodensities are seen within the left lobe of the liver (3b 137-139) that are too small to characterize.,0
Pneumobilia is in the biliary tree is consistent with common bile duct stent patency.,0
The stent has a small amount of debris.,0
There is enhancement of the gallbladder wall with surrounding pericholecystic fluid.,0
A history of cholangitis is noted.,0
Air within the gallbladder is likely due to stent patency.,0
The pancreatic duct is dilated over its entire length up to the junction with the stent in the common bile duct.,0
The proximal pancreatic duct measures 8 mm (3a:65).,0
No definite hypodensity or mass is identified in the pancreatic head.,0
The superior mesenteric vein is 50% effaced.,0
The splenic and portal veins are patent.,0
There is a replaced left hepatic artery off the left gastric artery.,0
Small subcentimeter portacaval lymph nodes measuring 7-8 mm (3A:56) are noted.,0
"The spleen, adrenal glands and intra-abdominal portions of the small bowel are within normal limits.",0
Scattered diverticula are seen in the visualized portions of the large bowel without inflammatory changes.,0
"Calcifications are noted in the aorta, which is normal in caliber.",0
BONE WINDOWS: No sclerotic or lytic lesion suspicious for malignancy.,0
Pancreatic Tumor Table: I: Pancreatic tumor present: No definite hypodensity or mass identified a) Location: Not applicable (Over) 3:33 PM CTA ABD W&W/O C & RECONS Clip # Reason: please eval pancreatic mass for surgery Admitting Diagnosis: PANCREATIC HEAD CANCER Field of view: 45 Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (Cont) b) Size: Not applicable c) Enhancement relative to pancreas: Not applicable d) Confined to pancreas with clear fat planes (duodenum and IVC do not apply): Not applicable e) Remaining pancreas: Not applicable II.,0
"Adenopathy present: Subcentimeter portacaval lymph nodes a) Size and location of largest lymph node: Portahepatis, 8 mm (3A:56) b) Necrosis in lymph nodes: No c) Size of gastroduodenal artery node, ""node of importance"": No III.",0
"Metastatic disease, definitely present: No IV: Ascites/peripancreatic fluid: No Pancreatic Vascular Table I: Vascular Tumor Involvement: Yes a) Celiac involvement: No b) SMA involvement: No c) SMV involvement and percent encasement: SMV effaced greater than 50% d) Less than 1 cm SMV between tumor and first major SMV branch: Not applicable e) Portal vein involvement: No g) Splenic vein involvement: No h) Splenic artery involvement and distance from tumor to celiac artery bifurcation: No i) Vascular Involvement, Other: No II: Thrombosis, any vessel: No III: Aberrant Anatomy: Yes.",0
Replaced left hepatic artery of left gastric artery.,0
No definite hypodensity or mass in the pancreatic head identified.,0
Stent in the common bile duct.,0
Intrahepatic pneumobilia consistent with stent patency.,0
Enhancement of gallbladder wall and pericholecystic fluid.,0
"Air in the gallbladder likely due to stent patency, although a history of cholangitis is noted.",0
Bilateral pleural effusions with associated compressive atelectasis.,0
(Over) 3:33 PM CTA ABD W&W/O C & RECONS Clip # Reason: please eval pancreatic mass for surgery Admitting Diagnosis: PANCREATIC HEAD CANCER Field of view: 45 Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (Cont),0
"2:07 AM CTA NECK W&W/OC & RECONS Clip # Reason: cervical artery injuries s/p strangling / choking Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with ligature marks on neck, unclear story, presented with slit mark on wrist and then obtunded and intubated OSH REASON FOR THIS EXAMINATION: cervical artery injuries s/p strangling / choking No contraindications for IV contrast ______________________________________________________________________________ WET READ: SJBj 2:50 AM Patent cervical and intracranial vasculature.",0
"Several small foci of air surrounding the trachea are most likely air within small veins, rather than the seqelae of tracheal injury.",0
No cervical spine fracture or malalignment.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 27-year-old man with ligature marks on neck, unclear story.",0
Evaluate for cervical arterial injury status post strangling/choking.,0
TECHNIQUE: MDCT data were acquired through the neck after the administration of intravenous contrast.,0
Images were displayed in multiple planes in thin slices and maximum intensity projections.,0
FINDINGS CTA: The carotid and vertebral arteries are widely patent throughout their cervical course.,0
The visualized portions of the intracranial circulation are also patent.,0
The patient is intubated with the endotracheal tube terminating appropriately above the carina.,0
There are nasopharyngeal secretions extending down the side of the endotracheal tube.,0
"Several tiny foci of air are seen outside of the airway, e.g., lateral and inferior to the cricoid cartilage (2:159), anterior to the airway at the C7-T1 level (2:136) and anterior to the thyroid cartilage (2:175).",0
These are felt to more likely represent air in tiny superficial veins.,0
A larger focus of air is seen in the brachiocephalic vein (2:165) and anterior right atrium (2:3) which supports this hypothesis.,0
There is no soft tissue swelling in the neck.,0
The heart and great vessels have normal caliber and appearance.,0
There is partial collapse of the left lower lobe.,0
Minimal dependent right lower lobe atelectasis is seen.,0
"Otherwise the lungs are clear with no consolidations, pneumothoraces or effusions.",0
Patent cervical and intracranial vasculature.,0
Several tiny foci of air external to the trachea.,0
These are felt most likely to represent small foci of air within small superficial veins.,0
Injury to the trachea is felt to be less likely.,0
"NOTE ADDED AT ATTENDING REVIEW: Incompletely imaged, there appears to be at least partial left lower lobe collapse with air bronchograms.",0
This revised finding was discussed by telephone with Dr. by Dr. at 5:53 (Over) 2:07 AM CTA NECK W&W/OC & RECONS Clip # Reason: cervical artery injuries s/p strangling / choking Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) pm on .,0
"7:54 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate, atelectasis, ptx, masses Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with lung SCC freely communicating with the esophagus, oxygen saturation low eightieth percentiles on room air.",0
"REASON FOR THIS EXAMINATION: r/o infiltrate, atelectasis, ptx, masses ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST: INDICATION: Lung cancer, found to freely communicate with the esophagus.",0
Now with increased shortness of breath and low oxygen saturation.,0
Correlation is made to prior CT examination of .,0
FINDINGS: Bilateral enlargement of the hilar shadows is consistent with known mass and esophageal dilatation from metastatic cancer involvement.,0
"On today's examination, there is new left lower lobe opacity obscuring the left hemidiaphragm, consistent with collapse and/or consolidation.",0
Surgical clips in the left upper quadrant are noted.,0
"IMPRESSION: 1) New left lower lobe opacity, consistent with collapse and/or consolidation.",0
"2) Posterior mediastinal mass at the hilar level, as noted on prior CT exam of .",0
9:44 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
e/o pneumothorax Admitting Diagnosis: URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman s/p pacemaker placement today.,1
e/o pneumothorax ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON HISTORY: Pacemaker placement.,0
FINDINGS: There is a new dual-lead pacemaker with tips projecting over the expected regions of the heart.,0
There continues to be moderate cardiomegaly and some mild pulmonary vascular re-distribution.,0
6:39 PM PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: please evaluate Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with recent GI bleed REASON FOR THIS EXAMINATION: please evaluate ______________________________________________________________________________ WET READ: WED 8:08 PM appearance of lucency under both diaphragms and hazy appearance along the mid abdomen concerning for pneumoperitoneum.,0
apparant rigglers sign in right lower quadrant further raising concern for large intraperitoneal free air.,0
if further confirmation is reqd then a left lateral decubitus image can be obtained.,0
d/w dr. at 7:49pm on via tel.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 82-year-old female with recent GI bleed.,0
COMPARISON: CT of the abdomen and pelvis from .,0
FINDINGS: There is air seen underneath both hemidiaphragms and an overal haziness of the abdomen suggesting significant pneumoperitoneum.,0
"In addition, a Riggler's sign is noted in the right lower quadrant.",0
There are air filled loops of large and small bowel as aspected given the history of recent colonoscopy.,1
Significant amount of free air in the abdomen.,0
"Air filled loops of small and large bowel, not unexpected given recent colonscopy.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 70 -year-old female who presents on transfer from for evaluation of change in mental status and lethargy.,0
The patient had an admission to - earlier in the month of for weakness.,0
At that time she was ruled out for myocardial infarction and was found to have a normal left ventricular function with an ejection fraction of 55% by echocardiogram.,0
She was also noted to have pulmonary hypertension and mitral regurgitation.,0
She had a ventilation - perfusion scan at that time which ruled out pulmonary emboli as a cause of her pulmonary hypertension.,0
She was found to have matched defects on that scan.,0
She was put on ACE inhibitors for her mitral regurgitation.,0
"She was discharged to rehabilitation and was returned on , after staff noted a change in mental status, coarse tremor, and lethargy, although she remained responsive.",0
She was also recently diagnosed with hypothyroidism on her previous admission.,0
"PAST MEDICAL HISTORY: Notable for chronic renal insufficiency, hypothyroidism, mitral regurgitation, insulin dependent diabetes, coronary artery disease, anemia of chronic disease, anxiety, and depression.",1
"ADMITTING MEDICATIONS: Aspirin 325 mg per day, Colace 100 mg per day, Epogen 4,000 units biweekly, hydralazine 10 mg po bid, a sliding scale of regular insulin, Synthroid 50 mcg per day, Niferex, thiamine 100 mg po q day, miconazole 30 mg po q day.",0
"PHYSICAL EXAMINATION: The patient was afebrile, blood pressure was 80/palp.",0
"She was lethargic, but responsive to verbal questions.",0
"Examination of the head and neck revealed normocephalic, atraumatic, pupils are equal, round, and reactive to light, there is no lymphadenopathy, no jugular venous distention.",0
"Thyroid is mildly enlarged, no nodules.",0
Lungs were clear to auscultation.,0
"Cardiovascular examination revealed a normal S1, S2, regular rate and rhythm, no rubs, or gallops.",0
She had a II/VI systolic ejection murmur in the right upper sternal border.,0
"Belly was soft, distended secondary to obesity, neurologic bowel sounds.",0
She had no costovertebral angle tenderness.,0
"Extremity examination: 2+ pitting edema at the calves, nonpitting edema of the feet.",0
"Neurologic: she was moving all extremities, had a coarse resting tremor of the arms.",0
"LABORATORY DATA: Laboratory analysis at that time showed a hematocrit of 30.5, 108 platelets.",0
"Urinalysis with 30 protein, 4 white blood cells, no red blood cells, PT of 14.7, INR of 1.4, PTT of 46.3.",0
"Chem 7 was a sodium of 144, potassium 4.7, chloride of 116, pCO2 of 17, BUN of 79, creatinine 4.0, glucose of 97.",0
"TSH was 24, free T4 was 1.0.",0
"CT scan showed multiple strokes of indeterminate age, not acute, and diffuse periventricular white matter changes, likely secondary to small vessel ischemic changes.",0
The patient underwent a lumbar puncture during which she showed some seizure activity.,0
She was intubated emergently and transferred to the Medical Intensive Care Unit for further care.,0
HOSPITAL COURSE: In the Medical Intensive Care Unit she was hypotensive and hypothermic.,0
She became septic with Enterococcus faecalis.,0
She was treated with a two week course of vancomycin for Enterococcus.,0
Relative pancytopenia was noted there.,0
Hematology / Oncology work up suggested likely myelodysplastic syndrome.,0
They recommended a bone marrow biopsy in the future.,0
Electroencephalogram showed moderate to severe encephalopathy without epileptiform activity.,0
She was gradually weaned from the ventilator and weaned off pressors.,0
She was extubated on and transferred back to the Medicine floor.,0
"On the floor, neurologic work up continued.",0
"A repeat head CT scan was done, which was unchanged, demonstrating right frontal, temporal, cerebellar, and left occipital hypodensities.",0
She was also found to have an ectatic basilar artery.,0
"Lumbar puncture was performed and CSF analysis demonstrated no white blood cells, normal protein, normal glucose.",0
Encephalopathy was felt to be due to a combination of hypotension and sepsis.,0
An Endocrine consult was obtained for assessment of the HPA access.,0
"No definite abnormalities were found, although recommendation for MRI of the sellae was encouraged.",0
"She was gradually improving on the floor with improved mental status, until approximately , when she began hallucinating and underwent progressive decline.",0
"Clinical suspicion focused on seizure with a postictal state, versus status epilepticus.",0
She was transferred back to the Medical Intensive Care Unit on when she was found to be hypotension to 68/palp.,0
"She was initially treated with IV hydration, then with IV Decadron with the presumption that she may be in adrenal crisis.",0
An electroencephalogram was obtained during that time period which revealed status epilepticus.,0
The patient was treated with IV Ativan with good response via electroencephalogram and transferred to the Medical Intensive Care Unit once again.,0
Summary of the ensuing Medical Intensive Care Unit course is summarized as follows: 1.,0
"Neurologic: The patient was found to be in nonconvulsive status epilepticus upon transfer to the Medical Intensive Care Unit, and as stated, was treated with Ativan.",0
She was also loaded with Dilantin and was monitored for several days with a continuous electroencephalogram until it was felt that seizure activity had discontinued.,0
She was then slowly weaned off of her sedation in an attempt to wake her up.,0
"Her mental status remained poor, however.",0
A free Dilantin level was checked and it was found to be markedly elevated.,0
At that time all further Dilantin was held under the assumption that elevated Dilantin was causing her continued decreased mental status.,0
"Over the ensuing three weeks her Dilantin level very slowly trended down with corresponding increase in her mental activity, until she was back to near baseline functioning by the time of discharge.",0
"At the time of discharge, her goal was to have a therapeutic Dilantin level of between 1.5 and 2.0 on free Dilantin testing, with levels followed closely and doses adjusted accordingly.",0
"It was also felt that she would continue to need an MRI scan to further evaluate for cause of her seizures, as no definite etiology was ever found.",0
"She would also benefit from an MRI of the sellae as per Endocrine to further assess hypothermia, hypotension, and mild endocrine abnormalities.",0
MRI was not able to be performed at the Hospital secondary to the patient's body habitus.,0
"Renal: The patient's creatinine was found to be increased on transfer back to the Medical Intensive Care Unit to a level 4.0, baseline of 2.5 to 3.0 as an outpatient.",0
"It was felt that this was likely secondary to a hemodynamic insult, causing acute tubular necrosis.",1
"In the setting of her hypotension on transfer, she was mostly treated with IV fluids with no response for creatinine.",0
She was bolused repeatedly and became markedly edematous.,0
"Eventually, after several days, a Swan Ganz catheter was placed which showed a mixed picture with high filling pressures and a low SER.",0
"She was then diuresed, started on a Lasix drip.",0
"This was in conjunction with the switching of the pressor support from Neo-Synephrine to Dopamine, led to an increase in her urine output.",0
"Although she was never able to diurese entirely, she did begin to make urine and creatinine trended down slightly.",0
"However, any attempt to discontinue the Dopamine led to a markedly decreased urine output level.",0
Despite this she was transitioned to a regimen which could be continued at a rehabilitation facility.,0
"She was taken off the Dopamine, taken off the Lasix drip, and placed on Bumex and Zaroxolyn.",0
"Bumex was used secondary to concern about autotoxicity with Lasix, as the patient has some baseline hearing abnormalities.",0
Bumex was given with salt poor albumin in order to increase efficacy.,0
Urine output was judged to be adequate by the Renal consultation service.,0
She will need continuous follow up for her renal failure at her rehabilitation facility and continued assessment of the efficacy of her diuretics.,1
Cardiovascular: The patient was hypotensive on transfer back to the Medical Intensive Care Unit.,0
"Initially it was thought that this may result from Addisonian crisis; however, the patient exhibited no response to stress dose steroids which were gradually tapered off.",0
"Another theory was that this hypotension was secondary to a Dilantin level, although this theory was deemed less likely as Dilantin varying frequently causes hypotension and is normally transient only at the time of loading.",0
"There was, however, another possibility entertained, was sepsis, although all blood cultures remained negative during her second day in the Medical Intensive Care Unit.",0
She was gradually weaned off pressors over the course of her stay with blood pressures stabilizing in the 90s.,0
"It was initially felt that her mentation was better with a higher mean arterial pressure; however, this proved not to be the case, as she woke fully after the Dilantin level weaned off.",0
"She did exhibit a markedly improved urine output on Dopamine, however.",0
This cannot be continued outside the Intensive Care Unit and was discontinued.,0
"Endocrine: The patient was recently found to be hypothyroid based on her presentation with lethargy, hypothermia, her dose of Synthroid was increased.",0
The Endocrine service recommended rechecking in two to three weeks following her discharge from the hospital.,0
"The possibility was also raised at one point of adrenal insufficiency, although she did not respond to high dose steroids.",0
"She did have low gonadotropins, raising the possibility of an HPA access problem.",0
"The Endocrine consult service felt this was unlikely, but recommended MRI of the sellae to further evaluate, which she should have if feasible at a future date.",0
"The patient was also found to have high estradiols, thought that this was secondary to the high levels of Dilantin in her system.",0
Pulmonary: The patient was intubated emergently in the setting of her seizures.,0
Her oxygenation and ventilation were excellent throughout her Medical Intensive Care Unit stay.,0
She remained intubated for some time for airway protection.,0
"When she began to awake, she was quickly weaned off the ventilator and extubated with excellent results.",0
"The patient does, however, likely have obesity hypoventilation syndrome as well as obstructive sleep apnea.",0
"She was tried on BiPAP, but did not tolerate it and kept removing the mask.",0
This will probably need further work up as an outpatient.,0
"Hematology: The patient was seen by the Hematology consult service on her initial Medical Intensive Care Unit stay and based on mild pancytopenia and the appearance of a peripheral smear, she may benefit from a bone marrow biopsy at a future date to assess fully for myelodysplastic syndrome.",0
She was also worked up for antiphospholipid antibodies and her IgM.,0
"The cardiolipin antibody came back positive, although the Hematology / Oncology service felt this was not consistent with antiphospholipid antibody syndrome given her lack of thromboembolic disease.",0
DISPOSITION: The patient was discharged to a rehabilitation facility in stable condition.,0
"DISCHARGE MEDICATIONS: Include Bumex 1.0 mg IV q day, dosed with 50 cc salt poor albumin, Tums 500 mg po tid, NPH insulin 5.0 units subcutaneous , Zaroxolyn 10 mg po bid, Nephrocaps one po q day, Nystatin swish and swallow 5.0 cc to 15 cc po qid prn, Zoloft 50 mg po q day, Prilosec 20 mg po q day, Synthroid 150 mcg po q day, regular sliding scale, thiamine 100 mg po q day, Miconazole powder prn, Epogen 10,000 unit subcutaneous Tuesday, Thursday, Saturday.",0
"FOLLOW UP: The patient was to follow up with her new primary care physician, .",0
Dictated By: MEDQUIST36 D: 13:38 T: 15:35 JOB#:,0
2:32 PM CHEST (PORTABLE AP) Clip # Reason: see below Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 75M s/p s/p NG tube placement REASON FOR THIS EXAMINATION: see below ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old man with recent NG tube placement.,0
SINGLE PORTABLE UPRIGHT AP VIEW OF THE CHEST: An NG tube is seen coiling within the stomach.,0
A right-sided central venous line is seen at the cavoatrial junction.,0
A left lower lobe atelectasis has improved.,0
"Additionally, there are decreased pulmonary vascular markings, and slight decrease in heart size, indicating improved cardiac failure.",0
The feeding tube has been removed.,0
IMPRESSION: 1) Successful placement of NG tube.,0
Improving left lower lobe atelectasis.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: CC: Major Surgical or Invasive Procedure: -Bilateral Burr hole evacuation History of Present Illness: HPI: Mrs. is known to the neurosurgery service.,1
"Briefly, she is a 52 year-old female who initially presented in with headaches without findings on CT scans.",0
She was eventually diagnosed with migraines after a neurology evaluation and placed on amitriptyline.,0
She reports that she had continued to have headaches since that time.,0
She presented to Hospital today per report confused with difficulty walking.,0
"A CT scan of her head there revealed symmetrical bilateral subdural hematomas with approximately 1 cm thickness in the frontal and parietal regions, sparing the vertex, with effacement of sulci and slight compression of the lateral ventricles and possible evidence of subtentorial herniation.",1
"At this time, she was transferred to for further management.",0
"Currently, she reports to have a continued headache bilaterally located behind her eyes.",0
She has never had nausea or vomiting and denies any trauma in the past.,0
"She denies chest pain, shortness-of-breath, fevers, or chills.",0
"Recent hospitalization (, for RUQ pain.",0
"Starting in , patient reports ""squeezing"" pain in abdomen, which increased in intensity up to prior to the admission.",0
"No specific diagnosis was made, and the pain significantly subsided prior to discharge.)",0
Ventral hernia (s/p surgical repair) .,0
Open roux-en-Y gastric bypass () 2.,0
Repair of ventral hernia 4.,0
Excision of 4 cm right knee lymphocele() 5.,0
Cholecystectomy () Social History: Patient lives at home with her son.,1
"She works as a business manager at a group home for kids, and manages the financing and staff.",0
Smoking: Hx 1.5 ppd x 10 yrs (patient quit smoking 30 years ago).,0
EtOH: Patient drinks 2 glasses of wine every other night.,0
"Family History: mother: CAD, HTN father: Diabetes (type II) 2 sisters: Diabetes (type II) Physical Exam: On admission:PHYSICAL EXAM: O: T: BP:111/66 HR:86 RR:20 O2Sats:98% on room air Gen: WD/WN, comfortable, NAD.",0
"HEENT: Pupils:PERRLA, EOMs intact Neck: Supple.",0
Does not know why she is in the hospital.,0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2mm bilaterally.",0
"No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally.",0
"Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On the day of discharge: She was AVSS, A&Ox3, full motor, no drift and no neurological deficits.",0
Pertinent Results: 03:44AM PT-11.1 PTT-24.5 INR(PT)-0.9 03:44AM PLT COUNT-271 03:44AM NEUTS-59.2 LYMPHS-32.2 MONOS-6.3 EOS-1.7 BASOS-0.7 03:44AM WBC-6.1 RBC-4.13* HGB-13.0 HCT-38.4 MCV-93 MCH-31.4 MCHC-33.8 RDW-13.6 03:44AM CALCIUM-9.3 PHOSPHATE-4.6* MAGNESIUM-2.0 03:44AM estGFR-Using this 03:44AM GLUCOSE-99 UREA N-30* CREAT-0.8 SODIUM-141 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 04:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 04:56AM URINE COLOR-Yellow APPEAR-Hazy SP -1.029 04:56AM URINE GR HOLD-HOLD 04:56AM URINE HOURS-RANDOM 09:13AM CK(CPK)-35 Radiology Report CT HEAD W/O CONTRAST Study Date of 4:53 AM 1.,0
"Bilateral subacute subdural hematomas and diffuse cerebral edema with resultant effacement of the sulci, fissures and basal cisterns and slightly low lying cerebellar tonsils.",1
"In the setting of multiple prior LPs, these findings may be secondary to intracranial hypotension.",0
"MRI could be considered for further evaluation, including dural venous sinuses.",0
Radiology Report CHEST (PORTABLE AP) Study Date of 5:05 AM Final Report Portable AP chest radiograph was compared to .,0
Lungs are essentially clear except for the left cardiophrenic angle that was not included in the field of view.,0
"Bifrontal hypodensities may represet artifact, but infarct cannot be excluded.",0
Findings are otherwise in the spectrum of post- surgical change.,0
There is minimal residual subdural hematoma.,0
"The brain parenchyma remains separated from the inner table, which suggests the subdural hematoma was chronic.",1
Brief Hospital Course: This is a 52 year-old female who initially presented in with headaches without findings on CT scans.,0
A CT scan of her head there revealed symmetrical bilateral subdural hematomas and she was transferred to for further management on .,1
She was admitted to the ICU and pre-operaticvely was reportaed to have short term memory loss X 1 week per her family's reports.,0
"On exam, she exhibited a slight right sided drift.",0
Consent for the procedure was signed by the patient and her son as the patient has had recent memory issues.,1
She underwent bilateral burr holes post op CT showed good expansion of the brain.,1
On she was transferred to the floor and was neurologically intact.,0
While on the floor she tolerated a regular diet was seen by PT who determined she was safe to go home.,0
"Medications on Admission: Protonix40 mg , Allegra180 mg qd,Diovan 160mg qd, amitriptyline 10 mg qd, Lunesta qd, Retin-A, Veramyst, lorazepam 0.5qd, hydrocodone PRN headache, Bentyl 10 mg qd, Vitamin B12.",0
Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QD ().,0
Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Tretinoin 0.025 % Cream Sig: One (1) Appl Topical QHS (once a day (at bedtime)).,0
Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 months.,0
Lunesta 3 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).,0
Discharge Disposition: Home Discharge Diagnosis: Bilateral Subacute Subdural Hematomas Discharge Condition: Neurologically Stable.,1
You may wash your hair only after sutures have been removed.,0
You may shower before this time using a shower cap to cover your head.,0
?Please return to the office in days(from your date of surgery) for removal of your sutures and a wound check.,1
"10:29 AM CT HEAD W/O CONTRAST Clip # Reason: is there any edema Admitting Diagnosis: SEIZURES;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman with prolonged seizure, unresponsive REASON FOR THIS EXAMINATION: is there any edema No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT HEAD: CLINICAL INFORMATION: Prolonged seizures.",0
TECHNIQUE: Noncontrast axial brain CT.,0
"FINDINGS: There is extensive beam hardening artifacts arising from the overlying EEG leads, severely effecting image quality.",1
"Allowing for this limitation, basilar cisterns appear patent, and no obvious hemorrhage is identified.",0
IMPRESSION: Suboptimal study due to the above-mentioned technical factors.,0
"No obvious hemorrhage,hydrocephalus or mass effect.",0
"Suggest a followup study, if there is ongoing clinical indication.",0
"1:13 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed, tumor, sinusitis ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with increasing headache for 4 days, nausea, vomiting, photophobia.",0
"REASON FOR THIS EXAMINATION: r/o bleed, tumor, sinusitis No contraindications for IV contrast ______________________________________________________________________________ WET READ: MGGb WED 2:08 PM No intracranial hemorrhage or edema.",0
Prominent adenoids of uncertain clinical significance.,0
"INDICATION: Increasing headache for four days, associated with nausea, vomiting and photophobia, rule out bleed, tumor or sinusitis.",0
TECHNIQUE: Non-contrast axial images of the brain were obtained.,0
FINDINGS: There is no intracranial hemorrhage.,1
There is no evidence of mass effect or shift of normally midline structures.,0
Bone windows demonstrate no fracture or other osseous abnormality.,0
"There is significant hypertrophy and prominence of the nasopharynx, which is of unclear clinical significance, and may represent inflammation vs. infiltrating lesion.",0
IMPRESSION: No intracranial hemorrhage or fracture identified.,0
No mass effect or evidence of acute infarction.,0
"Prominent, enlarged nasopharyngeal tissues of unclear significance.",0
2:57 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"PNA Admitting Diagnosis: DELERIUM, AFIB RVR ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with altered mental status REASON FOR THIS EXAMINATION: ?",0
PNA ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Mental status.,0
PORTABLE AP CHEST RADIOGRAPH COMPARED TO .,0
"Mediastinal position, contour, and width are unremarkable.",0
"There is interval progression in bilateral pleural effusion, although still small, and bibasal opacities consistent with atelectasis.",0
"No areas worrisome for pneumonia are demonstrated, although followup of this bibasal atelectasis is recommended to exclude the possibility of developing infection.",1
8:51 AM CHEST (PORTABLE AP) Clip # Reason: Eval pneumothorax.,0
"PLEASE DO XRAY AT 3AM ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with AI/MR, hx pulm edema now with fever, chills, increased sputum production.",0
Now s/p Chest tube removal.,0
REASON FOR THIS EXAMINATION: Eval pneumothorax.,0
PLEASE DO XRAY AT 3AM ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Evaluate pneumothorax.,0
Compared to one day earlier.,0
There is a persistent right apical pneumothorax present.,0
"Allowing for differences in patient positioning and technique, this is unchanged in the interval since the previous study.",0
A tracheostomy tube remains in place.,0
"There is a new left subclavian vascular catheter, which terminates at the junction of the superior vena cava and right atrium.",0
There remains left retrocardiac opacification.,0
Note is made of previous median sternotomy and aortic valve replacement.,1
"There is some widening of the superior mediastinum, which is stable in the interval, compared to previous postoperative radiographs.",0
Persistent small right apical pneumothorax.,0
Left subclavian vascular catheter terminates at junction of SVC and right atrium.,0
12:50 PM CHEST (PA & LAT) Clip # Reason: please eval prior to d/c Admitting Diagnosis: AORTIC INSUFFICIENCY\AORTIC AND MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p avr/mvr REASON FOR THIS EXAMINATION: please eval prior to d/c ______________________________________________________________________________ FINAL REPORT HISTORY: Post-cardiac surgery.,1
"FINDINGS: In comparison with study of , there is little change in this patient with two replaced valves and dual-channel pacemaker device in place.",1
Lungs remain clear and there is again somewhat low lung volumes.,0
"LINE PLACEMENT Clip # Reason: check position, r/o ptx Admitting Diagnosis: FEVER UNKNOWN ORIGIN ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman s/p introducer placement for swan REASON FOR THIS EXAMINATION: check position, r/o ptx ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE INDICATION: 73-year-old woman status post introducer placement for Swan.",0
CHEST PORTABLE: Comparison is made to a prior study from earlier the same day.,0
Again noted is cardiomegaly which is stable in appearance.,0
There is haziness of the pulmonary vasculature consistent with CHF.,0
Multifocal patchy opacities are seen in both lungs.,0
These are stable and concerning for multifocal pneumonia.,0
"An introducer sheath is identified in the right internal jugular vein, the tip of which is seen in the upper SVC.",0
There is no evidence for a pneumothorax.,0
Introducer sheath with its tip in the upper SVC.,0
"Cardiomegaly and mild CHF, unchanged.",0
Multifocal patchy opacities concerning for pneumonia.,0
Evaluate for thrombus seen on CTA.,0
Height: (in) 66 Weight (lb): 159 BSA (m2): 1.82 m2 BP (mm Hg): 123/54 HR (bpm): 100 Status: Inpatient Date/Time: at 10:45 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
No LA mass/thrombus (best excluded by TEE).,0
Conclusions: The left and right atrial are moderately dilated.,0
No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography).,0
The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis.,0
"IMPRESSION: Right vevntricular cavity enlargement with free wall dysfunction c/w primary right ventricular process (ischemia, ARVC, etc.)",0
Mild symmetric left ventricular hypertrophy with preserved global and regional systolic function.,0
No left ventricular thrombus identified.,0
"If clinical information regarding a left atrial appendage thrombus is desired, a TEE would be more useful.",0
"CLINICAL IMPLICATIONS: Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended).",0
5:00 AM CHEST (PORTABLE AP) Clip # Reason: Please assess interval change.,0
"Admitting Diagnosis: COPD EXCERBATION ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with pneumonia, hypoxia, COPD.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia, hypoxia, COPD, question interval change.",1
Again seen are relatively interstitial and alveolar opacities at both lung bases.,0
"Allowing for technical differences, these are unchanged compared with .",0
10:41 PM MR W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: TLS spine to r/o infarct in patient with signif decreased mo Admitting Diagnosis: THORACO-ABDOMINAL ANEURYSM \ THORACO-ABDOMINAL ANEURYSM/SDA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with s/p aortic replacement REASON FOR THIS EXAMINATION: TLS spine to r/o infarct in patient with signif decreased mobility ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Decreased mobility status post aortic replacement.,1
MR OF THE LUMBAR SPINE AND LOWER THORACIC SPINE WITH GADOLINIUM: FINDINGS: There is no evidence of abnormal cord morphology or signal.,0
There is mild disc bulging at L2-3.,0
There is no evidence of focal disc protrusion.,0
There is a hemangioma within the body of L4.,0
There is no evidence of disc infection.,0
There is no evidence of paravertebral or epidural mass.,0
"IMPRESSION: Minimal disc bulging, L2-3.",0
No evidence of cord compression or intrinsic cord abnormality.,0
4:08 PM MRA ABDOMEN W&W/O CONTRAST Clip # Reason: celiac SMA/Renal arteries Admitting Diagnosis: ANEURYSM\THORACOABDOMINAL ENDARTERECTOMY/ RIGHT PARTIAL BYPASS; LUBAR DRAIN Contrast: MULTIHANCE Amt: 17 ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman s/p thoracoabd.,1
repair REASON FOR THIS EXAMINATION: celiac SMA/Renal arteries No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post thoracoabdominal aneurysm repair.,1
Elevated LFTs in 3000s and elevated total bilirubin.,0
"Evaluate for perfusion of the celiac artery, SMA and renal arteries.",0
"COMPARISON: CTA of the chest and abdomen, .",0
TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were performed prior to and following the administration of 17 cc of MultiHance contrast.,0
IFIR images were also obtained.,0
MRA OF THE ABDOMEN: There is heterogeneous signal intensity at the left lung base with enhancing plate-like tissue likely representing atelectatic lung.,0
"There is T2 bright fluid adjacent to the aorta in this area, likely representing effusion or seroma, with a small amount of T1-bright blood products and some enhancement of the pleural.",0
The abdominal aorta is significantly smaller in size (2.9 cm in diameter) compared to the prior CTA.,0
"The proximal portion of the celiac axis, SMA and renal arteries are also enlarged compared to the prior exam, also consistent with grafting material.",0
"There is attenuation and irregularity of each of these vessels at their anastomosis with the native vessel (series 1501, images 41, 51, 59, 62 and 64), however, all of the major vessels are patent and opacify normally.",0
"The right and left hepatic arteries are patent, and there is an accessory left hepatic artery arising from the left gastric artery.",0
"There is slight heterogeneity to the perfusion of the lateral segment of the left lobe of the liver, of uncertain significance.",0
"The remainder of the liver appears normal in signal intensity, and there is no evidence of fatty infiltration.",0
"The spleen, gallbladder, pancreas and right adrenal gland are normal.",0
The left adrenal gland is not well visualized.,0
The right kidney enhances normally.,0
There is slightly decreased enhancement along the medial aspect of the left kidney (1501:56).,0
"There are also two cysts within the left kidney, measuring 2.7 cm in the interpolar region and 1.1 cm in the lower pole, both of which demonstrate some T1 hyperintensity within, which likely represent blood or proteinaceous material.",0
The intra-abdominal small and large bowel loops are grossly normal.,0
There is a small amount of free fluid in the pelvis (5:12).,0
A 1.7 cm right adnexal cyst is noted.,0
(Over) 4:08 PM MRA ABDOMEN W&W/O CONTRAST Clip # Reason: celiac SMA/Renal arteries Admitting Diagnosis: ANEURYSM\THORACOABDOMINAL ENDARTERECTOMY/ RIGHT PARTIAL BYPASS; LUBAR DRAIN Contrast: MULTIHANCE Amt: 17 ______________________________________________________________________________ FINAL REPORT (Cont) There is slight rightward dextroscoliosis of the lumbar spine.,1
The bone marrow signal is normal.,0
A left-sided Tarlov's cyst is noted at approximately the S2 level.,0
"Status post thoracoabdominal aortic graft placement with grafting of the celiac artery, SMA, and renal arteries.",1
"There is slight mural irregularity at the sites of the anastomoses, however, all of these vessels remain patent.",0
"Slight heterogeneous perfusion on the left lateral segment of the liver, of uncertain significance.",0
Left-sided pleural effusion/seroma with associated atelectasis.,0
"Slightly decreased enhancement of the medial left kidney, which may be due to ischemia.",0
Proteinaceous or hemorrhagic left renal cysts.,0
"Findings were discussed with , nurse practitioner c surgery, at 6:30 p.m. on .",0
8:18 AM CHEST (PORTABLE AP) Clip # Reason: Eval.,0
for interval change Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with hypoxia REASON FOR THIS EXAMINATION: Eval.,0
for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia.,0
"FRONTAL CHEST RADIOGRAPH: Endotracheal tube, nasogastric tube, right-sided PICC and left-sided central line are in unchanged position.",0
Multiple lines and tubes including biliary drain again seen overlying the abdomen.,0
Cardiac and mediastinal contours appear stable.,0
"Increasing layering bilateral effusions, left greater than right are identified.",0
There is also increase in retrocardiac opacity.,0
IMPRESSION: Increasing bilateral left greater than right pleural effusions.,0
"Increasing retrocardiac opacity, likely a combination of atelectasis and effusion, although consolidation cannot be excluded.",0
"5:02 AM CHEST (PORTABLE AP) Clip # Reason: ETT placement, interval change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 83 yo F w/ H1N1 & superimposed PNA, intubated for respiratory failure REASON FOR THIS EXAMINATION: ETT placement, interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Endotracheal tube placement.",1
FINDINGS: Portable AP upright chest radiograph is compared with that performed on the same date at 12:42 A.M.: The endotracheal tube terminates 2.5 cm above the carina.,0
New right central venous catheter is unchanged in position.,0
Again seen is a left-sided pacemaker and left upper abdominal clips.,0
The orogastric tube terminates beneath the diaphragm.,0
There is slight improved aeration of right lung consolidation within the right upper and lower lobes.,0
There is no consolidation appreciated within the left lung.,0
"1:18 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: MULTIPLE FXS,S/P FALL ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall, multiple facial fractures.",1
"COMPARISON: CT head, performed on the same day.",0
TECHNIQUE: CT orbit with no IV contrast was performed in the axial plane.,0
Coronal reconstructions were then performed.,0
FACIAL CT WITH NO IV CONTRAST: Again multiple nasal fractures are seen.,1
There is associated deviation of the nasal bones to the left.,1
Fractures are seen through the anterior and medial walls of the maxillary sinuses bilaterally.,1
There is a fracture of the medial wall of the left orbit and small amount of air is seen within the right orbit adjacent to the lamina paprycea.,0
There are fractures of the pterygoid plates bilaterally.,0
"There is also a small amount of air in the right orbit adjacent to the lamina papyrecea and the superior orbital fissure, also suspicious for a right orbital wall fracture.",0
Although this is not readily identified.,0
"There is extensive subcutaneous emphysema tracking along the temporal bones bilaterally, within the masticator and pterygopalatine spaces on both sides, posterior to the posterior wall of the maxillary antra bilaterally and anterior and lateral to the maxillae and masticator muscles.",1
There is high attenuation material consistent with blood within the paranasal sinuses.,0
Air fluid levels are present within the sphenoid and frontal sinuses and left maxillary sinus.,0
Nasal packing material is present in the left anterior nasal cavity.,0
A right nasal tube is present.,0
Premaxillary soft tissue swelling is present on the right and to a lesser extent on the left.,0
"Small pockets of air again noted in the right orbit adjacent to the lamina paprycea, although fracture site is not readily identified.",0
The coronal reconstruction images are consistent with the above findings.,0
IMPRESSION: Multiple facial fractures as described above.,1
"7:31 AM CHEST (PORTABLE AP) Clip # Reason: 78 yo female with lonstanding pulmonary history, including o ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with OSA, PHTN, chronic hypercapnea.",1
"REASON FOR THIS EXAMINATION: 78 yo female with lonstanding pulmonary history, including obstructive sleep apnea, pulmonary hypertension, and chronic hypercapneic respiratory failure.",1
"Admitted to MICU yesterday following worsening respiratory decompensation at home, duiresed approximately 2 liters overnight.",0
"Please evaluate for CHF, pneumonia, effusion.",0
______________________________________________________________________________ FINAL REPORT Comparison with the prior study from .,0
INDICATION: Chronic hypercapnia and pulmonary hypertension.,1
Despite the AP projection there is concern for cardiomegaly.,0
In addition the left hemidiaphragm is completely obscured consistent with left lower lobe atelectasis or consolidation.,0
There is blunting of the costophrenic angles bilaterally consistent with bilateral pleural effusion.,0
The lungs are otherwise relatively clear.,0
CONCLUSION: 1) Possible left lower lobe atelectasis/collapse.,0
2) Small bilateral pleural effusions.,0
11:54 AM PORTABLE ABDOMEN Clip # Reason: check NG placement Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with REASON FOR THIS EXAMINATION: check NG placement ______________________________________________________________________________ FINAL REPORT STUDY: Nasogastric tube placement.,0
Single upper view of the abdomen demonstrates that the side port of the nasogastric tube is above the gastroesophageal junction.,0
This should be advanced several centimeters for more optimal placement.,0
There is air and stool seen throughout the transverse colon.,0
No definite free air is identified.,0
Degenerative changes are seen of the lumbar spine.,0
"IMPRESSION: The nasogastric tube is high, and the side port and tip could be advanced further for more optimal placement.",0
"3:06 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with morbid obesity, s/p trach with persistent fevers amd sputum production REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 31 y/o woman with morbid obesity, status post trach.",1
Persistent fevers and sputum production.,0
A single semi-upright portable chest radiograph was obtained and is compared to the next prior study of .,0
There is a tracheostomy tube in place which appears offset to the right with respect to the tracheal air column.,0
An NG tube is again identified with its tip passing out of the field of view of this study.,0
Penetration of the thorax is suboptimal secondary to the patient's body habitus.,0
"Allowing for these limitations, there is stable cardiac enlargement with some upper zone redistribution of the pulmonary vascularity.",0
"Again noted are bilateral ill-defined infiltrates in the lower lung zones, with blunting of the costophrenic angles which have cleared slightly in the interval since the prior study.",0
No new infiltrates are identified.,0
IMPRESSION: 1) Slight interval clearing of infiltrates in the lower lung zones bilaterally.,0
2) Questionable position of the tracheostomy tube with respect to the tracheal air column.,0
This should be assessed clinically.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline Attending: Chief Complaint: increased chest tightness with exertion Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 3 on History of Present Illness: 73 year old surgeon with increased chest tightness with exertion, over the last 3 years.",1
"Had EKG changes in , followed by stress echo on .",0
"Pre-stress EF 60%, post-stress EF 50% with some ST depressions.",0
"Had cath which showed LAD 100%, diag 70%, CX 100%, OM1 60%, RCA 70%, EF 45%, 1+ MR.",0
Referred for CABG to Dr. .,0
Past Medical History: BPH elev.,0
esophageal spasm s/p RIH appy R mastoidectomy age 6 diverticulosis (colonoscopy ) Social History: semiretired surgeon married Family History: neg.,0
"for CAD Physical Exam: 5'7"" 167# NAD AVSS NC/AT, PERRLA, EOMI, oropharynx benign neck supple, full ROM, no lymphadenopathy or thyromegaly, carotid 2+ bilat without bruits lungs CTAB S1S2 no m/r/g RRR soft, NT, ND, no HSM or masses extrems no c/c/e neuro non-focal Pertinent Results: 06:00AM BLOOD Hct-23.2* 06:45AM BLOOD PT-12.7 INR(PT)-1.1 06:45AM BLOOD Plt Ct-263 06:45AM BLOOD Glucose-136* UreaN-25* Creat-1.1 Na-138 K-4.2 Cl-100 HCO3-27 AnGap-15 05:55AM BLOOD UreaN-21* Creat-0.9 K-4.7 Brief Hospital Course: Admitted and underwent CABG x3 (LIMA to LAD, SVG to ramus, SVG to diag ) with Dr. .",0
Transferred to the CSRU in stable condition on titrated propofol and neosynephrine drips.,0
Transferred to the floor on POD #1 and gentle diuresis started.,0
Beta blockade was also begun.,0
He began to increase his activity level and chest tubes and central line were removed on POD #2.,0
"HCt decreased to 23 on POD #3, but patient wished to avoid transfusion, so iron and Vit.C were started.",0
"Pacing wires were removed on POD #3.HCt decreased to 21 on POD #4 and he was somewhat tachycardic, but did not want to be transfused.",0
Low dose ACE started on the day of discharge also.,0
"Hct up to 23.2 on POD #5, patient asymptomatic, and cleared for discharge to home with VNA.",0
Medications on Admission: lipitor 20 mg daily ASA 81 mg daily Discharge Medications: 1.,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks.,0
Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks.",0
"Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 8.",0
Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Hypercholesterolemia esophageal spasm BPH Discharge Condition: Good Discharge Instructions: Can take shower.,1
Wash incisions with gentle soap and water.,0
"Do no apply lotions, creams, ointments, or powders to incisions.",0
Do no drive for 1 month.,0
Do not lift more than 10 pounds for 10 weeks.,0
If you notice sternal drainage or experience fever greater than 101.5 please contact office immediately.,0
p Instructions: Dr. in 4 weeks Dr. in weeks Dr. in weeks Completed by:,0
3:46 PM CT HEAD W/O CONTRAST Clip # Reason: ?,0
SEIZURE ACTIVITY Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with ?,0
seizure activity REASON FOR THIS EXAMINATION: R/O intracranial hemorrhage No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT HEAD CLINICAL INFORMATION: ?,0
TECHNIQUE: Non-contrast axial head CT.,0
FINDINGS: No evidence of hemorrhage.,0
"No hydrocephalus, midline shift, or effacement of the basal cistern is identified.",0
-white matter differentiation is within normal limits.,0
"Review of bone windows demonstrates no bony abnormalities, or discernable radiolucent fracture line.",0
"8:59 AM CHEST (PORTABLE AP) Clip # Reason: interval change of infiltrate, effusion Admitting Diagnosis: HEPATIC FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with hx of pneumonia, hepatopulmonary syndrome, aspiration risk, recently extubated and completed 7 day course for VAP, with continued secretions and sob REASON FOR THIS EXAMINATION: interval change of infiltrate, effusion ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess for pneumonia.",1
Bibasilar atelectasis are grossly unchanged.,0
8:24 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change.,0
"Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with pancreatitis, febrile o/n, ESRD.",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient with fever and known pancreatitis.,0
The patient continues to be in mild volume overload giving the bilateral hilar engorgement and perihilar vascular engorgement as well as indistinctness of the perihilar vessels.,0
"The degree of the vascular engorgement/pulmonary edema is unchanged, mild.",0
"Bibasilar opacities are present but overall, there is improved aeration of the lung bases.",0
Small bilateral pleural effusion is unchanged.,0
"There are no new focal consolidations, but the left retrocardiac opacity might represent a combination of atelectasis and infection.",0
"Admission Date: Discharge Date: Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Left sided chronic loculated subdural hematoma with significant mass effect, and right sided acute and chronic septal hematoma with mass effect.",1
"Major Surgical or Invasive Procedure: Left sided bur hole evacuation of left sided chronic subdural hematoma, membrane lysis, evacuation of cystic fluid, and right sided bur hole evacuation of acute and chronic subdural hematoma.",1
"History of Present Illness: 86yoM with h/o Anemia, Afib off anticoagulation, CAD, bi ventricular CHF (EF 30%), hypothyroidism, transferred from nursing facility.",1
"Patient was admitted in with decompensated heart failure, and again in with a low hematocrit.",1
He has been worked up for hematocrit (presumed GI bleed)however colonscopy did not find a source.,0
"He had required near weekly transfusions, now stable on procrit.",0
His family reports a fall approximately 3 weeks ago while on Coumadin.,0
The coumadin has subsequently stopped the coumadin due to low crits and fall risk.,0
Approximately 1 week ago he was noted to have near complete paralysis of his RUE and dragging right leg.,0
His family has noted that it has improved over the last week to the point where he can lift his right arm now.,0
"Past Medical History: Atrial fibrillation Biventricular failure (EF 30%) Coronary artery disease (pMIBI with partially reversible lateral and inferior defects) Hypothyroidism Anemia Social History: previously lives alone; transferred from Center Tob: smoked pipe x60yrs, quit 2mos ago EtOH: none Family History: non-contributory Physical Exam: O: T:97.9 BP: 122/66 HR:82 R 15 O2Sats Gen: cachetic ill/ appearing, awake and cooperative HEENT: Pupils: slightly reactive EOMs Neck: Supple.",1
"CV: irreg irreg, II/VI SEM at LLSB, PMI nondisplaced Resp: CTA Abd: thin, cachectic, +BS, soft, NT, ND; large right inguinal hernia Ext: no edema, 1+ DP pulses Neuro: Mental status: Awake and alert, cooperative with exam, normal affect.",0
"Cranial Nerves: I: Not tested II: Pupils equally round and slightly reactive to light, 3mm Visual fields are full to confrontation.",0
"VIII: Hearing decreased IX, X: Palatal elevation symmetrical.",0
"Motor: B T IP AT G R 4- 4- 4- 3 3 4- L 5 5 5 5 5 5 (less than 5 but equal/ full based on age) Profound right sided drift Sensation: Intact to light touch, Reflexes: unable to illicit Toes downgoing bilaterally Pertinent Results: 11:45PM BLOOD WBC-9.1 RBC-3.29* Hgb-10.6* Hct-32.6* MCV-99* MCH-32.1* MCHC-32.4 RDW-17.7* Plt Ct-180 11:45PM BLOOD PT-17.0* PTT-63.5* INR(PT)-1.6* 11:45PM BLOOD Glucose-348* UreaN-36* Creat-1.2 Na-140 K-4.1 Cl-107 HCO3-23 AnGap-14 11:05PM BLOOD Glucose-192* UreaN-37* Creat-0.6 Na-142 K-5.2* Cl-109* HCO3-21* AnGap-17 11:45PM BLOOD CK-MB-7 cTropnT-0.07* 06:20AM BLOOD Phenyto-9.4* 11:49PM BLOOD Type-ART pO2-297* pCO2-56* pH-7.18* calHCO3-22 Base XS--7 Brief Hospital Course: The patient was admitted to on for bilateral subdural hematomas.",0
"A CT of his head from that date confirmed the presence of large bilateral subdural hematomas, with chronic and acute components.",1
A carotid ultrasound deomnstrated less than 40% bilateral carotid stenosis.,0
A medicine consult was obtained on HD 2 because of his significant comorbidities.,0
They declared him at is at low-moderate risk of developing cardiovascular complications during his anticipated surgery and recommended continuing current care.,0
"The following day, the patient underwent a left sided bur hole evacuation of left sided chronic subdural hematoma, membrane lysis, evacuation of cystic fluid.",1
"In addition, he also had a right sided bur hole evacuation of acute and chronic subdural hematoma.",1
The operation was performed by Dr. and it went well with no complictions (please see operative note for details).,0
A post-operative CT demonstrated stable appearance of bilateral subdural hematomas with chronic and acute components causing flattening of both cerebral hemispheres.,1
"It also showed interval development of moderate pneumocephalus, most prominently seen at the frontal lobes with increasing mass effect.",0
"After reviewing this scan, the patient was given 100% FiO2 and kept flat for 48 hours.",0
He was given perioperative ancef as well as morphine for pain.,0
He was also give dilantin 100mg TID.,0
He was transferred to step down in stable condition on POD 1.,0
"On POD 2, he was noted to be alert and oriented to self, but not totally cooperative.",0
His pupils were reactive but sluggish.,0
He was able to follow commands.,0
He was transfused one unit of RBCs for blood loss anemia.,0
His 100% O2 was discontinued.,0
"On POD 3, he was still not quite strong enough to be discharged back to his rehabilitation center.",0
His metoprolol was increased for tachycardia.,0
"That night, he sustained sudden and unexpected cardiopulmonary arrest.",0
His nurse found him unresponsive and not breathing.,0
"She proceeded to call a ""code blue.""",0
Several physicians responded and proceeded to resuscitate the patient.,0
"He was intubated emergently and treated with epinepherine, atropine, chest compressions, and ultimately cardioversion.",0
We were able to obtain a sinus rhythum.,0
A right groin line was placed for access.,0
He was transferred to the ICU for further monitoring.,0
"Due to the extremely grave nature of his prognosis, his daughter subsequently decided to declare him DNR.",0
He was treated with a morphine drip for comfort and died at 3:30am on POD 4.,0
"Medications on Admission: metoprolol XL, folic acid, MVI, atorvastatin, levothyroxine, colace, albuterol/atrovent Discharge Disposition: Expired Discharge Diagnosis: bilateral subdural hematomas, CHF, A-fib, blood loss anemia Discharge Condition: dead Discharge Instructions: none Followup Instructions: none Completed by:",1
"3:23 PM CTA HEAD W&W/O C & RECONS Clip # Reason: evaluate for spasm Admitting Diagnosis: SUBARACHNIOD HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 45 y/o c/o HA, SAH on CT, basilar aneurysm s/p coil of left pica aneurysm REASON FOR THIS EXAMINATION: evaluate for spasm No contraindications for IV contrast ______________________________________________________________________________ WET READ: JMGw SAT 4:13 PM tip of right frontal approach shunt appears to be in the right frontal , displaced since .",0
"increased 7mm focus of hyperdense hemorrhagic products in the region of the left parietal , be layered SAH, although slighly enlarging intraparenchymal hemorrhage cannot be excluded.",0
ventricles stable to slight decrease in size with stable low lying cerebellar tonsils.,0
left PICA coils cause streak.,0
final read pending 3d recons.,0
prelim read discussed with dr. ______________________________________________________________________________ FINAL REPORT EXAM: CTA of the head.,0
"CLINICAL INFORMATION: Patient is status post PICA aneurysm coiling, for further evaluation to exclude vasospasm.",0
TECHNIQUE: Axial images of the head were obtained without contrast.,0
"Following this, using departmental protocol, CT angiography of the head was acquired.",0
Comparison was made with the previous CT of .,0
FINDINGS: HEAD CT: There is a right frontal ventricular drain identified with the tip minimally within the anterior of the right lateral ventricle.,0
This appears to be withdrawn since the previous CT examination.,0
There has been evolution of the blood products in the subarachnoid space.,0
A small hyperdensity in the left parietal cortical/subcortical region appears to be layering blood or small area of intraparenchymal hemorrhage.,0
There is no midline shift.,0
No loss of -white matter differentiation seen.,0
The cerebellar tonsils appear to be slightly low in position below the level of foramen magnum.,0
A coil artifact is seen in the region of left cerebellomedullary angle.,0
CT ANGIOGRAPHY OF THE HEAD: There is mild decreased caliber of the anterior and posterior circulation arteries visualized compared to the initial CT angiography of indicating mild non-occlusive vasospasm.,0
No vascular occlusion is identified.,0
Slightly bulbous tip of the basilar artery is again seen.,0
No other aneurysms are identified.,0
(Over) 3:23 PM CTA HEAD W&W/O C & RECONS Clip # Reason: evaluate for spasm Admitting Diagnosis: SUBARACHNIOD HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,0
Head CT demonstrates no evidence of new hemorrhage with evolution of previously seen hemorrhage.,0
Other findings as described above.,0
"CT angiography of the head demonstrates slightly decreased caliber of the arteries of anterior and posterior circulation when compared to the initial CT of , which is suggestive of mild non-occlusive vasospasm.",0
"6:06 AM CHEST (PORTABLE AP) Clip # Reason: eval failure, ptx, infiltrate Admitting Diagnosis: CHANGE IN MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with aspiration PNA, hypoxemia REASON FOR THIS EXAMINATION: eval failure, ptx, infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Aspiration pneumonia and hypoxemia.",1
Comparison is made with the prior chest x ray from .,0
SUPINE AP CHEST: There is an ETT in stable position.,0
There is a VP shunt overlying the right hemithorax.,0
There is stable left ventricular enlargement.,0
The pulmonary vascularity is not changed.,0
There is interval development of new left lower lobe atelectasis/consolidation.,0
There is also some minor atelectasis at the right base.,0
IMPRESSION: Interval worsening of left lower lobe atelectasis/consolidation.,0
"3:18 PM CT HEAD W/O CONTRAST Clip # Reason: ICH, CVA Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with Afib, not anticoagulated, admitted with pna now with mental status changes.",0
"REASON FOR THIS EXAMINATION: ICH, CVA CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old with AFIB, admitted with pneumonia and change in mental status.",0
TECHNIQUE: Contiguous axial images through the brain were obtained without intravenous contrast.,0
"FINDINGS: There is no intra- or extra-axial hemorrhage, mass, edema or shift of midline structures.",0
No major or minor vascular territorial infarction is identified.,0
There is dilatation of the ventricles which appears out of proportion with sulcal atrophy raising the possibility of underlying communicating hydrocephalus.,0
Comparison with prior studies would be useful.,0
Periventricular and subcortical white matter hypodensity is consistent with chronic microvascular ischemia.,0
The visualized paranasal sinuses are well aerated.,0
There is opacification of the bilateral mastoid air cells which may be inflammatory.,0
There is diffuse anasarca in the regional soft tissues.,0
Increase density of tentorium and falx due to calcification.,0
No intracranial hemorrhage or mass effect.,0
Dilatation of the ventricles which appears out of proportion to sulcal atrophy.,0
"While findings may represent central atrophy, underlying communicating hydrocephalus is not excluded.",0
Correlation with clinical presentation is recommended.,0
Changes of chronic microvascular ischemia.,0
"Opacification of the mastoid air cells, likely inflammatory.",0
"12:00 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate for mass, mass effect ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with h/o prostate ca and R MCA stroke transfer from OSH with persistent fevers on 2 weeks broad abx now with change in MS (obtundation).",0
"REASON FOR THIS EXAMINATION: evaluate for mass, mass effect No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Mental status change fevers history of prostate CA and right MCA stroke.",0
TECHNIQUE: Non-contrast head CT FINDINGS: There is a small left posterior frontal region of hypodensity consistent with a chronic infarction.,0
There is a larger area of hypodensity extending through the distribution of the anterior division of the right middle cerebral artery.,0
There is encephalomalacia in this region.,0
There is no evidence of mass effect.,0
The ventricles cisterns and sulci are not dilated.,0
There is no evidence of acute intracranial hemorrhage.,0
The osseous structures and visualized paranasal sinuses are normal.,0
IMPRESSION: There is evidence of chronic infarctions involving the distribution of the right anterior division of the middle cerebral artery and a small posterior left frontal infarction.,0
There is no mass effect.,0
"6:31 PM CHEST (PORTABLE AP) Clip # Reason: CHEST PAIN, SOB ______________________________________________________________________________ FINAL REPORT INDICATION: An 82-year-old man with chest pain and shortness of breath.",0
Portable AP chest radiograph demonstrates motion limiting the diagnostic value of the exam.,0
There is cardiomegaly with a left ventricular configuration to the heart.,0
There is engorgement of the pulmonary vascularity and diffuse hazy appearance to the lungs with interstitial infiltrates extending to the periphery.,0
This is suggestive of severe interstitial and alveolar pulmonary edema.,0
There is blunting of both costophrenic angles consistent with pleural effusions.,0
There is mild gastric distention.,0
There is an ACID entering from the left whose tip cannot be clearly identified on this single projection.,0
There is a dual-lead pacer entering from the right with its leads in appropriate position on this single projection.,0
IMPRESSION: Cardiomegaly and severe interstitial and alveolar pulmonary edema.,0
Underlying infectious process cannot be excluded.,0
", S. MED 1:10 PM BLADDER VOLUMETRIC US PORT; US ABD LIMIT, SINGLE ORGAN Clip # Reason: ?",0
"true bladder volume, evidence adhesions Admitting Diagnosis: MULTIPLE MYELOMA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with MM s/p chemo and SCT with bladder spasm and incomplete bladder emptying with foley in place REASON FOR THIS EXAMINATION: ?",1
"true bladder volume, evidence adhesions ______________________________________________________________________________ PFI REPORT Persistent moderate ascites, particularly in the pelvis.",1
"Bladder is collapsed around Foley catheter, with no residual.",0
This was confirmed by instillation of sterile saline into the bladder.,0
"2:42 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed, eval for interval change Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with REASON FOR THIS EXAMINATION: r/o bleed, eval for interval change No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 4:35 PM No intracranial hemorrhage.",0
"Subtle hypodensity along the parasagittal right frontal lobe, corresponding to infarct, better evaluated on MRI.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for bleed or interval change.,0
"COMPARISON: CT/CTA, , MRI, .",0
"FINDINGS: There is no intracranial hemorrhage, shift of midline structures, or hydrocephalus.",0
"Subtle hypodensity along the parasagittal right frontal lobe is identified, which would be consistent with distal right ACA territory infarct identified on the prior MRI.",0
-white matter differentiation otherwise appears unremarkable.,0
IMPRESSION: No evidence of acute intracranial hemorrhage.,0
"Subtle hypodensity along the parasagittal right frontal lobe, corresponding to infarct, better evaluated on prior MR.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: new line placement Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH AVR ?,1
"MYOMECTOMY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with s/p CAGB, MVR REASON FOR THIS EXAMINATION: new line placement ______________________________________________________________________________ WET READ: 9:23 PM 1. post sternotomy changes.",0
RIJ sheath exhanged for a new line w/ tip at caval atrial junction and w/o evidence of complication.,0
3. continued mild pulmonary edema and small bilateral pleural effusions w/ associated atelectasis.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Portable line.,0
"FINDINGS: In comparison with study of earlier in this date, there has been placement of a right IJ catheter that extends to about the level of the cavoatrial junction.",0
"Continued enlargement of the cardiac silhouette with elevation of pulmonary venous pressure and small bilateral pleural effusions with bibasilar atelectasis, more prominent on the left.",0
"1:43 PM CHEST (PA & LAT) Clip # Reason: evaluate for effusion Admitting Diagnosis: CRITICAL AORTIC STENOSIS;PULMONARY EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with POD 4 s/p CABG AVR MVR REASON FOR THIS EXAMINATION: evaluate for effusion ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG, followup pleural effusions.",1
Comparison is made with prior study .,0
Patient has known mediastinal lymphadenopathy.,0
Moderate bilateral pleural effusions have increased.,0
Small right pneumothorax is new.,0
Moderate degenerative changes are in the thoracic spine.,0
Findings were discussed by phone on at 2:30 p.m. with .,0
3:56 PM BABYGRAM (CHEST ONLY) Clip # Reason: r/o atelectasis/pneumonia Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: infant with CO2 retention REASON FOR THIS EXAMINATION: r/o atelectasis/pneumonia ______________________________________________________________________________ FINAL REPORT PORTABLE VIEW OF THE CHEST CLINICAL HISTORY: CO2 retention.,1
The PDA ligation clip is seen in the expected location and thoracotomy changes are present in the left-sided ribs following placement of the PDA clip.,0
The nasogastric tube tip is in the stomach.,0
"The lungs are low volume and demonstrate hazy bilateral opacity, which is overall significantly improved when compared to the prior film.",0
No focal abnormalities are seen.,0
11:39 AM CHEST (PORTABLE AP) Clip # Reason: eval for pneumothorax s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH RADIAL ARTERY /SDA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT HISTORY: 71-year-old male status post CABG.,1
Please evaluate for pneumothorax after chest tube removal.,0
COMPARISON: Chest radiograph from two days prior.,0
"SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: A right internal jugular Swan-Ganz catheter, an endotracheal tube, and a nasogastric tube have been removed.",0
There is evidence of improved hyperhydration.,0
There is slight increase in density of the left retrocardiac opacity consistent with atelectasis.,0
There is no evidence of pleural effusion or infectious consolidation.,0
There is no change in appearance of CABG clips or sternotomy wires.,0
The bony thorax is otherwise unremarkable.,0
IMPRESSION: Increase in left retrocardiac atelectasis.,0
"No evidence of effusion, pneumothorax, or pneumonia.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is a 20 year old male who was brought in by ambulance to the Trauma Bay following a high speed motor vehicle collision where he was ejected through the front windshield.,1
"He was found to have decreased mental status at the scene, was noted to be vomiting, and also tachycardic, hypotensive and was electively intubated on the scene.",0
"In the Emergency Department, he was noted to be moving all four extremities.",0
PAST MEDICAL HISTORY: Unable to be obtained on presentation.,0
PAST SURGICAL HISTORY: Unable to be obtained on presentation.,0
ALLERGIES: Unable to be obtained on presentation.,0
MEDICATIONS ON ADMISSION: Unable to be obtained on presentation.,0
"PHYSICAL EXAMINATION: On physical examination, he was noted to be sedated, intubated.",0
"The pupils were equal, round and reactive to light and accommodation.",0
His extraocular movements were intact.,0
His pupils were two millimeters but responsive.,0
His heart was tachycardia but regular.,0
His chest had breath sounds that were equal bilaterally with rhonchi on the left.,0
"His extremities - He was noted to have open fractures of his bilateral hands, as well as laceration of his left knee.",1
"His femoral, popliteal and dorsalis pedis and posterior tibial pulses were all two plus bilaterally.",0
"On rectal examination, he was guaiac negative, normal tone.",0
"LABORATORY DATA: His initial laboratories were significant for a hematocrit of 32.5, white blood cell count 13.6, platelet count 198,000.",0
"Sodium 134, potassium 4.0, chloride 113, creatinine 0.9, glucose 119, amylase 40.",0
His urine toxicology was positive for benzodiazepines.,0
His chest x-ray showed a right pneumothorax and subcutaneous emphysema as well as bilateral lung contusions and right sided rib fractures and bilateral clavicular fractures as well as multiple pelvic fractures.,1
His head CT had no evidence of intracranial hemorrhage.,0
Cervical spine showed no fracture of the cervical vertebra with possible widening of the atlantoaxial distance and prevertebral soft tissue swelling as well as possible foreign body anteriorly to C6.,1
"Hand x- rays showed third, fourth and fifth metacarpal fractures of his right hand and a small fracture fragment dorsum of the wrist likely from a fifth metacarpal or triquetrum.",1
CT of the thoracic spine demonstrated no fracture.,0
CT of the lumbar spine showed bilateral spondylolysis at L4-5 with no definitive evidence of acute spine fracture.,1
"HOSPITAL COURSE: In the Trauma Bay, the patient had a chest tube placed on the right side for pneumothorax and was given ten liters of intravenous fluids as well as two units of packed red blood cells.",1
His peritoneal lavage was grossly positive and the patient was taken emergently to the operating room where exploratory laparotomy and splenectomy were performed and the liver was packed.,0
The abdomen was left opened.,0
It was closed the following day.,0
The patient was then admitted to the Surgical Intensive Care Unit.,0
"In addition, the orthopedic service and plastic surgery service were consulted.",0
"The patient was started on Flagyl, Levaquin and Ampicillin prophylaxis for his injuries.",0
"On hospital day number two, postoperative day number one, plastic surgery service washed out his right hand open metacarpal fracture.",0
"On hospital day number three, postoperative day number two, the patient remained in stable condition with stable vital signs.",0
"He did, however, remain intubated on SIMV with oxygen of 40 percent and total volume of 500.",0
He was continued on all his antibiotics.,0
"On , hospital day three, postoperative day number two, the patient was taken to the operating room by the orthopedic surgery service where his left pelvis fracture was fixed with an open reduction internal fixation and he was discovered to have a Classification LC2 pelvic fracture.",1
"The patient tolerated this procedure well and returned to the Surgical Intensive Care Unit where he remained intubated and sedated with a Propofol, Fentanyl and Cisatracurium drips and also continued on Flagyl, Levaquin and Ampicillin.",0
He continued to have increasing ventilator requirements possibly secondary to his bilateral pulmonary contusions.,0
"On hospital day number five, total parenteral nutrition was started.",0
"His paralysis was discontinued and he continued to be diuresed, however, he remained intubated on Propofol and Fentanyl drips.",0
"On postoperative day number five from his liver laceration repair and splenectomy, hospital day six, he was extubated, however, upon extubation, the patient was found to be somewhat agitated and self discontinued his nasogastric tube.",1
"His vital signs, however, remained stable.",0
"Repeat chest x-ray on hospital day seven, postoperative day number six, demonstrated continued persistent right pneumothorax and the chest tube was left in place, however, put to water seal.",1
"On postoperative day number seven and five from his repair of his pelvic fracture, the patient was discharged from the Surgical Intensive Care Unit and sent to the floor.",1
"He remained, however, on Ampicillin, Levofloxacin and Flagyl.",0
He remained somewhat agitated and confused and was requiring a one to one sitter.,0
"However, his vital signs were stable.",0
"On hospital day nine, postoperative day number eight and six, the patient began having flatus and the physical therapy and occupational therapy services were consulted.",0
"He was vaccinated with Hemophilus influenza B, Pneumovax and meningococcal vaccinations, as well as the influenza vaccine.",0
"In addition, although his cervical spine collar had been removed in consultation with the spine service, cervical spine collar was reapplied for concerns about prevertebral edema and potential soft tissue injury of his cervical spine.",1
"In addition, the spine surgery service commented that the bilateral spondylolysis which was asymptomatic and likely posttraumatic required no urgent treatment and only follow-up flexion and extension x-rays as an outpatient.",0
Hospital day eleven he continued to be stable and somewhat tachycardic and requiring fluid boluses.,0
"On hospital day twelve, postoperative day number eleven and nine, the plastic surgery service repaired his right hand fractures with open reduction internal fixation of his third, fourth and fifth metacarpal fractures.",1
"On hospital day twelve, postoperative day number twelve, ten and one, the patient was discharged home in good condition with medications for pain control, crutches, strict instructions about being nonweight-bearing on his left lower extremity, and strict follow-up with the Trauma Surgery service, the Orthopedic service, and the Plastic Surgery service.",0
"DISCHARGE DIAGNOSES: Right hand third, fourth and fifth metacarpal fractures.",1
Soft tissue cervical spine injury.,0
"FOLLOW UP: The patient is to follow-up with Dr. of Orthopedics on , and follow-up in the Trauma Clinic on , and follow-up with the Plastic Surgery service on .",0
"In addition, he was instructed to leave the splint on his right hand and to be nonweight-bearing on his left lower extremity.",0
", Dictated By: MEDQUIST36 D: 18:56:46 T: 19:10:12 Job#:",0
4:16 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with increased O2 requirements.,0
"REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Increased oxygen requirement, evaluate interval change.",0
FINDINGS: Single AP view chest shows ET tube to be 4.1 cm above the carina.,0
A left PICC terminates in the mid-to-low SVC.,0
A right IJ catheter terminates within the right atrium and could be safely withdrawn 4 cm to be at the atriocaval junction.,0
An OG tube is seen extending well past the GE junction.,0
"The bilateral opacities are likely from pulmonary edema, but an underlying pneumonia cannot be excluded.",1
These are slightly improved from prior.,0
Again seen is moderate pulmonary edema and left lower lobe atelectasis.,0
IMPRESSION: No change in moderate pulmonary edema.,0
"3:18 PM CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o PE Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with hypotension and min responsive, hypoxic, Trop 4, ?syncope REASON FOR THIS EXAMINATION: r/o PE ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old female with hypotension and hypoxia.",0
TECHNIQUE: Contiguous helical images of the thorax were obtained after the administration of 100 of intravenous Optiray.,0
Optiray was used per the fast bolus of the CT PA protocol.,0
"Subsequently, multiplanar reformatted images of the thorax were generated.",0
CT THORAX WITH IV CONTRAST: There are no filling defects within the main pulmonary arteries or visualized tributaries.,0
There is an endotracheal tube with tip approximately 3.5 cm above the carina.,0
A nasogastric tube passes through the esophagus.,0
There has been median sternotomy and CABG.,0
The heart demonstrates a multichamber enlargement.,0
"There are numerous mediastinal lymph nodes, specifically parartracheal, AP window, and precarinal.",0
The largest lymph node is in the precarinal region measuring approximately 1.2 cm in short axis dimension.,0
Evaluation of the lungs reveals a bibasilar consolidation/atelectasis with air bronchograms.,0
Some air trapping is evident in the right lower lobe.,0
There is a single bulla noted in the right lower lobe as well.,0
Bone windows demonstrate degenerative changes of the spine.,0
In the imaged portion of the upper abdomen the visualized dome of the liver is unremarkable.,0
MULTIPLANAR RECONSTRUCTIONS confirm above fndings.,0
IMPRESSION: 1) No evidence of pulmonary embolus.,0
3) Mediastinal lyphadenopathy as described.,0
"This may be reactive, correlate clinically.",0
(Over) 3:18 PM CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o PE Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ FINAL REPORT (Cont),0
7:48 PM CT HEAD W/O CONTRAST Clip # Reason: Acute injuries ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p fall REASON FOR THIS EXAMINATION: Acute injuries No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd SUN 9:24 PM no acute intracranial process.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old man status post fall.,0
"FINDINGS: There is no acute hemorrhage, large areas of edema, large masses or mass effect.",0
There is preservation of normal -white matter differentiation.,0
"There is complete opacification of a shruken, right maxillary sinus.",0
Contents of the right maxillary sinus measure simple fluid density.,0
This is likely due to chronic sinusitis.,0
The remainder of the paranasal sinuses and mastoid air cells are clear.,0
Complete opacification of a shrunken right maxillary sinus is likely due to chronic sinus disease.,0
"3:36 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please eval interval change Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with desat on vent, hypotension REASON FOR THIS EXAMINATION: please eval interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Hypotension, to assess for change.",0
"FINDINGS: In comparison with the earlier study of this date, the hazy opacification bilaterally is not appreciated.",0
There is still poor definition of the left hemidiaphragm that could reflect some residual pleural fluid and atelectasis.,0
Less prominent changes are seen in the opposite side.,0
No vascular congestion or acute focal pneumonia.,1
10:11 AM CT CHEST W/CONTRAST Clip # Reason: f/u after suspicious chest film showed r. apical Admitting Diagnosis: ISCHEMIC LEFT FOOT Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with REASON FOR THIS EXAMINATION: f/u after suspicious chest film showed r. apical wall thickening No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Further characterization of right apical pleural thickening demonstrated on recent chest radiograph.,0
"TECHNIQUE: Helical chest CT using 100 cc of IV Optiray contrast (allergy), and 5 mm collimation.",0
1.25 mm slice thickness image were retrospectively reconstructed.,0
CHEST CT WITH IV CONTRAST: The soft tissue window images demonstrate slight increase of pleural fat at the right apex.,0
"There is a loculated small right effusion with a thickened rind, at the posterior right lung base.",0
"There are calcified right pleural plaques and also right apical pleural thickening, which contains calcifications.",0
"There is no significant mediastinal, hilar, or axillary lymphadenopathy.",0
There are coronary artery calcifications and the patient is status post CABG.,0
There is a small axial hiatal hernia.,0
"The lung window images demonstrate centrilobular emphysematous changes, particularly at the lung apices, with biapical bullae.",0
There is right upper lobe volume loss with scarring and traction bronchiectasis.,0
There is also scarring adjacent to the right effusion.,0
There are peribronchovascular ground-glass opacities within the left upper lobe and lingula.,0
"They are also faintly seen on the scout AP images, but not on the pre-op chest radiographs of .",0
The airways are patent to the level of the segmental bronchi bilaterally.,0
"In the imaged portions of the upper abdomen, teh visualized portions of the liver, kidneys, adrenal glands, spleen, and pancreas appear normal.",0
There are calcifications of the right renal artery.,0
The skeletal structures of the thorax demonstrate no significant abnormality.,0
"Calcified right fibrothorax with right apical scarring, a small loculated right effusion, and increased right apical pleural fat.",0
"The presence of increased extrapleural fat and pleural calcification are suggestive of benign post inflammatory changes, and this constellation of findings is probably due to prior granulomatous infection.",1
"However, active disease in the pleural space cannot be excluded and sampling of pleural fluid (Over) 10:11 AM CT CHEST W/CONTRAST Clip # Reason: f/u after suspicious chest film showed r. apical Admitting Diagnosis: ISCHEMIC LEFT FOOT Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) may be considered for further evaluation.",0
Peribronchovascular ground-glass opacities within the left upper lobe and lingula.,0
"Given the apparent acute onset of this process from , this may represent asymmetric pulmonary edema, an early infectious process, or aspiration.",0
Continued follow up is recommended to ensure resolution.,0
4:42 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"change Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with respiratory failure, intubated REASON FOR THIS EXAMINATION: ?",1
"change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Respiratory failure, intubated patient.",1
"ETT tube is seen in standard position, right PICC tip is in the lower SVC.",0
The lungs are grossly clear with resolution of edema.,0
"2:31 AM CHEST (PORTABLE AP) Clip # Reason: INCREASED WOB AND C/O DIFFICULTY BREATHING Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: year old woman with small bowel obstruction, h/o CHF and HTN now with increased WOB and complaining of difficulty breathing REASON FOR THIS EXAMINATION: ?",0
worsening CHF ______________________________________________________________________________ FINAL REPORT PORTABLE UPRIGHT CHEST: Compared to CLINICAL INDICATION: Difficulty breathing.,0
A permanent pace maker remains in satisfactory position as well as a nasogastric tube.,0
The pulmonary vascularity is within normal limits for technique.,0
"Patchy opacities at both lung bases are again demonstrated, slightly worse in the interval, and there are also bilateral pleural effusions present, left greater than right.",0
There is likely a component of underlying chronic lung disease such as emphysema based on review of older chest radiographs dating back to 5/.,0
"IMPRESSION: Slight worsening of patchy bibasilar opacities, which may relate to atelectasis, aspiration or pneumonia.",0
"In a patient with underlying emphysema, atypical distribution of CHF is also in the differential diagnosis.",0
"10:19 AM PERC G/G-J TUBE PLMT Clip # Reason: Place G-tube for tube feeds Admitting Diagnosis: CHOLEDOCHOLITHIASIS\ERCP Contrast: OPTIRAY Amt: 20 ********************************* CPT Codes ******************************** * REPLACE G OR C TUBE, ALL INCL.",0
* **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with s/p multiple failed swallow evals; aspiration risk.,0
REASON FOR THIS EXAMINATION: Place G-tube for tube feeds ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 78-year-old woman treated fro Mirizzi's syndrome with course complicated by MCA CVa and now s/p 3 failed swallowing studies.,0
Requires NG tube placement for tube feeds and will require long-term enteric nutrition.,0
CLINICIANS: Dr. and Dr. .,0
"The attending, Dr. was present and supervising during the entire procedure.",0
ANESTHESIA: Moderate conscious sedation was provided by administering divided doses of 1 mg of midazolam and 50 mcg of fentanyl during the total intra-service time of one hour during which the patient's hemodynamic status was continuously monitored by a trained radiology nurse.,1
Local anesthesia was provided using 1% buffered lidocaine.,0
"PROCEDURE AND FINDINGS: After explaining the risks, benefits and alternatives to the procedure, informed consent was obtained via telephone from the patient's brother.",1
The patient was brought to the angiography suite and placed supine on the angiography table.,0
A pre-procedure huddle and timeout was performed as per protocol.,0
"Pre-procedure, a limited uppper abdominal ultrasound was performed to assess location of the left lobe of the liver in this patient with no prior cross-sectional abdominal imaging here.",1
"Under fluoroscopic guidance, a nasogastric tube was placed through the left nostril.",0
Air was injected to confirm the position of the tip of the nasogastric tube within the stomach.,0
The anterior abdominal wall was prepped and draped in the usual sterile fashion.,0
Sufficient air to inflate the stomach was injected through the Dobbhoff NG tube.,0
Fluoroscopy was used to outline the stomach.,0
"Local anesthesia was provided with 1% lidocaine and under fluoroscopic guidance, three T-fasteners were inserted sequentially through the anterior abdominal wall into the anterior stomach wall and tightened, elevating the stomach wall to the anterior abdominal wall.",0
A small skin incision was made between the three T-fasteners.,0
A 19-gauge needle was then introduced into the stomach under fluoroscopic guidance.,0
Position was confirmed by injecting a small amount of contrast.,0
A 0.035 short wire was placed through the needle and the needle removed.,0
The tract was dilated with a 12 French dilator.,0
This was followed by a placement of a 12 French (Over) 10:19 AM PERC G/G-J TUBE PLMT Clip # Reason: Place G-tube for tube feeds Admitting Diagnosis: CHOLEDOCHOLITHIASIS\ERCP Contrast: OPTIRAY Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) Wills- tube over the wire.,0
The wire was removed and the pigtail locked.,0
Contrast was injected to show the tip of the catheter within the stomach lumen.,0
The catheter was secured with 0 silk sutures and Flexi-Trak and sterile dressings applied.,0
The patient tolerated the procedure well without any immediate complications.,1
The stomach was outlined with inflated air and shows normal orientation and volume.,0
It lies superior to the transverse colon and the area of the gastrostomy is clear.,0
There was no liver in the path to the stomach.,0
Final image demonstrating optimal position of the tip of the Wills- tube within the stomach lumen with a well-locked pigtail.,0
IMPRESSION: Uncomplicated placement of a 12 French Wills- gastrostomy tube.,0
The tube should gravity drain over 24 hours after which it is ready for feeds.,0
11:32 AM CHEST (PORTABLE AP) Clip # Reason: removal of chest tubes ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with s/p cabg chest tubes removed REASON FOR THIS EXAMINATION: removal of chest tubes ______________________________________________________________________________ FINAL REPORT INDICATION: S/P CABG/chest tube removed.,0
"COMPARISON: Preop film of CHEST, PORTABLE: The patient is s/p interval median sternotomy s/p CABG.",0
"There is a Swan-Ganz catheter in place, with the tip within the main pulmonary artery.",0
There are nonspecific areas of increased density in both lung bases left greater than right.,0
"This may reflect bilateral pleural effusions, although superimposed pneumonia cannot be excluded.",0
"There is mild prominence of interstitial markings in more cephalad portions of both lung fields, which may reflect chronic change accentuated by portable film technique; possibility of mild CHF cannot be entirely excluded.",0
Swan-Ganz catheter tip in main pulmonary artery; no evidence of pneumothorax.,0
"Findings suggesting bilateral pleural effusions, left greater than right.",0
Superimposed pneumonia cannot be excluded.,0
Mild CHF cannot be excluded.,0
"2:43 AM CHEST (PORTABLE AP) Clip # Reason: eval infiltrate Admitting Diagnosis: GASTROINTESTINAL BLEED;DIABETIC KETOACIDOSIS;S/P CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man s/p cardiac arrest, intubation s/p left intrajugular CVL placement.",0
"REASON FOR THIS EXAMINATION: eval infiltrate ______________________________________________________________________________ WET READ: WWM TUE 8:51 AM Question sac in LUS, size smaller than dates, no fetal pole or yolk sac seen.",0
Left ov with corpus luteum.,0
No US evidence of ectopic but not excluded.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of central venous line placement.,0
FINDINGS: The left internal jugular line tip terminates in mid SVC.,0
There is no pneumothorax or apical hematoma.,0
There is increased left perihilar predominantly lower lobe opacity with minimal increase in the right perihilar haziness.,0
These findings are more consistent with developing pulmonary edema.,0
There is no appreciable change in the left retrocardiac consolidation most likely consistent with atelectasis.,0
"IMPRESSION: LIKELY NEW DEVELOPING PULMONARY EDEMA STABLE LEFT RETROCARDIAC OPACITY LIKELY REFLECTING AN EFFUSION AND ATELECTASIS, DIFFICULT TO EXCLUDE PNEUMONIA.",0
"8:03 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for consolidation Admitting Diagnosis: PERICARDIAL EFFUSION;NON SMALL CELL CARCINOMA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with pericardial effusion, with mediastinal mass, now with leukocytosis REASON FOR THIS EXAMINATION: evaluate for consolidation ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb MON 11:34 AM Slight increase in size of small left pleural effusion with persistent left lower lung atelectasis.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old male with pericardial effusion and leukocytosis.,0
"COMPARISON: CXR, , and CT torso, .",0
PORTABLE CHEST: Linear opacities at the left lung base appears unchanged compared to three days prior and likely reflects volume loss.,0
A small left pleural effusion is slightly increased in size compared to the prior study.,0
"The right lung remains clear, and there is no evidence for pneumothorax.",0
"A Port-A-Cath tip projects over the mid superior vena cava, unchanged.",0
IMPRESSION: Slight increase in size of left pleural effusion with persistent left lower lung atelectasis.,0
PATIENT/TEST INFORMATION: Indication: assess for endocarditis Height: (in) 71 Weight (lb): 170 BSA (m2): 1.97 m2 BP (mm Hg): 181/91 HR (bpm): 81 Status: Inpatient Date/Time: at 14:32 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,0
RIGHT VENTRICLE: RV function depressed.,0
The increased transaortic velocity is related to high cardiac output.,0
Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
"No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality.",0
There is no valvular aortic stenosis.,0
The increased transaortic velocity is likely related to high cardiac output.,0
The aortic regurgitation jet is eccentric.,0
"The mitral valve leaflets are moderately thickened.There are torn, calcified mitral chordae seen.",0
Two eccentric (anterior and posterior directed) jets of mitral regurgitation are seen with moderate to severe mitral regurgitation (3+) .,0
A small perforation of the posterior leaflet cannot be excluded on the basis of this study.,0
No masses or vegetations are seen on the tricuspid valve.,0
Impression: No valvular vegetations seen.,0
"Moderate to severe, eccentric mitral regurgitation.",0
4:00 PM CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # Reason: Signs of infection or malignancy?,0
Admitting Diagnosis: ACETAMINOPHEN OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: Ms. is a 32 year old woman with a PMHx s/f newly diagnosed Crohn's disease who presents with hypotension and altered mental status in the context of a possible overdose of bendadryl.,0
REASON FOR THIS EXAMINATION: Signs of infection or malignancy?,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Patient with newly diagnosed Crohn's disease, now presents with hypotension and altered mental status in the context of a possible Benadryl overdose.",0
COMPARISONS: CT abdomen and pelvis of obtained at an outside hospital.,0
TECHNIQUE: MDCT-acquired contiguous images from thoracic inlet to pubic symphysis were obtained with oral contrast at 5-mm slice thickness.,0
Coronally and sagittally reformatted images were displayed.,0
"FINDINGS: CT OF THE CHEST: There are numerous bilateral airspace nodular opacities, many of which display central cavitation.",0
"For example, a 1.5 x 1.3 cm nodular opacity involving left upper lobe is seen with central cavity (2:24).",0
A cluster of such nodular opacities predominate in right lung apex (2:14).,0
Left perihilar consolidation is noted.,0
Right lung base consolidation is also present with associated peripheral ground-glass opacities.,0
Moderate right and small left nonhemorrhagic pleural effusions appear progressed from prior study.,0
There is notable obliteration of the bronchus intermedius by surrounding consolidation (2:25).,0
"Otherwise, tracheobronchial tree appears patent.",0
The heart is normal in size with small pericardial effusion.,0
The aorta appears normal in caliber without aneurysmal changes.,0
The great vessels appear unremarkable.,0
"There is no pneumothorax-a few bubbles of air around the epipericardial fat region are seen, decreased from prior outside study and of uncertain significance.",0
Thyroid gland displays homogeneous attenuation.,0
No pathologically enlarged axillary lymph nodes are seen.,0
There is no mediastinal lymphadenopathy.,0
"The esophagus is patulous with significant amount of contrast material layering within its lumen, which predisposes the patient to aspiration.",0
An ET tube appears appropriately positioned.,0
NG tube is seen coursing through the esophagus terminating in the stomach.,0
Small hiatal hernia is present.,0
CT OF THE ABDOMEN: Evaluation of visceral organs is limited due to lack of intravenous contrast.,0
(Over) 4:00 PM CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # Reason: Signs of infection or malignancy?,0
"Admitting Diagnosis: ACETAMINOPHEN OVERDOSE ______________________________________________________________________________ FINAL REPORT (Cont) Liver demonstrates decreased attenuation, suggestive of fatty deposition.",0
No discrete hepatic lesion is identified.,0
There is no evidence of intrahepatic or extrahepatic biliary ductal dilatation.,0
"Gallbladder demonstrates increased attenuation, suggestive of vicarious excretion of contrast.",0
"Spleen, pancreas, adrenal glands, and kidneys appear unremarkable.",0
No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen.,0
Moderate amount of ascites appears progressed from prior study.,0
Small and large bowel loops are normal in caliber without evidence of obstruction or pneumatosis.,0
"There is minimal wall thickening involving the ascending colon, which may be at least partially attributable to under-distention.",0
CT OF THE PELVIS: A Foley is within the bladder with small amount of air within its lumen.,0
Rectum and sigmoid colon is unremarkable.,0
Small amount of contrast material is seen throughout the colon related to recent CT exam.,0
Moderate amount of free fluid is seen within the pelvis.,0
No pathologically enlarged pelvic or inguinal lymph nodes are noted.,0
Generalized soft tissue anasarca is present.,0
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.,0
"Numerous bilateral nodular opacities, many of which demonstrate central cavitations.",0
Left perihilar consolidation is present.,0
Right lung base consolidation is also noted with adjacent areas of ground-glass opacities.,0
The constellation of the above findings is concerning for infectious etiology.,0
"Given patient's immunosuppressed status, opportunistic infections are also considered, namely TB.",0
Other less likely differential considerations include vasculitis and septic emboli.,0
Moderate right and small left non-hemorrhagic pleural effusions appear progressed from prior study.,0
"Patulous esophagus is filled with moderate amount of contrast material, which predisposes the patient to aspiration.",0
Moderate amount of ascites and generalized anasarca appears progressed from prior exam.,0
Admitting Diagnosis: ACETAMINOPHEN OVERDOSE ______________________________________________________________________________ FINAL REPORT (Cont) 7.,0
"Decreased attenuation of the liver, suggestive of fatty deposition.",0
Findings discussed with Dr. at 6 p.m. on by phone.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: ?,0
"PICC tip Admitting Diagnosis: HUMAN IMMUNODEFIENCY VIRUS;GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with ESLD, HIV.",1
45 cm right basilic double lumen PICC placed.,0
PICC tip ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa TUE 4:38 PM Right PICC within the right atrium.,0
Left-sided central line terminating in the brachiocephalic vein.,0
______________________________________________________________________________ FINAL REPORT LINE PLACEMENT COMPARISON: .,0
FINDINGS: A right-sided PICC terminates within the right atrium.,0
"A left- sided catheter sheath is terminating within the brachiocephalic vein, unchanged.",0
There are no new consolidations or effusions.,0
Persistent bibasilar atelectasis is stable.,0
IMPRESSION: Right PICC terminating in the right atrium.,0
Left central line catheter sheath terminating in the brachiocephalic vein.,0
"Findings discussed with , IV nurse.",0
Shortness of breath Left ventricular function.,0
Height: (in) 70 Weight (lb): 200 BSA (m2): 2.09 m2 BP (mm Hg): 110/54 HR (bpm): 70 Status: Inpatient Date/Time: at 10:35 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
IMPRESSION: Normal biventricular cavity sizes and global systolic function.,0
"Compared with the report of the prior study (images unavailable for review) of , mild pulmonary artery systolic hypertension and mild mitral regurgitation are seen.",1
Global biventricular systolic function is similar.,0
"2:01 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: acute process Admitting Diagnosis: ANEMIA JAUNDICE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with new O2 requirement REASON FOR THIS EXAMINATION: acute process ______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old male with new O2 requirement, evaluate for acute process.",1
COMPARISON: Chest radiograph on at 9:03 a.m.,0
FINDINGS: ONE AP UPRIGHT PORTABLE VIEW OF THE CHEST.,0
A right lower lobe opacity concerning for pneumonia is unchanged.,0
The previously seen questionable area of either pneumothorax or skinfold is no longer apparent on this study and likely represented a skinfold.,0
"The cardiac, mediastinal, hilar contours are normal.",0
Right internal jugular line ends in the upper SVC.,0
Unchanged right lower lobe opacity concerning for pneumonia.,0
Previously seen abnormality in the right lateral lung is no longer apparent and likely represented a skinfold.,0
"10:19 AM CT HEAD W/O CONTRAST Clip # Reason: HX DVT - S/P SUBARCH BLEED - NOW MS CHANGES - EVAL FOR BLEED ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with hx DVT, s/p subarch bleed.",0
now with mental status changes.,0
"s/ filter placement.with worsening neuro exam REASON FOR THIS EXAMINATION: to rule out bleed ______________________________________________________________________________ FINAL REPORT INDICATION: STATUS POST SUBARACHNOID BLEED, MENTAL STATUS CHANGES.",0
"NOW WITH WORSENING NEURO EXAM, RULE OUT BLEED.",0
TECHNIQUE: Routine head CT without contrast.,0
HEAD CT WITHOUT INTRAVENOUS CONTRAST: There is no significant change from the prior study.,0
The metallic clip in the region of the left middle cerebral artery is redemonstrated.,0
An intraventricular drain is also unchanged in position.,0
The left basal ganglia hemorrhage with intraventricular and subarachnoid hemorrhage is unchanged.,1
"For a more detailed report, see report for the study dated .",0
IMPRESSION: No significant change from study dated .,0
"8:53 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate, consolidation, fluid overload Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with acute sinusitis, likely C. diff, now w/ high fever, rigors, new O2 requirement REASON FOR THIS EXAMINATION: eval for infiltrate, consolidation, fluid overload ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:08 P.M. .",1
HISTORY: Acute sinusitis high fever and rigors.,0
Suspect volume overload or pneumonia.,0
"IMPRESSION: AP chest compared to at 12:47 a.m.: Lung volumes are lower and subsegmental atelectasis at the left base is new, but lungs are clear of any findings of pneumonia or cardiac decompensation.",0
No pleural effusion is evident.,0
"5:47 PM CHEST (PORTABLE AP) Clip # Reason: eval for pneumonia, line placement ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with right subclavian central line, ?hypoxia REASON FOR THIS EXAMINATION: eval for pneumonia, line placement ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, , AT 1750 HOURS.",0
HISTORY: Status post right subclavian central line placement.,0
"FINDINGS: Consistent with the given history, there has been interval placement of a right subclavian approach central venous catheter.",0
The distal tip projects just proximal to the cavoatrial junction.,0
Three surgical staples overlie the lateral aspect of the upper right chest.,0
"There is mild cephalization, engorgement of the vascular pedicle, and intralobular septal thickening, all consistent with mild hydrostatic edema.",0
Again noted is mild tortuosity of the thoracic aorta.,0
The cardiac silhouette is globally enlarged but stable.,0
Bridging osteophytes are noted throughout the thoracic spine.,0
IMPRESSION: Mild cardiogenic hydrostatic edema.,0
8:46 AM CT HEAD W/O CONTRAST Clip # Reason: please check post op Admitting Diagnosis: SUBDURAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p evacuation L SDH REASON FOR THIS EXAMINATION: please check post op No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NON-CONTRAST HEAD CT SCAN HISTORY: Status post evacuation of left-sided subdural hemorrhage.,1
FINDINGS: Comparison with the preceding preoperative study shows interval placement of a subdural drain within the left frontal subdural hemorrhage.,1
"While the width of the hemorrhage has decreased, there has been substantial increase in the density of the hemorrhage, as well as a small quantity of subdural gas.",1
The increased density implies rebleeding into at least one of the compartments of the subdural hemorrhage.,1
There is continued effacement of the adjacent left cerebral hemispheric convexity sulci and body of the left lateral ventricle.,0
"There is, at most, a few millimeters rightward degree of shift of the septum pellucidum.",0
"An extensive left frontal craniotomy defect, surgical clips and staples are demonstrated.",0
"There is mild opacification of the mastoid sinuses, with a few tiny air-fluid levels suggesting at least a portion of this opacification is due to fluid, as opposed to mucosal thickening.",0
There is moderate opacification of both ethmoid sinuses.,0
CONCLUSION: Status post insertion of left-sided subdural drainage catheter with rehemorrhage into at least a portion of the subdural hematoma.,1
"However, the extent of the subdural hemorrhage is reduced, compared to the prior study.",1
3:42 PM IVC GRAM/FILTER Clip # Reason: IVC filter placement Admitting Diagnosis: ABDOMINAL PAIN Contrast: OPTIRAY Amt: 130 ********************************* CPT Codes ******************************** * INTERUP IVC INTRO CATH SVC/IVC * * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with DVT going to surgery for exlap.,0
hep gtt off REASON FOR THIS EXAMINATION: IVC filter placement ______________________________________________________________________________ FINAL REPORT INDICATION FOR EXAM: 44-year-old woman with DVT and need for surgery.,0
"RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the attending radiologist, who was present and supervising throughout the procedure.",0
"PROCEDURE AND FINDINGS: After informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on angiographic table and the right groin was prepped and draped in standard sterile fashion.",0
"Using ultrasonographic guidance and after injection of 5 cc of 1% lidocaine, the right common femoral vein was accessed with a micropuncture sheath system.",0
A 0.035 wire was then advanced into the inferior vena cava and the sheath was exchanged for a 4 French Omniflush catheter which was placed at the L4 vertebral level.,0
Multiple venograms were performed demonstrating a single patent inferior vena cava with no evidence of thrombus.,0
"Based on these findings, it was decided to perform placement of inferior vena cava filter at the infrarenal position.",0
The renal veins were detected at the level of L1/L2 vertebral body.,0
"Using a Gunther Tulip inferior vena cava filter, the filter was deployed at the level of L1/L2 vertebral body level.",0
A final fluoroscopic image of the abdomen demonstrates a Gunther Tulip inferior vena cava filter at the infrarenal position at the level of L1/L2 vertebral body.,0
Inferior vena cava venogram demonstrates a patent single vena cava with the renal veins at the level of L1/L2 vertebral body.,0
Successful placement of a Gunther Tulip IVC filter at the infrarenal position.,0
The filter may be retrieved within a few months as clinically indicated.,0
(Over) 3:42 PM IVC GRAM/FILTER Clip # Reason: IVC filter placement Admitting Diagnosis: ABDOMINAL PAIN Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont),0
1:19 PM CHEST (PA & LAT) Clip # Reason: Please do PA/Lat/and right decubitus to evaluate right sided Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with RLL PNA/effusion with hypoxia on RA.,1
REASON FOR THIS EXAMINATION: Please do PA/Lat/and right decubitus to evaluate right sided pleural effusion.,1
______________________________________________________________________________ FINAL REPORT Two view chest of compared to previous study of earlier the same day.,0
CLINICAL INDICATION: Right-sided pleural effusion.,1
Please note that no lateral decubitus view was obtained.,0
"There is a persistent moderate sized right pleural effusion, which is not significantly changed in size allowing for difference in technique.",1
There remains adjacent consolidation and atelectasis within the right middle and right lower lobes.,0
"Patchy and linear opacities are also noted in the left retrocardiac region, and appears stable.",0
There is no definite left pleural effusion.,1
Minimal linear opacity is noted in the left upper lobe suggestive of discoid atelectasis.,0
11:23 AM CHEST (PORTABLE AP) Clip # Reason: pls assess ETT and CVL.,0
"Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with malignant thymoma, ?encephalitis, intuabted.",0
REASON FOR THIS EXAMINATION: pls assess ETT and CVL.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Malignant thymoma, evaluation for ETT.",0
Also unchanged is the appearance of the opacities in the left lung and the position of the post-surgical clips.,0
"In the right lung, there are minimal atelectatic changes at the bases but no evidence of focal parenchymal opacities suggesting an infectious lung disease.",0
", NMED SICU-A 8:10 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: PE?",0
Admitting Diagnosis: SEIZURE Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with high suspicion of PE REASON FOR THIS EXAMINATION: PE?,0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.,0
No central or segmental PE.,0
"Subsegmental PE unlikely, but cannot definitely rule out subsegmental PE in area of atelectasis at the right lung base posteriorly; atelectasis compresses vessels.",0
Moderate bilateral pleural effusions and atelectasis dependently.,0
Nodular opacities at the lung apices could reflect edema or infectious etiology.,0
"10:08 AM CT UP EXT W/C BILAT; CT 100CC NON IONIC CONTRAST Clip # Reason: Requesting CT-guided drainage of parascapular abscess Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with known parascapular abscess, from which 1cc was drained by IR under CT-guidance previously.",1
"Recent wbc scan done persistent fevers, still lighting up this region REASON FOR THIS EXAMINATION: Requesting CT-guided drainage of parascapular abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: CT scan of the chest performed on .",1
HISTORY: 55-year-old woman with known left parascapular abscess.,0
Status post prior drainage in .,0
Recent WBC scan demonstrated increased uptake in this region.,0
FINDINGS: Comparison is made to the prior WBC scan report from as well as CT scan from and CT thoracentesis study from .,0
The enhancing collection in the left periscapular area extending at the level of C7 down for approximately 8 cm is not well seen on today's study.,0
No enhancing fluid collection in this region is identified.,0
There is some soft tissue stranding and some mild increased density in this area.,0
No drainable collection is noted.,0
"There is again seen marked destructive changes, seen of several mid thoracic vertebral bodies likely the T8, T9, and T10 vertebral bodies.",0
"There is a epidural fluid collection which is persistent, however, it is slightly decreased when compared to the prior studies.",0
"Several nodular opacities seen throughout both lung fields, which are peripherally based.",0
These lesions appear similar to the previous study and again may represent either septic emboli or infectious etiology.,0
"Overall, the appearance of the lungs are unchanged.",0
There are emphysematous changes with multiple bullae noted bilaterally.,0
"There is a small right-sided pleural effusion, which has remained stable in the interim.",0
"There is no axillary, mediastinal, or definite hilar lymphadenopathy.",0
Limited images of the upper abdomen are grossly within normal limits.,0
There are joint effusions in bilateral shoulders.,0
There is soft tissue irregularity in the left paraspinal region with no discrete enhancing collection.,0
"This likely due to improvement of the collection; however, due to the early timing of the imaging study with the contrast bolus, a rim enhancing collection maybe less apparent.",0
(Over) 10:08 AM CT UP EXT W/C BILAT; CT 100CC NON IONIC CONTRAST Clip # Reason: Requesting CT-guided drainage of parascapular abscess Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,1
Extensive osteomyelitic changes noted of the mid thoracic spine with a persistent epidural fluid collection.,0
The collection has decreased slightly when compared to the prior study.,0
Multiple peripherally based nodular opacities throughout both lung fields.,0
"These can be secondary to septic emboli, however, other infectious etiologies should also be considered.",0
There are bilateral effusion in both shoulder joints.,0
"7:07 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for CHF vs. PNA in this pt with increasingly Admitting Diagnosis: S/P CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p vfib arrest LAD occlusion, s/p extubation with fevers REASON FOR THIS EXAMINATION: Please evaluate for CHF vs. PNA in this pt with increasingly coarse BS.",0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 7:28 A.M., HISTORY: V-fib arrest.",0
"IMPRESSION: AP chest compared to and 14: The increasing opacification at both lung bases can be explained by atelectasis and dependent edema, though pneumonia cannot be excluded, since there is persistent engorgement of mediastinal veins and upper lobe pulmonary vessels.",0
Mild tubulated narrowing of the subglottic and upper trachea has been evident since extubation on and could be due to that or previous intubation as well as enlargement of the thyroid gland.,0
Height: (in) 61 Weight (lb): 63 BSA (m2): 1.16 m2 BP (mm Hg): 119/76 HR (bpm): 61 Status: Inpatient Date/Time: at 10:30 Test: Portable TTE (Focused views) Doppler: Limited Doppler and no color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RA pressure (10-20mmHg).,0
TRICUSPID VALVE: Normal PA systolic pressure.,0
"There is a large circumferential pericardial effusion with a small layer (0.9 cm) echo dense material on the right ventricle consistent with blood, inflammation or other cellular elements.",0
No right ventricular diastolic collapse is seen.,0
There is brief right atrial diastolic collapse.,0
The heart swings with each cardiac cycle and the anterior echolucent pericardial effusion varied between 2 cm and 0 cm.,1
"Apically, the effusion varied between 2.1 cm and 0.8 cm.",0
IMPRESSION: Large circumferencial pericardial effusion with no clear evidence of tamponade.,0
There is significant cardiac motion with variable local pericardial effusion size between cardiac cycles.,0
7:40 AM CHEST (PORTABLE AP) Clip # Reason: ESLD now with ards.,0
"______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with hep c cirrhosis, ascites, intraabdominal bleed S/P INTUBATION FOR DESATURATION, WITH MASSIVE ABDOMINAL DISTENTION.",0
REASON FOR THIS EXAMINATION: ESLD now with ards.,0
"______________________________________________________________________________ FINAL REPORT INDICATIONS: Hep C cirrhosis, ascites, GI bleed, abdominal distention, pulmonary edema.",0
PORTABLE SUPINE CHEST: Patient is significantly rotated.,0
There is interval removal of Swan-Ganz catheter.,0
A right IJ central venous catheter is present with its tip likely at the SVC RA junction.,0
ETT is present with tip in good position.,0
A feeding tube and NG tube present with the tip in the stomach.,0
Appearance of interval enlargement of left ventricle is most likely related to rotation.,0
There is no significant change in bilateral diffuse alveolar opacities.,0
No pleural effusions are present.,0
IMPRESSION: Interval removal of Swan-Ganz catheter otherwise no change since .,0
PATIENT/TEST INFORMATION: Indication: CoreValve Height: (in) 65 Weight (lb): 190 BSA (m2): 1.94 m2 BP (mm Hg): 150/52 HR (bpm): 75 Status: Inpatient Date/Time: at 09:16 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.,1
Conclusions: Overall left ventricular systolic function is normal (LVEF 70%).,0
A paravalvular aortic valve leak is present at the aorticopulmonic crux/septum.,1
The CoreValve stent may not be fully expanded at the aorticopulmonic crux/septum.,1
A component of intravalvular regurgitation cannot be excluded.,0
The aortic regurgitation appears moderate (2+) by color flow Doppler.,0
"Compared with the findings of the prior study (images reviewed) of , the appearance of aortic regurgitation by color flow Doppler is increased.",0
"9:13 AM CHEST (PORTABLE AP) Clip # Reason: eval swann position Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with ischemic cardiomyopathy, s/p incarcarated ventral hernia repair REASON FOR THIS EXAMINATION: eval swann position ______________________________________________________________________________ FINAL REPORT INDICATION: Ischemic cardiomyopathy, incarcerated ventral hernia, evaluate Swan position.",1
VIEWS: Single semi-upright AP view compared with PA and lateral view from .,0
FINDINGS: There has been interval placement of a Swan-Ganz catheter with the tip suboptimally located within an interlobar segment of the descending right pulmonary artery.,0
The left-sided ICD device is again noted with leads in stable and satisfactory positions.,0
Low lung volumes are present bilaterally.,0
"There has been interval improvement in the bilateral, diffuse interstitial opacities consistent with improving pulmonary edema.",0
The cardiac and mediastinal contours remain stable.,0
No pleural effusions are identified.,0
IMPRESSION: 1) Slightly distal location of the tip of the Swan-Ganz catheter within an interlobar segment of the descending right pulmonary artery.,0
2) Interval improvement in mild interstitial pulmonary edema.,0
11:20 AM HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) Clip # Reason: EVALUATE FOR LEFT HIP FX S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with L hip pain after fall.,0
REASON FOR THIS EXAMINATION: Evaluate for hip fx ______________________________________________________________________________ FINAL REPORT INDICATION: Left hip pain after fall.,0
"LEFT HIP, THREE VIEWS: There is a minimally displaced left intertrochanteric femoral neck fracture.",0
The right femoral head appears intact.,0
No definite pelvic fractures are identified.,0
"IMPRESSION: Minimally displaced, comminuted left intertrochanteric femoral neck fracture.",0
9:05 PM CHEST (PA & LAT) Clip # Reason: cough and fever ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with cough and fever REASON FOR THIS EXAMINATION: cough and fever ______________________________________________________________________________ FINAL REPORT INDICATION: Fever and cough.,0
"PA AND LATERAL CHEST: In the interval since the prior study the patient's heart appears larger, likely related to the interval CABG.",0
The mediastinal contours are otherwise unchanged.,0
There is stable scarring at the left base laterally.,0
There is a small focal nodular density in the left midlung zone on the frontal view laterally which is not seen on the lateral view.,0
This is present since .,0
There is band- like opacity slightly more medially in the left midlung zone and likely superior segment of left lower lobe which may be atelectasis.,0
An early focus of pneumonia is not excluded.,0
IMPRESSION: New focal band-like opacity in left mid lung.,0
be atelectasis v. early PNA.,0
Follow chest film after appropriate treatment is warranted.,0
If no resolution a CT should be considered.,0
"10:00 AM BILAT LOWER EXT VEINS Clip # Reason: PT WITH PE, R/O DVT Admitting Diagnosis: CHEST PAIN,SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 37 year old morbidly obese woman with massive PE, HIV, seizure d/o REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ FINAL REPORT HISTORY: Massive PE.",0
"BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Color and scale son images of the right and left common femoral, superficial femoral and popliteal veins were obtained.",0
"Normal color flow, compressibility and augmentation was demonstrated.",0
5:21 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"pulm edema Admitting Diagnosis: LEFT NON-HEALING FOOT ULCER ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with renal failure, possible fluid overload REASON FOR THIS EXAMINATION: ?",1
"pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old man with renal failure, possible fluid overload.",0
COMPARISON: Chest preop PA and lateral from .,0
"CHEST AP SEMI-UPRIGHT PORTABLE: In the interim between and the time of this study, the patient has developed large bilateral pleural effusions.",1
Please note that the quality of this film is poor.,0
The right mediastinum is poorly seen and the heart is probably enlarged.,0
Note is made of the staples in the right upper quadrant.,0
IMPRESSION: Poor quality radiograph illustrating large bilateral pleural effusions.,0
3:07 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: S/P left chesttube removal.,0
Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with CAD s/p CABG with and new subclavian REASON FOR THIS EXAMINATION: S/P left chesttube removal.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Status post left chest tube removal.,0
Coronary artery disease status post CABG.,1
"SUPINE AP PORTABLE CHEST AT 15:26 HOURS: Skin staples, median sternotomy wires and surgical clips are compatible with given history of CABG.",0
A tracheostomy tube remains in similar position.,0
The cardiomegaly remains similar in appearance.,0
The left chest tube has been removed.,0
The loculated left pleural effusions remain similar in appearance.,0
There is moderate pulmonary edema.,0
Patchy opacities in both lungs raise the possibility of superimposed pneumonia or aspiration.,0
The right subclavian line ends at the cavoatrial junction.,0
IMPRESSION: 1) No pneumothorax status post left chest tube removal.,0
Patchy bilateral opacities raise the possibility of superimposed pneumonia or aspiration.,1
5:30 AM CHEST (PORTABLE AP) Clip # Reason: s/p re-intubation.,0
______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with acute aortic dissection REASON FOR THIS EXAMINATION: s/p re-intubation.,1
"______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM.",0
HISTORY: Aortic dissection with intubation.,0
ET tube is 3 cm above carina.,0
NG tube is in proximal stomach.,0
"There is cardiomegaly and tortuosity of the thoracic aorta and ill-defined air-space opacities in the right upper and right lower zones, as well as in the left lower lobe obscuring the left hemidiaphragm.",1
The left CP angle is not included on the film.,0
"IMPRESSION: Multilobar opacities, consistent with pulmonary edema/multilobar pneumonia.",0
These are increased since the prior study of .,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Bactrim / Actonel / Codeine / Synthroid Attending: Chief Complaint: fatigue, BRBPR Major Surgical or Invasive Procedure: exlap, tumor and small bowel resection History of Present Illness: 77F with PMH significant for previous endometriosis and benign tumor removed from uterus, who presented to ED with GI bleeding and BRBPR.",0
"On the day of presentation, she felt fatigued and lightheaded like she was going to syncopize.",0
She also felt increased abdominal pain and bloating.,0
"Upon going to the bathroom, she noticed a large amount of bright red blood in the toilet bowel.",0
She called her PCP and was told to go to the ED.,0
"There, her initial Hct was 22.8.",0
"She received 3 units of packed red blood cells and her Hct came up to 31.2, but then dropped to 26.1.",0
"Overnight she was prepped for colonoscopy with a GoLYTELY, but threw most of it up, so spent another day prepping.",0
She still had continuous bleeding through her .,0
"She underwent a colonoscopy on the day of transfer showing continuous bleeding potentially above the ileocecal valve, but was not well-visualized.",0
She had a CTA of the abdomen that showed a uterine mass that could be eroding into the intestinal wall.,0
Patient was transferred here for potential hysterectomy and surgical repair of her small intestine.,1
"Of note, patient states she has been feeling more fatigued for the past 3-4 months, and has been worked up by both her PCP here and in for anemia.",0
Her notes on anemia do not mention guaiac or GI bleeding.,0
"Of the past few weeks, she has also experienced more abdominal distention and pain, which she attributed to weight gain.",0
The patient's last pelvic exam was by a gynecologist in in and was normal per the patient.,0
"In the ICU, her initial vitals on transfer were T 98.6 HR86 BP133/97 HR17 O2sat 100(RA).",0
"She denied shortness of breath, chest pain, or abdominal pain.",0
"No dizziness, confusion, does not feel like she's about to faint again.",0
She is on a bed pan and still bleeding a little.,0
Past Medical History: (per OMR) ECTOPIC PREGNANCY - - REMOVED 1 TUBE ENDOMETRIOSIS ENDOMETRIAL TUMOR - BENIGN - REMOVED ATROPHIC VAGINITIS D&C X 1 FOR EVAL POST MEN BLEEDING - HAD UTERINE POLYPS in SBO DUE TO ADHESIONS - RX CONSERVATIVELY CHOLECYSTECTOMY SQUAMOUS CELL CA X2 BASAL CELL CA X2 MACULAR DEGENERATION HYPOTHYROIDISM OSTEOPOROSIS HERPES ZOSTER HIATAL HERNIA ALLERGIC RHINITIS ROTATOR CUFF TEAR NEGATIVE STRESS TREADMILL TEST THROMBOCYTOPENIA WRIST INJURY Social History: Married lives with husband - lives in from to each year.,1
Imaging: CT ABDOMEN AND PELVIS: ABDOMEN: There are several subcentimeter hypodense lesions in both lobes of the liver.,0
These are too small to accurately characterize by CT.,0
The left hepatic duct and common hepatic and common bile duct are moderately dilated down to the level of the sphincter of Oddi.,0
No obstructing lesion is identified.,0
There are bilateral circumscribed hypodense lesions in the kidneys consistent with cysts.,0
Almost all of these are too small to accurately characterize by CT. No lymphadenopathy is apparent.,0
PELVIS: The uterus is markedly enlarged and has an irregular lobulated contour.,0
Its density is very inhomogeneous.,0
"Overall, it measures 17.2 cm longitudinal x 10.4 cm transverse x 9.5 cm AP.",0
There is a short segment of small bowel abutting the uterine fundus that demonstrates some ill-defined hyperemia or active bleeding.,0
A cluster of numerous surgical clips in the right pelvic adnexa.,0
The ureters are mildly prominent.,0
Abdominal and pelvic wall structures are intact.,0
No osteolytic or osteoblastic lesion is noted.,0
IMPRESSION: ABNORMAL ENLARGED UTERUS AS DESCRIBED.,0
FINDINGS ARE SUSPICIOUS FOR MALIGNANT NEOPLASM SUCH AS LEIOMYOSARCOMA OR ENDOMETRIAL CARCINOMA.,1
THERE IS AN ADJACENT SHORT LOOP OF ABNORMAL SMALL BOWEL.,0
ITS ENHANCEMENT SUGGESTS POSSIBLE INVASION BY TUMOR AND THERE BE ACTIVE BLEEDING AT THIS SITE.,0
"MRI Pelvis w/ and w/o contrast: Large, heterogeneously enhancing, multilobulated mass within the pelvis, with central areas of necrosis and focal hemorrhage.",0
"Given its large size, its relationship to adjacent structures is difficult to discern.",0
"However, it appears to displace, rather than arise from, the uterus.",0
It is intimately associated with and inseparable from a distal loop of small bowel.,0
"Given this relationship to the small bowel and its appearance, this is thought most likely to represent a small bowel GIST.",0
"While neither ovary is seen, this is thought less likely to be ovarian in origin given only the trace amount of free fluid and no evidence of metastatic disease within the pelvis.",0
"Discharge Labs: 11:00AM BLOOD Hct-29.1* 06:10AM BLOOD WBC-4.1 RBC-2.61* Hgb-8.4* Hct-24.2* MCV-93 MCH-32.1* MCHC-34.7 RDW-17.7* Plt Ct-210 Pathology: Small bowel, segmental resection: Atypical spindle and focally epithelioid neoplasm (13.5 cm in greatest dimension), consistent with gastrointestinal stromal tumor of high malignant potential; see note.",1
Nine mesenteric lymph nodes with no tumor seen (0/9).,0
"Note: The tumor demonstrates a predominantly spindle cell pattern arranged in irregular fascicles, with focally epithelioid areas and foci of prominent necrosis.",0
Tumor nuclei demonstrate areas of marked pleomorphism with coarse chromatin and irregular nuclear contours.,0
"Immunohistochemical stains of the tumor are diffusely, strongly positive for C-kit, focally, weakly positive for actin, and negative for desmin and S-100, consistent with a gastrointestinal stromal tumor (GIST) immunophenotype.",0
Mitoses number greater than 15 per 50 high power fields and frequent tumor cell apoptosis is identified.,0
"The tumor size of greater than 10 cm and mitotic activity of greater than 15 per 50 high power fields confer a high risk of malignant potential The tumor appears to arise within the muscularis propria, but extensively involves the submucosa and subserosa, with focally marked attenuation of the overlying mucosa, and the exact layer of origin is difficult to discern; definitive mucosal invasion by tumor cells is not identified.",0
"The tumor is received partially disrupted, precluding definitive evaluation of the serosal surface for invasion in these areas.",0
"Where evaluable in non-disrupted areas, however, a thin (from <1 mm to 3 mm) rim of serosal tissue is present along the external surface.",0
"Brief Hospital Course: 77F with PMH significant for previous endometriosis and s/p benign uterine tumor removal, who presented to ED with GI bleeding and BRBPR, found on colonoscopy to have bleeding from above the ileocecal valve, and on CTA to have a uterine tumor impinging on small bowel at OSH and she was transferred to .",0
MRI pelvis here demonstrated that the primary mass was actually in the small bowel abutting the uterus.,0
Source of bleed appeared by colonoscopy to be from above the ileocecal valve.,0
"Based on CTA at , there was suspicion for uterine tumor eroding into small bowel leading to GI bleeding.",0
"On arrival to , Hct was stable (at 31.1, up from 26 which was the last prior to transfer from ).",0
Hemactocrits were checked every 6 hours.,0
She was transfused 1 more unit of PRBCs on for Hct 26.,0
Gynecology and general surgery were consulted for managment of the tumor.,0
"Tumor markers were sent, CEA, CA -9 and CA125 all came back normal.",0
An MRI of the pelvis demonstrated that the primary tumor was in the small bowel and was abutting but not invading the uterus.,0
"Throughout the course, patient was not lightheaded and did not have melena.",0
Patient was then transferred to surgery service.,0
The patient has hx of hypertension.,0
Antihpertensive medications were held in the setting of active GI bleed.,0
Patient has chronic cough from and followed by pulmonology.,0
Continued home guaifenasin and .,0
The patient had a stable course on the floor.,0
Her foley was d/c'd on POD #6 mostly due to patient anxiety about having to void on her own.,0
Her pain was well controlled on PO Diluadid.,0
She received HSQ for prophylaxis and encouraged to ambulate on her own.,0
"At the time of discharge on POD#8, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, passing gas and pain was well controlled.",0
Medications on Admission: CLONAZEPAM - 1 mg PO daily ESTRADIOL [ESTRACE] 0.01 % Cream twice weekly LEVOTHYROXINE - 50 mcg PO daily MOM 100/50 Tessalon pearls NORTRIPTYLINE 10 mg PO qhs OMEPRAZOLE 40 mg po daily VAGIFEM weekly ZOLPIDEM 10 mg PO qhs PRN MVI CALCIUM 600 2X DAILY WITH 400 IU VIT D PER PILL VIT C OCCUVITE B12 VIT D IU QD Fish oil 1000mg Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain.,0
Disp:*80 Tablet(s)* Refills:*0* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation (2 times a day).,0
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for before bed.,0
Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: GIST tumor Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You were admitted to the acute care surgery service for exploratory laparotomy for removal of a GIST tumor and a portion of small bowel.,0
"Since you have had an abdominal operation, this sheet goes over some questions and concerns you or your family may have.",0
"If you have additional questions, or ?",0
"?t understand something about your operation, please call your .",0
ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency.,0
But avoid traveling long distances until you see your at your next visit.,0
?t lift more than 20-25 pounds for 6 weeks.,0
(This is about the weight of a briefcase or a bag of groceries.),0
"This applies to lifting children, but they may sit on your lap.",0
You may start some light exercise when you feel comfortable.,0
You will need to stay out of bathtubs or swimming pools for a time while your incision is healing.,0
Ask your doctor when you can resume tub baths or swimming.,0
"Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first.",0
You may resume sexual activity unless your doctor has told you otherwise.,0
HOW YOU FEEL: You may feel weak or ?,0
You might want to nap often.,0
Simple tasks may exhaust you.,0
You may have a sore throat because of a tube that was in your throat during surgery.,0
You might have trouble concentrating or difficulty sleeping.,0
You might feel somewhat depressed.,0
You could have a poor appetite for a while.,0
All these feelings and reactions are normal and should go away in a short time.,0
"If they do not, tell your .",0
YOUR INCISION: Your incision may be slightly red around the area where staples were.,0
You may gently wash away dried material around your incision.,0
Do not remove steri-strips for 2 weeks.,0
(These are the thin paper strips that might be on your incision.),0
"But if they fall off before that, it?????",0
It is normal to feel a firm ridge along the incision.,0
Avoid direct sun exposure to the incision area.,0
Do not use any ointments on the incision unless you were told otherwise.,0
You may see a small amount of clear or light red fluid staining your dressing or clothes.,0
"If the staining is severe, please call your .",0
"As noted above, ask your doctor when you may resume tub baths or swimming.",0
"Over the next 6-12 months, your incision will fade and become less prominent.",0
YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine.,0
"If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as Milk of Magnesia, 1 tablespoon) twice a day.",0
You can get both of these medicines without a prescription.,0
Do not worry if you see blood with your first bowel movement.,0
"After some operations, diarrhea can occur.",0
"If you get diarrhea, ?",0
Drink plenty of fluids and see if it goes away.,0
"If it does not go away, or is severe and you feel ill, please call your .",0
PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery.,0
This pain is often described as ?,0
Your pain should get better day by day.,0
"If you find the pain is getting worse instead of better, please contact your .",0
You will receive a prescription from your for pain medicine to take by mouth.,0
It is important you take this medicine as directed.,0
Do not take it more frequently than prescribed.,0
Do not take more medicine at one time than prescribed.,0
Your pain medicine will work better if you take it before your pain gets too severe.,0
Talk with your about how long you will need to take prescription pain medicine.,0
"?t take any other pain medicine, including non-prescription pain medicine, unless your has said it is OK.",0
"If you are experiencing no pain, it is OK to skip a dose of pain medicine.",0
"To reduce pain, remember to exhale with any exertion or when you change positions.",0
Remember to use your ?,0
for splinting when you cough or when you are doing your deep breathing exercises.,0
"If you experience any of the following, please contact your : sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than 101 a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently.",0
"In some cases, you will have a prescription for antibiotics or other medication.",0
"If you have any questions about what medicine to take or not to take, please call your .",0
DANGER SIGNS: Please call your or go to the emergency room if you develop: Worsening abdominal pain Sharp or severe pain that lasts several hours Temperature of 101 degrees or higher Severe diarrhea Vomiting Redness around the incision that is spreading Increased swelling around the incision Excessive bruising around the incision Cloudy fluid coming from the wound Bright red blood or foul smelling discharge coming from the wound An increase in drainage from the wound Followup Instructions: Call the Acute Care Clinic at upon discharge to arrange a follow up appointment in weeks.,0
"Office is located at , Medical Office Building, .",0
11:45 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: evaluate for cause of respiratory distress Admitting Diagnosis: ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with rapid shallow breathing on vent REASON FOR THIS EXAMINATION: evaluate for cause of respiratory distress ______________________________________________________________________________ WET READ: EHAb SAT 1:10 AM Curvilinear lucency under the right hemidiaphragm could correspond to free intraperitoneal air.,0
This finding was discussed with Dr. by Dr. by telephone at 12:35 a.m. on .,0
______________________________________________________________________________ FINAL REPORT STUDY: AP chest .,0
HISTORY: 66-year-old man with rapid shallow breathing.,0
FINDINGS: The endotracheal tube and right-sided Port-A-Cath are unchanged in position.,0
There is again seen prominence of the heart size.,0
There is a curvilinear lucency underneath or adjacent to the right hemidiaphragm medially.,0
This is unclear if this may represent a confluence of shadow versus free intraperitoneal air.,0
This finding was discussed by Dr. with Dr. .,0
"There again remains some pulmonary interstitial marking prominence; however, this is improved slightly.",0
There remain areas of increased density at the right and left bases.,0
2:08 PM FEMORAL VASCULAR US LEFT Clip # Reason: 80M with L femoral pseudoaneurysm s/p thrombin injection ass Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80M with L femoral pseudoaneurysm s/p thrombin injection REASON FOR THIS EXAMINATION: 80M with L femoral pseudoaneurysm s/p thrombin injection assess for resolution ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb SAT 2:48 PM PFI: Echogenic material within both lobes of the previously seen left femoral pseudoaneurysm without internal blood flow.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 80-year-old male with left femoral pseudoaneurysm status post thrombin injection.,0
TECHNIQUE: Focused ultrasound examination with -scale and duplex Doppler was performed of the left groin.,0
FINDINGS: The previously visualized pseudoaneurysm no longer demonstrates flow.,0
Echogenic material within both lobes of the pseudoaneurysm likely represents clot.,0
"The larger lobe adjacent to the common femoral artery measures 2.7 x 1.8 x 1.7 cm and the second more superficial lobe measures 2.2 x 1.8 x 1 cm, both similar compared to prior.",0
Normal waveforms are seen in the common femoral artery and common femoral vein.,0
IMPRESSION: Echogenic material within both lobes of the previously seen left femoral pseudoaneurysm without internal blood flow indicating good therapeutic respnse post-thrombin injection.,1
These findings were discussed with Dr. by Dr. in person at 3:05 p.m. on .,0
"1:02 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: r/o abscess, pancreatitis, perforation Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with periumbilical pain, vomiting, elevated WBC REASON FOR THIS EXAMINATION: r/o abscess, pancreatitis, perforation No contraindications for IV contrast ______________________________________________________________________________ WET READ: JWK MON 2:44 AM FINDINGS ARE POSITIVE FOR: SBO.",0
Two transition points are likely identified in the left lower quadrant.,0
There is diffuse mesenteric engorgement and likely differential wall enhancement.,0
The findings are concerning for closed loop obstruction versus internal hernia.,1
Ischemia should be considered given the appearance and close correlation with biochemical markers is advised.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 77-year-old female with periumbilical pain, vomiting, and elevated white blood cell count.",0
TECHNIQUE: MDCT axial images through the abdomen and pelvis were obtained following the administration of intravenous contrast with multiplanar images reformatted.,0
CT ABDOMEN WITH IV CONTRAST: There is bibasilar atelectasis and a moderate sized hiatal hernia.,0
"The spleen, gallbladder, adrenal glands, and pancreas are unremarkable.",0
There is fatty infiltration of the liver.,0
A 5.1 x 4.4 cm exophytic cyst is again seen arising from the upper pole of the left kidney.,0
"Smaller hypodensities in both kidneys likely represent cysts, but are not fully characterized.",0
Again identified is a ventral abdominal wall hernia containing small amount of omentum and fluid.,0
There is a moderate amount of intra-abdominal ascites.,0
Dilated loops of jejunum in the left upper and lower quadrants with multiple air-fluid levels measure 3.0 cm in greatest dimension.,0
"Two transition points are likely identified within the left lower quadrant (series 300B, image 20 and series 301B, image 46).",0
There is a fecalized loop of small bowel proximal to the distal transition point and marked mesenteric congestion.,0
"While there is no pneumatosis or submucosal edema, there is differential enhancement of several loops of small bowel (series 300b, image 16) concerning for ischemia/infarction.",0
There is no intraperitoneal free air.,0
The colon is not collapsed.,0
"CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, and bladder are unremarkable.",0
"Osseous structures demonstrate chronic wedge compression of the inferior (Over) 1:02 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: r/o abscess, pancreatitis, perforation Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) endplate of L1 and mild compression deformity of the L4 vertebral body.",0
IMPRESSION: Findings are consistent with small-bowel obstruction likely secondary to a closed loop obstruction.,0
"Additionally, presence of abdominal ascites, mesenteric engorgement and differential enhancement of the wall raise concern for intestinal ischemia/infarction.",1
These findings were discussed with Dr. on immediately following this examination.,0
"11:48 AM CHEST (PORTABLE AP) Clip # Reason: chf, ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with new aflt REASON FOR THIS EXAMINATION: chf, ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, , 11:48 A.M. HISTORY: New atrial flutter.",1
"COMPARISON: Multiple priors, the most recent dated CTA of the chest earlier same day.",0
FINDINGS: Lung volumes are diminished.,0
There is central pulmonary vascular congestion and mild interstitial edema.,0
Bilateral pleural effusions are evident.,0
IMPRESSION: Mild interstitial edema and bilateral pleural effusions.,0
"9:44 PM CHEST (PORTABLE AP) Clip # Reason: pna Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with fever, sob REASON FOR THIS EXAMINATION: pna ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:59 P.M., HISTORY: Fever, shortness of breath, and pneumonia.",0
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lateral aspect of the left lower chest is not included on the examination.,0
"The imaged portions of the pleural surfaces are normal, and lungs are clear aside from mild right basal atelectasis.",0
"An accessory bone extends parallel to the upper thoracic spine from the T1 to T3 level, whether this is surgical is not cleared.",0
11:20 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?,0
retroperitoneal bleed Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;ELEVATED TROPONIN\CATH Field of view: 50 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with dropping hematocrit s/p attempted perc nephrostomy tube placemennt today REASON FOR THIS EXAMINATION: ?,1
"retroperitoneal bleed CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old woman with dropping hematocrit, status post attempted percutaneous nephrostomy tube placement, evaluate for retroperitoneal bleed.",1
TECHNIQUE: MDCT acquired images were obtained through the abdomen and pelvis without administration of oral or intravenous contrast.,0
CT ABDOMEN: The lung bases demonstrate bibasilar atelectasis although cannot exclude pneumonia in dense right lower lobe consolidation.,0
Extensive coronary artery calcifications are noted.,0
"On this non-enhanced study, the liver, spleen, right kidney, adrenals are grossly unremarkable.",1
Vicarious excretion of contrast is noted in teh gallbaldder.,0
"There is a small amount of air surrounding the left kidney with high-density contrast material extending into the perirenal, consistent with contrast extravisation.",1
A small amount of lower density material exteing along teh retroperitoneum to the left mid iliac crest.,0
A 7- mm stone in the left UPJ and a nonobstructing right lower pole stone measuring 4 mm are unchanged.,0
"CT PELVIS WITHOUT CONTRAST: The rectum, uterus, bladder, pelvic loops of large and small bowel are unremarkable.",0
"Bone windows demonstrate diffuse degenerative changes, but without evidence of suspicious lesion.",0
"Small localized extravasation of contrast from left kidney, with associated small left perinephric hematoma with hemorrhage tracking along the retroperitoneum to the level of the left mid iliac crest.",1
Decompression of left sided hydronephrosis with stable stone at the left UPJ.,0
Right lower lobe consolidation may represent pneumonia.,0
(Over) 11:20 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?,0
retroperitoneal bleed Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;ELEVATED TROPONIN\CATH Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont),1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Demerol Attending: Chief Complaint: Enterocutaneous fistula Major Surgical or Invasive Procedure: Enterocutaneous fistula takedown.,0
"History of Present Illness: The patient is a 68 y/o female with h/o of Crohn's s/p proctocolectomy, total abdominal colectomy, proctectomy, end ileostomy in and ileostomy stenosis s/p multiple reoperations in who presents with a enterocutaneous fistula.",1
"Past Medical History: 1.Crohn's disease s/p proctocolectomy and s/p total abdominal colectomy, proctectomy, and end ileostomy in .",1
2.incarcerated parastomal hernia s/p repair with mesh in .,0
"3.stenosis of an ileostomy in s/p multiple operations 4.Multiple enterocutaneous fistulas 5.diabetes mellitus 2 6.hypertension 7.depression Social History: She takes no ethanol, prior tobacco use, quit 20 years ago.",1
Family History: Father died of stroke.,0
**FINAL REPORT ** GRAM STAIN (Final ): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
TISSUE (Final ): REPORTED BY PHONE TO AT 4:30PM.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final ): NO ANAEROBES ISOLATED.,0
5:01 am MRSA SCREEN Source: Nasal swab.,0
**FINAL REPORT ** MRSA SCREEN (Final ): STAPH AUREUS COAG +.,0
Oxacillin sensitivity performed by agar screen.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | OXACILLIN------------- R 6:40 am BLOOD CULTURE **FINAL REPORT ** AEROBIC BOTTLE (Final ): NO GROWTH.,0
ANAEROBIC BOTTLE (Final ): NO GROWTH.,0
5:17 am URINE **FINAL REPORT ** URINE CULTURE (Final ): PROBABLE GARDNERELLA VAGINALIS.,0
Brief Hospital Course: Pt was admitted for management of her enterocutaneous fistula and tpn was continued.,0
Her albumin was 3.2 and Transferrin was 185 at that time and it was deemed that her nutritional status was sufficient for an enterocutaneous fistula takedown.,1
"On , the patient went to the OR for an exploratory laparotomy, lysis of adhesions (3 hours), enterectomy enteroenterostomy, repair of 2 enterostomies and gastrostomy.",0
The patient tolerated the operation well and was transferred to the SICU in stable condition.,0
"Post-op day 1, the patient spiked a fever and had an elevated WBC count of 25.6 and was treated empirically with broad spectrum Ampicillin, gentamicin, and metronidazole.",0
KUB and showed no evidence of obstruction.,0
The patient was transferred to the floor and her diet was advanced to clears.,0
The patient continued to have nausea and G-tube clamping trials were started.,0
The G-tube would be clamped for 1 hour and be unclamped for 3 hours.,0
The patient was started on Reglan for her ileus.,0
", the patient's diet was advanced to fulls.",0
Patient spiked a fever of 102 the following day and was treated empirically with Vancomycin for possible line infection and Zosyn for possible intraperitoneal abscess.,0
CT scan did not show intraperitoneal abscess and did not show bowel obstruction.,0
Chest x-ray was negative for pneumonia.,0
The patient's fever subsided and she was advanced to a regular diet which she tolerated well.,0
G-tube clamping trials were gradually advanced and the patient did not experience nausea with her G-tube clamped full time.,0
"Because the patient had good PO intake, TPN was discontinued .",0
The patient was discharged home on and arrangements were made for the patient to receive another week of Vancomycin and Levoquin as an outpatient.,0
The patient was switched to Levoquin from Zosyn because Levoquin can be dosed on a 24 hour basis.,0
Medications on Admission: Lopressor Celexa Discharge Medications: 1.,0
Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks.,0
"Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 2 weeks.",0
Levofloxacin 25 mg/mL Solution Sig: 500mg Intravenous once a day for 2 weeks.,0
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day.,0
Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO twice a day.,0
K-Phos Original 500 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: , MA Discharge Diagnosis: Enterocutaneous fistula Discharge Condition: stable Discharge Instructions: Call your doctor if you experience any fever, chills, lightheadedness, dizziness, chest pain, shortness of breath, palpitations, severe abdominal pain, nausea/vomiting, or bleeding from abdominal wound.",0
Do not drive while taking pain medications.,0
Do not swim or take baths.,0
No lifting anything over 10 lbs.,0
Followup Instructions: Please follow up with Dr. in 2 weeks.,0
Please follow up with your primary care physician 1 week.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Suicide attempt, tylenol ingestion Major Surgical or Invasive Procedure: None History of Present Illness: 30 y/o female w h/o depression, anxiety, and polysubstance abuse, prior suicide attempt with Tylenol and Lithium, found to have suicide attempt with tylenol ingestion admitted to OSH on .",0
Patient took approx 150 tabs of tylenol PM.,0
"After 1 hour of this ingestion (per patient), she came to the ED and was found to have a Tylenol level to 470.",0
"In OSH ED, she was given IV acetylcysteine gtt, unclear dosing.",0
Her LFT initially was AST 67 ALT 257 which steadily climbed to AST 2550 ALT 1557 then today AST ALT 4825.,0
Her INR also risen (1.2->3.1).,0
Her renal function is within normal limits still.,0
Her most recent ABG is 7.39/30.7.,0
No evidence of hepatic encephalopathy.,0
She has persistent nausea and abdominal pain.,0
"At OSH, she had elevated glucose up to 255, no history of DM.",0
Amylase and lipase of 69 and 33 respectively.,0
Hepatitis panel (A and B negative).,0
Hep C and HIV were pnding.,0
Has been a heavy alcohol user with no h/o withdrawal.,0
"At OSH, she was given 21 hours of acetylcysteine and was d/c, but her LFT continued to rise.",0
"After discussion with poison control, she was continued on her IV acetylcysteine (goal till her AST/ALT down below 1000) and her tylenol level below 10.",0
She was transferred to for further management of her ingestion of tylenol.,0
"Pt reports a long history of anxiety with panic attacks as well as polysubstance abuse including oxycontin, heroine, cocaine, and xanax.",0
"On the floor, she was found to be alert and oriented without any issues.",0
"Review of systems: (+) Per HPI Past Medical History: Past Medical History: -Cellulitis -Thrombocytosis -h/o lithium/tylenol overdose in -depression -anxiety -polysubstance abuse including IVDU, marijuana use, cocaine use Social History: Patient currently lives alone.",0
"She previously lived with husband, but he has been in jail since .",0
They are also in the midst of divorce proceedings.,0
Fiance has been at bedside during ICU stay.,0
"Previously worked as a crime analyst, but not currently.",0
Drinks alcohol (unsure of amount).,0
"Uses cocaine (intravenous), marijuana, percocet.",0
Family History: Father - History of substance abuse that developed in .,0
He had long period of sobriety until a few years ago when he was put on opiates for pain control and developed addiction.,0
"Per report, he fell and died following head trauma, which may have been related to intoxication.",0
Mother - History of anxiety.,0
Discharge Labs: 05:45AM BLOOD WBC-6.0 RBC-3.98* Hgb-11.6* Hct-34.5* MCV-87 MCH-29.2 MCHC-33.7 RDW-16.5* Plt Ct-313 05:45AM BLOOD PT-13.4 PTT-30.7 INR(PT)-1.1 05:45AM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-139 K-3.7 Cl-106 HCO3-26 AnGap-11 05:45AM BLOOD ALT-1172* AST-83* LD(LDH)-133 AlkPhos-117* TotBili-1.7* 05:45AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.6 .,0
"Microbiology: HCV VIRAL LOAD (): HCV RNA detected, less than 43 IU/mL.",0
- VIRUS VCA-IgG AB (Final ): POSITIVE BY EIA.,0
- VIRUS EBNA IgG AB (Final ): POSITIVE BY EIA.,0
- VIRUS VCA-IgM AB (Final ): NEGATIVE <1:10 BY IFA.,0
CMV IgG ANTIBODY (Final ): NEGATIVE FOR CMV IgG ANTIBODY BY EIA.,0
CMV IgM ANTIBODY (Final ): NEGATIVE FOR CMV IgM ANTIBODY BY EIA.,0
VARICELLA-ZOSTER IgG SEROLOGY (Final ): POSITIVE BY EIA.,0
Rubella IgG/IgM Antibody (): POSITIVE by Latex Agglutination.,0
RAPID PLASMA REAGIN TEST (Final ): NONREACTIVE.,0
"CXR : Heart size is top normal, most likely within normal limits and the study is slightly exaggerated by the portable technique of the study.",0
"Lungs are clear but note is made that external devices are projecting over the right hemithorax, precluding detailed evaluation of that examination.",0
"Pending: HBcAb, HBc IgM Brief Hospital Course: 30yo female with h/o polysubstance abuse, previous suicide attempt in (lithium and tylenol OD) requiring ICU admission and subsequent inpatient psych admission, who presented to OSH after ingestion of 150 Tylenol PM in setting of marijuana and percocet use, and cocaine use the day prior.",0
Patient was transferred to ICU at for further evaluation and management of tylenol overdose.,0
"# Tylenol ingestion: The patient's transaminases, AlkPhos, Tbili, and INR continued to trend down since admission.",0
"Pt was seen by hepatology, toxicology, and psych.",0
Hepatology reassured with her downtrending LFTs.,0
Patient not a transplant candidate at this time given recent substance abuse.,0
"Toxicology felt that since the pt's NAC was stopped for a period of 10 hrs at the OSH, it should be restarted here for 21 hr protocol (which was done).",0
NAC was d/c'ed on .,0
"Psych evaluated the pt, and given her SI, they determined she would need to go for inpatient psych treatment once medically stable.",0
The patient did not develop any signs of encephalopathy or cerebral edema.,0
She did not develop any acute kidney injury.,0
A RUQ US was negative for any acute pathology (as per hepatology).,0
"The patient was transferred to the general medicine floor, with all of her labs continuing to trend down.",0
"The patient remained hemodynamically stable, asymptomatic, and was medically cleared for transfer to inpatient psych.",0
"# Suicide attempt: Patient's suicide attempt with tylenol ingestion was in setting of marijuana and percocet use, as well as IV cocaine use the day prior.",0
She also had a previous suicide attempt in .,0
"Patient seen and evaluated by psych, who felt patient will need inpatient psych treatment once medically stable.",0
"Patient has been on 1:1 sitter, and at time of discharge from medical floor denies any further suicidal ideation.",0
"# Depression and Anxiety: Patient previously on fluoxetine as outpatient, but stopped taking this medication several months ago.",0
"She will need to get appropriate outpatient follow-up after inpatient psych treatment, with proper dosage of her home psych meds.",0
"# HCV Ab Positive - Patient has h/o IVDU, and HCV Ab noted to be positive on this admission.",0
HCV viral load was less than 43 IU/mL on testing.,0
"Patient HAV Ab positive, but HAV IgM negative, indicating previous exposure/vaccine for HAV.",0
"HepBsAg negative, and patient may benefit from Hep B vaccine as outpatient.",0
"Also ordered HepB core Ab and HepB core IgM, which will be pending at time of discharge.",0
"If HBV core Ab and IgM negative, patient should receive Hep B vaccine.",0
"Patient should follow-up with her PCP, have repeat LFT testing and viral load testing.",0
"If any abnormalities, she may be referred to hepatology as needed.",0
"Medications on Admission: Home Meds (stopped several months prior to admission): - Quetiapine 50 mg Tablet Sig: 1-2 Tablets PO BID PRN anxiety, insomnia.",0
- Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY Medications on transfer: Albuterol 1 puff inhaled q2h prn sob D5 1/2 NS with 40 KCl 150ml/h Pepcid 20mg po bid D50 prn hypoglycemia Glucagon 1mg IM prn hypoglycemia Glucose 4g 2 tabs prn hypoglycemia Novolog ISS Acetylcysteine 100mg/kg Discharge Medications: None Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: Primary Diagnosis: 1.,0
Suicide attempt Secondary Diagnosis: 1.,0
Anxiety Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You were admitted to the ICU after ingesting a large amount of tylenol.,0
This amount was toxic and caused significant injury to your liver.,0
"We monitored your liver function, and all of your lab values and symptoms continued to improve during your hospital course.",0
"You were seen by the liver team, who were encouraged by the improvement in your lab values.",0
"You were also seen by psychiatry, who felt that you would benefit from going to an inpatient psychiatry treatment center once you were medically stable.",0
One of your blood tests showed you have been exposed to the Hepatitis C virus.,0
You will need to follow-up with the liver doctors as outpatient for further evaluation.,0
"You should also be vaccinated against the Hepatitis B vaccine, and your PCP can help coordinate this vaccination.",0
Followup Instructions: You will be discharged from the general medicine service to an inpatient psychiatric service.,0
"Following your discharge from inpatient psychiatry, you should follow-up with a psychiatrist as an outpatient for ongoing evaluation and treatment of your previous depression, anxiety, and suicidal ideation.",0
You should also follow up with your PCP.,0
11:53 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate/edema/Fx ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with trauma and shortness of breath REASON FOR THIS EXAMINATION: Evaluate for infiltrate/edema/Fx ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP.,0
HISTORY: Shortness of breath status post trauma.,0
FINDINGS: Please note the right costophrenic angle and the lung apices were excluded on this film.,0
There is calcification of the aortic arch noted.,0
There is no focal consolidation or large effusion.,0
There is no large pneumothorax identified.,0
There is no evidence of displaced posterior rib fractures identified.,0
Known anterior rib fractures are not identified.,0
IMPRESSION: Limited study due to patient positioning.,0
No definite evidence of pneumothorax or focal consolidation.,0
"9:27 PM US ABD LIMIT, SINGLE ORGAN; DUPLEX DOP ABD/PEL LIMITED Clip # Reason: assess for gallbladder pathology, vasculature if possible Admitting Diagnosis: LIVER LACERATION,TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man s/p trauma with liver lac, hct stable, now new RUQ pain REASON FOR THIS EXAMINATION: assess for gallbladder pathology, vasculature if possible ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AKSb MON 10:57 PM PFI: Left lobe liver laceration redemonstrated.",1
Patent portal and hepatic veins.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 19-year-old with liver laceration.,1
Now with rising liver enzymes and right upper quadrant pain.,0
COMPARISON: CT of the torso.,0
"RIGHT UPPER QUADRANT ULTRASOUND: The large laceration in the left lobe of the liver, measuring approximately 6 cm in diameter, is again present.",1
There is no bile duct dilation.,0
The common duct measures 3 mm.,0
The portal vein is patent with anterograde flow.,0
"There is also normal flow within the right, left and middle hepatic veins.",0
"The gallbladder is normal with no wall thickening, gallstones or pericholecystic fluid.",0
There is no appreciable ascites.,0
Limited view of the right kidney demonstrates no hydronephrosis.,0
Redemonstration of left lobe liver laceration.,1
No intrahepatic bile duct evaluation.,0
Normal gallbladder and no ascites.,0
6:38 PM BABYGRAM (CHEST ONLY) Clip # Reason: assess line placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with UVC REASON FOR THIS EXAMINATION: assess line placement ______________________________________________________________________________ FINAL REPORT CHEST X-RAY TAKEN PORTABLY 6:50PM FINDINGS: Endotracheal tube is unchanged at the thoracic inlet.,0
The infant is rotated to the left.,0
There is haziness in the left lower lobe which is unchanged.,0
Aeration is somewhat better when compared to the prior most recent film.,0
Umbilical venous catheter is at body of T10 which represents a lower position than on the prior two studies.,0
"10:23 AM EMERG BILAT LOWER EXT VEINS PORT Clip # Reason: AFIB,EVAL FOR DVT Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with hx of AFib, off coumadin s/p stroke REASON FOR THIS EXAMINATION: r/o dvt ______________________________________________________________________________ WET READ: NATg SUN 1:09 PM no dvt b/l ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: 67-year-old male with history of atrial fibrillation, now off Coumadin following a stroke.",1
TECHNIQUE AND FINDINGS: There is normal respirophasic waveform in the bilateral common femoral veins.,0
"There is normal compressibility, color Doppler flow, and response to augmentation in the bilateral common femoral, superficial femoral, and popliteal veins.",0
Normal flow and compressibility is seen within the posterior tibial and peroneal veins of the calves bilaterally.,1
8:37 PM CHEST (PORTABLE AP) Clip # Reason: evaluation of ETT Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p CABG x3 now re-intubated REASON FOR THIS EXAMINATION: evaluation of ETT ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of ET tube placement.,0
The ET tube tip is 5.2 cm above the carina.,0
The NG tube tip passes below the diaphragm and terminates in the stomach.,0
The lung volumes are lower than on the previous study.,0
"The cardiomediastinal silhouette is slightly widened, most likely related to lower lung volumes.",0
Large bilateral pleural effusion is unchanged.,0
Underlying mild vascular engorgement cannot be excluded.,0
5:10 PM CHEST (PA & LAT) Clip # Reason: eval effusion Admitting Diagnosis: AORTIC STENOSIS\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with s/p avr cabg POD 4 REASON FOR THIS EXAMINATION: eval effusion ______________________________________________________________________________ WET READ: ENYa FRI 11:21 PM Similar bilateral small pleural effusions.,1
Interval removal of large-bore RIJ CVL.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG.,0
"FINDINGS: As compared to the previous radiograph, the tip of a left PICC line projects over the mid SVC.",0
Minimal left and right pleural effusions.,0
No current evidence of pulmonary edema.,0
An apparent small nodular opacity at the left lung apex is caused by a vessel.,0
"2:58 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with respiratory failure, pneumonia REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Respiratory failure, evaluation for interval change.",1
"Unchanged size of the cardiac silhouette, unchanged mild overhydration.",0
No newly appeared focal parenchymal opacity suggesting pneumonia.,0
Unchanged position and course of monitoring and support devices.,0
"10:21 AM CHEST (PORTABLE AP) Clip # Reason: s/p right picc placement read wet and page# with result Admitting Diagnosis: FX HIP,R ______________________________________________________________________________ MEDICAL CONDITION: year old woman s/p r hip fx requiring tpn and abx REASON FOR THIS EXAMINATION: s/p right picc placement read wet and page# with result ______________________________________________________________________________ FINAL REPORT INDICATION: Recent PICC placement.",0
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The patient's head and neck obscure the apical portion of this exam.,0
A right-sided PICC is seen terminating in the proximal SVC.,0
"No pneumothorax is identified; however, as stated above, the apices cannot be fully evaluated.",0
"As previously seen, there is cardiomegaly with increased pulmonary vascular markings.",0
Probable bilateral pleural effusions are seen on this single view.,0
Surrounding osseous and soft tissue structures are unchanged.,0
"5:33 AM CHEST (PORTABLE AP) Clip # Reason: assess for pneumothrax Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 70M s/p esophagectomy s/p chest tube d/c , now w/ ptx, and placement of mini-thorax catheter REASON FOR THIS EXAMINATION: assess for pneumothrax ______________________________________________________________________________ FINAL REPORT STUDY: Portable chest .",0
FINDINGS: A small bore catheter remains in place in the right pleural space.,0
A previously noted pneumothorax is no longer visualized.,0
There is interval improved opacity in the right lower lobe with residual patchy and linear opacity remaining in this region.,0
Small pleural effusions are again demonstrated bilaterally.,0
IMPRESSION: Resolution of right pneumothorax.,0
1:37 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate placement of tube Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with esphogeal bleeding REASON FOR THIS EXAMINATION: evaluate placement of tube ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Esophageal bleeding.,1
Comparison is made with prior study performed two hours earlier.,0
The balloon is located in the mid and distal esophagus.,0
The tip is not visualized; is below the diaphragm distal to the GE junction.,0
Widened mediastinum is minimally increased.,0
Right IJ catheter tip is in unchanged position.,0
The tip is in the right brachiocephalic vein.,0
If any there is small left pleural effusion.,0
Moderate pulmonary edema has worsened.,0
Left apical opacity is a combination of atelectasis and pulmonary edema.,0
3:59 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: Eval septic emboli Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with endocarditis and concern for septic emboli.,1
Intubated but remains obtunded off sedation.,0
"REASON FOR THIS EXAMINATION: Eval septic emboli No contraindications for IV contrast ______________________________________________________________________________ WET READ: MDAg MON 5:43 PM multiple small infarcts, suggesting embolic phenomenon.",1
"in the setting of septic emboli, there is a substantial risk she has a mycotic aneurysm.",0
These are frequently distal and the infarcts are distal.,0
We do not see a mycotic aneurysm in the central vessels.,0
We have called the MRI tech and requested that they perform a MRA of the more distal vessels to be added to this study.,0
-MAgarwal d/ by phone at 5:41pm .,0
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 47-year-old woman with endocarditis and concern for septic emboli.,1
Evaluate septic emboli and for contraindications to anticoagulation as the patient may proceed for a procedure requiring anticoagulation.,1
"TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR, T2* GRE, and diffusion-weighted images of the brain were obtained.",0
"Additionally, 3D time-of-flight of the circle of with reconstructions were obtained for MRA.",0
The patient is unable to receive intravenous contrast due to renal function.,0
"FINDINGS: There are multiple areas of restricted diffusion in the bilateral cerebral hemispheres, splenium of the corpus callosum, and cerebellum compatible with acute infarcts, likely due to embolic phenomenon.",1
There is no mass effect or compression of the fourth ventricle and no hydrocephalus.,0
"Two, possibly three of these infarcts demonstrate susceptibility artifact on the GRE images compatible with microhemorrhages.",0
Principal vascular flow voids are preserved.,0
There is no evidence of intracranial arterial stenosis or mycotic aneurysm.,0
The paranasal sinuses are well aerated.,0
Opacification of the mastoid air cells is likely related to intubation.,0
"Numerous, diffuse acute infarcts without mass effect or hydrocephalus.",0
"The findings are compatible with septic embolic infarcts, some of which have microhemorrhages.",0
"In the setting of septic emboli, there is a substantial risk this patient may have a mycotic aneurysm, which may be a further contraindication to anticoagulation.",1
"We do not see a mycotic aneurysm on this study, but these are frequently distal and the infarcts are distal.",0
"If clinically indicated, an MRA of the more distal vessels could be performed (Over) 3:59 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: Eval septic emboli Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ FINAL REPORT (Cont) (from the vertex to the supraclinoid ICA) to evaluate for a more distal mycotic aneurysm.",1
"We had requested that the additional MRA sequence be performed prior to formal reporting of this study, but these were unable to be performed.",0
"Initial findings discussed with Dr. by phone at 5:41 p.m., .",0
"Findings again discussed with Dr. by phone at 9:45 a.m., .",0
3:35 AM CHEST (PORTABLE AP) Clip # Reason: Intubation- OETT placement Admitting Diagnosis: INTRACRANIAL MASS ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with REASON FOR THIS EXAMINATION: Intubation- OETT placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: Compared to previous study of 1 day earlier.,0
"An endotracheal tube is in place, terminating approximately 6 cm above the carina.",0
The cuff of the tube appears slightly overdistended.,0
There remains complete opacification of the right hemithorax with slight epsilateral shift of the mediastinum.,0
"Within the left lung, there is increasing vascular engorgement and perihilar haziness.",0
A left vascular catheter remains in satisfactory position.,0
Note is made of prior right mastectomy and axillary lymph node resection.,0
IMPRESSION: 1) Endotracheal tube cuff slightly overdistended.,0
"2) Complete opacification of right hemithorax with associated epsilateral shift of the mediastinum, concerning for post obstructive collapse.",0
Findings communicated with referring clinical physician.,0
"8:15 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with sepsis, concern for asp PNA REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT COMPARISON: Portable chest radiograph .",0
FINDINGS: The right IJ line tip projects just below the cavoatrial junction.,0
Retrocardiac opacity has worsened since .,0
There is subtle increase in the background opacification of the right lung base with silhouetting of the right hemidiaphragm.,0
Overall findings are concerning for aspiration pneumonia in the correct clinical setting.,0
"The cardiac, mediastinal, and hilar silhouettes are unremarkable.",0
IMPRESSION: Bibasilar opacifications concerning for aspiration pneumonia in the correct clinical setting.,0
Dr. notified of the results at 10:59 a.m. on .,0
"9:15 AM CHEST (PORTABLE AP) Clip # Reason: eval for pulm contusion Admitting Diagnosis: S/P FALL;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with s/p MVC REASON FOR THIS EXAMINATION: eval for pulm contusion ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM.",0
"Allowing for technique, the heart is slightly enlarged with tortuosity of the thoracic aorta and calcification in the arch and descending portions.",0
A dual chamber left-sided pacemaker is present with atrial and ventricular leads in situ.,0
"Since prior film of , there has been partial clearing of the right mid-zone opacity with a small area of persistent opacity in this location.",0
Probable fractures of anterior portions of several right ribs.,0
IMPRESSION: No pneumothorax or obvious pleural effusion in this single view.,1
Probable fractures of some of the right anterior ribs and persistent small area of opacity in the right lower zone.,0
Admission Date: Discharge Date: Service: CARDIOTHOR CHIEF COMPLAINT: Chest pain.,0
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old gentleman who is transferred from after undergoing a catheterization which had revealed three-vessel coronary artery disease.,1
"The patient had been describing a week of increasing substernal chest pain which would last ten minutes, and only resolving at rest.",0
This had been happening up to 20 times a day over the last several weeks.,0
He has a history of a myocardial infarction 20 years prior which was medically managed and since then has been in relatively good health.,0
"He currently denies any radiation of his pain, any palpitations, nausea, vomiting, or diaphoresis.",0
He presents to for evaluation and coronary artery bypass graft surgery.,1
Significant for coronary artery disease status post myocardial infarction in the .,1
SOCIAL HISTORY: The patient has a remote history of tobacco use.,0
He quit in the 80s.,0
The patient has approximately one beer a week.,0
He is a retired meat packer.,0
"FAMILY HISTORY: The patient's father died of a myocardial infarction at age 54. REVIEW OF SYSTEMS: The patient has positive claudication but denies any cough, shortness of breath, dyspnea, myalgias or arthralgias.",1
Denies any hematuria or dysuria.,0
PHYSICAL EXAMINATION: The patient is an older gentleman in no acute distress.,0
Pupils equally round and reactive to light.,0
He has no jugular venous distention.,0
Good breath sounds bilaterally which is clear to auscultation.,0
"His heart is regular with no murmurs, rubs or gallops.",0
"He has no cyanosis, clubbing or edema.",0
He is alert and oriented times three.,0
"The patient's neurologic functions, sensory intact bilaterally.",0
"LABORATORY: Laboratory examination included a white blood cell count of 8.2, hematocrit of 43.4, platelets of 306.",0
"Sodium 137, potassium of 4.1, chloride of 99, bicarbonate of 28, BUN of 20, creatinine 1.2, glucose of 160.",0
"PT 12.6, PTT 30.2, INR 0.9.",0
"ALT was 20, AST was 26.",0
"Total bilirubin was 0.5, albumin was 4.7, CK was 120 with an MB fraction of 2.8.",0
"RADIOGRAPHIC STUDIES: The patient had a carotid Duplex done on , which showed 40 to 59% stenosis bilaterally internal carotid arteries.",1
"On , he underwent a Myoview which showed a large fixed defect on the inferior wall, moderately visible defect at anterior wall, moderate early reversible defect on inferior apical wall and an ejection fraction of 29%.",0
There was overall global hypokinesis.,0
"EKG was sinus rhythm with a rate of 61 with Q waves in II, III, AVF, V2 through V6 and ST depression in III and AVF.",0
Preoperative chest x-ray showed no evidence of congestive heart failure.,0
There was a tiny nodule on the left lung which was noted should be followed postoperatively since there was no prior film here at this institution.,0
"HOSPITAL COURSE: The patient, on hospital day number two, was taken to the Operating Room where he underwent a coronary artery bypass graft times four with grafts in the left internal mammary artery to left anterior descending, saphenous vein graft to right coronary artery, saphenous vein graft to obtuse marginal 1 and saphenous vein graft to diagonal 1.",1
He also underwent aortic valve replacement with a 22 mm pericardial valve which was secondary to a ricket deficiency noted on transesophageal echocardiogram done interoperatively.,1
The patient tolerated this procedure well and was transferred to the Cardiothoracic Intensive Care Unit.,0
"Hemodynamically, the patient was weaned off of pressor support, was initially A-paced and the underlying rhythm was sinus rhythm.",0
The patient was able to maintain cardiac indexes greater than 2 with good urine outputs.,0
The patient was weaned to extubation and was extubated without incident.,0
"Initially, the patient's hematocrit was 22.0; he was transfused two units to a hematocrit of 27 and the patient's hematocrit remains stable.",0
"On postoperative day number two, the patient's chest tubes and pulmonary artery catheter were discontinued.",0
The patient was evaluated by Physical Therapy and diet was advanced as tolerated.,0
"The patient on hospital day three, was transferred to the Floor.",0
"On the Floor, the patient had one episode of a six-beat run of ventricular tachycardia which was captured by the monitors.",1
This was during a time of excitation and the patient has otherwise remained in sinus rhythm with no other evidence of any arrhythmias.,0
The patient has been stabilized on a regimen of Lopressor which is providing adequate rate control with good blood pressure control.,0
The patient is stable and is now ready to be discharged to rehabilitation to follow-up in Cardiothoracic Surgery office.,0
Coronary artery disease status post coronary artery bypass graft times four.,1
Status post aortic valve replacement with pericardial valve.,1
twice a day times seven days.,0
.................... one to two p.o.,0
The patient is to follow-up with Dr. in four weeks.,0
"The patient will follow-up with Dr. in two weeks, his primary care physician.",0
Dictated By: MEDQUIST36 D: 11:57 T: 13:00 JOB#:,0
4:51 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: eval common bile duct as well as duplex hepatic artery Admitting Diagnosis: ANEURYSM\THORACOABDOMINAL ENDARTERECTOMY/ RIGHT PARTIAL BYPASS; LUBAR DRAIN ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman s/p TAA repair REASON FOR THIS EXAMINATION: eval common bile duct as well as duplex hepatic artery ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 7:23 PM PFI: Technically limited evaluation due to difficulty with breath-holding and overlying bowel gas.,1
"There is no intrahepatic ductal dilation, the common bile duct is normal in caliber.",0
Main portal vein is patent with antegrade flow.,0
"Normal waveforms are seen in the main hepatic artery, left, and right hepatic arteries.",0
"However, there is concern for vascular compromise to the liver, further evaluation with CTA should be considered.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 40-year-old female status post thoracic aortic aneurysm repair.,0
Evaluate for biliary ductal dilation or abnormal arterial flow in the hepatic artery.,0
FINDINGS: Limited evaluation of the right upper quadrant was performed.,0
The examination was technically difficult due to overlying bowel gas and difficulty with breath-holding instructions.,0
"There are no definite focal liver lesions, though evaluation is extremely limited.",0
There is no intrahepatic biliary ductal dilation.,0
The common bile duct is normal in caliber measuring 4 mm.,0
The main portal vein is patent with normal antegrade flow.,0
"Doppler waveforms were obtained from the main hepatic artery, right hepatic artery, and left hepatic artery, and appear grossly normal.",0
There is no free fluid in the right upper quadrant.,0
Limited views of the gallbladder are unremarkable.,0
IMPRESSION: No evidence for biliary ductal dilation or hepatic arterial compromise.,0
"Given the technically limited nature of this examination, there is high concern for compromised hepatic arterial flow, cross-sectional (CTA) imaging is recommended.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: please check PICC tip left basilic 47 cm thanks please page Admitting Diagnosis: S/P HANGING ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman with REASON FOR THIS EXAMINATION: please check PICC tip left basilic 47 cm thanks please page IV with wet read ______________________________________________________________________________ WET READ: CHgc TUE 9:30 PM PICC TIP in distal SVC, d/ , IV RN ______________________________________________________________________________ FINAL REPORT AP CHEST 8:49 P.M. ON Brain injury.",1
"IMPRESSION: AP chest compared to through , 2:49 p.m.: Endotracheal tube is in standard placement, nasogastric tube ends in the distal stomach, left PIC line tip at the superior cavoatrial junction.",0
"Right lower lobe consolidation has improved substantially since earlier in the day suggesting it may have been due to atelectasis, while severe left lower lobe atelectasis is more pronounced now than it was on , consistent with pneumonia.",0
Small right pleural effusion has enlarged.,0
2:19 AM CHEST (PA & LAT) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with acute SOB no infxs complaints REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 88 year-old with shortness of breath.,0
"FINDINGS: The heart is mildly enlarged with a tortuous and calcified aorta, but stable in appearance.",0
"The pulmonary vasculature is normal, and there is no pneumothorax.",0
The osseous structures are demineralized.,0
There is a moderate scoliosis of the upper lumbar spine convexed to the left.,0
Patient is post CABG with unchanged appearance of the median sternotomy wires.,0
IMPRESSION: No radiographic evidence of acute cardiopulmonary process.,0
"11:43 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: pulmonary embolism Admitting Diagnosis: PNEUMONIA Contrast: OMNIPAQUE Amt: ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with metastatic rectal cancer pw fever, PNA ?",1
PE REASON FOR THIS EXAMINATION: pulmonary embolism No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): NMKa MON 2:45 PM PFI: 1.,0
"No evidence of pulmonary embolism within main, lobar, and segmental branches of pulmonary arteries.",0
"Due to minimal motion artifacts and multifocal lung opacities, assessment of pulmonary embolism in subsegmental branches of pulmonary arteries was limited.",0
Multifocal ground glass and consolidations with smooth septal thickening reflect multifocal pneumonia with an element of pulmonary edema.,1
Multifocal osseous metastases have minimally progressed.,0
Fullness of the left renal pelvis which appears new since .,0
Ultrasound of abdomen and pelvis is recommended for further evaluation.,0
______________________________________________________________________________ FINAL REPORT TECHNIQUE: Contrast-enhanced multidetector CT of thorax was performed using a standard department protocol for assessment of pulmonary embolism.,0
Contiguous axial images at 5-mm and 2.5-mm slice thickness were reviewed concurrently with coronal and sagittal reformats.,0
The study was reviewed in comparison with prior chest CT from .,0
FINDINGS: MEDIASTINUM: Main pulmonary artery before bifurcation measures 28 mm and is normal in caliber.,0
"There are no filling defects within main, lobar, and segmental branches of pulmonary artery to suggest pulmonary embolism.",0
"Due to motion artifact and multifocal lung opacities, assessment of subsegmental pulmonary arterial branches was limited.",0
"Few small lymph nodes are seen in the upper and lower paratracheal and subcarinal regions, but none of them meet CT size criteria for pathological enlargement.",0
No pathologically enlarged supraclavicular or axillary lymph nodes.,0
Mild mediastinal fat stranding is present.,0
Heart size is normal without pericardial effusion.,0
Right Port-A-Cath ends at lower SVC.,0
AIRWAYS AND LUNGS: Airways are patent to subsegment bronchi.,0
Multifocal consolidation and ground-glass opacities in dependent and anti-dependent portions of both lungs overlying moderately severe emphysema reflects multifocal pneumonia.,1
"Associated mild and diffuse smooth interlobular septal (Over) 11:43 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: pulmonary embolism Admitting Diagnosis: PNEUMONIA Contrast: OMNIPAQUE Amt: ______________________________________________________________________________ FINAL REPORT (Cont) thickening represents small component of pulmonary edema.",1
Bilateral pleural effusions are minimal.,0
"ABDOMEN: The study is not designed for assessment of subdiaphragmatic pathology; however, limited views were remarkable for fullness of left renal pelvis which is new since .",0
Ultrasound of abdomen and pelvis is suggested for further evaluation to rule out a possibility of obstructive hydronephrosis given the clinical history.,1
BONES: Multifocal osseous metastases have progressed since .,0
Post-surgical changes are evident at cervicothoracic junction.,0
Extensive osseous metastasis to the spine is better evaluated on the recent MRI studies.,0
"No evidence of pulmonary embolism within the main, lobar, and segmental branches.",0
Assessment of subsegmental arteries is limited due to motion artifacts and multifocal lung opacities.,0
Multifocal pneumonia with a likely component of superimposed pulmonary edema.,1
"Multifocal osseous metastases, progressed since .",0
"8:53 AM CT HEAD W/O CONTRAST Clip # Reason: s/p trauma, now increasing somulence, please evaluate for bl ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with trauma ?",0
"head injury REASON FOR THIS EXAMINATION: s/p trauma, now increasing somulence, please evaluate for bleed ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.",0
TECHNIQUE: Noncontrast head CT. HEAD CT W/O CONTRAST: There is no intra or extra-axial hemorrhage.,0
The ventricles and sulci are normal.,0
No major vascular territorial infarct is seen.,0
There is opacification within the right maxillary sinus.,0
IMPRESSION: No acute intracranial pathologic process.,0
No change since exam from one day prior.,0
"7:10 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: r/o splenic or liver injury Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman s/p MVC transferred with known C2 fx and dropped BP on route, FAST indeterm REASON FOR THIS EXAMINATION: r/o splenic or liver injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 78-year-old female status post MVC.",0
"TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained following the administration of IV Optiray contrast.",0
CT CHEST WITH IV CONTRAST: An endotracheal tube is seen appropriately positioned.,0
The heart and great vessels are unremarkable without mediastinal hematoma.,0
No enlarged mediastinal or hilar lymph nodes.,0
The bronchi are patent bilaterally.,0
Lung windows reveal mild basilar consolidation/aspiration.,0
Two 4 mm pulmonary nodes are seen within the left lower lobe.,0
A 3 mm right lower lobe nodule abuts the pleura.,0
CT ABDOMEN WITH IV CONTRAST: A 4-mm hypodensity in the caudate lobe cannot be further characterized.,0
"The gallbladder, spleen, adrenal glands, stomach and abdominal loops of small and large bowel are unremarkable.",0
Small hypodensities in both kidneys likely represent cysts but are not fully characterized.,0
CT PELVIS WITH IV CONTRAST: There are scattered sigmoid diverticula without evidence of diverticulitis.,0
There are no enlarged pelvic or inguinal lymph nodes and no free fluid in the pelvis.,0
Osseous structures demonstrate no suspicious lytic or sclerotic foci.,0
There are bilateral L5 pars defects with grade II anterolisthesis of L5 on S1.,0
Superior endplate compression at L3 is age indeterminate.,0
There are moderate degenerative changes of the lumbar spine.,0
There is abnormal articulation of the left sternoclavicular joint.,0
No soft tissue stranding is seen within this region.,0
(Over) 7:10 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: r/o splenic or liver injury Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
L3 superior endplate deformity age indeterminate.,0
Chronic bilateral pars defects at L5 resulting in grade II anterolisthesis of L5 on S1.,0
Abnormal articulation of the left sternoclavicular joint.,0
Three sub 5 mm pulmonary nodules.,0
Follow-up CT can be performed in one year if there is a history of smoking.,0
These findings were discussed with on .,0
", S. SICU-B 1:28 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate interval change.",0
"Admitting Diagnosis: DRAIN LEAKAGE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with desat, decreased breath sounds REASON FOR THIS EXAMINATION: Please evaluate interval change.",0
"______________________________________________________________________________ PFI REPORT PFI: Increase in left retrocardiac consolidation, concerning for infectious pneumonia.",0
"Otherwise, stable appearance of the chest.",0
"7:58 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: TAMPONADE\PERICARDIAL TAP ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with pericarditis presented with cardiac tamponade, hypoperfusion with MODS, s/p pericardiocentesis.",1
"REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 8:40 A.M., HISTORY: Pericarditis, cardiac tamponade.",1
"IMPRESSION: AP chest compared to and 2: Moderate left pleural effusion has increased since , partially obscuring the cardiac silhouette.",0
"Mediastinal widening at the level of the aortic arch has increased slightly, which could be due to increased central venous pressure.",0
Small right pleural effusion stable.,0
Pericardiocentesis catheter unchanged in position.,0
These findings were discussed by Dr. with Dr. by telephone two hours prior to this dictation.,0
"10:01 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: assess abd distention, on hi fi Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity at 24 weeks, on hfov nec REASON FOR THIS EXAMINATION: assess abd distention on hi fi ______________________________________________________________________________ FINAL REPORT Examination is of the chest and abdomen.",1
Comparison is made with an examination performed on the 17th.,0
There has been little change.,0
An ETT ends above the carina.,0
The right upper lobe collapse is partially resolved.,0
The patient continues to have moderately severe diffuse lung disease probably chronic in nature.,1
There is more focally loculated interstitial air in the left lower lobe.,0
The bowel gas pattern has changed since our last exam.,0
There is a rather amorphous loop in the right lower quadrant.,1
There are no specific signs of necrotizing enterocolitis.,0
There is a bulge in the left flank which based on prior films is probably due to fluid-filled bowel loops.,0
"8:59 AM CHEST (PORTABLE AP) Clip # Reason: Eval interval film Admitting Diagnosis: RENAL CANCER;BACK PAIN ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with ?fluid overload REASON FOR THIS EXAMINATION: Eval interval film ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH: INDICATION: Fluid overload, evaluation.",0
"FINDINGS: As compared to the previous examination, the patient is after spinal stabilization surgery.",1
According material is in situ.,0
The pre-existing bilateral pulmonary metastasis (history of renal cell carcinoma) are unchanged.,1
"11:49 PM CHEST (PA & LAT) Clip # Reason: eval acute process, free air.",0
"______________________________________________________________________________ MEDICAL CONDITION: year old woman with cough, low grade temps, abd distension REASON FOR THIS EXAMINATION: eval acute process, free air.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: -year-old woman with cough, low-grade temperature, abdominal distention.",0
PA AND LATERAL CHEST RADIOGRAPH: Comparison was made with the prior chest radiograph dated .,0
The heart is top normal in size allowing the technique.,0
Again note is made of markedly elongated and tortuous aorta.,0
"Lung volumes are low, probably due to low inspiratory level.",0
"There is faint opacity at the lung bases, probably representing atelectasis.",0
No evidence of CHF or other consolidation is noted.,0
Degenerative changes of thoracolumbar spine is noted.,0
No evidence of free air below the diaphragm.,0
The lateral view is limited due to overlying soft tissue.,0
3:17 AM MR-ANGIO HEAD; MR HEAD W/O CONTRAST Clip # Reason: L cerebellar bleed in patient on heparin for dvt.,0
Eval for ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman s/p renal and pancreas transplant with dvt now with L cerebellar bleed on heparin.,0
REASON FOR THIS EXAMINATION: L cerebellar bleed in patient on heparin for dvt.,0
Eval for extent of bleen and any aneurysm.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Left cerebellar bleed on Heparin.,0
TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were obtained without IV contrast.,0
Diffusion weighted sequences were also obtained.,0
"MR BRAIN W/O CONTRAST: There is an approximately 4.3 x 2.4 cm area of heterogeneous signal within the left cerebellum, consistent with the patient's known area of intraparenchymal hemorrhage.",0
There is no evidence of intraventricular blood or hydrocephalus.,0
No areas of restricted diffusion are seen to suggest the presence of an acute infarct elsewhere within the brain.,0
MRA BRAIN TECHNIQUE: 3D time of flight images of the circle of and its major tributaries was performed and multiplanar reformatted images were created.,0
FINDINGS: No abnormality is seen involving the circle of or its major tributaries.,0
"Specifically, no definite aneurysm is seen with special attention to the left posterior inferior cerebellar artery.",0
IMPRESSION: No significant change in the size of the left cerebellar hemorrhage when compared to the head CT from .,0
"No definite evidence of aneurysm, however, the mass effect from the left cerebellar hemorrhage could potentially obliterate an aneurysm in the region of the left PICA.",0
"If there is continued clinical suspicion for an aneurysm, cerebral angiography or a follow up MRA after the hemorrhage has resolved or been evacuated is suggested.",0
"12:04 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: assess for intracranial bleed, mass effect, other brain path Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with esrd with fever, leukocytosis, and significant mental status changes.",0
"REASON FOR THIS EXAMINATION: assess for intracranial bleed, mass effect, other brain pathology.",0
PLEASE PROTOCOL FOR ABOVE INDICATIONS RE: CONTRAST.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Fever, leukocytosis and significant mental status change, evaluate for intracranial bleed or mass effect.",0
"TECHNIQUE: Multiplanar MRI of the brain utilizing T1, T2, gradient, FLAIR and diffusion sequences MR angiogram of the brain utilizing 3D time-of-flight technique.",0
"FINDINGS: Moderate-sized left frontal lobe restricted diffusion is present, conforming to left middle cerebral artery territory.",0
"Another area of restricted diffusion is present in the right paramedian caudal left occipital lobe, predominantly involving the matter.",0
These are associated with mild cytotoxic edema.,0
"There is no midline shift, acute intra-axial hemorrhage or abnormal extra-axial fluid collection.",1
Multiple small foci of periventricular white matter T2 signal abnormality and along the peritrigonal region likely represent microangiopathic ischemic changes.,0
"The mastoids are clear, so are the visualized paranasal sinuses.",0
"MR ANGIOGRAM OF THE HEAD: The bilateral internal carotid, and anterior cerebral arteries are within normal limits.",0
There are apparent filling defects withing peripheral branches of left MCA.,0
"The anterior communicating artery is not visualized, likely congenitally absent.",0
The right vertebral artery is dominant.,0
"The P1 segment of right posterior cerebral artery is not seen, likely congenitally absent.",0
No aneurysm or dissection is present.,0
"Moderate-sized acute infarct in the left frontal lobe corresponding to left middle cerebral artery territory, and smaller acute infarct in the left caudal occipital lobe, corresponding to left PCA territory.",1
These findings likely represent sequelae of an embolic event.,0
"MRA: Apparent filling defects within peripheral branches of left MCA, (Over) 12:04 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: assess for intracranial bleed, mass effect, other brain path Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ FINAL REPORT (Cont) which could represent emboli.",0
No aneurysm or dissection in the anterior posterior circulation.,0
"The results were discussed with Dr. at 3:50 p.m. on , .",0
"10:12 AM US ABD LIMIT, SINGLE ORGAN Clip # Reason: please eval for solid mass vs abscess Admitting Diagnosis: DEHYDRATION;DIARRHEA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with 5 cm R lobe liver lesion REASON FOR THIS EXAMINATION: please eval for solid mass vs abscess ______________________________________________________________________________ FINAL REPORT LIVER ULTRASOUND, INDICATION: 49-year-old man with 5-cm right lobe liver lesion seen on CT.",0
Please evaluate for solid mass vs. abscess.,0
COMPARISON: Correlation is made with CT dated .,0
"FINDINGS: Corresponding to the lesion seen on CT, there is a predominantly hyperechoic lesion within the right lobe measuring approximately 6.1 cm transverse x 7 cm AP x 5.9 cm CC.",0
There is no demonstrable through transmission.,0
The lesion does not appear to be hypervascular by Doppler imaging.,0
"Based on the ultrasound appearance alone, a large hemangioma could have a similar appearance.",0
"However, the CT appearance is not typical.",0
Perihepatic ascites is again identified.,0
IMPRESSION: Lesion within the right lobe of the liver is not consistent with abscess.,0
"Differential considerations are broad, and include primary as well as secondary solid neoplasms.",0
MRI is recommended for further characterization.,0
"11:16 AM BABYGRAM (CHEST ONLY) Clip # Reason: respiratory distress Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with desaturations, dusky spells in newborn nursry REASON FOR THIS EXAMINATION: respiratory distress ______________________________________________________________________________ FINAL REPORT HISTORY: New born infant with dusky spells and desaturations.",1
"FINDINGS: Portable chest, 11:25 a.m., .",0
"Overall, the lungs appear clear with scattered areas of subsegmental atelectasis seen.",0
Heart size is normal and pulmonary vascularity is normal.,0
There are no effusions and no other abnormalities identified.,0
"IMPRESSION: Mild scattered areas of subsegmental atelectasis, otherwise clear lungs.",0
10:50 PM CHEST (PORTABLE AP) Clip # Reason: check ETT Admitting Diagnosis: SQUAMOUS CELL CARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with s/p neck dissection.,1
check ETT REASON FOR THIS EXAMINATION: check ETT ______________________________________________________________________________ FINAL REPORT INDICATION: Patient status post neck dissection.,0
Assess for ET tube placement.,0
FINDINGS: The endotracheal tube terminates 4.6 cm above the carina.,0
"There is no pleural effusion, focal consolidation or pneumothorax.",0
Perihilar vascular congestion is noted.,0
Aortic arch calcifications are seen.,0
Hilar and mediastinal silhouettes are unremarkable.,0
Heart size is normal in size.,0
IMPRESSION: The endotracheal tube terminates 4.6 cm above the carina.,0
"PATIENT/TEST INFORMATION: Indication: Intraop CABG, AVR, evaluate vales, aortic contours, ventricular function Height: (in) 72 Weight (lb): 185 BSA (m2): 2.06 m2 BP (mm Hg): 142/90 HR (bpm): 74 Status: Inpatient Date/Time: at 13:35 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.",1
Complex (>4mm) atheroma in the aortic arch.,0
AORTIC VALVE: Moderate AS (AoVA 1.0-1.2cm2) No AR.,1
Conclusions: Pre bypass: The left atrium is markedly dilated.,0
"There is complex atheroma of the ascending, arch and descending thoracic aorta.",0
An epiaortic scan was conducted to deliniate areas of least plaque/calcifcation for aortic cross clamp and cannula prior to bypass.,0
There is moderate aortic valve stenosis (area 1.0-1.2cm2).,1
There is calcium extending onto a significant portion of the posterior mitral leaflet.,0
"A torn mitral chord is present, originating from the posteromedial papillary muscle.",0
"There is borderline mild valvular mitral stenosis (area 1.8 cm2, 3.2 on recheck at higher blood pressure).",0
"Mild to moderate (+) mitral regurgitation is seen, most prominent when blood pressure is in 170's systolic.",0
Vena contracta <.5 cm consistently.,0
Post byass: Preserved biventricular funciton.,0
An aortic valve bioprosthesis is seen (#23 magna per surgeons).,1
"Peak gradient 12 mm Hg, Mean gradient 6 mm Hg post bypass.",0
"No AI, no perivalvular leaks on aortic valve.",1
2:56 AM CHEST (PORTABLE AP) Clip # Reason: interval change of pna Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with afib and pna REASON FOR THIS EXAMINATION: interval change of pna ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 11:33 AM 1.,0
Persistent bilateral small pleural effusions.,0
"Left lower lobe opacity could be due to atelectasis or pneumonia, better evaluated on the recent chest CT. ______________________________________________________________________________ FINAL REPORT FRONTAL CHEST RADIOGRAPH INDICATION: 84-year-old man with atrial fibrillation and pneumonia.",1
"FINDINGS: The cardiomediastinal silhouette is stable, compared to the most recent prior study.",0
"No significant change in the appearance of the chest is noted, including bilateral small pleural effusions.",0
"A patchy left lower lobe opacity remains present, this could be due to atelectasis or pneumonia, and is better evaluated on the recent chest CT.",0
Mild pulmonary vascular congestion is present.,0
"2:09 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CHEST PAIN Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CAD, s/p cath/angioplasty , scheduled for CABG later this week.",0
REASON FOR THIS EXAMINATION: Pre-op for CABG ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Pre-operative for CABG.,0
"FINDINGS: Relatively small lung volumes, mild elevation of the left hemidiaphragm caused by an air bubble in the stomach.",0
No evidence of pleural effusions.,0
"Normal structure and transparency of the lung parenchyma, no focal parenchymal opacity suggesting pneumonia, no overhydration, no lung nodules or masses.",0
The diameter of the cardiac silhouette is at the upper range of normal.,0
Normal hilar and mediastinal contours.,0
5:05 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please assess for free air (evidence of duodenal perforation ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman s/p recent ERCP with abdominal pain and tachycardia REASON FOR THIS EXAMINATION: Please assess for free air (evidence of duodenal perforation) or contrast extravasation.,0
Evaluate for free air (evidence of duodenal perforation) or contrast extravasation.,0
COMPARISON: Right upper quadrant ultrasound from 1.5 hours prior.,0
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases through the pelvis following the administration of Gastroview oral contrast.,0
Intravenous contrast was not used due to the patient's history of multiple myeloma.,1
NON-CONTRAST CT ABDOMEN: Bibasilar linear opacities are consistent with atelectasis.,0
Evaluation of abdominal viscera for focal lesion is limited without the use of intravenous contrast.,0
"The gallbladder is markedly distended, and demonstrates wall thickening and edema and extensive surrounding fat stranding and inflammatory change.",0
"There are multiple foci of hypodensity within the gallbladder lumen, consistent with stones and foci of gas in the non-dependent portion of the lumen, some of which may be located within the wall of the gallbladder.",0
There is extensive bowel wall thickening at the hepatic flexure that is likely reactive in nature due to the gallbladder inflammatory process.,0
"(Over) 5:05 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please assess for free air (evidence of duodenal perforation ______________________________________________________________________________ FINAL REPORT (Cont) Within the liver, multiple hypoattenuating lesions are present.",0
Intra- and extra-hepatic ductal dilation is present.,0
"The common duct measures approximately 11 mm, and the pancreatic duct measures approximately 3.5 mm within the head.",0
The spleen and adrenals are unremarkable.,0
There is bilateral perinephric stranding without hydronephrosis.,0
Oral contrast is present within the stomach and extends into the jejunum.,0
There is no evidence of extraluminal oral contrast.,0
Mesenteric and retroperitoneal lymph nodes are not enlarged by size criteria.,0
The abdominal aorta is normal in caliber and mildly tortous with scattered atherosclerotic calcifications.,0
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The colon is unremarkable.,0
There is a small amount of free pelvic fluid.,0
The urinary bladder is under- distended but is unremarkable.,0
There are calcifications within the uterus which may be related to calcified leiomyomata.,0
BONE WINDOWS: No suspicious lytic or blastic osseous lesion is identified.,0
"Acute cholecystitis, with suggestion of emphysematous cholecystitis/early gangrenous changes.",1
"If clinically warranted, these could be further assessed with MRI.",0
Marked wall thickening and inflammatory changes of the hepatic flexure is likely reactive in nature.,0
", M. MED MICU-7 2:11 AM CHEST (PORTABLE AP) Clip # Reason: any evidence of pneumomediastinum Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p CPR REASON FOR THIS EXAMINATION: any evidence of pneumomediastinum ______________________________________________________________________________ PFI REPORT Linear lucency along the right tracheal border that may represent artifact versus free mediastinal air.",1
Recommend short-term followup radiograph for further assessment.,0
Height: (in) 70 Weight (lb): 150 BSA (m2): 1.85 m2 Status: Inpatient Date/Time: at 15:41 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Upon imaging of the left atrium the patient was found to have cor triatriatum.,0
"AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque.",0
MITRAL VALVE: Large vegetation on mitral valve.,1
Severe (4+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized.,0
Conclusions: Pre-bypass: The left atrium is mildly dilated.,0
"The right ventricular cavity is mildly dilated The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque.",0
There is a large vegetation on the mitral valve.,1
"An eccentric, posteriorly directed jet of Severe (4+) mitral regurgitation is seen.",0
Post-bypass: The patient is receiving 0.15 mcg/kg/min of norephinephrine post-CPB.,0
There is a well-seated bioprothesis in the mitral position.,0
There is good leaflet excursion with a mean pressure gradient of 4 mm Hg.,0
There is no paravalvular or transvalvular regurgitation.,0
The left atrium no longer has a septum transversing it and the left atrial appendage has been excised.,0
Biventricular systolic function is preserved.,0
All other findings are consistent with pre-bypass findings.,0
The aorta is intact post-decannulation.,0
All findings communicated to the surgeon.,0
"2:38 AM CHEST (PORTABLE AP) Clip # Reason: r/o aspiration Admitting Diagnosis: ACUTE PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with pancreatitis s/p trach, GJ tube, with emesis, ?aspiration, now with decr O2 sats REASON FOR THIS EXAMINATION: r/o aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old man with hypoxia and possible aspiration with recent emesis.",1
"SINGLE UPRIGHT PORTABLE VIEW OF THE CHEST AT 9:55 A.M.: The tracheostomy tube is in unchanged position, terminating approximately 2 cm from the carina.",0
"Layering bilateral pleural effusions are slightly improved, now moderate in size.",1
"However, pulmonary vasculature is more engorged, indicating worsening edema, particularly in the left lung.",0
"IMPRESSION: Interval decrease in bilateral pleural effusions, but worsening pulmonary edema, particularly in the left lung.",1
"3:27 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: Please assess for increased hematoma, evidence of active ret Admitting Diagnosis: PNEUMONIA VS.",0
INFLUENZA Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with L retroperitoneal bleed s/p embolization L3.,0
Now w/ L side abd pain and LLQ tenderness.,0
"REASON FOR THIS EXAMINATION: Please assess for increased hematoma, evidence of active retroperitoneal bleeding, investigate for diverticulitis.",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Left retroperitoneal hematoma status post embolization on of the L3 lumbar artery.,0
TECHNIQUE: Axial images through the abdomen and pelvis with coronal and sagittal reformatted images.,0
Oral and IV contrast was administered.,0
Optiray was administered due to patient debility.,0
CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is a stable small left and right pleural effusion with basilar atelectasis.,0
"The liver, spleen, pancreas, adrenal glands, and kidneys are stable in appearance.",0
The left kidney remains displaced by the left retroperitoneal hemorrhage.,1
This left retroperitoneal hemorrhage containing different attenuation has increased in size since the prior study.,0
There is evidence of active extravasation seen on series 2 image 41.,0
"There is now free fluid adjacent to the spleen, liver, and multiple bowel loops.",0
The retroperitoneal hemorrhage involves the left iliac muscle.,0
The right iliac muscle also contains hemorrhage.,0
This hemorrhage extends into the left pararenal space.,0
There is evidence of embolization clips adjacent to the left aspect of the upper lumbar spine.,0
No free air in the abdomen.,0
The large and small bowel are normal.,0
CT PELVIS WITH INTRAVENOUS CONTRAST: The retroperitoneal hemorrhage extends into the pelvis and along the left iliacus muscle.,0
The rectum and sigmoid colon are normal.,0
No evidence of diverticulitis or diverticulosis.,0
BONE WINDOWS: No suspicious lesions.,0
Reformats: The largest portion of the retroperitoneal hematoma has increased from 9x13x 13 cm to 14x 18x16 cm.,0
IMPRESSION: Interval progression and expansion of the large left retroperitoneal hematoma with evidence of active extravasation.,0
"These findings were discussed with Dr. 3:27 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: Please assess for increased hematoma, evidence of active ret Admitting Diagnosis: PNEUMONIA VS.",0
INFLUENZA Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) .,0
"10:27 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: S/P MVC,HCT DROP Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 18 year old male s/p trauma/MVC w/ HCT drop REASON FOR THIS EXAMINATION: PO and IV contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: An 18-year-old male status post motor vehicle collision, now with decreased hematocrit.",1
TECHNIQUE: Contiguous axial images were obtained from the lung bases through the symphysis pubis without intravenous contrast.,0
"CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases demonstrate patchy opacities involving the anterior right middle lobe and medial right lower lobe, consistent with contusions.",1
There are no pleural or pericardial effusions.,0
"Allowing for the limitations of a noncontrast exam, the liver, gallbladder, spleen, pancreas, and left adrenal gland appear grossly normal.",1
There is a 2.6 x 1.4 cm hyperdense focus arising from the lateral limb of the right adrenal gland.,1
This could represent focal area of hemorrhage.,0
Stomach and visualized bowel loops are unremarkable.,0
No pathologically enlarged retroperitoneal or mesenteric lymph nodes are present.,0
There is no free- fluid.,0
"CT OF THE PELVIS WITHOUT IV CONTRAST: Urinary bladder contains small focus of air, likely relating to instrumentation.",0
"The seminal vessicles, prostate gland and pelvic loops of bowel are within normal limits.",0
There is no free- fluid within the pelvis.,0
"However, there is a 6.4 x 3.7 cm hematoma between the right gluteal muscles and just adjacent to the site of the patient's right hip fracture.",1
BONE WINDOWS: Note is made of a right hip prosthesis.,0
No additional fractures are identified.,0
Right middle and lower lobe contusions as above.,0
6 cm right gluteal muscle hematoma.,0
These findings were reported to Dr. at the time of interpretation.,0
ADDENDUM: Comparison was subsequently made to the study.,0
There has been interval improvement in the lung contusions.,0
"The right adrenal hematoma was (Over) 10:27 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: S/P MVC,HCT DROP Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) present at this time and is unchagned.",1
"4:17 PM CT CHEST W/O CONTRAST Clip # Reason: please assess for lung abscess Admitting Diagnosis: PNEUMONIA Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with cerebral palsy, epilepsy and history of recurrent aspiration pneumonias now with fever, RLL cavitation REASON FOR THIS EXAMINATION: please assess for lung abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Cerebral palsy, epilepsy, and history of recurrent aspiration pneumonia.",1
"Now with fever, and right lower lobe cavitation on chest x-ray.",0
Please assess for lung abscess.,0
COMPARISON: No prior chest CT.,0
Chest radiograph of is available for comparison.,0
TECHNIQUE: Axial multidetector CT images were obtained from the thoracic inlet through the adrenal glands without intravenous contrast.,0
CHEST CT WITHOUT CONTRAST: There is extensive consolidation in the right middle and lower lobes.,0
"Evaluation of these areas is somewhat limited by the patient's body habitus, lack of intravenous contrast enhancement, and streak artifact from surgical hardware in the spine.",0
"There is a large rounded cavity with irregular margins and a fluid level in the right lower lobe, which appears most consistent with an abscess.",0
There are necrotizing areas in the adjacent lung in the right lower and middle lobes.,0
No definite pleural disease is seen in this area or in the remainder of the thorax.,0
"There are patchy peribronchiolar ground-glass opacities in the dependent portions of the left lung, suggestive of aspiration.",0
Paraseptal emphysema is noted in the medial left lower lobe.,0
The airways appear patent to the level of segmental bronchi.,0
The heart and great vessels appear unremarkable.,0
"There is high-density material layering within the gallbladder, suggestive of previously administered intravenous contrast.",0
The patient did not have any radiology studies with intravenous contrast at our institution.,0
"Alternatively, this finding may represent unusually dense sludge or stones.",0
There is a hiatal hernia.,0
There are gas-distended bowel loops in the upper abdomen.,0
"Evaluation of the visualized portions of the liver, spleen, pancreas, adrenal glands, and kidneys is limited by streak artifact from the rod in the spine.",0
The findings were discussed with Dr. at 10:50 A.M. on .,0
IMPRESSION: (Over) 4:17 PM CT CHEST W/O CONTRAST Clip # Reason: please assess for lung abscess Admitting Diagnosis: PNEUMONIA Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,0
Necrotizing right middle and lower lobe pneumonia with a large abscess in the right lower lobe.,0
"Patchy ground-glass opacities in the left lung, with appearance suggestive of aspiration.",0
"Dense material in the gallbladder, which may represent intravenous contrast or unusually dense sludge or stones.",0
"Contrast in the gallbladder could represent an adverse reaction to intravenous contrast, or it may be seen in renal failure.",0
"Gas-distented bowel loops, incompletely assessed.",0
Consider dedicated abdominal radiograph series.,0
"10:56 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: RUQ PAIN SOB HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with CP, SOB, hypoxia, clear CXRay REASON FOR THIS EXAMINATION: eval for PE No contraindications for IV contrast ______________________________________________________________________________ WET READ: 11:40 AM Massive acute PE, invlvg both R and L main PAs, extdg into lobar brchs.",0
"No def evid RV ""strain.""",0
No evid acute traumatic injury abd/pelvis.,0
"______________________________________________________________________________ FINAL REPORT CT OF THE TORSO WITHOUT AND WITH CONTRAST DATED HISTORY: 75-year-old woman with acute chest pain, shortness of breath and hypoxia; evaluate for PE.",0
"TECHNIQUE: Routine non- and contrast-enhanced CTPA, including coronal, sagittal, and paired oblique sagittal reformations, was performed.",0
"This was followed by contrast-enhanced CT of the abdomen and pelvis, without oral contrast prep.",0
FINDINGS: There are no comparisons.,0
"There is evidence of massive acute pulmonary embolism with large thrombi impacted in both the central right and left main pulmonary arteries, extending into their lobar branches and reaching the segmental branch level.",1
"In the region of thrombus, there is relative paucity of more distal branch vessels.",0
There is no focal airspace process to specifically suggest the development of pulmonary infarction.,1
There is relatively minor underlying panacinar emphysema with scattered subpleural blebs.,0
"The heart appears somewhat enlarged; however, there is no specific evidence of right ventricular ""strain""; specifically, no definite leftward bowing of the intraventricular septum is seen, and there is no dilatation of the superior or inferior vena cavae or abnormal reflux of contrast into the hepatic veins.",0
No acute rib fracture or pleural effusion is seen.,0
"Incidentally noted is a large, 3.8 x 3.3cm heterogeneous mass with peripheral calcifications,arising in the left lobe of the thyroid gland and extending caudally to a retrosternal location in the superior mediastinum.",0
"There is associated rightward deviation, without significant compression of the lower cervical trachea.",0
"There is no ascites, and the liver and spleen enhance normally without focal lesion.",0
"Stomach, gallbladder, pancreas and both adrenal glands are unremarkable, and both kidneys enhance normally, as do the major retroperitoneal vessels, with mural calcification of the abdominal aorta and its branches.",0
"There is no free fluid or blood in the pelvis, with Foley catheter and a small amount of air present in and otherwise unremarkable bladder.",0
"There are numerous fibroids with chunky calcifications in an (Over) 10:56 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: RUQ PAIN SOB HYPOXIA ______________________________________________________________________________ FINAL REPORT (Cont) otherwise atrophic uterus, with the ovaries not definitely identified.",0
"The unopacified bowel loops throughout the abdomen and pelvis are grossly unremarkable, without adjacent inflammatory change.",0
"There is no mesenteric, retroperitoneal or pelvic adenopathy.",0
The regional skeleton demonstrates no evidence of acute traumatic injury.,0
Noted is multilevel degenerative change involving the lumbar spine with evident spinal canal narrowing at several levels.,0
"Massive acute pulmonary embolism involving both main pulmonary arteries, extending into the lobar branches with relative regional oligemia.",1
No definite CT evidence of pulmonary infarction or acute right heart strain.,1
"No evidence of acute traumatic injury to the chest, abdomen or pelvis.",0
"Heterogeneous mass in the left thyroid lobe, with retrosternal extension.",0
"The thyroid gland is incompletely imaged, and could be further assessed with focused son.",0
Multilevel degenerative lumbar spinal stenosis.,0
"COMMENT: Findings discussed with Dr. (EU) at 11:35 a.m., , and subsequently with Dr. (EU).",0
"8:14 AM CHEST (PORTABLE AP) Clip # Reason: 78 YO WITH CAD, EF < 15%; s/p vats/decort for R hemothorax; ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p cabg, s/p thoracotomy with removal of 2L of blood from L pleural space, now w/ b/l chest tubes.",0
"REASON FOR THIS EXAMINATION: 78 YO WITH CAD, EF < 15%; s/p vats/decort for R hemothorax; please evaluate pleural effusions ______________________________________________________________________________ FINAL REPORT INDICATION: 78 y/o man s/p CABG.",0
CHEST: A single semi-erect AP chest radiograph is provided.,0
A tracheostomy tube is in unchanged position.,0
Intact midline sternal wires are identified.,0
A left sided central venous catheter has a tip that terminates within the proximal SVC that is unchanged from the prior exam.,0
An aortic valve prosthesis is in unchanged position.,0
2 right sided chest tubes are in unchanged position.,0
The cardiac silhouette is enlarged but unchanged from prior exam.,0
Again identified are diffuse bilateral patchy opacities identified.,0
Moderate right greater than left pleural effusions are present.,0
IMPRESSION: Unchanged appearance chest radiograph with diffuse patchy opacities.,0
9:12 PM CHEST (PORTABLE AP) Clip # Reason: Increasing vent requirements today.,0
"Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with multi-trauma, s/p exploratory laparotomy.",1
& now with chest tube REASON FOR THIS EXAMINATION: Increasing vent requirements today.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY DATED .,0
"Since the recent chest radiograph, a left subclavian Swan-Ganz catheter has been removed with a residual left subclavian vascular sheath remaining in place.",0
Other lines and tubes are unchanged in position.,0
"There is improving opacity in the left hemithorax, likely due to a combination of improving asymmetric edema and effusion.",0
"On the right, there is also improving edema with residual perihilar haziness and septal thickening remaining.",0
Removal of Swan-Ganz catheter with no pneumothorax.,0
Improving asymmetric edema and decreasing left effusion.,0
"7:51 AM CATH CHEK/REMV Clip # Reason: S/P OTL Admitting Diagnosis: LIVER FAILURE Contrast: OPTIRAY Amt: 10 ********************************* CPT Codes ******************************** * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM * **************************************************************************** ______________________________________________________________________________ FINAL REPORT INDICATIONS: Status post orthotopic liver transplant, two weeks previously.",0
PROCEDURE/FINDINGS: An antegrade cholangiogram was performed with only 10 cc of Optiray 320 60%.,0
"There was poor transit of contrast material from the catheter through the anastomosis, with all contrast refluxing into the biliary tree.",0
"This was followed by injection of cc of saline, at which time, contrast was visualized in the common bile duct.",0
The findings suggest significant stricture at the anastomosis.,0
The cystic duct fills proximal to the anastomosis.,0
The biliary ducts are relatively decompressed and smooth in appearance.,0
IMPRESSION: Findings suggesting a significant stricture at the anastomosis.,0
Findings were discussed with Dr. at the time of the study.,0
1:43 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?,0
"hemothorax Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with attempted left subclavian line, inadvertently hit subclavian artery, please eval for new hemothorax or pneumothorax REASON FOR THIS EXAMINATION: ?",1
"hemothorax ______________________________________________________________________________ FINAL REPORT INDICATION: Attempted left subclavian line, inadvertently hit subclavian artery.",0
Please assess for hemothorax or pneumothorax.,0
FINDINGS: AP upright frontal bedside chest radiograph is compared to .,0
Moderate left pleural effusion is unchanged in size.,0
There is no apical cap.,0
"The ETT, NG tube, and right IJ catheter are in standard position.",0
The tracheal stent is unchanged in position with the inferior aspect within the carina.,0
Stable moderate left pleural effusion.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: is the former 864 gram product of a 34 week gestation pregnancy born to a 25 year-old G2 P0 woman.,0
"Prenatal screens: blood type 0 positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status abortion at seven months.",0
"This pregnancy was notable for an abnormal alpha fetoprotein and triple screen, which was followed with serial ultrasounds.",0
They showed normal biophysical profiles and structurally normal fetus.,0
There was a lag in prenatal care.,0
The mother presented to her office on the day of delivery showing poor fetal growth and reported leaking of amniotic fluid for two months.,0
No kidneys or lungs were visualized.,0
She was transferred from to the .,0
She underwent a cesarean section for concern for fetal heart rate decelerations.,1
Apgars were 8 at one minute and 8 at five minutes.,0
"The baby required blow by O2, drying and bulb suctioning.",0
He was admitted to the Neonatal Intensive Care Unit for management of his prematurity.,0
HOSPITAL COURSE/PERTINENT LABORATORY DATA: Respiratory: was intubated shortly after admission and given one dose of Surfactant.,1
He was extubated to nasal cannula O2 on day of life number one.,0
He remained on nasal cannula O2 until day of life number twenty five when due to increased work of breathing he was placed on nasopharyngeal CPAP.,0
He remained on the nasopharyngeal continuous positive airway pressure through day of life number forty nine.,0
"Since that time he has remained on high flow nasal cannula O2 400 to 500 cc of flow, 45 to 65% fraction of inspired oxygen.",0
His evolving chronic lung disease is treated with Diuril.,0
A trial of bronchodilators showed no added benefit.,0
On three occasions within a week he has had respiratory arrest events marked by profound bradycardia.,1
"The etiology of these is unclear, and a bronchoscopic examination is planned at for .",0
Cardiovascular: Heart size on chest x-ray was noted to be large.,0
An echocardiogram was performed on day of life number two and showed moderate to severe biventricular dysfunction.,0
A small pericardial effusion was noted.,0
The heart was otherwise structurally normal with a small atrial septal defect.,0
"The echocardiograms were repeated several times, which showed gradual improvement in the cardiomyopathy.",0
"Most recent echocardiogram was on showing a moderate atrial septal defect, mild right ventricular overload and left peripheral pulmonic stenosis.",0
He required treatment with Dopamine through day of life number nine.,0
At the time of discharge his heart rates are in the 140 to 160 range with mean pressures 50 to 60s.,0
"Fluids, electrolytes and nutrition: was initially NPO and maintained on intravenous fluids.",0
He required monitoring with an umbilical arterial catheter for the first two weeks of life.,0
Enteral feeds were started on day of life number ten and gradually advanced to full volume.,0
Feedings have always been well tolerated.,0
"At the time of discharge he is on mother's breast milk fortified to 34 calories per ounce, 4 with human milk fortifier, 6 by calories by medium chain triglyceride oil and 4 calories by Polycose.",0
"On a 32 calorie per ounce regimen, he had only gained 9 gms/kg/d.",0
The etiology of the poor growth is also unknown.,0
Weight on the day of discharge is 2.56 kilograms.,0
Serum electrolytes have been closely monitored due to the diuretic treatment.,0
"Most recent electrolytes were on with a serum sodium of 137, serum potassium of 3.9, chloride 97, PCO2 of 29.",0
"He is on sodium, potassium, chloride and potassium phosphate supplements.",0
Infectious disease: had a sepsis evaluation at the time of birth.,0
"A white blood cell count was 4200 with 34% polys, 9% bands, 49% lymphocytes.",0
Blood culture was obtained prior to starting antibiotics.,0
The culture was no growth.,0
He received a seven day course of Ampicillin and Gentamycin.,0
On an abscess was noted over the left wrist.,0
The abscess was unroofed and Citrobacter koseri was cultured.,0
Due to prior concern for sepsis was being treated with Vancomycin and Gentamycin.,0
His coverage was changed to include Ceftazidime to provide better coverage.,0
A second incision and drainage was performed on and again the same Citrobacter koseri was cultured.,0
"He received a total of fourteen days of the Vancomycin, Gentamycin and Ceftazidime with resolution of the abscess.",0
Also of concern with infectious disease with his hepatic workup he was found to be hepatitis A antibody positive.,0
Further testing showed him to have the hepatitis A immunoglobulin negative.,0
Gastrointestinal: has presented with some unidentified liver dysfunction.,0
An extensive metabolic and gastrointestinal workup has been undertaken and multiple metabolic tests sent.,0
"A HIDA scan showed a normal gallbladder and ruled out biliary atresia, alpha one antitrypsin level had MM typing.",0
"The only metabolic test found to be abnormal was the carnitine panel with his level slightly low, carnitine replacement therapy was started and his most recent carnitine levels were on .",0
Free carnitine is 90 with a range of 27 to 49.,0
Total is 104 with a rate of 38 to 68.,0
The axo carnitine is 14 with a range 7 to 19 and the aso to free carnitine ratio was 0.2 with a normal of 0.2 to 0.5.,0
The free and total carnitine levels being slightly higher then normal range represent the change on the increased carnitine supplementation.,0
"has also had an elevated direct bilirubin, which peaked at 8.3 on day of life 45.",0
He has been treated with both Phenobarbital and Actigall.,0
The Phenobarbital was discontinued .,0
Most recent direct bilirubin was 6.4 mg per deciliter on .,0
PT and PTT were normal on .,0
Hematologic: is blood type O positive antibody negative.,0
His hematocrit at birth was 36.8%.,0
He has received multiple transfusions of packed red blood cells.,0
Most recent transfusion was on .,0
Most recent hematocrit was 31.4% on with a reticulocyte count of 3.6%.,0
He is receiving supplemental iron.,0
Endocrine: has had persistent problems with hypoglycemia despite multiple attempts to wean him from continuous feeds.,0
He responds with intermittent blood glucoses less then 40.,0
Serum insulin growth hormone and Cortisol levels have been drawn on numerous occasions with the episodes of hypoglycemia and all levels have been within the normal range.,0
Endocrine consult from is involved in following.,0
The etiology of his glucose requirement is unclear.,0
It does not appear to be a result of hyperinsulism and may explain his poor growth.,0
Endocrine does not have suggestions at present for further evaluation.,0
We have consulted the metabolism team.,0
Neurology: Head ultrasound has been performed on two occasions during his admission.,0
Both were within normal limits.,0
Musculoskeletal: A fracture of the right humerus was noted incidentally on a chest x-ray.,1
This was likely a result of severe metabolic bone disease.,0
Sensory: Audiology screening has not yet been performed.,0
"Ophthalmology, defect later described as a coloboma was noted shortly after birth.",0
Serial retinal examinations have been performed and showed mature retinas on .,0
DISCHARGE DISPOSITION: Transfer to .,0
The primary pediatrician has not yet been identified.,0
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: NPO in preparation for the Operating Room.,0
"When feeding expressed breast milk 45 to 34 calories per ounce, 4 calories by human milk fortifier, 6 calories by medium chain triglyceride oil, 4 calories by Polycose.",0
One half teaspoon ProMod powder per 100 cc of the breast milk.,0
"MEDICATIONS: Ranitidine 4.8 mg po q 8 hours, Carnitine 100 mg po b.i.d., potassium phosphate 2.3 millimoles po b.i.d., vitamin D 300 international units po q day, calcium glubionate 46 mg as elemental calcium po b.i.d., Reglan 0.2 mg po q 8 hours administered one half hour prior to feeds.",0
"Fer-In- 25 mg per ml dilution 0.25 cc po q.d., Diuril 43 mg po pg b.i.d., sodium chloride supplement 1 milliequivalent po b.i.d., potassium chloride supplement 1 milliequivalent po b.i.d., Actigall 30 mg po b.i.d., vitamin E 5 international units po q day.",0
Car seat positioning screening not yet performed.,0
State newborn screening have been sent on multiple occasions with only the carnitine abnormality detected.,0
"Immunizations were administered between and and included hepatitis B vaccine, diptheria, cellular pertussis, hemophilus influenza, the injectable polio vaccine and the pneumococcal seven valent conjugate vaccine.",0
"Immunizations recommended, Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria - born at less then 32 weeks gestation, born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with preschool siblings or with chronic lung disease.",1
Before this age the family and other care givers should be considered for immunization against influenza to protect the infant.,0
"FOLLOW UP: Follow up with Consult Services at to include endocrine, cardiology, genetics, metabolism, gastrointestinal and otorhinolaryngology.",0
Prematurity at 34 weeks gestation.,1
Citrobacter koseri cellulitis of the left wrist.,0
Coloboma of the right eye.,0
Dictated By: MEDQUIST36 D: 02:55 T: 06:22 JOB#:,0
", M. MED 5:51 PM CT HEAD W/ & W/O CONTRAST Clip # Reason: pls eval for mass, ischemia, hemorrhage Admitting Diagnosis: LUNG CANCER ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with metastatic NSCLC, with brain mets, bone mets, now unresponsive REASON FOR THIS EXAMINATION: pls eval for mass, ischemia, hemorrhage No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No evidence of acute intracranial hemorrhage, new region of edema, new mass effect, or evidence of new large vascular territory infarction.",1
Previously described ring-enhancing lesion in the parafalcine right frontal lobe is not well demonstrated on the current study and may be due to differences in technique and modality.,0
"For more direct comparison with prior MRI and also for more sensitive evaluation for acute infarct, MRI may be performed as clinically indicated.",0
Height: (in) 62 Weight (lb): 156 BSA (m2): 1.72 m2 BP (mm Hg): 117/57 HR (bpm): 121 Status: Inpatient Date/Time: at 15:46 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior - hypo; mid inferior - hypo; septal apex- akinetic; inferior apex - hypo; apex - akinetic; RIGHT VENTRICLE: Normal RV wall thickness.,0
No MR. PERICARDIUM: Trivial/physiologic pericardial effusion.,0
Left ventricular function is moderately to severely depressed.,0
Resting regional wall motion abnormalities include septal and apical akinesis with inferior hypokinesis.,0
6.There is a trivial/physiologic pericardial effusion.,0
"Compared to the previous study of , the overall function appears unchanged.",0
"1:50 AM CHEST (PORTABLE AP) Clip # Reason: stat Admitting Diagnosis: SPINAL CORD BLEED' ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p C3-5 hematoma evacuation, extubated-re-intubated.",0
REASON FOR THIS EXAMINATION: stat ______________________________________________________________________________ FINAL REPORT INDICATION: Re-intubation.,0
Status post C3-4 hematoma evacuation.,0
The tracheostomy tube appears in good position.,0
Aeration of the left lung is markedly improved.,0
There is a new sizable right effusion and ill-defined increased density in the mid-lower lung zone.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: intubation and mechanical ventilation History of Present Illness: 85 year-old Mandarin-speaking woman with a history of recent hip fracture (discharged to rehab ) and pulmonary mycobacterium avium intracellulare infection (on Ethambutol and Azithromycin) admitted post cardiac arrest.,1
The patient was eating breakfast with her daughter this AM and became unresponsive.,0
"No choking episode observed, but patient presumed to have an aspiration event.",0
"The patient was found to be in asystole with non-shockable rhythm on AED, and CPR was started by EMS.",0
She received 4 rounds of epinephrine.,0
She was intubated and an I/O was placed in the field.,0
Presumed time in asystole 10 minutes.,0
"On arrival to the ED, pulses were present.",0
"The patient was hypotensive, with BP 80s/40s and HR 80s.",0
"Right IJ was placed, but no pressors were initiated as blood pressure increased to SBP 90s.",0
The patient underwent head CT that did not show any acute event.,0
"CTA chest demonstrated left bronchiectasis, supporting aspiration.",0
The patient was started on the post-arrest cooling protocol.,0
She did become bradycardic following initiation of cooling.,0
VS at time of transfer to the MICU BP 97/47 HR 41 Temp 32.2.,0
Current vent settings FIO2 50% Vt 400 RR 16 peep 5. .,0
"On arrival to the MICU, the patient displayed 4-5 episodes of activity that began with opening her eyes, followed by rhythmic movements of upper extremities bilaterally.",0
Otherwise non-responsive while not on sedation.,0
Hypertension (ambulatory BP range 140-160 mmHg systolics) 2.,0
"Chronic renal insufficiency (stage III), creatinine clearance 35 mL/min/1.73 m^2 most recently in ; GFR has fluctuated between 35-60 per Nephrology notes; followed by Dr. at - likely secondary to hypertensive nephrosclerosis and diabetic nephropathy with proteinuria (no history of biopsy) 3.",1
"Non-insulin dependent diabetes (last HbA1c 6.7% in , home blood glucose well-controlled in 120-130 mg/dL range) 5.",0
"Pulmonary mycobacterium avium intracellulare infection (diagnosed in with CXR showing prominent interstitial markings and scarring; PFTs noted a restrictive pattern; PPD negative, AFB positive - started triple therapy with Azithromycin, Ethambutol and Rifabutin; followed by Pulmonology and Infectious Disease.",1
Rifambutin stopped in - planning to maintain her on suppressive therapy indefinitely) 6.,0
Multiple liver masses (likely cysts per records) 8.,0
Left occipital infarct () 9.,0
Malnutrition 10. s/p excision of left breast mass () 11. s/p left vitrectomy and endolaser () 12. s/p excision of left forearm mass () 13. s/p right inguinal hernia repair () 14.,0
Recent left hip fracture - discharged to rehab Social History: Patient in rehab since recent admission for hip fracture.,1
She normally lives at home with her husband and is only; she has 2 daughters and 1 son.,0
She immigrated from over 20 years ago.,0
No history of tobacco use or alcohol use; no recreational substance use.,0
Patient is independent in ADLs and ambulates unassisted at baseline.,0
"Family History: Per daughter, no significant family history of early MI, arrhythmia or sudden cardiac death.",1
"Physical Exam: Admission Physical Exam: Vitals: T: 32.2 BP: 110/61 P: 83 R: 16 O2: 100% on FIO2 50% Vt 400 RR 16 peep 5 General: Intubated, unarousable to painful stimuli; does exhibit intermittent clonic movements of upper extremities preceeded by eye opening HEENT: Sclera anicteric, MMM, intubated Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breath sounds in bases bilaterally Abdomen: cooling packs in place GU: foley in place draining yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Dolls eyes abnormal; corneal reflexes negative; does not withdraw to painful stimuli in all 4 extremities .",0
Physical Exam at time patient expired: Neuro: Pupils fully dilated and unresponsive; corneal reflexes negative CV: No cardiac sounds; carotid and femoral pulses absent Lungs: No breath sounds Pertinent Results: Admission Labs: 09:08AM BLOOD WBC-8.1 RBC-2.73* Hgb-8.7* Hct-29.7* MCV-109* MCH-32.0 MCHC-29.4* RDW-15.8* Plt Ct-399 01:45PM BLOOD Neuts-94.2* Lymphs-2.4* Monos-3.2 Eos-0.1 Baso-0.1 01:45PM BLOOD PT-9.9 PTT-54.8* INR(PT)-0.9 09:08AM BLOOD Glucose-738* UreaN-50* Creat-1.5* Na-138 K-8.0* Cl-112* HCO3-15* AnGap-19 01:45PM BLOOD ALT-64* AST-104* CK(CPK)-274* AlkPhos-86 TotBili-0.3 01:45PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-0.07* 01:45PM BLOOD Calcium-6.7* Phos-4.9*# Mg-2.9* .,0
Labs 1 day prior to when patient expired: 03:14AM BLOOD WBC-17.8* RBC-2.76* Hgb-8.5* Hct-27.2* MCV-99* MCH-30.9 MCHC-31.4 RDW-16.4* Plt Ct-382 03:14AM BLOOD PT-10.9 PTT-31.2 INR(PT)-1.0 03:14AM BLOOD Glucose-148* UreaN-54* Creat-2.0* Na-144 K-5.5* Cl-115* HCO3-17* AnGap-18 03:14AM BLOOD CK-MB-7 cTropnT-0.06* 03:14AM BLOOD Calcium-7.7* Phos-6.6* Mg-2.9* Brief Hospital Course: 85 year-old Mandarin-speaking woman with a history of recent hip fracture admitted s/p PEA cardiac arrest.,1
She underwent ACLS for 10 minutes and received 4 rounds of epinephrine prior to admission.,0
"Unclear etiology of arrest, although likely due to hypoxemia secondary to aspiration as patient was eating breakfast at time of arrest, and had bronchiectasis on CTA indicating likely chronic aspiration.",1
She was treated with vancomycin and Zosyn to cover for aspiration pneumonia.,0
No evidence of ischemia or new infarct on EKG.,0
"On admission, the patient was started on the Arctic Sun cooling protocol, with goal temperature 33 degrees C. She began to warm prematurely against the machine to 35.8 degrees, and was started on midazolam, cisatracurium, Keppra, and Tylenol to cover for fevers, subclinical shivering, and potential seizures.",0
"During the re-warming phase, the patient exhibited poor neurologic return, with absent corneal reflexes and increasing burst-suppression on EEG.",0
She also exhibited myoclonic jerks.,0
"She was evaluated by neurology, who discussed the patient's poor neurologic status with the family in detail.",0
"On the ventilator, the patient showed markedly poor respiratory drive when placed on pressure support.",0
"The patient's neurologic and respiratory status was discussed with the family, and per the family's request, goals of care were transitioned towards comfort.",0
"The patient was extubated per the family's request, and expired within 10 minutes of extubation.",0
Amlodipine 5 mg PO BID hold for SBP<100 2.,0
Azithromycin 250 mg PO Q24H 3.,0
Carvedilol 12.5 mg PO BID 4.,0
CloniDINE 0.3 mg PO BID 5.,0
Docusate Sodium 100 mg PO BID constipation 6.,0
Ethambutol HCl 400 mg PO BID 7.,0
Furosemide 20 mg PO DAILY 8.,0
Polyethylene Glycol 17 g PO DAILY:PRN constipation 9.,0
Ranitidine 150 mg PO BID 10.,0
Valsartan 80 mg PO BID hold for SBP <100 11.,0
Acetaminophen 1000 mg PO Q8H 12.,0
Heparin 5000 UNIT SC BID last day 13.,0
Alendronate Sodium 35 mg PO 1X/WEEK (MO) 14.,0
Nateglinide 120 mg PO BID 15.,0
Non-Aspirin Extra Strength *NF* (acetaminophen) 500 mg Oral QID:PRN 1 tablet 4 times a day as needed 16.,0
Proctosol HC *NF* (hydrocorTISone) 2.5 % Rectal 17.,0
"Sodium Polystyrene Sulfonate 15 gm PO 3X/WEEK (MO,WE,FR) Mon/wed/fri.",0
Zolpidem Tartrate 5 mg PO DAILY 1.5 tablets once a day 19.,0
TraMADOL (Ultram) 25 mg PO BID:PRN pain hold for sedation Discharge Medications: Patient expired.,0
Discharge Disposition: Expired Discharge Diagnosis: Status Post Pulseless Electrical Activity Cardiac Arrest Discharge Condition: Expired,1
"9:49 AM CHEST (PORTABLE AP) Clip # Reason: follow PTX bilaterally, chest tube placement.",0
"______________________________________________________________________________ MEDICAL CONDITION: 82 year old man s/p bradycardic arrest with L PTX, new R PTX REASON FOR THIS EXAMINATION: follow PTX bilaterally, chest tube placement.",0
______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Follow up bilateral pneumothoraces.,0
Portable AP chest dated is compared to the prior study performed one day earlier.,0
"FINDINGS: The endotracheal tube, nasogastric tube, and left subclavian catheter remain in stable position.",0
"There are two chest tubes present, one terminating at the right medial apical region and the other adjacent to the left hilum.",0
Tiny biapical pneumothoraces are identified.,0
They appear unchanged in the interval as compared to the two prior films.,0
The cardiac and mediastinal contours appear stable.,0
There is persistent extensive subcutaneous emphysema which limits adequate assessment of the chest.,0
"However, there are persistent diffuse alveolar opacities within the right lung as well as a probable small right pleural effusion.",0
"This could represent asymmetric pulmonary edema, aspiration, or pneumonic process.",0
"Diffuse air-space opacities within the right lung which could represent asymmetric pulmonary edema, aspiration, or infection.",0
4:14 AM CHEST (PORTABLE AP) Clip # Reason: assess interval change Admitting Diagnosis: ASPIRATION; FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: 80 year with increasing O2 requirements possibly seconday to aspiration from previous small bowel follow through - Blood cx x2 grew out GPC in clusters REASON FOR THIS EXAMINATION: assess interval change ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
FINDINGS: AP single view of the chest with patient in semi-upright position is analyzed in direct comparison with a similar preceding study of .,0
The previously described left subclavian approach central venous line remains in unchanged position.,1
Unchanged appearance of moderate cardiomegaly without evidence of significant pulmonary vascular congestion.,0
The previously described left-sided retrocardiac density which obliterates the diaphragmatic contour and that of the descending aorta remains and is indicative of persistent left lower lobe consolidation.,0
No new parenchymal abnormalities are identified.,0
"1:11 PM FOOT AP,LAT & OBL LEFT; ANKLE (AP, MORTISE & LAT) LEFT Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man with foot pain REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT INDICATION: Foot pain.",0
"LEFT FOOT, SIX VIEWS: Note is made of fusion of the middle and distal phalanges of the third, fourth and fifth digits which is likely congenital.",0
"The rest of the study is unremarkable without evidence of fracture, joint space narrowing or osteophytes.",0
The mineralization is within normal limits.,0
"12:04 PM CT HEAD W/O CONTRAST Clip # Reason: eval for bleed Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with asymetric pupils, nonresponsive.",0
h/o craniotomy for aneurysm REASON FOR THIS EXAMINATION: eval for bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Pupils nonresponsive.,0
TECHNIQUE: CT head without IV contrast.,0
"FINDINGS: There is no evidence of hemorrhage, infarction, shift of normally midline structures, loss of -white matter junction differentiation, or major abnormality in size or contour of ventricles, sulci, and cisterns.",1
Clips from prior aneurysm repair are seen and there has been a left craniotomy.,0
"No other major osseous defects are demonstrated, and the mastoid air cells and visualized paranasal sinuses are clear.",0
IMPRESSION: No CT evidence for acute intracranial process.,0
3:23 AM PELVIS (AP ONLY) PORT Clip # Reason: ?,0
fracture ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with fall REASON FOR THIS EXAMINATION: ?,0
fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall.,0
TECHNIQUE: Single frontal radiograph of the pelvis.,0
FINDINGS: No acute fracture or dislocation is seen.,0
"There are degenerative changes of the lower lumbar spine, incompletely evaluated.",0
"A few prominent loops of bowel are overlying the pelvis and obscure the bony detail of the sacrum, SI joints, and puboc symphysis.",0
No air-fluid levels are seen.,0
"If there is concern for an occult hip fracture, recommend further evaluation with MRI.",0
", R. VSURG PACU 5:40 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: ?",0
"extension of clot - LEFT arm Admitting Diagnosis: NON HEALING LEFT LEG ULCER ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with LUE swelling, h/o thrombosis in LUE REASON FOR THIS EXAMINATION: ?",0
"extension of clot - LEFT arm ______________________________________________________________________________ PFI REPORT No evidence for left upper extremity venous ultrasound, although evaluation of the left subclavian vein was suboptimal.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: s/p lt. IJ placement.,0
"Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 38 y/o with ETOH intoxication/withdrawal, intubated, hematoma seen on CT but no evidence of active bleeding REASON FOR THIS EXAMINATION: s/p lt. IJ placement.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post left IJ placement, evaluate for pneumothorax.",0
COMPARISON: CXR and CT chest .,0
FINDINGS: ET tube is seen with the tip approximately 3.5 cm from the carina.,0
NG tube appears appropriately positioned and unchanged from one day prior.,0
Left internal jugular line appears appropriately positioned with the tip at the atrial-caval junction.,0
"Although difficult to fully evaluate on a supine film, there is no evidence of left-sided pneumothorax.",0
"A thin lucency is seen along the right hemidiaphragm, which may represent a right-sided tiny pneumothorax in a supine patient; however, there is no evidence of a pneumothorax on the chest CT performed a day prior.",0
It is unclear if any more attempts of central venous access were made on the right side since the chest CT was performed.,0
Lung volumes are diminished bilaterally.,0
"Allowing for technical differences and rotation, the cardiomediastinal silhouette is overall unchanged.",0
There is a linear band of atelectasis in the right mid lung field.,0
Increased area of infiltrate versus atelectasis is noted in the left mid lung field.,0
Appropriate position of left internal jugular line with no evidence of left-sided pneumothorax.,0
Lucency along right hemidiaphragm raises the question of a tiny right pneumothorax.,0
"If clinical suspicion is raised, can perform a left lateral decubitus to evaluate for a right-sided pneumothorax.",0
Increased infiltrate versus atelectasis in left mid lung field compared to film from prior today.,0
These findings were discussed with Dr. .,0
1:48 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: evaluate lung fields Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 27 wks now 3 days old on HFOV REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST TAKEN AT 14:00 HOURS AND COMPARED TO AT 21:06 HOURS.,0
FINDINGS: Endotracheal tube is at the body of T2.,0
"Umbilical venous catheter appears to have been advanced, tip at the junction of the SVC/right atrium.",0
The infant is rotated toward the left slightly.,0
The heart silhouette cannot be well seen but it is most likely unchanged and slightly prominent.,0
"Pulmonary parenchyma remains increased in density, progressively more so than on the most recent prior study.",0
"Again, no bony or soft tissue abnormalities are noted.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: position of lines and ET tube, ?LUL infiltrate Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man s/p cardiac arrest, with left subclavian placment and intubation REASON FOR THIS EXAMINATION: position of lines and ET tube, ?LUL infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: 86-year-old male status post cardiac arrest.",0
Evaluate for positioning of lines and tubes.,0
Comparison is made to prior radiograph from earlier in the day.,0
SINGLE UPRIGHT PORTABLE CHEST X-RAY An endotracheal tube has been repositioned and now is approximately 3 cm from the carina.,0
There is stable appearance to a large-bore dual-lumen right-sided subclavian central venous catheter and a left-sided central venous catheter sheath with its tip in the mid left subclavian vein.,0
"Overall lung volumes remain low and there is a new patchy opacity identified within the medial portion of the right lower lobe likely representing an overlying vascular shadows, however area of atelectasis or aspiration pneumonitis cannot be excluded.",0
No evidence of pneumothorax or pulmonary edema.,0
There is perhaps mild blunting of the left costophrenic angle.,0
Appropriate repositioning of endotracheal tube with tip of left subclavian central venous sheath in mid left subclavian vein.,0
New patchy right lower lobe opacity likely representing overlying shadows.,0
Recommend repeat radiographs to evaluate as atelectasis; or aspiration pneumonitis appear similar.,0
"11:10 AM ANKLE (AP, MORTISE & LAT) LEFT Clip # Reason: please evaluate Admitting Diagnosis: FALL ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with L ankle pain REASON FOR THIS EXAMINATION: please evaluate ______________________________________________________________________________ FINAL REPORT HISTORY: Left ankle pain.",0
There is soft tissue swelling about the ankle.,0
No fracture or dislocation is identified.,0
No gross degenerative change is identified except moderate-sized posterior and small inferior calcaneal spurs.,0
Surrounding soft tissue swelling present.,0
10:23 AM ESOPHAGUS Clip # Reason: Please eval esophageal stent position Admitting Diagnosis: PLEURAL EFFUSION;QUESTION OF EMPYEMA Contrast: OPTIRAY Amt: 50 ______________________________________________________________________________ MEDICAL CONDITION: 49M s/p esophageal stent placement for esophagopleural fistula REASON FOR THIS EXAMINATION: Please eval esophageal stent position ______________________________________________________________________________ FINAL REPORT INDICATION: Esophageal stent placement.,1
"BARIUM ESOPHOGRAM: COMPARISON: Chest radiograph , CT chest .",0
"FINDINGS: Scout radiograph demonstrates a metallic stent in the esophagus, similar to the prior chest radiograph.",0
"Through a nasogastric catheter, the tip of which was withdrawn to the level of the inferior stent margin, Omnipaque was injected, filling the distal stent without any evidence for leak of contrast beyond the margins of the stent and esophagus.",0
"However, the contrast that was injected into the esophagus remained in the esophagus with no free passage of contrast beyond the lower esophageal section nor beyond the GE junction.",0
"Only when the nasointestinal tube was passed through the distal esophagus, beyond the GE junction, did oral contrast enter into the stomach.",0
"The narrowing at the lower esophagus/GE junction is smooth, suggestive of edema rather than an extrinsic compressive mass.",0
"At the end of procedure, the nasointestinal tube was withdrawn to the level of the distal esophageal stent, and the contrast that was injected was aspirated.",0
The nasointestinal tube was left with its tip near the distal esophageal stent.,0
"Only the distal two-thirds of the stent were evaluated, the upper esophageal stent was not fully evaluated given the risk of aspiration if the upper esophageal stent was over-distended with contrast.",0
"No evidence for leak around the esophageal stent, only the distal two-thirds were fully evaluated.",0
"Smooth narrowing and stricturing at the distal esophagus/gastroesophageal junction, likely related to edema or esophageal dysmotility in the setting of a metallic stent along a large segment of the esophagus.",0
These findings were discussed via telephone with Dr. at 11:05 a.m. on .,0
(Over) 10:23 AM ESOPHAGUS Clip # Reason: Please eval esophageal stent position Admitting Diagnosis: PLEURAL EFFUSION;QUESTION OF EMPYEMA Contrast: OPTIRAY Amt: 50 ______________________________________________________________________________ FINAL REPORT (Cont),1
7:26 PM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with CABG REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ WET READ: MDAg FRI 8:29 PM No sigifnicant change from .,1
"______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, AT 19:29 CLINICAL INDICATION: 52-year-old status post CABG, to assess for interval change.",0
Comparison to portable study of at 13:39.,0
"PA and lateral views of the chest, at 19:29 are submitted.",0
Right internal jugular central line continues to have its tip in the mid-to-distal SVC.,0
"There are small layering bilateral pleural effusions with a more focal lateral pleural opacity at periphery of the right mid lung, which may represent loculated fluid or focal pleural thickening.",1
"In addition, streaky linear opacities at both bases, left greater than right, are again seen, suggestive of patchy atelectasis.",0
Stable cardiac and mediastinal contours in this postoperative patient status post median sternotomy for CABG.,0
"Admission Date: Discharge Date: Service: CARDIOTHORACIC Allergies: Morphine Sulfate Attending: Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABG x 5 (LIMA->LAD, SVG->OM3, SVG->OM1->OM2, SVG->PDA) Trach and PEG History of Present Illness: 82 yo M with h/o CAD, presented to OSH with 48 hours of chest pain.",0
"Cath showed 20-30% LM, 90% LAD, 90% Lcx, RCA 90%.",0
"Past Medical History: MI , CHF, Afib (currently NSR), lipids, HTN, BLE vein surgery , bilat knee surgery.",0
"Social History: retired lives with wife at Place quit tobacco 15 years ago, 30 pack year history occasional etoh Family History: NC Physical Exam: Admission: NAD, pain free on NTG gtt Lungs CTAB ant/lat RRR, no M/R/G Abd soft/NT/ND Extrem cool, no edema.",0
Well healed scars bilat knees.,0
"Extensive UE ecchymosis Some varicose veins Discharge: VS: T98.7 HR82AF BP122/63 RR22 O2sat 97% 50% trach collar Gen: NAD Neuro: Awake, responsive to verbal stimuli, occaisionally follows commands Pulm: Course rhonchi, trach in place CV: Irreg/irreg.",0
"Incision CDI Abdm: soft, NT, +BS, Gtube in place, site CDI Ext: warm, EVH site healing.",0
1+ pedal edema Pertinent Results: RADIOLOGY Preliminary Report CHEST (PORTABLE AP) 7:56 AM CHEST (PORTABLE AP) Reason: s/p ?,0
aspiration-r/o infiltrate MEDICAL CONDITION: 83 year old man s/p urgent cabg x5 remains intubated.,0
REASON FOR THIS EXAMINATION: s/p ?,0
"aspiration-r/o infiltrate INDICATION: Aspiration, recent CABG.",0
"Comparison is made to films dating back to , the most recent being .",0
PORTABLE UPRIGHT VIEW OF THE CHEST AT 8:10 A.M.: The tracheostomy tube and right subclavian catheter remain in unchanged and adequate position.,0
There has been interval improvement in left hazy opacity indicating improved pulmonary edema.,0
The left pleural effusion is slightly smaller.,0
The right lower lobe consolidation persists and may represent aspiration pneumonia.,0
"The persistent retrocardiac opacity likely represents atelectasis associated with the left pleural effusion, but may also reflect a component of consolidation.",0
IMPRESSION: Interval improvement in pulmonary edema.,0
"Unchanged right lower lobe pneumonia, likely aspiration.",0
Left lower lobe atelectasis versus additional focus of pneumonia.,0
DR. DR. Cardiology Report ECHO Study Date of PATIENT/TEST INFORMATION: Indication: Left ventricular function.,0
Height: (in) 70 Weight (lb): 161 BSA (m2): 1.91 m2 BP (mm Hg): 97/49 HR (bpm): 68 Status: Inpatient Date/Time: at 12:28 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. MEASUREMENTS: Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%) INTERPRETATION: Findings: Patient was intubated and sedated on a propofol drip as per CSRU orders.,0
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.,0
LEFT VENTRICLE: Severely depressed LVEF.,0
No atheroma in ascending aorta.,0
The patient was monitored by a nurse in throughout the procedure.,0
Emergency study performed by notified of the echocardiographic results by e-mail.,0
Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage.,0
left ventricular systolic function is severely and globally depressed (LVEF= 25-30 %).,0
There are simple and complex (>4mm) nonmobile atheroma in the aortic arch and descending thoracic aorta.,0
There is spontaneous echo contrast in the descending aorta and arch consistent with a low cardiac output state.,0
There is mild posterior leaflet mitral valve prolapse.,0
IMPRESSION: Posterior mitral leaflet systolic prolapse with mild to moderate mitral regurgitation.,0
Severely depressed left ventricular systolic function.,0
"Electronically signed by , MD on 19:46.",0
"The NTG was restarted, he was started on a heparin drip.",0
He underwent preop testing including vein mapping and carotid ultrasound.,0
He was taken to the operating room on .,0
"On induction of anesthesia he arrested, he then underwent an emergent CABG x 5.",0
"He was transferred to the ICU in critical but stable condition on epinephrine, milrinone, insulin, propofol, and phenylephrine.",0
He was started on levofloxacin for pneumonia.,0
He had atrial fibrillation for which he underwent TEE and was unsuccesfully cardioverted.,1
He was started on cisatracurium.,0
He was seen by wound care for groin and foot wounds.,0
He remained intubated on pressors in cardiogenic shock.,1
He was changed to zosyn and flagyl on .,0
His pressors were slowly weaned and he was off all pressors on .,0
On he had a large retroperitoneal bleed which required 7 UPRBCs.,0
On he had a percutaneous trach and PEG and tolerated the procedure well.,0
He coninued to improve but was neurologically withdrawn and was evaluated by neurology and they thought it was metabolic.,0
He was started on Zoloft and became a little more responsive.,0
"He continue to wean slowly from the ventilator and on he was discharged to rehabilitation to progress with ventilator weaning, and physical therapy.",0
"Medications on Admission: coreg, lasix, lisinopril, digoxin, fluvastatin Discharge Medications: 1.",0
Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Subcutaneous once a day.,0
Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day.,0
Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day).,0
Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours).,0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours).,0
Warfarin 1 mg Tablet Sig: target INR 1.5-2.0 Tablets PO DAILY (Daily).,0
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed.,0
Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO DAILY (Daily).,0
Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoclopramide 5 mg/mL Solution Sig: Five (5) mg Injection Q6 Hrs/PRN as needed for nausea/vomiting.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: CAD s/p MI CHF Afib Hyperlipidemia HTN Discharge Condition: Stable.,0
Discharge Instructions: Keep wounds clean and dry.,0
"Call with fevers, redness or drainage from incisions or weight gain more than 2 pounds in one day or five in one week.",0
Followup Instructions: Dr. 2 weeks after discharge from rehab Dr. 2 weeks after dischrge from rehab Dr. 4 weeks after discharge from rehab MD Completed by:,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: rigid bronchoscopy intubation bronchial embolization History of Present Illness: 56 y/o female with PMH significant for metastatic renal cell CA with mets to the lung and multiple lymph node chains admitted to on with hemoptysis and now transferred to the MICU for further care after bleeding from right upper lobe during bronchoscopy.,0
Pt was recently admitted to from to with hemoptysis at which time she underwent rigid bronchoscopy with argon photocoagulation therapy on .,0
"Following this, the pt had no further hemoptysis.",0
CT scan obtained during this admission showed interval progression of disease.,0
Pt was only home for a few when she had three episodes of hemoptysis and returned to .,0
"Per notes, pt had no SOB on admission.",0
She was admitted and on the morning of went to the OR for rigid bronchoscopy.,0
This showed heavy bleeding from the posterior segment of the right upper lobe.,0
Pt remained intubated underwent successful right bronchial artery embolization by IR.,0
"Later that morning, Pt extubated without complication and transferred to medical service.",0
"ONCOLOGICAL HISTORY(per OMR): Ms. is a 55-year-old female with metastatic renal cell cancer to the lungs and lymph nodes noted on work-up for shortness of breath () associated with a hgb=17: CT demonstrated bilateral cystic kidneys and confirmed pulmonary nodules as well as prevascular, supracarinal and infracarinal, mediastinal and bilateral hilar lymph nodes.",1
"CT-guided biopsy of the right lung nodule at Center was suspicious for, but not diagnostic of malignancy.",0
She was diangosed with metastatic renal carcinoma based on the large left kidney necrotic hypernephroma and polycystic kidney disease.,0
"After one cycle of IL-2 Ms. was followed with stable CT scans every three months until when extensive periaortic adenopathy, pulmonary nodules and an 8.8 cm left renal mass were noted.",0
"At this time she had episodes of shortness of breath and hemoptysis, including an episode during bronchoscopy that required emergent intubation .",0
"She has done well on with resolution of hemoptysis, shortness of breath and a decrease in target lesions initially and stable since then.",0
"Her course on the trial has been complicated by high pressure, leg pain/scaliness, both of which have resolved.",0
Her diarrhea has stabilized on immodium.,0
"Her hct has risen to pre-hemotypsis levels, but is generally under 50.",0
In she developed new onset asymptomatic Grade II a-fib requiring cardioversion s/p TEE (?,0
The study drug was held until after procedure.,0
She was restarted in .,0
"Metastatic renal cell carcinoma-treated with IL-2 now on protocol, overall course c/b hemoptysis, AF, SOB 2.",0
Adult polycystic kidney disease 3.,0
H/O atrial fibrillation in 01/.,1
Pt was cardioverted s/p TEE with good response.,0
Acute renal failure- Pt was admitted for ARF in 04/.,0
Her BUN and creatinine had increased from 33/1.7 to 83/4.4.,0
"By the time of discharge, her creatinine had decreased to 2.2.",0
8. h/o hemoptysis after bronch () Social History: The patient lives in .,0
She works as a bank teller for the last 29 years.,0
Positive tobacco history; quit ten years ago.,0
Family History: Father died at age 72 of lung cancer.,0
"Mother living, age 76 with hypertension and cerebrovascular accident.",0
"Physical Exam: vs: Afeb, 87, 150/66, 20 94% 2LNC gen- sitting comfortably in chair, NAD heent- PERRL, EOMI, anicteric sclera, OP wnl, MMM neck- supple, no LAD cvs- RRR, nl S1/S2, no M/R/G pulm- CTAB abd- soft, NT, ND, NABS, no HSM but palpable kidneys ext- no edema, 2+ DPs skin- warm and well perfused neuro- A&O-3, CNs roughly intact, strength 5/5, sensation intact Pertinent Results: 142 100 21 97 AGap=17 3.3 28 1.4 Ca: 8.8 Mg: 1.9 P: 3.0 89 14.0 8.0 272 42.2 PT: 13.6 PTT: 32.9 INR: 1.2 CXR (PA/LAT): The heart is upper limits of normal in size.",0
There is bulky bilateral hilar lymphadenopathy as well as mediastinal lymphadenopathy.,0
"The mediastinal nodes are most prominent in the right paratracheal, aorticopulmonary window and subcarinal regions.",0
"Numerous pulmonary nodules are seen in both lungs, ranging in size from less than a cm in diameter to several cm in diameter.",0
The nodules appear more conspicuous than on the prior study were likely more difficult to visualize previously due to portable technique.,0
The lungs reveal no focal areas of consolidation or areas of significant atelectasis.,0
There are trace pleural effusions which have improved compared to chest radiograph.,0
Skeletal structures reveal diffuse demineralization and degenerative changes.,0
Extensive metastatic disease involving the thoracic lymph nodes and pulmonary parenchyma.,1
No areas of collapse are identified.,0
Improved pleural effusions with small residual effusions remaining.,0
"IR Embolization: 1) Thoracic aortogram revealed a single, hypertrophied right bronchial artery supplying the right lung field.",0
"However, there was significant hypervascularity from this vessel within the right lung field.",0
"Of note, the right upper lobe is collapsed with compensatory hypertrophy of the right middle and lower lobes.",0
2) Superselective embolization of 3 tortuous branches arising from the right bronchial artery using 3 vials of 700-900 micron-sized embosphere particles with good angiographic success.,0
Brief Hospital Course: A/P: 56 y/o female with PMH significant for metastatic renal cell CA with mets to the lung and multiple lymph node chains admitted with hemoptysis after bleeding from right upper lobe during bronchoscopy.,0
Pt with episodes of hemoptysis in the past and now returns with similar complaints.,0
Underwent rigid bronchoscopy on admission where bleeding was seen from the right upper lobe.,0
Bleeding controlled with right bronchial embolization.,0
Transferred to medical service after successful extubation.,0
While on the floor Pt stable without evidence of respiratory distress.,0
"Morning after embolization/bronch, Pt c/o some residual hemoptysis that resolved.",0
Pt without evidence of further bleeding.,0
"If after D/C, Pt to have hemoptysis, she will contact Dr and considerations made for repeat bronchoscopy in the future.",0
Metastatic renal cell carcinoma- Pt is currently on the experimental protocol followed by Dr and Dr .,0
Pt to be discharged home with f/u in Oncology on Monday .,0
Pt will likely resume treatment after being seen by Dr .,0
Hypertension- hypertensive regimen held during MICU stay but quickly restarted afterwards Pt to be d/c on pre-admission regimen.,0
Hyperthyroid: Pt continued outpt regimen (Methimazole 5 mg PO Q5days) Medications on Admission: 1.,0
Methimazole 5 mg PO Q5days 2.,0
Bydrochlorothiazide 25 mg daily 3.,0
Atenolol 100 mg daily 4.,0
Amlodipine 10 mg daily 5.,0
Experimental protocol Discharge Medications: 1.,0
Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Discharge Disposition: Home Discharge Diagnosis: Renal Cell CA HTN Hemoptysis Discharge Condition: good Discharge Instructions: Please take all medications as prescribed; you will be restarted on your previous medical regimen without changes.,0
Do not restart your protocol until told to by your oncologist.,0
Please make all follow up appointments; if unable reschedule as soon as possible.,0
"Please call your PCP or return to ED if you have: persistent fever >101, shortness of breath, Chest pain, hemoptysis.",0
Followup Instructions: 1) You have several Oncology follow-up appointments scheduled.,0
Your next one is for .,0
Dr and Dr would like to see you on .,0
Their office will contact you to schedule a time.,0
Please feel free to call them at .,0
"a) Provider: , MD Where: HEMATOLOGY/ONCOLOGY Phone: Date/Time: 1:40 b) Provider: , MD Where: HEMATOLOGY/ONCOLOGY Phone: Date/Time: 1:30 c) Provider: , HEMATOLOGY/ONCOLOGY-CC9 Where: HEMATOLOGY/ONCOLOGY Phone: Date/Time: 1:30 2) Please call your PCP and update her as to your recent admission and ask if she wished to see you in follow up.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 56 year old Portugese-speaking only man with no significant past medical history who was presented as a transfer from with acute onset of right hemiparesis and aphasia.,0
History is obtained from a Portugese translator on the telephone from speaking with his wife and who were at the bedside with us outside the magnetic resonance imaging scan.,0
He came home from church around 10:30 PM this evening.,0
He was noted at some point between 10:30 PM and 11 PM while getting ready for bed to have some strange gurgling sounds.,0
His wife then noted that he was sitting down on the bed and he had a right-sided weakness and was unable to speak.,0
The wife also noted that he was shaking but it was difficult for her to clarify it further.,0
It does not seem that he is rhythmically shaking his arms and legs but history is somewhat limited.,0
"He was taken to an outside hospital where he was noted to be lifted out of the car in order to get into the Emergency Department, with dense hemiparesis on the right, nonperipheral movements, nonverbal, minimal response to pain on the right hand and unable to follow commands.",0
The Emergency Department called the Stroke Team in who then transferred him to for further evaluation.,0
On arrival he was sent urgently to magnetic resonance imaging scan and on the way he had total parenteral alimentation brought to the bedside and monitored with history taken by family and with help of that translator on the phone.,0
"His wife states that he had not had any similar episodes in the past and has generally been in good health, no recent illness, fever, chills, nausea, vomiting, chest pain, shortness of breath or other complaints.",0
SOCIAL HISTORY: He works in landscaping at .,0
He stopped one month ago after season changed.,0
He has been married to his wife for 16 years.,0
He drank alcohol years ago before the present marriage.,0
There was no history of tobacco or drug use.,0
He is involved in church.,0
"FAMILY HISTORY: Father died from myocardial infarction in his 60s, mother discontinued from bronchitis at an early age.",0
"PHYSICAL EXAMINATION: Afebrile, blood pressure 110s to 130s/70s, pulserate 80s, respiratory rate 18.",0
"General, he is a well nourished man.",0
"Lungs, clear to auscultation bilaterally.",0
"Heart, regular rate and rhythm.",0
"NIH stroke scale on presentation was 23 to 24 for, one for consciousness, two for month and year and two for eye/grip, one to two for gaze, two for face, eight for motor, one for limited ataxia, one to two for sensory, three for best language and two for attention.",0
"On the neurologic examination the patient was intermittently awake, opens eyes to stimulation, the patient does not follow commands in English, Spanish or with an interpreter on the phone or with the family.",0
His language is mostly involved with being mute and grunting times one.,0
On the cranial nerve examination his eyes are deviated to the left and will just go to the midline but not past.,0
He does not blink to threat on the right.,0
His funduscopic examination could not be done due to lack of cooperation.,0
"Pupils are equally round and reactive to light, 3 to 2 mm bilaterally.",0
"There is a right facial droop, upper motor neuron.",0
On motor examination he has normal bulk and tone bilaterally.,0
He had minimal movement of the right leg greater than arm.,0
At first there was some grasping of the right arm but not on command.,0
He does not protect his face when lifted above his head.,0
There is spontaneous movement in the left arm and leg.,0
On sensory examination he was intact to deep pain on the left with minimal movement of the right leg to pain although he did grimace.,0
"Reflexes, decreased throughout and symmetric 1 to 2 out of 4.",0
His toes were downgoing bilaterally.,0
Coordination and gait examination could not be assessed.,0
"LABORATORY DATA: Laboratory data upon admission revealed white count 8.8, hematocrit 44.8, platelets 219, INR 1.1, PTT 21.5, PT 12.8, sodium 137, potassium 3.7, chloride 102, bicarbonate 26, BUN 23, creatinine 1, glucose 202.",0
Computerized tomography scan of the brain showed flat loss of foci on the left in the MCA distribution with calcified basal ganglia bilaterally.,0
Magnetic resonance imaging scan/ magnetic resonance angiography showed a left MCA infarction with a left M1 occlusion.,1
"Neurology - Stroke, given the patient's initial presentation of a large left MCA infarct, he was given total parenteral alimentation without resolution of his symptoms.",0
"Despite total parenteral alimentation, the patient continued to have a right-sided flaccid paralysis and global aphasia.",0
He initially was put on an Aspirin and statin for stroke prevention.,0
"However, hypercoagulable workup showed an abnormally elevated fibrinogen at 540 and Factor VIII at 182.",0
Therefore he was put on heparin and Coumadin in light of the fact that he also had a right to left shunt PFO upon a transesophageal echocardiogram.,0
"The rest of his hypercoagulability was normal with the following results, antithrombin 3 at 137, Protein-C at 139 and Protein-S at 77, anticardiolipin IgG was 6 and IgM was 3.8 which were normal values.",0
Prothrombin mutation and Factor V Leidin are still pending upon discharge.,0
"A hemoglobin A1c was checked to see if he had any evidence of diabetes and it was only slightly elevated at 6.6, so it was decided that he should follow up with a primary care physician on this number.",0
"His lipid panel showed normal values of cholesterol at 175, triglyceride 171, HDL at 41, LDL at 100.",0
He is still given a low dose statin for stroke prevention.,0
His homocysteine level was normal at 9.6.,0
He was ruled out for myocardial infarction.,0
"As noted above, his transesophageal echocardiogram did showed a preserved ejection fraction greater than 60% and no clots, but did show a right to left shunt in the form of PFO.",0
Carotid ultrasounds were then showing no carotid stenosis.,0
An ultrasound of his legs was done looking for a deep vein thrombosis given his PFO but it showed no evidence of deep vein thrombosis.,0
"Given his stroke, he was unable to initially swallow and had to have an nasogastric tube placed.",0
"However, later on he was able to take pureed nectar-thick foods and liquids so the nasogastric tube was taken out.",0
Infectious disease - The patient had a urinary tract infection with Escherichia coli.,1
He was given three days of Levofloxacin.,0
Repeat urinalysis did show clonus of the Escherichia coli.,0
Left MCA infarction secondary to a left M1 occlusion 2.,1
Urinary tract infection DISCHARGE MEDICATIONS: 1.,1
4-6 hours prn FOLLOW UP: 1.,0
"The patient is to follow up with Dr. in the Clinic on , at 10:40 AM.",0
The patient is to follow up with Dr. one month after discharge from the rehabilitation center.,0
DISCHARGE STATUS: To rehabilitation center.,0
Dictated By: MEDQUIST36 D: 12:42 T: 14:36 JOB#:,0
11:10 AM CHEST (PA & LAT) Clip # Reason: ?,0
PNA Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with s/p cerebral angiogram with coiling acom - now fever 101.8 REASON FOR THIS EXAMINATION: ?,1
PNA ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Fever.,0
PA and lateral upright chest radiographs were reviewed with comparison to .,0
"Heart size, mediastinum are unremarkable.",0
Lungs are essentially clear except for suspected left retrocardiac opacity with potentially represents developing/resolving infectious process.,0
Attention to this area on the subsequent studies is recommended.,0
5:03 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ct placement Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 23 year old woman ARDS and influenz w/ acute hypoxia REASON FOR THIS EXAMINATION: ct placement ______________________________________________________________________________ FINAL REPORT INDICATION: 23-year-old female with ARDS and influenza with acute hypoxia.,1
PORTABLE CHEST: Examination is compared to the prior from eight hours earlier.,0
The endotracheal tube terminates 5.8 cm above the carina.,0
A right internal jugular central venous catheter terminates in the mid SVC.,0
There has been interval placement of bilateral chest tubes.,0
The left chest tube terminates lateral to the left pulmonary hilum.,0
The right chest tube terminates at the right lung base.,0
There has been interval development of a lucency in the medial right lung likely representing a pneumothorax.,0
The lung fields again show diffuse bilateral air space consolidation consistent with ARDS.,0
"A nasogastric tube terminates at least one hand width below the diaphragm; however, the tip is not imaged.",0
Note is made of an artifact overlying the upper portion of the film.,0
IMPRESSION: Interval development of a large medial right pneumothorax.,0
Interval placement of bilateral chest tubes.,0
Artifact overlying the upper portion of the film.,0
These findings were discussed with the clinical team caring for the patient and a repeat film will be obtained after adjustment of the chest tubes.,0
"7:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate lines, infiltrates Admitting Diagnosis: CARDIOGENIC SHOCK ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man in cardiogenic shock with tandem heart, intubated REASON FOR THIS EXAMINATION: evaluate lines, infiltrates ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Cardiogenic shock, evaluation.",1
Slight increase in extent of the left basal and retrocardiac opacity that likely reflect atelectasis.,0
"The other parenchymal opacities, including the large right perihilar opacity, are unchanged.",0
8:39 AM CHEST (PORTABLE AP) Clip # Reason: R subclavian line inserted.,0
"PT ALREADY HAS R ptx, R/O COMPLI Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with REASON FOR THIS EXAMINATION: R subclavian line inserted.",1
"PT ALREADY HAS R ptx, R/O COMPLICATIONS ______________________________________________________________________________ FINAL REPORT INDICATION: Central line placement.",0
PORTABLE SUPINE CHEST: Comparison is made to film from 02:49 AM the same day.,0
The ET tube is in satisfactory position.,0
"The tip of the NG tube is in the proximal stomach, with the sidehole at the level of the distal esophagus.",0
It is recommended the NG tube be advanced approximately 8 cm.,0
"Note that on this single view, the distal aspect appears kinked and folded back upon itself, although the course of the tube cannot be acertained from this single view.",0
The tip of the new right subclavian central line is in the SVC.,0
The patient's known upper lobe pulmonary contusions are vaguely seen on this portable film.,1
New central line tip in SVC; no evidence of pneumothorax.,0
NG tube sidehole in distal esophagus; recommend advancing.,0
See above comments regarding the appearance of the right chest tube on this single view.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Tetracyclines / Atenolol Attending: Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: angiography Colonoscopy with biopsies History of Present Illness: Ms. is a 66 yo female with a h/o CAD s/p CABG, PVD, afib/flutter on coumadin, ASA, plavix who presents with BRBPR since yesterday afternoon.",1
Patient was transferred from The following two episodes of bright red blood that filled the toilet bowl.,0
"Per transfer note, BP dropped from 139/69 to 100/65 and patient reported feeling dizzy at time of transfer.",0
"Of note, patient was recently discharged from following hospitalization for ulcer/cellulitis of the right foot complicated by atrial flutter.",1
She underwent LE angiography which revealed total occlusion of the right DP at the site of the previous PTA.,0
This lesion was not amenable to intervention.,0
Hospital also started on coumadin for afib/aflutter prior to discharge.,0
"On arrival to ED, T 98.4, HR 65, BP 105/70.",0
"Hematocrit was 29.8, unchanged from 29.6 on day of discharge .",0
She received Vitamin K 5 mg SC x 1.,0
She had an episode of right-side chest pain and pressure that did not radiate.,0
Chest pain resolved with Morphine 1 mg IV.,0
She had one episode of maroon stool in the ED.,0
NG lavage was attempted but was not successful.,0
GI consult was called and recommended admission to the MICU.,0
"HEENT: MMM, sclera anicteric, clear OP.",0
"CV: regular rhythm, no m/r/g appreciated Chest: No chest wall deformities, scoliosis or kyphosis.",0
"Respirations unlabored, no accessory muscle use.",0
"CTAB but decreased air movement, no crackles, wheezes or rhonchi.",0
"Extrem: Edema to BLE, with chronic skin changes.",0
Gangrenous first toe of right foot.,0
A left anterior oblique view of the pelvis was also obtained.,0
Blood flow images show no abnormalities.,0
Dynamic blood pool images show tracer extravasation in the right lower quadrant with movement both laterally across the abdomen and superiorly.,0
Bleeding was first noticed at 2 minutes.,0
CXR : The moderate cardiomegaly is unchanged.,0
The multiple fractures in the post sternotomy wires as well as the severe displacement is unchanged as well.,0
"Normal angiogram of the superior mesenteric artery and inferior mesenteric artery with no signs of active bleeding, vascular malformation, or pseudoaneurysm.",0
Atherosclerotic disease within the .,0
"CXR : O2 requirements, evaluation for interval change.",0
Unchanged aspect of the multiple fractures in the sternotomy wires.,0
"There might be a newly occurred minimal left-sided pleural effusion, although apparent blunting of the left costophrenic sinus might also be caused by a different patient rotation.",0
The right sinus is clear.,0
"Despite moderate enlargement of the cardiac silhouette, no signs indicative of overhydration is seen.",0
"Colonoscopy : Diverticulosis of the sigmoid colon 5cm segment of ucleration erythema and friability at the hepatic flexure with smaller area of ulceration distally (biopsy) Polyp in the sigmoid colon Otherwise normal colonoscopy to terminal ileum Additional notes: Despite the findings on the previous taggged RBC scan, the bleeding site is clearly the lesion noted at the hepatic flexure.",1
The cecum and TI were completely normal without fresh or old blood.,0
The differential for the lesion includes ischemic colitis and possibly neoplasm.,0
Further management depends on biopsy findings.,0
"If the biopsy does NOT show neoplasm, recommend repeat colonoscopy in months to reassess the area.",0
Mucosal colon biopsies : A. Hepatic flexure: Fragments of colonic mucosa with ulceration and acute inflammation.,1
Note: Some fragments show ulceration with acute inflammation/granulation tissue.,0
Others are more intact showing limited abnormality.,0
"No dysplasia or granulomas identified; findings could represent ischemic changes, but inflammatory bowel disease cannot be ruled out.",0
"B. Transverse: Colonic mucosa, with chronic changes (crypt branching and irregularity).",1
b/l LE Dopplers : No evidence of DVT.,0
"Brief Hospital Course: Ms. is a 66-year-old woman with history of coronary artery disease s/p 4-vessel CABG, peripheral vascular disease, atrial fibrillation/atrial flutter on warfarin, who presented with bright red blood per rectum for one day.",1
# Gastrointestinal bleed: Patient has chronically guaiac-positive stool and was recently started on warfarin.,1
She has a history of gastrointestinal bleeding secondary to peptic ulcer disease.,1
A colonoscopy in revealed sigmoid diverticulosis and internal hemorrhoids.,1
"Shortly after admission, her hematocrit dropped from 29 to 21; her Hct nadir was 16.",0
"Her aspirin, clopidogrel, and warfarin were held, as were her anti-hypertensives.",0
"In the MICU, she received 7 units of pRBCs, 7 units of FFP, 2 bags of platelets.",0
She still had dark red stools.,0
Her hematocrit was stable in the low 30s on transfer out of the MICU.,0
"A tagged RBC scan revealed terminal ileum bleed, though angiographic study on was negative.",0
Colonoscopy on revealed a 5cm ulcerated lesion that was biopsied.,0
"Biopsy showed inflammatory changes that could be due to ischemia, although inflammatory bowel disease could not be ruled out.",0
She was scheduled for repeat outpatient colonoscopy.,0
"At the time of discharge, her hematocrit had been stable for a week without evidence of further bleeding.",0
"At some point in the future, she will likely benefit from restarting coumadin given her risk for stroke.",0
It was not felt to be safe to have her on 3 different blood thinners at once.,0
"# Acute on Chronic diastolic heart failure: Patient was noted to have crackles on exam, increased LE edema, and a new oxygen requirement in setting of holding her diuretics and receiving transfusions with pRBCs, platelets, and FFP.",1
"Once her GI bleed had stabilized, she was diuresed with IV lasix gtt with resolution of oxygen requirement.",0
She continued to have LE edema at the time of discharge; this edema had been present for years.,0
She was sent home on 120mg of lasix .,0
# Coronary artery disease: Patient is status post 4-vessel CABG.,1
"Although she reported chest pain in the ED in the setting of GI bleed, her troponin was negative x 3.",0
Her initial CK was elevated in the 600s but quickly trended down to the 20s.,0
"Her anticoagulants were held after discussion with her cardiologist, Dr. .",0
She was continued on the home dose of simvastatin.,0
Aspirin was restarted at discharge.,0
"# Peripheral vascular disease: Patient is status post left tibial artery and right dorsal pedis angioplasty in , also s/p previous toe amputation.",1
"Another angiography was performed during recent hospitalization, without intervention.",0
Her toe wound was dressed with xeroform and sterile dry gauze.,0
"Although she had some mild erythema of her left lower extremity, this was not felt to be cellulitis and antibiotics were not given, especially in light of her recent treatment for C diff.",0
# Atrial fibrillation/atrial flutter: Rate controlled with metoprolol XL and diltiazem at home.,1
She was also recently started on warfarin on recent admission in .,0
"Her anticoagulants, metoprolol, and diltiazem were held initially.",0
"At the time of discharge, her metoprolol had been restarted.",0
"Diltiazem and coumadin were still held, although she would likely benefit from coumadin in the future given her risk of stroke.",0
"# Diabetes: She was continued on her home regimen of 70/30 50 units qAM, 15 units qPM and was given an insulin sliding scale as well.",0
"# Hypertension: Stable blood pressures despite being off metoprolol, diltiazem, nitrate, and benicar which were held in the setting of gastrointestinal bleeding.",0
"Her metoprolol had been restarted, but her other antihypertensives were still held at the time of discharge.",0
# Acute renal failure on Chronic renal insufficiency: Patient has stage-IV chronic kidney disease with baseline creatinine of 1.4-1.8.,1
Her creatinine was 2.1 on admission then trended down to 1.4 after fluid and blood infusion.,0
She received peri-angiography HCO3 infusion and N-acetylcysteine.,0
Her creatinine remained stable at 1.8 until she was started on IV lasix for diuresis.,0
"When her creatinine increased to 2.4, she was switched to oral lasix and discharged home.",0
Her creatinine should be rechecked by her providers as an outpatient.,0
"Sometime in the future, her benicar should be restarted.",0
# Hypothyroidism: continued on levothyroxine.,0
# Code status: full code.,0
"Medications on Admission: Levothyroxine 100 mcg daily Quinine sulfate 324 mg qHS Plavix 75 mg daily Tolterodine 4 mg daily Simvastatin 40 mg daily ASA 325 mg daily Isosorbide SR 90 mg daily Toprol XL 25 mg daily Omega-3 fatty acids 1000 mg PO BID Hexavitamin PO daily Bupoprion SR 150 mg qAM Pantoprazole 40 mg daily Diltiazem SR 180 mg daily NPH 50 units qAM, 15 units qPM Lasix 80 mg Metolazone 5 mg daily Benicar 20 mg daily Tylenol PRN Flagyl 500 mg TID (end date ) Coumadin 5 mg daily Discharge Medications: 1.",0
Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
"Tolterodine 4 mg Capsule, Sust.",0
Release 24 hr PO once a day.,0
Release 24 hr(s)* Refills:*2* 4.,0
Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)).,0
Disp:*30 Tablet Sustained Release(s)* Refills:*2* 7.,0
Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day.,0
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 8.,0
Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Forty Five (45) units Subcutaneous every morning.,0
Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Seven (7) units Subcutaneous at bedtime.,0
Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.,0
"Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO twice a day.",0
"Discharge Disposition: Home with Service Facility: - Discharge Diagnosis: Primary Diagnosis: Lower GI bleed Secondary Diagnoses: Peripheral vascular disease, Acute on chronic diastolic heart failure, Acute on chronic renal insufficiency, Coronary artery disease, Atrial fibrillation, Diabetes Discharge Condition: No further evidence of GI bleed, hemodynamically stable.",1
Discharge Instructions: You were admitted with bleeding from you large intestine.,0
You were treated in the ICU and your bleed stopped.,0
You were then given lasix to remove your extra fluid.,0
"Medication changes: - you can take 81mg of aspirin a day - increased lasix to 120mg twice a day - changed your NPH insulin to 45 units in the morning and 7 units in the morning - increased your toprol XL to 50mg daily - stopped your coumadin and plavix - stopped imdur (isosorbide), benicar, and diltiazem 2.",0
Please attend all follow-up appointments listed below.,0
"Please call your doctor or return to the hospital if you develop chest pain, shortness of breath, fevers, palpitations, bloody or black stools, lightheadedness, or any other concerning symptom.",0
Adhere to 2 gm sodium diet Fluid Restriction: 1500ml Followup Instructions: You have an appointment with Dr. on Monday at 1:15pm at .,0
"You have an appointment with podiatry: Provider: , DPM Phone: Date/Time: 2:30 You have a colonoscopy scheduled.",0
Please go to the of at .,0
You will get a phone call at home with instructions as to how to prepare for the colonoscopy since you will need to drink a fluid that will clean out your bowels.,0
"Provider: (ST-3) GI ROOMS Date/Time: 10:30 Provider: , MD Phone: Date/Time: 10:30.",0
"Height: (in) 63 Weight (lb): 119 BSA (m2): 1.55 m2 BP (mm Hg): 91/535 HR (bpm): 100 Status: Inpatient Date/Time: at 01:00 Test: Portable TTE (Focused views) Doppler: Color Doppler only Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV systolic function.,0
Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR.,0
Overall left ventricular systolic function is probably preserved (LVEF>50%).,0
"9:00 AM CHEST (PORTABLE AP) Clip # Reason: 70 F s/p failed extubation attempt, eval for pulm process -- ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with chf, intubated, s/p L frontal infarction REASON FOR THIS EXAMINATION: 70 F s/p failed extubation attempt, eval for pulm process --> failure to wean ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: CHF, intubated.",0
"CHEST, AP SEMI-UPRIGHT: The tip of the ET tube lies in satisfactory position.",0
The tip of the NG tube lies below the diaphragm.,0
The film is considerably rotated and quite difficult to assess.,0
No gross failure is present.,0
"The left hemidiaphragm is poorly demonstrated and a left lower lobe infiltrate could be present, but a film would be necessary.",0
"IMPRESSION: No gross failure, possible left lower lobe infiltrate.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CSU ADDENDUM: This 48-year-old man, as previously described in the previous discharge summary, had a minimally invasive procedure on to repair the mitral valve.",1
"On postoperative day 4, the patient did well.",0
"On discharge, his heart was regular in rate and rhythm, had no murmurs, rubs or gallops.",0
His lungs were clear to auscultation bilaterally.,0
"His abdomen was soft, nontender, nondistended.",0
The patient was taking a regular diet and tolerating p.o.,0
MEDICATIONS: Medications were described in pervious discharge summary.,0
"DISCHARGE DIAGNOSES: Mitral regurgitation, status post minimally invasive mitral valve repair.",1
DISCHARGE DISPOSITION: To home in stable condition.,0
FOP PLANS: The patient is to follow up with Dr. in 1 to 2 weeks.,0
The patient also has been instructed to follow up with his PCP .,0
in 1 to 2 weeks.,0
The patient is to follow up with Dr. on at 1:15 p.m.,0
DISCHARGE STATUS: Three were no other issues with this patient over night between postoperative day 3 and 4.,0
He is in stable condition and looks excellent.,0
Dictated By: MEDQUIST36 D: 12:31:54 T: 15:10:26 Job#:,0
9:54 AM ART EXT (REST ONLY) Clip # Reason: eval ABI- basline Admitting Diagnosis: AORTIC VALVE DISEASE;CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with left foot gangrenous and right foot w/ interdiginous ulcers REASON FOR THIS EXAMINATION: eval ABI- basline ______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old male presenting with gangrenous left toes and right foot interdigital ulcers.,1
"TECHNIQUE: Non-invasive evaluation of the arterial system in the lower extremities was performed with Doppler waveforms, pulse volume recordings and segmental limb pressure measurements.",0
"FINDINGS: On the right side, triphasic Doppler waveforms was seen at the common femoral and superficial femoral arteries.",0
"However, monophasic Doppler waveforms are seen at the popliteal, posterior tibial, and dorsalis pedis arteries.",0
"On the left side, triphasic Doppler waveforms were seen at the common femoral and superficial femoral arteries.",0
"However, monophasic Doppler waveforms were seen at the popliteal, posterior tibial, and dorsalis pedis arteries.",0
The right ABI was 0.63 and the left ABI was 0.34.,0
"Pulse volume recordings showed decreased amplitudes bilaterally, at all levels.",0
IMPRESSION: There is moderate arterial insufficiency in the right lower extremity.,0
There is severe arterial insufficiency in the left lower extremity.,0
"3:51 PM SHOULDER VIEWS NON TRAUMA RIGHT Clip # Reason: Rule out lytic disease, fracture.",0
Admitting Diagnosis: MULTIPLE MYELOMA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with right shoulder pain and multiple myeloma.,1
"REASON FOR THIS EXAMINATION: Rule out lytic disease, fracture.",0
______________________________________________________________________________ FINAL REPORT RIGHT SHOULDER ON AT 16:58 INDICATION: Multiple Myeloma with pain.,1
FINDINGS: Just below the humeral head within the humeral shaft there are two focal lytic lesions measuring approximately 1.5 cm in diameter.,0
Findings wouild be consistent with Multiple Myeloma.,1
There is no evidence of fracture or dislocation and no abnormal periosteal reaction.,0
"7:05 AM CHEST (PORTABLE AP) Clip # Reason: r/o pneumonia, CHF ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with h/o enterocutaneous fistulae, liver failure and CHF now with fever to 103.4 REASON FOR THIS EXAMINATION: r/o pneumonia, CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Fever, assess for pneumonia.",1
FINDINGS: Right internal jugular CV line is at the cavo-atrial junction.,0
"There is no pulmonary vascular congestion, definite pleural effusion or pneumothorax.",0
Retrocardiac density has cleared in the interval.,0
"Persistent hazy opacity is seen at the right base, improved in the interval, and may represent atelectasis/infiltrate.",0
IMPRESSION: Improved appearance of bibasilar opacities.,0
Height: (in) 65 Weight (lb): 145 BSA (m2): 1.73 m2 BP (mm Hg): 150/90 HR (bpm): 94 Status: Inpatient Date/Time: at 15:37 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
No MS. Normal LV inflow pattern for age.,0
"Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%).",0
"Compared with the findings of the prior study (images reviewed) of , mitral valve prolapse is no longer evident.",0
3:11 PM CHEST (PA & LAT) Clip # Reason: PTX?,0
"Admitting Diagnosis: HEMATEMESIS ______________________________________________________________________________ MEDICAL CONDITION: 16 year old man with SW to chest, s/p ex lap, s/p L chest tube pulledPlease perform study around p.m. REASON FOR THIS EXAMINATION: PTX?",0
______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST at 15:21 hours.,0
HISTORY: Stab wound to the chest post-removal of left chest tube.,0
An interval chest CT is also available for comparison.,0
"FINDINGS: As noted on multiple prior exams including CT, there is marked elevation of the left hemidiaphragm with blunting of the left costophrenic angle.",0
Small linear opacity is noted laterally in the right mid lung.,0
This likely represents discoid atelectasis.,0
"Otherwise, the aerated lungs are clear.",0
IMPRESSION: Relatively stable appearance of the chest relative to CT a day prior with marked elevation of the left hemidiaphragm.,0
6:45 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"PNA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with hypoxia, fevers, rhonchi, REASON FOR THIS EXAMINATION: ?",0
"PNA ______________________________________________________________________________ WET READ: 9:23 AM right apical opacity is nonspecific - could be atelectasis, pneumonia or pulmonary infarct increased right suprahilar mass from ______________________________________________________________________________ FINAL REPORT HISTORY: 71-year-old male with hypoxia, fevers, and rhonchi.",0
"CHEST, PORTABLE UPRIGHT FRONTAL VIEW: The suprahilar right lung mass is again identified, now measuring 3.9cm (previously 2.9cm).",0
"Right apical opacity may reflect atelectasis, pneumonia or pulmonary infarct.",0
The cardiac silhouette is unchanged.,0
There is no effusion on this frontal view.,0
Shunt catheter courses over the right lung into the peritoneum.,0
Interval growth of right suprahilar lung mass.,0
"Right apical opacity is a non-specific finding, may reflect atelectasis, pneumonia, or pulmonary infarct.",0
A wet read was entered into the ED Dashboard on .,0
"7:22 AM CHEST (PORTABLE AP) Clip # Reason: pls evaluate level of effusions Admitting Diagnosis: CONGESTIVE HEART FAILURE;NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with CAD, HTN, renal failure, and ?",1
"GI bleed here with SOB and crackles, being diureesed REASON FOR THIS EXAMINATION: pls evaluate level of effusions ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Hypertension, renal failure, shortness of breath.",1
SINGLE AP PORTABLE VIEW OF THE CHEST.,0
Compared to prior study performed today earlier.,0
Left lower lobe retrocardiac consolidation is unchanged.,0
Small bilateral pleural effusions and/or pleural thickening is stable.,0
There is no overt CHF.,0
IMPRESSION: Left lower lobe retrocardiac opacity consistent with pneumonia.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ampicillin Attending: Chief Complaint: Melena .,0
Major Surgical or Invasive Procedure: Upper endoscopy .,0
"History of Present Illness: 78-year-old woman with history of multiple sclerosis, hypertension, transferred from Hospital with GIB after reporting near syncope and dark maroon stools at nursing home, is now being transferred out of the MICU.",1
Patient reports one episode of black stool the evening of .,0
"EMS notes suggest that she had syncope, possible stroke-like symptoms and appeared cyanotic and SOB.",0
"Pt denies hematochezia, N/V, abdominal pain, chest pain, palpitations, lightheadedness or increased fatigue.",0
Uses aspirin and ibuprofen on a daily basis at home.,0
"While at Hospital, SBP was in the 80s and Hct was 20.",0
NG lavage was not performed.,0
"Pt got 2 units of noncrossmatched blood, 3 L of NS and was transferred because Norward had no available ICU bed.",0
"In the ED, BP was 115/56 and HR was 90.",0
NG lavage revealed coffee grounds that cleared with 1 L of NS.,0
Guaiac positive on exam with melena.,0
Hct had appropriately bumped to 29.,0
Admitted to the MICU for further management.,0
Patient underwent an EGD on that showed clotted old blood in the fundus with a single cratered bleeding 8mm ulcer in the proximal second part of the duodenum.,0
She received 2 units pRBCs for Hct 26.5; post-transfusion Hct was 30.2.,0
Transferred to floor for further management.,0
Past Medical History: Multiple Sclerosis ?,1
CAD-pt denies history and not on any cardiac meds HTN Glaucoma Depression .,0
Family History: Mother had heart problems.,0
"Physical Exam: VS: T 97.2, 131/55, 72, 97%RA GEN: Elderly woman lying in bed in NAD, awake, alert HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2.",0
"CHEST: Resp were unlabored, no accessory muscle use.",0
"ABD: Soft, NT, ND, no HSM EXT: No c/c/e SKIN: No rash .",0
Pertinent Results: ADMISSION LABS: WBC-14.5 Hgb-10.0 Hct-29.5 MCV-94 Plt Ct-149* Neuts-90.3 Bands-0 Lymphs-4.7* Monos-4.8 Eos-0.1 Baso-0.1 Glucose-132 UreaN-53 Creat-0.6 Na-145 K-4.2 Cl-114 HCO3-23 Albumin-2.8 Calcium-7.1 Phos-3.9 Mg-1.9 10:15AM CK(CPK)-99 cTropnT-0.04 03:59AM CK(CPK)-224 CK-MB-5 cTropnT-0.01 .,0
Hct trend: 10:15AM Hct-29.5 02:12PM Hct-26.5 --> received 2 units pRBC 12:09AM Hct-36.2 11:15AM Hct-30.2 05:30AM Hct-29.4 07:30AM Hct-31.9 .,0
STUDIES: CXR (): Cardiac size is normal.,0
"Some tortuosity of the aorta is present, but there is no evidence of failure or infiltrate.",0
The costophrenic angles are clear.,0
EGD (): Esophagus: Normal esophagus.,0
Stomach: Clotted old blood was seen in the fundus.,0
Duodenum: A single cratered bleeding 8 mm ulcer was found in the proximal second part of the duodenum.,0
A visible vessel was seen after injecting the area with epinephrine.,0
"Blood was seen in the second portion of the duodenum and after careful washing and examination of the area, we were able to identify the area of bleeding.",0
"Once we identified the ulcer, an endoclip was placed successfully and we injected epinephrine.",0
6 1cc Epinephrine 1/ injections were applied for hemostasis with success.,0
Impression: Ulcer in the proximal second part of the duodenum (injection) Blood in the fundus .,0
Brief Hospital Course: Ms. is a 78-year-old woman with history of multiple sclerosis who was transferred from hospital with GI bleed.,1
# GIB: She was transferred to the ICU with an UGI bleed manifested by melena.,0
She was followed by the GI consult service and EGD revealed a bleeding duodenal ulcer that was clipped.,1
She received 2 units of pRBCs on for hematocrit of 26.5.,0
Her hct responded appropriately and she did not require further transfusions.,0
Patient was transferred to the regular medical floor on hospital day #2.,0
Risk factors for PUD include aspirin and ibuprofen use almost daily at home.,0
"Also, her smoking might have worsened the underlying peptic ulcer disease.",0
She was couseled to stop NSAID use and also to quit smoking.,0
She was treated with IV PPI twice daily initially and transitioned to PO.,0
Hct is stable at 31.9 on the day of discharge.,0
Serology for H. pylori is pending at time of discharge.,0
# L Hand swelling: Minimal near an IV in left arm.,0
IV was removed from the left arm and warm compresses applied.,0
"This should be further monitored at the and if no improvement with elevation and warm compresses, consider ultrasound monitoring.",0
"# Leukocytosis: On admission, she had an elevated WBC to 14.5, with left shift, no bandemia.",0
"She denied cough, fever, chills, or dysuria.",0
"WBC at was 7.7, so unclear if leukocytosis is related to transfusion.",0
Leukocytosis resolved and WBC is 8.9 on day of discharge.,0
"# Multiple sclerosis: She complained of frequent spasms from her MS, triggered by movement.",1
Her baclofen dosing was increased from 10mg qHS to .,0
She was continued on her outpatient regimen of diazepam and tolterodine.,0
# HTN: Her outpatient cozaar was initially held in the setting of GI bleed.,0
Once hematocrit was stable she was re-started on her outpatient regimen of cozaar 100mg PO daily.,0
"# CAD: Unclear if h/o CAD, as pt denies and not on cardiac meds.",0
EKG shows TWF on EKG with no old for comparison.,0
CEs negative x 2. .,0
# Depression: Continued her outpatient sertraline.,0
# Glaucoma: Continued her outpatient latanoprost eye drops.,0
# Code status: Full code.,0
"# Dispo: She was discharged to House Rehab Center in , MA.",0
Medications on Admission: MEDICATIONS ON TRANSFER: 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS Continuous at 120 ml/hr Acetaminophen 325-650 mg PO Q6H:PRN Baclofen 10 mg PO HS Diazepam 10 mg PO HS Evista *NF* 60 mg Oral Daily Latanoprost 0.005% Ophth.,0
1 DROP BOTH EYES HS Nicotine Patch 14 mg TD DAILY Pantoprazole 40 mg IV Q12H Sertraline 100 mg PO DAILY Tolterodine 1 mg PO QAM Tolterodine 4 mg PO HS .,0
HOME MEDS: Detrol 1 mg QAM/4 mg QHS Zoloft 100 mg PO QD Baclofen 10 mg PO QHS Diazepam 10 mg PO QHS Evista 60 mg PO QD Cozaar 100 mg PO QD Lumigan gtt .,0
Tolterodine 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)).,0
Tolterodine 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime).,0
Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Diazepam 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime.,0
Raloxifene 60 mg Tablet Sig: One (1) Tablet PO Daily ().,0
Baclofen 10 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Disp:*8 Patch 24 hr(s)* Refills:*2* 10.,0
Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Discharge Disposition: Extended Care Facility: House Nursing & Rehabilitation Center - Discharge Diagnosis: Primary diagnoses: 1)Upper gastrointestinal bleed 2)Leukocytosis .,0
Secondary diagnoses: 1)Multiple sclerosis 2)Hypertension 3)Cardiovascular disease 4)Depression 5)Glaucoma .,1
Discharge Instructions: 1)You were admitted to the hospital for a gastrointestinal bleed.,0
You underwent an upper endoscopy which showed an ulcer.,0
"Therefore, you should avoid taking large amounts of NSAIDs (like Ibuprofen, Motrin, Aspirin)since these medications can cause gastrointestinal bleeds.",0
2)Please take all medications as listed in the discharge instructions.,0
You have been started on a new medication called Protonix to help decrease the acid in your stomach.,0
This will help prevent future bleeds.,0
3)Please schedule a follow-up appointment with your primary care physician 1-2 weeks after being discharged from the hospital.,0
"4)If you experience any fevers, chills, chest pain, shortness of breath, abdominal pain, bloody or black tarry stools, or any other concerning symptoms please seek immediate medical attention.",0
Followup Instructions: Please schedule a follow-up appointment with your primary care physician 1-2 weeks after being discharged from the hospital.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: nonsensical speech Major Surgical or Invasive Procedure: none History of Present Illness: Ms. is aphasic and unable to provide any history, the history is obtained from speaking with the Fire Chief where she works.",0
Ms. is a 75 year-old left-handed woman with an unknown PMH at this time who presents with speech changes.,0
"She was reportedly speaking with a police officer and not making sense on the phone, so the police officer went to see her and was concerned she may be having a stroke.",0
She was not responding to questions appropriately.,0
"After speaking with the fire chief, he notes that he though she has been having having speech difficulties for the past few days, using the wrong words and saying things that were not making sense.",0
"For example, last Thursday, when the fire chief said good morning, she responded ""well its Friday.""",0
"She then had dinner with a friend last night, who also noted that she was not sounding right and were saying things that were not making sense.",0
She also was acting confused last night as she was trying to cut her bread with a fork and a spoon.,0
ROS: unable to obtain from patient due to her aphasia.,0
Past Medical History: none known (patient does not regularly go to PCP) Social History: She lives alone.,0
She was as an administrator in the Fire Dept.,0
"No smoking, ETOH or illicit drug use.",0
Family History: Unable to obtain from patient.,0
"Physical Exam: Physical Exam on Admission: Vitals: T: 98.3 P: 94 R: 20 BP: 234/79 SaO2: 99% RA General: Awake, NAD.",0
"HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: lcta b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, ND, +BS Extremities: warm, well perfused Neurologic: NIH Stroke Scale score was: 6 1a.",0
Level of Consciousness: 0 1b.,0
LOC Commands: 2 (comprehension defeicit) 2.,0
"Motor arm, left: 0 5b.",0
"Motor arm, right: 0 6a.",0
"Motor leg, left: 0 6b.",0
"Motor leg, right: 0 7.",0
"Extinction and Neglect: 0 Mental Status: Awake, alert.",0
Her speech is fluent with frequent paraphasic errors and neologisms.,0
She is able to state her name correctly when asked but otherwise her comprehension is impaired.,0
She has an anomia and is unable to repeat (aside from occasionally being able to repeat a short word).,0
"She is unable to read and unable to write a sentence, though she was able to write her name when asked.",0
Unable to perform remainder of mental status testing due to her aphasia.,0
Cranial Nerves: PERRL 3-->2 mm b/l.,0
She blinks to threat b/l but unable to test VF by confrontation due to aphasia.,0
"Motor: Normal bulk, tone throughout.",0
"Her aphasia limits formal strength testing, but she is able to maintain all extremities antigravity with no deift.",0
Sensory: She grimmaces and withdraws to noxious stimulation throughout.,0
DTRs: Tri Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was extensor bilaterally.,0
Coordination: No intention tremor or dysmetria on FNF.,0
"Physical Exam on Discharge: Vitals:T 99 BP 136/86 HR 62 RR 16 O2 98 RA General: Awake, cooperative, NAD.",0
"Neurologic: -Mental Status: Alert, oriented to self, oriented to hospital, repetition intact for short phrases (""the weather is sunny""--> ""the weather is sun""), unable to repeat /, can name thumb, can read and folllow simple written commands.",0
"When asked to name watch, says she knows what it is but can't say the word.",0
Can follow 1 step commands but unable to follow multistep ones.,0
Able to name a pen.,0
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch.,0
-DTRs: Tri Pat Ach L 1 1 1 1 0 R 1 1 1 2 0 Plantar response was flexor bilaterally.,0
Unable to cooperate with finger to nose testing.,0
-Gait: deferred Pertinent Results: Labs on Admission: 01:04PM WBC-9.6 RBC-4.85 HGB-14.7 HCT-43.3 MCV-89 MCH-30.3 MCHC-33.9 RDW-13.5 04:21AM BLOOD Glucose-175* UreaN-17 Creat-0.8 Na-142 K-3.4 Cl-106 HCO3-27 AnGap-12 04:21AM BLOOD ALT-34 AST-26 AlkPhos-86 TotBili-0.3 10:12PM BLOOD cTropnT-<0.01 04:21AM BLOOD cTropnT-<0.01 04:21AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.2 Mg-2.3 Cholest-247* Relevant Labs: 04:41AM BLOOD %HbA1c-8.7* eAG-203* 04:21AM BLOOD Triglyc-186* HDL-49 CHOL/HD-5.0 LDLcalc-161* Imaging Studies: CTA: 1.,0
"Extensive completed infarction in the left parietotemporal lobe, encompassing more than one-third of the MCA territory.",0
"Hypodensity in the pons is nonspecific, but may represent another focus of infarct.",0
Probable occlusion of the inferior division of the left middle cerebral artery at the bifurcation.,1
Evidence of intracranial atherosclerotic disease in the basilar artery with narrowing of the right supraclinoid artery.,0
"If the patient has no risk factors for malignancy, no follow up is needed.",0
"If there is no prior imaging documenting stability and if the patient has risk factors for malignancy, follow up with dedicated chest CT is recommended in 12 months.",0
"Large territorial infarct involving the left temporal and inferior left parietal regions, consistent with acute/subacute ischemic event, there is no evidence of hemorrhagic transformation or shifting of the normally midline structures.",0
"Multiple scattered foci of high signal intensity identified in the subcortical and periventricular white matter as well as in the pons, thalamus and basal ganglia, consistent with a combination of small vessel disease and lacunar ischemic changes.",0
TTE: The left atrium is mildly dilated.,0
"No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest and with cough.",0
The left ventricular cavity size is small.,0
Overall left ventricular systolic function is normal (LVEF>65%).,0
No cardiac source of embolus identified (cannot definitively exclude).,0
TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage.,0
IMPRESSION: Complex non-mobile artheroma in the throracic aorta and aortic arch.,0
Carotid US: Findings: Duplex evaluation was performed of bilateral carotid arteries.,0
On the right there is intimal thickening seen in the ICA .,0
On the left there is no plaque seen in the ICA.,0
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 88/10, 61/8, 72/13 cm/sec.",0
CCA peak systolic velocity is 92 cm/sec.,0
ECA peak systolic velocity is 163 cm/sec.,0
The ICA/CCA ratio is .96.,0
These findings are consistent with <40% stenosis.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 59/10, 70/13, 64/19 cm/sec.",0
CCA peak systolic velocity is 79 cm/sec.,0
ECA peak systolic velocity is 174 cm/sec.,0
The ICA/CCA ratio is .81.,0
There is antegrade right vertebral artery flow.,0
There is antegrade left vertebral artery flow.,0
Impression: Right ICA <40% stenosis.,0
Labs on Discharge: None Brief Hospital Course: Patient is a 75yo LH woman who has not seen a physician in many years who p/w 5-7 days of difficulty finding words.,0
Pt was brought to from her place of work (fire company) where chief had noted patient was not responding appropriately during conversation.,0
"Of note, pt had been making mistakes with the use of words which has been progressively worsening to the AM of presentation.",0
"Per further questioning of the chief, patient was at dinner the evening prior to admission acting confused, e.g., attempting to cut bread with a spoon and fork.",0
"On exam, pt had fluent speech, but paraphasic errors, word finding difficulty, difficulty with repetition and naming.",0
"#NEURO: On arrival to ED, a code stroke was called.",0
"On imaging, the NCHCT showed a hypodensity that was more consistent with subacute infarct than acute infarct and on CT perfusion studies, there was a complete match, which is also consistent with completed infarct.",0
"For all of these reasons, decision made to not proceed with tPA for subacute L MCA stroke.",0
"Stroke w/u was completed, showed pt has DM II (HbA1c 8.7), HL (LDL 161) and pt was hypertensive to >200 (see below for more details).",0
"TTE with no PFO, no structural , wnl.",0
"TEE showed complex, nonmobile atheroma in the thoracic aorta.",0
"Most likely, infarct was thromboembolic.",0
"For HTN, pt started on metoprolol 25mg as well as lisinopril 30mg qd.",0
"For DM II, started metformin 1000mg PO bid.",0
"For HL, started simvastatin 80mg qd (80mg rather than 40mg in the setting of thoracic atheroma).",0
"Also, pt started on Aspirin 325mg.",0
"(Did consider starting Coumadin for anticoagulation given complex atheroma, but, since it is nonmobile, and no objective evidence that there is a benefit to coumadin over aspirin 325 in this case, decided to continue aspirin).",0
Pt will f/u with Dr. in stroke clinic on d/c.,0
"#CV: On admission, pt SBP was found to be >200 for which she was started on Nicardipine drip.",0
She was then transitioned to oral metoprolol 25mg PO bid and lisinopril 40mg qd.,0
Will likely need further titration of anti hypertensive medications.,0
"ECG with no ichemic changes, troponis neg.",0
"Patient was monitored on telemetry, did not have any arrhythmias.",0
"#ENDO: HbA1c 8.7, started on metformin 1000mg twice daily.",0
Will likely need further titration of anti hyperglycemic agents.,0
TRANSITIONS OF CARE: -Will likely need further titration of anti hypertensive medications.,0
-Will likely need further titration of anti hyperglycemic agents.,0
"-4mm pulmonary nodules on CT; however, no known tobacco abuse history, so unlikely malignancy but should be re-addressed once pt able to answer social history questions -Will need to establish care with PCP /u in stroke clinic with Dr.",1
Aspirin 325 mg PO DAILY 2.,0
Atorvastatin 80 mg PO DAILY stroke secondary prophylaxis (& LDL 161) 3.,0
MetFORMIN (Glucophage) 1000 mg PO BID diabetes&stroke 4.,0
"Lisinopril 40 mg PO DAILY Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: Left MCA ischemic stroke Hypertension Hyperlipidemia Diabetes mellitus II Discharge Condition: Alert, oriented to self, hospital, able to name high frequency objects, able to repeat simple phrases and short words, follows commands, speech fluent.",1
"Discharge Instructions: Dear Ms. , You were admitted to the hospital with difficulty with your speech.",0
Imaging of your brain showed that you had a stroke.,0
"We did many tests and found that you have high blood pressure, high cholesterol, and diabetes.",0
You also had a partial blockage with cholesterol in one of blood vessels.,0
"Most likely, you had your stroke because a part of that cholesterol broke off and blocked a smaller blood vessel in your brain.",0
We started you on medications for these conditions.,0
"It is VERY important that you take these medications on discharge as all of these conditions, especially if untreated, increase your risk of another stroke.",0
It is EXTREMELY IMPORTANT that you establish care with a primary care doctor and see him/her REGULARLY for management of your newly diagnosed conditions.,0
You absolutely MUST do this to prevent further deterioration in your health.,0
"We have made the following changes to your medications: START -Aspirin 325mg daily -Lisinopril 40mg daily -Metoprolol 25mg twice per day -Simvastatin 80mg daily -Metformin 1000mg twice per day After discharge from rehab YOU MUST follow up with Dr. , your new neurologist, and your new primary care doctor.",0
"It was a pleasure taking care of you, we wish you all the best!",0
"Followup Instructions: Department: NEUROLOGY When: TUESDAY at 1:30 PM With: , M.D.",0
Building: Campus: EAST Best Parking: Garage Completed by:,0
8:39 PM CHEST (PA & LAT) Clip # Reason: r/o pna ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with prod.,0
"cough sob REASON FOR THIS EXAMINATION: r/o pna ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, AT 20:35 HOURS.",0
HISTORY: Productive cough and shortness of breath.,0
FINDINGS: Post left pneumonectomy findings are again noted.,0
There is an ill-defined density now projecting in the mid lower right lung in the infrahilar region.,0
A secondary focus of increased density is noted slightly inferior at the right lung base as well.,0
There is slight progression of the interstitial markings throughout the right lung as well with intralobular septal lines identified.,0
No definite effusion or pneumothorax is seen.,0
The mediastinal structures cannot be entirely evaluated post-pneumonectomy.,0
Clips are again identified projecting over the upper left hemithorax.,0
The visualized osseous structures reveal degenerative changes throughout the thoracic spine.,0
There is at least two foci of increased density in the right perihilar and right lung base as detailed above.,0
This is on a background of increased interstitial markings.,0
Diagnostic considerations are broad and include the possibility of infection with milder interstitial edema.,0
The possibility of metastatic disease if the patient has had a primary prior malignancy is also possible with lymphangitic spread accounting for the interstitial abnormalities.,1
Baseline pulmonary edema with confluent edema at the lung bases is also another diagnostic consideration.,0
"If indicated, CT may be of benefit to further evaluate.",0
"8:10 PM CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # Reason: r/o infection Admitting Diagnosis: HYPERGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 30 year old man with cough, fever REASON FOR THIS EXAMINATION: r/o infection ______________________________________________________________________________ WET READ: 8:33 PM no acute cardiopulmonary process.",1
"( , ) ______________________________________________________________________________ FINAL REPORT HISTORY: Cough and fever.",0
"FINDINGS: In comparison with the previous study of this date, there is no change or evidence of acute cardiopulmonary disease.",1
"3:35 PM PICC LINE PLACMENT SCH Clip # Reason: Please reposition existing PICC line placed by IV therapy, Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with PICC line placement, unable to get down into chest vasculature REASON FOR THIS EXAMINATION: Please reposition existing PICC line placed by IV therapy, ______________________________________________________________________________ FINAL REPORT PICC LINE EXCHANGE / REPOSITIONING INDICATION: Malposition of indwelling PICC line, reposition existing PICC line.",0
RADIOLOGIST: Dr. and Dr. performed the procedure.,0
Dr. was the attending radiologist who supervised.,0
A new single-lumen PICC line measuring 54 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 4-French single-lumen PICC line.,0
"Final internal length is 54 cm, with the tip positioned in the SVC.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE As noted in the previous discharge summary, the patient was transferred from the Medical Intensive Care Unit to the general medicine service on .",0
Pulmonary - This remained the only area of active care for the patient during her stay.,0
She required treatment for her severe chronic obstructive pulmonary disease for which she is on two liters of home oxygen.,1
She required four to five liters oxygen to maintain saturation greater than 93%.,0
"She also was maintained on Levaquin throughout her hospital course until her date of discharge, .",0
"Over her hospital course, she was slowly weaned down to her baseline of two liters nasal cannula oxygen on , however, that evening she became anxious and agitated and desaturated on the two liters down to 60% and required increasing oxygen to four to five liters.",0
"Throughout the rest of her hospital course, she required anywhere from four to five liters, occasionally six, and rarely three liters, to maintain adequate saturation.",0
"During the hospital course, the patient also required nebulized treatments with Albuterol and Atrovent.",0
"Attempts were made to space these out to every six hours, however, the patient would become bronchospastic and desaturate to the mid to low 80s on her four to five liters nasal cannula oxygen.",0
"After receiving treatments, the patient would begin to breathe more easily.",0
Her wheezing on examination would decrease and she would begin to move more air and her saturation would come up to the mid to low 90s.,0
Attempts to wean her nebulized treatments were unsuccessful and the patient continued to require them approximately every 3.5 to 4.5 hours through her entire stay until her date of discharge.,0
The patient was also maintained on Levaquin until her date of discharge.,0
The patient was also on Prednisone which was slowly weaned early on and then maintained at 30 mg because the patient showed no improvement in her decreased use of oxygen or decreased use of nebulized treatments and Prednisone was left at 30 mg p.o.,0
"At the time of discharge, it is unclear if this represents a new baseline pulmonary status for this 76 year old woman with severe chronic obstructive pulmonary disease and extensive smoking history or whether with time she will slowly return to baseline of two liters nasal cannula oxygen at home with nebulized treatments and MDIs every six hours.",1
"Also during this time, she was maintained on MDIs of Serevent and Flovent.",0
Cardiovascular - The patient showed no signs of clinical heart failure.,0
"A repeat echocardiogram was not obtained as the patient had no episodes of chest pain, no episodes of tachycardia or other rhythm abnormalities and on clinical examination was not in failure, either left or right sided.",0
The last echocardiogram obtained prior to discharge from transfer from the Medical Intensive Care Unit to the general medicine floor showed an ejection fraction of 40% with clean coronaries.,0
"The presumed diagnosis is a myocarditis which should improve with time, however, repeat echocardiogram was not performed.",0
No other cardiac care was given.,0
The patient was maintained on an ace inhibitor for blood pressure control and remodeling benefits.,0
The patient was not maintained on a beta blocker because of her severe chronic obstructive pulmonary disease.,1
DISPOSITION: The physical therapy team saw the patient and recommended a short term rehabilitation stay.,0
"The patient was screened for short term rehabilitation without response until , when stated they could take the patient and handle her pulmonary issues including monitoring oxygenation and nebulized treatments.",0
The patient has remained approximately stable for the previous ten days requiring four to five liters oxygen nasal cannula per minute and nebulized treatments every 3.5 to 4.5 hours consisting of Albuterol and Atrovent.,0
"Also, the patient was maintained on Serevent and Flovent MDIs during this time.",0
Attempts to wean the oxygen and space out the nebulized treatments were unsuccessful.,0
is aware of this and is ready to accept the patient upon transfer.,0
The patient is aware of this and the patient's son is also notified and the primary care physician arranged the transfer for closer monitoring by Dr. and the patient's primary care team.,0
"The patient was discharged on , to in stable condition with her chronic medical problems.",0
Non Q wave myocardial infarction by troponin leak with clean coronaries on cardiac catheterization.,0
Atrovent MDI two puffs q4-6hours as needed when not taking nebulized treatments.,0
Heparin 5000 units subcutaneous b.i.d.,0
Albuterol nebulizer treatment one nebulizer p.o.,0
q3-5hours as needed for wheezing and hypoxia.,0
Flovent 110 mcg MDI two puffs p.o.,0
Serevent MDI two puffs p.o.,0
"The patient has been treated on Levaquin for two weeks as of , the date of discharge.",0
"The patient was discharged on , to in stable condition with her chronic obstructive pulmonary disease requirements necessitating a short term rehabilitation stay.",1
Dictated By: MEDQUIST36 D: 13:19 T: 13:59 JOB#: cc:,0
2:36 PM CHEST (PORTABLE AP) Clip # Reason: STAT PORTABLE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with REASON FOR THIS EXAMINATION: STAT PORTABLE ______________________________________________________________________________ FINAL REPORT INDICATION: S/P line placement.,0
TECHINIQUE: Portable AP view of the chest without comparisons.,0
FINDINGS: The cardiomediastinum is normal.,0
"There is a right-sided IJ central catheter, with the tip in the mid-SVC.",0
"No focal pulmonary opacities, pleural effusions, or pneumothorax.",0
"IMPRESSION: Right-sided IJ catheter, with the tip in the mid-SVC.",0
"10:08 AM CHEST (PA & LAT) Clip # Reason: R/O infiltrate Admitting Diagnosis: TRACHEOBROCHOMALACIA'/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman s/p flex bronch w/ lavage & tracheobronchoplasty now with increased sputum production REASON FOR THIS EXAMINATION: R/O infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old female status post tracheobronchoplasty, now with increased sputum production.",0
"PA AND LATERAL CHEST: A right IJ line is in unchanged position, extending to the low SVC.",0
"The lungs are better aerated, with decreased atelectasis.",0
"There is chronic rib deformity and lateral pleural thickening on the right, with linear areas of atelectasis in the right mid lung and elevation of the right hemidiaphragm.",1
The left lung is relatively well aerated.,0
There is no appreciable left pleural effusion or pneumothorax.,1
There is no focal consolidation to suggest pneumonia.,0
"Heart size is unchanged, and there is persistent tortuosity of the aorta.",0
There is no pulmonary vascular congestion or edema.,0
No acute osseous abnormality is detected.,0
IMPRESSION: No evidence of pneumonia.,0
"Improved aeration, with persistent post-surgical changes in the right hemithorax including lateral pleural thickening, multifocal atelectasis, and elevated hemidiaphragm",0
1:29 AM CHEST (PORTABLE AP) Clip # Reason: Recheck OGT placement after repositioning Admitting Diagnosis: COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man w/ resp failure/COPD with respiratory failure REASON FOR THIS EXAMINATION: Recheck OGT placement after repositioning ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: OGT placed check position.,1
The tip of the OG tube lies below the diaphragm within the stomach.,0
The position of the tip is not included on the film.,0
The heart remains enlarged the degree of failure however has improved since the prior film of .,1
Bilateral effusions persist and some pulmonary plethera is still seen.,0
IMPRESSION: Nasogastric tube in satisfactory position some improvement in degree of failure since prior film.,0
11:08 PM CHEST (PORTABLE AP) Clip # Reason: Old Chest tube site considerable output?,0
increased collect Admitting Diagnosis: UNSTABLE ANGINA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with redo cabg; bleeding REASON FOR THIS EXAMINATION: Old Chest tube site considerable output?,0
"increased collection S/P last film ______________________________________________________________________________ FINAL REPORT HISTORY: 66 y/o man with redo CABG, now with considerable output at the old chest tube site.",0
"AP PORTABLE SUPINE CHEST AT 23:40: Compared to prior study 12 hours earlier, there is no significant change.",0
"There are patchy densities at both bases, left greater than right, with some obscuration of the medial portion of the left hemidiaphragm, indicating fluid.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: /INTERNAL MEDICINE CHIEF COMPLAINT: Status post suicide attempt.,0
HISTORY OF PRESENT ILLNESS: A 33 year-old woman with a history of depression and multiple psychiatric hospitalizations brought to the emergency department because of medication overdose.,0
"The patient states that she was feeling ""pretty good"" after discharge from inpatient psychiatric unit on where she ad been hospitalized for depression.",0
The patient reports two prior suicide attempts as well as many episodes of suicidal ideation.,0
She was discharged on five different psychiatric medications on .,0
"She was apparently feeling better but in the past day began to feel ""the pressure getting better.""",0
She states that on the way to the pharmacy to refill her medications yesterday she got into a disagreement with her husband.,0
"On arriving home she called her therapist who ""was not helpful.""",0
The patient states that she had been thinking about committing suicide for several hours after th disagreement with her husband.,0
"After getting off the phone with her therapist she impulsively took all of her medications, thirty 100 mg Trazodone tablets, 30 of 25 mg nortriptyline tablets, fifteen 20 mg tablets, 45 75 mg Effexor XR and thirty 0.5 mg Klonopin.",0
She then called her therapist back and left a message.,0
Her therapist returned the call and emergency medial services dispatched.,0
In the emergency department the nasogastric tube was placed.,0
The stomach was lavaged and she was given two doses of charcoal.,0
In the emergency department she hemodynamically stable and was able to converse appropriately although she was sedated.,0
The patient reports that she did intend to kill herself with that suicide attempt although she was glad that she is alive.,0
"She states that she was ""upset"" but was not depressed.",0
She reports that she is easily angered.,0
PAST PSYCHIATRIC HISTORY: No known psychiatric history until endometrioma removal in 4/.,0
"Since then she has had ongoing depression, suicidality, suicide attempts and multiple psychiatric admission ( and at , and at Hopsital and at ).",0
"History of intentional overingestion of pills, and two suicide attempts by hanging (with a curtain and with a belt of a rope) while on the inpatient unit.",0
No history of violence to other people.,0
"Currently being treat at by , 13, and Dr. , 32 and attending day treatment at The Center since discharge from Hopsital.",0
"PAST MEDICAL HISTORY: Asthma, status post left ovarian endometrioma removal in , endometriosis.",0
Head injury as child with loss of consciousness after go-kart accident.,0
Second head injury with loss of consciousness when working for EMS (was hit in the head by something on the truck).,0
Her primary care physician is .,0
"MEDICATIONS ON ADMISSION: Trazodone 200 mg q.h.s., 220 mg q.d., Effexor XR 225 mg q.d., Klonopin 0.5 mg b.i.d., nortriptyline 50 mg q.d.",0
FAMILY HISTORY: Brother with depression and alcohol abuse.,0
"Father status post traumatic brain injury and then ""diagnosed with bipolar disorder and schizophrenia.""",0
SOCIAL HISTORY: Born and raised in .,0
Finished two semesters of college.,0
Is an unemployed computer programmer.,0
Moved to two years ago and has been married for two years.,0
"Denies alcohol, drug and cigarette use.",0
One older brother and one younger brother both in .,0
Reports the biggest past stressor was having to put her vols asleep ten years ago due to potential threats to other and neighbors.,0
REVIEW OF SYSTEMS: States she is nauseated but all other symptoms negative.,0
"PHYSICAL EXAMINATION: On arrival to the emergency department temperature 98.6, heart rate 90s, blood pressure 110/60, O2 saturation 100% on room air.",0
In general a young woman who is alert and conversant but this is waxing and with somnolence.,0
"Head, eyes, ears, nose and throat: normocephalic, atraumatic, pupils equal, round and reactive to light 4 to 3 mm.",0
Chest clear to auscultation bilaterally.,0
"Cardiovascular: regular rate and rhythm, no murmur, rubs or gallops.",0
"Abdomen soft, nontender, nondistended, positive bowel sounds.",0
"Extremities: the right upper arm is edematous but nonpitting, nontender, otherwise without edema.",0
Mental status examination is assessed by psychiatry on .,0
Patient sedated/somnolent but able to open eyes and respond to verbal stimuli.,0
Speech is soft and slowed but not slurred.,0
"Thought process is goal directed, occasionally tangential.",0
Thought content intermittent suicidal ideation with wishes to be dead but with no clear plan to harm self in hospital.,0
No auditory hallucinations or visual hallucinations.,0
Oriented to self and place and date.,0
Able to name five past presidents.,0
Object naming three of three immediately and at five minutes.,0
"LABORATORY VALUES: On WBC 6.8, hemoglobin/hematocrit 11.2/33.1.",0
"Differential neutrophils 78.9, lymphocytes 15.9, monocytes 3.5, eosinophils 0.8.",0
"On WBC 7.2, hematocrit 30.7, platelets 282 on , and 217 on .",0
"On sodium 137, potassium 4.4, chloride 98, CO23, BUN 11, creatinine 0.8, glucose 117.",0
"ALT 19, AST 20, LD 161, alkaline phosphatase 85, amylase 64, total bilirubin 0.3, lipase 21, calcium 7.6, phosphate 2.3, magnesium 1.8, lithium less than 0.2.",0
"Serum toxicology screen was negative on and on for aspirin, ethanol, acetaminophen, benzodiazepines, barbiturates, tricyclic antidepressants.",0
The urine was also negative.,0
Urine culture final no growth.,0
Chest x-ray : lungs are clear.,0
"Electrocardiogram #1: normal sinus rhythm, 91 beats per minute, interval 0.14/0.08/0.466, prolonged QT interval, no ST wave changes.",0
"Electrocardiogram #2: 94 beats per minute, interval 0.15/0.08/0.460.",0
"On electrocardiogram: Normal sinus rhythm at 86 beats per minute, normal axis, PR 0.16 seconds, QRS 0.086 seconds, QT/QTC 398/441 milliseconds (stable).",0
HOSPITAL COURSE: Impression and plan: A 33 year-old woman with a past medical history of depression and multiple suicide attempts who attempts to the emergency department status post polysubstance overdose.,0
Although patient reports having taken large amounts of pills the toxicology screen was negative including for tricyclics and for benzodiazepines.,0
"Therefore, it is not clear the exact amount of medications that she took.",0
It is very likely that she took much less than she remembers having done so.,0
Se was initially transferred from the emergency department to the Medical Intensive Care Unit where she was monitored for 1 1/2 days.,0
She was somnolent there but was arousable and oriented and had vital signs that were stable.,0
On the patient was transferred to he floor where she became increasingly less somnolent and she was able to walk around the room and even to take a shower by herself.,0
Of note of her laboratory studies is that she is anemic to the low 30s.,0
Iron studies will be sent and the anemia can be followed as an outpatient.,0
She received intravenous fluids but otherwise her medications were held and she was only given Tylenol p.r.n.,0
She currently is awaiting transfer to an inpatient psychiatric bed when a bed become available.,0
Dictated By: MEDQUIST36 D: 11:26 T: 13:23 JOB#:,0
Height: (in) 65 Weight (lb): 133 BSA (m2): 1.66 m2 BP (mm Hg): 134/60 HR (bpm): 80 Status: Inpatient Date/Time: at 10:55 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
RIGHT VENTRICLE: The right ventricular cavity is mildly dilated.,0
There is moderate mitral stenosis.,1
TRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen.,0
Overall left ventricular systolic function is appears normal.,0
The right ventricular cavity is mildly dilated with probably normal systolic function.,0
Moderate mitral stenosis with annular fibrosis/calcification.,1
Grossly normal LV systolic function.,0
5:01 AM CHEST (PORTABLE AP) Clip # Reason: evaluate pleural effusions Admitting Diagnosis: NEC PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with pancreatitis and recurrent pleural effusions.,1
REASON FOR THIS EXAMINATION: evaluate pleural effusions ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old male with pancreatitis and recurrent pleural effusions.,1
"PORTABLE CHEST: Right PICC, endotracheal tube, and small bore feeding tube remain in unchanged and adequate position.",0
"There are persistent bilateral layering pleural effusions, not appreciably changed from one day prior.",1
There is likely resultant bibasilar atelectasis.,0
No new focal opacity to suggest pneumonia.,0
Stable hilar and cardiomediastinal contours with upper lobe vascular prominence but no pulmonary edema.,0
IMPRESSION: No change in moderate bilateral pleural effusions.,1
"3:31 PM CT CHEST W/O CONTRAST Clip # Reason: evaluate mediastinal mass Admitting Diagnosis: RESPIRATORY FAILURE;CHRONIC OBSTRUCTIVE PULMONARY DISEASE Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with mediastinal mass on CXR concerning for aortic aneurysm, please evaluate REASON FOR THIS EXAMINATION: evaluate mediastinal mass No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old female with mediastinal mass on chest x-ray, concerning for aortic aneurysm.",1
TECHNIQUE: CT of the chest without IV contrast.,0
CT OF THE CHEST: The ET tube is in good position.,0
There is no evidence of axillary lymphadenopathy.,0
The widening of the mediastinum seen in the chest radiograph is secondary to large mediastinal lymphadenopathy.,0
Two largest one are located in the prevascular space and measure 2.0 x 1.8 cm (image ) and 4.5 x 2.2 cm (series 400B/image 16).,0
"Another mildly enlarged lymph node is seen in the precarinal region and measures 1.5 x 1.2 cm (series 2, image 24).",0
These lymph nodes are worrisome for metastatic disease or lymphoma.,0
There is a left subclavian central line with the tip in the SVC.,0
There is a tiny pericardial effusion.,0
The ascending aorta is of normal size.,0
The aortic arch is calcified.,0
There is no evidence of aortic aneurysm.,0
Examination of the lung windows demonstrates a moderate left pleural effusion with associated atelectasis.,0
There are emphysematous changes of the lungs.,0
There is a somewhat spiculated ground-glass lung nodule in the right upper lobe measuring 8-9 mm (image ).,0
Another noncalcified nodule is seen on the right upper lobe (image ).,0
There are several other more linear opacities throughout the lung likely representing atelectasis or scarring.,0
Limited images of the upper abdomen demonstrate a JJ tube.,0
There is a hypodense area within the left kidney likely representing a simple cyst.,0
The adrenal gland is probably within normal limits.,0
"There is a tiny nodular density adjacent to the right adrenal gland, which measures 9 mm, is of unclear significance.",0
Widening of the mediastinum secondary to lymphadenopathy.,0
"This is worrisome for malignancy including primary lung cancer, metastatic disease or lymphoma.",0
Two noncalcified pulmonary nodules that are slightly concerning.,0
(Over) 3:31 PM CT CHEST W/O CONTRAST Clip # Reason: evaluate mediastinal mass Admitting Diagnosis: RESPIRATORY FAILURE;CHRONIC OBSTRUCTIVE PULMONARY DISEASE Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont) 3.,1
"Overall, the findings could be further evaluated with a PET/CT when the patient is stable.",0
Moderate left pleural effusion with associated atelectasis.,0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion/Tamponade Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with CAD s/p CABG.,1
Please pager ordering PA with abnormalities.,0
REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade ______________________________________________________________________________ FINAL REPORT HISTORY: CABG postoperative study.,0
PORTABLE CHEST RADIOGRAPH: There has been interval median sternotomy and mediastinal clips indicative of the patient's interval CABG surgery.,0
The endotracheal tube tip is in satisfactory position at the thoracic inlet approximately 7 cm from the carina.,0
There is a right IJ line with its tip in the distal SVC.,0
There is an NG tube whose tip is poorly visualized.,0
It is seen at least to the level of the distal esophagus.,0
Mediastinal drains and left-sided chest tubes are noted.,0
The appearance of the mediastinum is consistent with postoperative change.,0
There is atelectasis at the left base.,0
NG tube tip position was discussed via telephone with on .,0
NG tube not confidently visualized below diaphragm.,0
Additional radiograph following repositioning of external structures may be helpful.,0
3:56 PM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: LIVER FAILURE;ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with respiratory distress.,1
"FINDINGS: As compared to the previous radiograph, the Dobbhoff tube has been pulled back.",0
The tip of the tube now projects over the gastroesophageal junction.,0
"Otherwise, the radiographic appearance is grossly unchanged.",0
The size of the cardiac silhouette is at the upper range of normal.,0
Unchanged extent of bilateral basal parenchymal opacities.,0
No evidence of larger pleural effusions.,0
8:36 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"size of pleural effusion, CHF evaluation.",0
"Admitting Diagnosis: POST OPERATIVE BLEEDING ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with shortness of breath, s/p attempted R thoracentesis.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath.,0
Status post attempted right thoracocentesis for known pleural effusion.,0
COMPARISON: Prior chest radiograph from at around 10 a.m. and chest CT performed the same day at 3:15 p.m.,0
TECHNIQUE AND FINDINGS: A portable frontal chest radiograph was obtained in upright position.,0
"The cardiomediastinal silhouette is unchanged, with multiple sternotomy wires and prosthetic heart valve.",1
Left-sided pacemaker and its two leads are unchanged as well.,0
The right basilar pleural effusion appears grossly unchanged or minimally worsened as compared to yesterday.,0
No free air is seen under the diaphragm.,0
CONCLUSION: Relatively stable appearance as compared to yesterday.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: dyspnea and confusion Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a yoF w/ a h/o dementia, s/p head trauma and SDH/SAH (in ), is a long term nursing home and presents from the with dyspnea and confusion.",0
"At the labs and a u/a, urine cx were obtained and the patient was started on levaquin 500mg IV x 1.",0
"She was noted to have a HR of 112, RR of 26, RA O2 sat of 74% and 91% on 2L NC.",0
"In the ED, initial vs were: P 126 BP 160/palp R 42 O2 sat 99%.",0
"During her ER stay she rec'd cipro for a +u/a, duonebs and aspirin.",0
"Her RR improved to 30, her HR improved to 84, T was 98.8 and O2 sat was 100% on 3L NC.",0
The ER discussed with the cardiology fellow on call the slightly elevated troponin and given her age and h/o SAH / SDH she was thought not to be a candidate for anticoagulation but to use aspirin only.,0
"The patient has been DNR/DNI for at least 5 years, when in the ER her daughter had reversed her code status and per the ER staff her daughter was very clear about the reversal.",0
Anemia of chronic disease 5.,1
History of urinary tract infection.,1
Contracture of Left upper extremity.,0
"Social History: lives at , nonverbal at baseline.",0
"HCP is daughter in , phone # .",0
"Family History: NC Physical Exam: Vitals: T: 98.6 axillary BP: 150/100 P: 90 R: 34 O2: 98% on 4L O2 General: moaning / grunting continuously, able to answer questions but answering inconsistently HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, difficult to assess JVP Lungs: poor inspiratory effort and non cooperative, inspiratory ronchi at least way up bilaterally.",0
and due to grunting during expiration expiratory sounds are difficult to hear.,0
No evidence of pneumonia or overt CHF.,0
CT head (): Preliminary Report !,0
No acute intracranial process MR is more sensitive in the detection of acute stroke .,0
CTA chest (): Preliminary Report !,0
No PE Mild patchy opacifications both lobes raise poss of infectious process No effusions Vasc including coronary artery calcs GWlms Brief Hospital Course: The patient is a yoF long term nursing home pt with dementia who presents from the with dyspnea and confusion.,0
# Tachypnea: The patient was initially tachypneic to the mid 40s in the ED.,0
"Upon arrival to , she was breathing more comfortably at a rate of 30.",0
Initially noted to have wheezes on exam and be tachycardic.,0
"CXR was unremarkable, and no acute cardiopulmonary process was noted.",0
CTA chest w/o PE or other reason for respiratory distress however she has slight bibasilar opacities.,0
Given that she is dehydrated it is possible her respiratory distress is related to pneumonia and obstructive airway disease.,1
She has an unknown smoking history and her daughter was for collateral information.,0
"Given she had wheezes, she was given atrovent nebs q6h, albuterol nebs q6h.",0
"As patient with possible infiltrates on CTA, low grade temp at , respiratory distress and leukocytosis, she will be treated for nosocomial pneumonia with cefepime for 8 days.",1
A sputum sample was not able to be obtained for sputum culture.,0
Final read on CXR and chest CTA pending on discharge.,0
# Confusion: This altered mental status was most likely secondary to respiratory distress and UTI.,0
UA in the nursing home was reportedly positive.,0
"Upon arrival to , daughter, patient's mental status returned to baseline.",0
"Patient will be treated with cefepime for 8 days for possible pulmonary infections, and UTI.",0
CT head was negative for any intracranial pathology.,0
Urine culture was pending on discharge.,0
# UTI: Patient had a positive u/a at the and was started on levaquin.,0
Per report she has cultures pending there.,0
"Given that patient has a history of proteus resistant to cipro (in ), quinolone was changed to cefepime (for PNA as above).",0
She will be discharged with 8 day course of cefepime.,0
# Leukocytosis: Likely related to urinary tract infection and possible pulmonary infections.,1
Blood culture and urine cultures were pending on discharge.,0
"# Elevated troponin: In the setting of sinus tach w/ PACs, hypertension, tachypnea so likely related to demand, especially since MB not elevated but small NSTEMI is also a possibility.",0
At this point she is symptom free.,0
Troponin trended down from 0.22 to 0.21.,0
EKG was unchanged from her prior studies.,0
"Given her h/o SAH and SDH, age, as well as likely demand, anticoagulation was held off.",0
Patient should discuss the pros and cons of starting aspirin therapy with her primary care doctor.,0
"# Elevated BUN, dehydration: Patient was given 1L normal saline after coming to ICU, and her BUN and creatinine trended down.",0
"# FEN: Patient was seen by speech and swallow, who didn't note aspirations but couldn't rule out micro-aspiration unless a video swallowing study is done.",0
"As patient has been tolerating POs at the nursing home, a video swallowing study is deferred.",0
# Prophylaxis: Patient was on subutaneous heparin tid for DVT prophylaxis.,0
# Code: Full (discussed with daughter).,0
"Patient was DNR/NRI, but daughter reversed the order in the .",0
We confirmed with daughter on the status.,0
"# Communication: Patient's daughter: in , phone # .",0
We attempted to contact daughter and granddaughter prior to discharge however couldn't reach either of them.,0
Medications on Admission: erythromycin ophthalmic 0.5% 0.5 in TID multivitamin daily Tylenol 325 mg 2 tab(s) Q6h prn MiraLax - 17 g once a day Colace sodium 60 mg/15 mL 30 mL once a day (at bedtime) Discharge Medications: 1.,0
Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 7 doses.,0
Colace 60 mg/15 mL Syrup Sig: Two (2) PO at bedtime.,0
Miralax 17 gram/dose Powder Sig: One (1) PO once a day.,0
Tylenol 325 mg Tablet Sig: Two (2) Tablet PO q6h prn as needed for fever or pain.,0
Multivitamin Tablet Sig: One (1) Tablet PO once a day.,0
Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic three times a day.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary diagnoses: - Urinary tract infection - Possible pneumonia Secondary diagnoses: - Dementia - Depression - Anemia - Contracture of Left upper extremity Discharge Condition: Stable, afebrile, satting well on room air.",1
"Discharge Instructions: It was a pleasure to be involved in your care, Ms. .",0
You were admitted to because of breathing difficulties and confusion.,0
"You likely have a urinary tract infection, and possibly a lung infection.",1
Your breathing and mental status were back to baseline on discharge.,0
"You will be treated with an IV antibiotic called ""cefepime"" for 8 days.",0
Your medications have been changed.,0
- Cefepime for 7 more days.,0
You already received one dose in the hospital.,0
"If you develop worsening respiratory difficulties, shortness of breath, chest pain, high fevers, or any other symptom that concerns you, please call your doctor or come back to the Emergency Department immediately.",0
"6:46 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: r/o aortic aneurysm Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with Marfan's syndrome and chest + mid-scapular pain last two days, though none now.",1
"REASON FOR THIS EXAMINATION: r/o aortic aneurysm No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Marfan's, mid-scapular pain yesterday, currently no pain.",0
TECHNIQUE: Axial images of the chest and abdomen were obtained before and after the administration of IV contrast.,0
"CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no enlarged mediastinal, hilar or axillary lymph nodes.",0
There is no evidence of aortic dissection.,0
The aortic root is slightly prominent measuring 4.3 cm in greatest dimension.,0
The ascending aorta measures 3.1 cm at the level of the pulmonary artery.,0
The pulmonary artery and its branches are unremarkable.,0
"The heart is normal in size, there are no pericardial or pleural effusions.",0
Lung windows demonstrate no evidence of consolidation or pneumothoraces.,0
"CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There are multiple well defined cystic lesions throughout the liver, the largest one in the right lobe measures 4.7 x 3.3 and is consistent with a cyst.",0
"A few of the lesions are too small to characterize, they likely also represent cysts.",0
"The gallbladder, pancreas, spleen, adrenals and both kidneys are normal.",0
Loops of small bowel and large bowel are unremarkable.,0
The visualized portions of the bladder are unremarkable.,0
"Sagittal reformations again demonstrate no evidence of aortic dissection or aneurysm, there is slight prominence of the aortic root.",0
Findings were discussed with cardiothoracic surgery at the time of the exam.,0
"Impression: No evidence of aortic dissection, mild dilatation of the aortic root.",0
", 4:34 AM CHEST (PORTABLE AP) Clip # Reason: evidence of cardiopulmonary process Admitting Diagnosis: SOB ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with hypoxia REASON FOR THIS EXAMINATION: evidence of cardiopulmonary process ______________________________________________________________________________ PFI REPORT Small right pleural effusion causing hazziness in right lower lung.",0
New small area of patch opacity in LLL probably due to atelectasis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Bactrim Attending: Chief Complaint: Right shoulder pain, fever Major Surgical or Invasive Procedure: Intubation .",0
Urethral dilatation for foley placement .,0
: Right shoulder MRI IMPRESSION: 1) Tendinosis in the distal supraspinatus and infraspinatus tendons without evidence of tearing.,1
"2) Edema in the medial aspects of the supraspinatus and infraspinatus muscles without associated atrophy, which is nonspecific.",0
: Thoracic spine MRI IMPRESSION: Multilevel degenerative disease with at least moderate spinal canal narrowing as above.,0
No abnormal signal within the cord.,0
Study is severely limited due to patient motion artifact.,0
"However, given the absence of abnormal T2 signal in the disc spaces or within the vertebral bodies, osteomyelitis is considered unlikely.",0
Abd US IMPRESSION: Unremarkable abdominal ultrasound.,0
"No evidence of cholecystitis, cholangitis, or focal mass lesion identified.",0
No fluid collection or source of MRSA identified.,0
No obvious vegetations are seen.,0
"Compared with the prior study (images reviewed) of , LV function may have improved.",0
Video speech and swallow () FINDINGS: Oropharyngeal swallowing evaluation was performed today in collaboration with speech and swallow pathologist.,0
"The thin liquid, nectar thick, pureed, and of cookie were administered.",0
There were moderate defects with decreased bolus control and premature spillover of thin and thick liquids to the valleculae and piriform sinuses.,0
"There was a decreased high laryngeal excursion, laryngeal valve closure, and only partial epiglottic deflection.",0
There was mild-to-moderate deep penetration that occurred during the swallow with both thin and nectar thick liquids.,0
"However, though barium was seen on the vocal cords, no aspiration below the vocal cords was definitively demonstrated.",0
IMPRESSION: A moderate dysphasia with deep penetration to thin and nectar thick liquids.,0
Shoulder XRAY No fracture or dislocation is detected.,0
No bony destructive changes are seen.,0
No obvious soft tissue abnormalities are appreciated.,0
Minimal degenerative changes of the acromioclavicular joints are present.,0
No aortic dissection or pulmonary embolism.,0
"Trace bilateral pleural effusions, decreased from the prior study.",0
Unchanged compression deformities of the thoracic spine .,0
CT Head IMPRESSION: No acute intracranial hemorrhage.,0
No change compared to the prior study.,0
"History of Present Illness: Pt is an 81 yo priest w/ h/o CAD s/p MI, HTN, DM2, who p/w altered mental status, R shoulder pain x 5d and fever spike to 99.9 at home.",1
"He had apparently had worsening shoulder pain for five days, wincing when the shoulder was touched.",0
"Pt initially treating shoulder pain at w/ ASA, heat pack per his PCP.",0
", noted to have altered MS changes by his , he was brought to ED.",0
"In , pt noted to be febrile to 101.9, other VSS.",0
"Labs notable for WBC 14.2, lactate 2.4.",0
"While in the ED, he became increasingly hypertensive, up to the 230's systolic, difficult to control with a NTG-gtt and eventually became increasingly hypoxic.",0
"There was questionable seizure activity, and the patient was intubated for acute respiratory failure.",1
"At this point, he underwent CTA showing no PE, dissection, or pulmonary abnormality, as well as no soft tissue or osseous abnormalities that could explain his shoulder pain.",0
"He also received ceftriaxone, metronidazole, vancomycin, and furosemide 40mg IV x 1. .",0
"Past Medical History: -HTN -DM2 -Hypercholesterolemia -CAD with 4 prior MIs, prior PTCA, s/p CABG in with LIMA to LAD, SVG to D2/Om3, SVG to RCA; cath with stent to SVG-RCA, 40%LMCA lesion, patent LIMA-LAD, diffusely disease LCX.",0
-Bladder outlet obstruction and BPH -Multiple prior UTIs -Depression -Tardive dyskinesia -Anxiety -status post TKR .,1
Lives in facility at JP.,0
History of tobacco in the past.,0
No alcohol or IVDU history.,0
His niece is his HCP.,0
"Physical Exam: t 100.0 (rectal), bp 135/72, hr 87, rr 17, spo2 98% Vent- A/C 600/5/14/1.00 peak 25/plateau 14 gen- sedated, intubated; non-acutely-ill appearing heent- anicteric, op with mmm cv- rrr, s1s2, no m/r/g; cabg scar pulm- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no cyanosis/edema, warm dry, full dp pulses bilat nails- no clubbing, no pitting/color changes/indentations neuro- sedated, not following commands, perrl, mae .",0
Pertinent Results: 03:20PM BLOOD WBC-14.2*# RBC-5.40 Hgb-16.8 Hct-46.3 MCV-86 MCH-31.1 MCHC-36.2* RDW-14.8 Plt Ct-166 03:21AM BLOOD WBC-17.6* RBC-5.59 Hgb-17.0 Hct-47.7 MCV-85 MCH-30.4 MCHC-35.7* RDW-14.6 Plt Ct-164 05:34AM BLOOD WBC-9.3 RBC-5.14 Hgb-15.3 Hct-44.9 MCV-87 MCH-29.8 MCHC-34.1 RDW-14.6 Plt Ct-199 .,0
03:20PM BLOOD Glucose-261* UreaN-14 Creat-0.9 Na-131* K-3.5 Cl-92* HCO3-27 AnGap-16 12:20PM BLOOD Glucose-153* UreaN-21* Creat-1.0 Na-135 K-3.6 Cl-96 HCO3-27 AnGap-16 05:34AM BLOOD Glucose-142* UreaN-33* Creat-0.8 Na-140 K-4.0 Cl-101 HCO3-30 AnGap-13 .,0
03:20PM BLOOD CK(CPK)-69 03:20PM BLOOD cTropnT-<0.01 11:55PM BLOOD CK(CPK)-261* 11:55PM BLOOD CK-MB-3 cTropnT-<0.01 03:21AM BLOOD CK(CPK)-102 03:21AM BLOOD CK-MB-4 cTropnT-0.06* 12:20PM BLOOD CK(CPK)-109 12:20PM BLOOD CK-MB-4 cTropnT-0.02* .,0
"Brief Hospital Course: Pt is a 81 yo man with PMH CAD s/p MI, HTN, DM2, who p/w altered mental status, R shoulder pain x 5d and fever.",1
"#Respiratory failure -- Given overall story, normal initial CXR, lack of presenting respiratory complaints, pre- and post-intubation CXR's, and post-intubation CTA, it seems the most likely diagnosis was acute pulmonary edema secondary to a hypertensive emergency.",1
"He has known depressed systolic function and MR and likely could not tolerate the elevated afterload, causing sudden fluid back-up into the pulmonary tree.",0
"This scenario is further supported by his rapid improvement (in terms of o2 sats, abg, and post-intubation cxr) as the positive-pressure ventilation likely dropped both his preload and afterload.",0
"There was probably a modest contribution from his RUL pneumonia, seen on the next day's CXR as well.",0
"Other possibilities, such as aspiration and PE were excluded his post-intubation CTA.",0
No known history of obstructive lung disease and was moving air well on exam.,0
"On the second day of admission, he was easily reduced to minimal ventilatory settings and then extubated with the use of a nitroglycerin drip to control both preload and afterload.",0
"A moderate diuresis was He did quite well afterwards, quickly being weaned down from a 70% face-mask to 4L NC with good o2 saturations.",0
On the floor he was satting in the mid 90s on room air and did not have any further respiratory difficulties.,0
He was found to have a RUL pneumonia (likely MRSA).,0
Will continue furosemide 40mg PO.,0
#CHF -- Pt seems to have experienced acute pulmonary edema as above.,0
"Has baseline systolic dysfunction, last EF was 30-40%, and current EF on after acute exacerbation was 50-55%.",0
"Continued on lisinopril, metoprolol for afterload reduction and isosorbide dinitrate for afterload/preload reduction.",0
Arrempted to keep balance -500cc per day.,0
"HTN -- Unclear cause of sudden elevation in ED, possibly to pain, confusion, anxiety.",0
Better controlled on the floor with no issues in terms of hypertension.,0
"Fever/leukocytosis -- Although it's of unclear etiology, clinically the only presenting symptom was his right shoulder pain.",0
"ID work-up in ED included: CSF negative, CXR with RUL pneumonia, blood cxs positive for MRSA (last +bcx was on ), 3/4 bottles with MRSA, urine culture negative.",0
ID consulted while in house.,0
"Shoulder MRI did not show any evidence of osteo, and neither did thoracic MRI.",0
RUQ ultrasound and repeat echo did not show a source.,0
The plan is to treat him for four weeks (started should end vancomycin course on ).,0
"He will need weekly CBC, LFT, BUN/Cr, Vanc trough, which should be faxed to Dr. (ID fellow) at (.",0
"#Right shoulder pain -- As above, main clinical sx.",0
"#MS changes -- Likely underlying infectious process, possibly pain.",0
He was mentating well on the floor.,0
Haldol was given as needed for agitation.,0
#CAD -- No evidence of active ischemia on ECG or by cardiac enzymes.,0
Pt on numerous cardiac meds.,0
MI was ruled out with enzymes.,0
"Con't asa, clopidogrel, atorvastatin, metoprolol.",0
He had multiple episodes of chest pain while in house with negative ECGs.,0
The pain was reproducible on palpation and likely secondary to sternotomy scar.,0
# DM: Pt on glyburide as outpt.,0
He was kept on an insulin sliding scale while in house and his glyburide should be restared once at the rehab facility.,0
(He was taking glyburide 5 mg po qd).,0
# Anxiety/OCD: Pt on numerous anxiolytics.,0
# BPH: Patient had urethral dilatation by GU and foley was left in place for duration of his hospital stay.,0
He should have his Foley in place on discharge to the rehab facility.,0
He has an outpatient follow up with Dr. on (from URology) for a voiding trial.,0
He was started on Flomax and continued his Proscar while in house.,0
# FEN: Video speech and swallow done in house.,0
"Recommended nectar prethickened liquids Please crush PO meds, assist patient with feeding.",0
"Cue patient to swallow every bites/sips, and cute patient to clear cough and swallow every bites.",0
"# PPX: SC heparin, ppi .",0
# Code status: Presumed full .,0
# Dispo: To rehab facility.,0
# PCP (Gershegorn ) Medications on Admission: Lisinopril 20 mg PO DAILY (Daily).,0
Finasteride 5 mg PO DAILY (Daily).,0
Folic Acid 1 mg PO DAILY (Daily).,0
Glyburide 5 mg PO DAILY (Daily).,0
Clopidogrel 75 mg Tablet PO DAILY Hydrochlorothiazide 25 mg PO DAILY Furosemide 40 mg PO BID Aspirin 325 mg PO DAILY (Daily).,0
"Atorvastatin 10 mg PO DAILY Isosorbide Mononitrate 240 mg PO HS Trazodone 50 mg PO HS Metoprolol Tartrate 25 mg PO TID Nitroglycerin 0.3 mg Sublingual PRN Bisacodyl 10 mg Tablet, PO DAILY (Daily) as needed.",0
Ferrous Sulfate 325 (PO DAILY (Daily).,0
Multivitamin PO DAILY Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops TID Docusate Sodium 100 mg PO BID Lorazepam 0.5 mg PO Q4-6H (every 4 to 6 hours) as needed.,0
Clonazepam 0.5 mg PO BID Fluvoxamine 50 mg PO TID Mirtazapine 15 mg PO HS Pantoprazole 40 mg PO Q24H Discharge Medications: 1.,0
Fluvoxamine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
"Release 24HR Sig: One (1) Capsule, Sust.",0
Release 24HR PO HS (at bedtime).,0
Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for chest pain.,0
Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed.,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical (2 times a day) as needed.,0
Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): Continue through .,0
Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Discharge Disposition: Extended Care Facility: Discharge Diagnosis: .,0
MRSA bacteremia: You have a bloodstream infection with MRSA (a resistant bacteria).,0
"You need treatment with Vancomycin intravenously for at least four weeks (Started on , need to continue through ).",0
Flash pulmonary edema: You had a sudden increase in fluid in your lungs because of your high blood pressure.,0
You need to keep your blood pressure under control.,0
"Discharge Condition: Good Discharge Instructions: Please call your PCP if you have high fevers, chills, chest pain uncontrolled with nitro.",0
"Followup Instructions: Dr. , urologist, as an outpatient for a voiding trial.",0
You will be discharged with a Foley in place.,0
"- ; Tuesday, @ 8:15, , , surgery specialty .",0
"Dr. , ID specialist will follow up on Mr. labs, to be drawn by Rehab facility.",0
"They should include a weekly CBC, LFTs, BUN/Cr and Vanc trough.",0
They should be faxed to ( .,0
Dr. of ID will follow up with him in clinic prior to antibiotic completion on @ 10am.,0
"9:54 AM CHEST (PRE-OP PA & LAT) Clip # Reason: END STAGE LIVER DISEASE Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man here for liver transplant REASON FOR THIS EXAMINATION: rule out effusion, infiltrate, pulmonary edema ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Preoperative evaluation before liver transplantation.",1
Mediastinal contours and position are unremarkable.,0
The right pleural effusion is small to moderate and is new with adjacent lung atelectasis.,1
The effusion also enters the major right fissure.,0
IMPRESSION: New right pleural effusion.,1
This effusion is most probably related to ascites in this patient with known liver disease.,1
"LINE PLACEMENT Clip # Reason: postop film- contact NP # if abnormal Admitting Diagnosis: CAD ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman s/p cabg x5 REASON FOR THIS EXAMINATION: postop film- contact NP # if abnormal ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 56-year-old woman status post CABG, evaluate for abnormality.",0
AP CHEST X-RAY: The heart is moderately enlarged.,0
A Swan-Ganz catheter is noted with its tip in the right main pulmonary artery.,0
Bilateral chest tubes are in satisfactory position.,0
Post-CABG changes are noted with six intact sternal wires.,0
IMPRESSION: No change since one hour ago.,0
10:15 AM CHEST (PORTABLE AP) Clip # Reason: s/p dophoff placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 50F w/R basal ganglion IPH REASON FOR THIS EXAMINATION: s/p dophoff placement ______________________________________________________________________________ FINAL REPORT HISTORY: Dobbhoff placement.,0
FINDINGS: The Dobbhoff tube and nasogastric tube have their tips in the antral region.,0
"1:50 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Rule out obstruction, free air - DO NOT DO LATERAL FILM PLEA Admitting Diagnosis: HYPOGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with sepsis and dilated bowel on CXR - DO NOT DO LATERAL FILM PLEASE REASON FOR THIS EXAMINATION: Rule out obstruction, free air - DO NOT DO LATERAL FILM PLEASE ______________________________________________________________________________ FINAL REPORT PORTAL AP CHEST INDICATION: Sepsis and dilated bowel.",1
"FINDINGS: Comparison made to , 08:05.",0
"Endotracheal tube remained in place but the cuff is noted to be overinflated, and the tube is angled towards the right aspect of the trachea.",0
ETT tip is roughly 5 cm above the carina.,0
"Nasogastric tube remains in place, but has been pulled back since prior exam, with the tip now in the mid esophagus.",0
"Pulmonary edema has worsened in the interval, now moderate.",0
"Lung volumes remain low, and there is moderate bibasilar atelectasis as well.",0
There is no sizeable pleural effusion.,0
"Multiple dilated loops of bowel in the upper abdomen, are now seen throughout.",0
Surgical clips in the left upper quadrant are unchanged.,0
There is no sign of free intraperitoneal air.,0
No sign of free intraperitoneal air.,0
"Endotracheal tube cuff overinflated, recommend ET tube repositioning as catheter is also angled towards the right aspect of the trachea.",0
"Nasogastric tube has been withdrawn, with catheter tip now in the mid esophagus.",0
Recommend advancement at least 10 cm for more optimal positioning within the stomach.,0
These findings were discussed via telephone with Dr. at 15:30 hours on .,0
11:09 AM BABYGRAM (CHEST ONLY) Clip # Reason: bpd incr.,0
o2 requirement ______________________________________________________________________________ MEDICAL CONDITION: Infant with bpd incr.,0
o2 requirement REASON FOR THIS EXAMINATION: bpd incr.,0
o2 requirement ______________________________________________________________________________ FINAL REPORT INDICATIONS: Infant with BPD and increased oxygen requirement.,0
FINDINGS: The endotracheal tube is at the carina.,0
Nasogastric catheter is at the gastroesophageal junction.,0
The lungs show no significant change in appearance of BPD.,0
No areas of infiltrate are noted.,0
The bones and soft tissues are unremarkable.,0
The abdominal gas pattern is normal in the portion that is seen.,0
6:23 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval NGT Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man status post NGT.,0
REASON FOR THIS EXAMINATION: eval NGT ______________________________________________________________________________ FINAL REPORT INDICATION: Status post NG tube.,0
COMPARISONS: Radiograph obtained 3 hours earlier.,0
"The NG tube has been retracted, and the side hole is now located near the GE junction.",0
"The PICC line stellate has been removed, and the PICC line is located with the tip at the mid SVC.",0
A right internal jugular vein central catheter has been removed in the interval.,0
Bilateral pleural effusions are stable.,0
Prominent air-filled bowel loops are seen in the abdomen.,0
IMPRESSION: Retraction of NG tube with the side hole near the GE junction.,0
Removal of right IJ catheter.,0
CHF with stable bilateral pleural effusions and stable consolidations.,0
6:01 PM CHEST (PORTABLE AP) Clip # Reason: need to evaluate acute change in status - ?edema ?infection Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with tachypnea REASON FOR THIS EXAMINATION: need to evaluate acute change in status - ?edema ?infection ?additional process?,1
"______________________________________________________________________________ FINAL REPORT HISTORY: Tachypnea, acute change in status.",1
"Question edema, infection, additional process.",1
"Compared with at 16:20 p.m., the overall appearance is similar.",0
"Again seen is cardiomegaly, with upper zone re-distribution, diffuse vascular blurring, and relatively diffuse alveolar opacity in the mid and lower zones, with fluid tracking along the minor fissure and probable small bilateral effusions, all compatible with CHF.",1
"In addition, there is underlying bibasilar collapse and/or consolidation, similar in appearance.",0
The oro- or nasogastric tube is coiled over the stomach and extends beyond the inferior edge of this film.,0
"A dual-lumen right-sided catheter overlies the right heart, unchanged.",0
"A right-sided PICC line is present -- the tip is obscured by the other catheter, but is probably unchanged and probably lies at the level of the mid SVC.",0
"IMPRESSION: CHF with pulmonary edema and bilateral effusions, together with bibasilar collapse and/or consolidation, similar in appearance to .",1
"Status: Inpatient Date/Time: at 08:07 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
"8:31 AM CHEST (PORTABLE AP) Clip # Reason: eval for change Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: year old woman with new pacer REASON FOR THIS EXAMINATION: eval for change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: New pacemaker, evaluation for interval change.",0
"FINDINGS: As compared to the previous radiograph, the signs suggestive of pulmonary edema have minimally decreased in severity.",0
Unchanged presence of bilateral pleural effusions.,0
The placement of the pacemaker in the left pectoral region and the course of the pacemaker leads is unchanged.,0
12:35 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: please evaluate for pathology Field of view: 45 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman ped vs. truck REASON FOR THIS EXAMINATION: please evaluate for pathology No contraindications for IV contrast ______________________________________________________________________________ WET READ: JWK WED 1:50 PM 1.,0
Small left hemothorax and multiple left sided rib fractures.,1
Stranding in the anterior and lateral left subcutaneous tissues.,0
Hyperdense foci in the superior anterior subcutaneous tissues may represent blood vessels or foci of extravasation.,0
Delayed images were not obtained.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old female struck by truck.,0
"TECHNIQUE: MDCT axial images through the chest, abdomen and pelvis were obtained following the administration of IV Optiray contrast with multiplanar images; no delayed imaging was obtained.",0
There is a small amount of layering left hemothorax.,1
Minimally displaced rib fractures are seen of the left second through seventh ribs anterolaterally.,1
There is moderate stranding within the anterior and lateral chest wall and enlargement at the left pectoralis muscle.,0
"Small foci of high attenuation are seen in anterior to the sternum (series 2, image 19) which may represent vessels or subcutaneous foci of active extravasation (delayed imaging was not performed).",0
"CT ABDOMEN WITH IV CONTRAST: 8 mm hypodensities within segments , VIII, and VI of liver likely represent hemangiomas or cysts.",0
"The gallbladder, spleen, pancreas, adrenal glands and left kidney are unremarkable.",0
A 13-mm cyst is seen within the upper pole of the right kidney.,0
There are no enlarged mesenteric or retroperitoneal lymph nodes and no free fluid or free air within the abdomen.,0
CT PELVIS WITH IV CONTRAST: Streak artifact from left hip prosthesis limits evaluation of the pelvis.,0
There is asymmetric enlargement of the right piriformis muscle may represent intramuscular hematoma.,0
There is no free fluid in the pelvis and no enlarged pelvic or inguinal lymph nodes.,0
Mild stranding is seen adjacent to the left lateral thigh.,1
Osseous structures demonstrate a sclerotic focus in the right iliac .,0
There is mild grade 1 anterolisthesis of L5 on S1 and a chronic appearing right-sided pars fracture.,0
(Over) 12:35 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: please evaluate for pathology Field of view: 45 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,0
Small left-sided hemothorax and left second through seventh rib fractures.,1
Moderate amount of stranding within the left anterolateral chest and body walls.,0
Small foci of hyperdensity within the superior anterior left thoracic subcutaneous tissues represents vessel vs. foci of extravasation.,0
No delayed images were obtained.,0
2:55 PM CT HEAD W/O CONTRAST Clip # Reason: assess for LP feasibility Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with strep pneumo.,0
"REASON FOR THIS EXAMINATION: assess for LP feasibility No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Strep pneumonia, consider LP.",0
"There is no midline shift, mass effect or hydrocephalus.",0
There is atherosclerotic disease within the vertebral and internal carotid arteries.,0
4:50 PM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: mri/mra according to stroke protocol ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with acute left hemiplegia REASON FOR THIS EXAMINATION: mri/mra according to stroke protocol ______________________________________________________________________________ FINAL REPORT INDICATION: Acute left hemiplegia.,0
TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were obtained.,0
Diffusion weighted scans are provided.,0
3D time of flight MR angiography of the circle of was performed.,0
Multiplanar reformatted images and source image data are reviewed.,0
FINDINGS: There are no previous studies for comparison.,0
Examination is limited due to the patient's inability to lie still for some of the imaging sequences.,0
"However, there is abnormally increased diffusion signal in the posterior limb of the right internal capsule and this indicates acute infarction.",0
There is also a small amount of increased signal in the medial right temporal lobe.,0
"MR angiography reveals absence of normal flow signal in the right internal carotid artery, from the level of the skull base and extending through the siphon.",1
Abnormally decreased flow is also present in the right middle cerebral arterial branches.,0
"Both anterior cerebral arteries are identified, and normal flow signal is present within the left middle cerebral artery.",1
Faint flow is identified in the right proximal anterior and middle cerebral arteries (A1 and M1 segments) but not in the sylvian branches.,0
"There is flow in the vertebral arteries, the basilar artery and the proximal posterior cerebral arteries.",1
IMPRESSION MRI of the brain and MRA of the COW: Acute right internal capsule infarction with concern for large middle cerebral arterial territory at risk due to absence of flow in the right internal carotid artery and markedly diminished flow in the right middle cerebral arterial distribution.,1
"5:20 AM CHEST (PORTABLE AP) Clip # Reason: r/o evolving infiltrate Admitting Diagnosis: CODE SPESIS ______________________________________________________________________________ MEDICAL CONDITION: 52M ESLD s/p failed R subclavian and successful R IJ line placement --s/p repositioning of R IJ REASON FOR THIS EXAMINATION: r/o evolving infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: History of end-stage liver disease, status post right subclavian and successful right IJ placement.",0
"PORTABLE AP CHEST RADIOGRAPH: ETT, NG tube and central venous line are unchanged in position.",0
There is bilateral diffuse opacities consistent with worsening multifocal pneumonia.,0
There is slight hyperinflation of the ET tube cuff.,0
The cardiac and mediastinal contours are stable in appearance.,0
There is probable superimposed congestive heart failure.,1
The soft tissue and osseous structures are unchanged.,0
IMPRESSION: Bilateral opacities consistent with multifocal pneumonia.,0
"10:03 AM CHEST (PORTABLE AP) Clip # Reason: respiratory wheezing crackles/new onset Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with SAH with PA line REASON FOR THIS EXAMINATION: respiratory wheezing crackles/new onset ______________________________________________________________________________ FINAL REPORT HISTORY: SAH with PA line, wheezing and crackles that are new.",1
"CHEST, SINGLE AP PORTABLE SUPINE VIEW The pleural and parenchymal findings are in great part unchanged compared with .",0
There is a cage-like device superimposed over the right hilum.,0
Review of the electronic record describes placement of a filter in the for thrombus in the left subclavian axillary and brachial veins on .,0
"Alignment is unchanged compared with , although the filter was not seen on the x-ray.",0
Again seen is the right subclavian PIC line.,0
It is looped within the vessel.,0
"Compared with , it has advanced into the proximal immediately above the filter.",0
There is a 1 cm rounded lucency superimposed over a right hilar vessel -- question confluence of shadows.,0
Attention to this area on followup films is recommended.,0
"Upper zone redistribution, interstitial edema, and small bilateral pleural effusions.",0
Underlying infectious infiltrate cannot be excluded.,0
Overall pattern is similar to that seen on .,0
PICC line which is abnormally looped and has now advanced into the .,0
"Because it is doubled-back, the tip of the line remains in the .",0
Clinical correlation is required regarding possible replacement of this line.,0
Venacaval filter in the proximal .,0
"2:25 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for pulmonary edema, effusion, acute change Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with recent abdominal surgery, continued hypoxia, acutely short of breath REASON FOR THIS EXAMINATION: evaluate for pulmonary edema, effusion, acute change ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: Recent abdominal surgery, hypoxia, pulmonary edema.",1
"Moderate cardiomegaly, partial left lower lobe atelectasis.",0
"No pneumothorax, no larger pleural effusions.",0
4:04 PM CHEST (PORTABLE AP) Clip # Reason: baseline CXR Admitting Diagnosis: INTRA CRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with 3rd ventricle lesion in ICU for close monitoring REASON FOR THIS EXAMINATION: baseline CXR ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
"INDICATION: Elderly male patient with third ventricular lesion, now in intensive care unit for close monitoring.",0
"Baseline chest examination, evaluate for CHF or infiltrates.",0
FINDINGS: AP single view of the chest with the patient in supine position demonstrates moderate cardiac enlargement with prominence of the left ventricular contour to the left.,0
Generally widened and elongated thoracic aorta is identified.,0
This combination is consistent with longstanding systemic hypertension and arteriosclerosis.,0
"There is some mild degree of perivascular haze on the bases, but no advanced interstitial or alveolar edema can be identified.",0
The diaphragmatic contours are free and so are the lateral pleural sinuses.,0
No signs of acute parenchymal infiltrates are present.,0
There exists no prior chest examination or records available for comparison.,0
"IMPRESSION: Moderate cardiomegaly, no signs of advanced CHF or acute infiltrates.",0
"5:59 PM KNEE (AP, LAT & OBLIQUE) BILAT Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman s/p ped struck REASON FOR THIS EXAMINATION: trauma ______________________________________________________________________________ FINAL REPORT TWO VIEWS LEFT KNEE, TWO VIEWS RIGHT KNEE, AT 18:15 HOURS.",0
FINDINGS: LEFT KNEE: There are large osteophytes in all three knee compartments.,0
Amorphous calcification is seen in the joint space consistent with chondrocalcinosis.,0
No joint effusion is evident.,0
Soft tissue calcification is identified medially along the length of the distal femur.,1
RIGHT KNEE: There is an oblique nondisplaced fracture of the proximal fibula.,1
"Osteophytes are seen in all three knee compartments, more severely at the patellofemoral compartment.",0
"Again as noted on the left, there is amorphous calcification consistent with chondrocalcinosis, indicating underlying pseudogout.",0
No joint effusion is noted.,0
Nondisplaced oblique fracture of the proximal right fibula.,1
"Extensive tricompartmental osteoarthritis of both knees, worse on the left.",0
There is chondrocalcinosis consistent with underlying pre-existing pseudogout.,0
8:27 AM CHEST (PORTABLE AP) Clip # Reason: evaluate effusion Admitting Diagnosis: AORTIC VALVE DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with AS REASON FOR THIS EXAMINATION: evaluate effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Status post recent aortic valve repair for stenosis.,1
COMPARISON: Prior chest radiograph from yesterday at 14:45.,0
"Since yesterday, there has been removal of the Swan-Ganz catheter, with only its outer sheath left in the right internal jugular vein, with its tip at the level of the confluence of the brachiocephalic veins.",0
The endotracheal tube and nasogastric tube have also been removed.,0
"Due to lesser inspiration on today's examination, heart size appears relatively stable as compared to yesterday.",0
"There is now new opacity at the left base and in the retrocardiac area, consistent with pleural effusion and/or consolidation/atelectasis.",1
Lamellar atelectasis is also seen in the right perihilar region.,0
No significant pleural effusion is seen on the right side.,1
Multiple sternotomy wires and prosthetic heart valve are again seen.,0
CONCLUSION: New left basilar opacity consistent with pleural effusion and/or atelectasis/consolidation.,1
"Interval removal of the Swan-Ganz catheter, endotracheal tube, and nasogastric tube.",0
10:16 AM CHEST (PRE-OP PA & LAT) Clip # Reason: HEAD MASS;S/P SEIZURE Admitting Diagnosis: HEAD MASS;S/P SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with REASON FOR THIS EXAMINATION: please evaluate for abnormality; pre-op film for stx bx ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 2:04 PM PFI: Mild cardiac enlargement and upper zone redistribution pattern indicative of mild CHF.,0
______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest PA and lateral.,0
INDICATION: Preoperative examination for surgery scheduled .,0
FINDINGS: There is moderate cardiac enlargement.,0
"No typical configuration abnormality is seen; however, the markedly widened and elongated thoracic aorta with some prominence of the left ventricular contour is suggestive of systemic hypertension.",0
"The pulmonary vasculature demonstrates an upper zone redistribution pattern, but there is no evidence of interstitial or alveolar edema.",0
Mild blunting of the posterior pleural sinuses as seen on the lateral view suggests some small pleural effusions.,0
Acute parenchymal infiltrates are not present.,0
"On the next previous chest examination dated , the patient was intubated and an NG tube was identified.",0
The patient is now extubated and the NG tube has been removed.,0
"No new infiltrates are seen, however, the pulmonary vasculature shows now a mild increase of upper zone redistribution compatible with mild degree of left-sided failure.",0
9:27 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"PNA, pleural effusion Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with ALS, persistent fevers, and h/o pleural effusion.",1
"PNA, pleural effusion ______________________________________________________________________________ FINAL REPORT INDICATION: ALS, persistent fever, history of pleural effusion, question pneumonia, pleural effusion.",1
AP UPRIGHT RADIOGRAPH OF THE CHEST: Lungs are clear with the exception of mild retrocardiac atelectasis.,0
"There is no focal consolidation, pleural effusion, or pneumothorax.",1
Heart size and hilar contours are unremarkable.,0
Tracheostomy tube is terminating 1 cm above the carina.,0
Left PICC is terminating in the mid SVC.,0
There is a G tube.,0
A tracheostomy tube terminating 1 cm above the carina.,0
"12:29 PM HAND (AP, LAT & OBLIQUE) BILAT PORT Clip # Reason: eval joints ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with ?multiple septic joints REASON FOR THIS EXAMINATION: eval joints ______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old man with question of multiple septic joints.",0
"BILATERAL HANDS, THREE VIEWS: There are multijoint periarticular erosions with overhanging edges, most prominantly affecting the right 2nd distal interphalangeal joint with extensive resorption of the distal phalanx.",0
"There is extensive soft tissue swelling, may reflect tophi.",0
No subcutaneous emphysema is noted.,0
"IMPRESSION: Extensive multijoint erosive changes with overhanging edges and associated soft tissue swelling, highly suggestive of gout.",0
However it is noted that the extent of resorptive changes are markedly pronounced at the right 2nd DIP joint and coexisting infection can not be excluded.,0
", P. CSURG FA9A 10:16 AM CHEST (PA & LAT) Clip # Reason: assess CT placement, area of consolidation, dilation of neo- Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p EGD, MIE, and Lap J-tube placement REASON FOR THIS EXAMINATION: assess CT placement, area of consolidation, dilation of neo-esophagus ______________________________________________________________________________ PFI REPORT IMPRESSION: Mild bibasilar atelectasis.",0
Admission Date: Discharge Date: Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Difficulty breathing Major Surgical or Invasive Procedure: Radiation sessions for esophageal cancer A-line placement Endotracheal Intubation Central Line Placement History of Present Illness: Fr.,1
"is an 88 year old man with esophageal esophageal and prostate cancer s/p prostatectomy (), severe AS s/p valvuloplasty.",1
"He was admitted from XRT for SOB, hypervolemia.",0
His family states that he has had poor PO intake for the past few weeks odynophagia thought to be to his esophageal CA.,0
He usually is on a regimen of 40mg PO Furosemide .,0
"However, given his poor PO intake and diarrhea this was stopped.",0
After he was noted to be more edematous last week his Furosemide was restarted 40mg daily.,0
He has undergone XRT over the past 2 weeks and has received boluses of NS during each treatment session.,0
He was undergoing XRT today when he was noted to be mildly tachypneic and total body overloaded.,0
Past Oncologic History: Pt was originally diagnosed with prostate cancer and underwent a prostatectomy in .,1
On he was noted to be hypotensive at home and was taken to the hospital where he was found to be severely anemic.,0
He had an EGD and colonoscopy which showed a large mass in the GE junction.,0
Biopsy showed poorly differentiated adenocarcinoma with signet features.,0
He underwent a PET/CAT scan which showed focus at the GE junction.,0
He is currently on Oxaliplatin x 6weeks and Xeloda every other week in addition to XRT.,0
Other Past Medical History: severe AS s/p valvuloplasty ( ranged from 0.8->1.6 per daughter) - Hypertension - multivessel CAD - radical prostatectomy for prostate cancer in - Lymphedema of the left leg following prostatectomy - left inguinal hernia - hiatal hernia - renal calculi - COPD - hypertension - hyperlipidemia.,1
Social History: He is an Armenian priest.,0
He came to the US in .,0
"He has five children, four living.",0
One of his daughters died in the peripartum period after she gave birth to her child.,0
"He has seven grandchildren, five boys and two girls.",0
He recently retired from the priesthood.,0
smoked four to five cigarettes a day for 40 years and quit 20 years ago.,0
Family History: Mother had died of an aneurysm.,0
Sister died when her gallbladder ruptured at age 27.,0
"Physical Exam: GEN: Grossly fluid overloaded Male sitting up in examination chair with mild tachypnea HEENT: EOMI, MMM, sclera anicteric Neck: difficult to ascertain JVP 2/2 neck size CV: distant S1, S2, no m/g/r, RRR PULM: Distant breath sounds, wheezes and crackles noted diffusely ABD: Obese, distended (at baseline), tenderness in epigastric area with palpation, +BS x 4 LIMBS: 2+ edema noted b/l in upper extremities, + edema noted in the LLE to level of knee, 3+ edema noted in the (pt usually has edema L>R following prostatectomy) NEURO: Obtained history with the aid of pt's daughter, x 3, CN II-XII intact.",1
Pertinent Results: Microbiology Results Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.1 <0.5 .,0
"Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- 113 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL .",0
TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES Negative COMMENT: Negative for Heparin PF4 Antibody Test by Complete report on file in the laboratory .,0
5:51 pm BLOOD CULTURE Source: Venipuncture.,0
"**FINAL REPORT ** Blood Culture, Routine (Final ): ACINETOBACTER BAUMANNII COMPLEX.",0
"""Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component"".",0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S .,0
10:28 am SPUTUM Source: Expectorated.,0
RESPIRATORY CULTURE (Final ): SPARSE GROWTH Commensal Respiratory Flora.,0
# REQUESTS ORGANISM IDENTIFICATIONS AND NEGATIVE ROD SENSITIVITIES .,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | KLEBSIELLA OXYTOCA | | AMPICILLIN/SULBACTAM-- <=2 S 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 4 S <=1 S CEFTAZIDIME----------- 8 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S MEROPENEM------------- <=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S .,0
5:21 pm BRONCHOALVEOLAR LAVAGE BRONCH LAVAGE.,0
4:58 pm SPUTUM Source: Endotracheal.,0
1 COLONY ON 1 PLATE.,0
8:42 pm URINE Source: Catheter.,0
**FINAL REPORT ** URINE CULTURE (Final ): YEAST.,0
9:46 am URINE Source: Catheter.,0
Imaging Studies CXR: IMPRESSION: 1.,0
New atelectasis and inflammation probably due to aspiration left lower lobe.,0
"Multiple new predominantly peripherally located nodular opacities since , with new small bilateral pleural effusions, favors an infectious process such as fungal infection or COP remains in the differential diagnosis.",0
Moderate airways disease as manifested by moderate bronchiectasis.,0
"Post-treatment radiation change, predominantly affecting the right middle lobe and lingula.",0
"Component of tracheobronchial collapsibility, not fully assessed on this non-dynamic respiratory phase imaging CT. 4.",0
Area of asymmetric soft tissue involving the aortic arch and descending thoracic aorta likely related to plaque though a component of inflammation from post-treatment is not entirely excluded.,0
Known esophageal cancer as manifested by circumferential esophageal wall thickening at the gastroesophageal junction.,0
Bronchial Washings Brochial washing: ATYPICAL.,0
Rare atypical cells in a background of degenerated bronchial cells and macrophages.,0
"CT chest, abdomen, pelvis IMPRESSION: 1.",0
Changing appearance of peripheral opacities favors cryptogenic organizing pneumonia over fungal infection or other infectious etiologies (such as septic emboli).,1
Bilateral pleural effusion and third spacing inclduing as mild ascites and pronounced scrotal edema are consitent with CHF.,0
Bilateral adrenal fat- adenomas versus myelolipomas.,0
Right hepatic lobe indeterminate lesion may be a cyst or hemangioma.,0
Small hypodensity in the thyroid.,0
Consider obtaining outpatient LFTs and if needed ultrasound.,0
is an 88 year old man with esophageal cancer and aortic stenosis s/p valvuloplasty.,0
He presented to the ICU with respiratory failure.,1
A CXR was performed on as part of a fever work-up and showed new atelectasis and inflammation probably due to aspiration in left lower lobe.,0
He was started on Unasyn 3gm q6 on to cover aspiration which was transitioned to cefepime as prelim sensitivities were resistant to ampicillin.,0
He was then transitioned back to Unasyn on when final sensitivities returned.,0
He had blood cultures and sputum cultures that were positive for Acinetobacter Baumannii.,0
His sputum culture later grew aspergillus and klebsiella.,0
On he had a worsening of his respiratory status.,0
He was transferred to the ICU where he was intubated.,0
"His antibiotics were broadened to vancomycin, meropenem, and eventually voriconazole.",0
He required several liters of fluid to help maintain his blood pressure.,0
He was intermittently placed on pressors.,0
He continued to have fevers despite antibiotic treatment.,0
A CT scan was obtained on to look for an abscess.,0
There was no evidence of an abscess.,0
He had large pleural effusions.,0
He had urine and sputum cultures that both grew out yeast.,0
No further invasive procedures were planned per the goals of care discussed with the family.,0
The ID team was following his hospital course.,0
Respiratory Failure: On initial examination Fr.,1
was grossly overloaded with evidence of edema in the upper and lower extremities.,0
He was diuresed on the floor.,0
His low albumin was thought to be contributing to some 3rd spacing due to a decrease in his oncotic pressures.,0
On the day of transfer to the ICU he was intubated for respiratory distress.,0
"Several weaning trials were attempted, but he required more and more ventilator support throughout the hospitalization.",0
He was unable to be weaned from the ventilator.,0
"A tracheostomy was discussed with the family, but they did not think this was in the goals of his care.",0
"He was briefly started on furosemide in the ICU, but his blood pressure would not tolerate it.",0
Mr. was scheduled to complete his course of XRT on .,0
No treatment was delivered while in the ICU.,0
Malnutrition: Mr. had poor PO intake which was likely related to his esophageal mass which caused him some odynophagia.,1
He received tube feeds in the ICU.,0
Pulmonary Embolus: On review of the CTA from radiology found a subsegmental PE (amended report).,0
He was started on a heparin gtt.,0
underwent a repeat echo which showed his valve area 0.8-1.1.,0
The cardiology service was consulted for assistance in management of his preload.,0
Goals of Care: On admission Fr.,0
was a full code and aggressive treatment was pursued.,0
In the ICU he was intubated on admission.,0
"As his prognosis worsened, his family decided to transition to comfort measures only.",0
He was terminally extubated and passed with his family by his side.,0
Medications on Admission: Diltiazem SR 120mg daily Enalapril 10mg qAM Furosemide 40mg daily (was ) Xeloda 2000mg Prilosec 20mg Colace PRN Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis Sepsis Pneumonia Esophageal Cancer Hypoxic Respiratory Failure Aortic Stenosis Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired,1
", C. NSURG FA11 3:15 AM CT HEAD W/ CONTRAST Clip # Reason: PLEASE PERFORM AT 0400 PRIOR TO AM ROUNDS ON .",0
PLEAS Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with S/P WOUND WASHOUT.,1
S/P CRANI REASON FOR THIS EXAMINATION: PLEASE PERFORM AT 0400 PRIOR TO AM ROUNDS ON .,0
PLEASE R/O INFECTIOUS PROCESS No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No overt findings of intracranial infection status post washout.,0
"3:19 PM BILAT LOWER EXT VEINS PORT Clip # Reason: ?dvt Admitting Diagnosis: ETOH INDUCED CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with sudden drop in o2 sats to 78, increased respiratory rate, longterm bedrest.",1
REASON FOR THIS EXAMINATION: ?dvt ______________________________________________________________________________ FINAL REPORT ULTRASOUND OF THE BILATERAL LOWER EXTREMITIES.,0
HISTORY: 76 year old male with sudden decrease in oxygen saturation and increasing respiratory rate.,0
"FINDINGS: The bilateral common femoral veins, femoral veins, deep femoral veins, greater saphenous and popliteal veins are normal in flow and compressibility.",0
There is normal response to augmentation bilaterally.,0
IMPRESSION: 1) No evidence of deep venous thrombosis involving either lower extremity.,0
"12:04 PM CHEST (PORTABLE AP) Clip # Reason: eval for acute cardiopulm process ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with dyspnea, hypoxia, tachypnea, hx of COPD REASON FOR THIS EXAMINATION: eval for acute cardiopulm process ______________________________________________________________________________ FINAL REPORT INDICATION: 83-year-old female with dyspnea, hypoxia, and tachypnea.",0
"AP PORTABLE CHEST: The lungs remain hyperexpanded, compatible with known history of chronic obstructive pulmonary disease.",1
Diffuse interstitial coarsening is also again noted.,0
"There are eqiovocal superimposed new opacities seen at the bilateral bases, which may reflect atelectasis, though evolving consolidation cannot be excluded.",0
The upper lung zones are well aerated.,0
"There is no effusion, and no pneumothorax.",0
Hilar and cardiomediastinal contours are unchanged.,0
Degenerative changes are again noted in the spine.,0
IMPRESSION: Redemonstration of hyperexpansion and interstitial changes compatible with chronic lung disease.,1
"Equivocal new nodular opacities at the bases, though may be better evaluated by PA and lateral chest radiographs if there is concern for infectious etiology.",0
3:59 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate OG tube Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with pancreatitis s/p intubation REASON FOR THIS EXAMINATION: evaluate OG tube ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.,0
The tube projects over the proximal parts of the stomach and could be advanced by 5 cm.,0
"The parenchymal opacities in both upper lobes, in the retrocardiac area and at the left lung base as well as the pleural effusion on the right are unchanged.",0
Also unchanged is the position of the endotracheal tube and the left-sided venous access line.,0
"8:00 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman with respiratory distress, s/p suicide attempt , aspiration, likely chemical pneumonitis, ARDS.",1
Please assess interval change REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: A 32-year-old female with respiratory distress status post suidical attempt.,0
FINDINGS: AP portable semi-upright view of the chest.,0
There is again noted a left subclavian central line with the tip in the mid-SVC in unchanged position.,0
The NG tube is difficult to visualize.,0
The esophageal probe in the stomach.,0
The cardiomediastinal and hilar contours are unchanged in appearance.,0
There is a moderate increase in lung inflation which could be due to improvement or due to change in ventilatory settings.,0
IMPRESSION: Slight increase in lung inflation could be due to improvement or due to change in ventilatory settings (eg.,0
"3:01 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: Please evaluate for ascites, intrabdominal abscess.",1
"Please o Admitting Diagnosis: ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 67 F with HCV, DM2 presents with worsening ascities despite 2 months of PO lasix and with intermittent fevers.",0
"REASON FOR THIS EXAMINATION: Please evaluate for ascites, intrabdominal abscess.",1
Please only use PO contrast (no IV).,0
"CONTRAINDICATIONS for IV CONTRAST: Increased creatinine ______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old woman with hepatitis C, diabetes, presenting with increased ascites by two months of Lasix and intermittent fevers.",1
TECHNIQUE: Axial MDCT images were acquired from the lung bases to the symphysis pubis following oral contrast.,0
Intravenous contrast was withheld at the request of the referring physician.,0
"COMPARISON: CT thorax, abdomen, and pelvis, .",0
CT ABDOMEN: There has been interval development of small bilateral pleural effusions.,0
"Otherwise, the lung bases appear clear.",0
Visualized portions of the heart and pericardium are unremarkable.,0
Some calcification of the mitral valve is again noted.,0
There has been interval development of moderate amount of ascites.,0
"There is no loculated fluid collection seen, although assessment is somewhat limited due to lack of intravenous contrast.",0
"The liver is small and nodular in contour, consistent with the patient's known cirrhosis.",1
Assessment of the hepatic vasculature and focal lesions is not possible in the absence of intravenous contrast.,0
"The gallbladder is moderately distended and contains dependent high-attenuation material, consistent with small gallstones.",0
"The spleen is not enlarged, measuring 10.5 cm.",0
"Non-contrast examination of both kidneys and both adrenal glands is unremarkable, no hydronephrosis.",0
Non-contrast examination of the pancreas is grossly normal.,0
No bulky porta hepatis or retroperitoneal lymphadenopathy.,0
Oral contrast adequately opacifies the small and large bowel.,0
No abnormal bowel dilatation is seen.,0
"There is mild thickening of the cecal pole (2:56), this was also seen on the prior CT of .",0
CT OF THE PELVIS: The urinary bladder is decompressed with a Foley catheter.,0
The uterus and rectum are unremarkable in appearance.,0
Free fluid extends into the pelvis.,0
There is diffuse anasarca of the subcutaneous tissues.,0
The visualized osseous structures are unremarkable without lytic or sclerotic destructive bony lesions seen.,0
"(Over) 3:01 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: Please evaluate for ascites, intrabdominal abscess.",1
Please o Admitting Diagnosis: ASCITES ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,0
New moderate ascites without loculated fluid collections.,0
New small bilateral pleural effusions and small pericardial effusion.,0
Nodular cirrhotic liver incompletely evaluated on this non-contrast study.,0
Dependent gallstones within the gallbladder.,0
The pertinent findings were discussed with Dr. by telephone at 4 p.m. on .,0
"2:48 PM CHEST (PA & LAT) Clip # Reason: assess size of pleural effusion Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with CAD, ESRD, pleural effusions s/p thoracentesis on .",1
REASON FOR THIS EXAMINATION: assess size of pleural effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP 3:50 PM PFI: Persistent pulmonary edema.,1
Quantification of pleural densities and comparison cannot be performed on these portable examinations.,0
"______________________________________________________________________________ FINAL REPORT CHEST, AP PORTABLE SINGLE VIEW INDICATION: Coronary artery disease and end-stage renal disease, pleural effusions, now status post thoracocentesis on .",1
Assess size of pleural effusion.,1
"FINDINGS: AP single view of the chest has been obtained with patient in semi-erect position, and analysis is performed in direct comparison with a preceding similar study dated .",0
"Previously described findings such as old sternotomy with wires, double-lumen dialysis catheter terminating deep in right atrium, and left internal jugular approach central venous line are unchanged.",0
A previously suspected small right apical pneumothorax cannot be identified anymore.,0
"The lung remains well expanded; however, the previously described marked perivascular haze indicative of pulmonary edema remains.",0
There is a diffuse haze over the lung bases most likely coarse by the bilateral pleural effusions layering posteriorly in patient's semi-erect position.,1
Quantification of fluid in comparison with the two studies cannot be performed.,0
"Grossly, it appears rather unchanged.",0
IMPRESSION: Persistent advanced pulmonary edema.,0
11:18 AM CT HEAD W/O CONTRAST Clip # Reason: interval changes Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman w/ L posterior temporal lobar hemorrhage REASON FOR THIS EXAMINATION: interval changes No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MRAf TUE 5:38 PM PFI: Unchanged large left temporoparietal intraparenchymal hematoma with intraventricular extension.,0
"Stable foci of scattered subarachnoid blood, without evidence of new hemorrhage.",0
"Slight reexpansion of the left frontal , otherwise, no change in mass effect.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Left posterior temporal lobar hemorrhage, evaluate interval change.",1
TECHNIQUE: Contiguous axial sections of the brain without contrast.,0
"FINDINGS: Again seen is a large left temporal/parietal parenchymal hematoma, which is unchanged in size.",0
"The surrounding edema is unchanged, with persistent effacement of the sulci and atrium of the left lateral ventricle.",1
The left frontal has reexpanded since prior study.,0
Unchanged slight narrowing of the left quadrigeminal cistern.,0
Blood within the occipital horns of the lateral ventricles is unchanged.,0
Multifocal subarachnoid hemorrhages are unchanged.,0
The mastoid air cells are well aerated.,0
Mild mucosal thickening of the ethmoidal air cells persists.,0
IMPRESSION: Unchanged large left temporoparietal intraparenchymal hematoma with intraventricular extension.,0
"Slight reexpansion of the frontal of the left lateral ventricle, but stable mass effect more posteriorly.",0
1:12 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o pulmonary embolus Admitting Diagnosis: BRONCHOPLEURAL FISTULA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with shortness of breath; bronchopleural fistula since .,0
REASON FOR THIS EXAMINATION: r/o pulmonary embolus No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Bronchopleural fistula since /.,0
TECHNIQUE: CT of the chest was performed before and after the administration of IV contrast using the CT pulmonary angiography protocol.,0
100 cc of Optiray nonionic contrast was then administered for this examination.,0
Nonionic contrast was given due to patient debility.,0
COMPARISON: Comparison is made to the examination dated .,0
CT CHEST W/O & W/CONTRAST: There is no axillary lymphadenopathy.,0
Multiple mediastinal lymph nodes are present.,0
"There is a 1.2 cm mediastinal lymph node in the AP window, as well as a smaller 9 mm lymph node adjacent to this.",0
"Small precarinal lymph nodes are present, not meeting CT criteria for pathologic enlargement.",0
There is no significant hilar lymphadenopathy.,0
Note is also made of a 1.6 mm nodule in the expected location of the left thyroid gland (incompletely imaged on the 1st couple of slices of this examination).,0
"There is a moderate left-sided pleural effusion, which was only trace in size on the prior examination.",0
A trace right-sided pleural effusion is also slightly larger on today's examination than it was previously.,0
Examination of lung windows demonstrate opacification of the dependent portion of the left upper lobe and lingula.,0
There is dependent atelectasis at the left lower lobe.,0
These are both new findings since the prior examination.,0
Mild peribronchial opacity at the right lower lobe is not significantly changed since the prior examination.,0
"Multiple pleurally-based nodular opacities are seen within both lungs, more in the right upper lobe than in the other lobes of the lung.",0
"Of note, there is a 9 x 13 mm pleurally-based opacity in the right upper lobe, which was slightly less prominent- appearing on the prior examination.",0
"Diffuse prominence of intralobular septae as well as pulmonary veins, predominantly in the upper lobes, is suggestive of pulmonary edema.",0
The packed right posterior chest wall surgical defect is again seen.,0
Multiple midline anterior abdominal staples are present.,0
High density material along the anterior abdominal wall could be from prior abdominal wall repair/omental flap.,0
The remainder of the visualized upper abdominal structures appear unremarkable.,0
(Over) 1:12 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o pulmonary embolus Admitting Diagnosis: BRONCHOPLEURAL FISTULA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) CTA: No evidence of pulmonary embolus.,0
"Coronal and sagittal reformatted images were also obtained, which also failed to demonstrate any evidence of emboli.",0
"Again, the apical pattern of interlobular septal thickening, as well as the left upper lobe dependent consolidation are also well-seen on the reconstructed images.",0
"The thickening of the intralobular septi at the lung apices, associated with ground glass opacity, is particularly apparent using these projections.",0
A tiny amount of ascites fluid is present.,0
"On the noncontrast images, there is a 1.3 x 2.0 cm nodular appearance of the right adrenal gland.",0
Attenuation characteristics on the noncontrast images are insufficient to define adenoma.,0
MRI of the adrenal glands could characterize this more completely if it has not been previously characterized.,0
"Examination of the osseous structures shows rib resections of the right posterior chest wall, as well as recent callus formation and dystrophic bone formation in this region, consistent with prior surgical instrumentation.",0
No evidence of pulmonary embolus.,0
Diffuse interstitial thickening and prominence of the pulmonary venous system is consistent with pulmonary edema.,0
"Opacity along the dependent portion of the left upper lobe, which has developed since the prior examination, is consistent with consolidation from pneumonia or aspiration.",0
Interval development of moderate left-sided effusion.,0
"If this has not been previously characterized, further evaluation could be performed using thyroid ultrasound.",0
"This does not meet CT criteria to be definitively considered an adrenal adenoma, but if further characteriza- tion is required, MRI could aid in differentiation of this finding.",0
"Several mediastinal lymph nodes are present, and AP window lymph nodes measure up to 1.3 cm in short axis.",0
"Right-sided upper lobe subpleural nodule could be related to surrounding atelectasis, but follow up evaluation is recommended.",0
(Over) 1:12 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o pulmonary embolus Admitting Diagnosis: BRONCHOPLEURAL FISTULA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont),0
"9:43 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: ELEV LFT'S Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with hx ovarian cancer s/p colectomy p/w N/V/Abd pain c/w obstruction, elevated bili REASON FOR THIS EXAMINATION: pls evaluate GB ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old female with nausea, vomiting and abdominal pain.",1
FINDINGS: The liver shows no textural abnormalities.,0
Within the left lobe of the liver a cystic area is seen measuring 4.2 x 1.6 x 3.0 cm.,0
There are no solid lesions identified in the liver.,0
There is no biliary dilatation and the common duct measures 0.3 cm.,0
The gallbladder is difficult to visualize.,0
It is contracted and entirely filled with echogenic material and .,0
There are no signs of cholecystitis.,0
The spleen is unremarkable and measures 11.4 cm.,0
A right pleural effusion is seen but no ascites is identified.,0
IMPRESSION: Contracted gallbladder completely filled with sludge and tiny .,0
Height: (in) 62 Weight (lb): 134 BSA (m2): 1.61 m2 BP (mm Hg): 146/80 HR (bpm): 73 Status: Inpatient Date/Time: at 11:00 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%).,0
8:40 AM CHEST (PORTABLE AP) Clip # Reason: Rt IJ swan changed to a triple lumen Admitting Diagnosis: SYMPTOMATIC ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with aaa now hypotensive in unit s/p new IJ swan placement.,1
"REASON FOR THIS EXAMINATION: Rt IJ swan changed to a triple lumen ______________________________________________________________________________ FINAL REPORT AP CHEST, 8:42 A.M., .",0
HISTORY: Hypotensive following AAA repair.,0
"IMPRESSION: AP chest compared to : Lung volumes are lower, and mild pulmonary edema is new.",0
Moderate cardiomegaly and left lower lobe atelectasis are stable.,0
Tip of the right IJ catheter projects over the upper right atrium.,0
LINE PLACEMENT Clip # Reason: s/p left 47cm # Admitting Diagnosis: STEMI ______________________________________________________________________________ MEDICAL CONDITION: year old woman with picc REASON FOR THIS EXAMINATION: s/p left 47cm # ______________________________________________________________________________ FINAL REPORT HISTORY: -year-old female with new left PICC.,0
"COMPARISON: Chest radiographs dating back to , most recent from .",0
PORTABLE AP FRONTAL CHEST RADIOGRAPH: The tip of the new left PICC projects over the expected location of the mid SVC.,0
"There is a stable right lung base opacity and probable small-to-moderate effusion, findings consistent with the history or pneumonia.",0
"However, there is increasing opacification of the left lung base and blunting of the left costophrenic angle, likely a new pleural effusion and associated compressive atelectasis.",0
"However, new left lower lobe aspiration or pneumonia should be considered in the appropriate clinical circumstance.",0
"New left PICC, at the mid SVC.",0
Stable right basilar opacity and probable small effusion.,0
Increasing left basilar opacity and probable new small left effusion.,0
"Differential includes new atelectasis, aspiration or pneumonia.",0
Dr. communicated the PICC line position to (IV RN) at 11:30 am on by telephone.,0
2:01 PM CHEST (PORTABLE AP) Clip # Reason: Collections?,0
Admitting Diagnosis: COLON CA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman s/p sigmoid colectomy with rapid afib and wet cough with desats REASON FOR THIS EXAMINATION: Collections?,1
"______________________________________________________________________________ FINAL REPORT AP CHEST 2:14 P.M. HISTORY: Sigmoid colectomy, rapid atrial fibrillation, question collections.",1
IMPRESSION: AP chest compared to and 27th: Increasing opacification at the right lung base is due in part to persistent right pleural effusion but new atelectasis or aspiration is of concern.,0
Left lower lung shows new mild pulmonary edema.,0
12:30 PM CHEST (PORTABLE AP) Clip # Reason: s/p ct removal ?,0
PTX Admitting Diagnosis: AORTIC VALVE INSUFFIENCY\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with s/p AVR REASON FOR THIS EXAMINATION: s/p ct removal ?,1
PTX ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: AVR.,0
Streaky density at the lung bases consistent with subsegmental atelectasis persists.,0
There is increased density in the retrocardiac area consistent with atelectasis or consolidation as before.,0
The patient is status post median sternotomy and AVR has demonstrated previously.,0
"A nasogastric tube, pulmonary arterial line and Swan-Ganz catheters have been removed.",0
A right jugular sheath remains in place.,0
IMPRESSION: No significant change post-extubation.,0
"9:05 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: please evaluate for obstruction Admitting Diagnosis: SMALL BOWEL OBSTRUCTION;SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with abdominal distension, n/v REASON FOR THIS EXAMINATION: please evaluate for obstruction ______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old female with abdominal distention, nausea and vomiting, here to evaluate for bowel obstruction.",0
"COMPARISON: Abdominal radiographs, last performed on and CT of the abdomen and pelvis performed on .",0
FINDINGS: A single upright and two supine frontal views of the abdomen demonstrate retained oral contrast in the bowel from recent CT. No dilated loops of bowel or air-fluid levels are present.,0
The bowel gas pattern is nonspecific.,0
"No free air is detected; however, the upright film is limited by patient motion.",0
Rounded calcified radiodensities projecting in the right upper quadrant of the abdomen are consistent with calcified gallstones.,0
An IVC filter is in place.,0
The patient is status post bilateral total hip arthroplasty.,0
IMPRESSION: Nonspecific bowel gas pattern with retained oral contrast and no evidence of bowel obstruction or ileus.,0
8:41 PM CHEST (PORTABLE AP) Clip # Reason: assess for ETT placement ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p ETT REASON FOR THIS EXAMINATION: assess for ETT placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post ET tube placement.,0
COMPARISON: Approximately 1 hour earlier.,0
"CHEST, AP PORTABLE: There has been interval placement of an endotracheal tube with the tip approximately 1.9 cm above the carina.",0
The tip of a newly inserted nasogastric tube cannot be definitively visualized.,0
The left heart border and left hilar contour are unchanged.,0
The visualized portions of the lungs are stable in appearance.,0
The soft tissue and osseous structures are unremarkable.,0
IMPRESSION: Tip of endotracheal tube approximately 2 cm above the carina.,0
Tip of nasogastric tube not definitively visualized.,0
Height: (in) 62 Weight (lb): 121 BSA (m2): 1.55 m2 BP (mm Hg): 89/50 HR (bpm): 85 Status: Inpatient Date/Time: at 09:13 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
PULMONIC VALVE/PULMONARY ARTERY: Severe PR.,1
Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %).,0
Severe pulmonic regurgitation is seen.,0
"Compared with the prior study (images reviewed) of , the degree of aortic regurgitation has probably increased.",0
The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation.,1
The degree of stenosis across the valve is probably slightly less (although is calculated as the same).,0
"10:39 AM CHEST (PORTABLE AP) Clip # Reason: eval for ptx Admitting Diagnosis: CONGESTIVE HEART FAILURE\Transcatheter Aortic Valve Implant (TAVI) with Pump Stand-by (CoreValve) ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman s/p ct pull REASON FOR THIS EXAMINATION: eval for ptx ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Status post chest tube, evaluation for pneumothorax.",1
FINDINGS: Right-sided chest tubes have been removed.,0
There is volume loss/infiltrate at both bases.,0
Right IJ line with tip in the SVC is again visualized.,0
LINE PLACEMENT Clip # Reason: Pt.,0
"had a right sided picc line placed,43cm and needs tip co Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with PICC who needs it for antibiotics.",0
REASON FOR THIS EXAMINATION: Pt.,0
"had a right sided picc line placed,43cm and needs tip confirmation please page at with wet read,thanks.",0
______________________________________________________________________________ FINAL REPORT HISTORY: PICC placement.,0
"FINDINGS: In comparison with the study of , there has been placement of a right subclavian PICC line extends to the lower portion of the SVC.",0
Aeration at the left base has improved and the left hemidiaphragm is visible.,0
Incidental note is a gastrostomy tube in place.,0
"10:50 AM CHEST (PA & LAT) Clip # Reason: eval for ptx, interval change on 24 hours water seal Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 59M s/p MVC with persistent PTX, chest tube to water seal am.",1
"REASON FOR THIS EXAMINATION: eval for ptx, interval change on 24 hours water seal ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old male patient status post MVC and pneumothorax.",1
"COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared with the previous study of yesterday.",0
The previously identified right chest tube has been removed.,0
There is probably a small right apical pneumothorax (5%).,1
There is small right pleural effusion and patchy atelectasis at the right lung base.,0
The heart and mediastinum are within normal limits.,0
IMPRESSION: Status post removal of the right chest tube with the remaining tiny right apical pneumothorax (5%).,1
Height: (in) 65 Weight (lb): 162 BSA (m2): 1.81 m2 BP (mm Hg): 136/72 HR (bpm): 82 Status: Inpatient Date/Time: at 14:28 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (tape not available) of .,0
No cardiac source of embolus identified.,0
"Compared with the report of the prior study (tape unavailable for review) of , there is no significant change.",0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: s/p left 45cm picc Admitting Diagnosis: CHOLEDOCHOLITHIASIS\ERCP ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with mutiple med issues requiring iv access REASON FOR THIS EXAMINATION: s/p left 45cm picc ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf TUE 1:48 PM 1.,0
New left PICC ends 5.2 cm beyond the expected cavoatrial junction.,0
This finding was relayed to IV nursing at the time of the study.,0
"Slight interval decrease in the bilateral opacities suggesting a component of her disease included edema, which has decreased.",0
______________________________________________________________________________ FINAL REPORT INDICATION: New PICC line placement.,0
TECHNIQUE: Portable AP upright radiograph of the chest.,0
"COMPARISON: Chest radiograph, most recently at 0312 hours.",0
FINDINGS: Tracheostomy is in appropriate position.,0
New left PICC line ends within the right atrium 5 cm below the expected superior cavoatrial junction.,0
No change to the nasointestinal tube or right PICC line which overlies subclavian vein.,0
Slight improvement in the bilateral opacities suggests decreased edema with persistent heterogeneous consolidative and infiltrative opacities.,0
Cardiac silhouette is unremarkable with the exception of residual pneumomediastinum.,0
"7:47 PM PORTABLE ABDOMEN Clip # Reason: eval for interval changes and line placement Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with R MCA stroke now with new NGT placement REASON FOR THIS EXAMINATION: eval for interval changes and line placement ______________________________________________________________________________ FINAL REPORT HISTORY: 73-year-old man with right MCA stroke, now with new NG tube placement.",0
SUPINE ABDOMEN: There is a normal bowel gas pattern without evidence of obstruction.,0
Nasogastric tube tip is appropriately positioned in the stomach.,0
No intraperitoneal free air is identified.,0
Degenerative changes of the lower lumbar spine are observed.,0
Osseous and soft tissue structures are otherwise unremarkable.,0
There appears to be a small left pleural effusion and associated atelectasis.,0
Satisfactory placement of nasogastric tube with the tip in stomach.,0
2:00 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ASSESS DOBHOFF PLACEMENT.,0
Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: year old man with new dobhoff tube REASON FOR THIS EXAMINATION: assess position ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old male with new Dobbhoff feeding tube.,0
Single AP chest radiograph compared to 5 hours prior shows placement of a feeding tube with tip probably in the proximal duodenum.,0
"Otherwise, mild pulmonary vascular congestion and probable atelectatic changes in the left lung base shows no short term change.",1
5:53 AM CT HEAD W/O CONTRAST Clip # Reason: eval interval change - PLEASE PERFORM AT 6AM Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with R parieto-occipital ICH REASON FOR THIS EXAMINATION: eval interval change - PLEASE PERFORM AT 6AM No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old woman with right parietooccipital intracranial hemorrhage.,0
"NON-CONTRAST CT HEAD: The large right posterior cerebral hemorrhage now measures approximately 7.2 x 4.4 cm, slightly increased in size from 6.8 x 4.6 cm with associated edema.",1
"There is approximately 6 mm shift of midline structures, unchanged.",0
"There is slightly increased uncal herniation which is mild, but evolving.",0
The hemorrhage extends into the ventricular system with blood layering along the occipital of the left lateral ventricle as well as blood within the third ventricle.,0
A small hyperdense extra-axial hematoma extending from the focus of intraparenchymal hemorrhage is again noted.,0
IMPRESSION: Large right posterior parenchymal hemorrhage with intraventricular and subdural extension demonstrates slightly increased mass effect with a suggestion of early uncal herniation.,0
"7:29 AM CHEST (PORTABLE AP) Clip # Reason: cxr in intubated pt with recent MI and COPD exacerbation Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE ______________________________________________________________________________ MEDICAL CONDITION: 75M s/p reintubation, replacement of NGT REASON FOR THIS EXAMINATION: cxr in intubated pt with recent MI and COPD exacerbation ______________________________________________________________________________ FINAL REPORT INDICATION: Status post reintubation, replacement of NG tube.",1
Recent MI and COPD exacerbation.,0
"SUPINE AP CHEST: The endotracheal tube is seen, with the tip located approximately 5 cm from the carina.",0
A left subclavian central venous catheter is unchanged in position.,0
"A nasogastric tube is seen, with the tip overlying the stomach.",0
The heart does not appear enlarged.,0
"Once again, there is patchy opacification of the right lung field, consistent with an infectious process, that is unchanged compared to yesterday.",0
"The left lung field is relatively lucent, consistent with the patient's emphysema.",0
A nipple shadow was seen on the right.,0
IMPRESSION: Unchanged appearance of the chest since one day ago.,0
Alveolar opacification of the right lung consistent with pneumonia is unchanged.,0
9:41 AM CT HEAD W/O CONTRAST Clip # Reason: eval ICH Admitting Diagnosis: PROSTHETIC VALVE ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man w ICH s/p AVR REASON FOR THIS EXAMINATION: eval ICH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Followup intracranial hemorrhage status post AVR.,1
TECHNIQUE: Non-contrast CT of the head.,0
FINDINGS: Again there is a left intraparenchymal hemorrhage centered within the frontoparietal region with adjacent small pneumoencephalus from prior evacuation.,0
There is a similar amount of surrounding extensive vasogenic edema.,0
There is a slight improvement in compression of the left lateral ventricle with decreased amount of focal dilatation of the temporal of the left lateral ventricle.,0
There is no new intracranial hemorrhage.,0
"The small extra-axial collection overlying the left parietal lobe is unchanged containing a small amount of air, secondary to recent craniotomy.",0
IMPRESSION: Slight improvement in trapping of left temporal .,0
Otherwise minimal change compared to prior study.,0
"7:43 AM CHEST (PORTABLE AP) Clip # Reason: pna resolution, chf, intubated Admitting Diagnosis: THROMBOCYTOPENIA;ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with MDS, now with fevers, intubated, resolving pneumo on previous films, now more hypoxic post bronch.",0
"please assess interval change REASON FOR THIS EXAMINATION: pna resolution, chf, intubated ______________________________________________________________________________ FINAL REPORT INDICATION: Myelodysplastic syndrome, fever, hypoxia.",0
FINDINGS: Single portable AP view of the chest shows improvement in left lower lobe aeration.,0
"Small bilateral pleural effusions persist, as do bilateral lower lobe consolidations.",1
"Cardiomegaly and increased pulmonary vascular markings suggest cardiac failure, which is unchanged.",1
"Endotracheal tube, right-sided central venous line, and nasogastric tube remain in place.",0
IMPRESSION: Improved left lower lobe aeration.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 62 year old male who was admitted to the Intensive Care Unit for urosepsis.,0
He has a complex past medical history.,0
He was recently discharged from after decortication of bilateral fibrothoraxes and subsequently required placement of a tracheostomy.,0
He was being intermittently ventilated at rehabilitation and had reportedly been doing well.,0
"Approximately one to two days prior to admission, he developed a fever to 104.0 F., tachycardia with heart rate to the 150s and hypotension with systolic blood pressure to the 60s.",0
"He was brought to the Emergency Department and was placed on the MUST protocol as his white blood cell count was 43,000, he was febrile and hypotensive.",0
A right internal jugular central line was placed in the Emergency Department and he was given initially five liters of intravenous fluids and was placed on Levophed to support his blood pressure into the mid 90s.,0
"He was given an initial one dose of Timentin through a peripheral intravenous in his foot and was later put on ceftriaxone, Levofloxacin and Vancomycin after a central access was obtained.",0
"On admission, he was found to have an elevated creatinine of 2.7 with a prior baseline as high as 1.6.",0
He was also found to have a positive troponin of 0.26 with flat CKs.,0
Initial infectious work-up was positive for urinalysis with over 50 white blood cells and he was admitted to the Intensive Care Unit for suspected urosepsis.,1
Bilateral fibrothoraxes status post right lung and diaphragm decortication and tracheostomy placement in of this year.,0
History of a Roux-en-Y reconstruction after a laparoscopic cholecystectomy in .,0
History of knee replacement and chronic leg pain.,0
Benign prostatic hypertrophy with a history of prostatitis.,1
ALLERGIES: Reportedly has hallucinations with Vicodin.,0
SOCIAL HISTORY: The patient recently admitted to Rehabilitation.,0
He previously lived at home with his wife.,0
Colace 100 mg twice a day.,0
Lopressor 75 mg twice a day.,0
Lasix 40 mg twice a day.,0
Ibuprofen 400 q. eight p.r.n.,0
Levofloxacin 750 mg q. day.,0
Pepcid 70 mg twice a day.,0
Albuterol / ipratropium inhalers q. six hours.,0
Neutra-Phos packets three times a day.,0
Subcutaneous heparin 5000 units three times a day.,0
Aspirin 325 mg q. day.,0
"PHYSICAL EXAMINATION: Upon arrival to the , his temperature was 95.4 F.; blood pressure 130/62 on Levophed; heart rate 72 to 79; on assist controlled 500 at a rate of 12 with 5 of PEEP, over breathing the vent 10 to 12.",0
"On examination, he was sedated, ventilated, minimally responsive.",0
Head and Neck examination: Nonicteric.,0
Lungs were clear to auscultation anterior and laterally.,0
Cardiac examination was regular rate and rhythm.,0
"Abdomen had positive bowel sounds, nontender, nondistended, no rebound noted.",0
Extremities with trace lower extremity edema bilaterally.,0
Neurologic examination: The patient was minimally responsive; otherwise a nonfocal examination.,0
Skin with no obvious rashes.,0
"LABORATORY: Initially significant for a white blood cell count of 43.4, hematocrit 31.2, platelets 369.",0
"Initial Chem-7 notable for a sodium of 140, potassium 3.0, chloride 89, bicarbonate 43, BUN and creatinine 70 and 2.7, glucose of 125.",0
"Initial cardiac enzymes notable for a troponin of 0.26, but a CK of 18; follow-up troponin trended down, 0.16.",0
"Urinalysis was notable for cloudy urine, negative nitrite, moderate leukocyte esterase, more than 50 red blood cells, more than 50 white blood cells with moderate bacteria, zero to two epithelials.",0
"Initial arterial blood gas was 7.38, 76, 149.",0
Chest x-ray showing stable postoperative changes; small bilateral pleural effusions and bibasilar atelectasis.,0
Previous cardiac catheterization in showing clean coronaries except for mild coronary artery disease in left circumflex of 30 to 40% lesion.,0
"SEPSIS: With initial positive urinalysis and negative chest x-ray, the patient was thought to be in urosepsis.",1
"He was initially placed on pressors, given aggressive intravenous fluid hydration.",0
"After approximately an hour on pressors, the pressors were weaned off and the patient had stable blood pressure.",0
He was initially febrile in the Emergency Department and subsequently became hypothermic.,0
His temperature after the first 24 hours was within normal limits.,0
"Initially he was given central access, serial lactates were drawn; an arterial line was placed, and he was placed on steroids for presumed relative adrenal insufficiency.",0
"He was placed on ceftriaxone, Vancomycin and Levofloxacin.",0
"After the patient's blood pressure stabilized, he became afebrile and his urine culture returned as infective pseudomonas, he was taken off steroids and placed on Zosyn for pseudomonas coverage.",0
"The pseudomonas was resistant to Ciprofloxacin, so fluoroquinolones were not used.",0
"As he became hemodynamically stable throughout the rest of his hospital course, his central access was discontinued as well as his arterial line.",0
INFECTIOUS DISEASE: He had a presumed urine infection with pseudomonas that was resistant to fluoroquinolones.,0
He was placed on Zosyn for complete three week course.,0
A PICC line was placed for long term antibiotics.,0
Pseudomonas was also cultured from his sputum and was thought to be a colonization.,0
BENIGN PROSTATIC HYPERTROPHY: The patient has had a Foley catheter in place for at least one to two months because of a history of benign prostatic hypertrophy and urinary retention.,1
A Foley catheter was continued during his inpatient hospital stay but he will likely need an outpatient urology evaluation and / or possible transurethral resection of the prostate procedure as indwelling Foley catheter may increase his risk for recurrent urinary tract infections and / or future episodes of urosepsis.,1
PULMONARY: The patient was continued on the ventilator intermittently as he had done previously and he was not thought to have a primary pulmonary process as the cause of this admission.,0
"Because of air leak around the cuff of his tracheostomy, his tracheostomy was changed to a Portex #7.",0
He did well on intermittent pressure support and no vent changes were made.,0
He will continue with a ventilatory wean as he had done previously at rehabilitation.,0
CARDIOVASCULAR: The patient had initial elevated troponin of 0.26 in the setting of hypotension and acute renal failure.,1
His CKs were flat and he had a previous cardiac catheterization showing fairly clean coronary arteries.,0
"Given the clinical circumstance, his elevated troponin was thought to be due to demand ischemia.",0
He was continued on aspirin and beta blocker.,0
Consideration was made to starting an ACE inhibitor but was not started given his renal failure.,0
ACUTE RENAL FAILURE: His creatinine was elevated up to 2.7 on admission thought to be due to his sepsis and decreased intervascular volume.,1
"After aggressive intravenous fluid hydration, this currently dropped to 1.2 at the time of discharge which is well within his baseline.",0
"FLUIDS, ELECTROLYTES AND NUTRITION: The patient had a swallowing study to evaluate his ability to take a p.o.",0
diet which he did poorly.,0
"To maintain adequate nutrition, Gastroenterology was consulted and a PEG was placed on .",0
The patient had minimal bleeding around the site of the PEG placement so his aspirin dose was lowered from 325 mg to 81 mg which is a prophylactic dose.,0
"His PEG was safe for tube feeds, so tube feeds were begun.",0
DIABETES MELLITUS: The patient had some elevated glucose while on steroids.,0
He was continued on a Regular insulin sliding scale.,0
DISPOSITION: The patient's mental status improved dramatically and it was felt by both the patient and his family that he had improved from his baseline.,0
He was afebrile with stable hemodynamics and doing well on a ventilator.,0
He was felt to be safe for discharge to Rehabilitation for continuation of his ventilatory wean and for continued intravenous antibiotic therapy.,0
Urosepsis with pseudomonas urinary tract infection.,1
"Acute renal failure, now resolved.",1
"Percocet Elixir, 5 to 10 ml q. four to six hours as needed for leg pain.",0
Eye drops; Artificial tears one to two drops p.r.n.,0
Ranitidine 150 mg q. day.,0
Zosyn 4.5 grams intravenously q. eight hours for another 18 days.,0
"The patient was told to follow-up with his primary care physician, .",0
", within one to two weeks of discharge.",0
Will likely need referral to outpatient Urology to evaluate his benign prostatic hypertrophy.,1
Will likely need follow-up care with Pulmonary within the next two to three weeks.,0
He was told to continue taking all medications as prescribed.,0
"He was told that if he developed any recurrent fevers or chills, episodes of nausea, lightheadedness, confusion or any other concerning symptoms whatsoever, that he should seek immediate medical attention.",1
Dictated By: MEDQUIST36 D: 13:51 T: 14:05 JOB#: cc:,0
"6:14 PM CHEST (PA & LAT) Clip # Reason: eval for pulmonary process Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with fevers, chills; hx of chronic renal disease with chronic graft rejection REASON FOR THIS EXAMINATION: eval for pulmonary process ______________________________________________________________________________ WET READ: PXDb TUE 10:33 PM No acute cardiopulmonary process.",1
( ) ______________________________________________________________________________ FINAL REPORT HISTORY: Fever and chills with history of chronic renal disease and graft rejection.,1
"FINDINGS: In comparison with the study of , there is little change.",0
"Calcification projected over the right upper quadrant of the abdomen is seen far posteriorly in the base of the lungs, consistent with an old calcified granuloma.",0
Height: (in) 62 Weight (lb): 155 BSA (m2): 1.72 m2 BP (mm Hg): 153/110 HR (bpm): 124 Status: Inpatient Date/Time: at 15:33 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
No evidence of endocarditis seen.,0
", S. TSURG TSICU 6:19 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for consolidation Admitting Diagnosis: LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man s/p RULobectomy with chest wall resection/reconstruction with goretex mesh REASON FOR THIS EXAMINATION: evaluate for consolidation ______________________________________________________________________________ PFI REPORT 1.",0
"Unchanged or slightly decreased right apical pneumothorax, small.",0
Unchanged right upper lung consolidations and right hilar fullness.,0
5:38 AM ABD COMPL INCLUDING LAT DECUB PORT Clip # Reason: r/o perforation Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with distended abdomen REASON FOR THIS EXAMINATION: r/o perforation ______________________________________________________________________________ FINAL REPORT INDICATIONS: Distended abdomen.,1
Supine and left lateral decibutis views compared to an examination earlier the same day demonstrates a slight increase in the gaseous distention of the bowel.,0
"The feeding tube appears in good position, terminating in the stomach.",0
"No pneumatosis, pneumoperitoneum or portal venous gas is identified.",0
"5:47 PM BILAT HIPS (AP,LAT & AP PELVIS) Clip # Reason: eval for fracture ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman s/p fall REASON FOR THIS EXAMINATION: eval for fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall.",0
Frontal and frogleg views of the pelvis: There are degenerative changes of the hips and lower lumbar spine.,0
Sacral detail is obscured by overlying bowel gas and stool although no sacral fractures are identified.,0
There are phleboliths within the pelvis and vascular calcifications.,0
IMPRESSION: Degenerative changes with no definite fracture.,0
11:22 AM CHEST (PORTABLE AP) Clip # Reason: lung path?,0
Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with rales REASON FOR THIS EXAMINATION: lung path?,0
______________________________________________________________________________ FINAL REPORT HISTORY: 47-year-old male with rales.,0
COMPARISON: No prior exam is available on PACS for comparison.,0
"PORTABLE CHEST X-RAY: On this semi-upright portable chest radiograph, with no prior exam for comparison, there is no clear evidence of congestive heart failure or acute pulmonary infiltrate.",1
The heart size and the mediastinal and hilar contours are within normal limits.,0
A diffuse density over the left lung base is unexplained due to overlying artifacts.,0
"This could represent pleural fluid or artifact; if detailed information regarding the left lower lobe and possible left pleural effusion is required, a PA and lateral chest radiograph is recommended.",0
4:11 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX s/p L IJ placement Admitting Diagnosis: PORTAL VEIN OCCLUSION ______________________________________________________________________________ MEDICAL CONDITION: 72 y/o f s/p L IJ placement REASON FOR THIS EXAMINATION: r/o PTX s/p L IJ placement ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate left internal jugular line placement.,0
AP CHEST RADIOGRAPH: This region has been interval placement of a left internal jugular vein line with its tip in the upper SVC at the right lateral margin.,0
These findings were discussed with Dr. on .,0
The pulmonary vascularity is normal in appearance without redistribution.,0
There has been interval blunting of the costophrenic angles bilaterally with small bilateral pleural effusions.,0
Left IJ line tip abuts the lateral aspect of the upper SVC.,0
4:15 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate pleural effusions Admitting Diagnosis: CHRONIC PULM DISEASE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with squamous cell lung ca.,1
"REASON FOR THIS EXAMINATION: Evaluate pleural effusions ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, CLINICAL INFORMATION: Squamous cell lung cancer, evaluate pleural effusion.",0
Endotracheal tube terminates just below the thoracic inlet.,0
There is mid thoracic vertebroplasty.,0
There is a small left pleural effusion with atelectasis at the left lung base.,0
There is also mild atelectasis at the right lung base.,0
There is mild underlying interstitial lung disease.,0
IMPRESSION: No change from the prior study.,0
11:04 AM CHEST (PORTABLE AP) Clip # Reason: r/o chf ______________________________________________________________________________ MEDICAL CONDITION: 71M CAD with CP/SOB REASON FOR THIS EXAMINATION: r/o chf ______________________________________________________________________________ FINAL REPORT INDICATION: Chest pain and shortness of breath.,0
PORTABLE AP CHEST: Images from prior studies are not available for comparison.,0
Reference is made to the report.,0
"There are areas of increased opacity in the perihilar areas, as well as asymmetrically increased opacity in the left upper lung zone and left lower lobe.",0
"The findings are likely due to asymmetrical pulmonary edema, but evaluation is limited without comparison studies.",0
An acute multifocal pneumonia or aspiration cannot be excluded.,1
There are surgical clips in the right upper abdomen.,0
"IMPRESSION: Likely asymmetrical pulmonary edema, but evaluation limited without prior comparison studies.",0
"Should these become available, an addendum will be issued to this report.",0
Multifocal pneumonia or aspiration cannot be excluded.,0
ADDENDUM: Comparison CXR of and have become available.,0
The appearance on the current CXR is worse than on .,0
"Based upon review of prior studies, the appearance favors asymmetrical edema.",0
1:47 PM CHEST (PA & LAT) Clip # Reason: eval for pleural effusions Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after aortic valve replacement.,1
COMPARISON: Preoperative study from as well as several studies obtained between and .,0
There is gradual decrease in pulmonary edema which is currently minimal.,0
"Chronic changes in the right upper lung and both bases are demonstrated, stable.",0
"Left lower lobe consolidation is still present and might reflect an area of atelectasis, but infectious process is a possibility .",0
Height: (in) 70 Weight (lb): 185 BSA (m2): 2.02 m2 BP (mm Hg): 95/46 HR (bpm): 54 Status: Inpatient Date/Time: at 12:35 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
Moderate (2+) tricuspid regurgitation is seen.,0
Pulmonary artery systolic pressure was not estimated.,0
"9:02 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: interval change- head CT priro to TPA administration at 2300 Admitting Diagnosis: LEFT THALMIC BLEED ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with left thamic IPH, EVD placed with q 8 hour TPA administered REASON FOR THIS EXAMINATION: interval change- head CT priro to TPA administration at 2300- please perform by 2100 No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SUN 11:55 PM Stable left thalamic hemorrhage and left ventricular blood with stable mild mass effect.",0
No new area of bleeding.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old woman with left thalamic hemorrhage, evaluate for interval change.",0
"FINDINGS: Since the earlier study today, there has been a slight decrease in the amount of hyperdense material within the left lateral ventricle, although the degree of midline shift remains unchanged, approximately 9 mm.",0
"The adjacent left thalamic intraparenchymal hemorrhage is also unchanged in extent, with surrounding edema.",1
A small amount of blood layering dependently in the right lateral ventricle is also stable.,0
There is no new evidence of vascular ischemia.,0
"The basilar cisterns are symmetric, and there is no evidence of herniation.",0
There is no new fracture or new bony abnormality.,0
"Since the earlier study, pneumocephalus has decreased.",0
"Stable appearance of left thalamic parenchymal hemorrhage, with slight interval decrease in amount of left ventricular hemorrhage, with no change in mild mass effect.",0
No new area of hemorrhage.,0
(Over) 9:02 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: interval change- head CT priro to TPA administration at 2300 Admitting Diagnosis: LEFT THALMIC BLEED ______________________________________________________________________________ FINAL REPORT (Cont),0
"1:32 AM CHEST (PORTABLE AP) Clip # Reason: please eval for pulm process Admitting Diagnosis: INTRACRANIAL HEMORRAGE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with intracranial hemorrhage s/p craniotomy, s/p Dobhoff replacement REASON FOR THIS EXAMINATION: please eval for pulm process ______________________________________________________________________________ FINAL REPORT EXAM ORDER: Chest.",0
"HISTORY: Intracranial hemorrhage status post craniotomy, status post feeding tube replacement.",0
CHEST: A single AP supine view at 2:00 a.m. is compared to previous examination of .,0
There is a feeding tube with the tip below the diaphragm.,0
A tracheostomy tube is present.,0
There is a small right pleural effusion with probable subsegmental atelectasis in right lung base.,0
"The evaluation of the lungs is limited due to motion artifact, however overall the lungs are clear.",0
The right hemidiaphragm is elevated.,0
9:32 PM CT HEAD W/O CONTRAST Clip # Reason: progression of bleed?,0
(has ct from OSH) ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with ICH blood in ventricles REASON FOR THIS EXAMINATION: progression of bleed?,0
(has ct from OSH) No contraindications for IV contrast ______________________________________________________________________________ WET READ: KMcd MON 10:39 PM Acute right frontal intraparenchymal hemorrhage with extensive intraventricular extention.,0
Blood-filled and dilated 4th ventricle indicating obstruction.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 69-year-old man with IVH, diagnosed at outside hospital.",0
Evaluate for progression of bleed.,0
COMPARISONS: The head CT from the outside hospital is currently not available for review.,0
CT HEAD WITHOUT CONTRAST: There is an acute right frontal intraparenchymal hemorrhage measuring 3.6 x 2.8 x 5 cm.,0
"The hemorrhage extends into the right lateral ventricle and further into the left lateral, third and fourth ventricles, as well as in the subarachnoid space around the pons and medulla.",0
The lateral ventricles are equal in size.,0
"Note is made of a blood- filled, very large fourth ventricle likely dilated due to obstruction.",0
"The lateral ventricles and third ventricle are enalerged as well, indicating obstructive hysrocephalus.",0
There is no significant midline shift.,0
There is crowding of sulci around the right frontal intraparenchymal hemorrhage due to the mass effect of the hemorrhage and surrounding edema.,0
"Though the basilar cisterns are overall preserved, the right ambient cistern is somewhat effaced, which could indicate early right- sided transtentorial herniation.",0
Visualized paranasal sinuses and mastoid air cells are clear.,0
"IMPRESSION: Acute right frontal intraparenchymal hemorrhage with extension into lateral, third, and fourth ventricle as well as into the subarachnoid space.",0
Probable early right- sided transtentorial herniation.,0
"12:49 AM CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: eval for interval change, Field of view: 20 Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with HA, SAH REASON FOR THIS EXAMINATION: eval for interval change, No contraindications for IV contrast ______________________________________________________________________________ WET READ: BTCa MON 3:57 AM Small left fronto-parietal subarachnoid hemorrhage.",1
Occlusion of the right common carotid artery.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old female with intracranial hemorrhage.,0
COMPARISONS: No prior studies were available for comparison at the time of dictation.,0
FINDINGS: High-density material is seen layering within the left postcentral gyrus consistent with subarachnoid hemorrhage.,1
No other focal areas of hemorrhage are identified within the brain parenchyma.,0
"There is no evidence of hydrocephalus, mass effect or shift of normally midline structures.",0
There is prominence of the ventricles and sulci consistent with age-related involutional change.,0
Periventricular white matter hypodensities are suggestive of chronic small vessel ischemic change.,0
There is minimal mucosal thickening within the ethmoid sinuses.,0
"CTA OF THE HEAD: TECHNIQUE: Following administration of 90 cc of Optiray contrast, contiguous axial images through the head were obtained during opacification of internal carotid, vertebral arteries and circle of .",0
Multiplanar reconstructed images remain pending at the time of this report.,0
FINDINGS: Preliminary images of the head demonstrate extensive plaque within the right carotid artery and complete occlusion of the right common carotid at the level of the C4 vertebral body.,1
Vertebral and basilar arteries are patent.,0
There is no evidence of aneurysm.,0
The major arteries of the circle of are patent and received contributions from the left internal carotid and posterior circulation.,0
Left-sided subarachnoid hemorrhage of unknown etiology.,1
No evidence of mass effect or hydrocephalus.,0
Complete occlusion of the right internal carotid artery at the level of the fourth cervical vertebra.,1
The posterior circulation and vessels of the circle of are patent.,0
"(Over) 12:49 AM CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: eval for interval change, Field of view: 20 Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ FINAL REPORT (Cont) These findings were discussed with Dr. at 4 a.m. on the date of dictation.",0
"7:54 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for CHF Admitting Diagnosis: RECURRENT VENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with VT, CHF exacerbation on OSH CXR.",1
"REASON FOR THIS EXAMINATION: Evaluate for CHF ______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old man with ventricular tachycardia, CHF exacerbation on outside hospital chest radiograph.",1
CHEST AP: There is moderate cardiomegaly.,0
"Pulmonary vascular congestion, increased interstitial opacities as well as alveolar opacities are identified.",0
Four-lead pacemaker is again noted.,0
No definite pleural effusion is identified.,0
Degenerative changes of the thoracic spine are observed.,0
IMPRESSION: Moderate-to-severe congestive heart failure.,1
2:18 PM CHEST (PA & LAT) Clip # Reason: dyspena ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with REASON FOR THIS EXAMINATION: dyspena ______________________________________________________________________________ FINAL REPORT INDICATION: 42-year-old woman with dyspnea.,0
COMPARISON: Chest x-ray from and PET CT from .,0
"FRONTAL AND LATERAL CHEST: Since the prior study, there has been development of a small right-sided pleural effusion.",1
"Linear atelectasis vertically oriented in the retrocardiac left lower lobe is again seen, slightly more prominent.",0
There is persistent elevation of the right hemidiaphragm.,0
Rounded opacity projecting over the left lower lobe is consistent with nipple shadow.,0
No new consolidation is identified and the pulmonary vascularity is within normal limits.,1
Some linear opacity emanating from the right hilum is also likely related to atelectasis.,0
IMPRESSION: New small right-sided pleural effusion and more prominent vertically oriented linear opacity in the left lower lobe.,1
A CT of the chest may be of value to further evaluate these findings.,0
"5:46 PM PORTABLE ABDOMEN Clip # Reason: Evaluate for infiltrate; Evaluate placement of NG tube Admitting Diagnosis: NEUTROPENIA,CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with ALL, likely pulmonary aspergillosis; neutropenic fever.",0
Now s/p NG tube placement.,0
"REASON FOR THIS EXAMINATION: Evaluate for infiltrate; Evaluate placement of NG tube ______________________________________________________________________________ FINAL REPORT EXAM ORDER: ABDOMEN HISTORY: Status post nasogastric tube placement, ALL.",0
A single supine portable abdominal film is compared to previous examination a day ago.,0
The abdomen appears gasless with fecal material in left hemicolon.,0
The linear lucencies in the splenic flexure and descending colon is felt to be intraluminal rather than within the wall of the colon.,0
The tip of the NG tube is not visualized in distal esophagus and stomach.,0
12:04 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for position Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with new ETT placement REASON FOR THIS EXAMINATION: eval for position ______________________________________________________________________________ FINAL REPORT CHEST X-RAY HISTORY: New ET tube placement for position.,1
Diffuse bilateral pulmonary infiltrates consistent with edema persist.,0
There is evidence of bilateral pleural effusions before.,0
"The difference in the appearance of the chest is presumably due to differences in technique, improved lung volumes and redistribution of pleural fluid.",0
An endotracheal tube has been inserted and terminates at the thoracic inlet.,0
A nasogastric tube has been placed and terminates in the region of the stomach.,0
A PICC line remains in place.,0
"A radiopaque catheter is recoiled in the abdomen, as before.",0
IMPRESSION: Endotracheal tube and nasogastric tube in satisfactory position.,0
7:59 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: question evidence of thrombosis in L upper arm venous system Admitting Diagnosis: MULTIPLE MYELOMA;RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with multiple myeloma with unilateral L upper arm swelling.,1
"REASON FOR THIS EXAMINATION: question evidence of thrombosis in L upper arm venous system ______________________________________________________________________________ FINAL REPORT VASCULAR ULTRASOUND INDICATION: 60-year-old woman with multiple myeloma and unilateral left upper arm swelling, rule out thrombosis.",1
"FINDINGS: The left jugular vein is patent, compressible and demonstrates normal respiratory variability.",0
"The subclavian, axillary, brachial, basilic and cephalic veins on the left are patent and demonstrate normal flow, compressibility and respiratory variability.",0
"There is edema within the subcutaneous soft tissues, most marked within the left antecubital fossa.",0
OPINION: No evidence of upper arm deep or superficial venous thrombosis on the left.,0
Subcutaneous edema within the left antecubital fossa.,0
"3:45 AM CHEST (PORTABLE AP) Clip # Reason: Interval hange Admitting Diagnosis: ACTIVE HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with hypoxemic respiratory failure REASON FOR THIS EXAMINATION: Interval hange ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:30 A.M. ON HISTORY: Hypoxemic, respiratory failure, question interval change.",1
"IMPRESSION: AP chest compared to and : Right upper lobe has regained aeration, middle and lower lobes are still collapsed.",0
"Mild-to-moderate pulmonary edema is present in both the reexpanded right upper lobe and the left lung, probably worsened since , 9:16 a.m. A new channel ET tube has been inserted, the tip in the proximal left main bronchus.",1
The jugular line ends at the junction of brachiocephalic veins.,0
Small left pleural effusion might be present.,0
There is no appreciable left pleural effusion.,0
Right heart border is obscured by adjacent atelectasis in the right lung.,0
"Widening of the mediastinum suggests elevated central venous pressure, though hematoma cannot be excluded with certainty, particularly following insertion of right bronchial artery coils.",0
"2:04 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: with po and IV contrast, for necrotising pancreatitis Admitting Diagnosis: PANCREATITIS Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman transferred from OSH with report of necrotizing pancreatitis REASON FOR THIS EXAMINATION: with po and IV contrast, for necrotising pancreatitis No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 48-year-old woman transferred from outside hospital with necrotizing pancreatitis by CT.",0
Outside Hospital CT not on PACs for direct comparison.,0
TECHNIQUE: Axial MDCT images through the abdomen and pelvis with oral and 150 cc of nonionic contrast.,0
"CT OF THE ABDOMEN WITH IV CONTRAST: At the lung bases, there are small bilateral pleural effusions with associated passive atelectasis/consolidation.",0
Feeding tube is identified with its tip in the distal stomach.,0
There is a small amount of ascites around the liver.,0
"In segment VII of the liver, there is a tiny hypodensity too small to further characterize but likely representing simple cyst.",0
There are no other focal lesions within the liver.,0
The kidneys and adrenal glands are within normal limits.,0
There is extensive liquefaction and necrosis of the pancreas involving the majority of the body and tail.,0
There only remains residual pancreatic parenchyma in the proximal body and head.,0
"In the anterior pararenal space, there is a complex loculated fluid collection/phlegmon that extends throughout the anterior pararenal space, gallbladder fossa, lesser sac, and into the paracolic gutters, especially on the left to which it extends inferiorly below the level of the kidneys.",0
"There is mild prominence of the common biliary duct distally, however, no definite stone or filling defect is seen within it.",0
"On one isolated imaged on series 3, image 29, there is a crescentic soft tissue density, which appears to originate from the liver abutting the common duct, but does not appear within it.",0
"There is a high-density object within the descending portion of the duodenum, which appears to represent a pill.",0
No free air is seen within the abdomen.,0
There is no evidence of free gas within the loculated fluid collection.,0
The small hypodense areas along the left paracolic gutter measure fat density and not air density.,0
The surrounding mesenteric and splenic vasculature are unremarkable without evidence of pseudoaneurysm.,0
There is no evidence of venous thrombosis.,0
There is fluid surrounding the gallbladder and the fossa.,0
There is some fluid extending through the small bowel mesentery.,0
"(Over) 2:04 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: with po and IV contrast, for necrotising pancreatitis Admitting Diagnosis: PANCREATITIS Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) CT PELVIS WITH IV CONTRAST: Free fluid is identified within the pelvis.",0
The intrapelvic bowel is unremarkable.,0
"The uterus demonstrates fluid within the endometrium and a small defect inferiorly, with fluid in it, which appears contiguous with the endometrium of unclear etiology.",0
There are no pathologically enlarged lymph nodes within the pelvis.,0
The uterus and adnexa are otherwise unremarkable.,0
Foley catheter is seen within the bladder.,0
The osseous structures are generally unremarkable.,0
"IMPRESSION: 1) Extensive necrotizing pancreatitis, with fluid collection extending throughout the anterior pararenal space, gallbladder fossa, lesser sac, and inferiorly into the paracolic gutters.",0
"There is no evidence of air within this collection, though infection cannot be excluded.",0
There is no evidence of venous thrombosis or arterial vascular complications.,0
No definite calculus is identified within the common duct.,0
Findings communicated with the surgical housestaff.,0
2) Small bilateral pleural effusions with associated passive atelectasis/consolidation.,0
"4) Small hypodense lesion within segment VII of the liver, too small to further characterize but likely representing a simple cyst.",0
PATIENT/TEST INFORMATION: Indication: Congestive heart failure Height: (in) 72 Weight (lb): 142 BSA (m2): 1.84 m2 BP (mm Hg): 102/56 HR (bpm): 75 Status: Inpatient Date/Time: at 14:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,1
Overall left ventricular systolic function is normal (LVEF 75%).,0
There is borderline/mild posterior leaflet mitral valve prolapse.,0
Height: (in) 71 Weight (lb): 150 BSA (m2): 1.87 m2 BP (mm Hg): 142/80 HR (bpm): 94 Status: Inpatient Date/Time: at 16:00 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
No valvular pathology or pathologic flow identified.,0
5:31 PM PORTABLE ABDOMEN Clip # Reason: check dobhoff tube placement Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with DHT REASON FOR THIS EXAMINATION: check dobhoff tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old man with DHT.,0
COMPARISON: Supine abdominal x-ray dated .,0
AP PORTABLE SEMI-ERECT X-RAY AT LEVEL OF DIAPHRAGMS: A Dobbhoff catheter descends below the diaphragm with the tip in the area of the lower gastric body.,0
It does not extend beyond the pylorus.,0
A left- sided subclavian central venous catheter overlies the upper superior vena cava.,0
No free air is detected under the diaphragm.,0
"Wires and sutures are again identified within the left upper quadrant, and overlying the cardiac silhouette and mediastinum.",0
"Skin staples extend over the entire left hemithorax, and left upper quadrant.",0
Contrast is seen within nondilated loops of bowel.,0
IMPRESSION: Dobbhoff catheter with tip in area of distal stomach.,0
12:24 PM CT HEAD W/O CONTRAST Clip # Reason: headache ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with headache REASON FOR THIS EXAMINATION: headache No contraindications for IV contrast ______________________________________________________________________________ WET READ: SHfd FRI 2:11 PM No ICH New occipital subgalial air and fluid collection (5.6x 2.6 cm) at the site of surgery (infection not excluded ).,0
Adjacent intracranial air and fluid collection is stable-decreased in size.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Headache.,0
The patient has history of metastatic breast cancer status post resection of brain metastasis.,1
"COMPARISON: Multiple head CTs with the most recent from , multiple brain MRIs with the most recent from .",0
TECHNIQUE: Multidetector CT images of the head without administration of IV contrast was obtained.,0
Coronal and sagittal reformatted images were also submitted for interpretation.,0
"FINDINGS: No intracranial hemorrhage, mass effect, or -white matter differentiation, abnormality is seen.",1
"Again noted, there is an area of air and fluid collection at the location of previously seen brain mass with adjacent small amount of pneumocephalus and hypodensity of the cerebellum, mildly decreased in size since prior exam.",0
Prominence of the ventricles and extra-axial spaces is related to age-appropriate atrophy.,0
Multiple periventricular and subcortical hypodensities are consistent with small vessel ischemic disease.,1
"There is a 5.7 x 2.6 x 5.8 cm air and fluid collection within the subgaleal region of the posterior scalp at the location of prior surgery, which is new since prior exam.",0
Adjacent mild inflammatory changes and punctate foci of air extending in the subgaleal space are also seen.,0
"Cranioplasty and metallic plate placement is seen, stable.",0
Fluid in the right mastoid air cells is unchanged since prior exam.,0
Soft tissue within the right external ear canal is stable and may represent cerumen.,0
The left mastoid air cells are clear.,0
A new area of fluid collection in suboccipital subgaleal region measuring up to 5.8 cm.,0
Stable air fluid collection in the posterior cranial fossa.,0
(Over) 12:24 PM CT HEAD W/O CONTRAST Clip # Reason: headache ______________________________________________________________________________ FINAL REPORT (Cont) 3.,0
"Fluid-filled right mastoid air cells, stable.",0
"2:53 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, effusion, interval change Admitting Diagnosis: EMPYEMA ______________________________________________________________________________ MEDICAL CONDITION: 74 y.o.",0
"male, intubated, s/p chest tubes for empyema REASON FOR THIS EXAMINATION: assess for infiltrate, effusion, interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Interval change in a patient with chest tube inserted for empyema.. Portable AP chest radiograph compared to .",0
The ET tube tip is 7.4 cm above the carina.,0
The right internal jugular line tip is in low SVC.,0
The NG tube passes below the diaphragm most likely terminating in the stomach.,0
The three right chest tubes are in unchanged position.,0
There is no significant change in the bilateral lung opacities as well as loculated right pleural effusion.,0
", P. MED MICU-7 10:37 AM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: ELEVATED LFT'S ASSESS FOR MASS OR LIVER INFILTRATION OR OBSTRUCTION Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with mild transaminitis REASON FOR THIS EXAMINATION: assess for mass or liver infiltration or obstruction ______________________________________________________________________________ PFI REPORT distended gallbladder with some sludge and tiny amount of fluid between the gb wall and liver.No gb wall edema.",0
No definite findings of acute cholecystitis.,0
Rec continued observation and correlation with LFTs.,0
"If clinically indicated, a HIDA scan may be obtained.",0
12:06 AM CT C-SPINE W/O CONTRAST Clip # Reason: S/P FALL Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with fall and bleed REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 2:31 AM No acute fracture or subluxation.,0
"______________________________________________________________________________ FINAL REPORT CT CERVICAL SPINE WITHOUT CONTRAST INDICATION: 74-year-old male with fall and hemorrhage, rule out fracture.",0
TECHNIQUE: MDCT axial images of the cervical spine were obtained without administration of intravenous contrast.,0
FINDINGS: There is no evidence of fracture.,0
The alignment of the vertebral bodies is maintained.,0
There is a preservation of the atlantoaxial and atlanto-occipital relationships.,0
The prevertebral soft tissues are unremarkable.,0
"There are multilevel degenerative changes, with multilevel disc space narrowing and spondylosis, most pronounced at C5-6 level, where there is a narrowing of the bony canal as well as bilateral neural foramina.",0
Review of imaged lung apices demonstrates emphysema.,0
No fracture or abnormal alignment.,0
"NOTE ADDED AT ATTENDING REVIEW: There is a disk protrusion at C4-5 across the anterior aspect of the spinal canal, larger on the left than right.",0
This indents the spinal cord and narrows the proximal left foramen.,0
At C6-7 there is an osteophyte narrowing the right side of the spinal canal and an uncovertebral osteophyte narrowing the neural foramen.,0
(Over) 12:06 AM CT C-SPINE W/O CONTRAST Clip # Reason: S/P FALL Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ FINAL REPORT (Cont),0
Height: (in) 63 Weight (lb): 251 BSA (m2): 2.13 m2 BP (mm Hg): 131/35 HR (bpm): 68 Status: Outpatient Date/Time: at 10:48 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Diastolic function could not be assessed.,0
AORTIC VALVE: No valvular AS.,0
Trivial MR. Normal LV inflow pattern for age.,0
"Compared with the prior study (images reviewed) of , image quality is not as good.",0
The estimated pulmonary artery systolic pressure is lower.,0
8:11 AM CHEST (PORTABLE AP) Clip # Reason: interval change of CHF ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with mitral and aortic stenosis and CHF REASON FOR THIS EXAMINATION: interval change of CHF ______________________________________________________________________________ FINAL REPORT INDICATION: congestive heart failure and valve disease.,1
FINDINGS: Compared to the prior study there is some improvement in aeration of the right lower lung field but this is a subtle change and the majority of the pattern is consistent with continued congestive features.,0
"In addition, the patchy density in the left upper lobe remains.",0
The endotracheal tube remains in place and is somewhat low; it could be pulled back 3 cm.,0
The swan ganz catheter remains in place.,0
The left hemidiaphragm is again not well seen.,0
IMPRESSION: Slight improvement in aeration of the right lower lung field but diffuse and prominent congestive features persist.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: He remained in the hospital for evaluation for a drop in hematocrit down to 22.1 for which he received 2 units of PRBC with increase 25.7.",0
A hemolysis workup was done that revealed a haptoglobin <2 and ldh of 341.,0
Heme/Onc was called to review case.,0
It was felt that this was not hemolysis given negative coombs and no schistocytes seen on peripheral smear.,0
"Also, the t.bili was stable at 0.8.",0
He remained in hospital pending his family being ready to take him home.,0
"On the last hospital day, his right leg appeared larger than the left leg.",0
A non-invasive ultrasound was done to evaluate for dvt.,0
"He was discharged home in stable condition, ambulating and toleraterating a regular diet.",0
Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.,0
Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO four times a day.,0
Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours).,0
Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day).,0
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous daily in the morning.,0
Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day: Fingerstick QACHSInsulin SC Fixed Dose Orders Breakfast NPH 10 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz.,0
Juice 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 0 Units 2 Units 0 Units 141-160 mg/dL 3 Units 0 Units 3 Units 0 Units 161-180 mg/dL 4 Units 0 Units 4 Units 0 Units 181-200 mg/dL 5 Units 3 Units 5 Units 0 Units 201-220 mg/dL 6 Units 5 Units 6 Units 2 Units 221-240 mg/dL 7 Units 7 Units 7 Units 3 Units 241-260 mg/dL 8 Units 8 Units 8 Units 4 Units 261-280 mg/dL 9 Units 9 Units 9 Units 5 Units 281-300 mg/dL 10 Units 10 Units 10 Units 7 Units > 300 mg/dL Notify M.D.,0
"Ordered by , A., MD Beeper#: on @ 0915 .",0
13. syringes for insulin injection 1 box refill:2 14.,0
"Test stips 1 box refill:2 Discharge Disposition: Home With Service Facility: , Center MD Completed by:",0
", M. TSURG SICU-B 8:31 AM BILAT LOWER EXT VEINS PORT Clip # Reason: RULE OUT DVT'S/PT IN SICU WITH FEVERS OF UNKNOWN ORIGIN Admitting Diagnosis: THYMOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 34 year old woman with post-op fevers of UO REASON FOR THIS EXAMINATION: rule out DVTs ______________________________________________________________________________ PFI REPORT No evidence of DVT in the lower extremities.",0
7:25 AM CHEST (PORTABLE AP) Clip # Reason: eval for effusion Admitting Diagnosis: AORTIC INSUFFIENCY\AORTIC VALVE REPLACEMENT; ?,1
"MAZE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for effusion ______________________________________________________________________________ FINAL REPORT AP CHEST, .",0
Large postoperative cardiomediastinal silhouette is stable including distended azygos vein suggesting elevated central venous pressure or volume.,0
"Bibasilar atelectasis is moderately severe, unchanged since , increased on the right since .",0
"Pleural effusion, if any, is minimal.",0
Right jugular line ends centrally.,0
"3:51 AM CHEST (PORTABLE AP) Clip # Reason: please assess for interval change Admitting Diagnosis: MYASTHENIA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with myesthenic crisis, intubated REASON FOR THIS EXAMINATION: please assess for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old woman with myasthenic crisis, intubated, evaluate for interval change.",0
SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: Lung volumes remain low with mild bronchovascular crowding and bibasilar atelectasis.,0
There is mild cephalization indicating mild overhydration.,0
Right IJ catheter is terminating at the cavoatrial junction.,0
"Endotracheal tube is 2 cm above the carina, part of which is explained by neck hyperflexion.",0
"NG tube is extending into the stomach, however, the side port is still in the gastroesophageal junction.",0
Further advancement by around 8 cm is recommended.,0
"IMPRESSION: Mild volume overload, unchanged.",0
"NG tube is extending into the stomach, however, the side port is at the gastroesophageal junction.",0
PATIENT/TEST INFORMATION: Indication: Cardiac arrest Status: Inpatient Date/Time: at 07:53 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: PERICARDIUM: No pericardial effusion.,0
Conclusions: There is no pericardial effusion.,0
IMPRESSION: Cardiac standstill visualized duirng ACLS protocol.,0
There is what seems to be a clot in transit in the right atrium.,0
Dr. was notified in person of the results during the study.,0
10:54 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: po contrast only.,0
no iv contrast to assess eval for duodenal Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM Field of view: 40 ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p EVAR for AAA c/b sbo with possible perforation treated emirically with antibiotics.,1
Has PTC that has been capped.,0
now febrile REASON FOR THIS EXAMINATION: po contrast only.,0
"no iv contrast to assess eval for duodenal leak, aorto-enteric fistula, para aortic air CONTRAINDICATIONS for IV CONTRAST: elevated creatinine;elevated creatinine ______________________________________________________________________________ WET READ: DXAe TUE 11:56 PM Small decrease in the density and size retroperitoneal hematoma, as well as slightly less air around the aortic graft since .",0
No evidence of enteric leak or aorto-enteric fistula.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Status post endovascular repair for ruptured AAA with small-bowel obstruction and possible perforation.,1
Evaluate for signs of enteric leak or aortoenteric fistula.,0
Comparison is made to and CT exams.,0
TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and pelvis with oral contrast only.,0
Intravenous contrast was withheld per request of referring team.,0
CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Limited evaluation of the lung bases displays interval decrease in the size of bilateral simple pleural effusions (right greater than left) with mild interstitial edema.,0
No focal consolidations are noted.,0
Post-surgical changes from prior CABG are again identified.,0
Unenhanced images of the abdomen display stable appearance to external- internal biliary drain and CBD stent with no significant ductal dilatation and gallstones again noted within a decompressed gallbladder.,0
"The stomach, duodenum, spleen, small bowel, pancreas with head mass, right nephrectomy/adrenalectomy site, left adrenal gland, and left kidney are unchnaged.",0
There is stable appearance to a small and large bowel containing ventral hernia.,0
"Retroperitoneal hematoma has decreased in size, but displays more prominent regions of low attenuation within it, especially inferiorly (2:58).",0
"A few locules of air are still noted intraluminally adjacent to the graft near its Y-bifurcation point (2:40), improved from prior exam.",0
No abnormal oral contrast is noted within this region with contrast from prior exams and today's exams noted down to the rectal vault.,0
CT OF THE PELVIS WITH ORAL CONTRAST ONLY: Air is noted within a decompressed urinary bladder with the prostate appearing unremarkable.,0
Extensive colonic diverticula are unchanged with no evidence of acute diverticulitis.,0
The cecum (Over) 10:54 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: po contrast only.,0
no iv contrast to assess eval for duodenal Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM Field of view: 40 ______________________________________________________________________________ FINAL REPORT (Cont) and appendix are again noted to be contained within the large ventral hernia.,1
No pathologically enlarged inguinal or pelvic sidewall lymph nodes are identified.,0
Induration along both inguinal canals is likely related to a recent endovascular repair.,0
Partially visualized right femoral graft appears hyperdense and is thrombosed as noted on initial CT exam of .,1
Large scrotal hydroceles are present bilaterally.,0
An 11 mm left inguinal lymph node is not significantly changed from prior exam.,0
BONE WINDOWS: No malignant-appearing osseous lesions are identified.,0
Degenerative changes of the spine are unchanged.,0
Continued reduction in the amount of air adjacent to the stent graft within mural thrombus.,0
"Given that it is declining, it is likely post- procedural with ongoing infection felt less likely.",0
"There are no findings on current exam to suggest an aortoenteric fistula, although this is not excluded by CT exam.",0
Interval reduction in size of retroperitoneal right-sided hematoma with more low attenuation within it.,0
"This likely represents evolution of the hematoma; however, superinfection cannot be excluded by imaging.",0
Unchanged appearance to indwelling biliary stent and internal-external biliary stent as well as pancreatic head mass.,0
Stable appearance to small and large bowel-containing ventral hernia.,0
Interval decrease in size of bilateral pleural effusions.,0
"Admission Date: Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: dyspnea and cough Major Surgical or Invasive Procedure: None History of Present Illness: 74 year old female with a history of severe, Gold IV COPD who presents with dyspnea, wheezing, and cough.",0
"Symptoms started five days prior to admission when she developed a sore throat, sinus congestion, and dry cough.",0
"She became progressively sob, especially with exertion.",0
"No PND, orthopnea, or le edema.",0
One day PTA went to primary care and got amoxicillin and prednisone 40mg which did not help.,0
"On the day of presentation, went to Hospital where she recieved solumedrol 125mg and 500cc of IVF.",0
She was transferred to as her pulmonary care is provided here.,0
"In the ED, initial VS were: 121 140/82 20 95% 2L Nasal Cannula.",0
"She was treated with duonebs, no abx, 2L ivf, ekg sinus tach.",0
"Upon transfer 132/84, hr 113, RR 22, Sat 96 on 2L NC.",0
"On arrival to the MICU, pt was anxious, with intermittent cough and dyspnea.",0
Review of systems: Per HPI.,0
"Denies fever, chills, night sweats, recent weight loss or gain.",0
"Past Medical History: Severe COPD S/P TIA Cricopharyngeal myositis, on low-dose prednisone.",1
"Dysphagia, cricopharyngeal muscle dysfunction, s/p myotomy.",0
Prolapsed uterus Social History: Lives with husband.,0
Quit smoking 30 yrs prior.,0
Mother is alive at yo.,0
"Physical Exam: On admission: VS: Tm 99.9 Tc 96.8 133/89 112 94% on 2L NC General: SOB, speaking in full sentences EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous membranes, no lesions CV: tachycardic, normal S1, S2, no murmurs / rubs / gallops Pul: decreased BS throughout BACK: no focal tenderness, no costovertebral angle tenderness GI: normoactive bowel sounds, soft, non-tender, non-distended, no hepatosplenomegaly Extremities: warm and well perfused, no edema, 2+ DP pulses palpable bilaterally.",0
"no joint swelling or erythema LYMPH: no cervical lymphadenopathy SKIN: no rashes, no jaundice NEURO: awake, alert and oriented x3, CN 2-12 intact PSYCH: non-anxious, normal affect On : VS: T96.1 130/76 97 18 97%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, no murmurs, rubs, gallops Lungs: Diminished breath sounds throughout.",0
"Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: On admission: ( 01:51PM) WBC-9.9 RBC-4.54 Hgb-14.6 Hct-43.1 MCV-95 MCH-32.0 MCHC-33.8 RDW-12.4 Plt Ct-384 Neuts-95.7* Lymphs-2.8* Monos-1.2* Eos-0.1 Baso-0.3 Glucose-120* UreaN-16 Creat-0.7 Na-144 K-3.7 Cl-106 HCO3-24 AnGap-18 Calcium-7.3* Phos-3.1 Mg-1.9 %HbA1c-5.4 eAG-108 On : ( 07:05AM) WBC-9.6 RBC-4.03* Hgb-12.9 Hct-37.5 MCV-93 MCH-32.0 MCHC-34.4 RDW-12.0 Plt Ct-370 Glucose-83 UreaN-12 Creat-0.5 Na-140 K-3.5 Cl-100 HCO3-36* AnGap-8 Calcium-8.8 Phos-3.1 Mg-2.0 CHEST (PORTABLE AP) IMPRESSION: Despite pulmonary hyperinflation suggesting a substantial COPD, pulmonary vasculature is engorged, suggesting that mild interstitial abnormality is edema due to cardiac decompensation.",0
Nevertheless heart size is normal and mediastinal veins are not engorged.,0
Thoracic aorta is tortuous but not dilated.,0
No appreciable pleural effusion or pneumothorax.,0
VIDEO OROPHARYNGEAL SWALLOW : Swallowing videofluoroscopy was performed in conjunction with the speech and swallow division.,0
"No gross aspiration was seen, however, penetration was noted with thin liquids.",0
"The patient was observed to be coughing during the exam and was likely secondary to her COPD, not aspiration.",0
A severe amount of residue was seen with all consistencies.,0
A cricopharyngeal bar is noted.,0
"Brief Hospital Course: 74 year old female with a history of severe, Gold IV COPD who presented with dyspnea, wheezing, and cough.",0
#COPD Exacerbation: Pt admitted to the MICU and started on solumedrol 125mg q8 hours for HD1.,0
"Also started on q1 hour duonebs, five day course of azithromycin.",0
Nasopharyngeal viral screen and sputum cultures sent.,0
On HD2 she improved clinically to some degree though continued to wheeze.,0
Nebs changed to alternating albuterol and ipratropium every 2 hours.,0
Solumedrol discontinued and prednisone 40mg daily started orally.,0
Patient found to have RSV and ID was consulted for possible treatment.,0
"In discussion with infection control, patient did not require respiratory precautions as she is not chronically immunocompromised.",1
"As patient's breathing improved, she was transferred to the floor unit.",0
Nebulized treatment were continued every four hours except during the night.,0
Prednisone was decreased to 30mg after 5 days.,0
"Patients breathing continued to improve, but required persistent oxygen at 2L to keep saturations above 90%.",0
She will taper steroid dose by 5 mg every four days until reaching a dose of 15 mg/day then contact her pulmonologist for further instructions.,0
"Patient was discharged to an extended care facility, Pleasant Bay, to continue physical therapy.",0
# Dysphagia: Patient had a video swallow evaluation that showed severe limitation on swallowing due to cricopharyngeal narrowing.,0
"Patient was evaluated by ENT team and recommended further procedures such as a balloon dilation or Botox injections, but it is reasonable to wait after recovery from this exacerbation.",0
#S/P TIA: Dialy Aspirin was continued .,0
#GERD: omeprazole was continued Transitional Issues: -She will contact Dr. when she reaches a dose of 15mg/day of prednisone to discuss further titrating down the dose -She will follow up with ENT for further management and possible procedures for her dysphagia and cricopharyngeal myositis Medications on Admission: albuterol neb qid prn albuterol inh 2 puffs qid prn omeprazole 20mg daily prednisone 5mg daily salmeterol 50mcg 1 puff theophylline 200mg capsule daily tiotropium 18mcg inh daily vitamin c asa 81mg daily vitamin D Medications: 1. albuterol sulfate 5 mg/mL Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing.,1
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing.,0
4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain.,0
5. cetirizine 1 mg/mL Solution Sig: One (1) dose PO three times a day.,0
"6. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
7. salmeterol 50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day.,0
"8. theophylline 200 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day.",0
"9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day.",0
11. acetaminophen-codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs PO Q6H (every 6 hours) as needed for cough/pain.,0
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily).,0
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
14. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
Vitamin B Complex With C Capsule Sig: One (1) Capsule PO once a day.,0
16. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day: Take 3 tablets for 3 days.,0
"then 2.5tablets (25mg) for 5 days, then 20mg for 5days, then 15mg until discussed with Dr. .",0
Disp:*60 Tablet(s)* Refills:*0* Disposition: Extended Care Facility: Pleasant Bay Nursing & Rehabilitation Center - Diagnosis: Primary diagnosis: COPD exacerbation RSV Secondary diagnosis: Cricopharyngeal dysfunction prolapsed uterus s/p TIA Condition: Mental Status: Clear and coherent.,0
"Instructions: Dear Mrs. , You were admitted for your shortness of breath.",0
You were found to have a severe exacerbation of your COPD.,0
"You were admitted to the Intensive Care Unit and were given steroids at higher dose, nebulized treatments, and antibiotics.",0
"You were found to have a virus called RSV, which might have been the trigger to your exacerbation.",1
Your breathing improved and you were transferred to the floor where you continued to improve.,0
"Because you were quite weak, it was highly recommended you continue to recuperate at a rehab facility.",0
Your swallowing was evaluated and found to have very limited swallow.,0
It is recommended you supplement your meals with nutritional shakes and crush your medications.,0
"The following changes were made to your medications: # START prednisone at 30mg for 2 more days, then decrease to 25mg for 5 more days, then decrease to 20mg for 5 days, then decrease to 15mg and at that time call Dr. for further recommendations.",0
It was a pleasure taking care of you.,0
We hope you will soon regain your strength and enjoy your time in .,0
Followup Instructions: Please follow up with your primary care doctor from rehab.,0
6:17 PM CHEST (PORTABLE AP) Clip # Reason: assess aspiration pna and ngt placement ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with cough/GI bleed and aspir pna REASON FOR THIS EXAMINATION: assess aspiration pna and ngt placement ______________________________________________________________________________ FINAL REPORT HISTORY: 85 year old man with cough and upper GI bleed.,0
PORTABLE AP SUPINE CHEST: Evaluation of the apices is again limited by patient position.,0
The cardiac silhouette is stable.,0
"Allowing for position, the mediastinal contours are unremarkable.",0
There is no consolidation or effusion.,0
Again noted is slight elevation of the left hemidiaphragm and left basilar atelectasis.,0
The nasogastric tube tip is within the stomach.,0
"Small rounded metallic densities overlie the upper neck/lower face, correlate with exam/history.",0
9:55 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 25 year old woman with shortness of breath REASON FOR THIS EXAMINATION: please evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath.,0
PORTABLE UPRIGHT AP VIEW OF THE CHEST: The heart size is normal.,0
The mediastinal and hilar contours are within normal limits.,0
The lungs are clear without focal consolidation.,0
No pleural effusion or pneumothorax is visualized.,0
There are no acute osseous abnormalities.,0
"4:38 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CHEST PAIN;+ETT\CATH Admitting Diagnosis: CHEST PAIN;+ETT\CATH ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with CAD, plan for CABG REASON FOR THIS EXAMINATION: pre-op eval ______________________________________________________________________________ FINAL REPORT INDICATION: Preoperative for CABG.",0
PA AND LATERAL CHEST: The lungs are clear.,0
"Cardiac, mediastinal, and hilar contours are within normal limits.",0
Surrounding osseous and soft tissue structures are unremarkable.,0
There is gas in the large bowel.,0
4:22 PM CHEST (PORTABLE AP) Clip # Reason: s/p chest tube removal.,0
Please eval f Admitting Diagnosis: CORONARY ARTERY DISEASE;R/O MI ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with an aortic dissection s/p asc.,1
REASON FOR THIS EXAMINATION: s/p chest tube removal.,0
Please eval for location of Duboff feeding tube ______________________________________________________________________________ FINAL REPORT INDICATION: Feeding tube repositioned.,0
FINDINGS: The feeding tube is coiled in the esophagus with the tip in the lower esophagus.,0
Again seen is right IJ Swan-Ganz catheter with tip in the pulmonary outflow tract.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Morphine / Coumadin Attending: Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr is a 76 y/o M with a history of multiple sclerosis, paroxysmal atrial fibrillation on aspirin and , hypertension, hyperlipidemia, previously diagnosed ""vasovagal syncope,"" prostate cancer, neurogenic bladder with chronic suprapubic cath, history of ESBL UTI, chronic constipation, and left parietal AVM, presenting from home after a syncopal episode.",1
Patient apparently woke up this morning feeling extremely weak and tired.,0
"Per his wife, he was also difficult to arouse with multiple episodes of somnolence.",0
"EMS was called in the morning, but patient refused to be taken to the hospital as he felt well by their arrival.",0
"Patient was then eating a bowl of fruit this afternoon, and his wife found him slumped in a chair.",0
He regained conciousness several minutes later.,0
EMS was subsequently called again.,0
"Patient has no recollection of passing out, nor did he feel any prodrome of chest pain, nausea, diaphoresis, SOB, dizziness.",0
"On EMS arrival, HR 30s BP 70s, and patient was asymptomatic.",0
"On arrival to the ED, HR was in the 30s-40s, BPs labile 80s-120s.",0
Patient had no symptoms during low BPs.,0
"He was given IV cipro for history of UTI, 2L NS and sent to the unit.",0
His Hct was 26 and was guiac negative in the ED.,0
"On transfer to the unit, patient was afebrile HR 44, 114/49 18 100% on 2L NC.",0
"Of note, patient had been admitted in for a similar episode of unresponsiveness with a negative workup, as well as prior synopal workups in the past.",0
He reports that todays episode was similar in nature in that he did not feel any prodrome and did not remember passing out.,0
"He also has had several episodes of diagnosed ""vasovagal syncope,"" prior to which he sometimes feels weak and nauseous.",0
"On review of prior notes, patient is also chronically bradycardic with HRs in 40s at , with transient episodes of hypotension.",0
"He has a Holter monitor in our system from , which showed no ectopy, HRs 49-70, with prolonged PR intervals .24. .",0
"On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",0
"Of note, he had a EGD/colonoscopy on for workup of Fe deficiency anemia, which showed a non-bleeding adenoma.",0
"His last bowel movement was 1.5 weeks ago, whichg he states is roughly his .",0
"Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations.",0
"CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2.",1
CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3.,0
Multiple sclerosis - followed by Dr. at .,1
Neurogenic bladder - suprapubic catheter in place; followed by Dr. .,1
Severe constipation - followed by Dr. .,0
Prostate cancer - s/p hormonal therapy and radiation.,0
He has been pursuing watchful waiting since the Spring .,0
He is followed at the Cancer Institute.,0
History of AVM in the left parietal lobe 13.,0
Obstructive sleep apnea utilizing CPAP at night 14.,0
History of left foot fracture 21.,0
Shingles - Social History: Lives with wife in .,0
"Former etoh, sober since via AA.",0
Quit cigars a few years ago.,0
Retired judge (at age 68 due to fatigue).,0
"Family History: Per notes, daughter and cousin with MS, mother with AD, father with leukemia, brother with arrhythmia.",0
Physical Exam: VS: T= 97 BP= 108/57 HR= 44 RR= 12 O2 sat= 100% RA GENERAL: NAD.,0
NECK: Supple with JVP of 6 cm.,0
"Nontender, no guarding or rebound.",0
PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: 1.,0
Labs on admission: 05:40PM BLOOD WBC-7.8 RBC-3.31* Hgb-8.7* Hct-26.8* MCV-81*# MCH-26.4* MCHC-32.6 RDW-15.3 Plt Ct-178 05:40PM BLOOD PT-14.1* PTT-31.7 INR(PT)-1.2* 05:00AM BLOOD Glucose-159* UreaN-16 Creat-0.9 Na-139 K-3.6 Cl-112* HCO3-23 AnGap-8 05:00AM BLOOD CK(CPK)-40* 05:40PM BLOOD cTropnT-<0.01 05:00AM BLOOD CK-MB-3 cTropnT-<0.01 05:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0 05:54PM BLOOD freeCa-1.08* .,0
Labs on discharge; 05:59AM BLOOD WBC-5.2# RBC-3.80*# Hgb-9.9*# Hct-30.7*# MCV-81* MCH-26.0* MCHC-32.3 RDW-14.6 Plt Ct-161 05:59AM BLOOD Glucose-110* UreaN-17 Creat-0.9 Na-140 K-3.9 Cl-111* HCO3-23 AnGap-10 05:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0 .,0
Imaging/diagnostics: - CXR (): No acute cardiopulmonary process.,0
- EKG (): Sinus bradycardia and A-V conduction delay with slight shortening of the P-R interval as compared to the previous tracing of .,0
The Q-T interval remains prolonged.,0
"- Tilt-table test (): *preliminary finding*: delayed neurally mediated syncope with orthostatic hypotension, systolic blood pressure drop from 160s to 60s.",0
"Brief Hospital Course: Mr is a 76 y/o M with a history of multiple sclerosis, paroxysmal atrial fibrillation on aspirin and , hypertension, hyperlipidemia, previously diagnosed ""vasovagal syncope,"" neurogenic bladder with chronic suprapubic cath, history of ESBL UTI, chronic constipation, and left parietal AVM, presenting from home after a syncopal episode.",1
Syncope: EKG on admission showed first degree heart block.,0
Patient did not have any other arrythmia throughout the hospital course.,0
Symptoms similar to prior vaso-vagal episodes.,0
Tilt table test was done which showed delayed neurally mediated syncope with orthostatic hypotension (sBP 160s-->60s).,0
Patient to follow-up with outpatient cardiologist.,0
Atrial Fibrillation: Remained in sinus bradycardia and was kept on home regimen of aspirin/ rather than coumadin in the context of known AVM.,1
# HTN: Kept on home enalapril.,0
New home amlodipine was stopped.,0
# HLD: Continue one home simvastatin .,0
# Chronic UTI: History of ESBL UTI with suprapubic catheter site.,0
Urinanalysis on admission was positive and urine culture grew out E. coli.,0
Speciation at the time of discharge was not available.,0
"Per outpatient urologist, this is consistent with chronic colonization and will be treated with outpatient antibiotics regimen by urologist.",0
# Neurogenic bladder: Patient was on oxybutynin while in patient and discharged with home darifenacin on discharge.,1
"Constipation: Secondary to neuropathy from MS, chronic problem.",0
Aggressive bowel regimen administered with effect.,0
Medications on Admission: - Amlodipine 7.5 mg daily - Baclofen 20 mg qhs - Brimonidine .1% drops TID - 75 mg daily - Darifenacin 7.5 mg daily - Dorzolamide-timolol 1 drop TID - Enalapril 20 mg - Latanoprost 1 drop qhs - Macrobid 100 mg daily one out of 3 weeks - Omeprazole 40 mg - Peg-electrolyte solution 420 1 bottle daily - Simvastatin 10 mg qhs - Aspirin 325 mg daily - Calcium 600 mg + D daily - Cascara - Colace - Multivitamin - Omega-3 fatty acids Discharge Medications: 1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours).,0
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime).,0
"4. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day).",0
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
10. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
11. baclofen 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
12. darifenacin 7.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)).,0
13. carbamide peroxide 6.5 % Drops Sig: 5-10 Drops Otic (2 times a day) for 4 days.,0
14. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day).,0
15. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day).,0
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Discharge Disposition: Home Discharge Diagnosis: Primary: Vasovagal syncope Discharge Condition: Mental Status: Clear and coherent.,0
Activity Status: Ambulatory - requires assistance or aid ( or cane).,0
Discharge Instructions: You were seen in the hospital because a syncopal episode.,0
This episode was likely secondary due a vasovagal cause.,0
"You had a tilt table test to explore possible causes for your syncopal episode, which showed a drop in your blood pressure with tilting.",0
You will need to follow up with your cardiologist Dr. (appointment below) to discuss the final results.,0
We made the following changes to your medications: STOPPED Amlodipine .,0
It was a pleasure taking care of you during your hospital stay.,0
Followup Instructions: -You have an appointment scheduled with Dr. : Monday at 11:30 AM -You should also make a follow up appointment with your PCP .,0
Height: (in) 65 Weight (lb): 128 BSA (m2): 1.64 m2 BP (mm Hg): 158/80 HR (bpm): 115 Status: Inpatient Date/Time: at 11:57 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Doppler parameters are most consistent with Grade I (mild) LV diastolic dysfunction.,0
"[Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction.,0
A small (8 mmHg) mid-cavitary gradient is identified.,0
IMPRESSION: Vigorous global and regional biventricular systolic function.,0
"1:13 AM CHEST (PA & LAT) Clip # Reason: Evaluate for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 22 year old woman with fever, worsening cough REASON FOR THIS EXAMINATION: Evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST INDICATION: 22-year-old woman with fever, worsening cough.",0
FINDINGS: There has been interval development of mild interstitial and alveolar opacities bilaterally.,0
11:18 AM CHEST (PORTABLE AP) Clip # Reason: r/o pneumo R ______________________________________________________________________________ MEDICAL CONDITION: 30 year old man with s/p MVC REASON FOR THIS EXAMINATION: r/o pneumo R ______________________________________________________________________________ FINAL REPORT INDICATION: Status post trauma.,0
"CHEST X-RAY, AP: Comparison made to film of , one day prior.",0
There has been interval removal of one right chest tube.,0
"There still remains one right chest tube, two left chest tubes, SG catheter, NG tube, and ET tube.",0
The ET tube is unchanged in position with tip 6.6 cm from the carina.,0
The SG catheter is seen with tip in the main pulmonary artery.,0
The two left and remaining right chest tubes are unchanged in position from one day prior.,0
"Bilateral patchy opacities are seen, which are unchanged from prior.",0
These are likely consistent with ARDS vs. pneumonia.,0
A small left apical pneumothorax is seen.,0
No pneumothorax is seen on the right side.,0
"IMPRESSION: Bilateral patchy infiltrates, ARDS vs. pneumonia.",0
"11:56 AM BABYGRAM AP ABD ONLY Clip # Reason: bloody stools, R/O NEC Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with bloody stools REASON FOR THIS EXAMINATION: bloody stools, R/O NEC ______________________________________________________________________________ FINAL REPORT PORTABLE KUB: at 12:16 p.m. HISTORY: 10-day-old girl with bloody stools.",0
COMPARISON STUDIES: None are available.,0
FINDINGS: A bubbly bowel gas pattern is seen in the left lateral abdomen.,0
"There are a few gas-filled, mildly dilated loops in the central and lower abdomen that have a tubular, unwound appearance.",0
Mild bowel wall thickening is also suggested in this region.,0
A degree of bowel gas asymmetry is present.,0
No portal venous gas is identified.,0
Remainder of visualized abdominal structures are unremarkable.,0
An enteric tube projects over a left-sided stomach.,0
The basilar lungs appear clear.,0
IMPRESSION: Findings suspicious for necrotizing enterocolitis.,0
Pneumatosis is probably present in the left lateral abdomen.,0
RECOMMENDATION: Follow up images are recommended.,0
NOTE: Discussed in person with members of the patient's NICU treatment team at about 12:45 p.m. on .,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: - Right thoracotomy, Mitral Valve Repair(28mm ring) History of Present Illness: 78 year old male with history of previous heart surgery status post previous CABG/Redo CABG now with a several month history of shortness of breath.",1
He has had known mitral valve regurgitation over the past several years followed by serial echocardiograms.,1
Most recent echo shows moderate to severe mitral regurgitation.,0
He is admitted for surgical management of his mitral valve disease.,1
"Past Medical History: Mitral Regurgitation s/p minimally invasive Mitral valve replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft ' and again in ' (LIMA->D1, SVG->LAD, SVG->RCA) Peripheral Disease s/p stents to left renal artery, bilateral iliacs, and distal aorta Diabetes Mellitus II Atrial Fibrillation Hypertension Hypercholesterolemia Congestive Heart Failure, EF < 25% Chronic Renal Insufficiency (baseline Cr 1.6-1.9) Renal Artery Stenosis Gastroesophageal Reflux Disease Chronic Obstructive Pulmonary Disease Benign Prostatic Hypertrophy s/p Bilateral carotid endarterectomies s/p Laproscopic Cholecystectomy s/p hernia repair Social History: The patient lives with his wife in , MA.",1
He is a retired custodian.,0
He denies tobacco or alcohol at present but formerly smoked ppd x 30 years.,0
"Family History: Noncontributory Physical Exam: NEURO: Awake and alert HEENT: PERRL, EOMI, OP benign HEART: RRR, + murmur.",0
"Well healed sternotomy CHEST: Clear lungs ABD: soft and nontender Extermities: warm, no edema, 1+ DP/PT pulses Pertinent Results: 06:13PM PT-13.7* PTT-26.8 INR(PT)-1.3 06:13PM PLT COUNT-174 06:13PM WBC-4.2 RBC-3.95* HGB-11.8* HCT-36.1*# MCV-91 MCH-29.8 MCHC-32.7 RDW-18.7* 06:13PM ALBUMIN-4.2 CALCIUM-8.2* PHOSPHATE-3.9 MAGNESIUM-2.3 06:13PM ALT(SGPT)-48* AST(SGOT)-47* ALK PHOS-155* TOT BILI-0.8 06:13PM GLUCOSE-128* UREA N-56* CREAT-2.2* SODIUM-140 POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-24 ANION GAP-16 06:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 06:39PM URINE COLOR-Straw APPEAR-Clear SP -1.012 09:30AM BLOOD WBC-8.9 RBC-3.56* Hgb-10.4* Hct-32.3* MCV-91 MCH-29.4 MCHC-32.3 RDW-17.3* Plt Ct-176# 06:55AM BLOOD PT-14.6* INR(PT)-1.5 06:55AM BLOOD Glucose-110* UreaN-65* Creat-2.5* Na-138 K-4.9 Cl-104 HCO3-28 AnGap-11 09:22PM BLOOD ALT-28 AST-55* LD(LDH)-336* AlkPhos-84 Amylase-97 TotBili-1.0 CXR Persistent moderate loculated right pleural effusion.",0
Improving atelectasis in the right middle and right lower lobes.,0
Probable old inferior wall myocardial infarction.,0
Compared to the previous tracing of no diagnostic interim change.,0
ospital Course: Mr. was admitted to the on for elective surgical management of his mitral valve regurgitation.,1
He was started on heparin as his INR was allowed to drift down for surgery.,0
"On , Mr. was taken to the operating room where he underwent a mitral valve repair utilizing a 28mm annuloplasty ring via a right thoracotomy.",1
He underwent a bronchoscopy for secretions.,0
"On postoperative day one, Mr. neurologically intact and was extubated.",0
Beta blockade and aspirin were started.,0
He developed rapid atrial fibrillation which converted to normal sinus rhythm with amiodarone and lopressor.,1
"On postoperative day two, he was transferred to the step down unit for further recovery.",0
He had a mild bump in his creatinine which stabilized with holding his lasix.,0
The endocrinology service was consulted for assistance with his diabetes medication management and acute hypoglycemia.,0
"As his oral intake increased to normal, he had no further episodes of hypoglycemia on glyburide.",0
"As Mr. continued to have paroxysmal atrial fibrillation, coumadin was started for anticoagulation.",1
Mr. continued to make steady progress and was discharged home on postoperative day seven.,0
"He will follow-up with Dr. , his cardiologist and his primary care physician as an outpatient.",0
Medications on Admission: Lipitor 8omg daily Zetia 10mg daily DIovan 80mg daily Toprol XL 200mg daily Cardura 2mg daily Prilosec 20mg daily Aspirin 81mg daily Proscar 5mg daily Glyburide 2.5mg twice daily Lasix 40mg daily Coumadin Epogen Iron Discharge Medications: 1.,0
Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).,0
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2* 5.,0
Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days.,0
Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.,0
"Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day: Take once in AM, and tab in PM.",0
Follow-up with PCP for diabetes management this week.,0
Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Mitral valve regurgitation in the setting of two previous cardiac surgeries.,1
Discharge Instructions: Follow medications on discharge instructions.,0
"Check blood glucose when you wake up before breakfast, and before you go to sleep at night, call PCP if BS<70 ir >200.",0
You should not lift more than 10 lbs for 3 months.,0
You should not drive for 4 weeks.,0
"You should shower daily, let water flow over wounds, pat dry with a towel.",0
"Do not use creams, lotions, or powders on wounds.",0
"Call our office for sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. for one week.",0
Make an appointment with Dr. for 4 weeks.,0
Make an appointment with your caridologist to 2-3 weeks.,0
Status: Inpatient Date/Time: at 14:20 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
The IVC is normal in diameter with collapse during respiration (estimated RAP 0-5mmHg).,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
The estimated right atrial pressure is 0-5mmHg.,0
POST-BYPASS: Patient is AV paced on phenylepherine infusion.,0
"Slightly improved global biventricular function, LVEF 50-55%.",0
No change in wall motion.,0
There is mild to moderate central mitral regurgitation.,0
There is no apparent residual ASD by color flow analysis and 2-D evaluation.,0
11:03 AM MR ENTEROGRAPHY (&) SBFT Clip # Reason: eval for stricture prior to capsulte study.,0
"Admitting Diagnosis: LOWER GI BLEED Contrast: PROHANCE Amt: 30 ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with disease, gi bleed REASON FOR THIS EXAMINATION: eval for stricture prior to capsulte study.",0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PJBj SAT 4:01 PM PFI: The small bowel appears normal.,0
"INDICATION: Assess for small bowel stricture, patient awaiting capsule endoscopy.",0
Study is significantly limited by inability of the patient to breath-hold adequately.,0
"TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 T magnet including dynamic 3D imaging obtained prior to, during and after the uneventful intravenous administration of 0.1 mmol/kg gadolinium-DTPA.",0
"FINDINGS: The duodenum, jejunum and ileum appear normal without significant dilatation.",0
No mucosal thickening is identified.,0
No collection or free fluid is identified.,0
There is a pelvic kidney on the left side with a 6.6 x 6.4 cm cyst in the lower pole.,0
No internal enhancement or nodularity is present.,0
There is a 1 x 1.4 cm cyst in the interpolar region of the right kidney.,0
"Visualized portions of the liver, pancreas and adrenal glands are normal.",0
Mild splenomegaly at 14 cm is present.,0
IMPRESSION: The small bowel appears normal.,0
"3:38 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: please push NG tube (already placed) to be post-pyloric Admitting Diagnosis: PLEURAL CUT FISTULA PE Contrast: OPTIRAY Amt: 30 ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with malnutrition, anxiety, pulmonary abscesses REASON FOR THIS EXAMINATION: please push NG tube (already placed) to be post-pyloric ______________________________________________________________________________ WET READ: PRib WED 6:20 PM Successful placement of post-pyloric nasointestinal tube with tip in the second portion of duodenum, slightly coiled, but with enough slack to allow peristalsis to correctly align the tube.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: Malnutrition, anxiety, pulmonary abscesses, please push NG tube post-pyloric.",1
FINDINGS: NG tube was already placed in the stomach on patient's arrival.,0
"Under fluoroscopic guidance, the tube was advanced into the duodenum and remains with its tip in the second portion of the duodenum, slightly coiled, however, with enough slack to allow for peristalsis to place the tube in the correct alignment.",0
Contrast was injected into the tube to confirm its intra-intestinal location.,0
"IMPRESSION: Successful placement of post-pyloric nasointestinal tube with tip in the second portion of duodenum, slightly coiled, but with enough slack to allow peristalsis to correctly align the tube.",0
2:17 PM CHEST (PRE-OP PA & LAT) Clip # Reason: preop ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with cecal mass for resection on REASON FOR THIS EXAMINATION: preop ______________________________________________________________________________ FINAL REPORT INDICATION: 55-year-old woman preop for cecal mass resection.,0
PA and lateral chest radiographs were obtained and compared to the next prior study of .,0
The heart size is normal and the mediastinal and hilar contours are unremarkable.,0
The pulmonary vascularity is within normal limits with no evidence of heart failure.,0
Both right and left lungs are clear without infiltrates and there are no pleural effusions.,0
Note is made of contrast material within the bowel in the left upper quadrant.,0
"Since the prior study, there has been complete resolution of the previously seen bilateral pleural effusions.",0
IMPRESSION: Normal radiographic appearance of the chest.,0
"10:23 AM CT HEAD W/O CONTRAST Clip # Reason: f/u on prior intracranial bleed Admitting Diagnosis: HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man, motorcycle accident s/p evacuation SDH REASON FOR THIS EXAMINATION: f/u on prior intracranial bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Status post evacuation of subdural hematoma.",1
FINDINGS: There has been no change from the prior examination.,0
There is no evidence of significant subdural accumulation at the present time.,0
Hemorrhagic contusions are again noted.,0
Ventricular dimension is unchanged and the slight degree of herniation is likewise similar to the prior study.,0
IMPRESSION: 1) No change from prior examination.,0
Status: Inpatient Date/Time: at 08:50 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Mildly thickened aortic valve leaflets (?#).,0
Trace MR. AI remains +.,0
"2:30 PM PELVIS U.S., TRANSVAGINAL PORT Clip # Reason: please evaluate for gyn pathology Admitting Diagnosis: MYELODYSPLASTIC SYNDROME\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 52 year old postmenopausal woman with MDS s/p stem cell transplant with pancytopenia with vaginal bleeding REASON FOR THIS EXAMINATION: please evaluate for gyn pathology ______________________________________________________________________________ FINAL REPORT US pelvis INDICATION: 52-year-old postmenopausal female with myelodysplastic syndrome, status post stem cell transplantation with pancytopenia.",1
The patient's last period was reported in .,0
FINDINGS: Transabdominal and transvaginal ultrasound was performed for optimal evaluation of the endometrium and adnexae.,0
The uterus is neither anteflexed or retroflexed.,0
It measures 8.3 x 4.6 x 7.1 cm and appears heterogenous in echotexture.,0
"Moderate-to-large amount of free fluid is seen within the pelvis, similar to recent prior CT exam.",0
The endometrial stripe is slightly heterogeneous and thickened to 1.0 cm.,0
Evaluation is limited given patient habitus and inability to fully cooperate for the exam.,0
"Although a partially calcified exophytic fibroid is suggested on recent prior CT extending from the left lateral aspect of the fundus, this was not seen on ultrasound.",0
The right ovary appears normal measuring 1.1 x 1.6 x 1.2 cm.,0
"The left ovary also appears normal without masses, measuring 1.5 x 1.8 x 1.5 cm.",0
"Heterogeneous uterus with thickening of the endometrial stripe measuring up to 1 cm, concerning in a postmenopausal patient.",0
Consider hysteroscopy/direct visualization for further evaluation.,0
"Normal appearance of both ovaries, without adnexal masses.",0
"Although an exophytic partially calcified fibroid is suggested extending from the left lateral aspect of the fundus on recent prior CT, this is not visualized on ultrasound.",0
"6:49 PM PELVIS PORTABLE Clip # Reason: R HIP REPLACEMENT ______________________________________________________________________________ FINAL REPORT PELVIS, SINGLE AP FILM.",0
S/P total right hip replacement with non-cemented intrafemoral components and cerclage wires.,0
Position of prosthesis appears satisfactory in this single view.,0
"10:31 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for CHF/flash pulm edema Admitting Diagnosis: VENTRICULAR TACHYCARDIA\CATH ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with COPD on 4L home O2, s/p extubation, positive 3.7 L. REASON FOR THIS EXAMINATION: eval for CHF/flash pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old female with COPD, status post extubation.",1
Evaluate for CHF or flash pulmonary edema.,0
"COMPARISONS: Comparison is made to radiograph performed the same day, 3 hours earlier.",0
"FINDINGS: There is probably mild cardiomegaly, allowing for difference in technique.",0
"There are bilateral increased interstitial patchy opacities in the posterior segment of the right upper lobe, that could represent an infectious process.",0
There is a transfemoral pacemaker lead with the tip in the right ventricle.,0
IMPRESSION: Findings are consistent with CHF and bilateral pleural effusions.,0
Questionable patchy area in the right upper lobe could represent pneumonia.,1
"4:22 PM CHEST (PORTABLE AP) Clip # Reason: Is there persistant or worsening pulmonary vascular congesti Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man H/O systolic CHF (EF 40-45%), dilated cardiomyopathy, CAD s/p stents, and rectal cancer with oxygen sats to 88% on trach mask with fiO2 of 50%.",0
History of hemoptysis x 5 days.,0
REASON FOR THIS EXAMINATION: Is there persistant or worsening pulmonary vascular congestion?,0
______________________________________________________________________________ WET READ: EAGg WED 5:10 PM worsening pulmonary edema.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Dilated cardiomyopathy with decreased ejection fraction.,0
"There is slight interval increase of left perihilar opacity, most likely consistent with asymmetric pulmonary edema, although infectious process cannot be entirely excluded.",0
The tubes and lines are in unchanged position.,0
Cardiomegaly is moderate to severe.,0
Left pleural effusion is present.,0
1:19 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Please assess for ET and OG tube positioning.,0
"Admitting Diagnosis: MELANOMA\CHEMOTHERAPY (HD-IL2) ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with met melanoma, admitted for HD IL-2 therapy s/p intubation and OG placement.",1
Now ET tube has been advanced for optimum positioning.,0
OG tube was not visible in the stomach due to quality of prior film REASON FOR THIS EXAMINATION: Please assess for ET and OG tube positioning.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Assess ET tube and NG tube positioning.,0
Compared to prior study performed 1 hour before the NG tube is more clearly visualized with tip out of view below the diaphragm.,0
ET tube tip is 4.7 cm above the carina.,0
There are no acute interval changes.,0
7:13 AM CAROT/CEREB Clip # Reason: eval Rt MCA aneurysm post clipping Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 95 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT * * VERT/CAROTID A-GRAM CAROTID/CERVICAL UNILAT * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with SAH REASON FOR THIS EXAMINATION: eval Rt MCA aneurysm post clipping ______________________________________________________________________________ FINAL REPORT CEREBRAL ANGIOGRAM performed on .,1
Correlation is made with CTA head dated and CT head dated .,0
INDICATIONS: Mr. is a 46-year-old male who presented with subarachnoid hemorrhage in the right sylvian fissure and was discovered to have a right MCA aneurysm.,1
The patient went to the operating room to have clipping of the aneurysm.,0
The angiogram today is being performed as a postoperative evaluation.,0
TECHNIQUE: Informed written consent was obtained.,0
The patient was brought to the angiography suite and both groins were prepared and draped in usual sterile fashion.,0
The patient was under general anesthesia and 1% lidocaine was used for local anesthesia.,0
"Using a 19 gauge needle, a single wall puncture was made into the right common femoral artery through which a 0.35 Berenstein wire was advanced.",0
"Over the wire, a 5 French Berenstein catheter was advanced and the following vessels were selectively catheterized and AP and lateral filming was performed.",0
FINDINGS: Right common carotid artery and right internal carotid artery injection showed a well clipped right MCA aneurysm.,0
There is no evidence of residual flow or residual neck.,0
There is mild spasm of the right M2 branches.,0
Note is made of a trifurcation of the A2 segmentation.,0
No other aneurysms were identified.,0
There is no evidence of flow-limiting stenosis or dissection.,0
Several of the right anterior temporal branches were not visualized during the arteriogram.,0
(Over) 7:13 AM CAROT/CEREB Clip # Reason: eval Rt MCA aneurysm post clipping Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 95 ______________________________________________________________________________ FINAL REPORT (Cont) Left vertebral artery arteriogram demonstrates mild fusiform dilatation of the basilar artery.,1
"No saccular aneurysms, areas of flow-limiting stenosis or occlusion were identified.",0
A fetal origin of the right posterior cerebral artery was noted.,0
Left internal carotid artery arteriogram demonstrates a 2-mm aneurysm near the origin of the left posterior communicating artery.,0
"No other aneurysms, areas of flow-limiting stenosis or occlusion were identified.",0
Well clipped right MCA aneurysm without evidence of residual flow.,0
Mild spasm of the right M2 branches.,0
"Of note, several of the right temporal branches were not visualized on the examination.",0
2 mm aneurysm near the origin of the left PCOM.,0
OR THERAPEUTIC; FEE ADJUSTED IN SPECIFIC SITUATIONClip # GUIDANCE FOR /ABD/PARA CENTESIS US; FEE ADJUSTED IN SPECIFIC SITUATION Reason: please U/S guided do DIAGNOSTIC ONLY paracentesis.,0
Labs in Admitting Diagnosis: ALCOHOLIC CIRRHOSIS ********************************* CPT Codes ******************************** * PARACENTESIS DIAG.,1
"OR THERAPEUTIC FEE ADJUSTED IN SPECIFIC SITUATION * * GUIDANCE FOR /ABD/PARA CENTESIS FEE ADJUSTED IN SPECIFIC SITUATION * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with ESLD and mental status, small pocket of ascites.",1
REASON FOR THIS EXAMINATION: please U/S guided do DIAGNOSTIC ONLY paracentesis.,0
CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ FINAL REPORT Please see report for clip # for ultrasound-guided diagnostic paracentesis.,0
Pre ablation evaluation of coronary anatomy and gradient on Dobutamine.,0
Height: (in) 63 Weight (lb): 184 BSA (m2): 1.87 m2 BP (mm Hg): 124/60 HR (bpm): 60 Status: Inpatient Date/Time: at 16:00 Test: Portable TTE (Focused views) Doppler: Focused pulse and color flow Contrast: Optison Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
There is a severe resting left ventricular outflow tract obstruction.,0
AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with good leaflet excursion.,0
Mitral regurgitation is present but cannot be quantified.,0
PATIENT/TEST INFORMATION: Indication: Hypotensive s/p cath procedure; ?effusion Height: (in) 65 Weight (lb): 152 BSA (m2): 1.76 m2 BP (mm Hg): 111/80 HR (bpm): 140 Status: Inpatient Date/Time: at 14:52 Test: Portable TTE(Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
"Left ventricular wall thickness, cavity size, and systolic function are normal.",0
5:22 PM CHEST (PA & LAT) Clip # Reason: r/o ptx s/p ct's removed Admitting Diagnosis: ATRIAL SEPTAL DEFECT\ REPAIR ATRIAL SEPTAL DEFECT; REDO W/RIGHT ATRIAL MASS EXCISION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with atrial mass resection REASON FOR THIS EXAMINATION: r/o ptx s/p ct's removed ______________________________________________________________________________ FINAL REPORT INDICATION: 44-year-old male who is status post atrial mass resection.,0
TECHNIQUE: AP single view of the chest.,0
"FINDINGS: Cardiac, mediastinal, and hilar contours are unchanged when compared to prior study.",0
There is again noted a left IJ central line with the tip in the SVC.,0
The ET tube was removed.,0
There is interval development of multiple patchy and plate-like opacities throughout the bilateral lung fields that most likely represent atelectasis.,0
There is persistent opacity in the left retrocardiac zone that is unchanged when compared to the prior study.,0
"A very small right apical pneumothorax, it was not seen in the prior study, probably due to positioning.",0
No large effusions are seen.,0
Small residual right apical pneumothorax.,0
Interval development of new atelectasis.,0
12:03 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: To reassess for necrotizing pancreatitis.,0
"Had CT one week a Admitting Diagnosis: GALLSTONE PANCREATITIS Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with necrotizing pancreatitis, improving.",0
REASON FOR THIS EXAMINATION: To reassess for necrotizing pancreatitis.,0
Had CT one week ago.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Necrotizing pancreatitis, improving.",0
COMPARISON: No prior studies are available.,0
TECHNIQUE: Pre- and post intravenous contrast images of the abdomen with post-contrast images of the the pelvis.,0
ABDOMEN WITH AND WITHOUT CONTRAST: There are small bilateral pleural effusions with associated atelectasis and/or consolidation at the lung bases.,0
"The liver, spleen, adrenal glands, and kidneys are within normal limits.",0
Dense bile is seen within an otherwise unremarkable- appearing gallbladder.,0
A large collection of fluid with a minimally enhancing rim is noted replacing the bulk of the pancreas.,0
"Normally-enhancing pancreatic parenchyma is seen in the region of the uncinate process and the pancreatic head, but no enhancing pancreatic tissue is evident in the regions of the body and tail.",0
A small amount of ascites is present surrounding the liver laterally and inferiorly.,0
Oral contrast reaches the level of the transverse colon.,0
"There is dilatation of several small bowel loops, but no evidence for obstruction.",0
"PELVIS WITH CONTRAST: The uterus is bulky and heterogeneous, suggesting the presence of fibroids.",0
A Foley catheter is present within the decompressed bladder.,0
There is no inguinal or deep pelvic lymph adenopathy.,0
Soft tissue edema is noted along the dependent portions of the back and lower- half of the torso.,0
BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions.,0
Findings consistent with necrotizing pancreatitis.,0
Passage of contrast to the transverse colon.,0
Bilateral pleural effusions with atelectasis/consolidation.,0
"Bulky heterogeneous uterus, suggesting the presence of fibroids.",0
"Should the previous CT scan become available, we will gladly make a comparison.",0
(Over) 12:03 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: To reassess for necrotizing pancreatitis.,0
Had CT one week a Admitting Diagnosis: GALLSTONE PANCREATITIS Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont),0
"8:58 PM CHEST (PORTABLE AP) Clip # Reason: please eval r/o pneumothorax ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with mediastinal hematoma, rib fractures REASON FOR THIS EXAMINATION: please eval r/o pneumothorax ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON .",1
Comparison is made with a reference chest CT performed at outside hospital from earlier today.,0
"CLINICAL HISTORY: 71-year-old man with mediastinal hematoma, rib fractures, assess for pneumothorax.",1
FINDINGS: Supine portable AP view of the chest is obtained.,0
The lungs are clear bilaterally without signs of pneumothorax.,0
There is subtle bibasilar opacity likely reflective of atelectasis.,0
Mediastinal contour is grossly unremarkable though more thoroughly assessed on the outside hospital CT.,0
Known left-sided rib fractures are not clearly seen on this study.,0
Refer to outside hospital CT for further details regarding left-sided rib fractures and mediastinal hematoma.,0
4:00 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with hypoxemic respiratory failure REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Hypoxic respiratory failure.,1
The opacification in the left mid and lower lung zones may be increasing.,0
Continued elevation of pulmonary venous pressure.,0
"10:38 AM BABYGRAM (CHEST ONLY) PORT Clip # Reason: assess lung expansion, on cpap Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 331/2 week idm REASON FOR THIS EXAMINATION: assess lung expansion, on cpap ______________________________________________________________________________ FINAL REPORT BABYGRAM, CHEST.",0
HISTORY: Infant with 33 1/2 weeks.,0
The lung volumes are low and the multifocal diffuse lung opacities are largely obscured by lung and mediastinal contours.,0
These opacities are likely due to hyaline membrane disease.,0
The heart size appears mildly enlarged and this was discussed with Dr. .,0
4:05 AM CHEST (PORTABLE AP) Clip # Reason: eval right infiltrate Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with resp failure + fever.,1
REASON FOR THIS EXAMINATION: eval right infiltrate ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 3:01 PM Lungs clear.,0
______________________________________________________________________________ FINAL REPORT AP CHEST 5:21 A.M. : HISTORY: Respiratory failure and fever.,0
"IMPRESSION: AP chest compared to and 7: Small foci of new infection in the right mid lung, resolved.",0
Lungs fully expanded and clear.,0
6:45 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o IVI at 1 week of age Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: prematurity REASON FOR THIS EXAMINATION: r/o IVI at 1 week of age ______________________________________________________________________________ FINAL REPORT PORTABLE HEAD ULTRASOUND PERFORMED ON AT 07:57 HOURS.,1
"HISTORY: Prematurity, rule out intraventricular hemorrhage.",0
FINDINGS: There are no prior examinations for comparison.,0
The ventricles are symmetric and normal in size with no evidence of dilatation.,0
There is no intraaxial or extraaxial fluid collection.,0
The midline structures are normal.,0
There is no evidence to suggest intracranial hemorrhage.,0
The visualized -white matter differentiation is preserved.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 47 yo chronic alcoholic w/ multiple previous ED visits and admissions for alcohol withdrawal and acute on chronic pancreatitis, most recently in .",1
Pt was brought to ED via ambulance for symptoms of alcohol withdrawal.,1
"Pt states that he has been drinking ~1 quart of liquor daily, but that he has been trying to cut back.",0
He states his last drink was 1 glass of brandy at noon on .,0
"Pt states that he has been feeling tired for ""a while"" and was very anxious.",0
"Per his most recent discharge summary from , he is a type 2 diabetic on metformin and glypizide, but he has not been taking any of his medications.",0
"Pt only has mild abdominal pain, and vomited 1 x ""for a few minutes"" yesterday and had 1 x diarrhea.",0
"Pt is currently A&O x 3, and states that he has never had any withdrawal seizures, but ""had DTs"".",0
"Denies any fevers, chills, SOB, chest pain, or urinary symptoms.",0
"In the ED inital vitals were, 96.7F, BP 180/78, HR 125, RR 20, Sat 100% RA.",0
"Pt was started on an insulin drip, given thiamine 100mg iv, 1L NS bolus, and given lorazepam 2mg iv x 2.",0
Pt also received morphine 4mg iv x 1 and ondansetron 4mg iv x 1 before being admitted to FIUC.,0
"Serum alcohol level was 358, lipase 3131, serum sodium 126, and WBC 14.1.",0
"On arrival to the ICU, Pt's vital signs were: HR 130, BP 178/82, RR 18, Temp 36.2, Sat 100%.",0
Pt currently appears to be intoxicated.,0
Pt is A&O x 3.,0
"Past Medical History: Anxiety Diabetes, type 2, on oral medications, poorly controlled Alcohol abuse Hypertension Hyperlipidemia Chronic pancreatitis Social History: Patient states he owns business doing house repairs.",1
"He has had difficulty with ETOH in the past and has attended AA, but not recently.",0
"He lives with his wife and has custody of his 3 grandchirlren, 10, 7,5 years old.",0
DM/HTN/HL run in the family.,0
Physical Exam: Admission Physical: Vitals: T: 36.2C BP: 160/91 P: 122 R: 18 O2: 100% RA.,0
"General: sluggish responses, but A&O x 3.",0
"HEENT: Sclera anicteric, MMM, poor dentition, PERRL, EOMI, CN2-12 intact.",0
"Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic rate, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild epigastric tenderness, non-distended, bowel sounds present, no rebound or guarding, no organomegaly GU: no foley : warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN2-12 intact, grossly 5/5 strength in upper and lower extremities bilaterally, grossly normal sensation throughout.",0
"Discharge physical exam: BP 126/83, HR 100, RR 20, 100% RA In NAD OP moist Lungs CTA B Bilateral antecubital fossae contact dermatitis without edema Pertinent Results: Admission labs: 05:30AM BLOOD WBC-11.2* RBC-4.05* Hgb-11.7* Hct-35.6* MCV-88 MCH-29.0 MCHC-33.0 RDW-13.8 Plt Ct-247 01:30AM BLOOD Neuts-88.8* Lymphs-7.8* Monos-3.0 Eos-0.2 Baso-0.2 01:30AM BLOOD Glucose-400* UreaN-9 Creat-1.1 Na-126* K-4.6 Cl-83* HCO3-6* AnGap-42* 01:30AM BLOOD ALT-65* AST-89* TotBili-0.5 10:47PM BLOOD Ethanol-NEG 01:30AM BLOOD ASA-NEG Ethanol-358* Acetmnp-10 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 05:30AM BLOOD Triglyc-664* 05:30AM BLOOD PT-10.9 INR(PT)-1.0 Cardiac enzymes negative X 3 ABG: 04:18PM BLOOD Type-ART Temp-37.6 pO2-31* pCO2-32* pH-7.43 calTCO2-22 Base XS--2 Intubat-NOT INTUBA .",0
Lipase trend: 05:20AM BLOOD Lipase-37 05:30AM BLOOD Lipase-1662* 01:30AM BLOOD Lipase-3131* .,0
Lactate trend: 08:43AM BLOOD Lactate-0.9 06:17PM BLOOD Lactate-1.1 09:30AM BLOOD Lactate-3.0* 06:25AM BLOOD Lactate-3.9* .,0
"Other labs: 03:20PM BLOOD Calcium-8.6 Phos-2.2* Mg-1.9 Iron-18* 03:20PM BLOOD calTIBC-218* Ferritn-886* TRF-168* 08:49AM BLOOD %HbA1c-11.5* eAG-283* TSH 1.1 Micro: URINE CULTURE (Final ): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.",0
Blood culture and : pending .,0
Compared to the previous tracing of T wave abnormalities are no longer present.,0
"Studies: CXR : CHEST, SINGLE AP PORTABLE VIEW.",0
Slightly rotated positioning and low lung volumes.,0
The aorta is slightly tortuous.,0
"No CHF, focal infiltrate, or effusion is detected.",0
Minimal right basilar atelectasis is present.,0
CXR : Lung volumes are quite low.,0
"Tip of the left PIC line is difficult to see because of cardiac motion, approximately 3 cm below the estimated location of the superior cavoatrial junction.",0
"Mild cardiomegaly has increased since , but there is no pulmonary edema or particular mediastinal venous engorgement.",0
Small left pleural effusion may be present.,0
"Discharge labs: 09:05AM BLOOD WBC-5.3 RBC-3.31* Hgb-9.5* Hct-28.8* MCV-87 MCH-28.6 MCHC-32.9 RDW-14.7 Plt Ct-342# 09:05AM BLOOD Glucose-219* UreaN-4* Creat-0.8 Na-134 K-4.1 Cl-102 HCO3-23 AnGap-13 09:05AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.6 Brief Hospital Course: Brief course: Pt is a 47 yo chronic alcoholic w/ multiple previous ED visits and admissions for alcohol withdrawal and acute on chronic pancreatitis, now admitted for alcohol withdrawal, DKA, and acute on chronic pancreatitis.",1
"He was initially admitted to the ICU for insulin gtt, and close monitoring.",0
"Once his AG was closed and started on SC insulin, he was transitioned to the medical floor on .",0
Active issues: # Hyperglycemia/DKA: AIC 11.5%.,0
"Pt had serum glucose 400, HCO3 6, and anion gap of 42 on presentation.",0
"Though he is a Type 2 diabetic, given high anion gap, ketones in the urine, pt thought to have DKA +/- non-ketotic hyperosmolar state (can have overlap).",0
Precipitating factors thought to be alcohol use and non-compliance on home oral diabetic medications.,0
He was started on insulin gtt and monitored in the ICU.,0
"His anion gap initially closed, and was started on Lantus.",0
"However, his anion gap re-opened and he was restarted on the insulin gtt.",0
was consulted and recommended starting Lantus 20 units daily in addition to the drip.,0
"Once his AG closed, he was transitioned to sliding scale insulin and glargine.",0
"On the medical floor, pt expressed that he only wanted to do a regimen.",0
"Pt received diabetic teaching, nutritional support, and social work consult during his admission.",0
He wishes to follow up at clinic after discharge and an appointment has been made for him.,0
Ace inhibitor treatment is recommended.,0
# Mixed AG and non-AG acidosis: AG acidosis attributed to DKA and possible alcoholic ketoacidosis and lactic acidosis as above.,1
"He also developed a non-AG acidosis, attributed to aggressive normal saline resuscitation, which resolved once eating and NS stopped.",0
"# Alcohol abuse: Pt was tachycardic, hypertensive, and agitated, 17 on CIWA scale upon arrival to .",0
"He was initially given IV lorazepam, but on hospital day 1, was no longer .",0
He was transitioned to po lorazepam prn.,0
He was seen by social work.,0
He did not display any signs of withdrawal on the regular medical floor.,0
Pt reported that he was done with drinking due to its many complications.,0
He was seen by SW to provide him with further resources.,0
Pt reported that anxiety was a significant contributor to his drinking and expressed interest in starting SSRI therapy in the outpatient setting.,0
"# Acute on chronic pancreatitis: Pt had mild abdominal discomfort on presentation with elevated lipase to 3131 on admission, likely caused by alcohol intake.",1
He was also found to have elevated triglycerides.,0
His abdominal pain resolved and lipase had trended down to 1662.,0
"He was advanced to a regular diet, with some diarrhea that improved.",0
Lipase normalized and pt was able to tolerate a regular diet without complications.,0
"Would consider outpt GI follow up.. # Tachycardia: In the ICU, pt was tachycardic, possibly alcohol withdrawal initially, though continued to be tachycardic when out of range of withdrawal.",1
DKA likely initially as well given profoundly hypovolemic from osmotic diuresis.,0
"Pt had low-grade temps, but no fevers, and no sources of infection.",0
He was comfortable in no pain.,0
"PE was considered, but pt had no desats in oxygenation and no chest pain, making this unlikely.",0
This improved on the medical floor.,0
Would consider outpatient echo to evaluate for ETOH induced cardiomyopathy.,0
"#normocytic Anemia: Hct has fallen from 39 on admission to 27, 32.1 on day of DC.",0
Unclear what hct is at baseline as pt frequently presents with intoxication and hemoconcentrated hct.,0
"Pt denies melena, hematemesis, coffee ground emesis.",0
Iron studies c/w chronic disease.,0
This can be further monitored in the outpatient setting.,0
"Inactive issues: # Hypertension: unclear baseline but per prior DC summaries, generally SBP 140s-150s.",0
"Pt was previously on lisinopril 10mg po daily per report, but patient was not taking this medication recently.",0
# hyperlipidemia: Held statin given initially elevated LFT's.,0
"Transitional care: 1. f/u for continued reinforcement of DM regimen and teaching 2.consideration of SSRI for anxiety with psychotherapy 3.outpatient SW for ETOH/anxiety if pt willing 4.consideration of echo for what appears to be chronic, asymptomatic tachycardic 5.reinitiation of ACEI, statin, ?starting of ASA for DM.",0
Deferred on starting at time of discharge given concern for repeat ETOH abuse and recent acute illness.,0
"Medications on Admission: Home Medications (Per dc summary, Pt states he's not taking): - Metformin - Glipizide - Pioglitazone - Lisinopril - Simvastatin Discharge Medications: 1.",0
Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Fifteen (15) u Subcutaneous twice a day.,0
Disp:*1 month's supply* Refills:*1* 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*2* 4. other You reported that you were on lisinopril and simvastatin some time ago.,0
Please discuss with your PCP and whether you should restart these medications 5. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) for 5 days: To antecubital fossa.,0
Insulin Syringe 1 mL 29 x Syringe Sig: One (1) syringe Miscellaneous twice a day: use as directed for insulin injection.,0
"Disp:*1 month's supply* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Alcoholic acute pancreatitis Diabetes, Type II Metabolic acidosis Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: You were admitted with alcohol intoxication, abdominal pain that was found to be due to pancreatitis related to alcohol use and high blood sugars.",1
"Because of your high blood sugar and dehydration on admission, you were initially admitted to the medical ICU.",0
You improved on insulin and with IV fluids.,0
It is very important that you receive treatment for your anxiety and stop drinking as this could be very dangerous to your health.,0
It is also important that you take your insulin as directed and follow a diabetic diet.,0
You are being discharged on new medications: You are STARTING insulin therapy and you expressed understanding of your regimen.,0
"75/25 Mg twice a day, 15 units.",0
"Followup Instructions: DIABETES FOLLOW UP: , NP at 8:30am 1 Pl , ( Name: , MD Specialty: Internal Medicine When: Thursday at 10:20am Location: MEDICAL CTR-GENERAL MEDICAL ASSOC.",0
7:18 PM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST AT HOURS.,0
FINDINGS: Portions of the chest are obscured by overlying trauma backboard.,0
"Within that limitation, there is hazy opacity over the left mid lung zone.",0
"Lung volumes, however, are overall diminished.",0
"There is poor definition along the superior mediastinum, right margin.",0
The endotracheal tube is in place with the distal tip in the ostium of the right mainstem bronchus.,0
"No definite effusion or pneumothorax, although a buckle obscures entirely the left costophrenic angle.",0
No pneumothorax is detected on this supine radiograph.,0
No displaced fractures are noted.,0
IMPRESSION: There is poor definition of the superior mediastinum.,0
"In the setting of trauma, mediastinal vascular injury cannot be excluded.",0
ETT needs to be retracted as distal tip in ostium of RMSB.,0
NGT terminates in high thoracic esophagus.,0
8:38 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ETT and OG change Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: year old man REASON FOR THIS EXAMINATION: ETT and OG change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MH SAT 10:58 PM HISTORY: ET tube and OG change.,1
"The tip of the ET tube is partially obscured by the OG line, but appears to lie in satisfactory position 3 cm above the carina.",0
"An OG tube is present, tip extending beneath diaphragm.",0
"There is upper zone redistribution, without overt CHF.",0
There are small bilateral effusions with left lower lobe collapse and/or consolidation.,0
"Compared with earlier the same day, the CHF findings are slightly improved.",0
Carotid artery calcification and degenerative changes of the C-spine and right greater than left shoulders are noted.,0
______________________________________________________________________________ FINAL REPORT HISTORY: ET tube and OG change.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Fever, Abdominal pain, SOB Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: The patient is a 43-year-old man with HIV, Hep C, cardiomyopathy, hypertension, polysubstance abuse including cocaine in addition to membranous GN (MPGN from Hep C) now ESRD on HD (T/Th/Sat, last on Saturday), heavy smoker who presented to the ED with abdominal pain, fever, dyspnea.",0
Pt reports he was in his usualy state of health until this morning at 2am when he awoke feeling SOB.,0
"His BP at that time was ""very high.""",0
and he had abdominal pain.,0
"Notes 5 bm yesterday, formed stool with no blood.",0
He reported to the ED.,0
He had missed some of his doses of his blood pressure medications.,0
"In the ED, initial VS were: T 102.9, BP 179/95, HR 110, RR 23, 98% RA.",0
"Given 1g tylenol, ASA 325, 5mg IV morphine, Vancomycin 1g, ceftriazone 1g, azithromycin 500mg IV.",0
"Labs in ED: WBC 10, HCT 27, PLT 211.",0
"Na 142, K 4.5, Cl 105, HCO3 20, BUN 70, Cr 7.3, glucose 112.",0
"ALT 13, AST 19, AP 105, TBilli 0.2, Alb 4, lipase 48, Ca 8.3, Mg 2.2, Phos 4.",0
CT abd performed for abd pain.,0
The patient was sent directly to dialysis for HD session since he was 4 kilograms above his dry weight.,0
"Per fellow, he had episode of small hemoptysis, confirmed by RN.",0
"However, according to patient, he felt it was from the grape juice he was given earlier in the day.",0
Denies any history of hemoptysis.,0
"While in HD, patient became suddenly hypertensive up to the 200s/120s and has sudden acute worsening of his dyspnea, RR 40s, hypoxemic satting in 70s on RA.",1
Concern for flash pulmonary edema.,0
He continued HD to remove 4-5 L fluid.,0
He was given a nebulizer with no improvement.,0
Placed on non-rebreather and satting in 93-95%.,0
"He looked uncomfortable, sitting upright, using accessory muscle use to breath.",0
"Vitals in HD on initial evaluation of patient 226/128, HR 136, RR 40s, satting mid 90s on non-rebreather.",0
"While in HD he was given hydralazine 10mg IV (did not improve BP), tylenol 325mg, Epo 7600, Zemplar 3mcg, topical nitro-paste 1.2 inch, Lopressor 5mg IV.",0
Then given nitropaste 0.5 inch and BP improved to 160s.,0
"Vitals prior to transfer to MICU: BP 161/102, HR 124.",0
"Following his dialysis, the patient felt substantially better and was breathing more easily.",0
"In the MICU, the patient's vitals were T 98.7 HR 116 BP 179/90 RR 23 98% 3L.",0
"He complained of pain in his jaw, neck, hips, and left upper quadrant on exam.",0
The patient did think that he was breathing more freely than the event in hemodialysis.,0
"In MICU, pt's hypertension was controlled with nitro drip, carvedilol, clonidine, nifedipine, hydral and terazosin.",0
"On transfer to medicine, his vitals are 97.8, 146/86, 102, 21 98% 2L.",0
He reports that he is still having some hemoptysis and he was complaining of continued RUQ pain.,0
Pt reports that he thinks his pain has been inadequately controlled.,0
He is currently being dialysed.,0
HIV - He was diagnosed with HIV in .,0
Risk factors included unprotected heterosexual sex as well as intravenous drug use.,0
His nadir CD4 count is 91 and he has no known opportunistic infections.,0
"Last viral load undetectable, CD4 556 ().",0
"Viral load 187,000 in .",0
Cardiomyopathy with an EF of 45-50%.,0
Chronic renal insufficiency - MPGN by biopsy in and hypertensive nephrosclerosis 5.,1
Gynecomastia; s/p bilateral gynecomastia excision with liposuction .,0
"Polysubstance abuse, including cocaine and alcohol.",0
Hypertriglyceridemia - TG 282 in 11.,0
A subacute infarct in the right caudate head seen on MRI in 13.,0
Inguinal hernia repair in .,0
Left ankle ORIF in .,0
Social History: History of incarceration for 4 yrs.,0
"Reports marijuana use daily, denies tobacco or cocaine.",0
"Family History: Mother and father have hypertension; has 3 brothers, 3 sisters: all healthy, none with HTN.",0
There is also a family history of type 2 diabetes mellitus.,0
No family history of sudden death and premature atherosclerotic cardiovascular disease.,0
"Physical Exam: General: Alert, oriented, comfortable HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP around 12 CV: S1, S2, no murmurs auscultated Lungs: Crackles heard at bases Abdomen: Soft, slightly tender in RUQ, non-distended, bowel sounds present, no organomegaly GU: No foley Ext: Warm, well perfused, trace pedal edema.",0
No pulmonary embolism or aortic pathology.,0
Enlarged main pulmonary artery suggestive of pulmonary arterial hypertension.,0
Right middle and right lower lobe opacifications concerning for pneumonia on a background of pulmonary edema.,0
"Small right pleural effusion, periportal and pericholecystic edema as well as hazy mesentery, unchanged compared to and likely due to HIV diagnosis.",0
"Nonspecific bowel wall thickening in distal ileum likely exaggerated by collapse, though a mild ileitis is a consideration.",0
Echo The left atrium is mildly dilated.,0
The estimated right atrial pressure is 5-10 mmHg.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %).,0
Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction.,0
"CXR There has been interval improvement of pulmonary edema, substantial with only minimal residual Kerley B lines demonstrated.",0
"Right lower lung opacity is still present, consistent with known right middle lobe and right lower lobe infectious process.",0
Mild vascular engorgement is still demonstrated.,0
"Cardiomegaly is moderate to severe, unchanged.",0
"Micro: bcx -: no growth legionella urine is negative discharge 12:45PM BLOOD WBC-6.9 RBC-2.93* Hgb-9.2* Hct-31.0* MCV-106* MCH-31.4 MCHC-29.7* RDW-12.7 Plt Ct-345 12:45PM BLOOD Plt Smr-NORMAL Plt Ct-345 12:45PM BLOOD Glucose-117* UreaN-54* Creat-6.9* Na-140 K-5.3* Cl-100 HCO3-23 AnGap-22* 12:45PM BLOOD Calcium-8.7 Phos-4.5 Mg-2.7* 01:30PM BLOOD Vanco-12.6 Brief Hospital Course: 43 year old gentleman with HIV (CD4 619 on , HIV-1 RNA undetectable ), HCV (viral load 61,900 IU/mL ), MPGN now with ESRD on dialysis Tues-Thurs-Sat, history of cryoglobulinemia, who is admitted to hospital for dyspnea and abdominal pain.",0
Chest X-ray and CT suggest RLL pneumonia.,0
The patient appeared to have an episode of flash pulmonary edema in the setting of hypertensive emergency.,0
# Respiratory distress/HCAP: (RLL/RML) and acute-on-chronic diastolic heart failure.,1
Likely flashed in setting of PNA and volume overload.,0
In HD in setting of hypertension up to 220/120s.,0
"Opportunistic infections considered but given recent CD4 count of 422, unlikely.",0
"He was started on cefepime, vancomycin, levofloxacin and nebulizers.",0
"With this treatment, respiratory status improved to 2L NC requirement.",0
"Sputum culture, blood cultures, urine culture, C. diff toxin were pending at time of transfer from MICU, but all returned negative.",0
Pt was dialysed an additional 2 times before discharge and was euvolemic at discharge.,0
He was continued on levaquin and vanco and transitioned to ceftazadime for HD dosing.,0
He was discharged on these medications for his pna until .,0
"# Abdominal pain: LFTs wnl, CT shows ?ileitis?",0
(unchanged from prior) EGD in was normal.,0
Another possibility considered was hepatic congestion or gut edema in setting of acute on chronic CHF.,1
Final CT abdomen read was equivocal for ileitis but pt's pain improved over hospital course.,0
Pain could have been referred pain from RLL pna.,0
He did have constipation that was relieved with aggressive bowel reg.,0
# Hypertensive emergency: Has history of difficult-to-control hypertension.,0
Pts BP 220/120s in HD room in setting of missing his medications.,0
"Restarted patient's substantial home PO regimen, and SBPs on discharge improved to 150's-160s.",0
He was discharged on home medication regimen.,0
"# HCV/HIV: Repeat CD4 count 422, makes opportunistic infection less likelt.",0
Continued home regimen of antiretroviral therapies.,0
"# CKD, stage V, ESRD on HD: Received partial HD today, although mainly removed fluid.",0
Removed 4L fluid on day of admission.,0
Removed an additional 4L over next two days.,0
"Transitional: home BP monitoring, will need close follow up with PCP or nephrologist for bp control Medications on Admission: 1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).",0
2. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.,0
3. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"5. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,SA): after dialysis, every tuesday and saturday .",0
6. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours).,0
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).,0
8. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day.,0
"9. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
10. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea: take 30 minutes prior to Sustiva/Ziagen/Epivir 11. terazosin 1 mg Capsule Sig: Three (3) Capsule PO at bedtime.,0
"13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
B complex-vitamin C-folic acid 0.8 mg Tablet Sig: One (1) Tablet PO once a day.,0
15. docusate sodium 100 mg Capsule Sig: Capsules PO BID (2 times a day).,0
Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day).,0
2. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours).,0
4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).,0
5. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day).,0
6. prochlorperazine maleate 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as needed for nausea.,0
7. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime).,0
8. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily).,0
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
12. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"13. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,SA).",0
"14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain.",0
15. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia.,0
"16. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
17. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
18. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 days: take after dialysis (through ).,0
Disp:*3 Tablet(s)* Refills:*0* 19. ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Injection QHD (each hemodialysis) for 6 days: after HD for 6 more days (through ).,0
"20. vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous PER HD PROTOCOL for 6 days: Continue for six more days (through ).",0
Discharge Disposition: Home Discharge Diagnosis: Healthcare Associated Pneumonia Flash pulmonary edema ESRD - requiring emergent dialysis Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted to the hospital for hospital acquired pneumonia.,0
Your course was complicated by flash pulmonary edema.,0
We treated your pneumonia with IV antibiotics and your pulmonary edema with dialysis and blood pressure control.,1
We have made the following changes to your home medications: -start levaquin 500mg 1 tab by mouth every 48hrs.,0
-start ceftazadime and vancomycin to be given IV when you are at dialysis.,0
-Continue the remainder of your home medications.,0
Followup Instructions: Please call your PCP to make an appointment within one week of discharge.,0
"Also, please resume dialysis at your normal schedule.",0
Below are some additional appointments you have already scheduled Department: When: WEDNESDAY at 11:00 AM With: Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: ADVANCED VASC.,0
"CARE CNT When: MONDAY at 1 PM With: , MD Building: (, MA) Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: WEDNESDAY at 11:30 AM With: , NP Building: SC Clinical Ctr Campus: EAST Best Parking: Garage",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Penicillins / Ciprofloxacin Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with DES to RCA Intubation Intra Aortic Balloon Pump Placement.,0
"History of Present Illness: HPI: 51 yo M with IDDM, HTN, transferred from with STEMI.",0
Patient originally presented to with exertional chest pain nausea that started at work at 9 am.,0
"Had 2-3 episodes of moderate chest pressure with numbness down the back of both arms, as well as, diaphoresis, nausea, and lightheadedness while at work.",0
"No shortness of breath, headache, visual changes, back pain, or abdominal pain.",0
No history of prior episodes of chest pain.,0
"Admission EKG at was negative for ischemic changes, however, he later developed EKG changes consistent with an inferior STEMI.",0
"The pt was given Lopressor 50 mg po, Morphine 2 mg, Heparin 5000 U x 1, Plavix 600 mg po, Aggrastast bolus 44cc/hour over half hour, then 11cc/hour IV, and Aspirin 325 mg x 1.",0
Initial labs were significant for CPK 109 and Troponin of .17 (positive).,0
<BR> The pt was med flighted to the cath lab where a left heart cath revealed 3VD with TO of RCA.,0
Access for IABP was obtatined when cath was started.,0
"While trying to enagage the RCA, deploy the distal DES and remove the guidewire, patient deveoped asymptomatic hypotension with VT.",0
The guidewire and stent balloon were removed but he had continued VT and so was shocked.,0
Lidocaine was started and AIBP was inflated.,0
Vessel was opened again via balloon - initially unable to place DES at most distal location to recurrent VT progressiing to VF (requiring multiple shocks).,1
Then started on amiodarone 150 mg bolus followed by infusion; he was also intubated at that time for airway protection.,0
"Remainder of his cath revealed: L main w/out sig disease; LAD diffuse, prox 70 % lesion; L circ prox 80% lesion; OM1 diffuse 70%.",0
"Wiggle wire was used to deliver distal, overlapping stents to RCA for a total of 3.",0
"He was started on lidocaine gtt, Amiodarone gtt and Dopamine gtt while in the cath lab and then was transferred to the CCU intubated and sedated.",0
Hyperlipidemia Social History: Lives with his wife.,0
"Former smoker - smoked for 20 yrs, quit 23 yrs sgo.",0
"Family History: Mother - CAD (MI), DM Father - colon cancer Physical Exam: VS on transfer to CCU: T 97.8 BP 94/56 HR 79 RR 12 sat 100 AC FiO2 100 TV 600 RR 12 Peep 5 Wt: 212 lbs Gen: intubated HEENT: perrla Resp: clear anteriorly CV: reg, systolic murmur (likely IABP) Abd: + BS, non-tender Ext: DP 1 + bilat, no edema Neuro: sedated Pertinent Results: STUDIES: CXR - - Satisfactorily positioned ET tube and OG tube.",0
Bilateral basilar opacities most likely representing atelectases but consolidations cannot be excluded.,0
Probable bilateral small pleural effusions.,0
"EKG: - 11:52 am at OSH - NSR, HR 70s, ST seg elevation in II, III, aVF, V4-V6, ST seg dep I, aVL .",0
"- 3:33 pm - NSR, HR 80s, ST seg elevations in II, aVF, ?",0
"Qs in II and aVF, resolution of ST seg elevation in V4-V6, ST seg dep in I, aVL .. TTE: - EF 35-40% Regional LV and RV systolic dysfunction c/w CAD Brief Hospital Course: A/P: 61 yo M with Insulin dependent DM, HTN, Hyperlipidemia who presents with inferior STEMI s/p PTCA complicated by hypotension requiring balloon pump and DA gtt as well as VT/VF resulting in Amio and Lidocaine gtt.",1
CV: A. STEMI: 3VD as per cath with TO of RCA which was felt to be the culprit lesion.,0
He is now s/p 3 overlapping DES to the RCA.,0
Patient was monitored on telemetry and was followed with daily ECGs with no further events.,0
"He was discharged on aspirin, atorvastatin, metoprolol, lisinopril and clopidogrel.",0
He did not have any additional episodes of chest pain while in-patient.,0
His blood pressure was well controlled at time of discharge.,0
"Patient may need further intervention to deal with other areas of significant blockage, however, no intervention will be done acutely.",1
He may need stress-MIBI as out-patient prior to further intervention (PCI vs CABG).,0
He will follow-up with his PCP .,0
in one week and Dr. (cardiologist) in one month.,0
He will also see CT surgery in to discuss CABG.,0
B. CHF: In the cath lab the patient had hypotension as a result of the ischemia as well as arrhythmia.,0
This may reflect a RV infarct physiology given the proximal RCA lesion.,0
"As per PCWP and RA pressure from cath lab, he was effectively volume resuscitated.",0
"TTE on showed an ejection fraction of 35-40%, symmetric LVH, mild RV free wall hypokinesis.",0
The current hypotension may therefore reflect some amount of myocardial stunning and the heart may recover function at a future date.,1
Also weaned off dopamine and extubated on .,0
In an effort to keep volume status even patient was given furosemide as needed.,0
He was not discharged on furosemide.,0
He will need a repeat ECHO in three months.,0
C. Rhythm: The pt had episodes of VT and VT/VF in cath lab during the acute intervention.,1
This may be secondary to reperfusion or due to involvement of conduction system.,0
He is now s/p loading with both lidocaine and amiodarone.,0
Lidocaine was not continued after transfer to CCU; amiodarone was continued for 18 hours but was subsequently discontinued.,0
Patient was monitored on telemetry.,0
No further episodes of VT/VF.,0
He was not discharged on an anti-arrhythmic.,0
D. Valve: No evidence of acute valvular insufficiency on physical exam or by ECHO.,0
"DM: Based on the findings of DiGAMI II, there is no evidence to support use of glucose/insulin gtt in the setting of ACS to improve mortality or morbidity in diabetics.",0
"However the recent findings by Dr. , and TIMI study group in the Journal of American College of Cardiology suggests a ""U"" shaped relationship between admission glucose and mortality in ACS.",0
The admission glucose of 271 therefore is not a favorable finding.,0
Patient was initially placed on an insulin gtt for better control of DM.,1
He was then transitioned to NPH and a regular insulin sliding scale.,0
Respiratory: The pt was intubated during the cardiac arrest in the cath lab for airway protection.,0
"Given the discomfort of the invasive monitoring in the ICU at this time (swan, arterial and femoral sheath, IABP), sedation and intubation was continued until the IABP was removed on .",0
The patient was extubated without difficulty.,0
Medications on Admission: MEDICATIONS at home: 1.,0
Lantus with Sliding Scale Insulin 2.,0
Quinipril 20 mg qd 3.,0
Lipitor 10 mg qd .,0
"ALLERGIES: PCN - hives, shortness of breath, Cipro - hives Discharge Medications: 1.",0
Lantus 100 unit/mL Solution Sig: 35 units Subcutaneous QHS.,0
Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day.,0
"Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis STEMI * Secondary diagnoses DM - insulin dependent HTN Hyperlipidemia Discharge Condition: good, tolerating medications and ambulating without difficulty Discharge Instructions: You were diagnosed with a myocardial infarction or heart attack, which was treated with stents that were used to open an artery in your heart.",1
As a result you were started on several new medications.,0
It is very important that you take all of your medications as prescribed.,0
One of them called clopidogrel (or Plavix) and is used to keep the stent open.,0
You should not stop your medications unless you discuss this with your cardiologist.,0
"* Please call your doctor or return to the emergency room if you have chest pain, shortness of breath, you cannot eat drink or take your medications, or you develop any other symptoms that are concerning to you.",0
Followup Instructions: Please follow-up with your PCP .,0
He should check your blood pressure to make sure it is adequately controlled.,0
Please continue to follow-up your blood sugars at and discuss your insulin regimen with your PCP.,0
should also provide you with referrals for your appointments with Drs.,0
"* Please follow-up in the cardiology clinic with , M.D.",0
You will need a referral for this appointment from your PCP.,0
* Please follow-up with Dr. in the cardiac surgery department on at 1:30 pm to discuss having open heart surgery to correct your blocked arteries.,1
"6:50 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate, free air ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with lower GIB REASON FOR THIS EXAMINATION: eval for infiltrate, free air ______________________________________________________________________________ FINAL REPORT INDICATION: 49-year-old man with lower GI bleed, evaluate for infiltrate, free air.",0
"SUPINE FRONTAL VIEW, CHEST: The lungs are clear without focal consolidation, pleural effusion, or pneumothorax.",0
Slight right hilar asymmetric could be due to patient rotation.,0
"There is a tunneled catheter via right IJ approach, terminating at the mid SVC.",0
The right PICC is terminating at cavoatrial junction.,0
"Please note that this is a supine chest radiograph with AP technique, not sensitive for detection of pneumoperitoneum.",0
"10:00 AM DUPLEX DOPP ABD/PEL Clip # Reason: POD1 s/p orthotopic liver transplant , unusual anatomy o Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with OLT REASON FOR THIS EXAMINATION: POD1 s/p orthotopic liver transplant , unusual anatomy of IVC (curved) ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Postop day 1 following orthotopic liver transplant.",0
"The liver transplant is normal in size, echogenicity and architecture.",0
"Color flow and pulse Doppler assessment shows excellent flow in the hepatic veins, portal veins and hepatic arteries.",0
Resistive indices in the hepatic arteries range around 0.5.,0
There is good upstroke in the right and left hepatic arteries and full patency of all portal and hepatic veins.,0
The inferior vena cava also shows normal color flow and pulse Doppler characteristics.,0
There is a hyperechoic shadowing area beneath the right lobe that corresponds to an area of Surgicel.,0
"A small right pleural effusion is noted, but there are no peritransplant fluid collections.",0
CONCLUSION: Satisfactory ultrasound on Doppler appearance of the recent liver transplant.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: dyspnea, tachycardia Major Surgical or Invasive Procedure: Attempted TEE, failed TEE with cardioversion History of Present Illness: 65YM h/o DVT, DM c/b neuropathy presenting with DOE found to have multiple pulmonary emboli.",1
Per patient had been in USOH when developed worsening of breath over the last 3-4days.,0
Developed in the setting of rhinorrhea so patient thought symptoms reflective of URI so treated symptomatically.,0
In last 2 days developed worsening dyspnea on exerion with labored breathing after walking only a block.,0
"He reported associated chest tightness, pleuritic CP with deep breath as well as diaphoresis.",0
Symptoms prompted presentation to PCP .,0
In PCP's office EKG demonstrated Aflutter.,0
Patient received Lovenox 100mg in setting of arrhythmia and instructed to present to the ED.,0
"In the ED, initial VS: 98.6 83 103/40 18 98% 2L Nasal Cannula.",0
"EKG: aflutter@ 107, NA, NI.",0
"Labs with BNP 347, trop <0.01.",0
"CTA with PE involving RUL, RML, RLL, lingula, and LLL - no evidence of pulmonary infarct or R heart strain.",0
Started on heparin ggt without bolus (has already received Lovenox).,0
HR noted to elevate to 110sin flutter with exertion.,0
Due to c/o SOB and labile HRs decision made to admit to the MICU overnight for monitoring.,0
Hemodynamics prior to transfer: 145/90 HR: 100 in aflutter.,0
"On arrival to the MICU, patient with continued complaint of chest tightness and intermittent SOB.",0
"Regarding history of DVT, per patient reports two instances during which he was treated for coumadin in setting of DVT.",0
Both thromboembolic events occurred in the context of lower extremity surgeries.,1
Per patient last clot ~3-4years ago.,0
Has been off anticoagulation for several years.,0
He is uptodate with cancer screening; last c-scope during 2which benign polyps were removed.,0
No B sx with excpetion of sweats in acute setting.,0
No family history of clot.,0
"No recent immobilizations, recent car trips.",0
discharge exam Pertinent Results: Initial labs: 02:35PM WBC-8.2 RBC-4.36* HGB-14.5 HCT-39.2* MCV-90 MCH-33.3* MCHC-37.0* RDW-12.9 02:35PM NEUTS-74.1* LYMPHS-20.2 MONOS-4.6 EOS-0.7 BASOS-0.3 02:35PM PLT COUNT-301 02:35PM PT-10.2 PTT-30.0 INR(PT)-0.9 02:35PM GLUCOSE-167* UREA N-30* CREAT-1.1 SODIUM-136 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 02:35PM cTropnT-<0.01 02:35PM proBNP-347* 02:35PM ALBUMIN-3.9 CALCIUM-10.7* PHOSPHATE-3.0 MAGNESIUM-2.2 02:35PM TSH-0.58 .,0
On discharge: 06:30AM BLOOD WBC-6.5 RBC-4.38* Hgb-13.9* Hct-38.6* MCV-88 MCH-31.8 MCHC-36.1* RDW-13.4 Plt Ct-211 06:30AM BLOOD PT-24.6* PTT-31.2 INR(PT)-2.4* 06:30AM BLOOD Glucose-151* UreaN-30* Creat-1.1 Na-135 K-4.5 Cl-100 HCO3-26 AnGap-14 06:30AM BLOOD Calcium-10.2 Phos-3.3 Mg-2.0 .,0
IMAGING: admission ECG: Atrial flutter with variable A-V block.,1
Possible inferior wall myocardial infarction of indeterminate age.,0
"Poor R wave progression, probably normal variant.",0
Extensive pulmonary emboli as described above without evidence of right heart strain or pulmonary infarct although perfusion abnormalities are suspected in each lung.,0
"(Filling defects are present in the segmental and subsegmental branches of the left lower lobe pulmonary artery, lingular branch of the left upper lobe pulmonary artery, branches of the right lower lobe pulmonary artery, right middle lobe pulmonary artery and right upper lobe pulmonary artery.)",1
Right upper lobe ground-glass nodule of 13 mm and additional smaller nodules.,0
Follow-up chest CT is recommended in six months for surveillance.,0
Suspected bony demineralization and mild loss in height among several lower thoracic vertebral bodies.,0
LENIs: IMPRESSION: Near occlusive left popliteal venous thrombosis.,1
TTE: The left atrium is moderately dilated.,0
Overall left ventricular systolic function is low normal (LVEF 50-55%) secondary to very mild global hypokinesis.,0
Low normal left ventricular systolic function.,0
TEE Findings The TEE probe was passed to 50 cm.,0
The heart was unable to be adequately visualized due to poor contact between the probe and the esophagus despite multiple attempts and probe maneuvers.,0
GENERAL COMMENTS: Informed consent was obtained.,0
Image quality was suboptimald - poor esophageal the patient.,0
TEE The left atrium is mildly dilated.,0
Right atrial appendage ejection velocity is good (>20 cm/s).,0
There are simple non mobile atheroma in the aortic arch and descending thoracic aorta to 40 cm from the incisors.,0
"Brief Hospital Course: 65YM h/o DVT, DM c/b neuropathy presenting with DOE found to have multiple pulmonary emboli, course complicated by atrial flutter requiring cardioversion.",1
"ACTIVE ISSUES BY PROBLEM: # Multiple Pulmonary Emboli: Patient with h/o of DVT, however had been labeled as provoked in setting of LE surgeries.",0
Largest risk factor is history of previous DVT.,0
"In addition patient obese with relative immobility in setting of chronic lower extremity pain; however lacks recent surgical interventions, recent long travel, or hx of malignancy to additionally predispose.",1
"With recurrent thromboembolism, he will likely need lifelong anticoagulation.",1
Could consider an outpatient hematology work-up for evaluation of hypercoagulable state if this would alter future management.,0
His CT angiogram did not show signs of right heart strain and after a brief episode of hypotension on arrival to the ED he was hemodynamically stable.,0
"His troponin was normal, but his BNP was mildly elevated, suggesting that there may be some slight strain.",0
He was started on a heparin drip.,0
he was started on warfarin at an initial dose of 7.5mg daily which was briefly uptitrated to 10mg.,0
When therapeutic heparin gtt was discontinued and he was continued on warfarin 7.5 mg daily.,0
"His coumadin will be managed as an outpatient by his PCP, goal INR of .",0
# Atrial flutter: Likely triggered by pulmonary emboli resulting in acute stretch of right atrium.,1
Given his stable blood pressures his metoprolol dose was titrated up through the day to improve rate control.,0
Diltizem was also started and uptitrated.,0
Eventually he was transitioned to the long acting metoprolol succinate 200 mg daily and diltizem 360 mg daily.,0
He underwent an attempted TEE guided cardioversion which was unsuccessful on (could not get good visualization of heart to r/o thrombus).,0
He subsequently underwent a second attempt on which successfully ruled out thrombus and he was cardioverted to sinus without any complications.,0
"Per cardiology recommendations, his metoprolol was DC'd and his diltiazem decreased to 180mg.",0
He was discharged on this regimen and will follow up in clinic in 2 weeks.,0
# HTN: Lasix (which he does not take anyway) and lisinopril initially held in setting of acute clot.,0
He was continued on ASA 81mg.,0
He was restarted on half his home dose of lisinopril at 10 mg daily.,0
Patient was normotensive at time of discharge.,0
"He was not restarted on his lasix, as he said he has not taken this for quite some time at home.",0
Will defer to his PCP to decide about restarting.,0
"CHRONIC INACTIVE ISSUES: # Hyperlipidemia: on simvastatin 80 mg on admission, however this was decreased to 10 mg in the setting of starting diltiazem, given increased risk for rhabdomyolysis.",0
# DM: Followed with QID finger sticks.,0
His metformin was held in the setting of dye load.,0
He was continued on his home dose of NPH insulin and managed with a humalog sliding scale.,0
His metformin was restarted on discharge.,0
# GERD: continued omeprazole # Chronic LE pain: continued cymbalta and PRN tylenol TRANSITION OF CARE ISSUES: # Anticoagulation: will need to have INR followed at his PCP's office for titration of his coumadin dosing.,0
Next INR draw should be .,0
"# PE/DVT: will likely need lifelong anticoagulation now, given recurrence of DVT.",0
consider hypercoagulable work up as an outpatient # Lung opacity: CTA chest showed right upper lobe ground-glass nodule of 13 mm.,0
"Recommend follow up CT in 6 months # Patient remained FULL CODE on this admission Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth daily DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.)",0
"- 1 Capsule(s) by mouth once daily FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply to affected area maximum 12 hours in a 24 hour period LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth daily METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth q am OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.)",0
"- 1 Capsule(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth daily ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily CALCIUM [CALCIO ] - (OTC) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth daily NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other Provider) - 100 unit/mL Suspension - 50 units once a day Discharge Medications: 1. duloxetine 30 mg Capsule, Delayed Release(E.C.)",0
"2. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
3. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM.,0
Disp:*90 Tablet(s)* Refills:*2* 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: apply to affected area maximum 12 hours in a 24 hour period .",0
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO once a day.,0
"7. aspirin 81 mg Tablet, Delayed Release (E.C.)",0
"Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day.",0
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
10. multivitamin-minerals-lutein Tablet Sig: One (1) Tablet PO once a day.,0
NPH insulin human recomb 100 unit/mL Suspension Sig: Fifty (50) units Subcutaneous daily with dinner.,0
"12. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily).",0
"Disp:*30 Capsule, Extended Release(s)* Refills:*2* 13.",0
Outpatient Lab Work Please have INR checked at your PCP's office on 14. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: pulmonary embolism, atrial fibrillation Discharge Condition: Mental Status: Clear and coherent.",1
It was a pleasure caring for you while you were admitted to .,0
You were admitted because you were short of breath.,0
You were found to have blood clots in your lungs.,0
You were started on blood thinning medications to treat your clots.,0
During your admission your heart rate was in a fast irregular rhythm.,0
This was treated with cardioversion (shocking your heart into a normal rhythm) and a medication to help slow your rate.,0
"The following changes have been made to your medication regimen: Please START taking - warfarin 7.5 mg daily - diltiazem 180 mg daily - lisinopril 10 mg daily (rather than 20 mg) - simvastatin 10 mg daily (rather than 80 mg, as this can interact with diltiazem) Please STOP taking: - Atenolol .",0
Please take the rest of your medications as prescribed and follow up with your doctors .,0
"You will need to have your INR checked on Wednesday or Thursday at your primary doctor's office Followup Instructions: Name: , P. Location: MEDICAL ASSOCIATES Address: , , Phone: ***The office is working on an appt for you this week and will call you at home with the appt.",0
"If you dont hear from them by tomorrow afternoon, please call them directly to book.",0
"Department: CARDIAC SERVICES When: THURSDAY at 2:00 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage",0
"1:31 PM WRIST(3 + VIEWS) RIGHT; SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFTClip # Reason: evalaute for fx, dislocation, effusion Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with DM, CKD, CHF s/p fall with right knee effusion and right wrist swelling REASON FOR THIS EXAMINATION: evalaute for fx, dislocation, effusion ______________________________________________________________________________ FINAL REPORT HISTORY: Fracture.",1
Six radiographs of the left shoulder and right wrist are submitted.,0
LEFT SHOULDER: There is anatomic alignment of the glenohumeral joint.,0
The humeral head maintains a normal contour.,0
Nonspecific soft tissue calcification is seen to project over the acromiohumeral interval on the AP view.,0
Mild degenerative change involves the acromioclavicular joint.,0
Visualized lung and ribs are unremarkable.,0
IMPRESSION: Nonspecific soft tissue calcification projecting over the acromiohumeral interval on the frontal view only.,0
Diagnostic considerations include the sequela of chronic bursitis or less likely calcific tendinitis of the rotator cuff.,0
The finding is not present on .,0
RIGHT WRIST: Mineralization is normal.,0
Joint spaces are maintained without periarticular erosion.,0
"Assessment for ulnar variance is somewhat limited by angle of projection, but there may be 1-2 mm of positive ulnar variance.",0
"11:14 AM CHEST (PORTABLE AP) Clip # Reason: infiltrates, effusions, ptx, ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man w/ DM, s/p intubation for hypoglycemic coma.",0
"Patient self extubated this am REASON FOR THIS EXAMINATION: infiltrates, effusions, ptx, ______________________________________________________________________________ FINAL REPORT INDICATION: Infiltrate followup.",0
PORTABLE CHEST: Comparison made to film from one day earlier.,0
The ET tube and nasogastric tube have been removed.,0
"There are still patchy areas of increased density in both lung bases, although aeration does appear improved.",0
Blunting of the right lateral costophrenic angle may reflect effusion.,0
IMPRESSION: Improved aeration in both lung bases.,0
"5:14 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with diffuse axonal injury, C2 body fx, intubated, to be trached REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.",0
"FINDINGS: Tracheostomy, NG tube, spinal fixation hardware, right PICC line are unchanged.",0
There is increased left lower lobe atelectasis.,0
The remaining lungs remain unchanged.,0
"No newly developed consolidation, pneumothorax, or pleural effusion.",0
"IMPRESSION: New left lower lobe atelectasis, otherwise no change.",0
"11:56 AM BABYGRAM (CHEST ONLY) Clip # Reason: monitor lung fields, r/o infiltrates, infusion, progression Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with late-onset lung dz and O2 requirement (cardiac evaluation w/ ECHO negative).",0
"REASON FOR THIS EXAMINATION: monitor lung fields, r/o infiltrates, infusion, progression of dz ______________________________________________________________________________ FINAL REPORT CHEST.",0
Comparison is made with the exam done on .,0
The nasogastric tube reaches the stomach.,0
"The lung volumes are somewhat low, which probably accounts for most of the density in both lungs.",0
There is probably mild chronic lung disease.,1
"7:39 PM PORTABLE ABDOMEN Clip # Reason: eval for interval change in cecal size - please page w Admitting Diagnosis: BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with large bowel obstruction REASON FOR THIS EXAMINATION: eval for interval change in cecal size - please page with read - please do ASAP ______________________________________________________________________________ FINAL REPORT INDICATION: Large bowel obstruction, eval for interval change and cecal size.",0
COMPARISONS: Abdominal radiograph obtained approximately eight hours earlier.,0
"PORTABLE AP SUPINE RADIOGRAPH OF THE ABDOMEN: Again noted is severe gaseous distention of the right colon which measures up to 13.5 cm, minimally increased since the prior study.",0
Distended loops of small bowel measure up to 4.5 cm which is approximately stable.,0
Paucity of gas is again noted in the descending colon and rectum.,0
Possible air-fluid levels cannot be assessed on this supine view.,0
Patient is status post right bipolar hip arthroplasty.,0
An NG tube is seen projecting over the left upper quadrant.,0
IMPRESSION: Stable severe distention of the cecum/ascending colon.,0
The configuration of bowel loop together with the dilated small bowel loops but paucity of air in the descending and rectum and transverse colon are concerning for possible cecal volvulus of bascule type.,0
Close followup or CT is recommended.,0
This has been discussed with Dr. at 10:00 p.m. on .,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: assess CVL placement Admitting Diagnosis: TRACHEOBRONCHIOMALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man now s/p central venous line placement REASON FOR THIS EXAMINATION: assess CVL placement ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
"INDICATION: 46-year-old male patient, now status post central venous line placement, assess position.",0
FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position.,0
Comparison is made with the next preceding similar study obtained eight hours earlier during the same day.,0
"During the interval, a right-sided internal jugular approach central venous line has been placed, seen to terminate overlying the right-sided mediastinum at a level 2 cm below the carina.",0
This is compatible with the lower third of the SVC.,0
No pneumothorax can be identified.,0
Previously seen right-sided pleural drainage tube in unchanged position.,0
Observe that the hazy density in the right upper lobe persists and most likely represents an early pneumonic infiltrate.,0
was unavailable under page number.,0
"As no significant new finding was made, no further page was placed.",0
3:27 PM CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: r/o aortic leak Admitting Diagnosis: RUPTURED AAA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with ao.,0
"dissection, & aneurysm REASON FOR THIS EXAMINATION: r/o aortic leak No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAMINATION: CT chest, abdomen, and pelvis.",0
"INDICATION: Aortic dissection, aneurysm, rule out leak.",0
"A CT of chest, abdomen, and pelvis was performed with axial images taken from the lung apices to the symphysis pubis.",0
Noncontrast and dynamic images were performed with reconstructions in the coronal and sagittal planes.,0
COMPARISON: Comparison was made with previous CT from .,0
CT CHEST FINDINGS: Note is made of bilateral pleural effusions.,1
There is associated atelectasis and consolidation bibasally.,0
The attenuation of the pleural fluid is low.,0
Small subcentimeter axillary lymph nodes noted.,0
No focal lung nodules identified.,0
CT ABDOMEN The liver is unremarkable.,0
Some free fluid is seen around the liver.,0
A calcified gallstone is noted in the gallbladder.,0
The adrenals and kidneys are unremarkable apart from a simple cyst in the midpole of the right kidney laterally.,0
No evidence of any significant retroperitoneal lymphadenopathy.,0
The bowel where visualized is normal.,0
CT PELVIS Free fluid is seen in the pelvis.,0
The prostate measures 5.6 cm in transverse x 4.5 cm in AP diameter.,0
"Some fat stranding is noted in the inguinal areas bilaterally, right more than left side.",0
Bony windows reveal no suspicious sclerotic or lytic lesions.,0
Note is made of degenerative change.,0
(Over) 3:27 PM CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: r/o aortic leak Admitting Diagnosis: RUPTURED AAA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) CTA The ascending aorta is of normal caliber.,0
The descending thoracic aorta is ectatic and measures 5.1 cm in maximum transverse x 5.3 cm in maximum AP diameter.,0
Note is made of intramural thrombus.,0
The aorta is again ectatic as it enters the abdomen.,0
The celiac artery and its bifurcation into the splenic and hepatic arteries are normal.,0
Some atherosclerotic disease is seen at the ostium of the single renal arteries bilaterally.,0
Remainder of the renal arteries are widely patent bilaterally.,0
"There is an infrarenal abdominal aortic aneurysm, which measures 6.4 cm in transverse x 7.1 cm in AP diameter.",0
Again note is made of significant intramural thrombus.,0
The right common iliac artery measures 1.8 cm in diameter and is also ectatic.,0
A 1.79 cm _____ is again identified of the left common iliac artery.,0
Beyond the bifurcation of the common iliac arteries there is normal caliber.,0
"In relation to the intramural thrombus of the distal thoracic aorta, it is of slightly high attenuation.",0
"However, no significant change when compared to the previous CT from .",0
"No definite leaking aneurysm identified on CT, however, clinical correlation is advised as well as serial hematocrit measurement in view of the clinical symptoms and the rapidly developing effusions and free intraperitoneal fluid.",0
Multiplanar reconstructions were essential in depicting the anatomy and identifying the pathology.,0
"High attenuation intramural thrombus pre- and post-contrast in descending thoracic aorta, which is unchanged when compared with previous CT from three days ago.",0
Maximum diameter of descending thoracic aorta of 5.3 cm.,0
Rapidly developed bilateral pleural effusions and consolidation without atelectasis bilaterally 3.,1
"Infrarenal abdominal aortic aneurysm, which measures 7.1 cm in maximum diameter.",0
Small aneurysms of common iliac artery 6.,0
Cholelithiasis (Over) 3:27 PM CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: r/o aortic leak Admitting Diagnosis: RUPTURED AAA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 7.,0
Enlarged prostate The findings were discussed with the team at 5 p.m. on .,0
"11:28 AM CHEST (PORTABLE AP) Clip # Reason: check Dobhoff placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man s/p Dobhoff replacement REASON FOR THIS EXAMINATION: check Dobhoff placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 12:37 P.M., HISTORY: Dobbhoff replaced.",1
IMPRESSION: AP chest compared to : Feeding tube with a wire stylet in place ends low in the stomach.,0
Right PICC line ends in the mid SVC.,0
"Pleural effusion, if any, is minimal on the right.",0
Fever Weight (lb): 286 BP (mm Hg): 101/53 HR (bpm): 100 Status: Inpatient Date/Time: at 14:06 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness.,0
Overall left ventricular systolic function is normal/hyperdynamic (LVEF>55%).,0
No vegetation seen (cannot definitively exclude).,0
1:29 AM CT C-SPINE W/O CONTRAST Clip # Reason: Evaluate for C-spine fracture or other abnormality.,0
SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p fall with poor history from OSH now intubated.,0
REASON FOR THIS EXAMINATION: Evaluate for C-spine fracture or other abnormality.,0
CONTRAINDICATIONS for IV CONTRAST: slightly elevated baseline Cr.,0
______________________________________________________________________________ WET READ: MLHh 4:15 AM No fx.,0
"ETT just below thoracic inlet, pls advance.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 63-year-old male post fall, poor historian, now intubated.",0
TECHNIQUE: Helical MDCT images were acquired from the skull base through the T2 vertebral body without intravenous contrast.,0
2.5 mm bone and soft tissue kernel images were reconstructed in the axial plane.,0
2 mm coronal and 2 mm sagittal multiplanar reformats were also generated.,0
FINDINGS: There is no fracture or subluxation.,0
There is no prevertebral edema.,0
"Mild multilevel degenerative changes are present, with anterior osteophytes at C5 through C7.",0
"At C5/6, there is a left paracentral disc herniation deforming the spinal cord and causing moderate spinal canal narrowing.",0
There is milder canal narrowing due to disc/osteophyte complexes at C4/5 and C6/7.,0
There is moderate right neural foraminal narrowing at C4/5 and C5/6 due to uncovertebral osteophytes.,0
The mastoid air cells are clear.,0
"The patient is intubated, with a large amount of retained secretions in the pharynx.",0
The endotracheal tube terminates just below the thoracic inlet.,0
"The thyroid is slightly heterogeneous, without definite nodularity.",0
Evaluation of lung apices is limited by respiratory motion.,0
Left paracentral disc herniation at C5/6 deforms the spinal cord and causes moderate spinal canal narrowing.,0
"If there is a clinical suspicion for a cord contusion or chronic myelopathy, MRI would be helpful for further evaluation.",0
DFDkq (Over) 1:29 AM CT C-SPINE W/O CONTRAST Clip # Reason: Evaluate for C-spine fracture or other abnormality.,0
SEIZURE ______________________________________________________________________________ FINAL REPORT (Cont),0
"4:03 PM CHEST (PA & LAT) Clip # Reason: eval for interval change in efussions, atelectasis Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT W/ VENTRICULAR ACCESS DEVICE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with CABG REASON FOR THIS EXAMINATION: eval for interval change in efussions, atelectasis ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS CLINICAL INFORMATION: 53-year-old male with history of CABG.",1
FINDINGS: The lateral view is somewhat suboptimal due to patient motion.,0
No overt pulmonary edema is seen.,0
Frontal and lateral views of the chest are obtained.,0
"Trace effusion is seen at least on the right and possibly on the left, as best seen on the lateral view.",0
Mild right basilar atelectasis is seen.,0
"Persistent medial right base opacity is noted, best seen on the frontal view, new since , but also evident on the prior study, and underlying consolidation cannot be excluded.",0
Attention to this at follow-up is recommended.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: hemodialysis intubation History of Present Illness: 68-year-old woman with lymphoplasmacytic lymphoma diagnosed in .,0
Pt initially refused all therapies.,0
In pt admitted with ESRD found to be Glomerular Sclerosis attributed to her lymphoma.,0
"During that admission pt was started on hemodialysis along with chemotherapy (cytoxan, vinctristine and prednisone) and discharged to .",0
Pt's daughter noticed the pt became increasingly short of breath while in the rehab home and transferred her back to the hospital for evalution.,0
In pt found to be confused and lethargic and was emergently intubated for airway protection and increasing respiratory distress.,0
"Inititial CXR showed LLL collapse, B effusions and evidence of CHF.",1
Repeat CXR post intubation showed re-expansion of L lung but persistence of bilateral effusions.,0
CTA in the Emergency room ruled out acute pulmonary emboli.,1
"Pt started on broad spectrum antibiotics (Vancomycin, Azithromycin, Ceftriaxone and Flagyl) and admitted to the ICU under the sepsis protocol.",0
ED due to temp spike to 101 and elevated lactate of 6.8 (now nl).,0
Pt received one IVF bolus in ED.,0
L IJ was placed and CVP was .,0
"Lymphoplasmacytic Lymphoma, dx'd 1.5 yrs ago.",0
"Started on Chemotherapy in (Vincristine, Cytoxan and Prednisone).",0
"ESRD- glomerular sclerosis consistent with end stage disease, likely from the lymphoma-- started on HD 3.",1
Atrial Fibrillation on verapamil and atenolol 4.,1
Anemia from chronic disease 6.,1
Congestive heart Failure (EF 20%) 7.,1
"Mitral Regurg / Tricuspid Regurg Social History: She does not smoke or drink currently, previously smoked tobacco for 2 years 48yrs ago.",0
She is married with 2 sons and 2 daughters.,0
"daughters are Scientists; husband and sons are not, but are supportive of her religious beliefs and of her decisions in the past and presently about treatment.",0
She is a retired Science nurse.,0
"Family History: There is no family history of cancer, renal disease, or MI.",1
She has 1 brother who is alive and well.,0
Her mother is 86 years old and alive.,0
Her father died at the age of 38 at an accident.,0
"Brief Hospital Course: 68 year old female with history of lymphoblastic lymphoma started on CVP (Cytotoxan, vincristine and prednisone) last month.",0
Admitted to hospital with increasing respiratory distress requiring intubation for airway support.,0
CXR demonstrated bilateral pleural effusion with concern for pneumonia and echo obtained on confirmed a markedly decreased ejection fraction of 20%.,1
Respiratory failure - The patient was intubated in the ED for airway protection and increasing respiratory distress.,1
Chest CT angiogram ruled out acute pulmonary emboli.,1
Initial chest x ray showed bilateral pleural effusions and along with a retrocardiac opacity and bibasilar collapse.,1
Etiology of her respiratory failure thought to be multifactoral including volume overload in the context of her CHF and pneumonia.,1
"Cultures obtained and patient started on broad spectrum antibiotics including vancomycin, levofloxacin, and flagyl for her community acquired pneumonia.",0
Pt was also started on both albuterol and atrovent for maximal bronchodilation.,0
Pt's sputum cultures grew out oropharyngeal flora and her blood cultures remained negative throughout her admission.,0
Pt was successfully extubated 2 days after she admission and maintained good oxygen saturations on 2L NC.,0
She continued her dialysis sessions with a goal of .5kg fluid removed daily.,0
"Oxygen saturation >94% on room air; however, patient may prefer to have oxygen supplementation for comfort.",0
Encourage incentive spirometry to lower risk of recurrence of pneumonia.,0
Hold albuterol given history of rapid atrial fibrillation.,1
"Neuro / Psych - Mental status improved to baseline with difficulty word finding, mild anxiety, and occasional mild confusion.",0
Avoid benzodiazepines because they are oversedating even at low doses.,0
Continue to avoid sedating medications b.,0
Frequent reorientation c. Psych consult thought pt not competent to make major decisions .,0
ESRD - secondary to focal glomerulosclerosis likely from involvement of lymphoma.,0
"Pt was dialyzed daily, with removal of about 3kg fluid.",0
Discontinued phosphate binder for low phosphate as per renal consultation.,0
b. Dialysis three times weekly.,0
c. Renally dose all medications .,0
Pt presented with bilateral pleural effusions and was diuresed.,1
Found to be in atrial fibrillation and started on an esmolol drip in the unit.,1
obtained on showed a marked decrease ejection fraction of 20% with global LV hypokinesis aside from the inferior and posterior walls.,0
Echo also revealed a severly dilated RA and RV.,0
Compared to in the Ef down from 30% and the mitral regurg has increased.,0
a. Fluid removed by daily dialysis and ultrafiltration until three times weekly schedule resumed .,0
Gentle use of beta blockers to control rate because the patient may need the tachycardia to offset her markedly depressed EF of 20%.,0
Continue to hold her calcium channel blockers given her low ejection fraction and propensity for extensive lower extremeity edema.,0
c. Cardiac diet; control fluid status via dialysis three times weekly.,0
d. Not currently anticoagulated for her afib.,0
The patient had refused anticoag in past even after extensive discussions involving the risk of stroke.,0
"Now, she is likely not a good candidate for aggresive anticoagulation given the extensive tumor burden.",0
Testing of digoxin levels is recommended for goal of 0.7. f. Started on lisinopril.,0
"Anemia - thought to be due to anemia of chronic disease, likely from lymphoma, chemotherapy, and ESRD.",1
Hct stable from last admission.,0
Continue epogen with dialysis b.,0
"c. Follow hematocrit over time 6. lymphoma - Started CVP (Cytoxan, Vincristine and Prednisone)protocol in .",0
Pt's lymphadenopathy appears dramatically improved on most recent CT scan.,0
She will follow up with oncology in 1 month to determine future need for chemotherapy.,0
Continue renally dosed allopurinol for prevention of tumor lysis syndrome.,0
"b. Oncology is holding further CVP (Cytoxan, Vincristine and Prednisone) for now and will reevaluate need for further palliative chemotherapy at follow up outpatient appointment in one month.",0
"Prophylaxis - protonix, subcutaneous heparin Nutrition - Encourage oral intake.",0
"If unable to provide proper oral nutrition, resumption of tube feeding via nasogastric tube may be required.",0
Access - PICC line; PIV; HD catheter .,0
"- husband, sister and son.",0
Medications on Admission: MVI qd calcium acetate 1337 tid w/meals verapamil 80mg q8hrs colace 100mg metoprolol 60mg sc heparin 5000units tid compazine 10mg q6hrs prn allopurinol 100mg qd lansoprazole 30mg qd senna nystatin 5ml qid bisacodyl 10 qd acetamenaphen 1000mg q6hrs mag hydroxide 30mls q6hrs prn anzemet 12.5mg q8hrs epogen 3000units tiwk morphine prn ativan prn Discharge Medications: 1.,0
"Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q8H (every 8 hours).",0
Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day).,0
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
Phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN.,0
Inspect site every shift 12.,0
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<90.,0
Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day: hold for sbp<90 or HR<60.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: pneumonia volume overload due to renal disease end stage renal disease on hemodialysis lymphoma anemia from chronic disease atrial fibrillation congestive heart failure (EF 20%) other: hypertension Discharge Condition: hemodynamically stable, breathing comfortably on room air, and tolerating oral diet Discharge Instructions: Please take all medications as prescribed.",1
"Call your doctor or go to the ED for shortness of breath, chest pain, bleeding, excessive bruising, abdominal pain, nasea/vomiting, diarrhea, fever, chills, or other concerning symptoms.",0
"New Medications: To improve your heart function, you have been started on lisinopril and digoxin in addition to your usual metoprolol.",0
Continual the inhaled ipratroprium to improve breathing.,0
"Otherwise, continue your usual medical regimen including vitamin supplementation.",0
You are encouraged to eat a healthy low salt diet and drink plenty of fluid.,0
"If you are unable to provide adequate oral nutrition, resumption of nasogastric tube feeding may be required.",0
"To prevent future pneumonias, do not eat lying down or while excessively sleepy.",0
Monitor your weight and call your doctor if it increases more than 3 pounds in a short period of time to be evaluated for worsening heart function.,0
You will continue dialysis three times weekly.,0
You also have an appointment for one month at the oncology clinic where your need for additional chemotherapy medications will be evaluated.,0
Followup Instructions: Call Dr. ( to make a future appointment for after leaving the rehab facility.,0
"Provider: , MD Where: CARDIAC SERVICES Phone: Date/Time: 10:00 Provider: , MD Where: HEMATOLOGY/BMT Phone: Date/Time: 10:00 Provider: Where: HEMATOLOGY/ONCOLOGY Phone: Date/Time: 10:00",0
Height: (in) 61 Weight (lb): 255 BSA (m2): 2.10 m2 BP (mm Hg): 111/62 Status: Inpatient Date/Time: at 15:11 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is moderately dilated.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is markedly dilated.,0
RIGHT VENTRICLE: The right ventricular cavity is markedly dilated.,0
PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear structurally normal.,0
Mild pulmonic regurgitation is seen.,0
"Compared to the previous study dated , which was reviewed, RV has dilated, Rv function has declined and TR has increased in severity.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: HD line placement (L IJ) Admitting Diagnosis: HYPOTENSION;SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with ESLD REASON FOR THIS EXAMINATION: HD line placement (L IJ) ______________________________________________________________________________ WET READ: EAGg MON 8:23 PM Left IJ central venous line terminates at junction of upper SVC and bracheocephalic.,1
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Access line placement.,0
Left IJ catheter tip is in the junction of the upper SVC and the brachiocephalic vein.,1
ET tube is in the standard position.,0
Small right pleural effusion is unchanged.,1
Bibasilar opacity likely atelectasis greater on the right side have improved.,0
"12:24 PM CHEST (PORTABLE AP) Clip # Reason: eval for ptx, chf ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with chest pain at site of HD catheter REASON FOR THIS EXAMINATION: eval for ptx, chf ______________________________________________________________________________ FINAL REPORT HISTORY: 57-year-old male with chest pain at the site of hemodialysis catheter.",0
SINGLE PORTABLE VIEW OF THE CHEST: A left subclavian large-bore dual-lumen catheter reaches the high atrium.,0
"Cardiomegaly, interstitial edema, and bilateral pleural effusions (right greater than left), have not changed significantly since the prior exam.",0
The bony thorax is normal.,0
IMPRESSION: Overall no change since .,0
Please note that radiographic examination cannot address the site of catheter insertion.,0
"12:44 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: check heart size Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with h/o PDA, has persistent loud murmur.",0
REASON FOR THIS EXAMINATION: check heart size ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST AT 12:44 HOURS.,0
CLINICAL HISTORY: Assess heart size in an infant with a history of PDA with a persistent loud murmur.,0
"Since the prior study the endotracheal tube, UAC and UVC have been removed.",0
The cardiac silhouette is now moderately enlarged and there are increased interstitial lung markings in keeping with chronic lung disease.,0
The appearance of the lungs is improved compared to the prior study.,0
IMPRESSION: Increased heart size compared to the prior study with improved bilateral lung aeration.,0
"5:12 AM PORTABLE ABDOMEN Clip # Reason: signs of obstruction vs ascites Admitting Diagnosis: PANCREATITIS;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with pancreatitis, s/p NG tube decompression, w increasing abdominal distension, considering ascites vs obstruction REASON FOR THIS EXAMINATION: signs of obstruction vs ascites ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SZm FRI 10:59 AM PFI: 1.",1
Normal bowel gas pattern with no evidence of obstruction or ileus.,0
Diffuse haziness of the abdomen suggests abdominal ascites.,0
Nasoenteric tube seen coiled within the distal stomach.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 77-year-old female with pancreatitis status post NG decompression with increasing abdominal distention, consider ascites versus obstruction.",1
FINDINGS: There is a nasoenteric tube seen coiled within the distal stomach with the tip likely still remaining within distal stomach.,0
"There is an overall haziness projecting over the abdomen, suggestive of diffuse abdominal ascites.",0
There is contrast seen from prior CT from throughout the colon and in the rectum.,0
There is no evidence of obstruction or ileus.,0
Again seen are multiple surgical clips within the pelvis.,0
"In the right hip, there is a dynamic hip screw transfixing the right femoral neck.",0
Unremarkable bowel gas pattern with contrast seen throughout the colon and no evidence to suggest obstruction or ileus.,0
Diffuse haziness of the abdominal radiograph suggests the presence of abdominal ascites.,0
7:58 AM DUP EXTEXT BIL (MAP/DVT); DUP EXTEXT BIL (MAP/DVT) Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: upper and lower extremitiy vein mapping for conduit.,0
"Admitting Diagnosis: NON HEALING ULCER, RIGHT FOOT ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with ischemic rt.",0
foot ulcer REASON FOR THIS EXAMINATION: upper and lower extremitiy vein mapping for conduit.,0
______________________________________________________________________________ FINAL REPORT BILATERAL UPPER AND LOWER EXTREMITY VENOUS DUPLEX.,0
Preop for lower extremity bypass.,0
FINDINGS: Duplex evaluation was performed of the bilateral upper and lower extremity veins.,0
"In the upper extremities, the cephalic vein was not seen on the right.",0
The right basilic vein was visualized and noted to be very small with diameters ranging from 0.15 to 0.17 cm.,0
"In the left upper extremity, there was an IV line in the cephalic vein.",0
The basilic vein was visualized and noted to be very small with diameters ranging from 0.14 to 0.27 cm.,0
"In the lower extremities, the greater saphenous veins were patent bilaterally.",0
"On the right, the vein was visualized from the saphenofemoral junction to the knee with diameters ranging from 0.22 to 0.35 cm.",0
The right lesser saphenous vein was patent with diameters ranging from 0.17 to 0.33 cm.,0
"In the left lower extremity, the greater saphenous vein was patent from the saphenofemoral junction to the ankle with diameters ranging from 0.18 to 0.48 cm.",0
The left lesser saphenous vein was patent with diameters ranging from 0.24 to 0.49 cm.,0
IMPRESSION: Patent bilateral upper extremity basilic veins with small diameters as noted above.,0
Patent bilateral lesser saphenous veins with diameters as noted above.,0
Patent left greater saphenous vein with diameters as noted above.,0
Patent right greater saphenous from the groin to the knee with diameters as noted above.,0
"3:43 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with ETT, fevers REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY COMPARISON: chest x-ray.",0
"FINDINGS: Endotracheal tube and central venous catheter remain in standard position, and cardiomediastinal contours are unchanged.",0
Worsening atelectasis at right lung base.,0
"Newly developed confluent opacity in left lower lobe with a few air bronchograms, concerning for acute aspiration in the appropriate clinical setting.",1
Followup radiographs may be helpful to exclude a developing pneumonia in this region if warranted clinically.,0
"5:46 AM CHEST (PORTABLE AP) Clip # Reason: eval for ptx, effusion Admitting Diagnosis: PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with polytrauma , bilat CT to water seal REASON FOR THIS EXAMINATION: eval for ptx, effusion ______________________________________________________________________________ FINAL REPORT PORTABLE SEMI-UPRIGHT CHEST, .",0
INDICATION: Chest tube to waterseal.,0
Bilateral chest tubes remain in place.,0
The most superior left-sided chest tube side port is at least partially external to the left pleural space projecting lateral to the lateral left fifth rib.,0
"There is a tiny lateral left pneumothorax just above this level, new in the interval.",1
A small right pneumothorax is without change from a recent radiograph.,1
"Endotracheal tube remains in standard position, and cardiac and mediastinal contours are stable.",0
Bibasilar opacities presumably atelectasis have improved in the interval.,0
IMPRESSION: New tiny left lateral pneumothorax and stable small right apical pneumothorax with chest tubes in place.,1
"9:49 AM CT HEAD W/O CONTRAST Clip # Reason: Assess for interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with large R parieto-occipital bleed, SAH, and IVH REASON FOR THIS EXAMINATION: Assess for interval change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Assess for interval change status post massive parenchymal, as well as subarachnoid and intraventricular hemorrhage.",1
TECHNIQUE: Non contrast head CT scan.,0
FINDINGS: Comparison with the prior study of reveals no significant interval change in the extent of the huge right posterior temporal/occipital hemorrhage as well as an accompanying intraventricular hemorrhage.,0
There is also subarachnoid blood seen along the left cerebral convexity surface.,0
The huge hemorrhage continues to cause prominent leftward subfalcine herniation and likely a component of hippocampal heriation on the right.,0
There has been no interval change in ventricular size.,0
"CONCLUSION: Stable, grossly abnormal study as noted above.",0
"COMMENT: There is loss of aeration of the frontal sinus and what appears to be an expansile area of soft tissue density, 1.5 x 3 cm in size, within the left ethmoid sinus.",0
These findings could represent polyposis with the ethmoid abnormality also potentially representing a mucocele.,0
The posterior aspect of the left lamina papyracea is thinned by this lesion.,0
"When the patient's clinical condition stabilizes, further evaluation of this finding appears advisable.",0
6:29 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
Worstening PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with unknown etiology interstitial lung dx as well as PNA now on non rebreather with O2 sat 96%.,0
Worstening PNA ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON HISTORY: Interstitial lung disease and pneumonia.,0
FINDINGS: Compared to the film from the prior evening the right-sided patchy alveolar infiltrate is similar but the left infiltrate is more confluent and has a worsened appearance.,0
There is probably also an associated left small effusion.,0
IMPRESSION: Worsening infiltrate particularly on the left.,0
5:54 AM PORTABLE ABDOMEN Clip # Reason: evaluate dobhoff position Admitting Diagnosis: POST PROCEDURE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with NJ tube presumed in stomach.,0
"REASON FOR THIS EXAMINATION: evaluate dobhoff position ______________________________________________________________________________ FINAL REPORT ABDOMEN, 6:10 A.M. HISTORY: Nasogastric tube, assess location.",0
IMPRESSION: Two views of the upper abdomen show a feeding tube coiled in the stomach and ending at or just beyond the pylorus.,0
This study is not sensitive for free subdiaphragmatic gas.,0
Right upper quadrant drains and stents noted.,0
No particular intestinal distention is present.,0
", C. CSURG FA6A 1:22 PM CHEST (PORTABLE AP) Clip # Reason: eval for pneumothorax s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal ______________________________________________________________________________ PFI REPORT 1.",1
Interval removal of chest tube without pneumothorax.,0
Obscured left hemidiaphragm may be due to left basilar atelectasis or elevation of left hemidiaphragm as a sequela of the procedure.,0
PERSANTINE MIBI MIBI Clip # Reason: H/O MI IN 99 WORSENING CHF EVALUATE FOR ISCHEMIA ______________________________________________________________________________ FINAL REPORT RADIOPHARMECEUTICAL DATA: 29.2 mCi Tc-m Sestamibi; 30.0 mCi Tc-99m Sestamibi; HISTORY: 59 y/o with known CAD (Inferior wall MI ) with worsening congestive heart failure and inferior and septal wall motion abnormailty seen on recent echocardiography.,1
SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min.,0
INTERPRETATION: Image Protocol: Gated Planar.,0
Resting perfusion images were obtained with mibi.,0
"The image quality is suboptimal, limited by body habitus; as a result, only a gated planar study was performed.",0
Left ventricular cavity size is probably normal.,0
Resting and stress perfusion images reveal decreased tracer activity in the inferior wall with no definite reversibilty.,0
"Gated images reveal akinesis of the inferior wall, limited in intepretation given subotptimal resolution.",0
"Markedly limited study due to body habitus, such that only gated planar study could be performed.",0
Limited interpretation suggests fixed inferior wall defect with regional abnormal wall motion.,0
Approved: TUE 4:36 PM RADLINE ; A radiology consult service.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Morbid Obesity Major Surgical or Invasive Procedure: 1.,1
Laparoscopic converted to open approach.,1
Repair of colotomy (transverse colon).,0
Repair of ventral hernias x2.,1
"History of Present Illness: has class III morbid obesity with weight of 278.4 pounds as of (his initial screen weight on was 282.8 pounds), height 66 inches and BMI of 44.9.",1
His previous weight loss efforts has included most recently HMR for 26 weeks in losing 35 pounds that he is still maintaining.,0
He lost 120 pounds with 38 weeks of HMR in that he kept off for 15 months plus multiple other diets but has not been able to maintain the weight loss.,0
Past Medical History: PMH 1. hypertension 2. paroxysmal atrial fibrillation for about 10 years 3. obstructive sleep apnea on CPAP 4. hyperlipidemia 5. fatty liver by ultrasound PSH none Social History: tobacco: none alcohol at least two cocktails one to two times a week He is employed in the insurance business as a claims adjuster.,1
He has no children and lives with his spouse age 52.,0
"Family History: father deceased age 71 of cancer, heart disease and obesity.",1
"Physical Exam: Blood pressure was 162/94, pulse 82, respirations 16 and O2 saturation 96% on room air.",0
"On physical examination was casually dressed, pleasant and in no distress.",0
"His skin was warm, dry with no rashes, and there were a few follicular lesions on trunk and benign cherry hemangiomas.",0
"Sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue was pink and the oropharynx was without exudates or hyperemia.",0
"Trachea was in the midline and the neck was supple with no adenopathy, thyromegaly, carotid bruits or JVD.",0
Chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement.,0
"Cardiac exam was regular rate and rhythm with normal S1 and S2, no murmurs, rubs or gallops.",0
"The abdomen was obese but soft and non-tender, non-distended with positive bowel sounds and no appreciable masses or incision scars, there was a moderate sized ventral hernia that was reducible.",1
There was no spinal tenderness or flank pain.,0
"Lower extremities were without edema, venous insufficiency or clubbing, perfusion was good, pulses were intact.",0
There was no evidence of joint swelling or inflammation of the joints.,0
There were no focal neurological deficits and his gait was normal.,0
Pertinent Results: Abdominal US : 1.,0
Echogenic liver consistent with fatty infiltration.,0
Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study.,1
"12:15PM WBC-13.9*# RBC-4.87 HGB-14.2 HCT-41.7 MCV-86 MCH-29.1 MCHC-34.0 RDW-14.2 07:40PM WBC-19.4* RBC-4.03* HGB-11.5* HCT-33.8* MCV-84 MCH-28.5 MCHC-34.0 RDW-13.6 11:30PM WBC-19.6* RBC-3.35* HGB-9.8* HCT-28.3* MCV-85 MCH-29.3 MCHC-34.7 RDW-13.7 HCT : 34.4 Brief Hospital Course: Mr. was admitted to the hospital and taken to the Operating Room where he underwent a laparoscopic gastric bypass, repair of a colotomy in the transverse colon and hernia repair.",1
( See formal operative note for details ) He tolerated the procedure well and returned to the PACU in stable condition.,0
On the evening of surgery he gradually became tachycardic and pale.,0
His pre op hematocrit was 41 and post op drifted to 28.,0
Based on his symptoms and decreasing hematocrit he was taken back to the Operating Room for exploration.,0
No active bleeding was identified so he then underwent endoscopy which revealed adherent clot at the GJ anastomosis.,0
( See formal Operative Note for details ) He was transfused both intra and post op and always maintained stable hemodynamics.,0
Following exploration he was transferred to the SICU for close monitoring.,0
He developed paroxysmal atrial fibrillation on post op day #1 and was treated with IV Lopressor.,1
Over the next 48 hours he continued to have bursts of PAF eventually controlled with a Diltiazem drip and repletion of electrolytes.,0
PAF has been a pre op problem but so infrequent that he was not on any medications for rate control.,0
He was evaluated by the Cardiology service who recommended Lopressor 25 mg PO BID and titrate up as needed for rate control while the Diltiazem was weaned off.,0
Eventually he was controlled with 50mg PO TID.,0
Following transfer to the surgical floor he continued to make good progress.,0
He started a stage 1 diet and over a 48 hour period was advanced to stage 3.,0
He developed some gas and bloating on stage 3 and was eventually switched to a soy based diet which he tolerated much better.,0
He was up and walking independently and his hematocrit remained stable.,0
His surgical sites were healing well and after a prolonged hospital course he was discharged to home and will follow up with Dr. with in 2 weeks.,0
At that time his staples will be removed.,0
Medications on Admission: 1. aspirin 81 mg daily 2. vitamin C 1000 mg daily 3. vitamin B complex daily 4.,0
Biotin 300 mg daily 5. vitamin D 1000 units daily 6. folic acid 0.4 mg daily 7. glucosamine 1500 mg daily 8.,0
Garlic one tablet daily 9. iron 18 mg daily 10. magnesium 400 mg daily 11. potassium gluconate 595 mg daily 12.,0
MVI 1 tab daily 13.,0
Omega-3 fatty acids 1000 mg 200 mg daily Discharge Medications: 1.,0
"Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day.",0
Roxicet 5-325 mg/5 mL Solution Sig: ml PO every four (4) hours as needed for pain.,0
Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day.,0
"Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day.",0
Potassium Gluconate 595 (99) mg Tablet Sig: One (1) Tablet PO once a day: please crush.,0
Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day: Please crush.,0
Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day: Empty capsule in waater and mix.,0
Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day.,0
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1.,0
Acute blood loss anemia 6. paroxysmal atrial fibrillation Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you.",0
Diet: Stay on Stage III diet until your follow up appointment.,0
"Do not self advance diet, do not drink out of a straw or chew gum.",0
Medication Instructions: * Please follow-up with your PCP or Cardiologist regarding starting Metoprolol for Paroxysmal A-Fib.,0
"Resume your home medications, CRUSH ALL PILLS.",0
You will be starting some new medications: 1.,0
You are being discharged on medications to treat the pain from your operation.,0
These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely.,0
You MUST refrain from such activities while taking these medications.,0
You should begin taking a chewable complete multivitamin with minerals.,0
You will be taking Zantac liquid 150 mg twice daily for one month.,0
This medicine prevents gastric reflux.,0
You will be taking Actigall 300 mg twice daily for 6 months.,0
This medicine prevents you from having problems with your gallbladder.,0
"You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern.",0
"You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen.",0
These agents will cause bleeding and ulcers in your digestive system.,0
Activity: No heavy lifting of items pounds for 6 weeks.,0
"You may resume moderate exercise at your discretion, no abdominal exercises.",0
"Wound Care: You may shower, no tub baths or swimming.",0
"If there is clear drainage from your incisions, cover with clean, dry gauze.",0
Your steri-strips will fall off on their own.,0
"Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites.",0
"Followup Instructions: Provider: , RD Phone: Date/Time: 3:00 Provider: , MD Phone: Date/Time: 3:30 Completed by:",0
7:49 AM CHEST (PORTABLE AP) Clip # Reason: Check IABP placement.,0
"Admitting Diagnosis: ANGINA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CAD s/p cabg, ischemic cardiomyopathy, s/p cardiac cath 8/15k with IABP placement.",0
REASON FOR THIS EXAMINATION: Check IABP placement.,0
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Ischemic cardiomyopathy.,0
I am unable to see an intraaortic balloon pump or its radiopaque tip.,0
3:27 PM CHEST (PA & LAT) Clip # Reason: eval for acute change Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with LGIB REASON FOR THIS EXAMINATION: eval for acute change ______________________________________________________________________________ FINAL REPORT INDICATION: Lower GI bleeding.,1
"PA AND LATERAL CHEST: A nasogastric tube has been placed, with tip in the lower esophagus.",0
"The left hiatal hernia is again appreciated, and the tube has not definitively past below the hemidiaphragms.",0
The right apical and peripheral reticular opacities appear similar to the recent preceding exams.,0
Plate like atelectasis is seen within the left base.,0
No definite pleural effusion or pneumothorax.,0
The abdominal aorta is heavily calcified.,0
Left convex scoliosis is centered at the thoracolumbar junction.,0
IMPRESSION: NG tube tip is likely located in the hiatal hernia.,0
The tube could be advanced by several centimeters so that the tube would be located beneath the hemidiaphragm.,0
"Findings were discussed with , the nurse caring for the patient in the Intensive Care Unit.",0
Height: (in) 65 Weight (lb): 138 BSA (m2): 1.69 m2 BP (mm Hg): 120/70 HR (bpm): 80 Status: Inpatient Date/Time: at 13:30 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
AORTA: Mildly dilated aortic root.,0
"The aortic root, ascending aorta, and the aortic arch are mildly dilated.",0
"There is a 0.8 x 0.3 cm linear density on the ventricular side of the anterior mitral leaflet, which likely represents a torn chorda tendinae.",0
"However, a vegetation cannot be definitely ruled out.",0
There is no significant associated mitral regurgitation.,0
IMPRESSION: No definite transthoracic echo evidence of endocarditis.,0
A transesophageal study may better define the linear mitral valve density and assess for possible vegetations.,0
4:22 PM G/GJ TUBE CHECK Clip # Reason: please coordinate with IR PICC placement Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with PEG?peritonitis REASON FOR THIS EXAMINATION: please coordinate with IR PICC placement ______________________________________________________________________________ FINAL REPORT HISTORY: 46-year-old man with PEG.,1
PROCEDURE: The patient was placed supine on the fluoroscopy table.,0
"Air-filled stomach, small bowel loops and large bowel were seen.",0
No definite intraperitoneal free air was observed.,0
50 cc of Conray were infused through the PEG with the patient supine and in the left lateral decubitus position.,0
Contrast flowed freely into the stomach.,0
No extravasation of contrast or air was observed during the exam.,0
IMPRESSION: Appropriate positioning of PEG.,0
No extravasation of air or contrast seen during the exam.,0
3:41 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: Please assess for injury.,1
______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with face trauma.,0
REASON FOR THIS EXAMINATION: Please assess for injury.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 25-year-old man with facial trauma.,0
Multiple comminuted fractures are seen within the facial bones.,1
"There is a comminuted fracture of the left anterior maxillary sinus, lateral maxillary sinus and zygomatic arch, with air fluid level in the left maxillary sinus.",1
"Comminuted fractures are seen through the left orbital roof, and lateral wall with deformity of the globe, and lateral rectus muscle.",0
The lamina payracea is intact.,0
The optic nerve is also deformed.,0
Free fluid is extravasating from the left orbit into the left frontal sinus.,0
"There is a fracture through the left frontal bone, with disruption of both the inner and outer tables.",0
"There is diffuse subcutaneous emphysema, and hematoma involving the left masseter, and temporalis muscles.",0
"The endotracheal tube, and nasogastric tube, are seen within the oral and hypopharynx.",0
"Enucleation of the left globe, with optic nerve deformity.",0
12:50 PM PICC LINE PLACMENT SCH Clip # Reason: IV team unable to obtain access.,0
"Need PICC for dopamine, IVF Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * PICC W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION * * FLUOR GUID PLCT/REPLCT/REMOVE FEE ADJUSTED IN SPECIFIC SITUATION * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: F w/PNA, likely sepsis REASON FOR THIS EXAMINATION: IV team unable to obtain access.",0
"Need PICC for dopamine, IVF, Abx.",0
______________________________________________________________________________ FINAL REPORT HISTORY: This is a -year-old female with sepsis.,1
"Needs PICC line for IV antibiotics, dopamine, and fluids.",0
RADIOLOGISTS: The procedure was performed by Dr. .,0
No staff radiologist was present for the procedure.,0
TECHNIQUE: The patient was placed supine on the angiography table.,0
The right upper arm was prepared in a sterile fashion.,0
"Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein.",0
The right brachial vein presented patent and compressible.,0
"After local anesthesia with 3 cc of lidocaine 1%, access was gained through the right brachial vein with a 21-gauge needle under ultrasonographic guidance.",0
A 0.018 guidewire was advanced through the needle into the superior vena cava.,0
"The needle was removed over the wire, and a 5-French peel-away sheath was inserted into the vein.",0
"Based on the markers on the guidewire, it was determined that the length of 33 cm would be suitable.",0
The double lumen PICC line was trimmed to this length and advanced over the wire under fluoroscopic guidance into the superior vena cava.,0
A final chest x-ray image was obtained documenting adequate position with tip in the superior vena cava.,0
The catheter was flushed and heplocked and secured to the skin with a StatLock.,0
COMPLICATIONS: There were no immediate complications.,0
IMPRESSION: Successful placement of a 33 cm long double lumen PICC line through the right brachial vein with tip in the superior vena cava.,0
The catheter is ready for use.,0
"8:51 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with go bleed, tube REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: GI bleed.",0
An endotracheal tube remains in place.,0
The tip of the tube terminates approximately 2.5 cm above the carina.,0
The tube has been removed in the interval.,0
"Allowing for marked rotation of the patient, cardiac and mediastinal contoursa are stable.",0
There remains a right pleural effusion.,0
"No confluent areas of consolidation are seen in either lung, but part of the right lower lobe is not well demonstrated due to patient rotation.",0
An endotracheal tube terminates approximately 2.5 cm above the carina.,0
"10:20 AM CT HEAD W/O CONTRAST Clip # Reason: 71yo male s/p ventricular drain placement ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with sah,chf,htn REASON FOR THIS EXAMINATION: 71yo male s/p ventricular drain placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post ventricular drain placement.",0
COMPARISONS: CT head without contrast .,0
TECHNIQUE: Contiguous axial images were obtained from the foramen Magnum to the cranial vertex.,0
CT HEAD WITHOUT IV CONTRAST: There is evidence of diffuse subarachnoid hemorrhage and intraventricular hemorrhage with a fluid-fluid level observed in both occipital horns.,0
There is no significant change from prior study of .,0
There are no intra or extra axial masses.,0
There is no significant change in the hemorrhage in the lateral ventricles.,0
"The osseous structures, soft tissues and sinus are unremarkable.",0
No significant change in the intraventricular hemorrhage when compared to head CT of .,0
6:10 AM CHEST (PORTABLE AP) Clip # Reason: Interval change?,0
Admitting Diagnosis: ASTHMA;COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with oxygen desaturation REASON FOR THIS EXAMINATION: Interval change?,0
______________________________________________________________________________ FINAL REPORT HISTORY: Oxygen desaturation.,0
"FINDINGS: In comparison with the study of , the patient has taken a somewhat better inspiration.",0
Moderate cardiomegaly persists without definite pulmonary vascular congestion or acute focal pneumonia.,0
Streak of atelectasis is seen at the left base.,0
"PERSANTINE MIBI Clip # Reason: Known CAD, CABG, Awaiting surgery ______________________________________________________________________________ FINAL REPORT HISTORY: Known CAD, CABG, Awaiting surgery SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min.",0
INTERPRETATION: Image Protocol: Gated SPECT Resting perfusion images were obtained with thallium.,0
The image quality is good Left ventricular cavity is normal Resting and stress perfusion images reveal a moderate reversible perfusion defect of the anterior wall and apex that is more prominent when compared to .,0
The calculated left ventricular ejection fraction is low normal at 49% IMPRESSION: Moderate reversible perfusion defects of the anterior wall and apex that are more prominent compared to .,0
"Low normal LV EF 49% , M.D.",0
Approved: TUE 11:39 AM West RADLINE ; A radiology consult service.,0
"7:41 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o pvl Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 26 week twin, now two months old REASON FOR THIS EXAMINATION: r/o pvl ______________________________________________________________________________ FINAL REPORT HEAD ULTRASOUND PERFORMED : CLINICAL HISTORY: Ex 26 week twin, now 2 months of age.",1
"Compared to the prior ultrasound of , there is no significant change.",0
"The sulci, gyri and ventricles are symmetric and normal in size for the patient's age.",0
No extra-axial collection or hemorrhage is identified.,0
Midline structures and the posterior fossa appear unremarkable.,0
IMPRESSION: Normal neonatal head ultrasound.,0
3:57 PM CHEST (PORTABLE AP) Clip # Reason: check IABP after repositioning; acute desaturation ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with chest pain REASON FOR THIS EXAMINATION: check IABP after repositioning; acute desaturation ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Chest pain.,0
"CHEST, AP: Comparison is made to the prior film obtained six hours earlier.",0
"Again noted is the ET tube, with the tip about 5.7 cm above the carina.",0
"Also noted is Swan-Ganz catheter, with the tip in the main pulmonary artery.",0
"NG tube is also noted, with the tip in the stomach.",0
The tip of the intraaortic balloon pump is not well seen.,0
"Again noted is evidence of patchy opacities in the right lung, which remain unchanged from the prior exam.",0
"The left hemidiaphragm is not well visualized, consistent with left lower lobe collapse/consolidation.",0
IMPRESSION: The tip of the intraaortic balloon pump is not well seen.,0
"Otherwise, no significant change from the prior study.",0
"12:57 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate for ptx Admitting Diagnosis: AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with s/p cardiac surgery, CTs d/c'd REASON FOR THIS EXAMINATION: evaluate for ptx ______________________________________________________________________________ FINAL REPORT HISTORY: 74-year-old male status post CABG.",1
Patient with recent removal of chest tubes.,0
COMPARISON: Postoperative chest radiograph from .,0
PORTABLE AP CHEST RADIOGRAPH: Interval removal of the Swan-Ganz catheter and chest tubes is noted.,0
The sheath of the Swan-Ganz remains in the right internal jugular vein.,0
Previously identified vascular congestion has receded.,0
Bibasilar atelectasis and probable small effusions are unchanged.,0
Postoperative cardiac mediastinal widening is stable.,0
Interval removal of the Swan-Ganz catheter and chest tubes.,0
"Decreased pulmonary vascular congestion, now mild.",1
Stable bibasilar atelectasis and probable small effusions.,0
"6:34 PM CHEST (PA & LAT) Clip # Reason: eval for fluid overload, pneumonia Admitting Diagnosis: VENTRAL HERNIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58M s/p lap ventral hernia repair, with abdominal hematoma requiring multiple transfusions, now with dyspnea REASON FOR THIS EXAMINATION: eval for fluid overload, pneumonia ______________________________________________________________________________ WET READ: GMSj MON 10:34 PM Extremely low lung volumes.",1
No edema or vascular congestion.,0
Evalution of cardiac silhouette limited.,0
GSenapati WET READ VERSION #1 GMSj MON 10:30 PM xtremely low lung volumes.,0
GSenapati ______________________________________________________________________________ FINAL REPORT HISTORY: Possible fluid overload.,0
"FINDINGS: In comparison with the earlier study of this date, there are very low lung volumes that account for the prominence of the transverse diameter of the heart.",0
Bibasilar atelectatic changes are seen but no evidence of acute focal pneumonia.,0
"Specifically, no evidence of pulmonary vascular congestion.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: dysarthric speech & gait difficulties Major Surgical or Invasive Procedure: 1.,0
"Suboccipital craniotomy for resection of right cerebellar metastases, opening greater than 5 cm, autologous duraplasty using pericranial graft.",0
History of Present Illness: The patient is 80-year-old gentleman who was diagnosed with stage IV level V melanoma of the right nasolabial fold in .,0
He had a wide local excision completely excised with residual superficial spreading melanoma.,0
His sentinel lymph nodes were negative.,1
Routine chest x-ray in showed multiple bilateral nodular opacities measuring up to 1-2 cm.,0
A left upper lobe wedge biopsy was consistent with metastatic melanoma.,0
"A CT scan also showed a 10.5 mm pericarinal lymph node and MRI of the head showed two metastatic lesions, one in the left frontal and one in the right inferior frontal.",0
He received SRS to both on .,0
He started on Temodar 75 mg per meters squared times six weeks and two weeks off on .,0
"One month followup MRI on , , showed resolution of the right frontal met to 50% decrease of the left frontal met.",0
"Good response of lung mets on , torso CT. His second cycle of Temodar was interrupted for diarrhea and then was restarted in the end of .",0
"On , torso CT showed some progression of the lung nodules.",0
The abdominal and pelvic CT was negative for disease.,0
He is here for his five month post-radiation MRI.,0
"The patient states that since last being seen, he has been having some difficulties with double vision, unsteady gait, and some incoordination.",0
"He denies any headaches, no nausea or vomiting.",0
He states that he has not noticed if he is veering to one side more than the other.,0
The diplopia has been for four days and his imbalance has been for two weeks.,0
He also thinks he might have some slurred speech.,0
Excision of the facial melanoma 2.,0
Social History: He never smoked.,0
He drinks half a bottle of wine at night.,0
His son is present today: he is NP.,0
He used to work in the insurance business.,0
Family History: No melanoma in his family.,0
His father died of a stroke.,0
He believes his mother died of a stroke.,0
His family history knowledge is limited as his family was Scientist and did not seek medical attention.,0
"Physical Exam: PHYSICAL EXAMINATION: VITAL SIGNS: His blood pressure is 126/74, pulse of 74, respirations of 16, and temperature of 97.6.",0
"GENERAL: He is alert, pleasant elderly gentleman, who looks younger than his stated age.",0
CARDIOVASCULAR: The patient has a grade 2/6 systolic ejection murmur heard best at the right upper sternal border.,0
LUNGS: Clear to auscultation bilaterally.,0
NEUROLOGIC: HEENT: Head was normocephalic and atraumatic.,0
"Eyes, pupils equal, round, and reactive to light.",0
"Extraocular movements were intact on the left, but he did have a mild right sixth palsy.",0
Funduscopic exam showed blurred disks bilaterally.,0
Neck was soft and supple.,0
Cranial nerves II through VII and IX through XII were intact.,0
"Motor was bilaterally, normal tone, and no drift.",0
Sensation was intact to light touch throughout.,0
There was no extinction to double simultaneous stimulation.,0
"Cerebellar: The patient had some decrease in foot tapping on his right foot, but this was subtle compared to the left.",0
"Other than that, he had normal appendicular coordination.",0
"With gait, he did appear actually to have a difficulty positioning his left foot somewhat and not so much with the right.",0
"There was some unsteadiness of the gait and he was unable to tandem, however, he was able to toe and heel walk reasonably well.",0
"Pertinent Results: 02:21PM BLOOD WBC-8.6 RBC-3.26* Hgb-10.4* Hct-30.8* MCV-95 MCH-31.8 MCHC-33.6 RDW-14.8 Plt Ct-171 07:26AM BLOOD PT-13.1 PTT-23.8 INR(PT)-1.1 02:21PM BLOOD Glucose-156* UreaN-26* Creat-1.0 Na-137 K-3.7 Cl-98 HCO3-26 AnGap-17 02:21PM BLOOD Calcium-9.3 Phos-3.9 Mg-1.5* CT HEAD W/O CONTRAST 0729/05 6:19 pm CT HEAD WITHOUT IV CONTRAST: The patient has undergone suboccipital craniotomy with an osseous defect, parenchymal defect, pneumocephalus, and small amount of adjacent hemorrhage.",0
Small amount of pneumocephalus is seen layering anteriorly in the anterior and middle cranial fossae.,0
"There has been interval placement of a right frontal intraventricular catheter, which terminates near the right-sided foramen of .",0
There is a small amount of hemorrhage layering within the occipital of the right lateral ventricle.,0
The known hemorrhagic metastasis is again identified within the right posterior parietal lobe with surrounding edema.,0
There is a small amount of mucosal thickening within the right maxillary sinus.,0
"IMPRESSION: Postoperative changes, as described above.",0
"CT HEAD W/O CONTRAST 4:00 PM CT OF THE HEAD WITHOUT IV CONTRAST: A perforated ventricular drain is seen entering the right ventricle from the frontal aspect, terminating in what appears to be the medial aspect of the right thalamus.",0
"However, in the interval, there is loss of the -white junction, and hypodensity in the right frontal lobe, most likely indicating a subacute infarction.",0
The previously identified hyperdense mass with vasogenic edema in the right parietal lobe is stable.,0
"Pneumocephalus in the right cranial hemisphere overlying the right frontal lobe is again seen, though smaller than the previous exam.",0
"Also noted is craniotomy defect overlying the right subocciput, a defect in the brain tissue at the right cerebellum and surrounding edema, and small foci of hyperdensity, all consistent with postoperative changes, and not significantly changed in the interval.",0
Surrounding osseous and soft tissue structures are also unchanged.,0
"IMPRESSION: Interval development of subacute infarct in right middle cerebral artery territory CT HEAD W/O CONTRAST 11:45 PM FINDINGS: There is interval development of hemorrhage into a subacute right frontal lobe infarction, as indicated by new hyperdensity, and there is expansion of the affected area.",1
Mass effect is increased and there is narrowing of the right lateral ventricle and mild shift of the midline structures to the left.,0
The left lateral ventricle is unchanged in size.,0
"The large right parietal lobe intraparenchymal hemorrhage, and postoperative changes in the cerebellum are unchanged.",0
Additional hemorrhages in the right caudate head and left medial cerebellar hemisphere are stable.,0
The degree of pneumocephalus is slightly less compared to yesterday.,0
A ventricular drainage catheter is unchanged in position.,0
IMPRESSION: Expanded infarction and new hemorrhage in the right frontal lobe Pathology Tissue diagnosis Cerebellum with METASTATIC MALIGNANT MELANOMA Note: Immunohistochemistry reveals positive staining for melanoma antigen HMB-45.,1
Brief Hospital Course: Patient admitted on day of surgery for elective suboccipital craniotomy for resection of right cerebellar metastasis (from melanoma) with autologous duraplasty using pericranial graft.,0
A right sided frontal EVT was also placed intraoperatively.,0
"Post-operatively the patient remained intubated, initially secondary to prone position of the surgery to protect the airway from edema post-op.",0
"The patient waxed and waned in alertness and mental status, therefore he remained intubated and was transferred to the SICU on POD#1 after being observed in the PACU overnight.",0
Blood pressure was maintained on a nitroprusside drip post-operatively.,0
"He was noted to have a post-op hematocrit of 28, therefore he was transfused 1unit of PRBC on POD#0.",0
A CT showed post-op changes in addition to a previously identified metastasis in the right posterior parietal lobe.,0
The ventriculostomy drain was open to drainage and was clamped on POD#2.,0
ICPs were monitored and were noted to be within normal ranges.,0
"The patient was still minimally responsive and was noted to move his right side more than the left to stimuli, therefore a CT head was ordered on POD#2.",0
A new right sided MCA infarct was seen on the CT in addition to slightly increased amount of hemorrhage into a parietal metastasis.,0
The patient's family was informed of this finding.,0
The patient continued to be observed in the ICU and his level of consciousness remained unchanged.,0
The patient was made DNR by his family at this time.,0
A repeat CT on POD#3 showed interval worsening of the infarct with new hemorrhage into that area.,0
"A family meeting was held on POD 4, and the decision was made to continue comfort care only.",0
The patient was extubated following this decision and expired soon after.,0
"Medications on Admission: Decadron 4mg tid Keppra 250mg 5 tabs twice a day Coumadin 5mg daily Doxazocin 1mg daily Lipitor once daily, Digoxin half a tablet a day Metoprolol 50 mg twice daily.",0
Discharge Disposition: Expired Discharge Diagnosis: Metastatic Melanoma Discharge Condition: Expired,0
Height: (in) 70 Weight (lb): 185 BSA (m2): 2.02 m2 BP (mm Hg): 112/54 HR (bpm): 96 Status: Inpatient Date/Time: at 11:00 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: RIGHT VENTRICLE: The right ventricular cavity is unusually small.,0
PERICARDIUM: There is a large pericardial effusion.,0
"There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling.",0
Bilateral pleural effusions are present.,1
The left ventricular cavity is normal.,0
Overall systolic function is good.,0
There is a lsmall-moderate inferolateral partially echofilled pericardial effusion.,0
"A larger anterior partially echo filled (?blood, organized effusion) space is seen with right ventricular compression and accentuated respiratory variation in tricuspid valve inflows, consistent with impaired ventricular filling/tamponade physiology.",0
A chest CT/MR is suggested to evaluate a possible localized (anterior) pericardial effusion.,0
"Compared with the prior study of earlier in the day, the right ventricle and anterior effusion are more clearly defined.",0
Transtricuspid flow was not assessed on the prior study.,0
"10:19 AM HICK CHECK/REPO Clip # Reason: SVC venogram, possible exchange of existing catheter, possib Admitting Diagnosis: FAILURE TO THRIVE ********************************* CPT Codes ******************************** * EXCH CENTRAL NON-TUNNELED -78 RELATED PROCEDURE DURING POSTOPE * * FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man SVC syndrome, R subclavian clotted, L IJ clotted; patient's TPN port no longer working, hep gtt port working - this is his only access.",1
"REASON FOR THIS EXAMINATION: SVC venogram, possible exchange of existing catheter, possible intervention, thanks ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb SAT 4:55 PM Replacement of 10 French Bard Dual-Lumen central venous line with the tip of the line in the right atrium and the line is ready to use.",0
______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: The patient is a 55-year-old man with SVC syndrome.,0
Patient's existing tunneled double lumen venous catheter did not function properly.,0
A request was made to replace the existing central venous line to continue TPN and heparin infusion.,0
"OPERATORS: Dr. and Dr. , the attending radiologist who was present and supervised during the whole procedure.",1
PROCEDURE: Replacement of the existing central venous line.,1
ANESTHESIA: Lidocaine was used for local anesthesia.,0
"PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well as local anesthesia was explained, informed consent was obtained.",0
The patient was brought to the angiographic suite and placed supine on the imaging table.,0
The right chest and existing catheter were prepared and draped in the usual sterile fashion.,0
A scout image demonstrated the existing central venous line with its tip in the upper SVC.,0
"One 0.035 super-stiff glidewire was advanced into the existing catheter with its tip in the IVC, and a 0.08 glidewire was then advanced into the other port of the catheter with the tip terminating in the right atrium.",0
The catheter was removed over these two glidewires after the suture was removed and the catheter cuffs had been mobilized.,0
A new 10 French Bard Dual- Lumen central venous catheter was then advanced into the IJ over the two glidewires and was further advanced so that it's tip ended in the right atrium.,0
Both ports were flushed and aspirated easily.,0
The catheter was sutured to the skin and both ports were aspirated and flushed easily again.,0
"(Over) 10:19 AM HICK CHECK/REPO Clip # Reason: SVC venogram, possible exchange of existing catheter, possib Admitting Diagnosis: FAILURE TO THRIVE ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: Replacement of a 10 French Bard Dual-Lumen central venous catheter with the tip in the right atrium and the line is ready to use.",1
4:11 PM CHEST (PORTABLE AP) Clip # Reason: eval infiltrate Admitting Diagnosis: S/P MVC;HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with MVC extubated today now desaturating.,0
REASON FOR THIS EXAMINATION: eval infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress.,0
CHEST AP: Comparison is made to a film obtained 8 hours earlier.,0
The endotracheal tube and left-sided central venous catheter are unchanged in position.,0
There is interval removal of the Dobhoff tube.,0
There is distention of the stomach with air.,0
Low lung volumes are seen.,0
Patchy atelectasis in the basilar area bilaterally is again visualized.,0
"9:55 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: evaluate ileus Admitting Diagnosis: POSTOPERATIVE BILE LEAK ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with cholecystitis, bile leak, ileus, N/V REASON FOR THIS EXAMINATION: evaluate ileus ______________________________________________________________________________ FINAL REPORT STUDY: Abdomen supine and erect films, .",0
CLINICAL HISTORY: 75-year-old woman with cholecystitis and bile leak.,1
Evaluate for ileus given the nausea and vomiting.,0
FINDINGS: There is a catheter projecting over the right upper abdomen.,0
"There is air seen throughout the colon, and there are few air-filled loops of small bowel which are non-enlarged.",0
Air and stool seen within the rectum.,0
There is a nonspecific bowel gas pattern without definite signs for bowel obstruction.,1
There is no free intra-abdominal gas seen on the left side down decubitus films.,0
10:21 AM CHEST (PA & LAT) Clip # Reason: evaluate effusion and ?,0
consolidation RUL Admitting Diagnosis: ATRIAL FIBRILATION\THORACOSCOPIC MAZE PROCEDURE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with s/p mini maze s/p asp pna REASON FOR THIS EXAMINATION: evaluate effusion and ?,0
consolidation RUL ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest PA and lateral on .,0
"HISTORY: 79-year-old man with status post mini-Maze, status post aspiration or pneumonia.",1
Evaluate effusion and questionable consolidation in the right upper lobe.,0
"FINDINGS: There is interstitial thickening in both lungs, right more than left and upper lobe more than lower lobe.",0
The heart size is not enlarged.,0
A left-sided pacemaker with dual wires are again seen with no complications.,1
The lung volumes are stable.,0
"Pneumonic infiltration is seen involving both lungs, right more than left and right upper lobe more than right lower lobe.",0
4:52 AM PORTABLE ABDOMEN Clip # Reason: Eval distention and NGT placement ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p cabg with mental status changes REASON FOR THIS EXAMINATION: Eval distention and NGT placement ______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN: INDICATION: Bowel distention.,0
A single supine view of the abdomen reveals needles and wire projected over the right upper quadrant.,0
It is possible that the tip of an NGT is seen at the superior most aspect of this radiograph but no tip is seen within the stomach.,0
The tube may thus be in the esophagus.,0
"12:15 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: LEFT ARM SWELLING EVAL FOR FLUID COLLECTION V S CLOT Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with pain, erythema and swelling in left antecub fossa after MRI with contrast injected in that area.",1
abscess vs clot REASON FOR THIS EXAMINATION: eval for fluid collection vs clot ______________________________________________________________________________ FINAL REPORT LEFT UPPER EXTREMITY ULTRASOUND.,1
HISTORY: 79-year-old female with pain and erythema and swelling in the left antecubital fossa after MRI contrast injection infiltration.,0
"FINDINGS: -scale and color Doppler son were performed of the left internal jugular, left subclavian, left axillary, brachial, and cephalic veins.",0
Increased echogenic foci within the left cephalic vein limited to the antecubital fossa was identified and demonstrated no compression.,0
"There was, however, some flow identified through this area.",0
This is consistent with a partial thrombus in the left cephalic vein vs. recanalization of superficial thrombus.,0
There was normal flow and compressibility within the left brachial and left axillary veins.,0
The left basilic vein was not visualized.,0
IMPRESSION: Superficial thrombus within the left cephalic vein limited to the antecubital fossa consistent with either a partial acute thrombus or partially recanalized chonic thrombus.,0
The left basilic vein was not identified.,0
These findings were discussed with at the time of review.,0
6:09 PM CHEST (PORTABLE AP) Clip # Reason: assess placement Admitting Diagnosis: SUB DURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man received a new NG tube.,0
REASON FOR THIS EXAMINATION: assess placement ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST: @ 21:23.,0
FINDINGS: The NGT extends well below the diaphragmatic surface and its tip is beyond the coverage of the film.,0
Chronic interstitial changes are appreciated in the upper lungs bilaterally without significant difference.,0
"In the current study, a more nodular appearance projects over the left anterior rib two, which is likely artifactual considering that it is not seen on prior studies.",0
IMPRESSION: NGT well below the diaphragm.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEONATOLOGY HISTORY: The infant is a 30-0/7 week, 1855 gram female born who was triaged in the Neonatal Intensive Care Unit to monitor for possible transitional disorders as a result of prematurity and growth restriction.",0
"The infant was born to a 26 year old gravida 1, para 0 mother.",0
"SEROLOGIES: A negative, antibody negative, Hepatitis B surface antigen negative; RPR nonreactive.",0
Pregnancy was notable for increased blood pressures since .,0
Fetal growth restriction; mother received RhoGAM .,0
"Due to decreasing amniotic fluid volume and ongoing fetal restriction, the decision was made to deliver the infant by cesarean section for breech positioning.",0
Rupture of membranes at the time of delivery.,0
"PHYSICAL EXAMINATION: On admission, birth weight 1855 grams (10 to 25th percentile); length 43 cm (10 to 25th percentile); head circumference 31 cm (25th percentile).",0
"Pink, alert, no distress, non-dysmorphic.",0
Anterior fontanel soft and flat.,0
Lungs clear and equal with good and equal aeration.,0
Regular rate and rhythm; no murmur.,0
"Abdomen soft, positive bowel sounds.",0
"Patent anus, no sacral anomalies.",0
Hip splayed outward due to breech positioning.,0
Extremities pink and well perfused.,0
Respiratory: The infant has remained in room air throughout this hospitalization with respiratory rates 30 to 60.,0
The infant has not had any apnea of bradycardia this hospitalization.,0
The infant was not treated with methylxanthine therapy.,0
Cardiovascular: The infant has remained hemodynamically stable this hospitalization.,0
Heart rate 130 to 150 with mean blood pressures 50 to 56.,0
"Fluids, Electrolytes and Nutrition: The infant was started on enteral feedings of breast milk or Enfamil 20 calories per ounce p.o.",0
ad lib with a minimum of 60 cc per kilogram per day.,0
The glucoses throughout this hospitalization have been 51 to 144.,0
The infant required gavage feedings until day of life nine.,0
The infant tolerated feeding advancement without difficulty.,0
Feedings were advanced to 140 cc per kilogram per day by day of life five.,0
The infant is currently receiving NeoSure 24 calories per ounce and/or breast milk 24 calories per ounce mixed with 4 calories per ounce of NeoSure powder.,0
Discharge weight is 1885 grams.,0
Head circumference is 31.5; length 45 cm.,0
GI: The infant did not receive phototherapy this hospitalization.,0
The most recent bilirubin level day of life seven was 9 with a direct of 0.4.,0
Hematology: The infant did not receive any blood transfusions this hospitalization.,0
"The infant's blood type is A positive, Coombs negative.",0
Infectious Disease: Delivery was due to maternal pregnancy-induced hypertension.,0
There were no other sepsis risk factors.,0
The infant did not receive antibiotics this hospitalization.,0
The infant passed both ears.,0
Psycho-social: The parents live on .,0
They are very involved with .,0
CONDITION AT DISCHARGE: Former 35-0/7 weeks small for gestational age infant now stable in room air.,0
DISCHARGE STATUS: Home with parents.,0
"NAME OF PRIMARY PEDIATRICIAN: Dr. , phone number ; fax number .",0
"Feeding: At discharge, NeoSure 24 calories per ounce p.o., minimum 140 cc per kilogram per day or breast milk 24 calories per ounce mixed with 4 calories per ounce of NeoSure Powder.",0
NeoSure is recommended until six to nine months corrected age.,0
Medications: Fer-In- 0.15 cc p.o.,0
q. day; Poly-Vi- 1 cc p.o.,0
Car Seat Position Screening was performed and the infant passed.,0
State Newborn Screens were sent on ; results are pending.,0
The infant should receive the first Hepatitis B Vaccine at 2 kg or 2 months of age (whichever is first).,0
"According to AAP guidelines, an outpatient hip ultrasound is recommended due to several risk factors for developmental dysplasia of the hip (DDH) including: breech presentation, female, prematurity and cesarean section.",0
Follow-up appointment with Dr. .,0
"8. , Community and Home Health, phone number .",0
"Prematurity, 35-0/7 weeks gestation female.",0
Dictated By: MEDQUIST36 D: 16:03 T: 18:02 JOB#:,0
7:36 PM CT CHEST W/O CONTRAST Clip # Reason: etiology of fever Admitting Diagnosis: ABDOMINAL PAIN;NEUTROPENIA Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 33 year old man with hodgkins lymphoma and massive HSM w febrile neutropenia.,1
"REASON FOR THIS EXAMINATION: etiology of fever No contraindications for IV contrast ______________________________________________________________________________ WET READ: GWp MON 8:59 PM Resolved effusion, bibasal atelectasis but at left base cannot exclude infective process.",1
"Small focus GGO in RUL, apparently new, could represent infective process, Persistent R axiallary and mediatinal adenopathy & HSM GWlms WET READ VERSION #1 GWp MON 8:58 PM Resolved effusion, bibasal atelectasis but at left base cannot exclude infective process.",0
"GGO in RUL, apparently new, could represent infective process, Persistent R axiallary and mediatinal adenopathy & HSM GWlms ______________________________________________________________________________ FINAL REPORT CHEST CT, .",0
HISTORY: 33-year-old man with Hodgkin's lymphoma and massive hepatosplenomegaly with febrile neutropenia.,1
TECHNIQUE: Contiguous helical acquisition through the chest was performed.,0
1.5- and 5-mm axial images and 5-mm coronal and sagittally reformatted images were created.,0
FINDINGS: The heart is stable in size.,0
Again noted are multiple borderline enlarged mediastinal lymph nodes measuring up to 9.6 cm within the prevascular space with additional prominent lymph nodes noted in the pretracheal and subcarinal regions.,1
The airways are patent to the subsegmental bronchi.,0
There is bibasilar atelectasis including a focal area of consolidation within the left lower lobe with a single air bronchogram likely representing plate-like atelectasis secondary to hepatomegaly.,0
Within the right upper lobe are several nodular ground-glass opacities which are new compared to the prior study and concerning for infection.,0
There has been interval resolution of the bilateral pleural effusions.,1
The osseous structures are intact.,0
"There is right axillary lymphadenopathy with numerous enlarged lymph nodes measuring up to 1.7 cm in short axis, many of which are slightly smaller when compared to the prior study.",1
Again noted is a low- density cystic lesion measuring 2.9 x 3.1 cm which is slightly larger when compared to the prior study and also more organized in appearance which may represent a necrotic lymph node versus a post-biopsy seroma.,1
The remaining soft tissues of the chest are unremarkable.,0
"Although this study was not designed for subdiaphragmatic evaluation, again (Over) 7:36 PM CT CHEST W/O CONTRAST Clip # Reason: etiology of fever Admitting Diagnosis: ABDOMINAL PAIN;NEUTROPENIA Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont) noted is partially visualized hepatosplenomegaly.",1
"As contrast was not administered, the hypodense lesions within the spleen and liver are not identified on the current study.",1
"There is a small amount of perisplenic free fluid, unchanged compared to the prior study.",0
The visualized adrenal glands and kidneys are normal in appearance.,0
Bibasilar atelectasis and interval development of new ground-glass nodular opacities in the right upper lobe which are worrisome for infection.,0
Viral or atypical bacterial pneumonia is favored.,0
Stable mediastinal lymphadenopathy and slightly improved right axillary lymphadenopathy.,0
Interval enlargement of 3-cm well-circumscribed fluid collection in the right axilla which may represent a necrotic lymph node versus a post-biopsy seroma.,0
"Hepatosplenomegaly and a small amount of perisplenic fluid, unchanged.",0
2:52 PM CHEST (PA & LAT) Clip # Reason: ?pulmonary edema Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with HIV and St. with endocarditis and aortic root abscess REASON FOR THIS EXAMINATION: ?pulmonary edema ______________________________________________________________________________ FINAL REPORT CHEST TWO VIEWS PA AND LATERAL HISTORY: in HIV patient with endocarditis and aortic root abscess.,1
There is cardiomegaly but no evidence for CHF/pulmonary edema.,0
Atelectases are present in the lingula and left lower lobe.,0
The tip of The PICC line is in the distal SVC.,0
"4:37 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: evaluate for gastric tumor invasion, other lymphadenopathy o Admitting Diagnosis: GASTRIC OUTLET OBSTRUCTION Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with gastric ulcer and 17mm perigastric lymph node REASON FOR THIS EXAMINATION: evaluate for gastric tumor invasion, other lymphadenopathy or metastatic disease to liver.",1
No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKgc MON 11:17 PM 1.,0
Diffuse thickening of the gastric wall at the level of the pylorus.,0
These findings are concerning for a gastric malignancy with local lymph nodal disease.,0
No evidence of distant metastases in the abdomen and pelvis.,0
"Multiple bilateral adrenal lesions, consistent with adenomas.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old woman with gastric ulcer and 17 mm perigastric lymph node, to assess for gastric tumor invasion, lymphadenopathy and metastatic disease.",1
TECHNIQUE: MDCT helical images were acquired through the abdomen and pelvis after administration of oral and 100 cc Optiray intravenous contrast.,0
Additional non-contrast and three-minute post-contrast delayed images were acquired through the abdomen.,0
Sagittal and coronal reformats were generated and reviewed.,0
"FINDINGS: The imaged lung bases are normal, without suspicious pulmonary nodules or pleural effusions.",1
The imaged portion of the heart and pericardium are normal.,0
"There is diffuse circumferential thickening involving the gastric pylorus, with mild narrowing of the pyloric channel.",1
There is no evidence of a gastric outlet obstruction.,1
"As noted in history, there is a large perigastric lymph node along the greater curvature (3:30), now measuring 15 x 9 mm in dimensions.",1
Also seen are at least three subcentimeter lymph nodes in the perigastric region (3:31).,0
"The remainder of the stomach, small and large bowel are normal in appearance.",0
The liver enhances homogeneously without focal lesions.,0
"Small area of hypoenhancement adjacent to the falciform ligament (3:28), likely represents an area of focal fat infiltration.",0
There is no intra- or extra-hepatic biliary dilatation.,0
"A 9-mm right adrenal body nodule (3:14), demonstrates attenuation value consistent with fat (-11), and is consistent with an adenoma.",0
"Two 9 mm left adrenal nodules (3:17 and 3:19) demonstrate fat density in the non-contrast CT, consistent with adenomas.",0
"Both kidneys enhance and excrete contrast symmetrically without (Over) 4:37 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: evaluate for gastric tumor invasion, other lymphadenopathy o Admitting Diagnosis: GASTRIC OUTLET OBSTRUCTION Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) hydronephrosis.",1
Small retroperitoneal and mesenteric lymph nodes do not meet CT criteria for significant adenopathy.,0
There is no intra-abdominal free fluid or air.,0
"There is moderate diffuse atherosclerotic calcification of the abdominal aorta, without aneurysmal dilation.",0
"The celiac axis, superior mesenteric artery and renal arteries are normal.",0
"CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, sigmoid colon and rectum are unremarkable.",0
The uterus is not visualized.,0
There is no pelvic free fluid or significant adenopathy.,0
BONES: No bone lesions suspicious for infection or malignancy are detected.,0
"Diffuse symmetric thickening of the gastric wall at the level of the pylorus, with few perigastric lymph nodes.",0
"10:26 AM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with POD 3 CABG REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, AT 10:26 INDICATION: Postop CABG.",0
FINDINGS: Left retrocardiac density is seen localizing the left lower lobe on the lateral view.,0
This could be either atelectasis or pneumonia.,0
The frontal appearance is not significantly different compared to the prior.,0
There is better aeration of the lungs bilaterally with no evidence of congestive change.,0
The right CVL has been removed and there is no PTX.,0
IMPRESSION: Better aeration and persistent left lower lobe consolidation (atelectasis versus pneumonia).,0
12:01 PM FISTULOGRAM/SINOGRAM Clip # Reason: fistulogram of colostomy.,0
"will inject Admitting Diagnosis: UTI;ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with decreased colostomy output, need to eval for obstruction/kink/twisting REASON FOR THIS EXAMINATION: fistulogram of colostomy.",1
will inject contrast for fistulogram - pls page when ready.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old woman with decreased colostomy output.,0
COMPARISON: CT of the abdomen and pelvis with contrast from ; fluoroscopy from .,0
FINDINGS: The bowel was evaluated with Conray contrast in a retrograde and anterograde fashion.,0
A Catheter was used to first cannulate the colostomy in the right lower quadrant.,1
Contrast initially filled the bowel loops to the approximate distance of the cannula.,0
Conray contrast was then injected through the J-tube and a small length of bowel was opacified.,0
"However, after approximately 10 minutes, the central area of bowel failed to opacify.",0
IMPRESSION: Bowel loops opacified through retrograde and anterograde fashion with failure of contrast to reach the central portion of the bowel.,1
These findings are suggestive of obstruction.,0
The patient is to go to CT for further analysis.,0
"Dr. was present during the entire procedure and the results were discussed with him at time of the study today, .",0
8:32 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please assess for possible etiology Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with R frontal IPH w/ extension into the ventricles w/ clinical exam more severe than demonstrated per CT REASON FOR THIS EXAMINATION: Please assess for possible etiology No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 1:39 PM IMPRESSION: 1.,1
Right frontal intra-axial hematoma extending to the ventricular system with mild dilatation of the ventricles.,0
Mass effect is seen on the right lateral ventricle.,0
No enhancement is seen in this region or in other parts of the brain.,0
Small areas of restricted diffusion at the -white matter junction of right frontal lobe and also at the left parietal region likely representing diffuse axonal injury.,0
The appearances and location are not typical for ischemic foci.,0
______________________________________________________________________________ FINAL REPORT EXAM: MRI OF THE BRAIN.,0
CLINICAL INFORMATION: Patient with history of trauma and right frontal hemorrhage with clinical examination is much more severe than the hemorrhage seen on CT.,0
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images were obtained before gadolinium.,0
T1 axial and MP-RAGE sagittal images acquired following gadolinium.,0
Comparison was made with the multiple CT examinations.,0
FINDINGS: The larger area of right frontal intraparenchymal acute hemorrhage identified with little low T2 signal and portion of it showing high T1 signal indicative of acute hemorrhage.,0
There is surrounding edema seen and mass effect on the anterior of the right lateral ventricle.,0
There is intraventricular extension with fluid-fluid level within the occipital of both lateral ventricles with mild dilatation of the ventricles.,0
There is subarachnoid hemorrhage identified.,0
Periventricular hyperintensities due to small vessel disease are seen.,0
"On the diffusion images, several foci of restricted diffusion are seen at the convexity near the -white matter junction, which appeared to be within the parenchyma and not within the subarachnoid space and do not appear to represent blood products.",0
These findings likely indicate focal areas of diffuse axonal injury.,0
The location is more typical for the diffuse axonal injury than ischemic foci.,0
There is no large territorial infarct seen.,0
There (Over) 8:32 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please assess for possible etiology Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ FINAL REPORT (Cont) is no midline shift identified.,1
Fluid is seen in the ethmoid air cells.,0
"Following gadolinium administration, no definite abnormal parenchymal, vascular or meningeal enhancement identified.",0
12:28 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: stroke Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with R MCA infarct REASON FOR THIS EXAMINATION: stroke No contraindications for IV contrast ______________________________________________________________________________ WET READ: 2:57 AM multiple rt sided infarcts - cortical and subcortical - in right MCA territory.,0
at least some are subacute as seen on FLAIR.,0
right MCA occlusion as seen on CTA.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Right MCA infarct.,0
TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained.,0
3D time-of-flight MRA was also performed.,0
"FINDINGS: Multiple foci of increased signal consistent with slow diffusion identified in the right cortical and deep white matter, consistent with right MCA territory infarcts.",0
Corresponding increased T2 signal identified suggesting that these infarcts may be several days old.,0
"There is no acute hemorrhage, shift of normally midline structures, or hydrocephalus.",0
Signal intensity values of the brain parenchyma otherwise appear unremarkable.,0
"MRA demonstrates abrupt cutoff of the right MCA at the bifurcation, with M1 and M2 vessels not evaluated.",0
M2 vessels were seen on the previously performed CTA (please see separately dictated report).,0
"Anterior cerebral A1 and A2 vessels are also not well identified, though distal A2 vessels were seen on CTA (please see separately dictated report).",0
No findings suggestive of ischemia are identified in the ACA territory.,0
"Findings consistent with infarcts in the right MCA territory, with abrupt cutoff of the right MCA identified on MRA at the bifurcation.",0
"Findings on previously performed CTA suggest that there is collateral filling of more distal M2 branches, although those are not identified on this study.",0
"A1 and A2 branches not identified on the current MRA, although findings on prior CTA suggest posterior pericallosal collateral filling of the distal A2 vessels.",0
"Status: Inpatient Date/Time: at 14:31 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: Mr. is a 55-year-old male with end stage insulin dependent diabetes mellitus with triopathy who presents after complaints of progressive shortness of breath with sudden onset, developing on .",0
"He ultimately came to the Emergency Room on where work-up included a chest x-ray that showed cardiomegaly, cephalization, vascular engorgement with bilateral CT angle blunting consistent with pulmonary edema.",0
"Ultimately given this presentation, he was admitted to the C-Med service where he was put on a rule out protocol.",0
His troponin I did peak at 37.,0
"His CKs, however, remained negative.",0
"His preoperative hematocrit was noted to be 28 with platelet count of 152,000 and a white blood cell count of 11,000.",0
His BUN and creatinine were 37 and 1.4 with baseline creatinine of 1.3 to 1.5.,0
"Cardiac catheterization that was carried out on revealed trace MR, left ventricular ejection fraction of 35%.",0
"The left main coronary artery was non diseased, however, the LAD had diffuse disease with a 70% mid LAD lesion and another serial lesion on the LAD at 80% distally.",0
The left circ at the level of the OM1 had a 95% stenosis at the origin and the right coronary artery was diffusely diseased with 90% distal stenosis with thrombus.,0
"Given his significant three vessel coronary artery disease and mild to moderate systolic dysfunction, he was admitted to the C-Med service, placed on telemetry, given diuresis and beta blockade and ultimately referred to the cardiothoracic surgery service of Dr. .",0
The patient was evaluated by Dr. on .,0
At this time he was already on Heparin for the positive troponin and three vessel disease.,0
He was pain free at that time.,0
His JVD and pulmonary compromise with pulmonary edema were resolving.,0
He was transfused for a hematocrit of 24 on hospital day #2 and given one unit of packed cells followed by Lasix.,0
"PAST MEDICAL HISTORY: His other preoperative history included a past medical history of insulin dependent diabetes with peripheral neuropathy, questionable history of gastroparesis.",1
He has severe peripheral vascular disease.,0
He has chronic lower extremity leg ulcers on the left.,0
"He has had coronary artery disease, hypertension, degenerative joint disease including bilateral hips.",0
"He has history of CHF, has had a gunshot wound in the past.",0
PAST SURGICAL HISTORY: Significant for right below the knee amputation as well as a left transmetatarsal amputation.,0
"SOCIAL HISTORY: Significant for previous tobacco history, greater than 30 pack year as well as he lives alone and is a veteran.",0
His physical activity at baseline is wheelchair bound.,0
"He has had no history of TIA, CVA or GI bleed.",0
HOSPITAL COURSE: Ultimately Dr. felt the patient was appropriate to go to the OR.,0
He went for a three vessel coronary artery bypass graft on .,0
"Grafts included a LIMA to the LAD, a left saphenous vein graft to the OM1 and a left saphenous vein graft to the PDA.",0
Intraoperative TEE revealed an ejection fraction of 30-40%.,0
"Post-operatively out of the OR he was maintained on Epinephrine, Aprotinin, Levophed, an insulin drip and Propofol for sedation.",0
"He was brought to the cardiac surgical care recovery unit where his postoperative labs were noted to have a hematocrit of 30, normal coagulation parameters, INR of 1.2, PTT 33, potassium was noted to be 4.4, BUN and creatinine at this time were 63 and 1.5.",0
"He was started on Levaquin and Flagyl not only to cover his lower extremity leg ulcers, but also to cover some viscous pulmonary secretions that were noted.",0
He was extubated on postoperative day #1 and was maintained on a non rebreather.,0
"He was satting at 93% with gases of 7.26, 63, 167, 31 and 0.",0
"Given the tenuous nature of his gases, he had serial ABGs followed on postoperative day #1, was given aggressive pulmonary toilet.",0
He was started with diuresis.,0
His Aspirin was started and his Neo-Synephrine was weaned.,0
His insulin drip was maintained at 5 units per hour and he was normoglycemic.,0
By postoperative day #2 the patient remained in the cardiac surgical care recovery unit.,0
"He was on Levaquin and Flagyl, his perioperative Vancomycin dose was finished at his third dose, insulin drip was titrated to 6 units to maintain normoglycemia.",0
He was started on prophylaxis with Zantac as well as stool softeners with Colace.,0
"His oral diet was a diabetic , 1800 kilocalories with cardiac diet as well.",0
His day #2 labs included a hematocrit of 23 for which he was ultimately transfused two units.,0
This was thought to be secondary to small oozing that was in his chest tube.,0
BUN and creatinine were 69 and 1.8.,0
"After his volume being repleted as well as his transfusion being completed, he was continued on progressive pulmonary toilet and diuresis.",0
By postoperative day #3 the patient was deemed appropriate for discharge to the floor.,0
"He was maintained on chest tube suction because of high chest tube output, his sanguineous discharges on the first two days changed to more serosanguineous and his hematocrit was stable at 30 on postoperative day #3.",0
BUN and creatinine were noted to be 71 and 1.9.,0
He was changed to a q day Lasix regimen instead of and Lopressor was started as well as adding on a full dose Aspirin.,0
consultation was obtained for assistance with the patient's diabetic management.,0
He was tolerating his diet although he was complaining at this time of intermittent regurgitation.,0
This was felt to be due secondary to his probable underlying gastroparesis and autonomic neuropathy from his end stage diabetes.,0
Consequently the patient was started on Reglan which had satisfactory results and eliminated the majority of the patient's complaints of nausea and regurgitation.,0
"Of note, on postoperative day #3 the patient's Foley was removed, however, he failed to void in 9 hours post Foley removal and after attempts by the house officer and nursing staff to insert a Foley catheter, these failed, urology consultation was obtained.",0
The patient had his catheter inserted by the urology service who felt that he probably failed to void secondary to retention issues of the post-operative state with narcotic use and his autonomic neuropathy and perhaps small degree of benign prostatic hypertrophy.,0
FOley was instructed to stay in until which time the chest tube is removed so that once his pain requirements became less he would use less narcotic and as a consequence have less urinary sphincter tone.,0
"By postoperative day #4 the patient was undergoing transfers with physical therapy, was out of bed to a chair, tolerating it well.",0
He was noted to go into atrial fibrillation with rapid ventricular response to the 110's.,1
"This was easily treated and controlled with Lopressor and he was started on Amiodarone, converted to normal sinus rhythm after approximately 12 hours of therapy.",0
"By postoperative day #5 the patient was in sinus rhythm, was afebrile, tolerating his diet without complaints.",0
He had a Foley catheter and chest tube at this time.,0
"By postoperative day #6 his chest tubes were removed, chest x-ray showed a small left effusion with pneumothorax, normal cardiac silhouette, no focal infiltrate was identified.",0
He additionally had Foley catheter removed at midnight prior to discharge.,0
"Labs prior to discharge were notable for hematocrit of 35, BUN and creatinine of 64 and 1.6.",0
"His exam was notable for temperature of 98.3, pressure of 90/50, pulse rate of 64 and sinus.",0
"On exam he has a stable sternum with staples in place, no erythema or drainage.",0
Heart was regular with no murmur or rub or gallop.,0
Lungs with decreased breath sounds at the bases with crackles bilaterally.,0
Left lower extremity was noted to have trace edema.,0
"Saphenous vein harvest was well approximated, intact, no drainage or erythema were present.",0
"He did have a macular rash in the inguinal regions that was felt to be intertrigonal, likely secondary to Candidiasis.",0
Ultimately patient was accepted to Rehab facility where he will undergo aggressive rehabilitation regimen to get him back to his baseline of being wheelchair bound.,0
His activity restriction will include no pushing off with his arms as he is dependent on his upper extremities for mobility.,0
This cannot be utilized for 30 days so his sternal wound be allowed to adequately heal.,0
Additionally he will be put on subcu Heparin for DVT prophylaxis.,0
"He should be continued with an aggressive pulmonary rehabilitation effort including incentive spirometry, coughing and deep breathing, nebulizers as needed.",0
Follow-up will include seeing Dr. in 30 days from the time of discharge.,0
He is to see his PCP weeks from the time of discharge and the Rehabilitation facility will be able to evaluate his wounds.,0
"DISCHARGE MEDICATIONS: Lopressor 12.5 mg po bid, Lasix 20 mg po q a.m., K-Dur 20 mEq po q day, Colace 100 mg po bid, Aspirin 325 mg po q day, Eucerin cream to the left foot , Protonix 40 mg po q day, Heparin 5000 units subcu , Mycostatin powder to the affected skin area, Flagyl 500 mg po q 8 should be completed by , Levaquin 500 mg po q day to be completed by .",0
Both of these antibiotics were given for presumed pulmonic infection.,0
Blood cultures and sputum cultures taken on postoperative day #1 ultimately never revealed an organism.,0
"Percocet po q 4-6 hours prn and Amiodarone taper including 400 mg po tid times 7 days, then change to 400 mg po bid times 7 days, then change to final regimen of 200 mg po q day times 14 days, then stop.",0
"Reglan 10 mg po q 6 hours as well as NPH 40 units q a.m., NPH 30 units q p.m. and sliding scale insulin as directed by the Clinic.",0
"CONDITION ON DISCHARGE: Stable, sinus rhythm, afebrile, to go to rehab facility at .",0
"Status post three vessel coronary artery bypass graft including LIMA to LAD, saphenous vein graft to OM1 and saphenous vein graft to the PDA.",0
"Postoperative atrial fibrillation with rapid ventricular response, now in sinus, rate controlled.",1
"Insulin dependent diabetes mellitus with peripheral neuropathy, likely triopathy.",1
Dictated By: MEDQUIST36 D: 20:35 T: 20:36 JOB#:,0
11:09 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: rtij change over wire Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman s/p clipping Acomm aneurysm REASON FOR THIS EXAMINATION: rtij change over wire ______________________________________________________________________________ FINAL REPORT Portable chest compared at an earlier time.,1
CLINICAL INDICATION: Line change over wire.,0
A right internal jugular catheter has been placed and terminates within the body of the right atrium.,0
Endotracheal tube and nasogastric tube remain in place.,0
There is slight worsening of a patchy left retrocardiac opacity.,0
IMPRESSION: 1) Vascular catheter terminates in right atrium.,0
"2) Worsening patchy left lower lobe opacity, which may relate to atelectasis.",0
Developing pneumonia in this region cannot be excluded.,0
7:05 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: head MRI w/ gadollinium to r/o extension of surrounding infa Admitting Diagnosis: BRAIN TUMOR Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 51 yo M w/ h/o recently dx GBM s/p resection 2 weeks ago a/w worsening aphasia w/ CT c/w postsurg changes but unable to really visualize surrounding edema from prior infarct associated w/ surgery REASON FOR THIS EXAMINATION: head MRI w/ gadollinium to r/o extension of surrounding infarction ______________________________________________________________________________ FINAL REPORT INDICATION: S/P resection of glioma with extensive edema of the scalp and assess for fluid collection.,0
Multiplanar T1 and T2 weighted images of the brain were obtained.,0
"T1 axial, and coronal images are performed before and after Gadolinium administration.",0
Correlation is made to the prior examination of the brain from and the CT examination from .,0
The patient is s/p resection of the left sided glioblastoma.,0
There is increased T1 signal surrounding the surgical bed suggestive of postoperative small hemorrhage.,0
The previously seen large tumor has been resected.,0
There is minimal residual surrounding vasogenic edema and mass effect over the left lateral ventricle without significant midline shift.,0
There is susceptibility surrounding the left temporal lobe due to the presence of byproducts of blood.,0
Diffusion images reveal multiple foci of restricted diffusion along the left temperoparietal lobe within the surgical bed and surrounding the basal ganglia.,0
Additional foci of abnormal diffusion are noted along the left frontoparietal convexity.,0
There is also abnormal diffusion signal in the subdural space.,0
The findings are highly suspicious for either small embolic infarct or brain atrophy along the frontoparietal lobe away from the surgical site.,0
"In addition, there is subdural empyema which enhances peripherally along the right anterior frontal convexity.",0
There is mild sulcal effacement and abnormal meningeal enhancement noted following Gadolinium administration suggestive of meningitis in addition to subdural empyema.,0
Diffuse sulcal effacement is seen along the left hemisphere.,0
There is a large fluid loculation underneath the scalp and above the craniotomy site which measures 8 cm along the anteroposterior dimension and could represent collection of pus.,0
Small nodular enhancing component is seen posteriorly abuting the surgical bed.,0
The posterior fossa structures were unremarkable and the fourth ventricle is in the midline.,0
There is normal signal flow void along the intracranial portions of the carotid and basilar arteries.,0
IMPRESSION: 1) Moderate sized left frontoparietal subdural empyema with abnormal restricted diffusion and pathologic enhancement noted following Gadolinium administration.,0
2) Superficial fluid collection which could represent pus above the craniotomy (Over) 7:05 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: head MRI w/ gadollinium to r/o extension of surrounding infa Admitting Diagnosis: BRAIN TUMOR Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) site.,0
3) Abnormal left frontoparietal meningeal enhancement suggestive of meningitis related to the presence of subdural empyema.,0
4) Minor petechial hemorrhage surrounding the postoperative bed.,0
5) 3 abnormal foci of restricted diffusion along the left frontoparietal convexity suggestive of either a small brain abcesses or embolic infarcts.,0
Correlation with the symptoms and neurosurgical consultation is recommended.,0
The findings were conveyed to the requesting physician .,0
The patient is already scheduled for neurosurgical intervention tomorrow morning on .,0
Follow up examination will be recommended and would be helpful.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: Valium / Penicillins / Percocet / Benzodiazepines Attending: Chief Complaint: Seizures Major Surgical or Invasive Procedure: Intubation Lumbar puncture History of Present Illness: 44 F with hx RR-MS with recent admission for MS flare , s/p 5 days IV solumedrol, was found at home by family around 6 pm dressed in towels and drying to dress self with plastic bags.",0
"Shortly prior to her daughter arriving home, other family members (who live above and below her) had heard a variety of banging noises coming from the pt's apt, but thought it might have been the daughter coming home.",0
"The daughter found behaving very bizarrely, not following commands, and was becoming agitated and beligerent.",0
She was brought to the ER where she was noted to be very agitated and uncooperative with examination.,0
She was given ativan and haldol.,0
"At one point she became very somnolent with shallow breathing, but as RN tried to apply face mask, she resisted and stated she didn't need it.",0
She also had an episode where she was repeatedly sitting up and down in bed and was breathing in a staccato manner.,0
Over the course of several hours she was given a total of 8 mg ativan and 15 mg haldol.,0
"She was also given ceftriaxone, vancomycin, and acyclovir to cover for meningitis.",0
She also received 100 mg hydrocortisone in case of adrenal insufficiency her recent solumedrol infusions.,0
Finally she received 1000 mg Dilantin.,0
Family states that nothing like this has happened before.,0
"She has not been ill otherwise, and there have been no new meds added to her regimen recently.",0
They do note that her PO intake has been poor lately.,0
Past Medical History: MS - as above.,0
Gluacoma in the left eye.,0
Supercervical hysterectomy for 20 pound fibroid.,0
Hypercholesterolemia Social History: Lives on the of her family home.,0
Her mother lives on the and she lives on the .,0
She is currently on disability allowance.,0
She has worked as recently as for the Theater Company selling tickets.,0
She reports smoing for at least 25 years about 1 PPD.,0
Sh denied ETOH and illicit drug use.,0
Family History: Father passed away form lung CA at the age of 54.,0
No history of the mother's medical history or family history of neurological diseases was elicited.,0
"Physical Exam: T- F BP- 124/70 HR- 82 RR- 18 O2Sat 100%RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa; some blood noted in nostrils and on tip of tongue, but no clear lac.",0
"Neck: supple CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no c/c/e Neurologic examination: Mental status: sleeping, unarousable to verbal or tactile stim.",0
"(-) BTT B/L, (+) corneals B/L Motor: Normal bulk bilaterally.",0
No observed myoclonus or tremor spont mvmt of the RLE and RUE noted.,0
"withdraws to noxious in the LE B/L and the LLE, but not LUE.",0
Sensation: withdraws in all ext except the LUE Reflexes: 0 and symmetric throughout.,0
There is no evidence of abnormal enhancement or new lesions.,0
"Brief Hospital Course: 44 yo RHW with relapsing remitting multiple sclerosis, recently discharged from hospital after a 5 day course of IV solumedrol presents with bizarre, and uncharacteristic behavior.",1
"Her family mentioned that she is prone to agitation in the hospital setting, which is exacerbated with benzodiazepines.",0
"Family discussion with health care proxy and mother, indicated that she was unclear regarding the necessity for intubation and the lumbar puncture.",0
"As evidenced from Dr note from yesterday, Ms bizarre behavior continued in the ER, and it was felt that she was having seizures.",0
"In the ER when she received Dilantin, she became hypotensive.",0
She was then intubated in the ER.,0
"According to the patient's daughter, her mother kept wanting to go to the bathroom, rubbing her legs in the ER and not making much sense.",0
"Prior to the ER incident, when her daughter returned from college late at night, she found her mother in an uncharacteristic mess or paraphernalia, which was uncharacteristic of her, in addition, she had not gone to bed, which she normally does.",0
The patient's mother had described loud banging noises in her daughter's portion of the family house which is the .,0
Dr note from described the patient as having a pervasive sleep disorder for which she used baclofen and vicodin as Mirapex had not been useful for her.,0
In the neuro ICU service she was maintained on droplet precautions due to the concern of a viral encephalitis.,0
"She was switched from Midazolam to Propofol, due to her issue of agitation on benzodiazepines, which may have posed a problem while attempting to wean her.",0
"After extubation, despite attempts to convince her to stay in hospital, she self-discharged herself from hospital.",0
She was found to be competent (please refer to Dr note in OMR).,0
Medications on Admission: Copaxone 20mg injections daily Mirapex PRN yet not used in quite some time Timolol 0.05% 1 drop in left eye HCTZ 25mg PO qdaily Baclofen 40 mg QHS and 20 mg TID PRN Lorcet PRN Ranitidine 150 mg Tramadol 50 mg PO TID PRN Discharge Medications: Copaxone 20mg injections daily Mirapex PRN yet not used in quite some time Timolol 0.05% 1 drop in left eye HCTZ 25mg PO qdaily Baclofen 40 mg QHS and 20 mg TID PRN Lorcet PRN Ranitidine 150 mg Tramadol 50 mg PO TID PRN Discharge Disposition: Extended Care Discharge Diagnosis: Seizures Discharge Condition: Self discharged against medical advice Discharge Instructions: You have discharged yourself from hospital against medical advice.,0
"Followup Instructions: Neurology: , MD Phone: Date/Time: 9:00 MD Completed by:",0
"5:10 PM CT CHEST W/O CONTRAST Clip # Reason: evaluate for interval change/source of infection Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;CHEMOTHERAPY ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with AML, fever, with nodular densities on chest CT and recent D/C of rt sc cath/left port for bacteremia REASON FOR THIS EXAMINATION: evaluate for interval change/source of infection CONTRAINDICATIONS for IV CONTRAST: AVOIDING NEPHROTOXINS ______________________________________________________________________________ FINAL REPORT INDICATION: AML and fever and recently described enlarging nodular densities in the lungs.",1
TECHNIQUE: Non-contrast helical CT of the chest.,0
"NON-CONTRAST CT CHEST: The heart, pericardium, and great vessels are within normal limits.",0
"There is interval increase in small pleural effusions bilaterally, left greater than right.",0
"The lung window images reveal continued expansion of previously-described nodules in the upper lobes bilaterally, the middle lobe, and the right lower lobe.",0
"In the upper lobes, the lesions have become coalescent and extend centrally to abut the mediastinum.",0
The airways are patent to the segmental bronchi bilaterally.,0
"In the imaged portion of the upper abdomen, the spleen is again noted to be enlarged.",0
"The visualized portions of the liver, pancreas, adrenal glands, and kidneys are unremarkable.",1
"IMPRESSION: Rapid progression of bilateral nodular masses which are now quite extensive in the upper lobes, left greater than right.",0
There is also interval increase in small bilateral pleural effusions.,0
"The differential diagnosis includes aspergillosis, Nocardia, mucomycosis, or PCP.",0
leukemic infiltration cannot be excluded.,0
3:49 PM CHEST (PORTABLE AP) Clip # Reason: s/p swan placement ______________________________________________________________________________ MEDICAL CONDITION: 77M s/p cabg/trach/PEG post aspiration event and hypotension REASON FOR THIS EXAMINATION: s/p swan placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST HISTORY: Post aspiration.,0
A Swan-Ganz catheter has been inserted into the left subclavian vein terminating in the proximal right pulmonary artery.,0
There is no pneumothorax and the appearance of the chest is otherwise unchanged since the earlier chest x-ray this morning at 9 a.m.,0
"11:18 AM CHEST (PORTABLE AP) Clip # Reason: Upright chest to rule out free air ______________________________________________________________________________ MEDICAL CONDITION: year old woman with acutely distended abdomen, abd pain.",0
REASON FOR THIS EXAMINATION: Upright chest to rule out free air ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP UPRIGHT FILM HISTORY: Acute abdominal pain and distention.,1
There is no free gas under the diaphragm.,0
There is slight LV prominence and bibasilar linear atelectases.,0
11:25 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate trach placement Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with cerebral palsy chronically vented.,1
"replaced REASON FOR THIS EXAMINATION: please evaluate trach placement ______________________________________________________________________________ FINAL REPORT INDICATION: 28-year-old lady with cerebral palsy, chronically ventilated, to evaluate tracheostomy placement.",1
Frontal radiograph of the chest compared with the prior of .,0
The tracheostomy tube is in good position with its tip 3 cm above the carina.,0
A right PICC line is noted with its tip in the right atrium and unchanged compared to before.,0
There is atelectasis in the right lung base.,0
The right CP angle is not totally included in the radiograph.,0
7:26 AM CHEST (PORTABLE AP) Clip # Reason: Asses for worsening pleural effusion ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman s/p CABG with resp distress REASON FOR THIS EXAMINATION: Asses for worsening pleural effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress.,0
"Again noted is evidence of a right IJ central line and a left subclavian central line, both of which are in distal SVC in satisfactory position.",0
"The heart is slightly enlarged, but no evidence of CHF.",0
"There is development of the right sided pleural effusion, and also noted is evidence of patchy opacity noted at the right base.",0
Early focus of pneumonia should be considered.,0
IMPRESSION: 1) Interval development of a right sided pleural effusion.,0
2) Right lower lobe pneumonia likely.,0
"3:44 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: PNEUMONIA-R/O MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with pna and acs REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Pneumonia, assess for change.",1
Lung volumes are low and there is motion artifact.,0
Consolidation is again demonstrated in the left lower lobe.,0
This may have increased somewhat in distribution.,0
Change is difficult to assess due to limitations of technique.,0
The patient is status post median sternotomy and CABG as before.,0
IMPRESSION: Limited study demonstrating persistent left lower lobe consolidation.,0
"3:03 PM MR HEAD W & W/O CONTRAST Clip # Reason: MRI WITH and WITHOUT CONTRAST with DWI sequences to R/O infe Admitting Diagnosis: S/P PEDESTRIAN STRUCK Contrast: MAGNEVIST Amt: 11 ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with s/p R craniectomy for r SDH and skull base fx REASON FOR THIS EXAMINATION: MRI WITH and WITHOUT CONTRAST with DWI sequences to R/O infection- may need debridement/washout in OR No contraindications for IV contrast ______________________________________________________________________________ WET READ: DFDkq SAT 7:27 PM The right extraaxial and scalp fluid collections demonstrate only mild, interrupted rim enhancement.",1
"Only the dependent aspect of the parafalcine portion of the right subdural collection demonstrates slow diffusion, which could represent pus or other layering protenaceous material.",0
"Overall, no clear evidence of a well organized abscess, though infection cannot be definitively excluded by an imaging study.",1
Discussed with neurosurgery NP at 7:25 pm on .,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, HISTORY: 30-year-old female status post right craniectomy for subdural hematoma and skull base fracture; rule out infection (may need debridements/""wash"" in OR).",1
"TECHNIQUE: Routine non-enhanced MR examination, including T1-weighted axial SE and sagittal MP-RAGE sequences, post-contrast, the latter with axial and coronal reformations.",0
"According to the technologist's note, the patient was ""moving, medication bolus given by the nurse, twice, (with) patient still moving.""",0
"For this reason, T2-weighted and FLAIR FSE ""PROPELLER"" sequences were performed.",0
FINDINGS: The study is compared with the most recent CECT of as well as previous examination of and a series of studies dating to .,0
"The study is somewhat limited by persistent patient motion artifact (as above) as well as the extensive post-surgical changes, status post extensive right frontotemporoparietal craniectomy and partial temporal lobectomy.",1
"This includes residual hemorrhage, particularly in the inferior-anterior aspect of the middle cranial fossa, with substantial associated ""blooming"" magnetic susceptibility artifact, limiting the utility of the DWI sequence in this region.",0
"Re-demonstrated is the predominantly ""simple""-appearing collection in the craniectomy bed within the subgaleal scalp.",0
This demonstrates only thin and discontinuous rim enhancement and no evidence of slow diffusion.,0
The extensive right parafalcine subdural fluid collection demonstrates predominantly similar signal characteristics.,0
"However, though this process, (Over) 3:03 PM MR HEAD W & W/O CONTRAST Clip # Reason: MRI WITH and WITHOUT CONTRAST with DWI sequences to R/O infe Admitting Diagnosis: S/P PEDESTRIAN STRUCK Contrast: MAGNEVIST Amt: 11 ______________________________________________________________________________ FINAL REPORT (Cont) too, demonstrates only thin and incomplete rim-enhancement, its most dependent portion demonstrates layering ""sediment"" with uniformly slow diffusion (606,602:), not accounted for by susceptibility artifact (Series 9).",0
"Though this may be attributable to layering proteinaceous (or other complex macromolecular) material, pyogenic infection is also a consideration.",0
"Apart from the extensive residual blood products in the anteromedial aspect of the middle cranial fossa and the lateral aspect of the right frontal pole, there is no definitive evidence of slow diffusion elsewhere.",0
"Other than expected post-surgical pachymeningeal enhancement, there is no pathologic leptomeningeal or parenchymal focus of enhancement elsewhere.",0
"The principal intracranial vascular flow-voids, including those of the dural venous sinuses, are preserved, and these structures enhance normally.",0
"Noted is extensive fluid layering within the right sphenoid air cell and its pterygoid recess, as well as virtual-complete fluid-opacification of the mastoid air cells, bilaterally, unchanged from the recent CT studies.",0
"IMPRESSION: Study somewhat limited by difficulties with patient positioning and motion, as well as the extensive post-surgical changes with abundant residual blood products, 1.",1
"The right-sided extra-axial and scalp fluid collections demonstrate ""simple"" fluid with only thin and discontinuous rim enhancement more suggestive of post-surgical seromas.",0
"However, there is material demonstrating slow diffusion, apparently sedimenting within the dependent posterior component of the right parafalcine subdural collection, and purulent material related to pyogenic superinfection is a consideration.",1
"Again, no organized abscess is identified at this site.",0
"Extensive fluid-opacification of the mastoid air cells with layering fluid within the right sphenoid air cell; while this finding is commonly seen in intubated patients with protracted supine positioning, it should be correlated clinically.",0
"COMMENT: A preliminary interpretation to this effect was discussed with Ms. , N.P.",0
"(Neurosurgery service), by Dr. by telephone, and posted to CCC (7:25 p.m., ).",0
5:45 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PER NEHEN PTB\CHEMO HIGH DOSE INTERLEUKIN-2) ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with renal cell ca hypoxic after IL-2 treatment s/p trach.,0
now with worsening O2 sats intubation REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old male with renal cell carcinoma hypoxic after IL-2 treatment and tracheostomy placement.,0
COMPARISON: AP upright portable chest x-ray dated .,0
AP UPRIGHT PORTABLE CHEST X-RAY: A right subclavian central venous catheter is in unchanged position with the tip in the mid SVC.,0
A nasogastric tube descends below the diaphragm with the tip not clearly visualized.,0
Tracheostomy tube is in place.,0
Clips in the left upper quadrant are likely related to prior nephrectomy.,0
"A large right pleural effusion is stable, or minimally increased since the prior exam.",1
There is no pneumothorax bilaterally on this semi-upright film.,0
IMPRESSION: No significant interval change.,0
A large right pleural effusion is either stable or minimally increased.,1
", CSURG CSRU 9:13 AM CHEST (PORTABLE AP) Clip # Reason: r/o inf, eff Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with s/p mvr/avr/cabg/maze/laa REASON FOR THIS EXAMINATION: r/o inf, eff ______________________________________________________________________________ PFI REPORT PFI: Improved asymmetric edema in left upper lobe.",1
NG tube tip not seen on current study.,0
4:43 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: TRACHEOBRONCHIAL MALACIA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with TBM, ?PNA REASON FOR THIS EXAMINATION: ?",0
interval change ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Question pneumonia.,0
Comparison is made to prior study .,0
There is mild linear radiolucency projected over the left cardiac silhouette are unchanged representing pneumomediastinum or pneumopericardium.,0
"Tracheal stent is in place, right PICC tip is in the cavoatrial junction.",0
"Bibasilar opacities, left greater than right, are unchanged from prior study, the ill- defined appearance favors pneumonia over atelectasis.",0
"8:21 AM MR HEAD W & W/O CONTRAST Clip # Reason: evaluate for residual Admitting Diagnosis: RIGHT BRAIN TUMOR/SDA Contrast: GADAVIST Amt: 8 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with metestatic RCC, returns for resection of right temporal tumor.",0
"REASON FOR THIS EXAMINATION: evaluate for residual No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old man with metastatic renal cell cancer, status post resection of right temporal tumor, to assess for residual tumor.",0
"COMPARISON: MRI of the head with and without contrast, and limited MRI of the head, .",0
TECHNIQUE: Multiplanar multisequence MR imaging of the head was performed prior to and after the administration of 8 cc of Gadavist intravenous contrast.,0
FINDINGS: The patient is status post resection of right temporal lobe tumor on .,0
"There is an amorphous area of high signal intensity in the right temporal resection site, consistent with expected post-operative hemorrhage.",0
"Although no large residual tumor is seen at this time, the assessment for subtle residual tumor is limited, given the high signal intensity of hemorrhage.",0
Expected post-surgical changes including a small amount of subdural fluid and enhancement along the dura in the right temporal region is noted.,0
"A small new area of slow diffusion in the right inferior temporal lobe, anterior to the resection site indicates acute infarction.",0
Mild edema in the right temporal and insular cortex is not significantly changed since the prior study of .,0
"A second enhancing lesion in the right parietal lobe measuring approximately 14 x 8 mm with surrounding vasogenic edema, not significantly changed since the recent prior study of .",0
No new intracranial masses are detected.,0
The major vascular flow voids are intact.,0
A mucus retention cyst is seen in the left maxillary sinus.,0
"Status post partial resection of right temporal lobe mass, with small amount of hemorrhage in the resection site.",0
Assessment of residual tumor is limited at this time.,0
New area of slow diffusion in the anterior right temporal lobe may relate to ischemia or infarction- consider followup.,0
"Known right parietal lobe lesion, with surrounding moderate vasogenic edema, is stable since the recent prior study of .",0
The finding #2 was discussed with Dr. and Ms. at approximately 1:30 P.M on by Dr.. (Over) 8:21 AM MR HEAD W & W/O CONTRAST Clip # Reason: evaluate for residual Admitting Diagnosis: RIGHT BRAIN TUMOR/SDA Contrast: GADAVIST Amt: 8 ______________________________________________________________________________ FINAL REPORT (Cont),0
3:07 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate effusion s/p chest tube placement.,0
"Please e ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with HOCM, UGI bleed, intubated with reaccumulating effusion REASON FOR THIS EXAMINATION: Please evaluate effusion s/p chest tube placement.",0
Please evaluate for pneumothorax ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Chest tube placement.,0
Compared to previous study of two days earlier.,0
"There has been interval placement of a left-sided chest tube, which enters the chest laterally and courses inferomedially with the distal tip projecting just below the left hemidiaphragm contour.",0
"A left-sided pleural effusion has nearly resolved in the interval, and no significant pneumothorax is evident.",0
An ET tube and permanent pacemaker remain in place.,0
"There is vascular engorgement and perihilar haziness, as well as a layering right pleural effusion.",0
Subcutaneous emphysema is seen in the left chest wall.,0
Markedly improved left pleural effusion following left-sided chest tube placement.,0
Please see comments regarding course of chest tube.,0
Persistent congestive heart failure pattern with associated layering right pleural effusion.,1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. is a 41 year old man who fell 28 feet from a roof after slipping on some ice.,0
There was reported loss of consciousness at the scene.,0
He landed on his left side and was found to have crepitus in the left pelvis and deformity of the right arm.,0
He was taken to Hospital where a chest x-ray was negative.,0
Pelvic films showed left iliac fractures.,0
"A Foley catheter was placed, intravenous lines were placed and he was given four liters of intravenous fluid.",0
He was hemodynamically stable and air lifted to the .,0
"On arrival in our Emergency Room, he complained of abdominal and left pelvic pain.",0
His Coma Score was 15.,0
His systolic blood pressure was in the 70s to 80s.,0
He was given one unit of red cells which resulted in an increase into the 120s.,0
A fast scan in the Trauma Bay was negative.,0
Perforated ulcer status post operative repair.,0
He is allergic to penicillin.,0
"PHYSICAL EXAMINATION: On admission, was significant for a heart rate of 72; blood pressure of 150/palp.",0
He was boarded and collared.,0
His pupils are equal and reactive.,0
He had two facial lacerations.,0
"His abdomen was firm and distended, tender in bilateral upper quadrants.",0
He had an upper midline abdominal scar.,0
Pelvis was tender to palpation with ecchymoses on the left hip.,0
He had a left abrasion and a left elbow laceration.,0
The back with no step-offs.,0
"Rectal was heme negative, normal prostate.",0
Coma Score is 15 and he moved all extremities.,0
"LABORATORY: Initial labs were significant for a white count of 18.7, hematocrit of 31, normal coagulation studies, normal chemistries.",0
"His initial trauma films included a chest x-ray which was negative, cervical spine which was negative to C7.",0
Pelvis film showed a left iliac comminuted fracture.,1
Left elbow showed comminuted olecranon fracture.,1
Right wrist showed distal ulnar and radius fractures.,1
Head CT scan was negative.,0
"Chest CT scan showed right rib fractures of ribs 6 through 8, a left scapular fracture, right lung contusion.",1
"Abdominal CT scan revealed bilateral superior and inferior pubic rami fractures, a left iliac fracture, SI joint widening and a small retroperitoneal hematoma as well as a small mesenteric hematoma.",0
EKG was normal sinus with no signs of ischemia.,0
HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit.,0
"He was resuscitated and then taken to the Operating Room on hospital day number two for an incision and drainage of his open left olecranon fracture as well as open reduction and internal fixation of same, open reduction and internal fixation of right distal radius fracture.",1
He had a left chest tube placed in the Operating Room for a small pneumothorax.,0
He was also noted to have a left acromioclavicular joint separation which was treated conservatively.,0
Orthopedics also commented on his multiple pelvic fractures and recommended conservative therapy without any indication for operations at this time.,0
The patient was transferred from the Operating Room to the Floor where he did well.,0
"On the final of his chest CT scan, it was thought that he may have a small aortic intimal flap, not associated with any hematoma.",0
Repeat CT scan confirmed the same and a Cardiothoracic Surgery consultation was obtained.,0
"At the same time, the patient was transferred on , back to the Intensive Care Unit for intensive blood pressure control, using variously Esmolol drips, Nipride drips and intravenous Lopressor, Clonidine and hydralazine.",0
"The patient underwent an angiogram on , that showed an aortic isthmus contour irregularity with a question of a ductus diverticulum.",0
"Recommendations were for a transesophageal echocardiogram, which was carried out, which showed an aortic tear at 30 cm just distal to the arch.",0
"At this point, the patient had been electively intubated, but subsequently developed florid adult respiratory distress syndrome, likely secondary to his right lung contusion.",0
Early cultures showed Hemophilus for which he was started on Ceftriaxone.,0
The patient remained in the Intensive Care Unit requiring intensive ventilatory support.,0
"During this time, he was placed on Lovenox for deep venous thrombosis prophylaxis and he began developing fevers.",0
"Levofloxacin was added on , for Gram negative rod coverage.",0
The patient was also started on TPN as he had not tolerated trophic tube feeds.,0
"On , the patient had a bronchoscopy and had a right pleural effusion tapped.",0
He remained in the Intensive Care Unit.,0
A repeat transesophageal echocardiogram on showed a persistent tear and a question of a small hematoma associated with his aortic injury.,0
He was also started on Vancomycin at the time for Gram positive cocci in his sputum.,0
Subsequent cultures from this sample grew out Methicillin resistant Staphylococcus aureus.,0
"On , the patient underwent placement of IVC filter for pulmonary embolism prophylaxis.",0
He continued to spike and had an elevated white count.,0
Pseudomonas was cultured from nasal swabs for which he was started initially on Gentamicin which was changed then to Ceftazidime.,0
Infectious Disease consultation was obtained on .,0
"On , the Vancomycin and Ceftazidime were stopped.",0
ENT consultation saw the patient on ; did not recommended having his sinuses.,0
"On , the patient underwent delayed repair of his aortic intimal injury without any graft material.",0
"Subsequent to this material, the patient suffered acute renal failure likely secondary to perioperative hypotension.",1
His maximum creatinine was 2.1 and this subsequently normalized.,0
"On , the antibiotics were changed to Ciprofloxacin, Ceftazidime and Vancomycin for Methicillin resistant Staphylococcus aureus pneumonia and Pseudomonas pneumonia.",0
"On , he underwent a bedside percutaneous tracheostomy and antibiotics were discontinued.",0
The patient suffered from hypercalcemia.,0
PTH levels eventually came back as maximally suppressed.,0
He received one dose of Pamidronate due to this hypercalcemia likely secondary to immobilization.,0
Subsequently calcium levels have been normal.,0
"On , the patient had a low-grade temperature and was found to have Gram negative rods and Gram positive cocci in his sputum.",0
He subsequently grew out again Methicillin resistant Staphylococcus aureus and Pseudomonas.,0
He was started on Vancomycin and Imipenem for a 14 day course.,0
"On , he underwent a renal ultrasound which was normal.",0
"Throughout his postoperative course from his aortic repair, he intermittently was very agitated, requiring sedation.",0
Sedation was eventually weaned and the patient's ventilatory support was weaned.,0
"On , he was on sufficient support to allow for Passe Muir valve trials.",0
He rapidly advanced to a tracheostomy mask and was transferred to the Floor on .,0
"Since his transfer to the Floor, he has had no respiratory distress.",0
He has remained hemodynamically stable with a blood pressure of less than 150.,0
He requires minimal pain medications and his neurologic status has been alert and oriented times three.,0
The patient has been working with Physical Therapy and Occupational Therapy and is very motivated to make a full recovery.,0
Status by systems at this time: 1.,0
Neurologically: Minimal pain and requiring Tylenol only for pain control.,0
"He is alert and oriented times three, appropriate.",0
He has suffered from insomnia and is receiving Benadryl at night time.,0
"Cardiovascular: Again, his goal systolic blood pressures should remain below 150.",0
Please see his list of medications at the end of this summary for current cardiac medications.,0
Respiratory: The patient is on room air through his tracheostomy.,0
"The tracheostomy was placed on , so it is approximately two weeks old.",0
"Within the next week or two, the patient can be decannulated provided he has no further respiratory complications.",0
"He is finishing up Vancomycin and Imipenem for his Pseudomonas and Methicillin resistant Staphylococcus aureus pneumonias tomorrow, which will be day 14 of his most recent course of antibiotics.",0
Gastrointestinal: He is tolerating tube feeds at goal through a Dobbhoff tube.,0
The patient initially failed a bedside swallow evaluation shortly after his extubation around .,0
"A subsequent video swallow study was requested, however, the no longer has the capability to perform this study, therefore, the patient is being transferred to a Rehabilitation facility that can perform the modified barium swallow.",0
"Should he pass this, the Dobbhoff may be removed and he can start p.o.",0
He remains on Zantac prophylaxis.,0
Genitourinary: The patient's Foley catheter was removed and he voided without difficulty.,0
His acute renal failure has resolved with a creatinine most recently of 0.5 on .,1
Hematology: The patient has an IVC filter and has been continued on subcutaneous heparin for deep venous thrombosis prophylaxis.,0
His most recent hematocrit was 34.8.,0
Infectious Disease: The patient has been afebrile since discharge from the Intensive Care Unit.,0
"His white count on , was 9.9.",0
He is to complete a 14 day course of Vancomycin and Imipenem which will be finished with tomorrow's doses.,0
Please see this Discharge Summary medication list for current dosing schedule.,0
Endocrine: The patient had issues with hyperglycemia in the Intensive Care Unit while receiving TPN and tube feeds.,0
"Since transfer to the Floor, his fingersticks have been consistently in the 120s and he received no sliding scale insulin coverage.",0
"He, therefore, no longer needs fingersticks or insulin coverage.",0
"His calcium most recently was 9.5, which is within the normal range.",0
He has received no further doses of Pamidronate for his hypercalcemia.,0
"At this point, the patient is being discharged from the Trauma Service.",0
"He should follow-up in the Trauma Clinic which is the of the Building, on , at 01:00 p.m.",0
"Phone number there is , should a change need to be made.",0
Dr. is the Orthopedic Surgeon following his pelvic fractures.,0
The patient should follow-up with Dr. in mid-.,0
Dr. office number is .,0
Dr. saw the patient for his upper extremity fractures.,0
He should be seen in the office in one to two weeks' time.,0
"The number to schedule his appointment is , and ask for the Orthopedic Surgery Clinic with Dr. .",0
Current weight bearing recommendations: The patient is non-weight bearing on the right hand but may use a platform walker on the right using his proximal forearm.,0
The patient may use a crutch in the left hand.,0
He is weight bear as tolerated on the left.,0
He is touch-down weight bearing only on bilateral lower extremities.,0
Please see Page Three provided by Physical Therapy and Occupational Therapy for their assisted recommendations.,0
"Should the patient have any concerns regarding his aortic repair, he should follow-up with Dr. , whose office number is .",0
No specific follow-up appointment is required with Dr. .,0
Hydralazine 100 mg per the NG tube q. eight hours; hold for systolic less than 110.,0
Zantac 150 mg per NG tube twice a day.,0
Enalapril 15 mg per NG tube twice a day; hold for systolic less than 110.,0
"Lopressor 150 mg per NG tube three times a day; hold for systolic less than 100, heart rate less than 60.",0
q. day; hold for systolic less than 100.,0
"Vancomycin, 1 gram, intravenous q.",0
Imipenem 1 gram intravenously q. six hours through .,0
Colace 100 mg per NG tube twice a day.,0
Heparin 5000 units subcutaneously twice a day.,0
Ativan 0.5 mg intravenous q. four hours p.r.n.,0
Tylenol 650 mg per NG tube q. four to six hours p.r.n.,0
Benadryl 25 mg per NG tube q. h.s.,0
"Please note, the patient should have his systolic blood pressure less than 150 mm of Mercury at all times.",0
He has a tracheostomy which is a #8 Portex placed on .,0
The patient needs a video or modified barium swallow study early in his rehabilitation course as well as a cognitive and communication assessment by a Speech Pathologist.,0
The patient's diet is currently Impact with fibre via a NG Dobbhoff tube at 95 cc per hour.,0
Dictated By: MEDQUIST36 D: 10:11 T: 10:31 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain / shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Reason for MICU transfer: Hypotension, alcohol withdrawal .",1
Reason for admission: Chest pain .,0
"HPI: Briefly, this is a 47M PMH of alcohol abuse with history of DTs, cocaine abuse, alcohol related dilated cardiomyopathy (EF 40-45%), Hepatitis B and C who presents with chest pain and intoxication.",1
"Was discharged from 2 days PTA, but he developed chest pain and thought he should return.",0
He notes SOB with the CP.,0
"He says it's ""all over"" and ""is very bad.""",0
"Drinks liter of vodka per day, denies any other drug use.",0
"He also reports reinjury to L foot, and significant foot pain (reports chronic fracture) after his friend stepped on his foot yesterday.",0
"He is able to walk, but only on heel of foot.",0
Past Medical History: - EtOH abuse with multiple admissions for w/d - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (last records indicated an EF of 40-45% with mild global HK) - cocaine abuse - hypothyroidism: TSH 10 on -does not take prescribed levothyroxine - h/o head and neck cancer s/p resection and radiation in - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and albicans .,1
Multiple r/o for TB negative.,0
"Pt did not comply with course of anti-fungals, had 3 AFB smears here which were nagative - h/o C. diff colitis - h/o IVDA per OSH records (pt notes only cocaine iv) - HBV (core Ab, surface Ab positive ) - HCV () - HIV negative Social History: Social History: Tobacco, unable to say how long, PPD currently.",1
Prior to that he smoked 1 ppd.,0
"Heavy EtOH use, currently 1L vodka daily.",0
"Sober x10 years, started drinking again 2 years ago.",0
Also reports cocaine and marijuana.,0
Sexually active with his girlfriend Family History: Mother - CAD.,0
"Reports his father was the "" ,"" and that he and his mother changed their names after his arrest, etc.",0
"PE: VITALS: T 98 P 89 BP 95/64 RR 19 O2sat 98%RA GENERAL: Sitting up in bed, NAD : Sclera anicteric, PERRL, EOMI, MMM NECK: Flat JVP CV: RRR, no MRG LUNGS: CTAB ABDOMEN: NABS, soft, NTND, no HSM EXTREMITIES: No CCE SKIN: No jaundice, no spider angioma NEURO: CN II-XII intact, A&Ox3, biceps reflex , no tremulousness or asterixis .",0
"Vitals - T 98.8 P 79 BP 145/100 RR 18 O2sat 98%RA Gen - Well-appearing, but anxious man sitting up in bed talking with his girlfriend on the telphone : NC/AT, Sclera anicteric, conjunctivae pink, pupils equal, EOMI, poor dentition, MMM, OP clear.",0
Neck: No LAD or JVD.,0
Extensive loss of neck fullness in L neck s/p surgical dissection.,0
"No murmurs, rubs, or gallops appreciated.",0
"Pulm - CTAB, no wheezes, rales, or rhonci appreciated.",0
"Abd - Soft, non-tender, non-distneded, no organomegaly.",0
"Ext - No clubbing, cyanosis, or edema.",0
"No spider angiomata, no palamr erythema, no suputryens contractions.",0
Strength 5/5 bilaterally in extremities.,0
NEURO: CN II-XII intact except sensation along distribution of V3 on left.,0
Sensation otherwise intact to light touch.,0
Poor R wave progression which is non-diagnostic.,0
Lateral and inferolateral ST wave abnormalities which are non-specific.,0
Compared to tracing of there is no significant diagnostic change.,0
Peaked P waves with rightward P wave axis.,0
Non-specific lateral ST segment changes.,0
Compared to the prior tracing of the rate has increased.,0
"Otherwise, no diagnostic interim change.",0
"Chest X-ray - Pleuroparenchymal scarring in the upper lobes bilaterally, unchanged compared to the prior study.",0
No definite cavitary lesion is seen.,0
- No new cardiopulmonary abnormality.,0
Hyperinflation due to emphysema or small airways obstruction is longstanding.,0
The contents of the left apical cavity have decreased which may represent expectoration of previous mycetoma.,0
Smaller right apical lesion and adjacent pleural thickening are longstanding.,0
"No pulmonary edema, pneumonia or indication of pulmonary hemorrhage.",0
No pleural effusion Foot films A healing fracture is present at the base of the second metatarsal.,0
"Additionally, sclerosis is present at the base of the fourth metatarsal, consistent with a healing fracture at this site.",0
"In retrospect, a transverse lucency is seen through this area on the original study of .",0
"Additionally, there is a more subtle area of sclerosis at the base of the third metatarsal, also likely related to a healing fracture.",0
"Brief Hospital Course: In the ED his vitals were T 98.1, HR 106, BP 169/104, O2 sat 96% RA.",0
He was given ASA and placed on a CIWA scale.,0
His tox screen was positive for alcohol with a level of 435.,0
Also positive for cocaine and benzos.,0
He denied using these since the previous week.,0
His cardiac enzymes were negative x 1. .,0
He was admitted to SIRS1 in the morning of .,0
"He reported hardly any CP or SOB, endorsed left foot pain and anxiety, and requested valium.",0
"On the medicine floor his cardiac enzymes were negative x 2, completing his rule-out.",0
He was evaluated by psychiatry and placed on a CIWA scale.,0
His anxiety was managed with seroquel.,0
"He was given thiamine, folate, and MVI for his alcoholism.",1
He recieved a total of 560mg IV/PO valium over the course of the day and was found to be hypotensive to 70/30 at 2200.,0
He also had SBPs in the 170s and 180s earlier in the day.,0
"He had no signs of distress, lethargy, or obtundation - he was mentating well and protecting his airway.",0
He was given a 500cc bolus x1 w/ correction of BP to 90/60.,0
He was then given a second bolus before transfer to the MICU for observation.,0
"In the MICU, he was observed and given gentle IV fluid hydration.",0
His blood pressure medications were held and he was continued on a less agressive CIWA scale (10mg q2hrs) held for hypotension or sedation.,0
"He was found to have negative cardiac enzymes, which were not repeated.",0
"His LFTs and CXR were unremarkable, and blood and urine cultures were unrevealing.",0
"He was found to have an increased creatinine to 1.5; urine lytes revealed a FeNA<1%, and the creatinine improved with hydration.",0
Psychiatry saw the patient and recommended discontinuation of benzos and seroquel with the addition of zyprexa for anxiety.,0
"Upon transfer, the patient reported that he was very anxious and required 50mg of valium every 4 hours to avoid withdrawal.",0
He was experiencing diffuse myalgias that are alteranting in intensity.,0
"He complained of sharp, electric inferior sternal chest pain lasting a few seconds, followed by several minutes of shortness of breath.",0
"He also complained of severe L foot pain, and requested 50mg demerol for treatment.",0
"He denied current CP, SOB, nausea, vomiting, fevers, chills, lightheadedness, or other changes in sensation.",0
"He noted that he strongly wished to enter an alcohol rehabilitation program, and has arranged to leave his apartment and put his belongings into storage to further this goal.",0
"Per the patient, he had difficulty in entering programs because of his MassHealth insurance.",0
# Hypotension: Responded quickly to 500c bolus.,0
"Most likely secondary to large amount of valium patient received over course of day per CIWA protocol, as well as hypovolemia.",0
"# Substance abuse: EtOH, cocaine use.",0
History of DTs; has required ativan gtt in ICU setting in the past.,0
"Patient received valium 560 mg in early hospital course - per psychiatry, this was likely contributed to by his anxiety and med-seeking behavior.",0
These medications were stopped on transfer to the medicine floor outof consideration for likely self-taper.,0
"Patient had no objective signs of alcohol withdrawal on the medicine floor, and only occasional complaints of anxiety.",1
"Per psychiatry recs, his anxiety was managed with oral zyprexa.",0
"He called a large number of residential alcohol rehabilitation programs, and is looking forward to beginning detox.",0
# Hypertension: Pt suffered from mixed systolic & diastolic hypertension after transfer from MICU.,1
Differential included essential hypertension vs. volume overload vs. withdrawal.,1
Pt was euvolemic by exam and demonstrated no other signs of withdrawal.,0
He was restarted on his ACEI and begun on a beta-blocker fro blood pressure control with excellent results.,0
Brief creatinine elevation resolved with IV fluids - almost certainly prerenal azotemia.,0
"# Chest pain: Brief ""tazer-like"" chest pain followed by SOB.",0
Patient asymptomatic last 24-26 hours of hospital course.,0
Cardiac enzymes negative x 4.,0
No acute ECG changes during symptomatic episodes.,0
Thought likely related to anxiety given pain description.,0
Stress testing was therefore not felt to be indicated during this hospitalization.,0
# Dilated cardiomyopathy with EF 40-45%: Most likely related to alcohol use.,1
"- Continued ASA, increased lisnopril, added small-dose betablocker.",0
"# Anxiety: Contributed to high CIWA scales, likely cause of chest pain.",0
"Per patient, greatly relieved with Zyprexa 2.5mg PO TID.",0
"# Left foot pain: Has chronic fracture, no new injury.",0
- Ultram and tylenol given for pain with good relief .,0
# Hypothyroidism: No active issues.,0
- TSH nl (3.6) - Levothyroxine continued Medications on Admission: Pt denied taking any medications on admission out of concern that they would interact with ethanol or his illicit drugs.,0
Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed.,0
Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety.,0
Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for PRN: insomnia / anxiety.,0
Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 2 weeks.,0
Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Ethanol Intoxication Ethanol withdrawal Secondary Diagnoses: Cocaine ingestion Anxiety Hypertension Discharge Condition: Pt shows no signs of intoxication or withdrawal.,1
"The patient is not agitated, and his vital signs are stable.",0
He is anxious to begin treatment for his ethanol abuse.,0
"Discharge Instructions: You were seen, evaluated, and treated at for chest pain and intoxication.",0
"While here, you were also treated for variations in your blood pressure.",0
Your lab tests are reassuring that you did not incur any damage to your heart.,0
"You appear to have elevated blood pressure, and should be on medications to treat this condition.",0
"As you know, you also have multiple substance abuse problems, most prominently ethanol abuse.",0
To help with these conditions we recommend: - Take your medications as prescribed - Go to Father today and continue to contact the longer-term facilities that were discussed.,0
"- Call your pcp or return to the ED for severe chest pain, shortness of breath, fainting, seizure, or other conerning symptoms.",0
Followup Instructions: Community Health Center: Please call to schedule an appointment to be seen within the next 2 weeks.,0
Height: (in) 64 Weight (lb): 170 BSA (m2): 1.83 m2 BP (mm Hg): 92/54 HR (bpm): 100 Status: Inpatient Date/Time: at 14:04 Test: TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
"Sgnificant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.",0
The inferior vena cava is dilated (>2.5 cm).,0
"Impression: moderate circumferential pericardial effusion; cardiac tamponade Compared with the findings of the prior study (tape reviewed) of , the pericardial effusion is significantly more voluminous, and cardiac tamponade is now present.",0
4:53 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: CORD COMPRESSION;ATRIAL FIBRILLATION;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man L infiltrate REASON FOR THIS EXAMINATION: ?,1
interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa TUE 11:18 AM No significant change.,0
______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP COMPARISON: .,0
HISTORY: 86-year-old male with infiltrate.,0
FINDINGS: There has been interval removal of the Dobbhoff tube.,0
Spinal fusion hardware is again noted.,0
Dense retrocardiac opacity is unchanged and may represent partial lobar collapse versus consolidation.,1
Persistant left lower lobe hazy opacity likely represents effusion and atelectasis.,0
No new areas of consolidation are identified.,0
Right mid to upper lung zone opacity is likely artifactual.,0
IMPRESSION: Minimal change when compared to prior exam.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old gentleman found by Emergency Medical Service down in an alley with Coma Scale of 3 at the scene.,0
The patient was intubated at the scene.,0
He reportedly fell off a fire escape of unknown height.,0
He had a right occipital laceration.,0
He intubated and sedated on arrival.,0
PAST MEDICAL HISTORY: Past medical history is unknown.,0
PAST SURGICAL HISTORY: Past surgical history is unknown.,0
"MEDICATIONS ON ADMISSION: PHYSICAL EXAMINATION ON PRESENTATION: The patient was brought to the Emergency Department where his vital signs revealed his temperature was 98.6 degrees Fahrenheit, his blood pressure was 125/73, and his heart rate was 108.",0
He was intubated and sedated.,0
He had received 8 mg of Ativan prior to examination.,0
"Head, eyes, ears, nose, and throat examination revealed his pupils were 3 mm to 2 mm.",0
He had a right-sided occipital laceration which was now stapled.,0
Normal first heart sounds and second heart sounds.,0
The abdomen was soft and nondistended.,0
Extremity examination revealed a laceration on his left leg.,0
"Neurologically, he was intubated and sedated.",0
Again pupils were 3 mm to 2 mm.,0
Briskly localized on his right upper and lower extremities.,0
There was slight withdrawal of his left lower extremity.,0
There was minimal movement of his left upper extremity.,0
PERTINENT RADIOLOGY/IMAGING: On x-ray he had a L1 through L4 lumbar transverse process and left lumbar transverse process fractures.,1
The patient had bilateral punctate images in his temporal lobes bilaterally.,0
He had a right frontal subarachnoid hemorrhage.,1
The patient had a subdural hemorrhage around his tentorium.,1
There was no mass effect and no shift.,0
"PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's white blood cell count was 16.4, his hematocrit was 44.3, and his platelets were 370.",0
"The patient's prothrombin time was 13.9, his partial thromboplastin time was 22.6, and his INR was 1.3.",0
"The patient's sodium was 142, potassium was 3.5, chloride was 106, blood urea nitrogen was 21, creatinine was 1, and his blood glucose was 159.",0
"CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit to receive every 1-hour neurologic checks, to keep his blood pressure less than 150.",0
He was loaded with Dilantin 1 gram and then 100 mg three times per day for one week.,0
He was to be kept euvolemic.,0
"Later in the day on , the patient localized on the right not as well on the left.",0
He was moving both lower extremities briskly and spontaneously.,0
His pupils were 7 mm bilateral.,0
The patient had a repeat computerized axial tomography later that afternoon which showed an increased density in the anterior most aspect of the right frontal lobe which was slightly improved from the prior examination and was consistent with a hemorrhagic contusion.,0
"In addition, there was a slight small subdural collection at that site with a previously noted area of small foci around.",0
The subarachnoid hemorrhage toward the vertex were unchanged.,1
"The ventricles and foci were stable in size and symmetric, and the tentorium was largely unchanged.",0
"On the second day of the patient's admission, his vital signs revealed a temperature of 98.7 degrees Fahrenheit, and his blood pressure was 130s to 140s/60s to 80s.",0
Pupils were 4 mm to 3 mm.,0
He was moving his right side spontaneously.,0
Localized on the right greater than the left.,0
The patient withdrew his lower extremities on the right.,0
The patient was noted to have left-sided hemiparesis.,0
"He was still intubated, and he was recommended to be extubated.",0
A TLSO brace was ordered.,0
The patient was kept euvolemic.,0
"On the patient's third hospital day, he was extubated.",0
He was moving all four extremities equally with equal strength throughout.,0
He had slight left facial weakness.,0
The patient was moved to the regular floor on .,0
He was seen by Physical Therapy who recommended continuous physical therapy training along with Occupational Therapy who had recommended assistance in helping with activities of daily living.,0
The patient had a head computed tomography on which was stable with no changes.,0
"Also during the hospital stay, he had a cervical spine film which showed somewhat limited flexion but no instability detected.",0
On the Physical Therapy Service cleared the patient to go home after two more visits with Physical Therapy and he was to use his walker when walking at all times.,0
The patient was instructed not to drink alcohol any further.,0
The patient was instructed to return if he has a bad headache or develops fever or neck pain.,0
The patient was instructed to wear the TLSO brace at all times when out of bed or sitting up at all times for a maximum of eleven weeks.,0
The patient was instructed to follow up in four weeks with a head computed tomography and lumbar films with Dr. .,0
MEDICATIONS ON DISCHARGE: Percocet 5/325-mg tablets one to two tablets by mouth q.4-6h.,0
Dictated By: MEDQUIST36 D: 01:26 T: 01:50 JOB#:,0
"5:32 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please have patient swallow 30cc gastrograffin (not down NG) ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with s/p GBP w respiratory distress REASON FOR THIS EXAMINATION: please have patient swallow 30cc gastrograffin (not down NG), wait 5 minutes and shoot cuts through upper abd only.",0
r/o leak after gastric bypass.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Patient is in respiratory distress status post gastric bypass, upper abdominal pain, rule out anastomotic leak.",0
Please give water soluble oral contrast.,0
TECHNIQUE: The patient was scanned from the lung bases through the pubic symphysis immediately following the patient's study for pulmonary embolism.,0
30 cc of oral Gastrografin was administered prior to imaging.,0
CONTRAST: 150 cc of Optiray was given for the patient's CTA of the chest and delayed imaging was performed through the abdomen and pelvis.,0
"CT OF THE ABDOMEN WITH CONTRAST: There are opacities in both lung bases, likely dependent atelectasis.",0
The liver and spleen are unremarkable.,0
There is a small amount of fluid around the spleen.,0
Oral contrast can be seen in the esophagus and tracking along the nasogastric tube in the gastric remnant.,0
There is a small amount of air in the excluded stomach.,0
Contrast is not seen within the excluded portion of the stomach.,0
"In the post surgical bed there is stranding and a small amount of fluid, likely postoperative changes.",0
There is an area of contrast between the gastric remnant and the excluded portion of the stomach that also contains air and may simply represent an outpouching and rugae from the gastric pouch however this area is not well delineated.,0
The distal anastomosis appears mildly edematous and has surrounding fat stranding and a mild amount of surrounding fluid.,0
"The pancreas, kidneys and adrenals are unremarkable.",0
CT OF THE PELVIS WITH CONTRAST: There is a small amount of free fluid within the pelvis.,0
A Foley catheter is seen within a compressed bladder.,0
There is diverticulosis without evidence of diverticulitis.,0
Free air is noted within the midabdomen and in the lower pelvis.,0
"No evidence of oral contrast extravasation, however the contrast did not reach the distal anastomosis.",0
Free air and fluid within the abdomen.,0
While this may simply represent postoperative changes underlying pathology cannot be excluded.,0
Diverticulosis without evidence of diverticulitis.,0
(Over) 5:32 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please have patient swallow 30cc gastrograffin (not down NG) ______________________________________________________________________________ FINAL REPORT (Cont),0
"7:33 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line placement Admitting Diagnosis: RIGHT LEG CELLULITIS ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1752 CATH,HEM/PERTI DIALYSIS SHORT * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with severe cellulitis, needs long-term IV abx REASON FOR THIS EXAMINATION: PICC line placement ______________________________________________________________________________ FINAL REPORT PROCEDURE DATE: HISTORY: 61 year old male with bacteremia and known central venous occlusion.",0
Please place PICC line for antibiotics.,0
PROCEDURE: The procedure was performed by Dr. and Dr. .,0
"Dr. , the staff radiologist, was present and supervising the entire procedure.",0
The patient was placed supine on the angiography table.,0
His right upper extremity was prepped and draped in the standard sterile fashion.,0
"Since no suitable superficial vein was visible, ultrasound was used for localization of an appropriate vein.",0
The right basilic vein was patent and compressible.,0
The skin and subcutaneous tissues were anesthetized with 3 cc of 1% Lidocaine.,0
"Using ultrasound guidance, the right basilic vein was accessed with a 21 gauge micropuncture needle.",0
A .018 guidewire was advanced through the access needle into the axillary vein.,0
"Beyond this point, however, resistance was encountered.",0
The skin entry site was incised with a number 11 blade scalpel.,0
The access needle was exchanged for a 4 French micropuncture sheath with inner dilator.,0
"Based on the markers on the guidewire, it was determined that a length of 15 cm would be appropriate for midline use.",0
The catheter was trimmed to length and advanced over the guidewire through the peel-away sheath into the right axillary vein using flouroscopic guidance.,0
The guidewire and peel-away sheath were removed.,0
"The catheter was flushed, capped, and HEP-locked.",0
It was secured to the skin using a STAT- lock device.,0
"FINDINGS: A final AP chest x-ray was obtained, demonstrating the tip of the midline catheter to be present in the right axillary vein.",0
"IMPRESSION: Successful placement of a 15 cm, 4 French, single lumen midline catheter via the right basilic vein in a patient with known central venous occlusion.",0
The tip of the catheter is present in the right axillary vein.,0
The catheter is ready for immediate use.,0
(Over) 7:33 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line placement Admitting Diagnosis: RIGHT LEG CELLULITIS ______________________________________________________________________________ FINAL REPORT (Cont),0
", B. OMED 7S 2:23 PM CHEST PORT.",0
LINE PLACEMENT Clip # Reason: check line placement Admitting Diagnosis: METASTATIC MELANOMA\CHEMO (HIGH DOSE INTERLEUKIN-2) ______________________________________________________________________________ MEDICAL CONDITION: s/p right subclavian CVC placement REASON FOR THIS EXAMINATION: check line placement ______________________________________________________________________________ PFI REPORT Right subclavian central catheter terminates in the lower SVC.,1
2:58 PM CT HEAD W/O CONTRAST Clip # Reason: ?bleed Admitting Diagnosis: HEPATITIS;SEIZURE D/O ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with s/p seizure and fall w/ head trauma REASON FOR THIS EXAMINATION: ?bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: IPf SUN 3:28 PM No acute intracranial process.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 37-year-old woman with status post seizure and fall.,0
"FINDINGS: There is no evidence of acute hemorrhage, large acute territorial infarction, or mass effect.",0
Patient is status post right frontoparietal craniotomy with encephalomalacic changes and punctate calcification within the right parietal lobe.,0
Punctate calcification is seen in the left temporal lobe.,0
Visualized portion of paranasal sinuses and mastoid air cells are within normal limits.,0
", J. SICU-B 6:21 AM CHEST (PORTABLE AP) Clip # Reason: pulmonary status Admitting Diagnosis: CLOGGED DOBOFF ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman s/p liver transplant REASON FOR THIS EXAMINATION: pulmonary status ______________________________________________________________________________ PFI REPORT PFI: Interval worsening of the left atelectasis with almost complete opacification of the left lung.",0
"9:39 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: acute abdominal process, abscess, ect.. Field of view: 42 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man s/p colectomy, parastomal hernia, s/p recent ostomy revision, readmitted with enterocutaneous fistula s/p drain placement Bilat abd.Now has a new wound draining ?",1
"REASON FOR THIS EXAMINATION: acute abdominal process, abscess, ect.. No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Patient with history of enterocutaneous fistula.",1
Status post mesh removal with new wound drainage.,0
TECHNIQUE: Helically acquired contiguous axial images of the abdomen and pelvis with oral and IV contrast.,0
"COMPARISONS: CT ABDOMEN WITH CONTRAST: Since the prior exam, there is new ascites.",0
The anterior abdominal wall wound is again identified with packing material.,0
The packing material is hyperdense but there is no definite evidence of extravasation of orally ingested contrast.,0
"There is minimal subcutaneous air along the right aspect of the surgical wound, this is likely related to the recent mesh removal.",0
"There is a right ventral hernia with small bowel contents, as on the prior exam.",0
There is no evidence of strangulation of bowel.,0
There is a new 5.9 x 5.7 cm hyperdense collection consistent with hematoma adjacent to this hernia.,0
Small bowel loops are normal in contour and caliber.,0
There is an ileostomy tube on the left.,0
The small hypodense splenic lesion is again identified.,0
"There are bilateral pleural effusions, right greater than left.",0
The hyperdense right kidney cyst is again identified.,0
No other interval change is appreciated.,0
CONCLUSION: 1) Since the prior exam there is new mild to moderate ascites.,0
There is a hematoma in the right lower quadrant as described above which measures 5.9 x 5.7 cm.,0
3:50 PM PORTABLE ABDOMEN Clip # Reason: please evaluate position of ngt ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with CVA now s/p placement of ngt after patient self-d/c'd ngt this am.,0
REASON FOR THIS EXAMINATION: please evaluate position of ngt ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate NG tube.,0
The distal portion of an NG type tube is demonstrated.,0
Its tip overlies the expected course of the body.,0
"9:29 AM CHEST (LAT DECUB ONLY) RIGHT PORT; CHEST (PORTABLE AP) Clip # Reason: 66 year old woman with emphysema, RUL pneumonia, intubated.",1
"______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with COPD, R sided pneumonia, emphysematous bleb in left lower lobe REASON FOR THIS EXAMINATION: 66 year old woman with emphysema, RUL pneumonia, intubated.",1
Found to have layering R pleural effusion.,1
"Would appreciate AP Chest Xray and RIGHT lateral decub to follow efffusion-- if significantly larger, we may perform thoracentesis ______________________________________________________________________________ FINAL REPORT CHEST, RIGHT LATERAL DECUBITUS ONLY: INDICATION: History of emphysema, right upper lobe pneumonia, intubated.",1
Emphysematous bleb in left lower lobe.,0
Found to have layering right pleural effusion on .,1
FINDINGS: AP chest film with patient in semi-upright position demonstrates again the patient is intubated with the ETT terminating some 4 cm above the carina.,0
An NGT is present and reaches below the diaphragm.,0
No pneumothorax o or other placement related complication is seen.,0
The right-sided upper lobe infiltrates persist and have not changed significantly.,0
No new parenchymal infiltrates can be identified.,0
Observe however that the frontal view does not cover the entire lung base.,0
The right-sided decubitus film was then obtained and compared with the previous right-sided decubitus film dated .,0
The layering pleural density is practically identical and unchanged in size comparing the two films of and .,0
The local emphysematous area in the left lower lobe also appears unchanged.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: # Left hip fracture s/p fall # Hypoxia Major Surgical or Invasive Procedure: # Arterial line placement # Right internal jugular central venous line placement # Endotracheal intubation History of Present Illness: 78F h/o COPD, presumed idiopathic pulmonary fibrosis on home O2, CAD s/p MI, CHF and Afib, presented with L hip fracture s/p fall lightheadedness after transitioning from sitting to standing while doing laundry on the day of admission.",1
"Pt reported no LOC or seizure activity, and had fallen to the floor without striking furniture or head, remaining down approximately 30-40 minutes until a nursing assistant found her.",0
"Pt was unable to walk and needed to be lifted to bed, then was brought by EMS to .",0
"Pt stated that she also had noticed increased DOE and SOB x 1 week with yellow sputum, occasionally blood-streaked with recent epistaxis nasal drying due to home O2 NC.",0
"Pt denied fever, chills, diarrhea, decreased PO intake, or N/V; she did report constipation at baseline.",0
Pt had her flu vaccine this year and confirmed annual pneumonia vaccinations for the last 3 years.,0
"In the , pt was hypoxic to the mid 80s with venti mask 50%, 12 L; she was placed on 100% NRB with O2 sats rising to 100% (at baseline, pt is 90% on 5L O2 NC).",0
"Pt was also noted to have STD in lateral leads, notably different from baseline.",0
"Pt reported a sensation of midsternum ""heartburn"" which quickly resolved, and stated that her pain during her past MI felt more like pressure and was different than this sensation.",0
"Pt received 2L NS, fentanyl & morphine for pain, as well as aspirin.",0
Ortho was consulted about her L hip fracture as seen on x-ray and recommended ORIF as soon as medically stable.,0
"Pt was therefore admitted for further work-up of hypoxic respiratory distress, EKG changes, and consideration for surgical repair of her L hip fracture.",0
Past Medical History: # Cardiovascular --Diastolic heart failure: EF 60% --Atrial fibrillation --MR --CAD: h/o LCx stenosis on prior cardiac cath --PFO --HTN --Hyperlipidemia --Mesenteric ischemia --Renal artery stenosis s/p R renal artery stent --PVD --Pulmonary hypertension --CVA .,1
# Pulmonary --Home oxygen 5L --COPD --Presumed idiopathic pulmonary fibrosis stable RML lung nodule and anterior mediastinal soft tissue density .,1
# Musculoskeletal --Osteoporosis --h/o fall with rib fractures .,1
# Hematological --Fe deficiency anemia Social History: # Personal: Widowed.,1
"# Tobacco: 35 pack years of smoking, quit ~.",0
"Family History: # Mother: Rheumatic heart disease # Siblings: Twin sister died, 78.",1
"# Children: Two sons with MI, age 40s.",0
"Physical Exam: VS: Temp 96.8, BP 116/41, HR 70/NSR, RR 18/O2sat 96% GEN: Pleasant, NAD; speaking in full sentences with face mask, with decreased O2 sats with prolonged narration.",0
"HEENT: PERRL, EOMI, anicteric, MM mildly dry NECK: ?JVP = 10cm RESP: CTAB anteriorly, faint crackles as bases posteriorly CV: RR, S1 and S2 WNL, holosystolic murmur througout the precordium, loudest at apex ABD: Soft, ND, NT, BS+, no masses or hepatosplenomegaly EXT: No c/c/e, warm, good pulses SKIN: No rashes/no jaundice; 3cm skin tear on L distal shin NEURO: AAOx3.",0
No sensory deficits to light touch.,0
Pertinent Results: Admission labs: .,0
06:24PM WBC-10.6# RBC-3.88* HGB-8.7* HCT-28.9* MCV-75* MCH-22.4* MCHC-30.1* RDW-16.7* 06:24PM NEUTS-85.4* LYMPHS-8.8* MONOS-2.3 EOS-3.2 BASOS-0.3 06:24PM CK(CPK)-67 06:24PM cTropnT-0.02* 06:24PM GLUCOSE-127* UREA N-45* CREAT-1.6* SODIUM-139 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 .,0
"PELVIS (AP ONLY) 7:55 PM Extensively comminuted intertrochanteric fracture of the left proximal femur, with marked varus angulation, as described.",1
"CHEST (PORTABLE AP) 6:54 PM Probable mild pulmonary vascular congestion, superimposed on chronic, diffuse interstitial process which (according to previous reports) represents known idiopathic pulmonary fibrosis.",1
There is no definite new airspace process.,0
TEE (Complete) Done at 2:49:50 PM Emergency TEE performed in the operating room after cardiac arrest.,1
A patent foramen ovale with flow across it is seen by color Doppler.,0
The right ventricular cavity is dilated with severe global free wall hypokinesis.,0
There is mild mitral valve prolapse.,0
No thrombus/embolus is seen in the pulmonary artery.,1
"Brief Hospital Course: 78F h/o COPD, idiopathic pulmonary fibrosis, CAD s/p MI, admitted to MICU with hypoxia and L intertrochanteric femur fracture.",1
# PEA arrest: Pt was noted to enter into PEA arrest while undergoing induction in the OR for ORIF.,0
"Pt was intubated and received 20min CPR, after which she was placed on epinephrine and norepinephrine gtt; per verbal report to this author, pt had also received NS fluid resuscitation.",0
Emergency TTE performed in the OR demonstrated severe global free wall hypokinesis at the dilated right ventricular cavity.,0
"Pt was returned to the MICU, during which time she was ultimately placed on four pressors (norepinephrine, phenylephrine, dobutamine, and vasopressin), as well as NS boluses for hemodynamic support, and increased FiO2 for respiratory support.",0
"Given her poor prognosis, family members decided to withdraw care; pt expired within minutes of withdrawing pressor and ventilatory support.",0
# L femur fracture: Orthopedics was consulted in the ED and recommended ORIF after pt was deemed medically stable.,1
"Given h/o pulmonary disease and cardiac disease, MICU team discussed with the patient about risks associated with surgical repair, specifically perioperative MI and difficult post-op extubation.",1
"Pt stated her understanding of this risk, but that her quality of life would be very diminished if she did not undergo surgical repair.",0
"During a family meeting on AM, all family members present concurred that surgical repair was desired, and stated their understanding of pt's high perioperative risk.",0
"Pt reversed her DNR/DNI status in order to undergo surgery, and in prepartion for surgery, received 2units PRBC given her low hematocrit.",0
"During induction, pt entered into pulseless electrical activity while on the OR table and underwent 20min of CPR.",0
Surgery was aborted and pt was returned to the MICU.,0
"# CAD s/p MI: Lateral depressions on admission EKG resolved on repeat EKGs with troponin T elevated to 0.10, possibly indicating some cardiac demand.",0
"Pt reported ""heartburn"" but no chest pressure.",0
"Prior cardiac catheterizations demonstrated LCx involvement, and given this constellation of data, pt was considered a high peri-operative risk for MI.",0
"During induction, pt did enter into PEA arrest.",0
"# Hypoxia: Pt was noted to have increased O2 requirement from baseline of 90% on 5L O2 NC, with DDx including PE (thrombotic vs fat in the setting of fracture), COPD flare, worsening idiopathic pulmonary fibrosis, infection, or worsening heart failure with associated pulmonary congestion.",1
"Pt improved rapidly overnight, indicating possible reversible cardiac etiology as also evidenced on EKG changes.",0
"Based on the considerations for her quality of life, pt's chronic pulmonary pathologies were not considered obstacles to ORIF per communication with her pulmonologist Dr. .",1
"# Code status: Pt was initially DNR/DNI, but after deciding to proceed with hip fracture repair, reversed her status to full code.",0
"After coding during induction for surgery, pt was intubated and received CPR.",0
"Pt's status was changed back to DNR, and she was later made CMO after her family decided to withdraw care based on her poor prognosis.",0
Pt expired minutes after pressors and ventilatory support were withdrawn.,0
Discharge Disposition: Expired Discharge Diagnosis: Left hip fracture Cardiopulmonary arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:,1
"2:51 AM CHEST (PORTABLE AP) Clip # Reason: r/o new infiltrate Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man recovering from PCP, , , with persistent fevers, increased secretions REASON FOR THIS EXAMINATION: r/o new infiltrate ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST AT 0300 HOURS.",0
"HISTORY: History of Pneumocystis pneumonia, and persistent fever with increased secretions.",0
"COMPARISON: Multiple priors, the most recent dated at 0245 hours.",0
FINDINGS: There has been qualitative improvement in aeration particularly in the right perihilar region and involving the retrocardiac left lower lobe.,0
Extensive widespread diffuse parenchymal opacities persist.,0
There is a stable tracheostomy tube.,0
The mediastinum is grossly stable as well.,0
No definite large effusion is noted.,0
Subtle blunting of the right costophrenic angle may indicate a small effusion.,0
IMPRESSION: Improved aeration relative to the prior exam as above.,0
"12:53 PM CHEST (PORTABLE AP) Clip # Reason: w/fever last night ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with ARDS, hypoxia, necrotizing fascitis, s/p repeat L subclavian central line placement, s/p pneumothorax, now with chest tube.",1
REASON FOR THIS EXAMINATION: w/fever last night ______________________________________________________________________________ FINAL REPORT HISTORY: 35 y/o female with ARDS and hypoxia with fever last night.,0
COMPARISONS: PORTABLE CHEST: The endotracheal tube has been removed.,0
There is a left internal jugular and left sided chest tube which remain in place and in satisfactory position.,0
"The cardiac, hilar and mediastinal silhouettes are stable.",0
There has been no significant change in the bilateral lower lobe opacities.,0
There is minimal amount of subcutaneous air seen along the left chest wall.,0
There has been no change in the soft tissue defect seen in the right axilla.,0
IMPRESSION: No significant change in the bilateral lower lobe opacities.,0
"4:16 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: RENAL FAILURE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with hypoxic resp failure, renal failure, completing course for VAP/aspiration PNA.",1
"CHF, with recent CVVH course.",0
"Difficulty weaning off vent given profound weakness, volume.",0
REASON FOR THIS EXAMINATION: please eval for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Hypoxic respiratory failure and renal failure with difficulty weaning off ventilator.,1
The patient has taken a slightly better inspiration.,0
There is persistent pulmonary vascular congestion.,0
"The degree of right pleural effusion appears to have decreased, though there is now more haziness at the left base consistent with a left pleural effusion.",0
Overall cardiac size is within normal limits.,0
"2:32 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: h/o CHF, dyspnea, diminished breath sounds L Admitting Diagnosis: CARDIOMYOPATHY; HEART BLOCK\BIVENTRICULAR PACEMAKER IMPLANTATION ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman s/p intraoperative BiVentr.",0
"Lead placements REASON FOR THIS EXAMINATION: h/o CHF, dyspnea, diminished breath sounds L ______________________________________________________________________________ FINAL REPORT Portable chest of , compared to a previous study of earlier on the same date.",0
CLINICAL INDICATION: Diminished breath sounds in the left lung.,0
There has been interval extubation.,0
A biventricular ICD pacing device remains in place.,0
There is persistent congestive heart failure pattern.,1
Note is also made of deviation of the trachea towards the left above the level of the thoracic inlet.,0
Correlation with CT demonstrates enlargement of the right lobe of the thyroid gland.,0
Note is also made of interval increased opacity in the left retrocardiac region as compared to the recent study.,0
IMPRESSION: 1) Slight worsening of congestive heart failure.,1
"2) Increasing opacity in left retrocardiac region, as compared to recent study of a few hours earlier.",0
"This may represent a combination of atelectasis and effusion, but other process such as aspiration or infection cannot be excluded.",0
Attention to this region on followup films may be helpful.,0
"4:27 AM CHEST (PORTABLE AP) Clip # Reason: please eval for any acute cardiopulmonary processes, pt is i Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with 42M w DM2, HTN, and HLD p/w L facial droop/R hemiparesis and CT showing occlusion distal vertebral a/prox basilar a.",1
"REASON FOR THIS EXAMINATION: please eval for any acute cardiopulmonary processes, pt is intubated ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation, followup.",1
"There is an improvement of the pre-existing atelectatic opacities, right more than left.",0
"Also, pre-existing signs of mild fluid overload have decreased in severity.",1
"Moderate fluid overload, no larger pleural effusions.",1
2:15 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: dilated bowel seen on cxr r/o ileus vs. obstruction ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with severe pancreatitis.,1
REASON FOR THIS EXAMINATION: dilated bowel seen on cxr r/o ileus vs. obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN TWO VIEWS HISTORY: Pancreatitis with abdominal distention.,1
No evaluate for obstruction or ileus.,0
There are multiple gas filled and dilated loops of small bowel with gas and some retained contrast in the colon.,0
Appearances are consistent with an ileus.,0
The cecum is slightly dilated measuring approximately 10 cm in diameter.,0
There are bilateral pleural effusions and bibasilar atelectasis with possible consolidation at the left lung base.,1
IMPRESSION: Findings consistent with ileus with a distended cecum.,0
Correlate clinically and with follow up if indicated.,0
9:18 PM CHEST (PA & LAT) Clip # Reason: Eval pneumonia ______________________________________________________________________________ MEDICAL CONDITION: year old man with syncope REASON FOR THIS EXAMINATION: Eval pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old male with syncope.,0
"CHEST, PA AND LATERAL VIEWS: There is minimal linear atelectasis at the left base and possibly at the right base but the lungs are elsewhere clear.",0
There is unfolding of the descending aorta but the mediastinal silhouette is otherwise unremarkable.,0
The hilar contours are normal.,0
6:04 PM CHEST (PORTABLE AP) Clip # Reason: PULM EDEMA?,0
______________________________________________________________________________ FINAL REPORT EXAMINATION: AP chest 3:21 HISTORY: Pulmonary edema possible pneumonia.,0
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Patient has had right upper thoracoplasty.,0
Pleural thickening and scarring is present in the apex of the post resection right upper lung.,0
Opacification in the infrahilar right lower lung could be scarring but acute infection cannot be excluded.,0
There is no good evidence for pneumonia in the left lung.,0
"Pleural calcification or linear atelectasis is present at the right base, there also appears to be a small amount of fibrosis, but no appreciable pleural effusion is present nor is there evidence of pneumothorax.",0
"2:28 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: Please eval of PE.",0
"Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: Bilateral pulmonary emboli at the lobar, segmental and subsegmental levels should have been reported as Impression #1.",0
No evidence for right ventricular strain.,0
Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with ?PE.,0
REASON FOR THIS EXAMINATION: Please eval of PE.,0
"No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw FRI 7:48 PM PFI: Bilateral pulmonary emboli involving the left upper lobe pulmonary artery, lingular branch, and right upper lobe subsegmental branches.",0
"Right middle lobe, right upper lobe pneumonia partially organize right pleural effusion.",0
______________________________________________________________________________ FINAL REPORT CTA CHEST HISTORY: 52-year-old woman with possible pulmonary embolism.,1
"COMPARISON: Multiple prior chest radiographs, most recent from .",0
TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet through the upper abdomen without and with intravenous contrast according to the chest pain non-gated CTA protocol.,0
Sagittal and coronal reformatted images and right and left oblique MIPS were performed.,0
"CTA CHEST: There is nonocclusive thrombus in the left upper lobe pulmonary arterial branches, lingular branch, and at least one segmental branch of the left lower lobe pulmonary artery.",1
There is nonobstructive thrombus within two segmental branches of the right lower lobe pulmonary artery and occlusive thrombus within subsegmental segment VIII or IX of the right lower lobe.,1
There is no bulging of the intraventricular septum to suggest right ventricular strain.,0
The aorta and great vessels are normal in appearance without aneurysm or dissection.,0
There is trace pericardial fluid which is an expected postoperative finding.,0
The tip of the Port-A-Cath catheter terminates at the cavoatrial junction.,0
There is an air-fluid level in the neo-esophagus begning approximately at the level of the carina.,0
There is suture material and a drain adjacent to the neoesophagus.,0
"There is tissue edema surrounding the neoesophagus, however, there are no focal fluid collections adjacent to the neoesophagus.",0
There is atelectasis of the left lower lobe.,0
There is consolidation suggestive of pneumonia of the right middle and right upper lung.,0
A small right pleural effusion is partially organized.,0
"A small left pleural effusion (Over) 2:28 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: Please eval of PE.",0
Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ FINAL REPORT (Cont) is present.,0
The right-sided chest tube is in place with its tip near the apex of the right hemithorax and a left-sided chest tube is positioned along the left hemidiaphragm.,0
Small bilateral pneumothoraces are present.,0
"Although this study was not designed for evaluation of the subdiaphragmatic contents, there is a hypodensity in segment IV of the liver which is incompletely characterized.",0
"Otherwise, limited views of the upper abdominal contents reveals no abnormalities.",0
Evaluation of osseous structures reveals no suspicious sclerotic or lytic lesions.,0
"Bilateral pulmonary edema at the lobar, segmental and subsegmental levels.",0
Right middle and right upper lobe pneumonia.,0
Right pleural effusion partially organized.,0
Small bilateral pneumothoraces with bilateral chest tubes.,0
"The findings of this study were communicated to Dr. , the SICU resident via telephone at 3:20 p.m. on .",0
"4:11 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: check vasculature, r/o thrombosis Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p OLT, confusion REASON FOR THIS EXAMINATION: check vasculature, r/o thrombosis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 5:41 PM Patent hepatic vasculature.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old man with recent transplant and liver confusion, evaluate vasculature.",1
FINDINGS: The liver shows no focal or textural abnormality.,1
There are no fluid collections seen and there is no ascites identified.,0
No biliary dilatation is seen and the common duct measures 0.2 cm.,0
"DOPPLER EXAMINATION: The main portal vein, right portal vein and left portal vein are patent with hepatopetal flow.",0
The velocity of flow in the main portal vein is noted to be somewhat elevated measuring up to about 200 cm/sec however it is difficult to assess the extrahepatic main portal vein due to technical limitations.,0
Appropriate flow is seen in the hepatic veins and IVC.,0
"Appropriate arterial waveforms are seen in the main hepatic artery, the right hepatic artery and the left hepatic artery.",0
No collections and no ascites seen.,0
Height: (in) 72 Weight (lb): 170 BSA (m2): 1.99 m2 BP (mm Hg): 133/51 HR (bpm): 72 Status: Outpatient Date/Time: at 13:01 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
Mild-moderate global left ventricular hypokinesis.,0
MR present but cannot be quantified.,0
GENERAL COMMENTS: Suboptimal image quality - poor apical views.,0
"Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a high risk (prophylaxis strongly recommended).",0
There is mild to moderate global left ventricular hypokinesis.,0
The aortic root is mildly dilated.,0
Aortic stenosis is not present.,0
"A well seated bioprosthetic mitral valve prosthesis is present with high normal gradient but a small, 3mm partially mobile (but not chaotic movement) echodensity identified on the left ventricular side of the prosthesis near one of the struts - ?fibrotic chord (cannot exclude a vegetation if clinically suggested).",0
Mitral regurgitation is seen - ?mild paravalvular.,0
Compared with the report of the prior study (images unavailable for review) of the small echodensity within the mitral bioprosthesis is identified and the severity of pulmonary artery hypertension and tricuspid regurgitation have markedly increased.,1
"If clinically indicated, a TEE may be better able to define the mitral valve echodensity and to assess the severity of mitral regurgitation.",0
"Admission Date: Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Cefepime / Cipro Cystitis Attending: Chief Complaint: Cough, malaise, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 56 year old man with a h/o AML s/p allo SCT in c/b chronic skin and pulmonary GVHD treated with prednisone 10mg daily.",1
"He reports 5-6 days of URI symptoms, myalgias, cough productive of yellow sputum, decreased appetite, and poor PO intake.",0
"No fevers, though he has been taking tylenol.",0
He presented to heme/onc clinic today and reported headache and nausea with improved after 1L NS.,0
"He was afebrile but hypoxic to 90% on RA, which improved to 94% on 2L.",0
Nasal swab and blood cultures were sent.,0
He was given vancomycin/aztreonam (due to cefepime allergy) and admitted for further workup.,0
O2 sats were in the mid-80s on RA so he was placed on nasal cannula and then shovel mask.,0
Overnight pt became more hypoxic and tachypnic.,0
Azithro was added to his abx.,0
Chest CT tree opacities and concern for brochiolitis/pneuonitis.,0
"BMT wanted to give IVIG due to low IgG, but pt was too hypoxic.",0
"Pt given albuterol x 1, and CXR taken.",0
ROS: (+) As noted above.,0
"(-) No current chest pain, palpitations, SOB, abdominal pain, N/V/D.",0
Past Medical History: # Pulmonary embolism x2 ( and dx in RML and RLL): on warfarin # Acute myeloid leukemia: - : diagnosed - : underwent a matched unrelated allogeneic stem cell transplant.,1
"- post-transplant course c/b bx-proven GVHD of the liver and an intermittent skin rash, s/p management with cyclosporine, mycophenolate, rituximab, and currently, steroids.",1
"# type 2 DM: steroid-induced # hyperlipidemia # bilateral hip AVN # HTN # nephrolithiasis: s/p lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage # BCC s/p excision # SCC left cheek, s/p Mohs' # multiple back surgeries: L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware) # anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 # chronic numbness, neuropathic pain in left upper extremity # multilevel compression fractures T11, T12, L1 and mild compression L3 and L4 # OSA: refused biPAP at home Social History: Lives with his wife, and son.",1
"is retired, worked as a technician Tobacco - 40 pk year hx, quit 5 yrs ago.",0
EtOH - denies Drug use - denies.,0
Family History: Mother died suddenly in her 70s.,0
Father died of unknown cancer.,0
One sister has thyroid cancer.,0
"Physical Exam: Admission physical exam Vitals: 101.8 132/88 109 24 91% NRB FS 127 General: A&Ox3 but appears SOB, speaking full sentences HEENT: dry MMM, clear OP, no scleral icterus Neck: Supple, no masses Lungs: Coarse breath sounds througout, no wheezes.",0
"CV: Regular, nml S1/S2, no murmurs.",0
"Abdomen: Soft, NT, ND, +BS Extrem: Hands and feet warm and well perfused, no cyanosis, 2+ pedal pulses, no edema.",0
"Neuro: CN grossly intact, strength and sensation grossly intact.",0
physical Exam: Please refer to daily progress note.,0
"**FINAL REPORT ** Respiratory Viral Culture (Final ): TEST CANCELLED, PATIENT CREDITED.",1
Refer to respiratory viral antigen screen and respiratory virus identification test results for further information.,1
Respiratory Viral Antigen Screen (Final ): THIS IS A CORRECTED REPORT.,0
Positive for Respiratory viral antigens.,0
Negative for Respiratory Viral Antigen .,0
"Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence.",0
REPORTED BY PHONE TO FOREST AT 1135 .,0
Respiratory Virus Identification (Final ): REPORTED BY PHONE TO S. FOREST 11.35A .,1
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.,0
Viral antigen identified by immunofluorescence 11:17 am CMV Viral Load (Final ): CMV DNA not detected.,0
4:07 am URINE Legionella Urinary Antigen (Final ): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.,0
6:10 pm SPUTUM Source: Induced.,0
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.,0
RESPIRATORY CULTURE (Final ): HEAVY GROWTH Commensal Respiratory Flora.,0
Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): YEAST.,0
8:21 am Influenza A/B by DFA Source: Nasopharyngeal swab.,0
**FINAL REPORT ** DIRECT INFLUENZA A ANTIGEN TEST (Final ): Negative for Influenza A.,0
DIRECT INFLUENZA B ANTIGEN TEST (Final ): Negative for Influenza B.,0
================================================================ Imaging CTA chest 1.,0
"Bibasilar bronchiectasis, unchanged compared with yesterdays examination with mulktilobar peribronchovascular ground-glass opacity with a tree-in- configuration.",0
"This pattern is nonspecific infectious or inflammatory, and consistent with small airways infection, atypical infections including fungal infection such as aspergillosis.",0
There is no pulmonary embolism.,0
Echocardiography : Poor image quality.,0
"Brief Hospital Course: 56M with h/o AML s/p allo SCT c/b chronic skin/pulmonary GVHD, who presented to clinic with URI symptoms, myalgias, and decreased PO intake and was found to be hypoxic, admitted on and discharged on .",0
"# Hypoxia: On admission was hypoxic to 90% on RA, febrile and w/o leukocytosis then rapidly developed more profound hypoxia on the floor.",0
On transfer to the ICU required 100% non rebreather mask.,0
Underwent CTA which demonstrated multifocal tree- opacities consistent with bronchiolitis and ruled out PE.,0
Nasal swab DFA Was positive for influenza.,0
His high oxygen demand was thought to be multifactorial with viral bronchiolitis/pneumonitis and possibly exacerbation of underlying chronic pulmonary GVH.,0
"Other contributing mechanisms were atelectasis, under-recruitment and sleep apnea as evidenced by his improved oxygenation with non-invasive positive pressure ventilation.",1
Significant Heart Failure was ruled out per and normal echocardiography.,0
Patient was treated with Tamiflu 150mg and will complete 10 days of treatment on day of ICU (this increased dose and prolonged dose is as per recent guidelines for Flu treatment in BMT patients).,0
"D/t to his high risk of superinfection as well as possible LLL infiltrate he was also covered with Abx: Vanco+Aztereonem+Azithro were started on , on aztreonem was changed to meropenem for more wide spectrum coverage.",0
Azithromycine was intially given and then restarted on and continued untill when urine legionella returned neg.,0
On day of ICU patient is thus on day 11 of Vanco and day 5 of Meropenem.,0
"Patient's home prednsione dose of 10mg daily was increased to 40mg daily for suspected Acute on chronic pulmonary GVHD, this was reduced back to home dose a day prior to ICU .",1
IVIG was given on for hypogammaglobulinemia and influenza infection without complications.,1
Acyclovir and Bactrim prophylaxis were continued.,0
"Patient continued to require 60-80% of Oxygen throughout most of his ICU stay which we were able to wean to 50% on non-invasive ventilation, but patient did not tolerated this due to discomfort from the mask.",0
Over the final 24h of his ICU stay his oxygemnation improved remarkably and on ICU discharged O2 requirement is down to 4L through nasal canula with Saturations >92%.,0
"He was then transferred to the floor with gradual improvement of his oxygenation as he completed the antiviral (, 10 day course) and antibiotics (, 10 day course).",0
He declined CPAP on the floor.,0
His O2Sat remained stable and he was discharged with home oxygen.,0
He was instructed to have follow up appointment with his doctor to determine further need for oxygen requirement as his pneumonia improves.,0
"# AML: s/p SCT (), c/b chronic GVHD of skin/lungs.",0
Patient was on higher dose of prednisone while in the ICU which was tapered back to home dose of 10 mg by the time of transfer from ICU to floor.,0
He remained on home prednisone and ID prophylaxis with acyclovir and Bactrim.,0
He received 0.4g/kg of IVIG on .,0
IgG on improved to 523.,0
No additional IVIG was given.,0
His level can be monitored in the outpatient setting.,0
"# H/o PE: Patient was intially supertheraputic d/t azithromycin therapy, recieved vitamin K and warfarine was held.",0
He then became undertheraputic and was bridged with Lovenox.,0
"Warfarin was restarted on at 5mg daily, INR is 2.1 on day of ICU and Lovenox was discontinued.",0
He continued with 5 mg warfarin with INR beteween 2.0-2.3 until when INR level dropped to 1.8 and he received a total of 7 mg warfarin on the evening of with INR still at 1.8.,0
"He was instructed to take 7.5 mg of warfarin on Sunday and 5 mg of warfarin on with lab on Tuesday in the outpatient setting, so that his INR can be followed up by his doctor.",0
Adjustment of his warfarin is likely given recent discontinuation of antibiotics.,0
"Because of his poor po intake initially, NPH was held.",0
"As his appetite improved, his insulin was readjusted to 10 unit NPH and then to 12 unit NPH with insulin sliding scale.",0
Patient reports that his home dose insulin is 12 units and not 10 units .,0
He was discharged on home dose NPH.,0
He continued with home metoprolol tartrate 12.5 mg as at home.,0
He continued with home atorvastatin 20 mg daily.,0
"# Previous EKG changes: Early in ICU course patient noted to have transient lateral/posterior ST depressions in V4-V6, I and AvL.",1
With CE x 3 neg.,0
This was likely demand ischemia in this patient with multiple coronary risk factors but no known CAD.,0
He continued statin and beta blocker.,0
Patient refused a diabetic diet and preferred regular diet while on the floor.,0
# Access: PICC while in the hospital.,0
"# Code status: Full Code, ICU consent done with wife/HCP , h , c- Medications on Admission: MEDICATIONS: - Acyclovir 400mg PO TID - Atorvastatin 20mg daily - Budesonide 3mg TID - Folic acid 1mg daily - Gabapentin 300mg QHS - Oxycodone ER 40mg Q8h - Hydromorphone 4mg; 0.5-1 tablet daily prn - NPH 10units - Humalog SS - Metoprolol tartrate 12.5mg - Pantoprazole 40mg - Prednisone 10mg daily - Bactrim 400mg-80mg Tablet daily - Warfarin 2.5mg alternating with 5mg daily - Calcium carbonate 648mg TID - Cholecalciferol 1000unit daily .",0
ALLERGIES: - Cefepime - Cipro Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).,0
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.,0
"6. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
9. warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4 PM: Please take 1.5 tablets (7.5 mg) on Sunday and then take 1 tablet (5 mg) daily until your INR is above 2.,0
Further dosage adjustment per your healthcare provider.,0
10. calcium carbonate 648 mg Tablet Sig: One (1) Tablet PO three times a day.,0
"11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day.",0
"12. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO three times a day.",0
Insulin Sliding Scale Use Humalog insulin sliding scale as you have been at home.,0
Dosage per your healthcare .,0
oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q8H (every 8 hours).,0
15. hydromorphone 4 mg Tablet Sig: 0.5-1 Tablet PO once a day as needed for pain.,0
"16. vitamin B12 Injection per month, dosage per your healthcare .",0
Insulin NPH 10-12 units twice a day.,0
Dosage adjustment per your healthcare .,0
Home Oxygen Continuous oxygen 2-3L flow per minute via nasal cannula.,0
"Outpatient Lab Work Please have a PT and INR checked on Tuesday, , and have the results faxed or called in to your PCP's office (Dr. .",0
Disposition: Home With Service Facility: oxygen Diagnosis: Primary diagnosis: - Influenza A pneumonia Secondary diagnoses: - Chronic graft versus host disease- Lung and Skin - Type 2 Diabetes - History of pulmonary embolism Condition: Mental Status: Clear and coherent.,1
"Instructions: Dear Mr. , It was a pleasure to take care of you at .",0
You were admitted to the hospital for cough and increased trouble with breathing.,0
"In the hospital, it was found that you have influenza pneumonia.",1
"Because of your increased oxygen use, you were transferred to the intensive care unit for close monitoring.",0
You were treated with an antiviral for the flu as well as antibiotics for possible bacterial pneumonia as well.,0
You completed the course of the antiviral and antibiotics while in the hospital.,0
"Please note the following changes in your medications: - Please START supplemental oxygen at 2-3L/min, continuously, until your pneumonia and shortness of breath have resolved.",0
Your doctors when you can stop using oxygen.,0
"You will need to have your INR level checked on Tuesday, , and have the results faxed to your PCP who manages your coumadin.",0
It will be important for you to follow up with your doctors below.,0
"Followup Instructions: Department: HEMATOLOGY/BMT When: THURSDAY at 9:00 AM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: HEMATOLOGY/BMT When: THURSDAY at 9:00 AM With: , NP Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: DERMATOLOGY When: at 3:30 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Completed by:",0
"4:19 PM CHEST (PORTABLE AP) Clip # Reason: evaluate ET tube, CVL Admitting Diagnosis: VENTRICULAR FIBRILLATION ARREST ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man intubated post-op from aorto-bifem thrombectomy, RLE fasciotomy REASON FOR THIS EXAMINATION: evaluate ET tube, CVL ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF COMPARISON: Previous study of earlier the same date.",0
INDICATION: Evaluate tube and line placement.,0
Endotracheal tube terminates 6.5 cm above the carina and could be advanced slightly for standard positioning.,0
"Central venous catheter remains in standard position, and nasogastric tube continues to terminate below the diaphragm.",0
"Cardiomediastinal contours are stable in appearance, but there has been worsening of left retrocardiac opacity, likely a combination of atelectasis and effusion.",0
Persistent perihilar opacities in the right lung likely reflect asymmetrical pulmonary edema.,0
Intraop for CABG Bentall Height: (in) 69 Weight (lb): 195 BSA (m2): 2.05 m2 BP (mm Hg): 130/56 HR (bpm): 75 Status: Inpatient Date/Time: at 12:16 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
AORTA: Sinus of Valsalva aneurysm.,0
Moderate-sized vegetation on aortic valve.,1
"Significant AR, but cannot be quantified.",0
Conclusions: Pre bypass: The left atrium is moderately dilated.,0
There is an abcess in the proximal sinus of valsalva which tracks around most of the extent of the aortic valve with flow seen in the pocket.,1
There is a moderate-sized vegetation on the aortic valve.,1
"Significant aortic regurgitation is present, but cannot be quantified because of the contribution of flow around the valve through the abcess.",1
Post bypass: Patient is AV paced on phenylepherine infusion.,0
There is a homograft insitu in the aortic root that appears well seated.,0
The aortic valve leaflets are normal.,1
There is no Aortic insufficiency or stenosis.,1
The calculated aortic valve area is 3.3-4/3 cm2.,1
Wall motion is unchanged except septal motion is paradoxical and consistent with av pacing.,0
"Aortic contours are unchanged with the exception of the homograft in the ascending aorta, which has normal contours and dimensions.",0
All findings were discussed with the surgeons at the time of the exam.,0
1:52 PM CHEST (PORTABLE AP) Clip # Reason: please eval line placement s/p cath and transfer from OSH Admitting Diagnosis: AV BLOCK; CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with cardiogenic shock s/p intubation REASON FOR THIS EXAMINATION: please eval line placement s/p cath and transfer from OSH ______________________________________________________________________________ FINAL REPORT EXAMINATION: Single view of the chest.,1
A single AP image of the left side of the chest is performed at approximately 14:50 hours.,0
No prior films are available for comparison.,0
The study was not repeated as the patient was to have a chest CT immediately following.,0
Patient is intubated with the tip of the ET tube approximately 2.5 cm above the carina.,0
There is a mediastinal tube present.,0
A nasogastric tube is present with its tip in the gastric fundus.,0
A right IJ line has its tip in the proximal SVC.,0
Increased retrocardiac density is seen on the left side with blunting of the left costophrenic angle which likely represents combination of atelectasis and effusion.,0
Tubes and lines as described above.,0
Nonvisualization of the right side of the chest.,0
Please refer to the chest CT for a more detailed evaluation of the chest findings.,0
1:04 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: sbo?,0
"(no contrast, ARF) Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with nausea and emesis REASON FOR THIS EXAMINATION: sbo?",1
"(no contrast, ARF) CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ WET READ: JVg SAT 2:06 AM No evidence to explain pain.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old female with nausea and emesis.,0
Evaluate for small- bowel obstruction.,0
CT ABDOMEN WITHOUT IV CONTRAST: Again demonstrated is atelectasis within the lung bases bilaterally.,0
"The unopacified liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are unremarkable.",0
"There are extensive vascular calcifications within the coronary arteries, aorta and mesenteric vessels including renal arteries.",0
A gastric tube is present percutaneously with tip terminating in the jejunum.,0
There are no distended loops of small or large bowel and oral contrast is demonstrated extending to the rectum.,0
There is no free fluid or free air.,0
CT PELVIS WITHOUT IV CONTRAST: The appendix is not visualized.,0
There are no secondary signs to suggest appendicitis.,0
"The uterus, adnexa and rectum are unremarkable.",0
Atrophic changes of the muscles of the right hemipelvis are again demonstrated indicating likely hemiparesis.,0
IMPRESSION: No CT evidence to explain abdominal pain.,0
(Over) 1:04 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: sbo?,0
"(no contrast, ARF) Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont)",1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. is a 52-year-old female who was transferred to the in hyperacute fulminant liver failure thought to be secondary to either Bactrim reaction versus acetaminophen toxicity.,1
"She was admitted to the medical intensive care unit initially and became progressively obtunded, with significant encephalopathy requiring intubation and ventilatory support.",0
"Her liver function was notable for transaminases with an ALT and AST of 9500 and 17,500 respectively and worsening hyperbilirubinemia.",1
"She became progressively more coagulopathic, and it was thought that she was most likely going to need orthotopic liver transplantation for survival.",0
"Given the critical nature of her illness, she was transferred to the transplant surgical service and to the surgical intensive care unit for further management.",0
This management initially entailed aggressive control and monitoring of intracranial pressures in conjunction with the neurosurgical service.,0
This required placement of an intracranial bolt and aggressive volume management with the use of hypertonic saline and mannitol.,0
"She continued to receive aggressive cardiopulmonary support with again, as noted, full ventilatory support and vasopressor support for hypotension.",0
"COURSE BY SYSTEMS: Neurologically, as noted above the patient required placement of an intracranial bolt for ICP monitoring.",0
Her ICPs had climbed into the high 30s.,0
This was managed with hyperventilation and usage of mannitol and hypertonic saline.,0
"Over the course of the next 4-5 days as her liver function improved, her intracranial pressures decreased.",1
Her sedation and paralytics were weaned.,0
"She had removal of her intracranial bolt on , and it was noted on subsequent imaging that she had approximately a 4-cm, right frontal, intracranial hemorrhage.",0
This was followed serially with CT scans and there was no progression of the bleeding.,0
The bleeding was thought to be secondary to her severe coagulopathy and thrombocytopenia in the setting of her instrumentation.,0
She was started on Keppra for seizure prophylaxis to finish a 10-day course.,0
"On , the patient was extubated and her neurologic exam was notable for response to voice and opening of her eyes.",0
"She was moving her left upper extremity and her right lower extremity with 2/5 strength and had minimal movement in her right upper extremity and left lower extremity, not following the predicted neurologic pattern if this was a deficit associated with her intracranial bleeding.",0
"In terms of her respiratory status, it is noted that the patient required full ventilatory support and was extubated on .",1
"She initially did well, but, secondary to what was thought to be pulmonary edema, required reintubation on after failure of noninvasive positive pressure ventilation.",1
She had some degree of what appeared to be an ARDS-type reaction or transfusion- associated lung injury requiring high amounts of PEEP and oxygenation during the initial days of her intensive care unit stay.,0
This resolved over the course of the next several days with diuresis and supportive therapy.,0
"In terms of her cardiovascular status, the patient initially had blood pressure support with the use of vasopressors in order to minimize her intravascular volume which was thought to exacerbate her cerebral edema.",1
"The vasopressors were weaned by ICU day 6, and there was no further requirement for this.",0
There were no significant dysrhythmias.,0
"The patient, initially thought to most certainly require liver transplantation, spontaneously improved in terms of her liver function over the course of her 2 weeks in the intensive care unit.",1
"This was evidenced by progressive ability to metabolize her lactate, stabilization of her blood sugars, and autocorrection of her coagulopathy.",0
"By the time of her transfer, while she continued to have a hyperbilirubinemia, her transaminases had completely normalized.",0
A Dobbhoff feeding tube was in place for post- pyloric tube feedings.,0
The patient's transaminases were elevated; this was thought to be secondary to a possible mild ischemic pancreatitis which might have developed during her requirement for vasopressors.,1
She otherwise did not seem to be symptomatic for this and was tolerating tube feeds.,0
"Therefore, this was not aggressively pursued.",0
"In terms of her overall fluid status, her baseline weight is 37 kg.",0
"On the day of transfer, she weighed about 44 kg.",0
This volume overload was being managed with hemodialysis daily on an as-needed basis.,0
"The patient's renal function, which had been quite labile throughout her hospitalization, stabilized, with creatinine in the 2.9-3.4 range.",1
"She makes approximately 500-700 mL of urine per day, but is dialysis-dependent.",0
She currently receives hemodialysis through a left femoral hemodialysis catheter.,0
"In terms of her ID issues, the patient was initially started on vancomycin for prophylaxis against intracranial infection with the bolt in place.",0
"She developed a leukocytosis, and the thought was that she may have been developing pneumonia given the persistent difficulty oxygenating her.",0
She was started empirically on Zosyn.,0
"Sputum cultures failed to evidence any pneumonic process, and these antibiotics were discontinued.",0
"In terms of hematologic issues, the patient developed what appeared to be a DIC versus TTP picture, for which the hematology service was following.",0
She evidenced a consumptive coagulopathy with significant destruction of platelets.,0
Her thrombocytopenia likely contributed to her intracranial bleeding.,0
"The patient required special HLA-typed platelet transfusions in order to maintain a platelet count above 100,000.",0
She also developed a significant anemia without any evidence of bleeding.,0
This was thought to be secondary to hemolysis in the face of an elevated indirect bilirubin and a depressed haptoglobin.,0
"Her thrombocytopenia and anemia resolved by , and she no longer required any transfusion of any blood products.",0
"At the present time, the patient is requiring intensive care for management of respiratory failure and renal failure.",1
"She is no longer in need of liver transplantation, and therefore, given her primary medical issues, she will be transferred to the medical intensive care unit.",0
"At the time of transfer, the patient is receiving the following medications: Protonix 40 mg p.o.",0
once daily; insulin sliding scale; fentanyl as needed; heparin 5000 units subcu t.i.d.,0
; Keppra 500 mg IV q.12 hours.,0
", MD Dictated By: MEDQUIST36 D: 18:23:57 T: 19:19:38 Job#:",0
"3:08 PM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: L2-L4 COMPRESSION FRACTURES, LOWER BACK PAIN Admitting Diagnosis: ETOH WITHDRAWEL;LIVER FAILURE;RENAL FAILURE;ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with Cirrosis and now with L2 and L4 compression fractures.",0
Need Ct L-spine per Neurosurg for further eval (along with his MRI).,0
REASON FOR THIS EXAMINATION: L-spine Fractures?,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 54 old male with cirrhosis and L2 and L4 compression fractures.,0
TECHNIQUE: Direct axial CT imaging of the lumbar spine performed without IV contrast.,0
Additional reformatted images in the coronal and sagittal plane were also obtained.,0
FINDINGS: There is a compression fracture involving the anterior inferior portion of the vertebral body at the level of L2.,0
The central spinal canal is patent at this level.,0
There is a burst type fracture involving the L4 vertebral body with retropulsed bone fragments causing mild central spinal canal stenosis at the level of L4.,0
The remainder of the vertebral bodies are normal in height.,0
There is mild degenerative change with osteophyte formation and loss of intervertebral disc space present throughout the lumbar spine which is most prominent at the level of L5-S1.,0
There is no evidence of bone destruction or suspicious lytic or sclerotic lesions.,0
The posterior elements are intact throughout the lumbar spine.,0
CT RECONSTRUCTIONS: Images were formatted in the coronal and sagittal plane were essential in evaluating the patient's lumbar spine and demonstrate the above described compression deformity involving the anterior portion of the vertebral body of L2 as well as the burst type fracture involving the vertebral body at the level of L4.,0
IMPRESSION: 1) Burst type fracture of the vertebral body at the level of L4 with retropulsed bone fragments causing mild central spinal canal stenosis at this level.,0
2) Compression type fracture involving the anterior inferior portion of the vertebral body at the level of L2 which is not associated with central spinal canal stenosis.,0
3) Mild degenerative changes noted throughout the remainder of the lumbar spine with loss of intervertebral disc space and osteophyte formation which is most prominent at the level of L5-S1.,0
"(Over) 3:08 PM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: L2-L4 COMPRESSION FRACTURES, LOWER BACK PAIN Admitting Diagnosis: ETOH WITHDRAWEL;LIVER FAILURE;RENAL FAILURE;ENCEPHALOPATHY ______________________________________________________________________________ FINAL REPORT (Cont)",0
2:56 AM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: r/o cva/ischemia ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman s/p cerebral chemoembolization tonight now with bilateral visual field deficits REASON FOR THIS EXAMINATION: r/o cva/ischemia ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 56-year-old female status post cerebral embolization now presents with bilateral visual field defects.,1
"TECHNIQUE: Multiple sagittal T1-weighted images, multiple axial T1 and T2 and FLARE and susceptibility and axial images performed.",0
MRA and MRV was also performed.,0
"FINDINGS: There is no evidence of hemorrhage, edema, midline shift, mass effect, hydrocephalus or extra-axial collections.",0
No abnormal signal intensity is noted in the brain parenchyma.,0
No areas of decreased perfusion noted in the diffusion studies.,0
MR flow within the major intracranial vessels.,0
When compared to the previous angiogram no new deficits.,0
MR decreased flow in the left transverse sinus.,0
The significance of this finding is uncertain as no prior MRV examination is available for comparison.,0
No definite acute stroke noted.,0
"Decreased flow noted in the left transverse sinus, significance of this finding is uncertain, as there is no previous MRV for comparison.",0
8:30 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change and line/tube position.,0
Admitting Diagnosis: CHRONIC PULM DISEASE;HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p trach on with subQ emph and pneumomediastinum REASON FOR THIS EXAMINATION: Please eval for interval change and line/tube position.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient with subcutaneous air collection and pneumomediastinum.,0
Portable AP chest radiograph was compared to obtained at 04:49 a.m.,0
The tracheostomy tip is 3 cm above the carina.,0
There is slight interval additional decrease in the subcutaneous air collection.,0
Pneumomediastinum is difficult to appreciate on the current study giving the complete obscuration of the mediastinum by subcutaneous air.,0
"12:47 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: lung expansion ______________________________________________________________________________ MEDICAL CONDITION: Infant placed on HiFi, looking for chest expansion REASON FOR THIS EXAMINATION: lung expansion ______________________________________________________________________________ PRELIMINARY REPORT DR. CC: RADLINE ; A radiology consult service.",0
Height: (in) 60 Weight (lb): 168 BSA (m2): 1.73 m2 BP (mm Hg): 110/59 HR (bpm): 75 Status: Inpatient Date/Time: at 18:54 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
TASPE normal (>=1.6cm) AORTA: Normal aortic diameter at the sinus level.,0
Tricuspid annular plane systolic excursion is normal (3.2 cm) consistent with normal right ventricular systolic function.,0
8:13 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: mass?,0
"Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with h/o lymphoma, small bowel perf, and melena and RLQ pain REASON FOR THIS EXAMINATION: mass?",0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: MPtb SUN 12:29 AM No definite cause for abd pain and melena.,0
Signif improvement in retroperitoneal LAD.,0
Decrease in size of rim enhancing fluid collecttion in cul de sac.,0
"______________________________________________________________________________ FINAL REPORT 72-year-old female with history of lymphoma, now with melena and right lower quadrant pain with concern for mass or appendicitis.",0
TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis were obtained after oral and 130 mL Optiray IV contrast.,0
Coronal and sagittal reformatted images were also obtained.,0
CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases are clear.,0
"A 4.5 cm cyst of segment VIII of the liver is unchanged as are two smaller subcentimeter hypodensities, which are too small to definitively characterize but probably cysts.",0
"The gallbladder, spleen, pancreas, adrenal glands, and right kidney are unremarkable.",0
The appearance of the left kidney is unchanged.,0
Again demonstrated is a calyceal diverticulum with underlying cortical thinning.,0
"There are a few left renal subcentimeter hypodensities, which are too small to characterize but probably cysts.",0
There are post- surgical changes of the anterior abdominal wall with a small 3.4 x 1.6 cm area of fluid likely a postoperative seroma and not significantly changed.,0
There is free passage of oral contrast through to the descending colon without evidence of obstruction or inflammatory change of the bowels.,0
The appendix is visualized and is normal.,0
"There has been significant interval improvement in paraaortic retroperitoneal lymphadenopathy with a confluent nodal mass now measuring 3.7 x 2.1 cm, previously 5.7 x 3.7 cm.",0
"CT OF THE PELVIS WITH IV CONTRAST: The rim-enhancing pelvic fluid collection is now significantly smaller measuring 3.4 x 1.7 cm, previously 5.6 x 3.3 cm.",0
"The uterus again demonstrates fibroids, some of which are calcified.",0
The rectum and urinary bladder are unremarkable.,0
No definite cause for the patient's abdominal pain and melena identified.,0
(Over) 8:13 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: mass?,0
Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) Normal appendix.,0
Significant improvement in paraaortic retroperitoneal lymphadenopathy.,0
Decrease in size of rim-enhancing fluid collection within the cul-de-sac.,0
No change in hepatic cysts.,0
Admission Date: Discharge Date: Service: HISTORY OF PRESENT ILLNESS: The patient is a 77 history of woman with a history of diverticulosis by prior colonoscopy on status post total abdominal hysterectomy bilateral salpingo-oophorectomy for endometrial cancer followed by chemotherapy and radiation therapy in who now presents with a one week history of perfuse bloody diarrhea.,1
She has had five to six bowel movements per day for the past week.,0
"The character of the bowel movements have been bright red blood per rectum and occasional tarry black stools with the consistency of ""pudding.""",0
There has been consistent bright red blood to the color the toilet bowel.,0
"She denies abdominal pain, pain with bowel movements or tenesmus.",0
She has no history of a upper or lower gastrointestinal bleed.,1
As noted she has had diverticuli noted on prior colonoscopy.,0
She does take a daily aspirin.,0
She denies significant non-steroidal anti-inflammatory drugs use or alcohol use.,0
There is a family history of cancer in her brother.,0
The patient has taken Imodium several times this past week.,0
"REVIEW OF SYSTEMS: The patient denies chest pain, shortness of breath, lightheadedness and dizziness, but does admit to having been fatigued all week.",0
Physical examination in the Emergency Department her temperature was 97.1 with a pulse of 101 and a blood pressure of 205/85.,0
Repeat blood pressure was 165 systolic.,0
O2 sats were 99% on room air.,0
Her hematocrit was 21 down from a baseline of approximately 34.,0
"Nasogastric lavage was performed, which was negative.",0
Lavage did yield some bilious fluid.,0
Anoscopy revealed both internal and external hemorrhoids with possible bleeding from the internal hemorrhoids.,0
Starting in the Emergency Department the patient was transfused a total of 2 units.,0
She was hemodynamically stable without complaint upon her transfer to the floor.,0
Additional review of systems reveals that the patient has had chronic occasional left upper quadrant crampy abdominal discomfort.,0
"She has also had a ""pulsating"" sensation in her ears bilaterally all week.",0
History of basal cell carcinoma of the right eyelid.,0
Status post total abdominal hysterectomy bilateral salpingo-oophorectomy for endometrial carcinoma in .,0
Status post chemotherapy and radiation therapy completed in .,0
History of diverticulosis by prior colonoscopy.,1
History of syncope with negative Holter monitor study.,0
Patient with no history of coronary artery disease or diabetes.,0
Cardiac risk factors include hypertension and high cholesterol now being treated.,0
There is a possible family history of coronary artery disease with father deceased from myocardial infarction in his sixties.,0
Lipitor 10 mg po q day.,0
Mavic 4 mg po q.d.,0
Aspirin 325 mg po q.d.,0
Multi vitamin one po q.d.,0
Lasix 20 mg q Tuesday and Friday.,0
(The patient reports that she takes this for both hypertension and history of pedal edema).,1
"SOCIAL HISTORY: No tobacco, alcohol or intravenous drug use.",0
The patient lives on .,0
FAMILY HISTORY: Brother with cancer and a father with a history of coronary artery disease as noted.,0
ADMISSION PHYSICAL EXAMINATION: Vital signs temperature 98.7.,0
Blood pressure 150 to 170/70 to 80.,0
Pulse ox 97% on room air.,0
The patient was not orthostatic.,0
"Physical examination general appearance, the patient is awake, alert, well appearing, talkative amiable woman in no acute distress.",0
"Cardiovascular regular, 2 out of 6 systolic murmur radiating to the axilla.",0
"Abdomen is mildly obese, soft, nontender with active bowel sounds.",0
"ADMISSION LABORATORY STUDIES: White blood cell count 9.0, hematocrit 22.6, platelets 260, INR 1.1, urinalysis negative.",0
"Sodium 139, potassium 5.1, which was hemolyzed.",0
Repeat potassium was within normal limits.,0
"Chloride 101, bicarbonate 29, BUN 14, creatinine 0.8 and glucose 126.",0
"Prior studies and echocardiogram from showed an EF of greater then 60%, moderate mitral regurgitation, minimal aortic stenosis.",0
A Holter monitor study from showed no evidence of arrhythmia.,0
"An exercise treadmill test from showed a total exercise time of 8.5 minutes 100% maximal heart rate, no anginal symptoms or electrocardiogram evidence of myocardial infarction.",0
Gastrointestinal: The patient presented with one week of symptoms suggestive of both upper and lower gastrointestinal bleed.,0
"Her hematocrit was 21 down from a baseline of 34, but the patient was hemodynamically stable.",0
She was transfused a total of 2 units on the first night of admission and experienced recurrent bright red bleeding over the course of the evening up to four to five bowel movements.,0
Her vital signs again remained stable.,0
"The patient was sent for a tagged red cell scan, which localized bleeding to the left upper quadrant possibly the descending .",0
"The patient was subsequently sent for angiography, which revealed no evidence of acute bleeding and there was no acute intervention.",0
The patient's hematocrit on the following morning was 23 showing the patient had only bumped one point despite being transfused 2 units of packed red blood cells.,0
"Given her continued bleeding without a clear source, the patient was transferred to the Medical Intensive Care Unit for further monitoring.",0
Over the next several days the patient received an additional 5 units of packed red blood cells bringing her hematocrit up to the low 30.,0
She experienced continued gastrointestinal bleeding.,0
"While in the Medical Intensive Care Unit the patient underwent an upper endoscopy, which revealed no source of bleeding in the esophagus, stomach or upper small bowel.",0
"She also underwent a colonoscopy, which revealed pan diverticulosis throughout the .",1
Again no acute evidence of bleeding.,0
The patient's hematocrit stabilized at approximately 30 to 32.,0
Her bleeding gradually subsided and she was transferred back to the medical floor after approximately a three day course in the Medical Intensive Care Unit.,0
Following the transfer to the floor the patient remained hemodynamically stable with no further bleeding and stabilization of her hematocrit at approximately 30.,0
"Finally, the patient underwent a small bowel follow through, which revealed evidence of diverticulosis in the jejunum an area was noted would also localize to the upper quadrant on bleeding scan and may also have represented the source of the patient's initial bleeding especially given history of melanotic stools.",1
The patient was evaluated by the Surgical Service during this admission and will have follow up with Dr. as an outpatient.,0
The patient was discharged home on Metamucil and recommended to have a high fiber diet.,0
She will return to the hospital immediately should she note recurrent gastrointestinal bleeding.,0
Cardiovascular: Patient with a history of hypertension.,1
Patient was hypertensive on admission.,0
She was continued on her Mavic.,0
Lasix was held during this admission.,0
The patient experienced no symptoms of angina or dyspnea despite her low hematocrit.,0
Renal: The patient's creatinine and electrolytes were within normal limits on this admission.,0
Gastrointestinal bleeding of unclear source.,0
Diverticulosis of the large and small bowel.,0
Metamucil one teaspoon in water q.d.,0
The patient is recommended to take a high fiber diet.,0
The patient is recommended to start Metamucil and to follow a high fiber diet.,0
The patient will follow up with her primary care physician .,0
whom she will contact within the next two days.,0
The patient also has a follow up appointment scheduled with general surgeon Dr. next week.,0
The patient's primary care physician was alerted to the fact that the patient is at moderate risk for endocarditis given moderate mitral regurgitation.,0
He will follow up with the patient as an outpatient.,0
DR Dictated By: MEDQUIST36 D: 06:54 T: 09:34 JOB#:,0
Admission Date: Discharge Date: Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: Mr. is an 81-year-old white male with a vague history of chest discomfort over the past few months.,0
"He lives in and was here for his sister's funeral and had chest pain with nausea, dyspnea, diaphoresis on .",0
"His symptoms resolved, but recurred the following morning.",0
"He presented to Hospital and ruled-in for an MI with a peak CPK of 1,200.",0
"He had a cardiac cath which revealed a tight distal left main, two-vessel coronary artery disease, with an ejection fraction of 25%.",1
He was transferred to for CABG.,0
"PAST MEDICAL HISTORY: Significant for a history of 1) Hypertension, 2) History of type 2 diabetes, 3) History of nephrolithiasis, 4) Status post subdural hematoma.",1
"MEDICATIONS ON ADMISSION: 1) aspirin 81 mg po qd, 2) metformin 850 mg po bid, 3) Glucotrol 10 mg po qd, 4) Toprol XL 100 mg po qd, 5) Flomax 0.4 mg po qd, 6) Lo-Trol 50/20 po qd.",0
PHYSICAL EXAM: He was a well-developed elderly white male in no apparent distress.,0
"HEENT exam - normocephalic, atraumatic.",0
"Neck was supple, full range of motion, no lymphadenopathy or thyromegaly.",0
Carotids 2+ and equal bilaterally without bruits.,0
Lungs were clear to auscultation and percussion.,0
"Cardiovascular exam - regular rate and rhythm, normal S1, S2, with no rubs, murmurs, or gallops.",0
"Abdomen was obese, soft, nontender with positive bowel sounds, no masses or hepatosplenomegaly.",0
"Extremities were without clubbing, cyanosis or edema.",0
Pulses were 2+ and equal bilaterally throughout.,0
"HOSPITAL COURSE: On , the patient underwent a CABG x 3 with LIMA to the LAD, reversed saphenous vein graft to OM and PDA.",0
Crossclamp time was 77 minutes.,0
Total bypass time 92 minutes.,0
"He was transferred to the CSRU on epinephrine, insulin drip and aprotinin.",0
"He was transfused 2 units of blood on the first night, and remained intubated, as he would get agitated with weaning.",0
His epinephrine was DC'd on postop day #1.,0
He was extubated and started on Lopressor.,0
He did have some slight confusion and was treated with Haldol.,0
"On postop day #2, his chest tubes were DC'd.",0
He was transferred to the floor in stable condition.,0
"He did require some Haldol at night prn, but his confusion resolved.",0
"On postop day #3, his epicardial pacing wires were DC'd.",0
"He did have a slight bump in his creatinine to 1.6, but we think his baseline might have been around 1.5, so his lasix was DC'd, and his preop metformin was DC'd as well.",0
"On postop day #6, he was discharged to home in stable condition.",0
"LABS ON DISCHARGE: Hematocrit 32.8, white count 10,000, platelets 168, sodium 142, potassium 4.6, chloride 107, CO2 25, BUN 82, creatinine 1.5, blood sugar 81.",0
"DISCHARGE MEDICATIONS: 1) colace 100 mg po bid, 2) glipizide 10 mg po qd, 3) Flomax 0.4 mg po qd, 4) Ecotrin 325 mg po qd, 5) Lopressor 100 mg po tid, 6) Lipitor 10 mg po qd, 7) Plavix 75 mg po qd--he is on the Plavix for poor distal targets.",0
"FOLLOW-UP: He will be seen by Dr. in one week, and then will travel back to by plane, and should be seen by Dr. in , in one to two weeks.",0
Dictated By: MEDQUIST36 D: 10:27 T: 10:34 JOB#:,0
"1:00 PM CT HEAD W/O CONTRAST Clip # Reason: please evalute for any increased/new hemorrhage Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man s/p burr holes for bilateral SDH, now more lethargic REASON FOR THIS EXAMINATION: please evalute for any increased/new hemorrhage No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old man status post burr holes for bilateral subdural hemorrhage.",1
"FINDINGS: Again noted are four burr holes, two on each side, unchanged with skin staples still visible.",0
"A moderate amount of pneumocephalus remains, although less than on the previous study bilaterally.",0
"Compared to the most recent prior study, the heterogeneous subdural hemorrhage on the right appears roughly stable in size, measuring up to 16 mm in widest width.",1
"The subdural hemorrhage on the left appears slightly larger than previously, now measuring 14 mm in widest width compared to 11 on the prior study (2:23).",1
The configuration of the ventricles remains unchanged as is mild leftward deviation of the septum pellucidum.,0
"However, the obscuration of the basal cisterns is worsened compared to the most immediate prior study, although roughly similar compared to the study.",0
The appearance of the foramen magnum is unchanged.,0
"IMPRESSION: Slight increase in size of the left-sided subdural hematoma, and stable appearance of the right-sided subdural hematoma, both of which appear heterogeneous.",0
Decrease in the amount of pneumocephalus compared to the most recent prior study.,0
"More effacement involving the suprasellar cistern compared to the study, although relatively stable compared to the study.",0
6:20 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: where is the picc line?,0
Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: infant with NEC and new picc line REASON FOR THIS EXAMINATION: where is the picc line?,1
______________________________________________________________________________ WET READ: JRCi SAT 8:50 PM Picc likely at the right atrial/SVC junction.,0
Non descript lucency within the lower abdomen which does not appear to conform to bowel.,0
Recommend decubitus radiograph to evaluate for free air.,0
______________________________________________________________________________ FINAL REPORT PORTABLE AP BABYGRAM: at 18:23.,0
HISTORY: Five-week-old girl who is being treated for medical necrotizing enterocolitis.,0
COMPARISON STUDIES: Portable KUB from earlier on .,0
FINDINGS: The left arm PICC tip projects near the junction of the SVC and right atrium with the patient's arm abducted to a 90-degree angle.,0
The patient is rotated towards the right.,0
The lungs are clear and the pulmonary vascularity is normal.,0
The cardiothymic silhouette is normal.,0
The bony thorax is intact.,0
No evidence for pneumothorax or pleural effusion.,0
A prominent loop of transversely oriented bowel in the lower abdomen that appears to be draped over a urine-filled bladder.,0
Remainder of the bowel gas pattern is unremarkable.,0
"No convincing evidence for pneumatosis, wall thickening, or portal venous gas.",0
Remainder of the abdomen is unremarkable.,0
Satisfactory positioning of left arm PICC.,0
"Nonspecific bowel gas pattern with a prominent, transversely oriented loop in the lower abdomen and pelvis.",0
This can be reassessed on subsequent studies.,0
(Over) 6:20 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: where is the picc line?,0
Admitting Diagnosis: NEWBORN ______________________________________________________________________________ FINAL REPORT (Cont),0
6:16 PM ABD (SINGLE VIEW ONLY) IN O.R.,0
; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # Reason: IVC FILTER Admitting Diagnosis: MULTISYSTEM TRAUMA ______________________________________________________________________________ WET READ: JEKh SAT 7:44 PM IVC filter projecting just right of midline at the L3 level ______________________________________________________________________________ FINAL REPORT AP CHEST 5:56 P.M. ON EXAMINATION: Fluoroscopic spot film for IVC filter placement.,0
IMPRESSION: A single frontal fluoroscopic spot film centered over the mid lumbar spine is submitted for confirmation of an invasive procedure done under imaging guidance without a radiologist in attendance.,0
7:16 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: TRACHEO BRONCHIAL MALACIA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with s/p tracheal reconstruction REASON FOR THIS EXAMINATION: ?,1
interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 11:08 AM No evidence of pneumothorax.,0
"Worsening of the aeration of the left base that might represent atelectasis versus aspiration, followup on the subsequent studies is recommended.",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient after tracheal reconstruction.,1
Portable AP chest radiograph was compared to prior study obtained yesterday at 08:50 a.m.,0
The three right chest tubes are in unchanged positions.,0
There is no evidence of pneumomediastinum.,0
"Small amount of right chest wall air is noted, unchanged.",0
Left basal opacity is present that may represent atelectasis/aspiration and it is new compared to the prior study.,0
2:16 PM CHEST (PORTABLE AP) Clip # Reason: PICC line placed in right arm.,0
______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with Pancreatic CA....needs PICC for chemo.,0
REASON FOR THIS EXAMINATION: PICC line placed in right arm.,0
______________________________________________________________________________ FINAL REPORT HISTORY: PICC line placement.,0
Single view of the chest compared to a previous study dated .,0
The patient is slightly rotated to the right.,0
There is a newly inserted PICC line with the tip in the SVC right atrial junction.,0
The cardiomediastinal contours are otherwise unremarkable.,0
IMPRESSION: No acute pulmonary disease.,0
Appropriately positioned right-sided PICC line.,0
"11:25 AM CHEST (PORTABLE AP) Clip # Reason: ?interval change, PTX Admitting Diagnosis: CERVICAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with pelvic exenteration now s/p b/l thoracentesis REASON FOR THIS EXAMINATION: ?interval change, PTX ______________________________________________________________________________ FINAL REPORT AP CHEST, 11:30 a.m. on .",0
IMPRESSION: AP chest compared to and : Previous moderate-sized bilateral pleural effusion has been evacuated.,1
A multifocal consolidative abnormality in the lungs has improved substantially since .,0
"Tracheostomy tube, left subclavian central venous line, and nasogastric tube are in standard placements respectively.",0
"PORT Clip # Reason: please assess for pyelonephritis Admitting Diagnosis: LEG PAIN ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with metastatic bladder ca, with persistent hypotension, ?",0
pyelo REASON FOR THIS EXAMINATION: please assess for pyelonephritis ______________________________________________________________________________ FINAL REPORT RENAL PORTABLE ULTRASOUND.,0
INDICATION: 75-year-old male with metastatic bladder cancer presenting with persistent hypertension.,1
COMPARISONS: Ultrasound dated and CT exam dated .,0
FINDINGS: The examination is somewhat limited by the patient's body habitus.,0
A diffusely thinned cortex is again noted of the right kidney.,0
A left percutaneous nephrostomy tube terminates within the pelvis of the left kidney.,0
"There is no evidence of stones, masses, or hydronephrosis.",0
No perinephric fluid collections are identified.,0
"IMPRESSION: Within the limitations of this examination, no hydronephrosis or perinephric fluid collections are identified.",0
No significant interval change compared to CT and ultrasound examinations within the last week.,0
Findings were discussed over the telephone with Dr. following the examination by Dr. .,0
5:01 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for intrapulmonary process Admitting Diagnosis: BACTEREMIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with respiratory failure REASON FOR THIS EXAMINATION: evaluate for intrapulmonary process ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Respiratory failure.,1
FINDINGS: The endotracheal tube tip is 4.8 cm above the carina.,0
The NG tube and feeding tube tips are off the film.,0
Right IJ line tip is in the mid SVC.,0
There is bilateral lower lobe volume loss with bilateral small effusions similar in size compared to prior.,0
There is increased alveolar infiltrate and perihilar haze with increased patchy infiltrate in the right upper lobe as well.,0
While this likely represents pulmonary edema an underlying infectious infiltrate cannot be excluded.,0
12:19 PM CT CHEST W/O CONTRAST Clip # Reason: ?interstitial disease with ?,0
Admitting Diagnosis: RULE OUT LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with renal mass and mediastinal mass concerning for lymphoma vs. RCC mets.,0
REASON FOR THIS EXAMINATION: ?interstitial disease with ?,0
Patient to go to IR early afternoon for abdominal mass biopsy.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old man with renal mass and mediastinal mass concerning for lymphoma versus RCC mets.,0
Question interstitial disease with lymphoma.,0
COMPARISONS: Outside hospital CT from from .,0
TECHNIQUE: High-resolution CT imaging was obtained of the chest according to the HRCT protocol without the administration of intravenous contrast material.,0
FINDINGS: The thyroid gland is unremarkable.,0
There is no supraclavicular or axillary lymphadenopathy.,0
"There is extensive mediastinal and hilar lymphadenopathy, similar in extent to the prior study from only a few days earlier.",0
"For example, right anterior mediastinal node measuring 1.5 x 1.5 cm, previously measured 1.6 x 1.4 cm (4:11); 2.2 x 1.2 cm right precarinal node (4:20), previously measured 1.2 x 2.3 cm; more inferiorly, 2.5 x 1.9 cm node (4:23), previously was 2.5 x 2.0 cm.",0
Multiple nodes are seen in the prevascular station which also are similar in appearance to the prior exam.,0
Right paraesophageal nodal conglomerate is unchanged and measures 4.9 x 3.7 cm (4:33).,0
"Large right hilar nodal conglomerate, measures 4.9 cm in maximal dimension (4:28) compared to 4.8 cm.",0
Left hilar adenopathy measures 4.1 cm (4:29) compared to 4.3 cm.,0
There is resultant compression of the right main stem bronchus (4:27) and bronchus intermedius as well as the right lower lobe bronchus.,0
The heart has a rounded appearance with a small pericardial effusion.,0
This concerning for pericardial constriction from underlying process involving the lungs and mediastinum.,0
"LUNGS: In the right upper lobe there are multiple foci of consolidation, multiple nodules, ground-glass opacities and interlobular septal thickening.",0
This pattern is also seen in the right lower lobe but is less extensive.,0
More frank consolidation with air bronchograms are present in the right middle lobe and left lower lobe.,0
Within the left upper lobe there are innumerable predominantly sub-centimeter discrete rounded nodules.,0
"There are bilateral pleural effusions greater on the right, similar in extent compared to the prior study.",1
"These findings are suggestive of primary lung malignancy, lymphoma, possible infection such as tuberculosis and less likely vasculitis.",0
This study is limited for evaluation of subdiaphragmatic structures but (Over) 12:19 PM CT CHEST W/O CONTRAST Clip # Reason: ?interstitial disease with ?,0
"Admitting Diagnosis: RULE OUT LYMPHOMA ______________________________________________________________________________ FINAL REPORT (Cont) demonstrates extensive retroperitoneal lymphadenopathy, better assessed on the recent outside hospital scan with IV contrast, however, the overall extent appears unchanged.",0
"For example, right retroperitoneal node measuring 1.7 x 2.8 cm (4:63), previously measured 1.4 x 2.7 cm on the prior study; epigastric node measuring 1.8 cm, is similar to the prior study (4:57); left paraaortic nodal conglomerate measures 3.2 x 2.3 cm compared to 3.2 x 2.1 cm on the prior study.",0
OSSEOUS STRUCTURES: There are no suspicious bony lesions.,0
"Multifocal process within the lungs with frank consolidation in the right middle and left lower lobes, severe multifocal opacities with nodules, centrilobular septal thickening in the right upper lobe and less extensive in the right lower lobe with multiple nodules in the left upper lobe.",0
"Extensive mediastinal and hilar lymphadenopathy, unchanged from the prior exam.",0
"Possible etiologies include primary lung cancer, lymphoma, infection such as TB and less likely vasculitis.",0
"Associated compression of the right main stem bronchus, bronchus intermedius and right lower lobe bronchus from lymphadenopathy.",0
"Rounded appearance to the heart, with small pericardial effusion suggesting pericardial constriction from this underlying process.",0
"Bilateral pleural effusions, worse on the right, unchanged from the prior exam.",1
"Extensive retroperitoneal and paraaortic lymphadenopathy, similar in appearance to the prior study.",0
These findings were discussed in person by Dr. with the primary team at approximately 3 p.m. on the day of the study.,0
"5:36 PM CHEST (PA & LAT) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with history of renal cell carcinoma with 2 known lung mets, now presenting with dizziness, dull headache.",0
"REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: History of renal cell carcinoma with lung mets, now presenting with dizziness and headache, rule out infiltrate.",0
No comparison study is available.,0
"CHEST FRONTAL AND LATERAL VIEWS: An area of soft tissue density is noted superior to the right side of the aortic arch projecting over the trachea, which could represent focal lymphadenopathy.",0
The cardiac and mediastinal contours appear unremarkable.,0
Pulmonary vascularity is within normal limits.,0
There is no parenchymal consolidation.,0
The lung mets mentioned in the history are not well visualized on this chest radiograph.,0
A focal soft tissue density projecting over the trachea may represent lymphadenopathy.,0
Recommend comparison with outside study for confirmation.,0
6:47 PM HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.,0
; KNEE (2 VIEWS) RIGHT Clip # LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT Reason: HIP FX Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX ______________________________________________________________________________ FINAL REPORT INDICATION: Hip fracture.,1
RIGHT HIP/LEG INTRAOPERATIVE RADIOGRAPHS: Five intraoperative radiographs were obtained.,0
Three femoral head fixation screws are present within the proximal right femur.,0
No fracture line is visible on these radiographs.,0
Additional films demonstrate screw fixation of the patella.,0
The prior seen fracture on films has been reduced.,0
"Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with AVR REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
Pt will be in CSRU in 90 mins.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: .",0
FINDINGS: There has been interval median sternotomy and cardiovascular surgery.,0
"Endotracheal tube tip terminates about 4 cm above the carina, Swan-Ganz catheter extends at least into the distal right pulmonary artery (tip obscured by dense overlying sternal wires), and a nasogastric tube courses below the diaphragm.",0
Right chest tube is in place with no visceral pleural line detected.,0
"However, right hemidiaphragm appears unusually sharp, and this could potentially represent a small basilar pneumothorax.",0
Interval widening of cardiomediastinal contours is likely in part due to accentuation by patient rotation and portable supine positioning technique.,0
Attention to this on a non-rotated radiograph would be helpful.,0
Scattered areas of patchy and linear atelectasis are present in the left perihilar and basilar regions.,0
8:41 PM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: 18 y/o with lemiere's disease r/o mycotic anuerysm Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with ij septic thrombosis presents with seizure this evening.,0
Is intubated and sedated but has asymmetric clonus left greater than right.,0
REASON FOR THIS EXAMINATION: 18 y/o with lemiere's disease r/o mycotic anuerysm ______________________________________________________________________________ FINAL REPORT INDICATION: Internal jugular septic thrombosis and seizures.,0
Multiplanar T1 and T2 weighted images of the brain in addition to diffusion images were performed.,0
3D time of flight MRA of the intracranial circumscribed was obtained.,0
Comparison is made to the prior exam of .,0
There are no acute territorial infarcts seen within the brain on diffusion images.,0
The ventricular system is normal and symmetric.,0
"There is no midline shift, mass, mass effect, or hemorrhage.",0
Normal signal flow voids are present within the intracranial portions of the carotid and basilar arteries.,0
There is T2 hyperintensity within the mastoid sinuses bilaterally suggestive of either inflammatory or infectious process.,0
"Air fluid levels are noted within the maxillary, sphenoid, and ethmoid sinuses.",0
MRA of the intracranial circulation reveals patent distal vertebral basilar circulation.,0
There is no significant intracranial vascular stenosis or occlusions.,0
The cavernous portion of the internal carotid arteries are patent bilaterally.,0
No vascular malformations are seen.,0
There are no obvious aneurysms.,0
The examination is insensitive to detect tiny aneurysms less than 3 mm in diameter.,0
IMPRESSION: Negative MRA of the intracranial circulation without narrowing of the cavernous ICA.,1
There are no visible aneurysms although the examination is insensitive to detect very small tiny mycotic aneurysms less than 3 mm in diameter.,0
MRI of the brain reveals no acute territorial infarcts.,0
There is no mass effect or hemorrhage.,0
Diffuse paranasal sinus disease with multiple air fluid levels in addition to bilateral mastoiditis unchanged from the previous exam.,0
Clinical correlation and follow up are recommended.,0
"3:22 AM CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # Reason: eval for RP bleed.",0
"Admitting Diagnosis: SUPRATHERAPEUTIC INR Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with history of cerebal palsey, mild mental retardation, atrial flutter s/p cardioversion, PEs in , on coumadin who presented with a supertherpauetic INR now with 8 pt Hct drop.",1
REASON FOR THIS EXAMINATION: eval for RP bleed.,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: JBRe SAT 11:09 AM Large left rectus sheath hematoma which extends into the left extraperitoneal pelvic space.,0
"The rectus sheath component measures about 14 x 7 x 12 cm, the extraperitoneal pelvic component measures about 17 x 11 x 17 cm.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old with jaw pain.,0
TECHNIQUE: Contiguous MDCT images through the abdomen and pelvis were performed without intravenous contrast.,0
COMPARISON: CT of the torso from .,0
FINDINGS: CT OF THE ABDOMEN: There are mild bibasilar atelectasis.,0
There are no focal hepatic lesions.,0
The gallbladder is slightly distended but there is no evidence of cholecystitis.,0
The pancreas and spleen are normal.,0
"Multiple bilateral nonobstructive up to 14 mm (in the right mid pole) renal stones are seen, similar to .",0
The adrenal glands are prominent bilaterally but no evidence of focal lesions.,0
"There are scattered, non-pathologically enlarged retroperitoneal lymph nodes.",0
There are mild atherosclerotic calcifications of the abdominal aorta.,0
There is no free intraperitoneal fluid.,0
"The esophagus, stomach, small and large bowel are normal.",0
There is a large left rectus sheath hematoma which extends into the left extraperitoneal pelvic space.,0
The hematoma has a fluid-fluid level consistent with an acute on chronic component.,1
"(Over) 3:22 AM CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # Reason: eval for RP bleed.",0
Admitting Diagnosis: SUPRATHERAPEUTIC INR Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) The urinary bladder is displaced posteriorly.,0
"Additionally, there is subcutaneous stranding at the left flank overlying the left iliac crest, also representing a small amount of hematoma.",1
There is no evidence of active extravasation within the hematoma.,0
BONES: There are no suspicious lytic or sclerotic bony lesions.,0
IMPRESSION: Large left rectus sheath and left extraperitoneal acute on chronic hematoma as described above.,1
Discussed with Dr. at the time of image acquisition at 4 am by Dr. .,0
"7:24 AM CHEST (PORTABLE AP) Clip # Reason: eval for presence of RLL collapse Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION\LEFT HEART CATH ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with pneumonia, cavitary lesions on CT, COPD, has RLL collapse on today's CXR.",0
"REASON FOR THIS EXAMINATION: eval for presence of RLL collapse ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Right lower lobe collapse, pneumonia, cavitary lesion on CT. COPD.",0
Evaluation for right lower lobe situation.,0
"FINDINGS: As compared to the previous examination, the course of the right PICC line is unchanged, the line appears to have been retracted by approximately 2 cm.",0
Unchanged appearance at the right lung base.,0
"On the left, however, the image is improving, with increased transparency of the left lower lung.",0
Unchanged hilar and mediastinal contours.,0
"10:15 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for progression of infectious process Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with left sided decortication - h/o pleural effusion, pneumonia with fever REASON FOR THIS EXAMINATION: eval for progression of infectious process ______________________________________________________________________________ FINAL REPORT AP CHEST, 8:16 P.M., HISTORY: Left decortication.",1
IMPRESSION: AP chest compared to through 7:42 a.m. on : Lung volumes are slightly lower and mild interstitial pulmonary edema has worsened.,0
The extent of residual left pleural thickening and small effusion is stable.,0
Small right pleural effusion and pleural thickening is unchanged.,0
ET tube is in standard placement and a nasogastric tube ends in the upper stomach.,0
Right subclavian line passes at least as far as the lower right atrium and perhaps to the inferior vena cava.,0
Left subclavian line probably cannulates the origin of the azygous vein.,0
Findings were discussed by telephone with the house officer caring for this patient prior to dictation.,0
3:40 PM PORTABLE ABDOMEN Clip # Reason: eval for ileus Admitting Diagnosis: CORONARY ARTERY DISEASE; ACUTE CORONARY SYNDROME\CORONARY STENT ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man s/p cabg with postop ileus/ increasing abdominal distention REASON FOR THIS EXAMINATION: eval for ileus ______________________________________________________________________________ FINAL REPORT HISTORY: 86-year-old male status post CABG with postoperative ileus and increasing abdominal distention.,1
COMPARISON: Comparison is made to abdominal radiograph from .,0
FINDINGS: Supine and decubitus images of the abdomen demonstrate dilated small and large bowel with multiple air-fluid levels consistent with ileus.,0
This is not significantly changed since previous radiographs.,0
There is no pneumatosis or free gas.,0
IMPRESSION: Dilated loops of small and large bowel consistent with ileus that is not significantly changed since prior imaging.,0
"12:20 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: NEUTROPENIA, AND FUO Admitting Diagnosis: FEVER AND NEUTROPENIA ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with neutropenia and fever of unknown origin.",0
"REASON FOR THIS EXAMINATION: evaluate for infection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Neutropenia, fever of unknown origin.",0
TECHNIQUE: Noncontrast CT of the paranasal sinuses was obtained with axial imaging and reconstructed coronal imaging.,0
Comparison is made to the examination performed 11 days ago.,0
"FINDINGS: A moderate amount of opacification within the ethmoid air cells, as well as mild mural opacification within the maxillary sinuses and minimal opacification of the right air cell of the sphenoid sinus appears essentially unchanged.",0
"There is some improvement in the opacification/soft tissue swelling within the left nasal cavity, and extending into the nasopharyngeal tissues.",0
No discrete air-fluid levels are seen.,0
The orbits and the remainder of the imaged soft tissues appear within normal limits.,0
No significant change in the paranasal sinus mucosal thickening.,0
No evidence of air-fluid levels or other suggestion of acute sinusitis.,1
Slight improvement in the soft tissue fullness within the left-sided nasal turbinates and improvement in the pharyngeal soft tissue swelling.,0
"3:02 PM CHEST (PORTABLE AP) Clip # Reason: s/p extubation & NGT placement Admitting Diagnosis: NAUSEA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with hypertensive emergency, seizure and severe vasculopathy REASON FOR THIS EXAMINATION: s/p extubation & NGT placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Hypertensive emergency.",0
"The NG tube tip is in the stomach, but the sidehole of the NG tube is at the gastroesophageal junction and should be advanced for 10-15 cm.",0
The heart size is moderately enlarged but unchanged.,0
Tortuous aorta is again noted.,0
"The lungs are clear, with no pleural effusion or pneumothorax.",0
12:57 PM CHEST (PORTABLE AP) Clip # Reason: please eval for interval improvement.,0
"Admitting Diagnosis: SEPSIS;PNEUMONIA;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with mult med prob, resp distress, s/p intubation.",1
REASON FOR THIS EXAMINATION: please eval for interval improvement.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: CLINICAL INDICATION: Respiratory distress.,0
An endotracheal tube remains in place and is approximately 2 cm above the carina.,0
IV catheter remains in satisfactory position.,0
There is mild perivascular haziness and pulmonary vascular engorgement.,0
Overall the degree of perihilar haziness is slightly improved.,0
Bilateral pleural effusions and adjacent retrocardiac opacities are again demonstrated.,0
"IMPRESSION: 1) Relatively low position of endotracheal tube, terminating 2 cm above the carina.",0
2) Resolving congestive heart failure with otherwise no significant change.,0
8:15 AM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: HEP C NEWLY DIAGNOSED CHECK FOR HEPATOMA ASCITES AND CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with new HCV dx.,0
"REASON FOR THIS EXAMINATION: eval for hepatoma, ascites, cirrhosis ______________________________________________________________________________ FINAL REPORT ABDOMINAL ULTRASOUND: INDICATION: Hepatitis C virus.",1
FINDINGS: The hepatic parenchyma is coarsened and nodular compatible with cirrhosis.,1
A few tiny cysts are visualized in segment 4 measuring up to 7 mm.,0
"A tiny echogenic focus is seen in the right hepatic lobe, probably representing a granuloma.",0
No solid liver lesions are identified.,0
The main portal vein is patent with appropriate directional flow.,0
"There is no ascites, evidence of varices or splenomegaly.",0
The gallbladder is normal in appearance.,0
The common duct is not dilated.,0
The visualized pancreas is unremarkable.,0
The kidneys are normal in size and architecture with the right kidney measuring 11.7 cm in length and the left kidney measuring 11.5 cm in length.,0
"There is no hydronephrosis, renal mass or calculus.",0
IMPRESSION: Cirrhotic liver with no complications of chronic liver disease.,0
"7:00 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o new PE Admitting Diagnosis: ESOPHAGEAL CA/SDA Field of view: 40 ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with history of PE in januray- off lovenox for esophagectomy POD#7 REASON FOR THIS EXAMINATION: r/o new PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of pulmonary embolus.",0
Status post esophagectomy post- op day #7.,0
TECHNIQUE: Contrast-enhanced MDCT of the chest displayed in multiplanar collimation.,0
CTA CHEST: Patient is status post esophagectomy with stomach pull-through procedure.,0
There are multiple staples and sutures along the surgical sites.,0
There is a small retained fluid within the mediastinal stomach.,0
There is a small outpouching in the proximal mediastinum of the stomach (5:71) that appears contiguous with the stomach.,0
There is no good evidence for leak.,0
The heart and great vessels in the mediastinum are within normal limits though note is made of dense coronary artery calcifications.,0
The pulmonary arteries opacify normally without filling defects.,0
The evaluation for small subsegmental pulmonary emboli is limited secondary to contrast bolus timing.,0
There is no pathologic adenopathy.,0
There is a small loculated right pleural effusion containing multiple foci of air.,0
A larger but yet still very small collection of pleural air is noted along the right anterior base.,0
There is a small left pleural effusion that does not appear loculated.,0
There is a small amount of residual free intraperitoneal air along the anterior midline associated with 6.6-cm fluid collection that likely represents post-operative seroma.,0
There is no rim enhancement.,0
"There is confluent ossification along the left side of the thoracic vertebral body with relative preservation of the intervertebral discs, consistent with DISH.",0
There is a Port-A-Cath on the right side with the tip terminating in the distal SVC.,0
There are surgical staples overlying the neck and abdomen.,0
Small layering left pleural effusion.,0
No evidence for pulmonary embolism.,0
"(Over) 7:00 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o new PE Admitting Diagnosis: ESOPHAGEAL CA/SDA Field of view: 40 ______________________________________________________________________________ FINAL REPORT (Cont) 4.",0
"Free intraperitoneal air and fluid, all likely post-operative, though evaluation for a perforated viscus is thus suboptimal.",0
"If there is clinical concern for perforation, Gastrografin contrast can be orally administered and the patient can be rescanned to evaluate for contrast extravasation.",0
"8:38 AM CHEST (PA & LAT) Clip # Reason: assess pneumonia Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man s/p liver transplant with LLL pneumonia on levaquin REASON FOR THIS EXAMINATION: assess pneumonia ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 12:09 PM There is continuous increase in consolidation in the right lower lobe medially, left lower lobe consolidation with adjacent moderate pleural effusion is unchanged.",1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: S/P liver transplant with left lower lobe pneumonia in followup.,1
There has been interval worsening of right lower lobe medial consolidation.,0
Left lower lobe consolidation with moderate left pleural effusions is unchanged.,0
Cardiomediastinal contours are unchanged obscured by parenchymal abnormalities.,0
There is mild pulmonary congestion unchanged from prior.,0
Height: (in) 69 Weight (lb): 165 BSA (m2): 1.91 m2 Status: Inpatient Date/Time: at 10:12 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
No spontaneous echo contrast in the body of the RA.,0
[Intrinsic RV systolic function likely more depressed given the severity of TR].,0
"Severe (4+) MR. to the eccentric MR jet, its severity may be underestimated (Coanda effect).",0
Tricuspid leaflets do not fully coapt.,0
Conclusions: Prebypass The left atrium is markedly dilated.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 45-50%).,0
Right ventricular chamber size is normal with borderline normal free wall function.,0
There is moderate/severe posterior leaflet mitral valve prolapse.,1
"An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen.",0
The tricuspid valve leaflets fail to fully coapt.,1
Postbypass The patient is on infusions of epinephrine and nitroglycerin and is V-paced.,0
There is a new bioprosthetic valve which is well-seated in the mitral position.,1
There is no evidence of regurgitation or stenosis (peak gradient 4 mmHg with a CO of 3.8 L/min).,0
There is a new tricuspid valve annuloplasty ring with no evidence of stenosis of regurgitation.,1
Overall left ventricular function is now moderately depressed (LVEF = 35-40%) with paradoxical septal motion from V-pacing.,0
The thoracic aorta is intact.,0
10:34 PM CHEST (SINGLE VIEW) PORT; CHEST FLUORO WITHOUT RADIOLOGIST Clip # Reason: placement of temporary transvenous pacing wire Admitting Diagnosis: MITRAL VALVE INSUFFIENCY\MITRAL VALVE REPLACEMENT W/ MAZE /SDA ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with REASON FOR THIS EXAMINATION: placement of temporary transvenous pacing wire ______________________________________________________________________________ FINAL REPORT INDICATION: 38-year-old man with new temporary wire via right IJ.,1
"A single spot fluoroscopic image obtained without a radiologist's input demonstrates a magnified view of the mid thorax, demonstrating a catheter that extends into the right ventricle.",0
Median sternotomy wires and mitral valve prosthesis are also seen.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: ICD Pocket Infection Major Surgical or Invasive Procedure: Device and Lead Removal History of Present Illness: Mr. is a 77 year-old male with BiV ICD (placed in the setting of newly diagnosed CHF and h/o LBBB), paroxysmal AF on coumadin, and CLL who is a direct admit with ICD pocket infection.",1
The patient underwent a generator change in after which he developed cellulitis and a hematoma over the generator site.,1
These resovled and the patient did well until the day prior to admission when he noted pus draining from the ICD pocket and erethyma around the site.,0
Saw his outpatient cardiologist who started cephalexin (3 doses to date) and recommended direct admission.,0
He denies any pain over the site.,0
No subjective fevers or other systemic symptoms.,0
Portal of entry is believed to be small opening in the skin over the defibrilator.,0
On arrival to the patient is in stable condition and without any symptoms.,0
Initial vitals 98.4 114/78 78 20 96%RA.,0
Past Medical History: - CHF diagnosed in - CAD with PCI in - H/o LBBB - CLL diagnosed in ; Tx with rituxan and steroids for 4 months - Shingles on head and left eye - detached retina repair - hernia repair - intraocular lens implant - removal of left cheek basal cell carcinoma - laminectomy and discectomy on left Social History: Lives alone in .,0
4 children and 8 grandchildren.,0
80 pack year history but quit 20 years ago.,0
Family History: Mother died of Leukemia at 52; father died of CHF at 75.,0
"Physical Exam: On Admission: Vitals- 98.4 114/78 78 20 96%RA General- Patient sitting up in chair in NAD HEENT- PERRLA, EOMI, anicteric, MMM, OP clear Neck- Supple, No JVP CV- RRR, S1 and S2, no m/r/g Lung- CTAB, no w/r/r Abdomen- Soft, NT/ND, BSx4 Extremeties- No gross deformity or edema Neuro- Awake, alert and oriented, CN II-XII intact, strength 5/5 throughout Pertinent Results: On Admission: 11:15AM BLOOD WBC-52.7* RBC-4.66 Hgb-13.6* Hct-41.6 MCV-89 MCH-29.2 MCHC-32.8 RDW-14.4 Plt Ct-96* 01:55PM BLOOD Neuts-3* Bands-0 Lymphs-89* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-5* 11:15AM BLOOD PT-22.1* PTT-46.8* INR(PT)-2.0* 11:15AM BLOOD Glucose-192* UreaN-25* Creat-1.0 Na-141 K-3.9 Cl-103 HCO3-27 AnGap-15 11:15AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1 Studies: .",0
CXR - Transvenous right atrial and left ventricular pacer leads and right ventricular pacer defibrillator leads follow their expected course from the left axillary pacemaker.,0
"The heart is mildly enlarged, but there is no pulmonary vascular congestion, edema, or pleural effusion.",0
Brief Hospital Course: Mr. is a 77 year-old man who was admitted with a BiV ICD pocket infection.,0
ICD pocket infection - The patient noted pus draining from his ICD pocket on the morning prior to admission.,1
He went to his out-patient cardiologist who diagnosed and ICD pocket infection and started the patient on cephalexin and recommended a direct admission to .,1
"On arrival to on , the patient was noted to have pus draining from his ICD pocket and an area of skin that had been eroded by the device.",1
ID was consulted and blood/wound cultures were taken.,0
"On , the patient was started on vancomycina and cefepime.",0
The patient went to the OR for removal of ICD and leads.,0
"Intraoperative TEE showed possible small pericardial effusion, which on later TTE was neglible.",0
The patient remained intubated the day of procedure and was transferred to CCU.,1
He was extubated on the morning of POD #1.,0
The patient was started on nafcillin on once cultures grew MSSA.,0
4 days later the patient developed and nafcillin was stopped due concerns for AIN.,1
IV Cefazolin was started on and will be complete at home on .,0
He will be sent home with home with a VNA to monitor recovery from the pocket wound and with infusion services for cefazolin IV 2g q8.,0
The was resolving prior to discharge with the creatinine near the patient's baseline.,0
Atrial Fibrillation - The patient has a history of paroxysmal afib for which he is on coumadin.,1
His INR on arrival here was therepeutic at 2.0 and the patient was in sinus rhythym.,0
The coumadin as held pending intervention on .,0
"Given 5mg vitamin K. We helding his ASA and coumadin until five days postoperatively, then restarted prior to discharge.",0
The patient will need to follow up with coumadin clinic for monitoring.,0
CHF - The patient carries a history of CHF for which he received the ICD in .,0
"On arrival at , he appeared euvolemic.",0
"His carvedilol, losartan, statin, and furosemide were continued at his home dosing.",0
"The patient's ASA was held until POD#5, then restarted.",0
CLL/thrombocytopenia - Mr. carries a history of CLL for which he has received rituxan and steroids in the past.,0
During prior operations he has had significant bleeding and required platelet transfusions.,1
Hematology was consulted and he received 2 units of platelets perioperatively.,0
"Medications on Admission: Carvedilol 25mg'' Simvastatin 20mg' Warfarin 5mg Sun-Thurs, 2.5mg Fri-Sat Losartan 50mg' Furosemide 20mg Mon/Wed/Fri Cosopt eye drops 1 drop in left eye Alphagan 0.1% drops 1 drop in left eye Lotemax 0.5% drops 1 drop in left eye Lorazepam 1mg' QHS Lutein 10mg'' Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR).",0
2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic (2 times a day).,0
3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Anxiety.,0
Lotemax 0.5 % Ointment Sig: One (1) Ophthalmic once a day.,0
Cosopt 2-0.5 % Drops Sig: One (1) Ophthalmic (2 times a day).,0
6. cefazolin 1 gram Recon Soln Sig: Two (2) 2g Intravenous every eight (8) hours for 9 days.,0
"Outpatient Lab Work Please obtain a CBC, electrolyte, creatinine and PT/PTT/INR on Thursday, .",0
Please fax results to (attention to Dr. 8. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.,0
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM.,0
10. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: ICD Pocket Infection Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: It was a pleasure taking care of you at !,0
You were admitted due to infection of the pocket holding your ICD.,0
In the hospital you were treated with antibiotics and the device was removed in the operating room.,0
"You tolerated the procedure well, and we continued your antibiotics after the device was taken out.",1
See below for changes to your home medication regimen: Continue to take cefazolin See below for instructions regarding follow-up care: Followup Instructions: Please set up a follow up appointment with Dr. () on Tuesday .,0
Please set up a follow up appointment with Dr. () in two weeks,0
", 7F 11:02 AM CHEST (PORTABLE AP) Clip # Reason: Eval for infiltrates Admitting Diagnosis: LYMPHOMA/SPINAL CORD COMPRESSION ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with lymphoma, s/p chemo, recent confusion, now with new fever spike REASON FOR THIS EXAMINATION: Eval for infiltrates ______________________________________________________________________________ PFI REPORT Right Port-A-Cath is removed.",0
Left PICC ends at least in the upper SVC.,0
"Subtle multifocal opacity persists, increased.",0
"5:19 AM CT HEAD W/O CONTRAST; CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: s/p multiple stab wounds, s/p multiple stab wounds, assess f Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with s/p multiple stab wounds REASON FOR THIS EXAMINATION: s/p multiple stab wounds ______________________________________________________________________________ FINAL REPORT HISTORY: Multiple stab wounds, unresponsive.",0
TECHNIQUE: CT of the head with no IV contrast followed by CT of the neck with IV contrast.,0
80 cc Optiray administered IV for this trauma patient.,0
CT HEAD W/O IV CONTRAST: There is no evidence of acute intracranial hemorrhage or infarcts.,1
There is no abnormal intra or extra-axial collection.,0
Mild mineralization in the basal ganglia region is demonstrated.,0
"There is mass effect, shift of normally midline structures or hydrocephalus.",0
Bone windows reveal no evidence of acute fracture.,0
Air fluid levels are demonstrated in the left maxillary sinus and nasal pharyngeus most likely related to intubation.,0
There is also mucosal thickening of the right maxillary sinus.,0
CT NECK WITH IV CONTRAST: Imaged portion of the upper chest demonstrates a right main bronchus intubation and left pulmonary post traumatic abnormality.,1
Please see CT torso performed same day for detailed report.,0
Multiple foci of subcutaneous air pockets are demonstrated in the left anterior and mid cervical soft tissues.,0
"These correspond to the site of stab wounds, or could be secondary to gas tracking superiorly from the left pneumothrax.",0
Both carotid arteries appear intact.,0
An air collection is seen in close vicinity to the left internal jugular vein.,0
The left internal jugular vein appears intact.,0
Bone windows reveal no significant abnormality.,0
Multiple sites of soft tissue air in the anterior neck corresponding to site of stab wounds.,0
The carotid artery and jugular veins appear intact.,0
Post traumatic changes in the left lung.,0
See CT torso for detailed report.,0
11:55 AM CHEST (PRE-OP PA & LAT) Clip # Reason: PRE-OP FOR MANDIBLE Admitting Diagnosis: MANDIBULAR FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with pre-op for mandible fx surgery REASON FOR THIS EXAMINATION: pre-op ______________________________________________________________________________ FINAL REPORT INDICATION: Preop for mandible surgery.,1
PA AND LATERAL CHEST RADIOGRAPHS: The aorta is tortuous and there is a left ventricular prominence to the cardiac silhouette.,0
The osseous structures appear unremarkable.,0
12:33 PM CHEST (PORTABLE AP) Clip # Reason: any interval change?,0
Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with SOB REASON FOR THIS EXAMINATION: any interval change?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath, question interval change.",0
FRONTAL CHEST RADIOGRAPH Mild vascular congestion has increased.,0
Small-to-moderate size left-sided pleural effusion with associated atelectasis has also increase.,1
There is increasing opacity at the right lung base likely representing effusion and atelectasis although consolidation cannot be excluded.,0
"3:18 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with L loculated pleural effusions, intubated REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT TECHNIQUE: Single supine portable radiograph of chest.",1
Comparisons were made with prior chest radiographs through .,0
"Concurrently, a CT from was also reviewed.",0
FINDINGS: Endotracheal tube ends approximately 4 cm above the carina and is appropriate.,0
Left central line ends at lower SVC.,0
"Orogastric tube is seen to course below the diaphragm; however, the distal end is beyond the view of radiograph.",0
Bilateral lungs are very low with bibasal atelectasis and layering effusions bilaterally which is no different in appearance compared to radiograph.,0
"Large, extraparenchymal opacity in left upper lung around the tip of ventricular shunt catheter is unchanged and is better evaluated on the recent chest CT dated .",0
Appearance of cardiomediastinal silhouette is unchanged.,0
"Unchanged and persistent very low lung volumes, with bilateral layering pleural effusions and atelectasis.",1
"Large, left apical opacity representing a loculated fluid collection around the pleural tip of ventricular shunt and better characterized on the CT dated is similar.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Remicade / Prednisone / Vancomycin Attending: Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, drainage of intraperitoneal intraloop abscess, and small bowel resection.",1
"History of Present Illness: Ms. is a 39-year-old female with Crohn's disease which was first diagnosed 3 years ago, and she reports that it has never been fully controlled.",0
"She awoke yesterday morning with abdominal pain and subsequently presented to her local ED (, ) for evaluation.",0
"There, a CT scan of the abdomen revealed evidence of a likely bowel microperforation, and she was transferred to for further care.",0
"She has been on TPN since , and has been off of all medications for Crohn's disease for approximately a month (has taken steroids, pentasa, and methotrexate in the past).",0
"She denies having been on steroids for ""months"".",0
She had been feeling well until earlier yesterday.,0
"Her abdominal pain is diffuse and non-radiating, not improved by anything, and felt worse while going over bumps during the ambulance transfer.",0
"She had nausea and vomiting early yesterday afternoon, but currently denies either of those symptoms.",0
"Last bowel movement was yesterday, and she cannot recall if she has passed flatus recently.",0
Past Medical History: Past Medical History: 1.,0
Severe Crohn's disease of small bowel/colon (dx ) 2.,0
Iron deficiency anemia- s/p IV Fe infusions 4.,0
"GERD Past Surgical History: Denies Social History: Married, lives with husband and 2 children.",0
"No alcohol, tobacco, or IVDA.",0
Family History: Daughter with VSD.,0
Mother with history of breast CA.,0
Two younger brothers are healthy.,0
"Physical Exam: Physical exam on Admission: T 96.8 HR 130 BP 127/81 RR 16 SaO2 97% RA Alert & oriented x 3, visibly uncomfortable Dry mucous membranes Regular rhythm, tachycardic Lungs are clear bilaterally Abdomen is firm, distended, and diffusely tender with guarding.",0
There is no rebound tenderness and no discomfort with movement.,0
There is a reducible umbilical hernia.,0
"Rectal exam is deferred Extremities are warm, palpable pedal pulses, no edema.",0
Cranial nerves II-XII intact grossly.,0
"Pertinent Results: CT scan of abdomen from OSH: revealed evidence of a likely bowel microperforation Pathology Examination Name Birthdate Age Sex Pathology # , 39 Female Report to: DR. .",0
Gross Description by: DR. /cofc SPECIMEN SUBMITTED: small bowel.,0
"Procedure date Tissue received Report Date Diagnosed by DR. /axg Previous biopsies: SIGMOID COLON, RECTUM, PROXIMAL (JEJUNUM) & DUODENUM PART.",0
Consult slides referred to Dr. .,0
"DIAGNOSIS: Small bowel, segmental resection: 1.",0
"Small intestine with chronic active enteritis demonstrating: a. Foci of ulceration, focally transmural necrosis and associated perforation with abscess formation and extensive serositis.",1
"b. Focally prominent lymphoid aggregates, transmural.",0
c. No granulomas or dysplasia seen.,0
d. Resection margins free of active enteritis.,0
"Uninvolved mucosa with focally, mildly increased intraepithelial lymphocytes; see note.",0
"Note: The finding of increased intraepithelial lymphocytes, while non-specific, raises the possibility of concomitant celiac disease, a drug effect, or other immune-mediated injury.",0
Correlation with clinical and serological findings is recommended.,0
"Gross: The specimen is received fresh labeled with the patient's name "", "" and additionally labeled ""small bowel"".",0
The specimen consists of a portion of unoriented segment of bowel that measures 36 cm in length x 4.5 cm in diameter.,0
The specimen is stapled at both ends.,0
One stapled margin measures 3 cm and the other measures 4 cm.,0
Located 11 cm away from the 4 cm stapled margin is a single suture.,0
This area is inked black on the serosal surface.,0
The remainder of the serosa is hemorrhagic and granular.,0
The specimen is opened to reveal a lumen filled with fluid and fecal matter.,0
"The mucosa is cobblestoned, focally ulcerated with two separate ulcers, and hemorrhagic at the area of the stitch.",0
The ulcerated areas measure up to 4.5 cm.,0
"The specimen is represented as follows: A=4 cm staple margin, B=3 cm staple margin, C=representative section of ulcerated mucosa, D-E=representative sections of grossly unremarkable mucosa, F=representative section of possible lymph node and mesentery.",0
03:49AM WBC-8.0# RBC-4.98 HGB-13.6# HCT-42.5# MCV-85 MCH-27.3 MCHC-32.1 RDW-16.3* 03:49AM NEUTS-83* BANDS-13* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 03:49AM GLUCOSE-178* UREA N-16 CREAT-0.7 SODIUM-138 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13 07:26AM LACTATE-4.8* 04:02AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.2* Hct-24.4* MCV-88 MCH-29.2 MCHC-33.4 RDW-15.2 Plt Ct-481* 04:38AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-141 K-4.6 Cl-108 HCO3-24 AnGap-14 04:38AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0 04:02AM BLOOD calTIBC-191* Ferritn-210* TRF-147* 02:16PM BLOOD Lactate-1.2 04:02AM BLOOD Albumin-2.5* Iron-15* Brief Hospital Course: 39-year-old female with severe Crohn's disease and now with what appears to be a contained microperforation in the area of the distal ileum.,0
"She was afebrile and hemodynamically stable, though with persistent tachycardia even after resuscitation.",0
She had a normal WBC but with a bandemia.,0
"Due to the clinical picture it was decided to take her to the OR for exploratory laparotomy, drainage of intra loop abscess and small bowel resection.",1
Neuro: Immediately post-op she was on a propofol gtt and a fentanyl gtt which was switched to a Dilaudid PCA after she was extubated on POD 1.,0
When she was tolerating clear liquid she was switched to PO Dilaudid.,0
Her pain is well controlled on PO Dilaudid.,0
She also has anxiety at baseline and was given Ativan prn.,0
Her PCP is going to work on a regimen as an outpatient.,0
Cardiovascular: Patient has been tachycardiac since admission.,0
HR ranged up to 140s while she was in the ICU immediately post-op.,0
She was always hemodynamically stable and tachycardia did not improve even with PRBCs.,0
Talking to her PCP she is always tachycardiac in the office and it has never been treated previously so her baseline is HR of 100-110.,0
Her heart rate now ranges at her baseline.,0
Respiratory: Immediately after the OR she was intubated but on POD 1 she was extubated and has been weaned off the oxygen.,0
GI: She was continued on TPN during this hospitalization.,0
She had an NGT and was NPO until POD 8.,0
On POD 8 her NGT was removed when she started having flatus and she was started on sips.,0
POD 9 she was started on clear liquid diet which she tolerated without nausea or vomiting.,0
On POD 9 she started having numerous bowel movements which were sent for c.diff.,0
C.diff was negative times two.,0
On POD 10 she was started on low residue diet.,0
She is in control of her diet and her diarrhea has since improved to her baseline.,0
she is voiding on her own.,0
Heme: immediately post-op her HCT was 19.,0
She received a total of 4 units of PRBCS during this hospitalization and her HCT has been stable at approximately 25.,0
ID: since she had perforation of her abdomen she was started on broad spectrum antibiotics.,0
She spiked a temp on POD 9 and cultures were sent which at this time are preliminary negative.,0
She will go home on her Cipro and Flagyl.,0
Her temp max for 24 hours was 100.0 at time of discharge.,0
Endo: she is on a regular insulin sliding scale for her TPN.,0
"9. prophylaxis: heparin subcutaneous, venodyne boots, and she is ambulating.",0
"Medications on Admission: ALENDRONATE-VITAMIN D3 [FOSAMAX PLUS D] - (Prescribed by Other Provider) - 70 mg-2,800 unit Tablet - 1 Tablet(s) by mouth weekly pill CIPROFLOXACIN [CIPRO] - (Not Taking as Prescribed: Not taking for 3 1/2 weeks.)",0
- 500 mg Tablet - 1 Tablet(s) by mouth twice a day FOLIC ACID - (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
- 1 mg Tablet - 2 Tablet(s) by mouth once a day MESALAMINE [PENTASA] - (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
"- 500 mg Capsule, Sustained Release - Capsule(s) by mouth three times a day take as 3/2/3 capsules three divided doses(total 8/day) METHOTREXATE SODIUM - (Dose adjustment - no new Rx) (Not Taking as Prescribed: Not taking for 3 1/2 weeks.)",0
- 25 mg/mL Solution - 17.5 weekly shot Will hold for now and see how she is doing METRONIDAZOLE - (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
- 375 mg Capsule - 1 Capsule(s) by mouth twice a day OXYCODONE - (Prescribed by Other Provider) (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
- 5 mg Tablet - Tablet(s) by mouth as needed PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
"- 40 mg Tablet, Delayed Release (E.C.)",0
"- Tablet(s) by mouth once a day SODIUM-K+-MAG-CA-CHLOR-ACETATE [TPN ELECTROLYTES] - (Prescribed by Other Provider; Not listed) - Dosage uncertain VALACYCLOVIR [VALTREX] - (Prescribed by Other Provider) - 1,000 mg Tablet - as needed Dosage uncertain Medications - OTC CALCIUM - (Prescribed by Other Provider) (Not Taking as Prescribed: Not taking for 3 1/2 weeks.)",0
- 500 mg Tablet - Tablet(s) by mouth three times a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) (Not Taking as Prescribed: Not taking for 3 weeks.),0
- 400 unit Tablet - Tablet(s) by mouth twice a day GLUTAMINE - (OTC) - Powder - 10grams three times a day MULTIVITAMIN - (Prescribed by Other Provider) (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
- Tablet - 1 Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) (Not Taking as Prescribed: Not taking for 3 1/2 weeks.),0
"- 1,000 mg Capsule - 1 Capsule(s) by mouth twice a day PROBIOTICS - (OTC) - - taking 50,000,000 3 strains in the preparation Discharge Medications: 1.",0
Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED).,0
Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours).,0
"Mesalamine 500 mg Capsule, Sustained Release Sig: not taking as prescribed Capsule, Sustained Release PO three times a day: she takes 3/2/3 tablets during the course of the day.",0
Metronidazole 375 mg Capsule Sig: One (1) Capsule PO twice a day.,0
Sodium Chloride 0.9 % 0.9 % Piggyback Sig: One (1) mL Intravenous every twelve (12) hours as needed for PICC line flush.,0
Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Five (5) ML Intravenous PRN (as needed) as needed for line flush.,0
"Discharge Disposition: Home With Service Facility: SOUTHERN VNA Discharge Diagnosis: Crohn's disease with perforation Discharge Condition: Stable Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you.",0
No tub baths or swimming.,0
"If there is clear drainage from your incisions, cover with a dry dressing.",0
"Leave white strips above your incisions in place, allow them to fall off on their own.",0
Activity: No heavy lifting of items pounds until the follow up appointment with your doctor.,0
Medications: Resume your home medications.,0
"You should take a stool softener, Colace 100 mg twice daily as needed for constipation.",0
You will be given pain medication which may make you drowsy.,0
No driving while taking pain medicine.,0
"Followup Instructions: Provider: , MD Phone: Date/Time: 10:15 Provider: , MD Phone: Date/Time: 11:20 Completed by:",0
"12:16 AM CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # Reason: eval for pe Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with pleuritic chest pain/sob, h/o prostate ca REASON FOR THIS EXAMINATION: eval for pe No contraindications for IV contrast ______________________________________________________________________________ WET READ: PHRa 1:19 AM No PE or dissection.",0
Calcified pleural plaques suggesting asbestos exposure.,0
Ground glass opacities in lingula could represent infection.,0
Recommend follow up after treatment.,0
INDICATION: Pleuritic chest pain and shortness of breath.,0
TECHNIQUE: Multidetector helical axial imaging of the chest with intravenous contrast.,0
CONTRAST: 100 cc Optiray intravenously.,0
Nonionic contrast was administered due to the fast-bolus requirement.,0
CTA CHEST WITH CONTRAST: Examination of the pulmonary arterial tree failed to reveal any intraluminal filling defect that would suggest a pulmonary embolus.,0
Atherosclerotic calcifications are noted in the coronary arteries and aorta.,0
The heart and great vessels are otherwise unremarkable.,0
Multiple small mediastinal lymph nodes are present.,0
"Bilateral calcified pleural plaques are present, most notably along the right hemidiaphragm and the posteromedial wall of the right hemithorax.",0
There is a background of centrilobular emphysema.,0
Ground-glass and consolidative opacities are present in the lingula and right upper lobe.,0
There is also an area of focal consolidation in the posterior right lung base.,0
This area measures up to 3.0 x 1.7 cm.,0
CT RECONSTRUCTIONS: Coronal and sagittal reformatting performed for additional assessment of the pulmonary arterial tree fails to reveal any evidence of a pulmonary embolus.,0
The aorta is normal in caliber without evidence of acute injury.,0
BONE WINDOWS: No suspicious lytic or blastic lesions are detected.,0
IMPRESSION: 1) No pulmonary embolus detected.,0
2) Consolidative and ground-glass opacities in the lingula and right upper (Over) 12:16 AM CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # Reason: eval for pe Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
(Cont) lobe may represent pneumonia.,0
Irregular right lower lobe consolidative opacity is also noted.,0
Follow-up examination after treatment should be considered within three months to assess for change or resolution.,0
4) Calcified pleural plaques suggesting prior asbestos exposure.,0
"11:33 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: ELEVATED D-DIMER, EVAL FOR PE Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with evelated ddimer, eval for PE REASON FOR THIS EXAMINATION: eval for PE No contraindications for IV contrast ______________________________________________________________________________ WET READ: MGGb WED 12:57 AM No PE.",0
Cardiomegaly with mild CHF/volume overload and passive hepatic congestion.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old with elevated D-dimer, evaluate for PE.",0
"Patient is a longstanding diabetic, on hemodialysis, also with abdominal distention.",0
"TECHNIQUE: Axial MDCT images through the chest, abdomen, and pelvis with CTA phase through the chest per CTA PE protocol and delayed contrast phase through the abdomen and pelvis with coronal and sagittal reformats throughout.",0
CTA CHEST WITH IV CONTRAST: Non-contrast phase demonstrates no evidence of intramural hematoma.,0
There is prominent coronary artery calcification and scattered calcified atherosclerotic disease.,0
The pulmonary arteries enhance normally without filling defect.,0
"Note is made of minimal dilatation of the main pulmonary artery up to 3.3 cm and dilated right and left main segmental pulmonary arteries up to 2.9 cm, suggestive of pulmonary arterial hypertension.",0
The heart is markedly enlarged.,0
There is evidence of mild congestive heart failure or volume overload and a small right pleural effusion.,1
"The aorta is not optimally opacified to assess for dissection, but there is no evidence of aneurysmal dilatation.",0
CT ABDOMEN WITH IV AND ORAL CONTRAST: The liver is enlarged without focal lesions.,0
There is prominent hepatic venous reflux suggestive of congestive heart failure and passive congestion.,1
"There is a moderate amount of abdominal ascites and a large amount of pelvic ascites, all simple appearing.",0
"The stomach, spleen, pancreas, and gallbladder are within normal limits.",0
No abnormal adenopathy is appreciated.,0
CT PELVIS WITH IV AND ORAL CONTRAST: Large amount of pelvic ascites.,0
The distal bowel is unremarkable.,0
Atherosclerotic disease of the iliac systems.,0
"Low-attenuation lesion in the head of the pancreas, which may be continuous with the pancreatic duct, is not well evaluated on this CT.",0
"BONE WINDOWS: Diffuse degenerative changes and osteopenia without focal (Over) 11:33 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: ELEVATED D-DIMER, EVAL FOR PE Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) suspicious lesions.",0
"MULTIPLANAR REFORMATS: Sagittal reformatted images demonstrate a deformity of the superior endplate of L2, likely chronic.",0
"Additionally, there are disc herniations from L3-4 through L5-S1 which are not well evaluated on CT.",0
IMPRESSION: 1) No pulmonary embolism or evidence of bowel obstruction.,0
2) Moderate amount of ascites.,0
3) Cardiomegaly with evidence of mild congestive heart failure and passive hepatic congestion.,1
"5) Mild enlargement of the pulmonary arteries, suggestive of pulmonary arterial hypertension.",0
"6) At least one small cystic lesion in the head of the pancreas, which appears likely to connect to the main pancreatic duct but is not well evaluated on CT; this could be followed up in 6 months.",0
7) Adrenal lesions not well characterized on this study appear consistent with adenomas on prior studies.,0
12:16 PM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT GUIDANCE DRAINAGE Clip # Reason: please drain RUQ collection and leave drain in place.,0
Admitting Diagnosis: CONGESTIVE HEART FAILURE;RULE OUT CORONARY ARTERY DISEASE;ATRIAL FIBRILLATION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man POD 10 s/p Right colectomy w/ anastamotic leak.,1
REASON FOR THIS EXAMINATION: please drain RUQ collection and leave drain in place.,0
CONTRAINDICATIONS for IV CONTRAST: acute renal failure ______________________________________________________________________________ FINAL REPORT INDICATION: Status post right colectomy with anastomotic leak.,1
Please drain right upper quadrant collection and leave drain in place.,0
COMPARISON: CT of same date.,0
"PROCEDURE: The risks and benefits of the procedure were explained to the patient, and written informed consent was obtained.",0
A pre-procedure timeout was performed using two patient identifiers.,0
The skin of the right mid- abdomen was prepped and draped in standard sterile fashion.,0
"After local anesthesia with 6 cc of 1% lidocaine, and under direct CT guidance, 15-gauge needle was advanced into the collection and a small amount of fluid was observed draining from the tip of the needle.",0
"A 0.038 guidewire was advanced into the collection, and the tract was dilated with an 8 French dilator.",0
"Subsequently, an 8 French pigtail drainage catheter was advanced over the wire and 5 cc of feculent material aspirated and sent to microbiology.",0
Post-procedural scanning showed the pigtail catheter to be located in the collection just posterior to the colon and adjacent to the site of presumed anastomotic leak.,0
"The catheter was placed to continuous drainage with - bulb after forming and locking pigtail, and was secured to the skin using a StatLock device.",0
"The patient tolerated the procedure well, with no complications evident at the time of the procedure, and remained stable throughout his stay in the CT suite.",0
"The attending radiologist, Dr. , was present and supervising throughout, and performed portions of the procedure.",0
"ADDITIONAL FINDINGS AT CT: In addition to the above-described findings, it was noted that the collection in the right upper quadrant which was accessed and drained contained oral contrast from the bowel, which had not been opacified at the time of the prior CT performed earlier on the same date.",0
CT findings in the imaged portion of the abdomen and lower chest are otherwise unchanged from the examination of several hours prior.,0
IMPRESSION: Technically successful CT-guided placement of an 8 French drainage catheter into a mid abdominal fluid collection.,0
(Over) 12:16 PM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT GUIDANCE DRAINAGE Clip # Reason: please drain RUQ collection and leave drain in place.,0
Admitting Diagnosis: CONGESTIVE HEART FAILURE;RULE OUT CORONARY ARTERY DISEASE;ATRIAL FIBRILLATION\CATH ______________________________________________________________________________ FINAL REPORT (Cont),1
"5:55 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for effusion or other acute process Admitting Diagnosis: SYMPTOMATIC BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with hx of CAD, syncope event today with bradycardia REASON FOR THIS EXAMINATION: Please evaluate for effusion or other acute process ______________________________________________________________________________ WET READ: YGd SAT 12:52 AM No definite evid of acute cardiopulmonary process.",0
"x ______________________________________________________________________________ FINAL REPORT HISTORY: Syncope, bradycardia.",0
The aorta is mildly unfolded.,0
Right paratracheal soft tissues likely reflect vascular structures in someone of this age.,0
"No CHF, focal infiltrate, or effusion is identified.",0
Old healed right fifth rib fracture noted.,0
Narrowed right shoulder acromiohumeral distance could reflect rotator cuff thinning and/or tearing.,0
"Compared with , no change is identified.",0
IMPRESSION: No acute pulmonary process identified.,0
"PATIENT/TEST INFORMATION: Indication: serial, limited evaluation to f/u PDA.",0
"Status: Inpatient Date/Time: at 15:00 Test: Portable TTE (Congenital, focused views) Doppler: Focused pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: A 58-year-old female with a past medical history of severe coronary artery disease complicated by myocardial infarction, status post stenting, coronary artery bypass graft times two, atrial fibrillation/atrial flutter, status post ablation and cardioversion, pacemaker placement, congestive heart failure with an ejection fraction of less than 20%, hypertension, type 2 diabetes, hypercholesterolemia, and mitral valve replacement, who presented to Hospital status post a fall secondary to instability.",1
The patient was found to be hypotensive with a systolic blood pressure in the 70s to 80s.,0
This was complicated by acute renal failure and an elevated digoxin level.,1
"In addition, the patient also had a low hematocrit in the setting of an elevated INR.",0
The patient had a similar episode on her last admission to on ; admitted with hypotension and an elevated INR for which she received dopamine and fresh frozen plasma/vitamin K with good result.,0
She has had increasing edema and ascites since this last admission that has been resistant to outpatient diuretic treatment.,0
The patient has gained about 30 pounds since last admission.,0
"For the two months prior to admission, the patient has been experiencing worsening leg weakness.",0
On the a.m. of admission the patient began experiencing lightheadedness.,0
"On the afternoon of admission the patient was walking in her house and began losing her balance secondary to leg weakness, per patient.",0
She fell without loss of consciousness.,0
"She denied headache, fever, chills, sweats, dizziness, ""blacking out,"" change in vision or chest pain, shortness of breath, nausea, vomiting, palpitations, incontinence, and diaphoresis at the time of the fall.",0
The fall was complicated by a 1-inch laceration on the back of her head.,0
She was able to crawl to a cell phone and call a girlfriend who called an ambulance.,0
"The patient arrive via ambulance to Hospital where she received 1 unit of fresh frozen plasma, 1 liter of normal saline, and dopamine at 8 mcg per minute, as well as suturing of the laceration prior to her transfer to .",0
"At , the patient still denied headache, fevers, chills, sweats, dizziness, change in vision, chest pain, shortness of breath, nausea, vomiting, palpitations, and diaphoresis.",0
"At baseline, the patient denies chest pain or palpitations.",0
"She does complain of three-pillow orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema.",0
"The patient had a myocardial infarction in resulting in a left bundle-branch block, also complicated by ventricular tachycardia requiring lidocaine, and atrial fibrillation requiring cardioversion.",1
"The patient is status post catheterization, post myocardial infarction in .",0
Her proximal left circumflex and distal right coronary artery were stented.,0
Status post coronary artery bypass graft in .,1
"Left internal mammary artery to left anterior descending artery, saphenous vein graft to first obtuse marginal, saphenous vein graft to posterior descending artery, as well as a mitral valve ring placed.",1
The patient is status post catheterization in .,0
"Catheterization showed occlusion of left internal mammary artery and both saphenous vein grafts, severe systolic and diastolic dysfunction bilaterally, moderate pulmonary hypertension, and moderate-to-severe mitral regurgitation.",0
"The patient had a coronary artery bypass graft redo in ; saphenous vein graft to left anterior descending artery, saphenous vein graft to first diagonal to first obtuse marginal, as well as mechanical mitral valve replacement.",1
Pacemaker placement in ; pacemaker is a DDD-type with dual chamber leads.,0
"The patient has a history of atrial flutter, status post ablation and cardioversion in ; and a history of atrial fibrillation status post cardioversion in .",1
The patient had a MIBI stress test done in which showed severe fixed inferolateral wall defects.,0
"The patient had an echocardiogram done in which showed dilated left ventricle, global hypokinesis, right ventricular akinesis, significant mitral regurgitation and tricuspid regurgitation, mild pulmonary hypertension, and an ejection fraction of less than 20%.",0
"Type 2 diabetes controlled with diet, not requiring insulin.",0
Peripheral vascular disease with claudication.,0
The patient requires heart catheterization via brachial artery due to severe peripheral vascular disease.,0
Dysfunctional uterine bleeding with thickening endometrium on ultrasound.,0
This was found in .,0
Questionable history of a gastrointestinal bleed that has not been worked up.,0
FAMILY HISTORY: Family history is negative for coronary artery disease.,0
SOCIAL HISTORY: The patient has a 70-pack-year history of tobacco use; currently 5 to 10 cigarettes per day.,0
ALLERGIES: The patient has an allergy to CECLOR which gives her hives.,0
MEDICATIONS ON ADMISSION: The patient's medications on admission were gemfibrozil 600 mg p.o.,0
"b.i.d., digoxin 0.125 mg p.o.",0
"(Monday through ), Coumadin 2.5 mg p.o.",0
"q.d., Lasix 40 mg p.o.",0
"b.i.d., Ativan 1 mg p.o.",0
"for insomnia, trazodone 50 mg p.o.",0
"q.d., Zoloft 100 mg p.o.",0
"q.d., aspirin 81 mg p.o.",0
"q.d., Coreg 3.125 mg p.o.",0
"b.i.d., Imodium 1 tablet q.6h.",0
"for diarrhea, albuterol inhaler p.r.n., aldactazide 25/25 mg p.o.",0
"b.i.d., atenolol 25 mg p.o.",0
"q.d., Lipitor 10 mg p.o.",0
"q.d., enalapril 2.5 mg p.o.",0
"PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed pulse, the patient is AV paced at 70, blood pressure 91/25, respiratory rate 14, oxygen saturation 98% on 6 liters.",0
"In general, the patient was awake and verbal with unlabored breathing, in no apparent distress.",0
Skin examination revealed ecchymosis on right forearm and right shoulder.,0
HEENT revealed extraocular movements were intact.,0
"Pupils were equal, round, and reactive to light and accommodation.",0
"The oropharynx was clear, moist oral mucosa.",0
Stitches to the back of her head of about one inch in length.,0
"Neck had no lymphadenopathy, supple, no tenderness.",0
Cardiovascular examination revealed carotids with normal upstroke but low volume.,0
Precordium with a right ventricular heave and displaced point of maximal impulse to midclavicular line and superiorly.,0
"The patient had a regular rate, mechanical S1, loud S2, a to early systolic murmur radiating to the axilla and clavicles.",0
No S3 or S4 heard.,0
Lung examination revealed the patient had crackles one-third of the way up on the right side and crackles halfway up on her left side.,0
"There was good air movement, and slight wheezing throughout.",0
"Abdominal examination had positive bowel sounds, tense ascites, distended, and nontender.",0
"Extremities had 3+ pitting edema to middle thigh, right shoulder bruising and tenderness.",0
Neurologic examination revealed the patient was alert and oriented.,0
Cranial nerves II through XII were intact.,0
"LABORATORY DATA ON ADMISSION: White blood cell count 10.3, hematocrit 25.4, platelets 275.",0
"Sodium 132, potassium 5.1, chloride 97, bicarbonate 21, BUN 48, creatinine 3.4, glucose 65.",0
"PT 29.5, PTT 55.3, INR 5.7 (samples grossly hemolyzed).",0
Pertinent laboratory results revealed Helicobacter pylori was negative.,0
"Urine cultures performed on showed greater than 100,000 Escherichia coli.",0
"Peritoneal fluid, Gram stain, and culture performed on showed no growth and no organisms.",0
Blood cultures times two performed on showed no growth.,0
RADIOLOGY/IMAGING: Electrocardiogram #1 performed on revealed the patient was AV paced at 70 with diffuse low voltage.,0
Electrocardiogram #2 performed on revealed the patient was AV paced with no changes.,0
Echocardiogram #1 performed on showed mildly dilated left atrium.,0
No atrial septal defect or patent foramen ovale.,0
Severe left ventricular global hypokinesis with thinning/scar of left ventricular inferior wall.,0
Remaining left ventricle severely hypokinetic.,0
Hypokinesis of right ventricular free wall.,0
"Mitral regurgitation, 4+ tricuspid regurgitation.",0
"Stress test performed in on protocol, total time 3.37 minutes with 46% of maximum heart rate achieved.",0
Stopped because of dizziness and shortness of breath.,0
MIBI showed severe fixed defects in inferolateral walls.,0
Abdominal ultrasound performed on showed ascites; performed for paracentesis guidance.,0
"Abdominal CT performed on showed small-to-moderate bilateral pleural effusions, cardiomegaly, gallstones, ascites, inferior vena cava distention consistent with heart failure; otherwise unremarkable.",1
A pelvic CT was performed on which showed a large amount of fluid and anasarca.,0
An esophagogastroduodenoscopy was performed on showing hiatal hernia without signs of upper gastrointestinal bleed.,0
A colonoscopy was performed on showing proctitis.,0
Biopsy results: Rectal biopsy showed no abnormalities.,0
The biopsy was performed on .,0
"IMPRESSION: This is a 58-year-old female with significant cardiac history who presents with biventricular systolic dysfunction right greater than left, likely secondary to ischemic heart disease requiring dopamine for hypotension.",0
CARDIOVASCULAR: (a) PUMP: The patient has biventricular systolic dysfunction with an ejection fraction of less than 20% presumed secondary to ischemic heart disease.,0
The patient failed outpatient diuresis with a 30-pound weight gain over approximately one month.,0
"On admission, the patient presented with decompensated heart failure requiring dopamine.",1
"Outpatient ACE inhibitor, beta blocker, and diuretics were held.",0
"A Swan-Ganz catheter was placed on hospital day two once INR was less than 2 with the following findings: Central venous pressure of 30, pulmonary artery pressure of 66/28/41, pulmonary capillary wedge pressure of 40, cardiac output/cardiac index of 8.8/4.1, systemic vascular resistance of 282.",0
Elevated central venous pressure likely secondary to right heart failure and 4+ tricuspid regurgitation.,1
Intra-cardiac shunt was ruled out via echocardiogram.,0
Low systemic vascular resistance thought to be due to either sepsis or chronic outpatient use of beta blocker and ACE inhibitors.,0
Hypothyroidism and Addison disease were ruled out.,0
"Initially, dopamine/dobutamine were started on hospital day two with a poor renal response.",0
"Dobutamine was then discontinued, and Neo-Synephrine/dopamine was started on hospital day with increased urine output but decreased cardiac output/cardiac index to 4.5/2.1 with an systemic vascular resistance of 400 to 500.",0
"The thought was that the elevated central venous pressure was artificially depressing the calculated systemic vascular resistance; however, even with a normal central venous pressure the calculated systemic vascular resistance was lower than expected at around 600.",0
The Neo-Synephrine was weaned on hospital day four and switched to just dopamine with Lasix boluses with a good renal response and a cardiac output improvement of 6.5 and a calculated systemic vascular resistance of approximately 500.,0
The patient was continued on this regimen for a goal of a negative 2 liters of fluid output per day.,0
Dopamine was titrated to maintain an MAP of greater than 60.,0
"Dopamine and Swan-Ganz catheter were discontinued on hospital day nine with a central venous pressure of 27, pulmonary artery pressure of 65/27/45, pulmonary capillary wedge pressure of 30, cardiac output/cardiac index of 7.3/3.2, and a systemic vascular resistance of 373.",0
"After dopamine was discontinued, the patient's systolic blood pressure ranged in the high 70s to low 80s without symptoms.",0
The last measured central venous pressure transduced from the triple lumen while in the Coronary Care Unit was 22.,0
The patient was discharged to the medical floor on hospital day 13 and continued on aggressive diuresis.,0
"Aldactone and Zaroxolyn were eventually added and titrated to a maximum regimen of Lasix 125 mg intravenously t.i.d., Aldactone 50 mg p.o.",0
"q.d., and Zaroxolyn 5 mg p.o.",0
The patient's weight decreased from 94.9 kg to 76.4 kg by hospital day 22 with a significant amount of fluid overload still present.,0
"Dr. has been discussing the option of cardiac transplant with the patient; however, the patient refuses at the moment and want to contemplate the possibility once discharged from the hospital.",0
The patient will be followed by Congestive Heart Failure Clinic.,1
Dr. is recommending cardiac catheterization for further evaluation of cardiac function.,0
Digoxin level was elevated to 2.4 on admission likely secondary to acute renal failure.,1
"Digoxin was discontinued on admission, restarted on hospital day six, and maintained within normal limits.",0
Low-dose captopril was started on hospital day seven and slowly titrated up.,0
It was eventually switched to Zestril to avoid post dose hypotension.,0
(b) CORONARIES: The patient has severe coronary artery disease.,0
The patient was continued on aspirin and Lipitor.,0
We discontinued the gemfibrozil because of a low LDL and triglyceride level.,0
(c) RHYTHM: The patient is AV paced at 70.,0
(d) VALVES: The patient had a mitral valve replacement and was admitted on Coumadin with an elevated INR to 7.,0
"Once INR fell below 2 (on hospital day 10), heparin drip was started and PTT was maintained between 40 to 60 in the setting of slowly trending down hematocrit.",0
"Coumadin was restarted on hospital day 21, post gastrointestinal workup, with a goal INR of 2.5 to 3.5.",0
GASTROINTESTINAL: Chronic diarrhea was treated with Imodium and Metamucil with good results.,0
The patient was started on Protonix for a questionable gastrointestinal bleed.,0
"The patient has a history of a questionable gastrointestinal bleed in combination with a large melanotic stool and coffee-grounds via nasogastric lavage on hospital day three, and a low hematocrit that continued to slowly trend down with continuous guaiac-positive stools.",0
Esophagogastroduodenoscopy showed only a hiatal hernia.,0
Colonoscopy showed significant proctitis that was thought to likely be the etiology of her decreasing hematocrit.,0
The patient was started on Canasa per rectum on hospital day 21 and was to follow up with the Gastrointestinal Service.,0
HEMATOLOGY: Low hematocrit in the setting with elevated INR.,0
The patient was transfused a total of 6 units or packed red blood cells during her hospital admission with a poor response.,0
"The patient's hematocrit persisted between 25 and 30 for most of her hospital stay, sometimes stable and otherwise slowly trending down.",0
Abdominal/pelvic CT was negative for retroperitoneal bleed on hospital day three.,0
A paracentesis was negative for peritoneal bleed on hospital day three.,0
Examination otherwise negative for signs of bleeding.,0
"A gastrointestinal workup positive for gastrointestinal bleed, eventually found to be due to proctitis.",0
"The patient's elevated INR: The patient's Coumadin was held on admission, and the patient received 4 total units of fresh frozen plasma and 2 mg of vitamin K. INR slowly trended down to less than 2 on hospital day 10 when we began heparin drip with a goal PTT of 40 to 60.",0
This lower than normal goal was instituted because of a questionable gastrointestinal bleed.,0
"Coumadin was restarted on hospital day 21, post gastrointestinal workup with a goal INR of 2.5 to 3.5.",0
RENAL: The patient's admission creatinine was 3.1 with a baseline of approximately 1.1.,0
Acute renal failure likely secondary to decreased cardiac output.,1
Acute renal failure resolved with inotropic support and returned to baseline by hospital day six.,1
Digoxin levels were followed and maintained within normal limits.,0
The patient required pyrimidine and Ditropan for bladder discomfort during her hospital admission.,0
INFECTIOUS DISEASE: On admission the patient was found to have a low systemic vascular resistance thought possibly due to sepsis.,0
"Ultrasound-guided paracentesis was negative for spontaneous bacterial peritonitis, blood cultures were negative, urinalysis on admission was negative, abdominal/pelvic CT was negative for abscess, and the patient denied any symptoms of infection.",0
"On hospital day nine, the patient was complaining of bladder discomfort and was found to have a positive urinalysis.",0
"Urine cultures grew out greater than 100,000 Escherichia coli.",0
The patient only had a temperature maximum of 99.5 and a white blood cell count to 10.7.,0
She was treated with a 5-day course of antibiotics.,0
NEUROLOGY: Head trauma in the setting of an elevated INR.,0
CT was negative for an acute bleed.,0
Neurology examination was followed while INR was elevated without significant findings.,0
PULMONARY: The patient presented with mild congestive heart failure on chest x-ray and lung examination.,1
She was well oxygenated on nasal cannula and easily weaned off of oxygen requirement on hospital day 11.,0
"ENDOCRINOLOGY: The patient was admitted with a diagnosis of type 2 diabetes that had been controlled by diet, not requiring insulin.",0
"Initially, we followed the patient's fingersticks and started the patient on a regular insulin sliding-scale.",0
Fingersticks and regular insulin sliding-scale were eventually discontinued because the patient's serum glucose and fingersticks were usually within normal range.,0
The patient never required the use of the insulin sliding-scale.,0
PSYCHIATRY: The patient has a history of depression.,0
Depression was well controlled with continuation of trazodone and Zoloft.,0
MUSCULOSKELETAL: The patient with significant deconditioning.,0
"Physical Therapy was following, and the patient will likely be discharged to a rehabilitation center.",0
FLUIDS/ELECTROLYTES/NUTRITION: The patient was total body overloaded but hypotensive secondary to decreased cardiac output.,0
The patient was fluid restricted and aggressively diuresed with Lasix and eventually Aldactone and Zaroxolyn with good results.,0
"Potassium, magnesium, and phosphate were repleted as needed.",0
The patient was placed on a cardiac/diabetic diet.,0
CODE STATUS: The patient's code status was full.,0
DISCHARGE DISPOSITION: The patient was discharged to the Medicine floor.,0
An addendum is to follow with details of the patient's final hospital course.,0
MEDICATIONS ON DISCHARGE: Will follow as well.,0
DISCHARGE INSTRUCTIONS: Will follow as well.,0
Dictated By: MEDQUIST36 D: 09:35 T: 08:56 JOB#: cc:,0
5:51 PM CHEST (PORTABLE AP) Clip # Reason: sp tracheostomy Admitting Diagnosis: POLTRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p ett exchange REASON FOR THIS EXAMINATION: sp tracheostomy ______________________________________________________________________________ FINAL REPORT INDICATION: Status post endotracheal tube change.,0
"SINGLE VIEW CHEST, AP: The ET tube again terminates approximately 7 cm above the carina.",0
The left subclavian CVL terminates at the junction of the brachiocephalic veins.,0
"The cardiac, mediastinal, and hilar contours are stable.",0
"2:35 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ADTHMA;COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with copd, resp distress.",0
"REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:38 A.M., HISTORY: COPD and respiratory distress.",0
IMPRESSION: AP chest compared to and : Interstitial abnormality left lower lung is probably asymmetric pulmonary edema.,0
There is no consolidation to suggest pneumonia.,0
Severe emphysema is responsible for hyperinflation.,0
Pleural effusion if any is minimal.,0
11:35 AM PICC LINE PLACMENT SCH Clip # Reason: Please eval and place PICC line.,0
Failed bedside PICC line pl Admitting Diagnosis: FALL;HYPONATREMIS;HYPERKALEMIA ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with h.o.,0
"CAD s/p 3v CABG, MVR, DM II, HTN failed bedside PICC placement.",0
REASON FOR THIS EXAMINATION: Please eval and place PICC line.,0
"Failed bedside PICC line placement ______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT: INDICATION: For an 80-year-old female with history of CAD, CABG, MVR, and diabetes with limited vascular access.",0
Requesting PICC for access that failed bedside attempt.,0
A peel-away sheath was then placed over a guidewire and a single-lumen PICC line measuring 35 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC line placement via the right brachial venous approach.,0
"Final internal length is 35 cm, with the tip positioned in SVC.",0
10:25 AM CHEST (PA & LAT) Clip # Reason: size of pleural effusion ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with spiculated mass in LUL and moderate right-sided plueral effusion REASON FOR THIS EXAMINATION: size of pleural effusion ______________________________________________________________________________ FINAL REPORT 2 VIEWS CHEST: INDICATION: Spiculated left upper lobe mass and right pleural effusion.,1
There are no prior chest radiographs for comparison.,0
"However, comparison is made to a CT scan performed 1 day earlier.",0
The heart is upper limits of normal in size.,0
"There is bilateral mediastinal widening, consistent with lymphadenopathy in the right paratracheal and aorticopulmonary window regions.",1
There is also slight fullness of the left hilar contour.,0
The spiculated nodule in the periphery of the left upper lobe on recent CT scan is much less well demonstrated on the chest radiograph but is seen overlying the fourth anterior rib level.,0
"A small right pleural effusion is noted, with some fluid extending into the minor fissure as well.",1
Skeletal structures reveal degenerative changes within the spine.,0
"IMPRESSION: 1) Left upper lobe lung nodule and mediastinal and left hilar lymphadenopathy, concerning for lung cancer.",0
These findings were better demonstrated on recent CTA.,0
Dedicated PET scan may be helpful for initial further assessment.,0
2) Persistent small right pleural effusion.,1
"8:29 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: Eval for ileus Admitting Diagnosis: RIGHT SIDED WEAKNESS;ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with w/h/o ileus, now vomiting REASON FOR THIS EXAMINATION: Eval for ileus ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 73-year-old man with history of ileus.",1
FINDINGS: Three views of the abdomen are provided.,0
There are multiple air-fluid levels seen on the upright films.,0
There is also dilatation of the small bowel up to 4 cm.,0
These findings could represent ileus.,0
"There is also no gas seen within the colon, possibly representing an obstruction.",1
There are phleboliths noted within the pelvis.,0
There are degenerative changes within the spine.,0
There is no free air noted.,0
"CONCLUSION: Multiple air-fluid levels and some dilation of the small bowel consistent with ileus, less likely obstruction.",1
1:12 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: s/p liver transplant POD 21 now with increase in PT.,0
"Concer ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p liver transplant, re-explored for bleeding, needs confirmation that flow to the transplanted liver is not compromised.",1
REASON FOR THIS EXAMINATION: s/p liver transplant POD 21 now with increase in PT.,0
Concern is for hepatic artery thrombosis.,0
Please evaluate patency of hepatic artery.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Patient with elevated PT s/p re-exploration for bleeding in patient s/p liver transplant.,0
LIMITED RIGHT UPPER QUADRANT US: The hepatic parenchyma is normal in echogenicity with no focal masses.,0
There is no intrahepatic ductal dilatation.,0
"There is normal flow in the hepatic arteries, the hepatic veins, and the portal vein.",0
The common bile duct was not visualized.,0
IMPRESSION: No evidence of compromised flow to the transplanted liver.,1
"8:05 AM CHEST (PORTABLE AP) Clip # Reason: routine CCU, eval for abnormalities Admitting Diagnosis: LIVER FAILURE;RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with s/p liver transplant REASON FOR THIS EXAMINATION: routine CCU, eval for abnormalities ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.",1
REASON FOR EXAM: Post liver transplant.,1
"FINDINGS: In comparison to the previous chest radiograph, the right pleural effusion has increased and is now large with decreased aeration of the underlying lung.",0
A small left pleural effusion is unchanged and pulmonary edema has slightly worsened which is moderate in severity.,0
"Left subclavian catheter, left internal jugular placed Swan-Ganz catheter, NG tube and left ventricular/intra-aortic assist device are unchanged in position.",0
IMPRESSION: Worsening pulmonary edema with increasing right pleural effusion which is large.,0
10:21 AM US DRAIN PELV ABSCESS; GUIDANCE FOR ABSCESS () Clip # Reason: ultrasound guided drainage of B groin fluid collections.,0
"Admitting Diagnosis: VULVAR CANCER;CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 yo female with L vulvar ulcer, likely vulvar cancer, with L and R groin inflammatory collections on CT and cellulitis REASON FOR THIS EXAMINATION: ultrasound guided drainage of B groin fluid collections.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old female with left vulvar cancer and inflammatory collections/necrotic lymph nodes seen by CT.,1
"FINDINGS: The procedure was performed by Dr. with Dr. , the Attending radiologist present and supervising.",0
Informed and signed consent was obtained.,0
Both groins were prepped and draped in a standard sterile fashion.,0
"Under ultrasound guidance, approximately 5 cc of serosanguinous material was aspirated from the fluid component of a right inguinal lymph node.",1
Under ultrasound guidance fine needle aspiration of the solid component of this right-sided lymph node was then performed.,0
"Next, under ultrasound guidance approximately 10 cc of serosanguinous material was aspirated from the fluid component of a heterogeneous ill-defined lymph node within the left groin.",0
This fluid was sent for gram stain and culture.,0
Fine needle aspiration of a solid component of a left large inguinal lymph node was then performed.,1
All samples were assessed for adequacy by the pathology fellow.,0
COMPLICATIONS: None MEDICATIONS: Approximately 5 cc of local anesthesia with 1% Lidocaine.,0
IMPRESSION: 1) Large necrotic inguinal lymph node metastases bilaterally.,1
2) Successful aspiration of serosanguinous fluid from the fluid components of lymph nodes within both inguinal regions.,1
Fine needle aspiration of the solid components of lymph nodes within both inguinal regions was also performed without complication.,1
"11:12 AM HIP UNILAT MIN 2 VIEWS LEFT PORT Clip # Reason: r/o fracture Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with left hip pain REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ FINAL REPORT LEFT HIP CLINICAL INFORMATION: Left hip pain, question fracture.",0
FINDINGS: Two views of the left hip demonstrate no fracture or malalignment.,0
There is significant artifact on the radiograph.,0
There is a small os acetabulum.,0
"There is mild irregularity about the lesser trochanter, unclear if this represents enthesopathy or a small avulsion.",0
"1:21 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with resp failure, pulm hypertension.",1
"REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old with respiratory failure, pulmonary hypertension.",1
COMPARISON: CT of the chest performed on .,0
"TECHNIQUE: Volumetric CT of the chest performed after IV contrast administration per departmental protocol, including multiplanar reformations.",0
CT CHEST:Postoperative changes from prior left pneumonectomy are stable.,0
Shift of the mediastinal structures to the left.,0
There is diffuse adenopathy and infiltrating mass involving the right middle and right upper lobe and obstructing the bronchi of right middle and upper lobe.,0
"When compared to previous examination of , it is seen that there is increased confluent densities in the right upper and middle lobe representing areas of consolidation with peribronchiolar opacities.",0
All of these are concerning for multifocal progressive pneumonia.,0
Mild-to-moderate right pleural effusion present.,1
There is no evidence of pulmonary embolus within the main pulmonary artery or its segmental branches.,0
"However, there is encasement of the right pulmonary artery and its branches from the diffuse infiltrating mass in the right middle and upper lobe, with narrowing of multiple branches.",0
"In the right lower lobe subsegmental branch (series 3, image 64), there is complete occlusion of the branch by the encasing tumor.",0
Extrapleural enhancing nodules are seen in the posterior inferior aspect of the left thorax measuring approximately 1.5 cm.,0
",these are stable since .",0
The ET tube and NG tube are in good position.,0
The study is not specifically tailored for subdiaphragmatic evaluation.,0
"Limited views of the upper abdomen reveal a hypodense enhancing nodule in the left paraaortic region adjacent to the left adrenal gland measuring 2.8 x 2.4 cm, unchanged in size since , could represent a lymph node or an adrenal nodule and is concerning for metastases.",0
"The hypodense lesion in the spleen reveals minimal, if any, change from prior study.",0
Apparent muscular atrophy of the muscle adjacent to the scapula with fatty replacement on the left.,0
No evidence of endoluminal filling defects to indicate pulmonary embolus.,0
"However, multiple areas of progressive narrowing and at least one occlusion of pulmonary arterial branches by the infiltrative right hilar mass likely (Over) 1:21 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ FINAL REPORT (Cont) contribute to the described symptoms of pulmonary arterial hypertension.",1
2.Interval development of multiple foci of consolidation and peribronchiolar opacities in the right middle and upper lobe concerning for progressive multifocal pneumonia.,0
Findings were called to Dr. .,0
Diffuse adenopathy and infiltrative mass involving the right middle and upper lobe with progressive obstruction of the bronchi and pulmonary vasculature.,0
Enhancing nodule with central hypodensity adjacent to or within the left adrenal gland is consistent with either metastatic involvement of lymph node or adrenal gland.,0
10:00 PM CHEST (PA & LAT) Clip # Reason: eval infiltrate.,0
______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with fever and increased confustion REASON FOR THIS EXAMINATION: eval infiltrate.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Fever and confusion, evaluate for infiltrate.",0
AP UPRIGHT AND LATERAL VIEWS OF THE CHEST: Heart size is within normal limits.,0
The aorta appears tortuous with particular prominence of the aortic arch.,0
Lateral view is limited by motion.,0
No definite effusion is seen.,0
Markedly tortuous aorta with prominance of the arch contour.,0
Correlation with outside previous studies is recommended.,0
11:59 PM CHEST (PA & LAT) Clip # Reason: Possible PEs and will need V/Q scan - also to establish base ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with REASON FOR THIS EXAMINATION: Possible PEs and will need V/Q scan - also to establish baseline.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Possible pulmonary embolus.,0
CXR prior to VQ scan.,0
COMPARISON: Portable AP chest .,0
PA AND LATERAL RADIOGRAPHS OF THE CHEST: There is stable moderate cardiomegaly.,0
Again seen are the bilateral small layering pleural effusions associated with consolidation/collapse of the lower lobes.,1
Slight pulmonary vascular redistribution is again seen but not significantly changed.,0
A right PICC line catheter tip is seen in the mid SVC.,0
Cardiomegaly with unchanged mild CHF.,0
Bilateral pleural effusions associated with bibasilar collapse.,1
PICC line in satisfactory position.,0
"8:06 PM CHEST (PRE-OP PA & LAT) Clip # Reason: RE-DO CABBAGE\CORONARY ARTERY BYPASS GRAFT, RE-DO Admitting Diagnosis: RE-DO CABBAGE\CORONARY ARTERY BYPASS GRAFT, RE-DO ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with need for redo CABG REASON FOR THIS EXAMINATION: assess for CPP ______________________________________________________________________________ FINAL REPORT HISTORY: Preoperative evaluation for redo CABG.",1
FINDINGS: PA and lateral views of the chest.,0
There is stable cardiomegaly with evidence of CABG.,0
"The superior three sternal wires are broken, as seen previously.",0
"There is increased upper zone redistribution in the pulmonary vascular, representing mild congestive heart failure.",0
"A small round shadow is again noted overlying the right lower lung field on the PA view, probably representing a nipple shadow.",0
"In the future, this may be confirmed by using nipple markers with chest radiographs.",0
There is no pleural effusion or pulmonary consolidation.,0
IMPRESSION: Mild congestive heart failure.,0
"3:51 PM FEMUR (AP & LAT) RIGHT Clip # Reason: evaluate ______________________________________________________________________________ MEDICAL CONDITION: 60 year old ped struck by car, 30 MPH, no LOC REASON FOR THIS EXAMINATION: evaluate ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma, hit by car.",0
"RIGHT FEMUR, TWO VIEWS: No fracture or dislocation is present.",0
The right hip appears preserved.,0
Contrast material is seen within the bladder.,0
No radiopaque foreign bodies or soft tissue calcifications are noted.,0
The imaged right knee demonstrates no joint effusion or evidence of dislocation.,0
4:47 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with respiratory failure REASON FOR THIS EXAMINATION: ?,1
interval change ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON .,0
FINDINGS: The endotracheal tube and bilateral subclavian lines are unchanged.,0
There is new increased opacity at the left base obscuring the left CP angle suggesting volume loss/infiltrate in that region.,0
There are some patchy areas of atelectasis on the right as well.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Lisinopril / Penicillins / Codeine Attending: Chief Complaint: transfer for anterior STEMI Major Surgical or Invasive Procedure: Cardiac cath with placement of Cypher stent Temporary pacemaker x 2 Intra-aortic balloon pump Pulmonary artery catheter History of Present Illness: Ms. is a 59yo woman with h/o discoid lupus admitted to OSH on with dyspnea and wheeze felt to be from asthma vs CHF; although she initially reported 2 days of symptoms, on further questioning, she reports feeling congested ever since her knee surgery in .",1
"Upon presentation, she was in NSR, but she developed AFib with RVR to 160.",0
She was ruled out for MI with serial cardiac enzymes.,0
Echo demonstrated EF 75% with LVH but no atrial enlargement.,0
She was started on lovenox and coumadin and put on digoxin and diltiazem for rate control.,0
"Given concern for volume overload, she received lasix.",0
She was also put on steroids briefly.,0
"Shortly after lunch on , the patient complained of chest pain and palpitations.",0
"Although she was initially in VTach, she was coded for VFib/arrest and had CPR and then DCCV x 200J once.",1
She was started on lidocaine gtt and transferred to the ICU for persistent VTach; amiodarone gtt was started.,0
12-lead EKG revealed >10mm ST elevations in V3-V6 as well as 4mm STE in I.,0
She was transferred to for emergent cath.,0
"In the cath lab, she was maintained on amiodarone, lidocaine, and neosynephrine drips and continued to be in AFib with aberrancy with RVR; her systolic pressures did not drop below 80.",0
Her LAD was found to be totally occluded and Cypher stent was placed.,0
Thrombus was identified in her first diag; she had thrombectomy followed by POBA of D1.,0
Hemodynamic measurements were significant for LVEDP of 22 and PCWP of 22.,0
"Cardiac index was calculated to be 1.35 l/min/m2 by Fick method, and IABP was placed.",1
She received a total of 180cc of contrast.,0
Her blood pressures improved with the IABP and her neosynephrine and lidocaine drips were stopped.,0
She also received plavix 600mg.,0
"Upon arrival in the CCU, she had some right lower back pain, .",0
"She was on heparin, integrillin, and amiodarone gtt.",0
She denied any chest pain or dyspnea.,0
"On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools.",0
She has had 2 miscarriages.,0
"Past Medical History: HTN Discoid lupus erythematosis--facial scarring, hair loss Pseudotumor cerebri Legally blind caused by chloroquine GERD s/p b/l knee replacement s/p CCY s/p Tonsillectomy s/p C section Allergies: Lisinopril--lip swelling/angioedema Penicillin--rash Tetracycline--GI upset Codeine--GI upset OUTPATIENT CARDIOLOGIST: ?",1
of Social History: Social history is significant for the absence of current tobacco use: she smoked 39 years x 1 PPD; quit in .,1
Family History: There is a questionable family history of premature coronary artery disease or sudden death: one of her sons died at age 17 of a problem which she is unable to clarify at this time.,1
"Physical Exam: VS: T 96.3, BP 102/72, HR 101, RR 14, O2 % on 4L Gen: Pleasant, middle aged woman, somewhat tired but easily rousable and oriented, answering all questions appropriately.",0
Neck: Supple with JVP of 5 cm.,0
Irreg irreg and slightly tachycardic.,0
"Abd: Obese, soft, NTND, No HSM or tenderness.",0
Reproducible back pain on palpation.,0
Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: Cardiac Cath: 1.,0
Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease.,1
There was a total occlusion at the bifurcation of the proximal LAD and a large D1 vessel.,0
"The LMCA, LCx, and RCA were all patent.",0
Resting hemodynamic measurement demonstrated an elevated left sided filling pressure with an LVEDP of 22 mmHg and a mean PCWP of 22 mmHg.,0
The RVEDP was mildly elevated at 12 mmHg.,0
The mean PAP was normal at 25 mmHg.,0
Systemic arterial pressure was low at 96/64 mmHg while on a neosynephrine gtt.,0
The Fick calculated cardiac index was low at 1.35 l/min/m2 consistent with cardiogenic .,1
Pullback of the catheter across the aortic valve did not demonstrate a pressure gradient.,0
"Due to persistent cardiogenic , IABP was inserted with marked improvement in blood pressure.",1
Successful PTCA and stenting of the proximal LAD with a 3.0x 13 mm CYPHER DES.,0
"Final angiography revealed no residual stenosis in the stent, no dissection and TIMI II flow.",0
Successful thrombectomy of the Diagonal and PTCA with a 2.5 mm balloon.,0
"Final angiography revealed no residual stenosis in the diagonal, loss of a sidebranch and TIMI II flow (See PTCA comments) FINAL DIAGNOSIS: 1.",0
Anterior-Lateral STEMI with cardiogenic .,0
Successful placement of a DES to the LAD.,0
Successful placement of an IABP.,0
TTE : The left atrium is mildly dilated.,0
"There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the anterior septum and anterior wall, distal lateral and inferior walls, and apex.",1
The estimated cardiac index is depressed (<2.0L/min/m2).,0
with focal hypokinesis of the apical free wall.,0
The mitral valve appears structurally normal.,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with extensive regional systolic dysfunction c/w CAD with right ventricular infarction.,1
CT Abd/Pelvis without contrast : (done for concern of RP bleed) PRELIM READ--FINAL READ PENDING Patchy hypodensities in the right kidney are suspicious for infarct.,0
"Air in the kidney may represent post surgical change but post infectuous air cause is also a possibility, recommend correlation with urinalysisis and CBC.",0
CXR : Single AP chest radiograph without comparison shows bibasilar opacity which may represent atelectasis vs. aspiration.,0
"More focal opacity in the right suprahilar region extending to the apex may also represent aspiration, although mass lesion cannot be entirely excluded and therefore recommend followup with PA and lateral radiographs.",0
The heart size is mildy enlarged.,0
There is no pleural effusion or evidence of CHF.,0
The tip of intra-aortic balloon pump terminates 2 cm below the aortic arch.,0
Discussed with Dr.. Abdominal fluoro : A single spot fluoroscopic examination was obtained without a radiologist present.,0
This demonstrates partial visualization of aortic balloon pump catheter and a newly placed femoral approach pacing wire with its tip projecting in the region of the right ventricle.,0
"PRELIM CXR : IABP partially retracted, now 2.8 cm below aortic arch.",0
PA catheter terminates in right interlobar artery.,0
No change in bibasilar or right suprahilar oapcities.,0
"- PRELIM CXR : As compared to the previous examination, the intra-aortic balloon pump projects with its tip higher than on the previous examination, presumably due to patient position the tip is now located 5 mm below the upper margin of the aortic arch.",0
"Otherwise, the monitoring and support devices are unchanged.",0
"Higher lung volumes than on yesterday's examination, the perihilar opacities have slightly decreased, but a right upper lobe opacity persists.",0
There is no evidence of pleural effusion.,0
"Subtle deviation of the trachea to the left is likely to be the manifestation of a goiter, but should be monitored closely to excluded other potential causes such as mediastinal hematoma.",0
# Cardiogenic /Anterior STEMI: Patient was hypotensive in the cath lab requiring neosynephrine to support blood pressure; neosynephrine was weaned once IABP placed in cath lab.,1
Her PCWP and LVEDP were elevated in the cath lab suggesting fluid overload; it is likely that she has myocardial stunning in the setting of her recent MI as well as fluid overload.,0
"At the time of transfer out of the cath lab, she was on heparin, integrillin, and amiodarone gtt.",0
She never completed a full amio load; she has received approximately 2-3g of amiodarone at the time of transfer.,0
"In regards to her STEMI, she was loaded on plavix in the cath lab.",0
"She has been continued on ASA, plavix, high dose statin, and she had integrillin x 18 hours post-procedure.",0
She had Cypher stent to LAD and thrombectomy with POBA to D1.,0
TTE morning after her cath showed EF 25% with marked regional wall motion abnormalities consistent with infarct (images included).,0
Note that she has angioedema with ACE inhibitors.,0
"The morning after her cath, she had complete heart block with ventricular standstill.",1
Temp wire was emergently placed via femoral sheath; later that day a screw-in temporary pacemaker was placed in the cath lab.,0
She received 1g vancomycin x 1 in the setting of the urgent procedures.,0
"Her MAPs were in the 50s with poor urine output, so she was sent back to the lab and PA catheter was placed for milrinone titration.",0
"Overnight, dopamine was added to support her MAPs, after which she quickly developed increased ectopy.",0
"Dopamine was switched to levophed, which she initially tolerated well.",0
"Though levophed was kept low at 0.25, she developed increasing ectopy with frequent short bursts of VTach the morning of transfer to .",0
"As her frequent arrhythmias were limiting titration of her pressors, she was transferred to for LVAD.",0
"Although her MAPs were in the 50s, she had warm extremities with good peripheral pulses and was mentating.",0
She had become anuric in the setting of recent renal infarct and likely ATN.,0
There was question regarding a possible pro-thrombotic state given that she had coronary thrombus without significant CAD or risk factors other than HTN and remote smoking history.,1
"She does report 2 miscarriages in the past, but no other history of clot.",0
Anti-cardiolipin was sent and is pending at the time of discharge.,0
"# Anuria/Renal infarct/Acute renal failure: The night after her cath, she complained of right back and flank pain.",1
"In the setting of 6 point Hct drop, she had non-contrast CT, which was negative for RP bleed but demonstrated right renal infarct (prelim read).",0
"Renal was consulted, and felt her renal dysfunction was multifactorial in setting of renal infarct and ATN (likely due to hypotension).",0
"# Atrial fibrillation with aberrant conduction: Although she was in NSR when she presented to , it is unclear how long she has had AFib given her vague complaint of ""chest congestion"" which she dates back to .",1
"She was on lovenox and coumadin at the OSH, but it is unclear what date these were started (sometime between and ).",0
She has been on heparin gtt throughout her course at .,0
"Of note, although she was started on amiodarone and lidocaine at for VTach, it was unclear whether this was AFib with aberrancy.",0
Records from were requested but had not been sent by the time of transfer to .,0
# HTN: Patient's home norvasc and doxazosin were held.,0
Note that she had angioedema with lisinopril.,0
"# Leukocytosis: On the morning of transfer, she was noted to have count of 22.",0
"CXR following her complete heart block on demonstrated possible infiltrate/aspiration, and her PA catheter pressures were significant for SVR in the 300s.",1
There was concern that she may be developing septic in addition to her cardiogenic .,0
"She had received vancomycin 1g x 1 on , which was not redosed given her GFR of 14.",0
"She has an allergy to penicillin (rash), so she was given a dose of aztreonam No other evidence of infection; most likely elevated in setting of recent steroids and new MI.",0
"# Anemia: Patient had a hematocrit of 36 at the time of her cath, which dropped to 25 in the setting of multiple interventions.",0
CT pelvis on ruled out RP bleed.,0
She was continued on a heparin gtt while on the IABP.,0
She was noted to be oozing from her femoral sheath from the subclavian access site.,0
"Platelets were stable, so she was not felt to be in DIC.",0
She was not transfused RBCs because of concern for volume overload.,0
# Code: FULL # Communication: with son and pastor Medications on Admission: Ranitidine ?mg Norvasc 2.5mg daily Doxazosin 4mg daily MVI daily Medications on transfer: ASA Neosynephrine gtt Amiodarone gtt Lidocaine gtt Discharge Medications: 1.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for sedation.,0
Norepinephrine Bitartrate 1 mg/mL Solution Sig: currently at 0.25 mcg/kg/min Intravenous TITRATE TO (titrate to desired clinical effect (please specify)).,0
Atropine 1 mg/mL Solution Sig: 0.5 mg Injection X1 (ONE TIME) as needed for symptomatic bradycardia & hypotension.,0
Amiodarone 50 mg/mL Solution Sig: One (1) mg/min Intravenous INFUSION (continuous infusion).,0
Milrinone in D5W 200 mcg/mL Piggyback Sig: 0.5 mcg/kg/min Intravenous INFUSION (continuous infusion).,0
9. heparin IV at 500 units/hr 10.,0
"Aztreonam 1g IV x 1 currently being given 11. vancomycin 1g IV given Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Anterior STEMI Secondary Diagnoses: Cardiogenic , Acute renal failure, Anemia, Cardiac arrest, Atrial fibrillation, Ventricular tachycardia, Episode of Complete Heart Block Discharge Condition: Hypotensive with MAPs in 50s but warm extremities, mentating well.",1
"98.9 77/40 (art line) 110s-120s in AFib with RBBB pattern with frequent runs of NSVT, RR 21 sats 95-100% on NRB.",0
"Latest PA pressures: PA mean 24, wedge 17, CVP 7, CO (Fick) 6.6, CI 3.37, SVR 424.",0
Latest ABG: 7.42/31/136 Discharge Instructions: Patient was admitted for STEMI.,0
Being transferred to for LVAD.,0
Please follow-up and take your medications as directed at the time of discharge from .,0
Followup Instructions: As directed by doctors .,0
"10:21 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST Reason: HCT DROP,?BLEED INTO LIVER MASSES Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with met HCC and abd pain, diaphoresis, dramatic crit drop and elevated INR, concern for bleeding into one of hepatic masses REASON FOR THIS EXAMINATION: IV contrast only.",1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of known metastatic hepatocellular carcinoma, now with hematocrit drop.",0
Evaluate for source of bleeding.,0
COMPARISON: MRI from and CT from .,0
TECHNIQUE: CT acquired contiguous axial images were obtained from the lung bases to the pubic symphysis.,0
"Study was performed without contrast, followed by arterial phase and a delayed phase.",0
CONTRAST: 150 cc of IV Optiray contrast was administered.,0
"The patient has had a prior history of contrast allergy, and so received pre-medication with Benadryl by the covering house officer.",0
"CT OF THE ABDOMEN W/IV CONTRAST: Multiple pulmonary nodules are again seen at the lung bases, consistent with metastatic foci.",0
"Additionally, there is a pleural effusion at the left lung base, and focal atelectasis which demonstrates nodularity heterogeneity, and may represent a metastatic focus.",0
"There is a small amount of pleural enhancement adjacent to the effusion, raising the possibility of a malignant effusion in this area.",1
"The spleen, adrenal glands, and kidneys are normal.",0
"There is malrotation of the right kidney, likely congenital.",0
"A large heterogeneous mass is seen within the liver parenchyma, corresponding to the patient's known hepatocellular carcinoma.",0
"This appears to infiltrate almost the entire right lobe of the liver, and extends into the left lobe of liver.",0
This is heterogeneous in appearance.,0
There is occlusion of the main portal vein (as was seen on recent MRI study).,0
There is ascites within the intraperitoneal cavity.,0
"Additionally, adjacent to the liver, there is a large amount of hyperdense fluid, measuring 60 Hounsfield units, and corresponds to blood from recent hemorrhage.",0
This extends inferiorly and can be seen extending into the pelvis.,0
These findings are consistent with rupture and hemorrhage from the hepatoma.,0
"On contrast enhancement, multiple small tumor vessels can be seen within the large liver mass.",0
"However, no focal areas of active arterial extravasation can be identified.",0
"CT OF THE PELVIS: Free fluid, including hyperdense fluid extending inferiorly from the liver, is seen within the pelvis.",0
"The rectum (Over) 10:21 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST Reason: HCT DROP,?BLEED INTO LIVER MASSES Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) and sigmoid colon are normal.",0
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in delineating the anatomy and pathology.,0
IMPRESSION: 1) Large HCC is again seen within the liver.,0
There is a large amount of blood adjacent to the liver.,0
This likely resulted from rupture of this hepatoma.,0
Blood is seen extending into the pelvis.,0
No definite areas of active arterial extravasation are identified.,0
"2) Multiple pulmonary metastases are seen, most predominantly in the right lower lung zone, with an associated effusion which is may be malignant in nature.",0
Results were discussed with Dr. immediately after the study was performed.,0
6:43 PM CHEST (PORTABLE AP) Clip # Reason: check for ptx Admitting Diagnosis: HYPERKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with hx of bilateral IJ sticks REASON FOR THIS EXAMINATION: check for ptx ______________________________________________________________________________ WET READ: AJy WED 11:08 PM No pneumothorax.,0
Right mid-lung linear opacity c/w atelectasis.,0
cardiac enlargement likely exagerrated by technique.,0
mild vascular congestion without frank edema.,0
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Attempt bilateral IJ placement.,0
"Cardiac size is top normal, is accentuated by low lung volumes.",0
Widened mediastinum could be due to engorgement of vessels but adenopathy cannot be excluded.,0
Plate-like atelectasis is noted in the right lower lobe.,0
There is small right pleural effusion.,0
9:02 AM CHEST (PORTABLE AP) Clip # Reason: ?new infiltrate Admitting Diagnosis: AIRWAY OBSTRUCTION\BRONCHOSCOPY RIGID W/MICRODEBRIDER; MITOMYCIN C; ?,1
STENT PLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p tracheal resection .,0
"s/p bronch, r/o pneumonia REASON FOR THIS EXAMINATION: ?new infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST AT 9:23 A.M.",0
INDICATION: Status post tracheal resection.,0
"FINDINGS: Compared with , there now appears to be atelectasis and/or consolidation with air bronchograms seen in the right infrahilar region, although evaluation is limited by light technique.",0
The right upper and left lung fields are clear.,0
"1:26 PM EMERG BILAT LOWER EXT VEINS Clip # Reason: FEVERS, TACHYCARDIA, PLEASE RULE OUT DVT Admitting Diagnosis: CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with alcoholic hepatitis, now with tachycardia and fevers.",1
REASON FOR THIS EXAMINATION: Please rule out DVT.,0
______________________________________________________________________________ WET READ: JXKc FRI 3:03 PM No DVT bilateral lower extremities.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Alcoholic hepatitis, now with tachycardia and fevers, rule out DVT.",1
"FINDINGS: -scale and color Doppler son of bilateral common femoral, superficial femoral, and popliteal veins were obtained.",0
"There is normal compressibility, flow, and augmentation without evidence of DVT.",0
"Compression of the posterior tibial and peroneal veins within the calf were demonstrated, without evidence for thrombus.",0
IMPRESSION: No evidence of DVT in bilateral lower extremities.,0
"5:41 AM CHEST (PORTABLE AP) Clip # Reason: pls eval for interval change, ?infiltrate at L base Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 73M w/ likely MRSA PNA admitted with sepsis REASON FOR THIS EXAMINATION: pls eval for interval change, ?infiltrate at L base ______________________________________________________________________________ FINAL REPORT AP CHEST 6:12 A.M : HISTORY: MRSA pneumonia.",1
IMPRESSION: AP chest compared to and 14: Small region of consolidation at the base of the left lung is stable.,0
There is new consolidation at the right lung base which could represent a second focus of pneumonia.,0
ET tube and left internal jugular line are in standard placements.,0
There is no evidence of pneumothorax or pleural effusion although the lateral aspect of the right lower chest is excluded from the examination.,0
"11:24 AM ANKLE 1 VIEW PORT LEFT Clip # Reason: Per ortho, VIEW for eval of fracture.",0
Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man s/p fall.,0
"REASON FOR THIS EXAMINATION: Per ortho, VIEW for eval of fracture.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Status post fall, evaluate using view.",0
Single portable axial view of the calcaneus was obtained.,0
Detail is considerably obscured by overlying splint.,0
"There is irregularity along one of the lateral walls of the calcaneus, side uncertain.",0
Correlation with contemporaneous CT scan is recommended for full assessment.,0
5:38 PM CHEST (PA & LAT) Clip # Reason: + sternal click Admitting Diagnosis: INFERIOR MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with s/p CABG REASON FOR THIS EXAMINATION: + sternal click ______________________________________________________________________________ WET READ: JRCi 6:44 PM NEW MODERATE LEFT APICAL PNEUMOTHORAX AND INCREASED SIZE OF BILATERAL PLEURAL EFFUSIONS.,1
DISCUSSED WITH AT 6 43 PM.,0
______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST FROM HISTORY: Followup CABG.,0
IMPRESSION: PA and lateral chest compared to : Moderate left pneumothorax predominantly apical and a small layering left pleural effusion are new since .,0
Lungs are hyperinflated consistent with emphysema or small airways obstruction.,1
Mediastinum has a normal post-operative appearance following CABG.,0
Irregular left pleural thickening along the costal pleural margin may represent plaque.,0
Findings were reported by Dr. to at 6:43 p.m.,0
"7:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for fx, PTX ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with found down, with oral CA, trach REASON FOR THIS EXAMINATION: evaluate for fx, PTX ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, , AT 0753 HOURS.",0
HISTORY: Found at base of stairs.,0
FINDINGS: The distal tip of a tracheostomy tube is identified approximately 7 cm from the carina.,0
There is a dense area of consolidation in the right upper lobe.,0
The lungs are otherwise hyper-expanded but clear.,0
There is a tortuous aorta.,0
No definite effusion or pneumothorax is evident.,0
Minimally displaced fractures involving the lateral aspect of the left ninth and tenth ribs are noted.,0
Dense consolidation in right upper lobe.,0
Diagnostic considerations include aspiration versus contusion.,0
Left-sided lower rib fractures as detailed above.,1
"11:29 AM CHEST (PA & LAT) Clip # Reason: Are there signs of pulmonary edema or plueral effusion, is t Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with pneumonia and shortness of breath.",1
"REASON FOR THIS EXAMINATION: Are there signs of pulmonary edema or plueral effusion, is there improvement of infiltrate ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb FRI 4:21 PM PFI: Persistent bibasilar opacities and pleural effusions, possibly representing aspiration.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male with pneumonia and shortness of breath.,0
AP AND LATERAL CHEST: The cardiomediastinal silhouette is unchanged and the pulmonary vascularity is stable.,1
Left greater than right small-to-moderate pleural effusions and bibasilar opacities persist.,0
The upper lungs remain clear without pneumothorax.,0
Mild interstitial edema has resolved.,0
Bibasilar opacities may represent aspiration.,0
"Persistent small-to-moderate pleural effusions, left greater than right.",0
"3:53 AM CHEST (PORTABLE AP) Clip # Reason: VAP, Fluid status Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with VAP, loculated effusion s/p decortication REASON FOR THIS EXAMINATION: VAP, Fluid status ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with ventilator-acquired pneumonia and loculated effusion after decortication.",1
Portable AP chest radiograph was compared to obtained at 04:15 a.m.,0
The ET tube tip is 3.2 cm above the carina.,0
The Dobbhoff tube tip is in the stomach.,0
The right PICC line tip is at the low SVC.,0
There is slight interval increase in the right lower lobe consolidation but no change in the right loculated pleural effusion.,0
There is interval slight improvement of the left lower lung aeration.,0
Those findings might be consistent with worsening of the known pneumonia in the right lower lung.,0
"2:46 PM CTA HEAD W&W/O C & RECONS Clip # Reason: eval change, STAT CT/CTA Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with SAH s/p aneurysmal coiling with now mild HA, Double vision REASON FOR THIS EXAMINATION: eval change, STAT CT/CTA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CTA OF THE HEAD WITHOUT AND WITH IV CONTRAST INDICATION: 54-year-old female with vision change, status post left vertebral artery aneurysm coiling.",1
"COMPARISONS: Multiple priors, most recent .",0
TECHNIQUE: Non-contrast MDCT axial images of the head were acquired.,0
"Following the administration of 75 cc of Optiray intravenous contrast, MDCT axial images were acquired from the level of the C2 vertebral body to the cranial vertex.",0
"Coronal, sagittal, and 3D volume-rendered multiplanar reformatted images were then obtained.",0
NON-CONTRAST HEAD CT: Non-contrast images demonstrate persistent high-density material within the occipital horns of the lateral ventricles bilaterally.,0
A small amount of high-density material within the occiptial horns is unchanged compared to the previous examination.,0
A ventricular catheter from a right frontal approach terminating within the frontal of the right lateral ventricle is unchanged in position.,0
There is no shift of normally midline structures or hydrocephalus.,0
The sphenoid sinus contains some low-density material.,0
"Otherwise, the visualized portions of the paranasal sinuses and mastoid air cells are unremarkable.",0
CT ANGIOGRAM OF THE HEAD: Note is made of extensive streak artifact from the coiled aneurysm of the left vertebral artery.,0
"Thus, evaluation of the vertebral arteries and the basilar artery just adjacent is limited.",0
No specific areas of vasospasm are identified.,0
The visualized tributaries of the circle of are patent without focal areas of stenosis or dilatation.,0
IMPRESSION: Unchanged amount of subarachnoid hemorrhage compared to examination from one day prior.,1
Evaluation of the vessels just adjacent to the coiled aneurysm in the left vertebral artery is limited secondary to streak artifact.,0
No focal areas of vasospasm identified in the visualized vertebrobasilar system.,0
Findings were discussed with Dr. from neurosurgery at 5:00 p.m. on by Dr. over the telephone.,0
"(Over) 2:46 PM CTA HEAD W&W/O C & RECONS Clip # Reason: eval change, STAT CT/CTA Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont)",1
"10:09 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o pneumothorax Admitting Diagnosis: PNEUMONIA;VANCOMYCIN RESISTANT ENTEROCOCCUS;RULE OUT TUBERCULOSIS ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p vats with biopsy with acute respiratory acidosis, s/p vats--Ct now to water seal.",1
"REASON FOR THIS EXAMINATION: r/o pneumothorax ______________________________________________________________________________ FINAL REPORT HISTORY: Status post VATS with chest tube to waterseal, evaluate for pneumothorax.",0
COMPARISON: Same day at 8:25 p.m.,0
"The previously seen possible right basilar pneumothorax is not imaged on this repeat study, as a large portion of the right hemithorax has been excluded from the field of view.",0
"The tracheostomy tube, right basilar chest tube, left subclavian central venous line are unchanged.",0
Elevation of the left hemidiaphragm and low left lung volumes are unchanged.,0
"IMPRESSION: Evaluation of pneumothorax cannot be assessed on the present radiograph, as a large portion of the right hemithorax has been excluded, a repeat study is recommended.",0
Findings discussed with Dr. at 11:00 a.m. on .,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Word finding difficulty Major Surgical or Invasive Procedure: Craniotomy and drainage History of Present Illness: Pt is a 64 y/o male with a h/o AML/MDS, DM2, and COPD who presented to clinic today for a routine visit with a complaint of a difficulty finding words over the past week.",1
He states this came on suddenly.,0
"The primary trouble is with finding words to describe what he wants to say, not actually articulating the words.",0
"He denies any other neurologic symptoms, including weakness (no stumbling, dropping items), loss of sensation, or other confusion.",0
Mr. displays understanding of his current situation and location.,0
"He denies any specific symptoms, including fever/chills, headache, shortness of breath, chest pain/pressure, nausea/vomiting, diarrhea/constipation, melena/hematochezia, dysuria/hematuria, nosebleeds, and rashes.",0
"Hhis speech prompted the team in the clinic to investigate these symptoms, and an MRI/MRA demonstrated a left parietal fluid collection.",0
"In terms of his AML, Mr. was treated with LODAC in and subsequent to that has been on hydrea and donazol and has been transfusion dependant.",0
He is currently on hydroxyurea only.,0
")AML, converted from MDS 2.",0
)COPD Social History: Mr. lives alone.,0
His sister lives about one block from him and is very supportive.,0
He uses the ride to get to his clinic visits.,0
He lived in for many years where he worked at a VA.,0
He also has worked as a taxi driver.,0
He smoked for many years but quit around 30 years ago.,0
Pertinent Results: 09:05AM BLOOD WBC-22.4* RBC-3.40* Hgb-10.3* Hct-30.0* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.1 Plt Ct-6*# 12:30AM BLOOD WBC-15.5* RBC-3.20* Hgb-9.8* Hct-28.9* MCV-90 MCH-30.6 MCHC-33.8 RDW-14.4 Plt Ct-82* 05:45AM BLOOD WBC-14.9* RBC-2.87* Hgb-8.7* Hct-25.9* MCV-91 MCH-30.5 MCHC-33.7 RDW-14.7 Plt Ct-27*# 05:45AM BLOOD Glucose-83 UreaN-29* Creat-0.5 Na-140 K-4.2 Cl-100 HCO3-34* AnGap-10 05:45AM BLOOD Calcium-10.2 Phos-4.6* Mg-2.3 Brief Hospital Course: 64 y/o male with AML progressed from MDS currently being treated with hydroxyurea who was admitted for a word finding difficulty and was found to have a subdural bleed in the setting of platelets of six.,0
)Subdural bleed -- The patient was initially brought up to a platelet level of 50 and observed in the bone marrow unit.,0
"On the second day of admission, he experienced a sudden, severe headache and had a stat head CT, showing no definite change in the size of the lesion or the degree of midline shift, yet due to his symptoms, neurosurgery was consulted.",0
They felt it appropriate to take Mr. to the OR where the subdural bleed was drained; subsequent pathology demonstrated clotted blood.,0
He was kept in the neurosurgical ICU for two days where he did well with no post-operative complications and was then sent back to the bone marrow unit for further care.,0
"By his return to BMT, his speech and confusion had greatly improved, and his family members agreed that he was back to his baseline.",0
"Throughout the remainder of the admission, he continued to experience a slight headache, much improved from admission, that was well relieved by 5mg of oxycodone.",0
His word-finding symptoms did not recur.,0
The main challenge was maintaining his platelets at a an appropriate level due to his underlying myelodysplastic syndrome.,0
"Per the neurosurgery team, his goal for platelets was around 50 for three weeks; at the time of discharge, he will require an additional week of platelets at this level, usually achievable by giving two bags of platelets each morning, checking a post transfusion count 30-60 minutes thereafter.",0
"After this week has finished, he will be maintained at his prior level, getting transfusion two to three times per week at hematology clinic under the care of Dr. .",0
"He will follow-up with his hematologist, Dr. , for his AML in one week and with Dr. , a neurosurgeon, in two weeks (he will get a repeat CT scan at that time).",0
)AML -- Mr. is being treated with hydroxyurea and transfusions as needed.,0
"His WBC at ranged between 12 and 28, generally around 14.",0
"His goal hematocrit was over 25, and he generally required one unit of packed RBC's every three to four days.",0
Platelet requirements have been described above.,0
")Type two diabetes -- The prednisone Mr. takes makes his blood sugars somewhat difficult to control, however, a regimen of Humalog 75/25 with 45 units every morning and 25 units at night seemed to work the best.",0
"He was also covered with a routine regular insulin sliding scale for excessively high values (usually starting at 2 units of regular insulin for a glucose of 150-200, and going up by two units of insulin for every 50mg/dl of blood glucose increase).",0
")COPD -- Mr. was maintained on Advair 250/50, one puff twice a day.",0
He was also given an albuterol inhaler for shortness of breath/wheezing that he rarely needed.,0
"He became wheezier in the middle of the admission, and was given twice daily scheduled albuterol nebs to which he responded well.",0
"We would recommend continuing these for two more days, then stopping them, leaving him on only Advair and as needed albuterol inhalers.",0
")Fever -- One week prior to discharge, Mr. had a temperature to 101.",0
His blood and urine cultures were negative.,0
"Clinically and radiographically, his most likely source was pulmonary, although the chest x-ray did not demonstrate an obvious pneumonia.",0
"He was treated with levofloxacin, and will finish his course with seven more days of antibiotics.",0
Medications on Admission: Humalog 75/25 40 units sc every AM and PM Furosemide 20mg po daily Advair 250/50 one puff twice daily Hydroxyurea 1000mg po once daily Pantoprazole 40mg po daily Prednisone 15mg po daily Discharge Medications: 1.,0
Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Forty Five (45) Units Subcutaneous qAM.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb Inhalation twice a day.,0
Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days.,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation (2 times a day).,0
Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) Ml Intravenous DAILY (Daily) as needed.,0
Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty (20) Units Subcutaneous qPM.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary: Subdural hematomoa Secondary: Acute Myelogenous leukemia/Myelodysplastic syndrome Diabetes -- type two COPD Discharge Condition: Fair, with improved sx, stable hematoma, requiring frequent platelet transfusions.",1
"Discharge Instructions: Please return to the emergency department for fevers/chills, shortness of breath, chest pain, severe headaches, confusion, speech difficulties.",0
Followup Instructions: You have an appointment with Dr. on at 11:30.,0
"Provider: , MD Where: HEMATOLOGY/BMT Phone: Date/Time: 12:30 Please call Dr. , your neurosurgeon, at to be seen in two weeks.",0
"When you call, please remind them you will need another CT-scan of your head prior to the visit.",0
"PATIENT/TEST INFORMATION: Indication: Intra-op TEE for pulmonary vein isolation, Left atrial appendage ligation, lung Bx Height: (in) 64 Weight (lb): 163 BSA (m2): 1.79 m2 BP (mm Hg): 119/69 HR (bpm): 77 Status: Inpatient Date/Time: at 10:33 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.",1
Filamentous strands on the aortic leaflets c/with Lambl's excresences (normal variant).,0
Conclusions: 1.The left atrium is markedly dilated.,0
There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant).,0
Initially a small residual portion of LAA was noted.,0
This is not seen with subequent repeat ligation 2.,0
Biventricular fucntion is unchanged 3.,0
6:33 PM MR HEAD W & W/O CONTRAST; MR Clip # Reason: MRI with MR-P MR-S to evaluate for brain mets or changes Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with breast cancer with mets to brain s/p neurosurgical removal of tumor from R frontal lobe and known sz d/o presenting with increased seizure activity.,1
Please repeat MRI with MR-P MR-S as previously obtained in the past.,0
REASON FOR THIS EXAMINATION: MRI with MR-P MR-S to evaluate for brain mets or changes leading to increased seizures.,0
MR 3D RENDERING W/POST PROCESS obtained in the past.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: MRI of the head with and without contrast.,0
"CLINICAL INDICATION: 60-year-old woman with history of breast cancer and neurosurgical removable tumor from the right frontal lobe, increased seizure activity, repeat MRI and MRI and perfusion analysis.",0
COMPARISON: Multiple prior MRI examinations from through .,0
"TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained, axial T2, axial magnetic susceptibility, axial diffusion-weighted sequences.",0
"The T1-weighted images were repeated after administration of intravenous gadolinium contrast in axial T1, sagittal MP-RAGE and multiplanar reconstructions were provided.",0
"Arterial spin labeling sequence in axial projection, perfusion MRI including blood flow, blood volume and mean transit time color maps.",0
Single voxel and multi-voxel was also obtained at the right frontal lobe.,0
"FINDINGS: In comparison with the prior examination, again post-surgical changes are redemonstrated at the right frontoparietal region, the most anterior right frontal lesion appears relatively unchanged with associated vasogenic edema and irregular pattern of enhancement, measuring approximately 12.2 x 16.9 mm in transverse dimension and previously 14.7 x 16.9 mm.",0
"A second lesion is redemonstrated more posteriorly extending at the craniotomy site and involving the dura with heterogeneous pattern of enhancement in the temporal frontoparietal region, and extending in the subcortical white matter (image 17, series #12), the pattern of vasogenic edema appears slightly larger at the level of the right external capsule, please compare image 12, series #7 from and image 14, series #11 from the current examination.",1
"The perfusion sequences demonstrates avid perfusion in the dural lesion and also increased in perfusion on the corresponding ASL sequence, the most anterior frontal lesion otherwise appears unremarkable in the perfusion maps.",0
"There is also increase in the diffusion-weighted signal in this region, concerning for progression.",0
No other new areas with abnormal enhancement are identified.,0
Normal flow void signal is noted at the major vascular structures.,0
The is not conclusive for abnormal metabolites in the most (Over) 6:33 PM MR HEAD W & W/O CONTRAST; MR Clip # Reason: MRI with MR-P MR-S to evaluate for brain mets or changes Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) superficial lesion.,0
"The orbits are unremarkable, the paranasal sinuses demonstrate mild mucosal thickening at the posterior aspect of the sphenoid sinus, the mastoid air cells are unremarkable.",0
"IMPRESSION: Interval progression in the pattern of enhancement at the right temporal frontoparietal lesion with avid perfusion and increased signal on the corresponding ASL sequence, concerning for tumor progression, there is also mild increase in vasogenic edema extending at the external capsule as described above.",0
The most anterior frontal lesion appears unchanged.,0
No other lesions are identified.,0
"These findings were communicated to Dr. at 9:00 a.m. on , via telephone by Dr. .",0
"9:06 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change Admitting Diagnosis: INFECTED RIGHT FOOT' ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man s/p R 2nd toe amp, s/p MI now with CHF.",0
"REASON FOR THIS EXAMINATION: evaluate for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: S/P amputation second toe, now with MI and congestive failure.",1
PORTABLE CHEST: Upright exam is compared to a study of and shows clearing of congestive failure.,1
The heart and vascularity are now normal.,0
The heart size is unremarkable.,0
IMPRESSION: Complete clearing of congestive failure.,1
1:17 PM CT HEAD W/O CONTRAST Clip # Reason: ICH?,0
______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with acute change in MS. neuro deficits REASON FOR THIS EXAMINATION: ICH?,1
No contraindications for IV contrast ______________________________________________________________________________ WET READ: SVMc 2:23 PM no acute intracranial process WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: An 82-year-old woman with acute mental status changes.,1
"COMPARISON: Multiple priors, most recently from .",0
"FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or acute vascular territorial infarct.",1
The ventricles and sulci are normal in configuration and size.,0
Note is again made of extensive parafalcine calcifications.,0
The imaged portions of the mastoid air cells and paranasal sinuses appear well aerated.,0
"7:15 AM NEONATAL HEAD PORTABLE Clip # Reason: assess ventricle size, please assess resistive indices ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 26 weeks gestation with previous hus with bilateral ivh and ventriculomegaly REASON FOR THIS EXAMINATION: assess ventricle size please assess resistive indices ______________________________________________________________________________ FINAL REPORT INDICATION: 26 week premature infant born on the with history of bilateral intraventricular hemorrhage.",1
Comparison is made with an examination performed .,0
Once again noted are resolving grade I hemorrhages with intraventricular hemorrhage as well.,1
No new blood is noted.,0
"There may, though I am not certain, be some increase in the size in the ventricles since our last exam.",0
There is doubt that it is certainly not significant.,0
Doppler interrogation shows resistive indeces which range from about .7 without compression to about .8 with compression in the range of moderate elevation.,0
IMPRESSION: Essentially stable examination with evidence of bilateral femoral matrix and intraventricular hemorrhage with moderate ventriculomegaly and slightly elevated resistive indeces.,1
"9:58 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: r/o facial damage ______________________________________________________________________________ MEDICAL CONDITION: 34 year old woman with MVA REASON FOR THIS EXAMINATION: r/o facial damage No contraindications for IV contrast ______________________________________________________________________________ WET READ: DFDdp SAT 12:46 AM fractures through the right lateral and inferior wall of orbit, and lateral and medial walls of right maxillary sinus.",1
no compromise of rectus muscles or optic nerve or ophthalmic vein.,0
______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Status post motorcycle accident.,0
TECHNIQUE: Helically aquired contiguous axial images through the facial bones were obtained.,1
CT FACIAL BONES: Comminuted fractures through the lateral and medial walls of the right maxillary sinus are present.,1
There is blood within the right maxillary sinus.,0
"Additionally, fractures through the inferior and medial walls of the right orbit are present.",0
There does not appear to be any entrapment of the rectus muscles on the right.,0
The right superior opthalmic vein and right optic nerve as well as the right globe appear intact.,0
Nondisplaced fractures of the right zygomatic arch and zygomatic process are present.,0
"Additionally, air-fluid levels are identified within both sphenoid sinuses, right greater than left.",0
Possible fracture through the anterior wall of the right sphenoid sinus may be present.,0
Small amount of fluid is also seen within the right ethmoid air cells.,0
Significant preseptal peri-orbital soft tissue swelling is noted on the right with pockets of air seen.,0
Mastoid air cells are well pneumatized.,0
"IMPRESSION: 1) Multiple facial fractures as described above involving the right orbital walls, right maxillary sinus walls and right zygomatic arch and zygomatic process.",1
"2) Blood within both sphenoid sinuses, right maxillary sinus, and right ethmoid air cells.",0
3) Soft tissue swelling in the right peri-orbital preseptal space.,0
4) Right temporal bone fracture noted.,0
5) Blow out fracture of the right orbital floor without definite entrapment of the inferior rectus.,1
(Over) 9:58 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: r/o facial damage ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) 6) Questionable fracture of the lateral wall of the left orbit.,1
7) Partial sclerosis of the right mastoid air cells.,0
"2:26 PM CHEST (PORTABLE AP) Clip # Reason: please eval for pulm edema ______________________________________________________________________________ MEDICAL CONDITION: year old man with hypoxia, chest pain, now with worsened shortness of breath since this AM, rales on exam.",0
REASON FOR THIS EXAMINATION: please eval for pulm edema ______________________________________________________________________________ WET READ: KCLd WED 3:54 PM Interval development of interstitial edema bilaterally when compared to .,0
Left lower lobe consolidation again suggestive of pneumonia/aspiration.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: -year-old man with hypoxia, chest pain, now with worsened shortness of breath since this a.m., rales on exam.",0
"FINDINGS: AP chest radiograph dated , is compared to AP chest radiograph from .",0
There appears to have been interval development of interstitial opacities bilaterally consistent with pulmonary edema.,0
Again seen is a poorly defined retrocardiac opacity/consolidation consistent with left lower lobe pneumonia.,0
Interval development of interstitial pulmonary edema.,0
Again seen is evidence of left lower lobe pneumonia.,0
3:52 PM CT HEAD W/O CONTRAST Clip # Reason: Interval change Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with R frontal lobe mass s/p craniotomy.,0
Please send to CT at 1600 today.,0
"REASON FOR THIS EXAMINATION: Interval change CONTRAINDICATIONS for IV CONTRAST: renal insufficiency ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SAT 6:01 PM Persistent shift, unchanged.",0
Evolving hypodensity within the right frontal and right temporal lobe concerning for possible evolving infarction.,0
No significant change in post-surgical changes and herniation.,0
FINDINGS: Patient is status post right craniotomy with resection of large mass.,0
"Post-surgical changes are again identified including fluid, blood products and air within the resection cavity as well as overlying the right cerebral convexity, similar in appearance.",0
"Air-fluid level within the subcutaneous soft tissues overlying the right craniotomy, is slightly increased when compared to prior exam.",0
"There is marked hypodensity within the right frontal and temporal lobe, adjacent to the resection site, is more pronounced when compared to prior exam.",0
Persistent shift of normally midline structures towards the left measuring approximately 1.1 cm is unchanged.,0
Mass effect on the ipsilateral lateral ventricle and adjacent brainstem is similar in appearance.,1
"There is persistent effacement of the suprasellar cistern and high focus of attenuation within the basilar cistern, unchanged (2, 12).",0
"There is slight widening of the right prepontine cistern consistent with uncal herniation, unchanged.",0
Sulcal effacement in the right cerebral hemisphere is similar in appearance.,0
"Opacification in the bilateral maxillary sinus, ethmoid and sphenoid sinuses is unchanged.",0
No significant change in shift of normally midline structures measuring approximately 1.1 cm to the left.,0
"More prominent hypodensity within the right frontotemporal lobe (2, 13 and 2, 17) which may represent evolving infarction.",0
(Over) 3:52 PM CT HEAD W/O CONTRAST Clip # Reason: Interval change Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ FINAL REPORT (Cont) 3.,0
"Air-fluid level within the subcutaneous soft tissues overlying the right craniotomy, slightly increased.",0
"7:41 PM TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # Reason: trauma ped vs auto ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p trauma REASON FOR THIS EXAMINATION: trauma ped vs auto ______________________________________________________________________________ FINAL REPORT HISTORY: Trauma, pedestrian vs. auto.",0
CERVICAL SPINE X-RAY: There are no fractures or dislocations from C1 to the inferior aspect of C6.,0
"There are degenerative changes, more marked at C5-6.",0
AP VIEW OF THE CHEST: The heart and mediastinum are normal.,0
"There are no consolidations, effusions or pneumothorax.",0
AP VIEW OF THE PELVIS: There is a fracture of the right iliac and a comminuted fracture of the superior pubic ramus extending to the roof of the acetabulum.,0
There are probable fractures of bilateral inferior pubic rami.,0
8:27 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?,0
"pneumothorax, evaluate CHF Admitting Diagnosis: INFECTED ULCER ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with respiratory s/p intubation and acute desat REASON FOR THIS EXAMINATION: ?",1
"pneumothorax, evaluate CHF ______________________________________________________________________________ FINAL REPORT INDICATION: ___-year-old woman with status post intubation and acute desat to look for pneumothorax.",0
"The ET tube, right IJ catheter tip and the NG appear to be in good position.",0
Cardiomegaly with bilateral pleural effusion and interstitial pulmonary edema.,0
IMPRESSION: Moderate congestive heart failure stable since the earlier film done at 3:55 p.m.,1
"11:45 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: r/o fx Admitting Diagnosis: EPIDURAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with head trauma, retroorbital hematoma REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Head trauma and retroorbital hematoma.",0
"COMPARISON: CT studies of the head, one which is concurrent and the other done earlier on the same day.",0
TECHNIQUE: Helical axial 1.25mm MDCT images were acquired through the facial bones without the use of intravenous contrast.,0
Coronal and sagittal reformatted images (which do not comprise the entire temporal bone) were also reviewed.,0
"FINDINGS: Extensive right basilar skull fracture is redemonstrated, extending in a transverse plane through the temporal bone, into the superior mastoid air cells, laterally, and finally reaching the temporomandibular joint.",1
"A small osseous fragment, just posterior to the mastoid air cells and the temporal bone is minimally displaced internally, by about 1.5 mm.",0
"There is a fracture through the left orbital roof with minimal superior displacement of an osseous fracture fragment, by approximately 1 mm.",0
Both orbital floors are intact as are the laminae papyracea.,0
There is no other facial or skull fracture.,1
"A small amount of hematoma is seen in the superior aspect of the left orbital cone, the degree of which is unchanged from the comparison study.",0
Overlying subcutaneous hematoma is also unchanged.,0
Both globes and lenses are intact.,0
There is no definite evidence of superior rectus superior oblique muscle impalement or entrapment within the above fractures.,0
"There is mild mucosal thickening in the maxillary sinuses, bilaterally, as well as the dorsal aspect of the left sphenoid sinus.",0
The intracranial contents are better characterized on the concurrent head CT.,0
"IMPRESSION: Minimally-depressed comminuted left orbital roof and extensive right basilar skull and temporal bone fractures, as above.",1
", M. NSURG SICU-B 7:10 PM MR HEAD W & W/O CONTRAST Clip # Reason: please eval for mass and ligamentous injury Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: MAGNEVIST Amt: 11 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with ventricular lesion REASON FOR THIS EXAMINATION: please eval for mass and ligamentous injury No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",0
Arteriovenous malformation is again identified in the region of quadrigeminal cistern with blood in the ventricular system.,0
Decreasing size of the ventricles compared to the previous CT examination following placement of the right frontal ventricular drain which demonstrate a tract in the right frontal region with small amount of surrounding blood products.,0
Small area of acute right frontal lobe partial anterior cerebral artery territorial infarct.,0
No evidence of enhancing mass lesion.,0
PATIENT/TEST INFORMATION: Indication: Assess LV/RV Function s/p PEA Arrest Height: (in) 65 Weight (lb): 125 BSA (m2): 1.62 m2 BP (mm Hg): 160/73 HR (bpm): 54 Status: Inpatient Date/Time: at 12:51 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
AORTA: Markedly dilated ascending aorta.,0
AORTIC VALVE: Mild (1+) AR.,0
TRICUSPID VALVE: Moderate [2+] TR.,0
Conclusions: There is mild symmetric left ventricular hypertrophy with normal cavity size.,0
The ascending aorta is markedly dilated The descending thoracic aorta is mildly dilated.,0
"Compared with the prior study (images reviewed) of , the right ventricular function has improved and the estimated pulmonary artery systolic pressure is lower.",1
The markly dilated ascending aorta is better appreciated.,0
", V. MED CC1B 7:34 AM CHEST PORT.",0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: check line Admitting Diagnosis: PNEUMONIA;TROPONIN LEAK ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with s/p line placement REASON FOR THIS EXAMINATION: check line ______________________________________________________________________________ PFI REPORT Right-sided central line with tip in the mid-to-low SVC.,0
Unchanged asymmetric pulmonary edema and lingular consolidation.,0
"9:08 AM CHEST (PORTABLE AP) Clip # Reason: EVAL FOR NEW PROCESSES BECAUES NOW C/O SOB, INCREASED WORK O Admitting Diagnosis: ABD WOUND ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man w/ EC fistula now w/ retroperitoneal bleed w/ agressive fluid resuscitation REASON FOR THIS EXAMINATION: EVAL FOR NEW PROCESSES BECAUES NOW C/O SOB, INCREASED WORK OF BREATHING ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breasth status post aggressive fluid resuscitation for retroperitoneal hemorrhage.",0
"FINDINGS: Compared with , there has been interval pulmonary vascular engorgement with appearances suggesting early interstitial edema and a left pleural effusion.",0
IMPRESSION: Fluid overload with mild to moderate CHF.,0
12:09 AM CT HEAD W/O CONTRAST Clip # Reason: s/p R eVD placement Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with brain abscess REASON FOR THIS EXAMINATION: s/p R eVD placement No contraindications for IV contrast ______________________________________________________________________________ WET READ: 4:15 AM 1. sp R eVD with small amount of SAH in the right posterior frontal lobe.,0
Ventricles are slightly more prominent than on .,0
New mild midline shift to the right by about 5 mm.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old with brain abscess status post EVD placement.,0
COMPARISON: MRI of the head from and outside hospital CT of the head from .,0
FINDINGS: CT OF THE HEAD: The patient is status post right frontal approach EVD placement with the tip ending at the foramen of .,0
"The ventricles, especially the temporal horns are more prominent than on , .",0
"Small amount of subarachnoid hemorrhage is seen in the right frontal lobe (series 2, image 24), new compared to the prior exam.",0
Small amount of air in the frontal of the right lateral ventricles.,0
Vasogenic edema in the left parietal lobe from a left parietal lesion is more extensive than on the previous MRI.,0
"There is new mild midline shift to the right by about 5 mm, not seen on previous MRI from and the CT from .",0
The paranasal sinuses and mastoids are clear.,0
Post ventriculostomy catheter placement with new small amount of (Over) 12:09 AM CT HEAD W/O CONTRAST Clip # Reason: s/p R eVD placement Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ FINAL REPORT (Cont) subarachnoid hemorrhage in the right frontal lobe.,0
"Left parietal vasogenic edema has increased and there is slightly increased midline shift to the right by about 5 mm, new from the CT from , .",0
"Ventricles are normal in size, but slightly more prominent than on predominantly involving the temporal horns.",0
"NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation and note that the involvement of the corpus callosum and the fast diffusion seen in the nonenhancing core of the lesion on the MR study argue that a primary malignant neoplasm, such as a glioblastoma, is more likely than abscess or metastatic disease.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending: Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Surgical Wound Debridement History of Present Illness: Mr. is a 75 with chronic respiratory failure s/p tracheostomy, type II diabetes, peripheral vascular disease s/p right BKA, CAD, atrial fibrillation, and ESRD on dialysis who presented on from his chronic rehab facility with hypotension to the 70s systolic with associated cough and sputum production.",1
Since he has had multiple ICU transfers for hypotension and somnolence.,0
"On DOA on , he presented with BP of 50/33 and it was presumed to be sepsis from large known sacral decubitus ulcer which was felt to be infected.",1
He was admitted to the for concern for sepsis.,0
He was in the from to .,0
In he had a broad infectious workup.,0
Multiple blood cultures were negative.,0
Both sputum and urine cultures were positive for acinetobacter.,0
"He was treated with a prolonged course of daptomycin, meropenem and PO vancomycin.",0
Antibiotics were discontinued on prior to transfer to the floor.,0
While in the ICU his blood pressures were persistently in the 70s to 80s systolic but he was afebrile and was noted to be mentating appropriately.,0
His blood pressures were noted to be particularly sensitive to narcotic pain medications.,0
"He was followed closely by the renal, infectious disease and plastic surgery services.",1
He initially required CVVH given his labile blood pressures but was ultimately transitioned back to intermittent hemodialysis.,0
His back wound was debrided on multiple occassions by plastic surgery.,0
His back wound was noted to be consistently contaminated by fecal material despite flexiseal use.,0
Diverting colostomy was recommended but was declined by the patient.,0
He was transferred to the floor on for further management.,0
On he was transferred back to the MICU for hypotension.,0
"He was not febrile, new cultures failed to reveal a source.",0
"He was started back on daptomycin, meropenem and PO vancomycin.",0
He also received stress dose steroids.,0
His hypotension resolved with this regimen.,0
He was transferred back to the floor with blood pressures in the 90s to 110s systolic.,0
The patient did well on the floor until when 2 hours after receiving 10 mg oxycodone to control sacral decub pain in setting of dressing change he became unresponsive.,0
"Narcan did imporve his alertness but the medical staff was unable to obtain reliable vital measurements and in setting of worsening productive sputum and worsening leukocytosis, patient was transferred to ICU were he was monitored for 2 days.",0
The patient returned to the medicine floor on .,0
"However, on he again became hypotensive and returned to the ICU, again likely multifactorial.",0
Midodrine was restarted and uptitrated to 15mg tid.,0
He received one unit of PRBCs with hemodialysis for colloid volume resuscitation.,0
He was transferred back to the floor on .,0
On review of systems he does not note any pain/discomfort anywhere.,0
"He denies chest pain, shortness of breath, nausea, vomiting, abdominal pain, dysuria, leg pain.",0
"Past Medical History: # DM2 # CRI (baseline 2.5)- recently started on HD # CHF - EF 50-55% # Trached and Vent Dependent PNA in hypercarbic/hypoxic respiratory failure, bronchoscopy on .",1
He diffuse airway edema consistent with volume overload.,0
There were no significant secretions and a full survey of the airways reveals all airways were patent without any endobronchial lesions.,0
His trach was felt to be in appropriate position without any obstruction.,0
"# PNA (Stenotrophomonas - Bactrim sensitive) and Acenitobacter ( to Unasyn, Gent and Tobra, resistant to FQ, ceftaz, cefepime) # MRSA PNA # ESBL Klebsiella UTI # Morbid obesity # Afib on Coumadin # Hypercholesterolemia # Coccyx Ulcers # MGUS Social History: Used to live with wife, who is HCP.",1
Family History: Non-Contributory Physical Exam: Review of systems: ROS is is negative except for what is mentioned in the HPI .,0
"EXAM Vitals: 971., 115/40, 69, 16, 96%/40% FM GEN: NAD, lying in bed, +trach, obese, awake, alert, HEENT:PERRLA, EOMI, anicteric, MMM neck: +trach in place, c/d/I, supple, unable to assess for JVP.",0
"Chest/Pulmonary:b/l +poor respiratory effort, CTAB anteriorly.",1
"R.sided HD catheter Heart: s1s2 distant heart sounds, unable to appreciate m/r/g.",0
"Abdomen: +bs, obese, soft, NT, ND Ext: s/p R.BKA, wound at stub.",0
"L.leg dusky, dark in color, dry skin, faint pulses.",0
"Back: +stage 4 sacral decub, with multiple surrounding decubs of various stages.",1
+evidence of zoster infection/dermatomal vesicular rash.,0
Neuro: AOx3 Pertinent Results: 03:04AM BLOOD WBC-21.3* RBC-2.72* Hgb-8.3* Hct-25.7* MCV-95 MCH-30.4 MCHC-32.1 RDW-22.5* Plt Ct-232 07:40PM BLOOD WBC-13.2*# RBC-3.27* Hgb-9.1* Hct-29.7* MCV-91 MCH-27.8 MCHC-30.6* RDW-17.7* Plt Ct-415# 03:04AM BLOOD PT-24.6* PTT-64.0* (PT)-2.4* 03:04AM BLOOD Glucose-74 UreaN-22* Creat-1.9*# Na-146* K-3.3 Cl-110* HCO3-24 AnGap-15 03:04AM BLOOD Calcium-8.8 Phos-2.1*# Mg-1.9 08:28AM BLOOD Tobra-3.1* .,0
"CXR IMPRESSION: Cardiomegaly with bilateral small pleural effusions, left greater than right.",0
Retrocardiac opacity may represent a combination of atelectasis and pleural effusions.,0
FOOT 2 VIEWS LEFT PORT Study Date of 10:04 AM FINDINGS: No previous images.,0
There has been resection of the phalanges of the fourth and fifth digits as well as a substantial portion of the fifth metatarsal in a patient with vascular calcification consistent with diabetes.,0
"Specifically, no evidence of erosion of the calcaneus, though there is evidence of an adjacent ulcer.",0
TTE (Complete) Done The left atrial volume is increased.,0
The left atrium is dilated.,0
"Compared with the prior study (images reviewed) of , mild symmetric LVH is present, left ventricular cavity size is smaller and overall left ventricular systolic function has improved.",0
The degree of mitral regurgitation has increased slightly.,0
Moderate pulmonary artery systolic hypertension can be seen on the current study.,0
11:33 am SWAB Source: Stool.,0
**FINAL REPORT ** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ): ENTEROCOCCUS SP..,0
SENSITIVITIES: MIC expressed in MCG/ML ENTEROCOCCUS SP.,0
| VANCOMYCIN------------ >256 R .,0
4:51 am MRSA SCREEN Source: Nasal swab.,0
**FINAL REPORT ** MRSA SCREEN (Final ): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S .,0
6:10 am SPUTUM Source: Endotracheal.,0
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.,0
7:49 pm SPUTUM Source: Endotracheal.,0
RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL FLORA.,1
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | PSEUDOMONAS AERUGINOSA | | AMPICILLIN/SULBACTAM-- 4 S CEFEPIME-------------- =>64 R 32 R CEFTAZIDIME----------- =>64 R 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R 4 S IMIPENEM-------------- 8 I MEROPENEM------------- =>16 R PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- 32 S TOBRAMYCIN------------ 8 I <=1 S TRIMETHOPRIM/SULFA---- =>16 R .,0
11:48 am SPUTUM Source: Endotracheal.,0
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).,0
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.,0
RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT.,1
"COLISITIN AND TIGECYCLINE REQUESTED BY DR.. ,.",0
COLISTIN AND Tigecycline REQUEST SENT TO .,0
"TO ADD TIGECYCLINE ,DURAPENEM AND COLISTIN PER DR. PAGER .",0
DURAPENEM RESISTANT AT >32 MCG/ML Sensitivity testing performed by Etest.,0
TIGECYCLINE AND COLISTIN SENT TO LABORATORIES FOR SENSITIVITY.,0
COLISTIN AND TIGECYCLINE REQUESTED BY DR. .,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | ACINETOBACTER BAUMANNII COMPLEX | | PSEUDOMONAS AERUGINOSA | | | AMPICILLIN/SULBACTAM-- =>32 R CEFEPIME-------------- 32 R =>64 R 8 S CEFTAZIDIME----------- 32 R 4 S CIPROFLOXACIN--------- =>4 R =>4 R =>4 R GENTAMICIN------------ 4 S 2 S 4 S IMIPENEM-------------- =>16 R MEROPENEM------------- =>16 R =>16 R PIPERACILLIN---------- 32 S <=4 S PIPERACILLIN/TAZO----- 64 S 8 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- 2 S LEGIONELLA CULTURE (Final ): NO LEGIONELLA ISOLATED.,0
3:16 pm SPUTUM Source: Endotracheal.,0
"Brief Hospital Course: Mr is a 76 year old man with a chronic trach, s/p multiple admissions, End-stage renal disease, coronary artery disease, atrial fibrillation, type two diabetes and a plasma cell dyscrasia admitted originally with hypotension and sepsis from an infected sacral decub with prolonged hospitalization course involving multiple transfers back and forth between the ICU and floor for hypercapneic respiratory failure secondary to narcotic pain medication.",1
"# Stage IV Decubitus Ulcer: Overall, the patient has a very severe stage 4 sacral decubitus ulcer and multi-drug resistant organisms.",1
He completed a 6 week course of Meropenem on for empiric coverage.,0
A diverting colostomy was performed on to prevent fecal contamination of the wound and to facilitate any possible wound healing.,0
For pain control during wound dressing was managed with various regimens transitioned to IV morphine eventually.,0
# Hypotension: Pt was noted to have a baseline of sBP in the 70s to 80s.,0
On his original day of admission it was thought that it may be a component of sepsis however his BP has persisted even with resolution of sepsis.,0
Pt has been asymptomatic and mentating well with his above noted systolic pressures.,0
His baseline low BP is most likely due to autonomic dysfunction given his negative work up and lack of clinical findings.,0
pt did require intermittent low dose Levophed as pt's BP was decreased to the mid 60s most likely secondary to hypovolemia.,0
Pt was started and continued on midodrine 15 mg po tid.,0
"Throughout , BP's ranged from 60's/20's- 100's/40's thought likley to be chronic sepsis and autonomic dysfuntion.",1
#Pseudomonal Pneumonia: The patient was diagnosed with a possible drug-resistant pseudomonal pneumonia which was treated with a 14 day course of tobramycin finishing .,0
"Following treatment pt showed a negative sputum culture on , pt has not shown any positive blood cultures since admission.",0
# ESRD: Pt was briefly on CVVH for fluid removal for several days in early .,0
"Otherwise, he was maintained on MWF HD.",0
"By the last week of , his pressures were unable to tolerate fluid removal during HD.",0
"# Presumed C.Diff: Pt was started empirically on PO Vancomycin given his course on antibiotics, however they were discontinued given lack of diarrhea and C. diff negative toxin assays.",0
# Chronic Respiratory Failure: He has experienced several transfers between floor status and the ICU for hypercapneic respiratory failure.,1
"Pt is very sensitive to pain medication, particularly Oxycodone.",0
For his decub ulcer pain pt was trialed on Oxycodone of 10mg and became somnelent.,0
Pt has been transitioned to Fentanyl patch 100mcg for baseline pain control plus morphine for dressing changes.,0
"During , his respiratory failure worstened and he was put on ventilator for support.",1
# Coronary Artery Disease: Last echocardiogram with preserved ejection fraction.,0
Had troponin leak on admission which peaked at 0.53.,0
"Pt was continued on simvastatin, his beta blockers were held given his low pressures.",0
# Atrial Fibrillation: Pt's A. fib during hospitalization has been rate controlled.,1
"Due to his score 2 pt was continued on Coumadin in house, given his supratherapeutic pt's Coumadin was held.",0
"In early , coumadin was discontinued all together due to his comorbid conditions and risk of bleeding from multiple ulcers on feet and sacrum.",1
# Type II Diabetes: Pt has diabetes and has been noted to have lower blood sugars following his surgery.,1
His Lantus originally at 28 was transitioned down to 15.,0
Given his recent surgery it was thought he most likely had some malabsorption from bowel edema.,0
Lantus was changed to 15units daily without any further hypogycemia.,0
# Peripheral Vascular Disease: s/p BKA on right with left heel ulcer on leg.,1
Also left second toe ulcer.,0
Was followed by vascular surgery.,0
Left amputation was considered given chronic cyanosis but pt was too unstable for this.,1
"# Plasma Cell Dyscrasia: Known IgA kappa on electrophoresis, bone marrow with 5-10% plasma cells.",0
Also with known retroperitoneal mass s/p non-diagnostic FNA and needle core biopsy indicating lymphoid tissue with quiescent germinal centers.,0
# Pain Control: Patient with significant pain from sacral ulcer.,0
Unfortunately blood pressures and respiratory failure occur with his narcotic use.,1
Pain consult was obtained however recommendations were not favourable given their side effects.,0
He is maintained on the fentanyl patch and trying out morphine concentrate prn before dressing changes.,0
# Upper gastrointestinal bleeding: Patient with guaiac positive NG aspirates on .,1
He has had no subsequent gross bleeding as well as no bleeding out of the ostomy.,0
Following surgery pt's Hct was noted to be 19 and he received 1u PRBC.,0
He increased his Hct appropriately and his subsequent Hcts were noted to be in the mid 20s which is his baseline.,0
Pt was continued on PPI threrapy.,0
# Goals of care: a family meeting was held with ICU team at which the family was informed that there were no further medical or surgical options for treatment.,0
"Code status was changed to DNR/DNI and it was made clear to the family that CVVH, pressors or any escalation in care were not indicated.",0
"No further cultures, radiologic studies were ordered.",0
Pt continued to get MWF blood draws prior to dialysis but pt quickly became unable to tolerate fluid removal due to low BPs during dialysis.,0
Pain was controlled PRN and narcotics were not held in setting of hypotension.,0
"On another conversation with the family and the ICU team took place, at which time the family was informed that Mr blood pressure would not tolerate additional dialysis.",0
"The family decided that the pt would be CMO, and a morphine drip was initiated.",0
On at 11:45 pt passed away from cardiac arrest.,1
"Medications on Admission: epoetin alfa 20,000 units with HD famiotidine 20mg daily recent course with fluconazole/levoflox metoprolol 12.5mg zofran 4mg IV q6h prn nausea percocet 5/325 mg 1-2 tabs, q4h prn pain senna sevelamer 800mg TID simvastatin 10mg daily vanco 1g with HD at Discharge Medications: None Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: End stage renal failure Sepsis Stage 4 Decubitus Ulcer Upper GI Bleeding Pneumonia Hypoxemia Hypotension Altered Mental Status Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None MD Completed by:",1
"11:52 AM CHEST (PORTABLE AP) Clip # Reason: 57 M s/p acute AMI, has IABP in place ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with acute anterior MI REASON FOR THIS EXAMINATION: 57 M s/p acute AMI, has IABP in place ______________________________________________________________________________ FINAL REPORT INDICATION: 57 year old man with acute anterior MI with intra-aortic balloon pump in place.",0
AP PORTABLE SUPINE CHEST RADIOGRAPH: There is persistent stable cardiomegaly with a left ventricular configuration.,0
The mediastinal and hilar contours are stable in appearance.,0
"Allowing for supine, lordotic and portable technique the lungs are clear.",0
"However, the left costophrenic angle has been excluded from the study.",0
"Again noted is the radiopaque marker, presumed to be the IABP, in the mid- thoracic aorta.",0
This measures approximately 11 cm from the top of the aortic knob.,0
Stable cardiomegaly without evidence of failure.,0
IABP radioopaque marker 11 cm from the top of the aortic knob.,0
"8:28 AM CHEST (PORTABLE AP) Clip # Reason: r/o effusion, infiltrate Admitting Diagnosis: DISSECTING ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman s/p emergency asc.",0
"aortic replacement REASON FOR THIS EXAMINATION: r/o effusion, infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 8:32.",0
FINDINGS: The current study shows the right introducer sheath remains in place.,0
There is a sizable right pneumothorax demonstrated.,0
The left hemidiaphragm is not well delineated and left lower lobe atelectasis or pneumonia could be present.,0
IMPRESSION: Development of sizable right pneumothorax.,0
"7:55 PM CHEST (PORTABLE AP) Clip # Reason: eval ETT placement ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with ET intubation, SpO2 low 90s REASON FOR THIS EXAMINATION: eval ETT placement ______________________________________________________________________________ WET READ: DRT SAT 10:10 PM ETT high-riding, ~10cm prox to carina (cd be adv'cd ~4 cm).",0
"NG below diaph, and beyond film.",0
"Diffuse interst process, both lungs; no evid CHF.",0
"______________________________________________________________________________ FINAL REPORT SINGLE VIEW OF THE CHEST DATED HISTORY: 52-year-old woman with low O2-saturation, status post intubation; evaluate ET placement.",0
"FINDINGS: Single bedside AP examination labeled ""supine at 20:05"" with no comparisons.",0
"The newly-placed ET tube is high-riding, with its tip some 9.8 cm proximal to the carina.",0
"Endogastric tube extends below the diaphragm and beyond the study, with its tip and side-hole not seen.",0
"There is diffuse predominantly interstitial, opacity involving both lungs, which appears somewhat more confluent at the bases.",0
"Allowing for the positioning and technique, the heart size and pulmonary vessels are within normal limits, with no supine evidence of pleural effusion or pneumothorax.",1
"COMMENT: Findings posted to the ED dashboard, and discussed with Dr. (ED) at time of dictation.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Percocet Attending: Chief Complaint: shortness of breath, lower extremity edema Major Surgical or Invasive Procedure: Pericardiocentesis, tunneled catheter exchange History of Present Illness: Mr. is a 54-year-old man with a history of AML 11 months s/p matched related allo SCT with busulfan/cyclophosphamide conditioning with complications of CMV viremia, GVHD and hemorrhagic cystitis, and longstanding disseminated TB s/p treatment, who presented on to clinic with 2-day h/o cough, SOB.",1
"No fever, chills, URI symptoms, hemoptysis, chest pain, palpitations, N/V/D, weight change, urinary symptoms, or change in BMs.",0
He also noted discomfort in his left eye which had been bothering him for 1 month.,0
Past Medical History: ONC HISTORY (per OMR): 1.,0
Diagnosed in early with nightly fevers.,0
"Flow cytometry showed aberrant expression of CD2, CD7, HLA-DR, CD 34, dim CD33, CD 117, and CD 71.",0
"CT scan revealednecrotic lymph nodes in the superior mediastinum and periportalregion, and multiple low attenuation lesions in the liver and spleen concerning for microabscesses from a disseminated infection.",0
2. : Induction chemotherapy with cytarabine and idarubicin complicated by persistent fevers and extensive workup ultimately revealing disseminated tuberculosis infection.,1
His course was also complicated by rapid atrial fibrillation and hypotension and the development of a severe cardiomyopathy.,0
"S/P one dose of high-dose ARA-C at 1.5 mg per meter squared, lowered dose due to his disseminated tuberculosis, and then he received a second course of HiDAC at 3 gram per meter squared dose and developed acute onset of gait instability.",1
re-induction with ME on .,0
Noted for pulmonary nodules which were suspicious for aspergillus and empirically treated with Voriconazole with improvement noted on CT. 5.,0
Admitted on for maintenance therapy while awaiting BMT.,0
"However, upon admit he was again found to have blasts.",0
He proceeded with Idarubicin and Cytarabine(7+2) butdid not achieve a remission.,0
S/P High dose Ara-c with remission.,0
7. sibling related allo transplant on .,0
"Allo course c/b increased LFTs of unclear etiology, possibly from chemotherapy, renal failure attributed to CSA, and received only 1 dose of MTX due to mucositis.",0
Post transplant course complicated by asymptomatic CMV viremia and viral/URI syndromes.,0
In developed diarrhea with e/o GVH on endoscopy.,0
"He also had hematuria, but no evidence of BK virus.",0
Diarrhea abated but LFTs rose.,0
Therapy attempted for GVH of liver using pulse of prednisone and increase in CellCept with stabilization but no significant improvement.,0
Received 1mg of Pentostatin on .,0
Started Rituxan for 4 weeks in 5/.,0
"Non-onc PMH - Disseminated TB - s/p treatment with INH, levofloxacin and rifabutin - Hypertension and a heart murmur - Diabetes mellitus type 2 - Chemo related heart failure and cardiomyopathy, EF 35-40% - h/o atrial fibrillation, recent EKGs in NSR - CMV viremia () Social History: He is married and lives at home with his wife & children.",1
"He is a machine operator, but is currently not working.",0
He immigrated from in early .,0
He smoked approximately 3 cigarettes per day for 20 years and stopped 1 year ago.,0
He does not drink alcohol.,0
Family History: Notable for mother who passed away of myocardial infarction.,0
His father passed away of liver disease.,0
"He has four living brothers and two living sisters, all in good health.",0
"Physical Exam: PHYSICAL EXAMINATION ON TRANSFER TO BMT SERVICE: VS: T 98.7, BP 128/84, HR 86, RR 16, 96%RA GENERAL: Pleasant middle-aged man lying in bed in NAD HEENT: PERRL with anicteric sclerae.",0
"No diplopia, extraocular muscle movement intact.",0
"HEART: Reg rate, nl S1/S2, no m/r/g.",0
site without erythema or tenderness.,0
"ABDOMEN: Soft, NT, ND, BS present, no HSM EXTREMITIES: 2+ pitting LE edema to knees bilaterally SKIN: Warm and dry with marked hyperpigmentation changes noted on his torso and lower extremity.",0
Pertinent Results: LABS ON ADMISSION: 10:40AM WBC-2.2*# RBC-2.75* HGB-9.7* HCT-31.2* MCV-114* MCH-35.5* MCHC-31.2 RDW-22.4* 10:40AM NEUTS-32* BANDS-0 LYMPHS-29 MONOS-35* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 PROMYELO-3* NUC RBCS-14* 10:40AM PLT SMR-VERY LOW PLT COUNT-27*# LPLT-2+ 10:40AM GRAN CT-1150* 10:40AM GLUCOSE-115* UREA N-41* CREAT-1.2 SODIUM-141 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13 10:40AM ALT(SGPT)-231* AST(SGOT)-177* LD(LDH)-398* ALK PHOS-916* TOT BILI-1.3 DIR BILI-0.8* INDIR BIL-0.5 10:40AM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-2.1* MAGNESIUM-2.2 URIC ACID-6.0 .,0
STUDIES: * EKG : Sinus tachycardia.,0
Compared to the previous tracing tachycardia has appeared.,0
Voltage has increased in the precordial leads.,0
* Echo : LV systolic function appears depressed.,0
* Echo : There is mild symmetric left ventricular hypertrophy with normal cavity size.,0
* Echo : Very limited views.,0
There is only trivial pericardial effusion.,0
* Echo : Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %).,0
The right ventricular cavity is unusually small but is not frankly collapsing in diastole.,0
There is a large pericardial effusion.,0
"There is sustained right atrial collapse, consistent with low filling pressures or early tamponade.",0
* CXR : Marked short interval enlargement of the cardiac silhouette could represent pericardial effusion or myocarditis.,0
"Brief Hospital Course: Mr. is a 54-yo M h/o AML, 11 months s/p allo SCT, h/o disseminated TB, who presented with pericardial effusion, which was drained.",0
"# Pericardial effusion: In clinic he was found to have new cardiomegaly on CXR, and an echocardiogram revealed a large pericardial effusion.",0
"Mr. a pericardiocentesis in the cath lab, which removed 1300 ml of serosanguinous fluid, creating a fall in RA pressure from 25 to 13 mm Hg.",0
"The patient recovered well in the CCU, with no dyspnea.",0
Subsequent echocardiograms revealed no reaccumulation of the pericardial fluid.,0
The patient continued to recover well after his transfer to the BMT service.,0
"He experienced no dyspnea, no chest pain by discharge.",0
The pericardial fluid studies were unrevealing.,0
"The possible etiologies included post-viral pericardial effusion, GVHD, or TB reactivation.",0
He was sent home with an appointment for a repeat chest CT on .,0
"# AML: On , prior to this admission, the patient a bone marrow for persistent pancytopenia.",1
The marrow showed no sign of active leukemia.,1
"He was continued on prophylatic regimen of acyclovir, atovaquone, and posaconazole.",0
He was discharged with instructions to follow up with Dr. on .,0
# History of TB: Mr. recent disseminated TB infection prompted TB precautions and isolation.,1
Induced sputum was AFB negative.,0
The patient had no coughs by discharge.,0
He was to follow up in the clinic on .,0
# Urinary tract infection: The patient was found to have Morganella and enterococcus in his urine.,1
"Given his complicated history of hemorrhagic cystitis, he was started and sent home with cefpodoxime and daptomycin to finish a 14-day course.",0
"# GVHD: chronic extensive GVHD as evidenced by his increased liver enzymes, skin and mouth changes.",0
"He was continued on prednisone, and mycophenolate 250 mg was restarted.",0
# pancytopenia: The patient required platelet transfusions.,0
His WBC was 2.2 on admission.,0
"By discharge, however, his WBC was 5.5 with Hct 32 and platelets 63. .",0
"# Left eye discomfort: not injected, not painful.",0
Ophthalmology was consulted and recommended aggressive eye hydration and Lumigan drops.,0
He was sent home with instructions to follow up in the ophthalmology clinic.,0
# DMII: The patient was continued on an insulin regimen.,0
# HTN: He was continued on metoprolol.,0
"Access: His double-lumen catheter was exchanged, by Interventional Radiology, for a triple-lumen tunneled catheter.",0
"Medications on Admission: ACYCLOVIR 400 mg--1 tablet(s) by mouth twice a day ATOVAQUONE 750 mg/5 mL--10 ml suspension(s) by mouth once a day BACITRACIN ZINC 500 unit/gram--Apply topically four times a day as needed for penile pain BD Insulin Syringe 25 gauge X ""--as directed CELLCEPT mg--1 capsule(s) by mouth three times a day DEXAMETHASONE 0.5 mg/5 mL--5 ml by mouth twice a day swish and spit.",0
three times a day VITAMIN E 400 unit--1 capsule(s) by mouth daily Insulin Glargine 100 unit/mL--14 units sq daily PYRIDIUM 200 mg--1 (one) tablet(s) by mouth once a day Discharge Medications: 1.,0
Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours).,0
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*2* 2.,0
Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours).,0
Dexamethasone 0.5 mg/5 mL Solution Sig: 0.5 ML PO BID (2 times a day).,0
Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed.",0
Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY (Daily).,0
"Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic (2 times a day).",0
Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Artificial Saliva 0.15-0.15 % Solution Sig: Thirty (30) ML Mucous membrane Q2H (every 2 hours) as needed.,0
Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed.,0
Posaconazole 200 mg/5 mL Suspension Sig: Two Hundred (200) mg PO TID (3 times a day).,0
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Drops Ophthalmic q4hours and prn.,0
Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)).,0
Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime: both eyes.,0
Daptomycin 500 mg Recon Soln Sig: Three Hundred (300) mg Intravenous Q24H (every 24 hours) for 8 days.,0
Insulin Regular Human 100 unit/mL Solution Sig: resume your home insulin regimen Injection four times a day.,0
Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed.,0
Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QFRI (every Friday).",0
Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days.,0
Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
Disp:*90 Capsule(s)* Refills:*2* 29. catheter Sig: One (1) as needed: Please perform catheter care per protocol.,0
"When not in use, catheter is to be flused with 1000 unit/cc heparin equal to the volume of the catheter.",0
Caps on the catheter are changed every 7 days.,0
Heparin Flush 100 unit/mL Kit Sig: as needed 1000 units/cc Intravenous per protocol: 1000 units/cc heparin flush.,0
Saline Flush 0.9 % Syringe Sig: as needed Injection as needed.,0
"Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary diagnoses: Pericardial tamponade, urinary tract infections Secondary diagnoses: acute myelogenous leukemia, tuberculosis infection, diabetes mellitus type 2, hypertension Discharge Condition: Stable.",1
Lower extremity edema 2+ bilaterally.,0
Discharge Instructions: You presented to with shortness of breath on .,0
"You were found to have fluid in the sac surrounding your heart, a condition called pericardial effusion.",0
It was unclear what caused the fluid accumulation.,0
You were given medications to help remove extra fluid in body to help you breath better and reduce your leg swelling.,0
You were also found to have a urinary tract infection.,1
Please take your antibiotics as .,0
Please follow up with your doctors below.,0
Please take all medications as .,0
"If you develop shortness of breath, chest pain, any difficulty breathing, worsening leg swelling, fevers, chills, or any other symptom that concerns you, please call your doctor or go to the nearest Emergency Room.",0
"Followup Instructions: * Radiology for chest CT: 9 am , Building, , * Oncologist: Dr. , , at 2:30 p.m. * Infectious Disease: Dr. , , at 11:30 a.m. * Ophthomologist: please call to make an appointment within 2 weeks for follow-up care of your eyes * Primary care: please call Dr. office at to make an appointment within 2 weeks",0
"7:21 AM CHEST (PORTABLE AP) Clip # Reason: question interval change, pneumonia, effusion Admitting Diagnosis: SYNCOPE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with CAD, NSTEMI type II, in cardiogenic shock s/p PCI.",1
"REASON FOR THIS EXAMINATION: question interval change, pneumonia, effusion ______________________________________________________________________________ FINAL REPORT HISTORY: CAD, cardiogenic shock, question interval change.",1
"An ET tube is present, in satisfactory position.",0
"An NG tube is present, tip beneath diaphragm, extending off film.",0
"A thin-caliber tube extends along the mediastinum, with the tip overlying the gastric fundus.",0
An additional line overlying the mediastinum may lie outside the patient.,0
"A right IJ central line is present, tip over distal SVC.",0
"There is some increased retrocardiac density consistent with left lower lobe collapse and/or consolidation, and minimal atelectasis at the right base.",0
"Compared with at 8:12 a.m., no definite interval change.",0
10:51 AM C-SPINE SGL 1 VIEW Clip # Reason: 27 yr old male s/p adjustment of halo please do lateral view Admitting Diagnosis: MVA ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with REASON FOR THIS EXAMINATION: 27 yr old male s/p adjustment of halo please do lateral view c-spine xray ______________________________________________________________________________ FINAL REPORT INDICATIONS: Adjustment of halo in patient with C2 fracture.,0
"CERVICAL SPINE, SINGLE VIEW: The halo is in place.",0
Slight irregularity along the anterior cortex of the dens base is noted.,0
There is also irregularity along the posterior cortex at the junction between the dens and the C2 body.,0
"No listhesis of the body of C2 with respect to C3 is identified, although I suspect slight angulation at the junction between the dens fragment and the body of C2.",0
The atlantodental interval is not widened.,0
Height: (in) 65 Weight (lb): 155 BSA (m2): 1.78 m2 BP (mm Hg): 125/51 HR (bpm): 63 Status: Inpatient Date/Time: at 11:18 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.,0
"RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.",0
Doppler parameters are most consistent with c/w Grade II (moderate) LV diastolic dysfunction.,0
See Conclusions for post-bypass data Conclusions: PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
Dr. was notified in person of the results at time of surgery.,0
POST-BYPASS: The patient is AV paced.,0
The patient is on no inotropes.,0
"There is a well-seated, well-functioning bioprosthetic valve in the aortic position.",1
No paravalvular leak is seen.,0
There is a mean gradient of 7 mmHg across the aortic valve at a cardiac index of 2.1.,1
9:48 AM CHEST (PORTABLE AP) Clip # Reason: eval for fracture acute process ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman s/p MVC REASON FOR THIS EXAMINATION: eval for fracture acute process ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old female status post motor vehicle accident.,1
AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is normal in size.,0
There is no pneumothorax bilaterally.,0
There is slight bilateral hilar fullness.,0
The left lung is grossly clear.,0
"There is mild blunting of the right costophrenic angle, consistent with a small right-sided pleural effusion.",0
Additional linear atelectasis is seen within the right lung base.,0
The thoracic vertebral bodies are not clearly visualized due to overlying soft tissues.,1
No evidence of rib fractures.,0
Linear atelectasis within the right lung base.,0
"7:13 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: trauma Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with trauma REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: MXAk SUN 8:41 PM Bibasilar atelectasis but no significant intrathoracic, intraabdominal, or intrapelvic injury.",0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of patient status post trauma.,0
COMPARISON: CT head from .,0
TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet to the pubic symphysis after administration of 130 mL of Optiray nonionic intravenous contrast.,0
Multiplanar reformatted images were prepared.,0
FINDINGS: CT CHEST WITH IV CONTRAST: There is residual thymic tissue.,0
Bibasilar opacities are visualized consistent with atelectasis.,0
The visualized portions of the heart and great vessels are normal.,0
The aorta is normal in caliber and contour.,0
No pericardial or pleural effusion is present.,0
An endotracheal tube is visualized with the tip terminating in the proper location.,0
An NG tube is visualized with the tip in the stomach.,0
"No mediastinal, hilar, or axillary lymphadenopathy by CT size criteria.",0
"CT OF THE ABDOMEN WITH IV CONTRAST: There is mild periportal edema as well as a prominent inferior vena cava, likely due to fluid resuscitation.",0
"Otherwise, the liver, gallbladder, spleen, pancreas, bilateral kidneys, bilateral adrenal glands, and bilateral ureters are within normal limits.",0
Stomach and visualized loops of small and large bowel are within normal limits.,0
No free fluid or free air throughout the abdomen.,0
No mesenteric or retroperitoneal lymphadenopathy.,0
The abdominal aorta is normal in caliber and contour.,0
CT OF THE PELVIS WITH IV CONTRAST: A Foley is visualized in the bladder.,0
"The bladder, prostate, rectum, and sigmoid colon are within normal limits.",0
There is no free fluid or free air throughout the pelvis.,0
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous lesions.,0
No evidence of fractures or abnormal alignment.,0
"(Over) 7:13 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: trauma Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: No evidence of acute intrathoracic, intra-abdominal or intrapelvic injuries.",0
"Bilateral dependent airspace opacities in the lungs, likely atelectasis.",0
"LINE PLACEMENT Clip # Reason: pneumothorax after failed RSC CVL, now RIJ CVL Admitting Diagnosis: S/P MOTORCYCLE CRASH ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with multiple trauma, s/p CVL for IV access.",1
"REASON FOR THIS EXAMINATION: pneumothorax after failed RSC CVL, now RIJ CVL ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: History of trauma.",0
PORTABLE CHEST RADIOGRAPH: Compared to radiographs taken one day prior.,0
The tip of the right IJ central venous catheter overlies the proximal atrial caval junction.,0
"The heart size, mediastinum, hilar structures are normal.",0
IMPRESSION: Placement of right IJ central venous catheter as described above.,0
"4:25 AM PORTABLE ABDOMEN Clip # Reason: eval bowel changes Admitting Diagnosis: GASTRIC VOLVULUS ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with nausea/constipation, POD5 s/p paraesophageal hernia repair REASON FOR THIS EXAMINATION: eval bowel changes ______________________________________________________________________________ FINAL REPORT INDICATION: 89-year-old woman with nausea, constipation postoperative day 5, evaluation of bowel changes.",0
FINDINGS: Ventricular leads are seen ending at the apex of the heart.,0
Mild blunting of the right costophrenic angle and the left costophrenic angle suggests a pleural effusion.,0
"For complete thoracic evaluation, please refer to the concurrent chest radiograph.",0
Air and stool are seen throughout the large colon and air is seen within the small bowel.,0
There is no bowel distention or free air.,0
The lumbar cervical spine shows left-sided convex scoliosis.,0
The osseous structures are otherwise unremarkable.,0
"Height: (in) 72 Weight (lb): 168 BSA (m2): 1.98 m2 BP (mm Hg): 106/64 HR (bpm): 56 Status: Inpatient Date/Time: at 15:07 Test: TTE (Congenital, complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.",1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; mid inferior - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Eccentric AR jet directed toward the anterior mitral leaflet.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. of papillary muscles.,0
There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior wall.,0
The remaining segments contract normally and overall LVEF is preserved (LVEF = 60 %).,0
The aortic valve is bicuspid (fused right and left raphe) with mildly thickened/restricted leaflets.,1
"An eccentric jet of moderate (2+) aortic regurgitation is seen, directed toward the anterior mitral leaflet.",0
IMPRESSION: Left ventricular cavity enlargement with regional systolic dysfunction c/w CAD.,0
Bicuspid aortic valve with mild aortic stenosis and moderate eccentric aortic regurgitation.,1
"1:32 AM CHEST (PORTABLE AP) Clip # Reason: febrile, wkup Admitting Diagnosis: S/P RESECTION ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p right hepatic lobe resection, Roux en Y hepaticojejunostomy, c/ b/l lower lobe PNA, increased secretions REASON FOR THIS EXAMINATION: febrile, wkup ______________________________________________________________________________ FINAL REPORT INDICATION: Fever, history status post right hepatic lobe resection and hepaticojejunostomy, recent bilateral lower lobe pneumonia.",0
PORTABLE UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 1:40 A.M.: The right IJ remains in place at the cavoatrial junction.,0
2 drainage catheters remain in place in the upper abdomen.,0
Lungs are well expanded and clear without consolidation.,0
"The pleural effusions appear well resolved, however, the left costophrenic angle is not seen in its entirety on this film.",0
"There remains a hazy opacity over the right costophrenic angle, not obscuring the diaphragm, suggestive of a pleural reaction rather than pleural effusion.",0
The heart size is normal and there is no pulmonary edema.,0
IMPRESSION: No apparent interval change.,0
Opacity at the right costophrenic angle may be pleural reaction rather than effusion.,0
12:44 PM MR ORBIT W &W/O CONTRAST; MR HEAD W/O CONTRAST Clip # Reason: r/o worsening fluid collection periorbital or change in sinu Admitting Diagnosis: PERIORBITAL STREP CELLULITIS Contrast: MAGNEVIST Amt: ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with worsening left eye pain REASON FOR THIS EXAMINATION: r/o worsening fluid collection periorbital or change in sinus disease (please also review right eye which swelled yesterday but resolved) No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Worsening left eye pain.,1
Rule out worsening fluid collection or periorbital change.,0
TECHNIQUE: Multiplanar T1 and T2-weighted sequences were obtained through the orbits with multiplanar post-gadolinium T1 imaging.,0
"FINDINGS: As on the prior examination, there is a left periorbital post- septal abscess just lateral to the lateral rectus muscle with rim enhancement as on the prior examination.",1
"In addition, as on the prior exam, there is a large soft tissue fluid collection just lateral and inferior to the left eye measuring 1.4 x 3.8 cm.",0
This lies immediately superficial to the skin.,0
it courses inferiorly and laterally down to the level of the zygoma.,0
"However, there is a soft tissue plane between the fluid collection and the adjacent zygomatic arch.",0
Correlation with physical examination as this collection appears to be very superficial.,0
There is a large amount of both pre-septal and post-septal periorbital cellulitis.,1
"As on the prior exam, there may be some small areas of increased T2 signal on the STIR sequence within the intraconal fat, indicating intracranial extension.",0
No enhancement in this area is noted.,0
"Again, there is slow diffusion within the left optic nerve, as noted on the prior examinations.",0
This finding could be consistent with ischemic optic neuritis.,0
"As on the prior exam, there is enhancment and edema within the left temporomandibular joint, indicating it is likely infected.",0
These findings are contiguous with the periorbital phlegmon/cellulitis.,1
"The brain parenchymal signal appears, however, normal.",0
There are no enhancing intracranial abnormalities.,0
"As before, there is proptosis.",0
There is fluid within the mastoid air cells on the left.,0
"Polypoid areas of mucosal thickening are also noted within both maxillary sinuses, left greater than right.",0
The right eye appears normal with no evidence of post-septal abnormalities.,0
There is no evidence of periorbital cellulitis on the right.,1
IMPRESSION: (Over) 12:44 PM MR ORBIT W &W/O CONTRAST; MR HEAD W/O CONTRAST Clip # Reason: r/o worsening fluid collection periorbital or change in sinu Admitting Diagnosis: PERIORBITAL STREP CELLULITIS Contrast: MAGNEVIST Amt: ______________________________________________________________________________ FINAL REPORT (Cont) No significant change in the size of the abscess just lateral to the left lateral rectus muscle.,1
Unchanged large superficial soft tissue abscess just inferior to and lateral to the left orbit.,0
Unchanged appearance of the left periorbital pre- and post-septal cellulitis.,1
"Again, there is abnormally slow diffusion within the left optic nerve (?ischemic optic neuritis).",0
Unchanged appearance of the left temporal mandibular joint with enhancement and edema concerning for infection.,0
"8:15 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: Pleaseae eval hepatic and portal flows Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/o Liver Transplant REASON FOR THIS EXAMINATION: Pleaseae eval hepatic and portal flows ______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old man status post liver transplant, evaluate for hepatic and portal venous flow.",1
COMPARISON: Pre-transplant ultrasound from .,0
FINDINGS: The liver demonstrates no focal or textural abnormality.,1
There is a small amount of free fluid.,0
"There is no intra or extrahepatic biliary dilation, the CBD measures up to 3 mm.",0
"Doppler evaluation demonstrates hepatopetal flow in the portal venous system with normal waveforms in the MPV, RAPV and RPPV.",0
The inferior vena cava is patent with normal respiratory phasicity.,0
"The left hepatic vein waveform evaluation is technically limited, however, appears grossly patent.",0
Good venous flow is noted in the right hepatic vein.,0
"There is patent arterial vasculature with brisk systolic upstroke and good diastolic flow in main, right and left hepatic arteries.",0
IMPRESSION: No focal or textural hepatic parenchymal abnormalities.,1
Height: (in) 60 Weight (lb): 125 BSA (m2): 1.53 m2 BP (mm Hg): 136/73 HR (bpm): 69 Status: Inpatient Date/Time: at 15:45 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is markedly dilated.,0
MITRAL VALVE: A bileaflet mitral valve prosthesis is present.,0
TRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.,0
GENERAL COMMENTS: Bilateral pleural effusions are present.,0
A bileaflet mitral valve prosthesis is present.,0
There is an echogenic density in the right ventricle consistent with a pacemaker lead.,0
"Compared with the findings of the prior report (tape unavailable for review) of , there is a decrease in LV function",0
"Name: , A Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Iodine / Erythromycin Base Attending: Addendum: Please note that Ms. was discharged home with home IV antibiotics and home PT.",0
Discharge Disposition: Home With Service Facility: VNA MD Completed by:,0
"4:13 PM CHEST (PORTABLE AP) Clip # Reason: acute desat ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with unresponsiveness, intubated, question hemoptysis REASON FOR THIS EXAMINATION: acute desat ______________________________________________________________________________ FINAL REPORT Portable chest of compared to previous study of earlier the same day.",0
CLINICAL INDICATION: Acute oxygen desaturation.,0
"An endotracheal tube, feeding tube and central venous catheter are in satisfactory position.",0
There has been interval improvement in bibasilar areas of increased lung opacification.,0
There remains some increased opacity in the left retrocardiac region.,0
The right lower lobe peripherally has been excluded from the study and cannot be assessed.,0
No pneumothorax is evident in the imaged portions of the lungs.,0
IMPRESSION: Rapid interval improvement in previously present bilateral lower lobe consolidation.,0
"Given such rapid resolution, this may have been due to an aspiration event.",0
Some residual left lower lobe opacity remains in the retrocardiac region although this is significantly improved from before.,0
11:12 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: extent of the lesion Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: year old woman with stroke REASON FOR THIS EXAMINATION: extent of the lesion ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: -year-old female to rule out acute stroke.,1
MRI and MRA of the brain was performed without administration of contrast.,0
"FINDINGS: Abnormal diffusion is noted in the posterior left frontal lobe in the precentral gyrus region, consistent with acute stroke.",0
Subacute/chronic infarct is noted in the right cerebellar region as evidenced by abnormal signal on T2 and FLAIR images with shine through artifact on diffusion-weighted images.,0
Patchy areas of hyperintensity are noted in the periventricular deep white matter consistent with a small vessel disease.,0
"A punctate area of susceptibility abnormality is noted in the right cerebellum, may represent tiny calcification versus tiny punctate hemorrhage.",0
IMPRESSION: 1) Acute infarct is noted in the left posterior frontal lobe.,0
2) Subacute/chronic infarct noted in the right cerebellum.,0
"These findings were discussed with Dr. by the radiology resident on call, Dr. .",0
"12:39 PM CHEST (PORTABLE AP) Clip # Reason: check for pneuomothorax Admitting Diagnosis: CARDIAC STENOSIS\MITRAL VALVE REPLACEMENT; HEART PORT MINIMALLY INVASIVE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with AVR and pacemaker REASON FOR THIS EXAMINATION: check for pneuomothorax ______________________________________________________________________________ FINAL REPORT CHEST, AP PORTABLE: INDICATION: Pacemaker and aortic valve replacement.",1
AP single view of the chest is analyzed in direct comparison with the next preceding similar study of .,0
Patient is now extubated and NG tube and SG catheter have been removed.,0
The pacer wire has been advanced via the right IJ vein approach and its termination point coincides with the position in the apical portion of the right ventricle.,0
There is no pneumothorax or other placement related complication.,0
Heart size remains within normal limits.,0
Anatomy and position of aortic valve prosthesis metallic structures unchanged.,1
No significant pulmonary vascular congestion pattern and no new parenchymal infiltrates.,0
The lateral pleural sinuses are free.,0
IMPRESSION; Satisfactory findings on follow-up examination.,0
", M. TSURG FA7A 2:08 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: interval change.",0
"please give contrast through J tube Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man s/p esophagectomy, now septic?",0
s/p IR pelvic and thorax drainage REASON FOR THIS EXAMINATION: interval change.,0
please give contrast through J tube No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.,0
Increase in multifocal lung opacification consistent with worsening pneumonia.,0
Redistribution and slight decrease in right loculated pleural effusion with persistent small air locules.,1
"Persistent smaller left pleural effusion likely with chylous components, essentially unchanged appearance of neoesophagus.",1
Decreased size of intra-abdominal/intrapelvic air-containing fluid collection with pigtail catheter seen within this collection.,0
"7:03 AM CHEST (PORTABLE AP) Clip # Reason: CHF Admitting Diagnosis: LYME CARDITIS,CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with possible Lyme disease and CHF in respiartory distress REASON FOR THIS EXAMINATION: CHF ______________________________________________________________________________ FINAL REPORT INDICATION: 80-year-old man with Lyme disease, CHF, question congestive heart failure.",1
SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There are low lung volumes.,0
"Again seen are bilateral moderate pleural effusions with associated left lower lobe and right lower lobe consolidation, which likely represents a combination of pneumonia and atelectasis.",1
The perihilar hazy opacities have improved since the prior exam.,0
There is no evidence of central venous hypertension.,0
Again noted is some scarring at the upper lobes.,0
Interval improvement of mild congestive heart failure with persistent bilateral moderate-sized pleural effusions.,1
"Bilateral lower lobe consolidation, which likely represents a combination of atelectasis and pneumonia.",0
"4:29 PM N-G TUBE PLACEMENT Clip # Reason: g tube placement Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ********************************* CPT Codes ******************************** * NASAL/OROGASTRC TUBE PLMT, PRO -52 REDUCED SERVICES * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: year old woman with dysphagia due to stroke will need g tube placed under IR guidance REASON FOR THIS EXAMINATION: g tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old woman with left MCA stroke with need for G-tube placement.",0
The patient was in the IR suite having just had her picc line repositioned without incident.,0
Plans were for placement of a nasogastric tube in anticipation of new percutaneous g-tube insertion.,0
Multiple attempts were made to place a 5 French angiographic catheter (which would serve as a nasogastric tube) by Dr. (resident) and Dr. (fellow).,0
The patient was unable tolerate this and hence the procedure was terminated.,0
The patient was on hemodynamic monitoring (from preceding procedure)and she became hypertensive necessitating administration of hydralazine with good effect.,0
By the time of transport back to her room the patient was stable.,0
Findings were discussed with Dr. at 5:30 p.m. on via telephone.,0
"The findings also discussed with the healthcare proxy, Mr. , at 5:45 p.m. on in person.",0
6:13 PM MR HEAD W & W/O CONTRAST; MR Clip # Reason: Please obtain well localized arterial spin labeling perfusio Admitting Diagnosis: STROKE/TIA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with ?,0
R parietal stroke vs GBM.,0
Has MRI with stroke protocol on already.,0
"REASON FOR THIS EXAMINATION: Please obtain well localized arterial spin labeling perfusion, multi voxel , pre/post Gd T1, Gradient echo and DWI.",0
No need to repeat full stroke study.,0
CLINICAL INFORMATION: Patient with right parietal stroke versus infiltrating tumor for further evaluation with perfusion and .,0
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained before gadolinium.,0
"T1 sagittal, axial and coronal images were obtained following gadolinium.",0
Arterial spin labeling perfusion imaging of the brain was also acquired.,0
Comparison was made with the previous MRI examination of .,0
"FINDINGS: As seen on the previous MRI examination, there is an area of increased T2 and FLAIR signal seen in the right posterior frontal and parietal lobes with predominant subcortical involvement.",0
There are two small rounded areas of slow diffusion identified at the convexity which are atypical for infarcts.,0
"Following gadolinium, a small area of enhancement is identified within this signal abnormality.",0
The arterial spin labeling perfusion imaging demonstrate evidence of increased perfusion in the right parietal cortical/subcortical region.,0
This finding suggestive of neoplastic lesion as compared to an infarct.,0
The examination is otherwise unchanged with the left occipital meningioma as described previously.,0
Mild-to-moderate brain atrophy is seen.,0
IMPRESSION: The enhancement pattern and the ASL perfusion findings are suggestive of an infiltrative brain neoplasm as compared to an infarct.,1
Please also see the report of for further assessment.,0
"10:51 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p right chest tube pull, r/o pnuemothorax.",0
"Admitting Diagnosis: MYOCARDIAL INFARCTION;CONGESTIVE HEART FAILURE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman s/p cabg x2 REASON FOR THIS EXAMINATION: s/p right chest tube pull, r/o pnuemothorax.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old woman status post CABG.,0
COMMENTS: Portable AP radiograph of the chest is reviewed and compared to the previous study at 10:28 a.m.,0
The patient is status post CABG and median sternotomy.,0
The tip of the endotracheal tube is identified 2 cm above the carina.,0
The left jugular Swan-Ganz catheter terminates in the right main PA. A nasogastric tube terminates in the gastric body.,0
There is continued small left pleural effusion and patchy atelectasis in the left lung base.,0
Height: (in) 64 Weight (lb): 138 BSA (m2): 1.67 m2 BP (mm Hg): 117/78 HR (bpm): 98 Status: Inpatient Date/Time: at 16:26 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
MITRAL VALVE: Mechanical mitral valve prosthesis (MVR).,0
"No MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
Conclusions: The interatrial septum is aneurysmal.,0
There is severe global left ventricular hypokinesis (LVEF = %).,0
"Compared with the prior study (images reviewed) of , left ventricular systolic function has declined.",1
The severity of aortic regurgitation has increased.,0
"10:19 PM CHEST (PORTABLE AP) Clip # Reason: CHF,CAD ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with s/p fem- bpg.",0
"Hx IDDM, CAD, CRI (s/p renal transplant), HTN, COPD, PVD.",0
REASON FOR THIS EXAMINATION: dka r/o infection ______________________________________________________________________________ FINAL REPORT INDICATION: S/P vascular surgery with fluid overload and CHF.,0
FINDINGS: Single portable chest radiograph in comparison to .,0
A right internal jugular catheter is present unchanged in position.,0
The patient is S/P sternotomy.,0
Again seen is bilateral interstitial and alveolar consolidations that do not appear significantly changed when differences in technique are taken into consideration.,0
No pneumothorax or pleural effusions are seen.,0
The heart is unchanged in size.,0
IMPRESSION: Persistent bilateral interstitial and alveolar opacification.,0
"This likely represents persistent fluid overload; however, in a patient S/P renal transplantation, an atypical infection cannot be excluded.",0
Height: (in) 65 Weight (lb): 170 BSA (m2): 1.85 m2 BP (mm Hg): 125/67 HR (bpm): 86 Status: Inpatient Date/Time: at 08:07 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; inferior apex - hypo; lateral apex - hypo; remaining LV segments contract normally.,1
There is mild to moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the inferior and inferolateral walls.,1
The right ventricular cavity is dilated with mild global hypokinesis.,0
IMPRESSION: Small circumferential pericardial effusion with no echocardiographic evidence of tamponade.,0
Mild to moderate regional left vetnricular systolic dysfunction c/w CAD.,0
Right ventricular dilation and mild global hypokinesis.,0
Mild aortic and mitral regurgitation.,0
9:47 PM CT HEAD W/O CONTRAST Clip # Reason: eval s/p evd placement Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Field of view: 25 ______________________________________________________________________________ MEDICAL CONDITION: 31 year old man with sah REASON FOR THIS EXAMINATION: eval s/p evd placement No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc MON 11:26 PM Interval decrease in size and extent of hemorrhage within the right lateral ventricle following placement of ventricular catheter.,1
Stable left lateral ventricle and right frontal parenchymal hemorrhage.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old man with subarachnoid hemorrhage, status post EVD placement.",1
"FINDINGS: There has been interval placement of a right frontal approach ventricular catheter, which terminates in the right lateral ventricle at the midline.",0
"It follows a path similar to the course of the prior catheter, and runs adjacent to a small focus of hemorrhage noted on yesterday's study, which is unchanged.",0
"There has been a slight interval decrease in size of the right lateral ventricle, with a decrease in the amount of hyperdense material.",0
The left lateral ventricle is largely unchanged.,0
The third ventricle also contains less hyperdense material than previously.,0
The large intraparenchymal hemorrhage within the right frontal lobe is unchanged in configuration.,0
Hemorrhage again extends into the fourth ventricle.,0
There are no new foci of hemorrhage.,0
There is no new shift of normally midline structures.,0
Coils within the anterior communicating aneurysm are unchanged.,0
Surgical material is present in the right scalp anteriorly.,0
There is an adjacent burr hole through the right frontal bone.,0
"Otherwise, bony structures are unremarkable.",0
"IMPRESSION: Interval decrease in size and amount of hemorrhage within the right lateral ventricle, following placement of right ventricular catheter.",0
Stable appearance of left lateral ventricle and extensive right frontal parenchymal hemorrhage.,0
(Over) 9:47 PM CT HEAD W/O CONTRAST Clip # Reason: eval s/p evd placement Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Field of view: 25 ______________________________________________________________________________ FINAL REPORT (Cont),1
"1:31 PM PORTABLE ABDOMEN Clip # Reason: eval bowel gas pattern for obstruction Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with asthma, COPD, bronchiectasis, with LLL PNA on abx.",1
with persistent intolerance to bowel prep REASON FOR THIS EXAMINATION: eval bowel gas pattern for obstruction ______________________________________________________________________________ FINAL REPORT INDICATION: Intolerance to bowel prep.,0
FINDINGS: A single portable supine abdominal radiograph is reviewed and compared to CT of the abdomen from .,0
There is no free intraperitoneal air.,0
"Air is seen within a few loops of mildly distended transverse colon, but the cecum is not dilated.",0
No dilated loops of small bowel are seen.,0
"The lower pelvis is excluded on current film, and the presence of air within the rectum cannot be assessed.",0
No air-fluid levels are visualized.,0
"IMPRESSION: Mildly distended loops of colon, without definite evidence of obstruction.",0
Findings could represent colonic ileus.,0
"11:24 PM CHEST (PORTABLE AP) Clip # Reason: Suspect pulmonary edema, please evaluate for infiltrate vs.",0
"Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: year old woman with hypoxia, history of COPD and diastolic CHF with diffuse crackles REASON FOR THIS EXAMINATION: Suspect pulmonary edema, please evaluate for infiltrate vs. edema ______________________________________________________________________________ FINAL REPORT HISTORY: Hypoxia, question infiltrate Vs. edema.",1
"CHEST, SINGLE AP PORTABLE VIEW: There is mild diffuse blurring thought to relate to slight patient motion.",0
"The lungs are hyperinflated, consistent with COPD.",0
There is moderately severe cardiomegaly.,0
The aorta is tortuous and unfolded.,0
"There is upper zone redistribution and pulmonary vascular plethora, consistent with CHF, improved compared with .",1
"There are small bilateral effusions, increased retrocardiac density consistent with left lower lobe collapse and/or consolidation, and a smaller area of collapse/consolidation at the right base.",0
Changes at the right base are new compared with .,0
Retrocardiac density is difficult to compare due to differences in positioning.,0
Right apical calcified granuloma again noted.,0
Probable granuloma left upper quadrant as well.,0
Old healed left and right rib fractures are noted.,0
COPD and moderately severe cardiomegaly.,0
"Upper zone redistribution, with mild CHF, improved compared with .",0
Left lower lobe collapse and/or consolidation and probable small left effusion.,0
"Patchy opacity right base consistent with atelectasis and/or consolidation and probable small right effusion, new compared with .",0
10:52 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # Reason: evaluate for free air Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant BORN AT 27 WEEKS GESTATION REASON FOR THIS EXAMINATION: evaluate for free air ______________________________________________________________________________ FINAL REPORT The patient had compensated acutely.,1
"Prior supine film is concerning for free air, but the decubitus film negated this finding.",0
A repeat supine film including the chest and abdomen have been performed.,0
The cardiac silhouette remains enlarged and this is a stable finding.,0
"There are still diffuse interstitial opacities throughout the lungs, but overall the lung aeration seems improved from prior studies.",0
Endotracheal tube is in adequate position.,0
Bowel gas pattern remains stable with no dilatation of the bowel loops.,0
The prior lucency seen in the right abdomen is not appreciated on this study.,0
The left catheter tip is probably in the intrahepatic IVC.,0
The results were discussed with the NICU team.,0
5:00 PM FEMUR (AP & LAT) LEFT; TIB/FIB (AP & LAT) LEFT Clip # ANKLE (2 VIEWS) LEFT Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: year old with REASON FOR THIS EXAMINATION: trauma ______________________________________________________________________________ FINAL REPORT INDICATION: Pain.,0
"LEFT FEMUR & TIBIA/FIBULA, 6 VIEWS: There are no fractures or dislocations of the left femur.",1
Vascular calcification is present in the superficial femoral artery and popliteal artery.,0
Evaluation of fine detail in the tibia and fibula is limited by the overlying splint.,1
There are comminuted fractures of the medial diaphyses of both the tibia and fibula with medial displacement of the distal fragments.,1
There is cortical irregularity of the fibular head seen only on the AP view; evaluation of this area is limited by artifacts from the overlying splint.,0
IMPRESSION: Comminuted fractures of the proximal left tibia and fibula are present with medial displacement of the fracture fragments.,1
There may be a non-displaced fracture of the fibular head which is obscured by the overlying splint and only seen on the AP view.,1
There is no osseous injury of the left femur.,0
4:06 PM MR CERVICAL SPINE; MR THORACIC SPINE Clip # Reason: 62 yo woman metastatic breast CA to brain and meningesis s/p ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with metastatic breast ca see above Deem REASON FOR THIS EXAMINATION: 62 yo woman metastatic breast CA to brain and meningesis s/p IT thiotepa and Adriomycin.,1
For Monday ______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic breast cancer s/p chemotherapy.,0
"T1 and T2 sagittal images of the cervical and thoracic spine, in addition to gradient echo axial images from C3 to T1 were obtained.",0
No contrast was given on today's exam.,0
"The vertebral bodies demonstrate normal height, signal intensity and alignment.",0
No pathologic compression fractures are seen and there is no extrinsic cord compression.,0
Sagittal images through the posterior fossa reveal moderate dilatation of the fourth ventricle raising the suggestion for possible communicating hydrocephalus.,0
Correlation with MRI of the brain is recommended.,0
"There are several disc desiccations seen at C3/4, C4/5 and C5/6 level.",0
There is moderate uncovertebral hypertrophy seen at C4/5 and right worst than left at C5/6 levels resulting in narrowing of the exit neural foramina.,0
No significant spinal stenosis could be seen.,0
The previously noted changes of abnormal meningeal enhancement along the ventral aspect of the cord cannot be appreciated on today's examination due to the lack of Gadolinium administration.,0
IMPRESSION: Moderate cervical spondylosis mostly at C4/5 and C5/6 levels with narrowing of the exit neural foramina.,0
Examination of cervical and thoracic spine does not reveal any pathologic compression fractures and no extrinsic cord compression is seen.,0
Further evaluation with Gadolinium administration might be of additional value for assessment of leptomeningeal metastatic disease.,0
8:01 AM CHEST (PORTABLE AP) Clip # Reason: progression of CHF Admitting Diagnosis: CONGESTIVE HEART FAILURE EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with biventricular failure REASON FOR THIS EXAMINATION: progression of CHF ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: CHF.,1
There is cardiomegaly and mild upper zone redistribution.,0
There are small pleural effusions.,0
IMPRESSION: Cardiomegaly and possible mild CHF but no overt pulmonary edema or new lung lesions since the prior study of .,0
3:59 AM CHEST (PORTABLE AP) Clip # Reason: line replaced again due to poor position in last film.,0
Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with SAH and DTs.,0
Central line was in poor position.,0
repositioned REASON FOR THIS EXAMINATION: line replaced again due to poor position in last film.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Check reposition of central venous line.,0
FINDINGS: There is a left subclavian central venous line with tip in the proximal superior vena cava.,0
The heart and mediastinum appear within normal limits.,0
The lungs are clear bilaterally.,0
The tip of the nasogastric tube is in the fundus of the stomach.,0
IMPRESSION: Tip of repositioned central venous line is now in the proximal superior vena cava.,0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CCU ADDENDUM: This is an addendum to a Discharge Summary dated up to .,0
HOSPITAL COURSE: Please add: 1.,0
"Nonsustained ventricular tachycardia: On , the patient had a 25 beat course of nonsustained ventricular tachycardia which was asymptomatic and not associated with hemodynamic instability, however, non-sustained ventricular tachycardia seven days post myocardial infarction is suspicious for a re-entrant circuit present in the conduction system, which is a poor marker for long-term cardiovascular function and indicates possible risk for sudden death.",1
"Therefore, after the patient's INR was corrected to 1.6 with Vitamin K which was given subcutaneously, the patient was taken to the Electrophysiology Service laboratory on , to be evaluated for defibrillation and AICD placement.",0
The patient was taken to the Electrophysiology Service Laboratory and found to be inducible for ventricular tachycardia which indicated that he had a re-entrant circuit and he had an AICD placed successfully without complications.,1
The patient was restarted on Coumadin after the procedure for prophylaxis from cerebrovascular accident as a result of his atrial fibrillation.,1
"His INR, however, was subtherapeutic prior to discharge and he was therefore given subcutaneously Lovenox to cover him for atrial fibrillation prophylaxis.",1
This was to be given until his INR became therapeutic which would be in the range of 2.0 to 3.0.,0
"Endocrine: The patient's fingerstick blood glucoses remained in the range of 120 to 140 throughout the rest of his hospitalization and he was not started on an oral hypoglycemic at this time, however, due to his regularly elevated blood glucoses, he should be considered for an oral hypoglycemic to be started on an outpatient basis with proper surveillance of his sugars.",0
It will not be started at this time due to the possibility of medication induced hypoglycemia with a newly started .,0
Pressure Ulcers: The patient developed decubitus ulcers on his upper back noticed on .,0
The ulcers were from the patient's lack of activity despite the fact that he was being ambulated and rehabed by Physical Therapy every day.,0
The patient had difficulty even sitting up in bed and the constant pressure of laying on his back with his large body habitus put him at high risk for developing decubitus ulcers.,0
The ulcers were Grade 2 involving skin breakdown but not involving the underlying dermis.,0
They were not infected at any point and never exhibited purulent exudate.,0
The ulcers were dressed with silver sulfadiazine twice a day with dressing changes twice a day and improved after the 28th with increased activity and the dressings.,0
DISPOSITION: The patient will be discharged to an inpatient Physical Rehabilitation Center for his functionality status post myocardial infarction.,1
The patient reported being able to completely function with all his activities of daily living prior to his myocardial infarction and is currently unable to lift himself up in bed or walk on his own.,1
q. day times 25 days.,0
10 Celexa 20 mg p.o.,0
DISPOSITION: The patient is discharged to the Rehabilitation Facility.,0
Dictated By: MEDQUIST36 D: 15:21 T: 15:35 JOB#:,0
"1:13 PM N-G TUBE PLACEMENT (W/ FLUORO) Clip # Reason: please place post-pyloric feeding tube Admitting Diagnosis: HYPOTENSION;RENAL FAILURE;CIRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with malnutrition, needs post-pyloric feeding tube.",1
Tube placed on was accidentally removed by patient.,0
REASON FOR THIS EXAMINATION: please place post-pyloric feeding tube ______________________________________________________________________________ FINAL REPORT INDICATION: 52 year old woman with malnutrition.,0
Patient had post pyloric feeding tube placed yesterday but accidentally pulled it out.,0
PROCEDURE: Fluoroscopic guidance was utilized to advance an 8 French - feeding tube through the stomach and into the proximal small bowel.,0
Appropriate positioning of the tip of the tube was confirmed following the administration of 10 cc Conray contrast.,0
The tip of the tube is located just beyond the ligament of Treitz.,0
IMPRESSION: Successful replacement of NG tube into the proximal small bowel just beyond the ligament of Treitz.,0
5:10 PM CT C-SPINE W/O CONTRAST Clip # Reason: evaluate for injury ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man s/p trauma REASON FOR THIS EXAMINATION: evaluate for injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: FBr SUN 6:32 PM no fx or malalignment.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old man with trauma.,0
TECHNIQUE: Non-contrast spiral CT of the cervical spine.,0
"FINDINGS: The sagittal reconstructions demonstrate straightening of the cervical lordosis, otherwise the vertebral body heights and disc spaces are well preserved and normally aligned.",0
Incidental note is made of disc osteophyte complex at the level of C5-C6 cervical vertebra with mild to moderate posterior canal narrowing.,0
CT does not provide intrathecal details comparable to MRI.,0
"Calcification of both internal carotid arteries is visualized, left greater than right.",0
No fracture or malalignment of the cervical spine.,1
Posterior disc osteophyte complex at the level of C5-C6 causes mild to moderate canal narrowing at this level.,0
"4:40 AM CHEST (PORTABLE AP) Clip # Reason: check placement of new trach, r/o worsening infiltrates, con Admitting Diagnosis: RIGHT LUNG NODULE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with UIP intubated for resp failure.",0
"REASON FOR THIS EXAMINATION: check placement of new trach, r/o worsening infiltrates, consolidations ______________________________________________________________________________ FINAL REPORT HISTORY: UIP with intubation for respiratory failure.",0
The support and monitoring devices remain in position.,0
Bilateral pleural effusions and moderate pulmonary edema persists.,0
There may be developing bronchograms at the left base raising the possibility of consolidation in the retrocardiac region.,0
PATIENT/TEST INFORMATION: Indication: Intra-op TEE for emergent CABG Height: (in) 61 Weight (lb): 150 BSA (m2): 1.67 m2 BP (mm Hg): 135/56 HR (bpm): 78 Status: Inpatient Date/Time: at 21:12 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Pt transported from CCU to the OR for emergent CABG for severe LMCA stenosis on a IABP with hypotension.,0
Surgery aborted due to unexpected discovery of an abdominal mass LEFT ATRIUM: Mild LA enlargement.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
AORTA: Simple atheroma in aortic root.,0
"There is moderate regional left ventricular systolic dysfunction of the antero-septal, mid to apical septal walls.",0
Overall left ventricular systolic function is moderately depressed (LVEF= 35 %).,0
"There is no gradient across the valve, the CO at this point was 3.2 l/min as measured by a thermodilution PA catheter.",0
"3:01 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: DECOMPRESSED CIRRHOSIS;HYPONATREMIA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with hep C cirrhosis admitted for hyponatremia, mental status changes, reduced breath sounds REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Reduced breath sounds.",0
"Compared to the prior study, the patient has been extubated.",0
Tip of the left IJ line remains in the distal SVC.,0
There has been no significant change in the diffuse bilateral opacities.,0
There is some sparing of the right costophrenic angle and slight sparing of the right upper lobe.,0
"Otherwise, diffuse infiltrates are unchanged.",0
The NG tube has been removed.,0
Unchanged appearance of the lung parenchyma with diffuse bilateral opacifications.,0
The densest consolidation is in the right lower lobe.,0
"7:57 PM CHEST (PORTABLE AP) Clip # Reason: R/O PTX, CHECK PLACEMENT Admitting Diagnosis: AORTIC DISECTION ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with AORTIC ANEURYSM S/P LEFT SUBCLAVIAN LINE PLACEMENT.",0
"REASON FOR THIS EXAMINATION: R/O PTX, CHECK PLACEMENT ______________________________________________________________________________ FINAL REPORT AP CHEST.",0
"INDICATION: Status post left subclavian line placement, history of aortic aneurysm.",0
Comparison is made to the prior chest x-ray dated .,0
AP SEMI-UPRIGHT OF THE CHEST: There is a left-sided subclavian central venous catheter with the tip terminate at the junction of the brachiocephalic and subclavian vein.,0
"The heart, mediastinal and hilar contours are stable in appearance.",0
There is blunting of the left costophrenic angle which could be consistent with a small pleural effusion.,0
There is retrocardiac opacity which could be consistent with atelectasis or consolidation.,0
There is slight perihilar haziness and vascular indistinctness which could be consistent with mild failure.,0
IMPRESSION: 1) Satisfactory placement of left subclavian central venous catheter with no evidence of pneumothorax.,0
2) Please refer to the accompanying CT of the chest for additional details.,0
5:13 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: s/p right crani for evac sdh Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with acute sdh s/p fall on coumadin/asa REASON FOR THIS EXAMINATION: s/p right crani for evac sdh No contraindications for IV contrast ______________________________________________________________________________ WET READ: MDAg SAT 6:06 PM 1.,1
Small left parafalcine subdural hemorrhage is newly apparent.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old woman, status post craniectomy for subdural hemorrhage.",1
COMPARISON: CTs at 11:58 a.m. from and at 8:01 a.m. from .,0
TECHNIQUE: Non-contrast MDCT axial images were acquired through the head.,0
Coronal and sagittal reformats were displayed for evaluation.,0
FINDINGS: The patient is status post right craniectomy with interval evacuation of the right subdural hemorrhage.,1
"7:43 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Evaluate for intrabdominal lesion/obstruction Field of view: 44 Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with N/V now with fever REASON FOR THIS EXAMINATION: Evaluate for intrabdominal lesion/obstruction No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old man with nausea, vomiting and fever, evaluate for intra-abdominal lesion or obstruction.",0
TECHNIQUE: Contiguous axial images were obtained from the lung bases to the pubic symphysis with coronal and sagittal reformatted images.,0
CONTRAST: Images were obtained with IV contrast only.,0
CT OF THE ABDOMEN WITH IV CONTRAST: There are confluent consolidative opacities within the right lower and middle lobes.,0
"There is a VP shunt, with the tip positioned in the right lower quadrant.",0
"The pancreas demonstrates fatty infiltration, but is otherwise normal.",0
The aorta demonstrates normal caliber and contour throughout its course.,0
"There are prominent predominantly air-filled loops of small bowel, with collapsed distal loops of small bowel.",0
No free air is identified.,0
CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is seen within the bladder.,0
The rectum and colon contain stool.,0
There is no free fluid within the pelvis.,0
"There is a right femoral venous central line, with the tip in the right common iliac vein.",0
BONE WINDOWS: Degenerative changes are seen within the lower lumbar spine.,0
"Air-filled dilated loops of small bowel, with collapsed distal loops, suggesting partial small bowel obstruction.",0
No free air or free intraabdominal fluid is identified.,0
Confluent consolidative opacities in the right middle and lower lobes.,0
Differential includes pneumonia versus aspiration.,0
(Over) 7:43 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Evaluate for intrabdominal lesion/obstruction Field of view: 44 Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ FINAL REPORT (Cont),0
"12:11 PM CHEST (PORTABLE AP) Clip # Reason: r/o PNA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with resp distrss, intubated.",0
call with questions # REASON FOR THIS EXAMINATION: r/o PNA ______________________________________________________________________________ FINAL REPORT HISTORY: 76 y/o woman with respiratory distress.,0
PORTABLE CHEST: The endotracheal tube and nasogastric tube are in satisfactory position.,0
The tip of a right internal jugular catheter is located at the proximal right atrium.,0
The previously seen multifocal opacities have changed in distribution and are now predominantly located in the upper lungs.,0
Given the rapid change in the distribution and possibility of asymmetric edema should be considered however an infectious process cannot be completely excluded.,0
The cardiac silhouettes are within normal limits for size.,0
IMPRESSION: 1) Rapidly changing distribution of multifocal opacities which is unusual for pneumonia and raises the possibility of asymmetric edema or aspiration; infection is also possible.,0
2) Right IJ catheter tip is in the proximal atrium.,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement Admitting Diagnosis: PNEUMOCYSTIS PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with HIV/AIDS, nonprod cough, fevers, shortness of breath, now with new line placement, first attempt at R subclavian to L subclavian now second line, also R subclavian.",1
REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT INDICATION: Readjustment of central venous line.,0
Comparison is made to the previous exam on the same day.,0
"FINDINGS: Right subclavian central venous line has been adjusted, and now has its tip in the mid-to-distal SVC in good position.",0
There is slight decrease in the degree of diffuse edema compared to previous exam.,0
IMPRESSION: Satisfactory readjustment of right subclavian central venous line.,0
Admission Date: Discharge Date: Date of Birth: Sex: M HISTORY OF PRESENT ILLNESS: Baby is a 40 week gestational male infant transferred from Hospital at 50 hours of age to the for evaluation of a heart murmur.,0
The baby was the Transport Team because of lack of beds at the .,0
The pediatrician at Hospital was Dr. .,0
"Pregnancy - Mother is a 29 year old gravida 1, para 01, A negative, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, Group B Streptotoccus delivery, afebrile at the time of delivery.",0
"The cerebrospinal fluid screening was negative, - negative.",0
Family history was remarkable for Wilms tumor in mother's cousin.,0
Pregnancy was uncomplicated except for the first trimester of intravenous fluids for dehydration.,0
Mother used a Ventolin inhaler during the pregnancy.,0
The baby was described as being active in utero.,0
"Delivery was normal spontaneous vaginal delivery with Apgars of 7 at one minute and 9 at five minutes, born at 2047 on , birthweight 3730 gm.",0
"The baby was reported to be doing well in the Newborn Nursery at Hospital, though breastfeeding somewhat slowly.",0
"On the day of transfer the baby was noted to have a cardiac murmur, to be mildly tachypneic with respiratory rate in 60s to 70 and oxygen saturations reported to be greater than 95% on room air.",0
Cardiac workup was initiated with unremarkable results.,0
Transport Team evaluated the baby and determined that the baby should be transferred for further assessment.,0
"Cardiac workup at - Chest x-ray normal, heart size within normal limits, stitches.",0
Pulmonary vasculature probably slightly increased.,0
"Electrocardiogram normal sinus rhythm, rate 143, axis 133, QTC .398, ventricular forces upper limits of normal, normal septal Q wave.",1
"LABORATORY DATA: Complete blood count 17.7, differential 72 polys, 1 band, 16 lymphs, 10 monos, hematocrit 50.1, platelets 303,000.",0
PHYSICAL EXAMINATION: Physical examination on admission to the revealed slightly lethargic jaundiced male infant.,0
"Temperature 98.6, heartrate 128, respiratory rate 40s to 60s, four extremity blood pressures, right arm 71/54 with mean of 60, right leg 72/45 with mean of 52, left arm 66/48 with a mean of 54, left leg 72/40 with a mean of 51.",0
Oxygen saturation in room air 96 to 99%.,0
"Admission weight at the 3490 gm, length 52 cm, head circumference 35.5 mm.",0
"Head, eyes, ears, nose and throat, anterior fontanelle soft and flat, sutures mobile, palate intact.",0
"Respiratory breathsounds clear and equal, mild retractions, appears slightly barrel-chested.",0
"Cardiovascular, S1 and S2 with a split III/VI holosystolic murmur heard throughout the precordium loudest at the mid left sternal border.",0
"Femoral pulses 2+, perfusion good.",0
"Abdomen soft with normal bowel sounds, no organomegaly noted.",0
"Genitourinary, circumcised normal male, testes descended bilaterally.",0
"Neurological, tone within normal limits.",0
"Activity decreased, alert and responsive.",0
"LABORATORY DATA: Repeat chest x-ray revealed heart size normal, pulmonary vasculature within normal limits.",0
"HOSPITAL COURSE: (At ) Respiratory - The baby has remained in room air, had a preductal gas on admission of 7.50, carbon dioxide 26, pO2 of 184, 21, 0, post ductal gas, 7.50, 25, 182, 20, -1.",0
"The baby has remained in room air with respiratory rates in the 30s to 70s, most recently 40s to 60s with saturations greater than 95% in room air.",0
He had one spontaneous desaturation that was quickly self-resolved on .,0
Cardiovascular - The baby has had completion of his cardiac workup including consult with the Cardiology Team.,0
Cardiac echocardiogram revealed a small to moderate membranous ventriculoseptal defect with only 12 mm of flow and a small PFO.,1
The baby has been cardiovascularly stable.,0
"Electrocardiogram showed right ventricular predominant, normal for gestational age.",0
"Cardiology follow up will be in four weeks at one of the Outreach Clinics, parents would prefer to go to the Office.",0
They will schedule the appointment by calling .,0
They have been instructed if further cardiology consult is requested to page the cardiology consult on call via Page Operator which is and ask for the cardiology consult on call.,0
The cardiologist who has been following him throughout the stay from is Dr. .,0
He can be reached also through the page operator.,0
"Fluids, electrolytes and nutrition - The baby initially was NPO with peripheral intravenous fluids.",0
He had stable glucoses greater than 60.,0
His intravenous has been heparin-locked and he is ad lib feeding breastmilk or E20 ad lib.,0
He is voiding and stooling and declaring his ability to consistently orally feed.,0
"He had electrolytes upon admission of sodium 141, potassium 5.0, chloride 106, carbon dioxide 17, calcium 9.2.",0
He has not had further electrolytes.,0
Discharge weight 3530 gm on .,0
"Gastrointestinal - The baby is A negative, negative and had an initial bilirubin at Hospital of 10.2.",0
"He has physiologic jaundice which peaked on at 17.1, .4, 16.7.",0
"On he had a bilirubin of 14.3, 0.4, 13.9.",0
"Our plan was to discontinue the phototherapy at the time of transfer or early this evening and obtain a rebound bilirubin on in the AM with hope to discharge if orally feeding efficiently on , if there are no further issues.",0
"Fu arranged for Monday am Hematology - The baby did not require any blood products during this admission, admission hematocrit of 51.",0
"Infectious disease - The baby had a sepsis evaluation with a white count of 19, 63 polys, 2 bands, 23 lymphocytes, platelets of 434,000 and hematocrit of 51.5.",0
He was started on 48 hours of Ampicillin and Gentamicin.,0
Cultures remained negative at 48 hours and the antibiotics have been discontinued on .,0
There have been no issues with infections during this admission.,0
Neurology - The baby is neurologically appropriate for gestational age.,0
"Sensory - Audiology screening, passed his hearing screen on .",0
Ophthalmology examination not indicated based on gestational age greater than 32 weeks.,0
"Psychosocial - The parents have been staying at , look forward to transition closer to home and plan on following up with Cardiology as stated above.",0
DISCHARGE DISPOSITION: To the Hospital.,0
"PRIMARY CARE PEDIATRICIAN: Dr. , phone , fax .",0
"Continue breastfeeding, Enfamil 20 with iron ad lib.",0
"Medications, none at the time of transfer.",0
"Carseat screening, not indicated based on gestational age of greater than 37 weeks.",0
"Newborn screen, initial newborn screen sent on .",0
"Immunizations received, hepatitis B vaccine on at Hospital prior to transfer to .",0
"Immunizations recommended, I. Synagis respiratory syncytial virus prophylaxis should be considered from through for infants who meet any of the following three criteria: A.",0
Born at less than 32 weeks; B.,0
"Born between 32 and 35 weeks with plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings; or C. With chronic lung disease.",0
"Follow up appointments, with primary care physician per routine, with Cardiology in one month through the Outreach Program.",0
"Small to moderate ventriculoseptal defect , M.D.",1
Dictated By: MEDQUIST36 D: 16:11 T: 16:38 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Sudden Onset Headache, and vomiting.",0
Major Surgical or Invasive Procedure: : Emergent perioperative EVD placement : Emergent Angiogram : VP shunt placement History of Present Illness: Mr. is a 71 y/o male with previously observed right frontal meningioma who was seen by Dr. in .,1
"A possible left temporal AVM was noted on MRI at that time, and he was scheduled for a CT angio later this month.",0
"However, at approximately 0130 this am, he noted a sudden onset headache with associated nausea and vomiting.",0
"He also sustained a ground-level fall, and his wife took him to an outside hospital where a head CT revealed an intraventricular hemorrhage which involved the left temporal , 4th, 3rd, and left lateral ventricles.",1
He was transferred to for neurosurgical care.,0
"A CT angio at revealed the hemorrhage is stable, and left mesial temporal flow voids suggestive of AVM is noted as well.",0
"Past Medical History: benign prostatic hypertrophy,meningioma, s/p electrohydraulic lithotripsy of bladder stones Social History: resides at home with wife Family History: Non-contributory Physical Exam: On Admission: T: 99.1 BP: 183/64 HR:81 R16 O2Sats 98% Gen: WD/WN, comfortable, NAD.",1
HEENT: Pupils: bilaterally EOMs intact Neck: Supple.,0
Neuro: Mental status: Awake and alert but confused.,0
"Orientation: Oriented to person and place only Language: slurred speech Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally.",0
"Moves all 4 extremities symmetrically with 5/5 strength over right side and left leg, but left arm is 4+/5 in all muscle groups.",0
"Patient did not cooperate with pronator drift test Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally.",1
"Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On Discharge: The patient is oriented to himself and to the month.",1
His left pupil is slightly smaller than the right but both are reactive.,0
His face is symmetric and his tongue is midline.,0
There is evidence of thrush in the oropharynx which is significantly improved since he has been on nystatin.,0
The patient is following commands with all extremities.,0
His right side is full strength and he has mild weakness on the left side.,0
"The incision is clean, dry, intact and there are sutures in place.",0
His abdomen has 2 incisions that have steri-strips in place.,0
Pertinent Results: Labs on Admission: 04:35AM BLOOD WBC-23.1*# RBC-4.58* Hgb-13.8* Hct-40.8 MCV-89 MCH-30.1 MCHC-33.8 RDW-14.3 Plt Ct-449* 04:35AM BLOOD Neuts-89.9* Lymphs-6.9* Monos-2.8 Eos-0.1 Baso-0.2 04:35AM BLOOD PT-12.3 PTT-20.7* INR(PT)-1.0 09:32AM BLOOD Fibrino-262 04:35AM BLOOD Glucose-154* UreaN-22* Creat-1.1 Na-143 K-4.2 Cl-105 HCO3-27 AnGap-15 09:32AM BLOOD Mg-1.7 Labs prior to Discharge : Na 136 Cl 104 BUN 13 Glu 85 K 4.9 CO2 26 Cr 0.8 Ca: 8.7 Mg: 2.1 P: 3.1 WBC 21.3 Hgb 11.6 Hct 34.3 Plts 736 PT: 15.1 PTT: 22.7 INR: 1.3 Imaging: CTA() 10 mm left PCA saccular aneurysm.,0
6.4 x 3.8 cm right frontal mass with adjacent vasogenic edema.,0
Unchanged appearance of intraventricular hemorrhage with mild-to-moderate hydrocephalus.,1
Unchanged appearance of right frontal extra-axial mass with mass effect and vasogenic edema.,0
"Head CT(): Status post left-sided central ventricular drain placement with slight interval improvement in dilatation involving the frontal horns bilaterally, otherwise unchanged examination.",0
"Head CT(): IMPRESSION: In comparison with a prior examination, no significant changes are demonstrated, persistent effacement of the sulci and mass effect, related with the frontal extra-axial mass lesion.",0
"Left frontal ventriculostomy, apparently unchanged, persistent intraventricular hemorrhage.",0
Followup CT is recommended if clinically warranted.,0
Head CT(): IMPRESSION: No significant change.,0
Persistent sulcal effacement and mass effect related to the right frontal extra-axial mass lesion.,0
Left frontal ventriculostomy and persistent intraventricular hemorrhage.,0
Head CT(): CONCLUSION: No evidence of new hemorrhage.,0
Decrease in the volume of intraventricular hemorrhage since the study of .,0
Unchanged large right frontal mass most likely a meningioma with extensive mass effect and midline shift.,0
Head CT (): IMPRESSION: Interval decrease in intraventricular hemorrhage.,0
Head CT (): IMPRESSION: 1.,0
"Post-surgical changes, with a small amount of pneumocephalus overlying the left frontal lobe, as well as air within the left frontal of the lateral ventricle.",0
"Intraventricular hemorrhage, unchanged from 5:09 p.m., but decreased in extent from .",0
No new foci of hemorrhage.,0
"Stable large right frontal extra-axial mass, with calcifications and associated vasogenic edema.",0
Minimal increased leftward subfalcine herniation.,0
Brief Hospital Course: The patient is a 71 y/o male with previously observed right frontal meningioma who was seen by Dr. in .,0
"However, at approximately 0130 on the date of admission, he noted a sudden onset headache with associated nausea and vomiting.",0
"Due to a rather expeditious neurological decline, he was taken for an emergent placement of an intraventricular drainage catheter, followed by a emergent angiogram to further identify the lesion.",0
"Unfortunatley there was an aneurysm identified, however within the AVM itself, and thereby ineligible for coil embolization.",0
He was continued to be evaluated in the ICU for the next several days with multiple attempts at EVD clamping trials.,0
"Unfortunately due to persistantly elevated ICPs with clamping of the EVD, he was determined to be an appropriate candidate for VP shunt placement.",0
On he underwent an uneventful shunt placement.,0
Post-operatively he was transferred to the neuro step-down unit where his treatment continued.,0
He was getting out of bed with physical therapy.,0
Patient got CT angiography on to evaluate AVM for radiosurgery planning.,0
He was seen by Radiation oncology on for evaluation and will be treated in a few weeks.,0
The patient was deemed a suitable candidate for rehab and was discharged on .,0
**The patient needs to be on telemetry at rehab since he still has an AVM and an aneurysm that have not been secured.,0
** Medications on Admission: doxazosin 8 mg finasteride Discharge Medications: 1.,0
Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day) as needed for htn.,0
Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: AVM w/ intranidal aneurysm, intra-ventricular hemorrhage, Large superior right extra-axial lesion Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?",0
F. Followup Instructions: Follow-Up Appointment Instructions - Please return to the office in 7 days for removal of your sutures or the rehab may remove them on .,0
"- Please call ( to schedule an appointment with Dr. , to be seen in 4 weeks.",0
- You will need a CT scan of the brain without contrast.,0
- Radiation oncology will call you with an appointment.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Morphine Sulfate Attending: Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABGx4(LIMA->LAD, SVG->Diag, LPLV, PDA) History of Present Illness: Mr. is a 59 year old gentleman with a history of hypertension and hypercholesterolemia who recently has had increasing chest pain with radiation to the left arm which started 6 months ago.",1
Subsequent work-up for this complaint revealed two vessel coronary artery disease.,1
Past Medical History: hypertension hyperlipidemia kidney stones s/p stone removal Social History: Mr. is a physicist.,0
He lives with his wife.,0
Family History: Mr. father had a cardiac arrest while on a treadmill.,0
"Physical Exam: At the time of discharge Mr. was awake, alert, and oriented.",0
Auscultation of his lungs revealed rales at the right base.,0
His heart was of regular rate and rhythm.,0
"His sternal incision was clean, dry, and intact.",0
"His abdomen was soft, non-tender, and non-distended.",0
His extremeties were warm and trace edema was noted.,0
"His left lower extremity vein harvest site was clean, dry, and intact.",0
"Pertinent Results: 06:55AM BLOOD WBC-4.8 RBC-3.45* Hgb-10.4* Hct-31.0* MCV-90 MCH-30.0 MCHC-33.4 RDW-13.7 Plt Ct-227# 03:17AM BLOOD PT-13.5* PTT-31.9 INR(PT)-1.2* 06:55AM BLOOD Glucose-143* UreaN-15 Creat-0.9 Na-141 K-3.6 Cl-100 HCO3-31 AnGap-14 ECHOCARDIOGRAPHY REPORT , (Complete) Done at 3:59:33 PM FINAL Referring Physician Information , C. , Status: Inpatient DOB: Age (years): 59 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain.",0
"ICD-9 Codes: 786.51, 440.0 Test Information Date/Time: at 15:59 Interpret MD: , MD Test Type: TEE (Complete) Son: , MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Findings LEFT ATRIUM: Normal LA size.",0
No spontaneous echo contrast in the RAA.,0
Prominent Eustachian valve (normal variant).,0
LV WALL MOTION: Regional left ventricular wall motion findings as shown below; remaining LV segments contract normally.,0
Conclusions PRE-CPB: 1) The left atrium is normal in size.,0
2) No spontaneous echo contrast is seen in the body of the right atrium.,0
3) There is mild symmetric left ventricular hypertrophy.,0
There is an apical left ventricular aneurysm.,0
4) Right ventricular chamber size and free wall motion are normal.,0
There is no mass/thrombus in the right ventricle.,0
5) There are simple atheroma in the aortic root.,0
6) There are three aortic valve leaflets.,0
7) The mitral valve appears structurally normal with trivial mitral regurgitation.,0
Aortic contour normal post decannulation.,0
"Electronically signed by , MD, Interpreting physician 16:13 , J M 59 Radiology Report CHEST (PORTABLE AP) Study Date of 9:25 AM , CSRU SCHED CHEST (PORTABLE AP) Clip # Reason: s/p ct d/c MEDICAL CONDITION: 59 year old man with REASON FOR THIS EXAMINATION: s/p ct d/c Final Report STUDY: AP chest .",0
HISTORY: 59-year-old man status post removal of chest tubes.,0
The bilateral chest tubes have been removed.,0
No residual pneumothoraces are seen.,0
There is a vague left retrocardiac opacity which is stable.,0
There is likely a small left-sided pleural effusion.,0
There is no overt pulmonary edema.,0
"DR. Approved: SUN 3:53 PM Brief Hospital Course: Mr. a coronary artery bypass times four (LIMA to LAD, SVG to DIAG, SVG to LPLV, SVG LPDA) on .",1
This procedure was performed by Dr. .,0
He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit.,0
"His pressors were weaned, his chest tubes were removed, and he was extubated.",0
On post-operative day two he was transferred to the step-down floor.,0
His wires were removed and he was gently diuresed.,0
He was seen in consultation by the physical therapy service.,0
He had urinary retention on POD#2 and the foley was replaced for 24 hours.,0
He then voided and was weaned off O2 and discharged to home on stable condition on POD#5.,0
"Medications on Admission: prilosec 40 mg, norvasc 5 mg, vitamins, selenium, aspirin 325 mg Discharge Medications: 1.",0
"Prilosec 40 mg Capsule, Delayed Release(E.C.)",0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed.,0
Motrin 600 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain.,0
"Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Care Discharge Diagnosis: coronary artery disease hypertension hyperlipidemia kidney stones gastro-esophageal reflux disease Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Please see Dr. (PCP) in 2 weeks (.",1
Please see Dr. (Cardiologist) in 4 weeks.,0
Please see Dr. in 2 weeks.,0
8:53 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?pneumothorax Admitting Diagnosis: PLEURAL CUT FISTULA PE ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with bronchopleural fistula and left sided pleural effusion s/p pigtail placement.,1
"REASON FOR THIS EXAMINATION: ?pneumothorax ______________________________________________________________________________ FINAL REPORT AP CHEST 8:52 P.M. ON HISTORY: Bronchopleural fistula and left-sided pleural effusion after placement of a pigtail drain, question pneumothorax.",1
IMPRESSION: AP chest compared to through at 6:17 a.m.: A large volume if not all of the previous moderate left pleural effusion has been drained by insertion of a small basal pleural drain.,0
There is no pneumothorax now nor was there one previously to support the diagnosis of bronchopleural fistula.,1
Aeration in the left lung has improved which may be a reflection of a pleural drainage or a decrease in concurrent pulmonary edema.,1
"The consolidative and nodular abnormalities in both lungs, probably disseminated infection, are unchanged.",1
The heart size is normal size.,0
Mediastinal veins are slightly smaller.,0
ET tube and right internal jugular line are in standard placements and a nasogastric tube passes into the stomach and out of view.,0
There is still small volume of right pleural effusion or thickening and little if any right pleural air.,0
"2:40 PM RENAL U.S.; DUPLEX DOPP ABD/PEL Clip # Reason: **With doppler flow to assess renal perfusion Admitting Diagnosis: AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p Type A dissection/ARF REASON FOR THIS EXAMINATION: **With doppler flow to assess renal perfusion ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old man with recent aortic dissection, evaluate for renal perfusion.",0
"COMPARISON: Renal Doppler ultrasound, .",0
"FINDINGS: The right kidney measures 11.0 cm, and the left kidney measures 11.7 cm.",0
Imaging of the kidneys is limited due to the patient's body habitus.,0
DOPPLER EXAMINATION: Color Doppler and pulsed wave Doppler images were attempted.,0
"The Doppler examination is essentially not interpretable as the patient is unable to hold his breath, has a poor son window, and there are technical limitations in the visualization of the kidneys.",1
Arterial flow is identified within the right kidney and minimal vascular flow is seen within the left kidney on color Doppler imaging.,0
Essentially unsuccessful Doppler examination due to technical factors described above.,0
"10:34 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Eval for ptx Admitting Diagnosis: LUNG MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman s/p left basilar segmentectomy with small ptx seen on previous CXR, CT placed back to suction REASON FOR THIS EXAMINATION: Eval for ptx ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
CLINICAL HISTORY: 74-year-old woman status post left basilar segmentectomy and small pneumothorax seen on previous chest radiograph.,0
FINDINGS: Comparison is made to the previous study from .,0
There is again seen a small left apical pneumothorax.,0
There is a left-sided chest tube.,0
There is again seen a left retrocardiac opacity and increased consolidation at the bases.,0
Linear atelectasis within the right mid lung field is also stable.,0
Soft tissue emphysematous changes are seen within the left chest wall from the chest tube placement.,0
7:37 AM MR HEAD W/O CONTRAST Clip # Reason: ?,0
"extent of stroke Admitting Diagnosis: COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with new r sided weakness, parietal ?",0
stroke on CT REASON FOR THIS EXAMINATION: ?,0
"extent of stroke No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 12:27 PM Findings consistent with acute-to-subacute left hemispheric infarcts in the left MCA distribution, the largest area in the left parietal lobe.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old male with new right-sided weakness and a concern for parietal infarct on CT.,1
COMPARISON: CTA of the head one day prior () and head CT .,0
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed without administration of gadolinium.,0
Diffusion-weighted imaging with ADC maps were acquired.,0
FINDINGS: left hemispheric T2 and FLAIR hyperintensities with corresponding diffusion restriction predominantly involving the left posterior frontal and parietal lobes are consistent with acute to subacute infarct.,0
There is no intracranial hemorrhage or shift of midline structures.,0
The ventricles and cerebral sulci are unchanged in size and configuration.,0
Periventricular areas of T2 and FLAIR signal hyperintensity likely represents sequela of chronic small vessel ischemic disease.,1
Maxillary sinus mucosal thickening is again noted.,0
There is fluid within left mastoid air cells.,0
"Findings consistent with acute-to-early subacute MCA distribution infarcts of the left hemisphere, predominantly involving the left posterior frontal and parietal lobes.",0
The distribution suggests an embolic source.,0
"3:25 PM BABYGRAM (CHEST & ABDOMEN) PORT; BABYGRAM (ABD ANY SGL VIEW) () PORTClip # Reason: evaluate lung fields, bowel gas pattern, Please do at 4:00 P ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, bilious aspirate, abd distention REASON FOR THIS EXAMINATION: evaluate lung fields, bowel gas pattern Please do at 4:00 PM ______________________________________________________________________________ FINAL REPORT BABYGRAM, CHEST AND ABDOMEN AND LEFT LATERAL DECUBITUS SINGLE VIEW ABDOMEN, : HISTORY: Infant with prematurity, bilious aspirate and abdominal distention.",0
FINDINGS: Supine and left lateral decubitus views are submitted for interpretation on .,0
"There are some questionable curvilinear lucencies seen in the right lower quadrant which are not definite for pneumatosis and seen only on the decubitus view, nor are they definite for pneumoperitoneum.",0
There is diffuse gaseous distention which has increased since the study performed earlier the same day and now has an obstructive appearance.,0
The NGT tip is again noted to project over the left upper quadrant.,0
The ETT has been pulled back and now is just at the level of the thoracic inlet.,0
The lung volumes are unchanged in that they are very low and there are near coalescent lung opacities which largely obscure the cardiomediastinal contour.,0
8:39 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
R PNA aspiration Admitting Diagnosis: FEVER;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with MRSA in the blood REASON FOR THIS EXAMINATION: ?,0
"R PNA aspiration ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 3:37 PM Since , right pleural effusion is unchanged.",0
"Bibasilar opacity, probably mostly atelectasis, decreased.",0
______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP: REASON FOR EXAM: 72-year-old woman with MRSA in the blood.,0
"Since , bibasilar opacity decreased, most likely due to atelectasis.",0
Right pleural effusion is unchanged.,0
The cardiomediastinal silhouette and prior sternotomy changes are unchanged.,0
"9:00 AM CHEST (PORTABLE AP) Clip # Reason: assess for acute process, ETT placement Admitting Diagnosis: CARDIOGENIC SHOCK\CATH ______________________________________________________________________________ MEDICAL CONDITION: 68 YO man with CAD, cardiogenic shock, intubated REASON FOR THIS EXAMINATION: assess for acute process, ETT placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY: COMPARISON: .",1
Intraaortic balloon pump is again identified with radiodense tip in a relatively low position now about 9 cm below the superior aspect of the aortic arch.,0
"Endotracheal tube is in standard position with tip terminating 4.5 cm above the carina, and nasogastric tube remains in standard position.",0
"Bibasilar atelectasis is noted with interval slight worsening, and there remains elevation of the right hemidiaphragm.",0
"10:28 PM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate for ischemic areas or bleed Admitting Diagnosis: LIVER CANCER;SEVERE MUCUSITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with alcoholic cirrhosis and progressive HCC presents with severe mucositis and rash REASON FOR THIS EXAMINATION: Please evaluate for ischemic areas or bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: 11:57 PM No hemorrhage or edema ______________________________________________________________________________ FINAL REPORT HISTORY: 61-year-old male with alcohol cirrhosis, progressive HCC with severe mucositis and rash.",1
Evaluate for ischemia area or bleed.,0
"HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass effect, shift of normally midline structures, or evidence of major vascular territory infarction.",0
"The ventricles and sulci are slightly prominent, indicating a degree of involutional change.",0
The soft tissues appear unremarkable.,0
IMPRESSION: No hemorrhage or evidence of acute process.,0
"Admitting Diagnosis: STATUS POST CABG\SAPHENOUS VEING GRAFT - RIGHT CORONARY ARTERY PSUEDOANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with Redo sternotomy, resection of pseudoaneurysm REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old man with redo sternotomy, resection of pseudoaneurysm, pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: There has been interval introduction of an OG tube with its side hole above the diaphragm.,0
An ET tube tip is 5.4 cm from the carina.,0
A right internal jugular approach Swan-Ganz catheter is seen with its tip projecting over the right pulmonary artery.,0
Two right chest tubes are seen with tips in intrathoracic position.,0
"There are mediastinal sternotomy wires, unchanged from prior, and mediastinal clips.",0
"There is mild bibasilar atelectasis, worse on the left where retrocardiac opacifications obscures the aorta.",0
Pulmonary vasculature is grossly normal.,0
Non-standard position of orogastric tube.,0
Standard positions of other tubes and lines 3.,0
COMMENT: These results were discussed with Dr. by Dr. 1:10 p.m.,0
9:08 AM MR HEAD W & W/O CONTRAST Clip # Reason: please evaluate for contributory pathology Admitting Diagnosis: INTRACRANIAL BLEED;ETOH ABUSE Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with right temporal hemorrhage REASON FOR THIS EXAMINATION: please evaluate for contributory pathology No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MRI OF THE BRAIN WITHOUT AND WITH GAD HISTORY: Right temporal hemorrhage.,0
Patient has history of HCC.,0
Bifrontal subdural hygromas are unchanged compared to the prior CTA.,0
There is a hemorrhagic lesion in the right temporal lobe with surrounding edema and extension into the right-sided ventricular system.,0
"Following gadolinium administration, some enhancement is noted surrounding this lesion.",0
Possibility of a hemorrhagic metastasis cannot be excluded.,0
Enhancement may also be seen with a hematoma however.,0
No additional lesions are noted.,0
There is mucosal thickening in bilateral ethmoid and maxillary sinuses.,0
There are fluid levels in bilateral maxillary sinuses.,0
IMPRESSION: Right temporal hematoma with intraventricular extension.,0
There is suggestion of associated enhancement which may be seen in the setting of a subacute hematoma or a metastatic lesion.,0
Recommend followup study after resolution of acute blood products.,0
"11:21 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: eval for esophageal perforation/duodenal perforation, please Admitting Diagnosis: CHOLEDOCHOLITHIASIS ; SUBQ EMPHYSEMA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with extensive pneumoperitoneum, pneumomediastinum and pneumoretroperitoneum s/p ERCP REASON FOR THIS EXAMINATION: eval for esophageal perforation/duodenal perforation, please give gastrograffin PO No contraindications for IV contrast ______________________________________________________________________________ WET READ: JBRe FRI 11:56 PM Active oral contrast extravasation at the posterior wall of the distal descending duodenum (layering between the duodenum and the IVC/right gonadal vein) (se 2, img 65).",1
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old woman s/p ERCP at an OSH with extensive free air in the abdomen (intra and extraperitoneal) and chest (mediastinum and ptx).,0
Please assess site of perforation.,0
"TECHNIQUE: Contiguous MDCT images through the chest, abdomen, and pelvis were performed after the administration of intravenous and oral (Gastrograffin) contrast.",0
COMPARISON: Torso CT from the same day (from outside hospital).,0
CT OF THE CHEST: There is a2.6 x 2.7 cm hypodense nodule in the left thyroid lobe with peripheral coarse calcification.,0
Extensive soft tissue emphysema is noted at the base of the neck and supraclavicular region dissecting into the subpectoral space and the left breast.,0
There is pneumomediastinum and a small right pneumothorax.,1
A tiny left pleural effusion and scattered bilateral subsegmental atelectasis noted.,0
There are mild atherosclerotic calcifications of the left anterior descending coronary artery and the aortic arch.,0
There is no evidence of esophageal perforation as there is noextravasated contrast within the mediastinum.,0
CT OF THE ABDOMEN: Air is seen in the gallbladder related to recent ERCP.,0
There is extensive retroperitoneal and intraperitoneal free air.,0
"A small pocket of extravasated oral contrast is seen posterior to the vertical segment of the duodenum(series 2, image 65) which suggests perforation of the duodenum at this level.",0
"Given the presence of a periampullary duodenal diverticulum, perforated diverticulum from ERCP is a strong consideration.",0
No additional foci of active extravasation of oral contrast is demonstrated.,0
"There is interval development of peripancreatic edema likely indicating acute (Over) 11:21 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: eval for esophageal perforation/duodenal perforation, please Admitting Diagnosis: CHOLEDOCHOLITHIASIS ; SUBQ EMPHYSEMA ______________________________________________________________________________ FINAL REPORT (Cont) pancreatitis.",1
There is a stent present in the pancreatic duct at the level of the uncinate process with stent extending into the duodenum.,0
"The CBD is slightly dilated measuring 12 mm in diameter, appearing to taper at the level of the pancreatic stent.",0
The adrenal glands and both kidneys demonstrate no acute pathology.,0
Better seen on prior noncontrast exam is a 7-mm stone in the left renal upper pole calyx and a smaller stone in the left renal lower pole.,0
There is a hypoattenuating left mid pole 5-mm renal lesion.,0
There are bilateral extrarenal pelves.,0
There are moderate atherosclerotic calcifications of the abdominal aorta.,0
"A minimal amount of fluid is seen in the left paracolic gutter, unchanged from the prior exam.",0
CT OF THE PELVIS: A Foley catheter is seen in the urinary bladder.,0
The small bowel distal to the duodenum appears normal.,0
The large bowel is normal.,0
There is trace free fluid in the pelvis.Uterus and adnexa are normal.,0
BONES: No suspicious lytic or sclerotic bony lesions.,0
A bone island is seen in the L4 vertebral body.,0
Extravasation or enteric contrast adjacent to the proximal duodenum which given findings of a periampullary duodenal diverticulum raises concern for perforation at this level.,0
"Extensive free air within the abdomen, chest and body wall.",0
Acute pancreatitis with a stent in the proximal pancreatic duct.,1
Findings discussed with Dr. (Surgery) at the time of initial review.,0
11:31 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Eval for progression of pneumothorax after ventilating R lun Admitting Diagnosis: HEPATIC CYST/SDA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with pneumothorax REASON FOR THIS EXAMINATION: Eval for progression of pneumothorax after ventilating R lung ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Followup pneumothorax.,0
Comparison is made with prior study performed 4 hours earlier.,0
There is better aeration of the right lung.,0
The cardiomediastinal silhouette is less shifted towards the right side.,0
Right lower lobe atelectasis has improved.,0
Moderate right pneumothorax is unchanged.,0
There are no other interval changes.,0
10:00 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with s/p mvc c ejection REASON FOR THIS EXAMINATION: r/o bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: 1:54 AM subdural and subarachnoid bleed no shift of midline structures ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,1
NONCONTRAST CT OF THE HEAD.,0
INDICATION: 25 year old male with MVA and ejection from vehicle.,0
TECHNIQUE: CT imaging of the brain without IV contrast.,0
FINDINGS: There is evidence of high attenuation material within the subdural space on the left consistent with acute subdural hematoma.,0
There is evidence of high attenuation material along the right anterolateral aspect of the pons.,0
The finding is consistent with subarachnoid hemorrhage.,1
There is a tiny focus of high attenuation within the anterior right temporal lobe concerning for intraparenchymal hemorrhage.,0
The ventricles and sulci are normal in size and symmetrical.,0
There is mild shift of normally midline structures to the right.,0
"There is a large cisterna magna, a normal variant.",0
The visualized portions of the paranasal sinuses are clear.,0
Bone windows show no evidence of fracture.,0
"IMPRESSION: Acute left subdural hematoma measuring 4 mm in greatest transverse dimension, associated mild shift of structures to the right.",0
Subarachnoid hemorrhage along the right anterolateral aspect of the pons.,1
Punctate focus of likely intraparenchymal hemorrhage within the anterior right temporal lobe.,0
These findings were immediately relayed to the trauma surgery team responsible for this patient's care on .,0
"9:20 PM CHEST (PORTABLE AP) Clip # Reason: increased O2 requirements ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman s/p stroke, recent pneumonia with worsening rapid afib of unclear cause, worsening O2 sats.",0
REASON FOR THIS EXAMINATION: increased O2 requirements ______________________________________________________________________________ FINAL REPORT HISTORY: Increased oxygen requirements.,0
PORTABLE CHEST: NG tube is seen coursing beneath the diaphragms off the bottom of the film.,0
There is new collapse/consolidation of the left lower lobe with associated left sided pleural effusion.,0
-apical pleural thickening is again noted.,0
"Accounting for position, the pulmonary vasculature is likely normal.",0
Interval collapse/consolidation of left lower lobe and accumulation of left pleural effusion.,0
"1:49 PM CHEST (PORTABLE AP) Clip # Reason: pls evaluate for pneumothorax or other complication Admitting Diagnosis: INFECTED ULCER ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with PICC from OSH, with persisting respiratory failure, s/p R thoracentesis REASON FOR THIS EXAMINATION: pls evaluate for pneumothorax or other complication ______________________________________________________________________________ FINAL REPORT INDICATION: 53-year-old female with persisting respiratory failure status post right thoracocentesis.",1
"COMPARISONS: Comparison is made to portable AP view of the chest from , .",0
TECHNIQUE/FINDINGS: There has been interval improvement of the large right- sided pleural effusion with a worsening effusion on the left side.,0
The tracheostomy tube and right internal jugular line are in standard placements.,0
There has been interval removal of a nasogastric tube.,0
"There is unchanged mild pulmonary edema, which is slightly worse on the left side.",0
"A tiny right-sided apical pneumothorax is seen, which is best visualized just beneath the lateral border of the second rib.",0
Improvement of right-sided pleural effusion with some worsening on the left side.,0
"9:29 AM CT HEAD W/O CONTRAST Clip # Reason: pre-op ct, also interval change Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: year old man with acute on chronic sdh REASON FOR THIS EXAMINATION: pre-op ct, also interval change No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 11:33 AM PFI: No change from one day prior.",0
"Acute on chronic left subdural hematoma again causes mass effect on adjacent sulci, 9 mm rightward shift of normally midline structures, and rightward subfalcine herniation.",0
"Scattered basal ganglia lacunes are unchanged from , although one in the right caudate is new from .",0
"There is also a region of low attenuation in the left parieto-occipital lobe, unchanged from but again new from .",0
______________________________________________________________________________ FINAL REPORT INDICATION: -year-old male with acute on chronic subdural hematoma.,0
COMPARISON: CT of the head dated as well as .,0
NON-CONTRAST HEAD CT: There is no significant interval change compared to study performed one day prior.,0
"Again demonstrated is a mixed density, acute on chronic left subdural hematoma, unchanged in size and appearance compared to one day prior.",0
"Measured in a similar fashion, it again measures approximately 2.4 cm from the inner table.",0
"There is significant mass effect upon the adjacent sulci, as well as subfalcine herniation, with up to 9 mm rightward shift of normally midline structures.",0
There is no evidence for uncal herniation.,0
There is no new hemorrhage identified.,0
"There is no intraparenchymal, subarachnoid or intraventricular blood identified.",0
Several small basal ganglia lacunes are unchanged from multiple prior studies.,0
"However, hypodensity in the region of the right caudate, as well as a region of low attenuation in the left temporal-occipital lobe, while unchanged from , are new from .",0
The osseous structures and surrounding soft tissues remain unremarkable.,0
"Unchanged acute on chronic left subdural hematoma with associated mass effect on the adjacent sulci, as well as subfalcine herniation.",0
"Foci of low attenuation within the right caudate head and left parietooccipital lobe, unchanged from but new since .",0
These are consistent with subacute infarcts.,0
"(Over) 9:29 AM CT HEAD W/O CONTRAST Clip # Reason: pre-op ct, also interval change Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ FINAL REPORT (Cont)",0
10:12 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p radical abd surgery w/ GPC in sputum REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Gram-positive cocci in sputum.,0
Comparison is made to two days earlier.,0
There are increasing patchy opacities at both lung bases.,0
No pleural effusions or pneumothoraces.,0
"IMPRESSION: Patchy bibasilar opacities, which may reflect early pneumonia considering provided clinical history.",0
Aspiration is another possible etiology given bibasilar dependent distribution.,0
"Admission Date: Discharge Date: Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: This is an 81 year old woman with a past medical history significant for hypertension and heavy alcohol use, who presented after falling down at an outside hospital, down cement steps.",1
She subsequently hit her head on the cement and then after a rapid decline in mental status had a two minute generalized tonoclonic seizure after which she was intubated at the outside hospital.,0
"She was given Fentanyl, Versed, Ativan, Lidocaine, Curium and Succinylcholine.",0
She has since been loaded with Dilantin one gram intravenously prior to transfer to the Emergency Department at .,0
Her initial head CT at the outside hospital was reportedly negative for bleed.,0
"According to the hospital transfer report, the patient fell down the steps and hit her head and then walked into the Emergency Department triage with a laceration above her left eye.",0
"Initially, her blood pressure was 201/109, no reported loss of consciousness.",0
She was able to answer yes and no questions initially after the fall but otherwise was not speaking.,0
Then she began to mumble incoherently and had a witnessed two minute generalized tonoclonic seizure where her eyes rolled to the left and all four extremities were shaking.,0
"Also per report, she drinks a significant amount of alcohol at home.",0
There is no report of any recent illnesses.,0
"On talking with the daughter, the patient has been an alcoholic since the and has had seizures in the past in relation to stopping alcohol.",0
"Per the daughter's knowledge, she has had no seizures in years and has never taken any antiepileptic drugs.",0
"The daughter says that her brother knew that the patient was drinking as recently as the Friday, two days prior to the head trauma.",0
She has also been known to stop drinking on Sundays to go to church.,0
"She has no history of any bleeding disorder, stroke, cardiac illness or cancer in the past.",0
She also does not know of any liver dysfunction in the patient.,0
She does mention there is old right arm weakness from a past injury to the arm.,0
Tuberculosis exposure as a child.,0
Toprol XL 100 mg once daily.,0
Hydrochlorothiazide 12.5 mg once daily.,0
Lotrel 5 mg/20 mg one tablet once daily.,0
SOCIAL HISTORY: She is retired.,0
"She has two children, one who lives close by.",0
Children were taken from the mother and father and turned to care due to primarily the mother's alcoholism.,0
She has a history of smoking but has not smoked in years per her daughter.,0
"She has no known illicit drug use, over the counter medicines or herbal supplements.",0
FAMILY HISTORY: There is no family history of any seizures or bleeding disorder noted in the family.,0
"PHYSICAL EXAMINATION: On presentation to the , her blood pressure is 119/61, heart rate 83.",0
"Arterial blood gas on arrival was 7.39, 38, 457, 24 and minus one.",0
Her left eye had a large amount of edema and discoloration.,0
The neck was in a cervical collar.,0
"The heart was regular rate and rhythm, normal S1 and S2, no murmurs.",0
"The abdomen was soft, liver edge was palpable.",0
The extremities were warm and well perfused with no peripheral edema.,0
"Neurological examination showed she was intubated not following commands, off Propofol.",0
Her pupils were pin point but reactive bilaterally.,0
We were unable to visualize the fundi due to pupil size.,0
The cornea were intact bilaterally.,0
Motor examination - She localized purposely to pain in all four extremities.,0
She withdrew arms and legs briskly to noxious stimuli.,0
Her reflexes were symmetric but brisk throughout.,0
Sensation - She withdrew to noxious stimuli.,0
"LABORATORY DATA: On presentation, her white blood cell count was 17.4, hematocrit 35.3, platelet count 289,000.",0
Coagulation studies showed an INR of 1.0.,0
"Electrolytes showed a sodium 131, potassium 3.9, chloride 98, bicarbonate 23, blood urea nitrogen 29, creatinine 2.1.",0
She was subsequently ruled out for a myocardial infarction with three sets of cardiac enzymes.,0
Her serum toxicology screen was negative.,0
Her urine toxicology screen was negative.,0
Head CT done at showed a tiny subarachnoid hemorrhage in anterior right frontal lobe with extensive subcortical white matter density.,1
Unclear whether this was hypoxic injury versus long-standing abnormality.,0
She also had a left orbital floor fracture and posterior maxillary wall fracture.,1
There was blood in the sinus and of the orbit with proptosis.,0
Cervical CT showed cervical spondylosis.,0
Magnetic resonance scan of the cervical spine eventually was cleared for no fracture or dislocation.,0
"HOSPITAL COURSE: This was an 81 year old woman with a history of alcoholism and hypertension who presented with a fall and head trauma with a tiny subarachnoid hemorrhage, and had generalized tonoclonic seizure.",1
"Subsequently, she was extubated on hospital day number two and transferred to the general neurology floor on hospital day number three.",0
"Her mental status slowly cleared to the point that she was alert, oriented to person and place, not to time.",0
Her cervical spine was eventually cleared.,0
"She was evaluated by physical therapy, occupational therapy who also recommended intense rehabilitation.",0
"FEN, gastrointestinal wise, she was tolerating a low calorie low fat diet.",0
She was neurologically on Dilantin and initially had therapeutic Dilantin level.,0
"After discussing with Dr. in epilepsy, the patient was changed to Keppra secondary to the combination of possible Dilantin metabolism with alcohol use.",0
A repeat head CT was done which showed no progression of her tiny subarachnoid hemorrhage.,1
Her blood pressure was well controlled with p.r.n.,0
She was also evaluated by the oromaxillofacial team who evaluated her multiple facial fractures.,0
She was started on Unasyn for a seven day course.,0
"After day number three, she was changed to Augmentin.",0
The last day of a seven day course is .,0
We are now awaiting placement on this patient for acute rehabilitation as of .,0
MEDICATIONS ON DISCHARGE: To be included at the time of discharge finally to rehabilitation placement.,0
Dictated By: MEDQUIST36 D: 12:04 T: 12:47 JOB#:,0
"11:13 AM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # Reason: assess for fractures ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with REASON FOR THIS EXAMINATION: assess for fractures ______________________________________________________________________________ FINAL REPORT INDICATION: Shoulder pain.",0
"Three suboptimal views of the right shoulder are normal without evidence of fracture, dislocation, demineralization, or osseous destruction.",0
PATIENT/TEST INFORMATION: Indication: CABG WITH IABP Status: Inpatient Date/Time: at 16:57 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.,0
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.,0
There is an IABP in the proximal descending aorta 3 cm beyond the left subclavian artery.,0
Post-CPB: The patient is A-Paced on no inotropes.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male admitted to due to new onset of angina and a positive stress test.,1
He was fine until approximately two weeks prior to presentation when he started developing exertional chest pain.,0
The pain resolved with rest.,0
He had a stress test which showed inferolateral ST changes.,0
An echocardiogram was negative for ischemia.,0
The patient had a catheterization which showed 3-vessel disease.,0
He was referred to Cardiothoracic Surgery.,0
Basal squamous cell skin cancer.,0
Status post tonsillectomy and adenoidectomy.,0
"ALLERGIES: SULFA, SHELL FISH, and DYE.",0
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o.,0
"q.d., Lopressor 25 mg p.o.",0
"b.i.d., Zestril 10 mg p.o.",0
"PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure was 155/76, heart rate was 48.",0
Cardiovascular revealed a regular rate and rhythm.,0
"Extremities were well perfused, no edema.",0
"The abdomen was soft, nontender, and nondistended.",0
"PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed white blood cell count was 13.3, hematocrit was 46.2, platelets were 230.",0
"Sodium was 138, potassium was 4.7, chloride was 101, bicarbonate was 26, blood urea nitrogen was 19, creatinine was 1.2.",0
"HOSPITAL COURSE: The patient was taken to the operating room on where he had a coronary artery bypass graft times three with left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, saphenous vein graft to ramus.",1
The operation was without complications.,0
Pacing wires as well as chest tube were placed intraoperatively.,0
"On postoperative day one, the patient was afebrile.",0
He was extubated without complications.,0
His chest tube was removed successfully.,0
"On postoperative day two, the patient remained afebrile.",0
His intravenous line and Foley were removed.,0
The patient was transferred to the floor.,0
"On postoperative day three, the patient remained afebrile.",0
He started working with Physical Therapy.,0
He complained about pain and weakness in his left arm.,0
The patient reported it was worse immediately postoperatively and slowly improved with time.,0
"On serial examinations which were performed, the patient's strength had improved over the preceding two days.",0
"On postoperative day four, an Occupational Therapy consultation was obtained who found that the patient did not need immediate Occupational Therapy treatment at this time.",0
Their recommendation was to follow up on an outpatient basis in two to three weeks if he did not recover significantly at this time.,0
He was exercising with Physical Therapy.,0
DISCHARGE STATUS: The patient was discharged to home without .,0
DIE FOLLOWUP: The patient was to follow up with Dr. in four weeks for a postoperative check.,0
"The patient was to follow up with his primary care physician in two to three weeks for his left arm numbness and weakness; if symptoms do not improve at that time, he may request referral to the outpatient Occupational Therapy.",0
Enteric-coated aspirin 325 mg p.o.,0
Status post coronary artery bypass graft times three.,1
Dictated By: MEDQUIST36 D: 18:32 T: 19:32 JOB#:,0
2:00 PM CHEST (PORTABLE AP) Clip # Reason: ?CHF exacerbation ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with shortness of breath REASON FOR THIS EXAMINATION: ?CHF exacerbation ______________________________________________________________________________ FINAL REPORT HISTORY: 55-year-old female with shortness of breath.,0
STUDY: Portable AP upright chest radiograph.,0
FINDINGS: The heart size is enlarged.,0
The mediastinal contours demonstrate engorgement of the central venous vasculature.,0
Additionally small bilateral pleural effusions are present with basilar atelectasis.,0
There does not appear to be appreciable interstitial edema.,0
IMPRESSION: Cardiomegaly and small bilateral pleural effusions but no evidence of CHF.,0
7:51 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with bilateral pneumonia REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old female with bilateral pneumonia.,0
AP PORTABLE UPRIGHT RADIOGRAPH: A right internal jugular and nasogastric tube are unchanged in position with NG side port at the gastroesophageal junction.,0
"There is slight increased opacity in the left lung base, which is likely due to positional change.",0
The cardiomediastinal silloutte is unchanged.,0
Bilateral multifocal opacities are unchanged.,0
"There are probable small bilateral pleural effusions, which are also unchanged.",0
"8:35 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: assess for PNX Admitting Diagnosis: APML ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with AML now hypoxic and increased vent pressures REASON FOR THIS EXAMINATION: assess for PNX ______________________________________________________________________________ FINAL REPORT HISTORY: AML, now hypoxic, question PNX.",0
"Compared with at 5:15 a.m., I doubt significant interval change.",0
"Again seen is extensive opacification of both lungs, with relative sparing of both upper zones.",0
"An ET tube is present, tip approximately 4.0 cm above the carina.",0
"An NG tube is present, tip extending beneath diaphragm off film.",0
Two central lines and a right subclavian PICC line are also unchanged.,0
IMPRESSION: No significant change compared with at 5:15 a.m. Extensive bilateral opacities are essentially unchanged.,1
7:34 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
penumonia Admitting Diagnosis: GUN SHOT WOUND TO ABDOMEN ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man s/p gunshot wound.,0
penumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Status post gunshot wound.,0
"CHEST X-RAY, PORTABLE AP: Comparison made to prior study of two days earlier.",0
There is an endotracheal tube with tip 2.8 cm from the carina.,0
A nasogastric tube is positioned with tip in the stomach.,0
There is a right subclavian central venous line with tip in the right atrium.,0
Bilateral patchy perihilar opacities are present.,0
These are new from the prior study.,0
Right subclavian central venous line with tip in the right atrium.,0
This may be withdrawn 2-3 cm for optimal positioning in the lower superior vena cava.,0
"Patchy bilateral perihilar opacities, concerning for pneumonia or aspiration.",0
These results were communicated to Dr. at 9:30 p.m. on .,0
Status: Inpatient Date/Time: at 15:07 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Conclusions: PREBYPASS: Normal LV systolic function with LVEF > 55% with no SWMA.,0
"The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque.",0
Normal RV chamber dimensions and function.,0
Normal diastolic function with lateral mitral annular e' = 13 cm/sec.,0
"POSTBYPASS: Normal LV systolic function LVEF > 55%, no segmental wall motion abnormalities.",0
No dissection seen after cannula out.,0
7S 9:30 AM CHEST (PA & LAT) Clip # Reason: Please access lung for improvement Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman with chest tubes getting TPA REASON FOR THIS EXAMINATION: Please access lung for improvement ______________________________________________________________________________ PFI REPORT 1.,0
Unchanged loculated left pleural effusions with two chest tubes in place and moderate to large lateral left pneumothorax likely involving the left upper lobe.,1
Unchanged small left medial hydropneumothorax.,1
5:24 PM CT PELVIS ORTHO W/O C Clip # Reason: evaluate pelvic fracture ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman bicyclist struck by moving vehicle at 50mph REASON FOR THIS EXAMINATION: evaluate pelvic fracture No contraindications for IV contrast ______________________________________________________________________________ WET READ: 6:13 PM Left acetabular transverse fracture involving anterior and posterior coulums.,1
"fracture of the left posterior wall, free fragmentat medial wall and intraauticular and anterior bone fragments.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 38-year-old woman with bicyclist struck by moving vehicle.,1
CT OF THE PELVIS WITHOUT CONTRAST WITH MULTIPLANAR REFORMATION: There is no comparison.,0
"There is acute comminuted transverse fracture of the left acetabulum, involving both anterior and posterior column, as well as displaced and comminuted fracture of the left posterior wall and small free floating bone fragment of the medial wall.",1
There are both intraarticular and anterior bone fragments which are small.,0
The left femoral head is superiorly and posteriorly dislocated.,0
No fracture is seen in the left femoral neck.,0
There is hematoma surrounding the left pectineus muscle.,0
"On the right, there is mildly displaced fracture of the inferior pubic ramus, and medially displaced fracture of the superior pubic ramus.",0
Right femoral head is unremarkable.,0
Bilateral SI joints are symmetric.,0
There is residual contrast within the bladder.,0
"Left acetabular transverse fracture involving posterior and anterior columns with fracture fragments as well as displaced fracture of the posterior wall as described above, associated with superior and posterior dislocation of the left femur.",1
Displaced fracture of the right superior and inferior pubic rami.,0
Hematoma surrounding the left acetabular fracture.,0
"The finding was discussed with the trauma team in person, including Dr. in person at the completion of the study approximately at 6:00 p.m. on the day of the study.",0
6:14 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"Admitting Diagnosis: COUGH;DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with s/p alloSCT, with GVHD, h/o recurrent PNAs, and h/o PTX.",0
______________________________________________________________________________ WET READ: 7:48 PM Ill defined nodular opacity in the right mid-lung and opacities in the retrocardiac left lung base have not significantly changed since prior CT .,0
Tracheostomy tube ends 3 cm above the carina.,0
nasointestinal tube courses through the stomach and out of view.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Recurrent pneumonia after SCT with history of pneumothorax.,0
"FINDINGS: In comparison with study of , the ill-defined nodular opacity in the right mid zone and opacities in the retrocardiac region at the left base have not significantly changed since the prior CT of .",0
Tracheostomy tube is in good position and Dobbhoff tube extends at least to the second portion of the duodenum.,0
There is no evidence of pneumothorax or pulmonary vascular congestion.,0
"LINE PLACEMENT Clip # Reason: 46cm RUE Power PICC, # Admitting Diagnosis: SHUNT MALFUNCTION ______________________________________________________________________________ MEDICAL CONDITION: 34 year old woman with new right picc REASON FOR THIS EXAMINATION: 46cm RUE Power PICC, # ______________________________________________________________________________ FINAL REPORT AP CHEST, 1:01 P.M., .",0
HISTORY: 34-year-old woman with new right PIC.,0
"IMPRESSION: AP chest compared to : The wire in the new right PIC line can be traced as far as the upper SVC below which it is obscured by the right spinal rod, but we can see the catheter tip in the right atrium, no less than 35 mm beyond the estimated location of the superior cavoatrial junction.",0
Left internal jugular line passes as far as the left brachiocephalic vein and is obscured beyond that point.,0
Lungs are low in volume.,0
No evidence of pneumothorax or pleural effusion.,0
IV nurse and I discussed the line position by telephone at the time of dictation.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation and extubation History of Present Illness: Admission Note Primary Care Physician: .,0
"() Neurologist: Dr. () Chief Complaint: respiratory failure and altered mental status Reason for MICU transfer: intubated History of Present Illness: 63 yo F (real name ) with PMHx of alcohol abuse with withdrawal seizures, a SDH s/p R craniotomy, HTN and HL who presents intubated from for confusion.",1
"Per OSH records, patient fell the night prior to arrival on cousin's floor and struck her head; denied LOC, but c/o left brow pain, heaache, chipped tooth and sore R shoulder.",0
"A preliminary head CT showed no acute intracranial abnormality with chronic findings (old R parietal craniotomy, old R burr hole).",0
"Labs were notable for lactate 1.2, normal chem 7, normal CBC, normal UA, ammonia 32 (WNL).",0
"Tox negative for ethanol, salicylates, acetominophen.",0
The patient was intubated for failure to oxygenate/ventilate and inability to protect airway (sedation and confusion).,0
CXR showed R mainstem intubation--> pulled back 1 cm and improved L lung aeration.,0
"In the ED, initial VS were: 98.7, 91, 137/78, 21, 99%.",0
"Labs notable for UA with small WBC, Pos nitrite, few bact.",0
"Initially in the ED, she was ""fighting the vent"" and was making purposeful movements of all 4 extremities to attempt to remove the ETT, she was then heavily sedated in the ED with fentanyl and midazolam.",0
She received 500mg azithromycin and 1g of ceftriaxone.,0
Neurology was consulted who recommended EEG.,0
"On arrival to the MICU, patient's VS. 94.5, 73, 97/64.",0
Patient was intubated and sedated.,0
"Review of systems: unable to perform, patient intubated and sedated Past Medical History: SDH with coma for 3 mo about 5 years ago s/p Burr hole Seizures Alcoholism HTN HLD chronic cough of unclear etiology (sig second-hand smoke exposure) h/o colostomy for unclear reasons 8 pregnancies (G8) h/o breast bx x 2 foot and ankle fractures Social History: Patient lives alone in in .",1
"She has a brother in law in the area but often spends time with her cousin, , who is local.",0
"Denies having any problems with alcohol currently, but did before her stroke.",0
"Drinks 3 glasses of wine a night, no significant beer or liquor, CAGE negative, denies illicits or tobacco but her ex-husband (married for 25 years) smoked a lot Family History: Mother died of congenital heart condition in her 40s.",0
Brother died of an MI in his 60s.,0
"Physical Exam: ADMISSION EXAM 94.5, 73, 97/64.",0
ET tube is at the carina and should be repositioned.,0
Bilateral low lung volumes are noted with crowding of bronchovascular markings.,0
Cardiac silhouette is accentuated by low lung volumes.,0
"Additionally, opacification at the left lung base and in the retrocardiac region appears concerning for either pleural effusion versus atelectasis, infectious process such as pneumonia cannot be completely excluded in the correct clinical setting.",0
"CXR 8.21 In comparison with the study of , there again are lower lung volumes.",0
Cardiac silhouette is within upper limits of normal or slightly enlarged.,0
Minimal poor definition of pulmonary vessels could reflect slight elevation of pulmonary venous pressure.,0
Blunting of costophrenic angles could reflect small effusions or pleural thickening.,0
"No definite pneumonia is appreciated, though in the appropriate clinical setting a supervening consolidation would be difficult to exclude in lower zones.",0
"Brief Hospital Course: 63 yo F with PMH alcohol abuse with seizures, SDH s/p burr hole 5 years ago admitted with acute change in mental status.",1
# Acute Respiratory Failure: Patient arrived to the ICU intubated for respiratory failure in settting of acute confusional state.,1
The patient's initial ABG was reassuring and she was deemed able to extubate.,0
She was extubated on the day of arrival to the ICU and tolerated it well.,0
Her oxygen saturation remained in the mid to high 90s on room air.,0
The etiology of her respiratory was felt to be her toxic-metabolic encephalopathy as noted below.,1
"# Toxic-metabolic encephalopathy: The patient presented with acute altered mental status with history of alcohol abuse and seizures, also with history of SDH s/p craniotomy 5 years ago.",1
"The etiology was unclear, but the differential included alcohol withdrawal/seizure, toxic metabolic (hepatic encephalopathy), CVA/ICH, sepsis, wernicke's encephalopathy.",1
"Drug induced possible, home medications were difficult to clarify (the patient and her family were poor historians).",0
"The patient showed no signs of alcohol withdrawl and required only one dose of diazepam on the CIWA protocol, which was mostly given for insomnia.",0
"Neurology was consulted and they performed an EEG, which showed no epileptiform activity.",0
"The day of discharge, she developed a headache, but a repeat head CT was normal, and she felt better after Tylenol and ibuprofen so was discharged to follow-up as an outpatient.",0
"# Chronic cough: the pt had a non-productive cough during your admission, which has been present for several years, according to the patient.",0
"She had no fevers, chills, oxygen requirement or leukocytosis, so she was not treated for a pneumonia, and she felt this was at her baseline.",0
I suspect she may have COPD due to second hand smoke exposure (ex-husband smoked for 25 years with her).,0
She should have outpatient PFTs done to further evaluate this.,0
"# Coordination of care: I attempted to speak with the patient's PCP and Neurologist, but neither were available by phone on the day of discharge.",0
They will be sent a copy of this summary.,0
"# Inactive issues: The patient was continued on her home amitriptyline, fluoxetine, furosemide, gabapentin, topiramate, and methocarbamol.",0
Information was obtained from Family/CaregiverPharmacy.,0
1. risedronate *NF* 35 mg Oral WEEKLY 2.,0
Amitriptyline 100 mg PO HS 3.,0
Klor-Con *NF* (potassium chloride) 40 mg Oral 4.,0
Furosemide 40 mg PO DAILY 5.,0
Methocarbamol mg PO Q6H:PRN muscle pain 6.,0
Gabapentin 1200 mg PO TID 7.,0
Fluoxetine 60 mg PO DAILY 8.,0
Topiramate (Topamax) 100 mg PO QAM 9.,0
Topiramate (Topamax) 200 mg PO HS Discharge Medications: 1.,0
Amitriptyline 100 mg PO HS 2.,0
Fluoxetine 60 mg PO DAILY 3.,0
Gabapentin 1200 mg PO TID 4.,0
Methocarbamol mg PO Q6H:PRN muscle pain 5.,0
Topiramate (Topamax) 100 mg PO QAM 6.,0
Topiramate (Topamax) 200 mg PO HS 7.,0
Furosemide 40 mg PO DAILY 8.,0
"Klor-Con *NF* (potassium chloride) 40 mg Oral 9. risedronate *NF* 35 mg Oral WEEKLY Discharge Disposition: Home Discharge Diagnosis: Toxic-metabolic encephalopathy of unclear etiology -- resolved spontaneously Acute respiratory failure related to above -- resolved spontaneously Subdural hematomat with coma for 3 months about 5 years ago status post Burr hole Seizures, possibly related to alcoholism in the past Hypertension Hyperlipidemia Chronic cough of unclear etiology (significant second-hand smoke exposure) History of colostomy for unclear reasons 8 pregnancies (G8) History of breast biopsy x 2 Foot and ankle fractures Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: You developed confusion at home, fell and struck your head, suffering a headache, chipped tooth and sore R shoulder.",0
"You became progressively more confused until you were taken to - where your evaluation included a head CT, which was unchanged from your prior (not normal due to your history of subdural hemorrhage ~5 yrs ago with old R parietal craniotomy, old R burr hole).",0
You were intubated (placed on a breathing machine) because your mental status was so poor and you could not protect your airway and you were transferred to -.,0
Here you were quickly extubated (taken off the breathing machine) and you spontaneously improved.,0
The Neurology consult team saw you and could not explain what had happened.,0
"You developed a headache on the day of discharge, but a repeat head CT was normal, and you felt better after Tylenol and ibuprofen so were discharged to follow-up as an outpatient.",0
Followup Instructions: Primary Care Please follow-up with your primary care doctor within the next few weeks.,0
"Dr. (your - discharging physician) called Dr. , but he was unavailable.",0
"After reviewing your discharge summary, his office will call you with an appointment.",0
Please be sure to discuss your medications and possible pulmonary function testing at this appointment.,0
Neurology Please follow-up with Dr. as you had previously planned.,0
"4:48 PM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: evaluate for lesions elsewhere in the body****Patient cannot Admitting Diagnosis: CORD COMPRESSION Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with T4 metastatic lesion, h/o non-small cell CA REASON FOR THIS EXAMINATION: evaluate for lesions elsewhere in the body****Patient cannot take oral contrast**** No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT TORSO.",0
INDICATION: 73-year-old female with T4 metastatic lesion.,0
History of non-small cell cancer.,0
TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis with and without contrast.,0
Coronal and sagittal reconstructions were obtained.,0
CONTRAST: Oral and IV nonionic contrast was administered IV Optiray 350.,0
CT CHEST WITH CONTRAST: The thyroid is normal in appearance.,0
The major airways are patent down to the subsegmental level.,0
"Apical bullae are identified bilaterally, more prominent on the right.",0
Optimal evaluation of the lung parenchyma is not available secondary to respiratory motion.,0
There is nodular thickening and enhancement of the pleura in the bibasilar regions as well as the right anterior inferior hemithorax in which tumor involvement cannot be ruled out.,0
"Ground glass opacity layers posteriorly, more prominent on the left, likely consistent with atelectasis.",0
"No pathologically enlarged axillary, hilar, or mediastinal lymphadenopathy identified.",0
The heart is normal in appearance without pericardial effusion.,0
There are no pleural effusions identified.,0
Coronary calcifications are identified as well as calcification of the aortic valve.,0
"CT ABDOMEN WITH CONTRAST: A small hypodense lesion is identified in segment IV-B of the liver (3:62), which is too small to characterize.",0
No other lesions are identified within the liver.,0
"The main portal vein is patent, without intraluminal clot identified.",0
There is no intra- or extrahepatic biliary ductal dilatation.,0
"There are multiple bilateral hypodense lesions within the kidneys, too small to characterize.",0
The spleen and pancreas are visualized and unremarkable.,0
There is fullness of the left adrenal gland of uncertain significance.,0
The large and small bowel are visualized and unremarkable.,0
There is no free fluid or free air within the abdomen.,0
No pathologically enlarged lymph nodes are identified within the paraaortic or mesenteric regions.,0
Several colonic diverticula are identified without evidence of diverticulitis.,0
"CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, unopacified small bowel (Over) 4:48 PM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: evaluate for lesions elsewhere in the body****Patient cannot Admitting Diagnosis: CORD COMPRESSION Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ FINAL REPORT (Cont) loops are visualized and unremarkable.",0
The bladder is not opacified with contrast and thus not well evaluated for mass lesions.,0
OSSEOUS STRUCTURES: Hardware is identified within the left femur.,0
"There is a sclerotic focus within the left iliac bone, which abuts the cortex involving the left sacroiliac joint.",0
There is a predominantly sclerotic lesion involving the entire T4 vertebral body.,0
Compatible with osseous metastatic disease with loss of vertebral body height and retropulsion of vertebral body fragments into the central canal.,0
There is also evidence of an epidural soft tissue component with apparent compression of the cord in this region.,0
This soft tissue component displays enhancement.,0
Predominantly sclerotic lesion involving the entire T4 vertebral body with destructive components compatible with osseous metastatic disease.,0
There is also an enhancing soft tissue component within the epidural space compressing the cord in this region.,0
Further evaluation with MRI of the thoracic spine is recommended.,0
Please refer to CT T-spine for further details.,0
"Enhancing nodular thickening of the pleura bilaterally, worse on the right is identified.",0
Metastatic involvement cannot be excluded.,0
Sclerotic focus within the left iliac bone adjacent to the sacroiliac joint.,0
Please correlate with prior studies or bone scan.,0
"Multiple hypodense lesions within bilateral kidneys and segment IV-B of the liver, too small to characterize.",0
Coronary artery and aortic valve calcifications.,0
"8:01 PM CHEST (PORTABLE AP) Clip # Reason: s/p right IJ line placement ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man intubated for resp distress after 3 units PRBCs, s/p central line placement .",0
please assess placement + for pneumothorax.,0
REASON FOR THIS EXAMINATION: s/p right IJ line placement ______________________________________________________________________________ FINAL REPORT INDICATIONS: Right internal jugular line placement.,0
Comparison is made to the study from .,0
"SUPINE AP CHEST RADIOGRAPH: An endotracheal tube is present, in good position several centimeters above the carina.",0
"There has been interval insertion of a right internal jugular central venous line with the tip low, in the mid atrium.",0
"There is improvement in the bilateral lung interstitial opacities, suggestive of resolving congestive heart failure.",0
"But the interstitial markings are still prominent, and they reflect an underlying process.",0
Continued follow up is recommended.,0
"IMPRESSION: Right internal jugular central venous line tip low, in midright atrium.",0
"Improved bilateral interstitial lung opacities consistent with improving CHF, but continued follow up is recommended.",0
"3:00 PM MMS SUGICAL PLANNING SERVICE Clip # Reason: AAA ______________________________________________________________________________ MEDICAL CONDITION: AAA REASON FOR THIS EXAMINATION: AAA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT This report is for reference only, generated by M2S.",0
"(), DOB: (Age 62) AAA/TAA Date of Service: Physician : , MD Current Status was last scanned on and is a pre-operative AAA/TAA patient.",0
Mr. was previously scanned at Pre-op on -.,0
His AAA volume is 63.3cc.,0
His TAA volume is 323.2cc.,0
His AAA diameter is 2.9cm.,0
His TAA diameter is 4.2cm.,0
Nb: This note was automatically generated.,0
"12:45 PM CAROTID SERIES COMPLETE PORT Clip # Reason: eval for stenosis Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with large R sided stroke, SDH REASON FOR THIS EXAMINATION: eval for stenosis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 9:17 AM PFI: There is no diastolic flow in the right ICA and CCA suggestive of distal ICA occlusion.",1
There is a less than 40% stenosis within the left ICA.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 88-year-old woman with right-sided stroke.,0
RADIOLOGISTS: The exam was read by Dr. .,0
"TECHNIQUE AND FINDINGS: Extracranial evaluation of bilateral carotids was performed with B-mode, color and spectral Doppler ultrasound modes.",0
"On the right, peak systolic velocities are 23 cm/sec, 33 cm/sec and 94 cm/sec in the internal, common and external carotid arteries respectively.",0
The right ICA to CCA ratio is 0.69.,0
No diastolic flow was noted within the right ICA and CCA suggesting distal ICA occlusion.,0
"On the left side, peak systolic velocities are 70 cm/sec, 47 cm/sec, and 48 cm/sec in the internal, common and external carotid arteries respectively.",0
The left ICA to CCA ratio is 1.4.,0
IMPRESSION: There is no diastolic flow within the right ICA and CCA suggestive of distal right ICA occlusion.,0
There is less than 40% stenosis within the left internal carotid artery.,0
"8:56 AM CHEST (PORTABLE AP) Clip # Reason: interval change, ?evidence fluid overload Admitting Diagnosis: PERFERATED CECUM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with HTN, PVD, s/p ileostomy take down, now with REASON FOR THIS EXAMINATION: interval change, ?evidence fluid overload ______________________________________________________________________________ FINAL REPORT INDICATION: 82-year-old woman with hypertension and PVD, status post ileostomy takedown, now with acute renal failure, evaluate for fluid overload.",1
"COMPARISON: Portable AP chest radiograph, .",0
PORTABLE AP CHEST RADIOGRAPH: Feeding tube is noted extending below the diaphragm with the tip not clearly visualized within the field of view provided.,0
There is stable elevation of the right hemidiaphragm.,0
There is right basal opacification consistent with atelectasis.,0
Retrocardiac opacification appears consistent with atelectasis.,0
Small amount of pleural effusion at the left lung base cannot be excluded.,0
Left-sided pleural effusion with adjacent compressive atelectasis appears relatively similar to the most recent prior examination.,0
Underlying infectious process cannot be excluded in the correct clinical setting.,0
7:10 AM PICC LINE PLACMENT SCH Clip # Reason: Please place double lumen picc line.,0
"Admitting Diagnosis: CIRRHOSIS;MENTAL STATUS CHANGES;ETOH WITHDRAWAL Contrast: OPTIRAY Amt: 10 ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with ESLD and end stage CHF with poor access.",0
Please note the patient has coagulopathy due to poor synthetic function and will require reversal of INR to meet goal of 1.5 prior to the procedure.,0
REASON FOR THIS EXAMINATION: Please place double lumen picc line.,0
______________________________________________________________________________ FINAL REPORT INDICATION: End-stage liver disease and congestive heart failure.,1
Needs multiple incompatible medications and needs a 6-French power PICC line.,0
"Dr. , the attending radiologist being present and supervising.",0
The right arm was prepped in a sterile fashion.,0
"Since no suitable superficial veins were visible, ultrasound was used for localization of suitable vein.",0
The brachial vein was patent and compressible.,0
"After local anesthesia with 2 mL of 1% lidocaine, the brachial vein was entered under ultrasonographic guidance with a 21-gauge needle.",0
A 0.018 guidewire was advanced under fluoroscopy in the superior vena cava.,0
"Based on the markers on the guidewire, it was determined that a length of 37 cm would be suitable.",0
The PICC line was trimmed to length and advanced over a 6-French introducer sheath under fluoroscopic guidance into the superior vena cava.,0
Final chest x-ray was obtained.,0
A Statlock was applied and the line was hep locked.,0
"IMPRESSION: Successful placement of 37 cm total length 6-French power PICC line with tip in the superior vena cava, ready for use.",0
"7:31 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG w/hypoxia-evaluate R ?infiltrate/effusion Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with REASON FOR THIS EXAMINATION: s/p CABG w/hypoxia-evaluate R ?infiltrate/effusion ______________________________________________________________________________ FINAL REPORT AP CHEST, 7:55 A.M., HISTORY: Hypoxia after CABG.",1
IMPRESSION: AP chest compared to 10:42 p.m. on : Vascular engorgement of the mediastinum has resolved and small-to-moderate right pleural effusion decreased.,0
Cardiomediastinal silhouette has a normal postoperative appearance.,0
Atelectasis at the right lung base predates surgery along with elevation of the right hemidiaphragm.,0
Swan-Ganz catheter line ends in the right pulmonary artery.,0
12:42 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: lung expansion Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity REASON FOR THIS EXAMINATION: lung expansion ______________________________________________________________________________ FINAL REPORT TITLE: PORTABLE CHEST: DATE OF EXAMINATION: at 12:44.,1
CLINICAL HISTORY: Infant with prematurity.,0
"COMPARISON: Comparison is made to prior examination dated , time 16:16.",0
"FINDINGS: Overall, there are no significant interval changes from prior examination.",0
"Again noted is diffuse hazy opacities in both lungs, most likely due to surfactant deficiency.",0
"There is no new area of focal consolidation, pleural effusion, or pneumothorax.",0
Heart size and mediastinal contours are difficult to assess due to hazy bilateral opacities.,0
There is an endotracheal tube with its tip located approximately 0.5 cm above carina.,0
Nasogastric tube with its tip located in the region of the stomach is seen.,0
There is a right subclavian central venous line with its tip located in the superior vena cava.,0
The visualized osseous structures are normal in appearance.,0
"11:44 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with presumptive pneumonia REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Presumptive pneumonia, rule out infiltrate.",0
"An ET tube is present, tip at the level of the mid clavicles, approximately 8.1 cm above the carina.",0
"An NG tube is present, tip extending toward the diaphragm but unable to be traced beyond this level.",0
"A left central line is present, tip at junction of innominate vein and SVC.",0
The patient is status post sternotomy with multiple mediastinal clips.,0
There is moderate- to-moderately severe cardiomegaly unchanged or slightly more pronounced compared with .,0
There are bilateral effusions with underlying collapse and/or consolidation.,1
"There is upper zone redistribution, though I doubt overt CHF.",0
Prominence of the pulmonary hila could reflect an element of pulmonary hypertension.,0
"Compared with at 9:01 a.m., the effusions and underlying collapse and/or consolidation appear worse.",1
Distal portion of NG tube not well demonstrated due to positioning and underpenetration.,0
"If a side port is present, it may not lie below the diaphragm.",0
It is also difficult to confirm that the tip lies below the diaphragm.,0
"Bilateral left greater than right effusions with underlying collapse and/or consolidation, which appears worse compared with .",1
Upper zone redistribution without overt CHF.,0
This is probably slightly improved compared with .,0
4:09 AM CT HEAD W/O CONTRAST Clip # Reason: reval progress of IVB ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with REASON FOR THIS EXAMINATION: reval progress of IVB No contraindications for IV contrast ______________________________________________________________________________ WET READ: JLLW MON 5:47 AM SEE REPORT!!!,0
"TECHNIQUE: Noncontrast CT of the head was obtained, compared with the examination performed 2:02 A.M., at .",0
"FINDINGS: There is a large right-sided convexity subdural hematoma, which measures up to 2.2 cm in greatest thickness.",0
"In addition, in the right frontal lobe, lateral to the basal ganglia, there appears to be approximately 2 cm of rounded mass effect, with a central hyperdensity, which could be focal bleeding into a mass or contusion.. Superior to this, there is a 4 x 7 mm focal hypertensity, representing a small focus of parenchyma hemorrhage.",0
"There is marked subfalcine herniation (approximately 2 cm) with obliteration of the basal cisterns, and shift of most of the lateral ventricles into the left hemisphere.",0
There appears to be hyperdense hemorrhage probably running through the third and fourth ventricles.,0
"In addition, there is a 4 mm focus of hyperdensity, probably representing blood just medial to the bodies of the left lateral ventricle, again probably representing a focus of hemorrhage.",0
All -white matter differentiation remains preserved at this time.,0
There is complete obliteration of the cisternal spaces.,0
There is marked generalized edema.,0
There is a hematoma in the left upper pons extending to the midbrain.,0
Images do not extend below the tonsils.,0
Examination of osseous and soft tissue structures show no suspicious lytic or blastic lesions.,0
A small amount of air-fluid level is present within the sphenoid sinuses.,0
There are marked vertebral artery calcifications.,0
IMPRESSION: Subfalcine and transtentorial herniation.,0
"The amount of shift appears disproportionate to the size of the subdural hematomas, and there is probably a mass effect, most likel;y contusion just lateral to the right basal ganglia, also contributing to the mass effect which is seen today.",0
The possibility of transforaminal herniation cannot be excluded.,0
"Compared to the outside examination, there has been no significant interval change.",0
Findings were discussed with the surgical and neurosurgical teams at the time of evaluation.,0
(Over) 4:09 AM CT HEAD W/O CONTRAST Clip # Reason: reval progress of IVB ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
2:32 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: please eval for IC process.,0
"Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL ADDENDUM There is hypoplasia of the A1 segment on the left with significant left ACA narrowing vs. stenosis, there is also occlusion of the right anterior cerebral artery involving the A2 and A3 segments, noted on the MIPS and COW images.",1
Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with hx of post stroke p/w AMS and left sided defecits REASON FOR THIS EXAMINATION: please eval for IC process.,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: JMGw WED 4:00 AM C- Head: no acute findings.,0
CTA: severe stenosis and filling defect in the left proximal subclavian artery (3:31).,0
"no flow in the proximal left vertebral artery, with flow seen at level of C6 (3;82), may reconsititue from above with extremely dimunitive caliber.",0
moderate to severe proximal left ICA stenosis with adjacent soft and calcific plaque.,0
moderate proximal right ICA stenosis.,0
probable 2mm right ICA infundibulum (3:205).,0
"normal COW without aneurysm, dissection or stenosis.",0
atherosclerotic plaque of the aortic arch.,0
cervical spine djd with mild central canal narrowing at c5/6 and c6/7.,0
"final read pending 3D reformats ______________________________________________________________________________ FINAL REPORT HISTORY: Patient with history of stroke and mental status change, to assess for intracranial process.",0
TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material.,0
"Subsequently, rapid axial imaging was performed from the aortic arch through the brain post-administration of intravenous contrast.",0
"Images were processed on a separate workstation with display of curved reformats, 3D volume-rendered images, and maximum intensity projection images.",0
COMPARISON: With outside CT of .,0
FINDINGS: There are ill-defined foci of hypodensity in the left posterior parietal and occipital lobes consistent with established chronic infarcts.,0
There is periventricular hypodensity suggesting chronic microvascular ischemia.,0
The midline structures are central.,0
There is no mass effect or edema.,0
HEAD AND NECK CTA: There are emphysematous changes present at the visualized lung apices.,0
There is extensive calcified and noncalcified plaque present within the aortic arch.,0
"In its proximal course, there is severe stenosis of the left subclavian artery with a noncalcified plaque (image 28, series 3).",0
The proximal left vertebral artery is completely occluded in its mid and distal course demonstrates a (Over) 2:32 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: please eval for IC process.,0
Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) diminutive caliber with contrast opacification most likely via retrograde flow.,0
The right vertebral artery appears unremarkable.,1
"The intracranial course of the vertebral arteries, basilar artery and its branches are patent.",1
There is atherosclerosis present at the bifurcation of the left common carotid artery and the left internal carotid artery is diminutive in caliber in its proximal course.,1
There is also atherosclerosis present at the right common carotid bifurcation with stenosis due to atheroma at the origin of the right internal carotid artery.,1
"In addition, there is atherosclerosis present in the cavernous internal carotid arteries bilaterally.",0
"There is a probable 2-mm right internal carotid artery infundibulum (image 205, series 3).",1
The intracranial branches of the internal carotid arteries appear unremarkable.,0
Multilevel degenerative changes are present in the cervical spine.,0
The right internal carotid artery in its proximal course measures 7.5 x 5.8 mm and the right internal carotid artery in its distal course measures 4.3 x 4.0 mm.,1
The left internal carotid artery in its proximal course measures 4.6 x 4.4 mm and the left internal carotid artery in its distal course measures 3.3 x 3.5 mm.,0
Established areas of infarction in the left posterior parietal and occipital lobes.,0
"Diffuse periventricular hypodensity, most consistent with sequelae of chronic microvascular ischemia.",0
Severe stenosis in the proximal course of the left subclavian artery with an occluded proximal left vertebral artery.,0
Atherosclerosis at the carotid artery bifurcation bilaterally with stenosis of the proximal course of internal carotid arteries bilaterally as described above.,1
5:21 PM CHEST (PORTABLE AP) Clip # Reason: post chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man s/p cabg REASON FOR THIS EXAMINATION: post chest tube removal ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Chest tube removed following CABG.,1
An area of atelectasis is present within the right lower lobe.,0
A small pneumothorax is seen.,0
Some atelectasis is also present on the left side.,0
No evidence of failure is present.,0
The endotracheal tube and right IJ line have also been removed.,0
IMPRESSION: Small apical pneumothorax following removal of left chest tube.,0
", M. TSICU 4:53 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: PLEASE DO AT 6PM TONIGHT PER DR - THANKS Admitting Diagnosis: TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with LEFT SDH S/P ASSAULT REASON FOR THIS EXAMINATION: PLEASE DO AT 6PM TONIGHT PER DR - THANKS No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Slight interval decrease in left-sided subdural hematoma with no other changes identified.",1
Height: (in) 67 Weight (lb): 180 BSA (m2): 1.94 m2 BP (mm Hg): 124/66 HR (bpm): 76 Status: Inpatient Date/Time: at 11:25 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
Normal IVC diameter (<2.1cm) with <35% decrease during respiration (estimated RA pressure indeterminate).,0
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.,1
The right atrial pressure is indeterminate.,0
IMPRESSION: Borderline normal left ventricular systolic function.,0
", CSURG FA6A 1:17 PM CHEST (PORTABLE AP) Clip # Reason: f/u effusions, atx Admitting Diagnosis: CORONARY ARTERY DISEASE;MYXOMA\CORONARY ARTERY BYPASS GRAFT;LEFT ATRIAL MYXOMA REMOVAL/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with s/p resection REASON FOR THIS EXAMINATION: f/u effusions, atx ______________________________________________________________________________ PFI REPORT Mild volume overload is improving.",1
"5:05 PM CT HEAD W/O CONTRAST Clip # Reason: Please eval for interval changes in , other interval Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with known , afib, C.diff, s/p cardiac arrest.",1
"REASON FOR THIS EXAMINATION: Please eval for interval changes in , other interval changes.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 78-year-old woman with known, , atrial fibrillation, and C. difficile status post cardiac arrest.",1
Please evaluate for interval changes in or any other interval changes.,0
"FINDINGS: Again seen, but less apparent, is a small left frontal high- attenuation focus (series 2, image 18; series 400b, image 29).",0
No other foci suggestive of acute hemorrhage are seen.,1
There is no loss of -white matter differentiation.,0
"There is no mass, mass effect, or edema.",0
"Prominent fluid-filled extra-axial spaces seen best on coronals (series 400B, image 43) likely represent subdural hygromas versus old subdural hemorrhage.",0
"Ventricles and sulci are moderately prominent, suggesting age-associated involutionary changes.",0
The osseous and soft tissues are grossly unremarkable.,0
IMPRESSION: Decreased conspicuity of focus of high attenuation in the left frontal region which may represent an evolving very small focus of subarachnoid hemorrhage.,1
Prominent extra-axial frontal spaces likely represent a subdural hygroma versus old subdural hemorrhage.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: : Gastrointestinal arteriogram and embolization of metastatic pancreatic tumor feeding arteries with no immediate complications.,0
"IMPRESSION: Positive GI bleeding study at 60 minutes with findings highly suggestive of small bowel bleeding, likely related to known midline duodenal/pancreatic metastasis.",0
The transverse colon is noted to positioned more superior (on prior CT's) then site of bleeding on current study.,0
History of Present Illness: 67 y.o.m.,0
with metastatic renal cell carcinoma with metastasis to the pancreas and liver as well as known duodenal/ampullary mass presents with BRBPR x 2 days.,0
"Of note, the patient was recently started on sutent.",0
Pt states that he first noticed bloody bowel movement yesterday am.,0
He called his oncologist who recommended bowel prep in anticipation of colonoscopy today given known side effect of bleeding with sutent.,0
Pt has colonoscopy this am that showed blood in colon but no identifiable source.,0
Pt was referred to the ED for tagged RBC scan and labs.,0
"Here, a tagged RBC scan was positive at 60 min, and pt was taken to angiography.",0
"There, they couldn't find any obvious source of bleed, but was consistent with a small bowel source.",0
HCT noted to drop further to 21 and patient was then referred for MICU admission.,0
"On admission, he denies fast heart rate, lightheadedness, dizziness, chest or abdominal pain, tenesmus.",0
"He feels generally well, though a little anxious.",0
"Past Medical History: # GIB , EGD revealed duodenal ulcer c/w malignancy # Hypertension.",1
"# No cardiac problems, diabetes, or cholesterol.",0
# Traumatic fracture of the right fibula which require open reduction.,0
"# RCC in , treated with IL 2/LAK and was disease free until , now with metastatic disease to pancreas and likely liver.",1
Status post left nephrectomy followed by high-dose IL-2 .,0
3. st. post resection of residual renal bed mass in 4.,0
Recurrence in the left renal fossa and pancreas in 5.,0
"7. initiated on Nexavar 400 mg twice daily, dose reduced on 10/1005 in the setting of hypertension.",0
"His course has been complicated by a GI bleed with possible small bowel obstruction, and an admission to in for anemia and acute renal failure while on full dose Nexavar 400 mg given twice daily.",1
"Nexavar dose reduced to 400 mg q.a.m., 200 mg q.p.m.",0
Nexavar dose increased to 400 mg b.i.d.,0
"following CT in , which showed progression of pancreatic metastases.",0
Enrolled in perifosine trial 06-408 on .,0
Perifosine held since due to GI bleed.,0
"ERCP on showed a malignant appearing mass in duodenum, pathology consistent with metastatic renal cell Ca.",1
"Perifosine restarted for one week, held on due to SBO requiring hospital admission in , and restarted again on .",0
Perifosine held due to elevated LFTs on .,0
ERCP on - biliary stent placed to proximal CBD.,0
Social History: He is married and has two children.,0
He is retired from GM.,0
He is a part-time smoker and drinks alcohol socially.,0
"FAMILY HISTORY: Non-contributory Physical Exam: PHYSICAL EXAMINATION: VITALS: HR 89 BP 145/92 RR 15 Sat 99 (intubated) GENERAL: Well-appearing in NAD HEENT: NC/AT CARD: RRR, nl s1 s2, no m/r/g RESP: CTAB ABD: Soft, Non-tender, Non-distended, with scattered nodules.",0
RECTAL: Deferred BACK: Mild winging of right scapula.,0
"EXT: WWP, 2+ PT, DP pulses, No C/C/E Pertinent Results: 12:00PM BLOOD WBC-5.9 RBC-3.88* Hgb-9.0* Hct-29.0* MCV-75* MCH-23.3* MCHC-31.2 RDW-20.6* Plt Ct-149* 05:50PM BLOOD WBC-4.1 RBC-2.73*# Hgb-6.5*# Hct-20.6*# MCV-75* MCH-23.7* MCHC-31.6 RDW-19.5* Plt Ct-103* 12:04PM BLOOD WBC-7.2 RBC-3.88* Hgb-10.0* Hct-29.3* MCV-76* MCH-25.7* MCHC-34.0 RDW-19.3* Plt Ct-116* 05:45PM BLOOD WBC-7.5# RBC-3.77* Hgb-10.5* Hct-30.2* MCV-80* MCH-27.8 MCHC-34.8 RDW-18.1* Plt Ct-103* 12:18PM BLOOD Hct-31.0* 02:07AM BLOOD Glucose-120* UreaN-10 Creat-0.9 Na-137 K-4.5 Cl-110* HCO3-18* AnGap-14 12:49PM BLOOD Hct-30.1* 09:28PM BLOOD Hct-30.4* 10:09AM BLOOD WBC-9.2 RBC-4.25* Hgb-12.1* Hct-34.4* MCV-81* MCH-28.5 MCHC-35.1* RDW-19.0* Plt Ct-112* Blood cx NGTD x 2 .",0
"Bleeding study: Positive GI bleeding study at 60 minutes with findings highly suggestive of small bowel bleeding, likely related to known midline duodenal/pancreatic metastasis.",0
Arteriogram: Arteriogram of celiac trunk and superior mesenteric artery with no extravasation.,0
Bleeding Study: Intermittent brisk bleeding.,0
Origin of the bleeding appears to be just to the left of midline in the epigastrium.,0
IR study: Gastrointestinal arteriogram and embolization of metastatic pancreatic tumor feeding arteries with no immediate complications.,0
Femoral ultrasound: No evidence of pseudoaneurysm.,0
Left lower lobe retrocardiac opacity is most likely atelectasis.,0
Knee X-ray: Mild patellofemoral compartment osteoarthritis.,0
"Ultrasound: Examination limited by extensive bowel gas, which may represent the source of the patient's distention.",0
"Mild interval increase in size of a right hepatic mass, allowing for differences in technique.",0
"Bilateral pleural effusions, left greater than right.",0
Interval increase in intra-abdominal and intrapelvic ascites.,0
Mild edema of the colonic wall could reflect a mild portal colopathy.,1
"No significant change in multiple areas of metastatic disease, including multiple large masses of the pancreas.",1
Portal vein thrombosis with innumerable coallaterals.,1
"Suboptimal evaluation of the spleen; while the appearance may reflect heterogeneous enhancement due to the phase of contrast, the possibility of infarcts should be considered.",0
Attention to this area on follow-up imaging is advised.,0
Abd Ultrasound for diagnostic paracentesis: Very small amount of ascites adjacent to the liver dome.,1
"Brief Hospital Course: Mr. is a 67yM with metastatic RCC, h/o GIB c malignant ulcer, p/w BRBPR for 2 days and admitted to MICU for careful hemodynamic monitoring.",0
"GI Bleed: Likely related to a metastatic lesion, complicated by starting Sutent.",0
"Patient has a history of bleeding GI masses, and had been temporarily stopped in Atrasentan trial for anemia.",1
EGD showed no bleeding from duodenal/ampullary mass or hematobilia.,0
"He thus likely has a lower GI source, which is consistent with colonoscopy with blood throughout.",0
"Pt had RBC scan w/ bleeding at 60min and nothing on angio, then had more BRBPR in the MICU, was re-RBC scanned w/ bleeding at 7 min, and was re-angioed this am, where they embolized feeding arteries around tumor, but did not see any large bleeds.",0
"The following day () the patient was hemodynamically stable and had a Hct of 31 in the AM, yet her afternoon HCT was found to be 24 and confirmed on repeat.",0
The patient was transfused 2 units and responded appropriately.,0
"The patient was continued on a PPI , and had two IVs kept in place.",0
His hematocrit remained stable 24 hours after.,0
"However, he was transferred to given continued repeated drops in HCT.",0
GI and surgery consulted but did not recommend further interventions at time of transfer.,0
"Once transferred to the floor, his hematocrit remained stable.",0
He received a total of 12 units of pRBC's during this admission.,0
"He developed a gout flare during admission (despite being on allopurinol), confirmed by arthrocentesis.",0
"He was started on a steroid taper, which he will complete as an outpatient.",0
"His abdomen was noted to be distended, although nontender.",0
"An ultrasound identified mild ascites and increased bowel gas, and a CT abd/pelvis was performed, demonstrating pleural effusions and mild ascites.",0
A diagnostic paracentesis was attempted but could not be safely performed given the small amount of fluid.,0
His outpatient regimen was initially held in the setting of lower GI bleed.,0
"His nodal blocking agents were slowly added back (diltiazem first), and he was discharged to continue all of his home blood pressure medications.",0
He had low grade temperatures for several days during the admission but no sources were identified.,0
Cultures were negative at the time of discharge and should be followed up as an outpatient.,0
Renal Cell cancer: He will complete his course of XRT at discharge and will follow up with Dr. afterward.,0
Medications on Admission: Allopurinol 200 mg daily Atenolol 50 mg daily Diltiazem 360 mg daily Nexium 40 mg daily Lisinopril 40 mg daily Iron 325 daily Acetaminophen prn Discharge Medications: 1.,0
Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever.,0
"Gas-X 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every eight (8) hours as needed for gas.",0
"Diltiazem HCl 360 mg Capsule, Sust.",0
Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed.,0
"Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day for 6 days: take 3 tablets; take 2 tablets; take 1 tablet, then stop.",0
Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Discharge Disposition: Home Discharge Diagnosis: Metastatic Renal Cell Carcinoma Gastrointestinal Bleed Discharge Condition: The patient was hemodynamicall stable, afebrile and without pain.",0
Discharge Instructions: You were admitted for gastrointestinal bleeding which required ICU care.,0
Your bleeding was determined to be caused by a mass in your intestine.,0
You underwent endoscopy and blood vessels in your tumor were treated.,0
You received several blood transfusions but have had not evidence of bleeding for several days.,0
"In addition, you developed a gout flare of your right knee.",0
You should continue taking the prednisone as prescribed.,0
Take all of your medications as prescribed.,0
You should resume taking all of the pills you were taking prior to this admission (EXCEPT for Sutent; this will be discussed with Dr. at your next visit).,0
"If you develop any concerning symptoms, such as more bleeding from your rectum, vomiting any blood, increasing abdominal fullness or abdominal pain, dizziness, numbness, chest pain, shortness of breath, or other concerning symptoms, please seek medical attention immediately.",0
Followup Instructions: Follow up with Dr. after your radiation is finished; his office will contact you for an appointment.,0
Continue going to radiation until you complete the course; they will give you a time for daily visits.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old woman with a past medical history notable for peptic ulcer disease with a history of ""bleeding ulcer,"" coronary artery disease, diabetes mellitus type 2 and multiple sclerosis, who presented to the emergency department early on the morning of admission complaining of epigastric pain.",1
"The patient stated that, approximately two weeks prior to presentation, she began experiencing diarrhea alternating with constipation.",0
"Then, approximately two days prior to admission, the patient began having only constipation.",0
"When the patient did have bowel movements, they were black and tarry.",0
This was an unprecedented occurrence for her.,0
"The patient denied having any recent hematochezia, hemoptysis or hematemesis.",0
"At approximately 2 AM on the morning of admission, the patient was awakened by epigastric pain which was in severity and constant in duration.",0
The patient could not describe the quality of pain.,0
"She felt that it was well localized to her epigastrium, although she admitted that she also experienced interscapular pain with this episode of epigastric pain.",0
"She was not surprised by this, as she reported that she had interscapular pain ""whenever I get stomachaches--since I was a kid.""",0
"The patient was brought by EMS to the emergency department, where her pain abated completely shortly after receiving Maalox at approximately 9:30 AM.",0
"REVIEW OF SYSTEMS: Of note, the patient admitted that for approximately five years her stool had been of smaller caliber.",0
She denied any other change in her bowel or bladder patterns.,0
"She specifically denied fevers, chills, nausea, vomiting, diarrhea or headache.",0
"She denied sore throat, cough, recent change in weight and night sweats.",0
"In terms of the patient's cardiovascular status, she specifically denied having had any pain radiating to her left jaw (her anginal equivalent) since her coronary artery bypass grafting in .",0
"She denied chest pain, dyspnea, palpitations, diaphoresis, lower extremity edema, paroxysmal nocturnal dyspnea and orthopnea.",0
"(Although she used two pillows for sleeping, she said that she did not become dyspneic without them.)",0
"The patient denied any recent illnesses, including changes in her multiple sclerosis.",1
"Similarly, she denied recent changes in her appetite, diet and medication regimen.",0
Her fingerstick blood sugars had been consistently running under 120.,0
Coronary artery disease: The patient had no history of known myocardial infarction.,0
"She did have angina (left jaw pain), which led to cardiac catheterization, which subsequently led to coronary artery bypass grafting in .",0
The patient had not had any angina since her coronary artery bypass grafting.,0
"Congestive heart failure: The patient had an ejection fraction of 20-25% by echocardiogram in with left ventricular hypokinesis, moderate mitral regurgitation and mild pulmonary hypertension.",1
"Peptic ulcer disease: The patient had a history of a ""bleeding ulcer"" in with hematochezia.",0
"Per the patient, this was an upper gastrointestinal bleed.",0
No intervention was required at that time.,0
No pertinent records were currently available for this history of bleeding ulcer.,0
The patient was on ranitidine.,0
"Diabetes mellitus type 2: This was diagnosed approximately one year prior to admission, per the patient.",0
This was well controlled on Glyburide with fingersticks consistently under 120.,0
"Hypertension: Per the patient, her blood pressure typically ran in the 120s-130s/80s.",0
Multiple sclerosis: This was diagnosed when the patient was approximately 35 years old.,1
"Per the patient, this had not affected her vision but rather her lower extremities and balance, such that she had difficulty walking well.",0
"Urinary incontinence, likely functional, as the patient had trouble getting to the bathroom in time.",0
"History of right shoulder pain, status post a fall.",0
"Chronic lower back pain, which continued status post laminectomy in .",0
Status post appendectomy in .,0
Status post surgery to correct trigeminal neuralgia in .,0
Folic acid 400 mg p.o.,0
"SOCIAL HISTORY: The patient lived alone at home in , .",0
She had two boarders who lived upstairs in her home.,0
She would like to move to an facility soon.,0
The patient denied a tobacco history.,0
"She admitted rare alcohol use, but not abuse.",0
The patient denied any other drug use.,0
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a temperature of 97.2?????,0
"?F, a heart rate of 86, a blood pressure of 171/86 in the left arm and 181/80 in the right arm, respirations of 14 per minute and an oxygen saturation of 97% on room air.",0
"In general, the patient was a pleasant 75-year-old woman, awake and in bed, in no acute distress.",0
"On head, eyes, ears, nose and throat examination, the pupils were equal, round and reactive to light and accommodation bilaterally.",0
The extraocular movements were intact bilaterally.,0
The nasal and oral mucosa were clear.,0
The mucous membranes were moist.,0
"The neck was supple without thyromegaly, jugular venous distention, lymphadenopathy or bruits.",0
The heart had a II/VI systolic ejection murmur heard maximally at the apex with a sinus S1 and S2 and no rubs or gallops.,0
The chest had mildly decreased breath sounds with occasional rhonchi at the bases bilaterally.,0
"Otherwise, the chest was clear to auscultation bilaterally with a well healed sternotomy scar.",0
"The abdomen was soft, but mildly tender to palpation, especially in the left lower quadrant.",0
The abdomen was nondistended with positive normal active bowel sounds.,0
"There was a well healed midline scar, apparently due to exploratory laparotomy, which eventually led to appendectomy.",0
The gastrointestinal evaluation revealed dark stool that was guaiac positive.,0
"The patient was nasogastrically lavaged in the emergency department with 250 cc of fluid, revealing no blood and no bile.",0
"In the extremities, the venous graft harvest site was well healed at the right lower extremity with no clubbing, cyanosis or edema.",0
Pedal pulses were 2+ bilaterally.,0
"On neurological examination, the patient was alert and oriented times three.",0
Speech was normal and appropriate.,0
Cranial nerves II through XII were intact bilaterally with the possible exception of the tongue deviating slightly to the right.,0
Strength was in the upper extremities and lower extremities proximally and distally bilaterally.,0
Sensation was intact to light touch bilaterally at the distal lower and upper extremities as well as the three divisions of cranial nerve V. Rapid alternating movements were intact bilaterally.,0
Reflexes were 0 at the lower extremities bilaterally and 2+ symmetrically at the upper extremities.,0
The right toe was downgoing and the left toe was equivocal.,0
"LABORATORY DATA ON PRESENTATION: Note that the patient was guaiac positive, but nasogastric lavage negative (as noted above.)",0
"The CBC revealed a white blood cell count of 10,300, hematocrit of 30.0 (which upon repeat was 31) and platelet count of 289,000.",0
"Chem 7 revealed a sodium of 138, potassium of 6.0 (which upon repeat was 4.0), chloride of 108, bicarbonate of 19, BUN of 49, creatinine of 1.3 and glucose of 121.",0
"Coagulation studies revealed a prothrombin time of 12.4, partial thromboplastin time of 25.6 and INR of 1.0.",0
"Liver function tests and pancreatic function tests revealed an ALT of 33, AST of 52, total bilirubin of 0.2, amylase of 41 and lipase of 21.",0
"Cardiac enzymes were cycled times three: CK #1 was 287 with an MB of 6, CK #2 was 177 with an MB of 4 and a troponin of less than 3 and CK #3 was likewise negative.",0
RADIOLOGY DATA ON PRESENTATION: The chest x-ray showed cardiomegaly with no increase in pulmonary vasculature and no infiltrates or effusions.,0
There was degenerative joint disease of the spine.,0
There was no air under the diaphragm.,0
ELECTROCARDIOGRAM: The electrocardiogram showed an old left bundle branch block and sinus rhythm with no acute changes.,0
HOSPITAL COURSE: What follows is an outline of the hospital course by problem list.,0
GASTROINTESTINAL BLEED: The patient was admitted initially to the medicine service and the gastrointestinal service was consulted.,0
"On , the patient underwent an esophagogastroduodenoscopy, which revealed grade 1 esophagitis at the gastroesophageal junction as well as a large, cratered, 3 cm ulcer with adherent clot in the proximal bulb of the duodenum.",0
A visible vessel suggested recent bleeding.,0
BICAP electrocautery was applied successfully for hemostasis.,0
"Otherwise, the esophagogastroduodenoscopy was normal to the third part of the duodenum.",0
The patient was continued on Protonix 40 mg p.o.,0
Her aspirin and Vioxx had been held since admission.,0
"Helicobacter pylori was sent, which eventually came back as positive.",1
"Late in the evening of , the patient began to experience hematemesis.",0
Nasogastric lavage could not successfully clear the patient and thus she was transferred to the medical intensive care unit.,0
The patient was transfused two units of packed red blood cells and subsequently underwent embolization by the interventional radiology team.,0
"Following embolization, the patient experienced a second mild hematocrit drop and was transfused an additional two units.",0
"Thereafter, her hematocrit remained stable.",0
"In terms of the patient's Helicobacter pylori, she was started on a Prevpac, which she is to continue for two weeks.",1
"Following conclusion of the Prevpac, the patient should be maintained on Protonix or some other gastrointestinal prophylaxis and she should not be given non-steroidal anti-inflammatory drugs or aspirin, as she has a risk of re-bleeding.",0
Other gastrointestinal issues for the patient include the fact that she has a history of decreased stool caliber for approximately the past five years.,0
"Thus, she will need a follow up colonoscopy as an outpatient to evaluate for possible malignancy.",0
"CARDIOVASCULAR: a) In terms of the patient's coronary artery disease, she was ruled out for myocardial infarction.",0
Her aspirin was discontinued upon admission because of the risk of gastrointestinal bleed.,0
"She was continued on Lipitor, Lopressor and a cardiac diet.",0
"b) In terms of the patient's blood pressure, pump status and history of congestive heart failure, she was continued on Lopressor and Lasix.",1
DIABETES MELLITUS TYPE 2: The patient was maintained on her outpatient regimen of Glyburide and maintained good fingerstick blood sugars.,0
MULTIPLE SCLEROSIS: The patient was continued on her amantadine without any exacerbations of her multiple sclerosis.,1
"FLUID, ELECTROLYTES AND NUTRITION: Following embolization, the patient's diet was advanced successfully and she tolerated it without nausea, vomiting or diarrhea.",0
"PROPHYLAXIS: The patient was maintained for a time on Protonix drip, followed thereafter by her Prevpac which, after outpatient discharge, is to be followed by other gastrointestinal prophylaxis per her primary care physician.",0
CONDITION ON DISCHARGE: The patient remained stable and afebrile.,0
Upper gastrointestinal bleed: duodenal ulcer.,1
History of coronary artery disease.,0
"DISCHARGE MEDICATIONS: The patient was discharged on her above noted outpatient medication regimen with the notable exceptions of aspirin and non-steroidal anti-inflammatory drugs, which were discontinued due to the risk of re-bleed.",0
"Furthermore, the patient was discharged on Prevpac q.d., of which she is to finish a two week course.",0
"Following conclusion of her Prevpac, the patient should be placed on gastrointestinal prophylaxis such as Protonix or an H2 blocker.",0
FOLLOW UP: The patient should follow up with her primary care physician within the following week.,0
Dictated By: MEDQUIST36 D: 11:00 T: 11:52 JOB#:,0
"3:21 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for pleural effusion, volume overload Admitting Diagnosis: GVH OF LIVER ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with MM with PNA and new atrial fibrillation REASON FOR THIS EXAMINATION: Evaluate for pleural effusion, volume overload ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SESHa TUE 4:25 PM Worsening pneumonia in the left lung, probable right lower lung involvement as well.",1
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH PERFORMED ON .,0
Comparison is made with a prior chest radiograph dated as well as a chest CT from .,0
"CLINICAL HISTORY: 63-year-old man with multiple myeloma, now with pneumonia, new atrial fibrillation, question pleural effusion or volume overload.",1
FINDINGS: AP upright portable chest radiograph is obtained.,0
Port-A-Cath projects over the right axillary region with catheter tip extending into the expected location of the superior vena cava.,0
Dense consolidation in the left lower lobe is increased from prior likely indicating worsenning of pneumonia and involvement of the LLL basal segments.,0
Small left effusion may be slightly increased.,0
A band-like opacity within the right mid-to-lower lung is slightly more prominent when compared with multiple prior chest radiographs and this could reflect a superimposed pneumonia in this region.,1
Tiny right-sided pleural effusion is difficult to exclude.,0
Heart size appears grossly stable but somewhat obscured by the adjacent left lung consolidation.,0
Mediastinal contour is also grossly stable.,0
"Multiple right-sided rib deformities are better characterized on the prior CT, with overall demineralized appearance of the bones, likely reflective of patient's known multiple myeloma.",1
"IMPRESSION: Worsening pneumonia in the left lung, now involving the basal segments of the left lower lobe.",0
Apparent increase in right lower lung opacity which may reflect pneumonia.,0
"Small bilateral pleural effusions, possibly increased on the left.",0
Diffuse bony changes compatible with known multiple myeloma.,1
"5:16 PM CHEST (PORTABLE AP) Clip # Reason: ?PTX Admitting Diagnosis: SEVERE AORTIC STENOSIS;S/P CABG\CATH ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with AS s/p Redo-Sternotomy, AVR.",0
"now s/p mediastinal CT removed REASON FOR THIS EXAMINATION: ?PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Aortic stenosis, status post redo sternotomy and aortic valve replacement.",1
Status post removal of mediastinal chest tubes.,0
AP bedside film dated at 17:29 compared with the examination from yesterday at 13:22.,0
The patient has been extubated and the nasogastric tube has been removed.,0
Two mediastinal chest tubes and the right lung base chest tube have been removed.,0
A single right-sided tube terminating in the superior mediastinum remains.,0
The right internal jugular catheter sheath terminates in the proximal SVC.,0
The median sternotomy wires are stable.,0
The left lateral hemithorax is excluded from the film.,0
There is a small right apical pneumothorax.,0
There remain patchy opacities in the right lower lung zone.,0
There is no large pleural effusion.,0
IMPRESSION: Status post removal of two mediastinal and one right lung base chest tubes with interval development of small apical right pneumothorax.,0
Patchy airspace opacities in the right lower lung zone are stable.,0
"COMMENT: At the conclusion of this examination, these findings were discussed with the clinician caring for the patient, , PA, by telephone.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: sepsis and gangrene of the right foot Major Surgical or Invasive Procedure: - PROCEDURE: Right below-the-knee guillotine amputation.,1
- PROCEDURE: Closure of right below-knee amputation.,0
Upper endoscopy and placement of percutaneous endoscopic gastrostomy.,0
"History of Present Illness: 63 y/o M c/ R foot wound on vac at home, s/p multiple debridements, presented to ED septic with R foot gangrene Past Medical History: 1.",1
ESRD on HD DM and HTN (since on Tu-Th-Sat) 2.,0
DM - Retinopathy - Neuropathy in calves and feet 3.,0
Chronic cough 6. s/p cataract surgery 7.,0
History of Tobacco abuse Social History: Lives with wife.,0
Alcohol 3 times per week.,0
He was a heavy drinker in the past of unclear significance.,0
"Family History: Diabetes Mellitus Type II PAD Increase cholesterol ESRD on HD (M/W/F), transplant list, HTN Physical Exam: N/A pt expired Pertinent Results: 02:29AM BLOOD WBC-11.1* RBC-2.58* Hgb-7.7* Hct-23.6* MCV-92 MCH-29.7 MCHC-32.5 RDW-20.5* Plt Ct-234 09:30AM BLOOD PT-17.6* PTT-43.7* INR(PT)-1.6* 02:29AM BLOOD Glucose-162* UreaN-57* Creat-7.3*# Na-140 K-4.1 Cl-102 HCO3-26 AnGap-16 02:44AM BLOOD ALT-389* AST-144* AlkPhos-219* Amylase-24 BLOOD CULTURE AEROBIC BOTTLE (Final ): NO GROWTH.",0
ANAEROBIC BOTTLE (Final ): REPORTED BY PHONE TO 8AM.,0
Trimethoprim/Sulfa sensitivity testing available on request.,0
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin.,0
Screen predicts NO synergy with penicillins or vancomycin.,0
Consult ID for treatment options.,0
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin.,0
Screen predicts possible synergy with selected penicillins or vancomycin.,0
"Consult ID for details.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | ENTEROCOCCUS FAECALIS | | AMPICILLIN------------ <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S PENICILLIN------------ 8 S PIPERACILLIN---------- =>128 R TOBRAMYCIN------------ 8 I VANCOMYCIN------------ =>32 R Brief Hospital Course: - Pt admitted throught the ER / sepsis / ischemic foot Sent to the OR for immediate Amputaton In holding area of OR - He 'coded' in pre-op, becoming asystolic, with an initially failed intubation, entering the esophagus.",0
"Forty-five minutes elapsed before his cardiorespiratory state was stable, with an unclear duration and degree of cerebral hypoperfusion.",0
"He received multiple shocks, Epinephrines.",0
"Transfered to the CVICU in critical condition CVICU PEA, then asystole, then PEA again.",0
Pt started on pressors / resp support / pan cx'ed Pt critical / Bedside PROCEDURE: Right below-the-knee guillotine amputation.,0
Pt recieved line / cxr Broad spectrum Antibiotics started STAT ECG ECHO CTA CHEST CT ABDOMEN CT PELVIS CT HEAD Pt experiences shock liver / Transplant consulted - pt never recovered had ABD US IMPRESSION: 1.,0
"Periportal and gallbladder wall edema, in addition to ascites and small pleural effusions is consistent with third spacing.",0
Hypoechoic appearance of the liver is compatible with hepatic congestion or hepatitis.,0
No evidence of intra- or extra-hepatic biliary ductal dilatation.,0
"- During sedative medication pt was weaned He has been unresponsive whilst awake, and periods of sleep have been associated with hypotension and apnea.",0
He did not show apparent spontaneous movement.,0
Require Insulin drip for increase BS - followed pt / guidelines adhered to Nuerolgy consulted Mr is likely in a persistant vegetative state with cardiorespiratory support.,0
"Despite the withdrawal of sedatives, he has not regained a meaningful level of consciousness, instead only exhibiting some, but not other, brainstem reflexes, and neither myotatic nor noxious spinal reflexes.",0
"The disturbance of consciousness is suggestive of disruption of the rostral brainstem, hypothalamus, basal forebrain, or diffuse cortical injury.",0
"MRI will help resolve the cause of his coma, and now coma vigil, but it is unlikely that improvement in his level of consciousness will occur.",0
"Importantly, there is no other obvious sytemic cause to his impaired consciousness, such as electrolyte or metabolic disturbance, and his blood gases and temperature are within the normal range.",0
"One final test that may be considered, to exclude renal encephalopathy, is blood ammonia level.",0
"Since patient has been ongoing hemodialysis, we will repeat neurological examination to confirm his neurological state.",0
The absence of spinal reflexes are either due to peripheral neuropathy or damage to spinal motorneurons.,1
"In the context of asystole, spinal infarction is possible.",0
"Mr has absent oculocervical reflexes, which are more likely to be due to brainstem damage, than to symetric bilateral damage to either the eighth, or both the third and sixth cranial nerves.",1
"However, rest of the brainstem examination is relatively intact including the presence of blink to threat, the corneal reflex and gag reflex.",0
"Overall, Mr is likely to be in a persistant vegetative state, with quite limited meaningful neurological recovery if not none.",0
"In view of the hiatus since the asystolic event, may only recover marginally, and remain presistantly vegetative.",0
"Nonetheless, repeat serial examination will be performed to document any trends in his neurological function.",0
"Similarly, an electroencephalogram may provide some further information about the degree of forebrain activity and ruling out subclinical seizures - Thoracics consult / followed / PT DNR following shock liver Pt brought down for Closure of right below-knee amputation, 1.",1
EEG This is an abnormal portable EEG due to the slow and disorganized background rhythm.,0
"This is suggestive of a moderate encephalopathy which may be seen with medication effect, toxic metabolic abnormalities, or infections.",0
There were no regions of focal slowing and no epileptiform discharges noted.,0
PICC placed for access - pressure support / intubated / TF / DNR broad spectrum antibiotics continued / CX's followed echo Multiple family meeting to determine pt status / family unwilling to make CMO.,0
"Pt still requires full sedation / TF / Pressure support / fluid resusitation Family CMO Morphine drip Pt expires shortly after Medications on Admission: : NPH 23/15, albuterol, norvasc 5', ASA 81', Bumex 1', carvedilol 12.5'', flumisonide (home), fosinopril 40', metoprolol 50', metolazone 5 QOD Discharge Medications: n/a pt expired Discharge Disposition: Extended Care Facility: Northeast - Discharge Diagnosis: N/A pt expired Discharge Condition: N/A pt expired Discharge Instructions: N/A pt expired Followup Instructions: N/A pt expired Completed by:",0
LINE PLACEMENT Clip # Reason: left basilic PICC 49cm please page Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with new line placement REASON FOR THIS EXAMINATION: left basilic PICC 49cm please page ______________________________________________________________________________ FINAL REPORT CHEST X-RAY INDICATION: 61-year-old gentleman with new PICC line placement.,1
TECHNIQUE: Portable AP upright chest radiograph.,0
FINDINGS: There is interval placement of a left-sided PICC line with the tip terminating in the mid SVC.,0
There is mild enlargement of the cardiac silhouette which is possibly secondary to the AP technique as well as low lung volumes.,0
Cardiomediastinal contours are unchanged from the prior study.,0
Bibasilar opacifications seen previously have improved; few linear atelectatic changes remain.,0
IMPRESSION: Interval placement of a left-sided PICC line with the tip terminating in the mid SVC.,0
LINE PLACEMENT Clip # Reason: Fast Track Early Extubation Cardiac Surgery.,0
Pleural effusio Admitting Diagnosis: CHEST PAIN\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with CABG/AVR REASON FOR THIS EXAMINATION: Fast Track Early Extubation Cardiac Surgery.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 3:36 PM Status post CABG/AVR with support tubes and lines in place; no large effusion or pneumothorax.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 80-year-old female with CABG and aortic valve replacement.,1
STUDY: Portable supine AP chest radiograph.,0
FINDINGS: The endotracheal tube tip is 2 cm above the carina.,0
The endogastric tube side port is well below the GE junction.,0
The chest tubes and mediastinal drains are in appropriate location.,0
The right-sided Swan-Ganz catheter coils into the main pulmonary artery.,1
Prosthetic aortic valve projects over the expected location.,1
The heart and mediastinal contours are mildly exaggerated although this is expected given the patient's position and postoperative state.,1
The hila are unremarkable bilaterally.,0
"The lungs demonstrate no large consolidation, pleural effusion, or pneumothorax.",0
Expected retrocardiac atelectasis is seen.,0
IMPRESSION: Status post CABG/AVR with support tubes and lines in place; no large effusion or pneumothorax.,0
Status: Inpatient Date/Time: at 10:14 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Mild to moderate [+] TR.,0
The patient is in a ventricularly paced rhythm.,0
The patient has runs of a supraventricular tachycardia.,0
Conclusions: IMPRESSIONS: The left atrium is mildly dilated.,0
Mild-moderate (+) mitral regurgitation is seen.,0
POST-BYPASS: Pt is on a low dose phenylephrine infusion (<0.3 mcg/kg/min) and is normal sinus rhythm (not being paced).,0
Preserved biventricular systolic function without wall motion abnormalities.,0
Mild aortic regurgitation and mild-moderate mitral regurgation persist.,0
"The surgeon, Dr. , was notified of the findings in person.",0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: evaluate CVL placement Admitting Diagnosis: HYDROTHORAX;LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with hemochromatosis, hepatic hydrothorax now s/p replacement of CVL REASON FOR THIS EXAMINATION: evaluate CVL placement ______________________________________________________________________________ WET READ: 11:06 PM Rt IJ CVL now straight, with tip at top of Rt atrium.",1
again vertical sliver of lucency projecting over mid left lung could represent pneumothorax vs skin fold.,0
"increasing density in left lower lung -- again given short interval development/increase, concerning for aspiration.",0
"triangular rt lung opacity less apparent, perhaps due to difference in projection.",0
"______________________________________________________________________________ FINAL REPORT , 9:15 P.M. HISTORY: Hemochromatosis and hepatic hydrothorax.",1
IMPRESSION: AP chest compared to 5:08 p.m.,0
"Right internal jugular line has been repositioned, tip at or just below the superior cavoatrial junction.",0
Multifocal pulmonary consolidation is probably pneumonia.,0
Mild pulmonary edema and a moderate left pleural effusion with some left lower lobe atelectasis are worsening.,0
Drain projecting over the right diaphragmatic region could be intrathoracic or external.,0
"10:01 AM CHEST (PORTABLE AP) Clip # Reason: s/p chest tube placement for PTX, now on water seal-r/o PTX Admitting Diagnosis: CORONARY ARTERY DISEASE;MULTIPLE SYSTEM FAILURE\ANGIOPLASTY ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with CAD s/p CABG REASON FOR THIS EXAMINATION: s/p chest tube placement for PTX, now on water seal-r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: 71 y/o woman with coronary artery disease status post CABG, status post chest tube placement placed to waterseal.",1
Single AP view of the chest dated shows endotracheal tube approximately 3 cm above the carina.,0
There is a left sided chest tube which has not changed in position or appearance.,0
"A left sided pacemaker with wires in the right atrium and right ventricle is seen, and has not changed since the prior exam.",0
An NG tube terminates in the body of the stomach.,0
There is mild prominence of the pulmonary vasculature indicating mild congestive heart failure.,1
There are no focal opacities to suggest a consolidative process.,0
The heart and mediastinal contours have not changed.,0
Since the prior exam the right internal jugular central venous catheter has been removed.,0
IMPRESSION: Interval removal of the right central line.,0
"Otherwise unchanged positioning of lines, tubes and pacemaker.",0
10:30 AM CHEST (PORTABLE AP) Clip # Reason: trach tube position Admitting Diagnosis: INFECTED RIGHT HIP ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with respiratory failure s/p tracheostomy REASON FOR THIS EXAMINATION: trach tube position ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb 11:56 AM PFI: New tracheostomy in good position.,1
Nasogastric tube courses through the esophagus and stomach with termination out of field of view.,0
No change in small bilateral pleural effusions and basilar atelectasis.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Respiratory failure after tracheostomy.,1
AP PORTABLE CHEST: New tracheostomy tube is in good position.,0
Small bilateral pleural effusions persist.,0
The most superior sternal suture is fractured as before.,0
IMPRESSION: New tracheostomy in good position.,0
Persistent small bilateral pleural effusions and retrocardiac atelectasis.,0
"interval change Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman intubated, ?",0
fluid overload REASON FOR THIS EXAMINATION: ?,0
"interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 10:17 AM Worsening atelectasis of the left lower lobe, no evidence of fluid overload.",0
"______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Intubated patient, assess for fluid overload.",0
Left lower lobe atelectasis has worsened.,0
"If any, there are small bilateral pleural effusions.",0
Right lower opacity has slightly increased likely due to atelectasis.,0
Right subclavian catheter tip is in the SVC.,0
NG tube tip is out of view below the diaphragm.,0
", CC6A 3:27 PM CT LUMBAR W&W/O CONTRAST Clip # Reason: Please evaluate for hematoma, Admitting Diagnosis: WEAKNESS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with meningoencphalitis, arterial blood back during lumbar puncture REASON FOR THIS EXAMINATION: Please evaluate for hematoma, CONTRAINDICATIONS for IV CONTRAST: ?",0
Paraspinal arterial puncture ______________________________________________________________________________ PFI REPORT PFI: No definite evidence of hematoma.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Possible TCA overdose Major Surgical or Invasive Procedure: None History of Present Illness: This is a 32 yo male with a PMH of anxiety, depression, and recovering alcoholism who is transferred from OSH with ETOH intoxication and likely TCA overdose.",1
The patient was apparently found inebriated today in a hotel lobby where he was then escorted to his hotel room.,0
"In his room, a bottle of vodka, 6 empty beer cans, and multiple pill bottles were found (Effexor, imimpramine, nortriptylline, desipramine).",0
In ED at OSH pt was treated with IV NS at 175 cc/hr later changed to 1/2NS with 1 amp of bicarb/liter at 175 cc/hr with thiamine and folate.,0
CT scan of the head at the OSH was read as normal as was his CXR.,0
An NG tube was placed with little residual and choarcoal with sorbitol 50 gm was given via NG tube.,0
UA and urine tox were negative.,0
Serum tox showed an ETOH of 91.,0
"His K was 2.6 with Mg 1.2, Calcium 5.6, bicarb 19.7, glucose 64.",0
"He was treated with 1 amp of D50, KCL 20 mEQ, 1 amp calcium gluconate.",0
The patient is currently denying an alcohol intake and cannot recall if he took any of his medications last night.,0
"He denies chest pain, shortness of breath, or abdominal pain.",0
ROS otherwise is difficult to obtain as pt is very sleepy and mumbling his speech.,0
"Interestingly, the pt's mother reports that the pt recently transferred his care to a new PCP over the past month who prescribed him 6 psychiatric medications all at once (despiramine, nortriptyline, imipramine, ativan, clonazepam, effexor).",0
His sister reports a similar incident last year in which the pt overdosed on pills and alcohol.,0
"Past Medical History: anxiety depression alcoholism with h/o 3 Social History: Lives at home with his parents, works on heating/air conditioning, has a history of alcoholism, +tobacco (unclear how much) Family History: Father-DM Physical Exam: Vitals: T98.5 P 90 BP 118/73 R 23 Sat 96%RA Gen: WDWN, speech mumbled, somnolent but arousable, flushed face HEENT: NCAT, PERRL (5mm-->3mm), dry MM, +BL conjunctival injection Neck: supple, nontender, no LAD Lungs: CTAB, no w/r/r CV: RRR, no m/r/g Ab: soft, NTND, NABS, no HSM on percussion Extrem: full dp/pt pulses, warm and well perfused Neuro: toes mute bilaterally, glascow coma score 10 (withdraws to pain, open eye to verbal command, inappropriate responses) .",1
Pertinent Results: 08:34PM BLOOD Tricycl-POS 03:50AM BLOOD WBC-7.9 RBC-5.05 Hgb-15.3 Hct-45.0 MCV-89 MCH-30.3 MCHC-34.0 RDW-13.9 Plt Ct-214 03:50AM BLOOD Glucose-86 UreaN-11 Creat-1.2 Na-141 K-4.3 Cl-105 HCO3-29 AnGap-11 08:34PM BLOOD ALT-31 AST-31 AlkPhos-68 Amylase-34 TotBili-0.3 03:50AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.4 Brief Hospital Course: 32 yo male with a PMH of alcoholism who is transferred from OSH with ETOH intoxication and likely TCA overdose.,1
The following issues were investigated during this hospitalization: .,0
# ETOH intoxication: ETOH level at OSH was 91.,0
Pt is apparently a recovering alcoholic.,1
"Patient was placed on CIWA scale and started on thiamine, folate, multivitamins and IV fluids.",0
Social work was consulted for likely suicide attempt.,0
"Psychiatry was also consulted, with plans for the patient being transferred to the psychiatry service for further management.",0
"# TCA/Effexor Overdose: It is unclear if pt actually overdosed on his TCAs, but based on his flushed appearance and dry membranes, it is possible.",0
He received charcoal and IVF with bicarb at OSH.,0
Serial EKGs showed no interval prolongation.,0
"Neuro status, specifically concerning seizures and change in mental status, remained stable.",0
# Anxiety/Depression: A psych and SW consult were placed as mentioned above to deal with patient's ongoing psychiatric issues.,0
"TCAs, benzodiazepines and Effexor were held in the interim.",0
"Prior to discharge, re-assessment demonstrated no active suicidal ideation and the patient was felt to be safe for discharge to home.",0
Alcohol abstinence was encouraged and supported.,0
Medications on Admission: Imipramine 50 mg qhs Nortriptylline 75 mg qhs Desipramine 50 mg qhs Effexor 75 mg Lorazepam Clonazepam 0.5 mg Discharge Medications: 1.,0
Discharge Disposition: Home Discharge Diagnosis: Alcohol Withdrawal Suicidality Discharge Condition: Stable Discharge Instructions: Avoid alcohol and all drugs.,1
Take all of your medications as directed.,0
"Call your doctor or go to the ER for any of the following: thoughts of suicide/thoughts of hurting others, if you hear voices, if you see things that you or others believe are not really there or any other concerning symptoms.",0
"Followup Instructions: Call your primary care physician to schedule follow-up appointment, 5-7 days after discharge.",0
"1:39 PM CHEST (PORTABLE AP) Clip # Reason: s/p CABG w/hypoxia-r/o ptx ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with acute coronary syndrome, cva, dm, htn, hypothyroid REASON FOR THIS EXAMINATION: s/p CABG w/hypoxia-r/o ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG rule out pneumothorax.",0
"COMMENTS: Portable AP radiograph of the chest was reviewed, and compared with previous study of .",0
The tip of the endotracheal tube is identified at the thoracic inlet.,0
The right jugular Swan- Ganz catheter terminates in the main PA. A nasogastric tube courses to the stomach.,0
There is a chest tube seen overlying the left hemithorax.,0
There is a mediastinal drain overlying the cardiac silhouette.,0
Patchy atelectasis is seen in the left lower lobe.,0
A small left pleural effusion is seen.,0
The lung volume is small.,0
No evidence of congestive heart failure.,0
Heart is normal in size.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM DISCHARGE DIAGNOSIS: 1.,0
DISCHARGE MEDICATIONS: Amiodarone 200 mg p.o.,0
"q.d., Calcium Carbonate 1 g p.o.",0
"b.i.d., Glipizide 5 mg p.o.",0
"q.d., Prevacid 30 mg p.o.",0
"q.d., Levoxyl 50 mcg p.o.",0
"q.d., Peri-Colace 1 tab p.o.",0
"t.i.d., ................ 1 tsp p.o.",0
"constipation, Prednisone 15 mg p.o.",0
"x 5 days, followed by 10 mg p.o.",0
"x 5 days, then 7.5 mg p.o.",0
"q.d., Senna 1 tab p.o.",0
"q.h.s., Zoloft 100 mg p.o.",0
"q.d., Testosterone patch 5 mg p.o.",0
"q.h.s., Coumadin 5 mg p.o.",0
"to be adjusted per INR, NPH Insulin 22 U subcue q.a.m., 6 U subcue q.p.m., regular Insulin sliding scale, Hydrochlorothiazide 12.5 mg p.o.",0
"q.d., Lisinopril 5 mg p.o.",0
"q.d., Flagyl 500 mg p.o.",0
"total 14-day course, last day of treatment will be .",0
DISCHARGE INSTRUCTIONS: The patient will go home on a diabetic and cardiac diet to rehabilitation.,0
FOLLOW-UP: He will follow-up with Dr. .,0
"DISCHARGE PLAN: The patient's Coumadin should be adjusted per his INR levels, and also as the Prednisone is tapered, his Insulin requirement will probably decrease, so his NPH regular Insulin sliding scales may need to be adjusted as the Prednisone is tapered.",0
He should have aggressive chest physical therapy.,0
He should have incentive spirometry and follow-up chest x-ray in weeks.,0
He should also received physical therapy per their recommendations.,0
"if he has any evidence of infection or hypotension, he should strongly consider stress dose steroids because of his history of adrenal insufficiency.",0
"DR., 11-476 Dictated By: MEDQUIST36 D: 14:29 T: 14:32 JOB#: cc:",0
"9:35 AM CHEST (SINGLE VIEW) Clip # Reason: eval location of dobhoff Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with HCV cirrhosis requiring tubefeeds, pulled tube overnight REASON FOR THIS EXAMINATION: eval location of dobhoff ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Location of Dobbhoff tube.",1
AP radiograph of the chest was reviewed in comparison to and chest CT from .,0
The Dobbhoff tube tip is in the proximal stomach.,0
Right PICC line tip is at the level of cavoatrial junction.,0
"There is also no change in right basal loculated pneumothorax, atelectasis of the right lower lung and left pleural effusion.",1
There is potentially decrease in the left upper lobe consolidations within the limitations of the comparison between chest radiograph and chest CT.,0
", F. MED MICU-7 12:40 PM CT HEAD W/O CONTRAST Clip # Reason: please eval for acute process Admitting Diagnosis: PNEUMONIA;HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with h/o pontine stroke, prolonged hospital stay for MSRA PNA requiring intubation, now with ongoing altered mental status and aphasia REASON FOR THIS EXAMINATION: please eval for acute process No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",1
No evidence of acute hemorrhage.,1
White matter disease predominantly on the right side.,1
"Given the asymmetric nature of the white matter disease, a CTA or MRA of the neck would help for further assessment to exclude unilateral carotid disease if clinically indicated and if there are no prior studies to evaluate this abnormality.",0
Chronic lacune in the left thalamus.,0
Small size of the pons could be related to previous infarct.,0
A small slightly hyperdense area is seen in the left side of the midline of the pons which could be related to prior infarct.,0
"If there is clinical concern for acute infarct, MRI can help for further assessment as clinically indicated.",0
5:25 AM CHEST (PORTABLE AP) Clip # Reason: Interval change?,0
Admitting Diagnosis: ASPIRATION PNEUMONIA;SEPSIS;LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with liver failure and trach REASON FOR THIS EXAMINATION: Interval change?,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Liver failure.,1
Tracheostomy tip is approximately 2 cm above the carina.,0
The feeding tube tip passes below the diaphragm terminating in the stomach.,0
There is atelectasis of the lingula accompanied by bilateral pleural effusions.,0
Interstitial pulmonary edema is mild.,0
The left PICC line tip is at the level of low SVC.,0
"12:00 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: R/O PE Admitting Diagnosis: 35.5 WKS TWINS FOR C/SECTION Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman POD#3 s/p c-section with chest heaviness, tachycardia, mild decrease in O2 sat.",1
"REASON FOR THIS EXAMINATION: R/O PE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 36-year-old woman, status post cesarean section with chest heaviness and tachycardia.",0
TECHNIQUE: Axial MDCT images were obtained from thoracic inlet to the upper abdomen after administration of 130 cc of Optiray intravenously; no oral contrast was used.,0
CTA of the chest: No filling defect is noted within the main pulmonary artery and its branches to suggest pulmonary embolism.,0
The study is somewhat limited by patient breathing throughout the scanning.,0
The heart and great vessels appear normal.,0
No pathologically enlarged central lymph nodes are noted.,0
"Moderate bilateral pleural effusion, increased bronchovascular markings, septal thickening and fissural prominence are consistent with fluid overload; Focal areas of tree-in- appearance are noted diffusely bilaterally suggesting an underlying lung infection.",0
The tree- in- opacities in some areas have a confluent and consolidative pattern.,0
The visualized portion of the upper abdomen including dome of the liver and spleen appear unremarkable.,0
Moderate bilateral pleural effusion and diffuse septal thickening are consistent with fluid overload.,0
Areas of tree-in- appearance with confluent consolidation are concerning for a superimposed infection.,0
No pulmonary embolism is detected.,0
"(Over) 12:00 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: R/O PE Admitting Diagnosis: 35.5 WKS TWINS FOR C/SECTION Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"8:58 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: ?sinusitis Admitting Diagnosis: BOWEL RESECTION;CDIFFCOLITIS;LIVE TRANSPLANT LIST ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with PSC, persistent fevers, and NG in place x 1 month.",1
REASON FOR THIS EXAMINATION: ?sinusitis No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.,0
Coronal reformatted images were prepared.,0
"SINUS CT: There is bilateral mucosal thickening seen within the sphenoidal and maxillary sinuses, without the presence of air-fluid levels.",0
"The remainder of the paranasal sinuses are normally aerated, with no mucosal thickening or air-fluid levels identified.",0
The ostiomeatal units are patent.,0
The cribriform plates are intact.,0
There is no bony sclerosis.,0
The lamina papyracea is intact.,0
The nasal septum is midline.,0
The orbits and nasopharyngeal soft tissues are unremarkable.,0
There is partial opacification of the bilateral mastoid air cells.,0
"Allowing for helical acquisition, reconstruction algorithm, and section thickness, the imaged anterior portion of the brain is unremarkable.",0
Mucosal thickening affecting the sphenoid and maxillary sinuses without air/fluid levels or other signs of acute infectious process.,0
Bilateral partial opacification of mastoid air cells.,0
"8:40 PM CHEST (PORTABLE AP) Clip # Reason: rule out infiltrates, worsening effusions, consolidations Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with EtOH hepatitis with new onset hypoxia, SOB.",0
"REASON FOR THIS EXAMINATION: rule out infiltrates, worsening effusions, consolidations ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Worsening effusions and consolidation, new onset of hypoxia, SOB.",0
Comparison is made with prior study performed .,0
Cardiac size appears to be normal size.,0
There is a persistent elevated right hemidiaphragm with associated persistent right middle and right lower lobe atelectases.,0
Mild interstitial pulmonary edema asymmetric on the left is new.,1
"12:41 PM CT HEAD W/O CONTRAST Clip # Reason: eval for ICH ______________________________________________________________________________ MEDICAL CONDITION: year old man, demented at baseline, after fall REASON FOR THIS EXAMINATION: eval for ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: CXWc SAT 1:46 PM No ICH or acute abnormality ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old man status post fall.",1
TECHNIQUE: Non-contrast contiguous axial images were obtained through the brain.,0
Multiplanar reformatted images were generated.,0
FINDINGS: This study is somewhat limited by motion.,0
"However, there is no intracranial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarct.",0
Ventricles and sulci are normal in size and configuration.,0
The basilar cisterns are symmetric.,0
The mastoid air cells are only minimally pneumatized.,0
The paranasal sinuses are clear.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Vioxx / Bactrim / Codeine / Aspirin / Gabapentin / Ranitidine Attending: Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: mesenteric angiography via femoral catheter History of Present Illness: Pt is a 88 year old with history of diverticular bleed, who presents after two episodes of bright red blood per rectum last evening.",0
"She became concerned after she felt lightheaded, dizzy and weak and used her life line to call EMS.",0
"She denies any abd pain, nausea or vomiting, and has chronic diarrhea.",0
"Patient had diverticulitis, complicated by abscess in the past, has a history of 8 units of red blood cells transfusion in for lower gaterointestinal bleed, with negative angiogram.",0
"In the ED, initial vitals were: temp 98 pulse 82 blood pressur 160/70 respirations 16 Oxygen sat 100%.",0
"Patient was given 3L noramal saline and 2 IVs were place, GI consulted.",0
"In the MICU, GI was consulted.",0
She received 2 units of PRBCs on night of admission and hematocrits stabilized without further transfusion.,0
Her EKG was unchanged from baseline.,0
She went to angiogram suite on day of transfer without evidence of active bleed.,0
Vitals on transfer were temp 98.1 pulse 66 blood pressure 156/54 satuation of 97% on roonm air.,0
"Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain.",0
"Denied cough, shortness of breath.",0
"Denied nausea, vomiting, constipation or abdominal pain.",0
"No recent change in bladder habits, has chronic stools.",0
Past Medical History: - diverticulosis requiring 8 units transfusion with negative angiogram.,0
"- grade 1 internal hemorrhoids - sigmoid diverticulitis with an adjacent abscess - Afib: not on coumadin - Chronic diarrhea - Insulin Dependent Diabtes Mellitus - Hypertension - Asthma - Gout - Recurrent urinary tract infections - gastroesphogeal reflux - Tremor: essential tremor, followed previously by Dr. - Chronic Renal Failure - Choledocholithiases/cholangitis (): found to have pseudomonas bacteremia, treated with ceftazidime and flagyl, and referred for cholecystectomy but patient refused - Neuropathic pain - Right hip fracture - bilateral knee replacements - right leg pins - cataract repair Social History: No alcohol, tobacco, or other drugs.",1
Currently living with her daughter in .,0
"Three children, six grandkids, 7 greatgrandkids Family History: Father died of MI at 43 yo.",0
Maternal history of breast cancer.,0
"Uncle with stomach cancer, uncle with liver cancer, brother with prostate cancer.",0
Brother and 2 daughters with diabetes.,0
There is a late transition with tiny R waves in the anterior leads consistent with possible prior anterior infarction.,0
Compared to the previous tracing atrial fibrillation is new.,1
"Read by: , H. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 0 84 346/393 0 -10 79 ------------------- EKG Sinus rhythm.",0
Compared to the previous tracing of ectopy has resolved.,0
"Read by: , Intervals Axes Rate PR QRS QT/QTc P QRS T 80 172 78 358/393 23 -12 70 cxr HISTORY: New central line, check position or complications.",0
Tip of the new right internal jugular line projects low over the SVC.,0
"No pneumothorax, mediastinal widening or pleural effusion.",0
Angiogram- mesenteric -no active source of bleeding visible -------------------- Doppler LE INDICATIONS: 88-year-old female with GI bleed status post angiographic procedure and right-sided groin bruits.,0
Please rule out hematoma or fistula.,0
FINDINGS: Limited arterial and venous duplex was performed in the right femoral location.,0
The common femoral artery is patent with biphasic waveforms and uniform color saturation.,0
The profunda and proximal superficial femoral artery also patent with biphasic waveforms.,0
The common femoral and proximal saphenous are patent without any evidence of fistula.,0
There is no evidence of pseudoaneurysm and no significant hematoma.,0
IMPRESSION: Essentially normal Duplex of the right femoral vessels.,0
No source of the bruits identified.,0
Brief Hospital Course: ICU Course: The patient was admitted with hypotension and ongoing bright red blood per rectum.,0
Hematocrit on admission was 23.7.,0
"She was bolused with IV fluids and transfused 2 units of packed red blood cells, and her blood pressure stabilized.",0
Her post-transfusion hematocrit was 37.2.,0
GI and surgery were consulted upon admission.,0
"On hospital day one, per GI/interventional radiologist, she was taken directly to angiography, but no bleeding source was found.",0
"Upon removal of her femoral sheath, she developed groin pain and a bruit.",0
"Ultrasound was obtained, which showed no atriovenous fistula or pseudoaneurysm, with patent vessels.",0
"She was prepped for colonoscopy, but as she had no more bleeding over 36 hours.",0
"Therefore, GI decided not to pursue a scope during this admission.",0
"Given her prior history of diverticular bleed, it is likely that this episode was also from diverticula.",0
"Her hematocrit at the time of floor transfer was 31.0, stable over 36 hours.",0
"Her blood pressure had also stabilized and was increasing to SBPs 150s, with a plan to restart home BP medications on the floor.",0
"Medicine floor course: After transfer to the floor, the patients blood pressure increased overnight to the 170s.",0
She was given captopril and metoprolol short acting.,0
Her hematocrit remained stable overnight at 32.2 and then she was restarted on her home blood pressure medications of lisinopril and verapamil ER.,0
"She had no abdominal pain and her vitals remained stable, but with an improved blood pressure to the 130s.",0
She was seen by PT and was able to ambulate and climb stairs independently.,0
She had complaint of gas and was started on simethicone PRN.,0
She also had complaint of skin irritation under her left breast and was instructed to use a zinc oxide containing powder twice a day.,0
She was discharged home and will have follow up with her PCP and the clinic.,0
Medications on Admission: Insulin NPH SS Albuterol 2puffs prn Allopurinol 100mg PO Atorvastatin 1mg Duloxetine 20mg Fluticasone 110 mcg 2puffs Lisinopril 10mg Pantoprazole 40mg Verapamil 120mg Montelukast 10mg ASA mg Discharge Medications: 1.,0
Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours).,0
Insulin Regular Human 100 unit/mL Solution Sig: One (1) units Injection ASDIR (AS DIRECTED): use as before admission.,0
"Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO TID (3 times a day) as needed for gas: for gas.",0
"Disp:*45 Tablet, Chewable(s)* Refills:*3* 6. over the counter powder with zinc oxide, apply under the breasts twice a day, avoid inhalation 7.",0
Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation three times a day.,0
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation once a day: use as before.,0
Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing.,0
Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain.,0
"Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day.",0
"Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: primary: acute blood loss anemia lower gastrointestinal bleed secondary: type 2 diabetes gout hypertension chronic diarrhea Discharge Condition: stable, afebrile Discharge Instructions: You were admitted for blood in your stool complicated by anemia.",1
You received 2 units of blood while you were here.,0
You were initially monitored in the ICU.,0
"There, your blood pressure and blood counts were stable.",0
You had a scan to detect bleeding in your colon.,0
The results of that were negative.,0
Please see your gasteroenterologist to schedule a colonoscopy.,0
Please follow up with all of your appointments and take all of your medications as directed.,0
"If you should have further bleeding, lightheadedness/dizzyness, weakness, chest pain, or shortness of breath, please call your primary care physician or present to the emergency department.",0
Followup Instructions: You have the following appointments.,0
"Provider: , ORTHOPEDIC PRIVATE PRACTICE Phone: Date/Time: 11:00 Provider: , Phone: Date/Time: 10:10- Please recheck HCT as pt had recent admission for lower GI bleeding.",0
"Phone: Date/Time: 12:45 Call Dr. , your gasterenterologist, for an appointment, (.",0
You will need to discuss your need for a colonscopy.,0
Weight (lb): 227 BP (mm Hg): 100/47 HR (bpm): 73 Status: Inpatient Date/Time: at 11:49 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
3.Right ventricular chamber size is normal.,0
4.The aortic root is mildly dilated.,0
5.The aortic valve leaflets are mildly thickened.,0
6.The mitral valve leaflets are mildly thickened.,0
7.Moderate [2+] tricuspid regurgitation is seen.,0
6:01 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: s/p intubation Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT ?,1
TRICUSPIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with s/p avr REASON FOR THIS EXAMINATION: s/p intubation ______________________________________________________________________________ WET READ: 9:44 PM ET tube terminates 6 cm from the carina.,0
There is baseline chronic pleural thickening and loss of volume of the right hemithorax.,0
"Superimposed on the chronic changes are more acute atelecasis and small right pleural effusion, not appreciably changed from at 10 a.m. -jkang ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of a patient after aortic valve replacement.",1
"Portable AP chest radiograph was compared to prior study obtained on , at 10:02 a.m.",0
The ET tube tip is approximately 7.3 cm above the carina.,0
The right internal jugular line tip is in internal jugular vein.,0
The NG tube was removed.,0
"There is still present right lower lobe opacity, mostly in the retrocardiac area which most likely represent a combination of patient rotation and atelectasis, which can be seen back to , .",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old gentleman with a past medical history of hypertension, depression, anxiety and lower back pain.",0
He works at the Hospital and at 2:00 p.m. on the day of admission he had dropped a note out of his left hand and noted it to be weak.,0
He walked down to the urgent care and when he arrived there he had developed slurred speech.,0
For a 20 minute period he developed a left facial droop and worsening left sided weakness.,0
PHYSICAL EXAMINATION: His blood pressure was 192/95.,0
"He was alert and oriented, fluent, but dysarthric speech.",0
Comprehension and repetition were intact.,0
He had decreased V1 to V3 sensation in his left face and a left facial droop.,0
Motor strength in the right arm was 5 out of 5.,0
In the left arm he was able to give some effort against gravity.,0
Left leg he had decreased strength and right leg was 5 out of 5.,0
His gait was not tested.,0
Head CT showed a right posterior frontal hemorrhage primary lobar in location.,0
HOSPITAL COURSE: The patient was admitted to the neurological Intensive Care Unit.,0
He was taken emergently to the Operating Room on for an emergent evacuation of posterior frontal craniotomy for evacuation of hematoma.,0
"Postoperatively, the patient's vital signs were stable.",0
"He was neurologically alert, fluent speech.",0
He had left severe facial weakness and a left field cut.,0
"Strength wise he was 2 out of 5 in the deltoids and 4 out of 5 in the biceps, 4 out of 5 in the triceps and 0 out of 5 in the hands on the left side.",0
His hematocrit was 32 postop.,0
"On postoperative day number one he was alert, fluent speech, and was oriented times three.",0
The left facial weakness continued.,0
"He had 3 out of 5 deltoid strength, 4 out of 5 biceps, 4 out of 5 tricep and IP was 4 out of 5 on the left side.",0
Right side remains 5 out of 5.,0
Repeat head CT showed good evacuation of subdural hematoma.,0
He was also evaluated by the stroke service and was transferred to the regular floor after coming of his intravenous Nipride and keeping his blood pressure less then 140.,0
He was seen by physical therapy and occupational therapy and found to acquire rehab prior to discharge to home.,0
The patient remained neurologically stable and was discharged to rehab on and will follow up with Dr. in two weeks time.,0
The staples should be removed on postoperative day number ten.,0
Dictated By: MEDQUIST36 D: 11:44 T: 12:34 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HOSPITAL COURSE CONTINUED: The patient remained on the Service for an additional two days, as he was unable to learn to self inject Lovenox 40 mg subq q.d.",0
"Per Ortho's recommendations, he was not to be discharged unless he would be able to receive subcutaneous Lovenox for three consecutive weeks.",0
"On the day of discharge, his sister was successfully taught to administer his Lovenox.",0
He was clinically stable and discharged home.,0
DISCHARGE STATUS: Home with services.,0
FOLLOW-UP INSTRUCTIONS: The patient was instructed to call Dr. for a follow-up Orthopedic appointment in 7 - 10 days.,0
He was also instructed to follow-up with his primary care physician 7 - 10 days.,0
Lovenox 40 mg subcutaneously q.d.,0
Percocet 1 - 2 capsules p.o.,0
Dictated By: MEDQUIST36 D: 11:31 T: 12:49 JOB#:,0
11:54 AM CT HEAD W/O CONTRAST Clip # Reason: pls assess for interval change Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman s/p traumatic assault with SDH and midline shift.,1
Currently intubated and remains unresponsive off sedation.,0
REASON FOR THIS EXAMINATION: pls assess for interval change No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf FRI 3:03 PM No interval change in the appearance of the left subdural hematoma with stable 6-mm rightward midline shift.,0
______________________________________________________________________________ FINAL REPORT STUDY TYPE: Non-contrast head CT.,0
"INDICATION: Subdural hematoma, evaluate for interval change.",0
"COMPARISONS: Non-contrast head CT from from , under the medical record number G-.",0
FINDINGS: There has been no interval change in the patient's 11 mm subdural hematoma on the left or the associated 6 mm rightward shift of midline structures.,0
There is a small focus of hyperdensity along the left tentorium that likely represents redistribution of some of the subdural blood.,0
There is mild periventricular white matter hypodensity suggestive of small vessel ischemic disease.,0
There is bilateral cavernous carotid artery calcification.,0
"There are bilateral non-displaced fractures of the nasal bone, better seen on the patient's CT facial bones from .",0
There has been interval increase in the opacification of the paranasal sinuses with partial opacification of the bilateral ethmoid air cells and the right sphenoid sinus.,0
No interval change in the appearance of the left subdural hematoma with stable 6-mm rightward midline shift.,0
Stable appearance of the bilateral nondisplaced nasal bone fractures.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: s/p seizures Major Surgical or Invasive Procedure: Mechanical Intubation History of Present Illness: 82 year old with h/o of DMII, HTN, Asthma, OSA, dCHF, peripheral neuropathy who is admitted for AMS and hypercapnea.",0
"Patient was recently admitted at , at the time she had presented with AMS, was found to be hypercarbic and requiring intubation, she was noted to have fluid overload and was diuresed with lasix, she did not have evidence of pneumonia, LENIs were negative, and echocardiogram showed a preserved biventricular systolic function without pulmonary hypertension.",0
"Therefore, it was felt that her hypercarbia was due to not wearing night time BIPAP for successive days leading to slow increase in her PCO2 +/- central apnea.",0
She did well after extubation and was discharged to rehab with nighttime BiPAP and oral lasix.,0
Per her daughter at baseline prior to previous hospitalization was wheelchair bound most of the day but could make a few independent steps to the bathroom.,0
Demented with occasional visual + auditory halucination.,0
"At rehad continued to complain of weakness but did PT, walk around some with a walker.",0
Per daughter patient was using BiPAP rehab but continued to have issues with ill fitting mask.,0
"Per rehab patient was fine last night, on check this AM around 10:15 patient was found to be lethargic.",0
No recent fevers or illness recorded.,0
In the ED patient was conversant and reported wearing her BIPAP yesterday evening.,0
"Denied HA, blurry vision, CP, SOB, abdominal pain, dysuria, or increased LE edema.",0
Pt stated she's been compliant with meds at rehab.,0
"She stated she feel fine except for ""tiredness"".",0
"States she did not sleep well last night, cannot say why.",0
"Past Medical History: -type 2 diabetes mellitus -hypertension -atypical peripheral neuropathy with cutaneous sensations (""dust on her skin"", seen by , on gabapentin + olanzapine) - tactile hallucinosis per PCP : appears to be adult onset asthma.",1
spirometry is restrictive physiology with bronchodilator response.,0
"-macular edema s/p surgery -neovascular glaucoma secondary to her proliferative diabetic retinopathy - blind left eye > right eye -OSA (prescribed BiPAP, not currently using) -osteoarthritis -dementia .",0
Social History: Patient is wheelchair bound due to old osteoarthritis and vision loss.,1
"In setting of a few recent falls in her apartment, her daughter stays with her at her apartment.",0
Born and grew up in the Carribean.,0
Worked in a chocolate factory in in the .,0
Arrived in the US in .,0
Lived with her daughter in for the past 2 years.,0
In rehab since previous discharge .,0
"Family History: Father with diabetes mellitus, died at age 69.",1
"Mother with heart failure, died at age .",1
Oldest daughter with diabetes mellitus and polymyositis.,0
"Youngest daughter with anoxic brain injury trauma, in rehab.",0
"Physical Exam: On Admission: General: intubated and ventilated, sedated on versed 3mg/h, squeezes hands and wiggles toes to command, no acute distress HEENT: , conjuctiva are hyperemic bilaterally, surgical pupil on the left, non reactive pupils bilaterally, no tenderness with mild pressure on eyes, MMM Neck: supple, hard to assess JVP due to habitus,no LAD CV: distant reguilar heart, no clear murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally on anterior auscultation, no wheezes, rales, ronchi Abdomen: distended, hypertympanic, non-tender, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis, tibial edema + bil.",1
"Neuro: intubated, ventilated and sedated, squeezes hands and wiggles toes to command, moving 4 limbs, normal DTR's throughout, .",0
"On Discharge: Vitals: T: 99.1 BP: 143/90 P: 92 R: 18 O2: 100% RA General: NAD, well appearing.",0
"HEENT: Sclera anicteric, MMM, oropharynx clear, adentulous w/o dentures Neck: supple, JVP not elevated, no LAD Lungs: Diffusely rhoncorus.",0
"CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops.",0
"Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: Admission: 08:45PM WBC-10.2# RBC-4.47* HGB-13.2* HCT-40.2 MCV-90 MCH-29.5 MCHC-32.8 RDW-12.0 08:45PM NEUTS-57.1 LYMPHS-34.9 MONOS-5.4 EOS-2.1 BASOS-0.6 08:45PM PLT COUNT-220 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 08:45PM PHENYTOIN-LESS THAN 08:45PM ALBUMIN-4.5 CALCIUM-10.0 PHOSPHATE-4.3 MAGNESIUM-1.8 08:45PM ALT(SGPT)-31 AST(SGOT)-25 CK(CPK)-297 ALK PHOS-73 TOT BILI-0.4 08:45PM GLUCOSE-586* UREA N-18 CREAT-1.7* SODIUM-139 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-17* ANION GAP-22 10:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG 10:12PM URINE COLOR-Straw APPEAR-Clear SP -1.013 10:15PM LACTATE-4.1* .",0
Relevant: 02:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE 03:45PM BLOOD Phenyto-10.5 02:55AM BLOOD HCV Ab-NEGATIVE 02:47AM BLOOD Lactate-2.3* 06:10AM BLOOD Lactate-1.2 .,0
Discharge: 06:30AM BLOOD Glucose-104* UreaN-9 Creat-1.2 Na-141 K-3.7 Cl-108 HCO3-24 AnGap-13 06:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.5* .,0
Microbio: RPR negative Blood culture x2 negative Urine culture negative GC and CT urine and swab negative .,0
Imaging: CT head w/o con: IMPRESSION: No acute intracranial pathology.,0
"CXRay: IMPRESSION: Right perihilar and left infrahilar opacities, worrisome for aspiration in the setting of suspected seizure, although not entirely specific.",0
EEG: Prelim: No signs of seizure CXRay: Cardiac size is at the upper limits of normal.,0
Mild pulmonary plethora may be present.,0
Echo: Normal left ventricular cavity size with normal regional and low normal global systolic function.,0
Unchanged prominent perivascular space versus lacunar infarct on the left basal ganglia.,0
"Minimal asymmetry of the temporal ventricular horns, this finding is nonspecific and no frank evidence of mesial temporal sclerosis is identified.",0
There is no evidence of abnormal enhancement or diffusion abnormalities.,0
"Polypoid formation noted on the left maxillary sinus, likely consistent with a mucus-retention cyst.",0
"Brief Hospital Course: 57 year old male w/ DM, no known sz d/o, p/w seizures in the context of non ketotic hyperosmolar state, intubated for airway protection, loaded with Dilantin, stabilized, extubated, and without recurrence on floor.",0
# Seizures: Pt presented with 3-4 complex partial seizures on day of admission.,0
The seizures were thought to be secondary to CNS effects of non ketotic hypersomolar state (glucose on admission 690) in the setting of medication non-compliance.,0
The pt was treated with insulin and fluids and loaded with dilantin for the seizures.,0
No acute process on CT head or MRI.,0
Tox screen was negative and pt denied heavy drinking or substance abuse.,0
Prelim EEG read did not show any active seizure activity.,0
The patient was discharged on dilantin with follow-up.,0
# Non ketotic hyperosmolar state: Resolved with Insulin and fluids .,0
# DM II: HgbA1c was 13.6%.,0
"Family reported pt not compliant over past 2 weeks, but it has likely been longer.",0
Pt had low insulin requirement while on sliding scale and minimal need for insulin when orals were re-initiated.,0
came to see the patient and agreed that it was safe to discharge pt on metformin and glipizide.,0
The patients glucometer recently broke so the patient was given a script for a new one with instructions to measure pre-meal glucoses.,0
Pt will follow up at Clinic.,0
# Acute on chronic kidney disease: pre renal in the setting of NKHOS and now improved back to baseline after fluid resuscitation.,1
# Aspiration: CXR demonstrated opacities consistent with aspiration which likely happened during seizures.,0
Pt had minimal cough without fevers or elevated white count.,0
Repeat CXRay showed resolution of opacities.,0
# Urethral discharge: Seen by nurses in ED.,0
No recurrence while on floor.,0
"Urine cultures, CT and GC, RPR were negative.",0
# Depression: Very depressed after mother passed away and divorce from wife.,0
good social support and does not seem at risk for actively hurting himself at this time.,0
PCP has been following this and it looks like pt has been referred to see psychiatrist.,0
Pt will see PCP later this week.,0
# Hypertension: Not well controlled in hospital.,0
PCP should follow with labs next week.,0
# Vitamin B 12 Deficient: B12 supplementation.,0
"# Communication: pt's nieces and nephews, first contact : # Code: full code .",0
"- 1 Tablet(s) by mouth once a day BLOOD PRESSURE MONITOR [BLOOD PRESSURE KIT] - Kit - Use as directed twice a day Dx:401.9 Hypertension BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - test once a day & prn CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1.",0
Glucometer Please provide patient with One Touch Ultra Test Glucometer and 100 pack of One Touch Ultra Test strips.,0
Directions: BG prior to breakfast and dinner; please review BG should be 80-120 prior to meals.,0
"Please keep a record of this to show your PCP and the doctors 2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.",0
Disp:*60 Tablet(s)* Refills:*0* 3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*0* 4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily).,0
5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours).,0
Disp:*90 Capsule(s)* Refills:*0* 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Discharge Disposition: Home Discharge Diagnosis: Primary: Seizures, Hyperosmolar hyperglycemic state from DM II Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent.",0
"Discharge Instructions: Dear Mr , It was a pleasure taking care of you at .",0
You were admitted for seizures most likely from poor control of your diabetes.,0
and diabetes specialists saw you here.,0
You had a head MRI which was negative.,0
It will be very important for you to continue taking your diabetes medications.,0
Please also measure your blood glucoses prior to breakfast and dinner.,0
They should be between 80-120 prior to meals.,0
Please keep a record of this to show your PCP and the doctors.,0
The following changes were made to your medications: Increase Metformin to 1000mg twice a day for diabetes Increase lisinopril to 40mg daily for high blood pressure START Phenytoin for seizures Followup Instructions: Please call to set up an appointment with the Clinic if you do not hear from them by Wednesday.,0
The following appointments were made for you.,0
"Department: BIDHC When: FRIDAY at 9:15 AM With: , MD Building: 545A Centre St. (, MA) None Campus: OFF CAMPUS Best Parking: Department: When: THURSDAY at 9:30 AM With: DRS.",0
& PUNTAMBEKAR Building: Ks Building (/ Complex) Campus: EAST Best Parking: Garage Completed by:,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM: This is an Addendum to the Discharge Summary dictated on .",0
This is an Addendum to the Hospital Course.,0
HOSPITAL COURSE CONTINUED: Heparin was discontinued prior to his surgical percutaneous endoscopic gastrostomy tube placement on which occurred without any complications.,0
"Postoperatively, the patient was weaned back to his continuous positive airway pressure (CPAP) mode with a pressure support of 10, positive end-expiratory pressure of 5, and FIO2 of 40%.",0
After the placement of the percutaneous endoscopic gastrostomy tube the patient was not tolerating tube feeds due to nausea and vomiting.,0
The nausea and vomiting was thought to be secondary to gastroparesis and Fentanyl patch.,0
Reglan was added to his medical regimen.,0
Surgery was consulted regarding advancing the percutaneous endoscopic gastrostomy tube into the jejunum.,0
Surgery informed the team that a surgical gastric tube needs to mature for three weeks before advancing over wire by Interventional Radiology into jejunum.,0
"In the meantime, the slow introduction of tube feeds (Criticare HN) was planned.",0
"After the surgical percutaneous endoscopic gastrostomy tube placement, the patient was started on Lovenox 16 mg subcutaneously every 12 hours and Coumadin 5 mg p.o.",0
Lovenox was discontinued once the INR became greater than 2.,0
"On , his INR became supratherapeutic to 4.8, and Coumadin was held on that day.",0
"On the following day, his INR became 3.9 and started trending down, and Coumadin was restarted at 2 mg p.o.",0
and then subsequently raised to 3 mg p.o.,0
on for a goal INR of 2 to 3.,0
Mr. required anticoagulation for the deep venous thrombosis in his right upper extremity as well as for prevention of thrombosis from his pulmonary hypertension.,0
Anticoagulation in patient's with pulmonary hypertension has been shown to improve survival.,0
"On , hydralazine was discontinued and his pre-hospital antihypertensive regimen was reinstituted peace-meal.",0
"By the time of discharge, the patient was on lisinopril 20 mg p.o.",0
"q.d., atenolol 100 mg p.o.",0
"q.d., and nifedipine 40 mg p.o.",0
Nifedipine can be titrated up to 60 mg p.o.,0
The hospital course was also significant for repeat thyroid-stimulating hormones and free T4 levels which were sent.,0
The thyroid-stimulating hormone came back at 12.,0
The free T4 level was 0.9.,0
Synthroid was increased to 100 mcg p.o.,0
Paroxetine HCl 30 mg p.o.,0
Fentanyl patch 25 mcg per hour topically q.72h.,0
Clotrimazole cream to groin area b.i.d.,0
Simethicone 40 mg to 80 mg p.o.,0
Atrovent 2 puffs inhaled q.i.d.,0
Albuterol and Atrovent nebulizers as needed.,0
Ferrous sulfate 325 mg p.o.,0
Calcium acetate two tablets p.o.,0
(to be adjusted for a goal INR of 2 to 3).,0
Hemodialysis three times per week.,0
Diet is to be total parenteral nutrition with slow introduction of tube feeds.,0
Follow up on thyroid-stimulating hormone levels in six to eight weeks.,0
Follow up on INR and adjust Coumadin for a goal of INR of 2 to 3.,0
If hypertensive can titrate nifedipine up to 60 mg p.o.,0
The patient to follow up with his primary care physician.,0
The patient to follow up with Interventional Radiology to change gastric tube to gastrojejunostomy tube on if the patient continues not to tolerate tube feeds.,0
Please call telephone number to confirm date and time.,0
End-stage renal disease secondary to polycystic kidney disease; requiring hemodialysis.,1
Failure to wean from ventilator secondary to hemidiaphragmatic paralysis.,0
Dictated By: MEDQUIST36 D: 19:20 T: 19:35 JOB#:,0
"9:21 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: LUE SWELLING, ASSESS FOR DVT Admitting Diagnosis: ELEVATED BILIRUBIN ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man s/p newly placed PICC line now with L arm swelling REASON FOR THIS EXAMINATION: assess for dvt ______________________________________________________________________________ FINAL REPORT INDICATION: 77-year-old man with PICC line in the left arm and new left arm swelling.",0
"There is normal flow, compression and augmentation seen in all of the vessels.",0
The PICC line is identified within the left basilic vein and vascular flow is identified around the PICC line.,0
"Incidentally noted, the Doppler waveform of the contralateral right subclavian vein is asymmetrically flattened.",0
This appearance may suggest a clot within the central venous system.,0
No evidence of deep vein thrombosis in the left arm.,0
Asymmetrically flattened waveform in the contralateral right subclavian vein may suggest a central venous clot.,0
If there is clinical concern for a central venous clot further evaluation could be performed with an MRV.,0
"8:33 PM MR W & W/O CONTRAST Clip # Reason: Please perform lumbosacral protocol to rule out lubosacral t Admitting Diagnosis: ABDOMINAL PAIN Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man s/p ex-lap, LOA with foot drop REASON FOR THIS EXAMINATION: Please perform lumbosacral protocol to rule out lubosacral tumor/metastasis No contraindications for IV contrast ______________________________________________________________________________ WET READ: ENYa SAT 7:01 AM No abnormally enhancing lesion identifiied in the post-contrast images.",0
Otherwise unchanged exam compared to the study one day ago.,0
______________________________________________________________________________ FINAL REPORT EXAM: MRI of the lumbar spine.,0
CLINICAL INFORMATION: Patient with status post laparotomy and foot drop performed lumbosacral protocol for evaluation of lumbosacral tumor or metastasis.,0
"TECHNIQUE: T1 sagittal, T1, T2 and inversion recovery sagittal and T1 and T2 axial images were obtained before gadolinium.",0
T1 sagittal and axial images were obtained following the administration of gadolinium.,0
Comparison was made with the MRI of .,0
FINDINGS: Mild degenerative disc disease and bulging is again seen at L4-5 level with indentation on the thecal sac and mild narrowing of both foramina.,0
No compression of nerve roots is seen.,0
"The remaining levels in the lumbar region, no evidence of significant disc bulge or herniation identified.",0
There is no evidence of intraspinal hematoma or fluid collection.,0
No evidence of high-grade thecal sac compression seen.,0
The distal spinal cord demonstrates normal signal.,0
Note is made of somewhat ectatic and dilated abdominal aorta which was seen on the previous CT abdominal examination.,0
The dilatation and ectasia extends to both iliac arteries.,0
Correlation with the CT abdomen recommended.,0
Axial images extending through the sacrum demonstrate no evidence of presacral mass lesion.,0
There is free fluid in the pelvis.,0
No evidence of mass lesion is seen in the region of sacrosciatic notches bilaterally.,0
IMPRESSION: No change in appearance of lumbar spine compared to the previous MRI of .,0
Disc bulging is seen at L4-5 level with narrowing of foramina as described previously.,0
"No evidence of high-grade thecal sac compression seen or intraspinal hematoma, fluid collection or abscess identified.",0
No evidence of discitis or osteomyelitis.,0
Fluid is seen in the pelvis.,0
No evidence of presacral fluid collection or mass identified.,0
(Over) 8:33 PM MR W & W/O CONTRAST Clip # Reason: Please perform lumbosacral protocol to rule out lubosacral t Admitting Diagnosis: ABDOMINAL PAIN Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ FINAL REPORT (Cont),0
"1:31 PM MR HEAD W/O CONTRAST Clip # Reason: R/o mass, bleed, infectious process Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with new onset altered mental status with rigors, clonus, increased tone REASON FOR THIS EXAMINATION: R/o mass, bleed, infectious process CONTRAINDICATIONS for IV CONTRAST: Renal failure Yes to Choyke questions.",1
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 71-year-old woman with new onset altered mental status.,0
"Rule out mass, bleed, or infectious process.",0
TECHNIQUE: MRI of the brain.,0
"Sagittal short TR, short TE spin echo images were obtained through the brain.",0
"Axial imaging was performed of long TR, long TE, fast spin echo, FLAIR, gradient echo, and diffusion technique.",0
There are periventricular hyperintensities consistent with white matter disease.,0
There is no evidence of chronic microhemorrhage.,0
Periventricular hyperintensities consistent with white matter disease.,0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: Neonatology HISTORY: This is a 19 day old former 32-0/7 week female who is being transferred to the Special Care Nursery.,0
The infant was born to a 38-year-old G3-P1 to 2 woman.,0
"Her prenatal labs were A negative, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, GBS unknown and rubella equivocal.",0
Past medical history remarkable for ovarian cystectomy in .,0
"Her pregnancy was, otherwise, remarkable for gestational diabetes and the eventual development of pregnancy induced hypertension.",0
The decision was made to deliver this baby because of decreased fetal growth in the setting of severe pregnancy induced hypertension.,0
The mother was treated with magnesium sulfate and she was betamethasone complete at the time of delivery.,0
There was blood leaking from the umbilical cord and it was manually occluded before reclamping.,0
The infant required 10-15 seconds of positive pressure ventilation and had Apgars of 7 at 1 and 9 at 5 minutes.,0
FAMILY HISTORY: Remarkable for a healthy adolescent boy with a prior partner.,1
Mother and father are Witnesses.,0
The father has a history of epilepsy.,0
"Family and social history are, otherwise, noncontributory.",1
"PHYSICAL EXAMINATION: At discharge, the physical examination was remarkable for a well appearing preterm infant with a nasal cannula with a head circumference of 30 cm, length 43 cm and a weight of 2075 grams.",1
The anterior fontanel is flat and soft.,0
"There is no grunting, flaring or retracting.",0
"The abdomen is flat, soft, nontender.",0
The tone and activity are normal.,0
The external genitalia are normal female.,0
"HOSPITAL COURSE: Respiratory: The infant had grunting, flaring and retracting soon after delivery.",1
"The infant was placed on CPAP and received CPAP until the second hospital day, at which time she was weaned to nasal cannula O2 and eventually to room air on day 5.",0
The course was consistent with mild hyaline membrane disease.,0
The blood gases were reassuring.,0
The infant has not had a problem with apnea of prematurity.,0
The infant has been hemodynamically stable throughout her hospitalization.,0
"Four days prior to transfer, the infant developed a mild oxygen requirement and has required intermittent low flow cannula at 13 ml per minute.",0
Her respiratory rates remained in the 30-60 range.,0
"Fluid, electrolytes and nutrition: The infant was initially n.p.o.",0
She was started on feeds on day two and advanced.,0
She is currently on breast milk 24 with human milk fortified or special care 24.,0
She occasionally has saturation drifts with feeding.,0
"At this point, she requires intermittent gavage feeding but is about 50% p.o.",0
Hematologic: The infant's initial hematocrit was 56.,0
"The following day, her hematocrit was 53.",0
Another hematocrit was obtained on day 17 and this was 38.8 with a retic of 2.1%.,0
The infant is on ferrous sulfate at 0.3 ml daily.,0
Gastrointestinal: Maximum bilirubin was 7.6.,0
The infant required phototherapy for 4 hospital days.,0
There has been no evidence of gastrointestinal intolerance with feeds.,0
The baby's blood type is A positive and the DAT was negative.,0
Infectious disease: The infant had a blood culture on the day of birth and this was no growth.,0
The infant was treated with ampicillin and gentamicin for 48 hours pending cultures.,0
Neurology: There have been no neurologic issues.,0
Sensory: Part 1 audiology: The infant has not had hearing screen at this point.,0
Ophthalmology: The infant's eyes were examined on and were immature to zone 3.,0
Suggested followup was 3 weeks.,0
Psychosocial: The social worker was involved with this family.,0
DISCHARGE DISPOSITION: Transfer to the special care nursery.,0
PRIMARY PEDIATRICIAN: The family is considering Pediatrics at this point.,0
"CARE AND RECOMMENDATIONS: Feeds at discharge: 24 calorie breast milk or special care nursery p.o., p.g.",0
Ferrous sulfate (25 mg per ml 0.3 ml daily).,0
Iron and vitamin D supplementation.,0
Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age.,1
All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units ( be provided as a multivitamin preparation) daily until 12 months corrected age.,0
Car seat position screening has not been performed.,0
State newborn screening status: State screens were sent on and .,0
Immunizations recommended: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following four criteria: 1.,0
"Born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings.",0
Hemodynamically significant congenital heart disease.,0
"Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out of home caregivers.",0
The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age.,1
", Dictated By: MEDQUIST36 D: 13:57:25 T: 14:41:40 Job#:",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Atorvastatin / Nsaids / Haloperidol / Dextromethorphan / Egg Attending: Chief Complaint: Vomiting, high blood sugars Major Surgical or Invasive Procedure: None History of Present Illness: 59 yo F w/ PMH of ESRD s/p living-related kidney transplant and DMI w/ failed pancreas transplant , gastritis and esophagitis, who presents with hyperglycemia and vomiting.",1
"Patient states that she's had high blood sugars for 2-3 weeks, in the 600s.",0
"She started non bilious, non bloody vomiting two days prior to admission, two to three times per day.",0
Patient presented to an OSH one week ago with vomiting.,0
"At that time, no further work up was pursued.",0
She went to today complaining of high blood sugars and vomiting.,0
"At that time, she vomited once in the exam room, and was found to have ketonuria.",0
She was sent to the ED for further evaluation.,0
"In the ED, initial VS: T 96.7 BP 199/107 HR 108 RR 20 98% on RA.",0
"Labs remarkable for glucose of 1157, K of 6.1, anion gap of 23, and ketonuria.",0
"She was given IV normal saline, and started on an insulin gtt @ 5.5u/hr.",0
"Vitals on transfer were BP 166/69 HR 103 RR 20 O2 98% on RA Currently, she denies chest pain, shortness of breath, abdominal pain.",0
Denies change in dietary habits.,0
Unable to see MD over few weeks.,0
"No fevers, chills, diarrhea, dysuria, or cough.",0
"ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria.",0
"DM type 1 c/b recurrent hypoglycemia, gastroparesis, and retinopathy, s/p failed pancreas transplant 2.",1
"ESRD now w/ functional renal transplant, , baseline Cr 1.5 3.",0
DM retinopathy 5. s/p vitrectomy 6. depression 7. anterior tibia fx 8.,0
"Gastritis, esophagitis -admission Social History: Raised in with two siblings.",0
Has advanced practice nursing degree and works part-time as a psychotherapist and teaches nursing part-time.,0
Has one adult daughter with stage IV ovarian cancer.,0
Has one adult son who was recently in prison.,0
Family History: - Mother with depression - son with hx of alcohol and marijuana abuse - paternal cousin and his two sons completed suicide - Tic disorder in aunt and grandmother.,0
"Physical Exam: GENERAL: Sleepy, arousable to voice.",0
"Sleepy, though arousable to voice and able to relate history.",0
STUDIES: EKG: NSR @ 101 bpm.,0
TWI in lead III (seen on prior).,0
CXR: No acute cardiopulmonary abnormality.,1
She presented to the emergency department with diabetic ketoacidosis.,1
DKA: Initial glucose in ED of 1157 with an anion gap of 23.,0
Patient was initially admitted into the MICU for treatment of DKA.,0
Glucose levels quickly corrected to 200 range and the anion gap normalized.,0
She was transitioned to Lantus and sliding scale regimen.,0
She was monitored in the ICU overnight and was transferred to the medical floor the following afternoon.,0
was consulted for assitance with her insulin levels and recommended a regimen of 20 units of Lantus every morning.,0
The precipitant of DKA was unknown.,0
Patient had no evidence of infections or acute coronary syndrome.,1
ESRD s/p renal transplant in .,0
"On admission, Cr 1.9, likely secondary to intravascular depletion in the setting of DKA.",0
"On discharge, creatinine was 1.0.",0
Patient was followed by the transplant service.,1
There was no change in her immune suppression regimen.,0
Hypertension: Antihypertensives were held initially held upon admission.,0
They were restarted prior to discharge.,0
Patient had slightly elevated blood pressure on the day of discharge.,0
She was going to follow up at the post discharge clinic on .,0
Gastritis and esophagitis: Continued on omeprazole per outpatient regimen.,1
Mild transaminitis: Patient had mildly elevated liver enzymes on admission.,0
They were initially thought to be due to her DKA.,0
Hepatitis studies were pending on the day of discharge.,0
She was instructed to arrive at her clinic appointment early to have the liver studies repeated.,0
Code status: Patient was a full code.,0
Prophylaxis: Patient received subcutaneous heparin.,0
Prednisone 3 mg po qod 2.,0
Omeprazole 40 mg po bid 3.,0
Methyldopa 500 mg po q12h 4.,0
"Acetaminophen 325 mg po q6h PRN pain, fever 5.",0
Cyclosporine 75mg po bid 6.,0
Azathioprine 50 mg po daily 8.,0
Captopril 50 mg po bid 9.,0
Clonazepam 0.5mg po tid Discharge Medications: 1.,0
Prednisone 1 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY (Every Other Day).,0
Methyldopa 500 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours).,0
Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Captopril 50 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: See attached sliding scale.,0
Humalog 100 unit/mL Solution Sig: sliding scale dosing Subcutaneous four times a day.,0
Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day.,0
"Outpatient Lab Work Please draw a panel 7 (electrolytes and kidney function), LFTs (ALT, AST, Alk phos, LDH, Tbili), and a CBC.",1
"Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis Acute renal failure Secondary: Transaminitis History of end-stage renal disease status post a renal transplant Hypertension Depression Discharge Condition: Stable, blood pressure somewhat elevated with SBPs in the 160's.",1
Blood sugars were under good control.,0
Discharge Instructions: You were admitted to the hospital due to elevated blood glucose levels which led to diabetic ketoacidosis.,1
You were admitted to the Intensive Care Unit were you were treated for your elevated blood sugars with good response.,0
The diabetes doctors your insulin regimen and made some changes.,0
You should take lantus 20 units daily.,0
Your sliding scale was modified: Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL 4 oz.,0
Juice 71-80 mg/dL 0 Units 0 Units 0 Units 0 Units 81-120 mg/dL 3 Units 3 Units 3 Units 0 Units 121-160 mg/dL 4 Units 4 Units 4 Units 0 Units 161-200 mg/dL 5 Units 5 Units 5 Units 0 Units 201-240 mg/dL 6 Units 6 Units 6 Units 2 Units 241-280 mg/dL 7 Units 7 Units 7 Units 3 Units 281-320 mg/dL 8 Units 8 Units 8 Units 4 Units 321-360 mg/dL 9 Units 9 Units 9 Units 5 Units 361-400 mg/dL 10 Units 10 Units 10 Units 6 Units You were also found to have somewhat elevated liver enzymes.,0
It is unclear what is causing this elevation.,0
You will need to have these levels followed as an outpatient.,0
You blood pressure was also found to be somewhat elevated.,0
"However, no changes were made to your blood pressure medications.",0
You should have your blood pressure rechecked as an outpatient at your follow up visit.,0
"Call your primary doctor, or go to the emergency room if you experience persistently elevated blood sugars which you are unable to control, confusion, chest pain, shortness of breath, severe abdominal pain, or other symptoms concerning to you.",0
"Followup Instructions: Initially an appointment had been scheduled in the clinic with labs, but this had to be modified given that the patient's primary care doctor is not in the practice.",0
This was discussed with the patient by telephone on and she will contact her PCP this morning to arrange for labs and follow-up later this week.,1
She was feeling well at the time of the phone call.,0
You will also need to follow up with your primary doctor within the next two weeks as well as your diabetes doctor.,0
", C. MED CCU 7:21 AM CHEST (PORTABLE AP) Clip # Reason: ?interval change and ETT placement Admitting Diagnosis: PLEURISY ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with pneumonia and effusion REASON FOR THIS EXAMINATION: ?interval change and ETT placement ______________________________________________________________________________ PFI REPORT No significant interval change.",0
"LINE PLACEMENT Clip # Reason: Please read for right brachial PICC, 37cm.Thanks!",0
# Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with need for TPN/abx.,1
"REASON FOR THIS EXAMINATION: Please read for right brachial PICC, 37cm.Thanks!",0
# ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe FRI 5:47 PM Malpositioned right PICC which crosses over to the left subclavian.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Chronic pancreatitis and fever.,1
Comparison is made to CT and chest radiographs.,0
"UPRIGHT PORTABLE CHEST In the interval, a right PICC has been placed which crosses the midline and terminates in the opposite side mid left subclavian.",0
Retraction of approximately 11 cm before advancement would be recommended.,0
Multifocal consolidations appeared to be improving with decreased opacity projecting over both upper hemithoraces and decreased density over the right lower hemithorax.,0
"Bilateral pleural effusions, slightly greater on the right, are not appreciably changed.",0
Malpositioned right PICC line as described above.,0
"This finding was discussed with venous access nurse, , on date of exam at 3 p.m. 2.",0
"Improving bilateral parenchymal opacities, given the rapidity of development and improvement, they likley reflect at least a component of resolving pneumonitis on superimposed infection.",0
"6:40 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for pulmonary edema Admitting Diagnosis: CRITICAL AORTIC STENOSIS; PULM EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with severe AS, CAD p/w worsening SOB REASON FOR THIS EXAMINATION: Please eval for pulmonary edema ______________________________________________________________________________ WET READ: MXAk SUN 7:20 PM Moderate pulmonary edema, worsened in comparison to prior study from .",1
______________________________________________________________________________ FINAL REPORT HISTORY: Severe AS with CAD and worsening shortness of breath.,0
"FINDINGS: In comparison with study of , there is worsening pulmonary edema in a patient with intact midline sternal wires after CABG.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: r/o pneumothorax Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with REASON FOR THIS EXAMINATION: r/o pneumothorax ______________________________________________________________________________ FINAL REPORT AP CHEST, at 11:30 p.m. HISTORY: Lymphoma.",1
IMPRESSION: AP chest compared to through at 6:41 a.m.: The diffuse interstitial pulmonary abnormality which developed between and has not cleared.,0
"Although the abnormality has a nodular as well as a dominant linear character, the rapid onset makes it most likely pulmonary edema.",0
Continued followup to confirm that impression is essential.,0
"New opacification in both lower lungs could be due either to atelectasis or pneumonia, in either case concerning for possible aspiration.",0
"A filamentous opacity projecting over the sternal notch and left upper mediastinum is new, presumably external.",0
Upper mediastinal widening due largely to prevascular mass and adenopathy is stable over the past several days.,0
There may also be a component of vascular congestion.,0
However there is new leftward displacement of the trachea in the lower neck and greater thickening of the right apical pleural margin.,0
"This could be due to progressive adenopathy or, if an invasive procedure was performed, a new hematoma.",0
Dr. and I discussed these findings over the telephone at the time of dictation.,0
"9:20 AM BILIARY CATH CHECK Clip # Reason: please evaluate for tube obstruction/new abscess, inadequant Admitting Diagnosis: CHOLANGITIS Contrast: OPTIRAY Amt: 40 ********************************* CPT Codes ******************************** * BILIARY BIOSPY VIA T-TUBE -78 RELATED PROCEDURE DURING POSTOPE * * INTRALUMINAL DILATION STRICTUR MOD SEDATION, FIRST 30 MIN.",1
"* * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with obstructive jaundice s/p PTC and revisions now with recurrent fevers and mildly elevated lactate, concern for recurrent tube obstruction or new blockage.",0
"REASON FOR THIS EXAMINATION: please evaluate for tube obstruction/new abscess, inadequant drainage.",0
PLEASE PERFORM CYTOLOGIC BRUSHINGS OF BILIARY TREE WHILE PERFORMING CHOLANGIOGRAM- page Dr. with questions** Please get brushings of CBD for cytology ______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 86-year-old man with obstructive jaundice status post PTC and PTBD placement for suspected CBD stone.,0
"However, the lesion is unchanged after repeat cholangiograms and PTBD changes.",0
Now it is thought to be an obstructive mass at the ampullary region.,0
"Also, the patient developed recurrent fevers and mildly elevated lactate concerning for sepsis.",0
A request was placed for evaluation of the tube and biopsy of the lesion/brushings for cytology.,0
Dr. is the attending radiologist who was present and supervising throughout the entire procedure.,0
"ANESTHESIA: Moderate sedation was provided by administering divided doses of 100 mcg of fentanyl throughout the total intraservice time of 1 hour, during which the patient's hemodynamic parameters were continuously monitored.",0
Local anesthesia with 1% buffered lidocaine and lidocaine gel.,0
"PROCEDURE AND FINDINGS: An informed consent was obtained from the patient's son who is his healthcare proxy after explaining the procedure, benefits, alternative and risks involved.",0
The patient was brought to the angiography suite and placed supine on the imaging table.,0
His right flank and the indwelling biliary catheter were prepped and draped in the usual sterile fashion.,0
"An initial scout image of the abdomen demonstrating the existing percutaneous biliary drain was obtained, demonstrating the catheter to be in the expected position with pigtail coiled in the small bowel.",0
Cholangiogram by injecting contrast through the catheter demonstrated that the tube is patent and draining well.,0
It also demonstrated the previously noted filling defect in the distal CBD at the level of the ampulla.,0
"Following this, the suture was released and the catheter cut distal to the hub, releasing the locking mechanism.",0
"wire was placed through the catheter into the small (Over) 9:20 AM BILIARY CATH CHECK Clip # Reason: please evaluate for tube obstruction/new abscess, inadequant Admitting Diagnosis: CHOLANGITIS Contrast: OPTIRAY Amt: 40 ______________________________________________________________________________ FINAL REPORT (Cont) bowel unforming the pigtail and the catheter was removed over the guidewire.",1
A 9 French x 23-cm -Tip sheath was placed over the wire and advanced into the proximal CBD.,0
wire was also placed through the -Tip sheath and advanced into the small bowel.,0
The -Tip sheath was removed over both wires and replaced over the wire with the wire acting as a safety wire.,0
"After advancing the -Tip sheath into the mid CBD, the inner dilator was removed.",0
"Through the 9 French -Tip sheath, a 7 French sheath was placed over the guidewire in order to give the necessary angle to reach the lesion with biopsy forceps.",0
"After removing the inner dilator from the sheath as well as removing the guidewire, the biopsy forceps were placed through the sheath and three forceps biopsies were taken from the lesion under fluoroscopic guidance.",0
The samples were placed in formalin bottle.,0
"Following this, the biopsy forceps was removed and replaced with a Celebrity cytology brush set and brush biopsies obtained for cytology.",0
"Following the biopsies, contrast injection through the -Tip sheath demonstrated the filling defect in the distal CBD to be still present.",0
"After this, the wire as well as the -Tip sheath were removed.",0
A 12 French Flexima biliary internal-external catheter measuring 25 cm in length was then placed over the wire and advanced into the small bowel.,0
The pigtail was formed in the small bowel following removal of the guidewire and locked in position.,0
A cholangiogram through the newly placed catheter demonstrated satisfactory position and placement of the catheter with satisfactory drainage.,0
"The catheter was secured to skin with 0 silk suture, avoiding an adhesive devoce due to patient's fragile skin.",0
The catheter was connected to an external drainage bag.,0
A final fluoroscopic spot film was obtained and saved digitally.,0
"Cholangiogram demonstrating satisfactory position and placement of the existing internal-external biliary catheter, with no evidence of blockage of the tube.",0
Rounded mass effect in the distal CBD near the ampulla as seen before.,0
Multiple biopsies were taken from the lesion with a forceps and brushings taken for cytology.,0
"Cholangiogram also demonstrated a filling defect in the gallbladder which was also seen on previous studies, consistent with known stone.",0
Placement of a new 12 French internal-external biliary catheter connected to an external bag for drainage.,0
"(Over) 9:20 AM BILIARY CATH CHECK Clip # Reason: please evaluate for tube obstruction/new abscess, inadequant Admitting Diagnosis: CHOLANGITIS Contrast: OPTIRAY Amt: 40 ______________________________________________________________________________ FINAL REPORT (Cont)",1
10:19 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: Placement of NG tube Admitting Diagnosis: CLAUDICATION\LEFT LOWER EXTREMITY ANGIOGRAM ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p C3/C4 laminectomy who presents with inability to swallow.,0
"NG tube attempts X4, and patient has not had nutrition since .",0
"REASON FOR THIS EXAMINATION: Placement of NG tube ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 12:41 PM Nasointestinal tube placement, with tip in the stomach.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old man with inability to swallow, status post C3-4 laminectomy.",0
"NASOINTESTINAL TUBE PLACEMENT: Following administration of a small amount of topical 2% Lidocaine solution into the right nasal cavity, and Hurricaine spray to the posterior pharynx, - feeding tube was passed easily through the esophagus into the stomach under fluoroscopic guidance.",0
"After 12 to 15 minutes of fluoroscopic time, the catheter was unable to be advanced past the pylorus, and was left in the stomach, with sufficient slack to potentially allow peristalsis to carry the tube past the pylorus.",0
Approximately 5 cc of Conray contrast was administered to confirm tube positioning.,0
The patient tolerated the procedure well and there were no immediate post- procedure complications.,0
"IMPRESSION: Placement of nasointestinal tube, with tip in the stomach.",0
"5:40 PM CHEST (PORTABLE AP) Clip # Reason: right IJ CVP placement Admitting Diagnosis: COMMON BILE STRICTURE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with RIJ line, h/o polio, trach, s/p hepatacojejunostomy, vent dependent respinsufficiency REASON FOR THIS EXAMINATION: right IJ CVP placement ______________________________________________________________________________ FINAL REPORT INDICATION: Right IJ line placement, history of polio, respiratory insufficiency.",0
"COMPARISON: FINDINGS: A single portable AP view of the chest shows a right sided IJ central venous line, which appears to have been advanced several cm and is now in the distal SVC/right atrium.",0
"There has also been interval increase in the left lower lobe and right sided air space consolidations, representing pneumonia vs. failure.",0
"Right sided pleural effusion seen on the last exam is probably unchanged, allowing for differences in positioning.",0
Tracheostomy tube and pig-tail catheter remain in place.,0
Again noted is marked deformity of the chest.,0
IMPRESSION: 1) Advancement of right IJ central venous catheter.,0
"2) Increase in bilateral multifocal air space consolidations, representing aspiration pneumonia vs. failure.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Hypoxia, Hypersomnolence, Hypercapnea Major Surgical or Invasive Procedure: none History of Present Illness: PCP: , MD ( Community Health Center) .",0
"M with obesity hypoventilation syndrome, bipolar disease, and asthma admitted on to Psychiatry after an episode of mania after an argument with his mother.",1
wanted to be evaluated for medication change.,0
"Per report in the ED, he was irritable and responding to internal stimuli, but denies AH and VH.",0
ED VS: 98.9 HR 80 BP 150/76 RR 19 and 95% RA.,0
"While on the Pyschiatry service, he slowly improved with his psychiatric medications.",0
"On the day of transfer to the MICU team, at 4:50 PM, he was noted to be difficult to be aroused and required sternal rub to awaken.",0
An ABG was drawn that showed respiratory acidosis (7.23/92/55/41).,0
The patient was on 4 L O2 via NC with O2 sat of 83%.,0
"Bipap was initiated, and his O2 sat was 93%.",0
He denied SOB or pain at that time.,0
"Of note, PC02 at baseline is 55-60.",0
At home his Bipap is 16/12 @ 4L O2 at night with 2 L O2 during the day.,0
On the psych floor patient was switched from 2L o2 to 4L because patient was thought to be hypoxic.,0
This led to patient becoming hypercapneic and lethargic ABG : 7.23/92/55/41.,0
Pt was transferred to the MICU place on BiPap where his gas improved to 7.36/74/54.,0
This is near his baseline per pulm notes.,0
Pulm notes state that patient is supposed to be on 4L oxygen at home.,0
"He states that he wears 2L oxygen at home and that he has not been wearing his bipap at home, because his mask recently broke.",0
Allergies: NKDA Past Medical History: Past Medical History: 1.,0
Bipolar disease with ?schizoaffective/schizophrenia disorder 5.,1
"Hypertension Psych: 1.reports history of bipolar disorder/ schizophrenia diagnosed when he was 17 2.two hosptializations at and , mother, last was 5 years ago see psychiatrist Dr. at 3.Denies any suicide attempts in past Social History: Social History: No smoking, occasional alcohol, no drug use.",1
He is single and lives with his mom and sister.,0
out of high school during his senior year.,0
He states that he would eventually like to get his GED.,0
The only job he has held in the past is .,0
He is now on disability.,0
"Family History: Family History: Mother with asthma, Several sibling all in good health.",0
No family history of cardiac dz or DM.,0
"ARTERIAL BLOOD GASES 04:06PM BLOOD Type-ART Temp-36.7 pO2-55* pCO2-92* pH-7.23* calTCO2-41* Base XS-7 Intubat-NOT INTUBA Comment-O2 DELIVER 07:36PM BLOOD Type-ART pO2-46* pCO2-80* pH-7.29* calTCO2-40* Base XS-7 Intubat-NOT INTUBA Comment-O2 DELIVER 10:33PM BLOOD Type-ART PEEP-5 pO2-61* pCO2-75* pH-7.37 calTCO2-45* Base XS-13 Intubat-NOT INTUBA 07:02AM BLOOD Type-ART pO2-54* pCO2-74* pH-7.36 calTCO2-44* Base XS-11 CXR: : IMPRESSION: Although smaller lung volumes exaggerate heart size and pulmonary vascular crowding, since there has been an increase in moderate cardiomegaly, and vascular congestion in both the lungs and mediastinum just to the point of interstitial edema.",0
: ECHO The left atrium is normal in size.,0
"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.",0
IMPRESSION: Normal global and regional biventricular systolic function PFT Dx: Dyspnea.,0
Good test quality and fair reproducibility.,0
Mechanics: The FVC and FEV1 are moderately reduced.,0
The FEV1/FVC ratio is normal.,0
"Impression: Results are consistent with a restrictive ventilatory defect, which is confirmed by the reduced TLC measured on .",0
Compared to the prior study of the FVC has increased by 0.56 L (37%) and the FEV1 has increased by 0.24 L (18%).,0
Brief Hospital Course: HOSPITAL COURSE: .,0
"Mr. is a 43 y/o AAM w/ schizoaffective d/o, sleep apnea, asthma, obesity hypoventilation syndrome, on home o2 of 2L, bipap at night, w/ polycythemia likely to hypoxemia, originally admitted for mania, transferred to micu for hypercapneic resp failure, transferred to general medicine wards for further management of pulm issues.",1
"# Hypercarbic Respiratory Failure: Per pulmonary, most likely secondary to either decreased resp drive from increasing patient supplemental oxygen to quickly suppressing his respiratory drive or secondary to lack of proper bipap settings.",1
Patient had desaturated down to 70s while in inpatient psych facility.,0
ACS was ruled out as a cause of resp failure.,0
Patients baseline saturations on high 80s on 2L/NC on home o2.,0
Patient was seen by the sleep consultants who felt that his bipap should be set as follows.,0
Baseline sat 78-85 on RA per OMR.,0
"--Bipap used every night and w/ daytime naps, setting 16/12 w/ Oxygen 2L, titrated to sats above 85-90%.",0
--Keep oxygen saturations between 85 and 90%.,0
--During the day patient should be on n/c oxygen 2-4L titrate again sats btw 85-90%.,0
"--Avoid given supplement oxygen above 4L n/c, if needed while in house please reconsult pulmonary medicine and check ABG.",0
--cont albuterol and ipratroprium standing nebulizers q6H.,0
switch back to inhalers as desired.,0
# Asthma( see above) .,0
# Obstructive Sleep Apnea: (See above) Patient needs follow up with Dr. in sleep clinic.,1
He was evaluated by ENT for tonisellectomy.,0
"ENT felt tonsillectomy was not necessary at this time, but that pt may benefit from procedure at a later date.",0
Sleep team felt that amphetamines or stimulants for daytime sleepiness were not indicated at this time.,0
# Secondary Polycythemia: Seen by heme consult service in and again on .,1
"They felt polycythemia likely secondary to hypoxia, despite his epo being low in the past.",1
"He does not have the JAK2-V617F mutation, ,making a primary polycythemia less likely.",0
No therapeutic indications for phlebotomy at this time.,0
Heme did NOT think that hypoxia was secondary to sludging of RBCs in pulmonary vasculature.,0
"-Signs and symptoms to be aware of for sludging include headache, chest pain, and neurological or stroke like symptoms, numbness, weakness, sensory deficits, # Hypertension: Patient was normotensive during his hospital stay would continue.",0
"-continue lisinopril 10mg , HCTZ 25mg .",0
"# Hyperglycemia: No history of DM 2, however glucoses in 200s on the floor.",0
Maybe secondary to atypical antipsychotic.,0
No evidence of DM HgA1C 6.9 -cont insulin sliding scale okay to d/c if sugars normalize .,0
# Bipolar disorder: Defer to psychiatry team.,0
While on the medicine floor he was responding to active internal stimuli.,0
He was noted to have full conversation with himself while alone in his room.,0
He stated that he did not want to discuss who he was talking to.,0
He was followed by liason service while in house.,0
He was discharged on the following medications.,0
- geodon 80mg - valproic acid 250mg .,0
# Hypercholesterolemia: -continue simvastatin 20mg daily.,0
"# Patient needs follow up with Hematology, repeat sleep study and then appointment with Dr. , and Dr. .",0
Medications on Admission: Medications on Admission: HCTZ 25 mg po daily Lisinopril 10 mg po daily Abilify 30 mg po daily Depakote EC 500 mg daily Perphenazine 8 mg po daily .,0
Medications on Transfer to MICU: Fluticasone Proprionate 110 mcg 2 puffs INH Ziprasidone 80 mg po BID (?60) Lisniopril 10 mg po daily HCTZ 25 mg po daily Divalproez Sodium 500 mg po BID Simvastatin 20 mg po daily Ipratroprium Bromide MDI 2 puffs INH QID Beclomethasone Dipropionate 80 mcg IN daily Acetaminophen 650 mg po q4 hours prn Aluminum-MgOH-Simethicone 30 ml po q4 hours prn MOM 30 ml po q8 hours prn Senna 1 tab po BID prn Docusate 100 mg po BID prn Albuterol 2 puffs INH q6 hours prn .,0
Meds on Txfer from MICU to Floor: Fluticasone Proprionate 110 mcg 2 puffs INH Ziprasidone 80 mg po BID Lisniopril 10 mg po daily HCTZ 25 mg po daily Simvastatin 20 mg po daily Albuterol q6H neb Ipratropium q6H neb SC Heparin Discharge Medications: 1.,0
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB/ wheeze.,0
Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation (2 times a day).,0
Ziprasidone HCl 40 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day).,0
Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED).,0
Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: Hold if SBP below 90.,0
Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1.,0
Acute on Chronic Hypercapneic Respiratory Failure 3.,1
"Secondary Polythycemia Discharge Condition: Section 12 for psychosis, tranfer to inpatient psychiaty at -4 .",0
"Discharge Instructions: Mr. you were tranferred to the psychiatry facility to the ICU at , because of abnormalities in your breathing.",0
You were found to have low oxygen levels in your blood and high CO2 levels in your blood.,0
We believe this was because your bipap settings were not maximized.,0
During your hospital stay you had a study of your heart done called an echocardiogram which was normal.,0
You had a chest x-ray which was also normal.,0
You were seen by the pulmonary and who recommended that you continue using BiPap at night with a setting of 17/12 on 2-4L of oxygen titrating your pulse oximetry up to above 85%.,0
During the day you should be on 2-4L of oxygen by nasal canula.,0
This should be titrated to keep your oxygen sats above 85%.,0
Please continue to use all of your nebulizers and inhalers.,0
If you Followup Instructions: Please schedule a follow up with Dr. once you are discharged from the hospital .,0
Please follow up with Dr. from the department of pulmonary medicine on the of the of on at 10:00AM .,0
Please schedule a follow up appointment with Dr. at the sleep unit.,0
The phone number there is .,0
Please follow up with Dr. from hematology for your polythycemia.,0
You can call to make an appointment.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval line placement Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with pericardial effusion s/p drain placement and recent subclavian REASON FOR THIS EXAMINATION: eval line placement ______________________________________________________________________________ FINAL REPORT HISTORY: Pericardial effusion after drain placement, for subclavian line placement.",0
"FINDINGS: In comparison with the earlier study of this date, there has been placement of a left subclavian catheter that extends to about the junction with the upper portion of the SVC.",0
"10:13 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: check dophoff placement Admitting Diagnosis: MITRAL VALVE INSUFFICIENCY\CORONARY ARTERY BYPASS GRAFT WITH MVR POSSIBLE AVR AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman s/p cabg/mvr REASON FOR THIS EXAMINATION: check dophoff placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:30 A.M., HISTORY: Status post CABG.",1
"IMPRESSION: AP chest compared to through at 8:09 a.m. A feeding tube, minus the wire stylet, passes into the stomach, loops out of view, and ends in the fundus.",0
Left subclavian line tip projects over the mid SVC.,0
Left lower lobe atelectasis and moderate left pleural effusion have been present for several days.,0
Previous right pleural effusion and vascular congestion in the lungs have cleared since .,0
"8:37 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: assess liver parenchyma, assess for ascites, please perform Admitting Diagnosis: ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 58 yo F c h/o PBC c/b cirrhosis, HCC s/p hepatic resection with recurrence s/p TACE c/b hepatic abscesses s/p surgical drainage REASON FOR THIS EXAMINATION: assess liver parenchyma, assess for ascites, please perform doppler interrogation of portal vasculature ______________________________________________________________________________ FINAL REPORT ABDOMINAL ULTRASOUND AND LIVER DOPPLER: CLINICAL INDICATION: Cirrhosis, hepatoma status post hepatic resection and recurrence with chemoembolization.",1
Status post recent fluid collection drainage.,0
The liver remaining following surgical resection is markedly heterogeneous and nodular.,0
There are focal hyperechoic areas representing residua from prior chemoembolization.,0
There are also several centimeters' size hypoechoic nodules scattered throughout which could represent sites of hepatoma.,0
There is one dominant mass involving the caudate lobe as was mentioned on prior CT of .,0
This is seen and now measures approximately 2.6 cm in greatest diameter and shows no evidence of intratumoral Lipiodol.,0
There is no evidence of any intrahepatic bile duct dilatation.,0
There is no evidence of significant residual fluid collections now seen.,0
Multiple subcentimeter gallstones are again noted but there is no CBD dilatation.,0
There is no significant ascites and views of both kidneys are unremarkable.,0
The spleen is enlarged at 16.3 cm.,0
Doppler assessment shows patent normal direction of flow in the splenic and superior mesenteric veins as well as in the extrahepatic and intrahepatic portal vein branches.,0
The hepatic veins are also patent as is the inferior vena cava and arterial waveforms are also normal.,0
CONCLUSION: Nodular cirrhotic liver with a dominant 2.6-cm mass in the caudate lobe and several smaller suspicious nodules scattered elsewhere.,0
There is no residual fluid collection seen following prior drainage.,0
Gallstones and splenomegaly also noted.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old male with a single episode of chest pain at rest and minimal activity who went to the emergency department and was ruled out for a myocardial infarction by enzymes.,0
He followed up with an exercise stress test and it was stopped secondary to fatigue.,0
It also showed ST-segment depression in multiple leads.,0
It also showed mild basilar hypokinesis of the inferior wall and his EF was 60 percent.,0
"He was then referred for a cardiac catheterization, which showed 80 percent stenosis of his LAD, 70 to 80 percent stenosis of his OM1, his left circumflex showed no apparent CAD, and his right coronary artery had approximately 80 percent stenosis and 70 percent mid-stenosis.",1
Echocardiogram revealed an EF of 65 percent.,0
PAST SURGICAL HISTORY: Status post repair of anal fissure.,0
Status post left inguinal hernia.,0
Aspirin 81 mg once a day.,0
Verapamil 180 mg once a day.,0
Lipitor 20 mg once a day.,0
Lisinopril 10 mg once a day.,0
SOCIAL HISTORY: He is a nonsmoker.,0
"He drinks occasionally, one drink three times a week.",0
FAMILY HISTORY: He does have a positive family history for coronary artery disease.,1
His father died at the age of 50 of an MI.,0
Multiple brothers have coronary artery disease.,1
"PHYSICAL EXAMINATION: He is a 5 feet 5 inches male, 161 pounds.",0
"His vital signs were temperature 97.3 degrees, blood pressure of 140/70, pulse of 73, respirations 18, and he was 94 percent on room air.",0
"He was alert and oriented x3, and appropriately following commands.",0
His heart rate was regular rate and rhythm.,0
"No murmurs, clicks, rubs, or gallops.",0
His carotids revealed no bruits.,0
"His abdomen was soft, nontender, and nondistended.",0
His extremities were well perfused.,0
"No clubbing, cyanosis, edema, or varicosities.",0
His radial pulses bilaterally were 2 plus.,0
His PT and DP distal pulses were 2 plus bilaterally.,0
"LABORATORY DATA: On , a chest x-ray showed no cardiopulmonary abnormality; his UA was negative; his white blood cell count was 7.2, hematocrit of 37, and platelets of 142,000.",0
"His sodium was 138, potassium 3.8, chloride 106, bicarbonate 22.",0
"BUN 20, creatinine 1.1, glucose of 96.",0
"His PT was 13.2, PTT 26.1, INR 1.1.",0
"ALT 21, AST 22, amylase 54, total bilirubin 0.7, and albumin 3.9.",0
His hemoglobin A1c was 5.6.,0
"HOSPITAL COURSE: On , the patient was taken to the operating room and underwent coronary artery bypass graft operation x4.",1
"The grafts were as follows: LIMA to LAD, vein to RCA, vein to OM1, and vein to diagonal.",0
"Bypass time was 103 minutes, cross clamp time was 85 minutes.",0
The patient was in good condition and transferred to the CSRU.,0
"His drips were as follows: Propofol at 30 mcg/kg/minute, Neo-Synephrine at 0.6 mcg/kg/minute.",0
"His heart rate was 90 beats per minute, A paced.",0
"His mean arterial pressure was 70, CVP of 7, PA diastolic of 8, and PA mean of 15.",0
"On postoperative day one, the patient was successfully extubated.",0
His blood gas revealed metabolic and respiratory acidosis and patient received one unit of bicarbonate.,0
Physical examination revealed a patient in no acute distress with a heart rate that was regular in rhythm with no murmurs.,0
His lungs were clear to auscultation.,0
"His vital signs were as follows: 95 in sinus rhythm, blood pressure 129/59, he was at 85 percent saturation.",0
The patient was attempted to receive BIPAP.,0
His chest tubes put out 500.,0
His JP in his leg for the saphenectomy put out 50.,0
His urine output was 300.,0
"The plan on postoperative day one was to discontinue his Swan, give Lasix 20 mg b.i.d., start Lopressor at 12.5 mg b.i.d., try to get the patient out of bed, and have Physical Therapy see the patient.",0
"On , which was postoperative day two, the patient was in stable condition with a T-max of 96.5 degrees, 110/60 blood pressure, and heart rate of 87.",0
He was saturating at 94 percent on 2 liters of O2 via nasal cannula.,0
His chest tubes put out 310 and his JP was 50.,0
The patient's physical examination was unremarkable.,0
His orders were to discontinue his chest tubes.,0
"Also note, this day is the first day the patient was on Far 2 regular telemetry floor.",0
He was transferred from CSRU on to Far 2.,0
"On postoperative day three, which was , the patient was in stable condition.",0
His blood pressure was 115/64.,0
He was 96 percent on 3 liters.,0
"The patient, overnight, went into atrial fibrillation.",1
He was started on amiodarone and his Lopressor was increased.,0
The patient's current heart rate is in normal sinus on this day after the start of the medication.,0
"On postoperative day four, the patient received one unit of packed red blood cells, late yesterday, , for a hematocrit of 24.",0
He did not go back in any atrial fibrillation rhythm.,1
"Since early yesterday, he was draining some old blood from his saphenectomy in his right leg.",0
"Vital signs were as follows: T-max 99.4 degrees, pulse 64 in sinus rhythm, blood pressure of 130/70, input and output 1200 and 2100.",0
The patient was alert and oriented x3.,0
"The rest of his physical examination revealed clear lungs bilaterally; regular rate and rhythm, no murmurs; bowel sounds were positive; abdomen that was soft, nontender and nondistended.",0
"His sternum was clear, dry, and intact; no erythema, no drainage.",0
His right lower extremity had some drainage of old blood from the JP drain.,0
He was in stable condition and discharged to home with services.,0
DISCHARGE DIAGNOSES: Coronary artery disease.,1
Status post coronary artery bypass graft.,1
"FOLLOW-UP INSTRUCTIONS: The patient was recommended to follow up with Dr. in one to two weeks, follow up with Dr. in one to two weeks and follow up with Dr. in three to four weeks.",0
Lasix 20 mg 1 tablet p.o.,0
Potassium chloride 10 mEq capsule 1 p.o.,0
Colace 100 mg 1 capsule p.o.,0
Aspirin 325 mg 1 tablet p.o.,0
Pantoprazole sodium 40 mg 1 tablet p.o.,0
Atorvastatin 20 mg 1 tablet p.o.,0
Amiodarone 200 mg 2 tablets p.o.,0
Lopressor 25 mg 3 tablets p.o.,0
Ferrous sulfate 325 mg 1 tablet p.o.,0
Oxycodone/acetaminophen 5/325 one-to-two tablets p.o.,0
Dictated By: MEDQUIST36 D: 14:32:00 T: 01:04:19 Job#:,0
"10:10 AM CHEST (PA & LAT) Clip # Reason: s/p R chest tube, please eval for pneumothorax Admitting Diagnosis: SEPTIC SHOULDER ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with fever and shoulder pain REASON FOR THIS EXAMINATION: s/p R chest tube, please eval for pneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: 61 y/o man with fever and shoulder pain.",1
Status post right chest tube placement.,0
PA AND LATERAL CHEST: Comparison is made to portable AP view of the chest dated .,0
There has been interval proper positioning of the right subclavian central venous line which terminates in the right atrium.,0
There has been no change in the appearance or position of the right sided chest tube.,0
There is some slight interval improvement in the size of the right-sided pleural effusion.,1
There is associated right lung base atelectasis which may have slightly improved.,0
"Again the patient is status post right proximal clavicle resection, unchanged.",0
IMPRESSION: 1) Right subclavian PICC line terminating in the right atrium.,0
2) Slight interval improvement in size of the right pleural effusion with associated right lower lobe atelectasis.,1
", TSURG MICU-7 3:12 PM PORTABLE ABDOMEN Clip # Reason: ?",0
"dilated bowel, free air Admitting Diagnosis: RESPIRATORY FAILURE;TRACHEAL MALASIA;S/P BRONCHOSCOPY ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with respiratory distress, anasarca, tense abdomen REASON FOR THIS EXAMINATION: ?",1
"dilated bowel, free air ______________________________________________________________________________ PFI REPORT Patient uncooperative and moving limiting the study.",0
There are dilated loops of small bowel.,0
"4:51 AM CHEST (PORTABLE AP) Clip # Reason: rule out acute change, worsening Admitting Diagnosis: LUNG CANCER;TRACHEAL ESOPHAGEAL FISTULA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with NSCLC s/p right pneumonectomy now with hypotension s/p rigid bronch.",1
"REASON FOR THIS EXAMINATION: rule out acute change, worsening ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: 69-year-old woman with non-small cell lung cancer status post pneumonectomy now with hypotension and rigid bronchus.,1
There is again seen complete opacification of the right lung.,0
"There is an endotracheal tube, right IJ catheter which are unchanged as well as a left main tracheal stent.",0
There is increased density at the left base which is stable.,0
"Overall, there has been no interval change.",0
"6:31 AM CHEST (PORTABLE AP) Clip # Reason: ?improvement Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with multi-trauma, s/p exploratory laparotomy, intubated with slight sanguinous secretions from ETT REASON FOR THIS EXAMINATION: ?improvement ______________________________________________________________________________ FINAL REPORT INDICATION: Multi-trauma, exploratory laparotomy, intubated.",1
"SINGLE VIEW CHEST, AP: The ET tube, right IJ CVL, NG tube, and right-sided chest tube are in unchanged positions.",0
A left subclavian Swan-Ganz catheter tip extends into a right segmental pulmonary artery.,0
A focal area of increased opacity within the right mid lung zone is linear and likely represents atelectasis.,0
"Allowing for the supine nature of the study, there is no pulmonary edema.",0
There is a persistent left- sided pleural effusion.,0
Height: (in) 62 Weight (lb): 108 BSA (m2): 1.47 m2 BP (mm Hg): 114/40 HR (bpm): 45 Status: Inpatient Date/Time: at 09:57 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
RIGHT VENTRICLE: The right ventricular cavity is moderately dilated.,0
TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial tricuspid regurgitaton.,0
There is mild regional left ventricular systolic dysfunction with akinesis of the inferior basal wall.,0
Mild (1+) mitral regurgitation is seen during systolic but prominent diastolic mitral regurgitation indicating high degree AV block.,0
IMPRESSION: Inferior/ RV infarction with high degree heart block,1
"5:23 AM CHEST (PORTABLE AP) Clip # Reason: ?interval change Admitting Diagnosis: UTI/PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with MS presented in status epi, intubated, with desaturation overnight and requiring increased pressure support.",0
REASON FOR THIS EXAMINATION: ?interval change ______________________________________________________________________________ WET READ: ENYa SAT 11:10 AM Similar CXR from yesterday.,0
ETT 2.8 cm above the carina.,0
"Bilateral pleural effusions, moderate on R, and moderate-to-large on L. NGT in stomach.",0
L IJ CVL tip at mid-to-lower SVC.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Epileptic status.,0
The left internal jugular line tip is at the level of mid SVC.,0
There is no change in the appearance of the heart size and mediastinal contours as well as bilateral pulmonary edema and bilateral pleural effusions.,1
No change since the prior study noted.,0
"12:24 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ETT placement, eval for chest tube placement, pneumothorax Admitting Diagnosis: HEAD BLEED/SPLENIC LACERATION/KIDNEY LACERATION/MVC ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with bilateral chest tubes s/p trauma REASON FOR THIS EXAMINATION: ETT placement, eval for chest tube placement, pneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: 25-year-old man with bilateral chest tubes status post trauma, ET tube placement.",1
SINGLE FRONTAL CHEST RADIOGRAPH: The ET tube terminates 3 cm above the carina.,0
An NG tube passes out of view below the diaphragm.,0
Bilateral chest tubes end in the apices.,0
Left lung contusions are unchanged.,0
Only the left tenth rib fracture is visible on the current exam.,0
The known small pneumothoraces are not noted on this supine radiograph.,0
Right lung is well expanded and clear.,0
"There is minimal paraspinal fluid, unchanged.",0
Excretory contrast is noted in the right renal pelvis.,0
IMPRESSION: ET tube 3 cm above the carina.,0
Both chest tubes in bilateral apices.,0
"LINE PLACEMENT Clip # Reason: line placement Admitting Diagnosis: PACREATITIS/SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with sepsis, intubated, s/p L subclavian.",0
"REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old with sepsis, status post left subclavian line placement.",0
AP CHEST RADIOGRAPH: Right-sided internal jugular central venous catheter is in unchanged position.,0
The distal portion of the nasogastric tube likely resides within the stomach.,0
There has been interval placement of a left-sided subclavian central venous catheter with tip at the cavoatrial junction.,0
Left-sided subclavian central venous catheter with tip at the cavoatrial junction and no evidence of pneumothorax.,0
"Name: , K Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Haldol Attending: Addendum: After speaking with our attending and speaking with the Endocrinology Fellow, the recommendation was made that the TSH of 31 is very much elevated from what would be expected in this patient's case, and that the dose of the levothyroxine should be increased to 75mcg at this time with outpatient follow-up.",0
"However, it was also felt that it would be reasonable to allow the patient to continue treatment in rehab for a week prior to rechecking thyroid function tests, to allow the patient to recover from the inpatient setting and allow his thyroid function to normalize on his current dose of levothyroxine.",0
Discharge Disposition: Extended Care Facility: of MD Completed by:,0
"5:22 AM CHEST (PORTABLE AP) Clip # Reason: assess interval change Admitting Diagnosis: PEDESTRIAN STRUCK BY CAR ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with prolonged intubation, s/p VAP REASON FOR THIS EXAMINATION: assess interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH: INDICATION: Prolonged intubation, assessment of interval change.",0
Surgical material partially obstructs the visibility of the central monitoring and support devices.,0
Correct course of the nasogastric tube.,0
Apparently correct position of the endotracheal tube.,0
New right-sided internal jugular vein catheter.,0
Unchanged mild overhydration and retrocardiac atelectasis.,0
"8:00 PM CHEST (PORTABLE AP) Clip # Reason: resp distress ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with REASON FOR THIS EXAMINATION: resp distress ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress CHEST X-RAY, PORTABLE AP: There are no prior films for comparison.",0
There is a prominence of the pulmonary vasculature with upper zone redistribution.,0
No acute infiltrate or consolidation is appreciated.,0
IMPRESSION: Findings consistent with congestive heart failure.,1
"12:16 PM ESOPHAGUS; C-SPINE NON-TRAUMA VIEWS Clip # Reason: evaluate for esophageal perforation Admitting Diagnosis: PREVERTEBRAL ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with neck abscess, findings from OSH suspicious for perforated Zenkers REASON FOR THIS EXAMINATION: evaluate for esophageal perforation ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 47-year-old female with neck abscess, findings from outside hospital suspicious for perforated Zenker's.",1
FINDINGS/PROCEDURE: Initial scout image demonstrates upper cervical fusion with plate and four screws.,0
Water soluble Conray contrast was administered orally in the supine and left lateral decubitus position under constant fluoroscopic guidance.,0
Contrast passes freely through the esophagus without holdup.,0
"A tract of contrast is seen extending from the posterior esophgus at the level of the cervical fusion which appears to lead into two collections, the larger of which is located inferiorly and left posterolateral to the esophagus and the smaller collection more midline.",1
"Although a Zenker's diverticulum is present it is likely that a portion of the contarst lies outside the diverticulum; these finding are supicious for esophageal perforation, especially given the constellation of findings on the neck CT.",1
Impression: Findings concerning for esophageal perforation.,0
8:32 AM CAROTID SERIES COMPLETE Clip # Reason: r/o stenosis.,0
Pt scheduled for CABG on .,0
"Needs ultra Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with CAD, pre-op for CABG with bruit on left.",0
REASON FOR THIS EXAMINATION: r/o stenosis.,0
"Needs ultrasound first thing in the AM, prior to surgery.",0
______________________________________________________________________________ FINAL REPORT STUDY: Carotid series complete.,0
"REASON: Bruit, preop for CABG.",0
FINDINGS: Duplex evaluation was performed of both carotid arteries.,0
Moderate plaque was identified on the left.,0
"On the right, peak systolic velocities are 68, 58, and 98 in ICA, CCA, and ECA respectively.",0
The ICA to CCA ratio is 1.2.,0
This is consistent with less than 40% stenosis.,0
"On the left, peak systolic velocities are 120, 79, and 90 in the ICA, CCA, and ECA respectively.",0
The ICA to CCA ratio is 1.5.,0
This is consistent with 40% to 59% stenosis.,0
There is antegrade flow in both vertebral arteries.,0
IMPRESSION: Moderate left-sided plaque with 40% to 59% carotid stenosis.,0
"On the right, there is a less than 40% stenosis.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: is a 9 day old former 32 6/7 weeks gestation boy with a corrected gestational age of 34 3/7 weeks.,0
"He was born to a 32-year-old gravida 1, para 0 to 2 mom.",0
"prenatal screens were A+, Ab-, RPR NR, HBsAg negative, rubella immune, GBS positive.",0
Past medical history is also remarkable for albinism and visual impairment.,0
She is legally blind but does have functional vision.,0
"Finally, pregnancy was complicated by twin gestation.",0
"PERINATAL COURSE: Remarkable for elevation of blood pressure and proteinuria on , approximately 5 days prior to admission.",0
Mom was treated with Betamethasone and received a complete course.,0
On the day of admission she developed preterm contractions intermittently and then had spontaneous rupture of membranes 3 hours prior to delivery.,1
Mother was given antibiotics three hours prior to delivery for GBS prophylaxis.,0
DELIVERY COURSE: Remarkable for cesarean section delivery without complications.,1
Infant was vigorous in the delivery room with Apgars of at one and five minutes respectively.,0
Infant was transferred to the Neonatal Intensive Care Unit for further management.,0
"PHYSICAL EXAMINATION: On admission, alert, vigorous infant appearing at gestational age.",0
"Weight 1,775 gm, 50th percentile, length 42.5 cm which is 25th-50th percentile, head circumference 30 cm which is between 25th-50th percentile.",0
"Vital signs, heart rate 172, respiratory rate 36, temperature 99.2, blood pressure 62/36 with a mean arterial pressure of 46.",0
"HEENT: Anterior fontanel was soft, flat, sutures mobile, palate intact.",0
Lungs clear and equal to auscultation bilaterally without retractions.,0
"Cardiovascular, no murmur with a regular rate and rhythm and normal S1 and S2.",0
Femoral pulses were normal and brisk.,0
"Abdomen soft with normal bowel sounds, no masses.",0
Genitourinary exam revealed normal male with testes descended bilaterally.,0
Neurologic exam revealed good tone and appropriate reflexes.,0
Hips were stable with mildly increased laxity.,0
Respiratory: This infant did not have any evidence of Surfactant deficiency and was room air since birth with good respiratory effort and oxygenation.,0
"He did show evidence of mild apnea of prematurity with his last episode being on , over five days prior to discharge.",0
He has not been on caffeine.,0
Cardiovascular: This infant has not had a murmur.,0
"He intermittently did have a PPS murmur by report, however, this has not been confirmed on repeated exams.",0
His perfusion has remained excellent and there have been no other concerns from a cardiovascular standpoint.,0
"Fluids, Electrolytes & Nutrition: The infant had an early Dextrose stick of 38 soon after birth.",0
He had really no problems maintaining adequate blood sugar after that.,0
"He began ad lib feeding after the first 24 hours of life, taking a minimum of 80 cc/kilo/day.",0
"He is currently taking a minimum of 140 cc/kilo/day, however, has managed to take well in excess of that, having taken over 170 cc/kilo over the past 24 hours.",0
He is taking either mother's milk or Enfamil at caloric density of 24/oz and is stooling.,0
"His birth weight was 1775 grams and his weight at the time of discharge is 1,815 grams indicating attainment of his birth weight as well as gaining above that in the first 9 days of life.",1
We have been very happy with this progress.,0
"Gastrointestinal: He has been stooling, has a soft abdomen, there have been no concerns from a GI perspective.",0
"Hematology: The infant had hematocrit of 51.2 at birth, this has not been rechecked and platelet count 233,000 as well.",0
He had an indirect bilirubin of 8.1 on day of life #3.,0
He was placed on phototherapy.,0
Phototherapy was discontinued on day of life #6.,0
His last bilirubin was slightly above 5 on day of life #7.,0
Infectious Disease: This infant received sepsis evaluation due to preterm labor in the mother and antibiotics only three hours prior to delivery.,1
"The infant did not end up receiving antibiotics due to a benign exam, no evidence of distress or instability as well as a white blood cell count of 12.3 with 24% polys and 1% band forms.",0
Blood culture was sent and was negative in 48 hours.,0
There have been no other issues from an infection standpoint.,0
Neurology: This infant did not require a head ultrasound due to birth at greater than 32 weeks gestation.,0
"He has been neurologically appropriate, is feeding well, has a soft fontanel on exam with no other concerns.",0
Sensory: 1) Audiology: Hearing screen was performed with automated auditory brain stem responses which were unremarkable.,0
"CARE/RECOMMENDATIONS: 1) Feeds at discharge: The infant should take a total intake of at least 150 cc/kilo/day, divided into feedings every 3-4 hours.",0
The infant should be awakened for feedings as needed.,0
2) Medications: The infant is only receiving supplemental iron which should be continued after discharge.,0
The infant should also have mother's milk fortified with four calories per oz of Enfamil powder to maximize nutrition.,0
3) State Newborn Screening Status: Initial screen was sent and has been unremarkable and subsequent screen has been sent as well.,0
4) Immunizations received: None thus far due to patient's weight.,0
"5) Immunizations recommended: Synagis RSV prophylaxis should be considered from through for those infants who meet any of the following three criteria: 1) Born at less than 32 weeks; 2) Born between 32 and 35 weeks with plans for Day Care during RSV season, with a smoker in the household, or with preschool siblings; or 3) with chronic lung disease.",0
"This infant does not have evidence of chronic lung disease and there is no indication that the infant will be in Day Care during the RSV season, hence, his gestational age and weight is not an absolute indication for administration of Synagis.",0
This can be determined as an outpatient.,0
6) Follow-up appointments: Center Peds has been notified and follow-up needs to be scheduled through them.,0
"32 6/7 weeks preterm infant boy, now corrected to 34 3/7 weeks.",0
Dictated By: MEDQUIST36 D: 15:09 T: 13:47 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: This is a 61 year old female with a history of HTN and two previous intracranial hemorrhages (, ) who, at baseline is deaf, non-ambulatory, wheel-chair bound resident of the Home for the Deaf (NEHD).",1
The patient was in her USOH until last night when she noted to have a change in mental status and was seen slumped to the LEFT in her wheel-chair.,1
The patient was taken to Hospital where a CT scan of the brain revealed an acute RIGHT thalamic bleed (4:20 am) of about 10cc.,0
The patient's blood pressure was apparently >200/110.,0
Her INR at was 0.84.,0
She was transferred for for further management.,0
ROS: Unknown Past Medical History: -HTN -Intracranial Hemorrhage of unclear etiology in necessitating surgical evacuation.,0
Patient had had seizures controlled on phenytoin for 2 years after that episode.,0
"She had resultant RIGHT sided weakness, with short-term memory dysfunction but was eventually able to return home and take care of her own ADLs.",0
-Second intracranial event also of unclear etiology in .,0
"After rehab, patient was more unsteady than previous baseline.",0
"-Last year she reportedly had a ""deterioration"" of her ability to care for herself, of unclear etiology.",0
She was transferred to the Home for the Deaf .,0
Social History: former teacher deaf at baseline; knows sign language Family History: unknown.,0
Physical Exam: VS: T afebrile HR 108 BP 156/86 RR16 Sat 100 % on 1L NC .,0
"PE: Genl WD WN NAD HEENT AT/NC, MMM no lesions Neck Supple, no thyromegaly, no , no bruits Chest CTA B CVS RRR w/o MGR ABD soft, NTND, + BS EXT no C/C/E, distal pulses full, no rashes or petechiae .",0
Neuro MS: Patient non-verbal however able to communicate with sign- language interpreter.,0
Patient visibly agitated and seems angry.,0
She moves her RIGHT arm spontaneously.,0
She did not know she was in the hospital or why she might be in a hospital.,0
She repeatedly told this interviewer to call her daughter.,0
"She motioned to write but when given a piece of paper, just stared at it.",0
"CN: I--not tested; II,III-OS 2.5-1, OD 3.5-1.",0
"PRRLA, ; III,IV,VI-EOMI w/o nystagmus, no ptosis; Patient does not blink to confrontation on the LEFT V--sensation intact to LT; VII-LEFT sided facial droop, likely central (forehead spared); IX,X--voice hoarse, palate elevates symmetrically, gag intact; -- SCM/trapezii not tested secondary to lack of cooperation; XII-- tongue protrudes midline, no atrophy or fasciculation.",0
Motor: Patient lying tilted to RIGHT.,0
LEFT arm and leg with little spontaneous movement |ShFl|ElFl|ElEx|WrFl|WrEx|FgSp|HpFl|KnEx|KnFl|Dors|Plan| L | ?,0
| >2 | >2 | 1 | 1 | ?,0
| >2 | >2 | >2 | ?,0
| R | 5 | 5 | 5 | 5 | 5 | 5 | >2 | >2 | >2 | ?,0
Refl: Sustained clonus in both ankles | |tri |bra |pat | |toe | L | 3 | 3 | 3 | 4 | 4 | up R | 2 | 2 | 2 | 4 | 4 | dn | .,0
": responds to painful stimuli throughout, both left and right sides .",0
Gait: not tested Pertinent Results: 08:32AM WBC-9.3 RBC-5.58* HGB-14.4 HCT-45.7 MCV-82 MCH-25.9* MCHC-31.6 RDW-12.7 08:32AM NEUTS-82.0* LYMPHS-13.8* MONOS-3.1 EOS-0.5 BASOS-0.6 08:32AM PLT COUNT-178 08:32AM PT-12.2 PTT-24.9 INR(PT)-1.0 08:32AM GLUCOSE-126* UREA N-7 CREAT-0.5 SODIUM-142 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-33* ANION GAP-15 07:49AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG .,0
CT head at admission: Intraparenchymal hemorrhage involving the right thalamus with surrounding edema and mass effect.,0
"There is small amount of intraventricular extension, although no evidence of hydrocephalus at this time.",0
CT head : Stable right thalamic hemorrhage.,0
No change in the amount of mass effect.,0
No new hemorrhages are noted.,0
Brief Hospital Course: The patient is a 61 year old woman with a history of ICH (' and ') with residual R-sided symptoms who presented with new left sided weakness that was worse in the arm than leg and included her face.,0
She was found to have a R-thalamic hemorrhage in the setting of HTN.,0
Neuro: The patient is able to open her eyes and track.,0
As she is deaf she won't be able to follow any vocal commands.,0
The has increased reflexes on the R (related to her old hemorrhages).,0
A repeat CT-head showed no interval change.,0
For management of agitation she was started on seroquel.,0
Please try to avoid haldol as much as possible.,0
She was started on ASA .,0
"Given her history of previous hemorrhages and hypertension, the cause of the present hemorrhage is most likely hypertensive.",1
Cardiovascular: The patient has hypertension that was relatively well controled with labetolol and lasix (standing dose) and metoprolol PRN.,1
Please consider adding an ACE-inhibitor to keep her systolic blood pressure below 140. .,0
Respiratory: a) The patient was intubated for tachypnea.,1
She remained ventilator dependent and a trach was placed .,0
There is no neurological reason for her difficulties to wean.,0
"Prior to discharge, she was tolerating hours of CPAP and it is expected that she will be weaned successfully.",0
b) Following CVL placement on a small pneumothorax was caused on the Right.,1
A chest-tube was put in place.,0
The pneumothorax slowly improved and the chest tube was removed.,0
Haematology: Patient's Hct trended down and then stabilized around 25-27.,0
No source of GI bleeding was found.,0
Please continue to monitor Hct weekly.,0
Please guiac all stool and continue PPI .,0
Infectious disease: The patient developed a fever .,0
"Possible underlying etiology was aspiration pneumonia or UTI (enterococ in urine, sensitive to levaquin).",0
She received a course of levaquin that was finished .,0
"A PICC-line was placed , and the CVL was removed.",0
Endocrine: The patient was maintained on a RISS and FSBS.,0
"Prophylaxis: The patient was maintained on pneumoboots, heparin sc, PPI, and a bowel regimen.",0
FEN: A PEG tube was inserted after the patient failed to wean.,0
There is no neurological reason that explains her inability to wean off the vent and to swallow.,0
Continue to monitor i/o and electrolytes closely.,0
Replete eletrolytes and diurese if needed.,0
Code: full Medications on Admission: -ASA -Acetaminophen -HCTZ -labetolol Discharge Medications: 1.,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection TID (3 times a day): until mobilized.",0
Insulin Regular Human 100 unit/mL Solution Sig: Two (2) units Injection ASDIR (AS DIRECTED): per insulin sliding scale.,0
Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 150mg PO BID (2 times a day).,0
Acetaminophen 160 mg/5 mL Solution Sig: One (1) 800 PO Q4-6H (every 4 to 6 hours) as needed for Fever.,0
Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for fluid overload: based on daily weight.,0
Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) 500mg Intravenous Q24H (every 24 hours) for 6 days.,0
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14.,0
Lorazepam 0.5 mg IV Q4H:PRN agitation Discharge Disposition: Extended Care Facility: Medical Center - Discharge Diagnosis: 1.,0
R-thalamic hemorrhage 2. hypertension 3. failure to wean off ventilator 4. pneumothorax-R 5. deafness Discharge Condition: -Fair Discharge Instructions: -provide care to trach and PEG -continue medications -provide PT -patient is deaf at baseline -please monitor the BP closely; consider adding an ACE-inhibitor to keep SBP<140 Followup Instructions: Please follow up at the Clinic with Dr. / once weaned off the ventilator.,1
Please call to set up an appointment and to get further instructions.,0
"8:53 AM CHEST (PORTABLE AP) Clip # Reason: evaluate pulmonary effusion Admitting Diagnosis: VARICEAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with massive upper GI bleed s/p TIPS, intubated s/p change of endotrach tube REASON FOR THIS EXAMINATION: evaluate pulmonary effusion ______________________________________________________________________________ FINAL REPORT COMPARISON: and studies.",0
INDICATION: Change of endotracheal tube.,0
No endotracheal tube is identified.,0
There is a left internal jugular catheter terminating in the left brachiocephalic vein.,0
Again demonstrated are bilateral layering moderate to large pleural effusions.,0
There is also probable anasarca.,0
IMPRESSION: Persistent bilateral pleural effusions.,0
Low BP Height: (in) 61 Weight (lb): 160 BSA (m2): 1.72 m2 BP (mm Hg): 97/46 HR (bpm): 79 Status: Inpatient Date/Time: at 15:20 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
Moderate AS (area 1.0-1.2cm2) No AR.,0
Mild to moderate (+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
"1:27 PM CHEST (PORTABLE AP) Clip # Reason: eval PA line placement, r/o PTX Admitting Diagnosis: S/P VF ARREST;CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 58 yo male w/ lad stent s/p cath/revasc, morbid obesity s/p PA line placement via R IJ.",0
"REASON FOR THIS EXAMINATION: eval PA line placement, r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary artery catheter placement.",0
"CHEST, PORTABLE: Exam is limited due to body habitus of the patient.",0
A Swan- Ganz catheter has been placed.,0
"The catheter courses from the right atrium to the right ventricle, but it is difficult to confidently visualize the tip of the catheter on this radiograph.",0
An endotracheal tube and permanent pacemaker as well as a right internal jugular vascular catheter are also noted.,0
There is persistent congestive heart failure.,0
Left sided pleural thickening vs pleural fluid is unchanged.,0
IMPRESSION: 1) Difficulty visualizing tip of the Swan-Ganz catheter.,0
Repeat radiograph with differing technique is recommended to better determine the location of this device.,0
2) Persistent congestive heart failure.,0
Height: (in) 70 Weight (lb): 198 BSA (m2): 2.08 m2 BP (mm Hg): 111/57 HR (bpm): 84 Status: Inpatient Date/Time: at 15:32 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.,0
Right ventricular chamber size is mildly dilated with normal free wall motion.,0
"Compared with the prior study (images reviewed) of , the right ventricular cavity is now smaller, the severity of tricuspid regurgitation is now reduced, and the estimated pulmonary artery systolic pressure is now lower (previously overestimated on review of the prior study).",1
"9:13 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: evaluate for ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with s/p CABG, CTs d/c'd REASON FOR THIS EXAMINATION: evaluate for ptx ______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube removal, evaluate for pneumothorax.",1
FINDINGS: Single portable frontal view of the chest shows removal of bilateral chest tubes and right PA catheter.,1
"The right IJ sheath, feeding tube, and ET tube are in satisfactory position.",0
Again seen is bilateral pulmonary edema.,0
The right pleural effusion is slightly decreased compared to prior.,0
IMPRESSION: No pneumothorax after chest tube removal.,0
Height: (in) 56 Weight (lb): 142 BSA (m2): 1.54 m2 BP (mm Hg): 97/40 HR (bpm): 74 Status: Inpatient Date/Time: at 10:42 Test: TTE (Focused views) Doppler: Limited Doppler and no color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT VENTRICLE: Mild regional LV systolic dysfunction.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid inferior - akinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Focal basal hypokinesis of RV free wall.,0
TRICUSPID VALVE: Indeterminate PA systolic pressure.,0
Conclusions: There is mild regional left ventricular systolic dysfunction with focal basal to mid inferior akinesis.,0
The right ventricular cavity is mildly dilated with free wall hypokinesis.,0
"Compared with the prior study (images reviewed) of , the inferior wall motion abnormality is new and the right ventricular basal free wall motion abnormality is also new.",0
Additional views maybe helpful to fully assess the right ventricle.,0
5:06 AM CHEST (PORTABLE AP) Clip # Reason: NEW ADMISSION Admitting Diagnosis: LEFT LOWER EXTREMITES;INFECTED RIGHT FOOT WOUND ______________________________________________________________________________ FINAL REPORT HISTORY: New admission.,1
"FINDINGS: In comparison with the study of , there are continued low lung volumes with mild atelectatic changes at the bases.",0
Cardiac silhouette is essentially within normal limits and there is no definite vascular congestion.,1
Elevation of the right hemidiaphragm is seen.,0
Right IJ catheter extends to the mid portion of the SVC.,0
There is evidence of cervical fusion procedure and severe degenerative change involving the left shoulder.,0
PORT Clip # Reason: UTI EVAL.,0
FOR HYDRO/MASSES Admitting Diagnosis: STATUS EPILEPTICUS ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with UTI REASON FOR THIS EXAMINATION: Eval.,0
for hydro/masses ______________________________________________________________________________ FINAL REPORT INDICATION: Urinary tract infection.,1
RENAL ULTRASOUND: The left kidney measures 13.2 cm and contains an 8.7 x 4.0 x 7.7 cm anechoic thin-walled simple cyst.,0
"Additionally, within the mid pole of left kidney is a 0.6 x 0.8 x 0.6 cm hyperechoic focus consistent with an angiomyolipoma.",0
The right kidney measures 11.1 cm and is normal in appearance.,0
The bladder contains a Foley catheter and is otherwise unremarkable.,0
Large left renal cyst and tiny left benign hyperechoic focus most likely representing an angiomyolipoma.,0
"9:06 AM NEONATAL HEAD PORTABLE Clip # Reason: ventr dilatation ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity 28 3/7 weeks, IVH and ventriculomegaly with LP for therapeutic relief of pressure REASON FOR THIS EXAMINATION: ventr dilatation ______________________________________________________________________________ FINAL REPORT 9:25 HOURS.",0
HISTORY: Follow up intraventricular hemorrhage with ventriculomegaly s/p LP for therapeutic relief of pressure.,1
"In follow up to , the degree of dilatation of the lateral, third and fourth ventricles has improved in the interval.",0
The liquifying residual clot within the frontal of the left lateral ventricle with focal hemorrhagic infarction involving the left frontal periventricular white matter is unchanged in appearance from prior examination.,0
"There continues to be increased echogenicity of the ependymal lining in keeping with chemical ventriculitis as well as some mild debris in the right lateral ventricle, unchanged.",0
No new focal areas of ischemia are evident.,0
"Without compression, resistive indices range from .74 to .8.",0
"Following compression, resistive indices rise to .87.",0
IMPRESSION: Improvement in degree of lateral and third and fourth ventricular dilatation post lumbar puncture.,0
No change in degree of elevation of the resistive indices with and without compression.,0
Stable appearance of left intraventricular hemorrhage with intraparenchymal hemorrhage or infarction.,1
", J. TSICU 5:51 AM CHEST (PORTABLE AP) Clip # Reason: status of pulmonary edema and pleural effusions Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with ATN on CVVH and fluid overloaded REASON FOR THIS EXAMINATION: status of pulmonary edema and pleural effusions ______________________________________________________________________________ PFI REPORT Minimal pulmonary edema, left lower lobe atelectasis and tiny left pleural effusion remain.",1
Multiple left-sided rib fractures noted.,1
Lines and tubes in standard placements.,0
7:11 AM CHEST (PORTABLE AP) Clip # Reason: 67 year old man with heart failure.,1
Please evaluate for inte Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with heart failure.,1
Please evaluate for interval change.,0
REASON FOR THIS EXAMINATION: 67 year old man with heart failure.,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath.,0
The left side dual pacemaker defibrillator leads terminate in right atrium and right ventricle.,0
The right internal jugular line tip is at the cavoatrial junction.,0
The heart size is mildly enlarged.,0
The descending aorta is tortuous with no evidence of focal dilatation.,0
"The lungs are clear, and there is no pleural effusion or pneumothorax.",0
IMPRESSION: No evidence of acute cardiopulmonary process.,0
7:47 AM NEONATAL ABDOMEN Clip # Reason: f/u to assess splenic cysts Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with congenigal candidiasis REASON FOR THIS EXAMINATION: f/u to assess splenic cysts ______________________________________________________________________________ FINAL REPORT ABDOMINAL ULTRASOUND HISTORY: Infant with congenital candidiasis.,1
Follow up to assess splenic cysts.,0
FINDINGS: The report from the prior study is available but the images could not be directly viewed.,0
"Examination of the abdomen was unremarkable, without evidence of the previously identified small splenic cysts.",0
"Further imaging may be helpful with a higher resolution ultrasound probe, which has been arranged for later this week.",0
11:39 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: abscess Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with cerebellar hemorrhage from underlying malignancy and prolonged elevated WBC REASON FOR THIS EXAMINATION: abscess No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd FRI 6:20 PM Rim-enhancing mass seen in the right cerebellum which may be due to a primary rim-enhancing lesion as seen on prior MR or the presence of a superimposed infection.,0
Differentiation between these two is not possible on imaging alone and clinical correlation is advised.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old man with cerebellar hemorrhage from underlying malignancy and prolonged elevated WBC.,0
"COMPARISON: Multiple head CTs, most recent of and MR head of .",0
TECHNIQUE: Contiguous axial images were obtained through the brain prior to and after the administration of contrast.,0
FINDINGS: Again seen is a right cerebellar mass with surrounding area of edema.,0
The mass effect from this lesion has decreased slightly since prior scan with less compression on the fourth ventricle.,0
"On contrast-enhanced images, this mass appears rim-enhancing.",0
"On prior non-contrast head CTs, this mass appeared hyperdense but now has decreased in attenuation, consistent with evolution of prior hemorrhage within the lesion.",0
The enhancing rim may be due to the primary rim-enhancing lesion (as better seen on prior MR).,0
Again a small amount of air is seen along the track of the prior biopsy.,0
An associated right occipital burr hole is also seen.,0
"An extra-axial fluid collection overlying the right cerebral hemisphere is again noted and measures 10 mm at its widest diameter, unchanged, with associated sulcal effacement.",0
Again noted are lacunar infarcts in the left caudate head and encephalomalacic changes of the right caudate/frontal lobe due to prior infarct.,0
"IMPRESSION: Rim-enhancing lesion seen in the right cerebellum, the appearance of which may be due to the primary lesion.",0
In absence of increasing edema superimposed infection is less likely from imaging appearances alone but clinical correlation is advised.,0
3:51 PM CHEST (LAT DECUB ONLY) RIGHT PORT Clip # Reason: evaluating consolidated right lung ______________________________________________________________________________ MEDICAL CONDITION: Infant with right lung consolidatation and CLD REASON FOR THIS EXAMINATION: evaluating consolidated right lung ______________________________________________________________________________ FINAL REPORT HISTORY: Right lung consolidation.,0
"PORTABLE AP CHEST, 15:40, : The study is compared with the examination from the previous evening.",0
The ETT is now seen reaching the upper trachea.,0
NG tube projects to the level of the GE junction.,0
There is diffuse opacification of the right hemithorax with multiple locules of air again seen.,0
"In this patient with known staph aureus sepsis, the appearance is certainly concerning for empyema with either pneumatocele or abscess formation.",0
"Overall, the appearances of the right hemithorax is unchanged compared to the earlier study.",0
"The left lung is slightly better aerated compared to yesterday's study, however, changes of chronic lung disease persist.",1
The right arm PICC line again seen reaching the upper SVC.,0
"8:09 AM CHEST (PORTABLE AP) Clip # Reason: assess effusion Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\ RESECTION AORTIC ASCENDING ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: s/p Ao aneurysm repair and pigtail placement, known effusion.",0
"Just intubated for poor gas REASON FOR THIS EXAMINATION: assess effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Status post aortic aneurysm repair and pigtail placement, assess effusion.",0
"FINDINGS: An endotracheal tube is in place with tip terminating 2.1 cm from the carina, partially withdrawn in the interval.",0
"A right-sided PICC in unchanged position, with tip in SVC.",0
There is stable widening of the mediastinal contour.,0
Sternal suture wires in unchanged configuration.,0
Slight increase in right-sided pleural effusion and stable small left pleural effusion and left lower lobe atelectasis versus consolidation.,0
The osseous structures appear unchanged.,0
IMPRESSION: 1) Endotracheal tube and right-sided PICC in satisfactory position.,1
2) Stable mediastinal widening previously demonstrated on CT to be related to a fluid collection about the aorta.,0
3) Slight increase in right pleural effusion.,0
"9:45 AM CHEST (PA & LAT) Clip # Reason: r/o evolution of PTX -- DO FILM AT 0600 Admitting Diagnosis: TRACHEO-BRONCHEAL MALACEA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67F s/p tracheoplasty, small residual pneumothorax, R chest tube -- DO FILM AT 0600 REASON FOR THIS EXAMINATION: r/o evolution of PTX -- DO FILM AT 0600 ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST ON HISTORY: Tracheostomy, residual pneumothorax.",0
"IMPRESSION: PA and lateral chest compared to chest radiographs since , most recently at 7:05 p.m.: Moderate right pneumothorax is stable since .",0
No radiopaque pleural tube is seen.,0
"Severe subcutaneous emphysema in the chest wall and neck, right greater than left, is unchanged.",1
"Heart is normal size and mediastinum is midline, but persistent mild-to-moderate pneumomediastinum seen particularly at and above the aortic arch.",0
", NMED SICU-B 10:34 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for interval change, post-op Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK (TIA) ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with large R MCA/ACA stroke s/p R hemicraniectomy yesterday REASON FOR THIS EXAMINATION: evaluate for interval change, post-op No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",0
Status post right frontal craniectomy with dramatic decrease in the shift of midline structure.,0
Unchanged infarction of the entire right anterior cerebral and near the entire right middle cerebral artery distribution.,1
8:47 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"ischemic/hemorrhagic event Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE / ASCENDING AORTA REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with acute change in mental status, s/p AVR REASON FOR THIS EXAMINATION: ?",1
ischemic/hemorrhagic event No contraindications for IV contrast ______________________________________________________________________________ WET READ: LLTc SUN 10:27 AM No acute intracranial process.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Acute change in mental status, status post AVR.",0
"FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction.",1
"Ventricles and sulci are slightly prominent, reflective of diffuse cortical atrophy.",0
No acute fracture is present.,0
"The middle ear cavities, mastoid air cells, and included views of the paranasal sinuses are clear.",0
"Specifically, no hemorrhage or large vascular territorial infarct detected.",1
11:21 AM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: DVT?,0
"Admitting Diagnosis: HYPERCALCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 65F w primary hyperparathyroidism, AF, with assymetric LE edema R>L.",1
REASON FOR THIS EXAMINATION: DVT?,0
______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old female with asymmetric lower extremity edema.,0
"FINDINGS: Grayscale, color and Doppler images were obtained of the right common femoral, femoral and popliteal veins.",0
Note is made that despite diligent effort the right calf veins could not be visualized.,0
"Normal flow, compression and augmentation is seen in all of the visualized veins.",0
Superficial edema within the soft tissues is seen in the right calf.,0
IMPRESSION: No evidence of deep vein thrombosis from the right common femoral through the right popliteal veins.,0
Note is made that the right calf veins could not be visualized.,0
8:50 AM CHEST (PA & LAT) Clip # Reason: Evaluate for interval change.,0
"Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with fevers, white count, ?pna on CXR from .",0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MON 12:36 PM PFI: Slight improvement in bilateral small pleural effusions and basilar atelectasis.,0
Right lower lung field opacity of unclear etiology; recommend shallow oblique views to better evaluate.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 60-year-old with fevers, leukocytosis, concern for pneumonia.",0
TECHNIQUE: Chest AP and lateral radiograph obtained.,0
COMPARISON: Comparison is made to portable chest film obtained .,0
FINDINGS: NG tube is again seen passing through the stomach and out of view.,0
Left PICC line position is stable with tip at the confluence of the brachiocephalic vein and superior vena cava.,0
Small bilateral pleural effusion and bibasilar atelectasis are slightly improved compared to yesterday.,0
"Small rounded opacity projecting over right lower lung, not well evaluated on prior x-rays, may represent loculated effusion versus rib fracture callus formation.",0
Mediastinal and hilar contours are normal.,0
IMPRESSION: Slight improvement in bilateral small pleural effusions and basilar atelectasis.,0
Right lower lung opacity of unclear intrathoracic position; recommend shallow oblique views to better evaluate.,0
11:57 AM CHEST (PORTABLE AP) Clip # Reason: please eval placement of tunnled cath and r/o infiltrate Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with R tunneled cath that got pulled.,0
"also coughing with water/pills and low grade fever and leukocytosis REASON FOR THIS EXAMINATION: please eval placement of tunnled cath and r/o infiltrate ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Low-grade fever, evaluation of placement of tunneled catheter, and rule out pneumonia.",0
"FINDINGS: As compared to the previous radiograph, the catheter shows unchanged position and course.",0
No newly appeared pneumothorax or pleural effusions.,0
"3:27 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: assess for Pulmonary embolism and assess for biliary leak s/ Admitting Diagnosis: PANCREATIC MASS/SDA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with met renal cell CA to pancreas, now s/p biliary bypass.",1
VSS REASON FOR THIS EXAMINATION: assess for Pulmonary embolism and assess for biliary leak s/p hepaticojejunostomy No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 77-year-old man with metastatic renal cancer to the pancreas now for biliary bypass.,1
Evaluate for pulmonary embolism and for biliary leak status post hepaticojejunostomy.,0
TECHNIQUE: Multidetector contiguous axial of the chest were obtained both prior to and following the administration of intravenous contrast.,0
Delayed images of the abdomen and pelvis were obtained.,0
"This is a redictation, as the original report has not been transcribed.",0
CT CHEST: There are no filling defects in the pulmonary arterial vasculature.,0
"Compared to the prior abdominal CT study of , there has been interval development of moderate right pleural effusions and is small left pleural effusion.",0
"Small-calcified granuloma is seen in the right upper lobe (3, 35).",0
"There is near total collapse of the right lower lobe, and a lesser degree of atelectasis of the left lower lobe.",0
There are sternal wires indicating prior CABG.,0
No enlarged axillary lymph nodes are seen.,0
"Small precarinal lymph nodes measure up to 7 mm in short axis diameter (3A, 40).",0
"Prevascular lymph nodes (3A, 45) measure up to 6 mm in short axis diameter.",0
"Right hilar lymph node measures 7 mm in short axis diameter (3A, 44).",0
The aorta is of normal caliber.,0
No aortic dissection or aneurysm is present.,0
"CT ABDOMEN: Small amount of fluid is seen surrounding the liver which indents the right lobe seen on 3B, image 114, which has developed in the interval .",0
"A subdiaphragmatic lymph node is seen on 3B, 108 measuring 6 mm in short axis diameter, increased from the prior study where it measured 2-3 mm in size.",0
"Patient is post hepaticojejunostomy, and there is no fluid seen surrounding the hepaticojejunostomy or in the lesser sac.",0
"However, a leak cannot be definitely excluded.",0
There is no free air seen in the abdomen.,0
There is no intrahepatic biliary ductal dilatation.,0
"Again seen within the pancreas the multiple (Over) 3:27 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: assess for Pulmonary embolism and assess for biliary leak s/ Admitting Diagnosis: PANCREATIC MASS/SDA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) masses, unchanged largest of which is in the pancreatic head (3B, 130).",0
Prominence of the pancreatic duct is unchanged.,0
"Next largest pancreatic mass is seen of the mid to distal body (3B, 119) also unchanged.",0
"Within the lower pole of the left kidney, there is a simple cyst, unchanged.",0
"Small foci of low attenuation in the left kidney are too small to characterize, small left aortic lymph nodes measure at 6 mm in short axis diameter.",0
The loops of small and large bowel are normal in appearance.,0
Calcifications are seen of the abdominal aorta extending into the common and internal iliac arteries bilaterally.,0
Mild dilatation of the infrarenal abdominal aorta is noted but its maximal dimensions are 2.7 x 2.6 cm in size.,0
"CT PELVIS: Suture lines are also seen in small bowel in the left lower abdomen 3B, 148.",0
There is a Foley catheter in the bladder.,0
There are prosthetic calcifications seen.,0
Small amount of free fluid is seen in the pelvis.,0
"Small fat containing left inguinal hernia is present, very small amount of fluid is seen tracking into a small right inguinal hernia as well.",0
"Interval development of moderate right pleural effusion and small left pleural effusion with bibasilar atelectasis, right greater than left.",0
Post-hepaticojejunostomy without fluid surrounding the immediate hepaticojejunostomy site.,0
No fluid in the lesser sac.,0
"However, a leak cannot be fully excluded.",0
No intrahepatic biliary ductal dilatation.,0
Findings were discussed with surgical team taking care of the patient on .,0
Small amount of ascites present.,0
"10:21 PM TRAUMA #3 (PORT CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: LINE AND TRACHEA ______________________________________________________________________________ FINAL REPORT AP CHEST, , AT 2220 HOURS.",0
HISTORY: Status post line placement.,0
"FINDINGS: As previously noted, the triple-lumen catheter again extends up into the neck.",0
Diffuse mild interstitial edema is evident.,0
"Otherwise, the study remains stable.",0
There is likely a left pleural effusion with associated atelectasis.,0
IMPRESSION: Heart failure with left pleural effusion.,0
Tracheostomy tube in standard position.,0
Central line from a right subclavian approach coursing cephalad as relayed to Dr. earlier this evening.,0
Height: (in) 74 Weight (lb): 198 BSA (m2): 2.17 m2 BP (mm Hg): 130/67 HR (bpm): 63 Status: Inpatient Date/Time: at 11:40 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
Overall left ventricular systolic function cannot be reliably assessed.,0
Overall left ventricular systolic function is difficult to assess but is probably low normal.,0
Left ventricular systolic function cannot be reliably assessed.,0
"7:24 AM PERC G/G-J TUBE PLMT Clip # Reason: PEG placement Admitting Diagnosis: WEAKNESS Contrast: OPTIRAY Amt: 40 ********************************* CPT Codes ******************************** * G TUBE PLACMENT, ALL INCL.",0
"CONVERT G TO GJ, ALL INCL.",0
"* * -51 MULTI-PROCEDURE SAME DAY * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with ALS needing, peg for calorie supplementation REASON FOR THIS EXAMINATION: PEG placement ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old female with ALS needing gastrostomy for calorie supplementation.",0
RADIOLOGISTS: The procedure was performed by Dr. and Dr. .,0
"Dr. , the attending radiologist, was present and supervised throughout the procedure.",0
PROCEDURE AND FINDINGS: The risks and benefits of the procedure were explained to the patient and written informed consent was obtained.,0
The patient was placed supine on the angiographic table and the abdomen was prepped and draped in the standard sterile fashion.,0
MAC anesthesia was administered throughout the procedure.,0
The stomach was insufflated through a nasogastric tube and no overlying bowel loops were identified.,0
An adequate position of percutaneous puncture was accessed and the skin was anesthetized with 1% local lidocaine.,0
"Under fluoroscopic guidance, a 19-gauge needle was advanced into the stomach.",0
"After gas/air was returned, a T-fastener was deployed and sutured to the skin.",0
Two additional T-fasteners were placed in similar fashion.,0
A final gastric puncture was then performed at the center of the T-fastener configuration after a skin incision had been made with a 11 blade and a 0.035 inch Amplatz wire was advanced and coiled in the stomach.,0
The needle was then exchanged for a 6 French vascular sheath.,0
"Using a combination of a 0.035 Glidewire and 5 French catheter, the pylorus was successfully navigated and the Glidewire and catheter were advanced under fluoroscopic guidance into the jejunum.",0
The tract was progressively dilated and a 14 French peel-away sheath was inserted.,0
"gastrojejunostomy catheter was then inserted into the jejunum under fluoroscopic guidance and position confirmed via injection of small amount of contrast, without evidence of extravasation.",0
A locking loop was formed in the duodenum.,0
The wire was removed and the gastrojejunostomy tube sutured to the skin and dressed.,0
IMPRESSION: Successful percutaneous gastrojejunostomy tube placement.,0
The tube is now ready for use.,0
(Over) 7:24 AM PERC G/G-J TUBE PLMT Clip # Reason: PEG placement Admitting Diagnosis: WEAKNESS Contrast: OPTIRAY Amt: 40 ______________________________________________________________________________ FINAL REPORT (Cont) PLAN: The T-fastener skin sutures (green-colored sutures) can be cut and released in days.,0
"5:18 PM UNILAT UP EXT VEINS US RIGHT Clip # Reason: please eval for arterial embolism to R hand, wrist, or forea Admitting Diagnosis: GASTROINTESTINAL BLEED;VALVE DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with a cool and edematous thenar eminence on R hand, please evaluate for venous and for arterial clot.",1
Please use doppler to eval for arterial embolism.,0
"REASON FOR THIS EXAMINATION: please eval for arterial embolism to R hand, wrist, or forearm using doppler, please also eval for venous clot of R upper extremity ______________________________________________________________________________ WET READ: MRGe SAT 6:50 PM No DVT.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Cold right hand.,0
"FINDINGS: Ultrasound evaluation of the right upper extremity deep venous system using grayscale, color, and pulse wave Doppler reveals the veins to be fully compressible with normal color flow, Doppler waveforms, and respiratory variation in flow.",0
No arterial evaluation was performed.,0
IMPRESSION: No evidence of DVT involving the right upper extremity.,0
4:13 PM BABYGRAM (CHEST ONLY) Clip # Reason: PICC LINE PLACEMENT Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 29 weeks gestation REASON FOR THIS EXAMINATION: PICC LINE PLACEMENT ______________________________________________________________________________ FINAL REPORT BABYGRAM: CLINICAL HISTORY: Infant born at 29 weeks gestation.,1
Status post PICC line repositioning.,0
"PORTABLE CHEST, 4:14p, : The study is compared with the examination obtained 1 hour earlier.",0
"Since the previous study, the PICC line, which was coiled in the subclavian vein/axilla, has been pulled back.",0
The tip now projects just over the left humeral head.,0
"Since the earlier study, however the endotracheal tube has advanced down the right main stem bronchus, and should be repositioned.",0
Umbilical venous catheter remains at the IVC/right atrial junction.,0
"Hazy opacity of the lungs, likely reflecting hyaline membrane disease, is unchanged.",0
IMPRESSION: 1) PICC line now pulled back into the upper left arm.,0
2) ET tube too low in the right main stem bronchus and should be repositioned.,0
PATIENT/TEST INFORMATION: Indication: Source of embolism.,0
BP (mm Hg): 100/60 HR (bpm): 104 Status: Inpatient Date/Time: at 14:44 Test: Portable TEE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Patient was intubated and on propofol drip per SICU attending.,0
LEFT ATRIUM: The left atrium is normal in size.,0
RIGHT VENTRICLE: Right ventricular chamber size and systolic function are normal.,0
GENERAL COMMENTS: A transesophageal echocardiogram was performed in the location listed above.,0
Local anesthesia was provided by lidocaine spray.,0
There were no TEE related complications.,0
Right ventricular chamber size and systolic function are normal.,0
No cardiac source of embolus seen.,0
: (in) 69 Weight (lb): 181 BSA (m2): 1.98 m2 BP (mm Hg): 85/54 HR (bpm): 109 Status: Inpatient Date/Time: at 16:36 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: pt on vent.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; mid inferior - hypo; basal inferolateral - akinetic; mid inferolateral - akinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,1
Abnormal systolic septal motion/position consistent with RV pressure overload.,1
MITRAL VALVE: Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,1
Conclusions: The atria are markedly dilated.,0
There is mild regional left ventricular systolic dysfunction with inferior and inferolateral akinesis.,1
The remaining segments contract normally (LVEF = 45%).,0
There is abnormal systolic septal motion/position consistent with right ventricular pressure overload.,1
Severe (4+) mitral regurgitation is seen.,1
There is at least mild pulmonary artery systolic hypertension (likely underestimated given severity of TR).,1
"IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.",0
At least mild pulmonary hypertension.,0
"Compared with the prior study (images reviewed) of , pulmonary pressures are not well assessed on the current study.",0
"12:03 PM CHEST (PA & LAT) Clip # Reason: ?pneumonia Admitting Diagnosis: DIABETES MELLITUS;HYPERTENSION ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with SCC of head and neck, rigors, bacteremic at dialysis REASON FOR THIS EXAMINATION: ?pneumonia ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest PA and lateral on .",0
COMPARISON: and PET/CT scan examination.,0
"HISTORY: 54-year-old man with squamous cell carcinoma of the head and neck with vigorous bacteremia dialysis, rule out pneumonia.",0
"FINDINGS: New diffuse infiltrates are seen in both right and left lung, more severe on the right side predominantly in the right upper and middle lobe.",0
The patient is status post CABG procedure with multiple well aligned sternotomy wires and surgical clips.,0
New bilateral pulmonary infiltrates worrisome for atypical pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: 52-year-old male with insulin-dependent diabetes mellitus, coronary artery disease, severe congestive heart failure, end stage renal disease on peritoneal dialysis, who presents on the advice of VNA nurse for ""gangrene in the toe.""",1
"The patient is otherwise without complaints, no shortness of breath, no chest pain, no pre-syncope, no fevers or chills, no abdominal pain.",0
"Positive cough with sputum production, no myalgias, odynophagia or constitutional symptoms.",0
The patient received one liter of normal saline bolus x 2 for SBP in 70s with appropriate increase to 90s.,0
Normal peritoneal dialysis on .,1
"The patient is well known to the Medicine service, with multiple admissions in the past, most recently for SBP for which he was discharged from the hospital one week prior with continued oral fluconazole and was to continue to be followed up by Dr. .",0
Now the patient comes for evaluation of removal of the peritoneal dialysis catheter.,1
End stage renal disease on peritoneal dialysis 3.,1
Coronary artery disease status post myocardial infarction in 5/00 4.,0
Peripheral vascular disease status post right below the knee amputation 7.,1
"Right ocular prosthesis MEDICATIONS: Aspirin 81 mg by mouth once daily, Nephrocaps one once daily, Zestril 30 mg by mouth once daily, atenolol 25 mg by mouth once daily, Reglan 10 mg by mouth four times a day, Coumadin 2 mg by mouth daily at bedtime, Colace 100 mg by mouth twice a day, insulin 70/30 7 units every morning and 3 units every evening, Fluconazole 400 mg by mouth once daily.",0
"PHYSICAL EXAMINATION: Vital signs: Pulse 68, blood pressure 95/60, respiratory rate 16, 96% on 2 liters nasal cannula.",0
"General: Elderly male, in mild distress.",0
"Head, eyes, ears, nose and throat: Right orbit empty, left eye sclera clear, not injected, no lymph nodes, oropharynx dry, no jugular venous distention.",0
"Pulmonary: Decreased breath sounds bilaterally, left greater than right, no wheezes, rhonchi or rales, question possible dullness to percussion one-third of the way up the left side.",0
"Cardiovascular: Respiratory rate, without any murmurs, gallops or rubs, normal S1 and S2.",0
"Abdomen: Soft, nontender, nondistended, normal active bowel sounds, no rebound or guarding noted.",0
"Extremities: Chronic venous stasis changes noted to the left lower extremity, no open ulcers or lesions, no tenderness.",1
"Left third toe black, small necrotic-appearing ulcer, no scars or symptoms noted, no inflammation.",0
Positive distal pulse by Doppler.,0
Right below the knee amputation noted.,0
"LABORATORY DATA: White blood cells 8.2, 72% neutrophils, no bands, 19% lymphocytes.",0
"Sodium 134, potassium 3.5, chloride 93, CO2 28, BUN 37, creatinine 7.2, glucose 325.",0
"Chest x-ray: Atelectasis vs. scarring at the right base, new area of infiltrate with air bronchogram to the left base.",0
"Electrocardiogram showed normal sinus rhythm at 66, axis was normal.",0
"There were no acute ST/T wave changes, T waves in V1 and V4 consistent with prior electrocardiogram of .",0
"HOSPITAL COURSE: Mr. was admitted to , firm, for ongoing treatment and workup of fungal peritonitis and left third toe gangrenous ulcer.",0
"Infectious Disease: The patient was felt to have continued fungal peritonitis, as during his previous hospital stay.",0
He was continued on oral fluconazole 400 mg by mouth once daily in the first three hospital days.,0
"In discussion with the Infectious Disease team, it was felt he would benefit from change in the anti-fungal regimen, so he was switched to amphotericin intravenously.",0
"After a test dose, he was given amphotericin B 33 mg intravenously once daily with premedication with Demerol and hydrocortisone for seven days.",0
This was continued after his peritoneal dialysis catheter was removed.,1
He tolerated the amphotericin B well.,0
"He continued afebrile throughout the entire hospital course, however, on hospital day four, he was noted to have an elevated white count without a local source of infection.",0
His white count was followed and dropped over the course of subsequent days to 13.5 at the time of this dictation.,0
Access: The patient continued to have an infected peritoneal dialysis catheter at the time of hospital admission.,1
"On hospital day three, this peritoneal dialysis catheter was removed without complications.",1
He remained without dialysis access for several days.,0
"Finally, on hospital day six, the patient had a right femoral tunneled catheter placed after multiple attempts in surgery and interventional radiology to place the tunneled hemodialysis catheter in his subclavian/axillary/internal jugular veins.",1
"It was felt that these sites were all very poor access sites, and the only alternative at that time was felt to be a tunneled femoral hemodialysis catheter, although this is not felt to be ideal and is only a temporary bridge until we can replace the peritoneal dialysis catheter.",1
Vascular: Mr. was evaluated by the Vascular team on hospital day two for left second toe gangrenous ulcer.,1
"He was noted to have arterial insufficiency of the left leg evidenced by skin changes, nonpalpable pulses, however, his third toe was not felt to be gangrenous and no vascular intervention is indicated at this point.",0
"During the rest of his hospital stay, he was without complaint of his left second toe, and no further progression of his mild ulcer.",0
"If desired, Mr. can follow up with Dr. of the vascular team as an outpatient for possible treatment options.",0
Psychiatric: Mr. was followed by the inpatient psychiatric team for issues of competence and agitation on the hospital floor.,0
"Numerous times during the hospital course, Mr. was seen by the psychiatric team and was felt to be competent, fully aware of his decisions and repercussions.",0
"On hospital day eight, during hemodialysis, Mr. became acute agitated and was sedated during hemodialysis, which caused the hemodialysis session to be terminated early.",0
"He was given Ativan with good response, an calmed down appropriately.",0
He will be pre-mediated for future hemodialysis sessions with Ativan.,0
Hematology: Mr. had a baseline hematocrit of approximately 30 on admission.,0
"This was consistent with his previous hematocrits, and notable low secondary to his end stage renal disease.",1
"He received Epogen, however, this was not continued during the first part of this hospitalization.",0
"By hospital day six, he was noted to have a hematocrit of approximately 26, and was given Epogen after hemodialysis, and he was followed thereafter with appropriate increases in hematocrit.",0
"Further discharge diagnoses, status and discharge medications will be addended at a later time, at the time of hospital discharge.",0
Dictated By: MEDQUIST36 D: 02:58 T: 03:58 JOB#:,0
4:44 AM CHEST (PORTABLE AP) Clip # Reason: fever.,0
"Admitting Diagnosis: TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: year old woman with head bleed, s/p reintubation for respiratory failure s/p trach placement REASON FOR THIS EXAMINATION: fever.",0
______________________________________________________________________________ FINAL REPORT PORTABLE SUPINE CHEST X-RAY AT 5 A.M.: INDICATION: Query pneumonia.,0
FINDINGS: Comparison is made with the prior examination from three days earlier.,0
"There remains extensive scarring within both upper lobes, as well as post surgical changes in the left upper hemithorax, with associated pleural thickening and calcifications.",0
"The opacity at the right apex is perhaps slightly increased when compared with the prior examination, as well as mild apparent increased opacity of the right lung base, though the affect of differences in positioning between the two examinations is not known.",0
"Mild blunting of the right costophrenic angle is noted, suggesting effusion and/or pleural thickening.",0
"Coarse linear markings are seen at both lung bases, suggesting fibrosis.",0
"The left internal jugular line has been removed, and there is no evidence of pneumothorax.",0
Tracheostomy tube is in place as before.,0
IMPRESSION: 1) Apparent slight increase in opacification of the right apex and right base.,0
"2) Chronic fibrosis in the upper lobes, suggestive of prior granulomatous disease.",0
6:17 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: FALL ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with R traumatic flail chest / ptx REASON FOR THIS EXAMINATION: ?,1
"interval change ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Flail chest, pneumothorax, evaluate for change.",1
A small right pneumothorax persists.,1
Hazy density at the right base consistent with pleural fluid has increased.,0
There is additional streaky density in the lower right lung consistent with subsegmental atelectasis are also increased.,0
Right rib fractures and subcutaneous emphysema on the right are again demonstrated.,0
Interval increase in right pleural fluid and subsegmental atelectasis.,0
"10:54 AM CYSTOGRAM (, ) Clip # Reason: ?",0
leak Contrast: CYSTO CONRAY II Amt: 250 ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with bladder cancer s/p neobladder creation.,0
"Please perform cystogram by filling to gravity (i.e, allow the contrast to be poured in slowly until filling stops).",0
Please assess for leak and please check post-emptying film.,0
Do not remove catheter after study please.,0
Please perform before noon if poosible.,0
"leak ______________________________________________________________________________ FINAL REPORT INDICATION: Status post bladder resection, now with neobladder creation.",0
Rule out leak and please assess post-emptying film.,0
"CYSTOGRAM: Scout radiograph demonstrates multiple loops of distended bowel which are not completely evaluated on this study, however, are consistent with ileus.",0
250 cc of Cysto-Conray was infusede by gravity through the existing Foley catheter.,0
The neobladder distends somewhat longitudinally without evidence of leak.,0
The patient was able to void 200 cc of contrast at the end of the study.,0
This leaves a post-void residual volume of approximately 50 cc.,0
"IMPRESSION: Status post neobladder, no evidence of leak, post-void residual of 50 cc.",0
PATIENT/TEST INFORMATION: Indication: Dilated cardiomyopathy.,0
Height: (in) 70 Weight (lb): 176 BSA (m2): 1.98 m2 BP (mm Hg): 90/60 HR (bpm): 82 Status: Inpatient Date/Time: at 15:03 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: dyssynchrony added on .,0
TSI demonstrates significant LV dyssynchrony with significant septal wall contraction delay (vs. lateral wall).,0
Mild (1+) MR. TRICUSPID VALVE: No TR.,0
Conclusions: 1.The left atrium is mildly dilated.,0
There is severe global left ventricular hypokinesis with relative sparing of the basal lateral and inferolateral walls.,0
There is marked dyssynchrony (130 ms) seen with septal delay.,0
6.The estimated pulmonary artery systolic pressure is normal.,0
Height: (in) 70 Weight (lb): 200 BSA (m2): 2.09 m2 BP (mm Hg): 110/62 HR (bpm): 56 Status: Inpatient Date/Time: at 00:03 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
"Mild (1+) MR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded.",0
Overall left ventricular systolic function is normal (LVEF=55%).,0
Compared with the prior study (images reviewed) of no definite regional dysfunction is seen.,0
"If clinically indicated, a full study by laboratory personnel is suggested to assess the severity of aortic valve stenosis.",1
12:16 PM CHEST (PORTABLE AP) Clip # Reason: r/o ptx s/p ct's removed Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p cabg REASON FOR THIS EXAMINATION: r/o ptx s/p ct's removed ______________________________________________________________________________ FINAL REPORT AP CHEST 12:21: HISTORY: Status post CABG.,1
IMPRESSION: AP chest compared to at 1:30 p.m.,0
"There is a small region of atelectasis marking the previous position of the left pleural tube, since removed.",0
"Mild widening of the postoperative cardiomediastinal silhouette is exaggerated by low lung volumes, but probably stable.",0
Small pericardial effusion may be present.,0
Right jugular sheath ends at the thoracic inlet projecting over the junction of the brachiocephalic veins.,0
LINE PLACEMENT Clip # Reason: postop film-contact NP # if abnormal- will be Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p cabg REASON FOR THIS EXAMINATION: postop film-contact NP # if abnormal- will be in CVICu approx 4:30 PM -please call first ______________________________________________________________________________ WET READ: MBue MON 7:18 PM Rt CVC terminating in mid SVC.,1
median sternotomy wires intact.NGT term in stomach.,0
minimal retrocardiac opacity likely representing atelectasis.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Postoperative film.,0
COMPARISON: Preoperative images from .,0
FINDINGS: The endotracheal tube projects 6 cm above the carina with its tip.,0
"Status post CABG, median sternotomy wires in correct alignment.",0
"Correct position of nasogastric tube, mediastinal and pleural drains.",0
"No overhydration, small retrocardiac atelectasis, no safe evidence of a large pneumothorax.",0
", B. VSURG CSRU 2:41 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: confirm ETT position Admitting Diagnosis: RUPTURED AAA ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man s/p sigmoid colectomy, now intubated, decreased L breath sounds REASON FOR THIS EXAMINATION: confirm ETT position ______________________________________________________________________________ PFI REPORT PFI: ET tube 5.5 cm from the carina.",0
", M. NSURG SICU-A 7:57 PM CT HEAD W/O CONTRAST Clip # Reason: Elevated ICP, please eval for interval change Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with L ICA aneurysm s/p coiling REASON FOR THIS EXAMINATION: Elevated ICP, please eval for interval change No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",1
Interval decrease in size of lateral ventricles.,0
"Further progression of bifrontal inferior hypodensities, which may represent contusions or infarct.",0
Additional hypodensity more apparent in the inferior left temporal lobe.,0
Stable extent of subarachnoid and ventricular hemorrhage.,1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Metastatic adenocarcinoma of colon to liver Major Surgical or Invasive Procedure: Extended left hepatic lobectomy, segment mass resection, segment 6, mass resection x2.",1
Tru Cut bx of the right lobe of the liver.,0
Small bowel resection with primary anastomosis.,0
"wound vac Intubation Swan-ganz catheter History of Present Illness: The patient is a 58-year-old female who underwent a right hemicolectomy, ileal transverse colostomy and cholecystectomy on for an invasive, moderately differentiated adenocarcinoma of the cecum with invasion into the wall and into the pericolonic adipose tissue.",1
"Incidentally, metastatic tumor was present in 7 out of 10 regional lymph nodes.",0
"She was evaluated in , demonstrating 7 lesions in the liver consistent with metastatic adenocarcinoma of the colon.",1
Five were confined to the left lobe including the left lateral segment and medial segment.,0
"However, she also had a lesion in the inferior aspect of segment 6 in the right lobe and a deep lesion at the junction of segment 6 and 7.",0
A CT done at on demonstrated multiple rim enhancing low attenuation lesions throughout the liver consistent with a history of metastatic colon cancer.,1
She also had a large amount of low attenuation ascites in the abdomen and stranding was thought to represent peritoneal involvement with tumor.,1
Over the past year she has been treated with chemotherapy and has had follow-up CT scans that have shown resolution of the peritoneal findings and ascites along with significant shrinkage of the liver masses.,1
Follow up CT scan showing resectability of lesions.,0
She is admitted on this admission for elective hepatic resections.,0
"Past Medical History: Elevated cholesterol, colon cancer, R hemicolectomy, ileotransverse colostomy, and cholecystectomy (), craniotomy in for an aneurysm.",1
Two C-sections Social History: Lives with spouse.,0
"Family History: Non-contributory Physical Exam: Tmax 98 Temp 97.6 HR 81 BP ranges 90-140/57-66 RR 19 SaO2 98% General: NADS, Alert and awake Skin: Normal HEENT: no scleral icterus Oropharynx: multiple whittish plaques on tongue, buccal mucosa and palate Neck: No lymphadenopathy or thyromegaly Carotids: 2+/4+ without bruits Lungs: clear to auscultation and percussion Cardio: S1,S2, no S3, S4, murmurs or rubs, RRR Abdomen: normal bowel sounds, mildly distended, no hepatosplenomegaly, masses or tenderness, incision are well-healed, no ascites Extremities: No peripheral edema Neuro: grossly intact, no focal deficits.",1
"Peritoneal fibrous adhesions, with focal fibrosis extending into the muscularis propria.",1
Additional small bowel nodules (B): 1.,0
Peritoneal fibrous and fibrinous adhesions.,1
"Liver, needle biopsy (C): 1.",0
Minimal inflammation and mild steatosis.,0
"No tumor, necrosis or fibrosis.",0
"Liver, left lobe, resection (D-I): 1.",0
"Metastatic adenocarcinoma with necrosis, consistent with colonic origin.",0
There is no tumor at the resection margin.,0
"V. Liver, segment 4/segment 5, resection (J): Metastatic adenocarcinoma with extensive necrosis, present at tissue edge.",1
"Liver, segment 6 tumor, resection (K-M): Metastatic adenocarcinoma with necrosis, not present at resection margin.",1
"Liver, segment 6, resection (N-O): Metastatic adenocarcinoma with necrosis; not present at resection margin.",1
"Liver, segment 6, re-resection (P-Q): Small foci of metastatic adenocarcinoma, not present at resection margin.",0
"Liver, segment , resection (R-S): Metastatic adenocarcinoma with necrosis, not present at resection margin.",1
"Small bowel, resection (T-V): 1.",0
Small intestine with focal acute peritonitis and unremarkable mucosa.,1
Three lymph nodes: No tumor (0/3).,0
Colon segment with peritoneal fibrous adhesions and focal acute peritonitis.,1
"Patent hepatic vasculature with appropriate waveforms in all remaining vessels including portal venous, hepatic venous and arterial systems.",0
"2.6 cm hyperechoic lesion located anteriorly and inferiorly in the right lobe, most likely representing postsurgical change Liver US: IMPRESSION: 1.",1
No biliary dilatation and no intrahepatic fluid collection identified.,0
Scant trace of ascites in the perihepatic space.,0
Patent and appropriate hepatic vasculature.,0
Subcutaneous fluid in the right upper extremity as detailed above.,0
-intestinal tube Positioned post-pyloric CT abdomen IMPRESSION: 1.,0
Interval development of more focal left upper lobe and probable right middle lobe pneumonia.,0
Decrease in bilateral pleural effusions as described above.,0
No organized intra-abdominal fluid collections identified.,0
Can not exclude component of carcinomatosis.,0
Hyperdense collections along multiple surgical resection beds likely represent resolving postoperative hematoma and indwelling surgical glue and Surgicel.,1
New left groin hematoma as above.,0
Interval development of a small bowel containing ventral hernia at the midline without signs of strangulation.,0
This is consistent with underlying dehiscence of the abdominal wall musculature/fascia of approximately 6.5cm Echo The left atrium is mildly dilated.,0
The estimated cardiac index is high (>4.0L/min/m2).,0
"CXR The position of the Dobbhoff tube, Port-A-Cath and the PICC line as well as abdominal drains is unchanged.",0
Widening of left upper mediastinum again can be seen with no significant change since the prior study and actually is due to a left upper lobe consolidation adjacent to the mediastinum.,0
There is no interval change in left basal atelectasis and right basal plate-like areas of atelectasis.,0
Liver US No evidence of a portal vein thrombosis.,1
"CXR Findings: There has been no interval change in the position of Port Cath, PICC line, endotracheal tube, NG tube, the drainage tube of the right upper quadrant.",0
There has been interval improvement in aeration of the left upper lobe.,0
The left retrocardiac consolidation is unchanged.,0
There has been interval clearing of the right upper lobe opacity.,0
New middle lobe density has developed.,0
1:33 pm SWAB Source: Abd wound.,0
**FINAL REPORT ** GRAM STAIN (Final ): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
"WOUND CULTURE (Final ): STAPHYLOCOCCUS, COAGULASE NEGATIVE.",0
10:15 pm STOOL CONSISTENCY: LOOSE Source: Stool.,0
**FINAL REPORT ** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ): REPORTED BY PHONE TO @ 6:00A .,1
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.,0
A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse).,0
10:16 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal.,0
7:18 am SPUTUM Source: Endotracheal.,0
5:52 pm URINE Source: Catheter.,0
"10,000-100,000 ORGANISMS/ML.. 4:49 pm BRONCHIAL WASHINGS GRAM STAIN (Final ): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.",0
RESPIRATORY CULTURE (Final ): ~1000/ML OROPHARYNGEAL FLORA.,0
"Brief Hospital Course: Patient was admitted to Dr. general surgery service and taken to the operating room on for a left hepatic lobectomy, segment mass resection, segment 6, mass resection x2, extensive lysis of adhesions, biopsy of the right lobe of the liver, and small bowel resection with primary anastomosis.",1
"She received 6000ml of crystalloid, 10 units FFP, 10 units pRBC, 1 unit of platelets intraoperatively.",0
She was kept intubated and transferred to the intensive care unit in stable condition for further monitoring.,0
Patient did require pressors and fluid for hypotension and oliguria overnight.,1
NG placed for gastric decompression.,0
Placed on insulin sliding scale for blood sugar control.,0
"On - , she was weaned off pressor support.",0
Succesfully extubated; encouraged use of incentive spirometry.,0
Still required mulitple fluid supplementation for oliguria.,0
LFT and electrolytes were checked and monitored daily.,0
Urine output only marginal throughout.,0
"Eventually, advanced to a clear diet with fluid for continued oliguria.",0
Ultrasound for right arm swelling and returned normal without any clots.,0
She was transferred to the general surgical floor on .,0
Pain controlled with IV morphine.,0
Received fluid bolus x 2 for marginal urine output.,0
Urine electrolytes analysis indicate FeNA < 1%.,0
"Developed sudden onset shortness of breath, SaO2 of 70%, requiring oxygen, tachypnea with concurrent diaphoresis.",0
This seemed to occur as she was receiving one liter bolus for oliguria.,0
"She was transferred to ICU, given lasix for diuresis.",0
CT angiogram negative for any PE.,0
"With prolonged NPO state, TPN initiated and nutrition consulted.",0
"She was kept on face tent of 50%; however, saturations did not improve with increased work of breathing.",0
Pt was then intubated for resp distress.,0
Started on Vanco/Flagyl/Zosyn for empiric coverage given elevated wbc (29); C.Diff sent with sudden development diarrhea; CT abd repeated; A-line and CVL placed; and Vigileo started.,0
ET found to be down right mainstem bronchus and had to be repositioned.,0
Placed on maximum volume of pressor support for hypotension.,1
On she received lasix with FFP to help with diuresis and improving respiratory status.,0
2u pRBC transfused to maintain intravascular volume.,0
She was pan-cultured for fever 101 as well.,0
"Noticed erythema around incisional site, requiring multiple dressing changes for leakage.",0
"C.diff returned positive, kept on IV flagyl.",0
Albumin infused intermittently for intravascular repletion.,0
Her pressors and vent settings were slowly weaned.,0
"Bilateral lower extremity ultrasound was negative for DVT, albumin started, vasopressin started.",0
"On , she received another two units pRBC on .",0
HIT panel sent concerning for low platelets returned negative.,0
Patient was weaned off all pressors and weaned to CPAP with pressure support.,0
Plan to continue with diuresis.,0
"Dobhoff placed to begin tubefeeds, picc line placed, zosyn was discontinued.",0
Her bilirubin continues to elevate daily at 13.8.,0
"With continued high stool output, she was changed to a PO vancomycin.",0
Patient succesffully diuresed with decreased vent settings.,0
"On , patient was extubated.",0
A rash noted over patient's left flank.,0
ID consulted for concerns of resistant cellulitus.,0
Dermatology also consulted for opinion of possible drug reaction.,0
Started on meropenem for better G- coverage for presumed cellulitis in addition to vancomycin.,0
TPN discontinued after meeting TF goal.,0
"With high drain output from abdomen, CT ordered, revealing wound dehiscence and bilateral pneumonia.",1
"She remained briefly hypotensive (SBP 80s), received albumin x 1 w/ good response, UOP remained stable.",0
Continues to have waxing and mental status.,0
Dermatology agreed with diagnosis of cellulitus.,0
"Hct slowly trending down, oliguria responsive to fluid boluses.",0
LFT continued to be elevated.,0
"Jaundice still objectively evident - colored stools, scleral icterus.",0
She continues to have oliguria with hypotension.,0
Attempted to continue intravascular protein repletion with albumin.,0
Pain medication held to improve mental status.,0
"On , patient repleted with IV hydration and albumin due to excessive drainage from wound vac.",1
She continues to have oliguira.,0
Vancomycin dosing held and adjusted based on trough levels.,0
CXR showing increased left lobe consolidation.,0
"Aztreonam started for G- coverage, meropenem stopped for questionable etiology of rash.",0
"TTE to assess cardiac function, which showed normal EF with hyperdynamic state.",0
She required boluses/albumin for prerenal (FENA 0.2).,0
"Patient desaturated overnight with bradycardia episodes to 30 and hypotension, responded with atropine.",1
"From - , patient continued to have worsening renal function with oliguria.",0
Responding to intermittent fluid boluses.,0
Treated with hepatorenal protocol with albumin infusion.,0
Liver enzymes continue to be elevated.,0
"With worsening respiratory status, increasing work of breathing, requiring intubation to support airway.",0
"Patient received bronchoscopy, which revealed no major mucus plugging.",0
Swan-ganz was attempted to assess and monitor patient's overall state given state of multi-organ failure.,1
"However, with thrombosed arteries to upper extremity, plan was aborted after several failed attempts.",0
TEE performed instead ruling out hypovolemic or cardiogenic shock.,0
"Given multi-organ failure (liver, renal, pulmonary distress) and prognosis, family's decision was to discontinue all intervention on .",1
Social work involved throughout hospitalization to help with coping.,0
Patient started on a morphine drip for comfort measures.,0
"Tube feeds, antibiotics and all other medications were discontinued.",0
DNR signed after clarification with family and attendings.,0
"Medications on Admission: citalopram 20mg PO daily cyanocobalamin 1000mcg/ml sq monthly warfarin 2.5mg PO daily Iron loperamide MVI Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Sepsis Hepatorenal syndrome -ARF (ATN) and liver failure Respiratory distress Rash of unclear etiology failure metastatic carcinoma of colon to liver Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None MD,",1
8:44 AM BABYGRAM (ABD ANY SGL VIEW) () Clip # Reason: evaluate bowel gas pattern ______________________________________________________________________________ MEDICAL CONDITION: Infant with bloody stool REASON FOR THIS EXAMINATION: evaluate bowel gas pattern ______________________________________________________________________________ FINAL REPORT PLAIN FILM OF THE ABDOMEN: CLINICAL HISTORY: Infant with bloody stool.,0
Comparison is made to a prior study from .,0
There is some increased irregularity to the bowel gas pattern compared to the prior study.,0
Continued follow-up is recommended to completely exclude NEC.,0
No definite pneumatosis is seen.,0
There is no evidence of free intraperitoneal air.,0
The end of the nasogastric tube is visualized in the stomach.,0
IMPRESSION: Slight irregularity to bowel gas pattern.,0
Follow-up is recommended to exclude NEC.,0
9:57 PM BILAT LOWER EXT VEINS Clip # Reason: EVAL FOR DVT FEVER Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman post up fever REASON FOR THIS EXAMINATION: please evaluate for DVT ______________________________________________________________________________ PFI REPORT No DVT either lower extremity.,0
"10:11 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # Reason: evaluate lung fields, uac/uvc placements Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Premature infant with UVC, UAC.",0
"on HFOV please to 2 views AP/lateral REASON FOR THIS EXAMINATION: evaluate lung fields, uac/uvc placements ______________________________________________________________________________ FINAL REPORT AP CHEST AND ABDOMEN ON .",0
Endotracheal tube is at the T2 level above the carina.,0
Umbilical arterial catheter has its tip at T5 level.,0
Umbilical venous catheter has its tip in mid right atrium.,0
There continues to be right upper lobe atelectasis.,0
"There are some patchy perihilar density, as before.",0
No new abnormalities as compared to film taken an hour previously.,0
"Admission Date: Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Ancef Attending: Chief Complaint: Tx from OSH for further management Major Surgical or Invasive Procedure: Interventional Pulmonary adjust/resize of trach Interventional Radiology: Placement of post-pyloric feeding tube History of Present Illness: HPI: This is a 76 YO M initially presented to OSH on with bilateral cellulitis, lower extremity edema on was noted to have respiratory distress failing his routine nightly bipap for OSA.",1
At that pt was transferred to CCU for monitoring.,0
His OSH was as follows - Cellulitis - was treated with unasyn for 11 days then discontinued on .,0
A LENI on was negative for DVT.,0
"- Cardiac- His CCU stay was complicated by VT with a code called, which required dopamine pressure.",0
"In addition a NSTEMI (peak trop 7.67 on ) occurred treated with aspirin, plavix, and coreg.",0
Apparently heparin was held to bleeding from the tracheostomy.,0
Then the beta blocker was held secondary to bradycarida.,0
"- Respiratory - On transfer to the CCU a ""possibly elective tracheostomy at this point"" which was performed on .",1
He was started on CPAP trach mask trials.,0
He was felt to be fluid overloaded and diuresed.,0
"A left sided pleural effusion developed and a thoracentesis was performed on , and he was started on cefazolin.",0
Sputum cxs grew out proteus with multiple sensitivies.,0
A lyme cx taken was negative.,0
"- On presentation- the pt is comfortable denies pain, sob, states his (myasthenia ) MG is longstanding causing difficulty with walking/ and breathing at certain pts.",1
ECHO IMPRESSIOn: Poor echo windows.,0
If clinically indicated a repeat study with echo contrast (Definity) may better characterize LVEF.,0
Chest Portable IMPRESSION: Increased layering of left pleural fluid - positional differences could explain.,0
-INTESTINAL TUBE PLACEMENT (W/FLUORO) IMPRESSION: Successful placement of post-pyloric tube in the third portion of the duodenum.,0
"04:05AM BLOOD WBC-8.7 RBC-3.22* Hgb-9.6* Hct-28.7* MCV-89 MCH-29.9 MCHC-33.5 RDW-16.6* Plt Ct-292 03:23AM BLOOD Neuts-73.7* Lymphs-14.9* Monos-5.3 Eos-5.7* Baso-0.4 04:05AM BLOOD PT-15.1* PTT-27.1 INR(PT)-1.4* 04:05AM BLOOD Glucose-90 UreaN-32* Creat-1.0 Na-144 K-4.5 Cl-107 HCO3-28 AnGap-14 04:05AM BLOOD ALT-18 AST-27 AlkPhos-86 TotBili-0.9 04:05AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2 05:01PM BLOOD Type-ART FiO2-50 pO2-102 pCO2-58* pH-7.33* calTCO2-32* Base XS-2 Brief Hospital Course: 76 yo male with pmhx significant for morbid obesity, OSA, trach'd p/w cellulitis with course complicated by NSTEMI.",0
"Cellulitis- At outside hospital was started on unasyn, then transitioned to ancef but developed an abx rash, and was changed to vancomycin by arrival to .",0
"He was noted to have bilateral cellulitis with increased lower extremity swelling and was to finished a 14 day antibiotic course, and monitor for resolving infection.",1
"He otherwise was treated symptomatically with aquaphor ointment, and did not spike a fever during his hospital course.",0
He has residual b/l LE erythema that has been stable with no other signs of infection.,0
"HYPOXIA- The patient arrived with a tracheostomy from an OSH, on AC ventilation, when a trach mask trial was attempted, he developed increasing tachypnea, anxiety, and chest pain, which was not cardiac in nature.",1
"With a history of MG a NIF was performed which demonstrated low values, but his limited ability for successful trach mask trial, was likely multifactorial, a sputum culture grew swarming proteus and he was started 8 day course of levaquin, he was to have daily NIFs as there are rare exacerbations of MG with levaquin, he remained stable.",1
"He otherwise was maintained on duonebs, and fluticasone was added.",0
"In addition fluid overload was another potential component of his inability to be weaned from the vent, and he was actively diuresed with 40mg lasix , but his creatinine became elevated to 2.2 from 1.1 baseline likely secondary to overdiuresis as his fena suggestsed a prerenal acute renal failure.",1
He was administered fluid boluses to maintain urine output.,0
Otherwise IP was consulted for a tracheostomy adjustment and felt he was maintaining appropriate oxygenation and ventilation and adjustments were not required.,0
"He tolerated weaning to pressure support with MMV at times but during his hospital course developed additional hypoxia associated with a RLL infiltrate, he was continued on levaquin started for a proteus positive sputum culture.",0
"A bronchoscopy was performed which did not reveal gross abnormalities, 2 BALs were taken and grew 3+GNRs, speciated as stenotrophomonas.",0
For the remainder of his course the patient remained stable.,0
Based on daily assessment he was placed on trach mask trials or pressure support as tolerated.,0
"He tolerated up to 8 hours of 50% trach mask, but became anxious and tachypneic and was restarted on CPAP 8/5 with 40 % FiO2.",0
At he was satting 94-97 % on CPAP 8/5 and 40 % FiO2.,0
"CV -He was transferred from the outside hospital after having an NSTEMI, not tolerating heparin secondary to bleeding from the tracheostomy site.",0
"He was transferred on a betablocker, aspirin, plavix.",0
"His lipid profile was checked while inpatient, and hot found to be elevated.",0
"He otherwise had an echocardiagram which demonstrated elevated PA pressures of 29, otherwise a suboptimal study without EF calculation, also an moderately dilated aortic root, which was not seen on previous outside hospital echos, he was to follow up as an outpatient for management of his dilatation.",0
He was strted on lisinopril 5 mg PO QD 2 days prior to which he tolerated well.,0
NSTEMI- He had an episode of supraventricular tachycardia self limiting without associated hypotension.,0
"An EKG at that time demonstrated lateral lead ST depressions, with an associated 1mm ST elevation in V1.",0
"Cardiac enzymes were cycled and noted to be elevated, likely secondary to demand ischemia.",0
"He was started on heparin, a betablocker, aspirin, plavix, and a statin were administered.",0
Cardiology was consulted and recommended continuing medical management.,0
The patient will need to be on plavix for 9-12 months and should follow up with a cardiologist as an outpatient.,0
DM- The patient's sugars were well controlled on a RISS .,0
"HTN- Initially admitted with lopressor, which was held after noting irregularity on ekg, his pressures remained in good range off lopressor.",0
His lopressor was restarted and was titrated up to 37.5 mg with HRs on 50s-60s.,0
Additionally and ACE-I was added once his creatinine stabilized and his pressures were stable in 120s-130s.,0
"Anemia- Normocytic, likely secondary to chronic disease, iron/folate/b12 studies were suggestive of chronic disease, tranfused to a HCT>30 after determination of his NSTEMI.",1
HCT was stable at .,0
"MG- Stable continued on mestinon, neoral.",0
"Discussed with outpatient neurologist, maintained on outpatient regimen, monitored CSA levels for toxicity.",0
"He had decreased mental status during his hospital course, and neurology was consulted for evaluation of exacerbation.",1
Neurology did not feel that his MG was contributing to his delta MS as much as perhaps ICU delirium.,0
He was continued on his outpatient regimen.,0
HE will need to establish care with a new neurologist.,0
"Anxiety- Maintained on zoloft, and ativan prn .",0
"FEN: A post pyloric tube was placed by IR for feeding, but it was d/c'd accident;y x2.",0
"AT the patient was tolerating softs solids, and therefore the tube was not replaced.",0
"PPX: heparin SC, lansoprazole, bowel regimen .",0
"Access: PICC placed at OSH on , cxr confirming placement.",0
A postpyloric feeding tube was placed by fluoroscopy.,0
"Contact: daughter + HCP (H) (C), (office) .",0
PCP Neurologist Upender (left practice) Medications on Admission: lopressor 25mg free h20 150cc q8h ancef 2gm q8h (D6/10) (although DC summary states vanco) benaprotein 2pkt zoloft 25mg qd alb/atrovent q4hr lotrimin cream to groin ASA 325 qd aquaphor ointment ble plavix 75mg qd prevacid 30mg qd mvi 15cc ft qd vit c 500mg zinc sulfate 220mg qd neoral 75mg mestinon 180mg tid insulin protocol lasix gtt 20mg/hr lovenox 40 sc qd lidocain patch qd dilaudid 1mg iv q3h prn Medications: 1.,1
Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Clotrimazole 1 % Cream Sig: One (1) Appl Topical (2 times a day).,0
Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed.,0
Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Pyridostigmine Bromide 60 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours).,0
Insulin Regular Human 100 unit/mL Solution Sig: Three (3) Injection ASDIR (AS DIRECTED): Sliding Scale Per Protocol.,0
"Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily).",0
Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety.,0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-12 Puffs Inhalation QID (4 times a day).,0
Cyclosporine Modified 100 mg/mL Solution Sig: Seventy Five (75) mg PO Q12H (every 12 hours).,0
Hydromorphone 0.5-2 mg IV Q3-4H:PRN 19.,0
Lorazepam 0.5-1 mg IV HS:PRN Hold for RR <12 22.,0
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed.,0
Disposition: Extended Care Facility: Northeast - Diagnosis: Primary Diagnosis 1.,0
"Secondary Diagnosis Ttpe 2 diabetes HTN obesity Myasthenia RHF Condition: Hemodynamically stable, HRs 50- 60s, satting 94-97 % on CPAP 8/5 40 % FiO2.",1
Instructions: You are being discharged to another care facility where they can take care of your respiratory care.,1
Information about your hospital stay has been communicated to the physician assuming responsibility for your care.,0
Followup Instructions: You should follow up with your primary doctor from rehab.,0
4:13 PM URIN CATH CHECK Clip # Reason: please do pull back nephrostogram.,0
"Please call Dr. w Admitting Diagnosis: URETERAL STRICTURE/SDA Contrast: OMNIPAQUE Amt: 60 ********************************* CPT Codes ******************************** * CHG NEPHROTOMY/PYLOSTOMY TUBE INJ NEPHROSTOMY/PYLOSTOMY * * -51 MULTI-PROCEDURE SAME DAY CHANGE PERC TUBE OR CATH W/CON * * ANTEGRADE UROGRAPHY CATHETER, DRAINAGE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with elevated creatinine s/p revision of tx ureter s/p cad renal tx REASON FOR THIS EXAMINATION: please do pull back nephrostogram.",1
"Please call Dr. with any questions ______________________________________________________________________________ FINAL REPORT HISTORY: 68-year-old man with elevated creatinine, status post revision of transplant ureter, status post cadaveric renal transplant.",1
"Comparison is made with multiple prior exams, most recent of which was from .",0
"and , with Dr. , the Attending Radiologist, present and supervising the entire procedure.",0
FINDINGS: An initial scout radiograph of the pelvis demonstrated an in situ biliary drainage catheter through the right lower quadrant in the expected region of the transplanted kidney.,1
The distal locking loop is in the expected region of the bladder.,0
"A right-sided dynamic hip screw is incompletely imaged, but the overlying femoral head cortex appears intact.",0
A drainage catheter is also seen present in the right lower quadrant of the abdomen.,0
The locking suture and catheter were cut to release the locking loop and then the catheter was removed over a guidewire.,0
A 7-French vascular sheath was positioned over the guidewire and an antegrade nephrostogram was performed through this sheath.,0
This demonstrated free flow of contrast through the ureter into the bladder.,0
A filling defect is seen in the bladder related to the Foley catheter.,0
The ureter is of good caliber with free flow.,0
The renal transplant collecting system is not dilated.,0
"Just inferior to the transplanted kidney and proximal portion of the transplanted ureter, a collection of contrast formed.",1
"The definite source of this collection of contrast was not seen, however, it is immediately superior to the remnant of the prior right-sided ureter.",0
The collection of contrast did appear to arise prior to opacification of the right-sided ureteric remnant.,0
The appearance is somewhat similar to a prior retrograde cystogram from .,0
"At this point, the vascular sheath was removed and a new 8-French biliary catheter was positioned to function as a nephroureterostomy.",0
Four additional sideholes were cut superior to the catheter mark.,0
Catheter was sutured in place with an 0 silk suture and a statlock device was used for catheter fixation.,0
Contrast injection through the (Over) 4:13 PM URIN CATH CHECK Clip # Reason: please do pull back nephrostogram.,0
Please call Dr. w Admitting Diagnosis: URETERAL STRICTURE/SDA Contrast: OMNIPAQUE Amt: 60 ______________________________________________________________________________ FINAL REPORT (Cont) catheter confirmed that the superiormost side hole was still within the renal collecting system.,1
IMPRESSION: No evidence of transplant kidney hydronephrosis or ureteric stenosis.,1
Free flow of contrast was seen from the renal transplant collecting system to the bladder.,0
A collection of contrast is seen just inferior to the renal transplant kidney.,1
"Although this may be related to the right ureteric remnant, a contrast leak cannot be entirely excluded.",0
Note that a leakage site was not definitely identified.,0
RECOMMENDATION: We recommend a follow up nephrostogram in 2 weeks' time to help allow for healing if this is indeed a leak and also to allow for further assessment.,0
It may be worthwhile at that time to perform an initial contrast injection in the bladder to see if the bladder or right ureteric remnant is a possible source for this contrast collection.,0
"9:44 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: question aspiration post op, question aspiration ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with REASON FOR THIS EXAMINATION: question aspiration post op, question aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: Question aspiration postop.",0
FINDINGS: The study was performed in conjunction with a speech therapist.,0
"Puree, nectar-thickened, thin, solid, and pill consistencies of barium were administered.",0
There is vallecular residue with slightly reduced hyoid elevation.,0
"There is poor epiglottic deflection with small boluses, but normal deflection with larger boluses.",0
"With large straw sips of thin liquids, there is penetration during and aspiration after swallowing without cough initiation.",0
IMPRESSION: Penetration and subsequent aspiration without cough on large straw sips of thin liquids.,0
"1:07 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with COPD, right pneumothorax, subcataneous emphysema , s/p line change REASON FOR THIS EXAMINATION: r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: S/P line change evaluate for pneumothorax.",1
COMPARISON STUDY: Cardiomediastinal silhouette is stable in appearance.,0
Again seen is a tracheostomy tube in good position.,0
There has been interval removal of a right-sided chest tube.,0
Some persistent parenchymal abnormality is seen in the right lung not changed since the previous exam.,0
There has been interval increase in size of a left-sided pleural effusion with some associated atelectasis.,0
Infection at this location cannot be excluded.,0
There is a left-subclavian central venous line terminating in the proximal superior vena cava.,0
IMPRESSION: 1) Interval removal of right-sided chest tube with no pneumothorax.,0
Persistent pulmonary parenchymal abnormality in the right lung unchanged.,0
2) Increasing small left-sided pleural effusion with associated atelectasis.,0
3) Left subclavian central venous catheter terminating in the proximal superior vena cava without pneumothorax.,0
"5:01 PM ANKLE (AP, LAT & OBLIQUE) RIGHT Clip # Reason: ped struck with r ankle pain ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with r/o fx REASON FOR THIS EXAMINATION: ped struck with r ankle pain ______________________________________________________________________________ FINAL REPORT INDICATION: Status post trauma.",0
"RIGHT ANKLE, THREE VIEWS: There is no evidence of fracture or dislocation.",0
The ankle mortise is congruent.,0
There is no evidence of soft tissue swelling.,0
5:35 PM CAROT/CEREB Clip # Reason: SUBARACHNOID BLEED Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 350 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER * * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT * * EXT CAROTID BILAT VERT/CAROTID A-GRAM * * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * EXT BILAT A-GRAM -52 REDUCED SERVICES * **************************************************************************** ______________________________________________________________________________ FINAL REPORT PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.,1
POSTOPERATIVE DIAGNOSIS: Small infundibular dilatation on the superior aspect of the anterior communicating artery complex measuring approximately 1 mm and a bulbous anterior communicating artery complex.,0
INDICATION: is a patient who presented with worst headache of her life and underwent a CT scan which revealed the presence of subarachnoid hemorrhage.,1
She is undergoing a cerebral angiogram to determine the source of the hemorrhage and to determine optimal therapy.,0
"CONSENT: The patient, her husband and family were given a full and complete explanation of the procedure.",0
"Specifically the indications, risks, benefits, and alternatives to the procedure were explained in detail.",0
"In addition the possible complications such as the risk of bleeding, infection, stroke, neurological deficit or deterioration, groin hematoma, and other unforeseen complications including the risk of coma and even death were outlined.",0
"The patient, her husband and family understood and wished to proceed with the operation.",0
PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and placed on the table in supine position The right groin area was prepped and draped in the usual sterile fashion.,0
"A 19 gauge single wall needle was then used to puncture the right femoral artery and upon the return of brisk arterial blood, a 4 FR vascular sheath was inserted over a guidewire and kept on a heparinized saline drip.",0
"Next a diagnostic catheter was used to selectively catheterize the following vessels over a guidewire in succession: Right common carotid artery, right internal carotid artery, right external carotid artery, right subclavian artery, right vertebral artery, left common carotid artery, left internal carotid artery, left external carotid artery, left subclavian artery, and then left vertebral artery.",0
RESULTS: Injection of both common carotid arteries in the cervical region reveal normal anatomy with normal anatomy with no significant atherosclerotic (Over) 5:35 PM CAROT/CEREB Clip # Reason: SUBARACHNOID BLEED Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 350 ______________________________________________________________________________ FINAL REPORT (Cont) disease.,1
Injection of both external carotid arteries reveal no evidence of arteriovenous shunting.,0
Injection of both subclavian arteries revealed no evidence of atherosclerotic disease at the origin of the subclavian arteries or at the origin of the vertebral arteries.,0
Injection of the bilateral vertebral arteries in the cervical region were within normal limits.,0
The right vertebral artery appear to be dominant.,0
The basilar apex of the vertebrobasilar junction and basilar trunk are within normal limits.,0
Injection of the right internal carotid artery reveals a dominant right anterior cerebral artery A1 segment.,0
The right middle vertebral artery bifurcation is within normal limits.,0
Three dimensional rotational angiography failed to reveal a definite source of the subarachnoid hemorrhage during the study specifically the anterior communicating complex appears to be duplicated and bulbous and is small 1/2 mm to 1 mm pointing aneurysmal dilatation on the anterior communicating artery complex.,1
This aneurysm is really an infundibular dilatation at the origin of what appears to be a recurrent artery.,0
"Accordingly, an additional repeat study is recommended to rule out the presence of other aneurysms.",0
Injection of the left internal carotid artery showed a significant posterior communicating artery which provides perfusion to the basilar apex as well as the posterior cerebral arteries.,0
The anterior cerebral artery is diminutive and atretic on this injection.,0
The middle cerebral artery is within normal limits.,0
"IMPRESSION: No evidence of definite aneurysmal source for the subarachnoid hemorrhage in this study, however, the presence of a small 1/2 mm to 1 mm infundibular dilatation at the origin of the recurrent artery appearing on the anterior communicating artery complex on the superior aspect, recommendation is made for repeat angiogram to rule out the presence of an thrombosed aneurysm.",1
7:21 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
increased pneumo Admitting Diagnosis: MULTIPLE MYELOMA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with multiple myeloma w/ enterococcal empyema.,1
Ct now d/c REASON FOR THIS EXAMINATION: ?,0
increased pneumo ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 18:40 INDICATION: Empyema.,0
FINDINGS: ETT and left CVL are in place and there is no PTX.,0
"There are extensive bilateral pulmonary opacities, left greater than right but since the prior film, there appears to be increased density in the right hemithorax.",0
This pattern can be seen with ARDS.,0
IMPRESSION: Extensive bilateral airspace disease worse compared to prior.,0
", C. CSURG CSRU 1:42 PM CHEST PORT.",0
"LINE PLACEMENT Clip # Reason: fast track extubation cardiac surgery, ?line placement, ?PTX Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with CAD s/p CABG.",1
"REASON FOR THIS EXAMINATION: fast track extubation cardiac surgery, ?line placement, ?PTX/Effusion ______________________________________________________________________________ PFI REPORT Post-CABG changes without evidence of large effusion or pneumothorax.",0
", S. 8:51 AM CHEST (PORTABLE AP) Clip # Reason: improvement in pulmonary edema Admitting Diagnosis: DM;MR;PULMONARY EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with severe MR, fluid overload, rll infiltrate REASON FOR THIS EXAMINATION: improvement in pulmonary edema ______________________________________________________________________________ PFI REPORT PFI: Since yesterday, right lower lobe opacity decreased.",0
1:06 AM T-SPINE; L-SPINE (AP & LAT) Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with back pain p mvc REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT INDICATION: Status post motor vehicle crash with back pain.,1
"THORACIC AND LUMBAR SPINE, AP AND LATERAL VIEWS: The films are slightly limited secondary to patient rotation.",0
No acute fracture or dislocation.,1
No loss of vertebral body height or disc height.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: headache x 3-4 weeks Major Surgical or Invasive Procedure: L craniotomy for mass resection History of Present Illness: 43 y/o M with no past medical history presents with headache x 3-4 weeks.,0
Patient states that he was today and developed a headache which caused him to go to an OSH.,0
Once at the OSH he had a CT scan which revealed a L frontal lesion with significant edema.,1
He was transferred to for further neurosurgical workup.,0
His headache is located in the temporoparietal region and describes it as a sharp pain that is not relieved with pain medication.,0
"He also reports intermittent blurred vision x 4 days, dizziness, and unsteadiness.",0
He denies any n/v or dysarthria.,0
"Past Medical History: none Social History: works in sales, drinks ETOH socially, but denies any tobacco or illicit drug use.",0
"Family History: NC Physical Exam: O: T:98.3 BP:151/85 HR:87 R: 18 O2Sats:99% Gen: WD/WN, comfortable, NAD.",0
"HEENT:atraumatic, normocephalic Pupils:5-4mm bilaterally EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect.",0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,5 to 4 mm bilaterally.",0
"No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger Pertinent Results: ADMISSION LABS: 11:00PM UREA N-14 CREAT-1.0 11:00PM estGFR-Using this 07:05AM BLOOD WBC-10.5 RBC-5.18 Hgb-14.3 Hct-42.3 MCV-82 MCH-27.6 MCHC-33.9 RDW-14.2 Plt Ct-224 07:05AM BLOOD PT-11.8 PTT-22.5 INR(PT)-1.0 07:05AM BLOOD Glucose-84 UreaN-17 Creat-1.0 Na-139 K-4.5 Cl-104 HCO3-29 AnGap-11 DISCHARGE LABS: CT torso : No metastatic disease MRI Head: Large heterogeneously enhancing lesion within the left frontal lobe, which causes significant mass effect, contralateral midline shift and FLAIR and T2 signal abnormality in most of the left frontal lobe.",0
The appearances are highly suggestive of a neoplasm like Oligodendroglioma or a GBM.,0
"Head CT: Post-left frontal craniectomy, with small amount of expected postoperative hemorrhage, pneumocephalus and overall decrease in degree of subfalcine herniation and compression of lateral ventricles.",0
Head CT FINDINGS: Patient is status post left frontal craniotomy with partial excision of large left frontal mass.,0
"There is stable appearance of hemorrhage, air, and residual mass in the postoperative site.",0
There is persistent rightward shift of normally midline structures of approximately 11.8 mm.,0
There is postoperative soft tissue swelling over the left frontoparietal bones.,0
"IMPRESSION: Stable postoperative appearance after left frontal craniotomy with continued hemorrhage, pneumocephalus, and rightward shift of normally midline structures.",0
"MRI brain FINDINGS: Since the prior MRI of , there has been interval resection of the large right frontal mass.",0
The patient is status post frontal craniotomy.,0
There is subcutaneous emphysema and swelling of soft tissues along the left convexity.,0
There is pneumocephalus within the surgical cavity.,0
"Hyperintensity on the T2-weighted images is consistent with surrounding edema, not appreciably changed in extent since pre-operative MRI .",0
Signal intensity compatible with early subacute blood products are seen within the surgical cavity.,0
"There has been interval decrease in the rightward shift from normally midline structures measuring 9 mm, previously 14 mm.",0
There has been slight interval improvement but persistent effacement of the left lateral ventricle.,0
"On post-contrast images, there is subtle enhancement at the margins and slightly inferior to the surgical cavity (13:15-16).",0
Diffusion-weighted images demonstrate restricted diffusion at the margins of the surgical bed.,0
A small amount of fluid is seen in the left mastoid air cells.,0
The remainder of the visualized paranasal sinuses is well aerated.,0
Status post frontal craniotomy with resection of frontal lobe mass with air and blood products in the surgical cavity.,0
Mild residual enhancement at the margins and slightly inferior to the surgical cavity.,0
Restricted diffusion at the margin of the surgical bed could be related to the surgery.,0
No evidence of territorial infarct.,0
Brief Hospital Course: 43 y/o M presents to OSH with 3-4 weeks of frontotemporal headaches.,0
Head CT showed large frontal mass.,0
He was transferred to for neurosurgical evaluation.,0
He was admitted to neurosurgery and nonfocal on examination.,0
MRI head revealed a large mass with edema.,0
"His CT scan of his chest, abdomen, and pelvis did not reveal a primary tumor.",0
On he went to the OR for a L frontal crani for resection of the mass.,0
The preliminary pathology was malignant metastatic tumor.,0
"He tolerated the procedure well and went directly to the PACU, extubated.His SBP was less than 140 with a nipride drip.",0
He initially followed commands and had a non focal exam.,0
His post op head CT dmonstrated no acute post op hemorrhage.,0
His neurologic examination remained non-focal.,0
On the evening on he was transferred to the ICU for Q1 neurochecks.,0
"In the morning, he felt well, and his neurological exam remained completely intact.",0
He no longer required the nipride gtt.,0
He was transferred to the floor and diet and activity were advanced.,0
His pain was well controlled.,0
The patient was evaluated by PT/OT and determined safe for discharge.,0
The patient was discharged on POD2.,0
Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: Tablets PO Q6H (every 6 hours) as needed for headache.,0
Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO three times a day for 2 days: THEN 2MG PO TID UNTIL FURTHER NOTICE.,0
Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: L frontal mass Discharge Condition: Mental Status: Clear and coherent.,0
You may wash your hair only after sutures and/or staples have been removed.,0
"If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days.",0
"you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring.",0
F. Followup Instructions: Follow-Up Appointment Instructions YOU WILL NEED TO BE SEEN IN THE BRAIN CLINIC AN APPOINTMENT HAS BEEN MAD FOR YOU ON AT 3PM / IF YOU NEED TO CANCEL THIS APPOINTMENT YOU NEED TO CALL - YOU WILL SEE Dr. AT THIS TIME ALSO.,0
"8:58 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate lung expansion and plueral effusions thank y Admitting Diagnosis: ESOPHAGEAL RUPTURE-FEVER ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with rupt esophagus, 3 CT now on water seal ; 3JP in place and loculated bilateral plueral effusions.",0
REASON FOR THIS EXAMINATION: please evaluate lung expansion and plueral effusions thank you.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF .,0
"On the right side, there is a small lateral basilar pneumothorax as well as a small amount of loculated fluid within the major fissure.",0
"On the left side, there is a moderate-to-large loculated left pleural effusion most prominent in the upper and mid hemithorax, which has progressed in the interval.",0
"Patchy opacities in the retrocardiac regions are unchanged, and surgical drains are again noted in the upper mediastinum.",0
Patchy opacities in the left retrocardiac region is without change.,0
Surgical drains overlie the upper mediastinum.,0
IMPRESSION: Increasing loculated left pleural fluid collection.,0
"8:33 AM CAROT/CEREB Clip # Reason: eval L carotid abnormality Admitting Diagnosis: STROKE/TIA Contrast: OPTIRAY Amt: 306 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 1ST ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * CAROTID/CERVICAL BILAT CAROTID/CEREBRAL BILAT * * VERT/CAROTID A-GRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with L carotid artery bifurcation dissection vs. thrombus on CTA REASON FOR THIS EXAMINATION: eval L carotid abnormality ______________________________________________________________________________ FINAL REPORT CEREBRAL ANGIOGRAM, : PROCEDURE: Cerebral angiogram with selective right vertebral artery arteriogram, right common carotid artery arteriogram and left common carotid artery arteriogram.",1
INDICATION: 48-year-old male who presented with multiple strokes involving his left hemispheric territory.,0
CT imaging was consistent with a dissection of the left internal carotid artery.,1
"Therefore, we were asked to perform this procedure.",0
"Informed consent was obtained from the patient after explaining the risks, indications and alternative management.",0
"Risks explained include: stroke, loss of vision, speech temporary or permanent with possible treatment with stents and coils if needed.",0
Patient is brought to interventional radiology suite and placed on the biplane table in supine position.,0
"Both groins were prepped and draped in the usual sterile fashion, access to the right common femoral artery was obtained using a 19-gauge single wall needle under local anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.",0
"Through the needle, a 0.035 wire is introduced and the needle is taken out over the wire.",0
A 5 French vascular sheath was placed and connected to a saline infusion .,0
A 4 French catheter was introduced and connected to continuous saline infusion with heparin mixture 1000 units of heparin and 1000 ml of saline.,0
The following vessels were selectively catheterized and arteriograms were performed from these locations.,0
"After review of films, the catheter and the sheath were withdrawn, and the pressure was applied on the groin until hemostasis obtained.",0
"The procedure was uneventful, and the patient tolerated the procedure well without complications.",0
The patient was sent to the floor with orders.,0
"The following blood vessels were selectively catheterized and arteriograms were obtained in AP and lateral projections: right common carotid artery, left common carotid artery and right vertebral artery.",1
"After review of films, the catheter and sheath were withdrawn and angioseal device used for groin closure.",0
(Over) 8:33 AM CAROT/CEREB Clip # Reason: eval L carotid abnormality Admitting Diagnosis: STROKE/TIA Contrast: OPTIRAY Amt: 306 ______________________________________________________________________________ FINAL REPORT (Cont) FINDINGS: Evaluation of the above vessels are as follows: right vertebral artery arteriogram shows good filling of the vertebral artery and the basilar artery along with its branches .,1
There is reflux into the left vertebral artery.,0
Right common carotid artery arteriogram shows normal carotid bifurcation.,1
The right internal carotid artery does not show any stenosis in the cervical petrous cavernous and supraclinoid portion.,1
A1 and M1 are seen normally along with its distal branches.,0
Left common carotid artery arteriogram shows what appears to be atherosclerotic plaque with dissection in the left internal carotid artery starting at the bifurcation and extending approximately 2-3 cm into the internal carotid artery.,1
There appears to be thrombus in this location.,0
"The distal branches fill well including the left M1, A1 and its branches.",0
We had only a demagnified view of the intracranial circulation as there was concern that multiple injections might force clot into the distal vasculature.,0
"IMPRESSION: Mr. underwent cerebral arteriogram for left internal carotid artery dissection, which reveals atherosclerotic plaque with dissection and possible thrombus of the internal carotid artery at its origin.",1
We decided not to stent this as there was no flow limiting stenosis and because of the risk of distal embolization.,0
8:53 PM CHEST (PA & LAT) Clip # Reason: R/o PNA or other pulmonary etiology for symptoms.,0
Thank you Admitting Diagnosis: BLADDER CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with mild postoperative tachycardia and leukocytosis.,0
REASON FOR THIS EXAMINATION: R/o PNA or other pulmonary etiology for symptoms.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 11:50 AM No consolidations suggestive of pneumonia.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 77-year-old male with mild postoperative tachycardia and leukocytosis.,0
Rule out pneumonia or positive pulmonary etiology for symptoms.,0
COMPARISON: Most recent chest x-ray in .,0
PA AND LATERAL CHEST RADIOGRAPHS: Previously seen consolidation in the right mid lung base has cleared.,0
There are no new focal consolidations.,0
There was interval removal of the left central line.,0
IMPRESSION: No evidence of focal consolidations that could suggest pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ranitidine Attending: Chief Complaint: Hypotension, hypothermia Major Surgical or Invasive Procedure: None History of Present Illness: Ms is a 63 year old woman with history of heart failure, diabetes, hypertension, and entero-uterine fistula, presenting with hypotension and hypothermia at her day care unit.",1
Patient was brought in by her daughter after she was notified by Day care unit that patient was found less responsive today and vitals had revealed 76/50 at 20:50.,0
Ms was also recently evaluated in podiatry clinic for a left foot ulcer and started on Bactrim.,0
"Patient is non verbal at baseline, daughter is not reachable at this time.",0
"In the ED, vitals: Temp 86 F oral (31.6C rectal), HR 44, BP 110/39, RR 14, O2 Sat 100%.",0
Patient given heated humidifier and heated blanket.,0
"Patient was given Vancomycin, Zosyn.",0
"Given hypotension, left internal jugular venous line was placed and 3 L NS were given.",0
"Urinalysis with >50 WBC, patient was admitted to for futher management.",0
"Of note, patient has presented to our hospital two prior occasions with hypothermia, hypoglycemia and sinus bradycardia.",0
On both hospitalizations patient has required agressive volume resusitation (11L on ).,0
"On both admissions differential diagnosis included myxedema coma, adrenal insufficiency and , although no final diagnosis was reached.",0
"Past Medical History: # Entero-uterine fistula # Chronic diastolic congestive heart failure (EF >60% 11/4/008) # Type 2 diabetes mellitus: complicated by nephropathy, peripheral neuropathy, retinopathy # Coronary artery disease: History of distant MI per family report, no PCI or CABG # Hypertension # Chronic kidney disease: Baseline creatinine 1.1-1.3 # History of pancreatitis status post pancreatic duct stent # Anemia: Mixed iron deficient and anemia of chronic disease # Thrombocytopenia # History of thickened endometrium # Osteopenia # History of stroke # Dementia # seizure disorder, on Kepra # Foot cellulitis s/p surgical debriedment , , s/p Right BKA Social History: Tobacco: Quit 1 year ago, previously 3 ppd x 50 years ETOH: Rare, illicits: None.",1
"Family History: Mother with diabetes, breast cancer, myocardial infarction in her 70s.",1
"Physical Exam: General Appearance: Thin, Ill appearing Eyes / Conjunctiva: No(t) PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: 1+, Right BKA well healed.",0
"Left foot with well demarcated ulcer, no drainage or purulence Musculoskeletal: Muscle wasting, Unable to stand Skin: Cool Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed GU: Stage II ulcer on left buttock.",1
"Foley catheter in place, dark milky urine in tube Pertinent Results: ==================== ADMISSION LABS ==================== 05:15PM BLOOD WBC-12.9*# RBC-2.84* Hgb-8.3* Hct-25.5* MCV-90 MCH-29.1 MCHC-32.5 RDW-17.5* Plt Ct-50*# Gran Ct- Glucose-186* UreaN-47* Creat-2.3* Na-134 K-4.7 Cl-111* HCO3-12* AnGap-16 Lactate-1.7 =========== ECHO =========== () The left atrium is normal in size.",0
There is severe symmetric left ventricular hypertrophy.,0
Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction.,1
"The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure.",0
"Compared with the prior study (images reviewed) of , left ventricular systolic function has improved.",0
", F 63 Radiology Report MR HEAD W/O CONTRAST Study Date of 4:48 PM , MED 4:48 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST Clip # Reason: please eval for new IC process MEDICAL CONDITION: 63 year old woman with epilepsy, worsened mental status from baseline REASON FOR THIS EXAMINATION: please eval for new IC process CONTRAINDICATIONS FOR IV CONTRAST: Final Report MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY OF THE NECK AND HEAD HISTORY: Epilepsy.",1
Worsening mental status from baseline.,1
Evaluate for new intracranial process.,0
"TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained, as well as three-dimensional time-of-flight imaging of the circle of and its tributaries.",0
"Finally, two- and three- dimensional time-of-flight imaging of the neck arterial vasculature was also acquired.",0
COMPARISON STUDIES ON PACS ARCHIVE: MR scan of the brain.,0
"FINDINGS: Unfortunately, nearly all images of this study are moderately to severely degraded by patient motion.",1
"Within these limitations, there is redemonstration of what has previously been characterized as a probable chronic infarct within the right frontal lobe.",0
"On the most extreme cephalad diffusion-weighted images, there is a question of a subcentimeter curvilinear area of restricted diffusion involving the left-sided sensory cortex (see series 600, images 23 and 24).",0
It is possible that this area could represent a tiny area of evolving infarction.,0
No other areas of diffusion abnormality are seen.,0
The principal vascular flow patterns are identified.,0
"There is moderate bilateral ethmoid sinus mucosal thickening, as well as milder sphenoid and frontal sinus mucosal thickening, which likely represents a chronic inflammatory process.",1
The intracranial MR angiogram is of extremely poor quality due to patient motion.,0
"There appears to be less flow within the right middle cerebral artery, relative to the left, which could indicate effects of the known right frontal lobe infarct.",1
"Similarly, the MR angiography of the neck arterial vasculature is of very poor quality.",0
No gross area of hemodynamically significant stenosis is seen.,0
CONCLUSION: Question of perhaps a tiny area of evolving infarction within the left sensory strip vertex region of the brain.,0
"Suboptimal study, without other overt interval changes appreciated.",0
", F 63 Radiology Report CT HEAD W/O CONTRAST Study Date of 4:15 PM , MED 4:15 PM CT HEAD W/O CONTRAST Clip # Reason: please eval for bleed MEDICAL CONDITION: 63 year old woman with baseline dementia, now with worsened AMS, concern for seizure activity REASON FOR THIS EXAMINATION: please eval for bleed CONTRAINDICATIONS FOR IV CONTRAST: None.",0
"Final Report INDICATION: Baseline dementia, now with worsening altered mental status and concern for seizure activity.",1
"COMPARISON: Multiple prior brain imaging studies, most recently MRI from .",0
"Right frontal hypodensity remains most consistent with encephalomalacia, consistent with subacute infarction demonstrated on most recent MRI of .",1
There is no sign of acute vascular territorial ischemia.,0
"Ventricles and sulci are unchanged in size and configuration, allowing for differences in modality.",0
Vascular calcifications are noted in the carotid siphons bilaterally.,0
"There is a small fluid level in the right maxillary sinus, and partial opacification of the ethmoid air cells.",0
"Right frontal encephalomalacia, consistent with evolution of previously noted subacute infarction.",1
Small fluid level in the right maxillary sinus.,0
"Brief Hospital Course: Ms is a 63 year old woman with a recent history of 2 prior episodes of recurrent hypotension, hypothermia, hypoglycemia, who was admitted to the ICU on for hypotension and hypothermia.",0
Hospital course by problem: .,0
"Hypotension: The pt has been admitted on 2 prior occasions for hypotension thought to be secondary to septic shock, and during these admissions an offending pathogen was never identified.",1
"On this admission pneumonia seemed a possible source of as the pt had a new opacity on chest x-ray, but the differential also included other infectious processes (known entero-uterine fistula, yeast in urine culture, lower extremity ulcers), myxedema coma, adrenal insufficiency, profound hypovolemia or hemodynamic process.",1
"The pt was started on broad-spectrum antibiotics (Vancomycin, Zosyn) given multiple potential sources of infection.",0
The pt also had a cortisol stimulation test that showed an appropriate response.,0
"The pt was transiently on pressors and quickly weaned off, and required a minimal amount of IVF resuscitation.",0
On transfer to the floor the pt had been hypertensive in the 160's systolic for 48 hours and was +7L for length of stay.,0
"BP meds held, slowly re-introduced as pressure tolerated, after auto-regulation given possible stroke.",0
"Hypothermia: On prior hospitalizations for hypothermia the cause has remained unclear, but has been attributed to .",0
"Also may have been due to hypothyroidism, T4 supplementation resumed/increased.",0
"# Acute renal failure: The pt's baseline Creatinine was 1.1 to 1.3, and elevated to 2.3 on admission.",1
The pt's acute renal failure was thought to be secondary to acute tubular necrosis in the setting of hypotension.,1
"Thrombocytopenia: Unclear etiology from prior admissions, suspect bone marrow supression vs consumptive process.",0
"Hematology/oncology followed in hospital, felt due to .",0
# Leukocytosis - unclear etiology.,0
Hematology recommended flow cytometry and outpatient follow up in one month with Dr. (see below).,0
No evidence of ongoing infection on d/c.,0
"Neg for c diff times two, no fevers, no abdominal pain, no dyspnea.",0
Urine with yeast only (chronic).,0
"Metabolic Acidosis: Very low bicarbonate on admission, lactate however was normal.",0
Most likely this represents GI losses vs decreased bicarbonate production from acute renal function.,0
"# Labile blood glucose - had low levels when glargine titrated up to 6 U, so, lowered back to 3 U q am, with conservative SSI regimen as per prior endocrine recommendations.",0
enterovaginal/enterouterine fistula - diarrhea c/w known pancreatic insufficiency/malabsorption.,1
"No abd pain, fever, to suggest c difficile infection, and cdiff assays negative times two.",0
"Fistula discussed with dtr (health care proxy) - have discussed previously, and decided against surgery.",0
# Grade II sacral ulcerations due largely to fecal and urinary incontinence/diarrhea - wound care as below.,1
"# Stroke, seizure d/o - MR with evidence of possible acute infarct.",0
"ASA should be resumed when thrombocytopenia has improved to over 100,000 per neurology.",0
Keppra continued for seizure d/o.,0
Medications on Admission: Kepra 500mg Novolog SS Aspirin Enalapril 20mg Ergocalciferol Amlodipine 10mg Glucagon pen PRN Discharge Medications: 1.,0
Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical (2 times a day).,0
Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Insulin Glargine 100 unit/mL Solution Sig: Three (3) Units Subcutaneous Q am.,0
"Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale, below units, insulin Subcutaneous QACHS: for BG: 201-250: 2 U 251-300: 4 U 301-350: 6 U 351-400: 8 U Over 400: MD.",0
"Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).",0
Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: ONLY WHEN PLATELETS OVER 100,000.",0
"Discharge Disposition: Extended Care Facility: Sachem Skilled Nursing & Rehabilitation - Discharge Diagnosis: Pneumonia with Thrombocytopenia due to above Leukocytosis, unspecified.",1
"Chronic Kidney Disease, stage III Acute Stroke Hypertension Dementia Diabetes, type II, uncontrolled, with complication Diarrhea due to malabsorption from pancreatic insufficiency Hypothyroidism Stage II sacral decubitus ulceration Discharge Condition: Stable, alert, at baseline of orientation (to self only), afebrile.",1
"BG labile 100s to 300, tolerating po intake.",0
Still having diarrhea due to known pancreatic insufficiency/malabsorption.,0
"Discharge Instructions: Return to the Emergency Department for: Fevers, lethargy.",0
"With Dr. of Hematology within one month - This is to follow up on the results of flow cytometry and cell counts, and for consideration of further work up of leukocytosis including possible bone marrow biopsy.",0
"See below: Arranged - Provider: , MD Phone: Date/Time: 1:00",0
1:10 AM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: assess for fx ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with found down REASON FOR THIS EXAMINATION: assess for fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: MMBn SUN 3:01 AM No fracture or malalignment.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 21-year-old man found down with occipital laceration.,0
TECHNIQUE: MDCT non-contrast imaging of the cervical spine was performed.,0
"FINDINGS: A 2-mm bony fragment extending off the anterior aspect of C5 maintains well-corticated margins, most likely representing an osteophyte.",0
No fracture or malalignment is seen within the cervical spine.,0
"The vertebral body, and intervertebral disc space heights are preserved.",0
"Although CT is not as sensitive as MRI in detecting spinal cord detail, the visualized outline of the thecal sac is unremarkable.",0
The surrounding soft tissues are within normal limits.,0
"5:39 PM CT HEAD W/O CONTRAST Clip # Reason: COAGULOPATHIC NOW WITH ""DOLL'S EYES"", ?",0
"CEREBRAL EDEMA, HEMORRHAGE Admitting Diagnosis: ALTERED MENTAL STATUS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p OLT who is in hepatic failure and coagulopathic now with ""Doll's eyes"" REASON FOR THIS EXAMINATION: please evaluate for cerebral edema, hemorrhage or other acute changes.",1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATIONS: 52-year-old man status post liver transplant, and hepatic failure with coagulopathy.",1
Evaluation for cerebral edema requested.,0
"FINDINGS: There is hypodensity extending to the cortex in the left frontal region, which corresponds to the infarct described previously.",0
"However, there are multiple punctate densities in this region of intermediate signal intensity, and these could represent petecheal hemorrhage within the site of prior infarction .",1
These punctate densities are new since the prior study.,0
"There is no mass effect, hydrocephalus or shift of the midline structures.",0
"The ventricles, cisterns, and sulci appear normal without effacement.",0
"There is panopacification of the sinuses, probably related to intubation, with some sparing of the maxillary sinuses.",0
Punctate densities in the region of hypointensity that was noted previously.,0
This may represent petecheal hemorrhages in an area of infarction.,1
MRI would help for further evaluation.. 2.,0
"However, no evidence of cerebral edema or significant mass effect.",0
"Opacification of the paranasal sinuses, probably related to intubation.",0
Status: Inpatient Date/Time: at 10:19 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,0
Conclusions: PREBYPASS: The left atrium and right atrium are normal in cavity size.,0
There are simple atheroma in the aortic arch and descending thoracic aorta.,0
POSTBYPASS: Normally functioning AV prosthesis with no significant AS or AI.,0
8:23 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 65 y/o F s/p total gastrectomy w/ E/J and J tube() p/w SBO now s/p ex lap, SBR, washout, primary repair now w/ PNA REASON FOR THIS EXAMINATION: ?",0
interval change ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON HISTORY: Followup infiltrates.,0
FINDINGS: There has been no significant interval change in the tracheostomy or left subclavian line.,0
There is dense alveolar infiltrate on the left with more patchy alveolar infiltrate on the right.,0
Compared to the prior day the left infiltrate has worsened and the right infiltrate has improved.,0
12:14 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: CATATONIA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with catatonia, found to have ?widened mediastinum on CXR REASON FOR THIS EXAMINATION: ?",0
"interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 12:11 P.M. ON HISTORY: Patient is catatonic.",0
"Wide mediastinum on chest x-ray, question interval change.",0
IMPRESSION: AP chest with the patient standing compared to supine chest on : Mediastinal widening is less severe with change in positioning as one would expect since the veins are dilated with the patient supine.,0
Chest CT in demonstrated that the severe mediastinal widening is due to marked fat deposition.,0
"The heart is probably normal size, also surrounded by mediastinal fat.",0
"Lung volumes are low, but lungs are grossly clear.",0
There is mild engorgement of the upper lobe pulmonary vasculature but no edema.,0
"Pleural effusion is small, if any.",0
"Of note, the prior chest CT, , showed multiple borderline enlarged lymph nodes in the hila and distributed throughout the mediastinum.",0
", B. MED 11R 10:01 AM PICC LINE PLACMENT SCH Clip # Reason: Placed L. arm PICC Won't advance last 10cm.",0
Admitting Diagnosis: PNEUMONIA Contrast: OPTIRAY Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with REASON FOR THIS EXAMINATION: Placed L. arm PICC Won't advance last 10cm.,0
______________________________________________________________________________ PFI REPORT Uncomplicated PICC exchange.,0
1:27 AM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: eval acute process ______________________________________________________________________________ MEDICAL CONDITION: 31 year old man with stabbing to face REASON FOR THIS EXAMINATION: eval acute process ______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old man with stabbing to the face.,0
COMPARISON: No relevant comparisons available.,0
ONE VIEW OF THE CHEST: The lungs are well expanded and clear.,0
"The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal.",0
No pleural effusion or pneumothorax is present.,0
IMPRESSION: No acute intrathoracic process.,0
"Admission Date: Discharge Date: Service: MED Allergies: A.C.E Inhibitors Attending: Chief Complaint: urosepsis Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo F with h/o DM II, htn, diastolic CHF and recent admit for fractured ankle in p/w MS on .",1
Discharged from rehab 1 wk PTA with hospice and a dx of end-stage dementia.,0
became progressively more confused and less communicative.,0
friend and contact pt's PCP who told her to come to ED.,0
"Apparently, per PCP, MS was far from pt's baseline and was more c/w delirium.",0
"In , pt was found to ahve hypotension and qualified for protocol.",0
She was noted to be febrile with a lactate of 4.4 and a U/A c/w urosepsis.,0
"SHe ahd a cr of 1.8, c/w ARF, that improved with hydration.",0
She was given levo/vanc/flagyl and aggressive hydration.,0
"EKG with ST, LAD, LVH with TWI in I, L, but not V5-6.",0
continued to get 4 L IVF.,0
"Had hematuria with hct drop from 31.3 to 26.1, guaic neg.",0
"given bladder irrigation, urology consulted.",0
"Continued on levoflox, renal U/S without hydro.",0
"developed hyperglycemia requiring insulin gtt until , then transitioned to long acting sq insulin.",0
"Noted to have cough, got swallow eval.",0
"Past Medical History: osteoarthritis hypertention hyperlipidemia DM2 CHF with EF >55% gastritis Social History: no tob, ETOH.",0
"Lives at home with /friend, who helps care for her.",0
)urosesepsis - please see MICU course - pt.,0
remained afebrile and hemodymically stable on the floor.,0
Whe was started on 2 wk course of levofloxacin which she is due to complete on .,0
)hematuria/urinary retention - was evaluated in MICU by urology for this complaint and initially felt to be secondary to trauma.,0
Hematuria resolved and pt's foley was eventually d/c'd on the floor.,0
"However, after 2 failed voiding trials, foley was re-inserted.",0
"Initially, there was was return of hematuria - this however, resolved.",0
Urology felt that hematuria was secondary to trauma.,0
The Foley will remain in place and she should f/u w/ urology in 1 weeks time.,0
)ARF - resolved with IVF and at time of d/c creatinine under 1.0 4.,0
")anemia - question if related to hematuria, guaic negative.",0
"Pt's hct remained stable on the floor, w/ crits greater than 26.",0
in mild overload on after aggressive hydration in the MICU.,0
"She, got 10 IV lasix on the floor which resulted in mild hypotension with ambulation.",0
Pt was not diuresed further but has been satting in the high 90's on RA w/o resp distress.,0
She was restarted on low dose bb for ?diastolic dysfunction.,0
)FEN - had 2 swallowing study performed.,0
"Currently as of , recommended for thin liquid and soft solid diet and whole meds w/ puree.",0
She should be followed for basic aspiration precautions.,0
)DM - lantus titrated up to 15 units qhs with humalog SS.,0
This can be further titrated at discretion of her PCP.,0
)HTN: stable after recovering from urosepsis and will be started on low dose bb.,0
)Hyperlipidemia: restarted on 10 qd on the floor.,0
)Gastritis: maintained on PPI for now.,0
"If pt does well over next several weeks, may consider d/c.",0
")Intermittent tachycardia: Late in course, pt w/ intermittent low grade tachycardia to 110, regular and narrow complex.",0
Aggressive w/u not sought at this time.,0
She was started on low dose BB (as had been on as outpt) and remained stable during the remainder of course.,0
)Dementia: pt cooperative during hospital course not requiring sedation/medication.,0
"As mentioned below, she has who should be consulted w/ re: medical decisions.",0
)dispo: Initial discussion w/ palliative care and pt/family planned for return to home after d/c from hospital.,0
"However, there were concerns from primary team and family about pt safety.",0
"After brief family meeting on , it was decided that pt would be safest at .",0
She remains DNR/DNI and is w/o defined HCP.,0
"However, is niece who can be reached at (h) or (c).",0
Medications on Admission: MOM prn 20 1g qd lasix 20 qd ?,0
bowel regimen Discharge Medications: 1.,0
Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 9 days: Take through .,0
Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain.,0
Milk of Magnesia 800 mg/5 mL Suspension Sig: teaspoons PO every 4-6 hours as needed for heartburn.,0
Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime.,0
"Humalog insulin sliding scale 8. outp meds commercial wound cleanser to apply q 3 days 9. wound cleaner please apply quacel to affected skin regions under breast followed by duoderm to skin regions q 3 days or prn AFTER commerical wound cleaner has been applied duoderm dispense 15 aquacel - dispense 100 grams, 5 refills 10. foley care foley catheter remains in place per protocol 11.",0
Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day).,0
"Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1) Injection twice a day.",0
PO once a day: may d/c in 2 weeks.,0
15. protonix please d/c in 2 weeks and resume only if develops sx.,0
"Discharge Disposition: Extended Care Facility: On - Discharge Diagnosis: urosepsis hematuria diabetes CHF gastritis hypertension hypercholesterolemia OA Discharge Condition: good Discharge Instructions: Please call your doctor if you have fever, dizziness, lightheadedness, chest pain, shortness of breath, pain with urination.",0
"We have started you on levofloxacin, to be taken through for your urinary infection.",0
Followup Instructions: Please make an appointment with Dr. to be seen within 7-10 days.,0
Please make an appointment to see Dr. in the division of urology within 2-4 weeks to workup the hematuria.,0
"Where: ORTHOPEDICS Phone: Date/Time: 10:00 Provider: ,THURSDAY ORTHOPEDICS-SCC2 Where: ORTHOPEDICS UNIT Phone: Date/Time: 10:20 Provider: , M.D.",0
Where: CENTER Phone: Date/Time: 1:30,0
"11:52 AM US EXTREMITY NONVASCULAR RIGHT Clip # Reason: Please evaluate for abscess, fluid collection Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with RLE cellulitis, now with area of fluctuance over right shin REASON FOR THIS EXAMINATION: Please evaluate for abscess, fluid collection ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:21 PM Edema but no fluid collections in the right shin area of tenderness.",1
"______________________________________________________________________________ FINAL REPORT HISTORY: A 40-year-old man with right lower extremity cellulitis with an area of fluctuance over the right shin, evaluate for abscess or fluid collection.",1
SOFT TISSUE ULTRASOUND COMPARISON: None.,0
"FINDINGS: In the region of the right shin in the area of redness, color and -scale son was performed.",0
"There is edema in the subcutaneous tissues, but no well-circumscribed fluid collections.",0
IMPRESSION: Edema but no fluid collections in area of tenderness at the right lower leg.,0
"3:40 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: CEREBELLAR MASS VERSUS STROKE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with increasing O2 requirements, mild pulmonary edema REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Increasing O2 requirements, mild pulmonary edema, evaluation for interval change.",0
"FINDINGS: As compared to the previous radiograph, the evidence of mild-to-moderate pulmonary edema is unchanged.",0
The presence of a left pleural effusion still cannot be excluded.,0
"Mild cardiomegaly, left-sided PICC line.",0
LINE PLACEMENT Clip # Reason: SL PICC inserted 42 cm to L cephalic.,0
Pls confirm tip placem Admitting Diagnosis: SEIZURE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with seizures REASON FOR THIS EXAMINATION: SL PICC inserted 42 cm to L cephalic.,0
Pls confirm tip placement ______________________________________________________________________________ WET READ: MPtb MON 10:47 PM New L PICC tip near cavoatrial junction.,0
"MPOWELL ______________________________________________________________________________ FINAL REPORT AP CHEST, 6:35 P.M., : HISTORY: Seizures.",0
IMPRESSION: AP chest compared to : The tip of the new left PIC line is at the superior cavoatrial junction.,0
"No pneumothorax, pleural effusion or mediastinal widening.",0
", E. OMED 7F 10:59 AM CENTRAL LINE PLCT Clip # Reason: triple lumen temporary line, spoke with , pt not NPO Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with CLL, chronic GVHD, pulled his LIJ out last night.",1
"REASON FOR THIS EXAMINATION: triple lumen temporary line, spoke with , pt not NPO ______________________________________________________________________________ PFI REPORT Uncomplicated successful placement of triple-lumen 7 French central venous catheter with tip terminating within the low SVC via a right internal jugular approach.",0
The line is flushed and ready to use.,0
6:48 PM CHEST (PORTABLE AP) Clip # Reason: check ETT and swan position Admitting Diagnosis: CHF\BENTALL PROCEDURE; PROXIMAL ARCH/SDA ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man s/p Bentall procedure/PDA closure.,0
"s/p intubation, RIJ and swan placement REASON FOR THIS EXAMINATION: check ETT and swan position ______________________________________________________________________________ FINAL REPORT HISTORY: Status post Bentyl procedure.",0
Status post intubation and Swan-Ganz catheter placement.,0
FINDINGS: AP PORTABLE SUPINE VIEW: The endotracheal tube terminates in satisfactory position at the thoracic inlet.,0
The right internal jugular Swan-Ganz catheter terminates in the main right pulmonary artery.,0
"The cadiac contour is poorly seen, but it appears unchanged.",0
"There is a persistent opacity in the left lung, likely representing atelectasis.",0
A pigtail catheter is again seen overlying the lower left hemithorax and the upper left abdomen.,0
Satisfactory position of the endotracheal tube and Swan-Ganz catheter.,0
"Persistent left lung opacity, likely representing atelectasis.",0
"9:42 PM CHEST (SINGLE VIEW) Clip # Reason: assess for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman cAD, CHF,m with R hip fx, L ulnar fx.",0
preop REASON FOR THIS EXAMINATION: assess for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Hip and ulnar fracture.,0
FRONTAL CHEST RADIOGRAPH: There is mild cardiomegaly.,0
"The lungs are clear, although the left costophrenic angle is incompletely evaluated.",0
"There is compression of the T12 vertebral body, age indeterminate.",0
The left costophrenic angle is incompletely evaluated.,0
"Compression of T12 vertebral body, age indeterminate.",0
7:32 AM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line while patient is in IR for J tube pro Admitting Diagnosis: RENAL FAILURE;RESPIRATORY FAILURE;DIABETES MELLITUS ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,1
ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with ESRD and multiple infections admitted for J tube replacement.,0
Central and peripheral access were attempted by IV nurse residents and attending.,0
REASON FOR THIS EXAMINATION: Please place PICC line while patient is in IR for J tube procedure.,0
______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT: INDICATION: IV access needed for antibiotics.,0
", and performed the procedure.",0
"Dr. , the Attending Radiologist, was present and supervised the entire procedure.",0
TECHNIQUE: A timeout was performed.,0
"Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set.",0
Hard copies of ultrasound images were obtained before and after establishing intravenous access.,0
"A peel-away sheath was then placed over a guidewire and a single lumen line measuring 24 cm in length was then placed through the peel-away sheath under fluoroscopic guidance, with its tip positioned in the mid-axillary vein due to known occlusions of the central venous system.",0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4-French single lumen line placement via the right brachial venous approach.,0
"Final internal length is 24 cm, with the tip positioned in mid axillary vein.",0
The line is ready to use as a midline.,0
(Over) 7:32 AM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line while patient is in IR for J tube pro Admitting Diagnosis: RENAL FAILURE;RESPIRATORY FAILURE;DIABETES MELLITUS ______________________________________________________________________________ FINAL REPORT (Cont),1
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: admitted from OSH s/p fall with subdural hematoma for management and evaluation Major Surgical or Invasive Procedure: None History of Present Illness: 89 y/o M with PMH of afib, DMII, hypercholesterolemia transferered to on for evaluation of subdural hematoma.",1
The patient initially presented to ED after having a syncopal episode on the morning of .,0
"Pt states that he went to his bathroom at 8 am to take a bath and was standing, turning on the fawcet and the next thing he remembers is finding himself lying on his back in the tub.",0
notes state that patient felt lightheaded prior to fall but patient later denied this.,0
"He denied any HA, CP or palpitations, shortness of breath, diaphoresis, dizziness/LH prior to fall.",0
"His daughter then called him at 9 am to help take him to an opthalmology appt, but pt did not answer phone.",0
"Ten minutes later daughter called him again and his father sounded ""breathy, winded"" and that he did not need to go to the doctor's office today and then his voice trailed off.",0
"The daughter then arrived at his apartment and found his father asleep in bed but with lacerations on both of his feet, specifically left toes.",0
"In bathroom, shower curtain rod was down on floor.",0
"Patient did not appear confused but seemed ""out of it"", no dysarthria, answered questions appropriately, no numbness/weakness in extremities, unclear if stool incontinence (soiled underwear in bathroom but often happens at baseline).",0
"Per daughters, patient has not taken his meds in 3 days, unclear if change in PO intake.",0
"ROS on admission: +HA frontal and temporal ""behind eyes"", no dizziness/LH, +neck pain secondary to collar, no melena, no BRBPR, no vision changes, no dysarthria, no n/v/abd pain, no sob.",0
Daughters state he has had falls in past after feeling dizziness/LH prior.,0
"At ED, found to have small L subdural hematoma with no midline shift or mass effect.",0
Was transferred to for further neurosurgical evaluation.,0
"Here in our ED, neuro exam unremarkable.",0
CT head without contrast confirmed right frontal subdural hematoma as well as low attenuation regions in L frontal and L anterior temporal lobes c/w infarctions and age indeterminant.,0
CT C-spine with no fracture.,0
No urgent neurosurgical intervention deemed necessary but admitted to ICU for q1hr neuro checks.,0
Also given 10 mg Vitamin K and 2 units FFP for INR 2.0.,0
Past Medical History: PMH (full records not available): 1) Atrial fibrillation on coumadin dxed 2) DMII 3) hypercholesterolemia 4) CAD 5) CHF with EF 30% by echo 6) Chronic renal insufficiency with baseline creat 2.0 7) h/o Zoster 8) Thrombocytopenia with plt count as low as 125 in Social History: Lives home alone.,1
Wife passed away from cancer.,0
Independent with all ADLs and IADLs.,0
"Family History: NC Physical Exam: T 96.6 BP 140/44 P 67 R 14 Sat 93-95% RA Gen: A+O x 3, lying comfortably, NAD, speech clear, answering ?",0
"'s appropriately HEENT: R surgical pupil and left pupil 1mm minimally reactive, EOMI, OP clear with MM slightly dry, OP clear CV: irreglarly irregular, no m/r/g Pulm: CTA anteriorly Abd: + BS, soft, NT, ND Ext: no LE edema to knees, +2 DP pulses bilaterally; R LE with purple discoloration over lateral aspect Neuro: CN 2-12 intact, strength 4+/5 equal and symmetric bilaterally, DTRs 2+ throughout flexors and extensors, neg Babinski, no pronator drift Skin: Abrasions on LEs.",0
Left foot with dressing c/d/i.,0
No overt CHF or pulmonary consolidations.,0
"Coarse bilateral interstitial markings, which may be chronic in nature.",0
"Comparison with prior outside radiographs is recommended, if available.",0
CT C-spine : Degenerative disease with no evidence of acute fracture.,0
Straightening of the normal cervical lordosis.,0
Emphysematous disease of the lung apices.,0
"CT head without contrast : isodense, extraaxial material c/w right frontal subdural hematoma; low attenuation regions in L frontal and L ant temporal lobes c/w infarctions, age indeterminate CT head without contrast : No significant interval change from previous day's study.",0
Echo : The left atrium is moderately dilated.,0
Overall left ventricular systolic function appears preserved (ejection fraction ?55%) but views are suboptimal.,0
"EKG: slow afib, rate 50 bpm, TWI III, V1 and V2; flat AVF, V4 and V6, no baseline for comparison Brief Hospital Course: 1.",0
"89 y/o M with h/o afib, CAD, hypercholesterolemia who presented s/p syncopal fall with new subdural hematoma.",1
SDH was felt to be likely a consequence of the syncopal fall.,0
Patient was initially admitted to ICU for close neurological monitoring and remained neurologically stable.,0
Head CT was repeated in 24 hours to assess for interval changes and SDH appearance was stable.,0
Neurosurgery recommended to hold anticoagulation for 4 weeks and to keep platelets >100 for 7 days after the event.,0
The patient may continue Aspirin.,0
The follow up appointment with neurosurgery was arranged for the patient.,0
He will follow up with neurosurgery in 3 months and will have CT head repeated prior to the appointment.,0
Etiology of syncopal fall was not entirely clear.,0
"As part of work up for syncope, the patient was ruled out for MI with two sets of enzymes.",0
Carotid US was done and showed <40% bilateral carotid artery stenosis.,0
CT head was negative for acute pathology that would explain syncopal event.,0
The etiology of his syncope was felt possibly to be due to orthostasis.,0
The patient was orthostatic initially on the floor.,0
Cosyntropin stim test was done to r/o adrenal insufficiency was normal.,1
Tamsulosin was discontinued to eliminate this as a cause of the patient's syncopal fall.,0
The patient was transfused one units of pRBCs and platelets and his orthostasis has resolved.,0
The possibility that he was dehydrated from Lasix and/or poor po intake prior to admission was entertained to explain his orthostasis.,0
Electrophysiology were consulted with the question of whether patient's slow a fib could have caused his syncope (patient with a fib with rate down to high 30's on telemetry at night) and whether he would be a candidate for a pacemaker.,0
They felt that this was unlikely and that no further EP investigation was warranted.,0
Patient had mild elevation of creatinine on admission from his baseline Cr of around 2.0.,0
Lasix was held and his Cr remained stable and was 1.7 at the time of discharge.,0
The patient has been in slow afib with HR down to high 30's when asleep.,0
Coumadin was held given new SDH.,0
Digoxin level was checked on admission and was 0.5.,0
Digoxin was held given his slow rate.,0
EP did not think that his syncope was from cardiac cause and felt that a pacemaker was not necessary.,0
They recommended Holter as an outpatient.,0
"Given patient's slow heart rate, his digoxin should not be restarted.",0
"If the patient starts having rapid atrial fibrillation, EP recommended metoprolol for rate control.",1
From and records appears to have baseline in low 100s.,0
Consider BM bx as outpatient given anemia and thrombocytopenia.,1
The patient was continued on Statin.,0
The patient was not on any antihypertensive .,0
His SBP were mostly within the normal range.,0
"If he needs to be started on a medication for BP control, would favor starting a beta-blocker as heart rate tolerates.",0
This was an incidental finding on CT head.,0
The patient was continued on aspirin 81 mg. 9.,0
The patient has a h/o systolic dysfunction and EF around 30%.,0
Echocardiogram was repeated here as part of work up for syncope and showed EF 55% but mild LVH.,0
Diuretics have been held during this hospital admission as the patent appeared euvolemic and because of slight increase in creatinine from baseline.,0
The patient will need to be closely monitored for signs of decompensated CHF with daily weight.,0
He needs to be on low Na diet.,0
Lasix can be given on as needed basis.,0
Work up showed no signs of intravascular hemolysis.,0
This felt likely to be secondary to hematomas after the fall.,0
Baseline HCT 36-38 from records.,0
Patient had slow decreased in HCT of about 3 points from admission and remained hemodynamically stable.,0
There was no evidence of hemolysis.,0
Fe studies were not consistent with iron deficiency anemia.,1
B12 level was low normal and the patient was started on B12 supplements.,0
Reticulocyte index was low 2.1% (not adjusted).,0
The patient is discharged on Epogen given his renal insufficiency.,1
The patient received a total of 2 units of pRBCs today for orthostatic hypotension.,0
UPEP and SPEP were checked and were normal.,0
Flomax was stopped to eliminate this as a cause of orthostatis.,0
Glycemic control was initially maintained with Insulin sliding scale.,0
The patient was then restarted on Avandia.,0
His finger sticks were mostly in low 100's.,0
Serum calcium was nornal but the patient did have an elevated Alk Phos and high PTH.,0
His secondary hyperparathyroidism is possibly due to chronic renal insufficiency.,1
The patient was started on Vitamin D supplements.,0
Lasix 80 mg daily 2.,0
Coumadin 4.5 mg daily 3.,0
Digitek 0.125 mg daily 4.,0
Namenda 10 mg daily 5.,0
Avandia 4 mg daily 6.,0
Mobic 15 mg daily 7.,0
Aricept 10 mg daily 8.,0
Lipitor 20 mg daily 9.,0
Aldactone 25 mg daily 10.,0
Flomax SA 0.4 mg daily Discharge Medications: 1.,0
Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Memantine 5 mg Tablet Sig: Two (2) Tablet PO qd ().,0
Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.,0
"Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection once a week.",0
Discharge Disposition: Extended Care Facility: Of Discharge Diagnosis: Primary diagnoses: 1.,0
Syncopal fall Seondary diagnoses: 1.,0
"Cerebrovascular accidents, seen on CT head Discharge Condition: Vital signs and neuro exam stable.",0
Discharge Instructions: Please take all medications as prescribed.,0
The patient should not be on Coumadin for 4 weeks until .,0
Then risk and benefits of continuing anticoagulation will need to be discussed with the patient's primary care physician.,0
Please follow up as listed below.,0
Please return to hospital if the patient having any new neurological symptoms or any other concerning symtpoms.,0
Followup Instructions: Please follow up with Dr. within 2 weeks after leaving the hospital.,0
Discuss risks and beneftis of restarting Coumadin with your doctor.,0
DIscuss if you need Holter monitor with your primary care doctor.,0
You will need to have a repeat CT head and a follow up with neurosurgery on the same date.,0
"Your CT scheduled for at 10 am on the , .",0
Appointment with Dr. at 11 am.,0
Please call ( with questions or if you need to reschedule.,0
"8:28 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: PLEASE DO CT AT SAME TIME AS HEAD CT,r/o retroperitoneal ble Admitting Diagnosis: CVA;TELEMETRY Field of view: 44 ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with R MCA on CT , s/p TPA,fem access bleed, now further MS changes, REASON FOR THIS EXAMINATION: PLEASE DO CT AT SAME TIME AS HEAD CT,r/o retroperitoneal bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: FKh FRI 1:37 AM Large right groin hemathoma.",0
"Moderate Hydronephrosis, but the ureters go all the way to the bladder.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 84 year old woman with right inguinal hematoma.,0
COMPARSION: No comparisons are available.,0
TECHNIQUE: Noncontrast CT of the abdomen and pelvis.,0
CT ABDOMEN W/O IV CONTRAST: There is scarring or atelectasis at the lung bases.,0
There are no consolidations or pleural effusions.,0
There are multiple large stones in the gallbladder.,0
The infrarenal abdominal aorta is ectatic and measures 3.0 cm at the largest diameter.,0
There is bilateral moderate hydronephrosis.,0
"However, the uterus go all the way to the pelvis without evidence of intraabdominal obstruction.",0
There is a large extrarenal pelvis on the right.,0
There is calcification of the aorta.,0
"The liver, spleen, adrenal glands, pancreas, are within normal limits.",0
There is no hematoma in the abdomen.,0
CT PELVIS W/O IV CONTRAST: There is a large hematoma in the right groin.,0
There is no significant retroperitoneal extension.,0
There is a Foley catheter within the bladder.,0
"There is no evidence of fluid in the urinary bladder, but there is air within the urinary bladder.",0
"The kidneys are retaining contrast, which can be seen in ATN.",0
"There is proeminence of the collecting system bilateraly, but no evidence of obstruction..",0
There is a severe uterine prolapse and the uterus is seen in the vagina with calcifications.,0
There is no significant pelvic lymphadenopathy.,0
Small inguinal lymph nodes do not meet CT criteria for pathology.,0
BONE WINDOWS: There is severe demineralization of the bones.,0
There are multiple compression fractures of the thoracic and lumbar spine of indeterminate age.,0
There are no suspicious lytic or blastic lesions.,0
"IMPRESSION: (Over) 8:28 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: PLEASE DO CT AT SAME TIME AS HEAD CT,r/o retroperitoneal ble Admitting Diagnosis: CVA;TELEMETRY Field of view: 44 ______________________________________________________________________________ FINAL REPORT (Cont) 1) No significant retroperitoneal extension of the large right groin hematoma.",0
4) Multiple compression fractures of the thoracic and lumbar spine of indeterminate age.,0
"11:10 AM TIB/FIB (AP & LAT) LEFT Clip # Reason: s/p fall, rule out fracture ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with s/p fall with SDH, SAH, left leg ecchymosis REASON FOR THIS EXAMINATION: s/p fall, rule out fracture ______________________________________________________________________________ FINAL REPORT INDICATION: 84-year-old female S/P fall with leg ecchymosis and pain.",0
"LEFT LEG, TWO VIEWS: There is a total knee prosthesis.",0
The alignment is anatomic and there is no evidence of hardware failure.,0
A well-defined opacity seen in the lateral view only along the distal fibula likely represents a bone island.,0
IMPRESSION: No evidence of fracture.,0
"3:18 PM CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # Reason: please re-read head and C/spine ______________________________________________________________________________ MEDICAL CONDITION: year old woman with MCV, positive FAST REASON FOR THIS EXAMINATION: please re-read head and C/spine No contraindications for IV contrast ______________________________________________________________________________ WET READ: 3:44 PM no evidence of intracranial injury.",1
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT HISTORY: -year-old female status post MVC.,0
STUDY: CT of the head without contrast; please note images were acquired at and have been submitted for second read; coronal reformatted images have also been provided.,0
"FINDINGS: There is no intracranial hemorrhage, edema, or mass effect.",0
The ventricles and sulci are unremarkable in size given the patient's age.,0
A left cheek soft tissue hematoma is present.,0
IMPRESSION: No evidence of intracranial injury.,1
4:40 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for new cardiopulmonary findings.,0
"Admitting Diagnosis: RECTAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with increased RR, recent vomiting, ?aspiration.",0
REASON FOR THIS EXAMINATION: Please eval for new cardiopulmonary findings.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Vomiting with possible aspiration.,0
"FINDINGS: In comparison with the study of , there are substantially lower lung volumes, which may account for much of the prominence of the cardiomediastinal silhouette.",0
"There is an area of increased opacification at the left base that could be consistent with aspiration, though atelectatic change cannot be excluded.",0
A left central catheter extends to the mid portion of the SVC as on the previous study.,0
"5:26 PM CT CHEST W/O CONTRAST Clip # Reason: eval sternum, effusions Admitting Diagnosis: MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with mid sternal serous drainage REASON FOR THIS EXAMINATION: eval sternum, effusions CONTRAINDICATIONS for IV CONTRAST: Creat ______________________________________________________________________________ FINAL REPORT INDICATION: Midsternal serous drainage.",1
COMPARISON: No prior chest CT is available for comparison.,0
Additional thin section reformatted images are provided.,0
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: The patient is status post median sternotomy with multiple sternal suture wires.,0
The sternal suture wires appear intact and there is no evidence of sternal dehiscence or of irregularity at the sternotomy site.,0
There is a marked quantity of fluid within the mediastinum and in retrosternal location.,0
"The quantity of fluid is more prominent than that expected for the chronicity of the patient's prior surgery, approximately 10 days ago.",0
There is a moderate pericardial effusion.,0
"Bilateral pleural effusions, right greater than left, with loculated components of the right pleural effusion anteriorly and laterally, and with fluid layering within the right major fissure and within the left major fissure.",1
"There are prominent coronary artery calcifications, and mediastinal clips.",1
"There is intralobular septal thickening and ground-glass opacity, consistent with congestive heart failure/volume overload.",1
Additional stranding is seen within the subcutaneous tissues of the chest wall consistent with anasarca.,0
"There is severe tracheomalacia, with bowing of the posterior membrane and near complete collapse of the tracheal lumen within the mid thoracic trachea (series 2, image 16).",0
Small amount of air tracking within the soft tissues of the anterior chest wall on the right.,0
"The pleural fluid, pericardial fluid, and retrosternal fluid are predominantly low in density, although there is a suggestion of possible heterogeneous density within a component of the upper mediastinal fluid collection.",0
This is limited in evaluation due to lack of intravenous contrast.,0
A right internal jugular venous access catheter terminates in the proximal right atrium.,0
"Limited images of the upper abdomen demonstrate a large hiatal hernia, a calcification within the spleen, and a calcified gallstone.",0
"The visualized portions of the liver, adrenal glands, and upper poles of the kidneys appear unremarkable.",0
"(Over) 5:26 PM CT CHEST W/O CONTRAST Clip # Reason: eval sternum, effusions Admitting Diagnosis: MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ FINAL REPORT (Cont) BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or sclerotic osseous lesions.",1
The sternotomy site demonstrates no evidence of dehiscence.,0
"IMPRESSION: 1) Large amount of retrosternal/mediastinal fluid, and bilateral pleural effusions, including loculated right pleural effusion.",1
"While some amount of retrosternal fluid can be visualized up to 15 days post-median sternotomy, the amount of fluid in the mediastinum and right pleural space is unusual, and infection within these collections should be considered in the appropriate clinical setting.",0
2) Congestive heart failure and anasarca.,1
"3) Severe tracheomalacia demonstrated within the mid trachea, with near complete collapse of the tracheal lumen.",0
"Once the patient is clinically stable, a dedicated CT examination of the trachea may be helpful in delineating the full extent of tracheomalacia.",0
2:19 PM CT HEAD W/O CONTRAST Clip # Reason: ICH/ischemic infarct Admitting Diagnosis: MI ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman s/p cardiogenic shock/VF arrest REASON FOR THIS EXAMINATION: ICH/ischemic infarct No contraindications for IV contrast ______________________________________________________________________________ WET READ: JXKc 3:06 PM No acute process.,1
"Dense diffusely, may reflect sequela of recent contrast administration.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old female status post cardiogenic shock, VF arrest.",1
Evaluate for intracranial hemorrhage or ischemic infarct.,0
TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast.,0
"FINDINGS: There is no intracranial hemorrhage, edema, mass effect, shift of normally midline structures, or acute major vascular territorial infarction.",1
"The ventricles and sulci are prominent, likely reflective of atrophy.",0
"The vascular structures are hyperdense diffusely, which likely reflects recent contrast administration.",0
Visualized paranasal sinuses and mastoid air cells are normally aerated.,0
"Hyperdense , reflect sequela of recent contrast administration.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Tracheostomy and GJ feeding tube placements Total abdominal colectomy with end ileostomy () History of Present Illness: 52 yo female with history of Syndrome, atrial fibrillation, CHF (?",1
"diastolic, last EF 70%), history of MVR s/p valvuloplasty , recent recurrent PNAs (last w/MSSA PNA s/p intubation), and severe COPD, who presents with shortness of breath.",1
Has had body aches for the last 2 days.,0
"She reports increased SOB, but denies cough, sputum, fever, chills, abdominal pain, nausea, vomitting, diarrhea, or dysuria.",0
"Normally, she is on oxygen at rehab on LNC.",0
"Because of the shortness of breath and fever, she was sent to the ED.",0
"In the ED, the patient had the following vital signs: 98.6 120 92/60 18 97% NRB.",0
"She was noted to be in a fib with RVR with rates up to the 140s, however, she was not rate controlled for fear of patient being periseptic.",0
"The patient was given levofloxacin 750mg IV ONCE, ceftriaxone 1gm IV ONCE.",0
The patient was given 2L of NS thinking she was tachycardic from dehydration.,0
"She was also given combivent, and morphine 2mg IV x 2 and tylenol 1gm PO ONCE for body pain and dyspnea.",0
Last set of vitals were: 98.1 131 106/61 22 90%5LNC.,0
"In the MICU, she arrived in acute respiratory distress and tachypneic with heart rate in the 130s in a fib with RVR, and hypoxic to the 80s on 6LNC.",1
"She was given morphine 1mg IV x 2, lasix 20mg IV x 1 (leading to 300cc of urine in hrs), a trial of bipap for 15 minutes with significant improvement in her symptoms.",0
"She was also given 5mg and 10mg IV dilt for HR in 140s, followed by dilt 60mg PO QID with improvement in her rate down to 110s.",0
"Past Medical History: PMH: syndrome, developmental delay, steroid-induced diabetes, afib with left atrial clot, diastolic CHF, COPD, diverticulitis, MR, malnutrition PSH: mitral valvuloplasty ( - ) Social History: She was at Bostonian after last discharge.",1
"Generally, lives in with 2 brothers.",0
"brothers, no longer able to walk or take care of ADLs; decline in last few months since recurrent PNAs.",0
"Former smoker, smoked PPD for 30 years, quit 2 years ago.",0
No EtOH or ilicit drugs.,0
Family History: Coronary artery disease.,0
"No other congenital abnormalities in the family Physical Exam: On admission: GEN: Small, pale, woman with facies, tachypneic, using excessory muscles to breath HEENT: Anisocoria (old), anicteric, dry MM, op without lesions, mildly elevated jvd, RESP: Bibasilar rales R>L, moderately reduced airflow, no wheezes, positive egophony at right base CV: Tachycardic, irregular, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3.",1
Pertinent Results: 10:47AM BLOOD WBC-26.0* RBC-2.91* Hgb-7.6* Hct-25.2* MCV-87 MCH-26.3* MCHC-30.3* RDW-19.5* Plt Ct-86* 10:47AM BLOOD ALT-4019* AST-5755* LD(LDH)-PND AlkPhos-57 TotBili-4.5* 10:58AM BLOOD Type-ART pO2-81* pCO2-45 pH-7.11* calTCO2-15* Base XS--15 10:58AM BLOOD Lactate-14.6* CXR : COMPARISON: .,0
Patient is status post median sternotomy.,0
"The lungs are hyperinflated, consistent with chronic obstructive pulmonary disease.",1
"Since the prior study, there has been development of bibasilar, right greater than left opacities, worrisome for pneumonia.",0
There is also blunting of the bilateral costophrenic angles concerning for small pleural effusions with possible pleural thickening.,0
Minimal superimposed pulmonary vascular congestion may also be present.,0
"Large right base opacity and possible small left base opacity, worrisome for pneumonia.",0
Possible small bilateral pleural effusions and/or pleural thickening.,0
CXR : Comparison is made with prior study performed a day earlier.,0
The lungs are hyperinflated consistent with patient's known COPD.,0
"Pneumonic consolidations, right greater than left are unchanged.",0
Probable small bilateral pleural effusions are stable.,0
CXR : A tracheostomy tube and left-sided PICC are in unchanged positions.,0
"The lungs are stable in appearance with background emphysema, bilateral pleural effusions and extensive consolidations which are greater on the right.",0
Probable atrial fibrillation with moderately controlled ventricular response.,1
Low QRS amplitude in the limb leads.,0
RSR' pattern in lead V1 is probably a normal variant.,0
Compared to the previous tracing of the ventricular response is more controlled.,0
Non-specific ST-T wave changes persist.,0
ECHO : The left atrium is elongated.,0
The right ventricular cavity is moderately dilated with borderline normal free wall function.,0
A mitral valve annuloplasty ring is present.,0
The mitral annular ring appears well seated with normal gradient.,0
"Brief Hospital Course: 53 yo female with history of Syndrome, atrial fibrillation, CHF (?",1
"diastolic, last EF 70%), history of MVR, recent recurrent PNAs, and severe COPD, who presents with shortness of breath, leukocytosis, bandemia, and RLL infiltrate.",1
#Lactic acidosis: Patient developed abd pain and required pressors overnight on .,0
Her lactate rose and her cdiff toxin returned positive.,0
She was started on pressors at times maxed levofed and neo.,0
Flaygl was started and surgery was consulted and determined need for emergent OR for colectomy.,0
"Dyspnea/hypoxia: Patient with a white count of 29 with bandemia, and dense RLL consolidation, which raises the concern for acute bacterial pneumonia.",1
"She has a history of MSSA but also given her stay at a rehab facility, healthcare associated pneumonia and hospital acquired pneumonia were also considered.",0
Also there was a component of acute pulmonary edema and COPD.,0
PE is unlikely given clear precipitant for dyspnea/hypoxia and that patient has been therapeutic on coumadin.,0
"Patient treated with Vanc/cefepime/levofloxacin given her recent hospitalization within 90 days, her stay at rehab, and severity of illness as well as MRSA positive in her Nares.",0
She was put on standing albuterol and ipratropium nebulizers and home dose of steroids.,0
Patient was diuresed with 20 IV lasix daily.,0
Over the first 5 days of admission the patient required 60-80% high flow to maintain sats in the 90s.,0
"Due to lack of clear improvement and concern for increasing sputum, she had a bronch (awake) which showed minimal secreations but significant airway collapse.",0
BAL fluid sent for culture and grew sparse coag + staph and spare yeast.,0
"On , the patient desaturated throughout the morning and on ABG was found to have pCO2 >80.",0
"She was intubated for hypercarbic respiratory failure and afterwards, significant secretions suctioned out.",1
Her abx were stop and she was given a bust of methylpred again with plans for long taper.,0
It is possible she mucus plugged or aspirated on her secretions in the morning prior to being intubated.,0
"Of note, the patient's CT chests document very little apical parenchymal reserve and significant blebs.",0
The patient tolerated mechanical ventilation well and was switched from assist control to pressure support.,0
Spontaneous breathing trial on was uneventful and patient was extubated on .,0
"On , she was weaned down to 5 L nasal cannula, but that same night, she developed an increasing O2 requirement.Intermittantly she was having mucuous plugging.",0
"All the while, discussions were held with the family about if she needed reintubation that she would require trach.",0
Acapella devicse used to help with chest PT.,0
Her steroids were down titrated.,0
"On , the patient developed incrasing hypoxia and was reintubated.",0
WBC was noted to rise to 23.8 and abx were restarted to cover VAP with Linezolid/tobra and zosyn.,0
Interventional pulmonology performed a tracheostomy on .,0
"However, interventional pulmonology was unable to place a PEG due to esophageal stenosis.",0
She underwent IR placement of JG tube on .,0
She was put on pressure support once trached which she tolerated initially but would pull low tidal volumes and needs resting at night or after oxycodone.,0
Her prednisone was down titrate.,0
She tolerated 2 hours of trach collar on .,0
"On , she tolerated trach collar for many hours but became hypercarbic to pCO2 of 57 and was put on the vent to let her rest.",0
Plan was initiated to use trach collar during the day and vent at night.,0
She completed 8 day course of zosyn on and will complete 10 day course of linezolid on .,0
"- Continue linezolid 600mg twice daily until (day ) - Continue albuterol nebs every 6 hours, ipratropium 6 puffs QID and Flovent 6 puffs twice daily .",0
#Fungal UTI: s/p 4 days of fluconazole with resolution of symptoms.,0
"# Nutrition: Patient with very poor PO intake during hospitalization, albumin low at 2.9.",0
Nutrition was consulted and the patient started on TPN.,0
consider eventual esophageal motility testing for CREST syndrome component to Disease.,0
"A Dobhoff was placed on , with placement confirmed by x-ray.",0
Tube feeds were started on although the Dobhoff then clogged.,0
"NGT was placed instead, which the patient tolerated well and maintained during intubation.",0
The patient received tube feeds during this time.,0
Interventional pulmonology attempted to place a PEG on but was unsuccessful due to esophageal stenosis.,0
Tube feeds started through G-J tube on .,0
"- Continue tube feeds: Nutren 2.0 Full strength; Starting rate: 30 ml/hr; Advance rate by 10 ml q12h Goal rate: 30 ml/hr Residual Check: q4h Hold feeding for residual >= : 200 ml Flush w/ 30 ml water q6h - Continue multivitamin, Vitamin B12 50mcg daily and Vitamin D 400mg daily - Continue lansoprazole, simethicone and zofran for GI upset, nausea .",0
Hypotension: Patient became hypotensive overnight on likely related to escalating doses of metoprolol amd small doses of narcotics and ultram which she seems sensitive to.,0
She required levophed for a brief term.,0
Cortisol levels could not be checked in setting of recent prednisone.,0
Her blood pressures were monitored through her arterial line.,0
BPs ranged from hypotensive (thought meds) to hypertensive (possibly pain related) and normalized on their own.,0
- Continue home digoxin and metoprolol per below - Limited narcotic medications for pain (oxycodone 2.5mg q8 hours if absolutely necessary).,0
"Atrial fibrillation with RVR: Most likely precipitant is infection, hypoxia, and dyspnea.",1
"Rate well controlled on PO diltiazem and home digoxin - this was later decreased to 30mg QID and her metoprolol decreased from 12.5 mg TID to given bradycardia into HR50s (asymptomatic), especially when intubated.",0
Coumadin was held for supratherapeutic INR and the patient started on lovenox bridge.,0
"Metoprolol was uptitrated again briefly for BP and HR control, but subsequently was downtitrated due to bradycardia.",0
Diltiazem was stopped on .,0
She was bridged back to coumadin after her procedures.,0
Metoprolol was increased to 25 mg on but held for hypotension and then decreased to 12.5mg .,0
- Continue Digoxin 0.125mg daily - Continue Metoprolol 12.5mg twice daily - Check INR daily as supratherapeutic on discharge.,0
Resume home coumadin 5mg daily when INR <2.5 .,0
History of dCHF: Patient with MVR s/p valvuloplasty in .,0
Lasix was initially used for aggressive diuresis and beta blockers given judiciously.,0
"The patient was felt to be overly diuresed eventually and received a few small fluid boluses while intubated, for lower urine output.",0
Gentle diuresis was resumed when she developed lower extremity edema (+).,0
ECHO was obtained with showed 3+TR and severe pulmonary hypertension.,0
- Continue gentle diuresis with Furosemide 20mg daily PRN (previous home dose was 20mg daily) .,0
Diabetes Type II: Steroid exacerbated.,0
Patient continued on lantus and SSI both of which were increased/tightened throughout hospital course.,0
"As the patient's steroids were tapered, her insulin requirement decreased.",0
Glargine was stopped on for hypoglycemia and her sliding scale was made more conservative to only cover glucose >200.,0
"- Continue low insulin sliding scale (fingersticks every 6 hours, 2 units for BS>200, 4 units for BS>250, 6 units for BS>300).",0
The patient can possibly be transitioned off insulin now that she is off steroids.,0
COPD: Patient on recent long steroid taper since .,0
Patient is on long acting advair and spiriva.,0
Patient quit smoking >2 years ago but has >40 pack year history.,0
"She was continued on standing nebs and advair, as well as steroids (intermittently home 10mg or 30mg vs. IV solumedrol).",0
"In particular, the patient was on IV solumedrol during intubation and slowed tapered to PO steroids.",0
Her spiriva was ultimately restarted and atrovent was discontinued.,0
"- Continue albuterol nebs every 6 hours, ipratropium 6 puffs QID and Flovent 6 puffs twice daily .",0
"Contact: (brother and HCP): , (brother) .",0
"Code: DNR, okay to intubate (trach/PEG) The above discharge summary was dictated by the MICU service.",0
On her care was taken over by the surgical team.,0
"She developed fulminant c.difficuile with a dramatically elevated WBC (18), INR (6.1) and lactate (14) with an increasing pressor requirement and concern for abdominal compartment syndrome.",1
She was taken emergently to the OR for a total abdominal colectomy with end ileostomy.,0
She was taken to the SICU intubated and on pressors post-operatively.,0
Echo findings demonstrated dramatic pulmonary hypertension and left-sided heart failure.,1
She required CVVH for anuric renal failure and dramatic volume overload.,0
Her liver enzymes increased and she developed shock liver.,1
She was difficult to ventilate and began having arrythmias.,0
"She was treated with zosyn, flagyl and vanco enemas for her rectal remanant but remained floridly septic with hypotension, hypothermia and profound acidosis.",0
After discussion with her two brothers the decision was made to make her CMO as her chance of recovery was thought to be very slim and she had previously expressed a desire that no extraordinary measures be taken to extend her life.,0
Medications were discontinued and she expired shortly thereafter.,0
Medications on Admission: 1. senna 8.6 mg Tablet Sig: One Tablet PO BID PRN Constipation.,0
2. bisacodyl 2 5 mg Tablet TabletPO DAILY PRN Constipation.,0
3. docusate sodium 50 mg/5 mL 10cc PO BID 4. digoxin 125 mcg Tablet PO DAILY 5. montelukast 10 mg Tablet One Tablet PO DAILY 6. therapeutic multivitamin 5cc PO DAILY 7. cholecalciferol (vitamin D3) 400 unit Two TAB PO DAILY 8. cyanocobalamin (vitamin B-12) 500 mcg 2 TAB PO DAILY 9. guaifenesin 600 mg Tablet Extended Release PO BID 10. tiotropium bromide 18 mcg Capsule INH DAILY.,0
"11. levalbuterol HCl 0.63 mg/3 mL Q4hrs as needed for wheezing, 12. trazodone 50 mg PO HS as needed for insomnia.",0
13. lorazepam 0.5 mg PO Q8H (every 8 hours) as needed for anxiety.,0
14. metoprolol tartrate 25 mg PO QID 15. diltiazem HCl 60 mg Tablet PO QID 16. fluticasone-salmeterol 250-50 mcg/dose Disk (2 times a day).,0
17. polyethylene glycol 3350 17 gram PO DAILY 18. warfarin 5 mg PO Once Daily 19. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime 20. furosemide 20 mg PO daily .,0
"Allergies: NKDA Discharge Medications: Not applicable Discharge Disposition: Extended Care Discharge Diagnosis: Respiratory distress (COPD, pneumonias) s/p intubation and tracheostomy, malnutrition, steroid-induced diabetes, atrial fibrillation on anticoagulation, diastolic CHF, fulminant c.diff with ensuing sepsis Discharge Condition: Death Discharge Instructions: Death Followup Instructions: Death",1
Status: Inpatient Date/Time: at 11:02 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.,1
Conclusions: PREBYPASS No atrial septal defect is seen by 2D or color Doppler.,1
There is mild symmetric left ventricular hypertrophy with a prominent septal knob.,0
POSTBYPASS Biventricular systolic function remains normal.,0
"There is a well seated, well functioning bioprosthesis in the aortic position.",0
Trace valvular AI is present.,0
The MR now appears mild.,0
The study is otherwise unchanged from prebypass.,0
"1:45 PM CT HEAD W/O CONTRAST Clip # Reason: Please eval for interval changes, evidences of new CVA Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with ?",0
"change in speech since awaking this AM REASON FOR THIS EXAMINATION: Please eval for interval changes, evidences of new CVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of prior CVA with change in speech.",0
"COMPARISON: Head CTs dated and , both from .",0
TECHNIQUE: Contiguous axial MDCT-acquired images of the head were obtained without administration of intravenous contrast.,0
"FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or other CT sign of an acute major acute vascular territorial infarction.",0
"The ventricles and sulci are prominent in size and configuration compatible with global age-related parenchymal atrophy, unchanged.",0
"Periventricular, deep, and subcortical white matter hypodensities are likely due to chronic small vessel ischemic disease.",0
There are no significant changes from the two prior studies.,0
"There is mucosal thickening in the imaged portions of the maxillary sinuses, left greater than right.",0
The bones are grossly unremarkable.,0
IMPRESSION: No evidence of an acute intracranial abnormality.,0
"MRI would be more sensitive for an acute infarction, if clinically indicated.",0
5:36 PM MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Reason: evaluate for R MCA stroke Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man s/p day 2 CABDG with R MCA syndrome REASON FOR THIS EXAMINATION: evaluate for R MCA stroke No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn MON 2:03 PM PFI: 1.,1
"Multiple punctate acute infarcts bihemispherically in watershed distribution, many more on the right than on the left.",0
High-grade proximal right internal carotid artery stenosis.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old man status post CABG with right MCA syndrome.,0
COMPARISON: Non-contrast head CT from .,0
TECHNIQUE: MRI and MRA of the brain were performed without intravenous gadolinium.,0
MRA of the neck was performed prior to and following gadolinium per standard departmental protocol.,0
"MRI OF THE BRAIN: There are multiple punctate foci of restricted diffusion, within the right centrum , corona radiata, and subcortical white matter, as well as in a parasagittal location in the left parietal lobe, and the left parietal subcortical white matter.",0
These appear to be in watershed distributions.,0
Several of these are vaguely hyperintense on the T2/FLAIR images.,0
There is a punctate focus of susceptibility artifact in the right frontal lobe (7:16).,0
The major intracranial flow voids appear preserved.,0
"The ventricles and sulci are mildly prominent, suggestive of age-related involutional change.",0
There is minimal mucosal thickening of the ethmoid and maxillary sinuses.,0
The signal within the bone marrow is within normal limits.,0
MRA OF THE BRAIN: There is decrease in flow signal in the cavernous internal carotid arteries bilaterally suggestive of atherosclerotic disease.,1
There is no evidence of occlusion or aneurysm.,0
There also appears to be some atherosclerotic narrowing of the inferior division of the right middle cerebral artery.,1
MRA OF THE NECK: The venous phase is degraded by motion artifact.,0
There is a high-grade stenosis involving the proximal right internal carotid artery just after the origin.,1
"No flow signal is seen to traverse this, though it cannot be appropriately graded.",0
"(Over) 5:36 PM MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Reason: evaluate for R MCA stroke Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ FINAL REPORT (Cont) The origins of the other great vessels appear unremarkable off of the aortic arch, the origins of the vertebral arteries are identified, the right appears unremarkable, and the left demonstrates some probable stenosis, although flow signal is seen throughout.",1
The common carotid arteries are unremarkable throughout their course.,0
The distal right internal carotid artery measures 4 mm and the distal left internal carotid artery measures 5 mm.,1
12:44 PM CTA HEAD W&W/O C & RECONS Clip # Reason: ?,0
"Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with SAH, not moving upper extremities.",1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old female with a history of subarachnoid hemorrhage status post coiling of the anterior communicating artery, who presents for evaluation of new onset decreased bilateral upper extremity movement.",1
COMPARISON: Head CTA's from and ; and non-contrast head CTs from and .,0
"Subsequently, rapid axial imaging was performed through the brain during infusion of 100 mL of Omnipaque intravenous contrast material.",0
"FINDINGS: NON-CONTRAST HEAD CT: In comparison with the prior head CT dated , , there has been no interval change in the overall amount of subarachnoid and intraventricular hemorrhage.",1
There has been interval improvement of the right frontal lobar parenchymal hemorrhage with unchanged surrounding edema.,0
"Again seen is streak artifact related to coil-pack in the the anterior communicating artery aneurysm, obscuring the anatomic detail in this area.",0
"The ventriculostomy catheter, via a right transfrontal burr hole, is unchanged in position from the prior exam.",0
The ventricular size is unchanged; there is no evidence of hydrocephalus.,0
"Periventricular white matter hypodensities are again demonstrated, consistent with chronic small vessel ischemic disease.",0
"In the context of significant background white matter disease, there is no finding to suggest acute territorial infarction, as the -white matter differentiation is otherwise preserved.",1
"Again noted are fluid and secretions layering dependently in the nasopharynx, likely related to the presence of an endotracheal tube.",0
No new fracture is identified.,0
Again also seen is mucosal thickening and air-fluid level in the left maxillary sinus.,0
There is also unchanged patchy mucosal thickening of the ethmoidal air cells.,0
"HEAD CTA: There is no change in vascular enhancement, caliber, contour, or overall branching pattern to suggest vasospasm.",0
The internal carotid and vertebral arteries and their major branches are patent with no evidence of (Over) 12:44 PM CTA HEAD W&W/O C & RECONS Clip # Reason: ?,0
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont) stenosis.,1
There is no evidence of other vascular abnormality.,0
"Noted is effective PICA-termination of the right vertebral artery and likely right AICA-PICA vessel, both normal variants, as seen on the previous studies.",0
The major dural venous sinuses are unremarkable.,0
"Interval improvement or stability of diffuse foci of hemorrhage, as described above.",0
No new hemorrhage or evidence of acute territorial infarction.,1
"Patent intracranial anterior and posterior circulation, without change in caliber, contour, or overall branching pattern to suggest vasospasm.",0
No evidence of other vascular abnormality.,0
No interval change in the size of the ventricles to suggest hydrocephalus.,0
"COMMENT: These findings were discussed with Ms. , PA-C (Neurosurgery service) by Dr. , via telephone at 4:20 p.m. on .",0
"Clip # Reason: NO URINE OUTPUT, R/O HYDRO Admitting Diagnosis: VARICEAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with end stage liver cirrhosis, coagulopathy, s/p frank hematuria yesterday, now with decreased UO and increased Cr.",1
REASON FOR THIS EXAMINATION: repeat US to r/o hydro again ______________________________________________________________________________ FINAL REPORT INDICATION: Hematuria with decreased urine output.,0
End-stage liver disease and coagulopathy.,0
Limited examination of the kidneys was performed.,0
The right kidney measures 14.1 cm.,0
The left kidney measures 14.2 cm.,0
"There is no stone, mass, or hydronephrosis.",0
Bladder is completely decompressed with catheter in place.,0
"11:41 PM CHEST (PORTABLE AP) Clip # Reason: fever spike, ?",0
"worsening PNA Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with s/p ett reposition and ogt REASON FOR THIS EXAMINATION: fever spike, ?",0
worsening PNA ______________________________________________________________________________ FINAL REPORT INDICATION: ET tube and OG tube repositioned.,0
FINDINGS: ET tube and NG tube appear unchanged.,0
There is slight improvement in the patchy density at the right lung base consistent with resolving pneumonia.,0
IMPRESSION: Improving right lower lobe pneumonia.,0
"8:51 AM SPINAL ART Clip # Reason: diagnostic spinal angiogram, dural AVM, Left Lower Extremity Contrast: OPTIRAY Amt: 175 ********************************* CPT Codes ******************************** * MOD SEDATION, FIRST 30 MIN.",0
"MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with dural AVM and left LE weakness REASON FOR THIS EXAMINATION: diagnostic spinal angiogram dural AVM, Left Lower Extremity Weakness ______________________________________________________________________________ FINAL REPORT Given the marked motion artifact/respiratory motion secondary to inability of patient to hold breath or maintain immobilization, procedure was terminated and subsequently performed under anesthesia.",1
Please refer to the same day performed spinal angiogram done with general anesthesia (clip #).,0
MODERATE SEDATION was provided by administering divided doses of Fentanyl and Versed throughout the 1 hour and 55 minute intraservice time with continuous hemodynamic monitoring.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: TRA HISTORY OF PRESENT ILLNESS: This is a 29-year-old gentleman who was stabbed in the right lower neck during an altercation at work.,0
He had an estimated litre of blood loss at the scene and was transferred to the Emergency Department by Emergency Medical Services with stable hemodynamics with some mild shortness of breath at the scene.,0
SOCIAL HISTORY: Denies alcohol and tobacco.,0
"PHYSICAL EXAMINATION: Temperature 97.7 degrees, heart rate 89, blood pressure 133/90, respiratory rate 18, O2 saturation of 100 percent under nonrebreather mask.",0
"LABORATORY DATA: Hematocrit was 35.3, INR was 1.2, lactate was 3.4, BUN and creatinine were 18 and 0.9, urine and serum toxicity screens were negative.",0
STUDIES: Fast exam within normal limits with no pericardial effusion.,0
Chest x-ray within normal limits.,0
"CTA of the neck showed subcutaneous air in the right neck with a hematoma within the right sternocleidomastoid muscle, but no vessel injury.",0
"PHYSICAL EXAMINATION: Alert, oriented, and follows commands.",0
Hematoma of the right neck with no subcutaneous emphysema or crepitus.,0
Chest has regular rate and rhythm.,0
Lung sounds were clear bilaterally.,0
"On his anterior chest wall, there was a 1-cm stab wound slightly to the right of the midclavicular line 1 cm above the clavicle.",0
"Abdomen was soft, nontender, and nondistended with normoactive bowel sounds.",0
There were no flank deformities.,0
"Rectal, he had good rectal tone, but was contaminated by blood.",0
"On his back, he had an additional punctate superficial wound at the left posterior axilla.",0
His extremities were without deformities or other abrasions.,0
HOSPITAL COURSE: Mr. was seen and evaluated in the trauma bay with injuries as outlined above.,0
He essentially had a stab wound above the clavicle with an associated hematoma.,0
The hematoma was not bleeding at the time of evaluation or expanding and he was hemodynamically stable.,0
Foley catheter was placed in the trauma bay for further monitoring.,0
"He was taken for CT of the neck, which did not show any major vessel injury and subsequently transferred to the Intensive Care Unit, where he had an esophagoscopy and flexible bronchoscopy.",0
These too did not reveal any injury to the airways or esophagus.,0
"on continuous O2 saturation monitoring with a serial hematocrits, which were stable at 35.",0
"On hospital day number 2, he was deemed to be stable from his injury.",0
His neck hematoma was unchanged and he continued to have a reasonable good phonation and swallowing.,0
His IV fluids were hep-locked.,0
He was mobilized out of bed and deemed stable for discharge to home.,0
DISCHARGE STATUS: The patient will be discharged home.,0
DISCHARGE DIAGNOSIS: Stab wound to the right neck.,0
", Dictated By: MEDQUIST36 D: 08:49:30 T: 09:26:29 Job#:",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: upper GI bleed.,0
Major Surgical or Invasive Procedure: 1.,0
"Placement of right arm PICC line (tip in SVC), discontinued on after antibiotics course complete.",0
History of Present Illness: 70 YO woman with MR p/w with coffee ground emesis x2 (250cc /episode) while at today.,0
"Denied abd pain, diarrhea, brbpr.",0
ED: in ED T 96.7 HR 85 BP 119/62 RR 20 Satting 94% on oxygen.,0
"NG tube placed 250 black coffee ground emeis noted, lavaged with 500cc NS.",0
Infused 1 U PRBC with 20 lasix.,0
Given a total of 2L NS and 1 U PRBC in the ED and started on a protonix drip 8mg/hr.,0
"GI was consulted and initially planned to perform EGD in am, though this was deferred as Hct stabilized and she would have had to undergo intubation to complete the colonoscopy.",0
She was transferred to the Medical ICU for mgmt of her respiratory failure thought aspiration pna and for mgmt of her UGIB.,1
"Past Medical History: - Mental retardation moderate-to-severe, lives in assisted group facility.",0
- Bibasilar PNA in s/p 12 dy course of levoquin - Hypertension.,0
- History of hypercalcemia secondary to hyperparathyroidism.,0
Last amylase was 372 in .,0
- History of iron deficiency anemia.,1
- Status post ORIF of the left femur and left tibia secondary to two falls.,0
- History of gastritis with positive H. pylori - Hepatits B - Pulmonary fibrosis - last evaluated by Dr. in who did not think that she was a candidate for prednisone or O2 to concerns about her tripping over the cord.,1
Social History: She lives in a group home at with phone number .,0
There is no history of tobacco or alcohol in the history.,0
She uses a walker at baseline.,0
"Family History: NC Physical Exam: T 98.8 P 95 BP 151/61 RR 25 O2Sat 94% 4L NC GENERAL:thin well appearing female, NAD.",0
"HEENT: NC/AT, PERRL, EOMI, dry MM, NG tube in place Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Diffuse bilat crackles way up posteriorly Cardiac: RRR, nl.",0
"Black stool but guiac positive per ED Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l.",0
"Neuro: alert, interactive, able to communicate small phrases/wishes in garbled speech.",0
Does not consistently obey commands.,0
Pertinent Results: ---------- Reports: .,0
EKG: Sinus rhythm Conduction defect of LBBB type No change from previous .,0
"CXR : Left lower lobe infiltrate, which could represent pneumonia.",0
Faint opacity in the right lower lobe may represent an early infiltrate.,0
CXR : The heart is enlarged but stable in size.,0
"There are persistent diffuse bilateral alveolar opacities with relative sparing of the left upper lobe, superimposed upon baseline areas of fibrosis.",0
This may reflect edema or diffuse infection.,0
There are probable small bilateral pleural effusions.,0
CXR : Evaluation of the lung apices is limited by head positioning.,0
Compared to prior study there appears to be minimal change in diffuse interstitial infiltrate within the right lung.,0
"Otherwise, cardiac and mediastinal silhouettes are unchanged.",0
There may be a small amount of volume loss within the left lung.,0
"Suggest pt be made NPO with alternate means of nutrition and hydration, as there were no safe consistencies to recommend based on today's evaluation.",0
Pt is not a candidate for an objective swallowing evaluation (videoswallow or FEES) as the pt is not expected to participate in either.,0
Suggest a family discussion to weigh the options/risks for nutrition regarding continued PO intake vs alternate means of nutrition and hydration.,0
"Should the family health care proxy decide to continue with PO intake, would suggest a PO diet of honey thick liquids and pureed consistency solids, knowing pt is at high risk to aspirate all consistencies.",0
"*** it was decided by HCP that pt should continue with PO diet, as per #4 above.",0
"AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S VANCOMYCIN------------ <=1 S BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT urine/serology Legionella Urinary Antigen -FINAL INPATIENT URINE URINE CULTURE-FINAL Brief Hospital Course: A/P: 70 yo F with PMH of Mental Retardation, IPL, Grade II gastritis from EGD on ASA daily who presents with 2 episodes of coffee ground emesis and heme + melena.",1
She was seen in ED by GI for possible scope.,0
GI bleed: Given her presentation and coffee ground emesis this thought to be consistent with a GI bleed.,0
She received IVF and 2 units of pRBCs and her Hct stabilized.,0
She was also started on protonix and her aspirin was held.,0
GI was consulted but since she no longer had emesis and her hematocrit was stable an endoscopy was not performed.,0
Her Hct remained stable throughout the remainder of the hospitalization.,0
"Pulmonary: LLL infiltrate with possible RLL infiltrate and possible L pleural effusion, in setting of chronic IPF.",1
"currently continues to need chronic O2, she desaturates to 70s on room air.",0
Pt needs to be frequently reminded to keep oxygen on.,0
"She has a h/o CHF (EF 20%), last CXR on with mod pulm edema, CXR on showed ground glass R>L, increased cardiac silhouette.",0
"Lasix 20mg IV given for several episodes of desaturation, then transition to PO lasix and also started on aldactone given her depressed EF.",0
"Difficult to measure Is/Os incontinence, but subjectively Pt.",0
"appeared more comfortable and interactive at the time of d/c, with clearer lungs and less work of breathing.",0
Will need K monitored closely given aldactone/lasix.,0
"ID: Enterococcus UTI, Aerococcus bacteremia.",0
"Blood cx was obtained from femoral site, very dirty appearing, suspect Aerococcus was contaminant.",0
"Urine cx grew enterococcus resistant to , treated with vanco.",0
"completed 14-day course of vancomycin and remained afebrile, with normalization of WBC count.",0
CHF: Her most recent echo from ' showed an LVEF of 20%.,0
"She was intermittently given IV lasix during her hospital stay, maintained on her ACEI and beta-blocker regimen.",0
Spironolactone and PO lasix were started prior to discharge.,0
Mental retardation: She was continued on fluvoxamine.,0
1:1 sitter with her at all times.,0
"Left upper extremity DVT: During her PICC placement, she was noted to have a left upper extremity DVT, likely from a previous IV line placement.",0
"Anti-coagulation was considered but given her recent history of a GI bleed, this was not initiated.",0
Should not have catheters in this extremity.,0
FEN: She was initially kept NPO for a potential procedure and was maintained on this once she was found to be aspirating.,0
A regular (soft-solid) diet was started after a meeting with her legal gaurdian (see below).,0
Dispo: A meeting with her legal gaurdian and multiple people involved in her care at her living facility was held on .,0
"At this meeting, it was decided to re-initiate her diet (although she was shown to aspirate on her food, she clearly enjoys eating and a PEG tube is contra-indicated given the high likelihood that she would pull it out).",0
It was also decided not to anti-coagulate her for her DVT.,0
This was considered in the setting of her recent GI bleed.,0
"Endoscopy was considered but due to her lung disease and desaturation, this was thought to be a risky procedure that might require intubation.",0
At the conclusion of the discussion it was decided to change her code status to DNR/DNI.,0
"Due to her tendency to aspirate and poor lung disease at baseline, she is likely to develop respiratory distress at some point but it was decided that aggressive interventions would be inappropriate.",0
She requires constant supplementary oxygen.,0
Medications on Admission: Atenolol 25mg QD Ferrous Sulfate 325 QD Fluvoxamine 50mg qam Fluvoxamine 50 qhs lisnopril 20mg qd aspirin 325 mg qd atorvastatin 80 mg qd docusate 100mg qd senna tylenol rantitidine Discharge Medications: 1.,0
Fluvoxamine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Potassium & Sodium Phosphates mg Packet Sig: One (1) Packet PO once a day.,0
"Sodium Chloride 0.65 % Aerosol, Spray Sig: Sprays Nasal QID (4 times a day) as needed.",0
"Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical (2 times a day).",0
Discharge Disposition: Extended Care Facility: Marguarat Discharge Diagnosis: 1.,0
"Upper GI bleed, stabilized without EGD.",0
"Congestive heart failure Discharge Condition: Hemodynamically stable, still requiring 4L NC to keep oxygen saturations in the mid-90s%.",1
Discharge Instructions: You are being discharged to a group home with care attendants to help you.,0
"Please take your medications as prescribed, cooperate with your healthcare providers, and come to your follow-up appointments.",0
"Followup Instructions: Please have your healthcare providers schedule a follow up appointment with your Primary Care Physician in the next week, to be re-evaluated after this hospitalization.",0
"You should have your electrolytes, in particular your potassium and phosphate levels, checked within the next 3 days and frequently thereafter until stable.",0
"You were started on spironolactone, furosemide and Neutra-Phos, all of which can effect your potassium levels.",0
You may need these medications adjusted based on the results of these tests.,0
Clip # Reason: check pacer pocket for fluid collection Admitting Diagnosis: LINE SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with recurrent VRE bacteremia and pace maker in place REASON FOR THIS EXAMINATION: check pacer pocket for fluid collection ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Recurrent VRE bacteremia.,0
The pacemaker in place to check for fluid collections.,0
Grayscale scans of the chest wall in the region of the pacemaker were performed and a very small 1 x 1.5 x 1.8 cm fluid collection was seen at the left cephalad edge of the pacemaker pocket.,0
No other larger fluid collection was seen elsewhere in the remainder of the chest wall around the pacemaker device.,0
"1:34 PM CHEST (PORTABLE AP) Clip # Reason: new c line placement, and eval ett and NGT ______________________________________________________________________________ MEDICAL CONDITION: 27 year old woman with tylenol OD s/p aspiration of charcoal REASON FOR THIS EXAMINATION: new c line placement, and eval ett and NGT ______________________________________________________________________________ FINAL REPORT HISTORY: Tylenol overdose, line and endotracheal tube placement.",0
FINDINGS: Single view compared to study earlier this same day.,0
NG tube is seen with its tip at the GE junction.,0
Endotracheal tube is in satisfactory position.,0
Right IJ line in the mid SVC.,0
"2:44 PM CHEST (PORTABLE AP) Clip # Reason: ETT and central line placement, ?",0
"pna/chf Admitting Diagnosis: MYOCARDIAL INFARCTION;VENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with VT arrest, intubated REASON FOR THIS EXAMINATION: ETT and central line placement, ?",1
"pna/chf ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old man with VT arrest, intubated and central line placed.",0
Evaluate for pneumonia and CHF.,0
"CHEST, SINGLE VIEW: Endotracheal tube, pacemaker leads, in expected location.",0
Left IJ line with tip in mid SVC.,0
Sternotomy wires and surgical clips overlying the mediastinum are noted.,0
"Evidence of a metallic spring-like device projecting over the right hila, incompletely evaluated without lateral views, correlate with overlying external objects, or history of other mechanical devices.",0
Streaky opacifications at the left lung base suggestive of bibasilar atelectasis and small bilateral pleural effusions.,0
There is no definitive evidence of pulmonary edema or congestive heart failure.,0
IMPRESSION: Small bilateral pleural effusion and left basilar atelectasis.,0
"Metallic spring like device projecting over right hilar region, incompletely localized without lateral views, correlate with external objects in patients vicinity or history of other mechanical devices",0
9:24 AM CT HEAD W/O CONTRAST Clip # Reason: assess SDH Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with s/p mvc REASON FOR THIS EXAMINATION: assess SDH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status-post MVC.,0
Comparison is made with prior CT dated .,0
FINDINGS: There is again demonstrated asymmetric high attenuation along the right tentorium consistent with subdural hematoma which is not significantly changed since the prior study.,0
There are no other areas of hemorrhage appreciated.,0
"There is no shift of the normally midline structures, mass effect of hydrocephalus.",0
The density values of the brain parechyma is otherwise within normal limits.,0
There is a small amount of mucus retention in the right ethmoid sinus.,0
A scalp hematoma is again appreciated along the posterior subcutaneous tissues.,0
IMPRESSION: Stable appearance of the brain.,0
8:37 AM PICC LINE PLACMENT SCH Clip # Reason: PICC placement Admitting Diagnosis: MITRAL REGURGITATION\AORTIC AND MITRAL VALVE REPLACEMENT; PULMONIC VALVE REPLACEMENT; VENTRICULAR SEPTAL DEFECT CLOSURE; RE-DO X 2/SDA ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,1
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with s/p mvr, tvr, pvr REASON FOR THIS EXAMINATION: PICC placement ______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for 56-year-old man with mitral, tricuspid and pulmonary valve replacement.",1
"RADIOLOGIST: Dr. , Dr. and Dr. , performed the procedure.",0
"Dr. , the Attending Radiologist, was present and supervised the entire procedure TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set.",0
A peel-away sheath was then placed over a guidewire and a double-lumen PICC line measuring 38 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right brachial venous approach.,0
"Final internal length is 38 cm, with the tip positioned in SVC.",0
(Over) 8:37 AM PICC LINE PLACMENT SCH Clip # Reason: PICC placement Admitting Diagnosis: MITRAL REGURGITATION\AORTIC AND MITRAL VALVE REPLACEMENT; PULMONIC VALVE REPLACEMENT; VENTRICULAR SEPTAL DEFECT CLOSURE; RE-DO X 2/SDA ______________________________________________________________________________ FINAL REPORT (Cont),1
"11:50 AM CHEST (PORTABLE AP) Clip # Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax Admitting Diagnosis: MITRAL VALVE ENDOCARDITIS\MITRAL VALVE REPLACEMENT,HEART PORT MINIMALLY INVASIVE ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman s/p MVR REASON FOR THIS EXAMINATION: pleural effusion, pulmonary edema, tamponade, pneumothorax ______________________________________________________________________________ FINAL REPORT AP CHEST 12:22 P.M. HISTORY: Status post MVR.",0
IMPRESSION: AP chest compared to and 16: Lungs are clear.,0
Cardiomediastinal silhouette has a normal postoperative appearance following median sternotomy and MVR.,0
"ET tube, nasogastric tube, midline and pleural drains in standard placements.",0
"11:13 PM CHEST (PA & LAT) Clip # Reason: BILAT CRACKLES ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with IDDM, ESRD, non-healing leg ulcer here for evaluation, bilateral crackles on exam REASON FOR THIS EXAMINATION: r/o infiltrates or CHF ______________________________________________________________________________ FINAL REPORT INDICATION: End-stage renal disease, bilateral crackles on exam.",1
"CHEST, PA AND LATERAL: There is cardiomegaly with left ventricular configuration.",0
The aorta is slightly unfolded with wall calcifications.,0
There is no overt left ventricular heart failure.,1
There may be a tiny left sided pleural effusion.,0
There are no focal opacities within the lungs.,0
"10:36 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: Speech and swallow - aspiration risk Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with hypoxia, delirium, pulmonary process of unclear etiology (?aspiration, infection, vasculitits) REASON FOR THIS EXAMINATION: Speech and swallow - aspiration risk ______________________________________________________________________________ FINAL REPORT HISTORY: 77-year-old male with hypoxia, delirium, with concern for aspiration risk.",1
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division.,0
"When administered nectar-thick liquids, the patient was noted to aspirate and then spit out the ingested material.",0
One teaspoon of pudding consistency was administered and the patient had significant residual within the pharynx.,0
The patient again spit out the barium and refused to cooperate with rest of the examination.,0
"For details, please refer to speech and swallow division note in OMR.",0
IMPRESSION: Aspiration of nectar-thick liquids and significant pharyngeal residue with pudding consistencies.,0
Please see speech and swallow note for further details.,0
"3:46 AM CHEST (PORTABLE AP) Clip # Reason: Eval for PTX, s/p Tracheoplasty Admitting Diagnosis: TRACHEAL BRONCHEAL MALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman s/p thoracotomy and tracheobronchoplasty.",0
"REASON FOR THIS EXAMINATION: Eval for PTX, s/p Tracheoplasty ______________________________________________________________________________ FINAL REPORT INDICATION: Status post thoracotomy and tracheobronchoplasty.",0
"CHEST X-RAY, PORTABLE AP: Comparison made to prior study of .",0
There is an upper mediastinal drainage catheter with tip terminating at the superior portion of the sternum.,0
A left subclavian Port-A-Cath is present with tip in the lower superior vena cava.,0
The right posterior fifth and sixth ribs are fractured consistent with history of thoracotomy.,0
Atelectasis is present at the left lung base.,0
The lungs are otherwise unremarkable.,0
IMPRESSION: No pneumonia or pneumothorax.,0
"LINE PLACEMENT Clip # Reason: line placement Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with new RIJ CVL & R trisegmentectomy REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT INDICATION: Right internal jugular central venous catheter, right trisegmentectomy, evaluate line placement.",0
COMPARISON: Chest radiographs dating back to and most recently .,0
FINDINGS: Two new right upper quadrant surgical drains and a new right internal jugular central venous sheath with the distal tip at the mid SVC are identified.,0
The pre-existing tunneled right subclavian central venous catheter tip is projected over the expected location of the cavoatrial junction without interval change.,0
Prominence of the upper lobe vasculature is suggestive of mild pulmonary venous distention.,0
"There is no evidence of consolidation, effusion, or atelectasis.",0
The tip of the newly inserted right internal jugular central venous sheath lies at the expected location of the upper SVC.,0
Mild new pulmonary venous distention.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Tremor Major Surgical or Invasive Procedure: Attempt at Stage 1 DBS, Stereotactic frame and burr hole placement History of Present Illness: Mr. is a 69 year old gentleman with a 20 year history of Parkinsons disease.",1
"Presenting symptom, right arm tremor.",0
Now things are progressed and they are still strongly asymmetric with the right side still being the worse.,0
"Major problems are tremor, rigidity, muscle cramping, bradykinesia, and dyskinesias as well.",0
Gait is not as bad.,0
Freezing is an issue as well.,0
Poor balance and dysarthria is also a problem.,0
"problems are stooped posture and swallowing trouble, whereas he has problem with memory loss or hallucinations.",0
He needs assistance when he is walking and he is off.,0
He has to to use a walker.,0
The difference between his best on and worst off is extreme and he thinks he spends at the most about 50% on during the day.,0
He takes Sinemet six times a day.,0
"Past Medical History: PD, R>L tremor, gait Ds, mild hypothyroidism, knee surgery, pilonidal cyst surgery Social History: Lives with family Family History: Non contributory Physical Exam: Upon discharge: Patient afebrile and heamodynamically stable.",1
"He is oriented to person, place, day, date, time of the day.",0
Mild difficulties in obeying commands.,0
But otherwise no clear cranial nerve deficits.,0
Able to move all 4 limbs.,0
Power grossly normal in all 4 limbs.,0
"Motor: Appears dyskinetic all over, hypomimic and hypophonic.",0
"There was no rest, action, or postural tremor.",0
"He had mild cogwheeling bilaterally, right more than left Pertinent Results: CT Head FINDINGS: The patient is status post cannulation of the left frontal bone for deep brain stimulation procedure.",1
"A small amount of subarachnoid hemorrhage adjacent to the surgical defect interdigitates along left frontal sulci, which demonstrate mild cortical swelling.",1
A small subdural hemorrhage may be present in this location as well.,0
A moderate amount of expected pneumocephalus is seen.,0
"As seen on prior MR, there is moderate dilatation of the ventricles.",0
"A small hypodense area in the left temporal lobe ( se 2, im 6) is likely artifactual.",0
Globes and orbits are intact.,0
"IMPRESSION: Status post aborted DBS with small amount of subarachnoid hemorrhage, mild cortical swelling, and possibly a small subdural hematoma present adjacent to the surgical site.",1
CT Head FINDINGS: Small left frontal subarachnoid hemorrhage with minimal associated sulcal effacement adjacent to craniotomy due to aborted attempt of place deep brain stimulator is stable.,1
"Previously suspected thin left frontal subdural hematoma is more evident on current study, but measures only 2-3 mm at greatest depth (2:21).",0
Stable moderate amount of post-procedural pneumocephalus evident.,0
Minimal mucosal thickening identified within the ethmoid air cells.,0
"IMPRESSION: Status post aborted DBS, with stable small amount of subarachnoid hemorrhage layering in the left frontal sulci with mild sulcal effacement; there is a very thin subdural hematoma at the surgical site, minimally-increased and measuring only mm in maximal thickness.",1
Brief Hospital Course: 69M elective admission for stage 1 DBS which was aborted secondary to bleeding.,0
Post-op head CT showed a small SAH on the left side.,0
He was admitted to the Neuro ICU.,0
He had a repeat head CT for an episode of freezing/ increased tremor/ unresponsive.,0
Heme was called to consult.,0
On his exam was stable and appeared at his baseline.,0
Heme felt the increased bleeding could be from a platelet dysfunction secondary to herbal supplements and recommended that patient discontinue taking these supplements.,0
"On , PT evaluation was obtained and they recommended home.",0
"Additionally, a CXR and UA was obtained to ensure that is post op confusion was not infectious.",0
"Now DOD, he is afebrile, VSS, and neuro stable.",0
He is ambulating at baseline.,0
He is set for d/c home in stable conditon and will follow-up accordingly.,0
Medications on Admission: Sinemet 25/100 two tablets six times per day ReQuip XL 2 mg at 8:00 a.m. and 10:00 a.m Discharge Medications: 1. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO 6 TIMES DAILY ().,0
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp/ha.,0
Requip XL 2 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO daily ().,0
Discharge Disposition: Home With Service Facility: Healthcare of CT Discharge Diagnosis: Parkinson's Disease SAH Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: Please remove your dressing on .,0
Keep sutures clean and dry until they are removed.,0
Followup Instructions: Please call to re-schedule your surgery and for a suture removal appointment in days from the date of your surgery.,0
"10:15 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: S/P PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man, tachy with thick secretions.",0
"REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT CHEST AP PORTABLE SINGLE VIEW INDICATION: Tachypnea with thick secretions, evaluate for infiltrates.",0
FINDINGS: AP single chest view has been obtained with patient in supine position.,0
A left subclavian approach central venous line is noted and seen to terminate in a position compatible with the lower SVC just above the expected entrance into the right atrium.,0
Remarkable is an unusual high positioned diaphragm there is no evidence of right-sided pleural effusion or any acute parenchymal infiltrates.,0
The left lung is also well aerated with the presence of a plate atelectasis in the mid-left lung field is noted.,0
No conclusive evidence exists for either pleural effusions or acute parenchymal infiltrates nor is there is evidence of significant pulmonary vascular congestion.,0
Comparison with very next previous chest examination of is made and shows that the previous film suffered more from motion blurring than it is now.,0
Still the portable single view examinations has limitations but again no conclusive evidence for acute infiltrates or pleural effusions.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 55 year old male with a history of hypertension, unspecified heart problems, who recently immigrated from six weeks ago, who presented to the Emergency Room with chest pain in the setting of cough.",1
"The patient, again, immigrated from six months ago.",0
"Over the past six months, he has been experiencing a dry cough; at baseline he does have some chest discomfort as well and it seems that this pain is exertional; however, over the last several weeks, he has begun to have a pleuritic sharp chest pain with radiation to the back, worse again when he coughs.",0
"On a trip to two weeks prior to admission, he did complain of a similar pain and presented to a local hospital.",0
All the details of that hospitalization are unclear.,0
did leave the hospital pain free.,0
The patient again came back to the US several days ago and on the date of admission he was in a car with his daughter when he experienced retrosternal discomfort once again with radiation to the back.,0
"Per the daughter, he looked pale and diaphoretic and for this reason, he was brought to the Emergency Room.",0
"He denies any history of syphilis, heart murmur, scarlet fever, Strep-throat or rheumatic fever.",0
He does take some medicines for his cough but does not know what they are.,0
"In the Emergency Room, he was noted to have a significant diastolic murmur.",0
His blood pressure was elevated in the 200 to 100 range similar bilaterally.,0
Chest x-ray noted a large widened mediastinum and the patient was initially placed on labetalol and then a Nipride drip for blood pressure control.,0
"Chest CT scan was performed which showed a large thoracic aneurysm but no evidence of dissection, and the patient was admitted to Coronary Care Unit for aggressive blood pressure control.",1
History of negative PPD six months ago.,0
Labetalol 200 twice a day.,0
Zestril over the last week.,0
"SOCIAL HISTORY: The patient is of Ethiopian origin, recently immigrated to the US six years ago.",0
"PHYSICAL EXAMINATION: On examination, temperature 97.3 F.; heart rate 70; respiratory rate 18; blood pressure was 180/60; saturation of 95% on room air.",0
"In general, this is an middle aged male in no acute distress.",0
Jugular venous pressure was not visualized.,0
There was a III/VI diastolic murmur at the right upper sternal border.,0
"Abdomen was benign, soft, good bowel sounds, no palpable masses.",0
Good motor and sensory in all extremities.,0
"LABORATORY: Initial laboratory data was notable for a white blood cell count of 7.5, hematocrit of 39.3, platelets of 259 with 13% eosinophilia.",0
SMA7 was notable for a creatinine of 1.3.,0
CK was 110; initial coagulation studies within normal limits.,0
"Initial EKG showed normal sinus rhythm, left ventricular hypertrophy, left atrial abnormality.",0
Chest x-ray revealed a large aneurysmal mass abutting the left hilar area.,0
"CT scan of the chest showed a 6.6 by 6.7 centimeter large oblong descending thoracic aneurysm compressing the left upper lobe bronchus with no evidence of dissection, no lung masses or infiltrates.",1
LARGE THORACIC ANEURYSM: The patient was admitted with a new diagnosis of a large thoracic aortic aneurysm without any evidence of dissection on initial chest CT scan.,1
The patient's blood pressure was aggressively managed with Nipride drip and labetalol and eventually was transitioned over to a PR regimen.,0
"CT Surgery was consulted initially, however, initially they wanted a cardiac catheterization and an echocardiogram prior to surgery, however, they did feel that the surgery was needed urgently.",0
"However, due to an episode of hemoptysis that the patient had in-house, they deferred surgery until the patient had a bronchoscopy and was further stabilized.",0
"Due to multiple other complications during the hospital course, the patient's surgery was deferred and to be done when the patient stabilized.",0
The patient was eventually discharged to return for an elective surgical resection.,0
"During the hospitalization, the patient had no evidence of dissection or any catastrophic effects of aneurysm.",0
HEMOPTYSIS: The patient was initially presenting with an aneurysm that had abutted the left upper lobe bronchus.,1
"During the hospitalization, the patient had episodes of hemoptysis.",0
"Bronchoscopy which was performed showed blood trickling from the left upper lobe bronchus, but did not reveal any discrete masses or lesions.",0
The question of fistula was entertained.,0
"The patient, however, was intubated electively due to recurrent hemoptysis for airway protection, however was able to be extubated eventually and discharged.",0
No further hemoptysis was noted after extubation.,0
AORTIC INSUFFICIENCY: The patient with a loud diastolic murmur.,0
A 2D echocardiogram revealed a three plus aortic insufficiency.,0
Cardiac catheterization revealed no coronary disease.,0
The plan was to replace the aortic valve at the time of aneurysm repair.,1
PNEUMONIA: The patient developed a Hemophilus influenzae pneumonia while on the ventilator.,0
The patient was treated with a prolonged course of Levaquin for his pneumonia with improvement.,0
STAPHYLOCOCCUS COAGULASE NEGATIVE LINE SEPSIS: The patient developed Staphylococcus coagulase negative bacteremia in the setting of peripheral line.,0
The patient's line was removed and the patient was treated with a prolonged course of intravenous Vancomycin with clearance of subsequent blood cultures.,0
MYOCLONIC JERKS: The patient with myoclonic jerks interrupted he setting of infection and medication.,0
He was seen by Neurology who recommended an EEG which did not show any evidence of epileptiform features.,0
The myoclonus resolved with treatment of the infection.,0
Large thoracic aortic aneurysm with communication to left upper lobe bronchus.,1
Hemoptysis secondary to a question of aortobronchus fistula.,0
DISPOSITION: The patient was discharged on .,0
The patient will follow-up with Dr. in CT Surgery for an elective admission for thoracic aortic aneurysm repair and possible aortic valve repair.,1
"DR., 12-463 Dictated By: MEDQUIST36 D: 09:32 T: 20:52 JOB#:",0
"4:41 AM CHEST (PORTABLE AP) Clip # Reason: ?Interval change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with metastatic colon cancer, intubated, not improving REASON FOR THIS EXAMINATION: ?Interval change ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.",0
REASON FOR EXAM: Metastatic colon cancer.,0
"FINDINGS: In comparison to the previous chest radiograph, the ET tube is unchanged and 4 cm above the .",0
An NG tube passes into the stomach and out of view.,0
Left internal central venous line and right-sided Port-A-Cath are unchanged in position.,0
"Dense consolidation within the left upper lobe and right lower lobe due to a combination of tumor, post-obstructive atelectasis and consolidation are unchanged with the exception of an increased focal mass-like consolidation in the left costophrenic angle.",0
Slight improvement in the opacity in the right upper lobe could be due to improving pulmonary edema.,0
A small right pleural effusion is unchanged.,0
"IMPRESSION: Essentially unchanged with the exception of increased focal consolidation in the left costophrenic angle, probably pneumonia and minimally improved opacity in the right upper lobe.",0
"However, this is worse since the chest radiograph of and could be due to superimposed pulmonary edema or infection.",0
11:41 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: fluid collection?,0
Admitting Diagnosis: ULCERATIVE COLITIS Field of view: 42 Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with peritoneo-cutaneous fistula REASON FOR THIS EXAMINATION: fluid collection?,1
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 68-year-old woman with peritoneal/cutaneous fistula.,0
Rule out intra-abdominal fluid collections.,0
TECHNIQUE: Multidetector CT through the abdomen and pelvis with IV contrast.,0
Images were obtained from the bases of the lungs through the symphysis pubis.,0
FINDINGS: There are bilateral large pleural effusions with segmental atelectasis of the adjacent lobe.,0
"The liver, spleen, gallbladder, adrenal glands, and left kidney are unremarkable.",0
"The right kidney has two simple cysts, the largest one is exophytic, has parapelvic component and measures 13 x 13.5 x 9.4 cm.",0
There are no intra-abdominal fluid drainable collections.,0
There is an NG tube in the stomach.,0
There is an ileostomy in the right lower quadrant.,1
Large pneumoperitoneum with small quantity of free fluid is seen within the abdomen.,0
There is a duodenal diverticulum.,0
There are two drainage tubes that enter through the anterior open wound with distal tips anterior to the small bowel loops in the left lower quadrant.,1
There is diffuse increase in the density and stranding of the subcutaneous fat through the abdomen likely due to anasarca.,0
PELVIC CT WITH IV CONTRAST: There is a rectal stump.,0
Fluid adjacent to the open posterior wound is seen at the level of the rectum in the right side with stranding of the adjacent fat.,1
A 25-mm soft tissue round density is seen in the subcutaneous fat anterior in the left inferior quadrant likely due to small hematoma.,0
(Over) 11:41 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: fluid collection?,0
Admitting Diagnosis: ULCERATIVE COLITIS Field of view: 42 Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ FINAL REPORT (Cont) Bilateral basal segmental atelectasis.,0
Large pneumoperitoneum with small quantity of free fluid.,0
There are no intra- abdominal fluid drainable collections.,0
Simple cysts in the right kidney.,0
Duodenal diverticulum Small quantity of fluid directly adjacent to the posterior inferior open wound to the right of the level of the rectum.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath/fevers/HA Major Surgical or Invasive Procedure: IP service thoracentesis History of Present Illness: PCP: : , O.",0
"Location: INTERNAL MEDICINE ASSOCIATES Address: , , , Phone: Fax: .",0
Date/Time: : 4:00 am .,0
"History obtained with the assistance of a speaking RN 84M with h/o recurrent pleural effusions s/p pigtail catheter placement, VATS with talc pleurodesis.",1
His thoracoscopy was complicated by a right pneumothorax requiring a chest tube.,0
"He also has CKD, DM, AS and presents with a HA x 24 hours but resolved on presentation to the ED.",0
He also here with SOBOE and fever to 101.2 on presentation.,0
He felt febrile so she took his temperature which was 99.3.,0
He then took 1 gm of tylenol.,0
"Even though per the ED he presented with worsening SOB per pt he did not have difficulties breathing, solely a headache.",0
S/p L US guided thoracentesis 4 days PTP which produced clear serosanguinous fluid.,0
He felt very weak and tired after his thoracentesis and there was no change in his breathing.,0
Not on oxygen at home.,0
His breathing improved dramatically after his recent surgery such that he was able to climb stairs without difficulty.,0
He is not very active at home but he is able to walk from one room to another.,0
"101.2 83 207/89-> BP improved without intervention 18 94 Meds Given: azithromycin and ceftriaxone, Fluids given: Radiology Studies:, consults called.",0
"[x] IVF (dry on exam, increased creatinine) [x] Cx and abx (ceftx, azithro) - admit medicine + 10 pt crit drop- guiac negative in ED.",0
Rsided PNA and L pleural effusion.,1
99F 70 162/68 17 99% 2L 02 .,0
ROS: -Constitutional: []WNL [+]Weight gain 8 lb []Fatigue/Malaise [+]Fever []Chills/Rigors []Nightweats [-]Anorexia -Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: []WNL [-]Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: []WNL [+]SOB [-]Pleuritic pain []Hemoptysis [-]Cough -Gastrointestinal: []WNL [-]Nausea [-]Vomiting [-]Abdominal pain []Abdominal Swelling [-]Diarrhea- [-]Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy -GU: []WNL [-]Incontinence/Retention [-]Dysuria []Hematuria []Discharge []Menorrhagia [+]dribbling with urination -Skin: [X]WNL []Rash []Pruritus -Endocrine: [X]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [X]WNL []Myalgias []Arthralgias []Back pain -Neurological: [X]WNL []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [X]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [] WNL []Seasonal Allergies All other ROS negative.,1
"Past Medical History: HTN DM2 CRI, baseline creatinine 2.5-3.0 hypothyroidism GERD antral ulceration with GI bleeding diverticulosis proctitis pancreatitis BPH colon polyps dperession AS chronic anemia .",1
"PSH: right VATS, talc pleurodesis, and pleural biopsise on .",0
s/p colectomy Social History: Lives with wife and 1 of his daughters.,0
"From republic, worked on farm there, last visit .",0
"denies tobacco, alcohol, drug use.",0
"- No visual aides - no dentures - independent of ADLS - continues to drive, no memory problems, no falls, walks without cane or walker.",0
grandaughter Daughter is HCP Family History: sister and mother had stomach cancer.,0
Daughter has CAD s/p PCIx3.,0
"Physical Exam: 97.8, 181/83L , 181/81, 64, 20, 88-89% RA, 96% 2L GENERAL: Thin, chronically ill appearing male in NAD.",0
"Nourishment: At risk Grooming: OK Mentation: Alert, speaks in full setences Eyes:NC/AT, 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.",0
"S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted.",0
Genitourinary: Skin: no rashes or lesions noted.,0
"No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l.",0
"Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted.",0
"Neurologic: -mental status: Alert, oriented x 3.",0
"-cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout.",0
-sensory: No deficits to light touch throughout.,0
"-cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted.",0
FNF and HKS WNL bilaterally.,0
"-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally.",0
Plantar response was flexor bilaterally.,0
"No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy * Physical exam on discharge: Patient now has good breath sounds on the left, but still has rhoncherous breath sounds on the right.",0
Pertinent Results: 01:22AM LACTATE-0.7 11:20PM GLUCOSE-179* UREA N-55* CREAT-2.9* SODIUM-136 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12 11:20PM estGFR-Using this 11:20PM WBC-10.8 RBC-3.31*# HGB-8.5*# HCT-25.8*# MCV-78* MCH-25.6* MCHC-32.9 RDW-17.4* 11:20PM NEUTS-82.4* LYMPHS-13.1* MONOS-4.2 EOS-0.2 BASOS-0.1 11:20PM PLT COUNT-223 11:20PM PT-13.2 PTT-30.8 INR(PT)-1.1 .,0
"Procedure date Tissue received Report Date Diagnosed by DR. ,DR. /stu Previous biopsies: PLEURAL FLUID (1 VIAL) Slides referred for consultation.",0
EGD DIAGNOSIS: Pleural biopsies (A): Granulation tissue with acute and chronic inflammation; organizing fibrinous exudate.,1
"Some degree of atypicality is seen, probably reactive.",0
"this was in addition to the recurrent pleural effusion that had formed on the left, even after being drained just a few days before.",1
With both problems he had significant resp comprimise and went to the ICU.,0
There he was given broad spectrum antibiotics after having a rising WBC's and recurrant fever with CAP therapy.,0
His fever improved and the fluid was drained.,0
he is now down to 2L by NC.,0
he will need to complete 10 days of broad abx therapy(until ).,0
"His vancomycin b/c of his renal function was dosed once, with vanc levels checked daily and given again for level <20(first dose lasted >72hrs).",0
He will also need close monitoring of his i/o's to make sure he stays even and gets IV lasix if needed.,0
he was previously on 40 mg of lasix prior to admission and the effusion returned.,0
"We are not entirely sure that this effusion is from CHF, so even if his volume status is maintained it may return.",0
If his O2 worsens he should get CXR's to monitor that left lung.,0
he will need f/u with the interventional pulmonary clinic 2 weeks after discharge.,0
they will be scheduleing him an appt the day after discharge.,0
He will also need pulm rehab as he lives up 2 flights of stairs.,0
"Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (15-29) ACUTE RENAL FAILURE- b/l 2.4 now increased to 2.9. will need monitoring frequently.",1
pls avoid nephrotoxins and dose vancomycin by level.,0
Secondary Diagnosis: 424.1 AORTIC STENOSIS-INSUFFICIENCY moderate aortic valve stenosis (valve area 1.0-1.2cm2).,1
the patient may be preload dependent so euvolemia is difficult but important to maintain.,0
"Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN When ill, the patient had all his hypertension meds held.",0
We recommend restarting his BB the night of discharge and the nifedipine if needed.,0
"Secondary Diagnosis: 249.40 SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED -stopped o/p DM meds and using only insulin.",1
had to add NPH for better control .,0
"Secondary Diagnosis: 600.90 HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS) -continued flomax.",0
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Continue o/p PPI .,1
"Code Status: FULL CODE, discussed with patient/family on admission.",0
HCP is (dtr) Medications on Admission: 1.,0
Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) scoop PO once a day.,0
Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily).,0
Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia.,0
Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lasix 20 mg PO BID 13.,0
Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day): to stop when ambulating.",0
Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Five (5) UNITS Subcutaneous twice a day.,0
Insulin Aspart 100 unit/mL Cartridge Sig: sliding scale Subcutaneous AC&HS.,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB or wheezing.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOb or wheezing.,0
Nifediac CC 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day.,0
Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days: until .,0
"Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous level <20.",0
Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection qdaily to if i/o are positive or weight +>3lbs.,0
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day.,0
"Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 518.81 RESPIRATORY FAILURE, ACUTE Secondary Diagnosis: 424.1 AORTIC STENOSIS-INSUFFICIENCY Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (15-29) Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Secondary Diagnosis: 428.32 HEART FAILURE, (B3) CHRONIC DIASTOLIC Secondary Diagnosis: 250.82 DIABETES TYPE II, UNCONTROLLED W/ COMPLICATIONS Secondary Diagnosis: 482.9 PNEUMONIA, BACTERIAL NOS Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Patient being transferred to facility Followup Instructions: with clinic in 2 weeks(appt to be made 1 day after discharge) also need f/u with PCP upon discharge(he has been updated on the hospital course).",1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Penicillin G / Codeine Attending: Chief Complaint: Left flank pain Major Surgical or Invasive Procedure: : Bedside drainage and washout of the left psoas abscess : EGD : CT-guided aspiration of right psoas collection.,1
": EGD : Left lateral open drainage, left retroperitoneal abscess.",0
: Successful placement of a right 10.2 French internal/external percutaneous transhepatic biliary drain.,0
: Exchange of a right 10.2 French PTBD s/t obstruction.,0
": ERCP, two stents placed History of Present Illness: Patient is a 55 year old male with past medical history significant for necrotizing pancreatitis secondary to abuse s/p necrosectomy on followed by takedown of end of the enterocutaneous fistula with small-bowel resection and primary anastomosis on .",0
Patient recently admitted on for RUQ pain.,0
MRCP at that time showed a filling defect in the pancreatic duct concerning for a stone.,0
Patient agreed to have ERCP as an outpatient with Dr. .,0
Patient returns today with worsening left flank pain.,0
"He denies fevers, chills, nausea, vomiting and notes regular bowel movements.",0
"Past Medical History: PMH: Hypertension, Ulcerative colitis s/p colectomy, J pouch, Removal of nonmalignant brain tumor, abuse, Chronic Methadone Maintenance for heroin abuse Past Surgical History: - colectomy - brain tumor excision Percutaneous tracheostomy.",1
(Dr. Percutaneous drainage of retroperitoneal collection abscess of the pancreas x2 for infected retroperitoneal fluid collection.,1
Replacement of percutaneous drains times 2 for a peripancreatic retroperitoneal abscess.,0
Replacement of percutaneous drains into retroperitoneal abscess.,0
Takedown of end of the enterocutaneous fistula with small-bowel resection and primary anastomosis.,0
(Dr. Social History: Currently smokes one pack of cigarettes a day.,0
Patient has a long term history of abuse and dependence.,0
Typically drinks 1 pint of per day though he stopped drinking 6 weeks prior to admission.,0
"Family History: Father was an alcoholic Physical Exam: VS: T 98.0 80 131/84 18 98% gen: NAD, AAO x 3 CV: RRR pulm: Coarse BS BL abdomen: + BS, thin, tender in midepigastric region, incisional ventral hernia through the midline laparotomy incision, reducible bowel contents, no rebound, Left flank with bulge, tender to palpation, old drain site healed extremities: no edema Pertinent Results: CBC: 12.3>10.4<619 138 95 22 ------------<117 4.0 36 1.0 ALT: 56 AP: 813 Tbili: 2.7 Alb: 2.7 AST: 79 LDH: 100 Dbili: TProt: : Lip: 15 N:85.8 L:9.4 M:4.1 E:0.3 Bas:0.4 CT scan : 1.",0
Interval worsening of psoas fluid collections demonstrating rim enhancement since the examination from .,0
There is now a large left psoas fluid collection measuring 13 x 7 x 3 cm that demonstrates a direct connection to the cutaneous tissues of the left lateral abdominal wall.,0
"This is either a primary fistula or has progressed through tract of a drain placed in the interval, though history or imaging evidence of such is not available here.",0
"In addition, there has been interval enlargement of a right psoas fluid collection measuring 7 x 3 x 3 cm.",0
Associated mild hydronephrosis and hydroureter of both kidneys demonstrated to the level of these psoas fluid collections.,1
Interval redevelopment of extensive small peripancreatic fluid collections with air within them since the examination from though present on prior examinations such as .,0
Calcific density within the proximal aspect of the common bile duct can be correlated to an intraluminal stone as noted on MRCP from .,0
Additional calcific densities within the pancreas compatible with chronic pancreatitis.,1
"Stable appearance of an atrophic pancreas, with continued homogeneous enhancement of the remainder of the parenchyma.",0
Stable intra- and extra-hepatic biliary dilatation.,0
Interval decrease in the size of bilateral psoas abscesses and peripancreatic pseudocyst.,1
7-mm stone noted in the pancreatic duct associated with pancreatic ductal dilatation; additional probably parenchymal calcifications in pancreatic head.,0
Findings are consistent with changes of chronic pancreatitis.,1
Diffuse intra- and extra-hepatic biliary dilatation is essentially unchanged compared to the prior examination.,1
2:50 pm ABSCESS Site: ABDOMEN RT ABD.,0
WOUND CULTURE (Final ): PSEUDOMONAS AERUGINOSA.,0
_________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 4 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R ANAEROBIC CULTURE (Final ): NO ANAEROBES ISOLATED 2:18 am BILE FLUID CULTURE (Final ): PSEUDOMONAS AERUGINOSA.,0
"_________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 4 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R Brief Hospital Course: Mr. , a 55 year old male s/p pancreatic necrosectomy in complicated by bilateral fluid collections who now presents with increasing left sided flank pain.",0
"Labs on admission also revealed a total bilirubin of 2.7 and alkaline phosphatase of 813, consistent with biliary obstruction.",1
CT scan was obtained and revealed a 12 mm CBD with a 5 mm intraluminal stone and gallbladder sludge.,0
It also demonstrated interval worsening of the psoas fluid collections in comparison to the prior study on .,0
Psoas collection on the left measured 13 cm and communicated with the left abdominal wall.,0
Right psoas fluid collection measured 7 cm.,0
"Pancreas appeared calcified and atrophic, consistent with chronic pancreatitis.",1
"He was admitted, made NPO and started on broad spectrum antibiotics, which were eventually tailored to cefepime and flagyl.",0
On the patient underwent bedside drainage of the left psoas abscess.,1
50cc's of fluid were expressed and a penrose drain was left in the sinus tract.,0
Cultures grew mixed bacterial flora.,0
"The patient later underwent CT-guided aspiration of right psoas collection, 30cc fluid aspirated which grew out pseudomonas.",1
On the patient was brought to the OR for washout of the left psoas abscess.,1
"He was bradycardic in pre-op holding, diagnosed as a self-limited vagal episode by cardiology.",0
Post-operatively Mr. failed to extubate and was transferred to the SICU where he remained stable overnight.,0
He was transfused a total of 3 units of blood for low hematocrits and later transferred to the floor in stable condition.,0
After several days of increasing nausea and abdominal distension Mr. went to IR for PTC drain evaluation which demonstrated occlusion at the level of the CBD.,0
A new 10 Fr internal/external drain was placed.,0
The drain was capped post-procedure which he tolerated well.,0
On he underwent ERCP which showed a 1.5 cm distal CBD stricture with proximal dilation.,0
Two 7 cm 10 Fr Cotton- stents were placed in the duct.,0
Brushings taken during the procedure revealed reactive epithelial cells without evidence of malignancy.,0
CT scan was obtained on and showed interval decrease in bilateral fluid collection size.,0
Pancreatic duct stone was still present as were intrahepatic and extrahepatic ductal dilation.,0
Mr. was started on TPN four days prior to discharge.,0
At this point he weighed 140 lbs and was approximately 35 lbs below his usual weight.,0
Toward the end of his hospitalization he was meeting his kcal/day nutritional requirement and taking nearly 100 grams of protein/day.,0
He will be discharged with home TPN to meet half of his daily caloric needs.,0
He will also continue cefepime and flagyl until his follow-up appointment with Dr. in approximately two weeks.,0
"At the time of discharge, Mr. was doing well, afebrile with stable vital signs.",0
"He was tolerating a regular diet, ambulating, voiding without assistance, and his pain was well controlled.",0
The patient received discharge teaching and follow-up instructions with verbalized understanding and agreement with the discharge plan.,0
"Medications on Admission: ASA, Celexa 20', Methadone 45', Klonopin 1 QHS, ibuprofen Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",0
2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
"3. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO DAILY (Daily).",0
Disp:*60 Capsule(s)* Refills:*2* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn.",0
)(s)* Refills:*2* 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).,0
Disp:*66 Tablet(s)* Refills:*0* 9. cefepime 2 gram Recon Soln Sig: One (1) Intravenous every twelve (12) hours.,0
Disp:*42 bags* Refills:*0* Discharge Disposition: Home With Service Facility: Home Therapies Discharge Diagnosis: 1.,0
Bilateral retroperitoneal psoas abscesses 3.,1
Biliary obstruction with LFTs elevation and leukocytosis 7.,1
Malnutrition Discharge Condition: Mental Status: Clear and coherent.,0
"Penrose drains Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever).",0
"*If the drain is connected to a collection container (ostomy bag), please note color, consistency, and amount of fluid in the drain.",0
"Call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character.",0
PTBD drain care: Keep capped.,0
"Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever).",0
"*Make sure to keep the drain attached securely to your body to prevent pulling or dislocation Followup Instructions: Provider: , MD Phone: Date/Time: 3:00 .",0
Please call Dr. office to schedule a follow up appointment to see him.,0
He would like to see you in 2 weeks.,0
"3:22 PM CHEST (PORTABLE AP) Clip # Reason: ?PNA, ETT placement Admitting Diagnosis: S/P V FIB ARREST ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with intubation s/p vfib arrest, fever REASON FOR THIS EXAMINATION: ?PNA, ETT placement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 5:57 PM PFI: Successful adjustment of ETT position and that of NG tube.",0
No significant findings in chest.,0
Left lower base retrocardiac atelectasis persists.,0
"INDICATION: Status post intubation, ventricular fibrillation arrest and fever.",1
FINDINGS: AP single view of the chest has been obtained with patient in supine position.,0
Analysis is performed in direct comparison with a preceding similar study of .,0
"Patient remains intubated, the ETT position slightly adjusted and now terminating at least 3 cm above the level of the carina.",0
Previously described NG tube has been further advanced and reaches far into duodenum.,0
No pneumothorax or any other placement-related complication is identified.,0
"Previously described retrocardiac density obliterates partially the lateral border of the descending aorta and central portion of the left diaphragm, remains unchanged and presents a sizeable atelectasis.",0
This remains rather unchanged and further followup is recommended.,0
No other new pulmonary abnormalities are identified and no pulmonary vascular congestion is present.,0
8:51 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: aspiration?,0
"Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 53 year old male with GIB, now with fever.",0
REASON FOR THIS EXAMINATION: aspiration?,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): NR SAT 1:19 PM No pneumonia.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, , 20:53.",0
"FINDINGS: There is no focal consolidation, and the left CP angle is sharply marginated.",0
The right is cut off from view.,0
"The pulmonary vascular markings, cardiac and mediastinal contours are all within normal limits.",0
9:26 PM PELVIS (AP ONLY) Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with fall pain on R hip REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
AP PORTABLE PELVIS: The bones are demineralized.,0
There is no fracture or dislocation.,0
", J. SICU-B 8:44 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: 52 YEAR OLD WOMEN WITH LIVER TRANSPLANT WITH UNILATERAL L UE EDEMA LT UPPER EXTREMITY DUPLEX FOR DVT Admitting Diagnosis: CLOGGED DOBOFF ______________________________________________________________________________ PFI REPORT No DVT.",0
9:13 AM CHEST (PORTABLE AP) Clip # Reason: F/u infiltrates and effusions in 37F intubated with ARDS.,0
S ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with likely ARDS in setting of heroin OD and subsequent aspiration two weeks ago REASON FOR THIS EXAMINATION: F/u infiltrates and effusions in 37F intubated with ARDS.,0
Study preferably performed 6-7am if possible.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Loculated ARDS and subsequent aspiration, followup.",0
Single frontal chest radiograph dated is compared with a prior chest radiograph dated .,0
There is no interval change in position of the lines and tubes.,0
There is interval decreased in the lung volumes.,0
The bilateral diffuse airspace opacities are probably of no significant interval change considering the interval decrease of lung volume.,0
"Again, a small right pleural effusion is noted.",0
1:56 PM CHEST (PORTABLE AP) Clip # Reason: Eval for OGT placement prior to starting tube feeds.,0
"______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with HOCM, UGI bleed, intubated after aspiration PNA.",0
OGT placed for tube feeds.,0
REASON FOR THIS EXAMINATION: Eval for OGT placement prior to starting tube feeds.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Intubated after aspiration pneumonia.,0
Check position of orogastric tube placed for tube feeding.,0
A new orogastric tube has been inserted and its tip is shown entering the lower portion of the stomach at the edge of the image.,0
The appearance is otherwise unchanged.,0
The endotracheal tube remains in good position.,0
The left subclavian central line tip is again noted to be in the upper SVC.,0
The left chest tube is directed downward in the lower zone.,0
There has been some increase in size of the right pleural effusion with blunting of the CP angle.,0
IMPRESSION: Satisfactory placement of new OG tube.,0
Slight increase in size of right pleural effusion.,0
"11:31 PM CHEST (PORTABLE AP) Clip # Reason: r/o free air in abdomen ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with metastatic melanoma, sepsis REASON FOR THIS EXAMINATION: r/o free air in abdomen ______________________________________________________________________________ FINAL REPORT INDICATION: Sepsis.",0
Evaluate for free air in abdomen.,0
FINDINGS: A left IJ central catheter is unchanged.,0
Multiple bilateral pulmonary nodules are again identified.,0
Low lung volumes result in accentuation of the pulmonary vasculature.,0
The cardiopericardial silhouette is unchanged.,0
"No intra abdominal free air is identified, however, there are several mildly dilated loops of small bowel within the left upper abdomen.",0
"No significant change, and no evidence of intra abdominal free air.",0
Nonspecific mildly dilated loops of small bowel in the left abdomen.,0
BP (mm Hg): 131/65 HR (bpm): 96 Status: Inpatient Date/Time: at 12:45 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: MD ( notified).,0
3.The right ventricular cavity is severely dilated.,0
Right ventricular systolic function appears severely depressed.,0
4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation.,0
Consider pumlonary embolus orRV infarct secondary to trauma.,0
9:01 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: r/o deep tissue infection Admitting Diagnosis: TRACHEAL STENOSIS Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with proximal tracheal stent externally fixed with worsening erythema.,1
REASON FOR THIS EXAMINATION: r/o deep tissue infection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 65-year-old female with worsening erythema around proximal tracheal stent.,1
"TECHNIQUE: Helical MDCT images were acquired from the skull base through the T3 vertebral body, following the administration of intravenous contrast.",0
Coronal and sagittal multiplanar reformations were generated.,0
"FINDINGS: There has been interval replacement of the tracheostomy tube by a silicone proximal tracheal stent, which is seen entering through the soft tissues of the neck and ending above the carina at the level of T1-T2.",1
"Surrounding the region of stent fixation in the mid neck, there is some increased soft tissue stranding and blurring/induration of fat planes, consistent with granulation and scar tissue.",0
"There are no enhancing fluid collections to suggest abscess, and no evidence of extension into the deep spaces of the neck.",0
There is diffuse circumferential narrowing of the hypopharynx above the level of the vocal cords.,0
Slight collapse of the intrathoracic posterior tracheal membrane is consistent with tracheomalacia.,0
"Surrounding the stent, there is increased tracheal wall thickening and inflammatory stranding, with multiple reactive mediastinal lymph nodes.",1
"Again noted is a 28 x 24 mm hypodense, heterogeneously enhancing right thyroid nodule (2:11).",0
The lung apices are unremarkable.,0
Coarse mural calcifications are noted in the aorta.,0
There is normal arterial branch anatomy.,0
The imaged paranasal sinuses and mastoid air cells are well aerated.,0
The orbits and visualized portion of the brain appear unremarkable.,0
The intracranial arteries and major venous sinuses are well opacified throughout their courses.,0
"There is mild multilevel degenerative disease of the cervical spine, with anterior osteophytes, slight disc space narrowing, and sclerotic endplate changes.",0
"There is minimal retrolisthesis of C3 on C4, with a Schmorl node present at this level.",0
Diffuse posterior osteophytic disc bulges also result in mild canal stenosis at multiple levels.,0
There is no significant foraminal stenosis.,0
(Over) 9:01 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: r/o deep tissue infection Admitting Diagnosis: TRACHEAL STENOSIS Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,1
Inflammatory/fibrotic changes surrounding tracheal stent.,1
Large heterogeneous right thyroid nodule.,0
Recommend ultrasound for further characterization.,0
"2:57 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with right pleural effusion s/p chest tube REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Right pleural effusion, evaluation for interval change.",0
Unchanged extensive right pleural effusion with right pleural pigtail catheter.,0
No evidence of right pneumothorax.,0
Unchanged normal appearance of the left lung and the left heart border.,0
4:39 AM CHEST (PORTABLE AP) Clip # Reason: b/l hazy infiltrates Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with diffuse SAH IVH with blood in the 3rd 4th and bilateral occipital horns of the lateral ventricles as well as a basilar aneurysm s/p EVD REASON FOR THIS EXAMINATION: b/l hazy infiltrates ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: SAH.,0
There is moderate vascular congestion.,0
"Retrocardiac opacities could be due to atelectasis, but aspiration or pneumonia should be considered.",0
3:41 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: feeding tube placement Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man s/p dubbhoff placement REASON FOR THIS EXAMINATION: feeding tube placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: Radiograph of earlier the same date.,0
"FINDINGS: Feeding tube has been replaced or repositioned, and now terminates below the diaphragm in the region of the gastroduodenal junction.",0
"Otherwise, the appearance of the chest is similar to the recent radiograph performed less than two hours earlier.",0
8:31 AM CHEST (PORTABLE AP) Clip # Reason: chf - eval s/p diuresis Admitting Diagnosis: ST ELEVATION MI; RESPIRATORY FAILURE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with pna s/p intubation and transfer from osh with s/p cath with IABP and stenting of LCx now with MVP and severe MR replacement.,0
REASON FOR THIS EXAMINATION: chf - eval s/p diuresis ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumonia.,0
Status post cath with severe mitral disease.,0
Evaluate CHF status post diuresis.,0
"FINDINGS: Compared with 8/24, the positions of the various tubes and catheters appear unchanged.",0
No overt CHF is now present and the left lung is grossly clear.,0
There is persistent perihilar infiltrate on the right which may reflect the patient's residual underlying pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 42-year-old woman with metastatic melanoma to the brain, breast and abdomen who presented to the oncology service at hospital on with hypotension, dehydration and anemia.",1
"She proceeded to develop peritonitis and was brought emergently to the operating room on where she underwent ex-lap, drainage of abdominal and pelvic abscess and jejunal-ileal small bowel bypass.",0
"The patient survived her operation, however, postoperatively was found to be profoundly acidotic with a pH of 7.08.",0
"A discussion was held with her family regarding her poor prognosis, not only at the current time, but giving consideration to her widely metastatic melanoma.",0
"The decision was made to make her ""comfort measures only"".",0
Propofol and morphine were administered for comfort and the patient passed away on .,0
"PAST MEDICAL HISTORY: Her past medical history included metastatic melanoma originating on her right arm, anemia, excision of variant cyst, and right axillary dissection.",0
Dictated By: MEDQUIST36 D: 05:52:52 T: 19:43:16 Job#:,0
"4:49 AM CHEST (PORTABLE AP) Clip # Reason: eval interval Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with hx SDH intubated REASON FOR THIS EXAMINATION: eval interval ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:34 A.M., HISTORY: Intubated.",0
"IMPRESSION: AP chest compared to : Mild interstitial pulmonary edema most visible at the right lung base is new, accompanied by small right pleural effusion.",0
"There is a new small left pleural effusion, and greater consolidation in the left lower lobe is more likely atelectasis than pneumonia, though the latter diagnosis is not excluded, and .",0
"The cuff of the endotracheal tube distends the trachea at the thoracic inlet, unchanged from .",0
Evaluation of tube size is recommended.,0
Minimally displaced fracture of the posterolateral aspect of a left middle rib is unchanged.,0
"7:36 AM CHEST (PORTABLE AP) Clip # Reason: eval for CHF Admitting Diagnosis: VENTRICULAR TACHYCARDIA\VENTRICULAR TACHYCARDIA ABLATION ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with chf, cad here for VT ablation REASON FOR THIS EXAMINATION: eval for CHF ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of CHF, coronary artery disease for VT ablation.",1
No significant change since previous film of same date.,0
Left-sided ICD with distal electrode overlying region of RV apex in this single view.,0
Chest tube in right lower hemithorax.,0
Bilateral pleural effusions and associated bibasilar atelectases as previously demonstrated.,1
"Marked cardiomegaly and tortuosity of the thoracic aorta, unchanged.",0
3:14 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: ?,0
"cholecystitis vs cholangitis Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with gall stone pancreatitis, persistent fever, unremarkable abd exam REASON FOR THIS EXAMINATION: ?",1
"cholecystitis vs cholangitis ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 70-year-old female with gallstone pancreatitis, persistent fever and unremarkable abdominal exam.",1
Rule out cholecystitis versus cholangitis.,0
RIGHT UPPER QUADRANT ULTRASOUND: Small stones and sludge are again seen within a nondistended gallbladder.,0
There is no gallbladder wall edema or adjacent pericholecystic fluid to indicate acute cholecystitis.,1
The common bile duct is not dilated and measures 0.3 cm.,0
Main portal vein remains patent with normal directionality of flow.,0
"IMPRESSION: Small stone and sludge within a nondistended gallbladder, without evidence of cholecystitis.",1
These findings are unchanged from prior study dated .,0
"12:08 PM CHEST (PA & LAT) Clip # Reason: pt had pacemaker placed yesterday, had portable CXR this am ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with DM, s/p R leg vasc surgery, hypotension admitted with DKA, also with cardiomyopathy and tachy-brady syndrome now s/p permanent pacemaker placement yesterday REASON FOR THIS EXAMINATION: pt had pacemaker placed yesterday, had portable CXR this am that showed tortuous pacemaker leads, want PA and lateral to eval further.",0
"Also, pt had worsening left sided pleural effusion that is now loculated.",1
Would appreciate comment regarding effusion.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Pacemaker lead placement.,0
Repeat study with lateral exam for better characterization.,0
AP & LATERAL RADIOGRAPHS OF THE CHEST dated is compared with prior study dated taken 4 hours earlier.,0
A dual lead pacemaker is seen with leads terminating in right atrium and right ventricular apex.,0
There is no pneumothorax identified.,0
"There are bilateral pleural effusions, persisting from prior exam though slightly smaller on the left in the interval.",1
There has been slight improvement in aeration of the left lung.,0
There is bilateral lower lobe collapse.,0
IMPRESSION: 1) Satisfactory placement of pacemaker leads.,0
2) Slight improvement in left sided pleural effusion with associated increased aeration of left lung.,1
3) Stable appearance of right sided effusion and associated collapse.,0
"5:10 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with s/p intubation/craniotomy w/ fever, inc O2 req REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:34 A.M., .",0
IMPRESSION: AP chest compared to and 22.,0
Heterogeneous opacification in both lower lungs has increased.,0
Although this could be asymmetric pulmonary edema in the absence of stigmata of cardiac failure or volume overload elsewhere suggests this is more likely developing pneumonia.,0
ET tube and nasogastric tube in standard placements.,0
"Shunt catheter projects over the right neck, chest and upper abdomen.",0
4:19 AM CHEST (PORTABLE AP) Clip # Reason: assess pulm edema Admitting Diagnosis: NECROTIZING FASCITIS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with nec fasc REASON FOR THIS EXAMINATION: assess pulm edema ______________________________________________________________________________ FINAL REPORT STUDY: AP chest .,0
HISTORY: 62-year-old man with necrotizing fasciitis.,1
FINDINGS: Comparison is made to prior radiograph from .,0
"The endotracheal tube, feeding tube, and right-sided central venous catheter are unchanged.",0
There are low lung volumes and cardiomegaly which is stable.,0
There is again seen some fluid within the right minor fissure.,0
There is a linear opacity within the left mid lung zone.,0
Attention to this area can be made on subsequent examination.,0
"PATIENT/TEST INFORMATION: Indication: Post ASD Closure Status: Inpatient Date/Time: at 08:25 Test: TTE (Congenital, complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A septal occluder device is seen across the interatrial septum.",1
Conclusions: A septal occluder device is seen across the interatrial septum.,1
IMPRESSION: A septal occluder device is seen across the interatrial septum.,1
It appears to be well positioned without residual shunt.,0
Normal regional and global biventricular systolic function.,0
PATIENT/TEST INFORMATION: Indication: Mitral valve disease.,0
Height: (in) 58 Weight (lb): 109 BSA (m2): 1.41 m2 BP (mm Hg): 160/70 HR (bpm): 58 Status: Inpatient Date/Time: at 12:26 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Well-seated mitral annular ring with normal gradient.,0
"The mitral valve leaflets are mildly thickened, and the posterior leaflet is immobile, likely as a result of surgical repair.",0
"3:27 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PNEUMONIA;HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with pneumonia, interval change REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST, HISTORY: Pneumonia.",0
"FINDINGS: The left hemithorax is completely opacified, similar in appearance to with a worsened appearance compared to where there has been some interval clearing.",0
"This opacity is due to a combination of infiltrate, volume loss, and effusion.",0
"In the right lung, there is pulmonary vascular redistribution with some hazy vasculature suggesting an element of fluid overload.",0
The NG tube and left-sided PICC line are unchanged.,0
IMPRESSION: Worsened appearance of the left lung.,0
"11:52 AM ERCP BILIARY ONLY BY GI UNIT Clip # Reason: R/O CBD stones Admitting Diagnosis: CHOLANGITIS ______________________________________________________________________________ MEDICAL CONDITION: year old woman with abd pain, fever and elevated LFTs.",0
"ERCP performed , req sent REASON FOR THIS EXAMINATION: R/O CBD stones ______________________________________________________________________________ FINAL REPORT INDICATIONS: -year-old woman with abdominal pain, fever, and elevated liver function tests.",0
FINDINGS: Ten spot images from the ERCP are submitted for review.,0
No radiologist was present during the procedure.,0
"The common hepatic and bile ducts are moderately dilated, and contain multiple smooth filling defects consistent with stones.",0
"According to the ERCP report, a balloon sweep was performed with extraction of stones with pus and sludge, and a sphincterotomy performed.",0
"1:15 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: interval change, after repeat bronchoscopy Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with respiratory distress REASON FOR THIS EXAMINATION: interval change, after repeat bronchoscopy ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.",1
"FINDINGS: The radiographic appearance is unchanged, except for a moderate reduction in extent of the pre-described left perihilar opacity.",0
No changes in right upper lobe atelectasis.,0
"5:58 PM CT PERITONEAL DRAINAGE; CT LOC DRAINAGE Clip # CT GUIDANCE DRAINAGE; CT FINE NEEDLE ASP Reason: 8x9cm collection on CT in abdomen s/p c-section, pt still w/ ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman post partum w/ DKA, increased WBC, HTN, and abd pain REASON FOR THIS EXAMINATION: 8x9cm collection on CT in abdomen s/p c-section, pt still w/ WBC 26 and very tender.",0
please drain fluid for diagnosis and therapy.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 28 year old woman post op day #11 for C-section.,0
"Currently with elevated white count, very tender abdomen and abscess seen on recent CT scan.",0
CT PELVIS WITHOUT CONTRAST: Again seen is an approximately 9 cm abscess between an anteverted/anteflexed uterus and the bladder.,0
Areas of high density are seen within the periphery and might represent clot retraction.,0
This might represent an infected hematoma.,0
"CT-GUIDED LOCALIZATION: Informed, written consent was obtained.",0
"Through an anesthetized skin approach and utilizing fluoroscopic CT, a #18 gauge spinal needle was inserted into the fluid collection.",0
"CT-GUIDED FINE NEEDLE ASPIRATION: Through a #18 gauge spinal needle, dark, thin liquid was aspirated after confirmation of placement utilizing fluoroscopic CT. 10 cc were obtained and sent for culture and sensitivity.",0
"CT-GUIDED CATHETER PLACEMENT: Utilizing a tandem approach and fluoroscopic CT guidance, a #10 French Flexima catheter was inserted into the fluid collection.",0
"Approximately 80 cc was obtained of dark, thin liquid.",0
This was felt to represent a hematoma that is likely infected considering the patient's clinical symptoms.,0
The patient tolerated the procedure well and no immediate complications were observed.,1
"Dr. , staff radiologist, was present throughout the entire procedure.",0
POST PROCEDURE CT SCAN: CT scan of the pelvis was then obtained without IV contrast post procedure.,0
The catheter is seen coiled within the previously identified cavity.,0
It is much smaller and contains no definitive liquid component on the post procedure images.,0
IMPRESSION: Technically successful aspiration and placement of #10 French pigtail catheter within a probably infected hematoma residing between the uterus and the dome of the bladder.,0
"10:12 AM WRIST(3 + VIEWS) LEFT PORT; HAND (AP, LAT & OBLIQUE) LEFT PORT Clip # Reason: fx Admitting Diagnosis: HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with hand pain s/p trauma REASON FOR THIS EXAMINATION: fx ______________________________________________________________________________ FINAL REPORT THREE VIEWS OF THE LEFT HAND AND THREE VIEWS OF THE LEFT WRIST INDICATION: 22-year-old male with hand pain following trauma.",0
COMPARISON: Not available at the .,0
FINDINGS: There is no acute fracture or dislocation.,0
There is no radiopaque foreign body or soft tissue calcification.,0
Peripheral IV line is in place in the volar distal forearm tissues.,0
"12:15 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for pulm edema Admitting Diagnosis: PNEUMONIA-URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 66 y/o m with DM, PVD, and decreased SpO2.",0
REASON FOR THIS EXAMINATION: Evaluate for pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia.,0
Again is noted a right IJ central venous catheter unchanged in position.,0
"There are persistent bibasilar patchy pulmonary opacities consistent with atelectasis/consolidation, as well as bilateral pleural effusions left greater than right.",0
These are not significantly changed from the prior studies.,0
There has been a slight increase in perihilar haziness compared to and similar in appearance to .,0
There is no significant upper zone redistribution of the pulmonary vasculature.,0
"IMPRESSION: Persistent bibasilar patchy pulmonary opacities with bilateral pleural effusions, unchanged in appearance.",0
Increase in perihilar haziness likely represents increasing pulmonary edema.,0
1:18 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: MVC ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVC.,0
AP CHEST: Two frontal chest radiographs are provided.,0
"On the initial chest radiograph, there is an endotracheal tube which is 2.7 cm above the carina.",0
The NG tube extends into the stomach and off the inferior border of the radiograph.,0
"There is excessive motion on this radiograph, limiting the evaluation.",0
The cardiac and mediastinal contours are unremarkable.,0
There is subcutaneous emphysema overlying the right lateral chest wall.,0
The right costophrenic angle is not included on this study.,0
No definite fracture is identified.,0
"On the second frontal chest radiograph, the patient is status post bilateral chest tube placement.",0
The right chest tube has a long course in the right thorax.,0
The left chest tube is relatively inferior and extends to the midline.,0
"A deep sulcus sign is present on the right, consistent with a right- sided pneumothorax.",1
Subcutaneous emphysema is again identified.,0
"There is also relative lucency over the left lung base, suggesting a pneumothorax.",1
The endotracheal tube now appears to be 1.3 cm above the carina which may be related to changes in the patient's head positioning.,0
"There are probable multiple bilateral rib fractures, though they are not well evaluated on this radiograph.",0
"SINGLE VIEW PELVIS: There is no evidence for fracture, dislocation, focal bone destruction or soft tissue abnormality.",0
"Right pneumothorax, now status post right-sided chest tube.",1
There is subcutaneous emphysema present on the right as well.,0
The left chest tube is inferior and extends to the midline.,0
The endotracheal tube is low and could be withdrawn by 1-2 cm.,0
"Probable multiple rib fractures, given the multiple findings.",0
This could be further assessed by CT.,0
"3:57 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please evaluate for pneumothorax, infiltrate, effusion, he i Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with Barretts and recnet URI w/ prod sputum w/ a h/o asthma, now pre-op for an esophagectomy REASON FOR THIS EXAMINATION: please evaluate for pneumothorax, infiltrate, effusion, he is POD#0 s/p a Transhiatal esophagectomy and Jtube placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, 4:09 P.M., INDICATION: Multiple medical problems as above.",1
Status post esophagectomy and J-tube placement.,0
"FINDINGS: Compared with the preop study at 9:05 a.m. earlier today, lung volumes are decreased with crowding of lung markings.",0
Mediastinal findings consistent with recent esophagectomy and gastric pullthrough appear unremarkable.,0
The NGT is passing below the lower edge of the image in the upper abdomen.,0
No overt CHF or pneumothorax.,0
"7:30 PM CT HEAD W/ CONTRAST Clip # Reason: Acute injuries ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with fall from horse REASON FOR THIS EXAMINATION: Acute injuries No contraindications for IV contrast ______________________________________________________________________________ WET READ: RSRc WED 9:45 PM fracture of C1, anterior and posterior rings.",1
See also CT C-spine for additional urgent findings.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 55-year-old female with fall from horse.,0
COMPARISON: Concurrent CT C-spine and CT torso.,0
TECHNIQUE: Imaging was performed from the cranial vertex to the foramen magnum without IV contrast.,0
"HEAD CT WITHOUT IV CONTRAST: There is fracture of the anterior and posterior rings of C1 (3:3, 3:5).",0
No skull fracture is identified.,0
"There is no subdural, epidural, or subarachnoid hemorrhage.",0
The ventricles and sulci appear normal in size and shape for the patient's age.,0
Visualized paranasal sinuses and soft tissues appear otherwise unremarkable.,0
See separate CT of cervical spine report for additional details.,0
Findings posted to the ED dashboard and marked urgent.,0
"12:49 PM MR WRIST W&W/O CONTRAST LEFT Clip # Reason: Evaluate for fluid collection Admitting Diagnosis: CELLULITIS LEFT WRIST AND ANKLE Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with h/o IV drug use with left wrist arthritis/cellulitis REASON FOR THIS EXAMINATION: Evaluate for fluid collection No contraindications for IV contrast ______________________________________________________________________________ WET READ: DSsd WED 3:21 PM rim-enhancing fluid collection c/w abscess, deep to extensor compartements measuring approx.",1
"1.7 x 0.5 cm, may be in communication with radiocarpal joint.",0
"radiocarpal joint also has small effusion, with heterogeneous signal suspicious for debris/phlegmon, and 1.7 x 1.2 cm fluid collection at the volar aspect of the wrist distal to the DRUJ that also has central areas of non- enhancement concerning for early abscess/phlegmon.",1
"dorsal edema/fluid centered around small veins and extensor indicis at ulnar aspect of wrist concerning for phlegmon and tenosynovitis, possibly septic.",1
______________________________________________________________________________ FINAL REPORT STUDY: MRI OF THE WRIST WITH AND WITHOUT CONTRAST .,0
"CLINICAL HISTORY: IV drug use, left wrist arthritis and cellulitis.",1
TECHNIQUE: Multiplanar T1- and T2-weighted images of the left wrist were acquired on a 1.5 Tesla magnet before and after uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA.,0
"FINDINGS: There is a small radiocarpal joint effusion, which contains heterogeneous debris on T2-weighted sequences, and focal fluid collection at the volar/ulnar aspect of the wrist that probably communicates with the joint (8, 18), measuring 1.8 x 1.2 cm.",0
"Following contrast administration, there is heterogeneous enhancement within this fluid, with a few areas of non-enhancement, worrisome for phlegmon/early abscess formation.",0
"Dorsal to the wrist, deep to the extensor compartment, there is a discrete fluid collection, which measures roughly 1.7 x 0.5 cm (12, 26), which has rim enhancement following contrast administration, and is consistent with abscess.",1
"There is questionable communication of this area with the radiocarpal joint, as it extends deep to the extensor digitorum tendon (12, 24), just above the proximal carpal row.",0
"There is edema throughout the dorsum of the hand, most severe at the ulnar aspect of the wrist (8, 1), centered around several superficial veins.",0
"There (Over) 12:49 PM MR WRIST W&W/O CONTRAST LEFT Clip # Reason: Evaluate for fluid collection Admitting Diagnosis: CELLULITIS LEFT WRIST AND ANKLE Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ FINAL REPORT (Cont) is edema and fluid also seen around the extensor digiti minimi tendon, and the most ulnar aspect of the extensor digitorum tendons (8, 8).",1
"Following contrast administration, there is heterogeneous enhancement in this area, suspicious for phlegmon or early abscess formation.",0
"There is relatively smaller amount of edema and focal fluid at the radial aspect of the wrist (8, 1), which shows slight peripheral enhancement and central non-enhancement following contrast, also concerning for phlegmon/early abscess formation.",1
There is heterogeneous intermediate signal within the extensor pollicis longus tendon most consistent with tendinosis.,0
Extensor tendons are otherwise grossly intact.,0
Flexor tendons and the carpal tunnel are grossly within normal limits.,0
This study is not specifically tailored for evaluation of wrist internal derangement.,0
"Within these limitations, the scapholunate and lunotriquetral ligaments are grossly unremarkable.",0
Triangular fibrocartilage complex is grossly intact.,0
"There is a small amount of fluid in the first CMC joint, and mild degenerative spurring at the first CMC and triscaphe joints.",0
Visualized marrow signal is within normal limits.,0
"Small rim-enhancing fluid collection dorsal to the proximal carpal row, deep to the extensor compartments, consistent with abscess.",0
"This may communicate with the radiocarpal joint, where there is also heterogeneous enhancement, small-to-moderate joint effusion, and collection of fluid adjacent to the distal radioulnar joint, which may represent an additional site of phlegmon/early abscess formation.",0
"Areas of dorsal soft tissue swelling as above, also concerning for phlegmon/early abscess formation, with likely tenosynovitis involving the extensor digiti minimi, and ulnar portions of the extensor digitorum tendons, as well as the extensor pollicis brevis and abductor pollicis longus tendons.",1
Findings were discussed with Dr. via telephone at 14:00 hours on .,0
(Over) 12:49 PM MR WRIST W&W/O CONTRAST LEFT Clip # Reason: Evaluate for fluid collection Admitting Diagnosis: CELLULITIS LEFT WRIST AND ANKLE Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ FINAL REPORT (Cont),1
"LINE PLACEMENT Clip # Reason: eval for new R IJ , PTX Admitting Diagnosis: CHOLANGITIS ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with new line REASON FOR THIS EXAMINATION: eval for new R IJ , PTX ______________________________________________________________________________ FINAL REPORT HISTORY: Central catheter placement.",0
"FINDINGS: In comparison with earlier study of this date, there has been placement of a right IJ catheter that extends to the mid to lower portion of the SVC.",0
", TSICU 9:40 AM AORTA AND BRANCHES Clip # Reason: ?",0
interval change Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with traumatic aortic dissection REASON FOR THIS EXAMINATION: ?,1
interval change ______________________________________________________________________________ PFI REPORT no change in size of focal aortic dissection 4cm above the bifurcation.,0
"10:46 AM C-SPINE, TRAUMA PORT Clip # Reason: S/P ANTERIOR FIXATION OF C-SPINE.",0
"OBTAIN AP, LAT AND ODONTOI ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with MI REASON FOR THIS EXAMINATION: S/P ANTERIOR FIXATION OF C-SPINE.",0
"OBTAIN AP, LAT AND ODONTOID VIEWS OF C SPINE.",0
______________________________________________________________________________ FINAL REPORT History of fusion.,0
C1 through C7 are included in the lateral view.,0
Status post discectomy and fusion C5-C7 with anterior plate screw device with screws in C5 and C7 vertebral bodies.,0
Screw overlies C2 and dens.,0
"3:03 PM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with known pleural effusion s/p chest tube placement REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, .",1
"A left-sided chest tube is unchanged in position, with persistent focal kinking with an abrupt subsequent inferior turn.",0
Loculated left basilar hydropneumothorax is without change.,0
Adjacent parenchymal opacity within the left lower lobe and lingula appear slightly worse and may be due to atelectasis and/or infectious pneumonia.,0
There is improved aeration at the right lung base with improving atelectasis and slight decrease in right pleural effusion.,1
11:15 AM DUPLEX DOPP ABD/PEL Clip # Reason: elevation of alk phos and alt today.,0
please assess arterial/ Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with liver tx for HBV cirrhosis 2 days postop REASON FOR THIS EXAMINATION: elevation of alk phos and alt today.,1
please assess arterial/venous flow as well as for intraductal dilatation ______________________________________________________________________________ FINAL REPORT EXAMINATION: Liver Doppler dated COMPARISON: Liver Doppler dated and .,0
"INDICATION: 47-year-old female with liver transplant for hep B cirrhosis, postop with elevation of alk phos and ALT today.",1
"FINDINGS: The middle hepatic, right hepatic, and left hepatic veins are patent and demonstrate normal directional flow.",0
"The right anterior and posterior, main, and left portal veins are patent and demonstrate normal directional flow.",0
The main hepatic artery at the hilum is patent and demonstrates normal waveform.,0
The left hepatic artery demonstrates a normal waveform with visualization of the left hepatic artery into the substance of the left hepatic lobe.,0
"The right hepatic artery is seen at the hilum, however, no good right hepatic arterial signal is demonstrated within the substance of the right lobe with minimal diastolic flow is seen within the right hepatic artery near the hilum, given that there is single arterial anastomosis, these findings may be technical in nature and close interval followup is recommended.",0
Again seen is a 5.3 cm x 5.2 cm x 3.1 cm complex collection in the subhepatic region which is not significantly changed.,0
Patent hepatic and portal veins.,1
"Normal waveforms seen within the main and left hepatic arteries with patent right hepatic artery at the hilum and non-visualization of right hepatic artery signal on the substance of the right lobe, due to the presence of a single anastomosis this may be technical, and further correlation with liver function tests is recommended.",1
Unchanged subhepatic fluid collection consistent with postoperative change.,0
These findings were discussed with Dr. by Dr. at completion of the exam.,0
(Over) 11:15 AM DUPLEX DOPP ABD/PEL Clip # Reason: elevation of alk phos and alt today.,0
please assess arterial/ Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ FINAL REPORT (Cont),1
"9:05 PM BILAT LOWER EXT VEINS Clip # Reason: EVAL FOR DVT, KNOWN PE Admitting Diagnosis: FEMUR FX ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with bilat.",0
LE swelling after trauma (LLE fracture) and history of DVT REASON FOR THIS EXAMINATION: Eval.,0
for DVT ______________________________________________________________________________ WET READ: 1:47 AM No right DVT.,0
Technically limited study secondary to patient tolerance on the left.,0
"Nevertheless no evidence of DVT on othe left, however, note that the left popliteal vein was not visualized.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Bilateral lower extremity edema status post lower extremity trauma with left lower extremity fractures.,0
FINDINGS: Note that the study is technically limited secondary to patient tolerance in the setting of recent lower extremity fractures.,0
The common femoral veins show symmetric waveforms bilaterally with appropriate response to Valsalva maneuvers.,0
"In the right lower extremity, the common femoral, proximal greater saphenous, superficial femoral and popliteal veins all compress appropriately with appropriate response to waveform, augmentation and wall-to-wall flow on color analysis.",0
A small amount of subcutaneous edema is present in the soft tissues of the right calf and the superficial veins of the right calf are not identified.,0
"On the left, compression was not possible secondary to patient tolerance.",0
"Nevertheless, the common femoral and proximal greater saphenous veins appear patent with wall-to-wall flow.",0
There is appropriate respiratory variation in the left common femoral venous waveform.,0
The left superficial femoral vein also appears patent with wall-to-wall flow.,0
The left popliteal vein is not assessed and the superficial veins of the left calf are also not visualized.,0
"IMPRESSION: Limited study secondary to poor patient tolerance with no evidence of DVT on the right and grossly normal appearing deep veins of the left, however, compression was not possible secondary to patient tolerance in the left popliteal vein is not identified secondary to patient positioning.",0
"2:23 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: r/o fx/disloc ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with wave injury, L hip pain, numbness REASON FOR THIS EXAMINATION: r/o fx/disloc ______________________________________________________________________________ FINAL REPORT SINGLE AP VIEW OF CHEST AND AP PELVIS PERFORMED ON CLINICAL HISTORY: 62-year-old man with trauma.",0
FINDINGS: AP CHEST: Study is limited secondary to the underlying trauma board.,0
There is poor inspiratory effort with crowding of the pulmonary vasculature.,0
"However, no focal pleural effusions or contusions are identified.",0
"Mediastinum is prominent; however, this may be technical.",0
Osseous structures are grossly intact.,0
AP PELVIS: Study is limited by the underlying trauma board artifact.,0
Limited evaluation of the hips demonstrates no definite evidence of acute fractures.,0
The rest of the pelvis is grossly unremarkable.,0
Visualization of the sacrum is limited by the overlying bowel gas.,0
IMPRESSION: No definite evidence for traumatic injury to the chest or pelvis allowing for the limitation of the studies.,0
"6:39 AM CHEST (PORTABLE AP) Clip # Reason: Please eval post intubation film Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with new intubation REASON FOR THIS EXAMINATION: Please eval post intubation film ______________________________________________________________________________ FINAL REPORT AP CHEST, 6:43 A.M., HISTORY: 78-year-old man newly intubated.",1
IMPRESSION: AP chest compared to through 4: Pulmonary edema has almost resolved since .,0
Left subclavian line ends in the SVC.,0
5:48 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: like to eval interval changes.,0
"Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with pancreatitis and pseudocyst, now like to eval interval changes.",1
REASON FOR THIS EXAMINATION: like to eval interval changes.,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: MBue TUE 9:03 PM STRANDING AND FLUID SURROUNDING PANCREAS C/W HISTORY OF PANCREATITIS.,1
HYPODENSITY IN THE PANCREATIC HEAD CONCERNING FOR NECROSIS.,0
"6.7 X 9.8 CM FLUID COLLECTION ANT TO PANCREAS, NOT ENLARGED C/T PRIOR, LIKELY REPRESENTING A PSEUDOCYST.",1
ATTENUATION OF SPLENIC VEIN WHICH REMAINS PATENT.,0
"ENLARGEMENT OF SMALL LEFT PLEURAL EFFUSION WITH ASSOCIATED BIBASILAR AIRSPACE DISEASE, REFLECT ATELECTASIS ______________________________________________________________________________ FINAL REPORT INDICATION: 40-year-old male with pancreatitis and pseudocyst.",1
TECHNIQUE: Helical MDCT images were acquired from the lung bases through the iliac crests with intravenous and oral contrast.,0
FINDINGS: Small left and trace right pleural effusions are slightly increased in size.,1
There is persistent left lower lobe atelectasis.,0
"ABDOMEN: Again noted is diffuse peripancreatic stranding, with fluid tracking throughout the mesentery and into the porta hepatis and perisplenic regions.",0
"A lesser sac pseudocyst (2:35) partially compresses the posterior wall of the stomach, and is slightly decreased in size at 11.5 cm AP x 6.9 cm TV x 9.1 cm CC, previously 12.3 cm AP x 7.9 cm TV x 10.5 cm CC.",0
"A hypodense mass in the pancreatic head measures 5.9 x 5.1 cm (2:47), previously 6.1 x 5.6 cm.",0
"This demonstrates residual parenchymal enhancement and corresponds to an area of prior fatty replacement, rather than complete necrosis.",0
The portal vein and SMV are patent.,0
"There is severe splenic vein attenuation, without thrombosis or collateral formation.",0
Multiple small mesenteric and retroperitoneal lymph nodes are not pathologically enlarged.,0
"The spleen is enlarged, measuring up to 16.5 cm.",0
Small nonobstructing calcified stones are again present in the upper pole of the left kidney (2:34 to 35).,0
"The right kidney, adrenals, and liver are normal.",0
"A left paraumbilical ventral hernia is again present, containing small bowel loops.",0
There is no evidence of obstruction or strangulation.,0
The visualized large bowel appears unremarkable.,0
(Over) 5:48 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: like to eval interval changes.,0
Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) Mild degenerative changes are present in the thoracolumbar spine.,0
Partial necrosis of pancreatic head with some persistent parenchyma.,0
Small bowel-containing ventral hernia without complication.,1
Small left pleural effusion and atelectasis.,1
", L. MED VICU 9:15 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: pls eval for RP bleed Admitting Diagnosis: AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with pmh of htn p/w type b aortic dissection, now w/ resolving transaminitis, improving MS, but with persistent anemia, on heparin for possible embolic strokes/afib REASON FOR THIS EXAMINATION: pls eval for RP bleed No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No evidence of retroperitoneal bleed.",1
Bilateral pleural effusions that are stable compared to,0
"6:19 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate right lower lobe/right middle lobe for infiltrate/e ______________________________________________________________________________ FINAL REPORT AP PORTABLE RADIOGRAPH, : INDICATION: History of respiratory failure.",1
COMPARISON: AP portable radiograph dated at 12:25 A.M.,0
FINDINGS: The heart is enlarged.,0
The bilateral patchy alveolar opacifications are slightly improved from the prior study.,0
The tip of the ETT is seen approximately 3 cm above the carina.,0
This study is suboptimal due to exclusion of a portion of the right hemithorax.,0
The OGT is seen with its tip extending below the field of view.,0
"There is blunting of the left costophrenic angle, possibly representing a pleural effusion.",0
IMPRESSION: 1) Suboptimal study due to exclusion of a portion of the right hemithorax.,0
The OGT appears to extend at least to the level of the stomach.,0
2) ETT in good position.,0
3) Slight improvement of pulmonary edema.,0
"12:18 PM C-SPINE, TRAUMA Clip # Reason: patient s/p mvc with head injury ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with head injury REASON FOR THIS EXAMINATION: patient s/p mvc with head injury ______________________________________________________________________________ FINAL REPORT HISTORY: MVA, head injury.",0
FINDINGS: There is normal alignment of the cervical spine from C1 to T1.,0
"There are extensive degenerative changes in the lower cervical spine, more prominent at C5-6, C6-7 and C7-T1, where there is prominent osteophyte formation.",0
Bone detail in the lower cervical spine is limited.,0
There is a nasogastric tube.,0
The tip of the odontoid is not well seen in the present study.,0
IMPRESSION: No evidence of cervical spine fractures.,0
Tip of the odontoid is not well seen in the present study although it was unremarkable on same-day CT.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Lasix / Diuril / Keflex / Iodine Attending: Chief Complaint: AMS Major Surgical or Invasive Procedure: none.,0
"History of Present Illness: 76 yo F with IPF, COPD on 4L O2 on chronic prednisone, CHF, mechanical mitral valve, s/p pacemaker placement, known high grade colonic adenoma with GIB (not resected), gastric varix (no history of liver disease) recently admitted with nocardia pneuomina, now presented with AMS.",1
Patient is transferred to the MICU given + melena and likely need for endoscopy which may need intubation for airway protection.,0
"Of note, per EMS, she was at baseline EMS on their arrival to the rehab.",0
She was hypoxic to the high 80s on RA.,0
In the ED inital vitals signs were 80 106/65 26 100% 12L Non-Rebreather.,0
"Pt denies any confusion and is A&O to self, place.",0
"Patient denies any complaints other than shortness of breath, which is typical for her.",0
Rectal with heme postive dark stool.,0
"Labs notable for WBC count 15, Hct 18, creatinine 2.9 from baseline 2.0, metabolic alkylosis on VBG (chronic).",0
She was crossed for four units.,0
"97.4, 80 (AV-paced), 100/56, 18, 100% On arrival to the floor she had a small melanotic BM visualized, also with dried blood in the right nare.",0
Her repeat Hct prior to transfusion was 26.,0
"Given melena, patient completed 1 uit of pRBC and is getting her 2nd FFP prior to transfer.",0
"She is also getting 1x dose of Bumex given she triggerred and required NRB with O2Sat in the mid 80s, which was weaned to 4L at low 90%.",0
ROS: She reported wanting to sleep.,0
"Increased frequency of BMs recently which she describes a dark, but not bloody.",0
Cannot recall if they are sticky.,0
"Denies fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or anything else.",0
"Past Medical History: - s/p mechanical mitral valve - sinus node dysfunction s/p DDD pacemaker placement - atrial flutter s/p ablation and cardioversion - congestive heart failure, Last Echo , mildly depressed (LVEF= 40-45%) systolic function - chronic obstructive pulmonary disease: 4LO2 trach at home at rest - idiopathic pulmonary fibrosis on chronic prednisone - chronic kidney disease; baseline creatinine 1.3-1.6 - anemia due to mechanical valve and chronic kidney disease - hypertension - hypercholesterolemia - hypothyroidism - meniere?????",1
?s disease (HOH) - spinal arthritis - breast cancer radical mastectomy right breast .,0
- s/p hysterectomy - s/p nasal embolization for refractory epistaxis - lower GI bleed secondary to high grade colonic adenoma s/p biopsy (but not resection) Social History: - Recently from MACU.,0
"- Lived with her husband, who suddenly passed away while the patient was intubated.",0
Patient is aware of this.,0
"-requires assistance with ADLs and IADLs -tobacco: smoked 36 years, quit in .",0
-alcohol: social -drugs: no IVDU.,0
Family History: Father had polymyositis and coronary artery disease; mother had metastatic bone cancer.,1
She has several cousins with breast cancer.,0
Physical Exam: Admission Exam: Vitals: Tmax: 35.3 ?,0
"?F) HR: 84 (80 - 84) bpm BP: 105/62(73) {84/47(55) - 107/64(73)} mmHg RR: 15 (14 - 17) insp/min SpO2: 99% General: lethargic, oriented to person and place, trying to pull things off HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, + mechanical click Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, 1+ pulses, no clubbing, cyanosis or edema .",0
"Discharge PEx: Vitals: 98/96.7 106/68 81 18 99%4L General: alert, aao, sitting in bed HEENT: Sclera anicteric, mucous membrane moist, oropharynx clear Lungs: improved wheezing.",0
Studies: CXR: Single AP upright portable view of the chest was obtained.,0
The patient is rotated to the left.,0
The patient's chin partially obscures the left lung apex.,0
"Dual-lead left-sided pacemaker is again seen, unchanged in position.",0
"Again, the pacer wires are seen to traverse a stent, presumably in the SVC.",0
The patient is status post median sternotomy and cardiac valve replacement.,1
"Abandoned epicardial leads are again noted on the left lower hemithorax/left upper quadrant, stable.",0
Surgical chain sutures are again seen at the right lung apex.,0
Evidence of basilar fibrosis is again seen.,0
There is persistent blunting of the costophrenic angles and trace effusions would be difficult to exclude.,0
No new focal consolidation or evidence of pneumothorax is seen.,0
"Discharge Labs: 06:06AM BLOOD WBC-4.9 RBC-3.56*# Hgb-10.6*# Hct-32.0*# MCV-90 MCH-29.7 MCHC-33.0 RDW-17.6* Plt Ct-72* 06:06AM BLOOD PT-13.6* PTT-24.7 INR(PT)-1.2* 06:06AM BLOOD Glucose-76 UreaN-55* Creat-3.0* Na-142 K-4.8 Cl-105 HCO3-28 AnGap-14 06:06AM BLOOD LD(LDH)-450* 06:06AM BLOOD Hapto-52 06:06AM BLOOD Calcium-7.6* Phos-5.2* Mg-2.5 Brief Hospital Course: 76yo female with extensive medical including gastric varix and colonoic adenoma with Hct drop and small melena, s/p transfusions with appropriate Hct bump, likely to chronic bleeding from colonic adenoma.",1
"# Goals of care: patient has been made DNR/DNI, confirmed with daughter/HCP after multiple family meetings.",0
"Patient not to have escalation of care, will only treat with acute blood loss through transfusion and supportive care.",1
"Overall plan is to eventually move towards comfort, but patient and family would still like time to deliberate.",0
Patient is eating a regular diet and knows that this may increase her risk of bleeding.,0
"Also, lab draws will be limited to daily, even in setting of transfusion for decreased Hematocrit.",0
"Also, after lengthy discussion about risks and benefits of taking anti-coagulation (given mechanical mitral valve), patient and family have decided to stop anticoagulation.",0
They are willing to accept the risks of stroke.,0
We are currently continuing to offer transfusions as well as antibiotics as below.,0
"# Melena/Dysplastic Adenoma: In ED, initial hct 18, which rose to 26 with 1 unit PRBC.",0
Started on pantoprazole and an octreotide gtt.,0
"Given therapeutic INR, patient was also given 2 units of FFP.",0
Slightly hypotensive on arrival with SBP mid 80s after having received her Bumex.,0
"Her daughter and HCP, stated that her mother would not want to have another colonoscopy or endoscopy.",0
Pressures improved with 250 cc fluid bolus.,0
Patient has a known malignant colonic mass and gastric varices.,1
"The colonic mass was proven malignant on biopsy, but GI felt that endoscopic resection carried a high risk of perforation (documented in d/c summary).",0
"GI was consulted, but no intervention was done.",0
she had a drop in her Hct with a large melanotic BM.,0
"with concern for thrombocytopenia, the octreotide was stopped despite continued slow bleeding.",1
Patient was then transferred to the medicine floor.,0
"Patient had one more episode of a 5-point hematocrit drop to 21, which bumped up to 32 after two units of packed red cells.",0
Thrombocytopenia has been stable in the 50-70s range and may be secondary to medications (?meropenem).,0
# - patient had worsening creatinine through her stay.,0
"FeNA >10%, suggesting an intrinsic cause.",0
Urine eosinophils were negative and there was no peripheral eosinophilia.,0
"Meropenem was stopped; Bactrim continued after discussion with ID service, which may elevate Cr falsly without changes to GFR.",0
"At time of discharge, Cr has improved somewhat from 3.5 (peak) to 3. .",0
# Thrombocytopenia: patient had worsening thrombocytopenia beginning on admission.,0
Fibrinogen was normal and she had no schistocytes.,0
"Heparin products were stopped and a HIT antibody sent, which was negative.",0
Octreotide was stopped as there have been case reports of octreotide-associated thrombocytopenia.,0
# Nocardia PNA: Diagnosed from BAL on previous admission.,0
Treated with imipenem and bactrim as outpatient for two weeks based on suspicion of possible dissminated Nocardia.,0
With plan to just do Bactrim for additional extended course per ID recommendations.,0
Patient to follow up with ID as outpatient for future management.,0
"# Altered mental status: Mental status waxed and waned, sometimes more confused, but generally oriented to person, place and year.",0
Often did not recall events from day to day.,0
It was felt that for most decisions she had decision-making capabilities.,0
"# Systolic congestive heart failure, chronic - Per Echo, mildly depressed (LVEF= 40-45%) systolic function.",1
Does not appear volume overloaded on exam presently.,0
"Echo on shows dilated right heart, severe TR, moderate MR w/ functional mechanical prosthesis.",1
"Given transfusions and hemodynamically stable, patient has been restarted on bumex @ home dose 5mg daily.",0
Metolazone held for now and can be restarted per acute care facility/nursing facility.,0
"# Mechanical MVR Valve: Anticoagulation held indefinitely after lengthy discussion with patient and HCP, as noted above, despite risks of annual stroke given mechanical mitral valve.",0
# Bullous upper extremity rash:Continued hydrocortisone 1% cream.,0
# COPD/IPF: continued nebs and steroids.,0
# HYPOTHYROIDISM: continued home levothyroxine .,0
"# HYPERTENSION: restarted bumex, holding metolazone for now.",0
Transitional Issues: -Please evaluate need for rectal tube and foley daily and remove asap -Please check CBC every day for 3 days and then every other day or as determined by physician at acute care facility.,0
-Please d/c PICC in 5 days at the discretion of the MACU.,0
"-Please continue Bactrim, double strength, two tablets until re-evaluated by ID team as an outpatient.",0
-Will need to reinitiate metolazone 5mg every other day as an outpatient pending volume status and lung exam.,0
"Medications on Admission: -albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization q4h prn -cholecalciferol 1,000 unit daily -ferrous sulfate 325 mg daily -fluticasone 110 mcg/Actuation Aerosol, 2 puffs -ipratropium bromide 0.02 % Solution Q6H prn -levothyroxine 125 mcg daily - multivitamin daily - nadolol 20 mg daily -warfarin 1 mg daily : Goal INR 2.5-3.5.",0
"-prednisone 10 mg daily - cortisone 1 % Cream qid -Bactrim DS 800-160 mg Tablet, 2 tabs tid X 14 days -nystatin 100,000 unit/g Cream daily -zinc oxide daily -MS Contin 15 mg qhs -oxycodone 5 mg, 0.5-1 tabs q4-6 hours prn -imipenem-cilastatin 500 mg, q8h X 2 weeks -bumetanide 5mg daily -metolazone 5 mg qod -omeprazole 40 Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for sob/wheeze.",0
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation (2 times a day).,0
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
5. ipratropium bromide 0.02 % Solution Sig: One (1) treatment Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
"6. omeprazole 40 mg Capsule, Delayed Release(E.C.)",0
"7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day.",0
8. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day).,0
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day.,0
10. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
"12. nystatin 100,000 unit/g Cream Sig: One (1) application to affected areas Topical once a day.",0
MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO at bedtime.,0
14. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every six (6) hours as needed for pain.,0
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain.,0
16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough.,0
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia.,0
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
20. bumetanide 2 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily): Please hold for SBP<100.,0
Labs Please check CBC daily for at least 3 days; then every other day or as determined by your physician at your acute care facility.,0
Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: gastrointestinal bleeding colonic mass nocardia pneumonia acute on chronic kidney failure Discharge Condition: Mental Status: Confused - sometimes.,1
"Discharge Instructions: Dear Ms. , It was a pleasure taking care of you at the .",0
You were admitted to the hospital for an acute gastrointestinal bleed.,1
We were able to stabilize you with blood transfusions.,0
"It is likely that this bleeding originated from the colon, where it is known that you have a mass.",0
"Also, you have a history of esophageal varices and these may bleeding as well.",1
"After multiple discussions with the MICU/medical and GI teams in conjunction with your daughter in law, you have decided to not pursue any further diagnostic or interventional procedures.",0
You have declined any EGD/colonoscopy.,0
"You will be transferred to a MACU, where you will be able to receive supportive care with blood product transfusion as necessary.",0
You have also decided to change your code status to do not resuscitate or intubate.,1
"We have also treated your pneumonia with antibiotics, which you will continue until you follow up with infectious disease physician as an outpatient.",0
We hope that you will be able to regain some strength at rehab and feel better soon.,0
"-STOP imipenem-cilastatin 500 mg, q8h X 2 weeks -We are currently holding your metolazone 5 mg every other day for now; your physician at will evaluate you in regards to reiniation of this medication as an outpatient based on your vital signs and breathing.",0
Please follow up with your appointments as listed below.,0
Followup Instructions: You have the following appointments: .,0
"Please follow up with your primary care physician, , , within one week of discharge from your rehabilitation facility.",0
They will help you make an appointment upon discharge.,0
"Department: PULMONARY FUNCTION LAB When: WEDNESDAY at 9:10 AM With: PULMONARY FUNCTION LAB Building: Campus: EAST Best Parking: Garage Department: When: WEDNESDAY at 9:30 AM Department: MEDICAL SPECIALTIES When: WEDNESDAY at 9:30 AM With: DR. & DR. Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: INFECTIOUS DISEASE When: MONDAY at 10:30 AM With: , MD Building: LM Campus: WEST Best Parking: Garage",1
"1:48 PM CHEST (PA & LAT) Clip # Reason: eval for effusion, pna ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with CHF and ESRD s/p thoracentesis.",0
"REASON FOR THIS EXAMINATION: eval for effusion, pna ______________________________________________________________________________ FINAL REPORT INDICATION: CHF endstage renal disease post-thoracentesis.",1
COMPARISON: CT chest dated and PA and lateral chest dated .,0
The dialysis catheter tip is located at the SVC/RA junction.,0
There are moderate sized bilateral pleural effusions.,0
The right pleural effusion has decreased compared with the prior chest CT.,0
There is a focal area of consolidation within the right upper lobe.,0
IMPRESSION: Right upper lobe pneumonia.,0
Bilateral pleural effusions moderate in size.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Bactrim Ds / Cellcept / Zosyn Attending: Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Tunneled Hemodialysis Line Placement History of Present Illness: This is a 52 yo female with ESRD on HD, s/p failed renal transplant, who was discharged 1.5 wks ago for septic shock thought due to CMV viremia and diverticulitis, who presented yesterday to with a fever to 104.",1
"To summarize her recent history, she was admitted / with ARF leading to her graft failure, found to also have CMV viremia and C. diff colitis.",0
"She was discharged on IV ganciclovir until 2 negative CMV VLs, and transitioned to oral valganciclovir secondary ppx to continue for 3 mos from her admission.",0
"How this was discontinued is unclear: possibly on due to neutropenia, and outside records note negative CMV VL on .",0
"She was also at Medical Center from septic shock due to pseudomonas bacteremia, completing a course of ?zosyn on .",1
On pt began having fevers.,0
A CMV viral load was rechecked (970) and repeat VL of 4059 on .,0
"It is unclear when ganciclovir was restarted, but by , she was on ganciclovir with HD dosing.",0
"She became hypotensive on with mild abdominal pain, sent to and admitted to MICU on norepinephrine.",0
"She was treated with stress-dose steroids, empiric PO vancomycin, IV vancomycin, IV zosyn and IV gancyclovir.",0
CT abd/pelvis showed uncomplicated sigmoid diverticulitis.,0
All other culture data and infectious workup (including c. diff toxin negative x 3) was unrevealing as to another source of infection.,0
She was started on midodrine for persistent hypotension to 70-80s systolic.,0
"Also was progressively pancytopenic, though to be from pip-tazo.",0
"She was discharged on PO cipro and flagyl for diverticulitis, 10 mg daily prednisone, with her tacrolimus decreased to 2mg .",0
"Also discharged on IV ganciclovir, planning to switch to oral after 2 negative VLs, although stopped at some point in rehab.",0
"While in rehab, BPs had remained normotensive.",0
"Yesterday am, she awoke nauseated and febrile, with a temp of 104.0.",0
Blood cultures (2 sets) were sent from rehab.,0
"In the ED, her Tmax was 102, with BP 142/82.",0
CT abd showed diverticulitis similar to prior.,0
Was given vanco/zosyn/flagyl and admitted.,0
"On arrival to HD today, she was tachycardic to 130s, apparently sinus rhythm.",0
"HD was stopped after 1 hour due to progressive tachycardia to the 160s, with fever to 103.2, despite running her volume even.",0
"After stopping HD, she became hypotensive to SBP 60s, with preserved mental status.",0
"After 1L IVF, her BP improved to 86/44 with HR 107.",0
Temp improved to 100.3 after acetaminophen.,0
"Currently c/o nausea and fatigue, no resting abd pain but 10/10 L sided abd pain with palpation.",0
"Also c/o fevers, no chills or sweats.",0
Has some diarrhea that pt notes as chronic and unchanged.,0
"Makes small amt urine and confirms dysuria, frequency, urgency.",0
"Denies vomiting, CP, SOB, cough, sputum, wheezing, HA, vision changes, confusion.",0
"Past Medical History: - ESRD due to SLE, s/p cadaveric renal transplant complicated by FSGS and transplant failure , now on HD - SLE, followed by Dr. in Rheumatology - Hypotension (started on midodrine ) - Septic shock - CMV viremia - Acute uncomplicated diverticulitis - hx of C. Diff - Paroxysmal atrial fibrillation - NSVT - hx of Hypertension - Hyperthyroidism - s/p bilateral knee surgeries and R ACL repair Social History: Single, currently at rehab.",1
"Denies tobacco, ETOH, and drugs.",0
"Family History: Mother and brother both with diabetes and , both deceased.",0
"Physical Exam: Vitals: T 101.2 BP 105/49 HR 113 RR 18 O2sat 98RA GENERAL: NAD, AAOx3, appropriate, comfortable HEENT: NCAT, EOMI, aniceteric sclerae, MMM NECK: No JVD CARDIAC: RRR, no m/r/g LUNG: CTAB ABDOMEN: NABS.",0
"Soft, ND, exquisitely TTP with in LUQ/LLQ with + rebound and grimacing, pain with bed movement, no significant guarding, graft palpable in RLQ without TTP EXT: Warm and dry, 2+ DP pulses, AVF in LUE.",0
Pertinent Results: Hematology: 12:40PM BLOOD WBC-2.4* RBC-3.37* Hgb-9.5* Hct-32.6* MCV-97 MCH-28.3 MCHC-29.2* RDW-17.1* Plt Ct-97* 09:00AM BLOOD WBC-4.1 RBC-3.70* Hgb-10.3* Hct-35.4* MCV-96 MCH-27.8 MCHC-29.0* RDW-17.0* Plt Ct-144* 12:40PM BLOOD Neuts-51 Bands-20* Lymphs-12* Monos-13* Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-0 09:00AM BLOOD Neuts-67 Bands-2 Lymphs-20 Monos-8 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-1* 12:40PM BLOOD Plt Smr-VERY LOW Plt Ct-97* 12:12PM BLOOD PT-15.1* PTT-29.8 INR(PT)-1.3* 09:00AM BLOOD Plt Smr-LOW Plt Ct-144* Chemistries: 12:40PM BLOOD Glucose-96 UreaN-24* Creat-5.9*# Na-147* K-4.2 Cl-108 HCO3-27 AnGap-16 09:00AM BLOOD Glucose-130* UreaN-30* Creat-5.1* Na-143 K-4.0 Cl-106 HCO3-26 AnGap-15 12:40PM BLOOD ALT-15 AST-12 AlkPhos-57 TotBili-0.3 12:45PM BLOOD Calcium-7.4* Phos-2.7 Mg-1.7 07:30AM BLOOD Vanco-19.5 12:47PM BLOOD Lactate-1.0 Imaging: CT Abdomen and Pelvis : 1.,0
"Extensive diverticulosis with diverticulitis of the sigmoid colon and distal descending colon, similar in extent when compared to the most recent study of .",1
No evidence of perforation or abscess formation.,0
"Mild enhancement of the transplanted kidney in the right lower quadrant, which is similar in appearance to the prior study.",1
No evidence of perinephric fluid collection or abscess.,0
Persistently dilated pancreatic duct may be related to ampullary stenosis or IPMN.,0
"As noted previously, if not already performed, consultation with the Pancreas Center may assist in evaluation.",0
"CXR : Since interval examination from , there has been improvement in left lower lobe atelectasis and removal of a central venous catheter.",0
The lungs are clear with no signs of pneumonia or congestive heart failure.,0
The cardiomediastinal silhouette is stable in size.,0
"Microbiology: Blood cultures , - pending Urine culture - 10,000-100,000 Klebsiella Clostridium Difficle - positive CMV Viral Load - negative Discharge Labs: Hematology: BLOOD WBC-2.7* RBC-2.85* Hgb-7.7* Hct-26.9* MCV-94 MCH-27.1 MCHC-28.7* RDW-17.3* Plt Ct-182 Neuts-41* Bands-8* Lymphs-37 Monos-11 Eos-0 Baso-2 Atyps-1* Metas-0 Myelos-0 BLOOD PT-11.9 PTT-25.3 INR(PT)-1.0 BLOOD Glucose-89 UreaN-17 Creat-4.2* Na-145 K-3.7 Cl-105 HCO3-32 AnGap-12 Brief Hospital Course: 52 yo female with ESRD on HD, recent admission for septic shock from diverticulitis vs CMV, here with fever and hypotension.",1
"Hypotension/Fevers: Patient presented with evidence of septic physiology with fevers and hypotension, along with abdominal pain and diarrhea.",1
"Cultures revealed negative blood cultures, urine culture positive for klebsiella 10-100,000 colonies and positive clostridium difficle.",1
She had a CT of the abdomen which revealed diverticulitis.,0
CXR did not show evidence of pneumonia.,0
She was initially started on broad spectrum antibiotics with vancomycin and cefepime and this was transitioned to PO vancomycin and tigacycline for coverage of clostridium difficle as well as IV Gancyclovir given her history of CMV viremia.,0
Her hypotension resolved with 1 liter of normal saline.,0
She also received stress dose steroids given her history of long term steroid use.,0
She was transitioned to the floor.,0
Cortisol stim test was performed which was negative.,0
Her hypotension was responsive to fluid boluses.,0
She was continued on midodrine.,0
On the floor she was found to have a positive c diff toxin.,0
She was started on vancomycin taper with resolution of her abdominal pain and diarrhea.,0
She was covered with valgancyclovir for CMV prophylaxis and atovaquone for PCP .,0
"Towards the end of her hospitalization, her fevers reappeared without accompanying hypotension.",0
Pan culture revealed no organism repeatedly.,0
Her left arm at the fistula site was painful and ultrasound revealed extensive clot burden.,0
Transplant surgery did not feel immediate correction was required; a tunneled line was placed for HD.,0
PICC line was removed and cultures were negative.,0
Her fevers were felt secondary to clot burden.,0
She was discharged on empiric vancomycin to be given with each HD treatment for a total of four weeks.,0
She was discharged on vancomycin taper for c difficile and prophylaxis as mentioned above in addition to the vancomycin with dialysis.,1
Pancytopenia: Patient has a history of pancytopenia of unclear cause.,1
"Differential diagnosis considered includes drug reaction from zosyn, CMV viremia versus lupus related.",1
Her blood counts were stable from recent admission and were trended.,0
CMV viral load was negative.,0
Renal transplant: Complicated by graft FSGS and ESRD on HD.,1
She received stress dose steroids as above in the setting of sepsis.,1
She was followed by the renal consult and transplant services.,1
She was continued on tacrolimus 1 mg (decreased from 2 mg ) and atovaquone for prophylaxis.,0
She received hemodialysis treatments three times a week as per her home schedule.,0
"Given her clotted fistula towards the end of her hospitalization, a tunneled HD line was placed as mentioned above.",0
Transplant surgery will see her in outpatient follow up for consideration of placement of new fistula on the right arm.,1
Her tacrolimus was discontinued at time of discharge given that she does not require tacrolimus any longer secondary to graft failure.,0
Hyperglycemia: Attributed to corticosteroid therapy.,0
She was treated with a humalog sliding scale.,0
Paroxysmal atrial fibrillation: In sinus rhythm on discharge 10 days ago and currently.,1
She was continued on aspirin.,0
"Dispo - Discharged to rehab following resolution of abdominal pain, diarrhea, fever work up, and tunneled line placement.",0
Medications on Admission: HOME MEDICATIONS: (from d/c summary dated ) - Atovaquone 1500mg (10ml) PO daily - Aspirin 325mg PO daily - Pantoprazole 40mg PO Q24hrs - B Complex-Vitamin C-Folic Acid 1mg capsule PO daily - Midodrine 10mg PO TID - Ciprofloxacin 500mg PO Q24hrs - ended - Flagyl 500mg PO Q8hrs - ended - Tacrolimus 2mg PO Q12hrs - Ganciclovir 110mg IV QHD - Heparin 5000units SQ TID - Insulin glargine 2units SQ QHS - Insulin NPH 4units SQ QAM - Insulin Humalog sliding scale - Prednisone 10mg PO daily - Zofran 4mg IV Q8hrs PRN nausea - Epogen 15000units QHD - Bisacodyl 5-10mg PO daily PRN constipation Discharge Medications: 1.,0
Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
"Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): To be administered during dialysis and dosed according to the Epoetin Alfa P&T Guidelines.",0
Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily).,0
"Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as below: One (1) Capsule PO every twenty-four(24) hours: Starting , take 125 mg daily for one week (- ) (b) then take 125 mg every other day for one week () (c) then take 125 mg every third day for two weeks (/10).",0
Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a day: One (1) Tablet PO 2X/WEEK (TU,TH).",0
10. insulin glargine 2 U SQ qhs NPH 4 U SQ qAM 11.,0
Vancomycin 1000 mg IV HD PROTOCOL please check trough prior to each dose 12.,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
Discharge Disposition: Extended Care Facility: Hospital Discharge Diagnosis: 1.,0
Chronic Kidney Disease Discharge Condition: Stable for discharge.,1
"On room air, ambulating with assistance.",0
"Resolved diarrhea and abdominal pain, intermittent continued low grade fevers.",0
"Discharge Instructions: Dear Ms , It was a pleasure caring for you while you were in the hospital.",0
You were first admitted to the hospital because of pain in your abdomen that was caused by Clostridium difficile.,1
"Because of this infection, you developed pain in your abdomen, fevers, and your blood pressure was low.",1
"During dialysis, your blood pressure fell even further.",0
"To treat you, we started you on antibiotics for the infection and your pain and fevers improved.",0
You will need to continue to take these antibiotics for several more weeks.,0
The course of antibiotics is described below.,0
"During your hospital stay, your fistula on your left arm also stopped working.",0
"Because you needed dialysis, we placed a new line (called a tunneled line) that will allow us to continue dialysis.",1
"The transplant surgeons want to create a new fistula for you to use, and you have a follow up appointment set up with them as an outpatient to arrange this.",1
We also decided to continue you on antibiotics to be given during dialysis to treat the possibility of infection in the area of the fistula.,1
The medication changes we made during this hospitalization were: 1.,0
We started you on oral vancomycin.,0
You should continue to take this with the following regimen: (a) take 125 mg daily by mouth for one week ( - ) (b) then take 125 mg every other day for one week ( - ) (c) then take 125 mg every third day for two weeks ( - ) 2.,0
You can take 5 mg of the prednisone every day instead of 10 mg. 3.,0
You will be receiving vancomycin intravenously with hemodialysis until to complete a 4 week course.,0
You should take vangancyclovir 450 mg twice a week with dialysis.,0
You can take oxycodone 5 mg as needed every 6 hours for pain.,0
You should stop taking gancyclovir IV.,0
You should stop taking tacrolimus.,0
Please keep the follow up appointments scheduled for you below.,0
"Followup Instructions: 1) You have an appointment with a transplant infectious disease doctor, , on at 930 AM.",1
Please call if you have any other questions.,0
"2) You have an appointment with your kidney doctor, Dr. on at 9:40 AM.",0
"If you have any questions, his phone number is .",0
3) You have an appointment with Dr. from transplant surgery at 1:40 PM on .,0
"If you have any questions regarding this appointment, please call .",0
"8:43 AM BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: s/p ct removal, PDA ligation Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: as above REASON FOR THIS EXAMINATION: s/p ct removal, PDA ligation ______________________________________________________________________________ FINAL REPORT CHEST X-RAY TAKEN PORTABLY .",0
"HISTORY: 16-day-old infant status post ductus repair, status post chest tube removal.",0
"FINDINGS: Endotracheal tube is lower, now at approximately T2.",0
"Left PICC line is unchanged, overlying the superior vena cava.",0
"Feeding tube is now coiled in the esophagus, turned upon itself, tip at approximately T1.",0
Left chest tube has been removed.,0
"3:47 PM CHEST (PORTABLE AP) Clip # Reason: assess for repositioning of RIJ ______________________________________________________________________________ MEDICAL CONDITION: 30 year old man with pneumonia s/p thoracoscopy for empyema drainage, s/p RIJ placement.",1
REASON FOR THIS EXAMINATION: assess for repositioning of RIJ ______________________________________________________________________________ FINAL REPORT INDICATION: Re-positioning of right internal jugular central venous catheter.,0
"A right internal jugular central venous catheter has been withdrawn in the interval, now terminating in the left brachiocephalic vein.",0
"The remaining portion of the examination is unchanged since the previous study several hours earlier, with the exception of improving aeration in the left lung base.",0
12:31 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for change Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with attempted NGT placement and desat REASON FOR THIS EXAMINATION: eval for change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 4:35 PM PFI: No significant change in NG tube at the GE junction.,1
______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST INDICATION: Feding tube placement.,0
FINDINGS: Comparison is made with the radiograph from 4:05 a.m. on the same date.,0
The tip of the NG tube is at the thoracoabdominal junction.,0
The radiograph is otherwise unchanged.,0
IMPRESSION: NG tube tip projects over the thoracoabdominal junction.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: Mrs. is a 46 year old woman with a chief complaint of headache and vertigo for one month.,0
She had a visit with her primary care physician who treated her for a possible inner problem.,0
"When this did not resolve, head CT and Magnetic resonance scan were obtained which revealed a midline cerebellar enhancing lesion with surrounding edema.",0
"Thus, the patient was admitted to the neurosurgery service at .",0
PAST MEDICAL HISTORY: The patient is past medical history is significant for the following: The patient is HIV positive.,0
ALLERGIES: The patient has known allergies to Penicillin and Bactrim.,0
MEDICATIONS: Medications at the time of admission to included the following: Lamivudine Zidovudine one tablet p.o.,0
Ritonivir Lopinivir three caps p.o.,0
PHYSICAL EXAMINATION: Physical examination at the time of admission to revealed the following: The patient was afebrile and vital signs were stable.,0
"Neurologic: Awake, alert and oriented times three; cranial nerves two through 12 intact.",0
Finger to nose is intact.,0
Motor examination was found to be intact in both the upper extremities and lower extremities.,0
HOSPITAL COURSE: The patient was taken to the operating room on .,0
Procedure done was a sub occipital craniotomy for resection of cerebellar tumor.,0
"Postoperatively, the patient was placed on Decadron.",0
"The lesion appeared to be consistent with a metastases during the operation, thus, CT of the chest, abdomen and pelvis were obtained.",0
The patient reports that she recently had a mammogram so that was not obtained.,0
"At the time of this dictation, the results of the CT of the chest, abdomen and pelvis have not been formally read by the radiologist.",0
Those will need to be followed up on.,0
"The patient was stable for discharge on , afebrile, voiding, eating on her own and will be discharged on her preoperative medications.",0
"She will also be discharged on a Decadron taper as well as on Percocet, one to two tablets p.o.",0
every four to six hours prn for pain.,0
The patient will follow-up with Dr. in brain tumor clinic and will also follow-up with staple removal in approximately one week subsequent to discharge.,0
Dictated By: MEDQUIST36 D: 03:44 T: 05:48 JOB#:,0
Weight (lb): 172 BP (mm Hg): 139/79 HR (bpm): 84 Status: Inpatient Date/Time: at 12:04 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,1
Transmitral Doppler and TVI c/w Grade III/IV (severe) LV diastolic dysfunction.,0
"Moderate (2+) MR. LV inflow pattern c/w restrictive filling abnormality, with elevated LA pressure.",0
There is severe global left ventricular hypokinesis with anterolateral wall contracting the best.,0
Overall left ventricular systolic function is severely depressed (LVEF= 20 %).,0
The right ventricular cavity is mildly dilated with depressed free wall contractility.,0
"Compared with the report of the prior study (images unavailable for review) of , the left ventricular systolic function is worse.",0
Mitral regurgitation and tricuspid regurgitation are worse.,0
5:46 PM CHEST (PORTABLE AP) Clip # Reason: Decreased breath sounds and higher O2 requirement.,0
Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with known pleural effusions (R>L) and infiltrate seen on imaging at OSH here with sepsis & tachypnea.,1
REASON FOR THIS EXAMINATION: Decreased breath sounds and higher O2 requirement.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 49-year-old male admitted with pleural effusions, sepsis, and tachypnea.",1
COMPARISON: Chest radiograph of and CT torso of .,0
FINDINGS: A left-sided PICC catheter terminates in the SVC.,0
The degree of congestive failure has not significantly changed.,0
Large bilateral pleural effusions and associated lower lobe atelectasis persist.,1
Evaluation for focal lung parenchymal consolidation is limited by the presence of effusions and atelectasis.,0
No definite focal consolidation is identified.,0
"IMPRESSION: Persistent congestive failure, large bilateral pleural effusions and associated lower lobe atelectasis.",1
"3:40 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with trach REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Tracheostomy, evaluation for interval change.",0
"FINDINGS: As compared to the previous radiograph, there is improvement with mildly improved ventilation of both lungs.",0
"The lung volumes, however, remain low.",0
Presence of small pleural effusions cannot be excluded.,0
Moderate cardiomegaly with retrocardiac atelectasis and overall mild pulmonary edema.,0
Tracheostomy tube is in unchanged position.,0
BP (mm Hg): 150/70 HR (bpm): 90 Status: Inpatient Date/Time: at 14:00 Test: TEE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%).,0
AORTA: No atheroma seen in the descending thoracic aorta.,0
There is small vegetation on the mitral valve.,0
There is no mass or vegetation detected on the tricuspid valve.,0
A left pleural effusion is present.,0
"There is small (0.5 X 0.3 cm) echo-bright, mobile mass on the atrial side of the anterior leaflet of the mitral valve.",0
"This is most consistent with a calcified (healed) vegetation, though infective vegetation or annular calcium cannot be excluded.",0
"9:28 PM LUMBAR SP,SINGLE FILM IN O.R.",0
; -76 BY SAME PHYSICIAN # Reason: CHECK PLACEMENT HARDWARE Admitting Diagnosis: RENAL CELL CARCINOMA ______________________________________________________________________________ FINAL REPORT HISTORY: Resection of L-1.,0
Two crosstable lateral views of the lumbar spine are submitted from the operating room showing a metallic mesh stent spanning the site of the resected L1 vertebral body from the inferior endplate of T12 to the superior endplate of L2.,0
Lumbar fixation hardware is in place posteriorly with pedicle screws seen at T10 at 11 and at L2 and L3.,0
"At T10, the pedicle screws extend anteriorly to within 3 mm of the anterior aspect of that vertebral body based on the appearance on film labeled #2.",0
"Four staples, possibly from towels are seen over the buttock region and a staple seen projected over the posterior inferior border of T12 on film #1 is no longer evident on film number #.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: End Stage Renal Disease Secondary to FSGS, s/p two prior renal transplants.",1
Major Surgical or Invasive Procedure: 1) s/p Living Unrelated Renal Transplant 2) s/p Exploratory Laparotomy for delayed graft function 3) s/p Transplant Nephrectomy following hyperacute rejection 4) s/p Attempted Right Upper Extremity AV Graft placement History of Present Illness: Ms. is a 49 year old female with end-stage renal disease secondary to FSGS.,1
She previously received 2 transplants.,0
The first transplant was performed in and lasted approximately 10 years before it was lost secondary to allograft nephropathy.,0
Her second transplant occured in and failed 7 years later secondary to chronic allograft nephropathy.,1
She has been on dialysis since .,0
She reports no prior problems with .,0
Both of her renal transplants are still in place.,0
"She presented with an ABO-incompatible donor (her husband), and under a live donor swap program, presents now for a living donor transplant from a compatible donor at another institution.",0
Past Medical History: Thalassemia minor.,0
S/p MI in requiring PTCA with stents placed S/p parathyroidectomy () Avascular necrosis of the both hips requiring surgery.,0
"H/o atrial fibrillation Hypertension S/P C-section CAD; s/p MIl; PTCA of Mid RCA () c.b stenosis s/p re-angioplasty, ; s/p LAD stent placement Social History: The patient was born and raised in , MA.",1
She has been married for 25 years and has one 23-year-old daughter.,0
She does not drink alcohol and does not use any illicit drugs and never has.,0
She has not smoked since high school.,0
"Physical Exam: General: Well nourished, well developed female in no apparent distress.",0
"Temp: 99.2, P83, R16, 02Sat: 97% BP: 95/65.",0
Heart: Regular rate and rhythm.,0
Both transplants are present in both the right and left lower quadrant.,0
There is no evidence of graft tenderness or swelling.,0
Vascular: Femoral pulses are 2+ equal bilaterally Ex: No peripheral edema.,0
"Pertinent Results: 09:35AM BLOOD PT-14.3* PTT-27.8 INR(PT)-1.3 09:38AM BLOOD Glucose-163* Lactate-1.9 Na-138 K-4.7 Cl-103 09:38AM BLOOD Hgb-10.8* calcHCT-32 Brief Hospital Course: The patient presented with an ABO-incompatible donor, and under a live donor swap program, the patient was taken to the operating room for live donor transplant from an ABO- compatible donor from another institution on .",0
"Pre-Op class II antigen was weekly positive so the patient was given IvIG in addition the usual thymogloblin, cellcept, and solumedrol prior to implantation.",0
The operative course was significant for a warm ischemia time of <1 hours.,0
"6 L fluids intraop, 300 cc EBL.",0
35 cc urine made on table.,0
"Immediately following arrival the the PACU the patient was noted to be oliguric, a renal transplant ultrasound was obtained showing a normal-appearing transplant kidney.",1
"There was reversal of diastolic flow in keeping with high organ resistance, concerning for acutre rejection.",0
"The patient was therefore taken back to the operating room approximately 8 hours following her arrival the the PACU where she underwent an exploratory laparotomy, renal vein thrombectomy, and renal transplant core biopsy.",0
"Frozen section revealed a dense eosinophilic material consistent with thrombi within glomerular capillaries, neutrophils within glomerular capillaries, and a neutrophilic infiltrate within interstitium with no acute interstitial hemorrhage or arteritis seen.",0
"Since these finndings were worrisome for hyperacute rejection, the patient was plasmapheresed immediately post-op, treated with IV IG, ATG, and Solumedrol.",0
"Over the ensuing days she received plasmapheresis, IVIG for a total of 5 days, thymoglobulin, and one dose of rituximab.",0
"Daily ultrasounds demonstrated persistently elevated RIs, with flow to the kidney.",0
The patient required multiple runs of dialysis secondary to volume overload.,0
On POD3 she developed atrial fibrillation during dialysis run secondary to fluid shifts.,1
She was treated with Amiodarone and subsequently converted to NSR.,0
On POD#7 a renal biopsy was obtained showing renal parenchyma with near-total hemorrhagic coagulative necrosis.,0
Foci of acute inflammation / organization were noted.,0
Several small arteries showed significant intimal fibroplasia.,0
"Given the biopsy findings, and failure of the kidney to produce urine, the patient was taken back to the OR on POD9 for an exploratory laparotomy with transplant nephrectomy.",0
"The kidney appeared firm but dusk, and histologic evaluation revealed almost no viable tissue.",0
"Over the ensuuing days, the patient recovered from the operation, and continued HD.",0
"On a right arm AV graft was attempted, but aborted secondary to extensive arterial disease.",1
"On the night prior to discharge, the patient was found to be febrile in the dialysis unit.",0
She also complained of swelling and pain at the site of her PIC line in the left arm.,0
This was therefore removed and the patient defervescred and she remained afebrile for the remainder of her time here.,0
"She was therefore discharged in the evening on HD#17 Medications on Admission: Neurontin, Allopurinol, Synthroid, Lipitor, Protonix, aspirin, Plavix, Venopril, Renagel, Discharge Medications: 1.",0
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QD (once a day).,0
Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD (once a day).,0
Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD (every other day) for 3 months.,0
"Synarel 2 mg/mL Aerosol, Spray Sig: One (1) Spray Nasal ().",0
Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours) for 2 weeks.,0
Disp:*10 Patch 72HR(s)* Refills:*0* 9.,0
"Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday).",0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every four (4) hours: ; 500 mg with each meal, 1000 mg imbetween meals (total 6 times/day) .",0
"Disp:*180 Tablet, Chewable(s)* Refills:*2* 13.",0
Ativan 1 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Living unrelated renal transplant Hyperacute rejection of renal transplant Nephrectomy of transplanted kidney End stage renal disease secondary to focal segmental glomerular sclerosis Thrombocytopenia secondary to immunosupression Hypocalcemia Coranary Artery Disease Post-Operative Atrial Fibrillation Thallasemia Minor combined with Blood Loss anemia requiring multiple blood transfusion Discharge Condition: Excellent Discharge Instructions: 1.,1
"Please monitor for the following: fever, chills, nausea, vomiting, inabilitity to tolerate food/drink.",0
"If any of these occur, please contact your physician .",0
Do not drive while taking narcotics.,0
"Followup Instructions: Provider: , (TRANSPLANT) TRANSPLANT CENTER (NHB) Where: LM CLINIC Phone: Date/Time: 2:20 Provider: , TRANSPLANT CENTER (NHB) Where: LM CLINIC Phone: Date/Time: 2:40",0
8:44 AM CAROTID SERIES COMPLETE Clip # Reason: new dx r ICA stenosis and head aches ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with REASON FOR THIS EXAMINATION: new dx r ICA stenosis and head aches ______________________________________________________________________________ FINAL REPORT CAROTID SERIES COMPLETE REASON: Headaches and carotid stenosis.,0
"FINDINGS: Duplex evaluation was performed of both carotid artereis On the right the PSV are 65,37, 39 in the ICA, CCA, ECA respectively.",0
"However, the waveforms and all the carotid arteries on the right side are tardus parvus which are most consistent with a proximal stenosis.The EDV is zero On the left, peak systolic velocities are 122, 130, 22 in the ICA, CCA, ECA respectively.",0
The ICA to CCA ratio is 0.9.,0
This is consistent with a 40-59% stenosis.,0
There is antegrade flow in the right vertebral artery.,0
The left vertebral artery shows elevated velocity consistent with intrinsic stenosis.,0
"IMPRESSION: On the right, there is no evidence of cervical internal carotid artery stenosis.",0
"However, based on the waveforms and velocities, there is likely to be a proximal arch stenosis that is severe.",0
In addition there may be a tandem intracranial carotid lesion.,0
"On the left, there is a 40-59% carotid stenosis.",0
3:26 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval changes.,0
"Admitting Diagnosis: FRACTURE,C2 & C5 ______________________________________________________________________________ MEDICAL CONDITION: year old woman with pneumonia, recent LLL collapse s/p trach and G tube placement.",1
please evaluate for interval changes.,0
REASON FOR THIS EXAMINATION: please evaluate for interval changes.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate for interval change.,0
"CHEST, SINGLE AP PORTABLE SEMI-UPRIGHT VIEW.",0
"Tracheostomy tube is in place, in satisfactory position above the carina.",0
"A left-sided dual lead pacemaker is present, with lead tips over right atrium and right ventricle.",0
"There is moderately large left effusion with underlying collapse and/or consolidation, slightly larger than on .",0
"I suspect the presence of background COPD, with underlying pulmonary hypertension.",0
"There are diffusely increased interstitial markings, more pronounced at the right base.",0
"Compared with and allowing for differences in technique, the left effusion appears slightly larger.",0
"The interstitial markings at the right base may be slightly more prominent and the blunting of the right costophrenic angle, suggesting a small amount of pleural fluid, is new.",0
IMPRESSION: Left lower lobe collapse and/or consolidation and left effusion.,0
Probable atypical distribution of CHF.,0
"An early infectious infiltrate at the right base is considered less likely, but cannot be entirely excluded.",0
"2:46 PM PELVIS U.S., TRANSVAGINAL; PELVIS, NON-OBSTETRIC Clip # Reason: ?",0
source of bleed Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with vaginal bleeding REASON FOR THIS EXAMINATION: ?,0
source of bleed ______________________________________________________________________________ WET READ: ENYa SAT 4:08 PM 1.,0
"Endometrial lesion up to 1.7 cm, with internal flow, likely represents an endometrial polyp, but cannot exclude neoplastic process.",0
Recommend short- term follow-up with son +/- for further assessment.,0
1.9 cm left ovarian cyst.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 44-year-old woman, with vaginal bleeding.",0
COMPARISON: CT abdomen and pelvis on .,0
FINDINGS: Transabdominal and transvaginal ultrasound examinations were performed.,0
The latter was performed to better assess the adnexal structures.,0
The uterus measures 8.3 x 4.7 x 6.8 cm.,0
The endometrium appears markedly thickened measuring up to 19 mm.,0
"In the endometrial cavity, there is a 17 x 14 x 6 mm lesion with demonstrable with internal vascular flow.",0
The right ovary measures 3.1 x 1.8 x 1.4 cm.,0
The left ovary measures 2.7 x 2.3 x 1.9 cm.,0
"There is a 1.9 cm rounded predominantly-anechoic lesion within the left ovary, compatible with a simple ovarian cyst.",0
No free fluid is noted.,0
Endometrial lesion measuring up to 17 mm with internal vascularity.,0
Most likely represents endometrial polyp but differential diagnosis consideration includes submucosal fibroid and hyperplasia.,0
"Neoplastic process deemed less likely given patient's age, but cannot be completely excluded.",0
Recommend short-term followup with son and/or biopsy for further assessment.,0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion/Tamponade Admitting Diagnosis: ATRIAL SEPTAL DEFECT\REPAIR ATRIAL SEPTAL DEFECT;MINIMALLY INVASIVE ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with ASD s/p Min Inv.,1
"REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade ______________________________________________________________________________ FINAL REPORT AP CHEST, TIME: 11:12 a.m. HISTORY: ASD.",0
"IMPRESSION: AP chest compared to : There is a tiny right apical pneumothorax, right pleural drain in place.",0
"Mediastinum is shifted to the right, and can be explained by right upper lobe atelectasis.",0
"Hyperinflation of the left lung may be secondary, though anterior pleural air could be missed on the supine view.",0
Nasogastric tube would need to be advanced at least 10.0 cm to move all the side ports into the stomach.,0
4:58 PM PICC LINE PLACMENT SCH Clip # Reason: please place PICC via IR guidance (attempte bedside failed).,0
Admitting Diagnosis: ENTEROCUTANEOUS FISTULA ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with prolonged NPO due to aspiration risk, now pod18 s/p ECF takedown, sbr, Jtube placement.",0
REASON FOR THIS EXAMINATION: please place PICC via IR guidance (attempte bedside failed).,0
______________________________________________________________________________ FINAL REPORT INDICATION: Heparin induced thrombocytopenia; also long period without oral intake.,0
"PROCEDURE: This procedure was performed by Dr. , with Dr. , the attending radiologist, present and supervising throughout.",0
The patient's right arm was prepped and draped in the usual sterile fashion.,0
"As no suitable vein was found by visual inspection, ultrasound was used to locate the left basilic vein.",0
"After administration of approximately 3 mL of 1% lidocaine in the subcutaneous tissues, a 21-gauge needle was introduced into the vein under ultrasound guidance.",0
A 0.018 guidewire was then threaded through the needle.,0
"The needle was removed, and an introducer sheath threaded over the wire under flouroscopic guidance.",0
"The wire was then removed, and a double lumen PICC was threaded through the introducer.",0
The tip of the catheter was advanced to the cavoatrial junction at the length of approximately 38 cm.,0
"The introducer sheath was removed, the line flushed, StatLocked.",0
"IMPRESSION: Successful placement of 38 cm PICC with its tip at the cavoatrial junction, ready for use.",0
8:58 AM PORTABLE ABDOMEN Clip # Reason: 77yo woman w/ decr abd distention.,0
"Eval for interval change ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with lower GI bleed with inability to pass stool, no flatus, increasing abd pain.",0
REASON FOR THIS EXAMINATION: 77yo woman w/ decr abd distention.,0
Eval for interval change in loops of bowel and content of colon.,0
"______________________________________________________________________________ FINAL REPORT ABDOMEN, SINGLE FILM.",0
HISTORY: GI bleed with abdominal distension and absence of bowel movements.,0
NG tube is in stomach.,0
Distribution of bowel gas is unremarkable with gas present throughout the colon and no evidence for ileus or intestinal obstruction.,0
"Large calcified gallstone in right upper quadrant and multiple calcific densities overlie left kidney, as previously demonstrated.",0
"3:36 PM CHEST (PORTABLE AP) Clip # Reason: eval for effusions, pna Admitting Diagnosis: HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with wheeze, sob REASON FOR THIS EXAMINATION: eval for effusions, pna ______________________________________________________________________________ FINAL REPORT HISTORY: Shortness of breath and wheezing.",1
"FINDINGS: In comparison with study of , there is little overall change.",0
Substantial cardiomegaly with bilateral opacifications most likely reflecting pulmonary edema.,0
The possibility of supervening pneumonia would have to be raised in the appropriate clinical setting.,0
Slight impression on the lower cervical trachea on the right could possibly represent a small thyroid mass.,0
"8:59 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for infiltrate Admitting Diagnosis: LEFT CEREBRAL VASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with recent stroke, h/o smoking and recent uri REASON FOR THIS EXAMINATION: evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 65 y/o woman with recent stroke.",0
FINDINGS: AP semi-upright single view of the chest.,0
The pulmonary vascularity is normal.,0
There is a right IJ Swan-Ganz catheter with the tip in the right main pulmonary artery.,0
The ETT is in good position and unchanged.,0
There is NG tube with the tip in the antrum of the stomach.,0
IMPRESSION: There is no evidence of pneumonia.,0
No radiographic evidence of CHF.,0
"1:45 PM MR CARDIAC MORPHOLOGY W/CONTRAST; MR FLOW MAP Clip # MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS Reason: LV function, coronary eval, valve function, sarcidosis.",0
"Admitting Diagnosis: TACHYARRYTHMIA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with Ef , sarcoidosis, MR 2+.",0
faxed over requisition this evening.,0
"REASON FOR THIS EXAMINATION: LV function, coronary eval, valve function, sarcidosis.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT Patient Name: , MR#: Date: Indication: 59 year-old woman with a history of sarcoidosis, status post XRT for breast cancer, presented with dilated cardiomypathy and ventricular tachycardia, referred for evaluation of possible cardiac sarcoidosis and ARVD.",1
"(Over) 1:45 PM MR CARDIAC MORPHOLOGY W/CONTRAST; MR FLOW MAP Clip # MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS Reason: LV function, coronary eval, valve function, sarcidosis.",0
Admitting Diagnosis: TACHYARRYTHMIA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) 1) Structure: Axial dual-inversion T1-weighted images of the myocardium were obtained with and without spectral fat saturation pre-pulses in 5 mm contiguous slices.,0
Axial dual-inversion T2-weighted images of the myocardium were obtained without spectral fat saturation pre-pulses in 5 mm contiguous slices.,0
Axial dual-inversion T1-weighted images of the myocardium without spectral fat saturation pre-pulses in 5 mm contiguous slices were obtained after injection of a total of 0.2 mmol/kg gadopentetate dimeglumine (22 ml Magnevist solution).,0
"2) Function: Breath-hold cine SSFP images were acquired in the left ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8 mm slices with 2 mm gaps), sagittal and coronal orientations of the left ventricular outflow tract, and aortic valve short axis orientations.",0
"Tagged C- SPAMM cine images were also obtained in the 4-chamber orientation, 2-chamber orientation, and three slices of the short axis orientation 3) Flow: Phase-contrast cine images were obtained transverse to the aorta (axial plane) and main pulmonary artery (oblique plane).",0
4) Myocardial Viability/Fibrosis: Delayed enhancement (DE) images were obtained using a segmented inversion-recovery TFE acquisition with spectral fat saturation pre-pulses.,0
"Short-axis (8 mm slices with 2 mm gaps), 4-chamber and 2-chamber long-axis images were obtained 15 minutes after injection of a total of 0.2 mmol/kg gadopentetate dimeglumine (22 ml Magnevist solution).",0
Findings: Structure and Function There was normal epicardial fat distribution.,0
The myocardium appeared to have homogenous signal intensity without evidence of myocardial fatty infiltration.,0
The pericardial thickness was normal without evidence of tethering on tagged images.,0
There was a small pericardial effusion.,0
The origins of the left main and right coronary arteries were identified in their customary positions.,0
The indexed diameters of the ascending and descending thoracic aorta were normal.,0
The main pulmonary artery diameter index was mildly increased.,0
The left atrial AP dimension was normal.,0
The right and left atrial lengths in the 4- chamber view were normal.,0
The coronary sinus diameter was normal.,0
The left ventricular end-diastolic dimension index was moderately increased.,0
The end-diastolic volume index was severely increased.,0
The calculated left ventricular ejection fraction was severely reduced at 28% with global hypokinesis and focal inferior akinesis and mid-basal septal akinesis/dyskinesis.,0
The left ventricular mass index was moderately increased.,0
The right ventricular end-diastolic volume index was normal.,0
"The calculated right ventricular ejection fraction was normal at 59%, with normal free wall motion.",0
There was no focal thinning or fatty infiltration seen in the RV free wall.,0
There were no aneurysms seen in the RV free wall or right ventricular outflow tract.,0
Admitting Diagnosis: TACHYARRYTHMIA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) The aortic valve was tri-leaflet with normal valve area.,0
A signal void was seen in the left atrium during systole consistent with mitral regurgitation.,0
Quantitative Flow There was no significant intra-cardiac shunt.,0
Aortic flow demonstrated no significant aortic regurgitation.,0
The calculated mitral valve regurgitant fraction was consistent with moderate to severe mitral regurgitation.,0
The resultant effective forward LVEF was severely depressed at 22%.,0
The right ventricular stroke volume and pulmonic flow demonstrated no significant pulmonic and mild tricuspid regurgitation.,0
Myocardial Perfusion and Fibrosis There was uniform resting perfusion of all visualized segments.,0
"There were no areas of focal hyperenhancement, consistent with the absence of myocardial scarring/infarction.",0
Additional Findings There was a 1 cm lymph node noted in the supracarinal region.,0
Severely dilated left ventricular cavity size with severe global hypokinesis and focal inferior akinesis and mid-basal septal akinesis/dyskinesis.,0
The LVEF was severely depressed at 28%.,0
The effective forward LVEF was severely depressed at 22%.,0
No MR evidence of prior myocardial scarring/infarction.,0
Normal right ventricular cavity size and function.,0
The RVEF was normal at 59%.,0
No MR evidence of right ventricular fatty infiltration/dysplasia.,0
Moderate to severe mitral regurgitation.,0
There was a 1 cm lymph node in the supracarinal region.,0
Findings indicate an LV cardiomyopathy.,0
"(However, cannot exclude ischemic etiology; coronary arteries were not assessed).",0
"The findings were not suggestive of cardiac sarcoid, although this diagnosis cannot be definitely excluded.",0
The images were reviewed by Drs.,0
", , , and .",0
Admitting Diagnosis: TACHYARRYTHMIA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont),0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Diarrhea, Weakness, Anemia Major Surgical or Invasive Procedure: Port-a-cath placement.",1
History of Present Illness: 69 yo F with h/o Anaplastic large cell lymphoma and granuloma annulare who presents with fatigue and weakness x 2-3 days.,0
Pt is poor historian but notes weakness x 2-3 days.,0
She also notes loose stools over this time period.,0
"She denies fevers, chills, night sweats.",0
"She denies chest pain, shortness of breath, cough.",0
"She denies melena, hematochezia, brbpr.",0
"Per the patient's son, she has had no PO intake and has not got OOB x 2 weeks.",0
She also has occcassional urinary/fecal incontinence.,0
"In the am of admission, she slipped and fell on leg.",0
"In , pt was found to have diarrhea and poor rectal tone, neuro consulted.",0
--CT head-multiple lytic lesions seen in the right parietal and both occipital bones.,0
--CT C-spine - Multiple lytic lesions seen in the occipital bones bilaterally and lateral mass of C1 --MRI L-spine - Degenerative changes seen in the lower lumbar spine with no evidence of nerve root compression.,0
"Diffuse mottled appearance seen within the vertebral bodies, the sacrum, and both iliac bones is nonspecific in etiology.",0
"This can be seen in diffuse osteopenia, myeloproliferative or lymphomatous involvement of the osseous structures.",0
"She also had a hematocrit of 19 and then 15 with fluids with LDH 380, I. Bili 1.3, INR 1.6.",0
The patient was transfused 1 U PRBC.,0
She also had elevated LFTs: --RUQ US - Multiple ill-defined small hypoechoic lesions throughout the right lobe of the liver and surrounding the gallbladder fossa.,0
"--CT ABD - Diffuse stranding in the mesentery, which could suggest infiltration by neoplastic process or fluid.",0
Progressive retroperitoneal and inguinal lymphadenopathy.,0
Pt admitted to MICU for ?,0
cord compression and hypotension with anemia.,0
"Found to be OB neg, received 4 units PRBC and ruled out for cord compression.",0
Transfered to medical floor once HD stable.,0
"In addition, pt found to have PNA with hx of exposure to Pertussis.",0
Past Medical History: HTN Anxiety No Hx of skin sensitivity to sun or creams.,0
"Granuloma Annulare Social History: Smokes ppd x 60 years No Etoh Lives at home with son Family History: Mother died of ruptured appendix Father died of EToh abuse No hx of CA in family Physical Exam: Vitals: T99.8, BP: 130/50, HR: 107, RR: 26, O2 98% RA.",0
"GEN: Moderately ill appearing female in NAD, mildly tachypneic, no use of accessory muscles, speaking in full sentences.",0
"HEENT: Pupils equal and reactive, MM dry, neck is supple with no LAD.",0
"CV: Tachy, reg, 1/6 SEM at axilla.",0
CHEST: Decreased BS at b/l bases.,0
No rales or wheezes appreciated.,0
"ABD: NDNT, normoactive BS, soft.",0
"EXT: trace pedal edema, warm and well perfused.",0
L inguinal LAD with skin changes.,0
4-5 cm ulcerative lesion on R calf with surrounding erythema and lichenifcation of skin.,0
Pt also has mult areas on both upper ext with scaly lesions.,0
Moving all ext with normal strength.,0
Pertinent Results: CXR : FINDINGS: There is interval increase in the left retrocardiac opacity with associated left pleural effusion.,0
This is consistent with an evolving pneumonia.,0
"There is prominence of the pulmonary vasculature, suggestive of mild CHF.",0
"IMPRESSION: Left retrocardiac opacity and associated left pleural effusion, which is increased in comparison to the prior study, likely representing an evolving pneumonia.",0
"There is mild prominence of the pulmonary vasculature, suggestive of associated mild CHF.",0
CT Head: FINDINGS: No previous examination available for comparison.,0
White and matter differentiation is preserved.,0
No intracranial masses effect and no hemorrhage is seen.,0
Ventricles and subarachnoid spaces are within normal limits.,0
No findings to suggest an acute territorial infarction are noted.,0
"MRI is more sensitive to detect acute infarction, consider this if clinically indicated.",0
Bone windows demonstrated lytic lesion seen in the left parietal skull measuring approximately 1 cm in diameter.,0
Multiple additional lytic lesions are seen in the occipital bones bilaterally.,0
Clinical correlation is necessary.. .,0
"RUQ ultrasound: IMPRESSION: 1) No evidence of cholecystitis, cholelithiasis, or choledocholithiasis.",0
Tiny comet tail artifact likely secondary to an adherent crystal versus a small cholesterol polyp.,0
2) Multiple ill-defined small hypoechoic lesions throughout the right lobe of the liver and surrounding the gallbladder fossa.,0
"These may be secondary to focal fatty sparing, however, given the history of lymphoma a CT or MRI is recommended for definitive characterization.",0
CT pelvis: IMPRESSION: 1) No evidence of retroperitoneal hematoma.,0
"2) Diffuse stranding, likely related to third-spacing.",0
"3) Progressive retroperitoneal and right inguinal lymphadenopathy, concerning for relapsed lymphoma; slight improvement in size of left inguinal adenopathy.",0
"This unexpected finding was discussed with Dr. in the morning of , .",0
5) Similar appearance of left adnexal cyst.,0
6) Liver lesions not assessed without intravenous contrast.,0
Mild mucosal thickening is seen involving both posterior ethmoid sinuses.,0
Small fluid level is seen within the left sphenoid sinus and inferior left maxillary sinus.,0
INTERPRETATION: 1) No acute intracranial abnormalities.,0
"2) Multiple lytic lesions seen in the right parietal and both occipital bones, clinical correlation is necessary.",0
04:39AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.4* Hct-28.7* MCV-93 MCH-30.5 MCHC-32.6 RDW-18.7* Plt Ct-492* 04:39AM BLOOD Neuts-92.6* Bands-0 Lymphs-2.8* Monos-2.3 Eos-2.1 Baso-0.1 04:39AM BLOOD Glucose-105 UreaN-13 Creat-0.6 Na-136 K-3.8 Cl-106 HCO3-23 AnGap-11 04:39AM BLOOD ALT-34 AST-41* LD(LDH)-164 AlkPhos-122* TotBili-1.7* 02:59AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE .,0
Pelvic U/S: Transabdominal ultrasound demonstrates a uterus measuring 5.7 x 3.1 x 5.7 cm.,0
"The endometrium is heterogeneous and thickened as it is seen transabdominally, measuring 1.4 cm.",0
There are echogenic foci within the myometrium.,0
The right ovary is not identified.,0
"A rounded left adnexal cyst is seen, measuring approximately 2.4 cm in diameter.",0
This corresponds to a left adnexal cyst seen on the recent CT exam.,0
The left ovary itself is not clearly identified.,0
Transvaginal examination was declined by the patient.,0
"The differential diagnosis includes endometrial hyperplasia, carcinoma, adenomyosis, or polyp.",0
Further evaluation with MRI could be considered.,0
This exam is limited as the patient declined transvaginal exam.,0
"The ovaries are not clearly identified Brief Hospital Course: A 69-year-old female with past medical history significant for anaplastic large cell lymphoma, granuloma annulare, who presented with weakness, anemia, and hypertension.",1
BRIEF HOSPITAL COURSE BY PROBLEM: .,0
Anaplastic large cell lymphoma: The patient has been treated in the past with methotrexate successfully.,0
"During this admission, she was found to have a white blood cell count that was consistently trending upwards, even with broad-spectrum antibiotics.",0
"After the patient had received approximately 14 days of broad-spectrum antibiotics, it was felt that this rising white blood count was likely secondary to reactive leukocytosis.",0
"The patient did not have any abnormal cells on blood smear; however, it was noted that she had new lymphadenopathy on the right side in the inguinal region per pelvic CT.",0
"In addition, progression of her left-sided inguinal adenopathy was noted as the patient developed open draining sores, which she had had on prior admissions prior to treatment with methotrexate.",0
"It was, therefore, felt that the patient's rising white blood counts and symptoms were likely secondary to reactive leukocytosis from her underlying lymphoma.",0
"The patient was, therefore, started on CHOP chemotherapy on , after placement of a right subclavian Port-A-Cath.",0
The patient successfully received 5 days of CHOP chemotherapy.,0
"She had some nausea and vomiting on the first day, which was treated with antiemetics.",0
The patient did not receive any further hydration during this chemotherapy as she was already quite anasarcous.,0
"After treatment with CHOP chemotherapy, her white blood cell count begin to trend down from 55 and is now at 16 after chemotherapy.",0
The plan will continue with CHOP chemotherapy as the patient will be unable to take methotrexate with pleural effusion seen on CT scan.,0
The plan for the next dose of chemotherapy will be .,0
Pt with need twice weekly CBC and chem 7 during rehab admission as Nadir will likely be around .,0
Pt will follow-up with Dr. prior to next dose of chemo.,0
Please communicate lab values to Dr. .,0
Fevers: The patient was transferred to the medicine floor and subsequently developed fevers up to 101.,0
The patient's symptoms included tachypnea without shortness of breath.,0
"She denied nausea, vomiting, abdominal pain, lightheadedness, dizziness, or headache.",0
"The patient also had a rising white blood cell count associated with fevers with a maximum while blood cell count of 55,000.",0
"The patient was initially started on Levaquin, Flagyl and azithromycin while in MICU.",0
She was started on the azithromycin for an exposure to pertussis per the patient's son.,0
"When the patient spiked again, she was started on vancomycin.",0
There was also a ?,0
of asp pna due to altered MS on admission.,0
The patient did continue to spike through these antibiotics.,0
Infectious disease was consulted at this point.,0
The patient was persistently febrile through these broad-spectrum antibiotics.,0
"They recommended coverage for Pseudomonas, which would be the only thing that was not covered.",0
"The patient was, therefore, started on Zosyn.",0
Her stools were cultured and all cultures were negative.,0
"All blood cultures, sputum cultures, and urine cultures were negative.",0
"However, on hospital day 10, the patient was found to have white blood cells in her urine and grew out yeast.",0
The patient was started on a 7-day course of fluconazole.,0
"In addition to this, Histoplasma, Brucella, and Bartonella were all sent per recommendation by the ID team.",0
A CT scan was performed which showed bilateral large pleural effusions.,0
It was felt that the left-sided pleural effusion should be tapped to rule out empyema.,0
A thoracentesis was performed and the fluid was a transudate with no bacteria seen on Gram stain and no growth on culture.,0
Wound cultures were also performed on the draining wounds in her left groin.,0
"These grew out both yeast and staph, coagulase negative.",0
"However, it was felt that these were likely secondary to normal skin flora.",0
The patient's fevers defervesced and all antibiotics were discontinued after a full 14-day course for suspected pneumonia.,0
"The patient remained afebrile and at the time of dictation, both Brucella and Bartonella results were negative.",0
The patient was also ruled out for pertussis by PCR and cultures.,0
"After fevers defervesced, the patient's white blood cell count continued trending up.",0
"Therefore, it was felt that her fevers and leukocytosis were secondary to a reactive leukocytosis from her lymphoma.",0
The patient was afebrile after her CHOP chemotherapy and white blood cell count trended down.,0
"Neuro: On admission, the patient was felt to be weak and there was a question of cauda equina syndrome.",0
The patient was assessed by neurology who felt that her symptoms of weakness and fatigue were likely associated with infection versus metabolic dysfunction.,0
"The patient was found to have a hematocrit of 15 at the time of admission, and after transfusions and treatment with broad-spectrum antibiotics, the patient's symptoms resolved.",0
The patient had an MRI as above which showed no evidence of compression.,0
Neurology signed off as they felt that the patient's symptoms were not secondary to neurologic dysfunction.,0
The patient was seen and evaluated by physical therapy.,0
They felt that her weakness is secondary to deconditioning.,0
The patient will need aggressive physical therapy and rehabilitation after discharge.,0
Anemia: Most likely secondary to inflammatory process with a background of lymphoma.,0
The patient had no clear source of bleeding initially on admission as well as stools were guaiac negative.,0
DIC labs were sent and were negative.,0
Haptoglobin was normal on admission.,0
Hematocrit was stable after receiving 4 units of PRBCs on admission.,0
The patient received 2 additional transfusions after CHOP chemotherapy for hematocrit less than 25.,0
Pt found to have vaginal bleeding on .,0
Vaginal bleeding: The patient was noted to have small amounts of vaginal bleeding after the CHOP chemotherapy.,0
The patient is postmenopausal and has never had the symptoms before.,0
"A transvaginal ultrasound was ordered; however, the patient refused this ultrasound.",0
"She did allow a pelvic ultrasound, which showed a thickened heterogeneous endometrium and a left adnexal cyst was also noted.",0
The ovaries were not clearly identified.,0
"OB/GYN was consulted, but the patient refused a pelvic exam and refused further workup at this time.",0
The patient stated that she wanted to discuss the issue with her family members.,0
The patient was educated and counseled about the risks of possible endometrial cancer.,0
She felt that she did not want any further intervention at this time.,0
After further discussion with the patient she agreed to had biopsy and further work-up as an outpatient.,0
"GYN agreed to this plan and an appointment was scheduled for , .",0
Tachycardia: The patient was found to be tachycardic between 100 and 120 during the entire admission.,0
Old records were reviewed which showed that her heart rate had been in this range since her first admission in 11/.,0
"It was noted in her prior records that the patient had been on both beta-blockers and calcium channel blockers in the past; however, her granuloma annulare seemed to worsen with these medications and they were therefore stopped.",0
"An Pt has a normal EF, but did have an element of diastolic dysfunction.",0
The patient received Lasix with transfusions and her heart rate did improve to between 80 and 90 after chemotherapy and decrease in white blood cell count.,0
The patient should be started on a beta-blocker or calcium channel blocker for another trial after her lymphoma is stabilized.,0
Pneumonia: It was felt that the patient had a pneumonia on initial admission to the MICU.,0
She was started on antibiotics as described above.,0
The patient's respiratory status improved after pleural effusion tapped on the left.,0
It is likely that her bilateral pleural effusions were secondary to volume overload as the patient was anasarcic after fluid resuscitation and transfusions.,0
The patient's respiratory status was back to baseline at the time of discharge.,0
Diarrhea: The patient noted on admission that she was having frequent loose bowel movements.,0
The patient had C. diff checked x3 and all were negative.,0
"She also had stool cultures sent for ova and parasites, Salmonella, Cyclospora, and Giardia, all of which were negative.",0
The patient was on Flagyl for 14 days.,0
"Nutrition: The patient was found to have an elevated INR on admission, which was felt to be nutritional.",0
The patient has had a difficult time with nutrition since her diagnosis.,0
She states that she is simply not hungry.,0
The patient received subq vitamin K and oral vitamin K x5 days.,0
Her INR then trended back down to normal.,0
She was noted to have hypoalbuminemia to 2.,0
The patient seemed to do well with encouragement while eating.,0
Nutrition was consulted and added a high-calorie shake to all of her meals.,0
The patient did well with this plan and was eating more with encouragement and assistance with eating.,0
The patient is able to feed herself.,0
Anxiety: The patient has a history of anxiety and was continued on her Valium during this admission.,0
Electrolytes: The patient had a creatinine that was trending up during this admission.,0
Checked FeNa which was 0.9 suggesting dehydration.,0
The patient received gentle hydration plus transfusion to increase her forward flow.,0
She was also encouraged p.o.,0
Creatinine trended back down to 0.8.,0
The patient also noted to have chronic hyponatremia.,0
The highest sodium that had been documented over the past year was 136.,0
Baseline appears to be closer to 131.,0
The patient has likely been equilibrated.,0
"She was placed on a fluid restriction initially, which did bring the sodium back up to the low 130s.",0
The patient was maintained on subq heparin and PPI.,0
13: Granuloma Annulare: Pt is being followed by dermatology as an outpatient.,0
Skin lesions are actually much improved after MTX treatment.,0
Used to have open draining wounds.,0
Contact: The patient gave her son at phone number .,0
Code status was full during this admission.,0
The patient states she would like to talk to her family further about her code status.,0
Medications on Admission: HCTZ (not taking) Valium 5 qd Prozac - not taking Folic Acid Doxacin - ?,0
taking Aranesp Discharge Medications: 1.,0
"Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day).",0
Diazepam 2 mg Tablet Sig: One (1) Tablet PO QD ().,0
Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) flush Intravenous DAILY (Daily) as needed.,0
Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg Injection every eight (8) hours as needed for nausea.,0
Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed.,0
"Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: Recurrent lymphoma Granulomata Annulare Discharge Condition: Stable to rehab Discharge Instructions: Please return to the hospital if you experience chest pain, shortness of breath, severe nausea/vomiting or any other severe symtoms.",0
Please follow-up with your appointments as below Followup Instructions: 1.,0
"Please follow up with Gynecology on with Dr. at 2:30; Please go to , 8.",0
Where: CUTANEOUS ONCOLOGY Date/Time: 9:45,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: ORT HOSPITAL COURSE: On the day of admission, this 20-year-old female was medically stabilized and evaluated with CT and MR her L2 burst fracture.",0
"Despite significant canal compromise, she remained neurologically intact.",0
"Due to her unstable pattern and neurologic compromise, anterior and posterior spinal reconstructive surgery was performed.",0
A left T12 thoracoabdominal approach was performed with corpectomy at L2 and L1-L3 anterior spinal fusion using a Harm's cage and screw and rod fixation from L1-L3.,0
"On postoperative day 1 from her anterior surgery, she underwent an uncomplicated posterior spinal fusion with instrumentation and iliac crest bone graft from levels T10-L4 with pedicle screws placed at L4 and hook and rod construct above.",0
Her postoperative course was unremarkable.,0
"She received homologous blood transfusion postoperatively after intraoperative transfusion, and her hemoglobin stabilized, and she remained asymptomatic for her residual anemia.",0
"The wounds were sealed, and she is healing primarily, both wounds, the flank, and posterior wounds.",0
She has resumed normal bowel and bladder function.,0
Her pain is controlled with oral medications.,0
She is immobilized in a TLSO brace.,0
She is discharged for continued rehabilitative care including psychiatric rehabilitation and physical rehabilitation.,0
She will follow-up with Dr. in days for examination of the wounds and assessment of the construct radiographically.,0
Long-term plans are for brace wear for three months and physical therapy for up to six months for full recovery of function after her surgery.,0
Her psychiatric care is deferred to the guidance of the consulting team.,0
", Dictated By: MEDQUIST36 D: 09:02:23 T: 09:25:03 Job#:",0
"12:01 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: evaluate cardiothymic silouette, evaluate for congenital hea Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with heart murmur at 1 week of age born at 33 weeks gestation REASON FOR THIS EXAMINATION: evaluate cardiothymic silouette evaluate for congenital heart disease ______________________________________________________________________________ FINAL REPORT Portable view of the chest dated at 11:20 a.m. CLINICAL HISTORY: One-week-old 33 week gestation infant with cardiac murmur.",1
The lungs are low volume but clear bilaterally.,0
"The cardiac apex, aortic arch, and gastric bubble are all on the left.",0
A nasogastric tube has been placed with the tip just distal to the gastroesophageal junction.,0
IMPRESSION: No radiographic findings suggestive of congenital heart disease.,0
"5:48 AM CHEST (PORTABLE AP) Clip # Reason: lines, ETT placement, infection Admitting Diagnosis: CHEST PAIN/ CHANGE IN MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with sob dropping sats s/p intubation s/p new R. IJ REASON FOR THIS EXAMINATION: lines, ETT placement, infection ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath with dropping oxygen saturation.",0
Check line placement and evaluate for lung infection.,0
Comparison study taken 6 hours earlier.,0
The positions of the endotracheal tube and the right IJ line are unchanged.,0
The NG line remains looped in the lower portion of the stomach with its tip in the fundus.,0
The heart again shows moderate LV enlargement.,0
"There is marked upper zone redistribution, partly postural but probably also due to left heart failure.",1
Some ill-defined loss of translucency is noted at both bases and there is blunting of both costophrenic angles consistent with bilateral pleural effusions.,0
"IMPRESSION: Findings are consistent with left heart failure, slightly worse than on the previous film of the same day.",1
There is also evidence of some left lower lobe collapse/consolidation.,0
"12:21 AM CHEST (PORTABLE AP) Clip # Reason: ett placement ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with intubation, ?",0
"stroke REASON FOR THIS EXAMINATION: ett placement ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, AT 00:28 HOURS.",0
HISTORY: Status post endotracheal tube placement.,0
"FINDINGS: Consistent with the given history, an endotracheal tube is in place with the distal tip approximately 1.8 cm from the carina.",0
There is pulmonary vascular indistinctness and engorgement of the vascular pedicle.,0
"There is subtle increased retrocardiac opacity, which is likely due to atelectasis, although a developing consolidation cannot be excluded.",0
Blunting of the left costophrenic angle highly suggests a small pleural effusion.,0
IMPRESSION: Mild hydrostatic edema presumably cardiogenic in etiology.,0
"Retrocardiac opacity likely reflects atelectasis, although an underlying infection cannot be entirely excluded.",0
Repeat radiography following appropriate diuresis recommended to assess for underlying infection.,0
Endotracheal tube placement as above.,0
"For optimal placement, consider retracting 1 cm.",0
12:44 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for interval development of infiltrates or Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with dyspnea s/p intubation REASON FOR THIS EXAMINATION: Please assess for interval development of infiltrates or edema.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST 03:11 A.M., .",0
IMPRESSION: AP chest compared to through : Bibasilar consolidation or atelectasis persists despite intubation.,0
The heart is mildly enlarged but unchanged.,0
A chest CT on showed very severe tracheomalacia above the level of the aortic arch.,0
The endotracheal tube presumably stents the trachea in the region of most severe narrowing.,0
8:03 PM CHEST (PORTABLE AP) Clip # Reason: please eval ETT placement and OG tube placement.,0
Admitting Diagnosis: ASPIRATION PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with hx aspiration pna now with inc work of breating and hypoxia and s/p intubation REASON FOR THIS EXAMINATION: please eval ETT placement and OG tube placement.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: History of aspiration pneumonia, increased work of breathing and hypoxia, please evaluate endotracheal tube placement and OG tube placement.",0
TeCHNIQUE: Single AP portable supine chest.,0
FINDINGS: Again seen is a stimulation device with leads overlying the right chest wall in unchanged position.,0
A right internal jugular venous access catheter remains in unchanged position.,0
"There has been interval placement of an endotracheal tube which terminates with tip approximately 5 cm above the carina, in satisfactory position.",0
The nasogastric tube terminates with tip below the diaphragm.,0
"Unchanged appearance of the heart size and mediastinal contours, with interval increased prominence of patchy opacities at the bases bilaterally, consistent with bibasilar atelectasis vs. consolidation.",0
IMPRESSION: 1) Satisfactory position of lines and tubes.,0
2) Slight interval increased prominence of bibasilar collapse vs. consolidation.,0
"8:22 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for pnx, fluid overload, etc Admitting Diagnosis: MULTIPLE MYELOMA;FEVER;NEUTROPENIA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with right lobe collapse v consolidation now with increased resp rate REASON FOR THIS EXAMINATION: eval for pnx, fluid overload, etc ______________________________________________________________________________ FINAL REPORT STUDY: AP CHEST, .",1
HISTORY: 51-year-old woman by right lobe collapse versus consolidation now with increasing respiratory rate.,0
"Evaluate for pneumothorax, fluid overload.",0
"There is again seen bilateral pleural effusions, right side much greater than left.",0
There is pulmonary vascular congestion which is unchanged.,0
There is a lobulated infiltrate in the right upper lobe which has developed since .,0
A central venous catheter with distal tip in the SVC is again seen.,0
There is also a PICC line from the left side with distal tip in the mid SVC.,0
"11:19 AM CHEST (PORTABLE AP) Clip # Reason: evidence of pna Admitting Diagnosis: BRADYCARDIA;HYPOTENSION;SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with hypotension and hypoxemia, septic shock now with bronchial BS and rales.",1
REASON FOR THIS EXAMINATION: evidence of pna ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: Compared to CLINICAL INDICATION: Septic shock.,1
Lines and tubes remain in satisfactory position.,0
The previously noted congestive heart failure pattern continues to improve with minimal residual peribronchial cuffing and perihilar haziness remaining.,0
There is no significant change in bilateral pleural effusions and retrocardiac opacity.,0
IMPRESSION: Resolving congestive heart failure.,0
Persistent pleural effusions and retrocardiac opacity.,0
5:13 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with hypercapnic respiratory failure REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 58 y/o female with hypercapnic respiratory failure.,1
FINDINGS: There is an endotracheal tube in satisfactory position at the thoracic inlet.,0
There is an NG tube in position with its distal tip located within the lower stomach.,0
There is atelectasis present within the anterior portion of the right upper lobe.,0
There is prominence of the right upper mediastinum.,0
IMPRESSION: 1) Atelectasis within the anterior segment of the right upper lobe.,0
2) Slight widening of the right upper mediastinum.,0
A upright chest radiograph is advised to better assess this finding.,0
2:58 PM CHEST (PORTABLE AP) Clip # Reason: please confirm picc tip placement; page w/ results.,0
"t Admitting Diagnosis: MVA;CLOSED HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man ejected from vehicle in MVC, s/p head injury, trach, vent drain, now with increased secretions/sputum.",0
REASON FOR THIS EXAMINATION: please confirm picc tip placement; page w/ results.,0
thanks ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST INDICATION: A 40-year-old man who was ejected from a vehicle in an MVC.,0
Check tracheostomy and PICC placement.,0
FINDINGS: Comparison is made with a previous study also a supine portable film obtained on the at 3:54.,0
The tip of the PIC line overlies the right atrium in the region of the mid- cavity.,0
The tracheostomy tube looks satisfactory and is unchanged.,0
"Since the previous examination, the pulmonary edema has largely resolved although a little may remain at the left lung base where there is a pleural effusion and loss of the left hemidiaphragm with some consolidation/collapsed lung.",0
IMPRESSION: Satisfactory placement of PIC line with tip in the right atrial region.,0
Complete resolution at the left base.,0
The right lung is largely cleared.,0
4:29 PM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with s/p Esophagectomy R CT removal REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: 64-year-old man with status post esophagectomy and right chest tube removal.,1
TECHNIQUE: PA and lateral chest radiograph.,0
COMPARISON: Chest radiograph from at 9 a.m.,0
FINDINGS: There is interval removal of a right chest tube.,0
There is a persistent small right apical pneumothorax.,0
"There are stable bilateral pleural effusions, with adjacent atelectasis at the lung bases.",0
"Interval removal of right chest tube, with persistent small right apical pneumothorax.",0
Follow-up radiograph recommended to document resolution.,0
Bilateral stable small pleural effusions with adjacent atelectasis.,0
2:30 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: interval change.,0
NOT PORTABLE Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with small bowel obstruction REASON FOR THIS EXAMINATION: interval change.,0
NOT PORTABLE ______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old woman with small-bowel obstruction.,0
"FINDINGS: Three views of the abdomen including left lateral decubitus, comparison to .",0
An NG tube has been placed in the stomach.,0
There is decreased dilatation of the stomach.,0
"Again noted is persistent dilation of multiple small bowel loops, with a decompressed colon.",0
"Extensive retained contrast from recent esophagram, although there has been some interval progression of contrast material.",0
There are no air-fluid levels identified.,0
"IMPRESSION: Persistent dilation of multiple small bowel loops with retained oral contrast, although some progression of contrast is noted.",0
"If clinically indicated, CT scan would be useful for further evaluation of obstruction.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Amitriptyline / Norvasc Attending: Chief Complaint: Cough and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 65 y/o M with PMHx of CAD s/p stenting, Afib/flutter, DM with neuropathy and tobacco dependance who presents with productive cough and SOB for 3 days.",1
Pt reports upper respiratory congestion and cough with yellow sputum but denies fever & chills.,0
"Pt describes PND, orthopnea and new nocturia but has minimal exertion capacity and denies DOE.",0
"He also reports approx 1 wk of difficulty swallowing, coughing with thin liquids though no prior history of aspiration.",0
Pt has poor dentition and difficulty chewing solid foods.,0
He initially presented to his PCP on morning and was discharged with prescription of Azithro and plan for outpt CXR.,0
"However, his shortness of breath worsened overnight and he presented to the ED early tuesday morning.",0
VS on arrival to the ED were: T 97.6 BP 148/104 HR 122 RR 28 Sats 100% on RA.,0
"CXR revealed LLL infiltrate and pt received Ceftriaxone 1gram, Azithromycin 500mg, Prednisone 60mg, Duonebs and 3L of NS IVF.",0
Pt was given diltiazem 20mg IV for HR of 130 and was noted to have increasing O2 requirement.,0
Pt was unable to wean from NRB and was started on diltiazem gtt for rate control.,0
Repeat CXR showed worsening pulm edema and LLL consolidation.,0
"On arrival to CCU, pt was feeling better, still c/o cough and mild SOB.",0
"Denies any fevers/chills, CP/palpitations, abd pain, nausea/vomiting or diarrhea.",0
Past Medical History: # CAD s/p PCI x 2 with a history of MI and angioplasty 12 years ago.,1
His most recent cardiac catheterization was in of at which revealed non-flow limiting three-vessel disease and no intervention was performed at that time.,0
"# Atrial flutter/atrial tachycardia status post ablation in with breakthrough atrial tachycardia and atrial flutter # Atrial fibrillation- baseline HR 100-120 outpatient # DM type II - on NPH, recent A1C 6.6 # Neuropathy- DMII wheelchair bound w/ caregiver # PVD followed by Dr. # Ca -- s/p partial colectomy , no radiation or chemo # Neuropathy -- progressing to R arm now; legs unchanged, uses # Spinal Stenosis -- MRI done , no emergent issues, but some retrolisthesis of L4-5.",1
"# Anemia--Longstanding normocytic, unclear etiology # Alcoholism- Likely Active # Retinopathy- # Intracranial bleed-- fainted after dose of Amytripile and had intracranial bleed by rt inner ear.",1
Social History: Lives at / with friend/partner (); this is also his HCP.,0
Alcohol: Reports drinks/day everyday for years.,0
"Denies problems with alcohol, but concern for abuse per previous notes.",0
"No h/o WD, DT's, seizure.",0
Tobacco: 1.5 PPD x 40 yrs Drugs: Remote marijuana only.,0
Family History: no family hx of heart disease.,1
"Both parents died at 92 of ""old age.""",0
"Physical Exam: Vitals: T: 97.5 BP: 127/82 P: 127 R: 24 O2: 93% on NRB General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated approx 3cm below angle of the jaw Lungs: No appreciable wheezes, occaisional rhonchi and inspiratory crackles at L>R base, clear with coughing.",0
"CV: Irreg/Irreg & tachycardic, diff to apprec murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding Ext: Warm, 2+ pulses, no edema Pertinent Results: 07:56AM URINE COLOR-Yellow APPEAR-Clear SP -1.012 07:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 07:56AM URINE RBC-5* WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 07:56AM URINE MUCOUS-RARE 04:56AM LACTATE-1.7 04:15AM GLUCOSE-81 UREA N-13 CREAT-0.4* SODIUM-138 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12 04:15AM estGFR-Using this 04:15AM WBC-7.3 RBC-3.64* HGB-10.4* HCT-30.8* MCV-85 MCH-28.7 MCHC-33.8 RDW-16.1* 04:15AM NEUTS-57.0 LYMPHS-35.2 MONOS-4.8 EOS-2.2 BASOS-0.8 04:15AM PLT COUNT-393 ECHO The left atrium is mildly dilated.",0
"Compared with the prior study (images reviewed) of , tricuspid regurgittaion is now more prominent and estimated pulmonary artery systolic pressure is now higher.",1
Left ventricular and right ventricular systolic function is less vigorous.,0
CXR COMPARISON: Chest radiograph from obtained of 04:16 a.m. and chest radiograph from .,0
The left lower lobe consolidation accompanied by pleural effusion is unchanged but there is overall progression of perihilar vascular engorgement continuing towards the right lower lung with small right pleural effusion present.,0
The radiological picture is consistent with mild-to-moderate pulmonary edema with the abnormality at the left lung being either a separate entity such as a pneumonia and parapneumonic effusion or potentially can be due to asymmetric pulmonary edema.,1
"ADDENDUM: Findings were discussed with Dr. over the phone by Dr. approximately at 8:55 a.m. on , .",0
Increase in consolidation at the left lung base with slight increase in pleural effusion is concerning for pneumonia.,0
CHF with new mild-to-moderate pulmonary edema is unchanged.,0
"Brief Hospital Course: 65 year-old male with coronary artery disease, atrial fibrillation, diabetes mellitus type with neuropathy and tobacco dependance admitted with productive cough and SOB for 3 days.",1
"Patient was initially admitted to MICU, then medicine service, and finally to cardiology service prior to discharge.",0
Hospital course was as follows.,0
"On initial presentation, patient was with adequate O2 saturation on RA and became progressively hypoxic with IVF resuscitation and Afib with .",0
Lobar pneumonia treated with good response with ceftriaxone (ten day course with 3 days of cefpodoxime prescribed at discharge) and azithromycin (5 day course).,0
"Pt became fluid overloaded intermittently with shortness of breath, which responded well to 20mg IV furosemide.",0
Pt also experienced great symptomatic relief with brochodilators suggesting a brochospasm component to his dyspnea.,0
"After several days of gentle diuresis, antibiotics and nebulizer treatments, patient was saturating 95% on room and breathing comfortably.",0
"Discharged on continued antibiotics, furosemide, and albuterol.",0
Chronic diastolic heart failure: TTE on revealed EF 50-55% with minimal decrease in systolic function from prior TTE.,1
"On cardiology service, patient experienced tachypnea at night which appeared consistent with PND.",0
He was given Lasix with good response.,0
Atrial fibrillation with : Patient has known atrial fibrillation and is status-post failed ablation.,1
"Suspect current worsening precipitated by CAP, hypoxia & long standing smoking history.",1
Patient not anti-coagulated per Dr. given history of IVH from multiple falls.,0
He was treated with increased doses of metoprolol and continued to enter A-Fib with to the 140's.,0
For a short time his Toprol XL dose was doubled.,0
"On discharge, his heart rate was well-controlled with diltiazem SR 240mg PO daily and metoprolol succinate 100mg PO daily.",0
Coronary artery disease: Patient was without chest pain during episodes of atrial fibrillation with .,1
EKGs essentially unchanged though low voltage in limb leads.,0
"He was continued on aspirin, Plavix, beta-blocker, and statin per his home regimen.",0
"Diabetes mellitus, type II: Blood sugars poorly controlled, in the 300-400 despite excellent outpatient control with A1C of 6.6.",0
This was likely due to prednisone treatment in the ED and the stress of his illness.,0
was involved in management and guided daily insulin regimen changes.,0
Patient's diabetes mellitus is complicated by neuropathy; he was continued on gabapentin 300mg PO TID per home regimen.,0
Alcohol use: Patient has been known to have significant alcohol intake.,0
His alcohol level was elevated on admission.,0
He was counseled on alcohol cessation.,0
He was monitored on CIWA protocol and showed no signs of withdrawal.,0
"He was also started on a MVI, folic acid, and thiamine.",0
Hypertension: Well-controlled throughout hospitalization with metoprolol and diltiazem as above.,0
Anemia: Hematocrit remained at baseline (~30).,0
Normocytic with labs consistent with iron deficiency.,0
Patient with known history of cancer s/p partial colectomy.,0
"Continued iron 325mg PO daily, and recommend to patient that he have a repeat colonoscopy as an outpatient.",0
?COPD: No PFTs in our system.,0
Unclear where how this diagnosis came about.,0
"Continued ipratropium prn, and discontinued albuterol given episodes of tachycardia.",0
Pulmonary hypertension: Moderate based on recent TTE.,1
"Source unclear, but may be related to left heart failure +/- acute illness.",1
Patient recommended to have pulmonary follow-up as an outpatient.,0
"Nutrition: He was evaluated by speech and swallow given presumed aspiration pneumonia, as described as above.He was recommended for a nectar prethickened liquid diet.",0
"**Communication: , PCA ( Medications on Admission: Lipitor 40mg daily Plavix 75mg daily Novolog 70/30 14units qam and 4units qpm Cymbalta 30mg daily Aspirin 325mg daily MIV daily Diltiazem SR 120mg daily Albuterol inhaler q4hr prn Azithromycin 500mg x 1, 250mg x 4 (started ) Gabapentin 300mg TID Folic Acid 1mg daily Toprol XL 100mg daily Discharge Medications: 1.",0
Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily).",0
"Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 10.",0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) inhalations Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
Disp:*1 month supply* Refills:*0* 14.,0
Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 3 days.,0
Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous In the morning.,0
Disp:*30 day supply* Refills:*2* 16.,0
Novolog 100 unit/mL Solution Sig: As per attached sliding scale algorithm Subcutaneous four times a day.,0
Insulin Syringes (Disposable) 1 mL Syringe Sig: As per Lantus prescription Miscellaneous once a day.,0
"Disp:*10 syringes* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - Lobar Pneumonia, community acquired pneumonia vs. aspiration pneumonia - Atrial fibrillation with rapid ventricular rate - Acute on chronic systolic heart failure Secondary: - Diabetes mellitus type II complicated by retinopathy and neuropathy - History of cancer - Iron-deficient anemia Discharge Condition: Hemodynamically stable.",1
Uses wheelchair for mobility (baseline).,0
Discharge Instructions: You were admitted to the hospital because of difficulties breathing and a fast heart rate.,0
You were found to have pneumonia and extra fluid in your lungs which was making it hard to breath.,0
"During your hospital stay, you were given antibiotics for your pneumonia and your heart rate was controlled by increasing some of your medications.",1
We also gave you a medication to keep fluid off of your lungs.,0
We also discovered you had a low blood count due to an iron deficiency.,0
"This may mean you have another problem in your , and it may be necessary to have another colonoscopy in the future.",0
Please discuss this with your doctor.,0
Your medication regimen has changed.,0
Please review your medication list closely.,0
Please attend all the follow up appointments indicated below.,0
"If you have any of the following problems or any symptoms that are concerning to you, please return to the emergency department or call your physician: Difficulty breathing, - Fever, - Fast heart rate, - Confusion, - Inability to eat, or - Pain or pressure in your chest.",0
"Followup Instructions: Provider: , MD (Primary care) Phone: Date/Time: 2:30PM Provider: , NP (Cardiology) Phone: Date/Time: 8:00AM, 7 Please follow-up with Dr. and at within one week.",0
"7:43 AM CHEST (PORTABLE AP) Clip # Reason: worsening hypoxia-r/o effusion/CHF Admitting Diagnosis: LUNG CANCER ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with hx of adenoca lung s/p TBBx REASON FOR THIS EXAMINATION: worsening hypoxia-r/o effusion/CHF ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, AT 8:09 A.M. HISTORY: Worsening hypoxia status post transbronchial biopsy in patient with adenocarcinoma of the lung.",0
"COMPARISON: Multiple priors, the most dated .",0
FINDINGS: Postsurgical changes consistent with prior median sternotomy and right thoracotomy again appreciated.,0
There is slight improved expansion of the lungs with persistent bilateral perihilar and right basilar opacities.,0
Fibrotic changes are noted in the right apex with traction bronchiectasis.,0
Persistent blunting of the right costophrenic angle is again identified due to effusion.,0
"Overall, no significant interval change.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Transplant HISTORY OF THE PRESENT ILLNESS: The patient is a 42-year-old male status post pancreas transplant in and kidney transplant in , who presented with a lower GI bleed, aspiration pneumonia, E. coli sepsis, and worsening kidney function.",0
The patient was admitted to the surgical tagged red cell scan that revealed a likely bleeding source in the mid jejunum.,0
"It was felt that due to this instability and immunosuppression that was onboard, endoscopy would not be pursued by the gastroenterology.",0
"Once his GI bleed was stabilized and resuscitated adequately, he was ultimately discharged to the floor.",0
dependent diabetes times 35 years.,0
He has coronary artery disease and he has a myocardial infarction in the past; end-stage renal disease; and he was transplanted in ; he had a pancreas after kidney transplantation in .,1
He has no history of COPD.,0
The patient's pancreas transplantation does have an enteric anastomosis.,0
HOSPITAL COURSE: (by system) NEUROLOGICAL: The patient was admitted in extremis secondary to GI bleed issues.,0
He was ultimately intubated due to his question of aspiration.,0
He was serially weaned off the vent.,0
He did require protracted ventilatory support.,0
"Ultimately, he was extubated on .",0
He was noted to have a high O2 requirement and large bilateral effusions.,0
These were ultimately tapped on .,0
The left pleural effusion was tapped for a total of 600 cc.,1
The right pleural effusion was tapped for a total of 520 cc.,1
This was a sterile transudative tap.,0
The white cells were ; red cells ; total protein 0.8; glucose 125; LDH 92; albumin less than 10.,0
No cultures were positive from the portal tap and it was presumed to be just to be secondary to likely volume issues and acute inflammatory response and his acute inflammatory response and his gram-negative rod sepsis.,0
"At the time of discharge, the patient had a discharge x-ray showing a left pleural effusion greater than right, but decreased status post tap.",1
He was requiring nasal cannula O2 for a total of approximately two liters to four liters to keep his saturations between 92% to 95% on room air.,0
He was getting Albuterol and ipratropium MDI p.r.n.,0
He will continue his aggressive pulmonary toilet and work with the Department of Physical Therapy to get control of his pulmonary status.,0
It is possible that he has a component of reactive airway disease induced secondary to his question aspiration pneumonia and prolonged ventilation in the ICU.,0
"CARDIAC: The patient has a history of CAD, status post MI.",0
"He did not have MI this time, nor did he have any ischemic changes on EKG, ICU, or floor stay.",0
He was being maintained on Isordil 10 mg t.i.d.,0
; Diltiazem 60 mg q.i.d.,0
"At the time of discharge, the blood pressure was ranging 140 to 150/60 diastolic.",0
"Heart rate was begun 70 and 80 and, otherwise, stable.",0
"Most recent EKG was on showing normal sinus rhythm, no ST/T segment changes; no evidence of ischemia.",0
"FEN/GASTROINTESTINAL: The patient had worsening BUN and creatinine requiring some dialysis early on in the course, likely secondary to the angiography dye.",0
He was on dialysis for several days and then ultimately he was weaned off it once the allograft nephropathy improved.,0
BUN and creatinine at the time of discharge were 55 and 4.4 and he was making approximately 1000 cc per day; not requiring any more hemodialysis support.,0
He was tolerating diet appropriately.,0
"Discharge chemistries were the following: 143 sodium, 4.4 potassium, 112 chloride, 22 bicarbonate, 58 BUN, creatinine 4.3, and blood glucose 113.",0
"The patient had received intermittent dosing of Lasix during his stay for his volume issues, but at the time of discharge, he was not on any standing dose of Lasix.",0
"He is getting aluminum hydroxide 5 cc to 10 cc q.8, as well as Renagel 800 mg t.i.d.",0
and Protonix 40 mg q.d.,0
The patient is still getting sodium bicarbonate 13 mg p.o.b.i.d.,0
for some slight persistent acidosis secondary to his allograft dysfunction as the Renal Department had been following and recommending this to continue.,0
GU/RENAL: The patient had a Foley during his resuscitation and intubation course in the ICU.,0
This was ultimately removed approximately a week prior to discharge.,0
"He was off dialysis and actually making adequate urine up to 1100 cc to 1800 cc per 24 hours, but usually around 1000 per 24 hours.",0
BUN and creatinine are as stated above.,0
"He does have chronic allograft nephropathy, as previously stated.",0
"ENDOCRINE: After the pancreas transplantation, the patient was not insulin requiring.",0
"Although, during his course here he did require intermittent dosing of Insulin to control his blood sugars, as he had insulin resistance as a result of his bacteremia.",0
"Otherwise, the blood sugars ranged anywhere from 122 to 198.",0
"He, otherwise, seems to have good pancreatic allograft function.",0
HEMATOLOGY: The patient did received a 21 day course of Levaquin for a blood culture from revealing E. coli.,0
This was also positive from .,0
"The patient had blood cultures from , but had no growth.",0
Gram stain of the pleural fluid from was negative.,0
"He had an RPR during his stay for metal status issue workup, which was negative from .",0
He had a C. difficile assay for loose stools from ; negative times two.,0
Cap tip from the central line was sent off on and was negative.,0
"Bronchial/alveolar lavage had been performed on , two days into this patient's admission revealing gram-negative rods.",0
"He was treated for presumed aspiration with Clindamycin, Ceftazidime, and Levaquin and this was carried out for a total of 14 days.",0
The E. coli in his blood was treated for 21 days with Levaquin.,0
"He did have HSV type I and II, as well as Varicella Zoster.",0
Culture sent and assay sent on were also negative.,0
"On he had blood cultures, which were sent, which were additionally negative.",0
The patient will continued on Epogen dose of 4000 subcutaneously two times per week.,0
"At the time of discharge, the patient's CBC revealed the following: White count 5.8, hematocrit 28, platelet count 80, and he was somewhat thrombocytopenic.",0
He was off any DVT prophylaxis.,0
He was no longer getting any heparin flush or any subcutaneous heparin.,0
He was not on any H2 antagonist as he was getting PPI.,0
Platelet count was stable and he had no evidence of bleeding at this point.,0
He remained afebrile for more than a week prior to discharge.,0
Temperature maximum on the day of discharge was 99.4.,0
Prophylaxis antibiotics include Valcyte 450 mg p.o.q.d.,0
; Bactrim single strength one tablet p.o.q.d.,0
"IMMUNOSUPPRESSION: The patient will go out on Rapamycin 1 mg q.d., Prednisone 5 mg q.d.",0
; Rapamycin level at the time of this dictation was pending.,0
"The last Rapamycin level that we have for this patient is from , which was 17.3.",0
The patient was on Prograf during his hospitalization here and this was ultimately stopped.,0
"TUBES, LINES, AND DRAINS: At the time of discharge the patient had only had a peripheral IV, which was removed.",0
He no longer had a Foley catheter and no central access.,0
He has an old A-V loop graft on his left arm from his previous dialysis-therapy days.,0
"DISPOSITION: The patient is to be discharged to rehabilitation, where he will continue to get PT/OT consultation, as well as aggressive pulmonary toilet issues.",0
He will follow up with the Pulmonology Clinic as an outpatient.,0
"Dr. felt that the patient did not require inpatient consultation as he was stable, otherwise.",0
He may ultimately require some home oxygen depending on how he does during his rehabilitation stay.,0
"After he has completed approximately a one week rehabilitation stay, he will be likely discharged to home after which time he should be following up in the Clinic.",0
"He will require a laboratory draw during his stay at the rehabilitation facility, including CBC, BMP with calcium-magnesium phosphatase, as well as a Rapamycin level.",0
"These should be sent to the Transplant Office at , , MS.",0
"GI bleed secondary to platelet dysfunction, aspirin, and uremia.",0
"Aspiration pneumonia ADDITIONAL FOLLOW-UP INSTRUCTIONS: The patient will have his endoscopy, esophagogastroduodenoscopy, and colonoscopy to be done as outpatient as this was not done during his hospitalization here.",0
The GI attending will be Dr. .,0
He will perform the procedure.,0
The patient will followup with Dr. as well.,0
", MD Dictated By: MEDQUIST36 D: 09:02 T: 09:11 JOB#:",0
8:21 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with history of infiltrates REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT COMPARISON: .,1
"At that time, the mediastinum had a snowman contour.",0
The cardiomediastinal silhouette is normal on today's exam.,0
No osseous abnormalities are seen.,0
"3:29 PM PICC LINE PLACMENT SCH Clip # Reason: please evaluate and place PICC Admitting Diagnosis: CONGESTIVE HEART FAILURE ********************************* CPT Codes ******************************** * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with CHF, AS, picc line placed by IV team and repositioned once, still in wrong place, REASON FOR THIS EXAMINATION: please evaluate and place PICC ______________________________________________________________________________ FINAL REPORT PICC LINE EXCHANGE INDICATION: Malposition of indwelling PICC line.",1
"TECHNIQUE: Using sterile technique and local anesthesia, a guide wire was advanced through the indwelling left arm PICC line, and subsequently into the SVC under fluoroscopic guidance.",0
The old PICC line was then removed and a peel-away sheath was then placed over the guide wire.,0
A new double-lumen PICC line measuring 57 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 5 French double-lumen PICC line.,0
"Final internal length is 57 cm, with the tip positioned in the SVC.",0
LINE PLACEMENT Clip # Reason: Check line placement R IJ Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE;RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with resp failure REASON FOR THIS EXAMINATION: Check line placement R IJ ______________________________________________________________________________ WET READ: JVg TUE 7:24 PM RIJ in mid SVC.,1
Particularly given apparent shift of the mediastinum leftward.,0
"This is likely real, along with left lower lobe opacity consistent with volume loss--LLL atelectasis.",0
Cant exclude superimposed consolidation or mass.,0
Upper lobe opacity also noted.,0
Rec repeat films with better positioning.,0
______________________________________________________________________________ FINAL REPORT AP CHEST 6:04 P.M. HISTORY: Respiratory failure.,1
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Severe leftward mediastinal shift and opacification of the lower left hemithorax indicate lower lobe collapse likely with some left pleural effusion.,1
Right lung is grossly clear.,0
The cause of left lower lobe collapse as well as its chronicity is radiographically indeterminate but if the patient does not respond to chest physical therapy and/or tracheal suction CT imaging would be indicated to exclude a bronchial occlusion of some sort.,1
Right jugular line passes to the SVC and a nasogastric tube ends in the upper stomach and should be advanced 2 cm to move all the side ports well beyond the gastroesophageal junction.,0
"Dr. and I discussed these findings by telephone, at the time of dictation.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: BRBPR Major Surgical or Invasive Procedure: sigmoidoscopy History of Present Illness: 66yo male with recurrent BRBPR.,0
"S/P Completion left hemicolectomy () including prior ileorectal anastomosis down to upper rectum, Ileorectal anastomosis, Repair multiple abdominal wall ventral hernias on .",0
"Pt notes he has been having diarrhea for the past few days, which was not bloody or melenotic.",0
Yesterday he began having BRBPR and today came to the ED where again BRBPR was noted.,0
In ED HCT was 29 and he recieve 2 units prbcs at ~5am.,0
"Past Medical History: CVA c/b residual facial droop, dysarthria, dysphagia urinary incontinence diverticulosis (?diverticulitis) recent colectomy on for a lower GI bleed and repair of several abd wall ventral hernias on HTN, Vitamin D deficiency, s/p appendectomy Social History: Currently at rehab facility.",1
Former cook at B&WH now retired.,0
Previously married x 2 but now single.,0
"20 pack years, quit 20 years ago.",0
"2 beers/week prior to staying at , unclear now.",0
Pt eats ground solids and drinks nectar thick liquids at .,0
"Family History: Mother - HTN Physical Exam: P 97, BP 164/57, RR 14, O2 100%RA Awake, alert HEENT: no jaundice , MM dry Lungs: CTA CVS: tachycardic, no murmers Abd: soft, NT, ND BS+ Ext: No edema/jaudice Pertinent Results: 08:22PM HCT-21.8* 03:38PM WBC-9.6 RBC-2.72* HGB-8.1* HCT-24.3* MCV-89 MCH-29.7 MCHC-33.3 RDW-16.3* 03:38PM PLT COUNT-300 07:00AM GLUCOSE-124* UREA N-29* CREAT-1.3* SODIUM-141 POTASSIUM-5.0 CHLORIDE-116* TOTAL CO2-16* ANION GAP-14 07:00AM PT-12.8 PTT-27.7 INR(PT)-1.1 03:50PM BLOOD WBC-5.7 RBC-2.78* Hgb-8.4* Hct-23.8* MCV-86 MCH-30.2 MCHC-35.2* RDW-15.8* Plt Ct-213 04:36AM Hct-22.5* 03:53PM BLOOD Hct-25.3* 04:25AM BLOOD Hct-24.6* 08:45AM BLOOD Hct-23.0* 07:40AM BLOOD Hct-29.3*# 7:34 pm STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.",0
EKG : Normal sinus rhythm.,0
Compared to the prior tracing of the axis has shifted rightward.,0
": Sigmoidoscopy: Blood in the colon Normal mucosa in the ileum to 35 cm There was clotted blood, many sutures and small ulcers found around the anastamosis site, no active bleeding was seen.",0
"Brief Hospital Course: Mr. , a pt.",0
"of Dr. , was admitted to surgery after evaluation of for BRBPR in the ED.",0
In the pt Hct was 29.9 on arrival and to 26.,0
He was transfused 1 U PRBC and admitted to surgery.,0
Te patient first went to TSICU and was then t/f to floor on day 2 when Hct stabilized.,0
"remained on proper GI/DVT prophylaxis throughout his stay, and the rest of the course is described by systems below: Neuro: Pt remained A/O throughout hospital stay, pain was well controlled with only tylenol throughout.",0
"Pulm: pt had no issues, maintained sats of 98-100% on RA CV: Pt remained on home B-blocker, ACEI and Statin.",0
"Despite issues of anemia, pt was normocardic/tensive w/ P in the 70-80's and BP 120-30's systolic.",0
EKG was unremrkable for ischemia on admission.,0
"GI/FEN: Pt received anoscopy without obvious source of bleed, and then sigmoidoscopy with the findings described in pertinent results section.",0
The pt's abd surgical wound was C/D/I and had no Si's of infection/bleeding.,0
"Pt was not able to take adequate PO and ws started on TF on the second day of admission, and remains on the TF at d/c.",0
"Electrolytes were repleted appropriately, and only had issues with low Ca.",0
Fluids status was maintained as well without any issues.,0
Heme/ID: Pt received a total of 3 units of PRBC.,0
"In the ED, first unit did not see an appropriate bump in Hct,(26.2->25.4) but was during active bleeding.",0
The second 2 units were given in TSICU overnight the 1st night with Hct response (23.7->25.7).,0
"Over the next day, pt did not have frank blood, though Giuac remained +, and Hct stabilized.",0
"On day 3, nurse noted increased in loose stools, but C.Diff was NEG.",0
GU/Renal: UOP remained adequate throughout and pt had no issues.,0
Medications on Admission: ASA 81mg po qd Prilosec OTC 20mg 2 tabs po qd Vit D3 Aggrenox 1 Metoprolol 25mg tid Sertraline Colace 200mg po qpm Simvastatin 20mg po qd Zoloft 75mg po qd Senna 8.6mg po bid Tylenl PRN Fleets/MOM PRN Discharge Medications: 1.,0
Cholecalciferol (Vitamin D3) 400 unit Tablet : One (1) Tablet PO DAILY (Daily).,0
Captopril 25 mg Tablet : Two (2) Tablet PO TID (3 times a day).,0
Sertraline 50 mg Tablet : 1.5 Tablets PO HS (at bedtime).,0
Simvastatin 40 mg Tablet : 0.5 Tablet PO HS (at bedtime).,0
Senna 8.6 mg Tablet : One (1) Tablet PO BID (2 times a day).,0
Magnesium Hydroxide 400 mg/5 mL Suspension : Thirty (30) ML PO Q6H (every 6 hours) as needed.,0
Docusate Sodium 50 mg/5 mL Liquid : PO HS (at bedtime).,0
Heparin Lock Flush (Porcine) 100 unit/mL Syringe : Two (2) ML Intravenous DAILY (Daily) as needed.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Lower GI bleed Discharge Condition: good Discharge Instructions: You have been admitted to for bleeding from you rectum.,0
You were evaluated with anoscopy and sigmoidoscopy and it was determined that bleeding was likely from the anastomosis site of your colostomy.,0
You were treated with blood transfusion.,0
Please take medications as directed.,0
"Follow up with Dr. , your surgeon, as directed below.",0
Please continue to follow with Dr. for your general care.,0
"Followup Instructions: Please follow up with Dr. in 1 week, call ( to make an appointment.",0
5:04 AM CHEST (PORTABLE AP) Clip # Reason: please assess for PNA or other acute process Admitting Diagnosis: POLYTRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 24 year old woman with possible PNA REASON FOR THIS EXAMINATION: please assess for PNA or other acute process ______________________________________________________________________________ FINAL REPORT HISTORY: Possible pneumonia.,1
"FINDINGS: In comparison with the study of , the monitoring and support devices have all been removed.",0
No evidence of acute cardiopulmonary disease at this time.,0
"Fractures of several upper right ribs are noted, as well as a fracture of the left clavicle.",1
"7:29 AM MR HEAD W & W/O CONTRAST Clip # Reason: viewscope protocol, brain , tumor Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with REASON FOR THIS EXAMINATION: viewscope protocol, brain , tumor ______________________________________________________________________________ FINAL REPORT INDICATION: Preoperative stereotatic MRI of brain prior to tumor resection.",0
TECHNIQUE: Axial WAND MRI images were obtained through the brain after the administration of 15 cc of Gadolinium iv.,0
"FINDINGS: There is redemonstration of the left parietal enhancing mass with associated edema, unchanged in appearance.",0
"In addition, there is abnormal enhancement in the region of the cavernous sinus and sella, which, in retrospect, was present in the prior study and is consistent with known h/o pituitary adenoma.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: Addendum: On Mr. presented with acute left-sided weakness, facial droop, and slurred speech.",1
A head CT was negative for intracranial hemorrhage.,0
These symptoms resolved by the time of discharge.,0
No follow-up with neurology is necessary.,0
"Urgent coronary artery bypass graft x5; left internal mammary artery to left anterior descending artery, saphenous vein graft to diagonal obtuse marginal, saphenous vein sequential graft to posterior descending artery, and posterior left ventricular branch.",1
"Past Medical History: Coronary Artery Disease PMH: hypertension, diabetes, COPD, diastolic heart failure, EF 45-50% Past Surgical History penile implant Social History: Race: Hispanic- born in Republic Last Dental Exam: edentulous Lives with: unknown/has family in -he is a resident of Contact: son and daughter living in Occupation: retired factory worker Cigarettes: Smoked no [] yes [x] last cigarette Hx: 1-2 packs x 50 years of smoking Other Tobacco use: Marijuana occasional ETOH: < 1 drink/week [] drinks/week [x] >8 drinks/week [] Illicit drug use: cocaine use weekly and just prior to NSTEMI Family History: unknown Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation.",1
Information was obtained from records from OSH.,0
Pt only knows insulin dose - does not know any other medications.,0
Isosorbide Dinitrate 10 mg PO TID 2.,0
Labetalol 200 mg PO TID 3.,0
Rosuvastatin Calcium 10 mg PO DAILY 4.,0
Furosemide 20 mg PO DAILY 5.,0
Aspirin 81 mg PO DAILY 6.,0
Tiotropium Bromide 1 CAP IH DAILY 7.,0
Albuterol Inhaler 2 PUFF IH Q6H 8.,0
70/30 20 Units Breakfast 70/30 15 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Discharge Medications: 1.,0
70/30 20 Units Breakfast 70/30 15 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner 2.,0
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing 4.,0
Atorvastatin 40 mg PO DAILY 5.,0
Cepacol (Menthol) 1 LOZ PO PRN sore throat 6.,0
Diltiazem 30 mg PO QID 7.,0
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing 8.,0
Metoprolol Tartrate 6.25 mg PO BID hold for SBP<110 9.,0
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Stop 10.,0
Ondansetron 4 mg PO Q8H:PRN nausea 11.,0
Pantoprazole 40 mg PO Q24H 12.,0
Vancomycin Oral Liquid 500 mg PO Q6H End date 13.,0
Warfarin MD to order daily dose PO DAILY for atrial fibrillation 14.,1
Warfarin 0.5 mg PO ONCE Duration: 1 Doses Daily coumadin dosing for goal INR for atrial fibrillation 15.,1
"Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. , 1:00 Cardiologist Dr. .",0
"office will call you with an appointment Please call to schedule the following: Primary Care Dr. , in weeks Please follow up with Dr.",0
"Call to schedule an appointment DIALYSIS,SCHEDULE HEMODIALYSIS UNIT Date/Time: 12:00 Renal: Dr. 10:30 ( Diabetes: If patient requires endocrine follow-up after discharge from rehab, please contact , at **Please call cardiac surgery office with any questions or concerns .",1
Answering service will contact on call person during off hours** INR draw on Goal INR Indication: atrial fibrillation MD Completed by:,1
", E. 5:06 AM CHEST (PORTABLE AP) Clip # Reason: evaluate interval change in edema, effusions Admitting Diagnosis: COLON CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with resp.",1
"failure s/p colectomy, on bipap, getting diuresis REASON FOR THIS EXAMINATION: evaluate interval change in edema, effusions ______________________________________________________________________________ PFI REPORT PFI: Moderate interstitial edema increased.",1
Unchanged mild-to-moderate bilateral pleural effusion.,1
6:02 AM CHEST (PORTABLE AP) Clip # Reason: resp distress Admitting Diagnosis: S/P AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with s/p asc aorta replacement REASON FOR THIS EXAMINATION: resp distress ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST INDICATION: Respiratory distress.,1
"FINDINGS: Comparison is made with prior radiograph from , CT from and .",0
A gastrostomy tube is seen projecting over the lower portion of the stomach.,0
Surgical staples are seen in the chest.,0
The right costophrenic angle has been cut off in this radiograph.,0
There is a left pleural effusion.,1
There is no evidence of pneumonia.,0
10:00 AM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT RETROPERITONEAL DRAINAGEClip # CT GUIDED NEEDLE PLACTMENT Reason: Please place drain.,0
Admitting Diagnosis: DUODENAL PERFORATION ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with retroperitoneal fluid collection RLQ.,0
REASON FOR THIS EXAMINATION: Please place drain.,0
______________________________________________________________________________ FINAL REPORT STUDY: CT guided abdominal abscess drainage.,0
CLINICAL HISTORY: 45-year-old woman with retroperitoneal fluid collection at the right lower quadrant.,0
"PROCEDURE: After the procedure was explained to the patient, including risks and potential complications, informed consent was obtained.",0
A time-out was performed to ensure accuracy.,0
The prior CT study dated at 1:40 a.m. was reviewed which revealed a multiloculated right lower quadrant retroperitoneal collection.,0
Pre-procedure CT scanning again demonstrated the collection.,0
An optimal entry site was identified in the right flank just superior to the right iliac bone.,0
The area was cleansed and prepped in the usual sterile fashion and 1% Lidocaine was administered locally.,0
"Under CT guidance, a 20 gauge spinal needle was inserted into the collection.",0
"Subsequently, a 10 French pigtail catheter was inserted into the collection with proper positioning confirmed by CT.",0
"Thin, brownish fluid spontaneously drained from the catheter, which was attached to a gravity collection bag.",0
Catheter was subsequently secured in place.,0
"Staff radiologist, Dr. , was present during the procedure.",1
"Conscious sedation was performed with divided doses of 2.5 mg of Versed and 100 mcg of Fentanyl for a total intraservice time of 30 minutes, during which time the patient's vital signs were continuously monitored.",0
IMPRESSION: Successful CT guided placement of drainage catheter into right lower quadrant retroperitoneal fluid collection.,0
8:26 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: STEMI ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with s/p VFib arrest REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient after cardiac arrest.,0
Portable AP chest radiograph was compared to prior study obtained on .,0
The ET tube tip is 5 cm above the carina.,0
The left subclavian line tip is at the junction of left brachiocephalic vein and SVC.,0
There is no interval increase in pleural effusion or pneumothorax.,0
"The NG tube tip passes below the diaphragm, most likely terminating in the stomach.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Erythromycin Base / adhesive tape / Tegaderm Attending: Chief Complaint: Abdominal pain, persistent portal vein thrombosis.",1
Major Surgical or Invasive Procedure: : Portal venography and thrombolysis.,1
": Portal venography, mechanical portal vein thrombolysis.",0
: Gelfoam embolization of right hepatic artery branch.,0
: Cholecystectomy and attempted portal vein thrombectomy.,0
History of Present Illness: Mr. is a 51 year-old male with a history of Crohn's disease who was seen in the emergency room at on with right upper quadrant abdominal pain.,1
"A CT of the abdomen and pelvis was performed, which demonstrated moderate colonic fecal load as well as a partially obstructing thrombus in the right posterior portal vein, main portal vein, and SMV before the portal vein confluence.",1
He was discharged home by the ED and returned again to the ED on .,0
He once again was complaining of right upper quadrant abdominal pain and an ultrasound demonstrated complete portal vein thrombosis.,1
"Past Medical History: -Crohn's disease -Non-alcoholic steatohepatitis with transaminemia -Glucocorticoid associated osteopenia -Peri-anal fistula -Nephrolithiasis requiring lithotripsy -Osteoporosis (spine T-score -3.0) -Hypogonadotrophic hypogonadism: treated with clomiphene since and had been taking testosterone supplementation prior -Toe fracture and spinal compression fracture -Ileocolectomy (at least 20cm of small bowel and possibly equal length of colon) after presenting with an obstruction two years after stopping 6-MP in effort to conceive Social History: No EtOH, tobacco, or other drug use.",1
Family History: No clotting/bleeding disorders.,1
"Physical Exam: Physical Exam on Admission: Vitals: T 98, HR 105, BP 123/64, RR 16, O2 100RA Gen: alert and oriented x3, NAD, lying comfortably on gurney; skin and sclerae anicteric CV: RRR, no murmur, neck veins flat Resp: cta bilaterally, no respiratory distress Abd: well-healed incision c/w previous surgery; soft, ND, +BS; mildly TTP in RUQ; negative sign; no fluid wave; liver and spleen not palpable Extr: warm, 2+ peripheral pulses bilaterally; calves soft, sign negative Physical Exam on Discharge: Vitals: T 97.8, HR 90, BP 134/76, RR 18, 99% O2 on RA.",0
"Gen: Alert, oriented, in NAD.",0
"Abd: Soft, non tender, mildly distended throughout.",0
Abdominal incision clean/dry/intact with steri-strips in place.,0
"Ext: 1+ peripheral edema bilateral lower extremities, TEDs in place.",0
Pertinent Results: 08:30PM BLOOD WBC-11.6* RBC-4.82 Hgb-14.5 Hct-42.5 MCV-88 MCH-30.1 MCHC-34.1 RDW-13.3 Plt Ct-235 05:15PM BLOOD Hct-31.6* 07:59PM BLOOD Hct-29.4* 02:07AM BLOOD WBC-18.1*# RBC-3.85* Hgb-11.3* Hct-32.3* MCV-84 MCH-29.5 MCHC-35.1* RDW-13.6 Plt Ct-163 02:00PM BLOOD WBC-13.9* RBC-3.08* Hgb-9.3* Hct-25.7* MCV-84 MCH-30.3 MCHC-36.3* RDW-14.1 Plt Ct-194 07:18PM BLOOD Hct-29.2* 11:59PM BLOOD Hct-29.0* Plt Ct-112* 11:37AM BLOOD Hct-31.0* 05:54AM BLOOD WBC-10.0 RBC-3.84* Hgb-11.5* Hct-31.9* MCV-83 MCH-29.9 MCHC-35.9* RDW-15.2 Plt Ct-154 05:03AM BLOOD WBC-9.5 RBC-3.89* Hgb-11.4* Hct-32.7* MCV-84 MCH-29.3 MCHC-34.9 RDW-15.4 Plt Ct-197 03:00AM BLOOD PT-13.5* PTT-22.0 INR(PT)-1.2* 02:07AM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4* 02:16PM BLOOD PTT-47.9* 07:59PM BLOOD PTT-79.3* 02:07AM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4* 11:25AM BLOOD PT-14.3* PTT-22.0 INR(PT)-1.2* 07:36PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2* 05:54AM BLOOD PT-12.6 PTT-26.9 INR(PT)-1.1 05:03AM BLOOD PT-15.2* PTT-31.7 INR(PT)-1.3* .,0
05:30AM BLOOD PT-28.2* INR(PT)-2.7* = ***INR ON DISCHARGE*** .,0
03:00AM BLOOD Fibrino-533* 02:11AM BLOOD Fibrino-559* 11:59PM BLOOD Fibrino-556*# .,0
Hematologic clotting workup laboratory values: 03:00AM BLOOD Fact V-100 03:00AM BLOOD ProtCFn-85 ProtSAg-92 03:00AM BLOOD ACA IgG-3.9 ACA IgM-2.8 03:00AM BLOOD PROTHROMBIN MUTATION ANALYSIS-Test: Negative .,0
08:30PM BLOOD Glucose-186* UreaN-15 Creat-1.0 Na-135 K-4.4 Cl-99 HCO3-27 AnGap-13 03:12PM BLOOD Glucose-133* UreaN-20 Creat-1.3* Na-141 K-5.3* Cl-110* HCO3-25 AnGap-11 05:03AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-139 K-3.7 Cl-106 HCO3-25 AnGap-12 08:30PM BLOOD ALT-25 AST-19 LD(LDH)-167 AlkPhos-85 TotBili-0.3 03:12PM BLOOD ALT-145* AST-120* CK(CPK)-194 AlkPhos-41 TotBili-1.8* 02:20AM BLOOD ALT-283* AST-225* AlkPhos-60 TotBili-0.9 03:20AM BLOOD ALT-209* AST-125* LD(LDH)-281* AlkPhos-68 TotBili-1.3 05:03AM BLOOD ALT-97* AST-44* AlkPhos-81 TotBili-0.6 03:12PM BLOOD CK-MB-3 cTropnT-<0.01 11:10PM BLOOD CK-MB-6 cTropnT-<0.01 06:14AM BLOOD CK-MB-5 cTropnT-<0.01 07:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0 03:12PM BLOOD Albumin-2.3* Calcium-7.9* Phos-4.8*# Mg-1.8 05:03AM BLOOD Albumin-2.5* Calcium-7.7* Phos-2.6* Mg-2.0 11:59PM BLOOD Hapto-97 11:59PM BLOOD D-Dimer-6140* .,0
Imaging and Interventional Radiology: .,0
"No flow demonstrated in the main or left portal veins, compatible with thrombosis.",1
Right portal vein not visualized and is also likely occluded.,1
"Echogenic liver, compatible with fatty infiltration; other forms of hepatic cirrhosis/fibrosis cannot be excluded.",0
Focal area of fatty sparing adjacent to the gallbladder in the right lobe.,0
No gallstones or evidence of acute cholecystitis.,0
"Thrombosis within the splanchnic venous circulation is more extensive with thrombus now seen within the main portal vein, left main portal vein, anterior/posterior branches of the right main portal vein, and throughout much of the SMV.",1
"The splenic vein, IVC, and hepatic veins remain patent.",0
Enhancing soft tissue lesion within the gallbladder fundus could be a polyp or adenomyomatosis.,0
Bilateral small renal hypodensities are too small to characterize but statistically are simple cysts.,0
"Extensive thrombotic occlusion involving the upper SMV, main portal vein and right portal vein.",1
Partial cavernous transformation of the portal vein.,0
Patent splenic vein and inferior mesenteric vein.,0
IMPRESSION: Successful percutaneous transhepatic portal venography and placement of - 5 French infusion catheter for TPA infusion.,0
PLAN: The patient will return to interventional radiology for repeat venogram and potential mechanical thrombectomy/thrombolysis on the following day.,0
Initial portal venography demonstrated substantial lysis of thrombus burden in the main portal vein and in the distal superior mesenteric vein relative to the initial procedure performed on .,1
Mechanical thrombectomy and pulse-spray tPA infusion was performed in the main portal vein and distal superior mesenteric vein followed by mechanical thrombectomy in the left portal vein.,0
Successful recanalization of the left portal vein by mechanical thrombectomy alone.,0
Persistent occlusion of the right portal vein at the conclusion of the procedure.,1
New large volume of complex fluid within the abdomen is highly concerning for hemoperitoneum given the patient's history of recent mechanical portal venous/SMV thrombolysis.,1
There is evidence of several sites of active extravasation involving hepatic segment V. Small regions of hyperdense fluid and an associated locule of air within hepatic segment V also reflect hepatic injury.,0
"Persistent thrombosis of the main portal vein, left main portal vein, and anterior/posterior branches of the right main portal vein.",1
Partial occlusion of the SMV is also again noted.,0
The splenic vein remains patent.,0
"New bilateral pleural effusions with associated compressive atelectasis, right greater than left.",0
"Unchanged enhancing lesion in the gallbladder fundus measuring 9 x 5 mm could be a polyp or adenomyomatosis, as previously described on recent CT. 5.",0
Transcatheter embolization: IMPRESSION: Identification of a region of active extravasation at the lateral periphery of segment VI of a branch of the right hepatic artery.,0
Interval extension of a portal venous clot now extending three-fourths of the way to the splenic hilum within the splenic vein.,0
Interval re canalization of a small branch of the left portal vein.,1
New areas of heterogeneous enhancement in the segment VI and inferior portion of segment VII concerning for early infarction.,0
Moderately high-density fluid around the liver could be postoperative.,0
No areas of active extravasation noted.,0
"Brief Hospital Course: On presentation to on , the patient was once again complaining of right upper quadrant abdominal pain, and an ultrasound demonstrated complete portal vein thrombosis (a progression from the thrombosis of the right posterior portal vein and a short segment of the SMV seen on his CT abdomen during his recent presentation to the ED for abdominal pain).",1
"On CT scan demonstrated a thrombosed portal vein including the main, right and left portal veins and extension of the clot into the superior mesenteric vein.",1
He was anticoagulated and underwent placement of a transhepatic catheter in the portal vein by interventional radiology on with infusion of TPA.,0
On he underwent successful transhepatic percutaneous thrombectomy by interventional radiology with the AngioJet and additional TPA.,0
"Flow was able to be reestablished in the main portal vein, superior mesenteric vein and left portal vein.",0
The right portal vein could not be thrombectomized.,1
"Postoperatively, he developed hypotension and was found on CT scan to be bleeding from a branch of the right hepatic artery that had been injured at the time of the percutaneous procedure.",1
"He was taken again to interventional radiology the morning of , where he underwent embolization of a branch of the right hepatic artery.",0
A CT scan showed a large amount of blood and clot in the abdomen.,0
"The CT further demonstrated that the right, left and main portal veins were once again thrombosed with thrombosis of the superior mesenteric vein as well.",1
Therefore the patient was brought to the operating room for evacuation of the intra-abdominal blood and hematoma with attempt at open portal vein thrombectomy on .,1
A large amount of old blood and clots were then removed.,0
"Since the porta was quite deep and foreshortened, the gallbladder was removed for better exposure.",0
"A dissection to identify the portal vein was attempted, however due to extensive collaterals and few viable planes, the attempt at portal vein thrombectomy was abandoned due to the risk of proceeding.",0
"Hemostasis was obtained, and Surgicel was used superiorly and inferiorly.",0
"The patient returned to the ICU postoperatively, off his heparin drip and intubated.",0
While in the ICU his hematocrit was stabilized with multiple units of blood products.,0
A postoperative CTA abdomen showed no areas of active extravasation.,0
"His heparin drip was restarted on , he was successfully extubated, and transferred to the floor.",0
"Warfarin was begun on , for a goal INR of .",0
"His heparin drip was discontinued , and he was begun on enoxaparin 80 mg twice a day.",0
"Enoxaparin teaching was provided, which the patient received well.",0
On discharge his INR was therapeutic at 2.7.,0
He was discharged home on warfarin and enoxaparin.,0
"His enoxaparin and warfarin dosages on discharge were appropriately titrated, and follow up labs were arranged, which the patient will fax to Dr. office for further titration and management of his anticoagulation regimen going forward.",0
His pain medications were transitioned from IV to oral when the patient was tolerating a regular diet.,0
"On discharge he was in minimal pain, and was ambulating independently, tolerating a regular diet.",0
"While inpatient, the patient was followed by the gastroenterology service given his history of Crohn's disease, and also was seen by the hematology service to asses the cause of his portal vein thrombosis.",1
"His home clomiphene and forteo were held given their association with clotting, and a hypercoagulability workup was sent, which was entirely negative at the time of discharge (see labs above).",0
He will follow up with hematology as an outpatient for potential further hematologic testing to determine the underlying cause of his clotting.,0
"Medications on Admission: Humira 40mg every other week, clomiphene citrate 50mg qd, vitamin D2 50,000 U tablet once a week, Lunesta 3mg qhs, Viagra 100mg prn, teriparatide 20mcg sq qhs, tumeric, ursodiol 1500mg once a day, Align, MVI, omega-3 fatty acids Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).",0
Humira 40 mg/0.8 mL Kit Sig: One (1) dose Subcutaneous every 2 weeks: Resume on Sunday .,0
Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day.,0
4. ursodiol 500 mg Tablet Sig: Three (3) Tablet PO at bedtime.,0
Lunesta 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia.,0
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for Pain.,0
Disp:*30 Tablet(s)* Refills:*0* 8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous (2 times a day): Use evening of only.,0
Disp:*10 syringes* Refills:*0* 9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Take at same time in early evening.,0
Disp:*150 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Portal Vein Thrombus with extension to the SMV.,0
Discharge Condition: Mental Status: Clear and coherent.,0
"Discharge Instructions: Please call Dr office at for fever, chills, increased abdominal pain.",0
"Monitor for signs of elevated INR from coumadin to include nosebleed, rectal bleeding, dark/tarry stool, easy bruising, bleeding that won't stop.",0
Have labs drawn on Monday .,0
Have results faxed to Dr office at .,0
Dr office will follow up with you regarding any dosage changes and time for next blood draw.,0
No heavy lifting greater than 10 pounds until notified you may do so.,0
"For now, walking is your best exercise.",0
Timeline for increasing intensity of exercise is dependent on your progress.,0
Walking is an excellent exercise for now and is highly encouraged.,0
"No driving if taking narcotic pain medication You may shower, allow water to run over incision and pat area dry.",0
No lotions or creams to incision area.,0
"Avoid green/leafy , multi-vitamin with Vitamin K in it.",0
These foods and Vitamin K can alter and bind your coumadin leaving you with a lower INR and increased risk of clot extension.,0
Followup Instructions: Labs at Building Outpatient Lab Friday Labs at Building Saturday at 8 AM ....,0
"Provider: , MD , ; Phone: Date/Time: 10:20 ...",0
"Provider: , MD, PhD , , Phone: Date/Time: 2:00 ... 11:00a , I. SC CLINICAL CTR, HEMATOLOGY/ONCOLOGY-SC ...",0
"Phone: Date/Time: 1:20 MD, Completed by:",0
Height: (in) 71 Weight (lb): 237 BSA (m2): 2.27 m2 BP (mm Hg): 148/63 HR (bpm): 80 Status: Inpatient Date/Time: at 15:40 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
The IVC is >2.5cm in diameter with <50% decrease during respiration (estimated RAP 16-20 mmHg).,0
Conclusions: The left and right atrium are moderately dilated.,0
The transaortic gradient is higher than expected for this type of prosthesis.,0
At least mild to moderate (+) aortic regurgitation is seen.,0
The pulmonary artery systolic pressure could not be quantified.,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global systolic function At least mild-moderate aortic regurgitation (valvular) with slightly increased aortic valve gradient (?due to aortic regurgitation).,1
"If clinically indicated, a TEE would be better able to define the abnormality of the aortic prosthesis and severity of aortic regurgitation.",0
"9:04 AM CHEST (PORTABLE AP) Clip # Reason: eval infiltrate Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT-FEMUR FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man s/p femur repair REASON FOR THIS EXAMINATION: eval infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, .",1
INDICATION: Status post femur repair.,0
Comparison: Trauma chest radiograph of .,0
The cardiac silhouette is upper limits of normal in size but is likely accentuated by apical lordotic projection and low lung volumes.,0
"There are bibasilar opacities, linear on the right and patchy on the left.",0
These are new compared to the prior chest radiograph.,0
There is also a possible small left pleural effusion.,0
Mild elevation of left hemidiaphragm may be due to gaseous distention of the adjacent splenic flexure.,0
"IMPRESSION: New bibasilar opacities, likely atelectasis.",0
Infection and aspiration are also possible explanations for the left lower lobe opacity.,0
"11:52 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for PE, eval for anatomic cause of elevated R hemidiaph Admitting Diagnosis: DYSPNEA Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with chronic multiple sclerosis, bedbound p/w 4 days increasing SOB REASON FOR THIS EXAMINATION: eval for PE, eval for anatomic cause of elevated R hemidiaphragm No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 62-year-old female with chronic multiple sclerosis, bed bound now presenting with 4 days of increasing shortness of breath to rule out a pulmonary embolism.",1
"TECHNIQUE: CT of the chest was performed without intravenous contrast followed by CT of the chest post-administration of intravenous contrast, reconstructions were performed in the axial, sagittal and coronal planes.",0
"FINDINGS: CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There is a 7 mm low-attenuation focus in the left lobe of the thyroid gland, this may be assessed further with a thyroid ultrasound.",0
There is atelectasis present at the lung bases with almost complete collapse of the right lower lobe and subsegmental collapse of the left lower lobe.,0
There are bronchial secretions almost completely occluded in the bronchus intermedius and the bronchus supplying the right lower lobe.,0
There are secretions also present in the collapsed segments of the left lower lobe as well as distal trachea.,0
There are ill-defined patchy opacities present in both lungs likely infectious or inflammatory.,0
There are scattered mediastinal lymph nodes.,0
"There is no central pulmonary embolism, however, given the extent of lower lobe collapse, a subsegmental pulmonary embolism cannot be excluded in the lower lobes.",1
"There are multiple hepatic hypodensities, these are too small to characterize and likely represent cysts and hemangiomas.",0
"There are multiple bilateral renal hypodensities, again these are too small to characterize and likely represent cysts.",0
MUSCULOSKELETAL: There are multilevel degenerative changes present in the spine.,0
"CONCLUSION: (Over) 11:52 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for PE, eval for anatomic cause of elevated R hemidiaph Admitting Diagnosis: DYSPNEA Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 1) Extensive mucoid impaction in the distal trachea and the lower lobe bronchi with complete collapse of the right lower lobe and segmental collapse of the left lower lobe.",0
"2) No central pulmonary emboli, however, given the extent of the lobar collapse, subsegmental pulmonary emboli cannot be excluded.",1
The findings were discussed with Dr. by Dr. at 12:50 p.m. on .,0
"8:04 AM CHEST (PORTABLE AP) Clip # Reason: s/p cabg with significant lung history, r/o pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with CAD including 3vd, COPD.",0
s/p reposition of PA catheter.,0
REASON FOR THIS EXAMINATION: s/p cabg with significant lung history r/o pneumonia ______________________________________________________________________________ FINAL REPORT COMPARISON: One day earlier.,0
CLINICAL INDICATION: Repositioning of pulmonary artery catheter in patient status post coronary bypass surgery.,1
"A Swann-Ganz catheter is present, with the tip in the right ventricular outflow tract.",0
A left-sided chest tube has been removed in the interval.,0
There is worsening left retrocardiac opacity and a slight increase in left pleural effusion.,0
Note is also made of a persistent small right pleural effusion.,0
Removal of left-sided chest tube with worsening left pleural effusion but no pneumothorax.,0
Swann-Ganz catheter in right ventricular outflow tract.,0
4:25 PM NEONATAL HEAD PORTABLE Clip # Reason: hydrocephalus Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 36 wk GA with prenatal dx of hydrocephalus.,1
REASON FOR THIS EXAMINATION: hydrocephalus ______________________________________________________________________________ FINAL REPORT PORTABLE NEONATAL HEAD ULTRASOUND: HISTORY: Less than one day old girl who was delivered today at 36 weeks EGA for increasing prenatal ventriculomegaly.,1
FINDINGS: Portable real-time son of the neonatal head was performed in the NICU.,0
The brain parenchyma has normal echogenicity without evidence for mass or hemorrhage.,0
Moderate to marked dilatation of both lateral ventricles without evidence for intraventricular hemorrhage.,0
The septum pellucidum appears to be absent.,0
Borderline enlargement of the third ventricle.,0
The fourth ventricle appears normal.,0
No abdnormal extraaxial fluid collections are identified.,0
the anterior cerebral artery resistive index measures 0.8 without compression and .88 with compression.,0
"IMPRESSION: 1) Moderate to marked bilaterally lateral ventriculomegaly, most pronounced in the atria and occipital regions.",0
The resistive index is mildly increased and shows mild accentuation with compression.,0
"Obstruction at the level of the cerebral aquaduct is not strongly suggested, given only slight, if any enlargement of the third ventricle.",0
"2) Findings of absent cavum septum pellucidum, which raises the question of septooptic dysplasia.",0
"11:15 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # CT RECONSTRUCTION Reason: CT urogramnew onset hematuria, s/p fallplease eval for injur Admitting Diagnosis: S/P FALL Field of view: 37 ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p fall from standing postion REASON FOR THIS EXAMINATION: CT urogramnew onset hematuria, s/p fallplease eval for injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: New onset of hematuria.",0
History of fall one day prior.,0
COMPARISON: contrast-enhanced CT of the abdomen and pelvis.,0
TECHNIQUE: Helically aquired axial images of the abdomen and pelvis were obtained without oral or IV contrast.,0
Sagittal and coronal reconstructions were performed.,0
ABDOMEN CT W/O CONTRAST: Cardiomegaly is again noted.,0
There is minimal bibasilar dependent atelectasis.,0
"A subcentimeter low-attenuation lesion is again noted within the liver, too small to characterize but likely representing a cyst.",0
Multiple gallstones are present within the gallbladder.,0
There is no CT evidence of cholecystitis.,0
"The pancreas, spleen, adrenal glands and small bowel are unremarkable.",0
"There is diverticulosis within the colon, without evidence of diverticulitis.",0
"The abdominal aorta, mesenteric vessels, common iliac, external and internal iliac arteries are extensively calcified.",0
"There is residual enhancement of both kidneys in corticomedullary phase, secondary to IV contrast administration of greater than 24 hours prior.",0
This suggests intrinsic renal disease.,1
"There are focal areas of cortical thinning in both kidneys, consistent with old infections.",1
A 2 cm low-attenuation lesion is again noted in the upper pole of the left kidney.,1
"On the prior contrast-enhanced study, it had attenuation suggestive of a hyperdense cyst, but there was no noncontrast study for confirmation.",0
"Due to residual iv contrast on the current study, further characterization cannot be made.",0
PELVIC CT W/O CONTRAST: There is possible thickening of the bladder wall.,0
This may be further evaluated by cystoscopy.,0
There is no stranding or free fluid around the bladder.,0
The prostate and seminal vesicles are unremarkable.,0
CT RECONSTRUCTIONS: Multiplanar reconstructions demonstrate corticomedullary phase enhancement of both kidneys which persists for greater than 24 hours after administration of IV contrast during the prior study.,0
"There are areas of focal cortical thickening within both kidneys, consistent with prior infections.",1
There is no perinephric free fluid.,0
"(Over) 11:15 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # CT RECONSTRUCTION Reason: CT urogramnew onset hematuria, s/p fallplease eval for injur Admitting Diagnosis: S/P FALL Field of view: 37 ______________________________________________________________________________ FINAL REPORT (Cont) There is no free fluid or contrast extravasation around the bladder.",0
BONE WINDOWS: Degenerative changes are noted in the lower lumbar facet joints.,0
IMPRESSION: 1) Persistent enhancement of both kidneys by IV contrast administered over 24 hours prior to the current study.,0
Bilateral foci of cortical thinning.,0
These findings are consistent with intrinsic renal disease.,1
2) Possible bladder wall thickening.,0
Cystoscopy may be helpful for further evaluation.,0
No evidence of bladder rupture.,0
3) Cholelithiasis without evidence of cholecystitis.,0
4) Diverticulosis without evidence of diverticulitis.,0
"5) Subcentimeter low-attenuation hepatic lesion, which is too small to characterize but likely represents a cyst.",0
"6) Probable hyperdense cyst in the left kidney, which cannot be fully characterized due to residual IV contrast within the kidneys.",0
"LINE PLACEMENT Clip # Reason: line position Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman s/p R IJ placement REASON FOR THIS EXAMINATION: line position ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of right jugular line CV placement.",0
single AP chest film does not include the lateral portion of the right hemithorax.,0
Previously noted right jugular CV line has been removed.,0
"There is a left-sided PICC line, the tip of which is likely in the distal SVC, although the film obtained is underpenetrated and suboptimal in detail and may be repeated for better detail if clinically indicated.",0
"8:08 PM CHEST (PRE-OP PA & LAT) Clip # Reason: ISCHEMIC RIGHT FOOT;RENAL INSUFFIENCY Admitting Diagnosis: ISCHEMIC RIGHT FOOT;RENAL INSUFFIENCY ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with R foot wet gangrene REASON FOR THIS EXAMINATION: pre-op, acute risk ______________________________________________________________________________ FINAL REPORT CHEST X-RAY HISTORY: Renal insufficiency, pre-op foot surgery.",1
"There is bilateral streaky density, consistent with subsegmental atelectasis or scarring.",0
"The heart appears prominent, but cardiac size is likely exaggerated by AP technique.",0
The aorta is tortuous and calcified.,0
Mediastinal structures are otherwise unremarkable.,0
The bony thorax is grossly intact.,0
IMPRESSION: Bilateral subsegmental atelectasis or scarring.,0
9:41 AM CHEST (PRE-OP PA & LAT) Clip # Reason: Please evaluate for infiltrates and effusions.,0
"Pleas ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with CAD, awaiting CABG Thanks REASON FOR THIS EXAMINATION: Please evaluate for infiltrates and effusions.",0
Please do in AM on Friday .,0
"______________________________________________________________________________ FINAL REPORT INDICATION: CAD, awaiting CABG.",0
"CHEST, PA AND LATERAL: Heart size and mediastinal contour are normal.",0
There is no pleural effusion or focal consolidation.,0
Multiple surgical clips are noted in the left abdomen.,0
No pneumothorax or fracture is identified.,0
LINE PLACEMENT Clip # Reason: please check placement r bas picc for TPN 43 cm.,0
call beeper Admitting Diagnosis: CEREBRAL VASCULITIS;ILIO-VESICULAR FISTULA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with REASON FOR THIS EXAMINATION: please check placement r bas picc for TPN 43 cm.,1
call beeper asap with wet read thanks ______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old female requiring PICC line for TPN.,0
AP UPRIGHT PORTABLE CHEST X-RAY: The right-sided PICC catheter terminates within the mid SVC.,0
The actual tip is obscured by an overlying electrode.,0
A VP shunt reverses the right hemithorax.,0
"The cardiac silhouette, mediastinal and hilar contours are normal.",0
The lungs are clear without consolidations or effusions.,0
The surrounding soft tissue and osseous structures are unchanged.,0
IMPRESSION: Right-sided PICC catheter terminating in the mid SVC.,0
"10:42 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval changes Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with IPF, intubated.",0
REASON FOR THIS EXAMINATION: Please eval for interval changes ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Interval change in a patient intubated with IPF.,0
The ET tube tip is 5.4 cm above the carina.,0
The right internal jugular line tip is in mid SVC.,0
The rest of the findings including widespread bilateral opacities are unchanged.,0
"Large trachea is again noted, unchanged since the prior study.",0
8:23 PM MR HEAD W/O CONTRAST Clip # Reason: ?,0
Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with abovePost op AVR() with LT weakness.,1
"No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DRT SUN 2:21 PM Somewhat limited study, with: 1.",0
"No acute intracranial abnormality; specifically, there is no acute hemorrhage or infarction.",1
"Moderately severe chronic microvascular infarction in bihemispheric subcortical, periventricular, and central pontine white matter, with chronic lacune in the right basal ganglion.",0
"Fluid opacification of the mastoid air cells, right more than left with fluid pooling in the nasopharynx and posterior nasal cavity, likely related to intubation and supine positioning.",0
"______________________________________________________________________________ FINAL REPORT MR EXAMINATION OF THE BRAIN WITHOUT CONTRAST, HISTORY: 79-year-old woman, post-op from AVR () with left-sided weakness, ""CT negative;""?",0
TECHNIQUE: Routine non-enhanced MR examination was attempted.,0
"According to the technologist's note, ""while in department, patient received 4 mg morphine, per CSRU resident, Bathos, was started on propofol.",0
Lots of motion artifact on images... these were the best possible images at this time.,0
"The patient is not a good MRI candidate.""",0
"For this reason, ""PROPELLER"" sequences were substituted for the usual T2-weighted and FLAIR FSE sequences.",0
FINDINGS: The study is compared with the NECT obtained the preceding day.,0
"Corresponding to that study, there is moderately severe focal and confluent FLAIR-hyperintensity in bihemispheric subcortical and periventricular, as well as central pontine white matter, representing chronic microvascular infarction.",0
"However, there is no focus of restricted diffusion to indicate a superimposed acute ischemic event and the major intracranial vascular flow- voids, including those of the dural venous sinuses, are preserved.",0
"There is a prominent chronic lacune in the genu of the right internal capsule, as on that study.",0
"There is no intra- or extra-axial hemorrhage and the midline structures are in the midline with incidentally noted largely ""empty sella turcica.""",0
"Noted is extensive fluid/opacification of the mastoid air cells, right more than left, with fluid pooling in the nasopharynx and posterior nasal cavity, likely related to prolonged intubation and supine positioning.",0
Also noted is mucosal thickening involving all visualized paranasal sinuses.,0
(Over) 8:23 PM MR HEAD W/O CONTRAST Clip # Reason: ?,0
"Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: Somewhat limited study, with: 1.",1
"Moderately severe chronic microvascular infarction in bihemispheric subcortical and periventricular, and central pontine white matter, with chronic lacune in the right basal ganglia.",0
"Fluid opacification of the mastoid air cells, right more than left, with fluid pooling in the nasopharynx and posterior nasal cavity, likely related to intubation and supine positioning.",0
"7:10 PM MR W &W/O CONTRAST Clip # Reason: 50 year old man with T5-7 epidural abscess drainage, evaluat Admitting Diagnosis: EPIDURAL ABSCESS Contrast: MAGNEVIST Amt: 23 ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with T5-7 epidural abscess drainage, evaluate for residual collection and postoperative changes.",0
"REASON FOR THIS EXAMINATION: 50 year old man with T5-7 epidural abscess drainage, evaluate for residual collection and postoperative changes.",0
Please perform with contrast.this is the second request- ordered and not performed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MR THORACIC SPINE WITHOUT AND WITH CONTRAST HISTORY: Status post drainage of epidural abscess.,1
"Sagittal imaging was performed with long TR, long TE fast spin echo, STIR, and short TR, short TE spin echo technique.",0
"Axial long TR, long TE fast spin echo and short TR, short TE spin echo imaging were performed.",0
"After administration of 23 cc of Magnevist intravenous contrast, sagittal and axial short TR, short TE spin echo imaging were repeated.",0
Comparison to a thoracic spine MR .,0
FINDINGS: The patient is status post laminectomy from T3 through T6.,0
No evidence of residual epidural abscess is detected.,0
"However, note that the axial images did not extend through the full surgical level, beginning at the bottom of the surgical site.",0
"Thus, there is no axial imaging through the area where the epidural abscess had been noted on the preoperative studies.",0
The patient should return for axial imaging from T1 through T6.,0
"If this is done within two days of the current examination, it would be better to avoid a repeat administration of intravenous contrast.",0
Images of the remainder of the spine appear unchanged.,0
Again demonstrated is cervical fusion and a T10 hemangioma.,0
CONCLUSION: Limited study demonstrates apparent complete removal of the spinal epidural abscess noted on the examination of .,0
"However, axial images were not performed through the surgical level, and a repeat examination is recommended as discussed above.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: fever, unresponsivness Major Surgical or Invasive Procedure: none History of Present Illness: This is a 68 yo M with h/o anoxic brain injury s/p cardiac arrest , PAF, DM 2, and HTN who presents with fever and intermittent unresponsivness.",1
"Per NH notes, pt became unresponsive at 7:45 am while perfomring ADLs.",0
"Pt afebrile at the time with BP 150/83, HR 90, O2 sat 95% on RA, FS 471.",0
He was given 10 units of lispro and became more responsive around 8:15 am.,0
The pt also received 6 units of lispro at noon and had KUB checked given complaints of abdominal pain that revealed a distended bladder.,0
He again had an episode of unresponsiveness at 1:30pm after lunch.,0
"At that time, he had a temperature of 100.0, HR 62, BP 180/100, RR 20, and O2 sat 93% on RA.",0
"At this point, he was transported to the ED for further evaluation.",0
"In the ED, T 104.2 rectally, BP 194/112, HR 170, RR 24, O2 sat 91% RA.",0
EKG revealed afib with RVR with slight ST depressions in the lateral leads.,0
He was given 1 L of NS with improvement in his HR to 94.,0
Foley placed with 1.5 L of urine drained.,0
"Port CXR without definitive evidence of consolidations, UA negative, CT abd/pelvis without acute inflammatory processes.",0
"Labs significant for WBC 13.9, Na 159, Cr 1.9, trop 0.79, CK 227, lactate 2.7.",0
"Given vancomycin 1 gm IV X 1, levoquin 500 mg IV X 1, flagyl 500 mg IV X 1, tylenol 1 gm PR, ASA 325 mg po X 1, metoprolol 50 mg po X 1, and a total of 3L NS and 1 L D5W with HCO3.",0
Cardiology was consulted who felt that ACS was unlikely.,0
"As SBPs remained elevated > 180, he was started on a nitro gtt and admitted to the MICU for further care.",0
The pt cannot say why he was taken to the hospital and does not recall any precipitating factors of his episodes of unresponsiveness earlier today.,0
He does report a new cough with sputum.,0
"On ROS, otherwise denies fevers, chills, headache, stiff neck, chest pain or pressure, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, and urinary frequency.",0
"Per pt's daugther, pt has been intermittently complaining of lower abdominal pain and had an episode of emesis last Friday.",0
"He apparently was also complaining of a headache in the ED, which the pt denies.",0
"Hyperlipidemia 4. h/o VFIB arrest in secondary to cocaine/EtOH use, complicated by coma, anoxic brain injury, and evidence if IMI, inferior ischemia with resultant improvement in heart function 5.",1
Paroxysmal AFib: not on anticoagulation due to fall risk 6.,0
BPH with urinary retention 9.,1
GERD Social History: Lives in after cardiac arrest and anoxic brain injury.,1
Is ambulatory though with memory delay.,0
Legal guardian is daughter who is a nurse.,0
"Past h/o cocaine, EtOH use.",0
"# Atrial fibrillation/ elevated troponin On arrival to MICU service, treated AF with RVR with lopressor 5mg IV x 2.",1
Patient reverted to NSR without recurrence of AF.,0
"Nitro gtt was quickly weaned off, and BP stabilized with BPs 130s/70s.",0
"Covered broadly with vanc/ceftaz/azithro, with no fevers overnight.",0
Satting 98% RA with no complaints.,0
"Much more alert, eating well.",0
Cardiology evaluated patient and believes elevated cardiac enzymes likely due to demand ischemia from RVR.,0
# Aspiration pneumonia Likely aspiration event in setting unresponsiveness.,0
Cover with levofloxacin for 7 days.,0
"Urine culture no growth, blood cultures with no growth thus far.",0
Ambulatory saturations were above 94%.,0
# Urinary retention Failed 2 voiding trials.,1
"Likely related to medications, currently not on any medications which would exacerbate the problem.",0
has follow up scheduled with Urology on with Dr. .,0
# Diabetes Placed back on metformin and glipizide.,0
HgBA1c was pending at the time of discharge.,0
# Altered mental status Poor baseline given anoxic brain injury due to ventricular fibrillatiobn arrest.,1
This acute change was likely related to hypertensive encephalopathy and severe hypernatremia.,1
He was back to baseline per HCP which is the daughter.,0
has short term memory problems but is easily re-oriented.,0
# Acute renal failure Resolved with IVF and back to baseline.,1
"# Communication Daughter and HCP is , Medications on Admission: Lasix 10 mg daily Lipitor 40 mg daily Lisinopril 2.5 mg daily Metformin 1000 mg Glipizide 5 mg daily Avodart 0.5 mg daily Flomax 0.4 mg qhs Pantoprazole 40 mg daily Trazodone 25 mg q2pm and qhs Metoprolol 50 mg Aricept 10 mg qhs Prozac 20 mg daily Reglan 5 mg prior to meals Compazine prn Lactulose qid prn Tylenol prn Duoneb prn Discharge Medications: 1.",0
GlipiZIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED).,0
Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation.,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Health care associated pneumonia Urinary retention Diabetes mellitus type II, uncontrolled with complications Hypertension Acute renal failure Discharge Condition: stable Discharge Instructions: You were admitted with fever and abdominal pain.",1
You are being discharged to complete 7 days levofloxacin for a pneumonia.,0
"You are leaving with a foley catheter in place given you failed 2 voding trials, you have an appointment with Dr. of Urology to pull the foley catheter.",0
"Followup Instructions: Provider: , MD Phone: Date/Time: 3:00 Provider: , MD Phone: Date/Time: 8:30 MD",0
1:53 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: HYPONATREMIA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with hep C cirrhosis with increased hepatic encephalopathy.,1
"REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
CLINICAL HISTORY: 57-year-old man with hepatitis C cirrhosis and increased hepatic encephalopathy.,1
The cardiac silhouette and mediastinum are grossly within normal limits.,0
There is no overt pulmonary edema or focal consolidation.,0
There is some atelectasis at the left lung base.,0
Height: (in) 72 Weight (lb): 200 BSA (m2): 2.13 m2 BP (mm Hg): 98/60 Status: Inpatient Date/Time: at 09:11 Test: TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
TRICUSPID VALVE: Mild [1+] TR.,0
GENERAL COMMENTS: Suboptimal image quality.,0
2.The right atrium is moderately dilated.,0
3.Left ventricular wall thicknesses are normal.,0
4.Right ventricular chamber size and free wall motion are normal.,0
5.The ascending aorta is moderately dilated.,0
6.The aortic valve leaflets (3) are mildly thickened but aortic stenosis or regurgitation is not present.,0
7.The mitral valve leaflets are moderately thickened.,0
No mitral regurgitation is present.,0
8.There is moderate pulmonary artery systolic hypertension.,0
5:09 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: INTUBATION ______________________________________________________________________________ FINAL REPORT SINGLE VIEW OF THE CHEST DATED : HISTORY: Intubation.,0
"FINDINGS: This single bedside AP examination labeled ""supine at 1710 H"" is available for interpretation on .",0
It is compared with a bedside study performed only eight minutes earlier and retrospectively compared with a series of studies through today.,0
"The tip of the ET tube lies 3.2 cm proximal to the carina and a newly-placed right subclavian central venous catheter reaches the distal SVC, with no supine evidence of pneumothorax.",0
The lung volumes remain somewhat low with left more than right basilar atelectasis.,0
"The ""reverse-P"" shaped opacity, projected over the lateral aspect of the right hemithorax, is no longer seen.",0
"The cardiomediastinal contour is unchanged, with extensive atherosclerotic change involving the thoracic aorta, but no pulmonary vascular congestion, supine pleural effusion, or other evidence of CHF.",0
"IMPRESSION: ET tube and right subclavian central venous catheter in satisfactory position, with persistent low lung volumes but no very short- interval change.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: GREEN SURGERY SERVICE HISTORY OF PRESENT ILLNESS: The patient is a 41 year old female with multiple sclerosis and a diagnosis of ulcerative colitis from .,1
"She has had four ulcerative colitis flares since the onset of disease, most recently in .",1
After evaluation by Dr. it was decided that a restorative proctocolectomy would be an appropriate treatment for her.,0
The patient reports rectal bleeding and change in bowel habit and fevers and chills.,0
Laparotomies x 3 for endometriosis.,0
Prednisone 27 mg po once daily 2.,0
Baclofen 130 mg po once daily (30/30/30/40) 3.,0
Elavil 30 mg po once daily 4.,0
Protonix 40 mg po once daily 5.,0
Copaxone one injection once daily 6.,0
Flonase one puff twice a day 7.,0
Asacol 2400 mg - po once daily 10.,0
Claritin 10 mg twice a day 11.,0
"Multivitamin supplement HOSPITAL COURSE: In the preop holding area, the patient was noted to have an increased swelling in her legs with 4+ pitting edema relatively equal bilaterally.",1
She was also noted to have 1+ posterior tibial pulses bilaterally.,0
She had no rash and no pain on palpation of her posterior legs.,0
In addition she was clear to auscultation bilaterally.,0
She had irregular rate and rhythm and her abdomen was soft with slight right lower quadrant tenderness but not distended.,0
The patient reported that this swelling had increased over the last 24 hours.,0
It was decided to take her to the Operating Room for her restorative proctocolectomy.,0
"On , the patient underwent a proctocolectomy and inverting ileostomy.",0
Please see dictated operative note for further details.,0
Postoperatively the patient was placed on cefazolin and Flagyl.,0
Dictated By: MEDQUIST36 D: 12:13 T: 22:23 JOB#:,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Acute pancreatitis.,1
Presumed pancreatic injury from percutaneous biopsy.,0
"Major Surgical or Invasive Procedure: Exploratory Laparotomy, Wide drainage of pancreatic leak Placement of a combined gastrostomy/jejunostomy tube (MIC tube).",1
History of Present Illness: This unfortunate 24-year-old lady had hepatitis B and was being worked up for this with a biopsy of her liver.,0
It is uncertain to my why she required this biopsy.,0
The patient had this done in the midline position 2 days prior to this procedure.,1
"In the interim, she became very sick and was treated at another hospital.",0
She developed abdominal and went to NSMC- ED where workup was significant for lipase of and amylase of 1351.,0
"CT showed diffuse hypoattenuation of the liver, suggestive of infiltration, and small amount of ascites.",0
She was admitted with a diagnosis of acute pancreatitits.,0
"On evening of , she became febrile and tachycardic.",0
"Repeat laboratories showed WBC 29.3 (from 20.0), amylase 3894 (from 1351), and lipase >2400 (from ).",0
"Repeat CT showed increase in intraperitoneal fluid, pelvic fluid, and bilateral pleural effusions She was transferred to our facility the day of this operation.",1
"In the interim, she developed clear-cut acute pancreatitis and was gravely ill. We found her to be profoundly dehydrated with all the sequelae of raging acute pancreatitis.",1
"What was worrisome, however, was her abdominal exam which showed peritonitis.",0
"In reviewing the reports, there was apparently a percutaneous biopsy attempt of the left lateral sector of the liver.",0
It was pretty clear that there was a traumatic injury to the pancreas through this biopsy precipitating acute pancreatitis.,1
I was very concerned that there was a ductal leak injury given her clinical state with a rigid abdomen with peritoneal signs.,0
Past Medical History: HBV x 5 years Social History: Has 2 young children.,0
"No EtOH or tobacco Physical Exam: Vitals - T 100.3, BP 139/64, HR 121, RR 18, O2 sat 98% 2L NC General - well-appearing female, speaking full sentences, no acute distress HEENT - PERRL, EOMI, OP clr, MMM, no LAD CV - RRR, syst flow mur Chest - CTAB Abdomen - subxiphoid biopsy set dressed, c/d/i; abdomen diffusely tender with voluntary guarding Extremities - no edema Pertinent Results: BCx-p S/BCx-p; UCx-neg UCx -> neg; Bld Cx -> pending; Bld fungal Cx -> pend; OR swab-GPC (broth only)- pending .",0
07:24AM BLOOD WBC-28.1* RBC-3.91* Hgb-11.5* Hct-33.6* MCV-86 MCH-29.5 MCHC-34.3 RDW-14.8 Plt Ct-293 06:30AM BLOOD WBC-13.3* RBC-3.41* Hgb-9.7* Hct-29.8* MCV-87 MCH-28.4 MCHC-32.5 RDW-14.8 Plt Ct-413 06:30AM BLOOD Glucose-102 UreaN-5* Creat-0.4 Na-138 K-4.0 Cl-103 HCO3-28 AnGap-11 06:30AM BLOOD ALT-25 AST-32 LD(LDH)-379* Amylase-170* TotBili-0.4 07:24AM BLOOD ALT-35 AST-25 AlkPhos-49 Amylase-2045* TotBili-1.1 07:24AM BLOOD Lipase-2662* 06:30AM BLOOD Lipase-190* 06:30AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.6 .,0
05:50AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.5 MCHC-32.9 RDW-15.3 Plt Ct-673* 05:05AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-137 K-4.5 Cl-101 HCO3-26 AnGap-15 05:50AM BLOOD ALT-72* AST-34 LD(LDH)-303* AlkPhos-99 Amylase-223* TotBili-0.4 05:50AM BLOOD Lipase-286* 05:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.7* 06:50AM BLOOD Albumin-3.0* .,0
CT ABDOMEN W/CONTRAST 1:12 PM IMPRESSION: Marked improvement post-drainage of fluid collection in the abdomen.,0
Decrease in amount of fluid seen in the pelvis as well.,0
Tiny amount of fluid is seen near the pancreatic tail and lesser sac.,0
"The celiac, superior mesenteric, and inferior mesenteric arteries are patent.",0
"The portal vein, and superior mesenteric veins and splenic veins are patent.",0
ERCP Procedures: A plastic pancreatic stent was removed from the ampulla with a snare.,1
Impression: PEG Stent in the major papilla A plastic pancreatic stent was removed from the ampulla with a snare.,0
Otherwise normal ercp to second part of the duodenum .,0
"Brief Hospital Course: She was admitted on //07 with a presumed pancreatic leak and peritoneal signs, fever, elevated WBC, tachycardic.",0
# pancreatitis: She was NPO and started on IVF resuscitation.,0
She was receiving Morphine for pain control.,0
She went to the OR later that evening for Exploratory laparotomy; Wide drainage of pancreatic bed for pancreatic leak; Placement of a combined gastrostomy/jejunostomy tube (MIC tube).,0
"On POD 2, she was extubated.",0
"She continued to have fevers for several days post-op, with a Tm 103.4.",0
"She was found to be MRSA+, likely colonized.",0
Urine grew out E.coli and she was started on Cipro for a UTI.,0
She continued to have a WBC and intermittent fevers.,0
She went for a ERCP for stent removal on .,0
"Her WBC trended down, she was not having fevers and clinically was stable.",0
"Her LFTs, Amylase and Lipase continued to trend down and did not bump with PO intake.",0
Her pancreatitis seemed to resolve.,0
#Abd/GI: She had 2 JP drains in place and a GJ feeding tube.,0
Her midlin incision was C/D/I.,0
The staples were removed on POD 11 and steri strips placed.,0
The other drains will remain in place for now.,0
"# Tachycardia: Normal response to acute pancreatitis, improved with IVF resuscitation and as fevers trended down.",1
# Chronic HBV - monitor clinically .,0
"# FEN: She was NPO, IVF.",0
She was started on trophic tubefeedings on POD 4 and started on clear liquids on POD 5.,0
Her lytes were repleted PRN.,0
Her diet was advanced over the next few days.,0
She was able to tolerate food and her tubefeedings were discontined.,0
Proph - SQ heparin - PPI while NPO .,0
Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for 2 weeks.,0
Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days.,0
"Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater Discharge Diagnosis: Pancreatic leak Tachycardia Peritonitis Fever UTI Discharge Condition: Good Tolerating diet Abdomen soft Pain Controlled Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness.",1
* If you are vomitting and cannot keep in fluids or your medications.,0
"* You are getting dehydrated due to continued vomitting, diarrhea or other reasons.",0
= = = = = ================================================================ Please resume all regular home medications and take any new meds as ordered.,0
You are being discharged on Cipro for a UTI.,0
Please complete the full course of antibiotics.,0
Continue to ambulate several times per day.,0
Followup Instructions: Please follow-up with Dr. in 1 weeks.,0
Call ( to schedule an appointment.,0
"6:14 AM BABYGRAM (CHEST ONLY) Clip # Reason: increased vent settings, evaluate ett placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with above.",1
"REASON FOR THIS EXAMINATION: increased vent settings, evaluate ett placement ______________________________________________________________________________ FINAL REPORT Compared to , the ETT is a vertebral body above the carina.",0
There has been marked interval improvement of the aeration of the lungs with some clearing of opacity within both lungs.,0
The UAC terminates at T8.,0
The UVC appears to be slightly lower than on the prior examination and possibly within the portal vein.,0
"1:55 PM CHEST (PORTABLE AP) Clip # Reason: ?fluid overload, CHF.",0
"S/P ANEURYSM COILING, ON VASOSPASM PRO ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with chf, copd,ptsd,sah REASON FOR THIS EXAMINATION: ?fluid overload, CHF.",0
"S/P ANEURYSM COILING, ON VASOSPASM PROPHYLAXIS ______________________________________________________________________________ FINAL REPORT HISTORY: 71 y/o male with CHF, COPD.",0
CHF status post aneurysm coiling.,0
Comparison to prior study from .,0
"PORTABLE CHEST: The left sided subclavian line has been withdrawn, and no longer travels up the right brachiocephalic vein.",0
"However, there is an abnormal increased density of the tip of the line suggesting that this line may be entiring the azygous vein.",0
Heart size and mediastinal and hilar contours are stable.,0
There is some blurring due to patient motion.,0
The left costophrenic angle is off the film and cannot be evaluated.,0
"IMPRESSION: 1) Left sided subclavian line with abnormally dense tip overlying azygous region, suggesting that this line may have entered the azygous vein.",0
Lateral chest radiograph would allow for better assessment of tip location.,0
2) No evidence of failure or pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Fever, Shortness of Breath, Cough Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 19 yo M with a history of OCD, Major Depressive Disorder, and Dissociative Personality Disorder as well as IVDU (not within the last two years), recent smoking cessation (2 pack-year history) and asthma who presented to the ED on with complaints of sore throat, productive cough, shortness of breath, and fever.",1
"Pt states that he was in his usual state of health until the morning of , one day after having unprotected sex with a new female partner, when he developed a severe sore throat that limited his PO intake.",0
"He denies any associated congestion, rhinorrhea, fevers or chills at that time.",0
"Within the next couple of days he developed a cough productive of sputum that was usually white, but intermittently green or red/.",0
With worsening shortness of breath and cough Pt presented to his student health services where he had a temperature of 101.4 and was brought to by ambulance on .,0
"He endorses symptoms of lightheadedness/dizziness when standing and rhinorrhea upon admission, but denies neck stiffness, LCO, chest pain, abdominal pain, diarrhea, nausea, vomiting, skin rash, myalgias, arthralgias, penile discharge, dysuria/pyuria, or known sick contacts.",0
"He was found to have multifocal pneumonia on CXR and was treated with Vancomycin, CTX, azithro, levofloxacin, and solumedrol (for concern of retropharyngeal abscess).",0
There was also initial concern of retropharyngeal abcess but his neck CT was negative for this.,0
He defervesced on the above antibiotics and 10L fluid resuscitation with imrovement in oxygen requirement from 100% NRB to 4L NC.,0
This morning Pt is feeling much better.,0
"He has a persistent cough, but denies shortness of breath on NC O2.",0
His sore throat is also improving.,0
"Mr. LP was negative for meningitis, the neck CT was normal, all cultures have been no growth to date, his CBC showed leukocytosis with WBC 14 with left shift and lymphopenia (2% of 14k).",0
"Past Medical History: - OCD with social seclusion (stayed in his room for 2 years in high school), Pt sees a psychiatrist in .",0
"- Major Depressive Disorder, Pt states that he has been hospitalized in the past for suicide attempt, but is not currently feeling depressed and has had no SI/HI.",1
- Dissociative Personality Disorder - h/o IVDU: Pt denies use within the last two years and says that he never shared needles.,1
"Social History: Social History: Hx of IVDU, cocaine, heroin, ?",0
Unprotected sex 5 days ago (3 partners total all female).,0
States drank malt liquor at times daily while at home (in ) but since being back in Bosotn (since ) has not had anything to drink.,0
Family History: Family History: non-contributory Physical Exam: VS: Temp: 99.1 (max 100.1) BP: 92/47-111/56 HR: 107 (122 when sitting up) RR: 16 O2sat: 96% on 3L NC.,0
"I/O 10L/3.2L GEN: Tired/ill-appearing male in no apparent respiratory distress, breathing comfortably without recruitment of accessory muscles.",0
"HEENT: NCAT, sclera are white, OP clear, minimal erythematous angular stomatitis.",0
"RESP: Good thoracic excursion, symmetric.",0
"No rales/rhonchi at the apices, minimal rhonchi at the bases and anteriorly b/l.",0
"CV: RRR, normal S1/S2, no murmurs/rub/gallops.",0
"ABD: Soft, non-tender, non-distended, no masses.",0
"EXT: WWP, distal pulses intact, no swollen joints.",0
"SKIN: No rashes, normal turgor.",0
"NEURO: Pt awake, alert and oriented x3.",0
Appears ill. Answering questions appropriately and is friendly in nature.,0
No unusual behaviors were observed.,0
Pt denies symptoms of depression as well as recent SI/HI.,0
Pertinent Results: 11:25AM BLOOD WBC-16.3* RBC-5.23 Hgb-16.1 Hct-45.6 Plt Ct-220 05:46AM BLOOD WBC-14.8* RBC-4.78 Hgb-15.2 Hct-42.4 Plt Ct-210 04:01AM BLOOD WBC-12.5* RBC-4.06* Hgb-12.9* Hct-36.0 Plt Ct-217 12:45PM BLOOD WBC-12.1* RBC-4.54* Hgb-13.8* Hct-40.3 Plt Ct-219 06:35AM BLOOD WBC-12.2* RBC-4.66 Hgb-13.9* Hct-42.0 Plt Ct-231 10:25AM BLOOD WBC-8.4 RBC-4.52* Hgb-13.7* Hct-39.5* Plt Ct-273 .,0
11:25AM BLOOD Neuts-79* Bands-14* Lymphs-2* Monos-4 Eos-0 Baso-0 05:46AM BLOOD Neuts-83* Bands-11* Lymphs-4* Monos-2 Eos-0 Baso-0 04:01AM BLOOD Neuts-89.1* Lymphs-3.6* Monos-5.5 Eos-1.8 Baso-0 12:45PM BLOOD Neuts-79.4* Lymphs-11.2* Monos-5.0 Eos-4.2* Baso-0.3 .,0
11:25AM BLOOD Glucose-119* UreaN-17 Creat-1.2 Na-136 K-3.6 Cl-98 HCO3-24 AnGap-18 05:46AM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-141 K-3.9 Cl-105 HCO3-23 AnGap-17 04:01AM BLOOD Glucose-95 UreaN-5* Creat-0.9 Na-142 K-3.6 Cl-109* HCO3-26 AnGap-11 12:45PM BLOOD Glucose-100 UreaN-4* Creat-1.0 Na-144 K-3.6 Cl-108 HCO3-29 AnGap-11 .,0
05:46AM BLOOD ALT-13 AST-15 LD(LDH)-173 AlkPhos-68 TotBili-0.3 .,0
08:05AM BLOOD HIV Ab-NEGATIVE HIV viral load negative .,0
11:25AM BLOOD ASA- Ethanol- Acetmnp- Bnzodzp-POS Barbitr- Tricycl- .,0
10:35PM BLOOD Type-ART pO2-204* pCO2-33* pH-7.44 calTCO2-23 BXS-0 12:07AM BLOOD Lactate-5.2* .,0
"SPUTUM PCP URINE GC/Chlamydia - URINE Legionella Urinary Antigen -FINAL INPATIENT SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT THROAT FOR STREP THROAT - R/O BETA STREP- negative URINE URINE CULTURE-no growth Influenza A/B by DFA - negative BLOOD CULTURE Blood Culture, Routine-no growth SPUTUM GRAM STAIN-; RESPIRATORY CULTURE-; SPUTUM-Pneumocystis jirovecii (carinii)-negative BLOOD CULTURE Blood Culture, Routine-no growth CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no growth RADIOLOGY CXR PA/LAT: IMPRESSION: Bilateral airspace consolidation in the lingula and right upper lobe, consistent with pneumonia.",0
"CXR AP port: FINDINGS: Single bedside AP examination labeled ""upright with grid"" is compared with the study obtained some two hours earlier.",0
The lung volumes remain low and (allowing for technical differences) the patchy airspace process involving the right mid lung and both lung bases has become more confluent.,0
"There is no pleural effusion and the cardiomediastinal silhouette and pulmonary vessels are unchanged, with no evidence of hilar adenopathy.",0
Incidentally noted is an apparent 'ostomy tube in the right central abdomen.,0
CXR AP port: Rapid progression of right lung consolidation involving right lower lobe/anterior right upper lobe.,0
"Left lower lobe process is also progressing, but less extensively.",0
"CXR PA/LAT: Widespread, multifocal areas of consolidation have progressed in the interval, particularly in the mid and lower lungs bilaterally.",0
"Additionally, new patchy ill-defined areas of consolidation have developed within the upper lungs, right greater than left.",0
"Small left pleural effusion with apparent loculation is also demonstrated, new in the interval.",0
"CXR PA/LAT: In comparison to the previous radiograph from , there is further progression of bilateral parenchymal consolidations.",0
"The size of the cardiac silhouette is normal, no evidence of pleural effusions.",0
CT CHEST: MPRESSION: Multifocal pneumonia characterized by the presence of consolidation in all lung segments along with some reactive lymphadenopathy and accompaning pleural fluid bilaterally.,0
"Non pathologically enlarged lymph nodes in mediastinum, most likely reactive.",0
"Brief Hospital Course: A/P: Pt is a 19 yo male with an extensive psychiatric history as well as a history of poly-substance abuse in the past who presents with fever, sore throat and respiratory distress.",0
"# Multifocal pneumonia: Initially, due to concern for respiratory distress and fever, Pt was assessed by CT scan for pharyngeal abscess, which was negative.",0
"His initial CXR, however, showed a multifocal pneumonia by CXR.",0
"Pt received Azithromycin, Ceftriaxone, and Vancomycin in the ED as well as solumedrol and stablized from a respiratory standpoint.",0
"He was admitted to the ICU because of the extent of his initial respiratory distress, but was saturating at or near 100% on RA at that point.",0
"Upon transfer to the floor pt remained febrile, but was saturating in the mid 90s on room air.",0
Vancomycin was discontinued in the setting of 72 hours of negative blood cultures.,0
"With continued fevers, Clindamycin was added given concern for the possibility of aspiration pneumonia.",0
This concern was raised in the setting of a multilobular process combined with the fact that Pt has been taking multiple sedating medications at relatively large doses.,0
"Pt defervesced following the addition of clindamycin with decreased cough and improved SaO2, including the maintanence of SaO2 in the 90's during ambulation on .",0
Given risk factors of IVDU and unprotected sex Pt was tested for HIV and both Antibody and viral load were negative.,0
Influenza a/b DFA was negative.,0
"GAHS throat swab was negative as was urine legionella, GC, and Chlamydia.",0
Pt was discharged in stable condition and was instructed to complete a 14 day course of levofloxacin and clindamycin for likely community acquired pneumonia.,0
# OCD/MDD: Pt did not manifest any signs or symptoms of active OCD or depression during this admission.,0
"He was made aware of the fact that there was concern for the possibility of an aspiration event secondary to over-sedation, but deferred psychiatric consultation on numerous occasions as he prefers to have his medications managed by his outside psychiatrist.",0
A detailed message regarding Pt's clinical course and concern for the possibility of overmedication was left with Pt's psychiatrist on the day of discharge.,0
Pt was otherwise maintained on his home doses of psychiatric medications during this hospitalization.,0
Medications on Admission: Xanax 2mg QID Diazepam 20mg Seroquel 300mg qhs Nortryptiline ?dose Zoloft 300mg daily Discharge Medications: 1.,0
Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day).,0
Diazepam 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Sertraline 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).,0
Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime).,0
Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 11 days days.,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days.,0
"Disp:*11 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - Community Acquired Pneumonia Secondary: - Obsessive/Compulsive Disorder - Major Depressive Disorder - Dissociative Personality Disorder Discharge Condition: Stable, no shortness of breath, saturating 95% on room air.",1
Discharge Instructions: You were admitted to the hospital with a fever and respiratory distress.,0
"You were found to have a pneumonia, an infection of the lungs, affecting multiple lobes of both your right and left lungs.",0
Following a brief stay in the intensive care unit your fever defervesced and you stabilized from a respiratory standpoint on intravenous antibiotics.,0
"Psychiatric consultation was offered on multiple occasions, but you insisted upon continuing your care with you outside provider.",0
the absence of acute symptoms of OCD or Depression this was considered a resonable request.,0
Please continue to take all medications as recommended (including 11 days of antibiotics after discharge as well as your home psychiatric medications).,0
Please follow up with both your student health services and you psychiatrist as outlined below.,0
"Should you experience increasing shortness of breath/cough/sputum production, fever, lightheadedness, chest pain or palpitations, abdominal pain, diarrhea, pus/bloody urine, or any other concerning symptoms please do not hesistate to visit your student health services or return to the hospital for evaluation.",0
Please call your psychiatrist following discharge to touch bases regarding your medication regimen and to discuss any ongoing mental health issues.,0
Please follow up at your student health services on Wednesday at 1:00pm.,0
"10:38 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for DBS electrode infection, abscess Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with DBS and recent lead removal, battery changeout presenting with fever and hypotension.",1
"REASON FOR THIS EXAMINATION: evaluate for DBS electrode infection, abscess No contraindications for IV contrast ______________________________________________________________________________ WET READ: RSRc WED 3:36 PM No hemorrhage, edema or e/o acute process ______________________________________________________________________________ FINAL REPORT HISTORY: 21-year-old male with deep brain stimulation and recent lead removal with fever, hypertension.",1
"Evaluate for electrode infection, abscess.",0
TECHNIQUE: Imaging was performed from the foramen magnum to the cranial vertex without IV contrast.,0
HEAD CT WITHOUT IV CONTRAST: Bifrontal deep brain stimulator leads appear in similar position to .,0
The distal tips are just lateral to the thalami bilaterally.,0
"Allowing for associated streak artifact, no acute hemorrhage or parenchymal edema is seen.",0
There is no pathologic extraaxial collection.,0
"There is encephalomalacia of the left caudate head and adjacent white matter, as before.",0
The ventricles and sulci are unchanged in size and configuration with no evidence of hydrocephalus.,0
"IMPRESSION: Stable appearance of the brain without evidence of acute intracranial abnormalities, within the limitations of noncontrast CT.",1
4:07 PM CHEST (PORTABLE AP) Clip # Reason: GI bleed- eval for CHF ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with REASON FOR THIS EXAMINATION: GI bleed- eval for CHF ______________________________________________________________________________ FINAL REPORT INDICATION: GI bleed.,0
Evaluate for left ventricular failure.,0
"CHEST AP: The heart size, mediastinal and hilar contours are unremarkable.",0
9:21 AM PUNC ASP ABSECC/HEMATOMA//CYST LEFT; -78 RELATED PROCEDURE DURING POSTOPERATIVE PERIODClip # GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) Reason: please drain complex fluid collection Admitting Diagnosis: ABDOMINAL PAIN ********************************* CPT Codes ******************************** * PUNC ASP ABSECC/HEMATOMA//CYST L -78 RELATED PROCEDURE DURING POSTOPE * * GUIDANCE/LOCALIZATION FOR NEEDLE BIO * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with cirrhotic with complex fluid collection in abdomen REASON FOR THIS EXAMINATION: please drain complex fluid collection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 54-year-old male with history of left lower abdominal wall abscess.,1
Patient now with fluid reaccumulation and signs of sepsis.,1
"EXAMINATION: Ultrasound-guided abscess drainage TECHNIQUE: After explanation of the risks, benefits, and alternatives, written informed consent was obtained.",0
A preprocedure timeout was performed to confirm the correct patient using three identifiers and the examination to be performed.,1
"Under son guidance, the site of the complex abdominal wall fluid collection was marked in the left lower quadrant.",1
The skin was prepped and draped in the usual sterile fashion.,0
1% buffered lidocaine solution was utilized to anesthetize the overlying skin.,0
A 5-French catheter was then advanced into the superficial abdominal wall fluid collection in the left lower abdomen under son guidance.,1
"37 cc of dark maroon fluid was aspirated, grossly similar in appearance to the most recent prior aspiration.",1
"At the end of the procedure, no significant residual fluid was evident in the abscess cavity.",1
"The fluid was sent for diagnostic evaluation for chemistry, cell count, and microbiology.",0
There were no immediate post-procedural complications.,0
"The attending radiologist, Dr. , was present and supervised the procedure.",0
IMPRESSION: Satisfactory drainage of a left lower quadrant abdominal wall fluid collection yielding 37 cc of dark brown/maroon fluid for diagnostic evaluation.,1
"10:33 PM CHEST (PORTABLE AP) Clip # Reason: intubated during cardiac arrest: please confirm tube placeme ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with hypercalcemia, VFib cardiac arrest REASON FOR THIS EXAMINATION: intubated during cardiac arrest: please confirm tube placement, evaluate for lung pathology ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: Compared to previous exam of .",1
INDICATION: Intubated during cardiac arrest.,1
"An ETT is present, in satisfactory position.",0
The heart demonstrates left ventricular configuration.,1
There is slight increase in pulmonary vascularity with perihilar haziness and peribronchial cuffing.,0
No confluent areas of consolidation are seen in either lung and no pleural effusions are evident.,0
Marked arthritic changes are seen at the right shoulder.,0
IMPRESSION: 1) Satisfactory placement of ETT.,0
2) Mild congestive heart failure.,1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Penicillins / Linezolid Attending: Chief Complaint: Fevers and increased WBC Major Surgical or Invasive Procedure: Interventional Radiology placed PICC line History of Present Illness: 64 year old female with two-day vascular surgery ~ 5/808.,1
Has bovine aortic arch and innominate artery aneurysm.,0
Had bypasses to all of his great vessels and then covered stent to aorta ( anatomy unclear).,0
Was dc'd to rehab and then represented to with resp distress and infection (multiple possible sources).,0
"Past Medical History: -- DM2 -- chronic foot ulcers/PVD -- HTN -- OA -- obesity -- asthma -- leg pain/neuropathy -- depression -- anemia -- h/o MRSA bacteremia , also septic arthritis treated at .",1
"Right thalamic hemorrhage resulting in a gait disorder and incontinence of urine, followed by Dr. .",0
Status post total abdominal hysterectomy.,0
Social History: The patient lives with her daughter and her three kids since being d/c'ed from a nursing home last .,0
"Has seven children, many grandchildren.",0
Smokes to 1 pack per day.,0
"Family History: Brother died of an MI in his 30's, she denies diabetes mellitus in the family.",0
"Cancer in parents (mother died in 40s, father in 80s), at least two siblings, but unsure what kind.",0
"Physical Exam: Obese AA woman laying in bed, appears to be acutely ill and older than staged age.",0
"cta rrr abd benign palp fems, dopp L DP only, dopp R DP/PT Nuero Comprehension seems intact.",0
Able to do months/days forwards but not backwards.,0
Registration intact but recall 0/3 in 3 min and with prompt.,0
Speech is extremely slowed but coherent.,0
Affect is flat Pertinent Results: ON ADMISSION: 05:22PM BLOOD WBC-11.8* RBC-2.68* Hgb-7.5* Hct-23.4* MCV-88 MCH-28.1 MCHC-32.2 RDW-17.3* Plt Ct-287 05:22PM BLOOD PT-21.8* PTT-38.9* INR(PT)-2.1* 05:22PM BLOOD Glucose-132* UreaN-25* Creat-1.6* Na-142 K-4.2 Cl-109* HCO3-22 AnGap-15 05:22PM BLOOD CK(CPK)-348* 05:22PM BLOOD CK-MB-2 11:00PM BLOOD Mg-2.1 08:57PM BLOOD Type-ART pO2-211* pCO2-25* pH-7.45 calTCO2-18* Base XS--4 05:28PM BLOOD Lactate-1.7 08:57PM BLOOD Glucose-103 Lactate-1.0 08:57PM BLOOD O2 Sat-98 10:22PM BLOOD freeCa-1.00* .,0
ON DISCHARGE: 05:26AM BLOOD WBC-10.1 RBC-3.23* Hgb-9.2* Hct-26.9* MCV-83 MCH-28.5 MCHC-34.2 RDW-18.1* Plt Ct-256 08:56AM BLOOD PT-15.9* PTT-33.4 INR(PT)-1.4* 05:26AM BLOOD Glucose-79 UreaN-11 Creat-1.1 Na-141 K-4.0 Cl-107 HCO3-24 AnGap-14 05:26AM BLOOD CK(CPK)-91 05:26AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.2 5:22 pm BLOOD CULTURE STAPH AUREUS COAG +.,0
STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ <=1 S 6:44 pm BLOOD CULTURE Source: Line-picc.,0
ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R 7:10 pm URINE Site: CATHETER PROTEUS MIRABILIS.,1
"10,000-100,000 ORGANISMS/ML.. PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Started on broad spectrum AB on admission Pan CX'd On first hospital night had resp distress followed PEA arrest after meds given for intubation.",1
"Got 1 min cpr, epi which led to af with rvr, and then dccv for AF.",0
Echo (reviewed with ) showed large anterior mi with aneurysmal apex.,0
EKG also suggests anterior event in past month (prwp).,0
Suspect that she decompensated from cariopulmonary perspective because of this infection and presented for care.,0
"Cardiology consult / ID consult obtained Pt delined / Cx's taken / Pt delined / blood, urine, surgical site, cxr Bronchoscopy performed Swnaz ganz placed orignal PICC pos for staph coag pos.",0
"proteus UTI epi weaned / extubate / transfer to VICU ID adjusts AB PT consult / OT consult heparin started per cardiology for ACAS / DVT upper extremity, possible catherizationn discusse.",0
"cipro dc for UTI vanco stopped / daptomycin started pt with 2 days negative blood cx's / PICC replaced foley DC'd Cardiolgy decides against catherization / to be arranged at alter date Id makes final recommendations Pt stable for DC Medications on Admission: vicodin 500, lipitor 20, lopressor 25"", aricept 10', celexa 10', plavix 75' Discharge Medications: 1.",0
Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours).,0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) INH Inhalation Q6H (every 6 hours).,0
Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) INH Inhalation (2 times a day).,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain.,0
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 100 or HR < 60.,0
Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 4 weeks: from / may DC Follow labs as on Pg 1.,0
Insulin Sliding Scale Fingerstick Q6H Insulin SC Sliding Scale Regular Glucose Insulin Dose 0-60 mg/dL 1 amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 4 Units 161-180 mg/dL 6 Units 181-200 mg/dL 8 Units 201-220 mg/dL 10 Units 221-240 mg/dL 12 Units 241-260 mg/dL 14 Units 261-280 mg/dL 16 Units 281-300 mg/dL 18 Units > 300 mg/dL Notify M.D.,0
Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 7 days: DC when INR is greater then 2/ Keep INR .,0
Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: INR goal is .,0
"Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: Primary: Wound infection PEA arrest after MI VRE, MRSA Secondary: HTN, PVD, depression, urinary incontinence, DM2, anemia(iron def), CRI (1.1-1.4), vascular dementia, Discharge Condition: Stable Discharge Instructions: WOUND CARE: PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your wound(s).",1
"New pain, numbness or discoloration of your lower or upper extremities (notably on the side of the incision).",0
Watch for signs and symptoms of infection.,0
"These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site.",0
"If you experience any of these or bleeding at the incision site, CALL THE DOCTOR.",0
Followup Instructions: Scheduled Appointments : Provider CAT SCAN Phone: Date/Time: 8:45 Please follow with Dr her office number is .,0
You have an appointment at 1030 hrs.,0
Appointments to be made: Please followup with Dr at .,0
This appointment should be in 4 weeks.,0
"Call Dr office, you should see him in 4 weeks.",0
"he can be reached at, Phone: .",0
2:43 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate?,0
______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with hypoxia REASON FOR THIS EXAMINATION: infiltrate?,0
______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old male with hypoxia.,0
AP UPRIGHT CHEST: There is no prior for comparison.,0
"Note is made of bibasilar opacities, left greater than right.",0
There is no significant effusion or pneumothorax.,0
"IMPRESSION: While atelectasis may represent a componet of the bibasilar opacity, pneumonia cannot be excluded; particularly on the left.",0
"9:57 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluation for edema, consolidation, other acute proc Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 22M with metastatic germ cell tumor w/trach, increasing secretions, s/p tx for MRSA and pseudomonas.",1
"REASON FOR THIS EXAMINATION: Please evaluation for edema, consolidation, other acute process, interval change.",0
"______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Patient with tracheostomy, increasing secretions, known metastatic germ cell tumor and MRSA.",0
Comparison is made with prior studies including most recent one chest CT .,0
Patient has known large mediastinal mass and multiple lung metastases greater in the lower lobe on the left side which are unchanged.,0
No new lung opacities are noted.,0
Right PICC line tip is in the right atrium.,0
Impression: No interval change DR.,0
"1:16 PM BILAT LOWER EXT VEINS PORT Clip # Reason: INC OX REQ DESPITE DIURESIS, R/O DVT ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with REASON FOR THIS EXAMINATION: increasing oxygen requirments despite diuresis.",0
s/p R fem- POD 5 ______________________________________________________________________________ FINAL REPORT INDICATION: Status post right fem/ post op day 5.,0
"Grayscale and Doppler son of bilateral common femoral, superficial femoral, superficial femoral and popliteal veins were performed.",0
There is no evidence of intraluminal thrombus.,0
IMPRESSION: No evidence of bilateral DVT.,0
"8:00 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with head trauma now w/ leukocytosis hypoxia REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: History of head trauma, now with leukocytosis and hypoxia.",0
"PORTABLE AP CHEST RADIOGRAPH: There is a faint airspace opacity in the right middle lung zone, which is new in comparison to prior study, and may represent aspiration or pneumonia.",0
"There is bibasilar atelectasis, and small bilateral pleural effusions, greater on the left.",0
"A left- sided PICC line is seen, with the tip in the upper SVC.",0
A tracheostomy tube is seen with the tip approximately 4 cm above the carina.,0
The pulmonary vasculature is stable in appearance.,0
Degenerative changes are seen within the mid thoracic spine.,0
The mediastinal and cardiac contours are stable in appearance.,0
IMPRESSION: Faint new airspace opacity within the right mid lung zone.,0
"As this is a new finding in a short time period, this is concerning for aspiration, though pneumonia should also be considered.",0
Again seen are small bilateral pleural effusions.,0
"7:13 PM CHEST (PORTABLE AP) Clip # Reason: new fever, ?",0
"Admitting Diagnosis: RENAL CELL CARCINOMA;FEVER,HYPOKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with metastatic renal cell CA to lungs, intubated, s/p bronch stents.",0
"REASON FOR THIS EXAMINATION: new fever, ?",0
______________________________________________________________________________ FINAL REPORT HISTORY: 74 y/o man with metastatic renal cell carcinoma to the lungs.,0
AP SEMI-ERECT PORTABLE CHEST @ 7:30 P.M.: Comparison is made to prior study 4 hours earlier.,0
There appears to be increase in the pulmonary edema.,0
Acute infiltrates cannot be ruled out.,0
5:03 AM CHEST (PORTABLE AP) Clip # Reason: Needs cxr to eval Admitting Diagnosis: RENAL CELL CA; RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with R RCC C/B MUCUS PLUG REASON FOR THIS EXAMINATION: Needs cxr to eval ______________________________________________________________________________ FINAL REPORT HISTORY: Mucus plugging.,1
"FINDINGS: In comparison with study of , the hazy opacification at the left base is less prominent, though there is more haziness now at the right base.",0
The findings are consistent with substantial bilateral free flowing pleural effusions.,1
Decubitus views would be helpful to precisely evaluate the amount of free pleural fluid.,0
"The endotracheal tube has been removed, as has the nasogastric tube.",0
2:03 PM C-SPINE NON-TRAUMA VIEWS Clip # Reason: assess post spine fusion - requesting ap & lat views Admitting Diagnosis: SPINAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with C6 Left lamina fx C7 L pedicle fxT7 & T8 Burst fx's following a MCC s/p fusion 2 months ago.,1
"F/u c-spine films per Ortho Spine REASON FOR THIS EXAMINATION: assess post spine fusion - requesting ap & lat views ______________________________________________________________________________ FINAL REPORT STUDY: Cervical spine, .",0
CLINICAL HISTORY: 36-year-old male with C6 laminectomy and T8 burst fracture.,0
FINDINGS: There are no displaced fractures or dislocations.,0
Vertebral body heights are within normal limits.,0
Prevertebral soft tissues are normal.,0
Reported C6 lamina and C7 pedicle fractures are not well seen on these radiographs.,0
"8:52 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: please eval for sinus infection Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with HIV, SCC s/p right lower lobe lobectomy with hypoxic respiratory failure with persistent fever REASON FOR THIS EXAMINATION: please eval for sinus infection CONTRAINDICATIONS for IV CONTRAST: started aminoglycoside, rapidly changing renal function ______________________________________________________________________________ WET READ: MDAg MON 3:27 PM Pooling of fluid in nasal cavity and nasopharynx.",1
"Ethmoid, sphenoid, maxillary and frontal sinuses are clear.",0
No evidence of bony destruction.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Persistent fever, evaluate for sinus infection.",0
TECHNIQUE: Non-contrast MDCT images were acquired through the paranasal sinuses.,0
Coronal and sagittal reformatted images were obtained for evaluation.,0
FINDINGS: There is partial opacification of the mastoid air cells bilaterally.,0
There is near-complete opacification of the middle ear bilaterally with fluid surrounding the ossicles.,0
This fluid could be sterile or infected.,0
"The maxillary, frontal, sphenoid and ethmoid air cells are clear.",0
Fluid layering is seen in the nasal choanae and nasopharynx.,0
An NG tube enters the right naris.,0
There is no evidence of bony destruction.,0
The visualized portions of the brain demonstrate mildly prominent ventricles and sulci compatible with global age-related volume loss.,0
The brain is otherwise unremarkable.,0
IMPRESSION: Partial opacification of mastoid air cells and near complete opacification of middle ear cavity.,0
The fluid could be sterile or infected.,0
3:37 AM CHEST (PORTABLE AP) Clip # Reason: evaluate Admitting Diagnosis: FULIMANT LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 48M with acute liver injury of unknown etiology who presented to OSH after prolonged seizure at group home.,1
REASON FOR THIS EXAMINATION: evaluate ______________________________________________________________________________ FINAL REPORT HISTORY: Acute liver injury with prolonged seizure.,1
The tip of the endotracheal tube now measures approximately 5.6 cm above the carina.,0
Cardiac silhouette is within upper limits of normal in size.,0
There is stable elevation of pulmonary venous pressure.,0
Hazy opacification at the right base is consistent with pleural fluid and mild basilar atelectasis.,0
2:44 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with CHF, intubated in ICU REASON FOR THIS EXAMINATION: ?",1
interval change ______________________________________________________________________________ FINAL REPORT INDICATION: CHF and intubated.,0
FINDINGS: A left-sided generator pack with leads positioned in the region of the right atrium and right ventricle appears stable.,0
A tracheostomy catheter is stable in position.,0
There is severe cardiomegaly which is unchanged.,0
"There is increasing opacity, particularly in the right upper lobe and in the left upper lobe.",0
Retrocardiac opacity has also increased.,0
Bilateral pleural effusions appear larger.,0
IMPRESSION: Interval progression of pulmonary edema and bilateral effusions.,0
10:34 AM CHEST (PORTABLE AP) Clip # Reason: r/o PTX after chest tube removal Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with 2 chest tubes removed.,0
"CHF EF 15%, CAD s/p CABG, s/p AICD, with AV endocarditis, ao root abscess REASON FOR THIS EXAMINATION: r/o PTX after chest tube removal ______________________________________________________________________________ FINAL REPORT INDICATION: Aortic root abscess and aortic valve endocarditis status post chest tube removal.",0
"SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median sternotomy, CABG, and aortic valve replacement.",0
"The endotracheal tube, Swan-Ganz catheter, and nasogastric tube remain in standard positions.",0
Bilateral chest tubes have been removed.,0
"There is a moderate-sized left pleural effusion, which appears increased since the prior examination.",0
Small right pleural effusion is also demonstrated.,0
Mild pulmonary edema is present which appears slightly worse in the interval.,0
"Bibasilar opacities, left greater than right are present likely representing atelectasis.",0
"There is unchanged widening of the mediastinum, likely due to postoperative changes.",0
Moderate sized left pleural effusion and small right pleural effusion status post removal of bilateral chest tubes.,0
Moderate cardiomegaly with mild congestive heart failure.,1
"Bibasilar opacities, left greater than right, likely representing atelectasis but developing infection cannot be excluded.",0
"6:53 PM CHEST (PORTABLE AP) Clip # Reason: assess volume status Admitting Diagnosis: APML ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with CHF REASON FOR THIS EXAMINATION: assess volume status ______________________________________________________________________________ WET READ: SJBj SUN 11:36 PM Stable ""batwing"" appearence of bilateral perihilar opacity is consistent with severe pulmonary edema.",1
Superimposed infection cannot be excluded.,0
R PICC and RIJ in low SVC.,0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Chronic heart failure, assessment for volume status.",1
"FINDINGS: As compared to the previous radiograph, there is stable bat- edema consistent with severe pulmonary fluid overload.",1
The right internal jugular vein catheter in the right PICC line is in unchanged position.,0
Unchanged normal to borderline size of the cardiac silhouette.,0
"1:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for failure Admitting Diagnosis: HYPERGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with DKA, s/p RIJ triple lumen placement now with hypotension, decreased urine output REASON FOR THIS EXAMINATION: evaluate for failure ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: INDICATION: Line placement.",0
COMPARISON is made to previous study of .,0
"There has been interval placement of a right IJ vascular catheter, which terminates within the superior vena cava.",0
No pneumothorax is evident on this supine study.,0
There is mild congestive heart failure pattern with vascular engorgement and perihilar haziness.,1
Minor areas of discoid atelectasis are seen in the lower lung zones bilaterally.,0
IMPRESSION: Vascular catheter in satisfactory position with no pneumothorax.,0
3:31 PM CHEST (PORTABLE AP) Clip # Reason: linje placement Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p renal transplant REASON FOR THIS EXAMINATION: linje placement ______________________________________________________________________________ FINAL REPORT INDICATION: 54 year old man status post renal transplant.,1
Now status post line placement.,0
AP SINGLE VIEW OF THE CHEST: There is stable cardiomegaly.,0
The right IJ central line tip is the low SVC.,0
There is no evidence of PTX.,0
Pulmonary vascularity is normal for technique.,0
There is no evidence of fluid overload.,0
The skeletal structures are unchanged.,0
There is a patchy opacity in the left lower lung zone.,0
IMPRESSION: 1) Right IJ central line tip is in the lower SVC.,0
3) Left lower lung zone opacity most likely represents atelectasis.,0
Differential diagnosis could include pneumonia.,0
"Height: (in) 69 Weight (lb): 148 BSA (m2): 1.82 m2 BP (mm Hg): 99/53 HR (bpm): 98 Status: Inpatient Date/Time: at 12:51 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Patient clinically brain dead, no sedation given for examination.",0
The patient is mechanically ventilated.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or vegetation on mitral valve.,0
"The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors.",0
No aortic valve abscess is seen.,0
IMPRESSION: No intracardiac mass or vegetation visualized.,0
Organ Bank notified of the results in person.,0
Height: (in) 60 Weight (lb): 135 BSA (m2): 1.58 m2 BP (mm Hg): 133/78 HR (bpm): 78 Status: Inpatient Date/Time: at 11:56 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Saline Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
No thrombus/mass in the body of the LA.,0
MITRAL VALVE: No mass or vegetation on mitral valve.,0
"Compared with the report of the prior study (images unavailable for review) of , no change.",0
"12:58 PM CHEST (PORTABLE AP) Clip # Reason: pulmonary infiltrate Admitting Diagnosis: SIGMOID COLON CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: year old man with sigmoid colectomy with recent mental status changed, with respiratory distress REASON FOR THIS EXAMINATION: pulmonary infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Sigmoid colectomy with respiratory distress.",1
"FINDINGS: In comparison with the study of , there is again diffuse bilateral pulmonary opacifications consistent with pleural effusions and underlying atelectasis and/or pneumonia.",0
There also is perihilar fullness consistent with increasing pulmonary congestion or overhydration.,0
The tubes remain in place.,0
BP (mm Hg): 90/60 HR (bpm): 92 Status: Inpatient Date/Time: at 10:15 Test: Portable TEE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is moderately dilated.,0
LEFT VENTRICLE: The left ventricular cavity is mildly dilated.,0
AORTA: There are simple atheroma in the aortic arch.,0
The prosthetic aortic valve leaflets are thickened.,1
TRICUSPID VALVE: There is no mass or vegetation detected on the tricuspid valve.,0
The prosthetic aortic valve leaflets are severely thickened.,1
There is at least moderate aortic valve stenosis.,1
"There are 3 moderate-sized mobile, echo dense masses and mutliple small sized mass on the aortic valve, in addition to a string of small sized masses extending from the anterior aortic ring into the ascending aorta.",1
11:45 AM ABDOMEN (SUPINE ONLY) Clip # Reason: pre-MRI Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with ICH REASON FOR THIS EXAMINATION: pre-MRI ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 65-year-old male with intracerebral hemorrhage.,1
SUPINE ABDOMINAL RADIOGRAPH: There is a nonobstructive bowel gas pattern with moderate amount of stool within the colon and the rectum.,0
Contrast is seen within bilateral collecting system and bladder.,0
Note is made of probable bilateral extrarenal pelvi.,0
A Foley catheter is present.,0
Suture material and NG tube projects over the abdomen.,0
IMPRESSION: No evidence of obstruction.,0
8:50 AM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate for changes after clamping of ventriculostom Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman s/p SAH REASON FOR THIS EXAMINATION: Please evaluate for changes after clamping of ventriculostomy.,1
"Please perform study at 8 AM CONTRAINDICATIONS for IV CONTRAST: Subarachnoid hemorrhage ______________________________________________________________________________ FINAL REPORT INDICATION: Lt SAH, S/P ventriculostomy, evaluate interval changes.",1
"COMPARISON: Technique: Contiguous axial images were obtained from the foramen magnum to the cranial vertex, without IV contrast.",0
FINDINGS: Unchnaged appearance of the left cerebellar hemorrhage.,0
Interval resolution of the intraventricular hemmorhage in the fourth ventricle.,0
"Unchanged appearance of the right frontal ventricular shunt, with tip located in the lateral aspect of the third ventricle.",0
"Unchanged appearance of the periventricular low attentuation areas, consistent with chronic microvascular ischemic changes.",0
"No masses, no midline shift noted.",0
Normal bones and well aerated paranasal sinuses.,0
Unchanged appearance of the left cerebellar hemmorhage.,0
"Right frontal ventricular shunt, with tip located in the lateral aspect of the third venticle.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old female with a history of diabetes, hypertension, asthma and heavy alcohol use who is admitted with facial cellulitis as well as alcohol withdraw.",1
The patient was well until Thursday when she awoke the following morning.,0
She was feeling ill and confused.,0
Her roommate was concerned and he took her to the Emergency Room for evaluation.,0
"At that time she started developing some pain in her face, which quickly progressed into facial cellulitis that started spreading and the patient became unable to open her eyes while she was in the Emergency Department.",0
At that time she also reported feeling chills and feverish since this has happened.,0
"However, she was denying fevers or chills the day prior to admission.",0
The patient denies any history of trauma.,0
She has not been swimming or in any pools.,0
She has no pets that could have scratched her in the face.,0
"Otherwise she is not complaining of any shortness of breath, chest pain, abdominal pain.",0
The patient also reports a history of drinking heavily and the last time she had a drink was the day prior to admission.,0
"MEDICATIONS ON ADMISSION: Klonopin 1 mg po b.i.d., Zestril 20 mg po q day, Advair one puff po b.i.d., Flovent two puffs po b.i.d., Albuterol MDI prn, Serevent, Humulin insulin 45 units q.a.m., 30 units q.p.m., Prilosec 20 mg po q day, Theophylline 300 mg po b.i.d.",0
and Fluoxetine 20 mg po q day.,0
SOCIAL HISTORY: The patient has a positive history of alcohol abuse and she continues to smoke tobacco half pack per day.,0
"HOSPITAL COURSE: After progression of the facial cellulitis in the Emergency Department, the patient was transferred to the Medical Intensive Care Unit.",0
She was seen by ophthalmology who felt that her examination was consistent with preseptal bilateral cellulitis.,0
"She had a CT scan, which was also consistent with preseptal disease.",0
"It also showed some evidence of sinusitis particularly in the left frontal, anterior ethmoid and maxillary sinuses right greater then left.",0
"Infectious disease was also consulted and they suggested initial triple antibiotic therapy with Vancomycin, Clindamycin and Levofloxacin.",0
Before antibiotics were obtained blood cultures were taken as well as there were cultures taken from several of the facial bulla as well as her eye cultures.,0
She was also evaluated by plastics who felt there was no acute issue at this time.,0
Alcohol withdraw: The patient began to go through progressive withdraw throughout the first several days of her hospital course.,0
She was started on Valium and a CIWA scale and placed on thiamine and folate.,0
Periorbital cellulitis: She was continued on Vancomycin and Clindamycin initially.,0
"Levofloxacin was discontinued as her cultures grew back beta strep group A as well as coag positive staphylococcus, which was not differentiated at that time.",0
She was eventually continued on Vancomycin alone and then when her staph came back as being consistent with Methacillin sensitive staph aureus she was switched to intravenous Cephazolin and then she was changed to po Keflex.,0
It was eventually decided to discharge her on a ten day course of Dicloxacillin 500 mg po q six hours.,0
The patient's facial skin became highly improved with markedly decreased erythema and some residual hyperpigmentation across both cheeks.,0
Asthma: The patient initially presented with significant wheezing.,0
She was continued on her various inhalers and nebulizers prn.,0
She eventually did not require the nebulizers and her wheezing had improved and stabilized.,0
"Cardiovascular: The patient had an episode of AVNRT while she was in the Intensive Care Unit and she was started on Diltiazem, however, she remained stable on telemetry with no further events.",0
Because of hypotension her Diltiazem was discontinued.,0
She remained on telemetry on the floor without any further cardiac events.,0
"She was restarted on Captopril, which was changed to Lisinopril prior to discharge.",0
DISCHARGE STATUS: Discharge to home.,0
Dicloxacillin 500 mg po q 6 hours times ten days.,0
Prozac 20 mg po q day.,0
Lisinopril 10 mg po q day.,0
Calcium carbonate 500 mg po t.i.d.,0
"Albuterol, Advair and Flovent inhalers per prior home regimen.",0
"Humulin 45 units q.a.m., 30 units q.p.m.",0
Prilosec 20 mg po q day.,0
Klonopin 1 mg po b.i.d.,0
Theophylline 300 mg po b.i.d.,0
Dictated By: MEDQUIST36 D: 10:56 T: 13:10 JOB#:,0
7:03 PM CHEST (PORTABLE AP) Clip # Reason: eval RSC placement Admitting Diagnosis: ASPIRATION PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 63 yo female s/p TEF fistula repair w/gnr bacteremia.,0
REASON FOR THIS EXAMINATION: eval RSC placement ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate right subclavian central line.,0
"CHEST, AP PORTABLE: Comparison is made to prior study obtained 12 hours earlier.",0
"There has been interval placement of right subclavian central line, with the tip extending into the right IJ (the tip is not included on the image).",0
"Again noted are left subclavian central line and tracheostomy tube, unchanged in position.",0
There is no other significant change from the prior study.,0
"IMPRESSION: Malpositioned right IJ central line, with the tip extending into the right internal jugular vein.",0
Discussed with Dr. by phone.,0
"10:39 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate, ?aspiration Admitting Diagnosis: ETOH WITHDRAWAL,DTS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with etoh withdrawal and hx seizure.",0
"REASON FOR THIS EXAMINATION: eval for infiltrate, ?aspiration ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST .",0
The heart size and pulmonary vascularity are normal.,0
"Mediastinal and hilar contours are normal, and the lungs are clear.",0
No pleural abnormalities are evident on this single portable projection.,0
"7:55 AM CATH CHEK/REMV Clip # Reason: Anatomy, tube palcement Admitting Diagnosis: HYPOTENSION Contrast: OPTIRAY Amt: 30 ********************************* CPT Codes ******************************** * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with poss t-tube out of place, please eval for leakge and t-tube placement REASON FOR THIS EXAMINATION: Anatomy, tube palcement ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: 70-year-old man, status post liver transplant, has T- tube in place, the T-tube has fell out of place, needs T-tube cholangiogram to evaluate leakage.",0
PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr. .,0
"Dr. , the attending radiologist, was present and supervising throughout the procedure.",0
The preexisting T- tube was cleaned with alcohol.,0
"Using gravity injection, contrast was visualized to fill the T-tube, common, right and left main bile ducts.",0
"Compared to the prior T- tube cholangiogram which was performed on , the tip of the T- tube is lower than the prior location.",0
"However, there is no leakage of contrast.",0
Contrast was seen passing freely into the small bowel loop.,0
No evidence of biliary stricture.,0
"IMPRESSION: Compared to cholangiogram performed on , the tip of the T-tube is lower than the prior location, but still located in the common bile duct.",0
No evidence of bile leak or biliary stricture.,0
"2:21 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: RECENT BILIARY STENT PLACEMENT WITH INCREASED FEVERS SEPSIS PLEASE EVALUATE RUQ Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with pancreatic mass, biliary sepsis, s/p ERCP with biliary stenting two days ago.",0
REASON FOR THIS EXAMINATION: Please eval for new RUQ pathology.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Pancreatic mass with biliary sepsis, status post ERCP with biliary stenting two days ago, clinically worsened.",0
Evaluate for new right upper quadrant pathology.,0
Comparison is made to prior ultrasound dated and prior portable intraoperative film dated and prior CTA dated .,0
RIGHT UPPER QUADRANT ULTRASOUND: The liver displays no focal masses and unremarkable parenchyma.,0
Again identified is mild prominence to the extra- hepatic biliary system measuring approximately 6 mm and large amount of sludge within the gallbladder.,0
Portal vein is patent with normal hepatopetal flow.,0
"Of note, the recently placed CBD stents were unable to be visualized by ultrasound.",0
IMPRESSION: No significant interval change with no acute pathology identified.,0
11:33 AM PHERESIS CATHETER PLMT Clip # Reason: Needs urgent plasmpharesis Admitting Diagnosis: HYPERTENSION ********************************* CPT Codes ******************************** * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with TTP-HUS and severe preeclampsia.,1
Platlet count 35 and droppping REASON FOR THIS EXAMINATION: Needs urgent plasmpharesis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JVg FRI 3:50 PM PFI: Successful placement of hemodialysis catheter with a third (Brown) port to allow for additional central access.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 30-year-old female pregnant with TTP-HUS and severe preeclampsia with low platelet count.,1
ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl (25 cmcg) over the total intra-service time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored.,0
"PROCEDURE: After risks and benefits of the procedure were explained to the patient, written informed consent was obtained.",0
The patient was brought to the angiography suite and placed supine on the table.,0
The right neck was prepped and draped in standard sterile fashion.,0
A pre-procedure timeout and huddle were performed per standard protocol.,0
The patient was placed in left semi-lateral decubitus position (LPO-).,0
"Under son guidance with hard copy images on file, the right internal jugular vein was cannulated with a 21-gauge micropuncture needle through which a 0.018 wire was advanced into the superior vena cava.",0
The needle was exchanged for a micropuncture sheath.,0
The inner dilator and wire were removed and a short wire was advanced into the inferior vena cava.,0
"Over the wire, sequential dilation was performed up to 14 French and the triple-lumen hemodialysis catheter (including VIP port) was advanced over the wire with tip terminating in the right atrium.",0
The wire was removed and the catheter aspirated and flushed easily.,0
A final fluoroscopic image of the chest was obtained from this location.,0
The catheter was sutured to the skin with 0 silk suture and capped and dressed appropriately.,0
IMPRESSION: Successful placement of a 20 cm temporary hemodialysis catheter via the right internal jugular vein.,0
This dialysis catheter has an additional third (Brown) port for additional access if needed.,0
(Over) 11:33 AM PHERESIS CATHETER PLMT Clip # Reason: Needs urgent plasmpharesis Admitting Diagnosis: HYPERTENSION ______________________________________________________________________________ FINAL REPORT (Cont),0
6:30 AM CHEST (PORTABLE AP) Clip # Reason: routine CXR in intubated patient Admitting Diagnosis: LEFT MAIN STEM OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with left hilar mass and pneumonia.,0
REASON FOR THIS EXAMINATION: routine CXR in intubated patient ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP single view.,0
"INDICATION: Hilar mass and pneumonia, intubated, evaluate for interval changes.",0
FINDINGS: AP single view of the chest is analyzed in direct comparison with the next previous similar study of .,0
"Chest tube, NG tube and right-sided PICC line in unchanged position.",0
Left sizable hilar mass grossly unchanged.,0
No significant interval changes can be identified.,0
Observe the patient is now in supine position and was in AP semi erect position on the previous study.,0
"11:18 PM CHEST (PORTABLE AP) Clip # Reason: r/o CHF, new infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with fungemia, ?crohn's on intermittent steroids with hypercarbic resp failure, wheezing and recently found to have low EF REASON FOR THIS EXAMINATION: r/o CHF, new infiltrate ______________________________________________________________________________ FINAL REPORT Portable chest at compared to previous study of earlier the same day.",0
A left subclavian vascular catheter remains in place.,0
The heart is upper limits of normal in size for technique.,0
There is increasing vascular engorgement and worsening perihilar haziness.,0
There are also confluent areas of consolidation in the lung bases centrally.,0
"There is increasing small right pleural effusion, and there is no change in the small left pleural effusion.",0
"IMPRESSION: Rapidly worsening pulmonary opacities, likely due to pulmonary edema.",0
Underlying infection is not excluded in this patient with history of fungemia.,0
Follow up films are suggested.,0
7:11 AM CHEST (PORTABLE AP) Clip # Reason: Eval for effusion Admitting Diagnosis: BRONCHIAL STENOSIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p bronchoplasty with LLL PNA REASON FOR THIS EXAMINATION: Eval for effusion ______________________________________________________________________________ FINAL REPORT HISTORY: Status post bronchoplasty with left lower lobe pneumonia.,0
Single semi-upright AP view of the chest is compared to .,0
Again seen is an ET tube as well as an NG tube and right chest tube in place.,0
There is persistent and slightly decreased bilateral lower lobe streaky opacities mostly compatible with atelectasis and/or pneumonia.,0
"Again seen is a small right apical pneumothorax, relatively unchanged.",0
Again noted is right rib surgical fracture.,0
Stable tiny right apical pneumothorax.,0
Height: (in) 67 Weight (lb): 185 BSA (m2): 1.96 m2 BP (mm Hg): 119/71 HR (bpm): 70 Status: Inpatient Date/Time: at 10:52 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,1
Moderate AS (area 1.0-1.2cm2) Cannot exclude AS.,0
"Mild (1+) MR. LV inflow pattern c/w restrictive filling abnormality, with elevated LA pressure.",0
There is moderate (low gradient) aortic valve stenosis (valve area 1.0-1.2cm2).,1
The study is inadequate to exclude significant aortic valve stenosis.,1
"5:47 AM CHEST (PORTABLE AP) Clip # Reason: expansion of pleural effusions, edema Admitting Diagnosis: ATRIAL FIBRILLATIOM ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with lymphoma, b/l pleural effusions.",1
"REASON FOR THIS EXAMINATION: expansion of pleural effusions, edema ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 10:36 AM Probable _____ in large right pleural effusion.",1
Stable _____ _____ large left pleural effusion.,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Patient with lymphoma and bilateral pleural effusions.,1
Moderate-large right pleural effusion has increased in size.,1
Moderate-to- large left pleural effusion probably unchanged.,1
"Of note, the lower portions of the hemithorax are not included on the film.",0
Stable moderate cardiomegaly and bibasilar atelectasis.,0
7:35 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: r/o aneurysm ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with SAH with decreasing MS REASON FOR THIS EXAMINATION: r/o aneurysm No contraindications for IV contrast ______________________________________________________________________________ WET READ: 9:20 AM Subarachnoid hemorrhage with aneurysm at origin of left PICA.,1
Dr. discussed with Dr. .,0
-ALee ______________________________________________________________________________ FINAL REPORT EXAM: CTA of the head.,0
CLINICAL INFORMATION: Patient with subarachnoid hemorrhage.,1
"Following this, using contrast administration, CT angiography of the head and neck was performed.",0
FINDINGS: CT HEAD: The CT head demonstrates a subarachnoid hemorrhage in the basal cisterns with blood in the ventricles.,1
There is moderate dilatation of the temporal horns indicating hydrocephalus.,0
There is no evidence of loss of -white matter differentiation seen.,0
CTA OF THE NECK: CTA of the neck demonstrates no evidence of vascular occlusion or high-grade stenosis.,0
CTA OF THE HEAD: CTA of the head demonstrates an aneurysm near the origin of left posterior inferior cerebellar artery.,0
The aneurysm measures approximately 5 mm with its neck inseparable from the origin of the left posterior inferior cerebellar artery.,0
"In the anterior circulation, subtle protuberance of the superior aspect of the left middle cerebral artery is identified which could be due to an infundibulum at the origin of lenticulostriate arteries.",0
"There is a hypoplastic A1 segment of the right anterior cerebral artery, a normal variation.",0
Subarachnoid hemorrhage with signs of obstructive hydrocephalus and intraventricular blood.,1
Normal CTA of the neck.,0
Left posterior inferior cerebellar artery aneurysm with the neck not (Over) 7:35 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: r/o aneurysm ______________________________________________________________________________ FINAL REPORT (Cont) definitely separable from the origin of posterior inferior cerebellar artery.,0
Correlation with cerebral angiography is recommended.,0
9:34 AM CHEST (PA & LAT) Clip # Reason: ?,0
pneumonia Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with s/p whipple with high WBC REASON FOR THIS EXAMINATION: ?,0
pneumonia ______________________________________________________________________________ FINAL REPORT EXAMINATION: Two views of the chest.,0
PA and lateral views of the chest are obtained at 09:44 hours and are compared with the prior radiograph performed on .,0
The nasogastric tube and the right IJ line have been removed since the prior examination.,0
"The lateral view of the chest does, however, appears to show a drain or tube in the upper abdomen anteriorly.",0
There remains bibasilar atelectasis with a right-sided pleural effusion.,0
A left-sided pleural effusion has almost completely resolved.,0
There is no evidence of congestive failure on the current examination.,0
IMPRESSION: Bibasilar atelectasis with persistent right pleural effusion and likely small left pleural effusion.,0
"8:39 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?ptx, effusion Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p R thoracotomy REASON FOR THIS EXAMINATION: ?ptx, effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 1:16 PM There is bibasilar atelectasis.",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: S/P right thoracotomy.,0
There is expected postoperative mediastinal widening.,0
Multiple surgical clips project in the mediastinum on the left.,0
There is no pneumothorax or enlarging pleural effusion.,0
If any there is a small left pleural effusion.,0
There is mild right subcutaneous emphysema.,0
Left subclavian catheter remains in place in unchanged position.,0
BP (mm Hg): 145/70 HR (bpm): 68 Status: Inpatient Date/Time: at 10:50 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,0
[Intrinsic LV systolic function depressed given the severity of valvular regurgitation.],0
The house officer caring for the patient was notified of the results by text page.,0
2.Left ventricular wall thicknesses and cavity size are normal.,0
4.There are simple atheroma in the descending thoracic aorta.,0
6.The mitral valve leaflets are moderately thickened.,0
IMPRESSION: No echocardiographic evidence of endocarditis.,0
3:30 PM CHEST (PORTABLE AP) Clip # Reason: tube placement Admitting Diagnosis: LEFT FEMUR FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: year old man with ETT REASON FOR THIS EXAMINATION: tube placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST .,1
"FINDINGS: Endotracheal tube tip terminates about 3 cm above the carina, nasogastric tube terminates in the stomach and a right internal jugular vascular catheter tip terminates below the expected level of the superior vena cava, right atrial junction, with no pneumothorax.",0
Areas of bibasilar atelectasis have developed as well as small bilateral pleural effusions.,0
"Possibly distended loops of bowel are seen in the imaged portion of the upper abdomen, but are incompletely evaluated on this radiograph.",0
"PATIENT/TEST INFORMATION: Indication: Bubble study, r/o shunt.",0
"Height: (in) 68 Weight (lb): 182 BSA (m2): 1.97 m2 BP (mm Hg): 109/62 HR (bpm): 103 Status: Inpatient Date/Time: at 16:37 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: Saline Technical Quality: Adequate INTERPRETATION: Findings: GENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver.",0
"Conclusions: No definite right-to-left passage of microbubbles identified at rest or with maneuvers (cough, post-Valsalva).",0
The right ventricle is dilated with prominent free wall hypokinesis.,0
5:55 AM CHEST (PORTABLE AP) Clip # Reason: placement of ET tube Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with ARDS and COPD and intubated REASON FOR THIS EXAMINATION: placement of ET tube ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf MON 12:24 PM 1.,0
Increase in moderate right and small-to-moderate left pleural effusions.,1
"Bilateral pulonary opacification likely edema but could also represent aspiration or hemorrhage in the appropriate clinical setting ______________________________________________________________________________ FINAL REPORT INDICATION: COPD and ARDS, intubated, assess placement of endotracheal tube.",0
TECHNIQUE: Supine portable radiograph of the chest.,0
FINDINGS: There has been increase in the moderate right and small-to-moderate left pleural effusion with associated atelectasis.,1
"There is also increase in the opacification of the lungs, right greater than left, with evidence of vascular congestion and hilar opacification, consistent with pulmonary edema.",0
There is stable cardiomegaly with normal cardiomediastinal silhouette.,0
"Endotracheal tube is located 6.9 cm above the carina with stable position of the left IJ, nasogastric tube, and right-sided single-lead pacemaker.",0
Bilateral pulonary opacification likely edema but could also represent aspiration or hemorrhage in the appropriate clinical setting.,0
"Stable position of endotracheal tube, left internal jugular catheter, and nasogastric tube.",1
", R. SICU-A 10:37 AM ABD (SINGLE VIEW ONLY) Clip # Reason: Please evaluate lower abdomen that was not captured on prior Admitting Diagnosis: ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with h/o cirrhosis, unclear if dobhoff out of place.",1
REASON FOR THIS EXAMINATION: Please evaluate lower abdomen that was not captured on prior film to better characterize positive of NG tube-- being used for tube feeds.,0
______________________________________________________________________________ PFI REPORT Feeding tube in post-pyloric position.,0
PATIENT/TEST INFORMATION: Indication: Aortic dissection.,0
Status: Inpatient Date/Time: at 12:20 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Descending aorta intimal flap/aortic dissection.,1
Thickened aortic wall c/w intramural hematoma.,0
A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection.,1
The aortic wall is thickened consistent with an intramural hematoma.,0
There is flow in the false lumen.,0
POST BYPASS: Preserved bivemtricular systolic function.,0
"Tube graft visualiozed in the descending thoracic aortic position, without any evidence of compression/abnormal flow.",0
"2:07 PM CT HEAD W/O CONTRAST Clip # Reason: MENTAL STATUS CHANGE, S/P FALL, ?",0
"BLEED ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with change in mental status, s/p fall.",0
REASON FOR THIS EXAMINATION: eval for bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: RKKR SUN 3:36 PM No bleed or mass effect ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
There is no prior study for comparison.,0
TECHNIQUE: Non-contrast CT images of the head were performed.,0
CT HEAD WITHOUT CONTRAST: There is no intra or extra-axial hemorrhage identified.,0
"The ventricles and sulci are prominent, but appropriate in size for the patient's age.",0
There is no acute major vascular territorial infarction.,0
Periventricular white matter hypodensities consistent with chronic microvascular ischemic/infarction.,0
BONE WINDOWS: Show no suspicious lesions.,0
There is mucosal thickening and near total opacification of the dominant left sphenoid sinus.,0
IMPRESSION: 1) No intracranial hemorrhage or mass effect.,0
2) Mucosal thickening of a left sphenoid air cell.,0
12:40 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: unstable c-spine?,0
Admitting Diagnosis: S/P PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with traumatic head injury.,0
REASON FOR THIS EXAMINATION: unstable c-spine?,0
______________________________________________________________________________ FINAL REPORT INDICATION: Severe traumatic head injury resulting in inability to clinically assess the cervical spine.,0
COMPARISON: No previous cervical spine MRI.,0
"Cervical spine CT dated , is available for correlation.",0
"TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the cervical spine were obtained, with axial T2-weighted and gradient echo images from C2/3 through C7/T1 interspaces.",0
CERVICAL SPINE MRI WITHOUT INTRAVENOUS CONTRAST: The vertebral alignment is normal.,0
"There are no signal abnormalities in the bone marrow, in the spinal ligaments, paraspinal soft tissues, or the spinal cord to suggest acute traumatic injury.",1
"Mildly elevated T2 signal in the paratracheal and paraesophageal soft tissues, which are distinct from the prevertebral soft tissues, is felt to be related to instrumentation and/or secretions.",0
"Spondylosis without significant central canal narrowing is present at C4/5, C5/5, and C6/7.",0
Findings were discussed with Dr. at 6 p.m. on .,0
No evidence of traumatic injuries in the cervical spine.,0
Please note that ligamentous injury cannot be definitively excluded by MRI.,0
Cervical spondylosis without central canal narrowing.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Quetiapine Attending: Chief Complaint: supraglottitis Major Surgical or Invasive Procedure: Emergent Cricothyroidotomy Tracheostomy Placement Mechanical Ventilation PICC line placement History of Present Illness: patient is a 64 yo M with atrial fibrillation on coumadin, transferred from an OSH with respiratory distress due to supraglottic edema.",1
He initially presented to because he was 'spitting up blood' after eating a at his rehab.,0
He was found to have supraglottic edema both on exam and in CT scan.,0
He was transferred to for airway management.,0
Surgery was called for respiratory distress in the ED and performed an emergent crichothyroidotomy in the OR.,0
ENT was consulted and changed the crich to a tracheostomy.,0
Admission labs pertinent for Hct of 50 (down to 33 on transfer) and INR of 3.0 reversed with 6 and 10 mg vitamin K (given at OSH) down to 1.6.,0
"Past Medical History: - Atrial Fibrillation (on coumadin) - s/p Pacer ( DDD) - COPD - Hypertension - PVD s/p Aortobifemoral bypass - Hyperlipidemia - Chronic liver disease EtOH (sober since ) - Anemia: h/o maroon stools colonoscopy in with hemorrhoids, colon polyps, adenoma - h/o epistaxis .",1
Social History: Social History: - unemployed.,0
Has a scooter at home.,0
Short term rehab resident at Healthcare in .,0
"health care proxy is his friend , (c) , (h) .",0
"- Tobacco: +1.5 ppd, no plans for quitting - Alcohol: per records, hx of heavy EtOH use but was abstaining from EtOH since .",0
- Illicits: none Family History: Family History: father and mother both died of CAD Physical Exam: Vitals: 99 132/54 (90 non-invasive) 20 100% on trach collar.,0
"General: elderly M with trach Alert NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: slight expiratory wheeze with otherwise clear breath sounds CV: distant HS, tachycardic, irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, TTP in LUQ and LLQ, non-distended, bowel sounds present, no rebound tenderness or guarding; bruises noted over bilateral lower quadrants.",0
"GU: no foley Ext: limbs cool to touch BL with 1+ DPs, PTs bilaterally; hair loss.",0
Moving all lower and upper extremities to command.,0
Pertinent Results: Images: CXR () - FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position.,0
Image field directed towards upper abdomen on purpose so to identify Dobbhoff line which is seen to be located in stomach pointing towards pylorus and duodenum but not having passed of yet.,0
This image has been obtained to complement a previous chest examination obtained two hours earlier.,0
"CT neck (OSH on ): Impression: Edema of the epiglottis, the R lateral oropharynx and the hypopharynx.",0
Mild narrowing of the supraglottic airway.,0
CT neck () IMPRESSION: 1.,0
Significant decrease in right supraglottic edema since .,0
"While no definite underlying mass is seen, a mass is difficult to exclude.",0
"Numerous lymph nodes at levels 1, 2 and 3, right greater than left, not pathologically enlarged by CT size criteria.",0
"Near-complete opacification of the paranasal sinuses, which may be related to the known nasal packing.",0
1 cm cystic lesion with wall calcifications in the left vallecula.,0
"Recommend direct visualization, when feasible.",0
CT Chest () FINDINGS: .,0
The patient is intubated through tracheostomy.,0
"For precise evaluation of the neck and the area of the glottis, please review CT of the neck obtained the same day and the corresponding report.",0
A central venous line terminates at the cavoatrial junction.,0
Pacemaker leads terminate in right atrium and right ventricle.,0
Aorta and pulmonary arteries are normal in diameter.,0
Extensive coronary calcifications are present.,0
"The evaluation of the airways demonstrate patent trachea, right and left main bronchi as well as the upper lung lobe and right middle lobe bronchial tree.",1
"Within the lower lobe, there are bibasal consolidations, with air bronchogram on the right and minimal air bronchogram on the left.",0
"Giving their relatively high enhancement, they most likely represent areas of atelectasis, but bibasilar infectious process cannot be excluded and it is accompanied by small amount of pleural effusion.",0
The upper lungs are essentially clear.,0
"Severe emphysema is involving the upper lobes, a combination of centrilobular and panlobular type.",0
The imaged portion of the upper abdomen demonstrates small degree of ascites.,0
"Sludge within the gallbladder is noted, but with no evidence of cholecystitis.",0
"The pancreatic duct is dilated up to 9 mm, the reason is unclear, and the pancreas is partially imaged.",0
"Significant lymphadenopathy is noted in the area of the celiac trunk bifurcation up to 14 mm, and might reflect both neoplastic or infectious etiology.",0
"Adrenals, imaged portion of the kidneys, spleen, and imaged portion of the liver are unremarkable.",1
"Extensive degenerative changes are present in the spine, but there are no lytic or sclerotic lesions worrisome for neoplasm or infection.",0
"Lateral view demonstrates wedge compression fracture of upper lumbar vertebral body, chronicity undetermined.",1
EGD (): Findings: Esophagus: Mucosa: Abnormal mucosa was noted throughout the esophagus.,0
There was 3 inches of circumferential dark mucosa starting at the GE junction.,0
Proximal to that in the distal and mid esophagus there are patchy areas of dark mucosa.,0
"it has an ischemic appearance, and most consistent with ischemic injury.",0
There is also evidence of punctate and patchy erythema consistent with esophagitis.,0
Stomach: Mucosa: Patchy discontinuous erythema of the mucosa with no bleeding was noted in the whole stomach.,0
These findings are compatible with gastritis.,0
Impression: Abnormal mucosa in the esophagus Erythema in the whole stomach compatible with gastritis Otherwise normal EGD to third part of the duodenum Recommendations: Would check H. Pylori serologies and treat if positive.,1
ENT has performed upper airway endoscopy and found no obvious upper airway source of bleeding and deemed that his supraglottic edema has resolved on neck CT compared to OSH CT. All oropharyngeal packing removed on .,0
Sputum cultures noted to have M. cattarhalis.,0
He was initially treated with Vancomycin/Unasyn but developed a rash on his abdomen.,0
He is currently being treated with Cipro/Flagyl (Vancomycin d/c-ed) and has received 7 days of antibiotic treatment to date.,0
No signs of deep space neck infection on CT scans.,0
He has been weaned to trach collar and tolerated it for 12 hours prior to being put on PS 5/5 last night for tachycardia and hypertension in the setting of agitation/delerium.,0
He has been guiac positive for several days.,0
His Hct has been stable between 33 and 37 without requiring any blood transfusions.,0
"Pacer interrogated by EP on , functioning well.",0
He was started on a heparin gtt yesterday by the SICU team for atrial fibrillation.,1
"Dobhoff was placed yesterday, was not migrated post-pyloric but TFs were started anyway.",0
"There is a note of history of PE on ENT/surgery admission notes, but this is not confirmed in his PCP (PCP has been called for further confirmation).",0
"The morning of transfer, the patient was noted to have 700 ccs of coffee ground emesis.",0
"When he vomited this morning, the Dobhoff came out was replaced with TFs.",0
Overnight he was also noted to be slightly hypertensive and tachycardic and was transferred back from trach collar to pressure support.,0
His stools were guiac positive.,0
"NG was placed, and lavage performed demonstrated 240 ccs of bilious fluid with specks of brown, no pink tinge or blood noted.",0
GI was consulted and plan to perform an upper endoscopy today.,0
"He was slightly hypotensive to SBPs of 90s, but was urinating and mentating well.",0
Responded well to 500 cc NS bolus x1.,0
He was transferred to the MICU for management of possible upper GI bleed.,0
"MICU stay: 68 yo M with AF on coumadin p/w respiratory distress, found to have supraglottic edema currently s/p tracheostomy.",1
Transferred to MICU service with question of upper GI bleed.,0
"# GI Bleed: Patient transferred to MICU service for evaluation of possible upper GI bleed given history of hemetemesis on admission, anticoagulation with heparin gtt, and coffee ground emesis.",0
NG lavage without frank blood or pink tinge.,0
"Possible patient had upper GI bleed in setting of recent Dobhoff placement (not passed post-pyloric, but was receiving TFs) and recent heparin gtt being restarted vs old blood passing from recent upper airway bleeding.",0
Also with hx of EtOH abuse in the past.,0
Colonoscopy in with history of polyps/adenomas per PCP .,0
Endoscopy performed by GI confirms gastritis but with no active bleeding or varices noted.,0
"Throughout MICU stay, HCT has been stable without the need for transfusions.",0
Pt has PICC for access.,0
On pt did have a leak from his trach and had a bronchoscopy done.,0
His trach was pushed in about 1 cm and the leak resolve.,0
# Pseudomonas bacteremia: Patient with rising temperature on transfer to 100.,1
Also with increased secretions around trach.,0
Treated for 7 days with Cipro/Flagyl.,0
"Cultures grew Pseudomonas from sputum, catheter tip, and blood, sensitive to cefepime.",0
"Rash to unasyn, on cefepime .",0
# Hematuria on : Likely traumatic.,0
"# Supraglottic edema/ Respiratory distress: Could have occurred in setting of upper airway infection (possibly M. cattarhalis PNA, common in patients with COPD).",1
Other etiologies include a viral illness given evidence of abdominal and cervical LAD on imaging.,0
No evidence of abscesses noted.,0
He has received 7 days of antibiotics.,0
Supraglottic edema appears resolved on .CT scan and all oropharyngeal packing has been removed.,0
Pt is on sildenafil for pulmonary htn.,0
On his trach was downsized.,0
# MCAT in sputum: Received 7 days of abx with Vanc/Cipro/Flagyl.,0
# Delirium: Patient noted to be agitated at night while on trach collar alone requiring placement back on PS overnight initially.,0
be in setting of prolonged hospitalization vs underlying infection.,0
"Patient appears alert and oriented today, communicating with team.",0
"Pt did pull out his dobhoff 2-3 times, but not in the last few days.",0
2 mg of Haldol and ativan prn was used for his agitation.,0
This regimen has worked well.,0
# Atrial fibrillation/wide complex: CHADS2 score is 1 (at minimum).,1
Evaluate need for anti-coagulation with Coumadin given CHADS2 score.,0
Increased metoprolol to 50 mg tid.,0
# COPD: Unknown severity but with emphysema on CT scan.,0
MCAT growing in sputum which is common organism found in PNA patients also with underlying COPD.,0
Received 7 days of Vancomycin/ Ciprofloxacin/ Flagyl.,0
# PVD: history of on ASA/plavix at home.,0
Holding all anticoagulation now in setting of possible bleed.,0
Restarted ASA 81 mg # Abdominal/Cervical LAD: sub-pathologic LAD noted in cervical area and also around celiac trunk.,0
Likely infectious given patient's recent supraglottic edema.,0
f/u CT scanning is needed in weeks.,0
# Wedge fractures - Noted in lumbar region on CT scan.,0
Likely in setting of previous prednisone use from COPD.,0
"has hx of colon adenomas, but no known history of lung, thyroid, renal, or prostate cancer which can metastazize to bone -> pathologic fracture.",1
Neurologic exam intact in lower extremities.,0
"calcium 500 mg PO TID, vitamin D 1000 U daily.",0
vitamin D levels need to bechecked as outpatient.,0
# HTN: metoprolol to 50 mg tid #Right arm : U/S with no evidence of DVT Medications on Admission: Imdur 30 mg PO daily Plavix 75 mg PO daily Simvastatin 80 mg PO daily Advair 250/50 1 puff Viagra 50 mg PO daily (except Thursday) Digoxin 0.125 mcg PO daily Coumadin 7.5 mg PO daily Lopressor 50 mg PO BID ASA 325 mg PO daily Albuterol 90 mcg INH 2 buffs Florinef 1 mg PO daily Famotidine 20 mg PO daily KCL 20 mEq PO BID Folic Acid 1 mg PO daily Vitamin B12- 100 mc PO daily Discharge Medications: 1.,0
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily).,0
Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day).,0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day).",0
Sildenafil 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing, sob.",0
Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours).,0
Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours).,0
Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed for agitation.,0
Discharge Disposition: Extended Care Facility: - - Discharge Diagnosis: Supraglottic Edema Hypoxic Respiratory Distress Upper Gastrointenstinal Bleed Pseudomonas Bacteremia Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted with in your throat that was compromising your breathing.,0
"You had an emergent breathing tube placed in your neck known as a tracheostomy, placed by Ear, Nose, and Throat Doctors.",0
improved and you have been weaned from the ventilator.,0
You also had a possible GI bleed and had an endoscopy by our GI doctors which did not show any active bleeding or need for intervention.,0
Please start the following medications: Please stop the following medications: Followup Instructions: Please follow up with Dr. on Thursday at 10:30 am.,0
Please bring your insurance card and a photo ID.,0
"Phone Number -- ( Office Location: , , Division: Completed by:",0
1:01 PM ILIAC Clip # Reason: Eval R hip vessels and embolization prn Admitting Diagnosis: HIP PAIN Contrast: OPTIRAY Amt: 150 ********************************* CPT Codes ******************************** * INITAL 3RD ORDER ABD/PEL/LOWER INITAL 2ND ORDER ABD/PEL/LOWER * * PELVIS SEL/SUPERSEL A-GRAM EA ADD'L VESSEL AFTER BASIC A- * * EXT BILAT A-GRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 56/M s/p R THA c/b hematoma.,1
Now s/p R hip evacuation hematoma POD0 - active bleeding in OR which was controlled at the time of closure but please eval for recurrence and embolize if needed.,0
REASON FOR THIS EXAMINATION: Eval R hip vessels and embolization prn ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old patient status post total hip replacement and presentation with gluteal hematoma about 10 days after surgery.,1
Surgical evacuation of hematoma with intraoperative finding of active bleeding which was controlled at the time of closure.,1
Evaluation for source of hemorrhage such as pseudoaneurysm.,0
"CLINICIANS: Dr. (fellow), Dr and Dr. performed the procedure.",0
ANESTHESIA: Analgesia was provided by divided doses of 100 mcg of fentanyl.,0
PROCEDURE DETAILS: Informed consent was obtained outlining the risks and benefits of the procedure.,0
The left groin was prepped and draped in the usual sterile fashion.,0
"A left common femoral artery access the selected given the exam indications Using the micropuncture Seldinger approach, access was obtained into the left common femoral artery.",0
"After placing a 0.035 wire over the micropuncture sheath, the latter was exchanged for a 25cm 5 French bright tip vascular sheath.",0
A Cobra catheter was then used to cross over to the right common iliac artery and then exchanged for a straight flush catheter.,0
A selective external iliac arteriogram was performed in multiple projections at this point.,0
"Following review of the images attention was then turned to the internal iliac artery With the help of a Terumo Glidewire, the internal iliac and more selectively the posterior division (superior gluteal arteries) were then selected and additional arteriograms performed.",1
Given the normal angiographic appearance no intervention was required .,0
"The (Over) 1:01 PM ILIAC Clip # Reason: Eval R hip vessels and embolization prn Admitting Diagnosis: HIP PAIN Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) wires, catheters and the sheaths were finally removed and hemostasis achieved by holding pressure at the left groin for 20 minutes.",0
"FINDINGS: Internal iliac, external iliac, and selective superior gluteal arteriograms in multiple projections demonstrated expected mild hyperemia involving the surgical site following right total hip arthroplasty No active contrast extravasation, vascular malformation or pseudoaneurysm identified.",1
"IMPRESSION: Uncomplicated internal iliac, external iliac and selective superior gluteal arteriograms with expected postoperative hyperemia, but no evidence of active contrast extravasation, vascular malformation or pseudoaneurysm.",1
"Findings were conveyed to ANP, immediately following the procedure.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin / Lasix Attending: Chief Complaint: left hand weakness Major Surgical or Invasive Procedure: Cervical embolization C7 Corpectomy PICC line placement bronchial artery embolization History of Present Illness: This is a 53 yo female with a past medical history metastatic RCC, diagnosed 2 years ago, with brain and lung mets s/p nephrectomy and chemo, most recently on experimental protocol, s/p bronchial stenting on , now with respiratory decompensation, hemoptysis, found to have occlusion of right side of stent by tumor growth, brought to IR today for bronchial artery embolization.",1
"Prior to this admission, the patient presented with LUE weakness after a visit to her chiropractor, s/p nephrectomy and chemotherapy, and was found to have a pathologic fracture of C7.",1
"She was brought for embolization of tumor and C7 corpectomy (received solumedrol for cord compression), however, after this procedure, her course was c/b post-op inability to move any extremities.",0
MRI showed no compression but edema of C2-T1.,0
"On , she was intubated for respiratory distress with SBP 70s, HR 130s, and she was started on Diltiazem gtt with Neo for SVT with hypotension.",1
"She also underwent a right sided thoracentesis on with 700cc removed, and broad spectrum antibiotics were started for fevers and empiric tx for VAP.",0
"She was extubated on , but then had a witnessed localized motor seizure and was started on dilantin which was transitioned to keppra.",0
"Over the next several days, her respiratory status appeared worse, and underwent another bronchoscopy on secondary to right lung collapse.",1
"At this time, the patient was considering transition to hospice, but then her respiratory status began to improve, and she regained some mobility in her arms and legs and decided she preferred to proceed to rehab instead.",0
"She was to be discharged on , when she suddenly began to have increasing respiratory distress.",0
"She was taken by IP for flexible bronch for therepeutic aspiration of secretions and visualization of Y stent, where it was discovered that, after therapeutic aspiration was performed, the left limb of the Y-stent was patent without endobronchial lesions or active bleeding, however, on the right side, there was a tumor ingrowth to the distal end of the stent which was approximately 90% occlusive.",0
This area was extremely friable and was the source of bleeding.,0
She was then taken by IR for out of concern for continued bleeding.,0
She was then transferred to the MICU from IR for monitoring s/p .,0
At night has anxiety induced dyspnea where she is placed on NRB and given ativan.,0
"On a CXR showed complete opacification of right hemithorax, likely a combination of atelectasis and fluid due to lack of signicicant midline shift (overall slight leftward shift) concerning for blood as patient is status-post embolization.",0
IP then spirated long obstructing blood clot from R main stem beginning at level of tumor.,0
She was then stable in the ICU and transferred to OMED for further observation.,0
Past Medical History: : Intermittent hematuria with urinalysis positive for e.coli and was treated with antibiotics :Symptoms recurred and a CT was performed on which revealed a 13.8 cm mass in the right kidney with cystic and solid components.,1
"CT of chest revealed multiple bilateral lung nodules, highly concerning for metaastic disease & retroperitoneal adenopathy : Right nephrectomy, clear cell histology, nuclear G3, LVI present with gross invasion into renal vein, invades renal capsule but not beyond capsule, 12 cm, pT3b, Nx M1 : CT torso with pulmonary disease progression; head CT negative.",1
consult with Dr. ; HD IL-2 therapy recommended.,0
Cardiology consult obtained due to h/o SVT & bigemingy and cleared for treatment; signed consent for 06-149 in ; HD IL2 Select : C1 Wk 1 HD IL2; doses; low-dose diltizaem with telemetry monitoring due to h/o SVT.,0
"Doses held for GI issues, confusion & fatigue.",0
"Additional side effects included rash, flu symptoms, arthralgias, headache, rigors, mucositis, ARF, metabolic acidosis responsive to repletion, hyperbilirubinemia, transaminitis & anemia/thrombocytopenia without transfusion requirement.",0
"Developed hives from Lasix after discharge : C1 Wk 2 HD IL2; doses with doses held for fatigue, flu symptoms, GI side effects, mucositis & fatigue.",0
"Additional side effects included N/V/D, rash, ARF, oliguria, hyperbilirubinemia & anemia.",0
"Telemetry monitoring throughout admission with SR noted and occasional PVC : CT with decrease (30%) in pulmonary disease; small pericardial effusion : CT with stable disease (wk 11 CT) : C2 Wk 1 HD IL2; doses with doses held for shock, flu symptoms & pt request for cumulative side effects.",1
"She also developed hypotension r/t CLS requiring vasoprssor BP support, N/V, rash, fatigue, mucosiits, ARF, oliguria, metabolic acidosis responsive to repletion, hyperbilirubinemia, anemia & thrombocytopenia.",1
"Telemetry monitoring demonstrated occasinal PVC : C2 Wk 2 HD IL-2; doses with doses held for shock, & recurrent hypotension r/t CLS requiring Neo-synephrine support.",0
Telemetry demonstrated NSR with occasional APCs & a short 5 beat run of SVT.,0
"Photodynamic therapy scheduled followed by debridement with rigid bronchoscopy : Rigid bronchoscopy; flexible bronchoscopy, RUL tumor destruction with cryo probe; tumor ablation with argon plasma coagulation : Flexible bronchoscopy; mechanical debridement & cryotherapy of RUL : Echo revealed small to moderate pericardial effusion with right atrial mass at the IVC-RA junction most likely representing tumor; admitted for evaluation & further w/u to determine if mass is a blood clot or tumor.",0
CT torso revealed no evidence of right atrial thrombus/mass but a conglomerate nodal mass in the azygo-esophageal recess near the junction of the IVC & RA.,0
She was hemodynamically stable & d/c home on wtih a plan to perform cardiac MRI to determine location of thrombus/mass : Cardiac mass identified in RA & in IVC; started on Sutent therapy soon after (~ ) : Flexible bronchoscopy for cough & hemoptysis : Signed consent for 08-313; RAD Biomarker trial : Cycle 1 Day 1 RAD001 (Everolimus) .,0
"PSH: c-section, right nephrectomy, multiple bronchs with RUL and tracheal cryotherapy and ablations, left knee surgery Social History: The patient is a school nurse .",0
"She is married with two children, a son aged 24 and a daughter aged 21.",0
She is a former smoker having smoked approximately one to one and a half packs per day for 10 years but quit 25 years ago.,0
She drinks alcohol very rarely.,0
She denies illicit drug use.,0
Family History: The patient says that one of her first cousins was diagnosed with a renal cell carcinoma.,0
Her father died of testicular cancer in his late 20s.,0
Her mother died of lymphoma at age 68.,0
Her maternal grandfather died of lung cancer but he was a smoker.,0
A paternal aunt has breast cancer and died at the age of 44.,0
"The paternal cousin had breast cancer at age 40 Physical Exam: Vitals: T:97.5 BP:118/70 P:98 R: 18 O2: 92NRB General: Alert, oriented, mild respiratory distress HEENT: Sclerae anicteric, MM dry, oropharynx clear with dried blood on teeth Neck: supple, JVP not elevated, no LAD Lungs: Loud upper airway rhonchi with obvious secretions CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds quiet, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ pulse in right, 1+ in left, no clubbing, cyanosis.",0
"1+ edema b/l Neuro: Pt unable to move left leg, can wiggle toes on right foot only.",0
Can move proximally fairly well in the upper extremities with 4-/5 strength on the left and 4/5 strength on the right.,0
CN II-XII in tact bilaterally.,0
Pertinent Results: MRI : 1.,0
Pathological compression fracture of C7 with associated retropulsion causing moderate spinal canal narrowing and mild compression of the cord with no abnormal cord signal intensity.2.,1
"Extensive enhancement in the left anterolateral epidural space extending from C6-T1 with associated involvement of the left C6/C7 and C7/T1 neural foramina Pathology Examination SPECIMEN SUBMITTED: C7 Tumor, posterior longitudunal ligament.",0
Procedure date Tissue received Report Date Diagnosed by DR. /ttl Previous biopsies: TRACHEAL TUMOR.,0
"C7 tumor, resection (A-B): Clear cell neoplasm consistent with known metastatic renal cell carcinoma.",0
"Ligament, posterior longitudinal (C):Collagenous material invaded by clear cel neoplasm consistent with known metastatic renal cell carcinoma.Clinical: Collapsed C7 vertebrae.",1
"Gross: The specimen is received fresh in two parts, both labeled with the patient's name, "" "" and the medical record number.",0
"Part 1 is additionally labeled ""C7 tumor.""",0
It consists of multiple fragments of bone and attached soft tissue that measure 3.5 x 3.0 x 1.0 cm in aggregate.,0
The specimen is represented in A-B which are submitted for decalcification prior to processing.,0
"Part 2 is additionally labeled ""posterior longitudinal ligament.""",0
It consists of a 2.0 x 1.2 x 0.5 cm piece of pink soft tissue with focal hard areas that are entirely submitted in C prior to processing.,0
"Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of 9:06 PM Final Report EXAM: CT of the chest, .",0
"INDICATION: Metastatic renal cell carcinoma, with increasing hypoxia and hypotension.",0
"COMPARISON: Multiple priors, most recently torso CT from .",0
CTA CHEST: There is no pulmonary embolism.,0
Thoracic aorta is normal in caliber and contour throughout.,0
"Right pleural effusion has increased in size, now moderate.",0
Small left pleural effusion is new.,0
Extensive mediastinal lymphadenopathy is not significantly changed.,0
"Large conglomerate nodal mass in the right upper paratracheal area is grossly unchanged, now measuring 6.2 x 4.8 cm (previously 6.2 x 5.1 cm).",0
Large subcarinal and bulky right hilar lymphadenopathy is not significantly changed.,0
AP window lymph node is stable in size.,0
Partial occlusion/invasion of the superior vena cava is unchanged.,0
"A tracheal Y-stent has been placed since previous CT, which is patent.",0
"There is apparent slight narrowing of the right upper lobe bronchus (3, 44) which appears increased since previous exam.",0
"Right main pulmonary artery passes directly through the conglomerate lymphadenopathy, but is not attenuated.",0
Small pericardial effusion is unchanged.,0
Multiple parenchymal nodules and pleural-based nodules are not significantly changed.,0
Moderate right basilar atelectasis is new.,0
"Scattered small centrilobular ground-glass and semi-solid nodules in the left lower lobe, and in portions of the anterior right upper lobe, and superior segment of the right lower lobe may represent small foci of infection or aspiration.",0
This study is not specifically tailored for subdiaphragmatic evaluation.,0
Limited views of the upper abdomen show multiple foci of early arterial hyperenhancement in the liver parenchyma which have not been visualized on previous imaging (though there is no prior imaging) which includes an early arterial phase for direct comparison.,0
"Partially imaged hardware is seen at the site of recent C7 corpectomy, bone graft, and plating, at the location of known pathologic fracture, which is better evaluated on recently performed MRI of the cervical spine.",1
There is no other definite osseous lesion suspicious for malignancy.,0
"Increased pleural effusions, right greater than left.",0
"No significant change in widespread pulmonary/pleural, and mediastinal metastases.",0
Unchanged thrombus/partial occlusion of the superior vena cava.,0
Multiple small foci of early arterial hyperenhancement in the liver.,0
"Given absence of prior arterial phase imaging for comparison, it is unclear if this is a new finding.",0
"Most likely, these represent hemangiomas, but if there are liver function abnormalities, or clinical concern for liver metastases, abdominal ultrasound could be performed for correlation.",0
"ECHOCARDIOGRAPHY REPORT , Portable TTE (Complete) Done at 4:02:43 PM FINAL Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Stroke Volume: 48 ml/beat Left Ventricle - Cardiac Output: 3.87 L/min Left Ventricle - Cardiac Index: 2.00 >= 2.0 L/min/M2 Aortic Valve - LVOT VTI: 19 Aortic Valve - LVOT diam: 1.8 cm Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.29 Mitral Valve - E Wave deceleration time: 199 ms 140-250 ms Findings Patient hypotensive on Phenylephrine 1 mcg/kg/min RIGHT ATRIUM/INTERATRIAL SEPTUM: RA mass.",0
GENERAL COMMENTS: The patient was sedated for the TEE.,0
"Conclusions Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%).",0
A homogeneous mass measuring 2.2x1.9 cm is seen in the IVC/right atrium junction.,0
"Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of 1:09 PM Final Report FINDINGS: Previously seen spinal cord edema expansion, spanning C2 through 7 levels has increased in the interval.",0
"At C4-5 level, there is a focal area of restricted diffusion with low signal on ADC map, highly concerning for cord infarction.",0
The appearance of the cervical spine with the corpectomy is not changed from the recent prior study.,0
IMPRESSION: Findings concerning for cord infarction at C4-5 level.,0
", F 53 Radiology Report CHEST (PORTABLE AP) Study Date of 4:31 AM , SICU-A 4:31 AM CHEST (PORTABLE AP) Clip # Reason: Resolution of PNA?",0
MEDICAL CONDITION: 53 year old woman with vent associated PNA- now extubated REASON FOR THIS EXAMINATION: Resolution of PNA?,0
Provisional Findings Impression: MLKb SAT 10:59 AM New collapse of RUL.,0
Interval improvement of right lower lung opacity.,0
"Final Report HISTORY: 53-year-old female with vent-associated PNA, now extubated.",1
"COMPARISON: Multiple prior studies, most recent chest radiograph on .",0
PORTABLE AP CHEST RADIOGRAPH: Interval development of collapse of the right upper lobe.,0
Previously seen mediastinal mass contours are obscured by the lung collapse.,0
Interval left lower lobe collapse is unchanged.,0
Right basilar opacity has improved.,0
Left pleural effusion appears to have improved.,0
"DR. DR. , F 53 Radiology Report CHEST (PORTABLE AP) Study Date of 3:00 AM , SICU-A 3:00 AM CHEST (PORTABLE AP) Clip # Reason: Assess lung fields MEDICAL CONDITION: 53 year old woman with metstatic renal cell CA with lung mets REASON FOR THIS EXAMINATION: Assess lung fields Final Report REASON FOR EXAMINATION: Evaluation of the patient with metastatic renal cell cancer to mediastinum and lungs.",0
There is slight interval improvement in the right basal opacity.,0
Mediastinal widening has increased most likely due to a combination of mediastinal lymphadenopathy and recurrent partial atelectasis of the right upper lung.,0
The bilateral pleural effusions and left retrocardiac opacity are unchanged.,0
"DR. Approved: WED 1:39 PM , F 53 Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of 9:11 AM , SICU-A 9:11 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: evaluate swallow MEDICAL CONDITION: 53yF p/w LUE weakness after visit to chiropractor, h/o metastatic RCC diagnosed 2y ago, w/pulmonary, trachea, & brain lesions, s/p nephrectomy and chemotherapy, recently found to have pathologic fracture of C7 s/p embolization of tumor and C7 corpectomy (received solumedrol for cord compression) c/b post-op inability to move any extremities, MRI showed no compression but edema of C2-T1.",1
REASON FOR THIS EXAMINATION: evaluate swallow Final Report HISTORY: Evaluate swallowing in patient status post C7 corpectomy with postop inability to move any extremities.,0
VIDEO OROPHARYNGEAL SWALLOW COMPARISONS: None.,0
"FINDINGS: In collaboration with speech and swallow pathology, barium of various consistencies was orally administered to the patient during continuous fluoroscopic evaluation.",0
There is free passage of orally administered material from the oropharynx into the proximal esophagus without evidence for holdup.,0
There was trace penetration and aspiration of thin liquids.,0
"A nasogastric tube is present in the patient's esophagus, which may have slightly impaired swallow function.",0
IMPRESSION: Trace penetration and aspiration of thin liquids.,0
"For full details including treatment recommendations, please refer to speech and swallow pathology note from the same day.",0
"DR. DR. Approved: FRI 12:38 PM PULMONARY ANGIO Study Date of 3:12 PM Right mediastinum metastatic tumor fed by branches of right bronchial artery, which was completely embolized with 300-500 micrometer Embospheres and three 2 mm x 4 cm coils.",0
CXR Final Report REASON FOR EXAMINATION: Shortness of breath.,0
Portable AP chest radiograph was compared to prior study obtained the same day earlier at 04:26 a.m.,0
There is no change in the right upper lobe collapse accured in the meantime interval.,0
"The multiple pulmonary nodules, bilateral pleural effusions, and bibasal consolidations are unchanged as well.",0
After hospitalization it was revealed that the pt had an outpt bronchoscopy that left her with some upper extremity weakness x 1 week.,0
She then sought chiropractic care for neck pain that left her with some LUE weakness.,0
Imaging of the cervical spine revealed C7 pathological fracture renal cell mets.,1
After she was admitted she was placed in a hard collar.,0
She was readied for the OR and on went to neuro interventional radiology for pre-op embolization prior to OR.,0
After the embolization she remained intubated but appeared to have left leg weakness.,0
Her sedation was lightened on the way to the OR and she was unable to move all 4 extremities.,0
She was then placed in traction in OR and underwent C7 corpectomy.,0
She was also started on solumedrol protocol for spine injury.,0
She tolerated the procedure and was kept intubated and transferred to PACU where she remained overnight for close monitoring.,0
She also underwent MRI of brain which demontrated the following: metastasis in the left frontal lobe and left occipital lobe.,0
Tiny areas of acute infarct in the cerebellum seen as restricted diffusion.,0
Normal MRA of the head.,0
She also underwent MRI c-spine which showed increased signal within the spinal cord from C2-T1 level could be due to ischemia or cord edema.,0
Status post corpectomy of C7 with normal alignment of the vertebral bodies.,0
Decrease in size of the left paraspinal mass related to surgery and embolization.,0
On the first post-op morning her motor exam improved slightly and she was moving her right arm with slight movement left hand/wrist.,0
Dressing was clean and dry.,0
was extubated and then re-intubated secondary to failure to clear secretions.,1
Two days later she was started on broad spectrum antibiotics for fevers and empiric coverage of VAP.,0
Family meeting held to decide on another trial of extubation and then trach if needed.,0
No further oncological treatment offered.,0
Pt aware and agrees with this plan.,0
The patient was successfully extubated a few days later and is tolerating a face tent for oxygenation.,0
On the patient was observed to have some focal motor seizures characterized by arm tremmors.,0
She required frequent bolus' of dilantin and was transition to Keppra for sz control.,0
She was seen by speech therapy and was ultimately cleared for a diet after extubation and when she was able to tolerate it safely.,0
In the meantime she was fed via NGT.,0
Her respiratory status was fluctuating and there was some discussion as to if the pt should be electively trached if she required reintubation.,0
Ultimately she did not require reintubation so this became a mute point.,0
She did express that she did not want hospice and that she would like to pursue agressive therapy and be transferred to rehab.,0
She was bronch'd on the for increasing RLL infiltrates and right lung collapse.,0
Neurologically she improved in her upper extremity exam with more stength proximally than distally.,0
Her lower extremity exam has remained poor.,0
Ultimately her respiratory status improved so that she could tolerate a video swallow eval.,0
Her NGT was removed and she was placed on thin liquids and moist ground solids.,0
Nutrition consult was obtained to assess caloric intake.,0
She was re-seen by Interventional Pulmonary to assist in clearing of her secretions on .,0
During their procedure they noted that the right mainstem bronchus was 50% occluded around the 13th and now is 60-80% occluded with blood clots overlying the protruding mass.,0
No intervention was performed during the procedure.,0
"The IP attending discussed course of action with pt, husband and children.",0
They would like to move forward with treatment of bronchial obtruction.,0
Her lovenox was discontinued in prep for intervention.,0
IR consult for embolization was called as well as RT consult for RT to mass.,0
This was discussed with family and performed .,0
Pt and family also decided upon DNR/DNI after long discusssion.,0
Pt was transferred to MICU after the procedure.,0
"After much thought, the family reconsidered code status and made the patient full code.",0
She then had a bronchial artery embolization and was then transferred to the MICU from IR for monitoring.,0
"On a CXR showed complete opacification of right hemithorax, likely a combination of atelectasis and fluid due to lack of signicicant midline shift (overall slight leftward shift) concerning for blood as patient was status-post embolization.",0
"She again had respiratory distress and was transferred back to the ICU, until finally, she decided to be CMO and was transferred back to the OMED service.",0
She then had respiratory depression/failure and passed away at 5:59PM on .,1
"Medications on Admission: BENZONATATE - 100 mg Capsule - 1 (One) Capsule(s) by mouth twice a day as needed for cough - No Substitution BENZONATATE [TESSALON PERLES] - 100 mg Capsule - 1 (One) Capsule(s) by mouth three times a day as needed for cough - No Substitution CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth DILTIAZEM HCL - (Prescribed by Other Provider) - 240 mg Capsule, Sust.",0
Release 24 hr - 1 Capsule(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - Tablet(s) by mouth every six hours as needed for nausea/sleep LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 0.5 mg Tablet - 0.5-1 Tablet(s) by mouth twice a day as needed OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - Tablet(s) by mouth every 6 hours as needed for pain RAD 001 - (Prescribed by Other Provider) - Dosage uncertain TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for pain Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider; Pt reports taking.),0
- 325 mg Tablet - Tablet(s) by mouth as needed for discomfort.,0
"DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 100 mg Capsule(s) by mouth as needed for constipation GUAIFENESIN [MUCINEX] - 1,200 mg Tab, Multiphasic Release 12 hr - 1 (One) Tab(s) by mouth twice a day - No Substitution IBUPROFEN [ADVIL] - (Prescribed by Other Provider) - 200 mg Tablet - 200-400 mg Tablet(s) by mouth as needed for pain Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired",0
"5:22 PM PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # Reason: eval stent and anastomosis with KUB Admitting Diagnosis: BLADDER TUMOR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with COPD, intubated POD#0 s/p radical cystectomy and neobladder rec'd 5L fluid in OR with stent placed ureteroilieal anastamosis REASON FOR THIS EXAMINATION: eval stent and anastomosis with KUB ______________________________________________________________________________ FINAL REPORT INDICATION: Radical cystectomy with ureteroileal anastomosis.",0
ABDOMEN SUPINE: Multiple surgical clips are seen in the pelvis.,0
A surgical drain is visualized in the right hemipelvis.,0
Three tubes are seen overlying the mid abdomen.,0
There is normal bowel gas pattern.,0
An NG tube is in place.,0
2:53 PM CHEST (PORTABLE AP) Clip # Reason: S/P ASD REPAIR-R/O PTX ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman with REASON FOR THIS EXAMINATION: S/P ASD REPAIR-R/O PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Status post ASD repair.,0
The ET tube is close to the carina.,0
It should be withdrawn approximately 2-3 cm.,0
There is collapse of the left lower lobe behind the heart.,0
The pulmonary vessels are unremarkable.,0
There is no evidence of cardiac failure.,0
No definite pleural effusions are identified.,0
"A NG tube is noted, its distal end in the distal portion of the stomach.",0
IMPRESSION: Low position of ET tube noted.,0
It should be withdrawn slightly.,0
Left lower lobe collapse/consolidation also noted.,0
"3:21 AM CHEST (PORTABLE AP) Clip # Reason: eval ETT Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with dyspnea- now intubated REASON FOR THIS EXAMINATION: eval ETT ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH CLINICAL INDICATION: 81-year-old woman with dyspnea, now intubated.",0
"FINDINGS: The endotracheal tube is approximately 4.5 cm above the carina, position unchanged.",0
"Nasogastric tube passes below the diaphragm, most likely terminating in the stomach.",0
"Left internal jugular line is at the brachiocephalic vein, unchanged.",0
"Overall, there is no significant interval change with no new focal airspace consolidation or evidence of CHF.",0
11:08 AM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung expansion on cpap Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with increasing o2 requirement on cpap REASON FOR THIS EXAMINATION: evaluate lung expansion on cpap ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 11:25 HOURS HISTORY: Chronic lung disease with increasing O2 requirement.,1
"In followup to , the patient has been extubated in the interval.",0
A feeding tube remains in place terminating below the level of the film in the left side of the abdomen.,0
"A right-sided PICC line remains in place with tip now crossing transversely over the mediastinum terminating in the left innominate vein, previously within the SVC.",0
Examination of lungs demonstrates improvement in perihilar hazy opacity consistent with edema superimposed on chronic lung disease.,1
There is also improving aeration of previously noted bibasilar atelectasis.,0
No significant pleural fluid or gas collections.,0
The heart size remains normal.,0
"7:29 AM CHEST (PORTABLE AP) Clip # Reason: r/o PNA with new RUL opacity Admitting Diagnosis: MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p cardiac arrest REASON FOR THIS EXAMINATION: r/o PNA with new RUL opacity ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: 58-year-old man s/p cardiac arrest, rule out pneumonia.",1
Comparison is made with prior study performed a day before.,0
"FINDINGS: There is opacity of the right upper lobe with air bronchograms, unchanged from prior study consistent with aspiration/ aspiration pneumonia.",0
Stable opacities in the right infrahilar region.,0
ET tube in adequate position.,0
NG tube with tip not included on the film passing the diaphragm.,0
"IMPRESSION: Persistent right upper lobe consolidation, which may be due to aspiration or evolving aspiration pneumonia.",0
"2:58 AM CHEST (PORTABLE AP) Clip # Reason: r/o pleural eff Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 46 yo M with obesity, pneumonia, CHF REASON FOR THIS EXAMINATION: r/o pleural eff ______________________________________________________________________________ FINAL REPORT INDICATION: 46-year-old male with obesity, pneumonia and CHF.",1
FINDINGS: The study is limited secondary to exclusion of the lung bases from the chest radiograph.,0
The tracheostomy tube remains unchanged in a standard position.,0
A nasogastric tube can only be traced as far as the mid esophagus.,0
A right PICC remains unchanged in position within the tip located in the region of the right subclavian vein.,0
A moderate-to-large right pleural effusion is probably unchanged.,0
There is continued left retrocardiac opacification reflecting atelectasis alone or in combination with pneumonia.,0
IMPRESSION: Unchanged bilateral pleural effusions with persistent left retrocardiac consolidation.,0
"8:10 AM CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: HX MELANOMA, METS TO CHEST, EVAL FOR BRAIN METS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT INDICATION: Rule out metastases.",0
TECHNIQUE: Axial CT scans of the brain were obtained before and after the administration of intravenous contrast.,0
FINDINGS: The brain appears morphologically normal.,0
-white matter differentiation is preserved throughout.,0
"On post contrast images, there are two faint foci of enhancement in the frontal lobes, one in the anterior right frontal lobe, near the cortical margin and another along the medial anterior right frontal lobe.",0
There is no surrounding edema or shift of structures.,0
IMPRESSION: Two right frontal foci of subtle enhancement which are suspicious for metastases.,0
MRI is recommended for further evaluation.,0
LINE PLACEMENT Clip # Reason: s/p left internal jugular CVL placement Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman s/p left IJ central line placement REASON FOR THIS EXAMINATION: s/p left internal jugular CVL placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Assessment of the patient after left internal jugular line placement.,1
COMPARISON: AP radiograph was reviewed in comparison to .,0
FINDINGS: The left internal jugular line has been inserted with its tip terminating in the cavoatrial junction.,0
There is no appreciable pneumothorax or apical hematoma noted on the left.,0
"The right pleural effusion is moderate, associated with atelectasis, unchanged since the prior study.",1
The ET tube tip is approximately 3 cm above the carina.,0
"3:01 AM CHEST (PORTABLE AP) Clip # Reason: pre op for nerve biopsy today Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with myopathy, on chronic trach REASON FOR THIS EXAMINATION: pre op for nerve biopsy today ______________________________________________________________________________ FINAL REPORT HISTORY: Chronic tracheostomy, preop for nerve biopsy.",1
"FINDINGS: In comparison with the study of , there is little overall change in the appearance of the heart and lungs.",0
Continued vascular congestion with probable left pleural effusion.,0
More coalescence in the left perihilar and lower lung region could reflect some supervening consolidation.,0
Monitoring support devices remain in place.,0
", R. CSURG FA6A 1:42 PM CHEST (PA & LAT) Clip # Reason: ?",0
effusion/ptx Admitting Diagnosis: AORTIC STENOSIS\CORONARY ARTERY BYPASS GRAFT WITH AVR ?,1
ASCENDING AORTA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with AVR/CABG with post op PTX requiring CT RT(now out).,0
effusion/ptx ______________________________________________________________________________ PFI REPORT Small right apical pneumothorax.,0
"Admission Date: Discharge Date: Service: SURGERY Allergies: Aspirin / Sulfur Attending: Chief Complaint: abdominal pain, small bowel obstruction Major or Invasive Procedure: exploratory laparotomy, lysis of adhesions, intestinal bypass History of Present Illness: 88F w/ abdominal pain and emesis since 2 am on day of admission, .",1
3 bouts of bilious emesis.,0
Pain is peri-umbilical and colicky.,0
"Past Medical History: DM, htn, angina, afib, arthritis Social History: lives at home alone, no tob/etoh, contact: niece ) .",0
"HD1: Pt given IVF, pain medication, NG tube placed, kept NPO.",0
Continued to have abdominal pain and did not pass gas.,0
HD2: had poor urine output overnight (50 cc from 12AM-6AM) which improved with increased IVF and fluid boluses.,0
Patients abdomen continued to be tender to palpation and distended.,0
The NG tube continued to put out bilious fluid throughout the day.,0
The patient did not pass gas.,0
"The patient was consented for surgery and taken to the OR for ex-lap, LOA, and intestinal bypass.",0
HD3/POD1: overnight the patient remained in the PACU and continued to have low urine output despite IVF and several boluses (the patient recieved ~5L post-operatively).,0
Transferred to SICU for persistent low UOP HD 4/POD2: continues to have low urine out put.,0
TTE done x2 for oliguria and decreased BP (bedside exam and formal exam) which shows worsening right sided function compared to previous echo in .,0
Urine output responds to fluid challenge.,0
"Cardiac enzymes sent (negative) HD5/POD3: Urine output improving, Cardiology consulted regarding right heart failure.",1
"Cardiology recommends avoiding fluid overload, PE workup, coagulationgulation for possible PE.",0
Decide to get LENI first and defer CTA at this point.,0
"HD6/POD4: Mild somnolence overnight, ABG normal with mild CO2 retention.",0
Patient transferred to the floor.,0
"PT ordered, Rehab screen started HD7/POD5: Diet held pending swallow eval.",0
"Pt failed bedside swallow, FEES study ordered.",0
UOP continues to be 15-25cc/hr.,0
HD8/POD6: Patient continuing to pass gas.,0
Pt had small BM overnight.,0
Passed bed side FEES (able to tolerated regular diet).,0
A regular diet was well tolerated.,0
"HD9/POD7: Stable for discharge Medications on Admission: diazepam 5 prn, glipizide 5'', hctz 50', metoprolol xl 25', nitroglycerin 0.4 prn, pravastatin 10' Discharge Medications: 1.",0
"Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain.",0
Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Hydrochlorothiazide 12.5 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily).,0
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain.,0
Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Small bowel obstruction Discharge Condition: hemodynamically stable, tolerating oral intake, pain controlled with oral regimen.",0
"Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness.",0
"* Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing.",0
* Do not drive or operate heavy machinery while taking any narcotic pain medication.,0
"You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.",0
"); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber.",0
* No heavy ( lbs) until your follow up appointment.,0
Incision: Your staples will stay in until your followup appointment.,0
Please keep the incision clean and dry.,0
there may be some leakage of clear fluid from the incision.,0
It is ok to place a clean bandage over the incision if you would like to.,0
"Followup Instructions: Provider: , MD Phone: Date/Time: 9:00 Provider: SPECIALTIES CC-3 (NHB) Follow-up appointment should be in 2 weeks Completed by:",0
Height: (in) 65 Weight (lb): 175 BSA (m2): 1.87 m2 BP (mm Hg): 109/46 HR (bpm): 65 Status: Inpatient Date/Time: at 14:18 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,1
Moderate AS (area 1.0-1.2cm2) AR may be underestimated.,0
The severity of aortic regurgitation may be underestimated.,0
"9:00 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrates, chf ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with prior lll pna, on abx, resolved lll infiltrate on followup films, now has fever, increased secretions, hypoxia, tachycardia.",0
"REASON FOR THIS EXAMINATION: r/o infiltrates, chf ______________________________________________________________________________ FINAL REPORT HISTORY: Fever, secretions, prior infiltrate.",0
PORTABLE UPRIGHT CHEST: Comparison to prior chest xray from .,0
"There is no evidence of consolidations, pleural effusions or pneumothorax.",0
Again seen is a tube in the left upper quadrant.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement Admitting Diagnosis: SYNCOPE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: year old woman s/p R IJ placement REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Right internal jugular line placement.,0
Portable AP chest radiograph was compared to prior study obtained the same day earlier at 3:33 a.m.,0
"The ET tube tip remains low, less than 1.5 cm above the carina and should be readjusted.",0
The right internal jugular line tip is at the level of cavoatrial junction.,0
"There is slight improvement of pulmonary edema and there are also pleural effusions demonstrated, bilateral.",0
No definitive pneumothorax demonstrated after insertion of the internal jugular line.,0
Findings were discussed with Dr. over the phone by Dr. on 10:20 a.m. on .,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARD HISTORY OF PRESENT ILLNESS: The patient is a 53 year old female with a past medical history significant for diabetes mellitus type 1, hypertension and family history significant for heart disease, who has known three vessel coronary artery disease (last cardiac catheterization performed on in the Bahamas), who presented with a dull aching substernal chest pain upon waking up the morning of admission.",1
"She denied any shortness of breath, nausea, vomiting, diaphoresis, lightheadedness or orthopnea.",0
The patient claimed that she has had chest pain in the past only with exertion at times associated with right arm radiation which resolved with rest.,0
The patient also claimed to have constant left arm spasm like pain from neck to left hand associated with weakness for the past month.,0
"The patient claims to be more fatigued, especially over the past few months.",0
The patient presented to for a possible coronary artery bypass graft procedure evaluation.,1
Known three-vessel coronary artery disease.,1
"Last cardiac catheterization on , showed 80% left anterior descending stenosis, 90% RLA stenosis, 50% proximal stenosis of the left circumflex and tight stenosis in D1 and D2.",0
The patient also had a positive stress test.,0
Diabetes mellitus type 1 times 24 years.,1
"Insulin 70/30, 40 units twice a day.",0
Enteric-coated aspirin 81 mg p.o.,0
FAMILY HISTORY: The patient has a sister with coronary artery disease.,1
SOCIAL HISTORY: Lives in the Bahamas.,0
No history of tobacco or alcohol use.,0
PHYSICAL EXAMINATION: Pleasant female lying in bed in no apparent distress.,0
Blood pressure 130/68; heart rate 68; respiratory rate 18 and 100% on room air.,0
HEENT examination within normal limits with no evidence of jugular venous distention or bruits.,0
Lung examination clear to auscultation bilaterally.,0
"Heart examination is regular rate and rhythm with normal S1 and S2, no murmurs, rubs or gallops heard.",0
"Abdomen soft, nontender, nondistended with bowel sounds present, no masses.",0
One plus dorsalis pedis pulses bilaterally.,0
"LABORATORY: On admission, hematocrit 43.6, white blood cell count 5.3, platelets 268.",0
"Sodium 139, BUN 10, creatinine 0.8, glucose 137.",0
"Creatinine kinase 148, creatinine kinase MB fraction 2, troponin less than 0.3.",0
"EKG performed at the time of admission showed normal sinus rhythm with flat T waves in leads II, III, AVF, V1, V3 and V6.",0
No ST changes were seen.,0
No Q waves were seen.,0
SUMMARY OF HOSPITAL COURSE: Cardiac Surgery was consulted on the day of the patient's admission to Medicine.,0
She was seen by Dr. .,0
It was thought that the patient would be a good surgical candidate for a coronary artery bypass graft.,1
Her preoperative evaluation was performed including a chest x-ray and additional laboratories.,0
"On , given the symptomatic coronary artery disease and unstable angina, the patient underwent coronary artery bypass graft times four, left internal mammary artery to left anterior descending, saphenous vein graft to patent ductus arteriosus, saphenous vein graft to obtuse marginal, saphenous vein graft to diagonal.",1
Please see the full Operative Note for details.,0
The patient was transferred to the Intensive Care Unit in stable condition.,0
"Neurologically, the patient was responsive and followed commands.",0
She was given perioperative doses of Vancomycin.,0
The patient was extubated on the same day as her procedure.,0
She remained in sinus rhythm.,0
"On postoperative day one, the patient was transferred to the regular floor.",0
Her chest tube was removed.,0
She was vigorously diuresed with Lasix.,0
"On postoperative day two, the patient continued to do well.",0
She was doing well on room air without any supplemental oxygen.,0
Her pacing wires were removed on postoperative day two.,0
Her urine catheter was removed on postoperative day two as well.,0
A diabetes consultation was called given persistently elevated fingersticks.,0
Her insulin regimen was consequently adjusted.,0
The patient was also placed on Plavix.,0
"Physical Therapy was consulted, who followed the patient throughout her hospitalization.",0
The patient was cleared by Physical Therapy to go home.,0
The patient was maintained on Lopressor which was gradually increased to control her heart rate.,0
The patient was discharged to home on .,0
Prior to discharge the patient was noted to have a small amount of serous drainage out of her chest wound.,0
"At the time, it was thought that there was no need for further intervention, but close monitoring of the incision site was warranted.",0
The patient was consequently discharged to home on an oral antibiotic.,0
DISCHARGE DISPOSITION: Home with services.,0
q. six hours times 14 days.,0
12 hours times seven days.,0
"Insulin sliding scale/NPH 35 units q. a.m., 32 units q. h.s.",0
"The patient is to follow-up with her surgeon, Dr. in approximately four weeks.",0
The patient is to follow-up with her primary care physician in approximately one to two weeks.,0
The patient is to be referred to a Cardiologist by her primary care physician as instructed and to be seen within the next three to four weeks.,0
The patient is to follow-up with her diabetes specialist.,0
The patient is to be visited by Visiting Nurses Association services to check her incision site.,0
Dictated By: MEDQUIST36 D: 15:22 T: 16:34 JOB#:,0
9:50 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for interval change.,0
Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with pneumothorax s/p CVL placement.,0
Chest tube placed but has stopped draining.,0
REASON FOR THIS EXAMINATION: eval for interval change.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 9:56 A.M. HISTORY: Pneumothorax after central venous line placed.",0
Chest tube has stopped draining.,0
"IMPRESSION: AP chest compared to , 1:37 a.m.: Large right pneumothorax has increased in size.",0
Large pneumoperitoneum which may have been present earlier is much larger.,0
Progressive decrease in heart size attests to decreased right ventricular filling due to tension pneumothorax.,1
Upper enteric tube ends in the upper stomach and could be advanced at least 5 cm to put all the side ports beyond the gastroesophageal junction.,0
"These findings were discussed over the telephone with Dr. at 10:30 a.m., 1 minute following the recognition.",0
Admission Date: Discharge Date: Service: CARDTHORAC CHIEF COMPLAINT: The patient is an 86-year-old woman with known aortic stenosis referred for outpatient cardiac angiography to evaluate aortic stenosis and coronary artery disease.,1
HISTORY OF PRESENT ILLNESS: Three weeks ago during a routine physical she mentioned to her doctor that she had been getting short of breath when she bends over to pick something up.,0
She denied chest pain and was referred for an echocardiogram.,0
The echocardiogram was done on .,0
At that time it revealed critical aortic stenosis with an aortic valve area of 0.23 cm squared and a peak gradient of 122 mm/Hg with a mean gradient of 67 mm/Hg.,1
There was 1+ aortic regurgitation and 2+ mitral regurgitation with concentric left ventricular hypertrophy.,1
She was then referred to for cardiac catheterization.,0
"PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, cerebrovascular accident in with no residual weakness, right knee surgery and an appendectomy.",1
"The patient denies diabetes, any family history of cardiac disease, any transient ischemic attacks, any melena or gastrointestinal bleeds, any orthopnea, edema or paroxysmal nocturnal dyspnea, any lightheadedness or claudication.",0
ALLERGIES: She has no known allergies.,0
MEDICATIONS PRIOR TO ADMISSION: Include: 1.,0
Atenolol 50 mg q. day.,0
Imdur 30 mg q. day.,0
Hydrochlorothiazide 25 mg q. day.,0
Lisinopril 20 mg q. day.,0
Lipitor 10 mg q. day.,0
Aspirin 81 mg q. day.,0
due to recent dental cleaning.,0
SOCIAL HISTORY: She lives alone and is independent.,0
"LABORATORY DATA: White count 6, hematocrit 39.4, platelet count 188,000.",0
"Sodium 134, potassium 3.5, chloride 93, CO2 29, BUN 13, creatinine 0.7, INR 1.",0
"PHYSICAL EXAMINATION: Height 5'1"", weight 116 pounds.",0
"Vital signs: Heart rate 64 sinus rhythm, blood pressure 160/48, respiratory rate 12, oxygen saturation 99% on room air.",1
Jugular venous distention to 9.,0
Respiratory: Breath sounds clear to auscultation bilaterally.,0
Cardiac: Regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the left sternal border.,0
"Abdomen is soft and non-tender, non-distended with seborrhea.",0
"Dorsalis pedis on the right 1+, posterior tibial 2+, dorsalis pedis on the left 1+, posterior tibial 2+.",0
"ELECTROCARDIOGRAM: Sinus rhythm, intervals 20, 0840, normal axis with left ventricular hypertrophy.",0
"CARDIAC CATHETERIZATION: Showed an aortic valve area of 0.38 cm squared with a peak gradient of 100 mm/Hg, an index of 1.9 and a wedge of 22, PA pressures of 66/22 with a mean of 40.",1
"Shared left main 20%, LAD 60%, left circumflex with minimal irregularities and RCA 90%.",0
"Following catheterization, Cardiothoracic Surgery was consulted, the patient was seen and accepted for aortic valve replacement and coronary artery bypass grafting.",1
"While awaiting surgery, the patient was seen by the Dental Service who extracted an infected tooth prior to her surgery.",0
On the patient was brought to the Operating Room.,0
Please see the Operating Room report for full details.,0
"In summary, the patient had an aortic valve replacement with a #19 Mosaic valve and coronary artery bypass grafting times two with the left internal mammary artery to the left anterior descending artery and a saphenous vein graft to the right coronary artery.",1
The surgery was complicated by an aortic tear which was repaired.,0
The patient's bypass time was 137 minutes.,0
Her crossclamp time was 126 minutes.,0
She was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit.,0
"At the time of transfer the patient had Neo-Synephrine at 1.5 mcg/kg/min, propofol at 20 mcg/kg/min and aprotinin at 25 cc/hour.",0
The patient did well in the immediate postoperative period.,0
"Her anesthesia was reversed, sedation was discontinued and she was weaned from the ventilator and successfully extubated.",0
She was weaned from all cardioactive intravenous medications.,0
"On the morning of postoperative day one the patient remained hemodynamically stable, however, neurologically, she was alert and oriented only times one.",0
"At that time she could identify that she was in the hospital, however, she believed that she was in the .",0
Other than that she followed commands.,0
Her pupils were equally round and reactive to light and she had bilaterally equal motor strength.,0
"On postoperative day two the patient was begun on captopril, Lopressor and intravenous nitroglycerin to control her blood pressure.",0
She was also kept in the Intensive Care Unit because of the need for vigorous pulmonary toilet and to monitor her neurological status.,0
The patient continued to do well.,0
Her intravenous nitroglycerin was weaned to off.,0
medications were increased she remained mildly confused and on postoperative day four she was transferred to the floor for continuing postoperative care and cardiac rehabilitation.,0
For the next several days the patient continued to progress slowly in her activity level.,0
On postoperative day six Neurology consult was called and the patient went for a head CT scan.,0
"CT scan showed no acute hemorrhage, no mass effect or shifts.",0
Two foci of the hypothalamus in the right parietal lobe that represented a probable prior infarction.,0
Neurology consult recommended working up any possible infectious processes that could exacerbate mental status changes and to hold all sedatives.,0
On postoperative day eight it was decided that the patient was stable and ready for transfer to a rehabilitation facility for continuing postoperative care and rehabilitation.,0
"At the time of anticipated transfer, the patient's physical examination is as follows: Vital signs: Temperature 97.0, heart rate 71 sinus rhythm, blood pressure 126/54, respiratory rate 18, oxygen saturation 93% on room air.",1
"Weight preoperatively 53 kilograms, at discharge 58 kilograms.",0
"LABORATORY DATA: White count 8.9, hematocrit 35, platelet count 144,000.",0
"Sodium 137, potassium 3.9, chloride 102, CO2 27, BUN 20, creatinine 0.6, glucose 115.",0
"PHYSICAL EXAMINATION: Awake, oriented times one, confused about place and time.",0
Cardiac: Regular rate and rhythm.,0
"Sternum: Stable incision with Steri-Strips, open to air, clean and dry.",0
"Abdomen soft, non-tender, non-distended with positive bowel sounds.",0
Left lower extremity incision with Steri-Strips.,0
A dry sterile dressing at the top pole of the incision with a small amount of serous drainage.,0
Pantoprazole 40 mg q. day.,0
Enteric coated aspirin 325 mg q. day.,0
Percocet 5/325 one to two tabs q.,0
Aortic stenosis status post aortic valve replacement with a #19 Mosaic valve.,1
Coronary artery disease status post coronary artery bypass grafting times two with left internal mammary artery to left anterior descending artery and saphenous vein graft to right coronary artery.,1
Status post cerebrovascular accident in .,0
Status post right knee surgery.,0
FOLLOW UP: Primary care physician two to three weeks after discharge from rehabilitation and follow up with Dr. four weeks from discharge at .,0
Dictated By: MEDQUIST36 D: 12:29 T: 11:53 JOB#:,0
"9:10 AM CT HEAD W/O CONTRAST Clip # Reason: eval for interval progression Admitting Diagnosis: S/P FALL;ICH ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with diffuse intracerebral hemorrhage intubated and sedated REASON FOR THIS EXAMINATION: eval for interval progression No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATIONS: 52-year-old man with diffuse intracerebral hemorrhage, status post intubation and sedation.",0
"FINDINGS: Bilateral subdural hematomas along the frontal convexities as well as extra-axial hemorrhage in the left anterior cranial fossa, subarachnoid hemorrhages, subdural hemorrhages along the falx and tentorium are not significantly changed.",1
"Numerous foci of large intraparenchymal hemorrhages, including one with a fluid-fluid level in the right frontal lobe are unchanged.",1
Large left parietal and temporal hemorrhages are also unchanged.,0
A round hemorrhage in the right temporal lobe anterior to the petrous bone is likewise similar.,0
There is hemorrhage layering in the fourth and bilateral lateral ventricles.,0
There is similar mass effect on the left lateral ventricle with effacement of the temporal and occipital horns and mild rightward shift of the normally midline structures up to 3-4 mm.,0
"BONE WINDOWS: Patient is intubated, with a nasogastric tube.",0
"There are fluid levels in the maxillary and the sphenoid sinuses, which can be seen in intubation as well as opacification of the ethmoid sinuses.",1
A parietal bone fracture is again visualized.,0
There is a similar overlying hematoma in the soft tissues above the parietal bone.,0
"IMPRESSION: Overall similar appearance of diffuse intracranial hemorrhage, including multiple large intraparenchymal hematomas and diffuse subarachnoid hemorrhage.",1
Similar degree of mass effect on the left lateral ventricle.,0
"NOTE ADDED AT ATTENDING REVIEW: There is a generalized increase in edema and extruded serum surrounding the intraparenchymal bleeds, compatible with the expected evolution of these lesions.",0
There is no evidence of new hemorrhage.,0
6:14 PM CHEST FLUORO WITHOUT RADIOLOGIST Clip # Reason: SWANZ CATH PLACEMENT Admitting Diagnosis: BOORHAAVE'S ______________________________________________________________________________ FINAL REPORT 6 minutes 6 seconds fluoro time in the OR without radiologist.,0
"7:00 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate for pneumothorax post bronchoscopy Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man now s/p paraesophageal empyema drainage from posterior approach, R rib resection, suture repair of esophageal tear, and flap on , now with increasing confusion and sats low 90% on 3L, s/p bronchoscopy REASON FOR THIS EXAMINATION: evaluate for pneumothorax post bronchoscopy ______________________________________________________________________________ WET READ: KYg SUN 7:34 PM Compared ot 10:59 there is no significant change.",0
Left basilar atelectasis/pleural fluid persists.,0
A large region of packing material projecting over the right lower lung with surrouding atelctasis/consolidation and pleural fluid is unchanged.,0
"RIght basilar chest tube, left picc.",0
esophageal stent in stable position.,0
"Small subcutaneous air in right neck, unchanged.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Increased confusion with prior surgery and bronchoscopy to evaluate for pneumonia.,1
"FINDINGS: In comparison with the study of , there is increase in the right pleural effusion and underlying atelectasis, with persistence of the smaller left lower lobe atelectasis and effusion.",0
Again the packing material at the right base simulates the pulmonary abnormality.,0
The left subclavian catheter remains in place.,0
Gas is again seen in the supraclavicular region on the right.,0
"IMPRESSION: Apparent increase in the right pleural effusion, but otherwise unchanged.",0
", S. MED 5:00 PM CT HEAD W/O CONTRAST Clip # Reason: check for angioinvasion, aspergillous lesions Admitting Diagnosis: LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: Ms is a 47 yoF who carries a diagnosis of HTLV-associated ATLL who was recently discharged from a complicated hospital course catalyzed by hypercalcemia, who presented w/ hypercalcemic started on ICE tx and transferred to the for AMS REASON FOR THIS EXAMINATION: check for angioinvasion, aspergillous lesions No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: No acute hemorrhagic mass seen, nor large area of edema or mass effect on non-contrast head CT.",1
"However, for evaluation of subtle process, MRI before and after IV gadolinium would be recommended for more sensitive evaluation.",0
"7:05 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with DM2, AVR on Coumadin, s/p cardiac arrest with complete heart block s/p temp pacer REASON FOR THIS EXAMINATION: evaluate for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old male, status post pacer placement.",1
FINDINGS: The patient is status post median sternotomy.,0
There is a stable postoperative appearance of the mediastinal and hilar contours.,0
The tip of an endotracheal tube is located 5 cm above the carina.,0
A left-sided pacer wire appears to be overlying a large right ventricle and continues out of view.,0
There is unchanged moderate cardiomegaly.,0
There is worsening left retrocardiac opacification likely representing atelectasis.,0
There is prominence of the central pulmonary vasculature with perihilar opacity.,0
Small right and moderate left pleural effusions remain unchanged.,0
IMPRESSION: Worsening left retrocardiac opacification which may represent atelectasis versus developing infiltrate.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Demerol / Sulfa (Sulfonamides) / Nitroglycerin / Morphine / Clindamycin / Benzonatate Attending: Chief Complaint: shortness of breath in setting of TBM and silicone Y stent Major Surgical or Invasive Procedure: flexible bronchoscopy History of Present Illness: 64F with history of tracheobronchomalacia s/p Y stent placement on .,0
"Today, presented to ER with SOB and difficulty clearing secretions.",0
Bronched there and with therapeutic aspiration.,0
Was transferred here for therapeutic aspiration and probably stent removal.,0
"Past Medical History: Tracheobronchomalacia s/p Y stent placement, GERD, COPD, OSA, CAD, Atrial fibrillation, Fibromyalgia Social History: + smoking 50 yr history married, lives w/husband Family History: noncontributory Physical Exam: PHYSICAL EXAM: Temp (F): 98.2 Heart Rate: 102 Blood Pressure: 115/83 Resp Rate: 19 O2 Sat(%): 97% RA HEENT; unremarkable CHEST: CTA bilat COR: RRR S1, S2 Extrem: no edema Brief Hospital Course: pt was admitted from to the sicu on for close pulmonary monitoring while wawiting bronch to eval status of tracheal silicone Y stent.",1
Placed on mucolytics and augmentin.,0
A flexible bronchoscopy was done on and copious amounts of secretions were aspirated.,0
Stent was in correct position and subsequently free of secretions.,0
Pt remained stable and was transfered out of the ICU w/ sats 97-98% on roomair.,0
D/c to home on mucolytic regimen and augmentin for 7 days.,0
Will return on for Y stent removal.,0
"Medications on Admission: Lipitor 10', Singulair 10', Advar 2puffs'', Spiriva 1', Lorazepam 1', Omeprazole 20', Mucinex 1200'', Augmentin, Amitriptyline 50', Albuterol Discharge Medications: 1.",0
Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day.,0
Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day).,0
Disp:*120 Tablet Sustained Release(s)* Refills:*2* 11.,0
Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days.,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).,0
Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours).,0
"15. normal saline normal saline nebs q 4-6hrs Discharge Disposition: Home Discharge Diagnosis: COPD, tracheobronchomalacia s/p Y stent placement Discharge Condition: good Discharge Instructions: Call Dr. office if you develop chest pain, shortness of breath, fever, chills, or nay symptoms that concern you.",0
Followup Instructions: You are scheduled to have your stent removed on MD Completed by:,0
2:02 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC - indication - long-term antibiotic therap Admitting Diagnosis: ABDOMINAL PAIN ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with high grade MRSA bacteremia REASON FOR THIS EXAMINATION: Please place PICC - indication - long-term antibiotic therapy (bedside IV team unable)> ______________________________________________________________________________ FINAL REPORT HISTORY: A 48-year-old male with MRSA bacteremia and need for intravenous antibiotics.",0
The right brachial vein was patent and compressible.,0
The skin and subcutaneous tissues were anesthetized with 3 cc of 1% lidocaine.,0
"Using ultrasound-guidance, the right brachial vein was accessed with a 21-gauge micropuncture needle.",0
"Hard copies of ultrasound images were obtained, before and after establishing an access.",0
A .018 guide wire was advanced through the access needle into the superior vena cava under fluoroscopic visualization.,0
The skin entry site was incised with a #11 blade scalpel.,0
The axis needle was exchanged for a 4- French micropuncture sheath with inner dilator.,0
"Based on the markers on the guide wire, it was determined that the length of 41 cm would be appropriate.",0
"The PICC line was then trimmed to length and advanced over the guide wire, through the Peel-Away sheath, into the superior vena cava.",0
The guide wire and Peel-Away sheath were removed.,0
It was secured with skin using a statlock device.,0
A dry sterile dressing was applied.,0
"FINDINGS: A final AP chest x-ray was obtained, demonstrating the tip of the catheter to be present in the superior vena cava.",0
IMPRESSION: Successful placement of a 41 cm 4-French single lumen PICC line via the right brachial vein.,0
The tip of the catheter is present in the superior vena cava.,0
(Over) 2:02 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC - indication - long-term antibiotic therap Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ FINAL REPORT (Cont),0
Height: (in) 68 Weight (lb): 178 BSA (m2): 1.95 m2 Status: Inpatient Date/Time: at 10:38 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.,0
"All 4 pulmonary veins are seen entering the left atrium; however, a vessel is seen entering the right atrium with a Doppler signature consistent with pulmonary venous flow which may be an anomalous pulmonary vein.",0
Postbypass The patient is A-paced on a phenylephrine infusion.,0
Left venticular systolic function continues to be normal (LVEF 60%) without regional wall motion abnormalities.,0
"Trace aortic regurgitation, trace mitral regurgitation, mild tricuspid regurgitation persist.",0
The thoracic aorta is intact after decannulation.,0
"7:49 AM CT C-SPINE W/O CONTRAST Clip # Reason: Evaluate for fx/dislocation ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with seizure, found down REASON FOR THIS EXAMINATION: Evaluate for fx/dislocation No contraindications for IV contrast ______________________________________________________________________________ WET READ: IPf 10:10 AM No fracture or dislocation seen.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 47-year-old man with seizure and found down.,0
TECHNIQUE: CT C-spine without contrast.,0
Coronal and sagittal reformatted images provided.,0
COMPARISON: No images for comparison at the time of dictation.,0
FINDINGS: There is no dislocation or fracture seen.,0
There are multilevel degenerative changes in the cervical spine.,0
"There is hypodensity in the thyroid gland, which could be evaluated with thyroid ultrasound in non-emergent setting (3:64).",0
There are emphysematous changes underlying apices bilaterally.,0
No definite fracture or dislocation in the cervical spine seen.,0
Emphysematous changes at the lung apices bilaterally.,0
Degenerative changes in the cervical spine at multiple levels.,0
"Hypodensity in the thyroid, could be evaluated with a thyroid ultrasound in a non-urgent setting.",0
Findings reported to the ED dashboard.,0
"10:35 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: evaluate basilar PTX post re-adjustment of chest tube Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with above REASON FOR THIS EXAMINATION: evaluate basilar PTX post re-adjustment of chest tube ______________________________________________________________________________ FINAL REPORT HISTORY: Status post readjustment of chest tube, revaluate pneumothorax.",0
Comparison is made to prior film from approximately 2 hours earlier.,0
"UPRIGHT PORTABLE CHEST RADIOGRAPH FINDINGS: Given mild differences in technique on current radiograph, there has been no significant interval change in small to moderate sized left pneumothorax, pneumomediastinum, and diffuse subcutaneous emphysema.",0
The chest tube is noted to be slightly retracted.,0
Bilateral airspace opacities/effusions are unchanged from prior radiograph as is scoliosis of the spine.,0
"LINE PLACEMENT Clip # Reason: eval location of PICC line Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with lower GI bleed REASON FOR THIS EXAMINATION: eval location of PICC line ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:07 A.M., HISTORY: Lower GI bleed.",1
"IMPRESSION: AP chest compared to : Previous pulmonary edema has resolved, though pulmonary vasculature is engorged and the heart is still mildly enlarged.",1
Right PIC line ends low in the SVC.,0
10:21 AM CHEST (PORTABLE AP) Clip # Reason: r/o aspiration/?pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman s/p AVR/CABG REASON FOR THIS EXAMINATION: r/o aspiration/?pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Status post AVR and CABG.,0
"AP CHEST: A right IJ pulmonary artery catheter appears to have been replaced or pulled back, with the tip now lying in the distal SVC.",1
An NG tube extends into the stomach and turns to point caudad.,0
The endotracheal tube has been removed in the interval since the prior study of .,0
Median sternotomy wires and prosthetic aortic valve are unchanged in appearance.,1
There has been interval increase in heart size.,0
"Patchy bilateral airspace opacities have a somewhat more perihilar distribution, and there is a new left pleural effusion.",0
There is probably a small right pleural effusion as well.,0
The left paramedian mediastinal tube has been removed.,0
"Left retrocardiac opacity, likely atelectatic, less likely consolidation.",0
"11:24 PM CHEST (PORTABLE AP) Clip # Reason: DESATS Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man s/p MVC with respiratory failure, fever; now desatting w/copious secretions REASON FOR THIS EXAMINATION: change in cardiopulm status?",1
______________________________________________________________________________ FINAL REPORT INDICATION: 84 y/o male with respiratory failure.,1
AP upright single view of the chest is compared to .,0
The right chest wall pacemaker with dual chamber electrode is unchanged in position.,0
There is interval removal of NG tube.,0
There is interval improvement in the lung inflation.,0
"There is left ventricular enlargement, stable in the interval.",0
There are again noted bibasilar atelectasis.,0
IMPRESSION: Improvement of the lung volumes in the interval.,0
Otherwise unchanged appearance of the chest radiograph.,0
12:26 PM CHEST (PORTABLE AP) Clip # Reason: eval central line position s/p change over wire Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 72 yo female WITH HYPOXIA s/p intubation REASON FOR THIS EXAMINATION: eval central line position s/p change over wire ______________________________________________________________________________ FINAL REPORT INDICATION: 72 year old with hypoxia and status post intubation.,1
ET tube is in place.,0
The tip is 9.6 cm above the carina.,0
There is an NG tube and a right jugular vein CVP line in place.,0
The tip of the CVP line is in the superior vena cava.,0
Diffuse bilateral pulmonary infiltration is unchanged since the previous study.,0
"In addition, there is associated left lower lobe atelectasis.",0
a left pleural effusion cannot be excluded.,0
The overall appearance of the chest has not significantly changed since the previous study.,0
Tip of the NG tube is not included on this film.,0
Position of the right CVP line not changed since the previous study.,0
IMPRESSION: Diffuse bilateral pulmonary infiltrate and left lower lobe atelectasis is unchanged.,0
Multiple lines and tubes in place.,0
"7:14 PM CT C-SPINE W/O CONTRAST Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: PXDb SAT 8:10 PM limited study due to excessive motion, despite repeat acquisition There is minimally displaced C5 spinous process fracture, given the motion it is difficult to exclude other C spine injurie.",0
"Upper lung consolidation, no pneumothorax, ______________________________________________________________________________ FINAL REPORT INDICATION: 25-year-old man with trauma.",0
TECHNIQUE: Helical CT acquisition from the skull base through T1 vertebral body with multiplanar reformations.,0
Multiple repeat scanning attempts were made due to patient motion.,0
Evaluation is limited due to motion.,0
FINDINGS: ETT and NGT are noted.,0
There is a minimally displaced fracture of the posterior neural arch of C5.,0
There is another area of vague linear lucency involving the left lateral mass at the superior portion of the C5 (2:42).,0
This area is not well evaluated due to extensive motion artifact and not seen on repeat acquisition.,0
"No other fractures are noted; however, evaluation of other associated fractures is limited due to extensive respiratory motion, not significantly improved upon re-acquisition.",0
The pre- and para-vertebral soft tissues are difficult to assess given the ETT and NGT.,0
Limited evaluation of the central canal is within normal limits without CT evidence of cord involvement.,0
Cervical spine alignment is normal.,0
Fluid in the oropharynx and along the vallecula is noted.,0
"The visualized lung apices demonstrate -apical airspace consolidation, right more than left, better evaluated on the concurrently obtained CT study.",0
NG tube and ET tube are noted in standard location.,0
Minimally displaced C5 posterior arch fracture.,0
"Extensive motion artifact not significantly improved on multiple re- acquisitions, limiting evaluation for other associated fractures.",0
Consider repeat CT when patient is stable to further assess for additional fractures.,0
"-apical consolidation, right more than left, better evaluated on concurrently obtained CT torso.",0
SESHa (Over) 7:14 PM CT C-SPINE W/O CONTRAST Clip # Reason: trauma ______________________________________________________________________________ FINAL REPORT (Cont),0
9:20 AM CHEST (PORTABLE AP) Clip # Reason: assess for CVL location Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67F s/p IvorLewis Esophagectomy REASON FOR THIS EXAMINATION: assess for CVL location ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Patient is status post Ivor- esophagectomy.,0
Assess for central line placement.,0
"CHEST: Since the previous film, the Swan-Ganz catheter has been removed.",0
A new line is seen with the tip in the region of the junction of the left innominate vein and the SVC.,0
The position of the right subclavian line is unchanged.,0
Left apical pleural fluid is present.,0
Bilateral infiltrates are seen consistent with a pneumonic process.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 74 year old male with a history of pulmonary fibrosis with home O2 requirement of 2-3L, former smoker with COPD, who presented on to with complaints of dyspnea.",1
"The patinet has been followed for the last three years by Dr. at , carying a diagnosis of IPF.",0
"He reports to have been treated for many years for COPD, but describes a change in his dyspnea in .",0
"Of note, in patient had an oil spill in his basement with significant concrete dust in the construction requiring hospitalization due to pulmonary symptoms.",0
He also describes a remote asbesstos exposure when in the arm.,0
"He has been managed by Dr. , but has never been on any immunologic therapy.",0
We have no recent CT scan or PFTs available to us at this time.,0
"Over the last year, he has also been on home O2, and has noted a progessive worsening of symptoms over the last 6 months.",0
He has noted increasing dyspnea and a slow escalation of O2 requirment.,0
"He was started on a prednisone taper in , but has not been able to taper off 10mg daily.",0
"He is on a series of inhaler regimens given below, but not currently anticoagulated.",0
It does not seem the patient has had a lung biopsy.,0
"The patient had an admission to in , for which he was treated with a steroid burst and antibiotics for brochroncitis, which improved but again gradualy worsended.",0
It appears he was on an extended course of azythromycin.,0
"The patient noted that his respiratory symptoms worsened since around the holiday, with incrasing dyspnea on excersion, a productive cough with mildly blood tinged sputum.",0
"His symptoms continued to worsen, and he began to notice audible wheese and a marked decline in his dyspnea.",0
On the patients son found him to be hypoxic to the 70s on RA and activated EMS.,0
"The patinet was treated intermittent BIPAP 10/5, but was never able to maintain adequate oxygen saturations on less than 50% venti-mask oxygen supplementation.",0
CXR showed now right middle and lower chest opacities which were felt to most likely be consisent with airspace disease with possible superimposed pneumonia.,0
"BNP was 517, urine leginlla was negative, strep pneumoniae antigen were both negative.",0
BCx were no growth to date.,0
He was treated with solumedrol and levofloxacin with a pulmonology consultation.,0
The patient was transfered to for further manegment.,0
"Past Medical History: Pulmonary Fibrosis with 2L Home O2 CAD, w/ stent in at for UA HTN HLD AAA s/p endograft repair in Vasovagal syncope COPD Social History: The patient is a widower.",1
"History of smoking, but quit in after a bad pneumonia.",0
He worked as both a professor as was active in the US army Medicore.,0
No history of significant alcohol use.,0
"Live alone, but has invovled supportive family.",0
"He had multiple dogs, but never had pet birds or other animals.",0
"Family History: No family history of malignancy, autoimmune idease, or lung disease save for emphysema in his father.",0
Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final ): Negative for Respiratory Viral Antigen.,0
Refer to respiratory viral culture for further information.,0
"Moderate progression of diffuse interstitial abnormality, predominantly subpleural reticulation and fibrosis.",0
Honeycombing is new from previous exam.,0
Diffuse ground-glass opacity superimposed on background interstitial changes.,0
"Findings are concerning for acute pulmonary edema, and could be due to cardiogenic, or non-cardiogenic causes.",1
"Differential includes acute drug reaction, and ARDS.",0
"Pneumonitis secondary to infectious causes, such as PCP, also possible.",0
Mediastinal lymphadenopathy is consistent with reported history of IPF.,0
"Brief Hospital Course: The patient is a 74 year old male with a history of IPF, COPD, tobacco use who presents with hypoxia, tranfered for further.",0
# Hypoxia: Most likely etiology of patient's hypoxia and dyspnea is worsening of his underlying pulmonary fibrosis.,1
He was initially treated with antibiotics and steroids without any improvement.,0
He had a CT chest which showed worsening of his underlying disease.,0
His micro data did not show any new microorganism.,0
His viral respiratory panel was also negative.,0
He was maintained on a non-rebreather mask at 15L/min and nasal cannula at 10L/min.,0
"He was evaluated by palliative care, and after much discussion with the patient and family, he was made DNR/DNI and CMO with palliative care/hospice set up at home.",0
He will be discharged with morphine solution and oxygen for home therapy.,0
His other medications will be discontinued.,0
# CODE: DNR/DNI confirmed with patient- comfort measures only # CONTACT: (Son and HCP) Medications on Admission: Advair 500/50 1 puff Asprin 81mg daily Atenolol 50mg daily Boniva 150mg qmonth Plavix 75mg daily Spiriva 18mcg daily Prednisone 5mg daily (has not been able to taper off steroids; on for last 6 months) Albuterol neb PRN VB12 Fish Oil 300 Folic Acid Glucosamine MVI Lovastatin 80mg qHS Discharge Medications: 1.,0
Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H as needed for shortness of breath or wheezing.,0
Scopolamine Base 1.5 mg Patch 72 hr Sig: patches Transdermal every seventy-two (72) hours.,0
Ativan 1 mg Tablet Sig: 0.5-2 Tablets PO every four (4) hours as needed: sublingual.,0
"Disp:*60 Tablet(s)* Refills:*2* 5. oxygen high flow oxygen, 10-20L/min with non-rebreather mask Discharge Disposition: Home With Service Facility: VNA services Discharge Diagnosis: Primary Diagnosis: Idiopathic Pulmonary Fibrosis Hypoxia Discharge Condition: hypoxia to 78-85% on high flow oxygen.",1
unable to ambulate without further hypoxia.,0
Mental status normal and at baseline Discharge Instructions: You were admitted to for worsening of your breathing and low oxygen saturations.,0
This is likely worsening of your underlying pulmonary fibrosis.,1
"You were initially treated with steroids and antibiotics, but there was no significant improvement.",0
A repeat CT scan showed evidence of worsening of your disease.,0
This is an end stage process.,0
"You were seen by the palliative care team, and after further discussions with you and your family, you decided to go home with hospice services.",0
You will be sent home with medications for your comfort.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending: Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Aortic Valve Replacement (23mm CE pericardial), Coronary Artery Bypass Graft x 1 (LIMA to LAD) History of Present Illness: 69 y/o male with h/o atrial fibrillation, aortic stenosis, and coronary artery disease who is now having increased symptoms of dyspnea on exertion.",1
Along with fatigue and dizziness.,0
He was referred for surgical intervention.,0
"Past Medical History: Aortic Stenosis, Coronary Artery Disease, Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM , Erectile Dysfunction s/p Hernia repair, s/p Bilat knee arthroscopy Social History: Denies tobacco or ETOH use.",1
"Family History: NC Physical Exam: VS: 72 18 154/98 6' 195# Gen: WDWN male in NAD Skin: Unremarkable HEENT: EOMI, PERRL NCAT Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB Cardiac: Irreg rhythm with 3/6 SEM radiating to carotids Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: grossly intact, A&O x 3 Pertinent Results: Echo: PREBYPASS: 1.",0
The ascending and transverse thoracic aorta are normal in diameter and free of atherosclerotic plaque.,0
"There are three aortic valve leaflets, which are moderately thickened.",1
There is severe aortic valve stenosis (area <0.8cm2).,1
Dr. was notified in person of the results on at 1209.,0
Pt is currently on a phenylephrine infusion 2.,0
The pt has thickened LV walls with an underfilled ventricle.,0
"Wall motion is unchanged from prebypass, with EF 50% 3.",0
The aortic annular ring can be seen well seated with no perivalvular leak.,0
There is +1 Aortic insufficiency 4.,0
The contours of the aortic root are smooth after aortic cannular was removed.,0
"CXR: As compared to the previous radiograph, there is no relevant change.",0
There is no evidence of pneumothorax and no evidence of major pleural effusion.,0
No focal parenchymal opacities suggestive of pneumonia.,0
Mild overinflation of the stomach.,0
05:25PM BLOOD WBC-6.3 RBC-5.04 Hgb-15.7 Hct-44.2 MCV-88 MCH-31.2 MCHC-35.6* RDW-13.5 Plt Ct-210 05:35AM BLOOD WBC-21.5*# RBC-4.63 Hgb-14.0 Hct-41.6 MCV-90 MCH-30.3 MCHC-33.7 RDW-13.9 Plt Ct-142* 05:25PM BLOOD PT-15.1* PTT-30.8 INR(PT)-1.3* 09:11PM BLOOD PT-15.9* PTT-39.0* INR(PT)-1.4* 05:25PM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-142 K-3.9 Cl-108 HCO3-26 AnGap-12 05:35AM BLOOD Glucose-153* UreaN-20 Creat-1.2 Na-133 K-4.5 Cl-100 HCO3-19* AnGap-19 05:25PM BLOOD ALT-23 AST-23 LD(LDH)-203 AlkPhos-56 TotBili-0.9 08:16AM BLOOD WBC-7.6 RBC-4.02* Hgb-12.1* Hct-35.8* MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt Ct-174# 12:27PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Brief Hospital Course: Mr. was admitted a day before surgery d/t being on Coumadin for h/o Atrial Fibrillation.,1
He discontinued it 5 days before surgery.,0
Upon admission he was started on Heparin and appropriately worked up for surgery.,0
On he was brought to the operating room where he underwent a aortic valve replacement and coronary artery bypass graft x 1.,1
Following surgery he was transferred to the CVICU for invasive monitoring in stable condition.,0
On post-op day one EP was consulted to interrogate his pacemaker.,0
Later on this day Mr. appeared to be doing well and was transferred to the telemetry floor for further care.,0
Mr was in chronic afib that was difficult to control and his metoprolol was advanced.,0
He was re-started on coumadin on POD 2.,0
A rub was noticed and he was started on Ibuprofen.The remainder of his postoperative course was essentially unremarkable.,0
due to an elevated WBC ct. blood and urine cultures were sent and empiric antibiotics were started.,0
Urine Cx originally positive and sensitive to ABX but repeat finalized negative.,0
"The WBC ct improved to normal and his temp.remained afebrile, at time of discharge blood cultures were pending, it was decided to continue a full week of antibiotic coverage.",0
"He was restared on his preoperative dose of Digoxin, along with his preoperative Coumadin regiment of 5 mg alt.",0
"with 2.5 mg daily, with VNA.",0
He was advised on all follow up appointments.,0
"Medications on Admission: Atenolol 100mg , Prilosec 20mg qd, Tricor 146mg qd, Digoxin 0.25mg qd, Vit C, D and E, Zetia 10mg qd, Coumadin (stopped ) Discharge Medications: 1.",0
Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: resume 5mg alternating with 2.5 mg daily or MD .,0
Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day).,0
Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days.,0
Particle/Crystal Sig: Two (2) Tab Sust.Rel.,0
Particle/Crystal PO twice a day for 7 days.,0
Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 4 days.,0
"Disp:*32 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1 PMH: Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM , Erectile Dysfunction s/p Hernia repair, s/p Bilat knee arthroscopy Discharge Condition: good Discharge Instructions: Monitor wounds for signs of infection.",1
Report any fever greater then 100.5.,0
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week.,0
"No lotions, creams or powders to incision until it has healed.",0
No baths or swimming.Gently pat the wound dry.,0
o lifting greater then 10 pounds for 10 weeks.,0
No driving for 1 month Take all medications as directed Followup Instructions: wound clinic in 2 weeks Dr in 4 weeks Dr in weeks Completed by:,0
"12:19 PM PORTABLE ABDOMEN Clip # Reason: eval for change Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with previous resolving ileus REASON FOR THIS EXAMINATION: eval for change ______________________________________________________________________________ FINAL REPORT INDICATION: Resolving ileus, query change.",1
"ABDOMEN, ONE VIEW: Multiple air and contrast (likely from CT of ) are seen in non-dilated bowel loops.",0
"No gross osseous abnormalities are seen, and degenerative changes are again demonstrated.",0
IMPRESSION: Air-filled loops of bowel without dilatation.,0
"12:04 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval left carotid dissection, extend through circle of willi Admitting Diagnosis: CAROTID DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with TIAs s/p left CEA x 2, now w ?dissection on duplex REASON FOR THIS EXAMINATION: eval left carotid dissection, extend through circle of contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DBH SUN 3:50 PM PFI: Multiple apparent stenoses and dissections in the left common carotid artery and left subclavian artery with stenosis at the left vertebral artery origin and severe stenosis in the distal left common carotid artery.",1
The intracranial vasculature appears unremarkable.,0
"______________________________________________________________________________ FINAL REPORT CTA HEAD WITHOUT AND WITH CONTRAST HISTORY: Transient ischemic attack, status post left carotid endarterectomy.",0
Question dissection on Doppler ultrasound.,0
TECHNIQUE: Contiguous axial images were obtained through the brain before contrast administration.,0
"Subsequently, imaging was performed from the aortic arch through the vertex during infusion of 90 cc of Optiray intravenous contrast.",0
No prior brain or vascular imaging is available for comparison.,0
FINDINGS: Multiple vascular abnormalities are detected.,0
"There is an apparent stenosis at the origin of the left vertebral artery, along with calcification and apparent severe stenosis in the proximal left subclavian artery.",0
There is calcification along the proximal right vertebral artery with no evidence of stenosis or dissection.,1
"There is a poorly characterized, incompletely imaged, outpouching from the aortic arch that may represent a small aneurysm.",0
There is an apparent dissection in the proximal left subclavian artery.,1
There is a severe stenosis of the left common carotid artery just proximal to a patulous region that suggests the sequelae of prior carotid endarterectomy.,1
"The patulous segment is irregular and appears to have ulcerations, mural thrombi, or both.",0
"At its most severe, a residual lumen measures approximately 1 mm in diameter, reflecting an approximate 80% stenosis.",0
"Distal to the patulous segment, the left internal carotid artery appears normal.",1
"Images of the right common carotid artery demonstrate mild narrowing and calcification along its course with calcifications, but no narrowing, at the carotid bifurcation.",1
"A preliminary interpretation was provided that read ""no hemorrhage or acute infarction.",0
Old lacune in the left caudate head.,0
"CTA: At the level of the aortic arch is an outpouching only partially imaged, may reflect a pseudoaneurysm.",0
"Left carotid endarterectomy changes noted, with linear (Over) 12:04 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval left carotid dissection, extend through circle of willi Admitting Diagnosis: CAROTID DISSECTION ______________________________________________________________________________ FINAL REPORT (Cont) filling defect in left common carotid artery involving a short segment, may reflect a focal dissection.",1
There is severe stenosis of the left common carotid artery at the level of the vocal cords.,1
"Additionally, similar filling defect in the left subclavian artery, immediately distal to the takeoff, may also reflect a focal dissection.",1
discussed with Dr. at 3:00 a.m.,0
CONCLUSION: Multiple apparent stenoses and dissections in the left common carotid artery and left subclavian artery with stenosis at the left vertebral artery origin and severe stenosis in the distal left common carotid artery.,1
"10:55 AM CHEST (PA & LAT) Clip # Reason: r/o fracture, PNA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman w/ CAD, found down.",0
"REASON FOR THIS EXAMINATION: r/o fracture, PNA ______________________________________________________________________________ FINAL REPORT INDICATION: Coronary artery disease, found down.",0
"FINDINGS: The heart is not enlarged and the mediastinal contour has normalized, likely related to repositioning.",0
"Pulmonary vasculature remains prominent, suggestive of mild CHF.",0
"There is no focal infiltrate, pleural effusions, or pneumothorax.",0
", P. MED MICU-7 11:54 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: INTERMITTENT RUQ PAIN /TENDERNESS ON EXAM ASSESS FOR GALLSTONES/CHOLECYSTITIS Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with renal transplant, intermittent RUQ pain/tenderness on exam REASON FOR THIS EXAMINATION: eval for gallstones/cholecystitis ______________________________________________________________________________ PFI REPORT No gallstones and no signs of cholecystitis.",1
5:25 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: S/P PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with chest tube in place REASON FOR THIS EXAMINATION: ?,0
interval change ______________________________________________________________________________ FINAL REPORT PORTABLE UPRIGHT CHEST RADIOGRAPH AT 5:50 A.M.,0
Compared with examination from one day previous.,0
"FINDINGS: Left-sided chest tube remains in place, with the tip projecting over the mid lung zones.",0
Right hemithorax appears essentially clear.,1
There is persistent retrocardiac opacity at the left but with increased haziness.,0
This suggests the presence of a pleural effusion in addition to consolidation versus atelectasis.,0
There has been interval removal of NG tube as well as endotracheal tube.,0
Osseous structures appear grossly unremarkable.,0
Status post extubation and removal of NG tube.,0
"Persistent retrocardiac opacity, with increased haziness suggesting pleural effusion atop either atelectasis and/or consolidation.",0
"5:00 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate for evolving CVA since last CT head Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with severe CHF, h/o CVA REASON FOR THIS EXAMINATION: evaluate for evolving CVA since last CT head CONTRAINDICATIONS for IV CONTRAST: CKD ______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old man with severe congestive heart failure and history of stroke.",1
TECHNIQUE: Routine non-contrast head CT.,0
COMPARISON: CT head and .,0
"FINDINGS: There is no evidence of intraaxial or extraaxial hemorrhage, mass effect, shift of normally midline structures, or acute major or minor vascular territorial infarction.",0
"The ventricles and sulci are mildly prominent, but stable in size and appearance.",0
"Again seen are subtle hypodensities within the periventricular white matter which is an indication of chronic microvascular ischemic changes, stable.",0
Extensive carotid artery calcifications are identified.,0
The surrounding osseous and soft tissue structures are unremarkable.,0
IMPRESSION: No evidence of acute or chronic infarction.,1
Stable microvascular ischemic changes in the periventricular white matter.,0
9:46 AM CT HEAD W/O CONTRAST Clip # Reason: change in size of stroke Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with right MCA stroke REASON FOR THIS EXAMINATION: change in size of stroke No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JBRe FRI 4:17 PM PFI: 1.,0
Unchanged hypodense area in the right MCA territory with unchanged subarachnoid hemorrhage without evidence of further evolution or change in blood products.,0
"While this most likely represents a slowly evolving right MCA territory infarct, the slow evolution also puts an underlying mass in the differential diagnosis.",0
"Since the patient cannot have an MRI secondary to pacemaker, followup with CT preferably with intravenous contrast is recommended to assess for further evolution.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 87-year-old man with right MCA stroke.,0
Please assess for change in size of stroke.,0
TECHNIQUE: Contiguous axial images of the head were obtained without administration of IV contrast.,0
"COMPARISON: CT of the head from and CTA of the head from , .",0
"FINDINGS: Compared to the recent studies, there is an essentially unchanged hypodense region involving the right parietal and temporal lobes.",0
"While there are regions where the hypodensity involves the overlying cortex (2:15), there are also regions of relatively spared ""islands"" of matter, with the appearance of finger-like interdigitation between matter, most notable in the anterior temporal lobe (2:12), more typical of vasogenic than cytotoxic edema.",0
"There is unchanged amount and density of blood products associated with this hypodensity, mainly located in the overlying subarachnoid space.",0
"There is no evidence of further evolution of the blood products, or the hypodense region, itself.",0
"There is no evidence of new sites of intracranial hemorrhage, new infarctions, herniation or mass effect.",1
There is no evidence of extra-calvarial soft tissue abnormality or skull fracture.,0
"IMPRESSION: Unchanged hypodense region in the territory of the inferior division of the right MCA, with overlying subarachnoid hemorrhage, but no evidence of further evolution or change in density of the infarct or the blood products.",0
"(Over) 9:46 AM CT HEAD W/O CONTRAST Clip # Reason: change in size of stroke Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ FINAL REPORT (Cont) COMMENT: While this process most likely represents slowly-evolving right MCA territorial infarct, the relative lack of evolution, as well as the somewhat atypical edema pattern, may warrant further work-up to exclude an underlying mass.",0
"Since the patient cannot have MRI (due to cardiac pacemaker) follow-up CT, preferably with intravenous contrast, may be obtained for further characterization.",1
"4:44 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: LEFT UPPER LOBE NODULE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p LUL lobectomy with multiple chest tubes REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:15 A.M. ON : HISTORY: Left upper lobectomy.",1
"IMPRESSION: AP chest compared to and 31: Mild edema in the severely emphysematous right lung has improved since , accompanied by a stable small right pleural effusion.",1
Severe atelectasis at the base of the postoperative left lung is unchanged and there is also no radiographic change in the combination of air and fluid loculations in the left pleural space and partially fluid filled bullae in the left upper lung.,1
Solitary left apical pleural tube is in place.,0
Tracheostomy tube is in standard placement.,0
"Cardiac silhouette remains shifted leftward, not appreciably enlarged.",0
"6:32 AM CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # CT PELVIS W&W/O C ; CT 150CC NONIONIC CONTRAST Reason: eval for bleed Admitting Diagnosis: SUBDURAL HEMORRHAGE Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with REASON FOR THIS EXAMINATION: eval for bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma, status post MVC, hematocrit drop.",1
COMPARISON: TECHNIQUE: A trauma torso protocol was used.,0
Helically acquired images were obtained through the lungs after the administration of 150 cc non-ionic optiray contrast.,0
Non-ionic contrast was used secondary to fast bolus nature of the exam.,0
Images were also obtained through the abdomen and pelvis.,0
CT OF THE CHEST WITH IV CONTRAST: There is some bibasilar atelectasis.,0
The airways are patent down to the segmental bronchi.,0
There is some prominent thymic tissue vs. prevascular lymph nodes anterior to the heart.,0
"There is no significant axillary, mediastinal or hilar lymphadenopathy.",0
"CT OF THE ABDOMEN WITH IV CONTRAST: The liver, kidneys, adrenals, spleen and pancrease are unremarkable.",0
There is vicarious excretion of IV contrast from the previous study within the gallbladder.,0
"There is no free air, fluid or significant lymphadenopathy in the abdomen.",0
CT OF THE PELVIS WITH IV CONTRAST: There is a small amount of fluid within the pelvis.,0
A Foley catheter with iatrogenic air is within the bladder.,0
There is a nabothian cyst within the lower uterine segment.,0
The uterus and ovaries are otherwise unremarkable.,0
BONE WINDOWS: There is a left clavicle fracture.,1
There are also fractures of the left sacral ala and left superior and inferior pubic rami.,0
There are right acetabular subchondral cysts.,0
The acetabulum are intact bilaterally.,0
IMPRESSION: 1) Small amount of free fluid in the pelvis.,0
"Otherwise, no significant fluid collections or hematomas to explain the patient's hematocrit drop.",0
2) Left clavicle fracture and pelvic fractures as described previously.,1
(Over) 6:32 AM CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # CT PELVIS W&W/O C ; CT 150CC NONIONIC CONTRAST Reason: eval for bleed Admitting Diagnosis: SUBDURAL HEMORRHAGE Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont),1
Height: (in) 71 Weight (lb): 175 BSA (m2): 1.99 m2 BP (mm Hg): 130/80 HR (bpm): 55 Status: Inpatient Date/Time: at 10:28 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
5.The aortic root is mildly dilated.,0
6.The aortic valve leaflets are mildly thickened.,0
"9.There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded.",0
"7:48 PM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with mental status changes, possible sepsis REASON FOR THIS EXAMINATION: assess for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Mental status changes and possible sepsis.",0
SUPINE AP CHEST: Study is severely limited by rotation and supine positioning.,0
Moderate hiatal hernia is seen.,0
Elevated right hemidiaphragm and prominent irregular contour of the right mediastinum could be secondary to rotation or could represent right middle and/or partial right lower lobe collapse.,0
No other areas of parenchymal consolidation are seen.,0
Osseous structures show degenerative changes of the right shoulder.,0
IMPRESSION: Limited study due to rotation and supine positioning shows no evidence of pneumonia.,0
"However, volume loss of the right lung and unusual contour of the right mediastinum could represent right middle and/or lower lobe collapse.",0
Re-evaluation with dedicated PA and lateral chest radiographs is necessary.,0
7:22 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with sepsis.,1
"REASON FOR THIS EXAMINATION: ET tube placement ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Endotracheal tube placed, check position.",0
"CHEST: Compared with the prior chest x-ray of , the position of the endotracheal tube is essentially unaltered.",0
The tip of the right IJ line lies in the mid SVC.,0
Failure persists with the right effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Bactrim Attending: Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Previous admission: Transplant; : Exploratory laparotomy, orthotopic liver transplant, renal transplant.",1
": Abdominal washout and closure Admission Starting ; : Exploratory laparotomy with abdominal washout, biliary diversion, small bowel resection and liver biopsy : Exploratory laparotomy, Resection distal common bile duct, Resection debridement segments 4 and 5, Jejunal tube.",1
: IR drainage of hepatic abscess History of Present Illness: 50 yo M s/p liver and kidney transplant.,1
"ESLD secondary to hepatitis C and ESRD likely secondary to HTN, DM and hepatorenal syndrome who was on dialysis for short time prior to transplant.",0
"On he underwent OLT and cadaveric renal transplant abdomen packed and left open given intraoperative oozing and second look on POD# 1 for packing removal, hepaticojejunostomy for bile leak and abdominal closure.",0
"He was discharged three days prior to his current admission and initially did well at home,tolerating a diet, ambulating with regular non-bloody bowel movements.",0
He returned 2 days ago with increasing right upper quadrant and peri-umbilical abdominal pain.,0
"Past Medical History: hepatitis C () c/b cirrhosis, salmonella gastroenteritis with acute renal failure, chronic kidney disease with renal stones s/p lithotripsy (), DM (dx , off medications, diet-controlled), HTN (, well-controlled, off medications), ITP s/p splenectomy (), asthma PSH: splenectomy , lithotripsy , Combined liver/kidney transplant Social History: SH: Lives with sister, has two children.",1
"Prior heroin user, sober for two years, on methadone program.",0
Family History: FH: His family history is significant for an aunt and uncle with diabetes.,1
"Physical Exam: Vitals: 98.0 158 129/95 24 99 RA GEN: A&O, non-toxic appearing HEENT: No scleral icterus, mucus membranes dry CV: sinus tachycardic, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, tender to palpation in RUQ and peri-umbilical region, no rebound or guarding.",0
"Operative incisions well-healed, staples in place.",0
"DRE: normal tone, no gross or occult blood Ext: No LE edema, LE warm and well perfused Pertinent Results: On Admission: WBC-25.4* RBC-4.81 Hgb-14.7 Hct-45.5 MCV-95 MCH-30.6 MCHC-32.3 RDW-14.9 Plt Ct-355# PT-15.3* PTT-21.6* INR(PT)-1.3* Glucose-233* UreaN-32* Creat-1.3* Na-137 K-5.1 Cl-101 HCO3-23 AnGap-18 ALT-76* AST-85* LD(LDH)-530* AlkPhos-176* TotBili-2.0* Lipase-10 Albumin-2.7* Calcium-8.5 Phos-2.8 Mg-1.3* FACTOR V LEIDEN-Not Detected .",0
At Discharge: WBC-10.5 RBC-2.81* Hgb-8.7* Hct-26.8* MCV-96 MCH-30.8 MCHC-32.2 RDW-18.4* Plt Ct-482* PT-15.6* PTT-29.3 INR(PT)-1.5* Glucose-68* UreaN-34* Creat-0.8 Na-133 K-5.0 Cl-104 HCO3-23 AnGap-11 ALT-43* AST-41* CK(CPK)-22* AlkPhos-560* TotBili-0.7 Calcium-8.4 Phos-3.9 Mg-1.4* tacroFK-8.9 .,0
"Culture Data: 8:35 am FLUID,OTHER HEMATOMA (BEHIND THE LIVER AREA BLOOD CLOT).",1
Piperacillin/Tazobactam sensitivity testing performed by .,0
"YEAST, PRESUMPTIVELY NOT C. ALBICANS.",0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP.,0
"| KLEBSIELLA OXYTOCA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM------------- <=0.25 S PENICILLIN G---------- 32 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 1 S 6:05 am BLOOD CULTURE **FINAL REPORT ** Blood Culture, Routine (Final ): ENTEROCOCCUS FAECIUM.",0
"_________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R - : Blood Cultures: No growth Brief Hospital Course: The patient is a 50-year-old man who is 17 days out from a deceased donor liver and kidney transplant who has had a complication of hepatic artery thrombosis, based upon physical findings of tachycardia and he eventually developed peritoneal signs.",1
A CT was done on admission showing free air and fluid near the hepaticojejunostomy.,0
Dr took him to the OR on day of admission due to concern for disruption of the anastomosis.,0
"He underwent Exploratory laparotomy with abdominal washout, biliary diversion, small bowel resection and liver biopsy for Hepatic artery thrombosis and peritonitis with bile leak.",1
"The bile duct at this time was in discontinuity, with a drain to the outside.",0
"Following the initial surgery with Dr , the patient spent 4 days in the ICU.",0
Blood cultures and the peritoneal fluid sample taken in the OR both grew Bacteroides fragilis.,1
He had been started on Vanco and Zosyn.,0
"After the brief ICU stay, he was transferred out to the regular surgical transplant floor.",1
LFTs and Bilirubin were improving.,0
"On , the patient was taken back to the OR again, this time because of the bile duct discontinuity.",0
He was not eligible for additional MELD points or Status 1 due to the time frame of the original surgery.,0
"He underwent exploratory laparotomy with resection of the distal common bile duct, resection debridement of liver segments 4 and 5, and also had a Jejunal feeding tube placed.",0
He was again placed in the ICU.,0
At the time of surgery a hematoma was evacuated from behind the liver.,1
"This was sent for culture, and was found to be growing VRE, Klebsiella and yeast.",0
"He had been started on Micafungin and meropenem immediately after the surgery on the 13th, however once the culture data was finalized, the was stopped and cefepime was started, which he received for 3 weeks.",0
AST and ALT have normalized since the time of the surgery on the 13th.,0
"Bilirubin has remained stable around 0.6, however the Alk Phos has slowly risen over the course of his hospital stay.",0
"On , the patient had a Roux tube cholangiogram, findings include that the contrast rapidly opacifies the jejunal Roux limb.",0
Trace biliary reflux is inadequate to evaluate the biliary tree.,0
No evidence of anastomotic leak is evident.,0
The Roux drain was left uncapped with minimal output until the day it was capped on .,0
"The remaining JP drains in the surgical bed have decreased to around 10 cc daily, however, they absolutely will not be taken out until the patient receives a new transplant liver.",1
"Since the time of the first positive blood cultures, the patient was having daily blood cultures drawn.",0
These were persistently positive with VRE.,0
Daptomycin was started on the .,0
This has continued since that time and will remain indefinitely as will the Micafungin.,0
"CT of abdomen was done on , with findings consistent with necrosis and locules of air seen, concerning for superinfection.",1
"An attempt was made to drain this area, however, it was not liquid enough until when a pigtail drain was able to be successfully placed.",0
Drainage is approximately 100-300 cc daily.,0
"Since the time of the successful drainage however, the ensuing surveillance blood cultures have all been negative.",0
A PICC line was placed on for known long term antibiotic needs.,0
"Immunosuppression has been followed by level, and Prograf dosed accordingly.",0
"Cellcept was reduced to 500 mg , and prednisone taper was accelerated due to patients continued infection.",1
Patient has been receiving tube feeds via the J tube with no problems of nausea or diarrhea.,0
He may eat as tolerated.,0
Kidney function throughout has been excellent.,0
Creatinine remains around 0.8 with 1-2 liters urine daily.,0
"Of note the Ureteral stent was removed On TEE done, no vegetations seen, and he received pentamadine administered staples removed.",0
The patient has received 32 MELD exception points and is re-activated on the liver transplant list.,1
"Medications on Admission: tacrolimus 2'', Cellcept '', prednisone 20' (until ), valganciclovir 900', fluconazole 400', famotidine 20', Kayexalate 4 tsp prn, percocet prn pain, colace 100'', methadone 35', effexor 37.5', pentamadine inhaled monthly, NPH insulin 20 units with breakfast, humalog sliding scale, dilaudid 2 mg q 6 prn pain Discharge Medications: 1. diphenhydramine HCl 25 mg Capsule : One (1) Capsule PO HS (at bedtime) as needed for insomnia.",0
2. metoprolol tartrate 25 mg Tablet : 0.5 Tablet PO BID (2 times a day): Hold for sbp less than 110 or HR less than 60.,0
3. valganciclovir 450 mg Tablet : Two (2) Tablet PO Q24H (every 24 hours).,0
4. trazodone 50 mg Tablet : One (1) Tablet PO HS (at bedtime).,0
"5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day).",0
6. acetaminophen 325 mg Tablet : Two (2) Tablet PO Q8H (every 8 hours) as needed for pain: Max 2 grams per day.,0
7. mycophenolate mofetil 500 mg Tablet : One (1) Tablet PO BID (2 times a day).,0
"8. methadone 40 mg Tablet, Soluble : One (1) Tablet, Soluble PO DAILY (Daily): Please hold for over sedation.",0
9. hydromorphone 2 mg Tablet : 1-2 Tablets PO Q3H (every 3 hours) as needed for pain.,0
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. micafungin 100 mg Recon Soln : One (1) Recon Soln Intravenous Q24H (every 24 hours): End date to be determined by transplant clinic.,0
12. daptomycin 500 mg Recon Soln : One (1) Recon Soln Intravenous Q24H (every 24 hours): End date to be determined by transplant clinic.,0
13. insulin glargine 100 unit/mL Solution : Fourteen (14) units Subcutaneous at bedtime.,0
14. insulin lispro 100 unit/mL Solution : per sliding scale Subcutaneous four times a day: Please see insulin scale.,0
15. tacrolimus 1 mg Capsule : Three (3) Capsule PO Q12H (every 12 hours) for 2 doses.,0
"16. heparin, porcine (PF) 10 unit/mL Syringe : Two (2) ML Intravenous PRN (as needed) as needed for line flush.",0
Colace 100 mg Capsule : One (1) Capsule PO twice a day as needed for constipation.,0
"Discharge Disposition: Extended Care Facility: Hospital Discharge Diagnosis: Hepatic artery thrombosis s/p liver transplant Bile duct necrosis Hepatic abscesses Bacteremia; Enterococcus faecium, bacteroides fragilis Peritonitis Malnutrition Adjustment disorder Discharge Condition: Mental Status: Clear and coherent.",1
Discharge Instructions: You will be transferring to in .,0
Please note it is EXTREMELY important that all drains are not allowed to hang freely at any time.,0
Dressings should be well taped and stat locks well adhered to skin.,0
"Pin drains to garment, do not have drains tied to bedframes.",0
"If drains appears to be loosened or sutures come out, please call the transplant clinic right away.",0
It is imperative that the drains do not dislodge.,0
"Please send labwork every Monday and Thursday: CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Prograf.",0
Continue Tube feeds (cycled) via J tube .,0
Patient should not lift greater than 10 pounds .,0
Drain and record drain outputs twice daily and as needed.,0
Send copy of report with patient to clinic visits.,0
Dressings changed daily with good reinforcement of drains .,0
Please do not adjust medications without first discussing with the transplant clinic .,0
"Right arm PICC line care per facility protocol Followup Instructions: Labs q Monday and Thursday (add CPK q Monday while on Dapto) Provider: , MD Phone: Date/Time: 2:00, ( Medical Building) , , Ma Completed by:",0
LINE PLACEMENT Clip # Reason: new 47cm SL R basilic PICC - Admitting Diagnosis: POST OP KNEE INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with new PICC REASON FOR THIS EXAMINATION: new 47cm SL R basilic PICC - ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male with new PICC line.,0
FINDINGS: Two frontal images of the chest demonstrate a right PICC line in place with the tip in the low SVC.,0
There is no pneumothorax or other complication seen.,0
Cardiomediastinal silhouette is otherwise unremarkable.,0
A small right rotator cuff insertion calcification is noted.,0
"IMPRESSION: Right PICC line in position with the tip in the low SVC, otherwise unremarkable chest radiograph.",0
These findings were communicated to with the IV nursing team at 9:39 a.m. on .,0
These findings were made at 9:39 a.m.,0
"11:25 AM CHEST (PORTABLE AP) Clip # Reason: please eval for pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with h/o AVM w/ tracheostomy, w/ increased secretions, SOB and fever REASON FOR THIS EXAMINATION: please eval for pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: History of AVM with tracheostomy, now with increased secretions, and shortness of breath and fever, please evaluate for pneumonia.",1
FINDINGS: Single portable upright radiograph demonstrates patient with tracheostomy in place.,1
"Mediastinal, hilar, and cardiac contours are unremarkable.",0
"A partially imaged VP shunt is seen coursing over the left hemithorax, into the abdomen.",0
"1:28 PM CHEST (PORTABLE AP) Clip # Reason: Confirm ETT placement Admitting Diagnosis: HYPOTENSION;URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with hypotension, respiratory distress with rising pCO2 now intubated REASON FOR THIS EXAMINATION: Confirm ETT placement ______________________________________________________________________________ FINAL REPORT INDICATION: Hypertension and respiratory distress now intubated, please confirm endotracheal tube placement.",1
COMPARISON: Comparison is made to .,0
FINDINGS: Portable chest radiograph demonstrates interval placement of endotracheal tube with tip 4 cm above the carina.,0
Right-sided PICC line still with tip terminating in the mid to lower SVC.,0
Nasogastric tube is well positioned with side port beyond GE junction.,0
There is stable bibasilar consolidations likely representing combination of atelectasis and effusion with areas of dense opacification projecting over the right mid lung corresponding with area of right middle lobe atelectasis.,0
IMPRESSION: Stable large bilateral pleural effusions as well as left lower lobe and right middle lobe atelectasis.,1
Endotracheal tube is well positioned 4 cm above the carina.,0
"12:37 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: s/p fall, intubated, firm abdomen Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: year old with REASON FOR THIS EXAMINATION: s/p fall, intubated, firm abdomen ______________________________________________________________________________ FINAL REPORT INDICATION: Fall, intubated, Firm abdomen, R/O intra-abdominal injury.",0
TECHNIQUE: CT abdomen and pelvis with contrast.,0
Optiray 150cc was administered for trauma patient.,0
CT ABDOMEN WITH IV CONTRAST: The lung bases reveal minimal dependent atelectasis.,0
A linear lucency measuring approximately 3-4cm in size is demonstrated in a left hepatic lobe extending to the surface.,0
There is no significant associated hematoma.,0
Multiple cystic lesions are demonstrated in the liver consistent with liver cysts.,0
Some of the small lesions are too small to characterize.,0
"The spleen, pancreas, gallbladder, and adrenal glands appear unremarkable.",0
The pancreatic duct is visualized but does not appear to be abnormally dilated for the patient's age.,0
Multiple cysts are present in both kidneys.,0
The intra- abdominal bowel loops appear unremarkable.,0
There is no ascites or significant adenopathy.,0
CT PELVIS WITH IV CONTRAST: The distal ureters and urinary bladder appear within normal limits.,0
The pelvic bowel loops appear unremarkable.,0
There is no pelvic fluid.,0
"Incidental note is made of subcutaneous fat stranding in the right buttock, probably representing contusion associated with fall.",0
"IMPRESSION: 1) Left hepatic lobe linear lucency, in the setting of acute trauma, this could represent a small laceration.",0
There is currently no significant hematoma.,0
A follow up study can be done if indicated.,0
2) Buttock soft tissue contusion right greater then left.,0
"11:50 PM CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # Reason: assess for line placement Admitting Diagnosis: CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with R IJ, repositioned REASON FOR THIS EXAMINATION: assess for line placement ______________________________________________________________________________ FINAL REPORT HISTORY: Right IJ repositioning.",1
"FINDINGS: In comparison with the earlier study of this date, the right IJ catheter tip has been pulled back to the level of the mid portion of the SVC.",0
7:59 AM CT HEAD W/O CONTRAST Clip # Reason: assess post operatively Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p craniotomy and evacuation og L SDH REASON FOR THIS EXAMINATION: assess post operatively No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 11:21 AM Slight interval decrease in degree of right shift of midline structures.,0
Otherwise unchanged; no new hemorrhage.,0
______________________________________________________________________________ FINAL REPORT HISTORY: -year-old male with history of subdural hematoma evacuation.,0
COMPARISON: Non-contrast head CT one day prior.,0
"HEAD CT WITHOUT IV CONTRAST: There is slight interval decrease in degree of right shift of midline structures, with approximately 6 mm shift of the intraventricular septum (2:18), compared to approximately 9 mm one day prior.",0
There is again expected pneumocephalus and mass effect upon the left lateral ventricle.,0
There is no interval development of hydrocephalus or new hemorrhage.,0
"On the scout radiograph, degenerative changes seen at C4-5.",0
There are craniotomy changes of the left frontal bone again seen and mucosal thickening is again seen in the ethmoid air cells.,0
The remainder of the paranasal sinuses are clear.,0
"IMPRESSION: Slight interval decrease in degree of right shift of midline structures, with otherwise unchanged postoperative pneumocephalus and other postoperative change described.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: dizziness Major Surgical or Invasive Procedure: NONE History of Present Illness: History of Present Illness: Mr. is a 56 year old male with PMH notable for metastatic cancer (unknown primary) undergoing chemo now presenting with lighheadedness and hemoptysis.,0
"Pt is undergoing chemo with gemcitabine (, ) for malignant neoplasm of unknown primary with multiple bone, muscle, and soft-tissue metastases.",1
He came to the hospital to start RT to L femur today.,0
"Pt reports a couple days of lightheadedness, nonpositional.",0
Pt reports one episode of hemoptysis but none since then.,0
No sig lung lesions on chest CT .,0
Was scheduled to have transfusion on the day of admission.,0
"Orthostatics at Dr. office were Lying BP 94/52, pulse regular at 64.",0
Standing BP 90/52; pulse 66.,0
"In the ED, initial VS were: T98, P50, RR16, BP87/43, O2 100% RA.",0
(Per Dr. (rad/onc) pt generally has SBP 90s-100s).,0
He received 5.5L NS (put out 2.5L urine).,0
He was started on Vanc infustion but developed red itchy arm and it was stopped.,0
He was given benadryl with good effect.,0
Pt did receive Cefepime 2g IV.,0
"Labs notable for a white count of 2.2, Hct 22.9 (Hct 25 on ).",0
"CTA showed no PE, stable ground glass opacities and lytic lesions.",0
"On transfer, pt's VS were T 97.6, P62, R16, BP98/59, O2 99% on RA.",0
"On arrival to the MICU, patient's VS. T98.1, HR68, BP101/61, P70, 98%RA.",0
"Pt denies fever, chills, night sweats, cough, nausea/vomiting, diarrhea, dysuria.",0
Endorses constipation with last BM two days ago.,0
Denies bloody stool or melena.,0
BP was in the 80's systolic.,0
He received 5L of fluid since admission.,0
2.5L urine output in the ED.,0
One unit PRBCS was given for chronic anemia.,1
"HCT 20.6 on admission, bumped to 24 with the unit of blood.",0
No lung mets but there are ground glass opacities but similar to prior study 2 wks ago for staging purposes.,0
"bactrim and keflex for LLE cellulitis, was being treated prior to admission.",0
Tobacco use (30 pack years).,0
History of normal stress test.,0
"Recently evaluated by vascular surgery, imaging showed atherosclerotic plaque in the infrarenal aorta which causes a moderate to moderately severe stenosis.",0
"Recently dx w/HCAP by his PCP, = day of levofloxacin.",0
Social History: The patient used to work in construction and is a facilities manager.,0
He is able to walk except as described above.,0
He uses a cane when necessary.,0
He currently smokes a pack a day and has done so for 30 years.,0
"Family History: There is a family history of heart disease, diabetes and hypercholesterolemia.",1
"Physical Exam: ADMISSION PHYSICAL EXAM: T98, P50, RR16, BP87/43, O2 100% RA.",0
"General: Alert, oriented, no acute distress CV: Regular rate and rhythm, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: +BS, soft, non-distended, mild tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: T98.5, P54, RR16, BP 108/75, O2 99% RA.",0
#RADIOLOGY/STUDIES: [] LENIs - no evidence DVT [] CT chest/abdomen 1.,0
No pulmonary embolism or acute intra-abdominal process.,0
"Numerous bilateral bronchovascular ground-glass opacities, right greater than left, similar to or minimally increased from .",0
Smooth interlobular septal thickening and slight bronchial wall thickening.,0
This combination of findings is potentially due to bronchopneumonia with a component of pulmonary congestion.,0
"However, organizing pneumonia or small foci of hemorrhage cannot be excluded.",0
"Numerous lytic osseous lesions, similar to prior, involving lower lumbar vertebra and pelvic bones.",0
Other known osseous lesions are not imaged.,0
Eccentric soft and calcified abdominal aortic plaques.,0
"[] CXR: no intrathoracic process Brief Hospital Course: []BRIEF CLINICAL HISTORY: 56 year old male with PMH notable for metastatic cancer (unknown primary) undergoing chemo, being treated for LE cullitis, presenting with lighheadedness hypotension, s/p ICU transfer.",0
"At the time of discharge, patient is afebrile, normotensive and not orthostatic.",0
[]ISSUES: # Hypotension: Pt presented to the ED with lightheadedness and was found to have systolic blood pressures in the 80s.,0
The patient was fluid resuscited with good effect.,0
Initially it was unclear if his presentation was infectious in etiology.,0
Blood cultures from at were NGTD.,0
CT chest unchanged from baseline.,0
"Although afebrile, pt may not have been able to mount a white count and therefore might have remained afebrile despite infection.",0
Pt was at baseline blood pressure after fluids in ED.,0
Likely not obstructive shock as pt with negative CTA and negative LENIs.,0
Cardiogenic shock also unlikely given normal baseline EKG.,0
Hypovolemic shock not likely as good urine output with IVF.,0
Urine culture showed no growth.,0
He remained afebrile until discharge and was no longer orthostatic.,0
# Anemia: Unclear baseline - did have Hct of 29 a year ago.,0
Pt had episode of hemoptysis 4 days prior to admission.,0
Pt had Hct of 25 one week ago and is now at 23.,0
After significant fluid resuscitation in ED will likely have dilutional anemia.,0
H/o rectal bleeding so this was considered a possible source.,0
There also have been bleeding into his mets.,0
The patient was also on gemcitabine which suppresses the bone marrow which is consistent with his low retic count of 0.2.,0
"Iron studies c/w anemia of chronic inflammation (normocytic, high ferritin, low TIBC and low transferrin).",1
HCT remained stable since transfer from ICU to floor (24 --> 23.9).,0
# Cellulitis: patient began treatment with bactrim as an outpatient less than a week before admission.,0
There was moderate improvement in the erythema and swelling of the left lower extremity by the time of admission.,0
He was started on combination therapy with bactrim/keflex and had substantial improvement in his cellulits that largely resolved by the time of discharge.,0
He was sent home to finish his course of antibiotics and f/u with his PCP.,0
# Malignant epithelioid cancer of unknown primary (possibly carcinoma per path report): Patient received 2nd of 8 scheduled XRT while in house with f/u to complete the final 6 sessions.,0
Patient is to f/u with primary oncologist as an outpatient.,0
"# Hypothyroidism: -Continued on outpatient levothyroxine # Asthma: -Continued on outpatient flovent, albuterol PRN # Depression: -Continued on outpatient fluoxetine # GERD: -Continued on outpatient pantoprazole # HLD: -Continued outpatient simvastatin, niacin []TRANSITIONAL ISSUES: 1.)",1
patient with neoplasm of unknown primary that will be investigated by primary oncologist.,0
PCP will follow up for resolution of cellulitis.,0
Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation.,0
Information was obtained from PatientwebOMR.,0
Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheeze 2.,0
Fluoxetine 40 mg PO DAILY 3.,0
Fluticasone Propionate NASAL 2 SPRY NU DAILY 4.,0
Fluticasone Propionate 110mcg 2 PUFF IH 5.,0
Gabapentin 300 mg PO TID 6.,0
Levothyroxine Sodium 137 mcg PO DAILY 7.,0
"Lorazepam 1 mg PO Q8H:PRN nausea, anxiety or insomnia 8.",0
Milk of Magnesia 15-30 mL PO PRN constipation 9.,0
Morphine SR (MS Contin) 90 mg PO Q8H 10.,0
Ondansetron 8 mg PO Q 8H 11.,0
OxycoDONE (Immediate Release) 10-20 mg PO Q4-6HRS PRN pain 12.,0
Pantoprazole 40 mg PO Q12H 13.,0
Prochlorperazine 10 mg PO Q8H:PRN nausea 14.,0
Simvastatin 40 mg PO DAILY 15.,0
Docusate Sodium 100 mg PO TID 16.,0
Ibuprofen 200-400 mg PO Q4-6HRS PRN pain 17.,0
Magnesium Oxide 400 mg PO BID 18.,0
Niacin 500 mg PO DAILY 19.,0
Fish Oil (Omega 3) 1000 mg PO TID 20.,0
Senna 1 TAB PO HS Discharge Medications: 1.,0
Docusate Sodium 100 mg PO TID 3.,0
Fish Oil (Omega 3) 1000 mg PO TID 4.,0
Fluoxetine 40 mg PO DAILY 5.,0
Fluticasone Propionate NASAL 2 SPRY NU DAILY 7.,0
Gabapentin 300 mg PO TID 8.,0
Ibuprofen 200-400 mg PO Q4-6HRS PRN pain 9.,0
Levothyroxine Sodium 137 mcg PO DAILY 10.,0
"Lorazepam 1 mg PO Q8H:PRN nausea, anxiety or insomnia 11.",0
Magnesium Oxide 400 mg PO BID 12.,0
Milk of Magnesia 15-30 mL PO PRN constipation 13.,0
Morphine SR (MS Contin) 90 mg PO Q8H 14.,0
Niacin 500 mg PO DAILY 15.,0
Ondansetron 8 mg PO Q 8H 16.,0
OxycoDONE (Immediate Release) 10-20 mg PO Q4-6HRS PRN pain 17.,0
Pantoprazole 40 mg PO Q12H 18.,0
Prochlorperazine 10 mg PO Q8H:PRN nausea 19.,0
Senna 1 TAB PO HS 20.,0
Simvastatin 40 mg PO DAILY 21.,0
Cephalexin 500 mg PO Q12H RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 22.,0
Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypotension Secondary Diagnosis: malignant epithelioid neoplasm of unknown primary Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Dear Mr. , It was a pleasure treating you.",0
You were admitted to the for low blood pressure and dizziness.,0
You were initially sent to the intensive care unit to stabilize your blood pressures.,0
There was initial concern for infection and you were given intravenous fluids and antibiotics.,0
You quickly stabilized and were transfered to the regular inpatient floor.,0
You underwent two sessions of radiotherapy while here as well.,0
You will follow up with both your primary care physician and with your primary oncologist.,0
We wish you and your family the best.,0
"Please continue taking your medications as prescribed, EXCEPT: CONTINUE bactrim for 2 days ADD Cephalexin for 2 days Followup Instructions: 1.)",1
"You will follow up with your primary care physician, .",0
T. Guerzon on at 10AM .,0
"You will follow up with your primary oncologist, Dr. R. on , at 11AM.",0
8:32 PM CHEST (PORTABLE AP) Clip # Reason: eval ptx - please do at 2100 Admitting Diagnosis: INFERIOR MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with s/p cabg REASON FOR THIS EXAMINATION: eval ptx - please do at 2100 ______________________________________________________________________________ FINAL REPORT HISTORY: CABG with pneumothorax.,1
"FINDINGS: In comparison with the earlier study of this date, there has been almost complete clearing of the previously described pneumothoraces.",0
Continued enlargement of the cardiac silhouette with indistinct of pulmonary markings consistent with elevated pulmonary venous pressure.,0
Bibasilar effusions with atelectasis are again seen.,0
", H. NMED SICU-A 3:29 PM PELVIS (AP ONLY) PORT Clip # Reason: NEEDS XR TO EVAL FOR FRACTURE Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ PFI REPORT No fracture identified.",0
"12:36 AM CHEST (PORTABLE AP) Clip # Reason: NGT placement ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with 5 min asystolic arrest w/ elevated enzymes and neuro deficits, s/p endotracheal tube.",0
Defect in endotracheal tube led to extubation.,0
Also has new NG tube placed.,0
REASON FOR THIS EXAMINATION: NGT placement ______________________________________________________________________________ FINAL REPORT INDICATION: NG TUBE PLACEMENT.,0
PORTABLE AP CHEST: The endotracheal tube by now coils in the stomach and ascends to the mid esophagus.,0
The cardiomediastinal silhouette is stable with left ventricular configuration.,0
Lung volumes remain low and there is no consolidation or evidence of congestive failure.,0
IMPRESSION: Nasogastric tube coiled in the stomach.,0
Tip ascending into the esophagus.,0
These findings were discussed with the covering house officer.,0
"2:19 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: r/o pneuomthorax Admitting Diagnosis: GANGRENE ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with pneumonia and s/p left CT guided pleural pigtail now following failed LIJ central placement REASON FOR THIS EXAMINATION: r/o pneuomthorax ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess pneumothorax, following failed left internal jugular catheter.",1
Comparison is made with prior study performed seven hours earlier.,0
There is no evidence of pneumothorax or enlarging pleural effusions.,1
"Continued improvement of venous congestion; otherwise, there are no acute interval changes.",0
Weight (lb): 290 BP (mm Hg): 108/52 Status: Inpatient Date/Time: at 11:47 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
AORTA: The aortic root is mildly dilated.,0
The previous study of is not available for comparison at this time.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Penicillins Attending: Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: : ERCP, spincterotomy History of Present Illness: HPI: 53F with 2 weeks of jaundice, presenting with nausea, vomiting and RUQ/epigastric pain since last night.",0
Patient had not seen any doctor for her 2 weeks of jaundice.,0
Developed nausea last night and had 5 episodes of vomiting overnight.,0
"Also felt some chills, but no objective fevers.",0
"Pain started early this morning, constant in nature and progressively worse.",0
"Pt went to to , had a WBC of 18.5 (17% bands), Tbili 10.7, lipase 1131.",0
"An U/S showed a CBD 15 mm, gallstones, no gallbladder wall thickenning or pericholecystic fluid.",0
"In the ED patient was slightly confused and BP down to 80/60s, improved with 1L bolus of NS.",0
Prominent inferior lead Q waves are non-diagnostic.,0
Low precordial lead QRS voltage.,0
Modest diffuse ST-T wave changes.,0
No previous tracing available for comparison 04:45AM BLOOD ALT-24 AST-26 AlkPhos-129* TotBili-1.6* 05:07AM BLOOD ALT-29 AST-30 AlkPhos-132* TotBili-1.6* 06:30AM BLOOD ALT-37 AST-29 LD(LDH)-243 AlkPhos-144* Amylase-22 TotBili-1.9* 02:07AM BLOOD ALT-209* AST-119* LD(LDH)-218 AlkPhos-356* Amylase-523* TotBili-6.9* 06:40PM BLOOD ALT-216* AST-135* AlkPhos-360* TotBili-9.5* 06:30AM BLOOD Lipase-34 05:10AM BLOOD Lipase-41 02:13AM BLOOD Lipase-267* 02:07AM BLOOD Lipase-1529* 06:40PM BLOOD Lipase-3148* 04:45AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.2 05:07AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.3 05:15AM BLOOD calTIBC-217* TRF-167* 09:30PM BLOOD Lactate-0.9 01:24PM BLOOD Lactate-1.1 06:44PM BLOOD Lactate-2.5* K-4.3 09:30PM BLOOD Hgb-11.9* calcHCT-36 : EKG: Sinus rhythm.,0
: chest x-ray: FINDINGS: The lung volumes are low.,0
"There are bilateral areas of atelectasis, left more than right, with multiple air bronchograms.",0
Presence of a minimal left pleural effusion cannot be excluded.,0
"No evidence of pneumonia or pneumothorax : Chest x-ray: There is no change in cardiomegaly, left lower lobe consolidation and interstitial pulmonary edema.",0
"Bilateral atelectasis and pleural effusion are most likely present, unchanged.",0
": chest x-ray: FINDINGS: As compared to the previous radiograph, the lung volumes have increased, potentially reflecting improved ventilation.",0
"However, there is still evidence of moderate cardiomegaly with a mild-to-moderate left pleural effusion and subsequent left retrocardiac atelectasis.",0
"At the bases of the right lung, a plate-like atelectasis is seen.",0
No newly occurred focal parenchymal opacity suggesting pneumonia.,0
: cat scan abdomen and pelvis: IMPRESSION: 1.,0
Bibasilar atelectasis with small bilateral pleural effusions.,0
"Extensive peripancreatic fat stranding with a small-to-moderate degree of mesenteric and para-renal fluid, but no well-defined fluid collections.",0
"No pancreatic necrosis, pseudocyst, or vascular compromise.",0
Biliary stent without biliary ductal dilatation.,0
Nondistended gallbladder may contain sludge or stones.,0
"Brief Hospital Course: 53 year old female admitted to the Acute care service with abdominal pain, jaundice, nausea and vomitting.",0
"Upon admission to the emergency room, she was hypotensive, and confused requiring intravenous fluids.",0
She was admitted to the intensive care unit for intravenous hydration and monitoring.,0
The GI service was consulted and based on her physical examination and blood work an ERCP was recommended.,0
She underwent an ERCP on HOD #1.,0
She was reported to have an impacted stone in the bile duct and underwent removal of the stone with placment of a stent.,0
"Overnight, she was monitored in the intensive care unit requiring additional intravenous fluids for decreased urine output.",0
She was also maintained on ciprofloxacin and flagyl.,0
Her liver function tests slowly improved and the intensity of her pain diminished.,0
She was transferred to the regular floor on HD#3.,0
Her foley catheter was discontinued at this time and she was voiding without difficulty.,0
"During this time, she did have bouts of confusion which were thought to be related to the narcotics for analgesic management.",0
Nutrition service evaluated the patient and made recommendations about her nutritional status.,0
"She did have a mild elevation of her INR to 2.7 during her hospitalization, but his decreased to 1.6 over the last few days.",0
"On HD #7, she had an episode of decreased oxygenation.",0
"Despite a nebulizer treatment, she did receive a dose of lasix with improvment of her oxygenation.",0
She continued to have bouts of oxygen desaturation and was taken for a chest cat scan after placment of a PICC line for intravenous access.,0
The cat scan was negative for a pulmonary embolism but did show bibasilar atelectasis and small bilater pleural effusions.,0
"She has maintained her oxygen saturation at 96-98% on room air at rest, but continues to desaturate to 88-95% on room air while ambulating.",0
Her vital signs have been stable and she is afebrile.,0
She is tolerating a regular diet and voiding without difficulty.,0
She has ambulated in the and has been encouraged to use the incentive spirometer.,0
She is requiring minimal analgesia for management of her abdominal pain.,0
Her antibiotics were discontinued on HD#9.,0
She is planning for dicharge home with VNA services to assess her cardio-pulmonary status.,0
She has been intstructed to follow up with the Acute care service in 2 weeks for discussion about elective cholecystectomy.,0
She will need to follow-up with ERCP 1 month for stent removal.,0
Medications on Admission: Medications: calcium with vit.,0
"D 500 mg daily, dulcolax 5 mg bedtime, lopid 600 mg twice daily, zantac 150 mg daily, senakot 2 tabs twice daily, tylenol 650 mg as needed for h/a, body aches, clozaril 200 mg bedtime Discharge Medications: 1.",0
Lopid 600 mg Tablet Sig: One (1) Tablet PO twice a day.,0
3. senakot Sig: Two (2) tablets twice a day: hold for diarrhea.,0
"4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours: as needed for headache, body ache.",0
Clozaril 100 mg Tablet Sig: Two (2) Tablet PO at bedtime.,0
6. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO at bedtime: hold for diarrhea.,0
7. calcium with vitamin D 500 mg every morning Discharge Disposition: Home With Service Facility: Able Nursing Discharge Diagnosis: Cholangitis Cholelithiasis Gallstone pancreatitis Discharge Condition: Mental Status: Clear and coherent.,1
Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to the hospital with right upper quadrant pain.,0
You had an ultrasound done which showed gallstones.,0
You underwent ERCP which showed a large stone in the common bile duct.,0
The stone was removed and you had a stent placed in the bile duct.,0
Your pain has decreased and your liver enzymes have improved.,0
You are now preparing for discharge home with follow-up for gallbladder removal.,0
"Your discharge instructions are outlined: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness.",0
Followup Instructions: Please folow up with the Acute care service in 2 weeks.,0
You can schedule your appointment by calling # You will also need to follow up with ERCP in 1 month for stent removal.,0
They will contact you about this.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: line placement, PTX Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with resp failure and new right IJ placement.",1
"REASON FOR THIS EXAMINATION: line placement, PTX ______________________________________________________________________________ WET READ: SHSf FRI 11:00 PM RIJ line at cavoatrial junction.",0
ET and NG inappropriate position.,0
Edema slightly improved with LLL atelectasis again seen.,0
d/ 2300 WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with respiratory failure and new internal jugular line placement.,1
The newly inserted right internal jugular line tip is at the level of cavoatrial junction.,0
"As compared to the prior study, there is interval improvement of pulmonary edema.",0
Left lower lobe atelectasis has progressed in the interim.,0
"8:59 PM GB DRAINAGE,INTRO PERC TRANHEP BIL US; GUIDANCE PERC TRANS BIL DRAINAGE USClip # ; ; Reason: percutaneous cholecystostomy tube for cholecystitis progress Admitting Diagnosis: CHOLECYSTITIS ********************************* CPT Codes ******************************** * GB DRAINAGE,INTRO PERC TRANHEP BIL U GUIDANCE PERC TRANS BIL DRAINAGE US * * * * * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with CHF, mitral valve annuloplasty, afib here with cholecystitis.",1
"REASON FOR THIS EXAMINATION: percutaneous cholecystostomy tube for cholecystitis progressing for four days No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT PERCUTANEOUS CHOLECYSTOSTOMY, INDICATION: 51-year-old woman with CHF, mitral valve annuloplasty, and atrial fibrillation.",1
"Presents with cholecystitis, worsening over four days.",0
"PROCEDURE: The risks, benefits, and alternative to the procedure were described to the patient, who gave written informed consent.",0
"Preliminary scan of the gallbladder was performed, again demonstrating marked gallbladder wall thickening and edema.",0
Large gallstone was again identified.,0
It measures roughly 2.8 cm.,0
"A suitable site for access was chosen, and the overlying skin was then prepped and draped in the usual sterile fashion.",0
"Lidocaine was infiltrated into the skin and subcutaneous tissues, up to the liver capsule, for local anesthetic.",0
"Under ultrasound guidance, an 8 French catheter was advanced into the gallbladder.",0
The catheter was coiled within the gallbladder lumen.,0
"The catheter was aspirated, yielding dark bilious material.",0
A sample was sent for analysis.,0
"A drainage bag was attached to the catheter, and an additional 30-40 cc of bile were aspirated.",0
The catheter was then attached to the skin using a StatLock device.,0
"The patient tolerated the procedure well, without immediate postprocedural complication.",0
"Dr. , the attending physician, present for and participated in the procedure in its entirety.",0
IMPRESSION: Successful ultrasound-guided percutaneous cholecystostomy.,0
Material was sent for Gram stain and culture.,0
"(Over) 8:59 PM GB DRAINAGE,INTRO PERC TRANHEP BIL US; GUIDANCE PERC TRANS BIL DRAINAGE USClip # ; ; Reason: percutaneous cholecystostomy tube for cholecystitis progress Admitting Diagnosis: CHOLECYSTITIS ______________________________________________________________________________ FINAL REPORT (Cont)",0
7:02 PM CHEST (PORTABLE AP) Clip # Reason: s/p Swan replacement.,0
check position Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with hep c cirrhosis s/p OLTx.,0
REASON FOR THIS EXAMINATION: s/p Swan replacement.,0
check position ______________________________________________________________________________ FINAL REPORT HISTORY: Status post Swan replacement check position.,0
"Chest, single AP portable view.",0
A right IJ Swan-Ganz catheter is present.,0
"The tip lies relatively distal in the right pulmonary artery, likely in an interlobar vessel, and should be retracted.",0
"11:24 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: SLIGHT SOB Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with COPD, CHF, left loculated pleural effusion now in rapid a flutter and slight SOB.",1
REASON FOR THIS EXAMINATION: r/o pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: Now rapid atrial flutter and slight shortness of breath.,0
UPRIGHT AP CHEST AT 23:54: The left chest tubes and right IJ line are unchanged.,0
Pulmonary edema persists to a similar degree as seen earlier today.,0
IMPRESSION: Persistent moderate congestive heart failure.,1
The retrocardiac opacity appears slightly increased compared to earlier today.,0
9:28 PM BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: desats Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with increased O2 need REASON FOR THIS EXAMINATION: desats ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 20:58 HOURS HISTORY: Primi with increased O2 requirement.,0
"In followup to earlier on , the patient remains intubated with ETT at the lower cervical trachea with the neck neutral.",0
UVC terminates at the right atrium and ?,0
Aeration of both lungs has improved with improving appearance of RDS.,0
No significant pleural fluid or gas collection.,0
2:45 PM PICC LINE PLACMENT SCH Clip # Reason: Placement of double-lumen PICC in LEFT ARM only.,0
Admitting Diagnosis: BREAST CANCER;DEHYDRATION ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with metastatic breast CA, diarrhea Xeloda, unable to take POs REASON FOR THIS EXAMINATION: Placement of double-lumen PICC in LEFT ARM only.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 55 year old woman with metastatic breast cancer requiring PICC line for multiple medications and possible TPN.,0
PROCEDURE AND FINDINGS: The procedure was performed by Dr and who was supervising.,0
The patient's left arm was prepped and draped in standard sterile fashion.,0
After infusion of 1% Lidocaine the left basilic vein was accessed under ultrasonographic guidance with a 21 gauge needle.,0
Hard copies of the ultrasound images of the basilic vein prior and during cannulation were obtained.,0
An 018 wire was advanced into the SVC under fluoroscopic guidance.,0
Based on the markers of the guidewire it was determined that a length of 43 cm would be appropriate for the dual lumen PICC.,0
The PICC was cut to fit and advanced over a 4 French introducer sheath.,0
The sheath and wire were removed.,0
The line was flushed and HEP-locked and secured with a STAT-lock.,0
Final chest image demonstrated appropriate positioning of the line tip at the SVC.,0
IMPRESSION: Successful placement of left 43 cm total length dual lumen PICC via basilic access with tip in SVC.,0
Line is ready for use.,0
7:13 AM CHEST (PORTABLE AP) Clip # Reason: s/p repair of type A disection w/worsening hypoxia r/o effus Admitting Diagnosis: DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with as above REASON FOR THIS EXAMINATION: s/p repair of type A disection w/worsening hypoxia r/o effusion/infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old man status post repair of type A dissection with worsening hypoxia.,1
"COMPARISON: Multiple priors, most recent .",0
SINGLE FRONTAL VIEW OF THE CHEST: There is a right-sided central venous line which ends in the mid SVC.,0
Endotracheal tube ends approximately 4.7 cm above the carina.,0
"NG tube courses to the stomach, although the tip is excluded from view.",0
Lung volumes are low with bibasilar atelectasis.,0
"The retrocardiac opacity has increased, likely due to worsening atelectasis.",0
There are no appreciable pleural effusions.,0
"Enlarged mediastinum is consistent with recent aortic dissection, status post surgery.",1
5:53 AM CHEST (PORTABLE AP) Clip # Reason: ?acute pathology Admitting Diagnosis: HANGING ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with ETT REASON FOR THIS EXAMINATION: ?acute pathology ______________________________________________________________________________ FINAL REPORT HISTORY: 50-year-old male with tracheal injury and endotracheal tube.,1
"SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: An endotracheal tube terminates with the tip 5 cm above the carina, in satisfactory position.",1
Subcutaneous emphysema in the neck is persistent.,1
"There is bilateral lung base atelectasis, which appears to have increased slightly in the lateral left lungs.",0
"However, there is also somewhat more dense right retrocardiac opacity, which may represent atelectasis and/or pneumonia.",0
The bony thorax is unremarkable.,0
Satisfactory position of endotracheal tube.,0
Increased left lung base atelectasis and right retrocardiac atelectasis and/or pneumonia.,0
Status: Inpatient Date/Time: at 13:16 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Conclusions: PRE-BYPASS: The left atrium is mildly dilated.,0
Valvular heart disease Height: (in) 60 Weight (lb): 71 BSA (m2): 1.20 m2 BP (mm Hg): 110/70 HR (bpm): 80 Status: Inpatient Date/Time: at 10:01 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
There is abnormal septal motion/position consistent with right ventricular pressure/volume overload with reverse Bernheim effect.,0
There is borderline/mild anterior leaflet mitral valve prolapse.,0
8:09 AM CHEST (PORTABLE AP) Clip # Reason: 71 M s/p esophagogastrectomy (().,0
______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with esophageal ca REASON FOR THIS EXAMINATION: 71 M s/p esophagogastrectomy (().,0
______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old male with esophageal cancer S/P esophagogastrectomy.,0
Comparison to prior study from earlier the same day.,0
"CHEST SINGLE VIEW: The heart is enlarged, stable.",0
Mediastinal and hilar contours are also stable.,0
"The nasogastric tube terminates just at or below the diaphragm, with the side hole above the diaphragm, within the gastric pull through segment.",0
"Two right-sided chest tubes are unchanged in position, as is the right subclavian central line.",0
Persistent dense opacification is seen behind the heart on the left.,0
"IMPRESSION: 1) Stable appearance of post-surgical changes, with lines and tubes as described.",0
The side hole of the nasogastric tube is above the diaphragm.,0
2) Cardiomegaly with persistent left retrocardiac opacity which may represent fluid and/or consolidation/collapse on this supine radiograph.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: Please read for right PICC.,0
"Total length 53cm, only able to Admitting Diagnosis: CORONARY ARTERY DISEASE;AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with poor access needing PICC.",1
REASON FOR THIS EXAMINATION: Please read for right PICC.,0
"Total length 53cm, only able to thread 43cm.",0
"# ______________________________________________________________________________ WET READ: CXWc SAT 8:55 PM Right PICC loops into right internal thoracic vein, repositioning required.",0
No change in pleural effusions and atelectasis.,0
"______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: Patient with right-sided PICC line placement.,0
The left-sided chest tube and feeding tube are unchanged in position.,0
There is a right-sided PICC line which is coiled within the axilla and should be removed.,0
"This was discussed with PICC nurse, , at 7 p.m.",0
There is no change in the bilateral pleural effusions and left retrocardiac opacity as well as cardiomegaly.,0
contrast extends beyond anastamosis into non-dilated small bowel.,0
mural hypodensity at anastamosis and in proximal small bowel most likely mural edema - fluid-density collection underlying skin staples 7.4 cm (TRV) x 2.6cm (AP) x 11.4cm (SI) ______________________________________________________________________________ FINAL REPORT CT OF THE TORSO WITH CONTRAST HISTORY: -year-old male status-post small bowel resection for incarcerated femoral hernia with progressing right lung process on chest x-ray and erythema at the incision site.,1
COMPARISON: Non-contrast CT abdomen and pelvis and CTA of the chest .,0
Prior studies indicate that the patient has a history of mesothelioma.,0
CHEST CT WITH IV CONTRAST: There is new diffuse consolidation of the right mid-to-lower lung consistent with infection.,1
Left basilar atelectasis/consolidation is unchanged from .,0
There is a large right layering pleural effusion and a small left effusion with enhancing/thickened pleura.,1
Multiple pleural-based nodules and the left upper lobe pulmonary nodule have increased in size from .,1
"The thoracic aorta is normal in caliber, with atheromatous plaque and vascular calcifications.",0
The central pulmonary arteries opacify normally.,0
Multiple lymph nodes in the mediastinum do not meet size criteria for pathologic enlargement.,0
The endotracheal tube terminates in the trachea.,0
The nasogastric tube terminates in the stomach.,0
There is fluid in the esophagus.,0
The airways are patent bilaterally to the subsegmental level.,0
"The heart is enlarged, particularly the right atrium.",0
"There are dense calcifications of the aortic (Over) 5:33 PM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: evaluate for collection at abdominal incision, lungs for PNA Admitting Diagnosis: LOW URINE OUTPUT ______________________________________________________________________________ FINAL REPORT (Cont) valve and mitral annulus.",0
"CT ABDOMEN WITH IV CONTRAST: The liver has a heterogeneous appearance, likely related to vascular congestion in the setting of right heart failure.",1
"The gallbladder is normal in size, with high-density layering dependently consistent with gallstones.",0
"There are multiple bilateral renal cysts and additional hypodense lesions that are too small to characterize, statistically most likely cysts.",0
"The abdominal aorta is non-aneurysmal in caliber, with dense vascular calcifications extending into the iliac arteries.",0
"The proximal small bowel is dilated measuring up to 3.7 cm, with a transition point at the anastomosis in the right lower quadrant.",0
Contrast passes through the anastamosis into distal small bowel.,0
Low density adjacent to the anastomosis and within small bowel proximal to the anastomosis is likely mural edema (2:99 and 2:79).,0
There is extensive descending and sigmoid diverticulosis without evidence for diverticulitis.,0
"There is a small amount of ascites in the abdomen and pelvis, which is increased from the prior study.",0
There is diffuse body wall edema.,0
A left inguinal hernia contains fluid.,0
"A non-rim enhancing collection underlying the skin staples is identified, and measures simple fluid in attenuation.",0
This collection measures 7.4 cm (TRV) x 2.6 cm (AP) x 11.4 cm (SI).,0
There are no osseous lesions concerning for malignancy.,0
There are extensive degenerative changes of the lumbar spine.,0
New right mid-to-lower lung consolidation concerning for infection.,1
Large right and small left pleural effusions.,1
"Increase in size in multiple pleural-based pulmonary nodules and left upper lobe pulmonary nodule from , worrisome for progression of disease in this patient with probable mesothelioma.",1
Non-rim enhancing subcutaneous fluid-density collection underlying the incision site.,0
"Partial, low-grade small-bowel obstruction with transition point at the anastomotic site in the RLQ.",0
Areas of hypodensity of the small bowel wall at the anastomosis and in the proximal small bowel likely due to mural edema.,0
Increased ascites and body wall edema.,0
"(Over) 5:33 PM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: evaluate for collection at abdominal incision, lungs for PNA Admitting Diagnosis: LOW URINE OUTPUT ______________________________________________________________________________ FINAL REPORT (Cont)",0
6:28 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT TWO VIEWS OF THE CHEST AND SINGLE VIEW OF THE PELVIS.,0
TWO AP VIEWS OF THE CHEST: There is an endotracheal tube approximately 7 cm above the carina.,0
There is an NG tube in position with its distal tip in the upper-to-mid esophagus.,0
There is evidence of slight prominence of the upper mediastinum above the aortic arch for which a chest CT is recommended.,0
The lungs are clear with no evidence of definite parenchymal consolidation.,0
The soft tissues and osseous structures are grossly unremarkable.,0
"AP PELVIS: There is no evidence of fracture, dislocation, or suspicious soft tissue calcifications.",0
There is evidence of extensive subchondral sclerosis and spurring suggestive of degenerative change within the hip joints bilaterally.,0
Prominence of the upper mediastinum above the aortic arch.,0
Chest CT is recommended to better evaluate this finding.,0
Endotracheal tube in position with its distal tip approximately 7 cm above the carina.,0
NG tube in position with distal tip in the upper-to-mid esophagus.,0
This NG tube should be repositioned.,0
No evidence of fracture or dislocation in the pelvis.,0
"7:14 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for interval change Admitting Diagnosis: HEAD TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with ?PNA, desaturation REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ WET READ: PXDb WED 8:29 PM Linear atelectasis at the right lung base.",0
There is mild rotational asymmetry causing probably explaining the apparant relative left hilar fullness.,0
"ET tube, right subclavian line and NG tube are unchanged.",0
"( , ) ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient with known pneumonia.",0
Portable AP chest radiograph compared to obtained at 06:24 a.m.,0
The ET tube tip is 4.5 cm above the carina.,0
The right subclavian line tip is in distal SVC.,0
"Compared to the most recent radiographs, there is a slight improvement in the consolidations in the right lower lung, suggesting improvement of atelectasis, but still present opacities, which may represent a combination of atelectasis and/or pneumonia.",0
The left basal atelectasis has improved as well.,0
"11:20 AM CHEST (PORTABLE AP) Clip # Reason: eval for ptx, fx, infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with trauma REASON FOR THIS EXAMINATION: eval for ptx, fx, infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 78-year-old male with trauma.",0
"Please evaluate for pneumothorax, fracture, or infiltrate.",0
EXAMINATION: Single portable supine chest radiograph.,0
COMPARISONS: There are no prior studies available for direct comparison.,0
FINDINGS: There is an endotracheal tube with its tip 1.5 cm above the level of the carina.,0
There is prominence of the pulmonary vasculature and perihilar fullness consistent with mild congestive heart failure.,0
No focal infiltrates are identified.,0
The heart demonstrates a left ventricular configuration with mild tortuosity of the aorta.,0
"There is a widened mediastium likely due to patient and technical factors, however in the setting of trauma, mediastinal vascular injury not excluded.",0
The visualized osseous structures are stable.,0
There is an external projection of glasses over the left costophrenic angle.,0
"There is a rib fracture on correlation with CT torso, not well appreciated on this single radiograph.",0
Endotracheal tube 1.5 cm above the level of the carina.,0
Please refer to CT Torso for additional findings.,0
These findings were discussed with at 12:00 p.m. on .,0
9:34 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"aspiration Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man s/p seizure/IPH with increasing O2 requirement, ?",0
aspiration REASON FOR THIS EXAMINATION: ?,0
aspiration ______________________________________________________________________________ FINAL REPORT HISTORY: Seizure with possible aspiration.,0
"FINDINGS: In comparison with study of , the monitoring and support devices have been removed.",0
There again are low lung volumes with bibasilar opacification consistent with atelectasis and small effusions.,0
"Some indistinctness of mildly engorged pulmonary vessels could reflect some elevated pulmonary venous pressure, though they may merely be a manifestation of the low lung volumes.",0
5:48 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: Please eval for cholycystitis ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with RUQ abd pain REASON FOR THIS EXAMINATION: Please eval for cholycystitis ______________________________________________________________________________ WET READ: 6:41 PM gallbladder sludge.,0
echogenic focus with dirty shadowing w/in lumen of GB suggest air within GB.,0
(air in GB was also seen on CT from ).,0
______________________________________________________________________________ FINAL REPORT EXAM: Abdominal ultrasound.,0
CLINICAL INFORMATION: 82-year-old male with history of right upper quadrant pain.,0
COMPARISON: as well as reference made to non-contrast-enhanced CT of the abdomen and pelvis from .,0
FINDINGS: No focal intrahepatic lesion seen.,0
There is no evidence of intrahepatic biliary dilatation.,0
"The common bile duct measures 0.4 cm in diameter, it is not dilated.",0
Evidence of gallbladder sludge is seen.,0
Echogenic focus within the gallbladder lumen with dirty shadowing suggests air within the gallbladder.,0
This was also seen on prior CT from .,0
"Upon real-time imaging, the air appears to be within the lumen, not within wall of the gallbladder.",0
"The spleen is normal in size, measuring 9.0 cm in length.",0
"The left kidney measures 10 cm in length, and no evidence of hydronephrosis is seen on the single image of the left kidney.",0
The right kidney was not imaged on this study.,0
The pancreas is obscured by overlying bowel gas.,0
The main portal vein is patent and demonstrates hepatopetal flow.,0
There is a possible small right pleural effusion.,0
Evidence of air within the gallbladder lumen; may be result of prior procedure.,0
Air was also seen in the gallbladder on CT from .,0
Possible small right pleural effusion.,0
LINE PLACEMENT Clip # Reason: 36cm DL R basilic PICC placed ?,0
tip Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with adenoma removed REASON FOR THIS EXAMINATION: 36cm DL R basilic PICC placed ?,0
tip ______________________________________________________________________________ FINAL REPORT HISTORY: PICC placement.,0
"FINDINGS: In comparison with earlier study of this date, there has been placement of a right subclavian PICC line that extends to the upper portion of the SVC.",0
There are lower lung volumes without evidence of acute pneumonia.,0
7:37 PM CHEST (PORTABLE AP) Clip # Reason: eval for pna ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with fever REASON FOR THIS EXAMINATION: eval for pna ______________________________________________________________________________ FINAL REPORT HISTORY: 85-year-old man with fever.,0
"PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are stable.",0
There is a right lower lobe infiltrate.,0
Mediastinotomy wires and surgical clips are again noted.,0
These findings were discussed with the ER resident caring for the patient.,0
IMPRESSION: Right lower lobe pneumonia.,0
"11:52 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ?obstruction, anastamosis leakPO/IV contrast Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 58M s/p roux en y, choledochojej, j-tube, LOA w/emesis one liter, abd pain REASON FOR THIS EXAMINATION: ?obstruction, anastamosis leakPO/IV contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAMINATION: CT abdomen and pelvis.",0
COMPARISON: Comparison is made with previous study from .,0
TECHNIQUE: A CT of abdomen and pelvis was performed with axial images taken from the lung bases to the symphysis pubis.,0
CT ABDOMEN FINDINGS: Some increased interstitial markings are noted in the lung bases bilaterally.,0
Some airspace changes are seen in the left base that may be related to chronic aspiration.,0
Some dilated bronchi and scarring is noted in the right base and may be consistent with bronchiectasis.,0
"Below the diaphragm, note is made of a significant amount of bile duct dilatation as well as pneumobilia.",0
This bile duct dilatation is unchanged when compared to previous CT from .,0
"The pneumobilia, however, is new.",0
No mass lesions seen in the liver.,0
Some perisplenic varices are noted.,0
The adrenals and kidneys are unremarkable apart from a cyst which appears to be extending from the upper pole of the right kidney and measures 4.5 cm in transverse x 3.4 cm in AP diameter.,0
It contains some thin septation but no definite nodularity identified.,0
"The pancreas demonstrates significant calcification throughout its parenchyma, which may be consistent with chronic pancreatitis.",1
The common bile duct is markedly dilated measuring 2.5 cm in maximum diameter as it enters the head of the pancreas.,0
An IVC filter is in situ.,0
There is very little intraabdominal fat in this patient.,0
The large bowel is filled with feces.,0
There is dilatation of the proximal loops of small bowel measuring up to 5 cm in diameter.,0
There is fecalization of some of the small bowel.,0
The stomach is markedly distended.,0
No significant intra- abdominal free fluid.,0
There is decompression of the distal loops of small bowel.,0
No definite zone of transition noted.,0
Some surgical sutures are noted in the mid jejunal area in the mid abdomen CT OF PELVIS FINDINGS: The bladder is normal.,0
The prostate is enlarged at 5.8 cm in transverse x 6.4 cm in AP diameter.,0
"(Over) 11:52 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ?obstruction, anastamosis leakPO/IV contrast Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ FINAL REPORT (Cont) Bony windows reveal some degenerative change in the lumbar spine especially at the L2-L3 level.",0
There is some disc space narrowing and some subchondral sclerosis noted.,0
A well-circumscribed lytic lesion in the left iliac bone is unchanged when compared with the previous CT.,0
The appearances are most likely consistent with benign etiology.,0
Marked intrahepatic and extrahepatic duct dilatation with interval development of pneumobilia when compared with the previous CT from .,0
Pancreatic appearances consistent with chronic pancreatitis.,1
Dilatation of proximal loops of small bowel with fecalization and distal decompression.,0
Atelectasis in the left base and airspace disease which may represent chronic aspiration.,0
Bronchiectatic changes in right base.,0
2:17 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please assess for change from prior Admitting Diagnosis: CLOSTRIDIUM DIFFICILE COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with mucus plugging L main bronchus REASON FOR THIS EXAMINATION: please assess for change from prior ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 14:32 INDICATION: Assess for change in patient with left main bronchus mucus plugging.,1
FINDINGS: Much improved aeration of the left hemithorax with upper lung zone reasonably well aerated.,0
Left effusion is seen which is substantial.,0
An NG tube is visualized but its distal tip is not seen extending beyond the confines of the image.,0
IMPRESSION: Markedly improved aeration of the left lung with significant left pleural effusion.,0
Clip # Reason: please rule out ureteral obstruction and hydronephrosis ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with h/o CHF who presents with ARF and metabolic acidosis.,0
REASON FOR THIS EXAMINATION: please rule out ureteral obstruction and hydronephrosis ______________________________________________________________________________ FINAL REPORT HISTORY: 71 year old man with CHF presents with acute renal failure and metabolic acidosis.,1
TECHNIQUE: Multiple -scale images were obtained from the abdomen and pelvis.,0
FINDINGS: The right kidney measures 8.9 cm and the left kidney measures 8.9 cm.,0
"There are no stones, hydronephrosis or masses seen.",0
There is ascites seen around the liver.,0
The visualized portion of the liver is heterogeneous.,0
5:37 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change Admitting Diagnosis: TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with superior rib fractures and pneumothoraces REASON FOR THIS EXAMINATION: please evaluate for interval change ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Rib fractures and pneumothoraces.,1
Pneumothoraces are not evident in the current examination.,0
Small right and left pleural effusions are increasing on the right.,0
"There has been interval increase in right lower lobe opacity, likely a combination of increasing pleural effusion and atelectasis, minimal atelectasis is in the left lower lobe.",0
4:32 PM CHEST (PORTABLE AP) Clip # Reason: RESP.,0
"DISTRESS, STAT INTUBATION Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress, status post intubation.",1
Comparison is made to the prior exam of the same day at 15:02 hours.,0
FINDINGS: A newly inserted ET tube is in the mid trachea in good position.,0
"There has been interval development of near-total collapse of the left lung, with shift of the mediastinum to the left.",0
Previously identified cardiac failure with pulmonary edema is slightly improved in the interval.,1
Small right pleural effusion remains.,0
IMPRESSION: Near-total collapse of the left lung.,0
"Status post intubation, with ET tube in good position.",0
Mild improvement in cardiac failure.,0
12:27 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval ETT position Admitting Diagnosis: APLASTIC ANEMIA;PANCYTOPENIA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with AML s/p BMT with respiratory failure now s/p recent ETT reposition REASON FOR THIS EXAMINATION: eval ETT position ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Evaluate endotracheal tube position.,1
COMPARISON: at 0557 and at 0551.,0
AP SUPINE CHEST X-RAY: The endotracheal tube is at the level of the clavicle and is in satisfactory position.,0
A right upper extremity central venous catheter with its tip in the SVC is unchanged.,1
"A right subclavian catheter also its tip in the cavoatrial junction, unchanged.",0
"Nasogastric tube courses down below the diaphragm, unchanged.",0
There are improving bilateral airspace opacities since .,0
"Decreased perihilar and lower lobe parenchymal opacities consistent with improving pulmonary edema since , now of mild-to-moderate severity.",0
"11:31 AM CT HEAD W/O CONTRAST Clip # Reason: Acute changes Admitting Diagnosis: HEAD TRAUMA;S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p MCC REASON FOR THIS EXAMINATION: Acute changes No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl SAT 2:26 PM PFI: Slight interval increase in size of the lateral and third ventricles, concerning for developing hydrocephalus.",1
"A 4-mm rightward shift of midline structures (previously 4 mm leftward shift of midline structures on , ).",0
"Overall unchanged size, amount, and distribution of multicompartmental intracranial hemorrhage.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 48-year-old male with history of motorcycle collision.,0
"FINDINGS: As before, the patient is status post right frontoparietal craniectomy.",0
A small amount of expected pneumocephalus persists.,0
"The dominant right temporoparietal parenchymal hematoma is unchanged in size and configuration, with surrounding vasogenic edema.",0
Hypodensity of the right inferior temporal lobe with blood layering dependently is unchanged in configuration.,0
"A small amount of left temporal subarachnoid blood (2:12), and the bifrontal blood in the interhemispheric fissure is unchanged, as well as blood in the frontal of the right lateral ventricle, third ventricle and layering in the occipital horns bilaterally.",0
"The amount of dense subdural blood is unchanged, as well as scattered foci of subarachnoid hemorrhage bilaterally extending towards the convexities.",1
Sulci of the right hemisphere remain effaced.,0
Subdural blood again layers along the tentorium.,0
There is now 4-mm rightward shift of midline structures (previously 4 mm leftward shift of midline structures).,0
The third and lateral ventricle has decreased slightly in comparison to the previous study.,0
Mastoid air cells remain normally pneumatized and aerated.,0
Fluid in the ethmoid and sphenoid sinuses as well as the posterior nasopharynx persists.,0
"Slight interval increase in size of the lateral and third ventricles, concerning for developing hydrocephalus.",0
Unchanged amount of distribution of multicompartmental intracranial hemorrhage.,1
4 mm rightward shift of midline structures (previously 4 mm leftward shift of midline structures on ).,0
(Over) 11:31 AM CT HEAD W/O CONTRAST Clip # Reason: Acute changes Admitting Diagnosis: HEAD TRAUMA;S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ FINAL REPORT (Cont),1
", S. TSICU 10:49 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: needs to be placed post pyloric Admitting Diagnosis: CHOLECYSTITIS Contrast: CONRAY Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with coiled dobhoff REASON FOR THIS EXAMINATION: needs to be placed post pyloric ______________________________________________________________________________ PFI REPORT PFI: Successful advancement of a feeding tube into a post-pyloric position.",0
"10:30 AM BILAT LOWER EXT VEINS PORT Clip # Reason: DVT/ portable please, pt has high O2 requirement Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with focal pain in L calf and varicosities REASON FOR THIS EXAMINATION: DVT/ portable please, pt has high O2 requirement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc MON 12:48 PM No evidence of deep venous thrombosis.",0
"However, note is made of thrombosis of several superficial veins including the left greater saphenous vein, superficial vein in the upper medial left calf, and in the right posterior tibial vein (the latter two areas underlying areas of focal calf pain).",0
______________________________________________________________________________ FINAL REPORT HISTORY: 72-year-old male with areas of focal pain in both right and left calves.,0
Patient with increased O2 requirement concerning for PE.,0
"BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and color and pulse wave Doppler examinations were performed on bilateral common femoral, superficial femoral, and popliteal veins.",0
"These deep veins appear patent, with normal flow, compressibility, and respiratory variation.",0
"However, note is made of thrombosis involving superficial veins including the left greater saphenous vein, a superficial upper medial left calf vein (underlying area of focal pain), as well as the right posterior tibial veins (also underlying area of focal pain).",0
"IMPRESSION: Thrombosis is seen in several superficial veins, however, no evidence of deep venous thrombosis seen.",0
"7:35 AM PICC LINE PLACMENT SCH Clip # Reason: need IV access (PICC) for course of abx for transfer to Admitting Diagnosis: SUBDURAL HEMATOMA;FALL ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with respiratory failure with PNA to transfer to rehab with abx needs PICC prior to transfer REASON FOR THIS EXAMINATION: need IV access (PICC) for course of abx for transfer to rehab ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia, requiring IV antibiotics.",1
catheter requested due to HIT.,0
"The procedure was performed by Dr. and Dr. , the attending radiologist, present and supervising.",0
The left upper arm was prepped in a sterile fashion.,0
"Since no suitable superficial vein was visible, ultrasound was used for localization of a suitable vein.",0
The high left basilic vein was entered under ultrasonographic guidance after local anesthesia with 1% lidocaine.,0
A 21-gauge needle was used.,0
A 0.018 guide wire was advanced under fluoroscopy into the superior vena cava.,0
A 4- French introducer sheath was placed.,0
PICC line was advanced under fluoroscopic guidance into the superior vena cava.,0
The catheter was trimmed at 45 cm.,0
Digital chest image demonstrates the tip to be in the superior vena cava just above the right atrium.,0
"IMPRESSION: Successful placement of a 45-cm total length PICC line with the tip in the superior vena cava, ready for use.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: ciprofloxacin / latex Attending: Chief Complaint: Adenocarcinoma of the head of pancreas Major Surgical or Invasive Procedure: Whipple procedure with SMV reconstruction History of Present Illness: Born in , Mr. is a strong and healthy gentleman who suffered a recent episode of acute pancreatitis in of this summer of .",1
He was identified as having a pancreatic head mass on CT imaging amidst the pancreatitis.,0
This has been followed up further with subsequent MRI and MRCP imaging in .,0
"He lost some weight, suffered through some anorexia that is slowly improving, and was ultimately discharged from the hospital and has continued to improve.",0
"He is moving his bowels, making good urine, and has no diarrhea.",0
He has never developed obstructive jaundice.,0
The only recent symptom otherwise was just a general feeling of dizziness about three to four months ago.,0
He has no real prior surgical history.,0
"There was a question of coronary artery disease, but he did well according to his result with the stress test three to four years ago.",1
I asked him to determine from you if he has had any sort of carotid imaging in light of the dizziness feeling and question of a vision loss that occurred three to four months ago.,0
He had prostate cancer for which he received external beam radiation therapy and he has known Barrett's esophagus.,1
He also underwent an endoscopic ultrasound by Dr. .,0
"This clearly sees the pancreatic head lesion, which does not involve any of the vasculature.",0
"Quite surprisingly, in my judgment, the cytology report is negative for malignancy.",0
"He has no other symptoms of chest pains or palpitations; no pneumonia, shortness of breath, and he has not got diabetes.",0
"Other than the recent weight loss around this acute illness, he has been well.",0
There is no family history of pancreatic cancer.,0
"He is not anticoagulated, but does take aspirin 325 mg a day.",0
"Past Medical History: Barrett's esophagus RETINAL VASCULAR OCCLUSION - BRANCH CANCER, PROSTATE s/p radiation beam therapy in CORONARY ARTERY DISEASE HEADACHE - MIGRAINE HYPERCHOLESTEROLEMIA PRESBYOPIA HEARING LOSS, SENSORINEURAL GLAUCOMA Social History: Retired.",1
"Software developer (worked on the first computer system at the ), then product development consultant.",0
Two children from previous marriage.,0
Family History: No first degree relatives with cancer.,0
"Physical Exam: Pre-Op Exam On physical exam, he is well appearing, not jaundiced, and quite intelligent.",0
He understands the uncertainties of his case.,0
His neck is supple with midline trachea and no jugular venous distention.,0
His cardiac rate and rhythm is normal.,0
His abdomen is entirely benign today with no masses or tenderness.,0
His extremities show no peripheral edema and full range of motion with a normal gait and grossly normal neurologic and vascular exams.,0
"On , the patient underwent pylorus preserving pancreaticoduodenectomy with en bloc resection of superior mesenteric vein, superior mesenteric vein primary venorrhaphy (end-to-end), and CyberKnife fiducial placements, which went well without complication (reader referred to the Operative Note for details).",0
"Of note, a Left subclavian line was placed with a post-placement CXR that showed a Large left sided Pneumothorax.",0
"A pigtail catheter chest tube was placed and eventually, the lung fully expanded.",0
The chest tube was then removed with post-removal CXR showing continued expansion of the lung.,0
"After a brief, uneventful stay in the PACU, the patient was transfered to the ICU for increased monitoring given his vascular repair.",0
"After being stabilized in the unit for a couple days, the patient arrived on the floor NPO on IV fluids, with a foley catheter and a JP drain in place, and an epidural for pain control.",0
The hospital course was uneventful except for the need for a chest tube placement (see above) and followed the Whipple Clinical Pathway without deviation.,0
"Post-operative pain was initially well controlled with an epidural, which was converted to oral pain medication when tolerating clear liquids.",0
"The NG tube was discontinued on POD#3, and the foley catheter discontinued at midnight of POD#4.",0
The patient subsequently voided without problem.,0
"The patient was started on sips of clears on POD#4, which was progressively advanced as tolerated to a regular diet by POD#7.",0
JP amylase was sent in the evening of POD#6; the JP was discontinued on POD#7 as the output and amylase level were low.,0
"During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care.",0
The patient received subcutaneous heparin and venodyne boots were used during this stay.,0
The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated.,0
"At the time of discharge on , the patient was doing well, afebrile with stable vital signs.",0
"Staples were removed, and steri-strips placed.",0
The patient was discharged home without services.,0
"Medications on Admission: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
"2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily).",0
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic (2 times a day).,0
6. atorvastatin 20mg daily Discharge Medications: 1.,0
Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 2.,0
1 DROP LEFT EYE 3.,0
Diltiazem Extended-Release 120 mg PO DAILY 4.,0
Fluticasone Propionate NASAL 2 SPRY NU :PRN congestion 5.,0
HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *hydromorphone 2 mg tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 6.,0
Senna 1 TAB PO BID 7.,0
Ranitidine 150 mg PO HS 8.,0
Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 9.,0
Metoclopramide 10 mg PO Q6H RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth daily Disp #*56 Tablet Refills:*0 10.,0
1 DROP BOTH EYES HS 11.,0
Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home with Service Discharge Diagnosis: adenocarcinoma of the head of the pancreas Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You had a Whipple procedure for adenocarcinoma of the head of your pancreas with reconstruction of your superior mesentery vein.,0
"Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness.",0
*Your pain is not improving within 8-12 hours or is not gone within 24 hours.,0
"General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication.",0
"Followup Instructions: , MD Phone: Date/Time: 9:30am",0
"1:47 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: S/P HEP LOBECTOMY, ASSESS PV FLOW ______________________________________________________________________________ MEDICAL CONDITION: 31 year old man s/p left hepatic lobectomy and thrombectomy of portal vein.",1
REASON FOR THIS EXAMINATION: Please assess the flow in the portal veins.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Post left hepatic lobectomy and thrombectomy of the portal vein.,1
Please assess the flow in the right portal vein.,0
COMPARISON: LIMITED LIVER US: Limited abdominal ultrasound was performed.,0
The liver has diffuse coarse echo texture.,0
The left lobe has been removed.,0
There is no right sided intrahepatic ductal dilatation.,0
"The right anterior, right posterior, and the main portal veins are patent with appropriate flow.",0
The hepatic artery is patent with appropriate pulsatile flow.,0
IMPRESSION: Appropriate patency and wall-to-wall flow within the right sided hepatic arteries and portal veins.,1
4:54 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Eval placement of OGT Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with Strep bacteremia; fevers' with OGT.,0
REASON FOR THIS EXAMINATION: Eval placement of OGT ______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old female with Strep bacteremia and fevers.,0
COMPARISON: Prior study from earlier the same date at 14:46 hours.,0
"AP SEMI-ERECT CHEST: There has been interval placement of a nasogastric tube, which courses into the body of the stomach and out of view.",0
"An endotracheal tube remains in a standard position, 4 cm above the level of the carina.",0
The tip of a right subclavian venous catheter terminates in the distal SVC.,0
Moderate left pleural effusion and bibasilar atelectasis are unchanged.,0
"IMPRESSION: Gastric tube below the diaphragm, exact tip position not included in the film.",0
2:52 PM CHEST (PORTABLE AP) Clip # Reason: new cvl right IJ.,0
Admitting Diagnosis: DIABETIC LEG ULCER;CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with PVD; CVP ~19; Hx of CHF REASON FOR THIS EXAMINATION: new cvl right IJ.,1
______________________________________________________________________________ FINAL REPORT CHEST: HISTORY: CV line placement in patient with peripheral vascular disease.,0
The right jugular CV line is in distal SVC.,0
Endotracheal tube is 9 cm above the carina.,0
The tip of the Swan-Ganz catheter overlies the proximal right main pulmonary artery.,0
NG and feeding tubes well extend below the diaphragm.,0
Single lead right-sided pacemaker with tip of lead overlying region involving the apex in this single view.,0
There is cardiomegaly with pulmonary vascular engorgement and probable hyper-effusion versus CHF.,0
Linear atelectases are present in the right upper lobe and opacity of the left base obscuring the left hemidiaphragm is likely due to a combination of left pleural effusion and atelectasis in left lower lobe.,0
"CHF with pleural effusion, atelectases in right upper and left lower lobes.",0
5:07 PM CHEST (PORTABLE AP) Clip # Reason: pt to get in 45 degress in bed.,0
Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with s/p fall with rib fx and back injury REASON FOR THIS EXAMINATION: pt to get in 45 degress in bed.,0
______________________________________________________________________________ WET READ: 10:28 PM interval right chest tube removal.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Fall with rib and back injury.,0
Small apical lateral pneumothorax persists on the right.,0
9:12 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?,0
"Worsening pulmonary edema verus aspiration PNA in RLL Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with hypoxic respiratory distress known cirrohsis, alcoholic hepatitis, and hepatorenal snydrome REASON FOR THIS EXAMINATION: ?",1
Worsening pulmonary edema verus aspiration PNA in RLL ______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old female with hypoxia and history of cirrhosis.,0
Evaluate for pulmonary edema versus right lower lobe aspiration pneumonia.,0
"FINDINGS: Compared to most recent prior, there are reduced lung volumes.",0
Right lower lobe consolidation is less clearly visualized within this limitation.,0
Lateral radiograph would be helpful if patient's condition permits.,0
These findings were discussed with Dr. by telephone by Dr. at 10:15 a.m. on .,0
", 7F 9:34 PM MR W &W/O CONTRAST; REPEAT, (REQUEST BY RADIOLOGIST) Clip # Reason: Discussed with radiology Dr., want T10-L1 T1 and T2 pre a Admitting Diagnosis: LYMPHOMA/SPINAL CORD COMPRESSION Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with lymphoma and cord compression.",0
"REASON FOR THIS EXAMINATION: Discussed with radiology Dr., want T10-L1 T1 and T2 pre and post contrast.",0
Please call () with any questions.,0
Previously identified posterior epidural lesion in the region of T11 through L1 on outside imaging from is no longer identified on current study.,1
No abnormal enhancing lesions seen on current study.,1
No signal abnormality identified within the visualized cord.,0
"Unchanged diffuse abnormal heterogeneous signal throughout the vertebral bodies, most consistent with diffuse infiltration with lymphoma.",1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Linezolid / Betalactams Attending: Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 55 year old female with ICM (EF 20%), s/p AICD, STEMI, CRI (Cr baseline 1.5), adrenal insufficiency, hemorrhagic pancreatitis, recent complicated hospital course ( -) after transfer from OSH with large pancreatic pseudocyst, phlegmon and right flank fluid collection (VRE, pseudomonas, strep viridans) s/p drainage and multiple abx, course c/b ARF requiring CVVH, hypotension, VT, C diff, UTI, respiratory distress with intubation, then trach, now presents from rehab with abdominal pain.",0
Her abdominal pain has been similar in quality for several weeks but worsening yesterday.,0
C diff positive at rehab.,0
Please refer to recent discharge summary for detailed course of her hospital stay from to .,0
"Of note, she has been treated with Flagyl, then PO vanc for C diff colitis; with linezolid, then daptomycin (b/o leukopenia on linezolid) for VRE in fluid collection; with Zosyn, later aztreonam for Pseudomonas; with meropenem for Pseudomonas and Klebsiella UTI and Pseudomonas in her sputum.",0
"At rehab, she has been on the vent (AC 500x10, FiO2 28%, PEEP of 5) with difficulties to wean due to hypoxia.",0
No increased secretions per verbal report from rehab.,0
She has been maintained on IV Flagyl for positive C diff in her stool.,0
She was on Imipenem until .,0
"In adddition, she was started on Levaquin on for a 5 day course per rehab records.",0
Her chronic abdominal pain worsened on day of admission when it was decided to reverse her DNH status.,1
"In the ED, her VS were T95.6, HR76, BP 120/80, RR21, 100% on TM.",0
No rebound or guarding but tender to RUQ.,0
Greenish stool that was guaiac negative.,0
"Next of was , confirmed DNR/DNI but abx and lines okay.",0
UA was positive for infection.,0
Cr 3.4 up from 1.7.,0
WBC 18.2 with left shift.,0
"Normal pancreatic enzymes and AST, ALT.",0
AP of 489 and LDH of 405.,0
Trop 0.76 but normal CK and MB.,0
CXR and portable abdomen with no acute findings.,0
"30 minutes after she arrived in the ED, her BP dropped to 60s systolic.",0
A RIJ cordis was placed during which a NE gtt was transiently infused.,0
She received a total of approximately 7 L IVF with stabilization of her BP in the 100s/60s.,0
"Pt received one dose of Meropenem, Vanc and Aztreonam and was admitted to the ICU for further management.",0
"Past Medical History: PMH: hemorrhagic pancreatitis and pancreatic pseudocyst, HTN, CAD w/ ischemic cardiomyopathy (EF=15-20%) s/p STEMI, NSTEMI , CHF, IDDM, SLE, CRI SLE ?lupus nephritis vs. DM, baseline Cr=1.5, hypothyroid, ?",0
"embolic CVAs in , obesity, dyslipidemia, adrenal insufficiency chronic steroid use .",0
"There is decreased patchy opacity at both lung bases, suggesting interval improvement in pulmonary edema.",0
A nasogastric tube is coiled in the gastric fundus.,0
"The liver, spleen, and adrenal glands appear grossly unremarkable.",0
Dependent hyperdensity in the gallbladder suggest small stones.,0
Punctate calcifications in both kidneys are compatible with nonobstructing renal calculi.,0
"There has been interval removal of a pigtail catheter from a peripancreatic fluid collection, which now contains no air.",0
"It measures 8.2 x 5.1 cm, compared to 9.7 x 6.1 cm.",0
"Again, normal pancreatic parenchyma is difficult to separate from this fluid collection, with only a small amount seen in the head region.",0
"The perisplenic collection measures 5.4 x 3.9 cm, compared to 4.8 x 4.2 cm on the prior study.",0
A right flank collection demonstrates near complete collapse.,0
A left pericolonic collection is also smaller.,0
"There has been interval increase in simple ascites in the abdomen and pelvis, which is moderate in degree.",0
"However, no new fluid collections are seen.",0
"Scattered non-pathologically enlarged celiac axis, retroperitoneal and mesenteric lymph nodes appear similar, with unchanged moderate stranding of the peripancreatic fat.",0
There is no bowel dilatation to suggest obstruction.,0
"Atheromatous calcification of the aorta is moderate, without aneurysm.",0
PELVIS: A Foley catheter decompresses the bladder.,0
The uterus is not well evaluated.,0
The rectum is within normal limits.,0
"There are scattered sigmoid diverticula, without additional findings to suggest diverticulitis.",0
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no suspicious lytic or blastic lesions.,0
There is evidence of remote fracture of the right inferior pubic ramus.,0
Diffuse stranding of the subcutaneous fat suggests anasarca.,0
"Overall, slight interval decrease in the peripancreatic and additional fluid collections, with slight interval increase in ascites, which is moderate in amount.",0
No evidence of superimposed acute process within the abdomen or pelvis.,0
"Scattered nonobstructing renal calculi and sigmoid diverticulosis, as before.",0
CXR: The tracheostomy is central with again demonstrated over-inflated tracheostomy cuff.,0
The biventricular pacemaker leads are in expected unchanged position.,0
The right PICC line tip terminates in mid SVC.,0
The heart size is moderately enlarged.,0
There is overall increase in vascular engorgement suggesting worsening of pulmonary edema/fluid overload.,0
The bilateral pleural effusions are present also slightly increased.,0
Impression: Worsening of pulmonary congestion.,0
"Brief Hospital Course: Summary: 55 year old female with ICM (EF 20%), s/p AICD, STEMI, CRI (Cr baseline 1.5), adrenal insufficiency, hemorrhagic pancreatitis, recent complicated hospital course ( -) after transfer from OSH with large pancreatic pseudocyst, phlegmon and right flank fluid collection (VRE, pseudomonas, strep viridans) s/p drainage and multiple abx, course c/b ARF requiring CVVH, hypotension, VT, C diff, Klebsiella UTI, respiratory distress with intubation, then trach, now presents from rehab with hypotension, abdominal pain, elevated WBC and persistent abdominal fluid collection.",0
Pt was DNR/DNI/DNH prior to arrival but was admitted to the ICU and DNR status reinstated.,0
"Shortly after admission, in consultation with the patient's family (including her husband, her HCP), the decision was made to change the goals of care to patient comfort only, and that she would no longer receive antibiotics or pressors.",0
"# Hypotension: A wide ddx was initially considered, however it was felt that the patient was most likely in septic shock.",1
She was fluid repleted and broad spectrum antibiotics were started.,0
Shortly thereafter she was made CMO and these therapies were discontinued.,0
"# Respiratory: The patient was continued on her home ventilatory settings via trach, and oxygenated well in this way.",0
"As her illness progressed, her oxygen saturation and respiratory drive began to diminish.",0
"On the evening of death, in consultation with the patient's family, ventilatory support was discontinued and the patient expired shortly thereafter.",0
"# Comfort measures: Once the patient was transitioned to CMO status, a morphine drip was initiated and titrated to her optimal comfort while maintaining an appropriate level of responsiveness.",0
Lab draws were stopped and only limit monitoring was continued.,0
Medications on Admission: RISS Levaquin 250 daily PO (until for 5 day course) PPN EPO 4000 sc weekly Fentanyl patch 25 mcg q72h Heparin sc 5000 daily IV lopressor 2.5 mg q12h IV protonix 40mg dialy IV aminosyn daily IV flagyl 500mg q8h Kayexelate 30gm prn Lasix 40mg IV prn Dulcolax supp PR prn Zofran 4mg IV q4h prn Dilaudid 0.5mg IV q8h prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: sepsis respiratory failure Secondary: renal failure CAD adrenal insufficiency hypothyroidism HTN DM Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired MD,1
"3:52 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for PE, consolidation Admitting Diagnosis: SEPSIS;ACUTE PANCREATITIS;RENAL FAILURE Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with hypoxia, difficulty to wean REASON FOR THIS EXAMINATION: eval for PE, consolidation No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc MON 8:04 PM 1.",1
"Airspace opacities right lung apex, concerning for focal area of pneumonia.",0
"Moderate bilateral pleural effusions, with adjacent atelectasis of the lung.",0
"However, superimposed pneumonia cannot be excluded.",0
"Continued inflammatory changes surrounding the pancreas, compatible with pancreatitis.",0
"Moderate gallbladder irregularity, with wall irregularity, pericholecystic fluid, with a pigtail catheter in place.",0
These findings likely reflect continued inflammatory changes from adjacent pancreatitis.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 40-year-old female with hypoxia, difficult to wean, evaluate for PE or consolidation.",0
"COMPARISON: , CT abdomen and pelvis.",0
TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis with administration of IV and oral contrast.,0
Additional oblique reformatted images of the chest were obtained.,0
"CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are within normal limits, without evidence of pericardial effusion.",0
"The great vessels are unremarkable, without evidence of a pulmonary embolism.",0
"Few scattered mediastinal nodes are seen, measuring up to approximately 6 mm in short axis dimensions, not enlarged by CT size criteria.",0
"There are moderate-sized bilateral pleural effusions, with associated atelectasis of the adjacent lung parenchyma.",0
"However, superimposed infection cannot be excluded.",0
"Additionally, within the right lung apex (6A, 17), there is a more patchy airspace consolidation, concerning for pneumonia.",0
"CT OF THE ABDOMEN WITH IV CONTRAST: There is a cholecystostomy tube, with tip located within the gallbladder.",0
"The gallbladder is markedly irregular in appearance, with pericholecystic fluid and wall irregularity.",0
This is more irregular in appearance compared to .,0
"Additionally, there continues to be marked inflammatory changes surrounding the pancreas, with peripancreatic phlegmon and peripancreatic fluid seen.",0
"However, there is no (Over) 3:52 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for PE, consolidation Admitting Diagnosis: SEPSIS;ACUTE PANCREATITIS;RENAL FAILURE Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) drainable collection or definite evidence for pancreatic necrosis.",1
"The regional arterial vessels are patent, without evidence for pseudoaneurysm formation.",0
Evaluation of the portal venous system as well as the splenic vein is limited due to the phase of contrast.,0
The inflammatory changes in the gallbladder likely reflect secondary changes due to adjacent pancreatitis.,1
The liver is otherwise unremarkable.,0
There is a trace amount of perihepatic free fluid seen.,0
"The spleen, adrenal glands, and kidneys are within normal limits.",0
There is an NG tube that courses into the stomach.,0
"There is a focal loop of jejunum within the left upper quadrant (6B:157) that is in upper limits of normal in distention, which could reflect a focal ileus due to adjacent pancreatitis.",0
There is no evidence for small bowel obstruction.,0
Remainder of the small bowel and large bowel are within normal limits aside from mild diverticulosis of the colon.,0
"Again noted is a trace amount of fluid within a perihepatic location, as well as a small amount of fluid tracking inferiorly into the pelvis.",0
"Scattered prominent mesenteric and peripancreatic nodes are seen, likely reactive in nature.",0
CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.,0
"There is air seen within the bladder, which may be secondary to instrumentation.",0
The uterus and rectum are unremarkable.,0
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is identified.,0
"There are multiple rounded nodules within the subcutaneous tissues of the anterior abdominal wall, which may relate to injections.",0
"Moderate-sized bilateral pleural effusions, with associated atelectasis of the adjacent lung.",0
"Patchy airspace consolidation within the right lung apex, concerning for a focal area of pneumonia.",0
"Continued inflammatory changes surrounding the pancreas, with peripancreatic fluid and phlegmon.",0
"However, no drainable fluid collection identified.",0
"Markedly abnormal gallbladder, with gallbladder wall irregularity, pericholecystic fluid, and a pigtail catheter in place.",0
These findings likely reflect inflammatory changes secondary to the adjacent pancreatitis.,0
"Tiny amount of perihepatic free fluid, with a small amount of free fluid tracking inferiorly into the pelvis.",0
"(Over) 3:52 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for PE, consolidation Admitting Diagnosis: SEPSIS;ACUTE PANCREATITIS;RENAL FAILURE Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont)",1
8:41 PM HIP UNILAT MIN 2 VIEWS LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # Reason: PT WITH LT HIP FX.,0
Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ FINAL REPORT HISTORY: Fracture fixation.,1
AP AND LATERAL INTRAOPERATIVE RADIOGRAPHS OF THE LEFT HIP.,0
Since pre-operative exam five hours earlier on same day the intertrochanteric proximal left femoral fracture has been fixated by a partially visualized intramedullary rod and interlocking nail extending into the femoral head.,1
The fractured lesser trochanter is displaced proximally.,0
2:38 AM UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT; GLENO-HUMERAL SHOULDER (W/O Y VIEW) RIGHTClip # Reason: S/P REDUCTION UNDER FLUORO ______________________________________________________________________________ FINAL REPORT INDICATION: S/P reduction under fluoroscopy.,0
THREE LIMITED INTRAOPERATIVE FLUOROSCOPIC VIEWS OF THE RIGHT SHOULDER: Comparison - .,0
Again noted is a markedly comminuted fracture in the right proximal humerus.,1
The alignment is much improved from the last examination.,0
There is marked interval improvement of posterior displacement and anterior angulation.,0
Multiple surgical devices are seen overlying the right shoulder.,0
FIVE INTRAOPERATIVE VIEWS OF THE RIGHT TIBIA AND FIBULA: Comparison - .,1
Again noted is a complete oblique fracture in the right proximal tibia and a minimally comminuted fracture in the right proximal fibula.,1
"Later films demonstrate placement of an intramedullary fixation rod in the right tibia, transfixing the fracture.",1
"SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: Again seen is an ET tube with 2.6 cm from carina, right internal jugular catheter with tip projecting over the right atrium, two nasogastric tubes with tips projecting below the diaphragm.",0
There has been interval insertion of a left internal jugular catheter with tip projecting over the mid SVC.,0
Patchy multifocal opacities appear similar on the right but more confluent and dense on the left.,0
ET tube 1.6 cm from the carina and needs retraction.,0
"Progressed multifocal confluent becoming confluent opacities likely multifocal pneumonia, especially on the left.",0
"These results were discussed with Dr. by Dr. at 6:45 p.m., .",0
"9:26 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please eval ET tube placement and interval change Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p intubation REASON FOR THIS EXAMINATION: please eval ET tube placement and interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:40 P.M. HISTORY: Intubated.",0
IMPRESSION: AP chest compared to and 8:48 a.m. on .,0
ET tube and right supraclavicular central venous sheath in standard placements respectively.,0
Moderate left pleural effusion stable.,1
"Obscuration of the left heart border may be due to lingular pathology or adjacent pleural thickening, given extensive asbestos-related calcified pleural plaque.",1
Lung volumes lower than at 8:48 a.m. may account in part for vascular engorgement.,0
Previous gastric distension has resolved.,0
"3:21 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SKULL FRACTURE; HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with hx of etoh use, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:18 A.M. HISTORY: Alcohol use.",1
IMPRESSION: AP chest compared to and 29: Left lower lobe atelectasis and small left pleural effusion have worsened on the right.,0
"New opacification in the lung bases obscures the lateral aspect of the right hemidiaphragm, could be atelectasis or pneumonia.",0
Mild cardiac enlargement due in part to pericardial effusion is stable.,0
Left subclavian line ends in the upper SVC and a nasogastric tube passes into the stomach and out of view.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath, chest tightness Major Surgical or Invasive Procedure: Aortic Valve Replacement(25mm CE Perimount Pericardial Valve) History of Present Illness: This is a 68 year old male with known history of aortic stenosis and CREST syndrome.",1
"Over the past several weeks, he has noted worsening dyspnea and cough.",0
"While chipping ice from a drain pipe, he developed chest tightness that resolved within one hour of rest.",0
He presented to his PCP who noted new left bundle branch block.,0
He was subsequently admitted to Hospital for further evaluation.,0
BNP at admission was 349.,0
Echocardiogram revealed severe AS with a peak of 51 and mean of 31 mmHg.,0
"Cardiac catheterization showed clean coronaries, normal LVEF, elevated PA and wedge pressures, with normal pulmonary vascular resistance.",0
"He was then transferred to the for cardiac surgical intervention Past Medical History: Aortic Stenosis, Hypertension, Hyperlipidemia, CREST syndrome, Obesity, Sleep Apnea, BPH, Colonic Adenoma - s/p cecal polypectomy complicated by GI Bleed, s/p Right Colectomy, s/p Cholecystectomy, GERD, Hernia Social History: Does not smoke and drinks ETOH rarely.",1
He is married and works as a real estate .,0
"To evaluate his esophagus(given intraoperative use of TEE), a barium swallow was performed which found no evidence of stricture.",0
The rheumatology service found no contraindication for surgery as there was no evidence of pulmonary hypertension which is the main operative concern in CREST patients.,0
He also had no evidence of pulmonary fibrosis on preoperative chest x-ray.,0
It is recommended that he should followup with at for routine CREST care including high resolution Chest CT and esophageal evaluation in the future.,0
Mr. was also cleared by the dental service after bedside and radiographic examinations found no evidence of infection.,0
"On , Dr. performed an aortic valve replacment.",1
"For surgical details, please see separate dictated operative note.",0
"Following the operation, he was brought to the CSRU for invasive monitoring.",0
"On postoperative day two, he developed rapid atrial fibrillation initially treated with intravenous Amiodarone and Diltiazem.",1
He converted back to a normal sinus rhythm and transitioned back to PO beta blockade and calcium channel blockers.,0
He was transfused with PRBC for a postoperative anemia.,0
His CSRU course was otherwise uneventful and he transferred to the SDU on postoperative day three.,0
Pacing wires removed without incident on POD #4.,0
Prolonged QTc resulted in amiodarone discontinuation.,0
ACE was also titrated and pt.,0
cleared for discharge to home with services on POD #8.,0
to make all follow-up appts.,0
"Medications on Admission: Verapamil 240 qd, Lisinopril 40 qd, HCTZ 25 qd, Aspirin 81 qd, MVI, Zantac, Calcium, Iron, Lopressor 25 , Discharge Medications: 1.",0
Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed.,0
Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day.,0
Disp:*30 Tablet Sustained Release(s)* Refills:*0* 10.,0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days.,0
"Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 5 days.",0
"Disp:*10 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Care Discharge Diagnosis: Aortic Stenosis - s/p AVR, Postop Atrial Fibrillation, Hypertension, Hyperlipidemia, CREST, Obesity, Sleep Apnea, BPH, Colonic Adenoma, s/p Right Colectomy, History of GI bleed secondary to cecal polypectomy, s/p Cholecystectomy, GERD Discharge Condition: Good Discharge Instructions: Patient may shower, no baths.",1
"No creams, lotions or ointments to incisions.",0
No driving for at least one month.,0
No lifting more than 10 lbs for at least 10 weeks from the date of surgery.,0
Monitor wounds for signs of infection.,0
Please call with any concerns or questions.,0
"Followup Instructions: Dr. in weeks, call for appt Dr. in weeks, call for appt Dr. in weeks, call for appt Dr. (Rheum) after discharge Completed by:",0
Admission Date: Discharge Date: Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Flomax Attending: Chief Complaint: PNA Major Surgical or Invasive Procedure: none History of Present Illness: Mr. is an 87 yoM NH resident with PMH of Alzheimer's dementia and no known lung disease or smoking history who initially presented to for SOB and dyspnea after being found with a sat of 83% at his NH on room air.,1
Other VS included tachycardia and a FSG of >400.,0
"At that time he complained of N/V and by report, was incontinent of B/B, and more confused than baseline.",0
He was brought to and treated overnight for presumed CHF with lasix 40 mg.,0
He was also given a dose of levaquin for PNA.,0
He was also found to have a WBC of 23 and new renal insufficiency with Cr 2.4.,0
A CK was elevated at 2800.,0
"He was transferred to for further w/u of PNA, as well as concern for r/o MI if possible need for cath.",0
"In the ED, VS were rectal temp of 102, 126/79, 110, 96% NRB at 10L, RR 25; appeared comfortable.",0
"Didn't sound wet on exam, with no edema, and no obvious volume overload on CXR here.",0
"However, his CXR was concerning for a retrocardiac infiltrate.",0
"Blood cultures were drawn, and they added vanco in addition to levofloxacin b/c of his NH status and concern for PNA.",0
"His tachycardia prompted consideration of PE, but he could not receive a CT-A due to his poor renal function.",0
A V/Q scan was ordered.,0
Was not heparinized empirically b/c he was found to be guiaic positive.,0
"Finally, a CT head was performed for ?",0
"altered MS, which was negative for acute bleed or fracture.",0
Past Medical History: # Polymyalgia Rheumatica - not recently on any steroids # GERD # h/o collagenous collitis # Alzheimer's Dementia # TURP-- 20+ years ago Social History: no EtOH or tobacco history.,1
"married, retired, lives at ( ).",0
"At baseline, is alert and verbal but with confusion/dementia (oriented to person only).",0
"Ambulates independently with walker, able to feed himself.",0
"Family History: no CAD, father w/ memory problems at 90's; Physical Exam: VS: 97.0 109 (sinus tach) 142/102 23 92% on NRB--> weaned to 92% on 5L NC GEN: elderly male, NAD, A+O x 1 HEENT: NC/AT, pale COR: RRR RESP: CTAB ABD: s/nt/nd/ +BS EXT: WWP, no C/C/E Pertinent Results: 09:10AM BLOOD WBC-14.0* RBC-4.97 Hgb-16.0 Hct-45.1 MCV-91 MCH-32.3* MCHC-35.6* RDW-14.5 Plt Ct-186 12:39PM BLOOD WBC-13.0* RBC-4.64 Hgb-15.4 Hct-41.6 MCV-90 MCH-33.1* MCHC-37.0* RDW-14.3 Plt Ct-186 05:10AM BLOOD WBC-10.4 RBC-4.30* Hgb-13.8* Hct-38.4* MCV-89 MCH-32.1* MCHC-36.0* RDW-14.3 Plt Ct-190 .",0
09:10AM BLOOD PT-14.8* PTT-29.3 INR(PT)-1.3* 12:39PM BLOOD PT-14.3* PTT-27.3 INR(PT)-1.2* .,0
12:39PM BLOOD Glucose-189* UreaN-80* Creat-3.2*# Na-146* K-4.1 Cl-109* HCO3-21* AnGap-20 05:10AM BLOOD Glucose-141* UreaN-67* Creat-2.4* Na-153* K-3.4 Cl-119* HCO3-22 AnGap-15 .,0
12:39PM BLOOD CK(CPK)-1873* CK-MB-16* MB Indx-0.9 cTropnT-0.06* 05:10AM BLOOD CK(CPK)-779* CK-MB-8 cTropnT-0.06* .,0
CXR Left retrocardiac opacity concerning for pneumonia.,0
Head CT No acute intracranial hemorrhage or fracture.,0
CXR AP AND LAT 1.,0
New opacity right mid/upper zone--?aspiration or pneumonic infiltrate.,0
Suspect left lower lobe infiltrate.,0
"Lower lobe effusion on at least one side, ?",0
Chest CT Multifocal bilateral lung consolidation and ground glass changes involving all lobes worse at the right apex and bases.,0
Pneumonic consolidations and/or aspiration events should be considered with debris noted within the esophagus.,0
"CXR Brief Hospital Course: 87 year-old man, nursing home resident, presenting with health-care associated pneumonia, acute renal failure, and hypernatremia.",1
He was admitted initially to the ICU for monitoring in the setting of pneumonia and hypernatremia.,1
"He was covered broadly with vancomycin, ceftazadime, and azithromycin.",0
"On the second hospital day, his oxygen saturations had improved and he was transferred to the floors on 2L oxygen by nasal cannula.",0
"Over the weekend, he was continued on vanco/ceftaz but was noted to have increased tachypnea, tachycardia, fevers to 101, and worsening mental status.",0
"His antibiotic coverage was broadened to Flagyl for anaerobes (given concern of aspiration risk) as well as azithromycin and he was transferred back to the intensive care unit, while in the unit he was intubated.",0
His blood pressures continued to drop and he required fluids to maintain them.,0
"When they , attempt was made to diurese the patient with lasix.",0
"He had good output, but remained non-responsive despite no sedation.",0
"Per the family, a decision was made to extubate the patient.",0
His breathing became agonal and 12 hours later he expired.,0
He was admitted with creatinine of 3.2 up from baseline 1.2-1.4.,0
His acute renal failure resolved with IV hydration.,1
He received one dose of ASA in the ED.,0
There was low suspicion for ACS.,0
Cardiac enzymes were negative x2.,0
He has no diagnosis of diabetes but his sugars during this admission were elevated.,0
He was kept on insulin sliding scale.,0
Dementia We continued his outpatient Namenda.,0
This was believed due to hypovolemia in the setting of overdiuresis and aggressive rehydration with normal saline.,0
"On transfer to the floor, he was started on D5 1/2 NS for volume resuscitation and correction of hypernatremia.",0
Sodium levels were followed every six hours to avoid overcorrection.,0
"When his creatinine normalized, IVF were switched to D5W at 150 cc hour.",0
"With this treatment, his sodium gradually corrected.",0
This was not actively being treated at time of admission.,0
# FEN -- HH DM diet if able to tolerate po -- S/S consult as appears to be aspirating .,0
# ACCESS -- PIV .,0
# CODE: -- full per NH documents .,0
# COMM: -- -- wife or .,0
# DISPO: transfer to floor Medications on Admission: Namenda 10 daily KCl 20mEq daily Lasix 20mg daily omega 3 MVI Prilosec 20 Sertraline 50 qHS Senna/Colace Compazine 25mg PR daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Expired secondary to: Multifocal health-care associtated pneumonia .,0
Secondary Diagnoses Alzheimer's dementia Polymyalgia rheumatica Gastroesophageal reflux disease History of collagenous colitis History of transurethral resection of the prostate Discharge Condition: Vital signs stable.,1
Discharge Instructions: NA Followup Instructions: NA MD Completed by:,0
6:48 PM CHEST (PA & LAT) Clip # Reason: Eval acute process ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with weakness REASON FOR THIS EXAMINATION: Eval acute process ______________________________________________________________________________ FINAL REPORT INDICATION: Weakness.,0
FINDINGS: PA and lateral views of the chest redemonstrate minimal cardiomegaly.,0
Small calcified granulomas are redemonstrated over the left apex and upper mediastinum and note is made of left pleural thickening.,0
Retractile changes are also present in the left lung.,0
"The costophrenic angles are blunted bilaterally, new from comparison studies and suggesting some small pleural fluid and there is associated bibasilar consolidations, with considerations including atelectasis or infection.",1
Numerous old right rib fractures are redemonstrated.,0
New bibasilar opacities reflecting some component of small pleural effusions as well as bibasilar consolidations (infectious or atelectatic).,0
Multiple old healed right rib fractures.,0
Changes from previous granulomatous disease.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Topiramate / Aripiprazole Attending: Chief Complaint: Transfer from OSH for GI bleed Major Surgical or Invasive Procedure: Capsule endoscopy History of Present Illness: 42 y/o F with etoh cirrhosis and transferred from OSH where she originally presented on with two episodes of dark, tarry stools.",1
"OSH ED notes state patient is very well known to their ED, and had recently been admitted prior to ED presentation with large GI bleed requiring multiple transfusions and FFP.",0
"She had felt unwell the day prior to ED presentation, with some abdominal discomfort and decreased appetite.",0
"While at Hospital, the patient had working diagnosis of LGIB.",0
"Had upper and lower endoscopies revealing ulcers in distal esophageus at site of previous banding, mild gastritis in body/antrum of stomach, but no evidence of active bleeding.",0
"Per GI fellow, colonoscopy earlier today reportedly revealed non-bleeding internal hemorrhoids--there is no record of this in transfer paperwork.",0
"Per d/c summary, the patient did not have a hematocrit drop and was hemodynamically stable, was tolerating PO diet and had a benign abdominal exam.",0
The patient was transferred to for further workup to possibly include capsule endoscopy.,0
"VS as reported on d/c summary prior to transfer were 98.2, 99/16, 64, 20, 95% RA.",0
"Labs were INR 1.59, with normal Chem7 and Hct 29.6.",0
"Of note, AMA form signed by patient on , but lab technician confirmed that patient has been admitted since that day.",0
"Per OSH med sheets and paper orders, Protonix and octreotide gtt were started on .",0
She was given vitamin K 10 mg daily on and earlier today.,0
"Regular diet was started this afternoon, and her telemetry was discontinued.",0
"It appeared that the patient was ordered for a CT angiogram in the early morning of to evaluate for rectal bleeding, but this was later held.",0
"Review of sytems: Patient states ""everything,"" when asked if anything is bothering her.",0
"When requested to specify, she denies everything except anxiety and displeasure at being in hospital overnight.",0
"Specifically denied chest pain, dyspnea, abdominal pain, nausea, vomiting, diarrhea, tingling, or numbness.",0
"On floor, patient was tearful and anxious, stating her desire to go home and return for her capsule study tomorrow.",0
Past Medical History: Alcoholic cirrhosis s/p cholecystectomy Gastroesophageal reflux disease Bipolar disorder Htn Depression/anxiety Social History: Not participating in interview.,1
"Per OSH ED notes, SocHx notable for ""recently stopped drinking alcohol.""",0
"Per prior d/c summary in : ""Smokes 1 pack of cigarrettes per 1-2 weeks.",0
"Drinks heavily, unable to quantify how much.",0
Drink rum when husband is home (2 days per week).,0
Describes herself as a binge drinker - unable to say how much.,0
Denies current or prior IVDU.,0
"Lives with husband and 2 children, ages 14 and 15.""",0
"Physical Exam: Physical exam on discharge: VS - Temp 98.1, BP 94/58 , HR 73 , RR 18 , O2-sat 98% RA GENERAL - disheveled, anxious caucasian woman HEENT - NC/AT, EOMI, sclerae anicteric NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) LYMPH - no cervical LAD NEURO - awake, alert, oriented, muscle strength 5/5 throughout, sensation grossly intact throughout.",0
gait steady Pertinent Results: 1.,0
Labs on admission: 11:30PM BLOOD WBC-3.5*# RBC-3.12* Hgb-9.5* Hct-28.1* MCV-90# MCH-30.4# MCHC-33.8 RDW-19.0* Plt Ct-131*# 11:30PM BLOOD Neuts-59.2 Lymphs-25.1 Monos-9.9 Eos-4.2* Baso-1.6 11:30PM BLOOD PT-20.0* PTT-37.0* INR(PT)-1.8* 11:30PM BLOOD Fibrino-148* 11:30PM BLOOD Glucose-97 UreaN-5* Creat-0.4 Na-138 K-3.9 Cl-110* HCO3-23 AnGap-9 11:30PM BLOOD ALT-24 AST-51* LD(LDH)-127 AlkPhos-69 TotBili-1.4 11:30PM BLOOD Calcium-7.8* Phos-4.0 Mg-1.5* .,0
Labs on discharge: 05:10AM BLOOD WBC-5.5 RBC-3.35* Hgb-10.3* Hct-30.1* MCV-90 MCH-30.6 MCHC-34.0 RDW-18.5* Plt Ct-98* 05:10AM BLOOD PT-23.6* PTT-48.8* INR(PT)-2.2* 05:10AM BLOOD Glucose-84 UreaN-3* Creat-0.3* Na-136 K-3.2* Cl-105 HCO3-23 AnGap-11 05:10AM BLOOD ALT-27 AST-55* AlkPhos-118* TotBili-3.5* 05:10AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.5* .,0
"Imaging/diagnostics: - Capsule endoscopy (): Evidence of scars from prior banding, no varices seen.",0
Congestion and mosaic appearance in the stomach compatible with portal gastropathy.,0
No signs of active or recent bleeding.,0
No blood or clot seen anywhere in the lumen.,0
Otherwise normal small bowel enteroscopy to mid-distal small bowel (3M of scope inserted.,0
- Meckel's scan (): No evidence for Meckel diverticulum .,0
- CTA abdomen pelvis (): 1.,0
Intraluminal hyperdensity in the cecum and the right ascending colon consistent with gastrointestinal bleeding (the patient did not receive oral contrast).,0
No evidence of active bleeding or cause of gastrointestinal bleeding is seen.,0
Cirrhotic liver with multiple arterial enhancing lesions measuring up to 1.1 cm which were not appreciated on the prior MRI study from .,0
The differential diagnosis includes multifocal HCC vs. multiple regenrative nodules.,0
Further evaluation is recommended by MRI.,0
"Signs of portal hypertension with paraesophageal, esophageal and retroperitoneal varices, splenomegaly and small amount of ascites.",1
"Diffuse edema of the stomach wall and right colon, most probably due to cirrhosis.",0
Small left adrenal nodule which could also be evaluated at the time of the MRI study.,0
Old fractures at the anterior portions of ribs four and five on the right.,0
- CXR (): No active disease in the chest .,0
- GI bleeding study #1 (): No active hemorrhage .,0
- GI bleeding study # 2 (): No site of active extravasation identified .,0
- CT head w/o contrast (): No acute intracranial process .,0
- Abdominal ultrasound with Doppler (): 1.,0
"Flow within the right portal vein is noted to be in the direction of the TIPS shunt; however, flow in the left portal vein is noted to be away from the shunt.",0
A single hypoechoic lesion measuring 1.1 cm is seen in segment II corresponding with a small early enhancing lesion seen on the recent CT of .,0
"Brief Hospital Course: 42 yo F with alcoholic cirrhosis, complicated by variceal bleed and ascites, transferred from OSH where she presented with melena, s/p EGD and colonoscopy with varices banded, here for workup of bleeding source.",1
# GI bleed/anemia: Patient had ~1 unit of pRBC requirement for the first 5 days of admission.,0
Capsule endoscopy showed possible small bowel bleed but no concrete source.,0
CTA on floor no acute.,0
On hospital day 6 patient developed large- volume melena and hematemesis.,0
Code blue was called though patient never developed asystole.,0
Patient was emergent transferred to MICU where she was intubated for airway protection.,0
An endoscopy in the ICU showed varices but no evidence of recent bleed.,0
Patient was transfused 6Uprbcs and 1U FFP over first 24 hours ICU stay.,0
Tagged blood scan during first ICU day showed no active bleed.,0
"Repeat EGD showed duodenal variceal bleed, and patient went to IR for successful TIPS and embolization of duodenal varix.",0
Patient remained h/d stable for the next three days without change in her H/H.,0
"Continued to have hematochezia during ICU stay, but gastroenterology said this was expected even without further bleed given initial large volume of bleed.",0
"Back on the floor, patient remained hemodynamically stable with Hct ~28 for the remained of the hospitalization.",0
She was discharged with close followup with outpatient gastroenterologist.,0
"# Alcoholic cirrhosis: Patient had minimal jaundice and ascites on admission, which did not change.",1
"She initially developed encephalopathy after TIPS placement, which improved after rifaximin and lactulose.",0
"# Alcohol abuse: Patient has significant alcohol abuse history, though reports on admission that she had quit recently.",0
She was placed on CIWA scale but never showed signs of withdrawal.,0
Continued thiamine and folic acid.,0
Social work consul was obtained.,0
Patient will resume care with outpatient psychiatrist on discharge.,0
# Bipolar/depression: Patient was kept on home regimen of risperidone and trazodone prn for insomnia while taking po.,0
Psych was consulted after patient was extubated in the ICU and thought she was unable to understand her medical condition.,0
This improved after resolution of her post-TIPS encephalopathy.,0
Medications on Admission: CURRENT MEDICATIONS: (transfer meds) calcium 500mg PO BID Thiamine 100mg PO daily MVI tab PO daily Magnesium 800mg PO daily Latulose 30cc mix c OJ PO Q4H Iron sulfate 325mg PO BID Lasix 40mg PO daily Lidocaine patch to LB Q12H Nadolol 20 mg PO daily Omeprazole 20 mg PO BID .,0
"HOME MEDS: Levaquin 500mg every other day Lasix PO 60mg QAM 40mg Q PM Risperidone 0.5mg Trazodone 100mg PO QHS PRN Vitamin D 8000 unit/mL daily Folate 1 mg PO daily Aldactone 150 mg PO BID Lasix 40 mg PO ""daily, nightly"" Omeprazole 40 mg PO daily Amitiza 24 mcg PO BID Calcium FeSO4 325 mg PO BID Xifaxan two tablets Lactulose 30 g PO QID Discharge Medications: 1.",0
"Outpatient Lab Work Please check AST, ALT, Alk Phos, , INR, PTT, PT, CHEM 10 and fax to Dr. at .",0
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Disp:*60 Tablet(s)* Refills:*2* 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day).,0
"Disp:*3600 ML(s)* Refills:*2* 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
PO once a day: Ok to substitute omeprazole 40 mg qd if insurance does not cover.,0
)(s)* Refills:*2* 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*2* 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day.",0
Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Upper dastrointestinal bleed from duodenal varix Alcoholic cirrhosis Anemia Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Ms. , you were transferred to the because you had recurrent bleeding form your GI tract.",0
We transfused you with blood.,0
We did many tests to try to find the source of your bleeding.,0
"There included a small capsule endoscopy, a Meckel's scan, and multiple upper GI endoscopies.",0
We found that you had a blood vessel in your small intestine that was bleeding.,1
We did a procedure to decrease the blood flow to that area and the bleeding stopped.,1
Here is what we are sending you home on: LACTULOSE 30mL four times a day - make sure you have bowel movements a day.,0
"If you have less, take an additional dose.",0
RIFAXAMIN 550mg twice a day PANTROPRAZOLE 40mg once a day (for acid in your stomach) CALCIUM/VITAMIN D THIAMINE FOLIC ACID You do not need to take lasix or aldactone.,0
Dr. will determine if you need to restart this medication.,0
"***If you or your family notice that your thinking is unclear or you are confusion, TAKE AN EXTRA DOSE OF LACTULOSE and call Dr. at .",0
"***If you notice increase swelling in your legs or abdomen, call Dr. at .",0
"Finally, you have been given a prescription to have your labs checked.",0
Please have them check on Monday or Tuesday so they will be available when you see Dr. on Thursday.,0
The results will be faxed to Dr. office.,0
IT IS ESSENTIAL that you never drink alcohol again as you could die.,1
You were given information about relapse prevention programs which are very important to your recovery.,0
Please contact them as soon as you are home to arrange for follow up.,0
It was a pleasure meeting you and participating in your care.,0
Followup Instructions: An appointment has been made for you with Dr. on Thursday at 3:45pm.,0
", MA phone: fax: MD Completed by:",0
7:52 AM CT HEAD W/O CONTRAST Clip # Reason: eval Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: year old woman with sah and ivh REASON FOR THIS EXAMINATION: eval No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Follow up for subarachnoid and interventricular hemorrhage.,1
"TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT CONTRAST: Again noted is a moderate amount of subarachnoid hemorrhage extending into the lateral, 3rd and 4th ventricles.",1
There is no mass effect or shift of the normally mid-line structures.,0
Again noted is hypodensities in the periventricular white matter area bilaterally consistent with chronic microvascular infarction.,0
There is dense calcification of the supraclinoid carotid arteries.,0
Fluid/mucus is again noted in the right sphenoid sinus.,0
Lense replacements are seen in the orbits.,0
IMPRESSION: Unchanged appearance of moderate subarachnoid hemorrhage with intraventricular extension and hydrocephalus.,1
PATIENT/TEST INFORMATION: Indication: Atrial ectopy.,0
Height: (in) 61 Weight (lb): 145 BSA (m2): 1.65 m2 BP (mm Hg): 116/40 HR (bpm): 91 Status: Inpatient Date/Time: at 10:01 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
GENERAL COMMENTS: Suboptimal image quality - body habitus.,0
At least mild to moderate (+) mitral regurgitation is seen.,0
Mild left ventricular hypertrophy with normal global biventricular systolic function.,0
Compared with the prior study (images reviewed) of the severity of mitral regurgitation has increased and mild pulmonary artery systolic hypertension is now identified.,1
5:22 AM CHEST (PORTABLE AP) Clip # Reason: eval ards Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with hep c cirrhosis s/p OLTx.,0
Now s/p R chest tube removal.,0
REASON FOR THIS EXAMINATION: eval ards ______________________________________________________________________________ FINAL REPORT INDICATION: Status post liver transplant.,0
AP view of the chest dated is compared to AP view of the chest dated .,0
"FINDINGS: The ET tube, left IJ catheter and right Swan-Ganz catheter remain in good position.",0
The NG tube tip remains in good position in the stomach.,0
A second feeding tube is seen entering the duodenum.,0
Its tip is difficult to localize.,0
The diffuse pulmonary opacities are unchanged.,0
The right costophrenic angle is not included on this image.,0
"IMPRESSION: No change in the extent of the diffuse bilateral pulmonary opacities, which are consistent with ARDS.",0
", M. MED FA2 10:55 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Please give IV and po contrast.",0
Eval for progression of flui Admitting Diagnosis: NAUSEA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 21 year old woman with intraabdominal fluid collection s/p IR drainage.,0
"Also vomiting, not tolerating pos.",0
REASON FOR THIS EXAMINATION: Please give IV and po contrast.,0
Eval for progression of fluid collection.,0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Interval decrease in size of abdominal fluid collection with a drain in place.,0
Tiny foci of gas in the abdominal mesenteric fat adjacent to this drain likely related to the presence of the drain.,0
9:15 AM CHEST (PA & LAT) Clip # Reason: ?,0
Admitting Diagnosis: GERD/SDA ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman s/p lap nissen re-exploration POD5 for leak REASON FOR THIS EXAMINATION: ?,0
______________________________________________________________________________ FINAL REPORT TWO VIEW CHEST OF COMPARISON: .,0
INDICATION: Status post laparoscopic surgery with complication of leak.,0
"A left-sided chest tube remains in place, unchanged in position.",0
A small left pleural effusion and a small loculated left hydropneumothorax are without interval change as well as adjacent atelectatic changes within the left lower lobe and inferior aspect of the lingula.,0
Cardiac and mediastinal contours are normal.,0
"The right lung remains clear, and there is no evidence of right pleural effusion.",0
Postoperative changes are again demonstrated in the left upper quadrant.,0
IMPRESSION: No significant change in left pleural effusion and small loculated hydropneumothorax.,0
5:47 PM PICC LINE PLACMENT SCH Clip # Reason: pls place picc Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with colitis, ESRD on PD now on several abx REASON FOR THIS EXAMINATION: pls place picc ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: 78-year-old man with coronary artery disease, colitis, and peritonitis.",1
Request is made for PICC line placement for long-term antibiotics.,0
STAFF RADIOLOGISTS: Dr. who supervised the procedure.,0
ANESTHESIA: 1% lidocaine for local anesthesia.,0
PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and placed supine on the imaging table.,0
The right upper arm was prepped and draped in the usual sterile fashion.,0
Access was obtained into the right basilic vein under ultrasound guidance with a micropuncture needle through which an 0.18 wire was passed and advanced into the SVC under flouroscopic guidance.,0
Hard copy ultrasound images were obtained before and after access.,0
The needle was replaced with a 5 French peel-away sheath.,0
A new 38-cm double- lumen Vaxcel 5 French PICC line was advanced over the wire into the SVC.,0
The wire was removed and the sheath was peeled away.,0
Both ports were flushed with saline.,0
IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right basilic vein with tip in the SVC.,0
The catheter is ready to use.,0
"3:57 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: FEVER;COUGH ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with LLL, RUL PNA, hypoxic resp failure, intubated.",0
"REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:29 A.M, HISTORY: Bilateral pneumonia.",1
"IMPRESSION: AP chest compared to through 11: Compared to the supine chest radiograph on , the large left pleural effusion may be smaller.",1
"Extensive consolidation in the left lower lung and right upper lobes is stable, and there is worsening consolidation at the right lung base due to spreading multilobar pneumonia.",0
"ET tube ends above the upper margin of the clavicles, at least 6 cm above the carina and can be safely advanced to 2.5 cm.",0
"Dr. was paged, covered by Dr. .",0
"3:57 PM CHEST (PORTABLE AP) Clip # Reason: Eval for PTX and chest tube placement Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman s/p L. thoracotomy, LUL lobectomy REASON FOR THIS EXAMINATION: Eval for PTX and chest tube placement ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Left upper lobectomy.",1
CHEST: Left upper lobectomy has been performed.,0
Two chest tubes are present on the left side.,0
A right upper mediastinal density is seen which is thought to represent a collapsed right upper lobe with elevation of the minor fissure.,0
IMPRESSION: Probable collapse of right upper lobe.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: DKA Major Surgical or Invasive Procedure: None.,0
"History of Present Illness: This is a 47-year-old woman with a history of DM I, multiple admissions for gastroparesis and DKA, who presents from home with one-day history of nausea/vomiting consistent with previous bouts of gastroparesis.",0
Patient states she had been feeling nauseated for most of the day and had not eaten very much; she says she took her lantus this morning and was compliant with her sliding scale during the day.,0
"She had poor PO intake, and started vomiting around 7pm.",0
"Denies any change in routine since last discharge, no fevers, chills, cough, dysuria, headache, or rash.",0
"Of note, Ms. had a recent admission on for gastroparesis flare and had EGD botox injections by GI.",0
She was also seen by in the hospital and her lantus dose was increased to 30 units at bedtime.,0
She was discharged on levaquin and metronidazole for treatment of presumed aspiration pneumonia (course ended on ).,0
"Patient says that the only medication she takes is insulin, zofran, and ativan.",0
"She has not been taking her metoprolol, lisinopril, nexium.",0
"In the ED, initial vital were: 98.2, 130, 152/98, 24, and 100% on room air.",0
Labs were significant for a glucose of 637 and an anion gap of 22.,0
"Patient received 2 liters of normal saline, 8 units of IV insulin, and started on an insulin gtt at 8 units/hours.",0
She was also given zofran and ativan for nausea with little effect.,0
EKG was significant for sinus tachycardia with some peaked T's with a K of 5.6.,0
"Vitals on transfer to the MICU were: afebrile, 135 128/73 20 100%2L.",0
"Past Medical History: Type I Diabetes: neuropathy, h/o gastroparesis, h/o gastric pacer Hypertension GERD/Esophagitis Port placement in secondary to poor IV access Social History: Lives at home with her husband and has no children.",1
"She denies tobacco, alcohol and drug use.",0
"Works in a development office at , although currently on short-term disability.",0
Family History: Mother had lung cancer and diabetes.,0
Father died of heart disease.,0
Maternal grandmother and uncle have .,0
"# DKA: Unclear trigger, though unclear how compliant patient has been with her medications.",0
MI was ruled out with negative enzymes and UA and CXR were all negative for acute infectious process.,0
Insulin drip downtitrated with improvement in blood sugars and she was transitioned to subcutaneous insulin.,0
She was given 15 units lantus in pm on units in am on and her usual 30 units on in pm.,0
Her anion gap remained closed and she tolerated several meals on without further nausea or vomiting.,0
Blood sugars prior to discharge ranged 100-200s.,0
# GASTROPARESIS: Patient has failed multiple treatment modalities for gastroparesis.,0
Appears as though she has minimal benefit from botox injections in past.,0
Nausea was improved on and she was toelrating a diet so GI was not consulted.,0
She was treated symptomatically with anti-emetics.,0
"# EMESIS: Upon arrival to the MICU, patient had continued retching and emesis.",0
flecks of coffee ground material in emesis basin from dried blood likely from known severe esophagitis and irritation.,0
HCT trended down but she was likely hemconcentrated on admission and it was not far from baseline.,0
She was treated with IV PPI which was changed to PO when tolerating POs.,0
#?UTI: urine sample concerning for UTI and she was started on cipro.,0
Repeat UA was unconcerning for infection and antibiotics were discontinued.,0
She denied dysuria on discharge # HTN: Initially held home antihypertensives but then restarted on .,0
# DMI: Continued Lantus 30units QHS and humalog sliding scale once gap has closed.,0
"Medications on Admission: Metoprolol tartrate 50 mg Lisinopril 20mg QD Scopolamine patch Lorazepam 0.5mg prn nausea Doperidone Lantus 30 units at bedtime Humalog sliding scale Compazine 5mg tablets, every 6 hours Zofran 8mg every 8 hours prn nausea Metronidazole 500mg Q8 hours (supposed to be finished on , but patient says she is still taking this).",0
Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"3. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
4. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime.,0
Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day.,0
6. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea.,0
Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea.,0
Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea.,0
"Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic ketoacidosis Gastroparesis Secondary Diagnosis: Type I Diabetes Neuropathy Gastroparesis (s/p gastric pacemaker placement, botox injections) Hypertension GERD/Esophagitis Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: Dear Ms. , It was a pleasure participating in your health care at .",0
You were admitted to the hospital with diabetic ketoacidosis.,0
You were treated in the intensive care unit with an insulin drip.,0
"You also had nausea and vomiting, likely related to gastroparesis.",0
This has improved with Zofran and Compazine.,0
No changes were made to your home medications.,0
"Please continue your home medications Followup Instructions: Please follow up with your primary care doctor: Provider: , Phone: Date/Time: 9:45AM Department: INFUSION/ UNIT When: WEDNESDAY at 7:15 AM Building: GZ BUILDING (FELBEERG/ COMPLEX) Campus: EAST Best Parking: Main Garage Department: RADIOLOGY When: WEDNESDAY at 8:30 AM With: RADIOLOGY Building: (, MA) Campus: OFF CAMPUS Best Parking: On Street Parking",0
", T. SICU-A 11:36 AM CHEST PORT.",0
"LINE PLACEMENT Clip # Reason: Pt had a right sided picc line placed,42cm and needs tip con Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with recent CVA who needs picc line for access.",0
"REASON FOR THIS EXAMINATION: Pt had a right sided picc line placed,42cm and needs tip confirmation please page Cardmel at with wet read,thanks.",0
______________________________________________________________________________ PFI REPORT PICC line terminates in superior vena cava.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB ID: Baby Girl is a 10 day old former 33 wk premature infant being transferred from the NICU to the Special Care Nursery.,0
HISTORY OF PRESENT ILLNESS: Baby girl was delivered at 33 and 5/7 weeks gestation on and was admitted to the newborn intensive care nursery for management of prematurity.,1
Her birth weight was 1885 grams.,0
Mother is a 35-year-old gravida 1 with estimated date of delivery .,0
"Her prenatal screens included blood type A positive, antibody positive (nonspecific), hepatitis B surface antigen negative, RPR nonreactive, rubella immune, and group B strep unknown.",0
Pregnancy was complicated by anxiety treated with nortriptyline and pregnancy induced hypertension.,0
She presented to from on due to worsening pregnancy induced hypertension treated with magnesium sulfate and betamethasone.,0
Delivery was by cesarean section for worsening pregnancy induced hypertension.,1
The infant emerged active and crying.,0
Apgar scores were 8 and 9 at 1 and 5 minutes respectively.,0
She was noted to have a low heart rate in the 95 to 110 range prior to and after delivery with good color and respiratory effort.,1
"PHYSICAL EXAMINATION: Birth weight 1885 grams (50th percentile), head circumference 31 cm (50th percentile), length 46.5 cm (75th to 90th percentile).",0
"In general she was pink, well perfused infant, anterior fontanel soft, flat, sutures normal, intact palate, no dysmorphic features, neck supple, eyes with red reflex deferred.",0
Mild grunting and subcostal retractions.,0
"GENITOURINARY: Normal female external genitalia, anus patent.",0
"SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Respiratory distress was noted on admission, and infant was begun on CPAP therapy.",1
FiO2 remained near room air.,0
"Around 18 hours of life she transitioned off CPAP to room air and has remained in room air since then, with comfortable work of breathing, respiratory rates in the 30 to 50s, and oxygen saturations in room air greater than 96%.",0
Course was consistent with mild RDS.,0
"Mild apnea of prematurity and immaturity of respiratory control has also been noted, with 1-2 spells seen per day.",1
"These continue at the time of transfer, and have not been treated with medications.",0
CARDIOVASCULAR: She was noted to have a low resting heart rate at birth at 95 to 110 range.,0
"An EKG was done showing normal sinus rhythm, normal axis, normal PR and QRS intervals, and normal ventricular forces.",0
By day of life 4 her heart rates were in the more usual range of 120 to 150's and have remained stable since then.,0
"No murmur has been heard, and infant was hemodynamically stable throughout.",0
"FLUIDS, ELECTROLYTES AND NUTRITION: The infant was initially NPO and maintained on intravenous fluid of 10% dextrose.",0
Enteral feeds were started on day of life 1 and she advanced to full volume feeds on day of life 5 without difficulty.,0
"She is currently receiving breast milk with human milk fortified equal to 24 calories per ounce or if no breast milk is available, Similac special care 24 calories per ounce at 150 ml per kg per day.",0
She is alternating PO and gavage feedings and attempting to breast feed.,0
Her discharge weight is grams.,0
"GASTROINTESTINAL: Peak bilirubin was total 9.5, direct 0.4 on .",0
She received 1 day of phototherapy.,0
"Her most recent bilirubin on was 4.6, direct 0.2.",0
HEMATOLOGY: Hematocrit at birth was 51%.,0
She was started on iron supplementation.,0
INFECTIOUS DISEASE: CBC and blood culture was done on admission due to respiratory distress.,1
She received 48 hours of ampicillin and gentamycin.,0
Blood culture was negative and CBC was benign.,0
NEUROLOGY: Head ultrasound was not indicated.,0
SENSORY: Audiology- hearing testing has not been performed.,0
CONDITION ON DISCHARGE: Stable preterm infant with unresolved apnea of prematurity learning to PO feed.,1
DISCHARGE DISPOSITION: Transferred to .,0
NAME OF PRIMARY PEDIATRICIAN: Dr. in .,0
"Feeds: Breast milk 24 calorie per ounce or Similac special care 24 calories per ounce at 150 ml per kg per day, advance PO and breast feeding as tolerated.",0
Medications: Ferrous sulfate 0.15 ml daily.,0
Car seat position test has not been performed but is recommended prior to discharge.,0
State newborn screen has been sent and is pending.,0
Immunizations received: She has not received any immunizations.,0
Immunizations Recommended: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria.,0
Born at less than 32 weeks; 2.,0
"Born between 32 and 35 weeks with two of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; or 3.",0
"Appropriate for gestational age, preterm female.",1
"Low resting heart rate, resolved.",0
", MD Dictated By: MEDQUIST36 D: 22:08:46 T: 00:11:01 Job#:",0
"1:22 AM CHEST (PORTABLE AP) Clip # Reason: s/p RIJ CVP cahnged over the wire Admitting Diagnosis: HEPATITIS B, HEPITOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with segment 6 liver resection, RIJ CVL REASON FOR THIS EXAMINATION: s/p RIJ CVP cahnged over the wire ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: A 69-year-old male status post segment 6 hepatic resection.",1
New right internal jugular central line placement.,0
PORTABLE AP CHEST: Comparison is made to a prior study dated .,0
There has been interval removal of previously evident endotracheal tube.,0
Enteric tube courses well below the level of the hemidiaphragm.,0
Right IJ central venous catheter terminates within the distal SVC.,0
There is no associated pneumothorax.,0
"There is increased haziness within the right lung, suggesting a layering effusion on this supine film.",0
There has been interval development of a right upper lobe air space opacity concerning for pneumonia.,0
Left lung appears grossly clear.,0
IMPRESSION: 1) Satisfactory positioning of right IJ central venous catheter.,0
2) Right upper lobe air space opacity consistent with pneumonia.,0
3) Layering right pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Vicodin Attending: Chief Complaint: SOB, hypoxia, tachycardia after debulking nephrectomy Major Surgical or Invasive Procedure: Left debulking nephrectomy Flexible Bronchoscopy Left chest tube placement and removal History of Present Illness: Ms. is a 57-year-old female with renal cell carcinoma metastatic to bone and lung (including mediastinal dz compressing airways) who recently presented with cough and episodes of hemoptysis found to have a left renal mass and lung metastasis.",1
The renal mass was biopsied in and proved to be renal cell carcinoma.,0
"She had bronchoscopy with argon laser ablation and resection of endobronchial tumor, along with y-stent placement on .",0
Further imaging studies of the brain showed a lytic lesion in the skull measuring 5 cm.,0
There is also palpable abnormality in the skull treated with palliative radiation therapy.,0
On she had a radical left nephrectomy which involved entry into the chest and placement of a Chest tube; transfused 2 units in the OR.,0
Chest tube was pulled on wuth subsequent CXR revealing 30% pneumothorax and new atelectasis of the left lower lobe.,0
Plan was to follow pneumothorax with imaging until resolution and bronch on for new LLL findings.,0
"Early on , she desaturated to the low 70s repeatedly when taking off her shovel mask.",0
New tachycardia to the 130s prompted a repeat CXR which demonstrated new opacity over entire left lung field.,0
She was given lopressor 5mg IV and HR decreased to low 100s; O2 sat improved to mid 90s on 2L nc with coughing.,0
Transferred to for further mgt and bronchoscopy.,0
"Vitals at initial evaluation: 99.9, 136/76, HR 135-->100s, 16, 97% face mask.",0
"In , she had bronchoscopy on which revealed thick green copious secretions completely obstructing the left limb of the Y-stent and had therapeutic cleaning both of the right and left limb of the Y-stent.",0
"Subsequently, O2 sats on 50%FM 90-95% and remained tachycardic 120s (sinus) so was bolused with IVF.",0
"She received Vitamin K (5mg, then 10mg) for INR 2s.",0
"After multiple IVF boluses, HR came down slightly to 90s-100s and HCT was stable so she was subsequwntly called out to floor, initially to hospitalist service then transferred to OMED.",0
"This am, pt reports breathing still labored but overall improved.",0
Pain well controlled in abdomen at incision site but ahs increased pain with coughing.,0
Using flutter valve and IS.,0
"Denies CP, N/V/D, fever, chills.",0
"Past Medical History: Renal CA metastatic to skull, R hip, lungs, medistiastinum Airway compression s/p y-stent sciatica Social History: Married.",1
"Occ Etoh, 30-40pkyr Hx of smoking, no illicits Family History: .",0
The left chest tube is in place.,0
The cardiomediastinal silhouette is unchanged including the known mediastinal and bilateral hilar lymphadenopathy.,0
"CXR:FINDINGS: In comparison with the study of , following placement of the chest tube to waterseal, there may be a very tiny left apical pneumothorax medially, though this would be of no clinical significance.",0
The striking prominence of the hila bilaterally is consistent with extensive lymphadenopathy seen on the CT of .,0
CXR: IMPRESSION: Interval opacification of the left hemithorax likely related to significant increase in left pleural effusion with a component of atelectasis of the left upper and lower lobes.,0
CXR:IMPRESSION: Improved aeration of the left lung.,0
"Persistent opacification of the right upper lobe, raises the possibility of aspiration.",0
"Right posterior acetabular and left anterosuperior acetabular lytic lesions, most likely representing renal metastases.",0
These lesion were better depicted on the CT scan.,0
Equivocal lucency in the left anterior/subtrochanteric femur without definite corresponding lesion on the recent CT scan.,0
"Attention to this area on followup xray examination or, alternatively, if desired, further assessment with MR imaging could be performed.",0
Pathology MACROSCOPIC Specimen Type: Left radical nephrectomy.,0
Tumor Size Greatest dimension: 15.6 cm.,0
Macroscopic extent of tumor: Tumor extension into perinephric tissues.,0
MICROSCOPIC Histologic Type: Conventional (clear cell) renal cell carcinoma.,0
"Histologic Grade: G3: Nuclei very irregular, approximately 20 microns;nucleoli large and prominent.",0
EXTENT OF INVASION Primary Tumor: pT3a: Tumor directly invades perirenal and/or renal sinus fat but not beyond Gerota's fascia.,0
Regional Lymph Nodes: pNX: Cannot be assessed.,0
"Distant metastasis: pM1: Distant metastasis, lung (see separate pathology report #S09-).",0
Margins: Uninvolved by invasive carcinoma.,0
Adrenal gland: Uninvolved by tumor.,0
Additional Pathologic Findings: None identified.,0
Brief Hospital Course: Floor course prior to ICU transfer: Pt was admitted to Dr. Urology service after undergoing L debulking nephrectomy.,0
Please see the dictated operative note for details.,0
"In the first two post-operative days, pain control was especially difficult to obtain.",0
"Although the epidural catheter was working, its level was too high to cover the entire incision, and a significant narcotic load was necessary to control the pt's pain.",0
The patient's urine output remained excellent.,0
"On , the chest tube was removed, and post-pull CXR showed a 20-30% PTX and new left lower lobe collapse, likely from mucus plugging.",0
"Interventional pulmonology was consulted, who recommended bronchoscopy in the AM of .",0
"However, early in the AM of , she had oxygen desaturation down to 70% and was transferred to the , where she was stabilized.",0
course: On she had a radical left nephrectomy which involved entry into the chest and placement of a Chest tube; transfused 2 units in the OR.,0
Transferred to FICUon for further mgt and bronchoscopy.,0
"Vitals at initial evaluation: 99.9, 136/76, HR 135-->100s, 16, 97% fase mask.",0
Bronch done revealing extensive accumulation of mucus more so in left lung than right.,0
Procedure complicated by delirium likely from sedation.,1
Repeat CXR demonstrated renewed aeration of the lung.,0
"Pt oxygen requirement improved over , and plan to call out of the on was delayed by tachycardia and poor venous access.",0
Sinus Tachycardia into the 130s improved s/p 2L NS.,0
PICC was placed for venous access--PA/LATERAL ordered to confirm Picc placemant as ther was some concern that it might be coiled on portable film but was in place on repeat film.,0
"On the floor, she was called out to Medical Oncology.",0
Her pain was controlled with Dilaudid PCA initially which was subsequently changed to MS Contin with PO dilaudid for breakthrough.,0
She was seen by orthoopedics to clarify weightbearing status since had hip metastases with cortical involvement on CT. Orthopedics recommended weight bearing as tolerated using walker and she cleared physical therapy for discharge home with home PT.,0
She was instructed to follow up with Ortho (Dr. ) and have serial CTs on time course per their recommendations to monitor metastatic disease.,0
She was weaned off oxygen and was satting mid 90s at rest on room air and 88-91% with ambulation on discharge.,0
She was given prescription for home oxygento use with exertion.,0
"She was continued on nebs including mucomyst, levalbuterol and ipratropium and given flutter valve device.",0
"Medications on Admission: Folate xanax xopenex dilaudid (2mg tabs, 7-8 tabs/day x 2 months) metoclopramide Tessalon perles Discharge Medications: 1.",0
Home Oxygen Home Oxygen at 4L via NC conserving device for portability 2.,0
Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours).,0
Disp:*30 Tablet Sustained Release(s)* Refills:*0* 6.,0
Cool mist Cool mist via face tent at 4L 7.,0
Home neb Home nebulizer and supplies 8.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain.,0
Tessalon Perle 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for cough.,0
Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb Miscellaneous every six (6) hours as needed for cough.,0
Disp:*90 nebulized solution* Refills:*0* 11.,0
Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q4h () as needed for cough.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours).,0
Reglan 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea.,0
"Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO twice a day.",0
Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day.,0
Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for anxiety.,0
"Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Primary Diagnosis Renal cell Carcinoma Pneumothorax Lung collapse secondary to secretion impaction Secondary Diagnosis Sciatica Discharge Condition: hemodynamically stable, oxygen sats mid to high 90s on room air, high 80s to low 90s with ambulation.",1
Please use walker for ambulation.,0
Discharge Instructions: You were admitted to the hospital for a left nephrectomy (surgical removal of your kidney).,1
"After your surgery, you had some shortness of breath and were transferred to the intensive care unit.",0
You had a procedure which removed mucus from your airway and your breathing improved.,0
You also had a chest tube which was subsequently removed.,0
We made the following changes to your medications.,0
We added ativan as needed for anxiety We added mucomyst nebs We added ipratropium nebs We added MS contin for pain control and you should take We continued your dilaudid for pain We added lactulose as needed for constipation We added home oxygen which you should use with ambulation.,0
"Please return to the ER or call your primary care physician if you develop chest pain, shortness of breath, dizziness, abdominal pain lightheadedness, fever, chills, redness or drainage from your wound, or any other concerning symptoms.",0
"Followup Instructions: Please follow up with your oncologist as follows: Provider: , MD Phone: Date/Time: 3:30 Provider: , MD Phone: Date/Time: 3:30 Please follow up with Urology as follows for follow-up and removal of your staples: , M.D.",0
Phone: Date/Time: 8:30 Please follow up with Dr. .,0
You are scheduled to come to the Chest Disease Center on the ( 1) on .,0
Dr. wants to see you in clinic and do a repeat bronchoscopy to evaluate the Y-stent.,0
"Please do not eat or drink anything after midnight the night before, you may take your regular medications.",0
Please call ( with questions.,0
Please also follow up with orthopaedics (Dr. ) for re-evaluation of your right hip.,0
Call for an appointment in the next 3-4 weeks.,0
Height: (in) 59 Weight (lb): 140 BSA (m2): 1.59 m2 BP (mm Hg): 108/44 HR (bpm): 135 Status: Inpatient Date/Time: at 15:22 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure (0-5mmHg).,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - akinetic; septal apex- akinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
There is mild regional left ventricular systolic dysfunction with akinesis of the distal half of the septum and moderate global hypokinesis of the remaining segments (LVEF = 30 %).,0
"Normal left ventricular cavity size with diffuse biventricular systolic dysfunction c/w multivessel CAD, toxin, metabolic, etc.",1
"Compared with the prior study (images reviewed) of , biventricular systolic function is now depressed.",0
GALLIUM SCAN Clip # Reason: FEVERS OF UNKNOWN ORIGIN.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Forty-four year old male with persistent fevers of unknown origin.,0
"INTERPRETATION: Approximately 72 hours following the intravenous administration of tracer, whole body images were obtained in anterior and posterior projections.",0
These were used to plan subsequent SPECT acquisitions.,0
Whole body images show focal intense uptake of tracer in the infero-medial aspect of the left shoulder adjacent to the left glenohumeral joint.,0
"An irregular focus of increased gallium uptake is identified in the lateral aspect of the left mid lung field, at the site of prior segmental rib resection.",0
"Below the diaphragm, significant curvilinear distribution of tracer is identified and believed to reflect physiologic excretion into the bowel.",0
"Symmetric, mildly increased uptake of tracer is identified in both proximal femora, likely reflecting bone marrow expansion.",0
"Note is made of a small round photopenic defect overlying the right lobe of the liver, in the mid clavicular line, which appears to reflect attenuation from a surface EKG electrode at that position.",0
SPECT imaging will be utilized to further evaluate these findings and to discern any underlying lesions.,0
"SPECT images of the chest, abdomen and pelvis were performed and reconstructed in the axial, coronal and sagittal planes.",0
"SPECT images of the chest confirm an intense focus of gallium uptake in the left shoulder which appears to be extending from the lateral margin of the proximal humerus into the adjacent medial soft tissues, just inferior to the glenohumeral joint.",0
"Consideration should be given to further anatomic imaging of this region with CT or MRI to further evaluate this finding, if clinically indicated.",0
"SPECT images of the chest likewise confirm irregular and heterogeneous distribution of gallium in the left lateral mid lung, at the site of prior segmental rib resection.",0
Uptake in this region could reflect bone healing or a loculated empyema.,0
Review of the CT of the chest from demonstrates a small loculated fluid collection in this region which could represent an empyema and could explain the uptake of gallium in this region.,0
SPECT images of the abdomen and pelvis confirm physiologic excretion of tracer into the bowel.,0
No definite foci of abnormal gallium uptake are identified below the diaphragm.,0
"Again noted is mildly increased uptake of gallium in the proximal femora, likely reflecting bone marrow expansion.",0
"IMPRESSION: Abnormal study with multifocal uptake of gallium in the left shoulder and left lateral mid chest, as described above.",0
Uptake of gallium in the chest may reflect bone healing at the site of prior segmental rib resection or a loculated empyema or other infectious process in that region.,0
Further anatomic imaging of the left shoulder could be considered to further evaluate this site of intense gallium uptake if clinically indicated.,0
/nkg (Over) GALLIUM SCAN Clip # Reason: FEVERS OF UNKNOWN ORIGIN.,0
"______________________________________________________________________________ FINAL REPORT (Cont) , M.D.",0
Approved: TUE 7:06 PM West RADLINE ; A radiology consult service.,0
4:42 AM CHEST (PORTABLE AP) Clip # Reason: Eval interval film Admitting Diagnosis: EPIDURAL FLUID COLLECTION ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with difficulty weaning vent REASON FOR THIS EXAMINATION: Eval interval film ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Difficulty weaning vent.,0
Comparison is made from prior study from .,0
Diffuse lung consolidations worse in the left mid lung are grossly unchanged.,0
"3:23 AM CHEST (PORTABLE AP) Clip # Reason: ETT in proper place Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with resp failure, persistant hypoxemia REASON FOR THIS EXAMINATION: ETT in proper place ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST.",1
"REASON FOR EXAM: Respiratory failure, hypoxemia, intubated patient.",1
ET tube tip is in standard position 6.6 cm above the carina.,0
There is widened mediastinum due to increased mediastinal fat.,0
"The hila are enlarged, more so on the left side.",0
These findings are a combination of enlarge pulmonary arteries and probably adenopathy .,0
Left lower lobe opacity is a combination of pleural effusion and consolidation.,0
There is mild atelectasis in the left upper lobe.,0
"12:09 PM CHEST (PORTABLE AP) Clip # Reason: please assess for CHF and infiltrate Admitting Diagnosis: PNEUMONIA-URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: IDDM, PVD, s/p calcanectomy, with ongoing hypoxia and R pleuritic chest pain REASON FOR THIS EXAMINATION: please assess for CHF and infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Right-sided pleuritic pain, assess for CHF and infiltrate.",0
COMPARISON is made to the prior chest x-ray of .,0
"AP CHEST: The heart, mediastinal and hilar contours are unchanged in appearance.",0
There is again demonstrated a right-sided IJ central venous catheter in stable position.,0
There is continued vascular engourgement consistent with pulmonary edema.,0
There is persistent bilateral lower lobe atelectasis/consolidation.,0
There are also persistent small bilateral pleural effusions.,0
"IMPRESSION: Continued pulmonary edema, bilateral lower lobe atelectasis/consolidation and small pleural effusions.",0
"LINE PLACEMENT Clip # Reason: 38 cm Picc placed in right basilic vein, need Picc tip place Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with new Picc REASON FOR THIS EXAMINATION: 38 cm Picc placed in right basilic vein, need Picc tip placement text to ______________________________________________________________________________ FINAL REPORT HISTORY: PICC placement.",0
"FINDINGS: In comparison with the study of , there has been placement of a right subclavian PICC line that appears to extend into the right atrium.",0
It should be pulled back approximately 3-4 cm.,0
This information was telephoned to the IV team.,0
Remainder of the examination is unchanged.,0
Height: (in) 68 Weight (lb): 150 BSA (m2): 1.81 m2 BP (mm Hg): 81/53 HR (bpm): 60 Status: Inpatient Date/Time: at 11:39 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
No mass or thrombus in the RA or RAA.,0
Normal IVC diameter (1.5-2.5cm) with >50% decrease during respiration (estimated RAP 5-10 mmHg).,0
AORTA: Mildly dilated ascending aorta.,0
"Compared with the prior study (images reviewed) of , no right atrial mass is seen.",0
"Review of the prior images suggests the mass may have been extrinsic to the heart (e.g., liver) and is more clearly defined on the current study.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending: Chief Complaint: Transfer from cath lab after right carotid stent placement Major Surgical or Invasive Procedure: Carotid angiography Right ICA Acculink stent placement History of Present Illness: 62 year-old man, patient of Dr. and Dr. , with carotid stenosis, referred for carotid angiography, now status post right carotid stent placement, transferred to CCU for close observation.",1
Mr. has a history of a right carotid stenosis status post right CEA in by Dr. .,1
A carotid U/S in revealed bilateral 60-69% stenosis of ICA.,1
"He also has a history of CAD s/p IMI in treated with TPA, s/p PTCA to the LCx and RCA, with last EF 29% on MIBI, as well as a history of HTN and hyperlipidemia.",0
"On , he presented to the ER after having an episode of left arm tingling associated with a strange sensation in his left hand, with a similar event the following day.",0
"He also reports having some dizzy spells occasionally at work, the last being about 1-2 months ago.",0
"An MRI/MRA was performed at the OSH on , which was negative for acute/sub acute CVA, and revealed a normal circle of and moderate stenosis of the right distal CCA.",0
He was started on Aggrenox at the OSH and was referred for urgent evaluation.,0
He underwent a carotid ultrasound today which showed bilateral 60-69% stenosis.,1
A carotid angiography was then performed that showed a hazy 80-90% right ICA lesion proximally at the prior CEA site that was stented with a residual 10% stenosis.,1
He was transferred to the CCU for overnight observation.,0
CAD - Status post IMI in treated with TPA - Status post stent to Lcx in and RCA stent + repeat stent to Lcx in for in-stent restenosis.,0
"- Stress MIBI in (, 8.5 minutes, no symptoms, HR 78%) revealed a severe fixed inferior defect, severe partially reversible lateral defect and moderate reversible apical defect.",0
"Carotid stenosis, status post right CEA in by Dr. 3.",1
Gout Social History: Design draftsman for .,0
He quit 8 years ago.,0
+ EtOH: approximately 1-2 drinks per day.,0
Family History: Family history positive for CAD: father had MI and died at age 75.,0
Mother died of an MI at age 65.,0
One brother s/p CABG in his 60s.,0
"Physical Exam: Physical exam on admission to CCU: VITALS: T 97.8, HR 64, BP 128/78, RR 20, Sat 99% on room air.",0
"GEN: Well-nourished man, in NAD.",0
"NECK: Right carotid bruit, no audible left carotid bruit.",0
RESP: Anterior chest clear to auscultation.,0
"+ abdominal bruir over aorta, iliacs.",0
"EXT: Right groin cath site with mild oozing, mildly tender.",0
"Pulses right: 2+ PT, trace DP; left: trace PT, 1+ DP.",0
Pertinent Results: No laboratory data on admission.,0
"EKG: NSR, rate 61, PVC.",0
"Indeterminate axis, prior inferoposterior MI with prominent Q waves in leads III and aVF, and tall R waves in V1, V2, unchanged versus .",0
ICA prior to CEA site with 80-90% stenosis.,0
"MCA with early bifurcation, no evidence of lesion.",0
Left ICA with moderate proximal 70% lesion.,0
"Procedure: Acculink stent to right ICA, with 10% residual stenosis.",0
"Brief Hospital Course: 62 year-old male with a history of CAD s/p MI, HTN, hyperlipidemia and previous right CEA, referred for coronary angiography after having symptoms of left arm paresthesias, found to have a right ICA stenosis, now s/p right ICA stent.",1
He was monitored in the CCU overnight where he remained normotensive and asymptomatic.,0
His right groin (cath site) did not have any hematoma or bruit.,0
"His aggrenox was discontinued, and he was discharged on ASA (daily for life) and Plavix 75 mg daily for at least one month.",0
He will follow-up with Dr. office regarding the duration of Plavix therapy.,0
In addition he will follow-up with Dr. in months in his clinic.,0
He was asked to follow-up with his PCP to have his LDL checked as his goal should be an LDL of 70.,0
Medications on Admission: Lipitor 20 mg PO QD Lisinopril 10 mg PO QD Lopressor 50 mg PO BID Isordil 10 mg PO BID Aggrenox 200 mg PO BID (started on at OSH ER) Discharge Medications: 1.,0
Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Discharge Disposition: Home Discharge Diagnosis: Carotid stenosis transient ischemic attacks hypertension hypercholesterolemia s/p right internal carotid stent placement Discharge Condition: stable Discharge Instructions: Please call your PCP or return to the ED if you develop recurrent loss of sensation in your extremities, dizziness, lightheadedness, or visual changes.",1
The Plavix will replace this medication.,0
Please call Dr. office to determine the duration of PLAVIX therapy.,0
His office number is .,0
You should be taking plavix for at least one month.,0
Followup Instructions: Provider: Follow-up appointment should be in 2 months.,0
Please call to schedule an appointment.,0
Please follow-up with your primary care doctor in months.,0
You should have your cholesterol checked and your LDL cholesterol should be 70 or lower.,0
4:12 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change Admitting Diagnosis: TRACHEOBRONCHEOMALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with pneumonia REASON FOR THIS EXAMINATION: please evaluate for interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient with pneumonia.,1
"The tracheostomy is at the midline, approximately 8 cm above the carina.",0
"The heart size and the mediastinal contours are stable, unremarkable.",0
The mediastinum continues to be shifted to the right with no appreciable change since the prior study.,0
Post-surgical changes in the right upper lung is stable.,0
"Right basal consolidation has slightly improved, but there is minimal worsening of the right upper lobe, the left lung is essentially clear.",0
BRAIN SCAN Clip # Reason: EVAL FOR BRAIN DEATH.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate for brain death.,0
Trauma INTERPRETATION: Anterior and posterior images of the brain blood flow were obtained and show normal appearance of blood flow to the brain.,0
Delayed images show evidence of tracer activity within the brain.,0
The study is not consistent with brain death.,0
Approved: WED 11:42 AM RADLINE ; A radiology consult service.,0
4:59 AM CHEST (PORTABLE AP) Clip # Reason: interval change?,0
PULMONARY TUBERCULOSIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with miliary TB REASON FOR THIS EXAMINATION: interval change?,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient with miliary tuberculosis.,1
Portable AP chest radiograph was compared to multiple prior studies obtained on several recent days.,0
"The current study was obtained in more oblique projection and demonstrate the left PICC line tip at the level of the junction of left brachiocephalic vein and SVC, much better than was demonstrated on the prior radiograph.",0
There is no change in extensive miliary involvement of the lungs.,0
Prominence of the left hilum most likely consistent with the lymphadenopathy again better appreciated on the current study given the slightly oblique configuration of the radiograph.,0
No new abnormalities have been demonstrated since the prior study.,0
1:30 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate for bleeding Admitting Diagnosis: POST OPERATIVE BLEEDING ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with change in mental status and on heparin GTT REASON FOR THIS EXAMINATION: evaluate for bleeding No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for bleeding.,0
TECHNIQUE: A non-contrast head CT was performed.,0
"There are numerous periventricular and subcortical white matter hypodensities, especially in the frontal lobes, consistent with chronic microvascular ischemic changes.",0
There are atherosclerotic calcifications diffusely.,0
"There is mucosal thickening within both sphenoid sinuses, left greater than right.",0
IMPRESSION: Chronic microvascular ischemic changes without evidence of an acute hemorrhage.,1
Sphenoid sinus disease could be consistent with sphenoid sinusitis in the correct clinical setting.,0
Status: Inpatient Date/Time: at 09:07 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
MITRAL VALVE: Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion.,0
Moderate valvular MS (MVA 1.0-1.5cm2) Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR.,0
GENERAL COMMENTS: The patient was under general anesthesia throughout the procedure.,0
Aortic contour normal post decannulation,0
"9:46 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: PNA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with s/p tracheobronchoplasty, h/o gastric ulcer perf s/p repair, resp failure; copius secretions and having desat's REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT STUDY: Portable AP chest radiograph.",1
"COMPARISON EXAM: Portable AP chest radiograph though , .",0
INDICATION: 53-year-old man status post tracheobronchoplasty and abdominal surgery with copious secretions and desaturations.,0
FINDINGS: There are bibasilar consolidations and pleural effusions with mild pulmonary edema.,0
Cardiomediastinal and hilar contours are stable.,0
Monitoring and support devices are in good position.,0
IMPRESSION: Bibasilar consolidation and pleural effusions with mild pulmonary edema.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: right lower extremity pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 38 year-old man with a history of recent possible pulmonary embolism, cellulitis, type I diabetes, renal insufficiency who presents with 2-3 days of right lower extremity pain and edema.",1
Says it feels similar to when he last had cellulitis in .,0
Has also noticed increased swelling.,0
Has felt feverish over past few days.,0
"No water, insect or animal exposures or bites.",0
No trauma to the area.,0
Hospital admission in of this year for lower extremity cellulitis.,0
"During this admission, hypoxic respiratory failure thought to be due to possible PE vs. aspiration pneumonia vs. hosp acquired pneumonia.",0
Plan is for six months anti-coagulation.,0
"In ER given vancomycin, unasyn for cellultiis, morphine for pain control, aspirin, NPH 62 units at 4:30 AM.",0
"On ROS, reports intermittent shortness of breath associated with pleuritic chest pain occurring every few days and lasting for a few minutes.",0
"Presumed PE diagnosed in based on V/Q scan in setting of infiltrates on CXR, currently on coumadin with plan for 6 months of treatment--etiology attributed to immobility secondary to lle swelling/cellulitis 2.",1
"Type 1 diabetes, 4. hypercholesterolemia 5. hypertension 6. obesity 7. asthma 8. renal insufficiency 9. chronic tobacco use.",1
"Social History: He lives in with his wife, their 11 year-old son and two step sons.",0
"Currently not smoking, former long history of smoking.",0
Family History: Diabetes Physical Exam: VS: Temp:100.1 BP: 136/81 HR:105 RR:16 96%rm airO2sat .,0
"general: pleasant, discomfort secondary to leg pain, no distress HEENT: PERLLA, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd lungs: CTA b/l with good air movement throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: obese, nd, +b/s, soft, nt, no masses extremities: right lower extremity with 2+edema, tender over tibia, increased area of pigmentation over front of tibia-->area marked, left lower extremity with 1+edema, symmetric calor neuro: AAOx3.",0
vasc: 2+ dp pulses bilaterally Pertinent Results: Admit labs; 08:40PM WBC-14.8* RBC-4.33* HGB-12.3* HCT-34.1* MCV-79* MCH-28.3 MCHC-36.1* RDW-14.8 08:40PM NEUTS-80.7* LYMPHS-14.7* MONOS-3.4 EOS-1.1 BASOS-0.2 08:40PM PLT COUNT-295 .,0
08:40PM GLUCOSE-216* UREA N-39* CREAT-2.2* SODIUM-136 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13 .,0
08:40PM PT-30.0* PTT-34.3 INR(PT)-3.2* .,0
Discharge labs: 06:50AM BLOOD WBC-10.9 RBC-3.66* Hgb-10.2* Hct-29.4* MCV-80* MCH-28.0 MCHC-34.8 RDW-14.3 Plt Ct-407 07:55PM BLOOD Neuts-71.8* Lymphs-19.1 Monos-7.3 Eos-1.5 Baso-0.3 06:50AM BLOOD PT-26.6* PTT-33.3 INR(PT)-2.7* 06:50AM BLOOD Glucose-146* UreaN-43* Creat-2.4* Na-138 K-4.7 Cl-100 HCO3-31 AnGap-12 04:19AM BLOOD ALT-47* AST-35 AlkPhos-361* TotBili-0.5 .. .. Echo: Conclusions: The left atrium is mildly dilated.,0
"Compared with the prior study (images reviewed) of , the findings are consistent with normal diastolic function and normal left ventricular filling pressures (not fully evaluated on prior study).",0
.. v/Q scan: IMPRESSION: Normal lung perfusion scan.,0
"Compared with the prior study, there is no significant interval change.",0
.. Tib/fib films: IMPRESSION: No gas is noted within the soft tissue.,0
Prominent soft tissue swelling of the calf region is unchanged compared to the prior study.,0
".. CXR: FINDINGS: Comparison is made to the chest CT from , and plain film radiograph from .",0
"Cardiac silhouette demonstrates left ventricular prominence, which is stable.",0
"The left lung demonstrate some vague opacity in the left retrocardiac region, however, this may be secondary to atelectasis or due to vessel crowding from poor inspiratory effort.",0
No definite consolidation is identified.,0
There are no signs of overt pulmonary edema.,0
"Brief Hospital Course: Assessment and Plan: This is a 38 year old man with a history of recent possible pulmonary embolism, cellulitis, type I diabetes, renal insufficiency who presentsed with right lower extremity pain/edema.",1
The following issues were addressed on this admission: .,0
1)Right lower extremity pain/edema: Cellulitis: Patient maintained on vancomycin/unasyn over the course of his admission for first 6 days.,0
"(Got zosyn instead of unasyn for a few doses after he spiked and had respiratory decompensation, please see below).",0
Switched to augmentin and remained afebrile with improvement of cellulitis over the last two days of admission.,0
No evidence compartment syndrome other than pain.,0
LENI negative for dvt (already on coumadin) Anti-fungals maintained throughout.,0
No evidence of osteo on plain film.,0
"To complete 14 day total course of antibiotics, six more days of augmentin.",0
Patient has appointment in two days with Dr. for re-evaluation.,0
"2)Fever: on antibiotics, vanc and unasyn on .",0
Multiple blood cultures and urine cultures negative.,0
Initially unasyn broadened to zosyn and then antibiotics switched to augmentin on HD#6.,0
Afebrile on augmentin x2 days prior to discharge.,0
Blood cultures and urine cultures pending at time of discharge.,0
2)Respiratory: History of OSA and asthma as well as recent diagnosis of possible PE.,0
Intermittent shortness of breath reported on admission.,0
Initially stable but patient with decompensation/desaturation and again both in early AM while sleeping.,0
Also febrile at this time.,0
Felt to be secondary to not being on his usual home CPAP.,0
"Because of history of prior possible PE, V/Q scan repeated and demonstrated no PE.",0
"Cardiac enzymes cycled and negative, ECG without concerning changes, cxr unremarkable.",0
Echo checked and no evidence of heart failure.,0
"3)Acute renal failure/CKD stage 3: Patient developed renal failure in setting of fevere, hypoxia on .",1
"Ace, hctz held, patietn hydrated and bp allowed to auto-regulate.",0
patient's creatinine returned to baseline of low 2's.,0
"Continuing to hold ace, hctz through discharge, to be re-started at discretion of Dr. and .",0
Should have repeat chem-10 on Consider MRA to look for renal artery stenosis as outpatient.,0
"4)Alkaline phosphatase elevation: should have repeat testing as outpatient, no acute pathology noted.",1
"5)Possible recent PE: On last admission, decision made to maintain coumadin x 6 months.",0
"Maintained on coumadin throughout, inr therapeutic.",0
Discharged on 6mg to be taken and and will need repeat INR on .,0
6)OSA: Initially not on home CPAP.,0
Placed on home CPAP after desats and hypoxia resolved.,0
"Has machine at home, agrees to compliance.",0
7)DM: continued outpatient insulin regimen.,0
Low on AM of because patient did not eat full dinner.,0
Knows to decrease insulin if does not eat.,0
Will take lower dose on PM to avoid low in Am.,0
"9)Hypertension: continued lisinopril, diltiazem, hctz initially.",0
With renal failure lisinopril and hctz held and then hydralazine initiated.,1
Patient discharge diltiazem and hydralazine with plan to re-initiate ace and hctz at discretion of Dr. and Heonig once creatinine re-checked.,0
Off ace and hctz and on hydralazine BP's generally 150's to 160's.,0
10)Hyperlipidemia: off statin given lft rise during last hospital admission.,0
Mild lft elevation again here.,0
Needs repeat lft's as outpatient.,0
11)Smoking cessation: maintained on wellbutrin.,0
DVT prophylaxis:therapeutic on coumadin .,0
"Medications on Admission: 1. buproprion 100mg 2. diltiazem xr 180mg daily 3. advair 4. atrovent 5. albuterol 6. coumadin--varying dose, but currently 10qhs 7. hctz 50 8. lisinopril 40 9.",0
"Insulin--nph 62 qam, 52 q pm, sliding scale Discharge Medications: 1.",0
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation (2 times a day).,0
"Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QHS (once a day (at bedtime)).",0
Warfarin 6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): take this dose until you are seen by Dr. .,0
Terbinafine 1 % Cream Sig: One (1) Appl Topical (2 times a day).,0
Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 days.,0
"Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous once a day: as directed continue your current insulin dose, 62UNPH in AM and 52U NPH in PM.",1
Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a day: continue this medication until you are re-started on your other blood pressure medications.,0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day).,0
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed.,0
"Outpatient Work PT/PTT, Chem-10 to be done on when you see Dr. .",0
Discharge Disposition: Home Discharge Diagnosis: Primary: 1.,0
"Type II DM with renal complications, controlled 3.",0
"Tolerating PO, ambulating, using CPAP, breathing well.",0
Discharge Instructions: Take all your medications as prescribed.,0
I have changed a number of your medications.,0
You should not take the hydrochlorothiazide or lisinopril until you are seen by a doctor.,0
"Instead, you will be taking the hydralazine.",0
For the next two days take 6mg of coumadin each night until you have your INR checked on Thursday.,0
"Make sure to have your INR checked on Thursday, I have provided you a prescription.",0
clinic will adjust your coumadin appropriately based on that value.,0
You should also have your creatinine checked on thursday when you see Dr. .,0
Make sure to use your CPAP as scheduled.,0
"Continue to take your antibiotic as prescribed, Dr. will evaluate your cellulitis and may change your antibiotics.",0
"The doctors here noted some swollen lymph glands, make sure Dr. follows this up to make sure it resolves.",0
"You also were noted to have blood in your urine, make sure your kidney doctor knows about this.",0
Take your insulin as we discussed.,0
"Followup Instructions: You should schedule an appointment this week with your kidney doctor, Dr. at .",0
"You have the number, call him Thursday to make an appointment.",0
You must follow up with Dr. on thursday as below.,0
"Provider: , MD Phone: Date/Time: 4:40 .",0
"Provider: , MD Phone: Date/Time: 4:00 Provider: , MD Phone: Date/Time: 4:40",0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Fever and hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: 86 year old male resident of Nursing home sent to for w/up of fever w/ tachycardia, tachypnea and hypoxemia.",0
Pt reportedly transferred from dementia unit of nursing home to sub-acute unit on for IVF for 'dehydration' due to decreased PO intake.,1
"In sub acute unit pt noted to be SOB w/ T=102.2, R=36, BP 130/70, P132, O2 sat 71% on 3L NC.",0
At that time pt was noted to be alert and verbally responsive but confused.,0
Pt was transferred to on for further eval.,0
"Per daughter, pts mental status has deteriorated over the past two weeks.",0
Pt previously spoke in understandable sentances whereas now he mumbles largely incoherently.,0
In ED VS 102.4 HR 129 BP 112/88 RR 30 sat 71% on 2L.,0
pt was placed on BiPap.,0
CXR w/ finding of RLL pneumonia - pt given vanco/ceftriaxone.,0
"UA: mod blood, tr protein, occ bact, <1 epi, otherwise nl .",0
CXR: : FINDINGS: The heart is normal in size.,0
The aorta is mildly ectatic.,0
Large infiltrate can be seen within the right lower lobe.,0
"Aside from the left basilar atelectasis, the remaining lungs appear clear.",0
There is a probable small right pleural effusion.,0
There is no left pleural effusion.,0
There is evidence of spinal fusion of the lower lumbar vertebral bodies.,0
Multiple tiny clips project along the lateral aspects of the lower thoracic spine.,0
IMPRESSION: Right lower lobe pneumonia and small right pleural effusion .,0
"Brief Hospital Course: 86 yo male w/ fever, tachycardia, tachypnea and hypoxia presents from nursing home w/ RLL pneumonia.",0
"# RLL pneumonia: In ED patient hypoxic to 70s, put on bipap.",0
He was able to transition to facemask upon MICU arrival.,0
"His respiratory distress was likely secondary to pneumonia given clinical picture of fever, tachypnea and hypoxemia in light of CXR finding of RLL infiltrate.",0
"Given that he lives in nursing home and was hospitalized recently ( - ), and may also be at risk for aspiration pneumonia, he was covered for broad spectrum pathogens w/ vanco and unasyn.",0
Sputum cultures were taken but contaminated.,0
Blood cultures showed no growth to date.,0
He was transitioned to oxygen by nasal cannula.,0
He was able to go to the medical floor on and is currently on oxygen at 2L/min.,0
"His antibiotics were changed to oral levofloxacin and metronidazole, to complete a 10 day course.",0
Possible aspiration worked up as below.,0
"# Comfort care measures: per family, care directed towards comfort is most appropriate at this time.",0
They have seen progressive decline over the last few weeks and patient has not been taking in good PO.,0
He is DNR/DNI/no procedures/no lines.,0
He will likely become do not hospitalize following his discharge with involvement of hospice.,0
"We stopped restraints, IV fluids, lab draws, and some medications.",0
He can resume PO intake for comfort.,0
# Dehydration: His family reported very poor PO intake during the last few weeks.,0
He was given IV fluid boluses and maintenance fluids.,0
"Due to concern of aspiration, he was kept NPO; bedside swallow studies were performed but were inadequate.",0
"He was going to have a video swallow study; however he was too lethargic at the time and, after discussion with the family regarding goals of care, this was not reattempted.",0
He was allowed to eat pureed diet and thickened liquids as tolerated as part of his comfort care measures.,0
"# Renal Insufficiency: His Cr 2.0 at admission, up from 1.3 at d/c on .",0
"This was likely prerenal given recent decreased PO intake, tachycardia, clinical exam and chronic diarrhea.",1
He was given IV fluids as above.,0
This improved to his most recent value of 1.3. .,0
# HTN - He was hypertensive to SBP 180s beginning on w/ moderate tachycardia to 120.,0
He was restarted on home altace at 5 and also started on metoprolol 50 TID as well due to inadequate control on altace only.,0
His blood pressures have improved with this regimen.,0
# Chronic Diarrhea: Has had diarrhea for months to years and takes loperamide chronically.,1
Culture and C.diff were negative.,0
Loperamide was restarted for comfort.,0
# Hypernatermia: pt w/ hypernatremia on admission.,0
This resolved with IV fluids.,0
# Code status: DNR/DNI/no central access or procedures.,0
Likely will become hospice and do not hospitalize.,0
Medications on Admission: MEDS on admission: Namenda 5mg po BID zyprexa 2.5mg po BID prn agitation acetominophen 1000 po tid altace 5mg po daily lasix 20 mg po MWF loperamide 2mg po BID plavix 75 mg po daily tramadol hcl 25 mg po tid ALL: NKDA Discharge Medications: 1.,0
Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): hold for SBP<100.,0
Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).,0
Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation: may substitute Zydis dissolvable tablet .,0
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<100 and HR<60 .,0
Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days.,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days.,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever.,0
"Morphine Concentrate 20 mg/mL Solution Sig: 2-4 mg PO Q2H (every 2 hours) as needed for pain, dyspnea, or anxiety.",0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) inhalation Inhalation every four (4) hours as needed for shortness of breath or wheezing.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
"Discharge Disposition: Extended Care Facility: of Discharge Diagnosis: Pneumonia Hypoxemia Poor PO intake Dementia Discharge Condition: Stable, comfortable, on oxygen by nasal cannula Discharge Instructions: You were admitted with low oxygen levels and found to have a pneumonia.",0
You needed to stay in the intensive care unit for a few days to support your oxygen levels.,0
You are still getting oxygen for comfort.,0
We discussed the goals of your care with your family.,0
We are in agreement that the focus should be on making you comfortable.,0
"If these goals change, please discuss this with your primary care doctor, Dr. .",0
"We have made the following medication changes: We have stopped some of your medications, including Plavix, Namenda, and Lasix.",0
We have added sublingual morphine for pain control and comfort.,0
We added metoprolol for your blood pressure.,0
"We have also added 2 antibiotics, Levofloxacin and Metronidazole, for the treatment of your pneumonia.",0
You can also use nebulizer treatments for trouble breathing or wheezing if needed.,0
"Followup Instructions: Please followup with your primary care physician, .",0
", if you have any questions about your health or your care.",0
Your care providers will also be giving your family more information and involvement with Hospice services.,0
"7:30 PM CHEST (PA & LAT) Clip # Reason: interval change, effusion, Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 80F s/p ercp now wheezing after b2b nebs.",0
"REASON FOR THIS EXAMINATION: interval change, effusion, ______________________________________________________________________________ WET READ: 8:24 PM Removal of central line.",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Wheezing.,0
PA and lateral upright chest radiograph was compared to and several radiographs dating back to .,0
There is no significant change in mild-to-moderate cardiomegaly.,0
Bibasilar opacities has minimally improved in the interim on the left and unchanged on the right.,0
The right PICC line tip appears to be in the right atrium and should be pulled back at least 3 cm to secure its position in low SVC.,0
Upper lungs are essentially clear.,0
There is no evidence of pleural effusion or pneumothorax.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEONATOLOGY ID: is an 88 day old former 27 wk premature infant with chronic lung disease who is being discharged from the NICU.,0
"HISTORY: was a 27-5/7 week male infant born to a 32-year-old G1, P0 mother on via C-section for worsening preeclampsia.",0
The birth weight was 997 g and Apgars were 6 and 8.,0
"Maternal prenatal screens included blood type B positive, antibody negative, Rubella immune, RPR non reactive, Hep-B surface antigen negative, GBS unknown.",0
Mom's pregnancy was complicated by elevated blood pressure for 3 weeks followed by the onset of proteinuria.,0
Mom was treated with labetalol and received 1 course of betamethasone.,0
Prenatal ultrasound was remarkable for fetal hydronephrosis and dilated lateral ventricles.,0
DELIVERY: The patient emerged with decreased tone and weak respiratory effort.,1
He received PPV and then was intubated and transported to the NICU.,0
Birth weight was 997 g (25th percentile).,0
Length was 35 cm (25th percentile).,0
Head circumference was 26 cm (50th percentile).,0
PHYSICAL EXAMINATION: General Exam - no acute distress.,0
"HEENT - AFOF, no cleft lip, intact palate, intubated, red light reflex not well visualized.",0
"Heart - regular rate and rhythm, no murmur, pulses equal, good capillary refill bilaterally.",0
"Lungs - mild retractions, but good air exchange with ventilator breaths.",0
"Abdomen - soft, nontender, nondistended, no masses, no hepatosplenomegaly, good bowel sounds present.",0
Extremities - hips have negative Ortolani- Barlow sign.,0
GU - normal male genitalia.,0
"At that time, testes were not palpable.",0
Neurologically - normal tone for premature infant.,0
Respiratory distress syndrome progressing to chronic lung disease and apnea of prematurity.,1
"The patient was intubated, treated with surfactant, and then received mechanical ventilation until day of life 15.",0
He received CPAP from day of life 15 to 38.,0
"On day of life 38, he was placed on Vapotherm where he remained until day of life 49.",0
He was on nasal cannula oxygen from day of life 49 to day of life 76.,0
"He was weaned to room air and was only given nasal cannula for feeds between day of life 76 to 81, has been in room air since then.",0
Apnea of prematurity was treated with caffeine from day of life two to 57.,1
"For chronic lung disease, the patient was treated with Diuril from day of life 42 to present, and aldactone from day of life 42 to 79.",0
"The patient was on sodium chloride supplements from day of life 27 to 79, and potassium chloride supplements from day of life 49 to present.",0
"By the time of discharge, infant is breathing comfortably in room air, with no spells or desaturations noted for over 5 days.",0
"Diuril therapy at 30-40 mg/kg/day is recommended to continue at this time, but may be able to be gradually discontinued over next 1-2 months.",0
Infant received treatment for PDA documented by ECHO with two courses of indomethacin.,0
F/u ECHOs on and showed resolution of PDA with no other anomalies.,0
"Infant did require brief blood pressure support with dopamine for first 48 hours of life, but has been hemodynamically stable since that time.",0
"An intermittent murmur, physiologic in quality, persists at discharge.",0
The patient received initially a UAC and UVC line placement through which he received total parenteral nutrition from birth until day of life 9 at which time he was started on breast milk trophic feeding.,0
"Feeds were increased and total parenteral nutrition was discontinued on day of life 15, and he was advanced to max breast milk 30 calories/oz with ProMod supplementation.",0
There have been no GI complications.,0
"He has currently breast feeding ad lib with PO feedings per day of BM 26 cals/oz, made with enfamil powder and corn oil.",0
"Discharge weight is 3.120 kg, HC is 34 cm, and length is 48 cm.",0
"Last electrolytes were measured on , day of life 77, and revealed Na 136, K 5.1, Cl 98, and HCO3 28.",0
Periodic monitoring of electrolytes as an outpatient due to diuretic therapy is recommended.,0
Hyperbilirubinemia requiring phototherapy from day of life 1 through 5.,0
The maximum bilirubin was 5.2/0.3.,0
The patient was transfused on day of life 27 with 20 cc/kg of packed red blood cells for a hematocrit of 24.2.,0
"On , the patient had a hematocrit of 34.9 and a reticulocyte count of 3.5%.",0
He has been on iron from day of life 19 to present and is currently receiving 0.4 mL of ferinsol per day.,0
The patient underwent an initial rule out sepsis with ampicillin and gentamicin for 48 hours.,0
Blood culture at that time was negative.,0
Subsequent blood cultures were done on (negative) and which at that time the blood culture grew MRSA.,0
He was treated with a 5-day course of vancomycin and gentamicin and follow-up blood cultures on and 7 were negative.,0
"The patient also received ampicillin for prophylaxis for hydronephrosis from day of life 8 to 16 and then on day of life 16, he was changed to amoxicillin until day of life 27 at which time he received treatment for MRSA.",0
Follow-up renal ultrasound showed only minimal hydronephrosis and UTI prophylaxis was not deemed necessary at the time (that was day of life 52 when amoxicillin was discontinued.),0
Initial renal ultrasound on revealed mild bilateral hydronephrosis.,0
F/u on was improved with only minimal hydronephrosis noted.,0
Outpatient follow-up with repeat ultrasound or VCUG is recommended.,0
Infant is not on prophylactic antibiotics at discharge.,0
"Head ultrasounds on , , , and were all within normal limits.",0
Neurological exam at discharge is unremarkable.,0
The patient passed his hearing screen on .,0
"The patient had an eye exam on showing Stage 1 ROP, 2 clock hours on the right and immature on the left.",0
"On , exam showed Stage 2 ROP, zone 2 on the right and immature on the left.",0
Follow- up on showed immature retinas zone III bilaterally and no ROP at that time.,0
"F/U examination in first two weeks of is recommended (Dr. , ).",0
Social Work can be reached at .,0
OTHER: Infant was circumcised without complications on .,0
Exam at discharge is notable for right testes in scrotum but left testes palpable in inguinal canal.,0
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. of Pediatrics.,0
"FEEDING AT DISCHARGE: Breast feeding ad lib, with supplemental breast milk 26 calories/oz 3-4 times per day.",0
Potassium chloride supplements 2 mEq or 1 ml p.o.,0
"NEWBORN SCREENING: Normal on , and .",0
"On , hepatitis B vaccine.",0
"On , Prevnar, Haemophilus HIB.",0
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from through for infants who were born at less than 32 weeks.,0
"Before this age and for the first 24 months of life, immunization against influenza is recommended for household contacts and out-of- home caregivers.",0
"FOLLOW-UP: Infant will f/u with PMD within 1 week, and with VNA within 1-2 days of discharge.",0
Referrals have been made for Infant Clinic and Early Intervention.,0
F/U renal ultrasound or VCUG can be considered.,0
Outpatient follow-up with opthalmology is needed.,0
Methicillin resistant staphylococcus aureus sepsis.,1
Patent ductus arteriosus treated with Indocin.,1
Minimal bilateral hydronephrosis which is resolving.,0
Retinopathy of prematurity which has resolved.,0
", MD Dictated By: MEDQUIST36 D: 08:26:31 T: 09:59:52 Job#:",0
"10:29 AM CHEST (PORTABLE AP) Clip # Reason: s/p thoracentesis R and NGT ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with hypotension, sepsis, right hemothorax REASON FOR THIS EXAMINATION: s/p thoracentesis R and NGT ______________________________________________________________________________ FINAL REPORT INDICATION: Hypotension, sepsis, right hemothorax, status post right thoracentesis and NG tube placement.",0
"The NG tube is looped in the stomach, with the end pointing superiorly at the GE junction.",0
The ET tube and right IJ catheter demonstrate no interval change in positions.,0
"Again there is a loculated right pleural effusion and a probable small left pleural effusion, as well, not significantly changed since the prior study.",0
There appears slight interval improvement in the engorgement of pulmonary vascularity.,0
IMPRESSION: NG tube is looped in the stomach with the end pointing superiorly at the GE junction.,0
"Persistent bilateral pleural effusions, right greater than left.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: s/p R IJ placement ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with sepsis, s/p CVL REASON FOR THIS EXAMINATION: s/p R IJ placement ______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old woman with sepsis, status post CVL, right IJ, evaluate position.",0
COMPARISON: (3:32 p.m) AP SEMI-UPRIGHT CHEST: Interval placement of a right IJ terminating within the right atrium is noted.,0
There are no other short-time interval changes.,0
IMPRESSION: Right IJ in standard location without immediate post- procedure complications.,1
", R. CSURG FA6A 9:47 AM CHEST (PA & LAT) Clip # Reason: evaluate right lobe collapse Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT ?",1
"TRICUSPIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p AVR REASON FOR THIS EXAMINATION: evaluate right lobe collapse ______________________________________________________________________________ PFI REPORT Improved right lower lobe aeration, improved fluid overload.",0
"Small bilateral pleural effusions, greater on the right, are unchanged.",0
2:33 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: feeding acess Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with REASON FOR THIS EXAMINATION: feeding acess ______________________________________________________________________________ FINAL REPORT INDICATION: This is a male requiring post-pyloric tube feedings.,0
PROCEDURE: A small caliber feeding tube was placed in the right nostril.,0
"It was advanced under fluoroscopy in the fourth portion of the duodenum, very close to the ligament of Treitz (post-pyloric).",0
Approximately 10 cc of water soluable contrast was then injected for documenting the proper position.,0
IMPRESSION: Successful placement of post-pyloric feeding tube with the tip in the fourth portion of the duodenum close to the ligament of Treitz.,0
"5:24 PM ORBITS (WATERS, & LAT) PORT Clip # Reason: r/o metal Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with hep c cirrhosis who needs MRI but was a metal worked, told he needed to have orbit films to r/o metal.",0
REASON FOR THIS EXAMINATION: r/o metal ______________________________________________________________________________ FINAL REPORT HISTORY: Rule out metal prior to MRI.,0
Obtained portably in the MICU.,0
No radiopaque foreign body is detected over the orbits.,0
9:59 AM PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: Postpyloric?,0
Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with s/p AAA repair with NG tube REASON FOR THIS EXAMINATION: Postpyloric?,1
______________________________________________________________________________ FINAL REPORT History of feeding tube placement.,0
Distal end of feeding tube is in distal body of stomach.,0
There is atelectasis at the left lung base with probable elevation of the left hemidiaphragm.,0
Distribution of bowel gas is unremarkable.,0
"12:57 PM ABDOMEN (SUPINE ONLY) Clip # Reason: ap/lateral, check VP shunt placement Admitting Diagnosis: TREMOR;BRAIN TUMOR ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with s/p VP shunt, please check Ap and lateral REASON FOR THIS EXAMINATION: ap/lateral, check VP shunt placement ______________________________________________________________________________ FINAL REPORT EXAMINATION: Abdomen on .",0
HISTORY: Status post VP shunt and check shunt placement.,0
IMPRESSION: Supine frontal views of the chest and abdomen and lateral view of the abdomen are submitted.,0
Intact shunt catheter traverses the chest and upper abdomen ending anteriorly above the level of the umbilicus.,0
There is no evidence of intestinal obstruction or mass effect.,0
Height: (in) 67 Weight (lb): 165 BSA (m2): 1.87 m2 BP (mm Hg): 128/75 HR (bpm): 80 Status: Inpatient Date/Time: at 09:19 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
MITRAL VALVE: The mitral valve leaflets are moderately thickened.,0
"Compared with the findings of the prior report (tape unavailable for review) of , the LV function has improved,",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins / Valium / Demerol / Codeine / Bactrim Ds Attending: Chief Complaint: vomiting, diarrhea Major Surgical or Invasive Procedure: None.",0
"History of Present Illness: Ms. is an 84F with CAD s/p PCI, PAF on coumadin, SSS s/p transferred from - after presenting with vomiting and diarrhea since starting bactrim for UTI 4 days PTA.",0
"According to patient, her symptoms began as increased frequency/urgency in urination 1 week PTA.",0
She went to her PCP and was prescribed Bactrim.,0
"Upon starting Bactrim, she stated that she was felt nauseous and began vomiting.",0
Emesis was non-bloody/no coffee grounds.,0
She had few BM during this time but endorsed small amounts of loose stool (non-bloody) when she had them.,0
Endorsed poor PO intake for last 6 days but stated that she continued to take all of her medications despite not having any appetite.,0
Of note urinary symptoms resolved with antibiotic use.,0
"One day PTA, she went to PCP where her labs were abnormal and she was sent to -N for further evaluation/work-up.",0
"At -N, Labs there notable for K 7.1 (slightly hemolyzed) BUN 84 Cr 4.1 (was 0.9 in ) INR 9.3 WBC 11.5 lactate 1.1.",0
Given insulin/D50 for hyperkalemia but became unresponsive in the setting of hypoglycemia (FSG 30s) - mental status and FSG improved with D50.,0
Given vitamin K 10 mg for supratherapeutic INR.,0
Head CT showed 2 cm lesion meningioma vs ICH so transferred here for neurosurg eval.,0
"Of note, patient denies any dizziness, focal weakness/numbness/tingling, headache, or confusion.",0
"In the ED, initial VS: T 97.3 P 70 BP 102/50 RR 18 O2sat 100%RA.",0
Labs notable for K 5.2 BUN 67 Cr 2.8 CO2 18 INR 4.7 lactate 1.9.,0
"Seen by neurosurg who felt CT finding was most consistent with meningioma, no acute intervention necessary.",0
"Pt was initially admitted to the floor, but became hypotensive in the ED.",0
She was bolused with 3L of IVF and admitted to the ICU for further care.,0
Vital signs prior to transfer T 96.9 P 70 BP 79/40 RR 18 O2sat 100%RA.,0
"On encounter in the MICU, patient was lying comfortable in bed.",0
Stated she was mildly nauseous.,0
Denied any CP/SOB/LH/dizziness or abdominal pain/cramps.,0
Endorsed recent weight loss over last 6 days from poor PO intake.,0
Her SBPs remained in the 80s Past Medical History: CAD s/p PCI PAF SSS s/p PPM DM Chronic diastolic CHF HTN COPD Breast cancer s/p mastectomy Anemia - on iron supplements Social History: Resident of Healthcare.,1
DISCHARGE LABS: 05:48AM BLOOD WBC-5.2# RBC-3.60* Hgb-10.4* Hct-30.2* MCV-84 MCH-29.0 MCHC-34.6 RDW-16.4* Plt Ct-190 05:48AM BLOOD Glucose-119* UreaN-28* Creat-1.1 Na-136 K-5.7* Cl-111* HCO3-20* AnGap-11 05:48AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.8 **PENDING LABS AT DISCHARGE**: and BCx: NGTD.,0
"Brief Hospital Course: Ms. is an 84F with CAD s/p PCI, PAF on coumadin, SSS s/p PPM admitted with , hyperkalemia, hypotension.",0
Hypotension: Pt was admitted with SBP in 80s - likely to hypovolemia and also persistent effects of anti-hypertensive medications that she had taken prior to admission.,1
"She was given IVF and her anti-hypertensives (lisinopril, lasix, aldactone, diltiazem) were held.",0
SBP improved to 110s on discharge.,0
Consider restarting antihypertensives as tolerated although not done here as normotensive off all meds.,0
Acute renal failure: Pt admitted with Cr 4.1 - likely to Bactrim use (added to allergy list) and compounded by prerenal etiology given vomiting/poor PO intake and antihypertensive regimen.,1
"Pt given 5L IVF and Lasix, aldactone, lisinopril, and glyburide held.",0
"Cr trended down quickly over 2 days - Cr 0.9 on discharge, which is her baseline.",0
Would restart diuretic as BP improves.,0
Consider restarting lisinopril as Cr and K continue to trend down and as BP tolerates.,0
Hyperkalemia: Pt was noted to be hyperkalemic to K 7 at .,0
"However, FS dropped to 30 with insulin.",0
There were no EKG changes noted.,0
"Potassium likely high in the setting of with use of KCl supplements, Lisinopril, Aldatone, and Bactrim.",0
Presumed meningioma: Pt had CT head at after being lethargic (although FS 30 at the time due to treatment of hyperkalemia with insulin/D50).,0
She was noted to have an incidental finding of a 2cm hypervascular mass - most consistent with meningioma.,0
"However, should be ruled out for other vascular lesions.",0
She will have a CT head with and without contrast and CTA head done at on at 1pm at and will see Dr. in Neurosurgery for follow-up on at 2pm on the of the Medical Building at .,0
No immediate surgical intervention has been planned.,0
"Atrial Fibrillation, Coagulopathy: Pt arrived with supratherapeutic INR.",1
"Received Vitamin K 10mg IV at the OSH for reversal, given concern for possible head bleed.",0
Coumadin was initially held while hospitalized while supratherapeutic but restarted at home dose 2.5mg on .,0
Goal INR and was 1.2 on discharge; will need INR monitoring (INR to be checked and thereafter prn) and Coumadin adjustment as needed.,0
"Diltiazem was held due to hypotension, and patient remained rate controlled.",0
Can be restarted as an outpatient as BP tolerates - would consider decreased dose (e.g.,0
Type 2 DM uncontrolled with complications: Glyburide was held given elevated Cr while inpatient.,0
Pt was maintained on ISS.,0
"Given good glycemic control off glyburide and high risk of adverse event from hypoglycemia in elderly, would strongly consider not restarting.",0
Would continue on insulin sliding scale alone for now.,0
Chronic Diastolic CHF: Lasix held while inpatient.,1
Monitor daily weights and net fluid balance.,0
Could consider restarting as BP tolerates.,0
Bilateral right upper extremity swelling: Likely due to aggressive fluid repletion.,0
Recommend keeping arms elevated to promote drainage.,0
Code status: Patient confirmed DNR/DNI Status.,0
PENDING RESULTS: Will need to follow up final results of blood cultures from and .,0
Medications on Admission: Coumadin 2.5 mg daily Diltiazem SR 360 mg daily Lasix 20 mg Mon/Wed/Fri Lasix 10 mg Tues/Thurs/Sat/Sun Lisinopril 5 mg daily Imodium 2mg PO prn Potassium chloride SR 10 mEq Daily Aspirin 81 mg daily Spironolactone 25 mg daily Vitamin C 500 mg daily Glyburide 5 mg Iron 325mg PO BID Vitamin D-3 400 unit Simvastatin 40 mg daily Xalatan 0.005 % 1 gtt R eye daily Novolog SS QID Florastor 250 mg Lorazepam 1 mg qhs prn Mylanta q4-6 hr/prn Discharge Medications: 1.,0
Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.,0
2. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Vitamin C 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day.",0
4. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day.,0
Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO twice a day.,0
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Xalatan 0.005 % Drops Sig: One (1) gtt RIGHT EYE Ophthalmic once a day.,0
Novolog 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day.,0
Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a day.,0
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anixety/insomnia.,0
"Outpatient Lab Work Please check INR on Monday, and forward to attention of primary care physician for management of anticoagulation.",0
"Discharge Disposition: Extended Care Facility: Rehabilitation and Nursing Center Discharge Diagnosis: Primary Diagnosis: Acute kidney injury Hyperkalemia Hypotension Head mass, likely meningioma Secondary diagnosis: Atrial fibrillation Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: Dear Ms. , You were admitted to the hospital with kidney injury.",0
This was due to the medication dehydration and Bactrim.,0
You should no longer take this medication in the future.,0
Your kidney function has improved while you have been in the hospital.,0
"Your potassium level was also high, and this has improved.",0
Your blood pressure improved with intravenous fluids and holding of your blood pressure medications.,0
"Lastly, you were found to have a brain mass which is likely a meningioma but will need to be followed up by Neurosurgery.",0
The following changes have been made to your medications: #.,0
HOLD Diltiazem until directed by your physician #.,0
Lisinopril until directed by your physician #.,0
Lasix until directed by your physician #.,0
Aldactone until directed by your physician #.,0
Potassium chloride (your potassium level was high) #.,0
HOLD Glyburide It was a pleasure meeting you and taking part in your care.,0
Followup Instructions: You should follow up with your nursing home physician regarding your blood pressure and diabetes control as well as kidney function.,1
You are scheduled for CT and CTA head imaging with and without contrast on at 1pm at (ground level).,0
You are scheduled to follow up with Dr. in Neurosurgery on at 2pm on the of the Medical Building at .,0
"If you have any questions, call .",0
11:04 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with resp failure REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg WED 3:43 PM Moderate right pleural effusion obscures the right lung.,1
Severe left lower lobe consolidation is unchanged.,0
PA and lateral radiographs would be helpful for further evaluation if possible.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Respiratory failure, evaluate for interval change.",1
COMPARISON: Multiple radiographs from through .,0
"FINDINGS: The tracheostomy ends at the mid clavicles, 4.4 cm above the carina, unchanged.",0
A moderate right pleural effusion obscures the right lung.,0
"2:19 PM CHEST (PORTABLE AP) Clip # Reason: edema, infiltrates Admitting Diagnosis: LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with NHL, febrile REASON FOR THIS EXAMINATION: edema, infiltrates ______________________________________________________________________________ FINAL REPORT CHEST, AP PORTABLE SINGLE VIEW History of lymphoma, febrile, evaluate for edema or infiltrates.",0
FINDINGS: AP single view of the chest has been obtained with patient in upright position and analysis is performed in direct comparison with the frontal view of the preceding study of .,0
Cardiomediastinal structures are unaltered including the previously described right-sided PICC line.,0
The on previous examination described remaining parenchymal densities have further regressed and practically normalized in the right mid lung field whereas some left-sided apical cloudy densities and a possible density in the periphery of the lingula persist.,0
There is no evidence of new parenchymal infiltrates and the lateral pleural sinuses remain free.,0
"As before, no evidence of pneumothorax.",0
IMPRESSION: Further regression of previously described bilateral pulmonary abnormalities in patient with history of lymphoma.,0
"8:20 AM CHEST (PORTABLE AP) Clip # Reason: assess left lung ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with DM2, admitted with change in mental status, REASON FOR THIS EXAMINATION: assess left lung ______________________________________________________________________________ FINAL REPORT INDICATION: Diabetes mellitus, change in mental status.",0
Assess left lung for infiltrate.,0
FINDINGS: A single AP semiupright view.,0
There has been significant further reexpansion of the left upper lobe.,0
Persistent left lower lobe collapse/consolidation and some blunting of the left costophrenic angle are again noted.,0
The right lung appears fairly well inflated.,0
The heart again shows marked left venrtricular enlargement.,0
The pulmonary vessels do not indicate cardiac failure.,1
Status post CABG surgery again noted.,0
Bilateral axillary surgical clips are also again noted.,0
IMPRESSION: Marked reexpansion of left upper lobe.,0
Persistent left lower lobe consolidation and collapse.,0
10:01 AM CHEST (PORTABLE AP) Clip # Reason: pt has decreased BS in RLL Admitting Diagnosis: HYPONATREMIA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with ESLD and ESRD currently volume overloaded w/ SOB REASON FOR THIS EXAMINATION: pt has decreased BS in RLL ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Single portable semi-erect chest view was read in comparison with multiple prior chest radiographs through with the most recent from .,1
FINDINGS: A right PICC line terminates approximately at the level of the lower SVC.,0
Persistently elevated right hemidiaphragm is unchanged since .,0
Mild pulmonary vascular congestion persists.,0
"However, there is no evidence of frank pulmonary edema.",0
"Normal heart size, mediastinal and hilar contours have an unchanged appearance.",0
Surgical clips are seen over the left upper medial lung and upper mediastinal aspect.,0
Small bilateral lower lung atelectases are stable.,0
There is no pleural effusion or discrete lung opacities concerning for pneumonia.,0
1:56 AM CT HEAD W/O CONTRAST Clip # Reason: please perform head ct without contrast.,0
new onset afib with ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with REASON FOR THIS EXAMINATION: please perform head ct without contrast.,0
new onset afib with left sided opthalmoplegia.,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: DEWd SUN 2:30 AM right frontal (and possibly right parietal) infarct no ich ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
INDICATION: New onset afib and left-sided opthalmoplegia.,0
TECHNIQUE: CT head w/o contrast.,0
CT HEAD W/O CONTRAST: There is an area of low attenuation within the right frontal cortex in the region of the frontal operculum.,0
There is effacement of the sulci in this area.,0
There is a mass effect upon the caudate and putamen and there is effacement of the frontal of the lateral ventricle.,0
"The area of low attenuation extends superiorly and is contiguous with areas of low attenuation within the periventricular white matter, and in particular, the right centrum semiovale.",0
A secondary area of low attenuation is seen along the posterior lateral aspect of the right lateral ventricle within the parietal lobe.,0
There is fluid within the frontal sinuses bilaterally.,0
IMPRESSION: Findings are consistent with new right frontal and possibly right parietal infarct.,0
Findings were communicated with ER physician at time of study.,0
5:01 PM HIP UNILAT MIN 2 VIEWS Clip # Reason: ?,0
"L hip fracture Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: year old man with shortened, externally rotated Left leg c/p hip pain REASON FOR THIS EXAMINATION: ?",0
L hip fracture ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Left hip pain.,0
No evidence of fracture is seen.,0
The bones of the left pelvis and left hip appear intact.,0
"4:59 PM PELVIS PORTABLE; -77 BY DIFFERENT PHYSICIAN # KNEE( (SINGLE VIEW) RIGHT Reason: reduction ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with hip dislocation, just reduced REASON FOR THIS EXAMINATION: reduction ______________________________________________________________________________ FINAL REPORT INDICATION: Hip dislocation status post reduction.",0
"SINGLE AP VIEW OF THE PELVIS, AND SINGLE VIEW OF THE DISTAL RIGHT FEMUR: There has been interval reduction of the previously noted right posterior hip dislocation.",0
Fracture fragments from a comminuted right posterior acetabular fracture are noted.,0
Degenerative changes of both hips are seen with joint space narrowing and osteophyte formation.,0
"5:00 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: ASTHMA;COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with COPD exacerbation extubated yesterday, but requiring reintubation, with worsening SOB.",0
REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT HISTORY: COPD exacerbation with worsening shortness of breath.,0
"FINDINGS: Comparison with the study of , there is no significant change in the appearance of the heart and lungs.",0
The endotracheal tube tip remains about 3 cm above the carina.,0
Evidence of multiple old healed rib fractures again seen.,0
"The right subclavian line extends to the lower superior vena cava, several cm below the carina.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CHIEF COMPLAINT: Hypotension.,0
"HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man with a past medical history as noted below, who presented to the Emergency Department with complaints of several weeks of progressive weakness and fatigue.",0
"On the morning of admission, the patient states that he developed mild ""slow vertigo"" that was worse when sitting up.",0
The patient states that he had a similar episode one month prior to admission that was attributed to dehydration from diarrhea; the patient was hospitalized from through for this problem.,0
"has also noted slurred speech for about three weeks prior to admission, which his family attributes to cyclobenzaprine and Percocet use.",0
"He otherwise, denied fever, chills, headache, tinnitus, hearing loss, visual changes, chest pain, shortness of breath, or sensory loss.",0
"In the Emergency Department, the patient received hydrocortisone 100 mg IV, 1 gram of Vancomycin IV, ceftriaxone, Flagyl, and 2 liters of normal saline IV.",0
Coronary artery disease status post five vessel CABG in .,0
Congestive heart failure with an ejection fraction of 20% and moderate mitral regurgitation.,1
Left carotid endarterectomy in .,0
Prednisone 6 mg po q day.,0
Alendronate 70 mg po q Monday.,0
Atorvastatin 20 mg po q day.,0
Furosemide 20 mg po q day.,0
Ranitidine 150 mg po q day.,0
Voriconazole 200 mg po bid.,0
Metoprolol 25 mg po bid.,0
Cyclobenzaprine 10 mg po q day.,0
Acetaminophen 650 mg po q4-6h prn.,0
"SOCIAL HISTORY: The patient has a 100 pack year smoking history, but he quit smoking cigarettes five years prior to admission.",0
He denies any history of alcohol abuse.,0
"He worked in the Navy, which is where he had asbestos exposure.",0
"He walks with assistance at home, and he is on 2 liters of oxygen by nasal cannula at home.",0
His daughter is actively involved in his medical care.,0
FAMILY HISTORY: mother died of bone cancer.,0
His father died of lung cancer.,0
"PHYSICAL EXAMINATION: On initial physical examination, the patient's temperature was 96.6, heart rate 80, blood pressure 96/56, respiratory rate 24, and oxygen saturation 100% on 1.5 liters of oxygen by nasal cannula.",1
"The patient was a thin, elderly, cachectic gentleman in no acute distress.",0
"His sclerae were clear bilaterally, pupils were 4 mm and equally reactive to light bilaterally, his oropharynx was dry, and he had no jugular venous distention.",0
"He had no wheezes, he had empty breath sounds over the right upper lung fields, and had bibasilar crackles.",0
"His heart was a regular, rate, and rhythm, there were normal S1, S2 heart sounds.",0
"There was a 1-2/6 early systolic ejection murmur heard best at the right upper sternal border, no S3, S4 heart sounds, and evidence of a prior CABG scar.",1
"His abdomen was soft, nontender, nondistended, there were normoactive bowel sounds.",0
"There was no rebound or guarding, and he had a lower abdominal scar.",0
There was no lower extremity edema.,0
"He had palpable dorsalis pedal pulses bilaterally, and evidence of chronic rheumatoid arthritis deformations of his hands bilaterally.",0
"He was alert and oriented times three, had occasional slurred speech, cranial nerves II through XII were intact, strength was throughout, he had no focal sensory deficits, and his deep tendon reflexes were 1+ throughout.",0
"On initial laboratory evaluation, the patient's white count was 8.6 (with a differential of 83% neutrophils, 2% bands, 5% lymphocytes, and 9% monocytes), hematocrit of 29.9, and platelets of 203,000.",0
"Initial serum chemistries demonstrated a sodium of 130, potassium 5.5, chloride 101, bicarbonate 18, BUN 61, creatinine 2.3 (baseline creatinine is 1.3-1.5), and glucose of 108, his calcium is 8.8, magnesium 2.3, and phosphate 4.3.",0
"His INR was 1.1 and his PTT was 24.3, ALT was 8, AST 24, amylase 33, total bilirubin 0.4, and his albumin was 3.2.",0
His initial urinalysis demonstrated a specific gravity of 1.020 and was otherwise negative.,0
"Of note, the patient's initial CK was 60, but his initial troponin-I was 10.",0
"His initial electrocardiogram demonstrated normal sinus rhythm at 80 beats per minute, intraventricular conduction delay, normal axis, minimal ST segment depressions in leads V4 through V6; his ST segment changes were slightly different compared with an electrocardiogram dated .",0
"On initial chest radiograph, he had persistent chronic changes, no evidence of failure, and no acute cardiopulmonary process.",1
HOSPITAL COURSE BY SYSTEMS: 1.,0
"Cardiovascular: After the initial troponin value of 10, the patient subsequently had troponin values of 15 and then 9.",0
"Given his elevated troponins in the setting of hypotension on admission, the patient was felt to have had a recent NSTEMI in the setting of low effective circulating volume.",0
"In the absence of recent or active chest pain or anginal symptoms, and given the patient's acute renal failure, it was thought that this myocardial infarction most likely occurred within seven days prior to admission.",1
"Because he appeared to have a low effective circulating volume on admission, the patient was aggressive rehydrated with intravenous fluids with a subsequent good response in his blood pressure.",0
"In order to evaluate whether or not the patient had any new clinically significant ischemic changes resulting from his NSTEMI, a transthoracic echocardiogram was performed on hospital day two.",0
"This study demonstrated that the left atrium is mildly dilated, the left ventricular wall thicknesses are normal.",0
"The left ventricular cavity size is normal, there is severe global left ventricular hypokinesis.",0
"There is severe global right ventricular free wall hypokinesis, the aortic root is moderately dilated, and there were no significant valvular abnormalities noted.",0
"Overall, compared with the report of a prior transthoracic echocardiogram done on , no major changes were found on this transthoracic echocardiogram.",0
"In order to further evaluate the patient's NSTEMI, he had a small P-MIBI on the day prior to discharge.",0
"During this study, he had no angina or ischemic electrocardiogram changes.",0
"The nuclear portion of this study demonstrated a moderate, fixed defect in the inferior myocardial wall, enlarged left and right ventricles, and global hypokinesis with a left ventricular ejection fraction of 18%.",0
"When compared to the prior study of , there was significant interval deterioration.",0
"In terms of the patient's hypotension on admission, by hospital day two, his standing metoprolol dose was restarted.",0
"On hospital day three, his ACEI was reinstituted, and on the day prior to discharge, he was restarted on his standing furosemide dose for his significant congestive heart failure.",1
Renal: The patient's renal function improved dramatically following aggressive fluid resuscitation.,0
"On the day prior to discharge, his serum creatinine was 1.0; on the day of discharge it was 1.2 following the reinitiation of therapy with furosemide.",0
"Endocrine: Given the patient's presentation with relative hyponatremia, hyperkalemia, and hypotension, there was consideration given to the possibility of adrenal insufficiency, especially given the patient's prolonged steroid use.",1
"Of note, his prednisone dose had reportedly recently been changed from 7 mg daily to 6 mg daily.",0
"During the first day of his hospitalization, the patient received stress dosed steroids; he was changed to his standing prednisone dose of 6 mg daily on hospital day two.",0
"On hospital day three, a random morning cortisol level was checked; this level subsequently returned at 7.6.",0
"In talking with the Endocrine Department, it was felt that this level was difficult to interpret in the face of the patient's chronic prednisone therapy.",0
"In order to further evaluate for the possibility of adrenal insufficiency, a cortisol level was drawn prior to the administration of the patient's morning prednisone dose on the morning of discharge.",0
"However, the patient was no longer orthostatic at the time of discharge, and Dr. will follow up on the results of this cortisol level on an outpatient basis.",0
"Infectious Diseases: As noted above, the patient had MSSA osteomyelitis in late and early .",0
"At that time, the osteomyelitis was found to including the patient's left hip, which was subsequently replaced.",0
"According to OMR notes, it seemed possible that the patient may have had an occult source of infection at the time that his left hip was replaced.",0
"Because of this possibility, the decision was made in conjunction with the Department of Infectious Diseases at that time, to continue the patient on life-long antimicrobial therapy with levofloxacin.",0
His levofloxacin was therefore continued during this hospitalization.,0
"In addition, the patient was recently noted to have a cavitary pulmonary aspergilloma, for which he is continuing to receive long-term therapy with voriconazole.",0
"Of note, the patient's white blood cell count was mildly elevated at 11.6 on the date of discharge; Dr. will also follow this level on an outpatient basis.",0
"Hematology: The patient's hematocrit trended down over the first three days of his hospitalization, such that his hematocrit was 25.3 on hospital day three.",0
"Given his extensive history of coronary disease, the patient was therefore transfused 2 units of packed red blood cells on hospital day three.",0
His hematocrit subsequently increased to a level of 34; it was 32.3 on the date of discharge.,0
"Iron studies obtained prior to these transfusions were most consistent with a picture of anemia of chronic disease, although the patient's iron level was normal at 89.",0
"Neurology: By hospital day four, the patient began complaining of a severe right sided, periauricular headache.",0
"The etiology of this headache was unclear, but the patient did have a negative head CT scan at the time of admission.",0
"This headache was treated supportively, and on the day of discharge, the patient found that certain movements were able to alleviate the headache.",0
"Gastrointestinal: The patient's alkaline phosphatase level was found to be elevated in the absence of any nausea, vomiting, or abdominal pain.",0
This level will continue to be followed on an outpatient basis.,0
"Also of note, the patient had a bedside swallowing evaluation during this hospitalization, during which the Department of Speech Pathology felt that the patient could continue with his current diet.",0
DISCHARGE PLACEMENT: Home with services.,0
Please see the past medical history list for the remainder of the medical problems.,0
Aspirin 325 mg po q day.,0
Ranitidine 150 mg po bid.,0
Atorvastatin 10 mg po q day.,0
Celicoxib 200 mg po bid.,0
Acetaminophen 325-650 mg po q4-6h prn pain.,0
"DISCHARGE INSTRUCTIONS: The patient was instructed to call Dr. on the day following discharge to arrange for a follow-up appointment with him by , .",0
He was also instructed to maintain all previously arranged medical appointments.,0
Dictated By: MEDQUIST36 D: 18:47 T: 06:40 JOB#:,0
"3:09 PM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, edema ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with SOB x 1 day, warm to touch, h/o myeloproliferative disease REASON FOR THIS EXAMINATION: assess for infiltrate, edema ______________________________________________________________________________ FINAL REPORT HISTORY: 59-year-old female with shortness of breath.",0
PORTABLE CHEST RADIOGRAPH: The cardiac and mediastinal contours are stable including mild cardiomegaly and calcification at the aortic arch.,0
The lung volumes are slightly low which limits exam sensitivity.,0
"Bibasilar atelectasis is evident, left greater than right.",0
A left lower lobe infiltrate cannot be excluded.,0
A dedicated lateral view may be helpful.,0
", C. VSURG CSRU 3:09 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o ptx Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman s/p attempted thoracentesis REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ PFI REPORT Large left tension pneumothorax.",1
"10:33 AM CTA HEAD W&W/O C & RECONS Clip # Reason: Post-op, please evaluate for injury/rupture Admitting Diagnosis: EPIDURAL BLEED Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with right epidural s/p craniotomy.",0
"REASON FOR THIS EXAMINATION: Post-op, please evaluate for injury/rupture No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: CT of the head.",0
"CLINICAL INFORMATION: Patient with right-sided epidural hematoma and skull fracture, for further evaluation.",1
The examination is performed to exclude vascular injury.,0
Correlation was made with the previous CT examination of obtained earlier on the same day.,0
"FINDINGS: Since the previous study, the patient has undergone evacuation of a right-sided large epidural hematoma.",0
A small extra-axial hematoma is still seen in the right occipital region with slightly displacing the right transverse sinus.,0
Again multiple fractures are identified including fracture involving on the right sphenoid bone extending to planum sphenoidale.,0
There are soft tissue changes in the right sphenoid sinus.,0
There is now apparent a hemorrhagic contusion in the inferior right frontal lobe.,0
CT ANGIOGRAPHY OF THE HEAD: The CT angiography demonstrates normal patency of vascular structures in the arteries of anterior and posterior circulation.,0
There is no pseudoaneurysm identified.,0
No extravasation of contrast seen.,0
"Subtle irregularity of the right paraclinoid carotid only seen on coronal reformatted images, image 17, appears artifactual as despite close observation in other projections, no irregularity of the vessel is seen in this region.",0
This was not confirmed on 3D images.,0
"Otherwise, no definite signs of vascular injury seen.",0
"In the right side of the posterior fossa, extra-axial residual hematoma is identified which slightly displaces the transverse sinus medially.",0
No evidence of irregularity or extravasation of contrast seen in this region to indicate injury to the transverse sinus.,0
A small residual extra-axial collection is also seen in the right parietal region.,0
"IMPRESSION: (Over) 10:33 AM CTA HEAD W&W/O C & RECONS Clip # Reason: Post-op, please evaluate for injury/rupture Admitting Diagnosis: EPIDURAL BLEED Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) 1.",0
Head CT prior to CT angiogram demonstrates a newly apparent hemorrhagic contusion in the inferior right frontal lobe.,0
There is decrease in mass effect and midline shift.,0
Small residual extra-axial collection is seen after surgical evacuation of the subdural hematoma.,0
CT angiography demonstrates subtle irregularity of the paraclinoid right internal carotid artery only visualized on coronal reformatted images which appears artifactual as it is not confirmed on other images including 3D reformats.,0
No other vascular abnormalities suspected.,0
7:32 AM NEONATAL HEAD PORTABLE Clip # Reason: screen for IVH Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity at 29 3/7 weeks REASON FOR THIS EXAMINATION: screen for IVH ______________________________________________________________________________ FINAL REPORT PORTABLE NEONATAL HEAD ULTRASOUND .,1
HISTORY: One week old boy who was born prematurely at about 29 weeks EGA.,0
FINDINGS: Portable real time son of the neonatal head was performed in the NICU.,0
"The brain parenchyma has normal echogenicity without evidence for mass, hemorrhage, or structural abnormality.",0
There is a region of globular increased echogenicity in the right caudothalamic groove.,0
This does not extend into the ventricle and the right lateral ventricle is not enlarged.,0
The remainder of the ventricles appear normal.,0
No abnormal extraaxial fluid collections.,0
IMPRESSION: Grade 1 right germinal matrix hemorrhage.,1
Note: This was discussed in person with members of the patient's treatment team on the morning of .,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Neck pain Major Surgical or Invasive Procedure: Posterior cervical fusion C5-6 History of Present Illness: This is a 37 year old woman who was on a bicycle and was hit by a car.,0
She had +LOC and is amnestic to event.,0
"She reports headache, neck pain, thoracolumbar back pain.",0
"She denies nausea/emesis, change in vision, dizziness, extremity pain/numbness.",0
"She recalls UE paresthesias circumferentially when she was at , lasting > 1hr.",0
"Past Medical History: Toe amputation at infancy Social History: housewife, denies Tob use, right handed Family History: N/C Physical Exam: ON ADMISSION: PHYSICAL EXAM: Gen: WD/WN, NAD, Spine precautions, J collar.",0
HEENT: Pupils: 2-1.5 EOMs intact Extrem: Warm and well-perfused.,0
Language: Speech fluent with good comprehension.,0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1.5 mm bilaterally.",0
No pronator drift Sensation: Intact to light touch.,0
"Reflexes: B T Br Pa Ac Right 1 0 1 1 0 Left 1 0 1 1 0 ON DISCHARGE: motor full, incision clean dry intact with staples no /s sign, no clonus, rectal tone normal.",0
Pertinent Results: Admission labs: 12:35PM PT-12.8 PTT-26.6 INR(PT)-1.1 12:35PM WBC-25.0* RBC-4.43 HGB-13.4 HCT-40.3 MCV-91 MCH-30.2 MCHC-33.2 RDW-13.3 12:35PM GLUCOSE-139* UREA N-11 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 Discharge labs: 09:15AM BLOOD WBC-15.5* RBC-4.45 Hgb-13.5 Hct-39.6 MCV-89 MCH-30.3 MCHC-34.0 RDW-12.6 Plt Ct-572*# 09:15AM BLOOD Glucose-103* UreaN-15 Creat-0.5 Na-134 K-4.6 Cl-91* HCO3-28 AnGap-20 Imaging: MRI C-Spine : 1.,0
"Right C5 lamina fracture, right unilateral perched facet of C5 on C6, and traumatic grade II anterolisthesis of C5 upon C6.",0
Focal disruption of the PLL at C5 and ALL at C6.,0
Disruption of the ligamentum flavum at C5-6 with a small fluid collection which does not have any mass effect on the posterior thecal sac.,0
"Edema in the interspinous ligaments at C5-6, and in the nuchal ligament at C2-C6.",0
Mild flattening of the ventral cord at C6 without evidence of edema.,0
"Right-sided subdural hematoma along the right tentorial leaflet and falx, posteriorly, is stable.",0
Hemorrhage no longer seen extending into the foramen magnum.,0
"Foci of subarachnoid hemorrhage overlying the frontoparietal lobes, bilaterally.",1
"Previous subarachnoid hemorrhage within the suprasellar cistern is no longer seen, likely due to redistribution.",1
No new hemorrhage CT C-Spine : 1.,0
"Status post recent open reduction and internal fixation of the traumatic anterolisthesis at C5-6, with posterior instrumented fusion, and no evidence of short-term hardware complication.",0
"Relatively inferolateral position of the tip of the right C6 transpediculate screw, which appears to breach the caudal aspect of the right C6-7 neural foramen, unchanged.",0
"Persistent distraction at the previously ""perched"" right C5-6 facet articulation; however, this appearance likely relates to the presence of the morcellized corticocancellous bone graft material at this site.",0
"Non-displaced hairline fracture at the central aspect of the right lamina of C5, as before.",0
Brief Hospital Course: The patient was admitted to the ICU under the trauma service for Q1 neuro checks and C-Spine/log roll precautions.,0
"She was placed on Dilantin for seizure prophylaxis, and was kept comfortable with IV analgesia.",0
She had a repeat Head CT on that showed no change in the size of the SDH.,0
She remained on anti-epileptic treatment for one week.,0
"Because of her unstable C-Spine fracture, she was placed in cervical traction and went up to 50lb of weight but was unable to be reduced prior to going to the patient to the operating room on for a posterior fusion of C5-6.",1
"She tolerated the procedure well and following a short course in the ICU, she was transferred to the floor.",0
"She had some issues with pain control; valium was added to her pain regimen, and she was placed in a soft collar.",0
Her pain was much better managed following these interventions.,0
She was mobilized with PT.,0
Her incision was clean and dry with staples.,0
Her foley was removed and she was able to void.,0
On her foley was replaced for incompletion of voiding and then removed again later in the day.,0
She was able to void independently.,0
"On , she was ambulating well with good pain control, and was discharged to home.",0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on narcotics.,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain.,0
Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for no BM >48hr.,0
Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) for 2 weeks: 600mg x 1 wk then 300mg for 1 wk then dc.,0
Robaxin-750 750 mg Tablet Sig: One (1) Tablet PO three times a day.,0
Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) for 3 weeks: 30mg for 1wk then 20mg for 1wk then 10mg for 1 wk then dc.,0
Disp:*84 Tablet Sustained Release 12 hr(s)* Refills:*0* 7.,0
Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for neck pain.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain.,0
Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Discharge Diagnosis: C5 fracture and perched facets SDH/SAH Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?,0
Keep wound clean / No tub baths or pools until seen in follow up/ remove dressing 5/1/10/ begin daily showers ?,0
If you have steri-strips in place ?,0
keep dry x 72 hours.,0
Do not pull them off.,0
They will fall off on their own or be taken off in the office ?,0
"No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks.",0
Limit your use of stairs to 2-3 times per day ?,0
Have a family member check your incision daily for signs of infection ?,0
Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?,0
"Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc.",0
Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?,0
Pain that is continually increasing or not relieved by pain medicine ?,0
"Any weakness, numbness, tingling in your extremities ?",0
"Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?",0
Any change in your bowel or bladder habits Followup Instructions: YOUR SUTURES ARE UNDER THE SKIN YOU WILL NOT NEED TO BE SEEN UNTIL THE FOLLOW UP APPOINTMENT PLEASE CALL TO SCHEDULE AN APPOINTMENT WITH DR. TO BE SEEN IN 6 WEEKS.,0
YOU WILL NEED cervical spine XRAYS PRIOR TO YOUR APPOINTMENT and Head CT It is also reccomended that you follow up with Cognitive Neurology for your injury - please call to schedule this appt.,1
"7:45 PM CHEST (PORTABLE AP) Clip # Reason: FEVER Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with mvc, s/p BKA, now w/fever REASON FOR THIS EXAMINATION: eval for pna ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for pneumonia.",1
PORTABLE AP CHEST: HISTORY: Comparison made to study from .,0
"Again seen is a Dobhoff tube, with tip positioned in the stomach at the fundus.",0
"There has been interval repositioning of this tube, which was previously seen in the esophagus.",0
"Again noted are diffuse alveolar opacities, seen bilaterally and representing pulmonary edema.",0
There appears to be slight interval wosening of this.,0
A left retrocardiac density is again representing atelectasis/consolidation.,0
The heart size and mediastinal contours are unchanged.,0
"Again noted is diffuse pulmonary edema, which is slightly worse on today's exam.",0
Dobhoff tube is seen with the tip positioned in the stomach.,0
"4:23 AM CHEST (PORTABLE AP) Clip # Reason: rule out aspiration pna Admitting Diagnosis: TRICYCLIC ANTIDEPRESSANT ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with OD, intubated had charcoal suctioned from trach tube.",0
"REASON FOR THIS EXAMINATION: rule out aspiration pna ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Patient intubated, charcoal suctioned from tracheal tube, rule out aspiration.",0
"When compared to prior study dated and , moderate cardiomegaly is stable.",0
"Left lower lobe retrocardiac ill-defined opacity warrants further evaluation with PA and lateral views, this might represent area of atelectasis and/or aspiration.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEONATOLOG HISTORY OF PRESENT ILLNESS: This is a discharge summary documenting the hospital course of baby girl who expired on her date of birth due to significant devastating neurologic injury.,1
who had two previously healthy pregnancies in the past.,0
There were no prenatal risk factors.,0
"Mom's lab tests were negative including negative GPS, RPR nonreactive, hepatitis B surface antigen negative and a normal 18 week ultrasound.",0
"PERINATAL HISTORY: On the day of admission, fetus was at 35 weeks gestation and the mother presented to Antepartum noted.",0
Ultrasound revealed -physical profile of with a very large head consistent with 42 week gestation fetus.,0
Further analysis of the infant's head revealed evidence of a large intracranial hemorrhage on the right side with no ventricle being visible on the right and apparently normal sized ventricle on the left.,0
Mass affect was noted across the midline.,0
There was also a suggestion of intrathalamic hemorrhage with distortion of the vasoganglia.,0
The infant's had very poorly reactive fetal tracing as well.,0
"DELIVERY: Due to flat fetal tracing and concern over possibility of ongoing intracranial hemorrhage, the infant was delivered via stat Cesarean section.",1
"The infant emerged pale with absent respirations, floppy.",0
The infants heart rate was about 60s.,0
Positive peripheral ventilation was given with improvement in heart rate and color.,0
There was still no spontaneous respiratory effort.,0
Infant was intubated prior to five minutes of life.,0
Apgar's were noted as 3 at one minute and 6 at five minutes respectively.,0
"Following intubation, the tone remained poor and reactivity was poor.",0
"PHYSICAL EXAMINATION: On admission, the infant had a large tense head with evidence of bruising on the left side.",0
Fontanelles could not be palpated due to tension.,0
The infant's pupils were dilated bilaterally and minimally responsive to light.,0
The heart rate was regular without murmurs.,0
Breath sounds were equal and clear.,0
Blood pressure mean was in the mid 80s initially and then was in the mid 40s afterwards.,0
The infant was occasionally moving the lower extremities in a non-purposeful manner.,0
"Overall tone, however was poor.",0
There was no spontaneous respiratory effort noted.,0
MEASUREMENTS: The infant's birth weight was 2.77 kilograms which is over the 90th percentile.,1
Head circumference was 39 cm which was significantly over the 90th percentile for a 42 week infant.,0
Length was 47 cm which was around the 55th percentile for a 35 week infant.,0
RESPIRATORY: Initial impression was apnea secondary to massive brain injury.,1
Infant was intubated and placed on synchronized intermittent mechanical ventilation at physiologic rate and had reasonable arterial blood gasses with this level of management.,0
Endotracheal was in appropriate position.,0
CARDIOVASCULAR: The infant was not hypotensive.,0
There did seem to be some maintenance of normal vascular tone.,0
"Hematocrit was 27 so O negative packed red cells were brought in for transfusion, however infant was transferred to emergently prior to administration of packed cells.",0
Infant's pulse was within normal limits.,0
"FLUIDS, ELECTROLYTES AND NUTRITION: The infant was kept NPO and IV Dextrose was given at 50 cc per kilo per day as part of conservative management.",0
NEUROLOGIC: This infant's major issue was devastating brain injury.,0
"Due to a concern for active ongoing intracranial hemorrhage and presence of fixed and dilated pupils, the infant was emergently transferred to for neurosurgical evaluation and taken to the CT Scan prior to arrival in the ICU at .",0
A CT Scan revealed massive loss of functional brain tissue throughout the CNS.,0
The cerebellum was not well demarcated.,0
The brain stem was difficult to visualize.,0
There was a large cystic appearing lesion extending through the right hemisphere with midline shift and brain parenchyma was poorly visualized with very dark attenuation consistent with liquefaction and presence of primarily CSF throughout the cranial cavity.,0
There was some active or more acute hemorrhage occurring superiorly into this large cystic mass.,0
"After review by Neurosurgery and Radiology, conclusions were made that this type of a lesion was not amendable to any type of medical or surgical therapy.",0
The infant was prepared for transfer immediately back to to be with the family.,0
"FAMILY AND SOCIAL: Upon return to Hospital, we discussed the results of the evaluation at in detail with the parents.",0
"Part of this discussion including our assessment that given the devastating degree of brain injury and massive loss of functional brain tissue globally, that this infant's prognosis for neurologic morbidity was grim.",0
It was dsicussed that it was likely that was likely not to be able to breateh on her own given the radiographic findings and clinical presentaion.,0
We also explained that this opinion was in concurrence with the Neurosurgical staff at as well as the written opinion of the neonatologist at and the Care Team here at after careful examination of the CT Scan results and knowledge of this infant's clinical exam.,0
"As part of their discussion with us, the parents expressed their view that in her best interests, care should be redirected to comfort measures.",0
The parents came to the nursery to spend time with the infant who was on mechanical ventilation.,0
"At approximately 9:30 PM on the day of admission, the parents requested to have the infant extubated so that they could hold her.",0
Dr. was present at this time.,0
The infant demonstrated two evident agonal breaths following extubation with minor non-purposeful movement of her lower extremities.,0
She was held and subsequently expired at 10:30 PM.,0
A mom box was assembled and presented to the family.,0
The parents consented to a postmortem examination.,0
The medical examiner waved the examination.,0
A social worker was notified of the death and we have discussed all of these issues with the social worker today.,0
We will be notifying the primary obstetrician and primary pediatrician.,0
Dictated By: MEDQUIST36 D: 11:35 T: 11:44 JOB#:,0
Status: Inpatient Date/Time: at 15:59 Test: TEE (Complete) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Limited echocardiographic views for an emergency intraop TEE.,0
A C2 fracture is noted and discussed with surgeon -- Dr. .,0
Risk/benefit ratio in this case was discussed.,0
It was decided by both teams that the benefit outweighs the risk in this unstable patient.,0
Special care was taken to make sure the head was kept in neutral postion during probe placement.,0
Image acquisition was limited to the minimum necessary windows in order to prevent spinal damage.,0
Trivial MR. TRICUSPID VALVE: Moderate to severe [3+] TR.,0
Conclusions: This is an emergency intraop TEE for an unstable patient s/p MVA.,0
The left ventricle appears underfilled.,0
Right ventricular chamber size iand systolic function is normal.,0
The intrinsic function of RV might be overestimated given the degree of TR.,0
There is abnormal septal motion which may indicate right ventricular pressure overload.,0
There is a trivial/physiologic pericardial effusion without echocardiographic signs of tamponade.,0
10:03 PM CHEST (PORTABLE AP) Clip # Reason: eval for fever source Admitting Diagnosis: RIGHT SIDED WEAKNESS;ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with fever REASON FOR THIS EXAMINATION: eval for fever source ______________________________________________________________________________ WET READ: SHSf FRI 11:33 PM Bilateral hilar fullness with ground glass opacification likely reflects pulmonary edema (given thickened septal lines on CTA neck).,1
"Retrocardiac and left midlung opacities could reflect atelectasis, aspiration or pneumonia.",0
Consider reimaging after diuresis for further evaluation.,0
d/w Govindan 2325 WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Fever.,0
Heart size is enlarged as well as the mediastinum which might reflect supine portable character of the study.,0
"Bilateral perihilar and lower lobe opacities have developed in the interim most likely consistent with pulmonary edema, aspiration would be another possibility and less likely to represent infectious process.",0
Followup of the patient after diuresis is suggested.,0
"LINE PLACEMENT Clip # Reason: ETT and CVL placement Admitting Diagnosis: CHRONIC DISTAL COMMON BILE DUCT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with s/p biliary bypass and open choley REASON FOR THIS EXAMINATION: ETT and CVL placement ______________________________________________________________________________ WET READ: 9:31 PM 1. interval placement of ETT 4.5 cm above carina, LIJ line w/ tip in mid-SVC, and endogastric tube w/ side port just above GEJ - consider advancing several cm.",0
RUQ staple line an drains.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Line placement.,0
"FINDINGS: In comparison with study of , there has been placement of an endotracheal tube with its tip about 4.5 cm above the carina.",0
Left IJ catheter tip is in the mid SVC.,0
"Nasogastric tube extends into the stomach, though the side hole is above the esophagogastric junction and the tube should be pushed forward.",0
No evidence of acute cardiopulmonary disease.,0
Mild atelectatic changes at the bases.,0
"7:49 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: degree of RDS/lung inflation on vent ______________________________________________________________________________ MEDICAL CONDITION: 31wk premature infant, stat C/s REASON FOR THIS EXAMINATION: degree of RDS/lung inflation on vent ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST HISTORY: 31 week gestational age premature infant who was born following an emergency cesarean section.",1
Assess lung inflation and degree of RDS.,0
FINDINGS: A portable chest film demonstrates the presence of visceral situs solitus.,0
The aortic arch is probably left sided.,0
The chest film is mildly rotated.,0
Lung volumes are moderately increased.,0
There is an ET tube with its tip in satisfactory position below the thoracic inlet and above the level of the carina.,0
There is very mild granularity of the lung parenchyma in keeping with a mild degree of RDS or edema.,0
No other abnormality is noted.,0
"1:36 PM CHEST (PORTABLE AP) Clip # Reason: r/p ptx s/p thorac Admitting Diagnosis: PNEUMONIA,DEHYDRATION,ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with AIDS, hypoxia.",1
REASON FOR THIS EXAMINATION: r/p ptx s/p thorac ______________________________________________________________________________ FINAL REPORT INDICATION: History of AIDS and hypoxia.,0
FINDINGS: The previously seen perihilar and multifocal opacities have slightly improved.,0
"However, there has been interval development of bilateral pleural effusions.",1
There is no new consolidation.,0
"Pulmonary vasculature is normal, and there is no pneumothorax.",0
"IMPRESSION: Slight improvement in previously seen multifocal and perihilar opacities, but interval development of bilateral pleural effusions.",1
The nodular configuraiton of pulmonary opacities and the presence of pleural effusions argue against PCP and favor bacterial (e.g.,1
"septic emboli), fungal, or mycobacterial etiology.",0
Admission Date: Discharge Date: Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Sternal Drainage Major Surgical or Invasive Procedure: s/p Sternal rewiring History of Present Illness: 83 y/o male s/p Coronray Artery Bypass Graft x 4 on without post-op complications who present to ED with sternal drainage after coughing spell.,1
"Upom exam, pt was found to have an unstable sternum and cxr revealed displacement and rotation of sternotomy wires, consistent with sternal dehiscence.",0
Past Medical History: Coronary Artery Disease s/p Coronray Artery Bypass Graft x 4 on Hyperlipidemia s/p Appendectomy in Social History: He lives in with his wife.,0
retired 1 year ago from sales.,0
He uses no assistive devices.,0
He quit smoking in .,0
He has a 40-pack-year history.,0
He has 3 alcoholic drinks per year.,0
Family History: His father died of a MI at the age of 87.,0
Pertinent Results: CXR : Interval increase in moderate left pleural effusion.,1
"Displacement and rotation of sternotomy wires, consistent with sternal dehiscence.",0
06:07AM BLOOD WBC-12.3* RBC-3.74* Hgb-10.8* Hct-32.9* MCV-88 MCH-28.8 MCHC-32.7 RDW-14.4 Plt Ct-371# 05:55AM BLOOD WBC-10.9 RBC-3.03* Hgb-8.7* Hct-26.8* MCV-88 MCH-28.7 MCHC-32.5 RDW-14.1 Plt Ct-433 08:15AM BLOOD PT-13.3 PTT-26.4 INR(PT)-1.1 06:07AM BLOOD Glucose-93 UreaN-26* Creat-1.1 Na-139 K-4.4 Cl-102 HCO3-27 AnGap-14 05:35AM BLOOD Glucose-107* UreaN-32* Creat-1.3* Na-134 K-4.0 Cl-98 HCO3-26 AnGap-14 05:55AM BLOOD UreaN-29* Creat-1.2 K-4.8 06:07AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 05:35AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.1 12:13PM URINE Color-Straw Appear-Clear Sp -1.006 12:13PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Brief Hospital Course: Pt.,0
was admitted on with sternal dehiscence.,0
IV ABX were started and pt was kept NPO for preparation to OR the next day.,0
On HD #2 he was brought to the operating room and underwent sternal rewiring.,0
"tolerated the procedure well, was extubated in the OR and was transferred to the CSRU in stable condition.",0
POD #1 pt was recovering well after rewiring.,0
He was not receiving any gtts and pre-op meds were started.,0
"to need aggressive chest pt, nebs and O2 to remain adequate O2 stats.",0
He therefore remained in the CSRU until POD #2.,0
On this day he was transferred to the telemetry floor.,0
His chest tubes were removed and ABX were cont.,0
His pre-op culture (urine) was negative and the chest swab performed in the OR was negative as well.,0
From POD # pt slowly improved.,0
"to need O2 via NC which was slowly weaned with aggressive pt, IS and nebs.",0
Vanco was continued until day of discharge where it was stopped.,0
Exam on POD #5 was unremarkable.,0
"Chest was stable, without clicks or drainage.",0
Pt was discharged home with the appropriate follow-up.,0
Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Sterile sternal dehiscence after CABG Coronary Artery Disease s/p Coronray Artery Bypass Graft x 4 on Hyperlipidemia s/p Appendectomy in Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions.,0
You may not drive for 4 weeks.,0
You may not lift more than 10 lbs.,0
"You should shower, let water flow over wounds, pat dry with a towel.",0
Followup Instructions: Make an appointment with Dr. for 1-2 weeks.,0
Make an appointment with Dr. for 6 weeks.,0
5:03 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for worsening PTX Admitting Diagnosis: FUNGAL PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with right sided necrotizing fungal pneumonia and pneumothorax and acute drop in BP REASON FOR THIS EXAMINATION: Please eval for worsening PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Right-sided necrotizing fungal pneumonia.,1
Pneumothorax and acute drop in blood pressure.,1
Comparison is made to the prior examination of .,0
FINDINGS: The ET tube and right subclavian central venous line are in stable position.,0
"Allowing for technical differences, there is no significant change from prior exam.",0
"Note is again made of a small right lateral pneumothorax, dense consolidation in the right midlung zone, and left lower lobe consolidation.",1
Pulmonary vascular congestion is also unchanged.,0
"Note is also made of a right-sided chest tube, unchanged.",0
IMPRESSION: Stable appearance since the previous examination of .,0
3:51 AM CHEST (PORTABLE AP) Clip # Reason: Eval.,0
"for interval change Admitting Diagnosis: AAA REPAIR ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p emergent repair of AAA, now with dropping sats.",0
s/p abdominal closure REASON FOR THIS EXAMINATION: Eval.,0
"for interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST HISTORY: Abdominal closure, dropping O2 sat.",0
Interstitial markings are increased and pulmonary vasculature now appears less distinct.,0
"A focally increased density in the retrocardiac area is again demonstrated, as is blunting of the left costophrenic sulcus.",0
"The patient is status post median sternotomy, as before.",0
"An endotracheal tube, nasogastric tube, and right subclavian catheter remain in place.",0
IMPRESSION: Evidence for development of mild interstitial pulmonary edema.,0
Persistent retrocardiac density consistent with volume loss or consolidation.,0
8:58 AM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: please do noncontrast neck CT to eval for air and extenstion Admitting Diagnosis: FACIAL SWELLING ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with preseptal cellulitis now extending down neck and c/o left shoulder pain REASON FOR THIS EXAMINATION: please do noncontrast neck CT to eval for air and extenstion of cellulitis to chest/shoulder CONTRAINDICATIONS for IV CONTRAST: arf ______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old male with preseptal cellulitis extending down neck with complaint of left shoulder pain.,0
Evaluate for air and extension of cellulitis to chest and shoulder.,0
TECHNIQUE: Axial multidetector CT images of the neck were obtained without intravenous contrast.,0
FINDINGS: Again noted is diffuse fat stranding in the neck which is most prominent in the right preauricular and right upper neck area with extension into the left soft tissues.,0
Compared to the prior study there has been increased inferior obscuration of the fat planes and infiltration of the skin past the level of the hyoid down to the level of the thyroid.,0
Associated bilateral shoddy lymphadenopathy in the jugulodigastric chains is again noted and unchanged.,0
No drainable fluid collection is identified.,0
There is no subcutaneous emphysema or gas seen.,0
"The submandibular, parotid and salivary glands are unremarkable.",0
Visualized portions of the paranasal sinuses are well-aerated.,0
No dental abnormalities are detected.,0
The retropharyngeal and peritonsillar spaces are unremarkable.,0
"The visualized portion of the airway, thyroid gland and lung apices remain unremarkable.",0
Dense calcification in the bilateral common carotid arteries is again noted.,0
Multilevel degenerative change of the cervical spine most prominent at C5-6 and C6-7 is again noted.,0
In addition there is sclerosis of the odontoid process which is stable since .,0
IMPRESSION: Progressive diffuse soft tissue edema in the right preauricular area and neck with extension down to the level of the thyroid.,0
"No evidence of drainable fluid collection, subcutaneous emphysema or gas formation.",0
"Findings were discussed with Dr. , on the ENT consult team at the time of interpretation on .",0
Dr. of the primary team was also notified of these findings on .,0
(Over) 8:58 AM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: please do noncontrast neck CT to eval for air and extenstion Admitting Diagnosis: FACIAL SWELLING ______________________________________________________________________________ FINAL REPORT (Cont),0
"8:06 PM BABYGRAM AP ABD ONLY PORT Clip # Reason: EVALUATE BOWEL GAS PATTERN Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress syndrome, 27 wks gestational age ABDOMINAL DISTENSION REASON FOR THIS EXAMINATION: EVALUATE BOWEL GAS PATTERN ______________________________________________________________________________ FINAL REPORT HISTORY: Two-day old infant with RDS.",1
FINDINGS: Single supine view of the abdomen shows umbilical venous catheter now directed into either left portal venous branches or the ductus venosum.,0
"Air-filled mildly distended loops of bowel are seen throughout the abdomen, but the overall distribution of bowel gas is unremarkable, with air seen passing all the way to the rectum.",0
No focally dilated loops or featureless loops of bowel are seen.,0
The visualized lung bases are clear.,0
"12:27 AM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: please r/u fluid collection Admitting Diagnosis: PARSPINAL TUMOR/SDA Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 35M T9-T12 lami for tumor, fusion T9-L2, POD 5, now with fever.",0
REASON FOR THIS EXAMINATION: please r/u fluid collection No contraindications for IV contrast ______________________________________________________________________________ WET READ: 4:07 AM Moderate left pleural effusion (simple fluid density).,0
1 cm right base nodule (likely infectious as was not present ).,0
"S/p resection of neurofibromas now w/ 6.5 x 4.3 cm left paraspinal collection in surgical bed w/ fluid and air - could be post-op seroma, but infection cannot be excluded.",0
Edema in soft tissues of left flank and left ant.,0
"______________________________________________________________________________ FINAL REPORT EXAMINATION: CT of chest, abdomen and pelvis with contrast dated .",0
COMPARISON: CT chest scan from outside hospital scanned as reference on .,0
"INDICATION: Status post T9 through T12 laminectomy for tumor, fusion of T9 through L2 post-op day 5, now with fever, rule out collection.",0
Imaging was obtained through the abdomen without IV contrast.,0
"Then after the bolus intravenous administration of 100 cc of non-ionic contrast imaging was obtained through the chest, abdomen, and pelvis.",0
Images were reformatted in the coronal and sagittal planes.,0
FINDINGS FOR CT OF THE CHEST WITH IV CONTRAST: Within the subscapularis muscles bilaterally there are symmetric poorly defined low density new since CT chest .,0
"The differential includes extension of synovial fluid vs. edema related to positioing during recent surgery, and felt less likely to represent rhabdomyolysis due to its focal nature and not felt to represent neurogenic tumor as this usually enhances.",0
There is a small- to- moderate layering left pleural effusion with adjacent compressive atelectasis.,0
"At the right lung base, there is a 1-cm air space opacity which may represent atelectasis; however, early infection cannot be excluded.",0
Patient is status post left posterior thoracotomy extending from T8 through T10.,0
"In addition, patient is status post laminectomy extending from T9 through L1 with posterior fusion of T8 through L2.",0
"Along the paraspinal region in the surgical bed there is a fluid and gas collection which measures 4.3 cm in transverse (Over) 12:27 AM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: please r/u fluid collection Admitting Diagnosis: PARSPINAL TUMOR/SDA Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) dimension x 6.4 cm in the AP dimension x 8.2 cm in the craniocaudal dimension extending from the T8 level through T12 on the left which may represent a post-operative collection; however, infection cannot be excluded.",0
There is a small focus of gas in the epidural space posterior to L1/L2.,0
Multiple small foci of gas are demonstrated within the paraspinous musculature posterior to T12.,0
Evaluation of the thecal sac is limited on CT and if the patient has change in neurologic status further evaluation with MRI is recommended.,0
"CT OF THE ABDOMEN: The liver, spleen, pancreas, gallbladder, adrenal glands, pancreas, and kidneys are unremarkable.",0
"There is no ascites, lymphadenopathy, or free intraperitoneal gas.",0
The bowel is normal in caliber.,0
CT OF THE PELVIS: There is sigmoid diverticulosis without evidence of diverticulitis.,0
"Gas is demonstrated within the bladder, which may be related to recent instrumentation or catheterization, clinical correlation is recommended.",0
"The prostate, seminal vesicles are unremarkable.",0
BONE WINDOWS: Left iliac donor site is demonstrated.,0
There is posterior left thoracotomy extending from T8 through T10.,0
Status post thoracotomy at T8 through T10 with laminectomy extending from T9 through L1 and posterior fusion of T8 through L2.,0
"There is a collection of fluid and gas within the left paraspinal region extending from T8 through T12 as described above, which may represent post-surgical changes; however, infection cannot be excluded.",0
"Bilateral symmetric ill-defined low density involving the subscapularis muscles bilaterally, new since prior exam.",0
Differentail includes muscular edema from positioning during surgery vs synovial fluid.,0
If clinically warranted further evaluation with MRI chest may be helpful.,0
Layering left pleural effusion and adjacent compressive atelectasis.,0
Sigmoid diverticulosis without evidence of diverticulitis.,0
"Findings were discussed with Chip, the nurse practitioner on , at 8:30 a.m. (Over) 12:27 AM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: please r/u fluid collection Admitting Diagnosis: PARSPINAL TUMOR/SDA Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: Baby is a 40-1/7 week gestational age male born to a 27 year old G5, P2, 3, mother with the following prenatal labs.",0
"Blood type O positive, antibody negative, Hepatitis surface antigen negative.",0
Mother presented in spontaneous labor leading to a spontaneous vaginal delivery under epidural.,0
No intrapartum fever or clinical evidence of chorioamnionitis.,0
Rupture of membranes 6-1/2 hours prior to delivery yielding clear amniotic fluid.,0
Intrapartum antibiotic prophylaxis administered 3-1/2 hours prior to delivery.,0
The infant was delivered via SVD.,0
Vigorous at birth with spontaneous respirations.,0
Apgar's 9 and 9 at 1 and 5 minutes.,0
The patient was initially transferred to normal newborn nursery and was known to be increasingly tachypneic in the first 24 hours of life with respiratory rates ranging from 70 to 84 breaths per minute.,0
At this time the patient was transferred to NICU for further management.,0
"PHYSICAL EXAMINATION: On presentation term male infant in radiant warmer, in no apparent distress.",0
"Vital signs: Temperature 98.5, blood pressure 72/40, respirations 16, heart rate 135.",0
FAO2 95 percent in room air.,0
"Head, eyes, ears, nose and throat: No dysphoric features.",0
"Good air entry, no retractions.",0
"Abdomen: Soft, distended, normal active bowel sounds, no hepatosplenomegaly.",0
"Extremities: Well perfused, no cyanosis or edema.",0
Femoral pulses two plus bilaterally.,0
"Neurologic: Spontaneous MAE, appropriate to examination.",0
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The patient was transferred to the NICU for increasing tachypnea at which time he was placed on nasal cannula of 100 percent FIO2 with 20 cc of flow.,0
The patient was weaned off nasal cannula eventually to room air by hospital day three.,0
The patient exhibited no apnea of prematurity.,0
"By day of life four, the patient was stable with normal ventilatory rate on room air times 48 hours at which point he was transferred to the newborn nursery.",0
Cardiovascular: The patient remained cardiovascularly stable throughout hospital course.,0
"Fluids, Electrolytes and Nutrition: The patient was started on p.o.",0
ad lib feeds on hospital day one due to insufficiency p.o.,0
intake the patient was supplemented with gavage feeds.,0
At time of interim summary the patient is on p.o.,0
feeds of breast milk/Special Car 20 kilo count per ounce at a volume of 100 cc per kilo per day with supplemental gavage feeds.,0
"Infectious Disease: The patient's initial CBC was benign with a white count of 9.1, differential 73 neutrophils, 4 bands, hematocrit 46, platelet count of 264.",0
"The patient was started on Ampicillin and Gentamicin for a rule out sepsis at 48 hours, antibiotics were discontinued secondary to no growth in the blood cultures.",0
DISPOSITION: Transfer to normal newborn nursery.,0
"Primary Pediatrician is Dr. in , MA.",0
", Dictated By: MEDQUIST36 D: 10:55:48 T: 11:35:47 Job#:",0
1:46 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: assess for cervical injury; disc injury Admitting Diagnosis: PEDISTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man ped struck w/ evidence of injury (acute vs chronic) at C4 level REASON FOR THIS EXAMINATION: assess for cervical injury; disc injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: MRI of the cervical spine.,0
"CLINICAL INFORMATION: Trauma, rule out ligamentous injury.",0
"TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient echo and T2 axial images of the cervical spine were obtained.",0
Correlation was made with the CT examination of .,0
"FINDINGS: At the left C3-4 facet joint, increased signal is identified within the adjacent articular processes and within the joint, indicative of fluid.",0
There is no associated surrounding soft tissue abnormalities noted.,0
"These findings could be due to trauma, as suspected on the previous CT or could be due to advance degenerative changes.",0
"There is no evidence of disruption of the anterior or posterior longitudinal ligaments or ligamentum flavum, or intraspinous ligaments.",0
There is increased signal identified within the endplates of C5 and C6 with disc bulging secondary to degenerative change.,0
Mild degenerative changes are identified at other levels.,0
Bilateral mild-to- moderate foraminal narrowing is seen at C5-6 level.,0
There is no spinal stenosis seen or extrinsic spinal cord compression.,0
No evidence of intrinsic spinal cord signal abnormalities.,0
"Subtle increased signal is seen in the prevertebral soft tissue, which could be due to mild prevertebral edema.",0
Subtle increased signal in the anterior portion of the C6-7 disc appears to be secondary to partial degenerative change.,0
No evidence of disruption of the ligamentous structures or signs of unstable cervical spine injury.,0
Degenerative changes at multiple levels with bilateral mild-to-moderate foraminal narrowing at C5-6 level.,0
Abnormal signal within the left articular processes and facet joint at C3-4 level could be due to degenerative change or due to trauma.,0
"However, in absence of associated soft tissue abnormality, this could be more likely to be degenerative in nature.",0
(Over) 1:46 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: assess for cervical injury; disc injury Admitting Diagnosis: PEDISTRIAN STRUCK ______________________________________________________________________________ FINAL REPORT (Cont),0
1:22 PM CHEST (PA & LAT) Clip # Reason: r/o pna ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with weakness REASON FOR THIS EXAMINATION: r/o pna ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old with weakness.,0
PA AND LATERAL RADIOGRAPHS OF THE CHEST: The lungs are clear with no evidence of pneumonia.,0
Streaky opacity extending from the cardiac apex is likely due to the patient's epicardial fat pad as seen on prior CT.,0
The bones are osteopenic and there is mild kyphosis.,0
"1:25 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ WET READ: ARHb 2:40 PM Question of small osseous fragment projecting separate from right glenoid rim may represent an occult underlying fracture, however unclear.",0
Consider dedicated right shoulder films when patient more stable.,0
WET READ VERSION #1 ARHb 2:39 PM ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Trauma.,0
"SINGLE PORTABLE VIEW OF THE CHEST: Evaluation of cardiomediastinal contours is limited secondary to patient rotation, however, they appear grossly unremarkable.",0
Extreme left costophrenic angle is cut off on this film.,0
No lung consolidation or pleural effusion is identified.,0
Small osseous density noted adjacent to right inferior glenoid rim of unclear significance.,0
"AP PELVIS, SINGLE VIEW: No fracture, dislocation, or degenerative change is noted.",0
There is no SI or pubic symphysis diastasis.,0
No lytic or sclerotic lesions are identified.,0
No radiopaque foreign bodies are seen.,0
Small osseous density adjacent to right inferior glenoid rim may represent a fracture fragment and if clincially suspect dedicated shoulder films can be pursued.,0
"9:33 AM CT HEAD W/O CONTRAST Clip # Reason: S/P MUD BMT WITH THROMBOCYTOPENIA, COMPLAINT OF HEADACHES, ELEVATED BP Admitting Diagnosis: LEUKEMIA\BMT ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with See above.",0
REASON FOR THIS EXAMINATION: 48 year old female with ALL s/p MUD BMT now with thrombocytopenia and complaint of Headache.,0
BP elevated 190/110 and Heart rate in the mid 60's.,0
Would like to rule out head bleed.,0
"CONTRAINDICATIONS for IV CONTRAST: RENAL INSUFICCIENCY ______________________________________________________________________________ FINAL REPORT INDICATION: Headache, thrombocytopenia.",0
FINDINGS: There is no intraparenchymal or extra-axial hemorrhage.,0
"The ventricles, sulci, and cisterns are unremarkable, without effacement.",0
The visualized osseous and soft tissue structures are unremarkable.,0
There is minimal mucosal thickening of the sphenoid sinus and right maxillary sinus.,0
IMPRESSION: No acute intracranial pathology.,0
"11:34 AM CHEST (PORTABLE AP) Clip # Reason: follow effusions Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\BENTAL PROCEDURE W/ HEMIARCH REPLACEMENT/MAZE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with s/p cardiac surgery REASON FOR THIS EXAMINATION: follow effusions ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
CLINICAL HISTORY: 67-year-old woman with cardiac surgery.,0
There is large heart size which is stable.,0
"There are again seen bilateral pleural effusions, which have increased slightly since the prior study.",0
Consolidation at the lung bases cannot be excluded due to the effusions.,0
The right-sided IJ catheter has been removed.,0
"2:42 PM CHEST (PORTABLE AP) Clip # Reason: R PICC PLACED PLEASE PAGE WITH WET READ ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with HIV now with SOB, crackles REASON FOR THIS EXAMINATION: R PICC PLACED PLEASE PAGE WITH WET READ ______________________________________________________________________________ FINAL REPORT INDICATION: HIV positive, now with shortness of breath.",0
A single AP semiupright view.,0
There has been slight resolution of a bibasilar ill-defined pulmonary infiltrate since the prior study.,0
The appearances of the lungs are otherwise unchanged.,0
No definite pleural effusions are demonstrated.,0
The pulmonary vessels show minimal upper zone redistribution and very slight left heart failure cannot be excluded.,0
IMPRESSION: Slight resolution of bibasilar patchy ill-defined pulmonary infiltrates.,0
Minimal LV failure cannot be excluded.,0
"4:35 PM CHEST (PORTABLE AP) Clip # Reason: post op cabg ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with cad REASON FOR THIS EXAMINATION: post op cabg ______________________________________________________________________________ FINAL REPORT HISTORY: 84 y/o woman with CAD, postop from CABG.",0
PORTABLE CHEST: The patient is s/p CABG.,0
A left sided chest tube and mediastinal drain have been placed.,0
"The distal portion of the Swan-Ganz catheter is difficult to identify due to multiple overlying tubes and wires, though the tip is in the right main pulmonary artery.",0
"The ETT is in a low position, terminating approximately 1 cm above the carina and directed towards the right main stem bronchus.",0
The NG tube is in the stomach with the side hole just below the GE junction.,0
Again noted is cardiac enlargement with unfolding of the thoracic aorta.,0
The pulmonary vasculature is normal and there is no evidence of pleural effusion.,0
Minimal left mid lung zone atelectasis is seen.,0
IMPRESSION: 1) S/P CABG with left sided chest tube and mediastinal drain in place.,0
"2) Low positioning of ETT, with tip approximately 1 cm above carina directed towards the right main stem bronchus.",0
PATIENT/TEST INFORMATION: Indication: Valvular heart disease.,1
Height: (in) 73 Weight (lb): 240 BSA (m2): 2.33 m2 BP (mm Hg): 90/57 HR (bpm): 80 Status: Inpatient Date/Time: at 11:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %) with extensive severe hypokinesis of the entire mid to distal left ventricle.,1
There is relative preservation of basal lateral and septal wall motion.,0
The aortic valve (?# leaflets) are thickened with severe aortic stenosis.,1
There is mild functional mitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification.,1
Moderate left ventricular hypertrophy with severe left ventricular systolic dysfunction.,1
Mild functional mitral stenosis due to annular calcification.,1
PATIENT/TEST INFORMATION: Indication: Bentall and mechanical AVR .,0
Height: (in) 66 Weight (lb): 180 BSA (m2): 1.91 m2 BP (mm Hg): 130/65 HR (bpm): 80 Status: Inpatient Date/Time: at 15:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
"The aortic prosthesis appears well seated, with normal disc motion and transvalvular gradients.",0
"Compared with the report of the prior study (images unavailable for review) of , the severity of left ventricular hypertrophy is reduced.",0
Prosthetic valve and biventricular systolic function are similar.,0
"CLINICAL IMPLICATIONS: Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a high risk (prophylaxis strongly recommended).",0
9:28 AM CT HEAD W/O CONTRAST Clip # Reason: no contrast r/o bleed - s/p AVR with low plts Admitting Diagnosis: AORTIC STENOSIS\AVR; CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with s/p AVR with low plts REASON FOR THIS EXAMINATION: no contrast r/o bleed - s/p AVR with low plts CONTRAINDICATIONS for IV CONTRAST: ______________________________________________________________________________ WET READ: TXPb MON 11:24 AM No evidence of hemorrhage or mass effect.,1
"Thickening of the falx at the vertex, likely non-specific.",0
Scattered foci of cystic encephalomalacia likely old lacunar infarcts.,0
"If there is continued clinical concern, MRI is more sensitive for the detection of small hemorrhage and infarction.",0
- Aerosolized secretions in sphenoidal sinuses and fluid opacification of ethmoid air cells.,0
WET READ VERSION #1 WET READ VERSION #2 TXPb MON 11:23 AM No evidence of hemorrhage or mass effect.,0
______________________________________________________________________________ FINAL REPORT COMPARISON: None available.,0
Aerosolized secretions are noted in the bilateral sphenoidal sinuses with opacification of ethmoid air cells.,0
"Fluid opacification of sphenoid and ethmoid airspaces may be due to pooling of secretions due to recent operation, or inflammatory process in the appropriate clinical setting.",0
"8:56 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: evaluate for lung expansion Admitting Diagnosis: AIRWAY OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: left lung collapse REASON FOR THIS EXAMINATION: evaluate for lung expansion ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:48 P.M., HISTORY: Left lung collapse.",0
IMPRESSION: AP chest compared to 5:34 p.m. Left upper lobe has re-expanded.,0
Heterogeneous opacification in the left lower lobe is probably residual atelectasis.,0
Mediastinum has returned to midline.,0
Right lung is clear of any acute abnormalities.,1
"Although the stent appears to have been repositioned more proximally, this may be a function in the change of the disposition of the left bronchial tree to the mediastinal shift, rather than real change.",0
Left subclavian infusion port ends in the SVC.,0
LINE PLACEMENT Clip # Reason: ?picc tip position.,0
"44cm r basilic, B: IV Nurse Admitting Diagnosis: PNEUMONIA;SEPTIC ARTHRITIS;ACUTE LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with AML REASON FOR THIS EXAMINATION: ?picc tip position.",1
"44cm r basilic, B: IV Nurse ______________________________________________________________________________ WET READ: FRI 6:17 PM R PICC tip in mid-distal SVC, findings discussed with IV nurse at 6;13pm on via tel.",0
Left subclavian line tip in upper SVC in unchanged position compared to prior.,0
Linear atelectasis at right lung base.,0
Small right pleural effusion cant be excluded.,0
Previous right upper costal pleural loculation no longer well visualized.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Check PICC.,0
FINDINGS: The right-sided PICC line tip is in the distal SVC.,0
"The findings were discussed with the IV nurse, by Dr. at 6:13 p.m. on .",0
A subclavian line tip is in the SVC.,0
Lung volumes are low with some plate-like atelectasis in the right base.,0
The loculated pleural fluid on the right has resolved.,0
"9:43 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: eval for aspiration/dysphagia Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with FTT, now with ?aspiration, dysphagia REASON FOR THIS EXAMINATION: eval for aspiration/dysphagia ______________________________________________________________________________ FINAL REPORT INDICATION: Failure to thrive, evaluate for aspiration/dysphasia.",0
FINDINGS: Video oropharyngeal swallow study is performed in conjunction with speech and swallow pathology department.,0
Varying consistencies of barium were administered under constant video fluoroscopic monitoring.,0
"The patient demonstrated silent aspiration with nectar and thin liquids after the swallow, with ineffective coughing to clear aspirated material.",0
"For complete details and recommendations, please see the speech pathology note available in CareWeb.",0
5:07 PM CHEST (PORTABLE AP) Clip # Reason: eval tube placement ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with ETT REASON FOR THIS EXAMINATION: eval tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Endotracheal tube placement.,0
SUPINE AP VIEW OF THE CHEST: An endotracheal tube tip terminates approximately 3 cm superior to the carina.,0
A nasogastric tube tip and side port are within the fundus of the stomach.,0
"The mediastinal and hilar contours are unremarkable, with minimal aortic knob calcifications visualized.",0
Streaky opacities within the left lower lobe likely reflect atelectasis.,0
Blunting of the left costophrenic sulcus suggests the presence of a small left pleural effusion.,0
No displaced rib fractures are seen.,0
IMPRESSION: Satisfactory placement of the endotracheal tube and nasogastric tube.,0
Small left pleural effusion with left basilar opacity likely representing atelectasis.,0
"12:15 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: S/P PARENCENTESIS, ABD PAIN - ?",0
PERF VS ACUTE EVENT Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with wilson's dz had a parencentesis and then acutely decompensated.,0
REASON FOR THIS EXAMINATION: perforation or other acute event No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Wilson's disease.,0
TECHNIQUE: Contrast enhanced CT of the abdomen and pelvis.,0
Water soluble oral contrast was administered through post pyloric feeding tube.,0
CONTRAST: 100 cc of Optiray.,0
"CT ABDOMEN WITH IV CONTRAST: There is a segmental area of atelectasis vs. consolidation at the left lung base, and to a lesser degree at the right lung base posteriorly.",0
There is a trace left sided pleural effusion.,0
There is a massive amount of ascites.,0
The lvier and small and nodular in appearance.,0
There are no focal hepatic lesions identified.,0
The portal vein is opacified with contrast.,0
The umbilical vein is seen to be opacified with contrast.,0
There are spontaneous splenorenal collaterals and collaterals along the course of the left gastric vein.,0
"The gallbladder, pancreas, adrenal glands and kidneys are unremarkable.",0
The spleen contains a granuloma anteriorly but is otherwise unremarkable.,0
There is no free air in the peritoneal cavity.,0
The feeding tube terminates with its tip beyond the ligament of Treitz.,0
There are numerous sub-cm mesenteric lymph nodes.,0
CT PELVIS WITH IV CONTRAST: A large amount of ascites is again noted.,0
The bladder contains a foley catheter.,0
The abdominal aorta is of normal caliber but is calcified.,0
The osseous structures reveal a sclerotic density in the right iliac likely representing a bone island.,0
IMPRESSION: 1) No evidence of perforated viscus.,0
2) Cirrhotic liver with massive ascites and evidence of portal hypertension.,0
Incidental: 3) Bibasilar areas of atelectasis vs. consolidation.,0
"(Over) 12:15 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: S/P PARENCENTESIS, ABD PAIN - ?",0
PERF VS ACUTE EVENT Field of view: 38 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont),0
4:37 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: et placement Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION;PEUMONIA\CATH ______________________________________________________________________________ MEDICAL CONDITION: 75 yoM s/p cabg reintubated resp distress REASON FOR THIS EXAMINATION: et placement ______________________________________________________________________________ FINAL REPORT AP CHEST PERFORMED ON .,0
HISTORY: 75-year-old man status post CABG and reintubated.,0
FINDINGS: There is an endotracheal tube with its tip at the level of the aortic knob.,0
Multiple median sternotomy wires and surgical clips are seen within the anterior chest.,0
"There is a right-sided pacemaker, which is unchanged in position.",0
"There is again seen borderline cardiomegaly and pulmonary edema with a left retrocardiac opacity, which allowing for differences in technique, is not changed.",0
"There is a left-sided pleural-based catheter, which is also unchanged in position.",0
The nasogastric tube side port and tip are below the gastroesophageal junction.,0
"8:54 PM CHEST (PORTABLE AP) Clip # Reason: ett tube palcement Admitting Diagnosis: CORONARY ARTERY DISEASE;CARDIOGENIC SHOCK\LEFT ANTERIOR DESCENDING ARTERY; ANGIOPLASTY/STENT ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with CAD, resp distress REASON FOR THIS EXAMINATION: ett tube palcement ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess ET tube, patient with CAD and respiratory distress.",1
"ET tube tip is in standard position, 5 cm above the carina.",0
Intra-aortic ballon pump is in standard position.,0
10:24 AM BILAT LOWER EXT VEINS PORT Clip # Reason: ?,0
"DVT Admitting Diagnosis: (AML) ACUTE MYELOGENOUS LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with leukemia with tachypnea REASON FOR THIS EXAMINATION: b/l dvt ______________________________________________________________________________ FINAL REPORT BILATERAL LOWER EXTREMITY VEINS INDICATION: A 28-year-old man with leukemia and tachypnea, rule out DVT.",1
BILATERAL LOWER EXTREMITY VEINS: Portable Grayscale and color Doppler ultrasound were performed.,0
"There is normal compressibility, color flow, and Doppler signal within the common femoral, superficial femoral, and popliteal veins bilaterally.",0
", A. OMED SICU-A 1:39 PM FEMORAL VASCULAR US RIGHT Clip # Reason: RT HEMATOMA,EVAL FOR PSEUDOANEURYSM/ACTIVE BLEEDING Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with R inguinal hematoma on CT scan w dropping Hct REASON FOR THIS EXAMINATION: ?",0
pseudoaneurysm/active bleeding ______________________________________________________________________________ PFI REPORT No evidence of pseudoaneurysm.,0
"8:30 AM CHEST (PA & LAT) Clip # Reason: evaluate pleural effusion Admitting Diagnosis: PULMONARY EDEMA\CATH ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man s/p cabg,avr,mvr REASON FOR THIS EXAMINATION: evaluate pleural effusion ______________________________________________________________________________ FINAL REPORT PA & LATERAL VIEWS CHEST: REASON FOR EXAM: Follow up pleural effusion.",0
Comparison is made with prior study dated .,0
FINDINGS: There has been interval decrease in size in the small bilateral pleural effusions left greater than right.,0
Increasing density in the left lower lobe is a combination of a pleural effusion and atelectasis.,0
"Patient post median sternotomy, CABG and aortic and valve repair.",1
IMPRESSION: Improvement of bibasilar aeration and decrease in pleural effusion.,0
PATIENT/TEST INFORMATION: Indication: Aortic valve replacement.,0
Weight (lb): 182 BP (mm Hg): 121/55 HR (bpm): 95 Status: Inpatient Date/Time: at 13:34 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure (0-5mmHg).,0
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR).,0
MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR).,0
Conclusions: The estimated right atrial pressure is 0-5 mmHg.,0
Right ventricular cavity size and systolic function are normal.,0
The motion of the mitral valve prosthetic discs appeas normal.,0
Mechanical aortic valve prosthesis with increased gradient.,0
"Bileaflet mitral valve prosthesis with good disc motion, but increased gradient.",0
Preserved global biventricular systolic function.,0
"CLINICAL IMPLICATIONS: Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis IS recommended.",0
"3:09 PM RENAL U.S.; DUPLEX DOPP ABD/PEL Clip # Reason: history of polycystic kidney dz, HTN, assess for adequate re Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 33 year old man with known polycystic kidney disease, s/p aneurysm rupture REASON FOR THIS EXAMINATION: history of polycystic kidney dz, HTN, assess for adequate renal vascular flow ______________________________________________________________________________ FINAL REPORT INDICATION: 33-year-old with known polycystic kidney disease status post aneurysm rupture, assess for flow.",1
TARGETED RENAL ULTRASOUND: The left kidney measures 14.6 cm and the right kidney measures 17.6 cm.,0
There are innumerable simple cysts in both kidneys of varying sizes.,0
There is no evidence of soft tissue masses or echogenic cysts to suggest hemorrhage.,0
Vascular flow and normal waveforms are seen in the main renal arteries and into the segmental branches of the kidneys bilaterally.,0
IMPRESSION: Polycystic kidneys; normal flow demonstrated.,1
3:47 AM CHEST (PORTABLE AP) Clip # Reason: pls evaluate ETT placement and interval change Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman s/p gastric bypass w/ UGIB s/p intubation REASON FOR THIS EXAMINATION: pls evaluate ETT placement and interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 04:20 a.m. .,1
HISTORY: Status post gastric bypass.,1
"IMPRESSION: AP chest compared to : The patient is rotated to the right, making it difficult to assess tracheal position.",0
"Abnormal contour to the left of the mediastinum is probably atelectasis in the upper lobe, probably the apical posterior segment.",0
"10:01 PM CT C-SPINE W/O CONTRAST Clip # Reason: {See Clinical Indication Field} ______________________________________________________________________________ MEDICAL CONDITION: 67 yom presented to OSH with facial edema, developed subcutaneous emphysema, intubated, continued subcutaneous emphysema - please eval head/cspine and torso - eval for esophageal rupture, mediastinal air REASON FOR THIS EXAMINATION: {See Clinical Indication Field} No contraindications for IV contrast ______________________________________________________________________________ WET READ: MDAg FRI 10:49 PM no acute fracture or malalignment.",1
extensive subcutaneous air and pneumomediastinum.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 67-year-old man with facial edema and subcutaneous emphysema.,1
TECHNIQUE: Non-contrast MDCT axial images were acquired through the cervical spine.,0
Bone reconstructions and coronal and sagittal reformats were obtained for evaluation.,0
"CT CERVICAL SPINE: Again seen is extensive air in the subcutaneous tissues of the neck, entering the prevertebral space and mediastinum.",0
There are tiny foci of air in the right neural foramina (3:62) but not within the thecal sac.,0
A nasogastric tube is in the esophagus.,0
"The visualized outline of the thecal sac appears unremarkable, although CT cannot provide intrathecal detail compared to MRI.",0
The visualized paranasal sinuses and mastoid air cells are clear aside from mild mucosal thickening in the left maxillary sinus.,0
No acute fracture or malalignment.,0
Dr. discussed the findings with Dr. (surgery) at time of study interpretation .,0
"LINE PLACEMENT Clip # Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o Admitting Diagnosis: DYSPNEA ON EXERTION ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman s/p AVR/MVR.",0
"REASON FOR THIS EXAMINATION: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion ______________________________________________________________________________ FINAL REPORT AP CHEST 12:39 P.M., HISTORY: AVR and MVR.",0
"IMPRESSION: AP chest compared to preoperative chest radiograph, : Cardiomediastinal silhouette has a normal appearance of postoperative widening, not severe enough to raise any concern for mediastinal bleeding.",0
"Heterogeneous areas of peribronchial opacity are present in both lungs, probably atelectasis, soon after surgery.",0
"ET tube, left PIC catheter, Swan-Ganz line, ET tube, nasogastric tube, midline drains in standard placements.",0
"5:47 AM CT C-SPINE W/O CONTRAST Clip # Reason: ASSAULT ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with assault, oral trauma, intoxicated REASON FOR THIS EXAMINATION: eval for c-spine injuy No contraindications for IV contrast ______________________________________________________________________________ WET READ: DFDkq 8:44 AM Evaluation of C5 through C7 limited by motion artifact.",0
Questionable irregularity in the anterior enplate of C7 which may indicate a fracture.,0
Mild compression deformity of C6 without a definite acute fracture line.,0
Grade I retrolisthesis at C6/7 with mild spinal canal stenosis.,1
Suggest repeating the CT scan.,0
"Alternatively, if there is clinical suspicion for ligamentous or spinal cord injury, could do MRI.",0
"Also, asymmetric fullness in the left tonsillar region and base of tongue, which could be related to the ""oral trauma"", infection or tumor - recommend direct visualization.",1
WET READ VERSION #1 DFDkq 8:43 AM Evaluation of C5 through C7 limited by motion artifact.,0
______________________________________________________________________________ FINAL REPORT CERVICAL SPINE CT DATED .,0
"INDICATION: Assault, oral trauma, intoxicated.",0
TECHNIQUE: Axial non-contrast multidetector CT images of the cervical spine were obtained.,0
FINDINGS: Evaluation of C5 through C7 is limited by artifact due to patient motion.,0
"There is a questionable irregularity in the superior aspect of the anterior endplate of C7 (series 402B, image 24), which may indicate a subtle fracture.",0
"There is a mild compression deformity of the C6 vertebral body, without definite evidence of an acute fracture line.",0
Evaluation for anterior paravertebral soft tissue swelling below the level of C4 is limited.,0
There is a grade 1 retrolisthesis at C6/7 with mild associated spinal canal stenosis.,1
There is asymmetric fullness in the left tonsillar region and the left tongue base.,1
"(Over) 5:47 AM CT C-SPINE W/O CONTRAST Clip # Reason: ASSAULT ______________________________________________________________________________ FINAL REPORT (Cont) There are dependent pulmonary opacities at the imaged lung apices, possibly related to atelectasis.",0
Limited evaluation of C5 through C7.,0
Questionable subtle fracture in the anterior endplate of C7.,0
Mild compression deformity of the C6 vertebral body without a definite acute fracture line.,0
Grade 1 retrolisthesis at C6/7 with mild spinal canal stenosis.,1
Recommend repeating the CT scan.,0
"Alternatively, MRI could be obtained if there is a clinical suspicion for ligamentous injury or spinal cord injury.",0
"Asymmetric fullness in the left tonsillar region and the tongue base, which may be related to the stated history of oral trauma, infection, or malignancy.",1
8:37 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: please evaluate for pulmonary embolus Admitting Diagnosis: CEREBROVASCULAR ACCIDENT Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with stroke.,0
Now with desaturation to high 80's and tachycardia.,0
REASON FOR THIS EXAMINATION: please evaluate for pulmonary embolus No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old with desaturations and tachycardia.,0
"TECHNIQUE: Helically acquired contiguous axial images were obtained prior to and following the administration of intravenous contrast, according to the chest CTA protocol.",0
Non-ionic IV contrast was administered secondary to the rapid rate of bolus injection required for this study.,0
COMPARISON: None CT OF CHEST WITHOUT AND WITH IV CONTRAST: Contrast enhanced images show no suspicious filling defects within the visualized pulmonary artery to suggest an acute or chronic pulmonary embolism.,1
"There is, however, mild diffuse prominence of the main pulmonary arteries.",0
The heart is diffusely enlarged.,0
Lung windows show focal areas of consolidation within the dependent portion of both lower lobes.,0
"There are no additional focal consolidations, discrete nodules or pneumothoraces.",0
An endotracheal tube is in place.,0
"Within the imaged portion of the upper abdomen, the partially visualized liver, spleen, pancreas and adrenal glands are unremarkable.",0
Multiplanar reformatted images were essential in the interpretation of this examination.,0
These images also show no definitive evidence of acute or chronic pulmonary emboli.,1
IMPRESSION: 1) No evidence of pulmonary emboli.,0
"2) Bilateral lower lobe consolidations, suggestive of aspiration pneumonia.",0
"3) Mild diffuse prominence of the central pulmonary vasculature, suggestive of pulmonary artery hypertension.",0
(Over) 8:37 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: please evaluate for pulmonary embolus Admitting Diagnosis: CEREBROVASCULAR ACCIDENT Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont),0
"2:08 PM OTHER EMBO Clip # Reason: please embolize bleeding gastric artery Admitting Diagnosis: UPPER GI BLEED ********************************* CPT Codes ******************************** * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER * * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT * * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION * * F/U STATUS INFUSION/EMBO F/U STATUS INFUSION/EMBO * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * MOD SEDATION, FIRST 30 MIN.",0
"MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with gastric tumor, continued bleeding and hct drop REASON FOR THIS EXAMINATION: please embolize bleeding gastric artery ______________________________________________________________________________ FINAL REPORT INDICATION FOR EXAM: This is a 72-year-old man with gastric tumor.",0
Upper GI bleeding and hematocrit drop.,0
"and , the attending radiologist, who was present and supervised throughout the procedure.",0
"PROCEDURE AND FINDINGS: After informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on the angiographic table and the right groin was prepped and draped in standard sterile fashion.",0
"Using 5 cc of 1% lidocaine as a local anesthesia and fluoroscopic guidance, access was gained into the right common femoral artery with a 19-gauge needle.",0
A 0.035 wire was advanced through the needle into the distal part of the aorta under fluoroscopic guidance and the needle was then exchanged for a 5 French vascular sheath that was connected to continuous side-arm flush.,0
A C2 glide catheter was advanced up to the level of T12 vertebra and selective catheterization of the celiac trunk was performed.,0
"An angiogram demonstrated the proper hepatic artery, GDA, and splenic arteries as well as the right and left hepatic arteries.",0
There is vascular mass at the gastric antrum and proximal duodenum supplied by the GDA.,1
The catheter was then removed and placed into the SMA.,0
An angiogram demonstrated a replaced right hepatic artery and no areas of extravasation of contrast in the area of the distal duodenum.,0
"Based on the diagnostic findings, it was decided to proceed with embolization.",0
"Catheterization of the celiac trunk was then achieved again with the C2 glide and using a Glidewire, access was gained distally into the GDA.",0
"Using a 3 French microcatheter, access was gained distally into the GDA in order to embolize distal branches with coils.",0
This was performed with the use of five microcoils with that were deployed under fluoroscopic guidance.,0
"Subsequently, 5 cc of Gelfoam slurry were injected into the GDA up to the level of the proximal part of the GDA (Over) 2:08 PM OTHER EMBO Clip # Reason: please embolize bleeding gastric artery Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ FINAL REPORT (Cont) until stasis was achieved.",0
The microcatheter was removed and an angiogram via the main catheter was performed demonstrated stasis at the proximal level of the GDA with no opacification of distal branches after the embolization level.,0
Embolization with larger coils was performed at the proximal part of the GDA under fluoroscopic guidance.,0
Final angiogram demonstrates good angiographic results with no opacification of the vascular mass previously seen at the level of the gastric antrum and proximal duodenum.,1
"Moderate sedation was provided by administering divided doses of 25 mcg of fentanyl and 1 mg of Versed throughout the total intraservice time of 2 hours, during which the patient's hemodynamic parameters were continuously monitored.",0
IMPRESSION: Vascular mass at the gastric antrum and proximal duodenum level supplied by the GDA.,1
The GDA was embolized with coils and Gelfoam slurry.,0
No active extravasation of contrast was seen.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Vascular Surgery CHIEF COMPLAINT: Left leg pain.,0
"HISTORY OF PRESENT ILLNESS: The patient is a 67 year old white female with a 50 pack year smoking history, who underwent mediastinoscopy and lymph node biopsy on for Pancoast right upper lobe cancer at .",0
The patient was doing well after her procedure but developed acute onset of left leg pain at 11:30 p.m. on .,0
The pain was described as 200 out of ten.,0
She also noticed numbness of her left foot.,0
The patient has a history of bilateral claudication at one and one-half blocks of ambulation.,0
The patient has undergone an angioplasty previously.,0
"The patient denies any constitutional symptoms such as shortness of breath, wheezing or cough.",0
The patient was evaluated in the Emergency Room and then admitted to the vascular surgery service for further treatment and care.,0
"History of coronary artery disease, angina stable.",1
"Recently diagnosed lung carcinoma, nonsmall cell; right upper lobe surgical staging T3N0M0.",0
Balloon angioplasty to the right lower extremity times two in .,0
"Bronchoscopy, mediastinoscopy with lymph node biopsy on .",0
SOCIAL HISTORY: The patient is married and lives with her husband.,0
She has been in relatively good health until recently.,0
She has a 50 pack year smoking history and denies alcohol use.,0
"ALLERGIES: The patient has no known drug allergies, although she is allergic to contrast media (reaction not described in notes).",0
"MEDICATIONS ON ADMISSION: Tenormin 25 mg p.o.b.i.d., Maxzide 27.5 mg p.o.q.d., Reglan 5 mg p.o.q.i.d., aspirin 81 mg p.o.q.d., 1 mg p.o.b.i.d.p.r.n., Nitrostat p.r.n., Mavik 1 mg p.o.q.d.",0
"PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 97.3, pulse 67, respiratory rate 16, blood pressure 93/54 and oxygen saturation 96% in room air.",0
"Head, eyes, ears, nose and throat: Unremarkable.",0
Chest: Clear to auscultation bilaterally.,0
Cardiovascular: Regular rate and rhythm without extra heart sounds.,0
"Extremities: Left lower extremity cool to touch mid-leg to toes with mottling of foot and toes, sensory and motor intact, though sensory is diminished compared with right foot, no ulcerations.",0
"Pulses: Triphasic signal femoral on left, palpable on right, popliteal monophasic signal on left, triphasic on right, dorsalis pedis and posterior tibialis absent by palpation and by Doppler signal on left, palpable dorsalis pedis and triphasic signal posterior tibialis on right.",0
"LABORATORY DATA: White blood cell count 5.2, hematocrit 44, platelet count 341,000, coagulation profile normal, BUN 22 and creatinine 1.3.",0
HOSPITAL COURSE: The patient was given intravenous hydration and intravenous heparin was begun at 700 units without bolus.,0
Cardiology was requested to see the patient for perioperative risk assessment.,0
They thought she was an acceptable risk for surgery and was stable from coronary artery disease.,0
The patient was begun on Kefzol.,0
"On , the patient underwent a right iliobifemoral bypass graft with 6 mm Dacron.",0
The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit in stable condition postoperatively.,0
A chest x-ray was unremarkable.,0
Her partial thromboplastin time was serially monitored.,0
"On postoperative day one, there were no overnight events.",0
She had Dopplerable foot pulses.,0
She remained in the Vascular Intensive Care Unit.,0
"On postoperative day number three, the patient ran a low grade temperature of 99.8.",0
"She remained hemodynamically stable with a blood pressure of 109/51, central venous pressure 15, pulmonary artery pressure 35/15, index 2.69, systemic vascular resistance 1,117, 70% face mask, 93% oxygen saturation.",0
"Arterial blood gases: 7.21, 50, 88, 21 and minus 8.",0
"Hematocrit was 35, BUN 13, creatinine 1.3, potassium 4.1.",0
"Extremities showed the left foot cooler than right with monophasic dorsalis pedis, absent dorsalis pedis on the left and monophasic dorsalis pedis and posterior tibialis on the right.",0
"On postoperative day number two, the patient had episodes of respiratory wheezing with tracheal compression on examination.",0
Intravenous Solu-Cortef was given and urgent pulmonary consult was requested.,0
"Bronchoscopy was done which showed mild secretions, moderate malacia of the trachea and both main stem bronchi with more pronounced changes on the right than left; upper airway was without obstruction.",1
Prednisone was continued and aggressive pulmonary toiletry was begun.,0
The patient required supplementation of potassium for a potassium of 2.8.,0
Ativan for anxiety was begun on postoperative day number three.,0
Ambulation was begun and the patient's diet was advanced.,0
Diuresis was continued for volume overload.,0
"Stool was sent for Clostridium difficile on , which was positive and the patient was begun on Flagyl.",1
The patient was transferred to the regular nursing floor on .,0
Physical therapy evaluated the patient.,0
The patient continued to progress.,0
Her pulmonary status improved without further compromise.,0
Some swelling of the lateral aspect of the cervical incision was noted.,0
The patient was continued on Flagyl for a total of seven days.,0
Case management was consulted regarding discharge planning.,0
DISCHARGE MEDICATIONS: Albuterol nebulizer q.6h.p.r.n.,0
"Flagyl 500 mg p.o.t.i.d., started on and is to be continued through .",0
"Fentanyl 25 mcg/hr topical patch q.72h., begun on .",0
"Atenolol 25 mg p.o.b.i.d., hold for systolic blood pressure less than 100 or heart rate less than 60.",0
"Acute ischemic left leg with underlying peripheral vascular disease, status post right iliobifemoral bypass graft with 6 mm Dacron 2.",0
"Respiratory compromise secondary to allergic response of intravenous dye and volume overload status post bronchoscopy, improved.",0
"Nonsmall cell lung cancer, staging T3N0M0.",0
Dictated By: MEDQUIST36 D: 11:36 T: 11:46 JOB#:,0
Height: (in) 62 Weight (lb): 100 BSA (m2): 1.43 m2 BP (mm Hg): 134/64 HR (bpm): 80 Status: Inpatient Date/Time: at 15:10 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
"MVR well seated, with normal leaflet/disc motion and transvalvular gradients.",0
"Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.]",0
"The mitral prosthesis appears well seated, with normal disc motion and transvalvular gradients.",0
IMPRESSION: Normal functioning mitral valve prosthesis.,0
5:41 PM CHEST (PORTABLE AP) Clip # Reason: patient desat-ing postop ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with REASON FOR THIS EXAMINATION: patient desat-ing postop ______________________________________________________________________________ FINAL REPORT INDICATION: Postop.,0
"CHEST, AP: Comparison is made to the prior film dated .",0
"Again noted is ET tube placement, which is about 9 cm above the carina.",0
"Also noted is evidence of a right-sided subclavian central venous catheter, with the tip in the proximal SVC.",0
The heart is at the upper limit of normal size.,0
There is persistent bilateral pleural effusion.,0
"Again noted is evidence of numerous left rib fractures, but no evidence of pulmonary contusion.",0
"Multiple rib fractures noted on the left side, but no evidence of pulmonary contusion.",0
"3:13 PM TIB/FIB (AP & LAT) LEFT Clip # Reason: eval for healing of fracture ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with fracture REASON FOR THIS EXAMINATION: eval for healing of fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate fracture healing.. TIB/FIB, LEFT, TWO VIEWS: Detail is obscured by cast.",0
"Compared with and allowing for differences in positioning, alignment is unchanged.",0
There is mild lateral apex angulation of the distal tibial and fibular fractures.,1
"Fracture lines remain partially visible, though I suspect some underlying callus formation, more so than on .",0
There is osteopenia about the ankle.,0
"Exostosis arising from the medial aspect of the proximal tibial metaphysis noted, unchanged.",0
IMPRESSION: Fractures of the distal left tibia and fibula.,1
Alignment unchanged compared with .,0
Height: (in) 72 Weight (lb): 200 BSA (m2): 2.13 m2 Status: Inpatient Date/Time: at 12:10 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,1
Mitral leaflets fail to fully coapt.,0
Conclusions: Prebypass The left atrium is dilated.,0
The coronary sinus is dilated.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 50 %).,0
Right ventricular chamber size is normal with mild global free wall hypokinesis.,0
The mitral valve leaflets are moderately thickened and myxomatous.,1
There is posterior mitral leaflet flail involving primarily the P2 scallop.,0
The mitral valve leaflets do not fully coapt.,1
The tricuspid valve leaflets are mildly thickened with mild tricuspid regurgitation.,0
"The degree of tricuspid regurgitation did not increase in severity despite administration of 1.5 Liters of crystalloid, giving a pressor to increase afterload, and placing the patient in a Trendelenburg position.",0
Postbypass The patient is in atrial fibrillation on an epinephrine infusion.,1
There is a new annuloplasty ring in the mitral position.,0
There is now only trace mitral regurgitation.,0
Gradients across the valve at a cardiac output of 6.5 L/min are peak/mean of mmHg.,1
Biventricular systolic function appears unchanged.,0
Tricuspid regurgitation is now trace.,0
LINE PLACEMENT Clip # Reason: s/p right median vein SL 56cm PICC insertion.,0
Please page I Admitting Diagnosis: PANCYTOPENIA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man s/p liver transplant presents with pancytopenia and fever REASON FOR THIS EXAMINATION: s/p right median vein SL 56cm PICC insertion.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Liver transplant with pancytopenia and fever.,0
"UPRIGHT AP VIEW OF THE CHEST: A new right PICC is present with tip in the mid SVC, and the wire located at the junction of the right internal jugular and subclavian veins.",0
Continued volume loss is demonstrated within the right lung with tenting of the diaphragm.,0
Multiple drains are again seen overlying the right upper quadrant with several sponges.,0
Satisfactory placement of right-sided PICC.,0
Stable appearance of chronic right-sided volume loss.,0
"10:54 AM CHEST (PORTABLE AP) Clip # Reason: to look for a pneumonia Admitting Diagnosis: MENINGITIS ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with a meningoencephalitis, with fevers REASON FOR THIS EXAMINATION: to look for a pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Meningoencephalitis with fever, to evaluate for pneumonia.",0
"FINDINGS: In comparison with the study of , the patient has taken a much better inspiration.",0
"Specifically, there is no evidence of pneumonia or other acute cardiopulmonary disease.",0
IMPRESSION: No change or evidence of acute pneumonia.,0
Admission Date: Discharge Date: Service: NEUROLOGY Allergies: Penicillins Attending: Chief Complaint: expressive aphasia Major Surgical or Invasive Procedure: IR placement of PEG-J tube History of Present Illness: yo woman presents after acute onset of inability to speak at ~6:00 pm today.,1
History is obtained from daughter who was with her at onset.,0
She was eating dinner and was last seen well at ~5:50 pm.,0
Her daughter went into the other room and upon returning found her mother unable to speak and with a ?,0
She called EMS who arrived soon after and took a blood glucose at 143.,0
She arrived at at 6:17 pm.,0
"Code Stroke was called at 6:18 pm and I arrived at 6:20 pm, with Neurology Resident already at the bedside.",0
"NIHSS was ~22 (2 for not alert, 2 incorrect month/age, 2 incorrect commands, 2 forced deviation to the left, 2 complete hemianopia, 2 partial facial paralysis, 4 no movement right arm, 2 right leg some effort against gravity, 3 mute, 1 inattention).",0
"Labs were drawn and she was taken to CT scan at 6:28 pm, CT sone at 6:30 pm and read at 6:31 pm with no bleed, no sign of early infarct and ?",0
slight left dense MCA sign.,0
"She returned to ER and floey was placed, 2nd IV was placed and t- PA was mixed.",0
After lengthy discussion with daughter about risks and benefits (including bleeding risk) she agreed to treat with t-PA. tPA bolus given at 6:55 pm.,0
"Past Medical History: - Biliary adenocarcinoma - Pancreatitis, ?ischemic.",1
"- CAD status post MI in and again , medically managed.",0
- CHF with an EF of 35 to 40 percent with apical left ventricular aneurysm and wall motion abnormality.,0
"- Symptomatic bradycardia, she is now status post DDD pacemaker placement.",0
- Colon cancer status post resection.,0
- Previous stroke - Hysterectomy.,0
Social History: Lives with daughter.,0
"history of tobacco, alcohol or drug use.",0
"Family History: non-contributory Physical Exam: Vitals BP 170/76 P 70 R 18 General: Well nourished, sleeping in bed Neck: supple Lungs: Clear to auscultation CV: Regular rate and rhythm Neurologic Examination: Please see above for NIHSS Mental Status: No spontaneous verbal output, no command following Cranial Nerves: Gaze deviation to the left, + oculocephalic and corneals, pupils equal and minimally reactive, decreased blink to threat from the right, right facial paresis (partial) Motor: Normal bulk and tone decreased on the right No tremor.",0
No acute hemorrhage or mass effect.,0
"MR weighted images may help to exclude acute infarct,if clinically indicated.",0
"CTA head- 1) Large left middle cerebral artery territory infarct, with occlusion of the left internal carotid artery from just above the carotid bifurcation to and throughout the left middle cerebral artery.",1
"2) No evidence of dissection, aneurysm, or occlusion within the right carotid artery, right and left vertebral arteries, and the remainder of the vessels of the Circle of .",1
There is moderate regional left ventricular systolic dysfunction (estimated ejection fraction ?35-40%).,0
No apical thrombus is seen (however the apical aneurysm is a potential cause of thromboembolism).,0
"Brief Hospital Course: Year old woman presents with global aphasia, left eye deviation and right hemiparesis and NIHSS ~22 treated with tPA.",0
Neuro-She was admitted to the Neuro SICU with standard post tPA orders.,0
"Repeat CT scan on showed evolving left MCA infarct, small vessel disease and chronic left parietoccipital infarct.",1
CTA revealed a distal left ICA thrombus that extended in the M1 segment of the left MCA.,0
Her exam did not improve after tPA and she remained unresponsive with with flacid right hemiparesis.,0
Initial plan was for Aggrenox but this was held since the daughter did not want an placed and preferred PEG placement.,0
Per daughter the patient had been on coumadin in the past and repeat TTE revealed an apical aneurysm with telemetry no revealing any atrial fibrillation.,0
Coumadin was initially held for placement of PEG on but plan was made for NO anticoagulation due to the patient's poor prognosis and risk of bleeding.,0
She was restarted on ASA on .,0
Tube feedings were initiate per nutrition recs.,0
"Given poor prognosis for functional recovery, episodes of apnea, and hypoperfusion of extremities, her daughter decided to transfer the patient to hospice for comfort care.",0
Hypothyroidism-While NPO she was converted to 40mcg of IV levothyroxine but converted back to PO 88mcg after PEG-J tube placement.,0
HTN-All antihypertensives were initially held due to stable SBP's in the 110-150 range.,0
Outpatient lisinopril 5mg was restarted on and lasix was held until the patient was established on an appropriate tube feeding regimen.,0
Px-She was maintained on PPI and SC heparin was started after PEG placement Medications on Admission: 1.Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
2.Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3.Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
"4.Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)",0
5.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
6.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed.,0
7.Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO once a day.,0
"8.Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.)",0
Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
9.Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)).,0
10.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"11.Insulin Insulin NPH 23 units in AM, 18 units qpm Continue home sliding scale 12.Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.",0
Disp:*30 Tablet(s)* Refills:*2* 13.Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 4 days.,0
Disp:*4 Tablet(s)* Refills:*0* Discharge Medications: 1.,0
Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day).,0
"SL Morphine 20mg/ml 0.5ml q 1h PRN discomfort Discharge Disposition: Extended Care Facility: for the Aged - Acute Rehab Discharge Diagnosis: Left MCA stroke Billiary cancer Chronic pancreatitis Discharge Condition: Guarded-unresponsive, right hemiparesis, periods of apnea, hypoperfusion of extremities Discharge Instructions: Transfer to hospice for comfort care.",1
"Where: Phone: Date/Time: 3:00 MD,",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: This was a 25 year-old man who fell from a 70 foot height, presumably as a suicide attempt.",1
He was brought to the Emergency Room in hemorrhagic shock.,0
He was emergently intubated there and vascular access was obtained.,0
He was found to have a grossly deformed bilateral upper arms and right thigh.,0
He was bleeding from the nose and mouth.,0
An abdominal ultrasound demonstrated free intraperitoneal blood.,1
He was in shock and was brought to the Operating Room emergently.,0
There an exploratory laparotomy showed no significant intraabdominal injury.,1
He clearly had an unstable pelvic fracture.,1
A G tube and suprapubic tube were placed.,0
He was then brought to the angiography suite where extensive embolization of multiple bleeding vessels was obtained in the pelvis.,0
His abdomen had been left open and covered with an esmarch bandage.,0
He had nasal packs placed due to ongoing bleeding.,0
He had traction device placed on the left tibia.,0
"Postoperatively, the patient had an extremely complex course and ultimately died after extensive efforts within the Intensive Care Unit.",0
He required delayed closure of the abdominal wound with mesh on the third hospital day.,1
Following this he then developed peritoneal sepsis and required multiple explorations at the bedside.,0
He had multiple episodes of intraperitoneal sepsis.,1
He suffered repeated episodes of hemorrhage and was found to have a necrotic bowel.,0
As indicated after a complex Intensive Care Unit course complicated by anuria and a variety of other complications the patient was made CMO and allowed to expire with full involvement of the family.,0
"DISCHARGE DIAGNOSIS: Fall from height with multiple intraperitoneal injuries and open pelvic fracture, intracranial injury.",1
Dictated By: MEDQUIST36 D: 08:03 T: 07:14 JOB#:,0
9:37 PM PORTABLE ABDOMEN Clip # Reason: Illeus?,0
"Admitting Diagnosis: RIGHT KNEE OPEN WOUND INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with abdominal pain, nausea, vomitting REASON FOR THIS EXAMINATION: Illeus?",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Abdominal pain, evaluate for ileus.",0
"COMPARISONS: Two views of the hip, .",0
FINDINGS: Single supine portable view of the abdomen shows a nonobstructive bowel gas pattern without evidence for ileus.,0
A dilated cecum is present.,0
No intraperitoneal air is seen.,0
The imaged lung bases are unremarkable.,0
Old pelvic fractures are again noted.,0
"3:07 PM CHEST (PORTABLE AP) Clip # Reason: H/O COLON CA, NOW INSERTIONMOD PORTA-CATH TO BE USED W/ CHEMO Admitting Diagnosis: METASTATIC COLON CANCER TO LIVER/SDA ______________________________________________________________________________ FINAL REPORT HISTORY: Colon CA.",1
Single bedside frontal radiograph of the left hemithorax shows the tip of the left subclavian line to be poorly visualized but probably in the right atrium.,0
"Right IJ, ET, and NG tubes/catheters satisfactorily placed.",0
Heart not enlarged and no vascular congestion.,0
Equivocal small nodule left lung.,0
Surgical clips overlie left upper abdomen.,0
No PTX or effusion identified on this recumbent exam.,0
IMPRESSION: Subclavian line in right atrium.,0
"4:17 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: eval for lefort fx Admitting Diagnosis: TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p hit by car w/Lefort fx,basilar fx REASON FOR THIS EXAMINATION: eval for lefort fx No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Patient struck by car with evidence of facial and skull base fractures on CT.",1
Evaluate for Le Fort fracture.,0
TECHNIQUE: Thin-section contiguous axial images were obtained from just superior to the frontal sinus through the mandible.,0
Coronal reformations were subsequently obtained and reviewed.,0
No intravenous contrast was used.,0
FINDINGS: Extensive fractures are noted through the facial bones with the appearance of a mixed type II/III Le Fort fracture.,1
"Specifically, the fracture network on the left extends to the inner and outer tables of the frontal sinuses where there is comminution.",0
"The fracture plane extends inferiorly to involve the roof of the orbit, the floor of the orbit, and the laminae papyraceae.",0
The fracture plane extends posteriorly through the ethmoid air cells and across the sphenoid sinus and the body of the sphenoid bone and exits along the anterior sella turcica and right inferolateral sella turcica.,0
"The fracture continues across the midline, extending posteriorly through the right aspect of the clivus and exits at the foramen magnum.",0
Note that the fracture plane appears to traverse the medial-most aspect of the right carotid canal before exiting the foramen magnum.,0
Note that the fractures on the left also pass through the left maxillary sinus.,1
"On the right, the fracture plane extends through the maxillary sinus but does not appear to involve the right orbit.",0
The fracture plane as it extends posteriorly passes through the right pterygoid plate and across the right sphenoid sinus where the fracture appears to join with the fracture network involving the left facial bones.,1
There is bilateral proptosis slightly greater on the left without frank hemorrhage into the orbits.,0
There is extensive opacification of the paranasal sinuses with air-fluid consistent with associated hemorrhages.,0
"There is no evidence of pneumocephalus, though air is seen tracking in the soft tissues over the left forehead.",0
IMPRESSION: 1) Mixed Le Fort type fracture which extends through the orbit on the left (type III) and through the maxillary sinuses on the right (type II).,0
"Of note, the fracture plane appear to traverse the medial-most right carotid canal.",0
"Also of note, the fracture plane extends through both tables of the calvarium at the left frontal sinus, allowing communication between the cranial vault (Over) 4:17 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: eval for lefort fx Admitting Diagnosis: TRAUMA ______________________________________________________________________________ FINAL REPORT (Cont) and the frontal sinus.",0
"Also of note, the fracture plane extends to involve the sella turcica, crosses the sphenoid bone, and exits at the foramen magnum.",0
Please see report of the head CT and cervical spine performed on the same day for other findings.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CSU ADMISSION DIAGNOSIS: Coronary artery disease.,1
DISCHARGE DIAGNOSIS: Coronary artery disease.,1
Chronic renal failure on hemodialysis.,1
PROCEDURE: Five vessel bypass which included: 1.,0
Left internal mammary artery to the left anterior descending coronary artery.,1
Saphenous vein graft to posterior descending coronary artery.,1
Saphenous vein graft to obtuse marginal.,0
Saphenous vein graft to diagonal.,0
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female with a past medical history significant for Type I diabetes mellitus since age 9 with end-stage renal disease on hemodialysis times three months who is in the process of workup for living related kidney transplant.,1
Her workup included a positive stress test.,0
The patient presented for a catheterization on which showed severe three vessel coronary artery disease.,1
The patient was asymptomatic with no chest pain.,0
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus.,0
PAST SURGICAL HISTORY: Trigger finger Stapedectomy in .,0
Lipitor 20 mg q day.,0
Renagel 800 mg with meals three times a day.,0
Seroquel 25 mg twice a day and 50 mg once a day.,0
"SOCIAL HISTORY: The patient is married, she has no children.",0
"No tobacco for 20 years, no ETOH.",0
FAMILY HISTORY: Positive for coronary artery disease in her father.,1
"REVIEW OF SYMPTOMS: The patient denies chest pain, shortness of breath or history of congestive heart failure.",0
She does have some edema as well as foot neuropathy.,0
PHYSICAL EXAMINATION: On examination she is in no apparent distress.,0
"Her pupils equal, round and reactive to light and accommodation.",0
She has no jugular venous distension.,0
She has 2/3 systolic ejection murmur.,0
Her lungs are clear to auscultation bilaterally.,0
"Her abdomen is soft, nontender, nondistended.",0
Her extremities do have varicosities.,0
She has palpable femoral pulses as well as popliteal pulses and strongly dopplerable dorsalis pedis pulses.,0
LABORATORY FINDINGS: Significant for a potassium of 6.2 and creatinine of 4.0.,0
HOSPITAL COURSE: The patient was admitted to on .,0
"She underwent a cardiac catheterization which revealed a revealed a 90% right coronary artery lesion, 80% mid-PCA lesion and diffusely diseased right coronary artery and an 80% stenosis of the left anterior descending coronary artery with a 50% stenosis of the circumflex as well as 70% stenosis of Obtuse marginal #1 and obtuse marginal #2 .",1
The patient was seen in consultation by Cardiothoracic Surgery.,0
It was deemed that she was suitable for a coronary artery bypass grafting and she was taken to the operating room on .,1
"Of note, the patient did have dialysis preoperatively.",0
Her intraoperative course was uneventful.,0
She underwent a five vessel bypass.,0
The patient was transferred to the EFRU postoperatively where she was weaned from the ventilator and extubated.,0
Her postoperative course was essentially uneventful.,0
She underwent dialysis and was seen in consultation by the who helped with management of her brittle diabetes.,0
"Given the fact that the patient was doing well, ambulating, tolerating the regular diet she was deemed suitable to be discharged home on which was postop day five.",0
q 4 to 6 hours p.r.n.,0
three times a day with meals.,0
twice a day and 50 mg p.o.,0
The patient was instructed not to lift anything heavier then 10 pounds and not to lift herself out of a chair with her arms.,0
Follow-up appointments were arranged with Dr. as well as Dr. and Dr. .,0
Dictated By: MEDQUIST36 D: 10:11:39 T: 11:03:57 Job#: cc:,0
4:02 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: TRACHEO BRONCHIAL MALACIA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with s/p tracheoplasty REASON FOR THIS EXAMINATION: ?,1
interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb SAT 10:55 AM PFI: No change.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, AT 5:05 A.M.",0
INDICATION: 47-year-old woman with tracheoplasty.,0
FINDINGS: Right-sided chest tubes remain.,0
There is no appreciable pneumothorax.,0
Right IJ catheter is in stable satisfactory position.,0
Cardiomediastinal silhouette is stable when allowing for differences in the lung volumes.,0
"2:45 PM ABDOMEN (SUPINE ONLY) PORT Clip # Reason: assess post-pyloric placement of tube ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with REASON FOR THIS EXAMINATION: assess post-pyloric placement of tube ______________________________________________________________________________ FINAL REPORT ABDOMEN, SINGLE FILM.",0
The feeding tube and NG tube are in the body of the stomach.,0
8:24 AM CHEST (PORTABLE AP) Clip # Reason: please eval for worse pulm edema ______________________________________________________________________________ MEDICAL CONDITION: 68 y.o.,0
"man s/p trach c necrosis of tracheostomy revision, on vent REASON FOR THIS EXAMINATION: please eval for worse pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary edema.",1
PORTABLE AP SEMI-UPRIGHT CHEST: Status post median sternotomy and CABG.,0
Endotracheal tube projects 5 cm above the carina.,0
Right PICC line projects over the distal SVC.,0
"Again, there are multifocal patchy bilateral opacities and bilateral pleural effusions which are unchanged, allowing for differences in technique, compared to the exam of .",0
IMPRESSION: No significant change in pattern of pulmonary edema and bilateral effusions.,0
2:16 PM IVC GRAM/FILTER Clip # Reason: recent pulmonary embolism.,1
Patient cannot be anticoagulated Contrast: OPTIRAY Amt: 70 ********************************* CPT Codes ******************************** * INTERUP IVC 1SR ORDER BRANCH VENOUS SYSTEM * * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER * * IVC GRAM EA ADD'L VESSEL AFTER BASIC A- * * NON-IONIC 30 CC NON-IONIC 30 CC * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with s/p fall.,0
"ICU course complicated by pneumonia, GI bleed and now bil PE.",0
REASON FOR THIS EXAMINATION: recent pulmonary embolism.,1
Patient cannot be anticoagulated because of recent craniotomy and GI bleed.,0
______________________________________________________________________________ FINAL REPORT INDICATION: A 41-year-old man with status post fall.,0
"Additionally, the patient had pneumonia, GI bleed, and now pulmonary embolism.",1
The patient cannot be anticoagulated because of recently craniotomy and GI bleed.,0
"PROCEDURE: After obtaining informed consent, the patient was placed on the angiography table and the right groin was prepped and draped in the usual fashion.",0
The right common femoral vein was punctured with a single wall 19 gauge needle and an 035 wire was advanced into the inferior vena cava.,0
"Subsequently, a 5 FR pigtail catheter was advanced over the wire and the tip was positioned in the right common iliac vein, and an IVC gram was then performed in AP projection which showed renal in-flow defect at the level of T12-L1 interspace on the right and L1-L2 interspace on the left.",0
"Additionally, there was a questionable draining vein at the level of L2-3 interspace on the left, for which a 5 FR Cobra catheter was advanced into the lower IVC over the wire and this draining vein was catheterized selectively and a selective venogram was performed and digital subtraction images were obtained in AP projection.",0
"On this selective angiogram, neither the left renal vein nor any communication with upper IVC was noted.",0
"Subsequently, a 12 FR filter introducer sheath was advanced over the wire and the filter was deployed with the tip at the level of the renal vein in-flow on the left (at L1-2 interspace).",0
"Because of the above described draining vein at the level of L2-3 interspace on the left, the filter was somewhat tilted to the right.",0
A control IVC gram was performed through the filter's introducer sheath.,0
The patient received 70 ml of Optiray 320 60% during this procedure.,0
IMPRESSION: Technically successful IVC filter placement as detailed above.,0
"A small draining vein was identified on the left at the level of L2-3 disc space, for which a selective angiogram was performed, which did not show any communication with the upper IVC.",0
(Over) 2:16 PM IVC GRAM/FILTER Clip # Reason: recent pulmonary embolism.,1
Patient cannot be anticoagulated Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont),0
"LINE PLACEMENT Clip # Reason: evaluate line placement and for pneumothorax Admitting Diagnosis: ETOH ASPIRATION ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with ETOH intoxication, possible sepsis, hypotensive s/p right subclavian central line REASON FOR THIS EXAMINATION: evaluate line placement and for pneumothorax ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, FOR LINE PLACEMENT AT 13:57 HOURS.",0
"COMPARISON: Multiple priors including earlier, same day.",0
"FINDINGS: Consistent with the given history, there has been interval placement of right subclavian central venous catheter with the distal tip at the cavoatrial junction.",0
Remaining support tubes remain stable.,0
"Please note, the extreme left lateral aspect of the chest has been excluded from view.",0
There is no effusion evident.,0
IMPRESSION: Interval placement of right subclavian central line with no evident complication noted.,0
9:42 PM CHEST (SINGLE VIEW) Clip # Reason: ?hemothorax Admitting Diagnosis: MVR\CORONARY ARTERY BYPASS GRAFT WITH MVR ;TVR ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with s/p CABG with acute drop in HCT REASON FOR THIS EXAMINATION: ?hemothorax ______________________________________________________________________________ FINAL REPORT AP CHEST 9:53 P.M. HISTORY: Acute drop in hematocrit after CABG.,1
IMPRESSION: AP chest compared to and 8: Small bilateral pleural effusions have increased little if any since .,0
There are no pleural or mediastinal drains in place.,0
The mild widening of the cardiac silhouette is expected post-operatively and unchanged.,0
Moderate bibasilar atelectasis is improving.,0
Height: (in) 75 Weight (lb): 265 BSA (m2): 2.48 m2 Status: Inpatient Date/Time: at 11:30 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.,0
Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.,0
Mild (1+) MR. TRICUSPID VALVE: No TS.,0
Conclusions: Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
Post CPB: The patient is on a phenylephrine infusion being AV paced.,0
There is trace MR and trace AI.,0
Trace pulmonic insufficiency is now seen.,0
The biventricular systolic function is preserved.,0
The visible contours of the thoracic aorta are intact.,0
"There is a persistent LEFT sided pleural effusion/hematoma, which despite many attempts to drain by the surgeon, remains unchanged.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU-WEST CHIEF COMPLAINT: Shortness of breath.,0
HISTORY OF PRESENT ILLNESS: This is a 76 year old woman transferred from Hospital with complaints of increasing shortness of breath times two weeks status post a fall after which she presented to Hospital on the .,0
"Recently, arterial blood gas at Hospital was pH of 7.33, pCO2 of 100 and pO2 of 73 on a four liter per minute nasal cannula.",0
Chest x-ray there reportedly showed moderate congestion as well as bibasilar consolidation.,0
The patient was admitted to the Intensive Care Unit and intubated for hypoxia and hypercapnia.,0
The patient was diuresed for failure and also given nebulizers.,0
"She was successfully extubated on the , reintubated later that same day for flash pulmonary edema believed to be secondary to her aortic stenosis.",1
The patient also was found to have low platelets in the 40s but refused bone marrow biopsy work-up for etiology.,0
"The patient received Flagyl, Vancomycin and Gadafloxacin empirically for this presumed pneumonia, as the patient developed fever and leukocytosis after ventilation.",0
Congestive heart failure secondary to aortic stenosis; valve area of approximately 0.8 centimeters squared.,1
Chronic obstructive pulmonary disease on home O2.,1
ALLERGIES: Include penicillin and questionable sulfa allergy.,0
SOCIAL HISTORY: She is a former smoker; quit tobacco 15 years ago.,0
Denies ETOH or illicit drugs.,0
FAMILY HISTORY: Pertinent for coronary artery disease.,0
"PHYSICAL EXAMINATION: On presentation to the Coronary Care Unit, temperature is 99.3 F.; heart rate 85; blood pressure 93/39; respiratory rate 22, 97% on the vent.",1
"Examination shows a well developed, intubated woman in no apparent distress.",0
Lung examination was limited by the ventilator but is noted to be generally clear.,0
Cardiovascular examination notable for II-III/VI holosystolic murmur to the carotids.,0
"Abdomen soft, nontender, nondistended, normal bowel sounds were present.",0
Extremities notable for one plus bilateral lower extremity edema.,0
The patient arrived with a right intra... cordis.,0
"LABORATORY: EKG was notable for a normal sinus rhythm, normal axis, single Q in lead III.",0
"Initial white blood cell count 10.7, hematocrit 20.6, platelets 46.",0
"Initial arterial blood gas was 7.33 pH, pCO2 91, pO2 126.",0
This is on ventilator settings of CPAP with pressure support of 10 and PEEP of 5.,0
HOSPITAL COURSE: Attempts to extubate were deferred pending repair of her aortic valve.,1
"The patient was initially admitted to the Cardiac Surgery Service of for surgical intervention of her aortic stenosis, but after review of her comorbidities, the Surgical Team felt that the patient would be more appropriately served by the Coronary Care Unit team.",0
The patient underwent a valvuloplasty on the and her aortic valve area increased from pre-procedure to 0.73 squared centimeters with a mean gradient of 45 to an area of 1.27 squared centimeters with a mean gradient of 25.,1
Attempts were subsequently made to diurese her and then to wean her off of the ventilator.,0
"Diuresis was successful, however, attempts on respiratory trials while using RSBI values less than 105, however, the patient desaturated to 80%, therefore a final definitive attempt was made on the .",0
The patient tolerated the procedure well and did not require BiPAP or CPAP post extubation.,0
The patient's saturations remained approximately 90% on two to four liters of nasal cannula with initial supplements provided by a 40% oxygen tent.,0
The patient did remain wheezy after the initial procedure and required two -hour Albuterol q. six hours and Atrovent nebulizers.,0
"She also received supplemental treatments of Fluticasone, Salmeterol as well as additional supplementals of -leukacast.",0
The patient was less wheezy the subsequent day.,0
"Of note, during the patient's hospitalization, one sputum culture grew out sparse Aspergillus.",0
A call to Hospital revealed that they had a similar sputum culture for which the final identification is pending.,0
"Infectious Disease has been consulted but at this point a CT scan was recommended, however, the patient refused CT scan secondary to her claustrophobia.",0
"As of this dictation, her liver function tests are being evaluated.",0
"Pending normal values, the patient will be empirically started on anti-fungal agents for empiric treatment of Aspergillus, albeit the clinical suspicion given her lack of fever and leukocytosis to remain low.",0
Follow-up on these results as well as Discharge Medications will be dictated as an addendum to this discharge summary.,0
Dictated By: MEDQUIST36 D: 20:58 T: 21:03 JOB#:,0
4:00 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: FOUND DOWN.PAIN.,0
"?INTERNAL INJURY Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with bleeding from back of head, distended abdomen found down.",0
REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: MJGe SUN 4:55 AM 1.,0
Does this patient have liver disease?,1
No evidence of varices or venous collaterals to suggest portal HTN.,0
4. pancreatic calcifications suggest prior pancreatitis.,0
"5. probe/instrument within the rectum ______________________________________________________________________________ FINAL REPORT INDICATION: Distended abdomen, found down.",0
TECHNIQUE: Multidetector CT images are obtained through the abdomen and pelvis with intravenous contrast.,0
CT OF THE ABDOMEN WITH CONTRAST: There is minimal atelectasis at the bilateral lung bases.,0
Calcifications are seen within the coronary arteries of the heart.,0
There is mild thickening of the esophageal wall.,0
The liver is mildly small in size.,0
No focal liver lesions or biliary ductal dilatation is identified.,0
There is large volume of ascites throughout the abdomen and pelvis.,0
The pancreas contains few tiny focal calcifications but no peripancreatic stranding or pancreatic fluid collections.,0
"The spleen, and adrenal glands are normal.",0
The kidneys enhance symmetrically and excrete contrast normally.,0
"Both kidneys contain multiple tiny low-density foci, which are too small to characterize.",0
The stomach is distended with liquid and solid material.,0
The intra-abdominal loops of small and large bowel are normal in caliber.,0
There is no mesenteric or retroperitoneal lymphadenopathy seen.,0
"The aorta contains moderate atherosclerotic calcifications throughout its visualized length, and within its branches.",0
CT OF THE PELVIS WITH CONTRAST: There is a probe or instrument within the rectum.,0
The distal ureters and bladder are normal in appearance.,0
Coarse calcifications are seen within the prostate.,0
The seminal vesicles are normal.,0
The rectum and intrapelvic loops of small bowel are normal in appearance.,0
There is a large volume of ascites within the pelvis.,0
"There are bilateral inguinal hernias, right greater than left.",0
There is a small amount of fluid tracking into the right inguinal hernia.,0
There is diffuse stranding within the subcutaneous tissues consistent with anasarca.,0
(Over) 4:00 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: FOUND DOWN.PAIN.,0
?INTERNAL INJURY Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.,0
There is deformity of L1 vertebral bodies which suggests that the compression fracture of indeterminant age.,1
Large volume of ascites throughout the abdomen and pelvis.,0
Small liver and few small varices suggest liver disease.,1
Distended gallbladder without gallbladder wall thickening or gallstones.,0
Distended stomach containing solid and liquid material.,0
Pancreatic calcifications suggest prior pancreatitis.,0
No pancreatic inflammation or peripancreatic fluid collections.,0
Compression deformity of L1 vertebral body of indeterminate age.,0
"3:41 PM CHEST (PORTABLE AP) Clip # Reason: NGT placement Admitting Diagnosis: HEAD INJURY;SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;PI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with fall and SDH, on vent, now fever to 102 REASON FOR THIS EXAMINATION: NGT placement ______________________________________________________________________________ FINAL REPORT CHEST AP PORTABLE SINGLE VIEW.",0
"INDICATION: Status post fall and subdural hematoma, on ventilator, now fever to 102.",0
FINDINGS: AP single view of the chest obtained with the patient in semi-upright position demonstrates the advancement of an NG tube seen to terminate in the distal portion of the stomach probably entering the duodenal bulb.,0
The frontal chest view does not include the apical portions but the appearance of the mid portion of both lungs on the bases appears quite unchanged when comparing it with the next previous portable chest examination of .,0
The suspected pulmonary right basal density possibly representing a pneumonia has not progressed.,1
Also the pleural lateral sinuses remain free.,0
IMPRESSION: Successful advancement of NG tube reaching proximal duodenum.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY OF PRESENT ILLNESS: This patient was born weighing 3050 g, product of a term gestation with an EDC of , born to a 33-year- old, G2, P1, now 2 mother, with prenatal screens follows: Blood type B+, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative, GBS unknown.",0
This was an uncomplicated pregnancy.,0
The infant was born by cesarean section with meconium-stained fluid.,1
Apgar scores were 9 and 9 at 1 and 5 minutes respectively.,0
The NICU team was not required at delivery.,0
"According to records, the infant received bulb suctioning at the delivery and some stimulation and also some positive pressure bag-mask ventilation with 100% oxygen, followed by gastric suctioning.",0
She was initially taken to the newborn nursery.,0
"In the newborn nursery, she was found to have some nasal flaring and retractions and then was sent to the NICU on day 1 of life for management of respiratory distress.",0
PHYSICAL EXAMINATION: On admission the infant was a very active and well-appearing female infant in moderate respiratory distress.,0
O2 saturations on room air were 91-95%.,0
She was pink and well perfused with intercostal retractions.,0
Lungs were clear and equal bilaterally.,0
Chest was symmetric in movement with no tracheal deviation.,0
Cardiovascular showed a regular rate and rhythm.,0
Femoral pulses were 2+ bilaterally.,0
Abdomen was soft with active bowel sounds.,0
Extremities were warm and well perfused with brisk capillary refill.,0
"She had good tone, normal suck.",0
Spine midline without a dimple.,0
GU normal female external genitalia.,0
"Birth weight 3050 g, which is 25-50th percentile, length 49.5 cm, which is 50-75th percentile, head circumference 34 cm, which is 50-75th percentile.",0
"HOSPITAL COURSE: Respiratory: The initial chest x-ray in the NICU showed a right pneumothorax, not under tension.",0
The infant was treated with a nitrogen washout and placed in 100% oxygen .,0
"An ABG was drawn, and the ABG showed a pH of 7.36, CO2 39, pO2 of 60.",0
The infant weaned out of oxygen on day of life 2 and has remained on room air since that time.,0
"A follow-up chest x-ray was done on , showing a resolved pneumothorax.",0
"The infant his remained without any respiratory distress since , stable in room air with oxygen saturations greater than or equal to 98% in no respiratory distress or retractions.",0
Cardiovascular: The infant has maintained stable cardiovascular status but had a brief bradycardic episode on day of life 2 with a bradycardia to 63.,0
She has had no further incidence with bradycardia.,0
"The plan was to monitor for 3 days after that episode, and if the infant remained stable the plan is to discharge home.",0
"Fluid, electrolytes and nutrition: Intravenous fluids were initiated on admission to the NICU due to respiratory distress.",0
The infant was made NPO at that time.,0
"Enteral feedings were initiated on , which is day of life 3, and she was stable on room air at that time.",0
She then had ad lib p.o.,0
feedings with Similac-20 with iron and taking greater than 60 ml/kg/day p.o.,0
"Most recent set of electrolytes were drawn on , with a sodium of 144, potassium 5, chloride 106, CO2 23.",0
Her most recent weight is .,0
"GI: The infant had mild hyperbilirubinemia with a peak bilirubin level of 6.2/0.3 on day of life 3, .",0
She has required no phototherapy for jaundice and is stable at this time.,0
There are no other GI issues.,0
Hematology: No blood typing has been done on this infant.,0
The initial hematocrit on admission to the NICU was 33.8.,0
There is known etiology for this newborn anemia.,0
"Follow-up hematocrit was drawn on , day of life 4, which was 38.1.",0
Platelet count was 382 on admission.,0
Infectious disease: CBC and blood culture were screened on admission.,1
"The infant received 48 hours of ampicillin and gentamicin which were subsequently discontinued when the blood culture remained negative at 48 hours, and the infant weaned to room air well.",0
Neurology: The infant has maintained a normal neurologic exam.,0
"Sensory/audiology: A hearing screen by automated auditory brainstem response was performed on , which the infant referred in both ears.",0
"Follow-up hearing screen was done on , and the infant at that time passed in both ears.",0
Psychosocial: A social worker has been in contact with this family.,0
"There are no active ongoing issues at this time, but if there are any concerns, a social worker can be reached at .",0
DISCHARGE DISPOSITION: Home with the parents.,0
"PRIMARY PEDIATRICIAN: , M.D., telephone number .",0
"CARE RECOMMENDATIONS: Followup with the pediatrician; there is an appointment already planned for , at 11:15 a.m.",0
DISCHARGE MEDICATIONS: No medications at discharge.,0
"NEWBORN SCREEN: Sent on day of life 3, , results are pending.",0
CAR SEAT SCREENING: Not performed.,0
"IMMUNIZATIONS RECEIVED: IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks gestation, 2) born between 32 and 35 weeks gestation with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3) with chronic lung disease.",0
Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age.,0
"Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for all household contacts and out-of-home caregivers.",0
"Reviewed By: , Dictated By: MEDQUIST36 D: 17:51:57 T: 19:16:40 Job#:",0
"Admission Date: Discharge Date: Service: Allergies: Ace Inhibitors Attending: Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: EGD Colonoscopy Pill endoscopy History of Present Illness: 82M w/ CAD, AFib, CHF, PVD, s/p partial colectomy presents to w/ 1 day h/o BRBPR.",0
Pt was in usual state of health when he experienced 4 episodes of BRBPR throughout day prior to admission.,0
Pt felt dizzy and to ER.,0
Pt denies previous history of BRBPR.,0
ANAEROBIC BOTTLE (Final ): STAPH AUREUS COAG +.,0
SENSITIVITIES PERFORMED ON CULTURE # ().,0
6:12 pm BLOOD CULTURE **FINAL REPORT ** AEROBIC BOTTLE (Final ): NO GROWTH.,0
"ANAEROBIC BOTTLE (Final ): REPORTED BY PHONE TO ,SHUI -CC7B- @ 16:00 .",0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S 10:56AM URINE Hours-RANDOM UreaN-545 Creat-72 Na-102 5:57 pm URINE Source: Catheter.,0
**FINAL REPORT ** URINE CULTURE (Final ): THIS IS A CORRECTED REPORT ().,0
PREVIOUSLY REPORTED AS SENSITIVE TO PENICILLIN ().,0
"10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S <=0.12 S NITROFURANTOIN-------- <=16 S <=16 S OXACILLIN------------- 0.5 S <=0.25 S PENICILLIN------------ <=0.03 S Brief Hospital Course: 1.",0
BRBPR The patient was admitted to the medical service and was admitted to the medical intensive care unit for hemodynamic instability secondary to bleeding per rectum.,0
The patient had an initial hematocrit of 32.8 and was given two large bore IV's and was transfused w/ 1U PRBC's on HD 1.,0
"On HD 2, the patient was transfused an addition 3U PRBC's in order to keep hematocrit above 30.",0
"The patient underwent a bleeding scan, which was found to be negative.",0
"On HD 3, the patient was transfused an additional 3U PRBC's and underwent EGD and colonoscopy.",0
EGD was significant only for a small hiatal hernia and small diverticuli on the duodenum.,0
"Colonoscopy demonstrated maroon colored blood in the entire colon, a non-bleeding grade 1 internal hemorrhoid, and multiple non-bleeding diverticula with medium to large openings seen in the entire colon.",0
The patient was transfused 3 U PRBC's on HD 4.,0
The patient was transferred to the colorectal surgical service on HD 5 and was started on vancomycin for streptococcus baceteremia.,0
The patient was transfused 2 U PRBC's on HD 6.,0
"On HD 7, the patient underwent capsular endoscopy, which showed good visualization of the small bowel without any signs of bleeding.",0
The patient was switched to IV oxacillin following culture+sensitivities for bacteremia and was transferred to the floor.,0
"Following this, the patient remained hemodynamically stable.",0
The patient did not experience any furthery bouts of bloody stools and was discharged on HD 10 in good condition.,0
"CV The patient was maintained on beta-blockade, atorvastatin and heparin 5000U sc BID for DVT prophylaxis.",0
"The patient had several EKG's, none of which demonstrated any abnormalities of concern.",0
Medications on Admission: Metoprolol 50mg PO QD Amiodarone 200mg PO QD Lipitor 10mg PO QD ASA 325mg PO QD Discharge Medications: 1.,0
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QD (once a day).,0
Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO four times a day for 5 days.,0
"Disp:*20 Tablet(s)* Refills:*0* Patient may resume home medication regimen Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Diverticulitis Peripheral vascular disease Complete heart block, s/p pacemaker placement IMI Discharge Condition: Good Discharge Instructions: Please return to hospital if you experience bloody stools or profuse bleeding from your rectum.",0
Please return if you begin to appear pale or if you experience severe fatigue or lightheadedness.,0
Followup Instructions: Please follow up w/ your primary care physician following discharge.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: 47cm DL R basilic PICC placed ?,0
tip Admitting Diagnosis: ORAL ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with new R PICC REASON FOR THIS EXAMINATION: 47cm DL R basilic PICC placed ?,0
tip ______________________________________________________________________________ WET READ: EAGg FRI 5:54 PM Distal tip of right PICC in the upper to mid-SVC.,0
ETT 5.4 cm above the carina.,0
d/ hopper at 5:50pm on .,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, Comparison study of earlier the same date.",0
FINDINGS: Position of indwelling devices is described above in the preliminary report.,0
"As compared to the recent study, there has been interval improved aeration at both lung bases with some residual atelectasis remaining, as well as persistence of small bilateral pleural effusions.",0
No new or worsening abnormalities.,0
"7:30 AM CHEST (PORTABLE AP) Clip # Reason: s/p extubation Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH WITH BRACHY S/B ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p MI, intubated with R pnthx REASON FOR THIS EXAMINATION: s/p extubation ______________________________________________________________________________ FINAL REPORT HISTORY: Extubation.",1
"AP UPRIGHT CHEST: Compared with one day prior, the right IJ and left subclavian lines are unchanged.",0
There is no ETT seen.,0
"There are residual patchy infiltrates within the left lung base, essentially unchanged.",0
No pneumothorax or vascular congestion.,0
IMPRESSION: No significant change in the patchy infiltrate at the left lung base.,0
", NMED FA11 10:18 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: querying abdominal masses (see CT chest report) Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: year old man with a history of melanoma REASON FOR THIS EXAMINATION: querying abdominal masses (see CT chest report) No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",0
"Right hepatic lesion measuring approximately 3 cm, suspicious for a metastatic lesion.",0
"Additional smaller hypodensities within the right lobe are too small to characterize, and could represent additional metastasis.",0
"Hypodense lesions in the region of the kidneys bilaterally, may represent a metastatic melanoma deposits within the perirenal space.",0
"Small amount of free fluid within the abdomen and pelvis, with free fluid layering dependently within the pelvis.",0
These are better characterized on CT of the chest performed yesterday.,0
11:14 PM CLAVICLE LEFT Clip # Reason: s/p ped vs mv ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with clavicle fx seen on cxr REASON FOR THIS EXAMINATION: s/p ped vs mv ______________________________________________________________________________ FINAL REPORT INDICATION: Status post trauma with left clavicular pain and fracture seen on chest x-ray.,1
"LEFT CLAVICLE, TWO VIEWS: There is a transverse fracture through the distal clavicle with approximately 1 cm foreshortening and 5 mm superior displacement displacement.",1
The remainder of the clavicle and left shoulder are unremarkable.,0
The AC joint measures approximately 8mm.,0
"IMPRESSION: Transverse, foreshortened, and minimally displaced fracture of the left distal clavicle.",1
4:44 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"ptx s/p mt removal, pleural on water seal Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with s/p cabg REASON FOR THIS EXAMINATION: ?",1
"ptx s/p mt removal, pleural on water seal ______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube on waterseal, to evaluate for pneumothorax.",1
"FINDINGS: In comparison with the study of , all of the tubes have been removed except for the right IJ sheath.",0
Left chest tube remains in place on waterseal.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Nafcillin Attending: Chief Complaint: Epidural abscess and vertebral osteomyelitis and discitis Major Surgical or Invasive Procedure: : s/p L thoracotomy, vertebrectomy T10, partial vertebrectomy T11, instrumented fusion T9-T11.",1
Chest tube to 20 cm H2O continuous suction.,0
": posterior spinal fusion T5-L2, est blood loss 1050 mL transfused 3 u PRBC, 2 U FFP.",0
"History of Present Illness: Mr. is a 45yo man with ESRD on HD, DM, h/o ""staph bacteremia"" in for which he was treated at an OSH, h/o T11-12 discitis in who presents as a transfer from Hospital with report of possible epidural abcess.",0
MRI was read at OSH (by attg) as T11-12 discitis vs. osteomyelitis with a possible epidural abcess and small cord compression.,0
He was transferred here for neurosurgical eval and was seen by ortho spine team in the ER.,0
"The ortho and radiology residents examined the MRI and are not convinced the pt has epidural abcess, although are unsure.",0
The pt was admitted to medicine for perioperative management.,0
"ROS: Past Medical History: ESRD on HD DM T11-12 discitis in ?Staph bacteremia in Social History: Works as police dispatcher, lives in with a roommate.",0
"Family History: noncontributory Physical Exam: vitals T 99.6 BP 154/88 AR 130 RR 21 O2 sat 93% on NRB, 5L NC Gen: Patient appears acutely ill HEENT: MMM Heart: Sinus tachycardia, +systolic murmur Lungs: Decreased BSs from on L from posterior base to apex, scattered crackles on R side Abdomen: soft, NT/ND, +NS Extremities: No edema, 2+ DP/PT pulses bilaterally Pertinent Results: GLUCOSE-103 UREA N-18 CREAT-4.5* SODIUM-144 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-32 WBC-6.5 RBC-4.19* HGB-12.3* HCT-37.8* MCV-90 MCH-29.3 MCHC-32.5 RDW-16.5* PLT COUNT-319 - NEUTS-68.3 LYMPHS-22.1 MONOS-7.0 EOS-1.5 BASOS-1.0 Lactate 1.0. .",0
Ct - Anterior wedge deformities of T10 and T11 with moderate kyphosis.,0
There is fragmentation and destruction of the inferior T10 and superior T12 endplates concerning for osteomyelitis/discitis.,0
Surrounding soft tissue density may represent phelgmon.,0
No paraspinal fluid collections identified.,0
"CT does not provide intrathecal detail, and MRI is recommeded for further evaluation of the spinal cord.",0
MR at OSH: T11-12 discitis vs osteomyelitis with possible epidural abcess and some possible cord compression .,0
1)Cxray (): Improved aeration of the left lower lobe.,0
"2)Cxray (): New complete opacification of the left hemithorax with associated minimal right to left shift of the trachea likely reflects underlying effusion and atelectasis, cannot exclude pneumonia.",0
"Brief Hospital Course: Mr. is a 45yo male transferred to from where he presented to the ER with c/o chronic, severe lower back pain & weakness in his LE bilaterally.",0
BACK PAIN/OSTEOMYELITIS On arrival to ER was given Dilaudid 1 mg IV with no relief & was subsequently given morphine 7 mg IV.,0
"Stat MRI of the spine was ordered which showed ""Progression of osteomyelitis versus discitis at the T10-T11 region with further collapse.",1
Possible pus in the disc space.,0
"There is compression of the anterior cord which is significantly increased from .""",0
Per neurosurgery at (Dr. pt would need surgery with anterior approach & thus transfer to tertiary care facility.,0
Patient was discussed with Dr. at and transferred in stable condition.,0
"Mr. was seen in ER by ortho spine team; ortho spine and radiology residents examined MRI from OSH and were not convinced of presence of epidural abscess, although unsure.",0
Patient was thus admitted to medicine service for perioperative management.,0
"In our ED he received Dilaudid for pain, a CT of his T-spine and additional blood cultures were drawn.",0
"CT of T-spine showed ""Anterior wedge deformities of T10 & T11 with moderate kyphosis.",0
There is fragmentation and destruction of inferior T10 and superior T12 endplates concerning for osteomyelitis/discitis.,0
Surrounding soft tissue density may represent phlegmon.,0
"No paraspinal fluid collections identified.""",0
Further orthopedics consult recommended non-emergent surgical decompression and debridement due to failure of medical management and progression of symptoms.,0
Renal was made aware of pt with ESRD who receives scheduled HD on MWF & recommended to hold colchicine in HD patient.,0
ID also consulted on day of admission () and advised to hold abx and perform TTE prior to surgery (performed which showed no vegitations).,0
Patient was made NPO overnight for surgery the following morning and coags/type & screen were sent.,0
"Surgery not performed , was examined by Dr. of neurosurgery for 2nd opinion who also recommended anterior/posterior decompression with fusion.",0
Patient went to OR for L thoracotomy with T10 vertebrectomy and T11 partial vertebrectomy with fusion/anterior cage placement T9-T11.,0
"Patient remained sedated on propafol & intubated with L pleural chest tube post-operatively and was extubated , mom placed on CPAP and weaned to O2 by NC.",0
For pain control pt received dilaudid PCA with scheduled dilaudid 2 mg Q 2 hours.,0
"Started on IV nafcillin for history of recurrent MSSA bacteremia; on POD#3 operative tissue cultures grew MSSA, confirming this diagnosis.",0
"Patient also noted to be tachycardic post-operatively, most likely due to uncontrolled pain, and required increase in lopressor dose.",0
Patient remained sedated on propafol and intubated and was sent back to OR on for completion of posterior spinal fusion.,0
Post-operatively patient received care in MICU and antibiotics were changed back to IV nafcillin.,0
"Per ID recs, would need at least a week course of cefazolin due to his h/o recurrent MSSA bacteremia.",0
He will then likely require lifetime suppressive therapy.,0
ID follow-up needs are described in page 1/discharge instructions.,0
"As he recovered from the problems described below, he continued to have flares of intense back pain which we attempted to control.",0
"He was successfully moved out of bed with a torso brace on, on .",0
Physical therapy continuing to work with Mr to facilitate his recovery.,0
"Current neuro exam: hard to assess weakness in this context, possible L weaker than R; loss of sensation of first three toes of L toe.",0
RESPIRATORY FAILURE During HD POD#3 () patient noted to have O2 sat of 80% and with NRB recovered sats to 99%.,0
CXR showed complete opacification of L lung and patient was transferred to MICU Team for respiratory distress.,0
At that time differential dx was mucous plugging vs. L chest tube malfunction and per surgery patient was noted to have ++ secretions.,0
"In MICU patient was started on face mask, empiric ceftriaxone and azithromycin for CAP, atrovent & albuterol neb treatments.",0
Sputum samples were sent for culture.,0
Patient was bronched @ 17:30 by the MICU service.,0
"Thick, purulent, mucoid secretions were visualized in the L mainstem and L lingula.",0
BAL was perfomed in the lingula after which he developed copious fresh blood requiring intubation.,0
Post bronch CXR (17:45) actually revealed an aerated L lung with significant improvement.,0
He was bronched again at 19:30 which revealed thick secretions in the L mainstem and the end of the ETT.,0
"Post-bronch CXR (19:45) demonstrated L PTX and again L white-out.Later that day patient was intubated & bronchoscopy was performed which showed thick, purulent secretions in L mainstem and L lingula.",0
BAL was peformed in L lingula after which developed copious fresh blood.,0
"Wedge was kept in, bleeding slowed and fibrinous bloody material was suctioned from ETT.",0
"On CXRs L chest tube appeared to be kinked at chest wall, was pulled and restitched in an attempt to reposition the tube and decrease the kink.",0
Chest tube was D/C'd on .,0
Started on IV vancomycin and zosyn to cover S.aureus and gram negative/anaerobes.,0
Platelets decreased to 12 .,0
The differential diagnosis was DIC vs HIT vs drug effect (?nafcillin).,0
"Did have elevated fibrinogen and D-dimer, but this was muddied by the fact that he still had active osteomyelitis and these are acute phase reactants.",1
Fibrinogen was increased and thus less concerning for DIC.,0
"He was transfused one unit of platelets, and heparin and nafcillin were discontinued.",0
He was switched to cefazolin for his osteomyelitis.,0
He received argatroban on 8.25 with a plan to bridge to coumadin.,0
"However he got a very high INR with this (up to 9.4) and required 2 units FFP and 10 mg vitamin K, with INR going down to 1.5 on .",0
Low dose warfarin was briefly started.,0
"A PF4 assay was weakly positive for HIT antibodies (optical density just over threshold for judging positive) and a confirmatory serotonin release assay was negative, strongly suggesting that HIT was not responsible for the platelet drop.",0
Therefore the likely culprit was judged to be nafcillin based on prior case reports of this phenomenon and based on timing.,0
Cefazolin was kept as the antibiotic as above; subcutaneous heparin was restarted for DVT prophylaxis.,0
PAIN continues to be uncontrolled.,0
Initially on dilaudid PCA for control but started ketamine & fentanyl drips per pain mgmt recommendations.,0
Drips eventually weaned & discontinued on .,0
Fentanyl patch continued and dilaudid PCA restarted on .,0
Prior to transfer to floor patient started on oral regimen of Diluadid 6 mg PO Q 3 hrs.,0
"Fentanyl patch increased, PCA weaned off, and patient now on oral regimens.",0
"Of note, pt has much increased pain with movement/ transport/ physical therapy; should likely be pre-medicated for PT, may need to increase doses of PO PRN meds as PT becomes more frequent.",0
ELEVATED BILIRUBIN Did have elevated bilirubin during some of MICU stay.,0
Total bilirubin trending down since : 8.3--> 5.3-->4.5; Direct bilirubin 7.2 on .,0
By it was 1.3 after a long downward trend.,0
RUQ US showed sludge in gallbladder with no evidence of cholelithiasis/cholecystitis.,0
No clear diagnosis for elevation but now fine.,0
TYPE 2 DM Was on standing NPH and humalog sliding scale as outpatient with hypoglycemia.,0
BS were reasonably well-controlled though some adjustments in dose were needed.,0
"He was restarted on NPH on the floor and has been doing well with this, again with a few adjustments to optimize his regimen.",0
clinic consult service saw him and advised re his regimen.,0
RENAL FAILURE Continued dialysis here in the hospital.,0
Received lanthanum as a phosphate binder.,0
Renal dialysis team followed along with care.,0
"Per renal fellow, fine to transition from lanthanum to renagel (selvalamer) 1600 mg PO TID.",0
"(Discharge meds reflect this recommendation; change was made on discharge, not before.)",0
HTN Transitioned back to home BP meds when diet was advanced.,0
GOUT Continued with home allopurinol .,0
"PROPHYLAXIS +compression boots, subcutaneous heparin, PPI .",0
"ACCESS RIJ in place since admission, discontinued on upon placement of right PICC line .",0
1. lidoderm patch q 12 hrs 2. fentenyl patch 75mcg q3 days 3. celebrex 200mg daily 4. atenolol 25mg daily 5. ambien 5mg qhs prn 6. zetia 10mg daily 7.,0
NPH 55 units qam/70qunits q pm 8. nephrocaps 1 daily 9. nystatin powder 10. humalog sliding scale 11. colchicine 0.6mg daily 12. allopurinol 100mg daily 13.,0
ASA 81mg daily 14. catapres q monday Discharge Medications: 1.,0
Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia.,0
Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical HS (at bedtime).,0
Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO with meals.,0
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed.,0
Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday).,0
Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain.,0
Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).,0
Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation.,0
Prochlorperazine 10 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6 hours) as needed for nausea.,0
"Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal Q72H (every 72 hours): total fentanyl dose should total 175 mcg/hr, in any configuration of doses for patch(es).",0
Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours.,0
CefazoLIN 2 gm IV POST HD ON MONDAY AND WEDNESDAY 25.,0
CefazoLIN 3 gm IV POST HD ON FRIDAY 26.,0
Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed.,0
"Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous with meals, and at bedtime, per sliding scale: SLIDING SCALE.",0
"MEAL SCALE, BREAKFAST, LUNCH, DINNER: GLU 76-150: 0 UNITS.",0
SCALE: GLU 76-150: 0 UNITS.,0
GLU 351-400: JUICE AND RECHECK.,0
Discharge Disposition: Extended Care Facility: Rehab Unit at - Discharge Diagnosis: Primary: Osteomyelitis/diskitis MSSA septicemia .,0
"Secondary: Diabetes Mellitus type 2 End-stage renal failure on hemodialysis Discharge Condition: Good Discharge Instructions: As much as your pain will permit, work with physical therapists to try to use your muscles and progress towards walking as soon as possible.",1
"Followup Instructions: Please obtain weekly CBC and chem 7, fax results to infectious disease department (attn: Dr : .",0
Nephrology/Hemodialysis: as arranged by dialysis unit .,0
"Infectious Disease Clinic: ,MD MPH: Date/Time: 11:00 .",0
Phone: Date/Time: 10:00 ORTHO XRAY (SCC 2) Phone: Date/Time: 9:40 .,0
"3:22 PM CT HEAD W/O CONTRAST Clip # Reason: found unresponsive, intubated in ER ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with above r/o head bleed REASON FOR THIS EXAMINATION: found unresponsive intubated in ER No contraindications for IV contrast ______________________________________________________________________________ WET READ: JCCJ FRI 4:13 PM no bleed; cerebellar calcifications ______________________________________________________________________________ FINAL REPORT INDICATION: Patient found unresponsive.",0
FINDINGS: There is no intra or extraaxial hemorrhage.,0
"There is no mass effect, shift of normally midline structures, or hydrocephalus.",0
"Incidental note is made of calcifications of the dentate nucleus in the cerebellum bilaterally, which is a physiologic finding.",0
"There is moderate brain atrophy and evidence of tissue loss, more prominent on the right side adjacent to the posterior of the lateral ventricle.",0
There is a minimal amount of mucosal thickening within the ethmoid sinuses.,0
There is no soft tissue swelling or fracture identified.,0
IMPRESSION: No evidence of acute hemorrhage.,0
4:23 AM PORTABLE ABDOMEN Clip # Reason: r/o intra-abdominal process Admitting Diagnosis: DIC ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman s/p c-section and emergency hysterectomy with abdominal distension REASON FOR THIS EXAMINATION: r/o intra-abdominal process ______________________________________________________________________________ WET READ: PRib WED 1:43 PM Likely ileus but cannot rule out early small-bowel obstruction.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post C-section and emergency hysterectomy, now with abdominal distention, rule out abdominal process.",0
FINDINGS: There are some mildly dilated loops of small bowel in the center of the abdomen.,0
There is a small amount of air seen in the colon.,0
There are staples seen in the midline lower pelvis and abdomen.,0
IMPRESSION: Likely ileus but cannot rule out early small-bowel obstruction.,0
"5:24 AM CHEST (PORTABLE AP) Clip # Reason: edema, interval PE development?",0
Admitting Diagnosis: PULMONARY EMBOLISM ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with PE.,1
"REASON FOR THIS EXAMINATION: edema, interval PE development?",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Pulmonary embolism, to evaluate for chest changes.",1
"FINDINGS: In comparison with the study of , the opacification at the left base has slightly decreased, consistent with some improvement in the atelectasis and infarction related to the apparent pulmonary embolism.",1
Blunting of the left costophrenic angle has substantially cleared.,0
The right lung and upper portion of the left lung remain clear.,0
"11:47 AM BILAT LOWER EXT VEINS PORT Clip # Reason: AT RISK FOR PE ASSESS FOR DVT Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: year old woman with sudden SOB, concern for PE REASON FOR THIS EXAMINATION: please eval for DVT ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old woman with sudden shortness of breath.",1
"BILATERAL GRAYSCALE AND DOPPLER ULTRASOUND OF THE LOWER EXTREMITIES: Normal flow, compressibility, and augmentations are seen in bilateral common femoral, superficial femoral, and popliteal veins.",0
There is no evidence of DVT.,0
"9:09 PM CHEST (PORTABLE AP) Clip # Reason: eval pacer lead placement Admitting Diagnosis: PACEMAKER ESTRACTION ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with new pacemaker, now with very increaseed ectopy REASON FOR THIS EXAMINATION: eval pacer lead placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: New pacemaker, evaluation of lead placement.",0
The appearance of the pacemaker leads is constant.,0
There is no evidence of dislocation or lead fracture.,0
"Unchanged appearance of the lung parenchyma with thickening of the right minor fissure, moderate retrocardiac atelectasis and an area of scarring in the peripheral left mid lung parts.",0
No interval appearance of new parenchymal opacities.,0
Sclerotic lesion in the right humerus.,0
"Unchanged right PICC line, with its tip projecting over the right subclavian vein.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MED CHIEF COMPLAINT: Abdominal pain.,0
"This is a 31-year-old gentleman with longstanding history of Crohn's disease since age 12 years, status post ileo resection and ileocolic anastomosis.",0
The patient was recently admitted in for a Crohn's flare and has been on the steroid taper since his discharge.,0
"One week prior to admission, his prednisone was decreased from 20 mg to 10 mg, and on the day prior to admission, the patient developed mild discomfort in his abdomen then extreme pain with nausea and vomiting today.",0
The patient denied any diarrhea or bright red blood per rectum.,0
His last bowel movement was this morning.,0
The pain is located in the periumbilical area radiating diffusely.,0
"Of note, the patient has a new rash that started in his ears as mild pruritus.",0
He noted what was thought to be pimples that exposed to mild fluid initially in his ear.,0
"The rash has not progressed to his neck, back, and chest.",0
"The patient has had recent travel to , but is not fully coming about the details of his trip.",0
"Of note, the patient was given morphine in the ED for pain control and developed urinary retention.",0
PAST MEDICAL HISTORY: Crohn's disease times 12 years.,0
The patient has had immunosuppression with 6-MP and has also been recently on the steroid taper.,0
Ileal resection with ileocolic anastomosis and small bowel stricture.,0
Prior cryptococcal infection involving spleen.,0
Methenamine 250 mg four capsules q.i.d.,0
SOCIAL HISTORY: Smokes half pack per day.,0
He has been a smoker since years.,0
The patient drinks one to two beers per day.,0
"PHYSICAL EXAMINATION: On admission, vital signs, temperature 97.0, heart rate 80, and blood pressure 135/75.",0
"Generally, the patient was uncomfortable appearing, but in no acute distress.",0
"Pupils equal, round, reactive to light.",0
Pulmonary: Clear to auscultation bilaterally.,0
"Abdomen: Normal bowel sounds, soft, mild pain on palpation in the periumbilical region.",0
Neurologically: Alert and oriented times 3.,0
"Skin exam shows 2-3 mm papules over neck, back, and chest.",0
"LABORATORY DATA: Labs on admission, white blood count was 5.4 with 86 neutrophils, 11 bands, and 1 plasma cell.",0
"Hematocrit was 40.1 and platelets are 246. chemistry, sodium 141, potassium 4.3, chloride 105, bicarb 26, bun 8, creatinine 0.7, and glucose 109.",0
"ALT is 150, AST 90, alkaline phosphatase 58, LDH 328, total bilirubin is 1.1, lipase 20, and amylase 63.",0
CT of the abdomen and pelvis showed prominence of small bowel with mild thickening and a very few short segments.,0
Less extensive thickening than in .,0
HOSPITAL COURSE: This is a 31-year-old male with abdominal pain initially thought to be a Crohn's flare.,0
"However, over the next 24 hours after admission, the patient developed hypoxia and respiratory distress as well as worsening abdominal pain.",0
"On the following day after admission, again clinical course was declining.",0
"The patient was seen by the infectious disease, GI, and hematology oncology consultants.",0
"That night the patient did develop the transaminitis with ALT to 674 and AST 754 with an LDH of 861, and total bilirubin 1.6, pt 13.1, PTT 29.2, and INR of 1.1.",0
"D-dimer was found to be greater than 10, 000.",0
"At this time, the transaminitis in the setting of the rash was concerning for a viral etiology.",0
"Hep serologies were checked in addition to CMV, EBV, and an acute HIV infection.",0
"Other serologies, such as toxoplasmosis, cryptococcus, VDV, and HSV were also considered.",0
There is a thought that the patient's immunocompromised status under section PN steroid use might make him more susceptible to had seminate with zoster.,0
"Again that night, the patient was started on vancomycin for possible skin infection and doxycycline for question of tick borne diseases.",0
"on Cipro and Flagyl for a possible Crohn's flare, on acyclovir for possible seminated zoster, and on amphotericin for a possible histo.",0
"Dermatology acutely saw the patient on the night of , and noted a micropapular blenching rash, which was thought to be a viral exanthem.",1
TSA was performed showing evidence of varicella zoster virus.,0
"Of note, medical team was informed that the patient had never had chickenpox, and this is a primary disseminated varicella infection.",1
"The hematology consult obtained on the night of , was on the setting of thrombocytopenia, there was some concern for symptoms of process such as a cord, splenomegaly, or destruction by an immune mediated system such as a viral infection.",0
"Diagnosis such as GIC, HUS-TPP were considered.",0
Coagulations had currently been stable.,0
A smear was reviewed and showed no evidence of cystocytes and hypertension was elevated.,0
"There was again some concern for DIC and the patient's platelets, coagulations, LDH, and fibrinogen were followed closely.",0
"Again that night, the patient significantly decompensated and had evidence of respiratory distress.",0
The patient was transferred to MICU on the night of .,0
"Overnight in the MICU, the patient remained relatively stable.",0
"However, he again have evidence of hyper and hypothermia.",0
The patient's respiratory status remained stable.,0
"However, the patient began to require increasing levels of oxygen.",0
The patient's O2 saturation was approximately 90 percent on a 10 liter V-stent.,0
"In addition, the patient was noted to be tachycardic with heart rate in the 140s.",0
"On , which is hospital day 3, but MICU day 1, the patient was noted to have significant abnormality in his labs.",0
"ALT increased to 35.73, AST increased 53.23, alkaline phosphatase just 180, and total bilirubin increased to 5.8.",0
There is evidence of mild renal failure.,0
"Platelets declined to 23, haptoglobin was less than 20, and fibrinogen was 94.",0
"At this point, hepatitis serologies returned negative, cryptococcal antigen was negative, RPR was non-reactive, CMC was negative, toxo was negative, Histoplasma capsulatum antigen was negative, DFA for HSV was negative.",0
"However, DFA for VZV became positive and IgG for VZV was negative consistent with primary varicella infection.",0
"At this point, the patient's antibiotics were readjusted.",0
The patient was given high doses of acyclovir.,0
"In addition, secondary to respiratory distress, the patient was intubated for worsening hypoxia.",0
"After intubation, the patient became hypotensive and received aggressive fluid resuscitation with 12 liters fluid, initially normal saline, and subsequently lactate ringers.",0
The patient was started on Levophed for hypotension and despite full it does not remained around 55.,0
"The patient subsequently became difficult to oxygenate, and ventilator settings were adjusted to maintain pao2 in 70s to 80s.",0
"The patient's pulmonary status on hospital day 4, the patient was significantly difficult to oxygenate.",0
Paralytics were used to help ease the work of breathing.,0
The patient's chest films and pao2 to fio2 ratio were consistent with ARDS.,0
The patient was proned to assist with improvements on oxygenation and this initially helped.,0
"However, the patient became hypoxic again and was reproned.",0
"Regarding the patient's liver failure, LFTS continued to rise, chlorides continued to rise, and renal failure worsened.",1
The patient did have some evidence of DIC and was transfused cryo for fibrinogen less than 100.,0
The patient was continued to be treated with acyclovir.,0
"However, given repeated fevers, the patient was also started on cefepime and on vancomycin.",0
"Regarding his renal failure and multiple issues, the patient's acidosis was thought to be to secondary to shock versus tissue necrosis versus renal failure versus electrolyte abnormalities.",1
The vent was adjusted to compensate for pH.,0
The patient was given large doses of bicarbonates to adjust his acidosis.,0
"ABG at that time was 7.14, 38, and 86.",0
"Regarding his acute renal failure, the patient's bun and creatinine continued to rise despite fluids.",1
"There was some thought about initiating CVVH, and ultimately a catheter was placed by the renal team.",0
"On the hospital day next, the patient was significantly hypoxic with pao2 in 37 with increasing difficulty to oxygenate.",0
"Prior to this time, the patient had been ruled in an esophageal balloon study to help determine adequate peak.",0
"The patient secondary to ventilator protective strategies under the Argonaut protocol, the patient had been receiving higher doses of PEEP to improve oxygenation.",0
"However, on this day the patient developed evidence of pneumomediastinum.",0
The patient was proned with slight improvements in his po2.,0
"Other issues, the patient's acidosis continued to worsen.",0
"His hypotension, however, improved with the patient remained pressor dependent.",0
Further imaging was performed in order to understand etiology of liver failure.,1
"Ultrasound showed clots in the portal vein, decreased splenic vein flow, patent hepatic veins, and IVC.",0
The patient was started on low-dose heparin.,0
There is some concern that there is evidence of hypercoagulable state.,0
"Again at this time, the patient remains intubated on four pressors with increasing difficulty oxygenating.",0
The patient's transaminases continued to rise as well as coagulopathy worsening and renal failure worsening.,0
A lactate measured on this day was 26.,0
"Regarding his problem, his hypoxia and respiratory failure was thought to be due to varicella pneumonitis.",1
"The patient is on the ventilator with Argonaut protocol in the setting of pneumomediastinum, and there was concern for pneumothorax.",0
"At this point, it was thought to put him prophylactic chest tubes in the setting of the patient was to develop a pneumothorax.",0
"However, the patient's clinical status declined secondary to multisystem organ failure before this could be initiated.",0
The running of hypotension and shock; this was thought to be septic shock.,1
"The patient is currently on three pressors, and blood pressure was responsive to volume resuscitation as well as bicarbonate, but there is lot significant concern for volume overload and pulmonary edema.",0
"Regarding the patient's hepatic failure, hence the secondary to disseminated varicella, again transaminases continued to rise.",1
The patient has evidence of venous obstruction and was started on anticoagulation.,0
"Regarding his disseminated varicella, the patient was given renal doses of acyclovir.",0
Other micro data remained negative to date.,0
"Regarding his heme issues, he is concerned for DIC and thrombocytopenia.",0
The patient was transfused cryo; some thought about starting heparin versus Argatroban.,0
"It was thought that with the significant liver dysfunction, the patient may not have enough a T3 function.",0
"However, heparin was initiated until this issue was sorted out.",0
"Regarding his renal issues, acidosis continued to worsen, electrolyte abnormalities persisted despite aggressive correction and acute renal failure worsened.",1
"Catheter was placed with CVVH the day before, and the patient was initiated on CVVH to assist with volume overload.",0
"Later that afternoon, the patient became progressively hypoxic despite aggressive efforts to improve oxygenation.",0
Again CVVH had been started that day to help reduce volume to improve oxygenation status.,0
"Approximately, 15-20 minutes prior to the patient's death, heart rate was in the 170s naps were in 50s and began to decrease.",0
The patient had increasing evidence of ectopy.,0
The patient's code status had been changed two days prior to do not resuscitate.,0
Again patient's NAPS and heart rate continued to drop.,0
The patient was given 1 mg of epinephrine and then atropine.,0
The patient's dopamine was increased.,0
Volume resuscitation was begun without improvement in heart rate or bp.,0
NAPS continued to decline despite all medical efforts.,0
"Family at that time did not want further shocks or defibrillations and at 6 p.m. on , the patient expired.",0
"DISCHARGE DIAGNOSES: Disseminated primary varicella infection causing hepatic failure, pneumonitis, and the renal failure.",1
Hypotension requiring multiple pressor support.,0
DIC with evidence of venous obstruction.,0
", Dictated By: MEDQUIST36 D: 08:42:57 T: 12:51:32 Job#:",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: The patient is a 54 year old male with a history of hypercholesterolemia, hypertension, and known coronary artery disease who presents to an outside hospital with 7 out of 10 substernal chest pain.",1
"While he was working, he developed diaphoresis, shortness of breath, and nausea with progressive substernal chest pain.",0
"He did not receive pain relief at the outside hospital despite Nitroglycerin, Morphine, Integrilin and Plavix.",0
His electrocardiogram at that time showed inferior ST changes and he was transferred to the for cardiac catheterization.,0
"His catheterization revealed three vessel disease with 70% proximal left anterior descending, 30% distal occlusion of his left anterior descending, 70% mid vessel stenosis of his left circumflex and a right coronary artery with distal occlusion but bridging collaterals.",1
"Following catheterization, he was comfortable on the Heparin and Integrilin drip and also nitroglycerin drip and intra-aortic balloon pump was placed during catheterization.",0
"He states he had no prior history of angina, no dyspnea on exertion, shortness of breath, orthopnea, or paroxysmal nocturnal dyspnea.",0
"PAST MEDICAL HISTORY: His past history includes hypercholesterolemia, hypertension, cerebrovascular accident, malignant hypertension, hemorrhagic stroke, residual shortterm memory loss 15 years ago.",1
He also has a history of seizure disorder.,0
SOCIAL HISTORY: He lives with his wife and has two daughters.,0
He does drink alcohol occasionally and has no other drug use.,0
MEDICATIONS AT HOME: Dilantin 230 mg q.,0
"AM and 300 mg q. PM, Lisinopril 20 mg p.o.",0
"q.d., Atenolol 25 mg p.o.",0
"q.d., and Aspirin 81 mg p.o.",0
PHYSICAL EXAMINATION ON ADMISSION: He has no shortness of breath with speech.,0
He is lying flat and is alert and oriented times three.,0
"Vital signs include a temperature of 97.4, heart rate 69, blood pressure 121/88, respiratory rate 18 with an oxygen saturation of 97% on 2 liters.",0
"His head, eyes, ears, nose and throat shows pupils equal, round and reactive to light, extraocular movements intact, and his neck shows no jugulovenous distension.",0
His heart examination has regular rate and rhythm with I/VI systolic murmur.,0
"His abdomen is soft, nontender, nondistended.",0
His right groin line does have some oozing.,0
His extremities show 2+ pulses bilaterally.,0
"LABORATORY DATA: His laboratory data on admission to the outside hospital included a white count of 8.2, hematocrit of 46.1%, platelet count 219,000, sodium 139, potassium 3.8, chloride 105, carbon dioxide 27, BUN 22, creatinine 1.1, blood glucose 117.",0
His INR is 1.3 and PTT is 27.8.,0
"His creatinine kinase is 348, CKMB 6.2 and troponin of less than .04.",0
"His electrocardiogram showed normal sinus rhythm at 62, normal PR interval and delayed R wave progression.",0
He had less than elevations in leads 2 and AVF and less than depressions in lead 1 and AVL.,0
His chest x-ray is clear without any congestive heart failure or infiltrate.,0
HOSPITAL COURSE: While in surgery the patient remained asymptomatic with a balloon pump and his nitroglycerin drip was able to be weaned.,0
"On the morning of , he was taken to the Operating Room and underwent coronary artery bypass graft times four with the left internal mammary artery to the left anterior descending artery, saphenous vein graft to the posterior descending artery and saphenous vein graft to the obtuse marginal with a sequential graft to diagonal.",1
"The surgery was performed by Dr. with Dr. and , PA-C as the assistants.",0
The surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of 141 minutes and crossclamp time of 88 minutes.,0
"The patient tolerated the procedure well and was transferred to the Intensive Care Unit with two atrial and two ventricular pacing wires, two mediastinal and one left pleural chest tube and normal sinus rhythm at 93 and on a Neo-Synephrine drip.",0
During the overnight period he was successfully weaned and extubated from the ventilator and remained on the Neo-Synephrine drip.,0
"The morning of postoperative day #1, he was doing well, he did receive 1 unit of packed red blood cells for a hematocrit of 25.5% and was noted to have a rise in creatinine to 1.6.",0
"For this, he did receive a renal consult who felt that he had postoperative acute tubular necrosis.",1
"Also on postoperative day #1, his intra-aortic balloon pump was weaned and discontinued without incident.",0
Another event of postoperative day #1 was he went into atrial fibrillation for which he received an Amiodarone bolus and was started on a Amiodarone drip.,1
"On postoperative day #2, his line status was monitored closely as it was felt that his lungs were wet, although there was no desire to aggressively diurese him secondary to his postoperative acute tubular necrosis and making those numbers worse.",1
His atrial fibrillation continued although in the overnight of postoperative day #2 he did convert to normal sinus rhythm.,1
He also was noted to have a Dilantin level of about 3.6 and for this he was given an extra 400 mg of Dilantin.,0
Over the next couple of days there was a slight rise where his creatinine peaked at 2.8 but started trending downwards on postoperative day #3 to 1.9 and eventually by postoperative day #4 it was down to 1.4.,0
"By postoperative day #4, the Swan was able to be discontinued and he was converted to p.o.",0
Amiodarone and his drip discontinued.,0
In the days following he continued to have bursts of atrial fibrillation and eventually was started on heparin drip and begun to receive anticoagulation with Coumadin.,1
He was transferred to the Surgical Floor on postoperative day #6 and here he was seen and underwent cardiac rehabilitation with the physical therapists in a more aggressive fashion.,0
He continued to work with physical therapy until he achieved a Level 5 and was able to do stairs without difficulty.,0
He also continued on his heparin drip and received Coumadin daily until his INR reached 1.8 and then his heparin drip was discontinued.,0
He maintained normal sinus rhythm on Amiodarone and will continue on Amiodarone until he is seen in follow up by a cardiologist who feels it is safe to discontinue.,0
Also throughout this time he continued to receive Lasix for diuresis.,0
His BUN and creatinine were followed closely and he has maintained a creatinine in the range of 1.3 to 1.5.,0
"It is felt at this time that should his INR be in the range of 2 to 2.5 on the morning of , that he will be ready for discharge to home with services.",0
His discharge examination shows him to have bibasilar inspiratory crackles.,0
His heart is regular rate and rhythm.,0
"His abdomen is soft, nontender, nondistended with positive bowel sounds.",0
"His extremities show 1+ pitting edema bilaterally and his incisions are clean, dry and intact.",0
"His discharge laboratory data on include a hematocrit of 31%, platelet count of 530,000.",0
"His sodium is 139, potassium 4.5, chloride 102, carbon dioxide 28, BUN 22, creatinine 1.5 and a glucose of 102.",0
"He will most likely be discharged home on Coumadin to receive 5 mg each day on the two days following discharge with his first laboratory data to be drawn by services on Monday, with those results to be called to Dr. .",0
office and he should be maintained at a goal INR of 2 to 2.5.,0
Enteric coated Aspirin 81 mg p.o.,0
Percocet 1 to 2 tablets p.o.,0
4 hours prn pain 8.,0
AM and 300 mg p.o.,0
times seven days and then 400 mg p.o.,0
"q. day times seven days, then 200 mg p.o.",0
to be evaluated in one month by his cardiologist 10.,0
"or as needed and directed by his primary care physician, .",0
in order to maintain a goal INR of 2 to 2.5.,0
DISCHARGE DISPOSITION: To home with services.,0
"FOLLOW UP: He should follow up with Dr. in his office in one to two weeks, and with Dr. in his office in four weeks.",0
PRIMARY DIAGNOSIS: Coronary artery disease.,1
"PRIMARY PROCEDURE: Coronary artery bypass grafting times 4 of the left internal mammary artery to the left anterior descending artery, saphenous vein graft to the posterior descending artery, saphenous vein graft to the obtuse marginal with a sequential graft to the diagonal.",1
Dictated By: MEDQUIST36 D: 18:13 T: 19:43 JOB#:,0
Ultrasound-guided left common femoral artery access.,0
Selective right colic and ileocolic angiography.,0
Selective third and fourth order branch angiography of right colic and ileocolic branches (four separate branches selected).,0
CONTRAST: 130 cc of Visipaque INDICATIONS: Patient received 25 mcg IV fentanyl during the procedure and local lidocaine (1%).,0
"PROCEDURE: Prior to initiation of the procedure, written informed consent was obtained from the patient and his daughter.",0
The patient was placed supine on the angiography table and the left groin was prepped and draped in a sterile manner.,0
"Under ultrasound guidance, micropuncture access was obtained to the left common femoral artery over the mid femoral head, and a 5 French sheath was placed over wire.",0
A 25 cm long sheath was used to position within the common iliac artery.,0
"Next, a C2 catheter was used to select the SMA.",0
"A double angled Glidewire and STC microcatheter were used to select the right colic and angiography was performed, followed by SMA angiography through the C2 catheter.",0
A tiny focus of extravasation was seen on delayed images (Over) 3:02 AM OTHER EMBO Clip # Reason: Cecal embolization Admitting Diagnosis: LOWER GI BLEED Contrast: OMNIPAQUE Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) within the right colic distribution.,0
"Selective sequential microcatheter access was obtained to four potential branches, two from right colic and subsequently two from the ileocolic that could supply this area, but on selective angiography, no further extravasation was identified.",0
"After additional selective angiography, and no further extravasation identified, no branches identified for coil embolization.",0
The microcatheter and French catheter removed and the 5 French sheath was removed and manual compression was applied to hemostasis.,0
The patient was returned to the ICU in stable condition.,0
"Conventional vascular anatomy, with extensive atherosclerotic plaque within the SMA, aorta, and iliac arteries.",0
Left iliac stent was noted and patent.,0
"Initial right colic and SMA angiography demonstrated very delayed appearance of a tiny focus of contrast extravasation within the ileocecal area, likely corresponding CTA findings.",0
"Sequential selective catheterization of initially two potential third/fourth order branches within the right colic artery that might have supplied this area, followed by additional selection of two potential sources within the ileocolic artery did not demonstrate any further extravasation.",0
"After this tiny focus was seen on initial angiography, no it could not be re-demonstrated on the remaining portion of our study (over approximately hours).",0
"No further extravasation was identified, suggesting that the source of bleeding had stopped.",0
"As a specific source branch could not be determined, no embolization was performed.",0
"Tiny focus of contrast extravasation initially seen within the cecum, which stopped on subsequent angiography.",0
"The source branch could not be determined as bleeding had stopped, and no embolization was performed.",0
8:56 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line placement please Admitting Diagnosis: AORTIC STENOSIS ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 64 year-old male with aortic stenosis and pulmonary hypertension, course complicated by sepsis REASON FOR THIS EXAMINATION: PICC line placement please ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 10:21 AM Uncomplicated image-guided single-lumen PICC placement via right basilic vein.",1
______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for IV antibiotics.,0
"RADIOLOGIST: Dr. and Dr. performed the procedure, under supervision of Dr. .",0
A peel-away sheath was then placed over a guidewire and a single-lumen PICC line measuring 43 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC line placement via the right basilic venous approach.,0
"Final internal length is 43 cm, with the tip positioned in SVC.",0
(Over) 8:56 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line placement please Admitting Diagnosis: AORTIC STENOSIS ______________________________________________________________________________ FINAL REPORT (Cont),0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MICU/ CHIEF COMPLAINT: Respiratory distress.,0
"HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with multiple medical problems that include congestive heart failure, hepatitis B, hepatitis C, intravenous drug stage renal disease on hemodialysis, who was recently admitted from to for similar complaints of respiratory distress who now comes in with respiratory distress and obtundation.",1
wife notes that he had become progressively more somnolent over the 24-48 hours prior to his admission.,0
She discovered that he took an extra 30-40 mg of methadone on the morning of admission.,0
"Patient's course of the day prior to admission, his saturations dropped down into the 60s.",0
"Patient was not tachypneic, and wife reports that he appeared kind of drunk appearing.",0
"Per report, he also took an extra dose of amiodarone, but denied any Valium or alcohol present in the house.",0
"In the Emergency Department, patient's initial arterial blood gas was 6.9/153/32 and he was then intubated and his repeat arterial blood gas on 100% FIO2 on the ventilator was 7.11/82/311.",0
"Right heart failure with an echocardiogram in of this year showing mild left ventricular hypertrophy, an ejection fraction of 70%, right ventricular hypokinesis and right ventricular hypertrophy, 1+ mitral regurgitation, 1+ tricuspid regurgitation.",1
Had been previously found to have global systolic dysfcn c/w HIV cardiomyopathy; improved performance attributed to treatment with b blocker and ACEI.,0
"HIV/AIDS with last CD4 count of 89 in and last viral load of 15,000 in .",0
"Polysubstance abuse, on methadone, history of intravenous drug use.",0
Chronic obstructive pulmonary disease on home 02 with baseline 02 saturations in the low to mid 80s.,1
History of PE and deep vein thrombosis currently on Coumadin for thrombophilia and pulmonary HTN.,0
"End stage renal disease on hemodialysis on Tuesday, Thursday and Saturday.",1
"H/O sustained VT, s/p ablation MEDICATIONS ON ADMISSION: Albuterol MDI 2 puffs q.i.d.",0
"prn, Atrovent MDI 2 puffs q.",0
"8 hours, methadone 50 q.d., zinc sulfate 220 q.d., Coumadin 2.5, stavudine 20 q.d., Zoloft 50 q.d., lamivudine 25 q.d., Protonix 40 q.d., Vitamin C 500 b.i.d., amiodarone 200 q.d., Colace 100 b.i.d., Bactrim double strength 1 po q.o.d., Renagel 1600 b.i.d., levothyroxine 25 mcg q.d., Nephrocaps 1 q.d., Roxicet q.",0
"4 hours prn, baking soda half a teaspoon in eight ounces of water b.i.d.",0
"ALLERGIES: Haldol, Thorazine, codeine, H2 blockers, clindamycin, Stelazine.",0
SOCIAL HISTORY: The patient lives with wife.,0
FAMILY HISTORY: Mother died at 75 of myocardial infarction.,0
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood pressure 116/70.,0
General: Patient is sedated and unresponsive.,0
"Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light and accommodation.",0
Pupils at 3 cm going to 2 cm bilaterally but sluggish.,0
Neck: No jugular venous distention.,0
Right IJ tunnel site okay.,0
"Cardiovascular: Regular rate and rhythm, normal S1, S2, syst murmur, no rubs or gallops.",0
"Extremities: No edema, chronic venous stasis changes.",0
left toe with some scab and pus.,0
Skin: Grade 2 decubitus ulcer about 2 cm at buttock.,0
"LABORATORY STUDIES ON ADMISSION: White blood cell count 4.2, hematocrit 40, platelets 33,000, 89% neutrophils, 2% bands, 5% lymphocytes with toxic granulations.",0
"Sodium 140, potassium 5.7, chloride 100, bicarbonate 29, BUN 32, creatinine 2.8, glucose 205.",0
"Chest x-ray showed no pneumonia, no congestive heart failure.",1
"Electrocardiogram was normal sinus rhythm at a rate of 100 with left axis, old right bundle branch block with no significant changes compared to .",0
HOSPITAL COURSE: Pulmonary: The patient was intubated for respiratory failure thought to be secondary to narcotic overdose.,1
He was able to be weaned off the vent and extubated later that day.,0
"Eventually, his 02 requirement diminished so that he was in the mid to low 90s on four liters of nasal cannula at his baseline.",0
Patient continued to have a productive cough and a chest x-ray suggested bilateral aspiration pneumonia.,0
"He was put on ceftazidime and Flagyl, to cover a Pseudomonas that was grown from his sputum culture on his previous admission earlier this month.",0
He should continue on ceftazidime and Flagyl for a two week course.,0
Cardiovascular: Patient with borderline low blood pressure.,0
He was started on methedrine 2.5 one hour before hemodialysis.,0
"He was not restarted on beta-blocker, ACE inhibitor at this time because his blood pressure was not high enough to tolerate.",0
"Renal: Patient continued on hemodialysis, Tuesday, Thursday and Friday's without complications.",0
Endocrine: The patient's Synthroid was increased to 50 mcg q.d.,0
Pain management: The patient was weaned to 40 mg a day of methadone.,0
He should remain on this dose for about two weeks and follow-up with Dr. regarding a further taper of this.,0
He is written for Percocet prn for breakthrough pain.,0
He was given a prescription for a one months supply at 1 tablet t.i.d.,0
"Infectious Disease: Please note, in addition for Infectious Disease, the patient had a positive blood culture on , 1/2 bottles, the aerobic bottle was growing gram positive rods.",0
The speciation is not known at time of dictation.,0
He had repeat blood cultures drawn and these are still pending.,0
These results should be follow-up by the patient's PCP.,0
antibiotics should be changed to cover any new organisms if any should arise.,0
"It was thought these were most likely contaminant, so the patient's discharge was not held up because of that.",0
Bactrim Double Strength 1 po q.o.d.,0
48 hours times 12 days.,0
Baking soda half teaspoon in eight ounces of water b.i.d.,0
"FOLLOW-UP: Patient should follow-up with his primary care physician, .",0
Dictated By: MEDQUIST36 D: 11:03 T: 11:03 JOB#:,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: pls eval linec placement Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with CHF, AS, now with DOE s/p R IJ placement REASON FOR THIS EXAMINATION: pls eval linec placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 11:22 P.M. HISTORY: CHF and aortic stenosis.",1
Dyspnea on exertion following right IJ line placement.,0
IMPRESSION: AP chest compared to and earlier on at 4:03 p.m.: Tip of the new right jugular line projects over the superior cavoatrial junction.,0
"Mild interstitial pulmonary abnormality has progressed left lung greater than right, probably edema.",1
"Pleural effusion if any is minimal, on the right.",1
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: This is a yo female with history of severe COPD on home oxygen(4L), diastolic heart failure, and kyphoscoliosis who presented to the Hospital with increasing shortness of breath the evening prior to admission.",1
"She was being treated at her for heart failure exacerbation, however she had an aspiration event in the dining room at dinner, desatted to low 80s on 4liters, tachycardic prompting transfer to the ED.",1
"There she was febrile to 102 and felt to have active acute on chronic diastolic heart failure, copd flare, and pneumonia.",1
"She also complained of chest pain, but details are unclear.",0
She received vanco/solumedrol/lasix and ntg paste at OSH prior to ED to transfer to for further management at the request of the family.,0
"On arrival at , her room air sat was in the 80s and she was tachypnic to 40s.",0
She was started on bipap and received cefepime and gentamycin and blood cultures were sent.,0
"In the ED, initial vs were: T 102.2 HR 96afib BP 136/74 RR 26 POx 87.",0
Prior to transfer to the floor HR 98 BP 135/71.,0
Her IV infiltrated and was removed.,0
"She was given 1gm Vanc, 125mg solumedrol, and nitropaste at for SOB and ?",0
"At ED On the floor, she is comfortable on BiPAP, satting 92% on FiO2 30%, but does not remember what happened at dinner the previous night.",0
"Review of systems: (+) Per HPI (-) Denies any current pain, but unable to obtain further information given pt on BiPAP mask.",0
"Past Medical History: Diastolic Heart Failure Atrial Fibrillation on coumadin Remote h/o TIAs COPD on home O2 (3-4L at baseline) Scoliosis Osteoarthritis L hip/R pelvis fx managed nonoperatively Recent LLE cellulitis Anxiety Chronic Anemia (baseline hct 32) Social History: From chart, limited BIPAP Lives at nursing home.",1
Ambulates with a walker at baseline.,0
Alert and oriented x 3 at baseline.,0
Past smoker but quit 30 years ago.,0
No ethanol or illict drugs.,0
Son and daughter live nearby and are involved.,0
Family History: Positive for hypertension and type II diabets.,0
Given age non-contributory to current illness.,0
"Physical Exam: Vitals: T: 96.2 BP: 152/71 P: 94 R: 27 O2: 93% on BiPAP 30% FiO2, 14/8 General: Easily arousible, follows commands, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, diminished breath sounds at Right base.",0
"CV: Irregularly irreg, 2/6 SEM at LUSB without rubs, gallops Abdomen: soft, non-tender, minimally distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.",0
"Neuro: responds to verbal stimuli, unable to understand her while on BiPAP, moving all 4 extremities equally.",0
"Pertinent Results: 04:41AM TYPE-ART PO2-74* PCO2-76* PH-7.42 TOTAL CO2-51* BASE XS-19 04:41AM LACTATE-1.7 11:57PM LACTATE-2.1* 11:45PM GLUCOSE-191* UREA N-29* CREAT-1.1 SODIUM-142 POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-42* ANION GAP-14 11:45PM CK(CPK)-61 11:45PM cTropnT-0.04* 11:45PM CK-MB-NotDone proBNP-2595* 11:45PM WBC-8.2 RBC-3.94* HGB-11.7* HCT-36.2 MCV-92 MCH-29.7 MCHC-32.3 RDW-17.2* 11:45PM NEUTS-94.9* LYMPHS-3.6* MONOS-1.3* EOS-0.1 BASOS-0.1 11:45PM PLT COUNT-232 11:45PM PT-18.9* PTT-22.7 INR(PT)-1.7* 11:45PM URINE COLOR-Straw APPEAR-Clear SP -1.008 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: This is a yo F with severe COPD, diastolic heart failure, kyphoscoliosis who presents with acute on chronic diastolic heart failure and aspiration pneumonia.",1
# Hypoxia - Presented with aspiration pneumonitis/pneumonia and component of acute on chronic diastolic heart failure.,1
ABG with baseline hypercarbia of PCO2 76.,0
"Presented with lactate of 2.1, but down to 1.7 after 1 L NS resuscitation.",0
She was maintained at first on Bipap with sats >92% so was then weaned to NC with sats in the low 90s for most of the first hospital day.,0
When she fell asleep she did require CPAP with PS using full face mask set at IPAP of 15 and EPAP of 5 with 2-4L oxygen to maintain oxygen sats of 88-92%.,0
She was started on vanc/zosyn on for HCAP given that she lives in a and has had multiple recent hospital admission and her CXR had evidence of RLL infiltrate.,0
She will complete an 10 day course on .,0
She was maintained on her home dose of lasix which was increased the day of admission (she takes 80mg PO at home and got 40mg IV here) for goal fluid balance net negative 500mL daily.,0
"# ECG changes: hospital ED, patient was complaining of chest pain and given nitro paste.",0
"Cardiac biomarkers were flat (0.04->0.02), EKG in am was unchanged.",0
She was started on asa while awaiting results of ROMI.,0
She had no further episodes of chest pain and her cardiac enzymes were negative.,0
Aspirin was continued in place of coumadin for her atrial fibrillation.,1
# COPD on home O2 (3-4L at baseline): On admission bicarb was at her baseline and her hypercarbia was at baseline with PCO2 of 76.,0
Also was on prednisone for recent exacerbation and was given 125mg solumedrol at hospital.,0
Received scheduled Nebs and PRN for SOB.,0
Continued prednisone 20mg which should be tapered as she continues to improve.,0
# A fib on coumadin: She had a sub therapeutic INR of 1.7 on admission with good rate control with Cardizem and metoprolol.,0
She was switched to short acting dilt while hospitalized with HRs in low 60s and switched back at the time of discharge.,0
She was continued on metoprolol for rate control.,0
"Given the risk/benefit of coumadin in this patient, decision was made to treat with aspirin alone.",0
# Acute on chronic Diastolic heart failure: ECHO from showed EF of 70-80% with Mild PAH and significant pulmonic regurg.,1
She was given 1 L NS in ED for lactate of 2.1 which improved to 1.7 after fluids.,0
BNP was mildly elevated at level it had been on past admissions.,0
Her CXR did not appear grossly fluid overloaded so lasix was initially held but as above over the day she had some increasing O2 requirements and she was given her recently increased home dose of lasix.,0
"We recommend continuing with daily weights, maitain goal I/O at negative 500cc /day, titrating lasix and monitoring electrolytes as necessary.",0
# Chronic Aspiration - Patient should be maintain on aspiration precautions and dysphagia diet of pureed solids and nectar thickened liquids.,0
The risk of future aspiration events discussed with patient's family.,0
It is their wish to continue with feeding.,0
# Goals of Care - Family very interested in initiating palliative care/home hospice when the time comes for her to transition home and would like more information on this.,0
# hyperglycemia - In setting of steroids patient was noted to have elevated blood sugars.,0
A humalog sliding scale was started.,0
# Prophylaxis: Subcutaneous heparin and H2 blocker # Access: peripherals # Code: DNR/DNI per family and nursing home records # Communication: (son/power of attorney) .,0
Medications on Admission: prednisone 20 mg 1 tab(s) qd Atrovent 0.02% 3 mL QID Cardizem CD 180 mg/24 hours 1 cap(s) once a day Lasix 80 mg 1 q am Lasix 40 mg/60 mg 1 tab(s) q o 12 noon Lanoxin 0.0625 mg 1 tab qod Coumadin 2 mg as directed q pm BuSpar 10 mg 1 tab(s) TID Celexa 20 mg 1 tab(s) once a day ferrous gluconate 1 qd Prilosec 20 mg 1 cap(s) once a day senna 8.6 mg 2 tab(s) once a day (at bedtime) Bisac-Evac 5 mg 2 tab(s) once a day Lopressor 12.5mg as directed Q12H Vitamin C 500 mg 1 tab(s) once a day Discharge Medications: 1.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours).,0
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4 hours) as needed for SOB, wheezing.",0
Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Furosemide 20 mg Tablet Sig: Three (3) Tablet PO Q4PM ().,0
Vancomycin 1000 mg IV Q48H First dose 18.,0
Piperacillin-Tazobactam 2.25 g IV Q6H First dose 19.,0
Ondansetron 4 mg IV Q8H:PRN nausea 20.,0
"Cardizem CD 180 mg Capsule, Sust.",0
"Insulin Lispro 100 unit/mL Solution Sig: as directed units Subcutaneous QACHS: sliding scale, w/ meals start at BS 160 - 2units, go up by 2 units for every increase in 40 of BS.",0
"At HS, start at BS 200 same scale.",0
"Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: Primary - Pneumonia Secondary - Acute on chronic diastolic heart failure - Chronic obstructive pulmonary disease - Atrial fibrillation Discharge Condition: Hemodynamically stable, O2 sats 88-92% on nasal cannula.",1
Discharge Instructions: You were admitted with shortness of breath.,0
This was thought to be due a pneumonia with possible exacerbation of your congestive heart failure.,1
You were started on antibiotics with improvement.,0
You were continued on your pureed diet and thickened liquids as was consistent with your goals of care.,0
You also were started on CPAP w/ IPAP of 15/EPAP of 5 ccH2O while you sleep with great improvement in your respiratory status.,0
You will be discharged to Rehab for further care.,0
The following changes were made to your medications: Your coumadin was discontinued and replaced with aspirin You were started on vancomycin/zosyn for treatment of your pneumonia with plan for total of 10 day course from .,0
"Call your doctor or 911 if you develop chest pain, difficulty breathing, fevers > 101, dizziness, change in mental status, bleeding, or any other concerning symptoms.",0
"Followup Instructions: Please follow up with your PCP, , within 1-2 weeks of discharge.",0
Her office number is .,0
"7:21 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: POST OP INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with bilateral pleural effusions REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST X-RAY HISTORY: Bilateral pleural effusions, assess change.",1
"There is continued evidence of small pleural effusions, greater on the left, probably unchanged.",0
Increased density in the retrocardiac area consistent with atelectasis or consolidation persists.,0
The patient is rotated to the left as before.,0
2:09 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: interval change frmo post-op film.,0
PLease do at 2 PM Admitting Diagnosis: LEFT CHEST WALL TUMOR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman s/p drainage of left hemothorax yesterday REASON FOR THIS EXAMINATION: interval change frmo post-op film.,1
PLease do at 2 PM .,0
"CLINICAL HISTORY: 54-year-old woman, status post drainage of the left hemothorax.",1
FINDINGS: There is a left IJ central venous line and a right subclavian central venous line which are unchanged in position.,0
There is also a left-sided chest tube whose distal tip is at the lung apex.,0
There is also a second chest tube on the left with the distal tip at the lung base.,0
"Since the previous study, there has been slight decrease in left-sided pleural effusion with some loculated fluid at the left mid lung field.",0
5:38 PM CT CHEST W/O CONTRAST Clip # Reason: Patient with acute SOB overnight.,0
Has left sided consolidati Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with pneumonia.,0
REASON FOR THIS EXAMINATION: Patient with acute SOB overnight.,0
Has left sided consolidation with possible effusion.,0
Would like to further evaluate the parenchyma No contraindications for IV contrast ______________________________________________________________________________ WET READ: WED 11:27 PM 1.,0
"Bilateral pleural effusions, small-moderate on the right, moderate-large on the left with adjacent compressive atelectasis, however, underlying infection can't be excluded in the correct clinical setting.",0
Few axillary nodes b/l but do not meet ct size criteria for path.,0
3. minimal pericardial thickening vs minimal pericardial effusion.,0
4. lytic lesion T2 vertebral body.,0
WET READ VERSION #1 WED 6:55 PM 1.,0
"______________________________________________________________________________ FINAL REPORT CHEST CT, HISTORY: Pneumonia and possible effusion and lung nodules.",0
"TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and parasagittal images reviewed in conjunction with conventional chest radiographs and : FINDINGS: Previous pulmonary edema, seen on the :02 a.m., Chest radiograph has resolved.",0
"The bilateral, nonhemorrhagic, dependent pleural effusion, small on the right, moderate on the left, is comparable in volume or slightly increased relative to that study.",0
Multiple lymph nodes in both axillae are borderline enlarged up to 10mm wide.,0
"Intrathoracic nodes are numerous, not substantially enlarged, ranging up to 9 mm in the right lower paratracheal station.",0
"There might be more substantial left hilar node enlargement, inseparable visually from the nonenhanced hilar vessels, but there is no bronchial obstruction.",0
In the right lower lobe consolidative is sharply marginated and probably due to relaxation atelectasis.,0
A tiny volume of subpleural consolidation in the right upper lobe against the major fissure could be a very small pneumonia or aspiration.,0
Consolidation in the left lower lobe is more severe.,0
"It too is largely atelectasis, but could have started with a small pneumonia that incited the left pleural effusion, which in turn is responsible for the atelectasis.",0
In (Over) 5:38 PM CT CHEST W/O CONTRAST Clip # Reason: Patient with acute SOB overnight.,0
"Has left sided consolidati Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ FINAL REPORT (Cont) the absence of contrast , it is not possible to see either small lymph node collections or the heterogeneity in perfusion of the lung where there is concurrent pneumonia and atelectasis.",0
"A lytic process permeates most of the second thoracic vertebral body, which maintains normal dimensions, but is probably in imminent danger of collapse.",0
The mineralization of the vertebral body above it is also suspect.,0
"The paraspinal soft tissue is thickened, but there is no associated fluid collection.",0
This study is not capable of evaluating the thoracic vertebral canal which would require dedicated neuro imaging.,0
Lytic process T2 vertebral body and small associated paravertebral soft tissue mass could be infectious or malignant.,0
Dedicated neuro imaging recommended for assessment of the spinal canal.,0
"Moderate left and small right nonhemorrhagic layering pleural effusions may have increased slightly since :00 a.m. No evidence of extensive pneumonia, but small areas of infection could be missed given the large scale left lower lobe atelectasis and smaller atelectasis at the right base.",0
"Numerous borderline bilateral axillary lymph nodes and possibly in the left hilus, and less extensive lymph node enlargement in the mediastinum.",0
"10:57 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Evaluate for obstruction, leak, pneumotosis.",0
use po contrast Admitting Diagnosis: ENTEROCUTANEOUS FISTULA Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 70F w/EC fistula s/p open AAA repair in .,0
"Now s/p fistula takedown, end colostomy, feeding JT placement REASON FOR THIS EXAMINATION: Evaluate for obstruction, leak, pneumotosis.",1
"use po contrast - 1 bottle through NG tube No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 70-year-old female status post take down of enterocutaneous fistula, end colostomy, feeding J-tube placement, with decreased ostomy output.",1
"Please evaluate for obstruction, leak, or pneumatosis.",0
"COMPARISON: , , and .",0
TECHNIQUE: MDCT acquired axial imaging of the abdomen and pelvis was performed after administration of oral and intravenous contrast.,0
"CT ABDOMEN: Visualized lung bases show small bilateral pleural effusions, left greater than right, and associated atelectasis.",0
"Several tiny foci of punctate intrahepatic calcification likely represent old granulomatous disease, unchanged.",0
"There is no biliary ductal dilatation, or ascites.",0
The right adrenal gland is normal.,0
"The gallbladder is mildly distended, but otherwise unremarkable.",0
Nodular enlargement of the left adrenal gland is unchanged.,0
"Atrophic appearance of the pancreas is unchanged, with multiple foci of coarse and punctate calcification, most consistent with sequelae of chronic pancreatitis.",0
"Atrophic right kidney is unchanged, with mild urothelial thickening noted along the right renal pelvis, and upper right ureter.",0
"The left kidney is unchanged, with several small hypodensities, likely representing cysts, but too small to characterize.",0
Stomach and intra-abdominal loops of bowel are normal.,0
"There is no free air, or free intra-abdominal fluid.",0
3.3-cm saccular abdominal aortic aneurysm just proximal to the iliac bifurcation is unchanged.,0
"Nasogastric tube is in place, tip in the region of the pylorus.",0
"Jejunostomy tube is also in place, with enteric contrast is seen extending from the region of the catheter tip to the upper jejunum.",0
A small caliber tube is also in place in the patient's end colostomy in the right lower quadrant.,1
"Near the distal end colostomy, just as it enters the fascia, there is mild inflammatory stranding and soft tissue thickening, with a minimal amount of fecalization within immediately proximal bowel, but there is no definite evidence of (Over) 10:57 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Evaluate for obstruction, leak, pneumotosis.",1
use po contrast Admitting Diagnosis: ENTEROCUTANEOUS FISTULA Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) obstruction.,1
There is only mild borderline dilatation of bowel loops to approximately 3.0 cm.,0
Relatively few air-fluid levels are seen.,0
Previously noted pneumatosis has nearly completely resolved.,0
"There is a tiny focus of extraluminal air seen just lateral to the loops of bowel proximal to the end colostomy (2, 47) in the right lower quadrant.",1
"This may represent post- surgical change versus residuum from recent pneumatosis, versus air in a small diverticulum.",0
Large open wound in the lower midline abdomen is largely unchanged.,0
"There is soft tissue thickening and enhancement in the midline fascia, and wall of some adjacent bowel loops which abut the lower aspect of this wound (2, 63).",0
No definite fistulous connection is seen.,0
There is trace amount of free pelvic fluid.,0
"Surgical staple line is seen in the left lower abdomen, at site of blind ending residual left colon.",0
Trace free pelvic fluid is present.,0
OSSEOUS STRUCTURES: No suspicious lesions are seen.,0
"No definite evidence of obstruction, fistula, or leak.",1
Near complete resolution of pneumatosis.,0
"Tiny focus of extraluminal air in the right lower quadrant, may represent post-surgical change, verus residuum of pneumatosis, versus air in small diverticulum.",0
"Area of nodular tissue thickening, and enhancement in the lower abdomen adjacent to open wound, involving fascia, and adjacent bowel loops.",0
Unchanged appearance of 3.2-cm saccular abdominal aortic aneurysm.,0
Increased small left pleural effusion.,0
Unchanged appearance of findings consistent with chronic pancreatitis.,0
Unchanged small left adrenal nodule.,0
Findings discussed with Dr. at 3:30 p.m. on .,0
"(Over) 10:57 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Evaluate for obstruction, leak, pneumotosis.",0
use po contrast Admitting Diagnosis: ENTEROCUTANEOUS FISTULA Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont),0
9:28 AM CHEST (PORTABLE AP) Clip # Reason: assess effusions infiltrates Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with CAD s/p CABG.,0
^temp REASON FOR THIS EXAMINATION: assess effusions infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: Fever and the patient with coronary artery disease status post CABG.,1
FINDINGS: Comparison is made to prior study from the previous day.,0
An NG tube and an endotracheal tube have been removed.,0
Bilateral chest tubes and mediastinal drains are in place.,0
A right IJ Swan-Ganz catheter terminates with its distal tip in the proximal main right pulmonary artery.,1
There is atelectasis/consolidation at the left base associated with a small left-sided pleural effusion that appears unchanged when compared to the prior examination.,1
IMPRESSION: Removal of an endotracheal tube and NG tube.,0
"Otherwise, unchanged exam when compared to the previous day with atelectasis/consolidation and effusion at the left base.",0
", B. MED CC1B 1:10 AM CHEST (PORTABLE AP) Clip # Reason: please eval for effusion / consolidation Admitting Diagnosis: ABDOMINAL PAIN;HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with hypotension REASON FOR THIS EXAMINATION: please eval for effusion / consolidation ______________________________________________________________________________ PFI REPORT Diffuse patchy airspace opacities with prominence centrally near the hila consistent with alveolar edema.",0
"8:00 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: r/o masses, effusions ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with hx of RCC, pit tumor, now intubated secondary to severe respiratory acidosis REASON FOR THIS EXAMINATION: r/o masses, effusions No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 70 year old man with history of renal cell cancer and pituitary tumor, now intubated secondary to severe respiratory acidosis.",1
"TECHNIQUE: Multiple helically-acquired axial images were obtained from the chest, abdomen and pelvis without IV contrast.",0
CT OF THE CHEST WITHOUT CONTRAST: The heart is enlarged and there are coronary artery calcifications seen.,0
There is a small left pleural effusion and left lower lobe consolidation.,0
There is also minimal atelectasis seen in the dependent portion of the right lung.,0
There is also hyperdense material seen in the left lung in its peripheral and basal segment which was seen on the prior study of .,0
There is also a consolidation seen in one portion of the left upper lung.,0
There is an endotracheal tube present.,0
The trachea and major airways are patent.,0
The thyroid is heterogeneous and contains calcifications.,0
There are no nodules seen in the lungs.,0
"CT OF THE ABDOMEN WITHOUT CONTRAST: The liver, spleen, pancreas and adrenals are unremarkable.",0
There is a gallstone seen in the gallbladder which is not significantly distended.,0
There is no pericholecystic fluid collection seen.,0
The left kidney is smaller than the right and has post-surgical changes consistent with patient's history of left partial nephrectomy.,1
There is no hydronephrosis seen.,0
The evaluation for masses in the abdomen is somewhat limited by the lack of IV contrast which was not administered secondary to elevated creatinine.,0
CT OF THE PELVIS WITHOUT IV CONTRAST: The sigmoid is massively distended and contains feces and air.,0
The sigmoid extends up to the level of the diaphragm and fills a large portion of the abdomen and pelvis and displaces the bowel loops.,0
The dimensions of the sigmoid measure approximately 20 x 13 cm and there is marked thinning of the wall of the sigmoid.,0
The transverse and ascending colon are normal in caliber.,0
There is no abrupt zone of transition seen.,0
There is no free air or free fluid seen in the pelvis.,0
There is no significant pelvic or inguinal lymphadenopathy.,0
There is heavy vascular calcification .,0
The bladder is not adequately distended to evaluate and there is a Foley catheter in place.,0
BONE WINDOWS: There are degenerative changes seen throughout the thoracic spine.,0
"(Over) 8:00 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: r/o masses, effusions ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1) Left upper and lower lung consolidation and small left pleural effusion.",0
2) Marked fecal impaction of the rectum and sigmoid colon with massive dilatation of the sigmoid which extends up to the level of the diaphragm.,0
10:23 AM CHEST (PA & LAT) Clip # Reason: evaluate rt effusion Admitting Diagnosis: AORTIC STENOSIS \BENTAL VERSUS AVR ACCENDING AORTA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p AVR/Asc Ao replacement w/bilat effusion REASON FOR THIS EXAMINATION: evaluate rt effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Patient is status post aortic valve replacement.,1
COMPARISONS: Chest x-ray from .,0
FINDINGS: Moderate right and small left pleural effusions are unchanged since exam.,0
Bibasilar areas of compressive atelectasis are stable.,0
Hilar and mediastinal silhouettes are stable.,0
"No pulmonary edema, focal consolidations or pneumothorax is identified.",0
Moderate right and small left pleural effusions with adjacent compressive atelectasis are unchanged.,0
"LINE PLACEMENT Clip # Reason: cardiac surgery fast track extubation, ?line placement, ?PTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with CAD s/p CABG.",1
"REASON FOR THIS EXAMINATION: cardiac surgery fast track extubation, ?line placement, ?PTX/Effusion ______________________________________________________________________________ WET READ: AJy TUE 7:49 PM s/p sternotomy and CABG with expected post-op changes.",0
ETT 6 cm above carina.,0
"NG passes to stomach, sideholes just beyond GE junction.",0
"RIJ swan extends to right margin of the vertebral body, likely in central right pulm artery.",0
left basilar chest chest tube and two mediastinal drains and temp pacing wires noted.,0
slight mediastinal widening is consistent with recent surgery.,0
retrocardiac opacity is most likely atelectasis with possible small effusion.,0
______________________________________________________________________________ FINAL REPORT AP CHEST 6:08 HISTORY: Coronary artery disease and CABG.,1
"IMPRESSION: AP chest compared to pre-operative chest radiograph : Moderate widening of the post-operative cardiomediastinal silhouette is expected, particularly on supine view.",0
"Left lower lobe opacification is considerable, probably atelectasis.",0
"Subcentimeter nodule projecting over the left second anterolateral rib was not visible on pre-operative study, presumably transient residual atelectasis, but should be followed.",0
No pneumothorax or more than small pleural effusion.,0
"ET tube ends above the upper margin of the clavicles, 7 cm above the carina and 3 cm above optimal placement.",0
"Swan-Ganz catheter ends in the right pulmonary artery, nasogastric tube in the stomach, and midline and left pleural drains are in place.",0
"8:45 AM CHEST (PORTABLE AP) Clip # Reason: assess interval change Admitting Diagnosis: FEVER-FOOT WOUND ______________________________________________________________________________ MEDICAL CONDITION: 60 yo F with h/o diabetic foot ulcer and fevers, sats 90's tachypneic REASON FOR THIS EXAMINATION: assess interval change ______________________________________________________________________________ FINAL REPORT HISTORY: 60 year old woman with history of diabetic foot ulcer and fevers.",0
AP PORTABLE UPRIGHT CHEST AT 9:15 AM: The exam is limited due to cut off of the left CP angle.,0
Comparison is made to prior study on .,0
"The patient still appears to be in failure but there is increased opacity at the left base now obscuring the left hemidiaphragm consistent with infiltrate, atelectasis and probably effusion.",0
IMPRESSION: Worsening congestive failure with obscuration of the left hemidiaphragm and probable pleural effusion.,1
"LINE PLACEMENT Clip # Reason: Pt had a right sided picc line placed,44cm and needs tip con Admitting Diagnosis: ICD FIRING,RF,DM ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with PICC who needs it for IV access.",0
"REASON FOR THIS EXAMINATION: Pt had a right sided picc line placed,44cm and needs tip confirmation please page at with wet read,thanks.",0
HISTORY: Patient with PICC line placed.,0
There is a right-sided PICC line whose distal tip is in the mid SVC.,0
Median sternotomy wires and a Dual-lead left-sided pacemaker are again seen.,0
There is some improvement of the atelectasis at the left lung base.,0
No pneumothoraces or focal consolidation is seen.,0
The page has been sent to from the venous access pain.,0
"7:30 AM CHEST (PORTABLE AP) Clip # Reason: please verify right picc tip placement Admitting Diagnosis: ABDOMINAL ABSCESS;BACTEREMIA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with GNR bacteremia, abdominal abscesses and bilateral PE's who needs picc line for tpn and antibiotics.",0
REASON FOR THIS EXAMINATION: please verify right picc tip placement ______________________________________________________________________________ FINAL REPORT HISTORY: Check line placement.,0
"chest,1 vw Compared with earlier on the same day, the PICC line now extends further cephalad into the jugular vein.",0
The tip now overlies the area of the right mandible.,0
"2:30 AM CHEST (PORTABLE AP) Clip # Reason: SOB, Acute changes Admitting Diagnosis: RIGHT LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p Left upper lobectomy REASON FOR THIS EXAMINATION: SOB, Acute changes ______________________________________________________________________________ FINAL REPORT AP CHEST, 2:30 A.M. ON HISTORY: Right upper lobectomy.",1
"IMPRESSION: AP chest compared to and 9: Extensive right pleural effusion or thickening is stable since , increased since .",0
"Some of the apparent mediastinal widening is due to adjacent pleural collection, but mediastinal vascular engorgement is also likely.",0
Edema in the postoperative right lung has worsened.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB This is an interim summary up to .,0
"HISTORY: This is a 28-5/7 week male infant, birth weight 914 grams, born to a 31-year-old G1, para 0 mother with a history of chronic hypertension, IGA nephropathy and renal failure with multiple admissions to .",1
She was first hospitalized at 25 weeks and was treated with betamethasone at that time.,1
She was on Levodopa and labetalol throughout her pregnancy and currently remains on those medications.,0
One week prior to delivery she was re- admitted with vaginal bleeding and the night of delivery she complained of persistent vaginal bleeding and progression of labor.,0
The baby was delivered via cesarean section for breech position and bleeding as well as preterm labor.,1
"Prenatal labs are as follows: Blood type B+, antibody negative, heparin B surface antigen negative.",0
"GBS unknown, rubella immune, RPR nonreactive.",0
History of Hepatitis B positive father of the baby.,0
At delivery apgars were 7 and 8.,0
Infant was resuscitated with oxygen and intubated for increased work of breathing.,0
PHYSICAL EXAMINATION: Birth weight is 914 or 25% percentile.,0
"Length is 34.5 cm, 25th percentile.",0
"Head circumference is 25.3 cm, 25th percentile.",0
"Pink, non-dysmorphic,well saturated and perfused.",0
Respiratory: ET tube in place.,0
"Chest: Mild retraction, coarse breath sounds.",0
"Normal male genitalia, left testicle and scrotum right in the canal.",0
"Neurologically nonfocal exam, age appropriate.",0
The patient was intubated and given surfactin times two.,0
"Blood gases were normal 7.42, CO2 32.",0
The patient was extubated on day of life five and re- intubated on day of life six.,0
Again extubated on day of life 12.,0
"CPAP on day of life 12 to 23, weaned to nasal cannula from the 23 day of life to 27 day of life.",0
"Again, on nasal CPAP until day of life 32.",0
"Was on nasal cannula again from day of life 32 to 35, weaned to room air on day of life 35 and is currently on room air.",0
Has a history of drifting desats with feeds.,0
Apnea of prematurity was treated with caffeine from day of life two through day of life 54 for apnea of prematurity.,1
MEDICATIONS: Vitamin A as per protocol.,0
Apneic spells were periodically more frequent and requiring infectious workup three times in his course.,1
"Cardiovascular: Initially had hypotension requiring Dopamine 5 to 7 mcs per kilo per minute for the first 24 to 48 hours of life, has remained normotensive since that time.",0
"History of patent ductus arteriosus, status post Indomethacin therapy times two courses and still remaining open.",1
Three echocardiograms have been performed.,0
"One, showing a large 4 mm PDA left to right shunt.",0
"Two, small PDA with left to right flow and on was the latest echo showing a small 1.5 mm PDA with left to right flow.",0
Good cardiac function and no aortic arch obstruction.,0
The murmur has since that time considerably decreased in harshness and in audibility and the PDA is clinically presumed to be closed and has been asymptomatic for the past month.,0
EKG was performed also on showing normal sinus rhythm with some occasional PAC's some which were blocked.,0
GI: The patient suffered from chronic abdominal distension but has had good GI function with normal stools throughout.,0
Abdominal distension has improved significantly since stopping caffeine therapy.,0
Reflux is being investigated and the patient is at this time doing well with Enfamil AR 20 calories.,0
Initially the patient was on breast milk but that was discontinued due to the mother's medical condition.,0
Levodopa is known to decrease milk production.,0
"Fluids, Electrolytes and Nutrition: A UAC was placed in the abdomen day of life 0 to 5, umbilical vein catheter day of life 0 to 7, PICC line was placed on day of life 7 to 22.",0
The patient was advanced to full feeds and was on full gavage feeds via NG feeding tube from day of life 23 to 64.,0
The patient began to take all nutrition enterally p.o.,0
from day of life 64 to present and is on iron supplementation at this time and is tolerating feeds well.,0
The baby is easily agitated at rest and sometimes bears down and bringing up some contents.,0
If Enfamil AR does not improve this patient's symptoms of reflux Reglan will be considered.,0
Do not use Enfamil AR with Zantac as it becomes ineffective with elevated gastric pH.,0
Status post rule out sepsis times four initially requiring ampicillin and gentamicin until day of life two blood cultures were negative.,0
"Due to severe apneic spells the patient received vancomycin and gentamicin for rule out sepsis course between days of life 9 to 11, 40 to 42 and 62 to 64.",0
The last apneic episode day of life 62 to 64 was associated with having had the eye examination and vaccines at that time.,0
Neurology: Ultrasound findings were as follows.,0
"Ophthalmology: at five weeks of life immature, , immature zone 2, follow up in two weeks.",0
On immature zone 2 follow-up in two weeks.,0
Scheduled to have follow-up eye examination this week.,0
Psychosocial: social worker is involved with the family and can be reached at .,0
Condition is currently stable but observant.,0
Primary care pediatrician is going to be Dr. from Nadik.,0
Car seat screening has yet to be performed.,0
State newborn screen on was normal.,0
Genitourinary system: The patient has a very large hydrocele in the left testicle and a small hydrocele in the right testicle.,1
As proven by scrotal ultrasound on .,0
There is a questionable component of hernia which was ruled out by exam and the ultrasound was not consistent with hernia.,0
Follow-up should be scheduled with Dr. at the time of discharge probably two weeks after discharge from the NICU and he can be reached at Ext 8097 just for follow-up of hydroceles.,1
Genetics: The patient was found to have simian creases.,0
Genetics consult was performed on to rule out Downes' syndrome.,0
Karyotype was normal at 46 XY.,0
Immunizations received: Hepatitis B vaccine .,0
Immunizations recommended: Synergist RSV prophylaxis should be considered from through for infants who were born at less than 32 weeks.,0
Influenza immunization is recommended annually in the Fall for all infants once they have reached six months of age before this age and the first 24 months of the childs life immunization against influenza is recommended for hospital contacts and out of home caregivers.,1
Sepsis ruled out times four.,0
PDA status post Indocin times two courses.,0
History of PAC's on EKG.,0
"Familial Simean creases, karyotype normal.",0
"Apnea of prematurity, status post caffeine therapy.",1
Bilateral hydrocele left greater than right.,0
", MD Dictated By: MEDQUIST36 D: 19:18:05 T: 21:32:18 Job#:",0
"8:19 AM BABYGRAM (CHEST ONLY) Clip # Reason: 31 week triplet #3 with RDS s/p intubation, , ?",0
ett positio ______________________________________________________________________________ MEDICAL CONDITION: Infant with see above REASON FOR THIS EXAMINATION: 31 week triplet #3 with RDS s/p intubation ?,0
"ett position, lung status ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Triplet with RDS.",0
ET tube present with tip overlying T2 vertebral body.,0
Diffuse hazy opacification of both lungs with a reticulonodular pattern consistent with HMD.,0
No other significant abnormalities are identified.,0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with CAD s/p CABG.,1
REASON FOR THIS EXAMINATION: r/o PTX/Effusion ______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old male with CAD post-CABG.,0
"CHEST, AP: Patient is status post CABG with endotracheal tube 5.5 cm from the carina, Swan-Ganz catheter at the RVOT-main PA junction, nasogastric tube coiled in the stomach, mediastinal drains, and left basal chest tube.",0
Cardiomediastinal silhouette and hilar contours have a normal post-operative appearance.,0
"9:25 AM CHEST (PA & LAT) Clip # Reason: eval for interval change of pleural effusion, pulm edema.",0
"Admitting Diagnosis: CONGESTIVE HEART FAILURE EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with CHF exacerbation, cough, hemoptysis REASON FOR THIS EXAMINATION: eval for interval change of pleural effusion, pulm edema.eval for PNA ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Chronic heart failure exacerbation, cough, evaluation.",1
"Substantial cardiomegaly, bilateral pleural effusions and substantial basal and retrocardiac atelectasis.",0
Height: (in) 72 Weight (lb): 235 BSA (m2): 2.28 m2 BP (mm Hg): 101/59 HR (bpm): 72 Status: Inpatient Date/Time: at 16:06 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - akinetic; septal apex- akinetic; apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal PA systolic pressure.,0
There is mild regional left ventricular systolic dysfunction with akinesis of the mid- and distal septum and apex.,0
The remaining segments contract normally (LVEF = 40-45%).,0
"Compared with the report of the prior study (images unavailable for review) of , the findings appear similar.",0
"9:10 AM HUMERUS (AP & LAT) LEFT Clip # Reason: please eval for fracture ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with hematoma, OSH report of fracture REASON FOR THIS EXAMINATION: please eval for fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Hematoma with report of fracture.",1
TWO VIEWS OF THE LEFT HUMERUS: There is a comminuted fracture of the left proximal humerus involving the left humeral head and surgical neck.,1
There appears to be lateral displacement of a dominant fracture fragment.,0
The glenohumeral articulation remains preserved.,0
The acromioclavicular joint demonstrates mild degenerative spurring.,0
Visualized right lung is clear.,0
The imaged left elbow appears grossly unremarkable.,0
IMPRESSION: Comminuted fracture of the right proximal humerus DFDdp,1
6:26 PM BILAT LOWER EXT VEINS PORT Clip # Reason: SOB ?PE ?DVT Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with acute desaturation concerning for PE REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ FINAL REPORT INDICATION: 89-year-old male with acute desaturation concerning for PE.,1
"BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of the bilateral common femoral, superficial femoral and popliteal veins were performed.",0
"On the right, there is complete occlusive thrombus within the right superficial femoral and popliteal veins extending to the calf.",0
The right common femoral vein appears patent.,0
"On the left, no visualized flow and intraluminal echogenic thrombosis is seen within the common femoral, superficial femoral and popliteal veins.",0
"IMPRESSION: Occlusive thrombus involving the left common femoral, superficial femoral and popliteal vessels and the right superficial femoral and popliteal veins consistent with bilateral deep venous thrombosis.",0
Findings were discussed with Dr. at 9 pm on .,0
"4:11 PM CHEST (PA & LAT) Clip # Reason: pls eval effusions and for infiltrate Admitting Diagnosis: HERNIA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with CAD, Parkinson's, s/p hernia repair, with dyspnea REASON FOR THIS EXAMINATION: pls eval effusions and for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Dyspnea, evaluate for pleural effusions.",0
PORTABLE CHEST RADIOGRAPH: The cardiac and mediastinal silhouettes are stable in the interval.,0
Again noted are small bilateral pleural effusions which are unchanged from one day prior.,0
Persistent right lower lobe opacity is unchanged as well.,0
"IMPRESSION: Persistent right lower lobe opacity which could represent either pneumonia or atelectasis, for which clinical correlation is recommended.",0
Small bilateral pleural effusions unchanged.,0
"3:57 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o worsening pulmonary edema Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 54F w/ renal failure, suspected PE on trach mask now, with increasing resp distress REASON FOR THIS EXAMINATION: r/o worsening pulmonary edema ______________________________________________________________________________ FINAL REPORT INDICATION: Renal failure, suspected pulmonary embolism with increasing respiratory distress.",1
AP VIEW OF THE CHEST: The patient is status post median sternotomy and CABG.,0
Tracheostomy tube and right PICC remain in unchanged standard positions.,0
"Moderate pulmonary edema and s mall bilateral pleural effusions, left greater than right, persist.",0
Bibasilar opacities likely indicating atelectasis are unchanged.,0
Marked calcification of the mitral annulus is again demonstrated.,0
"IMPRESSION: Unchanged moderate pulmonary edema with small bilateral pleural effusions, left greater than right, and bibasilar atelectasis.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEONATOLOGY This is an interim dictation from to .,0
Respiratory: The infant was extubated by and remained on nasal cannula for less then 48 hours and subsequently remained on room air without any complications.,0
The infant was loaded with caffeine prior to extubation.,0
The infant had no apnea nor bradycardia for several weeks and caffeine was discontinued during the third week of .,0
"Cardiovascular: The infant had an echocardiogram on , which revealed a PFO and left ventricular hypertrophy.",0
The Cardiology Service recommends a repeat echocardiogram one to two weeks from the last echocardiogram (re-echo around the date of ).,0
"Fluids, electrolytes and nutrition: The infant is on 150 cc per kilogram per day of PE 28 with ProMod.",0
The infant has been making good weight gain on calories of 28.,0
Therefore there was no advancement to 30 calories thus far.,0
"The infant is fed via NG tube, but takes po feeds approximately times one q shift.",0
"He had nutrition laboratories on Thursday of last week, which would have been the , which were within normal limits.",0
"His last set of electrolytes show a sodium of 141, potassium of 4.6, chloride of 111 and a bicarb of 19.",0
This set of electrolytes is after Diamox was started.,0
Diamox was started during the week of .,0
He is on Diamox to decrease CSF production.,0
He is currently on 25 mg per kilogram per day.,0
The infant was made NPO at 0100 on in preparation for surgery.,0
Infectious disease: The infant received 21 days of Ampicillin.,0
He received 19 days of Gentamycin.,0
The infant had many repeat blood cultures all of which show no growth.,0
He had another blood culture drawn after finishing the 21 day course of antibiotics.,0
This as well shows no growth to date.,0
He also has had serial LPs (therapeutic taps).,0
"CSF culture has also been sent, which is showing no growth.",0
Hematology: Baby boy most recent hematocrit was also on .,0
"He in preparation for surgery he has had a repeat CBC, coags and a clot sent to the blood bank.",0
These were sent on the evening of .,0
Results at this time are pending.,0
Neurological: The infant has grade 4 IVH bilaterally and a posterior fossa hemorrhage.,1
He has had numerous head ultrasounds to follow the ventricular dilatation.,0
"His last head ultrasound was on Wednesday , which shows moderate ventricular dilatation.",0
His head circumference as of is 31 cm.,0
It has increased by 2 cm over the past seven days.,0
"As mentioned previously, the infant has undergone serial LPs over the last week and a half.",0
The amounts that have been collected have ranged from 7 cc to 18 cc per day.,0
The fluid is amber in color.,0
Ultrasound revealed that even with doing serial LPs q.d.,0
the degree of ventricular dilatation has not decreased and in fact over the course of the week and a half has increased.,0
"CSF protein was sent on , which was 197.",0
It was sent again on .,0
"A cell count from the CSF revealed white cells of 39 with 27 polys, 23 lymphocytes, 22 monocytes, red cells of , glucose 8, total protein of 178.",0
As mentioned the last head ultrasound was on showing restrictive indices of 0.81/0.87.,0
Both the Neurology Service ( and ) have been following the patient as well as the neurosurgical team (Dr. .,0
The decision was made to place a shunt.,0
The infant will go for shunt on Friday .,0
As mentioned he was made NPO at 1:00 in the morning on .,0
Preoperative laboratories have been sent and the surgical team has obtained consent from mother .,0
The infant will be transferred to for this surgery.,0
Please note his weight as of is 2.045 kilograms.,0
"Phenobarbital, which had been started within the first few days of life for seizure activity was discontinued on .",0
General information: mother is supported by her mother as well.,0
They have both been involved in all family meetings.,0
pediatrician will be Dr. of Pediatrics.,0
Her fax number is .,0
", mom her phone number is .",0
Dictated By: MEDQUIST36 D: 07:64 T: 08:50 JOB#:,0
10:51 AM CHEST (PORTABLE AP) Clip # Reason: pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman s/p L hemipelvectomy for osteosarcoma with RLL collapse REASON FOR THIS EXAMINATION: pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Status post left hemipelvectomy for osteosarcoma.,0
Follow up right lower lobe collapse and evaluate for pneumonia.,1
"TECHNIQUE: Single portable AP view of the chest was obtained, compared with examination from yesterday.",0
FINDINGS: Cardiac and mediastinal silhouettes are within normal limits.,0
Right-sided IJ catheter terminates at the cavoatrial junction.,0
Left-sided subclavian central venous catheter terminates in the mid SVC.,0
"NG tube is again seen, extending into the stomach.",0
Endotracheal tube tip is approximately 2 cm above the carina.,0
Cardiac and mediastinal silhouette remain stable.,0
There is diffuse alveolar opacity consistent with volume overload versus CHF.,0
There has been aeration of the right lower lobe in the interval.,0
IMPRESSION: CHF versus volume overload.,0
Aeration of previous collapsed right lower lobe.,0
5:21 PM CHEST (PORTABLE AP) Clip # Reason: please assess ET tube placement.,0
Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with gi bleed .,0
ET tube repositioned REASON FOR THIS EXAMINATION: please assess ET tube placement.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: GI bleed central line intubated ET tube repositioning, assess ET tube placement.",0
TECHNIQUE: Single AP portable semiupright chest.,0
FINDINGS: The endotracheal tube has been pulled back and now terminates with tip approximately 3.5 cm from the carina.,0
Unchanged position of right internal jugular venous access catheter and of nasogastric tube.,0
"In comparison with the next previous examination of several hours earlier, there is worsening congestive heart failure and stable cardiomediastinal contours.",0
"IMPRESSION: Satisfactory position of lines and tubes, including endotracheal tube status post pull back.",0
"8:24 AM CHEST (PORTABLE AP) Clip # Reason: assess for edema, infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with STEMI REASON FOR THIS EXAMINATION: assess for edema, infiltrate ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Assess for edema and infiltrate.",0
FINDINGS: The cardiac and mediastinal silhouette are unremarkable.,0
There is a haziness over the apical lung fields bilaterally.,0
This may represent an overlying structure or pulmonary parenchymal process.,0
Would recommend PA and lateral views for further evaluation.,0
There is no evidence of effusion or pneumothorax.,0
The visualized bony structures are unremarkable without evidence of fracture.,0
"IMPRESSION: Biapical haziness that may represent overlying structures, pleural thickening or pulmonary parenchymal process.",0
Would recommend additional views for further clarification.,0
These results were discussed with Dr. at 10:10 a.m. on Sunday by telephone.,0
"4:29 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval changes Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 72 yo female , intubated with RIJ and right lower lung consolidation/ effusion/ atelectasis.",0
please evaluate for interval changes REASON FOR THIS EXAMINATION: please evaluate for interval changes ______________________________________________________________________________ FINAL REPORT AP CHEST 5:17 A.M. .,0
HISTORY: Consolidation and pleural effusion.,0
IMPRESSION: AP chest compared to through .,0
A large area of new consolidation in the infrahilar left lung could be pneumonia or pulmonary hemorrhage.,0
"Mild-to-moderate generalized pulmonary edema has worsened since , accompanied by increasing size of mediastinal veins suggesting volume overload.",0
"ET tube, nasogastric tube, and right jugular line are in standard placements.",0
"Bilateral pleural effusion, small to moderate on the right is stable and small on the left has increased.",0
"Dr. covered by Dr. , was paged to report these findings, at the time of dictation.",0
"2:30 PM CT CHEST W/CONTRAST Clip # Reason: PLEASE DO 3D RECONSTRUCTIONS OF AIRWAYS - looking specifical Admitting Diagnosis: RIGHT UPPER LOBE LUNG MASS;COPD ______________________________________________________________________________ MEDICAL CONDITION: 59 y/o M w/new RUL mass, adm to OSH w/post-obs pna, found to have empyema now s/p chest tube placement, ?",1
"obstructing RUL mass REASON FOR THIS EXAMINATION: PLEASE DO 3D RECONSTRUCTIONS OF AIRWAYS - looking specifically at RUL No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT CHEST WITH CONTRAST, INDICATION: Right upper lobe mass.",1
Multidetector CT of the chest was performed following intravenous administration of 70 cc of Optiray.,0
Images are presented for display in the axial plane at 5 mm and 2 mm collimation.,0
A series of coronal reformation images are also presented for display.,0
Additional dedicated 3D reconstructions of the airway are also being performed and will be interpreted when available.,0
"A tracheostomy tube is present, terminating at approximately the thoracic inlet level.",0
There is obstruction of the right upper lobe bronchus at the level of the origin of the segmental branches.,1
The anterior and posterior segments are completely occluded.,0
The apical subsegmental bronchus is narrowed at their origins but appear patent distally.,0
There is mediastinal lymphadenopathy in the right paratracheal and subcarinal nodal stations extending into the azygoesophageal recess.,0
There is also bulky right hilar lymph node enlargement.,0
Left prevascular lymph nodes do not meet size criteria for significant enlargement.,0
"There is a right-sided chest tube present, terminating in the deep posterior costophrenic sulcus.",0
A moderate- sized right pleural effusion is present and is partially loculated.,0
A small dependent left pleural effusion is also present.,0
"In the imaged portion of the upper abdomen, assessment is limited due to extensive image noise.",0
There is an approximately 2 cm diameter posterior segment right lobe of liver hypodensity difficult to characterize due to the extensive streak artifact related to suboptimal positioning of the patient's arms.,0
No definite additional focal abnormalities are evident in the imaged portions of the liver or spleen on this limited exam.,0
"Post-obstructive changes are present in the right upper lobe, likely representing a combination of post-obstructive atelectasis and pneumonia.",1
There is also partial atelectasis of the right lower lobe.,0
"Within the right upper lobe distal to the area of bronchial obstruction, there is an unusual multiloculated cystic abnormality measuring approximately 5.3 cm in greatest dimension.",1
"There is also a small gas bubble within this low- density area (image 30, series 3).",0
"There are several thickened septal lines in the right upper lobe, which could be due to lymphatic obstruction or lymphangitic carcinomatosis.",1
"Scattered areas of linear atelectasis are (Over) 2:30 PM CT CHEST W/CONTRAST Clip # Reason: PLEASE DO 3D RECONSTRUCTIONS OF AIRWAYS - looking specifical Admitting Diagnosis: RIGHT UPPER LOBE LUNG MASS;COPD ______________________________________________________________________________ FINAL REPORT (Cont) present in the left lung as well as minimal dependent atelectasis adjacent to the left pleural effusion, but there are no consolidative or mass-like lesions on the left.",1
Motion artifact somewhat limits evaluation of fine lung detail.,0
MULTIPLANAR REFORMATION AND 3D-RECONSTRUCTION IMAGES: These images confirm the presence of a mass obstructing the right upper lobe bronchus at origin of segmental bronchi with patency of apical segment and also show the septal thickening in the right upper lobe to greater detail.,1
"On coronal reformation images, the multiloculated cystic abnormality is shown to be bordered by the minor fissure inferiorly and extends proximally to the right hilar region.",0
Degenerative changes are present in the spine.,0
No suspicious lytic or blastic skeletal lesions are identified.,0
"IMPRESSION: 1. obstructing right upper lobe bronchus at origin of segmental bronchi with obstruction of anterior and posterior segments, highly suspicious for primary lung cancer.",1
Post-obstructive atelectasis and necrotizing pneumonia with possible abscess formation (and less likely peripheral necrotic neoplasm).,1
Moderate partially loculated right pleural effusion with chest tube in place.,0
"Bulky right hilar lymphadenopathy and right mediastinal lymphadenopathy, concerning for neoplastic involvement although hyperplastic nodes are also possible in the setting of post-obstructive lung abnormalities.",0
Incompletely characterized hypodense lesion in right lobe of liver posteriorly.,0
Hepatic ultrasound may be helpful for further characterization to exclude metastatic disease.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath, cough Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: Mr. is a 55 year old Creole speaking man with multiple myeloma on Velcade and Cytoxan and s/p failing renal transplant on tacrolimus and currently on HD who presented to the ED on with dyspnea and non-productive cough.",1
"He developed a ""high fever"" and chills with a nonproductive cough on and came in to the ED after developing dyspnea .",0
"He had chest discomfort with coughing, but no pleuritic pain and no hemoptysis.",0
"No known sick contacts or recent travel, denies h/o +PPD but not sure when this last was done.",0
He had received in influenza vaccination .,0
"Review of systems negative for sweats, abdominal discomfort, nausea, vomiting, diarrhea, myaglias, arthralgias, rhinitis, sore throat, headache.",0
"In the ED, vitals were T 102.4 P 105 Bp 185/91 RR 16 O2 94% on room air.",0
"His chest film showed a RLL opacity and he was started empirically on vancomycin, ceftazidime, and levofloxacin.",0
Due to tachypnea 20-30 transferred to for close observation.,0
Admission labs notable for WBC 2.1 (57% polys no bands) and lactate of 2.7.,0
Multiple myeloma diagnosed - s/p cytoxan and high dose decadron end of - currently on on velcade/cytoxan q2wks.,1
"last seen in clinic cytoxan held for WBC 1.5, velcade given however 2. s/p DDRT , graft failing now back on HD - on tacrolimus, cellcept held in setting of cyclophosphamide tx - still makes some urine 3. h/o ESRD secondary to HTN on HD from - thought at that time to be HTN 4. s/p L AVF 5.",0
"Hordeolum Social History: 4 children, supportive in area.",0
He lives with a friend and does not work.,0
"He had been a preacher, last job was cab driver 4 years ago.",0
"He has never smoked, denies any alcohol usage.",0
States he has never used illicts.,0
His son is his HCP.,0
"Immigrated to the US ~ , lived in ~5 months then but in otherwise without residence elsewhere in US.",0
"Family History: noncontributory Physical Exam: Exam floor Tmax 102.8 (4:30pm in ED) T 99.6 P 96 BP 126/71 RR 22 O2 95% RA General: Appears older than stated age, coughing occasionally in mild respiratory distress HEENT: Sclera white, conjunctiva pale, moist mucus membranes, no thrush or other oral lesions.",0
R eyelid slight swollen Neck: No cervical or supraclavicular adenopathy Pulm: Speaking in full sentences.,0
"No dullness to percussion, +rhonchi, +crackles L>R CV: Regular rate S1 S2 II/VI systolic murmur Abd: Soft, +bowel sounds, mild tender epigastrium and over allograft in LLQ Extrem: Warm, well perfused, tr ankle edema.",0
Fistula L forearm with palpable thrill.,0
"Neuro: Alert, interactive, moving all extremities with no gross deficits Derm: Skin warm to touch, no rash Pertinent Results: 03:39PM BLOOD WBC-2.1* RBC-2.91* Hgb-8.7* Hct-27.7* MCV-95 MCH-29.9 MCHC-31.4 RDW-21.0* Plt Ct-197 06:00PM BLOOD PT-12.6 PTT-31.3 INR(PT)-1.1 03:39PM BLOOD Glucose-78 UreaN-27* Creat-6.9* Na-139 K-4.6 Cl-97 HCO3-32 AnGap-15 03:39PM BLOOD ALT-22 AST-15 AlkPhos-73 Amylase-76 TotBili-0.3 03:39PM BLOOD Albumin-3.4 Calcium-9.8 Phos-2.8 Mg-1.9 03:39PM BLOOD Lipase-89* 06:05AM BLOOD WBC-4.7# RBC-2.61* Hgb-7.8* Hct-24.9* MCV-95 MCH-29.7 MCHC-31.2 RDW-19.9* Plt Ct-148* 06:05AM BLOOD Gran Ct-3570 04:58AM BLOOD Glucose-83 UreaN-36* Creat-7.8* Na-136 K-5.1 Cl-97 HCO3-29 AnGap-15 04:58AM BLOOD ALT-17 AST-12 LD(LDH)-203 AlkPhos-66 Amylase-47 TotBili-0.3 04:58AM BLOOD Lipase-30 04:58AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9 04:58AM BLOOD Vanco-14.9 06:05AM BLOOD FK506-2.1* 03:13PM BLOOD Glucose-77 Lactate-2.7* Na-145 K-4.5 Cl-95* .",0
"DISCHARGE LABS WBC 18.4, Hb/Hct 8.5/27.7, Plts 173 BUN 25, Cr 7.7 (pre-dialysis) FK506 trough 12.2 .",0
IMAGING: CXR AP: Study is limited by respiratory motion.,0
"Relative to the prior examination, right internal jugular approach central venous catheter has been removed.",0
"There is a patchy opacity in the right lower lobe, highly suspicious for pneumonia.",0
Volume status has normalized since the prior examination.,0
Again noted is a tortuous aorta.,0
The cardiac silhouette remains enlarged but stable.,0
"IMPRESSION: Limited examination, highly suspicious for right lower lobe pneumonia.",0
"If clinically feasible, PA and lateral views in the radiology suite are recommended for better characterization.",0
"CXR PA/LAT: FINDINGS: In comparison with study of , there is again an area of patchy opacification in the right lower lobe, highly suspicious for pneumonia given the clinical history of immunesuppression.",0
Enlargement of the cardiac silhouette with some increase in pulmonary venous pressure persists.,0
Lspine plain films AP AND LATERAL LUMBAR SPINE: There is spondylosis of the L5 vertebral body without evidence of spondylolisthesis.,0
No discrete bony lesions are identified within the imaged bones to account for the patient's pain.,0
The remaining vertebral body and intervertebral disc space heights are preserved.,0
Sacroiliac joints are normally aligned.,0
"A catheter projecting over the right acetabulum represents a pigtail catheter extending along the course of the ureter, as seen on prior CT scan.",0
Multiple calcifications in the right lower quadrant likely represent central calcifications from prior right renal transplant.,1
IMPRESSION: No discrete osseous lesion within the imaged lumbar spine to account for the patient's symptoms.,0
"L5 spondylosis without spondylolisthesis, unchanged since .",0
Micro ********* BLOOD CULTURES PENDING DATE OF DISCHARGE 1/5 blood culture no growth as of blood culture no growth as of 1/2 blood culture no growth as of ********* urine legionella antigen negative blood cx negative sputum >10epis urine cx negative blood negative Brief Hospital Course: 1.,0
Pneumonia: Due to his initial tachypnea and fever he was admitted to the for close monitoring.,0
"He was initially treated empirically with broad spectrum antibiotics including vancomycin, levofloxacin, and ceftazidime due to recent hospitalization.",0
Antibiotic treatment lead to rapid improvement in his respiratory status and fever curve.,0
He was maintaining oxygen saturations in mid-high 90's on room air at time of discharge.,0
"Cultures remained negative at time of discharge, and his outpatient providers should follow up on the final results.",0
A bacterial etiology due to an encapsulated organism such as pneumococcus seemed most likely.,0
It was felt that his persistent leukocytosis at time of discharge reflected his treatment with neupogen as clinically he was much improved from a respiratory standpoint.,0
He will continue levofloxacin to complete a 14 day course of treatment.,0
Multiple myeloma: The patient was restarted on his cyclophosphamide and velcade on .,1
He will have close followup in oncology clinic.,0
Prophalaxis with acyclovir and bactrim was continued.,0
Neupogen was discontinued prior to discharge.,0
"ESRD, s/p renal transplant: The patient's Cellcept had been held while on Cytoxan but was restarted in hospital after discussion with Nephrology, prior to restarting his Cytoxan on .",0
He tacrolimus levels were adjusted per Nephrology and he will need to have a trough rechecked on Monday .,0
"Dialysis was continued during his hospitalization, last done the day of discharge .",0
He was continued on his phosphate binder.,0
He will follow up with Dr. from Nephrology.,0
"Per renal, dialysis sessions should be conservative in regards to volume removed.",0
Hypertension: He continued his home regimen metoprolol and amlodipine.,0
Chest pain and back pain: The patient complained of chest and low back discomfort overnight .,0
A cardiac etiology of the chest pain was thought unlikely given unchanged EKG and reproducibility of chest discomfort with palpation over the right throax.,0
His right sided chest discomfort was more likely related to the known right sided pneumonia.,0
"In regards to his back pains, he had no neurologic findings concerning for cord compression and plain films of his lumbar spine revealed no fracture or other acute pathology.",0
He was started on a fentanyl patch with oxycodone prn breakthrough for pain relief.,0
"Medications on Admission: Medications: per OMR Docusate Sodium 100 mg PO BID Amlodipine 10 mg PO DAILY Omeprazole 20 mg PO once a day Nystatin 500,000 unit/mL Suspension PO QID Oxycodone 5 mg Tablet PO Q6H as needed for pain.",0
Acylovir 400 mg PO DAILY Toprol XL 75 mg (though conflicting note states pt is on lopressor 75 mg ) Trimethoprim-Sulfamethoxazole 80-400 mg One Tablet PO DAILY Calcium Acetate 1334 mg PO TID W/MEALS MVI Tacrolimus 8 mg PO twice a day Doxazosin 2 mg PO HS Zofran prn Discharge Medications: 1.,0
Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain.,0
Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea.,0
Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours).,0
Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO twice a day.,0
Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours: First patch applied in hospital Saturday .,0
Change patch on Tuesday .,0
"Disp:*10 patches* Refills:*0* Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: dprimary 1. pneumonia secondary 1. multiple myeloma 2. s/p kidney transplant 3. renal failure chronic, dialysis dependent Discharge Condition: Good, breathing room air and in no respiratory distress, afebrile Discharge Instructions: You came to the hospital because of fever, cough, and dyspnea.",1
You had an Xray of your lungs that showed you had an infection of your lungs (pneumonia).,0
You were treated with antibiotics with improvement in your symptoms.,0
"You will need to continue taking an antibiotic, levofloxacin, for treatment of your pneumonia.",0
Please take the entire course of levofloxacin even if you are feeling well.,0
"The dose of the medicine used to protect your transplanted kidney, tacrolimus, was decreased to 6mg twice a day by your kidney doctors.",1
You need to have a blood test drawn on Monday to check that the level of the kidney medicine is at the right level.,0
Take your tacrolimus at 8pm on Sunday and have your blood drawn 12 hours later at 8am on Monday BEFORE you take your morning dose of tacrolimus.,0
Please do not take the Monday morning dose of tacrolimus before the blood draw because the medicine levels measured in the blood will not be accurate.,0
"Please continue taking all of your other medicines as directed and follow up with your primary care doctor Dr. , oncology (cancer) doctors .",0
"and Dr. , and with your kidney doctor Dr. .",0
"Call Dr. and seek medical attention if you develop: ** worsened cough, shortness of breath, high fevers (greater than 101 farenheit), shaking chills, drenching sweats, or other symptoms that worry you Followup Instructions: Please call Dr. office at on to set up an appointment for management of your kidney disease.",1
Please keep the following appointments Oncology Monday 7 at 12pm with Dr. and Dr.,0
"Provider: Date/Time: 12:00 Provider: , RN Phone: Date/Time: 12:00 Orthopedics Provider: , MD Phone: Date/Time: 1:30",0
9:01 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: tube position?,0
______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with asthma and recent intubation REASON FOR THIS EXAMINATION: tube position?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old male with asthma, and recent intubation.",0
Please evaluate for tube position.,0
The patient is also status post recent esophagogastrectomy.,1
"FINDINGS: Portable semi-upright chest radiograph is reviewed and compared to 8:42 p.m. Endotracheal tube is in place, with its tip roughly 2 cm proximal to the carina, which itself, is difficult to visualize .",0
Surgical staples in the left neck are unchanged.,0
Surgical staples in the mid abdomen have been removed.,0
"Right subclavian dual- lumen central venous catheter is unchanged, tip in the SVC.",0
"Post- surgical appearance of the right chest is unchanged, with unusual linear opacities, and areas of lucency.",0
"Lung volumes are decreased, and linear atelectasis and blunting of the left costophrenic sulcus have developed.",0
"Endotracheal tube appears to lie 2 cm proximal to the carina, which is difficult to visualize.",0
Recommend withdrawal 1-2 cm for more optimal positioning.,0
"Unchanged post-surgical appearance of the right lung base with linear opacities and ill-defined lucencies, which may be pneumonic.",0
Decreased lung volumes and new left basilar atelectasis and blunting of the left costophrenic sulcus.,0
"7:22 PM CT HEAD W/O CONTRAST; CT C-SPINE W/O CONTRAST Clip # CT RECONSTRUCTION Reason: s/p ped struck w/ deformity, s/p ped struck w/ deformity ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with REASON FOR THIS EXAMINATION: s/p ped struck w/ deformity ______________________________________________________________________________ FINAL REPORT HISTORY: Pedestrian struck by a car.",0
Assess for bleed or fracture.,0
TECHNIQUE: Contiguous axial images were obtained from the foramen magnum to the cranial vertex without the administration of IV contrast.,0
Additional axial images with multiplanar reconstruction were obtained through the cervical spine.,0
CT HEAD WITHOUT IV CONTRAST: There are no previous exams for comparison.,0
There is no evidence of intra or extra axial hemorrhages.,0
There is no mass effect or shift of midline structures.,0
The grey white matter differentiation is preserved.,0
"The ventricles, cisterns and sulci are unremarkable, without effacement.",0
"There is a very small low attenuation focus within the left frontal lobe, near the midline, which is non specific but may represent a small area of previous infarction.",0
"The soft tissues, paranasal sinuses and osseous structures are unremarkable.",0
"CT OF C-SPINE WITHOUT IV CONTRAST: There is no evidence of acute fractures, malalignment, focal osseous lesions or soft tissue abnormalities.",1
"Noted are diffuse degenerative changes, mostly demonstrated by anterior/posterior osteophytes and disc space narrowing.",0
The osteophytes all appear well corticated and are likely chronic.,0
Noted is a nondisplaced sternal fracture.,0
Multiplanar reconstruction images of the C-spine confirm the above findings.,0
No evidence of an acute intracranial pathologic process.,0
No evidence of acute C-spine fractures.,1
"8:47 AM IVC GRAM Clip # Reason: b/l iliac vein thrombosis, needing thrombolysis.",0
"Pt had ivc Contrast: OPTIRAY Amt: 180 ********************************* CPT Codes ******************************** * PERC MECHANICAL THROMBECTOMY I -50 BILATERAL * * -58 SERVIC BY SAME MD DURING POST OP 2ND ORDER OR> VENOUS SYSTEM * * -51 MULTI-PROCEDURE SAME DAY INTRO CATH SVC/IVC * * -59 DISTINCT PROCEDURAL SERVICE EXTREM BILAT VENOGRAPHY * * -59 DISTINCT PROCEDURAL SERVICE -52 REDUCED SERVICES * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with post hyst dvt, requiring IVC filter and further onc surgical intervention.",0
Pt now with extensive clot at level of filter to both LE's.,0
"REASON FOR THIS EXAMINATION: b/l iliac vein thrombosis, needing thrombolysis.",0
Pt had ivc filter placed .,0
"Pt seen by Dr. in clinic, and will do procedure.",0
pt to be admitted post procedure.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb MON 9:21 PM Bilateral iliac thrombolysis with AngioJet and balloon dilation mechanically and TPA infusion pharmacologically with no prominent improvement of the venous flow at both sides of the iliac veins.,0
______________________________________________________________________________ FINAL REPORT CLINICAL CONDITION: The patient is a 66-year-old woman who developed DVT and had IVC filter placed.,0
Patient had extensive clots at the level of the filter down to iliac veins on both sides.,0
A request was made to perform thrombolysis to recanalize the thrombolized vein.,0
"OPERATORS: Dr. , Dr. , and Dr. , the attending radiologist who was present and supervised during the whole procedure.",0
PROCEDURE: Bilateral iliac veins thrombolysis.,0
Sedation: Sedation was applied by administering divided doses of a total of 225 mcg of fentanyl and 4 mg of Versed throughout the total intra-service time of 2 hours 52 minutes during which the patient's hemodynamic parameters were continuously monitored.,0
Lidocaine was used for local anesthesia.,0
"PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well as sedation were explained, informed consent was obtained.",0
Both sides of the groins were prepared and draped in the usual sterile fashion.,0
The right common femoral vein was accessed with 19-gauge single wall needle under fluoroscopic guidance and ultrasound guidance.,0
A 0.035 wire was then placed through the needle into the right common femoral vein.,0
The needle was removed and replaced with a 6 French -Tip sheath.,0
The inner stiffener of the sheath and the wire were then removed.,0
"Contrast injection through the sheath demonstrated occlusive thrombosis started at the right external (Over) 8:47 AM IVC GRAM Clip # Reason: b/l iliac vein thrombosis, needing thrombolysis.",0
Pt had ivc Contrast: OPTIRAY Amt: 180 ______________________________________________________________________________ FINAL REPORT (Cont) iliac vein.,0
The sideport of the sheath was then connected to a heparinized normal saline drip.,0
The left common femoral vein was accessed in the same way and contrast injection demonstrated the thrombosis started at the lower portion of the left common iliac vein.,1
"Based on the diagnostic findings, the decision was made to perform mechanical thrombectomy.",0
A 0.035 regular glidewire and a 5 French Kumpe catheter were then placed through the sheath at the right common femoral vein with both tips of the glidewire and Kumpe catheter terminating above the IVC filter inside the IVC.,0
The glidewire was then removed and replaced with a 0.035 wire with the tip of the wire terminating in the IVC at the level above the IVC filter.,0
The Kumpe catheter was removed.,0
The sheath was then advanced upward over the wire and contrast injection through the sheath demonstrated a high- grade thrombosis from the IVC filter down to the right external iliac vein with almost no contrast flowing freely through the thrombolized veins.,0
The AngioJet device was then placed over the wire into the right external iliac vein up to the IVC below the filter.,0
Three mechanical thrombolysis passes with the AngioJet device were performed from the right external iliac vein up to the IVC below the IVC filter.,0
"The AngioJet device was then removed, and contrast injection through the sideport of the sheath demonstrated no obvious improvement of the right iliac thrombosis.",0
A 5 French 20-cm - infusion catheter was then placed over the wire through the sheath into the right iliac thrombosis.,0
"After the wire was removed, a total of 8 mg of TPA were infused into the right iliac thrombosis and it was about 10 minutes before proceeding to the next step.",0
The infusion catheter was then removed over the wire.,0
The 6 French -Tip sheath was then replaced with a 7 French -Tip sheath.,0
A 6 French 10 mm x 4 cm balloon was then placed through the sheath over the wire into the right iliac vein and was deployed along the right iliac veins up to the IVC below the filter.,0
The balloon was then removed and contrast injection through the sheath demonstrated minimal improvement of the right iliac thrombosis.,0
The glidewire and the Kumpe catheter were placed through the sheath at the right groin with both tips terminating at the left external iliac vein across the IVC bifurcation.,0
The glidewire was then removed and replaced with a 0.035 wire with the tip of the wire terminating in the left common femoral vein.,0
The 6 French 10 mm x 4 cm balloon was then placed over the wire into the left iliac vein and was deployed along the left iliac vein up to the IVC bifurcation.,0
The balloon catheter was removed and replaced with the Kumpe catheter with the tip of the Kumpe catheter terminating at the left external iliac vein.,0
"The wire was then removed, and contrast injection though the Kumpe catheter demonstrated no flow though the left common iliac vein to the IVC with abundant left lumber collaterals formed.",0
"The wire was then again placed through the Kumpe catheter with the tip terminating in the left common femoral vein, and the Kumpe catheter was then removed.",0
The 5 French - infusion catheter was then placed over the wire crossing the IVC bifurcation with the tip terminating at the lower portion of the left common iliac vein.,0
"After the wire was removed, a total of 7 mg of TPA (Over) 8:47 AM IVC GRAM Clip # Reason: b/l iliac vein thrombosis, needing thrombolysis.",0
"Pt had ivc Contrast: OPTIRAY Amt: 180 ______________________________________________________________________________ FINAL REPORT (Cont) was then infused into the thrombosis inside the left common iliac vein, the IVC bifurcation, and the right common iliac vein.",0
The infusion catheter was then redirected with its tip ending at the level of IVC filter.,0
A second infusion catheter was then placed through the left groin sheath with the tip terminated at the same level as the first one.,0
Overnight TPA infusion was planned for the patient.,0
"The patient had a Foley catheter placed after the procedure, and gross hematuria was noticed instantly.",0
The overnight TPA infusion was cancelled then.,0
The patient was sent to ICU for further monitoring overnight.,0
Both groin sheaths were then removed together with the infusion catheters.,0
Hemostasis was achieved at both groins by manual compression.,0
Occlusive bilateral iliac venous thrombosis extending to the level of infra-renal IVC filter.,1
"Mechanical thrombolysis with AngioJet device and balloon dilation, and pharmacological thrombolysis with TPA infusion resulting in mild thrombolysis and recanalization of the bilateral iliac veins upper to the IVC below the filter.",0
but persistent extensive occlusion with no signs of re-establishing the flow.,0
Overnight TPA infusion was planned but was cancelled due to the bleeding risks that the patient had and gross hematuria observed right after the procedure.,0
"3:31 PM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: Please review ERCP images from Admitting Diagnosis: CHOLANGIO CARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with cholangiocarcinoma/Klatskin tumor, s/p ERCP placed plastic stent in L hepatic duct, IR placed plastic internalized biliary drain in R hepatic duct.",0
"Pt for removal of stents, IR Rendezvous with placement of b/l biliary metal stents REASON FOR THIS EXAMINATION: Please review ERCP images from ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of patient with history of cholangiocarcinoma/Klatskin tumor, status post ERCP placed biliary drain in the right hepatic duct for removal of stent and replacement of bilateral biliary metallic stents.",0
FINDINGS: 17 fluoroscopic spot views from an ERCP are submitted for review.,0
Previously placed biliary drain as well as ERCP placed plastic drain is visualized.,0
The removal of both stents is visualized.,0
A metallic stent is visualized extending from the right hepatic duct to the duodenum.,0
"Furthermore, a left hepatic duct stent is visualized extending down to the distal CBD.",0
A third metallic stent was placed in the left duct stent extending from the proximal CBD to the major papilla.,0
IMPRESSION: Removal of previously placed plastic stent and percutaneous biliary drain.,0
Placement of of right hepatic duct metallic stent extending to the duodenum along with a left hepatic duct stent extending to the distal CBD with another metallic stent overlapping the left stent and extending through the major papilla.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p fall Major Surgical or Invasive Procedure: : Bedside placement of PEG History of Present Illness: This is a 70 y/o man who had a fall from a ladder after presumed syncopal episode.,0
"Per OSH reports, Mr. was working on a ladder, complained of light headedness and fell approximately feet.",0
"He was alert and oriented initially, but vomited three times en route to OSH, where he had a GCS of 10.",0
"He was then intubated for airway protection, and prepared for to .",0
"Upon arrival here, head CT was performed revealing a significant right SDH and basilar skull fracture.",1
"Past Medical History: Hypertension, Dyslipidemia Social History: Married, resides at home.",0
"Family History: Non-contributory Physical Exam: On admission: O: BP:148/108 HR:97 RR:18 O2Sats:100%CMV Gen: WD/WN, comfortable, NAD.",0
"HEENT: periorbital ecchymosis, there are air bubbles appreciated behind the left ear; right TM appears to be intact Pupils: PERRL EOMs: UTA MOTOR: minimal spontaneous movement of the upper extremities, withdrawal of the lower extremities to noxious nail bed pressure.",0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2mm to 1.5mm bilaterally.",0
"Reflexes: +gag, +corneals Toes upgoing bilaterally Exam on Discharge: A&Ox self, month, and year PERRL 4-2mm bilaterally EOMs: intact follows commands intermittently Face symmetrical tongue midline RUE: biceps and triceps, grip LUE: biceps and triceps, grip BLE: antigravity PEG incision: c/d/i Pertinent Results: CT C-spine 1.",0
No fracture or malalignment involving the cervical spine.,0
"Multilevel degenerative change most prominent at the level of C6-C7 with loss of intervertebral disc height, posterior disc-osteophyte complex, facet arthrosis and uncovertebral hypertrophy resulting in mild-to-moderate central canal stenosis and neural foraminal narrowing.",0
"This predisposes the patient to spinal cord injury with minimal trauma, and MRI of the cervical spine should be considered for further evaluation of cord injury if clinically indicated.",0
Basilar skull fracture involving the left occipital bone extending to involve the left occipital condyle and the left internal carotid canal within the petrous portion of the left temporal bone.,1
Recommend CTA for further evaluation.,0
Partially imaged is pneumocephalus involving the right temporal region as seen on concurrent CT examination.,0
"Extensive intracranial hemorrhage as detailed above with right cerebral convexity subdural hemorrhage measuring up to 11 mm, a small left frontal subdural hemorrhage measuring up to 4 mm, extensive right-sided cerebral subarachnoid hemorrhage, and likely component of intraparenchymal right frontal contusion.",1
"Multiple scalp hematomas involving the left occipital region, the right frontal region, and likely near the right frontal convexity.",0
"Left basilar skull fracture involving the left occipital bone with extension into the left occipital condyle and petrous portion of the left temporal bone, with involvement of the left internal carotid canal.",1
Sinus opacification likely related to recent intubation ankle X-ray Minimally displaced lateral malleolar fracture.,1
Small well corticated ossific density inferior to medial malleolus could represent sequelae of old trauma.,0
"CTA neck : No evidence of vascular injury, thrombosis or aneurysm.",0
The left basilar skull fracture involving the left occipital bone and extending into the left carotid canal is redomenstrated.,1
"The left carotid artery is suboptimally opacified in this region, however given symmteric appearance a focal intimal dissection is felt unlikely.",0
( ) ECHO The left atrium is normal in size.,0
Increase in the right inferior frontal intraparenchymal hemorrhage with mild increase in the leftward shift of the midline structures.,0
Increase in the conspicuity of the subarachnoid hemorrhage in the left frontal and parietal lobes.,1
Persistent mass effect on the right lateral ventricle with mild increase in the leftward shift of the midline structures.,0
Please see the prior CT head study for details regarding the osseous structures.,0
"Unchanged appearance of the scalp soft tissue swelling, on the left side.",0
MRI C-spine : IMPRESSION: 1.,0
Multilevel neural foramen narrowing as above.,0
Posterior disc bulge at C6-C7 and C7-T1 levels without impingement on the cord or central canal stenosis.,0
Incidental note is made of blood within the left cerebellar cistern.,0
"CT Head : IMPRESSION: Re-demonstration of multifocal intracranial subdural, intraparenchymal, and subarachnoid hemorrhage.",1
Right subarachnoid hemorrhage is somewhat less conspicuous than on prior study.,1
"There is continued mass effect upon the right lateral ventricle, and associated rightward shift of midline structures, again measuring approximately 1 cm.",0
Small amount of intraventricular blood is again identified in the occipital of the left lateral ventricle.,0
There is no new hemorrhage or increased mass effect identified.,0
LENIS : CONCLUSION: No evidence of DVT in the right or left lower extremity.,0
CTA Chest : IMPRESSION: 1.,0
Limited distal branch evaluation due to respiratory motion artifact.,0
"In a single posterior segment right upper lobe pulmonary artery, there is suggestion of a filling defect, although this opacity overlaps with adjacent airspace disease, and may be artifactual.",0
Brief Hospital Course: Mr. was admitted to on .,0
He was intubated and taken to the ICU with Q1hr neuro checks.,0
CT imaging showed worsening hemorrhage.,0
Platelets were goiven for history of aspirin use.,0
e was on Dilantin for seizure prophylaxis.,0
MRI c-spine was performed on .,0
He was see by Orthopedics who recommended an air cast for his ankle.,0
Dr. cleared his cervical collar on .,0
He was weaned toward extubation.,0
Repeat Head CT on was stable.,0
His Mannitol was held due to NA/OSM parameters.,0
He failed Speech and Swallow evaluation at the bedside and a Dobhoff was placed.,0
On his Mannitol was discontinued.,0
He was transferred to the step down unit.,0
His dilantin dose was increased for a corrected level of 6.1.,0
The patient had tachypnea overnight but his oxygen saturation remained within normal limits.,0
His neuro exam remained stable.,0
During the day on his tachypnea became worse and his ABG showed respiratory alkalosis.,1
He continued to oxygenate well.,0
Lenis were negative for DVT.,0
His RR went up to the 40s and he became more lethargic and stopped following commands.,0
The repeat head CT was stable.,0
He also spiked a fever of 102.,0
"Due to suspicion of a PE and the tachypnea, he was transferred to the ICU and had a chest CTA on the way there.",0
The patient's head of bed was kept elevated and he had nasotracheal suctioning and he several mucus plugs were removed.,0
He also had chest PT and his RR came down to the 20s.,0
By his mental status improved and he was following commands again with the right side.,0
Additionally ID was consulted to guide antibiotic managment for his pneumonia.,0
"A repeat speach and swallow evaluation was performed and unfortunately, he did not pass.",0
Therefore a general surgery consult was obtained.,0
"He was also transferred to the stepdown unit, where vancomycin increased to Q8H.",0
Urine culture was negative from .,0
Sputum culture found to have normal flora.,0
His dobhoff was replaced to restart tube feeds.,0
PEG was performed on to bridge his nutrition during his recovery.,0
"Post-operatively, he was tachypneic and reintubated for respiratory managment.",0
He was then transferred back to the ICU.,0
"After being placed on CPAP, his respiratory status improved, as it was thought his tachypnea was due to atelactasis and/or mucous plugs.",0
A NCHCT was again performed; revealing persistant right acute on chronic SDH and evolving right frontal contusion.,0
It was decided to take him to the operating room on to evacuate the right SDH to optimize his recovery.,0
"However, it was noted on morning rounds on , that he has much improved clinically(following commands, moving all extremities); so the OR case was cancelled.",0
The patient's mental status remained stable and he was successfully extubated on .,0
He continued to do well neurologically and he was breathing on room air with no difficulty.,0
Therefore he was transferred back to the neuro step down unit.,0
He continued to work with PT and OT and was screened for rehab.,0
He is stable neurosurgically and respiratory wise and will be discharged to rehab on .,0
Medications on Admission: Lopid Magnesium Calcium ASA Discharge Medications: 1.,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever.,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Inhalation Q6H (every 6 hours) as needed for wheezing.,0
Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day).,0
"HydrALAzine 10 mg IV Q4H:PRN sbp>160 , HR<100 hold for sbp<100 12.",0
Metoclopramide 10 mg IV Q6H:PRN nausea Discharge Disposition: Extended Care Facility: Discharge Diagnosis: subdural hematoma subarachnoid hemorrhage skull fracture cerebral contusion Minimally displaced lateral malleolar fracture Hospital Acquired Pneumonia Respiratory Failure Dysphagia Hyponatremia Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?,1
"Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen etc.",0
"You have however, already been restarted on your home dose of aspirin.",0
"You have been prescribed an anti-seizure medicine,Keppra.",0
You will not require any bloodwork to monitor this.,0
You will continue to take this until you are seen in follow up ?,0
?You will need a CT scan of the brain without contrast prior to this appointment.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: throat swelling Major Surgical or Invasive Procedure: None.,0
"History of Present Illness: -- per admitting resident -- Ms. is a 44 yo healthy woman who presents with sudden onset of throat swelling and difficulty swallowing, starting at 9pm yesterday.",0
"She was feeling well prior to the episode and denies fever, throat pain, or URI symptoms.",0
"No recent medication changes, no ACE inhibitor use, NSAID or ASA use, travel or new food exposures.",0
"She denies abdominal pain, rash, pruritus, or hives.",0
She ate a usual dinner of chicken and rice and mango juice (which are all typical for her).,0
"She works at in the animal research department and directly handles animals on a daily basis including mice, rats, rabbits, and monkeys.",0
"In the ED, initial vs were: T 97.6 P 67 BP 131/83 R 14 O2 sat 100% on RA.",0
"Patient was found to have uvular swelling without stridor and was given Solumedrol 125mg IV, famotidine 20mg IV, and diphenhydramine 50mg IV without immediate improvement and she was admitted to the ICU for close monitoring.",0
"On the floor, she reports some improvement and can swallow a little bit easier.",0
"Denies headache, rhinorrhea or congestion.",0
"Past Medical History: Hepatitis B infection (positive HBV sAb, cAb), laryngopharyngeal reflex, H. pylori status post treatment, gastritis.",0
Social History: Lives with her husband and 14 hr old son.,0
She is originally from .,0
She works at handling lab animals.,0
"She has never smoked, does not drink alcohol or drug use.",0
Family History: Denies family history of allergic conditions or angioedema.,0
"Physical Exam: -- per admitting resident -- Vitals: T 97.8 HR 73 BP 116/80 RR 13 O2 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, uvula is edematous, mainly on R, on erythematous, no exudate or tonsillar hypertrophy.",0
"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, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: 11:00PM BLOOD WBC-6.0 RBC-4.11* Hgb-12.4 Hct-36.2 MCV-88 MCH-30.1 MCHC-34.2 RDW-13.2 Plt Ct-279 11:00PM BLOOD Neuts-43.5* Lymphs-45.1* Monos-6.4 Eos-4.0 Baso-1.0 11:00PM BLOOD Glucose-111* UreaN-18 Creat-0.9 Na-139 K-4.7 Cl-106 HCO3-18* AnGap-20 04:00PM BLOOD Glucose-166* UreaN-15 Creat-0.8 Na-137 K-3.7 Cl-102 HCO3-19* AnGap-20 Brief Hospital Course: # throat swelling - History and exam was consistent with angioedema.",0
"An infectious source was thought less likely given that patient was without pain, fever, erythema, or URI symptoms.",0
"Patient denied rash or urticaria, making a mast-cell mediated response less likely.",0
Possible allergic exposures include mango juice and animal exposure.,0
Another possibility is an acquired angioedema.,0
The patient was given steroids and antihistamines and showed significant improvement in symptoms.,0
"At time of discharge, patient was tolerating a solid diet and was breathing comfortably with no residual symptoms, though she was drowsy, which was attributed to the use of antihistamines.",0
"- tryptase levels were drawn on admission, still pending at time of discharge.",0
This should be followed up as an outpatient to evaluate for an anaphylactic etiology.,0
"- The patient was discharged on a 2-day course of prednisone taper, famotidine, and diphenhydramine.",0
The patient was also given a prescription for an EpiPen in case of an airway emergency in the future.,0
# anion gap metabolic acidosis - The patient had a mild AGMA on admission (AG = 16).,0
This persisted throughout her hospitalization without improvement or worsening.,0
"As the patient was well-appearing and stable, we opted to discharge the patient, asking her to have her electrolytes rechecked by her PCP within the next week to ensure no worsening of her gap acidosis.",0
# chronic hepatitis B infection - As noted on serologies .,1
"We communicated this information to the PCP, may continue with further workup and/or management as appropriate.",0
Medications on Admission: Hydroquinone topically.,0
Omeprazole 40 mg daily (didn't take today).,0
EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) PEN INJECTION Intramuscular AS NEEDED as needed for shortness of breath or difficulty swallowing from throat swelling for 1 doses: Please go to a hospital immediately after use.,0
"Prednisone 10 mg Tablet Sig: 2 tabs (20 mg) x 1 day, then 1 tab (10 mg) x 1 day, then STOP PO once a day for 2 days.",0
"Diphenhydramine HCl 12.5 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every six (6) hours for 2 days.",0
"Disp:*8 Tablet, Chewable(s)* Refills:*0* 4.",0
Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 days.,0
Necon 0.5/35 (28) 0.5-35 mg-mcg Tablet Oral Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. angioedema Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You were seen at for throat swelling and difficulty swallowing.,0
"In the ED, the back of your throat looked swollen, so you were admitted to the ICU for observation.",0
We treated you with steroids and antihistamines for an allergic response; your symptoms improved with this treatment.,0
"Additionally, you were found to have a slight abnormality in your electrolyte panel that remained stable over your hospital stay.",0
We would like you to follow up with your PCP within the next 3-5 days and have your electrolyte panel re-drawn in order to ensure that this is not getting worse.,0
"You will be discharged on a short course of steroids and antihistamines: ADDED prednisone; 20 mg (2 tablets) tomorrow, and 10 mg (1 tablet) the day after ADDED benadryl 12.5 mg every 6 hours for 2 days ADDED famotidine 40 mg every day for 2 days Followup Instructions: Please follow up with Dr. (office phone: ) 1-2 weeks after discharge.",0
"Additionally, we would like for you to have blood drawn within 3-5 days from discharge to recheck your electrolyte panel.",0
We would also recommend you follow up with an allergist within 1-2 months after discharge.,0
"You can contact Dr. office at ( to set up an appointment, or you may ask Dr. for a referral to an allergist at your convenience.",0
"11:58 CHEST (PORTABLE AP) Clip # Reason: Please assess for infiltrate, effusion, ptx ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with tachypnea REASON FOR THIS EXAMINATION: Please assess for infiltrate, effusion, ptx ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old male with tachypnea.",0
"Please assess for infiltrate, effusion, or pneumothorax.",0
COMPARISON: Chest radiograph performed earlier in the evening.,0
SINGLE FRONTAL VIEW OF THE CHEST: Lung volumes are low.,0
There are no focal areas of consolidation.,0
Increased interstitial markings and pulmonary vasculature are consistent with worsening pulmonary edema.,0
"The cardiomediastinal silhouette is within normal limits, unchanged.",0
"12:06 PM CHEST (PORTABLE AP) Clip # Reason: assess interval change Admitting Diagnosis: THIGH ABSCESS;PORTAL HYPERTENSION ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with sarcoid liver, ascites now out of MICU and w/ increasing oxygen requirement.",1
"Concern for increasing effusions, failure on exam REASON FOR THIS EXAMINATION: assess interval change ______________________________________________________________________________ FINAL REPORT CHEST ONE VIEW PORTABLE.",0
INDICATION: 58-year-old woman with sarcoidosis in the river.,0
"COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of .",0
The previously identified congestive heart failure has been slightly improving.,1
There is continued cardiomegaly and small right pleural effusion.,0
The left-sided PICC line remains in place.,0
No evidence for pneumothorax is identified.,0
The patient probably has ascites.,0
PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for CABG procedure.,0
Height: (in) 70 Weight (lb): 163 BSA (m2): 1.92 m2 BP (mm Hg): 134/78 HR (bpm): 53 Status: Inpatient Date/Time: at 14:43 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.,1
Conclusions: Prebypass No atrial septal defect is seen by 2D or color Doppler.,1
Dr. was notified in person of the results on at 1330pm.,0
Post bypass Patient is AV paced and receiving an infusion of phenylephrine.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Heparin Agents Attending: Chief Complaint: confusion, chillc Major Surgical or Invasive Procedure: None History of Present Illness: 25M with a history of alcohol abuse who was admitted to the SICU with acute hepatic failure in setting of acetaminophen toxicity/EtOH abuse.",1
"According to SICU notes, the patient had been self-medicating for ongoing tooth pain with 20-30 tylenol tablets daily and unquantified doses ibuprofen X 8 days.",0
"Additionally, he had been binge drinking, with consumption of approximately 1L whiskey and 12-15 beers daily.",0
"On , the patient reported abdominal pain with accompanying nausea and non-bloody emesis.",0
"His symptoms progressed to include diffuse myalgias, confusion, chills and diaphoresis.",0
"He was brought to an OSH, where the patient was noted to have transaminases in , INR ~5, lactate 14.",0
He was resuscitated and NAC gtt was initiated.,0
He was subsequently transferred to SICU.,0
"While in the SICU, he was continued on NAC gtt, and the patient's LFTs trended to peaks of ALT 6880, AST 8562 on and subsequently trended downward.",0
"INR peaked at 14.3 on , and was given total 4 units FFP and 1 cryo, and since downtrended to 3.6.",0
Hepatitis serologies have all returned negative.,0
"RUQ U/S revealed patent vessels, no ascites, varices or acute liver lesions.",1
"He was seen by psych, who felt that he had EtOH dependence, but no acute psychiatric issues.",1
"Dental eval revealed poor dentition, panorex with 2 necrotic teeth, but no acute signs of infection.",1
"On the floor, the patient reports no current symptoms.",0
"He feels tired, but denies confusion, abdominal pain, N/V/D.",0
Past Medical History: - dental caries - tonsillectomy Social History: Lives with mother/step-father.,1
"Alcohol habits include binge drinking a ""few days/week"" as much as 1L whiskey, 12 beers/day.",0
Family History: No significant family hx GI cancers or liver disease.,0
"Physical Exam: ADMISSION EXAM VS: 98.8 94 104/57 24 96%RA GENERAL: Well appearing M. Comfortable, appropriate.",0
"CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g LUNGS: Resp were unlabored, moving air well and symmetrically.",0
"ABDOMEN: Soft, non-tender to palpation.",0
"EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.",0
"DISCHARGE EXAM VS: 98.1 131/52 67 18 100%RA GENERAL: Well appearing M. Comfortable, appropriate.",0
"Skin- papular erythematous rash over arms and chest, improved from previous Pertinent Results: LABORATORY DATA CBC 07:57PM BLOOD WBC-19.7* RBC-4.61 Hgb-14.1 Hct-42.4 MCV-92 MCH-30.6 MCHC-33.2 RDW-14.6 Plt Ct-163 07:57PM BLOOD Neuts-96.9* Lymphs-2.5* Monos-0.3* Eos-0.2 Baso-0.1 05:40AM BLOOD WBC-6.8 RBC-3.59* Hgb-11.0* Hct-33.3* MCV-93 MCH-30.6 MCHC-33.0 RDW-19.1* Plt Ct-72* .",0
INR 07:57PM BLOOD PT-62.7* PTT-36.8* INR(PT)-6.3* 06:30AM BLOOD PT-84.5* PTT-41.6* INR(PT)-8.6* 11:13AM BLOOD PT-100* PTT-42.3* INR(PT)-14.3* 05:30PM BLOOD PT-55.3* PTT-35.3 INR(PT)-5.5* 06:12AM BLOOD PT-85.0* PTT-37.8* INR(PT)-8.6* 01:43PM BLOOD PT-37.9* PTT-31.4 INR(PT)-3.7* 05:40AM BLOOD PT-21.8* PTT-41.3* INR(PT)-2.1* .,0
Fibrinogen 12:16AM BLOOD Fibrino-86* 05:30PM BLOOD Fibrino-67* 01:43PM BLOOD Fibrino-134*# 01:56AM BLOOD Fibrino-66* 06:20AM BLOOD Fibrino-167*# .,0
Chemistry 07:57PM BLOOD Glucose-167* UreaN-16 Creat-1.2 Na-135 K-5.3* Cl-101 HCO3-15* AnGap-24* 05:40AM BLOOD Glucose-85 UreaN-7 Creat-0.9 Na-136 K-3.9 Cl-104 HCO3-23 AnGap-13 .,0
LFTS 07:57PM BLOOD ALT-3237* AST-3970* AlkPhos-82 TotBili-6.7* 06:12AM BLOOD ALT-6346* AST-6129* AlkPhos-123 TotBili-6.2* 06:20AM BLOOD ALT-271* AST-39 LD(LDH)-220 AlkPhos-105 TotBili-15.8* 05:40AM BLOOD ALT-196* AST-42* LD(LDH)-269* AlkPhos-94 TotBili-15.3* .,0
MISC 12:16AM BLOOD %HbA1c-5.1 eAG-100 12:16AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE 12:16AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE 12:16AM BLOOD CEA-3.6 PSA-0.5 AFP-1.3 12:16AM BLOOD -NEGATIVE 01:43PM BLOOD AFP-1.8 12:16AM BLOOD IgG-859 IgA-216 IgM-28* 07:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-27 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 01:43PM BLOOD Acetmnp-NEG 12:16AM BLOOD Ab-NEGATIVE 09:27PM BLOOD Lactate-5.6* 07:55AM BLOOD Lactate-2.1* .,0
Test Result Reference Range/Units CA -9 37 H <37 U/mL CERULOPLASMIN 15 L 18-36 mg/dL COPPER 42 L 70-175 mcg/dL .,0
URINE STUDIES 08:50PM URINE Color-Yellow Appear-Hazy Sp -1.024 08:50PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-70 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG 08:50PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 .,0
CMV Viral Load (Final ): CMV DNA not detected.,0
"HBV, Viral load pending .",0
STUDIES Chest xray Semi-erect radiograph.,0
Borderline diameter of the azygos vein might indicate increased circulating blood volume.,0
"No focal liver lesions, varices or ascites.",0
Liver Doppler shows full patency of the portal and hepatic veins with normally directed flow.,0
Brief Hospital Course: PRIMARY REASON FOR ADMISSION The patient is a 25M with a history of alcohol abuse who was admitted with acute hepatic failure in setting of excessive acetaminophen use/EtOH abuse.,1
# Acute Liver Failure: Patient was initially presented to an OSH with abdominal pain and confusion.,1
He was found to have a transaminitis with ALT/AST of 3237/3970 respectively.,0
This was felt to most likely represent acetaminophen toxicity in the setting of extensive alcohol use.,1
Patient was started on a NAC gtt and transferred to for evaluation for transplant.,0
"Work-up of other possible etiologies included negative hepatitis serologies (HBV/ viral loads pending), normal copper and ceruloplasmin, negative AMA and anti-smooth muscle, normal IgG level, and negative HIV.",0
Liver US showed patent liver vasculature.,0
ALT/AST trended upward to maximum values of 6880/ 8562.,0
INR trended upward to 14.,0
Patient was continued on the NAC gtt.,0
"LFTs trended downward, acetaminophen levels normalized and the patient was transferred to the floor.",0
He was given vitamin K 5 mg x 3 days.,0
INR trended down to 2.1 and NAC gtt was discontinued and INR remained stable.,0
Bilirubin continued to trend upward to a max of 15.8.,0
"At the time of discharge labs were notable for ALT/AST of 196/ 42, INR of 2.1 and total bilirubin of 15.3.",0
Patient remained pain free without signs of hepatic encephalopathy.,0
The patient was discharged home with instructions to follow-up with the liver center.,0
He was given instructions to avoid both alcohol and tylenol.,0
# Alcohol Abuse: Patient has a history of alcohol abuse of many years duration.,0
He was evaluated by psychiatry who felt presentation was consistent with alcohol and cannabis dependence.,1
He was continued on thiamine and folate.,0
He exhibited no signs of withdrawal.,0
Per the patient he intends to quit using both alcohol and cannabis.,1
# Necrotic teeth: Patient was seen by dental who noted necrotic teeth on panorex.,0
They recommended extraction when INR normalized.,0
The patient will follow-up with dental as an outpatient regarding extraction.,0
# Rash- Patient developed an erythematous papular rash while on the floor.,0
This was felt to most likely represent a drug rash possibly due to NAC.,0
All unnecessary medications were discontinued.,0
Rash was improving at the time of discharge.,0
# thrombocytopenia- Patient's platelet count was noted to trend down from 163 on admission to a nadir of 63.,0
The etiology of this drop was not known.,0
HIT antibody was positive but with a low optical density.,0
Given the clinical scenario it was felt that HIT was unlikely.,0
EBV studies demonstrated previous exposure but no current infection.,0
Ultimately it was felt presentation might be representative of low grade DIC which was slow to improve given poor liver function.,0
Platelet count trended upward to 72 on discharge.,0
He was without signs of bleeding.,0
TRANSITIONAL ISSUES - Patient will follow-up with the liver center and a new PCP and HBV viral loads were pending at the time of discharge - Patient was full code throughout this hospitalization Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Tylenol/alcohol hepatotoxicity.,1
Discharge Instructions: It was a pleasure to care for at .,0
You were admitted with liver injury due to tylenol and alcohol.,1
After treatment and supportive care your liver recovered.,0
It was noted during the admission your platelet count was low.,0
Please follow up with your primary care physician and liver specialist as an outpatient in regards to your pletelet count and liver disease.,0
You will have to wait a couple of weeks to have dental work done as your blood is thin and you are prone to bleeding.,0
Please follow up with your new primary care physician regarding this.,0
You can make a dental appointment at ( when the time is appropiate.,0
"Please follow up with the outpatient appointments below: Followup Instructions: Department: LIVER CENTER When: TUESDAY at 4:20 PM With: , MD Building: LM Bldg () Campus: WEST Best Parking: Garage Department: When: FRIDAY at 2:35 PM With: , MD Building: SC Clinical Ctr North Campus: EAST Best Parking: Garage **Dr is your new physician at .",0
"He works closely with Dr. , both will be involved in your care.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Cortisporin / Bactrim / Levofloxacin / Sertraline / Ceftriaxone / Adhesive Tape / Keflex / Bee Sting Kit / Sarna Attending: Chief Complaint: R Leg Pain Major Surgical or Invasive Procedure: arterial cannulization History of Present Illness: PCP: , - confirmed with patient, last saw PCP in .",0
"Admission Date/Time: 1:00 am 65 yo female with history of COPD, morbid obesity, DM h/o DVT/PE on coumadin with INR = 1.8 who presents with RLE pain and SOB x 1 day and cough x 3/4 weeks.",1
She first develop URI sx 4 weeks ago which manifested itself as sore throat.,0
She then developed a dry cough.,0
A LE US was a limited study but it was negative for DVT.,0
She then reported SOB and a CXR and ECG.,0
pain in the back of calf x 5 days which is worsened when transfering from her wheelchair to the BR.,0
+ SOB with exertion and coughing but no SOB at rest.,0
A limited CXR demonstrated a LL infiltrate.,0
She was tachpneic in low 20s and she was 88% on RA.,0
She received levoquin and azithromycin.,0
She says that she has an to levofloxacin which resulted in emesis.,0
She received percocet for her chronic back pain which resulted in pruritis for which she received benadryl.,0
her HR increases to 170 when she stands up.,0
Her HR improved to 130 with IVF.,0
She also received zofran 4 mg IV xT.,0
"In ER: (Triage Vitals: ) 10 97.5 98 137/72 24 96% VS on 98.1, 134, 129/74, 27, 95% on 2L NC.",0
Given a total of 3100 cc NS in the ED.,0
Morbid obesity making her wheelchair bound 2.,1
Chronic pain osteoarthritis of bilateral knees and shoulders 3.,1
PE for which she is anticoagulated 4.,0
"Type 2 diabetes - previously on insulin, currently diet controlled, but per pt on regular diet when admitted to hospital 5.",1
"Obstructive sleep apnea - on BiPAP, 4L O2 at night 6.",1
"Recurrent UTIs - followed by ID and urogynecology, has estrogen ring/pessary in place.",0
"Urinary pathogens have included pseudomonas, Klebsiella, Proteus, and E. coli (which has been highly resistant in the past).",0
10. h/o panniculitis - Previous episode with infected hematoma and complications resulting in ICU stay afterwards.,0
Anxiety 12. h/o Anemia - hemolytic anemia after Keflex 13.,0
Gout - managed with daily allopurinol 15.,0
"Atrial fibrillation- followed by Dr. Social History: Home: single, lives at home on disability; perform her ADLs, goes shopping, and gets around in her wheelchair.",1
Has a weekly housemaker who helps w/ laundry/shopping/cleaning.,0
PCA comes 2x week and gives her sponge baths.,0
"Occupation: on disability; previously employed as an administrative assistant at School of Nursing at EtOH: Rare Drugs: Denies Tobacco: quit smoking > 40 years ago Family History: Father - deceased - MI in his 40s, died in his 60s.",0
"Mother - deceased at age 65 - diabetes mellitus, leukemia Physical Exam: VS: T = 98.1 P = 98 BP 88/56 -> 98/55 RR = 24 O2Sat = 95% 2L GENERAL: Obese female sitting up in bed Nourishment: OK Grooming: well groomed Mentation: alert, speaking 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 but poor exam due to body habitus Cardiovascular: RRR, nl.",1
"Enlarged pannus with erythematous Genitourinary:defferred Skin: rashes as stated above Extremities: 2+ edema b/l, 2+ DP pulses b/l, R leg with increased erythema, and warmth compared with right.",0
No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: somewhat limited but with occasional appropriate brightening.,0
"Pertinent Results: 09:45PM WBC-8.6 RBC-3.75* HGB-12.5 HCT-39.7 MCV-106* MCH-33.2* MCHC-31.4 RDW-14.7 09:45PM NEUTS-69.7 LYMPHS-20.8 MONOS-5.5 EOS-3.5 BASOS-0.5 09:45PM PLT COUNT-271 06:28PM PT-19.4* PTT-28.6 INR(PT)-1.8* Admission LE US: DVT CXR : FINDINGS: There are low lung volumes, which accentuate cardiomegaly.",0
"Lungs are clear, without consolidation, pleural effusion or pneumothorax.",0
Degenerative changes involving the left shoulder is noted.,0
Admission ECG; ST at 116 bpm without acute changes.,0
Subsequent ECGs: atrial fibrillation CT IMPRESSION: 1.,1
"Small bibasilar opacities, left greater than right, likely atelectasis.",0
Stable pulmonary nodules measuring less than 4 mm.,0
Unchanged pulmonary arterial enlargement may reflect underlying pulmonary hypertension.,0
ECHO The left atrium is mildly dilated.,0
Premature contrast is not seen in the left heart after intravenous injection of saline (suboptimal views).,1
Mild symmetric left ventricular hypertrophy with preserved globabl systolic function.,0
No definite evidence for intracardiac shunt identified.,0
"Discharge labs: 03:34AM BLOOD WBC-12.2* RBC-3.15* Hgb-10.9* Hct-32.9* MCV-104* MCH-34.7* MCHC-33.3 RDW-14.2 Plt Ct-283 03:34AM BLOOD PT-36.1* PTT-58.7* INR(PT)-3.7* 03:34AM BLOOD Glucose-154* UreaN-23* Creat-1.1 Na-142 K-4.2 Cl-96 HCO3-34* AnGap-16 03:34AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.1 03:00PM BLOOD Type-ART O2 Flow-4 pO2-83* pCO2-53* pH-7.41 calTCO2-35* Base XS-6 Intubat-NOT INTUBA Comment-NASAL 06:28PM BLOOD proBNP-685* 09:05AM BLOOD CK-MB-5 cTropnT-0.01 proBNP-5977* 08:23PM BLOOD CK-MB-4 cTropnT-0.02* 05:04AM BLOOD CK-MB-4 cTropnT-0.02* Brief Hospital Course: The patient is a 65 year old female with MMP including morbid obesity, hypothyroidism, DM, pulmonary embolism on anticoagulation who presents with RLE pain and shortness of breath.",1
"Her intial shorntess of breath was likely multifactorial in etiology: COPD, reactive airway disease, bronchitis, CHF, OSA, obesity, hypoventilation syndrome and possible PNA.",1
She had RLE edema but US was negative for DVT and CTA was negative for PE.,0
She completed a course of treatment for CAP with 5 days of azithro.,0
She was transferred to the MICU for hypercarbic respiratory failure.,1
"At this time, she was noted to have an elevated BNP.",0
She was also in atrial fibrillation with ventricular rates to the 140s.,1
"She improved over several days with a combination of BIPAP, rate control and diuresis.",0
"For her of the pannus, she was continue nystatin powder.",0
"Her statin was continued for her hyperlipidemia, her synthroid was continued for her hypothyroidism.",1
She was treated with her home dose of cymbalta and prn ativan for her depression and anxiety.,0
Her diabetes was managed with NPH and sliding scale.,0
Her allopurinol was continued for her gout.,0
Her coumadin was continued and then held for several days for supratherapeutic INR.,0
Continued morphine SR for pain.,0
prn for DJD/chronic back pain.,0
Macrobid for recurrent UTI was stopped.,0
DIURESIS: still actively diuresing with furosemide 80mg daily.,0
Monitor lytes and creatinine and weights.,0
Will need dose adjusted when at dry weight.,0
Diuresed 11L during ICU stay.,0
COUMADIN: Anticoagulated for history of PEs.,0
Coumadin now being held for supratherapeutic INR.,0
RESPIRATORY STATUS / OSA: She requires BIPAP at night.,0
If she takes the mask off she will drop her sats.,0
BICARB: Our hypothesis is that her goal bicarb should be 28-36 (compensation for chronic CO2 retention.,0
Her code status was full.,0
"Medications on Admission: --------------- --------------- --------------- --------------- Active Medication list as of : Medications - Prescription ALBUTEROL SULFATE - (Dose adjustment - no new Rx; medication reconciliation) - 2.5 mg/0.5 mL Solution for Nebulization - 1 solution via nebulizer every 4-6 hours as needed ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 po Tablet(s) by mouth qd (30mg) DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.)",0
"- 2 Capsule(s) by mouth every morning EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector - use in case of severe reaction and call 911 (use only once) EXTRA LARGE ADULT DIAPERS - - AS DIRECTED.",0
TWICE A DAY AND AS NEEDED.,0
"METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice a day MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet Sustained Release(s) by mouth twice a day NITROFURANTOIN MACROCRYSTAL - 100 mg Capsule - 1 Capsule(s) by mouth twice a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - Tablet(s) by mouth every four (4) hours max 8 tabs per day PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.)",0
- 1 Tablet(s) by mouth twice a day RANITIDINE HCL - 300 mg Capsule - 1 Capsule(s) by mouth at bedtime SOLIFENACIN [VESICARE] - 10 mg Tablet - 2 Tablet(s) by mouth at bedtime TRAZODONE - 100 mg Tablet - 1 to 3 Tablet(s) by mouth at bedtime as needed for insomnia URSODIOL [ 250] - 250 mg Tablet - 1 (One) Tablet(s) by mouth twice a day WARFARIN - 5 mg Tablet - 1-T Q T/Thurs/Sat WARFARIN - 2.5 mg Tablet - -- Tablet(s) by mouth once a day Take as directed by Clinic .,0
"Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet - Tablet(s) by mouth every six (6) hours as needed ASCORBIC ACID [VITAMIN C] - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - USE THREE TIMES PER DAY TO TEST BLOOD SUGARS.",0
"DX CODE 250.0 CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC; ) - Dosage uncertain CYANOCOBALAMIN [VITAMIN B-12] - (OTC; ) - Dosage uncertain DIPHENHYDRAMINE HCL [BENADRYL] - (OTC; medication reconciliation) - 25 mg Capsule - 1 Capsule(s) by mouth once a day FERROUS SULFATE - (OTC; Dose adjustment - no new Rx; per pt, medication reconciliation) - 325 mg (65 mg) Tablet - take one tablet by mouth once a day LORATADINE - 10 mg Tablet - take one Tablet(s) by mouth once a day MAGNESIUM OXIDE - 400 mg Tablet - 1 (One) Tablet(s) by mouth once a day MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC; medication reconciliation) - Tablet - 1 Tablet(s) by mouth once a day Caclcium Iron Discharge Medications: 1.",0
Atorvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).,0
"Duloxetine 20 mg Capsule, Delayed Release(E.C.)",0
Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia.,0
Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
"White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for dry skin, itch.",0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath.,0
Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Zofran 4 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for nausea.,0
Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for anxiety.,0
Insulin Aspart 100 unit/mL Solution Sig: sliding scale Subcutaneous QACHS: Sliding Scale 101-150 mg/dL: 2 Units; 151-200 mg/dL 4 Units; 201-250 mg/dL 6 Units; 251-300 8 Units; 301-350 10 Units; 351-400 12 Units .,0
NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous twice a day.,0
Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: HOLD UNTIL INR < 3.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary: congestive heart failure with preserved systolic function, obstructive sleep apnea, obesity, atrial fibrillation Secondary: diabetes mellitus, history of pulmonary emboli, gout, hypertension, hypothyroidism Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: Dear Mrs. , You were admitted to the hospital with difficulty breathing.",1
You had an abnormal heart rate that likely led to fluid building up in your lungs.,0
We used a medicine to make you urinate and your breathing improved.,0
You urinated more than 10 liters.,0
We also increased your metoprolol which helped your heart rate from going too fast.,0
"Medication changes: Increase metoprolol to 50 mg three times daily Increase furosemide to 80 mg daily Stop ursodiol Stop percocet (you havent needed it here) Stop macrobid You will need to restart your coumadin Followup Instructions: Provider: NURSE Phone: Date/Time: 7:55 Provider: , DPM Phone: Date/Time: 8:20 Provider: .",0
12:22 AM CT HEAD W/O CONTRAST Clip # Reason: H/O BLEED.,0
Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with subarachnoid hemmorhage REASON FOR THIS EXAMINATION: evaluate for extension of hemorrhage PLEASE DO AT MIDNIGHT.,1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT OF THE HEAD WITHOUT CONTRAST, INDICATION: Followup for subarachnoid hemorrhage.",1
FINDINGS: Extensive right and mild left subarachnoid hemorrhage is unchanged.,1
Small amount of blood in the interpeduncular cistern is unchanged.,0
Small amount of intraventricular blood layering in the occipital horns of the lateral ventricles is equivocally increased.,0
Right frontal hemorrhagic contusion is unchanged.,0
Prominent bifrontal hypodense subdural collections are unchanged.,0
Basal cisterns are not effaced.,0
There is no sign of an acute major vascular territorial infarction.,0
"Extensive sinus opacification, right supraorbital swelling, and right proptosis is not significantly changed.",0
IMPRESSION: Little interval change from previous exam.,0
7:58 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # Reason: Are there any signs of acute or chronic pancreatitis.,1
Please Admitting Diagnosis: RESPIRATORY DISTRESS AND FEVER Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with new elevation of pancreatic enzymes in the setting of known gallbladder distention and CBD dilation.,1
REASON FOR THIS EXAMINATION: Are there any signs of acute or chronic pancreatitis.,1
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 71-year-old female with new elevation of pancreatic enzymes in the setting of gallbladder distention and CBD dilatation.,0
Evaluate for signs of acute or chronic pancreatitis.,1
TECHNIQUE: Non-contrast MDCT acquired axial images of the abdomen followed by contrast-enhanced axial images of the abdomen and pelvis from the lung bases to the pubic symphysis.,0
"CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Lung bases show small bilateral pleural effusions, right greater than left.",0
"Bilateral lower lobe opacity, may represent atelectasis versus airspace consolidation.",0
Dense coronary artery calcifications are again noted.,0
"Tip of central venous catheter is seen within the SVC, with fibrin sheath extending into the right atrium.",0
"The liver shows no focus of low atenuation in segment IV, adjacent to the falciform ligament, likely fatty infiltration.",0
Distended gallbladder measuring 5 cm in diameter contains numerous stones.,0
Small amount of pericholecystic fluid.,0
"Compared to prior exam, there is decreased dilatation of the common bile duct as it measures 7.4 mm.",0
The pancreas is relatively atrophic with no fat stranding or peripancreatic fluid to suggest pancreatitis.,0
"Small foci of low attenuation is seen within the pancreatic head, which may represent side branch IPMT or focal fat.",0
"The adrenal glands, spleen, intra- abdominal loops of large and small bowel are within normal limits.",0
"Kidneys are relatively atrophic, unchanged.",0
"A subcentimeter low- density lesion is seen within the upper pole of the right kidney, too small to characterize.",0
Percutaneous gastrostomy tube is in situ.,0
"No free air, free fluid or lymphadenopathy.",0
Extensive vascular calcifications are seen throughout the aorta and branch vessels including splenic artery.,0
It is noteworthy also to mention calcification at the ostium of the bilateral renal arteries and take off of the SMA.,0
"Mild thickening of the distal esophagus, which may relate to recent NG tube.",0
"CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, intrapelvic loops of small bowel are within normal limits.",0
The uterus and adnexa are within normal limits.,0
No free fluid or lymphadenopathy.,0
(Over) 7:58 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # Reason: Are there any signs of acute or chronic pancreatitis.,1
Please Admitting Diagnosis: RESPIRATORY DISTRESS AND FEVER Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) BONES AND SOFT TISSUES: Diffuse anasarca and muscle wasting.,1
Large sacral decubitus ulcer with stranding of the subcutaneous tissues.,1
The bones are diffusely osteopenic.,0
No suspicious sclerotic or lytic lesion.,0
Compression deformity of L1 and grade I anterolisthesis of L4 on L5.,0
Multilevel degenerative changes involving the thoracolumbar spine.,0
"Large distended gallbladder containing multiple stones, unchanged.",0
"Compared to prior exam, the diameter of the CBD is decreased in size.",0
Pancreas enhances homogeneously without evidence of pancreatitis or adjacent fluid.,0
"Foci of low attenuation in the pancreatic head, which may represent side branch IPMT or focal fat, unchanged from .",0
Recommend followup in 6 months to assess for stability.,0
Fibrin sheath around tip of SVC catheter.,0
"Ill defined area of low attenuation in the liver adjacent to the falciform ligament, likely represents focal fatty infiltration.",0
"Mild distal esophageal wall thickening, may be related to recent NG tube.",0
Left lower lobe atelectasis versus airspace consolidaiton.,0
"10:59 AM ANKLE (2 VIEWS) LEFT PORT Clip # Reason: crepitus L lat malleolus on exam ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with s/p multi trauma REASON FOR THIS EXAMINATION: crepitus L lat malleolus on exam ______________________________________________________________________________ FINAL REPORT LEFT ANKLE, TWO VIEWS: HISTORY: Trauma, with crepitus over malleolus.",0
There is soft tissue swelling laterally.,0
Linear radiodensity overlying soft tissues lateral to the malleolus is likely an artifact but repeat films with better detail may be helpful to evaluate.,0
The ankle joint is grossly normal.,0
"6:59 AM CHEST (PORTABLE AP) Clip # Reason: eval for status of effusions and ?infiltrate Admitting Diagnosis: PERICARDIAL EFFUSION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with tachypnea, hypoxia, s/p thoracentesis at OSH REASON FOR THIS EXAMINATION: eval for status of effusions and ?infiltrate ______________________________________________________________________________ FINAL REPORT AP CHEST 8:04 A.M HISTORY: Tachypnea, hypoxia following thoracentesis.",0
IMPRESSION: AP chest compared to and earlier on at 2:15 a.m.,0
Moderately severe pulmonary edema has worsened since 2:15 a.m. Small to moderate left and moderate right pleural effusion are stable.,0
"A pericardiocentesis catheter projects over the cardiac apex, unchanged in position.",0
"Heart is normal size and mediastinal drains are unchanged, top normal caliber.",0
8:18 AM CAROT/CEREB Clip # Reason: 65 year old woman with SAH of unknown origin.,0
Eval for vascu Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 100ML OPTI240; 78ML OPTI320 ********************************* CPT Codes ******************************** * SEL CATH 2ND ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT * * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with SAH of unknown origin.,1
Eval for vascular abnormality REASON FOR THIS EXAMINATION: 65 year old woman with SAH of unknown origin.,0
"Eval for vascular abnormality ______________________________________________________________________________ FINAL REPORT HISTORY: Recent presentation of subarachnoid hemorrhage of unknown origin, CTA showed no aneurysms, recent cerebral angiogram of showed suboccipital epidural aVF.",1
INDICATION: Assess for source of bleeding.,0
ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl and Versed throughout the total intraservice time of 40 minutes during which the patient's hemodynamic parameters were continuously monitored.,0
"PROCEDURE PERFORMED: Left vertebral artery arteriogram, left common carotid artery arteriogram, and right common carotid artery arteriogram.",0
"ATTENDING: NEURORADIOLOGIST FELLOW: Ramachandran, MB, MRCP, FRCR.",0
"DETAILS OF THE PROCEDURE: Oral informed consent was obtained from the patient's relative after explaining the risks, benefits and alternative management.",0
The patient was brought to the neurointerventional suite and placed in the supine position on the biplane angio table.,0
"Following this, anesthesia was induced and the patient groin was prepped and draped in the standard sterile fashion.",0
A preprocedure timeout was performed using two different identifiers.,0
"Using local anesthetic into the right groin, access was gained into the right common femoral artery.",0
"Using Seldinger technique, a 5 French vascular sheath was successfully placed through the right common femoral artery and connected to continuous drip of heparin and saline mixture.",0
"Through the sheath, using 2 catheter and with the aid of 0.038 angled Glidewire connected to continuous pressure and drip of heparin and saline mixture, the above-mentioned arteries were catheterized.",0
AP and lateral filming was done.,0
"Following this, the right femoral artery puncture site was closed with Angio-Seal device to achieve adequate hemostasis.",0
There were no post-procedure complications.,0
FINDINGS: (Over) 8:18 AM CAROT/CEREB Clip # Reason: 65 year old woman with SAH of unknown origin.,0
"Eval for vascu Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 100ML OPTI240; 78ML OPTI320 ______________________________________________________________________________ FINAL REPORT (Cont) LEFT VERTEBRAL ARTERY: The left vertebral artery injection demonstrated filling of both posterior cerebral, superior cerebellar arteries, AICA and left PICA with normal distal runoff.",1
Left vertebral artery injection demonstrated subtle filling of an arteriovenous fistula fed by a musculo spinal arterial branch of left V3/V4 segment and draining via extracranial route into the suboccipital venous plexus.,0
The feeding artery appears to arise proximal to the left PICA origin.,0
There is retrograde filling of the posterior fossa venous plexus.,0
"RIGHT COMMON CAROTID ARTERY: The right common carotid artery injection demonstrated normal filling of the anterior cerebral and middle cerebral arteries, and external carotid artery branches with normal distal runoff.",0
The capillary and venous phases were unremarkable.,0
"LEFT COMMON CAROTID ARTERY: The left common carotid artery injection demonstrated normal filling of the anterior cerebral and middle cerebral arteries, showing normal caliber and external carotid artery branches with normal distal runoff.",0
The capillary and venous phases are unremarkable.,0
IMPRESSION: Small suboccipital epidural arteriovenous fistula fed by musculo spinal arterial of left V3/V4 vertebral segment with venous drainage into the suboccipital extracranial venous plexus.,0
"Intracranially, there is retrograde filling of the posterior fossa venous plexus.",0
Images were discussed with Dr .,0
Recommended follow up MRI and MRA brain and cervical spine.,0
"4:44 AM CHEST (PORTABLE AP) Clip # Reason: interval changes Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman intubated with sepsis, suspected aspiration pneumonia REASON FOR THIS EXAMINATION: interval changes ______________________________________________________________________________ FINAL REPORT HISTORY: Possible aspiration pneumonia.",1
"FINDINGS: In comparison with the study of , there is again diffuse area of increased opacification in the right lung, consistent with aspiration pneumonia.",0
A developing area in the left lower lung zone could well be the same etiology.,0
Endotracheal tube tip lies approximately 3.5 cm above the carina.,0
Right IJ catheter again extends to the lower portion of the SVC.,0
1:10 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for dobhoff placement Admitting Diagnosis: PULMONARY EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with new dobhoff for feeding REASON FOR THIS EXAMINATION: eval for dobhoff placement ______________________________________________________________________________ FINAL REPORT STUDY: AP chest radiograph.,0
COMPARISON EXAM: AP chest radiograph .,0
FINDINGS: There is placement of a Dobbhoff in satisfactory position in the stomach.,0
There remains a left PICC with tip terminating in the mid SVC and a Port-A-Catheter with tip terminating in the cavoatrial junction.,0
"There remains diffuse bilateral lung opacities, stable compared to prior exam.",0
The cardiomediastinal and hilar silhouettes remain stable.,0
IMPRESSION: Satisfactory placement of Dobbhoff tube with tip in the stomach.,0
"5:41 PM CHEST (PORTABLE AP) Clip # Reason: Please do x-ray at 5:15pm, after dialysis.",0
"Thank you., Pleas ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with VF arrest, ESRD, CAD, and GI bleed, intubated.",0
Please do X-ray at 5:15pm after dialysis.,0
"REASON FOR THIS EXAMINATION: Please do x-ray at 5:15pm, after dialysis.",0
Please assess infiltrate once dialysis has hopefully improved pleural effusions.,0
"______________________________________________________________________________ FINAL REPORT INDICATIONS: Evaluate post dialysis in patient status post VF arrest with ESRD, CAD and GI bleed, now intubated.",0
AP radiograph dated at 17:40 is compared with AP film dated at 7:19.,0
The endotracheal tube remains in satisfactory position.,0
The left subclavian cortis appears kinked where it overlies the lateral left thoracic cavity.,0
The dual lumen right subclavian catheter is unchanged in position.,0
There is slight clearing of the diffuse ill defined pulmonary infiltrate.,0
There is persistent left lower lobe consolidation/collapse.,0
The right costophrenic angle is not included in the radiograph.,0
IMPRESSION: Slight clearing of diffuse ill defined pulmonary infiltrate consistent with slight improvement in left heart failure.,1
Persistent left lower lobe consolidation/collapse.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Fatigue Major Surgical or Invasive Procedure: Hemodialysis Placement of temporary coronary sinus pacing wire Placement of permanent pacemaker Central venous intrajugular line Femoral venous line for dialysis Femoral venous sheath for pacing wire placement History of Present Illness: Mrs. is an 84 year old female with history of CLL, HTN, lymphedema of LE, atrial fibrillation, and HCV, who is sent in by her PCP for symptomatic bradycardia and creatinine elevation.",1
"The patient says that she first noted fatigue and weakness on , in addition to increase in her baseline shortness of breath.",0
"At that time she spoke with Dr. , her PCP, scheduled her for an echocardiogram.",0
"She says that on the day prior to admission, while walking with a home physical therapist, she felt extremely weak and her pulse was found to be 40, with a BP of 85/40, per report from the patient.",0
She came in for her scheduled echo on the day of admission and again felt lightheaded.,0
"Her pulse was noted to be as low as the 30s at times, and she was sent to the ED.",0
"The patient denies recent medication changes, and says that her weight has been stable.",0
"Additionally, the patient says that she has recently been treated for a UTI with bactrim.",0
"She first noted difficulty urinating about 2 months prior to admission, at which time she had urgency, but decreased urine output.",0
"She was found to have a UTI and treated with Bacrim, however symptoms recurred recently and she was treated with a second course of abx which she just finished on the day prior to admission.",0
"She denies any increase in thirst, but she continues to have decreased urine output.",0
"Denies fevers/chills, changes in urinary color, dysuria.",0
"In the ED her HR ranged in the 30s to 50s, with sbp 80-100.",0
"She was afebrile, with O2 sat 100% on RA.",0
"She recieved one dose of ASA 325 mg, and a 500 CC bolus of NS, with 50 cc urine output.",0
"Past Medical History: 1) Chronic lymphocytic leukemia 2) Hypertension 3) Paroxysmal atrial fibrillation, on amiodarone since .",1
Gets palpiations with atrial fibrillation though not consistently.,1
Had a holter in that did not demonstrate atrial fibrillation.,1
4) Hepatitis C 5) Irritable bowel syndrome 6) Anxiety 7) Status post cholecystectomy 8) Status post hysterectomy Social History: Patient lives in senior apartment in with her husband.,0
She denies any smoking history of alcohol use.,0
Family History: No family history of CAD.,0
"Physical Exam: VS: 94.8, 89/27, 35, 14, 100% on RA Gen: Overweight russian speaking female, lying flat in bed, appearing comfortable and non-tachypneic.",0
Neck: JVP difficult to evaluate secondary to obesity.,0
"Cor: RR, bradycardic, distant heart sounds.",0
Lungs: Rales at bases b/l.,0
"Abd: NABS, soft, NT/ND, non-palpable liver/spleen.",0
"Extr: Massive pitting edema b/l with hyperpigmentation, skin fissuring and thickening.",0
8:56 am BLOOD CULTURE Site: A LINE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): 11:15 am URINE Site: CATHETER **FINAL REPORT ** URINE CULTURE (Final ): NO GROWTH.,0
4.The mitral valve leaflets are mildly thickened.,0
CXR : IMPRESSION: No acute cardiopulmonary process.,0
A follow-up PA and lateral set of radiographs might be helpful if there is continuing clinical concern for pneumonia.,0
EKG : Sinus bradycardia with top normal P-R interval of 200 milliseconds.,0
Possible left anterior fascicular block.,0
Compared to the previous tracing of cardiac rhythm is now sinus mechanism.,0
Multiple other abnormalities as previously noted persist without major change.,0
Renal US : RENAL ULTRASOUND: The right kidney measures 9.7 cm.,1
The left kidney measures 9.7 cm.,0
There is a Foley catheter within the urinary bladder.,0
Compared to the previous tracing no major change.,0
CXR : Temporary transvenous femoral pacemaker terminates in the region of the tricuspid valve.,0
Left basilar subsegmental atelectasis versus early infiltrate.,0
CXR : IMPRESSION: Satisfactorily placed cardiac pacemaker.,0
R Hip x-ray : IMPRESSION: No evidence of right hip fracture.,0
EKG : Atrial paced rhythm.,0
Intraventricular conduction delay - probable atypical left bundle branch block.,0
Consider prior anteroseptal myocardial infarction.,0
"Since previous tracing of , atrial pacing seen.",0
CXR : IMPRESSION: Small bilateral pleural effusions with associated compressive atelectasis.,0
"Brief Hospital Course: 84 year old female with history of CLL, HTN, lymphedema of LE, atrial fibrillation, and HCV, who was sent in by her PCP for symptomatic bradycardia and creatinine elevation.",1
"In brief, she had an AV pacer placed in house, with normalization of her blood pressure and renal function subsequently.",0
"She was started on epogen for her anemia, attributed to her chronic renal insufficiency, however she may not need this in the future.",1
"1) Bradycardia: The patient had a history of PAF, and presented with symptomatic bradycardia, taken together likely representing sick sinus syndrome.",0
"However, the patient was on amiodarone and a beta blocker, and given her renal failure on admission, she may have had impaired clearance of her BB, further contributing to her bradycardia.",1
"She was hypotensive to systolic of 80s on admission, however asymptomatic, and was therefore kept on the floors overnight with an attempt at bringing up her blood pressure with IVF, and awaiting clearance of the beta blocker.",0
"Unfortunately the following morning she was becoming hypoxic from fluid overload, and her heart rate had not improved.",0
"The patient was therefore transferred to the CCU, where she was started on a dopamine drip with little resultant increase in blood pressure or heart rate.",0
"This refractoriness did not respond over several days, making beta blocker toxicity less likely as an etiology and indicating a likely underlying sinus node/conduction dysfunction.",0
"A temporary pacemaker was placed, followed by a permanent pacemaker (DDI at 75 bpm).",0
"Post-procedure she had an episode of afib, which was also complicated by a pacemaker sensing error and wide complex tachycardia from pacing.",0
"Given her PAF, she was restarted on coumadin for anticoagulation, which she should continue for the time being.",0
"If she is found to be in sinus rhythm and stays that way for a prolonged period of time, her PCP and Dr. can considering stopping the coumadin, as the patient is reluctant to be on it again.",0
"She was restarted on her amiodarone, as well as the atenolol, both at her outpatient doses.",0
"She remained atrial paced during the admission, however her pacer does not guarantee that she will not go into paroxysmal A-fib.",0
"2) Pump: Her echo on admission showed normal EF, however it may actually be lower given her MR. She had massive LE edema, with chronic changes, however this did improve significantly during the hospitalization, implying that she was volume overloaded on admission.",0
"The patient was hypotensive even on the dopamine (although this was likely inability to increase the heart rate), and was given large amounts of fluids to maintain her BP while in the CCU.",0
"Post-PPM placement, she was felt to be fluid overloaded with sat's decreasing occasionally into the low 90s, and was given multiple doses of 40-80 mg IV lasix.",0
Shortly after pacer placement she began auto-diuresing (polyuric phase ATN--see below) and became quite negative (4.6L Urine output on ).,0
"However, on transfer to she remained fluid overloaded by exam and CXR and therefore received 1 more dose of IV lasix prior to being switched over to her usual daily dose of 40 mg PO BID, which she will be discharged on.",0
"She had an oxygen saturation of 98% on RA on the day of discharge, and did not desaturate with ambulation.",0
3) Ischemia: Not an active issue during this hospitalization.,0
"She had no enzyme elevation, no chest pain, echo without evidence of ischemic changes.",0
She was continued on ASA 81 mg daily.,0
"4) Acute renal failure: Her creatinine had increased from 1.8 in to 3.3 on admission, most likely in the setting of decreased renal perfusion from hypotensive bradycardia.",1
"On transfer to the CCU, she was in frank oliguric ATN and over the next couple of days required hemodialysis once due to concerns of increasing acidosis and hypervolemia.",0
"Upon pacemaker placement, her urine output improved and her creatinine decrease back to around her baseline of 1.6 - 1.8.",0
"She continued to have satisfactory urine output on the floors, with creatinine decreasing to 1.4 on the day of discharge.",0
"Given that her kidney has just recovered, she was sent home on half of her usual dose of lisinopril (20 mg daily) - additionally, her blood pressure was well controlled on the lower dose.",0
5) Thrombocytopenia: Stably low platelets in the setting of CLL.,0
"HIT ab was sent, which was negative.",0
"6) Anemia: The patient was anemic throughout the hospitalization, with hct ranging around 30.",0
"This was felt secondary to her chronic renal insufficiency, and she was therefore started on epogen by the renal team.",1
"Given that her renal function has improved markedly since her pacer placement, to 1.4 which is better than it has been in over a year, she may not continue to require epogen.",0
"She will have her hematocrit checked by Dr. when he sees her in clinic, and monthly thereafter while she remains on the epogen.",0
"7) R Hip Pain: The patient complained of R hip pain with weight bearing, however there was no tenderness on palpation of the region, and a hip x-ray was negative for fracture.",0
"It is unclear what is causing this hip pain, however she was able to ambulate with physical therapy.",0
"She is encouraged to take advil sparingly for this pain, as needed.",0
"Medications on Admission: ACETAMINOPHEN 500MG--2 capsules four times a day as needed AMIODARONE HCL 200MG--3 tabs every day x 14 days then one tablet every day AMLODIPINE BESYLATE 10MG--One tablet every day ASPIRIN 81MG--One tablet every day ATENOLOL 25 MG--One tablet in morning, tablet in evening CELEBREX 200MG--One by mouth q day CELEXA 40MG--One tablet every morning CLONAZEPAM 2MG--One tablet at bedtime FLUOCINONIDE 0.05%--Apply 1-2 times daily to legs FUROSEMIDE 40MG--One tablet twice a day HYOSCYAMINE SULFATE 0.125MG--One tablet as needed ISOSORBIDE MONONITRATE 60 mg--1 tablet(s) by mouth every morning Incontinence Liner --use as directed for incontinence LISINOPRIL 40 MG--One tablet every day PRILOSEC 20 MG--One daily outside md PROTONIX 40MG--One a day SERAX 10MG--One daily as needed for nerves SPIRONOLACTONE 25MG--One tablet every day Discharge Medications: 1.",0
Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for bladder spasm.,0
Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).,0
Amlodipine Besylate 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: The coumadin clinic will change your dose according to your blood tests.,0
"Atenolol 25 mg Tablet Sig: One (1) Tablet PO See below: Take one tablet in the morning, tablet in the evening.",0
"Epogen 3,000 unit/mL Solution Sig: One (1) mL Injection once a week.",0
Disp:*8 syringes filled* Refills:*2* 14.,0
Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed.,0
"Discharge Disposition: Home With Service Facility: , Discharge Diagnosis: Sick Sinus Syndrome Acute on Chronic renal failure requiring dialysis Hypotension secondary to bradycardia Urinary tract infection Anemia secondary to chronic renal failure Discharge Condition: Good Discharge Instructions: You have the appointments below, with Dr. (Nephrology), Dr. for your heart, and Dr. .",1
We have started two new medications.,0
"One is called coumadin, which you have been on in the past.",0
"You will need to follow up in coumadin clinic to have your blood drawn every few days in the beginning, and then less frequently once you are on a stable dose of coumadin.",0
"The other new medication is called epogen, which is a subcutaneous injection once a week.",0
"The home health aid will help you with this, and Dr. , the kidney doctor, will check your blood when he sees you at the appointment listed below.",0
This medication will help to keep your blood level up.,0
We have also decreased your lisinopril dose to 20 mg daily (you were on 40).,0
"Otherwise, resume all of your previous medications, including lasix 40 mg twice a day, and amiodarone 200 mg once a day.",0
"Followup Instructions: Provider: CLINIC Where: CARDIAC SERVICES Phone: Date/Time: 3:00 Provider: , MD Where: Phone: Date/Time: 9:40 A.M.",0
"Where: MEDICAL SPECIALTIES Phone: Date/Time: 3:30 Provider: , M.D.",0
"Where: CARDIAC SERVICES Phone: Date/Time: 1:45 Provider: , M.D.",0
Where: CENTER Phone: Date/Time: 2:00,0
12:03 AM CT C-SPINE W/O CONTRAST Clip # Reason: please eval for fx ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with found down and SAH REASON FOR THIS EXAMINATION: please eval for fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: AGLc TUE 12:51 AM no acute injury seen in c-spine.,0
patchy vascular enhancement seen from contrast given for CTA head.,0
airspace consolidation seen in posterior lung apices with smooth septal thickening.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 52-year-old female found down with subarachnoid hemorrhage seen at outside hospital.,1
TECHNIQUE: MDCT axial imaging is performed through the cervical spine without administration of IV contrast.,0
"CT C-SPINE: IV contrast material is seen within vascular structures, from IV contrast administered for CTA head performed just prior to the exam.",0
An ET tube and left nasal NG tube is seen in place.,0
"The imaged skull base through the top of T2 demonstrates no evidence of acute fracture, malalignment, or paravertebral hematoma.",0
"High-density material is seen along the neural foramina at C6-7 and C7-T1 bilaterally, likely representing IV contrast material enhancing vascular structures.",1
High-density extra-axial material is seen in the limited views of the basal cisterns and anterior to the brainstem and upper spinal cord.,0
The visualized maxillary sinuses and mastoid air cells are normally aerated.,0
Lymph nodes in the neck are small.,0
Views through the lung apices show bilateral airspace consolidation in the lungs posteriorly along with smooth septal thickening.,0
No acute traumatic injury seen in the cervical spine.,0
Blood in the basal cisterns tracking inferiorly and anteriorly along the brainstem and upper spinal cord.,0
Thecal sac contents are not adequately assessed on the present study.,0
MR can be considered if there is concern based on neurological examination.,0
Airspace consolidation in the posterior lung apices with smooth septal thickening.,0
"Findings along with chest radiograph likely represents some pulmonary edema, although aspiration cannot be excluded.",0
(Over) 12:03 AM CT C-SPINE W/O CONTRAST Clip # Reason: please eval for fx ______________________________________________________________________________ FINAL REPORT (Cont),0
6:28 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: Eval interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 82F with right parietal/occipital parenchymal hemorrhage c/w amyloid angiopathy.,0
REASON FOR THIS EXAMINATION: Eval interval change No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa WED 7:58 PM 1.,0
No significant change in right occipital hemorrhage with persistent 2 mm shift towards the left.,0
Small amount of subarachnoid hemorrhage is also stable.,0
No new hemorrhage is identified.,0
"Small calcified meningioma, stable in the left frontoparietal region.",0
FINDINGS: A 5.5 x 2.9 cm right parietal and occipital hemorrhage is unchanged in size when compared to prior exam.,0
"There is surrounding vasogenic edema, similar in appearance.",0
Effacement of the posterior right lateral ventricle and sulcal effacement is similar in appearance.,0
"There is persistent shift of normally midline structures towards the left by approximately 2 mm, unchanged.",0
The suprasellar and ambient cisterns are patent.,0
There is no evidence of uncal or tonsillar herniation.,0
Small amount of subarachnoid hemorrhage in the right parietal lobe is similar in appearance.,0
Again identified is a calcified meningioma in the left frontal region measuring approximately 1.1 x 1.2 cm.,0
Periventricular white matter and subcortical white matter hypodensities are likely consistent with chronic small vessel ischemic changes.,0
Slight prominence of bifrontal extra-axial CSF spaces are similar in appearance.,0
(Over) 6:28 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: Eval interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont),0
Height: (in) 74 Weight (lb): 208 BSA (m2): 2.21 m2 BP (mm Hg): 103/79 HR (bpm): 110 Status: Inpatient Date/Time: at 16:56 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
"Compared with the report of the prior study (images unavailable for review) of , the severity of aortic regurgitation is decreased (may be related to the tachycardia on the current study).",0
9:00 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?,0
Interval change Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with intbation/sedation tachypnea tchycardia and dropping Sp02 REASON FOR THIS EXAMINATION: ?,1
Interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Dropping oxygen sat.,0
"CHEST, SINGLE AP PORTABLE VIEW Lines and tubes appear stable.",0
"There is dense alveolar opacity throughout much of the left lung and throughout a good portion of the right lung, with air bronchograms visible on the left.",0
"Probable small bilateral effusions, larger on the right.",0
"Compared with earlier the same day, the degree of opacification may be very slightly worse, but is likely accentuated by differences in technique.",0
"12:05 AM UNILAT LOWER EXT VEINS LEFT PORT Clip # Reason: bedbound patient w/ new very localized left thigh pitting e Admitting Diagnosis: LUNG CA LEFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with REASON FOR THIS EXAMINATION: bedbound patient w/ new very localized left thigh pitting edema ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old bed-bound with left-side edema, assess for DVT.",1
"LEFT LOWER EXTREMITY VENOUS ULTRASOUND: scale and pulse color doppler images of the left common femoral, greater saphenous, superficial femoral, and popliteal veins was performed.",0
"There is normal compressibility, color flow, waveforms, and augmentation.",0
IMPRESSION: No DVT in the left lower extremity.,0
"11:17 AM CHEST (PORTABLE AP) Clip # Reason: s/p Dobhoff placement Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with CVA on coumadin REASON FOR THIS EXAMINATION: s/p Dobhoff placement ______________________________________________________________________________ FINAL REPORT STUDY: AP CHEST, .",0
HISTORY: A 74-year-old woman with CVA and is on Coumadin.,0
FINDINGS: The left-sided pacemaker is unchanged.,0
There remains a Dobbhoff tube whose distal tip is beyond the gastroesophageal junction.,0
"Since the prior study, there has been development of focal consolidation within the right mid lung zone.",1
This could be secondary to aspiration or pneumonia.,0
There remains mild pulmonary interstitial edema.,0
A small right-sided pleural effusion is again seen.,0
11:27 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: recent removal of chest tube.,0
Admitting Diagnosis: SCOLIOSIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with see above.,0
REASON FOR THIS EXAMINATION: recent removal of chest tube.,0
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 35-year-old female with recent removal of chest tube.,0
AP chest radiograph compared to the exam from five hours prior demonstrate removal of left-sided chest tube.,0
"The remainder of the exam including moderate right, small left pleural effusions and retrocardiac atelectasis is unchanged.",0
Endotracheal tube is obscured by overlying rods.,0
Tip of NG tube is seen within the stomach.,0
Surgical staples project over the thorax and abdomen.,0
"7:19 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: VOMITING ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with COPD, tachypnea, tachycardia REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 12:02 PM Mild improvement of right lung pneumonia.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: COPD, tachypnea and tachycardia.",0
FINDINGS: Right lung opacity due to pneumonia has mildly improved since .,0
No new consolidation is seen.,0
IMPRESSION: Mild improvement of right lung pneumonia.,0
"6:39 AM CHEST (PRE-OP AP ONLY) Clip # Reason: END STAGE LIVER DISEASE Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with cirrhosis,fatigue, preop liver tx REASON FOR THIS EXAMINATION: pre-op liver tx ______________________________________________________________________________ FINAL REPORT INDICATION: End-stage liver disease, preenting for pre-operative assessment for liver transplant.",1
CHEST X-RAY: A single AP view was obtained.,0
Comparison is made to prior study of .,0
12:37 PM CHEST (PORTABLE AP) Clip # Reason: eval ptx s/p CT d/c Admitting Diagnosis: CAROTID STENOSIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p CABG REASON FOR THIS EXAMINATION: eval ptx s/p CT d/c ______________________________________________________________________________ FINAL REPORT HISTORY: Status post CABG and removal of chest tube.,1
"FINDINGS: In comparison with the study of , the endotracheal tube, Swan-Ganz catheter, nasogastric tube, and chest tube and mediastinal leads have all been removed.",0
Some increased opacification at the bases is consistent with bilateral atelectatic change and/or pleural effusion.,1
"5:23 AM CHEST (PORTABLE AP) Clip # Reason: N/V with SOB r/o PNA and Free air ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with REASON FOR THIS EXAMINATION: N/V with SOB r/o PNA and Free air ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW HISTORY: Nausea, vomiting, shortness of breath.",0
FINDINGS: The NG tube has been removed.,0
"Given technique, the cardiac silhouette is normal to upper limits of normal in size.",0
There is no infiltrate or effusion.,0
"7:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with multiple myeloma, with a new high oxygen requirement REASON FOR THIS EXAMINATION: evaluate for interval change ______________________________________________________________________________ FINAL REPORT SINGLE VIEW CHEST X-RAY.",0
"INDICATION: 55-year-old female, multiple myeloma with shortness of breath.",0
TECHNIQUE: Portable upright AP x-ray was obtained.,0
COMPARISON: Chest x-ray dated and CT torso .,0
FINDINGS: A right IJ dual-lumen catheter is seen with the tip at the distal superior vena cava.,0
The cardiac borders are indistinct and the hila are prominent.,0
"Diffuse new interstitial opacities seen throughout the lungs, greater on the right when compared to the left.",0
These findings are suggestive of edema versus infection.,0
Rib deformity from remote fracture is seen in the left fifth rib laterally.,0
IMPRESSION: Findings suggestive of diffuse interstitial edema versus infection.,0
1:00 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: r/o DVT in RUE Admitting Diagnosis: PYELONEPHRITIS;ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with h/o MM and h/o DVTs in RUE and RLE presents with urosepsis now has L arm larger than R arm.,1
"REASON FOR THIS EXAMINATION: r/o DVT in RUE ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old female with history of multiple myeloma and history of DVTs in right upper and right lower extremity, now with left upper extremity swelling.",1
Rule out left upper extremity DVT.,0
"LEFT UPPER EXTREMITY ULTRASOUND WITH DOPPLER: Grayscale, color flow, and Doppler ultrasound of the left internal jugular, subclavian, axillary, basilic, and cephalic veins were performed.",0
"Normal flow, augmentation, compressibility, and waveforms were demonstrated.",0
No intraluminal thrombus was seen.,0
IMPRESSION: No left upper extremity DVT.,0
3:45 AM CHEST (PORTABLE AP) Clip # Reason: eval for int change Admitting Diagnosis: CELLULITIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with resp failure REASON FOR THIS EXAMINATION: eval for int change ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP on .,1
"HISTORY: 66-year-old woman with respiratory failure, evaluate for interval change.",1
FINDINGS: The large opacity representing a cyst/bulla projecting over the left mid and lower lung is unchanged.,0
A left side catheter is again seen with no change in its course.,0
There is slight increase in the right lower lobe atelectasis.,0
The remainder of the right lung is otherwise clear.,0
An abnormal lucency is seen projecting over the left lung base.,0
The left upper lung is unremarkable.,0
A left-sided PICC and tracheostomy are unchanged in position.,0
Lucency in the left lung base which could represent a new developing subpulmonic pneumothorax and less likely a reexpanded left lung parenchyma.,0
Other radiographic abnormalities are stable.,0
Followup chest x-ray in the upright position is advised.,0
5:07 PM CT HEAD W/O CONTRAST Clip # Reason: please eval for bleed or CVA Admitting Diagnosis: CONGESTIVE HEART FAILURE;ATRIAL FIBRILATION ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with CHF s/p extubation with hypoventilation REASON FOR THIS EXAMINATION: please eval for bleed or CVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT CONTRAST.,1
"INDICATION: 74-year-old man with CHF, status post extubation with hypoventilation, please evaluate for bleed or stroke.",0
TECHNIQUE: MDCT-acquired contiguous axial images of the head were obtained without intravenous contrast.,0
"FINDINGS: There is no evidence of infarct, masses, mass effect, or edema.",0
There is mild prominence of the sulci consistent with cerebral atrophy.,0
IMPRESSION: No evidence of intracranial hemorrhage or infarct.,0
7:30 AM CHEST (PORTABLE AP) Clip # Reason: pre extubation ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with REASON FOR THIS EXAMINATION: pre extubation ______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative chest follow up.,0
"The ET tube, NG tube, left subclavian line, right cordis, and swan ganz catheter are appropriately positioned.",0
There is calcification and tortuosity of the aorta.,0
The heart is stable in size.,0
There is blunting of the right costophrenic angle probably representing a small pleural effusion.,1
There are clips and drainage cathaters overlying the upper abdomen.,0
IMPRESSION: Small new right sided pleural effusion.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p stab wound to left post axilla,left flank region Splenic injury Major Surgical or Invasive Procedure: s/p exploratory laparotomy s/p splenectomy History of Present Illness: 36 yo male s/p stab wound to left post chest/left flank, unresponsive at scene with intermitt combativeness; intubated at scene.",1
Past Medical History: Hepatitis B & C Social History: Currently homeless; resides in shelter.,0
"Has girlfriend who is reportedly pregnant Family History: Noncontributory Physical Exam: Gen- Unresponsive HEENT- EOMI Neck- + JVD; trachea midline, cervial collar in place Chest - + crepitus left chest Cor- tachycardic Abd- flat, soft Skin- diaphoretic Neuro- responds to pain Pertinent Results: 11:34PM LACTATE-3.2* 11:06PM GLUCOSE-119* UREA N-8 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16 11:06PM ALT(SGPT)-44* AST(SGOT)-54* ALK PHOS-67 AMYLASE-29 TOT BILI-0.5 11:06PM LIPASE-23 11:06PM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-3.4 11:06PM WBC-7.4 RBC-4.17* HGB-12.8* HCT-36.9* MCV-89 MCH-30.6 MCHC-34.5 RDW-14.2 11:06PM PLT COUNT-177 11:06PM PT-13.0 PTT-28.0 INR(PT)-1.1 Brief Hospital Course: Patient admitted to trauma service; intial chest xray revealed small left pneumothorax, chest tube placed.",1
"Patient taken to OR on for exploratory lap and splenectomy, he recived 4 units fresh frozen plasma and 2 units packed red cells in OR.",0
"Began clear liquids, diet advanced as tolerated.",0
Changed to oral pain medication.,0
Chest tube removed without complication.,0
Stab wounds and chest tube site dressed with dry sterile dressings.,0
"Ex lap incision staples remained in place, to be taken out at Trauma clinic in 1 week.",0
"Prior to discharge was vaccinated w/ pneumovax, meningococc, H.flu vaccinations & given Rx for Amox 3g to take if fever.",0
Medications on Admission: Unknown Discharge Medications: 1.,0
Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.,0
Amoxicillin 500 mg Capsule Sig: Six (6) Capsule PO once for fever >101: If you develop fever take all 6 tabs immediately and go to Emergency Department.,0
"Disp:*6 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: , Discharge Diagnosis: s/p stab wound s/p splenectomy Discharge Condition: Stable Discharge Instructions: *Should you develop fever over 101 degrees you should take the 6 Amoxacillin tabs prescribed for you and go to nearest emergency room immediately.",0
Avoid heavy lifting or any strenuous activities for next weeks.,0
Be sure to keep your followup appointment with Trauma Clinic.,0
Avoid contact with people who may have a cold.,0
"Followup Instructions: Follow up in Trauma Clinic in 2 weeks , call for an appointment",0
She underwent a revision decompression and beginning of re-instrumentation without complication.,0
She developed acute post-op blood loss anemia post-op but was found to have a rare blood type and was not able to adequately cross-matched.,1
A delay in the second stage was determined to be the safest course of action for her.,0
She was able to be mobilized on oral pain meds with a walker.,0
Her posterior incision is healing well with no signs of infection.,0
Medications on Admission: Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).,0
Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
"Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection MWF (Monday-Wednesday-Friday).",0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed.",0
"Disp:*60 Tablet, Chewable(s)* Refills:*0* 10.",0
Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours).,0
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Thoracolumbar kyphosis Discharge Condition: Stable Discharge Instructions: Please continue to take your pain medication with an over the counter laxative.,1
Call the clinic if you notice any redness or discharge from the incision site.,0
Call the clinic for any additional concerns.,0
Followup Instructions: Please follow up in the Spine Clinic during your previously scheduled appointments.,0
1:08 PM ABDOMEN (SUPINE ONLY) Clip # Reason: eval NGT plcmt Admitting Diagnosis: ISCHEMIC RIGHT LEG ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man s/p R-AKA now with questionable NGT plcmt REASON FOR THIS EXAMINATION: eval NGT plcmt ______________________________________________________________________________ FINAL REPORT STUDY: Abdomen supine only.,0
COMPARISON: CT scan from .,0
INDICATION: 72-year-old man status post NG tube placement.,0
FINDINGS: NG tube is visualized in the proximal portion of the stomach.,0
A portion of a Swan-Ganz catheter is also visualized.,0
The visualized bowel loops are normal caliber.,0
"7:08 PM CT HEAD W/O CONTRAST Clip # Reason: SAH, ASSESS FOR EXTENSION.",0
______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with SAH - assess for extension REASON FOR THIS EXAMINATION: Assess SAH No contraindications for IV contrast ______________________________________________________________________________ WET READ: DLrc MON 8:45 PM Known extensive subarachnoid hemorrhage extending into basilar cisterns.,1
Small amount of layering intraventricular hemorrhage in the bilateral occipital horns.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 45-year-old female with subarachnoid hemorrhage.,1
COMPARISON: Comparison is made to reference CT from 5 p.m. on same day.,0
"FINDINGS: There is diffuse bilateral subarachnoid hemorrhage involving the sylvian fissures, which tracks down and involves the basilar cisterns including the prepontine and ambient cistern.",1
Small amount of blood is likely present in the fourth ventricle.,0
There is a tiny amount of intraventricular hemorrhage seen bilaterally layering in the dependent portions of the occipital horns.,1
Effacement of the sulci is again seen bilaterally likely related to subarachnoid hemorrhage and edema.,1
"Otherwise, no change in caliber of the ventricular system with mild ventricular prominence of the temporal horns and the third ventricle measuring up to 4 mm.",0
"The -white matter differentiation is preserved, with no evidence of acute infarction.",0
There is mucus retention cyst seen within the right maxillary sinus.,0
There is mild mucosal thickening of the ethmoid air cells.,0
No acute fracture is seen.,0
"IMPRESSION: Extensive bilateral subarachnoid hemorrhage and mildly dilated lateral ventricles, little changed in extent since reference examination from 5 p.m. performed on same day.",1
Small amount of layering bilateral intraventricular hemorrhage seen in the occipital horns.,1
Please refer to CTA examination for additional findings and recommendations.,0
4:38 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: Pulmonary sourse of infection?,0
"Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with liver abscess, bacteremia, continued fevers REASON FOR THIS EXAMINATION: Pulmonary sourse of infection?",1
______________________________________________________________________________ FINAL REPORT A small parenchymal opacity projecting over the left costophrenic sinus has newly appeared.,0
This opacity could represent an embolic change in the light of the given clinical history.,0
There is no evidence for other parenchymal changes.,0
"was paged for notification at the time of dictation, 834, .",0
The findings were subsequently discussed over the telephone.,0
7:03 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o PVL Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 31 weeks now 1 month old REASON FOR THIS EXAMINATION: r/o PVL ______________________________________________________________________________ FINAL REPORT This is a child born at 31-week gestation.,1
She had a normal head ultrasound on .,0
Today's exam continues to be normal.,0
There is no evidence of hemorrhage or ventriculomegaly.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: Urgent Off Pump Coronary Artery Bypass Grafting x 2(left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal) History of Present Illness: This is a 63 year old male with PMH significant for hypertension, and hyperlipidemia who presented to his doctor with complaints of mid sternal chest burning that radiated to both shoulders with exertion.",1
It is associated with mild lightheadedness.,0
He had an abnormal stress test and was referred for cardiac catheterization.,0
"Past Medical History: Hypertension Hyperlipidemia Spinal stenosis Degenerative disc disease Obstructive Sleep Apnea, uses CPAP Left Hemidiaphragm Paralysis, s/p trauma Hemorrhoids GERD Mild depression Benign Prosatic Hypertropy s/p transurethral thermotherapy s/p Gastric bypass 3 years ago s/p cholecystectomy s/p bilat cataract surgery s/p right rotator cuff repair s/p removal of a benign throat polyp S/P tonsillectomy Social History: Denies tobacco and ETOH.",1
Lives with wife and daughter.,0
"Family History: Patient unsure of premature coronary artery disease Physical Exam: Pulse:53 Resp:18 O2 sat:96% RA B/P Right:126/86 Left:124/92 Height:6 Weight:245 lbs General: Middle aged male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur II/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Multiple incisions from lap gastric bypass, ?",1
"palpable liver edge Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities +1 Neuro: Grossly intact Pulses: Femoral Right: dressing in place Left: +2 DP Right: +2 Left: +2 PT : +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: none Left: none Pertinent Results: Cardiac Catheterization: 1.",0
Coronary angiography in this right dominant system demonstrated left main disease and non-obstructive coronary artery disease.,1
The distal LMCA had a 70% stenosis.,0
The LAD had no angiographically apparent disease.,0
The LCx had a 30% mid-stenosis.,0
The RCA had a 30% mid-stenosis.,0
Limited resting hemodynamics revealed elevated left sided filling pressures with LVEDP 23mmHg.,0
There was normal systemic arterial blood pressure with SBP 126mmHg and DBP 52mmHg.,0
Left ventriculography revealed an ejection fraction of 65% with normal wall motion.,0
There was no mitral regurgitation.,0
Echocardiogram: The left atrium is dilated.,0
Carotid Ultrasound: No significant carotid artery stenosis (less than 40% bilaterally).,0
ECHOCARDIOGRAPHY REPORT-intraop Left Ventricle - Ejection Fraction: 55% to 65% >= 55% Findings LEFT ATRIUM: Normal LA size.,0
No thrombus in the RAA.,0
Normal aortic diameter at the sinus level.,0
"REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions OFF PUMP CABG [The exam was limited to the esophagus due to history of gastric bypass.]",0
No thrombus is seen in the right atrial appendage 3.,0
"Following LIMA-LAD and SVG-OM, there was preserved biventricular systolic function.",0
The aortic contour is normal post side biter clamping.,0
"Electronically signed by , MD, Interpreting physician 10:26 Preop labs: WBC-6.7 RBC-3.61* Hgb-11.2* Hct-33.3* Plt Ct-195 PT-12.6 PTT-23.2 INR(PT)-1.1 Glucose-104* UreaN-25* Creat-0.7 Na-143 K-3.9 Cl-108 HCO3-29 ALT-23 AST-20 AlkPhos-59 TotBili-0.5 %HbA1c-5.7 Discharge labs: 05:35AM BLOOD WBC-6.0 RBC-2.82* Hgb-8.6* Hct-26.3* MCV-93 MCH-30.6 MCHC-32.8 RDW-15.4 Plt Ct-109* 06:00AM BLOOD Plt Ct-157 05:35AM BLOOD Glucose-121* UreaN-22* Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-29 AnGap-10 CHEST (PA & LAT) Study Date of 1:50 PM MEDICAL CONDITION: 63 year old man with CABG REASON FOR THIS EXAMINATION: post-op cxr Final Report: Comparison is made with prior study performed a day earlier.",0
Aeration in the left base has minimally improved.,0
There is persistent elevation of the left hemidiaphragm.,0
There is no evident pneumothorax or enlarging pleural effusions.,0
The sternal wires are aligned.,0
DR. Brief Hospital Course: Mr. was admitted after having had a positive stress test for cardiac catheterization which revealed a critical left main lesion - please see result section for details.,0
Cardiac surgery was therefore consulted and routine preoperative evaluation was performed.,0
"In addition to routine blood work and chest x-ray, further preoperative evaluation included an echocardiogram, carotid ultrasound and vein mapping - see result section for details.",0
"He remained pain free but given his critical coronary anatomy, he underwent urgent coronary artery bypass grafting on by Dr. .",1
"In summary he had: Urgent off-pump coronary artery bypass graft x2, with left internal mammary artery to left anterior ascending artery and saphenous vein graft to obtuse marginal artery.",1
"He tolerated the operation well and following the operation, he was brought to the CVICU for invasive monitoring.",0
"Within 24 hours, he awoke neurologically intact and was extubated without incident.",0
"His CVICU course was otherwise unremarkable, and he transferred to the step down unit on postoperative day two.",0
Chest tubes and pacing wires were removed per cardiac surgery protocol.,0
He continued to work with physical therapy to increase strength and endurance.,0
"On post operative day 4, he was tolerating a full oral diet, his incisions were healing well and he was ambulating without difficulty.",0
It was felt that he was safe for discharge home with visiting nurse services at this time.,0
"Medications on Admission: Atenolol 50mg po daily Nexium 40mg po daily Fluticasone 2 sprays to each nostril once or twice a day Gabapentin 300mg po qAM, qlunch, qdinner and 900mg qHS Imdur 30mg po daily NTG SL PRN Sertraline 50mg po daily Silodosin 8 mg po daily Simvastatin 20mg po daily Ascorbic Acid 1 tab po daily Excedrin Migraine B complex vitamins 1 cap daily Probiotic formula Calcium-Mg-Zinc Vit D3 1 tab daily MVI Fish OIl 1000mg po daily Fibercon Potassium Vit E 1 cap daily Discharge Medications: 1.",0
Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months: off pump .,0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days.,0
Silodosin 8 mg Capsule Sig: One (1) Capsule PO daily ().,0
Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): before breakfast, lunch and dinner .",0
Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime): at bedtime .,0
Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.",0
3:11 PM FEMUR (AP & LAT) LEFT Clip # Reason: assess for fx ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with REASON FOR THIS EXAMINATION: assess for fx ______________________________________________________________________________ FINAL REPORT HISTORY: Assess for fracture.,0
"LEFT FEMUR, FOUR VIEWS: There is no evidence of acute fracture or dislocation of the left femur.",0
There is no cortical disruption.,0
The visualized soft tissues appear unremarkable.,0
IMPRESSION: No evidence of acute fracture of the left femur.,0
2:03 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: confirm NGT placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 60F transfer from w/ extensive R SAH ruptured 3.5mm MCA aneurysm s/p coiling of aneurysm dome REASON FOR THIS EXAMINATION: confirm NGT placement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 5:26 PM 1.,0
Nasogastric tube within the stomach.,0
ETT ends 2.6cm above the carina and should be pulled back by 2.5cm.,0
"Resolved right lower lung opacity is probably aspiration rather than pneumonia, given short time interval.",0
"New retrocardiac atelectasis may be due to aspiration, possibly during reintubation ______________________________________________________________________________ FINAL REPORT INDICATION: Confirm NG tube placement.",0
FINDINGS: Nasogastric tube follows the expected course with the tip and side port in the stomach.,0
Left subclavian line is unchanged in position.,0
The right lower lobe opacity has resolved.,0
Pulmonary vascular engorgement is mildly decreased.,0
The right lower lung consolidation has resolved.,0
"New retrocardiac atelectasis may be due to aspiration, possibly during reintubation",0
10:45 AM CT HEAD W/O CONTRAST Clip # Reason: F/U BLEED Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT CT OF THE HEAD WITHOUT CONTRAST INDICATION: -year-old female status post fall with head bleed.,0
COMPARISONS: Comparison is made to the prior studies dated .,0
"FINDINGS: There is an area of encephalomalacia within the right frontal lobe with associated burr hole, most likely from remote surgery.",0
Hyperdense material is again seen layering along the right cranial convexity measuring 10 mm in maximal dimension consistent with subdural hemorrhage.,0
"Overall, the subdural hemorrhage has not significantly increased compared to the previous examination.",0
"Along the superior aspect of the right frontal lobe, there is noted to be component of subarachnoid hemorrhage which is also unchanged compared to the previous examination.",0
There is associated sulcal effacement and mild mass effect with a leftward shift of approximately 2 mm.,0
There is mild compression of the occipital of the right lateral ventricle.,0
A tiny punctate area of hyperdensity within the left superior aspect of the parietal lobe is unchanged.,0
An air-fluid level present within the right mastoid air cells is unchanged.,0
No definitive temporal bone fracture is identified.,0
The remaining density values of the brain parenchyma are maintained.,0
"The soft tissues, osseous structures, and visualized paranasal sinuses are otherwise unremarkable.",0
Incidental note is made of calcification of the cavernous portions of the carotid arteries and the vertebral arteries.,0
IMPRESSION: Stable appearance of right subdural hematoma with subarachnoid components and left parietal hemorrhage with minimal mass effect compared to the most recent examination from 15 hours prior.,0
Height: (in) 69 Weight (lb): 210 BSA (m2): 2.11 m2 BP (mm Hg): 160/80 HR (bpm): 85 Status: Inpatient Date/Time: at 11:49 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is moderately dilated.,0
Wall motion is difficult to assess.,0
Overall left ventricular ejection fraction cannot be reliably assessed.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Hydralazine / Opioid Analgesics / Compazine Attending: Chief Complaint: chest pain / epigastric pain Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 4 (LIMA-LAD,SV-DG,SV-OM,SV-PDA) left heart catheterization, coronary angiography History of Present Illness: The patient is a 74 year-old female who has a significant PMH for recent NSTEMI (), CAD, hyperlipidemia, hypertension, DM-2, and ESRD on hemodialysis who presented after several hours of epigastric pain which evolved into predominant complaint of chest pressure.",1
She had a similar presentation on and was diagnosed with an NSTEMI after positive cardiac enzymes noted with new LBBB on EKG.,0
"She underwent cardiac catheterization at that time which showed LAD lesion of 90% and totally occluded mid LAD lesion, RCA lesion of 90%, and circumflex showed minimal disease.",1
"Unfortunately, she had unsuccessful PCI, and CT Surgery consulted to arrange for future CABG plan.",0
"Past Medical History: -Hypothyroidism (thyroidectomy in for benign growth) -Diabetes type II for >10yrs -End-Stage Renal Disease: on hemodialysis left forearm AV graft in , now using Tunelled HD Line -CVA : left caudate infarct; several mini-strokes before that -Gait disorder/shaky and unsteady when she walks -Splenectomy in (trauma related) -SVC stenosis -Cataract surgery (bilateral) -Hypertension -Hyperlipidemia -Coronary Artery Disease (recent cath showing 90% proximal LAD totally occluded mid LAD and 90% RCA and minimal disease of the circumflex) Social History: Patient lives alone at home but daughter () is extensively involved in her care.",1
She has 7 other children.,0
"She uses a walker at baseline, but has been wheelchair bound for about 1 year per daughter because patient is afraid of falling.",0
"She denies current or past tobacco, alcohol or illicit drug use.",0
"Family History: Mother: died 5 year ago (cause unknown to pt) Father: died when pt was 17 (cause unknown to pt) Children have no major medical problems Physical Exam: Admission VS -T 98.6F, BP 153/100, HR 80s, RR 20, 96% 3L oxygen Gen: appears fatigued, middle aged female in NAD, Oriented x3.",0
Neck: Supple with JVP of 7-8cm.,0
Left EJ in place (clean/intact) and left IJ HD catheter in place with non-erythematous surrounding skin.,0
"CV: S1/S2 appreciated, RRR, II-III/VI systolic murmur noted @ LUSB, No murmurs, rubs, gallops.",0
"Chest: No chest wall deformities or scoliosis, but + Mild kyphosis.",0
Decreased aeration at bases bilaterally (R>L).,0
"Abd: Soft, mild upper epigastric tenderness, moderate distension.",0
No HSM or tenderness at RUQ.,0
"Due to distension, unable to ausculate well for abdominial bruits -but all 4 quadrants with +normoactive BS.",0
"Ext: cool, 1+ DP and PT pulses on left and 2+ DP and 1+ PT pulse on right.",0
No femoral bruits/femoral pulses 2+ bilaterally.,0
"Skin: LE calves with scaling of skin, no sores/lesions/rashes.",0
Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ .,0
"Discharge VS T 98.4 BP 144/71 HR 80 SR RR 20 O2sat 97%-2LNP Gen NAD, sitting in chair Neuro A&O x3, nonfocal exam Pulm CTA bilat CV RRR, sternum stable, incision CDI Abdm soft, NT/+BS Ext Warm, trace pedal edema bilat.",0
Skin staples L groin down thigh.,0
Left subclav HD catheter Pertinent Results: ADMISSION LABS: 03:57PM PT-41.6* PTT-37.8* INR(PT)-4.6* 03:03PM GLUCOSE-381* NA+-138 K+-4.4 CL--91* TCO2-27 03:03PM HGB-14.3 calcHCT-43 02:45PM GLUCOSE-385* UREA N-33* CREAT-4.2* SODIUM-137 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-27 ANION GAP-23* 02:45PM ALT(SGPT)-150* AST(SGOT)-104* CK(CPK)-46 ALK PHOS-205* TOT BILI-0.3 02:45PM LIPASE-50 02:45PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.2 02:45PM WBC-14.1* RBC-4.46 HGB-13.8 HCT-44.2 MCV-99* MCH-31.0 MCHC-31.3 RDW-17.4* 02:45PM BLOOD cTropnT-0.21* 01:10PM BLOOD CK-MB-NotDone cTropnT-0.29* 12:19AM BLOOD CK(CPK)-77 02:45PM BLOOD CK(CPK)-46 09:30AM BLOOD WBC-17.8* RBC-3.11* Hgb-9.6* Hct-30.0* MCV-97 MCH-30.8 MCHC-32.0 RDW-17.8* Plt Ct-280 09:30AM BLOOD Plt Ct-280 04:00AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3* 09:30AM BLOOD Glucose-233* UreaN-43* Creat-5.2*# Na-137 K-5.1 Cl-99 HCO3-28 AnGap-15 09:00AM BLOOD %HbA1c-7.0* 01:10PM BLOOD TSH-2.9 .,0
ADDITIONAL STUDIES: Cardiac MD/Thallium Viability study: IMPRESSION: 1.,0
Moderate Anterior wall/apical defect that is completely reversible by 24 h. 2.,0
Moderate septal defect that is partially reversible by 24 h. .,0
CTA Chest/Pelvis/Abdomen : IMPRESSION: 1.,0
"There is opacification of the SMA, without evidence of ischemic bowel.",0
"Extensive atherosclerotic disease, without aortic aneurysm or dissection seen.",0
"Extensive colonic diverticulosis, with minimal stranding surrounding the descending colon, suggesting mild uncomplicated diverticulitis.",1
Incompletely characterized hypodense lesions in the kidneys again noted.,1
Soft tissue nodule arising from the medial limb of the left adrenal gland again incompletely characterized.,1
"Increased number of mediastinal and retroperitoneal lymph nodes, without size enlargement.",0
"=============================================================== , F 74 Radiology Report CHEST (PA & LAT) Study Date of 4:15 PM MEDICAL CONDITION: 74 year old woman s/p CABG x4 REASON FOR THIS EXAMINATION: atelectasis Final Report HISTORY: Status post CABG with atelectasis.",1
"Extensive opacification at the left base persists, possibly increasing with further pleural fluid.",0
The right axillary catheter again remains outside of the hemithorax.,0
"DR. Approved: 6:21 PM = = = = = = = = ================================================================ , F 74 Radiology Report PICC W/O PORT Study Date of 12:30 PM , CSRU SCHED PICC LINE PLACMENT SCH Clip # Reason: ESRD on HD.",0
"LT scv Permacath, s/p mult RIJ caths.",0
Unable to MEDICAL CONDITION: 74 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ESRD on HD.,0
Unable to pass wire into IJs at time of recent CABG.,0
IV unable to thread wire for PICC at bedside.,0
please place as midline only ***** Final Report INDICATION: 74 year old woman requiring IV access.,0
Request right mid-line due to presence of left HD catheter in SVC.,0
"Dr. , the attending radiologist, was present and supervised the procedure.",0
Ultrasound images were obtained before and immediately after establishing intravenous access.,0
A guidewire was advanced into the right subclavian vein under fluoroscopic guidance.,0
A peel- away sheath was then placed over the guidewire and a double-lumen PICC measuring 20 cm in length was placed through the peel- away sheath with its tip positioned in the axillary vein under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC placement via right brachial venous approach.,0
"Final internal length is 20 cm, with the tip positioned in the right axillary vein.",0
Severe regional LV systolic dysfunction.,0
Moderate to severe (3+) MR. vena contracta is >=0.7cm TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
Dilated main PA. PERICARDIUM: Small pericardial effusion.,0
"REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre Bypass: The left atrium is markedly dilated.",0
"There is severe regional left ventricular systolic dysfunction with septal hypokinesis at the base and akinesis at mid and apical levels, and hypokinesis of anteroseptal and anterior walls..",0
Moderate to severe (3+) central mitral regurgitation is seen.,0
The mitral regurgitation vena contracta is >=0.7cm.,0
TEE used for hemodynamic monitoring throughout.,0
Estimated PASP 43 pre bypass.,0
Frequent cardiac output measurements obtained.,0
"CO 2.0 to start case, increased to 2.7, then later 3.9 just prior to bypass.",1
"Post Bypass: Patient is on epinepherine infusion (.08) and phenylepherine (2), AV paced.",1
Biventricular function is slightly improved on ionotropes.,0
The anterior wall motion has improved.,0
The septum is paced with paradoxical movement and cannot be fully evaluated.,0
Mitral reguritation is now +.,0
"Cardiac output post bypass initally , improved by end of case to 4.1 with ionotropes and volume.",1
All finidings discussed with surgeons at the time of the exam.,0
"Electronically signed by , MD, Interpreting physician 14:34 Brief Hospital Course: Ms. is a 74 year old female with a past medical history of a recent NSTEMI (), extensive coronary artery disease, hyperatension, diabetes mellitis type II, end stage renal disease on hemodialysis, who presented to the emergency department with several hours of epigastric pain and chest pressure.",1
She ruled out for acute coronary syndrome/myocardial infarction.,1
A workup for mesenteric ischemia was negative and she was scheduled for a coronary artey bypass.,1
On she underwent a coronary artery bypass grafting times four.,1
She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit.,0
"On post-operative day one she was dialyzed, extubated, and weaned from her pressors.",0
Dialysis resumed on the following day.,0
Her chest tubes and epicardial wires were removed.,0
She was seen in consultation by the physical therapy service.,0
"Over the next several days her hospital course was uneventful, she progressed very slowly with physical activity and on POD7 it was decided she was ready for discharge to rehabilitation at .",0
Medications on Admission: -Vitamin B Complex/Vitamin C -Folic Acid 1 mg daily -Renagel 800 mg tablet three times a day.,0
"-Levothyroxine 100 mcg tablet daily -Atorvastatin 80 mg Tablet PO daily -Heparin (Porcine) 5,000 unit/mL Solution : 4,000-11,000 unit dwell Injection PRN (as needed) as needed for line flush: **for use by dialysis ONLY.",0
"-Prevacid 30 mg Capsule, (E.C.)daily.",0
-Lorazepam 0.5 mg tablet PO Q6H as needed for Anxiety.,0
"-Acetaminophen 325 mg, 1-2 Tablets PO Q6H PRN -Warfarin 7.5 mg tablet PO daily at 4 PM.",0
-Aspirin 81 mg tablet once a day.,0
-Lisinopril 40 mg tablet daily.,0
Acetaminophen 325 mg Tablet : Two (2) Tablet PO Q4H (every 4 hours) as needed.,0
Bisacodyl 10 mg Suppository : One (1) Suppository Rectal DAILY (Daily) as needed for constipation.,0
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette : Drops Ophthalmic PRN (as needed).,0
"Heparin (Porcine) 5,000 unit/mL Solution : 5000 (5000) units Injection TID (3 times a day).",0
Sevelamer Carbonate 800 mg Tablet : Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
B Complex-Vitamin C-Folic Acid 1 mg Capsule : One (1) Cap PO DAILY (Daily).,0
Folic Acid 1 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
Levothyroxine 50 mcg Tablet : One (1) Tablet PO DAILY (Daily).,0
Senna 8.6 mg Tablet : Two (2) Tablet PO BID (2 times a day) as needed.,0
Ibuprofen 600 mg Tablet : One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment : One (1) Appl Rectal QID (4 times a day) as needed.,0
Metoprolol Tartrate 25 mg Tablet : 1.5 Tablets PO TID (3 times a day).,0
Glipizide 10 mg Tablet : One (1) Tablet PO BID (2 times a day).,0
Insulin Lispro 100 unit/mL Solution : sliding scale Subcutaneous Q AC&HS.,0
"Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: unsatble angina s/p coronary artery bypass grafts end stage renal disease hypertension cerebrovascular disease noninsulin dependent diabetes mellitus hypothyroidism s/p thyroidectomy s/p hysterectomy s/p splenectomy Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any fever greater than 100.5 report any redness of, or drainage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. in 4 weeks () Dr. in weeks () Completed by:",1
8:17 AM CHEST (PA & LAT) Clip # Reason: ?,0
infiltrate Admitting Diagnosis: BENIGN PROSTATIC HYPERTROPHY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with hypertension admitted after TURP now with ?,1
LLL infiltrate on PA cxr.,0
infiltrate ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Cough.,0
PA and lateral upright chest radiograph compared to obtained at 4:57 p.m.,0
The lungs are clear on the current radiograph.,0
Pleural surfaces are smooth and there is no pleural effusion.,0
"3:39 PM CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: eval for RP bleed, hematoma in R groin and R thigh; pt also Admitting Diagnosis: BRADYCARDIA Field of view: 39 ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with DM, HTN, CAD s/p stent to RCA/LAD, carotid stenosis, now w/ HCT drop, R thigh/groin ecchymoses REASON FOR THIS EXAMINATION: eval for RP bleed, hematoma in R groin and R thigh; pt also needs chest CT for abn noted on CXR w/?",1
chest wall mass; also cuts through R groin/thigh to eval for hematoma No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Hematrocrit drop with right thigh and groin ecchymoses.,0
Abnormality noted on chest CT. Assess for chest wall mass.,0
"TECHNIQUE: Contiguous axial images through the chest, abdomen and pelvis were obtained without oral or intravenous contrast.",0
"CHEST: There is no axillary, hilar, or mediastinal lymph adenopathy.",0
Dense calcifications are noted within the coronary arteries.,0
There is minimal atelectasis in the right upper lobe anteriorly.,0
"Also within the right upper lobe, there is a 7 mm x 10 mm non- calcified nodular density.",0
Healed right 8th posterolateral rib fracture is again noted.,0
There is no apparent soft tissue mass component to this lesion.,0
"ABDOMEN: Tiny calcifications are noted within the stomach and liver, likely residua of previous granulomatous disease.",0
No other focal liver lesions are seen.,0
"The spleen, atrophic pancreas, gallbladder, left adrenal gland, and right kidney are grossly unremarkable.",0
"There is a 2.4 cm fat-containing lesion within the medial limb of the right adrenal gland, consistent with an adenoma.",0
Two simple cysts are noted at the mid-pole of the left kidney.,0
There is no retroperitoneal lymph adenopathy.,0
There is no free abdominal fluid or free air.,0
"The bowel is not well assessed without oral contrast material, but loops are non-dilated and grossly unremarkable.",0
"PELVIS: There is a moderate amountof stranding within the soft tissues of the right groin, but there is no evidence of hematoma or fluid collection.",0
The bladder and prostate gland are grossly unremarkable.,0
Sigmoid diverticuli are noted without evidence of acute diverticulitis.,0
"There is vicarious excretion of contrast within the colon, likely residua of recent cardiac catheterization.",0
BONE WINDOWS: Degenerative changes are noted throughout the spine.,0
There is a healing fracture of the right 8th posterolateral rib as previously described.,0
"(Over) 3:39 PM CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: eval for RP bleed, hematoma in R groin and R thigh; pt also Admitting Diagnosis: BRADYCARDIA Field of view: 39 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.",0
No etiology for hematocrit drop identified.,0
A 9 mm right upper lobe lung nodule.,0
This should be followed with CT in 3 months.,0
No evidence of chest wall mass.,0
Healing 8th right posterolateral rib fracture.,0
4:05 PM CHEST (PA & LAT) Clip # Reason: interval chnage Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT RIMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with CABGx3 REASON FOR THIS EXAMINATION: interval chnage ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after CABG.,1
There is interval improvement of bibasal aeration.,0
There is minimal atelectasis still present in the lingula.,0
Small pleural effusion is noted.,0
"12:34 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna Admitting Diagnosis: INFECTED RIGHT HIP ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with leukocytosis REASON FOR THIS EXAMINATION: r/o pna ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Leukocytosis, fever.",0
"CHEST: Since the prior chest x-ray of , there has been some clearing of the opacification of the left lung.",0
"Some patchy infiltrates are, however, now seen in the right upper lobe, and this could represent an area of pneumonia.",0
IMPRESSION: Clearing of left lower lobe.,0
New opacities in right upper lobe.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Lovastatin Attending: Chief Complaint: CP & SOB Major Surgical or Invasive Procedure: CABG X 3, pericardial stripping on History of Present Illness: 66 y/o male s/p cardiac cath, presented to ED w/CP.",0
Workup revealed possible constrictive pericarditis (and know CAD from cath).,1
He was transferred to for surgery.,0
AORTA: Simple atheroma in descending aorta.,0
Mild to moderate (+) MR. TRICUSPID VALVE: Mild [1+] TR.,0
Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45%).,0
Post- CPB: Patient is AV paced on no pressors or inotropes.,0
EF now 50 - 55%.,0
MR remains 1 - 2+.,0
"Electronically signed by , MD, Interpreting physician 13:55 Brief Hospital Course: Transferred to from outside hospital.",0
"Underwent echo, cardiac MRI, and routine pre-operative evaluation.",0
"He was taken to the OR on , and underwent CABG X 3, and pericardial stripping (please see operative report for details of procedure).",0
"Post-operatively, he was taken to the ICU on IV NTG gtt.",0
"He was extubated the evening of surgery, weaned off NTG, and was transferred to the telemetry floor on POD # 1.",0
"On POD # 2, his chest tubes and epicardial pacing wires were removed, and he began to progress with ambulation.",0
"POD # 3 Pt stable - could not move bowels, bowel regime given.",0
POD # 4 pt stable for DC.,0
Medications on Admission: ASA 81' Verapamil 240' Synthroid 0.1' Lasix 20' Claritin Viagra Lovenox NTG Ambien Discharge Medications: 1.,0
"Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: care Discharge Diagnosis: CAD constrictive pericarditis HTN hyperlipidemia nephrolithiasis Discharge Condition: good Discharge Instructions: no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks shower daily, no swimming or bathing for 1 month no driving for 1 month Followup Instructions: With Dr. in weeks With Dr. in weeks With Dr. in 4 weeks Completed by:",1
"3:40 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST Reason: eval for obstruction, mass, ascites Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with 2 wks of abdominal distension, fever, tenderness ?",0
"malignancy REASON FOR THIS EXAMINATION: eval for obstruction, mass, ascites No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Abdominal distention with palpable abdominal mass.",0
TECHNIQUE: Contrast enhanced images of the abdomen and pelvis were performed.,0
Images were obtained after the administration of 150 cc of IV Optiray.,0
Nonionic IV contrast was used due to the patient's history of debility.,0
Images were reconstructed in the coronal plane.,0
CT ABDOMEN WITH CONTRAST: There are bilateral pleural effusions.,0
The right effusion is moderate in size and greater than the left effusion.,0
The right effusion is associated with greater associated compressive atelectasis.,0
"Within the liver, a 1.1 x 1.2 cm hypodense well delineated lesion is seen within the medial segment of the left lobe.",0
Smaller well delineated hypodense liver lesions are seen within the right hepatic lobe.,0
"The gallbladder, pancreas, spleen, and adrenal glands appear normal.",0
Both kidneys appear normal and contain simple renal cysts as well as bilateral extra-renal pelvices.,0
No hydronephrosis or hydroureter is identified.,0
There is a small amount of free fluid seen within both paracolic gutters.,0
"CT PELVIS WITH CONTRAST: An enormous 13.2 x 15.7 cm multiloculated cystic and solid mass seen occupying the entire lower abdomen and pelvis is identified, displacing the uterus to the right anterior abdominal wall.",0
The mass is also displacing loops of bowel to the periphery of the lower abdomen and pelvis.,0
"Numerous mesenteric and peritoneal implants are seen, causing omental caking seen most strikingly along the left lateral abdominal wall.",0
The bladder is distended but appears normal.,0
A small amount of pelvic free fluid is seen.,0
Intraabdominal and intrapelvic bowel loops appear unremarkable and contrast is seen to reach the lower portion of the descending colon.,0
"There is no definite evidence of obstruction, as there are no significantly dilated loops of large or small bowel identified.",0
A small amount of air and fluid is seen within the rectum Bone windows demonstrate no suspicious lytic or sclerotic lesions.,0
CORONAL RECONSTRUCTIONS: Images are reconstructed in the coronal plane confirm the above findings.,0
"(Over) 3:40 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST Reason: eval for obstruction, mass, ascites Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.",0
"Large multiloculated solid and cystic mass occupying the entire lower abdomen and pelvis, displacing loops of bowel to the periphery and the uterus anteriorly and to the right.",0
Small amount of free fluid identified.,0
Numerous mesenteric and peritoneal implants identified.,0
"Typical appearance of ""omental caking"" seen at the left lateral abdominal wall.",0
"Bilateral pleural effusions, right greater than left, moderate in size on the right with associated compressive atelectasis.",0
"Multiple hypodense liver lesions, too small to characterize, and likely representing simple hepatic cysts and/or hemangiomas.",0
"However, given the findings, metastatic foci cannot be excluded.",0
The above findings are most consistent with ovarian carcinoma with intraperitoneal spread.,0
Findings were communicated to the ER staff caring for the patient at the time of interpretation.,0
4:42 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: BILATERAL ANKLE FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with PNA REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Known pneumonia.,1
Concern for septic pulmonary emboli on recent CT-Chest.,0
COMPARISON: Multiple priors from through .,0
FINDINGS: Portable AP chest radiograph demonstrates the patient has been extubated and a tracheostomy tube placed.,0
The right IJ catheter terminates in the standard position.,0
The NG tube courses below the diaphragm and terminates outside the field of view.,0
"Bilateral parenchymal opacities are worsened from , particularly in the left upper lung.",0
"10:03 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with SAH with AMS and fever, Hx of PNA REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Subarachnoid hemorrhage with altered mental status and fever.",0
FINDINGS: Lung volumes have improved markedly since the prior exam and the opacity previously seen at the left lung base has nearly completely resolved.,0
"Opacity in the right mid lung has also cleared, but there is some persistent opacity at the right lung base, and followup to resolution is recommended.",0
Surgical clips are scattered throughout the abdomen.,0
The cardiac and mediastinal contours are within normal limits.,0
"IMPRESSIONS: Markedly improved lung volumes and infiltrates, but followup for the persistent right lower lobe opacity recommended.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Penicillins Attending: Chief Complaint: L sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 71 year old R handed male with HTN and cardiomyopathy of unclear origin who presents from with L sided weakness and dysarthria.,1
He was well until today around 10:30 am when he suddenly felt nauseous and dizzy.,0
He says he slumped over to the ground and need to go to the bathroom but could not get up to do so.,0
He lost continence on the ground.,0
He says he noticed then that his L arm and leg were weak.,0
"His landlord found his confused, on the floor of his house, 1 hour later and called EMS.",0
Pt was taken to hosptial where a head CT showed R MCA infarct.,0
He then was sent to for further management.,0
"He arrived in our ED at 5:30 pm, 7 hours after onset of symptoms.",0
"ROS: negative for recent illness, head or neck trauma, travel, change in mental status, headache, focal neuro deficits.",0
"Of note, pt had laparascopic polypectomy last tuesday for benign polyps, and since then has had diarrhea.",0
"Past Medical History: HTN cardiomyopathy, per pt recent ECHO and EKG were ""stable"" s/p L nephrectomy for renal tumor, pt did not know it's identity Social History: Lives on with a significant other, has 4 children, works as a police officer Denies Tobacco or drugs, occasional ETOH Family History: noncontributory Physical Exam: VS: T afeb HR 66 BP 156/83 RR18 Sat 95% on room air PE: sleepy but arousable, no acute distress HEENT AT/NC, MMM no lesions Neck Supple, no thyromegaly, no , no bruits Chest CTA B CVS RRR w/o MGR ABD soft, NTND, + BS EXT no C/C/E, distal pulses full, no rashes or petechiae Neuro MS: Awake, dysarthric, oriented x3.",0
"Speech: fluent w/o paraphasic error, repetition, high frequency naming intact.",0
"Neglects L side intermittently CN: I--not tested; II,III-- PERRLA, VFF by confrontation, seems to neglect L visual field.",0
"optic discs sharp; III,IV,VI-EOMI w/o nystagmus, no ptosis; V-- sensation intact to LT/PP, masseters strong symmetrically; VII-- L facial weakness; VIII--hears finger rub bilaterally; IX,X-- voice normal, palate elevates symmetrically, gag intact; -- SCM/trapezii ; XII--tongue protrudes midline, no atrophy or fasciculation.",1
"Motor: normal bulk and tone, no tremor, dense hemiparesis of L rm with minimal mvmt even on deep painful stimulation.",0
"Able to ift L leg above bed for 2-3 seconds, then drops it.",0
Wiggles toes n L. Cannot overcome resistence on L leg.,0
"Coord: rapid alternating and point-to-point (FNF, HTS, TTF)movements intact on R, cannot perform on L given hemiparesis.",0
"Refl: | |tri |bra |pat | |toe | L | 2+ | 2+ | 2+ | 2+ | 2+ | up | R | 2 | 2 | 2 | 2 | 2 | dn | : Decreased sensation to all modalities on L, a bit difficult to assess b/c of neglect.",0
Extinguishes on L to double stimulation consistently.,0
Pertinent Results: CT of Chest/Abdomen/Pelvis RESULTS PENDING CT and CTA HEAD W&W/O C & RECONS; CT NECK W/CONTRAST IMPRESSION 1.,0
Large right MCA infarct involving almost the entire territory supplied by this artery.,0
Almost total thrombosis of the origin of the right M2 segment with reconstitution of the distal branches.,0
A filling defect is noted in the right M2 segment.,0
CT HEAD W/O CONTRAST 7:49 AM IMPRESSION 1.,0
Evolving large right MCA distribution infarct.,0
No acute intracranial hemorrhage identified.,0
These results were called to Dr of Neurology at the time of interpretation (10:30 a.m.).,0
"CT HEAD W/O CONTRAST IMPRESSION: Again seen is a right MCA infarct, without evidence of new infarction or hemorrhage.",0
CAROTID SERIES COMPLETE IMPRESSION: No evidence of stenosis in either carotid artery.,0
TTE IMPRESSION: Moderate inducible mid-ventricular cavity gradient.,0
Mild aortic regurgitation with normal valve morphology.,0
TEE Conclusions: The left atrium is dilated.,0
There is probably systolic anterior motion of the mitral valve leaflets.,0
IMPRESSION: No cardiac source of embolism identified.,1
CXR IMPRESSION: Left subclavian central venous catheter with its tip in the superior vena cava.,0
Cardiomegaly without evidence of congestive failure.,0
"CEA, PSA, ESR, Fibrinogen all pending.",0
WBC-12.4* Hct-44.3 Plt Ct-178 WBC-8.3 Hct-39.2* Plt Ct-139* Neuts-87.6* Lymphs-8.7* Monos-3.3 Eos-0.3 Baso-0 PT-14.0* PTT-26.8 INR(PT)-1.2 PT-13.5 PTT-49.5* INR(PT)-1.1 PT-13.2 PTT-38.1* INR(PT)-1.1 ESR-5 Glucose-121* UreaN-22* Creat-1.0 Na-137 K-4.2 Cl-103 HCO3-24 Glucose-103 UreaN-20 Creat-1.1 Na-136 K-4.6 Cl-103 HCO3-29 ALT-21 AST-22 CK(CPK)-292* AlkPhos-59 Amylase-87 TotBili-0.8 06:20PM BLOOD CK-MB-3 cTropnT-<0.01 02:27AM BLOOD CK-MB-2 cTropnT-<0.01 10:00AM BLOOD CK-MB-2 cTropnT-<0.01 Calcium-8.9 Phos-2.9 Mg-1.8 Calcium-7.5* Phos-2.0* Mg-1.9 Calcium-8.4 Phos-3.2 Mg-1.8 Triglyc-46 HDL-50 CHOL/HD-2.9 LDLcalc-87 09:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG 09:10PM URINE RBC-* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 06:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: 71 y.o.,0
male presented w L hemiplegia and neglect of injury admitted for R MCA stroke.,0
"A summary of his pertinent hospital course by system follows: NEURO Pt presented from w L hemiplegia, dysarthria and neglect of injury.",0
Inital CT/CTA on showed a large right MCA infarct involving almost the entire territory supplied by this artery as well as almost total thrombosis of the origin of the right M2 segment with reconstitution of the distal branches.,0
The patient was not a candidate for tPA because of time elapsed since onset of symptoms.,0
"Follow-up head CT on showed evolving large right MCA distribution infarct, but no acute intracranial hemorrhage.",0
"Because of a persistent headache, pt was reimaged on and the head CT showed no evidence of new infarction or hemorrhage.",0
"The patient's stroke is currently of unknown etiology -- workup included carotid u/s, TTE, and TEE all of which were unrevealing for source of thrombus.",0
"With no known etiology as of , an oncologic w/u was initiated.",0
"ESR, CEA, Fibrinogen, PSA and a CT of the chest/abd/pelv were ordered and were pending as of 5PM.",0
Patient's L hemiplegia and L facial droop persisted through his entire hospital course.,1
"He did show improved understanding that he was not moving his L side, though he still maintained that he was capable of moving them.",0
CARDIAC Patient ruled out for MI.,0
Patient developed tachycardia and an irregular rhyhtm on .,0
A cardiology consult was called that concluded the patient was demonstrating PVCs and SVT likely secondary to effects of the stroke in the context of preexisting heart disease/cardiomyopathy.,1
"They recommended reinitiating BB and long term ACEi,as well as making sure Ca/K/Mg were properly repleted, and these recs were followed.",0
Pt continued to have intermittent PVCs through his hospital course.,0
FEN Swallowing eval cleared the patient for soft solids and thin liquids.,0
"PROPH Patient was initially given heparin 5000 U sc tid, pneumoboots, PPI.",0
Pt had isolated PTT rise from normal range to 49.5.,0
"Heparin sc was d/c'd, PTT fell started to trend downward, ?",0
Pt was d/c'd to rehab facility.,0
Atenolol 75 mg po qd 2.,0
ASA 325 mg qd 3.,0
Lipitor 20 mg qd Discharge Medications: 1.,0
Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Please start taking lisinopril on .,0
Discharge Disposition: Extended Care Facility: Rehab at Med CTR Discharge Diagnosis: 1.,0
Right MCA territory infarction 2.,0
"Patient has L facial droop, unable to move L arm or L leg, L leg has postural response to noxious stimulus, patient exstinguishes to double simultaneous stimulation at LLE and LUE.",0
"Patient has some neglect of injury: thinks he is capable of moving his L arm and L leg, does realize that he has not moved them.",0
Discharge Instructions: Patient may need ACE inhibitor in about a week or so after BP stabilizes.,0
"Please call your doctor and return to emergency department for increased weakness, visual changes, or worsening confusion.",0
Followup Instructions: Please follow-up with your PCP 1 week after discharge from the hospital.,0
Patient will need to follow up with Dr. in the Clinic after discharge from rehab.,0
"9:37 PM CHEST (PORTABLE AP) Clip # Reason: NGT placement Admitting Diagnosis: CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with HCT 25, s/p fall, encephalopathic, no obvious source of bleed and decreased BS now s/p intubation with increasing bloody secretions from ETT.",1
REASON FOR THIS EXAMINATION: NGT placement ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Decreased breath sounds and bloody secretions.,0
Comparison is made to previous study of earlier the same date.,0
A NG tube has been repositioned and is no longer coiling.,0
"It terminates below the diaphragm, but the tip is not included on the radiograph.",0
"There has been interval worsening of multifocal patchy parenchymal opacities, which are predominantly in the mid and lower lung zones.",0
"Although predominantly alveolar, there is underlying interstitial abnormality present as well.",0
Extensive bullous emphysema is noted in the upper lobes.,0
"IMPRESSION: Worsening multifocal pulmonary opacities, which are asymmetrically distributed.",0
This may be due to an evolving multifocal pneumonia.,0
Asymmetrical congestive heart failure pattern in a patient with emphysema is within the radiological differential diagnosis.,0
10:11 PM CHEST (PORTABLE AP) Clip # Reason: s/p ngt replacement ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with 3v CAD on cath today as well as chf on cxr in ed now with sob and wheezing.,0
"REASON FOR THIS EXAMINATION: s/p ngt replacement ______________________________________________________________________________ FINAL REPORT HISTORY: CAD with SOB, wheezing and NGT placement.",0
"Right jugular CV line difficult to accurately localize on film, in the region of the right brachycephalic vein.",0
There is cardiomegaly with bibasilar atelectases and probable small pleural effusion.,0
PATIENT/TEST INFORMATION: Indication: R/O Endocarditis.,0
Height: (in) 67 Weight (lb): 155 BSA (m2): 1.82 m2 BP (mm Hg): 160/70 Status: Inpatient Date/Time: at 14:00 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
Overall left ventricular systolic function is very difficult to assess but is probably normal (LVEF>55%).,0
No obvious vegetation is seen.,0
"In comparison to the previous report of , there is no significant change.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Mitral regurgitation HISTORY OF PRESENT ILLNESS: Mr. is a 48 year old male with a history of mitral valve disease.,1
Cardiac catheterization confirmed 4+ mitral regurgitation and normal coronary arteries.,0
He presents for evaluation and treatment of his mitral regurgitation.,0
"MEDICATIONS ON ADMISSION: Zestril 20 mg q.d., Klonopin 0.5 mg b.i.d.",0
"PHYSICAL EXAMINATION: Heartrate 68, blood pressure 120/80.",0
"His heart is regular rate and rhythm, systolic murmur at the apex.",0
His lungs are clear to auscultation bilaterally.,0
"His abdomen is soft, nontender, nondistended with normoactive bowel sounds.",0
"His extremities are without cyanosis, clubbing or edema.",0
HOSPITAL COURSE: Mr. was taken to the Operating Room on for minimally invasive mitral valve repair.,1
The procedure as performed without complication and Mr. was subsequently transferred to the Cardiac Surgical Intensive Care Unit.,0
"He was weaned off of drips, extubated and hemodynamically stabilized.",0
Postoperative chest x-ray revealed an air leak and consequently Mr. was left with his chest tube on suction.,0
Otherwise he had an uneventful stay in the Intensive Care Unit and was transferred to the floor on postoperative day #1.,0
By postoperative day #2 his air leak had resolved.,0
Chest x-ray revealed resolution of pneumothorax and subsequently the chest tube was discontinued.,0
He continued to improve on the floor.,0
He was tolerating an oral diet and his pain was controlled with oral medications.,0
He was switched from Percocet to Tylenol #3 and Motrin due to a feeling of over-sedation from the Percocet.,0
Mr. was ambulating well with physical therapy completing a Level 5 performance test.,0
On postoperative day #3 Mr. was felt stable for discharge home.,0
"Physical examination at discharge revealed temperature 99.6, pulse 67, blood pressure 130/60, respirations 18 and oxygen saturation 98% on room air.",0
"Incisions were clean, dry and intact.",0
"Abdomen was soft, nontender, nondistended with normoactive bowel sounds.",0
Tylenol #3 one to two tablets q.,0
4 hours prn FOP: Mr. should follow up with Dr. in three to four weeks and Dr. in four weeks.,0
DISCHARGE STATUS: Mr. is to be discharged home.,0
DISCHARGE DIAGNOSIS: Status post mitral valve repair.,1
Dictated By: MEDQUIST36 D: 09:50 T: 10:06 JOB#:,0
"PORT Clip # Reason: Please eval for hematoma, bleed,abscess,fluid collection Admitting Diagnosis: PULMONARY HYPERTENSION ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with lupus s/p recent left renal biopsy now with hypotension, ?",1
"bleed vs. infection REASON FOR THIS EXAMINATION: Please eval for hematoma, bleed,abscess,fluid collection ______________________________________________________________________________ FINAL REPORT RENAL ULTRASOUND HISTORY: 51-year-old woman with lupus status post recent left renal biopsy, now with hypotension, question of bleed or infection.",1
"Please evaluate for hematoma, bleed, abscess, or fluid collection.",0
COMPARISON: Images from left renal biopsy from three days prior ().,0
FINDINGS: The right kidney measures 11.4 cm in length.,0
The left kidney measures 12.7 cm in length.,0
There is no left or right hydronephrosis.,0
There is no perinephric fluid collection.,0
An 8-mm simple cyst arises from the interpolar region of the right kidney and is unchanged.,0
The urinary bladder is decompressed with a Foley catheter.,0
11:52 AM CHEST (SINGLE VIEW) Clip # Reason: please eval for effusion / consolidation ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with SDH REASON FOR THIS EXAMINATION: please eval for effusion / consolidation ______________________________________________________________________________ FINAL REPORT HISTORY: Subdural hematoma.,0
TECHNIQUE: Single frontal chest radiograph in the AP projection shows the lungs to be clear.,0
Cardiomediastinal and hilar contours are normal.,0
Visualized osseous structures are notable for a levoconvex thoracic scoliosis.,0
Visualized soft tissue structures are unremarkable.,0
PATIENT/TEST INFORMATION: Indication: CAD and mitral regurgitation.,1
Intraoperative management Height: (in) 64 Weight (lb): 148 BSA (m2): 1.72 m2 BP (mm Hg): 119/75 HR (bpm): 64 Status: Inpatient Date/Time: at 10:30 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
AR vena contracta is <0.3cm.,0
"Moderate to severe (3+) MR. to the eccentric MR jet, its severity may be underestimated (Coanda effect).",0
There are complex (>4mm) atheroma in the aortic arch and descending thoracic aorta.,0
Epiaortic imaging at the site of cross clamping and aortic cannulation revealed simple atheroma.,0
The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and trace aortic regurgitation.,0
There is partial mitral leaflet flail.,0
Dr. was notified in person of the results during the surgery on at 821.,0
Patient is on epinepherine and phenylepherine infusions.,0
AV and later A paced 2.,0
There is a mitral annuloplasty ring insitu with a shortened posterior leaflet consistent with a mitral valve repair.,1
There is trace mitral regurgitation.,0
Peak and mean gradients are less than 6 mm hg.,0
There is preserved biventricular function on low dose epinepherine infusion.,0
Initial septal diskinesis resolves when converted from AV to A pacing.,0
Aortic contours are intact 5.,0
All findings are discussed with surgeons at the time of the exam.,0
"12:32 PM CHEST (PORTABLE AP) Clip # Reason: dyspena ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with dyspena REASON FOR THIS EXAMINATION: dyspena ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, AT 12:36 P.M. HISTORY: Dyspnea.",0
FINDINGS: The lungs are well expanded and clear.,0
The visualized osseous structures reveal mild degenerative changes in the lower thoracic spine.,0
11:59 PM FEMUR (AP & LAT) IN O.R.,0
RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # Reason: RIGHT FEMUR ORIF Admitting Diagnosis: RIGHT FEMUR FRACTURE ______________________________________________________________________________ FINAL REPORT STUDY: Right femur intraoperative study .,1
HISTORY: Patient With ORIF of right femur.,0
FINDINGS: 35 fluoroscopic images of the right femur are submitted for dictation.,0
The total intraservice time of 181 seconds.,0
These demonstrate interval placement of a large lateral fracture plate with multiple associated cortical screws.,0
This is fixating an obliquely oriented fracture through the right distal femoral metaphysis.,0
There are no signs for hardware-related complication.,0
Inferior portion of the femoral prosthetic stem is visualized.,0
Please refer to the procedure note for additional details.,0
", 7F 11:44 PM HICK REMOVE Clip # Reason: removal for VRE bacteremia Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with AML 16 days s/p alloSCT now with VRE bacteremia REASON FOR THIS EXAMINATION: removal for VRE bacteremia ______________________________________________________________________________ PFI REPORT PFI: Removal of left-sided tunneled triple-lumen central venous line with the tip of the catheter cut and sent for culture.",1
6:07 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CARDIOMYOPATHY\CATH ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with h/o dilated cardiomyopathy EF 15%; cabg and avr REASON FOR THIS EXAMINATION: pre op ______________________________________________________________________________ FINAL REPORT INDICATION: Cardiomyopathy.,0
"CHEST, PA AND LATERAL: The heart size is normal.",1
IMPRESSION: No evidence of acute cardiopulmonary disease.,0
"8:13 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o PE Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with new onset hypoxia, several days post-op, also with severe COPD, DM, PVD, PAF REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast ______________________________________________________________________________ WET READ: MGGb 10:32 PM No PE.",0
"Severe fibrotic, bronchiectatic, and cystic change likely c/w with chronic COPD.",0
"Several other small areas of focal consolidation bilaterally; while these may represent infectious foci, F/U after treatment should be obtained to exclude malignancy.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old woman with severe COPD, postop several days, with new onset hypoxia, rule out pulmonary embolism.",0
COMPARISONS: Chest x-ray of the same day and CTA chest of .,0
"TECHNIQUE: Axial MDCT images through the chest with 100 cc of nonionic Optiray contrast, by CTA PE protocol.",0
Coronal and sagittal reformatted images were performed.,0
"CTA CHEST WITH IV CONTRAST: The contrast bolus and enhancement of the pulmonary arterial system is suboptimal, with the Hounsfield units in the main pulmonary artery measuring only 190 Hounsfield units.",0
"However allowing for this, there is no central pulmonary embolism.",0
The proximal subsegmental branches also demonstrate no evidence of thrombus.,0
"The heart, pericardium, and great vessels are normal.",0
The thyroid is diffusely nodular bilaterally.,0
Again noted are multiple enlarged mediastinal and hilar lymph nodes.,0
The two largest of these in the AP window and precarinal distributions measure 1.9 x 1.1 and 1.7 x 2.1 cm in maximum bidimensional measurements in the axial plane respectively.,0
They do not appear to have increased significantly in size compared to the prior chest CTA.,0
The aorta enhances normally throughout the thorax without evidence of dissection or other abnormality.,0
Throughout the lungs there are diffuse chronic changes consistent with COPD.,0
"Specifically, there is diffuse central bronchiectasis, and fibrotic changes bilaterally.",0
There is a small left-sided pleural effusion.,0
"There is consolidation at the posterior aspect of the right lung base, suspicious for pneumonia.",0
"Additionally, there is a more focal area of consolidation, best seen on series 3, image 52, which may represent another area of localized infection, however a mass lesion is not excluded, and followup should be obtained.",0
Multiple thin-walled cysts in the upper lobes are again seen.,0
"In the right upper lobe, there are several small patchy areas of consolidation which may represent fibrotic changes versus small nodules and could be reassessed on followup as well.",0
"In the left lower lobe, there are also several small areas of focal consolidation, which again may represent infectious etiology versus true (Over) 8:13 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: r/o PE Field of view: 36 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) parenchymal nodules.",0
IMPRESSION: 1) No central pulmonary embolism.,0
"2) Right lower lobe consolidation, suspicious for pneumonia.",1
"3) Several smaller, nodular areas of consolidation, likely also infectious in nature; however follow up is recommended after treatment to ensure resolution.",0
4) Small left pleural effusion.,0
"6) Severe fibrotic, bronchiectatic, and cystic changes consistent with the known history of COPD.",0
"7) Mild prominence of the central main pulmonary arteries, likely consistent with the given history of pulmonary arterial hypertension.",0
9:44 PM ANKLE (2 VIEWS) RIGHT IN O.R.,0
; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.,0
RIGHTClip # Reason: S/P FRACTURE SCREW IN ______________________________________________________________________________ FINAL REPORT Three images obtained on an image intensifier in the O.R.,0
demonstrate internal fixation of the distal fibula with plate-and-screws of the medial malleolus with two screws.,0
3:40 AM CHEST (PORTABLE AP) Clip # Reason: r/t effusion Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH ?,1
AVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with s/p avr & cabg.,0
REASON FOR THIS EXAMINATION: r/t effusion ______________________________________________________________________________ FINAL REPORT CHEST X-RAY COMPARISON: One day earlier.,0
INDICATION: Status post cardiovascular surgery.,0
"FINDINGS: Indwelling support and monitoring devices are unchanged in position, and cardiomediastinal contours are stable in appearance in postoperative setting allowing for lower lung volumes on the current radiograph.",0
"Patchy and linear atelectasis in left mid lung region is unchanged, but there has been improvement in atelectasis in the left retrocardiac region.",0
New atelectatic changes have developed at the right lung base as well as a new small right effusion.,0
"Small left pleural effusion is not appreciably changed, and there is no visible pneumothorax.",0
7:30 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for left pleural effusion Admitting Diagnosis: LEFT LUNG MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p left thoracoscopy w/ left lower lobectomy REASON FOR THIS EXAMINATION: Evaluate for left pleural effusion ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: CLINICAL INDICATION: Status post left lower lobectomy procedure.,1
Comparison is made to prior study of one day earlier.,0
"An endotracheal tube has been placed, and is in satisfactory position.",0
"However, the cuff appears overdistended.",0
Two chest tubes are present in the left hemithorax.,0
"There has been marked interval decrease in size of a previously present left pleural effusion, with a small residual effusion remaining.",0
"The lung volumes are quite low, accentuating the cardiac silhouette and bronchovascular structures, and precluding accurate assessment of the mediastinum and cardiovascular status of the patient.",0
"IMPRESSION: 1) Marked interval improvement in left pleural effusion, with two chest tubes in place.",0
2) Overdistention of cuff of endotracheal tube.,0
3) Repeat study at inspiratory phase of respiration is recommended to allow more accurate assessment of the mediastinum and cardiovascular status of the patient.,0
4:35 AM CHEST (PORTABLE AP) Clip # Reason: OGT well-positioned?,0
"Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with IPH, now intubated REASON FOR THIS EXAMINATION: OGT well-positioned?",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Assess NGT position.,0
Comparison is made with prior study performed the day before.,0
"9:39 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for interval change Admitting Diagnosis: STROKE;TIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with SDH s/p drain removal REASON FOR THIS EXAMINATION: evaluate for interval change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Subdural hematoma, status post drain removal.",0
TECHNIQUE: Axial non-contrast MDCT images were obtained through the head.,0
CT HEAD WITHOUT IV CONTRAST: There has been interval removal of the subdural drain with increase in the amount of extra-axial pneumocephalus.,0
The extra-axial spaces overlying the right frontal and parietal lobes appear slightly increased in the interval.,0
The degree of midline shift has not changed.,0
Intraparenchymal hemorrhage in the high right frontal lobe is unchanged consistent with an evolving contusion.,0
Postoperative changes are again seen overlying the right frontal bone.,0
Interval removal of subdural drain with increase in the right frontal extra-axial space and pneumocephalus.,0
The degree of leftward midline shift is unchanged.,0
High right frontal evolving contusion again identified.,0
"2:32 PM CT HEAD W/O CONTRAST Clip # Reason: please eval r/o ICH ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with confusion identical to prior stroke symptoms REASON FOR THIS EXAMINATION: please eval r/o ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: WED 4:08 PM hypodensity in the right posterior parietal region may represent subacute/old infarct, difficult to exclude vasogenic edema ; correlate clinically and may get MRI if clinically warranted for further evaluation.",0
d/w Dr. at 4pm on .,0
______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old woman with confusion.,0
TECHNIQUE: Contiguous axial images were obtained through the brain without the administration of IV contrast.,0
"FINDINGS: There is no evidence of acute hemorrhage, discrete masses, mass effect, or shift of normally midline structures.",0
"A hypodensity in the right posterior parietal region may represent subacute or old infarct, underlying vasogenic edema may be present.",0
There is no evidence of volume loss or mass effect.,0
Visualized osseous structures and paranasal sinuses appear unremarkable.,0
"Hypodensity in the right posterior parietal region may represent subacute/old infarct, underlying vasogenic edema may be present; no evidence of volume loss or mass effect.",0
Findings could be further evaluated on MRI.,0
Findings discussed with Dr. at 4 p.m. on .,0
10:22 AM BILIARY CATH CHECK Clip # Reason: PLEASE DO CONTRAST STUDY OF PTC TO MAKE SURE IT IS FUNCTIONI Admitting Diagnosis: PANCREATIC MASS Contrast: OPTIRAY Amt: 5 ********************************* CPT Codes ******************************** * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER * * TUBE CHOLANGIOGRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 65F s/p open chole and Whipple for T3N1 Panc adeno Ca presents with obstructive jaundice.,0
"ERCP attempt on unsuccesful s/p PTC with internal-external stent placement -- PLEASE DO CONTRAST STUDY OF PTC TO MAKE SURE IT IS FUNCTIONING PROPERLY/DRAINING REASON FOR THIS EXAMINATION: PLEASE DO CONTRAST STUDY OF PTC TO MAKE SURE IT IS FUNCTIONING PROPERLY/DRAINING ______________________________________________________________________________ FINAL REPORT TUBE CHOLANGIOGRAM INDICATION: 65-year-old female post-Whipple procedure and open cholecystectomy in for pancreatic adenocarcinoma, presenting with obstructive jaundice.",0
The patient is post placement of left internal- external biliary drain with decreasing external stent output.,0
"and , the attending radiologist, who was present and supervising throughout.",0
"PROCEDURE AND FINDINGS: After explaining the risks and benefits of the procedure, patient was placed supine on the angiography table.",0
"Scout film of the right upper quadrant demonstrates catheter, with distal end coiled in the roux loop.",0
"Following the injection of approximately 3 cc of Optiray through the catheter, opacification of the intrahepatic biliary ducts was observed.",0
There was no passage of the contrast into the roux loop.,0
"IMPRESSION/PLAN: Kinking of the left internal-external biliary drain within the Roux loop, leading to absent internal drainage.",0
Biliary catheter exchange can be performed when the healthcare proxy consents to the procedure.,0
(Over) 10:22 AM BILIARY CATH CHECK Clip # Reason: PLEASE DO CONTRAST STUDY OF PTC TO MAKE SURE IT IS FUNCTIONI Admitting Diagnosis: PANCREATIC MASS Contrast: OPTIRAY Amt: 5 ______________________________________________________________________________ FINAL REPORT (Cont),0
Height: (in) 67 Weight (lb): 138 BSA (m2): 1.73 m2 BP (mm Hg): 119/34 HR (bpm): 54 Status: Inpatient Date/Time: at 11:27 Test: TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (tape not available) of .,0
A catheter or pacing wire is seen in the RA and/or RV.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; AORTA: Normal aortic root diameter.,0
LV systolic function appears mildly to moderately depressed.,0
Resting regional wall motion abnormalities include inferior/inferolateral akinesis/hypokinesis.,0
There is at least moderate pulmonary artery systolic hypertension.,1
"Compared with the report of the prior study (tape unavailable for review) of , left ventricular wall motion abnormality may be similar but prior study not available for direct comparison.",0
"LINE PLACEMENT Clip # Reason: 38cm right basilic DL PICC, non heparin dependent, # I Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with new right picc REASON FOR THIS EXAMINATION: 38cm right basilic DL PICC, non heparin dependent, # ______________________________________________________________________________ WET READ: IPf FRI 7:06 PM PICC in the neck, likely in the IJ; tip not seen.",0
d/ (IV nurse )at 7 pm on by phone.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 6:55 P.M., ON HISTORY: New right PICC line.",0
IMPRESSION: AP chest compared to : New PIC line heads up into the neck and out of view.,0
Dr. notified the IV nurse at 7:00 p.m. on .,0
"Heart size is normal, no pleural abnormality.",0
Mild thoracic scoliosis is unchanged since at least .,0
"LINE PLACEMENT Clip # Reason: check line placement, right sc-tlc.",0
"Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with multiple trauma, intubated.",1
"REASON FOR THIS EXAMINATION: check line placement, right sc-tlc.",0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 3:56 PM PFI: Malpositioned right subclavian IV catheter.,0
"Left retrocardiac atelectasis, otherwise no significant change.",0
______________________________________________________________________________ FINAL REPORT FRONTAL CHEST RADIOGRAPH INDICATION: 21-year-old man with right subclavian IV catheter placed.,0
"FINDINGS: New right subclavian intravenous catheter has been placed, which travels superiorly, probably in the right internal jugular vein, the tip is out of the view.",0
The endotracheal tube terminates 5 cm above the carina.,0
"Left retrocardiac density has developed, likely secondary to atelectasis.",0
Pulmonary vascularity is not increased.,0
Re- demonstrated is a medial clavicular fracture.,0
Malpositioned right subclavian venous catheter.,0
"Left retrocardiac opacity, compatible with atelectasis.",0
"Findings were discussed with Dr. at 3:20 p.m. on ,",0
"4:46 AM CHEST (PORTABLE AP) Clip # Reason: evaluate R hydropneumothorax Admitting Diagnosis: RIGHT PLEURAL EFFUSION;MULTIPLE PULMONARY EMBOLI ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with multiple PE's, hypoxemia, and right hydropneumothorax REASON FOR THIS EXAMINATION: evaluate R hydropneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: PE, hypoxia, right hydropneumothorax.",0
Portable AP chest dated is compared to the prior from yesterday.,0
There has been no significant interval change.,0
The left lung remains clear.,0
The right lung again shows a large loculated pleural effusion containing air and right lung base atelectasis.,0
IMPRESSION: No significant interval change in the appearance of the large right hydropneumothorax.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: This 68 year old white male has a history of diabetes, hyperlipidemia and hypertension.",0
He was recently diagnosed with three vessel coronary artery disease in and was admitted with unstable angina.,1
The night prior to admission here he had mid sternal chest pain with radiation and diaphoresis in ten minutes.,0
He took Nitroglycerin without effect and was awoken with pain later on in the evening.,0
On his way to the Emergency Room he had nitroglycerin spray and was pain-free on arrival to the Emergency Room.,0
He was recommended to have a coronary artery bypass graft in and wanted to come back to for his surgery.,1
"PAST MEDICAL HISTORY: Significant for a history of Type 2 diabetes, history of peripheral neuropathy, history of retinopathy, history of coronary artery disease with a positive stress test and unstable angina in .",1
He ruled out for an myocardial infarction and a cardiac catheterization revealed three vessel coronary artery disease with an ejection fraction of 70%.,1
"He was status post cerebrovascular accident in as well with mild residua of the left hemiparesis, small lacunar hemorrhages.",1
He has a history of hypercholesterolemia and neurogenic bladder.,0
MEDICATIONS ON ADMISSION: Glyburide 5 mg p.o.,0
"q. day, Lopressor 75 mg p.o.",0
"b.i.d., Lipitor 10 mg p.o.",0
"q. day, Aggrenox 25/200 b.i.d., Metformin 1 gm b.i.d., Zoloft 100 mg p.o.",0
ALLERGIES: He is allergic to Bromocriptine.,0
"SOCIAL HISTORY: He does not smoke cigarettes, does not drink alcohol and lives alone.",0
"PHYSICAL EXAMINATION: He is a well developed, well nourished elderly white male in no apparent distress.",0
"Head, eyes, ears, nose and throat examination, normocephalic, atraumatic.",0
"Neck was supple with full range of motion, no lymphadenopathy or thyromegaly.",0
Carotids were 2+ and equal bilaterally without bruits.,0
"Cardiovascular, regular rate and rhythm, normal S1 and S2, no rubs, murmurs or gallops.",0
"Extremities, without cyanosis, clubbing or edema.",0
Femoral pulses were 1+ and equal bilaterally.,0
Dorsalis pedis was 1+ on the right and trace on the left.,0
HOSPITAL COURSE: He was admitted and seen by Neurology.,0
He had a head computerized tomography scan which revealed right small frontal subcortical hypodensity.,0
Dr. was consulted and the patient was uncertain as to whether he would like surgery.,0
"He eventually consented and on he underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to the posterior descending artery and obtuse marginal.",1
"Cross clamp time was 60 minutes, total bypass time was 75 minutes.",0
He was transferred to the Cardiac Surgery Recovery Unit in stable condition on Neo-Synephrine and Propofol.,0
He was extubated and had a stable postoperative night.,0
His chest tube was discontinued on postoperative day #2.,0
He did notice some slurred speech and was seen by Neurology and they recommended decreasing his pain medications.,0
He also complained of dysphagia.,0
He did have an magnetic resonance imaging scan on postoperative day #3 which was unremarkable.,0
He was transferred to the floor on postoperative day #3.,0
He had a small episode of rapid atrial fibrillation.,1
On postoperative day #4 he was treated with Lopressor and Amiodarone and converted to sinus rhythm.,0
He continued to slowly improve but required aggressive physical therapy and on postoperative day #7 he was discharged to rehabilitation in stable condition.,0
MEDICATIONS ON DISCHARGE: Lasix 20 mg p.o.,0
q. day for seven days.,0
times one week and then decrease to 400 mg p.o.,0
"and then decrease to 200 mg, for one week and then decrease to 200 mg p.o.",0
q. day Aggrenox 1 p.o.,0
"LABORATORY DATA ON DISCHARGE: Hematocrit 34, white count 9,800, platelets 352, sodium 136, potassium 4.1, chloride 100, carbon dioxide 27, BUN 24, creatinine 1.0, glucose 139.",0
FOLLOW UP: He will be followed by Dr. in one to two weeks and Dr. in six weeks.,0
"DR., 02-358 Dictated By: MEDQUIST36 D: 13:19 T: 16:03 JOB#:",0
1:37 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: CT changed to waterseal ** Please xray at 13:30pm ** Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with CT changed to waterseal ** Please xray at 13:30pm ** REASON FOR THIS EXAMINATION: CT changed to waterseal ** Please xray at 13:30pm ** ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH COMPARISON: Radiograph of earlier the same date.,0
"FINDINGS: Bilateral chest tubes remain in place, with no visible pneumothorax.",1
Indwelling support and monitoring devices are similar in position with endotracheal tube terminating about 2.4 cm above the carina.,0
"Bibasilar atelectasis is again demonstrated, slightly worse on the right, but improving on the left.",0
Small pleural effusions are also demonstrated.,0
6:04 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
pna ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with s/p liver txp now with fever and tachycardia REASON FOR THIS EXAMINATION: ?,0
"pna ______________________________________________________________________________ FINAL REPORT HISTORY: 56-year-old male status post liver transplant, now with fever and tachycardia.",1
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is normal.,0
There is overall better lung aeration with no pleural effusion or focal consolidation.,0
There is likely minimal basilar atelectasis bilaterally.,0
The right upper quadrant demonstrates a biliary stent.,0
5:38 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: is B lung base collapse improving?,0
Admitting Diagnosis: RECTAL ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with Crohn's.,1
earlier cxr showed b collapses lung.,0
REASON FOR THIS EXAMINATION: is B lung base collapse improving?,0
______________________________________________________________________________ FINAL REPORT INDICATION: 32-year-old man with Crohn's disease with earlier chest radiograph showing bilateral lobe collapse.,0
COMPARISON: at 13:20 p.m. AP CHEST RADIOGRAPH: Again seen is a left retrocardiac opacity as well as partial collapse of the right lower lobe.,0
The appearance is unchanged compared to the prior chest radiograph.,0
"There is gastric as well as small bowel and large bowel distension, unchanged compared to the prior study.",0
Unchanged left retrocardiac opacity likely representing left lower lobe atelectasis and less likely consolidation.,0
Unchanged right lower lobe atelectasis.,0
"Gastric, as well as small and large bowel distension.",0
"1:34 PM CHEST (PORTABLE AP) Clip # Reason: fluid overload vs. pneumonia Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant in , complicated by GVHD on chronic prednisone with multiple admission for infections now presents with somnolence in the setting if increased sedative medication use, hypercarbic respiratory distress, cough and CXR with LLL consolidation.",1
"REASON FOR THIS EXAMINATION: fluid overload vs. pneumonia ______________________________________________________________________________ FINAL REPORT AP CHEST, 1:58 P.M. ON HISTORY: 57-year-old man with AML and stem cell transplant.",1
IMPRESSION: AP chest compared to : Progressive heterogeneous opacification in the left mid and lower lung zone is most likely pneumonia worsening since .,1
"There could be a second focus of right infrahilar pneumonia, also advancing.",0
Cardiomediastinal silhouette is essentially unchanged over several years.,0
Dual-channel right supraclavicular central venous set ends close to the superior cavoatrial junction.,0
"2:58 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: assess gallbladder for any abnormalities Admitting Diagnosis: INCARCERATED HERNIA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with large incarcerated ing hernia and perf colon, s/p ex lap w/ colostomy.",0
gallbladder thickening on previous CT imaging and pt now with elevated WBC 24.9.,0
REASON FOR THIS EXAMINATION: assess gallbladder for any abnormalities ______________________________________________________________________________ FINAL REPORT ULTRASOUND GALLBLADDER INDICATION: History of incarcerated inguinal hernia with perforated colon post-laparotomy with partial colectomy and colostomy.,1
FINDINGS: Limited examination of the upper abdomen due to postoperative state and body habitus.,0
"The gallbladder is contracted on this imaging study, stable when compared with prior CT. No gallstones, pericholecystic fluid or abnormal wall thickening.",0
Normal echotexture to the liver without focal liver lesion.,0
The main portal vein is patent.,0
A single dilated small bowel loop is identified in the right upper quadrant measuring maximum diameter 3 cm.,0
This also corresponds to the findings on prior CT and may represent post-operative ileus; however clinical correlation recommended as bowel obstruction could have a similar appearance.,1
Normal son appearance of gallbladder and no biliary dilation.,0
Dilated small bowel loop in right upper quadrant may be related to post-operative ileus however clinical correlation recommended.,0
Results were discussed with the surgical resident caring for the patient.,0
Weight (lb): 206 BP (mm Hg): 110/59 HR (bpm): 114 Status: Inpatient Date/Time: at 12:02 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
"Dilated IVC (>2,5cm) with <50% decrease during respiration (estimated RAP 16-20 mmHg).",0
The estimated right atrial pressure is 16-20 mmHg.,0
There is moderate global hypokinesis without regionality.,0
The right ventricle is mildly dilated with moderate global free wall hypokinesis.,0
No aortic stenosis is seen.,0
"There is a very small, primarily anterior pericardial effusion withtout echocardiographic signs of tamponade.",0
"Compared with the prior study (images reviewed) of , there has been a decline in left and right ventricular systolic function.",0
"The severity of tricuspid regurgitation has increased, the effusion is more prominent (but remains very small) and atrial fibrillation is now present.",1
Ascites was also present on the prior study.,0
An atrial septal defect is not seen on the current study (may be related to technical differences).,0
"7:04 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval ET placement Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with PNA, now intubated REASON FOR THIS EXAMINATION: eval ET placement ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumonia; evaluate ET tube position.",0
SUPINE AP PORTABLE CHEST: A new endotracheal tube terminates 4.9 cm above the carina.,0
A new nasogastric tube is coiled in the stomach.,0
"There has been slight interval progression in diffuse opacities in both lungs, with minimal sparing of the apices.",0
New endotracheal and nasogastric tubes.,0
"Slight interval progression in diffuse lung opacities, compatible with known diagnosis of Pneumocystis pneumonia.",0
Height: (in) 64 Weight (lb): 186 BSA (m2): 1.90 m2 BP (mm Hg): 143/78 HR (bpm): 71 Status: Inpatient Date/Time: at 09:32 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
GENERAL COMMENTS: Suboptimal image quality - poor suprasternal views.,0
IMPRESSION: Mild pulmonary artery systolic hypertension.,0
Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function.,0
9:58 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: Please perform with dopplers to eval budd chiari Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 21 year old woman with pregnancy and liver failure REASON FOR THIS EXAMINATION: Please perform with dopplers to eval budd chiari ______________________________________________________________________________ WET READ: ARHb WED 3:55 PM Normal greyscal and Doppler evaluation of liver.,1
Small right pleural effusion and right perinephric fluid.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 21-year-old pregnant female with liver failure.,1
FINDINGS: There is no focal or textural hepatic abnormality.,0
There is no intra- or extra-hepatic biliary ductal dilatation.,0
The right kidney measures 11.8 cm and the left kidney measures 9.7 cm.,0
"There is no hydronephrosis, stone or renal mass.",0
A small amount of perinephric fluid is seen on the right.,0
The gallbladder appears normal without stones or wall thickening.,0
The head and body of the pancreas appear normal though the tail is poorly evaluated.,0
The spleen measures 10.9 cm in craniocaudal dimension and appears normal.,0
A small right pleural effusion is noted.,0
Doppler interrogation of the liver demonstrates normal flow and waveforms in the main portal vein as well as in the intrahepatic portal veins.,0
"Flow and waveforms in the right, middle, and left hepatic veins are normal.",0
The main hepatic artery demonstrates normal flow and waveforms.,0
Normal grayscale appearance of the liver without biliary ductal dilatation.,1
Normal Doppler interrogation of liver.,0
Small right pleural effusion and trace right perinephric fluid.,0
"9:40 PM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: TRAUMA.R/O FX Admitting Diagnosis: CONCUSSION ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with REASON FOR THIS EXAMINATION: r/o fracture CONTRAINDICATIONS for IV CONTRAST: creat bump ______________________________________________________________________________ FINAL REPORT INDICATION: Back pain, status post trauma.",0
TECHNIQUE: Helical axial images of the lumbar spine were obtained without intravenous contrast.,0
LUMBAR SPINE CT: The bones are markedly osteopenic.,0
Only half of L1 is visualized.,0
"There is compression of the L2 vertebral body, most pronounced in the central region.",0
"This appearance is likely consistent with an old compression deformity, and anterior osteophytes are present at L1-2.",0
"There is an irregular contour of the posterior aspect of the L2 vertebral body, with an osseous prominence extending into the spinal canal posteriorly.",0
This may represent an acute fracture.,0
"However, this appearance could be due to chronic changes.",0
Posterior osteophytes are seen at the L3-4 level and there is disc space narrowing at this level.,0
A Schmorl's node is present at the inferior endplate of L3.,0
The L4 and L5 vertebral bodies are unremarkable.,0
"There are posterior facet degenerative changes at multiple levels, most severe at the L5-S1 level.",0
There is first degree spondylolisthesis at L5-S1 due to facet degeneration.,0
CT RECONSTRUCTIONS: Coronal and sagittal reformatted images confirm the above-mentioned findings.,0
IMPRESSION: 1) Multilevel chronic degenerative changes.,0
2) Irregular contour of L2 with some retropulsion.,0
"This may be chronic, however, an acute fracture is also possible.",0
12:18 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall.,0
TRAUMA TWO SERIES: AP portable chest with overlying trauma board shows no evidence of traumatic injury.,0
There is mild emphysematous change without evidence of pneumothorax or contusion.,0
Cardiac leads in appropriate position.,0
Line overlying the left heart border is outside the patient correlating with the subsequent CT scan.,0
Three small pulmonary nodules seen in the right lung are below the level of detection on the current radiograph.,0
No evidence of fracture or traumatic injury in the osseous pelvis.,0
IMPRESSION: No evidence of traumatic injury throughout the chest and pelvis.,0
5:03 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: NEC PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with pancreatitis and cholangitis.,1
REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .,0
FINDINGS: Exam is limited by marked patient rotation.,0
"This factor, along with differences in positioning limit comparison to the previous study.",0
"There has been apparent enlargement of a large left pleural effusion and moderate right pleural effusion, accompanied by bibasilar atelectasis.",1
Repeat non-rotated radiograph may be helpful to allow more accurate comparison to the prior study.,0
"Endotracheal tube and right PICC are unchanged in position, but a feeding tube has been removed.",0
3:55 PM CHEST (PA & LAT) Clip # Reason: s/p CT removal f/u R side atelectasis Admitting Diagnosis: AORTIC STENOSIS\BENTAL PROCEDURE W/ TOTAL ARCH UNDER DEEP HYPOTHERMIC CIRCULATION ARREST; CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man REASON FOR THIS EXAMINATION: s/p CT removal f/u R side atelectasis ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 82-year-old man status post chest tube removal.,1
FINDINGS: In comparison to the prior film the left-sided chest tube has now been removed.,0
A small pleural effusion remains on the left side.,1
Opacities in the right lower lobe are stable.,0
PATIENT/TEST INFORMATION: Indication: S/P Ethanol Ablation Height: (in) 70 Weight (lb): 178 BSA (m2): 1.99 m2 BP (mm Hg): 116/72 HR (bpm): 81 Status: Inpatient Date/Time: at 09:23 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Conclusions: There is moderate symmetric left ventricular hypertrophy.,0
There is a mild resting left ventricular outflow tract obstruction.,0
There is systolic anterior motion of the mitral valve leaflets.,1
"There is mild LVH, with slightly more hypertrophy at the basal septum, with a small resting gradient and systolic anterior motion of the mitral valve.",1
Wall thicknesses may have been UNDERestimated on prior.,0
THIS STUDY WAS AMENDED ON DUE TO A TYPO IN THE PRIOR REPORT.,0
"7:07 AM CHEST (PORTABLE AP) Clip # Reason: Evalutate for interval changes in pneumonia and bilateral ef Admitting Diagnosis: ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with Takatsubo's/stress cardiomyopathy, SBO, PNA (bilateral upper lobe, ?",0
"RLL and retrocardiac), bilateral pleural effusions.",0
REASON FOR THIS EXAMINATION: Evalutate for interval changes in pneumonia and bilateral effusions.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia.,0
Bilateral pleural effusions persist as does increased airspace and linear opacities involving both lungs.,0
Right internal jugular central venous catheter is unchanged in position.,0
10:33 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with GIB with hct of 21 REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: GI bleed with shortness of breath.,0
PORTABLE AP CHEST: The heart size is normal.,0
BP (mm Hg): 125/59 HR (bpm): 77 Status: Inpatient Date/Time: at 09:54 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
"The inferior vena cava is dilated (>2.5 cm), with minimal respiratory variation consistent with a right atrial pressure >20 mmHg.",0
RIGHT VENTRICLE: The right ventricular free wall is hypertrophied.,0
There is moderate-severe global left ventricular hypokinesis.,0
IMPRESSION: Moderate-severe global left ventricular systolic dysfunction c/w diffuse process.,0
10:56 AM CHEST (PA & LAT) Clip # Reason: evaluate pulm funct.,0
"______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with newly diagnosed mesothelioma, s/p L pneumonectomy, pleurectomy, pericardiectomy.",0
REASON FOR THIS EXAMINATION: evaluate pulm funct.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonectomy.,0
"CHEST, TWO VIEWS: Comparison is made to study of .",0
There has been interval fluid accumulation in the left hemithorax with expected left mediastinal shift status post left pneumonectomy.,0
Note made of resected 6th posterior rib.,0
Right lung is clear and no pleural effusion is seen on the right.,0
IMPRESSION: Expected early postpneumonectomy changes with accumulation of fluid in the left hemithorax.,0
LINE PLACEMENT Clip # Reason: 56cm SL l basilic PICC ?,0
tip Admitting Diagnosis: DECUBITUS ULCER ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with new picc REASON FOR THIS EXAMINATION: 56cm SL l basilic PICC ?,0
tip ______________________________________________________________________________ FINAL REPORT HISTORY: PICC line placement.,0
"FINDINGS: In comparison with study of , there has been placement of a left subclavian PICC line that extends to the upper to mid portion of the SVC.",0
Obliquity of the patient makes it extremely difficult to evaluate the heart and lungs.,0
There is suggestion of some increasing prominence of the pulmonary vessels as well as haziness in both lower lungs that could reflect layering pleural effusions.,0
1:44 PM CHEST (PA & LAT) Clip # Reason: ?,0
PNA Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with REASON FOR THIS EXAMINATION: ?,1
PNA ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia.,0
Four radiographs of the chest again demonstrate a nasogastric tube with its tip in the stomach.,0
A right subclavian central venous catheter is present with its tip in the SVC.,0
The appearance of the heart and lungs are similar to that noted previously.,0
The right costophrenic angle is excluded.,0
Hyperinflation of both lungs is unchanged.,0
The right apex is again excluded.,0
1:18 AM CHEST (PORTABLE AP) Clip # Reason: ett placement Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with ett REASON FOR THIS EXAMINATION: ett placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Evaluate ET tube.,1
"ET tube tip is 7.6 cm above the carina, almost in the same position as in prior study performed a day earlier.",0
"GI BLEEDING STUDY Clip # Reason: 72 Y/O WITH GI BLEEDING,MAROON STOOLS, NO S/P 8U PRBC.",0
C SCOPE WITH BLOOD IN ASCENDING COLON + DIVERTICULOSIS ______________________________________________________________________________ FINAL REPORT RADIOPHARMACEUTICAL DATA: 15.2 mCi Tc-m RBC (); HISTORY:72 year old woman with melena.,1
"INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-m, blood flow and dynamic images of the abdomen for 90 minutes were obtained.",0
A left lateral view of the pelvis was also obtained.,0
Blood flow images show no active bleeding.,0
Dynamic blood pool images show no bleeding after 90 minutes.,0
"Note is made of non-visualization of the kidneys and bladder, uncertain etiology.",0
IMPRESSION:1.No evidence of active GI bleeding.,0
Non-visualization of kidneys and bladder could relate to chronic renal failure.,1
Approved: 4:34 PM RADLINE ; A radiology consult service.,0
"1:11 PM CTA HEAD W&W/O C & RECONS Clip # Reason: ?avm Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with basal ganglia bleed REASON FOR THIS EXAMINATION: ?avm No contraindications for IV contrast ______________________________________________________________________________ WET READ: AEBc SAT 3:29 PM 3 cm diameter intraparenchymal hemorrhage in the right thalamus and adjacent white matter, with eruption into the right lateral ventricle; mild surrounding edema without midline shift or herniation; no evidence of arteriovenous malformation; continued follow-up recommended.",0
______________________________________________________________________________ FINAL REPORT EMERGENCY HEAD CT SCAN AND CT ANGIOGRAPHY OF THE HEAD HISTORY: 73-year-old man with right basal ganglia bleed.,0
TECHNIQUE: Preliminary non-contrast CT scan of the brain was obtained.,0
"There were no prior studies, which were presumably obtained elsewhere to make the diagnosis, for comparison.",0
"FINDINGS: An approximately 20 x 29 mm hemorrhage is noted within the posterior aspect of the right thalamic area, extending across the posterior limb of the right internal capsule into the adjacent right lentiform nucleus.",0
"There is a moderate amount of extension of hemorrhage within the choroid plexus of the right lateral ventricle, with a minimal amount of layering of free intraventricular blood in the occipital horns.",0
There is no subfalcine herniation.,0
There is a small amount of edema anterior to the hemorrhage itself.,0
There is extensive atherosclerotic calcification involving the cavernous portions of both internal carotid arteries.,0
"No overt extracranial abnormality is seen other than moderate bilateral ethmoid sinus mucosal thickening, presumably inflammatory in origin.",0
"CONCLUSION: Moderate-sized right-sided thalamic/internal capsule/lentiform nucleus hemorrhage, with intraventricular extension as noted above.",0
"ADDENDUM: There is a 1 cm linear calcification adjacent to the anterior aspect of the left temporal lobe cortex, presumably dystrophic dural calcification.",0
CT ANGIOGRAPHY OF THE HEAD USING BOLUS INTRAVENOUSLY ENHANCED IMAGING.,0
FINDINGS: There is extensive atherosclerotic calcification involving the region of the visualized distal aspect of the common carotid bifurcations.,0
The major tributaries of the circle of appear patent.,0
There is no definite (Over) 1:11 PM CTA HEAD W&W/O C & RECONS Clip # Reason: ?avm Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) identification of pathologic vascularity in the area of the intracranial hemorrhage.,1
This finding argues against an underlying mass lesion that is frankly hypervascular.,0
"Occasionally, so-called vascular lesions may be difficult to discern acutely due to compression of their vascular component by hemorrhage.",0
"There is a punctate calcification, presumably post-inflammatory, in the region of the left oropharyngeal tonsil, as well as adjacent secretions approximating the endotracheal tube posteriorly.",0
CONCLUSION: No definite associated pathological vascularity in relation to the above-described hemorrhage.,0
Please see above report for additional discussion.,0
The preliminary findings provided by Dr. to the emergency department staff are in with those noted in this final attending review.,0
"1:43 PM CT HEAD W/O CONTRAST Clip # Reason: eval elevated intracranial pressure, mass ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with vomiting, hypertension REASON FOR THIS EXAMINATION: eval elevated intracranial pressure, mass No contraindications for IV contrast ______________________________________________________________________________ WET READ: SESHa MON 2:54 PM c/w ct dated .",0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT NON-CONTRAST HEAD CT PERFORMED ON Comparison is made with a prior CT head from .,0
"CLINICAL HISTORY: 69-year-old female with vomiting, hypertension, question intracranial mass/edema.",0
"TECHNIQUE: Non-contrast head CT with axial, coronal, and sagittal reformations.",0
"FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction.",0
"There is stable mild periventricular white matter hypodensity, compatible with chronic microvascular ischemic disease.",0
The ventricles are stable in size without enlargement.,0
"The paranasal sinuses, mastoid air cells, and middle ear cavities are well aerated.",0
"Chronic microvascular ischemic disease, unchanged.",0
"3:41 AM CHEST (PORTABLE AP) Clip # Reason: evaluate ETT, interval change Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with resp.",0
"failure REASON FOR THIS EXAMINATION: evaluate ETT, interval change ______________________________________________________________________________ FINAL REPORT EXAMINATION: AP chest.",0
Single AP view of the chest is obtained at 0505 hours and compared with the prior morning's radiograph performed at 0524 hours.,0
There has been worsening of the appearance of the chest since the prior examination with increasing edema and bilateral pleural effusions.,0
Right-sided IJ line is unchanged in position.,0
IMPRESSION: Worsening appearance of pulmonary edema and bilateral pleural effusions since prior morning.,0
Findings were discussed with Dr. at 0955 hours.,0
", F. SICU-B 4:53 AM CHEST (PORTABLE AP) Clip # Reason: access lungs, look at ETT placement Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man just intubated REASON FOR THIS EXAMINATION: access lungs, look at ETT placement ______________________________________________________________________________ PFI REPORT Normal ET tube placement.",0
"6:21 AM C-SPINE, TRAUMA Clip # Reason: r/o fracture ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with s/p rollover mvc REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Roll over MVA trauma.",0
"C-SPINE, 6 FILMS: There is no acute fracture or dislocation.",0
There is no significant loss of vertebral body or disc heights.,0
No significant prevertebral soft tissue swelling.,0
Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: 1.,0
"PICC placement History of Present Illness: F w/ h/o PE on coumadin, HTN, Afib, diastolic CHF p/w respiratory distress from NH.",1
Pat was noted to be in respiratory distress at rehab.,0
Was brought to ED for further eval.,0
"There, she was noted to have lots of oral secretions, fixed pinpoint pupils (not on narcotics), altered mental status.",0
She was afebrile and satting in 70s.,0
"She was originally DNR/DNI, but daughter ()changed code status to full at bedside.",0
"She was intubated, central and A-line access were established, and antibiotics (vanco/ Zosyn) given.",0
"She underwent CTA that in wet read showed no PE, opacities most likely consistent with pulmonary edema.",0
Patient was also hypertensive and was started on nitro drip.,0
No lasix given because of ARF w/ Crea 1.9 (baseline 0.9 in ).,0
ED Vitals upon transfer: 127/70 (A-Line correlates with cuff) 61 18 99% on AC.,0
Transfer to ICU for further care.,0
"Of note, on CTX for UTI recently (last day ).",0
WBC 14K (from peak 20K); BCX w/ GNR.,0
"Past Medical History: h/o multiple PEs on CTA , on lovenox HTN hypothyroidism GERD Afib (no anticoagulation)- possibly for fall risk?",1
"arthritis CHF- last EF>60% with LV diastolic dysfunction NKDA Social History: denies use of tobacco, ETOH, illicit drugs.",1
"Family History: non-contributory Physical Exam: Sedated, on vent.",0
Not responding to verbal or physical stimuli.,0
"Pupils pinpoint, not reacting S1, S2, regular but with frequent pauses, +systolic murmur at base Lungs with coarse BS b/l, decreased at bases Abd +BS, soft, NT, ND Ext: ++pitting edema to below knee b/l; skin is slightly erythematous and warm over legs b/l Pertinent Results: Labs: 9.0>30.8<360 N:92.3 L:4.6 M:2.9 E:0.2 Bas:0.1 138 97 71 214 4.8 31 1.9 Ca: 7.0 Mg: 2.1 P: 5.5 D CK: 23 MB: Notdone Trop-T: 0.04 PT: 31.6 PTT: 37.1 INR: 3.3 Lactate:3.1 ABG: 7.41/53/370 Intubated; FiO2%:100; AADO2:310; Req:56; TV:600; Mode:Assist/Control .",0
Imaging: CT HEAD W/O CONTRAST 7:45 PM CT HEAD W/O CONTRAST Reason: r/o ICH as cause of ALOC MEDICAL CONDITION: year old woman with resp failure INR 3.3 also ALOC REASON FOR THIS EXAMINATION: r/o ICH as cause of ALOC CONTRAINDICATIONS for IV CONTRAST: None.,0
"INDICATION: -year-old woman with respiratory failure, INR of 3.3 as well as loss of consciousness.",1
No definite trauma history provided.,0
"FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, hydrocephalus or acute vascular territorial infarct.",0
Moderate-to-severe involutional change is stable.,0
Periventricular and subcortical white matter hypodensity consistent with small vessel ischemic disease is also stable as are lacunes in the left external capsule and left basal ganglia.,0
Calcification of the distal vertebral and cavernous internal carotid arteries is again noted.,0
There is opacification of scattered ethmoid air cells as well as mucosal thickening within the right sphenoid air cell.,0
"CTA CHEST W&W/O C&RECONS, NON-CORONARY 4:45 PM CTA CHEST W&W/O C&RECONS, NON- Reason: eval for new/worsening PE Field of view: 36 Contrast: OPTIRAY MEDICAL CONDITION: year old woman with recent PNA and prior PE p/w resp failure, intubated REASON FOR THIS EXAMINATION: eval for new/worsening PE CONTRAINDICATIONS for IV CONTRAST: None.",0
INDICATION: -year-old female with recent pneumonia and prior PE presenting with respiratory failure.,1
COMPARISON: CTA chest from .,0
TECHNIQUE: MDCT axial images from the thoracic inlet through the mid abdomen were obtained prior to and following administration of 90 cc of intravenous Optiray contrast.,0
CT CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: Again demonstrated is a heterogeneously enhancing 3.5 x 5.4 cm mass in the right lobe of the thyroid gland.,0
"The lesion is compresses the trachea, displacing the endotracheal tube to the left.",0
"The tip of the endotracheal tube terminates in a slightly low position, only 1.3 cm above the carina.",0
No filling defects are seen within the pulmonary arterial vasculature to indicate underlying pulmonary embolus.,0
There is severe enlargement of all four cardiac .,0
Calcifications are noted in the coronary vessels and aortic valve annulus.,0
"No pathologically enlarged mediastinal, hilar or axillary lymph nodes are identified.",0
"The lungs demonstrate diffuse ground-glass opacities within the upper lobes, right greater than left, with associated smooth intralobular septal thickening, consistent with pulmonary interstitial edema.",0
There is mild dependent bibasilar atelectasis.,0
Nasogastric tube is seen with its tip in the stomach.,0
"In the imaged upper abdomen, the visualized liver dome, spleen and stomach appear grossly unremarkable.",0
There are no osseous findings suspicious for malignancy.,0
Moderately severe degenerative changes are present throughout the thoracic spine.,0
There is severe osteoarthritis involving the left shoulder with subchondral cystic change and heterotopic bone formation involving the head of the humerus and glenoid.,0
"Low-lying endotracheal tube, only 1.3 cm above the carina.",0
"Small bilateral pleural effusions with widespread ground-glass opacity in the upper lobes and interlobular septal thickening, consistent with pulmonary edema.",0
Heterogeneous mass in the right thyroid gland which displaces the endotracheal tube.,0
Severe osteoarthritis of the left shoulder.,0
Echocardiogram The left atrium is moderately dilated.,0
"If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis.",0
IMPRESSION: No evidence of endocarditis or abscess seen.,0
Dilated and hypokinetic right ventricle with severe pulmonary artery systolic hypertension.,0
"Compared with the prior study (images reviewed) of , the right ventricle appears slightly dilated and hypokinetic on the current study (may have been so on the prior but is not well visualized).",0
"UNILAT LOWER EXT VEINS 8:14 AM UNILAT LOWER EXT VEINS Reason: eval for DVT MEDICAL CONDITION: year old woman with known history of PE in , now with L>R lower ext edema REASON FOR THIS EXAMINATION: eval for DVT ULTRASOUND WITH DOPPLER STUDIES, LEFT LOWER EXTREMITY HISTORY: -year-old patient with known history of pulmonary embolism in , now with lower extremity edema, left greater than right.",1
"Assess for DVT, left side.",0
"FINDINGS: The common femoral, superficial femoral, and the popliteal veins show normal appearance, compressibility, and Doppler flow.",0
CONCLUSION: No evidence for DVT in the left lower extremity by ultrasound examination.,0
CHEST (PORTABLE AP) 5:47 AM CHEST (PORTABLE AP) Reason: interval change MEDICAL CONDITION: year old woman with pulmonary edema REASON FOR THIS EXAMINATION: interval change INDICATIONS: -year-old woman with pulmonary edema.,0
"CHEST, AP SUPINE PORTABLE: Comparison is made to the prior day.",0
"A nasogastric tube enters the stomach, and a PICC line terminates in the superior vena cava.",0
There is similar cardiomegaly with low lung volumes and moderately large bilateral pleural effusions.,0
"However, the visualized lung parenchyma is unremarkable.",0
The lung fields are partly obscured at the apices by the kyphotic orientation of the patient.,0
IMPRESSION: Bilateral pleural effusions with no significant change.,0
"Brief Hospital Course: F w/ h/o PE on coumadin, HTN, Afib, diastolic CHF p/w respiratory distress from NH.",1
MICU Course: Diuresed with IV lasix with good response.,0
"During ICU stay, anticoagulated with heparin gtt given history of PE in .",0
Coumadin restarted on in anticipation of call-out from ICU.,0
"As peripheral edema improved, developed apparent L>R LE edema.",0
LE dopplers were negative for DVT.,0
Developed new white count and diarrhea and started empirically on flagyl for suspected C diff.,0
"C diff toxin came back positive, confirming diagnosis.",0
"The patient was subsequently transferred to the floor, where her diuresis was continued with a combination of furosemide 20 mg twice daily and HCTZ 12.5 mg twice daily.",0
"It was held on the day of discharge due to rising serum bicarbonate and metabolic alkalosis, despite continued significant sacral edema and pleural effusions.",0
Her blood pressure and heart rate were tightly controlled in light of her diastolic CHF.,1
Her baseline oxygen requirement of 2 liters was maintained since transfer from MICU.,0
Her warfarin anticoagulation was also resumed and nearly at goal on discharge.,0
"The patient's delirium remained a significant concern during the hospitalization, with periods of clear sensorium alternating with periods of being difficult to rouse and converse.",0
"She was significantly debilitated during the hospitalization was largely limited to being in bed, physical therapy was initiated.",0
Medications on Admission: Confirmed with Rehab: Levothyroxine 50 mcg DAILY Omeprazole 40 mg Q24H Acetaminophen 1g TID Paroxetine 5 mg QHS Senna 8.6 mg daily Donepezil 10 mg QHS Hydrochlorothiazide 12.5 mg DAILY Lasix 40 mg once a day.,0
Coumadin 4mg (adjusted PRN for INR ) Discharge Medications: 1.,0
Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours.,0
Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.,0
Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP < 110.,0
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): Hold for SBP < 110 or HR < 60.,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks.,0
Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN.,0
Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO twice a day.,0
Discharge Disposition: Extended Care Facility: for the Aged - LTC Discharge Diagnosis: 1.,0
Acute on chronic diastolic congestive heart failure 2.,1
"Acute renal failure, resolved 3.",1
Chronic hypoxia on oxygen 4.,0
History of multiple pulmonary emboli 7.,0
"Clostridium difficile colitis Discharge Condition: Fair Discharge Instructions: Weigh yourself every morning, MD if weight > 3 lbs.",1
"Adhere to 2 gm sodium diet Please contact your primary care physician if you develop worsening shortness of breath, edema, or chest pain.",0
Followup Instructions: Make a follow up appointment with the Rehab physicians,0
"6:11 PM CHEST (PORTABLE AP) Clip # Reason: look for line placement, pneumothorax Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 59 yo m w/ bile leak, s/p routine line change REASON FOR THIS EXAMINATION: look for line placement, pneumothorax ______________________________________________________________________________ FINAL REPORT INDICATION: Status post line change, evaluate for pneumothorax.",0
"SINGLE VIEW CHEST: No pneumothorax is identified, though the sulci are excluded from the radiograph.",0
There is now a left internal jugular catheter which terminates in the left brachiocephalic vein.,0
The left subclavian and right- sided Swan- Ganz catheters are unchanged in position.,0
The tracheostomy tube is also unchanged.,0
"Again noted are extensive, patchy bilateral pulmonary infiltrates which are not significantly changed in the short interval.",0
"No evidence for pneumothorax, though the evaluation is limited as the sulci are not included on the film.",0
9:16 PM C-SPINE (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: please do AP and lateral c-spine films Admitting Diagnosis: PAIN CONTROL ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p ACDF C4-6.,0
Please do AP and Lateral C-spine films REASON FOR THIS EXAMINATION: please do AP and lateral c-spine films ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old status post ACDF of C4-6.,0
"TWO VIEWS, CERVICAL SPINE: The patient has undergone anterior fusion with anterior plate and screws transfixing the C4 through C6 vertebral body levels.",1
There are radiolucent interbody grafts.,0
There are multilevel degenerative changes.,0
No evidence of early hardware failure.,0
"4:32 AM CHEST (PORTABLE AP) Clip # Reason: eval resolution of volume overload Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with GIB, intubated with R IJ central line and OG tube REASON FOR THIS EXAMINATION: eval resolution of volume overload ______________________________________________________________________________ FINAL REPORT CHEST, AP FRONTAL VIEW, SEMI-ERECT: HISTORY: 58-year-old with GI bleed, intubated.",1
"FINDINGS: Frontal semi-erect radiograph, comparison , demonstrates interval improvement in the aeration of the left lung.",0
The small-to-moderate right pleural effusion is not significantly changed.,0
Mediastinal vascular engorgement continues to be present.,0
"Endotracheal tube terminates 2.2 cm above the carina, and the right central venous catheter terminates in the mid SVC.",0
Heart size and pleural surfaces are unremarkable.,0
IMPRESSION: Mild left and moderate right pulmonary edema with small-to-moderate right pleural effusion.,0
"1:32 PM CT HEAD W/O CONTRAST Clip # Reason: Follow up ventricle size post vent drain removal 1 week ago Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with sah, s/p coiling REASON FOR THIS EXAMINATION: Follow up ventricle size post vent drain removal 1 week ago No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 68-year-old female with subarachnoid hemorrhage, status post coiling.",1
Follow up for ventricular size.,0
This study is compared with the similar examination performed on .,0
There is again noted are metallic artifacts related to coil placement.,0
There is interval removal of the ventricular drain noted.,0
Periventricular deep white matter ischemic changes noted.,0
The previously noted intraventricular hemorrhage has now almost disappeared.,0
IMPRESSION: 1) Stable brain with no significant interval change in the status of the ventricles.,0
2) There is interval removal of the ventricular catheter noted.,0
5:23 PM HAND (AP & LAT) SOFT TISSUE BILAT Clip # Reason: Bilateral - r/o fracture ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman r/o fracture REASON FOR THIS EXAMINATION: Bilateral - r/o fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
"BILATERAL HANDS: Today's films are somewhat limited, due to patient positioning and overlying artifact from structures outside the hand.",0
"There does appear to be relative prominent soft tissue swelling over the dorsum of both hands, of uncertain chronicity.",0
There is degenerative change at the interphalangeal joints of both thumbs.,0
"Grossly, no fracture or dislocation is identified.",0
1:01 AM CHEST (PA & LAT) Clip # Reason: Eval for etiology CP and SOB ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman with chest pain and dyspnea.,0
Eval etiology of chest pain.,0
"REASON FOR THIS EXAMINATION: Eval for etiology CP and SOB ______________________________________________________________________________ FINAL REPORT INDICATION: 26-year-old woman with chest pain and dyspnea, evaluate etiology of chest pain.",0
COMPARISON: Portable AP chest radiograph .,0
PA AND LATERAL CHEST RADIOGRAPH: Opacification of the left hemithorax is concerning for empymea with pneumonia.,0
The cardiac silhouette is prominent concerning for pericardial efffusion.,0
The right lung appears unremarkable.,0
There is no significant shift of mediastinal structures.,0
Opacification of the left hemithorax concerning for empyema with pneumonia.,0
Prominent cardiac silhouette concerning for pericardial efffusion.,0
Recommend CT scan for further evaluation.,0
Findings discussed with Dr. at 8:05am on via telephone.,0
3:54 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with lung cancer REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT STUDY: AP chest .,0
CLINICAL HISTORY: 55-year-old man with lung cancer.,0
There has been removal of the endotracheal tube and the right IJ central line.,0
There is a left-sided central venous catheter with distal lead tip in the proximal SVC.,0
There is increased opacification within the left lung apex.,0
"There are areas of consolidation within the left lung, stable.",0
The right lung base appears relatively well aerated.,0
12:11 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval progression Admitting Diagnosis: BLADDER MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with s/p cystectomy now hypotensive REASON FOR THIS EXAMINATION: evaluate for interval progression ______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative hypotension.,1
"FINDINGS: In comparison with the study of , there are somewhat lower lung volumes, which may account for the apparent increase in the transverse diameter of the chest.",0
Engorgement of poorly defined pulmonary vessels is consistent with overhydration or vascular congestion.,0
"No definite focal pneumonia, though the area behind the heart cannot be evaluated in the absence of a lateral view.",0
"Nasogastric tube is in place with its tip at least extending to the cardioesophageal junction, where it passes the bottom of the image.",0
"8:46 AM CHEST (PORTABLE AP) Clip # Reason: please assess for pulm edema vs. pna Admitting Diagnosis: PAROTID CANCER; HYPERGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with hx parotid ca, copd with new onset cough/rll crackles REASON FOR THIS EXAMINATION: please assess for pulm edema vs. pna ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MXAk 10:11 AM PFI: No acute cardiopulmonary process.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of patient with history of parotid carcinoma and COPD with cough.,1
FINDINGS: A single upright portable chest radiograph is obtained.,0
There has been little change in comparison to prior study from two days ago.,0
"The lungs are clear with no evidence of consolidation, effusion, or pneumothorax.",0
There is a relative lucency of the lung apices suggesting a component of COPD.,0
Tortuosity of the aorta is again noted.,0
The visualized osseous structures are grossly normal.,0
"10:04 AM CT HEAD W/O CONTRAST Clip # Reason: LEFT MCA INFARCT, S/P TPA, ASSESS FOR INTERVAL CHANGE, EVOLVING INFARCT Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with left mca infarct, status post tpa .",0
"REASON FOR THIS EXAMINATION: assess for interval change, evolving left MCA infarct.",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Left MCA infarct status-post TPA; assess for internal change.,0
"FINDINGS: There is an area of low attenuation involving the left frontal, parietal and temporal lobes (i.e., the MCA territory).",0
This area of low attenuation was not visualized on the prior study.,0
"A linear hyperdensity is visualized along the course of the left middle cerebral artery, likely representing the dense middle cerebral artery sign for acute ischemia.",1
There is no evidence of hemorrhage.,0
The surrounding soft tissue and osseous structures are unremarkable.,0
IMPRESSION: Left dense MCA sign with evolving left middle cerebral artery infarct.,0
"3:08 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman L lung bleed, intubated REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST FILM, AT 3:04 AM CLINICAL INDICATION: 37-year-old with left lung bleed, intubated, assess for interval change.",0
Comparison is made to the patient's previous study dated at 13:08.,0
A single portable supine chest film at 3:04 a.m. is submitted.,0
There is persistent opacification of the left hemithorax with some residual aeration at the left lower lobe associated with volume loss and mediastinal and cardiac shift to the left.,0
"Overall, the appearance does not appear to be significantly changed.",0
The endotracheal tube continues to have its tip 4 cm above the carina.,0
A right internal jugular central line has its tip in the distal SVC.,0
Nasogastric tube is seen coursing below the diaphragm with the tip within the stomach.,0
A portion of an inferior vena caval filter is also visualized at the edge of the film within the abdomen.,0
"The right lung is well inflated without evidence of focal airspace consolidation, pulmonary edema, or pleural effusion.",0
There is a stable calcified nodule measuring 1.3 cm in the seventh interspace.,0
This most likely represents a calcified granuloma.,0
No acute bony abnormality is appreciated.,1
9:02 PM CHEST (PORTABLE AP) Clip # Reason: s/p R subclavian line ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with trauma REASON FOR THIS EXAMINATION: s/p R subclavian line ______________________________________________________________________________ FINAL REPORT INDICATION: Right subclavian line.,0
IMPRESSION: The tip of the right subclavian IV catheter in superior vena cava.,0
"COMMENT: Portable AP radiograph of the chest is reviewed, and compared with the previous study of yesterday.",0
The tip of the right subclavian IV catheter in the superior vena cava.,0
The patient has new tracheostomy tube.,0
Plate like atelectasis is seen in the right lung base.,0
11:16 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?,0
ngt placement Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman repeatedly pulling out own ngt REASON FOR THIS EXAMINATION: ?,0
"ngt placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 11:39 P.M. HISTORY: Replaced NG tube.",0
IMPRESSION: AP chest compared to 10:46 p.m.: Nasogastric tube would need to be advanced at least 10 cm to move all the side ports beyond the gastroesophageal junction.,0
"1:06 AM CHEST (PORTABLE AP) Clip # Reason: inc work of breathing, dropping sats, rec fluid for low BP Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: year old woman w/GIB, intubated for respiratory failure, extubated.",1
"underwent /egd - no active bleed REASON FOR THIS EXAMINATION: inc work of breathing, dropping sats, rec fluid for low BP ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: -year-old woman intubated for respiratory failure and then extubated.",1
Cardiac size is probably within normal limits.,0
Bilateral effusions are present consistent with failure.,0
Areas of atelectasis are seen in the right midzone.,0
There is increased density in the left retrocardiac area.,0
This could be due to the presence of the effusion but an underlying infiltrate is not excluded.,0
"IMPRESSION: Bilateral pleural effusions probably indicating failure, atelectasis, consolidation left lower lobe.",0
"5:25 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: HEMATURIA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old woman with bladder ca s/p pea arrest now with minimal neurologic activity, extubated REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Bladder cancer status post arrest.",1
Continued mild to large layering pleural effusion on the right with compressive atelectasis.,1
Similar opacification at the left base consistent with atelectasis and small pleural effusion.,1
Known bilateral pulmonary nodules are seen in better detail on the recent CT scan.,0
12:41 PM CHEST (PORTABLE AP) Clip # Reason: low sats- ?,0
pulmonary process Admitting Diagnosis: SPLENIC LACERATION ______________________________________________________________________________ MEDICAL CONDITION: 27 year old man with splenic infarct REASON FOR THIS EXAMINATION: low sats- ?,0
"pulmonary process ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Splenic infarct, low O2 sats.",0
CHEST AP: A left pleural effusion is present and an underlying consolidation or collapse is probably present also.,1
Elsewhere the lung fields appear clear.,0
IMPRESSION: Left-sided effusion and probable collapse/consolidation of the left lower lobe.,0
"OR THERAPEUTIC PORT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # US ABD LIMIT, SINGLE ORGAN Reason: Please remove 1-2 liters (MAX) of ascites from this patient.",1
"Admitting Diagnosis: ASCITES,CIRRHOSIS,RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with ESLD and new ARF REASON FOR THIS EXAMINATION: Please remove 1-2 liters (MAX) of ascites from this patient.",1
"In the past, she has required large french catheters suprapubically ______________________________________________________________________________ FINAL REPORT ULTRASOUND-GUIDED PARACENTESIS.",0
"FINDINGS/PROCEDURE: After discussion of the risks, benefits, and alternatives of the proposed procedure, written informed consent was obtained.",0
A preprocedure timeout confirmed the patient's identity using three different patient identifiers.,0
Limited ultrasound demonstrated moderate amount of ascites.,0
A spot in the right lower quadrant was marked for paracentesis and the overlying skin was prepped and draped in the usual sterile fashion.,0
1% lidocaine buffered with sodium bicarbonate solution was administered for local anesthesia.,0
"Because of patient's history for tendency for debris to occlude the 5 French catheter, an 8 French Flexima pigtail catheter was used for paracentesis which was easily advanced to the ascitic collection.",0
A total of 2.0 liters of yellow-brown fluid was obtained.,0
Small amount was sent to the laboratory for studies as requested.,0
No immediate complications were evident.,0
"Dr. , the attending radiologist, was present and supervised throughout the entire procedure.",0
"IMPRESSION: Successful diagnostic and therapeutic paracentesis, yielding 2.0 liters of ascites.",1
Small amount of fluid was sent to the laboratory as requested.,0
Weight (lb): 134 BP (mm Hg): 75/39 HR (bpm): 70 Status: Inpatient Date/Time: at 10:14 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal - akinetic; mid inferoseptal - akinetic; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - dyskinetic; septal apex- akinetic; inferior apex - dyskinetic; lateral apex - hypo; apex - dyskinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Thickened MVR leaflets.. Normal MVR gradient.,0
Small vegetation on mitral valve.,0
"There is severe regional left ventricular systolic dysfunction with akinesis of the septum, dyskinesis of the distal inferior wall and apex, and severe hypokinesis of the lateral wall Overall left ventricular systolic function is severely depressed (LVEF= 25 %).",0
There is probable small vegetation on the mitral valve which appears to be attached to the posterior mitral leaflet and prolapses through the valve orifice during the cardiac cycle.,1
Cannot exclude degeneration of the prosthetic valve but appears consistent with vegetation.,0
IMPRESSION: Prosthetic mitral valve vegetation.,0
Well-seated and normally functioning Severe regional left ventricular systolic dysfunction c/w CAD.,0
Mildly dilated and borderline hypokinetic right ventricle.,0
"Compared with the prior study (images reviewed) of , left ventricular function has significantly declined.",0
"Two bioprosthetic valves are present, with a probable vegetatation on the mitral valve.",0
IMPRESSION: Dr. was notified by telephone on at 10:39 am.,0
2:54 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: post / endoleak Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with post L EIA / CFA endo repair REASON FOR THIS EXAMINATION: post / endoleak No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: CTA of the abdomen.,1
CLINICAL HISTORY: 69-year-old man with history of endovascular AAA repair.,0
"TECHNIQUE: Axial images of the abdomen were obtained after administration of intravenous contrast, utilizing the abdominal aortic aneurysm protocol.",1
Sagittally reformatted images were also obtained.,0
Bilateral pleural effusions and patchy bibasilar atelectasis.,0
Liver is normal in size and appearance.,0
"Otherwise, the gallbladder is unremarkable.",0
"The pancreas, spleen and left adrenal gland are normal.",0
There is a stable 8-mm right adrenal nodule.,0
No abdominal or retroperitoneal lymphadenopathy.,0
The patient is post-endovascular repair of abdominal aortic aneurysm.,1
The graft is intact without evidence of endoleak.,0
The aneurysm measures 6.7 x 6.2 cm in maximal diameter.,0
"A right iliac aneurysm measures up to 2.2 cm (sequence 6, image #67).",0
"There is moderate celiac artery stenosis, that is stable.",0
"It is difficult to assess whether the suprarenal component of the endovascular stent graft crosses the renal origin, however, the renal arteries are widely patent.",0
The common femoral arteries are widely patent.,0
Fluid and post-surgical changes are identified in the subcutaneous tissues of the bilateral groins in this patient with interval common femoral artery repair.,1
"There is gas within the urinary bladder, presumably related to prior instrumentation.",0
The prostate contains a small calcification but is otherwise normal.,0
"The seminal vesicles, rectum and sigmoid colon are unremarkable.",0
Bilateral fat-containing inguinal hernias are noted.,0
(Over) 2:54 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: post / endoleak Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,1
"Status post endovascular repair of abdominal aortic aneurysm, without evidence of endoleak.",1
"7:24 AM CHEST (PORTABLE AP) Clip # Reason: Please eval interval change--pt now with significantly decre Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p MI, recent admission for PNA, who presents from rehab with altered mental status, found to have new fever and leukocytosis.",1
REASON FOR THIS EXAMINATION: Please eval interval change--pt now with significantly decreased BS on L side.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old man with chronic heart failure, evaluation of interval change because of decreased breath sounds.",1
"FINDINGS: As compared to the previous examination, there is increasing retrocardiac atelectasis as well as increasing blunting of the costophrenic sinuses.",0
"In conjunction with the increased perihilar haziness and a slight increase in diameter of the pulmonary vessels, moderate pulmonary edema must strongly be considered.",0
The responsible resident was paged at the time of dictation.,0
Unchanged position of the left pectoral pacemaker.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU TEAM HISTORY OF PRESENT ILLNESS: This is a 77 year old female with past medical history of congestive heart failure and coronary artery disease, who was in her usual state of health prior to admission.",1
On the night she was admitted patient was having increased chest pain that actually awoke her from sleep.,0
"She described the pain as , sharp, substernal pain that radiated down her left arm.",0
"She denied shortness of breath, nausea, vomiting, diaphoresis or heart palpitations.",0
EMS gave patient one sublingual nitroglycerin with immediate improvement in her symptoms.,0
She was then transferred to emergency room for further evaluation.,0
In the emergency room patient was given an aspirin that she was unable to chew and she ended up gagging on the aspirin.,0
Shortly after gagging on the aspirin patient appeared to have a vagal reaction and actually went into asystole.,0
She was given one dose of atropine and her cardiac rhythm returned to atrial flutter with variable block patterns.,1
Patient is a very poor historian and was unable to give any additional history.,0
At that time it was discussed at great length with her son about possible options to include a temporary pacer.,0
"The son chose not to have any cardiac intervention done, understanding the risks involved.",0
He stated that in the past his mother had been offered procedures that she had refused.,0
Patient was then admitted to the CCU for further observation.,0
REVIEW OF SYSTEMS: She had been complaining of some visual field defects.,0
"She states ""it is like a shade came down over my right eye.""",0
She was seen by an ophthalmologist for this complaint who told her that it was likely she had a vascular event.,0
In the past she had been offered anticoagulation for her significant history of a-flutter/a-fib which she had refused.,0
"PAST MEDICAL HISTORY: Coronary artery disease, status post two myocardial infarctions.",1
Congestive heart failure with an echo in that showed approximately 20% ejection fraction with moderate to severe mitral regurgitation and right ventricle hypokinesis.,1
She also had ischemic cardiomyopathy.,0
"MEDICATIONS ON ADMISSION: Zestril 10 mg q.d., Lasix 40 mg q.d., Valium p.r.n., Zaroxolyn p.r.n.",0
"ALLERGIES: The patient has an allergy to beta blockers, the reaction is unclear.",0
"She also has an allergy to barbiturates and digoxin, again the reactions are unclear.",0
FAMILY HISTORY: Mother passed away from a cerebrovascular accident.,0
SOCIAL HISTORY: The patient denied alcohol or smoking.,0
"LABORATORY DATA: On admission sodium was 136, potassium 4.1, chloride 98, bicarb 27, BUN 21, creatinine 1, glucose 117.",0
"White blood count 6.4, hematocrit 35.7, platelet count 180.",0
"Differential showed 59 neutrophils, 2 basophils, 28 lymphocytes, 6 monocytes, 1 eosinophil.",0
"Coags showed PT of 12.6, PTT 23.3, INR 1.1.",0
"PHYSICAL EXAMINATION: On admission the patient was afebrile, heart rate 83 beats per minute and regular, blood pressure 117/77, respiratory rate 16 breaths per minute, O2 sat was 98% on 2 liters.",0
"In general, this was a very frail, elderly appearing female who was slightly confused, mumbling and was not coherent.",0
Pupils were equally round and reactive to light.,0
Cranial nerves II-XII were grossly intact.,0
Patient was oriented to place and name only.,0
Pulmonary exam revealed bibasilar crackles.,0
She had decreased respiratory effort.,0
"Abdomen was soft, nondistended, nontender with positive bowel sounds.",0
"Heart was regular rate and rhythm with S1, S2 and S3.",0
"HOSPITAL COURSE: This is a 77 year old woman with a history of coronary artery disease, congestive heart failure, left bundle branch block with a-flutter who is not anticoagulated, status post multiple TIAs.",1
She presented to the emergency room with new onset chest pain that radiated down her left upper extremity.,0
At the time she was refusing any intervention.,0
She was admitted to the CCU for further observation.,0
The patient was admitted and her cardiac enzymes were followed.,0
Initial CK was 82 with troponin of 3.0.,0
"Second CK was 458, MB 88, troponin 34.3.",0
"Shortly after receiving these results, patient became bradycardiac down into the 20s to 30s.",0
"After emergent discussion with her son, the decision was made to place a temporary pacemaker.",0
Dr. discussed the severity of the patient's situation and her slow ventricular escape rate of approximately 20 and the son agreed to have the placement despite her previous wishes not to have this done.,0
"The son stated that she was scared of the procedure, but that she wanted to live and that she was just not thinking clearly at the time she presented to the emergency room.",0
"During placement of the temporary pacemaker, patient went into ventricular fibrillation arrest for which she received defibrillation shocks and then patient when into asystole for which patient was then emergently intubated.",1
Atropine was administered and a temporary pacemaker was placed.,0
She returned to a paced rhythm of approximately 80 beats per minute.,0
An emergent echo was performed at bedside which showed severe global left ventricular and right ventricular hypokinesis.,0
There was no pericardial effusion noted.,0
"On the third day of admission, patient was taken to the electrophysiology lab and a biventricular lead pacer was placed.",0
Patient had the pacer placed at 80 beats per minute.,0
Following extubation she complained of some chest pain around the incision site at which time the pacer configuration was changed to pace at about 70 beats per minute.,0
Pacer was performing well until the fifth day of hospital admission at which point she went into v-tach/v-fib cardiac arrest.,1
Patient was quickly defibrillated and intubated for airway protection.,0
"After a lengthy discussion with her son, it was determined that patient would go to the cardiac cath lab.",0
Cardiac cath revealed a 99% lesion in the LAD which was successfully stented.,0
Patient was then transferred back to the CCU for further management.,0
"For her coronary artery disease she was placed on aspirin 325 mg q.d., Plavix 75 mg q.d.",0
"for 30 days, low dose beta blocker and statin.",0
Her ACE inhibitor was being held until her creatinine returned to approximately 1.5.,0
For her congestive heart failure patient was placed on low dose beta blocker.,1
She received Lasix to relieve her pulmonary symptoms.,0
For her rhythm she received a biventricular lead pacer for which she will follow up with EP for further management.,0
The patient was intubated on two occasions for airway protection.,0
She was easily liberated from the ventilator on both occasions without complications.,0
The patient presented to the emergency room with creatinine of 1.0.,0
"Following her cardiac arrest and the dye load, patient went into acute renal failure with creatinine of 2.4.",1
All nonsteroidals and ACE inhibitors were held.,0
Patient's creatinine gradually improved over her course of stay.,0
Patient should have an ACE inhibitor added to her regimen once her creatinine returns to approximately 1.5.,0
The patient was placed on vancomycin following placement of the biventricular pacer.,0
Her cultures remained negative throughout her stay.,0
The patient is anemic at baseline.,0
During her stay she received 2 units of packed red blood cells.,0
It appeared that she had a minor reaction following the transfusion with a temperature of approximately 101.,0
"The patient had elevated blood sugars, approximately 150 to 200, during her stay.",0
"When discussed with patient, she stated she is not a diabetic and refused further blood sugars along with any additional insulin or hypoglycemics.",0
This issue should be addressed at some point as it appears that the patient is a diabetic.,0
During her stay the patient had to have potassium supplements several times.,0
Of concern is her refusal at times to take p.o.,0
"In addition to her diet, she should have nutritional supplements to include Boost shakes with each meal.",0
Her potassium should be followed closely.,0
The patient is extremely deconditioned and will need inpatient rehabilitation to return to her baseline.,0
Physical therapy worked with the patient while in the hospital.,0
This should continue on an outpatient basis.,0
We have had extensive discussions with her son about his mother's current status and the possibility that she may have daily arrhythmia.,0
"FOLLOWUP: She is to follow up with Dr. , her general cardiologist, within two weeks.",0
She should follow up with her primary care physician within one month.,0
She should follow up with Dr. in approximately one month.,0
DISCHARGE INSTRUCTIONS: Increase nutritional intake.,0
Work with physical therapy to gradually build up her strength.,0
Follow up with her cardiologist and primary care physician.,0
"to the hospital for any heart palpitations, chest pain, upper extremity or jaw pain or shortness of breath.",0
She should have her potassium followed closely.,0
"She should discuss the use of digoxin and Coumadin with her primary cardiologist, Dr. .",0
Plavix 75 mg for 21 additional days.,0
", MD Dictated By: MEDQUIST36 D: 11:48 T: 11:43 JOB#:",0
", F. MED MICU 9:57 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Please do upright film looking for air underdiaphragm Admitting Diagnosis: CONGESTIVE HEART FAILURE;SYNCOPE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with ?",1
air under diaphragm on CXR today REASON FOR THIS EXAMINATION: Please do upright film looking for air underdiaphragm ______________________________________________________________________________ PFI REPORT PFI: No evidence of pneumoperitoneum.,0
"10:11 PM CHEST (PORTABLE AP) Clip # Reason: eval pna, ptx, pmediastinum ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with ipf, h/o pneumomediastinum, low sats REASON FOR THIS EXAMINATION: eval pna, ptx, pmediastinum ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST AT 2211 HOURS.",0
HISTORY: Interstitial pulmonary fibrosis and history of pneumomediastinum with low oxygen saturation.,1
FINDINGS: Lung volumes are markedly diminished.,0
"There are extensive fibrotic changes at the lung bases, grossly stable from the prior exam.",0
Less traumatic opacifications are noted in the more cephalad lungs.,0
"Grossly, there is no superimposed acute process that can be identified when comparing to multiple remote studies.",0
The mediastinum is grossly unremarkable and stable.,0
No definite effusion or pneumothorax is noted.,0
IMPRESSION: Extensive baseline disease with fibrotic changes at the lung bases and scattered mostly peripheral opacities in the upper lungs.,0
No definite superimposed process identified.,0
"4:05 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with pneumonia REASON FOR THIS EXAMINATION: please evaluate for interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Pneumonia, evaluation for interval change.",1
Unchanged moderate cardiomegaly with small left pleural effusion and retrocardiac opacity that likely represents a combination of atelectasis and pneumonia.,0
Overall low lung volumes without evidence of relevant right lung findings.,0
"9:23 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate/edema ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with hx of COPD and weakness, abd pain REASON FOR THIS EXAMINATION: Evaluate for infiltrate/edema ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, AT 21:22 HOURS.",0
HISTORY: History of COPD and weakness with abdominal pain.,0
FINDINGS: The lungs are hyperexpanded and consistent with underlying obstructive lung disease.,0
The cardiac silhouette remains normal in size.,0
IMPRESSION: COPD with no superimposed pulmonary process.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: syncope, altered mental status, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: This is a 61yo male with ESRD on peritoneal dialysis, atrial fibrillation on coumadin, CAD (s/p CABG in ' and PTCA in ') and DMII, who was brought by ambulance from rehab for an episode of unresponsiveness.",1
The patient was apparently found at unresponsive in chair during lunch.,0
"At the time, the SBP was 60s (baseline 80/50s), HR 70s, Glucose 135, ABG: 7.4/44/195.",0
SBP increased to the 90s when placed supine and after receiving 500cc bolus NS.,0
"The patient awoke and was without complaints; he denied chest pain, palpitations, shortness of breath, and did not recall what happened.",0
"Pt was subsequently brought to for ?syncope and ?sepsis, although the latter was thought to be unlikely as he had been receiving broad spectrum antibiotics(vancomycin and meropenem) for heel ulcers that grew MRSA and klebsiella.",1
"In the ED, the patient was found to be tremulous with BP 80/50 and given 4L NS without change in BP.",0
"At this point, the patient was started on dopamine at which point he went into rapid afib.",0
Dopamine was subsequently discontinued and the patient was started on levophed with an increase in BP to 111/52.,0
The patient also had a positive UA with purulent urine (pyuria); he was thus started on fluconazole.,0
CXR and head CT were negative for acute changes.,0
The patient remained afebrile without changes in WBC.,0
"At this point, the patient was sent to the Intensive Care Unit for further evaluation of the patient's hypotension.",1
"CAD: 4 vessel CABG , PTCA/stent and (SVG->OM; SVG->RCA; LIMA-> LAD patent) 2.",0
Ischemic cardiomyopathy with CHF 40% 3.,0
Atrial fibrillation: on coumadin 4.,1
"Type 2 DM with neuropathy, nephropathy, and retinopathy 5.",1
ESRD on Peritoneal Dialysis since 7.,0
Anemia of chronic disease 8.,1
Right SFA-peroneal vein graft @ OSH 3.,0
Left SFA-BKpop vein graft @ OSH 4.,0
Right 1st toe amputation 6.,0
Multiple debridement Social History: Pt is divorced.,0
Quit smoking cigarettes in after 90 pack year history.,0
Retired vice president of insurance company.,0
Family History: Brother has DM.,0
"Physical Exam: Physical Exam: VS: 98 94/46 (baseline 80/40) 80 20 99%RA FS-148 GEN: pleasant, NAD, comfortable appearing male appearing his stated age, multiple bruises throughout HEENT: PERLLA, EOMI, sclera anicteric, no conjuctival injection, mucous membranes slightly dry, no lymphadenopathy, no thryroid nodules or masses, no supraclavicular lymph nodes, no posterior lymphadenopathy, neck supple, full ROM, neg JVD : CTA b/l but decreased breath sounds COR: RRR, S1 and S2 wnl, no murmurs/rubs/gallops ABD: positive bowel sounds, nontender but slightly distended,no guarding, no rebound or masses BACK: neg CVA tenderness EXT: no cyanosis, clubbing, edema.",0
Also has several stage II decubitis on lower extremity with one 3cmx4cm decub on lateral aspect of left leg that is still open.,1
Two others on heel bilateraly appear to be healing stage II ulcers.,1
NEURO: Alert and oriented x3.,0
"CNII-XII are intact, and patient with 5/5 strength throughout, normal sensation throughout.",0
Pertinent Results: 04:12PM URINE COLOR-Yellow APPEAR-Hazy SP -1.018 04:12PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD 04:12PM URINE RBC-* WBC->50 BACTERIA-FEW YEAST-FEW EPI-0-2 .,0
ECG : atrial flutter at 94.,0
"Q in II, III, F, V1, poor R wave progression.",0
"unchanged from previous CXR : no infiltrate, no pulm enlargement, mild CM, L PICC in place, R subclavian line in R atrium CT head : atrophy, chronic R subinsular white matter lacunae, calcification of carotids, no acute bleeds.",1
05:35AM BLOOD WBC-7.6 RBC-2.71* Hgb-8.5* Hct-25.3* MCV-93 MCH-31.3 MCHC-33.5 RDW-16.5* Plt Ct-176 04:48AM BLOOD Neuts-81.0* Lymphs-12.5* Monos-3.9 Eos-2.1 Baso-0.5 02:50PM BLOOD PT-26.3* PTT-57.6* INR(PT)-4.4 05:35AM BLOOD Glucose-150* UreaN-37* Creat-4.1* Na-133 K-3.6 Cl-100 HCO3-27 AnGap-10 04:25AM BLOOD CK-MB-5 cTropnT-0.41* 08:50PM BLOOD CK-MB-NotDone cTropnT-0.33* 02:20PM BLOOD cTropnT-0.42* 05:35AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8 03:58AM BLOOD Cortsol-35.2* XRAY of HEELS The anterior aspect of the calcaneus is not included on the lateral view.,0
Increased density along the extreme posterior periphery of the calcaneus is unchanged compared with and is thought to represent normal variation in the calcaneus.,0
"There is a small erosion in the posterior calcaneus, near the site of Achilles tendon insertion, likely relates to the retrocalcaneal bursa.",0
"Otherwise, no bone destruction, abnormal sclerosis, or periosteal new bone formation is detected.",0
No radiopaque foreign body is detected.,0
No radiographic findings to confirm the presence of osteomyelitis.,0
"URINE CULTURE: YEAST SWAB CULTURE: XANTHOMONAS (Bactrim sensitive), MRSA Brief Hospital Course: 1) SYNCOPE: The patient received a thorough workup for syncope, including evaluation for cardiogenic, neurogenic, and infectious etiologies.",0
"With respect to the cardiac workup, the patient was placed on telemetry to evaluate for possible dysrhythimias, the result of which was negative.",0
"Troponin was found to be slightly elevated compared to baseline, but this was attributed to ESRD.",0
ECHO was performed which revealed normal left ventricular cavity size with moderate global hypokinesis consistent with a diffuse process.,0
There was mild mitral regurgitation and EF was found to be 30-35%.,0
EKG was consistent with a possible old inferior infarct and nonspecific ST-T wave changes.,0
"With respect to a neurogenic etiology, the patient's presentation was found to be consistent with cerebral hypoperfusion in the context of multiple metabolic derangements such as hypotension.",1
Head CT revealed no acute intracranial process and the patient was already anticoagulated on coumadin with an INR of 1.9 for his chronic atrial fibrillation.,1
"With respect to infectious etiologies, the patient was found to have multiple sources, such as the peritoneal dialysis catheter, PICC line, purulent U/A, and multiple ulcers, that could be contributing to a septic hypotension and consequent syncope.",1
The PICC line was removed but found to have no growth on culture.,0
The patient was continued on vancomycin for MRSA cultured from the wound and meropenem for klebsiella cultured from the wound as well (but not documented at this hospital).,0
Bactrim was started to cover for stenotrophomas (from wound culture in past).,0
"Ultimately, the patient was found to have a negative workup with respect to all three interdisciplinary evaluations.",0
Further assessment of the patient's previous hospital records revealed the patient's baseline blood pressure is 80/40.,0
"As such, it is possible the patient's syncopal episode was secondary to hypovolemia in the context of an already brittle blood pressure.",0
"Without evidence of infection, that is without a white count/fever/positive blood culture, all antibiotics were discontinued except fluconazole which was used to treat the patient's UTI with yeast found in culture.",1
Blood pressure remained stable at discharge to the baseline value of 80/40 +/- 10 systolic.,0
"2) MENTAL STATUS CHANGES: On admission, the patient was found to be confused and disoriented.",1
"As stated above, the neurological service evaluated the patient and found this presentation consistent with cerebral hypoperfusion in the context of multiple metabolic derangements including hypotension and UTI.",1
"With resolution of the patient's hypotension and antibiotic treatment for the patient's MRSA, klebsiella, and yeast infections, the patient's mental status returned to baseline.",1
ESRD on peritoneal dialysis: The renal service was consulted and peritoneal dialysis continued.,0
"The patient's outpatient regimen was altered slightly to include: 4 cycles, Dextrose 2.5%, 2.5 liters, dwell time 4 hours with alternating Dextrose solutions between 2.5% and 1.5%.",0
DMII: The patient's outpatient lantus dose was initially held in light of the patient's decreased PO intake and substituted with a regular insulin sliding scale.,0
"After the patient was transferred to the floor from the intensive care unit, however, the patient's outpatient dose will need to be restarted.",0
"At discharge, however, the patient was able to tolerate his outpatient lantus dose of 4 units.",0
CAD: The patient was noted to have a baseline troponin of 0.2 and renal failure.,1
"The patient denied chest pain, which would not necessarily be surprising in a diabetic.",1
"However, troponins did not increased and the patient did not demonstrate other cardiac symptoms.",0
"He was continued on ASA and statin in the intensive care unit, but metoprolol was held initially secondary to hypotension.",0
"At discharge, the patient was able to tolerate a dose of 12.5 mg metoprol twice daily.",0
ATRIAL FIBRILLATION: The patient experienced an episode of RVR on dopamine which resolved with discontinuation of that drug.,1
Coumadin should be restarted when INR is less than 2.5 at a dose of 1 mg each night.,0
PAIN: Pain was adequately addressed with dilaudid iv as needed.,0
Code: DNR/DNI as per discussion with patient.,0
"(son, , , OR: B).",0
Dr. @ tel: / cell: Medications on Admission: 1.,0
Aspirin 81mg once daily 2.,0
Fentanyl Patch 75mcg q72hours (inc from 50mcg q72hours on ) 4.,0
Lexapro 20mg once daily 5.,0
Ambien 10mg PO QHS PRN 6.,0
Ativan 0.5mg PO Q8hours PRN 7.,0
Calcitriol 0.25mg once daily 8.,0
Calcium Carbonate 500mg TID 9.,0
"Epogen 10000units sub Q three times/week (Mon, Wed, Fri) 10.",0
Zocor 10mg once daily 11.,0
Coumadin 1.5mg QHS (last INR 1.9 on ) 12.,0
Protonix 40mg once daily 13.,0
Dilaudid 2mg 1-2 tabs q3-4 hours PRN 14.,0
Vancomycin 1gm Q22hours until 17.,0
Meropenem 500mg IV BID until 18.,0
Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection DAILY (Daily).",0
"Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday).",0
Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS PRN () as needed for agitation.,0
Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days.,0
Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed for pain.,0
Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed.,0
Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days.,0
Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Please restart when INR < 2.5.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: * hypotension complicated by syncope * bilateral heel ulcers with osteomyelitis * s/p multiple toe amputations with MRSA positive wound cultures * ESRD on peritoneal dialysis * Diabetes * atrial fibrillation * CAD Discharge Condition: good Discharge Instructions: 1.,1
Please take all of your medications.,0
"Please seek medical attention should you experience any of the following: shortness of breath, chest pain, palpitations, sudden weakness, lightheadedness, dizziness, loss of consciousness, fainting, nausea, vomiting, fever, chills Followup Instructions: Provider: Where: Date/Time: 8:00 Provider: , SURGERY Where: SURGERY Date/Time: 9:00 MD,",0
11:58 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?ptx s/p waterseal...please do around noon today.,0
"thanks Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with necrotizing fasciitis, now s/p RSC CVL line change over a wire REASON FOR THIS EXAMINATION: ?ptx s/p waterseal...please do around noon today.",1
thanks ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
"INDICATION: Necrotizing fasciitis, now status post RSC and central venous line change over a wire.",1
FINDINGS: AP single view of the chest has been obtained with patient in semi- upright position and is analyzed in direct comparison with a preceding similar chest examination obtained nine hours earlier during the same date.,0
Tracheal cannula is in place in appropriate position.,0
"Right subclavian central venous line seen to terminate overlying the SVC 2 cm below the level of the carina, also unchanged.",0
"Right chest tube in place, terminating in the apical area.",0
"The on previous examination identified up to 1-cm wide pneumothorax in the lateral pleural space cannot be identified any more, thus indicating effective chest tube suction.",0
"Possibility of some small remaining pneumothorax in unclear position cannot be completely excluded but under any circumstances, the pneumothorax is less marked than it was nine hours earlier.",0
Diffuse pulmonary parenchymal densities mostly on the left side have not changed significantly during the latest interval but are clearly improved since examination two days ago.,0
IMPRESSION: Uncomplicated exchange of line.,0
Decreased size of right-sided pneumothorax with right lung well ventilated.,0
"12:29 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION Reason: obstruction, gallstone illeus?",0
"Admitting Diagnosis: FEVER;JAUNDICE Field of view: 48 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with cholestasis of undetermined etiology, question of small bowel obstruction, gallstone illeus?",0
"REASON FOR THIS EXAMINATION: obstruction, gallstone illeus?",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Cholestasis of undetermined etiology, nausea, vomiting, abdominal pain.",0
TECHNIQUE: A CT enterography protocol was used.,0
"Axial MDCT images were obtained from the lung bases through symphysis pubis after the administration of 150 cc of nonionic Optiray contrast, used secondary to patient debility.",0
Coronal and sagittal reconstructions were also obtained.,0
CT OF THE ABDOMEN WITH CONTRAST: There are tiny bilateral pleural effusions with reactive atelectasis.,0
The visualized lung bases are otherwise clear.,0
The liver is enlarged and diffusely mottled and hypoattenuating consistent with fatty infiltration.,0
There is a small area of hyperattenuation within the left lobe of the liver anteriorly which may represent a hemangioma.,0
"There is also a 3.1 x 2.3 cm hypoattenuating mass within the medial segment of the left lobe, segment 4.",0
The is incompletely imaged on this single contrast study.,0
There appears to be a vessel coursing through this area.,0
The gallbladder is decompressed and unremarkable.,0
The liver is otherwise unremarkable without evidence of intra- or extrahepatic biliary dilatation.,1
"The spleen, pancreas and right adrenal gland are unremarkable.",0
There is a 2.5 x 2.6 cm lesion adjacent to the left adrenal gland.,0
There is a hypoattenuating area within the right kidney which is too small to definitively characterize but likely represents a simple cyst.,0
There is also free fluid around the anterior edge of the liver tracking down the right paracolic gutter.,0
CT OF THE PELVIS WITH IV CONTRAST: An NG tube is seen coiling within the stomach.,0
There is no evidence of obstruction and the bowel loops are unremarkable.,0
There is diverticulosis of the colon without evidence of acute inflammation.,0
No free fluid is identified within the pelvis.,0
CT RECONSTRUCTIONS: There is no obstruction as the oral contrast passes through freely.,0
There are mildly dilated loops of small bowel which may represent an ileus.,0
These measure up to 3.4 cm in diameter.,0
"(Over) 12:29 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION Reason: obstruction, gallstone illeus?",0
Admitting Diagnosis: FEVER;JAUNDICE Field of view: 48 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1. low density liver with ascites.,0
"Hypoattenuating area within segment 4 of the liver which may represent an area of focal fat, edema or hemangioma, but tumor cannot be excluded.",0
Further evaluation is recommended with MRI.,0
There is no intrahepatic biliary dilatation and the gallbladder is unremarkable.,0
This also could be further evaluated with MRI.,0
Mildly dilated loops of small bowel without evidence of obstruction consistent with an ileus.,0
1:01 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: ?evidence of abdominal/pelvic abscess Admitting Diagnosis: STROKE;TELEMETRY Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with R intraparenchymal hemorrhage and persistent fever of unclear etiology REASON FOR THIS EXAMINATION: ?evidence of abdominal/pelvic abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Fever.,1
TECHNIQUE: MDCT axial images were obtained from the lung bases to pubic symphysis after the administration of 100 cc of Optiray contrast.,0
CT ABDOMEN WITH IV CONTRAST: There are bullae at the lung bases bilaterally.,0
There are no nodules or effusions.,0
"The liver, spleen, gallbladder, adrenal gland, pancreas, and abdominal loops of large and small bowel are within normal limits.",0
There are hypodense lesions in the kidneys bilaterally too small to characterize.,0
"A feeding tube is visualized in the stomach, which likely explains air visualized in the small bowel.",0
There is no pathologic mesenteric or retroperitoneal lymphadenopathy.,0
CT PELVIS WITH IV CONTRAST: There is air in the bladder likely secondary to the visualized foley catheter.,0
"The rectum, sigmoid colon, and prostate are within normal limits.",0
"There is no pathologic, pelvic, or inguinal lymphadenopathy.",0
Note is made of a left sided inguinal hernia contaning a loop of non-obstructed small bowel.,0
Bone windows demonstrate no suspicious lytic or sclerotic foci.,0
Sagital and coronal reconstructions were essential in delineating the anatomy.,0
No evidence for abscess in the stomach or pelvis.,0
Hypodense lesions in kidney too small to characterize.,0
(Over) 1:01 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: ?evidence of abdominal/pelvic abscess Admitting Diagnosis: STROKE;TELEMETRY Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont),0
7:12 AM L-SPINE (AP & LAT) IN O.R.,0
"Clip # Reason: FUSION POSTERIOR LUMBAR THORACOLUMBAR T10-L5 ______________________________________________________________________________ FINAL REPORT STUDY: Lumbar spine, two views .",0
HISTORY: Status post posterior lumbar fusion.,0
"FINDINGS: Eight fluoroscopic images from the operating room demonstrate interval placement of pedicle screws within likely the L5, L4, and L3 vertebral bodies.",0
Definite level localizing is difficult due to intraoperative technique.,0
Interbody prosthetic disc device is also seen at likely the level of L5/S1.,0
Please refer to the surgical report for further details.,0
"11:04 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: post op scan for bleeding or other pathologic process Admitting Diagnosis: LEFT CEBELLAR ISCHEMIC STROKE ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with cerebellar mass REASON FOR THIS EXAMINATION: post op scan for bleeding or other pathologic process No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 12:44 PM IMPRESSION: Little interval change to appearance of involving left cerebellar infarct, surgical margins, and size of lateral ventricular system.",0
Stable mass effect within the posterior fossa.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Left cerebellar infarct status post ventriculostomy and suboccipital decompression.,0
Comparison is made to MRI and and CTs.,0
NON-CONTRAST HEAD CT Other than slight interval decrease in the amount of subcutaneous emphysema and pneumocephalus this exam displays no significant interval change.,0
The size of the frontal horns is minimally decreased as is size of the temporal horns.,0
Abnormal low attenuation/edema involving the left cerebellar hemisphere with mass effect on the fourth ventricle and effacement of the ambient cisterns consistent with upward transtentorial herniation as well as mass effect surrounding the foramen magnum is stable.,0
Mild blood products along the suboccipital craniotomy site with some thickening of the adjacent dura and trace blood products within the left cerebellum remains unchanged.,0
No new abnormalities are identified.,0
Right frontal approach ventriculostomy catheter terminating in the region of the foramen of is stable.,0
Paranasal sinuses and mastoid air cells remain well aerated.,0
"IMPRESSION: Little interval change to appearance of involving left cerebellar infarct, surgical margins, and size of lateral ventricular system.",0
2:36 PM CHEST (PORTABLE AP) Clip # Reason: please eval for pulmonary process.,0
"Admitting Diagnosis: HEPATITIS ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with alcoholic hepatitis, please eval for pulmonary process.",1
REASON FOR THIS EXAMINATION: please eval for pulmonary process.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Alcoholic hepatitis, to assess for pneumonia.",1
"FINDINGS: In comparison with the study of , there is some increased opacification at the left base consistent with progressive atelectasis.",0
Blunting of the costophrenic angles could reflect small pleural effusions.,1
7:37 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o hydrocephalus Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prenatal dx of hydrocephalus REASON FOR THIS EXAMINATION: r/o hydrocephalus ______________________________________________________________________________ FINAL REPORT This is our initial head ultrasound on this new born with a prenatal diagnosis of hydrocephalus.,0
Examination is somewhat limited by the patient's size and the small _____ of the anterior fontanelle.,0
There is mild-to-moderate dilatation of the lateral ventricles with minimal dilatation of the third ventricle.,0
Multiple septations are noted within the lateral ventricular system.,0
The fourth ventricle is not dilated.,0
The corpus callosum appears somewhat thinned for a patient of this size.,0
There is also some apparent disruption of the morphology of the brain parenchyma as it extends from the convexity to the level of the corpus callosum and about the midline.,0
I am uncertain whether this is a real finding or simply an artifact of scanning.,0
Flow within the anterior cerebral circulation appears grossly normal with a low resistive index in the 0.5 to 0.6 range.,0
Mild-to-moderate dilatation of the lateral ventricles with mild dilatation of the third ventricle.,0
"Multiple septations are present, raising the possibility of prior infection or hemorrhage.",0
Questionable findings of thinning of the corpus callosum and abnormal parenchymal pattern as described above.,0
Evaluation with MRI is recommended.,0
"4:36 PM CHEST (PORTABLE AP) Clip # Reason: check L-IJ line placement s/p change over wire ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with ERSD, CAD, PVD, DM s/p AKA now s/p L-IJ line change REASON FOR THIS EXAMINATION: check L-IJ line placement s/p change over wire ______________________________________________________________________________ FINAL REPORT INDICATION: S/P line change.",0
PORTABLE SEMI-UPRIGHT CHEST @ 18:28: There is a left IJ central venous catheter with tip in the region of the distal brachiocephalic vein/SVC confluence.,0
There is prominence of the interstitial markings which may be a reflection of interstitial edema.,0
Note is again made of bilateral pleural plaques and calcifications along the hemidiaphragms consistent with previous asbestos exposure.,0
No focal consolidations are appreciated.,0
IMPRESSION: Left IJ central venous catheter tip in the distal brachiocephalic vein/SVC confluence.,0
"Prominent interstitial markings, possibly from interstitial edema.",0
8:11 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for interval change Admitting Diagnosis: STEMI ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with hypoxemia REASON FOR THIS EXAMINATION: evaluate for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old male with hypoxemia.,0
"CHEST, AP: Diffuse pulmonary opacities have improved.",0
A right PICC again ends at the superior cavoatrial junction.,0
"There is no pneumothorax or large pleural effusion, although the right costophrenic angle is excluded.",0
"IMPRESSION: Rapidly improving pulmonary opacities, consistent with edema.",0
"9:28 PM CHEST (PORTABLE AP) Clip # Reason: pls assess lung fields Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with recent bowel surgery, afib rvr, volume overload.",1
"REASON FOR THIS EXAMINATION: pls assess lung fields ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: Radiograph of .",0
INDICATION: Atrial fibrillation and volume overload.,1
FINDINGS: PICC terminates within the proximal superior vena cava.,0
"Cardiac silhouette is mildly enlarged, and is accompanied by mild pulmonary vascular engorgement.",0
Moderate right pleural effusion with adjacent right basilar atelectasis and/or consolidation is new.,0
"Left hemidiaphragm appears indistinct, probably on the basis of motion artifact, but small effusion or early consolidation is not excluded.",0
"11:37 AM CT CHEST W/CONTRAST Clip # Reason: evaluate ""Rounded opacities projecting over the anterior por Admitting Diagnosis: LEFT ATRIAL THROMBUS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman s/p mvr REASON FOR THIS EXAMINATION: evaluate ""Rounded opacities projecting over the anterior portion of the first rib and might represent an external finding or be related to the rib or lung itself"" seen on pre-op cxr.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CHEST CT WITH CONTRAST INDICATION: Patient with MVR, evaluate rounded opacities projecting over the anterior portion of the right rib and might represent external finding.",0
Chest x-ray from to .,0
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the upper abdomen with administration of IV contrast.,0
Multiplanar reformatted images in coronal and sagittal axes were generated.,0
"FINDINGS: LUNGS AND AIRWAYS: Left upper lobe opacity described on pre-op chest x-ray does not have any correspondence in the CT; however, there is a right upper lobe 15 x 26 mm round opacity that is nonspecific in recent post-operative context: This could be related to hemorrhage, atelectasis changes due to the surgery, but underlying lesion has to be also considered.",1
The airways are patent until subsegmental levels.,0
"MEDIASTINUM: Small bilateral pneumothorax, pleural effusion, air in the mediastinum and pneumopericardium are expected after recent cardiac surgery.",1
"A loculated hemopericardium is posterior to right atrium, probably hemodynamically not significant, measuring 6 x 2.1 cm.",0
Left atrium is dilated to 4.9 cm.,0
The patient had recent sternotomy for redo for mitral valve repair.,1
"Borderline mediastinal lymph nodes are probably reactive, for example, in AP window measuring 16 x 9 mm.",0
UPPER ABDOMEN: This study is not tailored for assessment for intraabdominal organs.,0
There is no significant lesion.,0
"(Over) 11:37 AM CT CHEST W/CONTRAST Clip # Reason: evaluate ""Rounded opacities projecting over the anterior por Admitting Diagnosis: LEFT ATRIAL THROMBUS ______________________________________________________________________________ FINAL REPORT (Cont) OSSEOUS STRUCTURES: There is no bony lesion concerning for malignancy or infection.",0
Subcutaneous air in anterior lower chest wall is probably secondary to prior mediastinal tube.,1
"The patient had recent sternotomy for redo of mitral valve with expected findings including small pneumothorax, pleural effusion, pneumomediastinum.",1
Residual loculated hemopericardium is behind the right atrium and probably hemodynamically not significant.,0
There is no lung lesion corresponding to the left apical opacity described on pre-op chest x-ray.,0
"However, right upper lobe 2.6 cm nodular opacity will have to be followed up with a chest CT in three months to exclude progressive lung lesion.",0
"10:21 AM FEMUR (AP & LAT) RIGHT Clip # Reason: right hip pain ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with right femur lesion s/p allograft and hemiarthroplasty REASON FOR THIS EXAMINATION: right hip pain ______________________________________________________________________________ FINAL REPORT STUDY: Right femur, two views.",0
HISTORY: 74-year-old woman with osteosarcoma status post resection and allograft and hemiarthroplasty.,0
Two views of the right femur demonstrate a right proximal femoral allograft with a bipolar hemiarthroplasty.,0
There is a lateral plate with multiple cortical screws fixating the allograft to the native femoral shaft.,0
The osteotomy line and the allograft appear distinct without significant callus healing.,0
There is no evidence for hardware complication.,0
There is some calcification adjacent to the right greater trochanter.,0
IMPRESSION Status post proximal femoral resection with placement of a total hip arthroplasty and proximal femoral allograft without evidence for hardware complication.,0
"4:06 PM CHEST (PORTABLE AP) Clip # Reason: pna Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman with tbi now with fever REASON FOR THIS EXAMINATION: pna ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST CLINICAL INFORMATION: Traumatic brain injury with fever, pneumonia.",1
FINDINGS: AP chest is compared to the prior study from .,0
Tracheostomy is in the midline.,0
Right subclavian catheter terminates in the superior vena cava.,0
Multiple leads are present over the chest.,0
IMPRESSION: No active disease in the chest.,0
"11:46 AM CHEST (SINGLE VIEW) Clip # Reason: r/o pneumonia Admitting Diagnosis: LEFT SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with tachypnea REASON FOR THIS EXAMINATION: r/o pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Tachypnea, rule out pneumonia.",1
There is upper zone redistribution and mild diffuse vascular blurring.,0
There is patchy increased retrocardiac density.,0
Patchy retrocardiac density consistent with left lower lobe collapse and/or consolidation.,0
"1:54 PM CAROTID SERIES COMPLETE Clip # Reason: CHF, AS Admitting Diagnosis: PULMONAARY EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with CHF, aortic stenosis REASON FOR THIS EXAMINATION: please evaluate bilaterally for carotid disease ______________________________________________________________________________ FINAL REPORT CAROTID SERIES COMPLETE.",1
REASON: CHF and aortic stenosis.,1
"On the right, peak systolic velocities are 82, 65, 82 in the ICA, CCA, and ECA respectively.",0
The ICA/CCA ratio is 1.3.,0
This is consistent with no stenosis.,0
"On the left, peak systolic velocities are 66, 71, 85 in the ICA, CCA, and ECA respectively.",0
The ICA/CCA ratio is 0.9.,0
IMPRESSION: No evidence of stenosis in either carotid artery.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Compazine / Zantac / Hydromorphone Attending: Chief Complaint: Pedestrian struck Major Surgical or Invasive Procedure: : Left femur traction pin placement : ORIF Left anterior pelvis and iliac : ORIF Left posterior wall and column : Facial sutures removed : Left hip I&D with VAC placement : VAC changed at bedside : VAC removed : Anterior staples removed : PICC placement in interventional radiology History of Present Illness: Ms. is a 33 year old female who was struck from behind by a motor vehicle while getting into her car.,1
She was medflighted to for further evaluation.,0
"Crohn's disease with perianal fistuals s/p surgery, disease in TI and cecum, 14 years of disease - with ileosigmoid fistual -s/p colectomy -admitted in for flare, txt w/ steroids c/b anxiety/pressured speech with resolved -25 cm stricture and sessile poly on c-scope at 2.",0
"WPW s/p ablation years ago at , Dr 3.",0
Osteopenia on bone scan 4.,0
Glucose intolerance Social History: RN unable to work to disease Family History: 1.,0
"Breast and ovarian cancer on maternal side Physical Exam: BP:134/71 HR:112 RR:13 GCS:15 Awake, alert CTA b/l RRR S/NT/ND LLE: + ecchymosis in hip area, NVI distally superficial abrasions BLE Pertinent Results: 05:10AM BLOOD WBC-7.5 RBC-3.75* Hgb-10.6* Hct-31.5* MCV-84 MCH-28.3 MCHC-33.7 RDW-15.9* Plt Ct-358 01:38PM BLOOD WBC-8.3 RBC-3.77* Hgb-10.7* Hct-31.4* MCV-83 MCH-28.5 MCHC-34.2 RDW-16.0* Plt Ct-426 04:42AM BLOOD WBC-7.5 RBC-3.69* Hgb-10.2* Hct-31.5* MCV-85 MCH-27.6 MCHC-32.3 RDW-16.2* Plt Ct-511* 01:38PM BLOOD Neuts-69.8 Lymphs-17.5* Monos-7.9 Eos-4.3* Baso-0.6 05:10AM BLOOD Glucose-114* UreaN-4* Creat-0.6 Na-140 K-3.9 Cl-105 HCO3-30 AnGap-9 01:25PM BLOOD ALT-36 AST-57* AlkPhos-49 Amylase-31 TotBili-0.2 05:10AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.7 01:38PM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7 01:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Ms. presented to the on via medflighted.",0
She was evaluated by the trauma service and found to have a left acetabular fracture.,0
Orthopedics evaluated the patient was placed a femoral traction pin under conscious sedation in the emergency room.,0
She was then brought to the TSICU for further care and monitoring.,0
She was transfused one unit PRBC's and her tetanus was updated.,0
She was found to have no other injuries and she was transferred to the floor on the orthopedic service.,0
On she was prepped and brought to the operating room for fixation of her left anterior pelvis and iliac fractures.,1
On she was transfused with 2 units of packed red blood cells due to post operative anemia.,0
On the acute pain service was consulted for recommendations in her pain management.,0
On she was again taken to the operating room for the posterior wall and column ORIF of her left acetabular.,0
An NGT was placed in the operating room and it was maintained on low wall suction.,0
On her facial sutures were removed.,0
On she underwent an abdominal CT scan.,0
Her NGT was also removed and her diet was slowly advanced.,0
On she returned to the operating room for a left hip washout of her Merelli lesion.,0
A VAC was placed in the left hip wound.,0
She was also placed on a KinAir bed for skin protection.,0
On the VAC drain was changed at the bedside.,0
On the VAC was removed at the bedside.,0
On her prozac was restarted at her request.,0
A abdominal CT was done on which showed no interval change.,0
On a PICC line was placed in interventional radiology for long term antibiotics.,0
The remainder of her hospital course was otherwise without incident.,0
She was seen by physical and occupational therapy to improve her strength and mobility through her hospital stay.,0
Her labs and vitals remained stable.,0
Her pain was well controlled.,0
She is being discharged today in stable condition.,0
Medications on Admission: Toprol 100mg daily Pentaz 6 tabs Flagyl Prilosec Ambien Klonopin Cipro Discharge Medications: 1.,0
Ancef 1 g Recon Soln Sig: Two (2) gm Injection every eight (8) hours for 4 weeks.,0
Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed.,0
Diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for muscle spasm.,0
"Mesalamine 250 mg Capsule, Sustained Release Sig: Six (6) Capsule, Sustained Release PO BID (2 times a day) as needed for Chrons disease.",0
Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).,0
Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical (2 times a day).,0
Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe Subcutaneous DAILY (Daily) for 4 weeks.,0
Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed.,0
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6-8H (every 6 to 8 hours) as needed.,0
Discharge Disposition: Extended Care Facility: Rehab hospital Discharge Diagnosis: 1.,0
"Transverse process fractures L2, L3, L4 3.",0
Laceration to forehead (sutured) 4.,0
Post operative anemia Discharge Condition: Stable Discharge Instructions: Please continue to be touchdown weight bearing on your left leg.,0
Continue your IV antibiotics for a total of 4 weeks as instructed.,0
"Keep your incision clean and dry, you may apply a dry sterile dressing as needed for drainage or comfort If you notice any increased redness, swelling, drainage, report to the emergency room.",0
Please continue your lovenox injections for a total of 4 weeks.,0
You may resume any normal home medications.,0
Please follow up as below.,0
Physical Therapy: Activity: Activity as tolerated Right lower extremity: Full weight bearing Left lower extremity: Non weight bearing Treatment Frequency: You may apply a dry sterile dressing daily or as needed for drainage or comfort Followup Instructions: Please follow up with Dr. at the orthopedic clinic next week.,0
Call to make that appointment.,0
"Provider: , RD Phone: Date/Time: 11:00 Provider: , MD Phone: Date/Time: 1:00 MD, Completed by:",0
1:14 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?,0
"ETT placement Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with sob and chf and pneumonia, just electively intubated REASON FOR THIS EXAMINATION: ?",0
ETT placement ______________________________________________________________________________ FINAL REPORT EXAM ORDER: Chest.,0
"HISTORY: CHF and pneumonia, endotracheal tube placement.",1
CHEST: A single supine portable view at 13:20 hours is compared to previous exam at 4:30 a.m. from the same day.,0
"Since the previous exam, there has been insertion of endotracheal tube with the tip at the level of T2.",0
The cardiomegaly and diffuse parenchymal opacities show no significant change since the previous exam.,0
"5:01 PM CHEST (PORTABLE AP) Clip # Reason: upright please eval residual pneumothorax, placement of ches Admitting Diagnosis: RIGHT PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with hypotension after pleuroscopy and chest tube placement REASON FOR THIS EXAMINATION: upright please eval residual pneumothorax, placement of chest tubes ______________________________________________________________________________ WET READ: EHAb MON 5:37 PM INTERVAL PLACEMENT OF RIGHT CHEST TUBES WITH DECREASED RIGHT PLEURAL EFFUSION, WHICH NOW TRACKS TO THE APEX.",1
SMALL AMOUNT OF NEW RIGHT SUBCUTANEOUS EMPHYSEMA TRACKING ALONG CHEST WALL.,0
LOW LUNG VOLUMES WITH PERIHILAR AND LEFT LOWER LUNG ATELECTASIS.,0
RIGHT LOWER LUNG CONSOLIDATION BE COMPRESSIVE ATELECTASIS BUT INCOMPLETELY EVALUATED IN SETTING OF PLEURAL EFFUSION.,1
PERSISTENT LEFT APICAL DENSITY BE PLEURAL THICKENING OR FLUID.,1
LEFT SUPRAHILAR CALCIFICATION AGAIN NOTED.,0
RIGHT PORT-A-CATH NOW WITH SHARPER ANGLE INTO RIGHT SUBCLAVIAN REGION WITH TIP IN SIMILAR POSITION OVERLYING EXPECTED LOCATION OF LOW SVC.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Hypertension after pleuroscopy and chest tube placement.,0
The Port-A-Cath catheter tip is at the cavoatrial junction.,0
"2:28 PM UNILAT LOWER EXT VEINS LEFT PORT Clip # Reason: S/P MVC, INCREASED DECOMP OVER WEEKEND, EVAL FOR DVT Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with PE vs fat embolus REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary embolus vs. fat embolus, assess for DVT.",0
"Grey scale and Doppler images of the left common femoral, superficial femoral, greater saphenous, popliteal veins was performed.",0
"There is normal compressibility, augmentation, wave forms and flow.",0
IMPRESSION: No evidence of DVT in the left leg.,0
3:24 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"effusion, consolidation Admitting Diagnosis: SPONTANEOUS BACTERIAL PERITONITIS ______________________________________________________________________________ MEDICAL CONDITION: 49 49 y/o female with pmhx of ETOH cirrhosis presented for abdominal pain s/p ex-lap for pneumatosis on and closure now with free air/pooling contrast, s/p neg exlap REASON FOR THIS EXAMINATION: ?",1
"effusion, consolidation ______________________________________________________________________________ FINAL REPORT AP CHEST HISTORY: Alcoholic cirrhosis.",1
"IMPRESSION: AP chest compared to through : Greater opacification in the lower lungs and perihilar left lung, accompanied by increase in heart size, though still normal, suggests pulmonary edema is the explanation for the new pulmonary findings.",0
"Small bilateral pleural effusions, right greater than left are likely.",0
Nasogastric tube and feeding tube pass into the stomach and out of view.,0
"Left PIC line ends in the upper SVC, right jugular line in the lower.",0
"10:43 AM CHEST (PORTABLE AP) Clip # Reason: please check for NG tube placement Admitting Diagnosis: MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with hepatic failure, s/p NG tube placement REASON FOR THIS EXAMINATION: please check for NG tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: Hepatic failure status post NG tube placement.",1
Tip of the right IJ line remains in the distal SVC.,0
Tip of the NG tube is in the stomach.,0
There has been interval development and progression of a left lower lobe opacity now silhouetting the left hemidiaphragm.,0
There is blunting of both left and right costophrenic angles.,0
Blunting of the right costophrenic angle is new since the prior study.,0
The film was performed in a semi-upright position and there are signs of pulmonary vascular redistribution which may be related to patient positioning rather than fluid overload.,0
A dual lead pacer is in place.,0
IMPRESSION: NG tube and right IJ lines in adequate position.,0
Interval development of new left lower lobe opacity consistent with atelectasis or infiltrate.,0
Interval development of new right pleural effusion and increased left pleural effusion.,0
11:24 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: please evaluate for swallowing dysfunction Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with recurrent microaspirations REASON FOR THIS EXAMINATION: please evaluate for swallowing dysfunction ______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old woman with recurrent microaspirations.,0
SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing video fluoroscopy was performed in conjunction with the speech and swallow division.,0
"Barium is noted to pass freely through the oropharynx, without evidence of obstruction.",0
Noted evidence of penetration for thick and thin consistencies.,0
There was evidence of aspiration with multiple sips.,0
IMPRESSION: Penetration for thin and thick consistencies.,0
Aspiration with multiple quick swallows.,0
"For details and recommendations, please refer to speech and swallow division note in OMR.",0
"3:28 PM CHEST (PA & LAT) Clip # Reason: r/o pneumo/hemothorax ______________________________________________________________________________ MEDICAL CONDITION: 31 year old man with s/p self inflicted stab wound to chest; small effusion noted on previous radiographs REASON FOR THIS EXAMINATION: r/o pneumo/hemothorax ______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old man with history of self-inflicted stab wound to chest, small effusion on previous radiograph.",0
FRONTAL AND LATERAL CHEST: Cardiac silhouette appears enlarged compared to prior.,0
Pulmonary vascularity appears within normal limits.,0
No focal consolidations are seen within the lungs.,0
Interval improvement of previously seen small left effusion.,0
Subsegmental atelectasis again noted at the bases.,0
IMPRESSION: No evidence of pneumothorax or effusion.,0
"Cardiac silhouette is enlarged compared to prior, raising suspicion for pericardial effusion.",0
Discussed with Dr. following completion of study.,0
"LINE PLACEMENT Clip # Reason: s/p right subclavian placement Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\INJURIES ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with mvc, intubated for respiratory failure.",1
REASON FOR THIS EXAMINATION: s/p right subclavian placement ______________________________________________________________________________ FINAL REPORT INDICATION: 35-year-old man intubated for respiratory failure.,0
Status post right subclavian placement.,0
"SUPINE AP PORTABLE CHEST: This radiograph is underpenetrated, at least in part due to the patient's large body habitus.",0
These technical limitations limit the visible detail.,0
The endotracheal tube is probably in satisfactory position.,0
The nasogastric tube appears to descend into the abdomen.,0
The left subclavian line remains in satisfactory position.,0
"The right subclavian line is difficult to see, its tip is probably within the superior vena cava but is difficult to identify with certainty.",0
Right pleural effusion and bibasilar atelectasis persist.,0
The new right subclavian line appears to extend to the region of the cavoatrial junction but is difficult to see.,0
Low lung volumes with persistent pulmonary edema and right effusion.,0
1:10 PM CHEST (PORTABLE AP) Clip # Reason: Eval for pneumonia Admitting Diagnosis: ?,0
"RHABDOMYLSIS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with new tachypnea, hypoxia, fever being treated for neuroleptic malignant syndrome REASON FOR THIS EXAMINATION: Eval for pneumonia ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest, AP portable single view.",1
"INDICATION: 62-year-old male patient with new tachypnea, hypoxia and fever being treated for neuroleptic malignant syndrome.",1
Comparison is made with a preceding supine chest examination of .,0
Previously described left-sided PICC line remains unchanged.,0
Heart size is within normal limits and no significant aortic abnormality short of some calcium deposits in the wall at the level of arch.,0
The pulmonary vasculature is not congested.,0
No signs of acute infiltrates are present and the lateral pleural sinuses are free.,0
The on previous examination suspected right-sided basal density has not progressed.,0
IMPRESSION: No evidence of acute pneumonia or CHF on this portable single-view chest examination.,0
1:57 PM BABYGRAM (CHEST ONLY) Clip # Reason: full-term male grunting.,0
Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with grunting and flaring.,1
REASON FOR THIS EXAMINATION: full-term male grunting.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Initial film on this child born full term with respiratory distress.,0
The lungs demonstrate some opacities in both lower lungs more notable on the right side than the left.,0
"The findings could be due to pneumonia, though surfactant in an older gestational age baby can also have this appearance.",0
Height: (in) 66 Weight (lb): 175 BSA (m2): 1.89 m2 BP (mm Hg): 102/63 HR (bpm): 60 Status: Inpatient Date/Time: at 10:32 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,1
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - akinetic; mid anteroseptal - hypo; anterior apex - akinetic; septal apex - hypo; inferior apex - hypo; apex - dyskinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,1
There is mild to moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the anterior septum and anterior wall.,1
The apex is mildly dyskinetic.,0
"Compared with the report of the prior study (images unavailable for review) of , new regional left ventricular systolic function is now present c/w interim infarction/ischemia.",1
8:50 AM CT HEAD W/O CONTRAST Clip # Reason: new change?,0
Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with SDH REASON FOR THIS EXAMINATION: new change?,0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SAT 9:36 AM Stable large complex left subdural collection.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 83-year-old man with subdural hematoma.,0
Query change after beginning heparin treatment.,0
"FINDINGS: The complex collection overlying the left cerebral convexity, in the left subdural space, is unchanged.",0
"Again, it is predominantly hypodense, with a small region of hyperdense material posteriorly.",0
Internal septation within the collection is also stable.,0
There has been a slight interval decrease in the amount of pneumocephalus anteriorly.,0
"The falx remains displaced slightly to the right, by approximately 5 mm, which is unchanged.",0
The configuration of the ventricles and sulci is unchanged.,0
There is no evidence of new major vascular territorial infarct.,0
"The basilar cisterns are preserved, and the /white differentiation is preserved.",0
"Bony structures demonstrate two burr holes in the left superior calvarium, with adjacent soft tissue swelling and surgical staples.",0
"Otherwise, the mastoid air cells and paranasal sinuses are well aerated.",0
"IMPRESSION: Stable large, complex left subdural collection.",0
Unchanged 5-mm rightward displacement of the falx.,0
"8:36 PM BABYGRAM (ABD ANY SGL VIEW) () Clip # Reason: PREMIE S/P nec Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with abdominal distension, heme + stool--NOW RESOLVED.",0
FOLLOW-UP FILM REASON FOR THIS EXAMINATION: PREMIE S/P nec ______________________________________________________________________________ FINAL REPORT There is no significant change in the appearance of the bowel gas pattern.,0
The bowel loops are air-filled and minimally distended.,0
"There is no evidence of pneumatosis, free air or portal venous air.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Nsaids Attending: Chief Complaint: Stridor Major Surgical or Invasive Procedure: Endotracheal intubation Fiberoptic bronchoscopy Central venous line (L subclavian) placement Transesophageal echocardiography PICC line placed History of Present Illness: 79yo spanish speaking M Hx DM2, HTN, Pulm HTN, AF, transferred from hospital for further evaluation/management of worsening stridor.",0
Patient was initially admitted to OSH on .,0
"He presented complaining of back pain and dysuria, and was found to have a Klebsiella urinary tract infection, with ?",0
urosepsis as well as ARF (Cr 2.7 from baseline 1.7).,0
He was initially admitted to the ICU.,0
"During his stay, he developed worsening stridor.",0
"Per report, he was started on Solumedrol empirically.",0
"He evaluated first with a chest/neck CT, which showed ?",0
"bronchomalacia, but no obvious parenchymal disease.",0
A laryngoscopy performed by ENT was negative by report.,0
"He had bronchoscopy on the day of transfer, which demonstrated moderate tracheal occlusion and significant edema in the proximal of the trachea (?extrinisc compression vs malacia), RMSB with 50% circumferential/extrinsic occlusion at the orfice, and 30% LMSB narrowing.",0
"There was moderate mucous, but no endobronchial lesion or foreign body.",0
"He had been treated with Solumedrol, and nebulizers, but did not tolerate Heliox by facemask.",0
He was transferred to for further management by interventional pulmonary.,0
"Past Medical History: CRI- baseline Cr 1.7, Unknown etiology Paroxysmal A fib HTN Pulm HTN Hypercholesterolemia DM2 Hepatic steatosis Osteroarthritis Social History: no significant tob use, no drugs.",0
"Family History: Non-contributory Physical Exam: PE - VS 96.0 69 130/58 18 100% FM GEN - obses man, sitting upright, slight resp distress, audible stridor, able to speak words SKIn- slightly diaphoretic, warm HEENT - no JVD, PERRL, OP dry COR - RRR, no m/r/g PULM - diffuse inspiratory stridor, no audible rales ABD - obsese, soft, NT, ND Extr - WWP, no edema NEURO - grossly intact, MAE x 4 Pertinent Results: Bronchoscopy at OSH: 50% external compression of left main bronchus 70% external compression of right main bronchus CT Chest: No evidence of external compression of the bronchi, evidence of tracheobronchomalacia.",1
No evidence for endocarditis seen.,0
: CT scan chest/abdomen/pelvis with contrast: IMPRESSION: 1.,0
"Multilobulated right pleural-based mass without significant enhancement, local invasion or associated thoracic lymphadenopathy.",0
No primary neoplasm identified elsewhere within the torso.,0
"This may represent post- infectious sequelae, mesothelioma, nerve sheath tumor or metastatic disease from unknown primary.",0
"If clinically indicated, biopsy could be performed.",0
No significant change in distal sigmoid colonic wall thickening.,0
"Other issues included renal failure and metabolic derangement, resolving MSSA bacteremia.",0
"His current issues include a pleural based lung mass, anemia with occult positive stool, infections, hepatitis and paroxismal Afib.",0
A. Pleural based mass: Please see attached CT reports.,0
This pleural based mass on the right was stable on his various CT scans.,0
"Radiology was concerned about it being a multilobulated right pleural-based mass without significant enhancement, local invasion or associated thoracic lymphadenopathy.",0
Question as whether this is an old finding or a more recent one.,0
"Of note, his respiratory status is stable on room air at time of transfer.",0
"B. Tracheobronchomalacia/COPD: On initial arrival, patient had severe stridor concerning for urgent requirement of intubation.",0
"However, continuous bronchodilator treatment overnight induced near complete resolution of the stridor, and urgent intubation was not required.",0
"On hospital day two, however, pt was intubated for airway protection given continued poor mental status and underwent bronchoscopy at that time which revealed no airway stenosis or external compression without significant tracheobronchomalacia.",0
"Following stabilization, pt was extubated and again required continuous bronchodilator therapy (including racemic epinephrine) as well as corticosteroids as empiric therapy for restrictive airway disease, with ultimate resolution of stridor.",0
"Therefore, it was felt that pt most likely had bronchospasm as a result of his metabolic derangement and renal insufficiency/uremia.",0
He has been stable on room air for several days now with nebulizer treatments written prn.,0
The steroids are being tapered by 10mg of prednisone per day as his respiratory status has been stable and there is a concern for multiple infections including sigmoid colitis.,0
He is currently on 40mg.,0
C. Infections: His WBC had trended down to about 11 but has risen back up slowly to 18.,0
"This can partly be attributed to the steroid treatment, but also is concerning for infection.",0
CT scan showed sigmoid colitis (please see attached reports).,0
We do not think this is ischemic colitis as he was ruled out with a normal lactate and bicarb.,0
Of note he was occult blood positive and complained of abdominal pain especially when defecating.,0
He is being treated empirically for C Diff (antigen negative x2 thus far) and for gram negative coverage with levoquin started today .,0
"Given his recent high doses of steroids and his colitis, would have a low threshold for examining for free air if his abdominal pain worsens.",0
"MSSA Bacteremia: Per report, 12/12 bottles at OSH and started on nafcillin on , though no positive surveillance cultures here.",0
"Remained hemodynamically stable, no septic physiology and afebrile.",0
Both TTE and TEE (performed while intubated) were negative for endocarditis.,0
No evidence for septic emboli on complete CT chest/abdomen/pelvis.,0
"Pt had initially complained of back pain on admission to OSH, however denied this when he arrived here, so no search for epidural or paraspinal abscesses was made.",0
"Therefore, the source remains unknown for this infection.",0
Would continue the nafcillin for 4-6weeks.,0
3.Concern about the right pleural based mass is- does it represent an infectious source or malignancy?,0
"D. Acute on Chronic Renal Failure: Creatinine 2.7, FeNa 1.2%, no Eos on smear, and bland sediment.",1
"From chronic renal insufficiency (Cr 1.7), but was thought to have developed acute tubular necrosis, though the etiology was unclear.",1
"Nevertheless, uremia was felt to be the primary etiology of patient's poor mental status as well as partial contributor to bronchospasm.",0
Patient did require phos binders.,0
His renal function has returned to it's original state with a Cr of 1.7.,0
He was started in epoetin 4000 units SC qMWF.,0
"E. Heptatitis: No known Hx liver disease, Hep serologies show HBsAg HBsAb HBcAb HAV Ab IgM HAV NEGATIVE POSITIVE POSITIVE POSITIVE HEPATITIS C SEROLOGY HCV Ab NEGATIVE Hep B e antigen/antibodies were not evaluated during inpatient admission, but should be followed.",0
His liver enzymes are remaining high at ALT AST LD(LDH) AlkPhos TotBili 82* 158* 652* 136* 1.2 .,0
"F. Anemia/mild thrombocytopenia: On coumadin, though held throughout OSH stay.",0
Given FFP for central line placement.,0
His warfarin is still being held but he has been continued on aspirin.,0
He had occult blood positive stool.,0
And GI was consulted and suggested follow up after infection in colon calms down.,0
His Hct dropped to a low of 23 and he was transfused two units of packed RBC.,0
Would stop the ASA if his bleeding continues.,0
Warfarin is still being held.,0
"G. UTI: Klebsiella UTI at OSH, however negative UA/UCx here, felt to be resolved on arrival.",0
"H. Coronary artery disease: Not active during this admission, however continued ASA, lipitor, but held beta blocker for concern of bronchospasm.",1
I. Paroxysmal atrial fibrillation: Remained in sinus for most of MICU course with RBBB and LAFB.,1
"On the floor, he was placed on telemetry and had multiple episodes a day of short lasting afib with tachycardia.",0
His diltiazem was increased to 120mg daily to help rate control him.,0
His warfarin is being held secondary to his bleeding and his occult positive stool.,0
GI consult here suggeted that he will need GI follow up when the infection clears.,0
Will need to find out when to restart warfarin if origin of bleed remains unknown.,0
J. DM2: Glyburide discontinued given renal failure.,0
His sugars were quite high given the steroids and infections.,0
He is currently controlled to blood sugars in the 100's with NPH at 5units AM and PM and Humalog 4 units before meals.,0
"In addition, he had a sliding scale of Humalog if needed.",0
The patient insisted on transfer back to Hospital for the remainder of his acute hospitalization and ongoing care.,0
"This request was discussed with his primary care physician, at Hospital, who agreed to the transfer.",0
"Although a number of issues remain unresolved at the time of transfer, they were communicated directly with Dr to optimize continuity of care.",0
"Although the patient was stable at the time of transfer, sitting in a chair without complaints, eating, conversing, and feeling subjectively improved, a number of diagnostic and therapeutic interventions remain pending in his clinical care.",0
Medications on Admission: Nafcillin 2g q 4h x 4 weeks (start ) Solumedrol 80 tid Atrovent/albuterol nebs Heliox Dilt 30 po tid Lopressor 50 q6 Morphine Colace Senna ASA 325 Lipitor 80 qd Tylenol 650 prn MEDS at home include coumadin 5mg qd glyburide 5mg Discharge Medications: 1.,0
Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed.,0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.,0
Racepinephrine 2.25 % Solution for Nebulization Sig: One (1) ML Inhalation Q4H (every 4 hours) as needed.,0
"Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday).",0
Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation.,0
Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed.,0
Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed.,0
Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous twice a day.,0
Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) Intravenous Q4H (every 4 hours).,0
"Discharge Disposition: Extended Care Discharge Diagnosis: Acute on chronic renal failure Uremia with mental status changes Acute bronchospasm, reactive airways Staphylococcus aureus bacteremia with unknown source Sigmoid colitis Pleural based mass on right Mild thrombocytopenia Discharge Condition: Stable.",1
Respiratory status stable on room air.,0
Discharge Instructions: Transfer to Hospital under the care of Dr. .,0
Please see discharge summary for specific instructions.,0
Patient has Foley cath in place.,0
Followup Instructions: He will need follow up with nephrology for his chronic renal failure.,1
He will need follow up with Gastroenterology for the occult blood in his stool and for resolution of his colitis.,0
Admission Date: Discharge Date: Date of Birth: Sex: Service: ADDENDUM Please see prior discharge summary for full details.,0
"The patient is being discharged on , after a planned discharge on .",0
"It was found on , that the patient's white count had elevated up to 21, and there was a concern of whether or not the patient had a recurrence in infection.",0
"Therefore, it was decided that the patient would have a full set of cultures sent which was done.",0
A follow-up white count had dropped down to 19 the next day.,0
It was decided that all of his lines would be changed.,0
"Therefore, his central line was removed, and a PICC line was placed, and his left IJ central line was removed, and his PICC line was replaced On , the patient was noted to have some mild chills while having dialysis.",0
It was decided that his tunneled catheter would be changed in Interventional Radiology.,0
"They changed this tunnel catheter on , and it was planned that the patient would have cultures sent at that time.",0
"The patient was discharged on , after getting a new central line, as well as a new dialysis catheter to .",0
The patient was discharged in stable condition.,0
There were no changes to his medications from his prior discharge summary.,0
"Of note, it was decided by Renal that a 24-hour urine creatinine clearance would be done.",0
This was planned to be done at the rehabilitation facility to evaluate his creatinine clearance and plan for future dialysis.,0
CONDITION ON DISCHARGE: The patient is discharged in stable condition to a rehabilitation facility.,0
Dictated By: MEDQUIST36 D: 13:06 T: 13:19 JOB#:,0
Height: (in) 71 Weight (lb): 225 BSA (m2): 2.22 m2 BP (mm Hg): 143/76 HR (bpm): 94 Status: Inpatient Date/Time: at 15:40 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Normal biventricular cavity sizes with preserved global biventricular systolic function.,0
4:34 PM CHEST (PA & LAT) Clip # Reason: pna?,0
"______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with FEVER, REASON FOR THIS EXAMINATION: pna?",0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON COMPARISON: and .,0
"HISTORY: Fever, assess for pneumonia.",0
FINDINGS: PA and lateral views of the chest were obtained.,0
"A right chest wall pacer device is again noted with three leads extending into the expected location of the right atrium, right ventricle, and coronary sinus.",1
Kerley B lines are evident compatible with mild congestive heart failure.,0
No pleural effusions or pneumothorax is seen.,0
Mediastinal contour is stable with atherosclerotic calcifications along the aortic knob and along the descending aorta.,0
No free air below the right hemidiaphragm.,0
IMPRESSION: Mild cardiomegaly with Kerley B lines indicating mild heart failure.,0
3:45 AM CHEST (PORTABLE AP) Clip # Reason: Eval ETT placement and acute intrathoracic process.,0
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p intubation for resp distress/airway protection REASON FOR THIS EXAMINATION: Eval ETT placement and acute intrathoracic process.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory failure, intubation for airway protection.",0
FINDINGS: Lung volumes remain low.,0
Lungs are clear without focal consolidations.,0
"No pleural effusions, pulmonary edema, or pneumothorax is identified.",1
Hilar and mediastinal silhouettes are normal.,0
ET tube is approximately 5 cm from the carina.,0
Dobbhoff tube has been advanced and now is in nondistended stomach.,0
ET tube is in satisfactory position.,0
No significat interval change from exam.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: vomiting blood clots Major Surgical or Invasive Procedure: none History of Present Illness: 50 yo M with h/o EtOH abuse and HTN who presents with emesis with blood clots.,0
Pt states he was vomiting for 24 hours before coming to the ED.,0
States he last consumed EtOH 2 days PTA and that he drank about a fifth of wine x 2.,0
States he was sleeping at the and vomited again with red clots.,0
"Denies CP, SOB, palpitations, F/C, nausea, BRBPR.",0
"No black stools, constipation, or diarrhea.",0
Past Medical History: EtOH abuse HTN ?pna with empyema?,0
Social History: Pt is homeless.,0
Smokes 2 packs a day.,0
Family History: deferred Physical Exam: 97 140/92 93 18 97% RA Gen: in nad.,0
"thin, weak, ill-appearing HEENT: MMM, poor dentition.",0
"CV: RRR, no m/r/g Pulm: CTAB, +R thoracotomy scar Abd: s/nt/nd, +bs.",0
Rectal: guiac beg brown stool.,0
Skin: dry Neuro: Slightly tremulous.,0
"Brief Hospital Course: A/P: 50 yo hispanic M with h/o HTN, EtOH abuse a/w emesis with blood clots.",0
## GI bleed: Pt's hematocrit has been stable while in house and no further evidence of GI bleeding.,0
Etiology could have been small tear vs gastritis.,0
Pt has no evidence of cirrhosis by physical exam or labs.,0
He was maintained on IV PPI twice a day and denied any further GI sx's.,0
He will be discharged on once a day oral protonix.,0
Scope was initially deferred because of increased risk his DT's.,0
He was scheduled for scope on the day of discharge but refused.,0
## EtOH withdrawal: pt states has had DT's in past.,0
"Initially placed in ICU for closer monitoring, where he required large doses of benzodiazapines for withdrawl (hundreds of milligrams of valium).",0
"He was also started on scheduled haldol, which he should continue as an outpt.",0
Psych was consulted who agreed with this plan.,0
Thiamine and folate were continued.,0
"He left the ICU and tried to leave the hospital twice, each time requiring Code Purple to be initiated (psych emergency) where he needed to transiently be restrained to avoid self injury.",0
"By the time of discharge, the pt was no longer withdrawing and not delerious.",0
## ARF: BUN/Cr ratio indicate likely prerenal.,0
Anion gap likely ARF as well as starvation ketosis.,0
Renal failure and those associated abnormalities improved with IVF's and nutritional support.,0
His K and Mg were aggressively repleted.,0
"## Elevated pancreatic enzymes: Lipase/Amylase >2:1 likely affected by EtOH, however not elevated to a degree sufficient enough to call true pancreatitis.",0
##HTN: unclear of pt's outpt regimen: started prn hydral for SBP >160.,0
His htn was attributed to the unopposed sympathetic tone of alcohol withdrawl.,0
"Medications on Admission: unknown Discharge Disposition: Home Discharge Diagnosis: Hematemesis Alcohol Withdrawl Discharge Condition: Stable Discharge Instructions: If you have these symptoms, call your doctor or go to the ER: - vomiting blood - blood in stool - dizziness/visual change - fever/chills - chest pain/cough Take all your meds.",0
Followup Instructions: Please call your PCP and see him within 2 weeks Completed by:,0
10:31 AM PICC LINE PLACMENT SCH Clip # Reason: PLEASE place PICC at bedside under-ultrasound Admitting Diagnosis: ACUTE RENAL FAILURE ********************************* CPT Codes ******************************** * PICC W/O US GUID FOR VAS.,1
"ACCESS * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with MORBID obesity unable to see PICC line by x-ray, please place at bedside by ultrasound.",1
REASON FOR THIS EXAMINATION: PLEASE place PICC at bedside under-ultrasound ______________________________________________________________________________ FINAL REPORT HISTORY: This is a 61-year-old man with morbid obesity and abscess.,1
Needs PICC line for IV antibiotics.,0
RADIOLOGIST: This procedure was performed by Dr. .,0
"TECHNIQUE: Due to the patient's weight, PICC line was placed at bedside.",0
His right arm was prepared and draped in a sterile fashion.,0
"After local anesthesia with 5 cc of lidocaine 1%, access was gained through the right cephalic vein with a 21-gauge needle under ultrasonographic guidance.",0
Hard copies of ultrasound images before and after establishing an access were obtained.,0
The needle was then removed and a 5-French peel-away sheath was inserted into the vein.,0
"Then a PICC line was trimmed to a length of 50 cm and was advanced over the wire, through the peel-away sheath.",0
The peel-away sheath was removed.,0
The catheter was flushed and secured to the skin with a StatLock.,0
A bedside x-ray image was obtained documenting adequate position of the PICC line with tip in the superior vena cava.,0
"IMPRESSION: Successful placement of a right cephalic vein double lumen PICC line, which is 50 cm long with tip in the superior vena cava.",0
2:06 PM BILAT LOWER EXT VEINS Clip # Reason: DVT lower extremity?,0
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with > 10 days in hospital has intractable fever REASON FOR THIS EXAMINATION: DVT lower extremity?,1
"______________________________________________________________________________ FINAL REPORT BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND INDICATION: 52-year-old woman with subarachnoid hemorrhage, prolonged hospitalization.",1
"FINDINGS: Grayscale and color Doppler images of bilateral common femoral, superficial femoral, and popliteal veins were performed.",0
"These demonstrate normal flow, compressibility, and augmentation.",0
11:09 PM CHEST (PORTABLE AP) Clip # Reason: INTUBATION ______________________________________________________________________________ FINAL REPORT INDICATION: Status post intubation.,0
"PORTABLE AP CHEST RADIOGRAPH: The patient is status post intubation, with endotracheal tube terminating approximately 6.6 cm above the carina just below the thoracic inlet.",0
"Again note is made of tortuous aorta with dilated ascending aorta, as seen on the prior study in .",0
"Lungs are clear, without evidence of consolidation or effusion or CHF.",0
Linear atelectasis at the left lung base is noted.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Bilateral pulmonary embolus Major Surgical or Invasive Procedure: Inferior vena cava filter Midline intravenous catheter Cystoscopy History of Present Illness: other than kidney stones, presents with R side pain and SOB.",1
He reports that 4 days of worsening shortness of breath.,0
He was only able to walk 4 steps at a time.,0
"Prior to this, he was able to accomplish all of his activities of daily living and had not shortness of breath.",0
"He denies cough, chest pain, hemoptysis, fever, chills, nausea, vomiting, abdominal pain or back pain.",0
He initially presened to found to have large bilateral saddle PE.,0
"There are no records available from , although the pt was started on heparin gtt and transferred to because there were no ICU beds at .",0
"Of note, his creatinine was 2.0.",0
On arrival to ED here T 97.1 p90 165/71 20 94 on 3L.,0
LE US was perfomed revealing Nonocclusive thrombus in the left common femoral vein.,0
"He was admitted to for further mgmt, then to CCU, and finally transferred to medicine for further care.",0
"Past Medical History: Nephrolithiasis Social History: Widower, patient lives alone.",0
"No smoking, Etoh use daily 1.5 glasses of wine.",0
Family History: Mother died of cancer.,0
Chemistry: 10:00PM BLOOD Glucose-122* UreaN-46* Creat-1.7* Na-136 K-6.3* Cl-103 HCO3-20* AnGap-19 06:35AM BLOOD Glucose-85 UreaN-14 Creat-0.9 Na-140 K-3.5 Cl-106 HCO3-29 AnGap-9 05:26AM BLOOD ALT-26 AST-39 LD(LDH)-190 CK(CPK)-36* AlkPhos-76 Amylase-23 TotBili-0.6 07:50AM BLOOD LD(LDH)-153 TotBili-0.5 05:26AM BLOOD Lipase-18 10:00PM BLOOD cTropnT-0.11* proBNP-* 01:01AM BLOOD CK-MB-NotDone cTropnT-0.08* 07:35AM BLOOD CK-MB-NotDone cTropnT-0.07* 07:35AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 Iron-24* Cholest-103 10:15AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.6* Mg-2.2 07:35AM BLOOD calTIBC-150* VitB12-357 Folate-6.6 Ferritn-420* TRF-115* 07:35AM BLOOD Triglyc-61 HDL-33 CHOL/HD-3.1 LDLcalc-58 05:20AM BLOOD TSH-2.3 11:46PM BLOOD TSH-2.4 10:15AM BLOOD CEA-1.7 PSA-3.5 10:27AM BLOOD PEP-NO SPECIFI RPR non-reactive .,0
"Urine: Creatinine, Urine 147 mg/dL Total Protein, Urine 249 mg/dL Protein/Creatinine Ratio 1.7* Ratio 0 - .2 .",0
"Electrophoresis, Urine +/- MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING' Immunofixation, Urine - NO MONOCLONAL IMMUNOGLOBULIN SEEN, NEGATIVE FOR BENCE- PROTEIN .",0
URINE CULTURE (Final ): PSEUDOMONAS AERUGINOSA.,0
"10,000-100,000 ORGANISMS/ML.. STAPH AUREUS COAG +.",0
"10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations.",1
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R <=0.5 S IMIPENEM-------------- =>16 R LEVOFLOXACIN---------- =>8 R MEROPENEM------------- =>16 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TETRACYCLINE---------- 2 S TOBRAMYCIN------------ =>16 R VANCOMYCIN------------ <=1 S .,0
ECG (): Sinus rhythm with frequent atrial premature beats.,0
Left axis deviation with left anterior fascicular block.,0
Prominent early R wave progression with ST-T wave abnormalities in the anterior leads.,0
Consider myocardial ischemia versus right ventricular overload.,0
"BILATERAL LOWER EXTREMITY ULTRASOUND (): -scale, color, and spectral Doppler analysis of the right and left common femoral, superficial femoral, and popliteal veins was performed.",1
There is no evidence of right lower extremity DVT.,1
There is nonocclusive thrombus extending from the left common femoral vein to the proximal portion of the left superficial femoral vein.,0
The mid and distal superficial femoral veins on the left showed no evidence of thrombus.,0
IMPRESSION: Nonocclusive thrombus extending from the left common femoral vein to the proximal portion of the left superficial femoral vein.,0
No evidence of right lower extremity DVT.,1
A small pulmonary AV shunt is probably present.,0
"There is a small, loculated (apical) pericardial effusion with fibrin deposits on the surface of the heart.. .",0
CT abdomen/pelvis with contrast (): 1.,0
Very large bowel-containing right inguinal/scrotal hernia without evidence of obstruction or ischemia.,1
Thickening of the bladder wall with possible intraluminal blood clots.,0
Small bilateral pleural effusions and pericardial effusion.,0
No intraabdominal mass or lymphadenopathy.,0
"BLADDER ULTRASOUND STUDY (): Numerous images of the bladder demonstrate a diffusely abnormal wall with irregular thickness and contour, predominantly on the anterior aspect.",0
Some areas of the irregularly thickened anterior wall demonstrate increased vascularity.,0
"There is echogenic fluid in the bladder with debris seen in the dependent portion, some of which is mobile.",0
"IMPRESSION: Irregularly thickened bladder wall, most pronounced anteriorly with small areas of increased vascularity.",0
"Given the appearance of the wall, a cystoscopy is recommended to exclude malignancy.",0
CT head without contrast (): FINDINGS: There is no intracranial hemorrhage.,0
"There are areas of low attenuation within the periventricular white matter, most consistent with chronic microvascular ischemic change.",0
TTE (): The left atrium is moderately dilated.,0
"Compared with the findings of the prior study (images reviewed) of , contractile function of the right ventricle is now normal.",0
"The left ventricle was poorly visualized on the prior study, but was probably normal.",0
Urine cytology (): NEGATIVE FOR MALIGNANT CELLS.,0
Cystoscopy (): (per Dr. note) 3+ trabeculated bladder.,0
"Brief Hospital Course: 78M with no known past medical history originally p/w CP & SOB, found to have saddle PEs, ARF, and urinary retention.",1
Patient arrived to the ED from with known bilateral saddle pulmonary emboli.,0
"He was continued on heparin, started on IV fluids, and transferred to the CCU given evidence of heart failure on echo (EF 25%, RV dysfunction).",1
An US of his lower extremities showed a clot in his left common femoral vein.,0
"On day 2 of his hospital course, a removable IVC Filter was placed successfully without complications.",0
"The patient developed agitation and delerium, threatened to leave AMA, but was deemed not competent to make medical decisions.",0
Guardianship was pursued and evenutally decided on .,0
His course was also complicated by UTI for which he received antibiotics.,0
See below for further details.,0
"Course on the floor as follows: #) Bilateral saddle PEs: Presented with CP and SOB, found to have bilateral PEs and DVT with evidence of heart failure and RV dysfunction.",1
Anticoagulated with heparin and then coumadin briefly but then d/c'd coumadin in favor of lovenox as planned for inpaitent cystoscopy for malignancy workup (see below).,0
s/p IVC filter on given DVT present and concern for further embolization.,0
He was continued on lovenox for anticoagulation until cystoscopy performed and then started on coumadin.,0
He will continue lovenox until reaches goal INR at which time coumadin can be discontinued.,0
"Following resolution of the acute issues, he has remained hemodynamically stable with no respiratory complaints.",0
Discussed removal of IVC filter with IR but they believe high likelihood of failure and procedural risks so deferred.,0
Further hypercoagulability evaluation deferred to outpatient.,0
patient will need daily INR checks until therapeutic on coumadin at which time lovenox can be discontinued.,0
"#) Dementia, agitation, altered mental status: Patient was very agitated, confused early in hospital stay.",0
Likely etiology was toxic-metabolic acute illness and urinary infection in the setting of chronic dementia.,1
Improved somewhat with resolution of acute medical problems but not completely.,0
He repeatedly attempted to leave AMA and required code purple intermittently with physical restraints.,0
Psychiatry was consulted and the patient was started on standing haldol with improvement and resolution of his agitation.,0
"There was concern regarding his ability to understand his illness, comply with treatment, and care for self.",0
He required a 1:1 sitter due to flight risk and occasional agitation.,0
Guardianship was established (see below).,0
"At discharge the patient was calm, cooperative, and conversant.",0
"#) Urology: UTI, urinary retention, acute renal failure, abnormal bladder ultrasound.",1
On hospital day 4 the patient developed a UTI.,0
"He was initially treated with ceftriaxone, which was then switched to ciprofloxacin.",0
"His Foley catheter was removed, but patient developed urinary retention with drainage of 1.4L from his bladder.",1
Renal failure was likely post-renal due to obstruction and resolved with drainage of bladder.,1
Urology was consulted for very difficult foley placement and he was started on flomax.,0
"The foley was initially left in place due to the difficulty of placement and the fact that he was asymptomatic; he was continued on ciprofloxacin, but he developed symptoms of bladder irritation on .",0
Repeat urine culture grew pseudomonas resistant to quinolones and MRSA.,1
"Ciprofloxacin was discontinued and ceftazadime and vancomycin were started to complete a 2 week course (started on and , respectively).",0
A midline catheter was placed and should be removed on after completing his course of IV antibiotics.,0
He failed two voiding trials the week prior to discharge and therefore an indwelling foley was left in place with urology followup for urodynamics studies and consideration of TURP.,0
Also found to have bladder U/S with irregular wall thickening.,0
"Concern was for malignancy, however urine cytology was negative and the patient underwent cystoscopy on which revealed no evidence of malignancy.",0
Plan for outpatient urology followup with Dr. on .,0
"#) Malignancy screening: Given hypercoagulability, initiated cancer screening as possible etiology.",0
Abdominal/pelvic CT was notable for a thickened bladder wall and further followed up with a bladder US that confirmed the finding.,0
Urine cytology and cystoscopy was negative.,0
"Chest CT at presentation showed bibasilar nodular densities in the setting of bilat PEs, and repeat study revealed that these had completely resolved.",0
"However, an indicental finding of hypoattenuating liver lesion was noted that should be followed up with MRI per radiology as an outpatient.",0
He was also scheduled for screening colonoscopy with Dr. ; instructions for the bowel preparation are attached with the discharge information.,0
Followup with urology per above.,0
"#) Thrombocytopenia: Platelets 222 on arrival, and noted slow downward progression during initial hospital course with nadir in low 100s.",0
"Possibly consumption for underlying blood clots, but not clear.",0
Did not appear to meet trends for either Type I or II HIT; HIT antibody was sent and was negative.,0
"No other signs of DIC, TTP.",0
"Initially on heparin, then coumadin, and finally lovenox.",0
Discontinued protonix secondary to small likelihood that PPI/H2 blockers cause thrombocytopenia.,0
Platelets slowly increased and normalized around 150.,0
Would continue to monitor weekly as outpatient.,0
#) Cardiac: No known CAD and on no cardiac meds at home.,0
"Upon arrival, echocardiogram initially with EF 25% and RV dysfunction likely PE, so ACEi and BB were initiated for presumed cardiomyopathy.",0
Repeat echo was performed after acute events resolved and showed preserved EF with normal wall motion.,0
ACEi and BB were then discontinued.,0
"He remained in sinus rhythm, normotensive.",0
"#) Scrotal hernia: Large scrotal hernia noted on exam, althogh patient asymptomatic.",0
Abdomen/pelvis CT scan with large amount of bowel in hernia sac.,0
"No evidence of incarceration, volvulus.",0
Patient declining eval for herniorraphy and given no symptoms unlikely need at this time.,0
Monitor as outpatient with surgery referral as indicated.,0
"#) Disposition: On , the patient appeared to be medically clear discharge, however it was clear that patient was not safe to go home given limited mobility, anticoagulation, lack of social supports, and extremely limited understanding of his condition.",0
He was deemed to lack capacity to understand risks/benefits of refusing care and inability to care for self at home safely.,0
"In addition, it was discovered that his home was condemned by public health department.",0
"As a result, guardianship was pursued with family and his attorney.",0
"Official guardianship appointed between , JD and (cousin; ).",0
Hexavitamin Tablet Sig: One (1) Cap PO QAM (once a day (in the morning)).,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn as needed for constipation.,0
"Disp:*90 Tablet, Chewable(s)* Refills:*2* 5.",0
Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID prn.,0
Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)).,0
Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q8H (every 8 hours) for 5 days.,0
Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN.,0
Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation.,0
Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days.,0
Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous twice a day: discontinue when INR >2.,0
Release 24HR PO at bedtime.,0
Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Tablet(s) Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary: 1) Bilateral Saddle Pulmonary Emboli 2) Delirium 3) Alcohol Withdrawal 4) Dementia 5) Urinary retention 6) Complicated urinary tract infection 7) Thrombocytopenia NOS .,1
Secondary: 1) Macrocytic anemia 2) History of alcoholism 3) Hypertension 4) Lung nodules NOS Discharge Condition: Good Discharge Instructions: Please take all medications as prescribed.,0
"Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms.",0
Followup Instructions: You are scheduled for the following appointments.,0
Please contact the provider with any questions or if you need to reschedule.,0
You were found to have a possible abnormality in your liver.,0
It was suggested that you have an MRI of your liver for further evaluation.,0
You will need to be accompanied by an attendant or your guardian.,0
Followup for urodynamics studies and consideration of possible TURP procedure.,0
"Colonoscopy: GI WEST,ROOM ONE GI ROOMS Date/Time: 10:30 Gastroenterology: , MD Phone: Date/Time: 10:30.",0
You must arrive by 9:30am.,0
You will need to complete a bowel prep starting the day before this appointment.,0
Please see the sheet given to you at discharge for instructions on how to perform the preparation.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Codeine Attending: Chief Complaint: elective admission for craniotomy Major Surgical or Invasive Procedure: left craniotomy for tumor resection left EVD placement History of Present Illness: This is a 74-year-old woman with an intraventricular cancer who initially presented with ventriculitis secondary to a trapped left ventricle.,0
The patient's neurologic status improved subsequent to an EVD placement and an extended course of antibiotic.,0
The lesion was subsequently biopsied by Dr. and the pathology was consistent with anaplastic astrocytoma.,0
"After discussion of treatment strategies, the patient elected to undergo resection of the exophytic portion of the mass.",0
Past Medical History: Unknown Social History: non-contributory Family History: non-contributory Physical Exam: Patient is oriented x 1 only.,0
She moves all extremities spontaneously.,0
"Incision is clean, dry, intact.",0
Pertinent Results: MRI Brain : FINDINGS: There has been interval resection of the left frontal mass.,0
There is no evidence of residual tumor.,0
"There are postoperative changes, including intraparenchymal hemorrhage along the surgical pathway and surrounding edema are noted.",0
"The fluid signal intensity within the left lateral ventricle is higher on FLAIR than in the right lateral ventricle, this may represent a component of hemorrhage within the ventricle.",0
"Dependent material is noted within the left lateral ventricle, apparently representing a hematocrit level related to intraventricular hemorrhage.",0
A ventriculostomy is present in the left frontal .,0
A small amount of blood is present dependent within the left lateral ventricle.,0
"CT Head : FINDINGS: A left frontal craniotomy is again seen, with unchanged underlying extra-axial blood products.",0
Previously noted pneumocephalus has decreased in extent.,0
"A left frontal ventriculostomy is again seen, terminating in or just inferomedial to the inferior aspect of the frontal of the left lateral ventricle.",0
"Small amount of blood is seen along the ventriculostomy path in the left frontal lobe, less dense than on the previous study.",0
The amount of blood layering in the left lateral ventricle is unchanged.,0
"The frontal of the left lateral ventricle is slightly smaller, and other components of the ventricular system are stable in size.",0
Previously noted shift of the anterior falx and the septum pellucidum to the right has slightly decreased.,0
There is persistent opacification of the right posterior ethmoid air cell.,0
"There is new fluid in the right sphenoid sinus and new aerosolized secretions in the left sphenoid sinus, which may be related to the presence of a nasogastric tube.",0
"IMPRESSION: Expected evolution of postoperative changes, with slightly decreased shift of normally midline structures to the right and slightly decreased density of blood along the path of the left frontal ventriculostomy.",0
Slightly decreased frontal of the left lateral ventricle.,0
The remainder of the ventricular system is stable in size.,0
Brief Hospital Course: The patient was admitted for elective craniotomy for tumor resection.,0
The surgery went well and the patient went to the ICU afterwards.,0
She had an EVD that was placed at the same time and was at 15 cm above the tragus and open.,0
Her ICP remained within normal limits.,0
The patient was not following commands after the surgery.,0
She was noted to have a tremor in her lower extremities but this was not felt to be seizure activity.,0
The patient was also found to have yeast in her urine.,0
ID felt that no medication needed to be given.,0
The patient was transferred to the step down unit where her neuro status improved.,0
She was able to follow some commands and she was more alert.,0
The patient passed speech and swallow and was tolerating a regular diet.,0
She was seen by OT/PT who recommended rehab.,0
On Dr. removed the EVD due to normal ICP.,0
Her neuro exam had improved to near baseline with the exception of her RUE weakness ().,0
She was voiding on her own.,0
She was discharged in the afternoon of .,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever.,0
Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day).,0
Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): to continue until follow up appointment with Dr. .,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed.,0
Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed.,0
Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours).,0
Discharge Disposition: Extended Care Facility: Medical Center - Discharge Diagnosis: anaplastic astrocytoma Grade III Discharge Condition: neurologically stable Discharge Instructions: General Instructions/Information ?,0
"You have dissolvable sutures, you must keep that area dry for 10 days.",0
F. Followup Instructions: Follow-Up Appointment Instructions Your sutures will dissolve so you do not need to have them removed.,0
"Follow up with , MD Phone: Date/Time: 2:00 pm.",0
"12:50 PM CT HEAD W/O CONTRAST Clip # Reason: Evaluate for ICH or ischemiaEvaluate for c-spine fracture or ______________________________________________________________________________ MEDICAL CONDITION: History: 88F with lethargy, fall since Friday REASON FOR THIS EXAMINATION: Evaluate for ICH or ischemiaEvaluate for c-spine fracture or dislocation No contraindications for IV contrast ______________________________________________________________________________ WET READ: MDAg MON 1:24 PM no evidence of acute intracranial injury WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 88-year-old woman with lethargy and fall on Friday.",1
Bone reconstructions and coronal and sagittal reformations were obtained for evaluation.,0
The study was repeated due to patient motion.,0
"FINDINGS: The study is somewhat limited by patient motion, despite two separate acquisition.",0
"There is no evidence of acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct.",0
"Prominent ventricles and sulci are similar to , compatible with global age-related volume loss.",0
"Hypoattenuation in the subcortical and periventricular white matter is either stable or minimally progressed since , likely sequelae of chronic microvascular ischemic disease.",1
No calvarial fracture is identified.,0
A mucus-retention cyst in the right maxillary sinus is similar to .,0
Opacification of a left anterior ethmoid air cell is new.,0
The mastoid air cells are under-pneumatized.,0
IMPRESSION: No evidence of acute intracranial injury.,0
"6:26 PM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with fall, previous cervical fusion REASON FOR THIS EXAMINATION: r/o injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall, rule out injury.",1
TECHNIQUE: Contiguous axial images were obtained through the lumbar spine without intravenous contrast.,1
FINDINGS: There is a comminuted fracture of the L1 vertebral body with circumferential expulsion of bony fragments.,0
"There is retropulsion of osseous fragments into the spinal canal, with moderate narrowing(50 %) of the central canal at this level.",1
"There is also extension of this fracture into the posterior elements, specifically the right-sided lamina at this level.",1
The alignment of the lumbar spine is otherwise unremarkable.,1
There is moderate loss of the vertebral body height of L1.,0
"IMPRESSION: Comminuted, unstable fracture of L1 with retropulsion of osseous fragments into the spinal canal.",1
These findings were immediately relayed to the trauma team.,0
12:29 PM VENOUS DUP EXT UNI (MAP/DVT) LEFT; DUP EXTEXT BIL (MAP/DVT) Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: upper and lower extremity veing mapping.,0
"Admitting Diagnosis: RIGHT FOOT ULCER;CELLULITIS;INFECTION, ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with failed RLE bypass/ulcer and for RLEbypass friday.",1
REASON FOR THIS EXAMINATION: upper and lower extremity veing mapping.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Vein mapping.,0
Patient in need of lower extremity bypass.,1
FINDINGS: -scale evaluation was performed of both upper and lower extremities.,0
"On the right, the greater saphenous vein is patent from the knee to the groin with diameters as follows: 0.35, 0.42, 0.47, 0.38 cm at the knee, low thigh, high thigh and saphenofemoral junctions respectively.",0
"The right lesser saphenous vein is patent with diameters of 0.30, 0.36, and 0.36 cm from the ankle to the popliteal fossa respectively.",0
"Left greater saphenous vein is patent from the ankle to the groin with diameters of 0.24, 0.24, 0.36, 0.38, 0.38 and 0.48 cm at the ankle, calf, knee, lower thigh, high thigh, and saphenofemoral junctions respectively.",0
"The left lesser saphenous vein is patent with diameters of 0.40, 0.30, and 0.32 cm from the ankle to the popliteal fossa respectively.",0
"The left cephalic vein is patent with diameters of 0.52, 0.40, 0.47 from the elbow to the shoulder levels respectively.",0
"The left basilic vein is patent with diameters of 0.36, 0.52, and 0.50 in the same location respectively.",0
IMPRESSION: Patent bilateral lesser saphenous veins.,0
Patent bilateral greater saphenous veins.,0
"Of note, the distal portion of the right greater saphenous vein has been harvested.",0
Patent left basilic and cephalic veins.,0
"1:17 PM BABYGRAM AP ABD ONLY PORT Clip # Reason: 2 month old female former 26 weeks with bloody stools Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, 26 weeks rds uvs pulled back please do film at 0500 REASON FOR THIS EXAMINATION: 2 month old female former 26 weeks with bloody stools ______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN ON AT 13:32 HOURS HISTORY: 26-weeks primi with bloody stools.",1
"In followup to , supine view of the abdomen demonstrates an NGT terminating in left-sided stomach.",0
The bowel gas pattern is nonspecific with some moderate gaseous distention in the right and left abdomen as well as within the rectum with no evidence of obstruction.,0
"The gas pattern is more regular on the right associated with a linear appearance, which may be related to pneumatosis.",0
Further followup would be helpful.,0
Coarse interstitial pattern is present in the lung bases consistent with chronic lung disease.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: probable ovarian carcinoma, pancreatic pseudocyst Major Surgical or Invasive Procedure: For procedures completed from the dates of to , refer to Dr. of Gynecologic Oncology and Dr. of Pulmonary Medicine; No major surgical or invasive procedures were done while I was responsible for her care ( to ) History of Present Illness: As written on admission by Dr. : The patient is a 50-year-old G1, P1, who was recently admitted three times to with increasing abdominal distention, early satiety, and shortness of breath.",1
"She had a CT on , which revealed a large amount of ascites.",0
There were low attenuation capsular lesions along the right lobe of the liver consistent with liver surface implants.,0
"There was a large cystic lesion with some internal septations in the region of the pancreas consistent with a large pancreatic pseudocyst, measuring 13.9 cm in largest dimension.",1
There were multiple soft tissue masses or calcifications within the uterus consistent with fibroids.,0
The right adnexa had an 8 cm soft tissue mass.,0
There was no evidence of bowel obstruction.,0
These findings were felt to be most consistent with ovarian carcinoma.,0
"She had a CA-125, which was 160 and a CEA, which was 6.5.",0
"The patient was discharged after initial evaluation, but has been readmitted twice with increased symptomatic ascites, and ahs undergone two therapeutic paracenteses with good effect.",0
She states that she has been tolerating a regular diet and having bowel movements and urinating without difficulty.,0
Past Medical History: ObHx: -Preterm vaginal delivery twins GynHx: -LMP .,0
Has h/o menorrhagia secondary to uterine fibroids.,0
"U/S showed multiple large uterine fibroids, largest 11.5 x 10.5 x 10 cm.",0
s/p uterine artery embolization @ .,0
Traumatic in origin per pt after a fall.,0
Pt thinks she had drainage of fluid 2 years ago @ which excluded malignancy.,0
PSH: -Uterine artery embolization Social History: Pt is originally from .,0
Has lived in the States for approx 20+ years.,0
"Family History: Mother-80s, alive and well, had TAH/BSO for fibroids.",0
"Father-age 85, alive and well.",0
"No FH of breast, ovarian, uterine, cervical, colon CA.",0
"Physical Exam: Admission H and P as written by Dr. : Preoperative physical examination: GENERAL APPEARANCE: Well developed, well nourished, and in no acute distress.",0
LYMPHATICS: Lymph node survey was negative.,0
ABDOMEN: Severely distended with obvious ascites.,0
Large palpable mass in left upper quadrant.,0
PELVIC: The vulva and vagina were normal.,0
Bimanual and rectovaginal examination was limited by the abdominal distention.,0
"However, there was a firm mass palpable in the cul-de-sac.",0
The cervix was normal to palpation.,0
The rectum was intrinsically normal.,0
* The following is a summary of the care that I provided: Summary of care provided by Dr. from until : Ms. was transfered out of the medical ICU to my service overnight .,0
I met her on the AM of .,0
"She was suffering from multi-organ system failure due to end-stage, metastatic ovarian cancer and was actively dying with obtundation, and cheynes- respirations.",0
"Per her family's wishes she was ""Comfort Measures Only"", and was being palliated with an ongoing Dilaudid intravenous drip.",0
Her family remained at her bedside.,0
"No changes to her medication regimen were made, with the exception of the addition of a scopolamine patch to dry oral secretions that were noted to be causing some occlusion of her upper airway; this was done for palliation of dyspnea.",0
The palliative care team was following along.,0
She died peacefully early in the am of at approximately one in the morning.,0
The family declined post-mortem examination.,0
"For the details of her hospitalization prior to this time, please refer to DR. of Gynecology Oncology and Dr. of Pulmonary Medicine for her care on the Gynecology Oncology Service and in the Medical Intensive Care Unit, respectively.",0
* The following represents the care provided by the Gynecology Oncology Service from the dates of until * The patient was admitted to the gynecologic oncology service on and underwent an uncomplicated exploratory laparotomy; the details of her surgical procedure are dictated elsewhere.,0
Postoperative course was notbale for the following issues: #) Oliguria: The patient had notable postoperative oliguria thought to be due to intravascular depletion and third-spacing.,0
She received 4L of fluid boluses to maintain adequate urine output on POD#0-1.,0
"Hct was stable, and FeNa indicated increased sodium avidity consistent with intravascular volume depletion.",0
On POD#2 her urine output improved and she began to diurese spontaneously.,0
Her Foley catheter was discontinued.,0
#) Hyperkalemia: The patient's potassium was noted to be elevated on POD#.,0
"She was asymptomatic, and her ECG revealed no peaked T waves.",0
The hyperkalemia was presumed due to renal hypoperfusion.,0
"#) Pulmonary emboli: The patient was initially placed on subcutaneous heparin in prophylactic doses, and had both stockings and pneumoboots in place.",0
"On POD#, she was noted to undergo an acute oxygen desaturation to the 80s with minimal response to oxygen supplementation.",0
A CTA revealed two pulmonary emboli.,0
The patient was started on a heparin drip.,0
"Her oxygen saturation improved, and she remained asymptomatic.",0
#) Fluid overload: The patient received large quantities of IV fluid to maintain end-organ perfusion after her surgery.,0
"Her ascited reaccumulated, and she was notably symptomatic on POD#3.",0
She received a single dose of IV Lasix and diuresed appropriately.,0
"#) GI: The patient was transferred out of the OR with an NGT in place, with a plan to leave it until POD#4 to decompress her stomach and the pseudocyst.",0
"She self-D/C'd the NGT on POD#, and refused to have it replaced.",0
"After consultation with general surgery, the NGT was not replaced due to concern about trauma at the suture line.",0
She remained NPO until POD#4.,0
Medications on Admission: Refer to the admission History and Physical from the Gynecology Oncology Service under Dr. .,0
Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Metastatic ovarian cancer Discharge Condition: Expired Discharge Instructions: Patient expired Followup Instructions: None,0
"4:37 AM CHEST (PORTABLE AP) Clip # Reason: intubation Admitting Diagnosis: CAD/AS ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with resp distress REASON FOR THIS EXAMINATION: intubation ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Respiratory distress, intubation.",0
"FINDINGS: As compared to the previous radiograph, there is a newly appeared bilateral, right more than left perihilar alveolar opacity with central predominance.",0
"The opacity would be consistent with central pulmonary edema, notably given the accompanying signs of increased intravascular volume.",0
"The size of the cardiac silhouette is unchanged, there is no evidence of pleural effusions.",0
"Newly inserted endotracheal tube and nasogastric tube in correct position, the tip of the endotracheal tube projects 5 cm above the carina.",0
"No evidence of pneumothorax, unchanged course and position of the left pectoral pacemaker leads.",0
4:27 AM CHEST (PORTABLE AP) Clip # Reason: pls eval for interval changes Admitting Diagnosis: S/P CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with b/l pneumothoracies and resp failure REASON FOR THIS EXAMINATION: pls eval for interval changes ______________________________________________________________________________ FINAL REPORT HISTORY: 64-year-old male with bilateral pneumothoraces and respiratory failure.,1
COMPARISON: Multiple recent prior chest radiographs from through .,0
"PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: The patient remains intubated, with ET tube tip terminating approximately 5.9 cm above the carina.",0
"A left upper extremity PICC is new, and its tip is seen in the mid SVC.",0
"Bilateral mid pleural chest tubes are again noted, with the left chest tube appearing slightly retracted with its proximal port projecting approximately 1.7 cm from the lateral rib cage.",1
The OG tube is seen within the stomach.,0
"Extensive subcutaneous collections of air are slightly decreased, although it still obscures evaluation of small pneumothorax.",0
The heart size and mediastinal contours remain normal.,0
The lungs are moderately well inflated.,0
"There is new left retrocardiac opacity, which likely represents atelectasis and possible small pleural effusion.",0
Linear atelectasis also is seen in the right upper lung.,0
No definite new airspace consolidation is seen.,0
"IMPRESSION: New left retrocardiac opacity, likely representing atelectasis and possible small pleural effusion.",0
"Left chest tube possibly slightly retracted outward, now projecting 1.7 cm from rib cage.",0
"6:08 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please assess ett placement s/p reintubation Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with intubation REASON FOR THIS EXAMINATION: please assess ett placement s/p reintubation ______________________________________________________________________________ FINAL REPORT INDICATION: History of intubation, evaluate ET tube placement.",1
"PORTABLE AP CHEST RADIOGRAPH: In comparison to the prior study, again seen is an ET tube, with the tip positioned approximately 5 cm above the carina.",0
"A left subclavian central venous line is again seen, with the tip positioned within the SVC.",0
There has been interval removal of an NG tube.,0
IMPRESSION: ET tube is positioned with the tip approximately 5 cm above the carina with hyperinflation of the cuff.,0
Interval removal of an NG tube.,0
The remainder of the study is not significantly changed.,0
2:43 AM CT L-SPINE W/O CONTRAST Clip # Reason: to further assess compression fx.,0
"per NSGY, no contrast need Admitting Diagnosis: UGIB ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with compression fracture of l-spine REASON FOR THIS EXAMINATION: to further assess compression fx.",0
"per NSGY, no contrast needed.",0
"please include sacrum CONTRAINDICATIONS for IV CONTRAST: not needed ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa WED 1:34 PM There is evidence of compression fracture at the level of L4 with associated posterior retropulsion, causing anterior thecal sac deformity and narrowing of the thecal sac.",1
"Additionally, there is also apparently acute/subacute superior endplate compression fracture at L3 level.",0
Disc degenerative changes are identified at L5/S1 level with posterior central disc bulge.,0
______________________________________________________________________________ FINAL REPORT STUDY: CT of the lumbar spine without contrast.,0
CLINICAL INDICATION: 43-year-old man with history of compression fracture at the lumbar spine.,1
"COMPARISON: Prior MRI of the lumbar spine dated , and prior plain films of the lumbar spine dated .",0
TECHNIQUE: Contiguous axial images were obtained through the lumbosacral spine.,0
Sagittal and coronal reformatted images were provided.,0
The images were reviewed using soft tissue and bone window algorithms.,0
FINDINGS: There are five non-rib-bearing lumbar-type vertebral bodies.,1
Compression fracture is identified at the vertebral body of L4 with associated posterior retropulsion causing significant anterior thecal sac deformity and central spinal canal stenosis (2:63).,1
"Additionally, there is also an acute/subacute superior endplate compression fracture at the L3 vertebral body without evidence of retropulsion.",1
"From T12/L1 through L2/L3 intervertebral disc spaces, there is no evidence of significant neural foraminal narrowing or central spinal canal stenosis.",1
"At L5/S1 level, there is evidence of posterior central disc bulge, causing anterior thecal sac deformity.",0
"Additionally, there are bilateral sclerotic changes at the articular joint facets.",0
The sacroiliac joints are unremarkable.,0
The visualized aspect of the abdomen demonstrates residual radiopaque contrast material in the bowel.,0
"IMPRESSION: Compression fracture at the L4 vertebral body with posterior retropulsion, causing severe spinal canal stenosis as described above.",1
Fracture of the superior endplate at L3 as described above without evidence of retropulsion.,0
(Over) 2:43 AM CT L-SPINE W/O CONTRAST Clip # Reason: to further assess compression fx.,0
"per NSGY, no contrast need Admitting Diagnosis: UGIB ______________________________________________________________________________ FINAL REPORT (Cont) Disc degenerative changes identified at L5/S1, causing anterior thecal sac deformity and moderate spinal canal stenosis.",1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Mental Status Changes Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 73 yo woman with PMH of brain tumor s/p VP shunt , near deafness, hypothyroid and colon CA last year who presented to ED with mental status changes.",0
Apparently benign per daughter but was irradiated anyways (?).,0
had severe loss of hearing and imbalance following that.,0
Had Shunt placed that in conjunction with tumor treatment and has never had complications.,0
Colon Ca diagnosed 1 yr ago.,0
"Hypothyroidism Social History: no tobacco, social ETOH Family History: non-contributory Physical Exam: On Admission: Exam: T- 100.6/100.6 BP- 107-154/65-83 HR- 64 RR- 21 O2Sat 99 % RA Gen: Lying in bed, NAD HEENT: evidence of old crani at right posteroir region with bony abnormalities, dry oral mucosa with large brown mucous at back of oropharynx Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally, but shallow breaths aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Has just received 2mg Ativan IV about 2-3 hours ago.",1
"Has eyes closed, does not move spontaneously.",0
Groans to noxious stim and moves x 4 but not antigravity.,0
Does not follow any midline or appendicular commands.,0
"Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally.",0
Extraocular movements intact bilaterally with spontaneous roving movements.,0
No observed myoclonus or tremor Withdraws to noxious stim x 4 antigravity with no asymetries.,0
Sensation: withdraws x 4 Reflexes: +2 and symmetric throughout BUE.,0
Toes up bilaterally Coordination: cannot assess Pertinent Results: MRA():IMPRESSION: No significant new interval change in the previously described subdural hematomas and subarachnoid hemorrhage.,1
There is no evidence of diffusion abnormalities or acute ischemic changes.,0
"Diffuse leptomeningeal enhancement, likely related with the recent fractures and subdural hematomas.",0
Hyperintensity areas noted on FLAIR located in the subcortical white matter and basal ganglia consistent with chronic lacunar ischemic changes and small- vessel disease.,0
The shunt catheter is unchanged in position with the tip near to the foramen of .,0
"Slight interval increase in size of subdural hemorrhage in the inferior left frontal lobe, with minimal edema and mass effect on regional sulci.",1
"Otherwise, little interval change in the bilateral convexity subdural hemorrhages, and bilateral subarachnoid blood.",1
"Unchanged position of shunt catheter, with collapsed ventricles which may reflect intracranial hypotension or overshunting.",0
"Brief Hospital Course: Patient is a 73 yo woman with PMH of brain tumor s/p VP shunt , near deafness, hypothyroid and colon CA last year who presented to ED yesterday at 2300 with mental status changes.",0
"According to the daughter, the patient has in town from for the alst 2 weeks visiting for a graduation.",0
Last night she had had 3 glasses of wine the of her MS changes.,0
Last night during the graduation party said that she was feeling tired and that she was going to go upstairs to go to bed.,0
"About an hour later, she came down the stares and had notable face/eye trauma as if she had fallen.",0
Her speech was dysarthric and she was mumbling.,0
"She said ""I don't know what happened"" and could not give explanation.",0
She was found to have bilateral SDH L >R and was transferred here.,0
"Here in the ICU, would open eyes and intermittently seemed to follow commands.",0
She is very hard of hearing per daughter and nearly deaf.,0
"She was noted by ICU team to be moving x 4 but not speaking, and sleepy.",0
"She was obeserved in the ICU for 24 hours, and started on Folate, Thiamine, and Dilantin prophylactically.",0
"Subsequent CT scans revealved stability of SDH, and no worsening such to indicate surgical evacuation.",0
Given her medical history a MRI/MRA was obtained(results included previously in this summary).,0
Patient had inquired about receving her ongoing care in her come country of .,0
Discharge planning has been moving toward that goal.,0
"She has a neurologist who follows her in , Dr. .",0
"This is acceptable per Dr. , and case managment has been working with the daughter to make arrangements to this effect.",0
Physical therapy has continued to work with the patient in-house pending the finalization of these plans.,0
The PT and OT felt that she did not require rehab but that she did need continued therapy after discharge.,0
The patient will be discharged with the plan to go back home to with home PT and OT services.,0
"Medications on Admission: Lipitor, Colace, levoxyl 50 mcg dialy, Aggrenox 1 , protonix Discharge Medications: 1.",0
Home PT This patient requires home physical therapy as recommended by the inpatient therapists at .,0
Home OT This patient requires home occupational therapy as recommended by the inpatient therapists at .,0
Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO three times a day.,0
Medications Please resume all home medications except for Aggrenox.,0
Discharge Disposition: Home With Service Facility: Pts PCP will set up services in .,0
"Discharge Diagnosis: Bilateral SDH, SAH, s/p fall Conjunctivitis Discharge Condition: Stable Discharge Instructions: General Instructions ?",0
"If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered.",0
"Followup Instructions: Please call ( to schedule an appointment with Dr. , to be seen in weeks.",0
"You may follow up with your own physician, .",0
in for your convenience if it is too difficult to come back to the U.S.,0
"8:39 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate known intracranial bleed ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with hemorrhagic stroke, intubated REASON FOR THIS EXAMINATION: evaluate known intracranial bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: VK MON 10:01 PM Large lt frontoparietal intraparenchymal hemorrhage increased from outside study.",0
Increase in rt medial parietal hemorrhage.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old with intracranial hemorrhage.,0
"By report, the patient drove himself to an outside hospital emergency room, and subsequently became lethargic and obtunded.",0
TECHNIQUE: CT of the brain without IV contrast.,0
"Comparison is made to a study performed approximately 5:00 p.m. at an outside hospital, which was not available for review by the attending co-signing the report.",0
FINDINGS: There is a large left frontal and parietal intraparenchymal hemorrhage with surrounding vasogenic edema.,0
There is also subarachnoid hemorrhage seen superiorly in the left frontal lobe.,0
Intraparenchymal hemorrhage is also seen medially within the right parietal lobe along the falx.,0
There is hemorrhage layering bilaterally within the occipital horns of the lateral ventricles.,0
The extensive intraparenchymal hemorrhage is larger than on the earlier outside study in both cerebral hemispheres.,0
"In addition, the intraventricular hemorrhage is new since the prior study.",0
"There is mild shift of midline structures to the right, including medial displacement of the left uncus.",0
There is flattening of the left lateral ventricle due to mass effect.,0
Other ventricles are not dilated.,0
Marked sulcus effacement is seen within the left cerebral hemisphere.,0
The patient is slightly rotated on the scout view.,0
"An endotracheal tube is present, as is an NG tube.",0
Minimal mucosal thickening is seen in the ethmoid air cells.,0
"Soft tissues, osseous structures, and remaining paranasal sinuses are unremarkable in appearance.",0
IMPRESSION: Large left cerebral intraparenchymal hemorrhage and right parietal lobe intraparenchymal hemorrhage with associated left frontal lobe subarachnoid hemorrhage and bilateral intraventricular hemorrhage.,0
There is also mild left uncal herniation.,0
These findings were communicated to Dr. at the completion of the examination.,0
DFDgf (Over) 8:39 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate known intracranial bleed ______________________________________________________________________________ FINAL REPORT (Cont),0
"10:49 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: eval for fx ______________________________________________________________________________ MEDICAL CONDITION: year old man with left hemiparesis, s/p fall - intubated REASON FOR THIS EXAMINATION: eval for fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: ESE TUE 1:13 AM Extensive degenerative changes.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Left hemiparesis status post fall.,0
TECHNIQUE: Axial images of the spine were obtained from the skull down to T2 vertebra.,0
Reformated images were obtained in the coronal and sagittal planes.,0
CERVICAL SPINE CT: Extensive degnerative changes are present throughout the cervical spine.,0
"There is marked joint space narrowing at all levels of the cervical spine, most severe at the C5-6 and C7-T1 levels.",0
There is grade I anterolisthesis of C3 on C4.,0
This is likely degenerative in nature.,0
Osteophyte formation is seen at C5-T1 vertebra.,0
A small bubble of gas is seen within the T1-T2 disc space consistent with vacuum degenerative changes.,0
There is sclerosis of the posterior facet joints.,0
There is no evidence of dislocation.,0
The neck soft tissues reveal no abnormal fluid collections.,0
Calcifications are seen within the carotid arteries.,0
A nasogastric tube and endotracheal tube are visualized.,0
CT RECONSTRUCTIONS: Reformatted images in the coronal and sagittal planes confirm the above mentioned findings.,0
Extensive cervical spine degenerative changes.,0
"Mild anterolisthesis of C3 on C4, likely secondary to degenerative changes.",0
"4:29 AM CHEST (PORTABLE AP) Clip # Reason: past re-intubation please evaluate for re-inflation and for ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with Hx inf MI, admitted for obstruction, gastrectomy/Bilroth II, now intubated s/p chest tube removal REASON FOR THIS EXAMINATION: past re-intubation please evaluate for re-inflation and for lung patholgy.",0
______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Re-intubation.,0
Compared to previous study of earlier the same date.,0
An ET tube is in satisfactory position.,0
"A central venous catheter and NG tube remain in place, unchanged in position.",0
"There are multifocal patchy lung opacities bilaterally, with interval improvement in the lung bases.",0
No pneumothorax or definite pleural effusion is seen.,1
Satisfactory placement of ET tube.,0
Multifocal patchy lung opacities with interval improvement in both lung bases.,0
PATIENT/TEST INFORMATION: Indication: s/p cardiac arrest Height: (in) 66 Weight (lb): 170 BSA (m2): 1.87 m2 BP (mm Hg): 112/64 HR (bpm): 73 Status: Inpatient Date/Time: at 08:06 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %).,1
IMPRESSION: Severely dilated left ventricle with severe global left ventricular hypokinesis.,0
The right ventricle is not well seen but is probably mildly dilated and borderline hypokinetic.,0
"Compared with the prior study (images reviewed) of , overall left ventricular systolic function has substantially worsened.",1
The right ventricle appears dilated and hypokinetic on the current study.,0
Pulmonary artery pressures could not be estimated on the current study.,0
11:20 AM CLAVICLE LEFT Clip # Reason: assess fx ______________________________________________________________________________ MEDICAL CONDITION: 22 year old woman with clavicle fx REASON FOR THIS EXAMINATION: assess fx ______________________________________________________________________________ FINAL REPORT EXAM ORDER: Left clavicle.,0
Left clavicle two views show mildly displaced left mid clavicle fracture with angular deformity of the apex superiorly.,1
The acromioclavicular joint is unremarkable.,0
IMPRESSION: Mildly displaced left mid clavicle fracture.,1
"4:02 PM CHEST (PORTABLE AP) Clip # Reason: preop Admitting Diagnosis: LUMBAR FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: Preop REASON FOR THIS EXAMINATION: preop ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW, HISTORY: Preop.",1
Clips are seen overlying the lower neck.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: was born with a birthweight of 3.41 kg and a gestational age of 35-5/7 week born to a 34-year-old G2 P1-2 woman.,0
"Prenatal screens: Blood type O+, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta Strep status unknown.",0
The mother presented with ruptured membranes at 12 am on five hours prior to delivery.,0
There was no maternal fever.,0
Labor progressed rapidly and there was no precipitous vaginal delivery.,0
Apgars were 7 at one minute and 8 at five minutes.,0
The baby was noted to have prominent facial bruising and respiratory distress at delivery.,0
He was admitted to the Neonatal Intensive Care Unit for treatment of respiratory distress.,0
"PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 3.41 kg, length 51 cm, head circumference 35 cm.",0
General: Nondysmorphic infant with grunting and retracting.,0
"Head, eyes, ears, nose, and throat: Anterior fontanel is soft and flat, normal faces.",0
"Breath sounds equal and clear, improved after starting on continuous positive airway pressure.",0
"Cardiovascular: Normal S1, S2, no murmur.",0
Abdomen is soft without organomegaly.,0
Appropriate for gestational age male with testes palpable bilaterally.,0
"Hips: Slightly increased laxity, but stable.",0
Skin: Facial bruising as previously noted.,0
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1.,0
Continuous positive airway pressure was initiated shortly after admission to the Neonatal Intensive Care Unit.,0
required a maximum of 30% inspired oxygen.,0
"An arterial blood gas was a pH of 7.33, pCO2 of 43, a pO2 of 58.",0
"His respiratory distress gradually resolved over the next few hours, and by day of life #1, he was on room air with normal respiratory rates.",0
"A chest x-ray showed bilateral mild strict densities with normal lung volumes, normal situs and normal heart size.",0
His respiratory distress was thought to be due to retained fetal lung fluid.,0
Cardiovascular: maintained normal heart rates and blood pressures.,0
There were no murmurs noted during admission.,0
"Fluids, electrolytes, and nutrition: was initially NPO and maintained on intravenous fluids.",0
"Enteral feeds were started on day of life #1, and gradually advanced to full volume.",0
"At the time of discharge, he is breastfeeding well or taking Enfamil 20.",0
Discharge weight is 3.285 kg.,0
"Infectious Disease: Due to an unknown group B Strep status and the respiratory distress, is evaluated for sepsis.",0
"A white blood cell count was 23,000 with a differential of 35% polys, 0% bands.",0
A blood culture was obtained prior to starting intravenous ampicillin and gentamicin.,0
Blood culture was no growth at 48 hours and the antibiotics were discontinued.,0
Hematological: Hematocrit at birth is 55.4%.,0
did not receive any transfusions of blood products.,0
"Gastrointestinal: Peak serum bilirubin occurred on day of life five, a total of 15.0/0.3 mg/dl direct.",0
"Neurological: has maintained a normal neurological examination during admission, and there were no neurological concerns at the time of discharge.",0
Sensory: Audiology hearing screening was performed with automated auditory brain stem responses.,0
"PRIMARY PEDIATRICIAN: Dr. , , , , phone .",0
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1.,0
Adlib feeding breast feeding or Enfamil 20.,0
Car seat position screening was performed with oxygen saturations greater than 95% for 90 minutes without any episodes of apnea.,0
State Newborn Screen was sent on with no notification of abnormal results to date.,0
Immunizations received: Initial hepatitis B vaccine was administered on .,0
Follow-up bilirubin should be checked on Saturday at .,0
Results should be called into Dr. prior to the family's leaving.,0
VNA - Monday DISCHARGE DIAGNOSES: 1.,0
Prematurity at 35-4/7 weeks gestation.,1
Transitional respiratory distress due to retained fetal lung fluid.,0
Dictated By: MEDQUIST36 D: 04:32 T: 05:20 JOB#:,0
8:22 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: larger ?,0
?MUST BE DONE AT 0830 SHARP_ DEPENDING ON RESULTS P Admitting Diagnosis: S/P MVC ______________________________________________________________________________ MEDICAL CONDITION: 24 year old woman with large EDH and skull fracture REASON FOR THIS EXAMINATION: larger ?,1
?MUST BE DONE AT 0830 SHARP_ DEPENDING ON RESULTS PT GO TO OR EMERGENTLY No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb MON 11:16 AM No change in the size of the epidural hematoma or the left frontal fracture.,0
______________________________________________________________________________ FINAL REPORT ROUTINE UNENHANCED HEAD CT HISTORY: Large epidural and skull fracture.,1
Comparison is made with study performed at 5:25 a.m.,0
There is no significant change in the size of the 18 mm left frontal epidural with an overlying fracture of the frontal bone.,0
A small amount of pneumocephalus is again noted.,0
There is effacement of the sulci in the left cerebral hemisphere.,0
There is an overlying scalp hematoma.,0
There is a second tiny acute extra-axial hematoma inferior to the larger one.,0
"There is minimal midline shift to the right, which is unchanged.",0
IMPRESSION: No significant change in the size of the left frontal epidural hematoma with mass effect on the underlying brain.,0
There is an unchanged fracture and overlying scalp hematoma.,0
"9:41 AM CHEST (PA & LAT) Clip # Reason: please evaluate for possible pna Admitting Diagnosis: PERFORATED DUODENUM ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man s/p lap CCY OSH () c/b Luschka leak s/p ERCP/stent with free air - duodenal stump leak & enterotomy s/p duodenostomy tube, repair of enterotomy and feeding Jtube, s/p PTBD.",0
"Now with productive cough REASON FOR THIS EXAMINATION: please evaluate for possible pna ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for possible pneumonia in patient with multiple abdominal operations, now with productive cough.",0
COMPARISON: CT torso from .,0
A series of chest radiographs from dating back to .,0
FINDINGS: PA and lateral radiographs of the chest show interval resolution of pulmonary edema when compared to the prior studies from .,0
"There remains, however, minimal persistent bibasilar atelectasis and small right pleural effusion.",0
Two more rounded opacities in the left lower lung field and along the left diaphragmatic pleura represent calcified pleural plaques as correlated with the CT torso from two days ago.,0
Elevation of the right lung base is a chronic finding.,0
The heart is stably mildly enlarged.,0
"A right PICC is in unchanged position, terminating in the low SVC.",0
IMPRESSION: Interval resolution of pulmonary edema with mild persistent bibasilar atelectasis and small right pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEONATOLOGY HISTORY: Baby Girl is the former 27 week 910-gram female, who is admitted to the NICU for management of prematurity.",0
Infant was born to a 27-year-old G2 P0 mother.,0
"Serologies B negative, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, and rubella immune.",0
Mother was admitted on for cervical shortening with expectant management.,0
Spontaneous premature rupture of membranes on .,0
"She was started on ampicillin and erythromycin, and completed seven days of treatment.",0
"On day of delivery, with frequent contractions, decision was made to deliver.",0
Prolonged rupture of membranes as stated above.,0
"Infant emerged breech, good tone and activities.",0
"Spontaneous cry after suctioning, dry and stimulation.",0
Given facial CPAP for respiratory distress followed by intubation in the delivery room prior to transport to the Newborn Intensive Care Unit for care.,1
Apgars 7 at 1 minute and 8 at 5 minutes.,0
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 910 grams (25th to 50th percentile).,0
Length 35.5 (25th to 50th percentile).,0
Head circumference 25 cm (less than 50th percentile).,0
Discharge weight 3265 (75th percentile).,0
Length 46 cm (25th percentile).,0
Head circumference 34 cm (50th to 75th percentile).,0
"On physical exam, an extremely premature female on ventilator with bilateral breath sounds coarse and equal.",0
"Regular rate and rhythm, S1, S2, no murmur.",0
Abdomen is soft and nontender.,0
"Breech, lax hips, no click.",0
Reflexes symmetrical and appropriate for gestational age.,0
REVIEW OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant received one dose of surfactant.,1
Transitioned to CPAP and then into room air by day of life three.,0
"By day of life six, she had increased work of breathing, resumed CPAP and stayed on CPAP until day of life 41 (corrected gestational age of 32- 5/7 weeks).",1
She then transitioned to room air.,0
She has remained in room air with no further respiratory distress.,1
"Baby was started on caffeine citrate soon after birth, which remained on until day of life 47.",0
"At the time of discharge, she has been free of apnea, bradycardia, and desaturations for greater than five days.",0
Cardiovascular: Baby did not require any pressor support.,0
She has been cardiovascularly stable.,0
She has a soft intermittent murmur thought to be peripheral pulmonic stenosis.,0
This murmur should be followed clinically with a plan for furtehr evaluation if it persists.,0
"Fluid, electrolytes, and nutrition: Baby initially was nothing by mouth with a double lumen umbilical catheter in place.",0
She was started on parenteral nutrition on day of life 0.,0
She kept her UVC line in place until day of life six.,0
She was started on enteral feedings on day of life one and advanced to full feedings without issue by day of life nine.,0
"On day of life 11, she was made nothing by mouth for heme- positive stool.",0
"At that time, she had a sepsis evaluation (see infectious disease category).",0
Feedings were reintroduced again on day of life 12 and advanced to 26 calories slowly without incident.,0
She again was made nothing by mouth after small bilious aspirate and distended belly.,0
She again had a sepsis evaluation at that time and was once again resumed on enteral feedings after several days and increased to breast milk 30 with ProMod slowly without incident.,0
"At the time of discharge, she was eating Similac 20 with iron or Enfamil 20 with iron adlib taking all by mouth doing nicely.",0
She is on supplemental iron 25 mg/mL 0.3 mL which equals 2 mL/kg/day.,0
"Last electrolytes on day of life 20: Sodium 137, potassium 4.9, chloride 104, 21.",0
"Her last nutrition laboratories were on , day of life 45: Calcium of 10, phosphorus 5.6, alkaline phosphatase 3.5.",0
GI: Baby did exhibit some physiologic jaundice.,0
Had a peak bilirubin on day of life one of 4.3/0.2.,0
She received bilirubin of 6.3/0.2.,0
"She responded nicely to that, had her phototherapy discontinued on day of life 14 with a bilirubin of 2.7/0.3 and had a rebound bilirubin of 2.8/0.2.",0
She has had no further issues with jaundice.,0
"Hematology: She received O positive blood, two transfusions, the last one being on day of life 20, which was .",0
She had equivocal pre-transfusion testing to both A and B antigens.,0
"If further transfusion is required, per-transfusion crossmatch beyond the neonatal period might clarify this.",0
Her last hematocrit on was 34.,0
Infectious disease: Infant initially had a blood culture and a CBC sent on admission for prematurity and respiratory distress and concern for possible chorioamnionitis because of prolonged rupture of membranes.,1
"Initial white count was 4.2 with 42 polys, 5 bands, platelet count of 349,000 and hematocrit of 41.9.",0
She was started on ampicillin and gentamicin.,0
"A repeat CBC on day of life one showed a white count of 56, 59 polys, 2 bands, 16 lymphocytes, platelets of 358,000, hematocrit of 33.3.",0
She did have a lumbar puncture on day of life five prior to discontinuing the antibiotics on day of life seven.,0
"At that time, her white count was 23 with 7,725 red cells, protein of 143 and a glucose of 59.",0
For seven days the baby was clinically well.,0
Antibiotics were discontinued and cultures were negative.,0
"Late in the day on day of life eight, she had another sepsis evaluation, and was started on Vancomycin.",0
"At that time, her white count was 36.4 with 60 polys, 0 bands, 30 lymphocytes, platelet count of 509, and hematocrit of 29.",0
She received packed red blood cells and gentamicin was added.,0
That culture grew out gram-positive cocci in pairs and clusters.,0
She completed a seven day course of Vancomycin and gentamicin.,0
"Again at 21 days of life, there was concern that she was more lethargic than usual.",0
"She had another sepsis evaluation done, for which the CBC was benign.",0
Cultures remained negative and at 48 hours the Vancomycin and gentamicin were discontinued.,0
She has had no further issues with infection.,0
"Neurology: Baby has had serial head ultrasounds on , , and , which were all within normal limits.",0
Her exam is appropriate for gestational age.,0
Sensory: Audiology: Hearing screen was performed with automated auditory brain stem responses.,0
Baby did not pass and has been referred for follow-up testing.,0
"Ophthalmology: Baby has had serial eye exams, the last one being on , which showed Stage I, zone 2 5 o'clock hours right eye and 4 o'clock hours left eye with plan to followup in two weeks on an outpatient basis.",0
Psychosocial: Mom has been visiting daily.,0
Maternal grandmother is her primary support.,0
Father of the baby is .,0
Parents are in the process of divorce.,0
"Dad is living in , is in the military and calls for information on .",0
DISCHARGE DISPOSITION: Home with mother.,0
"NAME OF PRIMARY PEDIATRICIAN: Dr. , Pediatrics, .",0
Mother is to make an appointment for or .,0
CARE AND RECOMMENDATIONS: Continue adlib feedings as above.,0
Continue medication of ferrous sulfate.,0
Car seat position screening passed.,0
State newborn screens have been serially and have been within normal range.,0
Screening hip ultrasound is recommended by AAP based on breech presentation and female gender.,0
"IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on DTaP, hepatitis B, and IPV combination vaccine.",0
"On , HIB, Prevnar, Synagis.",0
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from through for infants who meet any of the three criteria: 1.,0
"Born at less than 32 weeks, 2.",0
"Born between 32 and 35 weeks with two of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3.",0
Influenza immunization is recommended annually in the fall for all infants once they reach six months of age.,0
"FOLLOW-UP APPOINTMENTS: Primary pediatrician, early intervention, , Early Intervention Program, .",0
Parents will call to clarify time.,0
Followup hearing screening: at at 8:30 in the morning.,0
Former 28 week premature female.,0
Status post respiratory distress syndrome.,1
"Breech female presentation Reviewed By: , Dictated By: MEDQUIST36 D: 05:41:26 T: 06:25:52 Job#:",0
6:09 PM CHEST (PORTABLE AP) Clip # Reason: r/o chf ______________________________________________________________________________ MEDICAL CONDITION: year old man with dyspnea REASON FOR THIS EXAMINATION: r/o chf ______________________________________________________________________________ FINAL REPORT INDICATION: Dyspnea.,0
SINGLE BEDSIDE FRONTAL VIEW OF THE CHEST: Lung volumes are low.,0
Mediastinal contours are also stable.,0
"There are bilateral pleural effusions as well as pulmonary edema and bibasilar opacities, which are nonspecific, though likely atelectatic.",0
Repeat imaging after diuresis to document resolution/improvement is recommended.,0
"1:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval post bronch Admitting Diagnosis: ETOH WITHDRAWAL;GASTROINTESTINAL BLEED;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 69 y/o M w/prolonged intubation for pna, was extubated on floor but now with worsening hypoxia and white-out of R lung, s/p intubation and bronch with mucus plug removed from right main bronch REASON FOR THIS EXAMINATION: eval post bronch ______________________________________________________________________________ FINAL REPORT INDICATION: Post-bronchoscopy for removal of mucus plug.",1
Comparison is made to study performed 3 hours earlier.,0
There has been interval intubation with an endotracheal tube terminating in the mid trachea.,0
"There is slight improvement in aeration at the right upper lobe, though the right middle and lower lobes remain collapsed.",0
Mediastinal shift towards the right is still present.,0
There have been no other changes compared to the study of 3 hours earlier.,0
8:52 PM CHEST (PORTABLE AP) Clip # Reason: Please assess interval change.,0
"Admitting Diagnosis: CHRONIC PULM DISEASE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with hx COPD, tracheobronchial malacia s/p tracheoplasty w/ recurrent SOB and hypoxia.",1
______________________________________________________________________________ FINAL REPORT INDICATION: History of COPD with recurrent shortness of breath and hypoxia.,1
AP SEMI-UPRIGHT VIEW OF THE CHEST: There is slight interval improvement in the previously demonstrated diffuse mild interstitial opacities.,0
The right IJ line and gastrostomy tube are unchanged.,0
IMPRESSION: Interval slight improvement in bilateral diffuse interstitial opacities.,0
6:10 AM CHEST (PORTABLE AP) Clip # Reason: Worsening or improvement of pneumonia/atelectasis?,0
"Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with history of disseminated TB, MDS/lymphoma, sickle trait, multiple watershed brain infarcts, and respiratory failure with vent dependency.",1
Admitted 2 weeks ago for sepsis from pneumonia.,0
REASON FOR THIS EXAMINATION: Worsening or improvement of pneumonia/atelectasis?,1
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST: REASON FOR EXAM: Followup pneumonia/atelectasis.,0
"Patient with lymphoma, disseminated TB.",0
Diffuse interstitial abnormalities and left lower lobe retrocardiac opacities (atelectasis or pneumonic consolidation) are persistent.,0
Small bilateral pleural effusions ( R>L ) are unchanged.,1
8:57 AM CHEST (PORTABLE AP) Clip # Reason: ICU admission CXR Admitting Diagnosis: PERIRENAL BLEED HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with fevers REASON FOR THIS EXAMINATION: ICU admission CXR ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old man with fever.,1
COMPARISON: CT abdomen from .,0
SINGLE PORTABLE CHEST RADIOGRAPH: The cardiomediastinal silhouette and hilar contours are normal.,0
The lungs appear clear with the exception of trace lower left lower lobe atelectasis.,0
There is no focal consolidation to suggest infection.,0
There is no pulmonary vascular congestion or pleural effusion.,0
"10:34 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval IABP position Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p CABG and IABP REASON FOR THIS EXAMINATION: eval IABP position ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: CABG, evaluation for intra-aortic balloon pump position.",1
"FINDINGS: As compared to the previous radiograph, the intra-aortic balloon pump has now been pulled back by approximately 1.5 cm.",0
The other monitoring and support devices are in unchanged position.,0
Unchanged appearance of the cardiac silhouette and the lung parenchyma.,0
"6:46 PM CTA CHEST W&W/O C &RECONS; CT PELVIS W/CONTRAST Clip # CT ABDOMEN W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: r/o PE (CTA) Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with 2 day hx of tachypnea and tachycardia, calf pain, no constitutional sx REASON FOR THIS EXAMINATION: r/o PE (CTA) No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Two day history of tachypnea and tachycardia, calf pain.",0
TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the pubic symphysis before and after the administration of intravenous contrast.,0
CONTRAST: 150 cc of Optiray was administered due to the patient's history of asthma.,0
CHEST CT WITHOUT AND WITH INTRAVENOUS CONTRAST: There are large low atteunuation bilateral filling defects within the right and left main pulmonary arteries.,0
Thrombus is present within all the proximal branch segments.,0
The main pulmonary artery is unremarkable.,0
There is a small focus of increased opacity within the left lower lobe which measures 9 mm x 12 mm.,0
No other parenchymal opacities are identified.,0
The aortic arch is unremarkable.,0
CT ABDOMEN WITH IV CONTRAST: Note these images were obtained in the early arterial phase.,0
"The liver, gallbladder, spleen, pancreas, adrenal glands and intra- abdominal bowel loops are unremarkable.",0
No renal lesions are noted.,0
Multiple small mesenteric lymph nodes are present.,0
The largest lymph node measures 4 mm in short axis dimension.,0
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is an enlarged fibroid uterus.,0
The uterus measures 11.4 cm x 10.7 cm (TRV x AP).,0
The urinary bladder and intrapelvic bowel loops are unremarkable.,0
There is no significant pelvic adenopathy.,0
No suspicious osseous lesions are identified.,0
There are large pulmonary emboli within the right and left pulmonary arteries.,0
There is a focal nodular density within the left lower lobe.,0
"Though this may represent a small focus of pulmonary infarction, a mass lesion cannot be (Over) 6:46 PM CTA CHEST W&W/O C &RECONS; CT PELVIS W/CONTRAST Clip # CT ABDOMEN W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: r/o PE (CTA) Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) excluded.",1
Further evaluation of the uterine myometrium and endometrium can be performed with a pelvic ultrasound.,0
No intra-abdominal or intrapelvic mass lesions are identified.,0
"12:26 PM CT HEAD W/O CONTRAST Clip # Reason: eval for acute IC process ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with altered MS, recently started on coumadin REASON FOR THIS EXAMINATION: eval for acute IC process No contraindications for IV contrast ______________________________________________________________________________ WET READ: TXCf WED 12:46 PM no acute ich.",0
"hypodensity of right parietal hypodensity, likely encephalomalacia due to remote infarct.",0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Patient with altered mental status, on Coumadin.",1
Assess for acute intracranial process.,0
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained without intravenous contrast.,0
FINDINGS: Confluent hypodensity in the right parietal region is compatible with encephalomalacia likely due to remote infarct.,0
A round hypodensity in the right cerebellar hemisphere likely also represents a prior infarction.,0
"The sulci and ventricles are mildly prominent, likely age related involutionary changes.",0
There is no cerebral edema or loss of grey/white matter differentiation to suggest an acute ischemic event.,0
The paranasal sinuses and mastoid air cells appear well aerated.,0
Right scalp lipoma is noted.,0
"Right parietal confluent hypodensity and right cerebellar hypodensity, are most compatible with remote infarct.",0
"8:04 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for pna, chf ______________________________________________________________________________ MEDICAL CONDITION: History: 89F with satting 88%, SOB, pna per REASON FOR THIS EXAMINATION: evaluate for pna, chf ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH HISTORY: Shortness of breath and hypoxia.",0
COMPARISONS: Radiographs are available from and a CT of the torso from .,0
"TECHNIQUE: Chest, semi-upright AP portable.",0
FINDINGS: Dextropositioning appears similar to the prior examination.,0
"The cardiac, mediastinal and hilar contours appear unchanged including moderate tortuosity of the aorta, a large epicardial fat pad, and substantial hiatal hernia.",0
"There is no definitive pleural effusion, but blunting of the right costophrenic sulcus suggests there may be a small effusion.",0
"Streaky basilar opacities are more prominent in the right lower lung than left, but not striking and compatible with atelectasis in the setting of low lung volumes, although early infection could be considered.",0
There is no frank congestive heart failure.,1
"IMPRESSION: No definite congestive heart failure or pneumonia, but it is possible that there is a developing infection versus atelectasis at the right lung base, possibly with a very small pleural effusion.",1
"It may be helpful, when feasible clinically, to obtain standard PA and lateral radiographs with optimal inspiratory effort, or alternatively chest CT might be of value, if symptoms were to persist without clear etiology.",0
11:51 AM CHEST (PORTABLE AP) Clip # Reason: assess chf Admitting Diagnosis: DRY GANGRENE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with PVD s/p aortobifem with high oxygen requirement REASON FOR THIS EXAMINATION: assess chf ______________________________________________________________________________ FINAL REPORT EXAM ORDER: Chest.,0
CHEST: A single upright AP view of the chest at 1300 hours is compared to previous examination a day ago.,0
Since the previous exam there is increased left pleural effusion.,0
There is also a small right pleural effusion.,0
Again note is made of bibasilar atelectasis worse on the left.,0
"There is increased left perihilar haziness, suggesting asymmetric pulmonary edema.",0
Note is made of right IJ central venous catheter with the tip in SVC.,0
The NG tube has been removed since the previous exam.,0
"IMPRESSION: Increased left pleural effusion, left perihilar haziness which may represent asymmetric pulmonary edema, bibasilar atelectasis worse on the left.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male unrestrained driver, ejected and thrown 10 feet from car, with a right femur fracture and no loss of consciousness.",1
Systolic blood pressure was 140.,0
SOCIAL HISTORY: The patient drinks half a gallon of alcohol per week.,0
He has not smoked since .,0
ALLERGIES: PENICILLIN (results in pruritus).,0
CODEINE (results in nausea and vomiting).,0
"PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission revealed a temperature of 98, his heart rate was 72, his blood pressure was 142/68, his respiratory rate was 22, and his oxygen saturation was 100%.",0
Dictated By: MEDQUIST36 D: 08:52 T: 09:01 JOB#:,0
8:27 AM CHEST (PORTABLE AP) Clip # Reason: Pls assess NGT position Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with chf w/ resp.,0
"failure, intubated, s/p NGT placement REASON FOR THIS EXAMINATION: Pls assess NGT position ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old female with CHF and respiratory failure, intubated, now status post nasogastric tube placement.",1
COMPARISON: AP supine portable chest x-ray dated .,0
AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: The study is extremely limited due to patient positioning.,0
A nasogastric tube descends below the diaphragm and follows the expected contour of the stomach.,0
The tip is not visualized.,0
All remaining lines and tubes are in unchanged position.,0
Small bilateral pleural effusions and left lower lobe atelectasis are unchanged.,0
IMPRESSION: NG tube in good position with the tip not visualized.,0
"9:09 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W/CONTRAST Reason: interval change?",0
Admitting Diagnosis: AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 55 year-old with PMHx only remarkable for HTN presents astransfer from OSH with reports of descending aortic dissection.,0
REASON FOR THIS EXAMINATION: interval change?,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 55-year-old male with PMH of hypertension, transferred from OSH with type B aortic dissection.",1
COMPARISON: Outside (reference) CTA two days prior.,0
CTA CHEST AND ABDOMEN: TECHNIQUE: Axial imaging was performed from the thoracic inlet to the pubic symphysis following the uneventful administration of IV contrast.,0
"CT CHEST WITH IV CONTRAST: There is an extensive descending aortic dissection just distal to the origin of the left subclavian artery, extending inferiorly to just proximal to the inferior mesenteric artery (2:15, 2:84).",0
"The true lumen supplies the celiac axis, SMA, and renal arteries.",0
The internal and external iliac arteries demonstrate normal contrast opacification.,0
"There is no supraclavicular, mediastinal, or axillary lymphadenopathy.",0
"A right middle lobe ill-defined opacity anteriorly has decreased somewhat since the prior study from two days ago, but persists.",0
"There is also surrounding ground-glass opacity throughout most of the right middle lobe, which may be infectious or inflammatory in etiology.",0
The aortic arch and coronary arteries demonstrate calcifications.,0
"CTA ABDOMEN: The liver, spleen, pancreas, kidneys, ureters, large bowel, and small bowel are unremarkable.",0
Solid organ and opacification is normal.,0
The adrenal glands appear normal.,0
There is no intra-abdominal free air or fluid.,0
There is no evidence of bowel obstruction or perforation.,0
"CT PELVIS WITH IV CONTRAST: The rectum, bladder, and prostate appear normal.",0
The sigmoid colon demonstrates numerous diverticula.,0
There is no pelvic free fluid or lymphadenopathy.,0
"OSSEOUS STRUCTURES: Osseous structures demonstrate mild degenerative changes at L4-L5 as well as likely degenerative deformity of T12, with mild central loss of vertebral body height, which may instead represent a distant (Over) 9:09 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W/CONTRAST Reason: interval change?",0
Admitting Diagnosis: AORTIC DISSECTION ______________________________________________________________________________ FINAL REPORT (Cont) compression fracture related to trauma.,0
No significant change in type B aortic dissection from two days prior.,0
"Normal contrast opacification of solid organs, with no evidence of ischemia.",0
"Mild improvement, but not resolution of right middle lobe opacity.",0
Persistent ground-glass opacity for which review CT chest can be used to confirm resolution after treatment.,0
"Diverticulosis, without evidence of diverticulitis.",0
"Atherosclerotic disease at the origins of the renal arteries, as well as extensive calcification of the aorta and its branches.",0
These findings were discussed with (vascular surgery) at 11:30 p.m. on .,0
"5:16 AM CHEST (PORTABLE AP) Clip # Reason: Eval lines, tubes, lungs Admitting Diagnosis: GANGRENE OF THE TOE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with intubation, ?pneumonia REASON FOR THIS EXAMINATION: Eval lines, tubes, lungs ______________________________________________________________________________ FINAL REPORT HISTORY: Intubation, question pneumonia.",0
The extreme lower costophrenic angles are excluded from the film.,0
An ET tube is present -- the tip lies approximately 6.2 cm above the carina.,0
An NG tube is present -- the tip extends to the inferior mediastinum.,0
"While the MG tube likely extends beneath diaphragm, the GE junction is excluded from this film, making that difficult to confirm.",0
There is increased retrocardiac density and prominent patchy opacity at the right base.,0
"ET tube and NG tubes, as described.",0
"If clinically indcated, a repeat view to better demonsyrate the lower chest/GE junction can be obtained at no additional charge to the patient.",0
"CHF with interstitial edema, probably slightly better compared with .",0
"Bibasilar collapse and/or consolidation, slightly worse compared with .",0
"6:29 PM CHEST (PORTABLE AP) Clip # Reason: Pt s/p line change -- please eval ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p liver transplant s/p extubation, s/p CVL placement , confirm placement, r/o ptx REASON FOR THIS EXAMINATION: Pt s/p line change -- please eval ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST .",0
A left subclavian central venous catheter has been placed.,0
The distal tip terminates at the junction of the brachiocephalic veins but does not make the expected turn inferiorly towards the superior vena cava.,0
The cardiac and mediastinal contours are stable in the interval.,0
There is hazy increased opacity in the right lower lung zone likely due to a combination of pleural fluid and adjacent atelectasis.,0
IMPRESSION: Left subclavian central venous catheter terminates at confluence of brachiocephalic veins but does not make expected downward turn into the superior vena cava.,0
Its tip is likely close to the lateral wall of the vessel and repositioning may be helpful.,0
9:12 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for resolution of pulm edema.,0
Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with respiratory failure s/p ventilator with h/o pulmonary edema REASON FOR THIS EXAMINATION: Please assess for resolution of pulm edema.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary edema.,0
"Comparison made to previous study of one day earlier, as well as an earlier study of 3 days prior.",0
"Pacing and ICD lead terminate in place, unchanged in position.",0
"There is stable cardiac enlargement and persistent upper zone vascular redistribution, perihilar haziness and reticular opacities.",0
There is also an asymmetrical area of alveolar opacification in the right lower lung zone.,0
"As compared to the prior studies of and , there has been a gradual improvement in the diffuse abnormalities.",0
IMPRESSION: Further slight improvement in congestive heart failure pattern.,1
Residual asymmetrical alveolar opacity at the right base is probably due to asymmetric pulmonary edema.,0
Continued follow-up may be helpful to exclude underlying infection in this region.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Drug ingestion, altered MS Major Surgical or Invasive Procedure: Intubation for Airway protection History of Present Illness: 34 yo male with a history of narcotic abuse who was attempting to detox himself at home who presented to OSH ED with altered MS.",0
Following history from patient's parents: He had been on OxyContin 80-100 mg tid for ~1 year.,0
On Monday (2d pta) he began an outpatient detox program (Primary Care Associates ).,0
"Medications listed below, he was given a 1d prescription and the medications were administered by his mother.",0
"On the 1st night he was restless and did not sleep well, therefore on Tuesday his regimen was changed to an increased dose of doxepin, librium, and neurontin and ambien and baclofen were added.",0
"Last night, he was well at 10pm, then his parents were awoken by the alarm system and found in the garage - he was agitated and delerius.",0
They called the treatment program who recommended they take him to the ED.,0
"At , he was agitated, HR 120-130s, SBP 130-150s.",0
"He was given ativan, fentanyl, haldol, versed and was eventually intubated and paralyzed (given etomidate, succinylcholine).",0
Also given banana bag and ancef (unclear etiology).,0
"Of note, parents are reasonably sure that he did not take any medications other than those prescribed by the detox program - in the house they have Tylenol, Lipitor, Detrol.",0
Past Medical History: Heart Murmur Dysphagia (?),0
The pt was not responsive and did not follow commands.,0
He moved all four extremities and did not seem in any acute distress.,0
The pt was switched from AC to CPAP with mmHg of PS before he extubated himself about one hour into his stay in the ICU.,0
He was able to maintain good saturations and did not have any respiratory distress.,0
The propofol was stopped and the pt was put on lorazepam for sedation.,0
He was able to follow commands and was orientated to time and person.,0
"He did not answer any questions about the medications he took, but denied taking any additional drugs apart from the ones that were prescribed for detoxication.",0
The pt was kept on supportive care to allow time for the metabolism of the drug OD.,0
Later in his admission the patient became agitated and disoriented.,0
It was unclear as to whether this was stil related to his initial drug intoxication or if he was undergoing possible withdrawal.,0
It was also possible that the patient was oversedated from the large quantities of ativan he had received since admission.,0
The dose of Ativan was reduced and Haldol was added to the regimen.,0
On day three of the hospital course the patient became oriented X3 and was now following commands appropriately.,0
A/P: 34 yom with h/o opoid abuse admitted with change in MS with likely opoid withdrawl and anticholinergic toxicity.,0
1) Anticholinergic toxicity/opoid withdrawl - Resolved signs of anticholinergic toxicity.,0
Initially had diahrrea and anxiety in the likely secondary to opoid withdrawl.,0
On the floor the symptoms improved during the course.,0
"Psych consult was requested which recommended using clonidine 0.1mg , ativan 1mg prn and tappered off.",0
Pt improved and chose to continue in a outpt detox program after discharge.,0
"Substance abuse - Seen by addiction team in the ICU, Patient will need to coopearate with outpatient detox and substance abuse facility.",0
"Leucocytosis - 14.6, patient afebrile and no symptoms of caugh so less likely to be PNA.",0
Does have urinary symptoms so ?UTI.,0
However urine culture was negative and patient remained afebrile.,0
Acidosis - Bicarb 21. likely from diahrrea.,0
Medications on Admission: Meds: -was not any medications prior to Detox .,0
hydroxyzine qid neurontin 400mg qid flexeril 5mg tid clonidine patch and 0.1mg tid chlordiazepoxide 20mg tid (?increased from 10mg qid) baclofen tid - added nabumetone 500mg tid bentyl 20mg tid doxepin 50 mg qhs ambien 10mg qhs .,0
"Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety,agitation.",0
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QD () for 1 days.,0
"Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO taper as directed as needed for nausea,vomiting,diahrrea,craving: Take one dose tonight () for a total of three times a day.",0
Take twice a day on .,0
"Then, take once a day on .",0
"Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Narcotic withdrawal Anticholinergic toxicity Mental status change Intubation for respiratory protection Discharge Condition: Stable, without evidence of withdrawal Discharge Instructions: If you develop symptoms of narcotic withdrawal such as aggitation, nausea, vomiting, diarrhea, runny nose; or if you develop any symptoms of benzo withdrawal such as confusion, tremulousness, rapid breathing call your doctor or return to the emergency room immediately.",0
Please be sure to follow up with the outpatient narcotics withdrawal program at Hospital Followup Instructions: Follow up with your primary care doctor within 2 weeks of discharge.,0
Please have them follow up on your elevated calcium level and abnormal liver function tests.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Shellfish Attending: Chief Complaint: Propranolol overdose Major Surgical or Invasive Procedure: None History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: Time: 23:50 The patient is a 40 M with a PMHx of depression who initially presented to an OSH with report that he had ingested 60 tablets of propranolol 10 mg at approximately 7:30 PM on in a suicide attempt.,0
He reports that he also drank 4-5 beers earlier that same evening.,0
He denies any other ingestions.,0
He confided in his friend about the overdose and the friend called EMS.,0
He had recently been admitted to Hospital for suicidal ideation.,0
"He was seen at the OSH ED within 2 hours of the ingestion, was given charcoal, and glucagon 5 mg IV x1 followed by a 5 mg/hr infusion during transport.",0
"Per report, he had one systolic blood pressure measurement in the 90s, but otherwise had been normotensive without any signs of bradycardia.",0
He was transfered to for further management of his overdose.,0
"He has a history of anxiety and depression, which he takes Effexor for.",0
"On , he was prescribed propranolol by his psychiatrist for social anxiety.",0
"On arrival to our ED, patient's BP was in the 110s, HR in the 80s.",0
"Initial fingerstick was 86, on repeat was 98.",0
"During his stay in the ED, was noted to have one of BP 80/40s, for which he was given IV fluids with recovery of blood pressure.",0
His BP otherwise was stable in the 100-110s.,0
He did not receive any further administrations of glucagon.,0
Physical exam was notable for rhonchi on lung exam.,0
Serum and urine tox were negative.,0
He was transferred to the ICU for hemodynamic monitoring.,0
"Vitals on transfer to ICU were: 85, 100/54, 21, 94%RA On arrival to the ICU, Vitals: 98.7, 102/62, 72, 15, 94% 2.5L.",0
He remained hemodynamically stable while in the ICU and was transfered to the floor for further observation.,0
"On review of OMR, he has recently been homeless, living in shelters and that he had just returned to work, ran out of his Effexor, and started having severe sleepiness (14 hours/day) and anxiety (unable to go outside of the house).",0
"As a result he was not able to work, is upset at coming up, is not sure how he will pay his rent, and now is also afraid that he had lost his job because of not making it to work.",0
"He saw a psychiatrist , got the medications filled, took one Effexor and then later in day had several beers and things ""built up"" and he took 60 10 mg propranolol tablets and almost immediately he called/texted his friend who called the police.",0
"Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain.",0
"Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia.",0
"Denies chest pain, palpitations, orthopnea, dyspnea on exertion.",0
"Denies shortness of breath, cough or wheezes.",0
"Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain.",0
No increasing lower extremity swelling.,0
No numbness/tingling or muscle weakness in extremities.,0
All other review of systems negative.,0
Past Medical History: Depression Anxiety Osteoarthritis of hips and lower back Social History: He works at Heating and Ventilating Contractors' Association.,0
He has 4 children between ages 8 and 15.,0
"Tobacco: 1 ppd since age 11 Alcohol: 4-5 beers on Friday nights Illicits: occasional THC (last ~1 month ago), remote cocaine (~1 year ago) Family History: Mother: Passed from lung cancer Grandmother: Cancer No deaths in primary relatives from a medical condition prior to age 50 years.",0
There is minimal bibasilar scarring and/or atelectasis.,0
"Both costophrenic angles are excluded from this study, although there are no definite pleural effusions.",0
No acute cardiac or pulmonary process.,0
Brief Hospital Course: Assessment and Plan: 40 M with h/o depression and SI presents following suicidal attempt with propranolol overdose.,0
Suicidal Ingestion with Propranalol: - He reported to have taken a total of 600 mg propranolol in a suicidal attempt.,0
"He had two episodes of hypotension with SBP to the 80-90s, one at the OSH for which he received glucagon, and one in ICU that responded to IVF bolus x 1.",0
His heart rate (67-88) and fingerstick glucose (97-129) were stable in the ICU.,0
"His EKG was without evidence of QRS, PR or QTc prolongation.",0
His electrolytes are without significant derangements.,0
Will continue to monitor (half life of propranolol is 3-6 hours).,0
- repeat EKG was normal - Telemetry was maintained with normal heart rates and no arrythmias.,0
He was removed from telemetry.,0
Suicide Ideation/Depression: -Recent admission to Hospital for suicidal ideation.,0
Had been taking Effexor at home.,0
Recently established care with outpatient psychiatrist and counselor 2 weeks prior to admission.,0
- Medically stable for discharge to inpatient psychiatry - 1:1 sitter for suicidality - Was calm and interactive while on floor - Sectioned by psychiatry - Continue home venlafaxine #.,0
- Ativan 2 mg po q4h prn breakthrough anxiety (no standing dose per psychiatry recs) #.,0
Osteoarthritis: - Tylenol prn pain .,0
Prophylaxis: Heparin sub-Q 5000 Units TID for VTE prophylaxis.,0
Dispo: To HRI inpatient psychiatric facility .,0
"CODE: Full Medications on Admission: Effexor 150 mg 1 po daily Propranolol 10 mg prn social anxiety Discharge Medications: 1. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily).",0
2. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for severe breakthrough anxiety.,0
Discharge Disposition: Extended Care Facility: Discharge Diagnosis: Suicidal Ingestion Suicidal Ideation Depression Osteoarthritis Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You were admitted after taking an overdose of propanolol.,0
"We monitored your heart, and there was no damage.",0
You are being discharged to an inpatient psychiatry facility.,0
You should make an appointment with your outpatient providers after being discharged.,0
Followup Instructions: You should make an appointment with your outpatient providers after being discharged.,0
6:12 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"aspiration event/fluid overload Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with recent flu, hosp acquired pneumonia now with new tachypnea REASON FOR THIS EXAMINATION: ?",0
aspiration event/fluid overload ______________________________________________________________________________ FINAL REPORT HISTORY: Hospital-acquired pneumonia with new rapid heart rate.,0
Diffuse areas of multifocal opacification are seen.,0
"In view of the enlargement of the cardiac silhouette, this most likely represents combination of pneumonia and vascular congestion/overhydration.",0
"2:26 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change or signs of new infiltra Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with severe systolic CHF, resolving hypoxic respiratory failure, extubated, with altered mental status and now increased secretions and periodic desaturations concerning for aspiration REASON FOR THIS EXAMINATION: please evaluate for interval change or signs of new infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF COMPARISON: .",1
FINDINGS: Persistent cardiomegaly but decrease in degree of pulmonary edema with residual mild interstitial edema remaining.,0
"Asymmetrical more confluent airspace opacity at right base appears slightly worse, however, with obscuration of right hemidiaphragm.",0
Followup radiographs may be helpful to exclude a developing area of infection in this region.,0
7:53 AM CHEST (PORTABLE AP) Clip # Reason: r/o effusion ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with AO ANEURYSM REPAIR; REASON FOR THIS EXAMINATION: r/o effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Aortic dissection and effusion.,0
Please evalaute for interval change.,0
There are midline sternotomy wires in place and skin staples overlying the mediastinum.,0
"The heart size is enlarged, but the heart size and mediastinal contours are stable compared to .",0
There is no evidence of heart failure with normal pulmonary vascularity.,1
There is minor linear atelectasis at the left base.,0
There are otherwise no areas of focal pulmonary infiltrates There has been interval removal of an ET tube.,0
Minor linear atelectasis at the left base with otherwise clear lungs and no evidence of heart failure.,1
Stable appearance of the mediastinum compared to .,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 45-year-old male with history of hypertension and diabetes, who presents with abdominal pain.",1
Patient was in his usual state of health until the day prior to admission when he began experiencing abdominal pain.,0
He had been taking his daughter to for similar symptoms when he began to experience acute onset abdominal pain which was low across his abdomen.,0
It was crampy in nature.,0
This was experienced with nausea and some vomiting.,0
He came to the Emergency Room for these symptoms.,0
He denied fever or chills.,0
Last bowel movement was two days prior to admission.,0
Denied chest pain or shortness of breath.,0
"In the Emergency Room, the patient received 8 mg of Morphine, 8 mg of Zofran.",0
"In addition, he was found to be hypertensive to 222/140 and was given IV Lopressor as well as IV labetalol with little change in blood pressure.",0
"Due to this he was started on labetalol drip, and admitted to MICU.",0
"Also in the Emergency Room, the patient had a Foley placed with 1100 cc out in urine and relief of his abdominal pain.",0
History of positive PPD treated with INH for nine months.,0
Increased iron of unclear etiology.,0
"Last echocardiogram in revealed an EF greater than 55%, last stress test was negative.",0
ALLERGIES: Sulfa secondary to G-6-P-D deficiency.,0
The patient reports not taking the lisinopril for the three months prior to admission due to the fact that he had run out of his prescription.,0
SOCIAL HISTORY: The patient moved from in .,0
He is married with six children.,0
"PHYSICAL EXAMINATION ON ADMISSION: Significant for a temperature of 97.6, blood pressure 170/80, pulse 80, respirations 14.",0
"Abdomen was soft, nontender, nondistended, good bowel sounds, no organomegaly.",0
"EKG revealed normal sinus rhythm at 85, normal axis and intervals, no ST-T wave changes.",0
No significant change from .,0
"LABORATORY VALUES ON ADMISSION: Urinalysis was 1,000, glucose otherwise negative, creatinine 1.1, hematocrit 42.6, white count 8.3.",0
LFTs were within normal limits.,0
"CT of the abdomen and pelvis was performed with contrast which revealed no aneurysm or dissection, no colonic inflammation.",0
Chest x-ray and KUB were negative for an acute process.,0
SUMMARY OF HOSPITAL COURSE: 1.,0
Abdominal pain: Patient's abdominal pain was relieved with Foley placement.,0
Abdominal pain was likely due to urinary retention.,0
"He has a negative abdominal CT scan and experienced no further abdominal pain, nausea, or vomiting during his hospital course.",0
"The Foley was removed two days prior to discharge, and a voiding trial was initiated, however, the patient was able to void 500 cc on his own, but when residuals were checked, he had 300 cc residual.",0
"Due to this, a Foley was left in place at the time of discharge.",0
They recommended the Foley placement to continue as an outpatient.,0
Also recommended prazosin for possible benign prostatic hypertrophy as well as her blood pressure control.,0
Patient will follow up with Urology on for further urologic testing.,0
Hypertension: Patient with blood pressures to 230/140 on admission.,0
He was started on labetalol drip and admitted to the MICU.,0
"The patient was quickly weaned from his labetalol drip, and was called out to the general medical floors.",0
"Patient's blood pressure was controlled with lisinopril 10 and terazosin 1 q.d., however, two days prior to discharge, the patient experienced episodes of hypotension.",0
This was possibly due to significant diuresis given the relief of the obstruction of urinary retention.,0
Patient quickly responded to fluids.,0
Patient was discharged on prazosin one b.i.d.,0
Planned for resuming lisinopril as an outpatient as his blood pressure tolerate.,0
"ID: Patient was afebrile throughout his hospital course, however, on the day of discharge, he experienced low grade temperature to 100.4.",0
"Urinalysis was sent, which revealed moderate leukocytes, negative nitrites, 40 WBCs, 6 RBCs.",0
The patient was started on levofloxacin 500 q.d.,0
for a total of seven days to continue as an outpatient for presumed possible urinary tract infection.,1
Cardiac: Patient was ruled out for myocardial infarction given his abdominal pain and question of left sided chest pain.,0
He had no events on telemetry.,0
Patient was continued on aspirin.,0
Beta blocker had been held given his low blood pressures.,0
Patient's cardiac risk factors include hypertension and diabetes.,1
"He did have negative enzymes in the setting of stress of increased blood pressure, but there was no need to stress the patient as an inpatient.",0
Patient will follow up with his outpatient primary care physician for further cardiac monitoring.,0
Diabetes: Patient was well controlled on his home dose of insulin 70/30 and NPH take 35 q.a.m.,0
"and 25 q.p.m., and regular insulin-sliding scale.",0
"CONDITION ON DISCHARGE: Stable, afebrile with Foley in place, home teaching performed for leg bag.",0
"FOLLOW-UP PLANS: The patient will follow up with his primary care physician, .",0
"Patient will also follow up Urology, Dr. on at 2:30 p.m. , M.D.",0
Dictated By: MEDQUIST36 D: 08:33 T: 11:17 JOB#:,0
9:02 AM CHEST (PORTABLE AP) Clip # Reason: Please check placement of left basilic PICC line.,0
"please pag ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with hypoxia, fever.",0
REASON FOR THIS EXAMINATION: Please check placement of left basilic PICC line.,0
please page IV nurse # thanks ______________________________________________________________________________ FINAL REPORT INDICATION: 39 y/o woman with hypoxia and fever.,0
"COMMENTS: Portable AP radiograph of the chest was reviewed, and compared with the previous study of .",0
There is worsening of diffuse bilateral opacity indicating PCP pneumonia in this patient with HIV.,0
The tip of the left sided PICC line is identified in the right atrium.,0
IMPRESSION: Increased diffuse opacity indicating PCP pneumonia in this patient with HIV.,0
Pulmonary edema is the differential diagnosis radiograph study.,0
12:41 PM PICC LINE PLACMENT SCH Clip # Reason: please place double lumen PICC for abx usage.,0
Admitting Diagnosis: RIGHT LUNG CANCER;WEAKNESS ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with metastatic lung cancer with brain mets, concerned for meningitis, on multiple anx, no peripheral IV access.",0
Nursing IV team indicated that patient needs PICC under IR.,0
REASON FOR THIS EXAMINATION: please place double lumen PICC for abx usage.,0
______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for antibiotics.,0
A peel-away sheath was then placed over a guidewire and a double lumen PICC line measuring 45 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5F-double lumen PICC line placement via the right brachial venous approach.,0
5:44 PM CT CHEST W/O CONTRAST Clip # Reason: eval for aortic root dilation Admitting Diagnosis: SEVERE AORTIC STENOSIS\RIGHT AND LEFT HEART CATH ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man pre-op AVR REASON FOR THIS EXAMINATION: eval for aortic root dilation No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 11:01 PM Dilatation of the aortic root and ascending aorta up to 4.5 cm.,1
Heavy calcification of the aortic valve.,1
3 mm nodule in the left upper lobe.,0
"Assuming no risk factors for malignancy, no further follow up is necessary.",0
______________________________________________________________________________ FINAL REPORT INDICATION: A 60-year-old male under preop evaluation for aortic valve replacement.,1
Evaluate for aortic root dilatation.,0
TECHNIQUE: MDCT-acquired axial images were obtained through the chest without IV contrast.,0
CT CHEST WITHOUT IV CONTRAST: There is a dilatation of the aortic root and ascending aorta to the level of the arch measuring up to 4.5 cm.,1
No mural irregularity is noted.,0
There is heavy calcification of the aortic valve.,1
Left ventricular enlargement is likely related to aortic valvular disease.,0
Mild coronary artery calcification is noted.,0
The heart and great vessels are otherwise unremarkable without pericardial effusion.,0
There is a 3 mm nodule in the left upper lobe (3:35).,0
The lungs are elsewhere clear without mass or pleural effusion.,0
No mediastinal or hilar lymphadenopathy meeting CT criteria for pathologic enlargement is noted.,0
"The visualized portion of the gallbladder, pancreas, spleen, and bilateral adrenal glands are unremarkable.",0
"There is a tiny calcification in the right lobe of the liver (2:61) which could be related to prior granulomatous disease, but the liver is otherwise unremarkable.",0
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.,0
Dilatation of the aortic root and ascending aorta up to 4.5 cm.,1
(Over) 5:44 PM CT CHEST W/O CONTRAST Clip # Reason: eval for aortic root dilation Admitting Diagnosis: SEVERE AORTIC STENOSIS\RIGHT AND LEFT HEART CATH ______________________________________________________________________________ FINAL REPORT (Cont),0
1:42 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with respiratory failure and sepsis REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW ON HISTORY: Respiratory failure and sepsis.,1
FINDINGS: The endotracheal tube tip is 3.5 cm above the carina.,0
The left IJ line is in the SVC.,0
There has been dramatic increase in the alveolar infiltrate with near-complete opacification of the right lung and dense opacification of the left lung with some peripheral sparing in the upper lung.,0
IMPRESSION: Dramatic increase in bilateral alveolar infiltrate.,0
This may represent diffuse pneumonia or ARDS.,0
"There are probable bilateral effusions but it is difficult to be sure on these films, CHF is a less likely etiology for this appearance.",0
"2:00 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Assess for stones, cholecystitis Admitting Diagnosis: AORTIC VALVE ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with hepatitis C, endocarditis with aortic root aneurysm REASON FOR THIS EXAMINATION: Assess for stones, cholecystitis ______________________________________________________________________________ FINAL REPORT INDICATION: Hepatitis C, endocarditis with aortic root aneurysm.",1
Assess for stones or cholecystitis.,0
COMPARISON: CT scan performed on the same day.,0
RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is normal without stones.,0
There is a right-sided pleural effusion.,1
Liver is grossly unremarkable with no intrahepatic biliary ductal dilatation.,0
IMPRESSION: No gallstones or evidence of acute cholecystitis.,0
8:41 AM CHEST (PA & LAT) Clip # Reason: Does this patient have increased pleural effusion or new inf Admitting Diagnosis: MALAISE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with tachypnea.,1
REASON FOR THIS EXAMINATION: Does this patient have increased pleural effusion or new infiltrate?,1
______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old man with tachypnea.,0
History of recent sigmoid resection complicated by delayed wound healing and bleeding at the anastomosis site.,1
FINDINGS: PA and lateral chest radiographs were obtained.,0
A large amount of pneumoperitoneum is also demonstrated on the concurrently acquired abdominal radiograph.,0
Right and left layering effusions are increased in size.,0
Aerated lung projects at the right lower lung.,0
A left-sided PICC line terminates in the upper right atrium.,0
There are no new abnormal cardiac or mediastinal contours.,0
IMPRESSION: Large volume of pneumoperitoneum is new since .,0
Finding was communicated promptly with the surgical team by Dr. at approximately 9:15 on .,0
Left PICC line tip in the right atrium and should be withdrawn 3cm.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEONATAL INTENSIVE CARE UNIT HISTORY OF PRESENT ILLNESS: is the former 1.085 kilogram product of a 24 week gestation pregnancy born to a 24 year-old gravida IV, para I to II woman.",0
"Prenatal screens O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta rupture of membranes which occurred 18 hours prior to delivery.",0
"The mother was treated with Ampicillin, erythromycin and was beta complete on .",0
There was increasing concern for chorioamnionitis and a Pitocin induction was undertaken.,0
The infant was born by vaginal delivery.,0
Apgars were 7 at one minute and 7 at five minutes.,0
She was admitted to the Neonatal Intensive Care Unit for care at .,0
"PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit - weight 1.085 kilograms, length 36 cm, head circumference 24.5 cm.",1
Skin without rashes or petechia.,0
"Head, eyes, ears, nose and throat: anterior fontanelle open and flat, positive red reflex bilaterally.",0
"Chest: grunting, flaring and retraction with inspiratory crackles.",0
"Cardiovascular: no murmur, normal S1, S2, pulses 2+ and equal.",0
"Abdomen soft, nontender, no masses.",0
"Extremities: moving all, hips stable.",0
Neurologic: tone and reflexes appropriate for gestational age.,0
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: System #1: Respiratory.,1
required intubation and exogenous surfactant for treatment of her respiratory distress.,1
She received two doses of surfactant and weaned rapidly to low vent settings.,0
She was extubated to continuous positive airway pressure on day of life number one.,0
She continued on the continuous positive airway pressure through day of life number three and then was in room air until day of life number 11 when she had drifting in her oxygen saturations and was placed on nasal cannula O2.,0
She remained on nasal cannula O2 until and she has been in room air since that time.,0
She also required treatment for apnea of prematurity with caffeine.,0
The caffeine was discontinued on .,0
Her last episode of spontaneous apnea and bradycardia occurred on .,0
System #2: Cardiovascular: An intermittent murmur has been noted during admission and has felt to be consistent with peripheral pulmonic stenosis.,0
She has maintained normal heart rates and blood pressures during admission.,0
"System #3: Fluid, electrolytes and nutrition: was initially n.p.o.",0
and maintained on intravenous fluids.,0
She received parenteral nutrition from day of life one through day of life eleven.,0
Enteral feeds were started n day of life number two and gradually advanced to full volume.,0
Her calories were supplemented to 30 calories per ounce.,0
At the time of discharge she is breast feeding or taking expressed breast milk fortified to 24 calories per ounce with Enfamil powder.,0
Serum electrolytes were checked several times during admission and were within normal limits.,0
"Weight on the day of discharge is 2.65 kilograms, head circumference 31.5 cm, length 45 cm.",0
System #4: Infectious Disease: Due to the concern for chorioamnionitis and the prematurity was evaluated for sepsis at the time of birth.,0
"Her white blood cell count was 10,200 with 54 percent polys, 3 percent bands.",0
The blood culture was obtained prior to starting intravenous Ampicillin and Gentamycin.,0
She received a ten day course of Ampicillin and Gentamicin.,0
Her culture remained no growth but was treated for presumed sepsis.,0
She had had no other infectious disease issues during admission.,0
System #5: Gastrointestinal: Imam required treatment for unconjugated hyperbilirubinemia with photo therapy.,0
Her peak serum bilirubin occurred on date of birth with a total of 9.9/0.2 direct.,0
She remained on photo therapy for six days.,0
Her rebound bilirubin was 6.1/0.3.,0
System #6: Hematological: is blood type O negative and was Coombs negative.,0
She did not receive any blood transfusion of blood products during admission.,0
Her hematocrit at birth was 41 percent.,0
Her low hematocrit occurred n day of life number 20 of 23.6 percent.,0
Reticulocytes at that point were 8.7 percent.,0
"Repeat was obtained on with a hematocrit of 25.4 percent, reticulocytes of 19.5 percent.",0
Her most recent hematocrit was on with 29.2 percent with reticulocytes of 18 percent.,0
She is being discharged home on supplemental iron.,0
System #7: Neurological: has had three head ultrasounds that have all been within normal limits.,0
There are no neurological concerns at the time of discharge.,0
System #8: Sensory: Hearing screening was performed with automated auditory brain stem responses.,0
Ophthalmology: had her initial eye examination on and her retinas were noted to be immature to zone 2.,0
Repeat examination on showed mature retinas bilaterally.,0
Recommended follow up at eight months.,0
DISCHARGE DISPOSITION: Home with parents.,0
"PRIMARY PEDIATRICIAN: Dr. , , , .",0
Feeding: Breast feeding or p.o.,0
feeding expressed breast milk fortified to 24 calories per ounce with Enfamil powder.,0
Medications: Poly-Vi- 1 cc p.o.,0
"q.d., Fer-in- 25 mg per ml dilution 0.2 cc p.o.",0
Car seat positioning screening was performed on .,0
maintained adequate oximetry saturations for 90 minutes.,0
State Newborn Screens were sent on and .,0
Results from the sample on were within normal limits.,0
No notification of abnormal results have been received regarding the specimens sent on .,0
Immunizations: received her initial hepatitis B vaccine on .,0
"IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or preschool siblings or 3) with chronic lung disease.",0
Influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age.,0
FOLLOW UP APPOINTMENTS RECOMMENDED: Ophthalmology at eight months.,0
"The infant follow up clinic at , appointment with Dr. within five days of discharge.",0
Prematurity at 27 4/7 weeks gestation.,0
Dictated By: MEDQUIST36 D: 07:59 T: 08:12 JOB#:,0
"8:05 PM CHEST (PORTABLE AP) Clip # Reason: s/p trach Admitting Diagnosis: MYASTHENIA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with resp failure s/p trach ,peg REASON FOR THIS EXAMINATION: s/p trach ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old with respiratory failure.",1
A single portable supine radiograph of the chest was performed on at 8:15 p.m. and compared to .,0
There is a midline tracheostomy.,0
A right IJ catheter to the superior vena cava/right atrial junction is noted.,0
The lung volumes are diminished and there is mild pulmonary vascular prominence.,0
Unchanged left greater than right bibasilar atelectasis is noted.,0
There is cholecystectomy clips in the right upper quadrant.,0
An ovoid density in the left upper quadrant is present which may represent a G-tube.,0
"IMPRESSION: Mild bibasilar atelectasis, left greater than right.",0
7:50 AM CHEST (PORTABLE AP) Clip # Reason: interval change?,0
"Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p esophagectomy, leak, esophageal placementx2.",0
"______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: S/P esophagectomy, leak.",0
Comparison is made with prior study chest x-ray and CT torso .,0
Single AP portable view of the chest performed at 8:20 a.m. Left PICC line is new with tip in the lower SVC.,0
Esophageal stent and right-sided chest tubes remain in place.,0
"Small bilateral pleural effusions, greater in the right side tracking through the fissures are unchanged.",0
Cardiomediastinal contour is unchanged in appearance.,0
Right lower lobe opacity is persistent.,1
Left lower lobe retrocardiac atelectasis is stable.,1
Increasing hazy right perihilar opacities may represent asymmetric pulmonary edema or aspiration.,0
3:47 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with respiratory distress REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): KKgc TUE 12:27 PM PFI: 1.,0
Interval increase in the moderate left pleural effusion and associated atelectasis of the left lung base.,0
Interval improvement in the multifocal airspace opacities of both lungs.,0
"Interval advancement of the nasogastric tube to an optimal position, with side holes below the gastroesophageal junction.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 86-year-old woman with respiratory distress.,0
SINGLE AP SUPINE CHEST RADIOGRAPH: Endotracheal tube ends 4.3 cm above the carina.,0
The multi-focal airspace opacities in both lungs have minimally improved since the prior study.,0
There has been interval increase in the moderate left pleural effusion and associated atelectasis of the left lung base.,0
There are no right pleural effusions.,0
A nasogastric tube has been advanced and in the current study courses through the stomach and out of view.,0
8:44 PM CT HEAD W/ & W/O CONTRAST Clip # Reason: pre op for AVR w/?colon CA-r/o metastatic disease Admitting Diagnosis: CHF ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with AS REASON FOR THIS EXAMINATION: pre op for AVR w/?colon CA-r/o metastatic disease No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Aortic stenosis.,1
TECHNIQUE: Contiguous axial images of the head were acquired before and after administration of 100 cc of Optiray IV contrast.,0
"CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no acute intra- or extra-axial hemorrhage, hydrocephalus, shift of normally midline structures, or evidence of acute major vascular territorial infarction.",0
There is mild prominence of the sulci and ventricles consistent with brain atrophy.,0
"There is a small focal area of decreased attenuation in the subcortical white matter in the right frontal lobe, which does not demonstrate abnormal enhancement, likely secondary to microvascular infarction.",0
No areas of abnormal enhancement are seen.,0
A calcific density in mucosal thickening is seen in the left sphenoid sinus.,0
An additional mucous retention cyst is seen in the left maxillary sinus.,0
"There are one of two lytic focus in the left frontal bone, and a bone scan should be considered to evaluate for bony metastatic disease.",0
No evidence of metastatic intracranial disease.,0
MRI is more sensitive in the detection of subtle abnormalities.,0
"9:49 AM CHEST (PORTABLE AP) Clip # Reason: eval chf Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman adm with sepsis, copd, and chf with increasing resp distress now intubated.",0
REASON FOR THIS EXAMINATION: eval chf ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .,0
Lines and tubes are unchanged in position.,0
"Allowing for slightly greater lung volumes, there is no significant change in the degree of CHF.",0
"There is worsening opacity in the left retrocardiac region, likely due to a combination of atelectasis and small pleural effusion.",0
There is otherwise no change.,0
10:03 AM CHEST (PORTABLE AP) Clip # Reason: eval for bilat PTX Admitting Diagnosis: MITRAL STENOSIS\REDO MVR ?,1
"CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with sternal debridement REASON FOR THIS EXAMINATION: eval for bilat PTX ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:55 A.M. ON HISTORY: Sternal debridement.",1
Small persistent right pleural effusion and right basal atelectasis unchanged following removal of the right pleural tube.,0
"Mild-to-moderate pulmonary edema in the left lung has worsened, and mediastinal veins are engorged suggesting volume overload.",0
Postoperative caliber of the mediastinum is otherwise unchanged.,0
Right jugular line ends in the region of the superior cavoatrial junction.,1
was paged to report these findings.,0
"9:44 AM CHEST (PORTABLE AP) Clip # Reason: assess for aspiration Admitting Diagnosis: S/P CEREBRAL CONTUSION ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with s/p SAH starting TF REASON FOR THIS EXAMINATION: assess for aspiration ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST, 9:47 A.M. ON : INDICATION: S/P subarachnoid hemorrhage.",1
Assess for aspiration pneumonia on tube feeds.,0
"FINDINGS: Compared with , there is now increased patchy infiltrate present at the left base and also involving more of the superior portions of the left lower lobe.",0
The remainder of the lung fields are grossly clear.,0
The tip of the NGT is in the proximal stomach.,0
"Its most proximal side-hole is difficult to precisely localize on this exposure, but appears near the level of the GE junction as previously, and could be advanced.",0
7:30 AM NEONATAL HEAD PORTABLE Clip # Reason: evaluate venticle and rule out PVL Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 29 weeks with h/o choroid plexus bleed now 1 month old REASON FOR THIS EXAMINATION: evaluate venticle and rule out PVL ______________________________________________________________________________ FINAL REPORT HISTORY: Follow up ultrasound for choroid plexus cyst.,1
Two small left caudothalamic goove cysts are unchanged.,0
They may represent choroid plexus cysts or the sequelae of prior hemorrhage.,0
There is no change in the size or configuration of the ventricles.,0
There is no evidence for hemorrahge.,0
There are no extra-axial corrections.,0
The brain is otherwise morphologically appropriate for the patient's gestational age.,1
IMPRESSION: Two small cysts in the left caudothalamic groove are unchanged.,0
The brain is normal otherwise.,0
"12:44 PM UNILAT LOWER EXT VEINS LEFT PORT Clip # Reason: SWELLING Admitting Diagnosis: OCCLUSIVE DISEASE RIGHT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with LLE edema, s/p AxBifem BPG REASON FOR THIS EXAMINATION: please r/o DVT ______________________________________________________________________________ FINAL REPORT INDICATION: Left lower extremity edema.",0
"FINDINGS: Grayscale and color Doppler son of the left lower extremity including common femoral, superficial femoral, and popliteal veins was performed.",0
Intraluminal thrombus was not identified.,0
"Normal flow, augmentation, and compressibility was demonstrated.",0
IMPRESSION: No evidence for DVT.,0
"12:03 AM CT HEAD W/O CONTRAST Clip # Reason: ?L sided weakness Admitting Diagnosis: AFIB WITH RAPID VENTRICULAR RESPONSE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with CAD, afib, and hx meningioma REASON FOR THIS EXAMINATION: ?L sided weakness No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: 79-year-old male with coronary artery disease, afib, and history of meningioma, which was resected.",0
Please evaluate for hemorrhage (on heparin).,0
"HEAD CT WITHOUT IV CONTRAST: The patient is status post resection of a right frontal lobe meningioma, with a severe pattern of encephalomalacia in the post-surgical site.",1
"There has been interval decrease in the degree of pneumocephalus, which persists.",0
A somewhat hyperdense-appearing focus of a right frontal lobe gyrus is identified (2:23).,0
"This is accentuated by surrounding encephalomalacia, and is only slightly hyperdense to the remote (normal) matter.",0
"A small amount of extra-axial hemorrhage remains in the right frontal lobe near the surgical site, with no definite new hemorrhage.",0
There is a pattern of periventricular and white matter hypodensity consistent with chronic small vessel ischemic disease.,0
The visualized paranasal sinuses and soft tissues are otherwise unremarkable.,0
Postoperative appearance of right frontal lobe with encephalomalacia and residual pneumocephalus.,0
"Hyperdense-appearing prominent gyrus, which likely does not represent a significant new hemorrhage.",0
"However, close followup is recommended if there is clinical concern for new hemorrhage.",0
Findings were discussed with Dr. at 1:00 a.m. on .,0
NOTE ADDED AT ATTENDING REVIEW: There is a new focus of hemorrhage in the right frontal lobe-the area of hyperdensity discussed above.,0
This suggests ongoing hemorrhage in and near the surgical site.,0
There is also an increase in surrounding edema.,0
These changes may relate to the patient's history of left sided weakness.,0
Might this be a consequence of venous ischemia?,0
"6:32 PM CT HEAD W/O CONTRAST Clip # Reason: please assess for edema, bleed.",0
"______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with metastatic cancer and ms changes REASON FOR THIS EXAMINATION: please assess for edema, bleed.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: A 51-year-old woman with metastatic cancer and mental status changes, evaluate for edema, hemorrhage or metastasis.",0
TECHNIQUE: Non-contrast axial images were obtained from the skull base to the vertex.,0
"CT OF THE HEAD WITHOUT IV CONTRAST: The ventricles, basal cisterns and sulci are unremarkable.",0
"There is no mass effect, shift of the normally midline structures, intra- or extra-axial hemorrhage, or hydrocephalus.",0
"The osseous structures, paranasal sinuses, and soft tissues are unremarkable.",0
There is no major vascular terrritorial infarction.,0
IMPRESSION: No evidence of acute intracranial hemorrhage or edema.,0
MRI with contrast is the ideal exam to exclude metastatic disease.,0
", MED CCU 8:02 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: ABDOMINAL METS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with fever, hypotension, tachypnea, ?infiltrate REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ PFI REPORT PFI: No significant interval change.",0
10:29 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: please place dop hoff post pyloric under fluro- this pt aspi Admitting Diagnosis: HEAD BLEED;OPEN SKULL FRACTURE Contrast: OPTIRAY Amt: 30 ______________________________________________________________________________ MEDICAL CONDITION: year old woman with who is NPO and requiring free water bolus' via NGT- multiple attempts at bedside without success REASON FOR THIS EXAMINATION: please place dop hoff post pyloric under fluro- this pt aspiration risk ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj FRI 12:10 PM PFI: Post-pyloric placement of - tube in the second portion of duodenum.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Pyloric tube placement for free water boluses.,0
PROCEDURE: The left naris was anesthetized with lidocaine jelly.,0
Multiple attempts were made to place the - tube into the stomach.,0
The tube repeatedly passed into the trachea.,0
"After a chin-tuck maneuver, nasogastric placement was achieved.",0
The tube was then advanced into the second portion of the duodenum.,0
Placement was confirmed with injection of Optiray water-soluble contrast.,0
IMPRESSION: Post-pyloric placement of - tube in the second portion of duodenum.,0
"4:29 PM CHEST (PA & LAT) Clip # Reason: r/o PNA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with dry cough, chest pain and hypotension REASON FOR THIS EXAMINATION: r/o PNA ______________________________________________________________________________ FINAL REPORT INDICATION: Dry cough, chest pain, hypotension.",0
"COMPARISONS: , and CT .",0
"CHEST, PA AND LATERAL: The cardiac and mediastinal contours are within normal limits with unfolding of the aorta and wall calcifications.",0
Bronchiectasis and scarring within the right mid lung is stable dating back to of .,0
"Emphysematous changes and bronchiectasis are partially visualized, better evaluated on previous CTs.",0
No new focal pulmonary opacity identified.,0
IMPRESSION: Stable right mid lung zone scarring and bronchiectasis.,0
No definite evidence of pneumonia.,0
"11:38 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with CAD s/p CABG and ct removal REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT AP CHEST, 11:39 A.M., HISTORY: Status post CABG following chest tube removal.",1
"IMPRESSION: AP chest compared to : The lung volumes have decreased, as expected following extubation, and there is more atelectasis at the base of the left lung.",0
The upper lungs are clear.,0
Cardiomediastinal silhouette shows expected widening due to lower lung volumes and termination of positive pressure ventilator support.,0
", M. SICU-A 3:26 AM CHEST (PORTABLE AP) Clip # Reason: interval exam, intubated Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with REASON FOR THIS EXAMINATION: interval exam, intubated ______________________________________________________________________________ PFI REPORT Findings concerning for bibasilar pneumonia.",0
"7:43 AM ACUTE ABD SERIES ( VIEWS OF ABD & SGL CHEST VIEW) PORT Clip # Reason: assess for abdominal pathology, perforation Admitting Diagnosis: VENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man present WCT, now with fever, leukocytosis and lower abdominal pain REASON FOR THIS EXAMINATION: assess for abdominal pathology, perforation ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Fever, leukocytosis and lower abdominal pain.",1
Supine and decubitus radiographs of the abdomen were reviewed.,0
There is no evidence of bowel dilatation.,0
There is unremarkable bowel gas and content pattern noted.,0
There are extensive calcifications and tortuosity of the splenic artery.,0
There is no evidence of free air demonstrated on the lateral decubitus.,0
Calcifications of the aorta are present as well.,0
5:07 PM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: s/p mvc Admitting Diagnosis: LEFT SIDED HEMATOMA;STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with REASON FOR THIS EXAMINATION: s/p mvc No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATIONS: MVC.,0
TECHNIQUE: Noncontrast CT of the thoracic spine and compared with the images from the torso CT performed one day ago.,0
FINDINGS: Please not that the patient's osteopenia limits our ability to detect subtle or nondisplaced fracture.,0
Examination of the sagittal images shows no alignment abnormalities aside from a marked thoracic kyphosis.,0
Vertebral body heights appear preserved.,0
"On axial images, no vertebral fractures are seen, and there is limited visualization of left sided posterior rib fractures at the left T3, T4, T5, and T6 levels.",0
"There is consolidation of the majority of the right lower lobe posteriorly, as well as significant consolidation within the left lower lobe as well as the posterior aspect of the left upper lobe.",0
The degree of consolidation has worsened significantly since the prior CT.,0
"There are atherosclerotic calcifications of the aorta, as well as at the takeoffs of the celiac axis, SMA, and renal arteries.",0
IMPRESSION: 1) No evidence of thoracic spine fracture.,0
"Kyphosis and osteopenia is present, and the degree of osteoporosis limits the sensitivity of fracture detection.",0
2) There is also a marked progression of bilateral consolidation.,0
"This could represent pulmonary contusion, aspiration, or less likely, asymmetric pulmonary edema.",1
Left ventricular function Height: (in) 60 Weight (lb): 213 BSA (m2): 1.92 m2 BP (mm Hg): 120/80 HR (bpm): 120 Status: Inpatient Date/Time: at 09:56 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness.,0
IMPRESSION: findings are suggestive of pulomonary embolism,0
8:59 AM CHEST (PORTABLE AP) Clip # Reason: r/o CHF ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman s/p CABG REASON FOR THIS EXAMINATION: r/o CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG.,0
FINDINGS: A single view of the chest in comparison to .,0
The endotracheal tube tip is 6.3 cm above the carina.,0
The IAVP tip is 2.4 cm below the aortic knob.,0
The pulmonary artery catheter is likely within the left main pulmonary artery.,0
"When compared to the prior study, there has been interval improvement in congestive heart failure.",0
"Left chest tube is in place, as before.",0
IMPRESSION: Interval improvement in congestive heart failure.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Seizures Major Surgical or Invasive Procedure: none History of Present Illness: Mr. is a 39-year-old right-handed man with a history of epilepsy which began at the age of /2.,0
He has been followed by Dr. from hospital since .,0
He recently moved back to for family reasons and was sent here by Dr. .,0
"He had a generalized convulsion at the time, without any associated fever or illness.",0
The EEG then apparently showed an abnormality in the left temporal region.,0
He was treated briefly with phenobarbital.,0
"He remained seizure-free until he was 23 years old, when he had his second generalized seizure while he was driving on I-95.",0
"He recalls that he suddenly felt like he could control or focus his eyes, and the eyes were rolling back uncontrollably, with the arms becoming rigid within a second.",0
His father was in the car at the time and noted that he had a 15-minute episode of generalized limb shaking.,0
"Luckily, this did not result in a car accident and the car eventually coasted to a stop.",0
He was taken to a local hospital and Dilantin 300 mg a day was started.,0
"About 3 years later in , he had another generalized seizure, again while he was driving.",0
He was taking Dilantin at the time.,0
"He woke up in the car confused, and the police told him that he had witnessed seizure activity.",0
His Dilantin was increased to 400 mg at that time.,0
"He was well until when he had an episode of status epilepticus, in the setting of stress and sleep deprivation.",0
"Within 1 hour, he had 2 episodes of 20-minute generalized seizure and another 10-minute episode.",0
He was taken to .,0
"After that, he noted significant cognitive problems with very poor memory and visuospatial skills.",0
"After this episode, he was tried on valproate, which did not work.",0
"Lamictal was then added to the regimen, and Ativan was also given for about 6 months.",0
"During this time, he continued to have occasional seizures, during which he would spontaneously lose his train of thought very briefly for a few seconds.",0
He may also lose track of time for up to 5-10 minutes at a time.,0
"If he forgot to take his medications, he noted an intense nervous or flighty sensation, which would build for several hours.",0
"He denies any olfactory, gustatory, or auditory hallucinations.",0
He denies any epigastric sensations or out of body experiences.,0
"In , he moved to for his PhD.",0
He was under the care of at Hospital.,0
He was admitted to the inpatient epilepsy monitoring unit for about a week.,0
The EEG showed left-sided slowing with epileptiform discharges.,0
"He eventually was weaned off the Dilantin as he had been on it for quite a long time, and it was not quite effective for him.",0
Keppra was added in .,0
"He states that his last seizure was about 3 years ago, both in terms of the generalized seizures, as well as the occasional interruptions in his train of thought.",0
He is currently doing well without any clear side effects.,0
"He continues to have memory difficulties, which he believes is a residual of the episode of status epilepticus in .",0
"He also has some difficulty with visual spatial abilities, and he may forget how to get into or out of a building.",0
He states that he had formal cognitive testing with a neuropsychologist at Hospital.,0
He takes his medications three times daily and prefers TID to dosing.,0
"This way, if he misses a dose, it is not a large amount.",0
He is typically delayed with his medications and misses a dose once a week at most.,0
"Aside from the medications above, he has not tried any other anticonvulsant.",0
Typical triggers for his seizures include stress and medication non-compliance.,0
"In terms of his epilepsy risk factors, his paternal aunt has generalized seizures, but he does not know the details.",0
His had a non-febrile seizure at age 4 years old.,0
"He denies any history of CNS infections, febrile seizures, or significant head injuries.",0
"Developmental and Birth History: As far as he knows, he was born full term via vaginal delivery, without complications.",0
He met all of his developmental milestones and did well in school.,0
Malaria in when he was travelling to .,0
Social History: He currently lives with his sister.,0
is single and has no children.,0
He just completed his PhD in anthropology at .,0
He is unemployed and in the process of looking for a job.,0
"He does not smoke, drink alcohol, or use drugs.",0
Family History: His mother has multiple sclerosis and mitral valve prolapse.,0
His father has rapid heartbeat and stroke.,0
His sister has no neurological problems.,0
His paternal aunt has epilepsy as described above.,0
Alzheimer disease also seems to run in multiple paternal relatives.,0
"Physical Exam: On examination, his blood pressure is 138/90, heart rate 88 and regular, and his respirations are 12.",0
"General Exam: He appears well, in no apparent distress.",0
"Eyes: Disc margins sharp bilaterally, no scleral icterus.",0
Abdomen: No positive bowel sounds.,0
Skin: No obvious hyper or hypopigmented lesions.,0
"Neurologic Exam: Mental Status: The patient is fully awake, alert, and oriented.",0
He gives a full history without difficulty.,0
His calculation and attention are also intact.,0
He is able to register and recalls after 5 minutes and with hints.,0
"Cranial Nerves: PERRLA, extraocular movements full without nystagmus, visual fields full, face and sensation intact, face symmetric, tongue midline, and no dysarthria.",0
Motor Exam: Normal bulk and tone throughout.,0
"There is a mild postural tremor in both hands, no asterixis.",0
Slightly decreased finger taps in the left hand.,0
Sensory: Intact to all modalities throughout.,0
Coordination: Finger- nose-finger and rapid alternating movements intact.,0
Reflexes: 2+ throughout and downgoing toes.,0
"Gait: Narrow-based gait, able to tandem, toe and heel walk without difficulty.",0
Two small areas of acute infarct right cerebellum.,0
Findings indicative of left mesial temporal sclerosis.,0
Brief Hospital Course: Seizures: Patient was transferred from after a status epilepticus.,0
At that time he were intubated for airway protection and admitted into our Neurology ICU.,0
Patient's episode of convulsive status epilepticus at least for 45 minutes by report.,0
There was no clear trigger to this in that he was compliant with his medications and he was not ill at that time.,0
A spinal tap was unremarkable and did not show any evidence of CNS infection.,0
There was no systemic infection as well after a thorough workup.,0
His EEG telemetry showed left greater than right temporal lobe discharges interictally but no electrographic seizures.,0
"As patient was also having mood disturbance and that Keppra can sometimes cause mood lability and psychiatric side effects, this was weaned off and replaced with Trileptal.",0
He did do well with the Trileptal transition.,0
"For the episodes noted of status, he was loaded with Dilantin and maintained on stable maintenance dose of 100 mg t.i.d.",0
The Lamictal remained the same.,0
"He remained stable for discharge on Trileptal 600 mg t.i.d., Lamictal 150 mg t.i.d., Dilantin 100 mg.",0
"The Dilantin can be tapered off per Dr. as an outpatient, and you should follow up with her.",0
Patient was also given the instructions that he cannot drive by state law.,0
"Psych: He was subsequently noted to have significant mood swings, suicidal and homicidal deation.",0
He was extremely angry with his previous Ph.D. professor who he believes has been dishonest and who has hindered his academic advancement.,0
We had psychiatry evaluate him during the hospital stay.,0
"At that time, he was no longer suicidal.",0
He was instructed to follow up with his primary care doctor about to an outpatient psychiatrist.,0
"Stroke: For further investigation, a brain MRI was done with and without contrast to evaluate for any new lesions or structural changes that may have precipitated this episode of status.",0
It is quite unusual given that he had been seizure-free for almost six years prior to this.,0
The brain MRI showed changes in the temporal region consistent with left mesial temporal sclerosis.,0
"In addition, there were two small areas of acute stroke found in the cerebellum that was incidental.",0
He was not symptomatic at that time.,0
"Given the embolic appearance, he had a stroke workup including telemetry, cardiac echo, which demonstrated a PFO.",0
His lipid profile indicated a slightly elevated cholesterol and LDL levels.,0
He was started on aspirin for stroke prophylaxis and Zetia for cholesterol control.,0
He was subsequently discharged on .,0
"Patient's (LDL) was found to be elevated, and since he had an adverse reaction to statins in the past, he was started on Zetia.",0
has been scheduled follow up with Dr. a stroke Neurologist for further work up and management.,0
Keppra 500 mg 3 times daily (since ).,0
Lamictal 150 mg 3 times daily.,0
"Omega-3, 3000 mg a day.",0
"Coenzyme Q10, 15 mg 3 times a week.",0
Discharge Medications: 1. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO three times a day.,0
Disp:*90 Capsule(s)* Refills:*2* 3. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Brand Name Only.,0
Disp:*90 Tablet(s)* Refills:*2* 4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN as needed for for seizure clustering.,0
"6. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO once a day.",0
Disp:*30 Tablet(s)* Refills:*2* 7. propranolol 60 mg Tablet Sig: One (1) Tablet PO twice a day as needed for tremors.,0
"Outpatient Lab Work In 2 weeks, have lab work drawn for Na (sodium), Trileptal level, Lamictal , and dilantin level.",0
Please fax these results to Dr. office.,0
Discharge Disposition: Home Discharge Diagnosis: Status Epilepticus Right Cerebellar Stroke Patent foramen ovale Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were transferred from after a status epilepticus (continuous seizure).,0
At that time you were intubated for airway protection and admitted into our Neurology ICU.,0
"You were monitored on EEG, which showed left more than right temporal slowing and occasional left temporal discharges.",0
"Your Lamictal level was slightly low, and you had taken an antibiotic a few weeks prior to admission which may have lowered your seizure threshold.",0
MRI head showed left mesial temporal sclerosis.,0
"You were tapered off Keppra, and started on Dilantin and Trileptal.",0
MRI head showed two small areas of infarct in your right cerebellum.,0
"An echocardiogram of your heart was done, which showed a Patent Foramen Ovale, which means that there is a small hole between the two of your heart, which may have allowed a small clot to pass up into your brain.",0
"An ultrasound was done of your legs, which showed no signs of clots there.",0
Since there were no clots found on ultrasound you were started on a full dose Aspirin 325 mg daily.,0
"Your cholesterol (LDL) was found to be elevated, and since you have had an adverse reaction to statins in the past, you were started on Zetia.",0
You have been scheduled to follow up with Dr. a stroke Neurologist for further work up and management.,0
You will need to have an insurance and call the number below to register.,0
"You had some suicidal ideation after your seizure, and should follow up with your primary care doctor to an outpatient psychiatrist.",1
***By massachusett's Law you are unable to drive within 6 months of having a seizure.,0
You should also avoid activities where having a seizure would place you at significant risk such as bathing or swimming alone.,0
"*** Followup Instructions: for your seizures: , D. Office Phone: ( Thursday, at 10am post hospitalization follow up and cholesterol: Primary Care Physician at 2:30 pm Name: ,SURENDRA Address: , , Phone: Fax: For your stroke: Dr. 2:30pm Please a)get an insurance from your PCP b)call to register Provider: , MD Phone: Date/Time: 2:30 Completed by:",0
"3:05 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate/chf Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with copd, on vent, with new dual chamber pacemaker; hypotensive on pressors REASON FOR THIS EXAMINATION: eval for infiltrate/chf ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:07 A.M. : HISTORY: COPD.",1
IMPRESSION: AP chest compared to and : Hyperinflation indicates emphysema.,0
"Small bilateral pleural effusions, right greater than left, unchanged.",0
"Opacification in the left lower lobe, probably atelectasis.",0
Peribronchial infiltration in the left upper lobe could be inflammation or edema at the site of previous infection.,0
Careful followup is recommended following stabilization of fluid status to exclude reactivation tuberculosis.,0
A tracheostomy tube and right subclavian line and transvenous right atrial and right ventricular pacer leads and a nasogastric tube are all in standard placements.,1
LINE PLACEMENT Clip # Reason: l dl picc 51cm Admitting Diagnosis: ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with picc REASON FOR THIS EXAMINATION: l dl picc 51cm ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 4:35 PM Limited study.,0
Left PICC tip is not definitely identified due to the larger central venous catheter.,0
The tip is likely within the left brachiocephalic vein or superior mediastinum but cannot be definitively determined.,0
"Otherwise, limited study due to motion and low lung volumes.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 55-year-old male with left PICC line.,0
COMPARISON: Chest radiograph from two days prior ().,0
"CHEST, AP PORTABLE UPRIGHT: The left PIC catheter courses to the superior mediastinum, beyond which where it is not definitely identified due to increased density within the mediastinum and the adjacent left subclavian central venous catheter.",0
"The tip cannot be definitively identified, and likely is located either within the left brachiocephalic vein or the upper superior vena cava.",0
Lung volumes are extremely low.,0
"The left effusion is not significantly changed, although the study limited due to technical factors.",0
Left PICC tip not definitely identified.,0
This was discussed with of the PICC service on at 400pm by Dr. .,0
"1:25 PM CHEST (PORTABLE AP) Clip # Reason: causes of respiratory distress Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with CHF, AFib, dyspnea, desatting REASON FOR THIS EXAMINATION: causes of respiratory distress ______________________________________________________________________________ FINAL REPORT HISTORY: CHF with respiratory distress.",1
"FINDINGS: In comparison with the study of , there is persistent enlargement of the cardiac silhouette with bilateral pleural effusions, more prominent on the left.",0
9:50 AM CT CHEST W/O CONTRAST Clip # Reason: eval for size and location of PTX Admitting Diagnosis: PNEUMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with mult myeloma and pulm amyloidosis p/w spontaneous PTX REASON FOR THIS EXAMINATION: eval for size and location of PTX No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 62-year-old woman with multiple myeloma and amyloidosis with spontaneous pneumothorax.,1
Evaluate for size and location of pneumothorax.,0
FINDINGS: Large left pneumothorax and a small right apical pneumothorax are new since 9/.,0
"Small bilateral pleural effusions, right greater than left are slightly increased since 9/.",0
"Moderate bilateral partial lung collapse, moderately worse since , may represent atelectasis or consolidation.",0
No mass is visualized to explain the collapse.,0
"The main pulmonary artery measures 3.5 cm, consistent with pulmonary hypertension, unchanged since 9/.",0
Large hiatal hernia is unchanged since 9/.,0
"Although this exam was not optimized for subdiaphragmatic diagnosis, the liver, spleen, large and small bowel are unremarkable.",0
"Bone windows demonstrates multiple areas of bone dstruction and compression deformities at T3, T11, T12, unchanged since 9/.",0
Large left pneumothorax and small right apical pneumothorax are new since .,0
"Moderate bilateral lung colapse, moderately worse since 9/.",0
"Small bilateral pleural effusions, slightly increased since 9/.",0
"Widespread skeletal involvment of multiple myeloma, unchanged since 9/.",1
Findings were discussed with ICU nurse Romi at 7 PM on .,0
(Over) 9:50 AM CT CHEST W/O CONTRAST Clip # Reason: eval for size and location of PTX Admitting Diagnosis: PNEUMOTHORAX ______________________________________________________________________________ FINAL REPORT (Cont),0
", M. MED 2:23 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?placement Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with UGIB.",0
Intubated REASON FOR THIS EXAMINATION: ?placement ______________________________________________________________________________ PFI REPORT Appropriately placed endotracheal and tubes.,0
New/worsening perihilar and retrocardiac opacities suggestive of aspiration or asymmetric edema.,0
"4:45 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please evaluate to further characterize lesion for XRT plann Admitting Diagnosis: NEW BRAIN MASS AND LUNG LESION Contrast: GADAVIST Amt: 7 ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with ataxia, vertigo now found to have new head mass.",0
REASON FOR THIS EXAMINATION: Please evaluate to further characterize lesion for XRT planning and ?possible bx.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MRI OF THE HEAD WITH AND WITHOUT CONTRAST CLINICAL INFORMATION: 65-year-old man with ataxia and vertigo now found to have new head mass.,0
Please further evaluate and characterize lesion for radiation therapy planning and question of possible biopsy.,0
COMPARISON: Head CT dated .,0
"TECHNIQUE: Sagittal and axial T1-weighted, axial susceptibility, FLAIR, T2 and diffusion-weighted images were acquired.",0
"Following the administration of 7.5 mL Gadovist, axial T1-weighted and sagittal MP-RAGE images were obtained with axial and coronal reformats.",0
FINDINGS: There is a rim-enhancing multiloculated cystic mass involving the left parietal and occipital lobes with extensive surrounding vasogenic edema/FLAIR signal hyperintensity.,0
The central cystic portion of this lesion measures 3.6 cm TV x 5.7 cm AP x 3.4 cm SI.,0
There is a second similar cystic lesion within the left parietal lobe which measures 1 cm AP x 1 cm TV x 0.9 cm SI.,0
These lesions do not demonstrate slow diffusion centrally.,0
A second satellite cystic lesion is again visualized in the occipital lobes with similar characteristics and measures 3.2 cm TV x 2.0 cm AP x 1.9 cm SI.,0
There is marked local less mass effect on the left lateral ventricle with near complete obliteration of the posterior .,0
"However, there is no hydrocephalus.",0
Slight shift of midline structures to the right measuring approximately 2 mm is noted.,0
There are no other definite enhancing lesions.,0
"Elsewhere, there are scattered punctate and confluent areas of signal intensity in the periventricular and subcortical white matter as well as in the pons, which likely reflect sequela of chronic small vessel ischemic disease.",0
There is no evidence of hemorrhage or of acute ischemia.,0
"The visualized portions of the paranasal sinuses, mastoids, and orbits are unremarkable.",0
IMPRESSION: Three cystic lesions are identified within the left parietal and occipital lobes with peripheral rim enhancement and no slow diffusion within the cystic portion of the lesions.,0
Extensive surrounding increased FLAIR signal and mass effect on the lateral ventricle without hydrocephalus.,0
"Primary considerations include metastatic disease, multifocal glioblastoma, or PNET.",0
"Infection with abscesses remains within the differential, but this is (Over) 4:45 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please evaluate to further characterize lesion for XRT plann Admitting Diagnosis: NEW BRAIN MASS AND LUNG LESION Contrast: GADAVIST Amt: 7 ______________________________________________________________________________ FINAL REPORT (Cont) less likely as there is no slow diffusion within the lesions.",0
3:19 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"change in head bleed Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ FINAL ADDENDUM The medical records have now been merged, and all the imaging studies are now listed under the .",0
DFDkq 3:19 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"change in head bleed Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 20 year old woman with ped struck, left IVH REASON FOR THIS EXAMINATION: ?",0
change in head bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Pedestrian struck by a car with intraventricular hemorrhage.,0
"COMPARISON: CT head , from 4:30 p.m.",0
Please note that the patient has two medical records in the system.,0
The comparison is done with the .,0
FINDINGS: There is a stable small hemorrhage in the occipital of the left lateral ventricle.,0
Minimal amount of blood in the occipital of the right lateral ventricle is better seen than on the prior study and may be new.,0
"No subdural, subarachnoid or parenchymal hemorrhage is seen.",0
"There is no evidence of parenchymal edema, and -white matter differentiation is preserved.",0
There is no effacement of the basal cisterns.,0
"A large right hemispheric subgaleal hematoma has slightly decreased in maximal width and redistributed, now larger posteriorly and smaller anteriorly on the right, and also extending to the left vertex.",0
"The bones were better assessed on the prior head CT with bone algorithm reformations and facial bone CT, which demonstrates a right zygomaticomaxillary complex fracture.",1
Fluid is again seen in the right ethmoid and maxillary sinuses.,0
No significant interval change in small intraventricular hemorrhage.,0
"Redistribution of large right subgaleal hematoma, which now also extends to the left vertex.",0
"Right zygomaticomaxillary complex fractures, as seen on the facial bone CT from .",1
"6:21 PM BILAT LOWER EXT VEINS Clip # Reason: eval for dvt Admitting Diagnosis: ACUTE LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with AML, diarrhea, new aflutter, ?PE.",1
REASON FOR THIS EXAMINATION: eval for dvt ______________________________________________________________________________ WET READ: 8:56 PM No DVT ______________________________________________________________________________ FINAL REPORT HISTORY: 51-year-old female with diurnal diarrhea.,0
"New atrial flutter, evaluate for DVT causing PE causing atrial flutter.",1
COMPARISON: Unilateral right lower extremity venous ultrasound .,0
"BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: The common femoral veins, superficial femoral veins, deep femoral veins, greater saphenous veins, and popliteal veins demonstrate normal color flow, respiratory phasicity, and appropriate responses to augmentation and Valsalva maneuvers.",1
The calf veins demonstrate color flow.,0
IMPRESSION: No evidence of DVT in the lower extremities.,0
"1:46 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for pna, aspiration, heart failure Admitting Diagnosis: ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with recent bone marrow transplant, concern for aspiration REASON FOR THIS EXAMINATION: evaluate for pna, aspiration, heart failure ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Recent bone marrow transplant, question aspiration.",1
FINDINGS: Left-sided PICC line is unchanged.,0
There is haziness projecting over the left lower lobe that felt to represent overlying soft tissue.,0
There is no definite infiltrate.,0
"If further delineation is desired, a lateral film would be helpful for more complete assessment.",0
"5:41 AM CHEST (PORTABLE AP) Clip # Reason: pls assess interval change, ETT position Admitting Diagnosis: AIRWAY OBSTRUCTION\ BRONCHOSCOPY RIGID ______________________________________________________________________________ MEDICAL CONDITION: hypoxiemiahx colon CA with mets to lungs and stent (now out) REASON FOR THIS EXAMINATION: pls assess interval change, ETT position ______________________________________________________________________________ FINAL REPORT HISTORY: Colon CA with metastasis to lung.",0
"Assess interval change, EG tube position.",0
"CHEST, SINGLE AP PORTABLE Semi-upright view.",0
Lower left chest wall and apex and lateral left base excluded from film.,0
An ET tube is present in satisfactory position above the carina.,0
An NG tube is present with tip beneath diaphragm.,0
There are dense patchy bilateral alveolar opacities.,0
The opacity in the right upper zone and its associated focal pleural thickening is slightly larger than on .,0
Otherwise findings are grossly unchanged.,0
Right subclavian line (question PICC line) with tip over distal SVC.,0
"8:08 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with STEMI, cardiogenic, septic shock.",1
"REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old male with STEMI, evaluate for change.",0
PORTABLE CHEST RADIOGRAPH: Aortic balloon pump marker seen approximately 5.4 cm from the top of the aortic arch.,0
Endotracheal tube seen with tip approximately 4 cm above the carina.,0
Swan-Ganz catheter again seen with tip at the main pulmonary artery.,0
"Nasogastric tube seen coursing over the stomach, tip incompletely imaged.",0
There is improving pulmonary edema compared to yesterday's study.,0
Increasing retrocardiac opacity likely represents combination of atelectasis and left-sided pleural effusion.,0
Aortic balloon pump marker tip approximately 5 cm from the top of the aortic arch.,0
This could be advanced approximately 2 cm for more optimal placment.,0
"Discussed with Dr. at 11:30 a.m., .",0
Increase in retrocardiac opacity likely representing a combination of atelectasis and effusion.,0
"2:19 PM CHEST (PORTABLE AP) Clip # Reason: eval line placement Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with sepsis now s/p left subclavian line pullback REASON FOR THIS EXAMINATION: eval line placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, AT 14:31 CLINICAL INFORMATION: Line placement.",0
"FINDINGS: Since the prior study, the right subclavian line has been pulled back somewhat.",0
It terminates at the cavoatrial junction.,0
IMPRESSION: Right subclavian line now terminates in the cavoatrial junction as appropriate.,0
", G. MED 11R 3:40 PM CT HEAD W/O CONTRAST Clip # Reason: eval for change in SDH Admitting Diagnosis: DIABETIC KETOACIDOSIS ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with seizure from DKA s/p fall, SDH seen on MRI REASON FOR THIS EXAMINATION: eval for change in SDH No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Tiny right subdural hematoma appears unchanged since the MR .",0
"3:06 PM CHEST (PORTABLE AP) Clip # Reason: pleural effusions ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with with b/l pleural effusions, chest tube on right just removed after pleurodesis x2 REASON FOR THIS EXAMINATION: pleural effusions ______________________________________________________________________________ FINAL REPORT INDICATION: Pleural effusions.",0
PORTABLE AP CHEST: Left sided pacer projects dual leads over the right atrium and ventricle.,0
Tracheostomy tube is in good position.,0
Mediastinal and hilar contours are otherwise unremarkable.,0
There is diffuse opacification of the right lung with thickening of the right pleural space suggesting a pleural effusion.,0
"Compared to exam of , this represents interval worsening of pleural fluid.",0
"IMPRESSION: Interval increase in size of bilateral pleural effusions, right greater than left.",0
10:47 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
FINDINGS: Portable supine chest and pelvis radiographs obtained on a trauma board and additional supine chest without trauma board are reviewed without comparison.,0
The lungs are hyperinflated but clear and there is no supine evidence for pneumothorax or pleural effusion.,0
"The heart, mediastinal contours, and pulmonary vasculature are within normal limits.",0
"There is severe osteopenia, which limits evaluation for fractures, but multiple bilateral posterior and lateral rib fractures are identified.",0
Evaluation for pelvic fractures is markedly limited secondary to severe osteopenia.,0
There is a right intertrochanteric screw and a lateral fixation plate traversing a prior proximal femur fracture.,1
Multiple right lower rib and left mid rib fractures.,0
"Severe osteopenia, which makes fractures difficult to detect, but no gross pelvic injury.",1
Height: (in) 65 Weight (lb): 210 BSA (m2): 2.02 m2 BP (mm Hg): 80/60 HR (bpm): 140 Status: Inpatient Date/Time: at 19:07 Test: Portable TTE (Complete) Doppler: Limited doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is markedly dilated.,0
LEFT VENTRICLE: Overall left ventricular systolic function is severely depressed.,0
MITRAL VALVE: Severe (4+) mitral regurgitation is seen.,0
Patient in rapid atrial fibrillation during the study Conclusions: The left atrium is markedly dilated.,1
"Compared with the findings of the prior report of , there may be more mitral regurgitation otherwise no significant change.",0
7:51 AM CT HEAD W/O CONTRAST Clip # Reason: follow-up scan Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with new left frontal IPH REASON FOR THIS EXAMINATION: follow-up scan No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb MON 12:19 PM IMPRESSION: 1.,1
Slight decrease in size of large left inferior frontal parenchymal hemorrhage.,0
"Although location and concomitant subarachnoid hemorrhage suggests traumatic etiology, in the absence of definitive trauma history, MR is recommended to evaluate for underlying etiology.",1
Interval resolution of hyperdense material layering within the left occipital .,0
"Unchanged hyperdensity layering within the frontal sulci bilaterally, right greater than left, consistent with acute subarachnoid hemorrhage.",0
Stable right frontal subdural collection with possible hyperdense acute hemorrhagic focus.,0
PFI VERSION #1 EHAb MON 11:22 AM IMPRESSION: 1.,0
"Unchanged hyperdensity layering within the frontal sulci bilaterally, right greater than left.",0
Stable right frontal subdural collection and post-craniotomy changes.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old female with left frontal parenchymal hemorrhage.,0
FINDINGS: Hyperdense hemorrhage in the inferior left frontal lobe is slightly decreased in size compared to prior.,0
There is persistent surrounding vasogenic edema.,0
There has been interval resolution of layering of hyperdense hemorrhage within the left occipital .,0
"Bilateral frontal hyperdense subarachnoid hemorrhage, right greater than left, is unchanged.",0
Hyperdense material within the previously seen right frontal subdural collection likely represents acute on chronic subdural hemorrhage.,1
Slightly prominent ventricles and sulci likely reflect age-related involutional changes.,0
The basal cisterns appear patent.,0
The patient is status post right craniotomy.,0
Chronic hypodense right frontal (Over) 7:51 AM CT HEAD W/O CONTRAST Clip # Reason: follow-up scan Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ FINAL REPORT (Cont) subdural collection and thickening of the adjacent membrane are again noted.,1
Right temporal lobe encephalomalacia is again noted.,0
Visualized bony structures are grossly unremarkable.,0
Stable right frontal subdural collection with acute hemorrhagic component.,0
The etiology of the left frontal parenchymal hemorrhage is unclear.,0
"the location in the inferior frontal lobe and concomitant subarachnoid and subdural hemorrhage, trauma is the most likely etiology.",1
"However, if there is not a definitive history of trauma, MR may be helpful to evaluate for other underlying pathology that would predispose this patient to parenchymal hemorrhage.",1
These findings and recommendations were discussed with Dr. by Dr. by telephone at 1:40 p.m. on .,0
"9:12 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: ?aspiration Admitting Diagnosis: POLYTRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man s/p trauma, in c-collar for C1 fracture (must stay on for 3 months) and ?aspiration.",0
Video Swallow study suggested by Speech&Swallow team.,0
"REASON FOR THIS EXAMINATION: ?aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: Status post trauma and C1 fracture, assess for aspiration.",1
TECHNIQUE: Swallowing oropharyngeal video fluoroscopy was performed in conjunction with speech and swallow division.,0
FINDINGS: Patient's posture is noted to have marked kyphosis.,0
There was aspiration with all administered preparations.,0
Early spill with delayed oral phase is noted.,0
There also appeared to be back flow of esophageal content with significant residual barium material seen in the proximal esophagus at the approximate level where it began to turn for a more horizontal alignment to vertical alignment due to patient's kyphosis.,0
It is unclear whether this reflects a diverticulum at this level or simply just impaired motility.,0
"For full details, please see the speech and swallow division note in the online medical record.",0
IMPRESSION: Aspiration with all administered preparations.,0
5:29 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate for placement Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman s/p feeding tube placement; REASON FOR THIS EXAMINATION: please evaluate for placement ______________________________________________________________________________ WET READ: DLrc WED 9:02 PM Feeding tube courses below diaphragm with tip coiled in the stomach.,0
"Slight interval increase in right effusion, otherwise no change in appearance since :00AM.",0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post feeding tube placement, evaluation for tube placement.",0
FINDINGS: Status post change of the Dobbhoff catheter.,0
"The course of the catheter is unremarkable, the catheter is coils in the stomach, with the tip pointing backwards to the gastric fundus.",0
No evidence of complications associated with tube insertion.,1
"Status post extubation, minimal decrease in lung volume.",0
"Admission Date: Discharge Date: Service: MICU CHIEF COMPLAINT: Hypotension, altered mental status and respiratory distress.",0
"HISTORY OF PRESENT ILLNESS: This 76 year-old white female with coronary artery disease, hypotension, atrial fibrillation, status post abdominal aortic aneurysm with recent repair of thoracoabdominal aneurysm with a long postop course complicated by aspiration pneumonia and ARDS transferred for altered mental status and respiratory distress and hypertension.",1
The patient underwent repair of thoracoabdominal aneurysm with the implantation of SMA and left renal arteries and spent two weeks in the Surgical Intensive Care Unit for aspiration pneumonia and ARDS.,0
She was extubated on and required reintubation on .,0
The patient underwent trach feeding tube placement and was discharged to Rehab Facility on .,0
On the patient had positive sputum culture for MRSA and was begun on Vancomycin and Ceftriaxone course antibiotics.,0
The patient also began on Fluconazole for urinary tract infection.,0
"On admission the patient was found with altered mental status and respiratory distress and found to have a blood pressure of 80/50, heart rate 85.",0
"Prior to this patient was alert and responded to voice by following eyes, but on admission she was unresponsive.",0
"Arterial blood gases on SIMV 650 by 12, FIO2 of 60%, peak of 7.5/7.44/51/136/34.",0
The patient was given intravenous fluid bolus and was transported to where her heart rate was 100 and blood pressure was 60/40.,0
The patient was started on a Dopamine drip in the Emergency Department.,0
Dopamine was weaned off with intravenous fluid boluses.,0
"In the Emergency Department the patient was alert and followed eyes to voice, but also unresponsive.",0
A triple lumen was placed after two unsuccessful attempts at subclavian.,0
"PAST MEDICAL HISTORY: Coronary artery disease, hypertension, atrial fibrillation, status post abdominal aortic aneurysm repair in , hyperthyroidism, thoracoabdominal aneurysm repair .",1
"MEDICATIONS ON TRANSFER: Coumadin 1 mg q day, Amiodarone 200 mg q..d, Lopresor 12.5 mg q day, Methimazole 10 mg q day, Ativan 2 mg q.h.s, Prevacid 30 mg q.d., Nystatin, Ceftriaxone 1 gram q 24, Vancomycin 1 gram q 36, fluconazole 100 mg q.d., Aldactone 550 mg q.d., Lasix 50 mg q.d., Albuterol nebulizers q 6 hours, Atrovent nebulizers q 6 hours and Haldol .5 mg q.h.s.",0
PHYSICAL EXAMINATION: The patient's temperature was 101.,0
"This is a frail, elderly appearing white female in no acute distress.",0
Grade 2 out of 6 harsh systolic murmur heard best at the apex.,0
Extremities are cool with no edema.,0
The patient is alert and following intermittent commands.,0
"There is a sacral decubitus ulcer, 5 x 3 cm in greatest diameter.",0
Also a stage .................... superficial ....................,0
"LABORATORY: The patient's white count was 27.5, hematocrit 34.8, platelets 286.",0
"Chem 7 146, 4.6, ................, ................... AST .................., ALT 260.",0
"Alkaline phosphatase 169, total bilirubin 0.6.",0
"Urinalysis showed trace protein, otherwise unremarkable.",0
"Chest x-ray, showed a large tortuous aorta, resolving bilateral alveolar infiltrates, improving right upper lobe pneumonia.",0
Head CT was negative for acute bleed.,0
No evidence or signs of disease.,0
Electrocardiogram was normal sinus rhythm at 83 and left atrial enlargement and left ventricular hypertrophy.,0
There were depressions in V4 and 5.,0
These were compared to electrocardiogram.,0
"Echo showed 2+ moderate left ventricular hypertrophy, normal left ventricular systolic function, trace mitral regurgitation.",0
"HOSPITAL COURSE: This 76 year-old female with coronary artery disease status post abdominal aortic aneurysm repair, atrial fibrillation with recent thoracoabdominal aneurysm repair with a very complicated postop course transferred from a vent weaning facility for fever, hypotension, altered mental status and recent sputum culture positive for MRSA presented with fever, increased white count, believed to be septic shock.",1
Cardiovascular: The patient was given fluid boluses and subsequent to the Emergency Department course was weaned off blood pressure medication.,0
Over the course of the hospitalization she had several episodes of hypotension believed to be due to hypovolemia.,0
The patient responded well to fluid boluses.,0
The patient had episodes of hypotension secondary to sedative medications in particular Ativan and morphine.,0
These episodes were also responsive to fluid boluses.,0
"Pulmonary: The patient's vent setting initially was SIMV 550/10, 40% FIO2 with a PEEP of 5.",0
"During the course of the day the patient was eventually changed over to pressor support 10 and 5, FIO2 of 40% with a PEEP of 5, which she tolerated well.",0
"Several spontaneous weaning trials were attempted; however, the patient failed these secondary to agitation, tachypnea, and mucous plugging.",0
Subsequently the patient's SIMV was stable with pressor support.,0
The patient developed a MRSA positive pneumonia while at rehab.,0
During the course of this hospitalization she completed her Vancomycin course.,0
Subsequent sputum cultures grew out Stenotrophomonas maltophilia and Providencia stuartii.,0
"Infectious Disease was consulted and believed these to be low virulence organisms, not likely to be the cause of the patient's original septic shock presentation.",0
The patient was started on admission on Ceftazidime 2 grams q 24.,0
This was subsequently discontinued on .,0
"The patient was also started on Flagyl 250 mg q 8, which was discontinued on .",0
Infectious disease: The patient's presentation was most consistent with septic shock.,0
"The most likely source was believed to be the MRSA positive pneumonia; however, subsequent workup did not reveal another source of infection.",0
The patient's urine was unremarkable.,0
Foley catheter was subsequently changed during this hospitalization.,0
Nasogastric tube was subsequently discontinued.,0
"The patient had multiple blood cultures, which showed no growth to date.",0
"The patient's peak white count was on admission at 27.5, and subsequently the white count trended downward.",0
"The issue of a graft infection was discussed with infectious disease, however, they felt that the likelihood of graft infection was low given that the graft was placed in of this year with no subsequent infection.",0
"Additionally, infectious disease believed that sinusitis was unlikely given that on admission head CT showed no evidence of sinus disease.",0
Neurological: The patient had head CT which showed no signs of intracranial bleed.,0
The patient's mental status was believed to be at her baseline.,0
"She would respond to voice; however, it did not appear that she recognized family members.",0
This was believed to be baseline.,0
Renal: On admission BUN and creatinine were elevated at 82 and 1.3.,0
"Subsequently over the course of the hospitalization the BUN and creatinine trended downward on , BUN was 29, creatinine 0.9.",0
"Hematology: The patient was recently admitted on Coumadin secondary to extensive deep venous thrombosis involving the brachiocephalic vein, axillary vein and left subclavian vein.",0
This was originally discovered on hospital admission during for which the patient had a thoracoabdominal aneurysm repair.,0
This was believed to be secondary to multiple central line catheters in place for prolonged course.,0
"During that hospitalization a chest and abdominal CT was obtained, which showed no evidence of malignancy.",0
FEN: The patient received multiple fluid boluses over the course of the hospitalization.,0
"During her hospitalization the patient became mildly hypernatremic at 152, subsequently water boluses returned sodium to normal levels.",0
Intravenous access: Upon admission the patient had a left groin triple lumen placed.,0
"The patient also initially had a left PICC line placed, however, this subsequently failed and the patient had a right PICC line placed.",0
CODE STATUS: The patient is a full code.,0
Dictated By: MEDQUIST36 D: 07:17 T: 07:44 JOB#:,0
Height: (in) 67 Weight (lb): 225 BSA (m2): 2.13 m2 BP (mm Hg): 115/60 HR (bpm): 65 Status: Inpatient Date/Time: at 10:19 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.,0
Conclusions: PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage.,0
POSTBYPASS: The patient is A paced on low dose phenylephrine infusion.,0
There is a well seated bioprosthetic valve in the aortic position.,1
"Peak & mean gradients across the valve are 37mmHg & 20mmHg, respectively with a cardiac output of 4.18.",0
The remaining valves are unchanged.,0
Height: (in) 59 Weight (lb): 198 BSA (m2): 1.84 m2 BP (mm Hg): 97/74 HR (bpm): 78 Status: Inpatient Date/Time: at 10:51 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size.,0
Focal apical hypokinesis of RV free wall.,0
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.,1
Mod functional MS due to MAC.,0
There is mild regional left ventricular systolic dysfunction with distal and apical LV hypokinesis (LAD territory).,0
The remaining segments contract normally (LVEF = 40%).,0
The mitral valve leaflets are severely thickened/deformed.,1
There is moderate functional mitral stenosis (mean gradient 13 mmHg) due to mitral annular calcification.,0
IMPRESSION: Post-radiation valvular disease with mild mitral stenosis and mild aortic stenosis.,1
"Mild regional biventricular systolic dysfunction, most c/w CAD, although post-radiation changes cannot be excluded.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIAC CARE UNIT HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old white female with hypertension, hypercholesterolemia, who began to complain of shortness of breath and became acutely cyanotic around 11:15 p.m. of .",1
EMS was called and upon arrival the patient became apneic and pulseless on monitor.,0
The patient was noted to have sinus tachycardia at 140-150 beats per minute.,0
The patient was intubated with vomitus of 60-80 cc of bilious material.,0
CPR was performed briefly for two minutes.,0
She was taken to an outside hospital where she was given Adenosine times two doses with 160 mg of IV Lasix and nitroglycerin.,0
"While at the outside hospital, it was noted that she had copious endotracheal tube secretions.",0
She was noted to have a left bundle branch block.,1
They were unable to locate and old EKG.,0
There was a question of ventricular fibrillation and she was given lidocaine.,0
She was Medflighted to for cardiac catheterization.,0
Cardiac catheterization showed a tight proximal lesion of 80-90% in the right coronary artery.,1
There was left-to-right collateral present.,0
The left circumflex showed a proximal 90% stenosis which was stented times one.,0
"There was diffuse left anterior descending artery disease, ejection fraction estimated to be 38%.",0
Pulmonary capillary wedge pressure was about 12.,0
"Left ventricular pressure was 114/15, aortic pressure 119/77.",0
SOCIAL HISTORY: She lives with her husband.,0
"PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate 100-110, blood pressure 90/60, on assist control of 700 times 16, 100% FI02.",0
She was sedated with endotracheal tube in place.,0
She opens eyes and responds.,0
She had good breath sounds bilaterally.,0
She had distant cardiac sounds with a systolic murmur at the base radiating to her neck.,0
"The abdomen was obese, soft, nontender, minimally distended.",0
Right groin with arteriovenous sheath in place.,0
Her lower extremities were warm and well perfused.,0
LABORATORY/RADIOLOGIC DATA: Her arterial blood gases on presentation to the outside hospital were 7.16/60/118 on 100% FI02.,0
"At the , her first arterial blood gas was 7.24/54/67.",0
The third set was 7.34/47/139.,0
"The white count was 16.1, hematocrit 46.5, platelets 195,000, INR 1.2, PTT 61.",0
"Sodium 141, potassium 3.8, chloride 103, bicarbonate 19, BUN 30, creatinine 1.4, glucose 325.",0
The chest x-ray showed mild to moderate congestive heart failure with endotracheal tube in good position.,1
The CK peaked at 477 and trended down to 72 by the time of discharge.,0
Her troponin was elevated at 31.5.,0
A cholesterol panel was sent off.,0
"Total cholesterol 197, triglycerides 137, HDL 46, LDL 124.",0
CARDIOVASCULAR: The patient finished her 18 hour course of Integrelin post cardiac catheterization and stenting.,0
"She was started on aspirin, Plavix, a beta blocker, and ACE inhibitor.",0
She continued to do well without any events on telemetry.,0
Her CKs and troponins trended down.,0
She had no further episodes of any active ischemia.,0
PULMONARY: The patient was diuresed and quickly weaned off the ventilator and extubated without any problems.,0
She was weaned off of her oxygen requirement and by the time of discharge was saturating 97% on room air with stable 02 sat on ambulation.,0
RENAL: She presented with acute renal failure with creatinine of 1.4 to 1.5.,1
Her creatinine trended down to 0.6 to 0.7 by the time of discharge.,0
"INFECTIOUS DISEASE: There was some concern about possible aspiration pneumonia; however, the patient remained afebrile with improving pulmonary status.",0
She was not started on antibiotics and remained stable.,0
"HEMATOLOGY: After catheterization, the patient had a drop in her hematocrit to the 30s.",0
It remained stable throughout the rest of her hospital stay.,0
"DISPOSITION: The patient was discharged in good condition to be followed-up by her primary care physician, .",0
", and with her cardiologist in less than two weeks.",0
Cardiac catheterization with stent placement.,0
Dictated By: MEDQUIST36 D: 08:19 T: 11:44 JOB#:,0
"12:52 PM CAROTID SERIES COMPLETE Clip # Reason: PREOP CABG, ASX ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with 3 vessel CAD - going for CABG; REASON FOR THIS EXAMINATION: r/o critical stenosis ______________________________________________________________________________ FINAL REPORT INDICATION: CAROTID BRUITS, PREOP FOR CARDIAC BYPASS.",0
Minimal plaques involving both internal carotid arteries.,0
Normal antegrade flow in both vertebral arteries.,0
IMPRESSION: Minimal bilateral ICA peak without appreciable associated stenosis.,0
Height: (in) 73 Weight (lb): 188 BSA (m2): 2.10 m2 BP (mm Hg): 129/80 HR (bpm): 83 Status: Inpatient Date/Time: at 15:26 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; remaining LV segments are hypokinetic.,0
"Given severity of TR, PASP may be underestimated due to elevated RA pressure.",0
There is severe regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral segments.,0
The remaining left ventricular segments are hypokinetic.,0
"An eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen.",0
"[In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.]",1
IMPRESSION: Moderately dilated left ventricle with mild symmetric left ventricular hypertrophy and severely depressed left ventricular systolic function with regional wall motion abnormalities as described above.,0
Mildly dilated aortic root and ascending aorta.,0
Severe pulmonary artery systolic hypertension.,1
"Compared with the prior study (images reviewed) of , the previously noted noncoronary sinus of Valsalva aneurysm is not clearly visualized.",0
The peak pulmonary artery systolic pressure has increased from 70 mmHg to 80 mmHg.,1
"4:41 PM CT ABD W&W/O C Clip # Reason: Please do triphase CT - liver protocol to eval for HCC in li Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with h/o OLT REASON FOR THIS EXAMINATION: Please do triphase CT - liver protocol to eval for HCC in liver, patient is on HD No contraindications for IV contrast ______________________________________________________________________________ WET READ: MLHh 6:23 PM Edematous liver venous congestion.",1
No suspicious arterially enhancing foci.,0
Prev visualized seg IV lesion not well seen.,0
"Hepatic, portal, spl, sup mes veins patent.",0
Continued distal CHA aneurysms- need 3D recons to better eval.,0
"Atherosclerosis w/ celiac and SMA stenosis, poststenotic dil, infrarenal mural irreg + ulcerated plaques.",0
Bowel wall edema third spacing.,0
Bibasilar pulm opacities = aspiration/pneumonia.,0
"14 x 6 mm nonobstructing L renal pelvic stone, unchanged.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old man with history of orthotopic liver transplant.,1
The patient is currently on hemodialysis.,1
COMPARISON: CT torso with contrast .,0
"TECHNIQUE: MDCT helical images were acquired through the abdomen using the multiphasic liver protocol, after administration of 150 cc of Optiray intravenous contrast.",0
FINDINGS: The imaged lung bases demonstrate mild paraseptal and centrilobular emphysema.,0
"Also seen are nodular airspace opacities in both lung bases, which may represent infection or aspiration.",0
Extensive coronary arterial calcification is present.,0
There is a small simple pericardial effusion.,0
"MULTIPHASIC CT OF THE ABDOMEN: There is heterogeneous attenuation of the liver, consistent with hepatic congestion.",0
The patient is status post orthotopic liver transplant.,1
No suspicious arterially hyperenhancing lesions are seen in the liver.,0
The previously seen arterially enhancing lesion in segment IV of the liver is not visualized in the current study.,1
(Over) 4:41 PM CT ABD W&W/O C Clip # Reason: Please do triphase CT - liver protocol to eval for HCC in li Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) The adrenal glands and pancreas are normal.,1
"The spleen is enlarged measuring 14 cm, and is increased in size since the prior study, 12 cm.",0
"Also seen are linear areas of hypoattenuation along the periphery of the spleen, which is likely related to hypoperfusion.",0
"Also seen is minimal subcapsular fluid along the superior edge of the spleen, (3A:24).",0
"Multiple hypodense lesions are seen within both kidneys, too small to characterize on this study.",0
A 14 x 6 mm left renal pelvic stone is present.,0
"Both kidneys enhance symmetrically with contrast, without evidence of contrast excretion in the kidneys even in the delayed images, consistent with the patient's known history of chronic renal disease.",1
"CTA/CTV: There is minimal calcification of the origin of the celiac axis, with normal opacification of the distal portion.",0
"The stable projection off the common hepatic artery (3A:52) at the site of anastomosis, likely relates to mismatch in size between the donor and recipient hepatic arteries.",0
The common hepatic and intrahepatic branches of the hepatic artery are normally opacified.,0
"There is mild increase in the calcification adjacent to the proximal superior mesenteric artery, with normal opacification distally.",0
The renal arteries are patent.,0
"The superior mesenteric, splenic and portal veins are widely patent.",0
The splenic vein is dilated and a few portosystemic collaterals are seen adjacent to the spleen.,0
No significant intra-abdominal free fluid or air is detected.,0
Extensive atherosclerotic calcification of the abdominal aorta is present without aneurysmal dilation.,0
No arterial hyperenhancing hepatic lesion suspicious for HCC is identified.,0
"Hepatic congestion, with a small simple pericardial effusion.",0
"Nodular airspace opacities in the lung bases, right greater than left, likely representing infection or aspiration.",0
Large left renal pelvic calculus.,0
"Splenomegaly, with peripheral areas of hypoattenuation likely secondary to hypoperfusion.",0
(Over) 4:41 PM CT ABD W&W/O C Clip # Reason: Please do triphase CT - liver protocol to eval for HCC in li Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont),1
6:22 AM CT HEAD W/O CONTRAST Clip # Reason: new left sided weakness in head injured pt ______________________________________________________________________________ MEDICAL CONDITION: 45 year old woman with trauma intracranial hemmorhage and facial fractures REASON FOR THIS EXAMINATION: new left sided weakness in head injured pt contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post head trauma with new left sided weakness.,1
COMPARISON: TECHNIQUE: Noncontrast CT of the head.,0
FINDINGS: Again there is a hemorrhagic focus in the right basal ganglia with a mild amount of low attenuation consistent with edema.,0
The overall size has not changed from the prior exam.,0
"There are persistent punctate hemorrhages at the -white matter junction within the left frontal lobe, not changed.",0
"The subarachnoid hemorrhage is again present, not progressed.",1
"The ventricles, cisterns and sulci are stable in appearance.",0
The -white matter differentiation remains preserved.,0
There is persistent fluid within the maxillary and sphenoid sinuses.,0
The orbits are within normal limits.,0
On bone windows again maxillary sinus fractures are noted.,1
IMPRESSION: 1) Stable appearance of the intracranial hemorrhages.,1
S/P Corevalve Height: (in) 60 Weight (lb): 125 BSA (m2): 1.53 m2 BP (mm Hg): 150/70 HR (bpm): 66 Status: Inpatient Date/Time: at 11:34 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
LV WALL MOTION: Regional LV wall motion abnormalities include: septal apex - hypo; apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
There is mild regional left ventricular systolic dysfunction with focal distal septal/apical hypokinesis to akinesis.,0
The reminaing LV segments have dyanmic systolic function.,0
"Compared with the prior study (images reviewed) of , no change (apical WMA was present but not reported).",0
"1:32 PM CHEST (PA & LAT) Clip # Reason: assess left apical PTX Admitting Diagnosis: SEVERE MITRAL REGURGITATION\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p MVR/ASD closure REASON FOR THIS EXAMINATION: assess left apical PTX ______________________________________________________________________________ FINAL REPORT TWO-VIEW CHEST, COMPARISON: .",1
A previously noted tiny left apical pneumothorax is now more visible laterally but the overall size is not significantly changed.,0
Cardiac and mediastinal contours are stable in the post-operative period.,0
"Bibasilar atelectatic changes and small pleural effusions, left greater than right are also without change.",0
IMPRESSION: Persistent tiny left pneumothorax.,0
"3:49 PM CT C-SPINE W/O CONTRAST Clip # Reason: eval for fx ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man found down, confused, + head trauma REASON FOR THIS EXAMINATION: eval for fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: RSRc FRI 4:57 PM No fracture or malalignment.",0
Moderate to severe multilevel degenerative change.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old male found down confused, positive head trauma.",0
COMPARISON: None available in the PACS.,0
TECHNIQUE: MDCT helical acquisition was performed from the skull base to the cervicothoracic junction without IV contrast.,0
CT CERVICAL SPINE WITHOUT IV CONTRAST: There is no fracture or malalignment.,0
"There is multilevel moderate-to-severe degenerative change, which has resulted in ankylosis of the C3-C4 vertebral bodies (401B:26).",0
"There is also disc height loss more diffusely, with anterior and posterior osteophyte formation from C5-C7.",0
"Posterior disc bulges at C4-C5 (3:38), C5-C6 (3:43), as well as C6-C7 (3:48) result in mild-to-moderate central canal narrowing.",0
There is moderate multilevel neural foraminal narrowing.,0
No prevertebral soft tissue swelling.,0
The lung apices demonstrate minimal parenchymal scarring.,0
"Remainder of soft tissues appears unremarkable, except for mild right maxillary sinus disease.",0
"Chronic degenerative changes with posterior disc bulges resulting in mild to moderate effacement of the thecal sac at C4-C5, C5-C6 and C6-C7.",0
These findings predispose the patient to cord injury even in the setting of minimal trauma.,0
"Clinical correlation is recommended, and MR can be obtained for further evaluation.",0
"11:15 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Please assess for any abnormality that might cause elevated Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with epidural abscess now POD#3 from laminectomy/debridement on , endocarditis, recent demand ischemia with increased troponins started on statin, now with myoclonic jerks of the UE.",1
LFTs are elevated compared with normal baseline on .,0
REASON FOR THIS EXAMINATION: Please assess for any abnormality that might cause elevated LFTs.,0
______________________________________________________________________________ WET READ: JKSd MON 12:14 PM Sludge in gallbladder.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old man with epidural abscess, now post-op day #3.",0
Please assess for any abnormalities.,0
COMPARISON: CT of the abdomen of .,0
FINDINGS: The liver is normal in echotexture without focal lesions.,0
The main portal vein is patent with appropriate direction of flow.,0
The distal pancreas is not well seen due to overlying bowel gas.,0
Visualized portions of the pancreas are within normal limits.,0
2:43 PM UNILAT UP EXT VEINS US Clip # Reason: LT UPPER EXTREMITY SWELLING Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ FINAL REPORT INDICATION: Left upper extremity swelling.,0
DUPLEX FINDINGS: There is normal wall-to-wall flow in the left internal jugular vein.,0
"The left subclavian vein, left axillary vein, left brachial vein, left basilic vein are widely patent with normal waveforms.",0
No fluid collections are identified.,0
CONCLUSION: No evidence of DVT.,0
10:32 PM CT C-SPINE W/O CONTRAST Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with SDH worsening REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: FBr WED 11:18 PM no fx or malalignment.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old man with worsening subdural hematoma.,0
TECHNIQUE: Axial MDCT images of the cervical spine were obtained with no IV contrast administration.,0
FINDINGS: No fracture or malalignment is detected.,0
"Multilevel degenerative changes of the cervical spine are visualized with anterior osteophyte formation, disc space narrowing and calcification of the posterior longitudinal ligament.",0
Severe degenerative changes are noted at the level of C1-C2 with calcification of the transverse ligament.,0
No definite canal stenosis is visualized.,0
Bilateral facet hypertrophy at the level of C5- C6 causes mild canal stenosis and bilateral neural foraminal narrowing.,0
The alignment of the cervical spine is normal.,0
The outline of the thecal sac is grossly intact.,0
Please note that CT does not provide intrathecal details comparable to MRI.,0
No prevertebral soft tissue swelling is noted.,0
No pathologically enlarged nodes are noted within the neck.,0
"Incidental note is made of a heterogeneous appearance of the thyroid, which contains hypodense nodules and dense calcification.",0
"12:02 AM BABYGRAM (CHEST ONLY) Clip # Reason: check ett placement ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 32 1/2 weeks gestation, triplet with rds REASON FOR THIS EXAMINATION: check ett placement ______________________________________________________________________________ FINAL REPORT This is our initial film on this premature infant who is a triplet.",0
Our film demonstrates an ETT just at the thoracic inlet.,0
The lung volumes are low and the lungs mildly granular compatible with mild hyaline membrane disease.,0
"1:40 PM ART DUP EXT LOW/BILAT COMP; ART EXT (REST ONLY) Clip # Reason: Please assess bypass graft in groin for flow, stenosis or an Admitting Diagnosis: PULMONARY INFUSION ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with REASON FOR THIS EXAMINATION: Please assess bypass graft in groin for flow, stenosis or aneurysm.",0
______________________________________________________________________________ FINAL REPORT ARTERIAL STUDY OF THE LOWER EXTREMITIES HISTORY: Lower extremity bypass graft.,0
FINDINGS: Duplex and color Doppler of both inguinal areas demonstrate patent common femoral arteries.,0
There is no evidence of graft involving either inguinal region.,0
There is a simple fluid collection within the right and left inguinal regions noted.,0
", B. VSURG VICU 4:50 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Cause of sbo?Oral contrast via NGT, No IV contrast Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man POD 6 from EVAr for contained rupture AAA now with SBO/ ileus x 1 week REASON FOR THIS EXAMINATION: Cause of sbo?Oral contrast via NGT, No IV contrast CONTRAINDICATIONS for IV CONTRAST: Renal failure- no iv contrast ______________________________________________________________________________ PFI REPORT PFI: Mild distention of the small-bowel loops relatively unchanged compared to the prior study with no evidence of mechanical obstruction.",1
Status post aortobifemoral stenting and stable right retroperitoneal hematoma.,0
1:43 PM CHEST (PORTABLE AP) Clip # Reason: check placement of L picc line.,0
"please page w/ results Admitting Diagnosis: LUNG CA LEFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with SCC s/p VATS, LULobectomy; trach.",0
REASON FOR THIS EXAMINATION: check placement of L picc line.,0
please page w/ results ______________________________________________________________________________ FINAL REPORT INDICATION: 47 year old male with squamous cell carcinoma status post left upper lobectomy and tracheostomy.,0
Placement of left-sided PICC line.,0
FINDINGS: Comparison is made to a prior film of the same day.,0
There is stable elevation of the left hemidiaphragm.,0
A left upper rib fracture is unchanged.,0
Opacity at the left upper hemithorax consistent with the patient's history of left upper lobectomy appears stable.,1
A right hilar mass appears unchanged.,0
A left-sided PICC terminates within the upper right atrium.,0
IMPRESSION: Left-sided PICC terminates within the upper right atrium.,0
Otherwise unchanged appearance of right hilar and left upper lobe opacities along with elevation of the left hemidiaphragm.,0
"3:42 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o ptx, s/p CT removal Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with CABG REASON FOR THIS EXAMINATION: r/o ptx, s/p CT removal ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old man with CABG, status post chest tube removal.",1
FINDINGS: Bilateral chest tubes have been removed.,0
A small right apical pneumothorax is present.,0
The presence of a tiny left apical pneumothorax is questionable.,0
Minimal left basilar atelectasis and small effusion are unchanged.,0
Postoperative changes to the mediastinum are stable.,0
A right internal jugular catheter tip remains in the low SVC.,0
Sternal wires are intact in midline.,0
IMPRESSION: Small right-sided and questionable left sided pneumothorax status post bilateral chest tube removal.,1
This finding was identified at 16:20 on and communicated promptly via phone with Dr. at 16:26 on .,0
"Status: Inpatient Date/Time: at 13:00 Test: Portable TTE (Congenital, focused views) Doppler: Limited doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
Height: (in) 68 Weight (lb): 413 BSA (m2): 2.78 m2 BP (mm Hg): 110/44 HR (bpm): 69 Status: Inpatient Date/Time: at 10:06 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
No MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Sepsis/ Major Surgical or Invasive Procedure: Intubation, right IJ central line, right femoral artery aline History of Present Illness: This is a 89F with a history of CVA, dementia, Type 2 DM, hypertension, recent diagnosis of chronic cholecystitis s/p perc.",1
drainage and ERCP sphincterotomy and recent diagnosis of cdiff who presents with altered MS .,0
She was referred to from her NH for reports of mental status changes .,0
Pt has had a long course concerning her recent diagnosis of chronic cholecystitis.,0
This was origianlly diagnosed in based on CT scan.,0
Surgery was consult but per discussion with family was felt not to be a surgical candidate.,0
At that time she had a perc.,0
"cholecystomy placed by IR and started on Abx(initially cipro/flagyl and then switched to zosyn), bile grew back only albicans which ID did not recommend treating.",0
She then underwent ERCP with sphincterotomy on .,0
"She was then sent to rehab where she continued to have low grade fevers, and leukocytosis.",0
She was found to be cidff positive despite not having any diarrhea and started on flagyl.,0
CT scan on showed diffuse colitis consistent with cdiff infection.,0
In the ED she was found to be hypotensive not responsive to fluids.,0
She was intubated and right IJ with sepsis catheter was placed.,0
She got a total of 5L of fluid.,0
She was started on levophed as well.,0
"She was given levofloxacin, flagyl, and vancomycin and decadron.",0
"She was also noted to be in significant ARF, hypernatremic Past Medical History: 1.",0
CHF - likely diastolic dysfunction w/ EF 60% 3.,0
Right-sided atrial and ventricular pacemaker for sinus pause 4.,0
CVA - left parietal lobe infarct 8.,0
Infrarenal aortic ulceration/dissection on abdominal CT- seen by vascular in .,0
"Plan is for repeat CT abd in months, otherwise medical management and BP control Social History: Lives at home with daughter and visiting nurse Family History: N/C.",0
"Diffuse colitis, which compared to prior CT from , appears worse.",0
"Fluid-filled loops of proximal small bowel with decompressed distal segment which may be suggestive of early or partial small-bowel obstruction, No definite transition point is identified.",0
Dilated contrast-filled stomach for which NG-tube decompression is recommended.,0
Bilateral diffuse peribronchovascular ground-glass opacity as well as consolidation within bilateral bases concerning for aspiration pneumonia and superimposed early ARDS picture.,0
Distended gallbladder with probable adjacent pericholecystic fluid.,0
Ultrasound may be preformed to evaluate for acute cholecystits if clinically warranted.,0
Brief Hospital Course: Pt arrived to the floor in severe septic shock.,1
"She was on levophed, but continued to have a drop in her pressures.",0
Also began have desaturations despite full oxygenation supprt.,0
She required addition of vasopressin and high dose dopamine.,0
She continued to get IVF's.,0
CXR showed pulmonary edema vs ARDS due to sepsis.,0
"She was given braod spectrum antibiotics of vanco(IV and PO), zosyn, flagyl.",0
Despite this treatment she continued to deteriorate.,0
Her BP continued to drop and given her poor prognosis a discussion was held with the family and decided to procede with aggressive care however patient was made DNR.,0
She passed away at 0125 with her family at the bedside.,0
Medications on Admission: Atenolol 100 mg Qday Bisacodyl 5 mg prn Humoloag sliding scale Insulin NPH 16 units QAM and 5 units QPM Lisinopril 40 mg Qday Pantoprazole 40 mg Qday Senna 8.6 mg Cholecalciferol 400mg Acetaminophen prn Fluconazole 200 mg qday Nifedipine 60mg Q8hrs Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired,0
"4:12 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: assess enterocutaneous fistula, r/o large intraabd leak/absc Field of view: 39 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman s/p total colect in distant past.",0
In ICU 1 month after surgery for small bowel obstruction.,0
Explored 2d ago for evacuation of hematoma.,0
Now has enterocutaneous fistula clinically.,0
"REASON FOR THIS EXAMINATION: assess enterocutaneous fistula, r/o large intraabd leak/abscess ______________________________________________________________________________ FINAL REPORT INDICATION: Status post total colectomy in past with small bowel obstruction with evacuation of hematoma with enterocutaneous fistula clinically.",1
TECHNIQUE: CT of the abdomen and pelvis with IV contrast.,0
150 cc Optiray is administered.,0
Optiray was selected secondary to debilitated state.,0
FINDINGS: CT of the abdomen with IV contrast.,0
There are bilateral new small pleural effusions with associated atelectasis.,0
The gallbladder is distended which may be seen in a debilitated patient.,0
There is extensive subcutaneous edema.,0
The pancreas and adrenal glands are unremarkable.,0
There is a small amount of fluid adjacent to the right kidney that is new from prior study and located within the perirenal space.,0
The kidneys themselves enhance homogeneously and excrete bilaterally and there is no evidence of hydronephrosis.,0
There is a minimal amount of free fluid within pouch.,0
Oral contrast had been administered and seen within the proximal small bowel.,0
The patient is status post colectomy.,0
The proximal jejunum is seen entering a region just posterior to the surgical scar in which the hematoma was present.,0
The oral contrast fills this cavity.,0
There are multiple non-dependent air bubbles additionally present within this collection.,0
The collection measures 5.2 x 14.2 cm.,0
This collection is directly posterior to the surgical scar.,0
Oral contrast is seen within the surgical scar bed consistent with an entercutaneous fistula.,0
The contrast has not arrived at the distal small bowel or the ileostomy.,0
Compared with the prior study there has been interval development of free fluid of mixed heterogenicity just inferior to the gallbladder.,0
Likely the areas of increased density are related to decompressed loops of small bowel in this region.,0
"The appearance of this fluid is concerning for leakage of fluid, and the relatively contained nature in this region raises the possibility of a loculated fluid collection.",0
CT of the pelvis with IV contrast.,0
Again seen are multiple hypodense lesions within the uterus consistent with uterine fibroid.,0
A Foley catheter is present within a decompressed urinary bladder.,0
There is no significant pelvic free fluid.,0
"(Over) 4:12 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: assess enterocutaneous fistula, r/o large intraabd leak/absc Field of view: 39 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) Bone windows.",0
There are no suspicious osseous lesions or erosions.,0
Since the prior study there has been evacuation of an intra- abdominal hematoma.,0
Currently a loop of jejunum appears to communicate with the region of the prior hematoma with a large collection of oral contrast accumulating posterior to the surgical scar.,0
There is evidence of an anterior enterocutaneous fistula with the oral contrast exiting the patient.,0
Additionally there is air present within this fluid collection which may represent an abscess formation or may be originating from bowel.,0
In addition to this collection there is a separate collection inferior to the gallbladder fossa which appears relatively well contained.,0
There appears to be loops of bowel present within this fluid collection.,0
The appearance of this fluid over a short period of time raises the possibility of leakage of bowel contents.,0
Bilateral small pleural effusions and atelectasis new from prior study.,0
There is a tiny amount of perirenal fluid adajcent to the right kidney which is new compared with prior study and is of uncertain significance but may be inflammatory or reactive in nature.,0
The kidneys are otherwise unremarkable.,0
The results were discussed with the ordering physician and offer to review the study in person was suggested.,0
"12:46 PM CHEST (PORTABLE AP) Clip # Reason: eval douboff placement Admitting Diagnosis: STROKE/TIA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with stroke, CHF and PNA s/p douboff placement REASON FOR THIS EXAMINATION: eval douboff placement ______________________________________________________________________________ FINAL REPORT INDICATION: Stroke, CHF, pneumonia, status post Dobbhoff placement.",0
COMPARISON: Chest x-ray performed on .,0
FINDINGS: Single AP upright view of the chest was obtained.,0
The previously seen Dobbhoff tube is no longer identified.,0
Mild pulmonary edema appears slightly improved compared to prior study.,0
Blunting of the costophrenic sulci compatible with mild pleural effusions are unchanged.,0
"Bibasilar atelectasis/consolidation, though still present also appears to have improved, particularly on the left side.",0
3:28 PM CHEST (PORTABLE AP) Clip # Reason: eval for resolution or pneumothorax Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man s/p left thoracentesis REASON FOR THIS EXAMINATION: eval for resolution or pneumothorax ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
INDICATION: 89-year-old male patient status post left thoracocentesis.,0
Evaluate for resolution of pneumothorax.,0
FINDINGS: AP single view of the chest obtained with patient in sitting semi-upright position is analyzed in direct comparison with a similar preceding study obtained on .,0
The degree of left-sided pleural effusion has changed and probably relates to a preceding tap which diminished somewhat its appearance.,1
One has now a clearer picture of the left lung base where a markedly crowded pulmonary vasculature is identified.,0
This raises possibility of parenchymal involvement such as pneumonic infiltrate or bronchial obstruction.,0
"In the other accessible lung areas, there is no conclusive evidence for pulmonary vascular congestion.",0
"IMPRESSION: No pneumothorax, left-sided pleural effusion, moderately reduced probably related to the tap.",1
Underlying pulmonary abnormality is suspected.,0
Better evaluation could be achieved with CT scan as recommended already on previous study.,0
1:39 PM CHEST (PA & LAT) Clip # Reason: r/o effusions Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with CABG REASON FOR THIS EXAMINATION: r/o effusions ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after CABG.,1
PA and lateral upright chest radiograph were compared to .,0
The previously demonstrated small left pneumothorax is not seen on the current radiograph.,0
Small bilateral pleural effusions have not significantly changed in the interim.,0
Lungs are essentially clear except for minimal bibasilar atelectasis.,0
The post-surgical appearance of the heart and the mediastinum is unremarkable.,0
"3:37 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with h/o spontaneous PTX being treated for intubated s/p trach and placement of Dobhuff tube REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:13 A.M. .",0
IMPRESSION: AP chest compared to : Feeding tube passes to the region of the proximal duodenum.,0
"Right lower lobe atelectasis has improved, though the lung base remains elevated.",0
"There may be a tiny right pleural effusion, probably of no clinical significance.",0
Heart is normal size and the mediastinum is midline.,0
Right subclavian line projects over the expected course of the SVC.,0
LINE PLACEMENT Clip # Reason: 45cm left picc.,0
Admitting Diagnosis: FEVERS ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with new picc REASON FOR THIS EXAMINATION: 45cm left picc.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old man with new PICC.,0
FINDINGS: A new left PICC terminates in the mid SVC.,0
Feeding tube courses into the stomach and out of view.,0
Right greater than left bilateral pleural effusions and accompanying atelectasis are as on the previous CT with elevation of the right hemidiaphragm as before.,1
Subphrenic collections are better assessed as on the previous examination.,0
The remainder of aerated lung is clear.,0
IMPRESSION: Satisfactory position of the new left PICC with bilateral small to moderate pleural effusions.,1
2:36 PM DUP EXTEXT BIL (MAP/DVT); -59 DISTINCT PROCEDURAL SERVICE Clip # DUP EXTEXT BIL (MAP/DVT) Reason: Please do upper and lower extremity vein mapping bilateral.,1
Admitting Diagnosis: HAND AND FINGERS INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man that needs L brachial to radial artery bypass REASON FOR THIS EXAMINATION: Please do upper and lower extremity vein mapping bilateral.,1
______________________________________________________________________________ FINAL REPORT INDICATIONS: 55-year-old male needs left brachial to radial bypass graft.,1
Please map upper and lower extremity veins for conduit.,0
FINDINGS: RIGHT LEG: There is a right above-knee amputation.,1
The right greater saphenous is visualized in the upper to mid thigh with diameters in the thigh and upper thigh of 1.7-1.8 mm.,0
The diameters at the saphenofemoral junction of 3.5 mm.,0
LEFT LEG: There is a left below-knee amputation.,1
The greater saphenous vein from the knee to the upper thigh is not visualized.,0
"In the highest portion of the thigh, there is a short segment of vein ranging from 1.5-3.4 mm at the saphenofemoral junction.",0
RIGHT ARM: The right cephalic vein is not visualized.,0
The basilic vein is present but thick-walled at the antecubital fossa.,0
There is a short segment in the upper arm of basilic vein that measures 1.9-2.6 mm.,0
"LEFT ARM: The left cephalic vein is patent with diameters from wrist to antecubital fossa of 2.5, 1.9, 2.2, 2.2 mm.",0
"The upper arm cephalic diameters are 1.6, 1.5.",0
"The left basilic vein is patent with diameters from antecubital fossa to upper arm of 2.1, 1.2, 2.5 mm respectively.",0
"IMPRESSION: Upper thigh, right greater saphenous is mostly less than 2 mm in diameter with the exception of the vein closest to the saphenofemoral junction.",0
"In the left leg, the greater saphenous is mostly absent with the exception of a very short, less than 10 cm length in the groin.",0
The right arm has no usable vein of any significant length.,0
"The best vein for conduit, albeit small in diameter is the left forearm cephalic vein.",0
4:48 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for interval changes Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with stage IV NSCLC REASON FOR THIS EXAMINATION: Please evaluate for interval changes ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 16:53 INDICATION: Stage IV lung cancer.,0
FINDINGS: An ETT is situated 6 cm above the carina.,0
A right lower lobe density is visualized which probably represents a combination of mass and some post-obstructive atelectasis.,0
That appears to be subsegmental.,0
There is a right effusion as well.,0
There is no pneumothorax and the remainder of the lungs is clear.,0
Recommend comparison to prior films when available.,0
"4:36 PM CHEST (PA & LAT) Clip # Reason: pre-op baseline study Admitting Diagnosis: LEFT ATRIAL THROMBUS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman pre-op MVR REASON FOR THIS EXAMINATION: pre-op baseline study ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Preop evaluation, MVR.",1
"Mild cardiomegaly, tortuous aorta and appearance of the mediastinum is unchanged.",0
"There is asymmetry in the density of the upper lobes with more density in the left upper lobe, of unclear etiology; could represent a lung abnormality.",0
The first rib is not clearly delineated.,0
Described nodular opacity in the right upper lobe is no longer visualized.,0
IMPRESSION: Ill-defined opacity in the left upper lobe warrants further evaluation with CT.,0
"LINE PLACEMENT Clip # Reason: postop film Admitting Diagnosis: MR\MITRAL VALVE REPLACEMENT REDO, ?",1
MYOMECTOMY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman s/p redo MVR REASON FOR THIS EXAMINATION: postop film ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST.,0
REASON FOR EXAM: Patient SP mitral valve repair postop film.,1
FINDINGS: ET tube with tip 4.5 cm above the carina.,0
Right internal jugular line with tip in the right brachiocephalic vein.,0
Swan-Ganz catheter with tip in the proximal main right pulmonary artery.,0
Patient SP median sternotomy and MVR.,0
NG tube with tip in the stomach.,0
Bilateral basilar chest tubes and mediastinal tubes in standard positions.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: TSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Right lower lobe mass Major Surgical or Invasive Procedure: Mediastinoscopy Right lower lobectomy and mediastinal lymph node dissection Bronchoscopy Foley catheter Central Line placement Epidural placement Chest tube placement History of Present Illness: This is a 79-year-old man with a history of hemoptysis who had subsequent work-up and was found to have a large right lower lobe mass.,1
PET scan demonstrated increased activity in the right hilum.,0
"Past Medical History: Emphysema Benign prostatic hypertrophy Gastroesophageal reflux disease Herniorrhaphy ' Parotidectomy ' Social History: 1 PPD for 60 years Occasional EtOH No IDU Worked as Civil Engineer Family History: Laryngeal and lung cancer Physical Exam: On Admission, patient's physical exam is as follows: Vitals: T=96.2, BP=162/64, P=89, R=12, SpO2=98%RA Gen: NAD, AAOx3 HEENT: PERRL, EOMI, no LAD, MMM, sclera anicteric CVS: RRR, no murmurs Pulm: CTA bilaterally Abd: soft, NT/ND, +BS Ext: trace clubbing, no cyanosis or edema Neuro: no focal deficits, CN2-12 grossly intact Pertinent Results: Pathology Examination A.",1
4R paratracheal lymph node: No evidence of malignancy.,0
2R upper paratracheal lymph node: No evidence of malignancy.,0
C. 7 subcarinal lymph node: No evidence of malignancy.,0
"D. Right lower lobe: Carcinoma, see synoptic report.",0
E. 8R paraesophageal node: No evidence of malignancy.,0
F. Level 7 subcarinal node: No evidence of malignancy.,0
G. Mediastinal nodes near thymus: 7 lymph nodes with no evidence of malignancy.,0
CHEST (PORTABLE AP) 7:13 PM IMPRESSION: Small right pneumothorax CHEST (PORTABLE AP) 11:37 AM 1) Interval placement of a right subclavian venous catheter in good position.,0
2) Stable size of the right apical pneumothorax.,0
3) Stable atelectasis at the left base.,0
CHEST (PORTABLE AP) 10:20 AM Comparison is made to prior study 2 days ago.,0
Right apical pneumothorax looks slightly smaller.,0
Basilar density is essentially unchanged.,0
"This may represent consolidation, atelectasis and/or effusion.",0
Brief Hospital Course: Mr. was admitted to the Thoracic Surgery service at under Dr. care on .,0
"On that day he underwent a cervical mediastinoscopy with biopsies, fiberoptic bronchoscopy and right lower lobectomy with mediastinal lymph node dissection.",0
"For details of the operation, see procedure note.",1
"Preoperatively, the patient had an epidural line placed and a foley catheter and 2 chest tubes placed intraoperatively.",0
His primary issue in the immediate post-op period was pressure support for which he was placed on a neosynephrine drip-stopped prior to going to the floor.,0
"Due to his BP issues, his epidural was removed on POD#1 and a PCA was installed for pain control.",0
"On POD#2, the patient went into atrial fibrillation and was treated with 2g of IV magnesium sulfate, fluid boluses, 150cc amiodarone bolus x2, calcium chloride, diltiazem and was then moved to the critical care unit for BP monitoring.",1
At that time he was started on a diltiazem drip.,0
"On POD#3, patient's hematocrit was noted to be 26.8; however, a repeat hematocrit was 29.3 and it was decided not to transfuse the patient with blood products.",0
"Also, the patient was moved to the floor after being deemed stable enough on the diltiazem drip that same day.",0
"On POD#4, the chest tubes and foley catheter were removed.",0
"Also, the patient was started on a Heparin drip and coumadin 5mg QHS for anticoagulation secondary to the atrial fibrillation.",1
"EPS was consulted at that time and recommended maintaining amiodarone at 800mg/day for 1 week, 400 mg/day 2 weeks thereafter and finally 200mg/day to finish.",0
"Also, the diltiazem drip was subsequently discontinued that day.",0
They also requested the patient follow-up with Dr. in Cardiology/ Clinic in 6 weeks and to continue on coumadin until then.,0
"On POD#7, patient became therapeutic on his coumadin with an INR of 2.3.",0
He was seen by physical therapy who had recommended he be placed in a rehabilitation facility for further conditioning the previous day.,0
"He was finally discharged on POD#8, , in good condition, tolerating a house diet and ambulating with assistance.",0
He is asked to follow-up with Dr. in weeks and to call for an appointment.,0
He must also continue having his PTT/INR checked on a daily basis for conitnued coumadin dosing.,0
Medications on Admission: Hytrin 10mg PO QHS Prilosec 40mg PO QD Discharge Medications: 1.,0
Terazosin HCl 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime).,0
"Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed).",0
"Disp:*30 Tablet, Sublingual(s)* Refills:*2* 4.",0
Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime).,0
Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: House Nursing & Rehabilitation Center - Discharge Diagnosis: Squamous Cell Carcinoma Atrial fibrillation Hypovolemia Discharge Condition: Good Discharge Instructions: You may restart any medications you were on prior to your admission.,1
You may have a regular diet.,0
You may ambulate with assistance as tolerated.,0
Followup Instructions: Please follow-up with Dr. in weeks.,0
Please follow-up with Dr. in Cardiology/ clinic in 6 weeks.,0
11:34 AM CHEST (PA & LAT) Clip # Reason: r/o pna Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with Down's syndrome and multiple intracranial hemorrhages with continued fevers.,1
REASON FOR THIS EXAMINATION: r/o pna ______________________________________________________________________________ FINAL REPORT HISTORY: 54 year old man with Down syndrome.,0
Patient has multiple intracranial hemorrhages and continues to have fevers.,0
"PA AND LATERAL CHEST: The cardiac, hilar and mediastinal silhouettes are stable in size.",0
There is bilateral improving interstitial edema.,0
There is left lower lobe consolidation consistent with pneumonia.,0
There is also a right lower lobe atelectasis.,0
There is a small left effusion.,0
IMPRESSION: 1) Left lower lobe pneumonia with small effusions.,0
9:35 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: S/P L TEMP LOBECTOMY Admitting Diagnosis: EPILEPSY/SDA Field of view: 25 ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with decreased R sided mvmt s/p L temp lobectomy REASON FOR THIS EXAMINATION: bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 39-year-old male with concern for postoperative hemorrhage.,1
"COMPARISON: Non-contrast head CT, at 16:10.",0
FINDINGS: Again demonstrated is prior left frontal craniectomy.,0
There is regional soft tissue scalp swelling and emphysema.,0
There remains pneumocephalus underlying the craniectomy site and layering along the left frontal convexity.,0
Several small locules of gas remain in the left temporal lobe at the surgical site.,0
Post-surgical edema at the resection site is similar.,0
A left subdural hematoma at the surgical site has not appreciably changed.,0
Maximal thickness is estimated at 7 mm.,0
"There remains shift of the septum pellucidum to the right by approximately 5-6 mm, indicating subfalcine herniation but not appreciably changed.",0
The ventricular system is stable in configuration and size compared to the study at 16:10 today.,0
No new areas of intracranial hemorrhage are seen.,0
There is no new major vascular territorial infarction.,0
Paranasal sinuses and mastoid air cells remain clear.,0
The mastoids are congenitally under pneumatized.,0
IMPRESSION: No appreciable change in appearance of the brain compared to prior study on at 16:10.,0
The left subdural hematoma measuring 7 mm maximal thickness.,0
Unchanged rightward subfalcine herniation by about 5-6 mm.,0
NOTE ON ATTENDING REVIEW: Subtle hypodensity in the left capsuloganglionic region.,0
MR HEAD WITH DWI is more sensitive in the detection of acute stroke and should be considered.,0
LINE PLACEMENT Clip # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Admitting Diagnosis: TVR ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with TVR REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Single supine portable radiograph of chest was compared with prior radiograph from .,0
FINDINGS: The Swan-Ganz catheter through the right internal jugular approach approximately terminates into the main pulmonary artery.,0
Endotracheal tube tip terminates 5.5 cm above the carina and is appropriate in position.,0
"Orogastric tube is seen to course below the diaphragm into the stomach, however, the side hole of the OGT is just few centimeters below the orogastric junction.",0
Consider advancing the orogastric tube further for better seating.,0
Status post median sternotomy with intact sternal sutures.,0
There are no lung opacities concerning for pneumonia.,0
"Mildly enlarged heart size, mediastinal and hilar contours have a stable appearance.",0
12:47 PM CHEST (PORTABLE AP) Clip # Reason: s/p Right chest tube removal ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CAD now with fever of unknown etiology.,0
Please assess for any infitrates.,0
REASON FOR THIS EXAMINATION: s/p Right chest tube removal ______________________________________________________________________________ FINAL REPORT HISTORY: Fever of unknown etiology.,0
A single view of the chest is compared to a previous study performed yesterday.,0
"The ET tube, left subclavian line and chest tube are appropriately positioned.",0
The cardiomediastinal contours are not significantly changed.,0
There are sternal wires and clips overlying the cardiac silhouette consistent with previous CABG.,0
There is decreasing prominence of the bronchopulmonary markings suggesting improved failure.,0
The right-sided pleural effusion is decreased.,0
The left-sided pleural effusion is slightly increased with increased atelectatic changes.,0
There is a small left apical pneumothorax (5%).,0
Decreasing right-sided pleural effusion and increasing left-sided pleural effusion.,0
Small (5%) left apical pneumothorax.,0
"2:31 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # Reason: pls eval for stones, obstruction, or cause of hypotension/se Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with ESRD on HD, afib, chf, p/w chills, hypotension.",0
"H.O stones, hydronephrosis REASON FOR THIS EXAMINATION: pls eval for stones, obstruction, or cause of hypotension/sepsis.",0
CONTRAINDICATIONS for IV CONTRAST: ESRD ______________________________________________________________________________ WET READ: PXDb SAT 5:03 PM no acute intrabdominal process to explain patient's symptoms.,0
No hydroneohrosis or urinary tract calculi left common and external iliac aneursyms are unchanged since .,0
"Please note on attending review, question of possible acute cholecystis was raised due to dilated gall bladder and possible trace peicholecystic fluid.",0
"if there are clinical signs and symptoms of cholecystitis, it may be benficial to obtain an US.",0
"Changes to wet read discussed with Dr. , resident WET READ VERSION #1 PXDb SAT 3:46 PM no acute intrabdominal process to explain patient's symptoms.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old man with ESRD on hemodialysis, afib, CHF, presents with chills, hypotension.",0
TECHNIQUE: Helical CT acquisition from the lung bases to pubic symphysis with and without administration of intravenous contrast.,0
CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: The lung bases demonstrate bibasilar atelectasis and calcified pleural plaques.,0
"There is no pleural effusion, focal consolidation.",0
The visualized portions of heart and pericardium are unremarkable.,0
"The liver demonstrates multiple hepatic hypodensities, less than 2 mm, may represent small cysts or biliary hamartomas (4:13, 15).",0
The gallbladder is distended measuring up to 5.7 x 12.6 cm.,0
There is enhancement of the gallbladder wall mucosa and mild amount of pericholecystic fluid.,0
"Overall, these findings are equivocal for cholecystitis and correlation with ultrasound in the right clinical setting is recommended.",0
There is no cholelithiasis or choledocholithiasis.,0
"The pancreas, adrenals bilaterally are normal in appearance.",0
Both kidneys are atrophic with significant cortical thinning and perinephric stranding.,0
No obstructive renal calculi are noted.,0
The lower pole of the left kidney demonstrates a 1.3 x 1.6 cm cyst.,0
"There is no (Over) 2:31 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # Reason: pls eval for stones, obstruction, or cause of hypotension/se Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) intraperitoneal free fluid or free air.",0
Shotty mesenteric and retroperitoneal lymph nodes are however noted.,0
The largest is noted in the aortocaval junction measuring 8 mm in short axis.,0
"CT OF THE PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid colon, intrapelvic bowel loops including the appendix are normal in appearance.",0
"There is no pelvic collection, free fluid or free air.",0
The urinary bladder is collapsed with Foley catheter in situ.,0
"Unchangd Aneurysmal dilation of bilateral iliacs more significantly involving the left common and external iliac vessel, measuring 3.7 cm in the left common iliac level and approximately 2.8 cm at the left external iliac level is noted.",0
There is also chronic dissection of the right proximal common iliac and left proximal external iliac artery.,1
Eccentric mural plaque or thrombus is noted involving the left common and external iliac as well as the common iliacs is seen.,0
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous lesions are noted.,0
Extensive multilevel degenerative changes with bridging osteophytes predominantly involving the lumbar vertebral bodies is also evident.,0
"There are also endplate erosive chanegs at multiple levels, raising the possibility of renal osteodystrophy.",0
Enlarged gallbladder with a trace amount of pericholecystic fluid.,0
"Overall, these findings are equivocal for acute cholecystitis and in the right clinical setting, correlation with ultrasound is recommended.",0
Chronic dissection and aneurysmal dilation of the left common and external iliac arteries.,0
LINE PLACEMENT Clip # Reason: 42cm picc.,0
Admitting Diagnosis: ARTERIAL OCCLUSION ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with new picc REASON FOR THIS EXAMINATION: 42cm picc.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Assessment of new left PIC catheter placement.,0
SINGLE AP CHEST RADIOGRAPH: A left PIC catheter terminates at the junction of the left subclavian and left brachiocephalic vein.,0
Right IJ catheter terminates in mid to low SVC.,0
The opacity in the left lung base is stable and may represent a small left pleural effusion with basal atelectasis.,0
The cardiomediastinal and hilar contours are stable.,0
IMPRESSION: A left PIC catheter terminates at the junction of left subclavian and left brachiocephalic vein.,0
The findings were discussed with Ms. of the central venous access team immediatley after the study.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Acetaminophen/Diphenhydramine Overdose Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: Ms. is a 48 year-old woman with no known medical history.,0
This history is deciphered from ED notes and the report of her .,0
Ms. has no history of depression but had been recently out of work and in relationship problems and was noted to be more down than usual.,0
"Today around 1500, she was found by a passerby wandering around outside her car in an empty area.",0
She had a bottle of tylenol/diphenhydramine 100 tabs of 500 mg each.,0
"She was also found with detergent bottles and alcohol bottles by report, although her deny this.",0
There was a suicide note stating that she was overwhelmed with financial problems and felt like a disappointment to her friends and family.,0
"At , the patient was unresponsive.",0
Urine tox was positive for tricyclics and cocaine.,0
Serum acetaminophen level was 348.,0
She was intubated with etomindate and succinylcholine and started on fentanyl and midazolam.,0
She was also paralized with rocuronium.,0
NG lavage with administration of activated charcoal was performed.,0
NAC and bicarbonate drips were started (unclear why bicarb drip started).,0
She was trasnferred to .,0
"At ,initial VS T 100.4, HR 111, BP 142/98, RR 14, O2 100% RA.",0
Urine tox was positive for benzos.,0
"Serum acetaminophen level was 155 at , approximately 5 hours after the ingestion.",0
EKG showed a QRS complex.,0
She was transferred to the MICU.,0
"VS prior to transfer HR 111, 142/78, 14, 100% on 400/14, PEEP 5, FiO2 .3.",0
"Past Medical History: per , thyroid problems (unknown hypo- or hyper) No history of psychiatric problems.",0
Social History: She lives with her boyfriend and works as an iron worker but has been out of work recently.,0
There have also been relationship problems with her boyfriend.,0
adamently deny that she ever uses alcohol or any illicit drugs.,0
"She is a ""heavy smoker.""",0
# Overdose: Primary concern was acetaminophen.,0
Level 155 ~5 hours after the presumed time of ingestion.,0
"Assuming the 1500 timing of the ingestion is correct, she is on the borderline of possible hepato-toxicity.",0
She received IV acetylcysteine load followed by 20 hour drip.,0
LFTs and acetaminophen levels were trended q8h until acetaminophen level undetectable.,0
LFTs remained normal and INR peaked at 1.2.,0
"With regard to other ingestions, she would have theoretically received 2500 mg of diphenhydramine.",0
This likely accounted for positive TCA screen.,0
"QRS was , the bicarbonate drip was stopped in the ED.",0
QRS duration was monitorred q1h for the first twelve hours and remained <100 ms .,0
The patient was easily extubated several hours after admission to the ICU.,0
Psychiatry was consulted the following day.,0
The patient was transferred to the floor following extubation.,0
On the floor she had tachycardia which was improved with fluid boluses.,0
"She had a fever on transfer however, this resolved after getting a fluid bolus.",0
"Given that the patient was tachycardic, and had episodes of temperature above 100, and a history of non-compliance with hyperthyroid medication, the patient had an endocrine consult placed.",0
She had no sequelae of acetaminophen and diphenhydramine overdose with normal exam and flat LFTS throughout admission.,0
# Suicidal Ideation: The overdose clearly a suicide attempt as the patient admits as well as evidenced by the suicide note that she left.,0
Psychiatry saw the patient and recommended that she be admitted for inpatient psychiatry .,0
She was placed on a 1:1 sitter and bed search began.,0
There were no medical contraindications to being admitted to an inpatient psychiatric facility.,0
"# Thyroid: Upon extubation, the patient stated that she had previously been on methimazole and that she had stopped this on her own for unclear reasons.",0
TSH was checked as was <.02.,0
Given that on the floor she had a elevated temperature as well as tachycardia she had an endocrine consult placed.,0
Endocrine recommended obtaining full thyroid panel which was obtained.,0
The panel came back unremarkable except for the antiTPO which had not resulted.,0
Endocrine team w/ attending saw patient determined that this was subclinical hyperthyroidism and that the patient was certainly not in thyroid storm.,0
The endocrine team did not recommend starting any medication and only warranted an outpatient radioiodine uptake test.,0
Medications on Admission: None Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.,0
Discharge Disposition: Extended Care Discharge Diagnosis: acetaminophen/diphenhydramine overdose suicidal ideation urinary tract infection Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were seen and evaluated for your tylenol pm overdose as well as your suicide attempt.,0
For your tylenol pm overdose you were given a medication which prevented any damage to your liver.,0
You remained stable throughout your hospital admission.,0
The psychiatrist saw you and recommended that you be admitted to an inpatient psychiatric facilty for further care.,0
Call your doctor or return to the Emergency Department right away if any of the following problems develop: * You feel unsafe.,0
"* You done something to harm yourself or someone else, or are afraid you might.",0
* You develop new or different symptoms that worry you.,0
You were seen by the endocrine doctor and found to not need any further intervention for your hyperthyroidism in the intpatient.,0
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR FOR A RADIOACTIVE IODINE UPTAKE TEST.,0
Please also follow up with your primary care doctor for your urinary tract infection.,1
You were given an antibiotic for it to continue for 7 days.,0
Followup Instructions: Please follow up with your primary care doctor in days after discharge from your psychiatric facility.,0
"PLEASE WHEN YOU FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR, HAVE LIVER FUNCTION TESTS DRAWN.",0
Please follow up with your outpatient psychiatric provider days after discharge from your psychiatric facility.,0
"9:29 AM CHEST (PORTABLE AP) Clip # Reason: assess for ptx Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p ct removal REASON FOR THIS EXAMINATION: assess for ptx ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Chest tube removal, assess for pneumothorax.",0
Small right pneumothorax is not longer visualized.,0
Right subcutaneous emphysema is improved.,0
Post-operative mediastinal widening is unchanged.,0
Continuously improving bilateral opacities that are greater on the right lower lobe.,0
Right IJ catheter tip and NG tube remain patent.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: Fever, headache Major Surgical or Invasive Procedure: Right IJ CVL placement History of Present Illness: Ms. is a 57yo F with depression and osteopenia who presented to the ED with HA and fever.",0
She started gfeeling poorly on Monday with a sore throat.,0
"On Tuesday and Wednesday, she began to feel more SOB, like her asthma was flaring, and a cough developed.",0
She has been using her albuterol 3xs/day with no relief.,0
The cough is wet but non-productive.,0
Diffuse body aches also developed.,0
Fever and HA developed today.,0
"The HA is similar to her prior migraines, associated with mild photophobia.",0
"Of note, her daughter and grandchildren may have been sick with something similar recently.",0
"In the ED, initial VS were: T 102.5, HR 115, BP 117/74, RR 24, sat 95% 3L NC.",0
She was noted to be tachycardic and dry-appearing in the ED.,0
"Initially BP was in the 110s, but decreased to the 80s during her ED course.",0
She was given 1g CTX and 500mg azithro to cover for CAP.,0
"Due to hypotension, R IJ CVL was placed, and she got a total of 4L IVF.",0
She was started on norepi prior to transfer.,0
"While in the ED, she was also given acetaminophen, Zofran, KCl repletion (40mEq po), and morphine IV.",0
"On arrival to the MICU, patient's VS: T 100.4, HR 117, BP 125/73 on 0.14mcg levophed, 93% RA Review of systems: (+) Per HPI (-) Denies constipation, abdominal pain, diarrhea, dark or bloody stools.",0
Past Medical History: asthma pulmonic stenosis (mild on echo in ) osteopenia R rotator cuff tear/impingement depression (psychiatrist at ) migraines Social History: No alcohol or tobacco.,1
"She is married, but separated and is currently on disability.",0
She has 2 adult children and currently lives with her son.,0
CXR: IMPRESSION: Left lower lobe and lingular pneumonia with background interstitial edema.,0
"Pulmonary hypertension, but no evidence of acute or chronic pulmonary emboli.",0
"Residual, multifocal edema or pulmonary hemorrhage.",1
Left lower lobe pneumonia or segmental atelectasis.,0
"Segmental and subsegmental bronchial lumens occluded by debris, not by mass.",0
Lymph node enlargement restricted to the contralateral (right) hilus and paratracheal mediastinal stations.,0
No evidence of cardiac tamponade or constrictive pericarditis.,0
Bronchoscopy Airways were visualized to the sub-segmental level bilaterally.,0
There were no endobronchial lesions.,0
LLL had retained mucus noted on inspection.,0
Edematous airway that are easily collapsable.,0
No active signs of bleeding or airway irregularities noted.,0
"Brief Hospital Course: 57yo F with depression, asthma, and osteopenia who p/w fever, HA, and cough found to be septic in the ED with LLL PNA on CXR and history of antecendent ILI.",1
"# PNA, septic shock: Met SIRS criteria with fever, tachycardia, and leukopenia with pressor requirement in ICU, Bacterial PNA as presumed source of her sepsis.",1
"Given Hx and sick contacts, her illness likely began as a viral influenza-like illness, and she appears to have developed a super-imposed PNA.",0
"No recent hospitalizations or other healthcare exposures, so CAP treatment is appropirate.",0
Vancomycin also added given hypotension and potential for MRSA superinfection with influenza.,0
"Pt began to have Sx > 72 hours PTA, so no role for Tamiflu.",0
"Patient was volume rescusitated, started on norepinephrine, and admitted to ICU.",0
"Norepinephrine weaned off, and she remained hemodynamically stable.",0
CTX/azithro/vanc was started for CAP and MRSA coverage.,0
"Sputum Cx, blood culture, urine legionella, viral swabs for flu, paraflu, adenovirus were negative.",0
Patient was started on fluticasone inhaler in place of home budesonide (nonformulary).,0
"She was also started on standing ipratroprium nebs, albuterol PRN, and morphine PRN dyspnea/pleuritic CP.",0
"She had hemoptysis for several days after admission, so the pulmonary team saw her in consultation.",0
"They performed a bronchoscopy that was unremarkable, and sent bronchoscopy brushings that are pending.",0
"She received 8 days of antibiotics for pneumonia and felt better, ending on .",0
She also received a 5d burst of steroids from some wheezes and pleuritis.,0
On discharge she was able to breathe comfortably on room air and had no evidence of wheezes.,0
#Hemoptysis: Probable cause include pneumonia.,0
In the ICU she had one episode of hemoptysis.,0
"Negative rheum studies including , anca, anti-gbm, negative BAL micro studies.",0
Has a history of pulmonic stenosis which may be contributing feature to hemoptysis.,0
"TTE done on showed normal EF and RV function with moderate PS, mild PR.",0
Pulmonology recommends outpatient f/u with potential RHC in the future.,0
Cytology from BAL showed atypical cells with the following path report: Bronchial lavage: ATYPICAL.,0
Many crowded groups of very atypical epithelial cells in a background of macrophages - highly reactive type II pneumonia versus well-differentiated adenocarcinoma.,0
Given active pneumonia it was felt that adenocarcinoma was unlikely.,0
I communicated with her pulmonologist to confirm this assessment and ensure she does not need further BAL or biopsy.,0
"# HA: Per pt, pain is c/w prior migraine HA, which could have been brought on by illness.",0
CT head in ED negative.,0
"Received supportive care with a combination of tylenol, nsaids, and oxycodone.",0
No focal neurological findings and no meningismus.,0
"Pain control moderate on discharge, but patient advised to try and limit opiate use to prevent rebound headache.",0
# GERD: Home PPI was continued.,0
"#She had periods of sinus tachycardia with HR in the 100s, at times wiht palpitations.",0
I communicated with her PCP who said clinic HR values were in the 100s before.,0
PE was not felt to cause this as she had negative CTA chest during ICU stay and no further hypoxia with treatment of pneumonia Discharge Medications: 1.,0
Omeprazole 40 mg PO BID 2.,0
Quetiapine Fumarate 200 mg PO HS 3.,0
Acetaminophen 650 mg PO Q4H:PRN pain 4. albuterol sulfate *NF* 90 mcg/actuation Inhalation PRN 5.,0
Budesonide *NF* 160 mcg INHALATION 6.,0
OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 8.,0
Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 10ml Suspension(s) by mouth four times a day Disp #*1 Bottle Refills:*0 9.,0
"Calcium Carbonate 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Bacterial pneumonia Hemoptysis Gastritis/GERD Pulmonic Stenosis, moderate (chronic) Discharge Condition: Mental Status: Clear and coherent.",1
Discharge Instructions: You were admitted with a pneumonia.,0
"You were coughing a concerning amount of blood initially, so you had a CT scan of the chest and a bronchoscopy to look for causes of bleeding.",0
It seemed most likely that this was from the pneumonia.,0
You completed a 7 day course of antibiotics for pneumonia.,0
You felt better on discharge.,0
You were also restarted on your medication for gastritis.,0
"You had stopped taking this at home because your abdominal pain had improved, but during this hospitalization it worsened, so we restarted it.",0
We also restarted a medication that coats the stomach called sucralfate.,0
You can continue to take this.,0
"TRANSITIONAL []PULMONARY F/U []R HEART CATH PER PULM FOR PULMONIC STENOSIS Followup Instructions: Name: , Location: HEALTH CARE - ADULT MEDICINE Address: 1000 , , Phone: *We are working on a follow up appointment for your hospitalization with your primary care provider.",0
need to be seen within 1-2 weeks of discharge.,0
The office will contact you at home with an appointment.,0
If you have not heard within 2 business days please call the office at the above number.,0
"Department: ADULT MEDICINE When: MONDAY at 11:00 AM With: , MD Building: (, MA) Campus: OFF CAMPUS Best Parking: Parking on Site",0
"6:50 PM PORTABLE ABDOMEN Clip # Reason: assess for dilated loops of bowel, free abdominal air, evide Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;FEVER;NEUTROPENIA;R/O TOOTH INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 63 y.o.",1
"female with AML, 88% blasts, with liver abscess and worsening abdominal pain/tenderness REASON FOR THIS EXAMINATION: assess for dilated loops of bowel, free abdominal air, evidence of perforation ______________________________________________________________________________ FINAL REPORT INDICATION: 63-year-old female with AML and liver abscess with worsening abdominal pain.",1
COMPARISON: Abdominal radiograph and CT abdomen and pelvis .,0
SINGLE SUPINE ABDOMINAL RADIOGRAPH: The hemidiaphragms are not included on the field of view.,0
There are mildly dilated loops of small bowel measuring up to 3 cm.,0
"Air and stool is seen throughout the colon, with residual contrast in the colon from recent CT scan.",0
There is no definite evidence of obstruction or free intraperitoneal air.,0
Right convex scoliosis of the lower lumbar spine is noted.,0
IMPRESSION: Mildly dilated loops of small bowel with no definite evidence of obstruction.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: GENERAL SURGERY COMPLICATIONS: Myocardial infarction and death.,1
HISTORY OF PRESENT ILLNESS: This patient is a 49 year-old male who had no significant past medical history except for chronic renal insufficiency and hypertension who was transferred from an outside hospital after sustaining a hemorrhagic stroke in the left basal ganglia causing symptoms of right hemiplegia on .,1
He was admitted to the Neurology Service for management of his hemorrhagic stroke.,0
"Subsequently his renal insufficiency worsened and he subsequently went into renal failure, which required hemodialysis.",1
Over the following week and a half he was managed on multiple antihypertensive regimens in the Intensive Care Unit and was stabilized and transferred to the floor on .,0
"He was receiving prophylaxis, stress peptic ulcer prophylaxis on Protonix.",0
"On , the patient complained of acute abdominal pain during dialysis and an upright chest x-ray was obtained.",0
He was noted to have free air and was brought to the Operating Room emergently.,0
He was found on exploration to have a perforated sigmoid colon secondary to diverticulitis with an abscess.,1
The patient was resected and immediately after his resection he suffered a cardiac arrest and developed PEA on the Operating Room table.,0
His abdomen was closed rapidly without maturation of his colostomy and he was brought to the Intensive Care Unit on pressors for resuscitation.,0
He ruled in for a massive myocardial infarction with peak troponins over 5 and CKMBs over 1000.,1
"The plan had been to return him to the Operating Room for completion of his colostomy, however, given that his cardiac status was so severe after consultation with cardiology consult we decided to wait until the following day before taking him back to the Operating Room given the stress to his heart.",1
"However, on postop day number three the day we had planned on returning him to the Operating Room for his colostomy, he suffered another cardiac arrest.",0
He was given multiple intravenous medications and ACLS protocol was initiated.,0
He was coded for approximately thirty minutes before expiring.,0
Autopsy revealed death caused by acute myocardial infarction.,1
Dictated By: MEDQUIST36 D: 17:04 T: 11:45 JOB#:,0
8:44 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: NGT position Admitting Diagnosis: STROKE/TIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with NGT REASON FOR THIS EXAMINATION: NGT position ______________________________________________________________________________ FINAL REPORT AP CHEST 8:51 P.M. HISTORY: Check NG tube position.,0
IMPRESSION: AP chest compared to 7:57 p.m.: NG tube has been advanced but still loops at the gastroesophageal junction with the tip in the lower esophagus.,0
It should be advanced at least 9 cm to move all side ports into the stomach.,0
"Hyperinflation suggests COPD, and the cardiac silhouette, left atrial enlargement.",0
Minimal pulmonary edema is present accompanied by increasing small left pleural effusion.,0
Pleural parenchymal scarring is probably responsible for opacification at the lung apices.,0
"5:14 PM CHEST (PORTABLE AP) Clip # Reason: TRAUMA , PT PINNED UNDER VEHICLE ______________________________________________________________________________ WET READ: SPfc 10:24 PM NGT ends at the GE junction and needs to be advanced.",0
"Also, the ETT ends 9.3cm and should be advanced by ~4cm.",0
A right mid-clavicular fracture is noted.,0
Further details are found in the report of the subsequent CT study from the same day.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 5:14 P.M. HISTORY: Trauma.",0
"IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Generalized interstitial abnormality suggests mild edema, but more focal consolidation at the periphery of the left lung could be extensive contusion.",0
"There is no definite pneumothorax, though anterior pleural air is easily missed on the supine view, and no indication of pleural effusion.",1
ET tube is several centimeters above the upper margin of the clavicles and should be advanced 5 cm for standard placement.,0
"Similarly, the nasogastric tube would need to be advanced 10 cm to move all the side ports into the stomach.",0
"This study is not designed for evaluation of subtle bony trauma, except to note an overriding fracture in the mid portion of the right clavicle.",1
"11:40 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for SBO, transition point.",0
"PO and IV contrast please Admitting Diagnosis: ABDOMINAL PAIN Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with non-resolving SBO REASON FOR THIS EXAMINATION: eval for SBO, transition point.",0
PO and IV contrast please No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): IPf FRI 7:02 PM PFI: High-grade partial small-bowel obstruction.,0
"It is difficult to locate the transition point but is in the right lower quadrant, in the ileum.",0
"There is abdominal wall hernia on the left, but that is not site of obstruction since we see dilated small-bowel loops above and below the hernia.",1
"______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate for small-bowel obstruction, transition point.",0
Patient has persistent small-bowel obstruction.,1
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with contrast.,0
Coronally and sagittally reformatted images were displayed with 5-mm slice thickness.,0
COMPARISON: There is no previous CT for comparison.,0
There is an abdominal radiograph from .,0
"FINDINGS: There are bilateral pleural effusions, with adjacent atelectasis at the right lung base.",0
There are post-surgical changes at the level of esophageal diaphragmatic hiatus from previous laparoscopic hernia repair.,1
"There is significant dilatation of the small bowel, indicating small-bowel obstruction.",0
"It is hard to define where exactly the transition point is, but it is distal and it is in the right lower quadrant, in the ileum.",0
"There is contrast whitin the below after the obstruction point, indicated partial but high- grade obstruction.",0
"There is a hernia in the lateral left abdominal wall containing part of the small bowel, but this hernia is not causing the obstruction since we do see dilated bowel loops below and above the site of hernia.",1
The oral contrast was administrated on for barium esophagus study.,0
There is no evidence of small-bowel wall ischemia.,0
The large bowel is compressed from the small-bowel obstruction bowel loops.,0
The liver appears within normal limits.,0
"The gallbladder is distended, but there is no evidence of cholecystitis.",0
The stomach is distended but within normal limits.,0
"There is a small hypodense area in the spleen, too small to differentiate, 2:20.",0
The pancreas is within normal limits.,0
"(Over) 11:40 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for SBO, transition point.",0
"PO and IV contrast please Admitting Diagnosis: ABDOMINAL PAIN Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) There is a large cystic lesion in the left kidney, 2:17 measuring 41 x 54 mm.",0
"There is a smaller cyst in the left kidney, 2:18 measuring 5 x 4 mm.",0
"There is a small hypodense area in the right kidney, 2:21, too small to characterize.",0
There is no mesenteric or retroperitoneal lymphadenopathy present.,0
There is no free air in the abdominal cavity.,0
There is calcification of the vessels.,0
There are degenerative changes in the thoracolumbar spine.,0
We are not able to clearly identify the transition point but likely is in ileum in the right lower quadrant.,0
There is no evidence of bowel ischemia.,0
There is left lateral abdominal wall hernia containing small .,1
This is not the site of obstruction.,0
Large renal cyst in the right kidney.,0
Bilateral plural effusions with adjacent atelectasis at the lung bases.,0
Results were discussed with Dr. .,0
"7:05 PM CT C-SPINE W/O CONTRAST Clip # Reason: eval for fx Admitting Diagnosis: S/P RIGHT CRANIOTOMY ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with fall and iph, needs c spine clearance REASON FOR THIS EXAMINATION: eval for fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: FXKd SUN 7:46 PM No recent acute fracture in the C-Spine.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 73-year-old male with large right intraparenchymal hemorrhage.,1
To rule out C-spine injury.,0
"TECHNIQUE: CT of the neck was performed without intravenous contrast as a followup study of a CTA of the brain, therefore there is some contrast seen in the dural venous sinuses in the brain.",0
"Reconstructions were performed in the axial, sagittal and coronal planes.",0
COMPARISON: There is no relevant prior imaging for comparison.,0
FINDINGS: There are multilevel degenerative changes present in the C-spine.,0
There is an ET tube and an OG tube seen in situ.,0
There are multiple low attenuation foci within the left lobe of the thyroid gland.,0
"There are multilevel degenerative changes present in the cervical spine, with most marked changes present at C4-C5, C5-C6, C6-C7 and C7-T1 levels.",0
The vertebral alignment is intact.,0
The soft tissues within the neck are unremarkable.,0
There is an old avulsion injury versus calcification of the ligamentum nuchae at the tip of the spinous process of C7.,0
"No recent acute fracture, with multilevel degenerative changes present throughout the cervical spine as described above.",0
Indeterminate low attenuation foci in the left lobe of the thyroid gland can be assessed further with a dedicated thyroid ultrasound.,0
"11:50 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please comment on interval changes Admitting Diagnosis: BILIARY CIRRHOSIS; ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with hepatic hydrothoax s/p right sided thoracentesis REASON FOR THIS EXAMINATION: please comment on interval changes ______________________________________________________________________________ FINAL REPORT INDICATION: 69-year-old female with hepatic hydrothorax status post right-sided thoracentesis, here to re-evaluate for interval changes.",1
COMPARISON: Chest radiograph performed earlier the same day at 10:06 a.m. PORTABLE FRONTAL CHEST RADIOGRAPH: A small right apical pneumothorax is new from 10:06 a.m.,0
The Dobbhoff feeding tube previously coiled in the neck has been removed since the preceding radiograph.,0
A right-sided PICC line is unchanged in position with the tip terminating at the cavoatrial junction.,0
"The previously large right pleural effusion is substantially decreased in size, now with small residual pleural fluid in the right hemithorax consistent with therapeutic thoracentesis.",0
A small left pleural effusion is unchanged with associated atelectasis.,0
No pulmonary vascular engorgement is present.,0
The cardiomediastinum silhouette is stable and within normal limits.,0
The aortic knob is partially calcified.,0
New small right apical pneumothorax.,0
"Decreased size of right pleural effusions, status post thoracentesis with small residual pleural fluid.",0
Stable small left pleural effusion.,0
Findings were communicated by Dr. to Dr. by phone at 14:05 p.m. on .,0
"5:06 AM CHEST (PORTABLE AP) Clip # Reason: e/f pneumonia Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man s/p MCC, with suspected aspiration pneumonia REASON FOR THIS EXAMINATION: e/f pneumonia ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 32-year-old man status post trauma with suspected aspiration pneumonia.",0
"FINDINGS: In comparison to the prior examination, the ET tube and subclavian line are in unchanged, correct position.",0
"At the right lower lung, there is an increase in the opacities seen on the prior study.",0
The left lung atelectasis appears improved since prior study.,0
IMPRESSION: Increasing right lower lobe opacities consistent with aspiration/infection.,0
"4:53 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W&W/O C Reason: Please evaluate for aortitis and interval change in ascites Admitting Diagnosis: EPIDURAL ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with enterococcal bacteremia, ostemyelitis at multiple levels of spine, and question of infrarenal and ascending aortitis on prior study REASON FOR THIS EXAMINATION: Please evaluate for aortitis and interval change in ascites No contraindications for IV contrast ______________________________________________________________________________ WET READ: MNIa FRI 6:57 PM Overall unchanged soft tissue around the ascending aorta and arch, mesuring up to 50 on post contrast (and 70-80 on precontrast, however the measurement on the precontrast is somehwat limited due to artifact and calcification), which can represent aortitis.",0
Associated fluid in the pericardial reecss can be present.,0
"Given the limited precontrast scan ,it is difficult to exclude intramural hmatoma, however, density on the post ontrast scan is somewhat low for hematoma.",0
"Unchanged wall thickening and fatstranding at the infrarenal aorta suspicious for aortitis, unchanged.",0
"pericardial effusion,bilateral pleural effusion with atelectasis again seen.",0
"Destructive changes of thoracolumbar spine centered at L2/3, representing osteomyelitis/diskitis as mentioned in the history.",1
Official read awaita for 3D reformats.,0
"d/w Dr. , at 6:45 PM.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 66-year-old male with enterococcal bacteremia, osteomyelitis of spine and question of infrarenal and ascending aortitis on prior study.",0
To assess the presence and extent of aortitis.,0
"TECHNIQUE: CT of the chest, abdomen and pelvis was performed pre- and post- administration of intravenous contrast, reconstructions were performed in the axial, sagittal, and coronal planes.",0
3D imaging was performed in the imaging lab.,0
FINDINGS: CT CHEST PRE- AND POST-ADMINISTRATION OF INTRAVENOUS CONTRAST: There are large bibasilar effusions present.,0
There is passive atelectasis of the lower lobes and the right middle lobe.,0
The remaining aerated upper lobes are unremarkable.,0
There are several scattered subcentimeter mediastinal lymph nodes.,0
There is a left-sided central venous line with the tip in the right atrium.,0
There is a pericardial effusion noted.,0
"CT ABDOMEN PRE- AND POST-ADMINISTRATION OF INTRAVENOUS CONTRAST: (Over) 4:53 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W&W/O C Reason: Please evaluate for aortitis and interval change in ascites Admitting Diagnosis: EPIDURAL ABSCESS ______________________________________________________________________________ FINAL REPORT (Cont) The study is limited due to scanning only in the early arterial phase.",0
"Within these limitations, there is focal enhancing nodule in the gallbladder in the region of its base, which is likely a polyp (image 126, series 3).",0
"There are two subcentimeter hypodense foci in the right kidney, likely cysts.",0
"The liver, spleen, adrenal glands, pancreas, and left kidney appear unremarkable.",0
CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: There is free fluid present in the pelvis.,0
There is diverticular disease present in the colon without evidence of diverticulitis.,0
"There is a urinary catheter noted within the bladder with pockets of air within it, likely representing recent instrumentation.",0
MUSCULOSKELETAL: There is extensive stranding in the subcutaneous tissues with anasarca and fluid present on the right side and is likely positional.,0
There is destruction of the disc space at L2-3 level with erosion of the adjacent vertebral endplates likely representing the site of infection.,0
There are degenerative changes present at L4-5 and L5-S1 vertebral levels with sclerosis of the adjacent endplates suggestive of disc degeneration at these levels.,0
CT ANGIOGRAM: The ascending aorta at the level of the right main pulmonary artery measures 36.1 x 34.5 mm and the descending aorta at the level of the left inferior pulmonary vein measures 27.9 x 26.3 mm.,0
Ther is an old infarct at the apex of the left ventricle with a borderline aneurysm.,0
"There is hypoenhancemnt of the anterior, lateral and septal subendocardium.",0
"There is enhancing soft tissue rind surrounding the ascending aorta, likely unchanged since the prior examination.",0
This may represent thickening of the wall versus abutting soft tissue.,0
This abnoramlity is in the region of the prior CABG and may be related to prior surgery.,0
There are several subcentimeter mediastinal lymph nodes.,0
The appearances could represent aortitis.,0
Extensive atherosclerosis is present in the coronary arteries and the left and right coronary artery arise from the normal anatomical locations.,1
A pericardial effusion is noted.,0
"(Over) 4:53 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W&W/O C Reason: Please evaluate for aortitis and interval change in ascites Admitting Diagnosis: EPIDURAL ABSCESS ______________________________________________________________________________ FINAL REPORT (Cont) There is haziness and stranding around the infra-renal aorta which does not enhance to the same extent as the aortic wall/ soft tissue in the proximal aorta and may represent dormant/old aortitis.",0
"The celiac artery, superior mesenteric artery and inferior mesenteric artery are patent.",0
There is a single right renal artery and a single left renal artery.,0
The renal arteries are patent with minimal atherosclerosis and calcific plaque at the origin of the renal arteries.,0
Enhancing assymetric wall thickening of the ascending aorta consistent with aortitis unchanged from CT.,0
Mild inflammation and possible subtle wall thickening and enhancement adjacent L2-L3 discitis and osteomyelitis is also concerning for mild focal aortitis.,0
Extensive atherosclerosis and calcific plaques are noted in the coronary arteries and the abdominal aorta.,1
Old apical cardiac infarct with small focal aneurysm and hypoenhancing subendocardium.,0
Destruction of the disc space and adjacent vertebral endplates at L2-3 consistent with discitis and osteomyelitis of indeterminate activity.,0
Enhancing soft tissue nodule in the gall bladder.,0
Correlation with ultrasound once the patients condition improves is recommended.,0
Large bibasilar effusions along with passive atelectasis of the right middle and both lower lobes.,0
Extensive anasarca with fluid in the tissue planes most marked on the right side of the body and small pelvic ascites.,0
Recent liver transplant with SVT.,0
Height: (in) 66 Weight (lb): 187 BSA (m2): 1.95 m2 BP (mm Hg): 166/83 Status: Inpatient Date/Time: at 15:14 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
There is left ventricular hypertrophy.,0
"There is moderate to severe regional left ventricular systolic dysfunction with anterior, anteroseptal, apical, and lateral hypokinesis/akinesis.",0
No apical thrombus seen (cannot exclude).,0
There is significant pulmonary artery systolic hypertension.,0
"Compared with the prior study of , left ventricular systolic dysfunction is new.",0
PATIENT/TEST INFORMATION: Indication: Left ventricular function Height: (in) 69 Weight (lb): 190 BSA (m2): 2.02 m2 BP (mm Hg): 104/72 HR (bpm): 118 Status: Outpatient Date/Time: at 14:11 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Small LV cavity.,0
No MS. TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
Conclusions: The left ventricular cavity is small.,0
The right ventricular cavity is small.,0
"Compared with the findings of the prior study (images reviewed) of , the heart rate is increased; otherweise no major change.",0
3:43 AM CHEST (PORTABLE AP) Clip # Reason: ETT PLACEMENT Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess ET tube.,0
"ET tube tip is in standard position, 4.7 cm above the carina.",0
Left central line tip is in the lower SVC.,0
Moderate pulmonary edema is new.,0
There is no evident pneumothorax or large pleural effusions.,0
"5:54 AM CHEST (PORTABLE AP) Clip # Reason: DESAT Admitting Diagnosis: TYLENOL OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: 22 year old woman intubated for airway protection, rhabdo, acet od.",0
"now desaturating REASON FOR THIS EXAMINATION: r/o aspiration ______________________________________________________________________________ FINAL REPORT 22 year old woman with shortness of breath, intubated, now desaturation, question of aspiration.",0
"CHEST film shows persistent bilateral patchy parenchymal densities in the upper lobes, which would be consistent with aspiration pneumonia.",0
The heart is not enlarged and the pulmonary vasculature that is underlying appears to be within normal limits.,0
CONCLUSION: Upper lobe patchy parenchymal density suggesting aspiration.,0
1:53 AM CHEST (PORTABLE AP) Clip # Reason: R/O aspiration.,0
"Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with possible stroke, r/o aspiration., REASON FOR THIS EXAMINATION: R/O aspiration.",0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 2:11 A.M. HISTORY: Possible stroke, rule out aspiration.",0
IMPRESSION: AP chest compared to : Previously pulmonary vascular congestion and borderline interstitial edema were evenly distributed throughout both lungs.,0
"On today's examination, somewhat exaggerated by anti-lordotic positioning, there is greater opacification at both lung bases, particularly the right.",0
"This could be the early appearance of dependent edema but given the history, aspiration pneumonia is certainly reasonable.",1
Heart is mildly enlarged but unchanged.,0
Vascular congestion in the upper lobes has not improved.,0
"Pleural effusions are small if any, more likely on the left than the right.",0
7:24 AM CHEST (PORTABLE AP) Clip # Reason: please assess for change from prior or for presence of new i Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with ESRD presented with SOB hypoxia - being treated for ESBL E. COLI pna REASON FOR THIS EXAMINATION: please assess for change from prior or for presence of new infiltrates in pt.,1
"sputum ctx, septic shock ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 54-year-old male with end stage renal disease with shortness of breath and hypoxia.",1
Please evaluate for change from prior or presence of new infiltrates.,0
FINDINGS: There has been no significant change from prior examination dated .,0
"The endotracheal tube, right subclavian central line and NG tube are unchanged in position.",0
There is persistent mild interstitial edema.,0
The left basilar consolidation is unchanged.,0
No significant pleural fluid is appreciated.,0
Cardiomediastinal silhouette is within normal limits.,0
IMPRESSION: No significant change from prior examination dated .,0
"10:54 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: evaluate for obstruction Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with lymphoma s/p ESHAP now with abdominal distension, no pain REASON FOR THIS EXAMINATION: evaluate for obstruction ______________________________________________________________________________ FINAL REPORT INDICATION: History of T-cell lymphoma, status post chemotherapy, radiation therapy and salvage chemotherapy, history of C-section, now with abdominal distention.",0
"SUPINE AND LEFT LATERAL DECUBITUS ABDOMINAL RADIOGRAPHS: Air-filled, distended loops of large bowel with multiple air-fluid levels are identified.",0
Air is seen to the level of the rectum.,0
There is no evidence of small bowel dilation.,0
No free intraperitoneal air is clearly identified.,0
IMPRESSION: Distended air-filled colon with air-fluid levels.,0
The differential includes low colonic obstruction with a competent ileocecal valve or a functional dilated colon.,0
", J. NSURG SICU-A 8:36 PM CT HEAD W/O CONTRAST Clip # Reason: ro stroke Admitting Diagnosis: CEREBRAL ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with REASON FOR THIS EXAMINATION: ro stroke No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No interval change from one day prior.",1
Stable small likely postoperative right extra-axial hematoma.,1
Slight interval increase in air-fluid level within the right sphenoid sinus which is likely related to intubated status.,0
PATIENT/TEST INFORMATION: Indication: BjorkShiley AVR with Bentall.,0
Positive blood cultures and septic emboli.,0
?vegetations Height: (in) 64 Weight (lb): 130 BSA (m2): 1.63 m2 BP (mm Hg): 98/70 HR (bpm): 130 Status: Inpatient Date/Time: at 17:00 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
AORTIC VALVE: Single tilting disk type aortic valve prosthesis (AVR).,0
Results were reviewed with the Cardiology Fellow involved with the patient's care.,0
"Left ventricular wall thicknesses and cavity size are normal with mild global hypokinesis and akinesis of the distal inferior, septal and anterior walls.",0
An aortic graft is identified with surrounding native aorta with no flow in the space anterior to the graft.,0
A single tilting disk type aortic valve prosthesis is present.,0
Trace aortic regurgitation is seen [may be normal for this prosthesis].,0
IMPRESSION: Normal functioning aortic prosthesis.,0
Mild global left ventricular hypokinesis (?rate related) with apical aneurysm.,0
No discrete vegetation is identified.,0
"If clinically indicated, a TEE would be better able to identify possible vegetations on the prosthetic aortic valve, in the aortic root, or on the pacing leads.",0
Preop evaluation of LV function Status: Inpatient Date/Time: at 10:08 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.,0
LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Moderately dilated RV cavity.,0
Conclusions: Prebypass: No spontaneous echo contrast is seen in the left atrial appendage.,0
There is critical aortic valve stenosis (valve area 0.5-0.6cm2).,1
Postbypass: There is preserved biventricular systolic function.,0
The TR now appears moderate.,0
Remaining study is unchanged from the prebypass exam.,0
"PATIENT/TEST INFORMATION: Indication: status post cardiac arrest Height: (in) 67 Weight (lb): 271 BSA (m2): 2.30 m2 BP (mm Hg): 135/64 HR (bpm): 84 Status: Inpatient Date/Time: at 10:18 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Optison Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",0
"Significant AS is present (not quantified) PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded.",0
"Conclusions: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded.",0
Aortic stenosis is present (not quantified).,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Lisinopril / Atorvastatin Attending: Chief Complaint: MS changes and seizure Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 70 year old woman with a history of hypertension, diabetes, dementia, CRI (1.8) who was recently discharged from the neurology service with a large temporo-parietal bleed in the setting of Lovenox now presenting from nursing home with mental status changes and possible seizure activity.",1
Believed that ICH was secondary to amyloid angiopathy and that surgical intervention would be in vain.,0
"Pt transferred to rehab on seizure prohphlaxis, but apparently was seizure free during initial hospitalization.",0
Pt transitioned from rehab to nursing home yesterday.,0
"Pt unable to provide history and there is no documentation of event, however, per EMS report they witnessed tonic-clonic activity.",0
"Review of Systems: unobtainable Past Medical History: -left temporo-parietal bleed -amyloid angiopathy -CKD (1.8) -diabetes ""labile"" -hypertension -CHF (unknown EF) -h/o hyperkalemia -depression -asthma/copd -peripheral neuropathy -dementia -s/p trach Social History: -resident of Home -no recent history of smoking or alcohol use Family History: -unobtainable Physical Exam: Physical Exam: Vitals: 98.9, 68, 160/71, 77, 98% RA General: Comfortable, NAD, does not respond to voice, shaking or sternal rub HEENT: pinpoint pupils, OP wnl Neck: supple, Lungs: CTAB anteriorly CV: regular rate and rhythm, s1/s2, no M/R/G Abdomen: soft, non-tender, non-distended, NA-bowel sounds present, GTube in place Ext: warm/dry, no edema Neurologic Examination: Patient does not respond to voice, shaking or sternal rub.",0
Patient not able to cooperate with neuro exam.,0
head CT : IMPRESSION: 2.8 x 2.2 cm rounded focus at the site of prior intraparenchymal hemorrhage.,0
"There is surrounding decreased attenuation, consistent with edema or malacia.",0
"While this could represent resorbing hematoma, this appearance is concerning for a mass lesion and further evaluation could be obtained .",0
"CXR : Opacity in the right middle lobe, not present on the previous study.",0
Findings represent aspiration and/or pneumonia .,0
There is moderate pulmonary artery systolic hypertension .,0
"Slight improvement in patchy right infrahilar opacity, which may be due to improving asymmetrical edema, focal atelectasis or pneumonia.",0
Persistent mild congestive heart failure.,1
Right infrahilar opacity is stable and may represent asymmetric edema or may be due to aspiration.,0
"EKG : Normal sinus rhythm, rate 70.",0
Compared to the previous tracing of probably no significant change.,0
CXR IMPRESSION: No evidence of congestive heart failure or pneumonia.,1
"Brief Hospital Course: 70 year old female w/ h/o HTN, diabetes, dementia, CRI, and recent temporo-parietal bleed presented with MS changes likely secondary to seizure, c/b acute renal failure.",1
# Neuro/Resp: Patient was admitted with seizures likely d/t temporo-parietal ICH with possible mass on CT. Was seen by neurology in the ER and loaded on dilantin and started on keppra.,0
"Tox-Met workup performed and was negative (negative serum and urine tox screen, neg.",0
"It was felt that the patient would benefit from additional imaging of mass to differentiate resolvind hematoma from other mass, but this was not able to be performed because patient was unable to tolerate MRI at any point d/t continued agitations hospital stay.",0
"Patient was on and off agitated throughout her hospital course, and a variety of antipsychotics including olanzapine, risperidone, seroquel, and eventually haldol were used.",0
"The patient required level II restraints for the majority of her hospitalization, renewed daily.",0
"Psychiatry was consulted, followed the patient, and made recommendations.",0
"A FM was used for a couple of days to maintain O2 saturations, but this was stopped for fear of decreasing resp drive and an increasing PCO2 (ABG showed pH 7.38/86/80, due to metabolic acidosis with significant chronic renal compensation).",1
"Patient was transferred to MICU on for bradycardia, hypotension, and hypoxia.",0
Cause unclear although there was some concern for seizure.,0
"(Patient had initially had evidence of PNA on CXR and this was treated with 14 days of abx, but the opacity cleared after two days and it was unclear if she actually had PNA).",0
Episode resolved on its own without intervention.,0
Thought to be d/t cenrally mediated process.,0
CT of head unchanged with no new bleed or mass effect.,0
Cardiology consulted and found no evidence of structural heart disease or conduction delay.,1
"A breast mass was found on exam in MICU, raising concern for etiology of head mass.",0
Plan was to work this up further once patient more stable.,0
No pressors required while in MICU.,0
"Patient remained agitated a frequently desaturated to 70's when agitated, but would bump to 100% with nebs.",0
"Etiology thought to be combination of asthma/COPD, CHF, agitation, and decreased respiratory drive.",0
"On , pt was noted to be more somnolent with ABG 7.16/110/39/51 and was transferred to unit for trial of BIPAP.",0
Etiology hypercarbic respiratory failure secondary to sedation and infection (UTI and +blood cultures 1/4) and COPD.,1
While in the MICU the patient was essentially made comfort care d/t poor prognosis and no improvement with BIPAP (pt DNR/DNI).,0
She was transferred to the floor where sshe continued to decline.,0
"Family meeting had and it was decided that her chances of returning to a meaningful life or even back to near baseline was minimal, and care was focused on comfort.",0
"Antibiotics, FS, insulin, and diuretics were stopped on and the patient passed on , likely d/t respiratory arrest.",1
Permission to perform autopsy was obtained from health care proxy with specific interest in identifying the intracranial mass.,0
# ARF: Pt with CKD and baseline Cr 1.8 who presented with acute worsening (cr 2.6).,0
"Thought to be pre-renal process, possibly secondary to over diuresis.",0
"Initially UA did not show any evidence of UTI, but pt eventually developed klebsiella UTI, for which she was treated.",0
"During second MICU stay there was some concern for urosepsis, and antibiotic coverage was broadened to cover this possibility.",0
"For part of her hospitalization the Cr returned to baseline with gentle IVF's, but eventually this again worsened and while in the MICU the second time she became anuric.",0
# CHF: Patient had an unknown EF but was on chronic lasix.,0
"Lasix was administered on as needed basis, taking into account her renal failure and pulmonary edema potentially contributing to respiratory distress.",1
# DM: Pt initially hypoglycemia (11) in ED after getting 10 units RI for BG ~325 and not receiving tube feeds.,0
Throughout hospitalization patient alternated between hypoglycemia and hyperglycemia.,0
"followed the patient closely but it was very difficult to control her sugars, especially in setting of receiving intermittent TF's d/t pulling out PEG and high residuals.",0
"#Hypernatremia: Patient fluctuated between normal and hypernatremic, likely because she was unable to take free water d/t agitation and delerium.",0
"Free water flushes via PEG were administered, but high residuals made this difficult.",0
# HTN: Outpatient lopressor continued with moderate control .,0
# Dementia: Acute on chronic.,1
Did not improve during hospitalization.,0
# DNR/DNI Medications on Admission: Lasix 40 mg NG qd z 2 days then 20 mg NG qd Risperidal 0.5 mg NG qAm and 0.75 mg qhs Insulin: Lantus 10 units qAM and NPH qPM RISS Lopressor 37.5 mg NG TID Heparin 500 units SC q 12 hrs Prevacid 30 mg qd Zantact 150 mg MVI Colace NG 100 mg Duonevs q 4 hrs PRN Lactulose 30 cc NG q12 hours PRn NaCL 2 gm with 300 cc H2O H20 300 cc NG Celexa 10 mg NG qd .,0
"Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Hypercarbic hypoventilation PNA Urosepsis COPD/Asthma Acute renal failure Dementia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None MD,",1
10:56 AM VENOUS DUP EXT UNI (MAP/DVT) LEFT Clip # Reason: Please Map left leg for vessels.,0
"Admitting Diagnosis: GANGRENE OF FOOT ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with DM, CAD s/p CABG, R 1st toe gangrene, preop for bypass REASON FOR THIS EXAMINATION: Please Map left leg for vessels.",1
"______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old man with DM, CAD status post CABG, right first toe gangrene, preop for bypass.",1
Please map left leg for vessels.,0
FINDINGS: The left greater esophagus vein is patent with diameters varying between 0.59 cm superiorly and 0.20 cm inferiorly.,0
This vein measures approximately 0.25 cm in diameter at the level of the knee.,0
IMPRESSION: Patent left greater saphenous vein with diameters as outlined above.,0
"For more complete listed measurements of the greater saphenous vein, please see the scanned report on the PACs system.",0
"2:28 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for abscess, colitis, perf Field of view: 50 ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with fever, right sided abd pain, recent sepsis REASON FOR THIS EXAMINATION: eval for abscess, colitis, perf No contraindications for IV contrast ______________________________________________________________________________ WET READ: JCT FRI 3:47 PM right uvj stone with associated mild hydronephrosis left mid ureteral stone with mild-moderate hydronephrosis and perirenal stranding.",1
right fascial thickening adjacent to right colon likely related to the ureteral calculus but mild diverticulitis is a possibility.,1
______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old man with fever and right-sided abdominal pain and recent sepsis.,0
TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained with oral contrast.,0
CT ABDOMEN: There is right lower lobe atelectasis.,0
"Within limits of this study without IV contrast, the liver, gallbladder, pancreas, spleen, adrenal glands, stomach, and small bowel loops are stable.",0
There is a 2 mm right ureterovesicular junction stone with associated mild hydroureter and hydronephrosis.,1
Stranding is noted along the course of the ureter.,0
"Additionally, there is a 3 mm mid left ureteral stone with associated hydroureter and mild-to-moderate hydronephrosis.",1
Prominent stranding is noted around the renal pelvis.,0
Additional small bilateral calcifications are noted in the kidneys.,0
Again noted are multiple bilateral rounded renal foci which are low in attenuation.,0
"They most likely represent cysts; however, some are higher in Hounsfield units than classic cysts.",0
There is extensive colonic diverticulosis.,0
"Along the right colon, there is stranding of the fascia and mild soft tissue thickening.",0
No mesenteric or retroperitoneal lymphadenopathy is identified.,0
CT PELVIS: Foley catheter and air are noted in the bladder.,0
There is no free fluid and no pelvic or inguinal lymphadenopathy.,0
"(Over) 2:28 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for abscess, colitis, perf Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.",0
Two-mm right ureterovesicular junction stone with associated mild hydroureter and hydronephrosis.,1
Three-mm left mid ureteral stone with associated mild hydroureter and mild-to-moderate hydronephrosis.,1
Stranding of the fascia along the right colon is likely related to the GU pathology.,0
"However, a small focus of diverticulitis is a possibility.",0
Additional small bilateral renal calculi.,0
"Multiple rounded low attenuation renal foci, which likely represent cysts.",0
"However, some of these measure higher in attenuation than classic cysts, and as per prior report, an elective renal ultrasound is suggested to exclude the possibility of solid lesions.",0
Height: (in) 60 Weight (lb): 135 BSA (m2): 1.58 m2 BP (mm Hg): 169/60 HR (bpm): 81 Status: Inpatient Date/Time: at 12:05 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Normal LV inflow pattern for age.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: L frontal tumor Major Surgical or Invasive Procedure: Left Craniotomy for tumor resection History of Present Illness: This patient is a cantonese chinese 63yo gentleman with limited past medical history incl.,0
"mild DM 2 and HTN; Recently, he unterwent work up of transient facial paresis from Bell's plasy , which also revealed an incidental L frontal lesion c/w meningeoma.",0
He has not been symptomatic of this.,0
"Since his last visit, he was doing well and the VII plasy has largely resolved; Past Medical History: - Type II diabetes mellitus - Hypertension - All: NKDA Social History: Lives with wife, denies alcohol or recreational drugs.",1
Retired construction worker Family History: non-contributory Physical Exam: AF VSS NAD HEENT: Pupils: PERRL EOMs intact Neck: Supple.,0
no LNN noticed Lungs: no SOB bilaterally.,0
"Cardiac: regular Abd: Soft, NT Extrem: Warm and well-perfused.",0
"Language: Speech with good comprehension, slight stutter with interpreted clear Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light bilaterally.",0
Strength full power Sensation: Intact to light touch No extrpyramidal signs No gait abnormalities Pertinent Results: MRI Brain: IMPRESSION: Left frontal meningioma is again identified with surface markers for surgical planning.,0
No mass effect or hydrocephalus seen.,0
Appropriate postoperative changes status post meningioma resection from a left frontal approach with blood products and air at the site of resection.,0
"No evidence of new hemorrhage, mass effect, or acute infarction.",0
"Evidence of vasogenic edema, mild pneumocephalus, and blood products in the postoperative bed consistent with postoperative changes.",0
"Restricted diffusion in the left medial frontal lobe adjacent to the operative bed, which could be secondary to postoperative cytotoxic edema versus infarct.",0
"No definite evidence of residual tumor; there is some enhancement at the margins of the operative bed, which could be secondary to postoperative changes, however cannot completely rule out residual tumor.",0
Would recommend follow-up imaging after resolution of acute postoperative state.,0
02:34AM BLOOD WBC-11.4* RBC-3.93* Hgb-12.9* Hct-39.2* MCV-100* MCH-32.9* MCHC-33.0 RDW-12.8 Plt Ct-232 12:40PM BLOOD WBC-12.4*# RBC-4.41* Hgb-14.6 Hct-42.9 MCV-97 MCH-33.1* MCHC-33.9 RDW-12.9 Plt Ct-235 02:34AM BLOOD Plt Ct-232 02:34AM BLOOD PT-12.3 PTT-31.9 INR(PT)-1.1 12:40PM BLOOD Plt Ct-235 12:40PM BLOOD PT-11.2 PTT-33.7 INR(PT)-1.0 02:34AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-139 K-4.1 Cl-106 HCO3-25 AnGap-12 12:40PM BLOOD Glucose-166* UreaN-15 Creat-0.8 Na-140 K-3.8 Cl-105 HCO3-26 AnGap-13 02:34AM BLOOD Calcium-8.3* Phos-4.2# Mg-2.2 12:40PM BLOOD Calcium-7.9* Phos-2.2* Mg-1.8 Brief Hospital Course: 63 y/o M with history of L frontal lesion presents for elective resection.,0
Patient was taken to the OR on .,0
Patient was taken to the ICU for monitoring.,0
A head CT was done within 4 hours to evaluate for post operative changes.,0
On he was neurologically intact.,0
His foley and arterial line were removed.,0
"He underwent an MRI which revealed post op changes, no hemorrhage or infarct.",0
He was cleared for transfer to the floor and PT/OT were consulted.,0
He was started on SQH and a decadron taper.,0
"On , he was cleared by PT as safe for discharge to home.",0
The patient and his family were in agreement with this plan and all questions were answered prior to discharge.,0
The appropriate follow-up instructions were provided to the patient.,0
"Medications on Admission: glimeperide, lisinopril, metformin Discharge Medications: 1.",0
"Acetaminophen 325-650 mg PO Q4H:PRN pain, fever, HA 2.",0
"Docusate Sodium 100 mg PO BID 3. glimepiride *NF* 2 mg Oral DAILY Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary.",0
LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5.,0
Lisinopril 2.5 mg PO DAILY 6.,0
HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *hydromorphone 2 mg tablet(s) by mouth every four (4) hours Disp #*90 Tablet Refills:*0 7.,0
Dexamethasone 1 mg po q8 Duration: 1 Days then d/c RX *dexamethasone 1 mg see instructions tablet(s) by mouth see taper instructions Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left-sided frontal parafalcine tumor Discharge Condition: Mental Status: Clear and coherent.,0
Dressing may be removed on Day 2 after surgery.,0
You have dissolvable sutures; you may wash your hair and get your incision wet day 3 after surgery.,0
?Please return to the office in days (from your date of surgery) for a wound check.,0
This appointment can be made with the Physician Assistant or Practitioner.,0
?You will need an MRI of the brain with/without gadolinium contrast.,0
2:37 PM MR HEAD W/O CONTRAST Clip # Reason: Full term neonate with severe clinical encephalopathy with s Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: As above.,1
"Infant with severe encephalopathy, metabolic acidosis and cardiomyopathy REASON FOR THIS EXAMINATION: Full term neonate with severe clinical encephalopathy with seizures, as well as refractory metabolic acidosis and cardiomyopathy.",1
Ultrasound shows bilateral white matter disease with thalamic vasculopathy.,0
For MRI and DWI please No contraindications for IV contrast ______________________________________________________________________________ WET READ: 5:26 PM Subdural hematoma in the tentorial region ; no intraventricular/parenchymal hemorrhage or white matter changes.,1
______________________________________________________________________________ FINAL REPORT This is a redictation of the report as the prior report was lost before transcription.,0
"INDICATION: Full-term neonate with severe encephalopathy, metabolic acidosis, bilateral white matter changes on ultrasound.",1
TECHNIQUE: Multiplanar T1- and T2-weighted imaging was performed without contrast; diffusion-weighted imaging was also performed.,0
"FINDINGS: There is moderate subdural hematoma on the undersurface of the tentorium with a fluid level within (series 2, image 9).",0
"However, there is no evidence of intraparenchymal or intraventricular hemorrhage.",1
No white matter changes are noted.,0
The cerebral parenchyma appears unremarkable.,0
No abnormality is noted on the diffusion-weighted images.,0
"The visualized segments of the bilateral vertebral, basilar, bilateral internal carotid arteries and their branches are normal.",0
The osseous and the adjacent soft tissue structures are normal.,0
No abnormality is noted on the Diffusion-weighted images.,0
IMPRESSION: Moderate subdural hematoma in the tentorial region.,0
No white matter changes/intraparenchymal/intraventricular hemorrhage.,1
(Over) 2:37 PM MR HEAD W/O CONTRAST Clip # Reason: Full term neonate with severe clinical encephalopathy with s Admitting Diagnosis: NEWBORN ______________________________________________________________________________ FINAL REPORT (Cont),0
11:56 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: interval change chest and abd CT. ?abscess Admitting Diagnosis: NECROTISING PNEUMONIA Field of view: 47 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with right sided necrotizing pneumonia.,1
Now with persistent fevers on abxs.,0
"REASON FOR THIS EXAMINATION: interval change chest and abd CT. ?abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Right-sided necrotizing pneumonia, now with fevers, assess interval change.",1
COMPARISON: CT of the chest from four years ago.,0
TECHNIQUE: Multidetector CT scanning was performed after the administration of oral and intravenous contrast.,0
CT OF THE CHEST: Again seen is a large area of consolidation with foci of air within the right lower lobe.,0
The surrounding right pleural effusion of simple fluid attenuation has increased in size since the prior study.,0
The multiple foci of ground-glass opacity in the right upper lobe are stable or possibly slightly improved.,0
Heart and pericardium appear unremarkable apart from calcifications of the coronary arteries.,0
"Again seen are prominent right paratracheal lymph nodes, unchanged.",0
Small amount of atelectasis is seen at the left base.,0
Emphysematous changes are seen in the left lung.,0
The great vessels appear unremarkable apart from calcifications of the aorta.,0
The airways are grossly patent.,0
An endotracheal tube and a nasogastric tube are visualized again.,0
"CT OF THE ABDOMEN: The liver, adrenal glands, spleen, and pancreas appear unremarkable.",0
Again seen are small gallstones within the full gallbladder.,0
There is no pericholecystic fluid or gallbladder wall edema.,0
No pathologic mesenteric or retroperitoneal lymphadenopathy is identified.,0
Minor nonspecific stranding are seen around the kidneys.,0
Visualized loops of small and large bowel are normal in caliber and contour.,0
The vascular structures demonstrate calcification of the arteries.,0
CT OF THE PELVIS: A Foley catheter is seen within the bladder.,0
There appears to be a rectal tube in place.,0
The prostate and seminal vesicles appear unremarkable.,0
The pelvic loops of small and large bowel appear unremarkable.,0
There is a small amount of nonspecific stranding within the pelvis.,0
The osseous structures demonstrate no concerning lytic or sclerotic lesions.,0
IMPRESSION: (Over) 11:56 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: interval change chest and abd CT. ?abscess Admitting Diagnosis: NECROTISING PNEUMONIA Field of view: 47 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
Stable appearance to the abnormalities within the right lung as described above.,0
Slight increase in the size of the right pleural effusion of simple fluid attenuation.,0
"Cholelithiasis, without evidence of cholecystitis.",0
"7:02 AM CHEST (PORTABLE AP) Clip # Reason: please assess for change and for persistent hypoxia Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with hx of CHF, effusion, now with palpitations REASON FOR THIS EXAMINATION: please assess for change and for persistent hypoxia ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: CHF, effusions, palpitations.",1
"CHEST: Compared to the prior chest x-ray, the opacifications in both lungs have become denser and somewhat more extensive.",0
The position of the lines and tubes remains satisfactory.,0
Some blunting of the costophrenic angles are again seen.,0
IMPRESSION: Worsening opacifications of both lungs.,0
"1:19 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: assess lung vol, 37 + weeks, iugr Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with nasal cannual o2 REASON FOR THIS EXAMINATION: assess lung vol, 37 + weeks, iugr ______________________________________________________________________________ FINAL REPORT CHEST: This appears to be our initial film on this child born with intrauterine growth retardation at 37 weeks.",1
There is a nasogastric tube present within the stomach.,0
The lung volumes are quite low but there appears to be little lung disease present.,0
4:41 AM CHEST (PORTABLE AP) Clip # Reason: evaluate ET tube placement Admitting Diagnosis: COFFEE GROUND EMESIS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with hx CAD/CHF who recently presented to the hospital with N/V in setting of bowel prep which was done in anticipation of TAH/BSO for new intrabd malignancy concerning for ovarian cancer; now intubated for hypoxic resp failure REASON FOR THIS EXAMINATION: evaluate ET tube placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Hypoxic respiratory failure.,1
"Patient with history of CAD, CHF and new intra-abdominal malignancy concerning for ovarian cancer.",0
Lower lung volumes account for the worsening bibasilar opacities consistent with atelectasis.,0
Bilateral pleural effusions are probably unchanged.,1
Mild-to-moderate interstitial edema is unchanged.,0
Lines and tubes remain in place in standard position.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval for PTX and line placement Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with s/p left subclavian CVL placement REASON FOR THIS EXAMINATION: eval for PTX and line placement ______________________________________________________________________________ FINAL REPORT INDICATION: Left subclavian line placement.,0
"FINDINGS: As compared to the previous radiograph, a left subclavian central venous access line has been placed.",0
There is no evidence of pneumothorax or other complications.,0
"The line has a normal course, the tip of the line projects over the superior SVC.",0
"Otherwise, the radiograph is unchanged, unchanged position of the endotracheal tube and the nasogastric tube, unchanged extent of cardiomegaly and the pre-existing right-sided pleural effusion.",0
"2:02 PM GB DRAINAGE,INTRO PERC TRANHEP BIL US; Clip # Reason: please place perc chole Admitting Diagnosis: CHOLANGITIS ********************************* CPT Codes ******************************** * GB DRAINAGE,INTRO PERC TRANHEP BIL U * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man here with cholangitis, sepsis, s/p ERCP and stent REASON FOR THIS EXAMINATION: please place perc chole ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe FRI 4:47 PM PFI: Uncomplicated 8 French percutaneous cholecystostomy tube.",1
Small sample was sent for Gram stain and culture.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Cholangitis, sepsis and acute cholecystitis status post ERCP, CBD stent with probable stone.",1
The patient was deemed to be not a surgical candidate currently and request for percutaneous cholecystostomy was made for treatment of acute cholecystitis.,1
COMPARISON: Outside ultrasound and outside CT .,0
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY: Limited preprocedural ultrasound demonstrated persistently mildly distended gallbladder at approximately 4 cm with some small echogenic stones within the lumen and unchanged wall thickening and mild edema.,0
These findings are again most consistent with underlying acute cholecystitis in concordance with the prior imaging.,1
Informed consent was obtained from the patient after explaining the risks and benefits of the procedure.,0
A preprocedure timeout was performed documenting the nature of procedure and the patient identity using two independent verifiers.,0
Appropriate spot for catheter placement was chosen using a lower right intercostal space and the overlying skin was prepped and draped in normal sterile fashion.,0
"Subsequently, under continuous ultrasound guidance, approximately 10 mL of sodium bicarbonate buffered 1% lidocaine was instilled for local anesthesia, extending down towards the liver capsule.",0
"Using trocar technique, an 8 French catheter was then advanced into the gallbladder lumen under continuous son observation with tip placement confirmed to be within the lumen under ultrasound.",0
The catheter was deployed after return of bilious material.,0
The pigtail was formed and the catheter was secured using a StatLock device and a total of 100 mL of slightly hemorrhagic bile with mild purulence was aspirated.,0
A small sample was sent for Gram stain and culture.,0
The patient tolerated the procedure well with no immediate post-procedural complications.,0
"The procedure was performed by Dr. and Dr. , the attending radiologist, who was participating throughout.",0
"(Over) 2:02 PM GB DRAINAGE,INTRO PERC TRANHEP BIL US; Clip # Reason: please place perc chole Admitting Diagnosis: CHOLANGITIS ______________________________________________________________________________ FINAL REPORT (Cont) Moderate sedation was provided by administering divided doses of 50 mcg of fentanyl and 1 mg of Versed throughout the total intraservice time of 20 minutes during which time the patient's hemodynamic parameters were continuously monitored.",0
IMPRESSION: Uncomplicated 8 French percutaneous cholecystostomy tube.,0
", C. NMED FA11 11:26 AM MR HEAD W/O CONTRAST Clip # Reason: eval R frontal hypodensity, ?",0
"infarct Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with spontaneous SAH, no aneurysm on CTA, but new R frontal hypodensity noted on repeat CTA REASON FOR THIS EXAMINATION: eval R frontal hypodensity, ?",1
infarct No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Bilateral subarachnoid hemorrhage reidentified with a small amount of subdural hemorrhage noted along the right convexity.,1
"The previously noted right frontal hypodensity seen on CT, most likely represents hemorrhage within the subarachnoid space.",1
"However, if this lesion is in fact intraparenchymal, contusion or subacute infarct are other diagnostic possibilities.",0
Recommend continued attenuation on followup.,0
"LINE PLACEMENT Clip # Reason: new line Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with REASON FOR THIS EXAMINATION: new line ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of AAA repair with CV line and intubation.",0
ET tube is approximately 2.4 cm above the carina.,0
Tip of the left subclavian introducer sheath overlies junction of right brachiocephalic vein and SVC.,0
There is moderate gaseous distention of the stomach with endovascular graft in abdominal aorta partly included on film and contrast in both collecting systems.,0
12:07 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for interval post op change.,0
please do non-contrast hea Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with R SDH s/p OR evacuation REASON FOR THIS EXAMINATION: eval for interval post op change.,0
please do non-contrast head AND CTA head and neck.,0
"please do study at 12:00 No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg 7:31 PM Slight increase in prominence of the right superior temporal lobe contusion, likely expected evolution of contusion.",0
Stable appearance of the remainder of the intracranial hemorrhages with stable mass effect.,0
No evidence of carotid dissection.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old male with right subdural hematoma status post OR evacuation.,0
Evaluate for interval postoperative change.,0
"COMPARISON: CT head of at 3:50 a.m., CT spine and CT head at 1:05 a.m.",0
"Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of intravenous contrast.",0
FINDINGS: HEAD CT: The patient is status post craniectomy.,0
The intraparenchymal hemorrhage in the right superior temporal lobe appears slightly more prominent and may be consistent with evolving contusion.,0
"The remainder of the intracranial hemorrhage including the inferior right temporal intraparenchymal hemorrhage, subarachnoid hemorrhage, and intraventricular hemorrhage are unchanged from prior.",1
"The leftward shift of the normally midline structures, subthalamic herniation and mass effect on the right lateral ventricle, quadrigeminal and suprasellar cisterns and transtentorial herniation are unchanged.",0
There has been slight interval increase in the subgaleal collection overlying the right frontotemporal vertex.,0
Left temporal bone fracture and left occipital fracture are again noted and unchanged.,0
"Fluid levels in the bilateral maxillary sinuses, nasal cavity and right sphenoid sinus are also unchanged compared to prior.",0
"HEAD AND NECK CTA: The intracranial vertebral internal carotid arteries and their major branches are without evidence of stenosis, occlusion, or aneurysm formation.",0
The bilateral common carotid arteries are diminutive in size without significant stenosis.,0
"There is circumferential wall thickening of the common carotid arteries, the visualized portion of the aortic arch and origin of vessels branching from the aorta, raising concern for arteritis versus (Over) 12:07 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: eval for interval post op change.",0
please do non-contrast hea Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT (Cont) anatomic variant.,0
There is no evidence of aneurysm formation or dissection in either carotid artery.,0
The distal cervical internal carotid arteries measure 5.6 mm on the left and 3.3 mm on the right.,0
The right vertebral artery is hypoplastic compared to the left.,0
"The vertebrobasilar system is otherwise unremarkable without evidence of stenoses, aneurysm formation, or other vascular abnormality.",0
"A small ground-glass opacity is noted in the peripheral left upper lobe (3:7), likely related to motion artifact.",0
There is multilevel cervical spine spondylosis.,0
"Stable right subdural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage and inferior right temporal lobe contusion with associated mass effect compared to CTA approximately nine hours earlier.",1
Slightly more prominent right superior temporal lobe contusion which may represent expected evolution of contusion.,0
"Stable left temporal and occipital bone fracture, best described on CT report of at 1:05 a.m. (clip ).",0
Wall thickening of the aortic arch and origins of vessels including the common carotid arteries.,0
"MRA of the chest on an nonemergent basis may be pursued to further assess for arteritis, such as Takayasu.",0
Small ground-glass opacity in the left upper lobe which is likely artifact.,0
Attention should be paid to this area on followup exam.,0
Findings were discussed with Dr. at the time of interpretation on .,0
"Admitting Diagnosis: MV ENDOCARDITIS\MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with MVR REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
"______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): IPf MON 3:08 PM Left lower lobe opacity with visible air bronchogram, which might be consistent with atelectasis or aspiration pneumonia.",0
Mild pleural effusion on the left.,0
"Appropriate placement of the right IJ, endotracheal tube, NG tube, and PICC line.",0
"For questionable area of right upper mediastinum gas, please correlate clinically.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate for pleural effusion, pulmonary edema, components of pneumothorax.",0
TECHNIQUE: Portable chest x-ray frontal view.,0
COMPARISON: Compared to chest x-ray from .,0
FINDINGS: There is opacification within the left lower lobe with visualized bronchogram which might be associated atelectasis in this area or aspiration pneumonia.,0
The right IJ catheter is ending in the right pulmonary artery.,0
The endotracheal tube is 5 cm above carina.,0
The nasogastric is ending in the left upper quadrant of the abdomen.,0
There are mediastinal lines overlying the chest.,0
The PICC line is ending in the mid superior vena cava.,0
"In the right upper mediastinum, there is small hypolucency which is suspicious for possible right upper mediastinal gas, please correlate clinically.",0
Post-surgical changes are noted in the mid thorax and normal alignment of the surgical changes.,0
Small pleural effusion on the left.,0
Left lower lobe opacification which might be consistent with atelectasis or aspiration pneumonia.,0
"Appropriate placement of right IJ, endotracheal tube, NG tube, PICC line.",0
"Small questionable gas in the right upper mediastinum, please correlate clinically.",0
Results were communicated with NP at 2:00pm.,0
7:55 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?,0
worsening PTX Admitting Diagnosis: ASTHMA;COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with PTX now with tachycardia REASON FOR THIS EXAMINATION: ?,0
worsening PTX ______________________________________________________________________________ FINAL REPORT STUDY: AP chest .,0
HISTORY: Patient with worsening pneumothorax and tachycardia.,1
No pneumothoraces are seen on either side.,0
The lines and tubes are all unchanged in position and again the side port of the nasogastric tube should be advanced several centimeters for more optimal placement as it is above the GE junction.,0
There is minimal prominence of the pulmonary vascular markings without overt pulmonary edema.,0
"10:38 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p ct d/c, r/o ptx Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with REASON FOR THIS EXAMINATION: s/p ct d/c, r/o ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Chest tube removed, question pneumothorax.",1
"CHEST, ONE VIEW: Comparison with exam of same day, 7:54 a.m.",0
Right apical pneumothorax is unchanged.,0
Left chest tube has been removed; small left apical pneumothorax has grown slightly.,0
Left lower lobe opacity/atelectasis is probably similar.,0
Also similar appearance of bilateral small pleural effusions.,0
IMPRESSION: Bilateral small apical pneumothoraces.,0
Remainder of the exam is unchanged aside from chest tube removal.,0
"Findings discussed with of cardiac surgery at 12:50 p.m., .",0
"9:08 PM PORTABLE ABDOMEN Clip # Reason: ileus/obstruction Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man sp esophagectomy now aspirated with distended belly REASON FOR THIS EXAMINATION: ileus/obstruction ______________________________________________________________________________ FINAL REPORT HISTORY: Esophagectomy, question ileus, obstruction.",1
There is a relative paucity of air in left abdomen.,0
A single dilated loop of small bowel seen in the right mid abdomen.,0
There are overlying skin staples.,0
Lung bases are abnormal -- please see contemporaneous chest x-ray report.,0
Linear density overlying the right costovertebral region noted (Review of a torso CT performed on suggests that this linear structure represents some form of catheter.),0
Clips noted in the left upper quadrant.,0
IMPRESSION: Relative paucity of bowel gas.,0
"Single minimally dilated loop of small bowel, without other evidence of obstruction.",0
4:39 PM CT HEAD W/O CONTRAST Clip # Reason: Follow up on size and location Admitting Diagnosis: SAH/SDH ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with SAH REASON FOR THIS EXAMINATION: Follow up on size and location No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate interval changes in traumatic intracranial hemorrhage.,1
COMPARISON: NECT of the head from and MRI brain from .,0
FINDINGS: The right parietal focus of intraparenchymal hemorrhage is less conspicous.,0
The left anterior inferior temporal hemorrhage is not well seen.,0
There has been continued evolution and redistribution of the multiple small foci of subarachnoid hemorrhage.,1
"The small bilateral occipital subdural hematomas tracking along the falx is unchanged from the MRI, allowing for different imaging modalities.",1
"There is no mass, mass effect, or infarct identified.",0
"IMPRESSION: Continued evolution of existing parenchymal, subdural, and subarachnoid hemorrhage, all of which are less conspicuous than on previous studies.",1
9:28 AM ABDOMEN (SUPINE ONLY) PORT Clip # Reason: Please eval for obstruction ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with n/v x 3d.,0
"REASON FOR THIS EXAMINATION: Please eval for obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN, SINGLE FILM: History of persistent nausea and vomiting.",0
The distribution of bowel gas is unremarkable and there is no evidence for intestinal obstruction.,0
No soft tissue masses or radiopaque calculi.,0
"8:57 AM US PERC DRAIN PANCREATIC PSEUDOCYST; GUIDANCE FOR ABSCESS ()Clip # Reason: Evaluation for infected necrotizing pancreatitis, please bio Admitting Diagnosis: PANCREATITIS ********************************* CPT Codes ******************************** * US PERC DRAIN PANCREATIC PSEUDOCYST GUIDANCE FOR ABSCESS () * * * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with necrotizing pancreatitis REASON FOR THIS EXAMINATION: Evaluation for infected necrotizing pancreatitis, please biopsy the phlegmon.",1
Please immediate gram stain of biopsy.,0
**NEEDS TO BE DONE AS 1ST CASE IN THE MORNING** No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Necrotizing pancreatitis and extensive peripancreatic fluid collections.,0
FINDINGS: Limited ultrasound in the left abdomen reveals a pocket of fluid in the left paracolic gutter.,0
This was felt to correspond to the left flank collection seen on the prior CT of .,0
PROCEDURE: This procedure was performed on an urgent basis at the bedside since the patient could not travel to the radiology department.,1
"After the risks and benefits of the procedure were explained to the patient's wife, written informed consent was obtained.",1
A preprocedure timeout was performed using three forms of patient identification.,1
The patient was sedated as patient was intubated.,0
"Using ultrasound guidance, an appropriate spot for aspiration of this left abdominal fluid was marked on the skin.",0
The area was prepped and draped in the usual sterile fashion and anesthetized with 1% buffered lidocaine solution.,0
"First, using direct ultrasound guidance, an 18-gauge needle was advanced into the fluid collection and approximately 10 cc of dark cloudy fluid was obtained.",0
"Given the large amount of spontaneous fluid return from the needle, it was decided to place a drainage catheter at this time as the collection appeared to be under pressure.",0
"Then, using direct ultrasound guidance and trocar technique, an 8 French pigtail catheter was advanced into the fluid collection.",0
The pigtail was formed and a total of 150 cc of fluid was aspirated.,0
The catheter was fastened to the skin and left to gravity drainage.,0
The sample was sent for stat Gram stain and culture.,0
There were no known complications.,0
"(Over) 8:57 AM US PERC DRAIN PANCREATIC PSEUDOCYST; GUIDANCE FOR ABSCESS ()Clip # Reason: Evaluation for infected necrotizing pancreatitis, please bio Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: Ultrasound-guided drainage of left abdominal fluid collection with 8 French pigtail catheter.",1
Sample sent for microbiology analysis.,0
"12:28 PM UNILAT UP EXT VEINS US Clip # Reason: ?PE LT ARM SWELLING, R/O DVT ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with REASON FOR THIS EXAMINATION: r/o thromb left arm ______________________________________________________________________________ FINAL REPORT INDICATION: Left arm swelling.",0
"UNILATERAL DUPLEX ULTRASOUND, LEFT UPPER EXTREMITY: scale, color and doppler son of the left jugular vein, subclavian vein, axillary vein, brachial vein and basilic vein were performed.",0
"Normal flow, augmentation, compressiblity and wave forms are demonstrated.",0
"IMPRESSION: No evidence of DVT, left upper extremity.",0
LINE PLACEMENT Clip # Reason: 48cm DL R basilic PICC placed ?,0
tip - Admitting Diagnosis: BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with new R PICC REASON FOR THIS EXAMINATION: 48cm DL R basilic PICC placed ?,0
tip - ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 76-year-old man with new right PICC.,0
"FINDINGS: A right-sided PICC is seen terminating likely within the atrium; however, the tip is difficult to visualize.",0
Would recommed either a new oblique film or to retract the cathetar about 2 cm past.,0
There are low lung volumes but the right lung is grossly clear as well.,0
"8:49 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for tube placement Admitting Diagnosis: T10 MASS ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with COPD, recently malignancy diagonosis s/p intubation REASON FOR THIS EXAMINATION: eval for tube placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with COPD and recent diagnosis of malignancy.",0
Portable AP chest radiograph was reviewed in comparison to prior study obtained on .,0
There is no change in the cardiomediastinal silhouette and orthopedic hardware.,0
There is increased opacity in the right lung base that might represent developing infectious process.,0
Mild fluid overload cannot be entirely excluded.,0
11:04 AM CHEST (PA & LAT) Clip # Reason: low saturation Admitting Diagnosis: PFO\AORTIC VALVE REPLACEMENT; PFU; MAZE PROCEDURE; ?,0
MVR ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p AVR REASON FOR THIS EXAMINATION: low saturation ______________________________________________________________________________ FINAL REPORT INDICATION: Patient with recent aortic valve replacement and poor oxygenation.,0
There are no overt signs of failure.,0
"A small right effusion is present, and there is an enlarging infiltrate in the left lower lobe since .",0
There is no definite pneumothorax.,0
The aortic valve replacement is again noted.,0
There is mild compressive atelectasis at the right lung base.,0
IMPRESSION: 1) Enlarging infiltrate in the left lower lobe since .,0
"5:50 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line asap Admitting Diagnosis: RESPIRATORY DISTRESS ********************************* CPT Codes ******************************** * CVL/PICC UD GUID FOR NEEDLE PLACMENT * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: year old woman hypotension REASON FOR THIS EXAMINATION: Please place PICC line asap ______________________________________________________________________________ FINAL REPORT HISTORY: year old woman with hypotension and aspiration pneumonia.",0
Patient needs IV access for antibiotics.,0
IV team unable to place PICC at bedside.,0
"RADIOLOGISTS: Dr. , Dr. , attending radiologist present and supervising throughout the procedure.",0
PROCEDURE: The right upper arm was prepped and draped in the usual sterile fashion.,0
As no suitable superficial veins were visible ultrasound was used to localize a suitable vein.,0
"Under ultrasonographic guidance, the right brachial vein was accessed using a 21 gauge micropuncture needle.",0
The needle was exchanged for a 4 French micropuncture introducer sheath.,0
Based on the markers on the guidewire it was determined that a length of 37 cm would be suitable.,0
The PICC line was trimmed to length and advanced over the 4 French introducer sheath into the superior vena cava.,0
A final chest x-ray was obtained demonstrating tip of the catheter in cavoatrial junction.,0
The catheter was flushed and aspirated.,0
A STAT lock was applied and the line was HEP locked.,0
The line is ready for immediate use.,0
ANESTHESIA: Local with 1% Lidocaine.,0
"IMPRESSION: Successful placement of a 37 cm total length 4 French single lumen PICC line via right brachial vein, tip in cavoatrial junction.",0
Line is ready for immediate use.,0
12:07 AM CT HEAD W/O CONTRAST Clip # Reason: herniated pupil Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with herniated pupil REASON FOR THIS EXAMINATION: herniated pupil No contraindications for IV contrast ______________________________________________________________________________ WET READ: DRS 12:58 AM multiple mets w/ leftward shift ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
"CT HEAD W/O IV CONTRAST: There is a large hemorrhagic focus within the left frontal lobe, which is significantly increased in size since the previous study.",0
There is effacement of all the surrounding sulci and large degree of vasogenic edema.,0
There is rightward shift of the normally midline structures of approximagely 9 mm.,0
"Smaller tiny hemorrhagic foci seen in the high left frontal, right temporoparietal and in the subependymal region of the right lateral ventricle.",0
The resected right cerebellar focus is again noted.,0
There is a large amount of beam hardening artifact and motion artifact seen producing high attenuation in the left pons and right cerebellum.,0
Repeat imaging with straightening of the CT gantry de-emphasizes this focus in the left pons.,0
There is no definite extraaxial collection.,0
The osseous structures again demonstrate the craniotomy site overlying the right occiput.,0
The paranasal sinuses are unremarkable.,0
IMPRESSION: When compared to the previous study of 17 days ago there are several new hemorrhagic foci consistent with worsening metastatic disease.,0
There is extensive new edema in the left frontal lobe with shift of the normally midline structures.,0
"11:35 AM CHEST (PA & LAT) Clip # Reason: Looking for effusions, fluid status and old PNA Admitting Diagnosis: MYOCARDIAL INFARCTION,ACUTE RENAL DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with reported to have ventilator assoc pna and pleural effusions at OSH.",1
"REASON FOR THIS EXAMINATION: Looking for effusions, fluid status and old PNA ______________________________________________________________________________ FINAL REPORT HISTORY: Ventilator-associated pneumonia and pleural effusion by history.",0
"FINDINGS: In comparison with study of , there is a patchy area of increased opacification silhouetting the right hemidiaphragm with blunting of the costophrenic angle and meniscus formation.",0
This is consistent with the clinical impression of pneumonia and pleural effusion at the right base.,0
"At the left base, there is a less prominent area of increased opacification with meniscus formation at the costophrenic angle, again consistent with pneumonia and pleural effusion.",0
Some indistinctness of pulmonary vessels raises the possibility of increased pulmonary venous pressure.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: n/v, weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. is a 67 yo M w/ h/o HTN, hyperlipidemia, prostate ca s/p prostatectomy, DJD, OSA who presented today with n/v and weakness and was found to have a Na level of 109. .",1
"Of note, the pt was admitted from here after syncopizing on the golf course.",0
Syncope was thought trifascicular block and PM was placed.,0
He also sustained a SDH during his syncopal episode which was managed non-operatively.,0
Pt had some hyponatremia to 120s during that admission thought SDH and cerebral salt wasting or SIADH.,0
This slightly improved with fluid restriction to 1.5L daily and was 128 on day of d/c.,0
"The pt states he had pesistent weakness since d/c but on , he had increasing nausea and weakness and felt unsteady on his feet.",0
"On the day of readmission, he vomitted x1, non-bloody.",0
He went to the ED where he was found to have a NA level of 109 and a non-focal neuro exam other than nausea on lat gaze and nystagmus.,0
Initial vs were: 98.1 64 160/77 18 98.,0
CT head done in ED with ?,0
"They recommended holding on any anticoagulation, maintaining Plt >100, INR>1.4.",0
"In ED, the pt recieved zofran IV x1.",0
"On arrival to the ICU, he c/o weakness, sinus h/a, mild nausea.",0
He states he had several e/o diarrhea o/n last night.,0
"Past Medical History: - Hypertension - Mitral insufficiency/prolapse - Hyperlipidemia - Prostate cancer s/p prostatectomy ( Hospital) - Rheumatic heart disease as child - Degenerative isc disease - Obstructive sleep apnea - Syncope, episodes in , , .",1
"Social History: - married and retired - denies tobacco use - social EtOH - denies IVDU, illicit or herbal drug use Family History: Father had ca and CABG at age .",0
No family history of CVA or sudden cardiac death.,1
"Physical Exam: Physical Exam: Vitals: T: 97.4 BP: 138/65 P: 60 R: 21 O2: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2.",0
II/VI holosystolic murmur loudest at the apex.,0
"Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, excellent historian, CNII-XII intact, 2-3 beats of asymptomatic nystagmus with lateral gaze bilaterally.",0
"Strength throughout, sensation grossly intact.",0
"Pertinent Results: LABS ON ADMISSION: 12:00PM BLOOD WBC-10.1 RBC-4.60 Hgb-15.2 Hct-45.0 MCV-83 MCH-31.8 MCHC-39.8*# RDW-13.1 Plt Ct-147* 12:00PM BLOOD Neuts-88.5* Lymphs-5.5* Monos-5.0 Eos-0.2 Baso-0.8 12:00PM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-109* K-4.8 Cl-75* HCO3-20* AnGap-19 04:55PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 04:55PM BLOOD Osmolal-236* LABS ON DISCHARGE: 06:40AM BLOOD WBC-6.5 RBC-4.79 Hgb-14.6 Hct-41.6 MCV-87 MCH-30.6 MCHC-35.2* RDW-13.2 Plt Ct-170 04:15PM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-129* K-5.5* Cl-94* HCO3-23 AnGap-18 06:40AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 IMAGING: HEAD CT: IMPRESSION: Small left frontoparietal subdural collection, with foci of hyperdensity suggesting acute on chronic subdural hematoma.",0
No midline shift or herniation detected.,0
Since the previous tracing there is no significant change.,0
"Brief Hospital Course: Mr. is a 67 year-old male with history of HTN, hyperlipidemia, prostate ca s/p prostatectomy, DJD, OSA who presented with nausea/vomiting and weakness, subsequently found to have a Na level of 109.",1
# Hyponatremia- The patient presented with a sodium of 109.,0
Hyponatremia with inappropriately normal urine osms was determined to be consistent with SIADH.,0
The cause was believed to be increased intracranial pressure secondary to the subdural hemmorhage visualized on CT.,1
The patient responded well to aggressive fluid restriction and liberal salt intake.,0
"He did not require hypertonic saline, and outside of his weakness and nausea, remained asymptomatic.",0
"At the end of his hospital course, his sodium level has risen to 127.",0
He will be managed as an outpatient by Dr. of the Renal Department.,0
He was sent home with instructions for fluid restriction and NaCl tabs.,0
# Subdural Hemmorhage- CT scan from showed a small acute on chronic SDH.,0
Neurosurgery felt that no surgical intervention was indicated at this time.,0
"Platelets and INR were monitored and remained stable, anticoagulation was held.",0
# S/p pacemaker placement- The patient was intermittently paced and asymptomic from a cardiac standpoint.,1
# HTN- Home lisinopril continued.,0
Medications on Admission: Simvastatin 20 mg daily Multivitamin daily Lisinopril 10 mg daily Co Q-10 100 mg daily Sildenafil 100 mg PRN Cephalexin 500 mg Q 6 prn x3 days to end today compazine PRN Discharge Medications: 1.,0
Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO twice a day.,0
Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Subdural Hemmorhage Hyponatremia (SIADH) Discharge Condition: Mental Status: Clear and coherent.,0
"Discharge Instructions: Dear Mr. , You were admitted to the hospital with nausea, weakness, and a low sodium level in your bloodstream.",0
You were treated for your low sodium with restriction of fluid intake.,0
"During your hospital stay, your sodium rose steadily, and is now close to normal levels.",0
Please be sure to follow-up in the clinic with Dr. .,0
"Also, continue to commit to the restriction of fluid intake.",0
"Please ADD the following medication: 1 gram NaCL, please take 1 tab twice per day Followup Instructions: You will be contact by Dr. clinic to set up an appointment later this week.",0
You will have your sodium level measured at this time.,0
"Please also contact your primary care doctor, Dr. , at , to make an appointment with him within the next week.",0
11:08 AM ABDOMEN (SUPINE ONLY) Clip # Reason: y.o.,0
"male with likely small bowel obstruction also with r ______________________________________________________________________________ MEDICAL CONDITION: year old man with cad, htn, hiatal hernia, walled off perforated duodenal diverticula, REASON FOR THIS EXAMINATION: y.o.",0
male with likely small bowel obstruction also with retained barium in the colon from previous study.,0
"Tried to obtain a gastrograffin sbft yesterday to look for leak in duodenal diverticular perf., but patient had too much barium in the colon to visulize anything in the small bowel.",0
Pt was given multiple enemas yesterday to help clean out his bowel of the barium.,0
Would like a kub to see if the amount of contrast in the colon has improved so he can have his sbft tomorrow.,0
______________________________________________________________________________ FINAL REPORT ABDOMEN: HISTORY: Probable small bowel obstruction with retained barium in the colon.,0
To evaluate prior to small bowel study.,0
There is retained contrast throughout the colon and in the rectum.,0
No evidence for intestinal obstruction on these plain films.,0
Distal end of NG tube is in region of pyloroduodenal junction.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Unasyn Attending: Chief Complaint: sepsis Major Surgical or Invasive Procedure: Paracentesis X 3 Intubation History of Present Illness: 57-year-old woman w/ h/o HTN, hyperlipidemia, alcoholic cirrhosis transfered from OSH for worsening renal and liver function.",1
She stopped drinking four months ago and is scheduled to have a BDIMC outpt liver transplant evaluation on .,0
"She was admitted from a to AJH on w/ worsening ascites, abnormal LFTs including increased ammonia level (61 on to 129) and ARF.",0
"She was admitted w/ a WBC of 22, Cr of 3.1 (baseline 1.2).",0
"Given concern for SBP, she was tapped and 3.5L fluid were removed but no cultures were sent.",0
She was started on Unasyn IV but developed desquamation of her soles on so it was stopped and steroid cream was used to treat the rash.,0
Renal consult diagnosed her w/ hepatorenal and started her on midodrine 10mg po tid and octreotide 100mcg SQ tid.,0
"The patient was retapped and cultures are pending, gram stain negative, WBC 280 with 29% neut..",0
Per OSH transfer note one out of four bottles BCx grew noncandidal yeast (however micro lab now says no yeast in cultures) and she was started on caspofungin IV.,0
"GI consult felt she was recovering from severe alcoholic hepatitis but recommended no specific therapy other than abstinence from EtOH, diet, and vitamins.",1
"During her hospitalization her INR was noted to be rising, reaching 2.6 on .",0
"Her WBC was 26.4 (88.5% and 15 bands), an increase from 16 over the past few days.",0
Her renal function improved gradually w/ creatinine 1.6 today from 3.1. .,0
"On speaking with her husband, he states there is no way she could have received alcohol within the last week and that she has been sober for about 2 months.",0
"Besides her family, a couple of family friends have visited her in the hospital and .",0
She is currently unable to answer questions.,0
"On the floor she was very agitated, she received 6mg Haldol and was placed in restraints.",0
An NG tube was placed and labs sent.,0
Based upon her labs MICU was called to evaluate.,0
"Past Medical History: 1. acute alcoholic cirhhosis, treated at AJH in 2. hypercholesterolemia 3.",1
HTN 4. chronic hyponatremia 5. depression 6. h/o TAH remotely 7. hemorrhoids seen on sigmoidoscopy Social History: Living at .,0
Quit smoking and drinking ~2 months ago.,0
Previously was drinking heavy liquor alcoholic beverages per day.,1
Used to work for children with special needs but now does not work.,0
"Father deceased, mother has dementia.",0
"2 children, one in and one in , NH, both well.",0
"Family History: n/c Physical Exam: VS: 98.9, 106/45, 112, 28, 98% on 2L NC Gen: agitated, trying to get out of bed, responded yes to name HEENT: MM dry, OP dried blood on palate and lips, anicteric, NG tube in place Neck: supple, no meningeal signs by agitated movement Lungs: Diffuse rhonchi throughout, left greater than right.",0
"CV: tachy, nl S1S2, no friction rub Abd: hypoactive bowel sounds, soft, nontender, distended, + ascites Ext: 3+ pitting edema in LE bilaterally, no c/c, patchy erythema/desquamation on feet bilaterally Neuro: agitated, not responding appropriately to commands, tremulous .",0
"EKG: sinus tach at 127, nl axis, nl intervals, low voltage, right atrial abnormality, poor baseline due to agitation Pertinent Results: OSH Abd U/S: Ascites throughout abdomen, echogenic liver, gallbladder sludge OSH CXR: inspiration poor, minimal atelectasis.",0
"OSH Head CT () : mild atrophy, no acute abnormality .",0
"Brief Hospital Course: A/P: 57F w/ alcoholic hepatitis, likely hepatorenal syndrome transferred from OSH w/ worsening liver function, fevers, agitation.",1
"Initially presented with sepsis based upon tachycardia, elevated lactate, anion gap acidosis, elevated WBC, and low grade temp.",0
admitted with decreased mental status and worsening renal function.,0
"Patient developed progressive Respiratory failure, Liver failure, Coagulopathy, Sepsis and Renal failure.",1
Was admitted to the MICU.,0
Was started on pressors and was also intubated.,0
"Was given multiple units of FFP, platelets and was put on many other life suportin measures.",0
However patient progressively deteriorated and ultimately she was made CMO.,0
Medications on Admission: Medications at nursing home: Protonix 40mg po qd aldactone 50 mg po bid thiamine 100mg po qd folate 1mg qd MVI qd Anusol Protein powder 1 scoop tid .,0
Meds on transfer: albumin 12.5g daily IV Lasix 40mg IV qd Caspofungin 35mg IV qd Levaquin 500mg IV qd (started ) Protonix 40mg po qd Thiamine 100mg po qd Folate 1mg po qd Aldactone 50mg po qam MVI qd Mycolog cream ointment Lactulose 30mL po q12h Neomycin 500mg po tid Ativan 0.5 po q6h prn Triamcinolone ointment Preparation H cream prn Oxycodone 5mg po q4h prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Liver Failure Renal Failure Coagulopathy Respiratory Failure Discharge Condition: Expired Discharge Instructions: Expired Completed by:,1
"3:44 PM CAROTID SERIES COMPLETE Clip # Reason: Syncopal workup Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80F s/p unwitnessed fall sustaining left subgaleal hematoma, rt 7th rib fx, left subtroch fx REASON FOR THIS EXAMINATION: Syncopal workup ______________________________________________________________________________ FINAL REPORT CAROTID DOPPLER CLINICAL INFORMATION: 80-year-old patient is status post fall, question syncope.",1
Real-time evaluation of the carotid bifurcations reveals moderate heterogeneous plaque extending from the distal common carotid into the internal and external carotid arteries on both sides.,0
"However, peak systolic and end-diastolic velocities are unremarkable.",0
The ICA/CCA ratio on the right is 1.0 and on the left 1.0.,0
IMPRESSION: There is plaque in the distal common carotid arteries and at the bifurcation extending into the internal and external carotid arteries.,0
"However, no significant stenoses on either side.",0
Flow in the vertebrals is prograde.,0
"8:31 AM CAROTID SERIES COMPLETE Clip # Reason: eval for CABG Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with 3V CAD, ESRD, Hep C eval for CABG REASON FOR THIS EXAMINATION: eval for CABG ______________________________________________________________________________ FINAL REPORT CAROTID DUPLEX REASON: A 62-year-old male with three-vessel coronary artery disease, end- stage renal disease and hepatitis C, to evaluate for CABG.",1
FINDINGS: Duplex evaluation was performed on the bilateral carotid arteries.,0
"On B-mode imaging, there is calcified plaque in the proximal ICAs bilaterally.",0
"On the right, peak systolic velocities are as follows, 50 in the proximal ICA, 57 in the mid ICA and 51 in the distal ICA.",0
In the CCA there is a velocity of 57 and in the ECA 35 the ICA/CCA ratio is 1.0 and this is consistent with a 1-39% right ICA stenosis.,0
"On the left, the peak systolic velocities are 64 in the proximal ICA, 62 in the mid ICA and 63 in the distal ICA.",0
There is a velocity of 49 in the CCA and 38 in the ECA.,0
The ICA/CCA ratio is 0.77 this is consistent with a 1-39% left ICA stenosis.,0
IMPRESSION: There is a 1-39% right ICA stenosis and a 1-39% left ICA stenosis with antegrade flow in both vertebral arteries,0
10:50 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: MVA ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
FINDINGS: Endotracheal tube is in satisfactory position below the thoracic inlet.,0
The NG tube passes into the stomach.,0
The left hemithorax is partially excluded from this examination.,0
"The visualized lungs are clear with no evidence of consolidation, pneumothorax, or pleural effusion.",0
The osseous structures demonstrate a fracture of the distal left clavicle.,0
IMPRESSION: Fracture of distal left clavicle with no evidence of an acute cardiopulmonary process.,0
The left hemithorax is partially excluded from this exam and a repeat chest X-ray is recommended.,0
10:05 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: ?able to take small amount of liquid/food for comfort Admitting Diagnosis: MYXEDEMA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with complicated myxedema for evaluation of swallow REASON FOR THIS EXAMINATION: ?able to take small amount of liquid/food for comfort ______________________________________________________________________________ FINAL REPORT INDICATION: Difficulty swallowing.,0
There was penetration of nectar and puree.,0
There was no gross aspiration but the patient is noted to be at high risk for aspiration.,0
"For full details, please refer to speech and swallow division note in OMR.",0
IMPRESSION: Penetration of nectar and puree.,0
Residue found in the vallecula.,0
"11:57 AM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP** Admitting Diagnosis: CIRRHOSIS;LIVER TRANSPLANT EVALUATION Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 41M with HCV/EtOH cirrhosis transferred with worsening liver failure MELD 28 for transplant evaluation REASON FOR THIS EXAMINATION: **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP** No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 4:51 PM No focal lesion to suggest HCC seen Persistent ascites Persistent effusions (gas containing on the left) and associated relaxation atelectasis (although pneumonia cannot be excluded) Persistent cholelithiasis, splenomegaly ______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old man with HCV and alcoholic cirrhosis, transferred with worsening liver failure, for transplant evaluation.",1
TECHNIQUE: Multiple MDCT axial images were obtained from the base of lungs through the pelvic brim after the uneventful administration of 200 mL of Optiray intravenously.,0
"Non-contrast, arterial and portal venous phase images as well as delayed images were obtained.",0
"CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: In the visualized thorax, again seen are bilateral pleural effusions, simple in attenuation with associated relaxation atelectasis.",0
Air is seen in the effusion on the right.,0
The heart is probably normal in size.,0
"In the abdomen, the liver has a nodular surface consistent with cirrhosis.",1
No focal enhancing lesions with rapid washout are demonstrated to suggest HCC.,0
Scattered tiny calcific foci are seen.,0
"There is moderate ascites, simple in attenuation.",0
There is no intra- or extra-hepatic bile duct dilatation.,0
The spleen is enlarged measuring 19.3 cm.,0
The kidneys symmetrically take up and excrete contrast without hydronephrosis.,0
"The abdominal aorta is normal in caliber and course, but demonstrates atherosclerotic calcification.",0
Arterial supply to the liver is conventional.,0
"There is narrowing towards the origin of the celiac axis (series 401B, image 38).",0
There is a post-pyloric feeding tube in place.,0
The portal venous system appears patent.,0
The hepatic veins appear patent.,0
MUSCULOSKELETAL: There is no suspicious osteolytic or osteoblastic lesion.,0
No focal lesion with characteristics to suggest HCC.,0
(Over) 11:57 AM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP** Admitting Diagnosis: CIRRHOSIS;LIVER TRANSPLANT EVALUATION Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) 2.,1
Unchanged appearance to nodular cirrhotic liver and pronounced ascites.,1
Narrowing seen at the origin of the celiac axis.,0
"Persistent bilateral pleural effusions (with new hydropneumothorax pockets on the left) and associated relaxation atelectasis, although pneumonia cannot be excluded.",1
"4:36 AM CHEST (PORTABLE AP) Clip # Reason: please eval interval changes Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 33 year old man with AML now with neutropenic fever, GPC bacteremia, and DIC, and new oxygen requirement REASON FOR THIS EXAMINATION: please eval interval changes ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: AML, neutropenic fever.",1
"Normal size of the cardiac silhouette, no pulmonary edema.",1
11:33 AM CT C-SPINE W/O CONTRAST Clip # Reason: Post op CT Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with C6-7 fracture dislocation and C1 fracture.,0
REASON FOR THIS EXAMINATION: Post op CT No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 2:11 PM Extensive post-surgical changes in the mid-to-lower cervical spine with improved alignment at C7-T1.,0
Evaluation of the cord and the thecal sac is markedly degraded due to artifact.,0
Unchanged C1 anterior and posterior ring fractures.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Postop cervical fracture.,1
Comparison is made with preop study from one day prior.,0
The fracture of the anterior and posterior arches of C1 is unchanged.,0
The patient is status post laminectomy at C6-C7 and posterior fusion with interpedicular screws from C3 through T3.,0
The right- sided screw at T2 terminates lateral to the vertebral body in a prevertebral/paravertebral space.,0
Bone graft material is noted laterally.,0
There is air within the thecal sac relating to surgery.,0
Evaluation of the thecal sac on the soft tissue windows is markedly degraded due to artifact and it is difficult to exclude either cord abnormalities or epidural hematomas.,0
There is mild anterolisthesis of C6 on C7 which is unchanged.,0
Previously noted malalignment at C7-T1 has been corrected.,0
Pedicle and articular pillar fractures of C7 are again noted best seen on the sagittal reformats.,0
IMPRESSION: Extensive post-surgical changes in the mid-to-lower cervical spine with improved alignment at C7-T1.,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: Please eval for appropriate line placement/PTX Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with intracranial aneurysm, s/p central line placement; please eval for PTX REASON FOR THIS EXAMINATION: Please eval for appropriate line placement/PTX ______________________________________________________________________________ FINAL REPORT CHEST X-RAY HISTORY: Intracranial aneurysm.",1
Status post central line placement.,0
There is bilateral streaky density consistent with subsegmental atelectasis.,0
Increased density in the infrahilar regions may represent parenchymal consolidation as well.,0
"A nasogastric tube terminates just below the level of the diaphragm, its side hole in the distal esophagus, as before.",0
A left subclavian catheter has been inserted and terminates in the region of the superior vena cava.,0
IMPRESSION: Left subclavian line placed in central position.,0
8:36 PM HIP UNILAT MIN 2 VIEWS IN O.R.,0
PORT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # Reason: ORIF LEFT HIP W/ HARDWARE Admitting Diagnosis: LT HIP FRACTURE ______________________________________________________________________________ FINAL REPORT HISTORY: ORIF left hip with hardware.,0
Fluoroscopic assistance provided to the surgeon in the O.R.,0
These demonstrate steps during placement of dynamic compression screw across a left intertrochanteric fracture.,1
2:16 PM CT HEAD W/O CONTRAST Clip # Reason: Assess for Post-op changes and interval change.,0
"Please perf Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man s/p assault w/ left depressed skull fracture, traumatic, and pneumocephalus.",1
REASON FOR THIS EXAMINATION: Assess for Post-op changes and interval change.,0
Please perform after patient returns from Angion.,0
"No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LLTc SAT 3:50 PM Status post craniectomy and evacuation of a left frontal intraparenchymal hematoma, with distribution of blood products along the left sylvian fissure, neighboring sulci, suprasellar cistern, and right tentorium.",0
No new hemorrhage or large vascular territorial infarction is seen.,0
"The ventricles remain normal in configuration and size, and no new mass effect is present.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post assault with left depressed skull fracture, post-op.",1
COMPARISON: CT available from .,0
TECHNIQUE: MDCT-acquired axial images of the head were obtained without the use of IV contrast.,0
"FINDINGS: Compared to the CT examination from at 6:46 a.m., there has been interval left craniotomy and evacuation of a left frontal intraparenchymal hematoma.",0
"Blood products remain present within the left sylvian fissure and neighboring sulci, with extension into the suprasellar cistern, with some redistribution along the right tentorium.",0
The quadrigeminal cistern remains preserved.,0
No new hemorrhage or mass effect is seen.,0
There is no evidence of a large vascular territorial infarct.,0
Ventricles are unchanged in configuration and size.,0
There is mild opacification of the left mastoid air cells.,0
Included views of the paranasal sinuses are unremarkable.,0
"IMPRESSION: Status post craniectomy and evacuation of a left frontal intraparenchymal hematoma, with distribution of blood products along the left sylvian fissure, neighboring sulci, suprasellar cistern, and right tentorium.",0
12:31 AM CT HEAD W/O CONTRAST Clip # Reason: assess for SDH Admitting Diagnosis: LEFT HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: year old woman with reported SDH on osh ct scan REASON FOR THIS EXAMINATION: assess for SDH CONTRAINDICATIONS for IV CONTRAST: elevated Cr ______________________________________________________________________________ FINAL REPORT INDICATION: Reported subdural hematoma on outside hospital CT.,1
COMPARISON: Outside hospital CT from approximately nine hours prior.,0
"NON-CONTRAST HEAD CT: There is a small hyperdense subdural hematoma layering along the posterior falx and left tentorium as seen on outside hospital CT, and consistent with a small subdural hematoma.",0
There is no associated mass effect.,0
Severe atrophy and small vessel ischemic disease as well as encephalomalacia from prior left frontotemporal infarct are noted.,0
There is mild opacification of the left maxillary sinus.,0
There is complete opacification of the right maxillary sinus with some sclerosis of the walls and volume loss suggesting sinus atelectasis.,0
"Small parafalcine subdural hematoma, stable from outside hospital CT of nine hours earlier.",0
"Atrophy, small vessel ischemic disease and prior left frontotemporal infarct.",0
Sinus atelectasis of the right maxillary sinus with complete opacification.,0
Findings were discussed with Dr. at 1:30 a.m. on .,0
"LINE PLACEMENT Clip # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Admitting Diagnosis: MITRAL STENOSIS\MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with MVR REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY ______________________________________________________________________________ FINAL REPORT INDICATION: Status post cardiac surgery, evaluating for fast track early extubation.",1
COMPARISON: Chest radiographs from .,0
FINDINGS: The endotracheal tube terminates 7.6 cm above the carina.,0
A Swan-Ganz catheter inserted from a right IJ approach terminates in the proximal right pulmonary artery.,0
There is a single midline mediastinal drain.,0
"An orogastric tube extends below the level of the diaphragm, terminating within the proximal stomach.",0
A prosthetic mitral valve is noted.,0
"The heart and mediastinum are slightly widened, expected postoperatively.",0
ET tube terminating 7.6 cm above the carina.,0
"Widening of the heart and mediastinum, expected findings in this postoperative patient.",1
"12:37 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for acute pulmonary change overlying existin Admitting Diagnosis: SHORTNESS OF BREATH;RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with h/o COPD, pulmonary fibrosis with respiratory failure and hypotension REASON FOR THIS EXAMINATION: Please evaluate for acute pulmonary change overlying existing pulmonary disease ______________________________________________________________________________ FINAL REPORT INDICATION: Pulmonary fibrosis, respiratory failure, hypotension.",1
Evaluate for acute pulmonary change.,1
VIEWS: AP view compared with supine AP view from .,0
"FINDINGS: The endotracheal tube, right internal jugular central venous catheter, and nasogastric tube all remain in stable satisfactory positions.",0
Again seen are diffuse bilateral interstitial opacities consisent with patient's known history of pulmonary fibrosis.,1
Assessment of vascular congestion is impossible given the extensive nature of the underlying interstitial disease.,0
The left ventricular enlargement is stable.,0
Small left pleural effusion is unchanged from prior exam.,0
Unchanged appearance of extensive pulmonary fibrosis.,1
3:28 AM CHEST (PORTABLE AP) Clip # Reason: interval eval Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with REASON FOR THIS EXAMINATION: interval eval ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient intubated.,0
Portable AP chest radiograph was compared to and multiple prior radiographs.,0
"The tracheostomy tip is at the midline, 5.4 cm above the carina.",0
The position of the Dobbhoff tube tip is unclear based on this radiograph but was demonstrated to be located in the proximal stomach on the fluoroscopy study obtained on .,0
The right pleural effusion is redemonstrated.,0
Mild vascular engorgement is seen.,0
7:04 PM CHEST (PORTABLE AP) Clip # Reason: CEREBELLAR ICH Admitting Diagnosis: CEREBELLAR ICH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with large left cerebellare bleed REASON FOR THIS EXAMINATION: pna?,0
______________________________________________________________________________ WET READ: KKgc SUN 10:20 PM ETT 45.0 cm above carina.,0
NG tube can be advanced by 3-4 cm for optimal positioning.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Large cerebellar bleed.,0
COMPARISON: Outside chest radiograph from .,0
"FINDINGS: As compared to the previous radiograph, the patient has been intubated.",0
The tip of the endotracheal tube projects 5 cm above the carina.,0
The nasogastric tube could be advanced by 4 to 5 cm.,0
"Unchanged moderate cardiomegaly, without evidence of overt pulmonary edema.",1
Unchanged retrocardiac and right basal atelectasis.,0
No evidence of newly appeared focal parenchymal opacities suggestive of pneumonia.,0
Unchanged alignment of sternal wire after cardiac bypass surgery.,0
2:30 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: NG tube placed appropriately?,0
Admitting Diagnosis: S/P TOTAL COLECTOMY ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with new NG tube placement.,0
REASON FOR THIS EXAMINATION: NG tube placed appropriately?,0
______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess NG tube.,0
The tip end of the NG tube cannot be evaluated due to technique.,0
The tube can be followed to the lower esophagus but exact location of the tip of the NJ tube is not visualized.,0
"There are no other interval changes with persistent low lung volumes, bibasilar atelectasis and cardiac size top normal.",0
"Right central catheter tip is at the confluence of the brachiocephalic vein, is not curving to the upper SVC.",0
Admission Date: Discharge Date: Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending: Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a year old female who was found down by her son in law.,0
She was a GCS of 3 at the scene and was intubated at the OSH.,0
She had a CT head which showed a 10cm x 7cm ICH with greater than 2cm of midline shift.,0
She received 5 units of FFP and vitamin K at the OSH to reverse an INR of 3.2 as she is on Coumadin for CVA in the past.,0
She was transferred to for further care and neurosurgical consultation.,0
Patient is intubated an not sedated upon first interaction.,0
Family not present but coming.,0
"Past Medical History: CVA, HLD, HTN Social History: Lives with daughter and son in law Family History: NC Physical Exam: Gen: intubated, not sedated HEENT: Pupils: fixed EOMs none Neck: Supple.",0
"Abd: Soft, NT, BS+ Extrem: slightly cool with cap refill >2 seconds.",0
"Neuro: Mental status: unresponsive Orientation: unable to assess Language: intubated and nonverbal, does not attempt to make sounds Cranial Nerves: I: Not tested II: Pupils are fixed and dilated at 7mm and are surgical III-XII: unable to assess given patients clinical status Motor: triple flexion BLE L>R, no response to deep noxious in BUE Sensation: unable to asses Reflexes: Cough/corneal/gag all negative Toes down on right mute on left Pertinent Results: CXR: Appropriately positioned ET and NG tubes.",0
Widened mediastinal contour likely secondary to tortuous thoracic aorta.,0
Please note in the setting of trauma if there is concern for mediastinal hematoma/aortic injury CT may be performed to further assess.,0
Brief Hospital Course: Patient presented to from OSH for evaluation for potential management secondary to massive ICH.,0
Imaging was reviewed and it was determined that no surgical intervention would be offered.,0
Patients family arrived and discussion was made regarding goals of care and ultimately decision was made to make her DNR/DNI and admit her to the ICU while awaiting further family members to arrive at which point she would be made CMO.,0
She expired at 836pm on .,0
"Medications on Admission: coumadin, amlodipine, zocor Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Intracranial Hemorrhage Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired",0
"9:50 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrates/effusions Admitting Diagnosis: RLE THROMBOSIS ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with RLE ischemia, MI s/p angio REASON FOR THIS EXAMINATION: assess for infiltrates/effusions ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient after _____.",1
"The bibasilar atelectasis and bilateral small pleural effusion is unchanged, and there is no evidence of congestive heart failure.",0
", R. MED 11R 11:23 AM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate for hypoxic injury/CVA/bleed in this patient Admitting Diagnosis: POST PROCEDURE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with delirium in setting of recent acute medical illness/septicemia.",1
Please evaluate for CVA/hypoxic injury/bleed.,0
REASON FOR THIS EXAMINATION: Please evaluate for hypoxic injury/CVA/bleed in this patient with recent septicemia/hypotension and persistent altered mental status/delirium.,1
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: No acute intracranial process.,0
"5:10 PM CHEST (PORTABLE AP) Clip # Reason: any edivence of infection Admitting Diagnosis: CEREBELLAR BLEED ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with cerebellar bleed, now with some PVC's.",0
"REASON FOR THIS EXAMINATION: any edivence of infection ______________________________________________________________________________ WET READ: RSRc MON 7:16 PM Post CABG with LV configuration of heart, biapical scarring, but no PNA or acute process.",1
"- ______________________________________________________________________________ FINAL REPORT AP CHEST 5:40 P.M., HISTORY: Cerebellar bleed.",0
IMPRESSION: AP chest compared to : The patient has had median sternotomy.,0
"Thoracic scoliosis may be positional, at least in part.",0
1:14 PM CHEST (PORTABLE AP) Clip # Reason: s/p right picc placement read wet and page # with resul Admitting Diagnosis: PANCREATITIS-GALLSTONES ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with ?,0
Pancreatic cyst who needs picc line for tpn.,0
REASON FOR THIS EXAMINATION: s/p right picc placement read wet and page # with result ______________________________________________________________________________ FINAL REPORT INDICATION: Assess PICC position.,0
PORTABLE UPRIGHT FRONTAL RADIOGRAPH: COMPARISON: .,0
FINDINGS: There is a right-sided PICC with its tip in the right atrium.,0
"Atelectatic changes and a small pleural effusion are again noted at the left base, though there has been slight improvement in aeration.",0
There is mild dilation of the bowel loops.,0
Contrast is seen within the large bowel from prior examination.,0
IMPRESSION: PICC in the right atrium.,0
"If this is withdrawn 6-7 cm, it will be in the distal SVC.",0
"Slight improvement in aeration at the left lung base, but with persistent left pleural effusion and atelectasis.",0
This was communicated to the IV nurse at the time of the study.,0
"4:01 AM BABYGRAM AP ABD ONLY Clip # Reason: evaluate bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 27 weeks, guiac + stool REASON FOR THIS EXAMINATION: evaluate bowel gas pattern ______________________________________________________________________________ FINAL REPORT INDICATION: 10 day old girl who was born prematurely at 27 weeks EGA.",1
COMPARISON STUDIES: Portable babygram .,0
FINDINGS: Interval extubation and removal of umbilical venous catheter.,0
There is a new enteric tube with the tip projected over the stomach.,0
Development of an asymmetric bowel gas pattern with a paucity of gas in the right abdomen.,0
The air filled loops in the left aspect of the abdomen are prominent.,0
"Some of these loops have a tubular, unwound appearance.",0
No convincing evidence for pneumatosis or portal venous gas.,0
The visualized bony structures are unremarkable.,0
The visualized basilar lungs are clear.,0
Skin folds project over the left hemithorax.,0
"IMPRESSION: Findings suspicious for necrotizing enterocolitis, although there are no specific findings of this entity.",0
4:23 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for change for infiltrates.,0
"Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with recurrent aspiration pneumonia, CHF REASON FOR THIS EXAMINATION: Please assess for change for infiltrates.",0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup, history of recurrent aspiration pneumonia and chronic heart failure.",0
"As compared to the previous radiograph, the nasogastric tube is in unchanged position.",0
The parenchymal consolidation at the right upper lobe base has markedly decreased in extent and has almost completely resolved.,0
"Otherwise, the radiographic appearance is not substantially changed.",0
There is extensive right-sided pleural effusion with subsequent basilar atelectasis.,0
Unchanged moderate left-sided pleural effusion with retrocardiac atelectasis and very subtle but diffuse parenchymal opacification of the left lung.,0
Unchanged position of the sternal wires.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Aspirin / Motrin Attending: Chief Complaint: Seizures, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 51yo M with h/o ETOH dependence who drinks 12 pack of beer and 1 pint of vodka daily and h/o chornic pancreatitis, h/o HCV s/p IFN presents with seizures and abdominal pain.",1
Pt was at Bourwood and was noted to have seizure activities and was sent to .,0
Pt does not recall any details but only remembers being confused.,0
Denies any chest pain/sob/LH/palpitations prior to passing out.,0
"On , Pt presented to for abdominal pain and was discharged around 1pm on after receiving ativan.",0
"While in the ED at , pt was noted to be on floor by tech, had fallen foward, did not strike head, no LOC.",0
"Pt was mumbling, eyes open, somewhat slurred speech, shaking extremities.",0
Pt was complaining of vision trouble.,0
"Pt was noted to have UE shaking and not answering questions but then after shaking stopped, pt became near instantly conversational.",0
CT head was obtained and was negative.,0
Psych was consulted and was sent to .,0
"There, pt had an episode as above.",0
No previous seizures h/o or DT per pt.,0
"Pt reports his abdominal pain feels like previous ""pancreatitis"" pain.",0
"Last ETOH on with 12 beer and ""some whiskey.""",0
+ anorexia and nausea but no vomiting.,0
"No fevers, chills, or bowel habit changes.",0
"In the , pt received morphine, valium, and zofran.",0
"ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain.",0
"Denies cough, shortness of breath, chest pain or tightness, palpitations.",0
"Denies vomiting, diarrhea, or constipation.",0
"Past Medical History: ETOH use HTN COPD Depression, treated with ECT never had suicide attempt in the past.",0
Pancreatitis Anxiety Autoimmune demyelinating neuropathy- tx with IVig Hepatitis C tx with IFN Lumbar disc surgery Social History: Pt lives alone.,1
Worked in electronics and as a musician.,0
Last worked 4 months ago in computers.,0
Has one son who is 27 yrs old.,0
"Smokes 1 ppd x 30 years, Drinks 12 pack and 1 pint of vodka a day.",0
Longest sobriety ~2wks in detox in .,0
Has been to AA in the past.,0
"Family History: Brother with anxiety, mother with depression.",0
"Physical Exam: VS: 98.2, 92, 130/84, 18, 96% on RA, abdominal pain Gen: NAD, appears comfortable HEENT: NCAT, EOMI, PERRL.",0
"Neck: No JVD, no LAD Cor: RRR no m/r/g Pulm: CTAB no w/r/r Abd: soft +BS, NT/ND, No HSM Extrem: no c/c/e Skin: no rashes Neuro: CN II-XII in tact bilaterally.",0
Strength is in upper and lower extremities.,0
Diminished sensation of L face to light touch (old per pt) and decreased sensation of upper extremities from fingers to elbow bilaterally (not new) + tremor.,0
Pertinent Results: 08:55PM BLOOD WBC-4.9 RBC-4.23* Hgb-12.3* Hct-35.5* MCV-84 MCH-29.1 MCHC-34.6 RDW-14.5 Plt Ct-287 08:55PM BLOOD Neuts-65 Bands-0 Lymphs-31 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 06:50AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0 05:00AM BLOOD ESR-23* 06:50AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-141 K-3.6 Cl-105 HCO3-28 AnGap-12 08:55PM BLOOD ALT-26 AST-70* AlkPhos-58 TotBili-0.4 06:50AM BLOOD ALT-18 AST-38 08:55PM BLOOD TotProt-7.1 Albumin-4.2 Globuln-2.9 Calcium-9.1 Phos-2.1* Mg-2.2 10:20AM BLOOD Iron-221* 08:55PM BLOOD Lipase-46 07:10AM BLOOD Lipase-31 10:20AM BLOOD calTIBC-339 VitB12-275 Folate->20 Ferritn-57 TRF-261 05:00AM BLOOD %HbA1c-5.5 10:20AM BLOOD Prolact-21* TSH-2.2 05:00AM BLOOD CRP-1.7 05:00AM BLOOD PEP-POLYCLONAL IgG-1010 IgA-426* IgM-178 09:03PM BLOOD Glucose-128* Na-136 K-7.7* Cl-100 calHCO3-27 08:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 08:33AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG 08:33AM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG .,0
Imaging: CT head non-contrast (): No acute intracranial process.,0
Sinus disease as described above.,0
EEG with video monitoring (): Final report pending.,0
Interpretation by neuro was that episodes of shaking show no correlated signs of seizure acitivty on EEG.,0
Brief Hospital Course: The patient was admitted with concern for alcohol withdrawal and seizure activity.,1
"Admission labs were notable for low grade anemia to Hct 34 otherwise normal electrolytes, LFT's and pancreatic enzymes.",0
Non-contrast head CT was negative for bleeding.,0
The patient was placed on a CIWA scale with valium.,0
The patient had clinical signs of good control of withdrawal symptoms including normal heartrate and blood pressure and only minimal tremulousness throughout his hospitalization.,0
"The patient had numerous episodes of unresponsiveness characterized by rigid, low frequency shaking of the upper and lower extremities.",0
These episodes were witnessed by both the primary medical team and the neurology consult service.,0
Initially there was concern for EtOH withdrawal seizures.,0
Ultimately these were deemed to be pseudoseizures.,0
"This was confirmed by EEG with video monitoring which revealed no seizure activity at the time of the events, reviewed by the neurology consult team.",0
Initially the patient was treated with IV ativan during these episodes with rapid resolution of his symptoms.,0
Later in his hospitalization he received IV saline with similar rapid resolution of symptoms.,0
These episodes last for up to 15 minutes without intervention before spontaneously remitting.,0
"When these episodes end there is rapid return of interactive, appropriately oriented mentation within seconds to minutes.",0
Sometimes the patient appears confused within the first minute after an episode.,0
He has no incontinence or tongue biting.,0
The patient was confirmed to have polysubstance abuse on urine tox screen including cocaine positive status.,1
This test was also positive for benzo's and opiates after the patient received benzo's as part of CIWA scale and morphine as part treatment for abdominal pain.,0
The patient complained of severe abdominal pain.,0
Initially there was concern for pancreatitis in the setting of EtOH use however the patient had normal pancreatic enzymes and abdominal exam was entirely benign.,0
He initially received narcotic pain medications however he does not require ongoing narcotics.,0
Presumed secondary to chronic alcohol use.,1
"Iron studies, B12 and folate were within normal limits.",0
The patient can have further work-up as an outpatient.,0
"As work-up for lower extremity neuropathy noted on neurology consultation, the patient had HgbA1c at goal, normal TSH.",0
SPEP was notable for a polyclonal hypergammaglobulinemia and UPEP was normal.,0
CRP was normal and ESR was mildly elevated at 23.,0
This can be further evaluated as an outpatient.,0
"For his history of hypertension, the patient was continued on home clonidine.",0
The patient was continued on his outpatient antidepressant regimen.,0
He requested to be DNR/DNI.,0
This should be further addressed during psychiatric care after discharge.,0
The patient was medically cleared for discharge on .,0
Medications on Admission: Klonipin 1mg /prn Clonidine 0.1mg Prilosec 20mg qday Neurontin 900mg QID per pt 60mg qday but not taking Discharge Medications: 1.,0
Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety.,0
Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QID (4 times a day).,0
Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q3H PRN (): For CIWA>10.,0
Discharge Disposition: Extended Care Discharge Diagnosis: Alcohol withdrawal Polysubstance abuse Pseudoseizures Depression Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted with alcohol withdrawal.,1
Please continue to receive valium as needed for withdrawal symptoms.,0
You will continue to receive psychiatry care regarding alcohol and cocaine use.,1
There was concern for seizures but these are pseudoseizures likely due to psychiatric disease.,0
You will continue to receive psychiatry care after discharge.,0
You complained of abdominal pain during your hospitalization.,0
There were no signs of pancreatitis on lab work.,0
You will contine to receive care at an inpatient psychiatry facility.,0
"Call your doctor or return to the hospital for any new or worsening nausea, vomiting, loss of consciousness or any other concerning symptoms.",0
Followup Instructions: You will contine to receive care at an inpatient psychiatry facility.,0
"After discharge from this facility, you should schedule new primary care.",0
"If you would like to be seen at , call .",0
10:03 AM CHEST (PORTABLE AP) Clip # Reason: Asses for lung volumes Admitting Diagnosis: NARCOTIC OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man s/p liver transplant REASON FOR THIS EXAMINATION: Asses for lung volumes ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Evaluate lung volume status post liver transplant.,0
The lung volumes are quite low.,0
The cardiac and mediastinal structures are stable.,0
"There has been an apparent interval increased vascular engorgement and perihilar haziness, but the lung volumes are slightly lower than on the prior study.",0
Drains remain in place in the right upper quadrant of the abdomen consistent with recent surgery.,0
"Note is made, however, of slight improved aeration in the left retrocardiac region when compared to the prior exam.",0
IMPRESSION: 1) Improving aeration in the left retrocardiac region.,0
"2) Increasing perihilar haziness, which could potentially be due to vascular crowding related to relatively expiratory phase of expiration.",0
"However, perihilar edema may also produce this appearance and follow-up radiograph with better lung volumes would be helpful in this regard.",0
"11:24 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p trach placement, ?",0
"PTX Admitting Diagnosis: SUB DURAL HEMATOMA,FALL,C6 FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p advancing of ETT and NGT.",0
"REASON FOR THIS EXAMINATION: s/p trach placement, ?",0
"PTX ______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old status post tracheostomy tube placement, assess for pneumothorax.",0
Comparison is made to prior exam obtained the same day at 06:18.,0
"Since the prior study, there has been removal of the ET tube and placement of a tracheostomy tube.",0
"The right subclavian central venous line remains in place, its tip in the mid SVC.",0
There is a mild degree of partial atelectasis in the anterior segment of the right upper lobe.,0
The remainder of the lungs are unchanged since the prior study.,0
Left lower lobe atelectasis is again noted.,0
IMPRESSION: Interval placement of a tracheostomy tube and no evidence of pneumothorax.,0
"10:11 PM CHEST (PORTABLE AP) Clip # Reason: PNEUMOTHORAX S/P LARYNGECTOMY ______________________________________________________________________________ MEDICAL CONDITION: REASON FOR THIS EXAMINATION: PNEUMOTHORAX S/P LARYNGECTOMY ______________________________________________________________________________ FINAL REPORT INDICATION: Status post laryngectomy, question pneumothorax.",0
A feeding tube extends below the diaphragm.,0
Surgical staples are present along the neck bilaterally.,0
There is left retrocardiac opacification.,0
Left lower lobe opacity likely represents atelectasis although aspiration should be considered in the proper clinical setting.,0
"4:54 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with basilar thrombus, pontine infarct REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 67-year-old male with posterior circulation infarction.",0
Interval evaluation of the chest.,0
"COMPARISON: Multiple prior examinations, most recent dated .",0
"FINDINGS: Again seen are scattered areas of atelectasis, not significantly changed in extent from the prior examination.",0
"No pleural effusion, pulmonary edema, or pneumothorax is present.",0
The endotracheal tube is in standard position.,0
Two esophageal catheters are present.,0
One probe terminates inferior to the diaphragm.,0
A second catheter courses inferior to the diaphragm and becomes obscured.,0
A left-sided subclavian line has been removed.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: CODE STROKE: left arm weakness, left facial droop, inability to speak Major Surgical or Invasive Procedure: Trans-esophageal echocardiogram History of Present Illness: Mr is a 32 year old man with no significant PMH who presented with left sided weakness and the inability to speak.",1
History is aided from his family friend at bedside and over the phone while patient was being transported from .,1
Patient was in a normal state of health at 11 am this morning and was speaking with his friend.,0
"night and this morning he also felt well, and was playing basketball with his friends.",0
At some point between 12-1pm today patient emerged from his room and he was not able to speak yet he was still walking.,0
He wrote on a piece of paper that he needed help and to go to the hospital.,0
He was then taken to where he had an NIHSS of 13.,0
"Initial vitals were 167/79, HR 115, Temp 97.7, 99% on RA.",0
Decision was made to give IV t-PA. tPA was given at 14:21 PM (6.8 mg IV push and 61 mg/hour).,0
Patient was then transferred to for potential neuro-interventional procedure.,0
On arrival to ED patient was able to communicate only by writing and was stating he had an headache.,0
Repeat NIHSS was done and was given a 14.,0
A repeat NCHCT was significant for extensive cerebral edema and decision was made to not persue an intervention.,1
"On general review of systems (obtained through his friends), the pt had not complainted of reecent fever or chills.",0
No night sweats or recent weight loss or gain.,0
"Denies cough, shortness of breath.",0
"Denies chest pain or tightness, palpitations.",0
"Denies nausea, vomiting, diarrhea, constipation or abdominal pain.",0
"Past Medical History: -none -no history of sickle cell, cardiac disease, or any medical problems this is his first time to a hospital ever.",0
Social History: Patient is originally from but has lived in the US for the past 6 years.,0
Was there several weeks back for a wedding.,0
Was living in and was planing on moving back to .,0
He is currently staying with a family friend here in .,1
Recently graduated from a masters in architecture program.,0
"Social etoh, no smoking, or illicit drug use.",0
"Family History: Sister: 2 miscarriages Father: possible stroke in his 20s with some paralysis--unclear history Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: T: 98 P:117 R: 25 BP:139/103 SaO2:97% General: Awake, cooperative, NAD.",1
"No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: sinus Abdomen: soft, NT/ND, no masses or organomegaly noted.",0
Extremities:warm and well perfused Skin: no rashes or lesions noted.,0
"Neurologic: -Mental Status: done by patient writing, he was alert, oriented x 3.",0
Attentive following midline and appendicular commands.,0
Language is fluent to writing but he remains mute with no attempt to speak.,0
was able to name both high frequency objects from stroke card by writing them out.,0
had good knowledge of current events.,0
He appears to be neglecting the left.,0
"Calculation was intact (answers (""4+3 = 7"" for seven quarters in $1.75) .",0
"left field cut vs heavy neglect on the left, but extingushes to DSS.",0
VII: left facial droop VIII: Hearing intact to voice .,0
-Motor: Delt Bic Tri WrE FFl FE IO IP Quad Ham TA EDB L 3 0 0 0 0 0 0 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 .,0
"-Sensory: he writes only ""slight feeling on the left"" -DTRs: Tri Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was mute .",0
"-Coordination: No intention tremor,on FNF on the right =========================== PHYSICAL EXAM ON DISCHARGE: Vitals: 98.2 110/75 62 18 100% RA Neuro: Severe aphonia (difficulty producing speech) but preserved comprehension and ability to communicate via written language.",0
+distal left arm weakness (3+/5 in left wrist and finger extensors).,0
Full strength in bilateral lower extremities and right arm.,0
Pertinent Results: LABS ON ADMISSION: -WBC-6.4 RBC-5.43 Hgb-15.1 Hct-44.2 MCV-81* MCH-27.8 MCHC-34.2 RDW-13.5 Plt Ct-260 -PT-11.9 PTT-22.4* INR(PT)-1.1 -Glucose-170* UreaN-10 Creat-1.1 Na-139 K-3.9 Cl-100 HCO3-26 AnGap-17 -CK(CPK)-836* -ALT-24 AST-23 LD(LDH)-198 AlkPhos-80 TotBili-0.4 Lipase-31 .,0
CARDIAC ENZYMES: - 4PM: CK-MB-2 cTropnT-<0.01 CK(CPK)-836* - 11:40PM: CK-MB-1 cTropnT-<0.01 CK(CPK)-706* - 8:47AM: CK-MB-1 cTropnT-<0.01 CK(CPK)-574* .,0
MODIFIABLE STROKE RISK FACTOR LABS: -Cholest-218* Triglyc-68 HDL-78 CHOL/HD-2.8 LDLcalc-126 -%HbA1c-7.3* eAG-163* .,0
"HYPERCOAGULABILITY WORKUP LABS: -Lupus-NEG -ProtCFn-136 -ProtSFn-228* (high, normal is 50-150%) -ACA IgG-1.6 ACA IgM-6.3 -AT-120 -ALPHA 2 ANTIPLASMIN-69% (low, normal is 80-150) -PLASMINOGEN ACTIVITY-90% (normal) -BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-<9% (normal) --NEGATIVE -HIV Ab-NEGATIVE .",0
LABS ON DISCHARGE: -WBC-3.7* RBC-4.79 Hgb-13.0* Hct-39.1* MCV-82 MCH-27.2 MCHC-33.2 RDW-13.8 Plt Ct-281 -PT-23.9* INR(PT)-2.3* .,0
"NONCONTRAST HEAD CT (): There is a large region of transcortical hypoattenuation in the right temporal lobe, with some superior extension into the parietal lobe, consistent with a right MCA distribution acute ischemic infarct, likely predominantly involving its inferior division.",0
"No definite ""hyperdense"" right MCA is appreciated.",0
"There is no intracranial hemorrhage, mass effect, or shift of normally midline structures.",0
"Apart from the site of infarction, the -white matter differentiation is preserved.",1
Ventricles are normal in size and configuration.,0
Mild sulcal effacement is seen in the right temporal region.,0
Suprasellar and basilar cisterns are patent.,0
Paranasal sinuses and mastoid air cells are well aerated.,0
Globes and orbits are preserved.,0
IMPRESSION: Large acute right MCA distribution ischemic infarct without significant mass effect or intracranial hemorrhage.,0
NONCONTRAST MRI HEAD (): 1.,0
"Large acute-to-subacute right MCA stroke, with expected parenchymal edema, but no midline shift.",1
No evidence of large amount of intracranial hemorrhage.,0
Small hypointense foci in the gradient echo images could represent either flow voids or a small amount of hemorrhage.,0
TTE (): The left atrium and right atrium are normal in cavity size.,0
IMPRESSION: No ASD/PFO or cardiac source of embolism.,0
TEE (): No cardiac source of embolism seen.,0
"However, there was quite vigorous inflow from the inferior vena cava which was baffled towards the septum by the Eustachian valve.",0
"As a result the upper part of the right atrium does not opacify well with bubbles, making less bubbles available for potential shunting.",0
MRI brain w/o contrast (): Evolving right MCA territory subacute infarct with hemorrhage.,0
BILATERAL LOWER EXTREMITY DOPPLERS (): No evidence of deep vein thrombosis of either right or left lower extremity.,0
Brief Hospital Course: Mr is a 32 year old man with no significant PMH who presented with left sided weakness and the inability to speak.,0
"# CRYPTOGENIC RIGHT MCA STROKE: Per HPI, patient received IV tPA at OSH prior to transfer to .",1
"On arrival to the ED, a repeat NCHCT showed extensive cerebral edema so decision was made not to pursue neuro-interventional procedure.",1
Patient was admitted to Neuro-ICU for close monitoring.,0
"On arrival to the Neuro-ICU, strength had improved in the left lower extremity, but patient remained plegic in left upper extremity and left lower face and was neglecting the left side.",0
"He also had a severe headache not responsive to toradol, dilaudid, fentanyl or Tylenol.",0
Repeat head CT 24 hours post tPA was stable compared to prior.,1
"CTA showed right MCA superior division cut-off, and MRI confirmed large right MCA stroke.",0
For first 2 days of hospitalization he was quite lethargic and remained in ICU for close neurologic monitoring given risk for herniation cerebral edema.,1
His lethargy improved after this and he was transferred to the regular neurology floor for further monitoring.,0
"Given presence of right MCA superior division cut-off on CTA head, etiology of patient's stroke was felt most likely embolic.",0
"Extensive workup for embolic stroke was pursued, none of which was revealing.",0
He had TTE which showed no PFO/ASD/atrial thrombi.,0
"Follow-up TEE showed Eustachian valve (fetal remnant) which caused artifact on study, but no clear PFO/ASD etc were seen.",0
Routine LENIs showed no DVT.,0
"Given family history of early stroke (father) and sister with h/o 2 miscarriages, hypercoagulable state was also considered so extensive lab panel was sent including , lupus anticoagulant, Protein C/S activity, anticardiolipin IgG/IgM, alpha 2 antiplasmin, plasminogen antibody, and beta 2 migroglobulin IgA/IgG/IgM.",1
All of these studies were negative.,0
"HIV antibody was also sent (as HIV can cause increased propensity for thrombosis, presence of anti-phospholipid antibodies, clotting factor abnormalities and TTP-HUS).",0
"However, of note ultra-sensitive HIV PCR was not sent.",0
"Patient also had routine modifiable stroke risk factor labs sent (A1C, full lipid panel) sent which revealed elevated A1C (7.3%) and elevated LDL (126).",0
He was started on atorvastatin 40mg daily for secondary stroke prevention.,0
"Metformin 500mg PO BID was initially started, then stopped as small vessel disease was clearly not likely etiology of this stroke and diet/exercise seemed more appropriate intervention.",0
"For directed stroke treatment, patient was initially started on ASA 325mg daily.",0
"However, as it was felt that etiology of this stroke was likely embolic, the decision was made to empirically start lifelong Coumadin for secondary stroke prophylaxis (day 1 = ).",0
Patient's INR remained stable between on Coumadin 2.5mg daily during hospitalization.,0
He will follow up with clinic for monitoring.,0
"Clinically, patient's symptoms improved slowly during hospitalization with the aid of extensive PT, OT and speech therapy.",0
His LLE strength quickly improved to full.,0
"His LUE strength improved to full in the proximal extremity, although he still has weakness in his distal LUE particularly in the wrist and finger extensors.",0
"His difficulty speaking was of particular interest to the neurology team, as aphemia (inability to vocalize, with preserved comprehension and written language) is almost always a left-sided brain lesion in right-handed patients.",0
Ultimately it was felt that he is probably genetically co-dominant in terms of handedness.,0
"For insurance reasons, patient was unable to be discharged to rehab.",0
"With extensive help from PT, OT, speech therapy and case management teams, plan was made for patient to be discharged to friend's home in with free care for outpatient PT/OT/ST.",0
"He will follow up with Neurology (Dr. in 2 months, at which point he will likely have repeat functional MRI for prognostic purposes.",0
He will also have new PCP appointment within the next month: would advise rechecking HIV at this point.,0
"===================== TRANSITIONS OF CARE: - Contact info: mother (), (friend he will be staying with upon discharge: ).",0
Patient's cell phone # is but he is unable to speak.,0
- Should consider repeat HIV test in future - Will follow up as outpatient with Dr. in clinic ==================== ============================================================ 1.,0
Dysphagia screening before any PO intake?,0
(x) Yes - () No 2.,0
(x) Yes - () No 3.,0
Antithrombotic therapy administered by end of hospital day 2?,0
(x) Yes - () No 4.,0
(x) Yes (LDL = 126 ) - () No 5.,0
"(for LDL > 100) () Yes - () No (if LDL >100, Reason Not Given: ) 6.",0
() Yes - () No (Reason (x) non-smoker - () unable to participate) 7.,0
(x) Yes - () No 8.,0
()x Yes - () No 9.,0
"() Yes - () No (if LDL >100, Reason Not Given: ) 10.",0
(x) Yes (Type: () Antiplatelet - () Anticoagulation) - () No 11.,0
Discharged on oral anticoagulation for patients with atrial fibrillation/flutter?,0
() Yes - () No - (x) N/A Medications on Admission: None Discharge Medications: 1.,0
Warfarin 2.5 mg PO DAILY16 Start in am RX *warfarin [Coumadin] 1 mg 2.5 tablet(s) by mouth once a day Disp #*100 Tablet Refills:*2 5.,0
Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: 1.,0
Right MCA stroke (likely embolic) 2.,0
High cholesterol Discharge Condition: Mental Status: Clear and coherent.,0
Neuro exam: severe aphonia (difficulty producing speech) but preserved comprehension and ability to communicate via written language.,0
"Discharge Instructions: Dear Mr. , You were admitted to the hospital after developing sudden-onset inability to speak and weakness in your left arm.",0
"You first went to an outside hospital where you were found to have a stroke and received IV tPA, a clot-busting medication.",0
You were then transferred to where you were initially monitored closely in the ICU for brain swelling.,0
"We did an MRI which showed that you had a large stroke on the right side of your brain, likely caused by a blood clot (embolus).",0
"We searched extensively for the cause of this clot, but could not find any particular reason why you developed it.",0
"To prevent you from having more strokes in the future, we started you on Coumadin, a blood thinning medication to prevent clots from forming.",0
"We also found you have high cholesterol, so we started you on a cholesterol-lowering medication (atorvastatin) to help prevent future strokes.",0
"During hospitalization you worked closely with speech therapy, occupational therapy and physical therapy to regain some of your speech and strength.",0
You will continue doing this as an outpatient.,0
"Now that you are on Coumadin, you will need to have your blood tested periodically to make sure the level (a.k.a.",0
You will be called by the Clinic on to arrange your lab tests.,0
"Please attend the outpatient appointments listed below with your new Primary Care doctor ( ), your Neurologist ( ), and physical therapy.",0
We made the following changes to your medications: 1.,0
STARTED Coumadin (Warfarin) 2.5mg by mouth daily 2.,0
"STARTED atorvastatin 40mg by mouth daily Followup Instructions: Department: NEUROLOGY When: Tuesday, at 5:30 pm With: , M.D.",0
"() Building: , Campus: EAST Best Parking: Garage Department: When: THURSDAY at 3:15 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage OCCUPATIONAL THERAPY APPOINTMENTS: Department: REHABILITATION SERVICES When: THURSDAY at 11:20 AM With: , OTR/L Building: Campus: EAST Best Parking: Garage Department: REHABILITATION SERVICES When: TUESDAY at 1:20 PM With: , OTR/L Building: Campus: EAST Best Parking: Garage Department: Speech Therapy When: , at 8:30-9:90 am When: Thursday, at 2:00-3:00 pm When: Thursday, at 3:30-4:30 pm Where: Span 106 (off enterance to Building, ) Department: Rehabilitation Services - Physical Therapy When: Thursday, at 2:15pm With: Where: Span 106 (off enterance to Building, ) Telephone: MD,",0
"7:52 AM CHEST (PORTABLE AP) Clip # Reason: eval for effusion Admitting Diagnosis: MITRAL VALVE INSUFFICIENCY\Mitral Valve Repair/Replace with Concomitant Maze Procedure /SDA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man s/p mv repair REASON FOR THIS EXAMINATION: eval for effusion ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, .",1
"CLINICAL INFORMATION: Mitral valve repair, evaluate for effusion.",1
FINDINGS: Frontal view of the chest is compared to the prior study from .,0
"The Swan-Ganz catheter has been removed, and the right IJ Cordis sheath remains but it appears to be kinked in the neck.",0
"The appearance of the chest is relatively unchanged with continued bilateral pleural effusions, bibasilar atelectasis, retrocardiac consolidation and cardiomegaly.",0
Admission Date: Discharge Date: Service: CHIEF COMPLAINT: Transfer from outside hospital for VT arrest.,0
HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old male with a reported history of a total right RCA occlusion found on catheterization report in .,0
"By EMS report, the patient was found lying in the grass in his yard, pale, and diaphoretic complaining of chest pain.",0
"In the ambulance on the way to the hospital, the patient became unresponsive.",0
AED device was used to deliver two shocks.,0
Rhythm was read as V-fib.,0
"On arrival to the hospital, the patient was still in cardiac arrest with CPR being performed.",0
"At the hospital, the patient was intubated and defibrillated.",0
"Initial assessment was inferior myocardial infarction based on ST elevations in leads II, III, and aVF.",1
"Patient was treated with aspirin, Heparin, and transferred to .",0
"The patient was sent to the Catheterization Laboratory, and in the Catheterization Laboratory, and CVP of 17, pulmonary capillary wedge pressure of 30, cardiac output 18.9, cardiac index of 8.70, and the O2 was 91%.",0
"No evidence of mitral regurgitation, ejection fraction of 40%.",0
Left ventriculogram also showed inferior akinesis.,0
"Catheterization of the left coronary arteries showed mild disease, LAD with mild disease.",1
Circumflex showed a nondominant lesion without critical lesions.,0
Right coronary artery showed dominant vessel with chronic total occlusion with large bridging collaterals.,1
"Of note, the patient developed ventricular tachycardia during catheterization likely secondary to irritation of the right ventricle from the PA catheter.",1
Tachycardia was resolved with immediate withdraw of the catheter.,0
"PHYSICAL EXAMINATION: Afebrile, pulse of 78, blood pressure 110/50, 92% on the vent.",0
"Generally, the patient was lying in bed, intubated, and sedated.",0
"HEENT showed pupils are equal, round, and reactive to light and accommodation.",0
"Neck was without carotid bruits, 8 cm jugular venous distention.",0
Lung exam showed bilateral crackles.,0
Cardiac examination was difficult to appreciate irregular heart sounds.,0
"Abdomen was obese, nontender, and nondistended.",0
Extremities were cool to the touch.,0
Neurological: Cranial nerves II through XII were intact.,0
"LABORATORIES ON PRESENTATION: White blood count 13.2, hematocrit 39, platelets 128.",0
"Chem-7: Sodium 144, potassium 4.2, chloride 115, bicarb 19, BUN 23, creatinine 1.3, glucose 176.",0
"Calcium 7.5, magnesium 1.6, phosphorus 3.6, initial CK was 108.",0
"Arterial blood gas showed a pH of 7.27, 46, 59 consistent with hypoxemia, respiratory acidosis, and metabolic acidosis.",0
"Chest x-ray is consistent with mild congestive heart failure, small bilateral pleural effusions.",0
ASSESSMENT AND PLAN: This is a -year-old male who presents to status post VT arrest in the field.,0
PAST MEDICAL HISTORY: Currently unknown.,0
"The patient was known to have previous right coronary artery disease given his prior history of coronary artery disease most likely cause is ventricular tachyarrhythmias, underling coronary artery disease.",1
Risk factors included advanced age and male sex.,0
"Patient was started on aspirin, atorvastatin.",0
Coronary arteries showing only mild disease and total occlusion of RCA which was adequately collateralized.,1
Lasix was initiated for diuresis.,0
"Rhythm: Patient was placed on amiodarone IV and metoprolol for arrhythmia and rate control, and was evaluated for AICD placement.",0
"Pulmonary: Patient was hypoxic on presentation, intubated in the field, however.",0
Patient was easily extubated on the morning after admission.,0
Patient was seen to have metabolic acidosis with an elevated lactate and abdominal pain.,0
Was concerning for ischemic colitis.,0
Further events were to monitor DVTs and wean patient off the vent.,0
"FEN/GI: Continue acid prophylaxis, Protonix.",0
Electrolytes were repleted as necessary.,0
"HOSPITAL COURSE: Overall, patient presented with V-fib arrest.",0
Received three ................ in the field.,0
The patient was reperfused after shocks and was shown to have inferior ST elevations consistent with an inferior wall myocardial infarction.,1
"The patient was taken to the Catheterization Laboratory, found to have a chronic collateralized RCA.",0
Thought to have scar-induced VT.,0
The patient was easily extubated and metabolic acidosis with elevated lactate improved during his hospital course.,0
Patient was evaluated for AICD placement due to an episode of VT. AICD was placed on .,0
Patient tolerated the procedure without any difficulty.,0
"Patient is currently ventricularly paced during implantation of this device, VT was induced and patient was able to be shocked out of VT with his device.",0
"Postprocedure, the patient was started on amiodarone, and will be continued on this medication for 1-1.5 months after followup as an outpatient.",0
"Patient's cardiovascular status improved, although his ventricular dysfunction and ejection fraction 39% remained the same, the patient received an AICD ventricular pacing at 80 beats per minute, and currently on antiarrhythmic therapy.",0
Patient was originally started on captopril and changed to lisinopril.,0
Also originally started on metoprolol and changed to Toprol XL.,0
"On discharge, the patient's abdominal examination had improved after adequate hydration and treatment with levofloxacin and Flagyl.",0
The patient did not have any further evidence of distention or abdominal pain.,0
"Patient was noted to have developed a mild thrombophlebitis of his right hand, however, he has remained afebrile.",1
Warm compresses tid and elevation of his arm were prescribed.,0
The patient is currently on antibiotics.,0
Physical Therapy consult was placed prior to discharge as this patient has been deconditioned during hospitalization.,0
DISPOSITION: The patient will be discharged to an intermediate-rehab facility as recommended by Physical Therapy consult.,0
"Patient is advised to followup with Cardiology as an outpatient for monitoring for further arrhythmias, interrogation of his device, and management of his home going medications.",0
"On discharge, patient was afebrile.",0
Levofloxacin 250 mg po q day x7 days.,0
Metronidazole 500 mg po tid x7 days.,0
Amiodarone 200 mg po bid.,0
Metoprolol XL 200 mg po q day.,0
"Again, the patient is to be discharged to rehab, and will follow up with Cardiology as an outpatient.",0
"DR., 12-749 Dictated By: MEDQUIST36 D: 11:39 T: 12:02 JOB#:",0
"10:05 PM CT HEAD W/O CONTRAST Clip # Reason: interval change Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with s/p nine story fall w/ multiple injuries including SDH and SAH REASON FOR THIS EXAMINATION: interval change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Nine-storey fall, intracranial hemorrhage.",1
"Multiple foci of intraparenchymal hemorrhage are seen in the right temporal lobe, left temporal lobe, right frontal lobe, left frontal lobe, left medial occipital lobe, and right parietal lobe.",1
"Some of these have increased in the interim, with the largest being in the left frontal lobe with some surrounding edema, measuring 9 mm.",0
"Subarachnoid small focus of blood seen in the right parietal lobe, and along both left and right frontal lobes near the vertex.",0
Probable tiny amount of subarachnoid blood in the right temporo-occipital region again seen.,0
"Tiny amount of subfalcine hemorrhage, slightly increased since the last examination, without mass effect.",0
"No hydrocephalus, shift of normally midline structures, or major vascular territorial infarct are identified.",0
"High-density material opacifying both maxillary sinuses and the nasopharynx, likely presenting blood.",0
Multiple facial fractures again noted.,1
Sphenoid sinus air-fluid levels increased in the interim.,0
Ethmoid air cells are completely opacified.,0
Mastoid air cells are clear.,0
Soft tissue swelling along the dependent aspect of the brain.,0
Small foci of air seen in both temporal fossae.,0
"Scattered multiple intraparenchymal hemorrhages slightly increased since the last examination, some with obvious edema, but none with mass effect.",1
"Slight increase in size of subfalcine hemorrhage, but without mass effect.",0
Multiple facial fractures as detailed in CT facial bones of previous day.,1
"Complete opacification of maxillary sinuses, ethmoid air cells, and air-fluid levels in sphenoid sinus.",1
High-density material likely reflects blood in these regions.,0
Tiny amount of subarachnoid hemorrhage in the right parietal and right temporo-occipital region.,0
(Over) 10:05 PM CT HEAD W/O CONTRAST Clip # Reason: interval change Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT (Cont),0
", R. CSURG CSRU 7:58 AM CHEST (PORTABLE AP) Clip # Reason: ?",0
effusion Admitting Diagnosis: CORONARY ARTERY DISEASE/SDA\AORTIC VALVE REPLACEMENT WITH STERNOTOMY ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with s/p asc aorta replacement REASON FOR THIS EXAMINATION: ?,1
effusion ______________________________________________________________________________ PFI REPORT Improved aeration right lower lobe.,0
Persistent partial collapse left lower lobe.,0
Small left pleural effusion is unchanged.,0
Continued improvement in fluid overload.,0
"3:04 PM ANKLE (AP, MORTISE & LAT) LEFT Clip # Reason: Assess for osteomyelitis Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with diabetes, left malleolar ulcer REASON FOR THIS EXAMINATION: Assess for osteomyelitis ______________________________________________________________________________ FINAL REPORT INDICATION: Assess for osteomyelitis.",1
"LEFT ANKLE, THREE VIEWS: A lateral fixation plate is seen at the distal fibula, with three transfixing screws.",0
No evidence of hardware complication.,0
"Similarly, two cannulated screws are seen across the medial malleolous, also without evidence of hardware complication.",0
No discrete fracture line is identified.,0
There are no findings to suggest osteomyelitis such as bony destruction or soft tissue defects.,0
"However, of note there is significant demineralization of the osseous structures, which decreases the sensitivity for detection of such findings.",0
Small plantar and posterior calcaneal spurs are also seen.,0
Marked vascular calcifications are present.,0
interval change Admitting Diagnosis: AIRWAY OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman R base PNA with TBM REASON FOR THIS EXAMINATION: ?,0
interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:22 AM No appreciable change.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient with known tracheobronchomalacia and right lower lung pneumonia.,1
The cardiomegaly with bulging of the pulmonary trunk is stable.,0
There is no change in the position of the mitral valve.,0
There is no appreciable change in the right lower lobe and left perihilar opacities as well.,0
There is no increase in pleural effusion.,0
"3:29 AM CHEST (PORTABLE AP) Clip # Reason: interval changes Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 77F with COPD on home O2, OSA s/p ex-lap for cecal perforation with right hemicolectomy and primary anastamosis , now with fluid overload, respiratory failure REASON FOR THIS EXAMINATION: interval changes ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with home oxygen supply after exploratory laparotomy with cecal perforation.",1
"Bilateral pleural effusions, bibasal atelectasis and mild interstitial pulmonary edema are unchanged.",0
Left central venous line and NG tube are unchanged.,1
Overall no significant change since the prior study.,0
"10:35 AM CHEST (PA & LAT) Clip # Reason: ro pna, chf, pulm edema, etc Admitting Diagnosis: BLADDER CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p cystectomy, neobladder.",0
"still on 2l o2 REASON FOR THIS EXAMINATION: ro pna, chf, pulm edema, etc ______________________________________________________________________________ FINAL REPORT STUDY: Chest x-ray.",0
INDICATION: Patient status post cystectomy.,0
TECHNIQUE: PA frontal and lateral chest radiographs were obtained.,0
"A left basilar pleural effusion is identified, the right basal pleural effusion is not clearly resolvable now.",0
Patient's NG tube has been removed.,0
Some generalized increased markings are present consistent with COPD.,0
"Medial basilar infiltrate identified in the right side is unchanged, but represents a definite new development when compared to radiographs going back to .",0
Unchanged significant biapical pleural capping.,0
CONCLUSION: Again identified is a right basilar infiltrate.,0
This is felt to reflect some developing consolidation.,0
Left-sided pleural effusion is seen.,0
4:38 AM CHEST (PORTABLE AP) Clip # Reason: PNA?,0
Admitting Diagnosis: ASTHMA;COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with COPD and respiratory failure REASON FOR THIS EXAMINATION: PNA?,1
"______________________________________________________________________________ FINAL REPORT AP CHEST, 5:23 A.M. ON HISTORY: COPD and respiratory failure, check pneumonia.",1
IMPRESSION: AP chest compared to through 27: Bibasilar opacification is improving.,0
Whether this was pneumonia or atelectasis is hard to say.,0
Heart size is normal and there is no pleural abnormality.,0
A small region of infection in the right upper lobe is slowly resolving.,0
Right jugular line ends in the upper SVC and nasogastric tube passes below the diaphragm and out of view.,0
2:27 PM BABYGRAM (CHEST ONLY) Clip # Reason: R/O PNEUMOMEDIASTINUM Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with RESP DISTRESS.,1
"REASON FOR THIS EXAMINATION: R/O PNEUMOMEDIASTINUM ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST X-RAY, , 14:48 HISTORY: Three day old boy who is a twin and was born prematurely.",0
Respiratory distress and prior pneumomediastinum.,1
COMPARISON STUDIES: Portable chest x-ray done on .,0
FINDINGS: There is an endotracheal tube with the tip at the thoracic inlet.,0
There is an umbilical venous catheter with the tip projected over the mid right atrium.,0
Bilateral diffuse granular pulmonary parenchymal opacities have likely not changed substantially.,0
"There are superimposed tubular and rounded lucencies, more so in the left lung.",0
The cardiothymic silhouette appears normal.,0
There is no convincing evidence for pleural effusion.,0
The visualized bowel gas pattern is unremarkable.,0
Findings most consistent with hyaline membrane disease.,0
The rounded and tubular lucencies are most compatible with Surfactant effect in a child of this age.,0
"However, the prior presence of pneumomediastinum is compatible with barotrauma.",0
"This raises the issue of pulmonary interstitial emphysema, although this would be unusual in a child of this age.",1
Suboptimal positioning of umbilical venous catheter.,0
Recommend repositioning nearer to the hemidiaphragm.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Losartan / Aspirin / Lisinopril-Hctz Attending: Chief Complaint: aspiration, hypoxia Major Surgical or Invasive Procedure: Multiple intubations Nasogastric tube Left internal jugular central line PEG tube placed and replaced History of Present Illness: This is a 69 year old bedbound Somalian speaking only woman well known to with end stage renal disease on hemodialysis, diabetes mellitus type 2, chronic hyponatremia, history of pulmonary embolus on coumadin and recent admissions to ICU with enterobacter/klebsiella/pseudomonas bacteremia who presents from rehab with hypoxia and decreased responsiveness in setting of apparent aspiration.",1
"Events at rehab unclear but during hemodialysis, patient desatted to 74%.",0
Apparently a code was called but event details not known.,0
"Pt was suctioned which produced ""thick yellow sputum and vomit"".",0
Concern of MD at that time was of mucus plug verse aspiration.,0
Pt placed on nonrebreather and transferred to .,0
Pt unable to give detailed history given baseline mental status.,0
Son says patient has not been feeling right since yesterday.,0
Reports decreased PO in setting of abdominal pain and nausea/vomitting.,0
Of note patient is a known chronic aspirator with history of failed multiple speech and swallow evals.,1
"Patient's family aware, yet continues to take PO despite inherent risks because patient refusing tube feeds.",0
"Per son, patient without specific complaint and she looks much improved than earlier in the day.",0
Patient was discharged from 2 days prior to admission after being admitted with fevers and hypotension.,0
Initially started on meropenum/linezolid in the ICU and then narrowed to meropenum for which she is currently completing a 7 day course (day 2).,0
Tagged WBC scan with uptake in femor:?,0
Needed MRI for further eval but given poor surgical candidate opted for medical treatment.,0
ED Course: Initially hypotensive but responded to 1.5 liters intravenous fluid.,0
Type 2 diabetes mellitus 2.,0
"Diabetic nephropathy resulting in ESRD for which she is on HD Mon, Wed, and Fri. 3.",0
Status post left femur fracture 4.,0
Hypertension 10.Anemia of chronic disease 11.,1
S/P L shoulder hemiarthroplasty following a left humeral fracuture in - Course was complicated by a PEA arrest secondary to PE.,0
PE leading to PEA arrest 13.,0
"Hospitalization for Sepsis (negative work-up) treated empricially with Vanc 14. h/o C-diff , Urine citrobacter (tx w/Cipro) Social History: Lives with son who is very involved and well informed regarding her care needs.",0
Patient most recently at Rehab prior to transfer here.,0
Patient has family members at the bedside 24 hours per day.,0
"Family History: Noncontributory Physical Exam: Vitals - ED: 100.4 (rectal) BP 90/47 HR 102 RR 24 O2sat 100%NRB - MICU: 98.7, 141/38, 33, 100% FM .",0
"GEN: comfortable, opens eyes HEENT: perrl, anicteric, OP clear Neck: supple, no LAD, no JVD Chest: diffuse rhonci bilaterally ant and laterally.",0
"CVR: RR, tachy, nl S1, S2, no M/R/G ABD: obese, soft, NT/ND, hypoactive BS Rectal (ED): guaiac negative EXT: Left UE in sling.",0
"3+ pitting edema in LUE, RUE with 1+ edema.",0
Bilaterally lower extremities with 2+ edema L>R.,0
"Left DP palp, Right DP dopp.",0
"Neuro: Awake and alert, opens eyes in response to voice.",0
Speaks with son -> answers some ?,0
"Skin: chronic changes, cool/dry LINES: R tunnelled chest HD line without erythema or tenderenss.",0
Left IJ Pertinent Results: Labs on admission: GLUCOSE-158* UREA N-14 CREAT-2.5* SODIUM-145 POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-26 ANION GAP-12 CALCIUM-7.7* -2.4* MAGNESIUM-2.1 .,0
WBC-18.5*# RBC-3.21* HGB-10.3* HCT-31.9* MCV-100* MCH-32.1* MCHC-32.2 RDW-21.2* NEUTS-77.7* LYMPHS-14.0* MONOS-3.5 EOS-4.2* BASOS-0.6 HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+.,0
ALT(SGPT)-9 AST(SGOT)-23 LD(LDH)-449* CK(CPK)-39 ALK PHOS-135* AMYLASE-19 TOT BILI-0.3 LD(LDH)-391* LIPASE-12 ALBUMIN-2.2* .,0
05:48PM CK-MB-3 cTropnT-0.78* 12:40PM CK(CPK)-35 cTropnT-0.71* .,0
10:00AM URINE Color-Yellow Appear-Cloudy Sp -1.014 Blood-MOD Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD RBC-0 WBC->50 Bacteri-MOD Yeast-NONE Epi-0 .,0
07:23PM URINE Color-Yellow Appear-Cloudy Sp -1.014 Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD RBC->50 WBC->50 Bacteri-MOD Yeast-MOD Epi- CastHy-* .,0
05:30AM URINE Color-Yellow Appear-Hazy Sp -1.025 Blood-LG Nitrite-POS Protein->300 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-8.0 Leuks-SM .,0
URINE CULTURE (Final ): YEAST.,0
">100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S).",0
9:59 am SWAB Source: right leg wound.,0
GRAM STAIN (Final ): THIS IS A CORRECTED REPORT .,0
2+ (1-5 per 1000X FIELD): YEAST(S) .,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- =>16 R MEROPENEM------------- 4 S PIPERACILLIN---------- 64 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ =>16 R .,0
12:02 am STOOL CONSISTENCY: SOFT CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final ): REPORTED BY PHONE TO @ 12:50 ON .,1
6:19 pm BLOOD CULTURE PICC LINE.,0
AEROBIC BOTTLE (Final ): NO GROWTH.,0
"ANAEROBIC BOTTLE (Final ): REPORTED BY PHONE TO , -CC7A- @ 12:30 .",0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S CHLORAMPHENICOL------- <=4 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S PENICILLIN------------ 2 S VANCOMYCIN------------ =>32 R .,0
10:45 pm CATHETER TIP-IV Source: R-PICC line.,0
"SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN----------- 1 I <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ =>16 R <=0.5 S LEVOFLOXACIN---------- =>8 R <=0.12 S OXACILLIN------------- 4 R <=0.25 S PENICILLIN------------ 4 R =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=1 S .",0
11:22 am BLOOD CULTURE LINE: PICC.,0
"ANAEROBIC BOTTLE (Final ): STAPHYLOCOCCUS, COAGULASE NEGATIVE.",0
"SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- 1 I ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 1 R PENICILLIN------------ 4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- S VANCOMYCIN------------ <=1 S .",0
STUDIES: Radiology PERC G/G-J TUBE PLMT .,0
"G/GJ TUBE CHECK : GJ-tube with the tip terminating in jejunum, without evidence of obstruction or leak.",0
ECHO : No thrombus is seen in the left atrial appendage.,0
CENTRAL TUNNELED W/O PORT 2:49 PM Reason: change old tunnelled HD line to new tunnelled HD line.,0
send Successful replacement of a 24 cm hemodialysis catheter through preexisting subcutaneous tunnel over the wire.,0
The tip of the preexisting catheter was sent for culture.,0
VIDEO OROPHARYNGEAL SWALLOW 2:14 PM Marked decreased oral motion was identified.,0
Premature spillover of contrast was seen with thin consistencies.,0
This was seen with a significant swallow delay.,0
There is also reduced laryngeal elevation with normal epiglottic deflection.,0
Penetration was seen with thin liquids although no aspiration was identified.,0
Limited evaluation of the esophagus was performed during the study.,0
No significant holdup of contrast is seen as it passed through the esophagus.,0
Numerous tertiary contractions of the esophagus were seen.,0
Small amount of reflux was also identified of contrast in the distal esophagus.,0
No extrinsic or intrinsic anatomic abnormalities were identified on this limited esophageal study.,0
"ART EXT (REST ONLY) 3:28 PM Reason: please do ABIs, PVRs, assess for arterial supply pre-debride 70 year old woman with bilateral lower extremity ulcers over calves REASON: Leg ulcer.",1
FINDINGS: Limited Doppler evaluation was performed of both lower extremities.,0
At both the ankle levels all waveforms are monophasic.,0
"On the right, the ABI is 0.6.",0
On the left it is 0.44.,0
Pulse volume recordings are dampened starting at the low thigh level and are essentially flat line at both the metatarsals.,0
IMPRESSION: Significant flow deficit to both lower extremities.,0
"The exact location of arterial disease cannot be determined by the study, but it appears to be multisegmental.",0
TIB/FIB (AP & LAT) BILAT : Four views of the left tibia and fibula were obtained.,0
There is marked diffuse osteopenia and mottled appearance of the diaphyses of the mid tibia and fibula.,0
No definite cortical destruction is identified.,0
There is diffuse edema of the leg.,0
UNILAT UP EXT VEINS US LEFT : Thrombosis of left AV fistula graft.,1
"The basilic vein, axillary vein, subclavian vein and internal jugular veins are patent.",0
PERC PLCMT GASTROMY TUBE : Successful placement of a gastrojejunostomy tube with the tip in the proximal jejunum .,0
CTA CHEST W&W/O C &RECONS : 1.,0
"No pulmonary embolism involving the main pulmonary arteries or segmental branches, although the subsegmental branches are not well evaluated due to body habitus and patient motion throughout the examination.",0
"Severe tracheobronchomalacia, which may be related to the patient's symptoms.",0
"In regions, the trachea diameter appears essentially obliterated.",0
The left lower lobe bronchus is also virtually obliterated in our imaging series.,0
"Volume loss of both lower lobes, partially atelectasis, and partially which may be chronic.",1
CT HEAD W/O CONTRAST : No acute intracranial pathology including no evidence of intracranial hemorrhage or mass effect.,0
No change from prior study .,0
"EKG : Sinus tachycardia Poor R wave progression - probable normal variant Low QRS voltages in precordial leads Nonspecific ST-T abnormalities Since previous tracing of , no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 114 118 68 322/389.71 52 2 54 .",0
CHEST (SINGLE VIEW) : No acute process or change.,0
"Brief Hospital Course: Briefly, this is a 69 year old bedbound Somalian speaking only woman with endstage renal disease on hemodialysis, diabetes mellitus type 2, chronic hyponatremia, history of pulmonary embolus on coumadin, history of enterobacter/klebsiella bacteremia (), klebsiella and pseudomonas UTI () who presents status post hypoxia and hypotensive episode.",1
Hypoxia: Patient was admitted with hypoxic episode thought to be secondary to aspiration versus mucous plug.,0
She was brought to and placed on a nonrebreather and was admitted to the MICU.,0
Initially she was hypotensive but responded to IVFs.,0
"Chest x-ray did not show a pneumonia and CTA was done which did not show evidence of PE but did show some tracheobronchomalacia, which could have caused the patient's symptoms.",0
"At that time, she was not intubated.",0
She was a known aspirator who had failed multiple speech and swallows in the past.,0
In the MICU she was given tube feeds through an NG tube.,0
She was stable for the floor after several days and did well for some time on room air.,0
A PEG tube was placed for feeds so the patient could reduce her PO intake and risk of aspiration.,0
Several bedside speech and swallow evaluations were done and recommended only small amounts of PO food for pleasure.,0
On the patient was noted to be less responsive and more tachypneic that improved with suctioning.,0
On the patient was noted to be hypoxic to 63% on room air.,0
RN thought the patient had an episode of emesis prior to the event and food particles were removed with suctioning.,0
The patient was intubated and sent to the MICU at that time.,0
She was extubated on and sent back to the floor on .,0
"She did well on the floor for a few days, though at times she appeared more tachypneic.",0
Multiple chest x-rays were done and showed no new infiltrates.,0
"The patient's family wanted to continue feeding her, so a video swallow and esophagram was done.",0
It suggested the patient was at risk to aspirate thin liquids and was refluxing her food.,0
She was already on lanszoprazole and reglan prior to this.,0
She was continued on aspiration precautions and allowed small volumes of food at a time.,0
Patient was subsequently transferred back to the MICU on given concern for new sepsis and hypercarbia.,0
"She was noted to be febrile to 100.3, tachycardic to the 100s with a blood pressure of 77/40 on forearm.",0
"When the cuff was moved to her upper arm, the blood pressure was found to be 120/60.",1
"Respiratory rate was noted to be in the 40s, 98% on 2L.",0
ABG 7.27/61/90 with a lactate of 1.4.,0
Hypercarbia was thought to be secondary to lethargy and confusion.,0
"However, Patient had received a liter of fluid on the floor and no sedative medications prior to new lethargy.",0
Increased CO2 in the setting of tachypneia was thought to be attributed to either increased CO2 production from infection or worsening dead space ventilation.,0
Patient was intially started on vancomycin on and subsequently switched to linezolid and meropeneum for pseudmonas in leg wounds on .,0
She was reintubated on for resp acidosis and successfully extubated without complications.,0
"While on the floor, she was breathing comfortably and sat'ing in high 90's on room air.",0
Patient was NPO and continued on tube feeds.,0
Hypotension: Patient was hypotensive at admission and treated with IVFs.,0
She became hypotensive again at hemodialysis and was on pressors for one day.,0
She was weaned off pressors after fluid boluses.,0
She was on meropenem at admission and improved with fluid boluses so likely not sepsis.,0
Could have been secondary to hypovolemia or fluid shifts associated with HD.,0
She was transferred to the floor and remained hemodynamically stable.,0
She completed a full 14 day course of meropenem and she was weaned off the steroids she had been started on in the MICU.,0
Patient was subsequently stable and discharged to the floor.,0
"Leukocytosis: Multiple sources of infection including coag neg Staph pansensitive, coag neg Staph oxacillin resistant and vancomycin resistant enterococcus from PICC line; C diff in stool and pseudamonas in LE wounds.",0
"Considered PICC line, dialysis cath and leg wounds as sources of infection.",0
"In addition, chronic urinary tract infections, aspiration pneumonia and c diff were also considerations.",1
PICC line was removed on .,0
Hemodialysis catheter was changed over wire by IR on .,0
Patient finished 14 day course of flagyl on for C. diff.,0
Patient started on a 14 day course of linezolid (for VRE & Staph) and meropenem (for pseudamonas) on .,0
Transesophageal echo was negative for vegetations and was not suggestive of no endocarditis.,0
After resuming antibiotics patient remained hemodynamically stable and afebrile with downtrending WBC.,0
Fevers: Patient spiked fevers several times during the admission.,0
"Could have been secondary to line infection, urinary tract infection, pneumonia or possible osteomyelitis.",1
"There was also a question of possible osteomyelitis in the past, but it was decided not to do an MRI earlier because no further intervention would be done based on the results.",0
Patient also had a question of aspiration pneumonia at admission but nothing was ever seen on chest x-ray.,0
"Blood cultures durng the early part of her admission showed no growth, so it was thought that UTI may have been the source.",0
"later in her admission she developed c. diff which could have contributed, as well as infection in leg ulcer.",1
"Her fevers subsided on meropenem, which was re-started empirically for her fevers.",0
She completed a 7-day course from in addition to the intial course of meropenem she completed.,0
Patient was noted to have a new fever on and was subsequently resumed on meropenum and linezolid for a 14 day course.,0
Urinary tract infections: Patient was noted to have a significant recent history of UTIs leading to sepsis.,1
Several urine samples were obtained during her stay and UA suggested UTI.,0
urine cultures grew out yeast or mixed bacterial colony types.,0
There was a concern that UTIs were leading to urosepsis.,0
the patient had been started on Meropenem (for her enterobacter/Kleb/psuedomonas UTIs )at her last admission and she was continued for a 14 day course.,0
"After the Meropenem was dc'd she did well for several dsy, remained afebrile with stable WBC.",0
She then developed low grade fevers.,0
"She was re-started on meropenem but per ID she was just to be continued on a 7 day course, because she had already been colonized by bacteria resistant to other antibiotics.",0
"Her fevers resolved and were thought to be secondary to urinary tract infection, though last few urine cultures grew out yeast only.",1
She was treated with fluconazole for 7 days for the yeast.,0
Blood cultures showed no growth.,0
It was thought that the patient will likely continue to get repeat UTIs as she makes a little urine that stays in the bladder for long periods of time.,0
"Spoke with ID regarding possible prohpylactic antibiotics, but they were resistant to start this as patient already had developed resistance to many bacteria.",0
Spoke with urology multiple times and they suggested qod straight caths to relieve the patient of urine.,0
This was attempted in the hospital but required 4 people to perform it.,0
"Additionally, little urine came out through this method, because much of it was sludge.",0
Spoke with urology who stated she should make an appointment as an outpatient and they would try to come up with the appropriate regimen for straight cath.,0
ID also recommended trying qd cranberry tablets.,0
Patient will be on meropenum until and linezolid until then left IJ line may be pulled if patient has peripheral IVs.,0
Endstage kidney disease - The patient is hemodialysis dependent (M/W/F) and received hemodialysis throughout her stay.,1
She was followed by renal.,0
She was arranged to have outpatient hemodialysis at .,0
Tunnelled HD cath was replaced per IR on .,0
"Melena: Patient developed melena during her admission, while on heparin.",0
Her hematocrit did not drop and she was continued on protonix.,0
Her anti-coagulation was not stopped because she had recently had a very severe pulmonary embolism and required anti-coagulation.,0
History of pulmonary embolus: Patient had a recent history of PE status post PEA arrest.,0
Her goal INR was and coumadin was adjusted to keep her in this therapeutic range.,0
"When she was subtherapeutic, she was on a heparin drip.",0
Patient was therapeutic on coumadin at discharge.,0
She will likely need anticoagulation for at least 12 months.,0
"History of atrial fibrillation : Her course was complicated by new atrial fibrillation with RVR while on Levophed for pressure support, was cardioverted with 200 J with successful return of MAP.",1
"Had transient atrial fibrillation during her ICU course without any hemodynamic instability, which spontaneously resolved.",1
INR was intially supratherapeutic INR 4.0 then 1.9 reversed with 3U FFP for central line placement.,0
Heparin drip was started on for anticoagulation and coumadin was resumed on .,0
Patient was continued on warfarin 5mg PO QHS with goal INR .,0
Heparin drip was discontinued on .,0
Sinus Tachycardia: Patient was found to be in sinus tachycardia on the floor and remained like that for many days.,0
Was thought to be likely secondary to and infectious process or fluid shifts during HD.,0
PE was less likely since patient was anticoagulated.,0
Diarrhea: Patient had intermittent diarrhea throughout her course.,0
Her c.diff toxin assay was checked several times during the admission and was initially negative.,0
She was found to be positive for c. diff on and started on Flagyl for a 14 day course which she completed on on .,0
Diabetes: She was well controlled on a sliding scale and had QID fingersticks.,0
Patient was started on insulin drip for better BS Control goal 80-120.,0
Weaned insulin drip to off and restart ISS on .,0
* Decubitus/Ischemic ulcers: She had ulcers on the posterior aspect of her calves.,0
They were healing well but during her admission she was noted to have some purulent exudate from the left leg.,0
This area was superficially swabbed and found to be growing pseudomonas.,0
She was already being treated with meropenem at that time.,0
An x-ray was done at the time and showed no evidence of osteomyelitis on films.,0
Vascular surgery was contact and did not think any intervention was necessary at this time.,0
She was followed by the wound care team and wound care recs were implemented.,0
Patient is now on wet to dry twice daily wound care.,0
* FEN - Patient was initially fed with an NG tube in the unit.,0
The necessity of a PEG tube to help patient's nutritional status and reduce the risk of aspiration was discussed with her family and a PEG tube was placed by IR on .,0
The patient was started on tube feeds with probalance and was followed by nutrition.,0
"She failed several speech and swallow evals and was noted to be at risk for aspiration, with reflux events by video swallow.",0
She was placed on aspiration precautions and only allowed to take 30 cc/hr of food PO.,0
She was continued on nephrocaps and her lytes were repleted PRN.,0
After an episode of possible aspiration patient was kept NPO and continued on tube feeds only.,0
"Prior to discharge, PEG was chronically plugged despite flushes, discontinuing banana flakes and viokase infusions.",0
GJ tube imaging showed patent and functional lumen.,0
Interventional radiology was consulted and replaced tube.,0
Tube requires vigorous flushing with 1/2NS after administering medications or tube feeds per tube using a 10cc syringe (to obtain enough pressure) as patient is prone to tube clogging.,0
"Make sure flushes are with normal saline, 10cc syrine and uncapped.",0
"PPx - Heparin drip, coumadin, PPI, bowel regimen .",0
"* Access: Left IJ ; R SCL - dialysis line , R Arm Picc ; Will d/c left IJ.",0
* Precautions: VRE/MRSA and Aspiration.,0
"* Code - FULL CODE (reconfirmed with son on , 2nd family meeting with Dr. reconfirmed Full Code status as well as if pt requires another intubation it will require a trach at that next Intubation, meaning no option of intubation without trach for next rewpiratory failure/distress in setting of multiple intubations/extubations) .",0
* Communication - son ( or ( Medications on Admission: 1.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed.,0
Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime).,0
Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed.,0
Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day).,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day).",0
Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN.,0
Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous once a day for 7 days.,0
Acetaminophen 160 mg/5 mL Solution Sig: Six y (650) mg PO Q4-6H (every 4 to 6 hours) as needed for fever.,0
Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day).,0
Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO DAILY (Daily).,0
Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Units Injection ASDIR (AS DIRECTED).,0
Amylase-Lipase-Protease 468 mg Tablet Sig: 1-2 Tablets PO once a day as needed for clogged PEG tube for 1 doses: Crush tabs with 1 tab NaHCO3 add to 5cc of water.,0
Infuse into tube and clamp for 10 minutes.,0
Then drain and attempt to flush.,0
Inspect site every shift 14.,0
Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 3 days: until .,0
Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed.,0
Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours) for 4 days: until .,0
Discharge Disposition: Extended Care Facility: Hospital Discharge Diagnosis: primary diagnosis: 1.,0
Decubitus/ischemic lower extremiy ulcers bilaterally with Pseudamonas on swab culture 3.,1
Chronic urinary tract infection 5.,1
Status post PEG tube on tube feeds 6.,0
History of atrial fibrillation status post cardioversion .,1
Type 2 diabetes mellitus 8.,0
Diabetic nephropathy/ESRD on HD MWF 9.,0
Status post left femur fracture 10.S/P L shoulder hemiarthroplasty following a left humeral fracuture in - Course was complicated by a PEA arrest secondary to PE.,0
"new humerus fracture 11.PE leading to PEA arrest 12.Hospitalization for Sepsis (negative work-up) treated empricially with Vanc 13.h/o C-diff , Urine citrobacter (tx w/Cipro) 14.Chronic Hyponatremia 15.Hypercholesterolemia 16.Unsteady gait 17.Cataracts 18.Back pain 19.Hypertension 20.Anemia of chronic disease Discharge Condition: Breathing comfortably on room air, sating high 90's on room air Afebrile NSR Therapeutic INR Discharge Instructions: Please take medications as prescribed.",1
Please have your INR/PT labs checked daily for goal INR .,0
Have your MD adjust your warfarin dose accordingly.,0
"If you have any nausea/vomitting, fevers/chills, chest pain, severe abominal pain, difficulty breathing or any other worrying department.",0
Frequent 1/2NS flushes required after administering meds or tube feeds per tube to prevent chronic clogging.,0
"Uncap the tube, use a 10cc or smaller syringe and vigorously flush.",0
Use flush and viokase if still clogged.,0
No banana flakes per tube.,0
Make sure medications are ground very finely.,0
"Followup Instructions: [] Provider: , M.D.",0
Date/Time: Wed 1:50pm Location: Clinical Center Floor 6 Phone: .,0
"[]Provider: , .D., PH.D. Date/Time: 1:30 .",0
[] Dialysis: Please continue outpatient dialysis on MWF Completed by:,0
"1:23 PM CHEST (PORTABLE AP) Clip # Reason: check tube placement ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with sz, ?",0
"brain mass, fever, intubated PTA REASON FOR THIS EXAMINATION: check tube placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: INDICATION: Seizure.",0
There are no prior films for comparison.,0
"An endotracheal tube is in satisfactory position, terminating about 3 cm above the carina.",0
A nasogastric tube terminates at the gastroduodenal junction.,0
The heart is normal in size but demonstrates left ventricular configuration.,0
"There is a focal opacity in the left retrocardiac region with associated inferior displacement of the left hilum, most likely due to an area of focal atelectasis.",0
Differential diagnosis includes aspiration and infectious pneumonia.,0
Follow up radiographs may be helpful in this regard.,0
11:52 AM UNILAT LOWER EXT VEINS LEFT Clip # Reason: eval for DVT Admitting Diagnosis: HEPATIC ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with LLE swelling REASON FOR THIS EXAMINATION: eval for DVT ______________________________________________________________________________ FINAL REPORT INDICATION: Left lower extremity swelling.,1
Please assess for deep vein thrombosis.,0
"FINDINGS: Grayscale and Doppler son was performed of the left common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins.",0
"Normal compressibility, flow, and augmentation noted throughout.",0
IMPRESSION: No deep vein thrombosis in left lower extremity.,0
"4:23 PM CT HEAD W/O CONTRAST Clip # Reason: assess progression of L temporal SDH Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p fall REASON FOR THIS EXAMINATION: assess progression of L temporal SDH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 48-year-old man status post fall, evaluate progression of left subdural hematoma.",1
COMPARISON: Comparison is made to study performed five hours earlier.,0
"FINDINGS: Again seen is a focus of high-density material within the left temporal lobe, consistent with a contusion, measuring approximately 1.6 cm in greatest axial dimension.",0
"High-density material also again seen layering along the left tentorium suggesting a subdural component of the hematoma, at the posterior floor of the middle cranial fossa.",0
- white matter differentiation is grossly preserved.,0
"Mucosal thickening seen within the ethmoid, sphenoid, and maxillary sinuses bilaterally, right greater than left.",0
Nondisplaced fracture of the right zygomatic bone is better evaluated on the dedicated facial CT.,0
"Left temporal lobe contusion, not significantly changed compared to prior.",0
"Likely subdural hematoma, layering above the left tentorium, at the margin of that middle cranial fossa.",0
"4:27 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate, effusion Admitting Diagnosis: SUBGLOTTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with rheumatoid arthritis, s/p tracheostomy adjustment, s/p L thoracentesis several days ago.",1
"REASON FOR THIS EXAMINATION: eval for infiltrate, effusion ______________________________________________________________________________ FINAL REPORT A INDICATION: 67-year-old with rheumatoid arthritis status post a tracheostomy adjustment.",1
Chest evaluate for infiltrate or effusion.,0
AP SEMI-UPRIGHT PORTABLE CHEST: Compared to study of .,0
The patient is markedly rotated with the chin obscuring the left apex.,0
"The tracheostomy tube seen, however, it is difficult to assess for changes in positioning.",0
The tracheostomy tube cuff may be slightly over inflated.,0
The right IJ tube is seen unchanged in position.,0
"The heart is completely obscured, as well as the mediastinal and hilar contours.",0
"There is recurrence of complete opacification of the left hemithorax, either indicating interval collapse or rapid reaccumulation of left-sided fluid.",0
It is difficult to assess for shift due to extreme rotation of this film.,0
Probable underlying congestive heart failure.,0
Gastric tube is again noted.,0
IMPRESSION: 1) Severely limited film due to rotation and chin obscuring the left apex.,0
"2) Recurrence of total opacification of the left hemithorax, either secondary to interval collapse or rapid reaccumulation of left-sided effusion.",0
In favor of collapse/mucus plugging is apparant left main bronchus cut-off.,0
"3) Due to limitations of the film and severe rotation, difficult to assess change in position of tracheostomy tube but it has likely been advance slightly; the cuff balloon remains mildly over inflated.",1
"11:10 PM CHEST (PORTABLE AP) Clip # Reason: ?interval change Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with recent PNA and recent drainage of right sided pleural effusion with new oxygen requirements REASON FOR THIS EXAMINATION: ?interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Recent pneumonia, drainage, evaluation for interval change.",1
"FINDINGS: As compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed.",0
The pre-existing left pleural effusion with subsequent parenchymal opacities is unchanged.,0
"However, on the right, at the site of a pleural pigtail insertion, there is increased parenchymal density, reflecting increased vascular diameters, and potentially alveolar opacities.",0
The changes could be caused by both an increase of pulmonary fluid and infection.,0
The size of the cardiac silhouette is constant.,0
6:24 PM CHEST (PORTABLE AP) Clip # Reason: F/U S/P CHEST TUBE ______________________________________________________________________________ MEDICAL CONDITION: 78M 9 days s/p trachoplasty now with respiratory decompensation and new PA cath REASON FOR THIS EXAMINATION: F/U S/P CHEST TUBE ______________________________________________________________________________ FINAL REPORT HISTORY: Tube insertion.,0
"Effusion in the right hemithorax is again noted, accumulating in the apex and at the right base.",0
A SG catheter is present terminating in the right pulmonary artery.,0
"The ETT is in satisfactory position, and there are two chest tubes overlying the right hemithorax.",0
There is opacification of the left base.,0
There is no pneumothorax and the heart is slightly enlarged.,0
IMPRESSION: No evidence of pneumothorax; recent chest tube insertions.,0
Height: (in) 69 Weight (lb): 214 BSA (m2): 2.13 m2 BP (mm Hg): 119/50 HR (bpm): 56 Status: Inpatient Date/Time: at 10:55 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,1
Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction.,0
IMPRESSION: Moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function.,0
Mild to moderate aortic regurgitation.,0
4:52 PM PORTABLE ABDOMEN Clip # Reason: bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with bloody stool REASON FOR THIS EXAMINATION: bowel gas pattern ______________________________________________________________________________ FINAL REPORT SUPINE ABDOMEN: There is a normal abdominal gas pattern.,1
No gross free air or pneumatosis intestinalis is seen.,0
7:48 PM ABDOMINAL FLUORO WITHOUT RADIOLOGIST; FISTULOGRAM/SINOGRAM Clip # Reason: FISTULOGRAM ______________________________________________________________________________ FINAL REPORT FISTULOGRAM: Images from a study performed have been detected and read on routine radiology QA surveillance.,0
The study was a fistulogram performed using the C- Arm at the bedside.,0
Images reveal contrast having been injected via percutaneous catheter with free spillage into the peritoneal cavity.,0
IMPRESSION: Extravasation of contrast into peritoneal cavity following administration via percutaneous catheter.,0
No contrast is noted in the adjacent bowel.,0
11:58 CHEST (PA & LAT) Clip # Reason: please assess for infiltrate Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with h/o large anterior mi and recent cardioversion who now c/o SOB and cough.,1
REASON FOR THIS EXAMINATION: please assess for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: 65 y/o man with history of MI and shortness of breath.,0
CHEST PA & LATERAL: Comparison is made to the prior study obtained on .,0
There has been interval improvement of previously noted pulmonary edema.,0
Also noted is interval improvement of illdefined opacities in the right lower lobe and left lower lobe.,0
There is new development of lingular opacity.,0
A small left pleural effusion cannot be excluded.,0
The visualized osseous structures appear unremarkable.,0
IMPRESSION: 1) There is interval improvement of CHF.,0
"2) There is interval development of ill-defined lingular opacity, and the differential diagnosis include aspiration vs. pneumonia.",0
"8:25 AM UNILAT LOWER EXT VEINS LEFT Clip # Reason: NEW LT IJ CLOT, PLEASE EVAL FOR LT LE DVT Admitting Diagnosis: LEFT IJ CLOT ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with LIJ DVT with dusky, ?",0
REASON FOR THIS EXAMINATION: Please evaluate for DVT.,0
______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Recent diagnosis of left internal jugular deep vein thrombosis.,0
"TECHNIQUE: Grey-scale, color and duplex Doppler imaging of the left lower extremity was performed.",0
"FINDINGS: The left common and femoral, greater saphenous, superficial femoral, popliteal and posterior tibial veins demonstrate normal flow, compressibility and augmentation with no evidence of deep vein thrombosis.",0
Plaque is noted along the posterior aspect of the left common femoral artery.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 71-year-old white male who has been healthy and active who had a syncopal event and chest tightness in .,0
He is status post myocardial infarction in and saw his cardiologist after the syncopal episode.,1
An echocardiogram was performed which showed an ejection fraction of 30%.,0
"He had a positive stress test, and he was referred for cardiac catheterization.",0
"He underwent cardiac catheterization on at which revealed 3-vessel coronary artery disease, and he is now referred for coronary artery bypass graft.",1
PAST MEDICAL HISTORY: (Past medical history is significant for) 1.,0
Status post myocardial infarction in .,1
Status post syncopal episode in .,0
Status post left ear basal cell carcinoma.,0
Status post right inguinal hernia and left inguinal hernia repair.,0
Status post .................... in .,0
Status post partial colon resection of benign tumor.,0
FAMILY HISTORY: Family history is unremarkable.,0
SOCIAL HISTORY: He lives with his wife and never smoked cigarettes.,0
He drinks 10 to 14 drinks per week.,0
REVIEW OF SYSTEMS: His review of systems was unremarkable.,0
"PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, he was well-developed elderly white male in no apparent distress.",0
"Vital signs were stable, and he was afebrile.",0
"Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic.",0
The neck was supple with full range of motion.,0
The lungs were clear to auscultation and percussion.,0
Heart examination revealed a murmur heard best at the left sternal border.,0
The abdomen was soft and nontender with positive bowel sounds.,0
There was a well-healed surgical scar.,0
He had mild varicosities; right greater than left.,0
"HOSPITAL COURSE: On , he underwent a coronary artery bypass graft times four with left internal mammary artery to the left anterior descending artery, sequential saphenous vein grafts to the first obtuse marginal and second obtuse marginal, and a saphenous vein graft to the ramus.",1
Cross-clamp time was 92 minutes.,0
Total bypass time was 137 minutes.,0
"He was transferred to the Surgical Intensive Care Unit in stable condition on propofol, Neo-Synephrine, and Milrinone.",0
He had a stable postoperative night.,0
He was weaned off the Neo-Synephrine and Milrinone on postoperative day one.,0
He did go into atrial fibrillation on postoperative day two.,1
He was started on Lopressor.,0
"On postoperative day three, pacing wires were discontinued.",0
He was transferred to the floor on postoperative day one.,0
He continued to have a stable postoperative course.,0
He did develop some erythema on his right lower extremity and was treated with Keflex with some resolution.,0
DISCHARGE STATUS: He was discharged to home on postoperative day seven.,0
twice per day (times seven days).,0
once per day (times seven days).,0
four times per day (times seven days).,0
"PERTINENT LABORATORY VALUES ON DISCHARGE: Laboratories on discharge revealed hematocrit was 30.2, white blood cell count was 6,500, and platelets were 149.",0
"Sodium was 142, potassium was 4, chloride was 105, bicarbonate was 26, blood urea nitrogen was 23, creatinine was 1.1, and blood glucose was 100.",0
"DIE INSTRUCTIONS/FOLLOWUP: He was to be followed by Dr. in one to two weeks, and by Dr. in two to three weeks, and by Dr. in four weeks.",0
Dictated By: MEDQUIST36 D: 17:20 T: 19:08 JOB#:,0
"10:37 AM SHOULDER 1 VIEW LEFT Clip # Reason: just AP view please, pt.",0
"can not move shoulderpost op Admitting Diagnosis: RT TIBIA,FIBULA FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man ped struck, L greater tub fx s/p ORIF REASON FOR THIS EXAMINATION: just AP view please, pt.",1
"can not move shoulderpost op ______________________________________________________________________________ FINAL REPORT LEFT SHOULDER, ONE VIEW.",0
INDICATION: Left greater tuberosity fracture status post ORIF.,1
FINDINGS: Single AP view of the left shoulder demonstrates evidence of previous greater tuberosity fracture.,1
Fracture fragments are noted in the acromiohumeral interval.,0
Visualized portion of the left lung apex is clear.,0
IMPRESSION: Left greater tuberosity fracture of the proximal humerus with fracture fragments projecting in the acromiohumeral interval.,1
No fixation hardware is seen.,0
4:52 AM CHEST (PORTABLE AP) Clip # Reason: interval changes Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with C. diff colitis now with respiratory failure and volume overload REASON FOR THIS EXAMINATION: interval changes ______________________________________________________________________________ FINAL REPORT HISTORY: C. diff colitis with respiratory failure and volume overload.,1
"An ET tube is present, tip in satisfactory position approximately 4.5 cm above the carina.",0
"IJ central line tip overlies the SVC/RA junction, unchanged.",0
There is mild cardiomegaly with a calcified unfolded aorta.,0
"There are small bilateral pleural effusions and underlying atelectasis, consistent with underlying collapse and/or consolidation.",0
"There is prominence of the perihilar markings, which may reflect the presence of mild fluid overload.",0
There is a right suprahilar patchy opacity which is similar to that seen on the 4:15 a.m. film from yesterday and likely reflects a pneumonic infiltrate.,0
An old healed right clavicular fracture is present.,0
IMPRESSION: Essentially unchanged compared with 4:15 a.m. on .,0
Right perihilar opacity concerning for pneumonic infiltrate.,0
Bilateral effusions with underlying collapse and/or consolidation.,0
4:36 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Dobhoff advanced.,0
Admitting Diagnosis: NECK MASS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with dobhoff placement.,0
REASON FOR THIS EXAMINATION: Dobhoff advanced.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old female with Dobbhoff placement.,0
"FINDINGS: Since the prior examination, the Dobbhoff tube has been further coiled within the stomach.",0
The remainder of the examination is stable.,0
There are no new focal area of current opacities concerning for pneumonia.,0
Clips overlie the right upper quadrant.,0
IMPRESSION: Dobbhoff feeding tube now coiled within the stomach.,0
Findings were discussed with Dr. via telephone by Dr. 5 p.m. on .,0
11:44 AM CHEST (PORTABLE AP) Clip # Reason: S/P HDC 5Fr Right- sided DL PICC placement.,0
"Please page me w ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with cad, s/p vfib arrest now with fever of 102 requiring a long term IV Vanco and Heparin drip.",0
REASON FOR THIS EXAMINATION: S/P HDC 5Fr Right- sided DL PICC placement.,0
Please page me with a stat wet read at 3-7202.,0
"THANKS, ______________________________________________________________________________ FINAL REPORT AP CHEST RADIOGRAPH DATED : INDICATION: Status post PICC line placement.",0
COMPARISON STUDY: AP chest radiograph dated .,0
FINDINGS: There is a new right sided PICC line which terminates in the upper SVC.,0
There is minimal left ventricular enlargement.,0
"Allowing for differences in positioning, there is a possible slight improvement in the appearance of the pulmonary vasculature.",0
IMPRESSION: PICC line tip in upper SVC without pneumothorax.,0
"9:38 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ?PE Admitting Diagnosis: BRAIN TUMOR/SDA Field of view: 40 Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with acute hypoxia and tachypnea with metastatic lymphoma REASON FOR THIS EXAMINATION: ?PE CONTRAINDICATIONS for IV CONTRAST: ______________________________________________________________________________ WET READ: NATg MON 11:04 PM 1.",1
Left lower lobe consolidation consistent with aspiration or infection 2.,0
Air fluid level in trachea - high risk of aspiration 3.,0
"No PE ______________________________________________________________________________ FINAL REPORT HISTORY: 85-year-old male with acute hypoxia and tachypnea and lymphoma, evaluate for pulmonary embolus.",1
TECHNIQUE: MDCT helical acquisition was performed before and after the uneventful administration of IV contrast through the chest.,0
Multiplanar reformations as well as axial 5 and 2.5 collimation images were reviewed.,0
"CT CHEST WITH IV CONTRAST: Pulmonary arterial opacification is adequate, and there is no evidence of pulmonary embolus.",0
"However, there is a large left lower lobe pneumonia.",0
"The right lower lobe and left upper lobe demonstrate a lesser degree of faint nodular tree-in- opacity, although evaluation of the left upper lobe is slightly limited by respiratory motion.",0
"There is a small left pleural effusion, but none on the right, and no pericardial effusion.",1
There is a large amount of tracheal secretion (3:16) but the trachea and bronchi are elsewhere patent.,0
Mild aortic valve calcifications and significant coronary artery calcifications are unchanged since days ago.,0
Limited imaging of the upper abdomen appears unremarkable as do osseous structures.,0
Large left lower lobe pneumonia with lesser degree of bronchiolar spread of pneumonia elsewhere.,0
"8:47 PM CHEST (PORTABLE AP) Clip # Reason: eval for failure / infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with trach and reported bloody secretions with diminshed LS at bibasilar area REASON FOR THIS EXAMINATION: eval for failure / infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Tracheostomy, bloody secretions with diminished breath sounds at bibasilar regions.",1
"SINGLE-VIEW CHEST, SEMI-UPRIGHT: A right-sided PICC is seen extending into the SVC although the tip is not clearly seen.",0
The tracheostomy tube appears in appropriate position.,0
"There are increased interstitial and alveolar opacities bilaterally which likely represent a component of pulmonary edema, similar in appearance to the previous exam.",0
"Focal pulmonary opacity is seen at the right lung base, which appears to be present previously.",0
"There are small, bilateral pleural effusions.",1
"IMPRESSION: Small, bilateral pleural effusions with increased interstitial and alveolar opacities concerning for pulmonary edema.",1
Overlying infection cannot be excluded.,0
"Admission Date: Discharge Date: Service: - Medicine HISTORY OF PRESENT ILLNESS: The patient is a year old male with past medical history significant for coronary artery disease, recent revision of left hip, who was admitted on , for a three day history of nausea, associated coffee ground emesis, episode of dark tarry stools, decreased p.o.",0
The patient was then brought to where in the Emergency Department he was found to have a hematocrit of 31.2; nasogastric lavage positive for coffee ground and did not clear after two liters.,0
The patient remained hemodynamically stable while in the Emergency Department and was given three liters total of intravenous fluids.,0
Gastroenterology consultation was called at this time.,0
The patient was then taken to the Medical Intensive EGD was deferred at the request of the patient and family.,0
"Coronary artery disease, status post myocardial infarction in , status post coronary artery bypass graft in .",1
Last echocardiogram revealed an ejection fraction of 55% and 4+ mitral regurgitation.,0
Status post left hip revision in .,0
Status post colectomy secondary to diverticulitis in .,0
Theophylline 100 mg twice a day.,0
twice a day since procedure for deep vein thrombosis prophylaxis.,0
SOCIAL HISTORY: The patient lives by himself in facility and was at since his procedure in .,0
Th patient has two sons who are involved in his medical care.,0
"PHYSICAL EXAMINATION: Generally, the patient is a pleasant elderly male in no acute distress.",0
"Vital signs revealed temperature 99.3, blood pressure 139/68, pulse 76, respiratory rate 17, oxygen saturation 100% on two liters nasal cannula.",0
"The oropharynx is clear, dry mucous membranes.",0
"The neck is supple, 7.0 centimeter jugular venous pressure noted.",0
"Cardiac examination - S1 and S2, regular rate and rhythm, III/VI holosystolic murmur that is best heard at the left lower sternal border with radiation to the apex.",0
Chest was notable for diffuse wheezes.,0
"Abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly.",0
The patient as guaiac positive per Emergency Department.,0
The extremities are warm and well perfused.,0
"Neurologically, the patient is grossly intact with no focal deficits and normal speech.",0
"LABORATORY DATA: On admission, hematocrit was 31.2.",0
Gastrointestinal bleed - The patient was brought to the Medical Intensive Care Unit where serial hematocrit levels were performed.,0
"Of note, on hospital day number one, the patient had a decrease in his hematocrit from 32.6 to 28.4.",0
"At this time, the patient was transfused one unit of packed red blood cells with an increase of hematocrit to 33.9.",0
Gastroenterology consultation service was called the following morning where there were preparations for emergent esophagogastroduodenoscopy.,0
"However, the patient's family deferred an esophagogastroduodenoscopy as well as upper gastrointestinal series at this time.",0
The patient was continued on Protonix twice a day and all anticoagulation was held.,0
"Given the patient's appropriate response to the red blood cell transfusion, stable hemodynamics and deferment of esophagogastroduodenoscopy, the patient was transferred to the medical floor for further management.",0
"On hospital day number two, the patient agreed to an upper gastrointestinal series to evaluate for possible sources or bleeding noninvasively.",0
Upper gastrointestinal series at that time was negative for any ulcers or tumors.,0
"Of note, there was mucosal prolapse into the duodenum of unclear significance.",0
"At the time of discharge, the patient will be continued on Protonix twice a day.",0
Serial hematocrits from the time of transfer from Medical Intensive Care Unit until the time of discharge have remained stable.,0
"Status post left hip revision - The patient clearly is at risk for deep vein thrombosis, however, given his history of gastrointestinal bleed, anticoagulation was held at this time.",0
"Two days prior to discharge (one week after admission), lovenox was started for DVT prophylaxis.",0
Coronary artery disease - The patient's has a known history of coronary artery disease.,0
"The patient's Aspirin was held throughout this hospital admission secondary to gastrointestinal bleed, and the patient's blood pressure medications were also held given low intravascular volume and to monitor.",0
Pulmonary - The patient has known history of pulmonary disease.,0
"Of note was wheezing on examination, and his Theophylline was restarted prior to discharge.",0
"Prophylaxis - Given the patient's history of bleed in the setting of recent orthopedic surgery, the patient was placed on pneumonic boots and ambulation was encouraged.",0
The patient also received influenza vaccine prior to discharge.,0
Albuterol two puffs inhaled q6hours p.r.n.,0
Atrovent inhaler two puffs four times a day.,0
Lovenox 60 mg sq until fully weight bearing 6.,0
Captopril 25 mg po tid The patient is to remain on pneumonic boots overnight and he is being encouraged to ambulate frequently for deep vein thrombosis prophylaxis.,0
"He will follow-up with his PCP, .",0
Dictated By: MEDQUIST36 D: 10:48 T: 12:44 JOB#:,0
9:57 PM PELVIS (AP ONLY) PORT Clip # Reason: Component alignment Admitting Diagnosis: RIGHT HIP OA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p right THA REASON FOR THIS EXAMINATION: Component alignment ______________________________________________________________________________ FINAL REPORT HISTORY: Right hemiarthroplasty.,0
COMPARISON: Hip radiographs from and intraoperative radiographs from .,0
Three intra/postopertive views of the right hip show hemiarthroplasty.,0
The hardware appears in normal anatomic alignment.,0
There is marked post fracture deformity of the proximal right femur.,1
Two broken interlocking screws are seen in the distal right femur.,0
10:31 AM CHEST (PORTABLE AP) Clip # Reason: 84M with esophageal cancer s/p esophagectomy with R chest tu Admitting Diagnosis: MAGLIGNANT NEOPLASM OF ESOPHAGUS /SDA ______________________________________________________________________________ MEDICAL CONDITION: 84M with esophageal cancer s/p esophagectomy with R chest tube/JP drain in place; CT to water-seal.,1
REASON FOR THIS EXAMINATION: 84M with esophageal cancer s/p esophagectomy with R chest tube/JP drain in place; CT to water-seal.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 84-year-old male with esophageal cancer, status post esophagectomy with right chest tube and JP-drain in place, CT to water seal, assess for interval change.",0
"COMPARISONS: Multiple prior radiographs, the most recently portable chest radiograph from .",0
FINDINGS: Single AP portable chest radiograph.,0
There has been no significant change since the most recent prior exam.,0
There is normal postoperative appearance of the right hemithorax.,0
Again seen is moderate cardiomegaly and left lower lobe atelectasis.,0
"Monitoring and support devices, including the chest tube, are stable.",0
"6:54 AM CHEST (PORTABLE AP) Clip # Reason: eval for pna, extent of chf Admitting Diagnosis: MULTIPLE MYELOMA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with sepsis and volume overload.",0
"REASON FOR THIS EXAMINATION: eval for pna, extent of chf ______________________________________________________________________________ FINAL REPORT HISTORY: Sepsis and fluid overload, evaluate extent of CHF.",0
COMPARISON: Comparison is made with prior study dated .,0
AP PORTABLE VIEW OF THE CHEST (TWO VIEWS): New mild right pleural effusion.,1
There is engorgement of the vasculature consistent with mild pulmonary edema.,0
Right PICC line with tip in the proximal SVC.,0
There is right lower lobe atelectasis.,0
Mild right pleural effusion and right lower lobe atelectasis.,1
LINE PLACEMENT Clip # Reason: ptx Admitting Diagnosis: MITRAL VALVE INSUFFICENCY\MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ?,1
"CORONARY ARTERY BYPASS GRAFT, ?",0
"MAZE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with s/p MV Replacement - please if there is concern with findings REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, .",0
INDICATION: Mitral valve replacement surgery.,1
FINDINGS: Interval median sternotomy and valvular surgery.,0
"Endotracheal tube, Swan-Ganz catheter, mediastinal drain and left chest tube are in place, as well as a nasogastric tube.",0
The side port of the nasogastric tube is near the GE junction and could be advanced a few centimeters for standard positioning.,0
Heart and central pulmonary arteries remain enlarged.,0
"Lungs are remarkable for minor areas of atelectasis at the bases, right greater than left, and are otherwise clear.",0
"1:06 PM PTBD Clip # Reason: left PTC, please place bilateral biliary metal stents Admitting Diagnosis: DUODENAL MASS Contrast: OPTIRAY Amt: 200 ********************************* CPT Codes ******************************** * INTRO PERC TRANHEPATIC CATH BILIARY STRICTURE DILATION WIT * * BILIARY STRICTURE DILATION WIT -59 DISTINCT PROCEDURAL SERVICE * * BILIARY STRICTURE DILATION NO BILIARY STRICTURE DILATION NO * * -59 DISTINCT PROCEDURAL SERVICE PERC TRANSHEPATIC BILIARY DRAI * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with gallbladder CA REASON FOR THIS EXAMINATION: left PTC, please place bilateral biliary metal stents ______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 68-year-old woman with gallbladder carcinoma status post right-sided PTBD placement on .",0
An attempt to access the left lobe of the liver was unsuccessful on .,0
The patient re-presents today for repeat attempt at left PTC and right and left biliary metallic stent placement.,0
COMPARISON: CT abdomen and pelvis performed on .,0
"CLINICIANS: Dr. , Dr. and Dr. .",0
ANESTHESIA: A general anesthesia was provided.,0
Local anesthesia with 0.5% bupivacaine.,0
"PROCEDURE AND FINDINGS: An informed written consent was obtained after explaining the procedure, benefits, alternatives and risks involved.",0
The patient was brought to angiography suite and placed supine on the imaging table.,0
General anesthesia was administered by anesthesiology service.,0
The right upper abdomen including the existing right PTBD catheter were prepped and draped in the usual sterile fashion.,0
Preprocedure huddle and timeout were performed as per protocol.,0
An initial scout image of the upper abdomen was obtained demonstrating the existing right biliary catheter and the duodenal stent in the expected location.,0
A limited ultrasound examination of the liver demonstrated dilated left biliary system.,0
"Under ultrasound guidance, a peripheral left biliary duct was accessed with a 21-gauge Cook needle.",0
Contrast injection through the needle demonstrated a dilated obstructed left biliary system.,0
"However, the access was lost while attempting to pass a guidewire through the needle.",0
"Then, a further access was obtained into the biliary system under ultrasound guidance, but this access was noted to be somewhat central.",0
"After further opacifying the left biliary system with dilute contrast, a peripheral left anterior duct was successfully accessed under fluoroscopic control and a guidewire was placed through the needle.",0
The needle was then exchanged for an AccuStick sheath.,0
"Cholangiogram through the AccuStick sheath demonstrated a (Over) 1:06 PM PTBD Clip # Reason: left PTC, please place bilateral biliary metal stents Admitting Diagnosis: DUODENAL MASS Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (Cont) markedly dilated left biliary system with a high-grade long segment narrowing of the left hepatic duct; there was no passage of contrast into the common hepatic duct from the left side.",0
The AccuStick sheath was then exchanged for a 6 French x 23 cm Tip sheath over a 0.035 guidewire.,0
"Through the Tip sheath using a combination of Kumpe catheter and Glidewire, the left hepatic duct stricture was successfully crossed into the common hepatic duct.",0
The guidewire and Kumpe catheter were then easily advanced into the bowel.,0
The guidewire was then exchanged for a super-stiff Amplatz wire.,0
The sheath was then advanced into the common bile duct and pullback cholangiogram was performed demonstrating a high-grade left hepatic duct stricture extending up from the confluence of right and left ducts.,0
"At this stage, a cholangiogram was performed through the existing right-sided biliary catheter demonstrating a nondilated right intrahepatic biliary system.",0
The right-sided catheter was then exchanged for a 7 French x 23 cm Tip sheath over a guidewire.,0
"Then, cholangiograms were performed through the Tip sheaths and the measurements were taken for the stent placement.",0
"Following this, a 10 mm x 94 mm Wallstent was placed from the right side and an 8 mm x 80 mm Wallstent was placed from the left side and were successfully deployed across the biliary obstruction.",0
"Both the stents were then simultaneously balloon dilated with a 10 mm and 8 mm high-pressure balloons, respectively.",0
Cholangiograms following the stent placement confirmed satisfactory position and placement of the stents with no residual narrowing on either side and distal ends of the stents were noted to be into the bowel but outside the duodenal stent.,0
"Also, contrast was noted to be flowing freely through the stents into the bowel with no holdup or obstruction.",0
"Following this successful stent placement, the Tip sheaths were removed and 8 French Amplatz anchor drains were placed on both sides and the guidewires removed.",0
The catheters were formed and locked and secured in place with 0 silk sutures and StatLock devices.,0
Both the catheters were connected to external drainage bags which can be capped after about 24 hours if there is no clinical contraindication.,0
The patient tolerated the above procedure well and there were no immediate complications.,0
"At the end of the procedure, the patient was transferred to PACU in a stable condition.",0
The above findings and procedure were discussed by myself with Dr. from the surgical team immediately after the procedure.,0
Limited ultrasound examination demonstrated dilated left intrahepatic biliary system.,0
A peripheral left biliary duct was successfully accessed under ultrasound and fluoroscopic guidance and a PTC was performed.,0
This demonstrated a high-grade left hepatic duct obstruction with marked dilatation of the left intrahepatic biliary system.,0
"The obstructed left hepatic duct was successfully crossed into the bowel and pullback cholangiograms were obtained demonstrating the feasibility of (Over) 1:06 PM PTBD Clip # Reason: left PTC, please place bilateral biliary metal stents Admitting Diagnosis: DUODENAL MASS Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (Cont) metallic stent placement.",0
Successful right and left biliary metallic stent (Wallstent) placement.,0
Post-stent placement cholangiograms were satisfactory with free flow of contrast through both the stents.,0
Placement of external biliary anchor catheters to provide access if further intervention is required.,0
PLAN: The patient is to return to interventional radiology after the weekend for check cholangiography and possible removal of the external biliary catheters.,0
11:07 AM UNILAT LOWER EXT VEINS LEFT Clip # Reason: R/O DVT ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with asymmetric left lower extremity edema.,0
REASON FOR THIS EXAMINATION: R/O DVT ______________________________________________________________________________ FINAL REPORT INDICATION: Asymmetric left lower extremity edema ?,0
"FINDINGS: The left common femoral vein, superficial femoral veins, and popliteal veins demonstrate normal compressibility.",0
"There is preserved flow through these vessels, as well as within the left calf.",0
Right-sided common femoral vein demonstrates normal compressibility with preserved flow.,0
IMPRESSION: No evidence of left-sided venous thrombus.,0
2:36 PM HIP UNILAT MIN 2 VIEWS RIGHT Clip # Reason: ?,0
______________________________________________________________________________ MEDICAL CONDITION: year old man with Fall REASON FOR THIS EXAMINATION: ?,0
______________________________________________________________________________ FINAL REPORT INDICATION: -year-old man after fall.,0
TECHNIQUE: Total of five views of the pelvis and right femur were obtained.,0
FINDINGS: There is an oblique spiral fracture through the right subtrochanteric femur with medial displacement of the distal fracture fragment by about 1.5 cm and with significant varus angulation of the fracture components.,1
IMPRESSION: Significantly displaced right subtrochanteric femur fracture.,1
7:20 AM US INTR-OP 60 MINS Clip # Reason: INTRAOPERATIVE GUIDANCE FOR WHIPPLE ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Obstructed distal common bile duct; to assess for possible mass lesion.,0
FINDINGS: High resolution intraoperative scans were performed directly over the duodenum to image the head of the pancreas.,0
"The pancreatic duct was well visualized and could be followed all the way to the ampulla, and measured 2 mm in diameter.",0
"The common duct was initially decompressed following cholecystectomy, but after suturing the cystic duct, the common bile duct refilled and was well visualized again to the immediate periampullary region.",0
The common duct measured up to 6 or 7 mm in diameter.,0
"The pancreas in the periampullary region as well as in the remainder of the head, neck and uncinate process was entirely normal in appearance.",0
"There was no evidence of a pancreatic mass nor of any mass impingeing into the common bile duct, nor was there any evidence of wall thickening of the common bile duct.",0
"CONCLUSION: Dilated common bile duct to the periampullary region and slightly prominent, but nondilated pancreatic duct, which enters separately at the ampulla.",0
"There was no mass visualized, and the appearance is most consistent with an ampullary stenosis of the CBD.",0
The ampullary region was localized in real time for surgical exploration and marked with a surgical clip.,0
"10:17 AM ART DUP EXT LO UNI;F/U LEFT Clip # Reason: Eval for graft patency Admitting Diagnosis: LEFT FOOT CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with hx of L AK -DP bypass , now left foot cellulitis/ulceration REASON FOR THIS EXAMINATION: Eval for graft patency ______________________________________________________________________________ FINAL REPORT Left foot ulcer.",1
Duplex evaluation was performed of the left lower extremity arterial system with concentration in the dorsalis pedis graft.,0
No flow was seen in the graft.,0
Proximal popliteal artery is patent.,0
There is flow in the distal dorsalis pedis.,0
IMPRESSION: Likely occlusion of left dorsalis pedis artery bypass graft.,1
"Status: Inpatient Date/Time: at 10:57 Test: Portable TTE(Congenital, focused views) Doppler: Focused pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
Report to be generated by the .,0
5:19 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: r/o obstruction Field of view: 38 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with gastric/pancreatic ca with distended abd and no stool x 2 weeks REASON FOR THIS EXAMINATION: r/o obstruction No contraindications for IV contrast ______________________________________________________________________________ WET READ: ARHb SUN 9:53 PM Gastric mass with extension posteriorly to pancreas as previously noted with diffuse peritoneal carcinomatosis and worsening of large volume ascities.,0
Abnormal hepatic perfusion with new mild intrahepatic biliary dilatation.,0
Reticulonodular pattern at lung bases new and may represent metastatic disease though infection should be excluded clinically.,0
Large bilateral hilar lymph nodes bilaterally.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Gastric/pancreatic cancer with distended abdomen.,0
TECHNIQUE: Contrast-enhanced axial images of the abdomen and pelvis were obtained with multiplanar reformatted images.,0
CT ABDOMEN WITH CONTRAST: There are small bibasilar pleural effusions which are new compared to .,1
"Additionally, there is reticulonodular parenchymal opacity at the bases bilaterally with the suggestion of subcentimeter nodules in a subpleural distribution which is overall more advanced compared to recent prior.",0
Enlarged bilateral hilar lymph nodes are partially imaged and measure up to 12 mm in short axis diameter.,0
There is no evidence of a pericardial effusion.,0
There is interval increase in the volume of abdominal ascites.,0
While no definite focal hepatic lesion is identified there is anomalous hepatic perfusion with relative hypoattenuation noted in the left lobe and the anterior aspect of the right lobe.,0
There is however no evidence of arterial or venous thrombosis within the hepatic vasculature.,0
This aberrant perfusion is therefore of doubtful clinical significance.,0
"There is mild intrahepatic biliary ductal dilatation which appears new compared to recent prior, thought CBD and gallbladder appear unremarkable.",0
Mild periportal edema also noted.,0
The spleen and adrenal glands are unremarkable.,0
Subcentimeter renal hypodensities are noted bilaterally but are too small to characterize but do not appear significantly changed compared to recent prior.,0
The abdominal aorta demonstrates scattered mural atherosclerotic calcification but is of normal caliber.,0
There again is an ill-defined mass centered in the gastric cardia and posterior fundus/body with a large hypodense mass within the pancreatic body (Over) 5:19 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: r/o obstruction Field of view: 38 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) which likely represent posterior extension of the gastric mass.,0
"There is posterior extension of mass to the aorta with encasement of the celiac and common hepatic arteries, though they appear patent.",0
Scant flow is again identified within the splenic artery and the splenic vein is likely obliterated.,0
There is again diffuse carcinomatosis in the peritoneum and disease infiltration of the omentum.,1
Intra- abdominal loops of large bowel are unremarkable.,0
The small bowel appears of normal caliber without evidence of obstruction.,0
"A previously described retroperitoneal lymph node measures up to 17 mm, not significantly changed.",0
A nasogastric tube is present within the stomach.,0
CT PELVIS WITH CONTRAST: There is a Foley catheter within the bladder.,0
"There is diminished caliber of the sigmoid colon with a large amount of free pelvic fluid and peritoneal thickening and enhancement within the pelvis, representing carcinomatosis.",0
Bone windows reveal sclerosis of the T7 vertebrae which is stable from a radiograph and may represent Paget's disease.,0
Facet degenerative change at the lower lumbar spine again noted.,0
Large gastric mass extending posteriorly to involve the pancreas with extensive peritoneal carcinomatosis.,0
Scant flow within the splenic artery with obliteration of the splenic vein as above.,0
New mild intrahepatic biliary dilatation with abnormal hepatic perfusion as described.,0
Increase in intra-abdominal ascites compared to recent prior.,0
New small bilateral pleural effusions.,1
New reticulonodular pattern at lung bases is partially imaged and may represent progression of malignancy.,0
The rapidity of progression also raises the question of an infectious etiology and clinical correlation is recommended.,0
No evidence of large or small-bowel obstruction.,0
"3:58 PM CT CHEST W/O CONTRAST Clip # Reason: eval L lung to help determine whether opacification on CXR r Admitting Diagnosis: CONGESTIVE HEART FAILURE;MORBID OBESITY ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with CHF, renal failure, AVR, afib, and MRSA bactermia, now with L lung opacification on CXR, unclear whether this represents lung collapse or pleural effusion REASON FOR THIS EXAMINATION: eval L lung to help determine whether opacification on CXR represents lung collapse or pleural effusion No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate opacification on chest x-ray to differentiate collapse from pleural effusion.",1
TECHNIQUE: CT of the chest was performed without IV contrast.,0
Images were obtained with 5-mm slice thickness and reconstructed to 1.25 mm.,0
FINDINGS CT OF THE CHEST WITHOUT CONTRAST: There is no axillary lymphadenopathy.,0
A dominant precarinal mediastinal lymph node measures approximately 1.5 cm in size (previously 1.1 cm in size).,0
Mild coronary artery calcifications are present.,0
"A small pleural effusion on the right is present, similar in size to the right-sided effusion in .",0
"Within the right lung, there is minimal basilar atelectasis.",0
"A diffuse ground glass opacity of the right lung is also present, but with generalized clearing of the more patchy ground glass opacities which were present on the prior examination.",0
"There has been a slight increase in the size of the left-sided effusion, with total collapse of the left lung.",0
Limited examination of the upper abdominal structures is unremarkable.,0
"There is a feeding tube entering the stomach and, and our scan does not extend inferiorly enough to tell the distal location of this feeding tube.",0
Prominent splenic artery calcifications are present.,0
There is trace amount of ascites present within the abdomen.,0
Examination of osseous structures shows no suspicious lytic or blastic osseous lesions.,0
IMPRESSION: Interval development of significant collapse involving the entire left lung.,0
"Increase in the left-sided pleural fluid is probably secondary to collapse, given the lack of a rightward mediastinal shift.",0
(There may be slight volume loss on the left on today's examination.),0
"There has been largely clearing of the patchy ground glass opacities throughout the right lung, and the residual homogenous ground glass opacity within the right lung may be related to the expiratory phase of which this study was captured.",0
Note is also made of slightly enlarged mediastinal lymph node as described above.,0
(Over) 3:58 PM CT CHEST W/O CONTRAST Clip # Reason: eval L lung to help determine whether opacification on CXR r Admitting Diagnosis: CONGESTIVE HEART FAILURE;MORBID OBESITY ______________________________________________________________________________ FINAL REPORT (Cont),1
Height: (in) 64 Weight (lb): 135 BSA (m2): 1.66 m2 BP (mm Hg): 175/75 HR (bpm): 57 Status: Inpatient Date/Time: at 18:20 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; RIGHT VENTRICLE: RV not well seen.,0
PULMONIC VALVE/PULMONARY ARTERY: Significant PR.,0
There is mild regional left ventricular systolic dysfunction with probable hypokinesis of the basal inferior segment.,0
The right ventricular cavity is dilated with mild global free wall hypokinesis.,0
IMPRESSION: Mild symmetric LVH with probable mild hypokinesis of the basal inferior segment.,0
The other segments have normal function.,0
Dilated and hypokinetic right ventricle with evidence of pressure/volume overload and likely pulmonary hypertension (could not estimate PA systolic pressure but PA diastolic pressure likely high).,0
"8:38 PM ELBOW (AP, LAT & OBLIQUE) LEFT PORT Clip # Reason: Please evaluate for reduction Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man s/p polytrauma with open elbow fx, s/p ex-fix and washout REASON FOR THIS EXAMINATION: Please evaluate for reduction ______________________________________________________________________________ FINAL REPORT INDICATION: 29-year-old with polytrauma.",1
TECHNIQUE: Two views of the elbow were obtained.,0
FINDINGS: Examination is limited by patient positioning.,0
External fixation is seen in the mid humerus and the proximal ulna.,0
There is a comminuted elbow fracture involving the olecranon and the articular surface of the ulna at the humeroulnar joint.,1
There is a small elbow joint effusion.,0
Repeat radiographs upon fixation recommended to evaluate for additional fractures.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: Baby is the 1,265 gram product of a 29- 5/7 weeks gestation born to a 32-year-old G3, P0 now 1 mother.",1
"Prenatal include blood type B-positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, and GBS negative.",0
"Maternal history notable for being hepatitis C positive with recent viral loads of 160-175,000, and she was not currently being treated with medications.",1
"Of note, father of baby is unaware of his status.",0
Maternal obstetrical history notable for 2 prior losses leading to early cerclage placement in this pregnancy and history of fibroids.,0
This pregnancy was then further complicated by cervical shortening at 25 weeks requiring cerclage removal and initiation of tocolysis.,0
She received a course of betamethasone at that time and was complete on .,0
She was also treated with antibiotics for a UTI.,0
Mother has been hospitalized since weeks with intermittent need for magnesium tocolysis.,1
"On day of delivery, she had progressive preterm labor despite magnesium and was taken for cesarean delivery.",1
She did not receive intrapartum antibiotic prophylaxis.,0
Membranes were intact at delivery and no fevers were noted.,0
"Infant emerged with moderate tone, weak cry, responded to vigorous stimulation, and required positive pressure ventilation.",0
Heart rate was greater than 100 throughout.,0
Apgars were 7 and 8.,0
"PHYSICAL EXAM ON ADMISSION: Birth weight was 1,255 grams (50th percentile), head circumference 28 cm (50th-75th percentile).",0
Length 40 cm (50th-75th percentile).,0
"Premature infant, active with exam, moderate to significant respiratory distress at rest.",1
Substantial bruising around face particularly on right side with scattered bruises of his left arm.,0
Fontanel is soft and flat.,0
"Pupils somewhat large, but responsive and equal.",0
"Chest: Poorly aerated, limited air movement, positive grunting, flaring, and retractions.",0
"Cardiac: Regular rate and rhythm, mildly tachycardic, no murmur or gallop.",0
"Abdomen is soft, nondistended, no hepatosplenomegaly, no mass, quiet bowel sounds, positive 3-vessel cord.",0
Neuro: Appropriate tone and activity.,0
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: was admitted to the newborn intensive care unit and was intubated for management of respiratory distress syndrome.,1
He received a total of 2 doses of surfactant and remained intubated for a total of 6 days at which time he transitioned to CPAP.,0
He remained on CPAP for a total of 8 days and was transitioned to nasal cannula O2.,0
He remained on nasal cannula until at which time he transitioned to room air and has been stable on room air since that time.,0
He was treated empirically with caffeine citrate for management of apnea and bradycardia of prematurity.,1
His caffeine citrate was discontinued on .,0
His last documented apnea and bradycardia episode was on .,0
He has had episodes of desaturations with enteral feedings which resolved quickly when the bottle was removed.,0
CARDIOVASCULAR: Infant received 3 courses of indomethacin therapy for management of patent ductus arteriosus.,1
His most recent indomethacin course was complete on .,0
His most recent echocardiogram on demonstrated no patent ductus arteriosus.,1
"Clinically, infant has an intermittent murmur and otherwise is cardiovascularly stable.",0
"FLUID AND ELECTROLYTES: Birth weight was 1,265 grams.",0
Discharge weight is 3290 grams.,0
Infant was initially started on 80 ml per kilogram per day of D10W.,0
Enteral feedings were initiated on day of life 8.,0
The delay was in light of indomethacin therapy.,0
He achieved full enteral feedings by day of life #18.,0
Max caloric enteral intake was 150 ml per kilogram per day of Premature Enfamil 26 calorie.,0
He is currently ad-lib feeding Enfamil 24 calorie taking in adequate amounts demonstrating good weight gain.,0
GI: Peak bilirubin was on day of life 8 of 5.1/0.3.,0
Infant was receiving phototherapy and that issue has since resolved.,0
HEMATOLOGY: Infant's blood type is O-positive.,0
He had an initial hematocrit of 42.1.,0
"He has received 2 packed red blood cell transfusions, the most recent being on .",0
His most recent hematocrit was on of 33.2 with a reticulocyte count of 1.1.,0
He is also receiving ferrous sulfate supplementation.,0
INFECTIOUS DISEASE: CBC and blood cultures were obtained on admission.,0
CBC was benign and blood cultures remain negative at 48 hours at which time ampicillin and gentamicin were discontinued.,0
Infant was started on erythromycin eye ointment for eye drainage of his left eye on .,0
He received a 5 day course with resolution.,0
Ongoing issue with is oral .,0
He was treated with oral nystatin for 3 weeks with no change.,0
He was changed at that time to fluconazole.,0
He remained on fluconazole until at which time it was changed to gentian violet with improvement.,0
"A KOH prep was sent, but was unable to be conclusive.",0
The plan is to continue gentian violet for 2 more days and to monitor clinically.,0
NEUROLOGY: Head ultrasounds performed at the were consistent with a question of a subacute hemorrhage in the septal veins that was evolving over time.,0
A head MRI was inconclusive.,0
A repeat MRI done at on was read as normal with unremarkable brain scan.,0
Recommended neonatal neurology followup at the clinic at 3 months of age.,0
Infant has been neurologically appropriate.,0
SENSORY: Hearing screen was performed with automated auditory brainstem responses and the infant passed.,0
OPHTHALMOLOGY: Most recent eye exam was on revealing immature zone III vessels with recommended followup in 3 weeks with Dr. .,0
PSYCHOSOCIAL: Social worker has been involved with this family.,0
The social worker's name is .,0
She can be reached at .,0
"NAME OF PRIMARY PEDIATRICIAN: at , telephone number is .",0
Appointment has been made for .,0
CARE AND RECOMMENDATIONS: Continue ad-lib feeding Enfamil 24 calorie.,0
MEDICATIONS: Gentian violet to oral x 2 more days.,0
CAR SEAT POSITION SCREENING: Was performed and infant passed.,0
STATE NEWBORN SCREENING STATUS: State screens have been sent per protocol and are within normal limits.,0
IMMUNIZATIONS RECEIVED: Infant received hepatitis B vaccine on .,0
"Received HIB, Prevnar, and Pediarix on .",0
"Born between 32 and 35 weeks with 2 of the following: Daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3.",0
FOLLOW-UP APPOINTMENTS: Ophthalmology 3 weeks with Dr. .,0
Her telephone number is .,0
"Neonatal Clinic at 3 months, telephone number is .",0
"Pediatrician, Dr. , on .",0
Premature infant born at 29-4/7 weeks 2.,0
"Conjunctivitis , Dictated By: MEDQUIST36 D: 01:04:01 T: 04:31:09 Job#:",0
"2:38 AM PORTABLE ABDOMEN Clip # Reason: acute abdominal process Admitting Diagnosis: URINARY TRACT INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man admitted with urosepsis, now with worsening abdominal pain.",1
REASON FOR THIS EXAMINATION: acute abdominal process ______________________________________________________________________________ FINAL REPORT ABDOMEN REASON FOR EXAM: Urosepsis with worsening abdominal pain.,1
There is inespecific bowel gas pattern with few nondistended small bowel loops and air-filled nondilated colon.,0
There is minimal air in the sigmoid with paucity of air in the rectum.,0
Degenerative changes are in the thoracic spine.,0
12:59 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with ET tube at carina REASON FOR THIS EXAMINATION: ET tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: ET tube placement.,1
FRONTAL CHEST RADIOGRAPH: An endotracheal tube terminates 3.4 cm above the carina.,0
Cuff is inflated just beyond the tracheal caliber.,0
A right-sided IJ terminates at the low SVC.,0
"The lung volumes are low, resulting in bronchovascular crowding.",0
"A small left pleural effusion is unchanged, accompanied by basilar atelectasis.",0
IMPRESSION: ET tube terminating 3.4 cm above the carina.,0
The tube cuff is expanded just beyond tracheal caliber.,0
Unchanged small left pleural effusion and bibasilar atelectasis.,0
4:15 PM BABYGRAM CHEST & ABD (2 FILMS STANDARD) PORT Clip # Reason: Term infant with known congenital heart disease.,1
Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with CHD - decreased ventricular function.,0
REASON FOR THIS EXAMINATION: Term infant with known congenital heart disease.,1
"______________________________________________________________________________ FINAL REPORT CHEST, : Views of the chest and abdomen were performed.",0
Overall pulmonary bloodflow is within normal limits.,0
There is no evidence of congestive heart failure or pneumonia.,0
There is a NGT present.,0
The bowel gas pattern is normal.,0
3:16 PM CAROTID SERIES COMPLETE Clip # Reason: evaluate for carotid stenosis.,1
"Admitting Diagnosis: MYOCARDIAL INFARCTION;ATRIAL FLUTTER\CATH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with new onset a flutter, s/p NSTEMI last week, triple vessel disease on cath, to have CABG .",1
REASON FOR THIS EXAMINATION: evaluate for carotid stenosis.,1
"______________________________________________________________________________ FINAL REPORT CAROTID DUPLEX REASON: 74-year-old male with new onset a-flutter, to have a CABG, evaluate for carotid stenosis.",1
"On B-mode imaging, there is heterogeneous plaque that is extensive in the left proximal ICA.",0
This is a technically difficult study due to severe flutter.,0
"On the right, the peak systolic velocities are as follows: 45 in the proximal ICA, 58 in the mid ICA and 51 in the distal ICA.",0
The CCA velocities are 70 proximally and 48 distally and the ECA velocity is 70.,0
The ICA/CCA ratio is 0.82.,0
This is consistent with a 1-39% right ICA stenosis.,0
"On the left, the peak systolic velocities are as follows: 251/129 proximally in the ICA, 305/103 in the mid ICA and 26 in the distal ICA.",0
The CCA velocities are 56 proximally and 43 distally.,0
The ICA velocity is 51.,0
The ICA/CCA ratio is 5.5 and this is consistent with an 80-99% left ICA stenosis.,0
"IMPRESSION: There is a 1-39% right ICA stenosis and an 80-99% left ICA stenosis with antegrade flow in both vertebral arteries, although this is extremely technically difficult study secondary to severe flutter.",1
11:22 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
ptx after CT removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with CABG/AVR REASON FOR THIS EXAMINATION: ?,1
"ptx after CT removal ______________________________________________________________________________ FINAL REPORT AP CHEST, 11:27 A.M., HISTORY: CABG and AVR, question pneumothorax after chest tube removal.",0
"IMPRESSION: AP chest compared to : Lower lobe atelectasis is worsened and small left pleural effusion may have developed following removal of the left pleural drain, but there is no pneumothorax.",1
"Mild-to-moderate cardiomegaly has increased, but this may be a function of the end of positive pressure ventilator support.",0
Moderate right basal atelectasis is stable.,0
Jugular introducer ends at the thoracic inlet.,0
"9:56 AM CHEST (PORTABLE AP) Clip # Reason: assess for edema Admitting Diagnosis: MVP\MITRAL VALVE REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman s/p MV repair REASON FOR THIS EXAMINATION: assess for edema ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, ONE VIEW: INDICATION: A 73-year-old woman status MV ART.",1
"COMMENTS: Portable AP radiograph of the chest was reviewed, compared with a previous study of .",0
The nasogastric tube has been removed.,0
CONCLUSION: Status post MV ART and median sternotomy.,0
Mediastinal drain and right chest tube remains in place.,0
There is continued mild congestive heart failure with small left pleural effusion.,1
Patchy atelectasis is seen in both lung bases.,0
", D. VSURG CSRU 4:01 PM CHEST PORT.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: s/p rt subclavian Tlc placement Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with s/p EVAR REASON FOR THIS EXAMINATION: s/p rt subclavian Tlc placement ______________________________________________________________________________ PFI REPORT Right subclavian catheter courses cephalad into the right internal jugular vein.,1
8:40 PM CT HEAD W/O CONTRAST Clip # Reason: LT SDH WITH MID LINE SHIFT FROMOSH.,0
______________________________________________________________________________ MEDICAL CONDITION: year old man with L SDH with 7mm midline shift dx'd on OSH CT scan today.,0
No films with patient REASON FOR THIS EXAMINATION: eval SDH No contraindications for IV contrast ______________________________________________________________________________ WET READ: MRGe TUE 9:49 PM Motion artifact limits the study.,0
Large left subdural hematoma measuring 1.8 cm in thickness.,0
Effacement of the left cerebral hemisphere sulci and mass effect over the left lateral ventricle.,0
Tiny extra-axial linear hyperdensity along the rigth occipital convexity may also represent a small focus of SDH.,0
WET READ VERSION #1 MRGe TUE 9:38 PM Motion artifact limits the study.,0
______________________________________________________________________________ FINAL REPORT History: Left subdural hematoma with 7 mm midline shift diagnosed on outside hospital CT scan today.,0
No images are available for comparison.,0
CT OF THE HEAD WITHOUT CONTRAST: There is a large extra-axial hyperdense (similar attenuation at matter) fluid collection along the left cerebral convexity measuring up to 1.8 cm in thickness.,0
Findings are compatible with subacute subdural hematoma.,0
There is a tiny hyperdense extra- axial collection along the right occipital convexity which measures up to 3-4 mm likely a small acute subdural hematoma (S2:16) 7- mm rightward subfalcine herniation noted and well as left uncal herniation.,0
Diffuse effacement of the sulci on the left cerebral hemisphere.,0
Mass effect over the left lateral ventricle with effacement of the occipital .,0
The study is limited due to motion artifact.,0
There is no hydrocephalus or hemorrhage in the ventricles.,0
IMPRESSION: Large left subacute subdural hematoma measuring 1.8 cm in thickness with associated subfalcine and left uncal herniation.,0
Tiny acute right occipital subdural hematoma.,0
Continued close followup is recommended.,0
A preliminary report was flagged on the ED dashboard at the time of preliminary review.,0
SESHa (Over) 8:40 PM CT HEAD W/O CONTRAST Clip # Reason: LT SDH WITH MID LINE SHIFT FROMOSH.,0
9:07 AM MR HEAD W & W/O CONTRAST Clip # Reason: Please evaluate for response to chemo.,0
"Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 73 F with CNS lymphoma status post rituximab and demozolamide, here with altered mental status.",0
REASON FOR THIS EXAMINATION: Please evaluate for response to chemo.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 73-year-old female with probable large B-cell dominant CNS lymphoma status post chemotherapy with worsening mental status.,0
"Comparison is made to prior MRI examinations dated and , .",0
"HEAD MRI: TECHNIQUE: Multiplanar T1, T2, diffusion-weighted, and post-gadolinium sequences were obtained.",0
"FINDINGS: Since most recent examination, there are now multiple small foci of precontrast increased T1 intensity lesions along the subcortical and deep white matter, predominantly within the prefrontal region bilaterally adjacent to the primary motor cortex and within the anterior superior right frontal lobe.",0
"These areas display evidence of restricted diffusion, with some displaying low signal on the ADC map.",0
Minimal FLAIR abnormality is noted within these lesions.,0
Post- contrast images display diffuse enhancing lesions most prominent within the superior frontal lobes bilaterally with probable leptomeningeal involvement.,0
"When compared to most recent examination, the size, ring enhancement, and total number of enhancing lesions is decreased.",0
"A minimal amount of rightward subfalcine herniation persists; otherwise, there is no other evidence of significant mass effect or hydrocephalus.",0
"Small punctate region of susceptibility artifact within the right frontal lobe, likely from prior biopsy is stable, with no new areas of susceptibility artifact are identified.",0
Diffuse vasogenic edema within the cerebral peduncles and frontal lobes persists and does not appear significantly changed.,0
Decreased total number enhancing lesions within the brain parenchyma suggestive of chemotherapy steroid response.,0
New hyperintense T1 lesions displaying restricted diffusion predominantly within the prefrontal subcortical white matter.,0
Differential diagnosis includes new small hemorrhagic metastatic lesions or hemorrhagic small vessel infarcts from an etiology such as vasculitis.,0
No new susceptability artifact (Over) 9:07 AM MR HEAD W & W/O CONTRAST Clip # Reason: Please evaluate for response to chemo.,0
Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ FINAL REPORT (Cont) currently.,0
Findings were discussed with Dr. on date of exam at approximately 3:30 p.m.,0
"11:38 AM CHEST (PORTABLE AP) Clip # Reason: eval for CHF Admitting Diagnosis: INTER CRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with SAH, thick sputum, increased WBC.",0
"REASON FOR THIS EXAMINATION: eval for CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Subarachnoid hemorrhage, thick sputum, white count please evaluate for congestive heart failure.",1
"VIEWS: Single AP portable semiupright view, comparison dated .",0
"FINDINGS: The pulmonary artery catheter enters via the right subclavian and terminates with tip in right pulmonary artery, in satisfactory position.",0
Nasogastric tube extends below the diaphragm and tip terminates below the borders of the radiograph.,0
"There is slight interval progression of pulmonary vascular upper zone redistribution, and bilateral alveolar and interstitial infiltrates.",0
The visualized osseous structures are unchanged.,0
Worsening congestive heart failure and bilatal pleural effusions.,1
Lines and tubes in stable and satisfactory position.,0
Admission Date: Discharge Date: Service: SURGERY Allergies: Fosamax Attending: Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: 1.,1
Placement of left-sided chest tube.,0
Primary repair 6 cm laceration to left forearm.,0
"History of Present Illness: The patient is an 89-year-old gentleman who presented with a GI bleed, underwent negative EGD times two before positive tagged red blood cell scan localizing to the upper GI tract.",0
The patient on endoscopy of was noted to have a clot adherent to the medial wall of the duodenum just distal to the bulb at the junction of the second part of the duodenum in proximity to the ampulla.,0
The patient was injected and cauterized.,0
"Today surgical service was called to see the patient, however, at that time the patient's hematocrit was 30.2 and vital signs stable.",0
"Subsequently, the patient became unstable with an hematocrit of 13 and surgery was notified.",0
"In the intervening period, a triple-lumen catheter was placed in the left side with multiple attempts and again the surgery service was consulted for access.",0
Surgical house officers discussed the findings and risks with the family who were cleared with their wishes to proceed with the operation at this time.,1
"Because the patient was unstable, the option for interventional radiology was not recommended.",0
"The patient was resuscitated with blood transfusions, intubated, access achieved and the patient transferred urgently to the operating room.",0
"He was managed medically with an active problem list including: c. diff- vanc and flagyl, COPD-nebs, CHF- secondary to flash pulmonary edema tx with diuresis, steroid dependence-solumedrol, diabetes, CRI CXR: 1.",0
"Mild congestive heart failure, not significantly changed since the prior examination.",1
Retrocardiac opacity which may represent collapse/consolidation HD 3 () Left upper extremity edema and swelling.,1
A doppler did not show any DVT.,0
HD 4 () Tc-m bleeding scan showed no evidence of active gastrointestinal bleed.,0
EGD showed: Oral secretions pooled in hypopharynx and valeculae.,0
These secretions were thick and difficult to suction.,0
Most were able to be suctioned from the region.,0
Atrophy and erythema in the antrum and stomach body compatible with gastritis.,0
"Ulcers in the distal bulb, posterior bulb and second part of the duodenum.",0
Erosions in the second part of the duodenum.,0
Food in the middle third of the esophagus.,0
"HD 8() Patient was transferred to the MICU under , .",0
EGD showed: There was no blood seen in the intestine.,0
There was evidence of oral secretions in the hypopharynx and valeculae.,0
Erythema in the duodenal bulb compatible with duodenitis.,0
Erosions in the second part of the duodenum and third part of the duodenum.,0
A submucosal lesion suggestive of a lipoma was detected in the 3rd part of the duodenum.,0
"Ulcers in the distal bulb, first part of the duodenum and second part of the duodenum (thermal therapy).",0
EKG showed: Wandering atrial pacemaker with rate approximately 60.,0
Cannot exclude old inferior myocardial infarction.,0
"Given low voltage and wandering atrial pacemaker, a pericardial process and/or pericardial effusion must be susepcted.",0
Consistent with this view is considerable diminution in QRS voltage compared to the previous tracing.,0
"CXR: 1) Placement of right internal jugular central venous catheter, terminating in the right atrium.",0
2) Left lung base consolidation improving.,0
3) Bilateral pleural effusions; the left-sided effusion is definitively smaller when compared to the prior exam.,0
HD 9 () Transfused 14 units PRBC.,0
EGD: A large blood clot was noted in the distal bulb.,0
There was fresh red blood noted coming from the clot with pooling of red blood in the dependant part of the duodenum.,0
The clot seemed to be adherant to the medial wall of the duodenum just distal to the bulb at the junction to the 2nd part of the duodenum.,0
This appeared to be anatomically close to where the ampulla would be expected to be.,0
A total of 16 ml of Epinephrine 1/ injections were applied in multiple sites around the clot for hemostasis with success.,0
Lavage of the clot after the procedure did not demonstrate any fresh red blood welling up in the duodenum any more.,1
"KUB: no free air Repeat bleeding scan: Active GI bleeding, abnormal tracer activity noted in the left upper quadrant, most likely within the stomach or duodenum.",0
Patient was taken urgently to OR for: 1.,0
Placement of left-sided chest tube Pathology showed would eventually show: 1.,0
Area of marked edema of antral mucosa and submucosa with prolapse into duodenum.,0
Brunner's gland hyperplasia consistent with chronic duodenitis.,0
Unremarkable fundic-type mucosa at proximal margin.,0
Duodenal mucosa at distal margin.,0
No ulcer seen HD 10 () Platelets: transfused 10units.,0
The patient is an 89-year-old gentleman who went antrectomy and oversewing of a duodenal ulcer.,1
"Prior to moving the patient to the ICU, an adhesive pad was removed from his left arm.",0
"Given his history of presumed steroids, this caused an avulsion of the skin on his left arm with a J-shaped injury of approximately 6 cm.",0
The patient was still intubated and had not yet been moved.,0
"At this time, the wound was prepped with Betadine and draped in a sterile fashion.",0
The wound was reapproximated with seven interrupted 3-0 nylon sutures using a vertical mattress suture.,0
It came across easily and a sterile gauze dressing was applied.,0
There was no blood loss.,0
No complications related to the repair.,0
I was present for all components of this procedure.,0
ECHO:The left atrium is mildly dilated.,0
Right ventricular free wall motion may be depressed.,0
HD 11 () Transfused 2units PRBC.,0
"HD 15 () Left lower extremity swelling and LENI showed: 1) Extensive thrombus involving the right common femoral, superficial femoral, and popliteal veins.",1
"2) Additional long segment thrombus involving the right common femoral, superficial femoral, and deep femoral veins.",0
"These findings were called to Dr. , who was caring for the patient at the time of the exam, at 4:00 p.m. on .",0
HD 17 () the chest tube was taken out CXR did not show pneumothorax but did show unchanged layering right pleural effusion and small left basilar pleural effusion.,0
Minimal bibasilar atelectasis HD Transfused 1unit PRBC.,0
HD 26 () CT to look for source of sepsis: 1) Small left pneumothorax and pleural effusion.,0
Left-sided chest tube appears somewhat kinked.,0
2) Small amount of mesenteric fluid likely postoperative in nature.,0
3) Stable left renal cyst.,0
"4) Continued wall thickening of the rectum and sigmoid colon, which is consistent with the patient's history of C. diff.",0
HD 29 () Left foot films to r/o osteo: The patient is in some form of supportive air filled boot.,0
The material associated with this obscures portions of the bone.,0
"However, allowing for this, I can see the ulceration along the posterior aspect of the calcaneus.",0
No focal bone destruction or focal lytic or sclerotic lesion in this area to confirm the presence of osteomyelitis is identified.,0
Moderately severe diffuse osteopenia and IP joint degenerative changes are noted.,0
HD 30 () Patient was made DNR/DNI.,0
This was confirmed with family prior to order.,0
HD 31 () The patient died in early morning.,0
Medications on Admission: albuterol tylenol #3 bisacodyl atrovent vit D zinc prednisone zocor MVI Lopressor Monteleukant calcium docusate Riss prevacid flovent Discharge Medications: does not apply Discharge Disposition: Expired Discharge Diagnosis: death Discharge Condition: dead Discharge Instructions: NA Followup Instructions: NA Completed by:,0
"7:06 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: positioning, rule out PTX Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with new tracheostomy REASON FOR THIS EXAMINATION: positioning, rule out PTX ______________________________________________________________________________ WET READ: EAGg WED 9:27 PM Tracheostomy tube terminates 5.1 cm from the carina.",0
Left sided subclavian central venous catheter terminates in right atrium.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Tracheostomy positioning.,0
FINDINGS: The tracheostomy tube terminates 5 cm above the carina.,0
The left-sided central venous access line projects over the right atrium with its tip.,0
The line could be pulled back by 3-4 cm.,0
", C. NMED MICU-7 9:12 AM MR HEAD W & W/O CONTRAST Clip # Reason: lesions Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with new sz REASON FOR THIS EXAMINATION: lesions No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Evidence of left occipital chronic infarction.",0
Areas of chronic small vessel disease in the subcortical and periventricular white matter.,0
No diffusion abnormalities are demonstrated.,0
There is no evidence of abnormal enhancement.,0
"Cortical areas of gyriform hyperintensity signal noted in the left occipital lobe, possibly consistent with pseudolaminar necrosis.",0
"Mucosal thickening is identified in the ethmoidal air cells and bilateral mastoid air cells, the patient is intubated.",0
10:26 AM CT HEAD W/O CONTRAST Clip # Reason: Please eval for ICH ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman s/p fall SDH / Small SAH REASON FOR THIS EXAMINATION: Please eval for ICH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 71 y/o female status post fall with subdural and subarachnoid hemorrhages.,1
Comparison is made to prior exam from one day earlier.,0
FINDINGS: There has been no significant interval change in the appearance of the patient's brain.,0
"Once again, there is a moderate sized right frontoparietal subdural hematoma which is stable in size.",0
It is associated with mild mass effect and effacement of the adjacent sulci.,0
"Also noted are a small right parafalcine and small left frontal subdural hematoma, both of which are unchanged in the interval.",0
There is a minimal amount of subarachnoid blood which appears stable in the interval.,0
The ventricles and cisterns are not effaced.,0
The -white matter differentiation is grossly preserved.,0
The visualized osseous structures and paranasal sinuses are unremarkable.,0
IMPRESSION: Stable appearance of bilateral frontal subdural hematomas and small subarachnoid hemorrhage as described above.,1
4:16 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please eval for position NGT Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with new NGT REASON FOR THIS EXAMINATION: Please eval for position NGT ______________________________________________________________________________ FINAL REPORT HISTORY: NG tube placement.,0
"FINDINGS: In comparison with the earlier study of this date, the tip of the Dobbhoff tube lies in either the distal stomach or the proximal portion of the duodenum.",0
Little overall change in the appearance of heart and lungs.,0
Endotracheal tube tip is in good position and the right IJ catheter tip is in the lower portion of the SVC.,0
"8:16 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Concern for mesenteric ischemia ______________________________________________________________________________ MEDICAL CONDITION: 83 year old male with severe abdominal pain x1 day, elevated lactate REASON FOR THIS EXAMINATION: Concern for mesenteric ischemia No contraindications for IV contrast ______________________________________________________________________________ WET READ: DSsd SAT 10:25 AM findings c/w acute pancreatitis.",1
"cholelithiasis, and tiny density in pancreatic head in region of distal CBD which could represent a small CBD stone.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 83-year-old male with severe abdominal pain for one day, and elevated lactate.",0
TECHNIQUE: Volumetric CT acquisition of the abdomen and pelvis was performed without oral or intravenous contrast.,0
CT ABDOMEN: There is mild dependent bibasilar atelectasis at the visualized lung bases.,0
Absence of intravenous contrast limits evaluation of the abdominal parenchymal organs and vasculature.,0
Non-contrast appearance of the liver is normal.,0
There is a mild amount of ascites around the liver.,0
"The gallbladder is slightly distended, and contains layering small stones or in dependent portions of the gallbladder.",0
"There is a large amount of peripancreatic inflammatory stranding, which extends throughout the abdominal mesentery, and down the right anterior pararenal space.",0
"There is a small ill-defined rounded density in the region of the pancreatic head, near the expected location of the distal common bile duct.",0
"This area is difficult to assess, but this could conceivably represent a stone in the distal common bile duct, versus calcification in the pancreatic head parenchyma.",0
There are borderline enlarged scattered peripancreatic and porta hepatis lymph nodes.,0
"There are bilateral hyperdense renal cystic lesions, which are incompletely characterized on this non-contrast examination.",0
Stomach and intra-abdominal loops of bowel are unremarkable.,0
"There is moderate atherosclerotic calcification of the abdominal aorta and its branches, but vascular assessment is limited without intravenous contrast.",0
CT PELVIS: Pelvic loops of large and small bowel are unremarkable.,0
"Mild apparent bladder wall thickening, is likely due to partially decompressed bladder, though the prostate is moderately enlarged, measuring 5.2 x 4.8 cm.",0
(Over) 8:16 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Concern for mesenteric ischemia ______________________________________________________________________________ FINAL REPORT (Cont) There is no osseous lesion suspicious for malignancy.,0
Mild-to-moderate multilevel degenerative changes are seen in the visualized thoracolumbar spine.,0
"Marked peripancreatic inflammatory stranding, most consistent with acute pancreatitis.",1
Evaluation for complications related to acute pancreatitis is limited without intravenous contrast.,1
"Presumably, given the presence of multiple small gallstones, and likely stone in the region of the distal CBD, these findings represent gallstone pancreatitis.",0
Bilateral incompletely characterized hyperdense renal cysts.,0
Followup renal ultrasound is recommended for further evaluation.,0
Acute findings discussed with Dr. at 10:15 a.m. on .,0
3:44 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: r/o injury ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with REASON FOR THIS EXAMINATION: r/o injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Prisoner in a fight now with significant trauma to the left eye.,1
TECHNIQUE: Axial 2.5 mm sections of the face was obtained and subsequent 1 mm coronal reformatted images and 1 mm sagittal reformatted images were reconstructed.,0
FINDINGS: There is a prominent amount of left periorbital soft tissue swelling as well as swelling of the intracoronal fat.,0
There is a hematoma in the anterior portion of the left optic nerve sheath.,1
There is a fracture through the left orbital floor which involves the inferior aspect of the left medial orbital wall as well.,0
There is an air fluid level in the left maxillary sinus and opacification of multiple left ethmoidal air cells.,0
There is also a small amount of fluid in both sphenoid sinuses.,0
The right orbit is normal.,0
The mandibular condyles are normal and well seated in the temporal mandibular joints.,0
The cribriform plate appears intact.,0
IMPRESSION: 1) Left optic nerve sheath hematoma.,1
2) Left orbital floor fracture which extends into the inferior aspect of the medial wall.,0
There is some herniation of the extracoronal orbital fat but no evidence of herniation of the inferior rectus muscle.,0
3) Blood fluid level in the left maxillary sinus.,0
This report was discussed with on at 5:00pm.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: Mrs. is a 68-year-old woman with multiple medical problems who underwent a coronary artery bypass graft x3 on by Dr. .,1
Her postoperative course was delayed due to pulmonary problems requiring reintubation for increased amount of secretions and also atrial fibrillation.,1
She was transferred out of the Intensive Care Unit on postoperative day 9 and finally discharged to rehabilitation on postoperative day 11 in a stable condition on po Kefzol.,0
She was seen by Dr. on for postoperative checkup where she was noted to have a small amount of purulent drainage from her sternal wound.,0
"As stated above, she had been on Keflex which was changed to clindamycin at that time.",0
Mrs. returned for a wound check on from rehabilitation where she had an open area approximately 1 cm long and 1.5 cm deep at the distal aspect of her incision with eschar and minimal erythema surrounding the open area.,0
She had been otherwise progressing well and remained afebrile.,0
The wound was debrided locally and she was placed on levofloxacin 500 mg and at that time was instructed to keep for 14 days.,0
A follow up appointment was scheduled for .,0
"On , she was admitted to Hospital in with an episode of hypertension, increased white blood cell count to 25,000.",0
"She was found to be in atrial fibrillation, hyperkalemia up to 9 as per outside report and found to be in renal insufficiency.",1
"She was intubated at that time for question of respiratory failure, placed on intravenous Diltiazem to control her heart rate and a dopamine drip for her hypertension.",0
She was admitted to the Intensive Care Unit for further management.,0
A chest CT at that time revealed a small substernal collection.,0
"Since she developed these findings and she was better known to the , she was transferred to this institution for further and definitive treatment, as well as assessment of that sternal wound.",0
Coronary artery bypass graft x3 on .,1
Asthma with occasional steroid use.,0
Chronic obstructive pulmonary disease 4.,1
The patient had a carotid ultrasound on that showed 40% to 59% bilateral ICA stenosis with right subclavian steel.,0
Status post lacunar stroke in 7.,0
Episode of anaphylaxis due to ACE inhibitors and aspirin in the past.,0
Status post THR in ALLERGIES: THE PATIENT HAS ANAPHYLACTIC REACTION TO ACE INHIBITORS AND ASPIRIN.,0
Dilantin 100 mg po tid 2.,0
Trazodone 100 mg po q hs 3.,0
Bumex 6 mg q a.m. and 2 mg q p.m. 4.,0
Procardia XL 120 mg po q day 5.,0
Hydrocortisone and acetaminophen prn 6.,0
Prevacid 30 mg po bid 7.,0
Ativan 1 mg po tid 8.,0
Hydralazine 25 mg po tid 9.,0
Reglan 10 mg po q hs 10.,0
Xanax 2.5 mg prn 11.,0
Insulin 75/25 50 units q a.m. and 60 units q p.m. 12.,0
Nitro-Dur patch at 7 a.m. and 10 p.m. 13.,0
"Catapres 0.3 mg transdermal patch once a week ADMISSION PHYSICAL EXAMINATION: GENERAL: The patient was in atrial fibrillation with a rate of 60s, intubated on assist control ventilation, but patient was awake and alert, moving all extremities well.",1
Nodded her head appropriately to questions.,0
LUNGS: Clear to auscultation bilaterally anteriorly.,0
"HEART: Irregularly irregular and no murmurs, thrills or rubs.",0
"STERNUM: Stable, small opening in the area at the distal aspect of the incision with no erythema and very small amount of scant yellow drainage.",0
"EXTREMITIES: Warm and well perfuse, no peripheral edema.",0
"LABS: A white blood cell count aspirate at the outside hospital was 24,000 with a hematocrit of 43.5.",0
"She had a neutrophil count of 85, sodium of 140, potassium of 3.0, chloride of 103, CO2 of 26, BUN of 21 with a creatinine of 1.3.",0
"The glucose level was 215, bilirubin 1.9, AST of 48, ALT of 49, alkaline phosphatase of 113, protein of 6.8.",0
"HOSPITAL COURSE: As stated above, the patient was admitted to the Intensive Care Unit and her Diltiazem drip was weaned to off.",0
"She required multiple fluid boluses to improve her blood pressure, but in spite of that the patient was kept on the dopamine drip overnight.",0
Her antibiotics upon transfer was levofloxacin and vancomycin that were kept on her admission in the Intensive Care Unit.,0
"By hospital day #2, , she was awake, alert and oriented.",0
"She had no complaints, except for some mild tenderness on her left flank.",0
"Her white count was 25,000 with a hematocrit of 35 and a platelet count of 144.",0
"Her Chem-7 was sodium 139, potassium 3.8, chloride 103, CO2 26, BUN 21 and her creatinine came down to 0.9 with a glucose level of 117.",0
"Once again, several exams documented that there was not a lot of purulent drainage coming out of her sternal wound.",0
"She had an abdominal CT done that morning that was negative for intraabdominal collections, diverticulitis or any other abnormality.",0
She was found to have a heterogeneously enhancing solid left renal mass that measured approximately 2.5 cm.,0
The patient required dopamine to be given through the entire day to keep adequate blood pressures.,0
"On , SICU day 3, Mrs. count was down to 14.6.",0
"She remained afebrile and her dopamine was weaned to off, keeping good blood pressures.",0
Sternal wound had dressing changes wet to dry and there was no increasing erythema observed.,0
"On the afternoon of that day, she was evaluated by the urology service for that incidental left renal mass.",0
The consultation stated that it was unclear whether the lesion was a renal CA primary versus an upper tract urothelial renal pelvis malignancy.,0
They were suggesting that this might be a renal cell carcinoma and suggested that the patient would require an MRI with gadolinium that could be obtained as an outpatient.,0
The patient should make follow up arrangements with Dr. office in the urology clinic to further work up this renal mass.,0
"By hospital day #4, Mrs. was off pressors, remained afebrile, was started on a diabetic diet tolerating well po's.",0
Her white count was 13.7 and her creatinine was 0.6.,0
She was offered a bed at rehabilitation where she is being discharged under stable conditions.,0
Prednisone 5 mg po qd 3.,0
Accolate 20 mg po q day 4.,0
Digoxin 0.25 mg po q day 5.,0
Aldactone 75 mg po q 12 hours 6.,0
KCL 20 milliequivalents po q 12 hours 7.,0
Heparin subcutaneous 5000 units tid 8.,0
Colace 100 mg po bid 9.,0
Plavix 75 mg po q day 10.,0
Albuterol/Atrovent metered dose inhaler 2 to 5 puffs q4h and prn 11.,0
Nystatin powder to groin area tid 12.,0
Protonix 40 mg po q day 13.,0
Amiodarone 20 mg po q day 14.,0
Imdur 90 mg po q day 15.,0
Regular insulin sliding scale 16.,0
Percocet 5/325 mg 1 to 2 tablets po q 4 to 6 hours prn 17.,0
Roxicet elixir 5 to 10 cc po q 4 to 6 hours prn DIET: American Diabetic Association diet DISCHARGE INSTRUCTIONS: The patient is to have sternal wound dressing changes wet to dry .,0
She will have to call Dr. office and make a follow up appointment.,0
"She is also instructed to call Dr. office, telephone (, to make a follow up appointment with the urology service.",0
Dictated By: MEDQUIST36 D: 11:42 T: 12:18 JOB#:,0
8:04 AM CHEST (PORTABLE AP) Clip # Reason: reaccumulation of pleural fluid.,0
Admitting Diagnosis: POLYTRAUMA S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man s/p fall with respiratory distress REASON FOR THIS EXAMINATION: reaccumulation of pleural fluid.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Reaccumulation of pleural fluid.,0
"FINDINGS: In comparison with study of , the right hemidiaphragm is more sharply seen.",0
This may merely reflect the semi-upright rather than supine portable technique.,0
The appearance is consistent with pleural fluid and volume loss at the right base.,0
Retrocardiac opacification with blunting of the left costophrenic angle is again consistent with volume loss and effusion.,0
Left chest tube remains in place and there is no definite pneumothorax.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: On , a CT of the chest revealed two pulmonary nodules in the right and left upper lobes, respectively.",0
A followup CT scan in three months was recommended to ensure stability of these findings.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: Urology LENIs were negative for DVT.",0
"A loopogram showed contrast in the J-P , there is evidence of a leak, though the location of the leak cannot be localized.",0
There is reflux of the contrast up into the left renal collecting system with rapid emptying once the drainage is allowed.,0
There is no obvious extravasation into the peritoneum.,0
The patient is stable for discharge with his right sided abdominal in place.,0
"He has been evaluated by PT, and has been accepted at the Rehab Facility.",0
Humalog insulin 28 units q.a.m.,0
"and q.p.m., occasionally 14-16 units during lunchtime.",0
Lantus insulin 48-50 units q.h.s.,0
Acetaminophen 325 mg 1-2 tablets p.o.,0
Lovenox 40 mg subQ q.12h.,0
Percocet 5/325 1-2 tablets p.o.,0
Lorazepam 0.5 mg to 2 mg p.o.,0
Calcium carbonate 500 mg two tablets p.o.,0
Insulin glargine 48 mg subQ q.h.s.,0
Insulin Humalog 28 units subQ b.i.d.,0
Regular insulin-sliding scale subQ q.i.d.,0
"for fingerstick 0-150 give no units; for 151-200 give 2 units; for 201-250 give 4 units; 251-300 6 units; 301-350 8 units; 351-400 10 units, greater than 400 12 units.",0
DISCHARGE STATUS: Was discharged to Rehab.,0
Dictated By: MEDQUIST36 D: 14:14 T: 14:44 JOB#: cc:,0
"2:58 PM CHEST (PA & LAT) Clip # Reason: pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with subjective fever, leukocytosis, chemotherapy REASON FOR THIS EXAMINATION: pneumonia ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, AT 14:57 HOURS HISTORY: Subjective fever and leukocytosis, on chemotherapy.",0
FINDINGS: Lung volumes are mildly diminished.,0
There is mild cephalization with indistinctness of the pulmonary vasculature and intralobular septal lines at the lung bases.,0
Linear atelectasis is seen at both lung bases as well.,0
Minimal fluid is noted tracking within the minor fissure.,0
There is calcification noted at the aortic arch.,0
The cardiac silhouette is borderline enlarged but stable.,0
The osseous structures reveal mild degenerative change noted throughout the mid and lower thoracic spine.,0
Recommend repeat radiography after appropriate diuresis to assess for underlying infection.,0
12:45 PM UNILAT UP EXT VEINS US RIGHT PORT Clip # Reason: Please check right arm for possible DVT before placement of Admitting Diagnosis: BILATERAL LEG FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with concern for right upper extremity DVT REASON FOR THIS EXAMINATION: Please check right arm for possible DVT before placement of PICC in right upper extremity.,1
Please do study at bedside.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 87-year-old woman with concern for right upper extremity DVT.,1
Please rule out DVT before placement of PICC line.,0
"FINDINGS: Color and grayscale Doppler images of the right internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed.",0
"6:33 PM CHEST (PORTABLE AP) Clip # Reason: assess ETT position, r/o infiltrate Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with sepsis, intubated at OSH REASON FOR THIS EXAMINATION: assess ETT position, r/o infiltrate ______________________________________________________________________________ FINAL REPORT CHEST: HISTORY: Sepsis, intubation, assess ET tube.",0
"The lungs appear clear, however.",0
A right internal jugular catheter has been inserted and terminates at the level of the right atrium.,0
An endotracheal tube has been inserted and ends at the thoracic inlet.,0
A nasogastric tube has been placed and extends down to the T9 level.,0
A left subclavian catheter has been withdrawn.,0
The nasogastric tube is high.,0
Result called to Micu 8:50 p.m.,0
"1:09 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG w/severe incisional pain r/o sternal dehiscence Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with as above REASON FOR THIS EXAMINATION: s/p CABG w/severe incisional pain r/o sternal dehiscence ______________________________________________________________________________ FINAL REPORT HISTORY: CABG with incisional pain, to assess for dehiscence.",1
"FINDINGS: In comparison with studies from , there is increasing prominence of the cardiac silhouette with substantial worsening of pulmonary edema.",0
The possibility of supervening pneumonia or even ARDS can certainly not be excluded.,0
There are substantial bilateral pleural effusions.,0
Right IJ sheath remains in place.,0
Retrocardiac opacification is consistent with atelectasis.,0
No definite pneumothorax is appreciated.,0
There is no definite evidence for dehiscence on these plain radiographs.,0
"Specifically, there is no displacement of the intact sternal wires.",0
"If dehiscence is a serious clinical concern, CT should be considered.",0
11:28 AM BILIARY CATH CHECK Clip # Reason: please assess for repositioning of the T Tube.,0
We would lik Admitting Diagnosis: GASTRIC OUTLET OBSTRUCTION Contrast: OPTIRAY Amt: 20 ********************************* CPT Codes ******************************** * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with ehlers danlos s/p CCY and open T Tube placement REASON FOR THIS EXAMINATION: please assess for repositioning of the T Tube.,1
We would like to remove the T Tube and leave a drain in place adjacent to the bile duct.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old female with Ehlers-Danlos, status post cholecystectomy and open T-tube placement.",1
Evaluate for position of T-tube.,0
", , and attending radiologist, Dr. who was present and supervised the entire procedure.",0
FINDINGS/PROCEDURE: Scout film demonstrates T-tube to be located in the right upper quadrant with draining tube traversing towards the left side of the abdomen.,0
There are surgical clips in the right upper abdominal quadrant.,0
"T- tube cholangiogram was performed using Optiray intravenous contrast material instilled via gravity demonstrating opacification of the common bile duct which is mildly dilated, however, without filling defect or evidence of extravasation.",0
Contrast material fills freely into the duodenum.,0
Stump of the cystic duct is opacified.,0
IMPRESSION: Stable position of T-tube within a mildly dilated common bile duct.,0
"There is no evidence of filling defect, obstruction, or leak.",0
12:46 PM PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # Reason: please assess position of Dobhoff Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p Dodhoff advancement REASON FOR THIS EXAMINATION: please assess position of Dobhoff ______________________________________________________________________________ FINAL REPORT HISTORY: Dobbhoff placement.,1
Single radiograph of the upper abdomen is submitted.,0
Diagnostic quality is severely limited by patient motion.,0
The previously seen Dobbhoff tube is not evident on the current exam.,0
Old right-sided rib fractures are noted.,0
IMPRESSION: Limited study secondary to patient motion.,0
Previously seen Dobbhoff tube is not identified.,0
Admission Date: Discharge Date: Date of Birth: Sex: F HISTORY OF PRESENT ILLNESS: Mrs. is a 58 year old woman with a complicated prolonged hospital course who was transferred to the Service on .,0
"Originally, she was admitted on , to the Vascular left below the knee amputation on .",0
Her postoperative course was complicated by suicidal ideations requiring a one-to-one sitter.,0
"For a more detailed review of the patient's stay on the Vascular Service, please refer to the Discharge Summary from .",0
The patient was subsequently transferred to Medical Intensive thought to be a combination of uremia secondary to acute on chronic renal failure and necrotic infection.,1
"In the Medical Intensive Care Unit, the EKG showed new inferior ST elevations and the patient subsequently ruled in for an acute myocardial infarction with peak CK of 369, MB of 23 and troponin of 38.5.",1
"Preoperative stress MIBI on , had shown moderate defects anteriorly, inferiorly, laterally and apically, with marked diffuse hypokinesis and ejection fraction of 20%.",0
Dialysis was initiated on with continued improvement in mental status.,0
"The patient was initially treated conservatively for an myocardial infarction with heparin, beta blocker, aspirin, ACE inhibitor.",1
The patient was taken to the Catheterization Laboratory on .,0
"In the catheterization, the patient was discovered to have three-vessel disease and underwent percutaneous transluminal coronary angioplasty of Obtuse marginal 1 lesion with good results.",1
"For more details, please refer to the Catheterization Report from .",0
"Post-catheterization, the patient did not have any chest pain, shortness of breath, dizziness, nausea, vomiting or other complaints.",0
Coronary artery disease status post myocardial infarction on ; catheterization on with percutaneous transluminal coronary angioplasty to obtuse marginal.,1
Congestive heart failure with an ejection fraction of 20%.,1
Insulin dependent diabetes mellitus for four years.,0
Chronic renal insufficiency which is now acute renal insufficiency on hemodialysis.,1
"Tracheal stenosis, status post tracheostomy in .",0
NPH 5 units q. a.m.; 1 unit q. p.m. 3.,0
Calcium bicarbonate 500 mg p.o.,0
PHYSICAL EXAMINATION: Physical examination revealed a pleasant 51 year old woman in no acute distress.,0
Temperature was 98.0 F.; blood pressure 131/71; heart rate 77; respiratory rate 16; oxygen saturation 97% on room air.,0
Examination of the Head: Oropharynx was clear.,0
"Heart was regular rate and rhythm, no murmurs, rubs or gallops.",0
Lungs: There were bilateral inspiratory and expiratory mild wheezes centrally more than peripherally consistent with tracheal stenosis.,0
"Abdomen was soft, nontender, nondistended.",0
Groin: Sheath sore in place.,0
Extremities: Status post left below the knee amputation.,0
Right foot ulcer is not necrosed and not cellulitic.,0
"Neurologic examination: Alert and oriented times three, grossly nonfocal.",0
"LABORATORY: On admission, white blood cell count 8.4, hematocrit 28.5, platelets 328.",0
"Sodium 131, potassium 3.2, chloride 102, bicarbonate 26, BUN 22, creatinine 2.0, glucose 63.",0
"EKG post-PTCA shows normal sinus rhythm, inferior Qs consistent with inferior myocardial infarction, normal intervals, borderline left anterior descending, T wave inversions in leads I and AVL.",1
Also in leads V4 and V6.,0
There were 0.5 to 1. depressions.,0
EKG was not significantly changed from .,0
HOSPITAL COURSE: The patient underwent cardiac catheterization on .,0
"Per catheterization report, the patient has a severe three-vessel coronary artery disease, moderate to severe pulmonary hypertension, and successful percutaneous transluminal coronary angioplasty of the obtuse marginal 1.",1
Left anterior descending was diffusely diseased throughout its course to a 30% in proximal segment with serious lesions of up to 80% in the mid segment and 90% in the distal vessel.,1
Cardiac output was severely reduced with mildly elevated right sided and moderate to severe pulmonary hypertension.,0
The patient did not have any complications post catheterization.,0
There is no groin hematoma.,0
"The patient did not have any chest pain, shortness of breath, nausea or vomiting.",0
DISPOSITION: The patient will be discharged to a rehabilitation today in stable condition.,0
CONDITION AT DISCHARGE: All her other medical issues remained stable.,0
The patient had hemodialysis today on .,0
"Per Renal consultation, AV fistula was most likely needed.",0
"Therefore, the patient was evaluated by a Transplant consultation for the placement of an AV fistula.",0
They recommended performing this procedure at a later date after the patient fully recovers from catheterization.,0
The patient's glycemic control has been stable.,0
The patient's renal issues: The patient continued to have acute on chronic renal failure and will require hemodialysis at the rehabilitation facility.,1
"Hematologically, the patient's anemia has been stable and hematocrit post-catheterization was unchanged.",0
"In the rehabilitation, the patient will need PET and Conair bed for her sacral and decubitus ulcers.",0
NPH 5 units q. a.m. and 1 unit q. p.m. 3.,0
Iron sulfate 225 mg p.o.,0
Heparin 1000 units subcutaneously twice a day.,0
The patient is not on an ACE inhibitor secondary to her renal failure.,1
The patient will require hemodialysis as an outpatient.,0
Dictated By: MEDQUIST36 D: 13:10 T: 13:31 JOB#:,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: Rigors Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: Patient is well known to the team as he was discharged on .,0
"Briefly, 63 yo M with PMH of HTN, BPV and s/p splenectomy in his 20 transferred from ICU on for management of pan-sensitve strep pneumo sepsis.",0
He was initially admitted to the MICU where he was treated with CTX and his infectious work up was only revealed sinusitis on brain MRI.,1
On HD2 he was weaned off pressors and on HD4 he self extubated.,0
he was subsequently transfered to the medical floor where he was continued on CTX and remained afebrile.,0
He was discharged with a PICC line and infusion company assistance to finish a 14 day course of IV CTX 2 g which he would have finished on .,0
He had been doing well since he was discharged until the day of admission when he developed rigors at around 12:30 pm.,0
He stated that they were the same type of rigors that he had prior to his previous hospitalization.,0
He took is temperature and it was 97.,0
He continued to rigor for ~ 1 hour.,0
He denied LOC or seizure activity and this was witnessed by his daughter.,0
"In the ED, his vital he was febrile to 100.8 and had a CXR done which revealed RLL atelectasis and could not exclude PNA.",0
He was given vancomycin 1 g x 1 and levofloxacin 750 mg IV x 1. Review of systems: (+) Per HPI.,0
Mild cough that he has had since self extubating but has been improving.,0
Lower neck pain and R flank pain (both of which he has had since discharge and are improving).,0
"Also had right chest pain in lower rib area (-) Denies fever, chills, night sweats.",0
"Past Medical History: S/p splenectomy after ruptured spleen at age 16 mono HTN S/p pan-sensitive Streptococcus Pneumonia sepsis Vertigo Social History: Works in desk job, lives with wife.",1
An underlying consolidative process cannot be excluded.,0
"CT OF THE CHEST WITHOUT IV CONTRAST : IMPRESSION: Somewhat increased bilateral pleural effusions, but decreased associated parenchymal opacities, which are compatible with compressive atelectasis although slightly improved pneumonic consolidations are not excluded.",1
MR HEAD W & W/O CONTRAST 11:01 AM IMPRESSION: There is no evidence of acute intracranial pathology.,0
"Interval decrease in the pattern of mucosal thickening involving the ethmoidal and maxillary sinuses, there is also mild decrease in the amount of mucosal thickening in the mastoid air cells, however, there are residual opacities, more significant on the left.",0
"Unchanged subinsular T2 and FLAIR hyperintensities, possibly consistent with chronic microvascular ischemic changes.",0
ECHOCARDIOGRAPHY REPORT TEE (Complete) at 3:15:01 PM No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
"There is a mass in the right ventricle that appears to be a calcified, torn chord associated with the tricuspid valve.",0
"No tricuspid valve vegetation is seen, and no significant tricuspid regurgitation is present.",0
There is a very small filamentous mass associated with the right coronary cusp of the aortic valve that could represent a Lambl's excrescence versus a small vegetation.,0
IMPRESSION: Possible aortic valve endocarditis.,0
CXR PA/LAT IMPRESSION: Persistent bilateral plate atelectasis and mild degree of pleural effusions.,1
Cause of process is unknown.,0
Further followup and clinical evaluation is recommended.,0
"Brief Hospital Course: # Fevers/rigors: Mr. presented to the ED on with rigors, fever, and an elevated white count.",0
A chest x-ray and CT showed bilateral pleural effusions R>L.,1
Ceftriaxone was discontinued and he was started on vancomycin and cefepime.,0
"For the remainder of the hospitalization, Mr. remained afebrile with a normal white count.",0
"To further evaluate the source of infection, Interventional Pulmonology attempted thoracentesis, but determined the effusion was too small to drain.",0
"Infectious Disease recommended an MRI of the head since a previous MRI study on showed enlarged ventricles and sinusitis, but there was no evidence of intracranial pathology.",0
A TEE showed no overt evidence of endocarditis.,0
"At this time, Infectious Disease recommended stopping all antibiotics, removing and culturing his PICC line, and monitoring for signs of infection for over 48 hours.",0
PICC line and blood cultures both showed no growth.,0
He remained afebrile at time of discharge on Friday .,0
"Haemophilus B, meninogococcal, and pneumococcal vaccines were given during hospitalization.",0
#Normocytic Anemia: Mr. presented with a normocytic anemia upon admission.,0
Immunoglobulin & SPEP/UPEP laboratory tests were negative for indicators of Multiple Myeloma.,0
"The etiology of his anemia is most likely anemia of chronic disease, but we strongly recommend an outpatient colonoscopy and continued monitoring.",1
#Chest Discomfort: Mr. developed significant right-sided chest discomfort during his hospital course.,0
This pain was most likely caused by his pleural effusion and musculoskeletal deconditioning.,1
"Lidocaine patches, heat packs, and ibuprofen were effective, but he should follow-up with an outpatient provider if the pain continues.",0
#HTN: We continued to hold BP meds.,0
Consider restarting as an outpatient if develops hypertension.,0
#Patient was full code during this admission.,0
Medications on Admission: Pravastatin 20 mg daily Aldactoside 25/25 mg daily (has been held since ) Ceftriaxone 2 g course Discharge Medications: 1.,0
Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Adhesive Patch, Medicateds Topical DAILY (Daily) for 14 doses: to affected area.",0
"Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0* 4.",0
Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 doses: at first sign of fever.,0
Then contact your PCP or go to the ER for evaluation.,0
"Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Care Network Discharge Diagnosis: PRIMARY DIAGNOSES: - Fevers and rigors, unspecified - Small right pleural effusion, too small to tap SECONDARY DIAGNOSES: - Pneumococcal bacteremia - Hypertension - Asplenia complication of mononucleosis at age 16 Discharge Condition: Mental Status: Clear and coherent.",1
Discharge Instructions: You were admitted to the because you had rigors and had a low grade fever on presentation to the emergency room.,0
At CT scan of your chest showed a fluid collection around your lung and this prompted us to change your antibiotics.,0
We did a brain MRI and this showed resolving sinusitis.,0
We did a transesophageal echocardiogram to look for a potential source but this was normal.,0
Your PICC line was then taken out and antibiotics stopped.,0
You did not have rigors or fevers even after stopping antibiotics.,0
"You received the pneumococcal, meningococcal and haemophilus influenza vaccines while in the hospital.",0
Your iron level was low and we started you on iron supplementation.,0
Please have your PCP this in 3 months to see if continued iron therapy is necessary.,0
Medication Changes: START: Levofloxacin 750 mg daily if you have a fever and then contact your PCP or go to the emergency room for further evaluation.,0
"START: Iron 325 mg daily START: Lidocaine patches to affected site for pain Followup Instructions: Department: NEUROLOGY When: TUESDAY at 10:00 AM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: INFECTIOUS DISEASE When: WEDNESDAY at 10:30 AM With: , MD Building: LM Bldg () Campus: WEST Best Parking: Garage",0
"12:29 PM ACUTE ABD SERIES ( VIEWS OF ABD & SGL CHEST VIEW) PORT Clip # Reason: evaluate for free air Admitting Diagnosis: BRANCHIAL STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with abdominal pain REASON FOR THIS EXAMINATION: evaluate for free air ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 3:21 PM PFI: Status post right-sided stent removal, no pneumothorax or pneumomediastinum.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 80-year-old woman with abdominal pain.,0
"PORTABLE ABDOMEN, SUPINE AND RIGHT DECUB: Two views of the abdomen demonstrate no evidence of free intraperitoneal air.",0
Bowel gas pattern is non-obstructive.,0
"Within limited examination of the lung bases, peripheral opacities are present in the left lung.",0
Surgical clips are noted overlying the mediastinum.,0
A small round lucency noted in the mid pole of left kidney is of unknown etiology.,0
No suspicious soft tissue calcification is identified.,0
Underlying osseous structures are largely intact.,0
IMPRESSION: No evidence of free air.,0
LINE PLACEMENT Clip # Reason: r picc 48cm Admitting Diagnosis: ABDOMINAL MASS ______________________________________________________________________________ MEDICAL CONDITION: 22 year old woman with REASON FOR THIS EXAMINATION: r picc 48cm ______________________________________________________________________________ FINAL REPORT INDICATION: 22-year-old woman with right PICC line placement.,0
COMPARISON: Chest portable AP from .,0
CHEST PORTABLE SUPINE AP: The tip of the PICC line is at or beyond the base of the right atrium near the junction with the IVC.,0
There is a new right upper lobe pulmonary opacity with improvement in the left-sided pulmonary opacity.,0
Right-sided PICC line in low position.,0
New right upper lobe opacity with rapid onset likely representing atelectasis.,0
The results of this study were discussed with the IV nurse this afternoon .,0
2:56 AM CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # Reason: S/P MVA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man s/p motorvehicle accident REASON FOR THIS EXAMINATION: CT Head No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd TUE 4:49 AM no acute intracranial process.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 45-year-old man status post motor vehicle accident.,1
"Second opinion is requested by our ED physicians on a head CT from , dated at 8:57 pm.",0
"TECHNIQUE: Axially acquired images were obtained through the head without contrast, displayed with 1 mm slice thickness in soft tissue and bone algorithms.",0
"FINDINGS: There is no acute intracranial hemorrhage, large areas of edema, or mass effect.",0
"There appears to be normal -white matter differentiation, though contrast resolution is limited by the low slice thickness.",0
There is prominence of the cisterna magna versus a retrocerebellar arachnoid cyst.,0
Small mucous retention cysts are noted within the maxillary sinuses bilaterally.,0
There is mild mucosal thickening in the left sphenoid sinus.,0
IMPRESSION: No evidence of acute traumatic injuries.,0
Height: (in) 72 Weight (lb): 188 BSA (m2): 2.08 m2 BP (mm Hg): 110/60 HR (bpm): 76 Status: Inpatient Date/Time: at 02:20 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
No significant respiratory variation in mitral/tricuspid valve flows.,0
GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.,0
"The effusion appears circumferential, but has preferential fluid deposition of up to 5.2 centimeters along the lateral aspect of the left ventricle vs.up to 1 centimeter along the free wall of the right ventricle.",0
"IMPRESSION: Large, circumferential pericardial effusion with brief right atrial diastolic collapse consistent with possible early pericardial tamponade.",0
Dr. notified of the results in person.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: Left arm PICC repositioned.,0
PICC tip location Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: Left arm PICC repositioned.,1
PICC tip REASON FOR THIS EXAMINATION: Left arm PICC repositioned.,0
PICC tip location ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: PICC line repositioning.,0
"FINDINGS: As compared to the previous radiograph, the PICC line has been minimally advanced.",0
The tip of the line now projects over the upper-to-mid SVC.,0
"The course of the line is unremarkable, there is no evidence of complications, notably no pneumothorax.",0
Unchanged appearance of the lung parenchyma.,0
3:02 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: post pyloric tube placement Admitting Diagnosis: NECROTIC PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with REASON FOR THIS EXAMINATION: post pyloric tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old man in for postpyloric tube placement.,0
"POSTPYLORIC TUBE PLACEMENT FINDINGS: - catheter was advanced through the left nostril, through the esophagus, into the stomach and through the pylorus without difficulty.",0
"The tip of the catheter was advanced to the distal third section of the duodenum, just proximal to the ligament of Treitz.",0
Approximately 10 cc of water soluble Optiray contrast was administered to confirm placement.,0
Patient tolerated the procedure well without complications.,0
IMPRESSION: Successful postpyloric tube placement; ready for use.,0
S/p VF arrest Height: (in) 66 Weight (lb): 145 BSA (m2): 1.75 m2 BP (mm Hg): 103/79 HR (bpm): 107 Status: Inpatient Date/Time: at 17:09 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: mid inferoseptal - hypo; basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; inferior apex - akinetic; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV wall thickness.,0
Overall left ventricular systolic function is moderately depressed with global hypokinesis with inferior akinesis along with inferolateral and mid and distal inferoseptal hypokinesis.,0
4.The aortic valve leaflets are mildly thickened.,1
"Compared with the findings of the prior study (images reviewed) of , there has been a significant decrease in LV function with new wall motion abnormalities.",0
Consider a myocardial ischemic event.,0
", E. TSICU 9:23 AM DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: evaluate hepatic vasculature and biliary tree Admitting Diagnosis: CHOLECYSITITS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with rising total bilirubin REASON FOR THIS EXAMINATION: evaluate hepatic vasculature and biliary tree ______________________________________________________________________________ PFI REPORT 1.",0
Cholelithiasis with marked gallbladder wall edema corresponding to that seen on CT of .,0
Gallbladder remains collapsed and there is no drainable fluid collection noted.,0
4:31 AM CT HEAD W/O CONTRAST Clip # Reason: please obtain thin cuts through temporal bone and cranial ba Admitting Diagnosis: POLY-TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with ICH and extension of fracture into right auditory canal REASON FOR THIS EXAMINATION: please obtain thin cuts through temporal bone and cranial base to rule out fracture through ethmoid air cells No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Intracranial hemorrhage with question of fracture in the right auditory canal.,1
COMPARISON: Head CT from TECHNIQUE: Axial CT images were acquired through the head without contrast.,0
FINDINGS: There is no evidence of edema or infarction.,0
"An epidural gas-containing hematoma on the left (series 103B, image 44) measures 4 mm in greatest depth and is unchanged.",0
Ventricles and sulci are normal in size and in configuration.,0
"A vertically oriented fracture is noted, extending from the left parietal bone (102B:411) inferiorly into the left temporal bone.",0
"Specifically, the fracture plane involves the mastoid air cells along its posterior and inferior margin.",0
"Anteriorly and inferiorly, the fracture extends to the anterior bony margin of the external auditory canal, and exits in the left mandibular fossa (102B:307).",0
A moderate amount of fluid is seen within the external auditory canal and middle ear.,1
Evaluation of the middle ear ossicles is slightly limited by the surrounding fluid.,0
There is no definite evidence of extension of the fracture into the middle ear.,0
"In addition, there is a small amount of gas seen within the left mandibular fossa.",0
The structures of the inner ear appear normal.,0
Left temporal and parietal fracture as above.,0
"NOTE ADDED AT ATTNENDING REVIEW: I agree with the above, but note that the temporal bone fracture courses near the left carotid canal, raising the possibility of injury to the carotid artery.",1
"For this reason a magnetic resonance examination, including MRA, is recommended to evaluate this vessel.",0
Note that this is more reliable than a CTA for this purpose.,0
1:38 PM CAROT/CEREB Clip # Reason: angio with coiling of aneurysm Admitting Diagnosis: CEREBRAL ANEURYSM/SDA Contrast: OPTIRAY Amt: 125 ********************************* CPT Codes ******************************** * EMBO TRANSCRANIAL SEL CATH 3RD ORDER * * -51 MULTI-PROCEDURE SAME DAY TRANSCATH EMBO THERAPY * * F/U TRANS CATH THERAPY * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with aneurysm REASON FOR THIS EXAMINATION: angio with coiling of aneurysm ______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 67-year-old female with a right posterior communicating artery aneurysm which is 3.8 mm in diameter.,1
She was very anxious about this and wanted this to be treated.,0
"Therefore, we decided to proceed with the stent assisted coiling of the aneurysm.",0
PROCEDURE PERFORMED: Right internal carotid artery arteriogram and coil embolization of right posterior communicating artery aneurysm Neuroform stent assisted.,0
Neuroform stent 4 mm into 20 mm stent assisted.,0
Right common femoral artery arteriogram and closure of right common femoral artery puncture with 6 French Angio-Seal device.,0
PROCEDURE: The patient was brought to the angiography suite.,0
Anesthesia was induced in the supine position.,0
"Following this, the right common femoral artery was accessed with a 6 French vascular sheath.",0
"Following this, we gained access to the right internal carotid artery with 2 catheter and this was exchanged out for a 6 French Envoy catheter.",0
Following this the patient was heparinized.,0
We now used a Synchro 2 microwire and an SL-10 microcatheter to gain access into the right middle cerebral artery M3 branches.,0
The Synchro 2 wire was exchanged out for an exchange length Synchro wire and the microcatheter removed over it.,0
We now passed a Neuroform 4 mm into 20 mm stent into the supraclinoid carotid artery and deployed it in the region of the posterior communicating artery aneurysm without any problems.,0
"Following this, the aneurysm was catheterized with an SL-10 microcatheter and the aneurysm was coiled with three coils of 2 mm helical super soft GDC coils.",0
"Following this, the aneurysm was almost fully obliterated with some stagnant contrast remaining.",0
"Following this, a right common femoral artery arteriogram was done.",0
This revealed a widely patent right common femoral artery.,0
"Therefore, we closed the right common femoral artery with a 6 French Angio-Seal device.",0
The patient was extubated and found to be neurologically unchanged.,0
She was taken back to the recovery room in a stable condition.,0
"(Over) 1:38 PM CAROT/CEREB Clip # Reason: angio with coiling of aneurysm Admitting Diagnosis: CEREBRAL ANEURYSM/SDA Contrast: OPTIRAY Amt: 125 ______________________________________________________________________________ FINAL REPORT (Cont) Right internal carotid artery arteriogram shows normal filling of the right internal carotid artery along the cervical, petrous, cavernous and supraclinoid portion.",1
The previously seen 3.8 mm aneurysm is seen in the posterior communicating segment.,0
Right internal carotid artery arteriogram status post stenting and coiling shows that the aneurysm is now obliterated except for some minimal stagnant contrast.,0
The internal carotid artery and its branches are patent.,0
Right common femoral artery arteriogram shows widely patent right common femoral artery.,0
IMPRESSION: underwent cerebral angiography and coil embolization of a right PCOM aneurysm without incident.,1
1:32 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: PAIN R/O DVT Admitting Diagnosis: AORTIC DISECTION ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with PE and palpable cord in LUE REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 58-year-old with pulmonary embolism and palpable cord within the left upper extremity.,1
"LEFT UPPER EXTREMITY VEINS ULTRASOUND: Grayscale and color Doppler images of the left internal jugular, subclavian, axillary, brachial, and basilic veins were obtained.",1
"Normal waveforms, compressibility, and augmentation was demonstrated.",0
No intraluminal thrombus was identified.,0
Additional images were obtained within the region of the patient's palpable superficial abnormality.,0
"Corresponding to this region, echogenic thrombus is seen within a superficial radial vein.",0
No blood flow is seen within this vein.,0
IMPRESSION: No evidence of left upper extremity deep venous thrombosis.,1
"Superficial venous thrombus, corresponding to the patient's palpable abnormality of the left forearm.",1
PATIENT/TEST INFORMATION: Indication: Acute decompensated diastolic CHF Height: (in) 63 Weight (lb): 188 BSA (m2): 1.89 m2 BP (mm Hg): 130/42 HR (bpm): 44 Status: Inpatient Date/Time: at 12:21 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
"There is mild regional left ventricular systolic dysfunction with focal akinesis of the mid to distal septum, distal inferior wall, and apex.",0
The remaining segments contract normally (LVEF = 45-50 %).,0
IMPRESSION: Regional left ventricular dysfunction consistent with multivessel CAD.,0
Mild right ventricular cavity dilation.,0
Moderate tricuspid and mitral regurgitation.,0
"Compared with the prior study (images reviewed) of , left ventricular function is more vigorous.",0
The severity of pulmonary hypertension has increased and there is evidence of right ventricular pressure/volume overload (images less optimal on prior study).,0
PATIENT/TEST INFORMATION: Indication: Pericardial effusion Height: (in) 68 Weight (lb): 150 BSA (m2): 1.81 m2 BP (mm Hg): 125/57 Status: Inpatient Date/Time: at 15:26 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness.,0
9:31 PM C-SPINE NON-TRAUMA VIEWS Clip # Reason: Please check AP/Lat checking alignment Admitting Diagnosis: MULTIPLE TRAUMA; S/P MOTORCYLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with Cervical ACDF.,1
REASON FOR THIS EXAMINATION: Please check AP/Lat checking alignment ______________________________________________________________________________ FINAL REPORT HISTORY: Cervical ACDF please check AP and laterals for alignment.,0
"AP AND LATERAL CERVICAL SPINE: Compared to prior pre-op study dated , , surgical skin sutures are seen posteriorly.",0
"Operative hardware is seen posteriorly over the C6, C7 and T1 spinous processes.",0
Vertebral alignment is within normal limits.,0
8:38 PM PORTABLE ABDOMEN Clip # Reason: R/O Perforation ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man S/P cabg w BLOOD PER ngt.,0
PLEASE INSTILL 60CC OF GASTROGRAF PER NGT PRIOR TO TAKING FILM.,0
REASON FOR THIS EXAMINATION: R/O Perforation ______________________________________________________________________________ FINAL REPORT HISTORY: Blood per NG tube.,0
Please inject contrast prior to taking film.,0
"FINDINGS: Two films were taken under this clip #, one of these is a chest X- ray prior to contrast being put in the NG tube and one is an abdominal film after contrast has been put into the NG tube.",0
"Swan ganz catheter is in place, tip not well visualized probably in the pulmonary outflow tract.",0
"There is an NG tube with tip poorly visualized, probably in the stomach.",0
Mediastinal drains are in place.,0
There is increased opacity over the right apex consistent with volume loss/infiltrate.,0
This is a rotated film.,0
The endotracheal tube is 2 cm above the carina.,0
"For the view of the abdomen a small amount of contrast was instilled into the stomach, however, the stomach is half off the film and cannot be totally assessed although no extravasation is seen.",0
There is nondilated loop of small bowel in the left abdomen that is relatively featureless.,0
This is a nonspecific bowel gas pattern.,0
IMPRESSION: Limited evaluation for extravasation.,0
No abnormality of the stomach identified.,0
"However, this study is markedly limited.",0
Height: (in) 58 Weight (lb): 163 BSA (m2): 1.67 m2 BP (mm Hg): 100/56 HR (bpm): 77 Status: Inpatient Date/Time: at 11:34 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RAP (10-20mmHg).,1
Suboptimal image quality - poor parasternal views.,0
Suboptimal image quality - poor apical views.,0
Conclusions: The estimated right atrial pressure is 10-20mmHg.,0
LV systolic function appears moderately-to-severely depressed (ejection fraction 30 percent).,0
"Compared with the findings of the prior study (images reviewed) of , findings are grossly similar although the suboptimal nature of both studies precludes definitive comparison.",0
"Right ventricular function Height: (in) 68 Weight (lb): 185 BSA (m2): 1.98 m2 BP (mm Hg): 141/61 HR (bpm): 64 Status: Inpatient Date/Time: at 11:46 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",1
Conclusions: Very limited image quality.,0
Overall left ventricular systolic function is normal-to-hyperdynamic (LVEF>60%).,0
Height: (in) 64 Weight (lb): 140 BSA (m2): 1.68 m2 BP (mm Hg): 126/56 HR (bpm): 49 Status: Inpatient Date/Time: at 12:59 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
There is mild to moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the inferior and inferolateral walls and distal septum.,0
The remaining walls contract well/low normal.,0
There is severe aortic valve stenosis (area 0.5cm2).,1
IMPRESSION: Severe aortic valve stenosis.,1
Symmetric left ventricular hypertrophy with regional systolic dysfunctionn c/w CAD.,0
2:25 PM CHEST (PA & LAT) Clip # Reason: Assess for pneumothorax Admitting Diagnosis: PANCREATIC FISTULA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man pleuro-pancreatico fistula w/ CT now to water seal.,0
REASON FOR THIS EXAMINATION: Assess for pneumothorax ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumothorax.,0
"Three radiographs of the chest again demonstrate a right-sided chest tube, unchanged from .",0
Small apical right-sided pneumothorax persists.,0
Right-sided PICC line is unchanged in position.,0
", 11R 9:01 AM VENOUS DUP UPPER EXT BILATERAL Clip # Reason: ?",1
"SVC syndrome Admitting Diagnosis: PERICARDITIS;PERICARDIAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with metastatic adenocarcinoma of the lung, s/p pericardial effusion, s/p chemo/radiation.",0
SVC syndrome ______________________________________________________________________________ PFI REPORT PFI: 1.,0
Persistent non-occlusive thrombus in the right subclavian vein with new occlusive thrombus within the PICC-containing right basilic vein.,0
Progression of occlusive thrombus involving the left internal jugular vein from the most recent CT. 3.,0
Slight loss of phasicity involving right and left subclavian veins.,1
"While nonspecific, this may suggest a more distal obstruction of the brachiocephalic or SVC, however, the SVC was noted to be widely patent on the most recent CT of .",0
"If there remains a high clinical concern and alteration in care will occur, a repeat contrast-enhanced CT or MRI examination could be obtained.",0
7:19 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # Reason: evaluate position of uvc after being pulled back 1 cm to 7 c Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: infant born at 28 weeks gestation with rds REASON FOR THIS EXAMINATION: evaluate position of uvc after being pulled back 1 cm to 7 cm ______________________________________________________________________________ FINAL REPORT BABYGRAM CHEST AND ABDOMEN AT 19:51 HOURS HISTORY: Infant born at 28 weeks gestation with respiratory distress syndrome.,1
Evaluate position of umbilical venous catheter after having been pulled back 1 cm to 7 cm.,0
FINDINGS: Comparison is made to the examination performed earlier today.,0
The umbilical venous catheter has been removed.,0
The umbilical arterial catheter tip has come back to the T6 level.,0
The endotracheal tube is now past the thoracic inlet.,0
The lung volumes remain low and the findings of hyaline membrane disease are similar in the left lung but slightly improved in the right lung.,1
A pneumothorax or pleural effusion are not seen.,0
The heart and mediastinal contours are normal.,0
Height: (in) 69 Weight (lb): 179 BSA (m2): 1.97 m2 BP (mm Hg): 136/80 HR (bpm): 61 Status: Inpatient Date/Time: at 13:53 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
There is mild regional left ventricular systolic dysfunction with inferior akinesis and inferolateral hypokinesis.,0
IMPRESSION: Mild regional left ventriculkar systolic dysfunction with inferior akinesis and inferolateral hypokinesis c/w CAD.,0
PATIENT/TEST INFORMATION: Indication: Constrictive Pericarditis.,1
Intra-op TEE for Pericardectomy Height: (in) 69 Weight (lb): 132 BSA (m2): 1.73 m2 BP (mm Hg): 123/67 HR (bpm): 78 Status: Inpatient Date/Time: at 16:03 Test: TEE (Complete) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
3.The right ventricular cavity is markedly dilated.,0
4.There are three aortic valve leaflets.,0
Post pericardiectomy the RV and LV function are slightly improved.,0
"5:49 AM CHEST (PORTABLE AP) Clip # Reason: Cardiopulmonary process Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 71 yo man s/p fall with large ICH, S/P craniotomy, evacuation, ventriculostomy placement now with significant neurological deficit.",1
REASON FOR THIS EXAMINATION: Cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old male status post neurosurgery.,0
AP SUPINE PORTABLE CHEST X-RAY: A Dobbhoff tube catheter is in unchanged position with the tip in the area of the stomach antrum.,0
Patient is status post coronary artery bypass graft with multiple sternal wires in place.,1
The heart size is upper limits of normal but stable.,0
"A left pleural effusion is either stable or increased, allowing for changes in position.",0
Retrocardiac consolidation persists and unchanged.,0
"Bilateral, perihilar patchy opacities are resolving.",0
Interval improvement in pulmonary edema.,0
"Stable, moderately large left pleural effusion allowing for differences in position.",0
Persistent left lower lobe consolidation - atelectasis or pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: ORIF left femur fracture with IM rod History of Present Illness: This is a 19 year-old otherwise healthy female who was the unrestrained driver in an MVC, with +LOC and pre- and post-event amnesia.",1
"She was first taken to Hospital, where she was found to have a left parietal subdural hematoma, a grade splenic laceration and a left femur fracture.",1
She was then transferred to boarded and collared.,0
En route and on arrival she was hemodynamically stable with a GCS of 15.,0
"Past Medical History: None Social History: PSA, reports only recent use as ""crutch"" in setting of stressors.",0
"Denies EtOH (says father is alcoholic) Family History: EtOH in father Physical Exam: Afebrile P96 BP124/80 R18 99%RA Gen: awake and alert, yelling and complaining of leg pain HEENT: PERRL, EOEMI, no head lacerations or skull deformities.",0
"Neck: +collar, diffusely tender but no step-offs or deformities.",0
"CV: RRR S1S2 Abd: soft and flat, tender R<L upper quadrants.",0
"No rebound/guarding Rectal: normal tone, no blood Pelvis: Stable.",0
"Foley placed without difficulty, no gross hematuria.",0
Ext: Right hand swelling and ecchymoses.,0
"Left femur tender, leg in traction splint.",0
"2+ DP pulses bilaterally, palpable popliteal/femoral pulses and radial pulses bilaterally.",0
"COMPARISON: Trauma chest and pelvis, earlier, same day.",0
"FINDINGS: This exam consists of 5 radiographs: AP pelvis, 2 views of the left hip, and 2 views of the distal left femur.",0
"There is a partially imaged transverse fracture of the proximal left femoral metaphysis, with complete dislocation and foreshortening.",0
This is incompletely imaged on these views.,0
The femoral neck and immediate subtrochanteric regions appear intact.,0
There is no hip joint dislocation.,0
The knee appears grossly unremarkable.,0
"IMPRESSION: Transverse, displaced proximal femur fracture with foreshortening.",1
CT HEAD W/O CONTRAST Reason: f/u L subdural hematoma MEDICAL CONDITION: s/p MVA REASON FOR THIS EXAMINATION: f/u L subdural hematoma CONTRAINDICATIONS for IV CONTRAST: None.,1
"INDICATION: Followup left subdural hematoma, status post MVA.",1
The prior study is not available for direct comparison.,0
FINDINGS: There is a small hyperdense left subdural hematoma along the inner convexity measuring up to 3 mm in its greatest thickness.,1
No other areas of hemorrhage are identified.,0
"There is no shift of normally midline structures, mass effect or hydrocephalus.",0
The density values of the brain parenchyma are otherwise within normal limits.,0
"The ventricles, sulci and cisterns are within normal limits.",0
The visualized paranasal sinuses are remarkable for a mucus retention cyst in the inferior right maxillary sinus.,0
The osseous structures are normal in appearance with no fractures identified.,0
IMPRESSION: Small left subdural hematoma.,1
Direct comparison with the prior outside study is recommended.,0
"CT ABDOMEN W/CONTRAST 5:09 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: evaluate splenic lac- IV contrast, please, no oral contrast Field of view: 32 Contrast: OPTIRAY MEDICAL CONDITION: 19 y/o with s/p splenic lac.",0
"; hct dropping REASON FOR THIS EXAMINATION: evaluate splenic lac- IV contrast, please, no oral contrast CONTRAINDICATIONS for IV CONTRAST: None.",0
INDICATION: Splenic laceration and decreased hematocrit.,0
TECHNIQUE: Multidetector CT images were obtained from the lung bases through the symphysis pubis following the administration of 120 mL of Optiray nonionic contrast material.,0
CT OF THE ABDOMEN WITH IV CONTRAST: No prior studies are available for comparison.,0
There is a 1-cm right basilar fat intensity lesion which could represent small hamartoma or focal pleural fat.,0
"The liver, gallbladder, pancreas, and adrenal glands appear normal.",0
"There are a few tiny low-attenuation foci within the left kidney, which are too small to characterize further but which most likely represent cysts.",0
The right kidney appears normal.,0
Both kidneys enhance and excrete contrast symmetrically.,0
Stomach and visualized loops of small and large bowel appear normal.,0
"A focal area of low attenuation within the mid portion of the spleen, which does not extend into the hilum and presumably represents the patient's known hepatic laceration.",0
No perihepatic fluid collections are identified.,0
There is no free fluid within the abdomen.,0
CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is present within the bladder.,0
"Uterus, adnexa, and pelvic loops of bowel appear grossly normal.",0
There is a moderate volume of free pelvic fluid.,0
BONE WINDOWS: The uppermost portions of the left femoral intramedullary rod are noted.,0
Many foci of gas are present adjacent to the left femur and are presumably postoperative.,0
IMPRESSION: Small splenic laceration as above.,0
Brief Hospital Course: The patient was hemodynamically stable and awake on arrival.,0
"Review of the outside scans and additional studies confirmed the subdural hematoma, splenic laceration and femur fracture.",1
The patient was seen by Neurosurgery and Orthopedic Surgery and admitted to the Trauma ICU under the care of the Trauma Surgery service.,0
1) Femur fracture: the patient was taken to the OR the following evening for ORIF of the fracture with IM rod; please see the operative note for details.,1
"Postoperatively the patient did well, with some swelling and/or bleeding in the leg but good advancement of activity with physical therapy.",0
When the patient's hematocrit decreased (see below) the Orthopedic service as consulted for concern she was bleeding in her thigh.,0
"Pneumatic boots were used for DVT prophylaxis along with SC heparin; once the subdural hematoma and splenic laceration were deemed stable, Lovenox was started.",1
She will need to continue the Lovenox for one month after discharge from hospital.,0
"She will follow up with Dr. , Orthopedics in 2 weeks for staple removal.",0
2) Subdural hematoma: the patient was loaded on dilantin with monitoring of blood levels.,1
"A repeat head CT showed no change in the hematoma, and the patient's neurologic exam remained nonfocal.",0
3) Splenic laceration: the patient was initially kept on bedrest and NPO with frequent hematocrit checks.,0
"On HD 3/POD 1 the patient's hematocrit decreased to 23.2 and she became tachycardic but otherwise asymptomatic, with no change in her abdominal exam or increase in leg pain.",0
"An abdominal CT was obtained and showed no hemoperitoneum, with a stable-appearing grade 2 splenic laceration.",0
4) Substance abuse: patient's initial Tox screen was positive; Social Work and Psychiatry were consulted for her ETOH/Substance abuse issues.,0
Enoxaparin 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous Q24H (every 24 hours) for 4 weeks.,0
Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 3 days: Continue for next 3 days.,0
"Discharge Disposition: Home Discharge Diagnosis: Small subdural hematoma Left femur fracture, s/p IM rod Bruised right hand (no fracture) Grade 2 splenic laceration Discharge Condition: Stable Discharge Instructions: 1.You will need to continue with your Lovenox injections for one month.",1
2.You will need to followup with Orthopedics and Neurosurgery after your discharge from hospital.,0
3.You may bear full weight on your left leg and can use your right hand.,0
You can continue to wear the right hand splint for comfort.,0
Followup Instructions: Call ( for an appointment with Dr. (Orthopedics) in 2 weeks.,0
Your staples will be removed at that time.,0
Call ( for a follow-up appointment with Dr. (Neurosurgery) in 8 weeks.,0
You will need a repeat head CT at that time.,0
9:16 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for infiltrate Admitting Diagnosis: RETROPERITONEAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with hemorrhagic pancreatitis and COPD REASON FOR THIS EXAMINATION: evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST.,1
"REASON FOR EXAM: COPD, hemorrhagic pancreatitis.",0
Large bilateral pleural effusions are greater on the right side associated with atelectasis of the lower lobes bilaterally.,0
Left PICC tip is in the proximal SVC.,0
"11:54 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: pls evaluate for fluid overload or other interval change; th Admitting Diagnosis: HYPOGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with COPD s/p intubation with ongoing hypoxia REASON FOR THIS EXAMINATION: pls evaluate for fluid overload or other interval change; this AM's film was of suboptimal quality ______________________________________________________________________________ FINAL REPORT AP CHEST, .",0
HISTORY: 65-year-old woman with COPD status post intubation and ongoing hypoxia.,0
Evaluate for fluid overload or other interval change.,0
There is an endotracheal tube whose distal tip is 4.5 cm above the carina.,0
"A nasogastric tube is seen; however, the distal tip is not included due to technique .",0
There is a left-sided central venous catheter with distal tip is in the mid SVC.,0
"There is poor inspiratory effort, which causes crowding of the pulmonary vascular markings at the lung bases.",0
Atelectasis is seen at the right base.,0
There is likely a pleural effusion on the left side.,0
Left retrocardiac opacity may be present.,0
"However, this may be all technical due to the patient's large body habitus.",0
There is minimal prominence of the pulmonary vascular markings.,0
Likely mild pulmonary edema with a left-sided pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: light-headedness Major Surgical or Invasive Procedure: central line placement History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: Time: 23:30 PCP: , .",0
"MD: ; The patient is an 84 year-old man with a PMH significant for ischemic cardiomyopathy EF 25%, CAD, DVT/A Fib on coumadin, bladder cancer s/p transurethral resection requiring straight cath who presents to the ED following episode of lightheadness.",1
Today wife was straight cathing the patient (typically done every 1-2 days) and a large amount of blood returned.,0
During this time patient became lightheaded/presyncopal and consequently presented to the ED.,0
"Denies recent fever, chills, cough.",0
Denies recent hematuria (other than todays episode) or blood in the stool.,0
Denies increase in lower extremity edema.,0
Has baseline orthopnea and PND - but no recent increase.,0
Patient had one transient episode of shortness of breath last week but resolved without intervention.,0
Overall patient has been feeling his usual state of health.,0
"In the ED, VS 97.8 HR 72 BP 74/47 RR 20 O2 97%.",0
"Labs notable for HCT 31.9, WBC 11.6 (89% N, 2% bands), creatinine 2.6, lactate 4.7 (improved to 3 with 3 L NS) and positive Ua with large blood.",0
Patient was broadly covered with Vancomycin/Zosyn.,0
Upon placement of foley a blood clot returned but urine turned clear with continuous irrigation.,0
Patient's blood pressure improved to 100-110 with 3 L NS but prior to ICU transfer became hypotensive (SBP 80s) requiring central line placement and started on Levophed.,0
"ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia.",0
Denies increase in cloudy urine.,0
"Past Medical History: -Two-vessel Coronary artery disease s/p stent to the LCx -Ischemic cardiomyopathy, TTE with EF 20-30%, 3+MR, 2+TR -Hypertension -s/p Implantable cardioverter-defibrillator -Atrial fibrillation, on coumadin (INR goal ) -Dyslipidemia -Chronic kidney disease, baseline Cr 1.6-1.8 -High-grade papillary TCC, non-invasive, s/p transurethral resection () and 6 cycles of BCG (last on ), s/p urethral stricture -Hypothyroidism -Sigmoid diverticulosis, internal hemorrhoids on colonoscopy -Iron deficiency anemia -History of deep venous thrombosis x3 (, , ) -s/p left carotid endarterectomy -History of syncope -Left lower extremity stasis dermatitis -s/p inguinal herniorrhaphy Social History: Lives with wife.",1
"Independent of ADLs, wife does the cooking.",0
Still works in the garden.,0
"Former smoker, quit at least 10 years ago.",0
Has not drank EtOH for 20-25 years.,0
Family History: Father died of emphysema.,0
Mother died at age .,0
There is no known history of kidney or GU tract disorders; there likewise is no known history of platelet disorders.,1
"Physical Exam: VS: 97.8 84 20 124/80 94% 2L (90% on RA) GEN: Well-appearing, no acute distress HEENT: dry mucosa, EOMI, PERRL, sclera anicteric, no epistaxis or petechia CV: RRR, distant heart sounds, displaced PMI.",1
"PULM: Bibasilar crackles ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E NEURO: alert, oriented to person, place, and time.",0
"SKIN: jaundice, cyanosis, or gross dermatitis.",0
R central line in place Pertinent Results: Labs: 06:00PM WBC-11.6* RBC-3.29* HGB-10.3* HCT-31.9* MCV-97 MCH-31.3 MCHC-32.2 RDW-15.1 06:00PM NEUTS-89* BANDS-2 LYMPHS-5* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 06:00PM PLT COUNT-158 06:00PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL 06:00PM PT-40.9* PTT-29.7 INR(PT)-4.3* 06:00PM GLUCOSE-93 UREA N-57* CREAT-2.6* SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-19* ANION GAP-19 06:13PM LACTATE-4.7* 06:20PM URINE COLOR-Red APPEAR-Cloudy SP -1.022 06:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD 06:20PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 .,0
Micro: GRAM STAIN (Final ): >25 PMNs and <10 epithelial cells/100X field.,0
RESPIRATORY CULTURE (Final ): DUE TO LABORATORY ACCIDENT CULTURE PLANTED ON .,0
SPARSE GROWTH Commensal Respiratory Flora.,0
C. Diff: negative x3 .,0
URINE CULTURE (Final ): ESCHERICHIA COLI.,0
IMPRESSION: TECHNIQUE: Axial MDCT images were acquired through the pelvis following injection of contrast via the Foley catheter.,1
Approximately 300 cc of diluted Cysto-Conray was administered via gravity to the Foley.,0
Coronal and sagittal reformats were produced and reviewed.,0
FINDINGS: The bladder is moderately well distended with contrast.,0
There is a small amount of free air in the bladder and a Foley catheter in situ.,0
There is prominent trabeculation at the right lateral wall of the bladder with bladder diverticula seen postero-laterally on the right.,0
"There is mild residual thickening of the bladder wall seen at the left side posteriorly, near but not at the left ureteral orifice.",0
There is reflux of contrast into the left distal ureter.,0
No bladder leak is seen.,0
There is a small amount of free fluid in the pelvis most seen in the right iliac fossa.,0
No cause for this is identified on the current study.,0
There is extensive vascular calcification noted.,0
BONY STRUCTURES: There is moderate-to-severe degenerative changes noted in both hips.,0
No destructive lytic or sclerotic bony lesions are seen.,0
Multiple small bladder diverticula seen.,0
"Mild thickening of the bladder wall, seen in the left posterior location.",0
Reflux of contrast into the distal left ureter.,0
"CXR -FINDINGS: Again seen, is a left-sided cardiac pacer/defibrillator with leads in the right atrium and right ventricle.",1
The cardiomediastinal and hilar contours are normal.,0
EKG clips and wires overly the chest and somewhat limit evaluation.,0
There is subtle opacity in the left lower lung which appears stable from prior and likely represents chronic scarring.,0
"However, there is a new ill-defined opacity in the lateral aspect of the right mid-lung which could represent pneumonia versus mass.",0
Heart and mediastinal contour appear stable.,0
IMPRESSION: New opacity in the right mid-lung may represent infection or mass - dedicated PA and lateral views or a chest CT recommended - discussed with at 19:53 on .,0
CXR -The position of the right internal jugular line and pacemaker leads is stable.,0
"There is overall slight interval increase in the right upper lobe diffuse opacity that might represent minimal gradual progression of infection, but there is no evidence of worsening of moderate interstitial engorgement since the prior study.",0
Chronic changes in the lung bases can be partially addressed on this non-dedicated study.,0
Left basal atelectasis and small amount of left pleural effusion are redemonstrated.,0
"If patient is short of breath, it might be attributed actually to diffuse interstitial lung disease and correlation with dedicated chest CT may be considered.",0
The position of the various support lines and tubes is unchanged.,0
The overall appearance of the chest and in particular lung fields is also unchanged.,0
"IMPRESSION: Chronic lung changes, no failure.",1
Some movement artifact is present.,0
There has been no significant change since the prior chest x-rays.,0
The position of the various lines and tubes is unchanged.,0
EKG -Ventricular pacing with pseudofusion.,0
The irregularities suggest the atrial rhythm is atrial fibrillation.,1
Since the previous tracing of pacing with variable fusion is now present.,0
On the prior tracing there was atrial pacing.,0
EKG -Ventricularly paced rhythm at 70 beats per minute.,0
Compared to tracing #1 no diagnostic change.,0
"BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) 08:56 66*1 08:56 25.6* 86.9* 2.5* 06:00 55*2 Source: Line-Right IJ 06:00 19.9* 62.0* 1.8* Source: Line-Right IJ 03:50 VERY LOW3 57*1 Source: Line-IJ 03:50 17.0* 81.3* 1.5* Source: Line-IJ 04:09 51* Source: Line-rij 04:09 15.5* 84.1* 1.4* Source: Line-rij 03:55 54* Source: Line-CVL 03:55 14.6* 91.4* 1.3* Source: Line-CVL 23:00 14.6* 90.9* 1.3* Source: Line-CVl 14:46 14.4* 150*4 1.3* Source: Line-CVL; heparin dose: 1250 02:43 VERY LOW 59*5 02:43 14.9* 29.6 1.3* 02:58 LOW 86*1 02:58 33.0* 42.4* 3.3* 14:56 105* Source: Line-central ine 14:56 56.4* 51.7* 6.3*6 Source: Line-central ine 02:50 172 ADDED DIFF @ 0601 ON 02:50 46.3*7 43.7* 5.0*7 18:00 158 18:00 40.9* 29.7 4.3* .",0
"Brief Hospital Course: Assessment/Plan: Pt is an 84 y.o male with h.o ischemic CMP EF 25%, CAD, DVT/afib on coumadin as outpt, bladder cancer s/p transurethral resection requiring straight cath who presented with hematuria and was initially admitted to ICU with urosepsis requiring pressors.",1
Pt now improved and transferred to medical floor.,0
"While in the ICU, pt developed new thrombocytopenia.",0
#Urinary tract infection (s/p shock and urosepsis)-Pt's urine culture grew pan-sensitve E.coli and Klebsiella.,1
"Initially, pt required pressors and IVF to maintain SBP.",0
"Initially covered broadly with vanco/zosyn, tailored to IV ceftriaxone on .",0
CT pelvis ruled out bladder perforation or abscess formation.,0
PO cipro begun and pt should continue this medication for 14 day course abx (day 1 )-last day for complicated UTI.,0
Discussed foley catether with urology.,0
Pt is to have foley catheter in place until his f/u with Dr. .,0
wife typically self-caths him at home 3xdaily.,0
#hematuria-present at home prior to admit during self-cath.,0
Resolved and did not reoccur this admission.,0
Urology follow-up for h.o bladder cancer arranged with Dr. .,0
#Thrombocytopenia-plts Dropped from 158->52 during admit.,0
Likely related to sepsis +/- antibiotic use.,0
Pt had not been receiving heparin products prior to this fall in counts.,0
CVL flush was ordered as saline.,0
Pt was started on heparin gtt after the plt fall as a bridge to coumadin an counts remained stable on this medication.,0
Pt did not display signs of bleeding.,0
Platelet count should be monitored after discharge to ensure continued recovery.,0
"If recovery does not occur, pt should follow up with a hematologist.",0
#normocytic anemia-baseline appears to be 31-39.,0
NO signs of active bleeding were present after initial hematuria.,0
"Likely related to recent hematuria, infection and hemodilution.",1
INR also supratherapeutic on admit.,0
HCt can be monitored at rehab.,0
Iron studies/B12 and folate can be performed if persisent.,0
Pt should discuss whether a colonoscopy is needed for routine screening.,0
#acute systolic CHF- EF 25%/ ICD in place Last TTE 5/.,1
s/p aggressive volume resuscitation due to sepsis in the ICU.,0
Intermittent lasix gtt during ICU.,0
Transitioned to IV lasix on .,0
Fluid balance +800cc at time of transfer to medical floor.,0
Pt was given daily doses of 40mg IV daily with good effect.,0
He was started on his home dose of 40mg PO lasix on day of discharge.,0
(In addition to 40mg IV lasix given).,0
Pt is sating 90-91% on RA and weight on discharge was recorded as 159lbs.,0
For increased SOB/hypoxia would consider 40mg IV lasix x1.,0
#hypoxia-Pt's oxygen requirment vascillated between 90-91% on RA and occasionally mid 90's on 2-3L.,0
Suspect that this was due to acute systolic heart failure.,1
Pt did not display other clinical signs to suggest PNA and this did improve with diuresis.,0
"In addition, pt with CXR findings suggestive of basilar scaring and possible interstitial lung disease.",0
So it is possible that 89-91% is patient's true baseline.,0
Pt should continue to follow up and can consider imaging with CT scan or pulmonary eval in the outpatient setting.,0
Sats 90-91% on RA at time of discharge.,0
1 episode of SOB .,0
EKG without signs of ischemia.,0
BB and ACEi had been initially held given hypotension but restarted BB (carvedilol 3.125mg and ACEI lisinopril 2.5mg) on with good effect.,0
Elevated to 2.6 on admit.,0
Restarted home dose ACEI .,0
#DVT-coumadin held on admit as supratherapeutic at 6.3.,0
Reversed with 5mg PO vitamin K. INR trended down and subtherapeutic.,0
Heparin gtt started on and bridge with coumadin begun.,0
Pt now therapeutic INR 2.5.,0
Pt should coumadin regimen upon discharge.,0
2.5mg mon/wed/fri/sun and 3.5mg tue//sat.,0
Pt's INR should be followed at rehab.,0
"INR elevated, given vit K, then heparin/coumadin started.",0
5mg coumadin daily during admit.,0
Pt should resume home dosing tonight.,0
(home dosing 3.5mg/2.5mg alternating) see above.,0
Carvedilol 3.125mg restarted with good effect.,0
"#b/l medial toe erythema-symmetric on toes, appears to be from pressure or sleep position rather than an acute gouty flare.",0
Areas are not warm and pt has full range of motion.,0
"Area of pain is localized to these specific areas and not the joints or the joints of the great toe.If signs of gout were to develop or occur, could consider renally dosed colchicine x1 and/or prednisone.",0
Would avoid NSAIDs in this patient.,0
#bladder cancer s/p transurethral resection-followed by Dr. .,0
"Hopefully, will be able to DC foley and allow pt to return to straight cath after rehab stay and f/u with Dr. .",0
FOley catheter should remain in place until schedule urology f/u with Dr. .,0
#incidential radiographic findings-CXR found subtle opacity in left lower lung that appears stable and likely represents scarring.,0
"However, CXR reports new ill-defined opacity in lateral aspect of R.mid lung that could be PNA vs. mass.",0
Repeat CXR shows lung base chronic findings that could be suggestive of interstitial lung disease.,1
Pt did not have fever or other clincal signs of PNA.,0
Pt should follow up with his PCP to discuss need for further imaging and workup.,0
Chest CT could be performed in the outpatient setting for further evaluation.,0
#dyslipidemia-continued atorvastatin at home dose .,0
#hypothyroidism-continued levothyroxine at home dose .,0
Medications on Admission: AMIODARONE [PACERONE] - 200 mg Tablet - 1 Tablet(s) by mouth once a day ATORVASTATIN - 10 mg Tablet - one Tablet(s) by mouth every day CARVEDILOL [COREG] - 3.125 mg Tablet - 1 Tablet(s) by mouth twice a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth daily LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth once per day LIDOCAINE HCL - 2 % Gel - inject into urethra every third day before catheterization.,0
- No Substitution LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day every evening NITROGLYCERIN - 400 MCG (1/150 GR) TABLET - PLACE ONE TABLET UNDER TONGUE Q5 MIN X 3 AS NEEDED FOR JAW OR CHEST PAIN WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily as directed by coumadin clinic.,0
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth as directed.,0
"Patient normally takes3.5mg Tues/Thurs/Saturday, 2.5mg all other days Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",0
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO q mon/wed/fri/sun.,0
Coumadin 1 mg Tablet Sig: 3.5 Tablets PO q tue//sat: 3.5mg tue//sun.,0
9. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days.,0
"Disp:*6 Tablet(s)* Refills:*0* 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever.,0
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation.,0
Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: shock due to urosepsis acute renal failure thrombocytopenia coagulopathy acute systolic CHF toe erythema .,1
CAD afib h.o DVT Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted to the hospital with blood in your urine and feeling lightheaded.,0
Your blood pressure was initally low and you were found to have sepsis (a severe infection) from your urinary tract.,1
"For this, you were initally monitored in the ICU.",0
You improved and you were transferred to the regular medical floor.,0
You were given antibiotics for this infection and will continue this upon discharge.,0
Your foley catheter should also remain in place until your follow up appointment with Dr. .,0
Your coumadin was held initially as your numbers were elevated.,0
This was restarted and you should continue to have your INR checked regularly.,0
You some extra fluid outside of your lungs and were given Lasix with good effect.,0
Medication changes: 1.Continue Cipro 750mg daily for 6 more days .,0
Please take all of your medications as prescribed and follow up with the appointments below.,0
Followup Instructions: Please have your rehab facility schedule you an appointment with your PCP .,0
Department: SURGICAL SPECIALTIES When: at 9:00 AM With: DR. Building: Campus: EAST Best Parking: Garage .,0
"Department: CARDIAC SERVICES When: TUESDAY at 1 PM With: DEVICE CLINIC Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: CARDIAC SERVICES When: TUESDAY at 1:30 PM With: , NP Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: SURGICAL SPECIALTIES When: THURSDAY at 10:15 AM With: DR. Building: Campus: EAST Best Parking: Garage",0
"1:56 AM CHEST (PORTABLE AP) Clip # Reason: interval change, ?fluid overload Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with hypoxemia, pneumonia REASON FOR THIS EXAMINATION: interval change, ?fluid overload ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxemia.",1
COMPARISON: BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: A right internal jugular central venous line ends in the right atrium.,1
"There are bibasilar opacities, greater on the left than right appearing similar to those seen previously, likely infection on the left and atelectasis on the right.",0
"There is a small, uchanged, left pleural effusion and no definite right pleural effusion.",0
4:41 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate for intra-abdominal hematoma; please give iv Admitting Diagnosis: CHOLANGIO CA/SDA Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: s/p open ccy - now with hct drop and diaphoretic and esphogatis on egd REASON FOR THIS EXAMINATION: please evaluate for intra-abdominal hematoma; please give iv and po contrast (via NGT) No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Hematocrit drop in patient with recent open cholecystectomy.,0
Esophagitis seen on prior endoscopy.,0
TECHNIQUE: CT imaging of the abdomen and pelvis performed after the intravenous administration of 150 cc of Optiray.,0
Nonionic contrast was used due to patient debility.,0
Comparison is made to a preoperative CT from .,0
CT OF THE ABDOMEN WITH CONTRAST: There is atelectasis within the dependent portions of both lungs with a small left-sided pleural effusion.,0
Post-surgical changes within the right upper quadrant abdominal wall consistent with the patient's recent open cholecystectomy are seen.,0
A surgical drain traverses the right upper quadrant and terminates in the region of the gallbladder fossa.,0
There is again seen biliary ductal dilatation that is little changed when compared to the prior CT from .,0
A stent within the common duct is in unchanged position extending from the extrahepatic common duct into the proximal third portion of the duodenum.,0
No new focal liver lesions are seen.,0
The pancreas enhances homogeneously with no evidence of pancreatic mass or pancreatic duct dilatation.,0
"The spleen, adrenal glands, kidneys and small bowel are within normal limits.",0
"Atherosclerotic disease is seen within the abdominal aorta, which is of normal caliber.",0
No pathologically enlarged retroperitoneal or mesenteric lymph nodes are seen.,0
There is esophageal wall thickening that is consistent with the patient's history of esophagitis.,0
"CT OF THE PELVIS WITH CONTRAST: The urinary bladder, prostate gland and rectum are within normal limits.",0
"Of note, the proximal and mid appendix are air filled and normal in appearance.",0
"The very tip of the appendix is fluid filled, with a small amount fluid in the right lower quadrant.",0
(these findings likely reflect the patients recent surgery)No retroperitoneal hematoma is seen.,0
IMPRESSION: 1) No evidence of retroperitoneal hematoma or other cause for the patient's hematocrit drop.,0
(Over) 4:41 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate for intra-abdominal hematoma; please give iv Admitting Diagnosis: CHOLANGIO CA/SDA Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 2) Post-surgical changes associated with the patient's recent cholecystectomy for chronic cholecystitis.,0
3) Esophageal wall thickening that is consistent with the patient's history of esophagitis.,0
These findings were discussed with the ordering physician at the time of interpretation.,0
5:07 AM CHEST (PORTABLE AP) Clip # Reason: r/o PTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with s/p CABG w/hypoxia/resp acidosis REASON FOR THIS EXAMINATION: r/o PTX ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 11:03 AM PFI: No pneumothorax.,1
Mild worsening in pulmonary congestion.,0
"Lower lung volumes with increase in bibasilar opacities, greater on the left side.",0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Hypoxia.,0
There are lower lung volumes.,0
Bibasilar atelectasis greater on the left base have increased.,0
Mild worsening in fluid overload.,0
Cardiomediastinal contours show vascular engorgement.,0
Swan-Ganz catheter tip is in the take-off of the right pulmonary artery.,0
Mediastinal and chest tubes are in place.,0
4:45 AM CHEST (PORTABLE AP) Clip # Reason: pulm edema?,0
"Admitting Diagnosis: CELLULITIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man s/p fem-distal bypass, with desat REASON FOR THIS EXAMINATION: pulm edema?",0
______________________________________________________________________________ FINAL REPORT AP CHEST HISTORY: Status post fem bypass.,0
IMPRESSION: AP chest compared to and 29.,0
Lung volumes are lower following extubation and there is new atelectasis at the medial aspect of the left lung base and pulmonary vascular engorgement has worsened to the point of borderline pulmonary edema.,0
Tip of the Swan-Ganz catheter projects over the right descending pulmonary artery.,0
"3:11 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for PTX Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p line attempt REASON FOR THIS EXAMINATION: eval for PTX ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:10 P.M., ON HISTORY: Attempted line placement.",1
IMPRESSION: AP chest compared to and :56 a.m.,0
"There is no pneumothorax or new mediastinal widening, or pleural effusion.",0
Left basal atelectasis which worsened after extubation is unchanged.,0
"The mild increase in cardiac diameter accompanied by mediastinal vascular engorgement of the azygos vein is stable and could represent mild cardiac decompensation, but there is no pulmonary edema.",0
8:41 AM CHEST (PORTABLE AP) Clip # Reason: eval fro infiltrate Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man s/p MVC REASON FOR THIS EXAMINATION: eval fro infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVC.,1
"FINDINGS: Compared with 5/23, allowing for somewhat lower lung volumes currently, no significant interval changes.",0
The right lung remains grossly clear.,0
There is patchy atelectasis in the left lung.,0
The mediastinal widening appears about the same.,0
10:11 AM PORTABLE ABDOMEN Clip # Reason: NGT readjustment Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with intracerebal hemorrhage REASON FOR THIS EXAMINATION: NGT readjustment ______________________________________________________________________________ FINAL REPORT INDICATION: Nasogastric tube readjustment.,0
A nasogastric tube has been withdrawn several cm in the interval.,0
The side port is now at approximately the GE junction level.,0
"Within the imaged portion of the chest, there is stable enlargement of the cardiac silhouette.",0
"Nasogastric tube withdrawal, with side port now located at approximately the GE junction level.",0
"Stable enlargement of cardiac silhouette, corresponding to pericardial effusion on CT of .",0
2:18 PM PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # Reason: r/o obstruction Admitting Diagnosis: DISSECTING THORACIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with s/p aortic dissection REASON FOR THIS EXAMINATION: r/o obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE FILM: HISTORY: Aortic dissection and abdominal distention.,1
A G tube overlies body of stomach.,0
There is moderate gasseous distention of the stomach.,0
Gas and retained contrast are present throughout the colon following introduction of contrast into the stomach via a G tube several hours earlier.,0
No extraluminal contrast identified in this single view.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old male who presents to the ED status post 30-feet fall from a ladder.,0
He had lost consciousness on exam.,0
"He awoke with no feeling, paresthesias, inability to move his legs.",0
"He was boarded, collared, and brought to the ER.",0
He received Solu-Medrol en route and the fall occurred at 11:30 a.m. on .,0
"PHYSICAL EXAMINATION: On exam, he had vitals of 96.2 for temperature, pulse 80, blood pressure 120/66, GCS 15.",0
He was alert and oriented times 3.,0
All extraocular movements were intact.,0
Pupils equal and reactive to light and accommodation.,0
He has a cervical collar in place.,0
"Heart is regular in rate and rhythm, no murmurs.",0
"His abdomen is soft, nontender, and nondistended.",0
"His neurology exam, he has total sensation loss below his umbilicus.",0
"He has a Foley in place, and his rectal exam has decreased tone.",0
"Extremities with no gross deformities, 2 plus deep tendon reflexes in the lower extremities and upper extremities.",0
"He has no deep tendon reflexes below his waist, 0/5 strength below his waist.",0
"Neuro, cranial nerves II to XII are intact.",0
"HOSPITAL COURSE: In the ED, he received a head CAT scan, which was negative.",0
CAT scan of the C-spine was negative.,0
"His chest x-ray was negative, and his thoracic spine film showed a comminuted T9 vertebral body fracture with canal obliteration.",0
"He has multiple bony fragments within the canal, and he has a bilateral T10 fracture, transprocess.",0
Abdominal CT with no free fluid and no organ injury.,0
The patient was admitted to the trauma ICU and then transferred to the neurosurgery service.,0
"After being transferred to the neurosurgery service, the patient underwent a post-thoracic spine fusion with instrumentation and harvest of the iliac crest on .",0
The procedure was done without complications.,0
"On postoperative day number 1, the patient developed a fever, T-Max 102.6.",0
"The fever workup consisting of a urinalysis, CBC, ultrasound for DVT, and chest x-ray were all negative for infectious process.",0
The fever resolved on its own on .,0
The patient also developed anemia postoperatively.,0
He was transfused with 3 units of red cells with good result.,0
He was also seen by physical therapy and occupational therapy.,0
He will require acute rehabilitation.,0
CONDITION ON DISCHARGE: His condition on discharge is stable with T9 paraplegia.,0
DISCHARGE STATUS: Discharge to an acute rehabilitation facility.,0
DISCHARGE DIAGNOSES: T9-T10 complete fracture with dislocation and T9 paraplegia.,1
"Dulcolax 5 mg tablet, 2 tablets q.d.",0
"Famotidine 20 mg tablet, 1 tablet p.o.",0
"Acetaminophen 325 mg tablet, 1-2 tablets p.o.",0
Heparin sodium 5000 units/mL 5 cc injections subcutaneously t.i.d.,0
"3, 5/325 mg 1-2 tablets p.o.",0
"Sodium chloride 1 g tablet, 2 tablets p.o.",0
"Calcium acetate 667 mg tablet, 2 tablets p.o.",0
"with meals, wean as tolerated.",0
Zolpidem tartrate 5 mg 1 tablet p.o.,0
FOLLOW-UP: The patient is to follow up with Dr. on Wednesday at 8:45 a.m. in the office.,0
Dr. Dictated By: MEDQUIST36 D: 15:36:55 T: 03:06:45 Job#:,0
"3:24 PM CHEST (SINGLE VIEW) Clip # Reason: patient with leukocytosis, eval for pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with above REASON FOR THIS EXAMINATION: patient with leukocytosis, eval for pneumonia ______________________________________________________________________________ FINAL REPORT PROCEDURE: Single view of the chest.",0
INDICATION: 52 year old female with leukocytosis.,0
The lungs are clear and there are no effusions.,0
IMPRESSION: No radiographic evidence of pneumonia.,0
"4:26 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields, s/p pda ligation with left chest tube Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: infant born at 25wks now 14 days old, s/p pda ligation with left chest tube in place REASON FOR THIS EXAMINATION: evaluate lung fields, s/p pda ligation with left chest tube in place ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST on at 1642 hours.",0
HISTORY: Status post PDA ligation.,0
"In followup to , the patient remains intubated with ETT high in position at the level of the cervical trachea.",0
"Left chest tube in place, status post PDA ligation with left thoracotomy changes to the ribs as well.",0
Some increased lucency is noted along the left superior mediastinum and left heart margin consistent with anterior pneumothorax.,0
"Diffuse interstitial prominence persists throughout both lungs with a hazy opacity as well consistent with edema superimposed on chronic lung disease, which is somewhat improved, although the lungs are more hyperinflated on the current examination.",0
Remaining support lines are unchanged.,0
12:29 PM CT HEAD W/O CONTRAST Clip # Reason: ICH Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with SDH and seizure.,0
"REASON FOR THIS EXAMINATION: ICH CONTRAINDICATIONS for IV CONTRAST: CR ______________________________________________________________________________ WET READ: MJMgb MON 4:10 PM Expanding left subdural hematoma, now with 12 mm rightward subfalcine herniation.",0
Basal cisterns are patent with evidence of early uncal herniation (2a:13).,0
"The subdural hematomas are more hypodense than suggesting evolution of blood products, but interval hemorrhage cannot be excluded.",1
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: History of subdural hematoma and possible new seizure.,0
COMPARISON: Multiple prior NECTs of the head from to .,0
"FINDINGS: In comparison to the last NECT of the head eight days prior, there is now markedly increased mass effect with 12 mm of rightward subfalcine herniation.",0
"The large left subdural fluid collection is larger, though more hypodense than on , suggesting evolution of blood products.",1
"In addition, there are dependent hyperdensities that suggest layering blood products.",0
The right occipital subdural fluid collection is also more hypodense in the most recent NECT of the head.,1
The quadrigeminal and perimesencephalic cisterns are patent.,0
"The suprasellar cistern appears patent, though there may be slight amount of effacement on the left side (2A:13).",0
Imaging of the vertex is limited by motion.,0
"Hypodense region in the right frontal lobe with a peripheral calcification may represent a granuloma, unchanged (2A:18).",0
Imaging in the vertex is limited by motion.,0
"There is fluid in the right mastoid air cells and paranasal sinuses, likely related to intubation.",0
The bony calvaria are unremarkable.,0
IMPRESSION: Expanding left subdural hematoma with 12 mm rightward subfalcine herniation.,0
Basal cisterns remain patent with possible mild effacement of the left lateral aspect of the suprasellar cistern.,0
Findings were discovered at 3:57 p.m. and conveyed by Dr. to Dr. by phone at 4:02 p.m. on .,0
MJMgb (Over) 12:29 PM CT HEAD W/O CONTRAST Clip # Reason: ICH Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ FINAL REPORT (Cont),0
"4:58 AM CHEST (PORTABLE AP) Clip # Reason: acute changes Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p RU Lobectomy REASON FOR THIS EXAMINATION: acute changes ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:27 A.M, .",1
"HISTORY: Right upper lobectomy, question any acute changes.",0
"IMPRESSION: AP chest compared to series of chest radiographs, through : Severe consolidation in most of the left lung and at the base of the postoperative right lung is stable over the past 36 hours.",0
Small volumes of pleural air at the apex and base of the right lung are stable.,0
"Tip of the endotracheal tube is just above the upper margin of the clavicles, no less than 8 cm from the carina, 4 cm above optimal placement.",0
Right apical pleural drain unchanged in position.,0
Right subclavian line ends at the superior cavoatrial junction.,0
Subsequent chest radiograph obtained at 2:14 p.m. showed endotracheal tube is in the same position.,0
8:22 AM MR HEAD W & W/O CONTRAST Clip # Reason: s/p frontal tumor resection .,0
Post op scan Admitting Diagnosis: BRAIN MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with metastatic melanoma REASON FOR THIS EXAMINATION: s/p frontal tumor resection .,1
Post op scan No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MRI SCAN OF THE BRAIN WITH GADOLINIUM ENHANCEMENT HISTORY: Metastatic melanoma.,1
Status post frontal tumor resection.,0
"TECHNIQUE: Multiplanar T1- and T2-weighted pre- and post-gadolinium enhanced imaging was obtained, including reconstructed MP-RAGE images in multiple planes.",0
STUDY ON PACS ARCHIVE: volumetric study.,0
"FINDINGS: At this time, there is pre-contrast T1 hyperintensity which appears to fill the right frontal region tumor resection bed.",0
There does not appear to be overt pathological enhancement to clearly identify residual tumor at this time within the operative bed.,0
"However, as noted by Dr. report of the prior study, there is enhancement along the undersurface of the left occipital lobe, which does raise the question of residual or recurrent tumor at that site.",0
"There is somewhat more extensive edema surrounding the right frontal hemorrhage, presumably reflecting the recent surgery.",0
Considerable susceptibility from overlying surgical material obscures a portion of the right frontal lobe cortex.,0
"There is moderate mucosal thickening involving the left maxillary antrum,, presumably representing an ongoing inflammatory process.",0
CONCLUSION: Postoperative study as defined above.,0
"3:52 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: vessel imaging Admitting Diagnosis: UGIB Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with stroke REASON FOR THIS EXAMINATION: vessel imaging No contraindications for IV contrast ______________________________________________________________________________ WET READ: TXPb FRI 5:12 PM NECT Head: Loss of /white differentiation in right temporal, parietal, and occipital lobes with mass effect from edema causing effacement of sulci and lateral ventricle, consistent with edema infarct.",0
CTA Head and Neck: Reconstructions pending.,0
"- MD, WET READ VERSION #1 TXPb FRI 5:07 PM NECT Head: Loss of /white differentiation in right posterior parietal lobe in MCA territory with mass effect causing effacement of sulci and lateral ventricle, consistent with edema acute infarct.",1
"- MD, ______________________________________________________________________________ FINAL REPORT STUDY: Head CT and CTA of the head and neck.",0
"COMPARISON: Prior MRI of the brain dated and , prior head CT dated .",0
TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast material.,0
"Subsequently, rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material.",0
"FINDINGS: CT HEAD: Ischemic changes again are redemonstrated in the bilateral parietal lobes, more significant on the right, effacement of the sulci is more pronounced on the right parietal region with associated vasogenic edema.",0
"Unchanged underlying subcortical areas of low attenuation, consistent with chronic microvascular ischemic disease.",0
Again dense vascular calcifications are redemonstrated in the carotid siphons bilaterally.,0
There is no evidence of hemorrhagic transformation or shifting of the normally midline structures.,0
The ventricular system appears unchanged with no evidence of hydrocephalus.,0
The soft tissues and bony structures are grossly unremarkable.,0
Multiple EEG electrodes are in place.,0
"CTA OF THE HEAD: The bilateral internal carotid arteries are patent, there is hypoplasia of the A1 segment on the right, both middle cerebral arteries are patent, the anterior cerebral arteries are unremarkable.",0
There is hypoplasia of the P1 segment on the left with fetal origin of the left posterior (Over) 3:52 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: vessel imaging Admitting Diagnosis: UGIB Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) communicating artery.,0
The V4 segment on the right is hypoplastic.,0
"IMPRESSION: There is no evidence of flow stenotic lesions in the circle of , note is made of vascular variations, consistent with hypoplasia of the right A1 segment, hypoplasia of the left P1 segment and V4 segment on the right vertebral artery.",0
CTA NECK: The origin of the supra-aortic vessels appears normal.,0
The bilateral common and vertebral artery origins are patent.,0
Atherosclerotic calcifications are identified at both cervical carotid bifurcations with no evidence of critical stenosis.,0
Punctate carotid calcifications are demonstrated at the carotid siphons bilaterally with no evidence of critical stenosis.,0
"The lumen of the left internal carotid measures approximately 5.2 mm in size and the lumen of the right internal carotid artery measures approximately 4.2 mm, which is considered within normal limits.",0
IMPRESSION: Moderate atherosclerotic calcifications of the cervical carotid bifurcations with no evidence of critical stenosis.,0
There is no evidence of critical stenosis or aneurysms in the circle of .,0
"Evolution of the bilateral parietal infarction, with associated vasogenic edema, producing effacement of the sulci on the right parietal lobe as described above, there is no evidence of hemorrhagic transformation.",1
"7:35 PM CT HEAD W/ & W/O CONTRAST Clip # Reason: evaluate for intracranial mets Admitting Diagnosis: HYPOXIA Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with metastatic NSCLC, confusion, evaluate for head metastasis.",0
Unable to get MRI Given aortic graft.,0
"REASON FOR THIS EXAMINATION: evaluate for intracranial mets No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic non-small cell lung cancer, evaluate for metastases, unable to MRI due to aortic graft.",0
TECHNIQUE: CT of the head with and without IV contrast.,0
NON-CONTRAST HEAD CT: STUDY SIGNIFICANTLY LIMITED DUE TO MOTION AND ARTIFACTS.,0
"There is no gross intra- or extra-axial hemorrhage, mass effect or shift of normally midline structures.",0
Evalaution of scattered hyperdense areas is limited due to artifacts.,0
The ventricles and sulci are moderately prominent with bilateral periventricular white matter hypoattenuation consistent with chronic small vessel ischemic disease.,0
Asymmetric skull base and middle ear structures is likely related to patient positioning.,0
Unchanged lacunar infarct is noted in the left basal ganglia.,0
CONTRAST-ENHANCED HEAD CT: No evidence of large enhancing masses or lesions to indicate metastases.,0
"However, evaluation is limited due to motion artifacts.",0
Evaluation of vessels is limited given study not optimized for arterial timing.,0
Remainder of the findings are unchanged as demonstrated by the non-enhanced contrast CT described above.,0
Study significantly limited due to motion.,0
"No CT evidence of large metastases, within the limitations.",0
"check the model and MR safety of aortic graft and if safe, consider MR without and with contrast.",0
Unchanged moderate volume loss and chronic small vessel ischemic disease.,0
"6:21 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate for intracranial hemorrhage Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with altered mental status REASON FOR THIS EXAMINATION: evaluate for intracranial hemorrhage No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old man with altered mental status, evaluate for intracranial hemorrhage.",0
"FINDINGS: No acute intracranial hemorrhage, shift of normally midline structures, or major vascular territorial infarct.",0
The appearance of the brain is somewhat asymmetric due to patient's head position.,0
"There is slight increase to mucosal thickening in the ethmoid sinuses and ongoing thickening of the sphenoid sinus The orbits, soft tissues, and osseous structures are unremarkable.",0
IMPRESSION: No evidence of acute intracranial hemorrhage or mass effect.,0
"4:57 AM ELBOW (AP, LAT & OBLIQUE) LEFT; FOREARM (AP & LAT) LEFT Clip # Reason: Please shoot elbow and forearm, assess for fx ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with MVC trauma REASON FOR THIS EXAMINATION: Please shoot elbow and forearm, assess for fx ______________________________________________________________________________ FINAL REPORT INDICATION: Motor vehicle collision.",1
"LEFT SHOULDER, TWO VIEWS: No fractures are identified.",0
"There is a soft tissue defect in the ulnar aspect, with a few retained pieces of glass .",0
An IV catheter is seen in the antecubital fossa.,0
No joint effusion is present.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. is a 42-year-old male with a history of end-stage liver cirrhosis secondary to hepatitis C and ethanol abuse, who for a long time had been followed by Dr. at for possible liver transplant.",1
"He presented to the Hospital on with worsening confusion, lethargy, and increased fatigue.",0
There was no evidence of bleeding or infection.,0
It was thought that he would do better with being transferred to and that this would expedite his chances for getting a new liver.,0
The patient was transferred to on .,0
"By the time of transfer, he was admitted with acute renal failure as well as encephalopathy.",1
ALLERGIES: There are no known drug allergies.,0
Lamictal 200 mg po bid.,0
Protonix 400 mg po q day.,0
Ursodiol 300 mg po tid.,0
Nadolol 20 mg po q day.,0
Aldactone 25 mg po bid.,0
Seroquel 100 mg po q hs.,0
Lorazepam 0.5 mg po bid.,0
Levaquin 500 mg po q day x6 days.,0
Lasix 800 mg po q day.,0
Mycelex five pills a day.,0
SOCIAL HISTORY: Occasional cigarettes a day.,0
"He denies any alcohol use, and the patient is single with one son, never married, and he lives with his sister.",0
PHYSICAL EXAMINATION: The patient appeared lethargic and jaundice appearing and is arousable in no acute distress.,0
"Vital signs: Blood pressure 100/48, pulse 70, respiratory rate 20.",0
"Head, eyes, ears, nose, and throat is normocephalic, atraumatic.",0
"Neck: There is no jugular venous distention, no lymphadenopathy.",0
"Heart: Regular, rate, and rhythm, normal S1, S2.",0
Lungs with crackles bilaterally at the base.,0
"Abdomen: Bowel sounds present, soft, slightly distended and nontender.",0
"Neurologically, the patient is drowsy, but arousable, alert and oriented times three, moves all four extremities.",0
"PERTINENT LABORATORY TESTS: Sodium 127, potassium 4.8, chloride 99, bicarb 22, BUN of 42, creatinine of 2.4 from baseline of 1.0.",0
"Total bilirubin 19.8, direct bilirubin 9.5, indirect 3.1.",0
"Amylase 78, lipase 57, alkaline phosphatase 115.",0
CHEST X-RAY: Revealed a large right sided density probably representing a large pleural effusion.,0
"ECHOCARDIOGRAM: On showed a left ventricular ejection fraction of 55%, mild mitral regurgitation, mild dilated left atria, with mild pulmonary hypertension.",0
"SUMMARY OF HOSPITAL COURSE: This is a 42-year-old gentleman with end-stage liver disease secondary to hepatitis C as well as ethanol use in the past, who was transferred from Hospital on .",1
"He had a variety of metabolic abnormalities, and he was encephalopathic.",0
He was transferred for better management and for possible liver transplant.,0
The patient had a thoracentesis the following day of his right pleural effusion.,0
He was also taken to the operating room on for orthotopic liver transplant.,0
The operation went well as described in the operative note.,0
"The patient was started on the usual prophylaxis of Bactrim, fluconazole, and Valcyte, and additionally on Unasyn as well as Vancomycin.",0
Patient was weaned off propofol as well as ventilation and extubation was attempted on postoperative day one.,0
An ultrasound of his liver was obtained indicating normal blood flow to the liver and a large pleural effusion on the right side.,0
That pleural effusion was tapped and cultured and there was no growth of organism.,0
"Additionally, blood cultures as well as sputum cultures were sent.",0
A sputum sample was negative as well.,0
"A bronchoalveolar lavage indicated no microorganisms seen, however, there was on fungal culture and no other organisms.",0
The patient was continued on ventilation and was noted to have a lot of secretions.,0
The patient was placed on Lopressor as well as hydralazine and actively diuresed.,0
Patient was started on TPN.,0
"The patient was extubated on postoperative day three, and oxygen saturation was in the high 90s.",0
He is having aggressive chest PT.,0
"During the hospital stay, the patient was transfused several units of blood as well as platelets.",0
The patient was maintaining excellent urine output.,0
His liver function tests have been trending downward.,0
An angiogram of his liver showed normal flow.,0
"The patient had been doing well on the floor, however, he is transferred back to the unit on postoperative day #7 with respiratory failure, decrease in oxygen saturation.",0
Imaging of his lungs were consistent with ARDS.,0
Collapse of the left upper lobe as well as the left lower lobe.,0
"The patient required increase in FIO2 as well as PEEP requirement, ...................and bronchoscopy was done as well as a bronchoalveolar lavage, which revealed no organism.",0
TPN was discontinued and tube feedings started in its place.,0
"The patient was eventually weaned off the vent and extubated, and remained hemodynamically stable.",0
clinic was consulted regarding blood sugar management.,0
Physical Therapy and Occupational Therapy was working with patient for rehabilitation.,0
"Again on postoperative day #18, the patient was transferred from the unit to the floor.",0
It was noted at that time that there was a large amount of ascites leaking from the upper aspect of his wound which required several stitches to be placed.,0
"The patient had an ultrasound guided paracentesis, which was within normal limits.",0
The patient was cleared by Speech and Swallow for po intake.,0
"Tube feeds were eventually discontinued, and patient's oral intake was supplemented with Boost shakes.",0
The patient was started on Fludrocortisone for some adrenal insufficiency.,0
Urology was consulted for a history of renal calculus as well as dysuria and positive urine culture.,0
"He was taken to the operating room on for uroscopy and laser lithotripsy, where a temporary stent was placed.",0
He was additionally placed on Levaquin for one week.,0
"As per patient's request, Psychiatry was consulted for his history of bipolar disorder, and appropriate recommendations were made.",0
The patient remained in the hospital for several extra days secondary to the patient not having medical insurance and could not go to a rehabilitation center.,0
The patient was to be discharged with his sister with whom he lives with at home.,0
Review of the patient's medications as well as medications schedule was reviewed with his sister by the Transplant Coordinator.,0
The patient was scheduled to review services.,0
The patient was to have laboratory work done twice a day on Monday and Thursdays at .,0
The patient was cleared by Physical Therapy as well as our service to return home on postoperative day #35 under the guidance of her sister at home as well as services.,0
"At that time, is on a combination of an immunosuppressive regimen of Neoral, prednisone, and CellCept.",0
End-stage liver disease with encephalopathy.,1
Acute respiratory distress requiring reintubation.,0
Status post orthotopic liver transplant.,0
Status post ureteroscopy with laser lithotripsy.,0
Valcyte 450 mg one tablet po q day.,0
Risperidone 1 mg/ml solution one tablet oral po bid.,0
Bactrim SS one tablet po q day.,0
Metoprolol 50 mg one tablet po bid.,0
Fluconazole 200 mg tablet two tablets po q day.,0
Fludrocortisone 0.1 mg tablet one tablet po q day.,0
Percocet 1-2 tablets po q4-6h prn pain.,0
Famotidine 20 mg tablet one tablet po bid.,0
CellCept mg tablet two tablets po bid.,0
Prednisone 12.5 mg po q day.,0
Insulin NPH 4 units at breakfast and 4 units q hs.,0
Furosemide 10 mg tablet po q day.,0
Neoral 100 mg capsule one capsule .,0
The patient is to followup with Dr. at the Clinic in .,0
He is to schedule an appointment in one month at telephone number .,0
He is to followup with Dr. at the Transplant Center in the at area code on at 11:20 am.,0
"He is to followup with Dr. at the in the Transplant Center, same telephone number on at 9:10 in the morning.",0
To follow-up again with Dr. on at 10:10 am.,0
He is to schedule an appointment with Dr. at the same telephone number at the Clinic.,0
Dictated By: MEDQUIST36 D: 17:41 T: 12:01 JOB#:,0
2:57 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: Has NGT in place.,0
Please keep NGT and place dubbhoff as well Admitting Diagnosis: CIRRHOSIS Contrast: CONRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman s/p OLT.,0
REASON FOR THIS EXAMINATION: Has NGT in place.,0
Please keep NGT and place dubbhoff as well.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): KKgc FRI 4:48 PM -intestinal tube advanced to the post-pyloric position.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old woman status post liver transplant, has an NG tube in place, for placement of -intestinal tube.",0
"-INTESTINAL TUBE PLACEMENT: After anesthetizing the left nostril with lidocaine jelly, an 8 French - feeding tube was advanced under intermittent fluoroscopic surveillance.",0
"The tube was advanced into a post-pyloric position, terminating in the third portion of the duodenum.",0
10 cc of Conray contrast was injected to confirm the tube position.,0
A nasogastric tube is positioned within the stomach with the side holes below the GE junction.,0
IMPRESSION: -intestinal tube advanced to the post-pyloric position.,0
"6:48 PM NECK SOFT TISSUES Clip # Reason: pls eval airway caliber Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with h/o laryngeal ca now with stridor REASON FOR THIS EXAMINATION: pls eval airway caliber ______________________________________________________________________________ WET READ: CXWc FRI 10:35 PM On frontal view, trachea appears narrowed at level of C5, extending for approximately 2cm.",0
"On Lateral view, difficult to evaluate at this level due to overlying soft tissues.",0
More proximal trachea is widely patent.,0
CT recommended for further evaluation.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Laryngeal carcinoma, now with stridor.",0
FINDINGS: Frontal and lateral views are presented.,0
"On the lateral projection, there is no evidence of airway narrowing, although this area is difficult to evaluate due to overlying soft tissues.",0
"On the frontal view, however, the trachea appears to be narrowed at the level of C5, extending for approximately 2 cm.",0
The more proximal portion of the trachea is widely patent.,0
"This information was discussed by the resident with Dr. , recommending CT for further evaluation.",0
"12:52 PM MR HEAD W & W/O CONTRAST Clip # Reason: Increasing frequency of seizures, please assess for underlyi Admitting Diagnosis: SEIZURES/HEMOPTITIS Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ FINAL ADDENDUM There is also mildly increased signal in the basal ganglia which could also be related to osmotic demyelination.",0
"12:52 PM MR HEAD W & W/O CONTRAST Clip # Reason: Increasing frequency of seizures, please assess for underlyi Admitting Diagnosis: SEIZURES/HEMOPTITIS Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with seizure disorder REASON FOR THIS EXAMINATION: Increasing frequency of seizures, please assess for underlying abnormality No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb MON 4:06 PM No seizure focus identified.",0
Resolution of previously noted hypoxic changes in the cortex.,0
New changes in the pons and midbrain which could represent a central pontine myelinolysis.,0
______________________________________________________________________________ FINAL REPORT MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM HISTORY: Increasing frequency of seizures.,0
Comparison is made with .,0
FINDINGS: The previously noted hyperintensity in the cortical ribbon bilaterally has resolved.,0
There is diffuse volume loss for age with prominence of ventricles and sulci.,0
No significant change in ventricular size has occurred.,0
There is no evidence for acute ischemia.,0
"There is no evidence for mesial temporal sclerosis, cortical dysplasia or heterotopia.",0
There is slightly increased signal within the pons and mid brain which is new compared to the prior study.,0
This finding could be seen in the setting of central pontine myelinolysis.,0
Intracranial flow voids are maintained.,0
IMPRESSION: No seizure focus identified.,0
New changes in the pons and midbrain which could represent a central pontine myelinolysis/osmotic demyelination.,0
"(Over) 12:52 PM MR HEAD W & W/O CONTRAST Clip # Reason: Increasing frequency of seizures, please assess for underlyi Admitting Diagnosis: SEIZURES/HEMOPTITIS Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"5:44 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for acute process and changes Admitting Diagnosis: ESOPHOGEAL CANCER;DYPSNEA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with severe AS (valve gradient 0.8 -1.6) and new diagnosis of esophogeal cancer, intubated REASON FOR THIS EXAMINATION: Please evaluate for acute process and changes ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Newly diagnosed esophageal cancer with severe aortic stenosis.",1
"There is interval worsening of pulmonary edema, severe.",1
The ET tube tip is approximately 8 cm above the carina.,0
The left internal jugular line tip is at the junction of the brachiocephalic vein and SVC.,0
The NG tube tip passes below the diaphragm most likely terminating in the stomach.,0
5:37 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE\LEFT HEART CATHETERIZATION Admitting Diagnosis: CORONARY ARTERY DISEASE\LEFT HEART CATHETERIZATION ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with cad REASON FOR THIS EXAMINATION: ?,1
pulm process ______________________________________________________________________________ WET READ: PBec WED 7:09 PM normal cardiomediastinal and hialr contours.,0
Faint retrocardiac and lingular opacity may represent early infectious process.,0
"Correlate clinically and recommend follow-up imaging to suggest resolutio, particularly of more focal lingular process.",0
pbishop ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: PRE-OP EVALUATION Cardiac size is normal.,0
Ill-defined opacity in the lingula could be atelectasis but superimposed infection cannot be excluded.,0
10:05 AM CHEST (PA & LAT) Clip # Reason: monitor ptx.,0
Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with CAD REASON FOR THIS EXAMINATION: monitor ptx.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old man with CAD, status post CABG, monitor pneumothorax.",0
PA AND LATERAL CHEST RADIOGRAPH: The patient is status post median sternotomy with midline staples still in place.,0
There has been interval improvement in the bilateral pleural effusions as well as in the pulmonary edema; there remain small bilateral pleural effusions.,0
"There has been resolution of the left-sided tiny apical pneumothorax, and improvement in the right-sided tiny apical pneumothorax.",0
Improvement in pulmonary edema with residual small bilateral pleural effusions.,0
"Improving tiny right apical pneumothorax, resolved left apical pneumothorax.",0
"4:04 AM CHEST (PORTABLE AP) Clip # Reason: interval cahnge Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with GI bleed, intubted for airway protection REASON FOR THIS EXAMINATION: interval cahnge ______________________________________________________________________________ FINAL REPORT AP CHEST 4 A.M. HISTORY: A 40-year-old man with a GI bleed, intubated for airway protection.",0
IMPRESSION: AP chest compared to through 17: A slight increase in heterogeneous opacification of the left mid lung could be due to either asymmetric edema or less likely aspiration.,0
"The heart is top normal size, unchanged.",0
Upper lobe pulmonary vasculature is mildly dilated indicating elevated left atrial pressure.,0
"Pleural effusion is presumed on the left, but small.",0
"ET tube in standard placement, right internal jugular line ends in the upper-to-mid SVC.",0
4:31 PM CHEST (PA & LAT) Clip # Reason: evaluate pleural effusions Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION;CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with CAD REASON FOR THIS EXAMINATION: evaluate pleural effusions ______________________________________________________________________________ FINAL REPORT HISTORY: Evaluate pleural effusions.,1
The right internal jugular central venous catheter has been removed.,0
The left pneumothorax is no longer visualized.,0
The left retrocardiac atelectasis has diminished.,0
"Persistent cardiomegaly, without pleural effusions or pulmonary edema.",0
IMPRESSION: Improving left lower lobe atelectasis.,0
LINE PLACEMENT Clip # Reason: s/p line placement Admitting Diagnosis: MITRAL REGURGITATION;CHF ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman s/p MVR/maze REASON FOR THIS EXAMINATION: s/p line placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post mitral valve replacement and status post line placement.,1
FINDINGS: Tip of a new internal jugular catheter overlies the right atrium.,0
Withdrawal of the tip at cavoatrial junction.,0
"Otherwise, the study is an unchanged.",0
"There are bilateral small pleural effusions and retrocardiac opacities likely atelectasis, less likely pneumonia.",0
A dual lead pacemaker wires are unchanged.,0
IMPRESSION: Right IJ catheter overlying the atrium for which a withdrawal 4 cm would be appropriate for optimal placement.,0
and I discussed these findings were telephoned at 5:00 p.m. on .,0
"9:27 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: RESPIRATORY FAILIRE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with COPD and PNA w/p trach now with GNR bacteremia REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, AT 8:27 A.M. HISTORY: COPD and pneumonia presenting with gram-negative rod bacteremia.",1
FINDINGS: Support tubes and lines previously described are stable and in appropriate position.,0
IMPRESSION: Stable support tubes and lines with no superimposed acute pulmonary process.,0
"5:37 PM CHEST (PORTABLE AP) Clip # Reason: s/p bronch Admitting Diagnosis: LUNG CA LEFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with SCC s/p VATS, on trach with labored respiration and increased secrretions.Right Subclavian cvl resited then pulled back REASON FOR THIS EXAMINATION: s/p bronch ______________________________________________________________________________ FINAL REPORT INDICATION: Status post bronchoscopy, squamus cell carcinoma, status post VATS.",0
Comparison is made to the chest X-ray obtained on .,0
FINDINGS: There is again present a right-sided subclavian line in stable position.,0
"The heart, mediastinal, and hilar contours are unchanged.",0
The previously identified opacities in the right hilum and left upper lobe are unchanged.,0
There is no pneumothorax evident.,0
The right costophrenic angle is not fully evaluated.,0
IMPRESSION: Stable appearance of the chest with no evidence of pneumothorax.,0
", M. NSURG FA11 1:19 PM CT HEAD W/O CONTRAST Clip # Reason: please evaluate for any post-op hemorrhage**please do within Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with brain mass s/p stx biopsy REASON FOR THIS EXAMINATION: please evaluate for any post-op hemorrhage**please do within 4 hours** No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No acute intracranial hemorrhage.",0
No change in the mass and 0.8cm shift of midline structures to the right.,0
12:24 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p ET tube placement Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with COPD REASON FOR THIS EXAMINATION: s/p ET tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of ET tube position.,0
TECHNIQUE: Portable chest radiograph was obtained.,0
COMPARISON: Comparison is made to prior radiograph from at approximately 4:10 a.m.,0
FINDINGS: Endotracheal tube tip is 7.5 cm from the carina.,0
Evaluation of the lungs is limited due to respiratory motion.,0
"However, opacities in the left lower lobe are persistent.",0
These opacities are worrisome for possible infectious process.,0
Previously seen density in the left hemithorax is no longer persistent and consistent with attribution to technical differences.,0
"Hilar and mediastinal lymphadenopathy, seen on prior CT from , remains unchanged.",0
IMPRESSION: Endotracheal tube tip is at 7.5 cm from carina.,0
"Persistent left lower lobe opacities, which could represent pneumonia in the proper clinical setting.",0
"7:41 PM MR CERVICAL SPINE Clip # Reason: fractures, ligamentous Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 33 year old woman with s/p mvc REASON FOR THIS EXAMINATION: fractures, ligamentous ______________________________________________________________________________ FINAL REPORT INDICATION: 33-year-old female status post motor vehicle accident.",1
Evaluate for fractures or ligamentous injury.,0
COMPARISON: CT C-spine without contrast dated .,0
TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained without intravenous gadolinium enhancement.,0
"FINDINGS: The signal patterns of the neck are within normal limits, and there is no evidence to suggest the presence of ligamentous injury.",0
No overt vascular abnormality is seen.,0
"No spinal stenosis or cord compression is identified, and there is no abnormal signal within the cord.",0
No intra or extranodal mass lesions are seen.,0
IMPRESSION: Normal noncontrast cervical spine MRI.,0
11:53 AM CHEST (PA & LAT) Clip # Reason: Please evaluate for infiltrate.,0
Admitting Diagnosis: NECROTIZING PANCREATITIS;ALCOHOL DELIRIUM TREMENS ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with necrotizing pancreatitis and fevers.,1
REASON FOR THIS EXAMINATION: Please evaluate for infiltrate.,0
______________________________________________________________________________ FINAL REPORT TWO-VIEW CHEST COMPARISON: Study of earlier the same date.,0
FINDINGS: Lung volumes are low.,0
Cardiomediastinal contours are stable in appearance allowing for this factor.,0
Small left pleural effusion is present with adjacent retrocardiac opacity favoring atelectasis over an infectious pneumonia.,0
IMPRESSION: Small left pleural effusion with adjacent opacity favoring atelectasis over infectious pneumonia.,0
12:35 PM CT HEAD W/O CONTRAST Clip # Reason: r/o head bleed ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p cardiac arrest ?,0
"to od REASON FOR THIS EXAMINATION: r/o head bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: DRT FRI 2:01 PM no acute intracran process extensive fluid in nasal cavity, post nasopharynx and R sph sinus, likely rel to supine position and intubation pre-exist mild sinus inflamm chgs ______________________________________________________________________________ FINAL REPORT HISTORY: 50 y/o male, s/p cardiac arrest; ?overdose; r/o intracranial bleed.",0
TECHNIQUE: Contiguous 5 mm axial tomographic sections were obtained from the skull base through vertex and viewed in brain and bone window on the workstation .,0
FINDINGS: There are no comparisons on record.,0
"There is no intra or extra-axial hemorrhage or fluid collection, the midline structures are in the midline and the ventricles and cisterns are normal in size and contour.",0
The grey white matter differentiation is maintained throughout with no evidence of cerebral edema.,0
The posterior fossa structures are grossly unremarkable.,0
"There is extensive fluid within the nasal cavity and the posterior nasopharynx, with fluid layering in the sphenoid sinus, which may relate to both supine positioning and intubation.",0
"Also noted is mild maxillary sinus mucosal thickening with bilateral antral mucous retention cysts, as well as more marked mucosal thickening involving the right sphenoid sinus and multiple ethmoid air cells, reflecting pre-existent inflammatory disease.",0
Also noted is moderate smooth rightward deviation of the nasal septum.,0
The included portions of the mastoid air cells and middle ear cavities are clear.,0
IMPRESSION: 1) No acute intracranial abnormality.,0
"2) Abundant fluid in the nasal cavity, nasopharynx and right sphenoid sinus, likely related to supine positioning and intubation, following cardiac arrest.",0
3) Pre-existent sinus inflammatory changes.,0
6:54 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"left pleural opacity Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH WITH BRACHY S/B ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p MI, intubated with R pnthx REASON FOR THIS EXAMINATION: ?",1
left pleural opacity ______________________________________________________________________________ FINAL REPORT HISTORY: Left infiltrate.,0
"AP UPRIGHT CHEST: Compared with 1 day prior, the NG tube, ETT, and pigtail catheters have been removed.",0
There is interval partial clearing of the left lower zone infiltrate.,0
The right IJ and left subclavian central catheters are unchanged.,0
Stable cardiac and mediastinal contours.,0
No definite pleural effusions or vascular congestion.,0
"IMPRESSION: Interval removal of NG tube, ETT, and right pigtail catheter.",0
"Partial clearing of the left lower zone infiltrate, possibly representing aspiration.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Clonidine / Trazodone / Bactrim / Morphine / Ultram / Ambien / Ditropan Attending: Chief Complaint: Passing out Major Surgical or Invasive Procedure: None History of Present Illness: 56 year old man with past medical history significant for cirrhosis, chronic bronchitis, depression, anxiety, alcohol abuse, presenting from home with episodes of ""passing out"".",1
Patient is profoundly somonolent and responding few questions.,0
"Reports having these episodes today, not eating well for past few weeks.",0
"Denies knowingly taking more medications but reports ""it is quite possible"".",0
Reports having passing out spells while sitting down.,0
"No chest pain, diaphoresis, shortness of breath.",0
No further history can be obtained at this time.,0
"Of note, patient has been recently evaluated for cough and significant weight loss as well as worsening depression.",0
"He had a chest x-ray which revealed patchy opacities, plan was for 2 week course of ciprofloxacin.",0
"In the ED, vital signs were initially: 97 72 94/64 16 100, however shortly thereafter HR decreased to 60's and 50's with SBP in the 80's to 90's.",0
Patient received 4 liter NS and was trasnferred to MICU for further evaluation.,0
"Immediately on arrival, patient noted to be bradycardic to 30's with SBP in 130's.",0
IV Glucagon 5mg was administered immediately with improvement in HR to the 50's.,0
"Past Medical History: 1) Chronic Bronchitis with asthma and intubation (intubation was several years ago) 2) Rheumatoid arthritis 3) Depression/anxiety 4) Chronic neck pain, headache (used to be drug seeking) 5) Alchohol abuse (quit for 10 years and then restarted.",1
"sober since ) 6) Diverticulosis 7) Barrett's Esophagus Social History: Per records, history of EtOH abuse, recently sober and followed by psychiatry.",1
"No IV drugs, lived with daughter who recently left for college.",0
"Family History: N/C Physical Exam: GEN:The patient is in no distress and appears comfortable SKIN:No rashes or skin changes noted HEENT:No JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted.",0
"CHEST:Lungs are clear without wheeze, rales, or rhonchi.",0
"CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.",0
"Non-distended, and soft without tenderness EXTREMITIES:no peripheral edema, warm without cyanosis NEUROLOGIC: Alert and appropriate.",0
"BUE , and BLE both proximally and distally.",0
"Pertinent Results: CT HEAD: GEN:The patient is in no distress and appears comfortable SKIN:No rashes or skin changes noted HEENT:No JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted.",0
Brief Hospital Course: # BRADYCARDIA/INTOXICATION : Patient felt to have acute intoxication of Nadolol which caused bradycardia.,0
He was started on a glucagon gtt which improved his HR and mental status.,0
Toxicology was consulted who felt that in the setting of renal failure the nadolol would persist for 48 hours.,0
His HR improved after initial 12 hours.,0
"Psychiatry was consulted and offered him inpatient psychiatric evaluation, which he refused.",0
He was eventually discharged back on his nadolol with follow-up in a partial day program.,0
#MENTAL STATUS CHANGES-Initially presumed secondary to ingestion.,0
Resolved before transfer to floor.,0
# BRONCHITIS: Unclear if patient completed treatment course recently but no active pulmonary symptoms.,0
"Initial concern for TB in the MICU given ETOH history and previous CT findings and current CXR with RUL findings, however a documented PPD was negative 2 weeks prior.",0
No need to r/o for TB.,0
# ACUTE RENAL FAILURE- Creatinine 2.8 (baseline 0.8); FENA 1.04; The patient was felt to be profoundly dehydrated and after fluids/PO intake this all improved to baseline.,1
Resolved on the floor with rehydration and return of cardiac output.,0
"#Elevated cardiac enzymes- Patient has bradycardia/hypotension, EKG on arrival with new TW flattening anterolaterally; Troponin markedly elevated in ED to 0.26 but has acute renal failure; enzymes trended down.",1
They were unconcerning on the floor.,0
"Medications on Admission: ACYCLOVIR [ZOVIRAX] - 5 % Cream - apply every few hours to HSV until healed on lips ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every four (4) hours as needed for shortness of breath, cough or wheezing CLINDAMYCIN PHOSPHATE [CLEOCIN T] - 1 % Solution - apply to face, chest, back, arms and legs up to twice daily CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth three times a day ERYTHROMYCIN [E-MYCIN] - 333 mg Tablet, Delayed Release (E.C.)",0
"- one Tablet(s) by mouth three times a day FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays intranasal once daily LACTULOSE - 10 gram/15 mL Solution - 15 cc by mouth three times daily for three BM per day LEVOTHYROXINE - 100 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METRONIDAZOLE [METROCREAM] - 0.75 % Cream - to face MUCUS CLEARING DEVICE [ACAPELLA] - Device - use as instructed daily per pulmonary rehab.",0
MUPIROCIN CALCIUM [BACTROBAN] - 2 % Ointment - apply to open areas daily NADOLOL - 80 mg Tablet - 1 Tablet(s) by mouth once a day OXYCODONE - 5 mg Tablet - 2 Tablet(s) by mouth twice a day as needed for chronic foot pain.,0
Total dose is 10mg .,0
NOT TO BE FILLED UNTIL .,0
SERTRALINE [ZOLOFT] - 100 mg Tablet - 2 Tablet(s) by mouth po qam SOLIFENACIN [VESICARE] - 10 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth daily TRIAMCINOLONE ACETONIDE - 0.1 % Cream - as directed three times per week to itchy spots on skin.,0
"CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day CANE - Device - use as directed dx: Rheumatoid Arthritis COMPRESSION STOCKINGS - Misc - use as directed once a day FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65 mg Elemental Iron) Tablet - Tablet(s) by mouth once a day OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed Release (E.C.)",1
- 2 Tablet(s) by mouth twice a day Discharge Medications: 1.,0
Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day).,0
Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Discharge Disposition: Home With Service Facility: Health Systems Discharge Diagnosis: Nadolol Overdose Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Lethargic but arousable Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital after you were found unresponsive by your family.,0
It was found that you had taken too much of your nadolol and likely your klonopin.,0
You required an extended stay in the ICU where life saving measures were provided.,0
Eventually you were moved to the floor where you did well from a medical standpoint and were cleared for discharge.,0
You were seen by our experts in psychiatry who offered you inpatient psychiatric hospitalization which you refused.,0
You were offered several other options and eventually settled upon.,0
"The following changes were made to your medications: Followup Instructions: Provider: FUNCTION LAB Phone: Date/Time: 3:40 Provider: ,INTERPRET W/LAB NO CHECK-IN INTEPRETATION BILLING Date/Time: 4:00 Provider: .",0
Phone: Date/Time: 4:00 Completed by:,0
"10:25 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: MS CHANGES, ASSESS SDH Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with SDH REASON FOR THIS EXAMINATION: assess SDH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Subdural hemorrhage.",1
COMPARISON: Study nine (9) hours earlier.,0
"FINDINGS: Again seen, is a left-sided craniotomy with a stable amount of left-sided subdural hemorrhage and post-operative air.",1
Stable mass effect with slight shift of normally midline structures to the contralateral side.,0
IMPRESSION: No change in appearance of the left-sided subdural hemorrhage.,1
1:07 AM CHEST (PORTABLE AP) Clip # Reason: central line eval Admitting Diagnosis: LEFT SIDED WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with R bg bleed evaluate central line REASON FOR THIS EXAMINATION: central line eval ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation of central venous access line.,0
The wires and clips are in correct position.,0
The endotracheal tube projects 4 cm above the carina with its tip.,0
The course and position of the nasogastric tube are unremarkable.,0
"Normal course of the right-sided central venous access line, the tip projects over the inflow tract of the right atrium.",0
Left pectoral pacemaker with correct position of wires.,0
Bilateral perihilar haze indicative of moderate central pulmonary edema.,1
No focal parenchymal opacities suggesting pneumonia.,0
Admission Date: Discharge Date: Service: GREEN HISTORY OF PRESENT ILLNESS: The patient is a year old female who was admitted with one day of abdominal pain.,0
The patient's pain began at 4 a.m. with acute onset and was of a nature that the patient had never experienced before.,0
"The pain was diffuse, but otherwise the characteristics were unknown.",0
"There was no ever reported radiation of the pain; no nausea, vomiting, fevers or chills.",0
The patient had a bowel movement the prior day.,0
There was no bright red blood per rectum or melena.,0
The patient had had an upper respiratory infection and dry cough for seven days prior to admission.,0
"No recent antibiotics, shortness of breath or chest pain.",0
"Coronary artery disease, status post myocardial infarction in ; status post right coronary artery stent; ejection fraction of 40%.",1
Zoloft 50 mg q. day.,0
Lasix 20 mg q. day.,0
Lipitor 20 mg q. day.,0
FeSO4 325 mg q. day.,0
Potassium chloride 20 mEq four times a day.,0
Benicar 20 mg q. day.,0
PHYSICAL EXAMINATION: Temperature 97.0 F.; pulse 83; blood pressure 160/43; respiratory rate 22; 98% on room air.,0
"In general, frail elderly female in no apparent distress pulling at her cover, awake, alert and oriented times one.",0
"Lungs: Expiratory wheezes, decreased breath sounds at bases bilaterally.",0
"Cardiovascular: Regular rate and rhythm; no murmurs, rubs or gallops.",0
"Abdomen: Soft, distended, nontender, hypoactive bowel sounds.",0
"Rectal: Normal tone, stool in vault, guaiac negative.",0
"LABORATORY: Studies reveal white blood cell count 7.7, hematocrit 37.7, platelets 235; neutrophils 71%, bands zero.",0
"Sodium 133, potassium 4.4, chloride 98, bicarbonate 27, BUN 18, creatinine 0.8, glucose 120.",0
"Calcium 9.2, magnesium 1.8, phosphorus 3.2.",0
"KUB: No free air, single air fluid level in mid abdomen, no evidence of colonic obstruction.",0
Abdominal CT scan reveals multiple dilated loops of small bowel with associated stranding in mesentery and thickening of bowel wall representing a high grade small bowel obstruction with incarcerated internal hernia; small pericardial effusion; ascites.,1
"HOSPITAL COURSE: Upon admission, an nasogastric tube was placed with marked improvement in the patient's abdominal distention.",0
"The initial plan was to continue the nasogastric tube with intravenous fluids, however, later in the morning of , the patient's abdominal examination worsened with more tenderness in her lower quadrant and a repeat white blood cell count had risen from 7.7 to 12.6.",0
It was therefore decided to take the patient to the Operating Room for exploration of a small bowel obstruction with possible ischemic small bowel.,0
The patient underwent an exploratory laparotomy with small bowel resection and primary anastomosis.,0
"There were several adhesive bands noted in the right lower quadrant sidewall that were likely the source of an internal hernia which appeared to have spontaneously reduced, however, there was a 35 centimeter segment of jejunum intussuscepted that had infarcted.",0
This portion of the jejunum was resected.,0
Please see dictated Op Note for further details.,0
"Immediately postoperatively, the patient was taken to the Surgical Intensive Care Unit, intubated and sedated.",0
She was medically stable and the plan was to wean the ventilator to extubation.,0
"She was on SIMV with 60% FIO2 and a blood gas of 7.38, 32, and 211.",0
The patient was placed on perioperative Kefzol and Flagyl and remained afebrile while in the Intensive Care Unit.,0
"On postoperative day one, the patient's blood gas was 7.38, 30, 145, 18, negative five.",0
"Because of the acidosis with base deficit, a Renal consultation was obtained.",0
The Renal Team recommended conservative management for what appeared to be a metabolic acidosis with respiratory alkalosis.,0
They expected that it would correct slowly on its own which it did over the course of two days.,0
The patient required a large amount of intraoperative fluids and by postoperative day one was positive 6.5 liters.,0
"On postoperative day two, the patient was extubated and had a blood gas of 7.3, 37, 120, 23, minus 2.",0
The patient was positive another 2.2 liters for that day.,0
The patient remained afebrile and the white count rose to 13.6.,0
A chest x-ray was obtained which showed bilateral pleural effusions with atelectasis.,0
"On postoperative day three, the nasogastric tube was removed and the patient was okayed for floor status.",1
Her white blood cell count dropped slightly to 12.9.,0
"Her last blood gas was 7.42, 35, 106, 23, zero, showing a resolution of her acid base.",0
"At this time, the patient was noted to be somewhat confused and an order was made to minimize the amount of morphine she received.",0
"Prior to this time, the patient had been sedated sufficiently to be unable to assess her mental status.",0
The patient ran a 95 cc surplus over the prior day leaving her positive approximately nine liters.,0
She was noted to have coarse breath sounds and aggressive pulmonary toilet was continued from previous days.,0
On postoperative day four at night the patient had a brief run of tachycardia.,0
The rhythm was a junctional rhythm and an EKG was obtained which was unchanged from previous electrocardiograms showing normal sinus rhythm.,0
The patient remained afebrile and heart rate was 72 and blood pressure 120/70.,0
"On examination, she was noted to have some moderate right quadrant tenderness with some slight distention.",0
Her lungs were clear and saturations were good at 96% on three liters of O2.,0
The patient nevertheless remained confused and she her morphine dose was decreased to 0.5 q. three hours p.r.n.,0
"On postoperative day five, the patient remained afebrile with good heart rate and blood pressure but her saturations dropped to 93% on three liters.",0
She was oriented times three and was noted to have crackles posteriorly.,0
The patient was therefore begun on her Lasix to help with diuresis and she appeared to be mobilizing fluids from the OR.,0
The patient's diet was advanced to sips which she tolerated well.,0
"A chest x-ray was also obtained which showed congestive heart failure with worsening effusions bilaterally; however, on the following day, postoperative day six, the patient was saturating at 94% on room air and her lung examination was clear in the posterior bases.",0
She continued to have mild abdominal tenderness but had had three bowel movements.,0
The patient was doing quite well.,0
She was starting to ambulate on her own.,0
"Later on, postoperative day six, while the patient was in the bathroom, she experienced a fall while being attended by three other people.",0
The patient fell backwards on her occiput on the bathroom floor.,0
"Following the fall, the patient's neurological examination was stable and she had no calvarial step-offs.",0
The patient was put on bed precautions and was only allowed out of bed under supervision.,0
The following morning a CT scan of the head was obtained which showed no acute bleeds and no midline shifts.,0
"On postoperative day seven, the patient continued to be poorly oriented as she was prior to her fall.",0
Her neurological examination was stable and her respiratory examination was noted for crackles in the posterior lung fields.,0
The patient continued on a clear liquid diet and had moderate distention.,0
"Later on postoperative day seven, the patient was advanced to a full liquid diet which she tolerated well.",0
"On postoperative day eight, a Foley catheter was replaced in order to get a better handle on the patient's intakes and outputs.",0
She continued to have crackles posteriorly and was moved to Lasix 40 mg p.o.,0
The patient's abdominal examination continued to be benign.,0
Her mental status was much improved.,0
"On postoperative day ten, the patient's mental status continued to clear.",1
"On postoperative day ten the patient's white blood cell count spiked to 14.7, but by postoperative day eleven, the white blood cell count was back down to 9.5.",0
The patient was placed on all of her home p.o.,0
She continued to receive metoprolol in its absence.,0
The patient's intravenous was Hep-locked.,0
Her abdominal examination continued to be benign and her Foley was taken out.,0
A chest x-ray showed a decrease in the size of the effusion.,0
The remainder of the hospital course is to be dictated at a later date.,0
MEDQUIST36 D: 21:07 T: 22:57 JOB#:,0
"4:52 AM CHEST (PORTABLE AP) Clip # Reason: r/o worsening consolidations, infiltrates, effusions Admitting Diagnosis: CHEST PAIN;TELEMETRY;SHORTNESS OF BREATH;ACUTE MENTAL STATUS CHANGES ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman admitted with neuroleptic malignant syndrome intubated for protection of airway with likely VAP.",1
"REASON FOR THIS EXAMINATION: r/o worsening consolidations, infiltrates, effusions ______________________________________________________________________________ FINAL REPORT HISTORY: Neuroleptic malignant syndrome, intubated for protection of airway, to evaluate worsening consolidation.",1
Endotracheal tube and nasogastric tubes remain in place.,0
The cardiac silhouette is again at the upper limits of normal or slightly enlarged.,0
Opacification at the left base with blunting of the costophrenic angle is again consistent with atelectasis and effusion.,0
The pulmonary vascularity appears within normal limits on the current study.,0
IMPRESSION: Little overall change except for improvement in pulmonary vascular status.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Sulfonamides Attending: Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo F with CAD, CHF, HTN, recent PE (), who presents from rehab with hypoxia and SOB despite Abx treatment for PNA x 3 days.",0
The patient was in rehab after being discharged from here for PE.,0
"She was scheduled to be discharged on ; on the day prior to discharge she deveoped fever, hypoxia, and SOB.",0
CXR showed b/t lower lobe infiltrates.,0
She was started on levoflox and ceftriaxone on .,0
When she became hypoxic on NC they brought her in to the ED.,0
"In the ED she was febrile to 102.7, P 109 BP 135/56 R 34 O2 90% on 3L.",0
"She was started on vanc and zosyn for broader coverage, tylenol, and 2L NS.",0
The patient reports having sweats and cough before admission.,0
She complains of SOB and some upper back pain.,0
"She denies chest pain, URI sx, nausea/vomiting, diarrhea, or dysuria.",0
"Of note she had had a rash and was given prednisone for 7 days, ending .",0
"The rash was speculated to be due to coumadin, but she was able to be continued on coumadin.",0
Past Medical History: CAD s/p stent in CHF HTN PE - pancreatic mass Depression--on fluoxetine Social History: The patient has been in rehab for the past month.,0
"She used to live alone, but has 2 grown daughters living nearby who are involved.",0
They are at the bedside and actively disagreeing about the patient's code status and what their mothers's goals of care are.,0
It is unclear if either are HCPs.,0
Family History: Doesn't know about siblings health.,0
Physical Exam: VS: T 99 BP 101/78 P 96 R 23 O2 96% on 100% NRB Gen: lying in bed in mild respiratory distress.,0
"MMM, OP clear Chest: bilateral crackles to mid-lung fields, clear anteriorly CV: RRR.",0
"nl s1/s2, no M/R/G Abd: + BS present; soft, ND/NT.",0
"guaiac positive stool in ED Ext: no c/c/e Neuro: A&O x 2. follow commands, MAE.",0
Pertinent Results: 06:26PM BLOOD WBC-9.6 RBC-3.33* Hgb-8.9* Hct-27.0* MCV-81* MCH-26.7* MCHC-32.9 RDW-14.4 Plt Ct-291 12:17AM BLOOD Hct-27.1* 06:26PM BLOOD Neuts-81.0* Lymphs-14.9* Monos-2.0 Eos-1.9 Baso-0.2 06:26PM BLOOD PT-21.7* PTT-45.7* INR(PT)-3.4 04:11AM BLOOD Plt Ct-273 06:26PM BLOOD Glucose-104 UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-18* AnGap-21* 04:11PM BLOOD Glucose-103 UreaN-22* Creat-1.1 Na-138 K-3.5 Cl-107 HCO3-17* AnGap-18 06:26PM BLOOD CK(CPK)-56 06:26PM BLOOD CK-MB-NotDone cTropnT-0.01 06:26PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 04:11PM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2 06:32PM BLOOD Lactate-3.8* 01:08AM BLOOD Lactate-1.1 01:16AM BLOOD K-3.5 .,0
PORTABLE AP CHEST RADIOGRAPH: The heart size and mediastinal contours are within normal limits.,0
No definite pleural effusions are seen.,0
"There is diffusely increased interstitial opacity disease, predominantly in the lower lung zones.",0
The osseous structures are stable.,0
A hiatal hernia is noted.,0
Tiny left pleural effusion is noted.,0
IMPRESSION: Diffusely increased interstitial opacities.,0
This appearance is consistent with pulmonary vascular congestion superimposed upon chronic interstitial changes.,0
"IMPRESSION: AP chest compared to and : Severe progressive interstitial abnormality accompanied by pulmonary and mediastinal vascular congestion is most likely edema, but severe interstitial pneumonia either infectious or drug related could simulate these findings.",1
"Brief Hospital Course: 82 yo F with CAD, CHF, HTN, recent PE (), who presents from rehab with PNA and hypoxia.",0
Chest x-ray revealed bilateral infiltrates.,0
Patient was started on Zosyn and vancomycin for pneumonia.,0
Her fluid status was closely monitored given her underlying CHF.,0
On admission her daughters were in disagreement over her code status and her original long standing DNR/DNI status was changed to allow for intubation if needed.,0
"However, when the patient's respiratory status continued to decline to the point of need for intubation, the patient refused intubation.",1
Her family was notified and agreed that their mother's wishes should be fulfilled.,0
She was started on IV morphine then converted to morphine drip on HD #3 for comfort and all other medications were discontinued.,0
Her family was at her bedside and their Rabbi was called.,0
She died on at 2:20 pm.,0
"An autopsy was offered, but the family declined.",0
Medications on Admission: ACETAMINOPHEN 1000 mg Q6 prn ALPRAZOLAM 0.25MG Qhs prn ASPIRIN 81 MG CA CARB.,0
500 mg PO BID FLUOXETINE 10 MG QHS FUROSEMIDE 40 mg QD IMDUR 30MG QD LIPITOR 40MG QD LISINOPRIL 10MG QD MECLIZINE HCL 12.5MG TID prn MULTIVITAMIN OMEPRAZOLE 20 mg QD WARFARIN Qhs dosed daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA MD,0
"5:45 AM CHEST (PORTABLE AP) Clip # Reason: Acute changes Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man intraventricular hemorrhage REASON FOR THIS EXAMINATION: Acute changes ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH: INDICATION: Intraventricular hemorrhage, evaluation for acute changes.",1
"Extensive bilateral parenchymal opacities, but no new opacities.",0
5:31 PM CHEST (PORTABLE AP) Clip # Reason: please eval for CHF and or infiltrate Admitting Diagnosis: VENTRICULAR TACHYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with recurrant VT REASON FOR THIS EXAMINATION: please eval for CHF and or infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Recurrent ventricular tachycardia.,0
"SINGLE VIEW CHEST, AP: There is cardiomegaly and unfolding of the aorta with wall calcifications.",0
"There are tiny, rounded nodular densities within bilateral lower lobes which likely represent nipple shadows.",0
There is a single-lead pacer in place with a lead overlying the expected location of the right ventricle.,0
There are no focal opacities.,0
There are prominent loops of bowel in the abdomen.,0
Rounded focal nodules at bilateral lung bases which likely represent nipple shadows.,0
Verification may be performed with repeat chest x-ray with nipple markers.,0
Clinical correlation is recommended and abdominal films if necessary.,0
Height: (in) 70 Weight (lb): 189 BSA (m2): 2.04 m2 BP (mm Hg): 170/105 HR (bpm): 96 Status: Inpatient Date/Time: at 09:30 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Overall left ventricular systolic function is low normal.,0
Quantitative biplane LVEF is 52%.,0
There is a small to moderate sized circumferential pericardial effusion without echocardiographic signs of tamponade.,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with low normal systolic function.,0
"Compared with the prior study (images reviewed) of , left ventricular systolic function is less vigorous and pulmonary artery systolic hypertension is now identified.",0
5:31 AM CHEST (PORTABLE AP) Clip # Reason: 55 year old man with MI; on balloon pump; new fever.,0
Please Admitting Diagnosis: STE MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with MI; on balloon pump; new fever.,1
REASON FOR THIS EXAMINATION: 55 year old man with MI; on balloon pump; new fever.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Fever in a patient after MI with intraaortic balloon.,0
The ET tube tip is 5.6 cm above the carina.,0
The intraaortic balloon tip is 3 cm below the superior margin of the aortic knob.,0
The pulmonary artery catheter inserted via the femoral approach terminates currently at the level of main pulmonary artery although its tip appears to be slightly kinked.,0
There is interval worsening in the left retrocardiac opacity consistent with interval worsening of atelectasis.,0
Underlying infection cannot be excluded.,0
Patient is continuing to be in mild pulmonary edema grossly unchanged since the previous study.,0
"3:04 PM CHEST (PA & LAT) Clip # Reason: rule out aspiration Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with Prader-Willi, DM, and new Right parietal stroke REASON FOR THIS EXAMINATION: rule out aspiration ______________________________________________________________________________ FINAL REPORT HISTORY: Stroke.",1
"CHEST, PA AND LATERAL: Comparison is made to the prior study obtained on , .",0
The hilar and the mediastinal contours appear unremarkable.,0
There is no pneumothorax or focal consolidation.,0
There are bilateral small pleural effusions noted.,0
IMPRESSION: 1) No evidence of acute pneumonia or CHF.,0
2) Bilateral small pleural effusions noted.,0
8:54 AM CT CHEST W/CONTRAST Clip # Reason: pneumonia v hemothorax v cancer?,0
CT with and without contras Admitting Diagnosis: HIP FRACTURE Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with L femur fracture after fall from chair REASON FOR THIS EXAMINATION: pneumonia v hemothorax v cancer?,1
"CT with and without contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CHEST CT INDICATION: 72-year-old man with left femur fracture and fall from chair, to rule out hemothorax versus pneumonia on the left side.",1
TECHNIQUE: Contrast enhanced CT of thorax was performed using standard department protocol.,0
Contiguous axial images at 5-mm and 1.25-mm slice thickness were reviewed concurrently with coronal and sagittal reformats.,0
No prior chest CT was available for comparison.,0
FINDINGS: LUNGS AND AIRWAYS: Airways are patent to the subsegmental bronchi.,0
There is low lung volume.,0
"On recent chest x-ray radiopacity seen in the left hemithorax which was concerning for hemothorax is largely attributed from the widened mediastinal shadow due to increased mediastinal, pericardial fat pad and cardiomegaly in conjunction with low lung volume.",0
There is no hemothorax/pleural effusion.,0
Assessment of lung parenchyma was suboptimal due to expiratory phase CT with motion artifacts.,0
"However, note is made of minimal amount of atelectasis in the bilateral lung bases, left side more than the right side.",0
Subpleural opacities are also seen along the anterior aspect on the right side and are likely due to the expiratory phase CT or les likely non specific interstitial changes.,0
MEDIASTINUM: The mediastinum is significantly wide due to moderate cardiomegaly and increased mediastinal and pericardial fat pad.,0
"There are no pathologically enlarged mediastinal, supraclavicular or axillary lymph nodes.",0
"ABDOMEN: The study is not tailored for evaluation of abdomen, however, limited views were unremarkable except for mild fatty changes in the liver.",0
BONES: Degenerative changes are seen at multiple vertebral levels.,0
There is no bone lesion suspicious for malignancy or infection.,0
There is no evidence of rib fracture on CT. (Over) 8:54 AM CT CHEST W/CONTRAST Clip # Reason: pneumonia v hemothorax v cancer?,1
CT with and without contras Admitting Diagnosis: HIP FRACTURE Contrast: OPTIRAY Amt: 75 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,0
There is no hemothorax or pleural effusion on the left side.,0
"Suboptimal evaluation of lung parenchyma due to low lung volumes, expiratory phase CT and motion artifacts.",0
Mild fatty infiltration of liver.,0
The findings were communicated with clinical team over phone on at 10:45 a.m.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGICAL HISTORY OF PRESENT ILLNESS: This 69 year-old gentleman with non-Hodgkin's lymphoma status post a bone marrow transplant with refractory thrombocytopenia is admitted with weakness and confusion.,1
He was recently discharged from the hospital with severe thrombocytopenia awaiting potential splenectomy.,0
He was found to have left hand weakness and noticed that he could not move his wrist and he was becoming more confused.,0
He was brought to the Emergency Room for evaluation.,0
PAST MEDICAL HISTORY: Non-Hodgkin's lymphoma treated with a bone marrow transplant in with recurrence status post chemotherapy.,1
"He also has chronic obstructive pulmonary disease, gastroesophageal reflux disease, clot in the inferior vena cava, glaucoma, chronic low platelets with past history of ITP and also of myelofibrosis.",1
"PHYSICAL EXAMINATION: He was awake, but drowsy and arousable.",0
There was gingival bleeding in the mouth.,0
On mental status he was oriented to self and to place.,0
There was decreased strength in his left upper extremity.,0
"ADMISSION LABORATORY: Hematocrit of 25.2, platelet count 51,000 after transfusion, which originally was 5000.",0
Chest x-ray showed no infiltrates.,0
HOSPITAL COURSE: The patient is admitted with decreased mental status and thought perhaps to have intracerebral bleed.,0
MRI showed some enhancement over the right side of the brain.,0
There was a question of carcinomatosis versus bleed.,0
"However, reread showed a probably small subarachnoid bleed.",0
The patient was treated conservatively and attempts were made to keep his platelets in a reasonable range.,0
He was admitted to the Intensive Care Unit.,0
He was followed by the stroke service and neurosurgery.,0
Over some length of time he began to improve from a neurological point of view.,0
He was placed on antibiotics.,0
"A lumbar puncture was performed and there was a question of meningitis for which he was treated with Acyclovir, Vanco, Clindamycin and Ceftriaxone.",0
There was no evidence of lymphoma on cerebral spinal fluid cytology.,0
Over some time he continued to improve.,0
"However, his platelet count still became a significant problem.",0
kept requiring large amounts of platelet products and had a gastrointestinal hemorrhage.,0
Consultation was then obtained again with the surgical service about the long term goals.,0
"A very long conversation was again had with the patient and his family about options and it was thought that perhaps the only way for the patient to have a reasonable life was to have a splenectomy, which may decrease the patient's requirement for platelet transfusion.",0
It was known that this was a high risk procedure.,0
"Therefore on the patient underwent a splenectomy, which was uncomplicated.",0
The spleen was somewhat large.,0
"Postoperatively, the patient initially did reasonably well requiring continued platelet transfusions though at a much lesser rate.",0
"However, over his Intensive Care Unit stay he had more difficulty with respiration and required reintubation for a pneumonia.",0
He also then had a higher requirements for platelets and red cells.,0
"There is no evidence of active bleeding, but the patient continued to have severe consumption of his platelets and probably no platelet production.",0
He was continued to be followed by the hematology/oncology service as well.,0
"He then had severe deterioration of his respiratory function with developing ARDS, increasing respiratory acidosis and dead space.",0
Because of his extremely poor prognosis and the fact that the splenectomy did not improve his platelet problem as well as severe respiratory failure it was thought that further measures were to attempt to improve the situation were futile.,1
"Discussion was had with the family, Dr. and Dr. in attendance.",0
"The decision was made to withdraw care, which was done and the patient expired.",0
Non-Hodgkin's lymphoma status post chemotherapy and bone marrow transplant.,1
Ventilator associated pneumonia with respiratory failure.,1
Dictated By: MEDQUIST36 D: 12:16 T: 14:37 JOB#:,0
"3:05 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for ETT placement and sources of respiratory Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC REGURGITATION ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with severe AI, diastolic CHF, airway edema and ?pneumonia admitted with respiratory failure, intubated.",1
"REASON FOR THIS EXAMINATION: Please evaluate for ETT placement and sources of respiratory failure (edema, infiltrate).",1
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST No prior radiographs.,0
Endotracheal tube is in standard position terminating about 4 cm above the carina.,0
Nasogastric tube terminates within the stomach.,0
The side port is proximal to GE junction and could be advanced several centimeters for standard positioning.,0
"Bibasilar areas of opacity are present, patchy on the right and more confluent on the left, as well as a small-to-moderate left pleural effusion.",0
"The lung abnormalities could be due to aspiration, infectious pneumonia, and/or atelectasis.",0
Position of nasogastric tube has been communicated by phone to Dr. on .,0
5:57 PM BABYGRAM (CHEST ONLY) Clip # Reason: ?,0
"ETT position, evaluate heart and lungs ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 31 weeks gestation; RDS REASON FOR THIS EXAMINATION: ?",0
ETT position evaluate heart and lungs ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST: CLINICAL HISTORY: 31 week infant with respiratory distress.,1
Endotracheal tube present with its tip overlying T3 vertebral body.,0
The lungs show a pattern of mild diffuse hazy opacification with scattered air bronchograms in right lower lobe.,0
These changes are consistent with surfactant deficiency.,0
No focal areas of atelectasis or pneumothorax are identified.,0
"12:54 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: LFTs rising, ?",0
"gall bladder pathology Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with pancreatitis, no Hx gall stones, c/b ARDS, , abdominal compartment syndrome, now with rising LFTs REASON FOR THIS EXAMINATION: LFTs rising, ?",1
"gall bladder pathology ______________________________________________________________________________ WET READ: JBRe SAT 6:01 PM Sludge, but no gallstones.",0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 69-year-old man with pancreatitis.,0
Please assess for gallbladder pathology.,0
TECHNIQUE: Grayscale and color ultrasound images of the liver and gallbladder were obtained.,0
FINDINGS: There are no focal hepatic lesions.,0
The portal vein is patent with normal hepatopetal flow.,0
There is no intra- or extra-hepatic biliary dilatation with the common bile duct measuring 2 mm.,0
"Sludge is seen in the gallbladder, but no evidence of stones.",0
"The pancreas is only partially visualized due to overlying bowel gas, but appears normal.",0
The spleen is normal measuring 11 cm.,0
"IMPRESSION: Sludge, but no stones are seen in the gallbladder.",0
PATIENT/TEST INFORMATION: Indication: S/P Pericardial tap of 600 cc.,0
Height: (in) 60 Weight (lb): 139 BSA (m2): 1.60 m2 BP (mm Hg): 137/93 HR (bpm): 109 Status: Inpatient Date/Time: at 17:19 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum.,0
Conclusions: The left ventricular cavity size is normal.,0
There is a very small somewhat echo dense region around the heart consistent with small residual organized pericardial effusion/pericardial thickening.,0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion/Tamponade Admitting Diagnosis: MR\MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with MR s/p MVR.,1
"Pt still in CSRU, please perform when in CSRU.",0
"REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade ______________________________________________________________________________ FINAL REPORT PORTABLE SUPINE CHEST RADIOGRAPH INDICATION: 46-year-old male with mitral regurgitation, status post MVR.",0
FINDINGS: The patient is status post median sternotomy and mitral valve replacement.,1
Endotracheal tube and Swan-Ganz catheter are in standard position.,0
Nasogastric tube terminates with its tip in the stomach.,0
A single left-sided chest tube is in place.,0
There is probably a small layering left-sided effusion.,0
The lungs are generally clear and fully expanded.,0
Note is made of bilateral cervical ribs.,0
Status post postoperative placement of multiple lines and tubes in standard position.,0
Probable small layering left pleural effusion.,0
"3:33 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: GI is asking for CTA of abdomen, w/o PO contrast to evaluate Admitting Diagnosis: LOWER GI BLEED Contrast: OMNIPAQUE Amt: 150 ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: Coinciding with collateral circulation is a chronic-appearing occlusion of the superior mesenteric vein (4b:255) with collateral venous drainage pathways associated with unusual varices seen in the hepatic hilum and along the proximal jejunum in the right upper quadrant.",1
This appearance is stable since the prior examination from .,0
Dr. discussed the contents of this addendum with Dr. at 8:30 a.m. on .,0
"3:33 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: GI is asking for CTA of abdomen, w/o PO contrast to evaluate Admitting Diagnosis: LOWER GI BLEED Contrast: OMNIPAQUE Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with abdominal pain and GI bleed REASON FOR THIS EXAMINATION: GI is asking for CTA of abdomen, w/o PO contrast to evaluate for bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: SJBj SAT 6:40 PM No evidence of active GI bleed.",0
"Extensive dystrophic abdominal calcifications, likely from prior trauma and surgery.",0
"Matted small bowel loops abut the anterior abdominal wall, suggestive of adhesions.",0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 49-year-old man with abdominal pain and GI bleed.,0
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis in multiple phases after the administration of intravenous contrast.,0
"FINDINGS: The visualized lung bases are free of nodules, consolidations or effusions.",0
The liver enhances homogeneously and no focal lesions are identified.,0
The portal and hepatic veins are patent.,0
Several gallstones are seen in the gallbladder.,0
"The pancreas, spleen, and adrenal glands are normal.",0
A 15 mm hyperdense lesion in the upper pole of the right kidney shows no definite enhancement and suggests a proteinaceous or hemorrhagic cyst is identified in the upper pole of the right kidney.,0
"Several other hypodensities are too small to characterize, but are most likely cysts.",0
"In addition, there is an isoattenuating nodular focus along the left lower pole, similar to background renal tissue on all three series and measuring 10 mm in diameter, but still potentially a small solid renal tumor.",0
No mesenteric or retroperitoneal adenopathy is present.,0
Scattered mesenteric nodes do not meet pathologic criteria for enlargement.,0
"The stomach, small and large bowel have normal caliber.",0
No active bowel extravasation is identified.,0
Several loops of bowel appear adherent to the anterior abdominal wall.,0
"The patient is status post small bowel resection with an apparent duodenal jejunal anastomosis with prominent mesenteric varices, although without suggestion of active bleeding.",0
"There is possibly a prior partial ileocolectomy as well, but the post-operative anatomy is not entirely delineated.",0
"(Over) 3:33 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: GI is asking for CTA of abdomen, w/o PO contrast to evaluate Admitting Diagnosis: LOWER GI BLEED Contrast: OMNIPAQUE Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) Extensive dystrophic calcification originates from the xiphoid process and costo chondral margin and interdigitates into the mesentery.",0
This finding is unchanged since at least .,0
PELVIS: Remainder of the bowel is of normal caliber.,0
The bladder and prostate are normal.,0
There is no free pelvic fluid.,0
There is no pelvic or inguinal adenopathy.,0
A stable cluster of lucencies is seen in left femoral metaphysis without evidence of associated cortical erosion or expansion; this appearance may be associated with fibrous dysplasia and appears benign.,0
No evidence of active gastrointestinal hemorrhage.,0
There are some unusual varices about the proximal jejunum shortly beyond what appears to represent a duodenal jejunal anastomotic site although without suggestion of active bleeding.,0
"Exophytic nodule (10 mm) along the lower pole of the left kidney, not significantly changed; it may represent an unusual lobulation but a small solid tumor such as renal cell carcinoma is a differential consideration.",1
Follow-up MR evaluation is suggested when clinically appropriate to evaluate further.,0
"At that time, a probably hemorrhagic or proteinaceous cyst in the right upper pole could also be reassessed.",0
The final report including recommendations was discussed with Dr. at 4:30 pm on by telephone.,0
10:25 AM UNILAT UP EXT VEINS US Clip # Reason: Rule out DVT Admitting Diagnosis: THORACIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman s/p TEVAR with LUE swelling REASON FOR THIS EXAMINATION: Rule out DVT ______________________________________________________________________________ FINAL REPORT STUDY: Left upper extremity duplex son.,0
"INDICATION: 76-year-old female, status post endovascular surgery with left upper extremity swelling.",0
"FINDINGS: There is normal flow, compression, and augmentation within the deep veins of the left upper extremity.",0
There is normal flow within the left cephalic and basilic veins as well.,0
IMPRESSION: Negative study for deep vein thrombosis within the left upper extremity.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: right internal jugular central venous catheterization left femoral arterial catheterization History of Present Illness: 38 yo M with history of HCV and heroin abuse, who collapsed after snorting heroin.",1
"His friends, who were also using drugs, hit him in an attempt to awaken him.",0
"They called EMS, who reportedly arrived after 5 minutes.",0
He was reportedly initially not in a shockable rhythm and received 20 minutes of CPR.,0
"During CPR, he received epinephrine 4 mg, narcan 4 mg, and 40 units of vasopression.",0
He was intubated by EMS.,0
"He was initially brought to Hospital, where he was found to be in Vfib and regained spontaneous circulation with 1 shock.",0
"Urine tox was positive for benzos, opioids, ethanol, marijuana.",0
"In the ED at , initial vital signs were T 32C HR 69 BP 127/66 RR 20 Sat 99%.",0
"He had no gag reflex, no reponse to painful stimuli, pupils fixed 6 mm.",0
He did overbreath the vent.,0
"He was taken for CT, which showed extensive cerebral edema with herniation, consistent with global hypoxic injury.",1
"After CT, he became hypertensive to 230s/140s, and there was concern for further herniation, but this was later felt to be secondary to asynchrony.",0
"The patient was given vecuronium and propofol and started on a propofol gtt, with normalization of his blood pressure.",0
The patient was also given mannitol 25 gm IV x 2.,0
A right IJ CVL was placed in the ED.,0
A left femoral A-line was placed due to difficulty placing a radial A-line.,0
The patient was noted to have copious urine and stool output.,0
"Neurosurgery was consulted in the ED, and communicated that due to the patient's extemely poor prognosis, there was no indication for intracranial pressure monitoring.",0
Vitals at the time of transfer to were HR 105 SBP 140s.,0
"On arrival to the MICU, the patient was unresponsive and unable to give a history.",0
ROS: unobtainable Past Medical History: Past Medical History ( Hospital ED records): hepatitis C h/o shoulder separation adjustment reaction with anxiety and depression .,1
Past Surgical History ( Hospital ED records) hernia repair laproscopic cholecystectomy Social History: Notable for drug use.,0
"Has a half-brother , who lives in , an a half-sister .",0
Family History: non-contributory Physical Exam: VS: HR 111 BP 124/78 Sat 95% GEN: Unresponsive.,0
HEENT: Pupils 6 mm and fixed.,0
"RESP: CTA b/l CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, copious stool output EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: Unresponsive to voice, sternal rub, or painful stimuli.",0
Pupils 6 mm and non-reactive.,0
Pertinent Results: 05:00PM BLOOD WBC-23.0* RBC-4.37* Hgb-13.8* Hct-42.0 MCV-96 MCH-31.5 MCHC-32.8 RDW-12.9 Plt Ct-186 07:17PM BLOOD PT-14.3* PTT-45.4* INR(PT)-1.2* 12:44AM BLOOD Glucose-43* UreaN-25* Creat-1.5* Na-142 K-4.2 Cl-123* HCO3-11* AnGap-12 09:51PM BLOOD Glucose-96 UreaN-22* Creat-1.3* Na-139 K-6.4* Cl-116* HCO3-13* AnGap-16 05:00PM BLOOD ALT-379* AST-453* 05:00PM BLOOD Lipase-85* 05:00PM BLOOD cTropnT-<0.01 05:00PM BLOOD CK-MB-5 05:00PM BLOOD Calcium-7.1* Phos-8.9* Mg-2.5 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG .,0
"Micro: 5:00 pm BLOOD CULTURE (resulted reported as positive after patient's death) Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI).",0
Anaerobic Bottle Gram Stain (Final ): GRAM POSITIVE COCCI IN PAIRS AND CHAINS.,0
CT head w/o contrast : 1.,0
Global cerebral edema and effacement of sulci consistent with global anoxic injury.,1
Early downward transtentorial herniation secondary to cerebral edema.,1
Findings discussed with the emergency room and the ICU team.,0
CXR (portable AP) : Limited study as above.,0
Question possible infiltrate at the right lung base versus atelectasis.,0
Endotracheal tube and nasogastric tube both in satisfactory position.,0
"Brief Hospital Course: 38 yo M admitted to MICU s/p cardiac arrest in setting of drug abuse, with head CT indicating anoxic brain injury and cerebral edema, with signs of early hearniation.",1
# Anoxic brain injury: Head CT showed anoxic brain injury with cerebral edema and early herniation.,1
"Neurosurgery was consulted in the emergency department and stated that the prognosis was very poor, with recovery highly unlikely.",0
"For this reason, neurosurgery recommended against any neurosurgical intervention.",0
This prognosis was discussed with the patient's half brother and half sister by the MICU team.,0
# s/p cardiac arrest: The patient was started on an Arctic Sun cooling protocol.,1
"However, after a family meeting in the MICU, during which the patient's very poor neurologic prognosis was explained, the family decided that it would be most consistent with goals of care for the patient to be made comfort measures only.",0
"At this point, the cooling protocol was stopped.",0
# Hypotension: The patient developed hypotension which was treated with phenylephrine and IV fluids.,0
"# Hyperkalemia: The patient had hyperkalemia to 6.4, which was treated with calcium, insulin, and dextrose, with improvement in the patient's potassium to 4.2. .",0
# Heroin overdose: Narcan given prior to admission.,0
"# Goals of care: The MICU team met with the patient's half brother , as well as wife.",0
The MICU team also spoke with the paient's half sister via telephone.,0
"and explained that the patient's parents were deceased and that the patient had no children, was never married, had no other siblings or half siblings, and had no other relatives.",0
They also explained that the patient had never selected a healthcare proxy.,0
"Therefore, and were determined to be the patient's next of .",0
"During extensive conversations, during which the patient's prognosis was discussed, and explained that the patient would not want to be kept alive on life support unless there were a reasonably good chance that he would have the ability to function and live independently.",0
"The MICU team explained that given the patient's anoxic injury and cerebral edema, such a recovery was extremely unlikely.",1
"and decided that it would be most consistent with the patient's wishes to be made comfort measures only, without any further life-sustaining therapy.",0
"The patient's vasopressors were stopped, and he was subsequently extubated.",0
He died peacefully and was pronounced dead at 3:04 a.m. on .,0
"The medical examiner was , and given the circumstances of the patient's cardiac arrest, the case was accepted for review.",1
Medications on Admission: unknown Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: 1. heroin overdose 2. cardiac arrest 3. hyperkalemia Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a,1
"2:01 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ETT tube moved; assess placement Admitting Diagnosis: FEVER-MANTLE CELL LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with mantle cell lymphoma s/p auto transplant, here with cough, fever, hypoxia now intubated REASON FOR THIS EXAMINATION: ETT tube moved; assess placement ______________________________________________________________________________ FINAL REPORT INDICATION: Mantle cell lymphoma, status post transplant with fever, cough.",0
COMPARISON: Chest x-ray obtained earlier on the same day.,0
FINDINGS: The endotracheal tube and left subclavian central venous catheter in stable position.,0
The NG tube has been withdrawn slightly now terminating just above the level of the gastroesophageal junction.,0
There has been gradual improvement in extensive areas of consolidation most pronounced in the right lung.,0
IMPRESSION: 1) Gradually improving right lower lobe opacity which again could represent infection though pulmonary edema remains a differential.,0
2) NG tube should be advanced further to terminate in the stomach.,0
"2:37 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: post pyloric placement of dobhoff Admitting Diagnosis: FTT Contrast: OPTIRAY Amt: 10 ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with multiple liver lacs s/p MVC in c/b infection, now s/p ERCP c/b severe post-ERCP pancreatitis REASON FOR THIS EXAMINATION: post pyloric placement of dobhoff ______________________________________________________________________________ FINAL REPORT INDICATION: 43-year-old male SICU patient requiring post-pyloric advancement of feeding tube.",1
FINDINGS: The existing Dobbhoff tube was seen in the appropriate position with the tip in the stomach.,0
The left naris was anesthetized with lidocaine jelly.,0
"Under fluoroscopic guidance, the Dobbhoff tube was advanced until the tip was in the second part of the duodenum.",0
Tube position was confirmed with a 10 mL injection of Optiray contrast.,0
There were no immediate post-procedure complications.,0
Final fluoroscopic spot images demonstrated post-pyloric feeding tube in the second portion of the duodenum.,0
IMPRESSION: Successful re-positioning of the Dobbhoff tube into the post-pyloric position.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Tape Attending: Chief Complaint: cc: Respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This 70 year old female with a history of COPD with trach, HTN, and CAD was transfered from with difficulty breathing/broncospasm.",1
"She was noted to have elevated PIP (40s), HR 110-120, BP 166/73, given Lasix/Morphine for presumed COPD exacerbation and transfered to .",0
Here she was treated with Albuterol/Atrovent nebs and IV Solumedrol.,0
She had been initially admitted to on after transfer from for failure to wean.,0
She had a tracheostomy and G-tube placement.,0
"Her course was complicated by MAT, steroid induced hyperglycemia, bronchitis, and c.diff colitis.",0
Pt has had COPD for 10 to 15 years.,0
She has required multiple intubation inthe last 5 years.,0
"Osteopenia Social History: Pt is married and lives with her husband, she comes from at this time.",0
He is her primary care giver.,0
They have seven children who are very involved.,0
She quit smoking 20 years ago after smoking 1 PPD for many years.,0
Family History: father had a CVA at age 38.,0
Her mother died from complications of ovarian cancer.,0
"Physical Exam: VS General alert, responsive trached patient in NAD HEENT Pupils unequal, reactive Pertinent Results: 11:00PM BLOOD WBC-18.8*# RBC-3.19* Hgb-10.0* Hct-29.1* MCV-91 MCH-31.4 MCHC-34.4 RDW-14.7 Plt Ct-307# 11:00PM BLOOD Neuts-89.5* Lymphs-7.1* Monos-2.8 Eos-0.3 Baso-0.2 11:00PM BLOOD PT-11.8 PTT-28.3 INR(PT)-0.9 11:00PM BLOOD Plt Ct-307# 04:46AM BLOOD Fibrino-269 11:00PM BLOOD Glucose-129* UreaN-33* Creat-1.0 Na-129* K-5.3* Cl-90* HCO3-29 AnGap-15 11:00PM BLOOD ALT-17 AST-18 LD(LDH)-285* CK(CPK)-29 AlkPhos-69 Amylase-38 TotBili-0.4 11:00PM BLOOD Lipase-27 08:08AM BLOOD CK-MB-2 cTropnT-0.01 proBNP-9437* 11:00PM BLOOD Albumin-3.4 Calcium-8.7 Phos-6.0*# Mg-1.7 04:46AM BLOOD calTIBC-192* VitB12-667 Folate-15.4 Ferritn-854* TRF-148* 05:18PM BLOOD Vanco-55.7* 10:53PM BLOOD Type-ART pO2-472* pCO2-62* pH-7.31* calHCO3-33* Base XS-3 10:53PM BLOOD Glucose-140* Lactate-1.0 Na-127* K-5.6* Cl-91* 10:13AM BLOOD TRYPTASE-Test Brief Hospital Course: 1.",0
Respiratory failure - This 70 year old female with severe COPD s/p trach was transfered from Rehab with respiratory failure most likely secondary to COPD exacerbation.,1
Her respiratory failure was felt to be most likely bronchospastic secondary to severe COPD and superimposed infection.,1
She might also have some component of fluid overload.,0
She was started on broad spectrum antibiotics given high risk since she was coming from a nursing home.,0
She was started on Vancomycin for possible MRSA and Zosyn for broad coverage including Pseudomonas.,0
On she grew Stenotrophomonas in her sputum and Timentin was added for coverage.,0
"On the Zosyn was discontinued, the Vanco was discontinued once a 14 day course was complete.",0
The Timentin was continued for a 5 day course.,0
Throughout her hospital stay attempts were made to wean her off the ventilator.,0
She was able to tolerate pressure support however every occasion when the PEEP was decreased below 8 she had episodes of desaturation and respiratory difficulty.,0
On a bronchoscopy was performed on which she was noted to have posterior membrane collapse on exalation with agitation.,0
Numerous further attempts to wean her off the ventilator were unsuccessful.,0
She was continued on steroids and nebs as treatment for her COPD.,0
In addition she was treated briefly with IV Aminophyline which she tolerated without complication.,0
Based upon this she was started on PO Theophyline which was titrated up to obtain levels between 8 and 12.,0
She was also diuresed aggressively for possible fluid overload as a cause of increased respiratory failure.,1
On she began to have copious bloody secretions per her trachostomy.,0
These were initially felt to be due to trauma and it they were monitored.,0
These bloody secretions continued for several days and repeat CXR showed increased nodular densities.,0
Given concern for vasculitis vs. trauma vs. other cause of hemoptysis.,0
"On a bronchoscopy was performed which showed diffuse oozing blood in all airways, no focal bleeding source.",0
Otherwise the airways were normal and BAL was performed.,0
A chest CT was also performed which showed bilateral upper love consolidation with nodular opacification.,0
She was briefly treated with Voriconazole and cyclophosphamide with concern for fungal infection vs. vasculitis.,0
These were d/cd given low clinical suspicion as well as a normal ESR and CRP.,0
It was felt that the most likely cause of bleeding was still trauma for suctioning and the frequency of suctioning was decreased.,0
"Pt continued to be intubated, in discussion with family, her code status was changed to comfort measures only and she was started on a morphine drip.",0
Pt died on from respiratory failure.,1
Hypotension - She had some hypotension post diuresis which resolved with fluid.,0
She had no further hypotension on admission.,0
Her blood pressure was monitored closely.,0
"Throughout admission she had episodes of tachycardia, diaphoresis, hypertension, and hypoxia.",0
These episodes were felt to be due to agitation.,0
However other possible causes were ruled out.,0
A Triptase was normal indicating no allergic reaction.,0
Her pain was controlled with morphine.,0
Psychiatry was involved in controlling her agitation.,0
They felt that she might have some level of delerium and held all benzos.,0
"In addition she was weaned off her Paxil, however she seemed more depressed and it was restarted.",0
She was treated with Haldol as needed for agitation.,0
She was continued on calcium channel blockers for tachycardia.,0
- Urine Metanephrines pending to evaluate for pheo.,0
5HIAA pending to evaluate for carcinoid.,0
C.diff - On admission she had just completed a course of PO Vanco for C.diff.,0
A repeat sample was sent for c.diff assay which was negative.,0
"She was monitored for diarrhea given the inititation of antibiotics, and had no further diarrhea.",0
Klebsiella UTI (based on cultures from - ).,0
She was treated with Zosyn on admission which covered the Klebsiella UTI.,0
Repeat urine cultures here were negative.,0
She had some Hyponatremia on admission which resolved with NS IV fluid.,0
CAD/HTN - She was continued on Diltiazem for a.fib and BP control.,0
Her Captopril was D/Cd on admission given hypotension.,0
Her HCT dropped at which time she was noted to have some guiaic positive stool.,0
She will need colonoscopy/EGD once active issues resolved.,0
Her HCT was also noted to be dropping at the time of the bloody hemoptysis.,0
Her HCTs were checked and she was transfused to keep her HCT greater than 30. .,0
Access - On this admission a second PICC line was placed as her single lumen PICC on the left was inadequate for IV antibiotics and her multiple other IV medications.,0
FEN - She was continued on tube feeds via her g-tube on this admission.,0
Her lytes were repleted as needed.,0
PPx - She was treated with Heparin SC for DVT prophylaxis.,0
She was also treated with a PPI.,0
Social work and Case Management were involved in her care and further dispo.,0
"Rt LE swelling - LENIs were performed for some LE swelling, they were negative for DVT.",0
"Medications on Admission: Seroquel, Zanax, Pulmicort, Oscal, Capoten, Cardizem, , Heparin SC, Atrovent, Prevacid, Xopenex, Mg Oxide, Vit D, RISS, Reglan, MVI, Paxil, Simethicone, Cefotaxime, Vanco PO (just completed course) Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a MD Completed by:",1
1:39 PM CT HEAD W/O CONTRAST Clip # Reason: post op tumor resection Admitting Diagnosis: LEFT FRONTAL MENINGIOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with post op tumor resection REASON FOR THIS EXAMINATION: post op tumor resection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HEAD CT INDICATION: Evaluation of postoperative resection of brain tumor.,0
TECHNIQUE: Contiguous axial images were obtained through the brain without administration of IV contrast.,0
COMPARISON: CT head without contrast performed .,0
FINDINGS: There is no evidence of hemorrhage.,0
There is extensive edema present similar in comparison to the comparison study performed in of .,0
A noncontrast CT scan cannot say anything meaningful about the extent of the resection.,0
"There is intracranial air located in the left frontal region, which is expected postoperatively.",0
There is no evidence of any new abnormalities.,0
IMPRESSION: Status post resection of recurrent brain tumor with expected postoperative changes.,0
"4:30 AM CHEST (PORTABLE AP) Clip # Reason: interval assesment Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: year old woman with respiratory distress and copd on BiPAP REASON FOR THIS EXAMINATION: interval assesment ______________________________________________________________________________ FINAL REPORT HISTORY: Respiratory distress and COPD, to evaluate for change.",0
Persistent bibasilar opacification consistent with pleural effusion and atelectasis.,0
There still appears to be some fullness of pulmonary vessels consistent with overhydration.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Bilateral shoulder pain Major Surgical or Invasive Procedure: Cardiac History of Present Illness: The patient reports that for the last two weeks she has been experiencing shoulder pain.,1
The pain started in her left shoulder and then migrated to her right shoulder.,0
"Within a week, both shoulder and her neck were in pain.",0
"She reported to her PCP, an EKG was evidently normal.",0
She was diagnosed with arthritis.,0
"The patient, however, continued to have increasing pain in her shoulders that radiated down to her fingers.",0
Soon it was accompanied by a feeling of tightness in her throat.,0
"Over the last weekend, the patient further experienced some diaphoresis.",0
She also had some difficulty in breathing.,0
The pain finally moved the patient to go to the ED.,0
"On Monday in the emergency room, the patient had a CPK of 334, CK-MB of 10.9, troponin 2.61.",0
"The patient was started on ASA, SL nitroglycerin, and heparin.",0
Her EKG showed significant ST depression in her inferior and lateral leads.,0
"The patient was then placed on Plavix, nitro drip, statin, and heparin drip before transfer to tomorrow.",0
"On review of systems, the patient denies any change of vision, sinus congestion, dysphagia, cough, palpitations, chest pain, nausea, vomiting, constipation, diarrhea, dysuria.",0
She says she regularly has headaches (migraines) and has always bruised easily.,0
"Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, and palpitations.",0
CARDIAC RISK FACTORS: Hypertension 2.,0
"OTHER PAST MEDICAL HISTORY: - Hypertension - Pre-eclampsia during both pregnancies - Anxiety - Depression - Migraines Social History: -Tobacco history: 20 years' smoking history; pack a day -ETOH: No -Illicit drugs: No The patient is currently unemployed, caring for 6yo and 4yo children Family History: Father had CABG x 6 in his 50s; alive in his 60s.",1
Mother has history of strokes and hypertension.,1
Physical Exam: PHYSICAL EXAMINATION: GENERAL: Obese woman in NAD.,0
"NECK: Supple, no cervical LAD.",0
LUNGS: No accessory muscle use.,0
"CTA bilaterally ABDOMEN: Soft, NTND, bowel sounds positive.",0
"EXTREMITIES: No cyanosis, clubbing, edema.",0
PULSES: Radial/pedal pulses 2+ Pertinent Results: Cardiac biomarkers: 12:00AM BLOOD CK-MB-19* MB Indx-9.1* cTropnT-0.91* 05:23AM BLOOD CK-MB-15* MB Indx-8.9* cTropnT-1.25* 03:48PM BLOOD CK-MB-11* MB Indx-7.4* 05:19AM BLOOD CK-MB-11* MB Indx-7.2* Admission labs: 12:00AM BLOOD Calcium-9.2 Phos-2.0* Mg-1.6 05:23AM BLOOD ALT-20 AST-39 LD(LDH)-271* CK(CPK)-168 AlkPhos-69 TotBili-0.3 12:00AM BLOOD Glucose-169* UreaN-12 Creat-0.7 Na-138 K-3.6 Cl-106 HCO3-25 AnGap-11 12:00AM BLOOD WBC-10.0 RBC-3.97* Hgb-12.6 Hct-35.3* MCV-89 MCH-31.9 MCHC-35.8* RDW-13.5 Plt Ct-223 Discharge labs: 05:23AM BLOOD WBC-9.8 RBC-3.98* Hgb-12.6 Hct-35.5* MCV-89 MCH-31.7 MCHC-35.5* RDW-13.3 Plt Ct-201 05:19AM BLOOD UreaN-14 Creat-0.8 Na-137 K-4.0 Cl-106 05:19AM BLOOD CK(CPK)-152 Cardiac 1.,0
Coronary angiography in this left-dominant system demonstrated two-vessel disease.,1
The LMCA had no angiographically apparent disease.,0
The LAD had a 60% ostial stenosis.,0
The LCx had a distal hazy 80% stenosis.,0
The RCA was non-dominant and had mild diffuse disease.,0
"Brief Hospital Course: # CORONARIES: NSTEMI, showing in inferior and lateral leads.",0
The patient underwent cardiac catherization.,0
"Her catherization showed LAD 60% obstruction at origin, LCX distal 80% onstruction, RCA non-dominant w/ diffuse disease.",0
A drug-eluting stent was placed in LCX.,0
Recommendations included that the patient undergo an exercise stress test to assess LAD in about a month.,0
"If the stress test should show anterior ischemia, the patient will likely need LIMA to LAD.",0
She tolerated the procedure well and had no signs of hematoma at her radial site of entry.,0
"The patient should continue aspirin, plavix, statin, lisinopril and metoprolol.",0
She should follow up with Cardiology in one month.,0
The patient was counseled on smoking cessation and reports that she is not experiencing any withdrawal symptoms.,0
She did not require nicotine replacement during her hospitalization.,0
The patient was also informed about the importance of follow up and of continuing on her medications.,0
"# PUMP: Echo from shows inferior wall hypokinesis, LVEF 50%.",0
# RHYTHM: Patient was in normal sinus rhythm for the duration of her stay in the unit.,0
"# HYPERTENSION: The patient's blood pressure was well controlled on metoprolol and lisinopril, which she should continue.",0
# DEPRESSION/ANXIETY: Continued the patient's home doses of Wellbutrin and Remeron.,0
Medications on Admission: - HCTZ 25mg PO QD - Mirtazapine 45mg QHS - Trazodone 100mg QHS - Wellbutrin 150mg - Cyclobenzaprine 5 mg TID Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily).,0
Disp:*14 Patch 24 hr(s)* Refills:*2* 6. mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).,0
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Disp:*60 Tablet(s)* Refills:*2* 8. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day).,0
9. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia.,0
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Non ST elevation myocardial infarction Secondary Diagnoses: Hypertension Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted for shoulder and arm pain.,0
"An electrocradiogram (EKG) and blood tests revealed that you had a heart attack, a blockage of one of the arteries in your heart.",0
You had a coronary and a stent was placed in your heart.,1
You were also treated with medications.,0
It is extremely important that you take the medications that you started in the hospital.,0
"Please start taking: PLAVIX (clopidogrel) 75mg tablet, take one daily LIPITOR (atorvastatin) 80mg tablet, take one daily Metoprolol 25mg tablet, take one twice daily Lisinopril 10mg, take one tablet daily Aspirin 325mg, take one tablet daily Please continue all other medications as you were before.",0
It is very important that you take plavix (clopidogrel) after having a stent.,0
DO NOT STOP taking plavix without talking to your cardiologist.,0
We have provided your with a prescription for a nicotine patch.,0
Followup Instructions: Please follow up with the following appointments: PCP: .,0
"Date/Time: , 10:00 am Telephone: Cardiology: , MD Phone: Date/Time: 11:20",0
"8:13 PM CHEST (PA & LAT) Clip # Reason: ?cerebral edema ?pneumonia ______________________________________________________________________________ MEDICAL CONDITION: History: 76M with altered mental status w/ hypernatremia REASON FOR THIS EXAMINATION: ?cerebral edema ?pneumonia No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CHEST, TWO VIEWS: HISTORY: 76-year-old male with altered mental status and hypernatremia.",1
FINDINGS: Frontal and lateral views of the chest.,0
The lungs are clear of focal consolidation.,0
Hypertrophic changes are seen in the thoracic spine.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: Neonatology HISTORY: Baby was born by cesarean section for frank breech presentation to a 35-year-old gravida 1, para 0 now 1 woman.",1
"Mother's blood type is A negative, antibody positive for anti-RH IG, RPR nonreactive, hepatitis surface antigen negative, rubella immune, and group B Strep unknown.",0
"This pregnancy was complicated by fetal ultrasound findings of bilateral fetal hydronephrosis, question of a small oomphalocoele, mild micrognathia, and a concern for coarctation of the aorta by antenatal US.",0
The arch was found to be normal on fetal echocardio.,0
"The prenatal evaluation was extensive on fetaldiology, Urolgram by Dr of CArdiologyogy, Genetics, and Surgery.",0
The mother's medications during pregnancy were Tapazole 5 mg each day for hyperthyroidism due to Grave's disease.,0
There were no sepsis risk factors intrapartum.,0
"At the time of delivery, the infant was noted to have a small amount of a question of hematoma or of bowel in the umbilical cord.",0
He initially went to the Newborn Nursery.,0
The infant was admitted to the Newborn ICU on day of life #1 after a renal ultrasound showed a significantly distended bladder and hydronephrosis.,0
"ADMISSION PHYSICAL EXAM: Revealed a vigorous, nondysmorphic term appearing infant.",0
Lung sounds clear and equal.,0
Abdominal wall within normal limits.,0
Cord notable for 3-4 mm pinkish structure noted within the jelly.,0
No defects in the umbilical cord were noted.,0
"A small abrasion or question of a fistula noted in the jelly about 1.25"" above the abdominal wall with no fluid leakage.",0
"Heart was regular rate and rhythm, no murmur.",0
Lungs are clear and equal.,0
Normal male genitalia with descended testicles bilaterally.,0
Neurologic examination is nonfocal and age appropriate.,0
"Infant's birth weight was 3,260 grams.",0
"The birth length was 20"" and the birth head circumference was 34 cm.",0
INFANT'S HOSPITAL COURSE BY SYSTEMS: Respiratory status: Infant has always remained in room air and well saturated.,0
There has been no apnea or bradycardia.,0
"On examination, respirations are comfortable.",0
Lung sounds are clear and equal.,0
Cardiovascular status: Infant has remained normotensive throughout the NICU stay.,0
There was a prenatal concern for question of coarctation.,0
A fetal echocardiogram at 32 weeks by Dr. at felt that the fetal cardiac structures were within normal limits.,0
A follow-up echocardiogram was planned on .,0
"Fluids, electrolytes, and nutrition status: The infant was initially NPO waiting evaluation of the renal structures and the umbilical cord structures.",0
"After these issues were resolved, the mother was attempting breast-feeding.",0
The mother has had previous breast surgery and has been unable to express or pump any milk since beginning pumping on the day of delivery.,0
She has been counseled it is unlikely that she will be able to breast-feed and will commence bottle feeding.,0
"Infant's electrolytes at 24 hours of age was sodium 145, potassium 4.7, chloride 108, bicarbonate 23, BUN of 10, creatinine of 1.0.",0
"Urine electrolytes were sodium 149, potassium 19, and chloride 45.",0
"Followup electrolytes on was sodium 140, potassium 3.8, chloride 102, bicarbonate 21, BUN 8, creatinine 0.9.",0
The infant had a Foley catheter until his renal evaluation was completed.,0
That catheter was removed on at approximately 9 p.m.,0
Infant has voided several times since that and on exam does not have a full bladder.,0
"Gastrointestinal status: The umbilical cord and abdominal wall is evaluated with ultrasound, and felt to have normal umbilical cord structures within the cord.",0
Infant is passing meconium and there are no other GI issues.,0
"A bilirubin done on was total 8.0, direct 0.3, and direct 7.7.",0
Genitourinary: Infant has been evaluated by Dr. of Urology Department.,0
A VCUG on showed bilateral vesicoureteral reflux and an enlarged bladder.,0
"The reflux was grade 4-5/5, severe.",0
"The renal ultrasound showed moderate hydronephrosis bilaterally, dilated ureters bilaterally with left renal parenchymal normal echogenicity, the right with increased echogenicity.",1
The diagnosis by Dr. is megacystitis and megaureter association.,0
"The plan is for the infant to continue prophylactic amoxicillin and to be followed by him two weeks after discharge, and to schedule a renal scan (DMSA) at in weeks.",1
"At that time, a decision will be made to either wait and to continue to observe or to schedule surgery for reimplantation of the ureters.",0
Endocrine: The mother has been taking Tapazole for her hypothyroidism.,0
The infant has no evidence of goiter or hypothyroidism.,0
State screen will be sent on .,0
A repeat screen or set of TFTs at approximately one week of life was recommended by the Endocrinology team at .,0
This has been discussed with Dr adn the parents.,0
"Hematology: The infant's blood type is A positive, DAT negative.",0
Infectious disease: Infant is being treated with prophylactic amoxicillin 50 mg q.d.,0
Neurology: There are no issues.,0
Sensory: Audiology hearing screening will be performed prior to discharge.,0
DISPOSITION: The infant is transferred to the Newborn Nursery for continuing care.,0
PRIMARY PEDIATRIC CARE: Will be provided by Dr. of Pediatrics.,0
Feedings: Formula feedings 20 calories/ounce on an adlib schedule.,0
Medications: Amoxicillin 50 mg p.o.,0
A state newborn screen will be sent on .,0
The infant has not yet received any immunizations.,0
"Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with two of three of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or with school-age siblings, or 3) with chronic lung disease.",0
Dictated By: MEDQUIST36 D: 02:16 T: 05:07 JOB#:,0
LINE PLACEMENT Clip # Reason: pleASE CHECK picc tip placement.,0
"#4f, sl, v-cath for abx.",0
pl Admitting Diagnosis: SEPSIS;RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 83 M with GI bleed intubated for resp distress and airway protection also with fever/wbc count REASON FOR THIS EXAMINATION: pleASE CHECK picc tip placement.,1
please page beeper # with wet read asap.,0
"thanks ______________________________________________________________________________ FINAL REPORT INDICATION: Fewer white count, status post intubation for respiratory distress secondary to GI bleed.",1
"FINDINGS: Right central venous catheter has been removed, and a left PICC has been inserted.",0
The tip of the left PICC lies within the upper one-third of the SVC.,0
"The pulmonary edema continues to improve, but underlying multifocal patchy opacities are thus more prominent, representing multifocal pneumonia versus asymmetric edema.",0
Discoid bibasilar atelectasis is present.,0
Multifocal pneumonia versus asymmetric edema.,0
Left PICC tip overlying SVC.,0
"3:00 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: year old man with respiratory distress, PNA on previous film.",1
"REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 11:26 AM Left lower lobe pneumonia or aspiration with associated left pleural effusion, unchanged from yesterday.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress, pneumonia on previous film.",0
"FINDINGS: AP portable semi-upright frontal chest radiograph compared to at 20:04, and demonstrates mild cardiomegaly, but no overt pulmonary edema, left pleural effusion, and retrocardiac opacity that has appearance on CT abdomen consistent with pneumonia, aspiration, or combination.",0
Dual-chamber pacemaker leads are unchanged coursing their anticipated paths.,0
Prior contrast within the renal collecting systems has cleared.,0
Left lower lobe pneumonia or aspiration.,0
", W. NMED FA11 1:55 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate for hemorrhage, swelling Admitting Diagnosis: S/P SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with secondary progressive MS who initially presented with 3 seizures and post-ictal Todds, now with altered mental status.",0
"REASON FOR THIS EXAMINATION: evaluate for hemorrhage, swelling No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No acute intracranial abnormality.",0
10:23 PM CT C-SPINE W/O CONTRAST Clip # Reason: pt intubated and sedated ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with known large bleed transferred---pt had unwitnessed fall and neck was not cleared at osh REASON FOR THIS EXAMINATION: pt intubated and sedated No contraindications for IV contrast ______________________________________________________________________________ WET READ: YMf FRI 12:22 AM No acute fracture or subluxation.,0
"Multilevel DJD with spinal canal narrowing at 4-5, and levels, which can predispose to spinal cord injury setting of trauma.",0
"______________________________________________________________________________ FINAL REPORT CT CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: INDICATION: 61-year-old man with large parenchymal hemorrhage, unwitnessed fall.",0
COMPARISON: Not available at .,0
TECHNIQUE: Noncontrast CT of the cervical spine.,0
Coronal and sagittal reformatted images were obtained and reviewed.,0
Vertebral body heights are preserved.,0
"There are multilevel degenerative changes, with disc space narrowing at C4-5, C5-6 and C6-7 levels.",0
The atlantoaxial and atlanto- occipital relationships are preserved.,0
The patient is intubated with mucosal thickening in the nasal cavity and left maxillary sinus.,0
"At C4-5 level, there is mild spinal canal nerrowing due to intervertebral osteophytes.",0
There is bilateral neural foraminal narrowing.,0
"At C5-6 level, there is mild-to-moderate spinal canal narrowing and bilateral moderate neural foraminal narrowing due to combination of osteophytes and and facet joint hypertrophy.",0
"At C6-7 level, there is bilateral neural foraminal narrowing as well as mild canal narrowing, secondary to combination of osteophytes and bilateral facet hypertrophy.",0
Extensive left cerebral hemorrhage with mass effect and findings concerning for cerebral edema described in the separate report.,0
There is a large pontine hematoma.,0
IMPRESSION: (Over) 10:23 PM CT C-SPINE W/O CONTRAST Clip # Reason: pt intubated and sedated ______________________________________________________________________________ FINAL REPORT (Cont) 1.,0
No acute fracture or subluxation.,0
"Multilevel degenerative changes with spinal canal narrowing, in the setting of trauma, these predispose to cord injury.",0
CT does not provide sufficient detail to evaluate spinal cord.,0
"Extensive intracranial hemorrhage, described in the separate report.",0
21 mm C-E aortic valve and 25 mm Mosaic mitral valve.,1
Height: (in) 60 Weight (lb): 260 BSA (m2): 2.09 m2 BP (mm Hg): 90/68 HR (bpm): 75 Status: Inpatient Date/Time: at 15:44 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: At one year the mean reported gradient for 25 mm Mosaic valve was 6.7 +/- 1.7.,1
TRICUSPID VALVE: Moderate to severe [3+] TR.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 50-55 %).,0
A bioprosthetic aortic valve prosthesis is present and appears well seated.,1
A bioprosthetic mitral valve prosthesis is present and appears well seated.,1
The leaflets were not well visualized.,0
7:15 AM CHEST (PORTABLE AP) Clip # Reason: elderly woman with intracerebral bleeding now with fever.,0
r/ ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with above REASON FOR THIS EXAMINATION: elderly woman with intracerebral bleeding now with fever.,0
r/o infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Intracranial bleed.,0
"Portable AP chest, one view: Comparison .",0
There is an ET tube 4 cm above the carina.,0
"The lungs are grossly clear without vascular congestion, focal consolidation, or pleural effusion.",0
Increased density in the retrocardiac region is unchanged and consistent with known large hiatal hernia.,0
"Allowing for differences in technique, there is no significant change since the prior exam.",0
2:33 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ptx Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT ?,1
TRICUSPIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p bronch REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 3:19 PM No pneumothorax.,0
______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP: REASON FOR EXAM: 78-year-old man status post bronch.,0
"Since earlier today, all tubes and catheters remain in unchanged position.",0
Right lower lobe aeration improved.,0
Left lower lobe atelectasis decreased.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Mercaptopurine Attending: Chief Complaint: dyspnea Major Surgical or Invasive Procedure: MV repair, CABGx1 History of Present Illness: Mr. is a 72 year old gentleman who recently was admitted to an emergency department with chest pain, dyspnea, and palpitations with known mitral regurgitation.",0
Past Medical History: Mitral regurgitation Hypertension Diabetes Mellitus Inflammatory Bowel disease Social History: Mr. is retired.,1
He does not consume alcohol.,0
Family History: Mr. family history is noncontributory.,0
"Physical Exam: On discharge today, Mr. is awake, alert, and oriented times three.",0
His heart is of regular rate and rhythm.,0
"His abdomen is soft, non-tender, and non-distended with positive bowel sounds.",0
"His sternal incision is clean, dry, and intact.",0
"His left leg incisions also are clean, dry, and intact.",0
His right anticubital space was noted to be reddened with a cord where an IV had just been removed.,0
Pertinent Results: 05:10AM BLOOD WBC-7.1 RBC-3.09* Hgb-9.9* Hct-28.0* MCV-91 MCH-32.2* MCHC-35.5* RDW-13.5 Plt Ct-123* 05:10AM BLOOD Glucose-186* UreaN-24* Creat-0.8 Na-136 K-4.2 Cl-102 HCO3-24 AnGap-14 05:47AM BLOOD Glucose-102 K-3.8 Brief Hospital Course: On Mr. went to the operating room and underwent a mitral valve repair (30mm band) with a coronary artery bypass graft times one (SVG to PDA).,1
He was extubated and his pressors were weaned.,0
By post-operative day 2 he was transferred to the step down floor.,0
"On the floor he went into atrial fibrillation, for which he was placed on amiodarone.",1
"He converted to sinus rhythm on oral amiodarone, but it was noted that his IV had infiltrated and he was placed on Keflex.",0
His epicardial wires were removed.,0
He was seen in consultation by physical therapy.,0
By post-operative day three he was ready for discharge to home.,0
Medications on Admission: Colozal 750 TID Mesalamine Quinipril Metformin ER 500 Discharge Medications: 1.,0
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days: for Right arm infiltrate.,0
Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: decrease to 200 daily in 2 weeks.,0
Balsalazide 750 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day).,0
Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days.,0
Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day.,0
Discharge Disposition: Home With Service Facility: Hospice and VNA Discharge Diagnosis: Severe mitral regurgitation Coronary artery disease hypertension diabetes mellitus Inflammatory bowel disease Discharge Condition: good Discharge Instructions: Follow medications on discharge instructions.,1
Do not drive for 4 weeks.,0
Do not lift more than 10 lbs.,0
"Shower daily, let water flow over wounds, pat dry with a towel.",0
"Call our office for temp>101.5, sternal drainage.",0
Followup Instructions: See Dr. in weeks ( See Dr. in weeks (.,0
Please call to make appointments.,0
"11:24 AM CT CHEST W/O CONTRAST Clip # Reason: r/o pna, infiltrative process.",0
"Admitting Diagnosis: MITRAL REGURGITATION\CATH Field of view: 32 ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with mechanical MV, ongoing fevers on zosyn/vanc for coverage of nasal packings.",0
"REASON FOR THIS EXAMINATION: r/o pna, infiltrative process.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Ongoing fevers, mechanical ventilation.",0
TECHNIQUE: MDCT acquired images of the chest were obtained without IV contrast.,0
"CT OF THE CHEST WITHOUT CONTRAST: There are bilateral pleural effusions, right greater than left.",0
There is multifocal consolidation affecting all lobes of the lungs with air bronchograms.,0
There are multifocal patchy areas of ground glass opacity and other patchy areas of opacity scattered throughout the lobes of the lungs.,0
There is interlobular septal thickening.,0
The airway is diffusely calcified.,0
No intra-airway lesion is seen.,0
An endotracheal tube is present and terminates above the carina.,0
An NG tube is present and courses into the stomach.,0
Note is made of extensive atherosclerotic disease with mural calcification of the aorta and great vessels.,0
There is a 14 mm pre- tracheal lymph node and multiple small superior mediastinal lymph nodes.,0
Evaluation for hilar lymphadenopathy is difficult on this noncontrast study.,0
Limited images of the upper abdomen demonstrate residual contrast material.,0
There appears to be trace ascites.,0
Multiple small retroperitoneal mesenteric lymph nodes are seen.,0
IMPRESSION: Multifocal areas of consolidation with bilateral pleural effusions and patchy areas of ground glass opacity with interlobular septal thickening.,0
These findings are consistent with multifocal pneumonia.,0
Aspiration (presumagbly of blood from the known nasal hemorrhage) is also in the radiologic differential diagnosis.,0
The bilateral pleural effusions and areas of ground glass opacity with interlobular septal thickening are consistent with superimposed fluid overload or CHF/interstitial pulmonary edema.,0
8:05 PM CHEST (PORTABLE AP) Clip # Reason: eval ETT ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with hx intubated REASON FOR THIS EXAMINATION: eval ETT ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH PERFORMED ON .,0
"CLINICAL HISTORY: Intubated, question ET tube position.",0
FINDINGS: Single AP supine portable chest radiograph is obtained.,0
Evaluation limited given exclusion of the lateral-most aspect of the right hemithorax.,0
There is an ET tube within the trachea positioned 5.6 cm above the carina.,0
"There are extensive bilateral lung opacities, which may represent multifocal pneumonia.",0
Heart size cannot be accurately assessed.,0
IMPRESSION: Adequate position of ET tube.,0
Extensive lung opacities noted concerning for pneumonia.,0
Height: (in) 71 Weight (lb): 170 BSA (m2): 1.97 m2 BP (mm Hg): 116/61 HR (bpm): 79 Status: Inpatient Date/Time: at 14:45 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
AORTIC VALVE: No masses or vegetations on aortic valve.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins Attending: Chief Complaint: 48yoW with h/o ESLD EtOH cirrhosis, Crohn's disease, chronic kidney disease, transfered from on for persistent MRSA bacteremia Major Surgical or Invasive Procedure: Admitted with PICC Femoral HD catheter placement History of Present Illness: 48yoW with h/o ESLD EtOH cirrhosis, Crohn's disease, chronic kidney disease, who was admitted to Hospital with liver failure, acute renal failure and hyponatremia, and is transferred now to with persistant MRSA bacteremia.",1
"The patient was initially referred to ED from her primary care physician's office for evaluation of elevated LFTs, confusion, ARF (Cr 3.4), and hyponatremia (Na+ 124).",0
At that time she complained of SOB and productive cough.,0
She was transferred to the ICU with hypotension (BP 65/40) and treated for urosepsis after E.coli grew in her urine.,0
She was treated with initially ceftriaxone and then aztreonam.,0
"Hypotension was treated initially with Neosynephrine, and then levophed.",0
Hospital course also complicated by LLL pneumonia.,0
She then developed a MRSA bacteremia.,0
"Exam was significant for pericardial rub, and echo showed a small-moderate effusion.",0
"No vegetations were seen on TTE , but she was treated for endocarditis with vancomycin/gentamicin.",0
A TEE was not done due to concern for causing a variceal bleed.,0
On the gentamicin her creatinine rose from 1.0 to 3.8.,0
On she had a single burst of non-sustained Afib.,0
Hospital course was also complicated by hypokalemia requiring repletion.,0
"Surveillance blood cultures were persistantly positive for MRSA, most recently , despite therapeutic doses of vancomycin.",0
Additionally the LLL infiltrate enlarged on CXR.,0
"Abdominal U/S on showed hepatosplenomegaly, ascites, and reversed flow in the portal vein.",0
On she had a urine culture that grew enterococcus.,0
She was transferred on Levophed via PICC line in left A/C vein.,0
Hospital course also complicated by indecision regarding code status.,0
"She was initially DNR/DNI, then full code, then reverted to DNR/DNI status prior to transfer.",0
"On presentation now she complains of chest pain when coughing, and cough productive of brown sputum.",0
"She c/o midepigastric abdominal pain and low back pain, which is her baseline.",0
"She denies headache, dizziness, confusion, vision changes, nausea, vomiting, diarrhea, constipation.",0
"Past Medical History: COPD Crohn's disease Liver failure d/t alcoholic cirrhosis c/b portal HTN, esophageal varices Sciatica Osteoarthritis Chronic kidney disease Social History: lives with her son.",1
daughter serves as her HCP.,0
on disability +Tob use; +EtOH use; denies illicit drug use Most recent drink was the day prior to hospitalization.,0
she denies having a h/o withdrawals.,0
"Family History: Father - h/o EtOH abuse, d. Alzheimer' dz at 64yrs Mother - alive, had stroke at 67yrs Brother - EtOH abuse MGM - EtOH abuse Physical Exam: T 97.2 HR 69 BP 93/36 RR 33 95%3Lnc Wt 94kg pulsus <10 GEN: alert, speaking full sentences, appropriate, NAD HEENT: icteric sclera, PERRL (2->1mm), conjunctiva pale, OP clear, MMdry Neck: supple, no LAD, JVP 11cm CV: PMI nondisplaced, regular rate, murmer vs rub, II/VI supine, III/VI sitting Resp: left basilar crackles, no rhonchi, no wheeze.",0
Labs closest to time of Death: 03:45AM BLOOD WBC-14.8* RBC-2.34* Hgb-8.5* Hct-24.6* MCV-105* MCH-36.3* MCHC-34.5 RDW-17.9* Plt Ct-106* 09:46AM BLOOD Glucose-342* UreaN-22* Creat-1.6* Na-128* K-3.9 Cl-95* HCO3-20* AnGap-17 09:46AM BLOOD CK-MB-NotDone cTropnT-0.03* 09:46AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.2 03:58AM BLOOD Type- pO2-48* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 .,0
MICRO: Urine culture with yeast.,0
IMAGING: CXR: AP UPRIGHT PORTABLE CHEST X-RAY: There is a ill-defined opacity within the left lower lobe consistent with patient's known pneumonia in this region.,0
The cardiac silhouette is difficult to evaluate.,0
The mediastinal and hilar contours appear within normal limits.,0
A left PICC catheter terminates in the upper SVC.,0
Cholecystectomy clips in the right upper quadrant.,0
IMPRESSION: Left lower lobe consolidation consistent with patient's known pneumonia.,0
Abd Ultrasound: FINDINGS: This was a technically difficult examination and was performed portably.,0
The liver is heterogenous in echotexture and is of increased echogenicity.,0
It is shrunken and the appearances are consistent with cirrhosis.,0
There is evidence of ascites.,0
The flow in the main portal vein is reversed and is centrifugal.,0
"The flow in the main hepatic artery reaches velocities of 80 cm/sec, but there is a normal waveform and the resistive index is 0.77.",0
The flow in the right anterior portal vein is centripetal and the flow in the right posterior portal vein is centrifugal.,0
The left portal vein is not well visualized.,0
Normal waveforms are seen in the right and left hepatic arteries.,0
"The flow in the left hepatic vein, right hepatic vein and middle hepatic vein is normal.",0
No intrahepatic bile duct dilatation.,0
The CBD measures 0.48 cm.,0
IMPRESSION: Technically difficult examination in a patient with cirrhotic liver with ascites with reversed flow seen in the portal veins.,1
ECHO: Conclusions: The left atrium is moderately dilated.,0
There is moderate aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate (+) aortic regurgitation is seen.,0
"MRI Abdomen: FINDINGS: The liver is shrunken and nodular, consistent with the given history of cirrhosis.",1
"Within the limits of the examination, no focal mass lesion is seen.",0
"A mild-moderate amount of ascites fluid is seen, primarily adjacent to the liver.",0
The pancreas is diffusely atrophic.,0
The spleen and kidneys also appear unremarkable.,0
"A serpiginous structure showing flow voids is seen in the right paraaortic/retroperitoneal region, with suggestion of communication between the superior mesenteric vein and the renal vein, probably representing a porto-systemic shunt.",0
"IMPRESSION: Right-sided vascular structure, probably representing a porto- systemic shunt between the SMV and the right renal vein.",0
No renal mass seen within the limits of this noncontrast examination.,0
"Brief Hospital Course: 48 y/o female with h/o end stage liver disease, EtOH abuse, COPD, Crohn's disease, and chronic kidney disease, transferred from OSH with MRSA bacteremia, liver failure, acute renal failure, LLL pneumonia, enterococcus UTI, and hypotension.",1
Her hospital course is as follows: .,0
Cirrhosis w/acute hepatitis: Patient was admitted with likely EtOH cirrhosis given her known history and lab data (discriminate score >32).,1
She remained coagulopathic with elevated LFTs and hyperbilirubinemia.,0
"We treated her supportively with lactulose, rifamixin.",0
We held her propranolol given her hypotnesion requiring pressors.,0
"US was negative for PV thrombosis, though there was reversal of flow.",0
A diagnostic paracentesis was unsuccessfully attempted.,0
"She was also started on pentoxyfylline for presumed EtOH hepatitis, as well as octreotide and midodrine for possible HRS.",0
"Nevertheless, given her multiple issues, she continued to decompensate.",0
She was transferred to the liver service after a final decision was made to make her comfort measures only.,0
ARF on CKD: Her baseline creatinine was unknown but per report creatinine was 1.0 prior to initiation of gentamicin.,0
She had no h/o large volume paracentesis.,0
"She had been hypotensive requiring pressors, including vasopressin, raising the concern for pre-renal azotemia vs ATN.",0
HRS was also considered given her decompensated liver failure.,1
Renal was consulted and initiated CVVH after placing a femoral HD cath.,0
"However, after she was made CMO all interventions were withdrawn.",0
MRSA bacteremia: Her source was unknown but was being treated for endocarditis given persistant bacteremia despite therapeutic doses of vancomycin at OSH.,0
She was started on gent in addition to vanco.,0
There were no positive cultures here.,0
"TEE was not done given concern for causing variceal bleed; however, EGD did not demonstrate varices.",0
Worsening LLL pneumonia on CXR at OSH could have been source of infection.,1
There was also a concern that her pericardial effusion might be infected/purulent pericarditis.,0
Spinal abscess or thrombophlebitis was also considered.,0
Multiple imaging studies were performed without clear source of infection (see above).,0
Her antibiotics were stopped once the patient was made CMO.,0
Hypotension: It was unclear what degree of hypotension this represented as patient's baseline SBP reported to be in the 80s.,0
However she was clearly septic at OSH.,0
"Sepsis, severe infection, ESLD were thought involved.",1
"She was maintained on levophed, neosynephrine, and vasopressin during her MICU stay.",0
Octreotide and midodrine were also started (see above).,0
"However, these interventions were stopped once she was made CMO.",0
Tachycardia/chest pain: Patient had an episode of A fib w/ RVR ; likely to fluid shifts w/ CVVHD and cardiac irritation from levophed.,0
"Echo at OSH showed normal EF, LA slightly enlarged.",0
"She was asymptomatic during event, cardiac enzymes were flat.",0
Levophed was changed to neo and pt bolused fluid.,0
She converted to NSR after 1-2hrs.,0
She remained tachycardic but looked to be in MAT.,0
"MS changes: Patient was not oriented, and she was unclear that she understood who made decisions for her.",0
Psych evaluated her and determined that she did not have capacity to make her own decisions.,0
There were multiple family meetings to discuss goals of care.,0
Palliative care also helped faciliate this decision making process.,0
"She remained disoriented, likely secondary to hepatic encephalopathy, infection, hyponatremia, and ARF.",1
Hyponatremia: It was thought to be hypervolemic hyponatremia given her ESLD.,0
It improved with fluid restriction .,0
"Code/End of Life Issues: Her code status continually fluctuated during her admission, between full code and DNR/DNI.",0
"However, after extensive family meetings and palliative care involvement, the decision was made to make her CMO .",0
"Once the patient was CMO, she was transferred to the - service.",0
There were no lab draws.,0
She was put on a morphine drip and appeared comfortable.,0
She was pronounced dead at 7AM on .,0
Cause of death likely end stage liver disease and infection.,1
They did not request an autopsy.,0
"Medications on Admission: Percocet 1-2tabs Q4hr prn Protonix 40mg Loratadine 10mg daily Singulair 10mg dialy Vistaril 25mg TID prn Lomotil 2mg TID prn Actos 15mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest End Stage Liver Disease Crohn's Disease Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired MD,",1
"5:51 PM CHEST (PORTABLE AP) Clip # Reason: ro ptx Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with CAD s/p CABG re-intubated, s/p bronch REASON FOR THIS EXAMINATION: ro ptx ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Reintubation, status post bronch.",1
COMPARISON: Film performed on the prior day.,0
The tip of the endotracheal tube is in good position 4.6 cm above the carina.,0
There is focal opacity at the left lung base.,0
"Compared to the prior study, there has been no significant interval change.",0
The tip of the left subclavian line is at the junction of the SVC and subclavian.,0
IMPRESSION: Endotracheal tube in good position.,0
No interval change from the prior study.,0
9:16 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
consolidation Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man febrile s/p mechanical fall REASON FOR THIS EXAMINATION: ?,0
consolidation ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST .,0
"FINDINGS: Left hemidiaphragm remains markedly elevated, consistent with diaphragmatic hernia reported on recent CT of one day earlier.",1
It is uncertain whether this is due to an acute traumatic herniation or a more chronic herniation.,0
"Persistent adjacent left lower lobe opacity which probably represents atelectasis, but no new areas of lung opacification to suggest a site of infection elsewhere in the chest.",0
9:35 AM CHEST (PORTABLE AP) Clip # Reason: eval Admitting Diagnosis: PONTINE HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with IPH and ET tube noted in different position after transfer from ER REASON FOR THIS EXAMINATION: eval ______________________________________________________________________________ FINAL REPORT Compared to .,0
CLINICAL INDICATION: Evaluate endotracheal tube position.,0
"An endotracheal tube is present in a relatively low position, with the tip approximately 1.5 cm above the carina.",0
A left subclavian vascular catheter is in satisfactory position.,0
There are stable linear opacities in the right upper lobe.,0
"The rest of the lungs appear clear, but it is difficult to fully assess the left retrocardiac region due to several overlying external devices.",0
"Endotracheal tube in relatively low position, 1.5 cm above the carina.",0
"10:20 AM CT HEAD W/O CONTRAST Clip # Reason: r/o hemorrhage ______________________________________________________________________________ MEDICAL CONDITION: 30 year old woman with s/p MVC REASON FOR THIS EXAMINATION: r/o hemorrhage No contraindications for IV contrast ______________________________________________________________________________ WET READ: DFDgf MON 11:11 AM no hemorrhage or mass effect ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVC, trauma.",0
"There is no shift of normally midline structures, mass effect or hyrocephalus.",0
The density values of the brain parenchyma are unremarkable.,0
The visualized paranasal sinuses and osseous structures are unremarkable.,0
"11:50 AM CT CHEST W/O CONTRAST Clip # Reason: please evalaute for effusions, consolidation Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 31 year old man with PNA, empyema, worsening opacity/effusion on CXR REASON FOR THIS EXAMINATION: please evalaute for effusions, consolidation CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ FINAL REPORT HISTORY: 31-year-old with pneumonia, empyema, worsening opacity on chest radiographs.",1
"COMPARISON: Multiple prior chest radiographs, most recent dated at 5:20 a.m.",0
TECHNIQUE: Multidetector axial images of the chest were obtained without contrast.,0
This study is read in conjunction with recent chest radiographs.,0
"CT CHEST: Severe multifocal pneumonia involving all lobes, worse on the right, cavitated in the right lower lobe has progressed dramatically over the past several days.",1
No pleural effusion is present.,0
Left- sided pleural catheter is well positioned.,0
Pericardial effusion is very small.,0
The left coronary artery contains dystrophic or atherosclerotic calcification.,0
Neither central nor axillary lymph nodes meet CT criteria for pathologic enlargement.,0
"Nodular liver contour, large venous collaterals, and splenomegaly indicate cirrhosis responsible for portal hypertension and probably for subcutaneous edema also.",1
The distended gallbladder contains numerous small stones.,0
There are no bone lesions suspicious for malignancy or infection.,0
"Severe, rapidly progressing, multifocal, necrotizing pneumonia.",1
"Cirrhotic liver, portal hypertension, ascites, anasarca.",1
Gallbladder distension may be related to n.p.o.,0
status; ultrasound indicated if there is clinical concern for cholecystitis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath, abdominal distension Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: Patient is an 81 y/o M with metastatic NSCLC on Alimta, HTN, CAD, COPD on home O2 and afib who presents with abdominal pain and SOB.",0
"Per the patient's wife, over the last week he has developed progressive abdominal distention and discomfort.",0
The pain is diffuse across his abdomen.,0
He denies nausea or vomiting.,0
He has also had progressive SOB over the same period of time.,0
He has been using his nebulizer up to every 2 hours with minimal relief.,0
"His wife reports that his appetite was intially ok, however over the last few days his PO intake has decreased and he did not eat anything for dinner last night.",0
"He denies fever, chills, or cough.",0
He has had constipation fo rwhich he took Milk of Magnesia tablets last evening and today with his last BM this morning.,0
Of note the patient was recently admitted to from for dyspnea.,0
He was admitted to the MICU for tachypnea to 50s and oxygen requirement.,0
"In the ICU, he required bipap which was gradually weaned off to his home 2.5L NC with sats in the 89-91 range.",0
A chest X-ray showed RUL infiltrate consistent with pneumonia.,0
He continued solumedrol and Abx were tapered to levaquin alone.,0
He developed new onset a fib and was started on diltiazem for rate control.,0
He was discharged home on prednisone taper and completed 7 day course of levofloxacin.,0
In the emergency department initial VS were BP 114/54 HR 108 RR 36 O2 sat 99% 4L.,0
CT abdomen was performed and showed new ascites and worsening of his liver and omental mets.,1
Surgery evaluated him for ?,0
"They did not see signs of obstruction, felt that he had likely ileus from progressive metastatic disease and is not a surgical candidate.",1
NGT was placed for comfort.,0
Labs were notable for K 6.0 without EKG changes.,0
He was given D50 and insulin.,0
"He also received solumedrol 125mg IV, vanco 1gm, zosyn 4.5gm, combivent nebs x2 and 2L NS.",0
Currently the patient states his breathing feels much better.,0
He continues to have some abdominal discomfort with exam.,0
"He denies chest pain, fever, cough, nausea or vomiting.",0
He reports that the NGT is uncomfortable when he swallows.,0
"Past Medical History: 1) CAD s/p MI in by EKG diagnosis, no admission, no symptoms, ETT/MIBI showing partially reversible defect in RCA distribution.",0
"2) HTN 3) Hyperlipidemia 4) COPD 5) DJD 6) Thoracic artery aneursym, stable 7) Nonsmall cell lung cancer (see below) ONCOLOGIC HISTORY: Mr. was in his USOH until when he presented with hemoptysis and weight loss of 10 pounds over previous 1-2 months.",1
"He had a CT scan of the chest on and it showed a 4.1 x 4.0 right hilar mass with subcarinal lymphadenopathy, 19 mm right axillary lymph node as well as multiple right lower lobe and left lower lobe nodules concerning for lung cancer.",0
"On , he was admitted to with chest pain and ruled out for a non-ST elevation MI.",0
"He was seen by the hematology-oncology consult service while in the hospital and underwent FNA of the right axillary lymph node, the pathology of which showed nonsmall cell cancer, squamous cell type.",0
"He was discharged on the third of and then on , he had a bronchoscopy done for evaluation of his hemoptysis as well as bronchial biopsy and the cytology confirmed metastatic nonsmall cell lung cancer.",0
He has subsequently completed 2 cycles of Navelbine.,0
Social History: He lives in .,0
He is married and has a daughter and a son.,0
He is here today with his wife & son.,0
"smoked for at least 50 years, stopped smoking 3-4 years ago.",0
"He used to work as a carpenter, it is unclear if he has had asbestos exposure.",0
Family History: Father died at age 43 of unknown causes.,0
Mother died of breast cancer complications at age 53.,0
"Sister had breast cancer and lung cancer and died at age 80 Physical Exam: VS: T 97.2, BP 122/70, HR 97, RR 24, O2sat 93% on 4LNC, Wt 140 lbs, Height 62"" GEN: Wearing NC, breathing with pursed lips on expiration.",0
"NECK: Thin, suppple, no lymphadenopathy PULM: Diffusely decreased breath sounds and air movement.",0
"CARD: RR, nl S1, Sl S2, II/VI systolic murmur RUSB ABD: BS+, soft, NT, ND EXT: Clubbing of fingernails on hands bilaterally, no LE edema SKIN: No rashes NEURO: Oriented x 3, non-focal exam PSYCH: Patient upbeat with joking manner Pertinent Results: CT abdomen Worsened metastatic disease with innumerable hepatic metastases, enlarging and new implants adjacent to the stomach and spleen in the omentum and new ascites and omental deposits.",0
"Progression of abdominal metastatic disease, partly visualized and better characterized on a CT from the prior day.",0
"Right hilar mass with a similar degree of narrowing of segmental pulmonary arteries, but exerting greater mass effect on descending airways serving the right lower lobe, some of which are now occluded.",1
"Patchy new peribronchovascular consolidation in the right lower lobe, most suspicious for post-obstructive pneumonia.",0
"Interlobular septal thickening in each lower lobe, more prominent on the right than left.",0
"The appearance may reflect fluid overload or lymphatic congestion, but the possibility of lymphangitic carcinomatosis on the right should also be considered.",0
"NG tube terminating in the stomach, but with the sidehole near the GE junction.",0
"If clinically indicated, it could be advanced to gain better purchase in the stomach.",0
Successful paracentesis yielding two liters of clear amber fluid.,0
Samples were sent to microbiology and cytology.,0
Brief Hospital Course: 81y/o M with metastatic non-small cell lung cancer on chemotherapy with Alimta last given on who presents with abdominal pain and SOB.,0
"Shortness of breath: This was likely multifactorial, with contributions from COPD, extensive lung cancer disease burden, possible post-obstructive pneumonia, and increased abdominal girth.",0
CTA chest negative for PE but showed tumor invasion of bronchi and pulmonary artery.,1
"NG tube for decompression was placed, vancomycin and zosyn were started, and he was given standing nebulizer treatments and supplemental O2.",0
He underwent two 2-L paracenteses with some improvement in shortness of breath.,0
"Several days into his hospital course he developed episodes of chest pain and increased shortness of breath without EKG changes, responsive to nitroglycerin and morphine.",0
These were thought to represent unstable angina with a possible contribution from aspiration events.,0
Goals of care were discussed with the palliative care team and eventually revised to include comfort measures only.,0
Morphine was given to help with shortness of breath and nitroglycerin as needed for comfort.,0
Abdominal distention: Found to have new ascites in setting of worsening metastatic disease to liver and omentum.,1
Also found to have ileus in setting of this and combination of these is likely contributing to his worsening discomfort.,0
in ED and were not concerned for SBO.,0
"He was found to have c diff, which was treated with PO vanc and zosyn.",0
He underwent two 2-L paracenteses under ultrasound guidance.,0
Antibiotics were stopped when goals of care were revised to CMO.,0
"Leukocytosis: WBC on admission 88K rose to >100k during this admission, increased from 68K on .",0
This had been discussed with heme/onc in the past and previously attributed to his cancer.,0
"The acute rise may have been related to infections (c diff, possible pneumonia).",1
"After goals of care were revised, labs were no longer checked.",0
Non-small cell lung cancer: Widely metastatic with worsening disease despite Alimta.,0
Palliative care assisted in discussions with the family and the goals of care were revised to comfort when it became clear that no further reasonable therapeutic options were available.,0
He expired several days later.,0
Folic Acid 1 mg daily 5.,0
"Combivent MDI, every four (4) hours as needed for shortness of breath or wheezing.",0
Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS 7.,0
Nitroglycerin SL as needed as needed for chest pain.,0
Prochlorperazine 10 mg every eight hours as needed for nausea.,0
Ambien 5 mg prn insomnia.,0
Calcium Carbonate 500 mg 11.,0
Diltia XT 120 mg daily 14.,0
Aspirin 325 mg daily 15.,0
Prednisone taper completed on 16.,0
Insulin Aspart SS qid Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:,0
10:32 AM CHEST (PORTABLE AP) Clip # Reason: line change Admitting Diagnosis: S/P PANCREATIC TX-RIGHT ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man 2 weeks s/p pancreas teansplant REASON FOR THIS EXAMINATION: line change ______________________________________________________________________________ FINAL REPORT INDICATION: Line change.,0
"A right internal jugular vascular catheter is present, and courses into the proximal right atrium.",0
"Unfortunately, the tip cannot be visualized due to an overlying external cardiac monitoring lead.",0
"Since the time of this radiograph, a repeat study has been obtained confirming the location of the lead, dictated separately under clip: .",0
Note is also made of an endotracheal tube terminating 6 cm above the carina.,0
There has been interval worsening opacities in the retrocardiac regions in the lower lobes.,0
"Finally, note is made of a nasogastric tube terminating within the stomach.",0
"2:22 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with respiratory distress and increasing abdominal girth/LE edema nasal intubation and increasing white count REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress and increasing white count, increasing edema, and abdominal girth.",0
Comparison is made to plain films dating back to and a CT of the chest from .,0
"PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST, AT 3:15 A.M: This exam is technically limited making the lines and tubes difficult to assess.",0
The ETT appears to remain in satisfactory position.,0
The NGT and the tip of the right IJ catheter cannot be visualized.,0
The bilateral pleural effusions and associated atalectasis have worsened since the prior film.,0
IMPRESSION: Interval worsening of bilateral pleural effusions with underlying atelectasis.,0
Exact positioning of lines and tubes difficult to identify on this technically limited exam.,0
3:55 PM CHEST (PORTABLE AP) Clip # Reason: eval for failure ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man S/P ICD placement now sob and tachypnea REASON FOR THIS EXAMINATION: eval for failure ______________________________________________________________________________ FINAL REPORT INDICATION: Status post ICD placement with shortness of breath and tachypnea.,0
UPRIGHT AP VIEW OF THE CHEST: A left-sided ICD device is again seen with leads in stable and satisfactory positions.,0
The heart is stablely enlarged.,0
"There is perihilar haziness with vascular indistinctness and upper zone redistribution, findings consistent with congestive heart failure.",1
"Subsegmental atelectasis is seen overlying the right middle lung field, new in the interval.",0
A small right effusion is likely present.,0
"IMPRESSION: Congestive heart failure, not significantly changed since the prior study.",1
New right middle lung field subsegmental atelectasis.,0
"5:32 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: follow-up PIE, HiFi ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity at 26 wks, PIE REASON FOR THIS EXAMINATION: follow-up PIE, HiFi ______________________________________________________________________________ FINAL REPORT CHEST: Comparison is made to previous films from earlier in the day.",0
Lung volumes are substantially lower than on prior exam.,0
There has been increasing collapse of both lungs in this child's hilan membrane disease.,0
There has been no significant change in the appearance of the diffuse interstitial air on the left side.,0
Endotracheal tube and umbilical artery and venous catheters are unchanged in position.,0
3:02 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate interval change in pneumediastinum Admitting Diagnosis: CONGESTIVE HEART FAILURE;S/P CABG ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with ARDS now s/p OR REASON FOR THIS EXAMINATION: evaluate interval change in pneumediastinum ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP.,1
REASON FOR EXAM: Evaluate interval change in pneumomediastinum.,0
FINDINGS: The tracheostomy tube and left central venous catheter are unchanged in position.,0
Widespread airspace opacities both lungs are unchanged with the exception of the left lower lobe which appears more dense and consolidated which could be evolving pneumonia.,0
The cardiomediastinal silhouette is unchanged with bilateral pleural effusions.,0
The position of the right humeral fracture is unchanged.,0
IMPRESSION: Worsening opacification at left lung base raises concern for evolving infection.,0
Otherwise the widespread airspace and interstitial opacities are unchanged.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: confirm line placemtn ______________________________________________________________________________ MEDICAL CONDITION: 23 year old woman with Vfib arrest REASON FOR THIS EXAMINATION: confirm line placemtn ______________________________________________________________________________ FINAL REPORT INDICATION: Ventricular fibrillation arrest.,1
SINGLE AP VIEW OF THE CHEST COMPARED WITH EXAMINATION PERFORMED ONE HOUR PREVIOUSLY: The patient has been re-imaged off the trauma board.,0
"There has been interval placement of the right IJ central venous catheter, with the tip in the mid SVC.",0
"NG tube remains in place, with the tip in the stomach.",0
"There is patchy opacity projecting over the entire left lung, as well as projecting over the right upper lung zones, with appearances suggesting asymmetric pulmonary edema versus aspiration.",0
No osseous abnormalities are appreciated.,0
Percutaneous pacemaker/defibrillator wires are seen.,0
"IMPRESSION: 1) Status post right IJ central venous line placement, tip in the mid SVC, without evidence of pneumothorax.",0
2) Asymmetric pulmonary edema versus aspiration.,0
"LUNG SCAN Clip # Reason: 55YR OLD W/MULTIPLE MYELOMA-NOW W/TACHYCARDIA, TACHYPNEA AND OXYGEN REQUIRED.",0
"R/O PE ______________________________________________________________________________ FINAL REPORT RADIOPHARMACEUTICAL DATA: 8.5 mCi Tc-m MAA (); 44.0 mCi Tc-99m DTPA Aerosol (); HISTORY:55YR OLD W/MULTIPLE MYELOMA-NOW W/TACHYCARDIA, TACHYPNEA.",0
R/O PE INTERPRETATION: This is a limited study due to low tracer count on the ventilation study.,0
Ventilation images obtained with Tc-m aerosol in 8 views demonstrate nonsegmental defects in the left lobe.,0
Perfusion images in the same 8 views show matching nonsegmental defects in the left lobe.,0
Recent chest CT from () shows nonspecific bilateral upper lobe tree-in opacities.,0
The above findings are consistent with a low probablilty of pulmonary embolism.,0
Limited study due to low tracer count on the ventilation study.,0
Low probablilty of pulmonary embolism.,0
"Discussed with Dr. at 7:25 pm, .",0
Approved: TUE 4:34 PM RADLINE ; A radiology consult service.,0
7:45 AM HIP UNILAT MIN 2 VIEWS LEFT Clip # Reason: fracture?,0
______________________________________________________________________________ MEDICAL CONDITION: History: 83M with fall onto left hip; groin pain REASON FOR THIS EXAMINATION: fracture?,1
______________________________________________________________________________ FINAL REPORT INDICATION: Fall onto left hip.,0
FINDINGS: There is an impaction fracture of the left femoral neck.,0
There is no displacement of the fracture.,0
The pubis symphysis is intact.,0
IMPRESSION: Nondisplaced impaction fracture of the left femoral neck.,0
6:44 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: confirm ngt placement Admitting Diagnosis: MIGRAINE HEADACHE ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with change in mental status.,1
vasculitis REASON FOR THIS EXAMINATION: confirm ngt placement ______________________________________________________________________________ WET READ: RSRc MON 8:15 PM NGT terminates in stomach; no other interval change.,0
- ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP on .,0
"HISTORY: 39-year-old man with change in mental status, cerebral vasculitis, confirm nasogastric tube placement.",1
"FINDINGS: A feeding tube has been placed in the interim, terminating in the stomach.",0
The endotracheal tube tip is 1 cm from the carina (low in position).,0
There is mild worsening of left pleural effusion.,0
Minimal left lower lobe opacity has worsened on today's examination.,0
Feeding tube in the stomach.,0
The endotracheal tube is low lying and needs to be retracted by at least 1 cm or 2.,0
This information was given to Dr. .,0
Slight worsening of small left pleural effusion and adjacent left retrocardiac opacity likely aspiration.,0
4:17 PM CHEST (PORTABLE AP) Clip # Reason: RESP DESTRESS ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory distress.,0
FINDINGS: There is interval removal of the tracheostomy tube.,0
There is an area of narrowing of the trachea in the area of entrance of the ET tube.,0
The diameter of the trachea at this level appears to be 1 cm.,0
There are again noted cardiomegaly and fibrotic changes throughout the lungs.,0
"When compared to the prior study, there is increased opacity in the right upper lung zone and right lower lung zone.",0
Interval increase of hazy opacities in the right upper lung zone and right lower lung zone.,0
"These findings could represent asymmetric CHF, but an infectious process cannot be excluded.",0
Interval removal of the tracheostomy tube.,0
"There is an area of narrowing of the trachea, where the lumen is as narrow as 1 cm.",0
This could reflect post intubation stenosis or edema.,0
Fibrotic changes of the lung and emphysema.,0
"4:12 AM CHEST (PORTABLE AP) Clip # Reason: S/P CABG, NOW WITH HCT DROP, PLEASE DO STAT FILM ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with REASON FOR THIS EXAMINATION: S/P CABG, NOW WITH HCT DROP, PLEASE DO STAT FILM ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 78 year old man with status post CABG.",0
"FINDINGS: There is bilateral increased density in both lung fields, predominantly in both lung bases consistent with bilateral pleural effusions and bilateral atelectasis of the lower lobes.",1
There is a mild widening of the mediastinum although is probably related to the supine possition of the patient and AP projection.,0
A right jugular line is demonstrate with its distal tip at the level of the right atrium.,0
ETT is noted approximately 4 cm above the carina.,0
A chest tube is also noted in the left hemithorax although the inferrior aspect is not seen as the laung bases were not included i the film.,0
A repeat chest X- ray is recomended for evaluation of this region.,0
Bilateral pleural effusions and atelectasis of the lower lobes 2.,1
Mild widening of the mediastinum,0
BP (mm Hg): 123/70 HR (bpm): 90 Status: Inpatient Date/Time: at 05:36 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: TR present - cannot be quantified.,1
There is mild global left ventricular hypokinesis (LVEF = 45-50%).,0
"Anterior to the right ventricular free wall, there is a relatively large (2.1 x 3.2 cm) echodensity within the pericardial space, which most likely represents a thrombus, and less likely - an epicardial fat pad.",0
No right ventricular diastolic collapse or other echocardiographic signs of tamponade is seen.,1
IMPRESSION: Small pericardial effusion with a likely thrombus in the pericardial space.,0
Symmetric LVH with mild global biventricular systolic dysfunction.,0
"Compared with the prior study (images reviewed) of , the size of epicardial thrombus appears to have slightly increased.",0
"The previously-described abnormal RV apical flow is not seen, however comparable views were not obtained during this emergent study.",0
5:22 AM CHEST (PORTABLE AP) Clip # Reason: PNA?,0
Admitting Diagnosis: STROKE;TELEMETRY;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with hemorrhagic CVA REASON FOR THIS EXAMINATION: PNA?,0
HISTORY: 68-year-old male with hemorrhagic CVA.,0
"There is left ventricular prominence, which is unchanged.",0
There are no signs for pulmonary edema or focal infiltrates.,0
There are again seen low lung volumes.,0
IMPRESSION: No signs for acute cardiopulmonary process.,0
Admission Date: Discharge Date: Service: SURGERY Allergies: Penicillins / Lisinopril Attending: Chief Complaint: Gastrointestinal stromal tumor of the duodenum with acute hemorrhage.,0
Placement of a jejunostomy tube.,0
Debulking of retroperitoneal tumor component.,0
Bedside opening of incision and drainage History of Present Illness: This totally healthy robust 91- year-old man presented to me 2 weeks ago with evidence of a presumed upper GI bleed and hemorrhage from a tumor in the periampullary area.,0
This was further worked up with endoscopic ultrasound and a biopsy showed this tumor mass to be highly suggestive of a GI stromal tumor.,0
It was positive for the c-kit mutation.,0
Both CAT scan and ultrasound examination revealed a hemorrhagic bleed extending into the retroperitoneum from the periampullary area.,1
There was a 4 cm tumor which was hyperenhancing in the third portion of the duodenum as it coursed close to the ligament of Treitz and this was intimate with the pancreas tissue itself.,1
The patient was mildly symptomatic from this and we observed him and cooled him down in the hospital and planned for an operative approach in a few weeks' time to allow the hematoma situation to reabsorb.,1
"I met Mr. with his daughter in my clinic prior to the operation and talked to his primary doctor, , about this scenario.",0
He is an absolutely vital and robust man for his age and acts like a 60-year-old.,0
He is physiologically in excellent shape.,0
I indicated to him that he has had a symptomatic manifestation of a tumor which likely is malignant in its nature.,1
I indicated to him that this should be removed and that medical therapy after a surgical debulking would be most optimal.,0
I told him this was most likely a GIST but could be a neuroendocrine tumor of the pancreas.,0
I indicated that it was going to be more than likely that he would require a Whipple resection of the pancreatic head to remove this tumor.,0
"Past Medical History: PMH: CAD, HTN, Hyperlipidemia, BPH, CRI w/ baseline Cr of 1.5, arthritis, depression, gout PSH: tissue MVR & 3V CABG, R foot surgery Social History: He is married but his wife has multiple sclerosis.",0
She lives on with 24 hour assistance.,0
"During the work week, Mr. lives in an apartment he keeps in .",0
"On the weekends, he drives out to to be with his wife.",0
He is a retired tax attorney who previously also worked for the IRS.,0
"He has three children, one living in , one in and a daughter who lives in Endeavor .",0
He names primarily his daughter as his main support system.,0
"His usual routine is to have about two cocktails a day, usually a scotch or .",0
Since the news of his retroperitoneal mass and plan for upcoming surgery has tapered down to one glass of wine per day.,0
He has no history of alcohol abuse He smokes briefly in college and has not smoked since.,0
He has no other history of exposures.,0
He belongs to a gym and exercises twice a week doing treadmill exercises and weight lifting.,0
Family History: He has a sister who was almost years old.,0
His brother died of prostate cancer at age .,0
Both of his parents lived to their 60s.,0
"Physical Exam: Geriatric Pre-op Physical: Vital Signs: Blood pressure today is 120/58, heart rate 76, weight 175 pounds.",0
"General: Mr. is a very pleasant, well groomed, well appearing man who appears younger than his stated age.",0
"He initially seemed somewhat inpatient, but later showed a good sense of humor and range of affect.",1
"He is alert, appropriate and has linear thought processes.",0
He presents very professionally dressed in a dress shirt and tie.,0
"HEENT: He has mild dry cerumen, which is not occluding the visualization of his tympanic membranes.",0
"In his left external auditory canal, he had a small plastic foreign object which I was able to remove with a lighted curet.",0
"After he inspected it, he told me this was a piece of a prior hearing aid.",0
Pupils are reactive to light and accommodation.,0
He has his upper and lower bridge work with no dentures.,0
Neck: Supple without carotid bruits or lymphadenopathy.,0
Heart: Regular rate and rhythm without ectopy or murmur.,0
Lungs: Good air movement at the bilateral bases.,0
"No rales, rhonchi or wheezes.",0
"Abdomen: Soft, nontender with normal active bowel sounds at four quadrants.",0
Back: No point tenderness diffusely.,0
Musculoskeletal: No active joint effusions.,0
Range of motion is well preserved without significant crepitus.,0
Muscle strength is in the upper and lower extremities.,0
Neurologic: Deep tendon reflexes are 2+ and symmetrical in the upper and lower extremities.,0
No muscle rigidity or cogwheeling.,0
Gait was observed for 25-foot walk.,0
Mr. has a well preserved normal velocity and stride length with normal arm swing.,0
Base of support is within normal range.,0
He shows good safety awareness and does not need any additional steps with the turning.,0
Pertinent Results: 04:12AM BLOOD WBC-11.6* RBC-3.26* Hgb-10.7* Hct-30.0* MCV-92 MCH-32.7* MCHC-35.5* RDW-14.0 Plt Ct-206 04:12AM BLOOD Glucose-142* UreaN-15 Creat-1.2 Na-136 K-3.8 Cl-101 HCO3-28 AnGap-11 .,0
DIAGNOSIS: I. Retroperitoneal mass (A): Gastrointestinal stromal tumor (see note).,0
"Gallbladder, cholecystectomy (B): Unremarkable gallbladder.",0
"Jejunum, resection (C-D): Unremarkable segment of small intestine.",0
Retroperitoneal mass (E-F): Gastrointestinal stromal tumor (see note).,0
V. Pancreaticoduodenectomy (G-Y): - Gastrointestinal stromal tumor (see note).,0
- Margins are not involved.,0
- Eleven (0/11) lymph nodes with no malignancy identified.,0
"- Pancreas with Pancreatic Intraepithelial Neoplasia (PanIN-2), margin is free.",0
"Note: Tumor cells are positive for C-Kit, synaptophysin, and chromogranin, but negative for cytokeratin (MNF116), desmin, actin and S100.",0
"The tumor has a component with epithelioid morphology (epithelioid GIST), multinucleated tumor cells and a brisk chronic inflammation infiltrate.",0
"The tumor forms a unifocal, encapsulated mass of 4.2 cm between the duodenum and pancreas (duodenal GIST) without involvement of the pancreas, gallbladder, or infiltration of the bowel wall.",1
Mitoses number up to 20/50 hpf and infarction and vascular invasion are noted.,0
Peripheral margins are negative with a 2 mm capsule at the inferior pole.,0
The features suggest a GIST with high risk for progression.,0
Staining for endocrine markers has been described in the subset of GIST formerly classified as gastrointestinal autonomic nerve tumor (GANT).,0
Clinical: Neuroendocrine tumor of pancreas.,0
1:01 pm SWAB Source: Abdomen.,0
WOUND CULTURE (Preliminary): STAPH AUREUS COAG +.,1
MODERATE GROWTH ANAEROBIC CULTURE (Preliminary): .,0
Brief Hospital Course: This is a year old male with Gastrointestinal stromal tumor of the duodenum with extension into retroperitoneum.,1
He went to the OR on for: 1.,0
"He did well post-operatively and followed the ""Whipple"" pathway.",0
Geriatrics was also helping with post-op management and delirium prevention.,0
Pain: He had a PCA for pain control and was followed by APS.,0
He was transitioned to a oral pain medications once tolerating a diet.,0
"GI/ABD: He was NPO, with a NGT and IVF.",0
"The NGT, per the pathway, was removed on POD 3.",0
His diet was slowly advanced as he had return of bowel function.,0
He was tolerating clears liquids by POD 5.,0
"On POD 6, a JP Amylase was measured and was 134.",0
The drain was subsequently removed the next day.,0
He has serous drainage from the previous drain site and a suture was placed.,0
"His abdomen was soft, nondistended and the incision with staples had extensive erythema along the staple line.",0
He was started on Clindamycin and then switched to Vancomycin.,0
"On POD 6, the 5 staples were removed due to sero-sang, thick drainage.",0
"A culture was send and showed STAPH AUREUS COAG +, MODERATE GROWTH.",0
The wound tracked medially 10cm and laterally 3cm.,1
The erythema improved after the wound was opened and drained.,0
Post-op Hyperglycemia: His blood sugars were noted to be elevated and was consulted.,0
"He was discharged with Glipizide 10mg , and will follow-up with for blood glucose checks.",0
He was discharged home with Keflex for 5 days and will continue with wound care for his postop wound infection.,1
He was seen by Oncology and will follow-up with them for continued treatment.,0
He was tolerating regular food and reported +flatus and +BM prior to discharge.,0
"Medications on Admission: atenolol 50mg PO daily, pravastatin 20mg PO daily, terazosin 1mg PO , 325mg PO daily (held pre-op), aricept 5mg PO (dosage uncertain, taking samples at the recommendation of his neice, PCP ) Discharge Medications: 1.",0
Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3 hours) as needed.,0
One Touch Ultra 2 Kit Sig: One (1) Miscellaneous Kit.,0
One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day.,0
One Touch Test Strip Sig: One (1) In four times a day.,0
GlipiZIDE 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Monitor blood sugars before meals and at bedtime.,0
Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Assoc.,0
of Discharge Diagnosis: Gastrointestinal stromal tumor of the duodenum with extension into retroperitoneum.,1
"Post-op Wound Infection Post-op Hyperglycemia Discharge Condition: Good Wound Care Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness.",1
* Take all new meds as ordered.,0
* Continue to increase activity daily.,0
No heavy lifting (>10lbs) for 6 weeks.,0
"* Monitor your incisions for signs of infection (increased redness, increased drainage).",0
* Continue with Wound care.,0
* Continue to check your blood sugars as instructed 4x/day.,0
Adhere to 2 gm sodium diet and low glucose diet.,0
Fluid Restriction: Followup Instructions: Please follow-up with Dr. on at 11:00am.,0
"Provider: , MD Phone: Date/Time: 9:30 Provider: , MD Phone: Date/Time: 9:30 .",0
Please follow-up with on .,0
4:08 PM CHEST (PORTABLE AP) Clip # Reason: RENAL CANCER/SDA Admitting Diagnosis: RENAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with hx of renal ca ?mets REASON FOR THIS EXAMINATION: hx of renal ca ?mets ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: CLINICAL INDICATION: Renal cell cancer.,0
"An endotracheal tube, nasogastric tube and central venous catheter remain in place.",0
The central line appears slightly more distal in location compared to prior studies but this may relate to patient positioning.,0
The cardiac and mediastinal contour are stable allowing for rotation.,0
"There is bilateral vascular engorgement and perihilar haziness present as well as more confluent, coalescing areas of opacity in the perihilar regions, which partially obscure underlying lung nodules.",0
The alveolar pattern has slightly progressed in the interval.,0
There is a small right pleural effusion tracking into the minor fissure.,0
"IMPRESSION: 1) Worsening perihilar opacities, most likely due to pulmonary edema.",0
"Of note, the area of coalescent opacity in the right perihilar region obscures a pre-existing pulmonary nodule which is seen to better detail on the pre- operative radiograph.",0
Other nodular opacities on the pre-op film are also partially obscured by the acute process.,0
Dedicated chest CT would be recommended for more complete assessment of the degree of metastatic disease of the thorax.,0
"2) Apparent advancement of right internal jugular vascular vascular catheter, possibly related to differences in positioning of the patient.",0
Repeat study with standard positioning would help assess the catheter position.,0
6:35 PM CHEST (PORTABLE AP) Clip # Reason: shortness of breath ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with REASON FOR THIS EXAMINATION: shortness of breath ______________________________________________________________________________ FINAL REPORT INDICATION: 81-year-old male with shortness of breath.,0
SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The patient is status post median sternotomy and CABG.,0
There is a left-sided pacemaker with leads in standard position.,0
"There are bilaterally increased interstitial markings, with some perihilar prominence.",0
No obvious pleural effusions are identified.,0
No pneumothoraces are clearly seen.,0
There is air seen within the stomach and within loops of bowel in the upper abdomen.,0
IMPRESSION: Cardiomegaly and findings consistent with mild congestive heart failure.,1
"3:35 AM CHEST (PORTABLE AP) Clip # Reason: 53 yo F decreased BS on left, evaluate for ptx vs worsening Admitting Diagnosis: HEMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: as above REASON FOR THIS EXAMINATION: 53 yo F decreased BS on left, evaluate for ptx vs worsening pulm edema, intubated, s/p VATS for hemothorax ______________________________________________________________________________ FINAL REPORT HISTORY: Decreased breath sounds on the left, to evaluate for pneumothorax or worsening pulmonary edema.",1
"FINDINGS: In comparison with the study of , there is probably little change in this technically limited study.",0
Continued cardiomegaly with bilateral pleural effusions and pulmonary vascular congestion.,1
Endotracheal tube and nasogastric tube remain in position.,0
4:11 PM CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # Reason: eval for osteo ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with neck pain and OSH with reported vertebral osteo although there is no read on this REASON FOR THIS EXAMINATION: eval for osteo No contraindications for IV contrast ______________________________________________________________________________ WET READ: ASpf SAT 4:28 PM Destructive process centered at the C6-C7 intervertebral disc space with involvement of the adjacent endplates is concerning for disciitis osteomyelitis at this level.,0
An MRI may be obtained to evaluate for thecal involvement.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old man with neck pain and outside hospital report of vertebral osteomyelitis.,0
TECHNIQUE: CT images were acquired at an outside hospital through the neck without IV contrast.,0
"Standard soft tissue algorithms, multiplanar reformations and bone kernel reconstructions were obtained and reviewed.",0
The sagittal and coronal reformatted images are somewhat degraded.,0
FINDINGS: There has been prior surgery with laminectomy changes at C3-C6.,0
There is severe loss of disc space at C6-7 level with osseous destruction spanning the C6-7 disc space.,0
There is pre-vertebral soft tissue thickening at this level.,0
No definite fluid collections are noted on this noncontrast exam.,0
Evaluation of the intrathecal detail is limited due to noncontrast technique.,0
The thyroid gland is unremarkable.,0
The partially imaged lung apices are clear.,0
IMPRESSION: Laminectomy changes at C3-C6 with osseous destructive process centered around the C6-C7 intervertebral disc space concerning for vertebral osteomyelitis and discitis.,0
MRI C-spine is recommended for further evaluation.,0
"10:35 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: catheter placement Admitting Diagnosis: PULMONARY HYPERTENSION;SYNCOPE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with pulmonary hypertension , swan ganz catheter, manipulation REASON FOR THIS EXAMINATION: catheter placement ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW ON HISTORY: Manipulation of Swan-Ganz catheter.",0
FINDINGS: The Swan-Ganz catheter tip is in the right main pulmonary artery and has been pulled back slightly compared to the study from earlier the same day.,0
There is improved aeration of both lower lobes with a small left pleural effusion.,0
The heart continues to be mildly enlarged.,0
There is no focal infiltrate.,0
4:45 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval re-expansion and CT position Admitting Diagnosis: TRAUMATIC LEFT ARM AMPUTATION ______________________________________________________________________________ MEDICAL CONDITION: 20 year old woman s/p MVC.,1
"s/p L CT placement for PTX REASON FOR THIS EXAMINATION: eval re-expansion and CT position ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVC with left chest tube placement, please of eval reexpansion of pneumothorax.",1
FINDINGS: Supine portable chest radiograph reviewed.,0
The left lung has reexpanded status post chest tube placement.,0
There is a small amount of apical pleural fluid.,0
Increased opacification of the left lung is secondary to recent reexpansion.,0
Retrocardiac atelectasis is still present.,0
The mediastinal and cardiac silhouettes are stable and midline.,0
Nasogastric tube is located in the stomach.,0
The patient is status post cervical spine fusion.,0
Tip of a right subclavian central venous catheter overlies the upper SVC.,0
There is a displaced left clavicle fracture.,1
"Left lung expansion, status post chest tube placement.",0
12:25 PM UNILAT LOWER EXT VEINS LEFT Clip # Reason: SWOLLEN LLE ANY DVT?,0
Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with now swollen L leg s/p skin cancer surgery.,0
REASON FOR THIS EXAMINATION: any DVT?,0
______________________________________________________________________________ WET READ: MLHh SUN 2:24 PM Popliteal fossa and calf collections could be ruptured cyst vs. hematoma/abscesss from surgery.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 88-year-old female with left ankle Mohs surgery for skin cancer one month ago, complicated by wound infection, now with swollen left leg.",0
"LEFT LOWER EXTREMITY ULTRASOUND: -scale, color, and Doppler images were obtained.",0
"There is normal compressibility, flow, and augmentation in the left common, superficial and deep femoral, and popliteal veins.",0
Flow is also noted in the calf veins.,0
"In the medial popliteal fossa, there is a lobulated 2.6 x 1.7 x 1 cm hypoechoic fluid collection, without detectable internal vascularity, and with mild overlying edema.",0
"In the left calf, subjacent to visible area of bruising, there is a heterogeneously hypoechoic fluid collection measuring 5.3 x 4 x 0.7 cm.",0
"This demonstrates internal septations, no internal vascularity, and moderate overlying subcutaneous edema.",0
No definite communication with the popliteal collection is identified.,0
No left lower extremity DVT.,0
Left popliteal and calf fluid collections.,0
This could represent ruptured cyst and/or hematoma/abscess from recent surgery.,0
"4:09 PM CHEST (PORTABLE AP) Clip # Reason: eval NGT position Admitting Diagnosis: HYPOXIA;NSTEMI;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with nausea and vomiting and coffee ground emesis, s/p NGT placement REASON FOR THIS EXAMINATION: eval NGT position ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF COMPARISON: Previous study of earlier the same date.",0
Nasogastric tube terminates in expected location of the gastroduodenal junction.,0
Examination is otherwise without change since the recent study of earlier the same date.,0
"3:34 PM CT CHEST W/O CONTRAST Clip # Reason: eval right upper lobe cavitary lesion on CXR Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with respiratory failure post pneumonia, now with trach, presented with hemoptysis, bleeding from trach site, diffuse bleeding on bronch today, extensive smoking history REASON FOR THIS EXAMINATION: eval right upper lobe cavitary lesion on CXR CONTRAINDICATIONS for IV CONTRAST: creatinine 2.3 ______________________________________________________________________________ FINAL REPORT PROCEDURE: CT chest without contrast on .",1
TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the subdiaphragmatic area.,0
Thinner slice 5 mm and 1.25 mm images were reconstructed in the axial plane at different window algorithms.,0
Sagittal/coronal reformatted images were also obtained for further evaluation.,0
"HISTORY: 40-year-old woman with respiratory failure post-pneumonia, now with tracheostomy, presenting with hemoptysis, bleeding from the tracheal site.",1
"Diffuse bleeding on bronchoscopy today, extensive smoking history and a questionable right upper lobe cavitary lesion on chest x-ray.",0
"FINDINGS: What seems like a cavitary lung lesion on the single frontal chest radiograph of are summation shadows secondary to ill-defined opacities in the anterior segment of the right upper lobe, with out cavitation.",0
"High attenuation areas of consolidation are seen involving the posterior segment of the right upper lobe medially, posterior and anterior segment of the left upper lobe medially and basilar segments of both lungs, right more than left.",0
"Although this examination is not intended for evaluation of the major airways; however, there is a decreased AP diameter of the trachea and main bronchi, very suggestive of tracheobronchomalacia with almost complete collapse of the left bronchus.",1
The abnormal narrowing starts just distal to the tip of the tracheostomy tube The heart size is normal in size.,1
There are no pathologically enlarged lymph nodes according to CT size criteria.,0
The bony structures do not show any lesions suspicious for malignancy and/or infection.,0
The limited evaluation of the abdomen shows no gross abnormality.,0
IMPRESSION: (Over) 3:34 PM CT CHEST W/O CONTRAST Clip # Reason: eval right upper lobe cavitary lesion on CXR Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ FINAL REPORT (Cont) 1.,0
Multifocal paramediastinal high attenuation consolidations in both upper and lower lobes suspicious for aspiration of blood given the provided clinical history.,0
There is no intracavitary lung lesion.,0
"Findings suggestive of tracheo- bronchomalacia, especially of the left main bronchus.",0
8:06 PM MR HEAD W & W/O CONTRAST Clip # Reason: pre-RT planning pot op left crani / tumor resection Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with left brain mass REASON FOR THIS EXAMINATION: pre-RT planning pot op left crani / tumor resection No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): ESBb WED 4:06 AM 4.7x3.2cm left prietal hematoma in resection cavity from recent tumor resection.,0
small regions of diffussion restriction anterior to hematoma likely small infarcts.,0
"size of hematoma, mass effect and edema all similar to CT performered a few hours before.",0
"discussed with , PA neurosurgery at 345am ______________________________________________________________________________ FINAL REPORT Final report will be dictated as addendum.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic CHIEF COMPLAINT: Chest pain.,0
"HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old male with a history of diabetes, hypertension, and hypercholesterolemia who presented after having a positive stress test to for workup.",1
For the last several months the patient has had axillary pain with exertion which is relieved with rest.,0
The pain has not increased in frequency or intensity in the last few months.,0
"He denies any radiation, shortness of breath, diaphoresis, nausea, and vomiting with these symptoms.",0
"He had an electrocardiogram done in the clinic which appeared abnormal, and this led to a exercise tolerance test.",1
"The stress test demonstrated electrocardiogram changes with ST changes in the anterior leads, and the patient was admitted to for further evaluation.",0
PAST MEDICAL HISTORY: (Past Medical History significant for) 1.,0
MEDICATIONS ON ADMISSION: Medications on admission included Avandia 4 mg p.o.,0
"q.d., Glucophage 850 mg p.o.",0
"t.i.d., Accupril 10 mg p.o.",0
"q.d., Pravachol 40 mg p.o.",0
"q.d., enteric-coated aspirin 325 mg p.o.",0
SOCIAL HISTORY: He denies any tobacco or alcohol use.,0
The patient is an engineer and lives with his wife.,0
PHYSICAL EXAMINATION ON PRESENTATION: On physical examination the patient was in no acute distress.,0
"Temperature was afebrile, pulse of 72, blood pressure of 140/72, respiratory rate of 18, satting at 96% on room air.",0
He had a clear chest bilaterally.,0
"He had a regular rate and rhythm with no murmurs, rubs or gallops.",0
"His abdomen was soft and nontender, with positive bowel sounds.",0
"He had no clubbing, cyanosis or edema.",0
"PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission included a white blood cell count of 10.6, hematocrit of 36.4, platelets of 339.",0
"PTT of 27, PT of 13, INR of 1.2.",0
"Sodium of 145, potassium of 4.7, chloride of 106, bicarbonate of 25, blood urea nitrogen of 18, creatinine of 1, glucose of 136.",0
"RADIOLOGY/IMAGING: Electrocardiogram revealed normal sinus rhythm at 93, poor R wave progression, normal axis, T wave inversions in V4 through V6.",0
HOSPITAL COURSE: The patient was admitted to the C-MED Service where he underwent a cardiac catheterization.,0
"A middle right coronary artery 95% stenosis, middle left anterior descending artery 80% stenosis, first diagonal with 40% stenosis, proximal circumflex with 60%.",1
There was an estimated ejection fraction of 37%.,0
The patient was then evaluated by Cardiothoracic Surgery.,0
"He was then taken to the operating room where he underwent a coronary artery bypass graft times four with a left internal mammary artery to left anterior descending artery, radial segment to the obtuse marginal and first diagonal, and a reversed saphenous vein graft to the right coronary artery.",1
The patient tolerated the procedure well and was transferred to the Coronary Care Unit where he remained hemodynamically stable.,0
He was weaned off of pressors and did well overnight.,0
"On postoperative day one, the patient was transferred to the floor.",0
The patient was stable overnight.,0
"On postoperative day two, he had an episode of rapid atrial fibrillation.",1
The patient was converted back to sinus rhythm after intravenous Lopressor was given.,0
"After bolus of 150 mg, he was started on amiodarone 400 mg p.o.",0
which he was to complete for one week and following the standard taper course.,0
He has remained in sinus rhythm since the initial episode.,0
The patient has otherwise remained afebrile and stable.,0
"The wound remained clean, dry, and intact.",0
The patient has had an elevation of his potassium of up to 6.,0
"His supplemental potassium chloride was discontinued, and the patient potassium appropriately dropped to 5.4.",0
The patient has been able to void.,0
He was tolerating a cardiac/diabetic diet and was ambulating with an activity level of V with Physical Therapy.,0
The patient was stable and is now ready for discharge.,0
"Coronary artery disease, status post coronary artery bypass graft times four.",1
MEDICATIONS ON DISCHARGE: (Medications on discharge included) 1.,0
(until ; the patient will then take 400 mg p.o.,0
from to ; then the patient will take 400 mg p.o.,0
CONDITION AT DISCHARGE: The patient was discharge in stable condition.,0
DISCHARGE STATUS: The patient was discharged to home.,0
DISCHARGE FOLLOWUP: The patient was to follow up with Dr. in four weeks and follow up with Dr. in two to three weeks.,0
Dictated By: MEDQUIST36 D: 12:46 T: 15:14 JOB#:,0
", F. MED MICU 2:01 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval NG tube placement.",0
Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with new NG tube placed.,0
REASON FOR THIS EXAMINATION: eval NG tube placement.,0
"______________________________________________________________________________ PFI REPORT Nasogastric tube was advanced, still with its sideholes just distal to the gastroesophageal junction.",0
Left lower lobe atelectasis increased.,0
"Right paramediastinal alveolar opacity increased, could be increased volume loss for aspiration.",0
"Small right pleural effusion also increased, still small.",0
Right PICC ends in the axillary region.,0
"8:57 PM CT HEAD W/O CONTRAST Clip # Reason: 55 year old man s/p L craniotomy for resection of tumor, ple Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man s/p L craniotomy for resection of tumor, please evaluate for post operative changes.",0
Please do w/n 4 hrs.,0
"REASON FOR THIS EXAMINATION: 55 year old man s/p L craniotomy for resection of tumor, please evaluate for post operative changes.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 55-year-old male status post left craniotomy for tumor resection, here for assessment of postoperative change.",0
COMPARISON: Multiple prior CTs dating back to and multiple prior MRIs dating back to .,0
TECHNIQUE: Contiguous non-contrast axial images were acquired through the brain.,0
FINDINGS: Patient is status post re-resection of a left temporoparietal lesion with expected post-surgical pneumocephalus and small amount of fluid in the surgical bed.,0
There is overall stable amount of extra-axial pneumocephalus and trace amount of linear hyperdensity along the surgical tract.,0
Extensive left parietotemporal white matter edema persists.,0
Configuration of ventricles and sulci are very similar as compared to two days prior with stable to mildly decreased rightward shift of normally midline structures.,0
Patient is status post left parietal craniectomy.,0
A single surgical clip is seen in the left frontal subgaleal soft tissues.,0
Vascular calcifications are seen in the cavernous carotid arteries.,0
Small amount of postoperative fluid and air in the left temporoparietal surgical bed.,0
No increase in mass effect.,0
Stable rightward shift associated with edema.,0
No new hemorrhage or major vascular territorial infarct.,0
8:55 AM CT CHEST W/O CONTRAST Clip # Reason: evaluate for progression of infectious process.,0
"Please do WI Admitting Diagnosis: MULTIPLE MYELOMA;R/O INFECTION VS BRONCHITIS OBLITERANS WITH ORGANIZED PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with MM s/p transplant with productive cough and changes on prior CT suggestive of small airway disease, now with worsening cough, SOB - please evaluate for proefression of likely infectious process REASON FOR THIS EXAMINATION: evaluate for progression of infectious process.",1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Multiple myeloma, status post transplant.",1
Productive cough which is worsening.,0
TECHNIQUE: Axial non-contrast MDCT images were obtained through the lungs in a supine position.,0
Expiratory images were also obtained.,0
CT CHEST WITHOUT IV CONTRAST: Significant worsening of ground-glass opacities with focal areas of airspace consolidation is seen.,0
These findings are most severe within the upper and mid lung zones.,0
There is also interval development of marked traction bronchiectasis within the upper lobes bilaterally and right middle lobe.,0
"Tree-in- opacities within the right lower lobe and nodular opacities within the left upper lobe have slightly improved in the interval, likely indicating an improved component of infection.",0
There has been interval development of small pleural effusions bilaterally.,0
There are increased smooth septal thickening consistent with a component of hydrostatic edema.,0
Coronary artery and aortic valve calcifications are again identified.,0
A left subclavian central venous line terminates within the SVC.,0
No pathologic lymphadenopathy is identified.,0
There is mild soft tissue stranding throughout the soft tissues consistent with anasarca.,0
Bone windows again show multiple lytic lesions consistent with multiple myeloma.,1
There is a pathologic fracture with callus formation within the right clavicle.,0
"Lytic lesions are also identified within the left eighth rib, slightly worse and the right-side of the T12 vertebral body.",0
Expiration views show excessive collapse of the trachea and bronchi consistent with tracheobronchomalacia.,0
"New extensive ground-glass opacities and focal areas of consolidation, predominantly in the upper and mid lungs.",0
These findings raise the possibility of an evolving acute interstitial pneumonia with areas of organizing fibrosis.,1
The differential also includes a hypersensitivity reaction to drugs (or other antigen) or (Over) 8:55 AM CT CHEST W/O CONTRAST Clip # Reason: evaluate for progression of infectious process.,0
Please do WI Admitting Diagnosis: MULTIPLE MYELOMA;R/O INFECTION VS BRONCHITIS OBLITERANS WITH ORGANIZED PNEUMONIA ______________________________________________________________________________ FINAL REPORT (Cont) possibly eosinophilic pneumonia.,1
"Coexisting infection is likely, although bronchiolitis seen on the previous exam has improved.",0
Mild smooth septal thickening consistent with hydrostatic edema.,0
Lytic lesions within the right side of the T12 vertebral body and left eighth rib.,0
Pathologic fracture of the right clavicle.,0
These findings were discussed with Dr. from the hematology/oncology service at the time of study.,0
Height: (in) 65 Weight (lb): 228 BSA (m2): 2.09 m2 BP (mm Hg): 120/67 Status: Inpatient Date/Time: at 11:22 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is moderately dilated.,0
"Compared with the findings of the prior report (tape unavailable for review) of , there are no significant changes.",0
Height: (in) 74 Weight (lb): 243 BSA (m2): 2.36 m2 BP (mm Hg): 138/70 HR (bpm): 87 Status: Inpatient Date/Time: at 11:06 Test: Portable TTE(Focused views) Doppler: No Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: AORTA: The aortic root is normal in diameter.,0
GENERAL COMMENTS: Image quality was suboptimal.,0
"Could not accurately evalute LV size, function or valves There is no pericardial effusion.",0
LINE PLACEMENT Clip # Reason: assess Right SC placement Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with head and c spine injury s/p right SC line placement REASON FOR THIS EXAMINATION: assess Right SC placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after insertion of subclavian line placement.,1
Portable AP chest radiograph compared to previous study obtained the same day earlier at 12:15 a.m.,0
The right subclavian line tip terminates in mid SVC.,0
No apical pneumothorax or hematoma has been identified.,1
The known posterior portions of the fifth and sixth rib fractures are again demonstrated.,0
New atelectasis in the right lower lobe is seen.,0
"The lucency overlying the right mediastinal border may be due to atelectasis, although given the supine position of the patient, a small pneumothorax cannot be excluded.",1
The known lung contusions are again present.,0
The left basal atelectasis is again demonstrated.,0
The ET tube tip terminates 4.3 cm above the carina.,0
"10:21 PM PORTABLE ABDOMEN Clip # Reason: please evlauate for evidence of SBO, or free air Admitting Diagnosis: HEPATIC ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with hx of ESLD w/ varriceal bleed today, relieved w/ -more and banding.",1
"Now with abdominal distention and hypotension REASON FOR THIS EXAMINATION: please evlauate for evidence of SBO, or free air ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 3:16 PM Multiple dilated loops of small bowel throughout the abdomen.",0
Please note that the right-most and left-most flanks were excluded.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN, TWO VIEWS.",0
"HISTORY: Abdominal distention, hypertension, evaluate for small bowel obstruction or free air.",1
FINDINGS: There are multiple loops of small bowel which are moderately dilated.,0
"No definite air is identified within the colon, although the entire abdomen was not imaged.",0
There is no evidence of free air or pneumatosis.,0
There is no portal venous gas.,0
"IMPRESSION: Multiple dilated loops of small bowel, concerning for obstruction.",0
Findings discussed with Dr. via telephone,0
10:52 PM CHEST (PORTABLE AP) Clip # Reason: please eval for acute cardiopulmonary process ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with acute ICH REASON FOR THIS EXAMINATION: please eval for acute cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: Acute intracranial hemorrhage.,0
"CHEST, ONE VIEW: Comparison with .",0
IMPRESSION: No acute lung disease seen.,0
"LINE PLACEMENT Clip # Reason: confirm RIJ placement ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with hx of subtance abuse, HIV/AIDS, GI bleed - with wheezes on exam bilat REASON FOR THIS EXAMINATION: confirm RIJ placement ______________________________________________________________________________ FINAL REPORT INDICATION: Right internal jugular line placement.",0
FINDINGS: AP upright portable view of the chest.,0
The right internal jugular central venous catheter terminates in the SVC.,0
Previously noted right subclavian venous catheter has been removed.,0
"The heart, mediastinum, and pulmonary vessels are within normal limits.",0
IMPRESSION: Satisfactory right internal jugular catheter position.,0
"8:25 AM CT HEAD W/O CONTRAST Clip # Reason: More lethargic assess for interval change Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with left subdural hematoma REASON FOR THIS EXAMINATION: More lethargic assess for interval change No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PBec FRI 10:49 AM Stable LSDH with incr bld layering over L parietal, falx, and tentorium.",1
"New L frontal lobe intraparenchymal hemorrhage (2.3 x 1.4 cm) with incr efacement of L lat ventricle, 3rd ventricle, and L side of quadrigeminal cistern.",0
No uncal herniation currently evident.,0
Incr shift of midline structures (8.4mm- >10.8mm) ______________________________________________________________________________ FINAL REPORT INDICATION: 84-year-old woman with left subdural hematoma after fall in bathroom while on Coumadin.,0
TECHNIQUE: Contiguous axial images obtained through the brain.,0
COMPARISON: Comparison is made to non-contrast head CT performed .,0
"FINDINGS: The left frontoparietal subdural hematoma is relatively stable in depth with slightly increased blood layering over the parietal lobe, falx, and cerebellar tentorium, likely due to redistribution of blood products.",0
"There is a new left frontal lobe intraparenchymal hemorrhage with surrounding vasogenic edema, increased sulcal effacement, and loss of -white differentiation.",1
The hemorrhagic component measures 2.3 cm x 1.4 cm.,0
There is increased effacement of the occipital and temporal horns of the left lateral ventricle as well as the third ventricle with mild effacement of the left side of the quadrigeminal cistern.,0
There is increased shift of midline structures with a rightward deviation of 10.8 mm compared to 8.4 mm on the prior study.,0
IMPRESSION: Stable left frontoparietal subdural hematoma with redistribution of blood products.,0
New left frontal lobe intraparenchymal hemorrhage.,0
"Increased mass effect with increased effacement of sulci, cisterns, and the lateral and third ventricles, increased shift of midline structures.",0
These findings were communicated to Dr. at 10:45 a.m. (Over) 8:25 AM CT HEAD W/O CONTRAST Clip # Reason: More lethargic assess for interval change Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ FINAL REPORT (Cont),1
3:24 AM CHEST (PORTABLE AP) Clip # Reason: interval change in intubated patient Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with ESLD REASON FOR THIS EXAMINATION: interval change in intubated patient ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 2:18 PM PFI: Cardiac size top normal.,0
No pneumonia or overt CHF.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Intubated patient with ESLD.,0
There are persistent low lung volumes.,0
"No pneumothorax or sizable pleural effusions, no pneumonia or overt CHF.",0
ET tube in standard position.,0
3:53 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with sepsis and now intubated REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of a patient with sepsis.,0
The ET tube tip is 6.5 cm above the carina.,0
"The NG tube tip passes below the diaphragm, most likely in the stomach.",0
The moderate-to-severe cardiomegaly is unchanged.,0
The lung volumes are preserved with almost complete resolution of left lower lobe opacity consistent with resolution of atelectasis/aspiration.,0
11:43 AM CHEST (PA & LAT) Clip # Reason: please evaluate for infiltrates Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with cryptogenic cirrhosis and CKD REASON FOR THIS EXAMINATION: please evaluate for infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: Cryptogenic cirrhosis with chronic kidney disease.,1
FRONTAL AND LATERAL CHEST: Heart remains borderline enlarged.,1
Mild pulmonary vascular redistribution is new since .,0
No overt edema is identified nor is parenchymal consolidation seen.,0
It would be difficult to exclude a small left pleural effusion.,1
IMPRESSION: Findings consistent with mild edema.,0
"5:59 AM CT HEAD W/O CONTRAST Clip # Reason: MVC, CAR VS.",0
"POLE ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man unrestrained driver, car vs. pole.",0
"REASON FOR THIS EXAMINATION: r/o bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: AHPb MON 6:31 AM somewhat limited by motion, but no evidence for intracranial hemorrhage or mass effect.",0
______________________________________________________________________________ FINAL REPORT INDICATION: MVC.,0
FINDINGS: The study is limited by patient motion.,0
"Given these limitations, there is no evidence for intracranial hemorrhage or mass effect.",0
"The ventricles, cisterns, and sulci maintain a normal appearance.",0
"There is soft tissue swelling about the left orbit as well as partial opacification of the maxillary and ethmoid sinuses, and nasopharynx, presumed blood in this traumatic setting.",0
There is medial blowout fracture of the left orbit on the lamina papyracea.,0
Dedicated facial bone CT will help elucidate the possible presence of an inferior orbital wall fracture.,1
"IMPRESSION: Left medial orbital blowout fracture, no evidence for intracranial hemorrhage.",1
Please note the study is limited by patient motion.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate for pneumothorax and line placement Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with COPD and RIJ REASON FOR THIS EXAMINATION: please evaluate for pneumothorax and line placement ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 77-year-old woman with right IJ.,0
"I comparison to the prior film from earlier today, a right internal jugular catheter is seen terminating within the mid-to-distal SVC.",0
"Lung volumes are increased compared to earlier today; however, bilateral opacities still exist.",0
The endotracheal tube is 3.7 cm from the carina.,0
IMPRESSION: Right IJ within the mid SVC.,0
Endotracheal tube 3.7 cm from the carina.,0
"9:44 AM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman s/p RLL wedge resection REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST FILM AT 948 INDICATION: 72-year-old status post right lower lobe wedge resection, assess for interval change.",1
Comparison is made to the patient's previous study dated at 1400.,0
PA and lateral views of the chest at 948 are submitted.,0
"Overall, cardiac and mediastinal contours are stable.",0
"A right basilar chest tube remains in place, and there continues to be some right lateral pleural thickening, subcutaneous emphysema of the right lateral chest wall soft tissues, chain sutures at the right lung base and the right mid lung, surgical clips at the right base and a streaky opacity in the right upper lobe which likely represents post-surgical or post-inflammatory change.",1
Clips in the right upper quadrant are consistent with cholecystectomy.,0
There is no evidence of pulmonary edema.,0
"GALLBLADDER SCAN Clip # Reason: TRAUMA, RIGHT UPPER QUADRANT PAIN, SUSPECT ACALCULOUS CCY, RECENT NORMAL ULTRASOUND.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Trauma, right upper quadrant pain, suspect acalculous cholecystitis, recent normal ultrasound.",0
INTERPRETATION: Serial images over the abdomen show normal uptake of tracer into the hepatic parenchyma.,0
Within 30 minutes the gallbladder is visualized with tracer activity noted in the small bowel within 30 minutes.,0
The above findings are consistent with a normal study without evidence of cholecystitis.,0
IMPRESSION: Gallbladder study within normal limits without evidence of cholecystitis.,0
Approved: WED 12:35 PM RADLINE ; A radiology consult service.,0
3:46 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
dobhoff placement Admitting Diagnosis: ENDOVASCULAR AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with s/p aaa REASON FOR THIS EXAMINATION: ?,1
dobhoff placement ______________________________________________________________________________ FINAL REPORT INDICATION: Dobbhoff placement.,0
FRONTAL CHEST RADIOGRAPH: There has been interval removal of the endotracheal tube.,0
The Dobbhoff tube is seen with tip projecting over the proximal duodenum.,0
Right-sided central venous line is in unchanged position.,0
"Otherwise, no significant change seen compared to prior study with persistent bibasilar opacities and small bilateral pleural effusions.",0
IMPRESSION: Dobbhoff tube seen with tip projecting over the proximal duodenum.,0
"Otherwise, no significant change from prior.",0
9:14 AM CHEST (PA & LAT) Clip # Reason: eval for interval change Admitting Diagnosis: TRACHEO BRONCHIAL MALACIA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman s/p removal of 1 of 3 chest tubes.,0
perform exam at 12pm today REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Follow up of a patient after removal of one of the three chest tubes.,0
PA and lateral upright chest radiograph was compared to prior study obtained the same day earlier at 3:43 a.m. One of the two right lower chest tubes has been removed in the interim.,0
There is no evidence of accumulation of pleural fluid.,0
The cardiomediastinal silhouette is stable and the lung aeration is well preserved,0
"7:28 PM CHEST (PORTABLE AP) Clip # Reason: Rule out cardiopulmonary process pre-op Admitting Diagnosis: SPINAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 79 y/o male with know HTN, CAD REASON FOR THIS EXAMINATION: Rule out cardiopulmonary process pre-op ______________________________________________________________________________ FINAL REPORT AP CHEST 7:45 A.M. HISTORY: Hypertension and coronary artery disease.",1
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Pleural abnormality along the lateral aspect of the left mid chest could be a calcified plaque due to asbestos exposure or prior trauma.,0
2-cm wide nodular opacity projecting over the anterior aspect of the right fourth rib could be a lung or pleural lesion.,0
No pneumonia or pulmonary edema.,0
The thoracic aorta is generally large particularly the ascending portion.,0
"Dr. covering Dr. , and I discussed these findings by phone, at the time of dictation.",0
", E. 3:47 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o retroperitoneal bleed ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman s/p cardiac catheterization with hypotension and persistent groin oozing.",0
"REASON FOR THIS EXAMINATION: r/o retroperitoneal bleed No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Small right inguinal hematoma with mild expansion of right psoas muscle, but no large degree of hemorrhage.",0
"5:33 PM MR L SPINE W/O CONTRAST Clip # Reason: eval for cauda equina syndrome, extent of bony mets with gad Admitting Diagnosis: LEUKOCYTOSIS;FEVER;END STAGE RENAL DISESE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with bony metastases known to C,L,S spine, now with decreased rectal tone and urinary retention REASON FOR THIS EXAMINATION: eval for cauda equina syndrome, extent of bony mets with gadolinium CONTRAINDICATIONS for IV CONTRAST: esrd, will advise renal, pt to get dialysis post-procedure Yes to Choyke questions.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old with diffusely metastatic adenocarcinoma and now with decreased rectal tone and urinary incontinence.,0
Evaluate for cauda equina syndrome.,1
"COMPARISON: MRI of the lumbar spine, .",0
"TECHNIQUE: Sagittal T1, T2, and STIR as well as axial T1 and T2 images through the sacrum were obtained.",0
FINDINGS: There has been interval development of extensive tumor infiltration of the sacrum since the prior exam of .,0
"Previously, the patient had a capacious thecal sac extending into the sacrum.",0
"Now there is extensive tumor infiltration throughout the sacrum, which obliterates the spinal canal at L5-S1 and presumably infiltrates the nerve roots below this level.",0
Tumor extends beyond the bony confines of the sacrum into the posterior soft tissues (5:30).,0
"The iliac wings appear unaffected, and the sacroiliac joints are intact.",0
There is a defect within the left iliac posteriorly with T1 hypointense scar tissue extending to the skin consistent with the patient's prior graft donor site.,0
"The visualized portion of the lumbar spine is unremarkable with no abnormal signal intensity within the vertebral bodies, conus, or cauda equina.",1
"There is mild edema in the inferior endplate of L5 and disc desiccation at L5- S1, likely degenerative.",0
The L5-S1 disc bulges into the sac causing mild indentation of the thecal sac ventrally.,0
IMPRESSION: Extensive tumor infiltration of the sacrum with obliteration of the thecal sac (and presumably the nerve roots) below the L5-S1 level.,0
These findings were discussed between Dr. and Dr. at 6:45 p.m. on .,0
"(Over) 5:33 PM MR L SPINE W/O CONTRAST Clip # Reason: eval for cauda equina syndrome, extent of bony mets with gad Admitting Diagnosis: LEUKOCYTOSIS;FEVER;END STAGE RENAL DISESE ______________________________________________________________________________ FINAL REPORT (Cont)",1
"LINE PLACEMENT Clip # Reason: 42 cm picc in left basilic vein, need Picc tip placement Admitting Diagnosis: SMALL BOWEL OBSTRUCTION AND ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with new Picc REASON FOR THIS EXAMINATION: 42 cm picc in left basilic vein, need Picc tip placement ______________________________________________________________________________ WET READ: MDAg MON 11:57 AM PICC projects just beyond superior cavoatrial junction.",1
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: New left PICC.,0
FINDINGS: Low lung volumes results in bronchovascular crowding.,0
"A left PICC projects over the right atrium, just beyond the superior cavoatrial junction and should be pulled back 1 cm.",0
The cardiac and mediastinal silhouettes and hilar contours are normal.,0
IMPRESSION: Left PICC projects over the right atrium and should be pulled back 1 cm.,0
", C. NMED SICU-A 9:06 AM CT HEAD W/O CONTRAST Clip # Reason: see progression Admitting Diagnosis: CEREBROVASCULAR ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with an intracerebral bleed REASON FOR THIS EXAMINATION: see progression No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT New intraventricular hemorrhage without evidence of new bleeding at the hematoma site.",1
"4:37 PM MR CERVICAL SPINE Clip # Reason: eval for cord compression Admitting Diagnosis: ALTERED MENTAL STATUS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with end-stage liver disease, chronic kidney disease, ?",1
cord compression on CT in neck collar REASON FOR THIS EXAMINATION: eval for cord compression ______________________________________________________________________________ FINAL REPORT CERVICAL SPINE MRI SCAN: HISTORY: End-stage liver disease and chronic kidney disease.,1
Question of cord compression on CT of the neck.,0
TECHNIQUE: Multiplanar T1 and T2-weighted as well as axial gradient echo scans of the cervical spine.,0
"COMPARISON STUDY: CT of the cervical spine dated interpreted by doctors and as revealing ""osteophytes at C5-6 cause moderate to severe narrowing of the spinal canal on the right and likely compress the spinal cord.""",0
"FINDINGS: Unfortunately, a number of the imaging sequences are of limited resolution due to patient motion.",0
"In that regard, the sagittal T1-weighted scans are nearly uninterpretable, despite repeat scanning attempts.",0
"FINDINGS: At C4/5, uncovertebral spurring produces prominent left and moderate right-sided neural foraminal stenosis, in with the recent CT scan.",0
"At C5/6, a moderate posterior spondylytic ridge causes moderate deformity of the spinal cord along its ventral margin with a slight caudal extension of the ridge to the right of midline, again mildly deforming the right ventrolateral cord margin.",0
"Motion artifacts render foraminal dimension assessment difficult, but I believe uncovertebral spurring at this locale again causes prominent foraminal stenosis, in with the recent CT scan.",0
This disc is moderately narrowed.,0
No other overt spinal or paraspinal pathology is seen.,0
CONCLUSION: Poor quality imaging secondary to patient motion but with reasonable correspondence of the MR findings as noted above.,0
COMMENT: There are probable secretions layering within the oro- and nasopharynx regions.,0
"Apparently, the patient is intubated.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Pt's stay was extended to by non-hemodynamically significant oozing at site of new tunneled HD catheter site.",0
"This was treated with gelfoam, thrombin spray, and pressure dressings.",0
IR had already stitched the line quite tightly so no surgical revision was performed.,0
DDAVP was considered but not given due to patient refusing to have peripheral IV replaced.,0
"All bleeding had resolved by , and pt was released after HD.",0
"Of note, labetalol was uptitrated to 800mg tid for persistently elevated systolic blood pressures.",0
"Admission Date: Discharge Date: Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is an 82 year old white female with a history of severe scoliosis, osteoporosis, hypertension, status post T3-T12 fusion on , status post compression fracture one to two years ago.",1
"The patient was doing well after her operation on the orthopedic service, apart from self-extubating herself on , requiring increasing amounts of oxygen on the floor.",0
"On , the patient had a fever of 101.4 and chest x-ray showed left lower lobe collapse with a right greater than left effusion.",0
"Blood cultures, one out of four, were positive for gram positive rods, thought to be a contaminant, and gram positive cocci.",0
"On , overnight, the patient had acute onset shortness of breath with an increase in oxygen requirement with an oxygen saturation of 93% on a 40% face mask.",0
"Arterial blood gases at that point were 7.45, 50 and 65 at 1:00 a.m. and then later, at 5:00 a.m., 7.41, 57 and 128 on 40% to 50% face mask.",0
Electrocardiogram was read as stable.,0
"A chest x-ray showed no congestive heart failure, with right sided effusion and left lower lobe collapse, unchanged from prior.",1
CT was negative for pulmonary embolus but also saw bilateral effusions.,0
"The patient's mental status was deemed stable, as she was alert and oriented times three, with some inappropriateness.",0
A medicine consult was called for this desaturation at 1:00 a.m. on and then on for falling.,0
"For the fall, she possibly hit her head and fell on her right side and also had a transient desaturation, for which were arterial blood gases were 7.41, 57 and 124.",0
She had a CT of her chest and head which showed no bleed and no fracture.,0
"She was put in a collar until she was cleared and, at that point, because a urinalysis was found to be positive for 46 white blood cells and greater than 1,000 red blood cells on at 9:00 a.m.",0
The patient was started on ciprofloxacin and then transferred to the medical service.,0
"Osteoporosis, status post compression fracture in last one to two years, here with T3-T12 fusion done on .",0
"3. echocardiogram, concentric left ventricular hypertrophy, left atrial enlargement, 1+ mitral regurgitation, no wall motion abnormalities, normal left ventricular ejection fraction.",0
Question of mitral valve prolapse but negative on echocardiogram.,1
"ALLERGIES: The patient has no known drug allergies except for morphine, which causes her to get very sick, nausea apparently.",0
"MEDICATIONS ON ADMISSION: Iron supplements, Zantac 150 mg p.o.q.d., Tenormin 25 mg p.o.q.d., Os-Cal 500 mg p.o.b.i.d.",0
"; on transfer, albuterol and Atrovent nebulizers, Zantac 150 mg p.o.b.i.d., Lopressor 12.5 mg p.o.t.i.d., Colace 100 mg p.o.t.i.d., and p.r.n.",0
"Lasix, Zofran, codeine, Haldol and Tylenol.",0
"PHYSICAL EXAMINATION: On physical examination on transfer, the patient's vital signs were 96.1, 66 to 80, 160 to 174/63 to 72 and 96% on 50% shovel mask, 84% in room air.",0
"Overnight ins and outs were 760 and 1,553, and urine output was 300 cc over the last eight hours.",0
General: In no acute distress.,0
"Head, eyes, ears, nose and throat: Moist mucous membranes, oropharynx clear, no jugular venous distention, no point tenderness.",0
"Chest: Clear to auscultation bilaterally, slight crackles at right base, scattered.",0
"Cardiovascular: Regular rate, S1 and S2 normal, II/VI systolic murmur at left upper sternal border, no gallops or rubs.",0
"Abdomen: Soft, nontender, nondistended, positive bowel sounds, no masses.",0
"Neurologic examination: Alert and oriented times three, recall immediately and in five minutes, strength 5/5 throughout, sensation to light touch intact throughout, finger-to-nose bilaterally intact, gait not tested, reflexes 1+ throughout bilaterally.",0
"LABORATORY DATA: White blood cell count was 11.7, hematocrit 37.7, down from 39.6, platelet count 256,000, and coagulation profile normal.",0
"Urinalysis showed specific gravity of 1.040, large blood, positive nitrite, greater than 300 protein, greater than 1,000 red blood cells, 46 white blood cells, many bacterial and no epithelial cells.",0
"Chem-7: Sodium 144, potassium 3.8, chloride 101, bicarbonate 32, BUN 22, creatinine 0.4 and glucose 127.",0
"The patient was ruled out with CKs of 252, 262 and 213 with negative MB, troponin less than 0.3.",0
Arterial blood gases: As above.,0
CT scan of head and chest: Negative for bleed and fracture respectively.,0
CTA: Negative for pulmonary embolus and bilateral pleural effusions with question of left lower lobe loculation.,0
Chest x-ray: Bilateral effusions as on .,0
"The patient was thought to have had flash pulmonary edema, possibly due to arrhythmia given her diastolic dysfunction by echocardiogram.",0
The patient was given 20 mg of Lasix.,0
"Lopressor was increased, eventually to 50 mg twice a day.",0
The patient was put on telemetry.,0
Pulmonary: The patient's effusions were thought likely due to her flash pulmonary edema and were considered stable.,0
Left lobe loculation was not considered accessible by ultrasound guided tap with risk of pneumothorax significant enough to cause her significant clinical deterioration.,0
Infectious disease: The patient's urinary tract infection was treated with five days of ciprofloxacin.,1
Blood cultures were negative and urine culture was pending at this time.,0
"Hematology: The patient's hematocrit remained stable during her hospitalization, ranging from 33 to 39 and, on discharge, was 37.2.",0
"Her white blood cell count continued to climb during her hospitalization, although she remained afebrile after transfer to medicine.",0
It was thought possible that she could have a pneumonia given her effusions and difficult chest x-ray assessment based on her skeletal changes.,0
"Ceftriaxone was started upon discharge for seven days, 1 gram daily.",0
Her wounds did not look infected.,0
"Fluids, electrolytes and nutrition: The patient initially had a BUN to creatinine ratio that was elevated but, during her hospitalization, her creatinine remained stable at 0.4 to 0.5 and her BUN fell from a peak of 23 on to 15 on discharge.",0
"The patient was intermittent getting intravenous fluids but mostly taking orals and, by the end of her hospitalization, the patient was taking adequate oral intake.",0
"Neurology: The patient's mental status fluctuated day to day and, as a result, she had a CT scan of her head initially on transfer that was negative, and then another one on that was also negative for a subdural hematoma.",0
"Her mental status changes were thought possibly due to ciprofloxacin but, also, her family said that this was her baseline.",0
She was off codeine and only on Tylenol for her pain.,0
"Renal: As above, the patient's BUN to creatinine ratio reduced over time.",0
Orthopedic surgery followed her after her transfer to the medicine service and after her fall.,0
"The patient had a thoracic spine film, read by orthopedic surgery who said that the alignment of the rods had shifted status post the fall and still was adequate in terms of stabilization of her spine.",0
"Another read on the thoracic spine was a left eighth rib fracture, unclear when that occurred based on this one film.",0
There were no management issues for that other than to heal spontaneously.,0
DISCHARGE STATUS: The patient was discharged to rehabilitation in stable condition.,0
"DISCHARGE DIAGNOSES: Thoracic compression fracture, status post T3 to T12 spinal fusion.",0
Acute desaturations secondary to possible congestive heart failure with diastolic dysfunction.,1
DISCHARGE MEDICATIONS: Ceftriaxone 1 gm i.v.q.24h.,0
"times seven days, until .",0
FOLLOW-UP: The patient is to follow up with orthopedic surgery as an outpatient and is to have her white blood cell count checked at Rehabilitation to see if it resolves with the ceftriaxone.,0
Dictated By: MEDQUIST36 D: 10:19 T: 11:14 JOB#:,0
"8:04 AM CHEST (PORTABLE AP) Clip # Reason: s/p d/c L CT, PTX?",0
"Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with multiple trauma bilat chest tubes REASON FOR THIS EXAMINATION: s/p d/c L CT, PTX?",1
INDICATION: Left-sided chest tube removal.,0
There has been removal of a left-sided chest tube and development of a small left apical pneumothorax.,1
Right subclavian vascular catheter and right-sided chest tube remain in place.,0
There has been apparent interval removal of both nasogastric tube and endotracheal tube.,0
"There is increasing patchy opacity within the left retrocardiac region, partially obscuring the descending thoracic aortic interface.",0
Right basilar opacity is not significantly changed.,0
"Subcutaneous emphysema persists in the left chest wall, and note is again made of a right clavicular fracture.",1
Small left apical pneumothorax following chest tube removal.,1
"Bibasilar opacities, with interval worsening in the left lower lobe.",0
Findings communicated to Dr. .,0
Height: (in) 70 Weight (lb): 192 BSA (m2): 2.05 m2 BP (mm Hg): 158/70 HR (bpm): 60 Status: Inpatient Date/Time: at 11:36 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
There is mild to moderate pulmonary artery systolic hypertension.,1
IMPRESSION: Mild global left ventricular systolic dysfunction.,0
PATIENT/TEST INFORMATION: Indication: coronary artery disease Height: (in) 73 Weight (lb): 238 BSA (m2): 2.32 m2 Status: Inpatient Date/Time: at 14:32 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,1
Conclusions: PRE-BYPASS: The left atrium is dilated.,0
Dr. was notified in person of the results before surgical incision.,0
Post_Bypass: Preserved biventricular systolic function.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: TRANS HISTORY OF PRESENT ILLNESS: The patient is a 21 year old female with end-stage renal disease of unclear etiology who had a cadaveric renal transplant on the .,0
The patient was initially discharged from that operation on the .,0
The patient is readmitted on the 6th with persistent nausea and vomiting and with hypertension.,1
The patient was seen by way of the Emergency Department by Transplantation Surgery and the patient was seen to have a blood pressure as high as 230/120.,0
The patient did not have nausea on the day prior to admission and had a bowel movement on the date of admission.,0
"The patient denied any abdominal pain, no nausea or vomiting, or bloody stools prior to that, however, on the date of admission the patient noted the onset of severe nausea and vomiting.",1
"The patient missed her medications since Sunday, including her blood pressure medications.",0
Immunosuppressant medications of Prednisone 20 q. day.,0
CellCept four times a day.,0
Bactrim Single strength one q. day.,0
Nystatin swish and swallow 5 cc four times a day.,0
Lamivudine 100 mg q. day.,0
Norvasc 10 mg q. day.,0
Labetalol 800 mg twice a day.,0
Hydralazine 75 mg four times a day.,0
Lasix 80 mg twice a day.,0
Clonidine 0.2 mg twice a day.,0
Tums three times a day.,0
PhosLo three times a day.,0
PHYSICAL EXAMINATION: The patient had vital signs of 96.9 F. Temperature; heart rate 75; blood pressure 230/100 up to 161/97.,0
The patient was actively vomiting.,0
The patient's HEENT was clear.,0
Chest had regular rate and rhythm with clear breath sounds bilaterally; no murmurs.,0
"The abdomen was soft, there was no guarding or rebound tenderness and no distention.",0
"LABORATORY: Values on admission revealed a white blood cell count of 7.8, a hematocrit of 25.6, platelets of 216.",0
"Chem-7 with sodium of 134, potassium of 4.7, chloride of 99, bicarbonate of 22, BUN of 82, and a creatinine of 9.0.",0
"Calcium, magnesium and phosphorus were 10.4, 1.9 and 6.7.",0
Liver function tests were within normal limits.,0
"Amylase was normal and bilirubin of 0.4, albumin of 3.9.",0
Urinalysis had blood but no white cells.,0
"HOSPITAL COURSE SUMMARY: This is a patient who had chronic renal disease complicated by delayed graft function with persistent nausea or vomiting question secondary to uremia, and hypertension.",1
The patient was admitted to he Intensive Care Unit for a Nipride drip.,0
"For control of her hypertension, the patient is admitted to the Intensive Care Unit, however, Nipride drip resulted in patient developing a headache and the patient was switched to Labetalol.",0
The patient was given an attempt at Lasix with some response and urinary output.,0
Her Hydralazine was increased to 20 q. six hours and the patient was given a Clonidine patch.,0
With the nausea and vomiting the patient's CellCept was discontinued and the patient was started on Rapamycin (which changed to Solu-Medrol intravenously).,1
The patient continued to improve in the Intensive Care Unit.,0
Creatinine decreased to 7.8 by hospital day two.,0
We changed her Metoprolol to 50 twice a day and her Hydralazine to 75 mg four times a day.,0
We continued her on her Norvasc.,0
"Her Clonidine was continued at 0.2, and she also had a clonidine patch placed.",0
"To assess her kidney's renal function, we obtained both an MRA of her native kidneys and adrenals to rule out renal artery stenosis or adrenal tumors, as well as an MRA of her transplanted kidney.",1
"The patient, for her increased phosphorus, she was continued on Amphojel 30 cc q. eight hours.",0
The patient's MRI and MRA of her transplanted kidney demonstrated good arterial flow with a slight slowing of the venous anastomosis consistent with a small non-hemodynamically significant stenosis.,1
The patient's blood pressure was better controlled with blood pressures running systolic of 140 to 190 and diastolic of 80 to 90 and MAPs of 110 to 130s.,0
We changed her clonidine to 0.2 twice a day and to a #2 clonidine patch q. week.,0
Her labetalol was increased to 800 mg p.o.,0
three times a day and hydralazine to 75 mg four times a day.,0
Her graft function continued to improve.,0
The patient became slightly prerenal and so her Lasix was discontinued.,0
The patient was transferred from the Intensive Care Unit to the Floor on the .,0
"From the 10th until the , the patient improved.",0
She had an MRI done of her native kidneys which demonstrated no renal artery stenosis and no evidence of tumors in the adrenals or the kidneys.,1
The patient's creatinine continued to improve.,0
The patient's nausea and vomiting became only a problem at night and then resolved.,1
The patient was made therapeutic on Rapamycin after a load.,0
"On the 14th, the patient was doing well.",0
Her creatinine had decreased to 5.3.,0
Her blood pressure was better controlled from the 120s to 160s over 50s to 90s with a heart rate in the 80s to 90s.,0
"The patient was maintained on Norvasc 10 mg q. day, Labetalol 800 mg three times a day; Clonidine patch #2, Hydralazine 75 mg four times a day, Clonidine 0.2 mg twice a day.",0
"DISPOSITION: The patient was discharged to home on those medications as well as Rapamycin 4 mg q. day, tacrolimus 3 mg twice a day; Prednisone 15 mg q. day; Bactrim Single strength tablet one q. day; Valcyte 450 mg four times a day; Chlortramizol troches; Lamivudine 100 mg q. day; Norvasc 10 mg q. day; Labetalol 800 mg three times a day; clonidine patch #2; Hydralazine 75 mg four times a day; clonidine 0.2 mg twice a day; Protonix 40; Colace 100. , M.D.",0
Dictated By: MEDQUIST36 D: 10:58 T: 22:49 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female, admitted to the cardiology service after a recent accident and presented with signs and symptoms of -Tsubo cardiomyopathy and myocardial infarction related to this.",0
"PAST MEDICAL HISTORY: Significant for hypercholesterolemia, diabetes mellitus, paroxysmal atrial fibrillation, hypertension and iron deficiency anemia.",1
ALLERGIES: She denied any known drug allergies.,0
Glyburide SOCIAL HISTORY: She does not smoke or drink.,0
PHYSICAL EXAMINATION: She appeared comfortable in no apparent distress.,0
There were bilateral rales on chest examination with a 9 cm jugular venous distension.,0
The heart was of a regular rate and rhythm.,0
"LABORATORY DATA: Significant for an EKG showing atrial fibrillation at 93 beats per minute and early repolarization in V1 to V3 with T wave inversions in V3 through V6 and 1, 2 and F. Her hemoglobin level was 11.6 and white count 13.7.",1
"ASSESSMENT: This is a 68-year-old female, admitted to the cardiology service with -Tsubo cardiomyopathy and myocardial infarction.",0
HOSPITAL COURSE: She underwent cardiac catheterization.,0
She was noted to have a depressed ejection fraction.,0
"On , she was noted to develop diffuse then focal right lower quadrant tenderness with nausea.",0
Workup revealed leukocytosis and a CT scan of the abdomen revealed mesenteric vessel air near the cecum.,0
"Repeat CT scan on , revealed pneumatosis of the cecum and proximal right colon.",0
"She was also in atrial fibrillation and flutter, which had been treated with amiodarone and heparin drip.",1
"The patient was seen in consultation by general surgery and was felt to have right colon and cecal ischemia, possibly a necrosis, and was taken urgently for exploratory laparotomy.",0
There were findings of ischemic cecum and scattered areas of ischemia throughout the transverse colon.,0
She underwent ileocecectomy with stapling of the ends as she was hemodynamically unstable with an arrhythmia in the operating room.,0
"Therefore, the abdomen was left open and closed with a bag and she was taken to the intensive care unit for further stabilization.",0
"She was stabilized and then brought back to the operating room on , where the remainder of the colon at this time appeared pristine and we were able to perform an ileocolostomy.",0
Please see the operative note for further details of these procedures.,0
She was eventually weaned and extubated.,0
"She remained on anticoagulation for the atrial fibrillation and flutter, as well as the amiodarone and Lopressor.",1
She continued to do well.,0
She was begun on her diet and advanced well with that.,0
She was noted to be C-diff positive and was treated with Flagyl for this.,0
"She was well enough on , to be discharged to home.",0
-Tsabu syndrome with myocardial infarction and cardiomyopathy.,0
"Comorbidities of diabetes mellitus, paroxysmal atrial fibrillation, high blood pressure.",1
DISCHARGE INSTRUCTIONS: The patient was asked to followup with Dr. in 1 week.,0
She was also to followup with her primary care physician 1 week.,0
"She was to followup with cardiology, who would monitor her heparin and Coumadin.",0
She was to continue taking Flagyl for the C-difficile colitis.,0
She was to supplement her diet with Boost or Ensure supplement as she advanced further on her diet.,0
", Dictated By: MEDQUIST36 D: 18:52:30 T: 19:31:13 Job#:",0
4:05 AM CHEST (PORTABLE AP) Clip # Reason: please assess interval change.,0
"Admitting Diagnosis: ASCITES;EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with ESLD, ARF, R hydrothorax, pulm edema, now intubated.",0
REASON FOR THIS EXAMINATION: please assess interval change.,0
Large right pleural effusion has decreased in size.,1
"Low lung volumes limit assessment of cardiovascular status of the patient, but there is probably mild vascular engorgement and perihilar edema present even allowing for risk factor.",0
Left basilar atelectasis and small pleural effusion are also demonstrated.,1
"4:40 AM CHEST (PORTABLE AP) Clip # Reason: placement of OGT Admitting Diagnosis: PELVIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman s/p exp lap, h/o large pleural effusions s/p OGT placement REASON FOR THIS EXAMINATION: placement of OGT ______________________________________________________________________________ FINAL REPORT HISTORY: Tube placement post-exploratory laparotomy.",0
AP semi-erect bedside radiograph shows a large partially loculated and partially layering right effusion and small left effusion.,0
There is vascular congestion and central interstitial edema.,0
The lungs are relatively hyperinflated with flattened diaphragms.,0
Right IJ and ET tubes normally positioned and unchanged.,0
"Since otherwise unchanged exam 9 hours earlier, a NG tube has been placed with its tip not visualized but lying well below the diaphragm (positioning of tube suggests possible Billroth gastric drainage).",0
1:32 PM CT LOW EXT W&W/O C RIGHT; CT 100CC NON IONIC CONTRAST Clip # CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE Reason: CT FOOT R/O abscess Admitting Diagnosis: RIGHT LEG CELLULITIS Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with REASON FOR THIS EXAMINATION: CT FOOT R/O abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old man with cellulitis and prior debridement of the medial ankle.,1
TECHNIQUE: Axial images were obtained from the lower leg through the foot before and after the administration of contrast.,0
LOWER EXTREMITY CT WITH AND WITHOUT CONTRAST: An ulcer is present on the medial ankle.,1
"Inferior to this, there is a low attenuation area with a rim of enhancement, which extends from the ulcer superiorly along the medial ankle and into the medial foot.",1
It terminates at the 1st metatarsal- tarsal joint.,0
"Additionally, there is another low density area with an enhancing rim in the lateral shin, the origin of which is not included on the images.",0
"Thus, the superior aspect is not known.",0
"This extends along the distal fibula, posterolaterally, and terminates at the level of the mid calcaneus.",0
A third low density area with an enhancing rim is present in the dorsum of the foot which measures 4 cm across and is 1 cm thick.,0
All of these collections appear to be confined to the subcutaneous tissues.,0
There is no evidence of underlying bony erosion to suggest osteomyelitis.,0
There is no evidence of a septic arthritis in the talar or subtalar joints.,0
"IMPRESSION: Subcutaneous collections with enhancing rims involving the dorsum of the foot, and the medial and lateral ankles which are quite extensive in length.",0
These findings were discussed with Dr. at 7:00 PM on .,0
"5:56 PM CT CHEST W/O CONTRAST Clip # Reason: please evaluate the extend of lung disease, location of the ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman with hiv, hep c, p/w pcp pneumonia, to today with large right sided pneumothorax, REASON FOR THIS EXAMINATION: please evaluate the extend of lung disease, location of the chest tubes in reference to the lung, ______________________________________________________________________________ FINAL REPORT INDICATION: 36 year old woman with a history of asthma, IV drug use, hep C, HIV and PCP.",1
Evaluate tube placement and size of pneumothorax.,0
TECHNIQUE: Helically-acquired contiguous axial images were obtained from the lung apices through the bases without contrast.,0
CT OF THE CHEST: There is a large pneumothorax on the right.,0
Entering the right right hemithorax are three chest tubes.,0
"These have been labeled A, B and C and have been correlated with most recent chest x-ray.",0
Tube A is entering from the mid right axillary line and its tip is in the anterior mediastinum with its side port flush against the lung.,0
Tube B is located more superiorly and its tip is in the anterior mediastinum flush against the soft tissues and crosses the midline.,0
Tube C is not located within the thorax.,0
"This enters in the soft tissues, curves and its tip appears to be abutting a rib and not entering the thorax.",0
This is associated with a significant amount of subcutaneous emphysema.,0
The patient has a tracheostomy which appears in appropriate position.,0
A right IJ catheter is present.,0
"Soft-tissue windows reveal no significant axillary, mediastinal or hilar adenopathy.",0
"Lung windows demonstrate extensive destructive bullous changes within both lungs, most severe on the right.",0
The remaining lung parenchyma has near- complete consolidation.,0
No portions of either lung are spared from this diffuse process.,0
There is no left pneumothorax.,0
There is traction bronchiectasis throughout both lungs.,0
"The visualized portions of the upper abdomen demonstrate an unremarkable unenhanced liver, spleen and stomach.",0
There is a nodularity to the left adrenal gland that measures approximately 9 mm.,0
This is a nonspecific finding.,0
IMPRESSION: 1) Chest tube positions as described above.,0
Tube C is not within the thorax.,0
Tubes A and B tips abut the soft tissues of the mediastinum.,0
"2) Extensive destructive bullous changes within both lungs, most severe on the right.",0
3) Complete consolidation with ground glass opacities within both lungs.,0
"The (Over) 5:56 PM CT CHEST W/O CONTRAST Clip # Reason: please evaluate the extend of lung disease, location of the ______________________________________________________________________________ FINAL REPORT (Cont) differential diagnosis for this includes ARDS and infection.",1
"This is a nonspecific finding but likely a normal variant, given the small size.",0
5) Subcutaneous air in the anterior chest.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins / Azithromycin Attending: Chief Complaint: Transfer from outside hospital with acute hepatitis and liver failure Major Surgical or Invasive Procedure: IJ line insertion Liver biopsy History of Present Illness: Ms. is a 50 year old female with questionable history of alcohol abuse in the past, HTN, CRI with baseline 2.8, and nephrolithiasis, who was transfered from an outside hospital with fulminant liver and renal failure.",1
Her current illness began 3 weeks ago at which time she presented to an ED with URI symptoms and was given cough medicine.,0
"She saw her PCP one week later with continued URI symptoms, and orthopnea, and was prescribed zithromax, prednisone, and flonase.",0
She began to note hematuria and numbness and weakness of her extremities.,0
"Over the next week she developed abdominal pain, bloating, decreased urine output, fever, and chills, at which time she presented again to the outside hospital.",0
"There, she was found to have markedly elevated transaminases, liver failure, and acute renal failure.",1
"She denied nausea, vomiting, dysuria, though has had decreased apetite.",0
She has had a cough productive of sputum.,0
She has been using 325 mg tylenol tabs a day.,0
"LABS AT OSH: wbc 14.3, no eos hct 31 plt 458 Na 134 K 7.2 CL 102 HCO3 10 BUN 94 CR 6.2 Gluc 95 Alb 3 Ca 8.6 TB 4.8, DB 3.9 TP 6.4 ALP 1344 AST 5476 ALT 3419 PT 27, INR 5.6, PTT 33.3 EKG unchanged from baseline.",0
"She was treated for hyperkalemia with kayexalate, ca gluconate.",0
"She was given mucomyst for possible tylenol OD, though tylenol levels were found to be normal.",0
Abdominal CT scan showed: No evidence of apendicitis.,0
"Marked thickening of GB wall, which could be related to ascites, however acute cholecystitis can't be ruled out.",0
Underdistension/thickening of the ascending colon.,0
LLL consolidation with b/l small pleural effusions.,0
She was then transferred to for further care.,0
"Past Medical History: 1) HTN 2) chronic renal failure, w/ baseline Cr 2.8 in : Limited medical care, admitted to in with renal failure.",1
"UA with 2+ protein, 2+ blood, BUN/cr 38/2.8 at that time.",0
apparently did not follow up for outpatient evaluation.,0
"3) Nephrolithiasis 4) Alcohol use/abuse, but not for few months prior to admission Social History: Married with 5 children.",0
She moved from 10 years ago.,0
"She denies any cigarette use, and quit alcohol, though she used to abuse alcohol.",0
Family History: No history of liver or renal disease.,1
"Physical Exam: VS: 97, 138/84, 70, 18, 97%RA Gen: Overweight african-american female, sitting in bed, getting ready to eat dinner, appearing well, obviously jaundiced.",0
"HEENT: Icteric sclerae, hyperpigmentation on face.",0
"CVS: RR, normal rate, no m/r/g lungs: CTA b/l, no w/r/r Abd: NABS, soft, NT, mild distention without rebound or guarding, mild fluid wave.",0
"Extr: No asterixis, 2+ bipedal edema, edema of upper extremities Neuro: CN II-XII intact, strength 5/5 bilaterally.",0
"AT OSH: AF, 74, 169/65, 100% on 2L Gen: Moderately chronically ill appearing female lying 40 degrees in bed with mild respiratory discomfort.",0
Neck: JVD noted to ear.,0
"Chest: Bronchial breath sounds at L mid lung Heart: RR, normal rate, no rub, holosystolic murmur at apex.",0
"Diffusely tender, without rebound or guarding.",0
Liver edge palpable 3 cm below costal margin.,0
"Extr: 1+ lower extremity edema, no rash.",0
"Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.",0
Greatly elevated serum protein with IgG levels > mg/dl may cause interference with CMV IgM results.,0
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.,0
"In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies.",0
Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life.,0
Presence of VCA IgM antibodies indicates recent primary infection.,0
TOXOPLASMA IgG ANTIBODY (Final ): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.,0
"Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.",0
TOXOPLASMA IgM ANTIBODY (Final ): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.,0
The FDA is advising that the result from any one toxoplasma IgM commercial test kit should not be used as the sole determinant of recent toxoplasma infection when screening a pregnant patient.,0
"CXR : There are bilateral pulmonary opacities in the perihilar regions, left worse than right.",0
"This may represent some failure, bilateral infiltrates cannot be excluded.",0
ABD US : Right liver lobe hemangioma.,0
Echogenic kidneys representing parenchymal disease.,1
"Worsening asymmetrical perihilar haziness, left greater than right, most likely due to worsening perihilar edema.",0
No evidence of a retroperitoneal hematoma.,0
Small amount of simple free fluid in the pelvis.,0
Patchy consolidation in the left lower lobe could represent pneumonia.,0
"Probable small hemorrhage in the liver, consistent with recent biopsy.",0
"Acute submassive hepatic necrosis, centrolobular and mid-zonal areas (zones ).",1
About 50% of liver is involved.,0
"Moderate lobular mononuclear cell inflammation with scattered neutrophils, and minimal portal inflammation.",0
Trichrome stain: No increased fibrosis.,0
Iron stain: No stainable iron.,0
Note: Probable causes include drug/toxic and ischemic disease.,0
Transthoracic echo : Conclusions: 1.,0
"Renal biopsy : DIAGNOSIS: Renal Biopsy, needle: Advanced Global Glomerulosclerosis, Interstitial Fibrosis, and Tubular Atrophy, see note.",1
"Note: Light Microscopy: The specimen consists of renal cortex and medulla, containing approximately 6 glomeruli, all of which show advanced injury or global sclerosis.",0
There is moderate to marked interstitial fibrosis and tubular atrophy.,0
Patchy chronic inflammation accompanies the scarring.,0
Arteries show moderate intimal fibroplasia.,0
"Arterioles show moderate-marked mural thickening, with hyaline change.",0
"Immunofluorescence: Not done, as the tissue did not contain glomeruli (block exhausted).",0
Electron Microscopy (C4047) : Fine structural studies of a single glomerular tuft with advanced injury reveal that most capillaries show obsolescence with loss of cellular elements.,0
Extensive foot process effacement with areas of total podocyte loss are seen.,0
Mesangial matrix is increased with occasional granular electron dense deposits.,0
"One loop is more preserved, and shows endocapillary cells with subendothelial electron dense deposits.",0
No subepithelial deposits are noted.,0
Comment: Sample size is limited.,0
Clinical correlation is indicated to determine if this small sample size is representative of the kidneys.,0
The findings are that of advanced injury that cannot be specifically categorized.. CT ABD/PELVIS : 1.,0
Interval development of moderate-size perinephric hematoma as above.,0
These findings were communicated to Dr. at the time of interpretation.,0
"Stable appearance of small, bilateral pleural effusions.",0
Small amount of fluid surrounding the liver.,0
Previously evident capsular hematoma is not well seen.,0
Moderate amount of free fluid is in the pelvis.,0
"Marked circumferential edema of the gallbladder wall in the setting of luminal contraction, secondary to known underlying liver disease.",1
"Brief Hospital Course: 50 year old female with history of HTN and nephrolithiasis, transferred from outside hospital with fulminant liver failure and acute on chronic renal failure, admitted to the MICU.",1
"Briefly, her liver failure had almost resolved by the time of discharge.",1
"The etiology still remains unclear, though zithromax was felt to be the most likely cause.",0
"Her renal failure continued, and she was discharged with anticipation of dialysis in the near future.",1
The cause of her renal failure also remains unclear.,1
"1) Liver failure: On admission, she was found to have transaminases in the 8000 range, as well as INR 3.8, PT 24.5, albumin 3.0, Total bili 9.2, and LDH 12,610.",1
She was admitted to the MICU and followed by the hepatology team.,0
"A number of blood tests were sent off to ascertain the etiology of her liver failure, however they were uniformly negative (these included tylenol, , CMV, EBV, toxoplasma, Hepatitis serologies, leptospirosis, and porphyria).",1
"She underwent a transjugular liver biopsy on the 3rd day of the admission, which showed a non-specific pattern of injury consistent with drug/toxic or ischemic disease.",1
"She unfortunately developed a subcapsular liver hematoma during the procedure, however this was stabilized with FFP and Vitamin K which the patient had already been receiving.",1
"She also received 2 U PRBC, and hematocrit was subsequently stable.",0
A repeat abdominal CT scan later in the course demonstrated resolution of the hematoma.,0
"She was followed by the transplant service, however she never met criteria for liver transplant (no encephalopathy), and liver function began to improve remarkably (see below).",0
"During her hospitalization she received more than 14 units of FFP to keep her INR < 1.5, as well as DDAVP x 5, and multiple dosese of vitamin K. Prior to discharge, her INR had remained < 1.5 on it's own for > 48 hours.",0
"Her transaminases had trended down almost into the normal range (111 and 41 for ALT and AST respectively), and her total bilirubin had trended down to 5.9 from a peak of 40.3.",0
"The etiology of the liver insult remains unclear, however the zithromax course that she had received is a potential , and she should therefore not receive zithromax in the future.",0
The hepatology team felt that she would likely return to completely normal liver function.,0
2) Acute on chronic renal failure: On admission she was also in acute renal failure with creatinine of 5.7.,1
"By report from the outside hospital, her recent baseline Cr was 2.8 in .",0
"Hepatorenal syndrome was in the differential, however her urine sodium was elevated, therefore this diagnosis could not be made.",0
"Initial urine sediment was felt to be consistent with ATN or AIN (RBCs, no acanthocytes, occasional WBC, hyaline casts, occasional renal tubular epithelial cells, granular casts, no muddy brown casts or rbc casts).",1
A renal US revealed echogenic kidneys consistent with parenchymal disease.,1
"A later urine sediment showed many acanthocytic and dysmorphic rbcs, many casts, granular and bite stained, no WBCs, no RBC casts, occasional RTE cells, and 100 mg/dl protein.",0
"The nephrology team felt that her acute insult had resolved, and the new sediment was suggestive of underlying glomerular injury, the possibilities for which included cryoglobulinemia, lupus, endocarditis, idiopathic MPGN, and post-infectious GN.",0
A renal biopsy was recommended.,0
Ms. had a renal biopsy on day 6 of her admission.,0
"Unfortunately there were only 5 glomeruli in the specimen, all globally sclerosed.",0
"The interstitium was severely fibrosed, and there was tubular atrophy, all consistent with advanced injury that could not be specified.",0
"Post-biopsy she developed flank pain, and was noted to have a hematocrit drop from 31 to 25.",0
A CT of the abdomen demonstrated a moderate-sized perinephric hematoma.,0
"She again received FFP, DDAVP, and 2 U PRBC.",0
Her hematocrit stabilized and she had no further flank pain prior to discharge.,0
"Her creatinine on discharge was still markedly above baseline at 6.1, and she was exhibiting mild signs of volume overload (orthopnea, peripheral edema).",0
"The renal team did not feel that she met criteria for urgent hemodialysis, however, and she was therefore seen by the dialysis team and set up with outpatient follow up for probable need for dialysis in the near future.",0
"Of note, her PTH prior to discharge was 369 (up from 15 only a few months prior).",0
"She was also started on lasix at the recommendation of the renal team, with the hopes of improving her fluid balance and controlling her hypertension (see below).",0
3) Pneumonia: At the outside hospital she had been found to have a LLL PNA and was therefore already on levo/flagyl on transfer.,0
These were continued to complete a 7 day course.,0
She remained afebrile throughout her course.,0
"Her wbc was elevated on admission, however this was felt to be related to the acute liver injury, and trended down throughout the admission.",1
"She felt well throughout, and had no shortness of breath other than orthopnea from her fluid overload.",0
Her oxygen saturation was consistenly > 95%.,0
"4) Hypertension: She has a history of hypertension, and had been taking toprol XL 25 mg daily.",0
"In the MICU she had very difficult to control hypertension, and was given metoprolol, hydralazine, and amlodipine.",0
"A labetalol drip was started very briefly, for only a few hours.",0
"On the floors, Mrs. blood pressure was moderately well controlled on metoprolol 50 mg , and amlodipine 10 mg daily.",0
"She was given lasix 40 mg PO once prior to discharge, and discharged on 80 mg PO daily, per renal, plus toprol XL 100 mg daily, and amlodipine 10 mg daily.",0
"5) Anemia: The patient had a persistently low hematocrit during the admission, however she also had an elevated LDH and persistent nucleated RBCs, therefore hematology/oncology was called.",0
Review of peripheral smear was consistent with stress hematopoesis due to acute liver failure and not autoimmune hemolytic anemia.,1
"They felt that her elevated LDH and bili, as well as low haptoglobin, were all a result of her liver disease.",1
She likely has an underlying anemia of chronic disease from her renal failure.,1
Her hematocrit was stable between 30 and 32 prior to discharge.,0
Medications on Admission: Toprol XL 25 mg daily Prednisone x 2 days Flonase Robitussin Discharge Medications: 1.,0
"Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day).",0
"Disp:*180 Tablet, Chewable(s)* Refills:*2* 2.",0
Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day.,0
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 4.,0
Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Acute liver failure, resolving Acute on chronic renal failure Hypertension Discharge Condition: Good, stable.",1
Discharge Instructions: We have increased your dose of Toprol XL to 300 mg daily.,0
"We have also started you on a new medication for your blood pressure called amlodipine, 10 mg daily.",0
We have also started furosemide (Lasix) 80 mg daily to help remove fluid.,0
"Call Dr. if you stop urinating, or get short of breath.",0
"You have a number of follow up appointments, listed below.",0
Followup Instructions: Someone from the kidney doctor's office (Dr. will be calling you to make an appointment for you with them.,0
"Provider: , MD Where: LM CENTER Phone: Date/Time: 1:00 Provider: , MD Where: LM CENTER Phone: Date/Time: 9:30 Provider: , TRANSPLANT SOCIAL WORK Where: TRANSPLANT SOCIAL WORK Date/Time: 11:00 You have an appointment with at Community Health Center on at 1:15 p.m.",0
", MED 3:57 AM CHEST (PORTABLE AP) Clip # Reason: Eval for worsening infiltrates Admitting Diagnosis: VASCULITIS ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with Wegeners and pulmonary hemorrhage REASON FOR THIS EXAMINATION: Eval for worsening infiltrates ______________________________________________________________________________ PFI REPORT Since yesterday, bilateral dense consolidations in mid and lower lung zones are unchanged.",0
There is no residual pulmonary edema.,0
"1:38 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: pooling in esophagus and disorganized swallowing Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with s/p arrest and intubated REASON FOR THIS EXAMINATION: pooling in esophagus and disorganized swallowing ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old man status post arrest, had intubated, pooling in esophagus and disorganized swallowing, evaluate swallowing.",1
FINDINGS: Video swallow fluoroscopy was performed in conjunction with speech and swallow division.,0
Barium passed freely through the esophagus without evidence of obstruction.,0
"There was aspiration with thin and nectar consistencies, which improved on chin tuck.",0
There was mild pharyngeal residue with pureed consistencies but no aspiration or penetration.,0
IMPRESSION: Mild aspiration of thin and nectar consistencies which improved with chin tuck.,0
Pharyngeal residue with pureed consistency.,0
Please see speech and swallow note in OMR for further details.,0
10:52 AM PORTABLE ABDOMEN Clip # Reason: Please evaluate for possible ileus/SBO.,0
"Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with ESLD, ARF, no bowel sounds.",1
REASON FOR THIS EXAMINATION: Please evaluate for possible ileus/SBO.,0
"______________________________________________________________________________ FINAL REPORT @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@ INDICATION: 76-year-old male with end-stage liver disease, acute renal failure and no bowel sounds.",1
Evaluate for ileus or small-bowel obstruction.,0
PORTABLE SUPINE ABDOMEN: The stomach is air filled.,0
There is mildly distended air-filled transverse colon along with some air-filled loops of small bowel.,0
There is overlying haziness consistent with ascites.,0
IMPRESSION: Findings most consistent with ileus.,0
8:18 AM CHEST (PORTABLE AP) Clip # Reason: eval lund fields for consolidation/effusion Admitting Diagnosis: PANCREATIC NECROSIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with abd fluid collect and persistent fever REASON FOR THIS EXAMINATION: eval lund fields for consolidation/effusion ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Persistent fever in a patient with abdominal fluid collection.,0
"A tracheostomy tube is at the midline, with its tip 4 cm above the carina.",0
Right PICC line is terminating at the level of cavoatrial junction.,0
"Bibasilar areas of atelectasis are unchanged, right slightly more than left.",0
Overall no new pathology demonstrated within the chest within the limitations of the chest radiograph.,0
"Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CABG REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
Pt in OR 4 and will be in CSRU in 30 mins.,0
______________________________________________________________________________ WET READ: RSRc WED 11:24 PM R IJ approach PA catheter terminates in prox PA at level of post L 6th/7th rib interspace.,0
NGT/L basilar chest tube satisfactory; ETT in somewhat high position; 7 cm above carina b/w clavicular heads.,0
Low volumes L > R basilar atelectasis.,0
Paged Dr. at 11p .,0
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST: REASON FOR EXAM: Post CABG.,0
ET tube tip is 7 cm above the carina just at the level of the clavicles.,0
Swan- Ganz catheter tip is in the main pulmonary artery.,0
Mediastinal tube is in place.,0
Left chest tube projects in the lower hemithorax.,0
"Aside from atelectasis in the left base, the lungs are grossly clear.",0
11:58 CT HEAD W/O CONTRAST Clip # Reason: Patient with emesis and decreased level of alertness in sett ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman struck by car with occipital bone fracture and SAH.,0
"REASON FOR THIS EXAMINATION: Patient with emesis and decreased level of alertness in setting of known ICH, evaluate for evolution.",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Mental status changes, evaluate for hemorrhage change.",0
Comparison is made with the study from 16 hours earlier.,0
FINDINGS: Again demonstrated are multiple skull fractures which are unchanged in appearance.,1
The left frontal parenchymal hemorrhage is unchanged in size or appearance.,0
"The right occiptial subdural collection, and subarachnoid blood at the cranial vertex are all unchanged.",1
The size of the lateral ventricles and sulci are stable.,0
No new intra or extraaxial collections are present.,0
No new major vascular territorial infarctions are seen.,0
IMPRESSION: Stable appearance of multiple areas of hemorrhage as described above.,0
5:36 PM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH PERFORMED ON .,0
An endotracheal tube is seen with its tip approximately 2.7 cm above the carina.,0
NG tube tip projects over the expected location of the distal esophagus.,0
"Confluent opacities are noted in the left mid and lower lung, which may reflect aspiration or extensive contusion.",0
"There is hilar prominence and pulmonary vascular prominence, likely reflecting mild congestive heart failure.",1
No pneumothorax or large pleural effusion is seen.,0
Left sixth posterior rib appears fractured.,0
"Ribs may be fractured, though suboptimally assessed given the extensive opacification in the left lung.",0
Ovoid calcific densities projecting over the left axilla may be external to the patient.,0
NG tube should be advanced for more optimal position.,0
Mild congestive heart failure with confluent opacity in the left mid and lower lung concerning for contusion or aspiration.,0
CT may be performed to further assess.,0
Apparent left sixth posterior rib fracture.,0
Consider CT or rib series to further assess.,0
"8:55 AM CHEST (PA & LAT) Clip # Reason: ?pulm edema/infiltrates Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 81 yo male with h/o CABG x2, CHF w/ EF 20%, ICD/PPM admitted w/ anterolateral STEMI s/p BMS in vein to diag, and cardigenic shock, now off dopamine drip and HD stable on cardiac meds including BB and ACEI but continues to have SOB.",1
"REASON FOR THIS EXAMINATION: ?pulm edema/infiltrates ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: STEMI, cardiogenic shock, assess for pulmonary edema.",1
There has been interval improvement of now mild pulmonary edema with mild vascular engorgement.,0
Patient is post-median sternotomy and CABG.,0
The transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle.,0
"Bilateral pleural effusions have increased in size in moderate amount, right greater than left.",1
"In the left, pleural effusion is tracking through the fissure, could be loculated.",1
IMPRESSION: Improvement in now mild interstitial pulmonary edema.,0
"Increasing bilateral pleural effusions, greater on the right and probably loculated on the left.",1
"6:51 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for ET tube placement Admitting Diagnosis: POLYSUBSTANCE ABOUSE;SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with seizure, substance abuse, intubated at OSH after seizure x2.",0
"REASON FOR THIS EXAMINATION: eval for ET tube placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Seizures, substance abuse, evaluation for endotracheal tube placement.",1
"FINDINGS: As compared to the previous radiograph, the tube has been advanced.",0
The tip of the endotracheal tube now projects 2.7 cm above the carina.,0
The nasogastric tube is in unchanged position.,0
The ventriculoperitoneal shunt is in unchanged position.,0
"No relevant changes in the lung parenchyma, the pleura and the cardiac silhouette.",0
2:01 PM CHEST (PA & LAT) Clip # Reason: eval LLL consolidation vs atelectasis Admitting Diagnosis: CHIARI MALFORMATION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with with tmax 101.9 / with prolonged bedrest and poor participation wtih IS REASON FOR THIS EXAMINATION: eval LLL consolidation vs atelectasis ______________________________________________________________________________ WET READ: NATg MON 2:53 PM stable compared with prior.,0
"______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Prolonged bed rest, left lower lobe consolidation.",0
"FINDINGS: Compared to the study from , there is improved aeration of both lower lobes.",0
There is no focal infiltrate or effusion.,0
Right IJ line tip is in the SVC.,0
10:23 PM CT C-SPINE W/O CONTRAST Clip # Reason: FALL.PAIN.R/O FX ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman s/p fall REASON FOR THIS EXAMINATION: eval for fracture No contraindications for IV contrast ______________________________________________________________________________ WET READ: ACKe SAT 11:43 PM no fracture or malalignment.,0
degenerative changes ______________________________________________________________________________ FINAL REPORT INDICATION: Fall.,0
CERVICAL SPINE CT WITHOUT CONTRAST: No prior for comparison.,0
"Alignment is maintained, though there is exaggeration of the normal lordotic curvature of the cervical spine.",0
"There are some associated facet degenerative changes, particularly at left C4-5, and degenerative change of the C1-C2 space.",0
There is minor scarring at the lung apices.,0
Minor polypoid mucosal thickening is seen in the left maxillary sinus.,0
"2:09 PM HAND (AP, LAT & OBLIQUE) LEFT Clip # Reason: r/o scaphoid fx, occult hand fracture Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with scaphoid pain and poor PROM of fingers.",0
"Echymosis on dorsum of hand REASON FOR THIS EXAMINATION: r/o scaphoid fx, occult hand fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Scaphoid pain and poor movement of fingers.",0
"Ecchymosis on dorsum of hand, evaluate for scaphoid fracture.",0
TECHNIQUE: Four views of the right hand.,0
There are prominent degenerative changes in the proximal and distal interphalangeal joints with joint space narrowing and prominent osteophyte formation.,0
"In the PIP joint of the fifth digit, there are extensive erosive changes involving the distal portion of the middle phalanx.",0
The metacarpophalangeal joints are preserved.,0
There are degenerative changes in the first carpometacarpal joint with joint space narrowing and cyst formation.,0
There are small cysts in the capitate and the triquetrum.,0
There is no evidence of scaphoid fracture.,0
Dedicated scaphoid views were not obtained.,0
There is calcification of the radial artery.,0
IMPRESSION: No evidence of fractures.,0
Extensive degenerative changes joint disease with erosive changes of the fifth right distal interphalangeal joint.,0
"10:49 AM CHEST (PORTABLE AP) Clip # Reason: fever, eval for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with REASON FOR THIS EXAMINATION: fever, eval for infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Fever and cough.",0
CHEST X-RAY PORTABLE AP: COMPARISON: chest x-ray.,0
An NG tube is visible with its tip in the stomach.,0
An endotracheal tube is visible with its tip 4.4 cm above the carina.,0
There is a right internal jugular catheter with its tip in the superior vena cava.,0
"The lungs demonstrate no consolidation, opacity, or pleural effusion.",0
"5:18 AM CHEST (PORTABLE AP) Clip # Reason: eval CHF/PNA Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man admitted with atypical chest pain, now in MICU for presumed treatment of DTs, intubated for airway protection.",0
"REASON FOR THIS EXAMINATION: eval CHF/PNA ______________________________________________________________________________ FINAL REPORT INDICATION: Atypical chest pain, delirium tremors, intubated for airway obstruction.",1
"FINDINGS: Single portable AP view of the chest shows a left pleural effusion, unchanged since the last exam.",0
"There is perihilar haziness and mild cardiomegaly, suggesting an element of cardiac failure.",0
Endotracheal tube and single lead pacemaker as well as NG tube remain in place.,0
"OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: therapeutic and diagnostis paracentesis please, also please Admitting Diagnosis: ABDOMINAL PAIN/ CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with h/o liver tx and grade III gastric varices admitted for ascites and abd pain.",1
"REASON FOR THIS EXAMINATION: therapeutic and diagnostis paracentesis please, also please check cell count, gram stain and cxs.",0
______________________________________________________________________________ FINAL REPORT ULTRASOUND-GUIDED PARACENTESIS.,0
"CLINICAL HISTORY: Ascites in a patient with liver transplant, therapeutic and diagnostic paracentesis desired.",1
FINDINGS: Ultrasound guidance was used to localize the patient's ascites and determine the best location in which to drain.,0
"The advantages and disadvantages of the procedure were explained to the patient, after which she gave written informed consent.",0
The skin of the lower mid anterior abdomen was prepped and draped in the usual sterile fashion and 10 cc of lidocaine 1% were administered subcutaneously.,0
A 19-gauge needle was inserted into the fluid collection and approximately 2 liters of amber colored fluid were removed.,0
Specimens of this fluid were sent for cytological and microbiological analysis.,0
The attending radiologist was present at all significant points during the procedure.,0
IMPRESSION: Successful removal of 2 liters of amber fluid from the patient's abdomen.,0
LINE PLACEMENT Clip # Reason: sp central line placement Admitting Diagnosis: MIRRIZI SYNDROME/SDA ______________________________________________________________________________ MEDICAL CONDITION: 85 y/o male s/p ERCP for abd pain and elevated LFTs.,0
Presents now for stent pull assessment of biliary narrowing.,0
"Post procedure wheezing and hypoxia REASON FOR THIS EXAMINATION: sp central line placement ______________________________________________________________________________ FINAL REPORT CHEST, AP PORTABLE SINGLE VIEW INDICATION: Status post ERCP for abdominal pain and elevated LFTs.",0
Presents now for stent pull.,0
"Post-procedure wheezing and hypoxia, status post central line placement.",0
FINDINGS: AP single view of the chest of patient in supine position demonstrates the presence of a right internal jugular approach central venous line seen to terminate overlying the SVC at the level of the carina.,0
No pulmonary congestion is present and the lateral pleural sinuses are free.,0
Also noted is the presence of an NG tube seen to terminate below the level of the diaphragm.,0
IMPRESSION: Uncomplicated central venous line placement.,0
"6:32 PM TRAUMA #3 (PORT CHEST ONLY) PORT Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with 40 foot fall REASON FOR THIS EXAMINATION: trauma ______________________________________________________________________________ FINAL REPORT EXAM: Chest, single supine AP portable view.",0
CLINICAL INFORMATION: 37-year-old male with history of 40-foot fall.,0
FINDINGS: Single supine AP portable view of the chest was obtained.,0
Underlying trauma board partially obscures the view.,0
There are relatively low lung volumes.,0
"Left lateral pulmonary contusions seen on subsequent chest CT are better appreciated on that study, as are multiple left-sided rib fractures.",1
No pleural effusion is seen.,0
"Small loculated left pneumothorax is also not appreciated on the current study, but seen on subsequent CT, due to differences in modality.",1
The superior mediastinum is slightly prominent.,0
9:09 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: assess for interval change Admitting Diagnosis: HYDROTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 61M s/p thoracentesis with worsening dyspnea REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Status post thoracentesis with worsening dyspnea.,0
There is a small-to-moderate right pneumothorax.,0
There is a new right lower lobe collapse.,0
Left lower lobe retrocardiac atelectasis has worsened.,0
"Right pleural effusion, right hilar mass and multiple areas of opacities in the left lobe are unchanged.",0
Findings were conveyed to Dr. at 10:.,0
"10:12 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for interval change in hepatic fluid collections, IV co Admitting Diagnosis: ELEVATED BILIRUBIN Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with hepatic fluid collections REASON FOR THIS EXAMINATION: eval for interval change in hepatic fluid collections, IV contrast only No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT PROCEDURE: CT abdomen and pelvis.",0
REASON FOR EXAM: Evaluate change in hepatic fluid collections.,0
TECHNIQUE: MDCTA abdomen and pelvis was performed following the administration of oral and IV contrast with multiplanar reformats.,0
Comparison is made to the previous study dated .,0
"FINDINGS: The internal-external biliary drain is unchanged in position; and a new internal-external drain has been placed traversing the segment VI of the liver with its tip also in the duodenum, the central intrahepatic biliary duct and lateral segmental biliary ductal dilatation have nearly completely resolved, although some mild dilatation still persists in the left lobe.",0
A new pigtail catheter has also been placed in a posterior subcapsular hepatic collection which has now resolved.,0
"Further seperate collections medial and lateral to the inferior right lobe of the liver are similar at 65 x 25 mm and 32 x 64 mm, loculated enhancing collections at the gallbladder fossa are stable, the largest component is 18 x 28 mm.",0
"The appearance of the pancreas, kidneys, adrenal glands, spleen is unchanged.",0
No large bowel dilatation or bowel wall thickening.,0
A small pocket of free fluid surrounds the anterior border of the spleen.,0
The prostate gland is enlarged.,0
"The abdominal aorta, renal arteries, SMA, celiac axis, and are all widely patent.",0
Bilateral pleural effusions have slightly increased in size and associated with overlying compressive atelectasis.,0
"Degenerative changes throughout the lumbosacral spine with vacuum phenomena at T11, T12 and L1 are unchanged.",0
Interval placement of a second internal-external biliary drain with resolution of intrahepatic biliary ductal dilatation in the right lobe of the liver.,0
2) New pigtail catheter which has drained a subcapsular fluid collection posteriorly to segment VI/VIII.,0
"(Over) 10:12 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for interval change in hepatic fluid collections, IV co Admitting Diagnosis: ELEVATED BILIRUBIN Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 3) Lateral and medial oblong hepatuic subcapsularfluid collections abutting the inferior right lower lobe and loculated enhancing collection in the gallbladder fossa are stable.",0
4) Interval increase in the bilateral pleural effusions which are now moderate with overlying compressive atelectasis.,0
The case was discussed with Dr .,0
"1:38 PM CHEST (PORTABLE AP) Clip # Reason: BRAIN;CHEST AND LIVER MASS Admitting Diagnosis: BRAIN;CHEST AND LIVER MASS ______________________________________________________________________________ MEDICAL CONDITION: 39 year old woman with widely metastatic lung ca to live, brain and bone to OR on for VP shunt placement REASON FOR THIS EXAMINATION: R/O infiltrates, effusions, edema ______________________________________________________________________________ FINAL REPORT INDICATION: History of metastatic lung cancer.",1
PORTABLE AP CHEST X-RAY: Comparison is made to study from .,0
"A left upper lobe opacity is again seen, indicating the previously documented lung malignancy.",0
No other opacities or pleural effusions are noted.,0
The heart size and mediastinal contours are unchanged from previous exam.,0
Osseous structures are unchanged from previous exam.,0
IMPRESSION: Again seen is previously reported left upper lobe opacity indicating malignancy.,0
No other opacities or pleural effusions are seen.,0
Height: (in) 76 Weight (lb): 181 BSA (m2): 2.13 m2 BP (mm Hg): 153/58 HR (bpm): 118 Status: Inpatient Date/Time: at 13:34 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
AORTIC VALVE: The aortic valve leaflets are severely thickened/deformed.,0
The distal half of the left ventricle and posterior wall are akinetic.,0
"Compared with the prior report (tape unavailable for review) of , LV function has decreased.",0
"7:08 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate, effusion Admitting Diagnosis: TRACHEAL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with COPD, pneumonia, tracheomalacia s/p LMSB stent removal.",1
"Please assess interval change post extubation REASON FOR THIS EXAMINATION: infiltrate, effusion ______________________________________________________________________________ FINAL REPORT INDICATION: An 80-year-old woman with COPD and pneumonia and tracheomalacia status post extubation.",0
"CHEST, AP PORTABLE RADIOGRAPH: The heart size is within the upper limits of normal.",0
There is a heavily calcified and unfolded aorta.,0
There is a persistent left lower lobe consolidation and small pleural effusion.,0
"The left internal jugular central venous catheter tip is in the upper SVC, without evidence of pneumothorax.",0
The osseus structures are unremarkable.,0
Persistent left lower lobe consolidation and small pleural effusion.,0
"2:33 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?ETT position Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman s/p RML wedge resection and RLL lobectomy now s/p intubation REASON FOR THIS EXAMINATION: ?ETT position ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: Right middle lobe wedge resection, right lower lobectomy and intubation.",0
Endotracheal tube is 4 mm above carina.,0
There is a small left pneumothorax.,0
This is unchanged since the prior film of the same date.,0
The diffuse bilateral pulmonary opacities are again demonstrated.,0
"3:50 AM CHEST (PORTABLE AP) Clip # Reason: s/p swan ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with h/o ulcerative cholitis, now w/ possible cholangitis; now febrile to 101.4, rigoring.",0
REASON FOR THIS EXAMINATION: s/p swan ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: Fever and Swan-Ganz placement in patient with possible cholangitis.,0
Swan-Ganz catheter is in an intralobar division of the right pulmonary artery.,0
12:52 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate or other abnormality.,0
Admitting Diagnosis: PERSISTANT NAUSEA AND VOMITING ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with hx of EtOH abuse admitted with dehyration/ metabolic acidosis now with hypoxia.,0
REASON FOR THIS EXAMINATION: Evaluate for infiltrate or other abnormality.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: ETOH abuse, admitted with dehydration, metabolic acidosis, now hypoxia, question infiltrate.",1
Heart size is at the upper limits of normal or slightly enlarged.,0
"A left side a pacemaker is present, with lead tips over right atrium and right ventricle.",0
"Compared with , the right hemidiaphragm is again elevated.",0
"However, there is new more patchy opacity at the right base.",0
There is minimal atelectasis at the left base.,0
"No gross effusion, though a small effusion at the right base cannot be entirely excluded.",0
Deformity along the right chest wall and along the right scapula probably reflects old healed fractures.,0
There is also evidence of a chronic right shoulder rotator cuff tear.,0
IMPRESSION: New patchy opacity at right base of uncertain significance -- ?,0
new atelectasis versus early infiltrate versus differences in appearance due to change in positioning.,0
"If clinically indicated, a lateral view may help to further assess this finding.",0
"11:02 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: chest tube placed Rt Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL VALVE DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman s/p mvr/cabg REASON FOR THIS EXAMINATION: chest tube placed Rt ______________________________________________________________________________ FINAL REPORT INDICATION: Mitral valve replacement, CABG.",1
"CHEST X-RAY, AP PORTABLE: Comparison study , at 7:59 a.m.",0
The current examination is not optimal due to poor patient position and technique.,0
"There is a new right chest tube, which has its tip overlying the medial mid thorax.",0
The remaining lines remain in stable position.,0
"Of note, the NG tube is not well seen but the tip is felt to be within the mid/distal esophagus.",0
There are persistent bilateral effusions and bibasilar atelectasis.,0
The appearance is otherwise similar to the prior study earlier same day.,0
IMPRESSION: Interval placement of a right-sided chest tube.,0
The nasogastric tube tip is presumed to be in the distal third of the esophagus and could be repositioned distally.,0
"OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: please perform diagnostic paracentesis, unable to perform at Admitting Diagnosis: SHORTNESS OF BREATH ********************************* CPT Codes ******************************** * PARACENTESIS DIAG.",0
"OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with cirrhosis, need diagnostic tap to r/o SBP, could not perform at bedside REASON FOR THIS EXAMINATION: please perform diagnostic paracentesis, unable to perform at bedside ______________________________________________________________________________ FINAL REPORT INDICATION: Diagnostic paracentesis to evaluate for SBP.",0
"PROCEDURE: After explaining potential risks and benefits, and alternatives of the procedure to the patient, written informed consent was obtained.",0
Patient identity was confirmed with three identifiers.,0
A pocket of ascites was localized in the midline of the lower abdomen.,0
"Using ultrasound guidance, aseptic technique and 1% lidocaine for local anesthesia, 3 liters of clear yellow fluid was drained from the abdomen, a portion of which was sent for the requested laboratories.",0
The 5 French UV catheter was then removed and adequate hemostasis was achieved.,0
There were no immediate complications and Dr. was an essential participant.,0
Patient status post ultrasound-guided diagnostic and therapeutic paracentesis.,0
5:25 PM CAROT/CEREB Clip # Reason: MCA STENOSIS Admitting Diagnosis: TIA;CEREBRAL STENOSIS;TELEMTRY Contrast: OPTIRAY Amt: 50 ********************************* CPT Codes ******************************** * SEL CATH 2ND ORDER CAROTID/CEREBRAL UNILAT * * CAROTID/CEREBRAL UNILAT C1760 CLOSURE DEVICE VASC IMP/INS * * C1769 GUID WIRES INFU/PERF C1769 GUID WIRES INFU/PERF * * C1894 INT/SHTH NOT/GUID EP NON-LASER * **************************************************************************** ______________________________________________________________________________ FINAL REPORT PREOPERATIVE DIAGNOSIS: Recurrent TIA referable to left middle cerebral artery stenosis.,0
Rule out worsening of middle cerebral artery narrowing.,0
"POSTOPERATIVE DIAGNOSIS: Progressive improvement in atherosclerosis of the left middle cerebral artery stenosis, however, with persistent stenosis at the origin of the superior division of the left M2 origin.",1
ANESTHESIA: Conscious sedation with local infiltration of the right groin.,0
INDICATION: Ms. is a patient who is known to left middle cerebral artery stenosis.,0
She has previously undergone balloon angioplasty of the left MCA centering most down the inferior division with excellent angiographic result.,0
"There was progression of her disease, however, on MR imaging and follow up angiography showed the partial restenosis of the previously treated segment.",0
"She remained asymptomatic, however, and according was not retreated using endovascular means.",0
She presents this time with a first onset of TIA involving her left middle cerebral artery distribution and according is undergoing the cerebral angiogram to determine optimal treatment.,0
CONSENT: The patient was given a full and complete explanation of the procedure.,0
"Specifically the indications, risks, benefits and alternatives to the procedure were explained in detail.",0
"In addition the possible complications such as the risk of bleeding, infection, stroke, neurological deficit or deterioration, groin hematoma and other unforeseen complications including the risk of coma and even death were outlined.",0
The patient understood and wished to proceed with the operation.,0
PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and palced on the table in supine position.,0
The right groin area was prepped and draped in the usual sterile fashion.,0
Next a diagnostic catheter was used to selectively catheterize the following vessels over a guidewire in succession: Left common carotid artery and a left internal carotid artery.,0
"RESULTS: Injection of the left common carotid artery reveals the presence of minimal atherosclerotic disease in the left internal carotid artery, however, shows a complete occlusion of the left external carotid artery which is unchanged from previously.",0
Injection of the left internal carotid artery (Over) 5:25 PM CAROT/CEREB Clip # Reason: MCA STENOSIS Admitting Diagnosis: TIA;CEREBRAL STENOSIS;TELEMTRY Contrast: OPTIRAY Amt: 50 ______________________________________________________________________________ FINAL REPORT (Cont) intracranially shows no atherosclerotic disease involvement of the supraclinoid segment and shows the previously noted narrowing of the left M1 trunk.,0
"This is actually improved compared to pre-treatment, however, one of the persisting findings is now a narrowing of the superior division of the left M2 trunk origin which is most likely be responsible for her symptoms.",0
"The inferior division which have been previously treated appears to be widely patent, although hypoplastic compared to normal.",0
"Nonetheless, there is significant pial to pial collaterals from intracerebral circulation towards the territory supplied by the left MCA distribution.",0
"Given the appearance of this stenosis, endovascular revascularization using balloon angioplasty will be deferred and a trial will be now to increase her anticoagulant regimen to include both antiplatelets and anticoagulate.",0
IMPRESSION: Left M2 origin persistent stenosis with overall improved appearance of the left M1 trunk and inferior M2 division narrowing.,0
"9:25 AM CHEST (PORTABLE AP) Clip # Reason: eval forPTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with removal of chest tubes REASON FOR THIS EXAMINATION: eval forPTX ______________________________________________________________________________ FINAL REPORT AP CHEST 9:55 HISTORY: Chest tube removed, evaluate for pneumothorax.",1
IMPRESSION: AP chest compared to through : There is no appreciable pneumothorax or pleural effusion following removal of the left pleural drain.,0
"Lungs are low in volume, and atelectasis is mild to moderate at the left lung base unchanged.",0
Cardiomediastinal silhouette has a normal post-operative appearance.,0
Right jugular line ends in the SVC.,0
"5:46 PM BABYGRAM (CHEST & ABDOMEN) PORT Clip # Reason: line adjustment, Please do lateral/cross table ______________________________________________________________________________ MEDICAL CONDITION: Infant with adjusted lines REASON FOR THIS EXAMINATION: line adjustment, Please do lateral/cross table ______________________________________________________________________________ FINAL REPORT INDICATION: Infant with line adjustment.",0
FINDINGS: A single cross table lateral view is submitted for interpretation on .,0
The radiograph is underpenetrated and this limits diagnostic evaluation of the lines.,0
An endotracheal tube is seen just pass the thoracic inlet and this appears to have been advanced since the radiograph performed earlier the same day.,0
Umbilical venous catheter tip is seen projecting over the chest at a mid thorax level.,0
The tip of the umbilical arterial catheter cannot be visualized due to underpenetration of the radiograph.,0
The film is markedly limited and this is discussed with IC team.,0
"11:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please evaluate for interval changes in liver abscesses, pla Admitting Diagnosis: UROSEPSIS-ANEMIA-ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with pancreatic ca s/p whipple, recurrent bacteremia, and mult liver abscesses s/p perc drain placement x2 and 1 self-dc'ed ON.",1
"REASON FOR THIS EXAMINATION: Please evaluate for interval changes in liver abscesses, placement of drain and need for repositioning/replacement of current drain and replacement of old drain.",1
"CONTRAINDICATIONS for IV CONTRAST: ARF resolving ______________________________________________________________________________ FINAL REPORT INDICATIONS: Pancreatic cancer status post Whipple with multiple liver abscesses, with prior CT and ultrasound-guided drainages.",1
TECHNIQUE: Non-contrast CT imaging of the abdomen and pelvis.,0
"COMPARISON: CT from , MR , and ultrasound from .",0
CT OF THE ABDOMEN WITHOUT CONTRAST: There is a large right and a small left pleural effusion with associated bibasilar atelectasis.,0
There has been interval accumulation of a very large amount of ascitic fluid throughout the abdomen.,0
One catheter is seen within this abscess within segment VII.,0
A larger abscess is identified posterior and lateral to the drained abscess.,0
An additional abscess is seen inferiorly within the right posterior lobe of the liver (segment VI).,1
"This was the abscess, which was previously drained.",0
The remaining appearance of the abdomen is unchanged with a large calculus in the right renal collecting system and several smaller stones in the left.,0
CT OF THE PELVIS WITHOUT CONTRAST: Foley catheter is present within the bladder.,0
There is a large amount of ascites within the pelvis.,0
Catheter previously placed in the segment VI no longer present.,0
Catheter present in segment VII abscess remains in satisfactory position.,0
Interval reaccumulation of a large amount of ascitic fluid throughout the abdomen.,0
This will require paracentesis prior to re-attempting catheter placement.,0
"Two remaining abscesses, one posteriorly and lateral to drained collection, the other inferiorly in segment VI (collection previously drained).",0
"(Over) 11:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please evaluate for interval changes in liver abscesses, pla Admitting Diagnosis: UROSEPSIS-ANEMIA-ACUTE RENAL FAILURE ______________________________________________________________________________ FINAL REPORT (Cont)",1
8:19 AM CT HEAD W/O CONTRAST Clip # Reason: 31 year old woman s/p pcomm aneursym clipping with new right ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with no pmh sudden onset worse ha life n/v photophobic REASON FOR THIS EXAMINATION: 31 year old woman s/p pcomm aneursym clipping with new right sided weakness please assess for infarct vs new bleeding ______________________________________________________________________________ FINAL REPORT HISTORY; Status posterior communicating artery aneurysm clipping with new right sided weakness.,0
Developing infarct or rehemorrhage suspected clinically.,0
TECHNIQUE: Noncontrast head CT scan was obtained.,0
FINDINGS: There is a nearly 2 cm area of diminished density within the area of the posterior limb of the left internal capsule extending through the genu towards the head of the left caudate nucleus.,0
This abnormality has developed since the prior study of .,0
"Most likely, it represents an area of developing infarction.",0
No definite rehemorrhage is identified.,0
"However, the basal cisterns are difficult to visualized in their entirety due to extensive streak artifacts arising from the aneurysm clip.",0
Post surgical changes representing a left frontal-temporal craniotomy are also seen with fairly extensive scalp soft tissue swelling.,0
CONCLUSION: Developing infarction within the left internal capsule and adjacent structures as discussed above.,0
COMMENT: There is fluid within the left sphenoid air cell which may be a reflection of prior intubation and/or developing paranasal sinus inflammatory change.,0
5:47 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"pulm process Admitting Diagnosis: LEFT MAIN STEM OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with CHF, hypotension REASON FOR THIS EXAMINATION: ?",0
"pulm process ______________________________________________________________________________ FINAL REPORT HISTORY: CHF, hypotension, question pulmonary process.",0
The side port of the NG tube lies near the GE junction.,0
BIlateral chest tubes again noted.,0
"Again noted is cardiomegaly, with a calcified left ventricular aneurysm.",0
"Also again noted is mild pulmonary vascular plethora, consistent with mild CHF.",0
Increased retrocardiac density is unchanged.,0
"1:16 PM CHEST (PORTABLE AP) Clip # Reason: h/o pe's too ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with sob and chf and pneumonia REASON FOR THIS EXAMINATION: h/o pe's too ______________________________________________________________________________ FINAL REPORT INDICATIONS: 83-year-old man with shortness of breath, congestive heart failure, and pneumonia.",1
"CHEST, UPRIGHT AP PORTABLE: The heart size is difficult to assess.",0
"There are bilateral small effusions, but no pneumothorax.",0
Bilateral mid lung alveolar opacities are consistent with acute pulmonary edema.,0
"In addition, there is patchy dense opacity in the right lower lobe, which is more focal, and although there is also edema, pneumonia cannot be excluded especially in this area.",0
Superimposed pneumonia is also possible and cannot be excluded.,0
"6:32 PM CHEST (PORTABLE AP) Clip # Reason: assess for fever, hypoxia and peripheral edema ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with history of asthma REASON FOR THIS EXAMINATION: assess for fever, hypoxia and peripheral edema ______________________________________________________________________________ FINAL REPORT INDICATION: 68 year old man with history of asthma.",0
PORTABLE SEMI-UPRIGHT AP VIEW OF THE CHEST: No prior images for comparison.,0
The heart size is upper limit of normal for AP technique.,0
There is prominence of the pulmonary vasculature and there are bilateral diffuse patchy alveolar opacities.,0
The right costophrenic angle is excluded laterally and cannot be assessed.,0
There is blunting of the left costophrenic angle consistent with an effusion.,0
There is a left retrocardiac opacity consistent with atelectasis and/or infiltrate.,0
Left lower lobe pneumonia cannot be excluded.,0
"5:33 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: Aortic dissection discovered on previous CT , please f/u Admitting Diagnosis: AORTIC DISSECTION Field of view: 45 ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with Abd Ao dissection REASON FOR THIS EXAMINATION: Aortic dissection discovered on previous CT , please f/u No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Follow up on aortic dissection flap seen on CT of .",0
TECHNIQUE: CTA of the abdomen with and without contrast and reconstructions.,0
CTA OF THE ABDOMEN: The visualized portions of the lung bases are clear.,0
There is minimal basilar atelectasis.,0
The previously noted small pericardial effusion has not increased in size.,0
"Liver, gallbladder, pancreas, spleen, and adrenal glands are normal.",0
There is again seen an unchanged left lower pole renal cyst.,0
"Several very small hypoattenuating lesions are seen throughout both kidneys, too small to characterize.",0
No abdominal lymphadenopathy is seen.,0
CTA OF THE PELVIS: Again seen is dissection flap with contrast opacification of the false lumen along a 5 cm segment of the infrarenal abdominal aorta.,1
"In the interval since , there has been increase in the aortic diameter of approx.",0
3-4 mm in sagittal and transverse dimension.,0
"On teh precontrast scan, there is a cresent of high density material surrounding the true lumen consistent with wall hematoma.",0
This is seen extending caudally into both commmon iliac arteries.,0
Comparison to the prior CT is limited this did not include a noncontrast study.,0
"On the postcontrast scan, a small connection between true and false lumen is seen at the superior aspect of the contrast opacified dissection.",0
The originates at the same level and is well opacified.,0
A ventral hernia containing omentum on large bowel is unchanged.,1
Rectum and sigmoid show diverticulosis without diverticulitis.,0
"No free air, free fluid or lymphadenopathy is seen within the pelvis.",0
BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.,0
"Moderate to severe degenerative changes are seen throughout the lower thoracic spine, lumbar spine and sacroiliac joints.",0
Progressive intramural hematoma in infrarenal abdominal aortic dissection.,1
Close clinical observation of the patient is recommended.,0
This has been communicated to Dr. at approx.,0
Otherwise no significant interval change to .,0
"(Over) 5:33 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: Aortic dissection discovered on previous CT , please f/u Admitting Diagnosis: AORTIC DISSECTION Field of view: 45 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"1:25 PM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # Reason: ?",0
shoulder fx or displacement ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with fall REASON FOR THIS EXAMINATION: ?,0
"shoulder fx or displacement ______________________________________________________________________________ FINAL REPORT STUDY: Right shoulder, three views, .",0
HISTORY: 86-year-old woman with fall.,0
Evaluate for fracture or displacement.,0
FINDINGS: No previous studies available for direct comparison.,0
No displaced fractures are seen.,0
"There are extensive degenerative changes of the glenohumeral joint with bone-on-bone appearance, best seen on the axillary view.",0
"There is also loss of the subacromial space, suggestive of rotator cuff pathology.",0
Sutures are seen within the right upper lobe.,0
There is overall demineralization which limits evaluation for subtle non-displaced fractures.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY: This baby girl, at 34 and 3/7 weeks, was admitted to the newborn Intensive Care Unit with issues relating to prematurity.",1
"She was via repeat Cesarean section secondary to a complete placenta previa and placenta accreta to a 38 year-old, Gravida 4, Para 3 to 4 mother.",1
"Prenatal laboratory studies were significant for blood type B positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen negative, group B strep unknown.",0
A routine ultrasound at 18 weeks demonstrated complete previa with accreta.,0
Fetal survey was normal at that time.,0
"Due to previa and accreta, plan was made for Cesarean section delivery.",1
"Mother was given Betamethasone and course was completed on , 2 days prior to delivery.",1
"At the time of delivery, infant emerged vigorous, cried spontaneously.",0
"She was brought to the warmer where she was bulb suctioned, dried and stimulated.",0
She had evidence of a good heart rate.,0
"Her tone, color and respiratory effort were strong.",0
Her Apgars were 8 at 1 minute and 9 at 5 minutes.,0
She was brought to the newborn Intensive Care Unit for further care.,0
"PHYSICAL EXAMINATION: Weight 2.2 kg, 50th percentile.",0
"Length 46 cm, 50th percentile.",0
"Head circumference 32.25 cm, 50th to 75th percentile.",0
"In general, this preterm female infant demonstrated mild respiratory distress with evidence of subcostal retractions.",1
HEENT: Anterior fontanel open and soft.,0
Eyes and ears: Normal position and rotation.,0
"Cardiovascular: Regular rate and rhythm, no murmur.",0
Lungs: Good and equal breath sounds with no grunting or flaring but minimal subcostal retractions.,0
"Genitourinary: Normal external female, patent anus.",0
Normal appearing spine with no pits or dimples.,0
"Neurologic: Alert, moves all 4 extremities.",0
Tone appropriate for gestational age.,0
"HOSPITAL COURSE: Respiratory: Due to increased work of breathing, the infant was electively intubated and was given 2 doses of Surfactant.",1
"She had a blood gas with capillary means showing a pH of 76, C02 of 36.",0
She had peak pressures of 24/6 with a rate of 20.,0
"She was weaned and by day of life 1, was extubated to C-Pap in room air.",0
She continued on C-Pap through day of life 3 breathing 40s to 80s.,0
"On day of life 4, she was removed from C-Pap and has been breathing comfortably with intermittent tachypnea to the 70's, 95% saturated in room air.",0
She has not had evidence of apnea or prematurity.,0
She had normal blood pressures and pulses noted throughout and had no inotropic support needed.,0
IV access was by peripheral intravenous.,0
with intravenous fluids of D-10-W.,0
Maintenance electrolytes were added as needed with serum electrolytes noted to be in the normal range.,0
Enteral feeds were initiated by gavage on day of life 4 and have advanced quickly to full enteral feeds by day of life 5.,0
Intravenous fluids have been discontinued.,0
Blood glucose was also noted to be in the normal range throughout.,0
Urine output was noted to be adequate and the infant has passed meconium stools.Her weight at discharge was 2155 grams and she is feeding Enfacare formula.,0
Gastrointestinal: Serum bilirubin has followed and peeked at 10.2 over 0.4 on day of life 3.,0
She was started on single phototherapy at that time.,0
Rebound bilirubin was 4.1/0.2 on .,0
"Hematologic/Infectious disease: CBC and blood culture were obtained on admission, revealing a white blood cell count of 13.6 with 63 polys and 0 bands.",0
"Hematocrit 56.5% and platelets 290,000.",0
Ampicillin and Gentamycin were initiated with negative cultures at 48 hours and improving clinical course were discontinued after 48 hours of treatment.,0
Infant has continued to improve and remained clinically well off antibiotics.,0
Neurologic: This infant appears appropriate for gestational age.,0
Audiology: Hearing screen passed on .,0
Ophthalmology examination is not indicated at this gestational age.,0
"NAME OF PRIMARY PEDIATRICIAN: , MD, Pediatrics.",0
Medications: None at this time.,0
Car seat position screening done prior to discharge home.,0
"State newborn screen was obtained on , results of which are pending at this time.",0
IMMUNIZATIONS: Received included Hepatitis B vaccine administered on .,0
Immunizations recommended include Synagis RSV prophylaxis which should be considered from through for infants who meet any of the following 3 criteria: 1. at less than 32 weeks.,1
"2. between 32 and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or; 3.",0
Infant's with chronic lung disease.,0
Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age.,0
"Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for house hold contacts and out of home caregivers.",0
FOLLOW UP: Appointments recommended are with primary pediatrician within 5 days after discharge home.Mother declined .,0
Prematurity at 34 and 4/7 weeks.,0
"Sepsis suspect, ruled out with antibiotics.",0
", MD Dictated By: MEDQUIST36 D: 01:27:52 T: 05:44:45 Job#:",0
3:13 PM CHEST (PORTABLE AP) Clip # Reason: r/o failure Admitting Diagnosis: ILEOSTOMY CLOSE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman s/p ileostomy reversal with new onset wheezing REASON FOR THIS EXAMINATION: r/o failure ______________________________________________________________________________ FINAL REPORT INDICATION: Recent abdominal surgery with wheezing.,0
"There are low lung volumes with atelectatic opacities at the lung bases, more currently at the left base than was present in the prior chest x-ray 24 hours ago.",0
An NGT terminates in the stomach.,0
A left subclavian catheter terminates in the mid SVC.,0
IMPRESSION: Increasing opacity at the left base since .,0
2:34 PM CHEST (PORTABLE AP) Clip # Reason: s/p R scv line placement ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with SUBDURAL HEMATOMA REASON FOR THIS EXAMINATION: s/p R scv line placement ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM.,0
History of subdural hematoma and CV line placement.,0
Endotracheal tube is 3 cm above carina.,0
Linear atelectases are present in both mid zones.,0
"LINE PLACEMENT Clip # Reason: eval for pTX, new R IJ CVL, s/p chest compressions for breif Admitting Diagnosis: LUMBAR STENOSIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with ?",0
"arrest REASON FOR THIS EXAMINATION: eval for pTX, new R IJ CVL, s/p chest compressions for breif loss of pulse ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg WED 4:13 PM 1.",0
Right internal jugular catheter projects over mid SVC.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Status post chest compression for brief cardiac arrest, new right CVL.",1
"FINDINGS: The patient is rotated to the left and lung volumes are slightly low, resulting in bronchovascular crowding.",0
Scoliosis is noted with fixation hardware in the lumbar spine.,1
A right internal jugular catheter projects over the mid SVC.,0
"3:42 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: Please do with dopplers to asses portal vasculature, liver s Admitting Diagnosis: SHORTNESS OF BREATH;WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with HCV, esophageal ca s/p chemo XRT REASON FOR THIS EXAMINATION: Please do with dopplers to asses portal vasculature, liver spleen echotexture and size, thanks.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old man with hepatitis C and esophageal cancer, assess portal vasculature and liver, spleen echotexture.",1
"FINDINGS: The liver is shrunken and nodular in appearance, but no focal liver lesion is identified.",0
There is no biliary dilatation and the common duct measures 0.2 cm.,0
No gallstones are seen within the gallbladder.,0
The midline organs could not be visualized due to overlying bowel.,0
"The spleen is enlarged, measuring greater than 15 cm.",0
The right kidney measures 11.4 cm and the left kidney measures 9.9 cm.,0
There is a large amount of ascites within the abdomen.,0
"The main portal vein, right portal vein and left portal vein are patent with hepatopetal flow.",0
Appropriate flow is seen in the IVC and the hepatic veins.,0
"Appropriate arterial waveforms are seen in the main, right and left hepatic arteries.",0
"Shrunken nodular liver consistent with cirrhosis, but no focal liver lesion identified.",1
7:04 AM CHEST (PORTABLE AP) Clip # Reason: Eval for interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE\BIVENTRICULAR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR PLACEMENT ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: There has been mild improvement in the hydrostatic edema and retrocardiac opacity previously noted.,1
There is persisting mild interstitial edema.,0
Continued surveillance is likely indicated.,0
"DR. 7:04 AM CHEST (PORTABLE AP) Clip # Reason: Eval for interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE\BIVENTRICULAR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR PLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with CHF, low LVEF.",1
REASON FOR THIS EXAMINATION: Eval for interval change ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST AT 0820 HOURS.,0
FINDINGS: There has been no significant interval change in the diffuse interstitial edema previously noted.,0
There is a subtle increased retrocardiac opacity.,0
Bilateral small effusions are evident.,0
The thoracic aorta remains tortuous.,0
The cardiac silhouette remains markedly enlarged and stable.,0
IMPRESSION: Continued failure secondary to cardiac decompensation as detailed above.,0
"A slightly more confluent opacity in the retrocardiac left lower lobe may be due to confluent edema; however, developing or evolving pneumonia and/or aspiration cannot be excluded.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Captopril / Neurontin / Shellfish / Nsaids / Promethazine Attending: Chief Complaint: # COPD exacerbation Major Surgical or Invasive Procedure: # None History of Present Illness: 69F h/o COPD + home 2L O2, previously hospitalized and intubated for COPD exacerbations, admitted with SOB x 2d not relieved by home regimen of albuterol nebs, ipratropium nebs, or prednisone 20mg daily.",1
"Pt reported chest tightness, intermittent L chest pain described as a ""twinge"", increased DOE, inability to catch her breath, increased swelling L>R BLE, fatigue, and nausea.",0
"Pt reported no coughing, coryza, or sputum production.",0
"ROS on admit: (+) for symptoms noted above, as well as chronic back pain, non-bloody mild diarrhea before onset of SOB, BUE tremors (-) for F/C, vomiting, pleurisy, myalgia/arthralgia, sweats .",0
"ED: Meds: Furosemide 40mg IV (500cc UOP), solumedrol 125mg IV, albuterol/ipratropium nebulizers, azithromycin 500mg PO Labs: ABG=7.42/40/68 Other treatment: BiPAP, 6L O2 NC.",0
Transferred to MICU for closer monitoring.,0
"MICU: Meds: Prednisone 60 mg, albuterol/ipratropium nebs, levofloxacin 250 mg PO Q24H (5 day course), furosemide IV for goal 500cc UOP daily Transferred to floor on 2L O2 NC.",0
"On transfer, pt reported continuing SOB but improved from admission, nausea, persistent intermittent chest pain pt attributes to musculoskeletal strain.",0
"ROS on transfer: (+) for symptoms noted above, as well as productive cough, nausea, chronic back pain (-) for BLE edema Past Medical History: CV # HTN # CHF # Hyperlipidemia .",1
Neuro: # CVA x 2: Residual L facial droop # Seizures CVA .,0
Pulm # PE s/p IVC # COPD: home 2L O2 at night # Asthma .,0
GI # CDiff colitis x2 # Esophagitis # GERD # GI obstruction s/p laparotomy () # Gastroparesis DM2 .,1
"Musculoskeletal/skin # Trochanteric bursitis () # Chronic lumbar back pain, s/p laminectomy () # B knee OA # Ventral hernia s/p repair x2 .",0
Psych # Depression Social History: # Employment: Retired seamstress and waitress # Personal: Lives in facility.,1
"# Tobacco: 3ppd x 30y, quit # Alcohol: Abuse in , quit remotely # Recreational drugs: Never Family History: # M, d53: Pancreatic CA # F, d60: Laryngeal CA, alcohol abuse # Siblings: DM2, heart disease Physical Exam: VS: Tm 98.5, Tc 98.5, BP 130-144/90, P 84-104, R 18, O2 94/2L-97/2L, FS=127 .",1
"Gen: NAD, obese elderly female HEENT: NCAT, no LAD, O2 NC in place CV: RRR, S1S2, no m/r/g/S3/S4 noted Chest: Diffuse wheezing all fields, no rales noted Abd: Vertical midline scar, soft, NTND, BS+ Ext: Trace edema BLE Neuro: Nonfocal Psych: Weeping Pertinent Results: Notable admission labs: .",0
"07:07PM TYPE-ART, PO2-68*, PCO2-40, PH-7.42, TOTAL CO2-27, BASE XS-0 INTUBATED-NOT INTUBA 02:33PM LACTATE-2.6* 02:30PM GLUCOSE-161* UREA N-37* CREAT-1.7* SODIUM-141 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-29 ANION GAP-17 02:30PM CK-MB-7 proBNP-420* 02:30PM WBC-17.8* RBC-3.69* HGB-11.0* HCT-34.0* MCV-92 MCH-29.9 MCHC-32.4 RDW-16.7* 02:30PM NEUTS-84.5* BANDS-0 LYMPHS-12.1* MONOS-2.4 EOS-0.5 BASOS-0.5 .",0
CHEST (PORTABLE AP) 8:06 AM PORTABLE UPRIGHT VIEW OF THE CHEST AT 8:10 A.M.: There has been no interval change since the prior radiograph of .,0
The lungs are well expanded without consolidation or pleural effusion.,0
The pulmonary vasculature is normal and unchanged.,0
IMPRESSION: No short interval change.,0
Brief Hospital Course: 69F h/o multiple COPD exacerbations admitted for SOB COPD exacerbation and contributing CHF.,0
"# SOB: Pt had extensive h/o steroid-dependent COPD, with home 2L O2, and documented reduced PFTs (: FEV1/FVC: 62%).",0
"Although pt reported no specific URI symptoms, pt's elevated WBC, diarrhea possibly viral gastroenteritis, increased DOE, and chest tightness, pt responded in the MICU to steroids and nebulizers, thereby implicating a likely COPD exacerbation URI.",0
"Both in the MICU and after transfer to the floor, pt was continued on standing nebulizers, nebulizers PRN, prednisone taper x5d (120mg-->60mg-->40mg x2d-->20mg x2d).",0
"Given that pt's SOB also improved with a significant UOP to furosemide, CHF may have also factored into pt's DOE.",0
"Pt was therefore administered furosemide IV, titrated to achieve goal 500cc UOP, which was later converted to her home regimen of furosemide 40mg PO.",0
"Additionally, pt was continued on levofloxacin 250 mg daily x7 days given concern for secondary bacterial pulmonary infection in the setting of COPD exacerbation with leukocytosis.",0
Blood cultures sent from the ED were negative.,0
"On discharge, pt's peak flow had improved to 210, she had completed her antibiotics course, and pt was discharged on her home dose of prednisone 20mg daily and furosemide 40mg daily.",0
"Pt was also given a prescription to check her potassium level on , the day of her follow-up appointment with her PCP.",0
"# BLE edema: Pt's presenting BLE edema likely was CHF exacerbation, which also contributed to her SOB.",0
"Pt reported that she had no increased sodium intake or missed furosemide doses, and proBNP=420 (slightly elevated), but she responded well to furosemide diuresis with improvement of her BLE edema.",0
Pt was continued on goal 500cc UOP.,0
"On discharge, pt was returned to her home dose of furosemide 40mg daily.",0
"# CKD: Pt's recent baseline Cr=1.6, likely HTN and DM2.",0
"Medications were renally dosed, and Cr was trended.",0
Pt maintained her baseline Cr.,0
"# DM2: Pt was continued on 15 units of insulin 70/30 QAM and 10 units of insulin 70/30 QPM with HISS, and followed with FS QID.",0
"Likely increased steroid dosages, pt's fingerstick glucoses were elevated into the low 300s, and therefore her insulin 70/30 was increased to 20 units QAM.",0
"On discharge, as pt was returned back to her home dose of prednisone, pt was returned to her home dose of insulin 70/30 15 units QAM and 10 units QPM, with instructions to call her PCP's office over the weekend if FS>=300.",0
Pt was provided a prescription for humalog insulin sliding scale with instructions to apply only for FS>=300.,0
# Hyperlipidemia: Pt was continued on atorvastatin 20mg daily and aspirin 81 mg PO daily.,0
# HTN: Pt was continued on amlodipine 5 mg PO daily and diltiazem HCl 120 mg SR PO BID.,0
# Seizures: Pt was continued on oxcarbazepine 300 mg PO BID.,0
"# Esophagitis, GERD: Pt was administered a PPI and continued on home regimen of sucralfate 1 g PO QID and nystatin solution.",0
# Depression: Pt was continued on desipramine 20 mg daily.,0
# Full code Medications on Admission: CV # Aspirin 81 mg PO daily # Amlodipine 5 mg PO daily # Lipitor 20 mg daily # Diltiazem HCl 120 mg SR PO BID # Furosemide 10 mg daily .,0
Pulm # Prednisone 20 mg tablet daily # Ipratropium Bromide Q6H # Albuterol Sulfate Q4H:PRN # Fluticasone-Salmeterol 250-50 mcg/Dose Disk 91) puff Inhalation .,0
Psych # Desipramine 20 mg daily .,0
Neuro # Oxcarbazepine 300 mg PO BID .,0
GI # Lidocaine Viscous 2 % Solution for esophageal pain.,0
"Not to exceed 8 doses daily # Sucralfate 1 g PO QID # Nystatin 100,000 unit/mL Suspension Sig: 5 ml PO QID # Ondansetron PRN # Bowel regimen: Bisacodyl, senna, docusate .",0
Musculoskeletal # Morphine 2 mg/mL Q3-4H:PRN pain .,0
Endocrine # Insulin 70/30 10 units + humalog SS .,0
# Colace 100 mg # Senna 1 tab PRN # Heparin SC TID # Atrovent neb q6 hrs # ASA 81 mg daily # Amlodipine 5 mg daily # Oxcarbazepine 300 mg # Lipitor 20 mg daily # Dilitizem 60 mg QID # Morphine Sulfate 2 mg IV q6 HRS PRN # Protonix 40 mg # Insulin 70/30 10 units + humalog SS # Prednisone 60 mg daily # Levofloxacin 250 mg daily x7 days # Albuterol nebs q6 hrs # Albuterol nebs q4 hrs PRN # Percocet 1 tab q4 hrs PRN # Advair 250/50 Discharge Medications: 1.,0
"Disp:*30 Tablet, Chewable(s)* Refills:*2* 2.",0
Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day).,0
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation (2 times a day).,0
Disp:*2 disks with device* Refills:*2* 7.,0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer inhalation Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing.,0
Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) as needed for constipation.,0
Guaifenesin 100 mg/5 mL Syrup Sig: 5-15 MLs PO Q6H (every 6 hours) as needed for cough.,0
Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for Cough.,0
Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation.,0
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Fifteen (15) units Subcutaneous QAM.,0
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Ten (10) units Subcutaneous QHS.,0
"Humalog insulin sliding scale # FS glucose 0-70 mg/dL: Breakfast amp D50, Lunch amp D50, Dinner amp D50, Bedtime amp D50 # FS glucose 71-150 mg/dL: Breakfast 0 Units, Lunch 0 Units, Dinner 0 Units, Bedtime 0 Units # FS glucose 151-200 mg/dL: Breakfast 2 Units, Lunch 2 Units, Dinner 2 Units, Bedtime 2 Units # FS glucose 201-250 mg/dL: Breakfast 4 Units, Lunch 4 Units, Dinner 4 Units, Bedtime 4 Units # FS glucose 251-300 mg/dL: Breakfast 6 Units, Lunch 6 Units, Dinner 6 Units, Bedtime 6 Units # FS glucose 301-350 mg/dL: Breakfast 8 Units, Lunch 8 Units, Dinner 8 Units, Bedtime 8 Units # FS glucose 351-400 mg/dL: Breakfast 10 Units, Lunch 10 Units, Dinner 10 Units, Bedtime 10 Units 19.",0
Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
Disp:*30 nebulizer inhalation* Refills:*0* 20.,0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Insulin Needles (Disposable) 29 x Needle Sig: One (1) insulin needles Miscellaneous twice a day.,0
Desipramine 10 mg Tablet Sig: Two (2) Tablet PO once a day.,0
Outpatient Lab Work Please check potassium level on when you see Dr. office.,0
Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary diagnosis # COPD exacerbation # CHF # Diabetes mellitus type 2 .,1
"Secondary diagnosis # HTN # Hyperlipidemia # Seizures cerebrovascular accident # Asthma # Esophagitis # GERD # Chronic lumbar back pain, s/p laminectomy () # B knee osteoarthritis # Depression Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you had trouble breathing.",1
"We felt that this was because you had a viral infection of your respiratory system, which caused your COPD to get worse.",0
"We gave you nebulizers, antibiotics, and steroids, and you improved.",0
"We also felt that your shortness of breath may also have been related to your congestive heart failure, so we gave you diuretics.",1
We have not given you any new medications and we have not changed any of your medications.,0
"REMINDER: You take 15 units of insulin 70/30 in the morning, and 10 units of insulin 70/30 at night.",0
REMINDER: WRITE DOWN your sugars daily and CALL Dr. office on MONDAY to tell them what your sugars are.,0
Dr. may want to adjust your insulin based on your weekend numbers.,0
Call Dr. office if your sugars are more than 300!,0
REMINDER: We are giving you the humalog insulin sliding scale ONLY to use if your sugars are above 300.,0
"If your sugars are above 300, call Dr. and then use the amount of humalog insulin according to the sliding scale.",0
REMINDER: You take prednisone 20mg daily to control your COPD!,0
"If you have fevers, chills, nausea, vomiting, shortness of breath, or any other symptoms you are concerned about, please call Dr. immediately and go to the nearest emergency room.",0
Followup Instructions: You have the following appointment with Dr. office: .,0
"Provider: , Date/Time: 6:20 .",0
"You also have the following appointments: Provider: , MD Phone: Date/Time: 10:00 Provider: , M.D.",0
"Phone: Date/Time: 11:00 MD, Completed by:",0
"5:12 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for PNA Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with cholangitis, s/p ERCP that had episode of hypoxia during procedure.",0
"REASON FOR THIS EXAMINATION: Please assess for PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old woman with cholangitis, status post ERCP and had episode of hypoxia.",0
SINGLE FRONTAL CHEST RADIOGRAPH: The patient has low lung volumes and increased opacification within the right lower lobe.,0
A right IJ catheter terminates in appropriate position.,0
No other areas of opacification are noted.,0
"The cardiac silhouette is mildly enlarged with splaying of the bronchi implying left atrial enlargement, unchanged.",0
The mediastinal silhouette and hilar contours are normal.,0
IMPRESSION: Right lower lobe atelactasis is new.,0
", C. NMED SICU-B 1:05 PM CT HEAD W/O CONTRAST Clip # Reason: eval for hemorrhage s/p tPA, evoluation of infarct - PLEASE Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with acute dysarthria, right facial s/p tPA REASON FOR THIS EXAMINATION: eval for hemorrhage s/p tPA, evoluation of infarct - PLEASE PERFORM AT 1 PM No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No evidence of an acute intracranial hemorrhage.",0
Low attenuation in the left subcortical white matter is compatible with an evolving infarct.,0
LINE PLACEMENT Clip # Reason: r/o pneumothorax; line placement Admitting Diagnosis: RENAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man s/p left nephrectomy with IVC thrombectomy REASON FOR THIS EXAMINATION: r/o pneumothorax; line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 48-year-old woman status post left mastectomy with IVC thrombectomy.,0
PORTABLE CHEST RADIOGRAPH: Comparison is made with the prior chest radiograph dated .,0
Right IJ line is terminating in mid SVC.,0
"Nasogastric tube is terminating in left upper quadrant, most likely in the gastric fundus.",0
Small effusion on the right may be present.,0
Multiple surgical clips are seen overlying the upper abdomen.,0
No definite pneumothorax seen on this portable radiograph.,0
Small right pleural effusion may be present.,0
3:22 AM CHEST (PORTABLE AP) Clip # Reason: please eval placement Admitting Diagnosis: GASTROENTERITIS ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with midline REASON FOR THIS EXAMINATION: please eval placement ______________________________________________________________________________ FINAL REPORT CHEST ON .,0
The aorta is mildly calcified.,0
"There are bilateral lower lobe infiltrates, left greater than right and a small left effusion.",0
"There is a left-sided PICC line with tip close to midline, not yet crossing to the superior vena cava.",0
Admitting Diagnosis: NOSE BLEED ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with possible acute on chronic renal failure.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Question acute on chronic renal failure.,1
COMPARISON: Renal ultrasound from .,0
RENAL ULTRASOUND: The right kidney measures 9.5.,1
There is diffusely increased echogenicity of the renal parenchyma.,0
"In the left kidney, prominent pyramid is noted, which appear larger than in .",0
Crystalline material is seen layering within a calix.,0
There is no evidence of hydronephrosis or renal mass.,0
"A trace amount of fluid is seen around the right kidney, which is nonspecific.",0
The partially distended urinary bladder appears unremarkable.,0
IMPRESSION: Increased echogenicity of the kidneys bilaterally as well as increased prominence of the left renal pyramid consistent with medical renal disease progression since .,1
"9:33 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: assess for effusion, consolidation Admitting Diagnosis: GASTRIC CANCER ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man s/p extensive resection gastric Ca, now with abdomen closed REASON FOR THIS EXAMINATION: assess for effusion, consolidation ______________________________________________________________________________ FINAL REPORT HISTORY: Gastric cancer, to evaluate for effusion and consolidation.",0
"FINDINGS: In comparison with the earlier study of this date, there is no significant change in the appearance of the heart and lungs, bilateral effusions, and support devices.",0
"9:52 AM CT HEAD W/O CONTRAST Clip # Reason: male s/p right frontal brain bx, now with seizure.",0
"fo ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with above REASON FOR THIS EXAMINATION: male s/p right frontal brain bx, now with seizure.",0
for bleed ______________________________________________________________________________ FINAL REPORT HISTORY: 67 year old man status post right frontal brain biopsy with new seizure.,0
TECHNIQUE: Axial images of the brain were obtained without intravenous contrast.,0
CT HEAD WITHOUT IV CONTRAST: There is a small amount of hemorrhage and surrounding edema in the right frontal lobe at the site of the biopsy.,0
There is minimal if any mass effect upon the right ventricle.,0
There is no shift of normal midline structures.,0
There is a craniotomy defect of the right frontal bone with small amount of pneumocephalus.,0
No evidence of intracerebral hematoma.,0
Right frontal lobe hypodense lesion as described above.,0
6:26 PM URIN CATH CHECK Clip # Reason: obstruction Admitting Diagnosis: UROSEPSIS Contrast: OPTIRAY Amt: 20 ********************************* CPT Codes ******************************** * INTRO CATH RENAL PELVIS FOR DR 78 RELATED PROCEDURE DURING POSTOPE * * INJ NEPHROSTOMY/PYLOSTOMY -59 DISTINCT PROCEDURAL SERVICE * * INTRO CATH TO PELVIS FOR DRAIN ANTEGRADE UROGRAPHY * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman s/p nephrostomy tube placement with reduced tube output REASON FOR THIS EXAMINATION: obstruction ______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 77-year-old woman with urosepsis associated with right hydronephrosis and hydroureter status post right nephrostomy catheter placement on .,1
No urinary drainage from the catheter over the last several hours.,0
A request was placed for nephrostogram and appropriate intervention.,0
COMPARISON: Right percutaneous nephrostomy performed .,0
"Dr. is the attending radiologist, present and supervising throughout.",0
ANESTHESIA: Moderate sedation was provided by administering divided doses of Fentanyl and Versed throughout the total intra-service time during which the patient's hemodynamic parameters were continuously monitored.,0
Local anesthesia with 1% Lidocaine.,0
The patient was brought to angiography suite and placed prone on the imaging table.,0
The right lower back including the existing nephrostomy catheter were prepped and draped in the usual sterile fashion.,0
An initial scout image of the right renal area was obtained showing a malformed pigtail of the nephrostomy catheter.,0
Contrast injection through the catheter demonstrated the catheter to have been pulled out of the renal collecting system.,0
Initial attempt to obtain access into the collecting system using a Glidewire was unsuccessful.,0
"Then, the catheter was removed over the Glidewire and further attempts to obtain access into the collecting system was made using a combination of 5 French Kumpe catheter and Glidewire.",0
"However, these attempts were also unsuccessful.",0
"Following these unsuccessful attempts, a decision was made to perform a de nephrostomy procedure.",0
"Under ultrasound guidance, a right posterior inferior calix was accessed with a 21 gauge Cook needle.",0
The position of the needle was confirmed by a small amount of contrast injection and also by free drainage of urine.,0
A 0.018 (Over) 6:26 PM URIN CATH CHECK Clip # Reason: obstruction Admitting Diagnosis: UROSEPSIS Contrast: OPTIRAY Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) guidewire was placed through the needle and the needle exchanged for an AccuStick sheath.,0
A nephrostogram was performed through the AccuStick sheath demonstrating satisfactory access and moderate right hydronephrosis and hydroureter.,1
"Through the AccuStick sheath, a 0.035 super-stiff Amplatz wire was placed and the AccuStick sheath removed.",0
The soft tissue tract was dilated with a 9 French dilator.,0
"Then, an 8 French Flexima nephrostomy catheter was placed over the guidewire and guidewire as well as the inner plastic stiffener were removed.",0
The catheter pigtail was formed and locked in the renal pelvis.,0
Satisfactory placement of the catheter was confirmed by injection of small amount of dilute contrast.,0
The catheter was then flushed and connected to an external drainage bag.,0
The catheter was secured in place with two x 0 silk sutures and two StatLock devices.,0
The patient tolerated the procedure well and there were no immediate complications.,0
"At the end of the procedure, the patient was transferred back to ICU in a stable condition.",0
Nephrostogram via existing catheter showing a malformed pigtail and the catheter to have been pulled out of the renal collecting system.,0
Attempts to regain access into the collecting system through the existing tract were unsuccessful.,0
A new de placement of an 8 French nephrostomy catheter under ultrasound and fluoroscopic guidance.,0
Nephrostogram again confirmed moderate right hydronephrosis and hydroureter with UVJ obstruction as noted during the initial nephrostomy placement on .,1
The above findings and procedure were discussed over telephone with Dr. from the primary team.,0
12:34 PM CT HEAD W/O CONTRAST Clip # Reason: YR OLD DEMENTED WOMAN S/P UNWITNESSED FALL.,0
"______________________________________________________________________________ MEDICAL CONDITION: year old demented woman s/p fall, unwitnessed REASON FOR THIS EXAMINATION: r/o bleed/mass ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: S/p fall.",0
"RESULTS: Comparison with the prior study of discloses no new intracranial hemorrhage, mass lesion or shift of normally midline structures.",0
"Considering patient age, there is negligible involutional change of the brain.",0
The surrounding osseous and soft tissue structures appear within normal limits.,0
CONCLUSION: No acute intracranial pathology.,0
COMMENT: The and studies show slight prominence of the right occipital/ mastoid suture.,0
There is no soft tissue swelling present on either study to suggest that there may be an underlying acute injury.,0
7:04 AM CHEST (PORTABLE AP) Clip # Reason: eval pneumothorax/infiltrate Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with CABG s/p chest tube removal.,1
"REASON FOR THIS EXAMINATION: eval pneumothorax/infiltrate ______________________________________________________________________________ FINAL REPORT PORTABLE SEMI-UPRIGHT CHEST, COMPARISON: .",0
INDICATION: Status post coronary bypass surgery.,0
Cardiac and mediastinal contours appear slightly widened but are stable in the postoperative period.,0
Small vertical lucency is present at the upper sternotomy site and can occasionally be a normal postoperative finding.,0
There is no alteration in the sternal wires.,0
"Bibasilar atelectasis is again demonstrated, slightly worse in the left lower lobe and unchanged on the right.",0
Small pleural effusions are present bilaterally.,0
Bibasilar atelectasis and small pleural effusions.,0
"Vertical lucency at upper sternotomy site, which may occasionally be a normal finding.",0
"Correlation with physical exam findings may be helpful to exclude sternal click, as a vertical sternal lucency may be associated with dehiscence in a minority of cases.",0
8:15 PM CT CHEST W&W/O C Clip # Reason: Please evaluate for empyema/soft tissue involvement.,0
Thank Y Admitting Diagnosis: LEFT EFFUSION;PNEUMONIA Field of view: 36 Contrast: OMNIPAQUE Amt: 75 ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with HCV and pleuritic cp.,1
REASON FOR THIS EXAMINATION: Please evaluate for empyema/soft tissue involvement.,0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: YGd MON 11:15 PM Left PICC w tip in lower SVC.,0
L pigtail chest tube in the left lung base (placed several days ago).,0
"Overall extent of left pleural effusion decreased since , but now with multiple loculated components anteriorly and posteriorly (700b, 50).",0
"Left anterior loculated fluid contains foci of air and shows faint parietal and visceral pleural enhancement (701b, 26), concerning for empyema.",0
"As per team, there's h/o fall and concern for bronchial injury - bronchopleural fistula could be alternative consideration, but felt less likely.",0
"Consolidation in lingula and left base could be unexpanded lung, but super infection is not excluded.",0
"Cluster of air bubbles extending from lingula through chest wall to subcutaneous tissue, likely tract for prior chest tube (removed one day ago).",0
Prominent small mediastinal nodes may be reactive.,0
"Subcentimeter liver hypodensity, incompletely characterized.",0
Bilateral multilevel healing rib fracutres.,0
- dw Dr. by via phone at 10:50p on .,0
"______________________________________________________________________________ FINAL REPORT COMPUTED TOMOGRAPHY OF THE THORAX INDICATION: Pleuritic chest pain, evaluation of empyema and potential soft tissue involvement.",0
"TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, acquisitions of images before and after administration of contrast material, multiplanar reconstructions.",0
FINDINGS: The examination is compared to .,0
A new pigtail catheter has been inserted into the pleural space on the left.,0
"Along the insertion tract and in the region of the left chest wall, there are traces of air.",0
The more lateral air bubbles are obviously originating from a prior insertion tract.,0
The amount of pleural fluid has markedly decreased as compared to the previous examination.,0
"However, loculated portions of fluid with air bubbles are seen in the anterior (5, 24) and lateral (5, 30) parts of the chest.",0
The adjacent pleura is slightly thickened and shows mild contrast enhancement.,0
Both the signs suggest empyema.,0
There is no evidence for a bronchopleural fistula.,0
Areas of atelectatic lung in the lingula and the left lower lobe.,0
The enhancement pattern suggests atelectasis over pneumonia.,0
Subtle non-characteristic right upper lobe ground-glass opacities.,0
(Over) 8:15 PM CT CHEST W&W/O C Clip # Reason: Please evaluate for empyema/soft tissue involvement.,0
"Thank Y Admitting Diagnosis: LEFT EFFUSION;PNEUMONIA Field of view: 36 Contrast: OMNIPAQUE Amt: 75 ______________________________________________________________________________ FINAL REPORT (Cont) Several borderline sized lymph nodes in the mediastinum, for example in the aortopulmonary window (2, 21).",1
"These lymph nodes have slightly increased in size since the previous examination, but their overall size is still in the normal range.",0
IMPRESSION: Newly introduced left pigtail catheter.,0
"Decrease in extent of the pleural fluid collection, but evidence of loculated fluid collections laterally and anteriorly of the thoracic cavity on the left, associated with pleural thickening and pleural enhancement, concerning for empyema.",0
Slightly increased size of the still normal lymph nodes in the mediastinum.,0
Atelectatic changes at the bases of the left lung.,0
No characteristic ground-glass opacities in the right lung apex.,0
Older healing rib fractures on the left.,0
8:10 AM CHEST (PORTABLE AP) Clip # Reason: Eval fluid overload vs PNA progression.,0
"Admitting Diagnosis: HIP FX ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with Parkinson's disease, aspiration PNA, noted to have increased oxygen requirement.",0
Check fluid overload versus PNa progression.,0
REASON FOR THIS EXAMINATION: Eval fluid overload vs PNA progression.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Aspiration pneumonia with possible fluid overload.,0
"FINDINGS: In comparison with the study of , there has been virtually complete resolution of the pneumoperitoneum.",0
"Persistent opacification at both bases is consistent with atelectasis, though the possibility of superimposed pneumonia can certainly not be excluded.",0
2:09 PM CAROT/CEREB Clip # Reason: diagnostic angiogram with Stent assisted coilingAnesthesia h Contrast: OPTIRAY Amt: 144 ********************************* CPT Codes ******************************** * EMBO TRANSCRANIAL SEL CATH 3RD ORDER * * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL UNILAT * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL UNILAT * * -59 DISTINCT PROCEDURAL SERVICE EXT UNILAT A-GRAM * * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with brain aneurysm REASON FOR THIS EXAMINATION: diagnostic angiogram with Stent assisted coilingAnesthesia has been booked on waitlist ______________________________________________________________________________ FINAL REPORT DATE OF SERVICE: .,1
PREOPERATIVE DIAGNOSIS: Unruptured right superior hypophyseal artery aneurysm for coiling.,0
"PROCEDURE PERFORMED: Right subclavian artery arteriogram, right common carotid artery arteriogram, right internal carotid artery arteriogram, right common femoral artery arteriogram.",0
INTERVENTIONAL PROCEDURE PERFORMED: Coil embolization of right superior hypophyseal artery aneurysm.,0
ANESTHESIA: General PROCEDURE: The patient was brought to the angiography suite.,0
"Following this, both groins were prepped and draped in a sterile fashion.",0
Access was gained to the right common femoral artery using a Seldinger technique and a 6 French long vascular sheath was placed in the right common femoral artery.,0
"We now catheterized the above-mentioned vessels and AP, lateral filming was done.",0
This revealed that the right subclavian artery was aberrant and came off separately from the aortic arch.,0
The right internal carotid artery was catheterized with 2 catheter.,0
There was significant fibrous dysplasia in this segment.,0
We exchanged out the 2 catheter for a Neuron 6 French catheter.,0
"Following this, 038 X 135 cm DAC catheter was advanced over a Synchro wire and SL-10 catheter into the distal right internal carotid artery.",0
"Following this, the aneurysm was catheterized with the SL-10 microcatheter without any problems.",0
ACT was maintained at around 204 during the procedure with IV heparin 5000 units bolus dose.,0
We now started coiling the aneurysm starting with a Micrusphere coil 3.5 mm into 6.6 mm.,0
"Following (Over) 2:09 PM CAROT/CEREB Clip # Reason: diagnostic angiogram with Stent assisted coilingAnesthesia h Contrast: OPTIRAY Amt: 144 ______________________________________________________________________________ FINAL REPORT (Cont) this, we used 2.5 mm UltraSoft Target coils and 2 mm UltraSoft Target coils.",0
"Following this, the aneurysm was completely obliterated.",0
"The catheters were removed and a right common femoral artery arteriogram done, following which the vascular access site was closed with a 6 French Angio-Seal device.",0
FINDINGS: Right subclavian artery arteriogram shows an aberrant right subclavian artery origin.,0
"Right common carotid artery arteriogram shows no evidence of stenosis; however, the right internal carotid artery is very tortuous, with significant fibromuscular dysplasia.",0
Right internal carotid artery arteriogram shows a superior hypophyseal artery aneurysm measuring approximately 4 mm and what appears to be a right middle cerebral artery aneurysm at the lenticulostriate origin measuring about 1.5 mm.,1
Right internal carotid artery arteriogram status post coiling shows no significant evidence of an aneurysm residual in the superior hypophyseal aneurysm.,0
Right common femoral artery arteriogram was widely patent .,0
IMPRESSION: underwent cerebral angiography and coiling of a right superior hypophyseal artery aneurysm.,1
"She has fairly dysplastic vessels possibly from fibromuscular dysplasia and a small right middle cerebral artery aneurysm, which would have to be monitored with serial MRI scans.",1
"7:48 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with chf, s/p PEA arrest REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for interval change in patient with congestive heart failure and PEA arrest.",1
"COMPARISON: A series of portable chest radiograph from , dating back to .",0
A presumed admission radiograph from was also reviewed.,0
FINDINGS: Bedside upright AP radiograph of the chest demonstrates little interval change when compared to prior study performed 24 hours ago.,0
"There is minimal, stable enlargement of the cardiomediastinal contours consistent with mild chronic heart failure.",1
Persistent obscuration of the pulmonary vascular markings in the right lung base is consistent with trace pulmonary edema.,0
"A left internal jugular central venous catheter, an endotracheal tube, and an orogastric tube are unchanged and appropriately positioned.",0
The chronic findings of atherosclerotic calcification of the aortic arch and bilateral glenohumeral joint degenerative changes are once again noted.,0
Mild chronic congestive heart failure with stable trace pulmonary edema at the right lung base.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Syncope, hematemesis Major Surgical or Invasive Procedure: Upper Endoscopy History of Present Illness: Mr. is a 46 year old man with a history of EtOH abuse, depression, transferred from OSH due to concern for GIB.",0
His sister (nurse) states the patient has a history of heavy EtOH depression.,0
"Recently completed detox program in , was sober for 6 weeks then relapsed.",0
"Has recently been trying to cut back on EtOH, only drinking vodka when he develops nausea/tremor.",0
Last drink was 3 days ago (per patient).,0
"Since then, patient reports severe nausea, unable to keep anything down except water, frequent nonbloody emesis.",0
"This morning, he felt extremely lightheaded when standing.",0
He remembers sitting down to watch TV when screen appeared blurry.,0
"His sister heard ""banging"" in other room, found pt unresponsive and incontinent of urine.",0
He regained consciousness after approx 2 min but was altered for 10-15 min.,0
"She called EMS, patient gradually became more alert.",0
"Prior to taking him to OSH, patient's sister noticed red and dark blood mixed with vomit on bathroom floor.",0
"At patient was tachycardic with HR 124, otherwise VSS.",0
Exam notable for guaiac positive stool.,0
"Labs notable for Hct 26.6 (HCT 44 per last available lab in ), K 2.3, HCO3 38, Creat 1.4.",0
"EKG showed sinus tach, no ischemic changes.",0
He complained of nausea but had no vomiting while at OSH.,0
"He received IV ativan, IV zofran 4mg x2, 40 meEQ K, Banana bag with K. He was started on IV pantoprazole and octreotide gtt and transferred to .",0
"On arrival to ED, vitals were 99.2 126 144/109 18 98% 2L.",0
"Patient complained of mild tremulousness, otherwise no complaints.",0
"Rectal exam yielded brown, guaiac positive stool.",0
No stigmata of liver disease on exam.,0
"Labs notable for HCT 26.9, K 3.1 (2.9 on ABG), HCO3 35, Creat 1.4, mild transaminitis.",0
NG lavage without blood or coffee ground emesis.,0
"Patient was given 40mEq K in 1L D5W, continued IV pantoprazole and octreotide gtt, given 1mg IV ativan for withdrawal symptoms (diaphoresis) with reported good effect.",0
"GI was consulted and recommended admit to ICU, likely will do EGD in AM.",0
Patient admitted to MICU for treatment of seizure and hematemesis.,0
Vitals prior to transfer: 109 140/90 98% 2L.,0
"On arrival to the MICU, vitals are 100.3 143/102, 110, 96% 2L.",0
He is a poor historian.,0
"Denies nausea, anxiety, tremor, abdominal pain.",0
"He denies history of withdrawal seizures, although he did ""pass out"" 2 weeks ago which he reports was due to his HTN meds, HCTZ was stopped in .",0
Denies any prior episodes of hematemesis or black/bloody stool.,0
States he has been drinking pints vodka per day until 3 days ago.,0
Past Medical History: -EtOH abuse -Depression -Hypertension -Anemia Social History: Lives with sister and nephew in .,1
"Used to work in cabinet repair, now laid off.",0
"Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 100.3 143/102 117 18 96% 2L General: middle aged in NAD, AAOx2.5, diaphoretic, talking comfortably HEENT: pupils 4mm, reactive.",0
"Neck: supple, no JVD Cardiac: RRR S1 S2 no rubs/murmurs/gallops Lungs: CTAB no crackles/wheezes/rhonchi : soft, obese, NTND.",0
DP/PT 2+ Neuro: CN II-XII grossly intact .,0
DISCHARGE LABS: 05:45AM BLOOD WBC-5.4 RBC-3.00* Hgb-9.1* Hct-28.1* MCV-94 MCH-30.4 MCHC-32.6 RDW-16.5* Plt Ct-201 05:45AM BLOOD Glucose-103* UreaN-10 Creat-1.1 Na-138 K-3.9 Cl-104 HCO3-23 AnGap-15 05:45AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 .,0
MICRO: 11:20 pm MRSA SCREEN (Final ): No MRSA isolated.,0
"EGD : Erythema, nodularity, and superficial ulcerations in the middle and lower third of the esophagus compatible with severe esophagitis.",1
Erythema in the whole stomach compatible with severe gastritis (biopsy).,0
Normal mucosa in the duodenum.,0
Otherwise normal EGD to third part of the duodenum.,0
"Brief Hospital Course: 46 year old man with a history of EtOH abuse, depression, anemia and transferred from OSH for LOC and hematemesis concerning for UGIB.",1
"# HEMATEMESIS/Acute blood loss anemia: Patient transferred from an outside hospital to the ICU with anemia to HCT 26 in the setting of witnessed hematemesis and multiple reported past episodes of coffee ground emesis, likely due to alcohol withdrawal.",1
NG lavage negative in the ED.,0
"On admission to MICU, he was initially continued on pantoprazole and octreotide drips.",0
"Octreotide was discontinued on HD#2, as patient had low likelihood of variceal bleed.",0
Home antihypertensives were held in setting of bleed.,0
Patient was transfused 1 unit blood on HD#2 when HCT trended down from 26.9 to 21.9; his HCT bumped to 27.,0
"He had no further episodes of emesis, and had no stool.",0
He was evaluated by GI in the MICU who recommended transfer to the floor.,0
"On the medical floor, the patient underwent scheduled upper endoscopy that showed severe esophagitis, gastritis, and multiple ulcerations, likely due to alcohol.",1
"The patient's diet was slowly advanced, and he tolerated it well.",0
He was discharged on 12 weeks of high-dose pantoprazole.,0
The patient will follow up with gastroenterology and have repeat endoscopy for resolution of findings on .,0
"# Likely Withdrawal Seizure: Prior to admission, the patient was found down, incontinent of urine, followed by likely post-ictal state.",0
He denies prior episode of withdrawal seizures to this episode.,0
The patient received 1mg IV ativan at the OSH.,0
"He was monitored on CIWA protocol while in MICU, but did not require any Diazepam.",0
"# EtOH Dependence/ABUSE: The patient has a significant EtOH history, recently relapsed after completing rehab in .",0
Now drinking pinks Vodka/day until 3 days ago.,0
"On admission he was 3 days out from last drink and his tachycardia, hypertension and diaphoresis suggested he was probably withdrawing.",0
"Also may have had withdrawal seizure, per above.",0
"He was monitored on CIWA protocol, received folate/thiamine/multivitamin, and Zofran PRN.",0
Family expressed concern that patient is self-medicating for depression.,0
The patient was seen by social work and was discharged with resources for depression and alcohol abuse.,0
"# : Cr 1.4 on admission (unknown baseline), likely GI losses and poor PO intake.",0
Creatinine improved to 1.1 with IV fluids.,0
# NORMOCYTIC ANEMIA: Likely acute due to hematemesis.,1
On iron supplements at home.,0
Patient should follow up with his PCP for HCT check following discharge.,0
# CODE STATUS: full code (confirmed with patient) ==================================== TRANSITIONAL ISSUES: # Patient should follow up with his PCP for HCT check following discharge Medications on Admission: -Metoprolol succinate 100 mg daily -Paxil 25mg daily -Iron supplements Discharge Medications: 1.,0
FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg daily Disp #*30 Tablet Refills:*0 2.,0
Multivitamins 1 TAB PO DAILY 3.,0
Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg daily Disp #*30 Tablet Refills:*0 4.,0
Paroxetine 20 mg PO DAILY 5.,0
Metoprolol Succinate XL 100 mg PO DAILY 6.,0
"Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Primary: Severe esophagitis and Severe Gastritis Secondary: Ethanol abuse, Large hiatal hernia Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: Mr. , .",0
You were admitted due to an upper GI bleed.,0
We gave you high dose anti-acid.,0
We performed an upper endoscopy to evaluate your esophagus and stomach.,0
"This test showed that you have severe esophagitis and severe gastritis (inflammation of your stomach and esophagus), likely due to alcohol.",1
"You should follow up closely with the GI doctors, continue to take your anti-acid medication and stop drinking.",0
You also likely had an alcohol withdrawal seizure before admission.,1
It is essential that you stop drinking in order to prevent this from happening in the future.,0
New Medications: START pantoprazole 40 mg twice per day START thiamine 100 mg by mouth daily START folic acid 1 mg daily It is important that you stop drinking.,0
"Followup Instructions: Name: , A.",0
"Address: , , Phone: When: , , 2:30 PM .",0
Department: ENDO SUITES When: WEDNESDAY at 11:30 AM .,0
"Department: DIGESTIVE DISEASE CENTER When: WEDNESDAY at 11:30 AM With: ,MD Building: Building (/ Complex) Campus: EAST Best Parking: Main Garage",0
"9:56 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: eval for bleed Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with s/p evd placement REASON FOR THIS EXAMINATION: eval for bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old female patient, with subarachnoid hemorrhage, status post IVD placement, to evaluate for additional bleed.",1
PRIOR STUDIES: CT of the head done on at 3:32 p.m.,0
TECHNIQUE: Non-contrast CT of the head was performed.,0
"FINDINGS: There is interval placement of the intraventricular drain, with tip in the region of the right foramen of .",0
"There is no significant change in the subarachnoid hemorrhage in the basal cisterns, upper spinal canal as well as in the cerebral sulci in the right temporal lobe and in the interhemispheric fissure.",1
There is a new small amount of blood in the posterior part of the body of the right lateral ventricle and unchanged appearance of small amount of blood in the left lateral ventricle.,0
No shift of midline structures is noted.,0
No osseous lytic or sclerotic lesions are noted.,0
"There is unchanged appearance of the diffuse mild cerebral edema, with effacement of cerebral sulci as well as the cerebral folia.",0
IMPRESSION: Interval development of small amount of blood in the body of the right lateral ventricle without significant change in the extent of subarachnoid hemorrhage as well as small amount of blood in the left lateral ventricle.,1
8:02 AM CHEST (PORTABLE AP) Clip # Reason: any interval change?,0
Admitting Diagnosis: PULMONARY EMBOLIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with chest pain and recent PE REASON FOR THIS EXAMINATION: any interval change?,0
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Chest pain.,0
Right central catheter tip is in the lower SVC.,0
Moderate-to-large right pleural effusion has decreased in amount.,0
The patient has no emphysema.,0
Surgical clips are present in the right lobe.,0
The left lobe is clear.,0
"5S 5:03 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: lung bases through pelvis, eval for PNA, abscess Admitting Diagnosis: CECUM POLYP/SDA Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p ileocecectomy c/b colonic perf s/p ileocolectomy, now w/ WBC 20 REASON FOR THIS EXAMINATION: lung bases through pelvis, eval for PNA, abscess No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 7.8 x 6.3 cm pelvic fluid collection concerning for abscess.",1
"6:35 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: s/p liver transplant with known pancreatic psuedocyst> comp Admitting Diagnosis: S/P LIVER TRANSPLANT;MENTAL STATUS CHANGES Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with ESLD 2'ary to hep C, ETOH s/p orthotopic liver transplant x2, nephrolitiasis.",0
REASON FOR THIS EXAMINATION: s/p liver transplant with known pancreatic psuedocyst> complete abd/pelvis ct sscan.,0
PLEASE PREFORM ARTERIAL AND PORTAL PHASE OF LIVER.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 43 y/o man with liver transplant and known pancreatic pseudocyst status post percutaneous drainage.,1
The patient presents with fever.,0
TECHNIQUE: Helically acquired contiguous axial images of the abdomen were obtained without contrast and with 150 cc of IV Optiray in arterial and portal venous phases.,0
Delayed images of the abdomen and pelvis were also obtained.,0
ABDOMEN CT WITH IV CONTRAST: There is dependent atelectasis at both lung bases.,0
There is a trace left pleural effusion.,0
A nasogastric tube extends from the esophagus into the distal stomach.,0
"The previously described low-attenuation splenic lesions are unchanged, probably representing infarcts.",0
"Anterior to the body of the pancreas, there is a pigtail catheter within a small fluid collection, which has an enhancing rim.",0
This is unchanged since the prior study.,0
"Immediately left of the old collection, two new fluid collections with enhancing walls are seen.",0
"The more lateral collection is larger, measuring 4.5 x 2.9 cm.",0
This was discussed with Dr. at 01:00 on .,0
Multiple nonobstructing stones are present in the right kidney.,0
"The largest stone is located centrally, measuring 12 mm.",0
"The left kidney, adrenal glands and ureters are unremarkable.",0
"PELVIS CT WITH IV CONTRAST: The small bowel, colon, rectum, prostate, and seminal vesicles are unremarkable.",0
Air and a Foley catheter are present within the urinary bladder.,0
BONE WINDOWS: The visualized osseous structures are unremarkable.,0
"Two new fluid collections with enhancing walls in the left upper abdomen, which are concerning for abscesses.",0
(Over) 6:35 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: s/p liver transplant with known pancreatic psuedocyst> comp Admitting Diagnosis: S/P LIVER TRANSPLANT;MENTAL STATUS CHANGES Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
"Stable appearance of the peripancreatic fluid collection, which is being drained by a pigtail catheter.",0
Stable appearance of splenic infarcts.,0
Multiple nonobstructing right renal stones.,0
"10:07 PM CHEST (PORTABLE AP) Clip # Reason: ?free air, brbpr ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with syncope REASON FOR THIS EXAMINATION: ?free air, brbpr ______________________________________________________________________________ FINAL REPORT INDICATION: The patient is a 66-year-old male with syncope.",0
FINDINGS: The lungs are clear.,0
7:18 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
ptx s/p ct removal Admitting Diagnosis: ACUTE CORONARY SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with s/p cabg REASON FOR THIS EXAMINATION: ?,0
ptx s/p ct removal ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 9:49 AM Moderate-to-large and small-to-moderate left pleural effusions are unchanged with adjacent atelectasis.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: S/P CABG after chest tube removal.,0
Comparison is made to prior study performed a day before.,0
Moderate-to-large right and small-to-moderate left pleural effusions associated with adjacent atelectasis are unchanged.,0
Cardiomediastinal contours are stable with widened mediastinum.,0
Right IJ catheter shift is in place.,0
Other lines and tubes have been removed.,0
"8:07 AM BILAT UP EXT VEINS US Clip # Reason: DO EXAM AT BEDSIDE (Pt on pressors, and right groin li Admitting Diagnosis: ACUTE RENAL FAILURE;CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with systolic CHF and h/o DVT who had difficult IJ access during recent procedure REASON FOR THIS EXAMINATION: DO EXAM AT BEDSIDE (Pt on pressors, and right groin line) Evaluate for bilateral IJ thrombus ______________________________________________________________________________ FINAL REPORT INDICATION: History of deep vein thrombosis and difficult IJ access during recent procedure.",1
TECHNIQUE: Grayscale and pulse wave Doppler of the bilateral neck vessels.,0
"FINDINGS: Son examination in the right lateral neck demonstrates a large compressible vascular structure with normal wall-to-wall flow, but located medial to the common carotid artery.",0
This position is inconsistent with internal jugular vein and therefore its anatomic course is not clear.,0
The left internal jugular vein is compressible and demonstrates normal flow.,0
"IMPRESSION: Large vascular structure located medial to the common carotid artery, inconsistent with an internal jugular vein due to its location.",0
"However, there is no evidence of DVT.",0
Findings were discussed with Dr. with Dr. by phone at 10:43 a.m. on .,0
1:56 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: eval for evidence of aspiration Admitting Diagnosis: SEPSIS;CHANGE IN MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with lack of gag reflex REASON FOR THIS EXAMINATION: eval for evidence of aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: Lack of gag reflex.,0
"VIDEO OROPHARYNGEAL SWALLOW: Fluoroscopic guidance was provided for the speech pathologist who administered barium, solids and liquids of various consistencies to the patient.",0
"With thin liquids, there is penetration to the level of the cords, but no aspiration.",0
"For additional report details, please consult the speech pathologist report, which is available on the medical record section of CCC.",0
7:50 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for change Admitting Diagnosis: ACUTE CORONARY SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p intubation for respiratory failure REASON FOR THIS EXAMINATION: please evaluate for change ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,1
"INDICATION: Status post intubation for respiratory failure, followup.",1
FINDINGS: AP single view of the chest has been obtained with the patient in semi-upright position.,0
"The image is analyzed in direct comparison with a similar previous study dated , obtained at 14:30 hours.",0
The ETT is in unchanged appropriate position terminating in the trachea some 5 cm above the level of the carina.,0
An NG tube has been passed seen to reach below the diaphragm.,0
A wide-caliber tube resembling in design a chest tube is traversing the lower thorax on the right side and terminating overlying the left upper lobe area.,0
It is questionable whether this tube is in external position.,0
There is no evidence of any pneumothorax.,0
Diffuse density on the right base is consistent with pleural effusion layering partially posteriorly related to patient's semi-recumbent position.,1
"On the previous examination described diffuse haziness over both lungs, probably related to pulmonary edema, has subsided markedly.",0
", M. TSICU 12:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval position of esophageal balloon catheter Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with sepsis REASON FOR THIS EXAMINATION: eval position of esophageal balloon catheter ______________________________________________________________________________ PFI REPORT Esophageal catheter ends at the GE junction.",0
"Endotracheal tube placed too high, distances between end of endotracheal tube and carina measures 10 cm.",0
End of endotracheal tube appears above carina.,0
Results discussed with Dr. at 2 p.m.,0
"10:19 PM CT HEAD W/O CONTRAST Clip # Reason: FOUND DOWN, OD VS ICH.",0
"______________________________________________________________________________ MEDICAL CONDITION: 40 year old man found down in bed, pinpoint pupils, OD vs ICH REASON FOR THIS EXAMINATION: eval for bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: DMFj MON 10:48 PM No acute intracranial hemorrhage.",0
______________________________________________________________________________ FINAL REPORT STUDY: CT OF THE HEAD WITHOUT CONTRAST.,0
INDICATION: 40-year-old male found down with pinpoint pupils.,0
"FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major or minor vascular territorial infarction.",1
The density values of the brain parenchyma appear maintained.,0
There is moderate mucosal thickening within the left maxillary sinuses with small air bubbles and air-fluid level noted.,0
Mild mucosal thickening is also noted within the anterior ethmoid sinuses.,0
"The nasal cavity is completely opacified, but the nasal septum is intact.",0
The remainder of the visualized of the paranasal sinuses and mastoid air cells appear well aerated.,0
"Left maxillary sinus disease, likely acute on chronic.",0
"1:54 PM ART DUP EXT LO UNI;F/U; ART EXT SGL LEVEL Clip # Reason: RT LEG INFECTION, LT FEM- GRAFT, ASSESS DISTAL FLOW ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with s/p left CFA-AT bypass.",0
REASON FOR THIS EXAMINATION: Please assess graft and distal flow ______________________________________________________________________________ FINAL REPORT ARTERIAL DOPPLER LOWER EXTREMITY AT REST: REASON: Patient is status post left femoral-posterior tibial bypass.,0
FINDINGS: Duplex evaluation was performed of the left femoral to posterior tibial bypass graft.,0
"Systolic velocities in cm/second are as follows: 119, 168, 75, 66 in the native proximal vessel, proximal anastomosis, distal anastomosis and native distal vessel respectively.",0
Throughout the body of the graft velocities range from 64-105.,0
There are no peak velocity ratios greater than or equal to 2.,0
The ankle brachial index is 1.2.,0
Pulse volume recordings are normal at the ankle and metatarsal level.,0
"On the right, based on pulse volume recordings there is diminished flow at both the level of the ankle and the metatarsal.",0
IMPRESSION: Widely patent left femoral-posterior tibial bypass graft without any evidence of stenosis.,0
1:40 PM CT HEAD W/O CONTRAST Clip # Reason: trauma ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man hit be car REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: JK WED 2:31 PM VERY LARGE ACUTE LEFT CEREBRAL CONVEXITY SUBDURAL HEMORRHAGE WITH SUBFALCINE HERNIATION!!!!!!,1
"HAS LARGE SKULL FRACTURE WHICH INTERSECTS THE SUPERIOR SAGITTAL SINUS, NEAR THE VERTEX!!",1
WET READ VERSION #1 YOf WED 2:24 PM VERY LARGE ACUTE LEFT CEREBRAL CONVEXITY SUBDURAL HEMORRHAGE WITH SUBFALCINE HERNIATION!!!!!!,1
WE are trying to reach you by telephone!!!,0
______________________________________________________________________________ FINAL REPORT (REVISED) *ABNORMAL!,0
"INDICATION: 70-year-old man, hit by car.",0
TECHNIQUE: Noncontrast enhanced CT scan.,0
FINDINGS: No previous examination available for comparison.,0
"A large left subdural hematoma is present and seen involving the frontal, parietal, and temporal lobes.",1
There is mass effect on the adjacent structures and extensive subfalcine herniation towards the right side.,0
"Prominent left uncal and hippocampal herniation is also seen, with extensive midbrain compression.",0
Subdural hematoma measures 1.8 cm at its greatest width.,0
Subarachnoid hemorrhage is also visualized in the frontal lobes bilaterally and left parietal lobe.,1
There is probable left temporal entrapment.,0
There is mass effect on the brain stem and uncal herniation.,0
Suprasellar cistern is not visualized.,0
"There is high convexity, non-depressed skull fracture involving both frontal bones and crossing the sagittal suture line.",1
A small mucous retention cyst is present in the right maxillary sinus.,0
Mucosal thickening is seen involving both ethmoid sinuses.,0
"IMPRESSION: Large subdural hematoma involving the left frontal, parietal, and temporal lobe, and minimal amount in the occipital region.",1
"Subfalcine herniation as well as left uncal/hippocampal herniation, and left temporal entrapment is noted.",0
Subarachnoid hemorrhage is also present in both frontal lobes and left parietal lobe.,1
(Over) 1:40 PM CT HEAD W/O CONTRAST Clip # Reason: trauma ______________________________________________________________________________ FINAL REPORT (REVISED) *ABNORMAL!,0
"(Cont) This report was given to the emergency medicine attending physician in charge on at 2:15 p.m, with advice for emergent neurosurgical intervention.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: repeat to clarify picc tip location Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with new right REASON FOR THIS EXAMINATION: repeat to clarify picc tip location ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Single upright AP radiograph of the chest was compared with prior chest radiograph from acquired 22 hours apart.,1
FINDINGS: The course of the right PICC line is unchanged with its tip seen coursing to the left side at the level of upper SVC and likely still within the distal left brachiocephalic vein.,0
This could be again reevaluated following wire removal and flushing.,0
A triple lead left chest wall pacemaker is seen with leads in the right atrium and right ventricle and left ventricle.,0
No interval changes in the lungs.,0
The lungs remain well aerated.,0
"IMPRESSION: The right PICC line is similar in position as before with its tip directed to the left side at the level of upper SVC, likely in brachiocephalic vein.",0
Repeat radiograph is again recommended to confirm positioning within SVC following wire removal and flushing.,0
", M. OMED 7F 8:36 PM CHEST PORT.",0
"LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # -76 BY SAME PHYSICIAN : Please assess line placement; assess for PTX Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with ALL s/p line removal and placement REASON FOR THIS EXAMINATION: Please assess line placement; assess for PTX ______________________________________________________________________________ PFI REPORT Left IJ catheter has been repositioned, tip is in the upper SVC.",0
"2:03 PM CHEST (PORTABLE AP) Clip # Reason: please assess for any acute changes s/p intubation Admitting Diagnosis: PELVIC MASS;URINARY RETENTION ______________________________________________________________________________ MEDICAL CONDITION: 86yo w/ past medical history of CAD s/p four veseel CABG in , HTN, HLD, vertigo, chronic urinary retention with indwelling catheter in place with pelvic mass now s/p ex-lap, TAH/LSO, procto, cysto.",1
REASON FOR THIS EXAMINATION: please assess for any acute changes s/p intubation ______________________________________________________________________________ FINAL REPORT HISTORY: History CAD with status post lap.,1
CHEST RADIOGRAPH PORTABLE AP VIEW: Endotracheal tube tip terminates approximately 6.8 cm above the carina and advancing 3 cm is recommended.,0
There are low lung volumes with no pneumothorax.,0
"The left costophrenic angle is mild blunted, likely positional.",0
Cardiomediastinal and hilar silhouettes are stable.,0
"9:40 AM CHEST (PA & LAT) Clip # Reason: eval for interval change, ptx on water seal Admitting Diagnosis: TRACHEAL BRONCHIAL MALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with s/p trachealplasty5/4/05, now w/ 2 CT in place for sub q air, on water seal x12 hours REASON FOR THIS EXAMINATION: eval for interval change, ptx on water seal ______________________________________________________________________________ FINAL REPORT INDICATION: 2 chest tubes in place for subq air status post trachealplasty.",0
Evaluate for interval change or pneumothorax.,0
"FINDINGS: Compared with , the 2 right chest tubes are unchanged in position on the PA view.",0
There is now a new medium sized loculated hydropneumothorax present laterally and anteriorly in the right mid to upper hemithorax.,0
"There has been interval reduction in the amount of soft tissue chest wall and neck emphysema, but a considerable amount still is present.",0
"On the lateral view, the first lateral projection obtained since the upper right chest tube was inserted on , the distal segment of that chest tube is seen to lie outside the rib cage posteriorly.",0
"The entire course of the upper right chest tube probably lies in the extrathoracic soft tissues, since it seems unlikely that it enters the pleural space laterally and exits posteriorly.",0
Thoracic surgery was paged and these findings discussed.,0
8:54 AM CHEST (PORTABLE AP) Clip # Reason: interval exam Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with REASON FOR THIS EXAMINATION: interval exam ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb SAT 1:27 PM Possible discoid atelectasis versus loculated fluid within the major fissure on the right.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST 9:06 A.M.,0
INDICATION: 67-year-old man status post thoracentesis.,0
FINDINGS: Support lines and tubes are in stable position.,0
Left-sided effusion is essentially unchanged.,0
"On the right, there is a band-like opacity projecting over the mid lung, which may represent discoid atelectasis versus fluid within the major fissure.",0
Left lower lobe atelectasis also unchanged.Cardiomediastinal silhouette is unchanged.,0
"IMPRESSION: Band-like opacity in the mid lung, new from the prior examination, which could represent either discoid atelectasis versus fluid loculated within the major fissure.",0
"10:37 AM SHOULDER VIEWS NON TRAUMA LEFT Clip # Reason: 86 year old woman with left shoulder pain, r/o fx,dislocatio Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with left shoulder pain, r/o fx,dislocation REASON FOR THIS EXAMINATION: 86 year old woman with left shoulder pain, r/o fx,dislocation ______________________________________________________________________________ FINAL REPORT STUDY: Left shoulder three views, .",1
HISTORY: 86-year-old woman with left shoulder pain.,0
There are severe degenerative changes of glenohumeral joint with subchondral sclerosis and large osteophytes.,0
"There is also a loose body, likely within the bicipital groove, best seen on the lateral view.",0
Mild degenerative change of the AC joint is seen.,0
There are no signs of acute bony injury.,0
The visualized left lung apex is clear.,0
TC WHITE BLOOD CELL STUDY Clip # Reason: 59-year-old woman with Gram-positive cocci sepsis and back pain.,1
Evaluate for source of bacteremia.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 59-year-old woman with Gram-positive cocci sepsis and back pain.,0
"INTERPRETATION: Following injection of autologous white blood cells labeled with Tc-m, images of the whole body were obtained for six hours.",0
These images demonstrate intense uptake in a rounded supraclavicular lesion.,0
This area was marked and corresponded to a palpable mass.,0
These findings were discussed with the caring physician at the time the exam was completed.,0
No other areas of active tracer uptake are seen.,0
"Normal uptake is seen within the liver, spleen, bowel and kidneys.",0
"IMPRESSION: Intense tracer uptake in the right supraclavicular region, worrisome for abscess.",0
Approved: MON 3:14 PM RADLINE ; A radiology consult service.,0
"11:45 AM CAROT/CEREB Clip # Reason: r/u vascular occlusion / stroke Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: OPTIRAY Amt: 200 ********************************* CPT Codes ******************************** * PRIMARY MECH THROMBECTOMY ART/ SEL CATH 3RD ORDER * * -51 MULTI-PROCEDURE SAME DAY CAROTID/CERVICAL UNILAT * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL UNILAT * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with altered mental status this am/ non verbal right hemiparesis REASON FOR THIS EXAMINATION: r/u vascular occlusion / stroke ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: 71-year-old female patient with altered mental status and development of right hemiparesis in this a.m. CTA was performed, which demonstrated a thrombus in the left MCA bifurcation.",1
"CEREBRAL ANGIOGRAM: Left common carotid artery arteriogram, Left internal carotid artery arteriogram, Left middle cerebral artery arteriogram, Left MCA chemical thrombolysis (6 units TPA) and mechanical thrombolysis with Penumbra catheter.",0
"TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications and alternative management.",0
"Risks explained included stroke, loss of vision and speech, temporary or permanent, with possible treatment with stent and coils if needed.",0
The patient was brought to the Interventional Neuroradiology Theater and placed on the biplane table in supine position.,0
Both groins were prepped and draped in the usual sterile fashion.,0
"Access to the right common femoral artery was obtained using a 19-gauge single wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.",0
"Through the needle, a 0.35 wire was introduced and the needle taken out.",0
"Over the wire, a 8 Fr vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units in 500 cc of saline) with a continuous drip.",0
"Through the sheath, a 5 French was introduced and connected to continuous saline infusion (with mixture of 1000 unitsof heparin in 1000 cc of saline).",0
The left common carotid artery was selectively catherized and arteriogram was performed.,0
The left ICA was catheterized and the II catheter exchanged (Over) 11:45 AM CAROT/CEREB Clip # Reason: r/u vascular occlusion / stroke Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) out for a Merci base catheter.,0
"Subsequently, the left MCA was sub- selectively catheterized.",0
The superior division of the left MCA was seen to be occluded.,0
"Based on the diagnostic findings, it was decided to perform mechanical thrombectomy.",0
Multiple attempts to remove the left MCA bifurcation thrombus using the Penumbra mechanical thrombectomy device were unsuccessful.,0
3 mg of TPA were then infused at the left MCA just proximal to the clot without success.,0
Sub- selective hand injection was performed at this level and continued to demonstrate a clot.,0
"Penumbra device was again advanced into the left superior division of the middle cerebral artery, however, the attempt to remove the thrombus was unsuccessful.",0
Another 3mg of TPA was again administered after whcih persistence of the thrombus was still seen.,0
At this point we felt that the vessel was not recanalizing because the cortex supplied by it was already infarcted.,0
FINDINGS: Left Common carotid artery arteriogram: Common carotid bifurcation is seen normally.,0
"The internal carotid artery fills well along the cervical petrous, cavernous and supraclinoid portion.",0
The middle cerebral artery is occluded after the origin of two small branches.,0
Left internal carotid arteriogram: Complete occlusion of distal M1 segment of the left middle cerebral artery.,0
Left middle cerebral artery arteriogram: There is a cutoff at the level of the left MCA bifurcation.,0
Two branches supplying the parietal lobe are seen to originate just prior to the occlusion.,0
Pial collaterals were identified from the ACA.,0
The left ACA is unremarkable.,0
IMPRESSION: Left MCA occluded distally by thrombus.,0
Attempts at chemical and mechanical thrombolysis were unsuccessful.,0
"8:13 AM CHEST (PORTABLE AP) Clip # Reason: assessment of pulmonary congestion compared to previous stud Admitting Diagnosis: NON ST ELEVATION MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with mi now new diffuse ronchi and upper airway sounds, O2Sat 97% 4L O2 REASON FOR THIS EXAMINATION: assessment of pulmonary congestion compared to previous study ______________________________________________________________________________ FINAL REPORT INDICATION: 87 year old man with new diffuse rhonchi.",1
FINDINGS: The patient is status post median sternotomy with multiple mediastinal clips.,0
The tip of the intravenous catheter is in the SVC.,0
"There is continued mild cardiomegaly with increased interstitial markings in bilateral lung, representing congestive heart failure and pulmonary edema.",1
"There is increased opacity in bilateral lung bases, suggesting effusion.",0
"Again noted is made of consolidations in right lung field and left lower lobe, suggesting pneumonia.",0
The overall appearance has not been changed compared to the previous study.,0
"IMPRESSION: Mild cardiomegaly with pulmonary edema and congestion, representing cardiac failure.",1
"Consolidations in right middle lung field in the left lower lobe, suggesting a pneumonia.",0
Overall findings shows a stable appearance compared to the previous study.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: ICU HISTORY OF PRESENT ILLNESS: Ms. is a 79-year-old woman with a severe history of chronic obstructive pulmonary disease, a history of a benign lung tumor, with a left lower lobe resection 20 years prior to admission who was initially admitted to the A-Cove Service on with a chronic obstructive pulmonary disease exacerbation.",1
Six days prior to admission she had felt fatigued with fevers.,0
She had a temperature spike to 100 at home.,0
"Her visiting nurse felt that she was breathing poorly, had a fast heart rate, and appeared weak and had her evaluated in the Emergency Room.",0
"The patient did not complain of cough, hemoptysis, nausea, vomiting, or abdominal pain.",0
She had lost approximately seven pounds in the preceding six months.,0
"In the Emergency Room, her temperature was 99.8.",0
Her heart rate was 107.,0
"Her blood pressure was 144/77, and her respiratory rate was 20, with a saturation of 97%.",0
"She appeared comfortable, spoke in full sentences.",0
"A chest x-ray was remarkable for a left upper lobe spiculated opacity; new since and concerning for pneumonia, tumor, or tubercular infection.",0
A CT scan was obtained and was pending while she was evaluated in the Emergency Room.,0
"She was initially treated with normal saline, levofloxacin intravenously, albuterol, and Atrovent and admitted to the A-Cove Service for further management.",0
A benign lung lesion; status post resection 20 years prior.,0
"Breast cancer, status post lumpectomy with radiation therapy.",0
"Rectal cancer, status post radiation therapy.",0
MEDICATIONS ON ADMISSION: (Medications on admission were) 1.,0
Flovent 220 4 puffs b.i.d.,0
Home oxygen at 2 liters.,0
"SOCIAL HISTORY: A nonsmoker currently, but with a 37-pack-year history.",0
"PHYSICAL EXAMINATION ON PRESENTATION: On admission temperature was 98.9, blood pressure was 126/62, heart rate was 108, respiratory rate was 20, saturating at 99% on 2 liters.",0
"In general, a cachectic, frail, elderly woman speaking in full sentences on 2 liters nasal cannula.",0
"Pupils were equal, round and reactive to light.",0
Heart rate and rhythm were regular with a normal first heart sound and second heart sound.,0
"She had a high-pitched inspiratory wheeze bilaterally in her upper lobes, left greater than right.",0
Her abdomen was soft and nondistended.,0
It was tender in the right upper quadrant to deep palpation.,0
She had multiple ecchymoses diffusely with peripheral tissue wasting.,0
"Neurologically, she was alert and oriented times three.",0
"PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data on admission revealed she had a white blood cell count of 13.2 (which was elevated from a prior of 11.2), hematocrit was 35 (down from the 40s), and a platelet count of 479.",0
"Sodium was 1453,, potassium was 3.8, chloride was 99, bicarbonate was 29, blood urea nitrogen was 22, creatinine was 0.7, blood glucose was 92.",0
"RADIOLOGY/IMAGING: Electrocardiogram revealed sinus tachycardia at 123, normal axis.",0
"A chest x-ray revealed increasing opacity with spiculated appearance, chordae at the left apex in a region previously described as scarring; worrisome for scar, carcinoma, or recurrent tumor.",0
Also concerning for infectious source.,0
HOSPITAL COURSE: Ms. was initially admitted to the A-Cove Service for further management of pneumonia versus chronic obstructive pulmonary disease exacerbation.,1
"Given the findings on her chest x-ray, the Pulmonary Service was consulted, and she underwent a diagnostic bronchoscopy and lavage.",0
She tolerated the procedure poorly and needed to initially be placed on BiPAP and admitted to the Medical Intensive Care Unit.,0
"Shortly after being admitted to the Intensive Care Unit, she had severe respiratory decompensation and required intubation for management of her respiratory.",0
She also had an A-line placed.,0
"Over the subsequent 12 days in the Intensive Care Unit, Ms. was treated aggressively for presumed pneumonia; although no infectious source was ever found.",0
She was also treated aggressively for a chronic obstructive pulmonary disease exacerbation with high-dose steroids as well as inhaled bronchodilators and Atrovent.,1
"Despite these intense interventions, she remained ventilatory dependent requiring pressor support at all times.",0
She failed to tolerate several attempts to wean.,0
"During this time, the Medical Intensive Care Unit team was in close contact with the patient's family including her daughters.",0
The patient did remain alert and able to interact and confirm her wishes during this course.,0
"Toward the end of her admission, it became evident that she would require a tracheostomy to further maintain her ventilatory status.",0
This was discussed with her daughters and with Ms. as well.,0
"Mr. made it quite clear that she did not wish tracheostomy, and this was confirmed by her daughters.",0
"On , Ms. deliberately self-extubated herself.",0
She was initially placed on a mask and CPAP.,0
"Her attending and family were notified, and the decision not to reintubate was confirmed.",0
"She was started on a morphine drip for comfort, and her family and sister were present.",0
She ultimately expired on .,0
Chronic obstructive pulmonary disease exacerbation.,1
Dictated By: MEDQUIST36 D: 09:21 T: 16:14 JOB#:,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: ACOVE Medicine Service HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old gentleman transferred from with two days of a diagnosis of babesiosis.,0
He had an episode of hypotension at the outside hospital and was started on dopamine.,0
He came to the Emergency Department at on 5 mcg of dopamine but was off on examination.,0
"On speaking to the patient, he states he started having fevers and rigors and was told he looked awful by his primary care physician on the before admission.",0
"He also had some gastrointestinal upset, abdominal pain, and diarrhea and was given atovaquone and azithromycin by his primary care physician.",0
reports a headache that is pounding.,0
"In the Emergency Department, the patient was also complaining of neck pain and neck stiffness.",0
A lumbar puncture was deferred secondary to low platelets.,0
He had been given 2 g of Rocephin at the outside hospital.,0
On the Monday night prior to admission the patient's mother called Emergency Medical Service secondary to the patient being found on the floor without the ability to get up himself.,0
He was not able to provide incite into what had happened to the paramedics due to confusion.,0
He was felt to have an change in mental status at the outside hospital.,0
A computed tomography scan at the outside hospital showed no bleed.,0
"On presentation to his white blood cell count was 1.9, platelets?",0
"were 2.8, and hematocrit was 36.",0
Plastic surgery times four of forehead after car accident.,0
MEDICATIONS ON ADMISSION: (Current medications include) 1.,0
Zithromax and atovaquone as an outpatient for two days.,0
Xanax as needed (for anxiety).,0
SOCIAL HISTORY: The patient lives in and has lived there for 35 years.,0
He is from and lives with a partner who is human immunodeficiency virus negative.,0
He states his human immunodeficiency virus test was negative two years ago.,0
He is a self-employed caterer.,0
"He denies any intravenous drug use, alcohol, or tobacco use.",0
"PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 100.3, heart rate was 106, respiratory rate was 26, blood pressure was 110/75, and oxygen saturation was 100%.",0
"In general, the patient was alert and oriented.",0
"Head, eyes, ears, nose, and throat examination revealed no meningismus.",0
A 2/6 systolic murmur at the left upper sternal border.,0
Respiratory examination revealed clear to auscultation bilaterally.,0
Abdominal examination revealed the abdomen was soft and nontender; benign.,0
Musculoskeletal examination revealed strength was with slight tremors.,0
Skin revealed a lesion on the right upper thigh.,0
Symmetrically decreased reflexes on the lower extremities.,0
"The patient was unable to focus for questions, but very talkative.",0
Lymph node examination revealed no lymphadenopathy.,0
"PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories upon arrival revealed complete blood count with a white blood cell count of 2.2, hematocrit was 28, and platelets were 43.",0
"Sodium was 135, potassium was 3.9, chloride was 102, bicarbonate was 26, blood urea nitrogen was 18, creatinine was 0.7, and blood glucose was 129.",0
Microbiology revealed Babesia smear reported positive at .,0
PERTINENT RADIOLOGY/IMAGING: A noncontrast computed tomography scan of the head at the outside hospital was negative.,0
"HOSPITAL COURSE: The patient was initially admitted to the Intensive Care Unit for close monitoring due to his hypotension; however, the patient's blood pressure resolved with aggressive hydration.",0
The patient was continued on atovaquone and azithromycin with the addition of doxycycline for coverage of babesiosis as well as Ehrlichia and Lyme disease.,1
"Many laboratory tests were obtained; including a peripheral smear for Babesia, Lyme titers, Ehrlichia titers, rapid plasma reagin, human immunodeficiency virus, parvovirus B19, as well as hepatitis panels.",0
Dictated By: MEDQUIST36 D: 09:07 T: 08:36 JOB#:,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: eval placement ______________________________________________________________________________ MEDICAL CONDITION: year old woman with new IJ Line REASON FOR THIS EXAMINATION: eval placement ______________________________________________________________________________ WET READ: JMGw MON 10:46 PM IJ satisfactory.,0
side hole of NGT above GE junction and could be further advanced.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Left IJ placement.,0
AP VIEW OF THE CHEST COMPARISON: at 19:38.,0
FINDINGS: There is a newly placed right-sided IJ catheter with the tip at the cavo-atrial junction.,0
"A nasogastric tube has been further advanced since the prior study; however, the side port still remains above the GE junction and could be further advanced.",0
The heart is mildly enlarged with left basilar atelectasis.,0
"There is radiodense material projecting in what appears to be a loop of bowel in the left upper abdomen, likely related to recent CT examination.",0
Right IJ line in satisfactory position.,0
NG tube with side hole above the GE junction and could benefit from further advancement so that it is well within the stomach.,0
Dr. is aware on 9pm.,0
"Cardiomegaly with left base opacity, likely combination of pleural effusion and atelectasis.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 65 year old male with a history of dyspnea on exertion for six to 12 months.,0
An echocardiogram performed in revealed aortic stenosis with a left ventricular ejection fraction of 55% to 60%.,0
The patient had an exercise tolerance test on which showed severe inferior defect with partial reversibility as well as reversible septal ischemia.,0
"Cardiac catheterization was performed on , which revealed a left ventricular ejection fraction of 60%, pulmonary artery wedge pressure of 11 and aortic stenosis with a mean gradient of 22 mm of mercury with a valve area of 1.2 cm2.",1
It also revealed three vessel coronary artery disease.,1
"MEDICATIONS ON ADMISSION: Atenolol, Lipitor, glyburide and aspirin.",0
"PHYSICAL EXAMINATION: On physical examination on admission, the patient had a blood pressure of 171/71, pulse 53, sinus bradycardia, temperature 96.3 and oxygen saturation 98% in room air.",0
General: Well appearing middle-aged male in no acute distress.,0
"Head, eyes, ears, nose and throat: Unremarkable with the exception of some jugular venous distention.",0
"Cardiovascular: Regular rate and rhythm, normal S1 and S2, grade II/VI systolic murmur.",0
"Extremities: Without edema, 2+ dorsalis pedis and posterior tibialis pulses bilaterally.",0
LABORATORY DATA: Preoperative electrocardiogram revealed normal sinus rhythm.,0
Preoperative laboratory values were unremarkable with the exception of a glucose of 307.,0
"HOSPITAL COURSE: The patient was admitted directly to the preoperative holding area and taken to the Operating Room on , where he underwent coronary artery bypass grafting times four as well as an aortic valve replacement with a 25 mm pericardial tissue valve.",1
"Postoperatively, the patient was transported from the Operating Room to the Cardiac Surgery Recovery Room, where he was being atrially paced.",0
He was on insulin and propofol drips.,0
"The patient was hemodynamically stable, however, due to increased chest tube output of approximately 400 cc/hour for the first couple of hours postoperatively, the patient was taken back to the Operating Room for re-exploration for bleeding on the evening of surgery.",0
"There was a small distal branch of the right internal mammary artery which was found to be bleeding, and repaired.",0
"Postoperatively from the re-operative procedure, the patient was transported again to the Cardiac Surgery Recovery Room, where he remained hemodynamically stable.",0
"He was on a low dose Neo-Synephrine drip initially, which was weaned off within the first few hours of arrival.",0
The patient was also on an insulin drip for a short while in the postoperative period.,0
The patient was weaned from the mechanical ventilator and extubated on postoperative day one.,0
He also transferred out of the Intensive Care Unit to the telemetry floor on postoperative day one in stable condition.,0
"The patient had a physical therapy evaluation on , postoperative day one, and was begun on cardiac rehabilitation.",0
"On postoperative day two, , the patient remained in stable condition.",0
His atrial pacing was discontinued and he had remained in normal sinus rhythm with a rate in the 80s and with a stable blood pressure.,0
The patient was noted to have some decreased breath sounds bilaterally.,0
"A chest x-ray was obtained at that time, which revealed bibasilar atelectasis and small bilateral pleural effusions.",0
"Later that day, the patient's Foley catheter was discontinued as well as his chest tubes, and he began ambulating.",0
"On postoperative day three, the patient continued to progress from a physical therapy standpoint and remained stable hemodynamically.",0
"Over the next two days, the patient continued to progress well.",0
"He remained hemodynamically stable and today, , postoperative day five, he remains stable and is ready to be discharged to home.",0
"CONDITION ON DISCHARGE: Temperature 98.3, pulse 72, normal sinus rhythm, blood pressure 98/58, respiratory rate 18 and oxygen saturation 94% in room air.",0
"The patient's weight today is 111 kilograms, which is up seven kilograms from his preoperative weight of 104 and his blood sugar has been in the 90s.",0
PHYSICAL EXAMINATION ON DISCHARGE: The patient is alert and oriented with no apparent neurologic deficits.,0
Heart sounds are a regular rate and rhythm.,0
"Sternum is stable with incision clean, dry and intact.",0
"Abdomen is soft, nontender and nondistended.",0
Extremities are warm and well perfused with some peripheral edema noted.,0
"The patient is also noted to have some blistering at his saphenous vein harvest site, however, there is no erythema or purulent drainage noted; there is a small amount of serous drainage.",0
"LABORATORY DATA: The patient's most recent laboratory values are from , which showed a white blood cell count of 11,000, hematocrit 26, platelet count 119,000, sodium 141, potassium 4.3, chloride 108, bicarbonate 24, BUN 19, creatinine 0.6 and glucose 162.",0
DISPOSITION: The patient is being discharged home today with visiting nurse follow-up due to the wound blistering on the right thigh area.,0
"Dressing changes, if the patient is having blistering, should be Vaseline or Neosporin applied to the blistered area and a dry sterile dressing placed over that as long as it continues to have any blistering.",0
"FOLLOW-UP: The patient is to follow up with Dr. in one month for a postoperative check, telephone number .",0
"The patient is also to follow up with his primary care physician, .",0
", in three to four weeks, or sooner if necessary.",0
"DISCHARGE DIAGNOSIS: Aortic stenosis, status post aortic valve replacement.",1
Dictated By: MEDQUIST36 D: 12:21 T: 12:30 JOB#:,0
9:32 AM CHEST (PA & LAT) Clip # Reason: eval lungs and volume status.,0
Admitting Diagnosis: RIB FRACTURE AND LUNG PUNCTURE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with left rib fxr and right PNA REASON FOR THIS EXAMINATION: eval lungs and volume status.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 11:12 AM 1.,0
Resolving left upper lobe pneumonia.,0
Stable right middle lobe opacification may represent stable right middle lobe pneumonia.,0
Improved right lower lobe opacification likely reflecting resolving right lower lobe atelectasis.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 63-year-old man with left rib fracture and right pneumonia, evaluate lungs and volume status.",0
"PA AND LATERAL CHEST RADIOGRAPH: In comparison with the study of , there is improved opacification in the right upper lobe above the level of the minor fissure, which may reflect resolving pneumonia.",0
"There is some opacification within the right middle lobe with silhouetting of the right heart border, which is stable since and may reflect unchanged consolidation.",0
The opacification in the right lower lobe has improved since .,0
Area of opacification in the retrocardiac region noted on is improved in this study.,0
There is trace loculated left-sided pleural effusion.,1
Metallic fixation devices are seen along several left posterior ribs.,0
Resolving right upper lobe pneumonia.,0
11:49 AM THORACOSTOMY TUBE INSERTION; CT THORACENTESIS DRAINAGE Clip # -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE CT GUIDED NEEDLE PLACTMENT; -59 DISTINCT PROCEDURAL SERVICE Reason: PLEASE PLACE PIGTAIL DRAIN.,0
"Send fluid for pH, LDH, T prote Admitting Diagnosis: EPIDURAL MASS ********************************* CPT Codes ******************************** * THORACOSTOMY TUBE INSERTION CT THORACENTESIS DRAINAGE * * -59 DISTINCT PROCEDURAL SERVICE CT GUIDANCE DRAINAGE * * CT GUIDED NEEDLE PLACTMENT -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with L pleural effusion, loculated, possible empyema.",1
REASON FOR THIS EXAMINATION: PLEASE PLACE PIGTAIL DRAIN.,0
"Send fluid for pH, LDH, T protein, cell count w/ differential, gram stain and culture.",0
______________________________________________________________________________ FINAL REPORT EXAM: CT interventional procedure obtained .,0
"HISTORY: 61-year-old male with left pleural effusion which is loculated, unable to drain under ultrasound guidance, need pigtail catheter placement.",1
"TECHNIQUE: Informed consent was obtained as the procedure, risks, and alternatives were discussed with the patient and the consent form signed.",0
A directed history and physical exam was performed prior to the procedure.,0
A directed CT of the area of concern was obtained and demonstrated similar findings to the recent CT of .,0
Again noted was the left loculated pleural effusion with associated adjacent compressive atelectasis.,1
"There appears to be two separate collections which do not communicate, one which is superior and one which is inferior to the collapsed lung.",0
A critical pause was performed with assisting personnel just prior to the procedure and the patient's identity was confirmed using two identifiers.,0
Imaging guidance was utilized to select the precise skin entry point.,0
Approximately 10 mL of lidocaine was administered for local anesthesia.,0
Conscious sedation was performed with sequential administration of fentanyl and Versed for a total dose of 100 mcg of fentanyl and 0.5 mg of Versed.,0
Cardiorespiratory monitoring was performed throughout the examination.,0
Total intraservice time was 90 minutes.,0
"The attending, Dr. , was present throughout the examination.",0
"PROCEDURE: Under CT guidance, an 18 gauge needle was advanced into the fluid collection.",0
Initially straw-colored fluid was aspirated for approximately 8 cc.,0
"Then, the fluid appeared somewhat cloudy with a reddish tinge.",0
A 10 French pigtail catheter was placed using Seldinger technique with sequential dilatation of the tract.,0
(Over) 11:49 AM THORACOSTOMY TUBE INSERTION; CT THORACENTESIS DRAINAGE Clip # -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE CT GUIDED NEEDLE PLACTMENT; -59 DISTINCT PROCEDURAL SERVICE Reason: PLEASE PLACE PIGTAIL DRAIN.,0
"Send fluid for pH, LDH, T prote Admitting Diagnosis: EPIDURAL MASS ______________________________________________________________________________ FINAL REPORT (Cont) Then, under CT guidance, the second area was localized, and a second 10 French catheter was placed utilizing seldinger technique with sequential dilatation of the tract.",0
"This collection yielded serosanguineous/hemorrhagic fluid, similar to the fluid aspirated the day before under us guidance.",0
Fluid was sent to the laboratory for analysis.,0
A post-procedure note was placed into the medical record.,0
IMPRESSION: Successful CT-guided placement of two 10 French pigtail catheters into the left pleural space into a loculated pleural effusion which has two components to it.,1
Post-procedure imaging demonstrated mild improvement in aeration of the lungs.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: The patient was admitted to the Medical Intensive Care Unit on and discharged from the Medical Intensive Care Unit to the floor on .,0
CHIEF COMPLAINT: Bright red blood per rectum times three.,0
"HISTORY OF PRESENT ILLNESS: This is a 71 year old man with a history of recurrent gastrointestinal bleeding in and , also with diverticulosis and polyps and internal hemorrhoids.",1
He was recently admitted to from through for lower gastrointestinal bleeding with a pre-syncopal episode and now presents again for bright red blood per rectum.,1
The patient reports three episodes of hematochezia today with a large amount of blood noted in the toilet.,0
He complains of lightheadedness in the evening with lower abdominal pain relieved after defecation.,0
The patient was noted to have two bloody bowel movements in the Emergency Department.,0
"He denies chest pain, shortness of breath, nausea or vomiting, headaches, orthopnea or paroxysmal nocturnal dyspnea.",0
No history of cardiac disease or bleeding disorders.,0
The patient has a known history of hypertension and states that his blood pressure runs in the 130s over 80s on a regular basis.,0
"Per his family, the patient took an anti-inflammatory medication for arthritic knee pain prior to the last admission that may have precipitated his previous admission.",0
"Recent studies include an esophagogastroduodenoscopy performed , which shows a small hiatal hernia, a single 2 millimeter nonbleeding polyp in his fundus.",0
"Colonoscopy performed shows nonbleeding Grade I internal hemorrhoids, diverticulosis of the ascending and sigmoid ; otherwise normal the cecum.",1
"Small bowel follow through on , shows normal small bowel loops, normal terminal ileum and pathology from shows samples of polyps, evidence of fragments of adenomas.",0
Status post transurethral resection of prostate and inguinal hernia repair.,0
FAMILY HISTORY: Significant for a father with cancer.,0
"SOCIAL HISTORY: No alcohol, smoking or intravenous drug use.",0
ALLERGIES: Ampicillin and gentamicin; rash was noted.,0
"PHYSICAL EXAMINATION: On admission, temperature 98.2 F.; heart rate 85; blood pressure 136/71; O2 98% on room air.",0
"Of note, the patient was orthostatic by pulse 85 on sitting, 130 when standing.",0
"The patient appeared tired, calm and pale.",0
Oropharynx was clear; no lymphadenopathy.,0
"Cardiovascular was regular rate and rhythm, S1, S2, no murmurs, rubs or gallops.",0
Lungs were clear to auscultation bilaterally.,0
"Abdomen with positive bowel sounds, obese, distended, tympanitic to percussion.",0
"Mild bilateral lower quadrant tenderness, left greater than right.",0
Extremities with trace edema on the left side.,0
"Pulses one plus, no femoral hematoma or bruits.",0
The patient was moving all extremities.,0
Deep tendon reflexes one plus bilaterally.,0
The patient was noted to have bright red blood.,0
"LABORATORY: On pertinent laboratories, the patient's hematocrit was 32.5, recently noted to be 32.9 on discharge.",0
"MCV of 87, RDW 14.9, CK was 98, CK MB not done.",0
"PT is 12.6, PTT 24.2, INR 1.1.",0
"EKG showed sinus rhythm at 90 beats per minute, normal axis, evidence of right bundle branch block, J-point elevation in V2 to V5.",1
No evidence of acute ischemia and possible T wave inversion in lead III.,0
This electrocardiogram was compared to prior EKG from primary care physician .,0
There were no acute changes.,0
The patient was sent for a mesenteric angiogram which did not show any evidence of acute bleeding.,0
HOSPITAL COURSE: Peripheral access was obtained with two large bore intravenous lines.,0
The patient was appropriate transfused to maintain his hematocrit above 30.,0
Volume resuscitation was given with normal saline.,0
The patient was started on proton pump inhibitor for gastrointestinal prophylaxis.,0
Colonoscopy was not indicated at this time as patient just recently had received this procedure.,0
The patient was observed in the Medical Intensive Care Unit and remained hemodynamically stable.,0
Hematocrit on discharge from the Medical Intensive Care Unit was greater than 30.,0
The patient was transferred to the floor for further monitoring and evaluation.,0
CONDITION ON DISCHARGE FROM THE MEDICAL INTENSIVE CARE UNIT was stable.,0
Blood pressure medications were held.,0
Dictated By: MEDQUIST36 D: 13:15 T: 23:47 JOB#:,0
PATIENT/TEST INFORMATION: Indication: Coronary artery disease; hypertensive heart disease Height: (in) 76 Weight (lb): 244 BSA (m2): 2.41 m2 BP (mm Hg): 120/70 HR (bpm): 70 Status: Inpatient Date/Time: at 15:30 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: mid inferoseptal - hypo; mid inferior - hypo; mid inferolateral - hypo; inferior apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Mild (1+) MR. TRICUSPID VALVE: Physiologic TR.,0
See Conclusions for post-bypass data Conclusions: PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage.,0
There is mild regional left ventricular systolic dysfunction with focalities in the mid and apical inferior.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 45 %).,0
The left coronary cusp is non mobile.,0
A 0.3 x 0.3 cm calcium deposit seenon the right coronary cusp.,0
There is mild aortic valve stenosis (valve area 1.6cm2).,0
"There is a mild improvement of wall motions in the inferior, inferoseptal and inferolateral segments.",0
Aortic valve findings remains the same as prebypass.,0
", F. TSICU 1:58 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate for placement and TPX Admitting Diagnosis: S/P ASSAULT ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with new L SC CVL REASON FOR THIS EXAMINATION: please evaluate for placement and TPX ______________________________________________________________________________ PFI REPORT PFI: No pneumothorax following left subclavian line placement, which ends in the mid-to-lower superior vena cava.",0
5:55 AM CHEST (PORTABLE AP) Clip # Reason: please assess for interval change.,0
Admitting Diagnosis: PER NEHEN PTB\CHEMO HIGH DOSE INTERLEUKIN-2) ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with renal cell ca hypoxic after IL-2 treatment s/p trach intubation REASON FOR THIS EXAMINATION: please assess for interval change.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 59-year-old male with renal cell carcinoma, on IL-2 treatment.",0
Comparison is made to prior radiograph dated and prior CT dated .,0
SINGLE PORTABLE AP CHEST RADIOGRAPH.,0
Please note that this is a redictation for an old study.,0
There appears to be slight improvement to a layering right-sided pleural effusion with no significant change to underlying basilar atelectasis.,1
More linear density is identified within the lingula on today's radiograph consistent with subsegmental atelectasis.,0
Tracheostomy tube remains approximately 8 cm from the carina and tip of right-sided subclavian central venous catheter is located within the mid SVC.,0
Nasogastric tube remains appropriately positioned.,0
Slight decrease to layering right-sided pleural effusion.,1
Stable right lower lobe atelectasis with new subsegmental lingular atelectasis.,0
"10:12 AM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate for herniation, hydrocephalus.",0
"Admitting Diagnosis: APNEA,MENTAL STATUS CHANGES ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with bilateral cerebellar infarcts, today significantly worsened clinical exam - not following commands, eyes with spontaneous upwards and downwards movements, no corneal reflexes.",0
"REASON FOR THIS EXAMINATION: Please evaluate for herniation, hydrocephalus.",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Bilateral cerebellar infarcts with significantly worsened clinical examination.,0
The patient is not following commands.,0
The eyes manifest spontaneous upward and downward movement without corneal reflexes.,0
Evaluate for hydrocephalus and herniation.,0
"FINDINGS: Compared to the previous day's examination, there is a little interval change appreciated.",0
The large bilateral cerebellar infarction as well as infarction involving the left half of the lower pons is again noted.,0
"Based upon the configuration of the fourth ventricle, there is negligible interval change in the associated mass effect.",0
"However, the infarction in the cerebellum does involve the cerebellar tonsils.",0
"Certainly, these latter structures, if edematous, could compress the medulla, although once again there does not appear to be an obvious change in the configuration of this portion of the brain stem.",0
The supratentorial ventricular system is unchanged.,0
No other new intracranial abnormalities are seen.,0
"CONCLUSION: Relatively stable, but markedly abnormal study as noted above.",0
9:15 AM CHEST (PORTABLE AP) Clip # Reason: OG tube placement Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with asthma s/p intubation REASON FOR THIS EXAMINATION: OG tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Asthma status post intubation and OG tube placement.,1
FINDINGS: ET tube is in unchanged position.,0
"A feeding tube has been exchanged for an orogastric tube, the tip of which is located well below the diaphragm, not entirely imaged.",0
Lungs remain hyperinflated but clear.,0
IMPRESSION: OG tube reaches the stomach.,0
"Findings reported to Dr. by telephone at 9:35 a.m., , as requested.",0
"LINE PLACEMENT Clip # Reason: Pleural effusion, pneumothorax, tamponade, pulmonary edema.",0
"Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with OP CABG REASON FOR THIS EXAMINATION: Pleural effusion, pneumothorax, tamponade, pulmonary edema.",1
Pt in OR 4 and will be in CSRU on 90 mins.,0
REASON FOR EXAM: SP CABG.,0
Swan-Ganz catheter tip is in the main pulmonary artery.,0
ET tube tip is 2.6 cm above the carina.,0
Mediastinal and bilateral chest tubes are in place.,0
There are bilateral discoid atelectasis in the mid lungs.,0
Left lower lobe retrocardiac opacity is consistent with atelectasis.,0
There are no sizeable pleural effusions.,0
Patient is post median sternotomy and CABG.,0
Cardiac silhouette is top normal size.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Hypotension.,1
History of Present Illness: Mr. is a 72 yo M with history of T4aN2cM0 squamous cell carcinoma of the left base of tongue recieving chemoradiation with cetuximab (radiosensitizer) complicated by diarrhea and hypotension who is admitted for hypotension.,1
He was last seen in heme onc for hydration after refusing to go to ED for hypotension.,0
He was 99/56 in clinic and refused admission.,0
"After not showing up to clinic on , the polidce were called and EMS arrived to his house and found him to be hypotensive with systolics in 70s and he was brought to the ED.",0
"In the ED, his initial BP was in the 50s.",0
He was also noted to be in afib.,0
"He was given vancomycin, levofloxacin, metronidazole, and 5L NS.",0
"On transfer he was afebrile, HR was afib at 110, BP was 110/60s.",0
"Past Medical History: Squamous cell carcinoma of the tongue, on XRT/cetuximab.",0
Prostate cancer s/p XRT at .,0
"Anemia Renal cysts on u/s Social History: Denies current drugs, etoh, smoking.",1
Previously smoked pack per day for 40 years.,0
Previously drank a lot of etoh.,0
Has been sober and cigarette free for 10 yrs.,0
Family History: Mother died of some kind of problem.,0
Brother died of lung cancer.,0
"Physical Exam: ADDIMISSION EXAM: General Appearance: No acute distress, Thin Head, Ears, Nose, Throat: Normocephalic Cardiovascular: RRR, no m/g/r PULM: CTAB no w/r/r Abdominal: Soft, Bowel sounds present, Tender: only around peg tube Ext: no c/c/e Pertinent Results: ADMISSION LABS: 06:40AM BLOOD WBC-7.8 RBC-3.43* Hgb-9.2* Hct-27.1* MCV-79* MCH-26.8* MCHC-34.0 RDW-11.8 Plt Ct-261 06:40AM BLOOD Neuts-93.4* Lymphs-2.9* Monos-2.9 Eos-0.8 Baso-0 06:40AM BLOOD PT-14.2* PTT-36.3* INR(PT)-1.2* 06:40AM BLOOD Glucose-137* UreaN-25* Creat-1.2 Na-137 K-3.3 Cl-106 HCO3-20* AnGap-14 06:50AM BLOOD Lactate-1.5 .",0
04:24AM BLOOD WBC-2.9*# RBC-3.25* Hgb-8.8* Hct-25.6* MCV-79* MCH-27.2 MCHC-34.5 RDW-12.0 Plt Ct-270 04:24AM BLOOD Glucose-133* UreaN-12 Creat-0.9 Na-139 K-3.7 Cl-109* HCO3-22 AnGap-12 04:24AM BLOOD CK(CPK)-98 06:40AM BLOOD cTropnT-<0.01 05:00PM BLOOD CK-MB-5 cTropnT-0.12* 04:24AM BLOOD CK-MB-4 cTropnT-0.10* 06:40AM BLOOD Calcium-7.5* Phos-2.0*# Mg-0.8* 05:00PM BLOOD Calcium-7.9* Phos-0.8* Mg-2.2 04:24AM BLOOD Calcium-7.8* Phos-1.3* Mg-1.4* .,0
"CXR: Bibasilar opacities likely reflects atelectasis, though aspiration or pneumonia cannot be excluded.",0
"Brief Hospital Course: 72yo man with afib, HTN, DM, and squamous cell carcinoma of the tongue T4aN2cM0, on XRT/cetuximab admitted for hypotension and diarrhea.",1
He was given IV fluids in clinic for BP 99/56 and refused admission or to go to the ED.,0
"After not showing up for clinic appt , the police/EMS were called and found him to be hypotensive (SBP 70s), but asymptomatic.",0
"He was brought to the ED, where SBP was in the 50s and his heart rhythm in afib.",0
"He was given vancomycin, levofloxacin, metronidazole, and 5L NS and admitted to ICU.",0
"Hypotension and afib resolved, antibiotics were stopped, metoprolol resumed, and he was transferred out of the ICU.",0
"Of note, all his anti-hypertensives had been stopped the week prior to admission.",0
"However, he was unaware of what medications he actually takes, but stated he is compliant.",0
Diarrhea recurred as soon as Glucerna tube feeds were re-initiated.,0
"Tube feeds were changed to IsoSource 1.5, which he tolerated well.",0
The patient completed 30/30 radiation fractions on .,0
Further cetuximab was held per the patient's primary oncologist.,0
# Hypotension: Due to diarrhea and rapid afib.,1
No signs of infection other than low-grade fever (resolved); antibiotics stopped .,0
Rate-related demand ischemia with ST depressions resolved after rehydration and NSR.,0
Blood cultures and stool cultures were negative.,0
Anti-hypertensives stopped; metoprolol restarted for afib.,0
Continued IV fluids until diarrhea ceased.,0
"# Diarrhea: Unclear etiology, possibly due to tube feeds (given timing) vs. chemo (25-39% with cetuximab).",0
No diarrhea in hospital until tube feeds restarted.,0
C. diff negative x1 negative.,0
Changed tube feeds to IsoSource 5 cans per day which patient tolerated well without recurrent diarrhea.,0
IV fluids and elecrolyte repletion.,0
Loperamide for chronic diarrhea started after stool confirmed C. diff negative.,0
# Atrial fibrillation: In setting of volume depletion.,1
Spontaneous conversion to normal sinus.,0
Not an anticoagulation candidate due to poor compliance.,0
# ST depressions: Rate related demand ischemia with possible contribution from Hypomagnesemia present on admission.,0
Resolved with NSR and IVF.,0
"# Squamous cell CA of tongue: Continued XRT (finished , he refused to go ).",0
Cetuximab stopped per primary oncologist Dr. .,0
# Anemia: Chemo-induced +/- iron deficiency (microcytic).,1
Mr. refused a blood transfusion.,0
Anemia labs suggested anemia of inflammation.,0
# HTN: Restarted metoprolol for atrial fibrillation.,1
Will not restart lisinopril or HCTZ given recent hypotension.,0
# Glaucoma: Continued outpatient eye drops.,0
# Hypomagnesemia: Due to cetuximab and diarrhea.,0
# FEN: Diarrhea with Glucerna tube feeds today.,0
# Pain (odynophagia): Controlled with fentanyl patch and viscous lidocaine/Maalox/diphenhydramine.,0
# GI PPx: H2 blocker.,0
No bowel regimen with diarrhea.,0
# DVT PPx: Heparin SC.,0
Refresh Tears 0.5 % Drops Sig: Two (2) Drops Ophthalmic four times a day: Each eye.,0
2. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours).,0
Multilex Tablet Sig: One (1) Tablet PO once a day.,0
6. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 mL Mouthwash Sig: Thirty (30) mL Mucous membrane four times a day as needed for pain.,0
7. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic (2 times a day).,0
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
9. oxycodone 5 mg/5 mL Solution Sig: mL PO Q6H (every 6 hours) as needed for Pain.,0
Disp:*200 mL* Refills:*0* 10. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2 times a day).,0
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).,0
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
13. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day) as needed for Constipation.,0
Disp:*600 mL* Refills:*1* 14. loperamide 2 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for Diarrhea.,0
Disp:*30 Tablet(s)* Refills:*0* 15. magnesium 250 mg Tablet Sig: One (1) Tablet PO twice a day: crush and put Through G tube.,0
Glucosamine Oral 17. psyllium Oral 18.,0
"Continuous Tubefeeds Isosource 1.5, Cal Full strength; 5 cans per day (250cc per can, total volume per day 1250cc).",0
"Additives: Banana flakes, 3 packets per day.",0
Sig: Give per G tube at 55ml per hour over 24 hours per pump.,0
Residual Check: Check residual every 6 hours.,0
Hold feeding for residual >= 200 ml.,0
"Flush w/30-50 ml water two to three times daily # 5 cans per day, 150 cans per month Refills: 3 refills of one month's amount Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: 1.",0
Severe hypotension (low blood pressure).,0
Mucositis (inflammation in the mouth).,0
Anemia (low red blood cell count).,0
Atrial fibrillation (fast irregular heart beat).,1
Esophagitis (inflammation of the eating tube called the esophagus) Discharge Condition: Mental Status: Clear and coherent.,1
Discharge Instructions: You were admitted to the hospital for severe hypotension (low blood pressure).,0
This improved with IV fluids.,0
"Antibiotics were initially started, but stopped the next day after no evidence of infection was found.",0
The low blood pressure was likely due to diarrhea and poor eating and drinking.,0
"Also all your blood pressure medication was stopped except for metoprolol, which was needed to control your fast heart rate (atrial fibrillation).",1
"The diarrhea stopped while you were in the hospital, so tube feeds were restarted.",0
"However, the diarrhea came back with the tube feeds, so the type of tube feed was changed to IsoSource 1.5, which you tolerated much better.",0
"You had low electrolyte levels (potassium, magnesium, and phosphorous) and will need to have these closely monitored after leaving the hospital.",0
"While you were in the hospital, radiation therapy was finished.",0
"Also, your red blood cell count was low.",0
"However, you refused a blood transfusion.",0
Continue metoprolol succinate (Toprol XL) 25mg once daily.,0
START oxycodone 5-10mg as needed for pain.,0
DECREASE simvastatin to 10 mg daily 7.,0
STOP diphenhydramine (benedryl) at bedtime 8.,0
"START magnesium twice daily, you will need to crush this and put through your G tube 9 START docusate sodium (colace) as needed for constipation Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY at 4:30 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage .",0
"Department: OTOLARYNGOLOGY-AUDIOLOGY When: FRIDAY at 3:50 PM With: , MD Building: LM Bldg () Campus: WEST Best Parking: Garage .",0
"Department: WEST CLINIC When: TUESDAY at 3:30 PM With: , MD Building: De Building ( Complex) Campus: WEST Best Parking: Garage",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval position of ETT, OGT, R IJ CVL Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with multiple trauma, recent intubation REASON FOR THIS EXAMINATION: eval position of ETT, OGT, R IJ CVL ______________________________________________________________________________ WET READ: JMGw MON 6:01 PM ett 6cm from carina, R IJ in mid SVC, NGT tip in stomach.",0
"slight increased opacity in left apex and retrocardiac, may be due to decreased inspiration.",0
"______________________________________________________________________________ FINAL REPORT AP CHEST 5:04 P.M., HISTORY: Multiple trauma and recent intubation.",0
"IMPRESSION: AP chest compared to :50 p.m.: Tip of the new endotracheal tube at the upper margin of the clavicles is no less than 6 cm from the carina, at least 2 cm above optimal placement since the mandible is elevated.",0
"Mild mediastinal and upper lobe pulmonary vascular engorgement suggests volume overload, but there is no pulmonary edema.",0
"Previous left apical pleural or extrapleural hematoma has decreased, perhaps drained into the pleural space dependently.",0
Right jugular line ends in the upper SVC.,0
Nasogastric tube ends in the upper stomach and should probably be advanced several centimeters to be sure that all side ports are beyond the GE junction.,0
"4:16 AM CHEST (PORTABLE AP) Clip # Reason: tube placement Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 24 year old man intubated, tube adjusted REASON FOR THIS EXAMINATION: tube placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess ET tube.",0
ET tube tip is 5.8 cm above the carina in a standard position.,0
Left upper lobe and left perihilar opacities have minimally increased consistent with aspiration.,0
1:39 AM CHEST (PORTABLE AP) Clip # Reason: evaluate rt ptx Admitting Diagnosis: CORONARY STENOSIS\AORTIC AND MITRAL VALVE REPLACEMENT REDO; ?,1
CORONARY ARTERY BYPASS GRAFT WITH AVR REDO /SDA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate rt ptx ______________________________________________________________________________ FINAL REPORT HISTORY: Status post CABG.,1
"FINDINGS: In comparison with study of , there is increased opacification involving the right upper lung with suggestion of some retraction of the trachea and mediastinal contents to this side.",0
"Although much of this may be due to patient rotation, some volume loss in the right upper lobe is suggested, most likely related to a mucous plug.",0
There may also be pneumonia within the right upper lobe.,0
The left lung remains essentially clear.,0
This information has been telephoned to the chief resident in Cardiothoracic Surgery.,0
2:06 PM CHEST (PORTABLE AP) Clip # Reason: pls eval for chest tube placement ______________________________________________________________________________ MEDICAL CONDITION: 40 yo M s/p fall from 2 stories.,0
intubated at OSH REASON FOR THIS EXAMINATION: pls eval for chest tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: 40-year-old male status post fall from two stories.,0
Evaluate for chest tube placement.,0
"COMPARISON: at 1:49 p.m. PORTABLE SUPINE CHEST ON A TRAUMA BACKBOARD, ONE VIEW: Endotracheal tube is unchanged in position.",0
"There is interval placement of a left chest tube, overlying the left hemithorax, with a possible intrafissural course.",0
Again seen are multiple serial rib fractures on the left with a left pneumothorax more clearly visualized.,1
"Additionally, subcutaneous emphysema on the right with a right pneumothorax is also more clearly visualized on this study.",1
Findings were discussed with the trauma team in person at the time of interpretation.,0
7:18 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval changes Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with ACute on chronic CHF intubated REASON FOR THIS EXAMINATION: please evaluate for interval changes ______________________________________________________________________________ FINAL REPORT HISTORY: Chronic CHF with intubation.,1
"FINDINGS: In comparison with study of , the tip of the endotracheal tube is now about 2.3 cm above the carina.",0
The cardiac silhouette remains at the upper limits of normal in size.,0
Mild fullness of pulmonary vessels is consistent with elevated pulmonary venous pressure.,0
Some layering bilateral effusions with atelectatic changes at the bases persist.,0
8:40 AM CT HEAD W/O CONTRAST Clip # Reason: please eval for new blood Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p ACA aneurysm bleed and clipping REASON FOR THIS EXAMINATION: please eval for new blood No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post anterior cerebral aneurysm clipping.,1
"Again, seen is a large amount of subarachnoid blood and subdural fluid collections.",0
"The amount of midline shift has decreased, although it is still present.",0
"Fluid along the left frontal cerebral convexity has increased in size, now measuring approximately 9 mm in greatest axial dimension, and appears to exert mild mass effect upon the adjacent sulci.",0
"Foci of intraparenchymal hemorrhage are again seen in the frontal lobes and bilateral temporal lobes, unchanged.",0
"In the interval, a hypodensity around both caudate nuclei is identified, which reflects a subacute infarction.",0
The amount of pneumocephalus has decreased.,0
"Again seen are right frontal craniotomy, aneurysm clip in the region of the anterior communicating arteries, and subcutaneous hemorrhage/edema overlying the craniotomy site.",0
"A ventricular drain is seen terminating in the region of the third ventricle, entering from the left frontal lobe.",0
"There is opacification of ethmoid air cells, mucosal thickening of the sphenoid sinuses, mucosal thickening and air-fluid levels in the maxillary sinuses, and scattered opacification of mastoid air cells.",0
Subacute infarction in bilateral caudate nuclei.,0
Interval decrease in amount of midline shift.,0
"Interval increase in left frontal cerebral convexity subdural fluid collection, which exerts mild mass effect on the adjacent frontal lobe.",0
"Otherwise, no significant interval change.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval cvl placement- L IJ Admitting Diagnosis: DECOMPRESSED CIRRHOSIS;HYPONATREMIA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with end stage liver disease, encephalopathy, ?pneumonia and worsening shortness of breath, recently intubated, now with L IJ cvl REASON FOR THIS EXAMINATION: eval cvl placement- L IJ ______________________________________________________________________________ WET READ: MNIa TUE 6:41 PM Left IJ line terminating in the upper SVC.",0
Persistent edema and patchy opacities in both lungs.,0
______________________________________________________________________________ FINAL REPORT HISTORY: End-stage liver disease and encephalopathy.,0
This is the third exam on .,0
"Since study three hours earlier, a left IJ line has been placed with its tip just reaching the proximal SVC.",0
Exam is otherwise unchanged with multiple tubes and catheters satisfactorily positioned.,0
Again noted is diffuse as well as more focal airspace disease throughout both lungs.,0
"12:43 PM US ABD LIMIT, SINGLE ORGAN Clip # Reason: Eval, drainage of pt w/ persistent pseudomonal peritonitis.",0
"______________________________________________________________________________ MEDICAL CONDITION: 58 year old obese woman with persistent peritonitis, ""crytpogenic"" cirrhosis, DM-2, HTN, AFib, DVT, has had recurrent ascites.",0
"Need image-guided paracentesis w/ abdominal CT. REASON FOR THIS EXAMINATION: Eval, drainage of pt w/ persistent pseudomonal peritonitis.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Persistent peritonitis, ""cryptogenic cirrhosis"", DM 2, HTN, atrial fibrillation, DVT, recurrent ascites.",0
FINDINGS: Limited ultrasound of the left lower quadrant demonstrates complex ascites with internal echoes suggestive of septations.,0
The study is limited by patient body habitus.,0
IMPRESSION: Complex ascites with appearance that may be suggestive of hematoma.,0
4:28 PM CHEST (PORTABLE AP) Clip # Reason: r/o ptx ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with s/p cabg AND ct removal REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT Portable chest compared to two days earlier.,0
CLINICAL INDICATION: Chest tube removal.,0
Status post coronary artery bypass surgery.,1
"There has been interval removal of endotracheal tube, nasogastric tube and mediastinal drains.",0
"A Swan-Ganz catheter remains in place, terminating in the region of the pulmonary outflow tract.",0
There has been interval increased vascular engorgement and perihilar haziness.,0
There is worsening atelectasis in the left lower lobe and there is a probable small left pleural effusion.,0
Note is made of coronary artery bypass surgery and aortic valve replacement surgery.,1
IMPRESSION: 1) Worsening left lower lobe atelectasis.,0
3) Probable small left pleural effusion.,0
"4:59 AM CHEST (PORTABLE AP) Clip # Reason: check for interval resolution of consolidations, infiltrates Admitting Diagnosis: 28 WEEKS PREGNANT;RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman a/w S. pneumomonaie leading to resp failure, ecclampsia now s/p extubation.",0
"REASON FOR THIS EXAMINATION: check for interval resolution of consolidations, infiltrates ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH COMPARISON: .",0
"FINDINGS: In comparison to previous examination, the central venous access line and the endotracheal tube has been removed.",0
The lung volumes are nevertheless unchanged as compared to previous examination.,0
Unchanged extent and configuration of the bilateral diffuse abnormalities.,0
No newly appeared pulmonary opacities.,0
The size of the cardiac silhouette is without relevant change.,0
"IMPRESSION: After extubation and removal of central venous access line, the lung parenchyma and cardiac silhouette show no relevant interval change.",0
11:54 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate ventricular size for OR planning Admitting Diagnosis: HYDROCEPHALUS ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with hydrocephalus REASON FOR THIS EXAMINATION: evaluate ventricular size for OR planning No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj WED 5:41 PM PFI: Ventricular size and resolution of intraventricular hemorrhage since prior study three days ago.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate ventricular size for OR planning.,0
"COMPARISON: Numerous prior CTs dated , , , MRI, and .",0
FINDINGS: The ventricles are relatively decompressed compared to .,0
A right frontal approach ventriculostomy catheter remains in stable location in the frontal of the right lateral ventricle.,1
Hemorrhage layering in the occipital of the left lateral ventricle has been resorbed.,1
Hyperdense cavernoma in the periaqueductal tectum of the midbrain is again seen and unchanged.,0
"No hemorrhage, large territorial infarction, edema, mass, or shift of normally midline structures.",0
Again seen is the surgical ventriculostomy defect.,0
Small mucus retention cyst is seen in the right maxillary sinus.,0
"Otherwise, the visualized paranasal sinuses and mastoid air cells are well aerated.",0
IMPRESSION: Reduced ventricular size and resolution of intraventricular hemorrhage since since most recent study of three days ago.,0
"3:05 PM CHEST (PA & LAT) Clip # Reason: r/o pneumonia, chf ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with increased edema, generalized complaints REASON FOR THIS EXAMINATION: r/o pneumonia, chf ______________________________________________________________________________ FINAL REPORT INDICATION: Increasing edema.",0
AP LATERAL CHEST: The cardiac silhouette is within normal limits.,0
The mediastinum is normal in appearance.,0
There are no pleural effusions or focal parenchymal opacities.,0
The right humerus is again noted to be absent.,0
IMPRESSION: No acute cardiopulmonary disease,1
"8:31 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement Admitting Diagnosis: FEVER UNKNOWN ORIGIN ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with fever, recent PNA, recent TRALI, s/p RIJ with HCT drop and wide mediastinum REASON FOR THIS EXAMINATION: ET tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: Fever, pneumonia, check ETT placement.",1
CHEST: The tip of the ETT lies 4 1/2 cm from the carinal angle.,0
The density in the right upper lobe is again noted and is unchanged.,0
There is a generalized interstitial alveolar pattern elsewhere suggesting some failure.,0
"Costophrenic angles, however, are sharp.",0
IMPRESSION: ETT in satisfactory position.,0
Opacity in right lung persists.,0
10:25 AM CHEST (PORTABLE AP) Clip # Reason: chest and abdomen to confirm NGT placement Admitting Diagnosis: S/P TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with sepsis REASON FOR THIS EXAMINATION: chest and abdomen to confirm NGT placement ______________________________________________________________________________ FINAL REPORT HISTORY: NG tube placement.,0
"AP SUPINE CHEST: A gastric tube is seen coiled within the lower abdomen, but not completely imaged.",0
This is consistent with being positioned in the jejunum.,0
The multifocal opacities bilaterally are unchanged and consistent with ARDS.,0
The right subclavian line is unchanged.,0
", R. CSURG FA6A 6:09 PM CT CHEST W/O CONTRAST Clip # Reason: eval aorta preop Admitting Diagnosis: REDO STERNOTOMY-MVR ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man preop redo MVR REASON FOR THIS EXAMINATION: eval aorta preop No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",0
_____ atherosclerotic calcification including three-vessel coronary artery calcification.,1
Calcification at the takeoff of the branches from the aortic arch.,0
"Ascending aorta measuring 2.9 cm, normal.",0
8:07 PM CHEST (PORTABLE AP) Clip # Reason: chest pain ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with REASON FOR THIS EXAMINATION: chest pain ______________________________________________________________________________ FINAL REPORT HISTORY: Chest pain.,0
Single portable chest radiograph demonstrates interval resolution of the linear markings previously seen on the right lung base on .,0
"The finding, therefore, represented atelectasis.",0
Mild-to-moderate changes related to COPD are again noted and remain similar in appearance.,0
"Cardiomediastinal contours are similar, when allowing for differences in phases of respiration.",0
No fracture or pneumothorax is detected.,0
IMPRESSION: Resolution of right basilar atelectasis.,0
"9:01 AM CHEST (PORTABLE AP) Clip # Reason: R/O PNA Admitting Diagnosis: SAH/S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with SDH, on vent, now desaturating REASON FOR THIS EXAMINATION: R/O PNA ______________________________________________________________________________ FINAL REPORT HISTORY: Ventilated patient with oxygen desaturation.",0
"AP CHEST RADIOGRAPH: The endotracheal tube tip is in satisfactory position, approximately 6.5 cm from the carina.",0
There is a left subclavian line with its tip in the distal SVC without pneumothorax.,0
The cardiomediastinal silhouette is unchanged in the interval.,0
There is mild prominence of the interstitial markings suggesting a component of heart failure.,0
"The bibasilar opacities are relatively unchanged, these could represent either atelectasis or foci of aspiration.",0
"OR THERAPEUTIC Clip # Reason: therepeutic/dx paracent Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with mult fluid collections s/p liver resection for cholangioCA, w/ ascites REASON FOR THIS EXAMINATION: therepeutic/dx paracent ______________________________________________________________________________ FINAL REPORT INDICATION: Ascites.",0
"THERAPEUTIC PARACENTESIS BY RADIOLOGIST: Preprocedural images demonstrate a large amount of ascites, predominantly in the left abdomen and pelvis.",0
The risk and benefits were explained to the patient and signed informed consent was obtained.,0
A preprocedure timeout was performed to verify the patient's identity and the planned procedure.,0
An appropriate spot was marked on the skin overlying the left lateral lower quadrant.,0
The area was prepped and draped in the standard sterile fashion.,0
Local anesthesia was achieved using 1% lidocaine.,0
A 20-gauge catheter was introduced into the fluid and approximately 1.6 liters of straw-colored ascites was removed.,0
The patient tolerated the procedure well and there were no immediate post-procedure complications.,0
"Dr. , the attending radiologist, was present and supervising the procedure.",0
IMPRESSION: Successful therapeutic paracentesis of approximately 1.6 liters of ascites.,0
9:16 PM CHEST (PORTABLE AP) Clip # Reason: r/o CHF Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 58 yo M sepsis REASON FOR THIS EXAMINATION: r/o CHF ______________________________________________________________________________ FINAL REPORT AP CHEST.,0
"INDICATION: Sepsis, rule out CHF.",0
Comparison is made to the prior chest x-ray on .,0
"There is a tracheostomy tube, NG tube, dual lead pacemaker, left internal jugular and right internal jugular central venous catheter in stable position.",0
There is again note of a right-sided PICC line which is malpositioned with its tip extending superiorly into the neck.,0
There is left ventricular enlargement.,0
"The pulmonary vascularity is somewhat prominent which may be due to supine technique, although some degree of failure cannot be excluded.",0
The right hemi-diaphragm is not fully seen.,0
There is left lower lobe/retrocardiac opacity consistent with collapse/consolidation.,0
IMPRESSION: 1) Cardiomegaly without overt failure.,0
2) Malpositioned right PICC line.,0
3) Left lower lobe collapse/consolidation.,0
3:15 PM CAROTID SERIES COMPLETE Clip # Reason: ?,0
significant carotid pathology Admitting Diagnosis: CHEST PAIN\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with preop CABG REASON FOR THIS EXAMINATION: ?,0
significant carotid pathology ______________________________________________________________________________ FINAL REPORT Study: Carotid Series Complete Reason: Pre/op Cabg Findings: Duplex evaluation was performed of bilateral carotid arteries.,0
On the right there is mild heterogeneous plaque in the tortuous ica.,0
On the left there is moderate cacified plaque in the ica.,0
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 85/32, 94/29, 77/24, cm/sec.",0
CCA peak systolic velocity is 70 cm/sec.,0
ECA peak systolic velocity is 72 cm/sec.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 150/47, 101/22, 45/16, cm/sec.",0
CCA peak systolic velocity is 83 cm/sec.,0
ECA peak systolic velocity is 120 cm/sec.,0
The ICA/CCA ratio is 1.8.,0
These findings are consistent with 60-69% stenosis.,0
Impression: Right ICA stenosis 40%.,0
"5:11 AM CHEST (PORTABLE AP) Clip # Reason: assess lung fields Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p craniotomy for L SDH REASON FOR THIS EXAMINATION: assess lung fields ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: -year-old man status post craniotomy for subdural hemorrhage.,1
"Since the previous study, there has been development of pulmonary vascular congestion.",1
There is prominence of the vascular pedicle.,0
There is also a developing infiltrate at the left retrocardiac region.,0
10:17 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: Please assess liver size and blood flow.,0
Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with CLL s/p allo MUD SCT with increasing Tbili and abdominal girth REASON FOR THIS EXAMINATION: Please assess liver size and blood flow.,1
"______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CLxc FRI 2:35 PM Normal Doppler ultrasound evaluation of the hepatic venous, portal venous, and hepatic arterial systems.",1
No evidence of intra- or extra-hepatic bile duct dilation.,0
Gallbladder is partially decompressed and contains a 5 mm gallbladder polyp or adherent gallstone.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 56-year-old man with CLL status post allo MUD SCT with increasing T bili and abdominal girth, please assess liver size and blood flow, evaluate for VOD.",0
TECHNIQUE: A real-time grayscale ultrasound of the abdomen with color and spectral Doppler was performed.,0
Comparison is made to a prior abdominal ultrasound dated .,0
FINDINGS: The liver is normal in contour and echotexture without focal lesion.,0
The gallbladder is partially decompressed.,0
Note is made of a 5 mm gallbladder polyp or adherent gallstone.,0
Main portal vein is patent with hepatopetal flow.,0
"Appropriate flow and waveforms are demonstrated in the left, middle, and right hepatic veins, main, left and right portal veins and IVC.",1
The periphery of the left lobe of the liver is obscured by bowel gas as is the pancreas and abdominal aorta.,0
Visualized portion of the right kidney is unremarkable.,0
"Normal Doppler evaluation of the hepatic venous, portal venous and hepatic arterial systems.",1
Gallbladder is partially decompressed and contains either a 5 mm gallbladder polyp or adherent gallstone.,0
PATIENT/TEST INFORMATION: Indication: Endocarditis; CHF Height: (in) 71 Weight (lb): 156 BSA (m2): 1.90 m2 BP (mm Hg): 120/35 HR (bpm): 98 Status: Inpatient Date/Time: at 10:53 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Large vegetation on aortic valve.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR.,0
There is moderate global left ventricular hypokinesis with significant anterior hypokinesis.,0
"The apex is akinetic, thinned, and heavily trabeculated.",0
"There is a large (2-3 cm), mobile vegetation on the aortic valve.",0
The right coronary cusp is flail.,0
", J. NSURG SICU-A 1:22 PM CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # Reason: 57 year old woman with SAH s/p PCOM aneursym coiling, Ventri Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with SAH s/p PCOM aneursym coiling, Ventric, rising ICPs, please perform CTA/P TO EVALUATE FOR VASOSPASM AND ALSO CT FOR HYDRO.",1
"REASON FOR THIS EXAMINATION: 57 year old woman with SAH s/p PCOM aneursym coiling, Ventric, rising ICPs, please perform CTA/P TO EVALUATE FOR VASOSPASM AND ALSO CT FOR HYDRO.",0
"No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Developing hypodensity in the left medial basal ganglia and anterior thalamus, which could represent early ischemia relating to vasospasm.",0
This area appears to correspond to decreased blood flow and volume on the CT perfusion images.,0
"On the CTA images, there is questionable irregularity of the right distal MCA branches which could be artifactual but possibility of vasospasm cannot be entirely excluded.",0
Recommend correlation with catheter angiography if clinically indicated.,0
"5:48 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: ett ua,uvc line placemen Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 27 week twin REASON FOR THIS EXAMINATION: ett ua,uvc line placemen ______________________________________________________________________________ FINAL REPORT Twenty-seven week gestation twin.",1
The cardiac contour appears in the upper limits of normal.,0
There is hazy opacity of the lungs consistent with hyaline membrane disease.,0
The endotracheal tube is at the thoracic inlet.,0
The umbilical artery and venous lines are both at the level of T8.,0
Bowel gas pattern is normal.,0
9:10 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: Ability to swallow without aspirating.,0
"Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with stroke, resulting left sided weakness.",0
REASON FOR THIS EXAMINATION: Ability to swallow without aspirating.,0
______________________________________________________________________________ FINAL REPORT STUDY: Video oropharyngeal swallow.,0
"INDICATION: Question of aspiration, status post stroke.",0
VIDEO SWALLOW: Various consistencies of barium were administered in conjunction with speech therapy.,0
Laryngeal penetration was seen with nectar and thin liquids.,0
Note was made of moderate residual with solid consistencies after initial swallowing.,0
"Furthermore, there is slowed transit time during the swallowing mechanism.",0
Please refer to speech and swallow note for further details.,0
IMPRESSION: Penetration of nectar and thin liquids without any aspiration.,0
"5:23 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: r/o ptx, assess lft effusion Admitting Diagnosis: AORTIC INSUFFICIENCY\AORTIC AND MITRAL VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman s/p asc ao replacement/avr/lft thoracentesis REASON FOR THIS EXAMINATION: r/o ptx, assess lft effusion ______________________________________________________________________________ WET READ: JXRl WED 9:21 PM Decreased left effusion.",1
"No pneumothorax identified, although evaluation of left lung limited by motion.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Thoracentesis, to evaluate for pneumothorax.",0
"FINDINGS: In comparison with the earlier study of this date, there has been a removal of a substantial amount of pleural fluid from the left chest.",0
"9:04 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: liver disease, budd-chiari, please do with PO and IV contras Admitting Diagnosis: INTRA-ABDOMINAL MASS/SDA Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with massive bloody ascites 7 years s/p Whipple, POD2 s/p ex lap for question of recurrence of disease.",1
"REASON FOR THIS EXAMINATION: liver disease, budd-chiari, please do with PO and IV contrast No contraindications for IV contrast ______________________________________________________________________________ WET READ: 10:39 PM Complete clinical history: : Rectal carcinoma s/p resection and colostomy : Cholangiocarcinoma - s/p Whipple Past 5 yrs doing well without recurrence Last 3-4 months developed vague abdominal pain.",1
Work-up done at OSH (CT and PET-CT - in PACS) OSH imaging concerning for recurrence of biliary tumor.,0
- Ex-lap - to attempt removal of recurrent tumor or fiducial placement for XRT.,0
"However, after midline incision - surgery met with liters of hemoperitoneum.",0
Hemostasis was achieved and surgery terminated.,0
Concern for portal hypertension leading to varices.,1
Any signs of primary liver disease to explain portal hypertension?,1
WET READ: -Moderate intra-abdominal ascites (with <15) c/w simple fluid and not hemorrhage -Patent hepatic veins and IVC -Atypical pneumobilia reaching the periphery of the liver.,1
Distribution could represent portal venous gas - though no air in the main portal vein or SMV.,0
No evidence of bowel pneumatosis.,0
-Homogenous liver parenchyma - no mass -In region of surgical anastamosis in porta hepatis is an ill-defined soft-tissue density which appears similar to prior OSH CT from -possibly representing area of concern for tumor recurrence.,1
-The main portal vein appears markedly attenuated adjacent to the above described soft tissue density (2:24).,0
Though the right and left branches and porto-splenic confluence are patent.,0
-The spleen measures at the upper limits of normal at 13 cm.,0
-Surgical anatomoses appear intact -LLQ colostomy - no bowel obstruction -Mildly thickened loop of small bowel in right mid abdomen - though may be due to underdistension (2:40) -Small foci of air in the bladder - likely secondary to recent instrumentation - correlate clinically.,1
Preliminary findings d/w Dr. at ~10pm on by telephone.,0
"GSenapati WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Patient with prior rectal as well as ampulla of Vater (Over) 9:04 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: liver disease, budd-chiari, please do with PO and IV contras Admitting Diagnosis: INTRA-ABDOMINAL MASS/SDA Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) adenocarcinoma in association with a type 1 choledochal cyst status post hepaticojejunostomy, now presents with biopsy-proven adenocarcinoma in the setting of bloody ascites evident on a recent ex-lap, postop day 2.",1
"Please assess for potential causes of ascites, portal hypertension, possibly Budd-Chiari or infiltrative hepatic lesion.",1
COMPARISON: Comparison is made to outside hospital CT performed and CT abdomen and pelvis performed and .,0
TECHNIQUE: Contrast-enhanced axial images were obtained from lung bases to pelvic outlet.,0
FINDINGS: Demonstrated portions of the lungs are clear.,0
CT ABDOMEN: There has been prior Whipple procedure.,0
No discrete mass or lesion identified within the liver.,0
"There is diffuse biliary dilation with prominent pneumobilia with air branching to the periphery, consistent with hepaticojejunostomy.",0
There is no evidence to suggest portal venous gas.,0
Biliary ductal dilatation is relatively stable compared to outside hospital study.,0
The gallbladder has been surgically removed.,0
"At the choledochojejunostomy site, there is a poorly defined soft tissue mass measuring approximately 1.7 cm (200B:28) consistent with the known recurrent tumor, though tumor borders are difficult to delineate.",0
Mass causes severe narrowing of the main portal vein at this level.,0
"The inferior vena cava, hepatic veins, intrahepatic portal vein including the left portal and anterior and posterior right portal branches are widely patent.",1
"The main hepatic artery is not well seen likely due to phase of study, though narrowing due to mass is not excluded.",0
"Sequelae of portal hypertension are evident with notable intra-abdominal varices and ascitic fluid of intermediate density, though no evidence of sentinel clot to suggest acute hemorrhage.",1
The spleen is top normal in size.,0
The small bowel reflects post-surgical anatomy with surgical clips within the root of the mesentery.,0
No significant bowel wall thickening or abnormal enhancement identified within the residual small bowel.,0
No intestinal pneumatosis is identified.,0
"The pancreatic duct within the atrophic pancreatic remnant is probably dilated, though no mass is identified adjacent to the pancreaticoduodenectomy anastomosis, and this could be due to post-surgical change.",0
The patient has a colostomy in the left lower quadrant.,0
"Inflammatory changes are noted throughout the mesentery, likely indicative of recent ex-lap procedure, with pneumoperitoneum also consistent with postoperative state.",0
The kidneys are normal in size and excrete contrast symmetrically.,0
"The bilateral adrenal glands are not well seen given surrounding ascites; (Over) 9:04 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: liver disease, budd-chiari, please do with PO and IV contras Admitting Diagnosis: INTRA-ABDOMINAL MASS/SDA Field of view: 36 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) however, there is no evidence of large mass.",1
"Scattered prominent mesenteric lymph nodes are identified, the largest of which measures 9 mm in greatest dimension, and thus does not meet CT criteria for pathologic enlargement.",0
No retroperitoneal or portacaval lymphadenopathy definitively identified.,0
"The aorta is of normal caliber throughout, with patent celiac and superior mesenteric artery ostia.",0
"CT PELVIS: No residual rectal pouch identified, compatible with prior abdomino-perineal type resection.",0
Low to intermediate density ascitic fluid is identified within the pelvis.,0
There is no pelvic sidewall or inguinal lymphadenopathy evident.,0
OSSEOUS STRUCTURES: No suspicious lytic or blastic lesions are evident.,0
"A small sclerotic focus is noted in the proximal left femur, likely reflecting a bone island, stable since .",0
"Findings consistent with known recurrence of tumor at the choledochojejunostomy site, resulting in biliary dilation and severe narrowing of the portal vein.",0
Sequela of portal venous hypertension are therefore likely related to this portal vein near-occlusion.,1
"Otherwise, main portal vein and hepatic veins are without filling defect to suggest thrombus.",0
"Intermediate density ascites consistent with sanguinous ascites observed at surgery, though without evidence of acute hemoperitoneum.",1
9:51 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"reaccumulation L pleural effusion Admitting Diagnosis: PULMONARY EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with AS, s/p retroperitoneal bleed with L-sided pleural effusion, s/p L-sided drainage x 2.",0
reaccumulation L pleural effusion ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF COMPARISON: .,0
Tracheostomy tube remains in standard position.,0
"Left pleural effusion is difficult to compare to the recent study due to positional differences, but is probably unchanged allowing for this factor.",0
Adjacent left lower lobe atelectasis is also stable.,0
"However, when compared to the earlier radiograph of , the effusion has increased.",0
"10:54 PM CHEST (PORTABLE AP) Clip # Reason: preop cabg Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with left main dx REASON FOR THIS EXAMINATION: preop cabg ______________________________________________________________________________ FINAL REPORT INDICATION: Left main disease, preoperative CABG.",1
TECHNIQUE: A single portable AP view of the chest was obtained without comparisons.,0
"FINDINGS: The cardiac and mediastinal silhouette are within normal limits, allowing for relatively low lung volumes.",0
"There are no focal pulmonary opacities, pleural effusions or evidence of pneumothorax.",0
"RIGHT PORT Clip # Reason: immunosuppressed liver transplant with fever, recent history ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with HCV, liver transplant, fever and pleural effusion.",1
"REASON FOR THIS EXAMINATION: immunosuppressed liver transplant with fever, recent history of cholangitis, now with large pleural effusion.",1
Pleas mark a spot for pleural tap.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ULTRASOUND, INDICATION: 44 year old female with pleural effusion.",0
Mark the spot for pleural tap.,0
RIGHT CHEST ULTRASOUND: Portable ultrasound examination was performed.,0
There is a moderate-sized right pleural effusion.,0
"Ultrasound was used to mark a spot for pleural aspiration, to be performed by the Clinical House Staff.",0
IMPRESSION: Spot marked for right pleural effusion tap.,0
10:54 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for interval change in intracranial hemorrhage Admitting Diagnosis: INTRAVENTRICULAR BLEED ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with recent intraventricular hemorrhage.,0
REASON FOR THIS EXAMINATION: evaluate for interval change in intracranial hemorrhage No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc WED 7:39 PM HISTORY: 66-year-old male with recent intraventricular hemorrhage.,0
Please evaluate for change in intracranial hemorrhage.,0
COMPARISON: Noncontrast head CT of one day prior.,0
TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to the foramen magnum without IV contrast.,0
"HEAD CT WITHOUT IV CONTRAST: There is no change in appearance of left caudate body intraparenchymal hemorrhage, with extension into the intraventricular system.",0
"The left lateral ventricle, third ventricle, and fourth ventricle demonstrate extensive filling with hemorrhage, unchanged in appearance.",0
"There is minimal right midline shift of the septum pellucidum, with no new hemorrhage.",0
There is no significant mass effect.,0
Periventricular hypoattenuation is consistent with chronic small vessel ischemic disease.,0
"IMPRESSION: No change in hemorrhage of body of left caudate, with intraventricular extent of hemorrhage.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 66-year-old male with recent intraventricular hemorrhage.,0
(Over) 10:54 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for interval change in intracranial hemorrhage Admitting Diagnosis: INTRAVENTRICULAR BLEED ______________________________________________________________________________ FINAL REPORT (Cont),0
4:46 PM CHEST (PORTABLE AP) Clip # Reason: reintubatin tube placement Admitting Diagnosis: PEA ARREST ______________________________________________________________________________ MEDICAL CONDITION: S/P resp arrest REASON FOR THIS EXAMINATION: reintubatin tube placement ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,0
"INDICATION: Status post respiratory arrest and reintubation, assess tube position.",1
Comparison is made with the next preceding supine chest examination of .,0
"The patient is intubated; the ETT is seen to terminate in the trachea, some 2 cm above the level of the carina.",0
"In comparison with the previous study, the chest tube has been advanced and is now closer to the carina than it was earlier.",0
An NG tube is seen and reaches below the level of the diaphragm.,0
Its final termination point cannot be identified as it exceeds the lower limit of the image.,0
A previously described right internal jugular approach central venous line is again seen and terminates overlying the upper portion of the right atrium.,0
Consider withdrawal by about 4 cm to ovoid contact with atrial structures as recommended already on the previous examination.,0
"The previously described bilateral pulmonary densities persist and most likely represent advanced congestion, but some additional parenchymal infiltrates cannot be excluded.",0
There is no pneumothorax in the apical area.,0
IMPRESSION: Stable chest findings in supine examination.,0
Mild cardiomegaly and congestion as before.,0
2:18 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: repeat CXR after repositioning R femoral Swan Admitting Diagnosis: INFECTED GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man s/p AVR/MVR/ closure aortic annular abscess REASON FOR THIS EXAMINATION: repeat CXR after repositioning R femoral Swan ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old male status post aortic and mitral valve replacement and closure of aortic annular abscess.,0
Status post repositioning of right femoral Swan-Ganz catheter.,0
AP SUPINE VIEW OF THE CHEST: Endotracheal tube terminates 5.5 cm above the carina.,0
Nasogastric tube follows a normal course with the left side port and tip in the left upper quadrant.,0
Swan-Ganz catheter from a right inferior approach coils within the right atrium and courses superiorly into the SVC.,0
Right-sided chest tube terminates in the costophrenic sulcus.,0
A left-sided chest tube terminates in the lateral left hemithorax.,0
Left-sided internal jugular central venous catheter follows a normal course terminating in the distal left brachiocephalic vein.,1
"Mediastinal drain, sternal wires and valvular prostheses are unchanged.",0
Right subclavian vascular stent is in unchanged position.,0
Bilateral perihilar edema is similar.,0
Findings discussed with by phone at 3 p.m. on .,0
7:52 PM MR HEAD W & W/O CONTRAST Clip # Reason: FOLLOW-UP Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with sudden onset of left hemiparesis and neglect this morning.,0
Please do study with diffusion and mra.,0
REASON FOR THIS EXAMINATION: please do with diffusion and perfusion between 6 and 8 pm tonight () per Dr. ______________________________________________________________________________ FINAL REPORT HISTORY: Follow up treated infarction.,0
"TECHNIQUE: FLAIR, susceptibility and diffusion weighted images were obtained.",0
FINDINGS: The study is of much better quality than the original study from 1:40 p.m.,0
"The infarcts in the right cerebral hemisphere characterized by restricted diffusion, more clearly seen than previously and FLAIR hyperintensity along with slight mass effect.",0
"There is involvement of several anterior right temporal gyri, the right lentiform nucleus, the anterior limb of the internal capsule and the caudate nucleus, and the overlying corona radiata.",0
There is slight hemorrhagic transformation in the right lentiform nucleus and corona radiata.,0
Susceptibility effect is seen consistent with the oxyhemoglobin.,0
There is slightly more mass effect on the right lateral ventricle.,0
Low signal intensity is seen in the region of the right internal carotid artery where no definite flow void was identified on the earlier study.,1
IMPRESSION: No extension of the right cerebral infarcts is seen compared to the earlier study.,0
The areas of restricted diffusion are more clearly seen.,0
There is associated petechial hemorrhage and slightly more mass effect than on the study from 6 1/2 hours previously.,0
MRA OF THE HEAD: HISTORY: Infarct.,0
TECHNIQUE: 3D time of flight study was derived from axial slab.,0
FINDINGS: There is diminished flow in the right internal carotid artery compared to the left.,1
There is a more pronounced diminished flow in the right A1 segment and the right MCA compared to the left.,0
The AP segments are symmetric and the anterior communicating artery is identified.,0
The left MCA is unremarkable.,0
The basilar artery and the PCA's are also normal.,0
IMPRESSION: There is markedly reduced flow in the right MCA and the right A1 segment and moderate reduction in flow in the intracranial portions of the (Over) 7:52 PM MR HEAD W & W/O CONTRAST Clip # Reason: FOLLOW-UP Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) right internal carotid artery.,1
", J. CC6A 5:18 PM MRA NECK W&W/O CONTRAST Clip # Reason: eval for vertebral artery dissection / with gad please Admitting Diagnosis: HEAD INJURY Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 21 year old woman with TBI after ped struck REASON FOR THIS EXAMINATION: eval for vertebral artery dissection / with gad please No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: Small left vertebral artery originating from the aortic arch with nonvisualization in the mid cervical segment is unusual for a congenital hypoplasia and could be due to occlusion or dissection in this segment.",1
Fat-suppressed images through the area would help for further assessment if clinically indicated.,0
7:39 AM CHEST (PORTABLE AP) Clip # Reason: please perform cxr.,0
"patient with ARDS s/p trach and bilatera ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman with ARDS, intubated.",0
REASON FOR THIS EXAMINATION: please perform cxr.,0
patient with ARDS s/p trach and bilateraly infiltrates.,0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH DATED : HISTORY: ARDS, intubated, decreased title volumes.",0
A single portable AP view of the chest is compared to study of .,0
IMPRESSION: There has been no significant change in the diffuse bilateral air space opacities which are consistent with the given history of ARDS.,0
Support lines and tubes are unchanged.,0
6:09 PM CHEST (SINGLE VIEW) Clip # Reason: preop film ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with REASON FOR THIS EXAMINATION: preop film ______________________________________________________________________________ FINAL REPORT INDICATION: Preop chest film.,0
UPRIGHT AP CHEST: The patient is post-median sternotomy.,0
"The lungs are clear, without vascular congestion or consolidation.",0
There are severe degenerative changes of the left shoulder.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic CHIEF COMPLAINT: This is a 72-year-old male with known 3-vessel coronary artery disease transferred from an outside hospital for coronary artery bypass graft after a positive exercise treadmill test and a catheterization which showed 3-vessel disease and an ejection fraction of 25%.,1
"HISTORY OF PRESENT ILLNESS: Treated medically since with good results until six months ago, at which time he noticed increasing dyspnea on exertion and chest pain/angina which presents as indigestion.",0
"Over the past month these symptoms have worsened, so that now he is dyspneic with ambulation.",0
MEDICATIONS ON ADMISSION: (Medications prior to admission included) 1.,0
NPH insulin 20 units q.h.s.,0
Pancrease two tablets (with meals).,0
SOCIAL HISTORY: A construction worker who lives at home with his wife.,0
reports occasional alcohol use and remote tobacco use (quit in ).,0
FAMILY HISTORY: A positive family history with early deaths after myocardial infarctions.,0
"RADIOLOGY/IMAGING: Cardiac catheterization showed severe pulmonary hypertension with pulmonary artery pressures of 80/35, and a wedge of 18.",1
Right coronary artery 100% occlusion.,1
Left anterior descending artery 95% occluded.,0
Left circumflex 100% occlusion with an ejection fraction of 25%.,0
"Electrocardiogram showed first-degree atrioventricular block with a rate of 55, a right bundle-branch, with Q waves in II, III, aVF, and V6.",1
Flipped T waves in V1 through V4.,0
ST depressions in V1 through V3.,0
"PERTINENT LABORATORY DATA ON PRESENTATION: Pulmonary function tests revealed FEV1 was 66% of predicted value, FEV1:FVC was 91% of predicted value, and FVC 72% of predicted value with diffusing capacity of lungs for carbon monoxide of 46% of predicted value.",0
"Peripheral laboratory values from the outside hospital revealed white blood cell count was 5.2, hematocrit was 44, platelets were 103.",0
"Sodium was 139, potassium was 4.8, chloride was 101, bicarbonate was 29, blood urea nitrogen was 40, creatinine was 1.7, and blood glucose was 167.",0
PTT was 76.9 (on heparin at 1400 units) with an INR of 1.07.,0
Urinalysis was negative from the outside hospital.,0
"PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed heart rate was 53, blood pressure was 110/50, respiratory rate was 16, oxygen saturation was 94% on room air.",0
"In general, an older gentleman in no acute distress.",0
"Neurologically, alert and oriented times three.",0
Sensation and motor were intact.,0
"Head, eyes, ears, nose, and throat examination revealed pupils were equally round and reactive to light.",0
Oropharynx with no erythema or exudate.,0
Respiratory examination was clear to auscultation bilaterally; although diminished bilaterally in the bases.,0
Heart revealed regular rate and rhythm.,0
Normal first heart sound and second heart sound.,1
A 3/6 systolic ejection murmur.,0
Extremities were cool with 1+ pedal edema with venous stasis color changes.,0
"Pulse examination revealed carotids were 2+ bilaterally, radially were 2+ bilaterally, femoral were 2+ bilaterally, dorsalis pedis and posterior tibialis pulses were 1+ bilaterally.",0
"HOSPITAL COURSE: On the morning of , the patient was brought to the operating room.",0
Please see the operating room report for full details.,0
"In summary, the patient had an off-pump coronary artery bypass graft times two with a saphenous vein graft to the left anterior descending artery and a saphenous vein graft to the diagonal.",1
He tolerated the operation and was transferred from the operating room to the Cardiothoracic Intensive Care Unit.,0
"At the time of transfer, the patient had Levophed at 0.6 mcg/kg per minute, Milrinone at 0.25 mcg/kg per minute, and propofol at 10 mcg/kg per minute.",0
"During the immediate postoperative period, the patient was noted to have continued pulmonary hypertension with pulmonary artery pressures in the 50/25 range, requiring nitric oxide initially at 30 parts per million, weaned to 5 parts per million overnight on the day of the surgery.",1
"On postoperative day one, the patient was weaned from sedation and successfully extubated.",0
His nitrous was also weaned to off.,0
"Milrinone, which had been shut off on the day of surgery, was restarted at 0.25.",0
The patient was also started on Levaquin postoperatively for sputum which showed 4+ gram-negative rods and 1+ gram-positive cocci.,0
"Additionally, the Electrophysiology Service as well as the Heart Failure Service were consulted on postoperative day two for assistance in the management of the patient's atrial fibrillation as well as pulmonary hypertension and advanced heart failure.",1
"Over the next several days, several attempts were made to wean the patient's Milrinone to off; each time meeting with elevated pulmonary artery pressures as well as sagging cardiac indices requiring reinstitution of Milrinone.",1
"During that time, the patient was also direct current cardioverted into a normal sinus rhythm.",0
"By postoperative day fifteen, the patient was finally weaned off of his Milrinone.",0
NOTE: Dictation ended after 7.5 minutes.,0
Dictated By: MEDQUIST36 D: 15:31 T: 15:32 JOB#:,0
Height: (in) 63 Weight (lb): 188 BSA (m2): 1.89 m2 BP (mm Hg): 118/48 HR (bpm): 94 Status: Inpatient Date/Time: at 09:04 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35% decrease during respiration (estimated RA pressure indeterminate).,0
"TDI E/e' < 8, suggesting normal PCWP (<12mmHg).",0
No MR. LV inflow pattern c/w impaired relaxation.,0
There is mild regional left ventricular systolic dysfunction with distal apical hypokinesis.,0
IMPRESSION: Regional dysfunction c/w distal LAD disease.,0
"Compared with the prior study (images reviewed) of , the resting heart rate is slower.",1
", C. MED MICU 4:06 AM CT HEAD W/O CONTRAST Clip # Reason: assess interval change, if lose IV access please do non-cont Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with known L parietal CVA with ICH REASON FOR THIS EXAMINATION: assess interval change, if lose IV access please do non-contrast Head CT instead No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No short-term change compared to .",0
"11:57 PM CT HEAD W/ & W/O CONTRAST Clip # Reason: r/o septic emboli Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with delierium, GPC bacteremia and cannot get MRI with new staples in place post laminectomy REASON FOR THIS EXAMINATION: r/o septic emboli No contraindications for IV contrast ______________________________________________________________________________ WET READ: 1:53 AM 1) No enhancing masses.",0
2) Unchanged appearance of the brain from one day earlier.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 43-year-old female with delirium, bacteremia, status post laminectomy.",0
COMPARISON: Non-contrast head CT dated at 1:21 a.m.,0
TECHNIQUE: MDCT imaging of the head was performed before and after the administration of 100 cc of intravenous Optiray.,0
Nonionic contrast was administered per protocol.,0
"FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures.",0
There is no major vascular territorial infarction.,0
"The density values of the brain parenchyma are within normal limits, and unchanged from one day earlier.",0
"The surrounding soft tissue and osseous structures reveal mucosal thickening in bilateral maxillary sinuses, right greater than left with no fluid in the ethmoid air cells, and inferior frontal sinuses.",0
The mastoid air cells are probably aerated.,0
Post-contrast enhanced images demonstrate no areas of enhancement.,0
No areas of enhancement within the brain parenchyma.,0
Unchanged appearance of the brain from non-contrast head CT one day earlier.,0
"New ethmoidal, inferior, frontal, and bilateral maxillary sinus disease as described above.",0
"Clip # Reason: elev creat and rbcs in urine, r/o hydro ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with REASON FOR THIS EXAMINATION: elev creat and rbcs in urine r/o hydro ______________________________________________________________________________ FINAL REPORT INDICATION: Elevated creatinine and right red blood cells in urine, r/o hydro.",0
RENAL US: The right kidney is normal and measures 11.2cm.,0
There is mild hydronephrosis of the left and the left kidney measures 11.2cm.,1
No renal calculi are identified.,0
The bladder is collapsed and the foley catheter is identified.,0
"12:52 PM CHEST (PORTABLE AP) Clip # Reason: eval tube placement ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with sezure, intubation REASON FOR THIS EXAMINATION: eval tube placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON .",0
Comparison is made with a prior chest radiograph from .,0
CTA of the chest also from used for comparison.,0
"CLINICAL HISTORY: 34-year-old man with seizure, status post intubation.",0
Evaluate position of ET tube.,0
FINDINGS: AP supine portable chest radiograph is obtained.,0
The tip of the endotracheal tube resides approximately 5.1 cm above the carina.,0
The NG tube courses into the left upper quadrant with its tip excluded from view.,0
Low lung volumes significantly limits evaluation.,0
"Allowing for technical limitations, the lungs are grossly clear.",0
Please note evaluation for subtle pneumonia or CHF is limited on this study.,0
"Cardiomediastinal silhouette is grossly stable, though patient's rotation to the left limits evaluation.",0
IMPRESSION: ET and NG tubes positioned as detailed.,0
Limited study with no gross intrathoracic process.,0
Please note evaluation is quite limited.,0
"11:37 AM CHEST (PA & LAT) Clip # Reason: evaluate effusion left please do this am thank you Admitting Diagnosis: OPEN WOUND CHEST ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman s/p CABGx2 , s/p sternal wound debridement REASON FOR THIS EXAMINATION: evaluate effusion left please do this am thank you ______________________________________________________________________________ FINAL REPORT EXAMINATION: PA and lateral chest.",1
Two views of the chest are obtained on and compared with the previous study of .,0
The left-sided pleural effusion has increased in size.,0
This is particularly obvious on the lateral view of the chest.,0
The patient shows evidence of prior thoracic surgery.,0
Skin clips are present in the anterior skin.,0
There is a drain overlying the anterior part of the chest on the left side.,0
A right-sided PICC line has its tip projected over the expected location of the cavoatrial junction.,0
"IMPRESSION: Left pleural effusion, increasing since prior examination.",0
"4:42 PM CHEST (PORTABLE AP) Clip # Reason: CT placed to waterseal, eval for PTX Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman s/p rollover MVC, has L lung contusion, now s/p OR and tube thoracostomy REASON FOR THIS EXAMINATION: CT placed to waterseal, eval for PTX ______________________________________________________________________________ WET READ: DMFj SUN 10:27 PM Tiny left apical pneumothorax is not evident on current study.",1
ETT and NG tube removed.,0
______________________________________________________________________________ FINAL REPORT PORTABLE FILM OF THE CHEST ON AT 1704 HOURS.,0
No pneumothorax is recognized but because of projection there could still be a tiny left pneumothorax.,1
The airway and the nasogastric tube have been removed.,0
The right lung is expanded and clear.,0
"The left hemidiaphragm is slightly elevated, which is a change since the airway has been removed.",0
This may be related to considerable atelectasis on the left side.,0
Left-sided fractured ribs again noted.,0
CONCLUSION:The primary change since the previous films is now there is slight elevation of the left hemidiaphragm.,0
"Lung parenchyma appears the same with no definite pneumothorax now recognized, tubes removed as described.",1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: bright red blood in stool Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 76F with no prior history of GI bleed, HTN, Sciatica who was at rehab for back pain, who for the past 2 weeks has had constipation & crampy abdominal pain associated with increased belching, flatus.",1
Patient is written for narcotics for pain control of sciatica but is unaware of whether she's taken them.,1
"On the morning of admmission she had 4 episodes of blood per rectum with initial bowel movements, which relieved her abdominal discomfort, and were described as dark maroon blood mixed with stool progressing to BRBPR.",0
"Patient denies any associated lightheadedness, dizziness, CP, SOB, change in vision, hematuria, epistaxis, ASA, NSAID, or EtOH use.",0
Patient has never had a colonoscopy and there is no family history of colon cancer.,0
Patient denies weight change or change in appetite.,0
"She says she and staff at rehab have disagreed about bowel regimen, and she may not have been receiving one regularly.",0
"Past Medical History: HTN Sciatica, L4/5 lumbar spondylolisthesis--seen by ortho.",1
Cervical Joint Disease Depression Narrow angle glaucoma Social History: Patient emigrated from > 50 yrs ago.,1
Used to work as a translator.,0
Currently lives in senior housing in JP with 12 yr old granddaughter.,0
Lives in elder housing with her 12 year old grandaughter.,0
"Per OMR, DSS was to get involved given that granddaughter was not in school: ""complicated family dynamics"".",0
"Per pastor who is friend of the patient, the child is in school and issue is resolved for now.",0
"She denies any EtoH, tobacco, or illicit drug use.",0
Family History: Patient denies any family history of colon cancer.,0
patient has one living relative who is years of age.,0
04:57AM BLOOD WBC-8.7# RBC-3.77* Hgb-11.9* Hct-34.9* MCV-93 MCH-31.5 MCHC-34.1 RDW-13.5 Plt Ct-288 07:04PM BLOOD Hct-34.5* 05:55AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.0* Hct-33.0* MCV-94 MCH-31.5 MCHC-33.4 RDW-13.9 Plt Ct-273 05:55AM BLOOD Glucose-71 UreaN-5* Creat-0.6 Na-139 K-3.6 Cl-102 HCO3-25 AnGap-16 05:40AM WBC 5.4 Hgb 10.3* HCT 30.9* MCV 95 Plt 256 09:55AM HCT 33.3* .,0
Colonoscopy: Findings: Excavated Lesions Multiple diverticula with medium openings were seen in the whole colon.Diverticulosis appeared to be severe.,1
A single diverticulum with signs of inflammation was seen in the ascending colon.Diverticulosis appeared to be of mild severity.,1
Impression: Diverticulosis of the whole colon.,1
Diverticulum in the ascending colon .,0
Tagged RBC Findings: Negative GI bleeding study.,0
MRI L-spine: The alignment of the lumbar spine demonstrate minimal anterolisthesis at L4-L5.,0
"The signal intensity in the vertebral bodies is slightly heterogeneous, likely consistent with degenerative changes.",0
The intervertebral disc space at L1-L2 appears unremarkable.,0
At L2-L3 no significant neural foraminal narrowing or spinal canal stenosis is identified.,0
"L3-L4 demonstrates disc desiccation and mild posterior diffuse disc bulge producing mild bilateral neural foraminal narrowing, no frank evidence of nerve root compression is detected.",0
Bilateral hypertrophy of the articularjoint facets as well as the ligamentum flavum is observed at this level.,0
"At L4-L5, there is evidence of disc desiccation, mild posterior broad-based disc bulge producing bilateral neural foraminal narrowing, right greater than left with possible contact on the right nerve root, please correlate specifically with this finding, bilateral articular joint facet hypertrophy is also noted associated with bilateral ligamentum flavum thickening.",0
"At this level, there is evidence of significant spinal canal stenosis, the thecal sac measures approximately 6 mm in the anterior, posterior diameter.",0
"At L5-S1, there is evidence of disc desiccation, posterior broad-based disc bulge producing bilateral neural foraminal narrowing and significant spinal canal stenosis, left greater than right with possible contact on the nerve root.",0
Bilateral articular joint facet hypertrophy and ligamentum flavum thickening is noted at this level.,0
There is also evidence of irregular contour of the inferior endplate at L5 consistent with a Schmorl's node and bone marrow replacement for fat in the endplates.,0
Vacuum phenomena is also detected in the intervertebral disc space.,0
"The sacroiliac joints, visualized aspect of the retroperitoneum and vascular structures appear grossly normal.",0
IMPRESSION: Multilevel degenerative changes of the lumbar spine as described in detail above.,0
"At L4-L5, there is evidence of disc desiccation and posterior broad-based disc bulge producing right side neural foraminal narrowing with possible contact on the right nerve root of .",0
"At L5-S1, there is evidence of a left paracentral disc protrusion producing left side neural foraminal narrowing and possible contact on the left nerve root, moderate-to-severe spinal canal stenosis is identified at this level.",0
Brief Hospital Course: 76 year old female with history of HTN and sciatica presented with 4x BRBPR in setting of 2 weeks intermittent constipation.,1
Brief hospital course by problem: 1.Diverticular bleed - The patient presented with BRBPR x4 and gassy abdominal pain in the setting of intermittent constipation of several weeks duration.,0
"GI was consulted, a NG lavage in the ED was negative, and the patient was treated with fluid resucitation with her systolic pressure running below baseline in the 110s.",0
Hematocrit on admission was 31.3 and stable for the first 12 hours.,0
"She had no white count, temperature or acute abdominal pain.",0
She was transferred to the MICU for observation overnight and prep for a colonoscopy in the am.,0
She had one episode of hypotension into the 90s associated with lightheadedness and one bloody BM overnight.,0
Her hct dropped to 28.3 and early on she was transfused 2 u PRBCs with an increase back to 34.9.,0
"She went for colonoscopy where numerous diverticula were seen throughout the colon, at least one with evidence of inflamation.",0
"Though no source of acute bleeding was seen, diverticuli were felt to be the etiology of bleed.",0
"On however, she experienced renewed melanotic stools and was transferred to the MICU for observation.",0
"Her hematocrit remained >30, and she returned to the floor on .",0
"Late on her first bowel movement since her MICU stay was streaked with bright red blood, and she was sent for a tagged red blood cell scan which did not demonstrate any bleeding.",0
"She remained hemodynamically stable and passed another stool with difficulty on that was formed, brown, but streaked with bright red blood, thought likely secondary to hemorrhoids.",1
Her HCT was stable and was at baseline (33.3) on the morning of discharge.,0
She will need to continue on an aggressive bowel regimen to prevent constipation as this may have aggravated what was surely underlying but silent diverticular disease.,0
2.HTN: The patient has a history of hypertension on HCTZ and CCB.,0
"These were held on and secondary to bleeding, but were restarted on as the patient was hemodynamically stable.",0
3.Sciatica - The patient continued to complain of lower back pain radiating into her leg consistent with her well documented hx of sciatica and L4/5 disease.,1
"She was seen by orthopaedics, who had recommended medical treatment and physical therapy with followup with ortho-spine if symptoms persist.",0
She comes to from where she has been receiving rehabilitation for this condition.,0
She was continued on Tylenol and opioids for breakthrough pain.,0
It appears her Amitryptiline had been recently discontinued.,0
"Opioids were initially used cautiously and at low doses given constipation and its role in potentially instigating her bleed, with minimal requests.",0
"Pain control was adequate at rest, but she was unable to ambulate.",0
She complained of increased left lower extremity weakness and was sent for an MRI of her lumbar spine.,0
MRI demonstrated the following findings: 1.,0
Multilevel degenerative changes of the lumbar spine; 2.,0
"At L4-L5, there is evidence of disc desiccation and posterior broad-based disc bulge producing right side neural foraminal narrowing with possible contact on the right nerve root of ; 3.",0
She was examined by the spine team who felt that she would likely benefit from an inpatient pain consult and outpatient work-up of her spine findings.,0
They deferred surgical intervention at this point given her unresolved GI bleeding issues.,0
"The chronic pain team was consulted and deferred steroid injection, saying that it might aggrevate her GI bleeding.",0
Under their recommendation she was started on neurontin 300mg TID to assist with the pain.,0
She is to follow up with orthopedics and chronic pain clinics as an outpatient.,0
She is being discharged to on standing Tylenol and neurontin with oxycodone for breakthrough pain.,0
We have reinforced the importance of continuing a bowel regimen if she continues narcotic pain medication.,0
Hyponatremia: Patient had a serum Na of 123 at presentation.,0
"Per her PCP, was 138 on .",0
Hyponatremia was thought likely secondary to volume depletion in the context of blood loss +/- cathartic diarrhea.,1
The urine was paradoxically dilute with Uosm =113.,0
A serum post-fluid repletion was 140. .,0
"Social: Patient was very distressed on am regarding a situation with her non-biological 12 year old granddaughter , who is in her care.",0
Her estranged biological daughter was threatening to call DSS to remove from a friend's apartment where she's staying.,0
"DSS was involved in past, but the patient's pastor confirms that she has helped to resolve that issue by enrolling in school.",0
The daughter additionally came to the hospital to convey the message that patient is drug seeking.,0
"The patient denied overuse of medications, and this accusation was not verified by her pastor or primary care physician.",0
Dispo: The patient was discharged back to her rehabilitation center in stable condition with instructions to return to the hospital if she has another bowel movement with significant blood loss (more than bright red blood streaking) or if she becomes hemodynamically unstable.,0
Medications on Admission: Tylenol Valium 5 mg prn Oxycodone 5mg prn Timolol ophth Verapamil 240 mg qd HCTZ 25 mg qd Ibuprofen 600mg QID Discharge Medications: 1.,0
Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily).,0
Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours): Hold for SBP <100; HR <55.,0
Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<95.,0
Docusate 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 1 weeks: Take for breakthrough pain.,0
Avoid if possible if constipated.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary Diagnoses: 1)Diverticular bleeding 2)Sciatica from lumbar degenerative disease and disc compression of nerve roots Secondary Diagnoses: 1)Hypertension Discharge Condition: Hemodynamically stable.,1
No large bloody stool since .,0
Since then she has had 2 formed stools with a small amount of blood streaking on the outside.,0
"Discharge Instructions: You have been diagnosed with diverticular bleeding, a condition in which abnormal outpouchings in the wall of your intestines can cause rapid bleeding via your rectum.",0
We treated you with fluids and a blood transfusion for support and completed a colonoscopy to locate any specific sources of the bleeding.,0
It was this test that showed the diverticula (outpouchings).,0
Constipation may cause diverticula or cause them to bleed.,0
It is very important that you continue on the regimen we've outlined to keep your bowels moving regularly.,0
"Your outpatient doctors to adjust your pain medications, since opioid narcotics (oxycodone, morphine, etc.)",0
"can aggravate constipation, especially if you are not taking other agents to keep your bowels moving.",0
We continued to treat your sciatica with pain medication.,0
We obtained an MRI of the lumbar spine which showed disc protrusion and possible compression of some of your lumbar nerve roots which would explain your symptoms.,0
You were evaluated by orthopedics who deferred surgical intervention at this point given your other medical issues.,0
"By their recommendation you were evaluated by the chronic pain clinic who decided not to give you a steroid injection at this point, but recommended adding neurontin to your medications for pain management.",0
We started this medication as well.,0
You are being discharged to where physical therapists and doctors with you more to treat this condition.,0
We are recommending that you take tylenol four times a day and oxycodone as needed for breakthrough pain.,0
We have also added a new medication (protonix) to help prevent your stomach from forming ulcers which may bleed.,0
Please take this medication as prescribed.,0
"Please call your primary care physician, .",0
", to schedule a follow-up visit once you leave rehab.",0
You should also modify your diet to include adequate fiber as this may help prevent constipation and diverticular disease.,0
"If you experience any blood in your stools (more than just blood streaks), black stools, maroon-colored stools, or change in your bowel movements, you should contact your primary care physician or go to the emergency room.",0
"Please also seek medical attention if you experience chest pain, shortness of breath, dizziness, lightheadedness or weakness.",0
Followup Instructions: - Please contact Dr. at Group to schedule a followup visit once you are discharged from Rehabilitation.,0
"- Please keep your previously scheduled appointment for your eye testing and with your eye doctor, , M.D.",0
"If you need to reschedule, please call his office at .",0
- Please also follow-up with your neurologist Dr. on 12:00.,0
"If you need to reschedule, please call her office at .",0
- Please also follow-up with your chronic pain clinic appointment on at 1:40pm.,0
It is located in the pain management center which is in the Building Fth Floor.,0
- You also have a follow-up appointment with Dr. in orthopedics on at 1:40 pm.,0
"6:45 PM BABYGRAM (CHEST ONLY) Clip # Reason: Evaluate lung fields, ETT placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, e. coli meningitis, respiratory acidosis, seizures REASON FOR THIS EXAMINATION: Evaluate lung fields, ETT placement ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST .",0
CLINICAL HISTORY: Respiratory acidosis and E. coli sepsis.,0
"Endotracheal tube, right PIC line catheter are unchanged and in satisfactory position.",0
Nasogastric tube tip is now near the gastroesophageal junction.,0
Worsening right upper lobe and near-complete left lung atelectasis appearing since last examination earlier in the day.,0
Again noted are multiple distended loops of bowel.,0
"IMPRESSION: Worsening atelectasis, as described above.",0
", R. FA10 1:01 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: Assess liver intra and extrahepatic vasculature especially P Admitting Diagnosis: LIVER FAILURE;HEPATITIS C ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with liver transplant, appears increasingly altered mental status REASON FOR THIS EXAMINATION: Assess liver intra and extrahepatic vasculature especially Portal vein ______________________________________________________________________________ PFI REPORT A very small amount of ascites is seen.",1
"Patent flow with waveforms satisfactory in hepatic artery, portal vein and hepatic veins.",1
"11:35 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna, acute process Admitting Diagnosis: HEPATOCELLULAR CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p L hepatic lobectomy with fever to 102.5 REASON FOR THIS EXAMINATION: r/o pna, acute process ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 23:31 INDICATION: Fever.",0
FINDINGS: There is significantly improved fluid status compared to the prior study and no evidence of focal consolidation.,0
Costophrenic sulci are sharply delineated.,0
IMPRESSION: Improved fluid status versus prior.,0
No pneumonia or lateral effusion.,0
"9:54 AM MR CERVICAL SPINE Clip # Reason: S/P TRAUMA, CERVICAL CORD CONTUSION ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with cord injury and neuro deficit at nipple level bilaterally REASON FOR THIS EXAMINATION: s/p cervical cord contusion, please assess cord edema and do fat supression to assess ligamentous injury ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Assess cord edema and ligamentous injury.",1
Multiplanar T1 and T2 gradient echo and STIR sequences.,0
The examination was compared to prior study of .,0
FINDINGS: There has been no change from the previous examination.,0
Again it is noted an area of increased signal within the cord at C3-C4 without cord expansion.,0
There is no definite evidence of abnormal signal posteriorly to suggest ligamentous injury.,0
There is no evidence of susceptibility within the cord to suggest hemorrhagic product.,0
IMPRESSION: No change from previous examination with persistent cord edema at C3-C4.,0
No definite evidence of ligamentous injury.,0
"12:40 PM CHEST (PA & LAT) Clip # Reason: please check placement l ceph picc for long term abx, pt has Admitting Diagnosis: FEVER;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with chest pain, h/o pulmonary fibrosis w/ 3+ pitting edema, SOB REASON FOR THIS EXAMINATION: please check placement l ceph picc for long term abx, pt has r subclav line, please call beeper with wet read asap thanks ______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old woman with chest pain, history of pulmonary fibrosis, and edema.",0
CHEST PA AND LATERAL: PICC tip is difficult to definitively identify.,0
It is seen entering the proximal right atrium but is obscured due to cardiac motion.,0
Right subclavian tip is at the distal SVC.,0
Patient is status post median sternotomy and CABG.,0
Mediastinal and hilar contours are stable in appearance.,0
Diffuse bilateral interstitial infiltrates are consistent with patient's underlying lung disease.,0
Small bilateral pleural effusions are unchanged in appearance.,0
Osseus and soft tissue structures are unchanged in appearance.,0
IMPRESSION: PICC seen entering proximal right atrium.,0
"However, the tip is difficult to identify due to cardiac motion.",0
Stable appearance of bilateral pleural effusions.,0
11:30 PM CHEST (PORTABLE AP) Clip # Reason: pna?,0
______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with hypoxia and hypoglycemia.,0
REASON FOR THIS EXAMINATION: pna?,0
______________________________________________________________________________ FINAL REPORT STUDY: Single portable AP chest radiograph.,0
"INDICATION: Hypoxia, hypoglycemia, history of diabetes, coronary artery disease, hypertension, and CHF with ejection fraction previously 20%.",1
"COMPARISON: Portable chest radiograph, , chest radiograph, .",0
FINDINGS: There is cardiomegaly as before.,0
Diffuse pulmonary vascular congestion with increased interstitial markings are new since and are consistent with moderate CHF.,0
The hilar structures appear unremarkable.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old male who was transferred to from an outside hospital on .,0
"Per report, he had been in a fight and had been hit on the side of the head.",0
A head CT at the outside hospital was positive for both subarachnoid and intraparenchymal bleeding.,0
"Upon arrival, he was intubated and a Neurosurgery consult was obtained.",0
"He was also observed to have a left posterior communicating aneurysm, and it was decided that he would be taken to the Interventional Radiology Suite for coiling of this aneurysm on hospital day number two.",0
"PHYSICAL EXAMINATION: At the time of admission, his vital signs were heart rate of 68, blood pressure 145/53, respiratory rate of 14.",0
He was saturating 100 percent on room air.,0
His pupils were 3 mm bilaterally.,0
"His heart rate was regular, normal rhythm, normal S1 and S2.",0
"No peripheral clubbing, cyanosis, or edema.",0
He was noted to have a right-sided hemiplegia at the time of admission.,0
"LABORATORY DATA: Labs include white count of 6.9, hematocrit of 32.7, platelets 382, sodium 139, potassium 3.9, chloride 102, bicarbonate 26, BUN 13, creatinine 0.8, and platelets 98.",0
HOSPITAL COURSE: He was admitted to the Neurosurgery Service and was placed in the Trauma Intensive Care Unit on hospital day number two.,0
He was taken to the Interventional Radiology Suite for coiling of his left posterior communicating aneurysm.,0
"On post-coiling day number one, a head CT revealed some increase in the hemorrhage, but decrease in ventricular size.",0
It was decided that a ventricular drain would be placed.,0
This was placed on post- coiling day number five.,0
It was actually a lumbar drain.,0
The rest of the hospital course was uneventful.,0
He was transferred to the floor on postoperative day number 17 and he did well.,0
"He was transferred to home on post-coiling day number 20l; and at this time, he was ambulating independently.",0
He had good urine output and was tolerating a p.o.,0
His drain had been discontinued prior to his transfer to the floor on postoperative day number 17.,0
"DISCHARGE DIAGNOSES: Subarachnoid hemorrhage, status post coiling of left posterior communicating aneurysm.",1
Acetaminophen 325 to 650 mg p.o.,0
DISCHARGE INSTRUCTIONS: The patient was instructed to follow up with Dr. as an outpatient in 7 to 10 days.,0
He was to call to make the appointment.,0
"Please call if questions, pager number .",0
", Dictated By: MEDQUIST36 D: 13:58:42 T: 15:07:01 Job#:",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Cath with balloon angioplasty to left circumflex artery Bronchoscopy with lavage and biopsy Lumbar puncture Brain biopsy with right sided craniotomy History of Present Illness: This is a 43 year old recently discharged from after admission for PCP pneumonia, unknown brain mass, seizures who presented with an episode of substernal chest pain today at 3 am.",1
"He describes the pain as associated with nausea, vomit and worse on inspiration and radiated to the L arm and jaw.",0
"In the ED, EKG with ST elevations on II-III-AVF- I-AVL v4-v5-v6.",0
"Patient was given Aspirin 325, Heparin, Plavix 300 and morphine.",0
Patient was taken to the cath lab.,0
"LMCA Normal LAD 70% ulcerated stenosis with TIMI 3 flow, D1 is TO LCX ulcerated thrombotic stenosis in the distal LCX with TIMI 2 flow RCA normal.",0
Balloon angioplasty was done on Cx lesion.,0
"On CCU arrival, Vs 108/69 HR 97 patient complaining of sub-sternal chest pain, .",0
Patient stated that it was similar to the pain he had when he came in.,0
"No new EKG changes compare to EKG post cath, ST elevation in precordial leads improving.",0
"the chest pain did not respond to 2 sublingual nitro, so Nitro drip was started and Morphine 2mg x2 was given obtaining pain relief.",0
The pt was eventually transferred to the Medical in a stable condition.,0
"HIV, last CD4 125 on , HIV VL 3 384 copies/uL.",0
History of oral HSV 4.,0
Eczema of skin over hips 5.,0
Unknown Brain lesion right temporal lesion Social History: Lives with roommate.,0
Quit smoking about 4 months ago.,0
"Family History: noncontributory Physical Exam: VS Bp 109/59 Hr 98 Sats 100 on RA Gen: Patient in moderate distress HEENT: no JVD, no LAD Lungs: Clear to auscultation bilaterally CV: RRR, s1-s2 normal, no murmurs, no gallops Abdomen: BS+, soft non tender, non distended Extremities: no edema, groin site clean, sheath still in.",0
"Cardiology: Cath Hemodynamics: Elevated left heart filling pressures with preserved ci Co 4.64, CI 2.88 PCW 20 PA 39/7 Mean 16 LV 97/11 25 RV 39 end 12 Left ventriculography: No mitral regurgitation, anterolateral and inferoapical hypokinesis LVEF ~45% .",1
"Coronary angiography: Right dominant LMCA Normal LAD 70% ulcerated stenosis with TIMI 3 flow, D1 is TO LCX ulcerated thrombotic stenosis in the distal LCX with TIMI 2 flow RCA normal .",0
Midly depressed systolic ventricular function.,0
Moderately elevated left heart filling pressure.,0
Successful balloon angioplasty of the distal CX lesion.,0
Trivial TR and MR .,0
Echo: () The left atrium is normal in size.,0
Overall left ventricular systolic function is mildly depressed (ejection fraction 40-50 percent) secondary to severe hypokinesis of the posterior and lateral walls.,0
"Compared with the findings of the prior study (images reviewed) of , posterior and lateral hypokinesis now present.",0
"Imaging: CT CHEST, W&W/O CONTRAST (): There is a 4.8 x 2.8 cm consolidative opacity within the left upper lobe with surrounding nodularity and ground-glass opacity, as described above.",0
"The differential for this includes a consolidative pneumonic process, though given the patient's history of HIV, atypical organisms such as aspergillus or TB should also be considered.",0
"Neoplasm is also on the differential, and followup evaluation should be obtained after treatment to evaluate for resolution.",0
"MR HEAD With GADO/ADC (): Signal abnormalities in the right temporal and occipital lobes, likely represent either evolving acute brain ischemia, an infiltrative process such as lymphoma, or inflammatory process.",0
"Severe right axis deviation *** LATERAL INFARCT - POSSIBLY ACUTE *** Tall R waves in lead V1, V2 - consider posterior wall myocardial infarct No change from previous .",1
"PATHOLOGY: BRAIN BIOPSY Encephalitis, chronic, mild.",0
Occasional microglial nodules at -white junction.,0
No diagnostic Toxoplasma gondii or multinucleated cells (e.g.,0
"Scattered gram-positive cocci isolated and in pairs, not directly associated with microglial nodules.",0
NOTE: This brain biopsy includes neocortex and a small amount of underlying subcortical white matter.,0
Several small microglial nodules are present at the -white junction in the several levels prepared from the tissue.,0
Microglia are increased near the nodules.,0
The nodules lack multinucleated cells that would be diagnostic for HIV encephalitis.,0
"They also lack diagnostic viral inclusions (including the inclusions of PML), giant cells, or Toxoplasma organisms.",0
The acid fast stain is negative for bacilli and the GMS silver stain lacks fungi or yeast forms.,0
"The tissue gram stain shows infrequent gram-positive cocci scattered over the tissue, sometimes near sites of pathology and sometimes in otherwise normal brain.",0
"While the lack of secondary tissue changes to many of these organisms suggests they may be a staining contaminant, the culture prepared from this same brain tissue did grow rare coagulase negative Staphylococcus.",0
"Based on the H&E and lack of staining in AFB and GMS stains, the main differential diagnoses for the microglial nodules at the -white junction would be HIV encephalitis and treated toxoplasmosis.",0
Additional stains are pending for other viruses.,0
The results will be issued in an addendum.,0
"Brief Hospital Course: Pt is a 43yo male with history of HIV, PCP pneumonia, seizures who was found to have a brain mass.",0
"The pt initially presented to the Ed with complaints of chest pain, underwent a cardiac workup which revealed a postero-lateral STEMI.",1
the pt underwent a cardiac catheterization with POBA to left circumflex.,0
He was transferred to the medicine team for evaluation of the brain mass.,0
The pt underwent a brain biopsy which revealed no evidence of lymphoma or focal infection.,0
The brain biopsy was significant for some gram positive cocci which were thought to be a contaminant.,0
The pt was recommended close follow-up with his primary care provider and neurology for results of pending studies.,0
CARDIAC: ISCHEMIA The pt has no known past cardiac history.,0
"He presented with acute onset chest pain and was noted to have inferolateral ST elevations with a CK peak of 5864, MB>500 and Troponin-T of 9.83.",1
He was immediately referred to the cardiac catherization lab.,0
His cardiac cath revealed a right dominant circulation with two vessel coronary artery disease.,1
The LMCA was without flow limiting disease.,0
The LAD had an ulcerated lesion in the mid segment with 70% stenosis and TIMI 3 flow.,0
The D1 was totally occluded.,0
The LCx had a proximal 40% stenosis and the distal segment had an ulcerated thrombotic stenosis with TIMI 2 flow after OM3.,0
"Resting hemodynamics demonstrated mildly elevated right heart filling pressure and moderately elevated left heart filling pressure (RVEDP 15 mmHg, LVEDP 26 mmHg, mean PCWP 20 mmHg).",0
There was mild to moderate pulmonary arterial hypertension.,0
The calculated CO was 4.7 L/min with a CI of 2.9.,0
Left ventriculography demonstrated anterolateral and inferoapical hypokinesis.,0
The calculated EF was 45%.,0
The distal CX thrombotic lesion was angioplastied using a Maverick and a Voyager balloon with lesion reduction from 95% to 10%.,0
The final angiogram showed TIMI III flow with no dissection but embolization in a small branch of the OM.,0
No stents placed given brain lesion and risk of bleeding with Plavix and Integrilin.,0
"In the post-cath period the pt developed repeat episode of chest pain, described as ""sharp"", ""14/10"" and focal over cardiac apex.",0
His EKG was without change from previous with exception of V1 with T-wave flattening/inversion.,0
The chest pain resolved with 1mg IV morphine sulfate.,0
The pt was noted to have one subsequent episode of chest pain on the day of the brain biopsy which was not associated with any new or acute EKG changes (unchanged compared to previous).,1
The pt's pain was relieved with 1 SL Nitro and 1mg IV morphine.,0
"The pt was maintained on a beta-blocker, aspirin, ACE inhibitor and Statin (low dose, on HAART).",0
in the post-cath period and was discharged on these medications.,0
His dose of beta-blocker was decreased prior to discharge in light of low pressure.,0
The pt was instructed to follow-up as an out-pt with Dr. in Cardiology.,0
CARDIAC: PUMP The pt was noted to have an ejection fraction of 40-50% on ECHO and 45% on cardiac catheterization.,0
"The cardiac cath was also significant for an elevated wedge pressure in 20's, severe hypokinesis of posterior and lateral walls, trivial mitral regurgitation and no effusion.",0
CARDIAC: RHYTHM The pt was noted to be in normal sinus rhythm on telemetry.,0
RENAL: The pt has a baseline creatinine of 0.6-0.9 and the pt continued to be in this range during the hospitalization.,0
LEUKOCYTOSIS: The pt was noted to have an elevated white count of 24.3 but no bands or fever on admission.,0
The WBC count decreased to within normal limits on subsequent lab readings the same day and it was thought that the pt may have had transient leukocytosis secondary to acute MI.,0
The pt was not noted to be febrile during the hospitalization and all his cultures showed no growth to date.,0
HIV: The pt was on anti-retroviral medications on admission.,0
"He had the following counts: Absolute CD4 (342), absolute CD8 (967) and a CD4/CD8 ratio of 0.4.",0
The pt's HIV viral load by RT-PCR was 562 copies/ml.,0
"On admission he was on a regimen of Efavirenz, Emtricitabine and Tenofovir Disoproxil Fum and Primaquine.",0
He was maintained on his regimen while admitted in the hospital.,0
He was discharged with instructions to follow-up with his primary care provider as an .,0
PCP : The pt was noted to have a CXR significant for a worsening of consolidation in the left upper lobe with cavitation.,0
It was thought that this may represent worsening of pneumonia or a hemorrhage from a recent biopsy (which showed no aspergillus or fungal elements).,0
The was placed on TB precautions until TB was ruled out with acid fast smears from induced sputum and a bronchoalveolar lavage which revealed Pneumocystis Carinii on immunofluorescence testing.,0
The pt was initiated on a 17 day course of Primaquine-clindamycin.,0
"The pt was subsequently noted to have x3 negative AFB smears, however AFB were noted to grow on culture.",0
"The samples were sent to the State of Lab for TB probe and the preliminary results, (Infection Control) were negative.",0
The pt was subsequently taken off precautions and was instructed to follow-up with Dr. for the final report.,0
The pt also underwent testing for Rapid Respiratory Viral Antigen Test in which no respiratory viral antigens were detected.,0
"However, the culture confirmation was pending at the time of discharge and will need to be followed by Dr. .",0
Dr. was informed of these pending results.,0
"INFECTIOUS DISEASES WORK-UP: The pt was noted to have negative tests for legionella urinary antigen, fungus (, biopsy and bronchoalveolar lavage), RPR (), Toxoplasma antibodies (IgG, IgM) and cryptococcal antigen.",0
"The following laboratory tests were pending at the time of discharge and will need to be followed as an out-patient: induced sputum AFB culture, AFB culture (brain biopsy) and CSF acid-fast bacillus.",0
SEIZURES: The pt was noted to have new-onset seizures during his last hospitalization.,0
He was started on Keppra and was noted to have a non-specific hypodensity in the right temporal lobe on CT. During that admission the pt had an EEG that showed the unknown hypodensity to be a likely source of his seizure activity.,0
"On discharge after his last hospitalization the pt was also informed of state law requiring 6 months of no seizures prior to driving again, and was instructed to make arrangements to inform his place of employment.",0
When the pt was admitted on he was not noted to have any focal deficits.,0
"The pt underwent a planned brain biopsy which showed no diagnostic Toxoplasma gondii or multinucleated cells, scattered gram-positive cocci isolated and in pairs, not directly associated with microglial nodules (the nodules lacked multinucleated cells that would be diagnostic for HIV encephalitis), the acid fast stain was negative for bacilli and the GMS silver stain lacked fungi or yeast forms, tissue gram stain showed infrequent gram-positive cocci scattered over the tissue, sometimes near sites of pathology and sometimes in otherwise normal brain.",0
"While the lack of secondary tissue changes to many of these organisms suggested they may be a staining contaminant, the culture prepared from this same brain tissue did grow rare coagulase negative Staphylococcus.",0
"After discussion with the Attending, Dr. and the infectious diseases team, it was thought that the coag negative Staph likely represented a contamination (especially in light of a delay between collection and processing of the brain biopsy specimen).",0
"A decision was made to discharge the patient on his HAART regimen, cardiac medications and PCP pneumonia treatment.",0
"No treatment was indicated based on clinical correlation (no mental status changes, no signs of meningitis or clinical signs of infection).The pt was instructed to follow-up with Dr. who will discuss the final results of the biopsy (brain) and pending microbiology studies.",0
FEN: The pt was maintained on a cardiac and heart healthy diet.,0
"COMMUNICATION: , Health Care Proxy (sister) .",0
Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)).,0
Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).,0
Efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).,0
Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 2 days.,0
Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four times a day for 17 days.,0
Primaquine 26.3 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 17 days.,0
Disp:*60 Tablet(s)* Refills:*2* Discharge Medications: 1.,0
Primaquine 26.3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days.,0
Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days.,0
Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Efavirenz 600 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Keppra 500 mg Tablet Sig: One (1) Tablet PO three times a day: please take with 750mg tablet twice daily for total dose of 1250mg twice daily.,0
"Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP<100, hr<60.",0
Tylenol 325 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for headache for 2 weeks.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Intracranial lesion unspecified PCP pneumonia Acid Bacilli PNA Posterolateral STEMI s/p balloon angioplasty to distal LCx Discharge Condition: Good.,0
"Patient is afebrile, hemodynamically stable.",0
Patient has known intracranial lesion with arranged plans for biopsy.,0
"Additionally, the patient is noted on discharge to have recurrent episodes of sharp chest pain.",0
"These episodes are without new ECG changes, although ECG demonstrates persistent, slowly resolving posterior and lateral ST segment elevations.",1
It is known that the patient is being discharged without complete resolution of his pain symptoms and does not require repeat admission unless the patient's symptoms are increasing in severity or duration and/or the patient demonstrates new ECG changes.,0
Discharge Instructions: Please take all medications as prescribed .,0
Please keep all outpatient appointments that are arranged for you.,0
The numbers of the healthcare providers involved in your care are being provided to you.,0
Please call the offices of any of these providers if you have any questions.,0
"Please return to the hospital if you experience repeat seizures, headaches, nausea, vomiting, chest pain that does not self resolve after a few minutes or is increasing in duration or intensity, shortness of breath or any other concerning symptoms.",0
There has been a change to your medications.,0
Please read teh attached list carefully.,0
You have scheduled for a follow-up appointment with Dr. who will discuss the results of all pending labwork when you meet him.,0
(who performed the procedure on your heart) DATE/TIME: at 1:30 p.m.,0
The doctor's office is located in .,0
"If you are unable to make it to his office for follow up, you should contact the cardiology department at at: and arrange a follow up with any available cardiologist.",0
It is imperative that you maintain follow up with a cardiologist after your heart attack (Myocardial Infarction).,1
"Provider: , MD Phone: Date/Time: 4:30 .",0
It is VERY important that you make it to this appointment .,0
It is very important for you to follow with your PCP regarding pending microbiology and lab studies.,0
"8:40 PM BABYGRAM (CHEST ONLY) Clip # Reason: p-cvl pulled back, ?",0
"tip position ______________________________________________________________________________ MEDICAL CONDITION: Infant with staph aureus pneumonia, CLD REASON FOR THIS EXAMINATION: p-cvl pulled back, ?",1
tip position ______________________________________________________________________________ FINAL REPORT HISTORY: Staph aureus pneumonia and chronic lung disease.,1
"PORTABLE AP CHEST, 21:00, : The ETT is now seen just reaching the thoracic inlet.",0
The right subclavian PICC line again reaches the SVC and is unchanged.,0
Diffuse opacification of the right hemithorax with focal areas of air are again seen and not significantly changed.,0
"In the setting of staph aureus pneumonia, pneumatocele formation with adjacent empyema fluid remains a consideration and is consistent with clinical findings.",1
"There is generally poor aeration of the left lung compared to the previous study, however, this may simply be a reflection of an expiratory phase of the ventilatory cycle.",0
"A repeat radiograph, therefore, is recommended with good inspiratory settings.",0
These findings were discussed with the ICU team.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Sulfonamides / Biaxin / Levaquin / Cefzil / Motrin / Erythromycin Base Attending: Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: For full HPI please see admission note.,0
"Briefly, this is a 42F with CVID on IVIg, HepC, Tyoe 1 DM, distant IBD > 20 yrs ago last flare, recent cryptospordial infection, c/o increasing voluminous nonbloody diarrhea (up to 20 BMs daily) and worsening diffuse sharp abdominal pain.",0
"Seen at Hospital, treated with IV fluids and discharged.",0
"The following morning abdominal pain, palpiations and diarrhea and fever of 103.5.",0
"In the ED she was found to be febrile to 101.5 88 120/38 16 100 RA, with tense abdomen and CT A/P was notable for pancolitis without a vascular distribution.",0
"She was started on broad spectrum abx, surgical consultation noted patient was not a surgical candidate.",0
She was admitted to the ICU.,0
"In the ICU, vancomycin and cefepime were continued as were fluids.",0
"-Of note she has been followed by Dr. in ID for cryptosporidium, which was diagnosed in and she was started on Nitazoxanide.",0
"She was on therapy until the end of at which time her insurance would no longer pay for the medications and was prescribed Flagyl for treatment, but did not start the medication.",0
"She denies raw foods, recent travel, NSAID use, EtOH use.",0
"Her diarrhea has decreased today, she has had 1 BM that was a little less watery and more formed today.",0
She continues to have abdominal pain but less so than yesterday.,0
She tolerated a small ginger ale without nausea/vomiting.,0
"Past Medical History: 1)Type 1 Diabetes, difficult to control, she has frequent admissions for AMS from hypoglycemia.",0
"2)CVID: treated with IVIG q2 weeks, last 3)UTIs 4)Asthma 5)CBP 6)HCV: diagnosed in .",0
"Most recent VL 7,980,000 IU/mL Biopsy showed Grade 2 inflammation, stage 2 fibrosis: 1.",0
"Marked portal, periportal, and lobular mixed-cell inflammation with focal bridging (Grade 3).",0
Marked bile duct proliferation with neutrophils (see note) 3.,0
Trichrome stain: Moderate increase of portal and septal fibrosis (Stage 2).,0
"7) cryptosporidium, as above 8) ?",0
"inflammatory bowel disease (UC)--per patient, last flare many years ago, not on any treatment Social History: lives with fiancee and daughter, smokes pack per day, denies any alcohol since , formerly used IV drugs but none since Family History: No family history of diabetes.",0
Multiple family members with anemia.,0
"Broad spectrum antibiotics were intiated on admission including PO/IV vancomycin, cefepime and flagyl.",0
The patient was started on IV fluids; leukocytosis and lactate were trended in the ICU.,0
"CT abdomen/pelvis showed diffuse severe pancolitis, small ileocolic intussiception wihtout evidence of obstruction.",0
The surgical service was consulted but saw no acute indication for surgery and followed the patient with serial abdominal exams.,0
The patient remained afebrile and hemodynamically stable in the ICU and was subsequently tranferred to the regular medical floor.,0
"The GI service was consulted and recommended a flexible sigmoidoscopy, stool cultures and labs to evaluate the etiology of her diarrhea.",0
Thus far all stool labs for infectious causes are negative.,0
The biopsy upon flexible sigmoidoscopy showed mild dysplasia and inflammation.,0
It was recommended the patient continue her PO flagyl for a 2 week course and follow up with GI for a colonoscopy after discharge.,0
# Bacteremia: the patient was found to have S.pneumoniae on blood culture while on vancomycin.,0
The Infectious Disease service was consulted.,0
TTE and TEE were negative for endocarditis.,0
Ceftriaxone was initiated and PICC placed for IV treatment for a 2 week course.,0
The remainder of the blood cultures are negative to date.,0
The patient remained afebrile during her admission.,0
She has ID follow-up with Dr. in several weeks.,0
# Chronic Hepatitis C: LFTs were elevated above baseline on admission.,1
"Initially cholestyramine, ursodiol and spironolactone were held.",0
Her LFTs were trended and slowly returned back to baseline.,0
"After transfer to the medical service, given agressive fluid resuscitation in the ICU, the patient was fluid overloaded and required diuresis.",0
Spironolactone was restarted and lasix 20mg po daily was added.,0
An abdominal US showed a moderate amount of ascites which was tapped via ultrasound guidance.,0
"Approximately 500cc of fluid was removed, and labs were consistant with SBP, althought the patient was asymptomatic and already on ceftriaxone at that time.",0
She will need follow-up for her ascites as an outpatient to ensure it does not reaccumulate.,0
"Her cholestyramine, ursodiol were restarted prior to discharge.",0
A follow-up appointment was scheduled with Dr. (hepatology).,0
"# DM Type I: Patient reportedly hypoglycemic was hypoglycemic in the ICU, glargine was discontinued while the patient was NPO.",0
Once her diet was advanced her home DM was restarted and fingersticks monitored.,0
No changes were made to her regimen prior to discharge.,0
"# Asthma: Home regimen of albuterol, pulmicort and tiotropium were continued.",0
# Coagulopathy: at baseline probably due to underlying liver disease.,0
"# Follow-up: the patient has follow-up with the GI service, Infectious Disease, Hepatology and her PCP (which she will make on her own).",0
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours).,0
"Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day.",0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days.,0
Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
NEHT NEHT per protocol 8.,0
"Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 14 days: last day .",0
Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO DAILY (Daily).,0
Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) Inhalation once a day: take as prescribed by Dr.. 14.,0
Novolog 100 unit/mL Cartridge Sig: One (1) Subcutaneous once a day: use as directed.,0
"Lantus 100 unit/mL Solution Sig: One (1) Subcutaneous twice a day: 16U in the morning, 12U at night.",0
Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime.,0
Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain.,0
Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO once a day: take as directed by your doctor.,0
"Discharge Disposition: Home With Service Facility: All Care VNA of Greater Discharge Diagnosis: Diarrhea Chronic hepatitis C Discharge Condition: hemodynamically stable Discharge Instructions: You were admitted to the hospital for abdominal pain, diarrhea and fever.",1
You were initially treated in the ICU for low blood pressure and infection with IV fluids and antibiotics.,0
Your stool studies are negative for an infectious process.,0
"On flexible sigmoidoscopy you had a biopsy of the colon shows inflammation and mild dysplasia, which needs to be further evaluated by the GI physicians.",0
You were also found to have bacterial infection in your blood for which you need to be treated with IV antibiotics.,1
A PICC line was placed to allow for a full 2 weeks of antibiotics (ceftriaxone).,0
You will also need to complete the course of flagyl (antibiotic) for which you have a prescription.,0
Your Alinia has been discontinued.,0
"Please make sure to keep your appointments below with the clinic, Infectious disease clinic and make sure to see your primary care doctor at your earliest convenience for follow-up.",0
"If you experience worsening abdominal pain, nausea/vomiting, no bowel movements for more than one day with abdominal distension, fevers, chills, chest pains, or any other concerning symptoms please return to the ER or call your doctor.",0
Followup Instructions: Please make an appointment to see your primary care doctor within 1-2 weeks of your discharge.,0
"Provider: , MD Phone: Date/Time: 8:40 Provider: , MD Phone: Date/Time: 3:00 Provider: , MD Phone: Date/Time: 10:30",0
5:57 PM CHEST (PA & LAT) Clip # Reason: please eval for infiltrate Admitting Diagnosis: PULMONARY EMBOLIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with esophageal cancer and fever REASON FOR THIS EXAMINATION: please eval for infiltrate ______________________________________________________________________________ WET READ: 10:09 PM No pneumonia.,1
"______________________________________________________________________________ FINAL REPORT CHEST, PA AND LATERAL.",0
"HISTORY: 62-year-old female with fever, evaluating for pneumonia.",0
FINDINGS: A right subclavian central line is seen terminating in the upper SVC.,0
There are no consolidations or effusions.,0
"9:19 AM CHEST (PORTABLE AP) Clip # Reason: evaluation of lung status Admitting Diagnosis: TORN MENISCUS;SEVERE ASTHMA ATTACK\ARTHROSCOPY KNEE; RIGHT ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with intubated for asthma now s/p extubation REASON FOR THIS EXAMINATION: evaluation of lung status ______________________________________________________________________________ FINAL REPORT INDICATION: 53-year-old woman with asthma, intubated for respiratory distress.",1
"SINGLE SEMI-ERECT PORTABLE AP VIEW OF THE CHEST: An endotracheal tube, left-sided central venous line, and nasogastric tube are unchanged in position.",0
"Again, seen are low lung volumes, but even for allowing for this, there is pulmonary vascular engorgement with cardiomegaly.",0
"Also, seen is left lower lobe atelectasis.",0
"IMPRESSION: No significant interval change in pulmonary edema/cardiac failure, and left lower lobe atelectasis.",1
", F. TSICU 8:29 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: facial bone ct to evaluate facial bone fractures Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES ______________________________________________________________________________ MEDICAL CONDITION: HPI: 17M, unrestrained front seat driver in high speed MVC.",1
Prolonged extrication 1 hour and ten minutes..ISSUES:1.,0
R grade 3 open tibia shaft fx s/p 4-compartment fasciotomy2.,1
R closed femoral shaft fx3.,1
L lateral leg wound 4.,0
Complex Facial laceration through upper and lower lip REASON FOR THIS EXAMINATION: facial bone ct to evaluate facial bone fractures No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Mucosal thickening with small air-fluid levels in the maxillary and sphenoid sinuses.,1
Absence of the left upper frontal and lateral incisors.,0
"12:01 PM CHEST (PORTABLE AP) Clip # Reason: interval chnage Admitting Diagnosis: PANCOAST TUMOR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with right upper lobectomy REASON FOR THIS EXAMINATION: interval chnage ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP 3:00 PM Unchanged, no pneumothorax.",0
"INDICATION: Status post right upper lobectomy, evaluate for interval change.",0
Analysis is performed in direct comparison with a previous study of .,0
Status post right upper lobectomy and apical chest wall resection as described before.,0
"Two right-sided chest tubes are in place, both terminating in the apical area.",0
Observe that the single frontal view examination does not completely include the left-sided lateral chest wall.,0
1:03 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: Extent of infection.,0
"Hx Psoas abscess Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman with MRSA bacteremia, L3-L4 epidural abscess, h/o right psoas abscess.",1
REASON FOR THIS EXAMINATION: Extent of infection.,0
Hx Psoas abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 67-year-old female with MRSA bacteremia status post neurosurgical drainage of L3/4 epidural abscess.,1
Evaluate for extent of left psoas abscess.,1
TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed following the administration of 150 cc of intravenous Optiray.,0
"CT ABDOMEN WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: There is diffuse ground glass opacification in bilateral lung bases.",0
The liver enhances normally without focal nodules or masses.,0
"The gallbladder is enlarged, measuring up to 4.9 cm in cross sectional diameter.",0
"The spleen, bilateral adrenal glands are unremarkable.",0
"The kidneys are somewhat atrophic in appearance with multiple bilateral low density lesions which appear stable, but are inadequately characterized on this single-phase study.",0
A single 8-mm fatty attenuation lesion within the upper pole of the right kidney is most consistent with an angiomyolipoma.,0
"Dense atherosclerotic changes are seen involving the splenic artery, abdominal aorta and proximal mesenteric vessels.",0
"A rim enhancing fluid collection is seen insinuating along, and extending to left psoas muscle into the pelvis.",1
"At maximum diameter, this collection measures 3.3 x 2.5 x 8.4 cm.",0
"The patient is status post L3/4 laminectomy, with surrounding inflammatory change, and mild gaseous foci.",1
A drainage catheter is in place with the tip adjacent to the L3 facet joint.,0
"CT PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: A Foley catheter is seen within a partially collapsed bladder.",0
"The bladder, sigmoid, rectum, uterus and adnexa are unremarkable.",0
IMPRESSION: (Over) 1:03 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: Extent of infection.,0
Hx Psoas abscess Field of view: 36 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
Left psoas rim enhancing fluid collection measuring 8.4 x 2.5 x 3.3 cm.,0
"Status post L3/4 laminectomy with surrounding inflammation, post-surgical changes, and drainage catheter in place.",0
Prominent gallbladder measuring up to 4.9 cm in cross sectional diameter.,0
No gallstones or pericholecystic fluid identified.,0
Multiple bilateral renal hypodensities which are incompletely characterized.,0
A single 8-mm fatty attenuation lesion within the interpolar right kidney most likely represents an angiomyolipoma.,0
8:44 AM CHEST (PA & LAT) Clip # Reason: Evaluate for pneumothorax and lead placement Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man s/p pacer REASON FOR THIS EXAMINATION: Evaluate for pneumothorax and lead placement ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest PA and lateral on .,0
COMPARISON: Chest PA and lateral on .,0
STUDY: Evaluate for pneumothorax and lead placement.,0
"FINDINGS: In the interim, a pacemaker has been placed with dual lead, the distal tip of the left atrial lead is in the atrium .",0
The ventricular lead is within the right ventricle.,0
The patient is status post aortic valve replacement with multiple sternotomy wires.,1
There is no left pneumothorax status post pacemaker implantation.,0
There is persistent small-to-moderate left pleural effusion with adjacent atelectasis of the left lower lobe.,0
The right costophrenic angle is unremarkable.,0
The visualized portions of the lungs do not show any airspace disease or interstitial disease with the exception of the left lower lobe.,0
The aorta is tortuous and ectatic.,0
The osseous structures do not show any lesions suspicious for malignancy.,0
Status post implantation of a dual-lead pacemaker with no apparent pneumothorax.,0
Persistent mild-to-moderate left pleural effusion with adjacent left lower lobe atelectasis.,0
6:30 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: assess line placements Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with embolic strokes REASON FOR THIS EXAMINATION: assess line placements ______________________________________________________________________________ WET READ: GMSj WED 9:17 PM ET tube 4.2 cm above the carina.,0
"NG tube at least within the stomach, though tip not imaged.",0
All other lines appear to be external to the patient.,0
No pulmonary edema or congestion.,0
Retrocardiac density is unchanged from prior and may represent atelectasis.,0
GSenapati ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess lines and tubes.,0
Comparison is made with prior study performed five hours earlier.,0
ET tube is seen in standard position.,0
The tip is 4.2 cm above the carina.,0
Bibasilar atelectases have worsened on the left side.,0
"9:14 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: Please do U/S with dopplers to evaluate for portal vein Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: Pt is a 36-year-old female with a history of schistosomiasis-induced portal hypertension with bridging fibrosis of the liver with complications of upper GI bleed secondary to esophageal varices status post banding and splenectomy, with no upper GI bleed in the past 3 years presents with melena and a significant drop in crit over her baseline, presently hemodynamically stable.",1
REASON FOR THIS EXAMINATION: Please do U/S with dopplers to evaluate for portal vein thrombosis ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 11:07 AM IMPRESSION: 1.,0
Heterogeneous hepatic echotexture as before with focal increased echogenicity in the gallbladder fossa likely secondary to bands of scarring from known schistosomiasis infection.,1
Patent hepatic vasculature with normal directional flow and waveforms.,0
______________________________________________________________________________ FINAL REPORT STUDY: RIGHT UPPER QUADRANT ABDOMINAL ULTRASOUND GRAYSCALE AND DOPPLER EVALUATION OF THE LIVER.,0
INDICATION: A 36-year-old female with history of schistosomiasis-induced portal hypertension with bridging fibrosis and complications secondary to esophageal bleeding.,1
Please evaluate liver with vascular evaluation.,0
"SCALE IMAGING: Hepatic echotexture is again demonstrated to be diffusely heterogeneous with increased echogenicity within the gallbladder fossa as before, likely representing bands of scarring.",0
No focal hepatic mass lesions are identified.,0
There is no intra- or extra-hepatic biliary ductal dilatation with the common duct measuring 2 mm.,0
The gallbladder is normal in appearance without wall thickening or pericholecystic fluid to suggest acute cholecystitis.,0
There is negative son sign and no intraluminal gallstones are identified.,0
"The pancreas is normal in appearance without mass lesion or ductal dilatation, however, the tail is not well visualized secondary to overlying bowel gas.",0
No intra-abdominal ascites is present.,0
The spleen is not visualized is consistent with given history of splenectomy.,0
No right or left renal hydronephrosis.,0
The main hepatic artery is patent with normal directional flow and waveforms.,0
Hepatic arterial waveforms demonstrate brisk upstroke and forward diastolic flow.,0
"The main, right, and left hepatic veins are patent with normal directional flow.",0
IMPRESSION: (Over) 9:14 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: Please do U/S with dopplers to evaluate for portal vein Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
Heterogenous hepatic echotexture without focal mass lesion identified.,0
11:14 AM CHEST (PORTABLE AP) Clip # Reason: STAT because of sudden tachypnea.,0
"Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with SAH, intraventricular hemorrhage.",1
Fever and positive sputum culture.,0
REASON FOR THIS EXAMINATION: STAT because of sudden tachypnea.,0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Intraventricular hemorrhage, fever.",0
CHEST: The heart is the upper limits of normal.,0
Some upper zone redistribution is present.,0
Increased opacification in both bases is seen suggesting the presence of fluid as on the previous occasion.,0
The positions of the various lines and tube remain unaltered.,0
IMPRESSION: Some evidence for failure.,0
"1:30 PM MR W & W/O CONTRAST Clip # Reason: Please obtain LS MRI with Gadolinium to evaluate for osteomy Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with hx of osteo, S. Aureus endocarditis, S. Aureus bacteremia- with worsening lower back pain REASON FOR THIS EXAMINATION: Please obtain LS MRI with Gadolinium to evaluate for osteomyelitis ______________________________________________________________________________ FINAL REPORT INDICATION: History of osteomyelitis, staph aureus endocardiis and bacteremia with worsening low back pain.",1
"TECHNIQUE: Sagittal T1, T2, IR and post-gadolinium T1W scans of the lumbosacral spine were obtained, as well as pre and post-gadolinium T1W axial images through the lumbosacral region.",0
There are no previous studies available for comparison.,0
"FINDINGS: T2 and IR scans demonstrate increased signal within the L2 and L3 vertebral bodies, especialy along the superior endplate margins, where there are invaginations of the intervertebral discs.",0
These vertebral bodies are of decreased height.,0
There is no evidence of deformity of the anterior-posterior margins of the vertebrae.,0
"There are mild bulges at the L3/4 and L4/5 intervertebral discs, without canal stenosis or foraminal encroachment.",0
"Overall, the spinal canal appears normal in caliber.",0
"Post-gadolinium images do not demonstrate abnormal enhancement of bones, discs or thecal contents.",0
There is no evidence of an epidural collection or abnormal epidural enhancement to suggest infection.,0
"There is motion artifact limiting evaluation, especially of the lower lubosacral spine.",0
IMPRESSION: There are compression deformities of the superior endlates of L2 and L3.,0
"There is increased signal within the vertebrae, which may represent edema.",0
There is no clear evidence of bony or soft tissue infection of the lumbosacral spine.,0
Examination is somewhat limited by patient motion artifact.,0
Findings were reported to Dr. at 16:30 on .,0
4:44 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: STATUS POST LEFT ILIAC ARTERY SURGERY; ?,0
"PANCREATIC MASS ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with h/o ex lap, retroperitoneal hematoma and ischemic lower extremities POD #2 REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: History of laparoscopy, evaluation for interval change.",1
"The monitoring and support devices, including the endotracheal tube and the right-sided PICC line as well as the right-sided internal jugular vein catheter and the left-sided internal jugular vein catheter are unchanged.",0
Unchanged evidence of axillary and infraclavicular clips on the left.,0
Unchanged normal size of the cardiac silhouette and presence of bilateral moderate pleural effusions with subsequent basal areas of atelectasis.,0
"No other parenchymal opacities, notably no evidence of pneumonia.",0
4:43 PM CHEST (PORTABLE AP) Clip # Reason: 72 yM s/p Swan placement; concern that cath tip has migrated ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with CHF and acute renal failure intubated for acute respiratory distress; page REASON FOR THIS EXAMINATION: 72 yM s/p Swan placement; concern that cath tip has migrated back to RV/PA; CXR to evaluate placement ______________________________________________________________________________ FINAL REPORT FRONTAL CHEST RADIOGRAPH: HISTORY: Reassess position of Swan-Ganz catheter.,1
COMPARISON: The Swan-Ganz catheter entering via right IJ access remains stablely positioned with the tip in the left main stem pulmonary artery.,0
Stable appearance of the ETT and NGT.,0
Persistence of diffuse bilateral hazy opacification and layering bilateral pleural effusions consistent with heart failure.,1
IMPRESSION: 1) Swan-Ganz catheter appears well positioned in the left main stem pulmonary artery.,0
2) Persistence of heart failure.,1
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: line placement Admitting Diagnosis: S/P LIVER TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman s/p liver transplant REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT HISTORY: Line placement.,1
"FINDINGS: In comparison with the earlier study of this date, there has been placement of a right IJ catheter that extends to the mid-to-lower portion of the SVC.",0
9:06 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Eval for hematoma.,0
"Admitting Diagnosis: ENCEPHALOPATHY;ST ELEVATION MI Field of view: 39 ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with HBV liver cirrhosis, s/p TIPS now with alt mental status and dropping HCT.",1
REASON FOR THIS EXAMINATION: Eval for hematoma.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Drop in hematocrit.,0
TECHNIQUE: Non-contrast CT of the abdomen and pelvis was performed.,0
CT OF THE ABDOMEN WITHOUT CONTRAST: Note is again made of a left lower lobe consolidation and small bilateral pleural effusions.,0
There is a slight increase to the amount of ascites around the liver.,0
"Compared to the prior exam, there is diffuse increased stranding in the mesentery and in the subcutaneous soft tissues consistent with edema.",0
No focal fluid collection is identified to suggest a hematoma.,0
"Since the prior exam, note is made of high density of fluid within the stomach which could indicate blood products.",0
No other changes to the abdominal organs since the previous exam are noted.,0
"CT OF THE PELVIS WITHOUT CONTRAST: Again, there is edema of the mesentery and a small amount of dependent fluid in the presacral space.",0
The pelvic organs are stable in appearance.,0
Bone windows show degenerative changes of the spine.,0
High-density fluid within the stomach.,0
"This finding was communicated to the clinical team, as it might reflect blood within the gastric fluid.",0
Small increase in the perihepatic fluid as compared to the previous exam.,0
"6:22 PM CHEST (PORTABLE AP) Clip # Reason: s/p ET tube change, now oxygenating poorly.",0
"Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with hep C cirrhosis, EtOh hepatitis presents w/ h/o pleural effusion, who p/w GIB, now intubated REASON FOR THIS EXAMINATION: s/p ET tube change, now oxygenating poorly.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 45 year old man with hepatitis C cirrhosis and alcoholic hepatitis who is intubated.,1
Evaluate ET tube placement after change.,0
COMPARISON: Chest radiograph from 16:03 from the same day.,0
Two portable chest radiographs are submitted.,0
"The endotracheal tube is in satisfactory position, 4.5 cm above the carina.",0
A nasogastric tube tip is within the stomach.,0
"There is hazy increased density in both lung bases, consistent with pleural effusions.",0
There is no definite new consolidation.,0
1:10 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: please eval for swallow and recommendation of diet consisten Admitting Diagnosis: HYPERCALCEMIA: LUNG CANCER ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with RVR and aspiration event on the floor tx'd to ICU for closer monitoring.,0
Now sats good and afebrile.,0
REASON FOR THIS EXAMINATION: please eval for swallow and recommendation of diet consistency.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 82-year-old man with suspected aspiration.,0
VIDEO-TAPED OROPHARYNGEAL SWALLOWING STUDY: The study was performed in conjunction with the speech and swallow pathologist.,0
"Multiple consistencies of barium were administered, and the pharynx was monitored fluoroscopically.",0
"Weakness of the oral muscles was noted, but no delay in bolus passage.",0
"Moderate retention in the right piriform, and to a mild extent, within the right vallecula, were noted with all consistencies, but the patient showed good clearance with cough.",0
There was trace aspiration of thin liquids only.,0
"A barium tablet was administered, which became lodged in the right valleculae.",0
"However, with repeated swallows, the patient was able to clear the pill into the esophagus.",0
Trace aspiration with thin liquids only.,0
Tendency to transient retention in the right pyriform sinus and valeculla.,0
Please see the report of the speech and swallow pathology on Careweb for further details.,0
9:52 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: please evaluate swallowing capability ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with REASON FOR THIS EXAMINATION: please evaluate swallowing capability ______________________________________________________________________________ FINAL REPORT PROCEDURE: VIDEO OROPHARYNGEAL SWALLOW INDICATION: 75 year old female with cough and decreased sats when eating.,0
FINDINGS: The radiologist was present to provide the speech pathologist with assistance during video oropharyngeal swallow examination.,0
Video imaging was performed during swallowing to evaluate solid and liquid consistencies.,0
There is mild loss of bolus control with premature spillover and intermittent penetration during swallowing of nectars.,0
"However, in this instance, there is spontaneous cough with clearing.",0
"With thin liquids, aspiration is seen and spontaneous cough is ineffective at clearing material.",0
Cued cough improves clearing of material.,0
Aspiration is due to mild reduced laryngeal elevation as well as reduced valve closure.,0
Swallowing to puree consistences was unremarkable.,0
IMPRESSION: Aspiration to thin liquids with ineffective spontaneous cough secondary to mild reduced laryngeal elevation and valve closure.,0
Please see the speech pathologist report for recommendations and further details.,0
"3:20 PM CHEST (SINGLE VIEW) Clip # Reason: f/u pnemothx Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p CABG s/p chest tube to H2O seal now d/c'd REASON FOR THIS EXAMINATION: f/u pnemothx ______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube to waterseal, then removed.",1
"There is a small left apical pneumothorax, similar in appearance compared to the film from the prior day.",0
There continues to be bilateral lower lobe volume loss with a more linear area of atelectasis/infiltrate in the right lower lung that has progressed slightly compared to the prior day.,0
Mildly dilated loops of bowel are seen in the mid abdomen and left upper quadrant measuring up to 6 cm.,0
Recommand clinical correlation and abdominal film if indicated.,0
"8:52 AM CT HEAD W/O CONTRAST Clip # Reason: concern for stroke, herniation Admitting Diagnosis: MULTIPLE MYELOMA Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with MM and mental status changes, now with respiratory distress and blown right pupil REASON FOR THIS EXAMINATION: concern for stroke, herniation No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Multiple myeloma status post bone marrow transplant with febrile neutropenia, now with change in mental status and a blown right pupil.",1
"FINDINGS: There a new, large parenchymal hemorrhage in the right parietal and occipital lobes, which extends into the right lateral, third, and fourth ventricles.",0
"There is extensive associated parenchymal edema, with shift of the septum pellucidum and the third ventricle to the left.",0
"There is right subfalcine herniation, right uncal herniation, and probably also left uncal herniation.",0
"In addition, there are multiple small foci of hypodensity at the /white junction in the cerebral hemispheres, some of which are new.",1
They likely represent additional septic emboli .,0
Findings were discussed with Dr. at approximately 9:15 a.m. on .,0
Dr. stated that she was already arranging for a neurosurgical consultation.,0
"New, large right parietal and occipital hemorrhage, extending into the ventricles.",0
"Extensive mass effect with right subfalcine, right uncal, and probably also left uncal herniations.",0
Hydrocephalus related to intraventricular blood.,0
"Multiple lesions at the /white matter junction in the cerebral hemispheres, many of which are new, likely representing progression of septic emboli.",1
"4:31 PM CHEST (PORTABLE AP) Clip # Reason: repositioning of ET tube, interval change of pleural effusio Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 25 year old man with MVA with increasing secretion from ETT.",0
"REASON FOR THIS EXAMINATION: repositioning of ET tube, interval change of pleural effusions ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW.",0
HISTORY: Increasing secretions from ET tube.,0
FINDINGS: The ET tube is 3 cm above the carina.,0
The left chest tube is unchanged.,0
There is increased dense opacification of the left chest with only a small amount of aerated lung superiorly.,0
"Mediastinal shift towards this side and therefore much of the opacification is due to the collapsed lung, but there is also likely contusion, effusion/hemorrhage and consolidation leading to the opacity of the hemithorax.",1
There is a smaller right lower lobe infiltrate/contusion.,0
There is herniation of the right lung across midline and into the left hemithorax.,0
5:23 PM CT HEAD W/O CONTRAST Clip # Reason: known SAH ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman bicyclist struck by moving vehicle at 50mph REASON FOR THIS EXAMINATION: known SAH No contraindications for IV contrast ______________________________________________________________________________ WET READ: 5:43 PM Subarachnoid hemorrhage in the right frontal lobe sulci.,1
"Hyperdensy fluid with air fluid level, correlation with physical exam is recommended.",0
Non displaced right skull base fracture.,1
WET READ VERSION #1 5:41 PM Subarachnoid hemorrhage in the right frontal lobe sulci.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 38-year-old woman with bicyclist struck by moving vehicle at 50 mph.,1
HEAD CT WITHOUT CONTRAST: Comparison was made with the prior outside study provided on CT.,0
"There is small amount of subarachnoid hemorrhage within the sulci of right frontal lobe, as seen on the prior CT scan.",1
There is no significant shift of normally midline structures.,0
There is no evidence of intraparenchymal or subdural hemorrhage.,1
"The ventricles are not dilated, and -white differentiations are preserved.",0
"There is air-filled level with hyperdense fluid measuring up to 60 in the left maxillary sinus, however, no definite fracture was noted on this head CT.",0
There is fluid in nasopharynx.,0
There is nondisplaced fracture through the right basiocciput extending to the lambdoid suture.,0
The patient is status post intubation.,0
Nondisplaced fracture of the right subocciput.,0
"Hyperdense fluid with air-fluid level in the left maxillary sinus, without definite fracture on this head CT.",0
Please correlate clinically for the possibility of facial fracture.,0
Findings was discussed with the trauma attending and Dr. in person at the completion of the study at 5:45 p.m.,0
The wet read was flagged to ED dashboard.,0
(Over) 5:23 PM CT HEAD W/O CONTRAST Clip # Reason: known SAH ______________________________________________________________________________ FINAL REPORT (Cont),0
"1:39 PM CHEST (PORTABLE AP) Clip # Reason: DESATURATION ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with pmh of endocarditis, chb, asd repair now p/w oxygen need NOW WITH DESTURATION AFTER SEDATION IS WEENED OFF REASON FOR THIS EXAMINATION: DESATURATION ______________________________________________________________________________ FINAL REPORT INDICATION: H/O endocarditis and ASD repair with increasing O2 sats.",0
CHEST AP PORTABLE: Comparison: AP portable .,0
The heart is stably enlarged.,0
The mediastinal and hilar contours are unchanged in appearance.,0
There has been slight interval improvement in the left lower lobe opacity with persistent right lower lobe opacification.,0
"There has been slight interval improvement in the perihilar haziness, bilaterally.",0
"The extreme right CP angle has been excluded from the study, but there is a layering pleural effusion which extends peripherally up to the minor fissure and lung apex.",0
An ET tube is seen with its tip 4 cm above the carina.,0
A single lead transvenous pacer is seen with lead in right ventricle.,0
An NG tube is seen with tip extending from field of view.,0
IMPRESSION: 1) Interval improvement in perihilar haziness and left lower lobe opacity.,0
2) Persistent right lower lobe opacity and increasing right layering effusion.,0
3) Lines and tubes in satisfactory position.,0
"5:35 PM CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # Reason: please eval for ptx s/p CT d/c Admitting Diagnosis: RIGHT LOWER LOBE NODULE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p RLL resection and RUL blebectomy, CT d/c REASON FOR THIS EXAMINATION: please eval for ptx s/p CT d/c ______________________________________________________________________________ FINAL REPORT INDICATION: Status post right lower lobe resection and right upper lobe blebectomy, chest tube removed, evaluate for size of pneumothorax.",0
FINDINGS: A right apical pneumothorax is again seen and is probably unchanged in size allowing for differences in patient positioning.,0
There is continued right-sided pleural effusion consistent with hydropneumothorax.,0
The right basilar chest tube has been removed.,0
Approximately stable opacities within the right lung base and stable atelectasis at the left base.,0
Stable moderate right apical pneumothorax.,0
Approximately stable right basilar hydropneumothorax.,0
More prominent density at the right base may represent atelectasis versus superimposed infectious process.,0
Height: (in) 66 Weight (lb): 157 BSA (m2): 1.81 m2 BP (mm Hg): 133/63 HR (bpm): 103 Status: Inpatient Date/Time: at 11:13 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
LV WALL MOTION: The following resting regional left ventricular wall motion abnormalities are seen: mid anteroseptal - hypokinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex - akinetic; apex - dyskinetic; RIGHT VENTRICLE: Right ventricular chamber size and free wall motion are normal.,0
Resting regional wall motion abnormalities include mid to distal anteroseptal hypokinesis/akinesis and apical akinesis/dyskinesis.,0
"5:08 PM CHEST (PRE-OP AP ONLY) PORT Clip # Reason: r/o infection, pre-op eval ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with SAH REASON FOR THIS EXAMINATION: r/o infection, pre-op eval ______________________________________________________________________________ FINAL REPORT INDICATION: Subarachnoid hemorrhage, preoperative evaluation.",1
UPRIGHT AP VIEW OF THE CHEST: The heart size is normal.,0
The hilar contours are unremarkable.,0
No pleural effusions or pneumothorax is visualized.,0
No acute osseous findings are seen.,0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion Admitting Diagnosis: AORTIC INSUFFICIENCY\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p AVR.,1
Please page Mark Courntey at with abnormalities.,0
"REASON FOR THIS EXAMINATION: r/o PTX/Effusion ______________________________________________________________________________ WET READ: JWK FRI 5:45 PM ETT, Swan Ganz catheter, left sided chest tube, NG appropriately positioned s/p AVR.",0
"No pneumothorax, effusion, or consolidation.",0
Mild subcutaneous emphysema in the left neck status post swan ganz placement.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, AT 17:10 CLINICAL INFORMATION: Line placement.",0
FINDINGS: Right IJ Swan-Ganz catheter tip is placed in the main pulmonary artery.,0
Nasogastric tube terminates in the stomach.,0
ET tube terminates at the thoracic outlet.,0
The lungs are otherwise grossly clear.,0
"LINE PLACEMENT Clip # Reason: eval line position Admitting Diagnosis: PERIPHERAL VASCULAR DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 45M s/p LE bypass, CVL placement REASON FOR THIS EXAMINATION: eval line position ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH, 3:45 A.M.: CLINICAL HISTORY: Evaluate line position.",0
There is a new endotracheal tube with its tip approximately 6 cm above the carina.,0
There is also a new right internal jugular central line with its tip in the SVC.,0
A small area of plate- like atelectasis is present in the left mid lung.,0
There is mild elevation of the left hemidiaphragm.,0
IMPRESSION: New endotracheal tube and right internal jugular central line.,0
Mild elevation of the left hemidiaphragm.,0
9:52 PM BABYGRAM (CHEST ONLY) Clip # Reason: picc line position Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with newly placed picc line REASON FOR THIS EXAMINATION: picc line position ______________________________________________________________________________ FINAL REPORT Chest x ray from at 21:39 hours compared to at 5:55 A.M.,1
FINDINGS: Endotracheal tube has been removed.,0
Nasogastric catheter overlies the stomach.,0
Central venous line is at T10-11.,0
The lungs are diffusely hazy consistent with hyaline membrane disease.,0
Abdominal gas pattern is unremarkable.,0
"There has been interval placement of a right PICC line, tip overlying the brachiocephalic vessels.",0
Abdominal gas pattern is unremarkable in the portion that is seen.,0
"6:15 AM CHEST (PORTABLE AP) Clip # Reason: ?pulm edema ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with with shortness of breath and bilaterl pedal edema REASON FOR THIS EXAMINATION: ?pulm edema ______________________________________________________________________________ WET READ: JEKh TUE 8:13 AM Cardiomegaly with right infrahilar airspace opacity, compatible with pneumonia versus asymmetric pulmonary edema.",1
"______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE 8:13 AM Cardiomegaly with right infrahilar airspace opacity, compatible with pneumonia versus asymmetric pulmonary edema.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 68-year-old female with shortness of breath and bilateral pedal edema.,1
"FINDINGS: The heart size is enlarged, apparently slightly increased from prior study, this maybe the magnifying effect of AP projection.",0
The mediastinal contours again demonstrate calcified atherosclerotic disease of the aortic knob.,0
Cephalization of pulmonary vasculature is accompanied by interstitial edema.,0
The lungs demonstrate airspace opacity in the right infrahilar region.,0
"Additionally, subtle blunting of the bilateral costophrenic angles persist, compatible with small pleural effusions.",0
"IMPRESSION: Cardiomegaly with interstitial edema; right infrahilar airspace opacity may reflect asymmetric pulmonary edema, but follow up radiographs may be helpful to exclude pneumonia.",0
10:22 AM CHEST (PA & LAT) Clip # Reason: r/o failure ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with severe HTN and HA REASON FOR THIS EXAMINATION: r/o failure ______________________________________________________________________________ FINAL REPORT No comparisons available.,1
HISTORY: 39 year-old man with severe hypertension and headache.,0
There is no evidence of pneumonia or CHF identified.,0
The heart is within the upper limits of normal with a left ventricular configuration.,0
The aorta is tortuous which is unexpected for the patients age.,0
There is mild buckling of the trachea which may be secondary to the aortic knob.,0
No pleural effusions or pneumothorax is identified.,0
IMPRESSION: Mild cardiomegaly with LV configuration.,0
Consider echocardiogram to further assess.,0
"LINE PLACEMENT Clip # Reason: intubated, RIJ line placed in OR.",0
"Please check RIJ and ETT p Admitting Diagnosis: BLADDER CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with RIJ and ETT REASON FOR THIS EXAMINATION: intubated, RIJ line placed in OR.",0
Please check RIJ and ETT positions ______________________________________________________________________________ WET READ: 9:44 PM ETT terminates 5.1 cm from the carinal.,0
Right IJ central venous catheter terminates in the upper SVC.,0
Pacer wires in similar position.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 7:24 P.M., HISTORY: Right IJ and ET tubes.",0
"IMPRESSION: AP chest compared to preoperative chest radiograph, .",0
"ET tube, right internal jugular line, and transvenous right atrial and right ventricular pacer leads in their expected positions.",0
Nasogastric tube would need to be advanced at least 15 cm to move all the side ports into the stomach.,0
"Lung volumes are slightly lower than on , consistent with mild bibasilar atelectasis.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: BLUE GENERAL SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old G3, P1 who presented to the OB service for Cytotec induction which was complicated by decreased fetal movement who was then taken to the Operating Room for stat cesarean section complicated by uterine atony and hemorrhage.",1
Status post extraction of wisdom teeth 2.,0
Status post rhinoplasty ADMISSION MEDICATIONS: 1.,0
Prenatal vitamins ALLERGIES: No known drug allergies.,0
"SOCIAL HISTORY: No tobacco, no ethanol use.",0
"HOSPITAL COURSE: The patient is a 35-year-old G3, P1 who presented to the labor and delivery floor for Cytotec induction.",1
"At that point, she was found to have decreased fetal movement and vaginal bleeding.",0
"She then became hypoxic, confused and hypotensive.",0
She was taken to the Operating Room for emergent cesarean section.,0
"At that point, the procedure was complicated by uterine atony and persistent uterine hemorrhage.",0
"At this point, her estimated blood loss was greater than 2 liters.",0
"She had started to received packed red blood cells intraoperatively, platelets and fresh frozen plasma.",0
"The patient actually delivered a healthy child and she was taken to the MICU/SICU for close monitoring, given that she remained intubated post procedure and was requiring massive transfusion of red blood cells, fresh frozen plasma and platelets.",1
"There, at this time, was also some question of amniotic fluid embolus.",1
"At 8 a.m. on the morning of , the patient went into pulseless electrical activity and chest compressions were started.",0
She was taken to the Operating Room emergently for exploratory laparotomy.,0
She had a repair of her hysterotomy and persistent bleeding from her round ligament and underwent left uterine artery and ligation.,0
"At this point, the patient also was found to have a rupture of her liver capsule and her entire abdomen was packed.",0
"Upon opening at this point, they also found approximately 5 liters of blood in the abdomen.",0
"After packing the abdomen, the patient was taken back to the Intensive Care Unit intubated and with an open abdomen continuing to receive massive transfusions of blood products.",0
"On the afternoon of , the patient returned to the Operating Room for abdominal compartment syndrome.",0
"During this operation, she underwent exploratory laparotomy with mobilization of the liver packing and also underwent median sternotomy for better exposure to control bleeding.",0
"She was still requiring blood products and the patient survived the operation, but was left with an open abdominal and chest wound and was on inotropic support.",0
She was taken to the Intensive Care Unit intubated and paralyzed.,0
"At this point, she had received approximately greater than 100 units of packed red blood cells and greater than 100 units of fresh frozen plasma.",0
"The patient was kept in the Intensive Care Unit intubated and sedated on inotropic support and then once stabilized on , the patient was taken back to the Operating Room for re-exploration of her abdominal wound and control of her liver bleeding.",1
"At this point, an attempt to close her sternum was made.",0
"She had bilateral chest tubes placed, but once her chest had been closed, she underwent hemodynamic collapse and arrhythmia and at that point her chest was reopened.",0
She was taken back to the Intensive Care Unit in critical condition and a CT at this point was negative for pulmonary embolus.,0
"On , the patient began to spike high temperatures.",0
Multiple cultures do not reveal any bacterial pathogens.,0
"On , the patient once again returned to the Operating Room and her chest was closed without hemodynamic compromise.",0
"At this point, cultures were taken both from her chest and abdominal wound.",0
"On , the patient was also started on TPN and tube feeds for nutritional support.",0
The patient continued spiking temperatures and on she was taken back to the Operating Room for re-exploration.,0
"At this point, she underwent abdominal wall closure, J-tube placement.",0
There was no evidence of abscess or fluid collection and infection.,1
"On , the patient also began to have purulent drainage from her sternum.",0
"An infectious disease consult was obtained and also a CT of her chest and abdomen was done on which revealed a right upper quadrant collection, as she underwent CT guided drainage with placement of pigtail catheter which revealed hemorrhagic purulent fluid.",0
"On , cultures from her CT guided aspiration revealed Enterobacter cloacae and infectious disease recommended changing her antibiotics from vancomycin, Flagyl, ceftriaxone and fluconazole to imipenem.",0
All other antibiotics were discontinued.,0
"On , her white count began to normalize and her fever curve resolved.",0
"On , the patient had another temperature spike and a repeat CT of her abdomen and pelvis did not reveal any discrete collection.",0
"On , given her extensive Intensive Care Unit course and failure to wean from the ventilators at bedside, a trach was placed and continued to attempt weaning sent for ventilation.",0
"On , a PICC line was placed for long term antibiotics.",0
She will need six weeks of antibiotics for presumed sternal osteomyelitis.,0
"On , the patient was finally weaned off all ventilatory support and speech consult was obtained, as the patient received a Passy-Muir valve to peak while she had her trach in place.",0
The patient was doing well and on her trach was removed and she was transferred to the floor.,0
"On the floor, the patient was stable and doing well.",0
Her tube feeds were switched to cycling overnight in order to stimulate her appetite.,0
She was tolerating a regular diet on the floor and her pain was well controlled.,0
"Her incisions remained clean, dry and intact.",0
"The patient, as of , was being screened for rehabilitation or deciding to go home with multiple services and tried to figure out support for her two children.",0
Zilastin 1 gm intravenous q6h for a total of 6 weeks.,0
She is currently day 23 of 42.,0
"Heparin flush for her PICC at 100 units per ml, 2 ml intravenous q day 4.",0
Ibuprofen 600 mg po q6h prn 5.,0
Tylenol 650 mg q6h prn 6.,0
Prevacid 30 mg po q day 7.,0
Percocet 1 to 2 tablets po q 4 to 6 hours prn 8.,0
"Impact with fiber at 65 ml per hour cycled from 2100 hours to 9 a.m. and once the patient is taking sufficient calories, her tube feeds can be weaned.",0
DISCHARGE CONDITION: Stable DISCHARGE STATUS: To be determined.,0
Status post cesarean section of healthy child complicated by uterine atony 2.,0
Rupture of liver capsule and liver hemorrhage 5.,1
"Status post chest and abdominal wound closure , M.D.",0
Dictated By: MEDQUIST36 D: 09:17 T: 09:28 JOB#:,0
6:11 PM CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY Reason: ?,0
"acute process ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with abd pain, hx of billiary surgery REASON FOR THIS EXAMINATION: ?",0
acute process No contraindications for IV contrast ______________________________________________________________________________ WET READ: SBNa TUE 6:38 PM liver hypodensities too small to characterize.,0
right adnexal hypodensity 3.1 x 3.7 cm.,0
______________________________________________________________________________ FINAL REPORT CT ABDOMEN AND PELVIS WITH CONTRAST COMPARISON: None.,0
HISTORY: 52-year-old female with abdominal pain and history of biliary surgery transferred from Hospital.,0
Images were obtained at Hospital and submitted for second opinion after transfer.,0
No formal report was provided.,0
Coronal and sagittal reformats were provided.,0
FINDINGS: The lung bases are clear.,0
Minimal bibasilar atelectasis is noted.,0
"Within the liver, there are multiple subcentimeter hypodense lesions which are too small to characterize (4, 15 and 4, 12).",0
Air within the biliary system is identified and consistent with choledochojejunostomy.,0
Anastomotic sutures are seen in the bowel in the left upper quadrant.,0
There is no evidence of obstruction.,0
"The spleen, pancreas, adrenal glands, kidneys are unremarkable.",0
There are bilateral extrarenal pelvises.,0
Small bowel loops are normal in caliber and without focal wall thickening.,0
CT OF THE PELVIS: The rectum and sigmoid colon are unremarkable.,0
Multiple fibroids within the uterus are identified.,0
"Within the right adnexa, there is a 3.1 x 3.7 cm hypodense lesion (4, 74).",0
Degenerative changes at L2-L3 with a Schmorl's node within the superior endplate of L3.,0
No acute pathology to explain patient's symptoms.,0
"Liver hypodensities, which are too small to characterize and some of which are incompletely evaluated.",0
(Over) 6:11 PM CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY Reason: ?,0
acute process ______________________________________________________________________________ FINAL REPORT (Cont) 3.,0
3.7 cm right adnexal cystic lesion.,0
Pelvic ultrasound in six weeks is recommended to ensure resolution.,0
Choledochojejunostomy with expected air within the biliary system.,0
Findings were posted to the ED dashboard.,0
Findings were discussed with Dr. via the telephone at 7:05 p.m.,0
Status: Inpatient Date/Time: at 16:43 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.,0
LEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - akinetic; mid inferoseptal - akinetic; RIGHT VENTRICLE: Severe global RV free wall hypokinesis.,0
MITRAL VALVE: Mitral valve annuloplasty ring.,1
Mild (1+) MR. TRICUSPID VALVE: Mild to moderate [+] TR.,1
Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
There is mild to moderate left ventricular Inferior and anterior septal akinesis with systolic dysfunction [EF 30-40%].,0
There is abnormal septal motion.The RV free wall is akinetic with normal motion of the apex.,0
A well seated bioprosthetic aortic valve prosthesis is present.,1
IMPRESSION: Severe RV dysfunction with free wall akinesis and apical sparing.,0
TR is mild to moderate.,0
A well seated AVR is seen.Mitral annuloplasty ring is seen.,0
The LV systolic function is reduced.,0
"6:29 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: r/o pulm edema Admitting Diagnosis: RIGHT HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with right hip fracture s/p R cvl placement REASON FOR THIS EXAMINATION: r/o pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old female with right hip fracture status post central venous line placement, evaluate for pulmonary edema.",0
SINGLE VIEW OF THE CHEST: The endotracheal tube is in similar position at the thoracic inlet.,0
A nasogastric tube has been placed and terminates below the field of view.,0
A right internal jugular catheter terminates at the cavoatrial junction.,0
"Allowing for rotation, the cardiomediastinal silhouette is stable.",0
There is a slight increase in perihilar opacity and lower lobe opacities consistent with slightly worsened pulmonary edema.,0
IMPRESSION: Slightly worsened pulmonary edema.,0
", G. MED CC7A 5:06 AM CHEST (PORTABLE AP) Clip # Reason: R/O acute cardiopulmonary process.",0
Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman in with subacute dyspnea now with acute desaturation.,1
REASON FOR THIS EXAMINATION: R/O acute cardiopulmonary process.,0
______________________________________________________________________________ PFI REPORT PFI: No failure.,0
Slight increase in right pleural effusion and questionable increase in right lower lobe consolidation.,0
"On arrival to the MICU, patient was pleasant, speaking minimal English, with vital signs 98.5 81 113/78 15 98% trach mask 40%.",0
"Past Medical History: Tracheomalacia s/p tracheostomy Hypoventilation syndrome Obesity Hypothyroidism Bipolar disorder Schizophrenia Hypertension morbid obesity ?Pneumonia (?Ventilator-associated) Tracheostomy placement Appendectomy Social History: Pt is a Russian speaking lady with some English ability, but prefers to have a translator or daughter present to explain.",1
Has been hospitalized at Hospital (psychiatric facility) for several Months.,0
She will be living with her daughter once the tracheostomy is closed.,0
No history of alcohol or drug use.,0
Family History: Patient states no chronic illnesses in family; confirmed by daughter.,1
"Physical Exam: Admission Exam: Vitals: 98.5 81 113/78 15 98% trach mask 40% General: No acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ radial/DP, no c/c/e Neuro: moving all extremities .",1
Drug Monitoring: 03:05AM BLOOD Valproa-39* 08:11PM BLOOD Lithium-0.5 03:05AM BLOOD TSH-0.79 .,0
DISCHARGE LABS 06:40AM BLOOD WBC-3.3* RBC-4.35 Hgb-12.5 Hct-38.1 MCV-88 MCH-28.8 MCHC-32.8 RDW-12.2 Plt Ct-231 06:40AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-143 K-4.1 Cl-103 HCO3-30 AnGap-14 06:40AM BLOOD Calcium-9.9 Phos-3.7 Mg-2.3 .,0
MICROBIOLOGY 4:16 am SPUTUM Source: Endotracheal.,0
RESPIRATORY CULTURE (Preliminary): NO GROWTH.,0
Chest X-ray (): Tracheostomy has been placed and is in standard position.,0
Right PICC terminates in lower superior vena cava.,0
"Heart is enlarged, accompanied by pulmonary vascular congestion and mild perihilar edema.",0
"Opacity at right lung base obscuring the medial right hemidiaphragm probably reflects atelectasis, but pneumonia is also possible in the appropriate clinical setting.",0
Probable small left pleural effusion.,0
"Brief Hospital Course: 50F w/schizoaffective disorder, tracheomalacia s/p chronic tracheostomy, recent hospital stay for trach downsizing and treatment of high tracheal stenosis admitted from an outside hospital for recurrent tracheostomy plugging and hypoxia to the 50s.",1
Hospital course was notable for upsizing of trach with resolution of mucous plugging and hypoxia.,0
"# TRACH PLUGGING/HYPOXIA Known hx trachea malacia s/p tracheostomy, recently undergoing trach downsizing presented w recurrent plugging of tracheostomy and hypoxia.",1
"Underwent trach upsizing intra-operatively by interventional pulmonology, to size 7.",0
"Patient did well thereafter, ambulatory w/O2 sats in the mid90s/RA.",0
Some thin mucous occasionally suctioned by nursing.,0
Also received home duonebs and mucinex.,0
#OSH CONCERN FOR PNEUMONIA There was also concern for PNA at OSH prior to transfer because sputum sample gathered (in setting of hypoxia and WBC 4.9 w 13% bands) grew MSSA.,0
"Had been receiving vanco/ceftaz there - this was stopped on MICU admission when she was found to be hemodynamically stable, breathing fine on trach mask, with unremarkable pulm exam.",0
"Afebrile, WBC remained wnl, bandemia already resolved on arrival.",0
"# OSH TROPONIN ELEVATION Trop I elevation to 0.144 at OSH, no ischemic changes noted on TTE.",0
Thought strain in setting of hypoxia and recurrent trach plugging before collar upsized.,0
Very low suspicion for ongoing cardiac process.,0
Cardiac enzymes repeated in the MICU were trop <0.01.,0
# SCHIZOAFFECTIVE DISORDER Chronic condition which prompted initial inpatient psych admission at State Hospital.,1
"Patient was initially continued on her home medications of divalproex, benztropine, trazodone, lithium, prn ativan.",0
"Psychiatry consulted for agitation in the MICU, followed closely.",0
"They recommended increasing valproate, decreasing benztropine, and dc'ing ativan.",0
"Patient remained agitated and pleasant but difficult to manage on the floor after MICU callout, requiring 2:1 nursing/MD reassurance and assistance nearly continuously.",0
She was discharged back to her previous Psychiatric facility.,0
HALDOL DEPOT DOSING Note: patient did not receive any of her 240 mg IV qmonth haldol depot injections because last date of administration could not be obtained from prior inpatient psych facility.,0
VALPROATE LEVEL MONITORING Dose increased to 750 on after level 39 (subtherapeutic).,0
Needs repeat valproic acid level check on and dose adjustment PRN for goal level 50-100. .,0
RESPIRATORY RECOMMENDATIONS Patient may need trach collar suctioning q2h or more frequently PRN for mucous plugging and/or hypoxia/dyspnea.,1
Needs humifified air by trach collar qHS.,0
Recommend duonebs q6H and PRN for any respiratory distress.,0
"Contact medical consult and alert outpatient pulmonologist with any tracheostomy issues including hypoxia, difficulty suctioning, excessive secretions.",1
NOTE: PATIENT MUST KEEP TRACH COLLAR IN AT ALL TIMES.,0
PSYCHIATRY CONSULT RECOMMENDATIONS (ENACTED): 1.,0
Decrease benztropine to 0.5 mg po bid - could be contributing to confusion and there are currently no signs of EPS - monitor for dystonia or tremor.,0
Clarify schedule and dose for next haloperidol decanoate injection.,0
"Continue current lithium, valproate, trazodone.",0
Discontinue lorazepam - can worsen confusion and disinhibition.,0
Haloperidol 5 mg po/iv/im q4h agitation or anxiety.,0
Monitor QTc and for dystonia (last QTc here 410).,0
"Given lithium therapy, monitor renal function, especially with any significant volume changes.",0
Medications on Admission: OUTPATIENT MEDICATIONS - Divalproex 500mg - Haldol Decanoate 240mg IV q28days (uncertain when last given) - Tylenol 650mg q4hrs prn - bisacodyl 10mg daily prn - milk mag 30ml prn - oxycodone IR 10mg q12hrs prn - duonebs - mucinex 1200mg - levothyroxine 50mcg daily - benztropine 1mg - trazodone 200mg qhs - lithium 300mg q8hrs - ASA 81mg daily - ativan 0.25mg qhs prn .,0
"MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL - Haldol 240mg IM q28d - duonebs - ceftaz 1g q8h - ativan 1mg IV q4h prn - zofran 4mg IV q6h prn - vanco 1gram q12h - tylenol 650mg q4h prn - ASA 81mg daily - benztropine 1mg - bisacodyl 10mg daily prn - divalproex 500mg daily - pepcid 20mg - mucinex 1200mg - levothyroxine 50mcg daily - lithiium 300mg q8h - milk mag prn - oxycodone IR 10mg q12hr prn - trazadone 200mg qhs - lovenox 40mg daily Discharge Medications: 1. divalproex 250 mg Tablet, Delayed Release (E.C.)",0
"Sig: Three (3) Tablet, Delayed Release (E.C.)",0
"Disp:*180 Tablet, Delayed Release (E.C.",0
Haldol Decanoate 100 mg/mL Solution Sig: Two y (240) mg depot Intramuscular once a month: note: none given in hospital because could not tell us last dose date.,0
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for Pain.,0
"4. bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for indigestion.,0
6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for pain.,0
DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing.,0
"Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO twice a day.",0
9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
10. benztropine 1 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).,0
Disp:*30 Tablet(s)* Refills:*2* 11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
13. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours).,0
Discharge Disposition: Extended Care Facility: state hospital Discharge Diagnosis: Chronic tracheomalacia Need for tracheostomy adjustment Schizoaffective disorder Discharge Condition: Mental Status: Confused - sometimes.,1
"Discharge Instructions: Dear Mrs , You were admitted to the hospital for difficulty breathing and low oxygen, which was solved by replacing your trach with a larger sized trach.",0
You were seen by interventional pulmonology daily - they arranged a follow-up appointment for you (see below for details).,0
You were breathing comfortably with the new trach collar.,0
You did develop sudden breathing difficulty whenever you removed the collar - your oxygen level improved once we cleaned it and replaced it.,0
You needed occasional mucous suctioning too.,0
We stopped antibiotics because we did not think you had pneumonia.,0
You required multiple doses of IM and PO haldol to control agitation.,0
We made the following changes to your medications: INCREASED DIVALPROEX TO 750 MG TWICE DAILY DECREASED BENZTROPINE TO 0.5 MG TWICE DAILY DISCONTINUED ATIVAN .,0
The psychiatrist who saw you in the hospital recommended you have valproic acid levels rechecked on (you will have received 4 doses of the new 750 mg dose by that date).,0
"Followup Instructions: Department: WEST CLINIC When: TUESDAY at 10:30 AM With: , MD Building: De Building ( Complex) Campus: EAST Best Parking: Garage Department: WEST CLINIC When: TUESDAY at 11:45 AM With: , MD Building: De Building ( Complex) Campus: WEST Best Parking: Garage",0
"3:42 PM CHEST (PA & LAT) Clip # Reason: eval pna, effusion, edema, ptx Admitting Diagnosis: S/P ASSAULT ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with fever, cough, desats REASON FOR THIS EXAMINATION: eval pna, effusion, edema, ptx ______________________________________________________________________________ FINAL REPORT CHEST, TWO VIEWS.",0
8:51 AM CT PELVIS ORTHO W/O CONTRAST W/3D Clip # Reason: pelvic fx Admitting Diagnosis: MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with pelvic fx REASON FOR THIS EXAMINATION: pelvic fx No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 37-year-old male status post MVC with pelvic fractures.,1
COMPARISON: Pelvic radiographs performed and .,0
Additional comparison is made to outside hospital CT.,0
TECHNIQUE: Non-contrast MDCT imaging of the pelvis was performed.,0
"Coronal, sagittal, and axial reconstructions were reviewed in bone and soft tissue algorithm.",0
"FINDINGS: A catheter decompresses the bladder, which contains a small amount of previously administered excreted contrast.",0
There is a moderate amount of hyperdense hemorrhage within the left pelvis tracking into the left inguinal region and retroperitoneum.,0
The bladder and rectum are displaced to the right.,0
"Additional hemorrhage is seen within the peritoneal cavity in the right lower quadrant, anterior and inferior to the cecum (3:32).",0
The underlying bowel appears normal.,0
"Thickening of the left rectus abdominal muscle suggest additional rectus sheath hematoma, and there is also thickening and expansion of the obturator and adductor muscles.",0
There is evidence of prior vasectomy and right inguinal hernia repair.,0
A small fat-containing left inguinal hernia is noted.,0
"There is a non-displaced fracture through the right sacral ala, extending to the neural foramen, as well as the inferior aspect of which enters the posterior inferior aspect of the SI joint.",0
"The SI joints are otherwise preserved, with no widening or other evidence of disruption.",0
"The pubic symphysis is diastatic, with widening to 1 cm, and superior displacement of the left symphysis by 1 cm relative to the right.",0
"Additionally, there is a comminuted fracture involving the left acetabulum.",1
"On volume rendered reconstructions, this seems predominantly T-shaped in configuration, though in addition to involvement of the posterior and anterior acetabular walls, there is disruption of the ilioischial line, consistent with posterior column fracture.",1
An additional fracture line is seen extending through the medial acetabular wall inferiorly to the ischial tuberosity.,0
"Articulation of the femoral head with relation to the acetabulum remains preserved, without evidence of dislocation.",0
There is no proximal femur fracture.,0
IMPRESSION: (Over) 8:51 AM CT PELVIS ORTHO W/O CONTRAST W/3D Clip # Reason: pelvic fx Admitting Diagnosis: MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
Nondisplaced comminuted right sacral fracture with extension to the neural foramen and SI joint.,0
"Comminuted fracture of the left acetabulum involving the anterior wall, posterior wall, medial wall, and posterior column, as detailed above.",1
Diastasis of the symphysis pubis.,0
Moderate hyperdense intrapelvic and intramuscular hemorrhage with rightward displacement of the rectum and bladder.,1
2:37 PM CHEST (PORTABLE AP) Clip # Reason: Assess PA cath line placement ______________________________________________________________________________ MEDICAL CONDITION: 79 yo M with enterocutaneous fistula REASON FOR THIS EXAMINATION: Assess PA cath line placement ______________________________________________________________________________ FINAL REPORT CHEST AP: INDICATION: Assess position of Swan-Ganz catheter.,0
"FINDINGS: The position of the ETT, left sided central line, NG tube are unchanged since prior examination.",0
The tip of the Swan-Ganz catheter is in the distal right main pulmonary artery.,0
The appearances of the lungs are unchanged since the prior examination with extensive opacification of the right mid and lower zones.,0
IMPRESSION: Swan-Ganz catheter in right pulmonary artery.,0
11:32 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: evaluate for pneumothorax Admitting Diagnosis: LUNG CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with chest tube desat to 82 REASON FOR THIS EXAMINATION: evaluate for pneumothorax ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumothorax.,0
"FINDINGS: In comparison with the earlier study of this date, the right lung appears to be reexpanded.",0
The extensive subcutaneous air with extension about the pectoral muscles and into the neck makes it very difficult to properly assess the right lung.,0
Increased opacification persists at the base.,0
Continued hyperexpansion of the left lung without definite pneumonia.,0
"3:44 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with renal failure, shock, hypothermia.",1
"REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 12:11 PM New multiple lung opacities could represent areas of pneumonia, but hemorrhage related to vasculitis can also be a possibility given patient's history of renal failure.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 65-year-old female with renal failure, shock, hypothermia.",1
COMPARISON: Prior chest radiograph from .,0
PORTABLE AP CHEST RADIOGRAPH: New discrete opacities in the right mid and lower lungs and in the left retrocardiac regions that could represent areas of pneumonia but hemorrhage due to vasculitis can also be a differential diagnosis due to patient's history of renal failure.,0
The decrease in the widening of the superior mediastinum is probably due to decrease in venous volume.,0
Reduction in the caliber of the vessels in upper lobes as well as decrease in size of the hilum suggests improvement of the pulmonary edema.,0
Persistent mild (may be slightly decreased) cardiomegaly.,0
"IMPRESSION: New discrete multiple lung opacities could be due to pneumonia, but hemorrhage related to vasculitis can also be considered due to patient's history of renal failure.",0
"Findings were communicated over the phone to Dr. at 11:15 a.m. on , by Dr. .",0
12:29 PM TRAUMA #3 (PORT CHEST ONLY); CHEST (PORTABLE AP) Clip # Reason: interval change ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH PERFORMED ON .,0
Comparison is made with an outside hospital CT torso from earlier the same day.,0
"CLINICAL HISTORY: 32-year-old man status post MVA rollover, evaluate position of tubes.",0
FINDINGS: AP supine portable view of the chest is obtained.,0
Underlying trauma board limits the evaluation.,0
"An NG tube is seen coursing into the left upper quadrant, tip excluded from view.",0
The ET tube is not clearly seen.,0
The lungs appear grossly clear bilaterally.,0
Cardiomediastinal silhouette is grossly unremarkable.,0
IMPRESSION: NG tube appears in good position.,0
ET tube is not clearly seen.,0
Please refer to CT torso for additional details.,0
2:37 PM PICC LINE PLACMENT SCH Clip # Reason: i am requesting a PICC line under fluoro.,0
"pt evaluated by PI ********************************* CPT Codes ******************************** * CVL/PICC UD GUID FOR NEEDLE PLACMENT * * CHEST AP ONLY * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with mult medical problems including CAD, type I DM, s/p renal transplant, sepsis, cellulitis of RLE REASON FOR THIS EXAMINATION: i am requesting a PICC line under fluoro.",1
"pt evaluated by PICC nurse, felt not candidate for them due to poor access.",0
pt currently with subclavian line from which we want to pull.,0
pt needs long term IV abx (2 weeks) for cellulitis.,0
______________________________________________________________________________ FINAL REPORT HISTORY/INDICATION: Patient with multiple medical problems and sepsis.,0
Needs PICC line for antibiotics.,0
RADIOLOGIST: Attending radiologist: Dr. .,0
Interventional radiology fellow: Dr. .,0
TECHNIQUE: Informed consent was obtained prior to the procedure.,0
Dr. was present for the entire procedure.,0
The left upper extremity was sterilely prepped and draped.,0
"As no superficial veins were visible, ultrasound was used to localized the left basilic vein, which was found to be patent.",0
"After local anesthesia with 1% Lidocaine, a 21 gauge needle was used to access the vein under son guidance.",0
"Under fluoroscopic guidance, .018 guidewire was advanced into the superior vena cava.",0
"Over the wire, a 5 FR sheath and dilator system were placed.",0
The PICC line was cut to length and placed over the wire for that its tip was in the superior vena cava.,0
MEDICATIONS: Local anesthesia with 1% Lidocaine.,0
COMPLICATIONS: No complications were evident.,0
FINDINGS: Son of the left upper extremity demonstrated a patent and compressible basilic vein.,0
Post-procedure radiograph demonstrates the tip of the PICC line to be in the superior vena cava.,0
"Successful placement of 49 cm, 5 FR dual lumen PICC line via the left basilic vein into the superior vena cava.",0
(Over) 2:37 PM PICC LINE PLACMENT SCH Clip # Reason: i am requesting a PICC line under fluoro.,0
pt evaluated by PI ______________________________________________________________________________ FINAL REPORT (Cont),0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Hytrin / niaspan Attending: Chief Complaint: Fatigue Major Surgical or Invasive Procedure: CABG x 4(LIMA-LAD; SVG to diag; SVG to OM; SVG to RCA) History of Present Illness: This is a 53 year old male with known coronary artery disease.,1
Cardiac catheterization dating back to showed total occlusion of right coronary and left anterior descending arteries.,1
"Currently, he remains relatively asymptomatic and has a decent functional status.",0
"He performs routine ADLs without difficulty, and remains very active.",0
"He denies history of chest pain, dyspnea, orthopnea, PND, pedal edema and syncope.",0
Recent SPECT showed viable myocardium with normal LV function.,0
He is now referred for surgical revascularization but has yet to undergo repeat cardiac catheterization.,0
"Past Medical History: - Coronary Artery Disease - Hypertension - Dyslipidemia - Diabetes Mellitus Type II - Fatty Liver - History of Pyelonephritis - GE reflux disease Social History: SOCIAL HISTORY : Lives with: Wife in Occupation: Glass Industry Cigarettes: Denies Other Tobacco use: Quit cigars over 6 yrs ago, smoked a cigar a day for 25 yrs ETOH: Quit , previously drinks/week Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.",1
Physical Exam: Pulse: 100 Resp: 16 O2 sat: 98% room air B/P Right: 180/104 Left: 147/100 General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none.,0
"Normal s1s2 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], small ventral hernia noted Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left: 2 DP Right: 2 Left: 2 PT : 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit: None bilaterally Pertinent Results: Imaging Cardiac Cath : 1.",0
Selective coronary angiography of this right dominant system demonstrated two vessel and left main coronary artery disease.,1
The LMCA had an 80% distal stenosis.,0
The LAD had a total occlusion at the mid-vessel.,1
The LCx is a large vessel without angiographically apparent flow-limiting stenosis.,0
Limited resting hemodynamics revealed systemic arterial normotension with a central aortic pressure of 105/67 mmHg.,0
Left-sided filling pressures are mildly elevated with LVEDP of 15mmHg.,0
Two vessel and left main coronary artery disease.,1
"Cardiac surgery evaluation, email sent and Dr. is aware.",0
Carotid Series : Findings: Duplex evaluation was performed of bilateral carotid arteries.,0
On the right there is no plaque seen in the ICA .,0
On the left there is mild heterogeneous plaque seen in the ICA.,0
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 65/21, 68/24, 76/29, cm/sec.",0
CCA peak systolic velocity is 106 cm/sec.,0
ECA peak systolic velocity is 148 cm/sec.,0
The ICA/CCA ratio is .71 These findings are consistent with no stenosis.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 65/26, 77/35, 54/24, cm/sec.",0
CCA peak systolic velocity is 109 cm/sec.,0
The ICA/CCA ratio is .70.,0
These findings are consistent <40% stenosis.,0
Impression: Right ICA no stenosis.,0
"CXR : FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax.",0
There are no acute skeletal abnormalities.,0
Intra-op TEE Conclusions PRE-CPB: The left atrium is moderately dilated.,0
04:51AM BLOOD WBC-9.2 RBC-3.48* Hgb-9.8* Hct-30.8* MCV-88 MCH-28.1 MCHC-31.7 RDW-13.5 Plt Ct-320# 07:00AM BLOOD WBC-10.9 RBC-3.59* Hgb-10.2* Hct-31.7* MCV-88 MCH-28.4 MCHC-32.1 RDW-13.6 Plt Ct-202 04:51AM BLOOD UreaN-16 Creat-0.7 Na-136 K-4.5 Cl-97 06:55AM BLOOD Glucose-145* UreaN-12 Creat-0.7 Na-138 K-4.1 Cl-99 HCO3-30 AnGap-13 Brief Hospital Course: The patient was brought to the Operating Room on where the patient underwent CABG x 4 LIMA-LAD; SVG to diag; SVG to OM; SVG to RCA) with Dr. .,0
See operative note for full details.,0
"The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support.",0
Chest tubes and pacing wires were discontinued.,0
He did develop a tiny left apical pneumothorax which remained stable on CXR.,0
He did have some minimal erythema surrounding left knee saphenectomy site without associated pain or drainage.,0
He was afebrile and WBC count was normal at the time of discharge.,0
"He was instructed to call with any increasing erythema, pain, drainage or temperature >100.4.",0
The patient was discharged home in good condition with appropriate follow up instructions.,0
Disp:*qs Gum(s)* Refills:*0* 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"5. aspirin 81 mg Tablet, Delayed Release (E.C.)",0
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
7. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily ().,0
"8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever.",0
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
Disp:*60 Tablet(s)* Refills:*0* 10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day).,0
Disp:*135 Tablet(s)* Refills:*2* 11. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day.,0
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days.,0
Disp:*7 Tablet(s)* Refills:*0* 13. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 7 days.,0
"Disp:*7 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater Discharge Diagnosis: Coronary Artery Disease, Hypertension, Dyslipidemia, Diabetes Mellitus Type II, Fatty Liver, History of Pyelonephritis, GE reflux disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage.",1
"Edema 1+ Bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon.",0
"Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. Date/Time: 1:00pm in the Medical office building, WOUND CARE NURSE Phone: Date/Time: 10:00 Medical office building, Cardiologist: Dr. 11:15a Please call to schedule appointments with your Primary Care Dr. in weeks **Please call cardiac surgery office with any questions or concerns .",0
Answering service will contact on call person during off hours** Completed by:,0
"12:11 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: r/o anastomotic disruption Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with abd pain, intractable vomiting, diarrhea, h/o fever.",0
recently had bowel perf and colostomy.,0
"REASON FOR THIS EXAMINATION: r/o anastomotic disruption ______________________________________________________________________________ FINAL REPORT INDICATION: 74 year old woman with ovarian cancer status post recent surgery, abdominal pain vomiting and diarrhea.",0
There are no prior CT examinations available for comparison.,0
TECHNIQUE: Contiguous axial imaging was performed from the lung bases through the pubic symphysis following the administration of intravenous contrast.,0
CT ABDOMEN WITH CONTRAST: There is minimal bibasilar atelectasis with a trace left pleural effusion.,0
The liver contains a tiny low attenuation lesion in the lateral segment of the left lobe.,0
There is no ductal dilatation.,0
"The pancreas, spleen, adrenals and kidneys are all within normal limits.",0
There is a large subhepatic fluid collection measuring approximately 7.8 x 3.4 cm with an attenuation of 22 .,0
"A smaller 3 x 2 cm adjacent collection is also seen, near the right sided ostomy.",0
"A small rounded fluid containing structure is seen adjacent to the posterior tip of the right hepatic lobe, with an adjacent coarse calcification.",0
"Trace fluid is also noted anteriorly, near the midline ostomy.",0
There are no dilated bowel loops to suggest obstruction.,0
Extensive vascular calcifications are noted.,0
Numerous sub cm retroperitoneal lymph nodes are present.,0
Degenerative changes are seen in the spine.,0
CT PELVIS WITH CONTRAST: There is a 6.5 x 5.8 cm cystic structure in the soft tissues adjacent to the anus on the left.,0
Numerous sigmoid diverticuli are seen with no evidence of diverticulitis.,0
There is no significant free fluid in the pelvis.,0
IMPRESSION: Multiple fluid collections/cystic structures in the abdomen and pelvis.,0
"The subhepatic collection, which was near the site of recent intervention, is suspicious for abscess with a slightly thickened, enhancing wall.",0
"The rounded cystic structure near the posterior aspect of the liver could represent a second abscess, though a cystic metastasis containing a coarse calcification from the patient's known ovarian cancer is also a possibility.",1
The cystic structure in the soft tissues of the right buttock is also suggestive of a cystic metastasis and would be in a somewhat unusual position for an abscess.,0
Comparison with prior outside films is recommended to determine whether the above findings were present prior to the recent surgery.,0
(Over) 12:11 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST Reason: r/o anastomotic disruption Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont),0
Height: (in) 65 Weight (lb): 150 BSA (m2): 1.75 m2 BP (mm Hg): 167/90 HR (bpm): 84 Status: Inpatient Date/Time: at 10:15 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Abnormal diastolic septal motion/position consistent with RV volume overload.,0
Moderate (2+) MR. TRICUSPID VALVE: Severe [4+] TR.,1
The inferior vena cava is dilated.,0
There is abnormal diastolic septal motion/position (D-shaped) consistent with right ventricular volume overload.,0
"The tricuspid valve leaflets are opened, thickened and fixed in position.",1
No clear sign of tamponade seen.,0
Conclusion: These finding are consistent with carcinoid syndrome.,0
"5:18 PM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: evaluate for retropharyngeal mass, swelling Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man intubated, continued subglottic swelling REASON FOR THIS EXAMINATION: evaluate for retropharyngeal mass, swelling CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ FINAL REPORT INDICATION: 78-year-old man status post intubation, has continued subglottic swelling, to evaluate for retropharyngeal mass or swelling.",1
COMPARISON: CT neck without contrast .,0
TECHNIQUE: MDCT images were acquired through the neck without intravenous contrast.,0
Intravenous contrast was deferred due to the patient's elevated creatinine.,0
Nasointestinal tube is in place.,0
"The nasopharynx, oropharynx, and hypopharynx appear unremarkable.",0
"The vocal cords are adducted, and there is narrowing of the subglottic airway, the latter likely due to inflammation.",1
There is no evidence of a retropharyngeal mass or abscess.,0
"A 1.7 cm lesion, mass or node, in the superficial lobe of the left parotid gland, is not characterized in this study.",0
The imaged portion of the brain is unremarkable.,0
Small scattered cervical lymph nodes do not meet CT criteria for significant adenopathy.,0
"Dense atherosclerotic calcification is seen in both carotid bifurcations, right greater than left.",0
The thyroid gland is normal.,0
The imaged lung apices are unremarkable.,0
Central venous catheter is partially imaged.,0
Mild atherosclerotic calcification is seen in the thoracic aorta.,0
Near complete opacification of bilateral underdeveloped mastoid air cells is seen.,0
No evidence of retropharyngeal mass or abscess.,0
"A 1.7 cm nodule in the left parotid gland, is not completely characterized in this study.",0
"Mild subglottic narrowing, without evidence of focal mass in this limited non-contrast CT.",0
"4:03 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval R ptx Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with R ptx, CT to suction REASON FOR THIS EXAMINATION: eval R ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Right-sided pneumothorax, chest tube inserted with flexion, evaluate residual right pneumothorax.",1
"FINDINGS: A medial right pneumothorax is moderate in volumes, the apical component, however, has improved significantly.",0
The right-sided chest drain tip is projected over the right apex with the side holes projected over the right mid lung.,0
The right subclavian central venous catheter tip is in satisfactory position with the expected location at the lower SVC.,1
Heterogenous opacity in both lungs most likely represents edema but could also represent multifocal consolidation or aspiration.,0
The endotracheal and nasogastric tubes are in satisfactory position.,0
Extensive subcutaneous emphysema is unchanged since .,1
"Extensive pulmonary edema, with relative stability since .",0
Satisfactory position of medical devices.,0
"4:29 PM CHEST (PORTABLE AP) Clip # Reason: Does this pt have CHF Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 72 yo man sp/p TIPS, with SOB REASON FOR THIS EXAMINATION: Does this pt have CHF ______________________________________________________________________________ FINAL REPORT INDICATIONS: 72 y/o male status post TIPS.",0
FINDINGS: There is interval placement of a right IJ central line with the tip in the cavo-atrial junction.,0
The patient is status post mediansternotomy and CABG.,0
"The cardiac, mediastinal and hilar contours are stable in appearance.",0
There is persitent upper zone redistribution of the pulmonary artery vasculature indicating mild CHF which is unchanged when compared to the previous study.,0
There may have been slight decrease in the size of the right pleural effusion.,0
There is again noted right humeral prosthesis.,0
Interval possible decrease in the right pleural effusion.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Headache Major Surgical or Invasive Procedure: none History of Present Illness: Mr. is a 59-year-old right man with a history of prior right temporal intracerebral hemorrhage who presented with headache and was found to have a recurrent right temporal ICH.,1
He first noticed a mild headache over the right temporal region on Tuesday evening (2 days pta).,0
This worsened over the course of Wednesday.,0
"By Thursday (today), it was a constant, sharp pain.",0
"As he never gets headaches (the last being with his prior ICH 10 years ago), he grew nervous and called his PCP, was similarly concerned.",0
"His PCP referred him to , where a head CT showed a recurrent right ICH.",0
"Also at , he received 2 units FFP and 5 mg IV Vit K for an INR of 2.9.",0
He received 20 mg IV labetalol for elevated SBP (> 200).,0
He was transferred to for further evaluation and management.,0
"In the ED, he was given 20 mg IV labetalol x2 for BPs sustained in the 180s, as well as an additional 1 unit of FFP and 5 mg IV Vitamin K for an INR of 1.9.",0
He has no complaint other than headache.,0
"Specifically, on neuro ROS, he denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty.",0
Denies difficulties producing or comprehending speech.,0
"Denies focal weakness, numbness, parasthesiae.",0
No bowel or bladder incontinence or retention.,0
"On general review of systems, he reports brief lightheadedness on standing one time last night.",0
He denies recent fever or chills.,0
"Past Medical History: - Intraparenchymal hemorrhage, right temporal lobe, ; presented with left-sided weakness and garbled speech; s/p evacuation at ; no residual symptoms.",0
"- Atrial fibrillation, on Coumadin - h/o seizures following hemorrhage, GTC, last .",1
"- s/p biomechanical AVR and MVR, - h/o rheumatic fever - Cardiomegaly Social History: Quit smoking 10 years ago.",0
Drinks 1 glass of port per day.,0
Lives with wife in .,0
Works as an Assistant at -.,0
Family History: Father died at 84 of lung cancer.,0
"Mother died at 78 with a ""multitude of health problems.""",0
"Physical Exam: Vitals: T: 97.9 P: 85 a fib R: 16 BP: 186/85 SaO2: 100% 3L General: Awake, cooperative, NAD.",0
"No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: Irregular, HSM Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted.",0
"Attentive, able to name backward without difficulty.",0
Language is fluent with intact repetition and comprehension.,0
There were no paraphasic errors.,0
was able to name both high and low frequency objects.,0
Able to read without difficulty.,0
Able to follow both midline and appendicular commands.,0
was able to register 3 objects and recall at 5 minutes.,0
There was no evidence of apraxia or neglect.,0
II: PERRL 5 to 2mm and brisk.,0
"Funduscopic exam revealed no papilledema, exudates, or hemorrhages.",0
"Delt Bic Tri WrE FFl FE IO IP Quad Ham TA EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout.",0
-DTRs: Tri Pat Ach L 2 2 2 4 1 R 3 2 2 4 1 Plantar response was mute bilaterally.,0
"Narrow-based, normal stride and arm swing.",0
Able to walk in tandem without difficulty.,0
This patient has metal prosthetic heart valves and requires ongoing anticoagulation with coumadin.,1
"In the short-term this was held, and his blood pressures were mananged.",0
"The patient was initially started on hydralazine in addition to his usual BP meds at a dose of 10 mg PO Q6hrs, however this was titrated up to 25 mg PO Q6hrs after pt sustained episodes of further hypertension, in one case as high as 210 systolic.",0
"An echocardiogram showed globally depressed LV function with an EF of 25-30%, without any mass, thrombus, or vegetations seen.",0
"Because the pt occsassionally became bradycardic to the 40's with a question of heart block, pt's digoxin was DC'd.",0
"Blood lipids returned at Chol = 183, TG = 117 HDL = 43, LDL = 117.",0
"On the day of discharge, , pt was aymptomatic with a normal neurological exam and blood pressures ranging in the 130-160 systolic range.",0
Pt was told to follow up with his PMD for coumadin dose management 2 days after discharge and with neurology 4-6 weeks after discharge.,0
Medications on Admission: Coumadin 2.5 mg 5x/wk (M-F) and 5 mg Sat and Sun Lopressor 150 qam/100mg qhs Keppra 500 mg po bid Accupril 12.5 mg po qhs Digoxin 0.125 mg po daily MVI Beoptic eye drops 1 drop OS qhs Discharge Medications: 1.,0
Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO QAM.,0
Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)).,0
Quinapril 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).,0
Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Mon-Fri. 7.,0
Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO QHS: Sat-Sun.,0
Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: right temporal intracerebral hemorrhage.,1
"Discharge Condition: stable Discharge Instructions: You have had a right temporal intracerebral hemorrhage, likely due to amyloid angiopathy.",1
"Because of your prosthetic heart valves, you require ongoing anticoagulation with coumadin, even though this could potentially worsen bleeding in the brain.",1
"However, we feel the overall risk/benefit ratio favors ongoing coagulation.",0
"Please return to the ER if you experience any sudden severe headaches, vertigo, double vision, weakness, change in sensation, or change in speech, or anything else that concerns you seriously.",0
"Followup Instructions: PCP: , in 2 days for INR management.",0
"Neurological follow-up with Dr. in weeks: MD, Completed by:",0
"PATIENT/TEST INFORMATION: Indication: History of MRSA bacteremia, cardiomyopathy, ICD placement, recurrent bacteremia.",0
Endocarditis Height: (in) 57 Weight (lb): 166 BSA (m2): 1.66 m2 BP (mm Hg): 131/80 HR (bpm): 80 Status: Inpatient Date/Time: at 16:43 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA.,0
PULMONIC VALVE/PULMONARY ARTERY: No vegetation/mass on pulmonic valve.,0
"Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium, left atrial appendage, or right atrium.",0
There are pacer wires in the right atrium and right ventricle which are also free of masses or vegetations.,0
"No masses or vegetations are seen on the mitral, aortic valve, or tricuspid valve.",0
There is a non-mobile echodense structure attached to the pulmonary artery which is c/w artifact.,0
10:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please assess for changes in infiltrates Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with respiratory distress REASON FOR THIS EXAMINATION: Please assess for changes in infiltrates ______________________________________________________________________________ FINAL REPORT HISTORY: Dyspnea.,1
"A single portable radiograph of the chest again demonstrates patchy opacities involving both lungs, similar to that seen on the chest radiograph obtained seven hours prior.",0
The support lines are unchanged.,0
The cardiomediastinal contours are similar in appearance.,0
Right-sided effusion and left costophrenic angle blunting are unchanged.,0
"3:43 PM CHEST (PORTABLE AP) Clip # Reason: ptx, pelvic fx ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with mvc REASON FOR THIS EXAMINATION: ptx, pelvic fx ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON .",0
COMPARISON: Chest CT from outside hospital from earlier same day.,0
FINDINGS: Portable supine chest radiograph is obtained.,0
A right-sided chest tube is in place.,0
Evaluation of the lungs is limited due to low lung volumes.,0
Atelectatic changes are noted in the right lung.,0
The left lung appears well aerated.,0
No definite pneumothorax is seen in this patient who had a small right pneumothorax which was evident on prior chest CT scan.,1
"Additionally, the patient's known rib fractures are not visualized on this study.",0
IMPRESSION: Limited study demonstrating atelectatic changes in the right lung.,0
Please correlate with chest CT from outside hospital which is available for reference on the PACS server.,0
"2:02 PM CT CHEST W/O CONTRAST Clip # Reason: size of hemothorax, r/ pneumonia or any fluid collections Admitting Diagnosis: S/P PEDESTRIAN STRUCK ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man with pm hx of MVA with L fem neck, Ltib fib fx, liver lac, with with hemothorax difficulty weaning from vent REASON FOR THIS EXAMINATION: size of hemothorax, r/ pneumonia or any fluid collections No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Motor vehicle collision with multiple fractures and liver laceration with difficulty weaning from intubation, evaluate left hemothorax.",1
TECHNIQUE: Multiple axial images of the chest were obtained without IV contrast.,0
CT CHEST WITHOUT IV CONTRAST: There is a small patchy opacity in the lingula.,0
A pneumonic consolidation is a consideration.,0
"In the dependent portion of the left upper lobe, there is ground-glass opacification as well.",0
"There is complete collapse of the right lower lobe, with a moderate sized pleural effusion.",0
The air bronchogram seen through the collapsed right middle lobe.,0
"However, in addition, there are large approximately 2 cm foci of air, and this could represent an air-fluid level with dense dependent material.",0
"Lack of IV contrast makes characterization of this finding difficult, in the setting of trauma this could reflect blood products.",0
There is a right-sided chest tube terminating medially in the right upper lobe.,0
There is a small amount of low attenuation fluid surrounding the tip of this tube near the apex.,0
"In the right middle lobe, there is a 2.5 x 2.8 cm lesion with an air-fluid level.",0
The dependent portion has higher attenuation material likely reflecting hemorrhagic products.,0
There is collapse of segments of the right middle lobe as well.,0
There is a right scapular fracture as well as multiple comminuted fractures of ribs of the right fourth through eigth ribs.,0
There is an NG tube seen coursing with its tip entering the stomach.,0
Few images through the abdomen demonstrate an IVC filter.,0
"Within segment 6 and 7 of the liver, there is a low attenuation lesion, likely representing the patient's known liver laceration in this region corresponding to the prior contrast study images of .",1
There is a small amount of fluid inferior to the liver on the right.,0
The previously seen right sided subcutaneous emphysema has resolved.,0
"Multiple lesions with air-fluid levels in the right middle and right lower lobe, with dependent fluid levels demonstrating higher attenuation.",0
"This (Over) 2:02 PM CT CHEST W/O CONTRAST Clip # Reason: size of hemothorax, r/ pneumonia or any fluid collections Admitting Diagnosis: S/P PEDESTRIAN STRUCK ______________________________________________________________________________ FINAL REPORT (Cont) could represent blood products.",1
"Right lower lobe collapse, with moderate-sized pleural effusion.",0
Partial collapse of the right middle lobe.,0
Multiple left-sided rib fractures and left scapular fractures.,0
"Continued opacity at left lower lobe, likely aspiration, unchanged.",0
2:05 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: assesss for cva Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\AORTIC VALVE REPLACEMENT; REPAIR ASCENDING AORTIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman s/p AVR/Asc Ao Hemiarch repair w/potop neuro changes REASON FOR THIS EXAMINATION: assesss for cva ______________________________________________________________________________ FINAL REPORT INDICATION: Status post AVR/ascending aortic hemiarch repair.,1
TECHNIQUE: MRI and MRA of the brain.,0
"T1, T2, diffusion-weighted, susceptibility weighted images were performed.",0
COMPARISONS: No prior studies are available on PACS for comparison purposes.,0
FINDINGS: There are multiple foci of restricted diffusion.,0
There are two foci of restricted diffusion in the left hemisphere of the cerebellum and one in the left caudate nucleus and cortical diffusion abnormalities in the left parietal lobe.,0
There also are two punctate areas of restricted diffusion in the right parietal lobe and in the right cerebellar hemisphere.,0
"There are two punctate areas of susceptibility artifact in the region of the left parietal perfusion abnormalities, consistent with small areas of hemorrhage within areas of ischemia.",0
The only area that shows abnormal increased T2 signal is the area matching with the restricted diffusion in the left cerebellum.,0
3D time-of-flight images show a complete circle of without apparent perfusion deficits.,0
IMPRESSION: Multiple foci of abnormal diffusion as described.,0
These are consistent with areas of acute ischemia after embolic events due to the recent surgery of the region of the aortic valve and arch.,1
"There are two punctate areas of hemorrhage within the left parietal area of ischemia, consistent with a small hemorrhagic component.",0
Findings have been discussed with Dr. at approximately 11:30 a.m. on .,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Amoxicillin Attending: Chief Complaint: Low Hct Major Surgical or Invasive Procedure: None History of Present Illness: yo M with Hx of Autoimmune hemolytic anemia and GI bleeds, CAD, CKD, Mechanical Aortic valve on coumadin with recent admission to for anemia felt to be secondary to GI bleed (), who was sent to the ED from Rehab for persistently low Hct.",1
"Per the patient, he has been in his usual state of health and has not experienced any dizziness, syncope, CP, SOB or other symptoms in the last several days, but has felt generally tired.",0
"His NH has been closely monitoring his Hct, which has been low but stable for the past several days.",0
"He received 2 units prbcs at rehab on for Hct 22, and did not have an adequate response (Hct was 23.8 and was 22.3 with INR 2.2).",0
"Patient was also reportedly noted to have a small amount of BRBPR yesterday, but he states he never saw the blood.",0
"Of note, the patient has had extensive workup in the past for GI bleed(EGD x4, x2, capsule x3, CT abd/pelvis, bleeding scan) without clear source or site, and felt to be most likely bleeding from an UGI source that is not possible to reach endoscopically.",0
"On prior admissions, further invasive testing was discussed, and the patient and HCP opted for more conservative measures including transfusions and iron supplementation.",0
"In the ED, initial vs were: 97.0 86 95/51 14 97% RA, pain 0/10.",0
"Labs were significant for Hct 20.5 (down from 22.3 at NH), INR 3.0.",0
He was found to have black guaiac positive stool.,0
No NG lavage was performed given patient's stability and multiple prior similar presentations.,0
Patient was given a protonix bolus and started on a drip.,0
He was typed and crossed 2 units but did not receive any blood prior to transfer.,0
He was admitted to the ICU for further management.,0
"On the floor, patient reports feeling generally tired and thirstly, but otherwise well.",0
"Specifically denies dizziness, chest pain, SOB, palpitations or other symptoms currently.",0
"Review of systems: (+) Per HPI, also reports several days of burning with urination.",0
Incontinent of urine and stool at baseline.,0
"Also reports left arm pain when his arm ""gets cold,"" which is responsive to tylenol and has been present for several weeks.",0
Does not walk or move much at baseline.,0
"(-) Denies fever, chills, night sweats, recent weight loss or gain.",0
"Past Medical History: # Anemia, multifactorial as below, baseline HCT 28 # Autoimmune hemolytic anemia (Coomb's +, warm autoantibody), on prednisone 10mg Po daily # Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped due to hemolytic anemia # Aortic mechanical valve, recently Coumadin resistant so intermittently on Lovenox bridge, followed by Dr. # hx recent GI bleeds: colonoscopy : noted normal colon with melanotic stool in terminal ileum # GERD: EGD Polyp in the area of the papilla; found on the wall opposite the ampulla.",1
"# H/o presyncope # CKD Cr 1.6-2.0 Stage III # CAD s/p NSTEMI # Chronic CHF, likely diastolic, ( EF=50%) # Hyperlipidemia # Hypertension # Depression vs adjustment disorder after death of brother # Prostate cancer- s/p radiation # Bladder/bowel incontinence # Right lateral malleolus stage 1 pressure ulcer # Dementia Social History: Never smoked, no EtOH or other drugs.",1
Requires a significant degree of assistance in all his ADLs and IADLs.,0
Has 2 sons and 4 grandchildren.,0
Family History: No bleeding diatheses.,0
No other cancers including colon.,0
"URINE CULTURE (Preliminary): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION.",0
CARDIAC ECHO : Poor image quality.,0
Overall left ventricular systolic function is probably mildly depressed (LVEF= 45 %) with a suggesiton of more prominent inferior hypokinesis (difficult to assess due to poor image quality).,0
"Compared with the prior study (images reviewed) of , no definite change.",0
"Electronically signed by , MD, Interpreting physician 16:28 PORTABLE CHEST, CLINICAL INFORMATION: Falling hematocrit, question change.",0
FINDINGS: Frontal view of the chest compared to multiple prior examinations.,0
PICC on the right is unchanged.,0
Small left-sided pleural effusion with left lower lobe atelectasis unchanged.,0
"Brief Hospital Course: M with autoimmune hemolytic anemia, mechanical aortic valve on coumadin and recurrent GIB, who presents with low HCT and guaiac positive stool.",1
"Anemia: Most likely multifactorial, and mostly from recurrent ongoing GIB.",1
Hemolysis not thought to be a significant factor given the Coombs test was negative and he had a normal LDH.,0
"He had dark guaiac pos stools, but has had work up in past including colonoscopy and capsule endoscopy without finding source of bleed.",0
"GI was consulted and felt as though, while he is anticoagulated, there is nothing to do.",0
If his anticoagulation could be stopped they would recommend monitoring his HCT over a few months time to evaluate stability.,0
His HCT was 20.7 on admission and he received 2 units PRBCs in the ED and his HCT had an appropriate bump to 25 and remained stable at 25 thereafter.,0
Hematology recommended transfusing to >30 and so he received one more unit on the medical floor.,0
CBC should be monitored periodically as well as stool output for recurrent bleeding.,0
"GI team was aware of him, but since prior EGD/Colonoscopy has failed to reveal a source, decided conservative treatment was the best.",0
"In the past, blood has been noted in the terminal ileum so a small bowel lesion is suspected.",0
"Capsule studies have not revealed a source, though was incomplete (in ).",0
Patient on brdiging IV Hep/Warfarin.,0
# Mechanical Aortic valve: The patient has a goal INR of (ideally 2.5).,0
Heme/onc wanted to consider stopping anticoagulation as pt frequently in hospital.,0
"Cardiology felt the risk was not well definable and not worth it, so he was continued on anticoagulation.",0
His INR was reveresed in the ICU with Vit K and he was restarted on IV heparin drip (wt based protocol without bolus) to bridge until therapeutic INR on warfarin.,0
"Per cardiology, the hep gtt should not be stopped until the INR level is therapeutic at around 2.2.",0
He is discharged to Rehab where this can be followed appropriately.,0
A TTE was updated and showed no change from prior (see report in results section).,0
# UTI: The patient complained of dysuria on admission and he had a positive U/A.,0
He was started on cipro 500mg Q12H with plans for a 7 day course.,0
"He had questionable delerium after ICU stay, and so Cipro was changed to Ceftriaxone.",0
"Urine culture is growing >100K organisms with a predominant GNR, not yet speciated with sensitivities.",0
This needs to be followed by Rehab by calling Micro Lab for results.,0
"# Delerium vs. Hospital Psychosis: When out of ICU on medical floor, he had vivid hallucinations of being visited by Chinese Immigration, and then by 2 men from the mafia who were after his patents.",0
"He was otherwise not inattentive as usually seen with acute delierum, and his psychosis was not agitated.",0
He received one nightime dose of Haldol 0.25mg on and slept very well without PM or AM recurrent hallucinations (though patient has good recollection of the hallucinations).,0
This should be followed by his medical team and geriatrician at Rehab.,0
# Autoimmune Hemolytic Anemia: Chronic - is on Prednisone for this.,1
"At the time this diagnosis was originally made, the patient was on Amoxicillin, so there was some concern at that time that Penicillin associated drug hemolyis was possible.",0
"While very unlikely, since he is on Ceftriaxone, hematolgoy team recommends checking LDH periodically while he is taking this drug.",0
# CKD: On admission his creatinine was at his baseline (1.2-1.5).,0
Medications were renally dosed as needed.,0
Creatinine varied 1.0 to 1.4 during hosptialization.,0
# GERD: Initially he was treated with PPI IV BID and subsequently transitioned to PO.,0
Held carvedilol in setting of GIB and stable blood pressures.,0
CODE: FULL HCP: () Phone number: Cell phone: Medications on Admission: -oxycodone 2.5 mg TID prn -warfarin 3 mg daily -tylenol 650 mg q6h prn -Vitamin B12 mcg daily -folic acid 4 mg po daily -omeprazole 40 mg -simvastatin 40 mg daily -carvedilol 3.125 -Bactrim SS daily (400-80) -clindamycin 600 mg prn po -levothyroxine 75 mcg daily -senna daily -prednisone 10 mg daily -acetaminophen 1000 mg Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain.,0
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily).,0
3. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).,0
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): give 1 hour prior to meals and PPI in the morning.,0
10. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM.,0
11. heparin (porcine) in NS 10 unit/mL Kit Sig: wt based units Intravenous continuous: until therapeutic INR 2.2.,0
"12. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
"13. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) as needed for UTI for 6 days.",0
Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Acute blood loss Anemia GI Hemorrhage MEchanical Heart Valve Delerium vs. Hospital psychosis Chronic Systolic Heart Failure Autoimmune Hemolytic Anemia (chronic) Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Weigh yourself every morning, MD if weight goes up more than 3 lbs.",0
You were admitted with recurrent GI bleed from suspected small bowel source.,0
"Your warfarin was held and reversed, you recevied a total of 3 units of blood with appropriate bump.",0
You are on IV heparin bridge while back on coumadin until therapeutic to protect your heart valve.,1
You had mild delerium vs. Hospital psychosis which will be followed by your team at Rehab.,0
Followup Instructions: By Geriatrician Dr. at Rehab.,0
Height: (in) 63 Weight (lb): 200 BSA (m2): 1.94 m2 BP (mm Hg): 90/60 HR (bpm): 120 Status: Inpatient Date/Time: at 10:27 Test: TEE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/rightatrial appendage.,0
Peak left atiral appendage blood velocity was normal (>20).,0
IMPRESSION: No 2D echo evidence for endocarditis identified.,0
"2:55 PM CHEST (PRE-OP PA & LAT) Clip # Reason: MENINGIOMA Admitting Diagnosis: MENINGIOMA ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with posterior fossa mass, going for third ventriculoscopy REASON FOR THIS EXAMINATION: evalute for acute cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old female with posterior fossa mass, going for third ventriculoscopy.",0
Evaluate for acute cardiopulmonary process.,0
PA AND LATERAL CHEST RADIOGRAPHS: There is increased atelectasis within the left lung base with stable to diminished atelectasis in the right base.,0
There is no pleural effusion and no pneumothorax.,0
"5:26 AM CHEST (PORTABLE AP) Clip # Reason: r/o pna, pulm edema Admitting Diagnosis: COLONIC PERFORATION ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p L subclavian and PAC placement REASON FOR THIS EXAMINATION: r/o pna, pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 80 year old with pulmonary edema.",0
COMPARISON: PORTABLE SUPINE FRONTAL RADIOGRAPH: The patient remains intubated with an ET tube terminating just inferior to the thoracic inlet.,0
The left subclavian Swan-Ganz catheter has been pulled back and terminates in the main pulmonary artery.,0
A right IJ central venous catheter is unchanged in position.,0
"There is a persistent left retrocardiac opacification, unchanged in appearance.",0
There are persistent bilateral layering effusions with prominence of the pulmonary vascularity consistent with mild congestive heart failure.,0
IMPRESSION: Interval repositioning of left subclavian Swan-Ganz catheter terminating now in the main pulmonary artery.,0
Slight increase in congestive heart failure.,0
Left retrocardiac density may be due to pleural effusion though consolidation cannot be excluded.,1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Neonatology HISTORY: Baby Girl is the gram product of a 34- week gestation born to a 35 year old G2 P0 now 1 mother.,0
"Prenatal screens were O positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown.",0
Maternal history of uterine fibroids and recurrent abdominal pain during this pregnancy.,0
Previous evaluations consistent with left fibroid pain and left ovarian cyst.,0
Mother presented at on with right abdominal pain.,0
"On ultrasound on the day of delivery, had features consistent with right ovarian torsion.",0
Mother's maximum temperature was 100.4.,0
The decision was made to deliver the infant by cesarean section.,1
"Of note, recent fetal scan was suggestive of horseshoe kidney.",0
Maternal medications included Dilaudid and non steroidal anti- inflammatories.,0
SOCIAL HISTORY: The father is involved and is a physician at .,0
The infant emerged with good tone and grimace.,0
"Dried, stimulated, and responded well, with spontaneous cry and improved color.",0
Apgars were 8 and 9.,0
"PHYSICAL EXAMINATION ON ADMISSION: Weight grams (25th percentile), length 43.25 cm (25th percentile), head circumference 32.25 cm (50th percentile).",0
"Pink, comfortable, eyes open, looking around.",0
Ears normal set without anomalies.,0
Neck supple with no masses.,0
"Lungs clear to apex, fair to good aeration.",0
"Positive subcostal retractions, but no flaring or grunting.",0
Cardiovascular - Regular rate and rhythm.,0
Genitourinary - Normal preterm female.,0
"Extremities pink, well perfused, except for mild acrocyanosis.",0
"Good grasp, plantar reflex, symmetric Moro.",0
has been stable in room air throughout hospital course.,0
Discharge weight is 1890 gms.,0
She was initially started on 60 cc/kg/day of D10W.,0
Enteral feedings were started at 24 hours of age.,0
"Infant is currently ad lib feeding breast milk or Enfamil 24 calorie, taking in good amounts.",0
Peak bilirubin was on day of life 3 of 11.2/0.3.,0
"She received phototherapy, and the issue has resolved.",0
Hematocrit on admission is 54.,0
She has not required any blood transfusions.,0
A CBC and blood culture were obtained on admission.,0
"CBC was benign, and blood culture remained negative at 48 hours, at which time ampicillin and gentamicin were discontinued.",0
NEUROLOGIC has been appropriate for gestational age.,0
Audiology - Hearing screen was performed with automated auditory brainstem responses.,0
"A renal ultrasound was done on , revealing a horseshoe kidney.",0
There was no hydronephrosis evident.,0
"NAME OF PRIMARY PEDIATRICIAN: Dr. , .",0
"CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk 24 calorie, Enfamil 24 calorie, or ad lib breast feeding.",0
"CAR SEAT POSITION SCREENING: Was performed, and the infant passed.",0
"STATE NEWBORN SCREENING: Screens have been sent per protocol, and have been within normal limits.",0
The infant received hepatitis B vaccine on .,0
Premature infant born at 34-3/7 weeks.,0
"Rule out sepsis, with antibiotics.",0
", Dictated By: MEDQUIST36 D: 20:50:49 T: 23:19:22 Job#:",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: please eval for wire placement Admitting Diagnosis: SYMPTOMATIC BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man s/p paver wire placement REASON FOR THIS EXAMINATION: please eval for wire placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Wire placement, evaluation for position.",0
"FINDINGS: As compared to the previous radiograph, a wire has been inserted over the right internal jugular vein.",0
The tip of the wire cannot be exactly visualized so that an additional lateral projection should be obtained.,0
The course of the wire appears to indicate position at the proximal aspects of the basal right ventricle.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with s/p CABGX1 following MVR REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY ______________________________________________________________________________ WET READ: IPf 9:11 PM Lines and tubes in place.,1
NG tube not seen going into stomach.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 8 P.M. ON HISTORY: CABG.",0
"IMPRESSION: AP chest compared to postoperative chest radiographs, most recently , 1:38 p.m.: Nasogastric tube ends low in the esophagus and should be advanced at least 12 cm to move all the side ports into the stomach.",0
Swan-Ganz catheter ends in the region of the pulmonic valve.,0
Transvenous right atrial and right ventricular pacer leads are in standard placements and unchanged.,0
"Tip of the intraaortic balloon pump is above the level of the left main bronchus, approximately 28 mm below the apex of the aortic knob.",0
Midline drains in standard positions.,0
"Moderate-to-severe asymmetric pulmonary edema, right lung greater than left, has not changed over six and a half hours.",0
"12:07 PM CT ORBIT, SELLA & IAC W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: EVALUATE FOR FACIAL FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p fall w/ head trauma REASON FOR THIS EXAMINATION: EVALUATE FOR FACIAL FRACTURES No contraindications for IV contrast ______________________________________________________________________________ WET READ: JK TUE 2:38 PM Right orbital floor and left orbital roof fractures.",1
Probable left lamina papyracea fracture.,0
Left orbital emphysema and pneumocephalus.,0
"Probable linear frontal bone fracture, left sided, seen only on axial sections.",0
"INDICATION: Head trauma, status post fall.",0
COMPARISONS: CT head done same day.,0
TECHNIQUE: Axial noncontrast images were obtained through the orbits.,0
ORBITAL CT: There is a right inferior orbital wall fracture without evidence of herniation of the orbital contents.,1
"There is a comminuted, orbital roof fracture on the left.",1
There is also a fracture of the lamina papyracea on the left including the posterior most extent of the lamina papyracea.,0
This is associated with orbital emphysema on the left as well as a tiny amount of pneumocephalus adjacent to the orbital roof anteriorly.,0
"There is a linear fracture through the left frontal calvarium, seen only on the axial images adjacent to this small area of pneumocephalus.",0
No other fractures are identified.,0
There is fluid within the right maxillary sinus.,0
There is soft tissue swelling and subcutaneous emphysema around the left orbit.,0
Right inferior orbital wall fracture without evidence of herniation of orbital contents.,1
Fracture of the left orbital roof and lamina papyracea associated with orbital emphysema and a tiny amount of pneumocephalus.,1
Nondisplaced left frontal bone fracture.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins / Tetracycline / Cephalosporins Attending: Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac cath s/p 3 drug-eluding stents to her RCA History of Present Illness: Ms. is a 74 yo woman who presents with chest pain.,1
"Six weeks prior to admission, she fell while taking the laundry up the stairs and either bruised or broke a couple of her right ribs.",0
"For the last 2 weeks, she experienced flu like symptoms.",0
"Additionally, she notes she has been fatiguing more easily with activity lately.",0
"For five days prior to admission, she was having intermittent chest pain in a band like pattern with SOB.",0
The pain rose in intensity to 10 out of 10 the night of admission and was not related with activity.,0
"She also c/o a second type of chest pain with was pleuritic in nature (worse with inspiration), which was worse when supine but improve when upright.",0
She was taken to an OSH ED and found to be in atrial fibrillation with rapid ventricular response.,1
She was given IV lopressor and noted to have 1-2mm ST elevations in her inferior leads when her heart rate decreased.,0
Cath revealed a totally occluded RCA that was stented with 3 Cypher stents.,0
Past Medical History: Hyperlipidemia Colon Cancer s/p resection in Social History: Lives with husband who has .,0
Drinks glasses per night of wine.,0
"Smoked ppd for about 40 years, quiting in the mid-'s.",0
Retired phone rep. Family History: Mom with DM.,0
"Physical Exam: Most notably, her vitals are normal, 96% on room air, clear lungs, III/VI holosystolic murmur, 2cm small hematoma in her right groin surrounded by a 10cm region of ecchymosis, 2+ dorsalis pedis pulses.",0
Pertinent Results: 07:25AM BLOOD WBC-7.6 RBC-3.70* Hgb-11.8* Hct-33.8* MCV-91 MCH-31.9 MCHC-34.9 RDW-13.4 Plt Ct-240 07:25AM BLOOD Plt Ct-240 09:30AM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2 09:30AM BLOOD D-Dimer-2508* 07:25AM BLOOD Glucose-98 UreaN-11 Creat-0.6 Na-138 K-3.8 Cl-106 HCO3-26 AnGap-10 10:37AM BLOOD ALT-22 AST-28 AlkPhos-74 TotBili-3.5* 05:17AM BLOOD CK-MB-NotDone cTropnT-0.05* 05:17AM BLOOD CK(CPK)-49 10:37AM BLOOD TSH-0.95 CTA Chest: 1.,0
"Biapical scarring, and additional scarring and architectural distortion at the superior segement of the left lower lobe.",0
Calcified lymph nodes and nodal mass.,0
Findings may relate to prior infectious process.,0
Patchy opacities at the right lower lobe posteriorly could represent infectious process 4.,0
"Multiple right-sided rib fractures, with osseous callus indicating a subacute state.",0
Two vessel coronary artery disease 2.,1
Successful placement of drug-eluting stents in RCA.,0
Diffuse ST-T wave changes with diffuse ST segment elevation.,0
Clinical correlation is suggested for injury/pericarditis.,0
Regional left ventricular systolic dysfunction c/w CAD.,0
Mild pulmonary artery systolic hypetension.,0
No evidence of pseudoaneurysm or arteriovenous communication.,0
Brief Hospital Course: Mrs. is a 74yo woman with PMH of hypercholesterolemia who presents with chest pain and atrial fibrillation.,1
"By history and EKG, she had pericarditis which was likely related to her recent flu-like syndrome.",0
It is probable that her pericarditis precipitated her atrial fibrillation with rapid ventricular response.,1
"The nature of her RCA occlusion, which was stented with 3 drug eluding stents, appeared chronic by history and by cath, which her RCA territory being fed by collatorals.",0
"By stressing her heart, her atrial fibrillation with RVR likely caused her chest pain to manifest because of this chronic RCA occlusion.",1
"A Fib with RVR: Pt had intermittent AF with RVR during her hospitalization, which spontaneously reverted to normal sinus rhythm.",0
She mostly remained in normal sinus.,0
"She was started on Amiodarone, which will be maintained for 6 weeks.",0
"She was also started on Coumadin, which will be maintained for 12 weeks.",0
"She was discharged with of Hearts monitor, with the rhythms sent to Dr. .",0
"Pt will follow up with her PCP, .",0
", in 6 days for an INR check and Coumadin adjustment.",0
"In about 10 weeks, when she is off Amiodarone, she will be fitted with another of Hearts monitor.",0
She will follow-up with Dr. and Dr. in one month.,0
"Most likely, her AF was related to her pericarditis, which is now resolving.",0
"She is unlikely to need long-term amiodarone or coumadin, and that decision will be made in 12 weeks.",0
Baseline LFT's and TFT's were normal.,0
Pericarditis: Pt's EKG and history of positional chest pain in the setting of flu-like symptoms supported the diagnosis of pericarditis.,0
"A pulmonary emboli was ruled out with a negative CTA, despite a positive D-Dimer.",0
Her pericarditis improved during her hospitalization.,0
Chronic RCA occlusion s/p 3 drug eluding stents: Pt remained chest pain free after cath and after her pericarditis improved.,0
"She was d/c'd on ASA, Plavix, beta-blocker, statin.",0
"Right groin hematoma: Pt's post-cath course was complicated by a right groin hematoma measuring about 2cm on exam, along with some hemorrhaging from her femoral artery.",1
She was transfused 2 units of packed red blood cells and her hematocrit remained stable (~33).,0
An ultrasound confirmed her small hematoma and ruled out fistula.,0
She had good distal pulses.,0
She was able to walk comfortably on discharge without further bleeding.,0
Her ecchymosis should resolve over several weeks.,0
Her PCP will check her hematocrit in 6 days.,0
Dispo: Pt was discharged home with services with the aformentioned follow up with her PCP and Cardiologist.,0
FULL CODE Discharge Medications: 1.,0
Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 weeks.,0
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: Primary: 1.,0
Atrial Fibrillation with Rapid Ventricular Response 3.,1
RCA occlusion s/p placement of three drug eluding stents Discharge Condition: Pt was in good condition with stable vital signs and hematocrit (33.8).,0
"Her right groin hematoma was also stable and resolving, about 2cm on exam, and she was able to ambulate well.",0
"Discharge Instructions: If you have any dental procedures, you will need to take prophylactic antibiotics.",0
Continue to take your medications as prescribed.,0
You will be on Amiodarone for 6 weeks to help.,0
You will be on Coumadin for 12 weeks to thin your blood.,0
"In 10 weeks from now, you will be set up with of Hearts monitor to assess your heart rhythm.",0
"You will see Dr. monthly, and in 12 weeks time she will make a decision regarding continuing your Amiodarone and Coumadin.",0
"Followup Instructions: See Dr. on Monday so he can check your hematocrit, INR, and right groin.",0
"Your appointment 10:45AM on Tuesday , .",0
Call Dr. office at to make a follow-up cardiology appointment with Dr. and Dr. for one month from now.,0
Your appointment needs to be on a Thursday morning.,0
A message was left with their office already.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: ADDENDUM: The patient's code status per previous discharge addendum had been changed to do not resuscitate and comfort measure only.",0
The patient had been treated once for hyperkalemia on .,0
After much discussion with the family it was decided to cease any blood draws as well.,0
The patient remained comfortable with deteriorating mental status until when the patient was not arousable.,0
The patient was receiving prn morphine for pain.,0
Mrs. passed away on at 1:45 p.m. from metastatic disease.,0
Dictated By: MEDQUIST36 D: 15:59 T: 06:42 JOB#:,0
"Clip # Reason: ELEVATED CR, ?PYEO Admitting Diagnosis: COMMON BILE DUCT STONE ______________________________________________________________________________ MEDICAL CONDITION: M c cholangitis (pus in CBD post stone extraction), choledocholithiasis, and mild pancreatitis (resolving) now with rising Cr REASON FOR THIS EXAMINATION: Pyelonephritis/hydro?",1
"______________________________________________________________________________ FINAL REPORT INDICATION: -year-old man with cholangitis and mild pancreatitis, now with rising creatinine.",1
RENAL ULTRASOUND: The right kidney measures 9.5 cm.,0
The left kidney measures 10.1 cm.,0
There is no evidence of hydronephrosis or nephrolithiasis.,0
A 2.2 x 1.9 x 2.0 cm simple cyst is noted in the lateral aspect of the left kidney.,0
10:27 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: please assess for interval changes in liver and pancreas ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with hepatic failure and now pancreatitis due to acetaminophen overdose.,1
Now c progressive abdominal pain and altered mental status.,0
Please see requisition for head CT as well.,0
"REASON FOR THIS EXAMINATION: please assess for interval changes in liver and pancreas CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ FINAL REPORT HISTORY: Hepatic failure, pancreatitis, abdominal pain and altered mental status.",1
TECHNIQUE: Axial images of the abdomen and pelvis were obtained without IV contrast due to elevated creatinine.,0
CT ABDOMEN AND PELVIS W/O IV CONTRAST: There are moderate sized bilateral pleural effusions which have slightly increased in the interval.,1
There are bibasilar dependent atelectases.,0
There are linear opacities in the lung bases consistent with discoid atelectases.,0
There are extensive calcifications in the aorta.,0
"There are multiple clips in the epigastrium, There are no focal liver lesions.",1
"The gallbladder is prominent, unchanged compared to prior study.",0
There is diffuse haziness of the mesentery which is unchanged compared to the prior study.,0
"There is a small amount of intraabdominal fluid, best seen in the paracolic gutters and the pelvis.",0
There are no peripancreatic collections.,0
There is no pancreatic ductal dilatation.,0
"The kidneys are normal in size, there are no stones, there is no hydronephrosis.",0
Loops of small bowel are not dilated.,0
There are sutures in the stomach.,0
CT PELVIS W/O IV CONTRAST: There is a foley catheter within the bladder.,0
"The uterus is present, there are a few intrauterine calcifications.",0
There are a few sigmoid diverticula.,0
There is diffuse edema in the soft tissues.,0
There are degenerative changes throughout the spine.,0
"IMPRESSION: 1) Haziness of the mesentery, intraabdominal fluid, subcutaneous edema and bilateral pleural effusions suggesting fluid overload.",1
No evidence of large intraabdominal collections.,0
"8:15 AM CT HEAD W/O CONTRAST Clip # Reason: eval for head bleed ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with multiple falls, unknown LOC, concern for PE and possible utilization of lytics REASON FOR THIS EXAMINATION: eval for head bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: CT of the head without contrast .",0
"INDICATION: Fall, with unknown loss of consciousness, and concern for PE, for possible lysis of clot.",0
FINDINGS: There is no acute intracranial hemorrhage.,1
"There is no mass, mass effect, edema, or infarction.",0
"There is moderate opacification of the maxillary sinuses bilaterally, with some aerosolized secretions.",0
Paranasal sinuses and mastoid air cells are otherwise normally aerated.,0
i Surrounding soft tissues are unremarkable.,0
Sinus opacification as detailed above.,0
"8:32 PM CHEST (PORTABLE AP) Clip # Reason: s/p min inv MVR Admitting Diagnosis: MTIRAL REGURGITATION\MINIMALLY INVASIVE MITRAL VALVE REPAIR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with REASON FOR THIS EXAMINATION: s/p min inv MVR ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old man, status post MVR.",1
"SINGLE SUPINE VIEW OF THE CHEST AT 8:55 P.M.: An endotracheal tube terminates approximately 5.5 cm from the carina, a nasogastric tube has its sideport at the GE junction (advancement recommended for standard positioning), a Swan- Ganz catheter terminates in the pulmonary outflow tract via a right internal jugular approach, and chest tubes terminate in the right apex and right lung base (although tip is not well visualized).",0
"The cardiomediastinal silhouette is enlarged, consistent with postoperative status.",0
"Pulmonary vasculature is congested, but there is no frank pulmonary edema.",0
There is no airspace consolidation or pneumothorax.,0
Pulmonary vascular congestion without frank pulmonary edema.,0
"7:42 AM CHEST (PORTABLE AP) Clip # Reason: CHF vs. consolidation Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with R sided HF, s/p swan placement, now with fever and cough,eval for consolidation REASON FOR THIS EXAMINATION: CHF vs. consolidation ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Swan-Ganz line placement.",1
The lungs appeared clear except for streaky density at the lung bases consistent with subsegmental atelectasis and a small retrocardiac infiltrate cannot be excluded.,0
"The patient is status post median sternotomy and the heart appears large, as before.",1
Cardiac size may be exaggerated by AP technique.,0
A Swan-Ganz catheter remains in place.,0
A small area of consolidation in the retrocardiac area cannot be excluded.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Adult Low Dose Aspirin Attending: Chief Complaint: CHIEF COMPLAINT: Pericardial effusion REASON FOR CCU ADMISSION: Monitoring post pericardial drain placement Major Surgical or Invasive Procedure: Pericardial drain placement History of Present Illness: Ms. is a 69F with a history of recently diagnosed synchronous stage IIIB non-small cell lung cancer (adenocarcinoma by bronchial brushings) and renal cell carcinoma, currently s/p left nephrectomy and undergoing chemotherapy and radiation.",1
"She underwent CT scan of her chest for re-staging of her lung cancer on , which demonstrated an increasingly large pericardial effusion (had been previously noted on PET scan in ).",0
"She has recently been experiencing worsening shortness of breath at home, which she notices only with exertion such as carrying a full basket of laundry.",0
"She has had some associated cough, but no sputum production.",0
"In addition, about 3 weeks ago she was seen at hospital for chest pain; she was ruled out for MI and planned for outpatient echocardiogram, which would have been today but she cancelled given her oncology appointments.",0
She has not had a recurrence of the chest pain.,0
"She was seen today in clinic today by her oncologist Dr. , who noted her complaints of worsening dyspnea on exertion and referred her to the ED for echocardiogram to evaluate for possible tamponade.",0
"In the ED, echocardiogram showed brief right atrial collapse and impaired filling of the right ventricle consistent with early tamponade physiology.",0
She was evaluated by interventional cardiology and taken to the catheterization lab for pericardial fluid removal.,0
"She underwent pericardial drain placement with ~400 cc of bloody fluid removed, followed by rapid drainage of another ~150cc into the drainage bag.",0
Immediate post-procedure echo showed small residual pericardial effusion with no Fluid was sent for cytology.,0
Her oncologist Dr. was contact and updated with the events of the procedure.,0
He requested transfusion of 2 units pRBCs for anemia.,0
"On the floor, she reports feeling well.",0
No current SOB at rest or chest pain (only very mild site tenderness with drain placement).,0
"Of note, her cancer history is well-documented in OMR note by Dr. dated .",0
"Briefly, she initially presented in with hematuria, and further work up revealed both a large 9-cm renal mass and a RUL 9-cm mass with mediastinal nodes.",0
"Based on renal biopsy (RCC, clear cell type) and bronchial brushings (likely adenocarcinoma) these are two separate cancers.",0
"She has been treated with chemotherapy with cysplatin and paclitaxel (start date ) and radiation therapy to the chest, in addition to unilateral nephrectomy in 4/.",1
"On review of systems, she endorses bilateral chronic hip pain with walking (not new or changed), and dark stool secondary to iron use.",1
"She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery (though had one GI bleed on aspirin in ), myalgias, hemoptysis, black stools or red stools.",0
"She denies recent fevers, chills, nightsweats or rigors.",0
No recent cold or flu symptoms.,0
She denies dysuria or other urinary symptoms.,0
"Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea (sleeps with one flat pillow), ankle edema, palpitations, syncope or presyncope.",1
Past Medical History: - Renal cell carcinoma (clear cell type by biopsy) s/p unilateral left nephrectomy - Non-small cell lung cancer (likely adenocarcinoma by bronchial brushings) stage IIIB s/p cisplatin/paclitaxel (day #1 = ) and radiation (ongoing) - Esophagitis secondary to chemo/radiation - Hypertension diagnosed > 30 years ago - Depression - Status post gastrointestinal bleed from GI ulceration from aspirin in - History of iron deficiency anemia - Status post rotator cuff repair in - History of sinusitis Social History: Lives at home with her husband.,1
Continues to work part time at her husband's business (he owns an automotive parts supply shop).,0
"- Tobacco history: Former smoker of packs per day until age 65 (~75 pack-year history) - ETOH: Recreational in past, none recent - Illicit drugs: None Family History: Mother died of stroke; father died of heart disease.",1
"No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; no family history of lung or renal cancer; one maternal aunt had cancer of an unknown type.",1
Physical Exam: ADMISSION EXAM: VS: T=98.7 BP=100/69 HR= RR=16 O2 sat=97% on 4L GENERAL: NAD.,0
NECK: Supple with no JVD.,0
"CARDIAC: Distant S1S2, no distinct murmurs, rubs or gallops.",0
Pericardial drain in place with ~150 cc of sanguinous fluid in bag.,0
2+ DP pulses SKIN: Erythematous rash over central anterior chest secondary to recent radiation treatment .,0
"Dressing in place at the site of pericardial drain, c/d/i LUNGS: CTAB, no crackles, wheezes or rhonchi.",0
2+ DP pulses SKIN: Erythematous rash over central anterior chest secondary to recent radiation treatment Pertinent Results: LABS ON ADMISSION: 07:35AM WBC-14.5* RBC-2.93* HGB-7.8* HCT-24.1* MCV-82 MCH-26.7* MCHC-32.4 RDW-18.3* 07:35AM PLT COUNT-486* 12:20PM GLUCOSE-97 UREA N-27* CREAT-1.3* SODIUM-131* POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-24 ANION GAP-18 12:38PM GLUCOSE-104 LACTATE-1.1 NA+-131* K+-5.0 CL--95* TCO2-25 02:45PM URINE COLOR-Yellow APPEAR-Clear SP -1.050* 02:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM 02:45PM URINE RBC-15* WBC-6* BACTERIA-NONE YEAST-NONE EPI-2 TRANS EPI-<1 OTHER SIGNIFICANT LABS: .,0
MICROBIOLOGY: - Pericardial fluid : Gram stain negative for organisms or PMNs.,0
- Pericardial fluid culture (blood culture bottles): NO GROWTH - MRSA screen : PENDING IMAGING: .,0
- ECHO (pre-procedure): Overall left ventricular systolic function is low normal (LVEF 50-55%).,0
"There is significant, accentuated respiratory variation in tricuspid valve inflows, consistent with impaired ventricular filling.",0
IMPRESSION: Moderate circumferential pericardial effusion with most of the fluid located over the right atrium and inferolateral wall.,0
There is relatively little fluid over the right ventricular free wall.,0
"There is variation in tricuspid inflows, along with brief right atrial collapse and impaired filling of the right ventricle consistent with early tamponade physiology.",0
- ECHO (post-procedure): Effusion is loculated.,0
"IMPRESSION: Limited study, Doppler images only.",0
No significant variation in mitral inflows.,0
Pericardial fluid amount is reduced.,0
- ECHO (post-procedure): Focused views s/p pericardial drainage.,0
There is a residual small pericardial effusion along the infero-lateral wall and right atrium.,0
The effusion is very small anterior to the right ventricle and significantly improved compared to the prior study dated .There are no echocardiographic signs of tamponade.,0
"LABS ON DISCHARGE: Pericardial Effusion Fluid: 04:45PM OTHER BODY FLUID WBC-1175* Hct,Fl-8.5* Polys-35* Lymphs-39* Monos-16* Eos-1* Macro-9* 04:45PM OTHER BODY FLUID TotProt-5.3 Glucose-85 LD(LDH)-996 Amylase-23 Albumin-3.4 CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.",1
"Lymphocytes, red blood cells, hemosiderin-laden histiocytes, and rare mesothelial cells.",0
"06:15AM BLOOD WBC-11.4* RBC-3.65* Hgb-10.1* Hct-30.5* MCV-83 MCH-27.7 MCHC-33.2 RDW-18.4* Plt Ct-411 06:15AM BLOOD Glucose-144* UreaN-19 Creat-1.0 Na-138 K-4.9 Cl-103 HCO3-25 AnGap-15 Brief Hospital Course: PRIMARY REASON FOR ADMISSION: 69 y/o woman with renal cell carcinoma and non-small cell lung cancer diagnosed early , undergoing chemotherapy and radiation, who presents with DOE and worsening pericardial effusion with evidence of early tamponade by echocardiogram.",1
Admitted to CCU for monitoring s/p pericardial drain placement.,0
# PERICARDIAL EFFUSION: Pericardiocentesis was performed with immediate drainage of 400cc sanguinous fluid.,0
"Overnight, another ~450cc sanguinous fluid drained, and samples were sent for gram stain, protein content, culture, electroyltes and cytology.",0
Post-procedure echo showed a small loculated residual effusion with no evidence of tamponade physiology.,1
"Cytology was negative for malignacy, but suspicion remains high for a malignant etiology.",0
"Pulsus was followed throughout her hospital course, and at the time of post-procedure echo pulses was 12 by doppler.",0
"Pt was asymptomatic at the time of discahrge and specifically denied CP/SOB/DOE, palpitations or lightheadedness.",0
"If pericardial effusion reaccumulates, would consider CT surgery consult for pericardial window.",0
"# RENAL CELL CARCINOMA, NON-SMALL CELL LUNG CANCER: No treatments were undertaken during this hosptial course.",0
Pt was discahrged with Heme/Onc follow-up with Dr. .,0
# TACHYCARDIA - Pt remained tachycardic to the 100-120s throughout her course.,0
"Initially it was felt this may have been tamponade physiology, but tachycardia persisted s/p pericardiocentesis.",0
"She was then transfused 2U pRBCs at the request of Dr. and bolused 1L NS due to concern for anemia/hypovolemia, but tachycardia persisted.",0
"Review of clinic visits revealed that she has been persistently tachycardic for several months, which may be related to the small loculated effusion that was not accessed by the tap.",0
The patient denied pain throughout her course and refused any pain medicaitons.,0
Orthostatics were checked at discahrge and were normal.,0
# ANEMIA: Her Hct has trended down over the past 6 months.,0
"This is likely related to chonric disease, and pt was transfused 2U pRBCs during this admission.",0
"She is taking Fe supplementation, which was continued during her hospitalization.",0
"# LEUKOCYTOSIS: She had a low grade leukocytosis throughout her admission, which is consistent with her baseline.",0
Suspect this is related to her malignancies.,0
"She remained afebrile and normotensive throughout her course, pericardial and urine cultures were negative and CXR showed no evidence of pulmonary process.",0
"Continued home meds (amlodipine 10 mg PO daily, HCTZ 25 mg PO daily) with holding parameters.",0
# HYPERLIPIDEMIA: Continued rosuvastatin 10 mg PO QHS.,0
# DEPRESSION/ANXIETY: Denies current depression.,0
States she takes Xanax once daily in the mornings.,0
Continued Effexor XR 150 mg PO daily.,0
Continued Xanax 0.5 mg PO daily (in AM).,0
# OSTEOPOROSIS: Continued alendronate 70 mg PO Q week (Mondays).,0
TRANSITION OF CARE: Pt was discharged home with Heme/Onc follow up.,0
She was also scheduled for an outpatient echo that should be followed up by her PCP/Oncologist.,0
"She was instructed to return to the ER if she experiecned worsening SOB/CP, as this may represet reaccumulation of pericardial fluid.",0
2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea.,0
3. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
4. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday).,0
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
6. halobetasol propionate 0.05 % Cream Sig: One (1) Topical QID (4 times a day) as needed for Dry skin.,0
Maalox:Benadryl:2%Lidocaine Mixture Sig: One (1) 15 minutes before meals and at bedtime.,0
"Fish Oil 1,200-144-216 mg Capsule Sig: One (1) Capsule PO once a day.",0
9. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.,0
10. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety.,0
11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day.,0
13. olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
"14. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day.",0
"15. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea.",0
Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Cardiac Tamponade SECONDARY DIAGNOSIS Lung Cancer Renal Cancer Anemia Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Dear Ms , It was a pleasure caring for you at the .",0
You were admitted for a condition called pericardial tamponade.,0
"This is caused by fluid surrounding the heart, and it can cause the heart to not beat effectively.",0
"For this you underwent pericardiocentesis, a procedure where a doctor drains the fluid with a needle to restore the normal functioning of the heart.",0
After this procedure we performed another Echocardiogram to confirm that the fluid had not reaccumulated and felt you were safe to return home.,0
"During this hospitalization, we made NO CHANGES to your medicatios.",0
It will be important for you to follow up the results of the cytology from your pericardial fluid analysis with you oncologist.,0
"Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY at 12:00 PM With: , RN Building: Campus: EAST Best Parking: Garage MD,",0
8:14 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CHRONIC RENAL FAILURE;INFECTED AV GRAFT Admitting Diagnosis: CHRONIC RENAL FAILURE;INFECTED AV GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with infected L AV graft.,1
REASON FOR THIS EXAMINATION: acute process ______________________________________________________________________________ FINAL REPORT INDICATION: Infected left AV graft.,0
FINDINGS: There is stable cardiomegaly.,0
IMPRESSION: Cardiomegaly without acute cardiopulmonary process.,0
12:43 PM CT HEAD W/O CONTRAST Clip # Reason: interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p seizure and fall - ?,0
aneurysm on CT head scan REASON FOR THIS EXAMINATION: interval change CONTRAINDICATIONS for IV CONTRAST: allergy ______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old male with seizure and fall; follow-up intracranial hemorrhage.,0
"COMPARISON: CT 12 hours prior, dated at 12:46 a.m.",0
TECHNIQUE: Helical MDCT images were obtained through the head without intravenous contrast.,0
FINDINGS: Again seen is a non-displaced fracture of the left frontal bone and orbital roof.,0
There is associated soft tissue swelling along the left frontal scalp and preseptal area.,1
A locule of gas is present underneath the left eyelid.,0
"The globe appears intact, and no orbital hematoma is identified.",0
"The right subdural hemorrhage has decreased to 10 mm in maximal depth(2:18), previously was 12 mm.",1
This collection again demonstrates irregular morphology and heterogeneous contents.,0
"It consists primarily of hyperdense material, with some non-dependent hypodense foci (""swirl sign""), suspicious for hyperacute hemorrhage.",1
"The blood collection surrounds the entire right cerebral hemisphere, tracking over the frontal convexity, and along falx cerebri and the tentorium cerebelli.",0
"There is very focal and minimal subarachnoid hemorrhage, limited to the subjacent frontotemporal sulci.",1
No definite acute intraparenchymal hemorrhage is seen.,1
"There is right-sided sulcal effacement, with stable 3-mm leftward shift of the normally-midline structures.",0
The perimesencephalic cisterns are preserved.,0
"Again seen is a ventriculoperitoneal shunt entering through the right temporal bone, with tip in the body of the right lateral ventricle.",0
Calcification is noted in the soft tissues surrounding the shunt.,0
"Stable periventricular and supratentorial white matter hypodensities represent sequelae of chronic microvascular disease, but no transependymal flow of CSF is seen to suggest significant obstructive hydrocephalus.",1
"The ventricles and sulci are only mildly prominent, consistent with age-related atrophy.",0
"Again noted in the region of the pineal gland is a 2.2 x 1.7 x 1.8 cm lobulated, hyperdense extra-axial mass with coarse internal calcifications, most consistent with a meningioma.",0
"Multiple punctate calcifications are seen within the pons in an unusual distribution, possibly representing calcification within capillary telangiectasia.",0
"(Over) 12:43 PM CT HEAD W/O CONTRAST Clip # Reason: interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont) Again seen is a 6-mm rounded hyperdensity in the region of the right carotid terminus (2:11), which may represent a tortuous vessel versus carotid terminus/PCom origin aneurysm.",0
Note is made of bilateral cavernous carotid calcifications.,0
The patient remains intubated with an orogastric tube.,0
Fluid and secretions are seen layering in the nasopharynx.,0
"There are air-fluid levels in the left sphenoid and maxillary sinuses, mucus retention cysts in the bilateral maxillary sinuses, and partial opacification of left ethmoid air cells.",0
There is complete opacification of the right and partial opacification of the left mastoid air cells.,0
A probable surgical defect is present in the left mastoid.,0
"Again noted is a patchy demineralized appearance of the skull, of uncertain significance.",0
Slightly decreased thickness of extensive subdural hematoma.,0
"Small focal subarachnoid hemorrhage, likely post-traumatic, unchanged, with no new SAH.",1
Right-sided VP shunt without significant ventricular dilatation or evidence of obstructive hydrocephalus.,1
"Incidental calcified pineal region extra-axial mass, likely meningioma.",0
Non-displaced left frontal skull/orbital roof fracture.,1
"COMMENT: These findings were discussed with , NP (Neurosurgery service) by Dr. , at 2:20 p.m., .",0
"12:38 PM CHEST (PORTABLE AP) Clip # Reason: interval change w/ clamped tube Admitting Diagnosis: RIGHT PLEURAL EFFUSION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with R pleural loculations s/p R decortication ; anteroir tube clamped and post tube to water seal REASON FOR THIS EXAMINATION: interval change w/ clamped tube ______________________________________________________________________________ FINAL REPORT PORTABLE UPRIGHT CHEST, : COMPARISON: .",0
INDICATION: Chest tube placed to waterseal.,0
Two chest tubes remain in place in the right hemithorax.,0
The lower of the two tubes has slightly changed in position in the interval.,0
"There is a small curvilinear opacity at the right apex suggestive of a small pneumothorax, and not seen on the recent examination.",0
Small pleural effusions and areas of atelectasis at the bases are not significantly changed in the interval.,0
IMPRESSION: New small right apical pneumothorax.,0
"Otherwise, no significant change since recent radiograph.",0
1:22 PM ESOPHAGUS Clip # Reason: to look for any leak Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man s/p lap esophagogastrectomy + J-tube for esophageal adenoca REASON FOR THIS EXAMINATION: to look for any leak ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PBec WED 4:18 PM Patent esophagogastrectomy with no associated leak.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: 84-year-old man status post laparoscopic esophagogastrectomy for esophageal adenocarcinoma, please evaluate for any leak.",1
SINGLE CONTRAST ESOPHAGRAM: Contrast passes easily through the esophagogastrectomy anastomosis with no evidence of holdup or leak.,0
Contrast is passes through the diaphragmatic hiatus into the abdominal portions of the stomach.,0
Incidental note of compressive atelectasis surrounding the gastric pull-through.,0
IMPRESSION: Patent esophagogastrectomy with no associated leak.,0
"9:45 AM CAROTID SERIES COMPLETE Clip # Reason: CAD, PREOP CABG AND VALVE REPAIR Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with CAD REASON FOR THIS EXAMINATION: assess for carotid artery thrombosis ______________________________________________________________________________ FINAL REPORT INDICATION FOR EXAM: This is a 78-year-old man with CAD, with suspected carotid artery thrombosis.",1
RADIOLOGISTS: This exam was read by Dr. and .,0
"TECHNIQUE: Extracranial ultrasound evaluation of bilateral carotids was performed by B-mode, spectral, and color Doppler ultrasound modes.",0
"FINDINGS: On grayscale examination, there is minimal amount of plaque seen within bilateral internal carotid arteries.",0
"On the right, peak systolic velocities are 77, 68, and 55 cm/sec in the internal, common, and external carotid arteries, respectively.",0
The right ICA to CCA ratio is 1.28.,0
"Left peak systolic velocities are 71, 74, and 66 cm/sec in the internal, common, and external carotid arteries, respectively.",0
The left ICA to CCA ratio is 0.95.,0
Both vertebral arteries present with antegrade flow.,0
"IMPRESSION: No evidence of internal carotid artery stenosis on either side, in their extracranial portion.",0
5:46 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with prolonged intubation REASON FOR THIS EXAMINATION: ?,0
interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 12:45 PM Small left pleural effusion and left lower lobe atelectasis are unchanged.,0
There are lower low lung volumes.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Prolonged intubation.,0
"ET tube tip is 4 cm above the carina, NG tube tip is out of view below the diaphragm, right supraclavicular catheter remains in place.",0
"Small left pleural effusion and left lower lobe atelectasis are unchanged, cardiomediastinal contours are stable.",0
"1:03 AM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with hypotension and syncope REASON FOR THIS EXAMINATION: r/o bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: YMf MON 3:53 AM No acute intracranial process, specifically no hemorrhage ______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT CONTRAST HISTORY: 55-year-old man with hypertension and syncope.",1
"NON-CONTRAST HEAD CT: There is no evidence of infarction, hemorrhage, edema, shift of normally midline structures or hydrocephalus.",0
The soft tissues and surrounding osseous structures are not remarkable.,0
"4:04 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma Field of view: 46 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with fall, brain injury, cspine deformity REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: JWK WED 5:09 PM Right lower lobe pulmonary contusion vs. atelectasis.",0
Diffuse tree-in- opacities predominantly within the right lung which may represent an underlying infectious process.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 43-year-old man with fall and brain injury.,0
"TECHNIQUE: MDCT axial images of the chest, abdomen, and pelvis were obtained following the administration of IV Optiray contrast.",0
COMPARISON: None CT CHEST WITH IV CONTRAST: The patient is intubated.,0
There are no pathologically enlarged mediastinal or axillary lymph nodes.,0
Consolidation in the right lower lobe is likely secondary to pulmonary contusion or aspiration.,0
"Additionally, the lung windows demonstrate diffuse tree-in- opacities, predominantly within the right lung but also within the left upper and lower lobes.",0
"CT ABDOMEN WITH IV CONTRAST: There is a small hypodensity in the spleen, too small to be further characterized.",0
"The liver, gallbladder, adrenal glands, kidneys, pancreas, stomach, and abdominal loops of small and large bowel are unremarkable.",0
There are no pathologically enlarged mesenteric or retroperitoneal lymph nodes.,0
"CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, prostate gland, and bladder are unremarkable.",0
OSSEOUS STRUCTURES: Demonstrate no fractures and no suspicious lytic or sclerotic foci.,1
Right lower lobe consolidation likely representing pulmonary contusion or aspiration.,0
"Diffuse tree-in- opacities, greater within the right lung than the left.",0
This may be consistent with an underlying infectious process.,0
(Over) 4:04 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma Field of view: 46 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont),0
"11:09 AM CT HEAD W/O CONTRAST Clip # Reason: VENT DRAIN X2/POST COILING Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with 2 vent drain, s/p coiling REASON FOR THIS EXAMINATION: r/o ICH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: Status post coiling of aneurysm.",1
FINDINGS: Comparison with the prior day's study re-demonstrates the extensive subarachnoid as well as intraventricular hemorrhage without apparent progression or regression of the hemorrhage.,1
The bilateral ventricular drains are again noted as well as the extensive streak artifact arising from the coiling material.,0
There does appear to be redundant course of the nasogastric tube.,0
"We will telephoned your house officer, who requested this study, with these results immediately after the conclusion of the scan.",0
"6:14 PM ELBOW (AP, LAT & OBLIQUE) LEFT Clip # Reason: fx?",0
"______________________________________________________________________________ MEDICAL CONDITION: History: 81M with s/p fall, brusing at pain at L elbow and R ankle REASON FOR THIS EXAMINATION: fx?",0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT LEFT ELBOW, THREE VIEWS: .",0
HISTORY: 81-year-old male status post fall with bruising and pain in left elbow.,0
"FINDINGS: AP, lateral, and oblique views of the left elbow.",0
There is no visualized fracture or acute osseous abnormality.,0
"Large soft tissue structure seen superficial to the olecranon, potentially due to bruising given patient's history.",0
"Alternatively, this could represent a bursa.",0
There is no elbow joint effusion or other soft tissue abnormality.,0
"IMPRESSION: Soft tissue swelling overlying the dorsal aspect of the elbow, potentially due to hematoma given history, however enlarged, inflamed bursa is also possible.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEONATOLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a male infant born to a 23-year-old G3, P2 mother at 38 and 2/7ths weeks gestation.",0
"PRENATAL SCREENS: O positive, antibody negative, hepatitis B GBS negative.",0
PRENATAL HISTORY: Prenatal ultrasound was concerning for congenital heart disease.,0
Evaluated by Department of Cardiology at .,0
"Fetal echocardiogram at on showed a hypoplastic mitral valve, small LV, but normal length, hypoplastic bicuspid A-V, suspected coarctation, PDA, good bilateral ventricular function.",0
"No prolonged rupture of membranes, clear fluid, spontaneous vaginal delivery.",0
ADMISSION EXAM: Infant emerged vigorous with strong cry requiring only bulb suctioning stimulation and drying.,0
APGARS: 8 and 9 at 1 and 5 minutes respectively.,0
Oxygen saturation on room air 95% post ductal.,0
"Anterior fontanelle soft, open, flat palpate, intact.",0
Nares and ears were patent.,0
Neck was without masses or defect.,0
"LUNGS: Good symmetrical aeration, no grunting, flaring, or retracting.",0
"CARDIOVASCULAR: Soft S1 and S2 that was splint, regular rhythm, soft 1/8 systolic murmur.",0
Well perfused capillary refill less than 2 seconds.,0
"ABDOMEN: Flat, soft, nontender, no masses, no enlarged liver or spleen.",0
"Three-vessel cord, anus patent in normal position.",0
"Normal phallus, testes, and scrotum bilaterally.",0
"NEUROLOGICAL: Normal tone, strength, suck, grimace, Moro and grasp.",0
"HOSPITAL COURSE: CARDIOVASCULAR: For concern of a coarctation, the patient was briefly admitted to the NICU, where IV access was obtained.",0
He was evaluated by the Department of Cardiology and transported uneventfully to the Cardiac Intensive Care Unit at .,0
"There, he had a postnatal echocardiogram that showed an open PDA and, otherwise, a normal study.",0
"However, since a coarctation could not be ruled out with a PDA present, the patient was transferred to NICU for further observation until the duct is closed.",0
"While he was here, he had four extremity blood pressures q.4 hours.",0
"Intermittently, there would be a gradient of slightly more than 10 in the systolic measurements comparing upper and lower extremities, however, this was never sustained.",0
"Throughout the admission, the patient remained well perfused in upper and lower extremities and had present femoral pulses.",0
"The most recent echocardiogram done today, , showed a small PDA and low likelihood of a coarctation.",0
"Therefore, the cardiology service has deemed baby boy fit for discharge to followup at the Cardiology Clinic next Monday, at 8:30 am.",0
RESPIRATORY: The patient has always remained stable and on room air.,0
"FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was initially on IV fluids.",0
Electrolytes and glucoses were monitored and remained within normal limits.,0
"When the patient proved to be cardiovascularly and respiratorily stable, he was started on PO feedings, which he has tolerated without difficulty.",0
HEMATOLOGY: The patient was noted to be clinically jaundiced.,0
A bilirubin total was 16.1 on day of life #4.,0
"The patient remained on single phototherapy until day of life #6, when phototherapy was discontinued at a level of 13.6.",0
"Rebound bilirubin, twenty-four hour later, was the same at 13.6.",0
The patient has passed in both ears.,0
PSYCHOSOCIAL: social worker was involved with the family.,0
DISCHARGE DISPOSITION: The patient is discharged to home with follow up with Dr. of Pediatrics.,0
CARE RECOMMENDATIONS: Feeds at discharge: Ad lib Enfamil 20 with iron.,0
STATE NEWBORN SCREENING STATUS: Pending.,0
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was administered.,0
FOLLOW UP APPOINTMENTS: Will see Dr. at mother's convenience either tomorrow or the day after at Pediatrics and will follow up with Cardiology on at 8:30 am.,0
Dictated By: MEDQUIST36 D: 15:45 T: 15:51 JOB#:,0
"7:09 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: RESPIRATORY FAILURE,VOLUME OVERLOAD ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with polymicrobial sepsis, hypotension, trached with resp failure.",1
REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old with polymicrobial sepsis.,0
"CHEST X-RAY, AP PORTABLE VIEW.",0
FINDINGS: The cardiac pacer leads project over the right atrium and the floor of the right ventricle.,0
The heart size is borderline normal.,0
"Pulmonary interstitial edema is noted, which appears to be worsening.",0
Old right posterior 6th rib fracture.,0
IMPRESSION: Bilateral small pleural effusions with worsening pulmonary edema.,0
7:57 PM CT HEAD W/O CONTRAST Clip # Reason: Please assess for bleed or shift ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man s/p moderate speed MVC REASON FOR THIS EXAMINATION: Please assess for bleed or shift No contraindications for IV contrast ______________________________________________________________________________ WET READ: MAlb SAT 9:30 PM Subarachnoid hemorrhage in a right supratentoral location and posterior to the right temporal lobe.,1
No other areas of hemorrhage.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 45-year-old man status post moderate-to-severe MVC.,0
Evaluate for intracranial hemorrhage or shift.,1
"TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT IV CONTRAST: There is increased density along the superior aspect of the tentorium on the left, consistent with subarachnoid supratentorial hemorrhage.",1
This also extends into sulci around the posterior aspect of the right temporal lobe.,0
There is no evidence of intraventricular hemorrhage or subdural or hemorrhage.,0
The parenchyma demonstrates normal density.,0
No fractures or soft tissue abnormalities seen.,0
"The visualized portion of the paranasal sinuses, middle ear cavities and mastoid air cells are well aerated bilaterally.",0
IMPRESSION: Subarachnoid hemorrhage localized along the right tentorium and abutting the posterior aspect of the right temporal lobe.,1
No other areas of intracranial hemorrhage.,1
10:03 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: ?perforation with free air Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with epigastric pain after ERCP REASON FOR THIS EXAMINATION: ?perforation with free air ______________________________________________________________________________ WET READ: PRib FRI 2:16 PM No evidence of free air.,0
No obstruction or ileus is seen.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Epigastric pain after ERCP, question of perforation or free air.",0
"FINDINGS: Compared to prior study, there is a common bile duct stent seen and appears in appropriate position.",0
The coil is seen in the right upper quadrant close to midline.,0
There is superficial staple seen in the mid and upper abdomen.,0
There is a drain seen in the right upper quadrant.,0
There is air seen in small and large bowel without evidence of dilatation.,0
"1:09 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate OG tube placement Admitting Diagnosis: NON-HODGKIN LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man NHL with respiratory failure now intubated REASON FOR THIS EXAMINATION: please evaluate OG tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: 64-year-old man with non-Hodgkin's lymphoma and respiratory failure, now intubated.",1
Patient has a new OG tube placement.,0
"TECHNIQUE: Supine portable chest radiograph, single view.",0
COMPARISON: Chest radiograph at 5:00 a.m.,0
FINDINGS: There is an endotracheal tube in place with tip 4 cm above carina in standard position.,0
There is a right central catheter in place with tip at the mid SVC.,0
"There feeding tube is not clearly seen, there is a tubular structure projecting at the upper esophagus; however tube is not seen more distally.",0
Right costophrenic angle is cut off from the projection.,0
There is marked improvement in bilateral airspace opacities.,0
There is a persistent small left pleural effusion.,0
There is stable retrocardiac opacity.,0
Marked interval improvement in bilateral airspace opacities.,0
Right costophrenic angle is cut off from current projection.,0
Endotracheal tube and venous line in stable position.,0
"NG tube possibly not clearly seen, could be due to overlapping summation of shadows with the spine, or might be coiling in the nasopharynx (upper neck not imaged).",0
D/w Dr. and repeat radiograph will be performed to evaluate further.,0
PATIENT/TEST INFORMATION: Indication: evaluate for pericardial effusion ; Focused study in cath lab s/p coronary perforation.,1
Height: (in) 62 Weight (lb): 140 BSA (m2): 1.64 m2 BP (mm Hg): 154/66 HR (bpm): 67 Status: Inpatient Date/Time: at 13:49 Test: Portable TTE (Focused views) Doppler: No doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Severe regional LV systolic dysfunction.,0
Conclusions: There is severe regional left ventricular systolic dysfunction.,0
"There is a trivial, small pericardial effusion.",0
"Compared to the prior study dated , there is no significant change.",0
"IMPRESSION: Stable, small pericardial effusion without tamponade.",0
Left ventricular function BP (mm Hg): 158/70 HR (bpm): 40 Status: Inpatient Date/Time: at 21:27 Test: TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.,1
Conclusions: There is symmetric left ventricular hypertrophy.,0
The right ventricular cavity is dilated with borderline normal free wall function.,0
"11:04 AM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with s/p L VATs decortication REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: VATS decortication, to assess for change.",1
Opacification involving the lower half of the left hemithorax is essentially unchanged.,0
There are mild atelectatic changes and possible small effusion at the right base.,0
"However, the remainder of the right lung is clear.",0
"4:10 PM PICC LINE PLACMENT SCH Clip # Reason: reposition Admitting Diagnosis: TACHYCARDIA; ELEVATED TROP; PNA; CH ********************************* CPT Codes ******************************** * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 87 year old man with r sided PICC going to IJ REASON FOR THIS EXAMINATION: reposition ______________________________________________________________________________ FINAL REPORT REPLACEMENT OF RIGHT VENOUS CATHETER WITH PICC INDICATION: 87-year-old man with right-sided attempted PICC placement, malpositioned.",0
Dr. was present during the key moments of the procedure.,0
SEDATION: Administered by the ICU staff.,0
PROCEDURE AND FINDINGS: Patient was placed supine on the imaging table in the interventional suite.,0
Timeout was performed as per protocol.,0
Initial scout fluoroscopic image demonstrated right arm venous catheter tip projecting over the expected location of right axillary vein.,0
"Under aseptic conditions, the catheter was cut close to the hub.",0
A 0.018 wire was advanced through the cut end of catheter and eventually into the IVC.,0
"After removing the catheter remnant (total length 45 cm), a peel-away sheath was placed.",0
"After appropriate measurements and removal of the inner cannula, a 5 French 42 cm double-lumen PICC was placed.",0
Catheter tip was confirmed under fluoroscopy to be in the lower SVC.,0
Ports were aspirated and flushed.,0
Catheter was secured by StatLock.,0
Site was dressed in a sterile fashion.,0
No immediate post-procedure complication was seen.,0
Incidental note of endotracheal tube and right IJV catheter was made.,0
IMPRESSION: Uncomplicated replacement of the right arm venous catheter with a new 5 French 42 cm PICC with its tip in the lower SVC.,0
Height: (in) 63 Weight (lb): 318 BSA (m2): 2.36 m2 BP (mm Hg): 139/86 HR (bpm): 68 Status: Inpatient Date/Time: at 12:41 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
AORTIC VALVE: Bileaflet aortic valve prosthesis ().,1
MITRAL VALVE: Mitral valve not well seen.,0
The mitral valve is not well seen.,0
Overall preserved left ventricular systolic function.,0
Bilealet with probably normal gradients (although size not known).,0
Cannot exclude valvular vegetations or mass given suboptimal image quality.,0
"If clinically indicated, a TEE may better assess for endocarditis/thrombus.",0
"1:24 PM CT SINUS/MAXLIOFACIAL W/O CONTRAST Clip # Reason: INTUBATED, LOTS OF ORAL SECRETIONS, PNA, FEVERS, EVALUATE FOR SINUSITIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman intubated for PNA: new fevers, with persistent, worsening oral secretions: requesting CT scan of sinuses to evaluate for sinusitis: please at with results.",0
"REASON FOR THIS EXAMINATION: REQUESTING SINUS FILM TO EVALUATE FOR SINUSITIS: intubated with LOTS of oral secretion, preventing extubation ______________________________________________________________________________ FINAL REPORT INDICATION: Intubated with secretions, fever.",0
COMPARISON: CT SINUS/MAXLIOFACIAL: TECHNIQUE: Noncontrast axial images were obtained through the paranasal sinuses.,0
Reformatted computerized reconstructions were provided in the coronal planes.,0
FINDINGS: The patient is s/p interval bilateral antrostomies and ethmoidectomies.,0
There is moderate mucosal thickening involving the right maxillary sinus.,0
This is not significantly changed compared with the prior study.,0
There is a new small air fluid level within the left maxillary sinus.,0
There is minimal mucosal thickening involving the ethmoid sinus.,0
There is moderate mucosal thickening involving the sphenoid sinus.,0
This is new compared with the prior study.,0
The mastoid air cells are incompletely visualized on this study.,0
"However, there is mild opacification of the mastoid air cells bilaterally.",0
No osseous destruction is identified.,0
Moderate mucosal thickening involving the right maxillary sinus.,0
There is an air fluid level within the left maxillary sinus.,0
The patient is s/p bilateral antrostomies and ethmoidectomies.,0
There is mild mucosal thickening involving the ethmoid sinus.,0
The frontal sinus is normal.,0
5:37 PM CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate pneumo progression with new B/L pneumos s/p chest t Admitting Diagnosis: ASCENDING AORTA\BENTAL PROCEDURE; POSSIBLE CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman s/p AVR and asc ao replacement REASON FOR THIS EXAMINATION: evaluate pneumo progression with new B/L pneumos s/p chest tube removal ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST: INDICATION: 61-year-old woman status post aortic valve and ascending aorta replacement.,1
"Pneumothorax, status post chest tube removal.",0
"COMPARISON: Multiple previous examinations, most recent dated at 11:50 a.m.",0
FINDINGS: Cardiomediastinal silhouette is unchanged from several hours earlier.,0
There is a prosthetic aortic valve in place.,1
There is linear atelectasis in the lingula.,0
There is no overt change in the extent of an equivocal right and slight decrease in small left apical pneumothoraces.,0
No change in appearance of gas- filled bowel loops under the left diaphragm.,0
IMPRESSION: No change in the appearance of the equivocal right and slightly decreased small left pneumothorax.,0
9:03 PM CT HEAD W/O CONTRAST Clip # Reason: ACUTE CHANGES IN NEUROLOGIC EXAM.,0
"Admitting Diagnosis: BRAIN EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with acute change in neurologic exam REASON FOR THIS EXAMINATION: ?bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NON-CONTRAST HEAD CT INDICATION: 53-year-old woman with intracranial lesion and edema, presenting with mental status changes.",0
"NON-CONTRAST HEAD CT: Again identified is a hyperdense lesion in the left putamen and globus pallidus, with hyperdense portion measuring 3.0 x 1.5 cm compared to 2.6 x 1.5 cm previously.",0
"Another lesion is seen in the corpus callosum, as before.",0
"The degree of vasogenic edema surrounding the lesion and involving the left frontotemporal lobes has not appreciably changed in extent, the degree of mass effect on the left lateral ventricle, 10 mm shift of septum pellucidum and degree of subfalcine herniation as well as uncal herniation are not changed.",0
Review of osseous structures again reveal status post left frontal craniotomy.,0
Air-fluid level is noted in the right maxillary sinus.,0
"IMPRESSION: Not significantly changed degree of vasogenic edema, surrounding left frontal/basal ganglia lesion with approximately 10 mm shift of normally midline structures, subfalcine and uncal herniation.",0
PATIENT/TEST INFORMATION: Indication: Massive pulmonary embolism.,1
Weight (lb): 120 BP (mm Hg): 102/70 HR (bpm): 128 Status: Inpatient Date/Time: at 12:03 Test: Portable TTE (Focused views) Doppler: Limited Doppler and no color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
There is moderate to severe pulmonary artery systolic hypertension.,0
IMPRESSION: Right ventricular cavity enlargement with preserved systolic function.,0
"7:05 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o ivh 292/7 week triplet, dol 8 Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant bornat 29 weeks gestation REASON FOR THIS EXAMINATION: r/o ivh 292/7 week triplet, dol 8 ______________________________________________________________________________ FINAL REPORT HISTORY: Former 29-week premature triplet who is now one week old.",1
This is the first neonatal head ultrasound.,0
Standard coronal and sagittal images of the brain were obtained via the anterior fontanel with additional mastoid views.,0
The ventricles and extraaxial CSF spaces are within normal limits.,0
No abnormal areas of increased echogenicity are present to suggest hemorrhagic or ischemic change.,0
No structural abnormalities are present.,0
IMPRESSION: Normal head ultrasound without evidence for intracranial hemorrhage or ischemia.,0
9:17 PM CT C-SPINE W/O CONTRAST Clip # Reason: fracture ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman MVC vs pole - high speed REASON FOR THIS EXAMINATION: fracture No contraindications for IV contrast ______________________________________________________________________________ WET READ: 11:01 PM No cervical spine fractures or dislocations.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old woman MVC versus pole.,0
TECHNIQUE: MDCT data were acquired through the cervical spine and displayed in multiple planes with reconstruction of bone and soft tissue algorithms.,0
FINDINGS: No acute cervical spine fracture or malalignment is present.,0
Mild degenerative changes are present with disc osteophyte complexes at C5-C6 causing mild canal narrowing at these levels.,0
Pre- and paravertebral soft tissues are not thickened.,0
Retained secretions in the nasopharynx are likely secondary to recent intubation.,0
The visualized lung apices are clear.,0
IMPRESSION: No acute cervical spine fracture or malalignment.,0
7:42 AM UNILAT LOWER EXT VEINS LEFT; US EXTREMITY NONVASCULAR LEFT Clip # Reason: ?,0
"hematoma vs fluid collection and r/o DVT Admitting Diagnosis: INFECTED RIGHT HIP/SDA ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with EDS and recent right hip fracture s/p surgery now w/worsening left thigh pain, warmth, erythema.",1
"hematoma vs fluid collection and r/o DVT ______________________________________________________________________________ FINAL REPORT INDICATION: 48-year-old woman with recent hip surgery of contralateral thigh presenting with left thigh pain, warmth, erythema and lowering hematocrits.",1
"FINDINGS: There is normal grayscale appearance, compressibility, color flow, and spectral Doppler waveforms of the left common femoral, superficial femoral and popliteal veins.",0
One visualized peroneal vein is patent.,0
The posterior tibial veins are not seen.,0
There is extensive subcutaneous edema throughout the left lower extremity.,0
A pocket of fluid in the popliteal fossa has some swelling debris on realtime visualization.,0
The pocket is not well circumscribed as would be seen with a cyst or abscess.,0
No DVT in the left lower extremity.,0
Moderate subcutaneous edema in the left lower extremity.,0
11:06 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: Needs CT head by 2300 to eval for ventriculostomy placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with hydrocephalus s/p ventriculostomy REASON FOR THIS EXAMINATION: Needs CT head by 2300 to eval for ventriculostomy placement No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd WED 12:12 AM New ventriculostomy cath.,1
appears to course through the left temporal and end at the level of the suprasellar cistern.,0
Stable appearance of left temporo-occipital intraparenchymal hemorrhage and intraventricular hemorrhage since prior study.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 63-year-old man with hydrocephalus status post ventriculostomy.,0
"Compared to the previous study performed approximately four-and-a- half hours prior, there is no significant change in the left parietal/temporal/occipital intraparenchymal and intraventricular hemorrhage, with surrounding edema and mild rightward midline shift.",0
Bilateral subarachnoid hemorrhage is also unchanged.,0
"There has been interval placement of a ventriculostomy, which enters from the left temporal approach, traverses the left temporal , and terminates in the suprasellar cistern.",0
The temporal of the left lateral ventricle has decreased in size; other ventricular system components are stable.,0
IMPRESSION: The ventriculostomy catheter courses through the left temporal and ends in the suprasellar cistern.,0
Left temporal smaller; other ventricular system components stable.,0
"Stable parenchymal, intraventricular and subarachnoid hemorrhage.",0
"9:16 PM CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # Reason: clarify CXR findings, eval for pnuemonia Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with MVC persistent fevers and RLL consolidation, peripheral nodular opacities and L pleural effusion on CXR REASON FOR THIS EXAMINATION: clarify CXR findings, eval for pnuemonia No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Persistent fevers, right lower lobe consolidation, peripheral nodular densities and left pleural effusion on chest x-ray, evaluate for pneumonia.",1
Comparison is made to the prior CT scan dated .,0
TECHNIQUE: Multidetector CT scanning of the chest was performed before and after administration of 100 cc of intravenous Optiray contrast.,0
"CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There is a left subclavian central venous catheter, endotracheal tube, and NG tube present in satisfactory position.",0
There has been interval repair of the previously identified pseudoaneurysm of the descending thoracic aorta with adjacent clips.,1
"A small amount of residual associated mediastinal hemorrhage is again demonstrated, without evidence of leak.",0
This is unchanged compared to the prior study.,0
"There are no pathologically enlarged axillary, hilar or mediastinal lymph nodes.",0
"There is a small left-sided pleural effusion, which has developed in the interval.",0
There is adjacent left lower lobe atelectasis.,0
There is also a band-like area of presumable atelectasis in the right lower lobe.,0
There are also diffuse bilateral patchy areas of ground-glass opacity.,0
There has been interval resolution of the prior pneumothorax.,1
The visualized portions of the upper abdomen are again remarkable for large laceration of the liver.,0
"There is a newly appreciated wedge-shaped area of hypoperfusion demonstrated in the inner polar region of the right kidney, which is most consistent with a small infarct.",0
"Note is also made of a small amount of free fluid in the abdomen adjacent to the spleen, slightly increased compared to prior.",0
BONE WINDOWS: There are again demonstrated multiple bilateral rib fractures as described previously.,1
"Bilateral diffuse ground glass opacities, which could reflect edema, inflammation or or sequella of trauma.",0
"Left lower lobe dependent area of enhancing air-space disease, most (Over) 9:16 PM CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # Reason: clarify CXR findings, eval for pnuemonia Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) typical for atelectasis with a smaller band-like area of atelectasis in the right lower lobe.",1
Small pleural effusions left greater than right.,0
"Interval development of wedge-shaped hypoperfused area, most typical of an infarct in the right kidney.",0
4:37 PM CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # Reason: eval PICC placement Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH MVR VERSUS REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man REASON FOR THIS EXAMINATION: eval PICC placement ______________________________________________________________________________ WET READ: MDAg FRI 5:35 PM L PICC ends in mid-low SVC.,1
ETT ends 3.8cm above carina.,0
interval removal of swan ganz.,0
introducer ends in right subclavian vein.,0
improved pulmonary edema WET READ VERSION #1 MDAg FRI 5:30 PM L PICC ends in mid-low SVC.,0
______________________________________________________________________________ FINAL REPORT SINGLE VIEW OF THE CHEST AT 1703 CLINICAL INDICATION: 60-year-old with PICC line placement.,0
Single AP supine chest film at 1703 is submitted.,0
Interval placement of a left subclavian PICC line with its tip in the distal superior vena cava.,0
Endotracheal tube has its tip 3.8 cm above the carina.,0
Nasogastric tube is seen coursing below the diaphragm with the tip not identified.,0
The Swan-Ganz catheter has been removed and an introducing catheter remains in place ending in the right subclavian vein.,0
"There are persistent patchy opacities at both bases, left greater than right, which likely reflect atelectasis possibly related to small effusions.",0
"Overall, pulmonary edema has significantly improved.",0
"No large pneumothorax, although the sensitivity of detecting pneumothorax is diminished on a supine radiograph.",0
Status post median sternotomy with overall stable post-operative cardiac and mediastinal contours.,0
10:24 PM BABYGRAM (CHEST ONLY) Clip # Reason: check line Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with PICC line REASON FOR THIS EXAMINATION: check line ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 22:59 HOURS: HISTORY: Former 29-week preemie.,1
"In followup to , a left arm PICC line has been advanced with tip terminating in the right atrium.",0
The patient has been extubated in the interval.,0
A feeding tube terminates in the left-sided stomach.,0
The lungs are hyperinflated with mild diffuse granular hazy opacity consistent with residual RDS/early chronic lung disease.,0
Some more confluent opacity is present in the right upper lobe consistent with atelectasis.,0
"7:57 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for infiltrate, fluid status Admitting Diagnosis: COLD LEG ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with NSTEMI, CHF, femoral thrombus REASON FOR THIS EXAMINATION: please evaluate for infiltrate, fluid status ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath in a patient with congestive heart failure, known ST elevation MI, and known femoral thrombus.",1
PORTABLE AP CHEST RADIOGRAPH WAS COMPARED TO .,0
"The heart size is moderately enlarged, stable.",0
The mediastinal contours are unchanged as well.,0
The Swan-Ganz catheter tip terminates in main pulmonary artery/right ventricle outflow tract.,0
The pacemaker leads terminate in right atrium and right ventricle.,0
Interval improvement in the left retrocardiac opacity is demonstrated considering partial resolution of atelectasis.,0
There is no change in the right basal atelectasis as well as in small bilateral pleural effusions.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Tetanus Attending: Chief Complaint: hypotension and fever Major Surgical or Invasive Procedure: central venous line History of Present Illness: 73 yo F with CVA, HTN, bladder ca s/p neobladder, who was recently d/c from morning prior to admission.",1
"In brief, pt was eval for bloody stools and abd pain and found to have an SMA embolus.",0
"She was taken to the OR with Dr for who found transverse colitis, no mesenteric ischemia.",0
"She was on TPN, levo/flagyl during that admission.",0
outpt c-scope; pt improved and d/c to NH on tolerating POs.,0
"Pt returned to with similar lower abd bandlike pain, N/V.",0
"She was admitted, negative GI infectious w/u of her pain.",0
She was briefly hypotensive during this admission which improved with IVFs.,0
"UA/u cx showed E Coli, bactrim switched to nitrofurantoin, pt d/c'd with this med.",0
"Pt presents to with 98.1, 100, 33, 182/121, 100% NRB (68% RA).",0
CTA neg for PE and CT abd neg for infection.,0
"She recieved ntg gtt, flagyl, levofloxacin, vanco, lasix 40 mg IV x 1, fentanyl 50 mcg x 1.",0
Transferred to for further mgmt.,0
"In the ED, 103.8, 122, 94/33, 100% NRB.",0
"Pt was given levofloxacin, flagyl; BP's decreased to SBP 70's.",0
Levophed started at currently at 0.05 mcg/kg/hr.,0
"Her breathing worsened; CXR with mild CHF, lasix 40 mg IV given.",0
"Trop also noted to be 0.2, EKG with some dep in v3-6.",0
"RN report, pt received 5500 with resucitation.",0
"On eval, pt c/o of some SOB, no cough.",0
"She denies CP, pressure or other sx.",0
Her only complaint is that she is hungry.,0
Admitted to MICU for sepsis and resp failure.,1
Bladder CA s/p neo bladder 3.,0
CVA with L paralysis on 4.,0
"UTI Social History: From NH Divorced Family History: Sister: endometrial CA Physical Exam: Temp 103.8 BP 122/54 (0.05 mcg/kg/hr on levophed) Pulse 122 Resp 19 O2 sat 97% 100 % NRB Gen - alert, tired, able to speak in full sentences HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes dry Neck - JVP to angle of jaw, no cervical lymphadenopathy Chest - poor air mvmt, diffuse wheezes, ?",0
"crackles at bases CV - tachycardia Abd - Soft, nontender, min distended, surgical midline scar C/D/I w/ staples Extr - trace edema.",0
"1+ DP pulses bilaterally; right leg with femoral line Neuro - Alert and oriented x 3, cranial nerves intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash Brief Hospital Course: MICU COURSE: The patient was admitted to the MICU service.",0
"She was covered with linezolid for h/o VRE, and zosyn for the E. Coli UTI/urosepsis.",0
"The patient was weaned off pressors, restarted when SBP decreased to 70s, then weaned off.",0
Briefly on steriods for a quetion of COPD exacerbation but this was discontinued by HD 2.,0
On HD 3 the patient had her femoral line removed and was transferred to the floor in stable condition for futher monitoring and treatment of her E. coli UTI.,0
"A/P: 73yo F with idiopathic colitis and hx of CVA, PVD, HTN who was recently admitted to surgery s/p ex lap, s/p E coli urosepsis vs. colitis and covered with Zosyn/Linezolid (w/ Linezolid d/c'd) s/p MICU from , stabilized, now transferred to Medicine service.",1
"# Abd pain, Idiopathic colitis: On exam, pt with diffuse abd pain, worse at suture line.",0
Pt felt to have resolved sepsis colitis vs. urosepsis.,1
"Repeat CT Abd showing no evid colitis, findings c/w cystitis, and pt being treated with Zosyn day of therapy.",0
"Transplant surgery evaluated pt, felt that mesenteric ischemia unlikely, and that her abdominal pain is c/w post op pain.",0
He noted that she had normal flow on angio .,0
"We continued w/ oxycodone prn and followed her abd exam closely, which went unchanged since transfer to medical floor.",0
"Her stool cx sent and were all negative, O&P negative, Cdiff negative.",0
"We checked her TSH, and it was slightly elevated at 4.6, but checked free T4 and this was found to be normal.",0
"She is , ANCA negative (elev CRP, ESR).",0
"She has follow up in clinic to evaluate her transverse colitis, and then should be scheduled for outpatient colonoscopy.",0
"# UTI s/p ?Urosepsis in MICU, resistant E coli to Zosyn, nitrofurantoin, cefazolin, ctx.",0
"Pt is on day of Zosyn therapy, which should cover her broadly for urinary tract pathogens.",1
She had a PICC line placed on for expected total of 2 weeks of Zosyn.,0
"She continues to be afebrile, with WBC reflecting eosinophilia recently, most likely secondary to Zosyn.",0
"Her repeat UA was negative X 2, urine cx negative.",0
Her foley catheter was changed and irrigated.,0
"Urine cytology was sent given her distant history of bladder cancer, and is pending at discharge.",1
This can be followed up at her PCP .,0
"# Leukocytosis: Pt is being broadly covered with IV Zosyn, which may be causing the elevated WBC count, which is predominately eosinophilia most likely antibiotics.",0
"Her UA and urine cx negative, blood cx negative, and stool is negative for bacterial, parasitic, Giardia/Cryptosporidium, and C diff negative.",0
"# Hct drop/Anemia, stable now.",0
Her hemolysis labs are negative.,0
Her B12 and folate are WNL.,0
Her iron was sent and is pending at discharge.,0
RN reports the pt's stool is guiaic negative.,0
She is to undergo outpatient colonoscopy.,0
We restarted lopressor 12.5mg po bid w/ hold parameters.,0
CV: A. CAD: Pt w/ risk factors for CAD.,0
"-cont ASA, statin, BB .",0
Has been tachycardic to 100s.,0
c. Pump: some evidence of lower extremity edema but no JVD.,0
-CXR showing no vol overload.,0
"4. h/o CVA -cont ASA, statin .",0
"Surgical wound: appears to be healing very well -removed staples , with good cosmetic result.",0
"Pulm: The pt has a hx of COPD and is on spiriva, alb and advair at baseline.",0
"Her most recent CXR shows mild interstitial pulm edema, resolving, and small b/l pleural effusions.",0
"We continued her outpatient regimen of spiriva, alb and advair.",0
Her sats continue to be stable on room air.,0
"PPx: heparin sub Q TID, bowel regimen.",0
Medications on Admission: flovent 250/50 IH tiotporium 1 cap qd albuterol sulfate neb q 6 neurontin 100 mg tid lipitor 20 mg qd metoprolol 50 mg oxycodone 5 mg q 4-6 prn nitrofurantoin 1 cap ASA Discharge Medications: 1.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing.,0
Disp:*qs nebulizer treatment* Refills:*2* 7.,0
Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed.,0
Disp:*1 Disk with Device(s)* Refills:*2* 12.,0
Ketoconazole 2 % Cream Sig: One (1) Appl Topical (2 times a day) for 7 days: apply to groin areas bilaterally until redness diminishes.,0
Disp:*1 largest stock tube* Refills:*0* 14.,0
Piperacillin-Tazobactam Na 2.25 gm IV Q6H 15.,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) sq Injection TID (3 times a day).",0
Disp:*90 sq* Refills:*2* Discharge Disposition: Extended Care Facility: & Rehab Center - Discharge Diagnosis: 1.,0
Sepsis secondary to urosepsis vs. idiopathic colitis 2.,1
Chronic Obstructive pulmonary disease 7.,1
"Hyperlipidemia Discharge Condition: Stable, good Discharge Instructions: If you experience any worsening of your symptoms, please report to the emergency room immediately.",0
Please take all of your medications as directed.,0
Please follow up with your doctors (see information below).,0
You will need to follow up with Gastroenterology for an outpatient colonoscopy.,0
"You have an appointment set for , at 9:30am (Friday) with Dr. .",0
"Please follow up with your Primary Care Physician, .",0
"on Friday, at 12 noon.",0
Her office number is: .,0
5:24 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with severe sepsis REASON FOR THIS EXAMINATION: ?,0
"interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Severe sepsis, evaluation for interval change.",0
"FINDINGS: As compared to the previous radiograph, small pleural effusions have occurred bilaterally.",0
"Deviation of the trachea to the right is likely caused by a thyroid goiter, which could be confirmed by ultrasound.",0
8:01 PM CT LOW EXT W/O C RIGHT Clip # Reason: evaluate distal right tib/fib/ankle for post-reduction evalu ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with ankle fracture s/p bedside splinting REASON FOR THIS EXAMINATION: evaluate distal right tib/fib/ankle for post-reduction evaluation/pre-op plans No contraindications for IV contrast ______________________________________________________________________________ WET READ: ASpf SAT 8:56 PM Communited distal tibial pilon and A fibular fracture.,1
The anterior tibial fracture fragment is distracted by 3 cm.,1
"______________________________________________________________________________ FINAL REPORT HISTORY: Ankle fracture, evaluate post reduction, preoperative.",1
TECHNIQUE: Contiguous thin section axial images were helically acquired from the lower calf through the mid foot and reconstructed using both bone and soft tissue algorithm.,0
Coronal and sagittal reformats were also generated.,0
Study dated presented now for official interpretation.,0
"RIGHT LOWER EXTREMITY CT WOTHOUT CONTRAST: There is markedly comminuted fracture of the distal tibia, extending to the tibial plafond, consistent with a pilon fracture.",1
There is 20-25 mm distraction of the major anterior and posterior fragments along the tibial plafond surface.,0
The anterior fragment is angled anteriorly/dorsally.,0
There is approximately 4 mm proximal displacement (depression) of the anterior fragment compared to the articular surface of the posterior fragment.,0
There is prominent anterior subluxation of the talus with respect to the distal tibia.,0
There is also lateral displacement of the talus with respect to the major medial tibial fragment.,0
An additional horizontal axial oblique fracture subtends the distal medial malleolus.,0
The medial aspect of the mortise joint is widened.,0
"A tiny calcific is interposed between the lateral malleolus and lateral talar dome (series 400B, image 87).",0
Additional tiny fragments project over the posterior tibiotalar joint space.,0
There is a comminuted fracture of the distal fibular diaphysis with disruption of the distal tibiofibular joint and lateral angulation of the major distal fibular fracture.,1
The subtalar joint remains congruent.,0
Note is made of a non-displaced fracture of the medial cuneiform extending to the first tarsometatarsal joint (2:179).,0
There is also a small fracture at the medial base of the second metatarsal (2:191).,0
"A tiny ossific is seen along the distal lateral corner of the navicular bone (2:187) -- although this likely represents a tiny fracture fragment, no obvious donor site is identified.",0
"There appears to be proximal distraction of the navicular ossicle with respect (Over) 8:01 PM CT LOW EXT W/O C RIGHT Clip # Reason: evaluate distal right tib/fib/ankle for post-reduction evalu ______________________________________________________________________________ FINAL REPORT (Cont) to the medial navicular bone (3:173), which raises suspicion for avulsion of the posterior tibial tendon.",0
"The calcaneus appears grossly intact, without lucent or sclerotic fracture line.",0
A large inferior calcaneal spur is noted.,0
Degenerative changes at the talonavicular joint are also noted.,0
There is considerable surrounding soft tissue swelling.,0
"Of note, there is a skin defect along the posteromedial ankle (3:144) with a large amount of fluid and air within the tibiotalar joint, extending proximally into the tibia itself and around the ankle.",0
"Assessment of the soft tissues is limited, but shows extensive stranding.",0
No obvious tendon entrapment is identified at this time.,0
"Comminuted intra-articular fracture of the distal tibia, with tibiotalar subluxation and widening of the medial mortise joint, as described.",1
"Air within the joint, consistent with an open fracture.",0
"Comminuted fracture of the distal fibular diaphysis, with disruption of the distal tibiofibular joint.",1
Non-displaced fractures involving the medial cuneiform and base of the second metatarsal and additional tiny fracture fragment adjacent to the navicular bone.,1
"Proximal distraction of the navicular ossicle, raising suspicion for possible avulsion of the posterior tibial tendon.",0
"6:57 PM CHEST (PORTABLE AP) Clip # Reason: eval for consol, aspiration, infx Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with GBS, weaker, worsening tachypnea REASON FOR THIS EXAMINATION: eval for consol, aspiration, infx ______________________________________________________________________________ FINAL REPORT RADIOGRAPH OF CHEST CLINICAL INDICATION: 56-year-old man with GBS, weaker, worsening tachypnea.",0
"Evaluate for consolidation, aspiration, or infection.",0
FINDINGS: There is a nasogastric tube seen with tip seen in the stomach.,0
There is a left-sided central venous catheter with tip projecting over the right atrium.,0
Cardiopericardial silhouette is unchanged in size.,0
There is stable degree of bibasilar atelectasis.,0
No new airspace consolidation is evident.,0
"There is mild interval increase in vascular distention, which may be related to interval development of mild interstitial edema.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Left sided weakness, difficulty speaking.",0
Major Surgical or Invasive Procedure: Angiography and administration of intracerebral intraarterial tPA.,1
History of Present Illness: Patient is a 61 year old right-handed male with no significant past medical history or known vascular risk factors who presented on as transfer from outside hospital with acute onset left sided weakness and slurred speech.,0
Patient was in his usual state of health until sometime around 2 pm on day of admission.,0
"He was last seen well by his wife ~1:30pm, when he dropped off something at her office.",0
"He reports that around 2pm, he arose from chair and fell onto his left side, landing on his shoulder.",0
"Prior to that, he reports a dull right frontal and orbital headache.",0
"Denies visual changes, head injury, loss of consciousness, paresthesias, chest pain, palpitations, vertigo, lightheadedness, shortness of breath.",0
His wife returned home from work at 4pm and found him slumped on the floor and noted his speech disturbed.,0
She notified emergency medical services and he was transported to .,0
"On transport to , he was noted to have blood glucose of 61 and given ampule of dextrose.",0
"On arrival to , vitals showed BP 133/68, HR 57, RR 16, T 97.7.",0
He was noted to complain of headache.,0
"Noted to have right gaze preference, left upper and lower extremity weakness, and left sided neglect.",0
"CT scan there read as right MCA ""dense"" sign.",0
He was therefore transferred to for further care.,0
"On arrival at , NIH stroke scale was 19.",0
He was immediately taken to the angiography suite and underwent administration of 20 mg intra- arterial tPA for right M1 MCA proximal occlusion.,0
Post-tPA NIH stroke scale of 17.,0
"Post-tPA, he complained of worsened headache.",0
He was taken to CT scan where a small area of right basal ganglia hemorrhage was noted.,0
"After arrival to the ICU, he was able to move left lower extremity against gravity.",0
"Social History: Married, lives with wife in .",0
"No tobacco, alcohol, drug use.",0
Retired from work in manufacturing.,0
Family History: No family history of stroke or seizure.,0
"Physical Exam: BP 140/70, HR 60, RR 20, O2 100%/3L Gen: WD/WN, comfortable, NAD.",0
"Abd: Soft, NT, ND, +NABS.",0
"Oriented to person, place, and date.",0
Able to recite forwards and backwards.,0
Recalled objects at 5 minutes.,0
Speech dysarthric with marked stuttering.,0
"Good comprehension for midline, appendicular and 2 step commands.",0
"Repetition intact, but limited by stuttering.",0
Left sided neglect in upper and lower extremities on double simultaneous stimulation.,0
"III, IV, VI: Right gaze preference.",0
Extraocular movements intact bilaterally without nystagmus.,0
"V, VII: Left central facial palsy.",0
: Trap no movement on left.,0
XII: Tongue deviated to right without fasciculations.,0
Not yet able fully hold against gravity.,0
Sensation: Intact to light touch and pinprick.,0
Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 0 Left 2 2 2 2 0 Grasp reflex absent.,0
"Coordination: Slowed finger-nose-finger, rapid alternating movements on right.",0
Unable to assess on left.,0
Pertinent Results: 06:30PM WBC-7.7 RBC-4.41* HGB-14.4 HCT-40.6 MCV-92 MCH-32.7* MCHC-35.5* RDW-13.1 06:30PM NEUTS-81.4* LYMPHS-15.2* MONOS-2.8 EOS-0.5 BASOS-0.1 06:30PM PLT COUNT-204 06:30PM PT-13.0 PTT-25.7 INR(PT)-1.1 CT head post tPA: Motion limited study.,0
Right basal ganglia hyperdensity consistent with acute hemorrhage without significant associated mass effect.,0
MRI : There is abnormal signal in the right basal ganglia consistent with the CT findings of acute basal ganglionic hemorrhage.,0
There is abnormal signal in the posterior frontal lobe involving the matter on diffusion and T2W sequences consistent with subacute infarction.,0
There is no evidence of a focal extra-axial lesion or fluid collections.,0
There is some deformity of the right lateral ventricle.,0
MRA : There is no evidence of aneurysm or definite flow abnormality.,0
Perhaps slight irregularity of the inferior division of the right middle cerebral artery but this is indefinite.,0
Transesophageal echocardiogram : No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage.,0
LAA ejection velocity was good (> 40 cm/s).,0
Carotid dopplers: Duplex ultrasonography was performed at the level of the cervical portions of the bilateral carotid and vertebral arteries.No plaque was found on either side.,0
"The waveforms and velocities in the bilateral internal, common and external carotid arteries and in the bilateral vertebral arteries were normal, with antegrade flow.",0
"Brief Hospital Course: Patient is a 61 year old right-handed male with no significant past medical history who presented on with acute onset slurred speech, left sided weakness.",0
"Neurological exam on presentation was remarkable for a left field cut, left facial, left hemiparesis, left neglect and dysarthria.",0
This was consistent with a right MCA infarct.,0
CT scan at showed a dense right MCA.,0
"On arrival to , he was taken immediately to angiography.",0
"Angiography confirmed a right MCA infarct with occlusion at the proximal M1 segment, likely secondary either to artery-artery or cardiogenic embolus.",0
Patient was treated with 20 mg of intra-arterial tPA.,0
Status post intra-arterial tPA he had improvement in left lower extremity movement and was able to hold his leg against gravity.,0
NIH stroke scale improved from 19 to 9.,0
"However, post-tPA he complained of worsened headache; CT scan demonstrated right basal ganglia hemorrhage.",0
He was monitored in the Intensive Care Unit overnight.,0
Repeat head CT in the am on revealed no significant interval change.,0
The patient's right groin sheath was removed and a hematoma was noted.,0
The patient was transferred to the neurological stepdown unit.,0
Head MRI demonstrated susceptibility change in the right basal ganglia with a superimposed area of increased DWI signal.,0
Head MRA demonstrated recannulization status post tPA except for absent right M2 MCA branch.,0
Transthoracic echocardiography revealed no atrial septal defect or patent foramen ovale.,0
Carotid dopplers revealed no significant stenosis.,0
"On , the patient developed an asymptomatic narrow complex tachycardia which was detected on telemetry and determined to be atrial fibrillation.",1
He was treated with IV metoprolol and diltiazem via standard ACLS protocol and successfully rate controlled.,0
He underwent transesophageal echocardiography which revealed no evidence of intracardiac or aortic arch thrombus.,0
In the evening the patient reverted back to a stable normal sinus rhythm after two doses of IV diltiazem.,0
The patient was started on aspirin.,0
The patient remained primarily in normal sinus rhythm but with intermittent episodes of atrial fibrillation.,1
The patient was begun on an oral diet and oral diltiazem after a speech and swallow evaluation determined he was at low risk for aspiration.,0
"However, he continued to have episodes of atrial fibrillation.",1
"Ultimately, diltiazem was felt not to be an ideal drug for rate control to do the patient's low baseline heart rate and blood pressure.",0
"Patient was started on Amiodarone with a loading dose of 400 mg po tid for 5 days; thereafter, he will continue on Amiodarone 400 mg po qd indefinitely.",0
"Due to likely embolic nature of his infarct and the persistent paroxysmal atrial fibrillation, we decided to begin coumadin.",1
Patient was started on heparin drip with goal PTT of 40-60.,0
He was started on coumadin with goal INR of 2.0-3.0.,0
"While at rehab, he should be monitored on telemetry and have episodes of atrial fibrillation recorded.",1
He will follow up with Dr. in the division of cardiology.,0
"At discharge, patient's neurological exam was stable.",0
"It is notable for occasional stuttering of speech, left facial droop and a mild left hemiparesis with strength in left deltoids/triceps/wrist and finger extensors/iliopsoas approximately 4+/5.",0
"He is being discharged to an acute rehabilitation facility for continued speech, occupational and physical therapy.",0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever.,0
Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 2 days.,0
Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO once a day: To begin on .,0
Diphenhydramine HCl 25 mg Capsule Sig: Capsules PO Q6H (every 6 hours) as needed for Itching.,0
Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for itching.,0
Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Nine Hundred (900) units/hour Intravenous ASDIR (AS DIRECTED): Continue until INR is therapeutic.,0
Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical (2 times a day) as needed for contact dermatitis.,0
Insulin Regular Human 100 unit/mL Solution Sig: Variable units Injection ASDIR (AS DIRECTED): Per regular insulin scale.,0
Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical (2 times a day) as needed for to rash.,0
Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): Goal INR 2.0-3.0.,0
Discharge Disposition: Extended Care Facility: Medical Center - Discharge Diagnosis: 1.,0
Intracerebral hemorrhage status post intraarterial tPA administration 3.,1
"Atrial fibrillation Discharge Condition: Stable; Residual left face, arm and leg weakness.",1
"Discharge Instructions: Please seek medical attention if you experience headache, visual changes, problems with speech, problems with gait, incoordination, chest pain, shortness of breath, increased weakness or numbness, or any other concerning symptoms.",0
Please continue Heparin with goal PTT of 40-60 until INR on Coumadin is therapeutic.,0
Please check PTT q6 hours.,0
Please adjust coumadin dose accordingly.,0
Followup Instructions: You can follow up with Dr. in the Neurology Clinic.,0
Call to schedule an appointment.,0
She would like to see you sometime during the month of .,0
"Alternatively, an appointment with Dr. has been scheduled for @ 2:00 PM in the Neurology Clinic, Clinical Center .",0
An appointment has been scheduled with Dr. at CENTER CARDIAC SERVICES Phone: Date/Time: 2:15.,0
"Finally, please follow up with your primary care physician within one week following your discharge from rehab.",0
"Where: CARDIAC SERVICES Phone: Date/Time: 2:15 MD,",0
"10:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # Reason: aortoenteric fistula Admitting Diagnosis: CARDIAC ARREST Field of view: 39 Contrast: VISAPAQUE Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with CAD, HTN, s/p AAA repair, now w GI bleed REASON FOR THIS EXAMINATION: aortoenteric fistula No contraindications for IV contrast ______________________________________________________________________________ WET READ: JXRl MON 11:49 PM RLL consolidation concerning for aspiration.",0
4.2cm infrarenal aortic aneurysm extends into left common iliac artery.,0
"no active extravasation noted, no contrast within bowel.",0
"retroperitoneal/left perinephric stranding, small amount of fluid left paracolic gutter.",0
"left psoas collection measures approx 40HU, 6.cm (CC) x 3.6cm (TRV) x 2.1cm (AP).",0
scoliosis/severe degenerative changes of LS spine.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old male with coronary artery disease, hypertension, status post AAA repair, now with GI bleed.",1
TECHNIQUE: MDCT of the chest and abdomen was obtained before and after administration of intravenous contrast.,0
"Images were reformatted in the axial, sagittal and coronal planes.",0
CT OF THE CHEST: ET tube is in place terminating above the carina.,0
NG tube is in place with tip located in the stomach.,0
"Several lung nodules located in both lungs, the largest one measuring 8.5 mm in right upper lobe and 7.6 mm in right lower lobe (3:25, 26, 54, 27, 28, 31, 36).",0
Emphysematous changes in the lungs.,0
Pleural based plaque is identified in the right upper lung.,0
Emphysematous changes in both lungs.,0
"Bibasilar consolidations, right more than left, probably represent atelectasis.",0
Focal atelectasis is located in the left lower lung (3:39).,0
"Heart size is within normal limits, and presents coronary calcifications.",1
No pericardial or pleural effusion.,0
Enlarged right hilar lymph node measuring 15 x 10 mm.,0
No other pathologically enlarged lymph nodes are identified.,0
"CT ABDOMEN: The liver, gallbladder, spleen, pancreas, adrenal glands are unremarkable.",0
Presence of contrast in teh interior of gallbladder probably from prior study (2-3 days before).,0
Adrenal glands are thickened without identification of nodules.,0
Kidneys present with round small hypodense lesions too small to be characterized.,0
The left kidney presents with some surrounding strandings.,0
Small amount of fluid is located in the left paracolic gutter.,0
"Left psoas collection measures approximately 40 , 6 cm x 3.6 cm x 2.1 cm CT ANGIOGRAM: Atherosclerotic calcifications throughout the aorta, major branches and more prominently in the iliac arteries.",0
"Focal bulging of the (Over) 10:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # Reason: aortoenteric fistula Admitting Diagnosis: CARDIAC ARREST Field of view: 39 Contrast: VISAPAQUE Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) lateral wall of the aortic arch (3:32).",0
An infrarenal abdominal aortic aneurysm measures up to 41.9 x 40.6 mm; which extends into the proximal left common iliac artery where measures 22 mm in diameter.,0
There is no active extravasation noted.,0
No contrast is identified within gastrointestinal tract.,1
BONE WINDOWS: Presence of a scoliosis and severe degenerative changes of the lumbosacral spine.,0
Infrarenal abdominal aortic aneurysm measuring up to 42 mm and extends into the proximal left common iliac artery.,0
There is no evidence of aortoenteric fistula.,0
Left perinephric and retroperitoneal stranding.,0
Small amount of fluid in the left paracolic gutter.,0
"Left psoas collection measuring 40 , 6 cm x 3.6 cm x 2.1 cm 5.",0
"Several lung nodules as described in the text, the largest one measuring 8.5 mm.",0
"If patient has history of smoking or known risk factors, a followup in six months is suggested.",0
"Bibasilar consolidations probably represent atelectasis, but could represent aspiration.",0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: assess HD cath placement, r/o PTX Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with change over wire of L IJ trauma line to HD line REASON FOR THIS EXAMINATION: assess HD cath placement, r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Change of left IJ line to hemodialysis line.",1
Assess placement and rule pneumothorax.,0
"COMPARISON: Chest, earlier same day, and chest x-ray .",0
FINDINGS: ET tube tip reaches the thoracic inlet.,0
"Left subclavian central venous line contains Swan-Ganz catheter, the tip within the right main pulmonary artery.",0
Left internal jugular central venous line tip reaches the proximal SVC.,0
NG tube tip over overlies the stomach.,0
Right upper quadrant surgical drains are noted.,0
There is bilateral interstitial pulmonary edema and layering effusions.,0
Bibasilar atelectasis is also likely.,0
IMPRESSION: CHF and bilateral effusions.,0
Findings reported to Dr. by telephone as requested at 10:07 a.m. .,0
", J. TSICU 12:12 PM CHEST PORT.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: L picc placement Admitting Diagnosis: CHOLANGIO CARCINOMA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with picc placed REASON FOR THIS EXAMINATION: L picc placement ______________________________________________________________________________ PFI REPORT There is a left-sided PICC catheter whose tip coils upon itself with the tip directed superiorly in the SVC.,0
Withdraw catheter approximately 5 cm.,0
No epidural abscess collection of the lumbar spine is noted.,0
"Please note that CT is not a sensitive modality for this , an MR is more sensitive for of epidural abscess collection.",0
"New development of enhancing fluid collection around the left hip joint, which also abuts the proximal femoral and is highly concerning for a septic left hip arthropathy.",0
"Multiple areas of enhancing fluid collections are noted within the left quadriceps femoris muscle, which appears quadriceps muscle.",0
New focus of enhancing fluid collection internal and external to the left iliac bone within the gluteal and iliacus muscles which might be start of an abscess collection.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 27-year-old man with multiple left thigh abscesses and MRSA bacteremia, who is unable to ambulate.",0
Please evaluate for epidural abscess.,0
TECHNIQUE: Axial MDCT images were obtained from the upper abdomen to the mid thighs bilaterally after administration of 130 cc of Optiray intravenously.,0
"CT OF THE ABDOMEN: The visualized part of the liver, gallbladder, adrenal glands, right kidneys, and pancreas has normal appearance.",0
There is a simple cyst in the upper pole of the left kidney measuring 46 x 46 mm.,0
Stomach and duodenal loops of small bowel and large bowel appear unremarkable.,0
"(Over) 6:15 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Pls eval for evidence of lumbar spine epidural abscess, oste Admitting Diagnosis: LOW BACK PAIN Field of view: 51 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) CT OF THE PELVIS: Urinary bladder contains a Foley catheter.",0
"The rectum, sigmoid colon, prostate, and seminal vesicles appear unremarkable.",0
"There is new rim-enhancing fluid collection lateral and medial to the left iliac bone, which is concerning for an abscess collection.",0
UPPER THIGHS: There is interval development of new enhancing fluid collection of the left hip joint.,0
Enhancing fluid collection is also abutting the left proximal femoral shaft.,0
Multiple foci of rim-enhancing fluid collection are noted within the left quadriceps femoris muscle.,0
Moderate-to- severe degree of swelling of the left upper thigh is noted.,0
Small amount of gas bubbles are noted deep to the subcutaneous tissue in the superficial fascia that are most likely related to the recent surgical procedure.,1
No signs of epidural abscess are noted within the lumbar spine.,0
Please note that CT is not as sensitive as MR of epidural abscess collection.,0
"New development of enhancing wall fluid collection pocket around the left hip joint, which also abuts the proximal femoral shaft.",0
Multiple pockets of enhancing wall fluid collections are noted within the left quadriceps femoris muscle.,0
New foci of enhancing wall fluid collection internal and external to the left iliac bone are concerning for abscess collection.,0
"2:06 PM CT HEAD W/O CONTRAST Clip # Reason: 47 year old man with bilateral SDH, s/p bilateral burr holes Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with bilateral SDH, s/p bilateral burr holes, please evaluate for post op changes, please do w/n 4 hrs.",0
"REASON FOR THIS EXAMINATION: 47 year old man with bilateral SDH, s/p bilateral burr holes, please evaluate for post op changes, please do w/n 4 hrs.",0
"No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj FRI 4:42 PM Status post bilateral burr holes, drain placement and evacuation of bilateral subdurals.",0
"Left hemispheric subdural hematoma has been replaced with a low-density CSF collection, which is causing persistent mass effect on the left lateral ventricle.",0
Findings were discussed with via telephone at 3:30 p.m. on .,0
______________________________________________________________________________ FINAL REPORT INDICATION: Bilateral subdural hematoma status post bilateral burr holes and evacuation.,0
FINDINGS: The patient is status post bilateral burr holes with drains.,0
High-density subdural hematoma has been replaced by a low-density fluid collection in the left frontoparietal region consistent with a CSF collection.,0
Mass effect on the left lateral ventricle is persistent.,0
"No hemorrhage, large territorial infarction, edema, mass is present.",0
"Other than postoperative burr holes, osseous structures are grossly unremarkable.",0
Visualized paranasal sinuses are well aerated.,0
"IMPRESSION: Status post bilateral burr holes, drain placement and evacuation of bilateral subdurals.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending: Chief Complaint: Anterior STEMI Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 50 yo male with history of hypercholesterolemia and a positive family history of CAD, but with no history of CAD, was transferred from with an acute anterior STEMI.",1
"He developed substernal 10/10 chest pain earlier the day of admission, which woke him up from sleep.",0
"He also was experiencing nausea, diaphoresis and dyspnea.",0
"The day prior, he was playing soccer and had to stop due to several episodes of dyspnea that was relieved with rest.",0
Mr. ECG at showed ST elevations in the anterior leads.,0
"He was started on heparin gtt and given asa, integrillin, morphine, lopressor 5 IV, and started on a nitro gtt.",0
CXR at showed no pulm edema.,0
"At , he continued to have nausea and was in sinus bradycardia in the 50s.",0
Right sided ECG showed no ST elevations in V4R.,0
"He was directly transferred to cath lab on a nonrebreather mask with HR in 50s, BP 124/88, and 2/10 chest pain.",0
At the cath showed elevated L and R sided filling pressures.,0
The LV gram estimated EF: 45%.,0
"There was anterior/lateral HK; no VSD or MR. dom system; the LMCA and LCx arteries were normal; proximal LAD with acute thrombotic total occlusion; the RCA was small and nondominant with occlusion proximal to the acute marginal, which was supplied by collaterals from LAD (RV supply).",1
"A Cypher DES to prox LAD was placed, resulting in TIMI 3 with good collaterals to RV marginal branch.",0
Hemodynamics revealed elevated PCWP and large V waves.,0
ECG on d/c: NSR 74; nl axis/intervals; anterior and anteriolateral Q-waves with ST elevation and T-wave inversion c/w evolving anterior MI.,0
"Initial wbc: 13.6, Hct: 42.6, plt: 257 CPK: 4522 -> 3725 CK-MB: 416 -> 265 Trop: 11.01 -> 9.14 LDL: 143 HDL: 38 Trigl: 271 Echo: EF: 35-40% mild LA enlargement mildly dilated LV cavity trivial MR/TR Anterior, distal septal, apical, distal inferior akinesis present.",1
"Brief Hospital Course: 50 year old man admitted with anterior STEMI, s/p revascularization of proximal LAD with good result and restored RCA supply via collaterals.",0
Pt's hemodynamics were stable from admission.,0
Cath showed elevated R and L filling pressures with evidence of RV involvement and preserved CO/CI.,0
"Mr. was started on ASA 325mg PO qD, plavix 75mg PO qD, integrillin x 18hrs, captopril 6.25mg PO tid, metoprolol 25mg PO bid, and lipitor 80mg PO qD.",0
"Over the next two days, Mr. ACEI and B-blocker were titrated up and switched to longer-acting formations for more convenient outpatient use.",0
His BP and HR tolerated this titration well.,0
"The day after admission, an Echo was done that was interpreted as EF: 35-40% with anterior, distal septal, apical, and distal inferior akinesis present.",0
"The Echo was reviewed by the CCU attending and cardiology fellow, and a decision was made to start Mr. on coumadin for low-flow state.",0
He was started on coumadin 5mg PO qD and sent home with one week supply of lovenox.,0
"He was instructed to follow up with his PCP for INR check (INR at D/C: 1.1) on , and to d/c the lovenox when he was therapeutic.",0
"He was given PT, trained in lovenox use, and d/c'ed with an appointment made for home health to visit for BP and med check.",0
A follow up appointment was made with Dr. on .,0
Mr. temperature rose to 101.5F and was diaphoretic during his stay.,0
"While this was most likely due to his MI, blood cultures were drawn, which were no growth at the time of discharge.",0
Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).,0
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 6.,0
Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 7 days: Please give as you were instructed in the hospital.,0
"When your coumadin level is therapeutic, you should stop this medication.",0
"Outpatient Lab Work Please have your primary care physician check PT/PTT/INR on Friday, .",0
"Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Myocardial infarction Coronary artery disease Hypercholesterolemia Hypertension Discharge Condition: Stable Discharge Instructions: Call your primary care physician or return to the ER if you have chest pain, shortness of breath, or any other symptom that bothers you.",1
Take your medications as directed and please follow up with physicians below.,0
Followup Instructions: Please follow up with primary care physician .,0
"() on Friday, to have your blood drawn for coagulation test.",0
Please follow up with Dr. () on at 1:15pm.,0
"5:59 AM CHEST (PORTABLE AP) Clip # Reason: evaluate pulm edema Admitting Diagnosis: LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with l lingula resection pulmonary edema respiratory ARDS and ILD REASON FOR THIS EXAMINATION: evaluate pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old man with left lingular resection, pulmonary edema, ARDS.",0
"COMMENTS: Portable AP radiograph of the chest was reviewed, and compared to previous study of .",0
The patient is status post resection of the left lingula.,0
There is continued pulmonary edema.,0
Again note is made of tortuosity of the thoracic aorta.,0
There is increased opacity in the left lower lobe indicating atelectasis versus pneumonia.,0
IMPRESSION: Continued pulmonary edema probably due to ARDS.,0
Left lower lobe consolidation indicating pneumonia versus atelectasis.,0
Status post left lingular resection.,0
PATIENT/TEST INFORMATION: Indication: Widened mediastinum on chest x-ray.,0
"Height: (in) 66 Weight (lb): 500 BSA (m2): 2.96 m2 BP (mm Hg): 142/82 HR (bpm): 63 Status: Inpatient Date/Time: at 11:54 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: Patient was intubated prior to start of TEE, and was receiving propofol drip for sedation.",0
LEFT ATRIUM: No thrombus/mass in the body of the LA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Good RAA ejection velocity (>20cm/s).,0
Conclusions: No thrombus/mass is seen in the body of the left atrium.,0
Overall left ventricular systolic function is probably normal (LVEF>55%).,0
Right ventricle is not well-visualized.,0
Probably preserved left ventricular systolic function without significant valvular regurgitation.,0
LINE PLACEMENT Clip # Reason: New Right SC CVL Admitting Diagnosis: SYNCOPY C2 FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p fall with C2 fx now intubated with recurrent temp spikes REASON FOR THIS EXAMINATION: New Right SC CVL ______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old male status post fall with C2 fracture and recurrent temperature spikes.,1
Comparison is made to radiograph performed in the prior date.,0
"FINDINGS: The patient is status post median sternotomy, CABG and aortic valve replacement.",1
"Pacemaker, NG tube and ET tube are in unchanged position.",0
There is slight improvement in areas of consolidation in the left lower lobe.,0
"There is persistent opacity in the right upper lobe, unchanged from prior studies.",0
It could be a chronic findings.,1
"If possible, correlate with old chest radiographs.",0
Possible improvement in pulmonary edema.,0
IMPRESSION: Slight improvement in the pulmonary edema and in left lower lobe opacity.,0
"8:47 PM CHEST (PORTABLE AP) Clip # Reason: Acute desats, assess atelectasis/lobar collapse Admitting Diagnosis: PANCREATIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with trach REASON FOR THIS EXAMINATION: Acute desats, assess atelectasis/lobar collapse ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Acute desats.",1
Small left pleural effusion is unchanged as is adjacent left basal atelectasis.,1
3:29 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: post discontinuation chest wall suction Admitting Diagnosis: S/P MCC ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with tib fib fracture REASON FOR THIS EXAMINATION: post discontinuation chest wall suction ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh MON 4:50 PM Right-sided chest tube without evidence of reaccumulating pneumothorax.,1
______________________________________________________________________________ FINAL REPORT HISTORY: 60-year-old male with tib-fib fracture and left chest tube that has been taken off wall suction.,0
STUDY: Portable AP chest radiograph.,0
FINDINGS: The right-sided central line tip is at the cavoatrial junction.,0
Right-sided chest tube projects over the right upper lung.,0
There is no sign of the previously described pneumothorax.,0
The heart and mediastinal contours appear unremarkable.,0
The hila appear unremarkable bilaterally.,0
"The lungs are clear without masses or consolidations, but demonstrate bibasilar atelectasis.",0
"The left lateral most costophrenic angle is limited for this study, although there is no evidence for a large pleural effusion.",0
The previously described right posterior rib fracture persists.,0
IMPRESSION: Right-sided chest tube without evidence of reaccumulating pneumothorax.,0
8:53 PM CT HEAD W/O CONTRAST Clip # Reason: WORSENING HA.,0
Admitting Diagnosis: HEADACHE ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with worsening headache REASON FOR THIS EXAMINATION: interval change CONTRAINDICATIONS for IV CONTRAST: pregnancy ______________________________________________________________________________ WET READ: 10:01 PM No significant interval changes of the known ICH.,1
No new foci of ICH.,0
No developing hydrocephalus or midline shift.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT HISTORY: 41-year-old woman, with worsening headache.",0
COMPARISON: CTA head on and CT head without contrast on .,0
TECHNIQUE: Non-contrast MDCT images were acquired through the head.,0
FINDINGS: There are no significant short-interval changes from the study approximately 34 hours ago.,0
"The hemorrhagic focus adjacent to the right cavernous sinus, now measures 10 x 9 mm compared to 12 x 11 mm, similar in size allowing for the difference of technique.",0
"The tiny focal hyperdensity in the contralateral side measures 3 mm in diameter, unchanged.",0
There is persistent intraventricular hemorrhage layering in the occipital horns.,0
There is no developing hydrocephalus.,0
No midline shift is noted.,0
"Small amount of bilateral subarachnoid hemorrhage remains right greater than left, overall less conspicuous compared to prior.",1
There are no definite new foci of acute intracranial hemorrhage.,1
No major vascular territorial infarct is noted.,0
The hyperdense metallic anchor is again noted in the left lateral C1 ring.,0
IMPRESSION: No significant short-interval changes of the known intraparenchymal and subarachnoid hemorrhage.,1
Persistent bilateral intraventricular hemorrhage in the occipital horns but without developing hydrocephalus.,1
No definite evidence of new foci of intracranial hemorrhage.,0
(Over) 8:53 PM CT HEAD W/O CONTRAST Clip # Reason: WORSENING HA.,0
Admitting Diagnosis: HEADACHE ______________________________________________________________________________ FINAL REPORT (Cont),0
"3:02 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: needs dobhoff placement for enduring nutritional support ove Admitting Diagnosis: LEFT PLEURAL EFFUSION/SDA Contrast: CONRAY Amt: 25 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with breast CA, pericardial effusion, pleural effusion, ARF, poor nutritional intake, will need dobhoff REASON FOR THIS EXAMINATION: needs dobhoff placement for enduring nutritional support over next 1 week + ______________________________________________________________________________ FINAL REPORT -INTESTINAL TUBE PLACEMENT INDICATION: 66-year-old woman with breast cancer, pericardial effusion, pleural effusion, acute renal failure, poor nutritional intake.",1
Please place Dobbhoff for ensuring nutritional support over the next week.,0
FINDINGS: -intestinal tube was placed via the right naris.,0
The tube coiled within the stomach.,0
Placement was confirmed by 5-10 cc of Optiray contrast.,0
IMPRESSION: Successful placement of -intestinal tube into the stomach.,0
"10:13 AM PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # Reason: please place a drain in the abscess Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION ********************************* CPT Codes ******************************** * PERITONEAL ABSCESS DRAINAGE US GUIDANCE FOR ABSCESS () * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with suspected right anterior abdominal abscess REASON FOR THIS EXAMINATION: please place a drain in the abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT ULTRASOUND-GUIDED DRAINAGE OF ABDOMINAL COLLECTION INDICATION: 75-year-old man with suspected abdominal abscess, for drainage.",1
"PROCEDURE/FINDINGS: Following discussion of the risks, benefits and alternatives to the procedure, informed written patient consent was obtained.",0
"Complex fluid seen within the right subdiaphragmatic spaces and throughout the abdomen, with larger collections seen in the pelvis.",0
All visualized pockets of fluid contained innumerable internal septations.,0
Moderate conscious sedation was provided by the nursing staff and the patient received 2 mg of midazolam and 100 mcg of fentanyl for a total in service time of approximately 50 minutes.,0
The left lower quadrant was selected for drainage and was prepped and draped in the usual sterile fashion.,0
1% lidocaine buffered with sodium bicarbonate was instilled into the subcutaneous tissues to provide local anesthesia.,0
"Using ultrasound guidance, an 8 French pigtail catheter was advanced into the largest pocket of fluid seen in the left lower quadrant.",0
Approximately 50 cc of predominantly clear yellow fluid was aspirated.,0
"In one loculation, purulent fluid was aspirated.",0
This was sent to the microbiology lab for culture and sensitivity.,0
It was not considered feasible to breakdown all of the internal septations.,0
"The 8 French catheter was pigtailed and left in situ, secured with external fixation device.",0
Dr. the attending radiologist and he was present throughout the procedure.,0
IMPRESSION: Technically successful insertion of 8 Fr drainage catheter into the left pelvic fluid collection.,0
Multiple loculations and complex fluid prohibit adequate drainage.,0
"Right abdominal and superior hepatic collections have a similar appearance and, therefore, their draiange was not attempted.",0
(Over) 10:13 AM PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # Reason: please place a drain in the abscess Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION ______________________________________________________________________________ FINAL REPORT (Cont),1
"9:00 AM CHEST (PORTABLE AP) Clip # Reason: ET placement Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man, intubated REASON FOR THIS EXAMINATION: ET placement ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old male, intubated.",1
Single AP chest radiograph compared to shows no change.,0
ET tube terminates 3.5 cm above the carina.,0
"NG tube enters the stomach, the tip has been excluded.",0
"The lungs remain hyperinflated, but clear.",0
"The heart, mediastinum, hila and pulmonary vascularity are normal.",1
"Weight (lb): 190 BP (mm Hg): 141/76 HR (bpm): 79 Status: Inpatient Date/Time: at 09:21 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%).",0
"Conclusions: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%).",0
Leaflet motion appears grossly intact.,0
The mitral leaflets are mildly thickened.,0
There is a moderate sized (1.5cm) echo dense pericardial effusion anterior to the right ventricle c/w hematoma.,0
Tamponade physiology is not suggested.,0
", F. TSICU 10:09 AM BILAT LOWER EXT VEINS PORT Clip # Reason: R/O DVT, SWELLING Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES ______________________________________________________________________________ MEDICAL CONDITION: HPI: 17M, unrestrained front seat driver in high speed MVC.",1
Complex Facial laceration through upper and lower lip REASON FOR THIS EXAMINATION: r/o DVT ______________________________________________________________________________ PFI REPORT No DVT in both lower extremities.,0
Height: (in) 72 Weight (lb): 192 BSA (m2): 2.10 m2 BP (mm Hg): 124/88 HR (bpm): 100 Status: Inpatient Date/Time: at 03:05 Test: TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
AORTIC VALVE: aortic valve leaflets.,0
MITRAL VALVE: mitral valve leaflets.,0
TR present - cannot be quantified.,0
The aortic valve leaflets are .,0
The mitral valve leaflets are .,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC SURGERY Date of surgery: CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: Ms. is a 59-year-old female with a history of diabetes mellitus, cerebrovascular accident without residual effect, chronic back pain with no prior known coronary artery disease who developed sudden chest pain on and was admitted to Hospital.",1
Electrocardiogram changes at this time were reported with anterior ST segment elevations and diffuse T-wave inversions.,0
She was ruled out for myocardial infarction by enzymes and taken for cardiac catheterization at on .,0
"Results of the CT scan included 80% stenosis of the LAD, 70% OM at the origin of the LAD circumflex, 90% D1, 95% proximal OM1, occluded RCA.",0
Exam was also remarkable for depressed ejection fraction with apical dyskinesis and apical inferior akinesis.,0
"She has been chest pain free, but has had recurrent nausea and vomiting.",0
She has not had any new electrocardiogram changes.,0
She is currently hemodynamically stable.,0
She has had difficulty controlling blood pressure and glucose.,0
"Given this history, Ms. was subsequently evaluated for cardiac surgery.",0
Cerebrovascular accident without residual 4.,0
Status post right detached retina on 6.,0
Left eye lens implant 7.,0
Status post L5 disc herniation 9.,0
Cervical ruptured disc MEDICATIONS: 1.,0
"MS Contin ALLERGIES: DARVOCET, DARVON, CODEINE, TALWIN, ROCEPHIN, PENICILLIN, BETADINE, MACRODANTIN, CLEOCIN, ERYTHROMYCIN, CODEINE, SULFONAMIDES, CIPROFLOXACIN, KEFLEX.",0
"REVIEW OF SYSTEMS: Significant for history of detached retina, gastroesophageal reflux disease, diabetes mellitus, disc herniation, history of cerebrovascular accident and multiple allergies.",1
PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile.,0
"Heart rate 80, blood pressure systolic is in the 140s.",0
GENERAL: She is an ill appearing female.,0
"HEAD, EARS, EYES, NOSE AND THROAT: Head is normocephalic, atraumatic.",0
Her neck is supple with no bruits.,0
HEART: Regular in rate and rhythm.,0
"ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds.",0
"EXTREMITIES: Weak without cyanosis, clubbing or edema.",0
HOSPITAL COURSE: Ms. was taken to the Operating Room on where a coronary artery bypass graft x4 was performed.,1
"Grafts included left internal mammary artery to LAD, saphenous vein graft to OM, saphenous vein graft to PDA, saphenous vein graft to diagonal.",0
The operation was performed without complications and Ms. was subsequently transferred to the Cardiac Surgical Intensive Care Unit.,0
"In the unit, she was weaned off drips and hemodynamically monitored.",0
She was extubated on postoperative day #1 and stabilized.,0
"Chest tubes were discontinued on postoperative day #2 and after adequate fluid resuscitation and assurance of hemodynamic stability, Ms. was initially transferred to the floor on the evening of postoperative day #2.",0
"On the floor, Foley catheter and pacer wires were discontinued.",0
Ms. had an unremarkable stay on the floor and recovered well.,0
She ambulated with physical therapy and improved daily.,0
She is tolerating an oral diet and her pain was under control.,0
Lopressor was initiated and gradually increased in dosage which Ms. well.,0
"On postoperative day #5, Ms. was felt stable to be transferred to a rehabilitation facility.",0
PHYSICAL EXAM ON DISCHARGE: VITAL SIGNS: Temperature 98.9?????,0
"?, pulse 71, blood pressure 150/84, respirations 18, O2 saturation 91% on room air.",0
HEART: Regular rate and rhythm.,0
EXTREMITIES: Remarkable for trace edema in the bilateral lower extremities.,0
"Her incisions were clean, dry and intact with no erythema.",0
Aspirin enteric coated 325 mg po qd 2.,0
Docusate 100 mg po bid 3.,0
Prevacid 30 mg po qd 4.,0
Reglan 10 mg po qid 5.,0
Trazodone 100 mg po q hs 6.,0
Metoprolol 37.5 mg po bid 7.,0
Morphine sulfate SR 30 mg po q 12 hours 8.,0
Calcium carbonate 500 mg po tid 9.,0
"NPH 6 units at breakfast, 5 units at dinner 10.",0
"Insulin sliding scale, regular insulin, glucoses measured q6h.",0
"For glucose 0 to 150 give 0 units, 150 to 200 give 3 units, 201 to 250 give 6 units, 251 to 300 give 9 units, 301 to 350 give 12 units, 351 to 400 give 15 units, greater than 400 give 18 units.",0
Give juice for glucose less than 60.,0
FOLLOW UP: Ms. should follow up with Dr. in four weeks and follow up with Dr. in three to four weeks.,0
DISCHARGE CONDITION: Stable DISCHARGE STATUS: Ms. is to be discharged to a rehabilitation facility.,0
"DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft x4 , M.D.",1
Dictated By: MEDQUIST36 D: 13:45 T: 14:01 JOB#:,0
"10:59 AM CT C-SPINE W/O CONTRAST Clip # Reason: eval c-spine injuries Admitting Diagnosis: EPIDURAL HEMATOMA; CSPINE FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with epdirual hematoma, with multiple c spine fx, continuing eval, mildly worsening neuro exam.",0
REASON FOR THIS EXAMINATION: eval c-spine injuries No contraindications for IV contrast ______________________________________________________________________________ WET READ: MDAg SUN 2:15 PM No change from .,0
______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 54-year-old man with subdural hematoma and multiple C-spine fractures with mildly worsening neural exam.,1
COMPARISON: CT and MRI .,0
CT C-SPINE: The patient is intubated with a nasogastric tube in place.,0
Fluid in the posterior nasal cavity is likely related to intubation.,0
"Again seen is a vertically oriented fracture through the C5 vertebral body, unchanged from the prior study.",0
There is slight anterior displacement of the anterior fragment.,0
The fracture at the left C4-C5 facet joint is also unchanged.,0
There is no acute malalignment.,0
Multilevel degenerative change is better delineated on MRI .,0
Small posterior osteophytes at C5-C6 and C6-C7 mildly narrow the spinal canal.,0
Disk protrusions at C5-6 and C6-7 are better displayed on the MR examination.,0
No prevertebral hematoma is identified.,0
The visualized lung apices demonstrate mild paraseptal emphysema and biapical scarring.,0
IMPRESSION: No change from .,0
C5 body and left C4-5 facet fractures again seen.,0
"9:46 AM BABYGRAM (ABD ANY SGL VIEW) () Clip # Reason: abd dist ______________________________________________________________________________ MEDICAL CONDITION: Infant with increased abd girth, tender abd, sepsis REASON FOR THIS EXAMINATION: abd dist ______________________________________________________________________________ FINAL REPORT HISTORY: Infant with increased abdominal girth.",0
FINDINGS: The bowel gas pattern is nonobstructive.,0
There is no definite evidence of pneumotosis or or pneumoperitoneum.,0
The nasogastric tube has been removed in one day.,0
"4:45 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please asses volume status, tubes/lines positions, ?",0
"elevate Admitting Diagnosis: PELVIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman s/p ETT tube repositioning REASON FOR THIS EXAMINATION: Please asses volume status, tubes/lines positions, ?",0
elevated left hemidiaphragm ______________________________________________________________________________ FINAL REPORT SINGLE PORTABLE AP CHEST RADIOGRAPH.,0
INDICATION: 60-year-old female with endotracheal tube repositioning and shortness of breath.,0
COMPARISON: Single portable AP chest radiograph from the same day.,0
FINDINGS: The cardiomediastinal silhouette is unchanged in appearance.,0
The endotracheal tube is in standard position with tip at the level of the clavicles.,0
The study is otherwise unchanged in appearance with loculated right pleural effusion within the minor fissure and posteriorly.,0
The pulmonary vascular congestion remains relatively unchanged.,0
IMPRESSION: Normal positioning of the endotracheal tube.,0
The study is otherwise unchanged from prior radiograph of the same day.,0
8:17 PM CHEST (PA & LAT) Clip # Reason: assess for evidence of effusion/infiltrate Admitting Diagnosis: GAIT ABNORMALITY ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with fever to 102.4 REASON FOR THIS EXAMINATION: assess for evidence of effusion/infiltrate ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: High fever.,0
PA and lateral upright chest radiograph.,0
PA and lateral upright chest radiograph was compared to .,0
The patient is after laparoscopic cholecystectomy.,0
Significant amount of subdiaphragmatic air is noted.,0
The lungs are essentially clear except for questionable faint opacity projecting over the right lung that potentially may be due to rotation of the patient and it is not seen on the lateral radiograph.,0
The left PICC line is inserted but it is difficult to follow after the level of the left brachiocephalic vein.,0
"8:19 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate, pulmonary edema Admitting Diagnosis: ACUTE LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with ALL and new hypotension/hypoxia.",1
"Has intermittent acute desats on NRB, requiring bipap.",0
"REASON FOR THIS EXAMINATION: r/o infiltrate, pulmonary edema ______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old woman with ALL and new hypotension and hypoxia.",1
"To r/o infiltrate, pulmonary edema.",0
Comparison was done to the prior x-ray of done at 3:30 p.m.,0
FINDINGS: There is mild cardiomegaly.,0
"Again are seen bilateral alveolar opacities consistent with diffuse areas of consolidation, which are unchanged from the prior x-ray.",0
Small left-sided pleural effusion is again noted.,0
"IMPRESSION: There is no interval change compared to the prior x-ray of , .",0
"4:45 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE CT CHEST W/CONTRAST Reason: r/o bleed, intraabdo injury Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 80M s/p fall REASON FOR THIS EXAMINATION: r/o bleed, intraabdo injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: DFDkq SAT 6:35 PM no vascular or solid organ injury; no free air or fluid; no fracture ______________________________________________________________________________ FINAL REPORT HISTORY: An 80-year-old man who was lifting a mattress and fell down 14 stairs.",0
"TECHNIQUE: Axial multidetector CT images of the chest, abdomen and pelvis were obtained without oral contrast and with 150 cc of intravenous Optiray per angiogram protocol.",0
CHEST CT WITH INTRAVENOUS CONTRAST: There are multiple foci of mural plaque within the aorta and scattered calcifications.,0
"There is no aortic aneurysm, dissection, or transection.",0
There is no mediastinal hematoma.,0
There is dependent atelectasis at both lung bases.,0
The airways are patent to the level of the segmental bronchi.,0
"There is no mediastinal, hilar or axillary lymph adenopthy.",0
The endotracheal tube terminates in the mid-thoracic trachea.,0
ABDOMEN CT WITH INTRAVENOUS CONTRAST: The orogastric tube terminates in the antrum of the stomach.,0
"The liver, spleen, pancreas, gallbladder, duodenum, adrenal glands, and kidneys appear intact without evidence of acute injury.",0
"There are two small subcentimeter low-attenuation lesions in the mid left kidney, which are too small to characterize but probably represent cysts.",0
Unopacified small bowel and colon loops appear unremarkable.,0
The aorta is calcified with multifocal intramural plaque.,0
PELVIC CT WITH INTRAVENOUS CONTRAST: There is a fat-containing right inguinal hernia.,0
"The bladder is decompressed by a Foley catheter, but the right anterior portion of the bladder abuts the neck of the right inguinal hernia.",0
"The prostate, rectum, and seminal vesicles appear unremarkable.",0
The ureters are normal in caliber.,0
BONE WINDOWS: No fractures are identified.,0
Degenerative changes are present in the lumbar spine and sacroiliac joints.,0
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential for evaluating the aorta and the spine.,0
"There is no aortic dissection, transection, or (Over) 4:45 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE CT CHEST W/CONTRAST Reason: r/o bleed, intraabdo injury Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) aneurysm.",0
There are no compression deformities in the spine.,0
"No evidence of acute traumatic injury in the chest, abdomen or pelvis.",0
Multifocal mural plaque in the aorta.,0
Two probable left renal cysts.,0
The bladder abuts the neck of the hernia.,0
"12:56 AM CHEST (PORTABLE AP) Clip # Reason: confirm ETT position, r/o infiltrate or effusion Admitting Diagnosis: BRAIN TUMOR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p craniotomy for metastatic tumor, remained intubated.",0
"REASON FOR THIS EXAMINATION: confirm ETT position, r/o infiltrate or effusion ______________________________________________________________________________ FINAL REPORT HISTORY: Confirm ET position.",0
"An ET tube is present, in satisfactory position approximately 6.0 cm above the carina.",0
"An NG tube is present, tip beneath diaphragm.",0
An apparent sideport lies at or slightly above the expected location of the GE junction.,0
"There is a upper zone redistribution and mild diffuse vascular blurring, consistent with CHF.",0
"There is increased retrocardiac density, consistent with partial left lower lobe collapse and/or consolidation, with minimal blunting of the left costophrenic angle.",0
Asymmetric left apical pleural thickening is noted.,0
"The lungs are hyperinflated, suggesting underlying COPD.",0
"The previously identified nodular opacity in the left upper zone, concerning for metastasis, is obscured on the current view due to an overlying EKG lead.",0
"1:54 PM BABYGRAM (CHEST ONLY) Clip # Reason: chest, , please do at 13:45 Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with r/o aspiration REASON FOR THIS EXAMINATION: chest please do at 13:45 ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST, AT 1:45 PM.",1
"Since last examination dated , the lungs show minimal improvement in aeration.",0
"Diffuse hazy opacification of the lungs, consistent with mild chronic lung disease, with or without aspiration, is present.",0
No focal areas of atelectasis or infiltrate are noted.,0
IMPRESSION: Minimal improvement in pulmonary inflation since last exam.,0
"9:55 AM CHEST (PORTABLE AP) Clip # Reason: s/p LIJ central line changed over guidewire, please evaluate Admitting Diagnosis: INCREASED FLUID AT GRAFT SITE ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman c ESRD s/p R ax fem & change in Swan position REASON FOR THIS EXAMINATION: s/p LIJ central line changed over guidewire, please evaluate position and r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Status post left IJ central line placement.",0
Evaluate position and rule out pneumothorax.,0
CHEST PORTABLE AP: Comparison is made to previous films 10 hours earlier.,0
There is interval removal of a Swan-Ganz catheter.,0
A left internal jugular vein catheter has been placed with its tip in the mid superior vena cava.,0
Right sided Quinton catheter is visualized with its tip in the right atrium.,0
A right sided PICC line is seen with its tip in the mid SVC.,0
There is cardiomegaly which is unchanged.,0
The perihilar haziness and interstitial opacities are unchanged.,0
Small left sided pleural effusion is also unchanged.,0
CHF and interstitial edema unchanged.,0
"12:41 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: FEVERS, ?",0
"ABCESS Admitting Diagnosis: FEVER;SEPSIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with fever REASON FOR THIS EXAMINATION: eval for infiltrate, pneumothorax, other acute process No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT TORSO COMPARISON: .",0
HISTORY: Status post splenectomy with splenic abscesses status post washout with fluid collections and now presenting with sepsis.,1
"TECHNIQUE: MDCT axially acquired images of the chest, abdomen, and pelvis were obtained.",0
"FINDINGS: CT CHEST: There are bilateral small-to-moderate pleural effusions, not significantly changed.",1
"There are severe emphysematous changes with apical bullae, similar in appearance.",0
There is a loculated hydropneumothorax on the right.,0
"There is a right lower lobe pulmonary nodule (2, 44), which has not significantly changed.",0
There is a small pericardial effusion measuring approximately 1 cm.,0
"There is no axillary, hilar, or mediastinal lymphadenopathy.",0
Calcified lymph nodes within the right hilum are identified.,0
CT OF THE ABDOMEN: There are multiple gallstones identified.,0
There is no intrahepatic or extrahepatic biliary dilatation.,0
"Within the liver, there is a hypodense lesion measuring 3.2 cm, not significantly changed.",0
"Small hypodense lesion within the dome of liver (2, 49) is too small to characterize.",0
An NG tube is identified within the stomach.,0
"Within the upper pole of the right kidney, there is a large hypodense lesion measuring 12.8 cm and likely represents a cyst.",0
"Smaller hypodense lesions within the bilateral kidneys are also identified, which likely represent cysts and others which are too small to characterize.",0
Small bowel loops are normal in caliber.,0
"Within the splenectomy bed (2, 56), there is new foci of air which extends to the descending colon (2, 61).",0
"In addition, air tracking along the left anterior abdominal wall is also identified and extends to the anterior surface of the descending colon(2, 70) concerning for colocutaneous fistula (2, 74).",1
"Adjacent to the descending colon, there has been interval enlargement of a fluid collection which now appears more organized and appears to have enhancement of the rim (2, 84).",0
This collection measures approximately 6.3 x 8.2 cm.,0
"Smaller adjacent (Over) 12:41 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: FEVERS, ?",0
"ABCESS Admitting Diagnosis: FEVER;SEPSIS Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) collection is also noted with foci of air (2, 92) concerning for fistulous connection with colon.",1
An infrarenal abdominal aortic aneurysm measuring 4.4 x 4.8 cm with a small amount of mural plaque.,1
CT OF THE PELVIS: A Foley catheter is within the bladder.,0
Extensive diverticulosis of the sigmoid colon is noted.,1
There is no evidence of acute diverticulitis.,0
Extensive degenerative changes of the thoracolumbar spine are noted.,0
Rim-enhancing fluid collections adjacent to the descending colon concerning for abscess.,1
This is increased in size.,0
"In addition, there is foci of air within some of these fluid collections as well as within the splenectomy bed.",0
Known colocutaneous fistula is again identified.,0
Emphysematous changes with loculated hydropneumothorax on the right.,0
Small pericardial effusion and pleural effusions.,1
"Small hypodensities, some of which are cysts and others are too small to characterize or incompletely characterized.",0
"Infrarenal abdominal aortic aneurysm, stable.",1
Findings were discussed with Dr. at the time of review.,0
12:37 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: NGT placement and ET tube Admitting Diagnosis: GUNSHOT WOUND TO FACE ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man with bullet to mandible and intubated and NGT - both repositioned REASON FOR THIS EXAMINATION: NGT placement and ET tube ______________________________________________________________________________ FINAL REPORT AP CHEST 12:37 P.M. ON : HISTORY: Blow to the mandible.,1
Repositioned both NG tube and ET tube.,0
IMPRESSION: AP chest compared to :47 p.m.: Lungs clear.,0
No pleural abnormality or evidence of central hematoma.,0
Nasogastric tube ends in the upper stomach and would need to be advanced 6 cm to move all the side ports beyond the GE junction.,0
Dr. and I discussed these findings at the time of dictation.,0
Status: Inpatient Date/Time: at 12:50 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.,1
Mild (1+) MR. LV inflow pattern c/w impaired relaxation.,0
Conclusions: PREBYASS: -No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage.,0
-No atrial septal defect is seen by 2D or color Doppler.,0
-There is mild symmetric left ventricular hypertrophy with normal cavity size.,0
-Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction.,0
-Right ventricular chamber size and free wall motion are normal.,0
-There are simple atheroma in the ascending aorta.,0
-There are three aortic valve leaflets.,1
-The mitral valve leaflets are mildly thickened.,0
-The left ventricular inflow pattern suggests impaired relaxation.,0
-The tricuspid valve leaflets are mildly thickened.,0
POSTBYPASS: The patient is AV paced on low dose phenylephrine infusion.,1
There is a well seated prosthetic valve in the aortic position.,1
Dr. was made aware of the results at the time of the study.,0
"4:17 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: NEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with respiratory failure, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Respiratory failure.",1
Compared to the study from the prior day there is no significant interval change.,0
12:54 AM CHEST (PORTABLE AP) Clip # Reason: congestive heart failure?,1
"pt desating, requiring inc O2, ?B Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with CAD REASON FOR THIS EXAMINATION: congestive heart failure?",1
"pt desating, requiring inc O2, ?Bipap ______________________________________________________________________________ FINAL REPORT INDICATION: Coronary artery disease with oxygen desaturation.",1
TECHNIQUE: A single portable AP view of the chest without comparisons demonstrates unremarkable cardiac and mediastinal silhouette with retrocardiac opacity.,0
There are bilateral pleural effusions and perihilar haziness.,0
No focal infiltrates are seen.,0
Right-sided cardiac pacemaker have leads in appropriate position within the right atrium and proximal right ventricle.,0
IMPRESSION: CHF and retrocardiac collapse/consolidation.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: weakness and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 88 y/o F h/o breast CA, AFib (on amiodarone), MDD, recently admitted in for FTT now presents with weakness, poor appetite and abdominal discomfort.",1
"At rehab, labs were notable for elevated LFTS and BUN 60, thus aldactone, lasix and amiodarone held and she was sent here for further evaluation.",0
"In the ED, initial vitals 97.2 96/71, HR 66 RR 16 97%RA but then HR 170s, SBP 70, afebrile.",0
"SHe was given 2L IVF, refused CVL.",0
"Levo/Vanc given for concern for infection (elevated WBC, afebrile, CXR with ?",0
Pts HR had minimal response to the IVF and remained hypotensive.,0
DCCV was considered in ED but pt declined because of the risk of stroke.,0
Heparin gtt was started but then stopped.,0
"In addition, given SBP pt was started on neosynephrine and transferred to CCU.",0
"Pt currently denies abdominal pain, CP, palpitations, N/V or diarrhea, just reports poor PO intake, decreased appetite.",0
SHe does report some SOB that is worse lying flat.,0
"CARDIAC RISK FACTORS:: -Diabetes, -Dyslipidemia, -Hypertension 2.",0
"OTHER PAST MEDICAL HISTORY: AFib - on amiodarone, coumadin stopped in late LGIB Breast CA -2.7 cm grade I infiltrating lobular cancer, negative lymph nodes, negative LVI,negative margins and ER positive, HER-2/neu negative.",1
"She went on to radiation and then tamoxifen for three years, switched to Arimidex and then back to tamoxifen in until stopping it in .",0
"TIA - sigmoid diverticulosis/antral gastritis by /egd T9 compression fX - not metastatic by bone scan Bronchiectasis - f/b pulm clinic by Dr. Osteoporosis Anemia: baseline 34, ACE & FE deficiency Social History: Lives at rehab currently.",1
-Tobacco history:denies -ETOH:denies -Illicit drugs:denies Family History: Heart disease in her sister.,1
"sister lives in , and her brother-in-law lives in .",0
Physical Exam: VS: SBP 112/77 HR 138 RR 20 97%3L GENERAL: WDWN ** in NAD.,0
"NECK: Supple with JVP to jaw CARDIAC: Irregularly irregular, no murmurs appreciated LUNGS: Crackles midway up back b/l ABDOMEN: Soft, NTND.",0
"EXTREMITIES: 2+ edema to mid-calves b/l, warm well perfused SKIN: Stasis dermatitis b/l PULSES: Right: Carotid 2+ DP dopplerable PT dopplerable Left: Carotid 2+ DP dopplerable PT dopplerable Neuro A&O x3 .",0
"Pertinent Results: EKG: Irregular irregular, tachycardic, no ST/T changes .",0
2D-ECHOCARDIOGRAM: The left atrium is elongated.,0
The aortic valve leaflets (3) are mildly thickened but not stenotic.,0
ETT: IMPRESSION: No anginal symptoms or ischemic ST segment changes.,0
LABORATORY DATA: ADDED LIP @ 12:37 PM ON .,0
130 / 98 / 47 / 97 AGap=18 -------------- 5.0 / 19 / 1.2 estGFR: 42/51 (click for details) CK: 60 MB: Notdone Trop-T: 0.01 Ca: 8.1 Mg: 2.6 P: 3.3 ALT: 345 AP: 323 Tbili: 1.6 Alb: 3.5 AST: 151 TProt: 6.2 11.1 11.2 >----< 184 34.8 N:81.7 L:12.8 M:5.4 E:0.1 Bas:0 .,0
PT: 16.2 PTT: 38.5 INR: 1.4 Lactate 3.3 .,0
"CXR: Overall, the constellation of findings is suggestive of CHF, follow up radiography is recommended post-diuresis and treatment.",0
RUQ U/S:Contracted gallbladder with gallstones.,0
Common bile duct could not be identified due to patient discomfort.,0
Brief Hospital Course: 88 yo female with h/o a.fibb who presents with poor PO intake and A fib with RVR and hypotension.,0
"ATRIAL FIBRILLATION - Patient has long history of a fibb, however her rapid rate on -presentation was thought to be due to infection and dehydration.",1
She has not been on coumadin since GIB and fall risk.,0
"She also requested not to have cardioversion at this time, as she is unwilling to tolerate the stroke risk.",0
Her heart rates were controlled by starting amiodarone and dig loads.,0
She was breifly given neosynephrine for BP support.,0
"Given her fall risk and history of GI bleed, she is not on heparin or coumadin.",0
She was anticoagulated with aspirin 325mg daily.,0
TSH was nl at 3.2. .,0
HYPOTENSION - Patient presented with SBPs in the 70s.,0
This low pressure was thought to be related to mild infection in the setting of hypovolemia.,0
She was briefly started on neosynepherin and given IVF.,0
"PNEUMONIA - She preseted with a lactate 3.3, mildly elevated WBC, and elevated LFTs.",0
Her CXR showed a possible infiltrate and U/A was negative.,0
"She was initially started on Vanc and Levofloxacin, which was narrowed to levofloxacin.",0
She should complete a seven day course for community-acquired PNA.,0
ABDOMINAL PAIN - She initially had some abdominal pain that resolved without intervention.,0
"She had an elevated ALT, AST, Alk phos and T.bili, and RUQ U/S showed gallstones but no sign Medications on Admission: Citracal + D 250-200 daily Lasix 20mg daily Amidoarone 100mg daily Spironolactone 50mg daily Paxil 10mg daily Colace 100mg aspirin 81mg daily omeprazole 20mg daily Remeron 15mg qhs spironolacton 50mg daily Lactulose 10gm Lasix 20mg daily Senna 1 tab B12 1000mcg daily Hydrocortisone acettate 25g qhs bisacodyl 10mg PRN Discharge Medications: 1.",0
Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day).,0
Calcium Citrate 250 mg Tablet Sig: Two (2) Tablet PO twice a day.,0
"Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day.",0
Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day.,0
Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.,0
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 15.,0
Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 days: take on .,0
Discharge Disposition: Extended Care Facility: Health Care Center - Discharge Diagnosis: Atrial Fibrillation Hyponatremia Pleural Effusions Discharge Condition: stable BUN=20 creat=0.8 hct=36.8 Na=134 O2 Sat: 96% K=4.3 Discharge Instructions: You had an increased heart rate with your atrial fibrillation.,1
We started you on digoxin and metoprolol.,0
You also had a low sodium level.,0
"You have effusions, collections of fluid in your lungs that we started to clear with fluid medicine.",0
You also had pneumonia for which we started you on an antibiotic.,0
You do not need oxygen at this time.,0
You were started on digoxin for rate control 2.,0
"Toprol XL 75mg, to control your heart rate 3.",0
"Levofloxacin: for pneumonia, take for one more day.",0
"Please have staff call your provider if you have any trouble breathing, fevers, increasing cough, palpitation or low blood pressure.",0
Please get out of bed and move around as much as possible.,0
"Followup Instructions: Breast Surgeon: Breast Surgeon: Provider: , MD Phone: Date/Time: 1:15 Cardiology: Dr.",0
Pt is on waiting list for earlier appt.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Slurred speech and leg weakness Major Surgical or Invasive Procedure: Myelogram History of Present Illness: This is a 71 y/o with h/o dm, HTN, CAD s/p PTCA distal LAD () who prsents to the ED with chest pain, worsening shortness of breath and substernal chest pain.",0
"Per ED and Neurology notes who spoke to son, patient was at her usual state of health until waking up this am.",0
She noted chest pain an dshortness of breath.,0
"Later on , her son noticed she was having slureed speech.",0
"Patient reports that over the last couple of weeks, she was feeling with decrease energy and intermittent left sided headaches.",0
"This morniing, she woke up with slurred speech and strange sensation on the left side of her face.",0
"She denied any any difficulty with word finding or speech comprenhension, no limb weakness or gait instability.",0
She also reports chest pain about that was all over her chest and was going to both arms.,0
She thought she was having another attacck.,0
She did not take anything for it.,0
"She denief any fevers, nasusea, vomit, chills, cough, diarrhea, abdominal pain associated.",0
"She currently feels 2/10 chest pain, and feels that her speech is not back to baseline.",0
She is oriented and coherent on her speech.,0
"In The ED vs: T 97, HR 68, BP 78-88; 92/37 RR 20on 2L NC.",0
Code stroke was initially called but cancelled given that her presentation was more consistent with encephalopatic process.,0
she was also bradycardic to the 40's with low BP.,0
She was given glucagon 5 mg IV x1.,0
"She was also given Dextrose 50%, and combivent nebs.",0
1.5 L of NS were given.,0
"Past Medical History: DM HTN OSA- uses BiPAP at home Asthma- uses O2 at home Restrictive lung disease on pt unable to ambulate, uses wheelchair Hyperlipidemia s/p cholecystectomy s/p hysterectomy Chronic back pain Social History: Lives alone in an appartment in , divorced.",1
"Has an aide that comes every day to help her with cleaning, dishes, etc.",0
"Denies ever smoking, using Alcohol, or IV drugs.",0
"Family History: Mother died at age 80yo - had CAD, DM Father passed away at age 89yo - had CAD Physical Exam: Vitals: T: P: 50 R:16 BP:95/45 SaO2:97 4 L General: Awake, alert, NAD HEENT: PEERLA, JVD difficult to appreciate.",0
no lymphadenopathies Pulmonary: + rhonchi and expiratory wheezing.,0
"Abdomen: soft, obes, non tender non distended.",0
"Neurologic: alert, oriented times 3, mild slrueed speech, tongue midline, no ptosis.",0
+ asterixix Pertinent Results: 11:26PM TYPE-ART PO2-63* PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 05:00PM GLUCOSE-79 UREA N-33* CREAT-3.1*# SODIUM-137 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18 05:00PM ALT(SGPT)-14 AST(SGOT)-21 LD(LDH)-254* CK(CPK)-380* ALK PHOS-84 TOT BILI-0.3 05:00PM cTropnT-0.06* 05:00PM CK-MB-14* MB INDX-3.7 05:00PM CALCIUM-9.2 PHOSPHATE-5.4*# MAGNESIUM-2.0 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 05:00PM WBC-8.0 RBC-3.84* HGB-9.7* HCT-30.6* MCV-80* MCH-25.2* MCHC-31.6 RDW-15.9* 05:00PM NEUTS-76.4* LYMPHS-17.5* MONOS-3.3 EOS-2.7 BASOS-0.2 05:00PM HYPOCHROM-3+ MICROCYT-1+ 05:00PM PLT COUNT-259 05:00PM PT-12.5 PTT-24.7 INR(PT)-1.1 .,0
CT head w/o contrast: IMPRESSION: No mass effect or hemorrhage .,0
CXR FINDINGS: Portable AP upright chest radiograph reviewed.,0
There is diffuse opacification of both lungs with more dense bilateral retrocardiac opacities.,0
The hila are hazy and the pulmonary vasculature are engorged.,0
The left costophrenic angle is not sharp and a small left pleural effusion on this poor quality radiograph cannot be excluded.,0
Renal U/S no hydronephrosis .,0
CT C/T/L spine without contrast FINDINGS: The study is severely limited due to patient body habitus and a mild amount of motion artifact.,0
Cord compression cannot be excluded based on non-contrast study.,0
"Within the limitations of the artifact, there are no large displaced fractures.",0
There is a large amount of degenerative change.,0
"At C2-3, , there is no spinal canal stenosis.",1
"At C5-6, there is a small posterior osteophyte with mild spinal canal stenosis.",1
There is a large osteophyte at the right side of the vertebral body.,0
"C5-6, there is a moderate sized posterior osteophyte which appears to cause at least a moderate spinal canal narrowing.",0
There are osteophytes at both uncovertebral joints.,0
"At C6-7, there is a small posterior osteophyte present.",0
This causes no significant canal narrowing.,0
"As the patient's body habitus produces significant artifact within the spinal canal, a disc or rather soft tissue masses could easily cause spinal cord compression would not be visualized on this study.",0
An alternative way to evaluate the central canal would be to obtain a CT myelogram.,0
IMPRESSION: Spinal cord compression cannot be excluded based on a non- contrast CT with this amount of artifact.,0
Multilevel degenerative changes and osteophytes causing at least moderate spinal canal narrowing at C5-6.,1
Myelogram: IMPRESSION: Successful fluorographically guided myelogram via the lumbar puncture at L3.,0
No evidence of significant central canal stenosis.,0
"For further detailed findings, please refer to the CT myelogram of the same day.",0
"Brief Hospital Course: A/P: 71 y/o female with HTN, DM, hyperlipidemia, CAD, OSA, Asthma with slurred speech and LE weakness .",1
"#) Slurred speech, LE weakness.",0
"Per patient, this was resolving by the date of discharge.",0
Had negative CT scan of head.,0
"CT of spine showed spinal canal narrowing at cervical, thoracic, and lumbar levels.",1
CT after myelograms shows severe stenosis at the thoracic level.,0
Patient refused the possiblity of neurosurgery.,0
#) CAD: CE neg X 2.,0
No additional chest pain complaints once transferred to the floor.,0
"- Continued ASA, plavix, metoprolol, atorvastatin, added back ACEI on last day (had been held secondary to ARF) .",0
#) Bradycardia with escape rhythm: Resolved.,0
Thought to be due to BB overdose in the setting of renal failure.,1
- monitored on Telemetry without events - continued on low dose beta blocker .,0
#) Wheezing: still unclear whether pulm edema or asthma or an element of both.,1
- continued alb and ip nebs .,0
#) OSA: continued on BiPAP.,0
#) ARF: Likley pre renal secondary to lasix as improved with hydration.,0
Renal u/s negative for hydronephrosis - Cr 1.0 at discharge - discharged on dose of Lasix that she was taking on admission: 40 mg po qd .,0
#) DM: Continued on glyburide.,0
Blood sugars well-controlled on floor.,0
#) Microcytic Anemia: needs outpatient colonoscopy .,0
#) FEN: Diabetic/Caradiac Diet .,0
#) PPX: Heparin SC .,0
#) Dispo: home with home PT eval and prior services Medications on Admission: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Amitriptyline HCl 50 mg PO HS Aspirin 325 mg PO DAILY Atorvastatin 80 mg PO DAILY Clopidogrel Bisulfate 150 mg PO DAILY Ferrous Sulfate 325 mg PO DAILY Fluticasone Propionate Nasal 2 SPRY NU DAILY Fluticasone-Salmeterol (250/50) 1 INH IH Furosemide 80 mg PO DAILY Gabapentin 600 mg PO TID Glyburide 5mg Ipratropium Bromide MDI 2 PUFF IH QID Lisinopril 20 mg PO DAILY Metoprolol 25 mg PO BID Pantoprazole 40 mg PO Q24H Discharge Medications: 1.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed.,0
Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.,0
Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a day.,0
Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day.,0
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day.,0
"Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) sprays Nasal once a day: one spray in each nostril.",0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: ALL CARE FAMILY SERVICES Discharge Diagnosis: Congestive Heart Failure Spinal Stenosis Bradycardia Acute Renal Failure DM2 Discharge Condition: Hemodynamically stable.,1
Discharge Instructions: Please take all medications as instructed.,0
Your Metoprolol and Furosemide doses have been changed.,0
"If you experience any nausea, vomiting, lightheadedness, chest pain, shortness of breath, or any other concerning symptoms please seek medical attention immediately.",1
Followup Instructions: Please follow-up with your PCP within the next week.,0
"Provider: , Date/Time: 2:00 Provider: , DPM Phone: Date/Time: 11:20 Provider: , M.D.",0
4:02 AM CHEST (PORTABLE AP) Clip # Reason: PNA?,0
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with intracranial bleed and aspiration REASON FOR THIS EXAMINATION: PNA?,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 5:17 A.M., HISTORY: Intracranial bleed and aspiration.",0
"IMPRESSION: AP chest compared to through : Lungs clear of consolidation, with minimal edema in the right lung, residual since .",0
Tracheostomy tube and left subclavian line in standard placements.,0
"Shunt catheter traverses the right neck, chest, and upper abdomen.",0
8:23 AM CHEST (PORTABLE AP) Clip # Reason: interval change.,0
"Admitting Diagnosis: MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman hypoxia, currently intubated.",1
REASON FOR THIS EXAMINATION: interval change.,0
______________________________________________________________________________ FINAL REPORT AP CHEST 9:13 A.M. HISTORY: Hypoxia.,0
"IMPRESSION: AP chest compared to : Pulmonary edema, which developed on , has resolved, leaving a small left pleural effusion and mild cardiomegaly.",0
"Extensive asbestos-related pleural calcification is present and should not be mistaken for lung nodules, particularly in the left apex.",0
"1:22 AM CHEST (PORTABLE AP) Clip # Reason: r/o failure ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with new RF and hypotension REASON FOR THIS EXAMINATION: r/o failure ______________________________________________________________________________ FINAL REPORT HISTORY: 44-year-old male with new renal failure and hypotension, rule out failure.",1
"PORTABLE UPRIGHT CHEST, ONE VIEW: The heart is enlarged in size.",0
"Otherwise, cardiomediastinal and hilar contours are unremarkable.",0
"There is slightly increased interstitial markings bilaterally, which suggests mild fluid overload.",0
LINE PLACEMENT Clip # Reason: postop film- contact NP # if abnormal- will be Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p cabg x5 REASON FOR THIS EXAMINATION: postop film- contact NP # if abnormal- will be in CVICU approx 6 PM- please call first!,1
"______________________________________________________________________________ WET READ: JXRl FRI 7:58 PM ETT at thoracic inlet, 6cm above carina.",0
NG tube terminates in stomach.,0
PA catheter terminates in expected location of main pulmonary outflow tract.,0
"sternal closure wires intact, mediastinal surgical clips.",0
"2 mediastianal drains, left chest tube in place.",0
no evidence of pulmonary edema.,0
"FINDINGS: In comparison with the study of , there has been a CABG procedure performed with intact midline sternal sutures.",0
"Endotracheal tube tip lies at the thoracic inlet, about 6 cm from the carina.",0
Left subclavian IJ Swan-Ganz catheter tip is in the pulmonary outflow tract.,0
Nasogastric tube extends to the stomach with the side hole at about the level of the esophageal gastric junction.,0
", MED MICU 12:38 AM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate for evidence of bleed/infarct Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with HIV, PCP PNA, now with hypertensive urgency, MS change, fever REASON FOR THIS EXAMINATION: Please evaluate for evidence of bleed/infarct No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",0
"No evidence of acute intracranial hemorrhage, nor large vascular territory infarction.",0
"However if clinical suspicion for acute infarction remains, MRI would be recommended for more sensitive evaluation.",0
Opacification of mastoid air cells and middle ear cavities bilaterally.,0
"7:27 PM CHEST (PORTABLE AP) Clip # Reason: pneumonia Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with SAH; s/p ventric drain; cerebral angio REASON FOR THIS EXAMINATION: pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: A 71-year-old man with subarachnoid hemorrhage, S/P ventricular drain and cerebral angio, rule out pneumonia.",1
"PORTABLE AP UPRIGHT CHEST AT 7:30 P.M.: Compared to prior study of two days earlier, right subclavian line has been pulled.",0
The right IJ catheter is still in place in good position.,0
Atelectasis at the right and left bases is unchanged.,0
"4:26 PM CHEST (PA & LAT) Clip # Reason: eval for acute process ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with AMS, liver disease REASON FOR THIS EXAMINATION: eval for acute process ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST.",0
REASON FOR EXAM: liver disease.,0
The lungs are mildly hyperinflated.,0
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.,0
11:33 AM KNEE (2 VIEWS) LEFT Clip # Reason: loosening?,0
Admitting Diagnosis: POST OP KNEE INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with failed/infected L TKA REASON FOR THIS EXAMINATION: loosening?,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Left TKA, failed/ infected, question loosening.",0
No previous knee films on PACS record for comparison.,0
The patient is status post three-component knee prosthesis in overall anatomic alignment.,1
"No periprosthetic lucency to suggest loosening, and no focal osteolysis is detected.",0
"There is possible increased density in the proximal tibia, though this may be a technical artifact.",0
Suspect very faint residual screw tracts in the proximal tibia.,0
There does appear to be soft tissue swelling along the distal thigh anteriorly.,0
Some periosteal new bone formation is noted along the medial metaphysis of the distal femur.,0
"No underlying focal lytic or sclerotic lesion is detected, and while indistinct, this could nonetheless represent muscle insertion site changes.",1
IMPRESSION: No evidence of loosening about the three-component knee prosthesis.,0
Equivocal sclerosis may be an artifact of technique.,0
Comparison with any prior (outside) films could help for further assessment.,0
5:24 PM TIB/FIB (AP & LAT) IN O.R.,0
RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.,0
"RIGHTClip # Reason: EXTERNAL FIXATION OF TIB-FIB FX ______________________________________________________________________________ FINAL REPORT HISTORY: Fixation of tibiofibular fracture, in O.R.",1
"Fluoroscopic assistance was provided to the orthopedist in the O.R., without the radiologist present.",0
4 spot views were obtained.,0
These demonstrate steps in the external fixation of fractures of the distal tibia and fibula.,1
Marked asymmetry of the mortise joint is noted.,0
"The external fixator screw extends into the talus, from a medial approach.",0
Offset and angulation of the tibial fracture fragment is noted.,1
"7:34 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for infiltrate, effusion, volume status.",0
Admitting Diagnosis: VR\ MVR REDO ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p redo MVR.,0
"REASON FOR THIS EXAMINATION: Please assess for infiltrate, effusion, volume status.",0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: Compared to previous study of 1 day earlier.,0
INDICATION: S/P mitral valve surgery.,0
"Since the previous study, the patient has been extubated.",0
"Chest tubes, mediastinal drain, and Swan-Ganz catheter remain in place.",0
The left chest tube has a low position but is unchanged.,0
The pulmonary vasculature demonstrates upper zone redistribution but there has been interval slight decrease in degree of perihilar haziness.,0
A few scattered interstitial opacities persist.,0
There is worsening retrocardiac opacity on the left.,0
A small left pleural effusion is new in the interval.,0
IMPRESSION: 1) Slight improvement in degree of congestive heart failure.,1
"2) Worsening left retrocardiac opacity, most likely due to atelectasis.",0
Aspiration is an additional consideration.,0
Height: (in) 77 Weight (lb): 320 BSA (m2): 2.73 m2 BP (mm Hg): 144/88 HR (bpm): 85 Status: Inpatient Date/Time: at 14:46 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
No atheroma in aortic arch.,0
Conclusions: No atrial septal defect is seen by 2D or color Doppler.,0
There is a catheter in the right atrium that appears to abut the tricuspid valve.,0
No mass or vegetation is seen on the tricuspid valve.,0
No mass or vegetation is seen on the pulmonic valve.,0
"10:59 AM CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # -76 BY SAME PHYSICIAN : please evaluate dobhoff position Admitting Diagnosis: FTT ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with liver abscesses s/p ERCP complicated by pancreatitis now s/p dobhoff placement REASON FOR THIS EXAMINATION: please evaluate dobhoff position ______________________________________________________________________________ FINAL REPORT INDICATION: 43-year-old male with liver abscesses, status post ERCP, complicated by pancreatitis, now status post Dobbhoff placement.",1
"COMPARISON: Comparison is made with chest radiographs from earlier the same day, and .",0
FINDINGS: Four frontal images of the chest demonstrate a Dobbhoff tube that is folded over the stomach and reenters the esophagus to the level of the mid chest.,0
Another image demonstrates the Dobbhoff tube folding over in the stomach and entering the distal esophagus.,0
"From discussion with the medical team, it appears that the tube was initially in the position with the tip in the mid chest and subsequently repositioned to the tube tip being in the distal esophagus.",0
The chest radiograph is otherwise essentially unchanged from imaging earlier the same day.,0
"Continued opacification at the right lung base is again seen, consistent with volume loss and small right effusion.",0
"IMPRESSION: Dobbhoff tube is seen in two different positions, both of which show the tube tip to be within the esophagus.",0
The tube will need to be repositioned to place the tip within the stomach.,0
"Otherwise, essentially unchanged chest radiograph.",0
These findings were communicated to Dr. at 4:00 p.m. by phone.,0
3:56 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with cirrhosis now intubated REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Cirrhosis.,1
Single AP view of the chest performed at 5:14 a.m. is submitted.,0
The tip of the endotracheal tube is 4.6 cm above the carina.,0
Tip of a feeding tube is coiled in the stomach.,0
Tip of a right IJ line is within the right atrium.,0
"Compared to the prior study, the diffuse opacity of the right lung has improved.",0
Prior study was done supine and today's study is semi-upright.,0
"Likely this represents partial resolution of the right pleural effusion, which had been layering posteriorly.",0
There is persistent blunting of the right costophrenic angle consistent with a small right pleural effusion remaining.,0
There is focal opacity in the right cardiophrenic angle consistent with atelectasis or infiltrate.,0
There is moderate blunting of the left costophrenic angle consistent with moderate left pleural effusion.,0
Focal increased opacity in the retrocardiac region is also consistent with atelectasis or infiltrate.,0
IMPRESSION: Tubes and lines in adequate position.,0
Likely decrease in the size of the right pleural effusion allowing for differences in prior supine versus current semi-upright technique.,0
Essentially stable left pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain on exertion Major Surgical or Invasive Procedure: - CABGx4 (Left internal mammary artery graft, left anterior descending, reverse saphenous vein graft to the diagonal branch, first marginal branch, left sided posterior descending artery.)",1
History of Present Illness: Mr. is a 59-year-old male with worsening anginal symptoms and a positive stress test who underwent a cardiac catheterization that showed three vessel disease.,0
He now is presenting for surgical revascularization.,0
Past Medical History: HTN Hyperlipidemia GERD Obesity Sleep Apnea BPH CAD Abdominal hernia Social History: School principal.,0
Divorced and lives with significant other.,0
Drinks socially and never smoked.,0
"Family History: Noncontributory Physical Exam: 67 135/72 16 70"" 206 GEN: Anxious HEENT: PERRL, EOMI, Anicteric sclera, OP benign NECK: Supple, No JVD, Question fo right carotid bruit LUNGS: CTA ABD: Benign HEART: RRR, Nl S1-S2 EXT: Warm, dry, no c/c/e.",0
NEURO: Nonfocal Pertinent Results: - ECHO Prebypass 1.No atrial septal defect is seen by 2D or color Doppler 2.,0
5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present.,0
There is sigmoid hypertrophy of the interventricular septum at the base.,0
No resting LVOT gradient present.,0
Patient is receiving an infusion of phenylephrine.,0
Brief Hospital Course: Mr. was admitted to the on for surgical management of his coronary artery disease.,1
He was taken directly to the operating room where he underwent coronary artery bypass grafting to four vessels.,1
Postoperatively he was taken to the cardiac intensive care unit for monitoring.,0
"As he had some postoperative bleeding, he was transfused with red blood cells, fresh frzen plasma and platelets.",0
A dose of aprotonin was also used and his bleeding stopped.,0
"By Postoperative day one, he awoke neurologically intact and was extubated.",0
"Aspirin, a statin and beta blockade were resumed.",0
Medications on Admission: Tramterene HCTZ 37.5/25 mg daily Diovan 320mg daily Norvasc 10mg daily Aspirin 81mg daily Lipitor 20mg daily Avodart 0.5mg daily Discharge Disposition: Extended Care Facility: Discharge Diagnosis: CAD s/p CABG HTN Hyperlipidemia GERD Obesity Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection.,0
2:11 PM CAROTID SERIES COMPLETE Clip # Reason: LEFT MCA STROKE Admitting Diagnosis: ACUTE STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with right facial droop and right arm weakness with likely left MCA stroke REASON FOR THIS EXAMINATION: r/o carotid stenosis ______________________________________________________________________________ FINAL REPORT REASON: Stroke.,0
FINDINGS: Duplex evaluation was performed of both carotid and vertebral arteries.,0
"On the right PSVs are 70, 62, 44 in the ICA, CCA, ECA resepctively.",0
The ICA:CCA ratio is 1.1.,0
"On the left PSVs are 47, 47, 63 in the ICA, CCA, ECA respectively.",0
The ICA:CCA ratio is 1.,0
4:12 AM ABD COMPL INCLUDING LAT DECUB PORT Clip # Reason: evaluate bowel gas pattern/check for free air Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with grossly bloody stool and abnl KUB previous REASON FOR THIS EXAMINATION: evaluate bowel gas pattern/check for free air ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Infant with grossly bloody stool and abnormal prior abdominal film.,1
FINDINGS: A supine film of the abdomen demonstrates the presence of an NG tube with its tip in the stomach.,0
The abdominal bowel gas pattern is normal.,0
There is no evidence of pneumatosis or free air.,0
"7:31 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement, infiltrate, edema Admitting Diagnosis: ACUTE RENAL FAILURE,THROMBOCYTOPENIA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman s/p intubation REASON FOR THIS EXAMINATION: ET tube placement, infiltrate, edema ______________________________________________________________________________ FINAL REPORT AP CHEST, 7:50 A.M., .",1
HISTORY: Check ET tube placement.,0
IMPRESSION: AP chest compared to and 25: ET tube in standard placement.,0
"Lung volumes have decreased since , and there is new atelectasis at both lung bases.",0
Upper lungs show vascular congestion but no edema.,0
Slight vascular engorgement in the mediastinum is probably due to supine positioning.,0
Nasogastric tube ends in the region of the proximal duodenum.,0
Tip of the right subclavian line projects over the mid SVC.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: IPH Major Surgical or Invasive Procedure: Right Craniotomy for evacuation of hemorrhage/AVM History of Present Illness: 35 yo F found down at home w/ slowed MS L hemiparesis.,1
Pt was drinking caffeinated beer at home when she was found down by her sister.,0
one witnessed the fall and pt reportedly had 2 carinated beers.,0
Pt was minimally responsive w/ sluggish speech and complete flaccidity of her L extremities.,0
She was taken by ambulance to OSH where she was found to have a L hemiparesis and L lower facial droop.,1
CT at that time demonstrated a large IPH in the R frontal lobe with 10mm of subfalcine herniation.,0
Pt was transferred to for neurosurgical evaluation.,0
"On arrival to the , pt was hemodynamically stable and sluggishly responsive (GCS 14).",0
CTA/CT demonstrated no interval enlargement of the hemorrhage nor the herniation.,0
"On initial evaluation pt was responsive and denied any blurred vision, dizziness, or numbness.",0
Pt was complaining of an inability to move her L arm and leg and endorsed a frontal headache.,0
"No n/v, no fever or chills, no SoB, Past Medical History: Anxiety Social History: lives w/ sister, EtOH, tobac, Family History: noncontributory Physical Exam: On Admission: Hunt and : 3 : 4 GCS E:3 V:5 Motor: 6 O: T:98.4 BP: 115/67 HR:104 R 18 98% 2L Gen: WD/WN, NAD, somnolent HEENT: Pupils: anisocoric w/ R:5 to 3, L 3 to 2 EOMs grossly intact Neck: Supple.",0
no LAD Extrem: Warm and well-perfused.,0
"Neuro: Mental status: Somnolent, opens eyes to loud voice, cooperative with exam but requires frequent stimuli.",0
Language: Speech slurred with good comprehension and repetition.,0
"Cranial Nerves: I: Not tested II: Pupils anisocoric R>L (5 vs 3), round and reactive to light, 5 to 3mm in R, 3 to 2 in L. Visual fields are grossly full to confrontation.",0
"III, IV, VI: Extraocular movements grossly intact bilaterally.",0
No pronator drift Stength: D B T WE WF IP Q H AT G R 3 5 5 4 4 5 5 5 5 5 5 L 1 1 1 0 0 0 0 0 0 1 1 Sensation: Intact to light touch and pinprick bilaterally.,0
"Reflexes: B T Br Pa Ac Right 2 - - 2 - Left 2 - - 3 - Upgoing toe on L Downgoing on R Upon Discharge: awake, alert + oriented x3 PERRL, EOM- restricted to left (passes midline though) left facial droop, tongue deviates left Left hemiparesis ( R IP 2+/5 ) Right UE and LE full strengths sensation intact to light touch and symmetric incision- sutures/staples removed, well healing R groin- angioseal.",1
C/D/I Pertinent Results: CTA HEAD : No contrast extravasation to suggest active arterial hemorrhage.,0
Vascular malformation such as cavernoma or AVM likely.,0
Stable right frontal intraparenchymal hemorrhage with subarachnoid and intraventricular extension.,1
11 mm leftward subfalcine herniation as before.,0
"CT HEAD : Status post right frontal craniotomy for evacuation of underlying hematoma, but expected post-surgical change.",0
"There is persistent edema within the right frontal lobe, though overall decreased mass effect compared to study performed preoperatively.",0
"CT Head : Status post right frontal craniotomy, with expected post-surgical change.",0
"There is persistent edema within the right frontal lobe and associated mass effect, though the degree of midline shift has decreased from 8 to 6 mm over the prior 6 hours.",0
Right upper extremity ultrasound : IMPRESSION: No evidence of DVT.,0
LE DVT: IMPRESSION: No evidence of DVT.,0
Cerebral angiogram: no evidence of vascular malformation or residual source of hemorrhage.,1
Brief Hospital Course: Patient presented to from an OSH and was admitted to the neurosurgery service for intracranial hemorrhage.,0
She recieved a STAT cerebral angiogram and it was found that she had a AVM of the parietal branch of the right MCA.,0
Prior to the angiogram she had an episode of seziure which consisted of her extensor posturing her LUE and flexing her RUE towards her face.,0
she went to the OR for evacuation vis craniotomy on the mornign of .,0
post-operatively she remained intubated and was trasnferred back to the ICU.,0
she had 2 episodes of presumed seizure in the post-op period similar in nature to the one she ahd prior to her angiogram.,0
"For this reason, she was placed on dilantin.",0
On she remained in the ICU for Q2 neuro checks.,0
On she was transferred out of the ICU to the Step down unit.,0
She was able to maintain a SBP of 100-140 without medications.,0
Her Dilantin level was corrected to greater than 10.,0
"She was seen by Speech and swallow, who recommended she was safe for a liquid diet with soft solids.",0
Dilantin level on was 10.6 and she was continued on 100mg TID.,0
Her exam continued to improve and she had some voluntary movement of her left leg.,0
"On , she complained of increased muscle spasms to her neck and arm.",0
She was placed on Robaxin 100mg QID.,0
She continued to work with PT for mobility.,0
the muscle spasms were improving and she was tolerating the robaxin.,0
Sutures and staples were removed.,0
On she had LENIs which were negative and continued to be OOB to chair with PT.,0
On & she continued to complain of pain and muscle spasm throughout her body.,0
It was noted that her spasticity had gotten worse again.,0
She was very tearful throughout the day and stated that she just couldn't sleep at night.,0
She was started on Ambien QHS as well as Zoloft.,0
Baclofen was added and the robaxin was continued.,0
Dilatin was 8.7 therefore she was bolused and her standing dose was increased.,0
Her exam remained stable through and she underwent a cerebral angiogram on which showed no vascular malformation.,0
This was via right femoral artery which was successfully angiosealed.,0
After remaining neurologically and hemodynamically stable for 3 hours she was cleared for discharge to rehab.,0
Medications on Admission: None Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain.,0
"3. bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
"6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day).",0
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain.,0
8. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical (2 times a day).,0
9. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day).,0
10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching.,0
"11. phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO BID (2 times a day).",0
12. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
13. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
14. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Discharge Disposition: Extended Care Facility: St. Hospital Rehabilitation Unit Discharge Diagnosis: Right MCA AVM Cellulitis Discharge Condition: Mental Status: Clear and coherent.,0
"If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week.",0
", W. SICU-B 8:35 AM DUPLEX DOPP ABD/PEL; US ABD LIMIT, SINGLE ORGAN Clip # Reason: S/P LIVER TX, EVALUATE VASCULATURE Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p liver transplant REASON FOR THIS EXAMINATION: evaluate vasculature ______________________________________________________________________________ PFI REPORT PFI: The portal vein, hepatic vein, and hepatic artery are patent.",1
"The hepatic arterial resistive index has increased to approximately 0.5 today, which is normal.",0
"11:32 AM CHEST (PORTABLE AP) Clip # Reason: Assess for pulmonary edema, pleural effusion Admitting Diagnosis: URINARY TRACT INFECTION; ______________________________________________________________________________ MEDICAL CONDITION: year old woman with h/o A-fib with dyspnea, O2 requirement REASON FOR THIS EXAMINATION: Assess for pulmonary edema, pleural effusion ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: History of AFib, assessment for pulmonary edema or pleural effusion.",1
"FINDINGS: As compared to the previous radiograph, there is moderately increasing evidence of pulmonary edema and bilateral pleural effusions.",0
Subsequent bilateral areas of atelectasis.,0
Unchanged low lung volumes with moderate cardiomegaly.,0
Height: (in) 64 Weight (lb): 160 BSA (m2): 1.78 m2 BP (mm Hg): 86/64 Status: Inpatient Date/Time: at 09:08 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Moderate-sized vegetation on mitral valve.,0
There is an echogenic density in the right ventricle consistent with a Swan-Ganz catheter.,0
There is a small and moderate-sized masses on the posterior and anterior leaflets of the mitral valve.,0
"Compared with the findings of the prior study (images reviewed) of , the left and right ventricular function have normalized with no wall motion abnormalities seen.",0
"There are echogenic densities on the tips of the mitral valves, which appear echogenic and bright(calcified) and not relatively mobile, consistent with rheumatic valvular changes(most likely) but can not rule out healed endocarditis.",0
6:30 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with 3 vessel disease REASON FOR THIS EXAMINATION: pre-op ______________________________________________________________________________ FINAL REPORT INDICATION: Preop for CABG.,1
"PA AND LATERAL VIEWS OF THE CHEST: Cardiac silhouette is normal in size, with a mild left ventricular predominance.",0
The aorta is slightly unfolded.,0
Deformity of several right-sided ribs suggests prior fractures.,0
Degenerative changes are seen within the thoracic spine.,0
"10:41 PM CHEST (PORTABLE AP) Clip # Reason: 78 year old woman with stroke, needs NGT placement co Admitting Diagnosis: TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with stroke, needs NGT placement confirmation, also r/o asp pna REASON FOR THIS EXAMINATION: 78 year old woman with stroke, needs NGT placement confirmation, also r/o asp pna ______________________________________________________________________________ FINAL REPORT HISTORY: Stroke and nasogastric tube placement.",0
CHEST: AP upright portable view.,0
"The nasogastric tube makes a large loop within the stomach, and its tip is in the fundus.",0
The left subclavian central venous catheter remains in good position with tip in the SVC.,0
Mild pulmonary edema is new since the previous study.,0
"Bibasilar atelectasis, left greater than right, is increased in the interim.",0
There is no evidence of a consolidation to suggest aspiration.,0
New mild congestive heart failure.,0
"Bibasilar atelectasis, left greater than right, increased in the interim.",0
4:45 AM CHEST (PORTABLE AP) Clip # Reason: eval fluid and resp status.,0
"Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p Whipple, sob,hypoxia and new onset of renal failure REASON FOR THIS EXAMINATION: eval fluid and resp status.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia assess fluid status.,0
Prior studies are not available for comparison as PACS is off-line.,0
The patient is post-median sternotomy.,0
An ET tube terminates several cm above the carina and is in satisfactory position.,0
A right IJ Swan-Ganz catheter is seen with its tip terminating in the main pulmonary artery.,0
An NG tube terminates within the stomach.,0
There is opacification at the left lung base and retrocardiac area consistent with atelectasis/consolidation.,0
There is slight haziness of the left hemithorax consistent with a layering effusion.,0
There are no focal consolidations in the right lung.,0
No pneumothorax is seen on this supine radiograph.,0
The pulmonary vasculature appears normal.,0
IMPRESSION: Multiple lines and tubes in satisfactory position.,0
Likely layering left pleural effusion.,0
"3:29 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: reposition of PM lead Admitting Diagnosis: CHF;SEVERE AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with arrest REASON FOR THIS EXAMINATION: reposition of PM lead ______________________________________________________________________________ FINAL REPORT AP CHEST, 3:21 P.M., HISTORY: Status post arrest.",1
"IMPRESSION: AP chest compared to 3:04 p.m.: Transvenous pacer lead has been repositioned, the tip now projecting over the body of the right ventricle.",0
Lateral view would be required for precise triangulation.,0
Right supraclavicular central venous lines end in the mid SVC.,0
Moderate right pleural effusion persists.,0
Left lower lobe collapse is worsened.,0
"Midline drainage tube has been partially withdrawn, now several centimeters below the level of the left upper lobe bronchus to the left of the midline.",0
8:10 PM CT HEAD W/O CONTRAST Clip # Reason: ?,0
ICH ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with active seizures.,0
Now intubated for airway protection REASON FOR THIS EXAMINATION: ?,0
ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: ENYa SAT 9:08 PM No acute ICH.,0
"Encephalomalacia in the L frontal lobe, with evidence of prior craniotomy.",0
No acute intracranial pathologic process.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT HISTORY: 40-year-old man, with active seizures.",0
Now intubated for airway protection.,0
Assess for acute intracranial hemorrhage.,0
TECHNIQUE: Non-contrast MDCT images were acquired through the brain.,0
FINDINGS: The study is slightly limited by patient's motion.,0
"Allowing for the limitations, there is encephalomalacia in the left frontal lobe, with adjacent old left frontotemporal craniotomy, compatible with prior injury with surgical intervention.",0
"There is otherwise no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct.",1
"Apart from the ex vacuo effect from the left frontal encephalomalacia, there is no shift of normally midline structures.",0
"The ventricles and sulci are prominent, representing age-advanced global atrophy.",0
There is no evidence of acute fracture.,0
Scattered anterior ethmoidal opacification is noted with minimal aerosolized fluid in the right maxillary sinus.,0
The remaining visualized paranasal sinuses and mastoid air cells are clear.,0
"Evidence of old left frontotemporal craniotomy, with severe left frontal encephalomalacia, compatible with old injury with surgical intervention.",0
No evidence of acute intracranial pathologic process.,0
10:20 AM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: MVC/FX Admitting Diagnosis: LIVER LACERATION ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man with REASON FOR THIS EXAMINATION: s/p trauma No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Trauma.,1
NON-CONTRAST CT OF THE LUMBAR SPINE WITH MULTIPLANAR REFORMATTED IMAGES: FINDINGS: There is bilateral spondylolysis at L4-5.,0
There is no definite evidence of spondylolisthesis.,0
There is a fracture through the left side of the pelvis with displacement of the left SI joint.,0
There is no definite evidence of acute spinal fracture or malalignment.,1
There is no definite evidence of paravertebral hematoma.,0
IMPRESSION: Bilateral spondylolysis at L4-5.,0
No definite evidence of acute spine fracture.,0
Fractures of the left pelvis and abnormality of the left SI joint as described.,1
"5:30 PM CT HEAD W/O CONTRAST Clip # Reason: pls eval for bleed Admitting Diagnosis: COPD EXACERBATION;RIB FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with metastatic lunc ca, s/p fall and mental status changes, n REASON FOR THIS EXAMINATION: pls eval for bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT CONTRAST INDICATION: 62-year-old man with metastatic lung carcinoma mental status changes.",1
"CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage, edema, mass effect or shift of normally midline structures or hydrocephalus.",0
Density values of brain parenchyma are within normal limits.,0
The appearance of the surrounding soft tissues and osseous structures is unchanged.,0
There is minimal mucosal thickening in the right maxillary sinus.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Vicodin / Penicillins Attending: Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: paracentesis Transfusion of packed red blood cells and fresh frozen plasma Upper endoscopy History of Present Illness: 57yoM with h/o EtOH cirrhosis, UGIB, CLL, a fib on coumadin p/w abdominal pain (mid abdominal) since this morning.",0
At worst the abdominal pain was and was worse with bumps in car ride to ED.,0
Sharp in nature and perhaps transiently better after BM.,0
He also notes increased lethargy over the past few days.,0
He has had softer/loose brown stool; denies black stool or BRBPR.,0
"Reports chronic, intermittent diarrhea x many years, however noted 4 loose stools (more frequent than normal during these episodes).",0
"Has noted perhaps slightly increased abdominal distention, but no significant increase in LE edema from recent baseline.",0
"Has been taking PO, but ""not as much as usual"" and he reports feeling dehydrated.",0
"Of note, he was hospitalized for CHF and hct drop at which time EGD was performed showing grade 2 varices which were banded.",0
Hct at time of discharge was 24.3 at time of discharge.,0
"In the ED, initial vitals were 98.8 112 81/45 18 96%RA.",0
NGL was negative for blood.,0
He had guaiac positive brown stool.,0
CT abd/pelvis was performed which showed moderate loculated ascitic fluid without other clear bowel pathology.,0
"He received levofloxacin 750mg IV, flagyl 500mg IV, and ceftriaxone 1g IV.",0
He also received zofran 4mg IV x1 for nausea after NGL.,0
Additionally he was noted to have transient SBPs to 70s (normally 90s); central line (right IJ) was placed and he received 3L NS to which his BP improved to high 80s-90s systolic.,0
+chronic LE edema which he denies being worse than baseline.,0
"Past Medical History: # EtOH cirrhosis -portal HTN -varices with h/o UGIB -ascites -no h/o SBP -no h/o hepatic encephalopathy # Hypertension # Diastolic CHF # Atrial fibrillation on coumadin # Seasonal allergies # Shingles # Dental abscess # Peptic ulcer disease # CLL Social History: Significant for no tobacco usage, significant alcohol usage.",1
"He used to drink heavily in the past, with no history of any withdrawals or delirium tremens.",0
"He reports previously was drinking about glasses of wine 3-4 times a week, but reports has stopped currently.",0
"Family History: diabetes, cancer and stroke.",0
"Physical Exam: VS: Temp: 97.2 BP: 85/48 HR: 90 a.fib RR: 19 O2sat 99% RA GEN: pleasant, comfortable, NAD HEENT: Left pupul 3->2.5mm, right pupil 2.5->2mm, EOMI, + scleral icterus, MM dry, OP without lesions NECK: no supraclavicular or cervical lymphadenopathy appreciated, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: no increased WOB, bibasilar rales L>R ( up on left), no rhonchi nor wheezes CV: irregularly irregular, S1 and S2 wnl, no m/r/g appreciated ABD: +mild distention, +b/s, soft, mildly tender mid abdomen just superior to umbilicus, + hepatosplenomegaly, no rebound/guarding EXT: + left lower extremity edema, 2+right lower extremity edema (reports asymmetry as chronic), warm, good pulses SKIN: no rashes, +jaundice NEURO: AAOx3.",0
No sensory deficits to light touch appreciated.,0
Pertinent Results: Labs on admission: 11:22PM LACTATE-1.3 02:37PM LACTATE-3.1* 02:37PM HGB-9.1* calcHCT-27 02:25PM GLUCOSE-151* UREA N-21* CREAT-1.3* SODIUM-135 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-10 02:25PM estGFR-Using this 02:25PM ALT(SGPT)-21 AST(SGOT)-41* ALK PHOS-109 AMYLASE-74 TOT BILI-5.5* 02:25PM LIPASE-28 02:25PM CALCIUM-8.3* MAGNESIUM-2.0 02:25PM AMMONIA-57* 02:25PM DIGOXIN-2.5* 02:25PM WBC-31.0* RBC-2.50* HGB-8.8* HCT-25.7* MCV-103* MCH-35.2* MCHC-34.3 RDW-24.7* 02:25PM NEUTS-15* BANDS-2 LYMPHS-79* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 02:25PM PLT COUNT-243 02:25PM PT-21.2* PTT-34.8 INR(PT)-2.1* .,0
Labs on discharge: 05:51AM BLOOD WBC-13.2* RBC-2.61* Hgb-8.7* Hct-25.1* MCV-96 MCH-33.5* MCHC-34.8 RDW-22.5* Plt Ct-121* 05:51AM BLOOD PT-20.0* PTT-50.8* INR(PT)-1.9* 05:51AM BLOOD Glucose-83 UreaN-24* Creat-1.0 Na-140 K-3.9 Cl-105 HCO3-24 AnGap-15 05:51AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 .,0
EKG: A. fib at rate 86.,0
"Biphasic TW in V2, TWI V3-V6 (old), TWI II, III, aVF (both old) .",0
"Microbiology: Blood cx - negative Urine cx - < 100K enterococcus Blood cx - negative Peritoneal fluid cx - gram stain 4+ PMNs, no microorganisms, cx negative .",0
"CXR: Wet read: Pleural plaques, bilateral haziness and cephalization c/w pulmonary edema vs. overlying pleural disease.",0
"Increasing ascites within the abdomen, layering non-dependently with some areas of partial loculation and mild rim enhancement--these findings raise the possibility of peritonitis.",0
"Stigmata of portal hypertension including splenomegaly, paraesophageal varices, and a large recanalized umbilical vein.",1
"Poor visualization of the left hepatic lobe, left hepatic vein, and left portal vein.",0
"Patent main portal, right portal, and right and middle hepatic veins.",0
Findings consistent with cirrhosis and portal hypertension.,1
Moderate to large volume ascites.,0
Markedly decreased amount of ascites.,0
No evidence of hematoma or intraperitoneal hemorrhage.,0
"Stigmata of portal hypertension including splenomegaly, periesophageal varices, gastric varices, and large recanalized umbilical vein are unchanged.",1
"EGD: Impression: Varices at the lower third of the esophagus Erythema in the gastroesophageal junction compatible with esophagitis Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 57 year old man with history of Alcoholic cirrhosis and portal hypertension with grade 2 varices status post banding in , CLL, diastolic CHF presents with increase in loose bowel movements and abdominal pain.",1
"Initially admitted to MICU for transient hypotension, stable throughout admission.",0
HOSPITAL COURSE BY PROBLEM: .,0
"# Abdominal pain/spontaneous bacterial peritonitis: Due to spontaneous bacterial peritonitis given loculated ascites and peritoneal enhancement on CT, as well as diagnostic paracentesis demonstrating greater than 250 PMNs.",1
Peritoneal culture with no growth.,0
Patient was treated with levofloxacin with resolution of abdominal pain.,0
"Discharged with instructions to complete 7 day course of levofloxacin, then to start on ciprofloxacin for SBP prophylaxis.",0
"# Hypotension: Normal SBPs run in the 90s per patient, but BP on presentation was below this, off of normal anti-hypertensives.",0
Therefore felt to be relative hypotension.,0
"was initially admitted to the MICU due to this, but BP stabilized with IVF.",0
No more episodes of hypotension throughout hospital course.,0
"# Alcohollic cirrhosis: Patient with known alcoholic cirrhosis, with esophageal varices.",1
"On furosemide, aldactone, nadolol as outpatient.",0
"These were initially held due to hypotension above, but then were added back (although furosemide and nadolol added at lower dose that on admission).",0
"Otherwise, treatement of SBP as above, and treatment of anemia as below.",0
The patient will follow up with hepatology as an outpatient.,0
"# Anemia: Patient presented with HCt of 25.7, trended to low of 18.5.",0
"Etiology of patient's anemia felt to be likely multifactorial - due to history of CLL, perhaps some low grade hemolysis (50% indirect bili, low haptoglobin, but normal LDH, and in setting of transfusions and cirrhosis, so difficult to interpret), as well as perhaps low grade bleed from esophageal varices.",1
"He is on coumadin for AFib and aspirin as an outpatient, which were held on admission.",0
"Patient received 6 units pRBC, 7 units FFP, vitamin K PO x 1 during hospital course.",0
"EGD demonstrated non-bleeding varices, no intervention done.",1
"He was discharged with stable Hct, off of his coumadin and aspirin, on protonix, with follow up with his PCP to check hematocrit as outpatient to ensure remains stable.",0
Re-starting anticoagulation will also be addressed by his PCP as outpatient.,0
# Acute renal failure: Creatinine 1.3 from previously normal baseline of 0.8-1.0.,1
# Rhythm: Patient has a history of atrial fibrillation on coumadin.,1
"As above, coumadin held on admission due to decreased Hct.",0
"Digoxin also held on admission, and was held on discharge, to be addressed as an outpatient.",0
Otherwise remained rate controlled on nadolol during hospital course.,0
"# Pump: Patient with known diastolic CHF, preserved EF followed by Dr. in outpatient setting.",0
"Patient was given IV lasix with blood transfusions, and as above, was discharged on lower dose of lasix than presented on.",0
Appeared euvolemic during hospital course.,0
Will follow up as outpatient.,0
# CLL: Followed by Dr. as outpatient.,0
To be followed up as outpatient.,0
Pravastatin 10 mg PO daily 2.,0
Omeprazole 40 mg PO daily 3.,0
Furosemide 80 mg PO BID 4.,0
Digoxin 250 mcg PO daily 5.,0
Nadolol 40 mg PO daily 6.,0
Spironolactone 50 mg PO daily 7.,0
Warfarin 6 mg alternating with 5 mg PO (alternating dose qod) 8.,0
Lisinopril 2.5 mg PO daily 9.,0
Aspirin 81 mg daily 10.,0
Testosterone patch (50mg/5gram TD) Discharge Medications: 1.,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 days.,0
Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day: Please start this after you have completed your course of levofloxacin.,0
"Outpatient Lab Work Please check CBC (including hematocrit), and INR (Please bring this lab slip with you to your doctor's office on Thursday, ) Discharge Disposition: Home Discharge Diagnosis: Primary: Spontaneous Bacterial Peritonitis Anemia Secondary: Cirrhosis Hypertension Diastolic Congestive Heart failure Atrial fibrillation on coumadin CLL Peptic Ulcer disease Discharge Condition: Good.",1
Discharge Instructions: You were admitted to the hospital with abdominal pain and found to have a spontaneous bacterial peritonitis (infection in the peritoneum of your abdomen).,1
This was treated with antibiotics.,0
"You also had low blood counts requiring transfusions, and therefore underwent an endoscopy for further evaluation, which demonstrated non bleeding esophageal varices.",1
"You were discharged with instructions to follow up with your primary care physician, well as hepatology.",0
"Please note that medication changes include: - new medications include levofloxacin (antibiotics) to complete a 7 day course, and after this is completed, you will need to be on prophylactic ciprofloxaciin (a similar antibiotic) continually.",0
- You had your dose of furosemide decreased from 80mg twice daily to 40mg daily.,0
- You had your dose of nadolol decreased from 40mg daily to 20mg daily.,0
- We have also discontinued your coumadin due to your bleeding for now - this will be re-addressed by your physician after discharge.,0
- We have also discontinued your aspirin due to your bleeding for now - this will be re-addressed by your physician after discharge - We also have discontinued your digoxin due to your low blood pressure - this will be re-addressed by your physician after discharge as well.,0
Please follow up with appointments as directed.,0
"Please contact physician if develop weakness/dizziness, blood in stool, black colored stools, abdominal pain, fevers, any other complaints.",0
"Followup Instructions: Please make a follow up appointment with your primary care physician, .",0
( in the next 1 week.,0
"At this visit, you will need to have your blood counts checked.",0
You will also have to re-address starting back on your coumadin.,0
(please bring the printed lab slip with you so that your physician knows which labs need to be checked).,0
"IF your doctor cannot see you in his office this week, please go in anyways on Thursday to have your blood drawn (bring in the slip) and your primary care doctor will follow up on the results.",0
"Please follow up with hepatology, Dr. at ( as directed.",0
Please call him to make a follow up appointment in the next 2-4 weeks.,0
"The following appointments had already been scheduled, prior to your hospitalization: Provider: , : Date/Time: 1:00",0
"3:03 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: Please evaluate for RP bleed, other source of bleeding Admitting Diagnosis: SYNCOPE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with bradycardia, hypotension s/p RHC with right femoral vein access REASON FOR THIS EXAMINATION: Please evaluate for RP bleed, other source of bleeding No contraindications for IV contrast ______________________________________________________________________________ WET READ: SAT 10:04 AM 1.",0
No evidence of retroperitoneal hematoma or abnormal fluid collection.,1
Soft tissue stranding and thickening in the right groin compatible with contusion from recent catheterization.,0
Extensive vascular calcifications including dense calcifications of the aortic valve as well as coronary calcifications.,1
______________________________________________________________________________ FINAL REPORT INDICATION: Bradycardiac and hypotension after right heart catheterization with right femoral vein access.,1
Evaluation for evidence of retroperitoneal hemorrhage.,0
TECHNIQUE: Multidetector helical CT scan of the abdomen was obtained without the administration of contrast.,0
Coronal and sagittal reformations were prepared.,0
FINDINGS: The included portions of the lung bases demonstrate bibasilar atelectasis with trace fluid.,0
There are dense calcifications of the aortic valve as well as the visualized coronary arteries.,1
A small amount of pericardial fluid is present.,0
"Within the abdomen, note is made of vicarious excretion of contrast into the gallbladder from recent catheterization.",1
"The non-contrast appearance of the liver, spleen, pancreas, adrenal glands and kidneys is grossly unremarkable.",1
Loops of small and large bowel are normal in size and caliber.,0
An esophageal catheter is in place with tip in the stomach.,0
There are extensive vascular calcifications.,0
"No fluid collection, free air or lymphadenopathy is seen.",0
"Within the pelvis, distal loops of large bowel and rectum are normal in size and caliber.",0
The bladder contains a Foley catheter.,0
The prostate gland is grossly unremarkable.,1
Again noted are extensive vascular calcifications.,0
"No pelvic free air, free fluid or lymphadenopathy is seen.",0
"In the right groin, there is soft tissue stranding and thickening compatible with contusion and hematoma from recent catheterization.",1
"There are multilevel degenerative changes of the visualized thoracic and (Over) 3:03 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: Please evaluate for RP bleed, other source of bleeding Admitting Diagnosis: SYNCOPE;TELEMETRY ______________________________________________________________________________ FINAL REPORT (Cont) lumbar spine as well as the symphysis pubis and bilateral hips.",0
No concerning osseous lesion is seen.,0
"9:31 AM CHEST (PA & LAT) Clip # Reason: evaluate pneumothorax Admitting Diagnosis: AORTIC STENOSIS\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p CABG REASON FOR THIS EXAMINATION: evaluate pneumothorax ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, .",1
IMPRESSION: PA and lateral chest compared to : Tiny left apical pneumothorax is almost entirely resolved.,0
"Severe left lower lobe atelectasis involving virtually all the basal segments, small left pleural effusion, and a retrosternal air and fluid collection, commonly seen after sternotomy, and a small right pleural effusion are all unchanged.",0
Mediastinum has a normal postoperative appearance.,0
"2:39 AM CHEST (PORTABLE AP) Clip # Reason: eval int change Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with ex lap fo perf diverticulitis REASON FOR THIS EXAMINATION: eval int change ______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative, to assess for change.",0
"FINDINGS: In comparison with the study of , the tip of the endotracheal tube now measures only about 1.5 cm.",0
"Otherwise, there is little change, with enlargement of the cardiac silhouette, bilateral pleural effusions with compressive basilar atelectasis, and elevated pulmonary venous pressure.",0
7:43 AM CHEST (PORTABLE AP) Clip # Reason: eval progression Admitting Diagnosis: ABD PAIN ______________________________________________________________________________ MEDICAL CONDITION: 37 year old woman with Hep C cirrohsis and SBO s/p ex lap LOA and fevers now REASON FOR THIS EXAMINATION: eval progression ______________________________________________________________________________ FINAL REPORT INDICATION: Hepatitis C cirrhosis and small bowel obstruction.,1
Status post exploratory laparoscopy and lysis of adhesions.,0
FINDINGS: A single AP semi-upright image.,0
"Comparison study dated , .",0
"The endotracheal tube, the two NG lines, and the right IJ central line all appear to be in good position.",0
The lungs appear beter inflated than before.,0
There has been almost complete resolution of the ill-defined infiltrate previously present in the right lower zone.,0
Minimal residual atelectatic changes are noted at the left base behind the heart.,0
No other infiltrates are seen.,0
There is no evidence of any pleural effusion.,0
"The cardiac silhouette appears slightly enlarged, predominantly left ventricular.",0
"The pulmonary vessels show minimal, if any, upper zone redistribution.",0
Substantial resolution of bibasilar infiltrates.,0
Slight LV enlargement of the heart.,0
"4:00 PM CHEST (PORTABLE AP) Clip # Reason: focal signs of infection in upper / lower airway Admitting Diagnosis: RESPITORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man transferred from OSH w respiratory distress of likely infectious etiology, known lesions of pharynx and upper airway REASON FOR THIS EXAMINATION: focal signs of infection in upper / lower airway ______________________________________________________________________________ FINAL REPORT HISTORY: Respiratory distress, possibly of infectious etiology.",0
Single view shows areas of increased opacification at the right base and involving much of the left lung.,0
There is also obscuration of the left hemidiaphragm in the retrocardiac region.,0
There is enlargement of the cardiac silhouette and some evidence of elevated pulmonary venous pressure.,0
The areas of bilateral opacification may in part reflect vascular congestion and atelectasis.,0
"However, especially in view of the clinical history, multifocal pneumonia should be seriously considered.",0
"12:29 PM CHEST (PORTABLE AP) Clip # Reason: s/p R SC PA cath Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with right upper lobectomy, empyema decortication.",0
Now with increased need for ventilation.,0
REASON FOR THIS EXAMINATION: s/p R SC PA cath ______________________________________________________________________________ FINAL REPORT INDICATION: Line placement.,0
AP semi-upright view of the chest dated at 12:58 p.m. is compared to AP supine view done earlier on .,0
The right IJ catheter has been removed.,0
The new right subclavian Swan-Ganz catheter terminates in the right main pulmonary artery.,0
The ETT remains in good position.,0
"The NG tube remains coiled in the stomach, and its tip is not included on the image.",0
3 right sided chest tubes are once again noted.,0
The right apical pneumothorax is unchanged in size.,0
"The appearance of the heart, lungs, and the right pleural effusion is stable.",0
IMPRESSION: Satisfactory position of the right subclavian Swan-Ganz catheter.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins Attending: Chief Complaint: Shortness of breath, unresponsive Major Surgical or Invasive Procedure: -tracheal intubation History of Present Illness: This is a 50 year old female with PMH of multiple c-spine operations with hardware in place, perforated Zenker's diverticulum in with subsequent seeding of hardware and development of paravertebral abscess and polymicrobial spine osteo with complicated course requiring multiple spinal revision operations, recurrent infections attributed to esophageal perforations and development of paravertebral/retroesophageal abscess with prior esophageal communication (not communicating on MRI ), on chronic opiates/benzos for pain/anxiety, and malnutrition presenting with tachypnea, fevers, congested cough, and cyanotic extremities.",0
She was hospitalized from - for malnutrition and dark stools (guaiac negative) and had J-tube placement on .,0
She was found by her boyfriend to be nonverbal and tachypneic to the 40s when he came home from work this evening and she was brought to the hospital by ambulance.,0
"In the ED, initial VS were T=99.2, HR=105, BP=139/86, RR=38, POx=99% on NC.",0
"Per the ED, the patient was breathing at a rate in the 40s, but satting well on nasal cannula, tachycardic, and normotensive.",0
A CXR was unremarkable and she was given albuterol/ipratropium nebulizer treatments.,0
She was also given vancomycin empirically with the plan to receive meropenem upon arrival to the ICU.,0
The patient appeared anxious and lorazepam was administered given that she is on chronic high doses of benzodiazepines at home.,0
"Vascular access was obtained with a triple lumen inserted into her right groin, but no A-line was placed.",0
She was then noted to have increased work of breathing and desaturated to 70-80% despite maximal nasal cannula.,0
"Given her complicated cervical neck pathology, anesthesia was called and performed -tracheal intubation through her left nostril and she was sedated on versed and fentanyl.",0
She quickly dropped her blood pressures with sedation and Levophed drip was started.,0
"Upon transfer to the MICU vitals were noted to be afebrile, HR=144, BP=133/89, RR=43 over breathing her vent settings which was set at a RR=20 with a PEEP=8 and 100% FiO2.",0
"Past Medical History: - Anterior cervical diskectomy and fusion at C5-6 with left iliac crest tricortical graft arthrodesis with anterior plating from C5 to C6 for C5/C6 disc herniation with severe R radiculopathy, RUE pain/weakness - Esophageal Perforation thought due to ruptured Zenker's diverticulum, complicated by epidural abscess, cervical osteomyelitis, and infected hardware.",0
"Went for I and D, with removal of hardware at C5-C6, and revision of C5/C6 diskectomy, new C6/C7 diskectomy.",0
"Cultures grew out Strep viridans, Strep milleri, lactobacillus, Prevotella, MSSA.",0
"C/b wound infection, delirium, VRE-infected pleural effusion, C diff.",0
Discharged on prolonged course of multiple abx.,0
"- Thrombosis of the L vertebral artery, discovered during hospitalization for esophageal perforation.",0
"- In developed bilateral upper extremity paresthesias and presented to the hospital with worsening cervical osteomyelitis, collapse of C5, C6 vertebral bodies, C7 subluxation causing cord compression and b/l UE radiculopathy -> C4-T1 arthrodesis, C5-C7 corpectomies, hardware placement.",0
"Unfortunately, this procedure was complicated by recurrence of her posterior esophageal perforation, which was repaired with an SCM flap and stent placement, and another removal of her cervical hardware.",0
- Reexploration in after barium swallow revealed extravasation of contrast from one of the posterior drains in her neck.,0
"This revealed a large, persistent esophageal perforation.",0
Stent was removed and new stent placed.,0
Cultures grew MRSA and viridans streptococcus.,0
She was discharged with a persistant neck fistula.,0
"- - admission for AMS, fevers, and dysarthria, found to have prevertebral abscess, maintained on chronic suppressive antibiotics.",0
- Otolaryngology surgery for chronic fistula and neck infection planned but not yet performed.,0
"- - represented with AMS, slurred speech - no change in prevertebral collection on imaging, was found to have multifocal PNA, likely aspiration - advanced emphysema on CT - Anxiety - PTSD - asthma - allergic Rhinitis - tonsillectomy Social History: She is smoker (up to 2-3ppd) but trying to quit now, no EtOH, no drugs.",0
Formerly worked as a pharmacist.,0
Family situation is stressful with two grown children with neuro-cognitive/psychiatric disabilities after they were assaulted by their father as children.,0
A third child perished in this attack.,0
"Has visiting nurses daily, speech/swallow, and pain management who see her at home.",0
The patient was found by her boyfriend to be nonverbal and tachypneic to the 40s when he came home from work this evening and she was brought to the hospital by ambulance.,0
"Shortly after arrival in the ED, the patient was intubated, sedated, and started on levophed.",0
"She was also given antibiotics, nebulizer treatments, and an anxiolytic prior to intubation.",0
"She was also noted to have an elevated lactate, an elevated troponin, acidemia, and elevated LFTs.",0
She was paralyzed with vecuronium and started on a cisatracurium drip on arrival to the MICU given her overbreathing and inability to synch with the vent.,0
"She was also noted to have a blown left pupil on exam and sluggish right pupil which were new for her suggesting an acute neurological event, but a head CT could not be performed given her medical instability.",0
An EKG was performed which showed sinus tachycardia.,0
"Her blood pressures quickly continued to drop significantly on the vent requiring maximal pressor support with Levophed, vasopressin, phenylephrine, and epinephrine which were added and titrated up in that order.",0
"Despite all of this pressor support, the patient's extremities remained mottled/cyanotic and her blood pressure could no longer be measured noninvasively.",0
Several attempts to place an A-line were unsuccessful given her poor pulses.,0
"The patient's boyfriend, , arrived to the MICU at this point after being called in 30 minutes prior.",0
"After relaying the severity of her illness and unlikely chance of any functional recovery, it was decided to make the patient CMO.",0
The pressors were stopped and the patient was extubated.,0
"Shortly thereafter I was called to her bedside and physical examination revealed no heart beat, breath sounds, or pulse.",0
The patient's boyfriend was at bedside and she was pronounced dead on at 1:20AM.,0
"Dr. , Dr. (PCP), and the medical examiner was notified of her passing.",0
An autopsy will be performed by the medical examiner.,0
"The patient's sister, , was also called at and informed of her passing.",0
"Tube feeds Tube feed recommendations: Fibersource HN at 20ml/hr, advance as tolerated to goal of 60 ml/hr.",0
1728 calories with 76 gram protein.,1
No residual checks with j tube.,0
Hydromorphone 4-6 mg PO Q3H as needed for pain.,0
Minocycline 100 mg PO BID 4.,0
Lansoprazole 30 mg Tablet PO BID 6.,0
Gabapentin 250 mg/5 mL Solution : Eight (8) ML PO TID (3 times a day).,0
Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid : Five (5) cc PO DAILY (Daily).,0
Cholecalciferol (Vitamin D3) 400 unit Tablet : Two (2) Tablet PO DAILY (Daily).,0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler : 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
Ascorbic Acid 500 mg/5 mL Syrup : Five (5) ml PO BID (2 times a day).,0
Polyethylene Glycol 3350 17 gram/dose Powder : One (1) packet PO DAILY (Daily) as needed for constipation.,0
Alprazolam 1 mg by mouth every four hours and 3mg at bedtime 15.,0
Cyanocobalamin (vitamin B-12) [Vitamin B-12] 17.,0
Nicotine 21 mg/24 hour once a day 18.,0
Zinc 50 mg by mouth once a day Discharge Medications: Patient expired.,0
Discharge Disposition: Expired Discharge Diagnosis: Patient expired.,0
"7:24 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: trach placement Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man with PMH MR/CP p/w fungemia, s/p ARDS s/p trach placement REASON FOR THIS EXAMINATION: trach placement ______________________________________________________________________________ FINAL REPORT INDICATION: 29-year-old man with fungemia, status post ARDS status post trach placement.",0
Again noted are patchy opacities throughout both lungs.,0
These are unchanged in appearance.,0
A central venous line is seen with its tip in the distal SVC.,0
The tracheostoma is seen with its tip 1.1 cm from the carina.,0
Tracheostomy tube with its tip 1.1 cm from the carina.,0
No change in the bilateral patchy opacity is consistent with a history of ARDS.,0
9:55 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: eval for pleural effusions/ pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for pleural effusions or pneumonia.,1
FINDINGS: The lung fields are clear.,0
The soft tissue and osseous structures are within normal limits.,0
IMPRESSION: No acute cardiopulmonary abnormalities are identified.,0
"2:15 AM BABYGRAM (CHEST & ABDOMEN) PORT Clip # Reason: r/o nec, assess lung expansion ______________________________________________________________________________ MEDICAL CONDITION: Critically ill infant with respiratory failure at 25 weeks gestation with mixed respiratory/metabolic acidosis and hypotension.",0
REASON FOR THIS EXAMINATION: r/o nec assess lung expansion ______________________________________________________________________________ FINAL REPORT INDICATION: Critically ill infant with respiratory failure at 24 weeks gestation.,0
Endotracheal tube present with its tip at the carina.,0
Right subclavian venous catheter crossing the midline with its tip near the medial tip of the left clavicle.,0
"Diffuse, near complete hazy opacification of both lungs with an alveolar pattern worsening since last examination .",0
These changes are consistent with pneumonia and/or sepsis.,0
No evidence of pneumothorax identified.,0
Nonspecific distention of multiple loops of bowel with gas and fluid.,0
IMPRESSION: Severe lung disease consistent with pneumonia or sepsis.,1
12:06 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: r/o CVA Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with new decreased left sided vision for past 3 days REASON FOR THIS EXAMINATION: r/o CVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT MRI AND MRA HEAD.,0
"HISTORY: 65-year-old man with COPD and coronary artery disease with decreased left-sided vision for the last three days, assess for infarct.",1
MRA HEAD: TECHNIQUE: 3D time-of-flight images of the head were obtained wih maximum intensity projection reconstructions.,0
"FINDINGS: There are no intracranial aneurysms, stenoses, occlusions, or vascular malformations.",0
MRI HEAD: TECHNIQUE: Multiplanar multisequence MR images of the head were obtained without IV gadolinium.,0
FINDINGS: No prior studies are available for comparison.,0
There are no intracranial hemorrhages or masses.,0
The /white matter differentiation is maintained with no areas of slow diffusion.,0
There is a minimal amount of deep and periventricular white matter T2 hyperintensities which likely represent chronic microangiopathic changes.,1
There are minimal T2 hyperintensities of the medial thalami bilaterally which may represent small lacunar infarcts.,0
The ventricles and extra-axial CSF spaces are prominent.,0
The visualized orbits and major flow voids are normal.,0
There is minimal mucosal thickening of the left sphenoid air cell.,0
No suspicious bony abnormalities are seen.,0
(Over) 12:06 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: r/o CVA Admitting Diagnosis: SEPSIS ______________________________________________________________________________ FINAL REPORT (Cont) COMMENT: The above findings were discussed with Dr. on at approximately 3:00 p.m.,0
11:46 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: PTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man post-pull CT-s/p OPCAB REASON FOR THIS EXAMINATION: PTX ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 3:21 PM PFI: No pneumothorax after chest tube removal.,1
"INDICATION: Post-pull of chest tube, status post OPCAB, evaluate for pneumothorax.",0
FINDINGS: AP single view of the chest obtained with patient sitting in upright position is analyzed in direct comparison with the next preceding similar study obtained two hours earlier.,0
"During the interval, the left-sided chest tube has been removed.",0
Previously described mild degree of left lateral blunting of the pleural sinus and hazy retrocardiac density remain unchanged.,0
No new abnormalities are seen and no pulmonary congestion is present.,0
IMPRESSION: No pneumothorax after chest tube removal in patient recently undergoing off pump LIMA-coronary bypass.,0
"12:01 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: Rule out epidural abscess Admitting Diagnosis: FEVER Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 47M w/ fevers, leukocytosis, bacteremia, and C-Spine tenderness over C5 REASON FOR THIS EXAMINATION: Rule out epidural abscess No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 8:18 PM 1.",0
No obvious epidural abscess identified.,0
"Multilevel degenerative changes of the spine including moderate neural foraminal narrowing on the left at C3-4, mild neural foraminal narrowing on the left at C4-5, mild bilateral neural foraminal narrowing at C5-6, moderate neural foraminal narrowing on the right at C6-7 with an associated bulging disc also causing mild narrowing of the spinal canal at this level, and grade 1 anterolisthesis of C3 on C4.",1
The spinal cord signal is normal and there is no evidence of abnormal enhancement following administration of contrast.,0
"Hypointense marrow signal at multiple levels on T2-weighted sequences may be within normal limits for the age; however, should be correlated with hematologic labs.",0
PFI VERSION #1 5:27 PM 1.,0
Hyperintense marrow signal at multiple levels on T2-weighted sequences should be correlated with hematologic labs.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Fevers, leukocytosis, bacteremia, and C-spine tenderness over C5.",0
"TECHNIQUE: Sagittal T2, sagittal T1, sagittal STIR, axial T2, axial gradient echo, sagittal T1 post-contrast, and axial T1 post-contrast sequences were acquired per departmental protocol.",0
FINDINGS: There is no obvious epidural abscess identified.,0
Minimal Grade 1 anterolisthesis of C3 on C4 is seen without evidence of associated obvious ligamentous injury.,0
Slightly hypointense marrow signal on T1-weighted images (Over) 12:01 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: Rule out epidural abscess Admitting Diagnosis: FEVER Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) is seen throughout the cervical spine.,0
Multilevel disc desiccation is also identified.,0
The cervical spinal cord is normal in appearance and does not show abnormal enhancement following contrast administration.,0
C2-3: There is no narrowing of the spinal canal.,0
No significant neural foraminal narrowing.,0
C3-4: Minimal Grade 1 anterolisthesis of C3 on C4 with uncovering of the disc and bulge along with uncovertebral osteophytes and facet joint hypertrophy causes moderate neural foraminal narrowing on the left and mild-moderate on the right with possible deformity on the nerves.,1
There is no narrowing of the spinal canal.,0
C4-5: Uncovertebral joint and facet joint hypertrophy cause mild-moderate neural foraminal narrowing on the left possible deformity on the nerve.,0
Uncovertebral joint and facet joint hypertrophy cause mild bilateral neural foraminal narrowing.,1
"Bulging of the disc with osteophytes causes mild narrowing of the spinal canal, without signal abnormality in the spinal cord at this level.",1
"The bulging disc, in combination with facet joint hypertrophy, also causes moderate-severe neural foraminal narrowing on the right and moderate on the left with deformity on the nerves.",1
C7-T1: There is no significant neural foraminal or spinal canal narrowing at this level.,0
The left vertebral artery is dominant with diminutive right vertebral artery.,0
No obvious epidural abscess identified in the c spine.,0
"Multilevel degenerative changes of the spine including moderate neural foraminal narrowing on the left at C3-4, mild neural foraminal narrowing on the left at C4-5, mild bilateral neural foraminal narrowing at C5-6, moderate-severe neural foraminal narrowing on the right at C6-7 with an associated bulging disc also causing mild narrowing of the spinal canal at this level, and grade 1 anterolisthesis of C3 on C4.",1
Hypointense marrow signal at multiple levels on T2-weighted sequences should be correlated with hematologic labs.,0
(Over) 12:01 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: Rule out epidural abscess Admitting Diagnosis: FEVER Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont),0
"10:04 AM CAROTID SERIES COMPLETE Clip # Reason: F/U BILATERAL CAROTID STENOSIS, PREOP CEA OR STENT Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with h/o bilateral carotid disease now being considered for surgery or stenting.",1
"REASON FOR THIS EXAMINATION: eval status of bilateral carotid artery disease ______________________________________________________________________________ FINAL REPORT INDICATION: Follow-up of known bilateral carotid artery disease in an 80-year- old man, who is now being considered for surgery or stent placement.",1
"COMPARISON: Prior similar examination from had shown (1) an 80 to 99% stenosis of the right internal carotid artery (ICA), (2) a 70-79% stenosis of the left ICA, and (3) the absence of visualization of the left vertebral artery.",1
"TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler examinations were performed at the level of the cervical portions of the bilateral carotid and vertebral arteries.",1
"On the right, plaque is present in the mid/upper portions of the common carotid artery (CCA) and in the lower and midportions of the ICA.",1
"The velocities in the ICA, CCA and ECA (external carotid artery) are 526/182, 73/12, and 126 cm/second, respectively.",1
The peak systolic velocity ratio between the ICA and CCA is 7.2.,0
"Again, the right vertebral artery is not visualized.",0
"On the left, plaque is detected in mid/upper portion of the CCA and at the origins of the ICA and ECA.",0
"The velocities are 257/54 cm/sec in the ICA, 70/16 cm/sec in the CCA (196/48 cm/sec in the distal portion of this CCA), and 154 cm/sec in the ECA.",0
The left ICA-to-CCA peak velocity ratio is 3.67.,0
"There is antegrade flow in the left vertebral artery, with a peak systolic velocity of 80 cm/second.",0
CONCLUSION: No major change as compared to the report of : 1.,0
"80 to 99% stenosis in the right ICA, 2.",0
"70 to 79% stenosis in the left ICA, and 3. absence of visualization of the right vertebral artery.",1
6:17 AM BABYGRAM CHEST & ABD (2 FILMS STANDARD) PORT; -76 BY SAME PHYSICIANClip # Reason: UVC RE-ADJUSTED Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant BORN AT 28 WEEKS GESTATION REASON FOR THIS EXAMINATION: UVC RE-ADJUSTED ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST AND ABDOMEN ON AT 555 HOURS HISTORY: Followup line placement.,1
"In followup to earlier on , the patient remains intubated with ETT at the level of the carina with the neck extended to the left.",0
UVC terminates at the right hemidiaphragm.,0
Persistent diffuse mild granular opacities throughout both lungs consistent with RDS.,0
No focal collapse or consolidation or significant pleural fluid collections.,0
"Some increased lucency is noted along the left superior mediastinum which may be related to skin folds, however, and a small anterior pneumothorax remains a possibility.",0
Examination of the abdomen demonstrates normal gaseous distension of bowel loops with no evidence of obstruction.,0
3:21 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"pulm edema Admitting Diagnosis: CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with HTN, COPD who is intermittently desatting REASON FOR THIS EXAMINATION: ?",0
"pulm edema ______________________________________________________________________________ FINAL REPORT AP CHEST 3:15 A.M., HISTORY: Hypertension and COPD.",0
"Intermittent desaturation, question pulmonary edema.",0
"IMPRESSION: AP chest compared to through 9: Mild pulmonary edema is present, slightly worse compared to with increase in moderate right pleural effusion and severe left lower lobe atelectasis.",0
"9:04 AM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: s/p ejection from high speed MVA Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with MVC, LOC, multiple injuries including left diaphragmatic rupture, pelvic fractures, femur fracture REASON FOR THIS EXAMINATION: s/p ejection from high speed MVA No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATIONS: 22-year-old male with motor vehicle collision, loss of consciousness, and multiple injuries including left diaphragmatic rupture, and pelvic fractures.",1
He is status post ejection in a high speed motor vehicle collision.,1
"TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained, and sagittal and coronal reconstructions were also performed.",0
FINDINGS: The patient is intubated and also has an oral esophageal tube.,0
There is diffuse overlying soft tissue edema.,0
There is air dissecting into the subcutaneous tissues of the left upper back.,0
There are multiple small cervical lymph nodes bilaterally which do not meet CT criteria for pathological enlargement.,0
"As better seen on the head CT of the same day, there is bilateral thickening of the mucosa in the maxillary sinuses.",0
The overall alignment of the cervical spine is preserved without listhesis.,0
There is no evidence of fracture or dislocation.,0
"Although CT is not optimized for evaluation of thecal contents, the intrathecal contents appear normal.",0
"There is prominence of the prevertebral soft tissues, but the significance of this finding is difficult to evaluate because of intubation.",0
Note that there is some motion artifact obscuring detail on the axial images.,0
IMPRESSION: No evidence of cervical fracture or dislocation.,0
3:25 AM BABYGRAM (CHEST ONLY) Clip # Reason: CONFIRM ETT POSITION Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant RE-INTUBATED REASON FOR THIS EXAMINATION: CONFIRM ETT POSITION ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST on at 330 hours HISTORY: Chronic lung disease.,0
"In followup to , supine view of the chest obtained portably demonstrates that the patient remains intubated with ETT just above the carina with the neck extended.",0
NGT terminates at the level of the GE junction.,0
"An intravascular catheter is also noted in the visualized portion of the upper abdomen terminating to the right of the L1 vertebral body, likely within the IVC.",0
The lungs remain hyperinflated with a marked coarse interstitial pattern of chronic lung disease.,0
Superimposed diffuse hazy opacity consistent with edema has improved from prior examination but still persists.,0
Focal collapse or consolidation of the right upper lobe has improved in the interval.,0
"There is now more confluent opacity at the bases obscuring the hemidiaphragms, likely related to atelectasis.",0
"LINE PLACEMENT Clip # Reason: evaluate line placement Admitting Diagnosis: UROSEPSIS,PNEUMONIA,COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with AS, CHF, ischemic colitis with lower GIB s/p RIJ line placement REASON FOR THIS EXAMINATION: evaluate line placement ______________________________________________________________________________ FINAL REPORT INDICATIONS: 77-year-old woman with aortic stenosis, congestive heart failure, ischemic colitis, lower gastrointestinal bleeding.",1
Status post jugular catheter placement.,0
"CHEST, AP UPRIGHT: The right internal jugular venous catheter, placed since the prior day, terminates in the upper right atrium.",0
"Cardiac and mediastinal contours are unchanged, with mural calcifications again noted along the ascending aorta.",0
Elevation of the left hemidiaphragm appears unchanged.,0
"Mild interstitial pulmonary edema persists, but has considerably improved since before.",0
IMPRESSION: New internal jugular venous catheter terminating in the upper atrium.,0
5:01 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change and assess R picc Admitting Diagnosis: ASPIRATION-RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: year old man with ?asp pneumonia with pulm infiltrates, with adjusted PICC REASON FOR THIS EXAMINATION: ?",1
interval change and assess R picc ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Status post PICC re-adjustment.,0
"Tip of the endotracheal tube is in good position, 4.1 cm above the carina.",0
Tip of the right-sided PICC is in the proximal right SVC.,0
There are perihilar opacities consistent with CHF.,0
There is left retrocardiac opacity consistent with atelectasis or infiltrate.,0
Stable appearance of the lungs since the prior study.,0
3:43 PM CT HEAD W/O CONTRAST Clip # Reason: eval bleed Admitting Diagnosis: HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with hx IPH REASON FOR THIS EXAMINATION: eval bleed No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SAT 8:01 PM PFI: 1.,0
"Tiny punctate hyperdensity in the right temporal lobe just medial to the temporal of the right lateral ventricle, which is not clearly seen on prior exam.",0
"Otherwise, stable appearance of intraparenchymal and intraventricular hemorrhages.",0
Stable appearance of bilateral occipital lobe infarcts.,0
Interval decrease in left frontal subdural hematoma.,0
Close interval followup is recommended.,0
"______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT CONTRAST COMPARISON: , 3.23pm as on images.",0
"HISTORY: Intraparenchymal hemorrhage, evaluate for bleed.",1
"FINDINGS: Within the left frontal lobe, there are multiple foci of intraparenchymal hemorrhage, the largest measuring approximately 9 mm, not significantly changed when compared to prior exam.",0
Small amount of intraventricular hemorrhage layering along the posterior of the left lateral ventricle and right lateral ventricles are stable.,0
"Tiny focus of hemorrhage adjacent to the right temporal (2, 10), is not clearly seen on prior exam.",0
"Inferior bifrontal intraventricular hemorrhages (2, 8) are also stable.",0
Areas of hypodensity involving the left occipital lobe and right parietooccipital lobe and right cerebellar hemisphere are unchanged.,0
There is otherwise normal -white matter differentiation.,0
The ventricles and sulci are unremarkable.,0
"There has been interval decrease of the left frontal subdural hematoma (2, 11).",0
Mild mucosal thickening of the left maxillary sinus is noted.,0
IMPRESSION: (Over) 3:43 PM CT HEAD W/O CONTRAST Clip # Reason: eval bleed Admitting Diagnosis: HEAD INJURY ______________________________________________________________________________ FINAL REPORT (Cont) 1.,0
Stable appearance of bilateral occipital lobe and right cerebellar infarcts.,0
Correlate with h/o trauma for ; given the distribution of priro infarcts- also needs evalaution of intracranial vessels and an embolic source.,0
"2:02 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W&W/O CONTRAST Reason: 53 year old woman with new stroke s/p TPA please do stroke p Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK Contrast: MAGNEVIST Amt: 30 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with new stroke s/p TPA please do stroke protocol MRI/MRA brain to look at vessels, and MRA neck to look for stenosis REASON FOR THIS EXAMINATION: 53 year old woman with new stroke s/p TPA please do stroke protocol MRI/MRA brain to look at vessels, and MRA neck to look for stenosis ______________________________________________________________________________ FINAL REPORT EMERGENCY MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY USING TIME-OF-FLIGHT IMAGING AND GADOLINIUM-ENHANCED SCANNING PROTOCOL HISTORY: New stroke.",0
"Please do stroke protocol, MRI/MRA to look at vessels and MRA neck to look for stenosis.",0
TECHNIQUE: MRI scan of the brain.,0
COMPARISON STUDY: Prior CT scan of .,0
FINDINGS: There is a question of a tiny area of restricted diffusion within the left thalamic region.,0
"Its reduced ADC value is extremely subtle in appearance, as well.",0
"Nevertheless, the finding could indicate an acute small vessel infarct.",0
"Unfortunately, the FLAIR images are degraded by motion artifacts, which are most severe at the level of the thalamus.",0
There are no areas of abnormal susceptibility seen.,0
"There is no hydrocephalus, shift of normally midline structures or major vascular territorial infarction.",0
There is a 1-cm probable mucous retention cyst along the floor of the left maxillary antrum.,0
CONCLUSION: Findings of concern for a tiny evolving left thalamic infarct.,0
MR ANGIOGRAPHY OF THE BRAIN TECHNIQUE: 3D time-of-flight imaging with multiplanar reconstructions.,0
FINDINGS: The major vascular tributaries of the circle of are patent.,0
There is a fetal type left posterior cerebral artery.,1
GADOLINIUM-ENHANCED MR ANGIOGRAPHY OF THE NECK FINDINGS: The origins of the great vessels appear within normal limits.,0
There is no definite sign for the presence of stenosis involving the common carotid bifurcations.,0
(Over) 2:02 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W&W/O CONTRAST Reason: 53 year old woman with new stroke s/p TPA please do stroke p Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK Contrast: MAGNEVIST Amt: 30 ______________________________________________________________________________ FINAL REPORT (Cont),0
"9:19 AM FEMUR (AP & LAT) RIGHT; PELVIS (AP ONLY) Clip # Reason: please eval ______________________________________________________________________________ MEDICAL CONDITION: year old woman with fall on R side with dx of femur fx at OSH, unable to load up films REASON FOR THIS EXAMINATION: please eval ______________________________________________________________________________ FINAL REPORT INDICATION: -year-old female with fall on right side.",0
TECHNIQUE: 7 views of the right femur.,0
FINDINGS: Patient is status post right hip hemiarthroplasty with a long femoral stem componenet secured by four cerclage wires.,0
"There is a comminuted fracture of the distal right femur, with anterior angulation of the distal fragment, and extension of the fracture line to the distal edge of the femoral stem.",1
There is no evidence of fracture extension into the knee joint.,0
"On cross-table lateral view, there is a fat-fluid level within the suprapatellar fossa.",0
Heterotopic ossification is noted along the medial aspect of the proximal femur.,0
"In the pelvic radiograph, there is a region of popcorn-like calcifications in the left hemipelvis, consistent with fibroid uterus.",0
"Again, there are extensive degenerative changes in the lower lumbar and sacral spine.",0
The proximal portion of the right hip hemiarthroplasty is intact.,0
There is extensive calcification of the iliac and femoral arteries.,0
"Comminuted fracture of the distal right femur, extending to the distal portion of the femoral prosthetic stem, with anterior displacement of the distal fragment, with no evidence of extension into the knee joint.",1
"There is a fat-fluid level seen on cross-table lateral views of the knee, compatible with lipohemarthrosis.",0
Extensive degenerative changes throughout the sacral spine.,0
Extensive calcifications of the iliac and femoral arteries.,0
Popcorn-like calcification within the pelvis is compatible with a fibroid uterus.,0
GALLBLADDER SCAN Clip # Reason: 80 YO F W HEP C CIRRHOSIS W RISING TBIL AND /LIP W N/V ?,0
"ACALCULOUS CHOLECYSTITIS ______________________________________________________________________________ FINAL REPORT RADIOPHARMACEUTICAL DATA: 4.3 mCi Tc-m DISIDA (); 2.2 mCi Tc-99m DISIDA (); HISTORY: Obstructive LFTs, nausea and vomitting TECHNIQUE: Following the intravenous injection of tracer, serial one-minute images of tracer uptake into the hepatobiliary system were obtained for 60 minutes.",0
"At the end of 60 minutes, following non-visualization of the gallbladder, morphine sulfate, 0.02 mg/kg, was administered intravenously followed by continued imaging for 30 minutes.",0
A static lateral projection was obtained.,0
The patient was then imaged for 5 minutes after oral water administration.,0
INTERPRETATION: Serial images over the abdomen show homogeneous uptake of tracer into the hepatic parenchyma.,0
Tracer activity is noted in the small bowel at 13 minutes.,0
"Starting at twelve minutes following morphine administration, a focus of tracer activity begins to appear below the right lobe of the liver.",0
Recent CT scan demonstrates that this overlies the expected position of the gallbladder.,0
"Subsequent imaging in frontal and lateral planes did not convincingly prove that this was indeed gallbladder, rather than bowel.",0
"Tracer washes out from the duodenum and the focus of tracer in the right upper quadrant remains, confirming location in gallbladder.",0
IMPRESSION: Acute cholecystitis is unlikely given gallbladder filling.,1
Delayed gallbladder filling only after morphine administration may indicate a chronic cholecystis.,0
Approved: 7:54 AM RADLINE ; A radiology consult service.,0
"Admission Date: Discharge Date: Service: NEUROSURGERY Allergies: Dilantin Attending: Chief Complaint: Gait instability Major Surgical or Invasive Procedure: Left craniotomy for evacuation of subdural hemotoma History of Present Illness: 82 yo man w/HTN, hyper chol and h/o in on Plavix recently seen by neurology for gait imbalance and for dragging of his right leg for about six months.",0
"For the last 2-4 weeks, he also has had slowing of his thinking with decreased speech output, increased irritability, less talking per his wife.",0
"denies any fall or injury, double vision, headache, nausea, vomiting, chest pain, shortness of breath or weakness.",0
The neurology service ordered MRI which is significant for a left-sided subdural hemorrhage.,1
Patient was admitted to the neurosurgery service for further management.,0
GERD 6. on Plavix ( MRA: no significant intracranial atherosclerotic disease nor aneurysm) Follow by Neurology Dr. Social History: He is a retired engineer.,0
No tobacco use for 55 years.,0
"Family History: No family history of neurological problems Physical Exam: O: T:99 BP:144/73 HR:58 R;16 O2Sats:96% Gen: WD/WN, comfortable, NAD.",0
"HEENT: no scleral hemorrhage, pupils are eccentric due to cataract surgery Neck: Supple.",0
Language: Speech slow with good comprehension and repetition.,0
Cranial Nerves: I: Not tested II: Pupils are eccentric difficult to assess reaction to light.,0
Reflexes: B T Br Pa Ac Right 2 2 2 3 2 Left 2 2 2 3 2 Toes downgoing right mute on the left Coordination: normal on finger-nose-finger.,0
Pertinent Results: GLUCOSE-86 UREA N-14 CREAT-1.0 SODIUM-143 POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-23 ANION GAP-12 CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-2.4 .,0
WBC-8.7 RBC-4.35* HGB-11.9* HCT-35.3* MCV-81* MCH-27.3 MCHC-33.6 RDW-14.3 PLT COUNT-348 .,0
URINE COLOR-Straw APPEAR-Clear SP -1.013 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG .,0
Studies: head CT: Large left subdural hematoma with subacute and chronic components.,1
"Maximum thickness 3.3 cm, contralateral midline shift of 1.6 cm.",0
No intraparenchymal hemorrhage or CT evidence of ischemic infarction.,0
MRI/MRA head: Large left frontoparietal convexity subdural hematoma with subacute blood products causing subfalcine herniation.,0
No evidence of loss of flow signal within the vessels.,0
No significant intracranial atherosclerotic disease nor aneurysm.,0
"SDH path: Fragments of blood and fragments of granulation tissue with organizing hemorrhage and subacute and chronic inflammation, consistent with chronic subdural hematoma.",1
EKG: Atrial fibrillation with a rapid ventricular response.,1
Compared to the previous tracing of the rhythm has changed.,0
Intervals Axes Rate PR QRS QT/QTc P QRS T 132 0 136 336/414 0 -23 8 .,0
Focal discoid left lower lobe atelectasis.,0
Compared to the previous tracing no change.,0
Intervals Axes Rate PR QRS QT/QTc P QRS T 75 -16 -4 .,0
Status post left frontoparietal craniotomy with persistent rightward midline shift and sulcal effacement.,0
"Improvement of pneumocephalus, however, with reaccumulation of the left sided subdural fluid and focal areas of more acute hemorrhage.",1
B/L LENIs: No evidence of DVT.,0
Gallbladder sludge without stones or biliary ductal dilatation.,0
"Slight interval increase in size of large left subdural hematoma, with mild increase in mass effect, but without change in subfalcine shift.",0
"New, small focus of slow diffusion within the inferior aspect of left occipital lobe is consistent with infarct, probably embolic.",0
Additional questionable tiny infarct just superior to this within the left occipital lobe.,0
Increase in small right subdural collection.,0
EEG: Brief Hospital Course: Patient was admitted to the ICU for close neurological monitoring.,0
He was taken to the OR for left craniotomy with evacuation of chronic subdural hematoma.,1
He tolerated this procedure and was transferred to the PACU overnight for close monitoring.,0
"He was following commands, moving all extremeties and oriented.",0
He was subsequently transferred to the floor.,0
His diet and activity were advanced.,0
He was found to have asymptomatic atrial fibrillation on and was seen by cardiology.,1
He was treated with lopressor and spontaneously converted to NSR within 24 hours of onset.,0
He was started on aspirin.,0
He was also transfused with 1 unit PRBC for Hematocrit of 24.7 which rose to 26.4 and IVF resuscitated.,0
He did have LFTs and pancreatic enzymes which were mildly elevated and was evaluated by Hepatology who felt it was related to transient post-operative biliary sludge seen on abdominal US.,0
"LFTs, amylase and lipase subsequently dowtrended and patient continued to be pain free and tolerating PO.",0
His incision remained clean dry and intact.,0
The sutures were removed .,0
He had repeat head CTs which showed decompression of SDH.,0
"However, patient did spike fever 101.6 and had a waxing/ neuro exam.",0
"Infectious workup included CXR, UA and blood/urine cultures which were all negative.",0
EEG was negative for epileptiform activity.,0
MRI did not show significant ischemia to explain patient's exam.,0
"Echocardiogram showed mild left ventriclar hypertrophy, LVEF 70% and was otherwise within normal limits.",0
He was seen by PT and OT and felt to be a candidate for a rehab stay.,0
"At time of discharge, patient was ambulating with assist, taking PO and following some commands.",0
Patient still has some residual expressive aphasia which will take time to improve.,0
Medications on Admission: norvasc toprol xl lipitor flomax Discharge Medications: 1.,0
Insulin Lispro (Human) 100 unit/mL Solution Sig: PER SLIDING SCALE UNITS Subcutaneous ASDIR (AS DIRECTED).,0
"Discharge Disposition: Extended Care Facility: Rehab Unit at - Discharge Diagnosis: Subdural hematoma Post-operative afib Anemia status post transfusion Discharge Condition: Neurologically stable Discharge Instructions: Call for fever or any signs of infection including redness, swelling or drainage from wound.",0
Call for mental status changes.,0
Followup Instructions: Follow up with Dr. in 4 weeks with head CT - call to make appointment.,0
10:01 AM BILAT LOWER EXT VEINS Clip # Reason: assess for DVT Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 40M w/ cholangiocarcinoma distal CBD w metastasis to RT hepatic lobe s/p Whipple & RT lobectomy c/b pancreatic leak with lower leg edema (Left >right).,0
concern for dvts REASON FOR THIS EXAMINATION: assess for DVT ______________________________________________________________________________ FINAL REPORT BILATERAL LOWER EXTREMITY VEIN ULTRASOUND DATE: .,0
There are no priors available for comparison.,0
"CLINICAL INDICATION: 40-year-old man with cholangiocarcinoma on the distal common bile duct with metastasis to right hepatic lobe, status post Whipple and right lobectomy on , complicated by pancreatic leak with lower leg edema (left greater than right).",0
"TECHNIQUE: Multiple son grayscale images of bilateral lower extremity vessels were obtained with select images supplemented with color Doppler, spectral waveform analysis, compression, and augmentation where appropriate.",0
"FINDINGS: The left and right common femoral, superficial femoral, and popliteal veins demonstrate normal grayscale appearance, spectral waveform analysis, color flow, and response to augmentation.",0
"The left and right posterior tibial and peroneal veins demonstrate normal grayscale appearance, compressibility, and color flow.",0
Note is made of bilateral subcutaneous edema.,0
IMPRESSION: No right or left lower extremity DVT.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Found down Major Surgical or Invasive Procedure: None History of Present Illness: 80M p/w a large R IPH with intraventricular extension, midline shift, and hydrocephalus.",0
The patient was found lying face up in his bathtub after having shaved.,0
There was no water in the tub and the shower was not turned on.,0
He was found by a neighbor.,0
"EMS, he was moaning and there was ""tone in his left arm"" which may have been consistent with posturing.",0
"He was taken to and head CT was performed, revealing a large intraparenchymal hemorrhage extending from the lower midbrain into the hypothalamus, thalamus and basal ganglia on the right, with significant mass effect, intraventricular extension with casting of the right ventricle and some blood product in the posterior of the left lateral ventricle.",0
Neurosurgery was called and on review of imaging and reported exam- Mannitol 100gm and Decadron 10mg x1 was recommended and given.,0
He was transferred to for a Neurosurgical evaluation.,0
"Dr discussed and offered surgical intervention, but this was refused based on the family's knowledge of his wishes to not prolong life if incapacitated.",0
He also had signed a DNR/DNI order.,0
He was clear that he did not want to be dependent of disabled.,0
The family asked to maintain his intubation while other family members arrive from inside and outside .,0
They offered that he is an organ donor.,0
"Past Medical History: - DIABETES TYPE II - HYPERLIPIDEMIA - GLAUCOMA - OSTEOARTHRITIS - CAROTID STENOSIS left 60-69%, rt 50 - VASOVAGAL SYNCOPE - BACK PAIN Family History: NC Physical Exam: No eye opening, pupils 2mm and minimally react.",1
"No corneal on left, minimal corneal on right.",0
"Extensor posture with LUE, RUE attempts to localize, BLE withdraw to noxious stim.",0
"No gag, not overbreathing the vent.",0
"Tone increased in left arm, normal bulk.",0
Pertinent Results: FINDINGS: There is a large intraparenchymal basal ganglionic based hemorrhage.,0
It is multilobulated in nature and at its greatest extent measures 6.5 x 5.3 cm.,0
This is causing mass effect and shift of the normally midline structures of approximately 1.1 cm at the level of the hemorrhage.,0
There is also intraventricular extension into the ipsilateral and contralateral lateral ventricles.,0
There is effacement of the ipsilateral frontal of the lateral ventricle Brief Hospital Course: Pt was admitted to the neurosurgery service and the ICU.,0
The organ bank was contact.,0
was extubated on without incident and a morphine drip was started and titrated to respiratory rate.,0
He passed away on at 12:55 p.m.,0
The family declined a post morteum exam.,0
Medications on Admission: None Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:,1
12:50 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: acute SOB Admitting Diagnosis: BILATERAL FOOT GANGRENE ______________________________________________________________________________ MEDICAL CONDITION: Mr. is a 72 year-old male with CHF REASON FOR THIS EXAMINATION: acute SOB ______________________________________________________________________________ FINAL REPORT CHEST SINGLE VIEW AT 13:30.,1
"HISTORY: CHF, shortness of breath.",0
"FINDINGS: Compared to the film from two hours previously, there is no significant interval change in the right-sided PICC line, valve replacement, sternotomy wires, moderate cardiomegaly, and bilateral alveolar infiltrates with volume loss in the right lower lobe.",0
The overall impression is that of CHF.,0
An underlying infectious infiltrate cannot be totally excluded.,0
"3:05 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION Reason: rule out toxic megacolon, other abdominal process Admitting Diagnosis: WEAKNESS;C-DIFF DIARRHEA Field of view: 40 Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with CAD, presenting with C. difficile colitis and ?thickening on KUB of colon REASON FOR THIS EXAMINATION: rule out toxic megacolon, other abdominal process No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 88-year-old woman with coronary artery disease, presenting with C. difficile colitis.",1
Question thickening of the colon on KUB.,0
Evaluate for toxic megacolon or other abdominal process.,0
TECHNIQUE: Contiguous axial images through the abdomen and pelvis were obtained following the administration of oral and 100 cc of Optiray contrast.,0
"As the patient had a creatinine of 1.7 (her baseline), contrast administration was discussed with the resident caring for the patient.",0
The patient will be given oral and IV hydration.,0
CT OF THE ABDOMEN WITH CONTRAST: There are bilateral small pleural effusions with associated atelectasis.,0
"At the anterior liver margin, there is a tiny hypodensity measuring 5 mm, too small to characterize but may represent a cyst.",0
No additional liver lesions are identified.,0
The gallbladder is not seen and may have been removed.,0
The spleen and adrenal glands are normal.,0
The pancreas is atrophic and is mostly fat replaced.,0
"Within the right upper quadrant, there are two rounded radiopaque densities, one immediately adjacent to the porta hepatis and the other between the liver and right kidney, likely old calcified granulomas.",0
"There are a couple of air fluid levels in the small bowel, and there is slight distention without frank dilation of the small bowel loops.",0
This finding is likely related to adynamic ileus in this clinical setting.,0
There is thickening of the colonic wall.,0
"Specifically, there is oral contrast throughout the ascending, transverse, and descending colon, and there is wall thickening in each of these areas, most notably in the right colon and cecum.",0
This finding is consistent with the given history of C. difficile colitis.,0
"There is no dilation of the colon, however, to suggest toxic megacolon.",0
There is a small amount of fat stranding adjacent to the colon.,0
"There is a small amount of ascites fluid within the abdomen, for the most part around the liver and in the right pericolic gutter.",0
There is a small amount of fluid in the left pericolic gutter.,0
No pathologically enlarged retroperitoneal or mesenteric lymph nodes.,0
There are pericardial nodes present.,0
There is calcification throughout the abdominal aorta without dilation.,0
"The proximal celiac, SMA, bilateral renal arteries, and are patent.",0
"There is stranding within the anterior abdominal wall (Over) 3:05 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION Reason: rule out toxic megacolon, other abdominal process Admitting Diagnosis: WEAKNESS;C-DIFF DIARRHEA Field of view: 40 Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ FINAL REPORT (Cont) that is consistent with heparin administration.",0
"CT OF THE PELVIS WITH CONTRAST: There is a Foley catheter within the bladder, and an air-fluid level.",0
"The air may be related to instrumentation, though correlation with urinalysis is requested.",0
There is sigmoid diverticulosis without evidence of diverticulitis.,0
"There is slight thickening/enhancement of the rectum, also related to C. difficile.",0
BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.,0
Multiplanar reformatted images were essential in delineating the anatomy and pathology in this case (grade 3).,0
"IMPRESSION: 1) Thickening of the colonic wall, greatest in the cecum, consistent with the given history of C. difficile colitis.",0
There is no evidence of toxic megacolon.,0
"There is a small amount of ascites fluid within the abdomen and pelvis, and no free air.",0
2) Small air fluid levels in slightly distended small bowel loops.,0
This finding likely represents adynamic ileus in this clinical setting.,0
3) Bilateral pleural effusions with associated atelectasis.,0
4) Air within the bladder.,0
"This is likely related to instrumentation, but correlation with urinalysis is requested.",0
2:58 PM UNILAT LOWER EXT VEINS RIGHT; FEMORAL VASCULAR US RIGHT PORT Clip # Reason: RT ARTERIAL STICK WITH NEW RIGHT LEG.,0
EVAL FOR PSEUDOANEURYSM/DVT Admitting Diagnosis: BILIARY COLIC;POST SPHINCTEROTOMY ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with gi bleed s/p right arterial stick with new large right le.,0
REASON FOR THIS EXAMINATION: Please evaluate for dvt and possible pseudoaneursm of right groin after needle stick.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old male with GI bleed.,0
Question large right groin hematoma.,0
"TECHNIQUE: Unilateral lower extremity venous ultrasound, right.",0
"There is no evidence of hematoma, pseudoaneurysm, or AV fistula.",0
Appropriate waveforms are seen within the right common femoral artery and vein.,0
"Appropriate compressibility and blood flow is demonstrated in the right common femoral, superficial femoral, and popliteal veins.",0
"IMPRESSION: No evidence of pseudoaneurysm, hematoma, AV fistula.",0
Status: Inpatient Date/Time: at 13:20 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
GENERAL COMMENTS: The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope.,0
Conclusions: PRE-BYPASS: The left atrium is moderately dilated.,0
There is moderate regional left ventricular systolic dysfunction with XXX.,0
Improve global LV systolic function /EF +50% (Epinephrine Infusion) 2.,0
Preserved right ventricular systolci function 3.,0
Full annuloplasty ring identrified in the mitral position.,0
Well seated and no leaflet restriction.,0
Peak gradient = 4 mm Hg.,0
MVA by PHT = > 3 cm2 4.,0
Bioprosthetic valve in aortic position.,1
Well seated and stable with good leaflet excursion.,0
No AI and PG = 19 mm Hg.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Lisinopril / Norvasc Attending: Chief Complaint: Sepsis, hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. is a 78 year-old male with hx of DM, htn, hypothyroidism presented with intermittent SOB for the past week and low back pain.",1
"Prior to admission the patient noted generalized malaise, weakness and dysuria.",0
"Over the past 24 hours he reports clear cloudy urine, without any hematuria or unusual orders.",0
"At the same time, he felt unsteady on his feet, and he noted a low grade temp ~ 100, as well as high blood sugers.",0
"He has a chronic dry cough, and 2 pillow orthopnea, but denies any PND, chest pain, palpitations, or CHF exacerbations.",0
"He reported no numbness or tingling in the feet, or changes in LE strength.",0
"In the ED, initial vs were: T 99.7 P 74 BP 200/68 R 22 100% O2 sat.",0
UA was consistent with a UTI.,0
Blood and urine cultures were sent.,0
"Labs were notable for a WBC of 14, sodium of 118, Cr of 1.3, and K of 5.7.",0
Patient was given 100 mg phenazopyridine and ciprofloxacin 400 mg IV.,0
Got 500 cc NS in the ED.,0
Guaiac negative on rectal exam.,0
"184/100 On the floor, he had some minor abdominal pain and nausea.",0
"His VS were 100.4, 99, 188/68, 16, 98%.",0
Diabetes mellitus type II 2.,1
Urine culture : Culture workup discontinued.,0
Further incubation showed contamination with mixed skin/genital flora.,0
--------- Images: CXR - Extensive pleural plaques from prior asbestos exposure.,1
L-Spine plain film: There are extensive degenerative changes of the entire lumbar spine with loss of intervertebral disc height in all levels.,0
There are moderate osteophytes in all vertebral bodies in the anterior and lateral aspects.,0
The of the vertebral bodies is preserved.,0
There is vacuum phenomenon in almost all the disc spaces.,0
There is mild rectification of the lumbar lordosis.,0
"EKG: Low voltage, but no peaked T waves or ST segment or T wave abnormalities.",0
"No ultrasound evidence of pyelonephritis (son is insensitive for this diagnosis), stones, abscess, or hydronephrosis.",0
"Equivocal wall thickening of the posterior aspect of the bladder may be reflective of known UTI, however this can also be seen in the collapsed bladder.",0
Chest CT w/contrast : 1.,0
Calcified pleural plaques consistent with asbestos exposure without evidence of interstitial lung disease.,1
No masses or evidence of intrathoracic malignancy.,0
"Multiple pulmonary nodules measuring up to 5 mm, given size, and asbestos exposure, a 6 month followup is recommended.",1
"Brief Hospital Course: This is a 78-year-old male presenting with fatigue, malaise, fevers, chills, and dysuria with lower abdominal pain and leukocytosis, a positive urine culture, and blood cultures with ESBL-producing E.coli.",0
"ESBL Urosepsis: The patient presented with subjective fevers and dysuria, and was noted to have a leukocytosis and positive urine and blood cultures with gram negative rods.",0
His blood culture from subsequently grew ESBL-producing E.coli.,0
A surveillance blood culture from had no growth.,0
"The patient was initially treated with ciprofloxacin, but was transitioned to meropenem on once sensitivities were revealed and the E.coli species was found to be resistant to all oral antibiotic regimens.",0
A renal ultrasound was done which showed no evidence of pyelonephritis or abscess.,1
"On day of discharge, the patient was transitioned to ertapenem due to its once daily dosing properties and ease of administration at home through a VNA service.",0
"His WBC had returned to within the normal range, and the patient remained afebrile during his admission.",0
"A PICC line was placed, and the patient will need to complete a 14-day course of ertapenem until .",0
Shortness of Breath: The patient initially described some progressive shortness of breath over the past week prior to admission.,0
A CXR only showed evidence of previous asbestos exposure with no areas of consolidation.,1
Cardiac biomarkers were negative x 2.,0
"The patient's lungs were also clear on exam, and his O2 sats were normal on room air.",0
"On the floor and after beginning appropriate therapy for his ESBL urosepsis, the patient no longer endorsed malaise and SOB.",0
"He did describe some episodic coughing, and was treated symptomatically with benzonatate PRN.",0
Hyponatremia: The patient's sodium at admission was 118.,0
The patient did not manifest any confusion or changes in mental status.,0
"His baseline sodium, last checked in had been normal, so this was a new finding for the patient.",0
He was intially treated with IVF for volume depletion.,0
His home doses of chlorthalidone and spironolactone were also held during his admission.,0
"The patient was treated with salt supplementation and free water restriction, and his Na slowly trended up; his Na was 128 on day of discharge.",0
"To work-up this patient's hyponatremia, we checked a TSH and cortisol level which were within the normal range.",0
We also checked multiple serum and urine chemistries after stopping his home diuretic medications.,0
"His lab work-up, including his serum and urine osmolality, sodium, and urate levels seemed to suggest SIADH.",0
"Because of this patient's history of asbestos exposure, we decided to check a Chest CT to rule out a lung lesion or intrathoracic malignancy that could be causing his SIADH.",1
"This patient had prior CXR imaging which showed calcified pleural plaques consistent with a history of asbestos exposure, but no other previous chest imaging.",1
"The chest CT revealed multiple calcified pleural plaques, and multiple pulmonary nodules of up to 5mm.",0
There was no evidence of intrathoracic malignancy.,0
The patient should have a follow-up chest CT in 6 months to evaluate for progression of his pulmonary nodules.,0
"The chest CT did not reveal a cause of his SIADH, so following his sodium levels and a further workup as an outpatient would be advised.",0
Hyperkalemia: The patient had an elevated potassium on admission.,0
We held his spironolactone andolmesartan and did not restart these medications at discharge.,0
"The patient was initially treated with kayexalate, and was then transitioned to PO furosemide.",0
"A cortisol level was also checked, as adrenal insufficiency could lead to both hyperkalemia and hyponatremia.",0
His cortisol level was normal/high which was not consistent with a diagnosis of AI.,0
That patient's potassium level at discharge was within the normal range.,0
That patient was discharged on daily furosemide.,0
Lower back pain: The patient reported lower back pain on admission.,0
"A lumbar XR was performed and showed extensive degenerative changes, with no evidence of fracture.",0
Chronic Kidney Disease: The patient has a baseline Cre of 1.1-1.2.,1
His admission Cre was initially elevated.,0
"It was trended during his admission, and remained stable.",0
Anemia of chronic disease and CKD: The patient has a baseline low hematocrit secondary to his chronic kidney disease.,1
His hematocrit remained stable during his admission.,0
"Diabetes, type II: The patient is followed at , and was continued on his fixed dose of humalin 70/30 .",0
"The patient did have one early morning episode of symptomatic hypoglycemia, which improved after drinking juice.",0
The patient reported that his PO intake had changed since his hospitalization.,0
"Adjustments were made to the patient's PO regimen, and he had no additional hypoglycemic episodes.",0
His insulin regimen was thus not changed.,0
He will follow-up with his PCP and endocrinologist as an outpatient.,0
Hypertension: The patient's blood pressures were stable during his admission.,0
He was continued on his home dose of labetalol.,0
Plavix 75 mg po daily 2.,0
Chlorthalidone 50 mg po daily (currently HELD) 4.,0
Spironolactone 25 mg po bid (currently HELD) 5.,0
Labetalol 100 mg po bid 6.,0
Pravastatin 80 mg po daily 7.,0
Insulin 70/30 35 am/28 pm 8.,0
Levothyroxine 50 mcg po daily 9.,0
Clonazepam 0.5 mg po bid 10.,0
Miralax daily Discharge Medications: 1.,0
Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day: Please administer until .,0
Humulin 70/30 Pen 100 unit/mL (70-30) Insulin Pen Sig: as directed Subcutaneous twice a day: 35 units every morning and 25 units every evening .,0
"Flomax 0.4 mg Capsule, Sust.",0
Release 24 hr PO at bedtime.,0
Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Miralax 17 gram/dose Powder Sig: Seventeen (17) grams PO once a day.,0
"Outpatient Lab Work Please check sodium, potassium, chloride, bicarbonate, BUN, creatinine, and CBC on Monday and Monday .",0
"Please fax results to PCP, .",0
"Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: PRIMARY DIAGNOSES: - E. coli (ESBL) bacteremia - Gram negative rod urinary tract infection - Hyponatremia secondary to SIADH - SIADH, undetermined etiology SECONDARY DIAGNOSES: - Hypertension - Diabetes mellitus - Hyperlipidemia - Hypothyroidism Discharge Condition: Mental Status: Clear and coherent.",1
"Discharge Instructions: You were admitted to the hospital for fevers, generalized weakness, and burning with urination.",0
"After your evaluation in the hospital, the cause of these symptoms was likely due to a urinary tract infection, and an infection in your bloodstream.",0
You were started on an antibiotic called meropenem to treat this infection.,0
You were started on this IV antibiotic because the particular bacteria in your bloodstream is resistant to every type of oral antibiotic.,0
You will need to complete a full 2-week course of ertapenem (the once daily version of meropenem) for your infection.,0
You were also found to have low sodium levels.,0
There are many causes of low sodium levels.,0
"One reason could be due to use of certain medications, and this is why we stopped your hydrochlorothiazide.",0
"Your sodium will be rechecked as an outpatient, and if it remains low your PCP may recommend further studies.",0
"We also looked at a CT scan of your chest, because certain lung lesions can lead to low sodium levels.",0
"This CT showed no evidence of malignancy, some evidence of prior asbestos exposure, and several small lung nodules.",1
You should have a follow-up CT in 6 months to make sure that these lung nodules have not changed in size or character.,0
The following changes were made to your home medication regimen: -We discontinued your home hydrochlorothiazide because of your low sodium levels.,0
"-We also discontinued your spironolactone, because of your high potassium levels.",0
-You were started on furosemide 20mg daily.,0
"-You were started on sodium chloride tablets, 1 gram tablet per day.",0
-You were started on IV ertapenem to treat the urinary tract infection and the infection in your bloodstream.,0
You will need to complete a full 2-week course of this antibiotic ending .,0
-You were also started on benzonatate for cough which you can continue taking three times daily as needed.,0
"Please take all of your medications as prescribed, and keep all of your follow-up appointments.",0
"Followup Instructions: Department: When: FRIDAY at 9:45 AM With: , MD Building: (, MA) Campus: OFF CAMPUS Best Parking: On Street Parking",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: seizures Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. is a 57 year old RHM with prior L MCA infarct () and seizure disorder who now presents following a seizure.,0
He was at home having coffee with his son this morning when he had sudden onset right arm rhythmic contractions.,0
He also seemed disoriented according to his son who brought him to the ED where opon pulling into the parking lot the movements generalized to GTC movements with LOC.,0
He was given 1mg Ativan IV which stopped the movements.,0
Head CT performed at was without acute process.,0
"Neurology was contact by the attending and he was given an additional 1g Keppra IV, and then transferred to for further care.",0
At present the patient has a productive speech deficit and is able to appropriately answer yes or no to questions.,0
His naming is not intact.,0
He reports he does not feel back to his usual self (unable to describe further).,0
His speech is worse than usual.,0
His right side is more weak than usual.,0
He denies any bowel or bladder incontinence.,0
"On general review of systems, He denies any recent fevers, chills, he denies diarrhea or constipation.",0
"No chest pain, rashes, arthralgias or myalgias.",0
"Past Medical History: -Left hemispheric stroke in / -Epilepsy sinc , last seizure was -?HTN after the stroke patient has been taken med for high blood pressure -Dyslipidemia -Two cataract surgery.",0
"-Left hemispheric stroke in / -Epilepsy sinc , last seizure was -?HTN after the stroke patient has been taken med for high blood pressure -Dyslipidemia -Two cataract surgery.",0
Since stroke can not do ADLs.,0
Heavy alcohol use until stroke.,0
"Family History: non-contributory Physical Exam: Exam on Admission: Vitals: T 97, BP 156/78, HR 90, R 14, 98% RA Gen- well appearing on gurney in the ED, NAD HEENT: NCAT, MMM, anicteric, OP clear Neck- no carotid bruits, no nuchal rigidity.",0
"CV- RRR, no MRG Pulm- soft crackles at bases bilat.",0
"Abd- soft, nt, nd, BS+ Extrem- no CCE .",0
"Neurologic Exam: MS- eyes open, attends examiner, appropriately answers yes or no questions.",0
He follows all axial and appendicular commands.,0
"Dense anomia- attempting to say the words, but visibly frustrated with inability to do so.",0
"CN- PERRL 3-->2mm, could not visualize fundi, EOMI no nystagmus, face appears symmetric with symm strength, palate elevates symm, hearing intact to FR bilat, SCM and trap full strength, tongue protrudes at the midline.",0
Motor- right arm > leg hemiparesis.,0
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA L 5 5 5 5 5 5 5 5- 5 5 5 5 5 R 3 4 3 3 4 3 3 3 - - 4 4 4 .,0
Sensory- + sensory neglect of right side to DSS.,0
detailed sensory exam was limited d/t productive speech deficit.,0
Coordination- unable to perform FNF or HKS on right.,0
"Reflexes: 3+ on right , tri, brachiorad, patellar.",0
"2+ left , tri, brachiorad, patellar.",0
"right great toe upgoing, left downgoing.",0
Gait testing deferred given marked R hemiparesis.,0
Pertinent Results: 05:50AM BLOOD WBC-17.6* RBC-4.72 Hgb-14.6 Hct-40.3 MCV-85 MCH-31.0 MCHC-36.3* RDW-14.0 Plt Ct-272 05:50AM BLOOD Neuts-84.2* Lymphs-8.6* Monos-6.6 Eos-0.2 Baso-0.5 05:50AM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-138 K-3.3 Cl-96 HCO3-29 AnGap-16 06:45AM BLOOD ALT-24 AST-22 AlkPhos-88 TotBili-0.8 DirBili-0.3 IndBili-0.5 09:31AM BLOOD CK-MB-NotDone cTropnT-<0.01 06:45AM BLOOD TotProt-6.6 Albumin-4.3 Globuln-2.3 Calcium-9.3 Phos-4.0 Mg-2.1 02:32AM BLOOD Triglyc-144 .,0
Sputum Culture: E. Coli .,0
"EEG : IMPRESSION: Markedly abnormal EEG due to the prominent slowing broadly over the left hemisphere with very frequent epileptiform sharp wave discharges in the parieto-temporal region, recurring every one to two seconds for much of the record though less as time went on.",0
"In the early portions of the record this appeared most suggestive of PLEDs (periodic lateralized epileptiform discharges), usually a sign of an acute lesion with epileptogenic potential.",0
No faster rhythms suggestive of ongoing seizures were evident.,0
The background appeared better on the right though it was frequently disrupted or disorganized .,0
Left lower lobe complete atelectasis with mucous plugging of the airways.,0
Right upper lobe and basilar atelectasis.,0
Transthoracic Echo : The left atrium is dilated.,0
"Compared with the findings of the prior study (images reviewed) of , the left ventricle is now small and hyperdynamic.",0
Brief Hospital Course: Mr. was admitted with status epilepticus.,0
His Keppra dose was initially increased and he was given Ativan for his seizures.,0
The Keppra was then changed to Trilptal and he was loaded with Depakote.,0
He was then started on a Propofol drip.,0
On the morning of he experienced and episode of hypoxia.,0
He was intubated after a likely aspiration event.,0
He transferred to the medicine service for further management of his seizures and aspiration.,0
His respiratory distress was likely secondary to aspiration from sedation as he had received large amounts of ativan.,0
He had a CTA which was negative for PE and cardiac enzymes were negative suggesting this was not an MI.,0
"He was started initially on Vancomycin, Ceftriaxone and Flagyl for his aspiration pneumonia.",0
This was changed to Vancomycin and Unasyn on .,0
"On , Acyclovir was added for possible HSV encephalitis.",0
"For his seizures, his propofol was increased in order to suppress seizure activity as recommended by the neurology team.",0
He was started on Levophed for hypotension.,0
He continued to have frequent seizure activity as monitored by his continuous EEGs.,0
He was loaded with Dilantin on .,0
An LP was attempted on by the medicine team and was unsuccessful.,0
An LP was attempted on by the Neurology team and was unsuccessful.,0
"His antibiotics were changed to include bacterial meningitis coverage with Vancomycin, Ceftriaxone and Ampicillin.",0
"In the early morning of , his telemetry changed.",0
A 12-lead ECG showed an abnormal appearing QRS.,0
The rhythm was regular without clear p waves and there were diffuse ST depressions in V2-V6 with ST elevations in leads II and AVL.,0
2 gm of magnesium were given.,0
An ABG with calcium was checked and the ionized calcium was normal.,0
Cardiology was consulted for aid in evaluation and management of changes in the ECG.,0
"Over the course of that morning, his propofol was decreased as was recommended by neurology.",0
His levophed requirements continued to increase and he was persistently hypotensive.,0
"An echo was checked and showed a small, hyperdynamic LV.",0
"At 1pm, the patient was noted to be markedly hypotensive.",0
He was started on a second and then third pressor.,0
He then lost a pulse.,0
A code blue was initiated.,0
After 30 minutes of resuscitative efforts the patient was still in asystolic and was pronounced dead at 1:42pm.,0
Medications on Admission: asa 81mg keppra 2000mg IV q12hr Lorazepam 1 mg IV Q4H:PRN seizure > 5min Seizure > 5min or more than 2 seizures in 30min.,0
Lorazepam 1 mg IV Q6H Oxcarbazepine 600 mg PO BID - not getting b/c no NGT in place Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Simvastatin 80 mg PO DAILY Order Fludrocortisone Acetate 0.1 mg PO DAILY Heparin 5000 UNIT SC TID Valproate Sodium 500 mg IV 12hr Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: 1.,0
Aspiration Pneumonia 3. prior L MCA stroke Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired,0
"1:28 PM BRONCHIAL Clip # Reason: evaluate for bleeding source Admitting Diagnosis: HEMOPTYSIS Contrast: VISAPAQUE Amt: 160 ********************************* CPT Codes ******************************** * SEL CATH 1ST ORDER SEL CATH 1ST ORDER * * -59 DISTINCT PROCEDURAL SERVICE VISCERAL SEL A-GRAM * * SPINAL SEL A-GRAM CERVICOCEREBRAL A-GRAM * * MOD SEDATION, FIRST 30 MIN.",0
"MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with hemoptysis emanating from right upper lobe posterior segment REASON FOR THIS EXAMINATION: evaluate for bleeding source ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 6:12 PM PFI: Aortogram with selective right intercostal and right bronchial lower lobe arteriograms were performed demonstrating no active bleeding or irregular clarity.",0
______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: 58-year-old male with hemoptysis emanating from the right upper posterior segment bronchoscopy.,0
COMPARISONS: CT chest from earlier the same date at 0436 hours.,0
"and , the attending radiologist who was present and supervised throughout the entire procedure.",0
ANESTHESIA: Moderate sedation was provided by administering divided doses of 125 mcg of fentanyl and 2 mg of Versed throughout the total intraservice time of 55 minutes during which the patient's hemodynamic parameters were continuously monitored.,0
"PROCEDURE AND FINDINGS: After the risks, benefits and alternatives of the procedure were thoroughly explained to the patient, informed consent was obtained.",0
The right groin was prepped and draped in usual sterile fashion.,0
A preprocedure timeout and huddle were performed per policy.,0
"Next, the right common femoral artery was punctured after local anesthesia was established with 1% lidocaine and a skin was made over the proposed puncture site.",0
wire was passed through the 19-gauge needle and into the abdominal aorta.,0
The needle was removed and an angiographic 5 French sheath was then placed over the wire.,0
The sidearm was connected to a continuous heparinized saline flush.,0
"Next, an Omniflush catheter was placed over the wire to the level of the aortic arch.",0
The wire was removed and a thoracic arteriogram was performed in the AP and left anterior oblique projections.,0
The resulting images demonstrated a normal arch with normal-appearing great vessels.,0
One right bronchial intercostal branch was (Over) 1:28 PM BRONCHIAL Clip # Reason: evaluate for bleeding source Admitting Diagnosis: HEMOPTYSIS Contrast: VISAPAQUE Amt: 160 ______________________________________________________________________________ FINAL REPORT (Cont) identified and selected with catheter.,0
An angiogram was performed at this level which demonstrated supply to the right apex without evidence of abnormal blush or contrast extravasation.,0
This branch also demonstrated supply to the mediastinum and midline structures.,0
"Given these findings, it was not felt indicative to embolize at this level.",0
The catheter was then exchanged for a SOS catheter which was used to select an additional bronchial artery arising off the thoracic aorta.,0
"A right bronchial arteriogram was performed, did not have parenchymal supply to the right upper lobe and did not show blush or extravasation.",0
Given the findings the catheter and wire were removed.,0
The sheath was removed and pressure was held for 20 minutes.,0
Aortogram of a solitary intercostal bronchial trunk on the right side demonstrating no evidence for extravasation or abnormal blush.,0
"Of note, this vessel did have supply to the mediastinum and other midline structures.",0
Normal right bronchial arteriogram demonstrating supply to the right lower lobe.,0
9:22 PM ABDOMEN (SUPINE ONLY) IN O.R.,0
Clip # Reason: CHECK FOR ?,0
"Admitting Diagnosis: HEPATITIS B, HEPITOMA/SDA ______________________________________________________________________________ FINAL REPORT QUESTION OF INCORRECT SPONGE COUNT: Two portable films from the OR of the abdomen fail to demonstrate any evidence of radiopaque foreign body having the appearance of a surgical sponge.",0
"1:32 PM CHEST (PORTABLE AP) Clip # Reason: evaluate palcement ______________________________________________________________________________ MEDICAL CONDITION: s/p RT IJ placement REASON FOR THIS EXAMINATION: evaluate palcement ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW HISTORY: Right IJ placement.",0
FINDINGS: There is a new right IJ line with tip in the right atrium.,0
There is pulmonary vascular redistribution and bilateral lower lobe volume loss/effusion.,0
"3:18 AM CHEST (PORTABLE AP) Clip # Reason: please eval for infiltrate or edema Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with aspiration event, intubated.",0
"REASON FOR THIS EXAMINATION: please eval for infiltrate or edema ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW.",0
FINDINGS: The endotracheal tube and NG tube have been removed.,0
"There are some patchy areas of volume loss in the left lower lobe, but no definite infiltrate.",0
"There is pulmonary vascular redistribution, but no gross failure.",0
"9:57 AM US ABD LIMIT, SINGLE ORGAN PORT Clip # Reason: Please evaluate liver BG GTT 1500 Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 82F SICU patient with MMP (incl distended GB), now w/ rising LFTs REASON FOR THIS EXAMINATION: Please evaluate liver BG GTT 1500 ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Rising liver function tests.",0
PORTABLE RIGHT UPPER QUADRANT ULTRASOUND: Grayscale images of the liver show no evidence of intrahepatic ductal dilatation.,0
"The main portal vein is patent, with flow in the appropriate direction.",0
Again seen is sludge and stones within the lumen of a nondistended gallbladder.,0
"There is a mild diffuse gallbladder wall thickening, but no evidence of wall edema.",0
"The common duct measures up to 7-8 mm in diameter, not significantly changed from the previous exam.",0
Again noted is a small amount of perihepatic ascites within the right upper quadrant.,0
"IMPRESSION: 1) Cholelithiasis and gallbladder sludge, not significantly changed from the exam of .",0
No son evidence of acute cholecystitis.,0
3) Small right pleural effusion.,0
"4:50 AM CT HEAD W/O CONTRAST Clip # Reason: assess bleed, scan for 0600 Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man s/p fall with Rt SDH REASON FOR THIS EXAMINATION: assess bleed, scan for 0600 No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc SAT 6:48 AM No significant interval change.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old male status post fall, right subdural hematoma, assess bleed.",0
"FINDINGS: A large right subdural hematoma overlying the right cerebral hemisphere is grossly unchanged from the prior study, measuring approximately 1.8 cm in maximal dimensions.",0
There is associated subdural hematoma also layering along the right side of tentorium and also likely tracking along the interhemispheric fissure.,0
"There is associated sulcal effacement, with local mass effect as well as leftward subfalcine herniation of approximately 1 cm, grossly unchanged.",0
No new foci of hemorrhage or acute infarct is identified.,0
"Ventricles and sulci are stable in configuration, without evidence for new hydrocephalus.",0
Osseous structures reveal no fracture.,0
"Large right subdural hematoma overlying the right cerebral hemisphere, without significant change in size.",0
"Associated leftward subfalcine herniation of approximately 1 cm, similar from prior study.",0
LINE PLACEMENT Clip # Reason: s/p Central Line evaluate for placement/pneumothorax Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: s/p Central Line evaluate for placement/pneumothorax REASON FOR THIS EXAMINATION: s/p Central Line evaluate for placement/pneumothorax ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST X-RAY INDICATION: Central line evaluation placement pneumothorax.,0
FINDINGS: New right-sided jugular line is too low and ends in lower atrium.,0
It could be pulled back 5 cm.,0
Mediastinal and cardiac contours are unchanged.,0
Lung volumes are low and there is small pleural effusion that is unchanged.,0
CONCLUSION: New right jugular line is too low; it could be pulled back 5 cm.,0
10:43 AM CHEST (PORTABLE AP) Clip # Reason: assess for signs of volume overload Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman s/p ex lap.,0
with increased secretions REASON FOR THIS EXAMINATION: assess for signs of volume overload ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: INDICATION: Increased secretions.,0
Comparison is made to prior study of earlier the same day.,0
There is stable cardiac enlargement and upper zone vascular redistribution.,0
There is mild perihilar haziness.,0
Small to moderate bilateral pleural effusions are again demonstrated and are probably unchanged allowing for differences in positioning.,0
Skeletal structures demonstrate evidence of vertebroplasty procedure and a compression fracture in the mid thoracic spine.,0
IMPRESSION: Mild congestive heart failure with associated bilateral pleural effusions.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: BRBPR/ hematemesis Major Surgical or Invasive Procedure: EGD, 1U PRBC History of Present Illness: 52M with BRBPR and hematemesis.",0
"Pt was feeling ""not great"" this morning, with some nausea and lightheadedness.",0
He then vomited bright red blood x 1 episode.,0
"Pt reports he later had 2 bowel movements with bright red blood, large quantities which filled the toilet bowl, and at that point, he called his doctor.",0
She advised him to come to the emergency room.,0
"He had one more episode of BRBPR at 12:30PM in the ED, but no further vomiting.",0
"He denies recent dark tarry stool, episodes of BRBPR, or abdominal pain.",0
"He notes that a few months ago, he did have abdominal pain for about 1 month, which was crampy in nature, relieved after eating, and then resolved.",0
"He denies SOB, chest pressure, or lightheadedness with the bleeding.",0
Pt had a few NSAIDs in the last few days.,0
Pt has h/o omentectomy as experimental surgery.,0
He later had a gastric bypass.,0
"Had been doing well from a postop standpoint, without h/o GI bleed and without complications from gastric bypass.",0
"In the , pt was given pantoprazole 40mg IV x1.",0
GI was called for EGD.,0
Hct dropped 10 points since 2 weeks ago.,0
Pt was hemodynamically stable in the ED.,0
"Monitored in the MICU,transfused 1U PRBC underwent EGD showing ulcer but no bleeding.",0
"Pt stable, transferred back to floor.",0
Past Medical History: h/o obesity complicated by DM - resolved after gastric bypass and 70# weight loss s/p gastric bypass 2y ago s/p omentectomy 4y ago (experimental surgery for DM) Social History: Lives alone.,0
"Has smoked on and off for about 30 years, less than one pack daily.",0
"+ EtOH, though not every day - does not feel it interferes with his functioning.",0
"Family History: FH: no bleeding problems Physical Exam: per admitting resident VS: 98.2, 120/70, 72, 18, 99RA Gen: well appearing, NAD HEENT: PERRL, EOMI, OP clear, MM dry CV: RRR, nl S1/S2, no m/r/g Pulm: CTAB, no wheezes or crackles Abd: soft, NT/ND, +BS, no masses Ext: no c/c/e Rectal: deferred; Pertinent Results: EGD: Mucosa suggestive of Barrett's esophagus Previous gastric bypass (gastrojejunostomy) of the stomach Ulcer in the gastrojejunal anastamosis on the jejunal side Otherwise normal EGD to jejunum Brief Hospital Course: 52 year old man with h/o bariatric surgery, diabetes s/p omentectomy and hypertension presented with hematemesis and BRBPR after alcohol and NSAID intake.",1
He was taken to the MICU and transfused 1U PRBC.,0
He underwent then EGD that showed esophagus and an non-bleeding ulcer.,1
He was started on PPis .,0
Patient was tolerating PO's before discharge.,0
He was told to continue omeprazole .,0
Enalapril was restarted at home.,0
He will have followup EGD (GI division will contact him).,0
"Also, the patient was told to avoid NSAIDs and alcohol.",0
He will follow up with his primary care doctor.,0
Medications on Admission: vasotec 5mg daily fish oil MVI 81mg daily Discharge Medications: 1.,0
Vasotec 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Fish Oil Discharge Disposition: Home Discharge Diagnosis: Primary - Upper GI bleeding Secondary - hypertension - DM II Discharge Condition: good, tolerating POs, Hct stable Discharge Instructions: You were admitted with GI bleeding.",0
You were transfused 1 unit of packed red blood cells.,0
You underwent EGD that showed a non-bleeding ulcer.,0
Please see below for appropriate followup.,0
"Please do not take aspirin, ibuprofen or similar non-steroidal drugs until you have been cleared by you primary care doctor.",0
These drugs may increase your risk of bleeding .,0
"We have started you on omeprazole, to be take twice daily, for stomach protection.",0
Please continue your medication as prescribed.,0
Please call Dr. to schedule a follow up within the next few days.,0
Please come to the emergency department if you have again red blood per rectum or you are vomiting blood or if you have any other concerning symptoms.,0
Followup Instructions: You will need a repeat EGD (for Barrett's) and a screening colonoscopy.,0
Dr. secretary ( will call you to arrange these procedures in the next month as an outpatient.,0
"Provider: , MD Phone: Date/Time: 1:00 Completed by:",0
Height: (in) 62 Weight (lb): 110 BSA (m2): 1.48 m2 BP (mm Hg): 95/57 HR (bpm): 88 Status: Inpatient Date/Time: at 12:46 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal - akinetic; basal inferoseptal - hypo; mid inferoseptal - akinetic; basal inferior - hypo; mid inferior - akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; apex - dyskinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,1
GENERAL COMMENTS: Right pleural effusion.,0
There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the septum and distal 2/3rds of the inferior and anterior walls.,1
The lateral wall contracts best (LVEF 30%).,0
IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and extensive systolic dysfunction c/w multivessel CAD or other diffuse process.,0
Mild aortic regurgitation.Minimal aortic valve stenosis.,0
"Compared with the prior study (images reviewed) of , the left ventricular cavity is smaller with improved inferolateral systolic function.",1
"CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibotor or .",0
5:19 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please eval for NG position.,0
"Admitting Diagnosis: ICH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with ICH and meningitis, now s/p NG tube repositioning.",0
REASON FOR THIS EXAMINATION: Please eval for NG position.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Intracranial hemorrhage and meningitis, status post nasogastric tube repositioning.",1
"COMPARISON: , and from 15:39.",0
"SEMI-UPRIGHT AP VIEW OF THE CHEST: There has been interval repositioning of the nasogastric tube, which is looped upon itself and the tip is directed cephalad and projects over the hypopharynx.",0
Patient is status post median sternotomy with pacer leads from a left- sided dual chamber pacemaker in stable positions.,1
Subclavian central venous catheter tip remains within the superior vena cava.,0
"Again, demonstrated are multifocal opacities within the right lung, which are minimally improved in the interval.",0
There is continued left basilar atelectasis and a small right pleural effusion.,0
"IMPRESSION: Nasogastric tube looped upon itself with the tip projected cephalad, overlying the hypopharynx.",0
Dr. was informed of these findings at 6:15 p.m. on .,0
"12:30 PM MESSENERTIC Clip # Reason: arterial embolization of active bleed Admitting Diagnosis: SYNCOPE;TELEMETRY ********************************* CPT Codes ******************************** * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER * * -51 MULTI-PROCEDURE SAME DAY TRANCATHETER EMBOLIZATION * * F/U STATUS INFUSION/EMBO MOD SEDATION, FIRST 30 MIN.",0
"* * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man with UC now with cecal bleed on CTA REASON FOR THIS EXAMINATION: arterial embolization of active bleed ______________________________________________________________________________ FINAL REPORT MESENTERIC ANGIOGRAM AND EMBOLIZATION.",0
INDICATION: Lower GI bleed secondary to ulcerative colitis.,1
Right common femoral arterial access.,0
Subselective angiogram of branches of the ileocolic artery.,0
Coil embolization of an inferior branch of the ileocolic artery.,0
Post-procedure subselective angiograms of ileocolic artery and its branches.,0
MEDICATIONS: Moderate sedation was provided by administering divided doses of 175 mcg of fentanyl and 2 mg of midazolam throughout the total intraservice time of 1 hour 30 minutes during which the patient's hemodynamic parameters were continuously monitored.,0
1% lidocaine was used for local pain control.,0
OPERATORS: Dr. (fellow) and Dr. (attending interventional radiologist) was present and supervising throughout the entire procedure.,0
"TECHNIQUE: After discussion of the risks, benefits and alternatives to the procedure with the patient and his family, written informed consent was obtained.",0
The right groin was prepped and draped in the usual sterile fashion.,0
"Under palpatory ultrasound guidance, a 19-gauge single wall needle was advanced into the right common femoral artery over the mid femoral head.",0
A 0.035 wire was advanced into the aorta under fluoroscopic guidance.,0
A skin was made at the anesthetized skin.,0
The needle was exchanged for a 5 French -Tip vascular sheath.,0
The sidearm was flushed and connected to a heparinized saline continuous flush.,0
"A 5 French C2 glide catheter was advanced over the wire, the wire removed, (Over) 12:30 PM MESSENERTIC Clip # Reason: arterial embolization of active bleed Admitting Diagnosis: SYNCOPE;TELEMETRY ______________________________________________________________________________ FINAL REPORT (Cont) and the SMA selected.",0
Superior mesenteric angiogram was performed.,0
A 0.035 Glidewire was used to advance the glide catheter into the superior mesenteric artery.,0
The wire was removed and a Renegade STC microcatheter loaded with a formed 0.018 transcend guidewire was advanced into the ileocolic.,0
Subselective and superselective angiograms of the ileocolic and its branches were performed.,0
"After definition of the bleeding source, the microcatheter, in conjunction with the Transcend guidewire, were advanced into the inferior branch of the ileocolic.",0
"After confirmation of the bleeding site, a 0.018 x 1 x cm x 2 mm Hilal coil was advanced using a true push wire and the coil formed.",0
Hand injection and subsequent subselective angiogram confirmed successful embolization.,0
The glide catheter was removed.,0
Manual pressure was applied and the sheath was removed and hemostasis achieved after approximately 10 minutes.,0
Extravasation demonstrated from an inferior branch from the ileocolic artery.,0
Embolization of the inferior branch of the ileocolic with a 2 mm x 1 cm Hilal coil.,0
Post-procedure subselective angiograms from the ileocolic demonstrate cessation of bleeding.,0
IMPRESSION: Successful coil embolization of an inferior branch of the ileocolic artery where extravasation was demonstrated.,0
This branch's location is in concordance with the CTA finding.,0
5:01 PM PORTABLE ABDOMEN Clip # Reason: s/p dobhoff tube placement Admitting Diagnosis: MOTOR CYCLE COLLISION ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p intubation and trauma patient REASON FOR THIS EXAMINATION: s/p dobhoff tube placement ______________________________________________________________________________ FINAL REPORT ABDOMINAL RADIOGRAPH PERFORMED ON Comparison is made with a CT torso from .,1
"CLINICAL HISTORY: 52-year-old male, status post Dobbhoff tube placement.",0
Evaluate position of the tip.,0
FINDINGS: Single portable supine view of the abdomen is obtained.,0
The Dobbhoff tube is seen extending into the left upper abdomen with its tip in the approximate location of the mid gastric body.,0
Bowel gas pattern is grossly unremarkable.,0
IMPRESSION: Dobbhoff tube tip positioned in the approximate location of the mid gastric body.,0
"2:56 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma Field of view: 42 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with trauma, stabbing.",0
REASON FOR THIS EXAMINATION: trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: LLTc SUN 4:26 PM 1.,0
Severe right lower lobe atalectasis.,0
Right thoracostomy tube tip abuts the distal esophagus.,0
Slight retraction of the tube is recommended.,0
Hematoma overlying the right chest wall.,0
"No active extravasation is seen, however, a repeat study can be performed if there remains a clinical suspicion for continued bleed.",0
"Subcutaneous emphysema ovelrying the posterior right chest wall, compatible with known injury to that region.",0
No acute intra-abdoiminal or intra-pelvic process.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.,0
"TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and pelvis were obtained with the use of IV contrast.",0
Coronal and sagittal reformats were performed at 5-mm slice thickness.,0
"CT OF THE CHEST WITH IV CONTRAST: The right lung is partially collapsed, with a moderate sized pneumothorax present (2:25).",0
Severe atelectasis at the right lung base is present (2:38).,0
"There is a large dense pleural fluid collection, compatible with a hemothorax.",0
A right thoracostomy tube located superiorly to this terminates adjacent to the distal esophagus (2:45) and should be withdrawn slightly.,0
Subcutaneous emphysema overlies the right posterior chest wall (2:52).,0
"Adjacent to this is a 26-mm thick hyperdense (50 Hounsfield units) fluid collection overlying the right chest wall (2:39), compatible with a hematoma.",0
"There is no active extravasation of contrast seen within these regions, however, further assessment is limited due to single phase of the study.",0
"Mild dependent atelectasis is seen within the left lung, which is otherwise unremarkable.",0
"Heart size is normal, and there is no pericardial effusion.",0
Great vessels are patent and normal in caliber.,0
CT OF THE ABDOMEN WITH IV CONTRAST: The liver demonstrates diffuse hypoattenuation relative to the spleen suggestive of fatty infiltration.,0
Remainder of the liver is unremarkable.,0
"The gallbladder, spleen, pancreas, adrenal glands, and left kidney appear normal.",0
A tiny 4-mm hypodensity in the posterior interpolar region of the right kidney is too small to fully characterize.,0
Remainder of the right kidney is unremarkable.,0
Trace amount of (Over) 2:56 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma Field of view: 42 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) pericholecystic fluid may be related to volume resuscitation.,0
The stomach is moderately distended and filled with food products.,0
Remaining intra-abdominal loops of small and large bowel are unremarkable.,0
"CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon and intrapelvic loops of small and large bowel are normal.",0
There is no intrapelvic free fluid or lymphadenopathy.,0
"The urinary bladder, prostate, and seminal vesicles are normal.",0
There is no acute fracture or dislocation.,0
No concerning blastic or lytic lesions are detected.,0
"Large right hemopneumothorax, with a right thoracostomy tube tip adjacent to the distal esophagus and should be withdrawn slightly.",0
There is atelectasis of the right lung.,0
"No active extravasation is seen, within the limits of this single phase study 2.",0
26-mm thick hematoma in the right chest wall.,0
Subcutaneous emphysema overlying the posterior right chest wall.,0
No intra-abdominal or intrapelvic injury seen.,0
9:59 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for pancreatitis Admitting Diagnosis: CONGESTIVE HEART FAILURE;?,1
"SEPSIS Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 79 yo F c FUO, minimal responsiveness, found to have elevated lipase on labs with diffuse abd tenderness REASON FOR THIS EXAMINATION: eval for pancreatitis No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd MON 11:44 PM 1.",0
"Moderately large bilateral pleural effusions, increased in size since .",0
"Likely compressive atelectasis at bases, left greater than right (underlying infection cannot be excluded).",0
Right rectus sheath hematoma unchanged in size and appearance.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 79-year-old woman with fever of unknown origin and minimal responsiveness found to have elevated lipase and mild diffuse abdominal tenderness.,0
COMPARISON: CT of the abdomen and pelvis on .,0
TECHNIQUE: Axially acquired images were obtained through the torso after the administration of 130 ml of Optiray intravenous contrast and oral contrast.,1
FINDINGS: CT OF THE CHEST WITH IV CONTRAST: There are bilateral moderately large pleural effusion which have increased in size since the previous study.,0
"There is adjacent bibasilar compressive atelectasis, greater on the left.",0
"A left-sided pacemaker is seen with leads terminating in the coronary sinus and right ventricle and right atrium, unchanged.",0
A left-sided internal jugular central venous line remains unchanged.,0
"Multiple mediastinal lymph nodes are noted, the largest measuring 9 mm in short axis diameter anterior to the aortic arch, not meeting CT criteria for pathologic enlargement.",0
An NG tube is seen terminating near the pylorus.,0
There are bilateral calcified breast implants.,0
"Marked cardiomegaly, emphysema and interlobular thickening indicating CHF.",0
"CT OF THE ABDOMEN WITH IV AND ORAL CONTRAST: The spleen, adrenal glands, liver, and pancreas are within normal limits.",0
There is no evidence of pancreatitis.,0
The kidneys are atrophic bilaterally.,0
Small hypodensities within the right kidney are too small to characterize but unchanged.,0
"The gastric diverticulum is again seen, stable.",0
There is dense calcification of the abdominal vasculature.,0
There is (Over) 9:59 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval for pancreatitis Admitting Diagnosis: CONGESTIVE HEART FAILURE;?,1
SEPSIS Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) no free air.,0
The intra-abdominal loops of bowel are within normal limits.,0
There is a minimal amount of left paracolic gutter fluid.,0
CT OF THE PELVIS WITH IV AND ORAL CONTRAST: There has been interval placement of a rectal tube.,0
"A Foley catheter is noted within the bladder with air seen within the nondependent portion, likely due to recent instrumentation.",0
There is extensive diverticulosis of the sigmoid colon without diverticulitis.,0
A small amount of free fluid is noted within the pelvis.,0
There is no pelvic or retroperitoneal lymphadenopathy.,0
A collection measuring 7.0 x 2.4 cm is again noted in the right rectus sheath (2:92) and is unchanged in size and appearance since the prior study.,0
A significant amount of soft tissue edema is noted throughout the entire body.,0
BONE WINDOWS: No suspicious osseous lesions are identified.,0
Compression fractures of T12 and L3 are unchanged.,0
Extensive degenerative changes are again noted.,0
"Moderately large bilateral pleural effusions, increased in size since the prior study, most c/w CHF.",0
"Bibasilar atelectasis, left greater than right.",0
Subacute rectus sheath hematoma remains stable in size and appearance.,0
"7:46 PM CHEST (PA & LAT) Clip # Reason: r/o pulm edema ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with abnormal stress test and SOB, lung exam c crackles.",0
please eval for pulm edema.,0
"REASON FOR THIS EXAMINATION: r/o pulm edema ______________________________________________________________________________ FINAL REPORT HISTORY: Abnormal stress test and short of breath, with crackles.",0
No previous chest xrays on CCC record for comparison.,0
"Patient position is rotated, limiting assessment of mediastinal contours.",0
"Allowing for this, the left hemithorax is abnormal, smaller than the right, with considerable left apical scarring and soft tissue intensity/scarring along the aortic knob.",0
There is a faint patchy opacity at the right base.,0
"On the lateral view, there is obscuration of the left costophrenic angle.",0
"Abnormal left hemithorax, with loss of volume and apparent left apical and paraaortic scarring.",0
I have no previous films for comparison and cannot determine the chronicity of this finding.,0
"In the absence of a relevent clinical history to account for this appearance, CT scan would be recommended.",0
"Faint patchy opacity in right lower lobe, with obscuration of the posterior costophrenic angle.",0
"In the acute setting, differential diagnosis would include a pneumonic infiltrate and small effusion, but this could also represent chronic scarring.",0
", F. MED CCU 2:58 PM RENAL U.S.",0
"Clip # Reason: eval for obstruction, parenchymal abnormalities Admitting Diagnosis: HYPOGLYCEMIA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with acute renal failure, found unresponsive REASON FOR THIS EXAMINATION: eval for obstruction, parenchymal abnormalities ______________________________________________________________________________ PFI REPORT No evidence of stones, mass, or hydronephrosis.",1
Small amount of perihepatic ascites.,0
Height: (in) 67 Weight (lb): 180 BSA (m2): 1.94 m2 BP (mm Hg): 126/66 HR (bpm): 77 Status: Inpatient Date/Time: at 12:49 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
AORTIC VALVE: Aortic valve prosthesis (AVR).,1
An aortic valve prosthesis is present.,1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woman who had not been seen for three days.,0
She reportedly lives in a boarding house and was locked in her room.,0
She was found down by her superintendent.,0
On admission her vital signs were stable.,0
She was awake and attentive to examiner.,0
She had ecchymosis under the right eye.,0
"Her pupils were equal, round and reactive to light.",0
She was oriented to self.,0
She had antigravity strength in all four extremities.,0
On head CT she had right bifrontal contusions with areas consistent with infarct and left temporal contusions.,0
HOSPITAL COURSE: The patient was admitted to the trauma intensive care unit and closely monitored.,0
The patient's neurologic status continued to wax and wane.,0
"She had periods of being awake and attentive, following commands, moving all extremities, and then periods of being lethargic.",0
"Osmolarity on admission was 329, sodium 156.",0
On the patient had a repeat head CT which showed continued contusions with large amounts of edema throughout.,1
"Her osmolarity on was 327, sodium was 156.",0
Therefore mannitol continued to be held.,0
Her examination remained the same.,0
"She was oriented x 1, localized with her upper extremities.",0
Pupils were equal and reactive.,0
She was attentive to the examiner.,0
On the patient's mental status deteriorated.,0
"She was obtunded with no eye opening to noxious stimuli, she localized in her upper extremities.",0
Pupils were 4.5 and minimally reactive.,0
Head CT demonstrated increased pericontusional edema with increased left to right shift.,1
"Despite administration of mannitol, there was no change in her mental status therefore the patient was taken to the operating room for a left frontotemporal craniotomy and evacuation of the left anterior frontotemporal hemorrhagic contusion without intraoperative complication.",0
Postoperatively the patient was monitored in the trauma intensive care unit.,0
She opened her eyes briefly to name at times with little to no spontaneous movement.,0
She withdrew all extremities to painful stimuli.,0
There was no seizure activity.,0
ICP ventriculostomy without waveform or cerebrospinal fluid drainage.,0
"Neurosurgery flushed the drain, still got no drainage therefore the drain was removed on .",0
The patient was eventually weaned from the ventilator.,0
INCOMPLETE DICTATION - LATER REDICTATED.,0
Dictated By: MEDQUIST36 D: 10:24 T: 11:03 JOB#:,0
"10:48 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: ASTHMA;COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with severe COPD, OSA, intubated for PNA, hypoxic overnight on stable vent settings REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CJMt SAT 1:07 PM There is slight increase in left lower lobe atelectasis.",0
______________________________________________________________________________ FINAL REPORT CHEST X-RAY INDICATION: COPD.,0
FINDINGS: There is left basal patchy atelectasis.,0
This has increased somewhat compared to recent chest x-ray.,0
No definite pleural effusion is seen.,0
No other significant findings are seen.,0
There is an endotracheal tube in situ.,0
The tip of the endotracheal tube is projected approximately 8 cm proximal to the carina.,0
IMPRESSION: Increase in left basal atelectasis compared to recent chest x-ray.,0
"5:04 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for evolution of infiltrates Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with PCP pneumonia /b ARDS, on mechanical ventilation REASON FOR THIS EXAMINATION: please evaluate for evolution of infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old female with PCP pneumonia and ARDS.",0
Single AP erect radiograph of the chest performed on and compared to .,0
The endotracheal tube tip is approximately 2.2 cm above the carina.,0
The NG tube courses below the diaphragm.,0
There is a right upper extremity PICC line to the right atrium.,0
There is interval worsening of diffuse bilateral airspace opacities consistent with ARDS/pneumonia.,0
There are numerous displaced bilateral rib fractures some of which demonstrate callus formation.,0
Right clavicular fracture is again noted.,0
IMPRESSION: Worsening diffuse bilateral airspace opacity.,0
"4:57 PM CHEST (PORTABLE AP) Clip # Reason: s/p CT guided paracentasis, now w/ resp distress.",0
"?ptx ?pulm Admitting Diagnosis: BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with cirrhossis s/p hartmann's now with abd distention REASON FOR THIS EXAMINATION: s/p CT guided paracentasis, now w/ resp distress.",0
?ptx ?pulm edema ?acute cardiopulm process ______________________________________________________________________________ WET READ: ASpf 8:24 PM PRELIMINARY REPORT: Mild edema.,1
NG tube and NIT in the stomach.,0
"______________________________________________________________________________ FINAL REPORT Patient with cirrhosis, status post paracentesis, now with respiratory distress.",1
There has been no significant change since the prior chest x-ray of .,0
"Bilateral effusions are present, also unchanged.",0
IMPRESSION: No change since prior chest x-ray.,0
"7:33 AM BILIARY DILATATION Clip # Reason: Please evaluate right Biliary tube on Monday, Admitting Diagnosis: BILIARY OBSTRUCTION;RESPIRATORY FAILURE Contrast: CONRAY Amt: 30 ********************************* CPT Codes ******************************** * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER * * TUBE CHOLANGIOGRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with adenoCA, obstructive jaundice REASON FOR THIS EXAMINATION: Please evaluate right Biliary tube on Monday, ______________________________________________________________________________ FINAL REPORT INDICATIONS: Status post placement of biliary stent and right sided percutaneous biliary drainage catheter for obstructive jaundice.",1
"Dr. , staff radiologist was present for the entire procedure and supervised it.",0
PERCUTANEOUS CHOLANGIOGRAM AND BILIARY DRAINAGE TUBE REMOVAL: The risks and benefits of the procedure were explained to the patient and signed written consent was obtained.,0
The patient was placed on the angiography table and prepped and draped in the usual sterile manner.,0
Scout views demonstrated metal stent within the common hepatic and common bile duct and the percutaneous biliary drainage catheter postioned with the pigtail at the confluence of the left and right hepatic ducts.,0
Approximately 30 cc of Conray was administered slowly via the right sided biliary drainage tube and imaging was performed in multiple projections.,0
The contrast passed freely and easily across the common hepatic and common bile ducts into the duodenum.,0
There was no intra or extrahepatic biliary ductal dilatation and no extravasation from the bile ducts of contrast.,0
"Upon confirming free drainage through the metal biliary stents, the existing right biliary drainage tube was removed.",0
"After removal, there was leakage of ascites via the drainage catheter insertion site which gradually slowed to a slow drip.",0
A bandage was placed and the patient was sent back to the floor.,0
There were no complications of the procedure.,0
IMPRESSION: Free drainage of the biliary system into the duodenum without evidence of intra or extrahepatic biliary ductal distention.,0
Successful removal of right biliary drainage catheter.,0
"(Over) 7:33 AM BILIARY DILATATION Clip # Reason: Please evaluate right Biliary tube on Monday, Admitting Diagnosis: BILIARY OBSTRUCTION;RESPIRATORY FAILURE Contrast: CONRAY Amt: 30 ______________________________________________________________________________ FINAL REPORT (Cont)",1
Height: (in) 62 Weight (lb): 110 BSA (m2): 1.48 m2 BP (mm Hg): 103/44 HR (bpm): 92 Status: Inpatient Date/Time: at 10:16 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; basal inferolateral - hypo; remaining LV segments contract normally.,0
PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets.,0
There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior and inferolateral walls.,0
The remaining segments contract normally (LVEF = 55-60 %).,0
The pulmonic valve leaflets are thickened.,0
Mild regional left ventricular systolic dysfunction with preserved ejection fraction.,0
Mild right ventricular free wall hypokinesis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Horrible headache Major Surgical or Invasive Procedure: Angiogram L ICA aneurysm coiling History of Present Illness: 53 y/o female with a hx of migranes, had a sudden onset headache yesterday which caused pain in the back of her head down her neck, she said it self resolved on it's own after 20 minutes and 2 advil.",0
"Early this morning she developed a sudden severe posterior headache with a ""popping"" feeling in her head with neck pain while drinking her morning coffee.",0
"She went to hospital where she was found to have an intraventricular hemorrhage and questionable SAH, her BP was 204/115 at hospital Past Medical History: Migraines, Hyperlipidemia, Back pain and anxiety Social History: 37 pack year history of smoking; Currently a smoker; Denies IV drug use or ETOH.",1
"She is not married, has 2 grown children and is sole caregiver of her 4 year old grandchild.",0
"She works as a nursing assistant Family History: 2 aunts with brain aneursyms Physical Exam: PHYSICAL EXAM: O: T: BP:159/68 HR: 80 R 18 O2Sats Gen: WD/WN, comfortable, NAD.",0
"HEENT: Pupils: EOMs Neck: + Meningismus Neuro: Patient received Fentanyl and Ativan for transport Mental status: Prefers eyes closed, opens eyes to voice.",0
"Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5 min reactive (recently received narcotic).",0
"No pronator drift Sensation: Intact to light touch, can discern warm and cold.",0
Toes downgoing bilaterally CT/MRI:Intraventricular hemorrhage and diffuse subarachnoid hemorrhage.,1
"Mild temporal diliation; CTA read pending initial no aneurysm or AVM noted Labs:Crit 40.5 plt 397, INR 1.0 EXAM ON DISCHARGE: Intact Pertinent Results: ADMISSION LABS: 10:20AM GLUCOSE-135* UREA N-13 CREAT-0.6 SODIUM-135 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13 10:20AM WBC-15.8* RBC-4.47 HGB-14.0 HCT-40.5 MCV-91 MCH-31.3 MCHC-34.5 RDW-12.8 10:20AM NEUTS-86.9* LYMPHS-8.7* MONOS-3.3 EOS-0.7 BASOS-0.5 10:20AM PT-12.3 PTT-24.1 INR(PT)-1.0 DISCHARGE LABS: IMAGING: CTA Head IMPRESSION: 1.",0
Intraventricular hemorrhage and diffuse subarachnoid hemorrhage.,1
Mild temporal dilatation indicating early obstructive hydrocephalus.,0
No aneurysm or AVM is seen.,0
Followup conventional angiogram or CT angiogram may be helpful.,0
Mild prominence of nasopharyngeal soft tissues.,0
Suggest correlation with direct visualization and immune status.,1
"CT Head : No significant change in intraventricular and subarachnoid hemorrhage, with mildly prominent temporal horns of lateral ventricles CTA : IMPRESSION: Mild to moderate vasospasm, most prominent in the distal (A2 and A3) ACA segments.",1
CT Head : IMPRESSION: 1.,0
No new intracranial hemorrhage or evidence of infarction.,0
Unchanged appearance of right AICA aneurysm coil in the right inferior portion posterior fossa; associated artifact limits evaluation for acute hemorrhage in the region.,1
"CTA 1. unchanged R AICA aneurysm coil w/ surrounding streak artifact limiting assessment of that area; otherwise, no acute ICH.",0
2. patent anterior & posterior circulations Brief Hospital Course: The patient was admitted to the ICU for Q1 hour neuro checks.,0
"She was placed on keppra for seizure prophylaxis, and nimodipine for vasospasm prevention.",0
"She went for a diagnostic angiogram, however, due to her pain and agitation, the procedure was unable to be completed.",0
She returned to the ICU.,0
Her post op check was negative.,0
"She continued to have a very severe HA, but her exam was non focal.",0
"On , the patient underwent another angio, but this time had a general anesthesia in order to complete the procedure.",0
This revealed a right AICA aneurysm that was successfully coiled.,0
Post angiogram patient was transferred to the ICU for observation and monitoring for Vasospasm.,0
She was maintained on IV fluids with a goal to keep her euvolemic.,0
Her severe headaches were treated with a steroid taper and narcotic pain meds which seemed to be effective.,0
Throughout her ICU course her exam remained non-focal.,0
On she was cleared for transfer to the floor.,0
Her IV fluids were decreased to 50ml/hr.,0
"Current pain regimen appears to alleviate the headaches, at least to a tolerable level.",0
on we discontinued her IV fluids and changed her pain medications to dilaudid P.O prn and obtained a CTA to evaluate the amount of bld and underlying vasospasm.,0
This was significant for mild to moderate vasospasm therefore her IV fluids were restarted on .,0
On and she remained neurologically stable but had persistant headaches.,0
She was started on Topamax in addition to her existing pain regimen to attempt to help with this.,0
"She also described some chest discomfort that she had x1 therefore an EKG was obtained which was negative for changes, NSR.",0
blood cultures that were obtained on for fever work up revealed VIRIDANS STREPTOCOCCI from sample that was obtained from PICC line therefore the PICC was discontinued.,0
Repeat blood cultures were ordered.,0
: CTA showed no vasospasm and pt was cleared for discharge from neurosurgical standpoint.,0
She was cleared for home without services from PT/OT.,0
She will be discharged home in stable condition on with plan to follow up in clinic in 4 weeks.,0
She will also have a repeat cerebral angiogram in 4 weeks as well.,0
"Medications on Admission: Lipitor 20mg QD, Percocet/Valium prn Discharge Medications: 1.",0
Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 12 days.,0
Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: Tablets PO Q4H (every 4 hours) as needed for h/a: Do not exceed 4gms of Tylenol per day.,0
Nicotine 21 mg/24 hr Patch 24 hr Sig: Three (3) Patch 24 hr Transdermal DAILY (Daily): Please have PCP follow you and write for further refils.,0
Disp:*3 Patch 24 hr(s)* Refills:*0* 6.,0
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for headache.,0
Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety.,0
Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Aneurysmal Subarachnoid hemorrhage R ICA Aneurysm coiling Discharge Condition: Mental Status: Clear and coherent.,1
You will also need to schedule cerebral angiogram for 4 weeks as well.,0
This can both be scheduled when you call to make your office visit appointment.,0
You stated that you have been having headaches everyday for many years.,0
We are recommending that you follow up with Dr. in the Clinic.,0
Please call ( to set up an appointment with him regarding pain control for your headaches.,0
4:56 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: confirm OG tube placement Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man intubated after MVC.,1
"OG tube fell off, put another back in REASON FOR THIS EXAMINATION: confirm OG tube placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:40 P.M., HISTORY: Patient intubated after motor vehicle collision.",1
IMPRESSION: AP chest compared to and 6 through 7:41 a.m.,0
Lung apices are excluded from this examination performed with the patient semi-erect.,0
"Left hemidiaphragm is progressively more elevated, presumably due to left lower lobe atelectasis.",0
Enteric drainage tube ends in the upper stomach.,0
Veil-like opacification on the right is probably due to posteriorly layering right pleural effusion which is seen to widen the right upper costal pleural margin.,0
"The right apical extrapleural hematoma is inadequately imaged, but presumably persists.",0
Extensive chest cage trauma previously described.,1
", MED MICU 2:18 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 59 year-old female with DAH, concern for cryoglobulinemia, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PFI REPORT PFI: Stable appearance of the chest.",0
8:15 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please eval position of ETT Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with ETT recently advanced 4cm REASON FOR THIS EXAMINATION: Please eval position of ETT ______________________________________________________________________________ FINAL REPORT CHEST ON AT 20:15 HISTORY: ET tube and NG tube.,0
FINDINGS: The ET tube has been advanced and the tip is now 7 cm above the carina is at the level of the aortic knob.,0
The NG tube is up too high with the tip of the NG tube just above the gastroesophageal junction.,0
This finding was known by the house staff at the time of dictating this report when the NG tube had already been advanced.,0
There is improved aeration in retrocardiac compared to the most recent study.,0
"3:14 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: evalfor fx ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with SYNCOPAL episode,with right eye laceration REASON FOR THIS EXAMINATION: evalfor fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: DFDkq TUE 3:59 PM no cervical spine fracture; no malalignment; facial bone fractures - see separate report ______________________________________________________________________________ FINAL REPORT HISTORY: Status-post syncope with right eye laceration.",1
TECHNIQUE: Axial noncontrast multidetector CT images of the cervical spine were obtained.,0
FINDINGS: There is no fracture or malalignment within the cervical spine.,0
"There is intervertebral disk space narrowing at C6-7, and there are degenerative sclerotic changes in the adjacent inferior end plate of C6.",0
There is blood in the right maxillary sinus.,0
Fractures of the right maxillary sinus are partially visualized.,1
Please refer to the facial bone CT report of the same day for further details.,0
"There is a 6 x 5 mm lung nodule at the right lung apex, which was not present on the torso CT of .",0
No fracture or malialignment in the cervical spine.,0
Please refer to the facial bone CT of the same day for further details.,0
Weight (lb): 220 BP (mm Hg): 109/60 HR (bpm): 82 Status: Inpatient Date/Time: at 14:01 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated IVC (>2.5 cm).,0
Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg).,0
"9:04 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: evaluate for abscess/collection Admitting Diagnosis: HEAD BLEED Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with burr holes on R, L craniotomy b/l SDH, erythema at incision expanding REASON FOR THIS EXAMINATION: evaluate for abscess/collection No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa TUE 12:03 PM PFI: Larger fluid collection is identified in the surgical area on the right parietal region, measuring approximately 2.1 x 1.7 cm in size associated with soft tissue swelling and expanding since the prior examination dated , .",0
The possibility of a small abscess or fluid collection is considerations.,0
"Additionally there is a larger area of low attenuation on the right frontoparietal region with punctate enhancement in the convexity and extending inferiorly with ill-defined contour, the possibility of an early abscess formation, vasogenic edema are consideration, residual blood products and subarachnoid hemorrhage are visualized in the pre-contrast study, persistent asymmetry and mass effect in the right ventricle.",0
"Almost complete resolution of the previously noted post-surgical pneumocephalus on the left frontal region, persistent bilateral hygromas and blood products on the left frontal region.",0
These findings were communicated at the time of this interpretation to Dr. .,0
______________________________________________________________________________ FINAL REPORT STUDY: CT of the head with and without contrast.,0
"CLINICAL INDICATION: 64-year-old man with burr holes on right and left, prior craniotomy, bilateral subdural hematomas, erythema under incision, expanding, please evaluate for abscess/collection.",0
The axial images were repeated after the administration of non-ionic intravenous contrast material.,0
FINDINGS: Comparison was made with the prior CT of the head dated .,0
"FINDINGS: There has been interval reduction in the amount of extra-axial pneumocephalus, trace of air still remain in the frontal regions.",0
"In comparison with the prior study, there is evidence of a larger fluid collection adjacent to the surgical area on the right parietal region, measuring approximately 1.7 x 2.1 cm in size, producing soft tissue swelling and apparently expanding since the prior examination.",0
"Additionally there is also evidence of low-attenuation areas in the right frontoparietal region extending inferiorly, raising the possibility of an early abscess formation versus vasogenic edema, this area measures approximately 3.1 x 3.6 cm in size (Over) 9:04 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: evaluate for abscess/collection Admitting Diagnosis: HEAD BLEED Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ FINAL REPORT (Cont) and more superiorly 1.9 x 3.6 cm, persistent mild mass effect is identified in the lateral ventricle.",0
Unchanged small subdural hematoma along the right tentorium.,0
"On the left frontal region there is a persistent collection with blood products, unchanged since the prior study.",0
The left frontal craniotomy also appears unchanged.,0
"The orbits are unremarkable, persistent mucosal thickening in the ethmoidal air cells, maxillary sinuses and frontal sinus, bilateral opacities are demonstrated in the mastoid air cells, also fluid level within the sphenoidal sinus.",0
"IMPRESSION: Comparative study demonstrating larger fluid collection in the soft tissues adjacent to the burr hole site on the right parietal bone, producing soft tissue swelling.",0
"Additionally there is a larger area of low attenuation in the right frontoparietal region measuring approximately 2.9 x 3.6 cm and inferiorly measuring 3.1 x 3.6 cm as described above, suspicious for an early abscess formation versus vasogenic edema, persistent mild mass effect in the lateral ventricle.",0
Residual blood products noted on the left subdural space.,0
Unchanged residual subdural hematoma along the right tentorium.,0
No significant pattern of enhancement is demonstrated after the administration of contrast.,0
"LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: l dl power picc 48cm, iv Admitting Diagnosis: DIVERTICULITIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with picc REASON FOR THIS EXAMINATION: l dl power picc 48cm, iv ______________________________________________________________________________ FINAL REPORT HISTORY: PICC placement.",1
FINDINGS: Single AP view of the chest shows the left upper extremity PICC whose tip location cannot be located.,0
The tip likely is within the left brachiocephalic but it does not cross the midline.,0
"Otherwise, the left retrocardiac atelectasis has resolved.",0
Decrease in the small left pleural effusion.,0
IMPRESSION: Left PICC tip location cannot be identified.,0
6:52 AM BABYGRAM (CHEST ONLY) Clip # Reason: s/p transport from community.,0
right main stem intubation ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity @ 26 wks.,0
REASON FOR THIS EXAMINATION: s/p transport from community.,0
right main stem intubation ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Premature infant with question of right main stem intubation.,0
FINDINGS: There is visceral situs solitus and a probable left aortic arch.,0
The lungs are moderately hyperinflated.,0
"There is a moderate ground-glass appearance of the lung parenchyma bilaterally, in keeping with RDS.",0
5:59 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ETT placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with IVH REASON FOR THIS EXAMINATION: ETT placement ______________________________________________________________________________ WET READ: EHAb FRI 9:27 PM Endotracheal tube tip approximately 2 cm above carina.,0
"Esophageal catheter tip projects over left upper quadrant, likely within stomach.",0
Low lung volumes; lungs otherwise clear.,0
______________________________________________________________________________ FINAL REPORT PORTABLE SUPINE CHEST FILM AT 1750 CLINICAL INDICATION: 68-year-old with ET tube placement.,0
Please note that comparison to old films can be helpful to detect subtle interval change.,0
A single portable supine chest film at 1750 is submitted.,0
Endotracheal tube has its tip approximately 2.5 cm above the carina.,0
Nasogastric tube is seen coiled within the stomach.,0
"A catheter overlying this location appears to be heading cephalad off the edge of the image but is felt to most likely be related to the balloon of the endotracheal tube as discussion with the patient's nurse, , confirms that the patient does not have any central venous access.",0
Overall cardiac and mediastinal contours are likely within normal limits given portable technique.,0
Lung volumes are relatively low with no evidence of pulmonary edema or focal airspace consolidation.,0
Blunting of the left costophrenic angle likely reflects a small effusion or scarring.,0
Calcification within the lateral neck soft tissues on the left may be carotid in etiology.,0
Clips in the right upper quadrant likely reflect prior cholecystectomy.,0
Calcifications in the left upper quadrant likely represent splenic arterial calcifications.,0
10:08 PM ORBITS PRE-MRI (WATERS LOOK UP&DOWN) Clip # Reason: MRI orbits ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with brain lesion REASON FOR THIS EXAMINATION: MRI orbits ______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old woman with brain lesion.,0
Two views of the orbits demonstrate metal objects around the upper row of the teeth consistent with braces.,0
No other metallic objects are identified.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: Neurology DISCHARGE SUMMARY ADDENDUM: The patient had an additinal episode of slightly increased lethargy in the morning of and increased left upper extremity weakness, which led to a second head CT, which was unchanged from prior.",0
A chest x-ray was obtained that demonstrated increased right started on Ceftriaxone and Flagyl on and was to continue a fourteen day course.,0
Otherwise her hospital course was unremarkable for the remainder of her stay.,0
Ceftriaxone 1 gram intravenous q 24 hours.,0
Flagyl 500 mg intravenous q 8 hours.,0
Please refer to the prior discharge summary for details of her discharge plans.,0
Dictated By: MEDQUIST36 D: T: 15:25 JOB#:,0
10:43 AM CHEST (PA & LAT) Clip # Reason: eval for pleural effusions Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG.,1
"Comparison is made with prior study, .",0
"Small bilateral pleural effusions are associated with bibasilar atelectasis, larger on the right side.",0
"These have improved on the left, worsened on the right.",0
There is no pneumothorax or pulmonary edema.,0
There are moderate degenerative changes in the thoracic spine.,0
"2:48 PM CHEST (PORTABLE AP) Clip # Reason: postop film Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p cabg x4 REASON FOR THIS EXAMINATION: postop film ______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative evaluation, s/p CABG.",1
Please note that this report is dictated on because the radiographs were previously not placed on the appropriate list in the PACS archiving system.,0
"The ETT terminates in satisfactory position, just below the thoracic inlet.",0
"However, the ETT balloon is hyperinflated.",0
"The NG tube terminates below the left hemidiaphragm, in the expected location of the stomach.",0
The right internal jugular central venous catheter terminates in the right main pulmonary artery.,0
There are 2 left sided chest tubes and one right sided chest tube.,0
The heart and mediastinal contours are within normal limits given preceeding surgery.,0
"New sternal wires, surgical clips, and skin staples noted.",0
The findings were discussed with at 11:50 a.m. on .,0
IMPRESSION: 1) ETT balloon hyperinflation.,0
2) Satisfactory position of lines and tubes.,0
PATIENT/TEST INFORMATION: Indication: Re-assess LVEF s/p CABG.,0
"Previous history of MI, arrest.",1
Height: (in) 67 Weight (lb): 140 BSA (m2): 1.74 m2 BP (mm Hg): 99/61 HR (bpm): 74 Status: Inpatient Date/Time: at 17:17 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
"Moderate (2+) MR. to the eccentric MR jet, its severity may be underestimated (Coanda effect).",0
"An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen.",0
10:13 PM CT HEAD W/O CONTRAST Clip # Reason: please evaluate post-drain removal.,0
Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with REASON FOR THIS EXAMINATION: please evaluate post-drain removal.,1
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 1:52 AM 1.,0
"Interval removal of a drain from the right subdural collection, which is unchanged in size.",0
Persistent hydrocephalus and leftward shift of midline.,0
______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT INTRAVENOUS CONTRAST INDICATION: 62-year-old man with extra-axial collection.,0
"FINDINGS: The subdural fluid collection overlying the right cerebral convexity, overall measuring up to 20 mm is unchanged.",0
"The degree of local mass effect is stable, with similar degree of right lateral ventricle compression and subfalcine leftward herniation of approximately 4 mm.",0
The right ventriculostomy catheter is in place.,0
There is no evidence of acute hemorrhage.,0
The drainage catheter from a collection has been removed in the interval.,0
Post-surgical changes within the right middle cranial fossa are unchanged.,0
Osseous structures again demonstrate right frontal and parietal craniotomy defect.,0
Evaluation of the osseous structures of the skull base is limited by significant motion artifact.,0
Imaged paranasal sinuses and mastoid air cells are aerated.,0
"Interval removal of a drain from the right subdural collection, which is not significantly changed in size.",0
Persistent hydrocephalus and stable leftward shift of the midline.,0
"1:49 PM CT HEAD W/O CONTRAST Clip # Reason: R/O bleeding, abnormal anatomy Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant ~ 12 hours of life with apnea, desaturations, ?",1
"seizure activity REASON FOR THIS EXAMINATION: R/O bleeding, abnormal anatomy No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 12 hour old infant with apnea and desaturations with possible seizure activity, evaluate for intracranial hemorrhage or abnormal anatomy.",0
TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified.,0
The appearance of the brain parenchyma demonstrates an expected density given the patient age.,0
The soft tissues are within normal limits.,0
"There is a linear lucency within the occipital bone in the midline, which is not in expected location of normal sutures.",0
"This may reflect an intraparietal accessory occipital bone suture, though fracture or dislocation is not excluded.",0
The remainder of the soft tissues are within normal limits.,0
Minimal soft tissue swelling is noted over the vertex.,0
There is a linear lucency within the occipital bone in the midline.,0
"This may represent an intraparietal accessory occipital bone suture, though a fracture or dislocation is not excluded and clinical correlation is recommended.",0
There is no significant soft tissue swelling overlying this lucency.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: ADDENDUM: Dr. with the patient's primary care physician, .",0
"at Clinic and informed him of the patient's hospitalization, her progress and her need for either a follow up mammogram or ultrasound of her breasts in the near future.",0
The patient has a follow up appointment with Dr. at Clinic for at 10:30 AM.,0
Dictated By: MEDQUIST36 D: 15:39 T: 16:15 JOB#:,0
"2:48 PM CT HEAD W/O CONTRAST Clip # Reason: eval for bleed, fx Field of view: 25 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with large head lac and loc s/p fall down stairs REASON FOR THIS EXAMINATION: eval for bleed, fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: 4:57 PM (1) left occipital laceration with subcutaneous air.",0
"likely non-displaced left occipital calvarial fracture, with pneumocephalus.",0
"fracture thru mastoid air cells with opacification of mastoid aircells, external and internal auditory canals, and gas tracking in soft tissues anterior to styloid process.",1
partial opacification of paranasal sinuses.,0
"(2) acute extraaxial hemorrhage, likely subdural, left occipital, parafalcine, and r>l frontal.",1
also likely subarachoid along frontal lobes.,0
"(3) hyperdensity along expected course of right MCA, ?thrombosis.",0
WET READ VERSION #1 4:33 PM (1) left occipital laceration with subcutaneous air.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 78-year-old male with large head laceration.,0
Patient with loss of consciousness after fall down eight to nine stairs.,1
Found down by family lying in pool of blood presumably from head laceration and from nasal bleeding.,0
Down for likely less than 15 minutes.,0
TECHNIQUE: MDCT axial imaging is performed through the brain without administration of IV contrast.,0
"NON-CONTRAST CT HEAD: The patient has high-density blood layering along the falx and the tentorium, along the left occipital region and along the bifrontal regions consistent with subdural hematoma.",0
"In addition, there appears to be subarachnoid hemorrhage along the bifrontal regions.",1
There is scalp hematoma along the right occipitoparietal region.,0
Mild prominence of the sulci and ventricles is likely due to age-related involutional change.,0
"Periventricular white matter hypodensities likely (Over) 2:48 PM CT HEAD W/O CONTRAST Clip # Reason: eval for bleed, fx Field of view: 25 ______________________________________________________________________________ FINAL REPORT (Cont) related to chronic small vessel ischemic disease.",0
Small lacunes are noted along the left insular region.,0
"Focus of hyperattenuation is noted along the expected course of the MCA on the right (2:15) which could represent calcification within the MCA, focus of subarachnoid blood, and although acute thrombus is possible, the - white matter differentiation is preserved on the current study.",1
Atherosclerotic calcifications are noted along the cavernous carotid and vertebral arteries.,0
There appears to be non-displaced fracture through the underlying right occipital bone (3:30) with subjacent small foci of pneumocephalus.,0
"There is also an oblique/transverse fracture in the temporal bone coursing through the mastoid air cells, with associated opacification of the mastoid air cells, as well as the external auditory canal and middle ear.",1
The ossicles appear grossly intact.,0
The carotid canal also is intact.,0
There are also small locules of gas noted in the soft tissues anterior to the styloid process and posterior to the temporomandibular joint.,0
Layering fluid is noted in the maxillary sinuses and also in the nasopharynx.,0
Mucosal thickening is noted in the sphenoid sinus and there is opacification of some of the ethmoid air cells.,0
The left mastoid air cells remain well aerated.,0
"There are severe, incompletely imaged degenerative changes at the craniocervical junction; for further evaluation of this please refer to CT C- spine performed concomitantly.",0
"Subdural and subarachnoid hemorrhage in the bifrontal regions, also with subdural hemorrhage layering along the falx, the tentorium and along the right occipital region.",1
Non-displaced right occipital bone fractures with associated pneumocephalus.,0
"Transverse/oblique right temporal bone fracture involving the mastoid air cells with opacification of the mastoid air cells, the middle ear, and external auditory canal.",1
Dedicated temporal bone CT is recommended for further evaluation and to evaluate for ossicular injury.,0
Increased density is seen along a portion of the expected course of the right MCA.,0
"While -white matter differentiation appears preserved, if there is a concern for acute infarction, MRI would be recommended.",0
Findings were initially discussed with the trauma team and also posted on the ED dashboard via CCC upon completion of the study.,0
"DFDdp (Over) 2:48 PM CT HEAD W/O CONTRAST Clip # Reason: eval for bleed, fx Field of view: 25 ______________________________________________________________________________ FINAL REPORT (Cont)",0
"5:37 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change Admitting Diagnosis: INTERSTITIAL LUNG DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with pneumonia, intubated.",0
"REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: 67-year-old man with probable pneumonia, intubated, assess for interval change.",0
Comparison made to prior radiographs dating back to and prior CTA chest dated .,0
"SUPINE PORTABLE CHEST RADIOGRAPH FINDINGS: There has been interval development of a moderate sized right-sided pneumothorax with grossly unchanged diffuse airspace opacities, likely progressed since examination of unclear etiology.",0
Endotracheal tube terminates approximately 4 cm from the carina and there is stable position to right-sided internal jugular venous catheter.,0
Mild atelectasis at the right base maybe slightly increased.,0
New moderate sized right-sided pneumothorax.,0
"Grossly unchanged diffuse airspace opacities likely represents underlying chronic interstitial lung disease with superimposed edema, infection, or rapidly evolving alveolitis.",0
D/W Dr. at approximately 10:00 a.m..,0
3:03 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST; CT RECONSTRUCTION Reason: r/o PNA Admitting Diagnosis: SHINGLES;CONSTIPATION Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: year old woman with acute hypoxic respiratory failure REASON FOR THIS EXAMINATION: r/o PNA CONTRAINDICATIONS for IV CONTRAST: ARF;ARF ______________________________________________________________________________ FINAL REPORT HISTORY: Acute hypoxic respiratory failure.,1
COMPARISON: Chest CT from .,0
TECHNIQUE: MDCT acquired contiguous axial images from the lung apices to the pubic symphysis were acquired following the administration of oral gastrografin.,0
No IV contrast was administered secondary to the patient's elevated creatinine.,0
CT OF THE CHEST WITHOUT IV CONTRAST: The patient is intubated with the endotracheal tube noted in the mid trachea.,0
"There is marked calcification of the ascending and descending thoracic aorta, however, the aorta is normal in caliber.",0
Marked calcifications are also noted within the coronary arteries.,0
"Heart, pericardium, and great vessels otherwise appear unremarkable.",0
Central venous catheter is seen with tip in the distal superior vena cava.,0
"No pathologically enlarged hilar, axillary, or mediastinal lymph nodes are noted.",0
Lung window images demonstrate emphysematous changes bilaterally.,0
"Additionally, there is airspace opacification within the lower lobes bilaterally, which may represent aspiration, atelectasis, or pneumonia.",0
"Within the superior segment of the left lower lobe, additionally, there are ill- defined nodular opacities noted, suggestive of infection or aspiration.",0
The airways are patent to the level of segmental bronchi bilaterally.,0
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Nasogastric tube tip is seen within the stomach.,0
There is no free air demonstrated.,0
Contrast is only demonstrated within the proximal loops of small bowel.,0
There is no evidence of contrast extravasation or bowel obstruction.,0
The colonic loops of bowel are mildly dilated and abnormally filled with fluid.,0
No definite bowel wall thickening is noted.,0
There is no evidence of pneumatosis.,0
"The liver, gallbladder, spleen, adrenal glands, right kidney, all appear within normal limits.",0
"The left kidney is atrophic, and multiple cysts are seen within the left kidney.",0
"One of these cysts, which is in the mid pole, appears hyperdense.",0
"The abdominal aorta is normal in caliber, but heavily calcified throughout.",0
Pancreas is atrophic without discrete mass noted.,0
There is no pathologically enlarged (Over) 3:03 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST; CT RECONSTRUCTION Reason: r/o PNA Admitting Diagnosis: SHINGLES;CONSTIPATION Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) mesenteric or retroperitoneal lymph nodes are demonstrated.,0
An umbilical fat- containing hernia is present.,0
"CT OF THE PELVIS WITHOUT IV CONTRAST: The sigmoid colon and rectum are dilated and filled with a large amount of stool, suggesting fecal impaction.",0
Small amount of free fluid is seen within the pelvis.,0
"Foley catheter is seen within the bladder, which is otherwise collapsed.",0
There is marked degenerative changes within the thoracic and lumbar spine and possible hemivertebra of a distal thoracic vertebral body.,0
Bilateral lower lobe airspace opacities with more ill-defined nodular opacities seen within the superior segment of the left lower lobe.,0
These findings can be due to multifocal pneumonia or aspiration.,0
No evidence of contrast extravasation or free air within the abdomen.,0
"Mildly dilated, fluid filled loops of colon with large amount of stool impacted within the sigmoid colon and rectum.",0
"While the fluid-filled colonic loops of bowel may be secondary to obstrution from stool impaction, colitis cannot be excluded on this examination.",0
Atrophic left kidney with multiple cysts.,0
12:06 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: ELEVATED LFT'S Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with epigastric pain and elevated LFTs.,0
"REASON FOR THIS EXAMINATION: evaluate for obstruction, evaluate kidneys for evidence of obstruction ______________________________________________________________________________ FINAL REPORT INDICATION: 45-year-old with epigastric pain and elevated LFTs.",0
Comparison is made to ultrasounds performed and .,0
The liver is normal in echogenicity without focal mass.,0
The kidneys measure 12.1 cm and demonstrate increased cortical echogenicity.,0
"No hydronephrosis, stone, or mass is seen in either kidney.",0
"The gallbladder is not distended, and contains no sludge or stones.",0
There is some mild gallbladder wall thickening/edema.,0
The common bile duct measures 3 mm.,0
The pancreas and spleen are unremarkable.,0
The aorta is normal in caliber.,0
There is a moderate amount of ascites seen throughout the abdomen.,0
Increased echogenicity of both kidneys consistent with underlying renal parenchymal disease.,1
Moderate amount of ascites throughout the abdomen.,0
Gallbladder wall thickening is likely due to the ascites.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old right-handed gentleman, who presented on transfer from Hospital after having a seizure.",0
Patient was found by his wife to be flailing his arms and legs and foaming at the mouth while asleep.,0
Patient has no recollection of this.,0
"Was taken to Hospital, stabilized, and transferred to .",0
"Dilantin, loaded on Dilantin on transfer.",0
"PHYSICAL EXAMINATION: On physical exam, he was afebrile at 97.9 temperature, blood pressure 128/67, heart rate 74, respiratory rate 16, and sats is 96%.",0
"He was alert, awake, oriented, conversant, fluent speech.",0
"Cardiac: Regular, rate, and rhythm.",0
"Abdomen: Positive bowel sounds, nontender, and nondistended.",0
"Pupils are equal, round, and reactive to light.",0
His reflexes are 1+ throughout.,0
Head CT scan at the outside hospital showed a 2 cm high attenuation lesion in the medial right temporal lobe without significant edema or mass effect.,0
Ventricles and sulci within normal limits.,0
"Patient had a MRI scan which also showed a 2 cm hemorrhage in the right medial temporal lobe with posteromedial to the temporal gyrus, hyperintense on both T1 and T2 sequences.",0
Minimal mass effect or edema.,0
Patient is admitted to the Neuro Intensive Care Unit for close monitoring.,0
Was seen by Dr. and on underwent an arteriogram which showed no evidence of high flow shunting.,0
"Postprocedure he was awake, alert, and oriented times three.",0
"His groin site was clean, dry, and intact.",0
His pedal pulses were positive.,0
"He was transferred to the regular floor on postprocedure day #1, and discharged to home on postprocedure day #2 on Dilantin 100 mg po tid.",0
Will follow up for surgery for removal of cavernous malformation at a later date.,0
He will follow up with Dr. in weeks.,0
Dictated By: MEDQUIST36 D: 10:55 T: 11:24 JOB#:,0
9:09 AM PICC LINE PLACMENT SCH Clip # Reason: Pt needs IR PICC ; IV nurse but Admitting Diagnosis: CONGESTIVE HEART FAILURE ********************************* CPT Codes ******************************** * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 56F w/PMH significant for ESRD s/p live donor kidney transplant p/w CP and SOB in setting of hypertensive urgency.,1
Now with pseudomonas/E.coli UTI resistant to cipro; started on meropenem .,0
"REASON FOR THIS EXAMINATION: Pt needs IR PICC ; IV nurse but went up neck, tried to readjust but still in neck ______________________________________________________________________________ FINAL REPORT PICC LINE EXCHANGE/REPOSITIONING INDICATION: Malposition of indwelling PICC line.",0
A new single lumen PICC line measuring 41 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 4 French single lumen PICC line.,0
"Final internal length is 41 cm, with the tip positioned in the SVC.",0
"LINE PLACEMENT Clip # Reason: please assess for PTX, line placement Admitting Diagnosis: ELECTROLYTE ABNORMALITIES;CANCER ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with new left IJ REASON FOR THIS EXAMINATION: please assess for PTX, line placement ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Left IJ placement, assess for pneumothorax.",1
There is interval development of hazy density at the lung bases consistent with accumulating pleural fluid.,0
A streaky density at the right base consistent with subsegmental atelectasis in the retrocardiac area is not well penetrated.,0
The heart and mediastinal structures are unremarkable and unchanged.,0
A left internal jugular catheter has been inserted and terminates at the level of the lower superior vena cava.,0
IMPRESSION: Increased bibasilar density consistent with pleural effusions.,0
An area of consolidation at the lung bases cannot be excluded.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CHIEF COMPLAINT: End-stage liver disease.,0
"HISTORY OF PRESENT ILLNESS: The patient is a 51 year old male with hepatitis C virus cirrhosis, right lobe hepatocellular carcinoma, status post radiofrequency ablation on who presents preop for a liver transplant in a.m.",1
"He reports loose stools x10 per 24 hours associated with chronic abdominal pain, no fever or chills, no nausea or vomiting, no cough, no urinary frequency, or symptoms of UTI.",0
Does admit to feeling hungry and has baseline shortness of breath.,0
Significant for hepatocellular carcinoma status post radiofrequency ablation.,0
ALLERGIES: Patient is allergic Penicillin.,0
Glotrimizole troche 1 five times a day.,0
Multivitamin one tab q. d. 11.,0
"Methadone 145 mg q. d. clinic is Discovery, phone number .",0
SOCIAL HISTORY: Lives in .,0
HABITS: History of alcohol abuse.,0
"PHYSICAL EXAMINATION: On admission, temperature 98.1, heart rate 65, blood pressure 122/84 with a respiratory rate of 18, 98% on room air.",0
"He was alert and oriented, no acute distress.",0
Heart regular rate and rhythm.,0
"Abdomen soft, obese, positive bowel sounds, nonfocal abdomen, tender, negative rebound, negative hemorrhoids, positive umbilical hernia.",0
"Rectal, guaiac negative, no hemorrhoids.",0
"Extremities, positive venous changes and no edema.",0
"LABORATORY DATA: On admission, the patient had a chest x-ray that showed no acute process, no suspicious nodules.",0
"EKG on , sinus bradycardia, rate 49, inferior lateral flat T-waves.",0
"On , CT of the thorax was stable, no lesions.",0
HOSPITAL COURSE: The patient was admitted to the transplant service.,0
He was made NPO after midnight.,0
Lab work was sent off to use preop for the OR.,0
"Labs preop: White count 3.7, hematocrit 38, platelet count 38, fibrinogen 135.",0
"Coags: PT 17, PTT 37, INR 1.6.",0
"Creatinine 1, BUN 19, sodium 139, potassium 3.9, chloride 105, CO2 26.",0
He was taken to the OR on for orthotopic liver transplant.,0
"Surgeon was Dr. , co-surgeon was Dr. .",0
"He was replaced with 5 liters of crystalloid, 6 units of FFP, 6 units of packed red blood cells, 3 bags of platelets and 1 bag of cryoglobulin.",0
"The patient was intubated and taken to the surgical intensive care unit in critical, but stable condition.",0
"He was given induction immunosuppression of 500 mg of Solu- Medrol, 1 gram of CellCept intraop.",0
"In the SICU, his hematocrits were followed closely.",0
He was replaced with IV fluid.,0
He was weaned and extubated.,0
"Properatively, his AST was 1463, ALT 1116, alkaline phos 55, total bilirubin 3.9, and an amylase of 279.",0
"On postoperative day 2, his AST was 476, ALT 746, alkaline phos 56, and a total bilirubin of 1.2.",0
A duplex ultrasound of the liver demonstrated perihepatic ascites.,1
"Portal veins and hepatic veins were visualized with normal direction of flow, poorly dopplered hepatic artery waveforms were noted, likely secondary to technical limitations.",0
A repeat ultrasound was done on postoperative day 2.,0
"This demonstrated appropriate waveforms and directionality of flow within the portal veins, hepatic veins, and hepatic arteries.",0
His LFTs continued to trend down.,0
His preop weight was 113.,0
"On postoperative day 1, his weight was 130.5.",0
He began on IV Lasix and his weight trended down and achieved a weight of 116.7 no postoperative day 14.,0
His hematocrit trended down to 23.5 on postoperative day 9.,0
He received 3 units of packed red blood cells.,0
A repeat hematocrit was 26.9.,0
He received another unit of packed red blood cells as well as 1 unit of platelets for a platelet count of 74.,0
Post-platelet transfusion was 114 and a post- hematocrit was 32.1.,0
His hematocrit remained in the range of 28 to 29 for the remainder of his hospital course.,0
He did undergo abdominal CT with and without contrast to evaluate for any bleeding.,0
The CT demonstrated no cause for drop in hematocrit.,0
There was moderate hepatic artery stenosis noted.,0
There was narrowing of the portal vein at the area of the anastomosis as well as mild stenosis at the origin of the right renal artery.,0
A small amount of ascites and perihepatic fluid was noted.,0
There were multiple low attenuation areas in the transplanted liver likely representing simple cysts.,0
"When the patient was in the SICU, as he awakened, he complained of pain control.",0
Patient was on Methadone 145 mg p.o.,0
q. d. at home and he had not been on this as of postoperative day 2.,0
Dilaudid 2 mg IV q.,0
"1 hour was ineffective in relieving the patient's pain, so the Dilaudid was increased to 4 mg IV q.",0
The patient was started on clear liquids.,0
He tolerated this without incident.,0
His blood sugars were elevated and consult was obtained.,0
He was placed on an insulin sliding scale to achieve normalization of blood glucoses.,0
He was hypertensive while in the SICU.,0
He was given Hydralazine and Lopressor.,0
Blood pressure improved and ranged between 130s to 140s down to 90 to 100 systolic.,0
Lopressor was changed to p.o.,0
His Solu-Medrol was tapered per protocol and he was started on 20 mg on postoperative day 7 of Prednisone and he remained on CellCept 1 gram b.i.d.,0
Prograf was started on postoperative day 2 at 2 mg p.o.,0
Prograf was adjusted and titrated to levels.,0
Prograf level increased to 18.9 on postoperative day 8.,0
His dose was decreased and he was stabilized on 2 mg p.o.,0
with a Prograf level of 9 to 14 on 2 mg twice a day.,0
He was transferred to the medical/surgical unit where he continued to recover slowly.,0
Pain control continued to be an issue.,0
Recommendations included continuation of Methadone 145 mg q. a.m. and adjusting Dilaudid p.o.,0
to 8 to 16 mg p.o.,0
"For the remainder of this hospital course, his pain continued to be monitored.",0
He complained primarily of right upper quadrant discomfort.,0
"Towards the end of his hospital stay, his pain was lessened and he was receiving 4 mg p.o.",0
approximately 4 times a day.,0
A physical therapy consult was obtained.,0
PT worked with him to ambulate.,0
"Given his deconditioning, it was recommended that he continue home PT.",0
He has 2 - drains; #1 was discontinued on postoperative day 5 and #2 JP drain continued to drain approximately 290 cc of serosanguineous fluid.,0
"On postoperative day 7, he was started on IV Vancomycin for some erythema around the incision at the left lower quadrant.",0
This erythema resolved towards the end of the hospital course and Vancomycin was stopped.,0
His white blood cell count remained in the 4.7 to 6.6 range.,0
The second JP was removed.,0
His LFTs continued to decrease.,0
He was tolerating a regular diet and needed a lot of encouragement to ambulate.,0
"On postoperative day 9, patient complained of right neck discomfort.",0
His right IJ site appeared mildly edematous.,0
A carotid ultrasound was done.,0
There was also noted of a right IJ partially occlusive clot.,0
He was not started on Heparin or Coumadin.,0
He was maintained on a sliding scale insulin regimen for moderately elevated blood sugars.,0
He required a minimal amount of regular insulin and this was tapered off towards the end of the hospital stay.,0
He was discharged home on postoperative day 15 in stable condition.,0
"His LFTs had trended down with an AST of 49, ALT 217, alkaline phos 102, total bilirubin 0.6, albumin of 3.1.",0
"His creatinine was 1.1, BUN 21, white blood cell count 6.6 and a hematocrit of 29.4.",0
He was urinating independently without any difficulty.,0
Blood pressure ranged between 118/72 to 135/78.,0
He was out of bed ambulating independently.,0
"Visiting nurse services were set up for medication management, AcuCheks and wound assessment.",0
"The plan was for him to return to the clinic on Monday, , for assessment for continuation of Methadone maintenance.",0
clinic was the Discovery House Clinic.,0
That telephone number was 1-.,0
He was discharged home in stable condition.,0
Bactrim single strength 1 p.o.,0
"Bupropion 100 mg sustained release tab, 1 tab p.o.",0
"Dilaudid 2 mg tabs, 1 to 2 tabs p.o.",0
q. d. He was scheduled to follow up with Dr. on at 9 a.m.,0
DISCHARGE DIAGNOSIS: End-stage liver disease secondary to hepatocellular carcinoma and hepatitis C virus.,1
"Chronic pain, chronic back pain.",0
History of alcohol and IV drug abuse.,0
", Dictated By: MEDQUIST36 D: 15:13:39 T: 19:12:00 Job#:",0
"4:26 AM BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # Reason: f/u previous film , r/o nec or obstruction Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with bloody stool please do film at 0400 REASON FOR THIS EXAMINATION: f/u previous film r/o nec or obstruction ______________________________________________________________________________ FINAL REPORT Infant with bloody stools.",1
KUB compared to films dated .,0
The nasogastric tube is in the distal esophagus approximately two vertebral bodies from the GE junction.,0
The bowel gas pattern shows a loop of bowel in the left quadrant of the abdomen that appears featureless.,0
No definite portal venous gas or pneumatosis is seen.,0
"IMPRESSION: Amorphous bowel loop in the left quadrant of the abdomen, as described.",0
Follow-up films as clinically indicated to rule out NEC.,0
Nasogastric tube position as noted.,0
"12:42 PM CAROTID SERIES COMPLETE Clip # Reason: evaluate for stenosis Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with 3vessel disease REASON FOR THIS EXAMINATION: evaluate for stenosis ______________________________________________________________________________ FINAL REPORT Radiology Department Vascular Laboratory: Study: Carotid Series Complete Reason: 45 year old man with 3 vessel CAD, pre/op CABG.",1
"On the right there is a tiny heterogeneous plaque in the ICA, and mild intimal wall thickening in the right CCA.",0
On the left there is no plaque seen .,0
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are, 103/29, 78/23, 57/23, cm/sec.",0
ECA peak systolic velocity is 95 cm/sec.,0
The ICA/CCA ratio is .94.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 78/17, 59/23, 48/25, cm/sec.",0
CCA peak systolic velocity is 93 cm/sec.,0
ECA peak systolic velocity is 128 cm/sec.,0
The ICA/CCA ratio is .83.,0
Impression: Right ICA with no stenosis .,0
Left ICA with no stenosis .,0
11:08 AM CHEST (PA & LAT) Clip # Reason: 68 y.o.,0
woman w/multi-lobar pneumonia dx'd on .,0
"No improv ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with IDDM, normal pressure hydrocephaluscough.",0
REASON FOR THIS EXAMINATION: 68 y.o.,0
Please reassess w/upright PA and Lat.,0
______________________________________________________________________________ FINAL REPORT INDICATIONS: Multilobar pneumonia.,0
COMPARISONS: Previous chest radiograph dated three days earlier.,0
PA AND LATERAL CHEST: The patient is S/P previous median sternotomy and coronary artery bypass surgery.,0
The heart size and pulmonary vascularity are within normal limits.,0
"There are multifocal alveolar opacities present in both lungs, affecting the right lung to a greater degree than the left.",0
The most severely involved area is the right upper lobe.,0
"Overall, there has been slight interval improvement in opacification in the left retrocardiac region, but there has been interval worsening in the left upper and right middle lobes.",0
"IMPRESSION: Multilobar pneumonia, with overall slight interval progression since previous study.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Erythromycin Base Attending: Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 39M with Duchenne's muscular dystrophy, chronic vent dependency, with 3 days RUQ pain, nausea originally admitted to MICU Green on the night of .",1
Left-sided PICC was placed in ICU on poor access and inability to draw labs.,0
Patient was seen by general surgery and ERCP.,0
It was decided that patient should have ERCP.,0
Patient was stable overnight and transferred East on for ERCP.,0
ERCP performed under MAC anesthesia.,0
Afilling defect that appeared like a stone in the lower of the CBD.,0
"Sphincterotomy was performed, the stone along with some sludge was extracted.",0
The patient was stable post-procedure and transferred to the as he is ventilator-dependent muscular dystrophy.,1
"In the , 87 111/72 15 98%.",0
"ROS significant for constipation, last BM Monday and increased secretions around his trach.",0
"HISTORY OF PRESENTING ILLNESS: 39M with Duchenne's muscular dystrophy, chronic vent dependency, with 3 days RUQ pain, nausea.",1
"Seen at Hospital on where he had imaging, was told he had gallstones and sent home with Vicodin and instructions to follow up with GI in .",0
"On next day, , developed worsening jaundice, subjective fever, with dark urine per home nurse and called his pulmonologist, Dr. and told to come into ED.",0
Denies fever or abdominal pain.,0
"Patient reports RUQ pain is crampy and intermittent, varies from to .",0
Took one dose of tylenol but not excessive amounts in last 3 days.,0
"The patient has a PEG for meds, but takes PO and eats a regular diet, and states his pain is unrelated to eating.",0
Has been nauseated with decreased appetite.,0
"Has not been traveling, eating any raw seafood or other exotic foods.",0
Denies eating more fatty foods than usual but does like to eat meat.,0
States prior cholesterol panel normal.,0
Does report similar RUQ pain 3 weeks ago which lasted a day but resolved.,0
No jaundice then per patient and family.,0
"No BM for 4 days, loose at that point, nl color.",0
"Denies sick contacts, no recent travel, no usual foods/restaurants.",0
Has been doing quite well from a respiratory standpoint without any infections in more than a year.,1
"At last pulmonary visit, patient was on assist control at 14 breaths per minute, tidal volume 700 mL, PEP of 7.5, and no supplemental oxygen.",0
"In ED, 98.2, 91, 132/91, 20, 100% on PEEP 7.5 (home vent settings).",0
"Had tenderness in RUQ, no tenderness, rebound, Murphys.",0
No hepatomegaly or splenomegaly or ascites or increased abdominal girth.,0
"RUQ ultrasound showing gallstones, no hepatic ductal dilatation.",0
"Seen by gerneral surgery, recommended ERCP for biliary obstruction and ERCP fellow aware.",0
"Unable to get CBC in ED, has 20gauge IV.",0
"Received levofloxacin 500mg to cover for cholangitis (allergic to penicillin), planned for flagyl.",0
"Received 1L of fluids, having no pain.",0
"On arrival to the MICU, patient was comfortable without any abdominal pain, denies nausea, vomiting, fever, chills.",0
"Past Medical History: Duchenne's Muscular Dystrophy chronic respiratory failure -- s/p trach, vent dependent since '.",1
"bronchiectasis Long QT interval Known RBBB, s/p open gastrostomy and PEG tube placement s/p systolic arrest in at the time of a viral pneumonia while an inpatient at Social History: The patient lives at home with parents & home nurses.",1
He eats a regular diet.,0
GT used for meds & H2O only.,0
"Denies increased ETOH use (only drinks on social occasions such as weddings), denies cigarettes or other IVDU.",0
Patient had ERCP and sphincterotomy on .,0
"His bilirubin, LFT and amylase, lipase were trended.",0
Hemolysis labs were checked as well as hepatitis serologies which were negative.,0
Levofloxacin was started and continued for a day course per ERCP recommendations.,0
A script for levofloxacin was provided at discharge.,0
Chronic respiratory failure: The patient has a tracheostomy and has been ventilator dependent since .,1
His home ventilator settings were continued.,0
His albuterol and atrovent nebulizer treatments were continued as well as suctioning prn and cough assist.,0
The patient remained without any respiratory complaints or complications.,1
Metabolic acidosis: patient with a low bicarb and AG of 20 on admission.,0
"Unclear in etiology, lactate was as above, ketones in urine but glucose normal.",0
"Patient is not uremic, not a known diabetic.",0
Likely secondary to poor po intake over days prior to discharge.,0
Given D5 1/2NS IV with resolving gap but bicarb levels remained low.,0
Will encourage patient to follow-up with PCP and have labs drawn several days post-discharge; script for outpatient blood draw was provided.,0
Duchenne's Muscular Dystrophy: Patient was continued on mechanical ventilation per home vent settings and turned frequently to prevent ulcers.,1
"h/o long QT interval, known RBBB: Patient had prior holter monitor which revealed isolated PVC's and infrequent ventricular couplets.",0
He was monitored on telemetry.,0
QT prolonging medications were avoided and EKGs were followed for any changes.,0
HTN: The patient's lisinopril was initially continued however he had an episode of hypotension during his stay.,0
"He was given fluid boluses, lisinopril was held, and he remained asymptomatic during this episode.",0
"Lisinopril had not been restarted on discharge, but was included in his medication reconciliation to ensure it will be restarted at home.",0
Code - Full code Follow-up: patient and family is encouraged to follow up with their PCP and have labs drawn within a week of discharge.,0
Medications on Admission: Protonix 40 daily chlorpheniramine maleate 4 mg Colace liquid 50 mg/5 mL - 10 mL albuterol neb Atrovent neb lisinopril 2.5 daily MVI daily trazodone 50 daily Enulose 40mg PG Bactrim sus 2 tsp via G tube at 5pm Free water 300cc PG QID Tobramycin inh prn respiratory infections Fleet enema prn Discharge Medications: 1.,1
Chlorpheniramine Maleate 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig: Twenty (20) ML PO DAILY (Daily).,0
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day) as needed for constipation.,0
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).,0
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: start day .,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Inhalation Q2H (every 2 hours) as needed.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every twelve (12) hours as needed.,0
Colace 50 mg/5 mL Liquid Sig: Two (2) PO twice a day.,0
M-Vit 27-1 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Outpatient Lab Work Please draw LFTs, bilirubin, amylase, lipase and chem 10.",0
"Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: cholelithiasis s/p ERCP Discharge Condition: stable, afebrile, on home ventilator settings Discharge Instructions: You were admitted with abdominal pain and nausea, caused by a gallbladder stone blocking emptying of the gallbladder.",0
You underwent an ERCP and sphincterotomy which relieved the blockage.,0
Please ensure that you continue your antibiotics (levofloxacin) for the entire course and follow-up with your primary care doctor to check labs and ensure that your elevated liver and bilirubin labs return to normal.,0
"If you experience any increasing right sided abdominal pain, nausea/vomiting, chest pain or shortness of breath, bloody or loose stools please contact your doctor or return to the hospital.",0
Followup Instructions: Please follow-up with your primary care physician within week of hospital discharge to review lab work as above.,0
Please also complete the entire course of antibiotics (levofloxacin).,0
1:11 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate progress of treatment Admitting Diagnosis: DYSPNEA;WEAKNESS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 79M with decompensated CHF undergoing diuresis with persistent dyspnea and R pleural effusion REASON FOR THIS EXAMINATION: please evaluate progress of treatment ______________________________________________________________________________ FINAL REPORT INDICATION: History of decompensated CHF with persistent dyspnea and right pleural effusion.,0
"PORTABLE AP CHEST, ONE VIEW: Comparison is made to a study from .",0
There has been interval development of a right-sided pleural effusion with associated patchy right-sided atelectasis.,0
"A left-sided IJ central venous catheter is again seen, and the tip remains unchanged in position.",0
Left ventricular enlargement is noted.,0
3:06 PM CHEST (PORTABLE AP) Clip # Reason: Assess for PNA Admitting Diagnosis: SYNCOPY C2 FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p fall with C2 fx now intubated with recurrent temp spikes REASON FOR THIS EXAMINATION: Assess for PNA ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.,1
"INDICATION: Status post fall with cervical fracture of segment, now intubated and with returned temperature spikes.",1
FINDINGS: AP single view of the chest has been obtained with the patient in supine position.,0
The study is analyzed in direct comparison with the next previous similar study of .,0
The patient was previously intubated and is now dependent on a tracheostomy cannula.,0
"As before, there is status post sternotomy, bypass surgery and a metallic ring in the center of the heart consistent with aortic valve replacement.",1
A permanent pacer in right anterior axillary position is connected to a dual electrode system with termination points consistent with the right ventricle for both.,0
"None of the two electrodes is likely to terminate in the right atrium, but single plain examination limits somewhat the analysis.",0
"Comparison with the next preceding portable chest examination demonstrate the appearance of 2 patchy infiltrates in the left upper lobe area, which were not seen at least to the same extent on the previous examination.",0
"The course of these densities is not clear, but possibility of aspiration occurring in recumbent position must be considered.",0
Telephone report was established to convey findings.,0
9:31 AM CHEST (PORTABLE AP) Clip # Reason: ETT placement check ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with S/P assault REASON FOR THIS EXAMINATION: ETT placement check ______________________________________________________________________________ FINAL REPORT HISTORY: 39-year-old male status post assault.,0
Please evaluate endotracheal tube placement.,0
"SINGLE PORTABLE SUPINE VIEW OF THE CHEST: An endotracheal tube has been placed, terminating 3.5 cm above the carina, in satisfactory position.",0
The nasogastric tube courses well below the diaphragm and terminates with the tip in the stomach.,0
The cardiomediastinal contour is normal.,0
The aortic contour is sharp.,0
"The bony thorax is normal, with no rib fractures.",0
IMPRESSION: Satisfactory placement of NG tube and endotracheal tube.,0
"12:12 AM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant on hifi REASON FOR THIS EXAMINATION: evaluate lung ______________________________________________________________________________ FINAL REPORT Portable of the chest on , its compared to the film of .",1
The UAC catheter UVC catheter and endotracheal tubes remain in similar position when compared to the prior examination.,0
"There is worsening confluent opacities in the left lung that may represent asymmetric pulmonary edema, pulmonary hemorrhage, or atelectasis in the setting of RDS",0
3:02 PM PICC LINE PLACMENT SCH Clip # Reason: Needs PICC placement in LEFT arm.,0
"Right arm with lymphedema Admitting Diagnosis: CHEMO ********************************* CPT Codes ******************************** * LIMITED EXTREM VENOUS US * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 61 yo F with h/o breast CA and subsequent development of AML s/p allo HSCT (on ) found to have a relapse of her AML with positive BM biopsy and chloroma of the L2 spine, admitted for C1 of MEC.",1
REASON FOR THIS EXAMINATION: Needs PICC placement in LEFT arm.,0
Right arm with lymphedema problems mastectomy.,0
______________________________________________________________________________ FINAL REPORT ATTEMPTED PICC PLACEMENT INDICATION: 61-year-old female with AML.,0
OPERATORS: Dr. (fellow) and (attending physician).,0
PROCEDURE: The patient was placed supine on the imaging table in the interventional suite.,0
"Under aseptic conditions, limited son was performed in the left arm.",1
"Mid brachial vein was incompletely compressed, likely as a result of non-occlusive thrombus.",0
IMPRESSION: Limited son of left arm demonstrated likely non-occlusive thrombus in the mid brachial vein.,0
The PICC was not placed.,0
Findings were discussed with Dr. over the phone at around 4:50 p.m. on .,0
1:59 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: s/p R pontine infarct?,0
need MRI DWI with gado.,0
Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with REASON FOR THIS EXAMINATION: s/p R pontine infarct?,0
______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Patient with question of pontine infarct.,0
"T1 axial, sagittal and coronal images obtained following gadolinium.",0
FINDINGS: Diffusion-weighted images demonstrate an area of slow diffusion in the right side of the pons indicative of an acute infarct.,0
This is a new finding since the previous MRI study.,0
Previously seen areas of increased signal indicating slow diffusion in the posterior portion of both lateral ventricles and basal cisterns are visualized.,0
The signal abnormalities in the basal cistern are less apparent compared to the prior study.,0
There is a diffuse enhancement seen along the ventricular margins in the basal system and basal cisterns indicative of ventriculitis and meningeal inflammation.,0
There is mild prominence of ventricles.,0
The right frontal shunt catheter is visualized with enhancement along the margin.,0
The left frontal shunt catheter is also seen.,0
Bilateral mastoid soft tissue changes are visualized.,0
IMPRESSION: Acute right-sided pontine infarct since the previous MRI of as demonstrated by the recent CT. Diffuse enhancement along the ventricles and basal cisterns indicate meningeal and ependymal inflammation.,0
9:00 AM CHEST (PA & LAT) Clip # Reason: Eval.,0
"Admitting Diagnosis: PERICARDIAL DISEASE\PERICARDIAL STRIPPING/SDA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p pericardial stripping with persistent O2 requirement, now SOB REASON FOR THIS EXAMINATION: Eval.",0
"______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Shortness of breath, evaluate interval change.",0
There is interval development of somewhat patchy increased density in the right lung with relative sparing of the right apex.,0
The minor fissure remains thickened.,0
Increased density is again demonstrated in the retrocardiac area.,0
Air bronchograms are present at both lung bases.,0
"The left costophrenic sulcus is blunted, as before.",0
The cardiac silhouette is prominent.,0
"IMPRESSION: Increased density in the right lung, suspicious for pneumonia.",0
Increased density in the retrocardiac area consistent with atelectasis and/or consolidation.,0
"2:59 AM CHEST (PORTABLE AP) Clip # Reason: ?tube placement, infection ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p intubation REASON FOR THIS EXAMINATION: ?tube placement, infection ______________________________________________________________________________ FINAL REPORT CHEST X-RAY DATED HISTORY: 70-year-old man status post intubation.",1
FINDINGS: A supine AP portable view of the chest was obtained.,0
An endotracheal tube terminates 3.3 cm above the carina.,0
A nasogastric tube terminates in the stomach.,0
A battery pack overlies the left chest wall.,0
"The lung volumes are low, which accentuates the size of the heart which is likely top normal in size.",0
There is linear retrocardiac atelectasis.,0
No focal consolidations are identified.,0
No acute osseous abnormalities are noted.,0
IMPRESSION: Endotracheal tube and NG tube in appropriate position.,0
Linear retrocardiac atelectasis and low lung volumes.,0
", F. MED 2:15 PM DUPLEX DOPP ABD/PEL Clip # Reason: pls assess liver, CBD, vasculature patency.",0
"Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with elevated LFTs, cholestatic pattern.",0
"REASON FOR THIS EXAMINATION: pls assess liver, CBD, vasculature patency.",0
______________________________________________________________________________ PFI REPORT PFI: 1.,0
Patent portal vein and hepatic veins.,0
"Near-absent diastolic flow within the right, left and main hepatic arteries.",0
not necessarily relate to a congestive hepatopathy.,0
The diminished diastolic flow within the hepatic arteries is likely due to this underlying hepatic parenchymal abnormality.,0
Gallbladder wall thickening related to underlying hepatic parenchymal abnormality.,0
"1:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: check dophoff placement Admitting Diagnosis: RUPTURED ASCENDING AORTIC GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 78 y/o man s/p Redo CABG/Repair Ascending Aorta Graft new feeding tube REASON FOR THIS EXAMINATION: check dophoff placement ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST, AT 13:45 HOURS.",0
"COMPARISON: Multiple priors, the most recent dated earlier, same day.",0
FINDINGS: Endotracheal tube is again identified with the distal tip in the gastric antrum.,0
The tube is in inadequate position for enteric feeding.,0
There has been interval development of a small right upper pneumothorax.,0
Maximal visceral and parietal pleural separation is approximately 4 mm.,0
"There is a large pleural fluid component as well, which is relatively stable.",0
A small left pleural effusion is also noted.,1
"There is diffuse bilateral perihilar haze and pulmonary vascular indistinctness, consistent with severe hydrostatic edema.",0
There is an enlarged cardiac mediastinal silhouette with a tortuous calcified aorta is again noted.,0
Post-surgical changes are again evident.,0
The patient has an indwelling tracheostomy unchanged in course or position.,0
New small right upper lobe pneumothorax.,0
Enteric feeding tube and gastric antrum.,0
This tube is not in adequate position to commence enteric feeds.,0
"Severe hydrostatic edema with bilateral pleural effusions, right larger than left.",1
"The nurse practitioner, , was informed of this finding at 2:00 p.m. on the day of the study.",0
"4:19 PM PORTABLE ABDOMEN Clip # Reason: s/p dobhoff placement Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 72 year-old RH man with a PMH of CAD, MI and prior TIA's who presented to the ED with a R hemiplegia, facial droop, L gaze preference, R field cut, and aphasia.",1
"His CTA shows a cut off the superior division of the MCA on the L. His last known well time is last night at 10pm, however he may have been able to walk at 5:45 am with the onset of his symptoms.",0
Given IV tPA by neuro at 0840 for L MCA embolic CVA.,0
REASON FOR THIS EXAMINATION: s/p dobhoff placement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe FRI 8:09 PM Approximately positioned feeding tube with tip in the region of the duodenal bulb/pylorus.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Acute stroke with Dobbhoff placement.,0
PORTABLE ABDOMINAL RADIOGRAPH No priors are available.,0
Enteric feeding tube tip terminates in the region of the duodenal bulb/pylorus with oral contrast noted within otherwise normal-appearing large bowel.,0
Degenerative disc disease is noted at L5-S1 with multilevel mild degenerative joint disease noted within the lumbar and lower thoracic spine.,0
IMPRESSION: Appropriately positioned feeding tube as described with the tip in the region of the duodenal bulb/pylorus.,0
8:06 AM RENAL TRANSPLANT U.S.,1
PORT; -76 BY SAME PHYSICIAN # Reason: post-op u/s Admitting Diagnosis: ELEVATED WHITE BLOOD COUNT ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with new renal transplant -- R iliac fossa REASON FOR THIS EXAMINATION: post-op u/s ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 12:11 PM 1.,1
RI's of transplant kidney 0.61 - 0.65.,1
"Sharp initial systolic upstroke with some blunting in late systole, forward flow in diastole, and normal venous waveform.",0
"No perinephric collection, but a small amount of fluid in pelvis around bladder.",0
Recommend short-interval followup for systolic waveforms and mild hydronephrosis.,0
Change in PFI paged to 12:10pm PFI VERSION #1 PFI VERSION #2 10:02 AM 1.,0
Normal waveforms of transplant kidney: RI's 0.63 - 0.73.,1
"Sharp systolic upstroke, forward flow in diastole, and normal venous waveform.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 43-year-old woman with new renal transplant.,1
COMPARISON: This is the first postoperative ultrasound.,0
"RENAL TRANSPLANT ULTRASOUND: The transplant kidney in the right hemipelvis is normal in echogenicity, measuring 11.2 cm.",1
The urinary bladder is collapsed around a Foley catheter.,1
There is a small amount of free fluid in the pelvis near the bladder.,0
DOPPLER ULTRASOUND: Color and Doppler ultrasound was used to evaluate the vasculature of the transplant kidney.,1
"Arterial waveforms of the main renal artery, and the arcuate arteries in the upper, mid, and lower poles demonstrate an initial sharp upstroke, slight blunting in late systole, and forward flow in diastole.",1
Resistive indices range from 0.61 to 0.65.,0
Flow in the main renal vein demonstrates a normal waveform.,0
"Arterial supply to transplant kidney demonstrates slight blunting of arterial waveforms in late systole, but with a sharp initial upstroke, and good flow in diastole.",1
Small amount of free fluid in the (Over) 8:06 AM RENAL TRANSPLANT U.S.,1
PORT; -76 BY SAME PHYSICIAN # Reason: post-op u/s Admitting Diagnosis: ELEVATED WHITE BLOOD COUNT ______________________________________________________________________________ FINAL REPORT (Cont) pelvis.,0
Recommend short interval followup to re-assess arterial waveforms and hydronephrosis.,0
Findings discussed with Dr. at 12:10 p.m. on .,0
"PORT Clip # Reason: eval for hydronephrosis, cause of ARF Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with pancratitis, now with ARF REASON FOR THIS EXAMINATION: eval for hydronephrosis, cause of ARF ______________________________________________________________________________ FINAL REPORT INDICATION: Hydronephrosis and pancreatitis with acute renal failure.",1
"COMPARISON: CT abdomen and pelvis, .",0
"RENAL ULTRASOUND: The right kidney measures 11.5 cm, and the left kidney measures 12.0 cm.",0
"Within the mid/upper pole of the left kidney, two shadowing calculi are demonstrated measuring approximately 1.2 cm each.",0
There is no hydronephrosis or renal masses otherwise identified.,0
The urinary bladder is collapsed about a Foley catheter.,1
Two nonobstructing left renal calculi.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril / Diltiazem Attending: Chief Complaint: shortness of breath, dyspnea on exertion Major Surgical or Invasive Procedure: : 1.",0
"Bentall procedure with a 29-mm Freestyle valve graft, serial #, with coronary button reimplantation.",0
"Hemi-arch replacement and replacement of ascending aorta with a 28-mm Vascutek Gelweave single side-arm graft, catalog #, lot #, serial number .",0
History of Present Illness: Mr. is a 67 year male with known aortic aneurysm involving the root and ascending portion.,1
His PMH is notable for COPD and hypertension.,0
His aneurysm has been followed with yearly echocardiograms and CT scans.,0
"Given current size of 5.7 centimeters, he was referred by Dr. for cardiac surgical intervention.",0
Patient denies chest and back pain.,0
He has longstanding shortness of breath and dyspnea on exertion secondary to his COPD.,0
He does experience palpitations with exertion.,0
"Past Medical History: ascending aortic aneurysm, s/p Bentall Procedure PMH: chronic obstructive pulmonary disease Hypertension Hypercholesterolemia supra-ventricular tachycardia Intention Tremor, mostly right hand Chronic Back Pain Renal Cyst peptic ulcer disease Arthritis gastroesophageal reflux disease Social History: Retired machinist.",1
Active smoker - about 3 cigs/day.,0
Admits to 45 pack year history of tobacco.,0
"Family History: Non-contributory Physical Exam: Height: 6'3"" Weight: 196 lbs General: Appears well, lying flat post cath, in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Clear with some ronchi bilaterally Heart: RRR [x] Irregular [] - distant heart sounds Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Trace edema LLE Varicosities: None [x] Neuro: Alert and oriented, CN 2-12 grossly intact, no focal deficits Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT : 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: Pre-bypass: 1.",0
Well-seated bioprosthetic valve in the aortic position.,1
No AI; systolic gradient is trivial.,0
Ascending graft visible in the aortic positoion.,0
Aortic contour is normal in the descending aorta.,0
"06:00AM BLOOD WBC-7.6 RBC-2.65* Hgb-7.8* Hct-24.5* MCV-93 MCH-29.6 MCHC-32.0 RDW-13.4 Plt Ct-146* 12:09PM BLOOD WBC-12.0* RBC-2.85*# Hgb-9.2*# Hct-26.6*# MCV-93 MCH-32.4* MCHC-34.7 RDW-12.9 Plt Ct-139* , M 67 Radiology Report CHEST (PA & LAT) Study Date of 1:36 PM , FA6A 1:36 PM CHEST (PA & LAT) Clip # Reason: pl.eff MEDICAL CONDITION: 67 year old man s/p Bentall/hemiarch REASON FOR THIS EXAMINATION: pl.eff Final Report TWO-VIEW CHEST OF COMPARISON: .",0
INDICATION: Evaluate pleural effusion in postoperative patient.,0
FINDINGS: Cardiomediastinal contours are stable in appearance compared to previous postoperative radiographs.,0
"Small pleural effusions, right greater than left, are unchanged from the two most recent radiographs.",0
Minor atelectatic changes persist at the bases.,0
"On the lateral view, retrosternal gas and fluid is likely related to the recent sternotomy.",0
"Due to patient obliquity, it is difficult to exclude small loculated anterior hydropneumothorax, but no visible apical pleural line is evident on the corresponding frontal view.",0
High-grade compression deformity in the mid thoracic spine is unchanged since the preoperative study.,0
"IMPRESSION: Small pleural effusions, right greater than left with adjacent basilar atelectasis.",0
DR. Approved: 2:18 PM Imaging Lab 01:30PM BLOOD PT-15.0* PTT-45.7* INR(PT)-1.3* 12:09PM BLOOD PT-16.0* PTT-43.2* INR(PT)-1.4* 06:00AM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-133 K-4.1 Cl-93* HCO3-32 AnGap-12 03:31AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-135 K-4.8 Cl-104 HCO3-25 AnGap-11 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on where he underwent Bentall procedure as well as ascending aorta and hemi-arch replacement.,0
See operative note for further details.,0
POD#1 he was transferred to the step down unit for further monitoring.,0
Physical therapy was consulted to evaluate mobility and strength.,0
He continued to progress although he was not able to be weaned off of supplemental oxygen completely.,0
"As discussed with his pulmonologist, Mr. continued his inhalers and diuresis, and would require O2 arranged for discharge to home.",0
Postoperatively he had transient hyponatremia requiring free water restriction and diuresis to correct his electrolytes.,0
On POD# 6 he was cleared by Dr. for discharge to home.,0
"Medications on Admission: HCTZ 25 qd, Atenolol 100 qd, Amiodarone 200 qd, Nifedipine 30 qd, Pravastatin 40 qd, Advair prn, Trazadone 150 qd, Oxycontin 20-60 TID, Alendronate 70 qweek, Spiriva 18mcg daily, ASA 81mg po daily, Fluticasone 50mcg 2 sprays each nostril daily, Albuterol PRN Discharge Medications: 1.",0
Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed for insomnia.,0
Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours) as needed for pain.,0
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0* 6.,0
Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.,0
Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Disp:*60 Disk with Device(s)* Refills:*2* 13.,0
Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.,0
Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.,0
Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ampicillin Attending: Chief Complaint: epigastric pain Major Surgical or Invasive Procedure: None History of Present Illness: 83 yoF w/ a h/o CAD and CHF (EF 50%) presented with epigastric pain, intermittent x 3 days.",0
"She states that the pain is intermittent, not related to PO intake, no nausea or vomiting.",0
She has also felt some headache and some photophobia which has improved.,0
"She has had no blood in her stool or melena, she has been constipated lately.",0
She also complains of dysuria x 1 month.,0
"She denies any blurred vision, lightheadedness, syncope or presyncope.",0
She states she has chest pain but when she describes it futher it seems she is referring to her epigastric pain.,0
She currently has no other symptoms.,0
"2 units PRBC, 2 units FFP, vitamin K. She was given cipro for + u/a.",0
"In the ED, initial vs were: T 99.1 P 60 BP 129/40 R 20 O2 sat 98% RA Past Medical History: CAD s/p anterior apical MI and s/p stent in past Chronic systolic and diastolic CHF, EF 50% afib s/p PPM and ICD DMII- diet controlledHypertension Hyperlipidemia Asthma Left Trochanteric Bursitis Cataract left eye- s/p extraction Chronic renal insufficency, baseline creatinine 1.7 - 2.0 Venous stasis Recurrent LE cellulitis Social History: The patient is Polish and does not speak English.",1
"She lives alone, but is very close with her son and daughter-in-law is a employee at .",0
"No alcohol, drugs, or smoking.",0
"Family History: Noncontributory Physical Exam: Vitals: T: 97.2 BP: 125/72 P: 60 R: 15 O2: 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, conjunctiva pale Neck: supple, JVP elevated to the earlobe at 90 degrees, no LAD Lungs: diffuse wheezes bilaterally CV: Regular rate and rhythm, normal S1 + S2, HSM at the LLSB Abdomen: soft, non-tender, mildly-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.",0
trace pedal edema with evidence of chronic venous stasis changes.,1
"The lungs appear essentially clear bilaterally, aside from mild bibasilar plate-like atelectasis.",0
Atherosclerotic calcification along the thoracic aorta is noted.,0
Old right lower posterolateral rib fractures are again seen.,0
"EGD: Normal mucosa in the stomach (biopsy, biopsy) Otherwise normal EGD to third part of the duodenum Gastric mucosal biopsy: A. Gastric body: Antral/corpus type mucosa with chronic inactive inflammation.",0
B. Antrum: Chronic focally active gastritis.,0
Note: stain for H. pylori will be reported in an addendum.,0
"Colonoscopy: Normal mucosa in the whole colon Polyp at a distance between 80 cm and 65 cm in the colon Polyp at 20cm in the sigmoid colon (polypectomy) Grade 1 internal hemorrhoids Otherwise normal colonoscopy to cecum Brief Hospital Course: Assessment and Plan: 83 yoF w/ a h/o CAD and CHF (EF 50%) presents with epigastric pain, hct drop and supratherapeutic INR.",0
"# upper GIB / Anemia: baseline hct 30- , dropped to 19.",0
"INR was supratherapeutic, and aspirin and coumadin were held.",0
"Following transfusions with 2 units prbcs, hct responded to 26.2.",0
Acute hct drop likely related to GI bleed in the setting of an elevated INR and guiac positive stools.,0
No other history for bleeding.,0
NG lavage and EGD were negative.,0
Colonoscopy did not show any clear source of bleeding.,0
A video capsule study was performed to evaluate the small bowel for a source of bleeding -- resutls were pending at discharge.,0
Folate and B12 levels were wnl.,0
"She will need to have hct checks 2-3 times / week with results followed by her primary doctor, Dr. .",0
She will need to follow up restarting her aspiring for coronary artery disease with the discharge clinic.,1
She will need to follow up her lower GI bleed with Dr. GI.,0
She will need to follow up her anticoagulation with Dr. .,0
At discharge her hematocrit was stable and she was restarted on aspirin # a-fib: Currently a paced.,0
Coumadin and carvedilol were initially held then restarted.,0
She has a Chad2 score of 6 indicative of a high stroke risk.,0
Plan to discharge on aspirin only.,0
After HCT remains stable restarting coumadin should be considered.,0
"# CAD: the patient has a h/o CAD, s/p MI and s/p LCx mid and prox stending and mid LAD stenting in .",0
Cath w/o intervention in .,0
Asa was held and should be restarted at outpatient discharge clinic appointment if hct is stable.,0
Cardiac enzymes were cycled and remained normal to rule out cardiac source of pain.,0
# + u/a: the patient has had 1 month of dysuria.,0
urinalysis was consistent with infection.,0
she was treated for three day course with ciprofloxacin.,0
EKG was monitored and showed no signs of QT prolongation.,0
# ARF: baseline Cr 1.7 - 2.0. admitted with Cr of 2.2 w/ high BUN of 80.,0
"Received 1L IVF in ER, FFP, and 2units of PRBC.",0
Given 40mg PO lasix x 1 dose between blood transfusions.,0
High BUN may be secondary to GI bleed as well.,0
Her Cr normalized to 1.5.,0
# DM: Placed on insulin sliding scale in hospital.,0
# Asthma: The patient was wheezing on exam at admission.,0
She was given duonebs with good response.,0
"She appeared comfortable, sating well on room air and expiratory phase is not prolonged.",0
Code: Full Medications on Admission: Amiodarone 100 mg daily Lipitor 10 mg daily calcitrol 0.25 mcg three days a week carvedilol 25 mg twice a day Aranesp as directed by renal vitamin D once a week Pepcid 40 mg daily furosemide 40 mg daily warfarin aspirin 81 mg daily iron daily Discharge Medications: 1.,0
Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day).,0
Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime.,0
"Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week.",0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing.,0
Iron-B Cplx-B12-Liver Extract Intramuscular 13.,0
"Outpatient Lab Work Blood draw for HCT 2 times a week, starting .",0
"Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Anemia, Lower GI Bleed Secondary Diagnoses: Chronic systolic and diastolic dysfunction with LVEF of 50%; long-standing hypertension; atrial fibrillation currently controlled on low-dose amiodarone with cardioversion in the past; CAD with PCI/stenting; DM; stage IV chronic kidney disease secondary to hypertension (baseline Cr 1.7-2.0); sick sinus syndrome with symptomatic bradycardia s/p post dual chamber pacemaker in ; bronchitis; s/p cholecystectomy; anemia (baseline hct 30) Discharge Condition: Good.",1
Discharge Instructions: You were admitted to the hospital for fatigue and abdominal pain.,0
"On admission, your blood levels were low.",0
You were transfused 2 units of red blood cells and given fluids.,0
A nasogastric lavage was performed and did not show any signs of blood in your stomach.,0
Likewise an EGD did not show any source of bleeding in your upper GI tract.,0
Colonoscopy was performed and did not show any bleeding source from your colon.,0
Finally a video capsule study showed was performed to look for a source of bleeding in your small bowel.,0
The results from the capsule study were pending at discharge and you should follow up with the GI doctors.,0
At the time of admission your blood thinner (coumadin) was stopped since you were bleeding.,0
"You will need to follow-up with your primary care physician, .",0
", regarding restarting your coumadin.",0
You will have a visting nurse come to do blood checks 2 or 3 times per week.,0
You will need to follow up with Dr. GI regarding your lower GI bleed.,0
You were also noted to have a urinary tract infection and were treated with three days of antibiotics.,1
Adhere to 2 gm sodium diet The following changes were made to your medications: Your coumadin was stopped.,0
"If you experience any of the following symptoms you should call your doctor or go to the emergency room: blood in your stool, diarrhea, vomiting (especially blood in the vomit), light-headedness or dizziness, abdominal pain, chest pain, shortness of breath, fevers or chills.",0
Followup Instructions: You will need to follow-up with the following appointments: A visiting nurse will come to draw your blood.,0
Provider: POST CLINIC Phone: Date/Time: 10:30 a.m.. Before this appointment you should go to the lab and have your blood drawn for a hematocrit level.,0
Date/Time: 10:30 a.m.. You should discuss restarting your coumadin with Dr.,0
"Provider: , MD Phone: Date/Time: 2:00 pm.",0
4:48 AM CT HEAD W/O CONTRAST Clip # Reason: eval for SDH.,0
"Admitting Diagnosis: ATRIAL FLUTTER; CHF; CAD; RENAL INSUFFIENCY; DIABETES\ATRIAL FLUTTER ABLATION ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man S/P AF-Ablation with (on anticoag) and recent L Retroper bleed, possible progressive LLE weakness S/P falling out of bed, hitting left frontal region of head.",1
REASON FOR THIS EXAMINATION: eval for SDH.,0
CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ FINAL REPORT INDICATION: Lower extremity weakness status post fall.,1
"FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, shift of normally structures, or major vascular territorial infarcts.",1
There are again noted large territorial infarcts in the regions of the left MCA and right posterior branch of the MCA.,0
This is unchanged when compared to prior study.,0
The ventricles and sulci are stable.,0
BONE WINDOWS: Multiple bilateral lacunar infarctions in the thalami and basal ganglia.,0
The patient is status post left craniotomy.,0
The visualized portions of the paranasal sinuses and mastoid air cells are clear.,0
"4:38 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ALCOHOLIC HEPATITIS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with liver failure REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with liver failure, for followup.",1
The NG tube and the feeding tube passing below the diaphragm terminating in the stomach.,0
The right internal jugular line tip is at the mid SVC.,0
Heart size and mediastinum are stable.,0
The left lower lobe opacity appears to be increased since the prior study - atelectasis?,0
"On the other hand, there is overall decrease in the parenchymal opacities that might reflect interval improvement, although mild, of pulmonary edema.",1
"Overall, findings are not substantially different as compared to at least to , .",0
8:23 PM MR CERVICAL SPINE Clip # Reason: Evaluate or ligamentous injury.,0
______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman S/p MVC REASON FOR THIS EXAMINATION: Evaluate or ligamentous injury.,0
"______________________________________________________________________________ FINAL REPORT (REVISED) MRI OF THE CERVICAL SPINE: HISTORY: Pedestrian struck by truck, assess for ligamentous injury.",0
"TECHNIQUE: Axial T1, T2 and STIR images of the cervical spine were obtained with axial gradient echo scans of the C2-3 through C7-T1 interspaces.",0
"FINDINGS: Nearly all of the images, aside from the sagittal T1 weighted scans are of poor quality due to excessive amounts of patient motion.",0
"There is the impression of moderate edema within the subcutaneous fat, as best seen on the STIR images.",0
No overt mal-alignment of the component vertebrae is identified.,0
"At C3-4, a mild posterior disc protrusion contacts the ventral cord margin.",0
"At C4-5, a somewhat larger posterior disc protrusion causes moderate spinal cord compression.",0
There is moderate right sided neural foraminal narrowing due to an uncovertebral spur.,0
"At C5-6, a milder posterior disc protrusion is seen contacting the ventral cord margin.",0
A mild C6-7 postrior disc protrusion causes negligible neural compressive changes.,0
IMPRESSION: Suboptimal study as noted above.,0
"It is not possible, given this examination, to exclude ligamentous injury.",0
1:05 AM CT HEAD W/O CONTRAST Clip # Reason: eval for progression of bleed ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with left basal gangia bleed REASON FOR THIS EXAMINATION: eval for progression of bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: EEZ WED 1:37 AM focal left basal ganglia hemorrhage 17 x 35 mm.,0
No priors to compare with.,0
INDICATIONS: Left basal ganglial bleed.,0
NONCONTRAST HEAD CT: There is a focal 17 x 35 mm area of parenchymal hemorrhage located in the left basal ganglia with associated edema and mass effect.,0
"At this time, there is no evidence of subfalcine herniation.",0
There is prominence of the ventricles and sulci consistent with brain atrophy.,0
heights and white matter differentiation remains preserved over both cerebral convexities.,0
The basal cisterns are not effaced.,0
Osseous and extracranial soft tissue structures are unremarkable.,0
IMPRESSION: Focal 17 x 35 mm parenchymal hemorrhage in left basal ganglia.,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: evaluate PICC placement, pulled back Admitting Diagnosis: OVARIAN CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with placement of PICC line today REASON FOR THIS EXAMINATION: evaluate PICC placement, pulled back ______________________________________________________________________________ FINAL REPORT FINDINGS: The PICC line has been pulled back by about 3 cm.",0
It now projects over the superior vena cava.,0
"5:03 PM G/GJ TUBE CHECK Clip # Reason: please inject gastrogaffin to evaluate if g-tube in correct Admitting Diagnosis: ACUTE CORONARY SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with severe AS, hypotensive, cardiac arrest, intubated REASON FOR THIS EXAMINATION: please inject gastrogaffin to evaluate if g-tube in correct location just prior to kub.",1
______________________________________________________________________________ FINAL REPORT INDICATION: For evaluation of GJ-tube.,0
Contrast introduced via the tube demonstrates location within the body of the stomach.,0
No evidence of extraluminal contrast in this single view.,0
Height: (in) 62 Weight (lb): 183 BSA (m2): 1.84 m2 BP (mm Hg): 98/24 HR (bpm): 80 Status: Inpatient Date/Time: at 09:04 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
LEFT VENTRICLE: There is mild regional left ventricular systolic dysfunction.,0
AORTIC VALVE: There is no aortic valve stenosis.,0
TRICUSPID VALVE: No tricuspid regurgitation is seen.,0
There is mild regional left ventricular systolic dysfunction (Ejection Fraction 50%).,0
There is basal inferior wall hypokinesis.,0
The remaining segment contract well.,0
The aortic valve leaflets are not well visualized.,0
"MR W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: Please eval for epidural abscess while patient is under gene Admitting Diagnosis: URINARY TRACT INFECTION Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with staphylococcal bacteremia and unknown source (?epidural abscess on prev MRI but lots of motion artifact), only symptom is lumbar-level back pain.",1
Had knee replacement surgery in and hip ORIF in .,0
REASON FOR THIS EXAMINATION: Please eval for epidural abscess while patient is under general anesthesia before she goes to OR.,0
______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: Staphylococcal bacteremia low back pain knee replacement surgery in .,0
MRI OF THE LUMBAR SPINE WITH GADOLINIUM: The exam is compared to prior study of .,0
FINDINGS: Again is shown the evidence of increased disc signal at L5-S1 with increased signal in the bodies of L5 and S1 consistent with discitis and osteomyelitis.,0
There is epidural enhancing material extending up to L4 with some non-enhancing material indicating epidural abscess extending anteriorly onto the body of L5 and up to L4 on the right side.,0
The material at L4 of could be a separate extruded disc fragment from L4-5 but in this setting this most likely represents additional abscess.,0
There is moderate canal stenosis of L4-5 attributable to disc bulging and to ligamentous redundancy posteriorly.,0
There is a compression fracture of the superior endplate of T12.,0
There appears to be a sizeable right pleural effusion.,0
IMPRESSION: Discitis with osteomyelitis and epidural abscess at L5-S1 and probably at L4.,1
Fairly acute compression fracture of T12.,0
11:52 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ?,0
abscess Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: year old woman s/p exp.,0
"lap , now wbc 26 REASON FOR THIS EXAMINATION: ?",0
"abscess No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post exploratory laparotomy, , now with elevated white blood cell count.",0
TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic symphysis after the intravenous administration of Optiray.,0
"CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Moderate bilateral pleural effusions are increased from , along with increasing compressive atelectasis in the lower lobes and right middle lobe.",1
"Coronary artery, aortic, and mitral annular calcifications are again noted.",1
"The liver, spleen, pancreas appear unremarkable.",0
Slight fullness of the left adrenal gland is present without a definite nodule.,0
Two cysts in the left kidney appear unchanged.,0
Multiple loops of distended small bowel containing air-fluid levels are seen throughout the abdomen without a clear transition point.,0
The patient is status post prior right hemicolectomy.,0
"A large amount of stool and retained contrast is seen within the residual portion of the colon, particularly its most proximal segment near the ileocolic anastomosis.",0
"Just adjacent to the anastomosis, an approximately 3- cm long segment of colon shows circumferential peripheral tiny foci of gas.",0
"This most likely represents trapped bubbles of gas surrounding luminal contents, although pneumatosis could have a similar appearance.",0
There is no free intraperitoneal air and no mesenteric or portal venous gas.,0
"The aorta is normal in caliber with mural calcification consistent with atheromatous disease, and the proximal celiac and superior mesenteric arteries are patent.",0
Surgical clips in the anterior midline are consistent with patient's recent laparotomy.,0
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder and distal ureters appear unremarkable.,0
"A moderate amount of gas and a small amount of fecal material are seen in the colon, along with peripheral hyperdensity coating the mucosa thought to relate to barium residual from the previous CT examination of several days ago.",0
There has been right salpingo-oophorectomy and a small amount of fluid without a clear enhancing rim seen in the right adnexal fossa (2:62).,0
"Another small pocket of fluid is seen just adjacent to the left adnexum (2:63), which appears to be free within the pelvis and shows no (Over) 11:52 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ?",0
abscess Admitting Diagnosis: SMALL BOWEL OBSTRUCTION ______________________________________________________________________________ FINAL REPORT (Cont) enhancing rim.,0
Central hypodensity in the uterus could relate to a uterine fibroid.,0
A couple of punctate calcifications are again seen within the uterus.,0
Subcutaneous tissue stranding is consistent with anasarca.,0
BONE WINDOWS: Bone windows show degenerative change of the thoracolumbar spine and no lesions worrisome for osseous metastatic disease.,0
Dilated loops of small bowel and moderate amount of stool in the colon.,0
Findings are most suggestive of ileus.,0
"Focal area of peripheral circumferential gas within the colon, just adjacent to the ileocolic anastomosis, most likely represents gas trapped around luminal contents, as no other signs to suggest bowel ischemia are present.",0
Increased bilateral pleural effusions and atelectasis.,1
Small amount of fluid in the pelvis without evidence of abscess.,0
"Left adrenal gland prominence could relate to adenoma as previously suggested, although a focal nodule is not definitely visualized on today's examination.",0
"11:34 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for change from prior Admitting Diagnosis: PROBABLE ACUTE LEUKEMIA;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with AML now with worsening lung infiltrates and high fever REASON FOR THIS EXAMINATION: Please evaluate for change from prior ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: AML, now worsening lung infiltrates, high fever.",1
Comparison is made with prior study chest x-ray and chest CT .,0
There are no sizable pleural effusions.,0
Right IJ catheter remains in place.,0
"Diffuse, mainly peripheral and upper lobe ill- defined opacities are unchanged.",0
"IMPRESSION Although low lung volumes are slightly improved from prior study, multiple lung opacities are grossly unchanged.",0
"The differential diagnosis still includes drug reaction, multifocal pneumonia, cryptogenic organizing pneumonia, and opportunistic infection (PCP, ).",1
"6:37 PM CHEST (PA & LAT) Clip # Reason: Eval for consolidation Admitting Diagnosis: KYPHO/SCOLIOSIS; SPINAL STENOSIS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with ?PNA REASON FOR THIS EXAMINATION: Eval for consolidation ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST, : HISTORY: Pneumonia, evaluate for consolidation.",1
IMPRESSION: PA and lateral chest compared to : Left infrahilar consolidation is probably left lower lobe collapse.,0
"Small volume of pneumoperitoneum persists, and there is still gaseous intestinal distention seen in the upper abdomen.",0
6:31 AM CHEST (PORTABLE AP) Clip # Reason: s/p pacemaker placement ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with VT s/p mulitiple ablations.,0
ICD placement on complicated by difficult access and hypotension REASON FOR THIS EXAMINATION: s/p pacemaker placement ______________________________________________________________________________ FINAL REPORT INDICATION: ICD placement on .,0
"CHEST, SINGLE VIEW: Comparison study dated .",0
There is a dual chamber pacemaker whose leads are not changed over the interval.,0
There is interval appearance of linear atelectasis at left lung base.,0
IMPRESSION: 1) Cardiomegaly without heart failure.,1
2) Interval appearance of linear atelectasis at left lung base.,0
"3:18 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: ESOPHAGEAL PERFORATION, EVAL WITH THIN BARIUM.",0
Admitting Diagnosis: ESOPHAGEAL PERFORMATION Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with esophageal perforation REASON FOR THIS EXAMINATION: please perform w/ thin barium to assess for perf No contraindications for IV contrast ______________________________________________________________________________ WET READ: MPtb 4:28 AM Lower esophageal perforation with communication into right pleural space which contains gas and extravasated esophageal contrast.,1
Right pleural drain terminates laterally outside of pleural collection.,0
Small associated right apical PTX.,0
"Extensive atherosclerosis, including coronary disease.",0
Distended gallbladder probably due to NPO status.,0
D/w Dr. at 420AM .,0
______________________________________________________________________________ FINAL REPORT INDICATION: 80-year-old woman with esophageal perforation.,0
TECHNIQUE: MDCT images of the torso were obtained with oral contrast only.,0
The lack of intravenous contrast limits evaluation of the solid organs.,0
Multiplanar reformations were essential to interpretation.,0
CHEST: An endotracheal tube terminates above the carina.,0
There is slight expansion of the trachea at the level of the inflated balloon.,0
"A nasogastric tube terminates at the gastroesophageal junction, within a moderate hiatal hernia.",0
A right-sided central venous catheter terminates in the distal superior vena cava.,0
Oral contrast partially opacifies the esophagus.,0
"Just below the tracheal bifurcation, there is a tract of oral contrast (2, 32) that extends into the right pleural space, which contains a moderate collection of oral contrast and air.",0
The right chest tube has cranial course and terminates in the right lateral pleural space.,0
"However, its tip is not within the collection.",0
Additional pleural air is seen in the right apex.,0
There is moderate consolidated lung adjacent to the pleural collection.,0
"A small left pleural effusion appears simple, and adjacent consolidated lung is presumed to represent atelectasis.",0
A small calcified granuloma is seen in the atelectatic left lower lobe.,0
"Calcification of the aorta, coronary arteries, and mitral annulus is extensive.",0
The left atrium is enlarged.,0
The left lower lobe of the thyroid gland is also slightly enlarged.,0
There is no definite thoracic adenopathy.,0
"ABDOMEN: There is an ill-defined 13-mm region of low attenuation in the liver (Over) 3:18 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: ESOPHAGEAL PERFORATION, EVAL WITH THIN BARIUM.",0
"Admitting Diagnosis: ESOPHAGEAL PERFORMATION Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) adjacent to the gallbladder fossa (2, 65).",0
There is no intra-hepatic biliary ductal dilatation.,0
"The common duct is prominent, measuring 10.5 mm in the pancreatic head region.",0
"The spleen, pancreas, and adrenal glands are within normal limits.",0
The right kidney is shrunken.,0
The left kidney contains a 15-mm nonobstructing calculus in the renal pelvis.,0
"A subcentimeter low attenuation lesion in the left posterior interpolar cortex is too small to characterize, but may represent a cyst.",0
"The left kidney itself has an unusual contour, which is most apparent in the coronal plane.",0
There is no definite bowel dilatation or free fluid within the abdomen or pelvis.,0
Scattered retrocrural nodes measuring up to 10 mm in short axis may be reactive in nature.,0
"The abdominal aorta is tortuous, with extensive calcification.",0
There is abrupt narrowing of both common iliac arteries.,0
Patency cannot be assessed on this unenhanced study.,0
PELVIS: Evaluation is significantly limited by streak artifact from bilateral hip prostheses.,0
The uterus is not seen.,0
A Foley catheter is present in the decompressed bladder.,0
"Large segments of the bowel cannot be evaluated, including the rectum and sigmoid.",0
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions.,0
"However, there is diffuse osteoporosis, with deformities of humeral necks, compatible with prior fracture.",0
"Multiple moderate-to-severe compression deformities are seen throughout the lower thoracic and lumbar spine, of indeterminate age.",0
"Gross esophageal perforation, with extravasation of oral contrast and air into the right pleural space.",0
The right chest tube is currently not lying within the pleural collection.,0
"Nasogastric tube terminating at the gastroesophageal junction, within a moderate hiatal hernia.",0
The tube should be advanced several centimeters.,0
"Distended gallbladder, prominent common duct, unusual contour of the left kidney, and focal low attenuation within the gallbladder fossa.",0
"These findings can be further assessed with ultrasound, to exclude gallbladder pathology, a left renal mass, and a focal hepatic lesion.",0
"7:18 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: pneumo, new rib fx?",0
"Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with asystole arrest, cpr REASON FOR THIS EXAMINATION: pneumo, new rib fx?",0
______________________________________________________________________________ WET READ: MBue FRI 8:38 PM lines and tubes in appropriate position.,0
rt perihilar and and mid lung opacities may reflect contusions secondary to multiple rt sided rib fractures.,1
linear opacity left base could reflect atelectasis.,0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Question rib fracture.,0
FINDINGS: The monitoring and support devices are in unchanged correct position.,0
Right perihilar and right mid lung opacities may reflect areas of contusion secondary to multiple right-sided rib fractures.,1
Right basal linear opacities are likely to represent atelectasis.,0
No evidence of newly occurred changes.,0
"5:52 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate Admitting Diagnosis: ESOPHAGEAL CANCER & TRACHEOESOPHAGEO FISTULA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man s/p bronchoscopy REASON FOR THIS EXAMINATION: please evaluate ______________________________________________________________________________ WET READ: 8:36 PM REDEMONSTRATION OF RT PARENCHYMAL OPACITIES, SMALL EFFUSIONS, AND HYPERLUCENCY OF LEFT LUNG W/O EVIDENCE OF PTX.",1
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Status post bronchoscopy.,0
Comparison is made with prior study performed the same day earlier in the morning.,0
Small basal right pneumothorax is unchanged.,0
Right upper lobe and right mid lobe opacities have worsened.,0
ET tube tip is in the standard position.,0
NG tube tip remains in place.,0
Right basal pig catheter is in place.,0
Multiple skin staples are again noted in the right neck.,0
"7:27 AM CHEST (PORTABLE AP) Clip # Reason: eval for pulm edema, pna.",0
"Admitting Diagnosis: BRADYCARDIA SHOCK ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with CAD s/p CABG and cath/stent in past, recent admissions for chf exacerbation and MI's, now with complete heart blocks, indwelling subclavian lines bilat, hypotensive s/p intubation.",0
"REASON FOR THIS EXAMINATION: eval for pulm edema, pna.",0
______________________________________________________________________________ FINAL REPORT HISTORY: Hypotension.,0
"PORTABLE AP CHEST, ONE VIEW: Comparison is made to study of 1 1/2 hours earlier.",0
The patient is status post sternotomy.,0
"There is mild vascular congestion with perihilar haze, consistent with mild CHF.",0
There are probable small bilateral effusions.,0
There is no focal area of consolidation to suggest pneumonia.,0
There is a double lumen right central line with tip in the right atrium.,0
IMPRESSION: Cardiomegaly with mild CHF.,0
I doubt the presence of underlying pneumonia.,0
8:53 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with thalamic bleed, htn REASON FOR THIS EXAMINATION: ?",0
"infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: CVA, ?",0
TECHNIQUE: Single portable AP view of the chest without comparisons.,0
FINDINGS: Endotracheal tube is placed in suitable position with the tip 3 cm from the carina.,0
"There is an NG tube with the tip in the stomach, and the side port just below the diaphragm.",0
Vascular calcification within the aorta is noted.,0
"There is opacification of the left lower lobe, with air bronchograms and loss of the left diaphragmatic border.",0
These are consistent with pneumonia.,0
No other focal pulmonary opacities or pleural effusions identified.,0
", T. PSURG TSICU 5:51 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Assess reduction.",1
"Please mark p Admitting Diagnosis: FACIAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 25 year old woman with multiple facial fractures, s/p ORIF/plating REASON FOR THIS EXAMINATION: Assess reduction.",1
Please mark plates/implants in color on reconstructions.,0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Status post fixation of multiple facial fractures.,1
3:22 PM PORTABLE ABDOMEN Clip # Reason: DHT placement Admitting Diagnosis: AORLTIC STENOSIS\AORTIC VALVE REPLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with AVR/MSOF REASON FOR THIS EXAMINATION: DHT placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Dobbhoff tube placement.,1
Portable AP radiograph of the abdomen was reviewed in comparison to .,0
"The Dobbhoff tube tip is seen most likely in the duodenum, but given significant rotation of the patient on this radiograph, it cannot be entirely evaluated.",0
A rectal tube is most likely present.,0
Contrast is noted throughout the colon.,0
"7:31 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Evaulate RLL collapse, exclude pneumothorax Admitting Diagnosis: MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with resp failure, increased pulm secretions s/p bronch REASON FOR THIS EXAMINATION: Evaulate RLL collapse, exclude pneumothorax ______________________________________________________________________________ WET READ: JRCi WED 8:57 PM Removal of right subclavian line with introduction of new left subclavian line with tip a jxn of left subclavian vein and SVC.",1
ETT 3.3 cm from carina.,0
Lower lobe atelectasis and collapse persists since chest radiograph from the same date.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of right lower lobe collapse.,0
"Portable AP chest radiograph was compared to , obtained at 05:48 p.m.",0
The ET tube tip is 3.5 cm above the carina.,0
"There is interval increase in right lower lobe opacity accompanied by pleural effusion with some degree of consolidation seen at the left base as well, grossly unchanged compared to prior studies and most likely representing a combination of bibasilar consolidations and pleural effusion.",0
7:11 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx Admitting Diagnosis: PAPILLARY RUPTURE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman s/p Sternal Closure s/p MVR CT to water seal REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT STUDY: AP upright portable chest x-ray from 07:55 a.m.,1
There has been interval removal of an ETT.,0
A chest tube is projected over the left thorax in good position and there is no pneumothorax.,0
A left subclavian line terminates with tip overlying the distal SVC.,0
A nasogastric feeding tube is seen to pass within the stomach and coils within the upper abdomen out of view of the film.,0
There is persistent right lower lobe atelectasis.,0
There is an increase in left lower lobe atelectasis and an underlying infiltrate cannot be excluded.,0
There ies small left pleural effusion.,1
There are multiple median sternotomy wires overlying the midline of the thorax.,0
IMPRESSION: Interval removal of endotracheal tube.,0
Increased in left lower lobe atelectasis that is new compared to and an underlying infiltrate cannot be excluded.,0
"2:32 PM VIDEO OROPHARYNGEAL SWALLOW PORT Clip # Reason: eval for safety of taking pos Admitting Diagnosis: SVA CLOT;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with SVC, ?",0
bedside S/s eval REASON FOR THIS EXAMINATION: eval for safety of taking pos ______________________________________________________________________________ FINAL REPORT INDICATION: An 83-year-old male with SVC syndrome.,0
FINDINGS: A radiologist was present to assist the speech pathologist in the performance of a video oropharyngeal swallow examination.,0
There is a moderate to severe oral dysphagia.,0
"There is reduced bolus formation with purees and solids, as well as reduced bolus control with thin liquids leading to premature spillover.",0
"There is tongue pumping with decreased anterior-posterior tongue movement, and increased oral transit time.",0
There is moderate residue in the oral cavity to purees.,0
"The pharyngeal phase of swallow shows a mild decrease in initiation of swallow, but better with larger boluses.",0
"There is mildly reduced laryngeal elevation, and normal epiglottic deflection.",0
There is consistent penetration to thin liquids during the swallow.,0
Trace aspiration from continued penetration was noted towards the end of the study.,0
"There was no spontaneous cough, and cued cough was ineffective to clear aspirate material.",0
"IMPRESSION: Moderate to severe oral dysphagia, and mild pharyngeal dysphagia with consistent penetration to thin liquids leading to trace aspiration.",0
Please see the speech pathology report in the OMR notes for further details and recommendations.,0
"10:29 PM CHEST (PORTABLE AP) Clip # Reason: centra line placement ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with Hx of fever, increasing O2 req,tachypnea for 2 days s/p ct placment for rt sided effusion s/p central line placement REASON FOR THIS EXAMINATION: centra line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 62 year old woman with history of fever, increasing 02 requirement and tachypnea.",0
"Status-post chest tube placement, central line placement.",0
AP PORTABLE UPRIGHT VIEW OF THE CHEST performed at 22:37 hours.,0
Comparison is made with prior study performed at 18:52 hours.,0
"A right IJ catheter has been placed in the interval, its tip is present in the region of the cavoatrial junction.",0
Right pneumothorax is unchanged in size.,0
A right-sided chest tube is present with a sideport outside of the thorax.,0
Endotracheal tube is approximately 1 cm above the carina.,0
Findings were called to the floor at 8:30 a.m.,0
"11:43 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval fluid status/pulm edema Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: year old man with hyperkalemia, low bicarb, acute MI, eval fluid status prior to giving large fluid volume with bicarb REASON FOR THIS EXAMINATION: eval fluid status/pulm edema ______________________________________________________________________________ FINAL REPORT AP CHEST 11:47 A.M., .",1
"HISTORY: Hyperkalemia, acute MI, and volume overloaded.",0
"IMPRESSION: AP chest compared to and 6: Pulmonary edema has changed in distribution, and only mildly improved, more pronounced in the right lung at the base than the left.",0
Small right pleural effusion is stable.,0
Tip of the right jugular line projects over the upper SVC and a nasogastric tube ends in the stomach.,0
Severe degenerative change of the right shoulder.,0
"11:06 PM CHEST (PORTABLE AP) Clip # Reason: verify tube placement pre- angio chest x-ray ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with ET Tube, large intercranial hemmorhage REASON FOR THIS EXAMINATION: verify tube placement pre- angio chest x-ray ______________________________________________________________________________ FINAL REPORT INDICATION: 76-year-old woman with ET tube placement and the large intracranial hemorrhage.",1
SUPINE RADIOGRAPH OF THE CHEST: The tip of the ET tube projects 1 cm above the carina.,0
The distal end of the NG tube projects at the level of the distal esophagus.,0
The cardiomediastinal silhouette appears normal.,0
There is central pulmonary vascular congestion.,0
No pleural effusion or pneumothorax is detected.,0
Left retrocardiac atelectasis is noted.,0
Right upper quadrant clips are noted.,0
ET tube is 1 cm above the carina should be retracted.,0
NG tube projects at the expected location of distal esophagus and advancement is recommended.,0
A follow up radiograph obtained several hours later demonstrates adequate position of NG tube.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / Codeine / Bactrim Ds Attending: Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 56F with EtOH cirrhosis initially found unresponsive in AM 3d ago.,0
"FSBGs 200s, no e/o sz, and initially intubated on arrival to the ED for airway protection.",0
"CT head was negative, LP deferred coagulopathy.",0
"with h/o of poor compliance with encephalopathy meds and mutliple admissions in past for AMS, though pt.",0
reports compliance with meds and BMS/day.,0
was extubated yesterday without complication and has had no e/o withdrawal on this admission (per pt.,0
with dirty U/A on admit and sputum cx.,0
"growing G+ cocci, and was placed on meropenem as has allergies to penicillins/levo.",0
"EtOH cirrhosis- dx , pt of Dr. , esophageal varices grade II in , h/o encephalopathy on lactulose and rifaximin with multiple admissions for altered mental status due to med noncompliance, h/o ascites now on diuretics, not a transplant candidate given active EtOH use 2.",1
"EtOH abuse- for ~40 years, + h/o DTs 3.",0
"?upper GI bleed hx Social History: lives with uncle and sister, on disability for cirrhosis, used to work as nurse's aide; drinks pint gin per day x40y, even heavier EtOH use in the past, last in ; 20 pack-yr history of tobacco abuse; denies IVDU Family History: non-contributory Physical Exam: Vitals: T 97.3, BP 108/65, HR 73, 20, O2sat 99% on 4L General: elderly AA woman, NAD HEENT: PERRL, EOMI, OP clear, sl.",1
"dry MM Neck: supple, no JVD, no Pulm: Crackles at L base, sl.",0
"coarse at R base, otherwise clear CV: RRR, nl S1S2, no MRGs Abd- distended but soft, dullness to percussion laterally, non tender Extrem- Trace LE edema Neuro- AA&O X 3, CN II-XII frossly intact.",0
"IMPRESSION: There is no definite evidence for pneumonia, and there is a slightly improved appearance to the pulmonary vasculature compared to prior study suggesting improved fluid status.",0
"Brief Hospital Course: A/P: 56F with decompensated EtOH cirrhosis w/ encephalopathy and esophageal varices, admitted to ICU after being found down, intubated.",1
"# Altered mental status: Likely hepatic encephalopathy, PA lateral CXR negative, sputum cx.",1
"Has had multiple admissions for encephalopathy med noncompliance, though pt.",0
and family report compliance with meds and 2-3 times daily BMs.,0
"pain, with minimal ascites, so unlikely SBP.",0
"Sputum gram stain with G+ cocci, but cultures negative and no e/o PNA on CXR.",0
Tox screen negative on admission.,0
"- continued lactulose q6h with PRN lactulose enemas - continued rifaximin, ursodiol at outpatient dose - MVI/thiamine/folate Pt.",0
's mental status cleared quickly and pt.,0
was sent home on increased lactulose/rifaxamin to prevent encephalopathy.,0
"# Respiratory failure: intubated for airway protection, as initially unresponsive, MS quickly improved with lactulose, and pt.",0
"# EtOH cirrhosis: Decompensated with encephalopathy, ascites, and varices.",1
"Last EGD , no known h/o melena or BRBPR, guaiac negative on exam.",0
Tbili trended down during admission.,0
"# Anemia: baseline wanders from 25-->36, hct stable during admit.",0
Medications on Admission: CALCIUM CARBONATE 500 mg tid FLUOXETINE 20 MG qd FOLIC ACID 1 MG qd IBUPROFEN 800 MG tid prn K-DUR 20 mEq MAGNESIUM OXIDE 400 mg MULTIVITAMIN qd PREVACID 30 mg qd RIFAXIMIN 400 mg tid SPIRONOLACTONE 50 mg qd THIAMINE HCL 100MG qd URSODIOL 300 mg tid VITAMIN D 800 unit qd LACTULOSE 2 TB qid Discharge Medications: 1.,0
Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
"Lansoprazole 30 mg Capsule, Delayed Release(E.C.)",0
Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily).,0
Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours).,0
"Disp:*90 Tablet, Chewable(s)* Refills:*2* 13.",0
K-Dur 20 mEq Tab Sust.Rel.,0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: hepatic encephalopathy alcoholic cirrhosis Secondary: hypertension anemia gastroesophageal reflux disease Discharge Condition: Good.,1
The patient's mental status has returned to baseline.,0
"Taking POs, ambulating, satting >94% on room air Discharge Instructions: Please take all medications as prescribed.",0
It is especially important to take your lactulose and rifaxamin so that you have at least 3 loose bowel movements a day.,0
Please follow-up with your appointments as below.,0
"Please contact your doctor or go to the emergency room if you experience: --confusion --stomach pain --nausea or vomiting --fevers or chills --shortness of breath --chest pain Followup Instructions: Liver physician: : , MD Phone: Date/Time: 10:15 Primary care physician: : , MD Phone: Date/Time: 1:30 MD, MSC, MPH",0
"10:52 AM BILIARY CATH CHECK Clip # Reason: Please replace biliary catheters (left and right) with new c Admitting Diagnosis: DIABETIC KETOACIDOSIS Contrast: OPTIRAY Amt: 60 ********************************* CPT Codes ******************************** * CHANGE PERC BILIARY DRAINAGE C CHANGE PERC BILIARY DRAINAGE C * * -59 DISTINCT PROCEDURAL SERVICE BILIARY BIOSPY VIA T-TUBE * * BILIARY BIOSPY VIA T-TUBE -59 DISTINCT PROCEDURAL SERVICE * * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with pancreatic CA, DKA, n/v.",0
REASON FOR THIS EXAMINATION: Please replace biliary catheters (left and right) with new catheters.,0
Please perform biliary tree BRUSHINGS for pathology/cytology.,0
______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 57-year-old woman with history of pancreatic cancer and obstructive jaundice.,0
Patient has indwelling 6 French pigtail catheters in the left hepatic and the common bile duct from Right side access.,0
Patient is due for routine catheter change and was recently admitted to hospital with DKA.,0
A request was placed for biliary catheter check and change as well as brushings for cytology.,0
Dr. is the attending radiologist who was present and supervising throughout.,0
ANESTHESIA: Moderate sedation was provided by administering divided doses of 150 mcg of fentanyl and 2 mg of Versed throughout the total intraservice time of 75 minutes during which the patient's hemodynamic parameters were continuously monitored.,0
Local anesthesia with 1% lidocaine and lidocaine gel.,0
Patient was brought to the angiography suite and placed supine on the imaging table.,0
The right upper quadrant including the existing biliary catheters were prepped and draped in the usual sterile fashion.,0
Initial scout image of right upper quadrant was obtained demonstrating the existing right and left external biliary catheters in the satisfactory position.,0
Contrast injection through the left-sided catheter demonstrated filling of the right and left intrahepatic biliary tree.,0
There is mild dilatation of the left hepatic duct.,0
Injection to the right duct demonstrated filling of both intra- and extra-hepatic biliary system with no evidence of dilatation.,0
Contrast was noted to be freely flowing into the small bowel both through and around the catheter.,0
"First, left duct was cut and removed over wire.",0
"A 6 French x 26 cm Tip sheath was placed over the wire and a second wire, a .035 (Over) 10:52 AM BILIARY CATH CHECK Clip # Reason: Please replace biliary catheters (left and right) with new c Admitting Diagnosis: DIABETIC KETOACIDOSIS Contrast: OPTIRAY Amt: 60 ______________________________________________________________________________ FINAL REPORT (Cont) Glidewire, was placed into the left biliary system through the Tip sheath.",0
"The sheath was then removed over both wires and replaced over the Glidewire, the wire acting as a safety wire.",0
"After removing the glidewire, two samples of brush biopsies were obtained from the left hepatic duct and the confluence of right and left hepatic ducts.",0
The sheath was removed leaving the wire in the left biliary ducts.,0
"Next, right pigtail catheter was cut and removed over wire.",0
"The 6 French x 26 cm Tip sheath was placed over the wire and used to place a second wire, 0.035 Glidewire.",0
The sheath was removed over both wires and replaced over the Glidewire with the wire acting as a safety wire.,0
A over-the-wire cholangiogram was performed through the sheath again demonstrating free contrast flow into the small bowel through the hepaticojejunostomy.,0
"Then, through the Tip sheath, two samples of brushings were obtained from the common bile duct and area of anastomosis and sent for cytology.",0
Then the sheath was removed and 6 French pigtail catheters with extra side holes cut were placed over both the wires.,0
Left-sided catheter pigtail was formed and locked in the left hepatic duct after removing the guidewire.,0
The right-sided catheter pigtail was formed in the small bowel and locked after removing the wire.,0
Contrast injection through both catheters demonstrated satisfactory position with free contrast flow into the small bowel.,0
Catheters were flushed and secured to skin with 0 silk sutures.,0
The left-sided catheter was secured in addition with a StatLock device.,0
Both the catheters were connected to external drainage bags.,0
Patient tolerated the above procedure well and there were no immediate complications.,0
Cholangiograms through the existing biliary catheters as well as over the wire cholangiogram demonstrating mild dilatation of the left hepatic duct and free passage of contrast material into the small bowel through the hepaticojejunostomy.,0
"Two sets of separate brushing samples were obtained for cytology, the first set from left hepatic duct and confluence of left and right hepatic ducts.",0
The second set was from common bile duct.,0
Left external biliary catheter was placed with a modified 6 French pigtail catheter and connected to an external drainage bag.,0
"A 6 French pigtail catheter was replaced on the right side, which was modified by cutting extra side holes to act as an internal-external drain.",0
The pigtail was formed and locked inside the bowel loop.,0
(Over) 10:52 AM BILIARY CATH CHECK Clip # Reason: Please replace biliary catheters (left and right) with new c Admitting Diagnosis: DIABETIC KETOACIDOSIS Contrast: OPTIRAY Amt: 60 ______________________________________________________________________________ FINAL REPORT (Cont),0
"8:58 PM CHEST (PORTABLE AP) Clip # Reason: Intubated, with pneumonia, evaluate progression of infiltrat ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with above REASON FOR THIS EXAMINATION: Intubated, with pneumonia, evaluate progression of infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: 70 y/o man with pneumonia.",0
CHEST: A single AP chest radiograph is provided.,0
An ETT is in place with its tip approximately 7 cm above the carina.,0
A Swan-Ganz catheter has tip that terminates in the descending right pulmonary artery.,0
Dual lead pacer tips are in appropriate position.,0
Multifocal patchy opacities are identified diffusely throughout the lungs.,0
Layering effusions are present bilaterally.,0
IMPRESSION: Multifocal patchy opacities consistent with pneumonia.,0
Bilateral layering effusions are present.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: UROLOGY HISTORY OF PRESENT ILLNESS: Mr. is a 53 year old male with a diagnosis of muscle invasive Grade II to III/III bladder carcinoma.,0
"In addition, his prostatic urethral biopsies had been positive for carcinoma in situ.",0
He is status post transurethral resection of bladder tumor and BCG therapy.,0
His pathology sides have been reviewed here at the and have shown a micro-papillary variant which tends to be very aggressive.,0
He had undergone MVAC chemotherapy with Dr. .,0
"At this time, he presents for discussion for his continent urinary diversion.",0
His cystoprostatectomy will be performed by Dr. .,0
"He had a CT scan and bone scan in , prior to his chemotherapy that showed no evidence of metastatic disease.",0
He had a recent prostate biopsy because of a prostatic nodule which showed no malignancy.,0
Diet controlled type 2 diabetes mellitus.,1
MEDICATIONS: He is on no medications except a multivitamin.,0
Transurethral resection of bladder tumor.,0
SOCIAL HISTORY: He quit smoking eight years ago.,0
He does have a 30 pack year smoking history previous to that.,0
He is a district service manager for the Steris Company.,0
He drinks two to three caffeinated drinks per day and one to two alcoholic beverages per day.,0
FAMILY HISTORY: Significant for his father with a history of lung cancer and a sister with diabetes mellitus.,1
ALLERGIES: Allergies are a questionable possible allergy to Ampicillin.,0
REVIEW OF SYSTEMS: Review of systems on pre-surgical evaluation showed mild urinary urgency after BCG treatment and had decreased erectile function.,0
PHYSICAL EXAMINATION: Vital signs were 130/88; pulse 78 and regular; respiratory rate was 16 and unlabored.,0
"Abdomen soft, nontender, no palpable masses.",0
"Genitourinary: Normal phallus, meatus and testes.",0
Rectal: Normal tone; 40 gram prostate.,0
Nodularity in the left prostatic lobe.,0
Extremities and Neurological: Moves all four extremities without difficulty.,0
"LABORATORY: White blood cell count 6.7, hematocrit 35, platelet count 267, BUN and creatinine are 20 and 1.0.",0
Urinalysis dipstick was three plus glucose; otherwise unremarkable.,0
"Given this preoperatively assessment, he was given a NuLYTELY bowel prep and erythromycin and Neomycin based antibiotics preoperatively.",0
He had a preoperative CT scan repeated that did not show any evidence of metastatic disease at that time.,0
"HOSPITAL COURSE: On , he came to the and underwent a radical cystoprostatectomy with bilateral pelvic lymph node dissection and a continent cutaneous diversion.",1
"This was performed by Dr. and also Dr. , with assistant of Dr. .",0
This was done under general endotracheal anesthesia.,0
Approximately ten liters of fluids were utilized interoperatively and the patient had a 1500 cc.,0
"Urine output was not complete measured but was thought to be ""very good"" per the Anesthesia Record.",0
He did receive two units of autologous blood interoperatively and received Clindamycin and Gentamicin for antibiotics during the case.,0
"Specimens from the case included bladder, prostate, bilateral pelvic lymph nodes, ureteral cuff margins bilaterally.",1
"Drains were the suprapubic tube, the diversion tube, bilateral stents, - times two, a subclavian line and an arterial line.",0
Findings overall were that of a normal anatomy.,0
"He was discharged, intubated, to the Post Anesthesia Care Unit and ultimately to the Intensive Care Unit.",0
His pain was being controlled with an epidural and he was otherwise feeling okay.,0
He was noted to have some mild hypotension immediately postoperatively in the 70s.,0
He was resuscitated with aggressive normal saline boluses.,0
His postoperative hematocrit was 32.,0
"Sodium was 138, potassium was 4.8, BUN and creatinine were 17 and 1.0.",0
His epidural was titrated back to help enhance his blood pressure.,0
His Propofol was weaned off to extubation.,0
The neobladder had flushes serially with normal saline and he was maintained on Clindamycin and Gentamycin for 48 hours postoperatively.,0
X-rays showed no pneumothorax and he had a left subclavian line that was in appropriate position.,0
"Over the next 48 hours, the patient had some low grade temperatures to 100.5 and 100.8 F., respectively.",0
He was requiring significant fluid boluses to keep his mean arterial pressure in the 50s to 70s.,0
Central venous pressures were measured to be around 12.,0
"Ultimately, his urine output through his suprapubic tube picked up.",0
He was transferred to the Floor on postoperative day number two.,0
His hematocrit at this time was 23.9.,0
He was given an additional two units of packed red cells.,0
His arterial line had been discontinued by this point.,0
He had a right internal jugular at this time; it was a new site and stick that was placed.,0
"He had two ureteral stents, a Foley catheter and a suprapubic tube.",0
"His epidural was still being utilized, but it had been titrated back and he was now on a total regimen of epidural and PCA for pain control.",0
"He had had a low-grade temperature to 100.3 F., the night before, but was ultimately deemed stable and appropriate for discharge, and sent to the Floor.",0
"On postoperative day number three, he was off antibiotics, feeling well with no pain.",0
His post transfusion hematocrit was 27.3.,0
His BUN and creatinine were 12.0 and 0.7 respectively.,0
His examination was otherwise benign.,0
He was now walking and out of bed without assistance.,0
He was learning to care for his drains.,0
"Over the next three to four days postoperatively, the patient did well.",0
He ultimately passed gas by postoperative day six.,0
"At this time, his diet was advanced.",0
He was being controlled for pain with a PCA.,0
He was tolerating a clear liquid diet.,0
"At this point of his postoperative course, the stents had essentially all but fallen out on their own, so they were discontinued.",0
"The - outputs had dropped off on the left side, but the right - was noted to increase immediately after the stent removal.",0
The fear for a possible urine leak status post stent removal was investigated and creatinine values on the - drains were drawn.,0
They were showing to be 0.6 on the right side and 0.4 on the left.,0
This all but practically refutes a possible urine leak.,0
"The patient did very well over the next couple of days and ultimately, by postoperative day number eight, he was afebrile with a temperature of 98.6 F., pulse 80, blood pressure 140/90; respiratory rate was 20 with 98% room air saturation.",0
He was tolerating a regular diet.,0
His fluids had been Hep-locked.,0
He was making over a liter and a half of urine through the suprapubic tube.,0
"His right - outputs were averaging 100 to 150 q. shift, and his left - out between 30 and 50 cc.",0
"Blood sugars were adequately controlled just on diet, ranging 106 to 112.",0
His examination was otherwise unremarkable.,0
His wound is well approximated with no drainage.,0
Steri-Strips were in place at this point postoperatively.,0
He did have bowel sounds and he was soft and flat otherwise.,0
- sites were secure times two.,0
Suprapubic tube was additionally in place draining yellow urine.,0
The remainder of his examination was unremarkable.,0
"At this point, he was deemed appropriate and stable for discharge.",0
"Percocet 5/325, one to two tablets p.o.",0
q. four to six p.r.n.,0
He will receive 30 to 40 cc.,0
of normal saline flushes with pull-back gently through the suprapubic tube three times a day and p.r.n.,0
- care and output recordings.,0
He will receive a visiting nurse him with these tasks.,0
Follow-up instructions will be to see Dr. in approximately one to two weeks.,0
He will have a cystogram to test the patency of the neobladder in approximately two weeks from time of discharge.,0
He will not be accessing his Foley catheter at that time in his continent cutaneous diversion.,0
This will be only accessed in the presence of Dr. in the office.,0
"The patient is going to be required to have follow-up with Dr. as well as Dr. , that his plan of care can be coordinated.",0
"PATHOLOGY: Final pathology was pending, and please refer to the interim pathology specimen report that is in the computer.",0
Dictated By: MEDQUIST36 D: 17:49 T: 18:17 JOB#:,0
"4:46 PM CHEST (PRE-OP PA & LAT) Clip # Reason: PARAGANGLIONOMA OF ABDOMEN/SDA Admitting Diagnosis: PARAGANGLIONOMA OF ABDOMEN/SDA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with right paraganglionoma, scheduled for resection AM.",0
REASON FOR THIS EXAMINATION: Please evaluate for peri-operative safety.,0
______________________________________________________________________________ WET READ: 7:48 PM No acute intrathoracic process.,0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPHS HISTORY: Right paraganglioma, pre-operative resection.",0
"TECHNIQUE: Chest, PA and lateral.",0
"Shortly after the study, Dr. provided a preliminary interpretation that stated: ""No acute intrathoracic process.",0
The aortic arch is partly calcified.,0
The mediastinal and hilar contours are otherwise unremarkable.,0
There is a prior healed left posterolateral seventh rib fracture.,0
Small anterior osteophytes are present throughout the thoracic spine.,0
IMPRESSION: No evidence of acute disease.,0
"10:27 AM CHEST (PA & LAT) Clip # Reason: s/p cabg, r/o chf Admitting Diagnosis: CORONARY ARTERY DISEASE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with cad, pre-op for CABG REASON FOR THIS EXAMINATION: s/p cabg, r/o chf ______________________________________________________________________________ FINAL REPORT INDICATION: Coronary diseae, preop for coronary bypass.",1
PA & LATERAL CHEST: Comparison is made to .,0
There are sternal wires from recent cardiac surgery.,0
There is cardiomegaly with bilateral pleural effusions.,0
"There is increased opacity within both lower lobes, particularly on the left lower lobe, which could be due to atelectasis or pneumonia.",0
Osseous structures are otherwise unchanged.,0
Cardiomegaly with mild CFH and bilateral effusions.,0
"Increased opacity in both lower lobes, left greater than right, due to atelectasis or pneumonia.",0
"3:38 PM CT HEAD W/O CONTRAST Clip # Reason: eval for stroke Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with delerium, weakness of LLE REASON FOR THIS EXAMINATION: eval for stroke No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old male with delirium, and left lower extremity weakness.",0
"FINDINGS: There is no evidence of hemorrhage, mass, mass effect, or infarction.",0
"The ventricles and sulci remain prominent, likely representing age-related atrophy.",0
"There is moderate periventricular and subcortical white matter hypodensity, most consistent with chronic small vessel ischemic disease.",1
"There is calcification of the cavernous portion of the internal carotid arteries bilaterally, as well as in the left vertebral artery.",0
"There is mild mucosal thickening in the bilateral maxillary sinuses, ethmoid air cells, and sphenoid sinus, and bilateral mucus retention cysts in both maxillary sinuses are unchanged.",0
There are dense proteinaceous secretions within the left sphenoid air cells.,0
"However, please note that MRI with diffusion-weighted imaging is more sensitive for the detection of acute brain ischemia.",0
"6:20 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: episodes of desaturation, mucus plugging, evaluate for pneum Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 52 M with right upper lobe lung abscess s/p RUL REASON FOR THIS EXAMINATION: episodes of desaturation, mucus plugging, evaluate for pneumothorax, ______________________________________________________________________________ WET READ: DLrc MON 10:02 PM Right apical hydropneumothorax.",1
Right sided subcutaneous emphysema and pneumomediastinum.,0
Postsurgical change in the right upper lobe.,0
Right pleural effusions and lower lobe opacification.,0
"New diffuse left-sided opacification, non-specific, with differential including infection, hemorrhage, edema, or ARDS.",0
______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Right upper lobe lung abscess.,0
The right apical air collection has minimally decreased.,0
There is unchanged position of the right chest tube.,0
The extent of the subcutaneous air collection and the pneumomediastinum is stable.,0
No evidence of newly appeared focal parenchymal opacities.,0
There is minimal increase in extent of a pre-existing retrocardiac atelectasis.,0
The apparent increase in density of the left lung might be caused by patient positioning but might also reflect increasing fluid accumulation.,0
Short-term radiographic followup is warranted.,0
"9:40 PM CHEST (PORTABLE AP) Clip # Reason: s/p intubation Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with liver failure REASON FOR THIS EXAMINATION: s/p intubation ______________________________________________________________________________ FINAL REPORT INDICATION: 44-year-old male with liver failure, status post intubation.",0
TECHNIQUE: AP upright single view of the chest.,0
FINDINGS: The ET tube is in good position.,0
The pulmonary vasculature is normal without evidence of CHF or fluid overload.,0
There is a patchy opacity in the left lower lobe in the retrocardiac area consistent with atelectasis.,0
There is an NG tube with the tip extending below the limits of the radiograph in the stomach.,0
The skeletal structures are otherwise unremarkable.,0
Patchy atelectasis in the left base with elevation of the left hemidiaphragm.,0
"5:49 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate/effusion Admitting Diagnosis: ANAL CARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p , onset of SOB/abd.distension REASON FOR THIS EXAMINATION: eval for infiltrate/effusion ______________________________________________________________________________ FINAL REPORT INDICATION: New onset of shortness of breath and abdominal distension.",0
The right-sided central venous catheter is unchanged in position.,0
There is stable bibasilar atelectasis.,0
Noted are prominent appearing loops of large/small bowel within the imaged portion of abdomen in left upper quadrant.,0
Distended loops of bowel within the imaged portion of the upper abdomen.,0
Correlation with the patient's clinical exam and abdominal radiographs may be helpful.,0
", NMED SICU-B 7:27 AM CHEST (PORTABLE AP) Clip # Reason: ?infection/PNA Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: year old man with hemorrhage febrile and with leukocytosis REASON FOR THIS EXAMINATION: ?infection/PNA ______________________________________________________________________________ PFI REPORT Increasing small bilateral pleural effusions.",1
"Increasing bibasilar opacities, greater on the left side are due to increasing atelectasis.",0
"7:26 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: NON ST MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with left main CAD s/p recent extubation, to OR in am for CABG REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG.",1
FINDINGS: The cardiomediastinal silhouette is unchanged.,0
Left lung base atelectasis are again noted and unchanged.,0
The pulmonary vasculature is unchanged.,0
Right-sided Swan-Ganz catheter is stable.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: found down Major Surgical or Invasive Procedure: PEG trach History of Present Illness: 82 h/o M h/o left stroke, afib on coumadin transferred from OSH after being found down incontinent today, last seen well 3 days ago per family, with R MCA infarct w/hemorrhagic conversion.",0
"At OSH, rec'd lidocaine, succinylcholine, fentanyl, etomidate, zosyn, 1L NS, 1mg norcurun, 1U FFP and versed from 11am to 12pm.",0
Seen by Nsurg at ED who felt there was no acute surgical intervention indicated.,0
"Past Medical History: - h/o left caudate stroke (appears to also have an old right cerebellar stroke on NCHCT) - s/p R ankle fusion - hyperlipid - htn Dr. @ hospital , MA Social History: lives alone.",0
"Family History: NC Physical Exam: T- 99.0 BP- 117/72 HR- 95 RR- 14 100 O2Sat Gen: Lying in bed, NAD HEENT: intubated Neck: supple CV: RRR Lung: vent'd to auscultation bilaterally aBd: +BS soft, nontender ext: scattered abrasions and ecchymoses on extremities b/l Neurologic examination: MS: Does not open eyes to voice or tactile stim.",0
"CN: PERRL 2mm to 1mm, unable to doll w/OCMs, +R corneal, moves head and jaw w/nasal tickle but no excursion.",0
Motor/Sensory: Some spontaneous movements of legs b/l.,0
Right arm flexes and left arm extends to noxious stim.,0
W/d vs triple flexion in LEs.,0
This extends to the periphery consistent with a large area of cytotoxic edema.,0
There are areas of high attenuation within the medial aspect of the abnoramlity c/w areas of hemorrhage.,0
Findings most c/w hemorrhagic R MCA distribution infarct.,0
There is mass effect with effacement of the sulci and compression of the body of the right lateral ventricle.,0
There is approx 2 to 3 mm of midline shift.,0
Hypodensity of the left periventricular white matter is unchanged.,0
There is likely an old right cerebellar infarct.,0
There is no evidence of skull fx.,0
"OSH PCXR: no ptx, pulm vasc congestion, no frank pulm edema.",0
"CT/CTA head, CTA neck: NON-CONTRAST CT: Again demonstrated is a large right MCA territorial infarct with hemorrhagic transformation.",0
"There is associated edema, with mass effect on the adjacent lateral ventricle, and mild leftward shift of normally midline structures.",0
"Allowing for differences in head positioning and slice selection, the overall size and extent of these findings are unchanged from three hours prior.",0
There is no new area of infarction identified.,0
Again demonstrated is encephalomalacia from a prior infarct in the right PCA territory as well as a lacunar infarct involving the left basal ganglia.,0
Visualized paranasal sinuses demonstrate minimal mucosal thickening of the posterior ethmoidal air cells.,0
"CTA: Within the right internal carotid artery, immediately above the bifurcation, there is equivocal evidence of an intraluminal filling defect, which could reflect a small carotid dissection.",0
Atherosclerotic calcifications are also seen within this region.,0
"Additionally, more superiorly, there is moderate narrowing of the caliber of the right cervical internal carotid artery all the way to the level of the carotid canal, which is of unclear etiology, and could represent either atherosclerotic narrowing or intimal hyperplasia.",0
"Mild narrowing of the left cervical internal carotid artery is also present, but to a lesser extent compared to the right.",0
"Additionally, there is severe narrowing of the right vertebral artery, with atherosclerotic calcifications seen.",0
"However, the circle of and its major tributaries appear largely patent.",0
"Large right MCA territory infarct with hemorrhagic transformation, and associated mass effect and leftward shift of midline.",0
These findings are largely unchanged from three hours prior.,0
"Equivocal evidence of a filling defect within the right internal carotid artery immediately above the bifurcation, which could represent a small carotid dissection.",0
Transthoracic ECHO : The left atrium is moderately dilated.,0
"An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen.",0
IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal systolic function.,0
"EEG : ABNORMALITY #1: Throughout the recording, there was a hemispheric asymmetry with lower voltages and loss of faster frequency activity noted broadly over the right side.",0
"ABNORMALITY #2: The background was mildly slow, in the 6.5-7 Hz frequency range in the posterior regions bilaterally with admixed bursts of moderate amplitude generalized theta frequency slowing.",0
HYPERVENTILATION: Could not be performed as this was a portable study.,0
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study.,0
SLEEP: The patient progressed from the waking to drowsy state but did not attain stage II sleep during the recording period.,0
CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 96 beats per minute and occasional ectopic beats.,0
IMPRESSION: This is an abnormal portable EEG in the waking and drowsy states due to a hemispheric asymmetry with lower voltages and loss of faster frequency activity noted broadly over the right side.,0
This finding suggests the presence of wide spread cortical and subcortical dysfunction on the right versus presence of material interposed between the cortex and surface recording electrodes (e.g.,0
"In addition, the background was mildly slow with admixed bursts of moderate amplitude generalized theta frequency slowing, consistent with a mild encephalopathy and suggestive of dysfunction of bilateral subcortical or deep midline structures.",0
There were no clearly epileptiform features and no electrographic seizure activity was noted.,0
NCHCT : Again demonstrated is a large right MCA territory and infarction.,0
Compared to study performed two days prior.,0
There has been an interval decrease in size in the extent of cytotoxic edema.,0
The intraparenchymal hemorrhage located within this infarct has remained stable measuring 2.7 x 9.0 cm.,0
There is a similar very mild shift of the midline leftward approximately 2-3 mm.,0
There is mild effacement upon the right frontal .,0
There is no intraventricular hemorrhage.,0
Interval decrease in size of cytotoxic edema within right MCA territorial infarct.,0
Stable basal ganglia hemorrhage within right MCA territorial infarction.,0
"MRI/MRA head, MRA brain : FINDINGS: BRAIN MRI: There is a large right middle cerebral artery territorial infarct identified.",0
Small amount of blood products seen within the basal ganglia as seen on the recent CT.,0
There is mild mass effect on the right lateral ventricle.,0
There is no midline shift seen.,0
Chronic left-sided white matter infarct and periventricular changes of small vessel disease are seen.,0
A chronic right cerebellar infarct is also seen.,0
No acute infarcts are seen in the posterior circulation.,0
IMPRESSION: Acute right MCA infarct with small areas of hemorrhage within the basal ganglia as seen on the recent CT. MRA OF THE NECK: 2D time-of-flight MRA of the neck demonstrates normal flow signal in the carotid and vertebral arteries without stenosis or occlusion.,1
The gadolinium- enhanced MRA of the neck is limited but demonstrates normal flow in the vertebral arteries.,0
IMPRESSION: Normal MRA of the neck with 3D time-of-flight and gadolinium MRA limited by delay in acquisition.,0
MRA OF THE HEAD: The head MRA demonstrates diminished flow signal within the right middle cerebral artery which could be secondary to the large infarct seen in the right MCA region.,0
The left MCA in the posterior circulation as well as both anterior cerebral are normal in appearance.,0
"In the posterior circulation, distal right vertebral artery is small, which could be a normal variation.",0
A tiny prominence near the origin of the left superior cerebellar artery could be due to a small infundibulum.,0
A portion of right posterior cerebral artery is not visualized which is artifactual as this portion as well seen on the source images.,0
IMPRESSION: Diminished flow signal in the right middle cerebral artery could be secondary to the large infarcts seen in the MCA territory.,0
No signs of occlusion of the basilar artery.,0
"LUE doppler : Grayscale, color and Doppler son of the left IJ, subclavian, axillary, brachial, basilic and cephalic veins were performed.",0
Thrombus is identified within the basilic vein which is a superficial vein.,0
This vessel does not compress and there is no flow identified.,0
"Normal flow, compression and augmentation is seen in the remainder of the vessels in the left arm.",0
IMPRESSION: No evidence of deep vein thrombosis in the left arm.,0
Thrombus identified in the basilic vein which is considered a superficial vein.,0
CXR : The left lower lobe opacity has almost resolved with reappearance of the left hemidiaphragm.,0
"There is slight increase in right pleural effusion which is extending into the right minor fissure, but this change could be just the way the patient was positioned during the procedure.",1
The tracheostomy tube is 4 cm from the carina.,0
"Complete resolution of the left lower lobe opacity, likely atelectasis.",0
"Slight worsening of the right pleural effusion, but this could be just technical secondary to patient's positioning during the procedure.",1
"Brief Hospital Course: 82M h/o left caudate stroke, afib on coumadin and htn transferred from OSH after being found down, unresponsive and incontinent of stool and urine.",0
Last seen well 3-4 days prior to presentation per family and OSH head CT showed R MCA infarct with minimal amount hemorrhagic conversion.,0
"Hospital course: Neurologic: Despite a therapeutic INR on presentation, it was thought that the patient had a right MCA stroke stroke with minimal hemorrhagic conversion on warfarin, likely had a cardioembolic in etiology.",0
"In the acute setting, his INR was reversed with profiline, FFP, and Vitamin K. Initial exam was notable for no clear purposeful response to voice or noxious stimuli, intact brain stem reflexes (PERRL, R corneal), flexion of the right arm, extension of the left arm and likely triple flexion in legs to noxious stimuli.",0
"Over the stay, the patient's examination improved somewhat clinically, though he remained with a left-sided hemiplegia and left-sided neglect.",0
Coumadin was re-started 24-hrs post-operatively after the trach & PEG placement (was on ASA and subcutaneous heparin in the interim).,0
"There was no heparin bridging, and the patient was also continued on a baby aspirin (given infarct in setting of therapeutic anti-coagulation).",0
"The patient was also initially started on Dilantin for concern of seizure activity, though subsequent EEG changes were likely reflective of his infarct (epileptiform changes were not noted).",0
Please note that his coumadin was held on and for INRs of 3.6 and 3.1 respectively.,0
His INR on was 1.8; he should receive 3 mg warfarin this evening ().,0
The INR should be checked each morning and his coumadin dosed to a target range of .,0
"Hematologic: The patient had a cool left hand associated with swelling, though there was no DVT noted on a left upper extremity ultrasound.",0
Respiratory: The patient was initially intubated and then dependent on a ventilator; a trach was placed successfully.,1
His respiratory status was stable.,1
ID: The patient had an initial leukocytosis and chest infiltrates suggestive of pneumonia.,0
He was initally broadly covered with antibiotics (including vancomycin and ceftriaxone).,0
"However, his sputum and subsequent BAL grew bactrim-sensitive Stenotrophomonas maltophilia, which responded to this antibiotic (discontinued after ~10 day course on ).",0
He remained afebrile and stable thereafter.,0
"CVS: On the day prior to discharge, the patient had several transient bradycardic episodes (into 30s) that resolved within seconds.",0
"The patient was asymptomatic with these events, and they resolved by evening after briefly holding his metoprolol and repleting his magnesium.",0
His metorpolol was resumed prior to discharge.,0
"FLUIDS/METABOLICS: He developed a hypernatremia, presumably due to hypovolemia.",1
He was treated with 1/4 NS to replete half of his free water deficit (only half to avoid excessive cerebral edema).,0
"After the PEG was placed, the patient's nutrition was maintained on tube feeds.",0
"The patient's initial elevated creatinine resolved with volume resuscitation, but became elevated again near the end of his stay.",0
The patient again appeared to be clinically dry and was resumed on intravenous fluids (normal saline) to correct his volume status.,0
"His renal function improved (Cr 0.9 on day of discharge) but should be monitored to determine the response to the fluid management, and adjustments to his tube feeds can be made as needed.",0
"Code status: The parimary team communicated with the patient's brother, , who made patient DNR.",0
"contact #s: (home), (cell), .",0
Medications on Admission: simvastatin 20mg QAM nifedipine 60mg QD fosinopril 40mg QAM warfarin 2.5mg QAM ALL: NKDA Discharge Medications: 1.,0
"Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day).",0
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed.,0
Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Intravenous fluids Normal saline intravenous running continuously at 100 cc/hour 12.,0
Lab Please check INR daily.,0
Please re-dose warfarin to target INR of .,0
"Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Please give a dose this evening, .",0
Please check an INR each morning and dose warfarin to target an INR of .,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: right MCA stroke with minimal hemorrhagic transformation Discharge Condition: Does not speak.,0
Discharge Instructions: Please administer medications as prescribed and follow up with appointments as scheduled.,0
The patient has had a stroke.,0
"If the patient should have any new, concerning, or worsening symptoms, including new or worsening weakness, please call the patient's primary care physician, neurologist at ( (), or bring the patient to the nearest ED.",0
"The patient is on warfarin for anticoagulation, and had an INR this morning of 1.8.",0
He should receive a dose a 3 mg dose of warfarin early this evening.,0
"Please check his INR daily, and dose coumadin so that his INR is in the target range of .",0
Followup Instructions: You have the following appointment with your neurologist.,0
"Provider: , MD Phone: Date/Time: 10:30 Please call the office of ( as soon as possible to update registration information prior to the appointment.",0
"1:23 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: please evaluation for swallowing ability, obstruction Admitting Diagnosis: AIRWAY OBSTRUCTION\BRONCHOSCOPY FLEXIBLE AND RIGID;STENT REMOVAL; ?",0
"CRYO THERAPY ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with esophageal cancer, dysphagia s/p chemo/xrt REASON FOR THIS EXAMINATION: please evaluation for swallowing ability, obstruction ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb WED 8:28 PM Marked aspiration and penetration of multiple consistencies of barium including ice chips, thin liquids, and nectar thick liquids.",0
No evidence of marked esophageal obstruction.,0
"PFI VERSION #1 TXPb WED 6:40 PM Marked aspiration and penetration of multiple consistencies of barium including ice chips, thin liquids, and nectar thick liquids.",0
No evidence of large esophageal obstruction.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 68-year-old man with esophageal cancer, dysphasia, status post chemotherapy and radiation.",1
The patient now presents with continued dysphagia.,0
FINDINGS: A small amount of barium did seem to pass freely through the oropharynx and into the proximal esophagus without evidence of marked obstruction.,0
"However, there was penetration, aspiration, and nasal regurgitation with ice chips, thin liquids, and nectar thick liquids.",0
"It was decided, at this point, that the patient would not be able to undergo the esophagram due to his inability to tolerate large amount of barium.",0
"For details, please consult speech and swallow division note in OMR.",0
"IMPRESSION: Marked aspiration and penetration of multiple consistencies of barium including ice chips, thin liquids, and nectar thick liquids.",0
"10:58 AM CT HEAD W/O CONTRAST Clip # Reason: Please evaluate pneumocephalus Admitting Diagnosis: ALTERED MENTAL STATUS;MENINGITIS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with meningitis, mastoditis, and pneumocephalus REASON FOR THIS EXAMINATION: Please evaluate pneumocephalus No contraindications for IV contrast ______________________________________________________________________________ WET READ: ENYa SAT 12:19 PM Interval resolution of the tiny left pneumocephalus.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 52-year-old man, with meningitis and mastoiditis.",1
Previous CT reviewed tiny left pneumocephalus.,0
COMPARISON: CT head on .,0
FINDINGS: There is interval resolution of the tiny left-sided pneumocephalus noted in the previous CT head study.,0
"The bilateral mastoid air cells remain opacified, with adjacent osseous sclerosis, compatible with chronic mastoiditis.",0
"There is a persistent small air-fluid level in the left sphenoid sinus, with hyperdense material, could represent a small hemorrhagic component.",0
A tiny mucous retention cyst is again noted in the medial wall of the left maxillary sinus.,0
There is interval resolution of mild right maxillary mucosal thickening.,0
Scattered ethmoid opacification is minimal.,0
"There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct.",1
The ventricles and sulci are normal in size and symmetric in configuration.,0
"Of note, non-contrast CT head is not sensitive for meningitis findings.",0
Interval resolution of tiny left-sided pneumocephalus.,0
Unchanged tiny mucous retention cyst in the left maxillary sinus.,0
Interval resolution of right maxillary sinus mucosal thickening.,0
"1:26 PM MRA CHEST W&W/O C Clip # Reason: MRV to Assess for subclavian clot in the setting of positive Contrast: MAGNEVIST Amt: 20CC ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with CAD, PVD, ESRD on HD, DM2, HTN admitted with NSTEMI, started on intergillin and Heparin deveopled GIB, now found to be HIT AB positive, with difficult access in neck- ?Subclavian vein clot REASON FOR THIS EXAMINATION: MRV to Assess for subclavian clot in the setting of positive HIT antibodies (will guide decision as to whether or not to start anti thrombin therapy.)",0
______________________________________________________________________________ FINAL REPORT INDICATION: End-stage renal disease on hemodialysis.,1
Admitted with non-ST- segment elevation myocardial infarction.,0
Started on heparin and developed GI bleed.,0
Now found to be HIT antibody-positive.,0
Axial dark-blood HASTE; axial T1 turbo FLASH; axial 2D time-of-flight; coronal HASTE; multiple coronal VIBE sequences with and without gadolinium; subtraction images were performed.,0
Multiplanar reconstructed images were generated and evaluated on the workstation.,0
"For this study, the patient was paralyzed, and a respiratory technologist was present to suspend respirations when necessary.",0
MR CHEST ANGIOGRAM WITH AND WITHOUT CONTRAST: There are large bilateral pleural effusions with severe compressive atelectasis of both lungs.,0
Note is made of subcutaneous edema in the chest wall.,0
"There is an area of marked decreased perfusion relative to adjacent myocardium within the subendocardial inferior and posterior wall of the left ventricle on the delayed contrast- enhanced images, which is consistent with known myocardial infarction.",1
"The left cephalic vein is prominent and has early contrast enhancement, likely due to left arm AV fistula.",0
An approximately 2.4-cm segment of the cephalic vein has high-grade stenosis as it drains into left subclavian vein.,0
"Only a short segment of cephalic vein is seen on the right side, and may be occluded.",0
Both subclavian veins and internal jugular veins are patent.,0
The brachiocephalic veins and SVC are patent.,0
There is no significant stenosis of the thoracic aorta or the great vessels.,0
The left common carotid artery arises from the brachiocephalic trunk.,0
There are small axillary lymph nodes bilaterally.,0
Multiplanar reconstructions were essential in delineating the anatomy and pathology and confirm the above stated findings.,0
IMPRESSION: 1) Large subendocardial inferior and posterior wall myocardial infarct in the (Over) 1:26 PM MRA CHEST W&W/O C Clip # Reason: MRV to Assess for subclavian clot in the setting of positive Contrast: MAGNEVIST Amt: 20CC ______________________________________________________________________________ FINAL REPORT (Cont) left ventricle.,0
2) Large pleural effusions with severe compressive atelectasis of both lungs.,0
3) Approximately 2.4-cm segment of high-grade stenosis in left cephalic vein prior to its insertion into subclavian vein.,0
"4) No thrombosis in the SVC, brachiocephalic, internal jugular, or subclavian veins.",0
3:07 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with CAD s/p CABG REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM.,1
Mediastinal and left chest tubes are present.,0
Tip of left chest tube is not included on this film.,0
Discoid atelectasis is present in the left mid zone and at the left lung base and there is a probable small left pleural effusion and atelectasis in the left lower lobe.,0
"2:06 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: 76 year old woman with trauma, reintubated for resp failu Admitting Diagnosis: PNEUMOTHORAX;FACIAL FX ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with trauma, reintubated for resp failuer, ?",1
"pulm edema REASON FOR THIS EXAMINATION: 76 year old woman with trauma, reintubated for resp failuer, ?",0
"pulm edema ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ONE VIEW AT 14:30 HOURS CLINICAL INFORMATION: Trauma, re-intubated for respiratory failure.",0
COMPARISON STUDY: Same day at 05:21 hours.,0
Endotracheal tube terminates at thoracic inlet.,0
There is increased opacification at the left lung base consistent with atelectasis versus consolidation.,0
The left apical chest tube is present.,0
There is mild opacification at the left apex.,0
Subcutaneous emphysema in the left chest wall.,0
Interval increased opacification of the left lower lobe consistent with atelectasis versus pneumonia.,0
Left chest tube position at the left apex with stable fluid at left apex.,0
Continued subcutaneus emphysema left chest wall.,0
4:52 PM TUNNELED CENTRAL LINE PLACEMEN Clip # Reason: please place NEW Left tunneled double lumen access line for Admitting Diagnosis: FEVER ********************************* CPT Codes ******************************** * EXCH CENTRAL TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with R tunnel line which was pulled out by accident and now has exposed cuff.,0
chronic TPN REASON FOR THIS EXAMINATION: please place NEW Left tunneled double lumen access line for chronic TPN.,0
"If not him, please notify patient and daughter.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old male requiring TPN.,0
Previous tunneled line was pulled out by accident.,0
"PROCEDURE AND FINDINGS: After informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on the angiography table and the left neck was prepped and draped in standard sterile fashion.",1
"Using the sterile technique, local anesthesia and direct ultrasound guidance, the left IJ was punctured and a 0.018 guidewire was advanced through the needle into the SVC under fluoroscopic guidance.",0
The needle was then exchanged for a micropuncture sheath.,0
The wire and the inner dilator of the sheath were removed and a 0.035 wire was advanced through the sheath into the IVC.,0
Attention was now directed to the creation of a subcutaneous tunnel in the left upper chest.,0
"After using approximately 10 cc of 1% lidocaine with epinephrine, the double-lumen central line was advanced through the subcutaneous tunnel and through the puncture site in the neck using a blunt tunneling device.",1
A peel-away sheath was advanced over the wire into the SVC under fluoroscopic guidance.,0
The wire and the inner dilator were removed and the line was advanced through the peel-away sheath and the peel-away sheath was removed.,0
Final fluoroscopic image of the chest demonstrates the tip of the catheter to be located within the SVC.,0
The catheter was secured to the skin with 0 silk suture and the puncture site in the neck was closed with Vicryl suture.,0
"The catheter was flushed, hep-locked, and capped.",0
(Over) 4:52 PM TUNNELED CENTRAL LINE PLACEMEN Clip # Reason: please place NEW Left tunneled double lumen access line for Admitting Diagnosis: FEVER ______________________________________________________________________________ FINAL REPORT (Cont) Moderate sedation was provided by administering divided doses of 75 mcg of fentanyl and 1 mg of Versed throughout the total intra-service time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored.,1
IMPRESSION: Uncomplicated placement of a double-lumen tunneled central venous line through the left internal jugular approach with Fluoro and ultrasound guidance with hard copy images on file.,1
"5:39 PM KNEE (2 VIEWS) BILAT Clip # Reason: injury/fracture Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with crush injury REASON FOR THIS EXAMINATION: PORTABLE, please ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: 45-year-old man with crush injury, evaluate for fracture.",1
"BILATERAL KNEE RADIOGRAPHS, FOUR VIEWS: There is extensive soft tissue swelling involving the distal thighs bilaterally.",0
The joint spaces are preserved.,0
"There is a linear density concerning for a soft tissue foreign body seen on the left AP view, which is also seen on the right lateral view - suggesting side mismarking.",0
"Additionally, there is an ossific density seen posterior to the proximal fibula on the lateral view marked as the right side, with a likely corresponding finding on the left AP view.",0
This is an osseous fragment which is well- corticated and likely reflects sequalae from prior trauma.,0
There is a joint effusion on the lateral view marked as the left side.,0
"There is apparent side mismarking of the lateral views - and repeat radiographs will be obtained to correct this, and to confirm the laterality of the various above-mentioned findings.",0
"There is an ossific density posterior to the proximal fibula, likely on the left, which may represent a small osseous fragment from prior trauma.",0
"There is a linear foreign body in the anterior soft tissues, likely on the left.",0
"Addendum: Repeat study confirmed mismarking, please see subsequent report for details.",0
The osseous fragment is indeed on the left.,0
"11:11 AM CHEST (PORTABLE AP) Clip # Reason: assess for pneumothorax, effusion Admitting Diagnosis: ATRIAL SEPTAL DEFECT ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man s/p ASD repair, now s/p chest tube removal REASON FOR THIS EXAMINATION: assess for pneumothorax, effusion ______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube removal, to evaluate for pneumothorax.",1
"FINDINGS: In comparison with the study of , the left chest tube has been removed.",0
No convincing evidence of pneumothorax.,0
Atelectatic changes persist at the left base.,0
The endotracheal tube and right IJ catheter have also been removed.,0
"9:23 AM CT HEAD W/O CONTRAST Clip # Reason: LARGE R SDH S/P EVACUATION Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with large R SDH s/p evacuation REASON FOR THIS EXAMINATION: f/u SDH on POD #3 No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT SCAN OF THE BRAIN INDICATION: Large right subdural hematoma after evacuation, postop day 3.",1
TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.,0
"FINDINGS: There continues to be residual hemorrhage within the right subdural space, not appreciably changed since the previous study of .",1
"The associated mass effect is also similar, with displacement of the brain to the left of midline and mild-to-moderate dilatation of the left lateral ventricle.",0
"There is a small area of cortical edema involving the right superior cerebrum, near the frontoparietal junction.",0
"Foci of decreased attenuation are also appreciated within both thalami and in the white matter, which is consistent with previous findings of multiple microvascular infarctions.",0
"Again, noted is sclerotic abnormality of the skull and skull base.",0
"IMPRESSION: There is persistent right subdural blood and shift of midline structures to the left, not definitely changed since .",0
A small area of cortical edema at the right frontoparietal junction is faintly evident on the previous study and likely represents an area of injury.,0
Stable exam findings were reported to at 12:00 noon on .,0
LINE PLACEMENT Clip # Reason: picc Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with post-op fever REASON FOR THIS EXAMINATION: picc ______________________________________________________________________________ FINAL REPORT INDICATION: PICC line placement.,0
AP UPRIGHT CHEST RADIOGRAPH: A right-sided PICC line terminates in the mid SVC.,0
Heart size and mediastinal contours are normal.,0
Right-sided PICC line overlying mid SVC.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: R sided weakness, intracranial hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: 71 yo L handed M with history of kidney stones, BPH, and pelvis fracture from a fall presents wtih acute R face, arm and leg weakness today found at OSH to have a L basal ganglia hemorrhage.",1
He was transferred from hospital to for further evaluation and managment.,0
"He was well until today, no recent illnesses.",0
"He was out gardening today, ~11:30-noon as he was walking back in the house he suddenly felt like something was wrong but not sure what.",0
Then he made brunch for he and his wife.,0
"cooking he felt somewhat clumsy with his R hand, though he is L handed so it wasn't a big deal.",0
"While eating his wife noticed his speech was slurred, his R face was drooped, and he was weak in his R arm.",0
He had trouble getting his R arm even up to the table.,0
Then when he stood he was dragging his R foot.,0
"At that point, his wife convinced him that he needed to go to the hospital, as she suspected he was having a stroke.",0
He went to hospital by ambulance.,0
There he was noted to have R face/arm/leg weakness.,0
"CT head showed a 3cm.1.3cm.2.6cm hemorrhage in the L basal ganglia, primarily putaminal.",0
He was transferred for further neurological management.,0
There blood pressure was close to SBP 200s.,0
He did not receive any antihypertensive or other medications at the OSH.,0
He was never sleepy or confused.,0
"He never had trouble coming up with words, just slurred speech.",0
"R face, arm, and leg weakness has gradually improved overall with slight fluctuation such as transiently more weak in ambulance on the way here.",0
"He takes allopurinol and ibuprofen daily, no antiplatelet or anticoagulant medications.",0
"no known history of hypertension, and he says he has been seeing his doctor over the last few years with normal BP checks.",0
"ROS: Denies fevers, neck stiffeness, vision changes (blurry, double or other), swallowing difficulties, numbness/tingling, difficulty sensing temperature.",0
He has been able to walk though dragging R leg.,0
Past Medical History: BPH Recent prostate biopsy normal.,0
"Kidney stones Fall off ladder 3 years ago with no LOC, but had a pelvis fracture.",0
"osteoarthritis After calling PCP it appears patient has had BPs in the 140s/90s for the last few years, and last a measurement of 170/100 Social History: Lives with wife , who is his health care proxy if he could not make decisions for himself.",0
"Her contact information is , home phone or patient's cell which she will take .",0
He is a retired carpenter.,0
"He smoked for 15yrs, average PPD, and quick 30 years ago.",0
One alcoholic drink per day (i.e.,0
"Have 5 grown children and 8 grandchildren Family History: No family history of bleeding or clotting disorders, vascular malformations or aneurysms, or brain tumors.",0
Children and grandchildren all healthy.,0
"Physical Exam: Physical Exam: T98.5 Hr 96 BP 172/120 -->155/90s RR 16 O2 98% RA Gen: Awake, alert, not in distress, sitting up in bed.",0
"Skin: No rashes Heent: NCAT, mucous membranes moist, oropharynx clear.",0
"Back: no spinal tenderness Resp: Clear to auscultation bilaterally CV: Regular rate, normal S1/S2, no murmurs, rubs, or gallops Abd: Abdomen soft.",0
Arthritic changes in joints especially PIP and DIP joints (appears to be osteoarthritis).,0
RLE slightly externally rotated on the bed.,0
"Neuro: MS - Awake, alert, interactive.",0
"Oriented to person, place (hospital, city, state, and room number in ED), and date (day/month/year).",0
"Intact registration, recall 0/3 and with clues.",0
Attentions is considered to be appropriate.,0
"Cranial Nerves - Pupils R 3.5--->3 and L 3-->2 both briskly reactive (likely physiologic anisocoria); EOMs smooth and full, no diplopia; no nystagmus; optic disc margins sharp on funduscopic exam, Visual field full with confrontation test, intact facial sensation V1-V3, R UMN facial droop less apparent with spontaneous than forced smile, slight dysarthria, hearing intact to finger rub bilaterally, palate elevation is symmetric, and tongue protrusion is symmetric and full movement.",1
Sternocleidomastoid and trapezius are strong and normal volume.,0
"Tone - Normal Strength - Pronator drift on R Delt Tri WrEx FEx FFlx IO /IP Quad Ham Gastr TA R 4+ 5 5 5* 5- 5 4+ 4+ 4+ 5 5- 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 *Note wrist extensor shakey on R but unable to break it Reflexes - Biceps Triceps Brachioradialis Patellar Ankle R 2+ tr 2+ 2+ 2+ L 2+ 2+ 2+ 2+ 2+ Plantar responses extensor bilaterally Sensation - Intact to light touch, temperature.",0
Mildly decreased vibration and JPS bilaterally at the big toes.,0
Vibration symmetric and intact at knees.,0
Coordination - Finger to nose intact with no dysmetria out of proportion to weakness.,0
"RAMs slightly slumsier on the R, again in proportion to weakness.",0
Gait - Narrow based and stable with slight circumduction and foot drop of RLE.,0
Unable to walk on toes.,0
Pertinent Results: 09:48PM CK-MB-3 cTropnT-<0.01 02:40PM cTropnT-<0.01 02:40PM TSH-1.6 04:45PM URINE COLOR-Straw APPEAR-Clear SP -1.016 04:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG 02:40PM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-99 02:40PM WBC-9.2 RBC-5.21 HGB-15.0 HCT-45.4 MCV-87 MCH-28.7 MCHC-33.0 RDW-13.3 Imaging: CT head : IMPRESSION: No short interval change of 1.3 x 3 cm left external capsule hemorrhage with minimal mass effect.,0
No evidence of herniation or midline shift.,0
"MRI/A brain : MRI OF THE BRAIN: A 33 x 13 mm left basal ganglia hemorrhage with minimal surrounding vasogenic edema, is stable in size and location compared to CT scan of , previously 13 X 34mm.",0
There is minimal local mass effect without shift of normally midline structures.,0
Suprasellar and basal cisterns are patent.,0
No area of abnormal enhancement or abnormal vascular structures are seen within the area of the hemorrhage.,0
No area of abnormal enhancement or abnormal vascular structures are seen within the remainder of the brain parenchyma.,0
A small hypointense focus in the right posterior temporal region on axial FLAIR likely represents encephalomalacia.,0
"BRAIN MRA: Arteries of the anterior and posterior circulation appear normal without evidence of stenosis, occlusion or aneurysm greater than 3 mm.",0
IMPRESSION: Left basal ganglia hemorrhage with surrounding edema is stable in size and appearance since CT scan of .,0
No underlying mass or vascular malformation identified.,0
"Brief Hospital Course: 71 yo M with h/o kidney stones, BPH, prior pelvic fracture, oseoarthritis admitted with acute onset R face, arm and leg weakness secondary to L basal ganglia hemorrhage.",1
Overall strength has gradually improved since onset.,0
The patient had a head CT at the OSH which showed the hemorrhage and he was transferred to .,0
He was admitted to the Neuro ICU The CT head repeated here shows stable size of hemorrhage 3cm.1.3cm.2.6cm.,0
"He is not on antiplatelet or anticoagulant medications, but does take NSAIDs for arthritis.",0
Platelet number is normal here.,0
Blood pressures have been ~SBP160s/100s.,0
His bleed was in a typical location for a hypertensive bleed.,0
"He did not report that he had a history of HTN, however on taking to his PCP his pressures over the last few years have ranged in the 140s/90, and his last measurement was in with a measurement of 170/100.",0
To rule out other possible etiologies the patient had an MRI/A of the brain which showed Left basal ganglia hemorrhage with surrounding edema as stable in size and appearance since CT scan on .,0
There was no underlying mass or vascular malformation identified.,0
MRA was normal The patient spent the evening in the ICU.,0
"His right sided weakness improved, and he was primarily left with some difficulty with rapid alternating movements and coordination in his right hand and foot.",0
He was restarted on his home medication and started on HCTZ for blood pressure.,0
The patient was awake and alert the entire time and did not suffer a headache.,0
"While on the floor, SBP remained elevated.",0
HCTZ was discontinued and pt.,0
was started on lisinopril 10mg daily.,0
BP improved on day of discharge and K and Cr were wnl.,0
"Given ICH, ibuprofen was discontinued.",0
"ASA 81 mg was not started for primary cardiac prevention, however if felt it would be appropriate, could be started at 1 month after discharge.",0
The above findings were communicated to patient's PCP.,0
Medications on Admission: Flomax 1 tab po qday Alloporinol 300mg po qday (not sure of dose) ibuprofen 600mg po qday for arthritis pain Discharge Medications: 1.,0
"Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Left basal ganglia hemorrhage, likely hypertensive in origin.",0
Discharge Condition: Neurological exam at time of discharge notable for: MS: Impaired FAS and Luria sequence.,0
Impaired recall at 5 minutes () items.,0
CNs: intact Motor: bilateral FE 4+/5 weakness.,0
Gait: Mild extension of RLE and abduction but overall normal stride and armswing.,0
Discharge Instructions: You were admitted to with right sided weakness.,0
You were found to have a bleed on the left side of your brain.,0
This was felt to be due to your persistently elevated blood pressure.,0
You underwent an MRI of your brain that did not reveal an underlying mass or another reaason for your bleed.,0
Your weakness and incoordination improved thoughout the hospital stay.,0
The following changes were made to your medications: - Started on Lisinopril 10mg daily (you will need to follow up with your PCP regarding blood pressures and checking your kidney function and your potassium).,0
- Your Ibuprofen was stopped.,0
- ASA 81 mg can be started in 1 month if it is deemed of benefit for primary CAD prevention in this patient.,0
"Followup Instructions: PCP: , within 10 days of discharge.",0
Please call to set up your appointment that is most convenient for you.,0
"Provider: , MD Phone: Date/Time: 1:30 Completed by:",0
"9:25 AM CHEST (PA & LAT) Clip # Reason: eval effusions, infiltrate, CHF Admitting Diagnosis: LEUKEMIA;SEPSIS;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with MRSA/Klebsiella PNA, paraPNA effusions, s/p thoracentesis.",1
"REASON FOR THIS EXAMINATION: eval effusions, infiltrate, CHF ______________________________________________________________________________ FINAL REPORT INDICATION: An 85-year-old man with MRSA/klebsiella pneumonia.",0
"Peripneumonic effusions, and status post thoracentesis.",0
COMPARISON: Made with a prior PA and lateral views of the chest dated .,0
PA AND LATERAL VIEWS OF THE CHEST: The right-sided PICC line is seen with the tip terminating in the upper superior vena cava.,0
"When compared with the prior exam approximately 15 hours earlier, cardiac silhouette cannot be fully evaluated.",0
The mediastinal contour looks stable.,0
Pulmonary vasculature and bilateral apices appears normal.,1
The pleural effusion within the right lung appear stable allowing for changes in position.,0
The pleural effusion on the left appears slightly decreased since prior exam.,0
"There continues to be complete consolidation of the left lower lung, with air bronchogram.",0
Surrounding soft tissue and osseous structures reveal a wedge compression fracture of the T11-T12 vertebrae which is stable since prior exam.,0
IMPRESSION: 1) Slight interval decrease in size of left pleural effusion.,0
2) Stable right pleural effusion.,0
3) T11 or T12 vertebral body compression fracture stable since prior exam.,0
PATIENT/TEST INFORMATION: Indication: s/p bilateral PE.,0
Eval for RV strain Height: (in) 74 Weight (lb): 197 BSA (m2): 2.16 m2 BP (mm Hg): 139/76 HR (bpm): 75 Status: Inpatient Date/Time: at 05:50 Test: TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Overall normal LVEF (>55%).,0
MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Moderate to severe [3+] TR.,0
Conclusions: Overall left ventricular systolic function is normal (LVEF>55%).,0
IMPRESSION: Moderately dilated right ventricle with evidence of mild hypokinesis of the RV free wall.,0
There is relative sparing of the RV apex ( sign).,0
Moderate to severe tricuspid regurgitation with moderate pulmonary artery systolic hypertension.,1
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: please check PICC tip right brachial 38 cm Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with neew line placement REASON FOR THIS EXAMINATION: please check PICC tip right brachial 38 cm ______________________________________________________________________________ FINAL REPORT HISTORY: 80-year-old male with new line placement.,0
COMPARISON: Chest radiograph one hour ago.,0
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is new placement of the right PICC which terminates in the mid SVC.,0
Tracheostomy and Dobbhoff are unchanged.,0
"Right basilar consolidation is unchanged, and there is a similar degree of left retrocardiac consolidation.",0
Osseous structures and soft tissues appear unremarkable.,0
IMPRESSION: New right upper extremity PICC terminates in the SVC; otherwise no short interval change.,0
", 7F 11:31 AM CHEST (PORTABLE AP) Clip # Reason: Eval for infiltrates, effusion Admitting Diagnosis: (AML) ACUTE MYELOGENOUS LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with AML, s/p chemo, with fevers and new SOB REASON FOR THIS EXAMINATION: Eval for infiltrates, effusion ______________________________________________________________________________ PFI REPORT PFI: Lower lung volumes, increased mild interstitial edema.",1
"9:16 PM CHEST (PORTABLE AP) Clip # Reason: eval fo rinfiltrate effusion Admitting Diagnosis: TRAUMA; HEAD INJURY; MULTI FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with REASON FOR THIS EXAMINATION: eval fo rinfiltrate effusion ______________________________________________________________________________ FINAL REPORT INDICATION: A 75-year-old woman, evaluate for infiltrate or pleural effusion.",0
FINDINGS: The right subclavian central line is in unchanged position with the tip in the right atrium.,0
The NG tube was removed in the interval.,0
"The cardiac, mediastinal and hilar contours are unchanged in the interval.",0
There is cardiomegaly with left ventricular enlargement.,0
The pulmonary vascularity is unchanged when compared to the previous study and there is a suggestion of mild CHF.,0
Interval worsening of bibasilar patchy opacities which could represent atelectasis or consolidation.,0
There is probably a left pleural effusion.,0
Left retrocardiac opacity could represent pneumonia or atelectasis.,0
"6:25 AM CHEST (PORTABLE AP) Clip # Reason: routine CXR in intubated patient to assess lines Admitting Diagnosis: CHEST PAIN;S/P SEIZURE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with seizure, intubated with hypoxia , strep pneumo bacteremia s/p ETT repositioning REASON FOR THIS EXAMINATION: routine CXR in intubated patient to assess lines ______________________________________________________________________________ FINAL REPORT INDICATION: Seizure, intubated with hypoxia.",0
There has been slight reexpansion of the previously collapsed left lower lobe and lingula.,0
Residual infiltrate is noted in the left mid and lower zone.,0
No definite effusion is seen on the left side.,0
The heart and mediastinum have returned to a more normal central position.,0
The endotracheal tube and the right IJ central line remain in good position.,0
The NG line appears to extend into the stomach but it is poorly visualized below the diaphragm due to underpenetration.,0
Some linear atelectasis is again noted in the right upper lobe and in the right lower lobe.,0
No definite pleural effusion is visible on either side.,0
IMPRESSION: Slight reexpansion of the left lower lobe and lingula noted.,0
The appearances are otherwise essentially unchanged.,0
The lines appear to be in satisfactory position but poorly visualized in the lower mediastinum.,0
9:40 AM CHEST (PORTABLE AP) Clip # Reason: Confirm PICC Line Placement.,0
"Admitting Diagnosis: MYASTHENIC ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with myasthenia , s/p choking episode with new PICC Line.",0
REASON FOR THIS EXAMINATION: Confirm PICC Line Placement.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Myasthenia , status post choking episode with new PICC.",0
SINGLE VIEW CHEST: The right sided PICC terminates in the mid SVC.,0
"There is subsegmental atelectasis at the left base, unchanged from the prior study done one hour earlier.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Worst headache of life Major Surgical or Invasive Procedure: : Cerebral Angiogram : Cerebral Angiogram History of Present Illness: 54 with no PMH presents from OSH for evaluation of headache on and SAH.,0
He noted sudden onset severe HA 10am on .,0
"He was sitting and preparing for speech and denies any strenous activity at that time like bearing down, coughing or valsalva.",0
The HA came abruptly and was at the back side of neck and in occipital region.,0
It was and dull pressure like.,0
He took motrin without relief and HA persisted for the entire day.,0
However the intensity of HA decreased over the day.,0
He woke up this am and noted HA to be persistent.,0
He consulted urgent care clinic and was advised to go to ED.,0
He went to ED and was found to have SAH on CT and CTA showed possible aneurysmal bleed.,0
He was sent to .,0
"Past Medical History: None PSH: Appendectomy Social History: Lives with wife, no smoking or alcohol.",0
"Family History: No history of aneurysms or strokes Physical Exam: On Admission: VS: 97.2 68 167/101 18 100 Gen: Well-appearing, pleasant man lying in bed, NAD Skin: No rashes, no jaundice HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, supple, no lymphadenopathy Lung: Clear to auscultation bilaterally, no wheezes/rales/rhonchi CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Abd: +BS soft, nontender nondistended, no masses or organomegaly ext: Warm, well-perfused, + distal pulses, no edema Neurologic examination: Mental status: Awake and alert, cooperative and appropriately interactive with exam, normal affect.",0
"ORIENTATION: Oriented to person, place, and date.",0
ATTENTION: Full- backwards SPEECH/LANGUAGE: Speech is fluent with normal comprehension and repetition; naming intact to high- and low-frequency objects.,0
Simple and complex command-following w/o L/R confusion.,0
"MEMORY: Registers , recalls in 15 minutes without prompts.",0
"PRAXIS: No evidence of apraxia (able to brush teeth) no evidence of neglect Calculation: Normal Cranial Nerves: I - not tested; II, III - Pupils equally round and reactive to light, 4 to 2 mm bilaterally.",0
"Fundi visualized bilaterally without papilledema III, IV, VI - Extraocular movements intact bilaterally, No nystagmus.",0
"No ptosis V - Sensation intact V1-V3 touch, pain VII - Facial movement symmetric, no facial droop VIII - Hearing intact to finger rub bilaterally IX, X - Voice normal, palate elevates symmetrically - Sternocleidomastoid and trapezius normal bilaterally XII - Tongue midline, movements intact Motor: Normal bulk bilaterally.",0
"No observed myoclonus, no adventitial movements.",0
"Tri WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pain, vibration, position throughout.",0
Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 2 1 Plantars are flexors.,0
Coordination: Normal FNF and KHS BL.,0
Speech clear and fluent Pertinent Results: Cerebral Angiogram: Negative for aneurysm or other vascular anomalies MRI/A Neck: IMPRESSION: 1.,0
Stable appearance of the perimesencephalic subarachnoid blood compared to the prior CT study.,0
No evidence of abnormal intracranial enhancement.,0
Normal MRA of the head and neck.,0
No change in the caliber of the vessels since the recent angiogram.,0
Cerebral Angiogram: Negative for aneurysm or vascular anomalies Brief Hospital Course: Mr was admitted to the neurosurgery service to the ICU.,0
He was found to have an aneursymal SAH ?,0
of small right posterior communicating artery aneurysm as the source of the subarachnoid bleed.,0
He was started on Nimodipine for prophylaxis againt vasospasm.,0
His SBP <140 and made NPO for angiogram with possible coiling on .,0
The result of the angiogram was negative for any vascular anomaly.,0
He remained in the ICU for closed monitoring.,0
A MRI/A of the neck was performed which was negative.,0
On a repeat angiogram was performed which showed no evidence of an aneurysm or other vascular anomalies.,0
Patient remained nonfocal and was discharged home on .,0
"Medications on Admission: None Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain,headache.",0
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for HA.,0
Disp:*30 Tablet(s)* Refills:*0* 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day).,0
"5. bisacodyl 5 mg Tablet, Delayed Release (E.C.)",0
Discharge Disposition: Home Discharge Diagnosis: Subarachnoid Hemorrhage Discharge Condition: Mental Status: Clear and coherent.,1
Followup Instructions: Please follow-up with Dr. in 4 weeks with a Head CT w/o contrast.,0
Please call to make this appointment.,0
"3:53 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: Evaluate area of crepitus along left back/flank that is caus Admitting Diagnosis: (AML) ACUTE MYELOGENOUS LEUKEMIA Field of view: 41 ______________________________________________________________________________ MEDICAL CONDITION: 28 year old man with AML s/p DLI, with fever, severe pleuritic pain, new crepitus along left back REASON FOR THIS EXAMINATION: Evaluate area of crepitus along left back/flank that is causing severe pain.",1
"*New finding* Please NO IV or PO contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 28-year-old male with AML, severe pleuritic pain, new crepitus along left back.",0
COMPARISONS AVAILABLE: CT of the chest from .,0
TECHNIQUE: Contiguous axial slices were obtained from the thoracic inlet down to the pubic symphysis without IV or enteral contrast.,0
Coronal and sagittal reconstructions were obtained and reviewed.,0
CT OF THE CHEST WITHOUT CONTRAST: There is no evidence of any axillary or mediastinal lymphadenopathy.,0
The visualized heart appears normal in size with no evidence of any vascular or valvular calcifications.,0
Again noticed is right greater than left pleural effusion along with right lower lobe collapse and consolidation.,1
There is no evidence of any subcutaneous emphysema along the thoracic chest wall.,0
Prior seen pulmonary nodule in the right lung apex is stable in appearance from prior.,0
The airways are patent down to the subsegmental level.,0
CT OF THE ABDOMEN WITHOUT IV AND ENTERAL CONTRAST: The liver appears normal in size.,0
"No evidence of any nodules, masses, intrahepatic biliary dilatation, portal or venous thrombus.",0
"The gallbladder appears normal in size with no evidence of any biliary distention, stones, or wall thickening.",0
"The spleen appears normal in size with no evidence of any infiltrative disease, masses or calcifications.",0
"The pancreas appears normal in size without evidence of any surrounding inflammatory changes, pseudocysts or calcifications.",0
"The bilateral adrenal glands, kidneys and ureters appear normal with no evidence of any increase in size, calcifications or masses.",0
The visualized small bowel appears normal without any evidence of any wall thickening and distention or surrounding inflammatory changes.,0
"There is extensive fluid collection in the abdominal cavity specifically in the right subhepatic space, pararenal space, pelvis and rectouterine pouch.",0
(Over) 3:53 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: Evaluate area of crepitus along left back/flank that is caus Admitting Diagnosis: (AML) ACUTE MYELOGENOUS LEUKEMIA Field of view: 41 ______________________________________________________________________________ FINAL REPORT (Cont) The ascitic fluid appears unchanged from the amount of fluid visualized on the prior chest CT.,1
"There is no evidence of any lymphadenopathy, abscesses or loculated fluid collections.",0
"CT OF THE PELVIS WITHOUT IV OR ENTERAL CONTRAST: The rectum and sigmoid colon appear normal with no evidence of any thickening, bowel distention or diverticulosis.",0
"There is no evidence of any nodules or masses of the bladder, prostate or seminal vesicles with no evidence of any calcifications of these organs either.",0
Again noticed is prior mentioned pelvic free fluid.,0
Pelvic subcutaneous tissue demonstrate edematous changes without evidence of any subcutaneous emphysema.,0
OSSEOUS STRUCTURES: The osseous structures appear normal with no evidence of any suspicious lytic or blastic lesions.,0
Moderate ascitic fluid extending from the right subhepatic space down to the pelvis.,0
Right greater than left pleural effusion with consolidation and collapse of the right lower lobe.,1
No loculated fluid collection or abscesses identified.,0
H/O cardiac surgery with distant CABG.. Left ventricular function.,1
Height: (in) 72 Weight (lb): 183 BSA (m2): 2.05 m2 BP (mm Hg): 120/50 HR (bpm): 64 Status: Inpatient Date/Time: at 16:48 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; inferior apex - hypo; AORTA: Normal aortic diameter at the sinus level.,0
Trivial MR. PERICARDIUM: No pericardial effusion.,0
There is mild regional left ventricular systolic dysfunction with moderate hypokinesis of the inferior wall and mild inferoseptal hypokinesis.,1
IMPRESSION: Mild focal LV systolic dysfunction consistent with inferior ischemia/infarction.,1
Indeterminate indices for diastolic dysfunction.,0
Overall ejection fraction was UNDERestimated on the prior as image quality was suboptimal (echo contrast was used on the current study).,0
"10:44 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R/o mass Admitting Diagnosis: STROKE/TIA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with unexplained strokes of embolic origin REASON FOR THIS EXAMINATION: R/o mass No contraindications for IV contrast ______________________________________________________________________________ WET READ: CHgc FRI 11:33 AM No mass or abscess in the chest, abdomen or pelvis.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Embolic strokes of uncertain etiology, evaluate for mass or abscess.",0
"TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and pelvis were obtained with oral and intravenous contrast.",0
"CT CHEST: There is no axillary, mediastinal or hilar adenopathy.",0
There is coronary artery and aortic calcification.,1
There is no pulmonary nodule.,0
"There is tree in opacity in the lingula and right middle lobe (2,20-25).",0
"CT ABDOMEN: The liver, gallbladder, pancreas, spleen, adrenals and kidneys are normal.",0
There is no retroperitoneal or mesenteric adenopathy.,0
There is extensive calcification of the abdominal aorta.,0
The intra-abdominal small and large bowel is normal.,0
CT PELVIS: There is a Foley catheter in the bladder.,0
The rectum and sigmoid are normal.,0
There is no inguinal or pelvic adenopathy.,0
There has been prior hysterectomy.,0
"Small regions of low attenuation in the adnexa likely represent ovaries, measuring 2.0 x 1.3 cm on the right (2,90) and 1.4 x 0.9cm on the left (2, 90).",0
BONE WINDOWS: There is marked osteophyte formation in the thoracic spine consistent with degenerative change.,0
There is mild anterolisthesis of L4 on L5.,0
Tree in appearance in the lingula and right middle lobe may represent infection or inflammation.,0
"No evidence of mass in the chest, abdomen or pelvis.",0
"Extensive atherosclerotic disease in the coronary arteries, thoracic and abdominal aorta and iliac vessels.",0
(Over) 10:44 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R/o mass Admitting Diagnosis: STROKE/TIA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) Findings were discussed with (Neurology) on the day of the study.,0
8:58 PM CT HEAD W/O CONTRAST Clip # Reason: CVA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with wheezing REASON FOR THIS EXAMINATION: chf vs copd No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKXa FRI 9:24 PM No hemorrhage.,0
Chronic infarct in L MCA distribution.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Recent right facial twitching and right facial droop.,0
Evaluate for hemorrhage or stroke.,0
History of stroke in the past.,0
NON-CONTRAST HEAD CT: There is no evidence of acute intracranial hemorrhage or shift of normally midline structures.,1
"There is encephalomalacia of portions of the left frontal, parietal and temporal lobes, consistent with prior infarction.",0
The -white differentiation is preserved.,0
Chronic infarction in the left MCA distribution.,1
"4:18 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST -59 DISTINCT PROCEDURAL SERVICE Reason: 46 yo M w/ chronic pancreatitis, pseudocyst at tail of pancr Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with REASON FOR THIS EXAMINATION: 46 yo M w/ chronic pancreatitis, pseudocyst at tail of pancreas, recent abscess at the head of pancreas now w/ fever, rising wbc's, confusion.",1
"also, AP cxr of RLL collapse.",0
"please eval for pancreatic abscess, rll infiltrate.",0
"thanks ______________________________________________________________________________ FINAL REPORT INDICATION: Chronic pancreatitis, now presenting with fever elevated white count and confusion.",0
TECHNIQUE: Contiguous axial images through the chest abdomen and pelvis were obtained following the administration of oral and intravenous contrast.,0
CHEST WITH CONTRAST: Multiple enlarged lymph nodes are seen within the mediastinum.,0
There is no axillary or hilar lymphadenopathy.,0
There is dense consolidation of the right lower lobe with air bronchograms.,0
"There is air space consolidation within the right middle lobe, and multiple additional small patchy densities are seen scattered throughout the left lung as well.",0
These all appear infectious in origin.,0
There is no definite pleural effusion.,0
The heart and great vessels appear grossly within normal limits.,0
"ABDOMEN WITH CONTRAST: There is moderate amount of pneumobilia, increased in volume since the prior study, and a biliary stent is again noted.",0
There are no focal liver abnormalities.,0
"In the region of the tail of the pancreas, a small fluid collection is seen measuring 1.5 x 3.6 cm.",0
This has decreased dramatically in size since the prior study.,0
Dense calcifications are again noted throughout the pancreas.,0
No other definite fluid collections are seen in the region of the pancreas.,0
A gallstone is seen within an otherwise normal appearing gallbladder.,0
The adrenal glands are unremarkable in appearance.,0
The opacified loops of bowel are normal in caliber.,0
PELVIS WITH CONTRAST: A Foley catheter is present within the bladder.,0
There is a moderate amount of iatrogenic gas within the bladder.,0
Pelvic loops of bowel are grossly unremarkable.,0
There is no appreciable inguinal or deep pelvic lymphadenopathy.,0
"(Over) 4:18 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST -59 DISTINCT PROCEDURAL SERVICE Reason: 46 yo M w/ chronic pancreatitis, pseudocyst at tail of pancr Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.",1
Interval decrease in volume of fluid within the collection at the tail of the pancreas.,0
No other fluid collections appreciated.,0
"Multifocal pneumonia, most severe at the right base.",0
Findings consistent with chronic pancreatitis.,0
"4:34 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: exchange of ETT please eval position s/p bronch Admitting Diagnosis: S/P AAA REPAIR ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment maneuver REASON FOR THIS EXAMINATION: exchange of ETT please eval position s/p bronch ______________________________________________________________________________ FINAL REPORT INDICATION: Ruptured AAA status post OR, exchange of endotracheal tube.",0
COMPARISON: Radiograph dated at 5:21 a.m.,0
SINGLE AP PORTABLE SUPINE VIEW OF THE CHEST: A right internal jugular catheter is unchanged.,0
An NG tube was again demonstrated with distal tip terminating below the diaphragm below the lower margin of this film.,0
Anterior abdominal midline staples are seen at the lower margin of the film.,0
There is an endotracheal tube with distal tip at the thoracic inlet.,0
The exam is otherwise not significantly changed compared to the prior study.,0
IMPRESSION: ET tube in satisfactory position with no other significant interval change compared to the exam of 12 hours prior.,0
", J. SICU-B 9:42 AM HEPATIC Clip # Reason: Evaluate hepatic artery for stenosis on this recent liver tr Admitting Diagnosis: CIRRHOSIS Contrast: OPTIRAY Amt: 80 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with OLT , with concern for hepatic artery stenosis on CT and ^LFTs REASON FOR THIS EXAMINATION: Evaluate hepatic artery for stenosis on this recent liver transplant recipient.",1
need to stent the hepatic artery if significant stenosis.,1
PLEASE PAGE TXPLANT CHIEF RESIDENT BEFORE INTERVENTION.,0
______________________________________________________________________________ PFI REPORT Hepatic angiogram demonstrating focal stenosis of the proximal common hepatic artery by 50%.,1
Findings discussed with Dr. during the procedure during which it was decided to observe the patient and have the patient return for repeat angiogram in one to two weeks.,0
11:14 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOP ABD/PEL LIMITED Reason: please assess vasculature Admitting Diagnosis: HEPATACELLULAR CARCINOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 65M for R trisegmentectomy for HCC with elevated LFTs REASON FOR THIS EXAMINATION: please assess vasculature ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old man status post trisegmentectomy with elevated LFTs.,0
COMPARISON: MRI and ultrasound .,0
FINDINGS: The examination is limited by overlying bandages.,0
"The left portal vein is patent, although there is nonocclusive thrombus at the prior right and left portal vein confluence, unchanged compared to the prior examinations.",0
A second area of nonocclusive thrombus with focal narrowing of the portal vein is seen proximally as demonstrated on the previous MRI.,0
A large portion of the main portal vein is poorly assessed secondary to technical factors.,0
The left hepatic vein and artery are patent with acceptable waveforms.,0
A pleural effusion is noted.,0
IMPRESSION: Unchanged nonocclusive thrombus within the left portal vein.,0
Main portal vein poorly evaluated due to overlying bandage material.,0
"7:04 PM CHEST (PORTABLE AP) Clip # Reason: assess for chf, cardiac silhouette, lungs ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with acute coronary syndrome, cva, dm, htn, hypothyroid REASON FOR THIS EXAMINATION: assess for chf, cardiac silhouette, lungs ______________________________________________________________________________ FINAL REPORT HISTORY: 75 year old man with acute coronary syndrome.",0
There are no priors on PACS for comparison.,0
AP UPRIGHT CHEST RADIOGRAPH: The heart size is at the upper limits of normal given technique.,0
The pulmonary vascularity is slightly redistributed consistent with mild failure.,0
The lungs are clear with no infiltrates or effusions.,0
IMPRESSION: No evidence for infiltrates.,0
8:46 PM CT C-SPINE W/O CONTRAST Clip # Reason: r/o fracture ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: r/o fracture ______________________________________________________________________________ FINAL REPORT HISTORY: 60 year old male status post fall.,0
TECHNIQUE: Helically acquired contiguous axial images were obtained through the cervical spine without IV contrast.,0
"CT OF C SPINE WITHOUT IV CONTRAST: No evidence of acute fractures, malalignment or areas of bone destruction.",0
"But there is sclerosis of the C3, C4, and C5 vertebral bodies, and fusion of C5 through C7.",0
There are diffuse degenerative changes within the cervical spine.,0
Coronal and sagittal reformatted images confirm the apparent fusion of the C5-7 vertebral bodies.,0
"Also noted is a well corticated irregularity of the T1 spinous process, likely a chronic finding.",0
There is sphenoid sinus fluid and mucosal thickening.,0
There is slight increased density in the upper lungs and probably a small right posterior bulla.,0
IMPRESSION: No evidence of acute fractures or malalignment of the cervical spine.,0
Degenerative changes with apparent fusion of the C5-7 vertebral bodies.,0
", MED CCU 1:44 PM CT HEAD W/O CONTRAST Clip # Reason: assess for infarct Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with CAD, ?pneumonia, AMS, s/p intubation.",0
"REASON FOR THIS EXAMINATION: assess for infarct No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT No acute intracranial hemorrhage, edema, or mass.",0
MR -weighted imaging is most sensitive for evaluation of acute infarction.,1
"Paranasal sinus disease, including slightly worsened opacification of the ethmoid air cells.",0
Chronic right corona radiata lacunar infarcts.,0
10:19 AM CHEST (PORTABLE AP) Clip # Reason: post chest-tube pull Admitting Diagnosis: MR\ MITRAL VALVE REPLACEMENT; HEART PORT MINIMALLY INVASIVE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with REASON FOR THIS EXAMINATION: post chest-tube pull ______________________________________________________________________________ FINAL REPORT INDICATION: 45 year old man post chest tube removal.,1
AP ERECT CHEST RADIOGRAPH: There has been interval extubation and removal of the NG tube.,0
There are sternal wires and mediastinal clips again seen indicative of a prior CABG.,0
The pulmonary vascularity shows no signs of redistribution.,0
"There are small bilateral pleural effusions, and some consolidation in the left lower lobe.",0
Consolidation in the left lower lobe compared to .,0
"12:30 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: interval change Admitting Diagnosis: TRACHEOBRONCHOMALACIA ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with respiratory failure REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 12:33 P.M. ON HISTORY: Respiratory failure, question interval change.",1
"IMPRESSION: AP chest compared to 5:12 a.m.: Lung volumes are still very small, and since there has been no improvement in lung volumes, the decrease in generalized pulmonary opacification represents real improvement in pulmonary edema.",0
"Heart is moderately enlarged, unchanged.",0
Pulmonary vasculature is difficult to discern.,0
"Pleural effusions are small, if any.",0
Infusion port ends in the right atrium.,0
4:26 PM CHEST (PORTABLE AP) Clip # Reason: please check line placement after change over wire Admitting Diagnosis: ESOPHAGEAL PERFORATION ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman s/p trach had RUL collapse yesterday REASON FOR THIS EXAMINATION: please check line placement after change over wire ______________________________________________________________________________ FINAL REPORT INDICATION: Status post trach with right upper lobe collapse evaluate for line placement after change over wire.,0
FINDINGS: A tracheostomy tube appears in unchanged position.,0
A right internal jugular venous access catheter terminates with tip in distal SVC.,0
The heart size and mediastinal contours are unchanged allowing for differences in patient positioning.,0
Unchanged left lower lobe opacity consistent with atelectasis and probable small left pleural effusion.,0
New linear opacity within the right mid lung field consistent with atelectasis.,0
Right IJ venous access catheter in distal SVC.,0
"Stable left lower lobe atelectasis versus consolidation, and probable left pleural effusion.",0
Atelectasis versus infiltrate within the right mid lung field.,0
"9:55 AM ABDOMEN (SUPINE ONLY) Clip # Reason: r/o obstruction ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with cirrhosis, choledocholithiasis, altered mental status, N/V REASON FOR THIS EXAMINATION: r/o obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE FILM: HISTORY: Cirrhosis and altered mental status with nausea and vomiting.",1
There are gas distended loops of small bowel with gas present in the colon and rectum.,0
compression screw in proximal left femur.,0
A rounded calcific densities in right upper quadrant possibly in costal cartilage but cannot rule out gallstones.,0
IMPRESSION: Findings could be due to an ileus or partial small bowel obstruction.,0
Correlate clinically and with follow up as indicated.,0
1:39 AM KNEE (2 VIEWS) LEFT Clip # Reason: fall ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with swelling REASON FOR THIS EXAMINATION: fall ______________________________________________________________________________ FINAL REPORT INDICATION: Swelling after fall.,0
"FINDINGS: AP, lateral and attempted oblique views of the left knee demonstrate no fracture or evidence of bone destruction.",0
Knee joint spaces are preserved.,0
"6:45 PM CHEST (PORTABLE AP) Clip # Reason: s/p removal of right subclavian hickman and insertion of lef ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with REASON FOR THIS EXAMINATION: s/p removal of right subclavian hickman and insertion of left subclavian CVL PLEASE CALL WET READ TO NURSING AT Thanks NTawa ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : CLINICAL INDICATION: Line placement.",0
"A new left subclavian vascular catheter has been placed, terminating in the superior vena cava.",0
Predominantly linear opacities are seen at both lung bases.,0
"IMPRESSION: 1) New vascular catheter terminates within the superior vena cava, with no pneumothorax.",0
"2) Low lung volumes with bibasilar opacities, likely reflecting areas of atelectasis.",0
"7:48 PM CHEST (PORTABLE AP) Clip # Reason: r/o PNA, mucous plug ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with h/o endocarditis, fungemia, intubated for months, now with fever,hypertensive, tachycardic, tachypneic, hypoxic.",0
"REASON FOR THIS EXAMINATION: r/o PNA, mucous plug ______________________________________________________________________________ FINAL REPORT CHEST, : INDICATION: History of endocarditis, fungemia, intubated for months.",0
"Now has fever, hypertension, tachycardia, tachypnea and hypoxia.",0
"Rule out pneumonia, mucous plug.",0
FINDINGS: A single AP semirecumbent image is provided.,0
Comparison study taken supine on .,0
"There is now marked worsening of the pulmonary infiltrates in the left mid zone and to a lesser extent in the right mid zone, associated with ill-defined loss of translucency in both lower zones and blunting of both costophrenic angles consistent with bilateral effusions.",0
The rib fracture in the left mid zone is again noted.,0
The heart shows fairly marked left ventricular enlargement.,0
Sternotomy sutures are again noted.,0
The previous skin staples in the region of the left rib fracture have now been removed.,0
A tracheostomy tube is in good position.,0
The right PICC line tip is again noted in the region of the SVC/right atrial junction.,0
IMPRESSION: Worsening bilateral mid zone pulmonary infiltrates.,0
"These could be due to superinfection, possibly associated with some cardiac failure.",1
Is there a clinical possibility of hyperhydration?,0
Some left heart failure may well be present.,0
"11:08 AM CHEST (PA & LAT) Clip # Reason: r/o inf, eff Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with s/p cabg REASON FOR THIS EXAMINATION: r/o inf, eff ______________________________________________________________________________ FINAL REPORT HISTORY: 64-year-old male status post CABG.",1
STUDY: PA and lateral chest radiograph.,0
FINDINGS/IMPRESSION: Sternotomy wires and mediastinal clips are unchanged.,0
The cardiomediastinal contours are stable.,0
Bibasilar atelectasis is demonstrated as well as small bilateral pleural effusions.,0
Left upper lobe atelectasis is improving.,0
There is no lobar consolidation.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Depakote / Zarontin / Phenobarbital / Aspirin Attending: Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 86 year old male with a history of CAD, congestive heart failure, and dementia who presents from with shortness of breath, hypoxia, and a chest x-ray showing pneumonia.",1
"He was reportedly feeling more short of breath all day, with general malaise.",0
He was given oxygen and nebulizer treatments without improvement and CXR at showed bilateral infiltrates concerning for pneumonia.,0
He was given a dose of Levofloxacin and Flagyl.,0
He was brought to by EMS.,0
"While en route, he was given a bolus of normal saline and Duonebs by EMS.",0
"In the ED, initial vital signs were T 97.0, BP 85/44, HR 107, RR 28, and SpO2 91% on NRB.",0
He triggered for hypotension and was given additional IV fluids.,0
Labs showed WBC 6.5 but with 37% bands and 3% metas.,0
"He had creatinine 2.1 with unknown baseline, bicarb 17 with anion gap 17, and lactate 5.5.",0
His Troponin was 0.05 and his BNP was .,0
CXR in the ED again showed bibasilar infiltrates concerning for pneumonia.,0
He was given Vancomycin 1000 mg IV and Levofloxacin 750 mg IV.,0
"Prior to transfer, his vitals were BP 119/53 (105/43 sleeping), HR 103, RR 15, and SpO2 97% on NRB.",0
"Once in the ICU, he reported some continued shortness of breath and cough.",0
"On questioning, he noted that he often coughs after eating.",0
He has been feeling unwell and more fatigued over the last few days.,0
"He notes having some intermittent chest pain at baseline, but no pain currently.",0
He was quickly weaned down to nasal cannula.,0
"Past Medical History: # Coronary artery disease -- stenting of D1 in # Ischemic cardiomyopathy # Cerebrovascular accident () # Hypertension Social History: # Tobacco: Past smoking history, none currently # Alcohol: None # Illicits: None Family History: Noncontributory Physical Exam: ICU admission exam: General: Alert, no acute distress HEENT: Sclera anicteric, PERRL, very dry MM Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles, wheezes and coare breath sounds throughout CV: Distant heart sounds, RRR, no murmurs appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: No clubbing, cyanosis, or edema.",1
Distal pulses 2+ Pertinent Results: ECHOCARDIOGRAM The left atrium is mildly dilated.,0
LV systolic function appears depressed (ejection fraction ?,0
30 percent) with regional variation.,0
Left ventricular mechanical function appears markedly dyssynchronous.,0
CXR : AP UPRIGHT VIEW OF THE CHEST: There is increased left retrocardiac opacity worrisome for infection .,0
There is no large effusion or pneumothorax.,0
"Brief Hospital Course: 86 yo M with CAD, systolic HF (EF 30%), h/o CVA (), HTN, recurrent , admitted from to ICU on with hypoxia, hypotension, apparent bilateral pneumonia (likely ), and acute renal failure.",1
"Per report, was feeling increasing dyspnea, malaise on .",0
CXR performed at was concerning for bilateral PNA.,0
He was given levofloxacin and metronidazole and transferred to .,0
"In the ED, he was hypotensive (85/44), hypoxic (91% NRB).",0
He received Vancomycin and was admitted to the .,0
"In the ICU, his blood pressure remained stable in the low 100s systolic and O2 sats in low 90s on 3L NC.",0
He was continued on vancomycin and levofloxacin and cefepime was added on the afternoon of to cover for hospital acquired pathogens.,0
A bedside swallowing study by his nurse of apple sauce as well as his own secretions.,0
ICU course also significant for elevated troponin suggesting demand cardiac ischemia.,0
# Sepsis due to PNA: PNA was felt unlikely to be due to MRSA so vancomycin was stopped upon transfer out of the ICU.,0
Levofloxacin and metronidazole were continued via parenteral route as he was not taking oral medications consistently.,0
Formal swallowing eval by Speech Therapy on showed gross of all consistencies.,0
"He appeared to have another event on , with increase in supplemental oxygen requirement and CXR showing worsening bibasilar opacities.",0
He remained NPO and completed a course of Levofloxacin and Flagyl IV on .,0
His clinical status improved to the point he was not requiring supplemental oxygen by and appeared comfortable at rest.,0
#Recurrent : Initial swallow evaluation done on showed gross of all consistencies.,0
He was placed NPO and a family meeting (discussed below) was held on .,0
Due to prolonged NPO status the patient was started on TPN for nutrional support for 4 days prior to re-evaluating swallow.,0
"His repeat swallow evaluation on showed persistent risk of , which was discussed with his guardian by phone communication.",0
"However, pt is at risk of even while being NPO due to continued from oral secretions and this is known to be a chronic condition, unlikely to improve.",0
"Knowing these risks, after discussion with guardian, patient was started on pureed solids and continued on strict precautions as deliniated by Speech Therapy with the goal of transferring back to NH.",0
"He tolerated pureed solids for 2 days without respiratory decompensation and will be discharged with the following recommendations: a) PO diet: pureed solids, nectar thick liquids b) PO meds crushed in puree c) Strict precautions d) Continue Q4 oral care including oral care just prior to any PO intake.",0
# Hypotension: Improved with aggressive fluid resuscitation.,0
"Home BP meds (metoprolol, furosemide) were held in the ICU.",0
"On his SBP was in the 130s, so metoprolol was restarted, nitrol patch was added instead of the prior Imdur(erratic PO intake)and metoprolol dose was changed to 12.5 mg .",0
His BP remained controlled during his stay on this dosing.,0
"# Acute on chronic renal failure: His initial creatinine was elevated to 2.1 (baseline ~1.2), improved with IVF resuscitation.",1
Creatinine at discharge was 0.8. .,0
# Known CAD with elevated troponin - likely demand cardiac ischemia.,0
"Statin was held due to his dysphagia/, this was be restarted at NH if felt indicated by PCP.",0
beta blocker and long-acting nitrate.,0
"# Systolic Congestive Heart Failure, chronic: TTE in the ICU showed an EF 30%.",1
"Held furosemide in house, as he was essentially NPO and getting IV fluids before initiation of TPN.",0
Daily weights were monitored and should continue to be monitored in NH as lasix has not been restarted due to decreased po intake.,0
Pt remained euvolemic off Lasix during admission.,0
"# While NPO, colchicine, Cyanocobalamin, vitamin D were all held.",0
These have not been restarted to simplify regimen and will be at the discretion of PCP whether to restart.,0
# Goals of care: family meeting was held on .,0
"In attendance were Mr. wife and son, his legal guardian ( ), attending physician at the time (Dr. ), and representatives from Social Work ( ), Speech Therapy ( ), and Nutrition ( ).",0
"Discussed Mr. current status, and in particular his high risk for .",0
"Agreements between Mr. wife and son and other providers at the meeting (to be acted upon by his legal guardian) included: -No PEG tube -Start TPN -NPO -Repeat evaluation by Speech Therapy on Friday -Further recommendations and discussion about oral feeding to occur after evaluation on Friday -Criteria for discharge to or another skilled nursing facility would include: requirement for little to no supplemental oxygen, plan for nutrition, and plan for action if he develops respiratory distress or failure -Would be OK for re-hospitalization -Code status now DNR-DNI -After repeat evaluation () with no major improvement in swallowing, it was felt pt will not improve and will have chronic .",1
"Since no expected improvement, TPN was weaned and pt was restarted on pureed solids after discussing with guardian following above recommendations for precautions.",0
"Medications on Admission: Diet: puree with nectar thick liquids, Ensure TID Cortisporin otic drops 2 gtt to L ear on 1st and 15th of each month mirtazapine 30mg QHS colchicine 0.6mg daily doxazosin 8mg daily (AM) furosemide 40mg daily Imdur 60mg daily Lipitor 20mg daily Plavix 75mg daily vit B12 500mcg daily Lactulose 15ml daily (AM) Senna 2tabs vit D3 400unit daily metoprolol tartrate 25mg docusate 100mg gabapentin 200mg QHS lorazepam 1mg QHS APAP 1000mg (not to exceed 4g/day) MOM 30ml PRN constipation Duonebs Q6H Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation.",0
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as needed for SOB.,0
4. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for SOB.,0
5. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime).,0
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Disp:*30 Tablet(s)* Refills:*0* 9. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).,0
"Cortisporin 3.5-10,000-1 mg-unit/mL-% Drops, Suspension Sig: Two (2) drops Otic on 1st and 15th of each month.",0
11. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours).,0
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).,0
Disp:*30 Tablet(s)* Refills:*0* 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: pneumonia NSTEMI Discharge Condition: Mental Status: Confused - sometimes.,0
"Discharge Instructions: You were admitted with pneumonia, dehydration, and kidney failure.",1
You received antibiotics and IV fluids and improved.,0
You also had evidence of damage to your heart muscle and a cardiac ultrasound showed that your heart does not empty normally.,0
"You had a swallowing evaluation which showed risk so you should continue on precautions (elevated head of bed to 30 degrees, frequent oral care and suctioning of secretions).",0
You have been given a diet of pureed foods and thicked nectar liquids as these would be best tolerated in your condition.,0
"If you experience shortness of breath, increased coughing with fever or decreased oxygen saturation you should be re-evaluated.",0
"Followup Instructions: You will be followed by your physician at the nursing home, Dr. .",0
She will determine what folow-up tests and physician evaluations are necessary.,0
"1:34 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: w/ oral & iv contrast to eval retroperitoneal collections Admitting Diagnosis: ABDOMINAL ABSCESS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with pancreatic necrosectomy on for nec pancreatitis, p/w bilateral retroperitoneal psoas abscesses s/p bedside drainage , washout and IR/ERCP CBD stents REASON FOR THIS EXAMINATION: w/ oral & iv contrast to eval retroperitoneal collections No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 55-year-old man with pancreatic necrosectomy on for necrotizing pancreatitis presents with bilateral retroperitoneal psoas abscesses status post bedside drainage.",1
COMPARISON: CT of the abdomen from and ERCP from .,0
TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV and oral contrast.,0
The partially imaged lungs show bibasilar scarring.,0
The partially imaged heart is unremarkable.,0
No pericardial or pleural effusions are present.,0
CT OF THE ABDOMEN WITH IV CONTRAST: There is unchanged diffuse intrahepatic biliary dilatation with pneumobilia and a right-sided percutaneous transhepatic drainage catheter terminating in the right hepatic duct.,0
Two biliary stents are noted in the common hepatic duct ending in the duodenum.,0
"Moderate amount of sludge is noted in the gallbladder, unchanged.",0
A stone measuring 5 mm x 7 mm is noted in the pancreatic duct with mild pancreatic ductal dilatation.,0
The pancreatic tail is atrophied.,0
"The spleen, both adrenals and left kidney are unremarkable.",0
"There is mild unchanged hydronephrosis of the right kidney with the ureteral dilatation noted to the level of a phlegmonous collection in the right psoas, unchanged.",1
"A 11 x 13 mm fluid collections is noted next to the pancreatic head, decreased in size from the prior examination.",0
The right psoas abscess measures 17 x 30 mm and has decreased in size compared to the prior examination where it measured 29 x 45 mm.,1
A left psoas abscess has also decreased in size measuring 45 x 20 mm versus 48 x 32 mm on the prior examination.,1
A left-sided JP drain is noted terminating in the left collection.,0
Both abscesses track superiorly along the psoas with the superior extent decreased compared to the prior examination.,1
There has been prior total colectomy.,0
A J-pouch is noted appropriately in the pelvis.,0
The small and large bowel loops are unremarkable.,0
"No abdominal, retroperitoneal or mesenteric lymphadenopathy by CT size criteria is noted.",0
There is a small amount of abdominal simple free fluid.,0
A 15 x 11 mm soft (Over) 1:34 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: w/ oral & iv contrast to eval retroperitoneal collections Admitting Diagnosis: ABDOMINAL ABSCESS Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) tissue nodule in the anterior abdominal subcutaneous tissues is new since and may represent a sebaceous cyst (2:48).,0
"CT OF THE PELVIS WITH IV CONTRAST: The J-pouch, bladder, prostate, and seminal vesicles are unremarkable.",0
No pelvic or inguinal lymphadenopathy by CT size criteria is present.,0
There are small bilateral fat-containing uncomplicated inguinal hernias.,0
OSSEOUS STRUCTURES: The visible osseous structures show grade 1 retrolisthesis of L2 on L3.,0
There is also anterior osteophyte formation but no suspicious lytic or blastic lesions or fractures are noted.,0
"3:13 PM CHEST (PA & LAT) Clip # Reason: r/o failure, check RLL infiltrate Admitting Diagnosis: CHF EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 26 year old woman with hx cardiomyopathy p/w sob.",0
"REASON FOR THIS EXAMINATION: r/o failure, check RLL infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: 26 year old evaluate for failure.",0
"Patient has a history of cardiomyopathy, presents with shortness of breath.",0
PA AND LATERAL CHEST: The cardiac silhouette is enlarged and there is improvement in the bilateral interstitial edema.,0
There is a patchy opacity seen in the right upper lobe which could represent asymmetric edema or pneumonia.,0
There are no significant pleural effusions.,0
The hilar and mediastinal silhouettes are normal in size.,0
Right upper lobe ill-defined patchy opacity which could represnt asymmetric edema or early pneumonia.,0
9:26 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: cholecystitis?,1
"in particular, eval for gas in bladder wall ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with CT findings c/f cholecystitis REASON FOR THIS EXAMINATION: cholecystitis?",0
"in particular, eval for gas in bladder wall ______________________________________________________________________________ WET READ: NATg SUN 10:02 AM Gallbladder wall thickening to 8mm without gas, sludge or stones.",0
"Normal CBD Findings can be seen in CHF, hepatitis, systemic disease.",0
______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: 78-year-old male with gallbladder wall thickening seen on ultrasound.,0
TECHNIQUE AND FINDINGS: Grayscale images of the right upper quadrant demonstrate normal appearing liver without focal or textural abnormalities.,0
"There is gallbladder wall thickening up to 9 mm, without gallbladder sludge or stones.",0
The common bile duct is normal in caliber measuring 3 mm.,0
Limited images of the right kidney demonstrate no hydronephrosis.,0
There is no gallbladder wall gas.,0
"IMPRESSION: Gallbladder wall thickening without sludge or stones, with a normal appearing common bile duct.",0
"These findings may be related to CHF, systemic inflammation, or hepatitis.",0
Height: (in) 67 Weight (lb): 140 BSA (m2): 1.74 m2 BP (mm Hg): 103/62 HR (bpm): 81 Status: Inpatient Date/Time: at 12:05 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral - akinetic; mid anterolateral - akinetic; inferior apex - akinetic; lateral apex - akinetic; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Effective regurgitant orifice is >=0.40cm2.,0
Severe (4+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
The left ventricular cavity is severely dilated with severe regional systolic dysfunction including akinesis of the inferolateral and anterolateral walls.,1
The effective regurgitant orifice is >=0.40cm2.,0
6:44 AM CHEST (PORTABLE AP) Clip # Reason: ETT placement ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p re-intubation REASON FOR THIS EXAMINATION: ETT placement ______________________________________________________________________________ FINAL REPORT HISTORY: Intubation.,0
"PORTABLE SUPINE AP CHEST, ONE VIEW: Comparison , 19:31.",0
"Since the prior exam, the patient has been intubated, and the ET tube is 4.8 cm above the carina.",0
There is a left central line with tip in the SVC.,0
There is no CHF or pleural effusion.,0
"There is new left retrocardiac density, which likely represents atelectasis, although developing pneumonia cannot be excluded.",0
"In the partially visualized soft tissues of the neck, the airway (ET tube) is somewhat deviated to the left.",0
"This may be due to head position or reflect deviation secondary to neck mass, possibly goiter.",0
"Interval development of patchy left retrocardiac density, likely representing atelectasis, although developing pneumonia/aspiration cannot be excluded.",0
Mild leftward deviation of the airways in the neck as described above.,0
"4:30 PM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, failure ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with sob, hypoxia REASON FOR THIS EXAMINATION: assess for infiltrate, failure ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath and hypoxia.",0
COMPARISON: Radiograph dated and .,0
AP PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: Aorta is tortuous.,0
"Heart size stable, allowing for technical differences.",0
There is lucency of both upper lung zones consistent with patient's known emphysematous disease.,0
Lung parenchyma is unchanged compared to the previous studies.,0
Left costophrenic angle is not imaged.,0
Right costophrenic angle is sharp.,0
The right apex is obscured by overlying breathing apparatus.,0
IMPRESSION: No significant interval change compared to the study of .,0
"3:48 AM CHEST (PORTABLE AP) Clip # Reason: pls eval interval change Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with SDH, Delirium, asp PNA, pulm edema REASON FOR THIS EXAMINATION: pls eval interval change ______________________________________________________________________________ FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view.",0
"INDICATION: Subdural hematoma, delirium, aspiration pneumonia and pulmonary edema, evaluate for interval change.",0
"FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position, and analysis is performed in direct comparison with a similar preceding study dated , cardiomegaly, bilateral interstitial edema and blunted pleural sinuses as before.",0
"Portable chest examination of a patient with SDH and chronic, rathere advanced, CHF.",0
"5:34 PM CHEST (PORTABLE AP) Clip # Reason: eval edema, effusions Admitting Diagnosis: THORACIC AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman s/p TAAA stent REASON FOR THIS EXAMINATION: eval edema, effusions ______________________________________________________________________________ WET READ: FBr 7:16 PM no acute intrathoracic pathology including no pneumonia or pulmonary congestion.",1
tiny left effusion might be present.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Status post AAA stent.,0
"FINDINGS: In comparison with the study of , there is no change in the appearance of the heart and lungs.",0
Mild blunting of the left costophrenic angle is suggested.,0
Endotracheal tube and central catheter have been removed.,0
11:54 AM CHEST (PA & LAT) Clip # Reason: eval for infiltrate and effusion Admitting Diagnosis: CHEST PAIN\CARDIAC CATHETERIZATION ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with s/p cabg and mv ring REASON FOR THIS EXAMINATION: eval for infiltrate and effusion ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: CABG.,1
There is interval improvement in pulmonary vascular congestion and small pleural effusions.,0
"An endotracheal tube, nasogastric tube, and right internal jugular sheath have been removed.",0
7:57 PM CTA HEAD W&W/O C & RECONS Clip # Reason: ?,0
"SAH Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with SAH, vasospasm, now new L frontal infarct REASON FOR THIS EXAMINATION: assess change, please do at 9pm No contraindications for IV contrast ______________________________________________________________________________ WET READ: YGd MON 9:12 PM No short interval change since .",1
Stable SAH and intraventricular extension allowing for redistribution.,0
No new parenchymal hypodensity to suggest ischemic infarct within limits of streak and motion artifacts.,0
Stable appearance of left M1 segment attenuation.,0
s/p L PCOM aneurysm coiling.,0
"- x ______________________________________________________________________________ FINAL REPORT HISTORY: Subarachnoid hemorrhage, vasospasm, now new left frontal infarcts.",1
TECHNIQUE: Contiguous axial CT images were obtained through the brain without contrast material.,0
"Subsequently, rapid axial imaging was performed from the skull base to the vertex during the infusion of intravenous contrast material.",0
"COMPARISON: CT of the head, ; CTA of the head, ; and also CTA of the head, .",0
"FINDINGS: Compared with the prior study, there is a new large area of diminished parenchymal density and sulcal effacement involving the left hemisphere in a left MCA distribution, best noted on image 23 of series 2, which is new compared to the prior study performed at 2:31 hours the same day.",0
The early subacute left MCA territory infarction present on the prior study earlier the same day is similar or possibly slightly larger in size.,1
The subarachnoid and intraventricular hemorrhage does not show significant change.,1
The ventricular catheter via a right frontal approach is not significantly changed in position.,0
The ventricular size is not significantly changed.,0
No new intraparenchymal hemorrhages are identified.,0
The left coil pack causes significant streak and beam hardening artifact limiting evaluation of the left PCom origin aneurysm.,0
There is no evidence of midline shift or downward herniation.,0
CTA HEAD: The coil pack limits evaluation of the left supraclinoid ICA as well as the proximal left MCA.,0
The internal carotid arteries are otherwise unremarkable.,0
The vertebral arteries and the basilar artery show normal post-contrast enhancement and caliber.,0
A fetal-type left PCA is present.,0
The left MCA M1 segment is narrowed compared to the right M1 segment which is (Over) 7:57 PM CTA HEAD W&W/O C & RECONS Clip # Reason: ?,0
"SAH Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) similar to that seen on the prior study, , although smaller than that seen on , likely representing stable vasospasm.",1
"There is no evidence of arterial occlusion, other arterial aneurysm, arteriovenous malformation, or AV fistula.",1
The remaining MCA and ACA branches are normal in caliber and post-contrast enhancement.,0
The PCA branches with the exception of a fetal-type anatomy are unremarkable.,0
"There is a new large region of left hemisphere hypodensity and sulcal effacement involving left MCA distribution (please see series 2, image 23), likely representing a large new infarction which was not definitely present on the prior study at 2:31 hours the same day.",0
"The early subacute left MCA infarction within the left MCA distribution, which was present on the prior study, is slightly larger than on the prior study and shows evolution.",1
The diffuse subarachnoid hemorrhage and intraventricular hemorrhage are unchanged.,1
No new hemorrhages are identified.,0
The ventricles are prominent and stable.,0
"CTA of the head demonstrates a small right M1 segment which is similar to that seen on the prior study, , although smaller compared with the study on , likely representing continued vasospasm of this vessel.",0
No new foci of vascular stenosis are identified.,0
No focus of left MCA occlusion is identified to explain the possible new left acute large infarction as described above.,1
"The above findings were discussed with Dr. at 12 p.m., , .",0
"9:10 AM CHEST (PORTABLE AP) Clip # Reason: interval change s/p pericardiocentesis Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man admitted with pericarditis, now with increasing O2 requirement, and cough.",0
"REASON FOR THIS EXAMINATION: interval change s/p pericardiocentesis ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:43 A.M. HISTORY: Pericarditis.",0
IMPRESSION: AP chest compared to through 3: Small bilateral pleural effusions which developed after have increased slightly.,1
Cardiomediastinal silhouette is slightly smaller today.,0
"Opacification at both lung bases has progressed, probably atelectasis, though pneumonia cannot be excluded.",0
Upper lobe vascular engorgement suggests borderline left heart dysfunction or volume overload.,0
Pericardial catheter projects over the middle of the heart shadow.,0
3:15 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with refractory chest pain REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Refractory chest pain with possible pneumonia.,0
"FINDINGS: In comparison with the study of , there is no change in the appearance of the heart and lungs, or the pacemaker device.",1
No evidence of acute pneumonia.,0
"5:23 AM CHEST (PORTABLE AP) Clip # Reason: volume status Admitting Diagnosis: (AML) ACUTE MYELOGENOUS LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman s/p allo sct severe GVHD of GI, sepsis for cellulitis, ATN, volume overload, increasing O2 requirements.",1
interval change REASON FOR THIS EXAMINATION: volume status ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Increased oxygen requirement in a patient with severe graft versus host disease.,1
The ET tube tip is more distally located now terminating less than 2 cm above the carina.,0
The Dobhoff tube is still proximal with its tip in the stomach.,0
There is marked worsening in bilateral perihilar opacities and basal consolidations especially in the right lower lobe.,0
The increase in _____ and pleural effusion cannot be excluded.,0
"The left subclavian line tip is terminating in mid SVC, unchanged.",0
IMPRESSION: Marked worsening of bilateral perihilar pulmonary consolidations especially in the right lung may represent worsening widespread infection underlying pulmonary edema cannot be excluded although it is likely giving the relatively patchy appearance of the consolidations.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: s/p r 57cm picc please do an oblque film unable to see tip o Admitting Diagnosis: LEFT UPPER LOBE LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with REASON FOR THIS EXAMINATION: s/p r 57cm picc please do an oblque film unable to see tip on previous film ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST Comparison to previous study of earlier the same day.,0
INDICATION: Oblique radiograph requested to assess tip of PICC.,0
Oblique radiograph centered on the right lung demonstrates the tip of the PICC terminating in the expected location of the mid to lower superior vena cava.,0
Evaluation of chest is limited but shows no gross interval change since the recent study allowing for technical differences.,0
BP (mm Hg): 117/60 HR (bpm): 68 Status: Inpatient Date/Time: at 18:42 Test: Portable TTE(Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Focused subcostal views obtained.,0
LEFT VENTRICLE: The left ventricular cavity is dilated.,0
Conclusions: The left ventricle is dilated with signficant systolic dysfunction.,0
The right ventricle is mildly dilated with good free wall motion.,0
There is no significant pericardial effusion.,0
11:26 AM CT HEAD W/O CONTRAST Clip # Reason: Fall - change in MS - eval for bleed on coumadin ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with REASON FOR THIS EXAMINATION: Fall - change in MS - eval for bleed on coumadin No contraindications for IV contrast ______________________________________________________________________________ WET READ: EKEK 12:05 PM NO BLEED ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old male with mental status change.,0
TECHNIQUE: Axial noncontrast CT imaging of the brain.,0
"COMPARISON: Comparison is made to a prior CT from , and MRI from .",0
"FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, or shift of midline structures.",1
A chronic area of infarction within the left temporal-parietal region demonstrates continued evolution when compared with the prior head CT. An area of encephalomalacia or widened CSF space along the medial right frontal lobe appears stable.,0
There is no CT evidence of acute major vascular territorial infarction.,1
IMPRESSION No evidence of acute intracranial hemorrhage or mass effect.,1
6:52 PM CHEST (PA & LAT) Clip # Reason: picc placement ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with picc REASON FOR THIS EXAMINATION: picc placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH PERFORMED ON COMPARISON: .,0
CLINICAL HISTORY: Assess PICC line position.,0
FINDINGS: Upright AP and lateral views of the chest were obtained.,0
There has been interval placement of a left upper extremity PICC line with its tip residing in the expected location of the superior vena cava.,0
Low lung volumes are noted.,0
The imaged portions of the lungs appear clear.,0
Tiny clips are seen along the left heart border.,0
IMPRESSION: Adequate position of new PICC line.,0
"6:57 AM CHEST (PORTABLE AP) Clip # Reason: Please perform exam at 6 AMassess for pnthx Admitting Diagnosis: PNEUMOTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man s/p MVC, now with adjustment of ETT, OGT, s/p removal of left chest tube, right chest tube to waterseal REASON FOR THIS EXAMINATION: Please perform exam at 6 AMassess for pnthx ______________________________________________________________________________ FINAL REPORT AP CHEST, 8:14 a.m. on .",1
IMPRESSION: AP chest compared to and 2: Tiny left apical pneumothorax is stable.,1
There is no right pneumothorax or any significant pleural effusion.,1
Right apical pleural tube still in place.,0
Mild persistent left basilar atelectasis.,0
The colon is persistently distended with gas.,0
1:35 PM CHEST (PA & LAT) Clip # Reason: evaluate for effusion - please do in afternoon Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate for effusion - please do in afternoon ______________________________________________________________________________ FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG.,1
"Small bilateral pleural effusions, left greater than right, with associated atelectasis, also left greater than left, have worsened.",0
Cardiac size cannot be evaluated.,0
Patient is status post CABG.,0
Patient has known minimal peripheral interstitial abnormality.,0
"10:59 AM CHEST (PORTABLE AP) Clip # Reason: eval for cardiopulmonary process ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with altered mental status, hypotension REASON FOR THIS EXAMINATION: eval for cardiopulmonary process ______________________________________________________________________________ FINAL REPORT INDICATION: Altered mental status.",0
"SINGLE PORTABLE AP SUPINE CHEST RADIOGRAPH: The cardiac, mediastinal, and hilar contours appear unremarkable apart from mild cardiomegaly.",0
No pleural effusions or pneumothoraces are identified.,0
No areas of consolidation are identified within the lung parenchyma.,0
There is mild interstitial prominence diffusely with mild pulmonary vascular redistribution.,0
IMPRESSION: Findings consistent with mild pulmonary vascular congestion.,0
"8:06 AM CT CHEST W/O CONTRAST Clip # Reason: further evaluation of soft tissue mass seen on CXR Admitting Diagnosis: SUBDURAL HEMATOMA Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man s/p drainage of SDH, noted to have mass on preop CXR REASON FOR THIS EXAMINATION: further evaluation of soft tissue mass seen on CXR No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT CHEST TECHNIQUE: Multidetector CT through the chest without oral or IV contrast.",0
5- and 1.25-mm collimation images were reviewed.,0
REASON FOR EXAM: Evaluate cause of leftward displacement of trachea seen in prior chest x-ray dated .,0
"FINDINGS: No mediastinal masses are present, leftward displacement of the trachea is due to an elongated non dilated brachiocephalic artery.",0
7-mm soft tissue nodule along the posterior wall of the distal trachea (2:14) may warrant further evaluation with bronchoscopy when the patient's condition improves.,0
Otherwise the airways are patent to the segmental level.,0
Left-sided pacemaker with leads in the right atrium and right ventricle.,0
Some of the non-enlarged paratracheal lymph nodes are calcified.,0
No hilar or mediastinal lymphadenopathy is present.,0
Fractures in the posterior aspect of the second to seven left ribs are of unknown chronicity.,0
No bone findings of malignancy.,0
Small stones are in the gallbladder lumen.,1
Simple cyst in the left kidney is incompletely imaged.,0
Otherwise the upper abdomen is unremarkable.,0
Leftward displacement of the trachea is due to elongated brachiocephalic artery.,0
Soft tissue nodule in the posterior wall of the trachea may warrant further evaluation with bronchoscopy when the patient's condition improves.,0
(Over) 8:06 AM CT CHEST W/O CONTRAST Clip # Reason: further evaluation of soft tissue mass seen on CXR Admitting Diagnosis: SUBDURAL HEMATOMA Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont) 6.,0
Incompletely imaged simple cyst in the left kidney.,0
Findings were discussed with Dr. at the time of dictation of the study.,0
9:18 AM CHEST (PORTABLE AP) Clip # Reason: Assess for new infiltrates.,0
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with ICH now spiking fevers REASON FOR THIS EXAMINATION: Assess for new infiltrates.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 09:30 INDICATION: Fevers.,0
FINDINGS: The lungs remain clear of focal consolidation and the lateral costophrenic sulci are sharply marginated.,0
A Dobbhoff catheter is seen with the tip just below the left hemidiaphragm high in the left upper quadrant of the abdomen.,0
"8:45 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: r/o acute process, new onset need of O2 to meet sats Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man POD from panc necrosectomy/IVC filter placement/repeat pancreatic debridement.",1
"REASON FOR THIS EXAMINATION: r/o acute process, new onset need of O2 to meet sats ______________________________________________________________________________ FINAL REPORT HISTORY: 60-year-old man status post pancreatic necrosectomy and debridement with new oxygen needs.",0
"CHEST AP: Cardiac, mediastinal and hilar contours are stable.",0
Left-sided pleural effusion and linear atelectasis is not significantly changed.,0
Right-sided PICC is in unchanged position.,0
IMPRESSION: Overall stable radiographic appearance of the chest with moderate left pleural effusion and linear left lower lobe atelectasis.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Demerol Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: cardiac catheterization, stents x 2 (left main, LAD) History of Present Illness: 81yo M with DM, HTN, CAD with recent hospitalization at for CP and SOB.",0
"At the time of this visit, he ruled out by enzymes but was found on diagnostic cardiac catheterization to have a 90% LAD; there was no therapeutic intervention at that time.",0
"He was subsequently referred to Dr. who had considered an outpatient intervention; however, Mr. had instead opted to undergo an elective cardiac catheterization in , where he could convalesce with his daughter.",0
"In preparation for the trip to , the patient awoke from sleep on at 01:30 on with chest pain and shortness of breath, which resolved with SL nitro x1.",0
He subsequently went to where his first Trop-I was 0.27 and d-dimer was negative (Cr 1.4).,0
"Given his known cardiac disease he was started on a hep gtt, integrillin gtt, and an NG patch was administered.",0
"In addition, the pt was given solumedrol and ceftriaxone/azithromycin for presumed COPD/PNA.",0
"Due to his known LAD lesion, he was transferred to for further care.",0
"In the ED, he was afebrile with HR of 74, SBP of 97, but was requiring NRB to maintain SaO2 in the mid 90s.",0
the pt had one episode of chest pain which resolved with SL NTG x3.,0
"He reported SOB and DOE in associated with his CP but denied any palpitations, PND, orthopnea, edema, presyncope or syncope.",0
He was started on heparin gtt and integrillin gtt and admitted to CCU.,0
CAD s/p diagnostic cath at with 90% LAD 2.,0
TB s/p left lobectomy ' 7.,0
Colon CA s/p colectomy 8.,0
Arthritis 10. s/p hernia repair x2 .,0
s/p hand surgery Social History: Patient resides alone in a housing project for the elderly.,0
"He admits to drinking beer, approximately 3+ beers per day.",0
"He denies any history of DT's, seizure, or other alcohol withdrawal symptoms.",0
He has a history of tobacco abuse but states that he quit in the 's.,0
"Family History: Non-contributory Physical Exam: VS: T: 99, HR: 79, BP: 95/49, RR: 19, SaO2: 95% on 2L NC O2 GEN: elderly male sitting upright in bed, in NAD.",0
Conversing appropriately in full sentences.,0
"HEENT: EOMI, OP clear, mmm NECK: supple, no JVD CV: RRR, S1, S2, no m/r/g CHEST: posterior left chest wall scar from prior thoracotomy, lungs with expiratory wheezes, decreased breath sounds over left upper lobe ABD: soft, NT, ND, BS+ EXT: 1+ edema bilaterally, no clubbing or cyanosis NEURO: A+O x3 Pertinent Results: STUDIES: 10:56PM BLOOD CK-MB-20* MB Indx-1.0 cTropnT-0.22* 05:58AM BLOOD CK-MB-24* MB Indx-1.1 cTropnT-0.38* .",0
"CXR : ""Heterogeneous opacification in the lower lungs, right substantially greater than left could be due to pneumonia.",0
"Vascular deficiency in the upper lungs suggests emphysema and rib deformities in the left chest suggest previous thoracotomy.""",0
"ECG : NSR at 90, left axis, left anterior fascicular block, TWI in L, occasional PVC.",0
05:58AM BLOOD Triglyc-112 HDL-46 CHOL/HD-4.0 LDLcalc-115 TTE: Conclusions: The left atrium is mildly dilated.,0
There is regional left ventricular systolic dysfunction.,0
Resting regional wall motion abnormalities include distal LV and apical hypokinesis.,0
IMPRESSION: Regional LV systolic dysfunction c/w CAD.,0
"The proximal LMCA lesion was predilated with a 2.5 X 12mm Maverick balloon, stented with a 3.0 X 08mm Cypher stent and post dilated with a 3.5 X 12mm Maverick and a 3.0 X 15mm NC Ranger balloon with lesion reduction from 80 to 10%.",0
"The mid LAD lesion was predilated with a 3.0 X 20mm Maverick balloon, stented with a 3.0 X 28mm Cypher stent and post dilated with a 3.0 X 15mm NC Ranger balloon with lesion reduction from 99 % to 0%.",0
Critical LMCA lesion successfully treated with stenting (Drug eluting) 2.,0
Successful stenting of the LAD (Drug eluting) .,0
"CXR ""Improvement of multifocal pneumonia.",0
"Stable post-surgical changes and emphysema.""",0
"Brief Hospital Course: A/P: 81yo M with known 90% LAD lesion, DM, and COPD p/w chest pain and shortness of breath in setting of new PNA.",0
CV: A. Coronaries: The pt presented with known h/o CAD.,0
He had recently undergone a diagnostic catheterization which detected 90% LAD lesion.,0
"Given the clinical presentation with symptoms of chest pressure, SOB, and persistently elevated cardiac enzymes, he underwent catherization with stent placement in two vessels on .",0
During his post-catheterization convalescence integrilin and heparin drips were discontinued.,0
He was started on chronic anti-platelet therapy with ASA 325 mg and Plavix 75mg.,0
"In the peri-MI setting, his outpatient regimen of Zocor 40 mg qday was changed to Lipitor 80 mg qday.",0
His beta-blocker and ACEI were titrated to doses of Atenolol 75 mg qday and Lisinopril 5 mg qday to achieve goals of heart rate<80 and BP <130/80.,0
In the peri-MI setting his outpatient Felodipine was discontinued for improved mortality.,0
"Pump: Post-catherization TTE revealed diminshed EF of 45% with distal LV and apical AK, nml valves.",0
"In the setting of heart failure, he was diuresed with furosemide 20mg PO daily and was discharged home on this dose.",1
C. Rhythm: The pt was maintained throughout his hospitalization in NSR with consistent findings on exam and telemetry.,0
"PNA: The pt was found on admission to have heterogenous opacifications in the lung bases, suggestive of an infiltrate.",0
This radiographic finding was further substantiated by his elevated WBC and oxygen requirement.,0
"Upon admission, he received 3 days of ceftriaxone and azithromycin and then was switched to levofloxacin 500 mg on day 4 of antibiotic therapy.",0
Mr. was discharged with RX for 7 additional days of antibiotic therapy to complete 14-day course.,0
"However, even with radiographic improvement of the pneumonia, he continued to require supplemental oxygen, both at rest and with activity, likely secondary to underlying lung disease and a picture of chronic hypoxia.",1
"He had a persistent cough throughout hospitalization and in the 48 hours prior to discharge had one episode of coughing up a moderate amount of blood clots, and the subsequently noted blood-tinged sputum.",0
"No changes were noted on chest x-ray at this time, and this was considered to be most likely secondary to his acute cough and trauma to the oropharynx.",0
"He remained hemodynamically stable, and was advised to return to the ER in the case of gross hemoptysis or to follow-up with his PCP in the case of persisting blood in his sputum.",0
COPD: No PFTs were available to us documenting the severity of his likely chronic lung disease.,0
"Given his h/o TB, s/p left thoracotomy, and h/o tobacco abuse, he was treated as if a COPD exacerbation were part of his clinical picture.",0
He was started as an in-patient on a Prednisone taper and jet nebulizer treatments with only mild improvement in his respiratory status.,0
"He was noted by PT to desat to 83-88% with ambulation on room air, and he was recommended repeatedly for home oxygen.",0
He refused the attempts to set up home oxygen for him on multiple occasions.,0
He was discharged with a prescription for an Atrovent MDI and with explicit instructions to complete the prednisone taper.,0
"DM: His blood sugars were noted to be labile throughout the hospitalization, likely secondary to the prednisone taper and his chronic DM.",0
"Initially, his blood glucose was managed with sliding scale insulin and NPH.",0
"Prior to discharge, he was controlled on an oral hypoglycemic and instructed to resume management at home with Glucophage 500 mg.",0
He was instructed that Glucophage was preferable to his previous regimen of Glyburide given his episodic hypoglycemia as an in-patient.,0
Arthritis/Neuropathy: The pt has pain from arthritis and neuropathy most likely secondary to his long standing DM.,0
He was continued on his home regimen of Neurontin 300 mg TID during this hospitalization.,0
FEN: He was fed with a cardiac heart healthy diet.,0
Electrolytes were repleted as needed to maintain K>4 and Mg>2.,0
"In the setting of his CHF, he underwent daily diuresis with Lasix 20 mg qday to maintain an even or negative fluid balance, and he was discharged with instructions to continue this regimen as an outpatient.",0
PPx: Patient received Protonix for GI prophylaxis and heparin for DVT prophylaxis.,0
Medications on Admission: MEDICATIONS: 1.,0
ASA 81mg once daily 2.,0
Lisinopril 10mg once daily 4.,0
Felodipine 2.5mg once daily 5.,0
Isosorbide Mononitrate 60mg once daily 6.,0
Darvocet 100mg TID PRN 11.,0
ALLERGIES: Demerol Discharge Disposition: Home Discharge Diagnosis: Unstable angina Pneumonia Discharge Condition: Good.,0
Patient desats into high 80's on room air with activity but has declined recommendation for supplemental oxygen at home.,0
Discharge Instructions: 1) You had a cardiac catheterization and placement of stents in the arteries that supply blood to your heart.,0
"You were started on new medications, one of which is called clopidogrel (or Plavix), which is important for keeping blood flowing through the stents.",0
It is very important that you continue to take this medication; do not stop taking it unless you discuss it with your cardiologist.,0
Stopping this medication on your own may result in death.,0
"* 2) You will also need to complete an additional 7 day course of levofloxacin, an antibiotic therapy for your pneumonia.",0
* 3) Your aspirin dose has been increased from 81 mg daily to 325 mg daily.,0
* 4) Your anti-lipid has been changed from Zocor to Lipitor.,0
* 5) Your Lisinopril dose has been decreased to 5 mg daily.,0
"If you have remaining 10 mg tablets, you may break them in half.",0
* 6) A new medication Lasix has been added to your regimen.,0
* 7) Your beta-blockade has been changed.,0
Discontinue your previous prescription of Metropolol and start Atenolol as prescribed in its place.,0
* 8) Your Felodipine was discontinued.,0
"* 9) Instead of your previously prescribed Albuterol inhaler, you should use the Atrovent inhaler 4x daily, as prescribed.",0
"* 10) You were started on a steroid taper (prednisone) to improve your respiration, which you will need to continue following your discharge.",0
"It is important that you take this medication as directed, since stopping this medication prior to the end of the complete course may have adverse effects.",0
"Starting tomorrow morning, take a dose of 30 mg for 3 days, followed by 20 mg for 3 days, then 10 mg for 3 days, then 5 mg for 3 days.",0
"* 11) Please call your doctor or return to the emergency room if you have recurrent chest pain, shortness of breath, if you cannot eat drink or take your medications, if you have bleeding from groin, or you develop any other symptoms that are concerning to you.",0
"Followup Instructions: Patient was instructed to return to the ER in the case of gross hemoptysis, chest pain, or shortness of breath.",0
He was instructed to follow-up with his PCP in the event of persistent blood-tinged sputum.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: UGIB, ?infection Major Surgical or Invasive Procedure: ERCP Messenteric catheterization +/- embolization History of Present Illness: This is a 67 y.o male with h.o metastatic RCC to the pancreas, recent ICU course for UGIB (12units pRBCs) who reports sudden intermittent chills since wednesday for which he took tylenol.",1
"Pt also reports R.side gnawing rib pain, while lying in bed before the onset of chills.",0
"In addition, pt reports dark stools for the last few days which started after taking ""iron pills"".",0
"Pt states he went to ED because of a fever of 101.3, however he felt better and did not want to wait to be seen.",0
"He returned to today and was transferred to after a dose of zosyn, HCT 25.",0
"Pt denies headache/dizziness/blurred vision, URI/cough, sick contacts, CP, +palp when anxious, -abd pain/n/v/d/brbpr, dysuria/hematuria, joint pain, rash, paresthesias.",0
"At , pt found to be hypotensive to 75/40, asymptomatic.",0
"He was given 3L IVF, lactate 6.8.",0
HCT 22.8 from a baseline of 35 a few weeks ago.,0
"He was found to have black, guaiac +stool.",0
"GI saw pt, pt s/p stent to pancreatic ampulla, ?blocked from blood.",0
"Plan is to transfuse, ERCP tomorrow.",0
ED also treated for possible cholangitis/sepsis and pt was given dose of vanco.,0
"Vitals 99.2, BP 99/66 HR 88 sat 98% on RA.",0
"Access 3PIV's 2, 20's, 18.",0
Pt also found to be in ARF.,0
"Currently, pt reports that he is anxious.",0
"Perifosine restarted for one week, held on due toSBO requiring hospital admission in , and restarted again on .",0
"Reports quit smoking , former 1/2ppd, quit ETOH as well in , no drug use Family History: Non-contributory Physical Exam: Per admission note: vitals:T. 96.9, BP 102/65, HR 92, RR 27, sat 96% on RA gen-nad, lying in bed, appears stated age, cooperative, anxious HEENT-perrla, eomi, anicteric, mmm, poor dentition neck-no lad, no JVD, supple chest-b/l ae no w/c/r heart-s1s2 +2/6 systolic flow murmur, no r/g abd-+bs,soft, NT, ND, +irregular hepatomegaly, ~2cm below costal margin, +abdominal masses ext-no c/c/e 2+pulses neuro-aaox3, CN2-12 intact, non-focal.",0
Pertinent Results: 07:36PM WBC-5.1 RBC-2.82*# HGB-7.5*# HCT-22.8*# MCV-81* MCH-26.6* MCHC-32.8 RDW-18.1* 07:36PM NEUTS-73* BANDS-14* LYMPHS-9* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 07:36PM PLT SMR-NORMAL PLT COUNT-142* .,0
07:36PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+ BURR-1+ .,0
07:36PM PT-15.6* PTT-35.0 INR(PT)-1.4* .,0
07:36PM GLUCOSE-78 UREA N-28* CREAT-1.6* SODIUM-141 POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-13* ANION GAP-22* 07:36PM ALT(SGPT)-59* AST(SGOT)-59* LD(LDH)-181 CK(CPK)-14* ALK PHOS-513* TOT BILI-2.5* 07:36PM LIPASE-12 .,0
07:36PM cTropnT-<0.01 07:36PM CK-MB-NotDone .,0
"TRENDS: HCT: Admit -> 23, 27, 22, 25, 27, 34, 28, 27, 26, 22, 28 .",0
"Bands on Diff: Admit -> 14, 10, 7, 0 .",0
07:42PM BLOOD Lactate-6.8* 02:52AM BLOOD Lactate-4.8* 05:30AM BLOOD Lactate-3.3* 02:22PM BLOOD Lactate-1.8 .,0
"ECG:sinus, poor baseline, similar morphology to EKG.",0
Imaging: CXR: : Added density behind the left heart border in the left lower lobe may represent a focus of pneumonic consolidation; alternatively metastases from the known metastatic renal cell cancer cannot be entirely excluded.,0
CT would be of benefit for further evaluation.,0
A CBD stent is seen in the upper abdomen.,0
Liver U/S : Increase in size and number of hepatic mets.,0
CBD or stent not seen.,0
Portal vein remains occluded with numerous collaterals.,0
Gallladder wall thickening and edema but no focal tenderness during scanning.,0
Large hypoechoic mass in the region of the pancreatic head not well assessed due to overlying bowel gas.,0
"""findings equivocal for cholecystitis, stones"" .",0
No filling defects within previously placed metallic common bile duct stent.,0
"Smooth impression on the common bile duct, proximal to stent, suggests extrinsic compression.",0
Please refer to GI procedural note for further details.,0
"MESSENTERIC CATHETERIZAION +/- EMBOLIZATION: ***Prelim Report*** Gastrointestinal arteriograms demonstrated massive tumor staining from multiple feeding arteries originating from celiac artery, superior mesenteric artery, and isolated pancreatic artery without active ______.",0
"Brief Hospital Course: 67 y.o male with metastatic RCC who presents with HCT drop, melena, recent fever, hypotension.",0
#melena/HCT drop - Pt has h.o GIB in past that were secondary to bleeding metastasis.,0
Pt had recent admit to MICU course where angiography was performed to stop bleeding.,0
"Hct on admit was 22.8, down from 35 on discharge.",0
"Patient underwent ERCP in which showed ulcerated mass at duodenum, able to temporarily stem blood flow.",1
"On day 3 of ICU stay he had more melena and was taken by IR for messenteric catheterization +/- embolization, but were unable to isolate source of bleeding.",0
"Melena continued and ERCP, IR and surgery say pt is not eligible for further interventions to stop the bleeding.",0
Pt continued to be transfused units of PRBC while H/H was being followed.,0
"This was consistent with patient's stated goals of living long enough to make it to hospice care, where he can be closer to family.",0
"# Infection - Pt with fever, normal white count but with bandemia, recent RUQ/rib pain.",0
"Slightly elevated LFT's, elevated bili -> RUQ u/s finding gallbladder wall thickening and edema, ""possible cholecystitis"".",1
Pt completed a total of 7 days of Vancomycin and Pip/Tazo.,0
# Metastatic RCC - Pain controlled.,0
Heme met with family offered chemo for one final round but with the caution that this could make the duodenal met bleed faster.,0
The patient and family did not want to pursue this.,0
# Lactic acidosis - likely from poor perfusion secondary to recent hypotension and infection.,1
Could also be secondary to metastatic disease.,0
"#ARF - baseline 0.9-1.0, admitted at 1.6.",0
"Likely prerenal in the setting of hypotension, hypovolemia.",0
"#HTN-currently normotensive, hold home anti-HTN medications.",0
# Anxiety - receiving scheduled ativan per pt request.,0
# Thrombocytopenia: - PLT count now improving - no heparin d/t bleed - HIT Ab negative - Transfused prn for bleeding .,0
CODE: DNR/DNI DISPO: discharged to hospice care: Family Hospice House - .,0
"Medications on Admission: allopurinol 100mg,2 tabs daily atenolol 50mg daily diltiazem 180mg, 2 capsules daily nexium 40mg daily lisinopril 40mg daily lorazepam 0.5mg 1-2tabs q6h prn anxiety compazine 5mg 1-2tab nausea acetaminophen 500mg Q6h prn ferrous sulfate 325mg 1 daily.",0
Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea.,0
Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours).,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed.,0
Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed.,0
Discharge Disposition: Extended Care Facility: Family Hospice House Discharge Diagnosis: # Gastrointestinal bleed; ongoing # Cholecystitis/Cholangitis # Metastatic renal cell carcinoma # Acute renal failure; resolved # Thrombocytopenia Discharge Condition: poor; dying.,1
Discharge Instructions: Patient is being discharged to hospice.,0
Please take medications as necessary for patient comfort.,0
"Followup Instructions: Provider: , MD Phone: Date/Time: 3:30 Provider: , MD Phone: Date/Time: 3:30",0
Height: (in) 62 Weight (lb): 273 BSA (m2): 2.18 m2 BP (mm Hg): 107/57 HR (bpm): 86 Status: Inpatient Date/Time: at 14:47 Test: Portable TTE (Focused views) Doppler: Limited Doppler and no color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
MITRAL VALVE: Mild mitral annular calcification.,0
"There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the septum and anterior walls, and distal inferior wall.",1
The apex is mildly aneurysmal and akinetic.,0
The remaining segments contract well (LVEF 30%).,0
There is no pericardial effusion..,0
10:05 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for pneumo Admitting Diagnosis: BOORHAAVE'S ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with Boerhaave's and multiple chest tube placement with accidental removal earlier REASON FOR THIS EXAMINATION: eval for pneumo ______________________________________________________________________________ FINAL REPORT INDICATION: Reevaluate after accidental recent chest tube removal in a patient with Boerhaave's syndrome.,0
"Prior history of endovascular stenting of the ascending, arch and descending thoracic aorta as well as ascending aorta to innominate artery.",0
The patient also had a left carotid artery bypass and a right axillofemoral bypass.,0
Multiple surgical re-interventions in .,0
COMPARISON: Prior chest x-ray from earlier today at 13:43.,0
TECHNIQUE AND FINDINGS: A single view frontal chest radiograph was obtained at the bedside in an upright position.,0
"There has been interval accumulation of additional fluid in the left basilar pleural effusion, now with complete obscuring of the cardiac apex.",0
The left apical and axillary pneumothorax is also mildly worsened.,0
The three left and single right chest tubes appear in similar position as before.,0
There is stable atelectasis at the right base.,0
"There is unchanged appearance and position of the tracheostomy tube, mediastinal clips, sternotomy wires, aortic stent, and left lateral thoracic cutaneous metallic staples.",0
Prior costotomy site is again seen at the level of the lateral arch of the left eighth rib.,0
CONCLUSION: Moderate re-accumulation of fluid in the left basilar pleural effusion.,0
Mild worsening of the left apical pneumothorax.,0
Otherwise unchanged appearance as compared to earlier today at 13:43.,0
"7:12 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Evaluate NGT placement Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;ACUTE SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with NGT REASON FOR THIS EXAMINATION: Evaluate NGT placement ______________________________________________________________________________ WET READ: JBRe SAT 12:55 AM Unchanged large bilateral effusions, moderate CMG and mod to severe edema.",1
"______________________________________________________________________________ FINAL REPORT AP CHEST, 7:42 P.M., HISTORY: Check NG tube placement.",0
IMPRESSION: AP chest compared to through at 9:53 a.m.: New nasogastric tube ends in the upper stomach.,0
"Large left pleural effusion unchanged, large right pleural effusion decreased minimally.",0
Pulmonary vascular engorgement has improved.,0
Left lower lobe is still largely atelectatic.,0
"7:40 AM CHEST (PORTABLE AP) Clip # Reason: 89 year old man with PNA, intubated.",0
"Admitting Diagnosis: PNEUMONIA; POST RESPIRATORY ARREST ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with PNA, intubated.",1
"REASON FOR THIS EXAMINATION: 89 year old man with PNA, intubated.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 89-year-old man with pneumonia, and intubated.",0
TECHNIQUE: AP portable semi-erect radiograph at 7:50 a.m.,0
FINDINGS: Endotracheal tube with tip 6.3 cm above carina.,0
Right IJ with tip at the mid SVC.,0
"Nasogastric tube with tip below GE junction, not imaged.",0
Stable large opacification in the right mid lung.,0
New interval worsening in retrocardiac opacity.,0
Costophrenic angles are incompletely imaged.,0
Stable large right mid lung consolidation.,0
New intreval increase in retrocardiac opacity concerning for interval left lower lobe consolidation.,0
"12:15 PM CHEST (PORTABLE AP) Clip # Reason: pls assess interval change Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 71yo man with Advanced Parkinson's Disease, HTN and COPD with SBO and sepsis.",1
REASON FOR THIS EXAMINATION: pls assess interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Parkinson's disease with hypertension and COPD with sepsis.,1
"FINDINGS: In comparison with the study of , the patient has taken a somewhat poor inspiration.",0
The degree of elevation of pulmonary venous pressure is less than on the prior study.,0
No definite acute focal pneumonia.,1
"There is mild prominence of the ascending aorta, which could be consistent with the clinical diagnosis of hypertension.",0
"However, no evidence of cardiomegaly.",0
Height: (in) 62 Weight (lb): 145 BSA (m2): 1.67 m2 BP (mm Hg): 93/47 HR (bpm): 94 Status: Inpatient Date/Time: at 12:31 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Normal IVC diameter (<2.1cm) with 35-50% decrease during respiration (estimated RAP (0-10mmHg).,0
"Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg).",0
IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function.,0
Mild mitral regurgitation with normal valve morphology.,0
1:43 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"pna ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with found down, head bleed REASON FOR THIS EXAMINATION: ?",0
pna ______________________________________________________________________________ FINAL REPORT INDICATION: Found down with possible head bleed.,0
UPRIGHT AP VIEW OF THE CHEST: The heart size is mildly enlarged.,0
There are patchy opacities in both lung bases most likely representing atelectasis.,0
The pulmonary vascularity is non-engorged.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Weakness, Cough and SOB Major Surgical or Invasive Procedure: None History of Present Illness: 54 y/oM with HIV on HAART (viral load undetectable, last CD4 in 374), stage IV squamous lung CA s/p RUL s/p lobectomy, chemo/XRT, local and distal recurrence, HCV who p/w worsening fatigue, weakness, increasing dyspnea and new pleuritic chest pain.",1
"was in USOH (able to ambulate on flat ground ~ 1mi w/o DOE, independent in majority of ADLs) until ~ 1wk ago when he develped malaise and fatigue.",0
"Over the next few days he developed a dry cough, which by 3 days PTA became productive of yellow/green sputum.",0
At the same time he developed left sided pleuritic chest pain.,0
"He never had subjective fevers or chills, no nightsweats, though had ~ 10-12lbs of wt loss over the past month.",0
"By 2 days PTA, his dyspnea had worsened to the point that he was unable to perform ADLs and required assisstance from his mother.",0
"has had weakness in RUE and has had difficulty using that arm, but this is unchanged from prior.",0
"Has not been exposed to anyone with RFs for TB, no recent travel.",0
Has not skipped any of the meds.,0
He had respiratory distress requiring intubation for hypoxemic failure in after his right thoracotomy and right upper lobectomy.,1
"In the ED initial VS were 97.9 82 116/79 16 he desaturated to 88% on RA, increased to 93% with 2L NC.",0
"CTA showed a small LLL PNA with no evidence of PE, and enlarging right apical tumor.",0
"Blood cultures were drawn and was treated with zosyn, bactrim, vancomycin.",0
"He was admitted to the floor and had a slowly increasing O2 requirement to the point that this AM was satting 86% on 6L NC, requiring an NRB.",0
He became more confused and sleepy per nursing staff.,0
"On evaluation, VS were 99.8F 106/72 88 26 93% on NRB, using accessory muscles of respiration and nasal flaring and tachypneic.",0
"STAT ABG was pH 7.40 pCO2 50 pO2 67, which was essentially unchanged from the one prior.",0
"He c/o of SOB and appeared slightly sleepy, though arousable to voice.",0
"Review of systems: (+) Per HPI, chronic weakness and tingling in right arm, otherwise negative in detail.",0
"Past Medical History: - stage IV squamous cell lung cancer (Superior sulcus, T3, N0 at presentation) - dx with biopsy right lung apex squamous cell carcinoma.",0
"- s/p right upper lobectomy in - localized recurrence: Right lung apex in rx with CTX and cyberknife - - metastatic dx: T1-T2 neural foramina and nerve roots - palliative CTX w/ gemcitabine d/ced due to liver dysfunction other medical history - Hx of Pulmonary Aspergillus fumigatus infection dx w/ BAL , tx w/ voriconazole, resolution in .",1
"- HIV on HAART, : viral load undetectable; CD4 count 374 - HCV: genotype 1a, bx - pulmonary aspergillus dx on BAL s/p voriconazole rx - hx of + ppd s/p rx with INH - hypotestosterone - polysubstance abuse - depressive d/o - arthritis s/p R shoulder replacement .",1
"Social History: - unemployed, disabled.",0
"Living at home with his mother - recovering addict (heroin, ETOH, other drugs) - tobacco use: formerly smoked 1ppd, now cigarettes daily - not currently sexually active, partners have been female Family History: FH: aunts w/lung cancer in 40s and 50s.",1
"father alive w/o CA, mother w/ asthma and s/p removal of breast lesion.",0
"Physical Exam: General Appearance: Thin, cachectic, appeared fatigued Eyes / Conjunctiva: Conjunctiva pale, R horners Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, No(t) Supraclavicular WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no m/r/g Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: right apex and laterally, Rhonchorous: throughout), no crackles appreciated Abdominal: Soft, ND, no shifting dullness Extremities: Clubbing, UEs and ; no edema, dry, warm Musculoskeletal: Muscle wasting Skin: Warm Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed, awakened eailsy to command and answered questios appropriately, inquired about status.",0
"R horners, EOMi, face symmeteric, intact to LT b/l, symmetric smile, tongue midline, tremor.",0
Mild biceps and finger flexion weakness.,0
Pertinent Results: 04:42AM BLOOD WBC-12.6* RBC-3.55* Hgb-13.4* Hct-40.1 MCV-113* MCH-37.8* MCHC-33.5 RDW-14.1 Plt Ct-148* 01:45AM BLOOD WBC-12.0* RBC-3.29* Hgb-12.3* Hct-36.9* MCV-112* MCH-37.3* MCHC-33.2 RDW-14.1 Plt Ct-129* 04:23PM BLOOD WBC-11.6* RBC-3.38* Hgb-12.8* Hct-39.3* MCV-116* MCH-38.0* MCHC-32.7 RDW-14.4 Plt Ct-132* 03:54PM BLOOD Lactate-2.2* 11:14PM BLOOD Lactate-1.2 08:59AM BLOOD Lactate-1.5 10:28AM BLOOD Lactate-1.4 06:51AM BLOOD Lactate-1.2 CXR: FINDINGS: Portable AP upright view of the chest is obtained.,0
Post-surgical changes related to prior right upper thoracotomy and reconstruction as well as right upper lobectomy are again noted.,0
"There is subtle increased nodular opacity at the left lung base, which raises concern for pneumonia.",0
"No large pleural effusions are seen, though the right CP angle is excluded.",0
Left humeral head prosthesis is noted.,0
IMPRESSION: Findings concerning for left basilar pneumonia.,0
"Brief Hospital Course: Mr. was a 54 yo man with HIV on HAART (viral load undetectable, last CD4 in 374), stage IV squamous lung CA s/p RUL s/p lobectomy, chemo/XRT, local and distal recurrence, HCV who presented with worsening fatigue, weakness, increasing dyspnea, new pleuritic chest pain, sputum production and confusion.",0
"# Stage IV lung CA: On presentation, Mr. had an apical mass expanding, adrenal mass on CTA suspicious for metastasis and radicular symptoms in right arm likely nerve compression but per Pain Clinic.",0
"On hospital day six, Mr. reported significnt concern over a new foot drop on the right which progressed to include right leg paralysis and numbness.",0
An MRI of the Spine revealed metastatic tumor cord compression at C7 to T3 with significant stenosis at T2.,0
Neuro-Surgery determined that he was a poor surgical candidate because of the extensive surgical debridment required or and high-risk nature of the surgery.,0
Radiation Oncology evaluated him and determined that re-radiation was unlikely to improve his symptoms because of poor tumor response in the past.,0
Pain control was maintined and he with his mother decided that inpatient hospice with a change of code status to DNR/DNI would be best for Mr. .,0
"# HYPOXIC RESPIRATORY FAILURE, CHRONIC - He was found to have a LLL consolodation consistent with a LLL pneumonia.",1
The pneumonia was believed to be aspiration vs. CAP and sputum culture failed to identify a pathogen.,0
"He recieved 7 days of imperic antibotics with azithromycin, ceftriaxone and flagyl which seemed to have resolved the pneumonia, but he continued to difficulty oxygenating.",0
A PE was ruled out w/ CTA.,0
And a Bubble study and Echo did not further identifying cause of hypoxia.,0
He was aided by albuterol nebs Q2 hours and ipratropium nebs Q6H PRN.,0
"In the setting of his lobectomy and recurrent lung cancer, his new hypoxia was believed to represent a new baseline oxygen need.",0
# ALTERED MENTAL STATUS ?,0
Mr. several paroxysmal episodes of profound agitation and combativeness that responded best to zyprexa 5mg.,0
These may have occured due to metabolic derangement in setting of tumor burden or possibly brain mets.,0
Bx in -chronic viral hepatitis C with grade 2 inflammation and stage 2 fibrosis.,1
No stigmata of acute liver failure or cirrhosis.,0
"- HCV VL = 9,060,000 .",0
# HIV/AIDS on HAART: CD4 374 in with undetectable VL.,0
Has had apthous ulcers recently.,0
- cont current antiretroviral medications - f/u CD4 count.,0
- nystatin swish and swallow .,0
"# Code status: DNR/DNI comfort measures only # Communication: Patient and mother ) FYI: Pain medications over the last 24 hours, patient required a total of morphine 52mg IV, morphine SR 60mg po, morphine IR 105mg po and a one-time dose of morphine SR 90mg at noon.",0
"Discharge Instructions: You were admitted to the hospital with fatigue, weakness and difficulty breathing.",0
You were treated for a pneumonia which improved your breathing.,0
You were found to have a spinal metastatic cancer causing right leg weakness.,0
You and your mother considered available options and decided to pursue hospice care.,0
"Followup Instructions: Please consult Dr. , MD Phone: or Dr. , MD Phone: with questions about your condition.",0
11:48 AM CT HEAD W/O CONTRAST Clip # Reason: r/o re-accumulation of SDH patient decompensated after place ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with hx of rt sided cva with hemiplegia- possible new facial droop also s/p fall REASON FOR THIS EXAMINATION: r/o re-accumulation of SDH patient decompensated after placement of bedside drain.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of right sided CVA with hemiplasia and possible new facial droop.,0
Patient has a known subdural hematoma on the right with recent decompensation after placement of bedside drain.,0
FINDINGS: There has been interval placement of a subdural drain and drain from the right frontal approach.,0
There is new high attenuation material within the subdural collection which was not present one day previously.,0
The greatest dimension of the subdural collection currently measures 2.5 cm.,0
This is increased slightly from the prior study.,0
"Again, there is new acute blood within this collection as well as air.",0
The blood tracks over the right cerebral hemisphere including the temporal and parietal lobes.,0
There is significant shift of the midline structures and subfalcian herniation.,0
The right frontal is nearly completely compressed.,0
The right occipital is obliterated.,0
"There is dilation of the left ventricle, not significantly changed.",0
There is no definite uncAL herniation.,0
No intraventricular blood is present.,0
No traumatic skull fractures are present.,0
There is significant soft tissue swelling overlying the right frontal area.,0
The orbits and paranasal sinuses are unchanged.,0
IMPRESSION: S/P subdural drain placement with new acute hemorrhage within the subdural collection and slightly worsened subfalcian herniation to the right.,1
These findings were relayed immediately to the neurosurgical staff caring for the patient.,0
The patient is going to the operating room at this time.,0
"5:34 PM CHEST (PORTABLE AP) Clip # Reason: assess for PTX Admitting Diagnosis: STATUS POST MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman s/p R. chest tube removed, EP pacing wires removed REASON FOR THIS EXAMINATION: assess for PTX ______________________________________________________________________________ WET READ: DSsd SAT 6:39 PM Slightly decreased size of small biapical pneumothoraces.",1
"1./, 18:45 ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumothorax.",0
"Single portable radiograph of the chest demonstrates small persistent bilateral pneumothoraces, similar to that noted on .",1
Previously demonstrated pneumopericardium is less conspicuous on the current study.,0
There is persistent left-sided pleural effusion and right basilar atelectasis.,0
"IMPRESSION: Persistent, small, bilateral pneumothoraces.",1
Bibasilar atelectasis and persistent left-sided pleural effusion.,0
"Persistent pneumopericardium, less conspicuous than seen on the previous exam.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: DISCHARGE DIAGNOSES: 1.",0
Acute cellular rejection status post cadaver kidney transplant.,1
", Dictated By: MEDQUIST36 D: 21:18:31 T: 01:37:52 Job#:",0
Height: (in) 62 Weight (lb): 220 BSA (m2): 1.99 m2 BP (mm Hg): 117/58 HR (bpm): 63 Status: Inpatient Date/Time: at 14:56 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for CABG Status: Inpatient Date/Time: at 10:35 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA.,0
"Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%).",0
Conclusions: PRE CPB Mild spontaneous echo contrast is seen in the body of the left atrium.,0
This is likely due to a slight retraction of the posterior leaflet.,0
Therev is mild to moderate tricuspid regurgitation.,0
Dr. was notified in person of the results in the operating room at the time of the study.,0
POST CPB Normal biventricular systolic function.,0
Mitral regurgitation may be slightly worse than in pre-CPB study.,0
No other changes from pre bypass study.,0
"6:08 AM BABYGRAM (CHEST ONLY) PORT Clip # Reason: evaluate lung fields Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity at 30 weeks, increased vent settings REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT CHEST.",1
Comparison is made with an exam done earlier in the day.,0
The endotracheal tube has been advanced to a position just above the carina.,0
The tip of an umbilical venous line can now be seen at the base of the right atrium.,0
"The lungs are nearly opaque, though better inflated than on prior exam.",0
"The findings more likely represent pulmonary hemorrhage, or pulmonary edema, rather than worsening hyaline membrane disease.",0
10:30 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
effusions Admitting Diagnosis: CONGESTIVE HEART FAILURE;ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with difficulty remaining off the vent REASON FOR THIS EXAMINATION: ?,1
effusions ______________________________________________________________________________ FINAL REPORT HISTORY: Difficulty remaining off ventilator.,0
"FINDINGS: In comparison with study of , there appears to be some increasing opacification at the right base consistent with some combination of effusion, atelectasis, and pneumonia.",0
The remainder of the examination is essentially unchanged.,0
7:03 PM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT TRAUMA CHEST FINDINGS: Single frontal view of the chest is limited as the right chest is incompletely visualized on this study.,0
Study is also limited due to the overlying trauma board.,0
"Given this, no gross focal lung consolidation is seen.",0
There is no obvious pneumothorax or pleural effusion on the left.,0
These cannot be evaluated on the right.,0
There is gaseous distention of the stomach.,0
"IMPRESSION: Limited study as above, but no obvious acute traumatic injury in the chest.",0
Gaseous distention of the stomach.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: RLQ Abdominal pain Major Surgical or Invasive Procedure: None.,0
"History of Present Illness: Mr. is a 64 year old man with a complex medical history including CHF and COPD, a poor surgical candidate, also with a history of medically managed appendicitis on 2 prior episodes.",1
He presents with RLQ pain.,0
"In , he was admitted to the West 2A service in for ruptured appendicitis and was treated with an IR-placed drain.",0
"For the current admission, he presented on with 2 days of abdominal pain and poor urine output.",0
"He did not complain of nausea, vomiting, changes in bowel movements, fevers/chills.",0
He was admitted for medical management for his likely recurrence of appendicitis.,0
"Past Medical History: Appendiceal abscess in treated with IR drain, recurrent appendicitis Insulin-dependent Diabetes Mellitus COPD Peripheral vascular disease Right fem- bypass graft x 2 ('s) CVA () - mild dysarthria/mild left facial weakness Hepatomagaly Pulmonary hypertension History of DVT GERD Hypercholesterolemia Hypertension Obstructive Sleep Apnea Osteoporosis Depression Social History: -Tobacco history: Former smoker, quit 8-10 years ago.",1
Family History: Mother with lung carcinoma.,0
"No family history of heart disease, HTN, or DM.",1
"Physical Exam: VITALS: T 96.9 HR 81 BP 138/92 RR 20 O2sat 99%/1L GEN: Obese man, sitting comfortably, A&Ox3 HEENT: Normocephalic, atraumatic.",0
"CVS: RRR, no murmurs, rubs or gallops.",0
Labored breathing with increased O2 requirement with ambulation.,0
"ABD: Nontender, soft, obese abdomen.",0
"EXTR: Warm, dry; small 0.3 cm ulcer on right 1st digit, DP and PT pulses palpable bilaterally.",0
"Pertinent Results: 08:45AM BLOOD WBC-8.7 RBC-3.51* Hgb-11.0* Hct-32.1* MCV-92 MCH-31.4 MCHC-34.3 RDW-12.6 Plt Ct-335 08:00AM BLOOD PT-29.5* INR(PT)-2.9* 08:45AM BLOOD Glucose-338* UreaN-23* Creat-1.4* Na-143 K-3.3 Cl-97 HCO3-38* AnGap-11 08:45AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.9 03:26AM BLOOD ALT-19 AST-18 LD(LDH)-152 AlkPhos-34* TotBili-0.2 10:50AM URINE Color-Yellow Appear-Clear Sp -1.006 10:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG URINE CULTURE (Final ): <10,000 organisms/ml.",0
BLOOD CULTURE (taken ): no growth to date CT ABD & PELVIS W/O CONTRAST Study Date of 1.,0
Findings consistent with acute appendicitis with no evidence of abscess or free perforation.,1
A 1.3 cm exophytic liver lesion is stable since and of doubtful significance.,0
CHEST (PA & LAT) Study Date of IMPRESSION: Lingular pneumonia.,0
"Brief Hospital Course: NEURO/PAIN: The patient was maintained on IV Dilaudid upon admission, and then transitioned to PO Dilaudid PRN on .",0
The patient remained neurologically intact and without change from baseline during his stay.,0
"The patient remained alert and oriented to person, location and place.",0
CARDIOVASCULAR: The patient remained hemodynamically stable.,0
His vitals signs were closely monitored.,0
"He has a history of congestive heart failure, and was noted to have basilar crackles, and has been kept on his home doses of furosemide and metolazone.",1
RESPIRATORY: The patient was maintained on his home COPD treatments.,0
"A CXR on demonstrated lingular pneumonia and he was started on a 10-day coure of azithromycin, and discharged with this medication.",0
"He is on 4L of oxygen at home and he was continued on this, maintaining adequate oxygenation with no acute desaturations.",0
GASTROINTESTINAL: The patient was kept NPO and maintained on IV fluids for hydration.,0
IV zosyn was used for antibiotic coverage until .,0
The patient was transitioned to sips on and advanced to a regular diet on ; he tolerated this well.,0
He did not have any episodes of nausea or emesis.,0
"He was transitioned from iv zosyn to PO cipro/flagyl on , and was discharged with these medications for a 2-week total course.",0
GENITOURINARY: The patient presented with an elevated creatinine of 2.6 and BUN of 72.,0
He was given IV fluids.,0
A Foley catheter was placed on to monitor urine output.,0
His creatinine eventually trended down to 1.4.,0
"His foley catheter was removed on , at which time the patient was able to successfully void without issue.",0
The patient's intake and output was closely monitored.,0
HEME: The patient's hematocrit has been stable at around 32.,0
"The patient has a history of DVT, and takes coumadin, but on admission his INR was elevated (4.0; goal 2.5-3).",0
"His home coumadin was held until the day of discharge when the INR was 2.9, at which point the coumadin was restarted.",0
He was instructed to follow up with his coumadin clinic as soon as possible after discharge.,0
"ID: The patient presented with an elevated WBC of 16.3, which trended to 8.7 by .",0
He was treated for appendicitis and pneumonia with antibiotics as above.,1
ENDOCRINE: The patient has insulin-dependent diabetes.,1
His blood glucose was monitored with q6 fingersticks and maintained at a satisfactory level with insulin sliding scale per protocol.,0
PROPHYLAXIS: The patient's anticoagulation was held secondary to supratherapeutic INR.,0
He was encouraged to ambulate as tolerated.,0
The patient also had sequential compression boot devices in place during immobilization to promote circulation.,0
GI prophylaxis was sustained with omeprazole.,0
"The patient was encouraged to utilize incentive spirometry, ambulate, and was discharged in stable condition.",0
"Medications on Admission: Albuterol nebulizer 2 Puff Q6H Alendronate 70 mg PO QWeekly Budesonide 0.5/2ml Citalopram 10mg PO QD Warfarin 12.5mg PO QD Furosemide 80mg PO QD Folic acid 800mcg PO QD Humalog 100 unit/mL PRN Humalin 45 units am, 15 units pm Lipitor 20mg PO QD Lisinopril 10 mg PO QD Metolazone 2.5 PO QD Omeprazole 40 mg PO QD Prednisone 5mg PO QD Proventil 2 Puff O2 4L Salsalate 750 mg PO BID, Spiriva inhaler daily ASA 81mg PO QD Vit B complex 300mg PO QD Vit B1 100mg PO QD Cal/vit D 1200mg PO QD Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours).",0
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.,0
3. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) ML Inhalation (2 times a day).,0
4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
5. warfarin Oral 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Humalog 100 unit/mL Cartridge Sig: sliding scale units Subcutaneous lunch and dinner.,0
NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: 45 units Subcutaneous QAM.,0
10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
12. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
15. salsalate 750 mg Tablet Sig: One (1) Tablet PO twice a day.,0
"16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily).",0
"17. aspirin 81 mg Tablet, Delayed Release (E.C.)",0
Vitamin B Complex Oral 19.,0
Calcium 500 + D Oral 21.,0
Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days.,0
Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 11 days.,0
Disp:*33 Tablet(s)* Refills:*0* 23. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days.,0
NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: Fifteen (15) units Subcutaneous QPM.,0
Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day: Please fllow up with clinic on to check your INR.,0
Discharge Disposition: Home Discharge Diagnosis: Recurrent Appendicitis Lingular pneumonia Discharge Condition: Mental Status: Clear and coherent.,1
Activity Status: Ambulatory Discharge Instructions: Discharge Instructions: You were admitted to Dr. surgical service for evaluation and management of your recurrent appendicitis.,1
You are now being discharged home.,0
"Please follow these instructions to aid in your recovery: Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness.",0
"* You develop new or worsening cough, shortness of breath, or wheezing.",0
"* You are vomiting and cannot keep down fluids, or your medications.",0
"* If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons.",0
"Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing.",0
"* You see blood or dark/black material when you vomit, or have a bowel movement.",0
"* You experience burning when you urinate, have blood in your urine, or experience an unusual discharge.",0
* Your pain is not improving within 12 hours or is not under control within 24 hours.,0
* Your pain worsens or changes location.,0
"* You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius.",0
* You develop any other concerning symptoms.,0
"General Discharge Instructions: * Please resume all regular home medications, unless specifically advised not to take a particular medication.",0
* Please take any new medications as prescribed.,0
* Please take the prescribed analgesic medications as needed.,0
You may not drive or operate heavy machinery while taking narcotic analgesic medications.,0
"You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day.",0
"* Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids.",0
"* Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions.",0
* Please also follow-up with your primary care physician.,0
Please also follow up with your coumadin clinic as soon as possible following discharge.,0
"Followup Instructions: Provider: FUNCTION LAB Phone: Date/Time: 9:10 Provider: , M.D.",0
"Phone: Date/Time: 9:30 Provider: ,INTERPRET W/LAB NO CHECK-IN INTEPRETATION BILLING Date/Time: 9:30 Provider: , MD Phone: Date/Time: 1:45 6, Please schedule an appointment with PODIATRY service at 1-2 weeks after discharge to continue monitoring your right great toe ulcer Please follow up with your coumadin clinic on or before Monday, Provider: , MD Phone: Date/Time: 9:00 3, .",0
You will have an abdominal CT scan prior your appointment with Dr. .,0
Dr. office will inform you about time of the scan.,0
"Please arrive in Radiology Department 30 min before the scan, please do not eat/drink 4 hours before the CT scan.",0
7:38 PM CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # Reason: S/P MVC- ?,0
"BLADDER INJURY, EVAL ACETABULAR FX Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with pelvic fx s/p fall REASON FOR THIS EXAMINATION: please do CT cystogram to r/o bladder injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT CYSTOGRAM AND CT PELVIS WITH CORONAL AND SAGITTAL RECONSTRUCTIONS.",0
INDICATION: 45 year old male with multiple pelvic fractures status post 30 foot fall.,0
There is no prior for comparison.,0
TECHNIQUE: A CT cystogram was performed following the Foley catheter administration of approximately 300 cc of Cystografin.,0
"In addition, thin cuts through the pelvis were performed and reformatted in the sagittal and coronal planes to assess the bony structures.",0
"CT OF THE PELVIS WITHOUT CONTRAST: A Foley balloon catheter tip is seen within the bladder which is well distended and demonstrates no evidence of rupture/laceration, and no extravasation of contrast within or outside of the peritoneal space.",0
Pelvic bowel loops are unremarkable.,0
A small amount of dependent higher density fluid consistent with blood is seen in the deep pelvis.,0
Two fractures through the inferior pubic ramus on the left are identified.,0
"Bone fragments from the more anterior fracture at this site are suspected to be in the region of the prostate adjacent to the Foley catheter, as suspected by Hounsfield units.",0
The more anterior of the inferior left-sided pubic rami fractures is comminuted.,0
"In addition, there is a comminuted fracture of the left superior pubic ramus as well as a comminuted fracture of the anterior left acetabulum.",1
"On the right, there is a fracture of the inferior pubic ramus and a more subtle fracture of the anterior acetabulum (as compared to the left).",1
Also there is a comminuted fracture through the sacrum.,1
It is seen on the right side at the superior aspect of the sacrum and seen to extend posteriorly and inferiorly into the posterior elements.,0
Another separate left-sided fracture of the distal-most sacrum is also appreciated.,1
The hip joints are intact and no hip fractures are seen.,0
The SI joints appear to be intact and a small tiny focus of air is seen within the right SI joint.,0
Note is made that a portion of bony fragment from the left anterior acetabulum is seen sharply impressing upon the bladder on the left side.,0
Small amounts of hematoma are seen around the left anterior acetabular fracture and within deep posterior pelvic musculature on the right.,0
(Over) 7:38 PM CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # Reason: S/P MVC- ?,0
"BLADDER INJURY, EVAL ACETABULAR FX Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) CORONAL AND SAGITTAL RECONS: Images reconstructed in the coronal and sagittal planes help to define the above findings.",0
Multiple pelvic and sacral fractures as described above.,0
Sharp fracture fragment seen to sharply indent the left lower portion of the bladder.,0
Fracture fragments seen in the region of the prostate adjacent to the Foley catheter.,0
Small foci of hematomas as described above.,0
The findings were communicated to the house staff caring for the patient at the time of interpretation.,0
"6:56 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: Please do with contrast to evaluate for osteomyelitis Admitting Diagnosis: OSTEOMYELITIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with PMHx significant for spinal stenosis with multiple discectomies ~4yrs ago c/b wound infection, concerning for osteomyelitis.",1
REASON FOR THIS EXAMINATION: Please do with contrast to evaluate for osteomyelitis No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old man with multiple neck surgeries and concern for C6-C7 osteomyelitis.,0
"COMPARISON: CT cervical spine, outside hospital study from .",0
"TECHNIQUE: Sagittal T1, T2, STIR and axial gradient echo images through the cervical spine were obtained without contrast.",0
Contrast could not be administered as patient refused to continue with the study.,0
FINDINGS: There is focal kyphotic angulation at C6-C7 with abnormal signal intensity involving contiguous C6 and C7 vertebral bodies and the intervening C6-C7 intervertebral disc with loss of disc height.,0
The vertebral bodies appear diffusely T1 hypointense and show heterogeneous high signal on the STIR images.,0
"There is retropulsion of the posterior cortex of C6 vertebra which is indenting the spinal cord, but no cord signal abnormality seen.",0
There is prevertebral soft tissue edema/phlegmon centered at C6-C7 and extending superiorly up to the C2-C3 intervertebral disc space and inferiorly to T1-T2 level.,0
There is mild canal narrowing at C6-7 level.,0
There is otherwise no significant spinal canal or neural foraminal narrowing in the cervical spine.,1
Posterior paraspinal soft tissues are unremarkable.,0
Contrast could not be administered as patient could not continue with the scan.,0
"Within these limitations, there is an area of abnormal signal intensity at C6-C7 level with mild C6 retropulsion into the spinal canal as described above with prevertebral soft tissue edema/phlegmon may represent vertebral osteomyelitis.",1
Followup scan with contrast is recommended.,0
12:11 PM PORTABLE ABDOMEN Clip # Reason: PD catheter placement?,0
Admitting Diagnosis: BACTERIEMA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with ESRD on PD and HD; PD catheter not working well REASON FOR THIS EXAMINATION: PD catheter placement?,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc WED 7:52 PM Dialysis catheter with tip overlying the pelvic inlet.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 55-year-old female with history of end-stage renal disease on peritoneal and hemodialysis, assess for peritoneal dialysis catheter placement position.",1
EXAMINATION: Single frontal supine abdominal radiograph.,0
COMPARISONS: Comparison made to CT scan of the abdomen from .,0
FINDINGS: There is a peritoneal dialysis catheter noted with its tip overlying the pelvic inlet.,0
There are fecal calcifications noted that are similar to previous examination.,0
The bowel gas pattern is otherwise unremarkable.,0
There is no intraperitoneal free air noted.,0
IMPRESSION: Peritoneal dialysis catheter tip overlying the pelvic inlet.,0
9:31 AM CHEST (PA & LAT); -76 BY SAME PHYSICIAN # Reason: r/o PTX R CT removal Admitting Diagnosis: TRACHEOBRONCHIO MALACIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman s/p tracheobrochoplasty REASON FOR THIS EXAMINATION: r/o PTX R CT removal ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Chest tube removal to exclude pneumothorax.,0
"FINDINGS: In comparison with earlier study of this date, the right chest tube has been removed.",0
There is a small apical pneumothorax.,0
Gas is seen along the right lateral chest wall extending into the neck as on previous study.,0
Some increased opacification is seen at the left base suggesting atelectasis or developing pneumonia.,0
Small residual apical pneumothorax following right chest tube removal.,0
Increasing opacification at the left base consistent with atelectasis or pneumonia.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Pollen/Hayfever Attending: Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: Mitral Valve Repair(#32 Annuloplasty band) History of Present Illness: 50 y/o male with known MVP since when murmur was detected.,1
Serial Echo's have shown 4+ MR with a LVEF of 50%.,0
Now presents for surgical repair.,0
"Past Medical History: MVP, Depression, Asthma, Laser eye , Colonoscopy/polyp removal, removal plantar warts Social History: Denies Tobacco.",0
Admits to 1 ETOH beverage/day.,0
Family History: Mother and sibling with MVP.,0
"Physical Exam: VS: 70 132/75 72"" 235# Gen: WD/WN male in NAD HEENT: PERRL, EOMI, NC/AT, OP benign Neck: Supple, FROM, -JVD, Murmur radiated to bilat.",0
"carotids Chest: CTAB -w/r/r Heart: RRR 4/6 Syst murmur Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: Echo: PRE-BYPASS: 1.",0
A small secundum ASD is present.,0
Left ventricular wall thicknessess is normall.,0
The left ventricle is mildly dilated.,0
Overall left ventricular systolic function is normal (LVEF>55%) but in the setting of severe mitral regurgitation there may be intrinsic dysfunction.,0
There are three aortic valve leaflets which are mildly thickened.,0
The mitral valve leaflets are mildly thickened and myxomatous.,1
There is partial mitral leaflet flail of the P2 scallop and prolapse of most of the posterior leaflet.,0
The anterior leaflet is slightly restricted.,0
An eccentric jet of Severe (4+) mitral regurgitation is seen directed anteriorly.,0
There is a physiologic pericardial effusion.,0
An annuloplasty ring is seen well seated in the mitral position.,0
The mean gradient across the mitral valve is 4 mmof Hg and the maximum about 8 mm Hg.,1
"LV function is moderately depressed globally, with slight improvement after starting an infusion of epinephrine.",0
RV systolic function is preserved.,0
Descending Aorta is intact post decannulation 4.,0
Other findings are unchanged and the secundum ASD is still seen.,0
02:43PM BLOOD WBC-11.3*# RBC-3.51* Hgb-11.4*# Hct-33.1* MCV-94 MCH-32.5* MCHC-34.5 RDW-13.6 Plt Ct-141* 02:43PM BLOOD PT-15.0* PTT-40.7* INR(PT)-1.3* 04:01PM BLOOD UreaN-14 Creat-0.9 Cl-111* HCO3-24 Brief Hospital Course: Mr. was a same day admit after undergoing all pre-operative work-up as an outpatient.,0
On the day of admission he was brought to the operating room where he underwent a minimally invasive mitral valve repair.,1
"Later on postoperative day one, he was weaned from sedation, awoke neurologically intact and extubated.",0
Beta blockade and aspirin were resumed.,0
"On postoperative day one, he was transferred to the step down unit for further recovery.",0
He had a short run of atrial fibrillation which converted to normal sinus rhythm with and increase in his beta blockade.,1
The physical therapy service worked with him daily for assistance with his postoperative strength and mobility.,0
Mr. continued to make steady progress and was discharged home on postoperative day three.,0
"Medications on Admission: Celexa 20mg qd, MVI, Flonase prn, Lasix 20mg , Evoclin topical qd Discharge Medications: 1.",0
"Disp:*90 Tablet, Delayed Release (E.C.",0
Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 7 days.,0
Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 weeks.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take while using narcotics.,0
Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months.,0
Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Mitral Regurgitation s/p Min.,0
"Mitral Valve Repair PMH: MVP, Depression, Asthma, Laser eye , Colonoscopy/polyp removal, removal plantar warts Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection.",1
"If you have any issues with you wound, please contact Dr. at (.",0
No swimming for 2 weeks.,0
"No lotions, creams or powders to wounds until they have healed.",0
"After your wounds have healed, please use sunblock on scar when in sun.",0
5) Take lasix 40mg once daily and potassium 20mEq once daily for 7 days then stop.,0
6) Take Ibuprofen 600mg three times daily for three weeks and then stop.,0
7) Take ranatadine (Zantac) for one month and then stop.,0
Take colace while taking percocet or as needed for constipation.,0
You may resume you at home multivitamins.,0
8) Continue to use antibiotic prophylaxis (Amoxicillin) with procedures (Dental/Surgical).,0
You may resume yor at home allergy and rosacea medications.,0
9) Please call with any questions or concerns.,0
Followup Instructions: clinic on 2 in 2 weeks.,0
( Follow-up with Dr. (Cardiologist) in 2 weeks.,0
( Please call all providers for appointments.,0
"1:53 PM CHEST (PA & LAT) Clip # Reason: r/o inf, eff Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with REASON FOR THIS EXAMINATION: r/o inf, eff ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for infection or effusion.",1
FRONTAL AND LATERAL CHEST RADIOGRAPHS: Median sternotomy wires are unchanged.,0
Left-sided PICC is again seen with tip at the superior SVC.,0
"Small area of linear opacity outlining the pericardium has decreased compared to prior study, consistent with resolving pneumopericardium.",0
Improving left basilar atelectasis is noted.,0
Small bilateral pleural effusions are also noted.,0
Persistent small bilateral pleural effusions.,0
", MED 8:21 AM CHEST (PORTABLE AP) Clip # Reason: worsening infiltrate?",0
"Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with trach, tachypneic REASON FOR THIS EXAMINATION: worsening infiltrate?",0
"______________________________________________________________________________ PFI REPORT Mild interstitial edema, improving right lung consolidation.",0
"7:05 AM NEONATAL ABDOMEN Clip # Reason: INFANT WITH ELEVATED BUN AND CREATININE, EVALUATE ABDOMINAL ORGANS AND KIDNEYS ______________________________________________________________________________ MEDICAL CONDITION: Infant with elevated BUN and creatinine REASON FOR THIS EXAMINATION: evaluate abdominal organs and kidneys ______________________________________________________________________________ FINAL REPORT INDICATION: Elevated BUN and creatinine.",0
Evaluate abdominal organs and kidneys.,0
Dr. has asked that we rule out fungal disease in the abdominal organs.,0
"FINDINGS: The liver, spleen, kidneys, pancreas, IVC, aorta and gallbladder are normal in appearance.",0
"The right and left kidneys measure 3.2 cm and 3.5 cm, respectively.",0
There is no evidence for fungal disease.,0
", C. NMED MICU 3:34 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: post-pyloric NGT placement Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with MCA and PCA strokes, CHF.",0
REASON FOR THIS EXAMINATION: post-pyloric NGT placement ______________________________________________________________________________ PFI REPORT Successful post-pyloric feeding tube placement with removal of the previous Dobbhoff tube.,0
9:12 PM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: Please evaluate piriform sinus mass.,0
"Admitting Diagnosis: DYSPHAGIA-ESOPHAGEAL STRICTURE-HYPERTENSION-DIABETES Field of view: 23 Contrast: OPTIRAY Amt: 85 ______________________________________________________________________________ MEDICAL CONDITION: 71yoM w/piriform sinus mass, being evaluated for possible biopsy per ENT.",1
Please evaluate piriform sinus mass.,0
REASON FOR THIS EXAMINATION: Please evaluate piriform sinus mass.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT OF THE NECK WITH CONTRAST INDICATION: 71-year-old male with a history of piriform sinus mass.,0
"TECHNIQUE: Following administration of 85 cc of Optiray intravenous contrast, MDCT axial images were acquired from the lung apices to the posterior fossa.",0
"FINDINGS: There is an ill-defined, heterogeneous, enhancing mass filling the left piriform sinus with the bulk centered at the C5 level on the lateral scout film.",0
This mass extends into the left tonsillar space and has several central areas of hypodensity consistent with necrosis.,0
There is associated narrowing and compression of the airway at the level of the hyoid bone and more inferiorly at the valleculae.,0
"At its largest size at the C5 level, this mass measures 4.8 x 3.0 cm in the axial plane.",0
The inferior portion of the mass abuts the superior aspect of the thyroid gland.,0
There is no associated neck pathologic lymphadenopathy.,0
There is diffuse atherosclerotic calcification at the aortic arch and of the carotid arteries bilaterally.,0
The cavernous portions of the carotid arteries are especially calcified.,0
Limited views of the inferior portion of the brain are unremarkable.,0
"Incidental note is made of extensive degenerative, multilevel disease with mild narrowing of the spinal canal at the C5 level secondary to posterior osteophytosis.",0
Limited views of the lung apices demonstrate striking centrilobular emphysematous changes with several peripheral bullae noted.,0
"Furthermore, there is a partially imaged tubular structure extending along the anterior aspect of the right lobe.",0
"IMPRESSION: Large, heterogeneously enhancing suspicious mass centered within the left piriform sinus at the C5 level suspicious for underlying malignancy such as squamous cell carcinoma.",0
Encroachment of the airway at the inferior border of the hyoid bone.,0
No pathologic associated lymphadenopathy within the neck.,0
Findings were discussed with Dr. .,0
Noodin by Dr. over the phone on at 4:30 p.m. (Over) 9:12 PM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: Please evaluate piriform sinus mass.,0
Admitting Diagnosis: DYSPHAGIA-ESOPHAGEAL STRICTURE-HYPERTENSION-DIABETES Field of view: 23 Contrast: OPTIRAY Amt: 85 ______________________________________________________________________________ FINAL REPORT (Cont),1
2:46 PM CT HEAD W/O CONTRAST Clip # Reason: r/o worsened edema or other acute process Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman with acute liver failure and new decerebrate posturing REASON FOR THIS EXAMINATION: r/o worsened edema or other acute process No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DBH MON 5:01 PM PFI: No evidence of hemorrhage or infarction.,1
Consider MR if there is ongoing concern of metabolic or ischemic injury to the brain.,0
"______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT CONTRAST, HISTORY: Acute liver failure and new decerebrate posturing.",1
Comparison to a head CT of .,0
FINDINGS: There have been no significant changes since the prior study.,0
The ventricles appear normal in caliber and configuration.,0
"The sulci, although small, are within the realm of normal for a patient of this age.",0
"There is no evidence of hemorrhage, edema, masses, mass effect, or infarction.",0
"Note that if there is a concern of metabolic injury or global ischemia, MR is more sensitive than CT for detecting such abnormalities.",0
Again noted is markedly full nasopharyngeal soft tissues.,0
"Although this is prominent for a patient of this age, the presence of nasogastric and endotracheal tubes imply that it may be due to swelling caused by mechanical trauma.",0
CONCLUSION: No evidence of hemorrhage or infarction.,0
"The sulci are quite small, but -white differentiation is maintained.",0
"If there is ongoing concern of metabolic or ischemic injury to the brain, MR imaging may be helpful.",0
"11:21 PM CHEST (PORTABLE AP) Clip # Reason: r/o free air ______________________________________________________________________________ MEDICAL CONDITION: 50 yo F GERD p/w epigastric pain, +BRB rectal and NGL, belly diffusely tender REASON FOR THIS EXAMINATION: r/o free air ______________________________________________________________________________ FINAL REPORT STUDY: Portable AP view of the chest.",0
INDICATION: 50-year-old female with epigastric pain.,0
FINDINGS: There is no subdiaphragmatic free air.,0
The heart and mediastinum are unremarkable in appearance.,0
A nasogastric tube is identified with side port well below the gastroesophageal junction.,0
6:40 PM CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: identify location of aneursym/hemorrhage Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with SAH likely arising from left ICA/middle cerebral A. please eval source of hemorrhage.,0
REASON FOR THIS EXAMINATION: identify location of aneursym/hemorrhage No contraindications for IV contrast ______________________________________________________________________________ WET READ: MRSg MON 8:39 PM 6 mm aneurysm at the bifurcation of the left internal carotid artery/ proximal MCA.,0
INDICATION: 77 year old male with subarachnoid hemorrhage and suggestion of a left ICA/middle cerebral aneurysm seen on noncontrast CT examination.,1
Comparison is made to the previous examination of at 17:11 hours.,0
TECHNIQUE: Contrast enhanced images of the brain following the rapid bolus administration of 150 cc of IV Optiray were performed.,0
Images were reconstructed in the sagittal and coronal planes.,0
3D reconstructions were also performed.,0
FINDINGS: There is a fusiform aneurysmal dilatation of the distal left internal carotid artery (supraclinoid portion) that also demonstrates an inferior extralobular component adjacent to the origin of the posterior cerebellar artery.,0
The length of fusiform dilatation is roughly 1.4 cm in size.,0
The previously identified diffuse subarachnoid hemorrhage is difficult to appreciate given contrast enhancement.,1
No enhancing mass lesions are appreciated.,0
No vascular occlusion of the major cerebral vasculature is seen.,0
IMPRESSION: Fusiform aneurysmal dilatation of the distal internal carotid artery with inferior extralobular component adjacent to the origin of the left posterior cerebral artery.,0
"1:35 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for PTX, tamponade, CHF.",0
Admitting Diagnosis: THROMBOTIC THROMBOCYTOPENIC PURPURA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with ?,0
"TTP/HUS and pneumonia, now with sudden hypotension.",0
"REASON FOR THIS EXAMINATION: Please assess for PTX, tamponade, CHF.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 79 year old man with ?,0
"Evaluate for pneumothorax, tamponade or CHF.",0
"CHEST AP: ETT, NGT, right IJ CVL and right PICC appear unchanged position.",0
"The cardiac, mediastinal, and hilar contours are stable in appearance.",0
There has been interval worsening of bilateral lower lobe consolidation which may represent atelectasis versus developing pneumonia.,0
Osseous and soft tissue structures are stable in appearance.,0
IMPRESSION: No pneumothorax or CHF.,0
Interval increase in bibasilar consolidations which may represent atelectasis versus pneumonia.,0
10:15 AM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: Please review ERCP images done ______________________________________________________________________________ MEDICAL CONDITION: 36 year old male with grade 4 liver laceration and abnormal LFTs REASON FOR THIS EXAMINATION: Please review ERCP images done ______________________________________________________________________________ FINAL REPORT HISTORY: 36-year-old male with grade IV liver laceration and abnormal liver function tests.,1
Referred for assessment of biliary injury.,0
ERCP: Nine spot fluoroscopic images were obtained during performance of ERCP by a gastroenterologist without a radiologist present.,0
"The ampulla was cannulated and contrast injected demonstrating good opacification of normal caliber biliary tree, cystic duct and gallbladder.",0
There is no evidence of contrast extravasation to suggest leak.,0
No filling defects are seen.,0
"For more information, please see the gastroenterologist's ERCP report of the same date.",0
1:22 PM CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # Reason: ANEURYSM Admitting Diagnosis: INTRAPARIETAL HEMORRHAGE Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ WET READ: 8:04 AM Still waiting for reconstructions but no aneurysms seen.,0
______________________________________________________________________________ FINAL REPORT STUDY: CT angiogram.,0
INDICATION: Patient with history of left intraparenchymal hemorrhage.,0
TECHNIQUE: CT angiogram was obtained after the administration of 150 mL of Optiray in without complications; 3-D reconstructions were subsequently performed.,0
FINDINGS: Study is being read in conjunction with prior head CT scan dated .,0
The circle of is normal in appearance.,0
No aneurysms are identified to the level of resolution of the study.,0
No feeding vessels are seen into the ovoid hyperdensity seen in the left parasagittal location of the posterior left frontal lobe.,0
No hemodynamically significant areas of stenosis are identified.,0
Posterior circulation is also normal in appearance.,0
Distal vertebral arteries and basilar arteries are within normal limits.,0
IMPRESSION: No aneurysms up to the level of resolution of this examination identified.,0
No hemodynamically significant stenosis seen.,0
No feeding vessels into the ovoid hyperdensity seen in the left parasagittal location of the posterior left frontal lobe suggesting that the finding is an intraparenchymal hemorrhage and not an aneurysm.,0
3:55 PM ERCP S&I () Clip # Reason: r/o Gastric outlet obstruction.,0
______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with h/o pancreatic caa and symptoms of gastric outlet obstruction.,0
EGD for duodenal stent requested.,0
"Exam performed , req submitted REASON FOR THIS EXAMINATION: r/o Gastric outlet obstruction.",0
______________________________________________________________________________ FINAL REPORT INDICATION: History of pancreatic cancer with symptoms of gastric outlet obstruction.,0
ERCP images were provided for interpretation.,0
Two stents were noted one in the CBD and one in the duodenum.,0
Due to partial obstruction of one of the stents it was replaced by another one until proper drainage was achieved.,0
IMPRESSION: Successful change of a partially obstructed stent.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Right upper lobe lung cancer.,0
"Major Surgical or Invasive Procedure: Video-assisted thoracic surgery right upper lobectomy, video-assisted thoracic surgery right lower lobe superior segmentectomy, mediastinal lymph node dissection and flexible bronchoscopy.",0
Flexible Bronchoscopy History of Present Illness: 76F who is a former smoker had a history of dry cough for the past year.,0
"She saw her physician and had CXR, which showed a RUL infiltrate.",0
She was treated with antibiotics without improvement.,0
"She then underwent a chest CT , which demonstrated a 5x3cm spiculated ilfiltrate in the RUL.",0
She was treated with another course of levo and had a repeat CT scan .,0
This scan showed an increase in size in the RUL consolidation with some new fullness in the R hilum.,0
"PET-CT was done on , revealing intense FDG activity in the R lung consistent with malignancy.",0
There was also an FDG-avid area in the proximal descending colon.,0
"The patient underwent a flex bronch , and the brushings and washings were negative.",0
No lymph nodes were biopsied.,0
She then underwent a CT guided biopsy of the mass which revealed NSCLC most consistent with poorly differentiated adenocarcinoma.,0
"Past Medical History: Cardiomyopathy Macular degeneration Detached retina Spinal Stenosis Asthma w h/o intubation, Arthritis osteoporosis Open cholecystectomy in the .",1
Cataract extraction bilateral Social History: Lives with family.,0
25 pack-year quit 12 years ago.,0
This includes the mediastinal and tracheal displacement as well as distortion of the right hilus.,0
The left lung remains essentially clear except for some atelectatic streaks at the base.,0
There appears to be a hiatal hernia in the retrocardiac region on the lateral projection.,0
"Tiny loculated right apical pneumothorax unchanged, small to moderate right pleural effusion probably decreasing, pleural tubes still in place.",0
": In comparison with the study of , right chest tube again extends to the apex and descends inferiorly to terminate at the level of the hemidiaphragm.",0
"The small to moderate right apical pneumothorax is again seen, though quite subtle.",0
"Right perihilar opacity persists, most likely representing a combination of atelectasis and contusion in this recently postoperative patient.",0
Left lung remains essentially clear.,0
"Micro: BC x 2 no growth to date, Ucx negative, sputum rare yeast Brief Hospital Course: Mrs. was admitted on for Video-assisted thoracic surgery right upper lobectomy, video-assisted thoracic surgery right lower lobe superior segmentectomy, mediastinal lymph node dissection and flexible bronchoscopy.",0
She was extubated in the operating room and monitored in the PACU prior transfer to the floor.,0
Overnight she developed respiratory distress and was re-intubated and transferred to the SICU for respiratory failure.,0
"Aggressive pulmonary toilet, mucolytic nebs were administered.",0
"Respiratory: Respiratory failure re-intubated on a vent, sedated, unable to to protect her airway and manage secretions.",0
Followed by serial ABGs (see above).,0
On she was extubated with oxygen saturations in the 94-98% with occasional desaturations to low 90's on 50% shovel mask.,0
Aggressive chest PT was administered her oxygen saturations improved 94-97% on 4 Liters nasal cannula.,0
She transferred to the floor on .,0
Oxygen saturations remained > 93% at rest on 3Liters of nasal cannula with desaturations to 88% with acitivity.,0
She required home oxygen to maintain oxygen saturations > 93%.,0
Flexible bronchoscopy was performed on which showed slight effacement of right middle lobe medial segment.,0
drain: right was removed on .,0
She was followed by serial chest films which showed atelectasis and stable right apical space.,0
Cardiac: she remained hemodynamically stable in sinus rhythm.,0
GI: prophylactis PPIs and bowel regime were administered Nutrition: She tolerated a regular diet.,0
Speech: Speech and swallow consulted for a weak voice.,0
Vocal cord paralysis since no signs of aspiration.,0
"Continue with regular diet, thin liquids, medications whole.",0
F/U with voice therapy as an outpatient.,0
Renal: ATN with peak CRE 1.9 base 1.1-1.3.,0
She was hydrated with CRE return to baseline.,0
On she was gently diuresed with IV lasix with good Urine output.,0
On she restarted her home lasix dose.,0
Pain: Acute on chronic pain.,0
history of spinal stenosis takes home oxycodone.,1
She was started with a Dilaudid PCA titrated to comfort.,0
Once extubated she was converted to PO oxycodone with good pain control.,0
Disposition: Physical therapy recommended Short term rehab.,0
She was discharged to in .,0
"Medications on Admission: Furosemide 20 mg a day, amlodipine 5 mg a day, Nexium 40 mg a day, Cymbalta 60 mg a day, Lipitor 10 mg daily, aspirin 81 mg daily, meclizine 25 mg three times a day as needed, oxycodone one tablet five times a day, Flovent two puffs twice a day, albuterol as needed, Actonel 150 mg once a month, multivitamin one tablet a day, vitamin C 500 mg daily, calcium plus D 600 mg two tablets per day, vitamin E 400 international units per day, flaxseed oil 1000 mg, and omega-3 tablets three times a day, Ocuvite one drop per day.",0
"Duloxetine 60 mg Capsule, Delayed Release(E.C.)",0
Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day).,0
Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.,0
Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain.,0
Meclizine 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for vertigo.,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Right upper lobe nodule Cardiomyopathy Macular degeneration Detached retina Spinal Stenosis Asthma w h/o intubation, Arthritis Osteoporosis Open cholecystectomy in the .",1
Cataract extraction bilateral Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Call Dr. office if you experience: -Fever > 101 or chills -Increased shortness of breath cough or sputum production -Chest pain -Incision develops drainage -You may shower no tub bathing or swimming for 3 weeks Followup Instructions: Follow-up with Dr. Date/Time: 2:30 on the Clinical Center .,0
Chest X-Ray 2:00pm before your appointment on the Radiology Department Completed by:,0
"Status: Inpatient Date/Time: at 13:11 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
7:59 AM BABYGRAM AP ABD ONLY PORT Clip # Reason: EVALAUTE BOWEL GAS PATTERN Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: INFANT WITH BLOODY STOOL REASON FOR THIS EXAMINATION: EVALAUTE BOWEL GAS PATTERN ______________________________________________________________________________ FINAL REPORT Examination is of the abdomen.,0
Comparison is made with an exam done on the 23rd in this child with bloody stool.,0
The bowel gas pattern remains normal.,0
No specific signs of necrotizing enterocolitis are apparent.,0
8:21 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
injury ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man motorcycle mvc - no helmet +LOC REASON FOR THIS EXAMINATION: ?,1
injury ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: MVC.,0
PORTABLE CHEST: Cardiomediastinal silhouette is unremarkable.,0
Increased opacities noted at the lung apices bilaterally.,0
There is no pleural effusion or evidence of pneumothorax.,0
Scapular and thoracic spinal fractures are better evaluated on accompanying CT. Curvilinear tiny radiopaque density is identified over the left hemidiaphragm but is likely external.,1
IMPRESSION: Biapical parenchymal opacity may represent contusion in posttrauma patient.,0
"6:21 PM CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # Reason: R/O PTX, assess effusion Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with large R pleural effusion, s/p 1.5L thoracentesis REASON FOR THIS EXAMINATION: R/O PTX, assess effusion ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST ON HISTORY: A large right pleural effusion after 1.5 L thoracentesis, assess a possible pneumothorax.",1
IMPRESSION: Frontal and lateral chest radiographs compared to and at 2:38 p.m.: Moderate to large right pleural effusion is appreciably smaller than it was four hours ago and there is no pneumothorax.,1
I do not see an indwelling right pleural drain.,0
Except for the pleural effusion projecting over the right lower chest lungs are clear.,1
"12:31 PM BILAT LOWER EXT VEINS PORT Clip # Reason: PE ON CT, EVALUATE FOR DVT ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with PE on CT REASON FOR THIS EXAMINATION: evaluate for DVT ______________________________________________________________________________ WET READ: 4:40 PM No DVT in right or left common femoral, superficial femoral, or popliteal veins.",0
Probably thrombosis of right anterior tibial (calf) vein.,0
"INDICATION: Pulmonary embolus seen on CT, evaluate for DVT in lower extremities.",0
TECHNIQUE: Bilateral lower extremity venous ultrasound.,0
"FINDINGS: scale, color, and Doppler images were obtained of the right and left common femoral, superficial femoral, and popliteal veins.",0
"Normal flow, compressibility, augmentation, and waveforms are demonstrated.",0
"A medial right calf vein is noncompressible and echogenic, and contains no color flow signal.",0
IMPRESSION: Likely thrombosis within the right anterior tibial vein within the calf.,0
"No evidence of deep venous thrombosis within the right or left common femoral, superficial femoral, or popliteal veins, and no residual clot proximal to the right anterior tibial thrombosis.",0
"11:44 AM CT PELVIS ORTHO W/O C Clip # Reason: please assess bony pelvis Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 21 year old woman with l native hip dislocation, reduced REASON FOR THIS EXAMINATION: please assess bony pelvis No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Left hip dislocation.",1
TECHNIQUE: Non-contrast axial images through the hips with multiplanar reformats.,0
FINDINGS: There is an impaction fracture of the superior medial surface of the left femoral head.,1
There is 2-3 mm of depression.,0
This is distinct from the normal fovea capitis.,0
There is a small left hip joint effusion.,0
"There is a well corticated ossicle in the region of the left pubic symphysis, without diastasis.",0
This likely represents sequelae of prior injury.,0
The right hip is intact.,0
There are no other osseous injuries.,0
"Limited views of the pelvis demonstrate high attenuation fluid within the pelvis, consistent with hemorrhage.",0
IMPRESSION: Intra-articular fracture of the superior and medial surface of the left femoral head with 2-3 mm of depression.,1
Small left hip joint effusion.,0
These findings were discussed with Dr on at 515 pm.,0
", R. MED SICU-A 10:11 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: eval for source of fever in chest or abdomen..",0
"Admitting Diagnosis: OVERDOSE ______________________________________________________________________________ MEDICAL CONDITION: 23 year old woman with fulminant hepatic failure, elevated ICP, now s/p arctic sun cooling protocol and on pentobarb coma, also w/ fever of unknown source, no bowel sounds, distended abdomen REASON FOR THIS EXAMINATION: eval for source of fever in chest or abdomen.. CONTRAINDICATIONS for IV CONTRAST: ARF on CVVH ______________________________________________________________________________ PFI REPORT CT CHEST WITHOUT INTRAVENOUS CONTRAST: There are bilateral small pleural effusions and compression atelectasis.",1
"No axillary lymphadenopathy is present, the presence of hilar or mediastinal lymphadenopathy is more difficult to exclude, but there are no pathologically enlarged lymph nodes.",0
The soft tissue in the breasts bilaterally is prominent and could be a normal variant in a state of recent pregnancy.,1
"Two enteric tubes are present, one ends at the gastroesophageal junction, and the other one reaches the stomach.",0
"CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Non-contrast evaluation of the liver, spleen, adrenal glands, pancreas, kidneys is unremarkable.",1
"Segments of the cecum, ascending colon, and proximal as well as distal transverse colon appear thickened, with some areas which are gas filled and thin walled.",0
"Large amount of ascites is present, which in the pelvis demonstrates slightly higher attenuation, concerning for hemoperitoneum.",0
"Evidence of third spacing, including anasarca is noted.",0
"The gallbladder is not distended, pericholecystic edema is likely due to third spacing.",0
"CT PELVIS WITHOUT CONTRAST: The uterus is enlarged, consistent with postpartum state.",0
The rectal tube is in place.,0
"The sigmoid colon, urinary bladder are unremarkable, given lack of IV contrast.",0
"The free pelvic fluid demonstrates high attenuation posteriorly, concerning for hemoperitoneum.",0
"There is an irregular area of higher attenuation adjacent to the abdominal wall, which in the setting of recent surgery is consistent with hematoma.",0
This measures approximately 9.7 x 6.0 cm.,0
Limited study without PO or IV contrast.,0
"Colon wall thickening may or may not reflect presence of colitis, correlate clinically.",0
"Large ascites ans anasarca, consistent with third spacing.",0
"(Over) , R. MED SICU-A 10:11 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: eval for source of fever in chest or abdomen..",0
Admitting Diagnosis: OVERDOSE ______________________________________________________________________________ PFI REPORT (Cont),0
6:48 PM PORTABLE ABDOMEN Clip # Reason: obstruction?,0
"Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with metastatic breast cancer (to the brain, liver, bone, spine) complicated by past cord compression now being transferred from unresponsiveness and a likely aspiration event.",1
"Now stable with NG suction, vomiting and bilious suction.",0
REASON FOR THIS EXAMINATION: obstruction?,0
______________________________________________________________________________ WET READ: ENYa MON 9:09 PM 1. retained PO contrast in the descending and sigmoid colon.,0
"2. unchanged caliber of a loop of ""dilated"" bowel in the mid pelvis, now with retained PO contrast.",0
"Given the progression of the contrast into this loop of ""dilated"" bowel, this likely represent the sigmoid colon.",0
No evidence of free air.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Vomiting and with bilious output from NG, concern for obstruction.",0
TECHNIQUE: Supine and left lateral decubitus radiographs of the abdomen.,0
FINDINGS: There has been interval progression of contrast from the transverse colon into the descending and sigmoid colon.,0
There is persistence of a dilated loops of small bowel within the lower mid abdomen that now appear to be filled with contrast.,0
"This is likely the contrast that the patient ingested during her video swallow exam earlier in the day, residing in the small bowel.",0
The dilatation of these loops is nonspecific and is not accompanied by any evidence of distal obstruction or proximal small bowel dilatation.,0
The NG tube is not well seen on this image.,0
"However, it appears that the distal tip still resides in the stomach.",0
There is no bony abnormality.,0
"Dilated loop of small bowel in the lower mid abdomen filled with contrast, likely from the patient's video swallow examination.",0
This is a nonspecific finding but is unlikely obstruction given the lack of proximal loop dilatation.,0
Progression of contrast through the transverse colon and into the descending and sigmoid colon.,0
8:02 AM CHEST (PORTABLE AP) Clip # Reason: eval for effusions.,0
"Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man s/p mvc-R hemothorax, s/p r chest tube REASON FOR THIS EXAMINATION: eval for effusions.",1
"______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Motor vehicle accident, right hemothorax, chest tube.",1
"Lung volumes are quite low, as before.",0
There is atelectasis and/or consolidation in the right lung and retrocardiac area as before.,0
The right hemidiaphragm remains symmetrically elevated.,0
Subpulmonic fluid on the right cannot be excluded.,0
Multiple rib fractures are seen on the right as before.,0
"An endotracheal tube, nasogastric tube, right subclavian catheter, and right chest tube remain in place.",0
A Swan-Ganz catheter has been withdrawn.,0
IMPRESSION: Removal of Swan-Ganz catheter.,0
"5:18 PM CHEST (PORTABLE AP) Clip # Reason: very decreased bs left side s/p line, please eval for ptx Admitting Diagnosis: THROMBOTIC THROMBOCYTOPENIC PUPURA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with increasing o2 req on vent - decr breath sounds on left REASON FOR THIS EXAMINATION: very decreased bs left side s/p line, please eval for ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Status post line placement with decreased breath sounds on the left.",0
"CHEST X-RAY, PORTABLE AP: Comparison made to study of one hour previously.",0
A left subclavian central venous line is again noted.,0
The tip is positioned at the junction of the brachiocephalic vein and the superior vena cava.,0
The nasogastric tube and endotracheal tube are unchanged in position.,0
There is atelectasis and a small effusion at the left lung base.,0
"The right lung is incompletely imaged, but there is opacity at the right lung base, consistent with atelectasis vs. infiltrate.",0
Persistent atelectasis at the left lung base.,0
"8:15 AM CT HEAD W/O CONTRAST Clip # Reason: eval for ICH ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with HA, collapse and respiratory failure REASON FOR THIS EXAMINATION: eval for ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: AJy SAT 9:17 AM large posterior fossa intraparenchymal hematoma measuring up to 4 x 7.3 cm axially with extension into the 4th, 3rd an lateral ventricles.",0
SAH is seen in the basal cisterns which are effaced by upward herniation.,0
there is compression of the brainstem anteriorly and herniation of the tonsils through the foramen magnum.,1
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male with headache, collapse, and subsequent respiratory failure.",0
The patient listed as EU Critical.,0
"NON-CONTRAST HEAD CT: There is a large intraparenchymal hematoma within the posterior fossa, measuring 4.0 x 7.3 cm axially.",0
"There is extension into the ventricular system, including the fourth, third, and lateral ventricles.",0
"There is extensive mass effect, with herniation of the tonsils inferiorly through the foramen magnum, and upward transtentorial herniation with effacement of the basal cisterns.",0
The brainstem is compressed anteriorly.,0
There is additional subarachnoid hemorrhage seen within the basal cisterns.,0
There is no further intraparenchymal hematoma supratentorially.,0
There is no subdural or epidural hematoma.,0
"The bones are unremarkable, and the visualized paranasal sinuses are clear.",0
"IMPRESSION: Large posterior fossa intraparenchymal hematoma measuring up to 4 x 7.3 cm, actually, with extension into the ventricles.",0
Additional subarachnoid hemorrhage is seen in the basal cisterns.,0
"There is extensive mass effect, with upward transtentorial herniation causing effacement of the basal cisterns, compression of the brainstem anteriorly, and downward tonsillar herniation through the foramen magnum.Dilated temporal horns indicate developing hydrocephalus.",1
Communicated to Dr. at the time of imaging.,0
Status: Inpatient Date/Time: at 11:14 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.,1
The non-coronary cusp is relatively fixed.,0
POSTBYPASS Biventricular systolic function remains preserved.,0
"11:52 AM HAND (AP, LAT & OBLIQUE) PORT LEFT Clip # Reason: r/o fracture L hand Admitting Diagnosis: C2 FRACTURE-S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with L hand pain s/p Mva REASON FOR THIS EXAMINATION: r/o fracture L hand ______________________________________________________________________________ FINAL REPORT HISTORY: Left hand pain S/P MVA rule out fracture.",1
A ring overlies portions of the left 4th proximal phalanx.,0
No fracture or dislocation is detected.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Seizure Major Surgical or Invasive Procedure: Intubation History of Present Illness: 62 year-old right-handed F who presented from her nursing home via EMS actively seizing.,1
History is per EMS and scarce medical records.,0
The patient was last seen normal at 1pm and presents after 45min of focal motor seizure activity and decreased responsiveness.,0
This consisted of left eye deviation and left arm convulsive activity.,0
She was intubated by EMS and received valium 5mg en route to no effect.,0
"Here, she received ativan 2mg IV x 2, 5 min apart and motor activity ceased.",0
She remained with left eye deviation until after a third round of ativan.,0
Propofol has of yet been held due to low systolic blood pressure on attempted administration.,0
Past Medical History: Advanced multiple sclerosis HTN Advanved schizophrenia DM Hyperlipidemia Tardive dyskinesias secundary to longterm neuroleptic use Dementia Institutionalized for at least 11 years Remote symptomatic seizure disorder Baseline functioning level unknown.,1
"Multiple attempts made to reach Nursing Home, but only single D/C summary from hospital received.",0
No calls back to date from her PCP will attempt again.,0
"Known remote symptomatic seizure disorder, but no semiological detail available - last admission for ""increased seizure activity"" was in , see fax in chart.",0
"She was thought to have a PNA or bronchitis, and subtherapeutic VPA levels.",0
Social History: Baseline functioning level unknown.,0
A family member (cousin or ) was not awawre of a diagnosis of MS. Family History: Unknown.,0
"Physical Exam: PE VS 101.9 130s 108/69 16 97% intubated, no sedation Gen intubaed HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated.",0
"No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Does not open eyes to verbal or noxious stimuli.",0
"CN Pupils 3->2mm b/l, gaze deviated to the left with slight nystagmoid movements.",0
Unable to overcome gaze deviation with oculocephalics.,0
"To noxious stimuli, both arms internally rotate; both legs with triple flexion.",0
"On my arrival, there was clonic activity of the left arm that ceased with ativan.",0
SENSORY As above REFLEXES Tri Pat Ach L 3 3 3 3 3 R 2 2 2 2 3 Plantar response was extensor bilaterally.,0
Pertinent Results: 07:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-29 GLUCOSE-140 07:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* POLYS-0 LYMPHS-100 MONOS-0 04:25PM URINE RBC-* WBC-0-2 BACTERIA-NONE YEAST-MOD EPI-0-2 TRANS EPI-0-2 04:00PM VALPROATE-44* 04:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG 04:00PM PT-12.5 PTT-26.3 INR(PT)-1.1 04:00PM NEUTS-86.5* LYMPHS-9.3* MONOS-3.5 EOS-0.2 BASOS-0.4 04:00PM WBC-7.7 RBC-4.36 HGB-11.6* HCT-35.2* MCV-81* MCH-26.7* MCHC-33.1 RDW-13.8 NCHCT 1.,0
Extensive chronic microvascular ischemic disease.,0
"Extensive calvarial hyperostosis, of uncertain etiology.",0
Focal lytic lesion in the clivus is likely fibrous dysplasia.,0
MRI/MRA Extensive T2 signal abnormality within the white matter of the brain.,0
CXR : New opacity in the right lower lobe is consistent with aspiration given the clinical history.,0
Small atelectasis is in the left base.,0
"NEURO - The patient arrived intubated with a non-focal exam, but with bilateral upgoing toes and only sparse medical history.",0
A NCHCT revealed no bleed.,0
"An MRI the next day revealed extensive white matter disease, with a maximum around the corpus callosum.",0
"There are no data to suggest CADASIL: No microbleeds on GRE, no temporal involvement of the WN lesions, no family history.",0
Tox-screen and basic screening labs including U/A were negative.,0
"Depakote level was 44 ug/mL, non-trough.",0
"She was bolused with VPA twice over the next 24 hours, as her repeat level remained 44.",0
"Of note, the values of VPA have been as high as 129, but none of the levels is a ""true trough"".",0
"Her maintenance dose was increased to a total of 2500 mg QD, divided in 3 IV doses in the ICU but switched to PO on transfer to floor.",0
There was no further seizure activity.,0
"She had an EEG done which showed semirhythmic theta range activity with occasional sharp waves in the R anterior temporal region, and a disorganized, low voltage BG with a 6 Hz posterior dominant rhythm.",0
Clinically she woke up slowly over the course of 3 days in the ICU.,0
"Her prolonged recovery time is not surprising given the prolonged seizure, the limited cerebral reserves at baseline and the benzodiazepines she received.",0
She returned to her baseline the day after transfer without any further concerns.,0
A repeat Depakote level was 122 with goal of >80.,0
It was felt that she was too sedated on this Depakote dose (1250mg ) and therefore was decreased back to 1000mg as her status epilepticus was likely triggered by her acute pneumonia.,1
"RESP - She was noted to have a pneumonia while on the respirator, with a suspicion of aspiration.",0
She spiked high fever and CXR confirmed a RLL infiltrate.,0
She was started on Piperacillin-Tazobactam Na 4.5g IV Q8H and Vancomycin 1000mg Q12H on .,0
She was remained in the ICU one day post-extubation due to excessive suctioning requirements.,0
She was weaned quickly to room air which she remained at upon discharge.,0
ID - Pneumonia as above.,0
"She had a fever on admission and was given Ceftriaxone 2 grams x 1 and Vancomycin 1 gram x 1, as well as Ampicillin 2 grams IV x 1 and Acyclovir 800 mg IV x 1 - per ED clinician order sheet in chart.",0
"LP on admission was sterile including Gram stain, culture no growth.",0
A blood culture on grew coagulase negative staph with repeat negative x 3.,0
Two respiratory cultures grew only normal flora.,0
She was treated with 10 days of antibiotics (zosyn & vancomycin).,0
CARDIOV - Metoprolol 10 IV Q4H switched to 12.5 mg TID in the ICU.,0
This was subsequently changed to 12.5mg and 25mg q HS for increased blood pressure.,0
Upon transfer there were no further concerns.,0
FEN/Endo - On D51/2NS in the ICU and D5NS upon transfer to the floor.,0
Started on tube feeds with a speech/swallow evaluation concering for aspiration.,0
A video swallow study showed aspiration with all consistencies and no voluntary cough.,0
"Therefore, a GJ-tube was placed on .",0
Feeds were restarted with Replete plus fiber for a goal of 55ml/hr which she tolerated.,0
Medications on Admission: Actos 15mg daily Actonel weekly Lisinopril 5 ASA 81 Megestrol Oxybutinin 2.5mg daily MVI Clonazepam 0.5mg Depakote 1000mg Metformin 500/500 Lovastatin 10 Discharge Medications: 1.,0
Valproate Sodium 250 mg/5 mL Syrup Sig: Four (4) mL PO Q12H (every 12 hours).,0
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
Discharge Disposition: Extended Care Facility: Healthcare Center Discharge Diagnosis: Primary Diagnosis: 1.,0
Hyperlipidemia Discharge Condition: Stable Discharge Instructions: You were admitted to the ICU secondary to focal status epilepticus and also treated for an aspiration pneumonia.,1
"After a swallowing evaluation, a GJ-tube was placed due to the concern of continued aspiration.",0
"Repeat Valproic Acid level in days Please see your primary medical doctor or go to the nearest emergency department if you develop fevers, vomiting, feeding intolerance, seizures, change in mental status or any other concerns.",1
Followup Instructions: Please follow up with your PCP.,0
"have not arranged follow up with the at this time, but if you wish to do so please call the main number , and ask for the outpatient neurology service.",0
Follow-up with your primary medical doctor in weeks 2.,0
Follow-up with your primary neurologist in weeks,0
"8:00 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: Please assess for PTX, infiltrate Admitting Diagnosis: PANCREATIC ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 51yo M s/p R VATS, decortication.",0
"now with low sats REASON FOR THIS EXAMINATION: Please assess for PTX, infiltrate ______________________________________________________________________________ FINAL REPORT Portable chest x-ray of with comparison .",0
Right-sided chest tube and feeding tube are unchanged in position allowing for positional differences.,0
Cardiac silhouette is mildly enlarged.,0
"There is upper zone vascular redistribution and slight worsening of asymmetrical perihilar edema, right greater than left.",0
"Moderate-sized pleural effusions are again demonstrated, with slight improvement on the left and slight worsening on the right.",1
"Finally, a catheter overlies the right axilla, likely due to a PICC line, without interval change but with the tip proximal to the subclavian artery.",0
8:37 PM BABYGRAM AP ABD ONLY PORT; -76 BY SAME PHYSICIAN # Reason: follow bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant former 26 wkr with concerning films for NEC REASON FOR THIS EXAMINATION: follow bowel gas pattern ______________________________________________________________________________ FINAL REPORT Former 26-week with concerning films for neck.,0
Examination date at 19:44 compared to the film earlier the same day demonstrates a nasogastric tube reaching the level stomach.,0
Again seen are dilated loops of bowel with air to the rectum.,0
The previously described stent loop in the right lower quadrant is not well seen on the current film due to overlying material on the baby's abdomen.,0
There is likely continued finding suggestive of pneumatosis in those loops.,0
No definite free air or portal venous gas is seen.,0
"6:59 PM CHEST (PRE-OP PA & LAT) Clip # Reason: GASTROINTESTINAL PERCUTANEOUS FISTULA Admitting Diagnosis: GASTROINTESTINAL PERCUTANEOUS FISTULA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with R PICC line placed at outside hospital, for enterocutaneous fistula repair/reversal of gastric bypass REASON FOR THIS EXAMINATION: assess R PICC line placement, also preop for OR ______________________________________________________________________________ FINAL REPORT INDICATION: 64 year-old man with right PICC placed at outside hospital; pre- op for enterocutaneous fistula repair.",0
FRONTAL AND LATERAL CHEST RADIOGRAPH A right-sided PICC is seen with tip overlying the mid-distal SVC.,0
Cardiac and mediastinal contours appear unremarkable.,0
There is no focal consolidation or pleural effusion.,0
"Coarse prominence of interstitial markings, diffusely, is of uncertain significance.",0
DISH noted in thoracic spine.,0
"Diffusely coarse interstitial markings raise the possibility of underlying interstitial lung disease, and comparison with previous (outside) radiography is recommended.",0
5:48 PM MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # MR W & W/O CONTRAST Reason: Please do total spine MRI with gadolidium to evaluate for sp Admitting Diagnosis: RESPIRATORY FAILURE Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man with germ cell tumor and known brain mets undergoing neuro-staging.,1
REASON FOR THIS EXAMINATION: Please do total spine MRI with gadolidium to evaluate for spine metastases for complete staging workup.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: MRI OF THE CERVICAL, THORACIC, AND LUMBAR SPINE WITH IV CONTRAST PERFORMED ON .",0
HISTORY: 22-year-old male with germ cell tumor and known brain metastasis undergoing staging.,0
Please evaluate for spinal metastasis.,0
"TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained of the cervical, thoracic, and lumbar spine.",0
Sagittal T1-weighted images were then obtained after IV contrast administration with 15 mL of Magnevist.,0
COMPARISON: No prior examination for comparison.,0
FINDINGS: Current study is limited by patient motion.,0
"Alignment of the cervical, thoracic, and lumbar spine is maintained.",0
There is a focus of increased T1 and T2 signal in the anterior superior portion of the L5 vertebral body that is not hyperintense on STIR imaging.,0
This likely represents focal fat or hemangioma.,0
There is also some desiccation of the adjacent L4-L5 disc.,0
"Otherwise, there is no signal intensity abnormality in the spine.",0
The spinal cord and conus medullaris appear normal.,0
No intradural abnormalities are seen.,0
There is no evidence of nerve root or spinal canal compression.,0
The large mediastinal lesion previously seen on CT of the chest is again partially visualized.,0
IMPRESSION: No spinal metastases seen.,0
A focus of hyperintensity on T1 and T2 but not on STIR likely represents focal fat or hemangioma in the L5 vertebral body.,0
Findings were discussed with Dr. at 2:41 p.m. on .,0
"11:21 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: r/o acute neuro event Admitting Diagnosis: PNEUMONIA Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 89 year old male intubated, sedated REASON FOR THIS EXAMINATION: r/o acute neuro event No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Patient intubated.",1
Rule out acute neurologic event.,0
TECHNIQUE: Contiguous axial MDCT-acquired images of the head were obtained before and after administration of intravenous contrast.,0
FINDINGS: Study is limited by motion artifact.,0
There is no acute intracranial hemorrhage or major vascular territorial infarction.,0
"No edema, mass effect or shift of normally midline structures is noted.",0
The ventricles and sulci are prominent in size and configuration likely due to age-related global atrophy.,0
Paranasal sinuses and mastoid air cells are clear.,0
Again noted are cavernous carotid vascular calcifications.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: is the former 3.025 kg product of a 37 week gestation pregnancy to a 36 year old gravida 5, para 2 to 3 woman, prenatal screens of blood type A positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, Group B Streptococcus negative.",1
PAST MEDICAL HISTORY: Notable for chronic hypertension.,0
Her prenatal course was unremarkable except for continued hypertension.,0
"She was admitted for elective induction of labor, rupture of membranes occurred three hours prior to delivery.",0
Second stage of labor was 18 minutes.,0
The baby was by spontaneous vaginal delivery with Apgars of 8 at one minute and 8 at five minutes.,0
A nuchal cord was noted at the time of delivery.,0
The baby was admitted to the Nursery.,0
"She exhibited symptoms of grunting, flaring and retracting.",0
These persisted and she was admitted to the Neonatal Intensive Care Unit for further observation and treatment.,1
"PHYSICAL EXAMINATION: Physical examination upon admission to the Neonatal Intensive Care Unit, weight was 3.025 kg, length 48 cm, head circumference 34.5 cm.",0
"General: Pink infant in nasal cannula oxygen, skin pink, no lesions.",0
"Head, eyes, ears, nose and throat: Soft anterior fontanelles, normal facies, intact palate.",0
"Chest: Mild grunting and retraction, fair air entry.",0
"Abdomen: Soft, nontender, no hepatosplenomegaly.",0
"Genitourinary: Normal external genitalia, patent anus.",0
"Musculoskeletal: Stable hips, small ecchymosis on the dorsal aspect of the right forearm, normal perfusion.",0
Neurologic: Normal tone and activity.,0
HOSPITAL COURSE: (By systems including pertinent laboratory data).,0
Respiratory - required nasal cannula oxygen through the first four days of life.,0
She weaned to room air at 9 AM on .,0
A chest x-ray was consistent with transient tachypnea of the .,0
"At the time of discharge, she is breathing comfortably in room air with respiratory rates in the 30s to 60s.",0
Cardiovascular - maintained normal heart rates and blood pressures.,0
"Fluids, electrolytes and nutrition - Breastfeeding was started on day of life #2.",0
Intravenous fluids had been started and were gradually weaned.,0
At the time of discharge she has been exclusively breastfeeding or taking Enfamil p.o.,0
ad lib for three days prior to discharge.,0
"Discharge weight is 2.735 kg which is 6 pounds 0.5 ounces, this also represents her low weight since birth.",0
"Infectious disease - Due to the unknown etiology of the respiratory distress, was evaluated for sepsis at the time of admission to the Neonatal Intensive Care Unit.",1
"A white blood cell count was 22,000 with a differential of 83% polymorphonuclear cells and 3% band neutrophils.",0
The blood culture showed no growth at 48 hours and the antibiotics were discontinued.,0
"Gastrointestinal - Peak serum bilirubin occurred on day of life #4, total of 13/0.3 mg/dl direct with an indirect of 12.7 mg/dl.",0
Repeat on the date of discharge is total of 10.8/0.2 with a new direct of 10.6 mg/dl.,0
Hematology - Hematocrit at birth was 41.2%.,0
did not receive any transfusions with blood products.,0
Neurology - has maintained a normal neurological examination during admission.,0
"Sensory - Audiology, hearing screen was performed with automated auditory brain stem responses, passed in both ears.",0
"PRIMARY PEDIATRICIAN: , Pediatric Associates, , , phone , fax #.",0
Feeding - Breastfeeding ad lib.,0
"Carseat position screening - Performed, was observed for 90 minutes in her carseat without episodes of bradycardia or oxygen desaturation.",0
State screen - Sent with no notification of abnormal results to date.,0
Immunizations received - Hepatitis B vaccine was administered on .,0
"Immunizations recommended - I. Synagis respiratory syncytial virus prophylaxis should be considered from through for infants who meet any of the following three criteria: at less than 32 weeks; between 32 and 35 weeks with two of the following - Daycare during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings; or with chronic lung disease.",0
FOLLOW UP APPOINTMENTS: Appointment with Dr. within five days of discharge.,0
Respiratory distress secondary to transient tachypnea of the .,0
"Suspicion for sepsis, ruled out.",0
Dictated By: MEDQUIST36 D: 06:36 T: 06:40 JOB#:,0
10:58 AM CHEST (PA & LAT) Clip # Reason: assess for effusions/infiltrates Admitting Diagnosis: AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman s/p AVR/Asc Ao Repair REASON FOR THIS EXAMINATION: assess for effusions/infiltrates ______________________________________________________________________________ FINAL REPORT TWO VIEW CHEST COMPARISON: .,1
INDICATION: Status post aortic valvular surgery.,1
Right internal jugular vascular catheter remains in place terminating at the junction of the superior vena cava and right atrium.,0
There is widening of the cardiac and mediastinal contours which is without change from the prior postoperative radiograph but is a change from the preoperative exam.,0
There is improving bibasilar atelectasis and interval decrease in size of bilateral pleural effusions with residual small effusions remaining.,0
"8:44 AM CHEST (PORTABLE AP) Clip # Reason: PTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with s/p AVR, CT post-pull REASON FOR THIS EXAMINATION: PTX ______________________________________________________________________________ FINAL REPORT HISTORY: Status post AVR, chest tube pulled, question pneumothorax.",1
"CHEST, SINGLE AP PORTABLE VIEW: Compared with at 11:41 a.m., the bilateral chest tubes have been pulled.",0
There are low inspiratory volumes.,0
"Patchy opacity at the left base again noted, slightly improved.",0
Blunting of the right greater than left costophrenic angles is also grossly unchanged.,0
"Upper zone redistribution, without CHF.",0
"Sternotomy wires and cardiomediastinal prominence again noted, unchanged.",0
IMPRESSION: Interval removal of chest tubes.,0
Small R>L effusions are grossly unchanged.,0
Height: (in) 66 Weight (lb): 160 BSA (m2): 1.82 m2 BP (mm Hg): 108/64 Status: Inpatient Date/Time: at 15:00 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
LEFT ATRIUM: The left atrium is mildly dilated.,0
"GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended).",0
A right pleural effusion is present.,0
IMPRESSION: Preserved global and regional biventricular systolic function.,0
"Compared with the prior study (tape reviewed) of , the estimated pulmonary artery systolic pressure is increased on the current study.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CCU HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old female with coronary artery disease who presented at an outside hospital with chest pain, shortness of breath, which started two days prior and was intermittent.",1
"However, one day prior to admission, it became constant.",0
"Initially, it was relieved with nitroglycerin times two.",0
EMS found her with 5/10 chest pain.,0
"On route to the outside hospital, she received nitroglycerin times two and aspirin 162.",0
She was tachycardiac with a blood pressure of 120/70.,0
She was started on IV nitroglycerin and IV fluids.,0
"The EKG demonstrated ST elevations in II, aVF, ST depressions in V1 through V4.",0
"Catheterization revealed 70% occluded SVG to RCA with TIMI-III flow, patent RCA, and patent other arteries.",0
She received packed red blood cells and Lasix.,0
She was then transferred to the CCU.,0
She originally presented to and was found to have a hematocrit of 17.6 down from 30.4 on .,0
Her INR at that time was 3.2.,0
"She did have Guaiac positive stools, at which point she was transferred to for catheterization with the above findings.",0
Raynaud's with chronic pain syndrome.,0
Coumadin 2 alternating with 3.,0
Digoxin 0.125 once a day.,0
Protonix 40 once a day.,0
Dilaudid 2 q. four hours.,0
"ALLERGIES: She is allergic to sulfa, Diamox, Neurontin, Bactrim, Valium, and erythromycin.",0
"SOCIAL HISTORY: She is married, a former smoker, quit in .",0
PHYSICAL EXAMINATION ON ADMISSION: Weight: 110.,0
"Vital signs: Heart rate 111, blood pressure 150/67.",1
"General: She was a pale, ill-appearing female.",0
HEENT: Her mucous membranes were dry.,0
She had a left eye which was glass.,0
Cardiovascular: She was tachycardiac with a mechanical S2.,0
Lungs: She had bronchial sounds but no crackles on lung examination.,0
"Abdomen: Her abdomen was soft, nontender, nondistended.",0
"Extremities: There was 1+ dorsalis pedis, mottled, but warm.",0
"LABORATORY DATA/STUDIES: The EKG demonstrated sinus tachycardia with an old Q wave infarction with ST elevations in III, aVF which were new, ST depressions in I, V2 through V5 which were old.",0
"Laboratories on arrival to the demonstrated a white count of 16.9, hematocrit 16.3, platelets 266,000.",0
"Sodium 140, potassium 3.8, chloride 102, bicarbonate 27, BUN 47, creatinine 1.2, glucose 126.",0
"ALT 9, AST 18, albumin 2.9, amylase 39, alkaline phosphatase 63.",0
HOSPITAL COURSE: She was admitted to the CCU Service following her cardiac catheterization.,0
"She was started on aspirin; however, Plavix was held given the possibility of GI bleed.",0
"Once her INR was less than 1.8, the heparin was resumed because of her mechanical mitral valve.",0
She was transfused in order to keep her hematocrit greater than 30.,0
She was started on a beta blocker.,0
"She underwent EGD on which demonstrated erythema, congestion, and diminished folds in the stomach, body, and fundus compatible with gastritis.",0
"Otherwise, it was a normal EGD to the second part of the duodenum.",0
"At that time, she was placed on Protonix 40 b.i.d.",0
"Therefore, GI was reluctant to do a colonoscopy given peri MI.",0
"She, therefore, underwent cardiac stress test which was negative for ischemia.",0
There was no further chest pain.,0
It was thought that this was originally due to demand ischemia from a dramatically decreased hematocrit.,0
The colonoscopy was negative for bleed at that time.,0
Her hematocrit had been stable for several days.,0
She was resumed on her Coumadin but left on heparin until it was therapeutic.,0
It was felt that this was possibly a small bowel bleed with small bowel follow through if bleeding was to resume.,0
"She was, therefore, monitored in-house on heparin until her INR was therapeutic, at which point she was transferred to the Medical Service to await the therapeutic INR of greater than 2.5.",0
"Additionally, she developed a pneumonia while in-house.",0
She was started on Levaquin and remained afebrile and the white count trended downward.,0
She was treated for a total of ten days.,0
"She had no further episode of chest pain during her hospitalization and, therefore, was discharged home in good condition.",0
Aspirin 325 once a day.,0
Lisinopril 5 once a day.,0
Lipitor 5 once a day.,0
FOLLOW-UP: She was discharged home with follow-up with her PCP.,0
Dictated By: MEDQUIST36 D: 02:11 T: 23:18 JOB#:,0
12:26 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
aspiration pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 89M s/p RSC TLC REASON FOR THIS EXAMINATION: ?,0
aspiration pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: S/P placement of right subclavian line and triple lumen catheter.,0
FINDINGS: Standard AP semiupright image.,0
The left subclavian Swan-Ganz catheter tip is in good position in the right interlobar pulmonary artery.,0
The endotracheal tube and the NG tube also remain in good position.,0
"The heart again shows fairly marked enlargement, probably biventricular.",0
In addition there is obvious upper zone redistribution and blurring of vascular detail at the bases as well as bilateral largely subpulmonary effusions.,0
"These findings indicate significant left ventricular decompensation, slightly worse than on the prior study.",0
IMPRESSION: Worsening left heart failure.,1
The various lines and tubes are in good position.,0
"12:22 AM BABYGRAM (CHEST ONLY) Clip # Reason: Verify ETT placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with CLD, self-extubated REASON FOR THIS EXAMINATION: Verify ETT placement ______________________________________________________________________________ FINAL REPORT HISTORY: Chronic lung disease.",1
"PORTABLE AP CHEST, 0:15, : The patient has been re-intubated with ETT reaching the upper trachea.",0
NG tube has been removed.,0
The lungs appear grossly clear with diffuse chronic lung disease persisting.,1
Bowel gas pattern reveals mildly distended loops of bowel with no focal abnormalities.,0
"9:21 AM CHEST (PORTABLE AP) Clip # Reason: please eval for CHF Admitting Diagnosis: TYPE B AORTIC DISSECTION-ODONTOID FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with c2 fracture, crackles on exam, increaseing o2 4requirement, REASON FOR THIS EXAMINATION: please eval for CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath.",1
"COMPARISON: SINGLE VIEW CHEST, AP: The post-surgical changes are unchanged.",0
There is persistent cardiomegaly as well as increased interstitial opacities consistent with left ventricular heart failure.,0
The rest of the study is unchanged.,0
IMPRESSION: Unchanged left ventricular heart failure.,0
"8:06 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: initial x ray for intubated infant with lines Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 30 weeks REASON FOR THIS EXAMINATION: initial x ray for intubated infant with lines ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST, AT 0825 HOURS CLINICAL HISTORY: 30-week triplet with respiratory distress.",1
Endotracheal tube present with its tip overlying T1 vertebral body.,0
Umbilical venous catheter seen with its tip near the inferior cavoatrial junction.,0
Hypoinflated lungs with diffuse hazy opacification bilaterally with a reticulonodular pattern.,0
Moderate dilatation of multiple loops of bowel consistent with recent bagging.,0
No evidence of pneumothorax or pneumoperitoneum identified.,0
IMPRESSION: Changes consistent with probable surfactant deficiency.,0
9:28 AM CHEST (PORTABLE AP) Clip # Reason: pna Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with cerebral hemorrhage REASON FOR THIS EXAMINATION: pna ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 3:40 PM Low lung volumes.,1
"______________________________________________________________________________ FINAL REPORT HISTORY: 88-year-old woman with cerebral hemorrhage, pneumonia.",1
COMPARISON: Chest radiograph from one day prior ().,0
"CHEST, SEMI-UPRIGHT PORTABLE FRONTAL VIEW: Low lung volumes result in bronchovascular crowding.",0
There is no airspace consolidation or evidence of pulmonary edema.,0
"12:01 PM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: evaluate for any infectious process Admitting Diagnosis: SPLENIC LACERATION Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with supposed spontaneous splenic laceration, esophageal varicies REASON FOR THIS EXAMINATION: evaluate for any infectious process No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old, currently in alcohol withdrawal, with supposed spontaneous splenic laceration.",1
Please evaluate for infectious process or esophageal varices.,0
No prior examinations available for comparison.,0
"The patient had an outside hospital CT at , which is not currently available.",0
"Per report conveyed by the Surgical team, there was a 13 cm TRV x 5 cm AP x 13 cm CC perisplenic collection/hematoma.",0
"TECHNIQUE: Multidetector helical scanning of the chest, abdomen and pelvis was performed using a multiphasic liver technique with delayed images through the chest, abdomen, and pelvis.",0
"CT OF THE CHEST: The lungs are clear, with minimal dependent atelectasis.",0
The aorta is of normal caliber and the great vessels are unremarkable.,0
"Though this study is not optimized for evaluation for pulmonary embolism, there is no central PE within the main or lobar pulmonary arteries.",0
No mediastinal or hilar lymphadenopathy.,0
Small axillary nodes are not pathologically enlarged.,0
"CT OF THE ABDOMEN: There is a small laceration in the superoanterior spleen and a large perisplenic hematoma which measures approximately 14.8 cm AP x 5.7 cm TRV x 13.6 cm CC, dimensions which are slightly larger than the conveyed report from the outside hospital, however without visualization of those images, direct comparison is limited.",1
"High-density fluid, presumably blood, extends into the perihepatic space and along the paracolic gutters, also extending into the mesentery and pelvis.",0
There is no blush of contrast during the arterial or delayed phases within or around the spleen to suggest active extravasation.,0
The liver is intact with no evidence of laceration.,0
There are no varices or other signs of hepatic cirrhosis.,0
High-attenuation layering material within the gallbladder is consistent with vicarious excretion of previously administered contrast.,0
The pancreas and right adrenal gland are normal.,0
"There is slight haziness of the left adrenal gland, though this may be due to hematoma extending from the spleen.",1
The intra-abdominal small and large bowel loops are normal.,1
(Over) 12:01 PM CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # CT PELVIS W/CONTRAST Reason: evaluate for any infectious process Admitting Diagnosis: SPLENIC LACERATION Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) The aorta is of normal caliber.,0
"CT OF THE PELVIS: Moderate amount of high-density fluid, presumably blood, extends into the pelvis.",0
Foley catheter and air are seen within a mostly decompressed bladder.,0
"The sigmoid colon, rectum, and prostate gland are normal.",0
"There may be a non-displaced fracture along the distal aspect of the left eleventh rib (6:66) which would not be unexpected given the splenic injury, however evaluation is limited due to slice thickness and a non-bone algorithm.",0
An old healed fracture is seen within the left tenth rib and left seventh rib posteriorly (6:29).,0
"Multiple Schmorl's nodes are noted within the thoracic and lumbar spine, however no acute fracture.",0
"Large perisplenic hematoma and small splenic laceration, with no evidence of active extravasation.",0
"Moderate hemoperitoneum, however no evidence of other intra-abdominal injury.",1
"If the outside hospital CT is made available, an addendum can be made following direct comparison.",0
"Probable left eleventh rib fracture, though evaluation is slightly limited due to the CT technique.",0
Findings were discussed with Dr. at 3 PM on .,0
"10:09 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for infiltrate, consolidation, infection Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man s/p stroke with fevers REASON FOR THIS EXAMINATION: Please evaluate for infiltrate, consolidation, infection ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 3:01 PM PFI: The PICC line terminates in the mid SVC.",1
"Lung volumes are _____ low with patchy bibasilar opacities that likely represent atelectasis, possibly with small effusions.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Status post stroke, now with fevers.",0
Also recent PICC line placement.,0
FINDINGS: A right-sided PICC has its tip in the mid SVC.,0
The lung volumes are markedly low with patchy bibasilar opacities.,0
"These likely represent atelectasis, possibly with small effusions.",0
An underlying pneumonia can certainly not be excluded.,0
The cardiomediastinal silhouette is difficult to evaluate secondary to low inspiratory volumes.,0
There is no frank volume overload.,0
Right-sided PICC line terminates in the mid SVC.,0
"Patchy bibasilar opacities with low lung volumes, likely representing atelectasis with small effusions.",0
"7:15 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man POD2 minimally invasive esophagectomy, acutely agitated, sats 02 91%RA, removed NGT this AM, concern for aspiration REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Post-operative with possible aspiration.",1
"FINDINGS: In comparison with the study of , the nasogastric tube has been removed.",0
There is little change in the appearance of the heart and lungs with no definite aspiration.,0
"The area at the right base could merely reflect post-operative change, though the possibility of supervening pneumonia would have to be considered.",0
Opacification at the left base with blunting of the costophrenic angle persists.,0
"7:55 AM CHEST (PORTABLE AP) Clip # Reason: ?infiltrate Admitting Diagnosis: RESPIRATORY DISTRESS; RENAL FAILURE; CARDIOMYOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with CHF, Pneumonia, s/p PEA arrest.",1
"REASON FOR THIS EXAMINATION: ?infiltrate ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Chronic heart failure, pneumonia, evaluation.",1
"FINDINGS: Compared to the previous radiograph, there is no relevant change.",0
The nasogastric tube is now in correct position.,0
"5:24 AM CHEST (PORTABLE AP) Clip # Reason: pna, effusion, edema, ptx Admitting Diagnosis: INTRAPARENCHYMAL ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man intubated now febrile REASON FOR THIS EXAMINATION: pna, effusion, edema, ptx ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST ON AT 05:52.",0
"FINDINGS: Compared to the prior study, the current is degraded by slight patient motion.",0
"However, I see no evidence of developing infiltrate.",0
"Lines and tubes remain in place and accounting for the degradation in image quality, there is no significant interval change.",0
"4:20 AM CHEST (PORTABLE AP) Clip # Reason: Please eval tubes, lines, drains and status of RLL and LLL a Admitting Diagnosis: PLEURAL EFFUSION;QUESTION OF EMPYEMA ______________________________________________________________________________ MEDICAL CONDITION: 49M w HIV and hx EtOH abuse s/p repair esophageal perforation c/b persistent leak, xfer from OSH w sepsis esophago-pleural fistula w necrotizing fungal RLL PNA, early LUL PNA.",1
"Now s/p esophageal stent/PEG (), trach (), IR drainage RLL pulmonary abscess .",0
"REASON FOR THIS EXAMINATION: Please eval tubes, lines, drains and status of RLL and LLL abscess/pneumonia.",1
______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative sepsis.,0
"Widespread airspace opacities, more prominent on the right, are consistent with diffuse pneumonia.",0
The known abscess in the right lower lobe is better seen in detail on recent CT scan.,0
"Pigtail catheter is again seen at the base of the lung on the right, presumably within the abscess cavity.",1
Little change in the moderate pleural effusion.,1
Height: (in) 70 Weight (lb): 116 BSA (m2): 1.66 m2 BP (mm Hg): 165/81 HR (bpm): 72 Status: Inpatient Date/Time: at 15:55 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
9:17 AM BAS/UGI Clip # Reason: please check for leaks Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p Ivor- esophagectomy REASON FOR THIS EXAMINATION: please check for leaks ______________________________________________________________________________ FINAL REPORT HISTORY: 76 y/o man status post Ivor- esophagectomy.,0
FINDINGS: Patient is placed in supine and oblique positions on the fluoroscopic table and thin barium was administered.,0
"The contrast medium passes freely through the proximal and distal anastomosis, without evidence of extravasation.",0
"The proximal anastomosis is slightly narrowed, which could be a normal postoperative finding.",0
The contrast medium is visualized within the stomach promptly.,0
"Subsequently, contrast is noted within the small bowel loops.",0
The patient tolerated the procedure without complication.,0
IMPRESSION: No evidence of leak at the proximal or distal surgical anastomosis.,0
11:11 AM CHEST (PA & LAT) Clip # Reason: eval for PTX Admitting Diagnosis: THORACIC SPINE INJURY;TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with right sided chest tube REASON FOR THIS EXAMINATION: eval for PTX ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST ON AT 11:16 INDICATION: Followup with a chest tube.,1
FINDINGS: The tip of the chest tube is more proximal now projecting over the middle of right posterior rib 6.,0
There is a small right apical pneumothorax visualized.,1
It was not definitely seen on the prior study but in that study there were multiple monitoring lines obscuring details.,0
The remainder of the lungs is within normal limits with no evidence of new focal consolidation or a decline in fluid status.,0
Orthopedic hardware seen over the lower thoracic and visualized lumbar spine.,0
IMPRESSION: Right chest tube has been pulled back a bit since prior study; a small right apical pneumothorax is visualized.,1
I directly communicated these results to Dr. at 1:59 p.m. on .,0
2:38 AM CT HEAD W/O CONTRAST Clip # Reason: eval for ICH ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man with assault REASON FOR THIS EXAMINATION: eval for ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd SAT 3:08 AM Subarachnoid hemorrhage overlying the left hemisphere with possible tiny subdural measuring up to 1 mm in thickness over the left frontal lobe.,1
no shift of midline structures.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 23-year-old man status post assault.,0
FINDINGS: There is a subarachnoid hemorrhage seen overlying the left cerebral hemisphere.,1
There may also be a tiny right-sided subdural hematoma over the left frontal lobe (2:14) measuring only 1 mm in thickness.,0
"However, the left lateral ventricle is slightly smaller than the right and there may be some mild mass effect on the side.",0
There is no acute intraparenchymal hemorrhage.,0
The soft tissues of the orbits and nasopharynx are within normal limits.,0
No shift of midline structures.,0
Findings were discussed with Dr. at the time of review on .,0
"Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: Baby boy was born on , at 0018 hours by spontaneous vaginal delivery to a 35-year-old G2, P1 mother.",0
Maternal prenatal history was uncomplicated.,0
"Mother's prenatal screens: blood type A positive, antibody negative, rubella immune, HBSAG negative.",0
She was ruptured less than 24 hours and RPR was nonreactive.,0
There was clear fluid at rupture.,0
No neonatal sepsis risk factors.,0
Apgars were 7 and 9 at 1 and 5 minutes at birth.,0
The infant received bulb suctioning and PPV x10 seconds.,0
"In the newborn nursery the infant was noted to have an intermittent dusky appearance, no respiratory distress.",0
He had some circumoral cyanosis during breast feeding which prompted the admission to the NICU.,0
"PHYSICAL EXAMINATION: Four extremity blood pressures, systolics: right arm systolic 78, right leg 75, left arm 82, left leg 63.",0
HEENT: Anterior fontanel soft and flat.,0
"Nose, mouth, ears, all appear within normal limits externally.",0
"Grade 1 to 2 systolic murmur heard best on the lower parasternal border, normal pulses, normal perfusion.",0
GENITOURINARY: Normal full term male.,0
"NEUROLOGIC: Appropriate for newborn strength, tone, movements, cry, Moro, wake, sleep, sucking.",0
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The infant had desaturations on admission to the NICU to 60%.,0
Otherwise he has remained stable on room air since that time.,0
"CARDIOVASCULAR: The infant had a murmur on admission to the NICU, four extremity blood pressures done were within normal limits.",0
EKG was done and found to be within normal limits.,0
Hyperoxia test also within normal limits.,0
Dr. from cardiology at saw the infant and an ECHO was done which showed normal cardiac structure with a trivial patent ductus arteriosus.,0
The infant has had no further cardiac issues.,0
No follow up is recommended.,0
"FLUIDS, ELECTROLYTES AND NUTRITION: The infant has remained PO ad lib feeding since admission to the NICU.",0
The most recent weight is 3520grams.,0
The infant is on no medications at this time.,0
GASTROINTESTINAL: There have been no GI issues.,0
Bilirubin was sent on day of life 3 and result is 4.8/0.3.,0
HEMATOLOGY: Hematocrit on admission to the NICU was 37.5 with a platelet count of 289.,0
No further hematocrits or platelets have been measured.,0
INFECTIOUS DISEASE: CBC and blood culture were screened on admission to the NICU due to the desaturation episode.,0
"The white blood cell count was 21,000 with 53 poly's and 7 bands.",0
There was no left shift.,0
Blood culture was sent at that time.,0
The blood culture remained negative at 48 hours.,0
NEUROLOGY: The infant has maintained a normal neurologic examination for term infant.,0
SENSORY: Hearing screen was performed with automated auditory brain stem responses and the result is passed.,0
DISCHARGE DISPOSITION: Home with the family.,0
NAME OF PRIMARY PEDIATRICIAN: Dr. from Pediatrics.,0
Ad lib PO feeding of breast feeding supplemented with Similac 20 as needed.,0
State newborn screen was sent on and results are pending.,0
Immunizations received: He received Hep B vaccine on .,0
Immunizations Recommended: Synagis RSV prophylaxis should beconsidered from through for infants who meet any of the following three criteria: 1.,0
Born at less than 32 weeks gestation 2.,0
Born between 32 and 35 weeks gestation with two of the following: daycare during the RSV season; a smoker in the household; neuromuscular disease; airway abnormalities; or school age siblings.,0
Follow up appointment is recommended with the pediatrician within 48 hours of discharge from the NICU.,0
"Congenital heart defect, ruled out.",0
", MD Dictated By: MEDQUIST36 D: 00:12:10 T: 03:11:41 Job#:",0
12:17 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: r/o obstruction Admitting Diagnosis: CORONARY ARTERY DISEASE;AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; ?,1
CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with s/p avr/cabg REASON FOR THIS EXAMINATION: r/o obstruction ______________________________________________________________________________ FINAL REPORT ABDOMEN 2 VIEWS SUPINE & UPRIGHT: HISTORY: CABG and AVR with abdominal distention.,1
Gas is present throughout the colon and in the rectum and there is no evidence for intestinal obstruction or significant ileus.,0
Endovascular stents are present in the abdominal aorta and the common iliac arteries and on the right side extends into the right common femoral artery.,0
No free intraperitoneal gas or soft tissue masses.,0
Calcific density versus contrast overlies the left upper quadrant.,0
IMPRESSION: No evidence for intestinal obstruction or significant ileus.,0
4:05 AM CHEST (PORTABLE AP) Clip # Reason: Acute pulm process - pneumo?,0
"Admitting Diagnosis: ATRIAL FIBRILLATION\PHARMACOLOGICAL / NON PHARM MGMT AFIB ABLATION **REMOTE WEST**/SDA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with RP bleed, describing pleuritic chest pain.",1
REASON FOR THIS EXAMINATION: Acute pulm process - pneumo?,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PSS TUE 10:53 AM Normal study.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 4:31 A.M., ON .",0
"HISTORY: Pleuritic chest pain, rule out pneumothorax.",0
"IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Normal heart, lungs, hila, mediastinum and pleural surfaces.",0
"3:20 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change, assess ET tube placement Admitting Diagnosis: PNEUMONIA;HYPERTENSION;DEPRESSION ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with ARDS, intubated.",1
"REASON FOR THIS EXAMINATION: eval interval change, assess ET tube placement ______________________________________________________________________________ FINAL REPORT AP CHEST 5:12 A.M. ON HISTORY: ARDS.",0
IMPRESSION: AP chest compared to through 10: ET tube has been advanced to less than 1 cm above the carina.,0
Right PICC or subclavian line ends in the mid SVC.,0
"Diffuse pulmonary infiltration progressed between and , subsequently stable.",0
"Heart is largely obscured so size is indeterminate, but probably not appreciably changed recently.",0
Findings suggest a component of volume dependent edema superimposed on organizing stage of ARDS.,0
"1:25 PM MR HEAD W & W/O CONTRAST; MRA CAROTID/VERTEBRAL W/CONTRAST Clip # MRA BRAIN W/O CONTRAST; MR CONTRAST GADOLIN Reason: r/o mass vs CVA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with lung CA, new R sided neuro deficits REASON FOR THIS EXAMINATION: r/o mass vs CVA ______________________________________________________________________________ WET READ: FKh TUE 4:24 PM Large are of intraparenchymal hemorrhage in the posterior fossa (right cerebelar hemisphere) causing compression of the brainstem and impending herniation.",1
The post gad images are not yet avaiable.,0
______________________________________________________________________________ FINAL REPORT INDICATION: This is a 72-year-old male with lung cancer and new right-sided neurologic deficits.,0
Partial comparison is made to CT of the head from .,0
TECHNIQUE: Sagittal and axial T1-weighted images were obtained before and after administration of gadolinium.,0
"Axial T2 star gradient echo, FLAIR, diffusion-weighted images, and T2-weighted images were obtained.",0
FINDINGS: There is a large area of intraparenchymal hemorrhage centered in the right cerebellar hemisphere measuring 4 x 5 cm in largest axial diameter.,0
"It is causing significant mass effect in the brain stem and compressing the fourth ventricle, though the lateral and third ventricles are not dilated at this time.",0
There is a fluid level in that area of hemorrhage suggesting hyperacute hemorrhage.,0
"Just adjacent to this area of hemorrhage, there is an area of enhancement that measures 13 mm and most likely represents a metastasis to the right cerebellar hemisphere.",0
There is an another area of abnormal enhancement in the right parietal region towards the vertex.,0
This lesion is very superificial and could represent a cortical or leptomeningeal metastasis.,0
"So far, there is no evidence of cerebellar herniation.",0
MRA OF THE CIRCLE OF .,0
TECHNIQUE: 3D time-of-flight imaging with multiplanar reconstructions.,0
FINDINGS: The major tributaries of the circle of are patent.,0
There are no areas of significant stenosis or aneurysmal dilatation.,0
"Within the limits of coverage of this study, no signal of an arteriovenous malformations are apparent.",0
(Over) 1:25 PM MR HEAD W & W/O CONTRAST; MRA CAROTID/VERTEBRAL W/CONTRAST Clip # MRA BRAIN W/O CONTRAST; MR CONTRAST GADOLIN Reason: r/o mass vs CVA Contrast: MAGNEVIST Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: Normal circle of MRA.,0
MRA OF THE CAROTIDS AND VERTEBRAL ARTERIES.,0
TECHNIQUE: MRA of the carotids and vertebral arteries were obtained with gadolinium.,0
"FINDINGS: No area of hemodynamically significant stenosis seen, particularly with reference to the common carotid bifurcations.",0
The left vertebral artery is dominant.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Penicillins Attending: Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: IVC venography Bladder repair; diverting colostomy ORIF sacral fracture; IVC filter History of Present Illness: 27 yo female s/p fall from 4 stories; transported to .,1
+EtOH Initial GCS 3; responsive to painful stimuli only.,0
FAST exam positive and hemodynamically unstable requiring PRBC's; she was taken to the operating room for exploratory laparotomy.,0
Past Medical History: Unknown Social History: +EtOH Family History: Noncontibutory Pertinent Results: 05:15AM BLOOD Hct-27.8* 09:36PM BLOOD Hct-26.4* 06:07AM BLOOD WBC-8.9 RBC-2.63* Hgb-8.6* Hct-24.1* MCV-92 MCH-32.7* MCHC-35.6* RDW-13.3 Plt Ct-246 06:07AM BLOOD Plt Ct-246 01:09AM BLOOD Fibrino-374# 06:07AM BLOOD Glucose-107* UreaN-7 Creat-0.6 Na-137 K-3.7 Cl-101 HCO3-28 AnGap-12 08:25PM BLOOD Glucose-145* UreaN-8 Creat-0.6 Na-136 K-4.1 Cl-100 HCO3-26 AnGap-14 06:07AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0 08:25PM BLOOD Calcium-8.7 Phos-2.5* Mg-2.1 11:55AM BLOOD Type-ART Temp-37.0 Rates-14/6 Tidal V-560 PEEP-5 FiO2-40 pO2-199* pCO2-37 pH-7.33* calTCO2-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED 08:05AM BLOOD Glucose-129* 06:04AM BLOOD Hgb-10.1* calcHCT-30 08:05AM BLOOD freeCa-1.17 .,0
VOIDING CYSTOGRAM - No masses or contrast extravasation was noted within the bladder.,0
The urethra was unable to be evaluated secondary to lack of voiding function.,0
ABDOMEN (SUPINE ONLY) - Three intraoperative frontal radiographs of the abdomen were obtained during placement of IVC filter.,0
I am uncertain of the exact level of placement.,0
Non-specific inferior T wave changes.,0
CT LOW EXT W&W/ - 1.,0
Comminuted fracture of the left calcaneus with intraarticular involvement.,1
Largely nondisplaced fracture of the right calcaneus.,1
Comminuted nondisplaced intraarticular fracture at the base of the right fourth metatarsal bone.,1
MR CERVICAL SPINE - No evidence of fracture or bone marrow edema.,0
Prevertebral fluid is present from C2 through C4-5.,0
There is soft tissue edema posterior to the spinous processes of C2 through C5.,0
"Clinical correlation is recommended as this could represent, at the very least, a ligamentous sprain.",0
BILAT LOWER EXT VEINS - No deep venous thrombus.,0
TIB/FIB (AP & LAT) - 1.,0
Comminuted fracture of the left calcaneus with extension into the subtalar joint and flattening of the calcaneal contour.,1
Right lateral malleolar soft tissue swelling with no evidence of fracture.,0
Right 4th metatarsal fracture is not well evaluated on the current study.,0
Evaluation of the spine is recommended given the appearance of the calcaneal fracture.,0
CT PELVIS W/CONTRAST - 1.,0
"Pelvic fractures involving both sides of the sacrum, the anterior column of the left acetabulum and the left inferior pubic ramus.",1
Slight asymmetry of the pubic symphysis.,0
No definite foci of active contrast extravasation are identified.,0
"Extraluminal air seen just superior to the bladder, just deep to the rectus abdominis muscles.",0
A bladder injury could be considered.,1
"Alternatively, bowel/mesenteric injury cannot be entirely excluded.",0
"Wedge/linear hypodensity of the right mid kidney, possibly indicating a laceration.",0
Free fluid throughout the abdomen and pelvisas described.,0
Right L5 transverse process fracture.,0
CT HEAD W/O CONTRAST - No evidence of acute intracranial hemorrhage.,0
CT C-SPINE W/O CONTRAST: No cervical spine fracture or malalignment.,0
Brief Hospital Course: Patient admitted to the Trauma service.,0
Her forehead laceration was closed.,1
She was immediatley taken to the operating room because of her extensive pelvic injuries for exploratory laparotomy; repair of bladder perforation and a diverting loop colostomy was performed.,0
The Wound/Ostomy nurse has followed patient closely during her hospital stay.,0
"On HD# 8 she underwent a voiding cystogram, no extavasation was noted in the bladder.",0
Her foley catheter was discontinued but she failed to void; subsequently the cathter was replaced.,0
Another voiding trial should be attempted in 7 days.,0
She was taken to the operating room on by Orthopedics for repair of her pelvic and calcaneal fractures.,0
An IVC filter was placed as well because of her extensive fractures and increased risk of thrombus.,0
Psychiatry was consulted because of concerns regarding possible suicidal ideation surrounding her fall; there were concerns that the fall may have been intentional.,0
Her evaluation revealed that she was not suicidal.,0
Social work was also closely involved in patient's care.,0
Her pain is being controlled with long acting narcotics.,0
She is on a bowel regimen.,0
Her ostomy output has been adequate.,0
She is tolerating a regular diet.,0
Physical and Occupational therapy were also consulted and have recommended short term rehab stay.,0
Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours).,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for breakthrough pain.,0
PO twice a day as needed for constipation.,0
Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical (2 times a day): Apply to open left foot blisters.,0
Milk of Magnesia 800 mg/5 mL Suspension Sig: Five (5) ML's PO twice a day as needed for constipation.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: s/p Fall Pelvic fracture Bladder Injury Comminuted fractures of left calcaneous, right 4th metatarsal bone & base of left 4th metatarsal Discharge Condition: Stable Discharge Instructions: Do not bear any weight on either lower extremity.",1
Continue with Lovenox injections until instructed otherwise by Orthopedics.,0
"Followup Instructions: Follow up with Orthopedics in 2 weeks, call for an appointment.",0
"Follow up in Trauma Clinic with Dr. , in 2 weeks, call for an appointment.",0
Inform the office that you will need a barium enema study; rectum to colostomy; on the same day prior to this appointment.,0
5:34 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: pls assess tip of right picc.,0
picc powerflushed x 4 Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with coiled picc.,0
attempt to repo via powerflush REASON FOR THIS EXAMINATION: pls assess tip of right picc.,0
"picc powerflushed x 4 ______________________________________________________________________________ WET READ: SJBj TUE 10:34 PM R picc looped in IJ, aproxiamately 10cm in IJ.",0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 5:44 P.M. ON .",0
I attempted to reposition with power flush.,0
IMPRESSION: AP chest compared to through at 10:29 a.m.,0
"Right PIC line has been repositioned, now looped in the right internal jugular vein terminating just above the thoracic.",0
"Moderate left pleural effusion may have increased, despite the apical pleural tube.",1
"Pulmonary vascular congestion has worsened, and there is a slight dilatation of mediastinal veins, all suggesting volume overload.",0
Consolidated left lower lobe is unchanged.,0
"Moderate cardiomegaly, increased slightly since earlier in the day.",0
", R. MED SICU-A 3:47 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with resp distress s/p SAH, acute vs renal failure REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ PFI REPORT PFI: Worsening pulmonary edema with moderate right-sided pleural effusion and underlying pulmonary collapse.",1
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: r dl power picc 48cm iv Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 38 year old man with picc REASON FOR THIS EXAMINATION: r dl power picc 48cm iv ______________________________________________________________________________ FINAL REPORT HISTORY: PICC placement.,0
COMPARISON: at 5:30 a.m. HISTORY: Single AP view of the chest shows a right upper extremity PICC whose tip terminates within the atriocaval junction.,0
"An ET tube, two esophageal catheters and left IJ catheter are unchanged in location.",0
Again seen are bilateral pleural effusions and bibasilar atelectasis which are unchanged since this a.m.,0
IMPRESSION: Properly positioned right upper extremity PICC.,0
"10:01 AM ESOPHAGUS; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: Please check for esophogeal anastamosic leak, no need for sm Admitting Diagnosis: RESPRIRATORY DISTRESS Contrast: OPTIRAY Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p esophagectomy with anastamotic leak.",0
"REASON FOR THIS EXAMINATION: Please check for esophogeal anastamosic leak, no need for small bowel follow through ______________________________________________________________________________ FINAL REPORT HISTORY: Esophagectomy with new anastomotic leak.",0
"FINDINGS: Under fluoroscopic observation, the patient ingested a small amount of water-soluble Conray contrast.",0
Contrast passed freely through the gastric pull-through into the subdiaphragmatic portion of the stomach.,0
"A note is made of a small, contained collection of what appeared to be extraluminal contrast at the right aspect of the cervical anastomosis, thereafter, the patient ingested approximately one cup of oral barium.",0
Contrast again passed freely through the gastric pull-through with redemonstration of a contained cervical collection adjacent to the cervical anastomosis on the right.,0
Also noted with ingestion of barium was contrast leakage into the left upper mediastinal JP drain.,0
Limited examination of the subdiaphragmatic portion of the stomach was unremarkable and without evidence of leak.,0
"After the study, plan was made in conjunction with the attending surgical physician, .",0
", to obtain a followup chest and abdominal radiograph in order to rule out the presence of leak into the patient's left pleural tube.",0
IMPRESSION: Contained pouch of extraluminal contrast on the right at the cervical anastomosis as well as leak into the left mediastinal drain.,0
"12:17 AM CT HEAD W/O CONTRAST Clip # Reason: eval for interval change in size of hemorrhage so decision r Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with L BG hemorrhage REASON FOR THIS EXAMINATION: eval for interval change in size of hemorrhage so decision re EVD can be made, please perform at 1:00 AM on No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 60-year-old woman with left basal ganglia hemorrhage.",0
"HEAD CT WITHOUT CONTRAST: Comparison was made to the prior head CT dated , taken at 10:00 p.m. Again note is made of large left intraparenchymal hemorrhage extending from basal ganglia, left thalamus to posterior left internal capsule into the left frontal and temporal lobes, surrounded by vasogenic edema, measuring 4.9 x 3.2 cm, with mass effect to bilateral ventricle and shift of normally midline structure measuring 1 cm, with ventricular hemorrhage and effacement of the cerebral sulci on the left.",1
The overall appearance of the brain and hematoma is not significantly changed since prior study.,0
"Again note is made of mass effect upon the pons and third ventricle as well, and fourth ventricle is effaced.",0
There is mucosal thickening in sphenoid sinus.,0
Skeletal structure is unremarkable with hyperostosis frontalis.,0
"IMPRESSION: Large left intraparenchymal bleed extending from left thalamus, basal ganglia and frontal and temporal lobes with vasogenic edema and shift of normally midline structures, with ventricular dissemination, and effacement of the cerebral sulci and fourth ventricle, without significant change since prior study.",0
4:48 PM CHEST (PORTABLE AP) Clip # Reason: eval acute path ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with CP REASON FOR THIS EXAMINATION: eval acute path ______________________________________________________________________________ FINAL REPORT INDICATION: Chest pain.,0
COMPARISON: Scanned in radiograph from Hospital dated .,0
UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is normal in size.,0
"No pleural effusion, focal consolidation or pneumothorax is visualized.",0
Soft tissue anchor is seen projecting over the right humeral head indicative of prior rotator cuff surgery.,0
"OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: please send fluid for cx, cell count Admitting Diagnosis: LIVER FAILURE ********************************* CPT Codes ******************************** * PARACENTESIS DIAG.",1
"OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 33M s/p OLT for autoimmune hepatitis and PSC, course c/b UGIB and afib RVR, high JP ascites output.",1
"Both JPs out and recurrent ascites REASON FOR THIS EXAMINATION: please send fluid for cx, cell count ______________________________________________________________________________ FINAL REPORT INDICATION: Ascites.",0
"PROCEDURE: Following a detailed discussion regarding the risks and benefits of the procedure, a signed informed consent was obtained from the patient.",0
A pre-procedural timeout was performed using three separate identifiers.,0
A target ultrasound examination revealed a large fluid pocket within the left lower quadrant.,0
This site was prepped and draped in the usual sterile fashion.,0
Local anesthesia was achieved using 1% lidocaine buffered with sodium bicarbonate.,0
"A 5 French catheter was advanced into the peritoneal cavity, and 6.0 liters of straw-colored fluid were aspirated.",0
The patient tolerated the procedure and there were no immediate post-procedural complications.,0
A portion of the fluid was sent for pathology for further analysis per the request of the primary team.,0
"The attending, Dr. , was present and supervising.",0
IMPRESSION: Successful aspiration of 6.0 liters of ascites via the left lower quadrant.,0
A portion of the fluid was sent to pathology department for further analysis per the request of the primary team.,0
"4:39 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for pulmonary edema, effusions.",0
"Admitting Diagnosis: CHF, NEW JUNCTIONAL BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with severe asthma, diastolic CHF, paretic left hemidiaphragm with SOB.",1
"REASON FOR THIS EXAMINATION: Please evaluate for pulmonary edema, effusions.",0
______________________________________________________________________________ FINAL REPORT SINGLE PORTABLE AP CHEST RADIOGRAPH INDICATION: 83-year-old female with severe asthma and pleuritic left hemidiaphragm with shortness of breath.,0
"FINDINGS: Stable elevation of the left hemidiaphragm is noted, however, increased volume loss and retrocardiac opacities consistent with moderate left lower lobe atelectasis.",0
Small underlying effusion cannot be excluded.,0
The right lung remains clear without focal consolidation.,0
"PORT Clip # Reason: DECREASED URINE OUTPUT ASSESS KIDNEYS Admitting Diagnosis: ;S/P MOTOR VEHICLE ACCIDENT;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with kidney, decreased urine output.",1
REASON FOR THIS EXAMINATION: eval of kidneys ______________________________________________________________________________ FINAL REPORT HISTORY: Single kidney and decreased urine output.,1
COMPARISON: No previous abdominal ultrasound.,0
Abdominal CT of is available for correlation.,0
"FINDINGS: As seen on the recent abdominal CT scan, the patient has two kidneys.",0
"The right kidney measures 8.7 cm, and the left kidney measures 7.8 cm.",0
There is a 1.8 x 1.7 x 1.6 cm cyst arising exophytically from the lower pole of the left kidney.,0
There is a small amount of free fluid in pouch.,0
"The bladder is partially distended, and it appears unremarkable.",0
"3:05 PM CT CHEST W/O CONTRAST Clip # Reason: 46 yo male with AML s/p FLAG chemo with multiple pulmonary n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;CHEMOTHERAPY ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with AML, fever, sore throat with nodular densities on chest CT REASON FOR THIS EXAMINATION: 46 yo male with AML s/p FLAG chemo with multiple pulmonary nodules and persistent fever.",1
CT to check if nodules are getting worse and if there is need to urgently change coure of management.,0
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: AML, fever, sore throat.",0
"Previous nodular densities on CT, persistent fever.",0
COMPARISON: CT chest without contrast .,0
TECHNIQUE: Helically acquired axial images were obtained through the chest without the administration of IV contrast.,0
"CT CHEST WITHOUT CONTRAST: There has been interval development of multiple, nodular and patchy opacities throughout both lung fields.",0
The previously visualized nodules have increased in size in the interval.,0
"For example, the right middle lobe nodule which previously measured 5 x 5 mm now measures 17 x 15 mm.",0
Also a right upper lobe nodule previously measured 10 x 8 mm and now measures 17 x 33 mm.,0
The left upper lobe is most affected.,0
"On top of the rounded opacities throughout both lungs, there are more confluent areas of opacification within both hila consistent with hilar adenopathy.",0
This was not present on the previous study.,0
The airways appear patent down to the segmental bronchi.,0
"There are tiny, bilateral pleural effusions.",0
"There are scattered, nonpathologically enlarged mediastinal nodes as well as axillary nodes.",0
Note is made of two central venous lines which both terminate at the cavoatrial junction.,0
Limited views of the upper abdomen show splenomegaly.,0
IMPRESSION: Significant interval progression of previously seen ill-defined nodules into more multifocal opacities throughout both lungs as described above.,0
There is also interval development of bilateral hilar lymphadenopathy.,0
The rapid development of this opacification in a neutropenic patient indicates an infectious etiology.,0
"Again, likely causes include atypical infections such as mycobateria and fungal infections such as Nocardia or aspergillosis.",0
These findings were discussed with Dr. at the time of the study.,0
(Over) 3:05 PM CT CHEST W/O CONTRAST Clip # Reason: 46 yo male with AML s/p FLAG chemo with multiple pulmonary n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;CHEMOTHERAPY ______________________________________________________________________________ FINAL REPORT (Cont),1
"12:39 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: evidence of colitis on last CT scan on right side - question Admitting Diagnosis: SEPSIS Field of view: 50 ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with diarrhea, sepsis, ?",1
colitis REASON FOR THIS EXAMINATION: evidence of colitis on last CT scan on right side - question of whether this colitis is evolving - PO contrast please CONTRAINDICATIONS for IV CONTRAST: renal failure ______________________________________________________________________________ WET READ: EHAb TUE 2:41 AM 1.,1
"Right colonic wall thickening, particularly in the region of the hepatic flexure, is not well evaluated on this non-contrast enhanced exam and may be exaggerated by underdistension.",0
Increased stranding and fluid in this area may be secondary to colitis or increased generalized third spacing.,0
"If colitis is present, differential diagnosis includes infectious, inflammatory and ischemic etiologies.",1
"Cecal wall thickening measures fat density, suggesting possible chronic inflammation.",0
"Increased bilateral pleural effusions, ascites (mostly pelvic), small pericardial effusion, and subcutaneous edema.",0
Ventral hernia now contains a portion of the stomach.,0
No other significant change from prior exam.,0
Findings and limitations of this study discussed extensively with Dr. by Dr. by phone at 2:15 a.m. on and in person at 2:35 a.m. on .,0
"This study was reviewed with the on-call body fellow, Dr. , prior to reporting.",0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT CT ABDOMEN AND PELVIS WITHOUT CONTRAST DATE: .,0
"CLINICAL INDICATION: 41-year-old woman with diarrhea, sepsis, question colitis.",1
Evidence of colitis on CT on the right side.,0
"TECHNIQUE: Axial images of the abdomen and pelvis were obtained without the use of intravenous contrast, with oral Gastrografin.",0
Coronal and sagittal reformatted images were constructed.,0
TOTAL EXAM DLP: 1252 mGy-cm.,0
FINDINGS: (Over) 12:39 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: evidence of colitis on last CT scan on right side - question Admitting Diagnosis: SEPSIS Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) ABDOMEN: There are small right greater than left pleural effusions with adjacent compressive atelectasis.,1
"There is a small pericardial effusion, stable from the prior examination.",0
Large paraesophageal varices are evident.,1
Lack of intravenous contrast limits evaluation of the solid abdominal viscera.,0
"Numerous hepatic hypodensities are poorly delineated on the current examination, but likely compatible with cystic hepatic disease seen on previous studies.",0
"There are numerous large upper abdominal varices, not significantly changed from examination.",1
The spleen is enlarged measuring 18.8 cm in craniocaudal dimension.,0
The adrenal glands appear thickened without discrete nodularity.,0
The pancreas appears within normal limits.,0
The gallbladder is surgically absent.,0
Redemonstrated polycystic kidney disease with innumerable hypodense and scattered hyperdense (proteinaceous or hemorrhagic) cysts.,1
A few punctate calcifications are present within the kidneys as well.,0
The abdominal aorta is normal in course and caliber.,0
There is no mesenteric or retroperitoneal adenopathy.,0
Oral contrast is seen to the level of the ascending colon with the proximal small bowel loops poorly opacified and the majority of the contrast within the distal ileum and cecum.,0
"There is no evidence of obstruction, bowel wall thickening or specific regional pericolonic fat stranding.",0
There is a small amount of ascites and generalized stranding within the mesentery.,0
There is low-attenuation submucosal fat within the terminal ileum and cecum.,0
9-cm diastasis of the abdominal rectus superiorly is present with herniation of the distal gastric body.,0
This is not resulting in obstruction.,0
"PELVIS FINDINGS: The bladder is decompressed with a Foley catheter and contains air, likely related to insertion of the Foley catheter.",0
"The uterus, adnexa and rectum are grossly unremarkable.",0
There is a moderate amount of pelvic ascites.,0
OSSEOUS STRUCTURES: Facet degenerative changes are present in the lower lumber spine.,0
There are no destructive osseous lesions.,0
Predominantly collapsed colon with oral contrast to the level of the cecum.,0
There is no definite bowel wall thickening.,0
Generalized anasarca limits evaluation for specific pericolonic fat stranding.,0
Submucosal fat in the terminal ileum and cecum suggests possible chronic inflammation.,0
Previously questioned colonic wall thickening in the region of the hepatic flexure is nonspecific and can be seen with portal colonopathy.,0
"Small right greater than left pleural effusions with stable small (Over) 12:39 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: evidence of colitis on last CT scan on right side - question Admitting Diagnosis: SEPSIS Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) pericardial effusion, ascites and subcutaneous edema consistent with anasarca.",1
Diastasis of the abdominal rectus muscle containing a portion of the gastric body.,0
"3:14 AM CHEST (PORTABLE AP) Clip # Reason: eval interval change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: year old man with pneumonia, afib w RVR, enterococcus bacteremia intubated REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: -year-old man with pneumonia and AFib with RVR, now intubated.",0
COMPARISONS: Multiple priors including a chest x-ray from .,0
FINDINGS: A moderate pleural effusion is worsening now obscuring the right hemidiaphragm.,0
A left-sided lower lobe consolidation is most likely atelectasis.,0
An NG tube runs into the stomach but the tip is indistinct.,0
An ET tube ends 2.5 cm from the carina.,0
Sternal wires are intact and unchanged.,0
Bilateral interstitial edema is increasing.,0
"IMPRESSION: Worsening right sided pleural effusion, moderate in size.",0
OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: Please perform diagnostic paracentesis (need 1 L for cell bl Admitting Diagnosis: SYNCOPE;TELEMETRY ********************************* CPT Codes ******************************** * PARACENTESIS DIAG.,0
"OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with h/o pancreatic adenoca s/p Whipple in , Afib (coumadin currently held), sCHF (EF 25-50%), and Type II DM, p/w presyncope; also with large pleural effusions and ascites; concern for malignant effusion vs. transudative from CHF vs. SBP (fever, hypotension) REASON FOR THIS EXAMINATION: Please perform diagnostic paracentesis (need 1 L for cell block); also perform tests to r/u SBP No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 64-year-old male with pancreatic adenocarcinoma.",1
"Now with enlarging ascites, shortness of breath, and a fever.",0
Request for diagnostic and potentially therapeutic paracentesis to evaluate fluid.,0
COMPARISON STUDIES: Abdominal ultrasound from .,0
"TECHNIQUE: Written informed consent for ultrasound-guided paracentesis was obtained from the patient, following a discussion involving the risks, benefits, and alternatives to the procedure.",0
"Once consent was obtained, the patient was placed in supine position in the ultrasound suite.",0
son images of the abdomen were acquired.,0
A suitable pocket of ascites was noted in the left lower quadrant and the skin was marked.,0
A standard timeout was then performed utilizing three patient identifiers.,0
The skin was then prepped and draped utilizing standard sterile technique.,0
A total of 10 cc of buffered lidocaine was used for cutaneous anesthesia.,0
"Under real time ultrasound guidance, a 5 French catheter was introduced into the left lower quadrant fluid pocket.",0
A total of 1600 cc of yellow ascites was removed.,0
Specimens were collected for the requested microbiology and cytology studies.,0
The catheter was then removed and hemostasis was obtained.,0
The patient tolerated the procedure without any immediate complication.,0
The patient was transferred back to his inpatient floor in stable condition.,0
Dr. supervised and was present for all portions of this procedure.,0
IMPRESSION: (Over) 1:21 PM PARACENTESIS DIAG.,0
OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: Please perform diagnostic paracentesis (need 1 L for cell bl Admitting Diagnosis: SYNCOPE;TELEMETRY ______________________________________________________________________________ FINAL REPORT (Cont) Ultrasound-guided diagnostic and therapeutic paracentesis as described.,0
"A total of 1600 cc of ascites was removed, with requested studies pending.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: ventricular tachycardia Major Surgical or Invasive Procedure: - Attempted VT ablation History of Present Illness: 84 yo woman with h/o HTN, dementia, breast cancer s/p lumpectomy/chemo 20 yrs ago and VT, evaluated at in at which time she did not undergo ablation and instead was loaded with Amiodarone who then presented to with incessant VT and is now transferred to for further management.",1
"In a holter monitor showed > runs of VT. She initially presented to her PCP with intermittent , which initiated her work up including holter.",0
She was subsequently admitted to .,0
"During admission had short runs (<30) of Ventricular tachycardia, which were asymptomatic and with blood pressures at her baseline.",1
"She opted for medical management with amiodarone, amio loaded and monitored in house.",0
"cMRI at that time showed mildly enlarged left ventricular cavity size with mild global hypokinesis, mildly depressed LVEF at 55%.",0
The effective forward LVEF was mildly depressed at 51%.,0
No CMR evidence of prior myocardial scarring/infarction.,0
"Normal RV, Mild MR. stress EKG after amiodarone loading which did not induce any VT.",0
Subsequent holter monitor showed no VT but ocassional Ventricular Bigeminy.,0
"Since this most recent admission, the patient reports feeling well.",0
"Denies any episodes of chest pain, palpitations, shortness of breath, trouble breathing, dizziness, light-headedness, or fainting episodes.",0
"The patient reports being in her usual state of health, and she went to her PCP appointment for what she thinks was a normal follow up appointment (she cannot remember for what).",0
"As per documentation from OSH, went to PCP for swollen ankles/cough, then developed CP and EKG showed sinus tachycardia.",0
"At OSH, had EP study on and found to have persistent wide complex tachycardia autonomic focus.",0
ECHO on with EF 40% (down from 55% in ) and ruled out for MI.,0
"On ROS, denies any chest pain, shortness of breath, trouble breathing, palpitations, light-headedness, dizziness, syncope.",0
"Pt had difficulty remembering her , but reports that nothing has been bothering her since last discharge.",0
"Past Medical History: CARDIAC RISK FACTORS: Dyslipidemia, Hypertension OTHER PAST MEDICAL HISTORY: Depression, dementia, breast cancer s/p lumpectomy/chemo 20yrs previously, anxiety, b/l total knee replacement, s/p appy, s/p tonsillectomy Social History: Lives at home with husband, forgetful at baseline -Tobacco history: Smoked 4 years back in college.",1
"-ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.",0
"Physical Exam: ADMISSION EXAM: GENERAL: pleasant elderly woman, NAD, laying comfortably in bed, AAOx3, but had difficulties remembering what happened/why she initially presented to PCP, : NCAT.",0
"NECK: Supple with JVP edge of mandible CARDIAC: irregular heart rate, S1, S2, no murmurs/rubs/gallops appreciated, no S3, S4 LUNGS: No chest wall deformities, scoliosis or kyphosis.",0
"EXTREMITIES: warm, well perfused, + LE pitting edema b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.",0
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ .,0
"Discharge exam: Vitals - Tm/Tc: 98.2/97.6 HR:66-68 BP: 120-128/62-71 RR:18 02 sat: 96% 2L, 90% RA.",0
In/Out: Last 24H: Last 8H: 100/450 Weight: 68 (71.3)different scale .,0
"Tele: SR, rate 50's-60's, no VEA .",0
"GENERAL: 84 yo M in no acute distress : mucous membs moist, no lymphadenopathy, JVD at 12cm CHEST: Crackles bibasilar Left> right, no wheezes, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops, pos diastolic click ABD: soft, non-tender, non-distended, BS normoactive.",1
"EXT: wwp, 2+ edema feet and ankles.",0
5/5 strength in U/L extremities.,0
"SKIN: no rash PSYCH: alert, oriented x2-3, pleasant and cooperative Pertinent Results: 03:16AM BLOOD WBC-6.0 RBC-3.53* Hgb-10.0* Hct-30.6* MCV-87 MCH-28.2 MCHC-32.6 RDW-15.5 Plt Ct-164 .",0
04:20AM BLOOD WBC-7.6 RBC-3.60* Hgb-10.1* Hct-31.7* MCV-88 MCH-27.9 MCHC-31.8 RDW-15.6* Plt Ct-196 .,0
04:24AM BLOOD PT-12.5 PTT-34.2 INR(PT)-1.1 .,0
03:16AM BLOOD Glucose-100 UreaN-22* Creat-1.0 Na-140 K-4.3 Cl-106 HCO3-26 AnGap-12 .,0
04:20AM BLOOD Glucose-102* UreaN-22* Creat-1.0 Na-140 K-4.2 Cl-100 HCO3-35* AnGap-9 .,0
04:20AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 .,0
03:16AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0 .,0
"CHEST (PORTABLE AP) - The cardiac silhouette is mildly to moderately enlarged, and is accompanied by pulmonary vascular congestion.",0
"Hazy opacity in left perihilar region could potentially represent early asymmetrical edema, but is not fully characterized on this portable view.",0
"Small pleural effusions are present bilaterally, with adjacent basilar atelectasis.",0
MRSA screen - negative Urine culture - vaginal flora .,0
"Labs at discharge: 07:05AM BLOOD WBC-6.9 RBC-3.46* Hgb-9.5* Hct-30.4* MCV-88 MCH-27.5 MCHC-31.4 RDW-16.1* Plt Ct-210 07:05AM BLOOD Glucose-96 UreaN-24* Creat-1.0 Na-141 K-3.9 Cl-101 HCO3-34* AnGap-10 07:05AM BLOOD Mg-2.0 Brief Hospital Course: 84 y.o woman with h/o HTN, dementia, breast cancer s/p lumpectomy/chemo 20 yrs ago and VT evaluated at in at which time she did not undergo ablation and instead was loaded with Amiodarone who then presented to with incessant VT and is now transferred to for further management.",1
"# VENTRICULAR TACHYCARDIA - Has failed medical management with amiodarone, which was started on admission in .",1
"Lidocaine and Procainamide were used without effect to try to convert her VT. She then a limited endocardial ablation, however, this failed to ablate the right ventricular outflow tract focus.",0
"Later she was given Flecainide which converted her rhythm to NSR but later reconverted to VT, so the dosing was increased.",0
"We maintained her on Flecainide 150 mg PO twice daily, which she tolerated.",0
"We also tried to add a low-dose beta-blocker to this regimen, but this resulted in some intermittent bradycardia and hypotension, which resolved with discontinuation of the beta-blocker.",0
"While on this medication, her electrolytes were closely monitored and her QRS complex was monitored for widening given the anti-arrhythmic medication.",0
The electrophysiology service was following her during this admission.,0
QTc at time of discharge is 0.47 secs.,0
# Acute on Chronic Diastolic CHF: cMRI performed with estimated LVEF 50-55%.,1
"Cardiac catheterization was without obvious stenosis, performed at the outside hospital.",0
"She did have mild crackles appreciated on lung exam (on admission), but does not have LE pitting edema or JVP elevation.",0
"A CXR showed mild pulmonary edema, and she received only PRN IV Lasix dosing because she was asymptomatic with SBPs in 100s and does not take home diuretics.",0
She responded to gentle IV Lasix dosing and diuresed appropriately without overt signs of failure.,0
We monitored her in's and out's and performed daily weights.,0
We continued her home dosing of Aspirin 81 mg PO daily.,0
She was not currently on a statin medication.,0
"She is still on 2L NP of oxygen and desaturates to 85% on RA with ambulation, 90% on RA at rest.",0
"She will need strict I/O's, daily weights and additional PO furosemide if her weight is increasing.",0
Unclear dry weight but weight at discharge is 68kg.,0
# DEMENTIA: She had stable evidence of short-term memory loss.,0
"We continued her Namenda 10 mg PO BID and we continued her Citalopram 20 mg PO daily, as her mood remained stable and her affect favorable.",0
Her husband appears to be somewhat forgetful but her daughter and son are involved.,0
# S/P BILATERAL TOTAL KNEE REPLACEMENTS: Tolerated Tylenol 650 mg PO Q4-6H as needed for pain control.,0
Patient was not complaining of any pain this admission.,0
"Her gait is shuffling with some weakness, she will need physical therapy to regain lost mobility.",0
# BREAST LESION - noted on cMRI last admission; patient should follow this up as an outpatient with PCP regarding further imaging (e.g.,0
mammography or breast U/S) .,0
TRANSITION OF CARE ISSUES: 1.,0
Will need close monitoring of her rhythm and assessment for pre-syncopal given her ventricular tachycardia history and use of anti-.,1
Will need electrolyte monitoring as an outpatient.,0
Please check Chem-7 on Monday .,0
"In speaking with , MD, if the patient continues to develop bradycardia or hypotension in the setting of anti-, need to later consider pacemaker placement, but this seems unlikely at this time.",0
She is tolerating the Flecainide well.,0
She will be discharged with 2 liters of oxygen therapy via nasal cannula which can be weaned as tolerated as she diureses 4.,0
Will need close monitoing of fluid status as above with additional furosemide as needed for goal of 500cc negative every day until she is off oxygen and her pedal swelling has improved.,0
Multivitamin 1 tab PO daily 2.,0
Namenda 10 mg PO BID 3.,0
Citalopram 20 mg PO daily 4.,0
Aspirin 81 mg PO daily 5.,0
Amiodarone 200 mg PO BID 6.,0
Calcium and Vitamin D (uncertain dosage) 7.,0
Acetaminophen 325 mg PO Q6H PRN pain 8.,0
Omega-3 Fatty Acids 1 tab PO daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain.,0
"2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
"Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day.",0
"4. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day.",0
5. memantine 10 mg Tablet Sig: One (1) Tablet PO bid ().,0
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
8. flecainide 50 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours).,0
Disp:*180 Tablet(s)* Refills:*0* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for weight gain or increasing edema: In addition to 40 mg of lasix standing dose.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Primary Diagnoses: 1.,0
Ventricular tachycardia originating from right ventricule outflow tract .,1
Depression Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: Patient Discharge Instructions: .,0
You were admitted to the Coronary Care Unit (CCU) at on 6 regarding management of your irregular heart rhythm (ventricular tachycardia).,1
You were initially managed with medications and we found that you responded best to Flecainide.,0
You tolerated this medication well.,0
"There was also a electrophysiologist that attempted to ablate your rhythm, but the source was not found and medication was used for treatment instead.",0
You were doing well and discharged in stable condition.,0
"Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness.",0
* You faint or pass out * You develop any other concerning .,0
CHANGES IN YOUR MEDICATION RECONCILIATION: .,0
"* Upon admission, we ADDED: START: Flecainide 150 mg by mouth twice daily (every 12-hours) START: Furosemide 40 mg daily .",0
* The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Amiodarone .,0
"* You should continue all of your other home medications as prescribed, unless otherwise directed above.",0
"Followup Instructions: We spoke with Dr. , your Cardiologist, and he recommended that you see Dr. .",0
His office will call you within 24-hours to schedule follow-up.,0
"His contact information is: Name: LOVE, Location: HEART CENTER OF Address: , SECOND FL, , Phone: Fax:",0
4:57 PM CHEST (PORTABLE AP) Clip # Reason: eval for change Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with tachypnea.,1
REASON FOR THIS EXAMINATION: eval for change ______________________________________________________________________________ FINAL REPORT CXR SINGLE FILM HISTORY: 62-year-old man with tachypnea.,0
"History of metastatic lung cancer, HIV, malignant pleural effusion.",1
CONCLUSION: There is no change in the left pleural effusion and underlying collapse consolidation of the left lower lobe and also parts likely of the left upper lobe/lingula.,1
No change from film done at 1022 hours on .,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: PICC placement Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with pleural effusions s/p VATS, talc pleuradesis REASON FOR THIS EXAMINATION: PICC placement ______________________________________________________________________________ FINAL REPORT HISTORY: 82-year-old female with pleural effusion status post VATS talc pleurocentesis and reattempt of right PICC line placement.",1
Comparison is made to prior radiographs from earlier in the day on .,0
"The right-sided PICC line has been repositioned, and its tip now lies either within the distal portion of the superior vena cava (SVC) or right atrium.",0
Full assessment is limited due to obscuration of mediastinal and right heart borders.,0
There is grossly unchanged appearance to opacification of the right hemithorax consistent with combination of effusion and atelectasis.,0
Left- sided basal atelectasis and effusion is unchanged.,0
"Right-sided PICC line, likely within the distal SVC or right atrium.",0
"Unchanged appearance to opacification of right hemithorax, likely representing combination of increased pleural effusion and compressive atelectasis.",0
"7:41 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: S/P MVC, UNRESTRAINED, ABD PAIN.",0
"Admitting Diagnosis: MOTOR VEHICLE ACCIDENT Field of view: 36 ______________________________________________________________________________ MEDICAL CONDITION: 20 yM s/p MVC, unrestrained, with significant intrusion into driverside, CT showed hemoparitoneum.",1
Now with tachycardia and worsening abdominal pain.,0
"REASON FOR THIS EXAMINATION: with contrast, assess for interval worsening abdominal pathology in the setting of seat belt trauma No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc TUE 10:55 PM PFI: Hemoperitoneum of intermediate density (40 ) appears slightly increased along the right paracolic gutter and in the deep pelvis.",1
"Loop of abnormal-appearing small bowel in the mid pelvis seen on the CT performed on at 1:22 a.m. is difficult to visualize on the current study due to lack of oral or IV contrast; however, findings of small-bowel wall non-enhancement and thinning with fecalization of the bowel contents within this loop is concerning for small-bowel infarction/ischemia due to either small-bowel injury or mesenteric injury.",1
Surgical exploration should be considered.,0
Findings and recommendations were discussed with Dr. .,0
______________________________________________________________________________ FINAL REPORT HISTORY: 20-year-old male with seat belt injury after MVC with significant intrusion into driver side and with initial trauma CT showing hemoperitoneum.,1
COMPARISON: CT torso of at 1:22 a.m.,0
TECHNIQUE: MDCT axial imaging was performed through the abdomen and pelvis without administration of oral contrast and without further administration of IV contrast.,0
Further IV contrast administration was withheld until discussion with the surgical team could be held.,0
CT ABDOMEN WITHOUT IV CONTRAST: Mild dependent atelectasis is noted in the visualized left lung base.,0
"Hemoperitoneum of intermediate density (40 ) is again noted surrounding the liver and spleen and tracking along the paracolic gutters, particularly on the right.",0
The amount of hemoperitoneum may be slightly increased along the right paracolic gutter compared to the initial trauma CT of 19 hours prior.,0
Assessment of the viscera is limited due to lack of IV contrast administration.,0
"The non- enhanced liver, spleen, pancreas, adrenal glands, kidneys and ureters appear unremarkable.",0
"Dense material in the gallbladder represents IV contrast excreted through the biliary system, likely representing underlying impaired renal function.",0
"The non-opacified and non- enhanced stomach and proximal small bowel appear (Over) 7:41 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: S/P MVC, UNRESTRAINED, ABD PAIN.",0
Admitting Diagnosis: MOTOR VEHICLE ACCIDENT Field of view: 36 ______________________________________________________________________________ FINAL REPORT (Cont) unremarkable.,1
"Abnormal-appearing mid pelvic loop of small bowel which was seen on the initial CT, characterized by nonenhancing and thinned bowel wall as well as fecalization of the bowel contents (see images 2:91-98; 300B:24), is not seen in a similar fashion on the current study, however there is a small bowel loop with wall thickening in the pelvis and new mesenteric hematoma measuring 59 .",0
Moderate stool remains within the colon.,0
No free air is noted within the abdomen.,0
"Mesenteric and retroperitoneal lymph nodes are increased in number, not by size.",0
The abdominal aorta maintains normal caliber.,0
"CT PELVIS WITHOUT IV CONTRAST: Air-fluid level is seen within the non- distended urinary bladder, with Foley catheter in place.",0
Moderate stool is seen within the rectosigmoid colon.,0
"The hemoperitoneum tracks along the paracolic gutters, mostly on the right, into the deep pelvis, where the fluid measures 34 and appears slightly increased compared to 19 hours prior.",0
OSSEOUS STRUCTURES: Again no acute fracture is seen in the visualized osseous structures.,0
"Irregular contour along the superior endplates at L3, L4, L5 and S1 likely represent Schmorl node formation.",0
IMPRESSION: Hemoperitoneum is slightly increased along the right paracolic gutter and tracking into the pelvis.,0
There is new mesenteric hematoma and bowel wall thickening in the pelvis.,0
This is concerning for bowel injury.,0
"Findings and recommendations were discussed over the phone with Dr. at 9:30 p.m., .",0
"12:51 AM CHEST (PORTABLE AP) Clip # Reason: acute resp distress Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p CABG, marginal oxygenation REASON FOR THIS EXAMINATION: acute resp distress ______________________________________________________________________________ FINAL REPORT INDICATION: Poor oxygenation.",1
PORTABLE CHEST: Comparison is made to film from one day earlier.,0
Today's study is limited by underpentration.,0
The ET tube tip remains at the thoracic inlet.,0
The central venous catheter is stable.,0
"A NG tube and mediastinal drains remain in place, although they are not well seen due to underpenetration.",0
"Cardiac and mediastinal contours are grossly unchanged, allowing for supine film technique and reduced lung volumes.",0
There is some motion artifact on the film.,0
A large area of nonspecific increased density persists without significant change at the left base.,0
"Vessel and hilar outlines are somewhat indistinct, again raising the question of mild interstitial edema.",0
Indisctinctness of vessels/hilar outlines could be related to motion artifact vs. mild interstitial edema.,0
No change in increased density left base.,0
"11:58 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with ICH REASON FOR THIS EXAMINATION: change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NON-CONTRAST HEAD CT, INDICATION: 88-year-old man with intracranial hemorrhage.",0
"COMPARISON: at 12:19 a.m., approximately 12 hours earlier.",0
"FINDINGS: The parenchymal hemorrhage centered in the left basal ganglia is stable compared to 12 hours earlier, measuring 3.2 x 3.1 cm.",0
Mild surrounding edema is stable.,0
"There is unchanged effacement of the frontal of the left lateral ventricle, but no significant shift of normally midline structures.",0
"There is persistent blood throughout the left lateral ventricle, and in the occipital of the right lateral ventricle.",0
"Blood clot in the frontal of the right lateral ventricle, near the foramen of , appears slightly retracted.",0
"There is less blood in the third ventricle, possibly also due to clot retraction.",0
There is a significant decrease in the amount of blood in the fourth ventricle.,0
"Overall, the ventricles are stable in size, without evidence of increased dilatation of the right lateral ventricle.",0
"Scattered periventricular and subcortical white matter hypodensities are again noted, likely related to chronic small vessel ischemic disease in a patient of this age.",0
No evidence of an acute major vascular territorial infarction is seen.,0
"Complete opacification of the left frontal and left anterior ethmoid sinuses, as well as mucosal thickening and fluid in other paranasal sinuses, is unchanged since the prior study, likely related to endotracheal intubation.",0
Stable hematoma in the left basal ganglia.,0
Decreased blood in the fourth ventricle.,0
Decreased blood versus clot retraction in the third ventricle.,0
"Stable blood in the lateral ventricles, left greater than right.",0
"Stable ventricular size, with partial effacement of the left lateral ventricle, and no increase in the dilatation of the right lateral ventricle.",0
4:59 AM CHEST (PORTABLE AP) Clip # Reason: assess interval change Admitting Diagnosis: LEFT LOWER EXTREMITES;INFECTED RIGHT FOOT WOUND ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with pulmonary edema REASON FOR THIS EXAMINATION: assess interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with pulmonary edema.,0
Right internal jugular line is at the level of low SVC.,0
Diffuse interstitial opacities are unchanged as well as bibasal consolidations.,0
"6:04 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: ICH Admitting Diagnosis: CEREBELLAR HEMORRHAGE Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with severe ICH REASON FOR THIS EXAMINATION: eval for aneurysm, vascular malformation No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAMINATION: CTA head and neck with contrast.",0
"HISTORY: 45-year-old male with severe intracranial hemorrhage, to evaluate for aneurysm or vascular malformation.",0
TECHNIQUE: Multiplanar CTA of the head and neck was performed following administration of intravenous contrast administration.,0
Additional 3D reconstructed images of the intra- and extra-cranial arterial vasculature were obtained.,0
"FINDINGS: CTA HEAD: There has been no significant interval change in the large irregular-shaped hyperdense collection within the posterior fossa when compared with the prior non-contrast CT examination performed earlier the same day, at 4:55 a.m. Hyperdense blood products are again seen layering along the tentorium and posterior portion of the brainstem.",0
There has been interval right frontal ventriculostomy catheter placement with tip in the body of the right lateral ventricle.,0
There is intraparenchymal hemorrhage surrounding the ventriculostomy catheter with greatest dimension 4.3 cm AP x 2.5 cm transverse in the right frontal lobe and new mass effect on the right lateral ventricle.,0
There is no significant shift of the normally midline structures.,0
There has been interval increase in intraventricular blood products within the right lateral ventricle.,0
There are stable blood products within the third ventricle and right occipital .,0
Again seen is effacement of the perimesencephalic cisterns with probable mild right-sided uncal herniation.,0
There is no cerebellar tonsillar herniation.,0
There is no evidence of acute territorial infarction.,0
"The vertebrobasilar system is diminutive but patent, which may be reflective of arterial vasospasm.",0
"The posterior cerebral arteries are patent but diminutive, which also may be secondary to vasospasm.",0
"There is no evidence of flow-limiting stenosis, occlusion, aneurysm greater than 2 mm, or arteriovenous malformation.",0
(Over) 6:04 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: ICH Admitting Diagnosis: CEREBELLAR HEMORRHAGE Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) The patient is intubated.,0
The tip of the endotracheal tube is within the right mainstem bronchus.,0
There is fluid within the nasopharynx and esophagus.,0
CTA NECK: The great vessels at the level of the aortic arch are within normal limits.,0
The vertebral artery origins are unremarkable.,0
"The paired vertebral arteries are diminutive in their entirety, but patent.",0
"The common, internal, and external carotid arteries are normal in course and caliber without evidence of flow-limiting stenosis, occlusion, or dissection.",0
"There are numerous bilateral cervical chain lymph nodes, none of which are enlarged by CT criteria.",0
"The thyroid gland is heterogeneous and enlarged, right greater than left.",0
There are biapical atelectatic changes.,0
Cross-sectional analysis of the internal carotid arteries is as follows.,0
On the right: Proximal D min 7.6 mm; distal D min 4.3 mm.,0
On the left: Proximal D min 9.6 mm; distal D min 4.5 mm.,0
Stable appearance of the large irregularly shaped posterior fossa intraparenchymal hemorrhage when compared with the previous examination.,0
No evidence of aneurysm or arteriovenous malformation to suggest etiology of this hematoma.,0
Status post right frontal approach ventriculostomy shunt catheter placement with surrounding intraparenchymal hematoma and new mass effect on the right lateral ventricle.,0
Interval increase in intraventricular blood products.,0
Ultrasound may be obtained for further evaluation if not already performed.,0
Questionable vasospasm of the posterior circulation.,0
Recommend continued short term interval follow-up.,0
", H. MED SICU-B 1:01 AM CHEST (PORTABLE AP) Clip # Reason: OGT placement Admitting Diagnosis: LIVER ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with new OGT REASON FOR THIS EXAMINATION: OGT placement ______________________________________________________________________________ PFI REPORT Progression of left lung consolidation that may be due to effusion and/or subpleural consolidation.",0
"6:45 PM CHEST (PORTABLE AP) Clip # Reason: resolution of CHF Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 67M ischemic CMP, h/o VF arrest, here w/ probable CHF exacerbation, but also fever.",1
"REASON FOR THIS EXAMINATION: resolution of CHF ______________________________________________________________________________ FINAL REPORT INDICATION: 67-year-old male with ischemic cardiomyopathy, probable congestive heart failure, fever.",1
AP SEMI-UPRIGHT CHEST: The view is lorditic.,0
Again seen is a left-sided AICD with its leads overlying the right atrium and floor of the right ventricle.,0
The patient is status median sternotomy.,0
The cardiac and mediastinal contours are stable given differences in positioning and technique.,0
There has been interval improvement in the pulmonary vascular congestion.,0
No regions of consolidation are identified.,0
There is mild left lower lobe atelectasis.,0
No pleural effusions are seen on this AP study.,0
IMPRESSION: Improvement in the previously seen pulmonary edema.,0
R/O vegetation/persistent fever Height: (in) 68 Weight (lb): 150 BSA (m2): 1.81 m2 BP (mm Hg): 121/60 HR (bpm): 107 Status: Inpatient Date/Time: at 13:15 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
"Clip # Reason: evaluate for hydronephrosis, masses Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with elevated Cr, urethral obstruction REASON FOR THIS EXAMINATION: evaluate for hydronephrosis, masses ______________________________________________________________________________ FINAL REPORT HISTORY: Elevated creatinine.",1
Rule out hydronephrosis or masses.,0
FINDINGS: The right kidney measures 13.5 cm and the left 12.0 cm.,0
The renal parenchymal thickness and echogenicity are normal without evidence of calculi or hydronephrosis.,0
The right kidney demonstrates a small cyst in the upper pole measuring 1.5 x 1.5 x 1.3 cm.,0
"Within the interpolar region of the left kidney, there is a 1.1 x 0.9 x 1.1 cm cyst.",0
The bladder is not fully distended.,0
"No evidence of hydronephrosis, renal calculi, or solid masses.",0
LINE PLACEMENT Clip # Reason: please check PICC tip right med.,0
cub 51 cm Admitting Diagnosis: CEREBELLAR INFARCT ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with REASON FOR THIS EXAMINATION: please check PICC tip right med.,0
cub 51 cm ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 12:27 PM Right PIC catheter terminates in lower superior vena cava.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old male with right PICC.,0
PORTABLE UPRIGHT CHEST: A right PIC catheter terminates in the lower superior vena cava.,0
"Lung volumes are low, though the lungs are clear without pleural effusion or pneumothorax.",0
IMPRESSION: Right PIC catheter terminates in lower superior vena cava.,0
4:34 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ?lucency around heart still there?,0
"Admitting Diagnosis: SEPSIS;RESPIRATORY FAILURE;ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with pancreatitis, bacteremia, with small left-sided pneumothorax seen on prior CXR REASON FOR THIS EXAMINATION: ?lucency around heart still there?",1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of suspected right-sided pneumothorax.,0
Portable AP chest radiograph compared to the previous film done eirlier at 10:13.,0
"The ET tube tip, the NG tube tip and the right internal jugular catheter tip are in standard expected positions.",0
"There is some worsening of bilateral patchy opacities which may represent pneumonia, aspiration but overlying pulmonary edema cannot be excluded.",0
The lucency around the right heart border has not been seen on the current film representing most probably artifact on the previous exam.,0
The left lower lobe consolidation/ atelectasis is unchanged with small left pleural effusion.,0
Normal position of tubes and lines.,0
Worsening of the bilateral pulmonary consolidations.,0
Left lower lobe atelectasis in addition to consolidations.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Cardiothoracic Surgery Service CHIEF COMPLAINT: Tracheomalacia HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old female with a history of congenital dwarfism and tracheomalacia who was has had progressively worsening respiratory problems since the early .,1
She had a tracheoplasty on a previous admission in and was admitted on after spiking a temperature at home with a productive cough.,0
She was brought up for a follow-up bronchoscopy on under LMA.,0
"During the procedure, there was noted to be a postoperative residual swelling of the trachea and main stem bronchus which resulted in significant subglottic stenosis and mucous plugging.",0
"Her stent was able to be cleared, but postoperatively she required intubation and pressure support with phenylephrine.",0
She was sent to the Medical Intensive Care Unit for further care.,0
PAST MEDICAL HISTORY: (Past Medical History includes) 1.,0
MEDICATIONS ON ADMISSION: (Medications at home included) 1.,0
Levofloxacin 500 mg by mouth once per day.,0
Vioxx 150 mg by mouth once per day.,0
Mucomyst nebulizer treatment at hour of sleep.,0
Paxil 10 mg by mouth once per day.,0
ALLERGIES: She has no known drug allergies.,0
FAMILY HISTORY: Her family history is of normal stature.,0
No history of respiratory difficulties.,0
SOCIAL HISTORY: She works as an actress in .,0
She denies any history of smoking.,0
"PHYSICAL EXAMINATION ON PRESENTATION: The patient was afebrile, her blood pressure was 90/52, her heart rate was 97, her respiratory rate was 25, and her oxygen saturation was 100% on assist-control with a positive end-expiratory pressure of 5, and a FIO2 of 50%.",0
"In general, the patient was a well-developed and well-nourished female on a ventilator in no apparent distress.",0
Head and neck examination revealed normocephalic and atraumatic.,0
"The pupils were equal, round, and reactive to light and accommodation.",0
The lung examination revealed coarse breath sounds bilaterally.,0
She did have inspiratory wheezes bilaterally.,0
"On neurologic examination, she was able to follow commands.",0
"PERTINENT LABORATORY VALUES ON PRESENTATION: Her admission laboratories revealed a white blood cell count of 18.6, her hematocrit was 34.4, and her platelets were 501.",0
"The SMA-7 revealed her sodium was 135, potassium was 3.5, chloride was 97, bicarbonate was 27, blood urea nitrogen was 9, creatinine was 0.4, and her blood glucose was 101.",0
Her arterial blood gas was 7.36/49/135.,0
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed no signs of acute ischemia.,0
"Her chest x-ray showed the endotracheal tube 5 cm above the carina in the left main stem bronchus in place with no pneumothorax, and also showed a right middle lobe collapse/consolidation.",0
"BRIEF SUMMARY OF HOSPITAL COURSE: She was transferred to the Thoracic Surgery Service on hospital day two after being extubated, and she was in good care there.",0
She was using 35% face mask and saturating about 98%.,0
"Her floor care required frequent racemic epinephrine nebulizers for her wheezing, but her need for this soon decreased during this admission.",0
"In addition, to the bronchoalveolar lavage from this bronchoscopy, it ended up growing out Aspergillus fumigatus.",0
An Infectious Disease consultation was obtained and the patient was started on by mouth voriconazole instead of Zosyn.,0
"Her diet was quickly advanced, and by she was ready to go.",0
Her physical examination on discharge revealed she was alert and oriented times three and in no apparent distress.,0
"She had good air entry bilaterally with some wheezing, but her lungs were clear to auscultation bilaterally.",0
She was saturating 100% on room air.,0
"Her abdomen was soft, nontender, and nondistended.",0
"Her extremities were without any clubbing, cyanosis, or edema.",0
DISCHARGE DISPOSITION/CONDITION: She was discharged to home in good condition.,0
Voriconazole 100 mg by mouth twice per day as needed.,0
Dilaudid by mouth twice per day.,0
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was recommended to follow up with Dr. in three months and with her primary care physician in the next one to two weeks.,0
Dictated By: MEDQUIST36 D: 13:14 T: 07:17 JOB#:,0
3:07 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PEL PORTClip # Reason: please eval Txp liver vasculature/parenchymal flow Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man s/p OLT here for CHF/vol.,1
"REASON FOR THIS EXAMINATION: please eval Txp liver vasculature/parenchymal flow ______________________________________________________________________________ FINAL REPORT LIVER AND GALLBLADDER ULTRASOUND, LIVER DOPPLER ULTRASOUND INDICATION: 68-year-old man status post liver transplant.",1
"FINDINGS: There is intrahepatic fluid collection, in the left liver lobe, measuring 7.6 x 7.7 x 5.1 cm, heterogeneous with low-level internal echoes.",0
"Subdiaphragmatic collection, measuring 8.3 x 7.9 x 3.7 cm, also heterogeneous with low-level internal echoes is noted and corresponds to a collection seen on the recent CT.",0
Smaller subhepatic collection is not imaged on the study.,0
There is a large right pleural effusion.,1
Doppler examination of the liver was limited by patient's inability to hold breath.,1
"Patency and appropriate waveforms are demonstrated in the main portal vein, anterior and posterior right portal veins, left portal vein, and bilateral hepatic arteries, as well as three hepatic veins.",0
Flow velocities are comparable to the ones registered on a prior examination.,0
"Intrahepatic fluid collection and subdiaphragmatic fluid collection, new in the interval since .",0
Differential diagnosis includes hematoma versus infection.,0
Patent vessels with appropriate waveforms and velocities.,0
Findings were discussed with Dr. at 6:05 p.m. on,0
"8:47 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: PLEASE DO ON AT 5PM; eval change in SDH/SAH and midli Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT;BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 37F s/p passenger MCC, + helmet, + etoh, LOC unknown, combative with all 4 extremities at time of EMS arrival.",1
"+TBI, R frontal contusions, R frontal SDH and sml amts tSAH, L occipital fx.",0
"REASON FOR THIS EXAMINATION: PLEASE DO ON AT 5PM; eval change in SDH/SAH and midline shift 24 hours after previous CT. No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 37-year-old female, status post MCC, for reevaluation of change in subdural hemorrhage, subarachnoid hemorrhage, and shift of midline structures.",1
"FINDINGS: Right convexity subdural hematoma is not significantly changed in size or configuration, with continued evidence of radiodense material within, suggestive of acute hemorrhage.",1
"Multifocal areas of intraparenchymal hemorrhage, predominantly involving the right inferior frontal lobe, but also the left inferior frontal lobe and right temporal lobe have increased in size since previous exam, with increased surrounding edema and effacement of right frontal and parietal sulci.",0
"There is increased leftward subfalcine herniation, currently approximately 9-10 mm, previously 8 mm.",0
"There is slightly increased compression of the frontal and occipital horns of the right lateral ventricle, but ventricular and sulcal size and configuration is otherwise unchanged.",0
"Osseous structures are again notable for oblique, minimally displaced fracture through the left occipital bone, extending into the temporal bone and left jugular foramen, and small foci of air are again seen within the jugular foramen and along the inner table deep to the left occipital bone.",1
"There is high density, reflecting thrombosis, in the left tranverse and sigmoid sinus.",0
"Fluid is again seen within the sphenoid air sinuses, with air- fluid level in the left sphenoid air cells, unchanged.",0
"Fracture to the left petrous bone, involving the carotid canal also appears unchanged.",0
"Please note that these fractures are better evaluated, and will be fully detailed and reported separately in skull base CT performed , 05:40.",1
"Increased intraparenchymal hemorrhage, particularly in the right frontal region, with surrounding mass effect, sulcal effacement, compression of the right lateral ventricle, and increased leftward subfalcine herniation.",1
(Over) 8:47 AM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: PLEASE DO ON AT 5PM; eval change in SDH/SAH and midli Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT;BLUNT TRAUMA ______________________________________________________________________________ FINAL REPORT (Cont) 2.,1
Unchanged moderate right subdural hematoma.,0
"Unchanged appearance of fractures involving the left occipital bone, temporal bone, and left jugular foramen, and fracture of the left petrous bone involving the left carotid canal.",1
"5:25 PM BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: evaluate lung fields and Et-tube placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress, 32wks REASON FOR THIS EXAMINATION: evaluate lung fields and Et-tube placement ______________________________________________________________________________ FINAL REPORT EXAMINATION: Portable chest, one view.",1
CLINICAL HISTORY: The patient is a newborn baby with a history of prematurity (32 weeker) who is now presenting with respiratory distress.,1
"COMPARISON: Comparison is made to prior examination dated , time 14:59.",0
"FINDINGS: In the interim, interval placement of endotracheal tube with its tip located at the level of carina is seen.",0
"Again noted is diffuse ground- glass opacities in both lungs associated with mildly decreased lung volumes, stable from prior examination.",0
Heart size and mediastinal contours are within normal limits.,0
The visualized upper abdomen is unremarkable.,0
IMPRESSION: ET tube tip located at the level of carina.,0
Findings were discussed with the clinician taking care of this patient at the time of dictation.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Cefepime Attending: Chief Complaint: Chest pain, shortness of breath.",0
"History of Present Illness: Patient is a 58 yo M with known CAD, diabetes and ESRD who presents with chest pain.",1
He was resting today and he started having chest pain.,0
The pain is located in the center of his chest and associated with shortness of breath.,0
It has been constant since this morning and started all of a sudden when he was walking to the kitchen.,0
It is a in severity.,0
He reports that he has had nausea and vomited 3 times today with some chest pain during the vomiting.,0
The vomit has been clear fluid without blood.,0
"He has been feeling weak with what is described as occasional black vision since but has not had any dizziness, syncope or headache.",0
"Of note, he has recently arrived from where he was for 10 days.",0
"While there he took his medications every day, but was only able to go to dialysis twice.",0
While in the ED initial HR 48 BP 123/102 rr 20 100% FS was 177.,0
Her atropine 1 mg was given at 1316.,0
Nitro gtt was started at 1336.,0
"Also given morphine, glucagon, anzemet.",0
Nitro drip was increased to 100 mcg/min without relief in chest pain.,0
"Additionally patient received sodium bicarb, calcium gluconate 3amps, magnesium sulfate, and 10 units insulin.",0
On arrival to the floor the patient still complained of chest pain and shortness of breath but would intermittently fall asleep.,0
"CAD - s/p CABG LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1 - cardiac cath: LMCA 40%, LAD mid 70%, LCx 60%, RCA previously known proximal 99% occlusion; Patent grafts.",1
- Stress : unchanged from ; moderately reversible inferolateral to inferior walls perfusion defects with EF 44% 2.,0
Diabetes mellitus: diet controlled 3.,0
"Congestive heart failure: Echo: EF >55%, severe dysfunction, estimated EF on Nuclear stress 54% 6.",1
Peripheral disease: s/p stent to bilateral CIAs (Genesis) and steft to - s/p POBA and atherectomy of L SFA 7.,1
End-stage renal disease: Diabetic Nephropathy - on HD T/Th/Sat - currently undergoing evaluation for renal transplant although considered high risk 8. ?,1
COPD - no PFTs available 9.,0
"Tracheomalacia 10. h/o c.diff colitis 11. h/o UGI bleed : EGD showed non-bleeding tear, gastropathy, and gastritis Social History: Patient is originally from .",0
His wife and family are still there.,0
"Patient currently lives alone, but his brother is nearby.",0
His sister-in law works @ in housekeeping.,0
Family History: Father died of CAD Mother and brother with Physical Exam: VS: T 94.7 BP 143/49 HR 45 RR 20 O2 99% 4L Gen: WDWN middle aged male in NAD.,0
"pupils equal but mildly reactive to light, EOMI.",0
Neck: Supple with JVP of cm.,0
"CV: bradycardic RR, normal S1, S2.",0
"No S3 or S4, though difficult to auscultate respiratory sounds Chest: No chest wall deformities, scoliosis or kyphosis.",0
"bilateral basilar crackles with occ wheezes and coarse bs Abd: Soft, NTND.",0
Left fistula without tenderness and with palpable thrill.,0
Pulses: Right: Femoral 2+ Popliteal NP DP 1+ PT 1+ Left: Femoral 2+ Popliteal NP DP 1+ PT 1+ Pertinent Results: ADMIT LABS: CBC: 01:10PM BLOOD WBC-9.2 RBC-3.25* Hgb-10.9* Hct-32.6* MCV-101* MCH-33.5* MCHC-33.4# RDW-15.3 Plt Ct-153 01:10PM BLOOD Neuts-87.4* Bands-0 Lymphs-6.9* Monos-4.7 Eos-0.8 Baso-0.2 01:10PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ COAGS: 01:10PM BLOOD PT-15.3* PTT-32.8 INR(PT)-1.4* CHEMISTRIES: 01:10PM BLOOD Glucose-163* UreaN-133* Creat-15.6*# Na-137 K-8.2* Cl-106 HCO3-14* AnGap-25* Calcium-6.9* Phos-8.6*# Mg-4.0* LFTS: 04:31AM BLOOD ALT-14 AST-13 LD(LDH)-242 CK(CPK)-85 AlkPhos-122* TotBili-0.5 CARDIAC ENZYMES: 01:10PM BLOOD cTropnT-0.20* CK-MB-13* MB Indx-8.4* 03:10PM BLOOD CK-MB-12* MB Indx-7.4* cTropnT-0.21* 10:00PM BLOOD CK-MB-11* MB Indx-8.0* cTropnT-0.23* MISC: 04:24PM BLOOD VitB12-1238* Folate-GREATER TH 01:10PM BLOOD TSH-1.3 EKGs demonstrated evolution in ED from sinus bradycardia to junctional bradycardia at a rate of 36-40.,0
Complexes were wide with IVCD and QT prolongation.,0
CXR (): CHF and effusion with slight interval worsening.,0
ECHO (): The left atrium is dilated.,0
"Compared with the findings of the prior study (images reviewed) of , the mitral regurgitation is somewhat reduced.",0
"However, if clinically suggested, the absence of a vegetation by 2D echocardiography does not necessarily exclude endocarditis.",0
"CAROTID US (): 60-69% stenosis of the bilateral internal carotid arteries; however, this estimate of percentage of stenosis may not be precise due to a generalized increase in systolic velocities in the bilateral common and internal carotid arteries.",1
"CT CHEST (): Interval worsening of right lower lobe opacity, and development of hazy lingular opacity, likely representing infiltrates, with adjacent pleural thickening.",0
No intrinsic or extrinsic airway obstruction is identified.,0
Atherosclerotic disease of the aorta and coronary arteries.,1
Hyperkalemia/ESRD: Presented with hyperkalemia (>7) in the setting of 2 dialysis sessions in 10 days.,0
"This was urgently treated, given symptoms (weakness, vomiting) and ECG changes.",0
"Follow acute treatment in ED, was dialyzed daily.",0
Last inpatient dialysis session was on with plan for next outpatient session on .,0
He was continued on sevelamer and nephrocaps.,0
CAD: Previously patent grafts on catherization.,0
"Presented with chest pains which were concerning but in the setting of persistent nontypical pain, this was thought to be likely secondary to other causes.",0
"Did have CK and troponin elevations, but has chronic troponin elevations.",0
He was continued on his aspirin and isosorbide mononitrate.,0
"His beta-blocker was initially held in the setting of bradycardia, but this was started after stabilitization of his rhythm and dialysis.",0
Rhythm: Presented in sinus bradycardia though briefly had junctional bradycardia while in the ED.,0
This may have been secondary to combination of both beta blocker effect (in the absence of dialysis) as well as severe hyperkalemia.,0
Patient was given glucagon as well as atropine in the ED with some improvement.,0
"At the time of discharge, was back in sinus rhythm and back on his beta-blocker.",0
Pneumonia: Found to have RLL opacity on CXR with leukocytosis and cough.,0
Treated as a community acquired pneumonia with azithromycin and ceftriaxone (changed to cefpodoxime upon discharge).,0
"A CT was performed which showed ""Interval worsening of right lower lobe opacity, and development of hazy lingular opacity, likely representing infiltrates, with adjacent pleural thickening.""",0
"Given the chronicity of the process, outpatient pulmonology follow-up was recommended.",0
"Upon discussion with radiology, it was recommended that an outpatient PET scan be obtained (to evaluate for possible malignant process).",0
Pump: Presented with a history of CHF in OMR but normal function on last echo and nuclear study.,0
"Furosemide listed as outpatient medication on last OMR note, but not taking as outpatient.",0
"Did have volume overload initially, but improved greatly after dialysis and was euvolemic upon discharge.",0
"Chest pain: Potential causes include angina, esophageal irritation, anxiety among other causes of atypical chest pains.",0
He was treated symptomatically with good result.,0
"Hypertension: Initially held beta-blocker, which was restarted later in admission.",0
"ACEI also held initially, given hyperkalemia.",0
This was restarted before discharge.. 9.,0
Diabetes mellitus: Diet controlled; hypoglycemic on after getting HS insulin as part of sliding scale.,0
This was probably seen secondary to ESRD with poor clearance of insulin.,0
"Thereafter, a less aggressive sliding scale was used.",0
Medications on Admission: - B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily).,0
- Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
- Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
- Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day.,0
- Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
- Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
- Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.,0
"- Pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
- Lyrica 25 mg Qday Discharge Medications: 1.,0
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day.,0
Pregabalin 25 mg Capsule Sig: One (1) Capsule PO qday ().,0
Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days.,0
Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 1 days.,0
Disp:*1 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1.,0
"Diabetes mellitus Discharge Condition: Hemodynamically stable, saturating well on room air.",0
Discharge Instructions: You were admitted after having missed a dialysis session.,0
"As you know, it is essential that you go to dialysis three times weekly and that you continue to take all the medications, as prescribed.",0
You should be sure to follow-up with Dr. (appointment below).,0
"In addition, you should call Dr. office on Tuesday to schedule an appointment for within one week.",0
"Weigh yourself every morning, call Dr. if your weight increases by 3 lbs.",0
You should also ddhere to a 2 gram/day sodium diet.,0
"Followup Instructions: Please be sure to keep the following appointments: 1. , MD Phone: Date/Time: 2:30 2. , MD Phone: Date/Time: 9:30 3.",0
"Phone: Date/Time: 8:00 In addition to the above, you should call Dr. office on Tuesday () to schedule a follow-up for within the week.",0
It will be very important for you to keep all dialysis appointments.,0
Your next scheduled dialysis is for Tuesday .,0
Requesting prophylactic embolization of left gastric artery.,0
"Dr. , staff radiologist, was present and supervising entire procedure.",0
MEDICATION AND CONTRAST: 0.25 mg IV Versed and 75 mcg IV Fentanyl was administered in divided doses under constant hemodynamic monitoring.,0
1 unit packed red blood cells.,0
4 cc subcutaneous 1% Lidocaine.,0
280 cc of nonionic contrast diluted by half administered due to patient's generalized debilitation and cardiopulmonary status.,0
"TECHNIQUE/PROCEDURE: Due to the emergent nature of the procedure, written consent was not obtained.",0
The patient was informed of the details and associated risks of the procedure.,0
"However, patient was under influence of sedation from previous endoscopy.",0
Multiple attempts were made to reach the patient's son and wife by phone prior to the study.,0
The patient was placed supine on the angiographic table and the right groin was sterile prepped and draped in the usual fashion.,0
Under fluoroscopic guidance the right common femoral artery was accessed using a 19-gauge single- wall puncture needle.,0
A 0.035 wire was advanced to the proximal abdominal aorta under fluoscopic guidance.,0
The needle was removed over the wire and a 5 French sheath placed and connected to continuous irrigation with heparinized saline.,0
"A 4 French SOS Omniflush catheter was advanced such that the tip was at the proximal abdominal aorta, just above the celiac axis.",0
"AP, lateral and oblique aortograms were obtained.",0
The SOS Omniflush catheter was exchanged over a 0.035 glide wire for a C2 (Over) 10:06 AM MESENTERIC Clip # Reason: 83 y/ with recurrent massive UGIB of unknown source now Contrast: OPTIRAY Amt: 230 ______________________________________________________________________________ FINAL REPORT (Cont) glide cath and the celiac axis was catheterized.,0
Celiac selective arteriogram was obtained.,0
The catheter was further advanced over a glide wire and selective angiography of the gastroduodenal artery was obtained.,0
The catheter was repositioned at takeoff of the splenic artery and selective angiography was obtained.,0
Attempts were made to selectively catheterize the left gastric artery using a 5 French selective SOS catheter and then a 4 French Berenstein catheter.,0
Following lateral aortogram it was evident that the left gastric artery arose separately from the aorta (anatomic variant).,0
The left gastric artery was then selectively catheterized using a French C2 glide cobra catheter and a 3 French Tracker microcatheter and its 0.018 guidewire.,0
Selective angiogram of the left gastric artery was obtained.,0
"The Tracker microcatheter was advanced distally into the left gastric artery, which was selectively embolized using Gelfoam slurry and Gelfoam pledgets.",0
Post-embolization selective angiography of the left gasrtric artery was obtained.,0
The catheters and sheath were withdrawn over a wire and hemostasis was obtained.,0
FINDINGS: The abdominal aorta is ectatic.,0
There is no visualization of the right kidney.,0
The left kidney is supplied by two left renal arteries; the more inferior renal artery appears to have stenosis at the ostium and both renal arteries appear mildly diffusely diseased.,0
The superior mesenteric artery is patent with mild diffuse irregularity.,0
There is no aneurysmal dilation of the abdominal aorta.,0
"The selective arteriograms of the celiac trunk, gastroduodenal and splenic artery does not demonstrate evidence of active bleeding.",0
Selective left gastric arteriograms demonstrated hyperemic area along the greater curvature of the stomach without clear major active extravasation suggestive of active bleeding.,0
"It is noted that the left gastric artery arises separately from the aorta, an anatomical variant, and the left gastric artery may be slightly stenotic near its takeoff.",0
Prophylactic embolization of the left gastric artery was performed with Gelform slurry and Gelfoam pledgets until very slow blood flow was demonstrated within the left gastric artery at postembolization selective arteriogram.,0
Previously demonstrated area of hyperemia along the greater curvature of the stomach is not demonstrated on postembolization aortogram.,0
"No definite active bleeding is demonstrated with selective arteriography of the celiac trunk, splenic artery and gastroduodenal artery.",0
"However, with selective arteriography of the left gastric artery, there is hyperemia demonstrated along the greater curvature of the stomach.",0
(Over) 10:06 AM MESENTERIC Clip # Reason: 83 y/ with recurrent massive UGIB of unknown source now Contrast: OPTIRAY Amt: 230 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
Successful prophylactic embolization of the left gastric artery with resultant slow arterial flow within the left gastric artery and exclusion of previously demonstrated hyperemic area along the greater curvature of the stomach.,0
"Enhancement of single left kidney with two left renal arteries, both demonstrating mild diffuse disease and suggestion of stenosis, without selective renal arteriography.",0
It is recommended that patient be well hydrated to prevent renal insufficiency.,0
These findings were reported to the House Staff at the time of the study.,0
It is recommended that further evaluation and possible endovascular treatment of the left renal stenoses be considered.,0
TC WHITE BLOOD CELL STUDY Clip # Reason: FEVERS OF UNKNOWN ORIGIN.,0
ASSESS FOR POSSIBLE SOURCE OF INFECTION.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Thirty-two year old female with traumatic brain injury and fever of unknown origin.,0
Assess for possible infection as a source of fever.,0
"INTERPRETATION: Following the injection of autologous white blood cells labeled with Tc-m, images of the whole body were obtained at approximately 4 and 24 hours.",0
The dose used was increased to permit early and higher sensitivity imaging.,0
These images do not show any abnormal uptake suggestive of an infectious focus.,0
No abnormal uptake is identified.,0
IMPRESSION: No evidence of a focal infection or other abnormal findings.,0
Approved: MON 11:43 AM RADLINE ; A radiology consult service.,0
Height: (in) 72 Weight (lb): 208 BSA (m2): 2.17 m2 BP (mm Hg): 125/64 HR (bpm): 56 Status: Inpatient Date/Time: at 13:21 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,1
RIGHT VENTRICLE: Borderline normal RV systolic function.,0
Conclusions: Pre-bypass: The left atrium is elongated.,0
Post-bypass: The patient is not receiving inotropic support post-CPB.,1
Biventricular systolic function is unchanged from pre-bypass findings.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: confirm placement Admitting Diagnosis: HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with new right internal jugular central line REASON FOR THIS EXAMINATION: confirm placement ______________________________________________________________________________ FINAL REPORT HISTORY: IJ line placement.,0
"FINDINGS: In comparison with the earlier study of this date, there has been placement of an internal jugular catheter on the right that extends to the mid portion of the SVC.",0
No pneumothorax or other change.,0
7:25 AM CT C-SPINE W/O CONTRAST Clip # Reason: ?,0
"acute injury ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with fall down stairs, EtOH, L shoulder, L chestwall tenderness REASON FOR THIS EXAMINATION: ?",0
"acute injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old man status post fall downstairs, ETOH, left shoulder and left chest wall tenderness.",0
TECHNIQUE: Axially acquired images were obtained through the cervical spine without contrast.,0
There is no prevertebral soft tissue hematoma.,0
"There is extensive gas in the soft tissues of the neck, predominantly on the left.",0
Correlation with the concurrent torso CT reveals that this is related to rib fractures with associated left pneumothorax and pneumomediastinum.,1
IMPRESSION: No cervical spine fracture or subluxation.,0
Soft tissue gas related to thoracic injuries.,0
"2:23 PM CHEST (PA & LAT) Clip # Reason: r/o inf, eff Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with s/p cabg REASON FOR THIS EXAMINATION: r/o inf, eff ______________________________________________________________________________ FINAL REPORT TWO-VIEW CHEST, COMPARISON .",0
INDICATION: Status post coronary artery bypass surgery.,1
Cardiomediastinal contours are stable in the postoperative setting.,0
"Patchy and linear atelectatic changes in the middle lobe, lingula, and both lung bases appear similar, as well as small pleural effusion.",0
Calcified pleural plaques are present suggesting prior asbestos exposure.,0
IMPRESSION: Persistent bibasilar atelectasis and small pleural effusions.,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Vancomycin / Percocet Attending: Chief Complaint: Left Hip fracture s/p fall Major Surgical or Invasive Procedure: Left Hip ORIF History of Present Illness: 85 y/o M with PMHx on CHF, CAD, PVD, HTN, DM and CKD presented today from his NH with a L Intertrochanteric hip fx.",1
"Per son, pt was attempting to ambulate around a chair, caught his foot and fell.",0
"There was no LOC, fall was witnessed.",0
"Pt was seen by ortho in the ED and will need surgical repair, it has been discussed with Pt's PCP () and Ortho attending .",0
"Pt arrived to floor after receiving Morphine in the ER, he was denying CP/SOB/Cough/N/V/Abd pain.",0
He has some Left hip pain but it is significantly improved since receiving the morphine.,0
"He is oriented to place, person, not time.",0
"Past Medical History: - CHF() EF 30-35%, inf/post hypokinesis - CAD s/p CABG x 4 - PVD s/p multiple amputations, h/o dry gangrene s/p LLE bypass - DM on insulin c/w nephropathy - CKD Cr baseline 3.8 - Ischemic colitis , colonoscopy w/polyp removal, but limited to sigmoid b/c of stricture at 40cm above anus; virtual colonoscopy was unable to be performed patient not tolerating bowel preparation.",1
"- Anemia (blood loss, GIB) - h/o A.fib not on anticoagulation Social History: Lives at Healthcare Center NH, speaks Toisanese, some english, used to be in Navy.",1
"No h/o etoh, tob, drugs.",0
"Family History: +CAD, son deceased from cholangiocarcinoma Physical Exam: GEN: NAD, slight upper extremity tremor (baseline per son) : eyes closed, opens to name, NCAT, EOMI, no lymphadenopathy CV: RRR no m/r/g Resp: Crackles noted bilaterally at bases (ant & post) otherwise clear Abd: soft, NT/ND, NABS Extr: warm, trace edema bilaterally, e/o vascular surgical scars, s/p toe amputations bilaterally, Left shin ulcer and Right foot ulcer with some active drainage.",1
"Left lower extremity- externally rotated and shortened, TTP Pertinent Results: 11:40AM PT-13.9* PTT-28.5 INR(PT)-1.2* 11:40AM WBC-9.4 RBC-3.76*# HGB-12.4*# HCT-37.7*# MCV-100* MCH-32.9* MCHC-32.9 RDW-15.0 11:40AM NEUTS-92.2* BANDS-0 LYMPHS-4.8* MONOS-1.9* EOS-1.0 BASOS-0.1 11:40AM CALCIUM-9.4 PHOSPHATE-2.4* MAGNESIUM-2.1 11:40AM CK-MB-4 11:40AM cTropnT-0.04* 11:40AM CK(CPK)-112 11:40AM GLUCOSE-313* UREA N-50* CREAT-2.9* SODIUM-137 POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 11:57PM LACTATE-8.9* Na 141 / K 3.8 / Cl 103 / CO2 23 / BUN 36 / Xe 2.1 / BG 146 / Calcium 8 / Mg 1.8 / Phos 3.2 WBC 8.3 / Hct 31.4 / Plt 164 Left Femur XR - Intertrochanteric fracture CXR 1.",1
"Evidence of mild congestive heart failure, with greater cephalization than before.",1
Persistent retrocardiac opacity without definite evidence for superimposed pneumonia.,0
Left Hip XR - Comminuted intertrochanteric fracture with mild valgus angulation.,1
These results were posted to the ED dashboard at approximately 1:45 p.m. on the day of the study.,0
No evidence of acute intracranial abnormality on the non-contrast study.,0
Findings consistent with chronic microvascular infarcts.,0
Echo Regional left ventricular systolic dysfunction c/w multivessel CAD.,0
Right ventricular free wall hypokinesis.,0
"Compared with the prior study (images reviewed) of , the severity of mitral regurgitation is increased and pulmonary artery systolic hypertension with right ventricular free wall hypokinesis are now seen.",0
"Brief Hospital Course: 85 yo with multiple medical problems including congestive heart failure with an EF of 35%, coronary artery disease s/p MI in , Atrial Fibrillation, diabetes mellitus, hypertension, and peripheral vascular disease was admitted to after left hip fracture.",1
Patient was admitted with left hip fracture.,0
His pre-op course was complicated by respiratory distress and aspiration pneumonia.,0
However he underwent his left hip ORIF on without complication.,0
Pain control has been with scheduled tylenol dosing and 2.5mg oxycodone prn for breakthrough.,0
Further narcotics have been avoided given patient's apneic episodes in the setting of narcotics use.,0
DVT prophylaxis has included lovenox 30 SC daily to be taken for four weeks after surgery.,0
"Respiratory Distress Shortly after admission, patient had respiratory apnea x 2, necessitating code blue and bag mask ventilation.",0
"During both episodes, patient improved with bag ventilation alone and was monitored in the MICU.",0
Neurology was consulted and his apnea was thought likely secondary to respirations that were further depressed with narcotics use.,0
"Shortly after these apneic episodes, patient developed a fever and was noted to have increased crackles with a productive cough.",0
CXR was notable for a left sided infiltrate.,0
He was started on ceftriaxone and flagyl for presumed aspiration pneumonia and is to complete a fourteen day course with PO ceftin and PO flagyl.,0
"He has continued to improve clinically with chest PT, increased mobility, nebulizer treatments, and antibiotics.",0
"Sparse growth of Aspergillus During the work-up for patient's respiratory distress, sputum cultures were sent.",0
Sparse growth of aspergillus was noted.,0
Unclear if sparse aspergillus growth represents an actual infection or contaminant.,0
"To further evaluate aspergillus, patient would need either a bronchoscopy/BAL and/or chest CT with contrast.",0
"Given patient's chronic renal insufficiency, chest CT was not recommended.",1
"Given patient's improving clinical appearance, decision was made with patient and family to not pursue any further invasive testing at this time, including BAL.",0
Would recommend continuing to follow closely.,0
Galactomannan and beta glucan tests are pending.,0
"Candiduria As part of fever work-up, urine cultur was sent and grew yeast.",0
Thought to be likely colonization and no further treatment was continued.,0
Gout Patient has a history of gout in both knees.,0
"Duringt his admission, he was found to have minimal erythema and swelling.",0
Uric Acid was slightly elevated at 9.5 and ESR was also elevated at 95.,0
Rheumatology was consulted and performed a tap of his knee which was notable for gout crystals.,0
Joint fluid cx was negative.,0
Coronary Artery Disease Patient has a history of CAD s/p CABG in .,1
"He remained on his outpatient regimen of metoprolol, imdur, and statin.",0
Unclear why patient is not on an ACEI.,0
Would consider adding to his regimen in the future.,0
Congestive Heart Failure Patient has a known EF of 30-35%.,1
His lasix was initially held and he became slightly overloaded.,0
His volume status improved with restarting of his home dose of lasix.,0
"He was otherwise maintained on his metoprolol, imdur.",0
Atrial Fibrillation Patient was maintained with rate control with metoprolol 25mg PO bid.,1
Patient is not on anticoagulation due to a history of GI bleed.,0
Peripheral Vascular Disease Patient has a history of peripheral vascular disease with a previous revascularization.,1
"During this admission, he was found to have a right foot infected ulcer with exposed necrotic bone.",0
WOund culture was notable for polymicrobial growth.,0
He was evaluated by wound care and podiatry who debrided the wound and recommend sulfasalazine and further outpatient follow-up.,0
Acute on CRI Patient has chronic renal insufficiency thought likely secondary to diabetes mellitus and hypertension.,1
His baseline creatinine was 2.5 and increased to 3.3 for a short time but improved initially with IV hydration.,0
Diabetes Mellitus Patient was maintained on an insulin sliding scale.,0
Code: DNR/DNI confirmed with son .,0
"HCP is daughter Medications on Admission: Furosemide 100 mg PO DAILY Multivitamins 1 CAP PO DAILY Ferrous Sulfate Isosorbide Mononitrate 30 mg PO DAILY Pantoprazole 40 mg PO Atorvastatin 10 mg PO DAILY Insulin Sliding Scale Mirtazapine 7.5 mg PO QHS Acetaminophen 650 mg PO Q6H:PRN pain Metoprolol 25 mg PO BID Docusate Sodium 100 mg PO BID Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN congestion, sob Bisacodyl 10 mg PR HS:PRN Senna prn Fleets Enema prn Discharge Medications: 1.",0
Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation.,0
Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).,0
Furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).,0
Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain.,0
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours).,0
Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day).,0
Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily).,0
"Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for congestion, sob.",0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed.,0
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days.,0
Ceftin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days.,0
"Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous four times a day: Please administer insulin according to the following sliding scale: FS 151-200 give 2 units, FS 201-250, give 4 units, FS 251-300, give 6 units; FS 301-350, give 8 units .",0
Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours) for 4 weeks.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: PRIMARY DIAGNOSIS: 1.,0
Apnea secondary to - respirations and narcotics .,0
"SECONDARY DIAGNOSIS: 1) CHF, last echo in with EF 35% with inferoseptal and inferoapical hypokinesis.",0
2) CAD s/p CABG x 4 in .,0
"P-MIBI in without reversible defects: Multiple fixed myocardial perfusion defects in all three major coronary artery territories, including severe fixed defects of the apex and inferolateral walls and moderate defects of the distal anterior wall, the anteroseptal wall, inferoseptal wall and inferior wall.",0
Global hypokinesis with calculated LVEF 29%.,0
"3) Atrial fibrillation, not on anticoagulation chronic GI bleeding.",1
"s/p pacemaker placement, appears to be abandoned on CXRs 4) PVD status post multiple amputations.",1
History of dry gangrene status post LLE bypass.,1
"5) DM on insulin, complicated by nephropathy.",0
"6) Chronic renal insufficiency, baseline creatinine appears to be around 2.5.",1
"7) Ischemic colitis , colonoscopy with polyp removal, but limited to sigmoid because of stricture at 40cm above anus; virtual colonoscopy was unable to be performed patient not tolerating bowel preparation.",0
"8) Anemia (blood loss, GIB) Discharge Condition: Stable.",1
"Patient is tolerating oral intake, ambulating with assistance, and is stable for discharge to rehab.",0
Discharge Instructions: You were admitted to the hospital with left hip pain and were found to have a left hip fracture.,0
You had your left hip fracture repair on without any major complications.,0
Your pain has been under good control with tylenol and oxycodone.,0
"While you were in the hospital, you were also found to have a likely pneumonia and have been started on two antibiotics.",0
You should take these antibiotics through .,0
"In evaluating your shortness of breath, your cultures also grew out very small amounts of a fungus called aspergillus.",0
It is unclear if this represents an actual infection or was a contaminant.,0
"To further evaluate this, you might need more invasive studies, which we discussed with your daughter.",0
"As we discussed with you and your daughter, your primary care doctor is aware and will continue to follow you closely.",0
"If you develop any worsening shortness of breath or sputum production, please seek immediate medical attention.",0
You were also in the intensive care unit for a short time due to difficulty breathing.,0
We think that your breathing became very slow in the setting of receiving pain medication.,0
"In the future, you and your doctors should be very careful in giving you narcotics for pain control and you will need to be monitored very closely.",0
Please continue to take your medications as prescribed.,0
"If you develop any new symptoms of fevers, chills, difficulty breathing, worsening cough, shortness of breath, abdominal pain, or leg swelling, please seek immediate medical attention.",0
Followup Instructions: Please continue to follow-up with your primary care doctor Dr. while you are at rehab.,0
Please also follow-up with your orthopedic surgeon Dr. on .,0
You have an Xray of your hip scheduled for 8:20am and and your appointment with Dr. at 8:40am.,0
Please also follow-up with podiatry.,0
We have scheduled an appointment for you with podiatry on 2:30.,0
"If you need to reschedule, please call their office at .",0
"10:17 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: r/o obstructive processes Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with GIB and sigmoid mass POD#11 left hemicolectomy concerning for obstructive process based on CT finding showing possible stricture at anastomosis; CT not showing any leaking REASON FOR THIS EXAMINATION: r/o obstructive processes ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 89-year-old man with sigmoid mass status post left hemicolectomy postop day 11, please evaluate for obstructive process.",1
FINDINGS: Supine and upright views of the abdomen are provided.,0
There are mildly dilated loops of small bowel throughout.,0
Bowel gas pattern is nonspecific.,0
There is no free air noted on the film.,0
There are bilateral pleural effusions which can also be seen on CT from .,0
There is contrast retained in the large bowel.,0
Height: (in) 70 Weight (lb): 200 BSA (m2): 2.09 m2 BP (mm Hg): 99/65 HR (bpm): 77 Status: Inpatient Date/Time: at 12:18 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
There is severe regional left ventricular systolic dysfunction with akinesis of the mid to distal septum and anterior wall including the apex.,0
The basal LV systolic function is hyperdynamic.,0
"6:34 PM CHEST (PORTABLE AP) Clip # Reason: yo man, intubated for PNA and lung mass, now s/p CVL plac ______________________________________________________________________________ MEDICAL CONDITION: year old man with REASON FOR THIS EXAMINATION: yo man, intubated for PNA and lung mass, now s/p CVL placement in right IJ.",0
HISTORY: Pneumonia with intubation and CV line placement.,0
CV line is in distal SVC.,0
No change in appeaerance or extent of large ill- defined opacity in the right mid and lower zones and at the left lung base.,0
"3:51 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval changes Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with respiratory distress, suspected aspiration REASON FOR THIS EXAMINATION: eval for interval changes ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Respiratory distress, suspected aspiration.",1
Since the prior radiograph there is new aeration of the left upper lung although there is peripheral lucency laterally that would be suspicious for left apical pneumothorax.,0
"The scoliosis, extremely elevated left hemidiaphragm and right lung interstitial opacities are unchanged.",0
Close follow up with subsequent radiographs to exclude the possibility of progressive pneumothorax is recommended.,0
Findings were discussed with Dr. over the phone by Dr. at 10:20 a.m. on .,0
Note is made that as per our consultation no interval intervention procedures have been obtained.,0
"10:40 AM CHEST (PORTABLE AP) Clip # Reason: EVALUATION OF CHEST, S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with SAH, SDH REASON FOR THIS EXAMINATION: EVALUATION OF CHEST S/P FALL ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: Subarachnoid hemorrhage.",1
FINDINGS: The single AP supine view is provided.,0
The heart and pulmonary vessels are unremarkable.,0
No pulmonary infiltrates or effusions are demonstrated.,0
However the right costophrenic angle is not fully displayed.,0
The endotracheal tube is in satisfactory position with its approximately 6 cm above the carina.,0
External monitoring electrodes are noted.,0
As far as can be seen the rib cage appears intact but this is a very limited study.,0
IMPRESSION: No significant thoracic abnormality is demonstrated.,0
Endotracheal tube in good position.,0
"Some radiopaque material is noted in the left upper quadrant, probably medication residue in the fundus of the stomach.",0
This should be reevaluated on any follow-up study.,0
1:09 PM HIP UNILAT MIN 2 VIEWS LEFT Clip # Reason: eval for fracture ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with L hip pain s/p fall REASON FOR THIS EXAMINATION: eval for fracture ______________________________________________________________________________ WET READ: RSRc FRI 2:00 PM Intertrochanteric fracture of left hip ______________________________________________________________________________ FINAL REPORT HISTORY: 85-year-old male with left hip pain status post fall.,1
THREE VIEWS OF THE LEFT HIP: There is a comminuted intertrochanteric fracture of the femoral neck with mild valgus angulation of the distal fracture fragment.,1
The femoral head is not dislocated.,0
There are extensive atherosclerotic vascular calcifications.,0
Incidental note is made of surgical clips in the left medial thigh.,0
IMPRESSION: Comminuted intertrochanteric fracture with mild valgus angulation.,1
", K. MED FA2 11:06 AM BILAT LOWER EXT VEINS Clip # Reason: SOB / CHEST PAIN EVAL FOR DVT Admitting Diagnosis: ACUTE RENAL FAILURE, CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with CAD, CHF, w/ unexplained tachycardia.",1
REASON FOR THIS EXAMINATION: Please evaluate for DVT ______________________________________________________________________________ PFI REPORT Negative for DVT bilaterally.,0
Left calf veins not well visualized.,0
"3:43 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; OUTSIDE FILMS READ ONLY Clip # Reason: eval PE ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with CP and resp failure, recent pna REASON FOR THIS EXAMINATION: eval PE No contraindications for IV contrast ______________________________________________________________________________ WET READ: 5:03 AM No PE Severe pulmonary edema +/- infection ______________________________________________________________________________ FINAL REPORT CLINICAL INFORMATION: 58-year-old male with respiratory failure.",1
"TECHNIQUE: Outside images performed at hospital at 1:17 a.m. on are submitted for second opinion read as no report was available including 5-mm axial images of the upper portion of the aortic arch without contrast, and 5-mm axial images of the chest following the administration of contrast, which are reformatted into sagittal MIPs.",0
FINDINGS: There is marked pulmonary edema in the dependent lungs with relatively small bilateral pleural effusions.,0
It has a consolidative appearance in the left lower and right upper lobes.,0
The central airways appear patent.,0
There is an endotracheal tube appropriately positioned within the trachea.,0
"Though incompletely imaged on the images submitted, there is no evidence of acute aortic syndrome of the thorax.",0
The abdominal aorta measures at least 3.7cm in the imaged portion.,0
"There are no pathologically enlarged hilar, mediastinal, or axillary lymph nodes.",0
The pulmonary arteries are patent to the subsegmental level.,0
Numerous hypodensities within the liver are not fully evaluated.,0
The left adrenal is prominent measuring 12 mm.,0
No concerning osseous lesions are seen.,0
Severe pulmonary edema which with left lower and right upper lobar consolidation.,0
Likely pneumonia resulting in edema.,0
"3.7 cm suprarenal abdominal aortic aneurysm, incompletely imaged.",1
Findings were discussed with Dr. at 4:15 a.m.,0
4:00 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: s/p bronchoscopy Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with REASON FOR THIS EXAMINATION: s/p bronchoscopy ______________________________________________________________________________ FINAL REPORT INDICATION: Status post bronchoscopy.,0
FRONTAL CHEST RADIOGRAPH: All lines and tubes are in unchanged position.,0
"There is mild increased aeration within the right lung, which is still predominantly collapsed with associated mediastinal shift.",0
Pulmonary edema within the left lung continues to increase.,0
Increased aeration within a predominantly collapsed right lung.,0
"8:43 PM CHEST (PA & LAT) Clip # Reason: Consolidaiton Admitting Diagnosis: AORTIC STENOSIS;CONGESTIVE HEART FAILURE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with AS, CHF, ?pneumonia from OSH REASON FOR THIS EXAMINATION: Consolidaiton ______________________________________________________________________________ FINAL REPORT TWO VIEW CHEST Comparison to .",1
"There are prominent interstitial markings bilaterally and Kerley B lines, which may be due to mild fluid overload, but atypical pneumonia also is a consideration.",0
Osseous structures are unchanged with a healed distal left clavicle fracture.,0
"IMPRESSION: Prominent interstitial markings, mild pulmonary edema versus atypical pneumonia.",0
10:58 AM CHEST (PRE-OP PA & LAT) Clip # Reason: HEAD MASS Admitting Diagnosis: HEAD MASS ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with no active CP issues - pre op for OR REASON FOR THIS EXAMINATION: 63 year old man with no active CP issues - pre op for OR ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST ON HISTORY: Preop chest radiograph.,0
IMPRESSION: PA and lateral chest compared to : Heart size top normal.,0
No pleural abnormality or evidence of central adenopathy.,0
Vascular clips denote prior surgery at the gastroesophageal junction.,0
"10:43 AM MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # MR RECONSTRUCTION IMAGING Reason: 36 yo male intubated with presumed toxic ingestion now comat Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with h/o etoh use transferred from OSH with presumed toxic ingestion c/b acute renal failure, hepatits, pancreatitis, and meningitis.",1
REASON FOR THIS EXAMINATION: 36 yo male intubated with presumed toxic ingestion now comatose with fixed pupils and loss of some brain stem function.,0
LP c/w possible bacterial meningitis.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Possible meningitis.,0
TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain and post contrast images were obtained.,0
BRAIN MRI WITH AND W/O CONTRAST: There is no intra or extra-axial hemorrhage.,0
No enhancing lesions are identified.,0
There is no evidence of edema or mass effect.,0
There is mucosal thickening within the maxillary and ethmoid sinuses as well as partial opacification of the mastoid air cells.,0
MRA TECHNIQUE: 3D time of flight images of the circle of and multiplanar reconstruction images were obtained.,0
MRA CIRCLE OF : No abnormality is detected.,0
IMPRESSION: 1) No abnormally enhancing lesions are identified.,0
"9:05 AM CT ABD W&W/O C Clip # Reason: evaluate for varices and anatomy pre-procedure for variceal Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with hep c and etoh cirrhosis with variceal bleed, failed tips yesterday, to go again for repeat attempt at tips today.",1
"REASON FOR THIS EXAMINATION: evaluate for varices and anatomy pre-procedure for variceal bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old male with hepatitis C and alcoholic cirrhosis, now with variceal bleeding and unsuccessful TIPS placement yesterday.",1
Evaluate anatomy prior to re-attempt TIPS placement.,0
TECHNIQUE: Axial CT images through the abdomen were acquired before and after administration of intravenous contrast.,0
"Hepatic arterial, portal venous, and three-minute delayed post-contrast images were acquired.",1
FINDINGS: There are small bilateral pleural effusions with compressive atelectasis.,0
Coronary artery calcifications are seen.,0
"There is a moderate amount of low-density ascites with a focus of high density adjacent to segment VI of the liver, which may represent blood clot.",1
"In segment of the liver, there is a 4.3 x 2.5 cm ill-defined heterogeneous mass with areas of arterial enhancement and washout.",0
"The liver demonstrates a nodular contour, consistent with known cirrhosis.",1
"An 11-mm round metallic density is seen in the left lobe of the liver, which may represent a foreign body.",0
In the right lobe of the liver peripherally hyperdense material likely represents Gelfoam with a small amount of adjacent contrast from yesterday's procedure.,0
The spleen is enlarged measuring 14 cm.,0
Multiple upper abdominal varices are noted.,0
Metallic variceal coils are seen in the left upper quadrant.,0
The portal vein is patent but small.,0
Air in the gallbladder and central biliary tree is of unclear significance.,0
Gallbladder wall edema is likely secondary to portal hypertension and third spacing.,1
The adrenal glands and pancreas are unremarkable.,0
"Non-contrast images demonstrate retained contrast in the kidneys, suggesting an element of acute tubular necrosis or hepatorenal syndrome.",1
Post-contrast images of the kidneys are grossly unremarkable.,0
tube is seen within the stomach and GE junction.,0
Hyperdense material within the stomach may represent blood.,0
Visualized loops of small bowel are grossly unremarkable.,0
"There is pancolonic low density wall thickening, which is likely secondary to venous congestion related to portal hypertension.",1
Note is made of extensive arterial calcifications.,0
(Over) 9:05 AM CT ABD W&W/O C Clip # Reason: evaluate for varices and anatomy pre-procedure for variceal Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) Degenerative changes are seen in the spine.,0
Cirrhosis with evidence of severe portal hypertension.,1
"Ill-defined mass in segment of the liver with areas of arterial enhancement and washout; although not classic for hepatocellular carcinoma, MR should be considered when the patient is clinically stable.",0
Retained contrast in the kidneys suggesting an element of acute tubular necrosis or hepatorenal syndrome.,1
"Round metallic density in the left lobe of the liver, which may represent a foreign body.",0
"Contrast within the lower lung fields, appearance suggest lipiodol or some other form of contrast unrelated to previous attempted TIPS procedure.",0
These findings and recommendations were discussed with Dr. by Dr. by telephone at 11:00 a.m. on .,0
PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for AVR.,0
Height: (in) 66 Weight (lb): 130 BSA (m2): 1.67 m2 BP (mm Hg): 134/78 HR (bpm): 66 Status: Inpatient Date/Time: at 09:19 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.,1
There is mild valvular mitral stenosis (area 1.5-2.0cm2).,0
Dr. was notified in person of the results on at 830am.,0
Post bypass Patient is A paced and receiving an infusion of phenylephrine.,0
Bioprosthetic valve seen in the aortic position.,1
Leaflets seem to move well and the valve appears well seated.,0
The images post bypass are not of great quality due to extreme rotation of the heart to the left.,0
Mean gradient across the valve is 10 mm Hg.,0
5:04 PM CT CHEST W/O CONTRAST Clip # Reason: ?,0
"vascular congestion Admitting Diagnosis: ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with pulmonary fibrosis, COPD, in house being treated for transferred to MICU for increased work of breathing now intubated with etiology thought secondary to mucus plugging vs vascular congestion.",1
"vascular congestion CONTRAINDICATIONS for IV CONTRAST: creatinine 1.9 ______________________________________________________________________________ FINAL REPORT CT CHEST CLINICAL HISTORY: Pulmonary fibrosis, COPD, increased work of breathing, now intubated.",1
Etiology may be mucus plugging or vascular congestion.,0
Query new acute process or vascular congestion.,0
TECHNIQUE: Axial CT images were acquired through the chest without contrast in soft tissue and lung algorithms.,1
FINDINGS: An endotracheal tube is in place in satisfactory position.,0
"A nasogastric tube is in situ, extending into the stomach.",0
The distal tip is not within the field of view of this examination.,0
There is a left anterior chest wall pacemaker with right atrial and right ventricular leads in satisfactory position.,1
Mitral valve prosthesis and superior vena cava stents are unchanged.,0
Stable diffuse coronary artery calcification is present.,0
"The heart is enlarged, but not significantly changed.",0
"There is a 1.0 cm right paratracheal lymph node (series 2, image 16), unchanged since .",0
Multiple small lymph nodes in the paraesophageal region are all less than a centimeter in diameter and not changed since the previous examination.,0
"There is a new, small right-sided pleural effusion.",0
"There is stable severe centrilobular and paraseptal emphysema, worst at the apices.",0
"There is severe honeycombing and architectural distortion with traction bronchiectasis at the lung bases, not significantly changed.",0
Linear radiopaque suture material in the right upper lobe consistent with prior biopsy.,0
There has been interval development of pulmonary consolidation in the right middle lobe.,0
(Over) 5:04 PM CT CHEST W/O CONTRAST Clip # Reason: ?,0
vascular congestion Admitting Diagnosis: ANEMIA ______________________________________________________________________________ FINAL REPORT (Cont) Limited evaluation of the upper abdomen reveals atherosclerotic calcification of the aorta.,0
"The IVC and hepatic veins are again prominent, not significantly changed.",0
There is a stable small hiatus hernia.,0
Mild thickening of the left adrenal gland appears unchanged.,0
Prior right mastectomy with no evidence of residual or recurrent disease.,1
OSSEOUS STRUCTURES: Multilevel mild degenerative changes within the thoracic spine.,0
No worrisome lytic or blastic bone lesions.,0
The patient has had a sternotomy.,0
New right middle lobe consolidation may represent infection or hemorrhage.,0
There is a small new right sided pleural effusion.,0
Stable severe emphysema and pulmonary fibrosis.,1
Stable enlarged mediastinal lymph nodes and cardiomegaly.,0
"10:38 AM CHEST (PORTABLE AP) Clip # Reason: respiratory distress on vent Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with s/p fall SAH, patchy infiltrates s/p CVL change REASON FOR THIS EXAMINATION: respiratory distress on vent ______________________________________________________________________________ FINAL REPORT HISTORY: Increasing respiratory distress.",0
"AP CHEST: Interval increase in the left retrocardiac density and bilateral perihilar infiltrates, compared with .",0
No cardiomegaly or pleural effusion.,0
Cannot exclude pneumonia superimposed pneumonia.,0
3:32 PM CT HEAD W/O CONTRAST Clip # Reason: r/o mass Field of view: 25 ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with seizure/.,0
REASON FOR THIS EXAMINATION: r/o mass No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKXa MON 6:53 PM This exam should be repeated without EEG leads in place.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Seizure.,0
NON-CONTRAST HEAD CT SCAN: Several sections are completely degraded by overlying EEG leads and gross patient motion.,0
No gross hemorrhage or shift of the midline structures is appreciated in the parenchyma assessed on approximately half of the images.,0
"Repeat exam is advised, after removal of EEG leads.",0
"6:45 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: CHF, PTX Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man with spo2 of 78 % REASON FOR THIS EXAMINATION: CHF, PTX ______________________________________________________________________________ WET READ: KYg 10:14 PM ETT TERMINATES 3.8 CM ABOVE THE CARINA.",0
DIFFUSE BILATERAL AIRSPACE OPACITY HAS PROGRESSED.,0
"DIFFERENTIAL INCLUDE NEUROGENIC/NON-CARDIOGENIC EDEMA, DIFFUSE HEMORRHAGE, MASSIVE ASPIRATION, OR POSSIBLY MULTIFOCAL PNEUMONIA.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 40-year-old male with hypoxia and oxygen saturation to 78%.,0
Please evaluate for congestive heart failure or pneumothorax.,0
EXAMINATION: Single portable chest radiograph.,0
COMPARISON: Comparison to chest radiographs from performed at 3:00 p.m.,0
FINDINGS: In the interval of four hours there has been a significant rapid development of hazy opacification overlying the entire lungs.,0
The cardiomediastinal silhouette is stable in appearance with no evidence of cardiomegaly.,0
An endotracheal tube is in stable position 3.8 cm above the level of the carina.,0
IMPRESSION: Rapid interval progression of diffuse bilateral airspace consolidation involving the entire lungs.,0
"In the absence of cardiac enlargement, the possibility of neurogenic edema must be considered.",0
"The development is somewhat fast for infection; ARDS would also have to be considered These findings were discussed with Dr. at 11:00 a.m. on , and upon correlation with clinical history the patient deceased secondary to severe brain injury, the differential diagnosis for this diffusely developed airspace consolidation includes neurogenic noncardiogenic pulmonary edema.",0
The differential diagnosis also includes hemorrhage or infection.,0
9:08 AM CHEST (PA & LAT) Clip # Reason: Eval for pleural effusion.,0
Please take film in am Admitting Diagnosis: LEFT PLEURAL EFFUSION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with h/o VATS decortication REASON FOR THIS EXAMINATION: Eval for pleural effusion.,0
Please take film in am ______________________________________________________________________________ FINAL REPORT HISTORY: 68 year old male patient with history of recurrent bilateral loculated pleural effusions status post VATS decortication for evaluation of recurrent pleural effusion.,1
TECHNIQUE: PA and Lateral chest radiographs.,0
FINDINGS: The three left chest tubes are unchanged in position.,0
"Small bilateral pleural effusions, mild left lower lobe atelectasis and costal pleural thickening persist.",0
Cardiac silhouette is enlarged but unchanged from prior study.,0
No pulmonary edema is seen.,0
Intestinal distention in the imaged portion of the abdomen is moderately severe.,0
"Persistent small bilateral pleural effusion, mild left basal atelectasis and costal pleural thickening, but no pneumothorax.",0
"Moderate intestinal distention in the upper abdomen, incompletely imaged.",0
"6:36 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # -76 BY SAME PHYSICIAN : r/o ptx or other acute process Admitting Diagnosis: CHF EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with bilateral pleural effusions s/p thoracentesis REASON FOR THIS EXAMINATION: r/o ptx or other acute process ______________________________________________________________________________ WET READ: KYg SAT 8:59 PM compared to the prior exam, the lung volumes are improved.",0
The right pleural effusion is decreased in size.,0
The left pleural effusion is stable.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Assess pleural effusions S/P thoracentesis.,0
There has been interval decrease in still small-to-moderate right pleural effusion with associated atelectasis.,0
Cardiomediastinal silhouette is obscured by the pleural parenchymal abnormalities.,0
Intrathoracic stomach is again noted.,0
Pacemaker leads and right supraclavicular catheter remains in standard position.,0
8:23 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: s/p sternal debridement and rectus flap w/decreased BS-r/o e Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman s/p sternal debridement and rectus flap REASON FOR THIS EXAMINATION: s/p sternal debridement and rectus flap w/decreased BS-r/o effusion/infiltrate ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: S/P sternal debridement and rectus flap placement.,0
FINDINGS: A single AP supine image.,0
There is now evidence of a longitudinal row of skin staples over the sternum and right upper quadrant of the abdomen.,0
Surgical drains are also visible with their tips in the mid mediastinum on the left and right side.,0
The previous sternal sutures have been removed.,0
These findings are consistent with the recent debridement surgery.,0
The heart again shows moderate left ventricular enlargement and there is evidence of the prior CABG surgery.,0
"However, the pulmonary vessels are unremarkable and there is no evidence to indicate cardiac failure.",0
Some minor linear atelectases are noted at the left base and there is some elevation of the right diaphragm suggesting right basal atelectasis as well.,0
IMPRESSION: 1) Satisfactory status following debridement surgery of the mediastinum.,0
2) No evidence of cardiac failure.,0
3) Some fairly minor bibasilar atelectasis noted.,0
4) Tracheostomy in good position.,0
"7:09 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, effusion.",0
Admitting Diagnosis: CORONARY ARTERY DISEASE;?,1
"MYOCARDIAL INFARCTION\CATH ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with STEMI, acute stent thrombosis.",1
"REASON FOR THIS EXAMINATION: assess for infiltrate, effusion.",0
"______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: STEMI, acute stent thrombosis.",0
CHEST: The cardiac size is normal.,0
3:47 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change and ?,0
aspiration pneumon Admitting Diagnosis: PANCREATIC FISTULA;ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with chronic trach vomitied overnight REASON FOR THIS EXAMINATION: please evaluate for interval change and ?,0
"aspiration pneumonitis ______________________________________________________________________________ FINAL REPORT INDICATION: Vomited overnight, evaluate for aspiration.",0
FINDINGS: Semi-upright portable chest x-ray is compared with .,0
Tracheostomy tube is in satisfactory position.,0
There is minimal increased opacification within the left mid lung.,0
"There is minimal bibasilar atelectasis as well as small bilateral pleural effusions, unchanged.",1
"IMPRESSION: New opacification within the left mid lung, suggests aspiration.",0
9:29 AM CT CHEST W/O CONTRAST Clip # Reason: PNA Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: year old man with two months of PNA not cleared with antibiotics.,0
Question if has a post obstructive component or any new findings.,0
Needs Chest CT ASAP per ID.,0
new findings No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATIONS: Right upper lobe pneumonia.,0
Not clearing on chest radiograph.,0
CT CHEST WITHOUT CONTRAST: TECHNIQUE: Helical CT images without IV contrast through the chest.,0
Comparison is made to previous films from without IV contrast.,0
The coronary arteries are noted to be calcified.,0
Secretions are noted within the inferior trachea as well as in the right and left main stem bronchi.,0
Secretions are also seen extending into the superior left lower lobe segment bronchus.,0
The lung window images demonstrate slight improvement in right upper lobe consolidation with improved aeration.,0
The previously seen small air space concerning for a necrotizing process is no loger present and there are no air fluid levels.,0
In the mid left upper lobe there is a new patchy area of opacification with a focally dense region with adjacent ground glass opacification.,0
"Additionally, there is new subtle nodular ground glass opacification in the superior segment of the left lower lobe with subpleural nodularity.",0
There is stable appearance of traction bronchiectasis at the left base.,0
"There are stable bilateral pleural effusions, right greater than left with associated atelectatic changes at the posterior right lung base.",0
There are small stable nodules in the right upper lobe as well as anteriorly in the left upper lobe which are unchanged.,0
"In the imaged portion of the upper abdomen, the visualized portions of the liver, spleen, adrenal glands, pancreas and kidney are unremarkable.",0
The gallbladder is noted to be distended.,0
Slight interval improvement in right upper lobe consolidation with improved aeration consistent with gradually resolving pneumonia.,0
"At this time, no features suggestive of a necrotizing pneumonia are present.",0
Subtle ground glass opacification with nodularity in the superior segment of the left lower lobe as well as focally in the mid left upper lobe.,0
These findings and the associated secretions are suggestive of aspiration.,0
(Over) 9:29 AM CT CHEST W/O CONTRAST Clip # Reason: PNA Admitting Diagnosis: SEPSIS ______________________________________________________________________________ FINAL REPORT (Cont) Multifocal pneumonia can be excluded.,0
"Stable bilateral pleural effusions, right greater than left.",0
Height: (in) 63 Weight (lb): 110 BSA (m2): 1.50 m2 BP (mm Hg): 127/92 HR (bpm): 90 Status: Inpatient Date/Time: at 11:48 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
AORTIC VALVE: Mild AS (area 1.2-1.9cm2).,0
Calcific aortic valve disease with mild stenosis and mild regurgitation.,0
"Compared with the prior study (images reviewed) of , mild aortic stenosis has developed.",0
"3:02 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOP ABD/PEL LIMITED Reason: assess TIPS Admitting Diagnosis: ACUTE KIDNEY FAILURE;HYPERKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man s/p TIPS on monday, please assess TIPS patency REASON FOR THIS EXAMINATION: assess TIPS ______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old man with recent TIPS procedure, assess TIPS.",1
FINDINGS: The hepatic architecture is coarsened in appearance however no concerning liver lesion is identified.,0
No biliary dilatation is seen.,0
The spleen is enlarged measuring 15.6 cm.,0
No ascites is seen in the abdomen.,0
DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was performed.,0
The Doppler examination of the TIPS shunt is limited by persistent air in the cover of the TIPS stent.,0
No reliable Doppler information could be obtained.,0
Cirrhotic-appearing liver with no focal liver lesion and no biliary dilatation seen.,0
A repeat Doppler exam should be performed in four to five days as the covered TIPS stent limits the effectiveness of the Doppler examination until that time.,0
These findings were conveyed to Dr. at 4:44 p.m. on .,0
6:35 PM CHEST (PA & LAT) Clip # Reason: eval location of bullet Admitting Diagnosis: GUNSHOT TO CHEST ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man with GSW to chest REASON FOR THIS EXAMINATION: eval location of bullet ______________________________________________________________________________ WET READ: MON 7:36 PM Pneumoperitoneum is similar to same day CXR and compatible with history of laparotomy on .,0
Radiodense body compatible with bullet remains superimposed on the left lateral aspect of the T9-10 vertebral bodies.,0
"Lung volumes are low, exaggerating bronchovascular markings.",0
"Moderate left pleural fluid remain similar to prior, with persistent adjacent atelectasis and/or contusion.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 20-year-old male with gunshot wound.,0
"COMPARISONS: Multiple prior chest radiographs, most recently of .",0
FINDINGS: Frontal and lateral views of the chest were obtained.,0
The patient is in slightly rotated position relative to the prior exam.,0
"Chest tube appears in stable position, accounting for patient position.",0
Left lung volume loss is slightly increased since the prior exam with mild elevation of the left hemidiaphragm.,0
"Hazy opacity of the left base is compatible with a moderate-sized left pleural effusion, similar to prior, allowing for differences in lung volumes.",0
The right hemithorax remains clear.,0
"Pneumoperitoneum is similar to the prior exam, expected in the setting of recent laparotomy.",0
Bullet overlies the posterior left lateral aspect of the T9-10 vertebral body interspace.,0
Numerous surgical clips overlie the midline.,0
Slight interval left lung volume loss with stable moderate left pleural fluid.,0
"7:42 AM US ABD LIMIT, SINGLE ORGAN PORT Clip # Reason: evidence of bleed.",0
"Admitting Diagnosis: PNEUMOMEDIASTINUM;RHABDO;GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man with alcohol intoxication, fall, seizure, decreased HCT.",0
REASON FOR THIS EXAMINATION: evidence of bleed.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 9:19 AM PFI: Limited evaluation of the abdomen demonstrates no gross evidence of intraperitoneal fluid.,0
"______________________________________________________________________________ FINAL REPORT LIMITED ABDOMEN ULTRASOUND, INDICATION: 34-year-old man with alcohol intoxication, fall, seizure, and decreased hematocrit.",0
Please evaluate for evidence of intraperitoneal hemorrhage.,0
COMPARISON: There is no relevant imaging available for comparison.,0
FINDINGS: Limited scanning of the abdomen demonstrates no evidence of intraperitoneal fluid collection or hemorrhage.,1
IMPRESSION: No evidence of fluid or hemorrhage.,1
"Admission Date: Discharge Date: Service: NEUROLOGY Allergies: Penicillins / Amoxicillin / Banana Attending: Chief Complaint: code stroke Major Surgical or Invasive Procedure: - IV-tPA given for stroke, with minimal improvement - Right thigh fasciotomy for hematoma / compartment syndrome - Made CMO - Deceased History of Present Illness: Ms. is a 86 yo W with h/o AF not on coumadin, MVR and recent hip fracture s/p ORIF who presents with acute onset L sided weakness and facial droop at rehab.",1
The patient was noticed by rehab staff to acutely develop left facial droop and left arm and leg weakness at 13:45 today.,0
There is no other collateral history available.,0
"Per patient's daugther, she has been declining since with more confusion, falls and finally the hip fracture for which she remained hospitalized for 3 weeks with complications including delirium.",0
"She is intermitently confused, but usually oriented x 2, she is able to feed herself.",0
"She has not walked since the surgery, but was previously using a walker.",0
"Before , she was living alone and independent.",0
"On arrival in ED, NIHSS 8 for L facial droop, L hemiparesis, answers name but not age correctly, dysarthria.",0
"Head CT showed hypodensity of the R MCA territory, no cut-off seen, no ICH.",0
Patient was deemed candidate for t-PA with no absolute contraindications (surgery was >14 days ago).,0
She was given t-PA with no immediate improvement.,0
"After 30 minutes, L arm was antigravity, she was opening eyes more and answering yes/no questions with nodding head.",0
"Upon completion of t-PA (1 hour), patient was lifting L hand antigravity to command, proximal strength better than distal strength (still not squeezing hand).",0
She was indicating she had pain in the right lower back and right thigh.,0
"Inspection of the right thigh revealed swollen, hard area c/w hematoma.",0
Ortho was consulted for possible compartment syndrome.,1
CT scan of the thigh was ordered.,0
Past Medical History: - MVR for prolapse - chronic Afib - HTN - hyperlipidemia - hypothyroidism - UTIs Social History: Had been @Rehab Facility.,1
"Had been living alone until , then went to rehab due to falls, then (), and then fell again prompting recent hospitalization and discharge to rehab.",0
"Family History: Non-contributory Physical Exam: <<on admission>> VS: T AF HR 84 BP 123/65 RR 19 02 100/face mask GEN: cachectic elderly woman, moderate distress HEENT: sclera anicteric CV: irregular PULM: CTAB AB: ND/NT EXT: no edema NEURO: MS: Eyes closed, do not open to command, open slightly to noxious stimuli.",0
"Answers name, says age is 61.",0
"Speech dysarthria, also moaning, difficult to assess language further.",0
CN: PERRL 2.5 to 2mm.,0
L facial droop at rest.,0
"Tongue midline MOTOR: moving R side spontaneously and to command (cannot lift RLE to command s/p hip surgery), moving LLE to command antigravity for 8 seconds, no movement of LUE to command.",0
Withdraws and localizes pain in all 4 extremities.,0
SENSATION: withdraws to pain in all 4 extremities.,0
COORDINATION: intact finger to nose on RUE Pertinent Results: 04:52AM BLOOD WBC-10.9 RBC-2.95* Hgb-9.2* Hct-26.9* MCV-91 MCH-31.2 MCHC-34.3 RDW-19.9* Plt Ct-243 09:34PM BLOOD WBC-15.1* RBC-2.44* Hgb-7.8* Hct-23.6* MCV-96 MCH-32.1* MCHC-33.3 RDW-19.5* Plt Ct-285 02:44PM BLOOD WBC-10.1 RBC-2.60* Hgb-8.8* Hct-26.3* MCV-101* MCH-33.9* MCHC-33.5 RDW-16.9* Plt Ct-359 09:34PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3* 02:44PM BLOOD PT-13.2 PTT-24.9 INR(PT)-1.1 04:52AM BLOOD Glucose-99 UreaN-28* Creat-0.6 Na-138 K-4.8 Cl-105 HCO3-26 AnGap-12 09:34PM BLOOD Glucose-101* UreaN-28* Creat-0.6 Na-135 K-5.0 Cl-106 HCO3-24 AnGap-10 02:44PM BLOOD Glucose-91 UreaN-29* Creat-0.7 Na-138 K-4.7 Cl-104 HCO3-27 AnGap-12 09:34PM BLOOD CK(CPK)-42 09:34PM BLOOD CK-MB-4 cTropnT-0.04* 02:44PM BLOOD CK-MB-5 02:44PM BLOOD cTropnT-0.04* 04:52AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.4 09:34PM BLOOD Calcium-7.9* Phos-4.3# Mg-1.8 ECG: <<a.flutter>> Cardiology Report ECG Study Date of 2:35:06 PM Possible atrial flutter with multiple premature ventricular complexes.,1
Left ventricular hypertrophy with secondary repolarization abnormalities.,0
Inferolateral ST segment changes secondary to left ventricular hypertrophy versus myocardial ischemia.,0
Compared to the previous tracing of the rhythm now appears to be more consistent with atrial flutter versus atrial fibrillation and multiple premature ventricular complexes are now seen.,1
"TRACING #1 Read by: FISH, E. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 0 122 364/411 0 69 35 HCT/CTA/CT-perfusion (@presentation to our ED): FINDINGS: HEAD CT: An extensive region of the right MCA distribution demonstrates loss of the -white matter differentiation and is diffusely hypodense.",0
There is minimal sulcal effacement.,0
There is no associated intracranial hemorrhage.,0
"Elsewhere in the brain, there is no edema, hemorrhage, mass effect, or evidence of infarction.",0
Ventricles and sulci are otherwise normal in size and configuration for the patient's age.,0
The right maxillary sinus is again atelectatic and completely opacified.,0
Remaining paranasal sinuses and mastoid air cells are well aerated.,0
"The configuration of the calvarium is again unusual, with thinning of the posterior calvarium bilaterally, with a congenital appearance.",0
"CT PERFUSION: The perfusion maps demonstrate an extensive region of prolonged transit time and reduced blood flow and blood volume throughout the right MCA distribution, compatible with infarct.",0
There is no mismatch to indicate a penumbra.,0
HEAD AND NECK CTA: There is an abrupt cutoff of the superior division of the right M2 segment of the right middle cerebral artery.,0
The inferior division arises early from the M1 segment on the right.,0
There is a relative paucity of distal opacification within the MCA territory on the right.,0
"However, a few opacified vessels are present, the result of collateral flow.",0
The remainder of the circle of is patent without other area of occlusion.,0
The anterior communicating artery has a slightly bulbous appearance.,0
The cervical carotid and vertebral arteries and major branches are patent with no high-grade stenoses.,0
"However, the entire right cervical ICA is slightly diminutive in caliber relative to the left, and slightly irregular suggesting a long segment of atherosclerosis.",0
Both carotid bulbs demonstrate atheromatous irregularity without high-grade stenosis.,0
There is atherosclerotic calcification of the cavernous carotids bilaterally as well.,0
"Lung apices demonstrate scarring and high-density material bilaterally, with bronchiectasis at the right lung apex.",0
The aortic arch and origin of the major vessels demonstrate dense atherosclerotic calcification.,0
"The right internal carotid artery measures 8.3 mm at the bulb, 3 mm just above the bulb, and 3 mm at its upper portion.",0
"The left internal carotid artery measures 9 mm at the bulb, 5 mm just above the bulb, and 3.3 mm along the upper segment.",0
"Large acute infarct in the right MCA distribution, with no perfusion mismatch.",0
"Abrupt occlusion of the superior division of the right M2 segment of the right middle cerebral artery, with decreased filling of distal branches.",0
"Otherwise, patent circle of .",0
"Atheromatous irregularity at the carotid bulb bilaterally, with slightly diminutive right cervical ICA along its entire length, suggesting long segment atherosclerosis versus vasculitis.",0
"However, no high-grade stenosis of either side.",0
Slightly bulbous appearance of the anterior communicating artery.,0
Complete opacification and atelectasis of the right maxillary sinus as seen previously.,0
NCHCT: FINDINGS: Again noted is loss of the -white matter differentiation in the right insula.,0
Sulcal effacement and loss of -white differentiation extends to the right frontal and parietal lobes in a right MCA distribution.,0
No evidence of acute hemorrhage is seen.,0
"There is some compression of the right lateral ventricle, not significantly changed from the prior examination.",0
"General prominence of the ventricles and sulci is compatible with generalized atrophy, age related.",0
Areas of periventricular and subcortical white matter hypodensity likely reflect sequela of chronic small vessel ischemic disease.,0
There are vascular calcifications of the bilateral carotid siphons.,0
Complete opacification of the right maxillary sinus is unchanged.,0
Infarction in right MCA distribution as previously seen.,0
NCHCT: FINDINGS: Again seen is a large right MCA territory infarct with expected evolution.,0
There is no evidence of hemorrhage within the infarct.,0
No significant mass effect or shift of midline structures is seen.,0
"The ventricles and sulci are mildly dilated, consistent with age-related involutional changes.",0
The basal cisterns are normal.,0
Calcification of the cavernous portion of bilateral carotid arteries is present.,0
The mastoid air cells and imaged paranasal sinuses are clear.,0
Expected evolution of the large right MCA territory infarct.,0
No evidence of hemorrhage within the infarct.,0
"Brief Hospital Course: 86y F with atrial flutter and recently worsening dementia (undiagnosed), who was not taking anti-coagulation for her afib, recently s/p right Femur repair .",1
"Returned from Rehab to our ED as a code stroke due to Left-sided weakness, and was found to have a Right-M2 (superior division) occlusion, presumably due to cardioembolic clot given her aflutter without A/C.",0
"Given IV-tPA in the ED, with some improvement in her LUE (anti-gravity strength), but this was c/b a large and painful hematoma in the region of her recent surgery, which required that she go to OR urgently with Orthopedics for fasciotomy to relieve pressure from compartment syndrome (70mmHg pressure measured by Ortho).",1
"Her H&H dropped, but improved appopriately after transfusion of 2U PRBCs.",0
Her family decided to stop pursuing aggressive care measures; fasciotomy and transfusion were performed due to their palliative value (pt.,0
in severe pain from pressure/compartment syndrome).,1
"Pt was made CMO by family and transferred to the floor, with removal of tubes, lines, and invasive interventions and testing measures.",0
"She remained comfortable, but minimally responsive, with PRN sublingual morphine and with scopolamine patch.",0
Medications on Admission: 1. docusate sodium 100 mg Capsule : One (1) Capsule PO BID (2 times a day).,0
2. senna 8.6 mg Tablet : One (1) Tablet PO HS (at bedtime).,0
"3. aspirin 81 mg Tablet, Chewable : One (1) Tablet, Chewable PO DAILY (Daily).",0
4. levothyroxine 100 mcg Tablet : One (1) Tablet PO DAILY 5. lisinopril 5 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
0.03 % Drops : One (1) drop Ophthalmic at bedtime.,0
7. megestrol 400 mg/10 mL (40 mg/mL) Suspension : One (1) pill PO DAILY (Daily).,0
8. cholecalciferol (vitamin D3) 400 unit Tablet : Two (2) Tablet PO DAILY (Daily).,0
"9. calcium carbonate 200 mg (500 mg) Tablet, Chewable : One (1) Tablet, Chewable PO TID (3 times a day).",0
10. sertraline 50 mg Tablet : Two (2) Tablet PO DAILY (Daily).,0
11. digoxin 125 mcg Tablet : One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
12. polyethylene glycol 3350 17 gram/dose Powder : One (1) packet PO DAILY (Daily) as needed for constipation.,0
13. bisacodyl 10 mg Suppository : One (1) Suppository Rectal DAILY (Daily) as needed for constipation.,0
"14. olanzapine 5 mg Tablet, Rapid Dissolve : 0.5 Tablet, Rapid Dissolve PO BID (2 times a day).",0
15. cyanocobalamin (vitamin B-12) 250 mcg Tablet : One (1) Tablet PO DAILY (Daily).,0
"16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR DAILY (Daily).",0
17. acetaminophen 325 mg Tablet : Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever.,0
18. enoxaparin 30 mg/0.3 mL Syringe : One (1) syringe Subcutaneous QHS (once a day (at bedtime)) for 10 days: Last day = .,0
19. mirtazapine 15 mg Tablet : One (1) Tablet PO at bedtime.,0
20. metoprolol succinate 25 mg Tablet Sustained Release 24 hr : 1.5 Tablet Sustained Release 24 hrs PO once a day.,0
Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased MD Completed by:,0
4:36 PM PELVIS (AP ONLY); ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.,0
"Clip # Reason: PAIN FX PIN PLACEMENT Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ FINAL REPORT INDICATION: Sacral fracture, pain.",0
FINDINGS: Six fluoroscopic spot film images are provided from intraoperative stabilization of the left sacral fracture and sacroiliac joint with a single long screw.,0
Please refer to the official operative note for more details.,0
"4:00 PM CT CHEST W/CONTRAST Clip # Reason: EMPYEMA,S/P DRAINAGE Admitting Diagnosis: BLUNT TRAUMA Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man s/p motocycle accident with purulent drainage from CT hole REASON FOR THIS EXAMINATION: ?empyema No contraindications for IV contrast ______________________________________________________________________________ WET READ: 10:54 PM Chest tube removed in the interim.",0
Persistent but smaller left ptx.,0
Left effusion without pleural enhancement to suggest empyema.,0
"Left posterolateral rib fractures at least 5-9th ribs, many of which displaced, with subjacent subpleural hematoma / lung contusion and left chest wall subcutaneous emphysema dissecting posteriorly into lumbar musculature.",1
"Superinfection of subpleural hematoma underlying rib fractures (2, 38) cannot be excluded.",0
d/w Dr. at pg by on evening of .,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 19-year-old man, status post motorcycle accident, with multiple left rib fractures.",1
Now with purulent drainage from the chest tube.,0
COMPARISON: CT torso trauma on and multiple subsequent chest radiographs with the latest on .,0
TECHNIQUE: MDCT images were acquired from the thoracic inlet to the lung bases after administration of IV contrast.,0
Multiplanar reformatted images were obtained in 5-mm slice thickness.,0
Additional thin-cut 1.25-mm axial reconstructions were obtained for detailed analysis.,0
"CT CHEST WITH IV CONTRAST: The left chest tube with lateral approach terminates in the apex, unchanged.",0
There is a small left anteromedial pneumothorax.,0
Small-to-moderate left posterior pleural effusion layers in the dependent position and does not appear loculated.,0
"However, there are a 4.2 x 1.8 cm lateral collection (2:38), a 3.5 x 1.4 cm anterior collection (2:39) and a 4.2 x 2.8 cm medial collection (2:33), all concerning for loculated fluid collections.",0
"In particular, small amount of interspersed pockets of gas are noted within the medial and lateral collections, raising suspicion for superimposed infection such as empyema.",0
"The location of the medial collection is also unusual for trauma, but could represent a coup and contrecoup mechanism from a high-impact parenchymal contusion.",0
There is interval decrease of subcutaneous soft tissue gas along the left lateral chest wall.,0
"The right lung is normally expanded without pleural effusion, pneumothorax or focal airspace consolidations.",0
The great mediastinal vessels are normal.,0
The central tracheobronchial tree is patent.,0
Tiny triangular soft tissue in the mediastinum is compatible with a thymic remnant.,0
"Small mediastinal lymph nodes are not pathologically enlarged, likely reactive from the underlying (Over) 4:00 PM CT CHEST W/CONTRAST Clip # Reason: EMPYEMA,S/P DRAINAGE Admitting Diagnosis: BLUNT TRAUMA Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT (Cont) trauma/infection.",0
There is no hilar or axillary lymphadenopathy.,0
The study is not designed for subdiaphragmatic diagnosis.,0
Small amount of subcutaneous soft tissue gas tracks inferiorly to the left posterolateral abdominal wall.,0
"BONE WINDOW: Moderately-displaced multilevel left lateral rib fractures are seen from left fifth to ninth ribs, grossly unchanged from the prior CT trauma exam on the day of admission of .",0
There is no acute spinal injury.,1
There are no osseous lesions suspicious for malignancy.,0
Four different compartments of fluid in the left thoracic cavity.,1
The posterior one likely a freely layering pleural effusion.,0
The anterior one likely a loculated effusion.,0
The medial and lateral collections are concerning for a combination of lung contusion/laceration and hematoma with superimposed infection such as empyemas.,0
"Left chest tube terminates in the apex, unchanged.",0
"Grossly unchanged multilevel displaced left lateral rib fractures, constituting a flail chest.",0
Interval decrease of left lateral chest/abdominal wall subcutaneous gas.,0
"10:55 PM CHEST (PORTABLE AP) Clip # Reason: r/o tamponade, line placement Admitting Diagnosis: CORONARY ARTERY DISEASE;HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with MR s/p MVR.",1
"REASON FOR THIS EXAMINATION: r/o tamponade, line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 70 year old woman with MR status post MVR.",0
"COMMENT: Portable AP radiograph of the chest is reviewed, and compared with previous study of 11:19 AM.",0
The tip of the endotracheal tube is identified 3 cm above the carina.,0
"The right jugular central venous catheter terminates in the main PA. A nasogastric tube, mediastinal drain, and right chest tube remain in place.",0
There is continued mild congestive heart failure with cardiomegaly.,1
There is continued left lower lobe patchy atelectasis.,0
Patient is status post MVR and mediansternotomy.,0
IMPRESSION: Continued mild congestive heart failure with cardiomegaly.,1
Left lower lobe patchy atelectasis.,0
1:24 PM CT HEAD W/O CONTRAST Clip # Reason: s/p vent drain for ACA aneurysm and SAH.,0
"______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with SAH, s/p ventriculostomy REASON FOR THIS EXAMINATION: s/p vent drain for ACA aneurysm and SAH.",0
"______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT CONTRAST INDICATION: Subarachnoid hemorrhage, ACA aneurysm repair.",1
"FINDINGS: Compared to the exam of , there has been no significant interval change.",0
"Specifically, the large right frontal intraparenchymal hemorrhage with circumferential edema is unchanged.",0
There is no change in the size or appearance of the subarachnoid hemorrhage with hematocrit affect in the occipital horns of the lateral ventricles.,1
A 2nd focus of intraparenchymal hemorrhage in the medial aspect of the left frontal lobe is also unchanged.,0
There is no change in the 7mm right subfalcine herniation.,0
Right ventriculostomy tube is in good position within the lateral ventricle.,0
ACA aneurysm clips are noted.,0
There is minimal mucosal thickening of the ethmoid air cells.,0
"IMPRESSION: No interval change in right frontal intraparenchymal hemorrhage and subarachnoid hemorrhage, with subfalcine herniation as described.",1
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: R picc 50cm Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with REASON FOR THIS EXAMINATION: R picc 50cm ______________________________________________________________________________ FINAL REPORT HISTORY: 80-year-old female with right PICC placement.,1
"COMPARISON: at 6:30 a.m. PORTABLE SUPINE CHEST, ONE VIEW: Tip of right PICC line terminates in the proximal right atrium, just below the cavoatrial junction.",0
Diffuse bilateral airspace opacities again seen with slight interval worsening in the left hemithorax compared to most recent study.,0
Moderate right and small left pleural effusions are without change.,0
Tip of right PICC line terminates in proximal right atrium.,0
"Diffuse bilateral airspace opacities, with slight interval worsening in the left hemithorax.",0
Findings discussed with venous access team at the time of interpretation.,0
"3:01 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with urosepsis, intubated.",0
"REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): AZB MON 10:58 AM Reduction in bilateral pleural effusions, otherwise unchanged.",1
______________________________________________________________________________ FINAL REPORT COMPARISON: .,0
"FINDINGS: As compared to the previous radiograph, the preexisting bilateral pleural effusions are markedly decreased.",1
The costophrenic sinus is now visible in both hemithoraces.,0
The preexisting cardiomegaly is unchanged.,0
There still is moderate retrocardiac atelectasis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin / Clindamycin / Dilaudid / Iodine Attending: Chief Complaint: headache, weakness Major Surgical or Invasive Procedure: Esophagoduodenoscopy History of Present Illness: This is a 63 year old woman with multiple sclerosis, paraplegia, DM, CAD s/p RCA stents in , PVD, prior CVA, multiple DVTs on warfarin, who presented to the with headache, fatigue, and nausea.",1
"She says that her headache has been gradually increasing over the past two days and is described as throbbing, like her head is going to explode.",0
She denies visual changes or photophobia but is mostly blind.,0
"She denies neck stiffness, fevers.",0
"Ms. tells me her last bowel movement was Monday (3 days ago) and was, to her recollection, normal.",0
In particular she denies bright red blood or black stool.,0
She does endorse light-headedness for several days.,0
She denies any NSAID use but does take warfarin and clopidogrel as prescribed.,0
"In the ED, 98 106 133/63 18 100% 15L.",0
"Patient's labs were significant for a Hct of 14.7 (baseline 25-28, most recently checked 1 month ago) and INR 7.6.",0
She was noted to have formed guaiac negative brown stool on rectal exam.,0
"She was given 5mg po Vit K, and startted on IV protonix .",0
The patient refused NG lavage.,0
She initially refused head CT head but later consented.,0
CT abdomen was attempted but the patient had a panic attack in the scanner despite pre-treatment with 2 mg IV Ativan.,0
She was given 2U FFP and 2U pRBC.,0
"On arrival to the MICU, the patient complains of ongoing headache.",0
She also complains of palpitations which she says are chronic.,0
"Review of systems was negative for nausea, abdominal pain, diarrhea, vomitting, fevers, chills.",0
"Past Medical History: # CAD -- () RCA stents x2, mild ICM.",0
"-- Echo with LVEF >55% # History of recurrent DVTs -- First DVT in , given Coumadin for 6 months -- Second DVT in , given Coumadin then Plavix -- Third DVT in , now on Coumadin and Plavix # MS diagnosed in , wheelchair bound since # CVA in , h/o TIAs on Plavix # PAD by angiogram () -- Significant left SFA, popliteal, and anterior tibial disease -- Not amendable to stenting.",1
Complicated by nonhealing LLE ulcer.,0
# Left BKA () for nonhealing ulcer # Spinal cord compression -- S/p C3-7 and T2-11 laminectomy and fusion surgeries -- Residual paraparesis and absent sensation in bilateral LE.,1
-- No sensation below T10.,0
"# Seizure disorder # Diabetes Mellitus Type 2 # Hypertension # Hypercholesterolemia # Sarcoidosis # Anemia # Uterine/cervical cancer s/p radical hysterectomy # Asthma/COPD # Cardiac arrest after delivery (C-sect) of her 1st child # OSA -- no BiPAP/CPAP use # GI Bleed () thought to be ischemic colitis in setting of hypotensive episode and supratherapeutic INR () Required 3 units pRBCs, patient declined endocscopy.",1
Social History: She lives at home and is wheelchair bound and primarily dependent on aides for her care (present daytime only).,1
"She is a former alcoholic, sober since y/o when pregnant.",0
"She also has a 70 pack-year tobacco history, quit at 36 years old.",1
She is retired RN at .,0
Daughter very involved in her care.,0
"Family History: Multiple relatives with DM, CAD, HTN, asthma, and cancers (at least two with brain cancers).",1
"Mother died age 50 brain cancer had DMII and ""mild MIs"", father died age 48 MI and had DMII.",0
"No FH of MS, or DVT/PE.",0
Brother deceased 53yo had 3 bypass surgery.,0
"Physical Exam: On admission: Vitals: T: 97.5, HR 96, RR 13, O2 Sat 100% 2L GEN: obese, hirsuit, friendly woman lying in bed : dry mucosa NECK: unable to move (patient states chronic), no pain to palpation COR: regular, no murmur appreciated PULM: lungs clear bilaterally ABD: obese, soft, nontender, hyperactive bowel sounds, no rebound or guarding EXT: L BKA, no significant peripheral edema NEURO: alert, oriented x 3, PERRL, CN 2-12 intact, moves SKIN: No jaundice, cyanosis, or gross dermatitis.",0
"On discharge: Vitals: T 98.9 HR 78 BP 108/54 RR 18 O2 sat 94%RA GEN: obese, hirsuit, friendly woman lying in bed : moist mucous membranes NECK: unable to move (patient states chronic), no pain to palpation COR: regular, no murmur appreciated PULM: lungs clear bilaterally ABD: obese, soft, nontender, no rebound or guarding EXT: L BKA, no significant peripheral edema NEURO: alert, oriented x 3, PERRL, CN 2-12 intact SKIN: No jaundice, cyanosis, or gross dermatitis.",0
Pertinent Results: On admission: 06:03PM BLOOD WBC-9.7 RBC-1.85*# Hgb-4.7*# Hct-14.7*# MCV-80* MCH-25.2* MCHC-31.8 RDW-19.6* Plt Ct-398 06:03PM BLOOD Neuts-76.8* Lymphs-18.7 Monos-3.3 Eos-0.7 Baso-0.5 06:03PM BLOOD PT-66.2* PTT-42.0* INR(PT)-7.6* 06:03PM BLOOD Fibrino-484* 01:04AM BLOOD Ret Man-6.0* 06:03PM BLOOD Glucose-271* UreaN-48* Creat-1.1 Na-135 K-4.1 Cl-102 HCO3-23 AnGap-14 06:03PM BLOOD ALT-21 AST-19 LD(LDH)-143 AlkPhos-46 TotBili-0.1 DirBili-0.0 IndBili-0.1 06:03PM BLOOD cTropnT-<0.01 06:03PM BLOOD Iron-11* 01:04AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9 06:03PM BLOOD calTIBC-445 Hapto-199 Ferritn-9.7* TRF-342 06:50PM URINE Color-Straw Appear-Clear Sp -1.010 06:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR 06:50PM URINE RBC-0-2 WBC- Bacteri-MOD Yeast-OCC Epi-0-2 .,0
On discharge: 04:58AM BLOOD WBC-9.4 RBC-3.04* Hgb-8.8* Hct-26.0* MCV-86 MCH-28.9 MCHC-33.7 RDW-16.8* Plt Ct-393 05:35AM BLOOD Glucose-94 UreaN-15 Creat-0.8 Na-142 K-4.0 Cl-106 HCO3-29 AnGap-11 05:35AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0 .,0
Portable CXR : FINDINGS: No consolidation or edema is evident.,0
Calcification is seen at the ascending aorta.,0
The cardiac silhouette is enlarged but stable.,0
CT Head w/o contrast : FINDINGS: Study is limited by patient inability to lie flat and large field of view used.,0
There is significant underlying hyperostosis totalis resulting in further degradation of image quality.,0
"With this limitation in mind, there is no large intracranial hemorrhage, large acute territorial infarction, or large masses.",1
Paranasal sinuses and mastoid air cells are within normal limits.,0
Diffuse hyperostosis is seen of the calvarium.,0
IMPRESSION: Limited study without gross evidence of acute intracranial process.,0
Abd Ultrasound : FINDINGS: -scale and color Doppler son evaluation of the abdomen was performed.,0
Evaluation of the liver is somewhat limited due to patient's body habitus.,0
"However, there is no intrahepatic biliary dilatation.",0
No focal hepatic lesions are identified.,0
"The gallbladder demonstrates sludge, but is otherwise normal in appearance.",0
The right kidney measures 9.9 cm.,0
"There is no hydronephrosis, stones or mass.",0
The left kidney demonstrates a cyst at the upper pole measuring up to 3 cm in size.,0
"The spleen measures up to 11.1 cm in size, which is unchanged since the prior CT study of .",0
The pancreas is not well visualized due to overlying bowel gas.,0
"Spleen measuring 11.1 cm in size, within normal limits, and unchanged since the prior CT of .",0
Gallbladder is otherwise normal in appearance.,0
EGD : Esophagus: Normal esophagus.,0
"Brief Hospital Course: 62 year old woman with multiple sclerosis, DM, CAD s/p RCA stens in , PVD, prior CVA, and multiple DVTs, h/o spinal cord compression with no sensation below T10 who presented with anemia with a Hct 14.7, hemodynamically stable.",1
"Anemia: Presented with Hct 14.7, was 28 about a monht ago in the setting of INR of 7.1 Was guaiac negative in the ED, refused NG lavage and abd CT, and did not have abd, back, or flank pain or ecchymosis to suggest RP bleed.",0
"Received 5 units of PRBC and 2 units of FFP over hospital course and anticoagulation, with plavix, aspirin, coumadin were held.",0
"GI was consulted and recommended IV PPI and also EGD and colonoscopy to evaluate for the source of what was likely a slow GI bleed, considering her hemodynamic stability with profound anemia.",0
Hemolysis labs were negative and iron studies were notable for iron deficiency.,0
"Patient refused golytely prep for , but EGD was performed with assistance from anesthesia considering her limited neck mobility.",0
EGD showed no source of bleed in the upper GI tract.,0
"Hct remained stable at 25-26 after transfusions and INR was 1.1 on discharge, and she remained hemodynamically stable.",0
She will be discharged with PO pantoprazole for the next two weeks and then once a day for presumed GI bleed.,0
She will also have weekly CBCs done by her VNA.,0
Headache: Iniitally presented to ED for headache.,0
Pt reports 2 days of headache and nausea.,0
"No evidence of intracranial pathology on noncon head CT. and she did not have fevers, neck stiffness, photophobia or other symptoms of meningitis.",0
No new focal neuro findings.,0
Headache improved during hospitalization with tramadol.,0
She will be discharged iwth tramadol PRN.,0
"CAD () RCA stents x2, mild ICM.",0
CE negative x1 and no ECG changes.,0
ASA and blood pressure meds were held.,1
"She was discharged with plavix once a day, and coumadin will be restarted as an outpatient.",0
# History of recurrent DVTs on coumadin.,1
Plavix and warfarin were held in the setting of likely bleeding.,0
"# MS diagnosed in , wheelchair bound since .",0
"# CVA in , h/o TIAs on Plavix at home, which was held.",0
"# Diabetes Mellitus Type 2: Continued home NPH, with dose halved while she was NPO.",1
she will be discharged with her home insulin regimen.,0
"# Hypertension: Home BP meds were held, and restarted on discharge .",0
"# Hypercholesterolemia: Statin was held, restarted on discharge Medications on Admission: Atorvastatin 80 mg daily Baclofen 10 mg TID Carbamazepine 200 mg QID Clopidogrel 75 mg Fluticasone 110 mcg/Actuation Lisinopril 5 mg daily Metoprolol Tartrate 75mg Mirtazapine 7.5 mg qhs Warfarin 12.5mg daily Albuterol Sulfate 2.5 mg /3 mL (0.083 %)q6:prn Famotidine 10mg q12 Acetaminophen 1000 mg TID prn Hydrocodone-Acetaminophen 5-500 mg 1-2 tabs q6prn Isosorbide Mononitrate 90mg daily NPH Insulin Human 85 units each morning and 25 units each evening.",1
"Insulin Regular Human 100 unit/mL 6U qam Nystatin 100,000 unit/g powder Discharge Medications: 1. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).",0
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. fluticasone 110 mcg/Actuation Aerosol Sig: Five (5) Puff Inhalation (2 times a day).,0
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache.,0
Disp:*20 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
"8. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
PO twice a day for 2 weeks.,0
"Disp:*28 Tablet, Delayed Release (E.C.",0
")(s)* Refills:*0* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.)",0
PO once a day: Take pantoprazole once a day after the first two weeks of taking twice a day.,0
NPH insulin human recomb 100 unit/mL Suspension Sig: Eighty Five (85) units Subcutaneous QAM.,0
NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous QPM.,0
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain.,0
15. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*0* 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing.,0
"17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, headache: Do not exceed 4g in 24 hours.",0
18. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.,0
Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary diagnosis: GI bleed Discharge Condition: Mental Status: Clear and coherent.,0
Discharge Instructions: You were seen in the hospital for severe anemia.,0
"For this, you received several blood transfusions and you had an EGD which looked at your GI tract for a source of a bleed.",1
These studies showed a normal stomach and esophagus and no source of bleed.,0
"You also had a headache initially, that improved with tylenol and tramadol.",0
A CT scan of your head didn't show a bleed or other cause for your headache.,0
"Changes to your medications: Start taking tramadol as needed for your headache Start taking plavix again, but only once a day Stop taking Coumadin Start taking pantoprazole twice a day for the next two weeks for a GI bleed, and then after that take once a day.",0
Start taking iron for your anemia Followup Instructions: Department: When: MONDAY at 11:10 AM With: Dr.,0
Location: POST CLINIC Building: SC Clinical Ctr Campus: EAST Best Parking: Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider.,0
"this visit, you will see your regular primary care doctor in follow up.",0
"8:53 AM CAROTID SERIES COMPLETE Clip # Reason: Please assess for carotid stenosis, pre-op for CABG Admitting Diagnosis: NON-Q-WAVE MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with NSTEMI s/p cardiac cathterization which revealed multivessel disease requiring CABG REASON FOR THIS EXAMINATION: Please assess for carotid stenosis, pre-op for CABG ______________________________________________________________________________ FINAL REPORT INDICATION: 26-year-old man with NSTEMI and cardiac catheterization with multivessel disease requiring CABG.",0
Evaluate for carotid artery stenosis.,0
"BILATERAL CAROTID ARTERY ULTRASOUND: Grayscale and color Doppler son with waveform analysis and velocity calculations were performed of the bilateral CCA, ICA, ECA, and vertebral arteries.",0
Grayscale images demonstrate a moderate-to-heterogeneous plaque in the proximal right ICA and in the proximal left ICA.,0
"Following velocity measurements were obtained: RIGHT: Proximal ICA 146/36 cm/sec, mid ICA 135/19 cm/sec, distal ICA 60/17 cm/sec, CCA 86/17 cm/sec, ECA 109 cm/sec, and vertebral artery 80 cm/sec.",0
"LEFT: Proximal ICA 92/18 cm/sec, mid ICA 71/17 cm/sec, CCA 84/17 cm/sec, ECA 76 cm/sec, and vertebral artery 73 cm/sec.",0
"Right ICA/CCA ratio 1.7, left ICA/CCA ratio 1.1.",0
Antegrade flow is seen in the vertebral arteries bilaterally.,0
IMPRESSION: No significant carotid artery stenosis (findings consistent with less than 40% stenosis bilaterally).,0
1:08 PM CT HEAD W/ & W/O CONTRAST Clip # Reason: ?,0
"bleeding vs. worsening edema Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 90 ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with left frontal mass, recent hypothermia, DKA/HONC, now with worsening somnolence REASON FOR THIS EXAMINATION: ?",1
bleeding vs. worsening edema No contraindications for IV contrast ______________________________________________________________________________ WET READ: RSRc 2:04 PM Large left frontal mass w/ surrounding edema appears unchanged.,0
"Severe right subfalcine herniation, compression of corpus callosum and lateral ventricles appears similar.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 55-year-old female with left frontal mass, recent hypothermia, DKA, worsening somnolence.",0
Evaluate for hemorrhage or worsening edema.,0
"HEAD CT WITHOUT IV CONTRAST: A large left frontal extra-axial mass measures 6.5 x 5.8 cm, not significantly changed from one day prior (2A:13).",0
"This causes subfalcine herniation, with 2.1 cm right shift of midline structures.",0
"There is surrounding edema, effacement of sulci, and severe effacement of bilateral frontal horns of the lateral ventricles.",0
There is also severe displacement of the corpus callosum.,0
There has been no interval hemorrhage.,0
There is no evidence of transtentorial or uncal herniation.,0
No other lesion is identified.,0
Soft tissues and osseous structures appear unremarkable.,0
"No significant interval one-day change in non-contrast head CT size, characteristics, or effect of large left frontal extra-axial mass lesion with subfalcine herniation.",0
Findings were discussed with Dr. at 2:00 p.m. on .,0
"5:52 PM CHEST (PORTABLE AP) Clip # Reason: PNA?, line?",0
"Admitting Diagnosis: ULCERATIVE COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman trach, CVL, chronically ill REASON FOR THIS EXAMINATION: PNA?, line?",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 68-year-old woman with tracheostomy, central venous line, question pneumonia.",0
"FINDINGS: The patient is status post tracheostomy, with tracheostomy tube terminating approximately 4 cm above the carina.",0
Left IJ line is terminating in upper SVC.,0
"Multiple overlying tubes are seen, probably outside of the patient.",0
Residual contrast is seen in the stomach.,0
Cardiac and mediastinal contours are within normal limits considering for technique.,0
"Note is made of bilateral pleural effusions, larger on the left.",0
"Atelectasis is noted in left lower lobe, however, pneumonia cannot be totally excluded.",0
"IMPRESSION: Tubes and lines as described above, with the tip somewhat transverse angle to SVC.",0
"Bilateral pleural effusions, greater on the left.",0
"Atelectasis in the left lower lobe, however, pneumonia cannot be totally excluded.",0
11:44 AM PICC LINE PLACMENT SCH Clip # Reason: No IV access.,0
"Needs TPN and antibiotics Admitting Diagnosis: LEUKEMIA\BMT ********************************* CPT Codes ******************************** * CVL/PICC UD GUID FOR NEEDLE PLACMENT * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with ALL s/p MUD BMT.",0
REASON FOR THIS EXAMINATION: No IV access.,0
"Needs TPN and antibiotics ______________________________________________________________________________ FINAL REPORT HISTORY: 48 year old woman with ALL, s/p bone marrow transplant.",0
Need for access for TPN and antibiotics.,0
"RADIOLOGISTS: Dr. , Dr. , the attending radiologist present and supervising during the procedure.",0
PROCEDURE: The left upper arm was prepped and draped in the usual sterile fashion.,0
Since no suitable superficial veins were visible ultrasound was used for localization of a suitable vein.,0
The left brachial vein was patent and compressible.,0
After local anesthesia with 1% Lidocaine access was gained into the left brachial vein with a 21 gauge single-wall puncture needle using son guidance.,0
A .018 guidewire was then advanced into superior vena cava.,0
Based on the markers on the guidewire it was determined that a length of 41 cm would be suitable.,0
The PICC line was trimmed to length and advanced over a 5 French introducer sheath into the superior vena cava.,0
A final chest x-ray was obtained demonstrating the tip of the catheter in the superior vena cava.,0
ANESTHESIA: Local anesthesia with 1% Lidocaine.,0
"IMPRESSION: Successful placement of 41 cm total length double lumen PICC line via left brachial vein, tip in superior vena cava.",0
Right common carotid artery arteriogram.,0
Left common carotid artery arteriogram.,0
Right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site.,0
Coil embolization of right cavernous sinus.,0
Coil embolization of left cavernous sinus.,0
DETAILS OF PROCEDURE: The patient was brought to the angiography suite.,0
Anesthesia was induced in supine position.,0
"Following this, access was gained to the right common femoral artery using a Seldinger technique and a 4 French vascular sheath was placed in the right common femoral artery.",0
We also now placed a 5 French vascular sheath in the right common femoral vein using a Seldinger technique.,0
These were both connected to continuous saline flush.,0
The right and left common carotid arteries were catheterized and AP and lateral filming done.,0
"This revealed carotid cavernous fistula fed by both internal carotid arteries and external carotid arteries; however, the fistula was primarily draining into the right sphenoparietal vein, which was engorged.",0
(Over) 12:49 PM CAROT/CEREB Clip # Reason: Transvenous coiling of cc fistulaAnesthesia has been booked Contrast: OPTIRAY Amt: 273 ______________________________________________________________________________ FINAL REPORT (Cont) The previously seen drainage into the left superior petrosal sinus was no longer seen.,0
"We now catheterized the left jugular vein using catheter and following this, we made multiple attempts to catheterize the left superior petrosal vein.",0
"Eventually, with a 0.038 Glidewire and a 5 French , we were able to enter the proximal portion of the left superior petrosal sinus.",0
"From hereon, we were able to catheterize the cavernous sinus using rapid transit and a Gold-Tip Glidewire through the occluded segment.",0
"Following this, roadmapping guidance revealed clearly where the cavernous sinus on the left and the right was.",0
We now exchanged out the rapid transit for Echelon 0.010 catheter.,0
"Following this, the Expedian 0.010 wire was used to catheterize the right cavernous sinus and the right sphenoparietal vein.",0
"Following this, coiling was done in the cavernous sinus and the proximal portion of the retrograde draining cortical vein.",0
We now pulled the catheter back into the left cavernous sinus and again Target coils were used to occlude the cavernous sinus.,0
"Following this, the fistula was seen to be completely occluded.",0
Right common femoral artery arteriogram was done and a 6 French Angio-Seal was used for closure of the right common femoral artery puncture site.,0
"FINDINGS: Right common carotid artery arteriogram demonstrates filling of the right internal carotid artery along with cervical, petrous, cavernous, and supraclinoid portion.",0
There is carotid cavernous fistula with drainage primarily into the right superficial cortical veins.,0
"Similarly, right external carotid artery branches also seen to supply this.",0
"There is cross fill into the left cavernous sinus; however, the previously seen left superior petrosal vein is now seen to be occluded.",0
Left common carotid artery arteriogram again reveals a carotid cavernous fistula with similar drainage.,0
Left transverse sinus venogram demonstrates that the left petrosal vein seems to be occluded.,0
Left petrosal vein venogram shows filling of the left cavernous sinus and the right cavernous sinus with drainage into the right cortical venous system.,0
"Right cavernous sinus venogram demonstrates that there is a large draining vein which is single, draining from the right cavernous sinus into the cortical venous system.",0
Right common carotid artery arteriogram status post coil embolization shows that there is no evidence of CC fistula at this point.,0
Left common carotid artery arteriogram status post arteriogram shows that there is no draining of the left CC fistula.,0
(Over) 12:49 PM CAROT/CEREB Clip # Reason: Transvenous coiling of cc fistulaAnesthesia has been booked Contrast: OPTIRAY Amt: 273 ______________________________________________________________________________ FINAL REPORT (Cont) Right common femoral artery arteriogram shows widely patent right common femoral artery.,0
IMPRESSION underwent cerebral angiography and coil embolization of both cavernous sinus and the proximal portion of the draining vein of the right cortical vein which resulted in cure of the cc fistula.,0
"7:04 AM CT C-SPINE W/O CONTRAST Clip # Reason: GUNSHOT WOUND, EVALUATE FOR TRAUMATIC INJURY ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man with GSW tx from OSH REASON FOR THIS EXAMINATION: eval for traumatic injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd SAT 8:06 AM No fracture.",1
"small right apical pneumothorax, better assessed on ct torso.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: Man status post gunshot wound, transferred from outside hospital.",0
TECHNIQUE: Axially-acquired image obtained through the cervical spine without contrast.,0
Prevertebral soft tissues are within normal limits.,0
"There is extensive subcutaneous air overlying the left neck extending along the left chest wall, incompletely assessed.",0
A small right apical pneumothorax is noted.,1
5:22 PM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: S/P MVA ______________________________________________________________________________ WET READ: AEBc MON 6:00 PM Possible trace left pleural effusion and fracture of the left sixth rib.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH HISTORY: Status post motor vehicle accident.,1
"TECHNIQUE: Chest, single AP view.",0
"FINDINGS: The cardiac, mediastinal and hilar contours are unremarkable allowing technique noting AP supine technique on a trauma board with low lung volumes.",0
There is mild elevation of the right hemidiaphragm.,0
There is potentially a trace left-sided pleural effusion noting blunting at the left costophrenic sulcus.,0
"There is slight angulation at the left sixth rib, possibly a fracture but not certain.",0
IMPRESSION: Possible trace pleural effusion on the left with possible non-displaced left sixth rib fracture suggested by limited technique.,0
"If clinically indicated, it may be appropriate to repeat the view with conventional technique to consider equivocal findings further.",0
1:24 PM CHEST (PA & LAT) Clip # Reason: r/o pulmonary source of infection/white count elevation Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with biloma s/p aspiration now w/ rising white count REASON FOR THIS EXAMINATION: r/o pulmonary source of infection/white count elevation ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST ON HISTORY: Bile collection.,1
IMPRESSION: PA and lateral chest compared to : Small bilateral pleural effusions have increased since .,0
"Aside from minimal plate-like atelectasis at the right lung base, lungs are clear.",0
The heart is normal size and the mediastinum is midline.,0
"12:12 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: interval evaluation Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 41 yoM s/p laparoscopic total abdominal colectomy peristent ileus versus obstruction REASON FOR THIS EXAMINATION: interval evaluation ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Status post laparoscopic total abdominal colectomy, evaluate for obstruction or persistent ileus.",1
"ABDOMEN, SUPINE AND DECUBITUS: Somewhat distended loops of small bowel are present with multiple air-fluid levels, more consistent with obstruction than ileus.",0
"This is, however, is not excluded.",0
"IMPRESSION: Dilated small bowel more consistent with obstruction rather than ileus, but either possible.",0
LINE PLACEMENT Clip # Reason: post 47cm SL R basilic PICC placement; please determine tip Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with REASON FOR THIS EXAMINATION: post 47cm SL R basilic PICC placement; please determine tip location ______________________________________________________________________________ WET READ: KCLd FRI 6:52 PM right picc with tip in inferior right atrium.,0
d/ of venous access at 650pm.,0
"retrocardiac opacity possibly atelectasis, vs consolidation.",0
"______________________________________________________________________________ FINAL REPORT PORTABLE LINE PLACEMENT , 18:27 COMPARISON STUDY: at 01:50.",0
FINDINGS: A right PICC has been placed.,0
The tip terminates in the right atrium.,0
Otherwise there is bibasilar atelectasis greater on the left than the right.,0
The upper lung zones are relatively clear.,0
The cardiomediastinal silhouette is within normal limits with the exception of mild tortuosity of the aorta.,0
IMPRESSION: The right PICC terminates in the right atrium.,0
This finding was discussed with the venous access team at the time this film was obtained by the on call resident.,0
"3:14 PM US DRAIN PELV ABSCESS; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # PELVIS U.S., TRANSVAGINAL; GUIDANCE FOR ABSCESS () Reason: ?",1
possible drainage of intra abd/pelvic abcesses Admitting Diagnosis: PERFORATED VISCUS ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: Moderate sedation was provided for this procedure by the radiology nurse.,0
Two doses of fentanyl were administered to a total dose of 75 mcg.,0
"One dose of Versed was administered, total dose of 2 mg. Intraservice time was 25 minutes.",0
possible drainage of intra abd/pelvic abcesses Admitting Diagnosis: PERFORATED VISCUS ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman s/p tubal ligation c/b jej perf now with intra abd abcesses REASON FOR THIS EXAMINATION: ?,0
"possible drainage of intra abd/pelvic abcesses ______________________________________________________________________________ FINAL REPORT PELVIC ABSCESS DRAINAGE INDICATION: 38-year-old woman status post tubal ligation, complicated by jejunal perforation, now with intraabdominal abscesses.",1
Evaluate for drainage of pelvic collection.,0
ULTRASOUND-GUIDED TRANSVAGINAL ABSCESS DRAINAGES: Transvaginal ultrasound was performed to evaluate the position of the pelvic collection in relationship anterior to the rectum and measures 2.8 x 2.8 x 4.9 cm.,0
"This collection extends posterior to the uterus, where it connects with the superior portion this collection that is seen on CT. For consent and preprocedure timeout, please see CT procedure from the same day.",0
The patient was prepped in the usual sterile fashion.,0
Local anesthesia was performed with lidocaine gel and 5 ml of lidocaine 1% were injected into the soft tissues overlying the pelvic fluid collection.,0
An 8 French catheter was then advanced into the collection and approximately 20 ml of pus were aspirated.,0
The catheter was secured in position.,0
IMPRESSION: Placement of 8 French catheter transvaginally in the pelvic fluid collection.,0
"8:31 PM CT HEAD W/O CONTRAST Clip # Reason: R/O BLEED ______________________________________________________________________________ FINAL REPORT HISTORY: Sepsis, mental status change.",0
No prior head CTs are available for comparison.,0
There is no shift of normal midline structures or mass effect.,0
"The ventricles, cisterns and sulci are normal.",0
There is no evidence of pathologic intra or extra axial fluid collections.,0
There is no evidence of a skull fracture.,0
"The left maxillary sinus is almost completely opacified, there is soft tissue density material in the left ethmoidal sinus.",0
There is a focal area of soft tissue density in the right side of the sphenoid sinus.,0
IMPRESSION: 1) No evidence of intracranial hemorrhage.,0
"2) Left maxillary, left ethmoidal and right sphenoid sinus disease.",0
Height: (in) 71 Weight (lb): 218 BSA (m2): 2.19 m2 BP (mm Hg): 124/62 Status: Inpatient Date/Time: at 12:17 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is moderately dilated.,0
4:33 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval change & ptx Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man s/p R chest tube removal REASON FOR THIS EXAMINATION: ?,0
"interval change & ptx ______________________________________________________________________________ WET READ: KYg SUN 5:31 PM COMPARED TO , RIGHT SIDED CHEST TUBE HAS BEEN REMOVED.",0
ET TUBE EXCHANGED FOR TRACHEOSTOMY.,0
RIGHT SUBCLAVIAN CVL IS UNCHANGED.,0
NG TUBE HAS BEEN REMOVED.,0
PATCHY OPACITY IN LEFT HEMITHORAX AND AIRSPACE OPACITY IN THE RIGHT APEX PERSISTS.,0
PERHAPS THERE IS MINIMAL IMPROVMENT IN THE AERATION OF THE LEFT LUNG BASE.,0
"BILATERAL PLEURAL EFFUSIONS, R>L, UNCHANGED.",1
"WET READ VERSION #1 KYg SUN 5:27 PM COMPARED TO , RIGHT SIDED CHEST TUBE HAS BEEN REMOVED.",0
"______________________________________________________________________________ FINAL REPORT In comparison to , the nasogastric tube has been removed.",0
The endotracheal tube has also been removed.,0
Newly placed tracheal cannula in regular position.,0
Complete removal of the right-sided chest drainage.,0
The right-sided central venous access is in unchanged position.,0
Slight decrease of the parenchymal opacities at the left lung base.,0
All other elements of the radiographs are unchanged as compared to the previous image.,0
Height: (in) 74 Weight (lb): 180 BSA (m2): 2.08 m2 BP (mm Hg): 112/50 HR (bpm): 100 Status: Outpatient Date/Time: at 11:20 Test: TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflow pattern for age.,0
There is borderline global left ventricular hypokinesis.,0
"Compared with the prior study (tape reviewed) of , left ventricular systolic function is now probably slightly depressed although views are technically suboptimal for comparison.",0
", D. OMED 7F 10:37 PM UNILAT UP EXT VEINS US RIGHT PORT Clip # Reason: please evaluate for DVT Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with swelling around PICC site, pain, non working PICC, concerning for DVT.",0
REASON FOR THIS EXAMINATION: please evaluate for DVT ______________________________________________________________________________ PFI REPORT PFI: Extensive DVT of the right axillary and basilic veins around the PICC line.,0
Discussed with Dr. at 1:15 a.m. on .,0
PATIENT/TEST INFORMATION: Indication: Rapid Atrial fibrillation/flutter.,0
?endocarditis Height: (in) 71 Weight (lb): 190 BSA (m2): 2.07 m2 BP (mm Hg): 98/62 HR (bpm): 140 Status: Inpatient Date/Time: at 12:30 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.,0
The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Dyspnea, SOB Major Surgical or Invasive Procedure: Bone Marrow Biopsy, History of Present Illness: 71 year old female with h/o HTN and HL who presents with SOB, fatigue, multiple tooth infections and BRBPR.",1
She is being admitted to for pancytopenia and a Hct of 13.9. .,0
"About 4-5 months ago, she began to develop dyspnea on exertion and intermittent bilateral leg swelling.",0
"She also started to have tooth bleeding and swelling, and has had 4-5 visits to her dentist in the last several months for recurrent tooth infections.",0
"She has had 8 teeth extracted, and has intermittently been on amoxicillin and then azithromycin for these infections (last course of azithro from to ).",1
"Over the last 2 weeks, her leg swelling and dyspnea have gotten significantly worse.",0
"She reports bilateral lower extremity edema, right greater than left.",1
She also has dyspnea on exertion - over the last several months she has been able to leave the house but needed to rest intermittently while walking due to dyspnea.,0
Over the last 2 weeks she has been unable to leave the house due to SOB.,0
She also describes intermittent pain on the lower right side of her chest and RUQ with exertion that improves with rest.,0
This has been intermittent over the last several months but also worse in the last few weeks.,0
Last episode was earlier today but currently she denies SOB or chest pain.,0
Denies any n/v/diaphoresis with these episodes.,0
Her chest pain is not pleuritic.,0
She also endorses BRBPR over the last 6 weeks associated with worsening constipation.,0
"She describes painful, infrequent bowel movements and blood is present on the stool when her bowel movements are most painful.",0
The frequency or amount of blood has not changed over 6 weeks.,0
The most blood present is about 10cc.,0
Denies abdominal pain (except for RUQ pain described above).,0
Has occasional nausea in the mornings.,0
She reports dizziness when she stands in the mornings.,0
"She reportedly had a colonoscopy earlier this month (""in downtown "") due to a PCP referral for these symptoms that was reportedly normal.",0
She denies any recent viral illness.,0
Denies any medication changes other than lidocaine and Anusol for hemorrhoids and azithromycin for her tooth infections.,0
"Denies fever, but has occasional chills.",0
Nonproductive cough has also been present over 4-5 months.,0
Today she went to her PCP who noted bilateral lower extremity edema and was concerned for right sided CHF and sent her to the ED.,1
"In the ED where workup was notable for pancytopenia (Hct 13.9, WBC 0.67 (>90% lymphocytes), platelets 75).",0
She was given 1 unit PRBCs.,0
Their heme/onc team recommended transfer to .,0
"In our ED, initial vitals were 97.8 71 124/77 16 100%4L.",0
Rectal exam showed mild BRBPR and was guaiac positive.,0
"Labs were significant for a WBC of 0.7, Hct 17.3, Plt 84.",0
The ED resident spoke with heme/onc who felt this was possibly MDS vs aplastic anemia.,0
Latest vitals 76 143/69 18 100%on4L.,0
"On the floor, she states she is feeling tired, but without SOB or chest pain.",0
"Past Medical History: Hypertension Hyperlipidemia Unclear history of heart disease (says she was seen in for chest pain, had many ECGs, may have had an MI but no cath done, no TTE) Hernia repair OSA on CPAP at home Botox injections monthly for blepharospasm Social History: Lives with extended family (husband, daughter, son-in-law) in .",1
"Denies current or previous smoking, alcohol, or drug history.",0
Family History: 2 brothers and sister died of MI (in 60's and 70's).,0
"No FH of cancer, DM, bleeding, or clotting disorders.",0
DIAGNOSIS: Acute promyelocytic Leukemia with t(15;17) (W.H.O.,1
"), (FAB subtype AML-M3), see note.",0
Note: Concurrent FISH studies demonstrate a PML-RARA (i.e.,0
t (15;17) (q22; q21)) rearrangement (see separate complete report).,0
ECHO: The left atrium is mildly dilated.,0
"No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality.",0
The tricuspid regurgitation jet is eccentric and may be underestimated.,0
"Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded.",0
The LV apex is particularly poorly seen and may be hypokinetic.,0
There is a catheter in the right atrium.,0
ECHO: Regional left ventricular wall motion is normal.,0
IMPRESSION: Normal global and regional left ventricular systolic function.,0
"Compared with the prior study (images reviewed) of , LV wall motion is better assessed with use of contrast.",0
Current study focused on LV function only.,0
No CT evidence of acute pulmonary embolism.,0
"Smooth interlobular septal thickening, likely due to interstitial edema.",0
Mild lower lobe bronchiectasis and mucoid impaction.,0
"Although nonspecific, this raises the possibility of chronic aspiration.",0
No substantial pleural or pericardial effusion.,0
"LE U/S: IMPRESSION: Normal Doppler ultrasound of both lower extremities, no evidence for DVT.",0
Findings are stable and unchanged when compared to prior ultrasound from .,0
CXR: IMPRESSION: No evidence of acute cardiopulmonary process within the limitation of the chest radiograph is seen.,0
"Brief Hospital Course: 71 year old female with h/o HTN, HL, and multiple recent tooth infections who presents with pancytopenia, dyspnea, bilateral leg swelling, and BRBPR, found to have promyelocytic leukemia on BM biopsy with course complicated by coagulopathy.",1
"Promyelocytic leukemia: Constellation of anemia, neutropenia, and thrombocytopenia with inappropriately low reticulocytosis was consistent with bone marrow pathology.",1
Reticulocyte index = 0.3 so abnl marrow response to anemia.,0
"BMT was consulted, and bone marrow was pursued.",0
"Hemolysis labs wnl, but coag panels abnormal (see below).",0
"As per protocol, the pt and family were informed and consented for treatment.",0
The patient was transferred to the BMT service and started on ATRA and Idarubicin.,0
Her counts had an initial recovery but then a prolonged nadir after treatment.,0
Her counts began to recover on and reached ANC 1160 at the time of discharge.,0
She was discharged with follow up with Dr. .,0
"# Disseminated Intravascular Coagulopathy: Elevation of coags, decrease in PLTs and fibrinogen, concerning for DIC.",0
"Received 1 bag (10U cryo), 1unit FFP, 2unit pRBCs transfusion while in ICU.",0
Central line was placed for access.,0
"We monitored labs first Q8h, and spaced to daily when DIC was reversed with transfusions of appropriate blood products.",0
ATRA was continued as above.,0
"# Neutropenic fever: Febrile to 100.8 on HD1 in context of receiving transfusion, and was intermittantly febrile throughout her course after chemotherapy treatment.",0
"Urine initially grew out ESBL and Enterococcus, and she was treated with meropenem and defervesced.",0
"She again became febrile almost two weeks later, in the setting of her blood count nadir, and was treated with Vancomycin, Meropenem and Micafungin.",1
Blood cultures and urine cultures remained negative.,0
Antibiotics were discontinued and she remained afebrle x 4 days at the time of discharge.,0
"She remained with a dry, non-productive cough at the time of discharge however this was not thought to be related to an infectious process.",0
Bright Red Blood Per Rectum: Had reports of BRBPR and seen to have small amount of BRBPR in the ED.,1
Most likely lower GI bleed in the setting of thrombocytopenia and DIC.,0
"While admitted, only scantly guaiac positive.",0
Did have recent normal colonoscopy and currently hemodynamically stable.,0
Dyspnea and Chest pain: Felt her dyspnea and overall fatigue was likely related to her profound anemia given that it subacutely developed over the course of several months.,1
Dyspnea improved after transfusion of PRBCs.,0
Most consistent with demand ischemia in the setting of anemia.,0
"# Episodes of 'throat tightening': After starting ATRA, the patient had episodes of feeling like her throat had tightened.",0
She was never hypoxic during these episodes and had no stridor on exam.,0
She was initially treated with steroids for concern for ATRA syndrome but when she developed no further symptoms it was felt that this was instead likely anxiety.,0
Steroids were tapered off and she was treated with Ativan.,0
Lower extremity edema: Does have report of bilateral lower extremity edema over the last several weeks.,1
Does have elevated d-dimer and likely at risk for thrombosis.,0
"Did have mildly elevated JVP and some dyspnea that could be related to CHF as well, although no signs of left-sided CHF and feel this is less likely.",0
LENIS negative and Echo showed normal systolic function.,0
"# Elevated AST/ALT: Following admission, patient developed mild elevation of AST and ALT likely related to chemotherapy.",0
"HBV surface Ag was negative, HBV surf Ab was borderline and HBV core Ab was positive.",0
HBV VL was negative but started Lamivudine after discussio nwith hepatology.,0
Repeat viral load prior to discharge was negative.,0
After discussion with Hepatology it was decided to continue lamviudine while patient is receiving chemotherapy.,0
# TB prophylaxis: Patient with a history of TB exposure and negative chest xray.,1
"Quantiferon gold test was intermdiate, Infectious disease consult recommended INH treatment however given elevated transaminases, treatment with INH was deferred.",0
She was given an appointment for outpatient followup with infectious disease.,1
Continued amlodipine at home dose.,0
# Constipation: Discharged with senna and colace.,0
Medications on Admission: Anusol HC 2.5% appl Lidocaine topical 3% 1 app tid Pravachol 20mg po daily Amlodipine 5mg po daily Omeprazole 20mg po daily ASA 81mg po daily - not taking MVI 1 tab po daily Calcium with D 500mg/400units po bid OPC-3 1 cap daily - not taking Azithromycin - took until Fiber OTC for constipation Dulcolax 5mg po prn constipation Ibuprofen 800mg po prn Botox injections for blepharospasm (monthly) Denies other OTC or Chinese herbal medications Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*0* 2. multivitamin Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*60 Tablet(s)* Refills:*0* 4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours).,0
Disp:*90 Tablet(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation.,0
Disp:*50 Capsule(s)* Refills:*0* 7. lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
"Disp:*30 Tablet(s)* Refills:*0* 8. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
)(s)* Refills:*0* 9. tretinoin (chemotherapy) 10 mg Capsule Sig: Four (4) Capsule PO twice a day.,0
Disp:*240 Capsule(s)* Refills:*0* 10. lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
Disp:*30 Tablet(s)* Refills:*0* 11. hydrocortisone acetate 1 % Ointment Sig: One (1) appl Rectal twice a day as needed for hemorrhoids.,0
"Botox Cosmetic Injection 13. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Acute Promyelocytic leukemia.,1
Secondary Diagnosis Pancytopenia Neutropenic Fever Discharge Condition: Mental Status: Clear and coherent.,0
"Discharge Instructions: Ms. , It was a pleasure taking care of you during your hospitalization.",0
"You were admitted to with low blood counts, and a bone marrow biopsy showed that you have Acute Promyelocytic Leukemia.",1
"We started you on the treatment for this (ATRA and Idarubicin), and we monitored you in the hospital during this course.",0
"Given your history of tuberculosis exposure, we recommend that you follow up with the infectious diseases clinic, we have made an appointment for you.",1
Your medications have changed since you were admitted to the hospital.,0
Please see the attached list of medications to know what you should be taking.,0
Do not take any medications that are not on this list.,0
"Specifically, STOP taking Pravachol and Aspirin, discuss resuming these medications with Dr. .",0
Please follow up with you physicians as indicated below.,0
"Followup Instructions: Department: HEMATOLOGY/BMT When: FRIDAY at 10:00 AM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: INFECTIOUS DISEASE When: FRIDAY at 2:00 PM With: , MD Building: LM Campus: WEST Best Parking: Garage",0
worsening b/l effusions Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with metastic Renal cell carcinoma (lungs) with b/l pleural effusions s/p Left thoracentesis w/ fluid data c/w chylothorax.,0
Now w/ respiratory distress REASON FOR THIS EXAMINATION: ?,0
worsening b/l effusions ______________________________________________________________________________ FINAL REPORT INDICATION: H/O metastatic renal cell carcinoma.,0
Now with bilateral pleural effusions.,0
"S/P left thoracentesis showing chylothorax, worsening sob.",0
PORTABLE AP CHEST: There is complete opacification of the left lung.,0
Moderate right pleural effusion limits evaluation of the right lung.,0
Aerated right upper and mid-lung zones show upper zone redistribution of the pulmonary vascularity.,0
"Mediastinal, hilar and cardiac contours cannot be assessed.",0
Metal clips in upper quadrant of the abdomen are consistent with s/p nephrectomy.,0
IMPRESSION: 1) Complete opacification of the left lung.,0
Increase in right pleural effuion.,0
2) Findings suggestive of chf.,0
3:02 PM TIB/FIB (AP & LAT) IN O.R.,0
RIGHT Clip # Reason: ORIF RIGHT TI/FIB Admitting Diagnosis: MOTOR VEHICLE ACCIDENT WITH UNSPECIFIED INJURIES ______________________________________________________________________________ FINAL REPORT INDICATION: ORIF RIGHT TIBIA/FIBULA COMPARISON: .,1
Fifteen intraoperative fluoroscopic views were submitted for review.,0
These demonstrate interval removal of an external fixator and placement of a long intramedullary rod and interlocking screws transfixing a markedly comminuted segmental fracture of the mid and distal fibula.,1
Again seen are laterally displaced fracture fragments.,1
Again seen is a comminuted segmental fracture of the fibula which appears unchanged.,1
Total fluoroscopic time was 296.4 seconds.,0
"For further details, please see the intraoperative report.",0
"5:08 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: BILIARY STRICTURE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman pancreatic adenocarcinoma, s/p whipple REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Post-Whipple.",0
Layering pleural effusions are seen bilaterally with compressive atelectasis at the bases.,0
"There may be some elevation of the pulmonary venous pressure, unchanged from the previous study.",0
12:06 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: ?traumatic injury Field of view: 42 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with ?pelvic fracture after fall REASON FOR THIS EXAMINATION: ?traumatic injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: JRCi WED 1:55 AM Grossly comminuted fracture of right acetabulum and right inferior pubic ramus.,1
Small amount of hemorrage in the right pelvis.,0
No active extravastation of contrast.,0
______________________________________________________________________________ FINAL REPORT STUDY: CT torso with contrast and reconstructions.,0
"INDICATION: Pelvic pain after fall, trauma.",0
TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet to the symphysis after the uneventful intravenous administration of 130 cc Optiray 350 contrast material.,0
CT CHEST WITH CONTRAST: Study is limited given motion artifact.,0
A right- sided pacemaker is noted with leads in expected position within the right atrium and ventricle.,0
"No axillary, mediastinal or hilar adenopathy is detected.",0
There are dense coronary artery calcifications.,1
No pericardial effusion is detected.,0
There is a small amount of secretions within the distal trachea (series 2: image 12).,0
Fluid is noted within the esophagus which is mildly dilated.,0
No pleural effusions are detected.,0
Evaluation for lung nodules is limited given respiratory motion.,0
CT ABDOMEN WITH CONTRAST: No masses are detected within the liver.,0
There are no liver lacerations identified.,0
"The gallbladder, spleen, adrenal glands and visualized abdominal large and small bowel appear unremarkable.",0
No free air or free fluid is detected within the abdomen.,0
There is fatty atrophy of the pancreas without focal mass lesion identified.,0
No intra- or extra-hepatic biliary ductal dilatation is present.,0
CT PELVIS WITH CONTRAST: A moderate amount of stool is present within the rectum and sigmoid colon.,0
A Foley catheter is present within a collapsed bladder.,0
A small amount of hemorrhage is present within the right side of the pelvis presumed secondary from right acetabular fracture.,0
A right penile prosthetic pump reservoir has mildly irregular margins and is located anterior to the right acetabular anterior column which demonstrates grossly comminuted fractures.,0
(Over) 12:06 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: ?traumatic injury Field of view: 42 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) OSSEOUS STRUCTURES: There is a mildly displaced fracture involving the right inferior pubic ramus.,0
"There are grossly comminuted complex fractures involving the anterior, posterior columns and roof of the right acetabulum with fracture line extending a large portion of the right iliac .",1
Small hematoma involving the obturator musculature is noted as well as the right iliacus muscle.,0
Grossly comminuted fracture involving the right acetabulum extending into the iliac .,1
There is no evidence of active extravasation of contrast material with small hematoma involving the right iliacus muscle and obturator internus.,0
Acute fracture is also present within the right inferior pubic ramus.,1
8:58 PM CHEST (PORTABLE AP) Clip # Reason: Please assess for interval improvement of CHF.,0
"Admitting Diagnosis: CHF EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with SOB, h/o HOCM s/p ethanol ablation and CHF.",0
REASON FOR THIS EXAMINATION: Please assess for interval improvement of CHF.,0
______________________________________________________________________________ FINAL REPORT History of CHF.,0
There is cardiomegaly but no definite CHF.,0
A left sided dual chamber pacemaker is present with atrial and ventricular leads in situ in good location on this single view.,1
No pulmonary consolidation or pneumothorax.,0
IMPRESSION: No evidence of CHF.,0
"8:19 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change since film - re:consolit Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 57 yo man with NHL s/p R vats, pleural bx and decortication returned w/ empyema now s/p R thoracic window, CXR showing worsening of opacities REASON FOR THIS EXAMINATION: please eval for interval change since film - re:consolitations and cardio pulm status ______________________________________________________________________________ FINAL REPORT INDICATION: Non-Hodgkin lymphoma status post right VATS and pleural biopsy, status post right thoracic window.",1
"AP chest radiograph shows tracheostomy tube, right-sided central line, left- sided IJ line, and nasogastric tube in stable position.",0
The tip of a right chest tube overlies the apex and a left pleural tube is looped at the base.,0
"There has been mild interval improvement of the previously described right middle lobe opacity, with today's study appearing similar in appearance to the study.",0
"Again seen is an externalized right pleural space with pleural thickening, unchanged from prior studies.",0
"A pleural air and fluid loculation persists at the left base, despite the drainage tube.",0
There has been mild increase in the left perihilar opacity.,0
"IMPRESSION: Mild improvement of right middle lobe opacity with interval increase in left perihilar opacity, suggest redistribution of edema, alternatively changing bilateral pneumonia.",0
"Name: , G. Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Iodine Containing Agents Classifier Attending: Addendum: after evaluation by physical thearphy and case manadment pantienty was ammendable to go to rheb.",0
Bed was avaible and patient was transfered to rehab in stable condition..,0
Discharge Disposition: Extended Care Facility: MD Completed by:,0
1:50 PM CTA HEAD W&W/O C & RECONS Clip # Reason: evaluate for change in basilar artery thrombosis Admitting Diagnosis: BASILLAR OCCLUSION Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with basilar artery thrombosis and R pontine stroke.,1
"REASON FOR THIS EXAMINATION: evaluate for change in basilar artery thrombosis No contraindications for IV contrast ______________________________________________________________________________ WET READ: MON 5:55 PM Slight increase in the extent of opacified basilar artery, indicating increased flow.",1
"A large degree of the basilar artery is still occluded, however.",1
"Focal 4-mm dilation of the left A2 arterial segment is likely due to patulousness at a branch point, although an aneurysm (less likely) is also possible.",0
Please see the full report for details.,0
______________________________________________________________________________ FINAL REPORT INDICATION: History of basilar artery thrombosis and right pontine stroke.,1
Evaluate for change in basilar artery thrombosis.,1
TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast.,0
"Subsequently, rapid axial images were acquired from the level of the foramen magnum through the brain during administration of intravenous contrast.",0
3D volume-rendered and curved reformatted images were created on an independent workstation.,0
COMPARISON: CTA head/neck from .,0
"FINDINGS: There is an increase in the length of opacified basilar artery, consistent with improved flow, compared to , although a significant portion of the basilar artery is still occluded.",1
"Hypodensity in the right aspect of the pons is seen, but was better visualized on MR from .",0
"There is an area of focal dilatation, measuring 4 mm in diameter, along the left A2 arterial segment that is seen at a branch point and most likely represents a patulous branch point, rather than an aneurysm.",0
"Excluding the previously mentioned basilar artery occlusion, no additional areas of occlusion, dissection, or aneurysm are seen in the anterior or posterior intracranial arterial circulations.",1
"Opacification of the right sphenoid sinus, multiple right ethmoidal air cells, and the frontal sinuses bilaterally are not significantly changed compared to .",0
"Slight increase in flow within the basilar artery, although a significant segment of the basilar artery is still occluded.",1
"Likely patulous left A2 arterial segment, centered at a branch point.",0
"(Over) 1:50 PM CTA HEAD W&W/O C & RECONS Clip # Reason: evaluate for change in basilar artery thrombosis Admitting Diagnosis: BASILLAR OCCLUSION Contrast: OPTIRAY Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) Less likely, this focal dilation could be a small, asymptomatic aneurysm.",1
"Opacification of the right maxillary sinus, multiple right ethmoidal air cells, and the frontal sinuses bilaterally could represent an ongoing inflammatory process.",0
Status: Inpatient Date/Time: at 14:42 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
Right-to-left shunt across the interatrial septum at rest.,0
AORTIC VALVE: Large vegetation on aortic valve.,1
Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets.,1
A right-to-left shunt across the interatrial septum is seen at rest.,0
Overall left ventricular systolic function is moderately depressed (LVEF= XX %).,0
"The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to XX cm from the incisors.",0
There is a large vegetation on the aortic valve.,1
There is a moderate-sized vegetation on the mitral valve.,1
Improved left and right ventricular systolci function with background inotropic support (Epinephrine) 2.,0
Bileaflet maechanical valves seen in mitral aortic position.,1
Well seated and stable with good lealflet excursion with mild valvular regurgitation jets (Washing jets) 3.,0
Minimal gradients across the prosthetic valves in aortic and mitral position.,1
Progressive worsening of trisuspid regurgitation (central) after separation from CPB with associated systolic reversal of hepatic venous flow.,1
"No lealfelt avulsion/restriction visualized, but necessitated re-institution of CPB.",0
"POST CPB#2 1, Annuloplqasty ring seen in the tricuspid position.",0
"Good leaflet excursion and mnimal gradient, with trace trisuspid regurgitation.",0
2:46 PM PORTABLE ABDOMEN Clip # Reason: please assess Dobhoff replacement for post-pyloric location Admitting Diagnosis: VENTRAL HERNIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with REASON FOR THIS EXAMINATION: please assess Dobhoff replacement for post-pyloric location ______________________________________________________________________________ FINAL REPORT INDICATIONS: For feeding tube placement.,0
PORTABLE AP CHEST: Distal end of feeding tube overlies 2nd portion of duodenum.,0
12:19 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: follow up Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;CEBREBRAL CONTUSION;S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with bifrontal contusions.,1
"REASON FOR THIS EXAMINATION: follow up No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 2:06 PM PFI: In comparison with the most recent examination dated at 0051 hours, again there is persistence of scattered ill-defined hyperdense foci in the bilateral inferior frontal lobes, compatible with hemorrhagic post-traumatic contusions, unchanged hyperdense attenuation at the vermis and along the left tentorium, may represent acute hemorrhage, and unchanged since the most recent study.",1
The previously described possible left frontal roof fracture is not confirmed in this study.,0
Unchanged left sphenoid sinus mucosal thickening.,0
The previously described small pneumocephalus on the left occipital region is not identified.,0
"Persistent effacement of the sulci, more significant at the convexity, apparently unchanged, followup is recommended.",0
Surgical staples are identified at the left parietal soft tissues.,0
______________________________________________________________________________ FINAL REPORT STUDY: CT of the head without contrast.,0
"CLINICAL INDICATION: 50-year-old woman with bifrontal contusions, followup examination.",0
COMPARISON: Prior CT of the head performed on at 00:51 hours.,0
"FINDINGS: Since the most recent study at 00:51 hours, there is persistent ill- defined hyperdense foci in the bilateral inferior frontal lobe, likely consistent with post-traumatic hemorrhagic contusion.",0
"There is persistent hyperdense attenuation in the region of the vermis and along the left tentorium, likely consistent with acute subarachnoid and subdural hemorrhage, unchanged.",1
"The possible left orbital roof fracture is not confirmed in this examination, persistent left sphenoid sinus mucosal thickening.",0
The previously small pneumocephalus at the left occipital region is not identified.,0
"No new lesions are visualized, persistent effacement of the sulci and edema at the convexity, surgical staples are noted at the left parietal region, unchanged right temporal bone complex fractures with mucosal thickening and soft tissue density at the right middle ear, patchy opacities are noted also on the left mastoid air cells, unchanged.",1
There is no evidence of acute hydrocephalus or shifting of the normally midline structures.,0
The foramen magnum appears patent.,0
"IMPRESSION: Unchanged ill- defined hyperdense foci in the bilateral inferior (Over) 12:19 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: follow up Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;CEBREBRAL CONTUSION;S/P FALL ______________________________________________________________________________ FINAL REPORT (Cont) frontal lobe, likely consistent with post-traumatic hemorrhagic contusions The possible left orbital roof fracture is not confirmed in this study, please correlate with the dedicated maxillofacial CT.",1
The small pneumocephalus at the left occipital region is not identified.,0
"Unchanged right temporal bone complex fractures with mucosal thickening and soft tissue density at the right middle ear, patchy opacities are noted also on the left mastoid air cells, unchanged.",1
Height: (in) 78 Weight (lb): 180 BSA (m2): 2.16 m2 BP (mm Hg): 119/78 HR (bpm): 64 Status: Inpatient Date/Time: at 12:05 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
The aortic valve may be functionally bicuspid with fusion of the right and left coronary cusps.,0
"If clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations.",0
"4:09 PM BABYGRAM (CHEST ONLY) PORT Clip # Reason: evaluate lung fields, neck Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with stridor REASON FOR THIS EXAMINATION: evaluate lung fields, neck ______________________________________________________________________________ FINAL REPORT PORTABLE VIEW OF THE CHEST CLINICAL HISTORY: One-day-old infant with stridor.",0
The cardiothymic contours are normal.,0
The lungs are somewhat low volume but clear bilaterally.,0
The trachea is not well visualized on this view.,0
Height: (in) 61 Weight (lb): 155 BSA (m2): 1.70 m2 Status: Inpatient Date/Time: at 09:26 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo; septal apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size.,0
"There are bilateral pleural of significant size, right greater than left.",0
POST-BYPASS: The patient is A-paced and on infusions of phenylephrine and epinephrine.,0
Left ventricular function is preserved.,0
The right ventricle is now mildly hypokinetic.,0
The bilateral pleural effusions have been drained.,0
"7:21 PM CHEST (PA & LAT) Clip # Reason: ?PNA Admitting Diagnosis: OPEN FRACTURE,LEFT LEG ______________________________________________________________________________ MEDICAL CONDITION: 49 year old man with fever REASON FOR THIS EXAMINATION: ?PNA ______________________________________________________________________________ FINAL REPORT INDICATIONS: 49-year-old man with fever, question pneumonia.",0
"CHEST, PA AND LATERAL: Comparison is made to .",0
"Since that time, the nasogastric and endotracheal tubes have been removed.",0
"The study is a PA and lateral but is suboptimal in terms of technique, as the right base of the thorax is not visualized, and the lung volumes are very low.",0
There are bilateral consolidations with upper zone predominance.,0
"This appearance could represent aspiration, multifocal pneumonia, or CHF, depending on the clinical setting.",0
"IMPRESSION: Bilateral alveolar opacities suggesting either aspiration, pneumonia, or CHF.",0
Height: (in) 74 Weight (lb): 230 BSA (m2): 2.31 m2 BP (mm Hg): 155/63 HR (bpm): 69 Status: Inpatient Date/Time: at 12:35 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
IMPRESSION: Mild symmetric left venticular hypertrophy with preserved global biventricular systolic function.,0
Admission Date: Discharge Date: Service: Cardiology HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old woman with a history of dilated ischemic cardiomyopathy who had been in her usual good state of health.,0
She went to a wedding on .,0
Following this she had dizziness while sitting down.,0
"She took a sublingual nitroglycerin tablet and felt worse, diaphoretic, and went to Hospital via Emergency Medical Service.",0
She was asymptomatic by arrival to their Emergency Room.,0
She experienced no pain during any of this.,0
While at Hospital on telemetry she had a run of wide complex tachycardia associated with hypotension to a systolic blood pressure of 80s.,0
She was started on intravenous amiodarone and planned for transfer to .,0
She did not have recurrence of the tachycardia after the amiodarone was started.,0
"She did, however, have bradycardia to a heart rate in the 40s and hypotension again to a systolic blood pressure in the 80s.",0
Amiodarone intravenously was given at 1 mg per minute from 1430 to 2230 on .,0
Amiodarone at 0.5 mg per minute was given from 2230 until arrival at at midnight when the bottle broke on transfer.,0
She has had some increased of shortness of breath with exertion over the past two months as well as a cold which has totally resolved.,0
"She denied headache, chest pain, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, abdominal pain, nausea, vomiting, dysuria or back pain.",0
She gets short of breath at one flight of stairs but is able to work out for 10 minutes on a stationary bike.,0
PAST MEDICAL HISTORY: (Previous medical history is significant for) 1.,0
"Coronary artery disease, status post myocardial infarction in , complicated by cardiogenic shock.",0
"Status post cardiac catheterization in with a normal right coronary artery, 70% proximal left anterior descending artery, 100% middle left anterior descending artery, a normal left circumflex, and diffuse second obtuse marginal.",0
"Cardiac stress test in with large fixed abnormalities involving anterior wall, lateral wall near the cardiac apex and sputum, mild reversible abnormality of the inferior wall, marked ventricular chamber dilatation with global diffuse hypokinesis and decreased ejection fraction of 13%.",1
Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy.,0
Peptic ulcer disease with a history of bleeding; last bleeding was greater than 30 years ago.,0
"Paroxysmal atrial fibrillation; echocardiogram on , revealed left ventricular ejection fraction of 10%, depressed right ventricular ejection fraction, 1+ mitral regurgitation, trace aortic insufficiency, entire intraventricular septum and anterior wall were thin, fibrotic and akinetic, apex was frankly dyskinetic; all other segments of the left ventricle were severely hypokinetic and extensive spontaneous echocontrast throughout the left ventricular cavity consistent with an old mural thrombus.",1
MEDICATIONS ON ADMISSION: Her medications at home include Lopressor 12.5 mg p.o.,0
"b.i.d., aspirin 81 mg p.o.",0
"q.d., digoxin 0.125 mg p.o.",0
"(held on admission), Coumadin 3 mg p.o.",0
"(held on admission), amiodarone 200 mg p.o.",0
"on Monday, Wednesday and Friday (was admitted on intravenous amiodarone at 0.5 mg per minute), Synthroid 75 mcg p.o.",0
"q.d., Zestril 20 mg p.o.",0
"q.d., Timoptic 0.5% OU q.h.s., Lovenox 50 mg p.o.",0
ALLERGIES: There were no known drug allergies.,0
SOCIAL HISTORY: The patient is widowed.,0
"Formerly worked managing a law firm, but retired at age 55.",0
Lives in apartment at Community Center in .,0
"Works out on machines, 10 minutes on a stationary bike.",0
Smoked an unclear amount from 17 until 52.,0
"PHYSICAL EXAMINATION ON ADMISSION: On examination, the patient was comfortable, wearing lipstick, talking on the phone.",0
"Temperature 98, heart rate 54, blood pressure 103/49, respiratory rate 19, saturating 96% on 2 liters.",0
Moist mucous membranes without lesions.,0
Jugular venous distention was observed at 6 cm.,0
"On heart examination, there was a dyskinetic point of maximal impulse laterally displaced.",0
"Rate was regular, soft S4, soft holosystolic murmur at the apex.",0
Examination of the lungs revealed crackles one-quarter of the way up.,0
"The abdomen was soft, nontender, and nondistended, normal active bowel sounds.",0
"Extremities revealed no edema, and 2+ dorsalis pedis pulses.",0
"LABORATORY DATA ON ADMISSION: Laboratories on admission were significant for a hematocrit of 34.1, with a MCV of 88.",0
"An INR of 3.4, and digoxin level of 1.3.",0
"RADIOLOGY/IMAGING: Her electrocardiogram showed somewhat broad complex tachycardia at 130 msec, QRS of right bundle-branch block type, RS complex was absent in all precordial leads with Q waves across the precordium.",0
Also in lead II probable AD disassociation.,0
"Her electrocardiogram on arrival at showed normal sinus rhythm with a long P-R, slightly broad QRS, poor R wave progression, and a left axis.",0
HOSPITAL COURSE: The patient was admitted with probable ventricular tachycardia or accelerated idioventricular rhythm and was referred to the Electrophysiology Service for evaluation.,1
An addendum to this dictation is to follow.,0
Dictated By: MEDQUIST36 D: 13:45 T: 19:36 JOB#: (cclist),0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Bloody pleural effusion in OSH, SOB Major Surgical or Invasive Procedure: VATS (Video assisted thorascopic surgery) and lung biopsy Insertion of hemodialysis catheter Cardiac arrest requiring CPR and electric cardioversion.",1
"History of Present Illness: This pt is a 60 y/o F with history of CKD, HTN, without treatment for either, who presents with 6 months of unintentional wt loss, increasing SOB on exertion, and increasing LE edema.",0
"She presented to a new PCP, sent her to ED where a large loculated left pleural effusion was found and 1L bloody effusion was removed ().",1
"CT scan from OSH showed no masses in abdomen or pelvis, only effusion in left lower lung.",0
"Since , the patient has had 85 pounds of unintentional wt loss.",0
She had shortness of breath on exertion after walking about 40 feet.,0
"patient had dependent edema at baseline, which she says has been worsenign over the past 2-3 months.",0
"She also c/o fatigue, decreased appetite.",0
"Patient went to the doctor several years ago, and was noted to have elevated creatinine, likely chronic renal failure from htn.",1
"Pt says she has occassional elevated blood pressure, and does not take medication for it.",0
She did not follow up the chronic kidney disease.,1
Patient has never had colonoscopy or mammogram.,0
Does not see doctor regularly.,0
"In our ED, VS 95 174/80 95% RA.",0
CXR w large left sided effusion.,0
"On ROS: denies dysuria, hematuria, or noted sediment/discharge.",0
"No HA, vision changes, no LAD, no CP palpitations, no abd pain, no const/diarrhea.",0
"Past Medical History: nephrolithiasis 4yrs ago HTN - Noted several times, but sometimes also normotensive, thus never took meds for this.",0
"CKD - noticed several years ago, never treated, never followed up.",0
Osteoarthritis Social History: lives with mother.,0
: case manager at NH currently.,0
"Family History: Colon ca in 52, GM 60 Lung ca in GF 65 Afib mom TIA mom DM sister and 2 Celiac, sogrens sister Physical Exam: 98, 166/92 HR 96 18 97% 2L Gen: pleasant, appears older than stated age.",0
"HEENT: anicteric, MMM, OP clear.",0
"Neck: no LAD, supple, postive JVD breast; large 3x5 cm right breast mass reportedly unchanged for over 20 years CV: II/VI SEM LUSB, nl S1S2 Reg, tachy Chest: decreased BS left base, +e->a egophany LLL, decreased fremetus LLL.",0
otherwise clear Abd: no CVA tenderness.,0
no masses Ext: mild edema.,0
"bilat very tender legs Lymphs: full cervical, inguinal, and axillary neg OB neg NEURO: AAO x3 Pertinent Results: 06:45PM WBC-10.7 RBC-2.97* HGB-8.5* HCT-27.0* MCV-91 MCH-28.6 MCHC-31.5 RDW-18.8* 06:45PM NEUTS-71.6* LYMPHS-21.1 MONOS-4.1 EOS-2.7 BASOS-0.5 06:45PM PLT COUNT-452* 06:45PM PT-13.1 PTT-27.3 INR(PT)-1.1 06:45PM GLUCOSE-80 UREA N-74* CREAT-6.1* SODIUM-136 POTASSIUM-5.4* CHLORIDE-110* TOTAL CO2-12* ANION GAP-19 .",0
Renal U/S RENAL ULTRASOUND: The right kidney measures 8.6 cm.,1
The left kidney measures 7.2 cm.,0
There is increased echogenicity of the renal sinuses and thinning of the cortex bilaterally.,0
There are no stones or hydronephrosis.,0
A 1.4 x 1.1 cm cyst is seen within the lower pole of the right kidney.,0
A partially full bladder is unremarkable.,0
IMPRESSION: Atrophic kidneys bilaterally consistent with chronic medical-renal disease.,1
CT Abdomen/Pelvis with contrast CT CHEST FINDINGS: Some subcentimeter mediastinal lymph nodes are noted that are not pathological by size criteria.,0
The main pulmonary artery is prominent at 3.2 cm with a maximum diameter of the right pulmonary artery measuring 2.8 cm.,0
There is some vascular calcification noted.,0
There is volume loss in the left hemithorax.,0
There is a left pleural effusion which extends circumferentially around the lateral side of the chest wall.,1
There is a slightly thickened rim of parietal pleura just adjacent to the chest wall in relation to this pleural effusion.,1
There is associated atelectasis; superimposed consolidation cannot be excluded.,0
There are calcified pleural plaques noted suggesting a history of asbestos exposure.,0
"CT ABDOMEN FINDINGS: Given that this is a non-contrast CT, the liver and spleen are normal.",0
There is calcification of the splenic vasculature.,0
The kidneys are reduced in size.,0
Some areas of low attenuation are seen in the right kidney which may be consistent with cysts.,0
Some tiny scattered punctate areas of high attenuation are seen in relation to the kidneys bilaterally which represent calculi that are nonobstructing.,0
CT PELVIS FINDINGS: Note is made of diverticulosis without evidence of diverticulitis especially in the sigmoid colon.,0
Bony windows reveal some degenerative changes at the L5-S1 level.,0
Volume loss in left hemithorax with moderate-sized left pleural effusion and associated collapse and atelectasis but no definite mass identified.,1
No evidence of high attenuation in pleural fluid to suggest recent hemorrhage.,0
Thickening of the parietal pleura surrounding the left pleural effusion.,1
Prominent pulmonary artery which may suggest pulmonary hypertension.,0
Renal cysts and nonobstructing calculi.,0
Echocardiogram Conclusions: The left atrium is normal in size.,0
IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function.,0
Venous duplex IMPRESSION: Right cephalic and basilic veins are patent.,0
The left basilic vein is patent and the left cephalic vein is clotted at the level of the forearm.,0
Persistent left loculated pneumothorax with air leaking along the chest wall into the subcutaneous tissue.,0
Bronchopleural fistula cannot be excluded.,1
Overall slight decrease in the amount of the right pleural effusion.,1
"Right pleural effusion, slightly increase in size, accompanied by left lower lobe atelectasis.",1
"New multiple bilateral, right more than left consolidations, which may represent aspiration and/or pneumonia.",0
Improvement of aeration of the left upper lobe compared to the most recent chest radiograph.,0
CXR REASON FOR EXAMINATION: Followup of a patient with known loculated hydropneumothorax on the left.,0
"PA and lateral upright chest radiograph compared to , .",0
The loculated left hydropneumothorax is unchanged.,0
"The right pleural effusion is small-to-moderate, unchanged.",1
The right lung is unremarkable as well as the left upper lung.,0
Subcutaneous emphysema within the left chest wall is stable.,0
IMPRESSION: No evidence of interval change.,0
"Brief Hospital Course: 60 y/o F with history of HTN and CKD (untreated) who presented with increasing SOB, bloody pleural effussion, and concern for ARF.",0
VATS for decortication and biopsy was attempted however had to be aborted as patient went into cardiac arrest PEA v. asystole v. fine vfib arrest she was resuscitated and transferred to MICU for continued care.,1
She had an elevation in cardiac enzymes following this event felt most likely due to cardiac defibrillation rather than ACS.,0
Renal function was worsened following this event and patient had to be started on hemodialysis for treatment on volume overload and uremia.,0
She also had a chest tube in place to treat her persistent pleural effusions.,1
The chest tube was removed prior to discharge which she tolerated well.,0
"Prior to discharge, outpatient hemodialysis was arranged as well as contact for consideration of peritoneal dialysis.",0
Brief Hospital Course by Problem: .,0
"#Persistent Bloody pleural effusion: On admission, VATS attempted for biopsy and decortication however the procedure had to be aborted due to cardiac arrest.",1
"Tissue sample and pleural fluid was obtained and was negative for AFB, fungus, bacteria, malignancy.",0
She had a chest tube placed in the OR following biopsy.,0
This was left in place with considerable drainage of bloody fluid.,0
Chest tube was removed prior to discharge which she tolerated without event.,0
She continued to have bilateral persistent pleural effusions and she was discharge on oxygen as she desaturated on ambulation.,1
She will follow up with Dr. .,0
hospital/ventillator acquired pneumonia - during MICU stay she was noted to have infiltrate felt most likely to be due to hopital/ventillator acquired pneumonia.,0
She was treated with 2 week course of cefepime and vancomycin with last dose on .,0
She was discharged on levofloxacin and vancomycin dosed with dialysis to complete course of treatment.,0
Acute renal on end stage renal failure - on admission she had end stage renal failure with likely hemodialysis in the near future however her renal function was significantly worsened following her cardiac arrest.,1
She did not recover any significant renal function in the days following the event and she was started on hemodialysis for treatment of uremia and volume overload.,0
She tolerated dialysis well and was discharge with outpatient hemodialysis and appointment to discuss option of peritoneal dialysis.,0
She was treated with epogen and iron with dialysis for anemia.,0
In addition she was started on nephrocaps and renagel.,0
#s/p asystolic/VF arrest at time of lung bipsy with NSTEMI and troponins up to 0.5- most likely cardioversion with resuscitation.,0
"She was started on metoprolol, ASA and lisinopril prior to discharge.",0
She opted not to have inpatient stress test to further evaluate risk for cardiac ishemia however agreed to have her primary care physician arrange this as an outpatient.,0
Echocardiogram showed low normal EF at 50% without focal wall motion abnormalities.,0
#Left cephalic vein clot on prior UE u/s - likely related to prior PICC on that side.,0
She refused repeat ultrasound to asses for extension or resolution of clot but agreed to have her primary care doctor arrange as an outpatient.,0
#.Weight loss- significant unintentional weight loss prior to admission.,0
"Pleural fluid without evidence of malignancy, no LAD or fevers/sweats.",0
No prior colonoscopy or mammogram.,0
"Concern for lipoma vs. breast mass, per pt-breast mass on R side has not grown, no bx done but U/S done in past.",0
Pt with family h/o colon CA.,0
She agreed to follow up with colonoscopy and mammogram as an outpatient.,0
"Anemia - ACD secondary to renal disease, stable hematocrit throughout admission.",1
Treated with epogen and iron with dialysis.,0
She will follow up with colonoscopy as outpatient.,0
CODE: DNR/DNI discussed Medications on Admission: tylenol daily for OA Discharge Medications: 1. mammogram bilateral mammogram.,0
Pt has never had one.,0
"H/O R.breast ""lipoma"" 2. colonoscopy Screening and diagnostic colonoscopy.",0
3. gynecology Pt needs gyn appointment/referral for complete pelvic exam and pap smear.,0
"Disp:*30 Tablet, Chewable(s)* Refills:*2* 5.",0
Vancomycin 500 mg Recon Soln Sig: per dialysis protocol based on trough Recon Soln Intravenous ONCE (Once) for 1 doses: you should get one additional dose of vancomycin with dialysis on based on your trough.,0
This will complete your course of vancomycin.,0
Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four to six hours as needed as needed for shortness of breath or wheezing.,0
Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).,0
"Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 days: take this pill on , then you are finished with your antibiotics.",0
"Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Nursing Services Discharge Diagnosis: CArdiac arrest Pleural Effusion, hydropneumothorax s/p Hospital acquired pneumonia Acute renal failure CKD V on hemodialysis HTN minor: breast lipoma Anemia from chronic kidney disease Discharge Condition: good Discharge Instructions: You were admitted because you were found to have a bloody pleural effusion.",1
In addition you had hypertension and chronic kidney disease that were not treated.,1
"A bloody pleural effusion can be a sign of malignancy, however the diagnostic studies have not shown any evidence of malignancy.",1
"However, you will need to have a mammogram and breast ultrasound, a pelvic exam and pap smear to continue to evaluate for any evidence of cancer.",0
You will also need a colonoscopy as you have not yet had these exams.,0
It is important that you take your medications as prescribed and follow up with the appointments below.,0
"In addition, you had a cardiac arrest during the lung biopsy procedure that you had.",1
"It is unclear why this happended to you but as we discussed, we feel that you should have further work up to make sure that you do not have coronary artery disease.",0
We wanted to do a stress test for your heart in the hospital however you opted not to have that.,0
Please ask your primary care doctor to arrange for you to have that test as an outpatient.,0
You are now on hemodialysis to treat your kidney failure.,1
Please follow up with dialysis as arranged.,0
In addition you have an appointment with the kidney doctor as listed below.,0
You should also follow up with the lung doctors as listed below.,0
You have a blood clot in the cephalic vein of your left arm.,0
Please ask your doctor an ultrasound to re-evaluate this to make sure that it has not gotten any larger.,0
You have some new medications including lipitor and lisinopril.,0
Please have your doctor check your liver enzymes and a chemistry panel at your appointment.,0
will be contacting you to set up follow up to discuss peritoneal dialysis.,0
"Call your doctor or return to the hospital if you experience any concerning symptoms including shortness of breath, chest pain, fever, worsening cough, or any other concerning symptoms.",0
"Followup Instructions: You will be having dialysis treatments at Physicians Dialysis, INC in , MA.",0
", PH# on monday wednesday and friday.",0
You will be getting one more dose of vancomycin at your dialysis appointment on monday based on your trough level.,0
"Provider: , MD Phone: Date/Time: 3:00 2.",0
You have an appointment with your PCP .,0
"on at 1:30 for treatment of your high blood pressure, kidney disease and to fascilitate mammography, breast ultrasound, colonoscopy, and gyn exam.",1
"In addition, please ask him to set up an appointment for a stress test for your heart.",0
You also need a repeat ultrasound of your arm to follow up on the blood clot that was seen in your left cephalic vein.,0
"Provider: , MD Phone: Date/Time: 9:30.",0
This appointment is to follow up from the chest tube.,0
The phone number to call and reschedule this appointment is .,0
"7:58 AM BILAT LOWER EXT VEINS Clip # Reason: SWELLING, R/O DVT Admitting Diagnosis: MOTOR VEHICLE ACCIDENT WITH UNSPECIFIED INJURIES ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with multi-trauma REASON FOR THIS EXAMINATION: r/o dvt ______________________________________________________________________________ FINAL REPORT INDICATION: 21-year-old with multi-trauma.",1
"BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler examination of the right and left common femoral, superficial femoral and popliteal veins were performed and demonstrate normal compressibility, augmentability and respiratory variation in flow.",0
IMPRESSION: No deep venous thrombosis involving the right or left lower extremity.,0
5:28 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: T12 BURST FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with respiratory failure s/p t11 - l1 fusion.,0
"REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Respiratory failure, status post T1-L1 fusion.",0
Right lower lobe collapse is new.,1
Left lower lobe opacities consistent with atelectasis are unchanged.,0
Left chest tube remains in place.,0
"Of note, the apices of the lungs were not included on the film and apical pneumothoraces cannot be excluded.",0
If any there are small bilateral pleural effusions.,0
ET tube tip is 3.7 cm above the carina.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: - Coronary bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the second obtuse marginal coronary artery; as well as reverse saphenous vein single graft from aorta to distal right coronary artery.,1
Resection of left atrial appendage.,0
History of Present Illness: Mr. is a 83 year old male with a 2 month history of dyspnea on exertion.,0
He was referred for cardiac catheterization after echo showed depressed LV function with an ejection fraction of 20-25%.,0
"Echocardiogram also notable for + mitral regurgitation, moderate tricuspid regurgitation and moderate pulmonary hypertension.",1
Subsequent cardiac catheterization was significant for left main and three vessel disease.,0
He is now admitted for surgical revascularization.,0
"Past Medical History: Coronary Artery Disease, Ischemic Cardiomyopathy Silent MI Hypertension GOUT Type 2 diabetes - diet controlled GERD Hypertriglyceridemia Duodenal ulcer/GI bleeding Asthma/Asbestosis Squamous Cell CA Mild Depression Right inguinal hernia repair Colonic polyps Industrial Accident with crushed/fractured pelvis Bell's palsy Chronic pain s/p pelvic fracture/crushing injury Mild arthritis/knees Social History: -Tobacco history: Prior smoking history 30 years ago.",1
-ETOH: Rare glass of wine.,0
He lives in MA with his wife .,0
Previously worked in a candy factory and was also an iron worker.,0
"Physical Exam: Pulse:81 Resp: 16 O2 sat: B/P Right:165/88 Left: Height:5'6"" Weight:162 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] No Murmur, frequent skipped beats Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Right 1+ Left none Varicosities: None [x] Neuro: Grossly intact[x] A&Ox3, MAE, follows commands Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 2+ PT : 1+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: none Left: none Pertinent Results: Intraop TEE: PRE-BYPASS: The left atrium is dilated.",1
Moderate to severe spontaneous echo contrast is present in the left atrial appendage.,0
A patent foramen ovale is present.Left ventricular wall thicknesses are normal.,0
There is severe regional left ventricular systolic dysfunction in mid to apical segments and especially in the RCA territory.,0
There is moderate to severe global left ventricular hypokinesis (LVEF = 20 %).,0
"Discharge Chest X-ray, PA and Lat: Moderate enlargement of the cardiac silhouette is stable since preoperative study and small right pleural effusion has been present throughout.",0
Extremely heavy asbestos-related pleural calcification obscures large areas of the lung.,0
Mediastinum has a stable and unremarkable postoperative appearance.,0
Atherosclerotic calcification in the aorta and innominate artery is very heavy.,0
Bloodwork: WBC-8.7 RBC-2.98* Hgb-8.4* Hct-26.4* RDW-16.1* Plt Ct-222 WBC-8.5 RBC-3.06* Hgb-8.6* Hct-26.5* RDW-15.4 Plt Ct-163 WBC-9.8 RBC-2.98* Hgb-8.4* Hct-25.5* RDW-14.9 Plt Ct-116* WBC-9.5 RBC-3.02* Hgb-8.6* Hct-25.8* RDW-14.4 Plt Ct-97* WBC-9.8# RBC-3.04*# Hgb-8.5*# Hct-25.6* RDW-14.5 Plt Ct-129* PT-21.1* INR(PT)-2.0* PT-19.4* INR(PT)-1.8* PT-15.1* INR(PT)-1.3* PT-16.1* PTT-36.9* INR(PT)-1.4* Glucose-123* UreaN-34* Creat-1.4* Na-140 K-4.6 Cl-103 HCO3-26 Glucose-111* UreaN-39* Creat-1.4* Na-141 K-3.8 Cl-101 HCO3-28 Glucose-100 UreaN-35* Creat-1.3* Na-139 K-3.6 Cl-101 HCO3-29 Glucose-128* UreaN-26* Creat-1.1 Na-135 K-4.7 Cl-104 HCO3-22 Glucose-75 UreaN-25* Creat-0.8 Na-139 K-4.4 Cl-109* HCO3-23 04:50AM BLOOD Mg-1.9 Warfarin doses: - 1mg - 2mg - 2mg - 2mg Brief Hospital Course: Mr. was admitted to the on for surgical management of his coronary artery disease.,1
He was taken to the the operating room where he underwent coronary artery bypass grafting to four vessels as well as resection of his left atrial appendage.,1
Postoperatively he was taken to the cardiac surgical intensive care unit.,1
"On postoperative day one, he awoke neurologically intact and was extubated.",0
He developed atrial fibrillation as well as non-sustained ventricular tachycardia which was treated with Amiodarone.,1
"Given his low ejection fraction and ventricular ectopy, the electrophysiology service was consulted.",0
"It was initially decided that if his ejection fraction remained below 40% 2 months after surgery by echoacrdiogram, then a primary prevention AICD would be placed.",0
"Given his poor ejection fraction, Warfarin anticoagulation was initiated with a goal INR between 1.5 - 2.5.",0
"On postoperative day three, he was transferred to the step down unit for further recovery.",0
Despite his poor ejection fraction he was unable to be started on an ACE-I due to a systolic blood pressure in the 90s.,0
"Prior to discharge, EP study was performed and negative for inducible sustained ventricular arrhythmias.",0
Therefore AICD was not recommended at this time with recommendations to advance beta blockade as tolerated.,0
"By post-operative day six, he was medically cleared for discharge to home.",0
"Prior to discharge, arrangements were made and confirmed with Dr. for outpatient management of Warfarin.",0
"Medications on Admission: albuterol MDI 2 puffs prn, atenolol 50mg daily, econazole 1%cream PRN, gemfibrozil 600mg twice daily, HCTZ 25mg daily, prilosec 20mg daily PRN Discharge Medications: 1.",0
Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain.,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days.,0
Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"Prilosec OTC 20 mg Tablet, Delayed Release (E.C.)",0
"Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 pills (400mg total) daily for one week, then decrease to 1 pill (200mg total) ongoing.",0
Coumadin 2 mg Tablet Sig: 0.5 Tablet PO once a day: take as directed by the office of Dr. phone Fax: .,0
INR to be drawn on .,0
INR goal for low EF is 1.5 to 2.5. .,0
Outpatient Lab Work INR to be drawn on .,0
Lab results to be sent to the office of Dr. phone Fax: .,0
INR goal for low EF is 1.5 to 2.5.,0
"Discharge Disposition: Home With Service Facility: homecare Discharge Diagnosis: Coronary artery disease, s/p CABG Chronic Systolic Congestive Heart Failure, LVEF 20-25% Postop Nonsustained Ventricular Tachycardia(EP study negative) Postop Atrial Fibrillation - resolved Mitral Regurgitation Tricuspid Regurgitation History of silent MI Hypertension Type II DM - diet controlled Dyslipidemia Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection.",1
7) INR to be followed by the office of Dr. phone Fax: .,0
Plan confirmed with Dr. on .,0
8) Call with any questions or concerns.,0
( Please follow-up with Dr. in weeks.,0
Please follow-up with Dr. in 8 weeks.,0
INR to be followed by the office of Dr. phone Fax: .,0
Please call above providers to schedule appointment.,0
"Scheduled appointments: Provider: , MD Phone: Date/Time: 8:30 Provider: .",0
", DPM Phone: Date/Time: 8:40 Completed by:",0
PATIENT/TEST INFORMATION: Indication: Pulmonary embolus.,0
Height: (in) 68 Weight (lb): 158 BSA (m2): 1.85 m2 BP (mm Hg): 448/ HR (bpm): 73 Status: Inpatient Date/Time: at 15:31 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LVOT gradient increases with Valsalva.,0
The gradient increased with the Valsalva maneuver.,0
The right ventricular cavity is moderately dilated with severe global free wall hypokinesis.,0
"There is apparent ""preservation"" of the RV apex function ("" sign), consistent with acute pulmonary hypertension, as in pulmonary embolism.",1
"IMPRESSION: Dilated and hypokinetic right ventricle in a pattern, consistent with acute pulmonary hypertension.",1
Small and underfilled left ventricle with functional outflow obstruction.,0
Findings discussed with Dr. at 1700 hours on the day of the study.,0
9:42 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval OG placement Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with intubation REASON FOR THIS EXAMINATION: eval OG placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess OG tube.,0
Comparison is made to prior study from 7 hours earlier.,0
There is no other interval change.,0
"7:52 PM CHEST (PA & LAT) Clip # Reason: ?PNA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with MS changes, chest pain REASON FOR THIS EXAMINATION: ?PNA ______________________________________________________________________________ FINAL REPORT CHEST (PA AND LATERAL) INDICATION: History of mental status changes with chest pain, evaluate for pneumonia.",0
PA AND LATERAL CHEST RADIOGRAPHS: Lung fields are clear.,0
"Again, seen are median sternotomy wires and clips from prior CABG.",0
Height: (in) 64 Weight (lb): 154 BSA (m2): 1.75 m2 BP (mm Hg): 95/51 HR (bpm): 77 Status: Inpatient Date/Time: at 10:48 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - akinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
GENERAL COMMENTS: Frequent ventricular premature beats.,0
"There is moderate to severe regional left ventricular systolic dysfunction with akinesis of the mid- and distal anterior wall, septum, as well as the distal inferior wall and apex (""wraparound"" mid-LAD distribution).",1
The remaining segments contract normally (LVEF = 30%).,0
There is trivial/physiologic mitral regurgitation.,0
"IMPRESSION: Moderate to severe regional left ventricular systolic dysfunction, c/w CAD.",0
No LV thrombus seen with echo contrast.,0
"10:47 AM CHEST (PA & LAT) Clip # Reason: interval change Admitting Diagnosis: NEW DEPRESSED EJECTION FRACTION; CONGESTIVE HEART FAILURE\CARDIAC CATHETERIZATION ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with bilateral effusions post cabg REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Bilateral effusions, evaluation after CABG.",1
"FINDINGS: As compared to the previous image, there is no relevant change.",0
"Moderate cardiomegaly, status post CABG.",1
"Small bilateral pleural effusions, better visible on the lateral than on the frontal image.",0
Unchanged right internal jugular vein catheter.,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: line placement Admitting Diagnosis: ACUTE ABDOMINAL PAIN;COLECTOMY;HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with new CVL REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest port line placement.,0
REASON FOR EXAM: New central venous line.,0
"FINDINGS: Since the previous chest radiograph earlier on the same date, the ET tube, NG tube, and left central venous line are unchanged.",0
The new right internal jugular line tip is in the upper SVC.,0
Diffuse airspace opacities throughout the right lung are unchanged and are most likely due to a combination of infection with pulmonary edema.,0
IMPRESSION: Satisfactory placement of right internal jugular central venous line with no pneumothorax.,0
"2:41 PM CHEST (PORTABLE AP) Clip # Reason: check feeding tube placement Admitting Diagnosis: C5-C6 FRACTURE,S/P MVA ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man s/p mvc and trach with quadraplegia.",0
REASON FOR THIS EXAMINATION: check feeding tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVA with tracheostomy.,1
Check feeding tube placement in this quadriplegic patient.,0
PORTABLE SUPINE CHEST: Tracheostomy tube and left subclavian line are present in stable and good position.,0
The Dobhoff feeding tube has been reinserted with the tip in the body of the stomach.,0
No other change is seen.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: SOB, Orthopnea and DOE Major Surgical or Invasive Procedure: Intubation Tracheostomy PEG tube placement Cardiac Catheterization History of Present Illness: Patient is a 67 year old male with history of DM-II, CKD, MI, CAD, CHF, A-fib, who was transferred from an OSH with reported fluid overload.",0
"Pt was initially referred to OSH with sxs of SOB, orthopnea, and DOE as well as a R thigh abscess at donor saphenous graft site.",0
"US performed @ OSH showed 7cm fluid collection in the right mid thigh, for which he was started on Vancomycin and Zosyn ().",0
"At , abx regimen was switched to Vancomycin/Levofloxacin/Flagyl ().",0
Vancomycin was discontinued and levofloxacin switched to cipro on .,0
Pt was on the vascular servive aduring this admission but was being followed by cardiology and diuresed on the floor since for gross total body fluid overload.,0
"The patient decompensated early am on the day of transfer with sats in the mid 80s, requiring Dopamine gtt to maintain MAP > 65.",0
"The patient was initially transferred to SICU on for further diuresis, continuation of Dopamine gtt, and commencement of BiPap.",0
"In the SICU, the patient had worsening SOB and hypercapnia that was not responding to diuresis.",0
The patient was transferred to CCU for management of above.,0
"In the CCU, the pt had worsening SOB, hypoxia, hypercapnia that was not responding to diuresis so he was tried on bipap and then intubated.",0
Pt was switched from dopa to neo to levophed.,0
"Initially diuresed to -3.3L, but didn't tolerated less PS despite this.",0
"Pt has had low-grade F (to 100.0) from , then up to 102 on .",0
"Pt was also given inhaled NO x ~1 day with reported decrease in PA BPs, then transitioned to Viagra.",0
"Upon transfer to MICU (), pt denies pain.",0
Continues to require levophed for BP support.,0
CCU team gave pt 80 IV lasix today x1 for diuresis.,0
Past Medical History: PAST MEDICAL HISTORY: 1.,0
DM-II w/neuropathy and nephropathy 3.,0
CAD s/p CABG x 5 () 4.,0
Hypercholesterolemia PAST SURGICAL HISTORY: 1.,0
R fem-peroneal bypass () Social History: Retired policeman.,0
"Lives in FL, former smoker (15-20pack year), occasional EtOH Family History: non-contributory Physical Exam: Vitals: BP 77/48 HR 75 RR 20 Gen: A/O x3, cooperative with commands, on BiPAP HEENT: PERRLA, NC/AT Neck: JVD COR: S1 S2 regular rate, rhythm.",0
2/6 SEM heard left parasternal border.,0
Carotid bruit exam not possible BiPAP.,0
"Pulm: wet crackles 2/3 up bilaterally, R>L.",0
gross interstitial and pitting edema observed in .,0
"R saphenous vein graft donor site indurated, with 4""x2"" irregular patchy erythema surrounding incision site.",0
Bil extremities w ACE wrap per vascular.,0
"MS: A/O x 3 (Upon transfer from CCU to MICU on ) -VS: T 101.3, HR 57-73, BP 104/54 (SBP 84-117), Sat 98-100% on vent -Vent: PS 15, PEEP 10, 40% FiO2 -I/O: 3800/1600 to MN; 1800/1400 since MN -PCWP 7-14 () -Swan (): CVP 13-16, RA 15-20; RV 75/7; PA 75/24 (69-80 PA systolic); wedge 15, CO 6.5, CI 2.5, SVR 665 (on dopa).",0
"-Swan (): CVP 14-19, PA 69/27, wedge 17-18, CO 5.9, CI 2.3, SVR 637 (on neo).",0
"-Gen: elder M sitting in bed, intubated, calm -Skin: bilat LEs in dressings; L-toe dry gangrene -HEENT: OP w/ETT, EOMI, anicteric sclera -Heart: S1S2 RRR, no M apprec -Lungs: coarse upper airway sounds bilat; fine crackles bilat lower lobes; fair air movement -Abdom: soft, obese, NT, ND, NABS -Genital: edematous penis & scrotum -Extrem: trace bilat LE pulses, 2+ bilat pitting edema -Neuro/Psych: alert, follows simple commands, moves all extremities Pertinent Results: Admission labs: .",0
06:30PM PT-48.9* PTT-39.3* INR(PT)-5.7* 06:30PM PLT COUNT-215 06:30PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+ 06:30PM NEUTS-77.6* LYMPHS-13.5* MONOS-5.5 EOS-3.1 BASOS-0.3 06:30PM WBC-10.1 RBC-4.81# HGB-14.0# HCT-44.2# MCV-92 MCH-29.1 MCHC-31.7 RDW-17.4* 06:30PM CALCIUM-9.0 PHOSPHATE-4.2# MAGNESIUM-2.2 06:30PM CK-MB-NotDone cTropnT-0.09* 06:30PM CK(CPK)-23* 06:30PM GLUCOSE-90 UREA N-35* CREAT-1.5* SODIUM-144 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-34* ANION GAP-12 .,0
: proBNP-* : proBNP-* .,0
Iron binding studies: calTIBC-264 Ferritn-80 TRF-203 Stim: 21.4 -> 27.3 -> 30.9 .,0
STUDIES PERTAINING TO RLE FLUID COLLECTION: : Right Noninvasive LE ultrasound - repeat imaging IMPRESSION: 1) Fluid collection tracking deep to the subcutaneous tissues; significantly smaller but more organized compared to the ultrasound of .,0
Superficial to and distinct from the bypass graft.,1
No flow to suggest pseudoaneurysm.,0
2) Subcutaneous tissue edema consistent with cellulitis.,0
: Right Noninvasive LE ultrasound There is evidence of extensive subcutaneous infiltration and induration consistent with cellulitis.,0
"In addition, there is a linear tract extending from the superficial surface - corresponding to the scar site that extends to a deeper collection that measures a maximum of 7 x 2 cm.",0
"This collection runs along the undersurface of the thigh, but lies superficial to the patient's graft site.",0
The graft is identified and is patent (see separate report).,0
The graft is separated from the superficial collection by a distance of 1.3 cm.,0
This superficial collection contains no flow and is not thought to represent a pseudoaneurysm.,0
Pulmonary Hypertension Work-up: -NEG RheuFac-<3 HIV Ab-NEG SCLERODERMA ANTIBODY-NEG .,1
: Swann Ganz Catheter Placement: RA 15-20 mmHg (A wave); RV 75/7; PA 75/24; PCWP 15 .,0
: CTA Chest: There is no CT evidence for pulmonary embolism.,0
"Specifically, the questionable filling defects seen in the left lower lobe on the prior CT are now well opacified.",0
This pulmonary branches demonstrate normal enhancement without filling defects.,0
There are moderate bilateral pleural effusions and bibasilar atelectasis.,0
There is mild diffuse ground glass opacities as well as septal thickening.,0
There is enlargement of the cardiac silhouette with increase in size of both left and right side .,0
"In addition, there is mild enlargement of the coronary sinus.",0
All these findings suggest congestive heart failure.,1
Congestive heart failure with bibasilar atelectases and moderate pleural effusions.,1
INTERPRETATION: LEFT ATRIUM: Mild LA enlargement.,0
"GENERAL COMMENTS: Compared with the findings of the prior study, there has been no significant change.",0
Blood Cultures: : NGTD : NGTD : NGTD : NGTD : NGTD : NGTD .,0
: Stool - C.diff Neg .,0
Catheter Tips : PICC - No significant growth : Swann Ganz - No significant growth .,0
"Wound: : Right Thigh - Sparse growth SERRATIA MARCESCENS, pan-sensitive .",0
Urine Cultures: : NGTD : NGTD .,0
"Sputum: : GRAM STAIN : PMNs <10 epis, NO MICROORGANISMS SEEN.",0
RESPIRATORY Cx: SPARSE GROWTH OROPHARYNGEAL FLORA.,0
": Gram Stain: >25 PMNs , <10 epis 3+ GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.",0
3+ GRAM POSITIVE RODS RESPIRATORY CULTURE: MODERATE GROWTH OROPHARYNGEAL FLORA.,0
"SPARSE GROWTH GRAM NEGATIVE ROD(S) : Gram Stain: > 25 PMNs, < 10 Epis 1+ MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.",0
RESPIRATORY CULTURE: ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R .,0
BAL : GRAM STAIN (Final ): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.,0
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.,0
RESPIRATORY CULTURE (Final ): ~8OOO/ML OROPHARYNGEAL FLORA.,0
: Lyme: POSITIVE BY EIA.,0
Brief Hospital Course: A/P: Patient is a 57 year old male with multiple medical comorbidities found to have severe pulmonary hypertension without known cause with hospital course complicated by right heart failure and respiratory failure.,1
"Respiratory Failure: The pt was initially intubated on , for hypoxic and hypercarbic respiratory failure.",1
"The etiology of the respiratory failure was felt to be multifactorial with contributions from fluid overload, PNA, diaphragmatic dysfunction (later diagnosed after intubation) on top of possible baseline chronic pulmonary disease (as pt was tobacco smoker).",1
The pt was overtly fluid overloaded and difficult to diurese in the CCU leading to the original intubation.,0
The difficulty diuresing was felt to be due to hypotension from .,0
intravascarul volume from septic physiology (vasodilatory).,0
He was transferred to the MICU where he was treated with abx (as below) and gradually he demonstrated recovery from his PNA.,0
However he remained difficult to wean and on physical examination was found to have parodoxical breathing pattern.,0
This was further investigated with a bedside US and the pt was found to have a left sided diaphragmatic paralysis resulting in paradoxical motion of the diaphragm.,0
After he had recovered from his infectious insult he was slowly diuresed with a lasix gtt maintaining goal diuresis of negative 500 to 1000cc/day.,0
"On , he was doing well from a respiratory perspective, breathing on PS with 5/5.",0
His RSBI in the AM was found to be 70 and after repeat was 56.,0
ABG demonstrated good ventilation and oxygenation and the pt was extubated.,0
"However several hours after extubation, the pt became short of breath with worsening ventilation by ABG.",0
This was felt to be due to his diaphragmatic dysfunction and the pt was re-intubated the same day.,0
He was evaluated by the interventional pulmonary team and received a tracheostomy and PEG tube placement on .,0
"The following day, the pt was doing well on PS of without any difficulty.",0
He was transferred to rehabiliation facility for further weaning and potential tracheostomy removal after improvement in his diaphragmatic function and further diuresis.,0
Diaphragmatic dysfunction: The pt was not previously not known to have any signficant neuropathy and the dx of diaphragment dysfunction was further investigated.,0
"During his MICU stay, the neurology team was consulted to further assist in management of this problem.",0
Unilateral diaphragmatic dysfunction/weakness are usually asymptomatic unless the pt is otherwise comprised (ie with pneumonia and heart failure).,1
"His physical examination was consistent with some amount of lower motor neuron weakness in his right leg, which was found to be fairly severe.",0
"Differential diagnosis includes: peripheral neuropathy affecting the phrenic nerve (diabetes, CIDP, vasculitis, connective tissue disease given + , possibly motor neuron disease) vs. prior injury during CABG in (can be injured during cooling) vs. spinal cord injury (C 3,4, 5), less likely given his arms are strong and nutritional deficits causing injury to nerves.",0
"Aside from treating the underlying cause, the only other treatment for this condition is surgical plication.",0
"The neurology service recommended supportive care at this moment with investigation into treatment later on after recovery from his acute insults (PNA, CHF, Pulm HTN).",0
"They recommended an EMG/NCS to help diagnose a neuropathy, and if the results demonstrate a demyelinating disorder then he may benefit from treatment with IVIG.",0
This should be followed up as an outpt.,0
Infectious Disease: The patient arrived at the OSH with suspected cellulitis/abscess at the saphenous donor site on his R medial upper thigh.,0
Vancomycin and Zosyn were initiated on .,0
"Blood cultures from revealed no growth, but wound cultures grew pan-sensitive serratia marscens.",0
"On , abx regimen was switched to Vancomycin/Levofloxacin/Flagyl.",0
"On , U/S of the R thigh collection revealed a 7.0 x 2.0 cm collection superficial to the saphenous donor graft site; although the skin over the R thigh donor site collection was indurated and erythematous, vascular surgery did not consider the collection to represent an abscess.",0
It was instead felt to be a residual fluid collection from post-op and not pathologically relevant.,0
Blood cultures from and showed no growth.,0
Vancomycin was discontinued and levofloxacin was switched to cipro on ; flagyl was continued.,0
"Although the patient was afebrile and had a normal WBC count since admission, broad-spectrum antibiotics were continued given concern for early sepsis in light of low SVR measured with the swan-ganz catheter and repeated episodes of hypotension.",0
"Potential sources included: (1) a peristent LLL infiltrate that was poorly characterized on CXRs taken throughout the hospital course, possibly representing PNA, (2) peripheral spread from the potential R thigh abscess, and (3) line infection.",0
The patient developed fever and had increasing WBC to 13.9 on .,0
"Blood, urine, lung, abscess, and line sources were considered.",0
"Blood and urine cultures were drawn on , and , and have shown no growth to date.",0
"Both PICC lines and Swann Ganz catheters were removed and tips were cultured, and showed no sinigicant growth to date.",0
Repeat U/S of the R thigh collection revealed a shrinking collection of fluid but persistent cellulitis.,0
Vascular surgery reiterated their contention that the fluid collection did not represent an abscess.,0
"Sputum gr st from showed GNR and GPC, but cultures showed no growth.",0
Repeat sputum gr st and cx on were clean.,0
"At the time of tranfer from the CCU, the most likely etiologies for the patient's fevers included: line infxn vs. PNA vs. cellulitis.",0
"On , ID service was consulted, and abx were changed to meropenem/vanc/flagyl.",0
The pt completed a two week course of antibiotics without further complication.,0
He was afebrile during the remainder of his MICU stay and his septic physiology (vasodilatory) resolved with continuation of antibiotics.,0
"All of his antibiotics were discontinued on , and he remained afebrile without significant concern for further infection.",0
Congestive Heart Failure: The pt was transferred from the OSH with initial complaints of SOB and DOE.,1
"On arrival to , the pt was felt to be volume overloaded, during the first 6 hospital days, the patient was agressively diuresed with transient improvement in SOB, dyspnea, and orthopnea.",0
"However, though pulmonary edema was minimal on CXR upon arrival to CCU, peripheral edema and JVD were still markedly increased.",0
Diuresis also did not improve heart function as measured by persistent hypotension and requirement for pressor support.,0
"The patient arrived at the CCU on dopamine gtt, then was switched to neosynepherine and finally levophed; attempts to wean were unsuccessful.",0
"Given the evidence for a diagnosis of primary pulmonary hypertension (see below) and the clinical picture of right-sided heart failure, the persistent CHF sxs in this patient were attributed to pulmonary hypertension resulting in right-sided heart failure.",1
Complicating the picture of this patient's CHF is his pre-existing LV dysfunction.,0
"Echocardiography from showed a LVEF of 40-45%, but qualitatively described LV function as mildly depressed with inferior and infero-lateral hypokinesis.",0
Repeat echocariography on was not able to assess LV function due to technical considerations.,0
"Although it is possible that some degree of LV dysfunction could also be abetting the CHF picture in this patient, the CCU team considered it to be a secondary concern given the overwhelming evidence for R sided failure.",0
"After transfer to the MICU, the pt was stabilized from an infection/sepsis standpoint and with resultant improvement in his blood pressure, he was able to be diuresed more aggressively.",0
He was started on a lasix gtt with good urine output (>100cc/hour) and after several days was transitioned to lasix IV bolus -TID with good diuresis.,0
The pt should continue to be diuresed to achieve a goal of neg 500cc to 1000cc/day until he regained his dry body weight or until his creatinine and/or bicarbonate demonstrated signs of increase.,0
"Until then, he should have routine electrolytes monitored to better assess his renal function and his body weight as well as daily ins and outs should be monitored to verify appropriate diuresis.",0
"Cardiac Ischemia: The patient arrived at with CEs under threshold levels for acute MI, but by , the patient's troponin reached 0.12.",0
However his EKGs were not consistent with sigificant ichemic changes.,0
He was continued on ASA/plavix/statin which he was on as an outpatient.,0
CEs again increased to their peak of TrT of 1.5 and CK-MB of 15 on .,0
EKG again showed no significant ST changes and the patient was asymptomatic.,0
CEs decreased thereafter and daily EKGs thereafter revealed no further ischemia.,0
His plavix was disontinued one week prior to his Trach/PEG placement after consultation with his vascular surgeon Dr. .,0
"After the Trach/PEG, the plavix was not re-started given his prior episode of GI bleed while in the MICU.",0
He should be continued on his ASA and statin.,0
"A decision re: re-initiation of plavix should be made in consultation with his PCP, and vascular surgeon as an outpt.",0
"Cardiac Rhythm: The patient arrived at with a pre-existing diagnosis of atrial fibrillation, which was controlled at home with digoxin and sotalol.",1
The patient was also on chronic anticoagulation at home with coumadin with a goal INR of .,0
Digoxin was discontinued upon arrival at given a lack of evidence for significant LV pump dysfunction.,0
"The sotalol was continued, with good control of the atrial fibrillation; telemetry revealed only infrequent bouts of paroxysmal a fib.",1
Temporary discontinuation of sotalol resulted in episodes of PVCs and occasional runs of SVT.,0
The sotalol was therefore maintained during this admission.,0
The pt's anticoagulation was initially held until given a supratherapeutic INR.,0
"However with an episode of GIB, the anticoagulation was discontinued all together.",0
Decision re: re-initiation of his anticoagulation should be made as an outpt after consultation with his PCP and cardiologist.,0
Primary Pulmonary Hypertension: The patient was initially trasnferred to the CCU for indication of fluid overload and respiratory distress with intention to perform pulmonary artery catheterization to investigate etiology of patient's symptoms.,1
"On admission the patient was maintained on non-invasive ventilation as he was noted to become increasingly hypercarbic, hypoxic and acidemic when off BiPap.",0
"Once relatively stabilized from a respiratory status, the patient underwent placement of a Swann Ganz catheter which was remarkable for severe pulmonary hypertension: RA 15-20 mmHg (A wave); RV 75/7; PA 75/24, with relatively low PCWP suggesting that the patient's right heart failure on admission was secondary to a primary pulmonary process rather than secondary to left heart failure.",1
Prior to admission to the CCU the patient has been undergoing aggressive diuresis given evidence of decompensated CHF.,0
"However, given the PA cath results it became evident that the patient was actually relatively the LA/LV which was likely contributing to the patient's hypotension and pressor requirements.",0
"Additionally, blood gas analysis revealed likely a chronic respiratory acidosis with compensatory metabolic alkalosis as well as a primary metabolic alkalosis, likely a contraction alkalosis secondary to aggressive diuresis.",1
It was thought that the patient's metabolic alkalosis was liekly contributing to his impaired respiratory drive and resultant hypercarbic respiratory failure.,1
"Given this, the patient was aggressively repleted with KCl to correct the underlying metabolic alkalosis.",0
"In addition to LV , swan tracings were noteable for a SVR ranging from 500 to 600.",0
In the setting of hypotension it would be expected that the patient's SVR would reflect a state of increased vascular resistance with an elevated SVR.,0
"Given that the patient's SVR was relatively depressed compared to it's expected values, there was additional concern for potential distributive shock, likely secondary to sepsis although the infectious source was not immediately obvious.",0
"As the patient's severe right heart failure appeared to be secondary to a primary pulmonary process, a pulmonary consult was requested.",1
"Pulmonary consult team recommended a number of studies that might identify the cause of primary pulm HTN including HIV Ab, Scleroderma Ab, , and RF (all neg).",1
The pulmonary consult team suggested inhaled nitric oxide as an initial empiric treatment for suspected pulm HTN.,0
"In response to iNO rx, BP increased and PAP decreased, which was taken as a verification of the diagnosis of pulm HTN.",0
"After two days of iNO therapy, the patient was started on sildenafil, dose escalating from 25mg PO TID to 100mg PO TID over several days.",0
"The patient initially tolerated this treatment well, with peripheral BP remaining stable or increasing.",0
"PAP improved slightly with sildenafil rx, but the PA catheter was removed on due to concern for a line infection.",0
"Later in his CCU course, the pt developed hypotension and fevers concerning for worsening sepsis/infection.",0
He was therefore transferred to the MICU where he was worked up for sepsis.,0
"After completion of his antibiotic course as above, his septic physiology resolved and he slowly regained appropriate BP and hemodynamics.",0
"After careful review of his records, the pulmonary hypertension was thought to be either primary in origin as above or secondary due to LVF.",1
"Prior to his CABG, the pt was known to have signficant CHF with compromised LVEF.",0
This may have led to the development of Pulmonary HTN over time.,0
"However after his CABG, his LVEF was significantly improved.",0
The pulmonary HTN may not have had time to resolve after the return of cardiac function.,0
"Howevever as he is currently hemodynamically stable with good diuresis, decision to start either CCB, prostacyclins or inhaled NO for management of his pumonary HTN was deferred until further discussion with his PCP and pulmonologist.",0
GIB: The pt was maintained on anticoagulation as noted above for his atrial fibrillation during most of his hospital stay.,1
"While in the MICU, the pt had one episode of coffee ground emesis which cleared with NGL.",0
"Given his concern for hemodynamic instability at the time, the anticoagulation was discontinued.",0
"Since that one episode, the pt was also found to have some coffee ground from his OG tube after re-placement of his ETT tube on '.",0
"In addition, the patient has displayed a slowly decreasing HCT over the time of his CCU course.",0
Stools have been guaiac'd and have not been positive to date.,0
It was planned to transfuse the patient if HCT drops below 21.,0
At time of discharge a decision as made to discontinue his anticoagulation.,0
A decision re: re-initiation of anticoagulation for atrial fibrillation should be made after discussion with his PCP and cardiologist as an outpt.,1
Vascular: The patient is followed as an outpatient by Dr. .,0
He had a R fem-peroneal bypass operation in .,0
"In addition to the R thigh fluid collection mentioned above, the patient's post-operative course was complicated by wound breakdown at the bypass site on the R calf.",0
Vascular service has managed wound dressing changes thoughout the hospital course and plans to place a vac dressing once the immediate issues have resolved.,0
"Most currently, the vascular service has recommended wet to dry dressing changes on the right calf wound.",0
His wound appear to heal well with almost aproxmiation/filling at time of dischage.,0
The pt will follow up with Dr. as an outpt.,0
"Renal: The patient has mild pre-existing CKD, with a baseline Cr of 1.0-1.4.",0
"During this admission, the patient has shown acute on chronic renal insufficiency, likely secondary to aggressive diuresis and potentially impaired perfusion given hypotension.",0
"Throughout the hospital course, meds have been renally dosed as appropriate.",0
Mucomyst and hydration have been given prior to any administration of contrast .,0
The pt did demonstrate improvements in his creatinine and at time of discharge his renal function was back at baseline.,0
"Endocrine: The patient has DM, which has been managed with an insulin sliding scale throughout his hospital course.",0
Sugars have been kept under good control with 8units of NPH in addition to RISS.,0
"FEN: After the patient was intubated, tube feeds were given through an NG tube.",0
He received a tracheostomy as well as a PEG tube placement on without complications.,0
The TF were given through the PEG tube and the pt was subsequently evaluated by Speech and Swallow for ability to take POs.,0
"PPx: The pt was maintained on DVT ppx with either a heparin gtt or heparin sub Q TID (After the episode of GIB, the gtt was stopped as above).",0
"In addition, the pt also recieved GI ppx with PPI and bowel regimen.",0
Code Status: Full code Medications on Admission: 1.,0
Lasix 40mg po bid 9.,0
Senna Discharge Disposition: Extended Care Facility: - - Discharge Diagnosis: pneumonia respiratory failure s/p intubation s/p tracheostomy s/p PEG placement paroxysmal AFib CHF pulmonary HTN PVD Discharge Condition: stable Discharge Instructions: Please continue diuresis with goal net negative 500cc to 1L daily until edema resolves or Cr increases.,1
Can dose 80mg IV lasix daily to twice daily to achieve this.,0
Please check electrolytes daily while diuresing.,0
Please continue to work with patient to wean ventilator.,0
in the next 2 weeks (or when able to travel for appointment).,0
Call to make an appointment.,0
Please make an appointment to follow up with your cardiologist in the next few weeks.,0
"Please also follow up with your vascular surgeon, Dr. in the next month.",0
Call ( to make an appointment.,0
"9:39 PM CHEST (PORTABLE AP) Clip # Reason: 65 yo M with h/o recent MVA and cardiogenic shock - Please c ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p mva currently in CHF/pnuemonia, s/p tracheostomy.",1
s/p R IJ PA catheter.,0
REASON FOR THIS EXAMINATION: 65 yo M with h/o recent MVA and cardiogenic shock - Please check placement of Right IJ cordis and PA line.,1
Attempted left subclavian line as well.,0
"Please r/o pneumothorax, infiltrate, effusions.",0
______________________________________________________________________________ FINAL REPORT HISTORY: History of recent MVA and cardiogenic shock.,1
Check placement of PA line.,0
PORTABLE AP CHEST: Comparison exam dated .,0
There has been interval placement of a PA line with the tip overlying the right main pulmonary artery.,0
The tracheostomy remains in satisfactory position.,0
"The heart size, mediastinal/hilar contours are stable.",0
There has been a slight interval increase in the left lower lobe collapse/consolidation which now obscures the medial left hemidiaphragm.,0
There has been partial resolution of the multiple ill-defined bilateral pulmonary infiltrates.,0
Satisfactory placement of pulmonary artery catheter.,0
Partial resolution of ill-defined bilateral pulmonary infiltrates which may represent resolving pulmonary edema.,0
Slight increase in collapse/consolidation of the left lower lobe.,0
"11:17 PM CT HEAD W/O CONTRAST Clip # Reason: r/o intracranial bleeding or structural anomaly or infarct Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with seizures right sided at 24 hours of age, infant full term REASON FOR THIS EXAMINATION: r/o intracranial bleeding or structural anomaly or infarct CONTRAINDICATIONS for IV CONTRAST: N ______________________________________________________________________________ FINAL REPORT report in pacs",1
Intra-op TEE for off pump CABG Status: Inpatient Date/Time: at 16:56 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
Post LAD Bypass: Bi ventricular systolic function is preserved.,0
Findings discussed with the surgeons at the time of the exam.,0
LINE PLACEMENT Clip # Reason: postop film-contact NP # if abnormal- will be Admitting Diagnosis: AORTIC VALVE INSUFFIENCY\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman s/p AVR REASON FOR THIS EXAMINATION: postop film-contact NP # if abnormal- will be in CVICU approx.,1
11:45 AM- please call first ______________________________________________________________________________ FINAL REPORT INDICATION: 30-year-old female status post aortic valve replacement.,1
Single AP chest radiograph compared to shows postoperative appearance of the mediastinum following sternotomy and aortic valve replacement.,1
Tip of Swan- Ganz catheter overlies the main pulmonary artery.,0
Right chest tube and mediastinal drains are in place.,0
ET tube terminates 4.9 cm above the carina.,0
There is mild bibasilar atelectasis and small left pleural effusion.,0
IMPRESSION: Bibasilar atelectasis and small left pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Dyspnea on exertion, chest pain Major Surgical or Invasive Procedure: CABG x 3 (LIMA->LAD, SVG->OM1, OM2), AVR (25mm pericardial valve) History of Present Illness: Delightful 72 year old gentlema with h/o aortic insufficiency and dilated ascending aorta who was being evaluated for a total knee replacement.",1
He has noted worsening dyspnea and angina with activity.,0
"In work-up for his knee surgery, a stress test was performed which noted early onset angina and inferolateral ischemia.",0
"A cardiac catheterization was performed which revealed moderate coronary artery disease, severe aortic insufficiency and a dilated ascending aorta.",1
He now presents for surgical management.,0
Past Medical History: Hyperlipidemia HTN Hypothyroid Arthritis BPH Social History: Retired Employee.,0
Never smoked and does not drink alcohol.,0
Lives with his wife in .,0
"Family History: Noncontributory Physical Exam: 74 SR 12 122/68 126/68 GEN: WDWN in NAD SKIN: Warm, no c/c/e, well healed ventral hernia incision.",0
"HEENT: NCAT, PERRL, EOMI, anicteric sclera, OP benign NECK: Supple, FROM, 2+ carotids without bruits.",0
"LUNGS: Clear HEART: RRR, II/VI late systolic and I/VI diastolic murmur.",0
"ABD: Benign EXT: Warm, well perfused, no edema NEURO: Nonfocal Pertinent Results: ECHO Prebypass: 1.",1
The increased transaortic gradient is likely related to aortic regurgitation.,0
Well-seated bioprosthetic valve in the aortic position with trivial central AI and washing jets.,1
Normal aortic contour post decannulation.,0
06:10AM BLOOD WBC-9.6 RBC-3.40* Hgb-10.8* Hct-30.4* MCV-89 MCH-31.9 MCHC-35.6* RDW-15.1 Plt Ct-164 06:10AM BLOOD Plt Ct-164 03:09AM BLOOD PT-13.8* PTT-33.1 INR(PT)-1.2* 06:10AM BLOOD Glucose-139* UreaN-13 Creat-0.6 Na-138 K-3.6 Cl-99 HCO3-29 AnGap-14 06:10AM BLOOD ALT-27 AST-27 AlkPhos-43 Amylase-78 TotBili-0.9 06:10AM BLOOD Lipase-49 Brief Hospital Course: Mr. was admitted to the on for surgical management of his heart disease.,0
He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels and an aortic valve replacement with a 25mm pericardial valve.,1
He was noted to have a high output from his drains and was thus returned to the operating room where he was re-explored for bleeding.,0
Hemostasis was acheived and he was taken back to the intensive care unit for monitoring.,0
"By postoperative day one, Mr. had awoke neurologically intact and was extubated.",0
He was then transferred to the step down unit for further recovery.,0
"On he was found to have a distended abdomen, KUB showed colonic ileus.",0
He was seen by general surgery who felt that he had a resolved ileus.,0
"He tolerated an advancing diet, and continued to pass gas and have bowel movements.",0
He was ready for discharge on POD #6.,0
"Medications on Admission: Synthroid 125mcg daily Aspirin 81mg daily Diovan 160mg daily Dyazide 37.5/25mg daily Zocor 40mg daily Flomax 0.4mg daily Finasteride 5mg daily Nabumetone 750mg daily Discharge Disposition: Home With Service Facility: home health Discharge Diagnosis: CAD, AI lipids HTN hypothyroid OA BPH s/p IHR s/p appy s/p R knee arthroscopy s/p cataract surgery Discharge Condition: Good.",0
"Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week.",0
"Shower, no baths, no lotions, creams or powders to incisions.",0
No lifting more than 10 pounds or driving until follow up with surgeon.,0
"Followup Instructions: Dr. 4 weeks Dr. 2 weeks Already scheduled appointments: Provider: Phone: Date/Time: 11:00 Provider: , M.D.",0
"12:33 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: pnuomothorax resolution Admitting Diagnosis: THYROID STORM ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with thryoid storm, multiple organ failure, intubated with increasing o2 requirment s/p chest tube REASON FOR THIS EXAMINATION: pnuomothorax resolution ______________________________________________________________________________ FINAL REPORT EXAM ORDER: Chest.",1
"HISTORY: Multiple organ failure, increasing oxygen requirement.",0
CHEST: A single portable supine view at 12:40 p.m. is compared to previous examination of .,0
"Since the previous exam, there has been insertion of left-sided chest tube with reexpansion of the left lung on this supine view.",0
There is new subcutaneous emphysema along the left hemithorax.,0
The cardiomediastinal silhouette remains stable.,0
Suggestion of interstitial pulmonary edema.,0
The support lines are in satisfactory position.,0
"6:59 PM CHEST (PORTABLE AP) Clip # Reason: eval after ct removed ______________________________________________________________________________ MEDICAL CONDITION: 22 year old man crush injury to chest s/p RIJ PAC, Bilat CT, falling BP.",0
on High frequency occilatory ventilation.,0
Now on SIMV pending removal of CT ct removed REASON FOR THIS EXAMINATION: eval after ct removed ______________________________________________________________________________ FINAL REPORT INDICATION: Follow up status post chest tube removal.,0
"COMPARISON: , approximately 6 hours prior to the present study.",0
"AP CHEST: In the interval since the prior study, the two right chest tubes have been removed.",0
There is no evidence of pneumothorax on either side.,0
"The endotracheal tube, right IJ, two left chest tubes, and two nasogastric tubes remain well positioned.",0
The overall appearance of the chest is unchanged with persistence of opacification in the left mid lung and right lateral lung.,0
Stable appearance of large lucencies consistent with parenchymal tears.,0
Status post removal of two right chest tubes with no pneumothorax.,0
The remainder of the chest is unchanged since the prior study.,0
1:17 PM CHEST (PA & LAT) Clip # Reason: Any new lung processes?,0
Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 36 year old man with PCP and HIV REASON FOR THIS EXAMINATION: Any new lung processes?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: History of PCP and HIV, any new lung changes.",0
FINDINGS: PA and lateral chest examination is compared to the next preceding examination of thus covering an interval of three days.,0
"The bilateral interstitial an parenchymal densities have further increased significantly, most marked in the right lung and occupying preferentially the central lung portions.",0
"As far as the pattern of the pulmonary vessels can be judged, there is no evidence of congestion and the lateral pleural sinuses remain free on the frontal view.",0
Also the heart size has not undergone any significant change.,0
Comparison of lateral views confirm the marked progression of the mostly centrally located changes but again the posterior pleural sinuses remain free.,0
IMPRESSION: Further progression of diffuse bilateral pulmonary processes mostly occupying the interstitium and again very compatible with PCP process in immunocompromised host.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: TRA HISTORY OF PRESENT ILLNESS: This is a 36-year-old otherwise healthy female who was transferred from an outside hospital after sustaining a dirt bike crash.,0
"Apparently, the dirt bike went out of control and hit a tree.",0
The patient was without a helmet.,0
She denied loss of consciousness.,0
She was transported to an outside hospital and was determined to have extensive facial fractures and abrasions as well as a grade 2 liver laceration and a right hand fracture.,1
The patient was transferred to the for further care.,0
SOCIAL HISTORY: The patient denies tobacco use or alcohol use.,0
She denies recreational drug use.,0
She lives at home with her husband and children.,0
PHYSICAL EXAMINATION ON PRESENTATION: The patient arrived to the Emergency Department with Coma Score of 15.,0
"Her vital signs revealed a temperature of 101.8, her blood pressure was 94/60, her heart rate was 114, her respiratory rate was 20, and she was saturating 100 percent.",0
She had a large stellate laceration over her right temple near the hairline.,0
She had multiple abrasions; mostly on the right side of her face.,0
The pupils were equal and reactive bilaterally.,0
The tympanic membranes were clear bilaterally.,0
She had a regular rate and rhythm with no murmurs.,0
Her chest showed no deformities or tenderness.,0
She was tender over the right upper quadrant.,0
She had no flank tenderness or deformities.,0
The cervical/TLS spine was nontender with no step off.,0
She was wearing a cervical spine collar.,0
Her rectal tone was normal with negative guaiac.,0
She had an obvious abrasion on the right hand and was tender.,0
There were no other deformities of her other extremities.,0
She had 2 plus pulses throughout.,0
"PERTINENT LABORATORY VALUES ON PRESENTATION: She had a white blood cell count of 15.1, her hematocrit was 36.2, and her platelets were 215.",0
She had trace blood in the urine.,0
Her toxicology screen showed opiates in the urine.,0
Her serum toxicology was negative.,0
PERTINENT RADIOLOGY-IMAGING: The patient had a chest x-ray which was within normal limits.,0
A pelvis x-ray was within normal limits.,0
Her FAST examination was neg.,0
"A head CT showed no intracranial hemorrhage; however, it did show multiple facial fractures.",1
A computed tomography of the sinus dedicated to facial fractures with a wall fracture.,1
"Described fractures of the right orbital wall, of the right maxillary sinus, the right zygomatic arch and zygomatic process.",1
"She was noted to have blood within the sphenoid, maxillary, and ethmoid sinuses.",0
There was a blow-out fracture of the right orbital floor as well as a questionable fracture of the lateral wall of the left orbit.,1
A computed tomography of the abdomen showed a grade 2 liver laceration within the right lobe of the liver.,1
No free fluid or intraperitoneal hemorrhage in the abdomen.,0
A computed tomography of the pelvis was otherwise normal.,0
A computed tomography of the cervical spine showed no fractures or malalignment.,0
A x-ray of the hand was obtained at the outside hospital which showed fourth and fifth metacarpal fractures of the right side.,1
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit for frequent monitoring and serial hematocrit checks to follow her liver laceration.,1
She also had serial abdominal examinations.,0
"Her hematocrit reached its lowest at 36.2 at the time of her admission, and she was discharged with a hematocrit of 36.9.",0
"Additionally, her belly examination became less tender during her stay in the hospital, and she was eventually transferred to the floor for continued care.",0
"She was to follow up with the Trauma Clinic for further evaluation of her liver laceration; which, after five days of observation was stable.",1
The patient was examined by the Ophthalmology Service on admission for evaluation of possible entrapment given the fact that she had a possible blow-out fracture.,0
Ophthalmology gave her a full examination and determined that there was no entrapment diplopia or an enophthalmus.,0
She was to follow up within one week for further examination.,0
An Oral Maxillofacial Surgery consultation was obtained for the patient's multiple facial fractures.,1
She was placed on antibiotics for sinus coverage and was to remain on this course for a total of 14 days.,0
"It was determined that her fractures were nonoperable as she had a nondisplaced CMC right sided fracture, and a nonoperable orbit sinus fracture.",0
She was to follow up with Oral Maxillofacial Surgery within one week and continue the antibiotics as stated.,0
The patient was evaluated by Plastics/Hand Surgery for her right shoulder and right hand pain.,0
She underwent open reduction internal fixation of her fourth and fifth metacarpal bone fractures of the right hand on hospital day two.,1
Her hand was splinted and remained in elevation throughout her hospital stay.,0
She is nonweightbearing on the right upper extremity.,0
She was to follow up with Plastic Surgery in one week for suture removal and evaluation.,0
"The patient complained of right shoulder pain; however, she had full range of motion and no obvious deformities of this extremity.",0
She was offered the Orthopaedic Service telephone number for outpatient followup.,0
The patient also complained of a chipped tooth of the third molar on the right side upper level.,0
"The area was examined, no dentin was exposed.",0
The patient will follow up with Oral Maxillofacial Surgery when she has appointment for her facial fractures for further evaluation of this.,1
The remainder of the hospital course followed in a routine manner.,0
"After operation, her diet was advanced.",0
"Pain medications were switched to by mouth, and the patient was ambulatory with assistance.",0
"At times she was noted to be tachycardic up to the 130s to 140s with activity; however, this was thought to be due to both dehydration as well as anxiety and resolved after a 1.5-liter bolus.",0
Serial hematocrit checks remained stable.,0
The patient was evaluated by Physical Therapy as well as Occupational Therapy and was deemed appropriate to go home.,0
Status post dirt bike crash.,0
Nondisplaced right CMC fracture; nonoperable.,0
Right lateral orbital wall fracture; nonoperable.,1
Right maxillary sinus fracture; nonoperable.,1
CONDITION ON DISCHARGE: The patient was discharged in good and stable condition.,0
She was awake and oriented times three.,0
She was eating a regular diet.,0
She was ambulatory and voiding.,0
"Of note, the patient's primary language is Spanish; however, she does speak good English.",0
She is to continue hand elevation of the right side and be nonweightbearing of the right upper extremity.,0
She is to take her by mouth pain medications as needed.,0
She is take antibiotics as prescribed.,0
"She has been instructed by nursing as to the appropriate manner to wash and address her facial abrasions, and she has been counseled to keep her face in the shade to avoid and minimize scarring.",1
Eye Clinic (telephone number ) in one week.,0
"Hand Clinic (telephone number ) for an appointment on Tuesday, .",0
"Oral Maxillofacial Surgery (telephone number ) for an appointment in one week; she must tell them to be ""fit in.""",0
At that time they will evaluate her facial fractures as well as address her chipped tooth.,1
Trauma Clinic (telephone number ) in one to two weeks for evaluation of liver laceration.,1
Orthopaedic Service (telephone number ) with Dr. ; she is to call to make an appointment if she continues to have right shoulder discomfort.,0
Augmentin 500 three times per day (times 10 days).,0
Percocet one to two tablets q.4-6h.,0
", MD 2211 Dictated By: MEDQUIST36 D: 11:40:37 T: 13:17:31 Job#:",0
10:54 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"chest tube placement Admitting Diagnosis: RIGHT LUNG CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with COPD, large R pleural effusion, s/p chest tube placed this morning.",0
"chest tube placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Follow up pleural effusions, status post chest tube placement.",0
Large right pleural effusion has markedly decreased in amount.,0
There is a basal right chest tube.,0
Tracheostomy tube is seen in standard position.,0
Interstitial abnormality in the right lung is likely reexpansion pulmonary edema.,0
Left lower lobe retrocardiac opacity consistent with atelectasis has minimally worsened.,0
Right lower lobe consolidation is unchanged.,0
Right apical pleural opacity is likely loculated pleural effusion.,0
"7:20 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: s/p ct d/c, check swan placement Admitting Diagnosis: AORTIC STENOSIS\AVR; CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with avr REASON FOR THIS EXAMINATION: s/p ct d/c, check swan placement ______________________________________________________________________________ WET READ: GMSj SUN 9:12 PM ET tube 3.1 cm from the carina.",1
Interval removal of right sided-chest tube.,0
"NG at least in the stomach, tip not imaged.",0
Swan-Ganz catheter in standard position terminating within the mediastinal contours in the region of the main pulmonary artery.,1
Stable enlargement of the cardiomediastinal contours.,0
GSenapati ______________________________________________________________________________ FINAL REPORT AP CHEST 7:11 P.M. ON HISTORY: AVR.,0
IMPRESSION: AP chest compared to through 11: Post-operative widening of the cardiomediastinal silhouette is stable.,0
Some of this is due to mediastinal venous distention.,0
"Lung volumes have improved, mild interstitial edema is still present.",0
Pleural effusions are small if any.,0
Atelectasis at the left base is subsegmental.,0
Tip of the Swan-Ganz catheter points rightward probably in the proximal right pulmonary artery.,1
"ET tube has been advanced to the upper margin of the clavicles, no less than 4 cm from the carina, with the chin slightly flexed.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICAL - ADMISSION DIAGNOSIS: Respiratory arrest This is a 55-year-old male with a past medical history of transverse myelitis, asthma who presented to the Emergency Department for evaluation of muscle spasms and cough.",1
"The patient was in the usual state of health until the night prior to admission after he, per his brother's report, had an episode of choking and aspiration at the dinner table.",0
"The next morning, the morning of admission, the patient had cough and increased muscle spasms, including his lower extremities and chest, as well as increased difficulty breathing.",0
"This prompted the patient's family to take him to the Emergency Department, where he was found to have extra two fentanyl patches.",0
"Per his wife's report, the patient is taking two 100 mg fentanyl patches, however on the morning of admission, he forgot to remove two and so he had four patches at the time of admission to the Emergency Department.",0
The patient was evaluated by Emergency Department personnel and it was felt that he was oversedated from narcotics and therefore the patient was given Narcan which lead to increased agitation and difficulty to control the patient in the department.,0
"In order to sedate him, he was given Ativan and morphine.",0
"Lopressor was given as well, however his blood pressure continued to fall.",0
The patient became non responsive and was intubated and transferred to the Medical Intensive Care Unit.,0
Chest x-ray on admission was consistent with right lower lobe pneumonia and Mr. was started on clindamycin and ceftriaxone for presumed aspiration pneumonia.,0
"In the unit, the patient continued to improve and was extubated on and transferred to the floor on .",0
"His asthma was treated with nebulizers, albuterol and Atrovent.",0
"He was receiving Neurontin, Baclofen for transverse myelitis.",0
His blood pressures were within normal range.,0
"On , the patient's sputum cultures came back positive for pseudomonas and his antibiotics were changed from ceftriaxone to Zosyn.",0
"On , the patient developed difficulty breathing.",0
"At midnight, he was saturating 93% on 100% nonrebreather mask with respiratory rate of 40.",0
"He became visibly tachypneic, anxious.",0
"His arterial blood gas was obtained and was significant for PCO2 38, PO2 56, pH 7.50 and the patient was transferred back to the Medical Intensive Care Unit.",0
"In the Medical Intensive Care Unit, he was not intubated, but was started on CPAP which adequately maintained oxygen saturations above 92%.",0
His treatment for pseudomonas pneumonia was double coverage with ceftazidime in addition to Zosyn.,1
The patient continued to improve and was transferred back to the floor on .,0
"On the floor, he was seen by psychiatry and his pain medication regimen was reevaluated.",0
Valium was taken off the regimen.,0
"Instead, risperidone was added and then gradually tapered down to 2 mg po q hs.",0
"Pulmonary wise, Mr. continued to improve on Zosyn and ceftazidime, however on he developed a rash which was thought to be secondary to antibiotics.",0
His Zosyn was stopped and he was started on Tobramycin.,0
"He received physical therapy and chest therapy, as well as nebulizer therapy during his stay in the unit and on the floor.",0
"His neurological and pain symptoms seemed to be well controlled with risperidone, Paxil, diazepam and Demerol for breakthrough pain.",0
He also received Baclofen for neurogenic bladder and gabapentin for pain.,0
"Hematologically, Mr. ' hematocrit decreased down to 26.6.",0
"The patient was offered a blood transfusion, however Mr. decided not to consent.",0
"His hematocrit remained low, but stable and went up to 33.1 prior to the discharge.",0
Mr. received daily doses of Coumadin because of the history of deep venous thrombosis.,0
His INR upon transfer to the floor was 5.20 and remained at this value for the next few days.,0
He received 2.5 mg of vitamin K on and his INR went up to 1.1.,0
His Coumadin dose was increased to 5.0 prior to discharge.,0
He was also given subcutaneous heparin 5000 units q 12 hours for adequate deep venous thrombosis prophylaxis.,0
Gastrointestinal - the patient continued on his bowel regimen.,0
He received disimpactions as needed.,0
He had bowel movements every one to two days.,0
"At the time of this dictation, the plan was for the patient to go home with services on the following medications: 1.",0
Heparin subcutaneous 5000 units q 12 2.,0
Iron polysaccharides complex 150 mg po qd 3.,0
Tobramycin 120 mg intravenous q8h for three days 4.,0
Risperidone 2 mg po q hs 5.,0
Warfarin 5 mg po qd 6.,0
Simethicone 80 mg po tid 7.,0
Paroxetine 40 mg po qd 8.,0
Trazodone 50 mg po q hs prn for insomnia 9.,0
Senna 2 tablets po bid 10.,0
Docusate 200 mg po bid 11.,0
Pantoprazole 40 mg po qd 12.,0
........... 10 mg po qd 13.,0
Theophylline 400 mg po q a.m. 14.,0
Gabapentin 400 mg q a.m. and 600 mg q hs 15.,0
Baclofen 10 mg po tid 16.,0
Ceftazidine 1 gm intravenous q8h for three days 17.,0
Fentanyl patch 100 mcg transcutaneous patch every 48 hours 18.,0
Bisacodyl 10 mg pr prn 19.,0
Atorvastatin 20 mg po qd 20.,0
Levothyroxine 50 milliequivalents po qd The patient was to be discharged to home in good condition on .,0
Respiratory arrest secondary to narcotic overdose 2.,0
Aspiration pneumonia Clinic appointment with Dr. from Internal Medicine was scheduled for the patient on at 1:30 p.m.,0
He was discharged on a regular diet.,0
Dictated By: MEDQUIST36 D: 16:28 T: 08:56 JOB#:,0
7:31 AM CT HEAD W/O CONTRAST Clip # Reason: r/o stroke acute changes LUE Admitting Diagnosis: SYMPTOMATIC CAROTID STENOSIS RIGHT ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with REASON FOR THIS EXAMINATION: r/o stroke acute changes LUE No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) HISTORY: Rule out stroke.,1
Acute changes involving the left upper extremity.,0
"FINDINGS: There are no previous imaging studies of the brain available for comparison, other than a single obliquely-positioned intraoperative right carotid angiogram dated .",0
"There is a very large area of low aborption, consistent with an acute complete right middle cerebral artery territory infarction, as there is effacement of the cortical sulci and loss of grey-white matter distinction.",1
This finding corresponds to the angiographic finding of occlusion of the right middle cerebral artery at its origin.,1
There is no definite associated hemorrhage.,0
"There is a so- called ""dense right middle cerebral artery,"" which could indicate the presence of clot within the vessel, although there is extensive atherosclerotic calcification also seen in this locale.",1
"There is a probable chronic lacunar infarct within the posterior aspect of the thalamus on the left side with low density in the left cerebral hemispheric periventricular white matter, also consistent with chronic small vessel infarction.",1
There is no shift of normally midline strucutres or hydrocephalus.,0
CONCLUSION: Near-complete involvement of the right middle cerebral artery territory by an acute infarction.,1
"We have telephoned these results to your house officer, immediately following the conclusion of the procedure.",0
"ADDENDUM: There is extensive, somewhat polypoid mucosal thickening within the maxillary sinuses and likely a large polypoid mass within the right side of the nasal cavity.",0
There is moderate ethmoid sinus mucosal thickening.,0
"The sinus abnormalities could represent sinonasal polyposis, as well as accompanying inflammatory disease.",0
"3:11 PM CHEST (PORTABLE AP) Clip # Reason: s/p cvl placement, check cvl placement ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with r hepatic lobectomy for metastatic colon ca REASON FOR THIS EXAMINATION: s/p cvl placement, check cvl placement ______________________________________________________________________________ FINAL REPORT INDICATION: Right hepatic lobectomy for metastatic colon CA, s/p central venous line placement.",0
There are no studies for comparison.,0
"AP PORTABLE CHEST RADIOGRAPH: Allowing for low lung volumes, the cardiomediastinal and hilar contours are unremarkable.",0
The lungs are clear without focal opacities or pleural effusions.,0
An ET tube is seen approximately 3 cm above the carina.,0
A right IJ sheath is noted with tip in the upper SVC.,0
A NG tube is seen with tip coiled in the stomach fundus.,0
A surgical drain is noted overlying the right upper quadrant.,0
There is gaseous distension of the stomach.,0
Soft tissue and osseous structures are otherwise unremarkable.,0
"Satisfactory positioning of lines and tubes, without evidence of pneumothorax.",0
5:48 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with influenza with MSSA superinfection REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATIONS: 79-year-old man with influenza and staphylococcal superinfection.,0
"CHEST, SUPINE PORTABLE: Comparison is made to the prior day.",0
"The patient has been extubated, and a nasogastric tube removed.",0
A left internal jugular venous catheter remains.,0
The lateral portion of the right chest is excluded.,0
There is persistent but mildly improved interstitial pulmonary edema.,0
"Otherwise, the appearance is unchanged with similar effusions and extensive left basilar opacity, likely attributable to atelectasis.",0
"9:16 AM CT HEAD W/O CONTRAST Clip # Reason: eval for change in bleed ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with frontoparietal bleed, now iwth unequal pupils REASON FOR THIS EXAMINATION: eval for change in bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: JMGw TUE 9:58 AM large right sided multifocal intraparenchymal hemorrhage involving the right frontal and temporal lobes with surrounding edema.",0
1.4 cm leftward shift with subfalcine herniation.,0
"subarachnoid hemorrhage in right sylvian fissure, hemorrhage layering in the left lateral ventrical atrium.",1
"air fluid levels in bilateral frontal, ethmoid, maxillary and sphenoid sinus.",0
NG and ETT present and could account for fluid in sinues ______________________________________________________________________________ FINAL REPORT HEAD CT: Contiguous axial imaging was performed through the brain without administration of intravenous contrast.,0
"HISTORY: 88-year-old woman with frontoparietal bleed, now with unequal pupils.",0
Evaluate for change in bleed.,0
"However, CD was brought from outside institution and is awaiting uploading into PACS for comparison.",0
FINDINGS: There is a massive right cerebral parenchymal hemorrhage with evidence of extra-axial and intraventricular extension.,0
"There is multifocal right sided subarachnoid hemorrhage and a small amount of subdural hematoma layering along the midline falx, tentorium and right temporal lobe.",1
"Intraventricular hemorrhage layers along the septum pellucidum, and dependently in the left occipital and is seen filling the fourth ventricle.",0
There is significant mass effect on the right cerebrum with complete effacement of the right lateral ventricle with approximately 1.4 cm leftward shift of normally midline structures.,0
There is also right uncal herniation.,0
There is partial effacement of the ambient cisterns suggestive of early downward transtentorial herniation.,0
Periventricular white matter hypodensity is noted likely related to chronic small vessel disease.,0
There are no fractures identified.,0
"There is fluid within the nasal cavity with air- fluid levels in the paranasal sinuses, likely the result of intubation.",0
There is a nasogastric and endotracheal tube present.,0
IMPRESSION: Massive right cerebral parenchymal hemorrhage with mass effect resulting in leftward subfalcine herniation and early downward transtentorial herniation.,0
Associated intraventricular and right extra-axial (SDH and SAH) noted.,0
(Over) 9:16 AM CT HEAD W/O CONTRAST Clip # Reason: eval for change in bleed ______________________________________________________________________________ FINAL REPORT (Cont),0
"4:44 AM CHEST (PORTABLE AP) Clip # Reason: please assess for interval change Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with ?reaccumulation of fluid s/p chest tube removal REASON FOR THIS EXAMINATION: please assess for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 5:17 A.M. HISTORY: Question reaccumulation of pleural fluid after chest tube removed.",0
IMPRESSION: AP chest compared to through 6: Small left pleural effusion and moderate-to-severe left lower lobe atelectasis are unchanged.,0
"Lung volumes are lower, which may explain change in configuration of the right hemithorax, but several acute right rib fractures are more separated today than they were on .",1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: fall, seizure in ED Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 60 year old female h/o CAD (s/p LAD stent in ', 40% in stent restenosis in ), Type 2 Diabetes, Hypertension, Hyperlipidemia, GERD and Alcohol Dependence presents with evidence of facial trauma and is noted to be seizing.",1
"Family reported to EMS that patient suffered mechanical fall yesterday and suffered facial injuries, AMS and lethargy.",0
"Of note, she has had multiple ED presentations for various complaints.",0
"Per dc summary from , pt endorsed chronic alcohol dependence and notes she drinks 3-4 times per week, either 4-6 beers per day or 1 pint of rum.",1
ED course: admission vitals 98.6 93 137/71 20 100%/RA.,0
She experienced a tonic-clonic generalized seizure in the ED and was intubated for airway protection during her seizure.,0
"She received etomidate, succinyl choline.",0
She was given fentanyl/midazolam boluses and propofol gtt.,0
"Exam otherwise notable for bilateral raccoon eyes, wo midface instability, left forehead head with abrasion.",0
"Labs notable for WBC 24.8 (post seizure), Na 125, AG 26, Hct 32.4, creat 1.1, and UA ketonuria/glucosuria.",0
"Chest xray confirmed ETT placement and low lung volumes, with probable mild pulmonary vascular congestion.",0
"CT head, c-spine, and face negative for fracture.",0
"LP (traumatic) to eval meningitis vs hemorrhage, noted to be grossly bloody and normal WBC, and high RBC.",0
"CTA head obtained and negative for occlusion, flow limiting stenosis or aneurysmal dilatation.",0
Admitted to MICU for EtOH withdrawal seizure and s/p fall.,0
Vitals prior to transfer: 97.6 110 166/94 17.,0
"100% Vt 500, r14, peep5, Fi02 50. .",0
"On the floor, patient is intubated and sedated but nods to answer some questions.",0
"Review of systems: (+) Per HPI - otherwise unable to obtain full ROS Past Medical History: Cath on POBA diagonal for 70% stenosis, in stent restenosis of 40% h/o CAD s/p DES to LAD in Type II Diabetes Hypertension Hyperlipidemia GERD Gastric h. pylori s/p treatment Osteoporosis Bipolar d/o Anxiety h/o tobacco use - quit in 1.5 pk x 30 yrs prior to that H/o EtOH and cocaine abuse Hyponatremia Social History: Tobacco Use: pt is motivated to quit drinkingbut isolation and loneliness are a trigger for her drinking.",1
"has begun an outpatient substance day program at counselling, but didn't go this week due to dysuria ,-- wants to complete ETOH program then go to De program, admits to intermittent Alcohol problems but is working on it,controlled drinking over weekend, Has morning religious devotion and church participation which helps .",0
"She is retired, but had worked in an electronic company previously.",0
She does not currently smoke but previously had a 40-50 pack year history and quit in .,0
She also has a history of ethanol and cocaine abuse.,0
She reports being drug free since .,0
She does not have a history of IVDU.,0
Relapsed 3 years ago with EtOH.,0
Family History: Her mother and father are both alive and healthy in their 80s.,0
Her aunt and grandmother problems in their 50s.,0
"Physical Exam: Admission Physical Exam: Vitals: T:98.4 BP:155/88 P:109 R:14 O2: 99/vent General: intubated female HEENT: Sclera anicteric, b/l sub-ocular bruising, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: Vitals: 97, 128/80, 69, 18 100RA General: comfortably standing up preparing to brush her teeth HEENT: Large hematoma with superficial hemorrhagic erosion on L. forehead.",0
"Neuro: AOx3, CN II-XII grossly intact.",0
Sensation grossly intact to light touch over digits on right hand.,0
No evidence of tremors or asterixis.,0
Neck: supple with full ROM.,0
"Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: RUE splinted.",0
WWP with no evidence of LE edema.,0
No evidence of an acute intracranial injury.,0
Left frontal subgaleal hematoma with periorbital extension.,0
Concurrent facial bone CT is reported separately.,0
CT MaxFace (): Left periorbital hematoma without intraorbital extension.,0
A left paracentral disc herniation at C2-3 flattens the left ventral spinal cord.,0
"If the patient has neurologic symptoms, the cord may be better assessed by MRI.",0
Endotracheal tube in optimal position.,0
"Low lung volumes, with probable mild pulmonary vascular congestion.",0
Subcutaneous soft tissue swelling involving the left frontal and periorbital region without evidence of fracture.,0
see prior CT Head study.,0
No evidence of aneurysm; moderate stenosis of cavernous carotid segments on both sides 3.,0
Interventional NeuroRadiology consult is suggested if clinically warranted to decide on the need for further workup given the h/o bloody CSF.,0
CXR (): Previous mild interstitial pulmonary edema and pulmonary and mediastinal vascular congestion have improved since .,0
There is no appreciable pleural effusion or indication of pneumothorax.,0
"Previous gastric distension has improved, nasogastric tube still in place.",0
EEG (): FINDINGS: BACKGROUND: Was characterized by a low amplitude 9 Hz symmetricposterior dominant alpha rhythm which attenuated symmetrically with eye opening.,0
HYPERVENTILATION: Was performed for 180 seconds with good cooperation and produced no effect.,0
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from flashes per second (fps) produced a normal photic driving with no activation of the record.,0
SLEEP: The patient became drowsy during the record but did not enter sleep.,0
CARDIAC MONITOR: A single EKG channel showed a generally regular rhythm with an average rate of 80 bpm.,0
IMPRESSION: This is a normal EEG during wakefulness and drowsiness.,0
No focal or lateralized abnormalities and no epileptiform discharges were present.,0
XR Right Wrist ():IMPRESSION: 1.,0
No definite right scaphoid fracture.,0
"If clinical concern for occult carpal bone fracture remains, MRI is recommended.",0
Expansile lesion in distal right ulna.,0
"If there is a history of trauma to this site, this lesion may represent a healing fracture.",0
"If there is no history of trauma, cannot exclude a pathologic lytic lesion and an MRI is recommended for further evaluation.",0
Very limited study due to motion artifact.,0
No gross evidence of temporal lobe lesion.,0
There is a focus of susceptibility artifact in the sub-cortical right frontal lobe likely representing hemosiderin deposition from a small hemorrhage.,0
Soft tissue swelling in the right frontal and periorbital subcutaneous soft tissues representing an evolving hematoma.,0
"Brief Hospital Course: 60y F hx of alcohol dependence, CAD, T2DM, HTN, and HL who presented with AMS and was intubated for a seizure after an unwitnessed mechanical fall.",1
"# Seizure: Upon admission, the patient was noted to have AMS following an unwitnessed mechanical fall with LOC and headstrike and subsequently had a seizure while in the ED that required intubation for airway protection.",0
She was transferred to the MICU as her seizure was initially thought to be secondary to alcohol withdrawal.,1
She was extubated and transferred to the floor with no subsequent symptoms to suggest alcohol withdrawal.,1
An EEG was done and identified an epileptiform focus in the right temporal lobe that was unremarkable on exam.,0
MRI was performed which revealed no focus for epileptiform activity.,0
Neurology did not feel that anti-epileptic drugs were indicated at this time.,0
"Given the lack of withdrawal symptoms during her hospitalization, it was thought that her seizure was likely either due to the head trauma associated with falling or due to toxic metabolic component given that her Na was 120 on presentation.",0
She is scheduled for follow up with neurology after discharge.,0
Cervical Disc Disease: Trauma CT spine on admission revealed left paracentral disc herniation at C2-3 which flattens the left ventral spinal cord.,0
Ortho spine was consulted and felt no further imaging or follow up was needed as the patient was completely asymptomatic.,0
"Should she develop symptoms such as pain, numbness, decreased dexterity in the upper extremity she will follow up with orthopaedic spine.",0
# Right Hand Pain: Pain noted in the right anatomical snuff box concerning for scaphoid fracture.,0
"Wrist radiographs did not demonstrate an acute fracture involving her carpal bones, but did demonstrate a healing fracture of her right ulna.",0
On review patient does recall a prior fall which caused a great deal of pain in her right hand which she never had evaluated.,0
Her hand was splinted as schapoid fractures can often be occult initially and she was setup with followup in orthopedic hand clinic.,0
EtoH Dependence: Patient with reports of 1 pint daily to every other day.,0
No signs of withdrawal during hospitalization.,0
Patient did feel that drinking was a problem for her.,0
In discussion with social work she agreed to enter outpatient treatment for her EtoH Dependence.,0
She was continued on thiamine and folate during her hospitalization.,0
"# Chest Pain - During the hospitalization the patient reported an isolated incident of chest pain that was likely secondary to indigestion/GERD given that her pain followed her meal, was associated with belching, and did not have any anginal equivalents (nausea, extremity numbness).",0
Her EKG was unchanged from admission and her symptoms improved with ranitidine.,0
"# Leukocytosis: Upon admission, she was noted to have a leukocytosis of 25, however she was afebrile and did not have any exam or imaging features concerning for an infectious etiology.",0
It was presumed that it was secondary to stress from her seizure.,0
Her WBC count returned to prior to discharge without intervention.,0
"# Hyponatremia: Upon admission, she was noted to have a Na of 120 that improved with IVF and normalized over the course of her hospitalization.",0
# HTN: The patient's blood pressure remained stable throughout admission on her home regimen of anti-hypertensives.,0
Transitional issues for PCP: patient acknowledged heavy alcohol use and was given contacts for support groups and rehabilitation programs.,0
Please follow-up with her regarding her attendance and subsequent desire to curb her alcohol use.,0
-Follow up with Hand Clinic for further evaluation of possible right scaphoid fracture Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO qAM.,0
"12. omeprazole 20 mg Capsule, Delayed Release(E.C.)",0
13. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
14. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day.,0
*HOLD* 15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* 8. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Disp:*15 Tablet(s)* Refills:*2* 9. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
10. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.,0
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day.,0
13. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day.,0
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.,0
Discharge Disposition: Home Discharge Diagnosis: Primary: Seizure likely secondary to head trauma Alcohol Abuse Secondary: HLD HTN Osteoporosis Discharge Condition: Mental Status: Clear and coherent.,0
"Discharge Instructions: Ms. , Thank you for allowing us to participate in your care.",0
You were admitted to the hospital following a fall where you suffered some external trauma to your head and subsequently had a seizure that we feel was likely from your head trauma.,0
You were evaluated by EEG (a test that evaluates for a cause of seizure) and because this test wasn't normal you had an MRI of the brain which was normal.,0
"Also, we noticed that you had some hand pain following your fall, and while an x-ray of your right hand didn't show a fracture, we still splinted your hand because a fracture could have been present but difficult to see on xray.",0
You will follow up in hand clinic for further evaluation of this pain on .,0
It is also important that you follow-up with the contacts we gave you regarding your alcohol use.,0
Please cut down on your alcohol intake as alcohol aubse can cause liver disease and death.,0
Please note the following changes in your medications: -START RANITIDINE 75mg by mouth daily Please follow up with the appointments listed below.,0
Bring this paperwork so your physician understand what happened during your recent admission.,0
"Followup Instructions: Department: BIDHC With: , : 545A , , MA Phone: When: TUESDAY at 11:15 AM Department: NEUROLOGY When: MONDAY at 2:30 PM With: , MD Building: Ks Building (/ Complex) Campus: EAST Best Parking: Garage Department: ORTHOPEDICS When: WEDNESDAY at 9:10 AM With: ORTHO XRAY (SCC 2) Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: ORTHOPEDICS When: WEDNESDAY at 9:30 AM With: Building: Campus: EAST Best Parking: Garage",0
"7:50 PM CHEST (PORTABLE AP) Clip # Reason: eval for trauma ______________________________________________________________________________ MEDICAL CONDITION: 22 year old woman intubated, transferred after MVC REASON FOR THIS EXAMINATION: eval for trauma ______________________________________________________________________________ FINAL REPORT INDICATION: 22-year-old female, intubated and transferred after motor vehicle collision.",1
ONE VIEW CHEST: Evaluation is limited as the patient is lying on a trauma board.,0
An endotracheal tube is seen approximately 1.5 cm above the carina.,0
An NG tube is seen with its tip in the distal stomach.,0
Lungs are clear without evidence of effusions or pneumothorax.,0
IMPRESSION: No evidence of fractures or acute cardiopulmonary process.,0
"8:58 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ?",0
PE Admitting Diagnosis: STATUS EPILEPTIC Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 20 year old man with persistent tachycardia and extensive L DVT REASON FOR THIS EXAMINATION: pulmonary embolus?,1
No contraindications for IV contrast ______________________________________________________________________________ WET READ: DLrc WED 10:12 PM Scattered segmental pulmonary emboli on the right.,0
Hypoattenuating material within collapsed region on the left indicative of component of consolidation such as infection or aspiration.,0
"Peripherally based nodular opacification in the right lower lobe, likely atelectasis (4:48/302B:112).",0
Status post tracheostomy in standard position.,0
Left subclavian approach CVC terminates at the cavoatrial jxn/right atrium.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 20-year-old man with persistent tachycardia and extensive left-sided DVT.,0
TECHNIQUE: Contiguous helical acquisition through the chest was performed with intravenous contrast.,0
"Coronal, sagittal, and oblique images of the pulmonary arteries were created.",0
There is no mediastinal or hilar lymphadenopathy.,0
The tracheostomy tube terminates 3.1 cm above the carina.,0
A central venous catheter terminates within the right atrium approximately 1.5 cm below the cavoatrial junction.,0
No pericardial effusion is identified.,0
"Following contrast administration, the aorta opacifies normally without evidence of aortic dissection.",0
Occlusive filling defects are noted within the segmental right upper lobe anterior and apical pulmonary artery segments causing expansion of the vessels consistent with acute pulmonary embolus.,1
Also noted is non-occlusive thrombus within the segmental and subsegmental pulmonary artery branches of the right lower lobe posterior basal segments.,1
"The left pulmonary artery, lobar, segmental and subsegmental branches opacify normally without intraluminal thrombus.",0
Secretions are noted within the left lower lobe posterior basal segment bronchus causing complete collapse of this segment and partial collapse of the remainder of the left lower lobe.,0
Atelectasis is noted involving the posterior basal segment of the right lower lobe.,0
"Additionally, there are adjacent patchy airspace opacities within the right lower lobe, which are suspicious for aspiration or infection.",0
"No pleural effusions or pneumothorax (Over) 8:58 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ?",0
PE Admitting Diagnosis: STATUS EPILEPTIC Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) is identified.,0
No suspicious lytic or sclerotic lesions are identified within the visualized osseous structures.,0
"Although this study was not designed for subdiaphragmatic evaluation, no acute abnormalities are noted in the visualized upper abdomen.",0
Acute segmental pulmonary emboli involving the right upper lobe anterior and apical segments and segmental and subsegmental emboli involving the posterior basal right lower lobe pulmonary arteries.,1
"Bilateral lower lobe atelectasis with marked endobronchial secretions within the posterior basal segment of the left lower lobe, consistent with partial drowned lung.",0
Additional foci of patchy airspace consolidation in the remainder of the right lower lobe is suspicious for superimposed aspiration or infection.,0
Central venous catheter terminates 1.5 cm below the cavoatrial junction within the right atrium.,0
These findings were communicated to Dr. at 10:05 p.m. on via telephone by Dr. and to Dr. by Dr. via telephone at 11am.,0
PATIENT/TEST INFORMATION: Indication: H/O cardiac surgery.,0
Height: (in) 67 Weight (lb): 170 BSA (m2): 1.89 m2 BP (mm Hg): 126/59 HR (bpm): 57 Status: Inpatient Date/Time: at 11:44 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
Moderate (2+) MR. TRICUSPID VALVE: Moderate [2+] TR.,0
Admission Date: Discharge Date: Date of Birth: Sex: M HISTORY: The patient is a 35-3/7 weeks gestational age male admitted with respiratory distress.,1
"MATERNAL HISTORY: Mother is a 28 year old Gravida 1, Para 0 negative, RPR nonreactive, Hepatitis B surface antigen negative, rubella immune, GBS unknown.",0
PREGNANCY HISTORY: Estimated date of confinement .,0
Rupture of membranes eight hours prior to delivery yielding clear amniotic fluid.,0
No maternal fever or fetal tachycardia.,0
"Proceeded to spontaneous vaginal delivery under NEONATAL COURSE: The infant emerged with spontaneous cry, was dried, bulb suctioned and given free flow oxygen.",1
Grunting respirations and retractions noted in Delivery Room.,0
Transported uneventfully to Neonatal Intensive Care Unit on oxygen.,0
"PHYSICAL EXAMINATION: On admission, the patient's birth weight was 2,515 grams, head circumference 33.5 cm, length 47.5 cm.",0
The patient is non-dysmorphic with an intact palate.,0
The chest with mild retractions with spontaneous breathing.,0
Good excursion on IMV settings.,0
"Cardiovascularly, regular rate and rhythm, femoral pulses are normal S1, S2.",0
"Abdomen is soft, nondistended, no organomegaly.",0
There is a three vessel cord.,0
"Active and alert with normal tone, moving all extremities.",0
"Has normal suck, gag, grasp and Moro reflexes.",0
"RESPIRATORY: The patient was initially intubated on SIMV settings of 24, flat at a rate of 20.",0
He was quickly weaned down to room air and extubated within 24 hours of life.,0
He subsequently transitioned to CPAP and over the next 48 to 72 hours transitioned to nasal cannula.,0
"By day of life five, he was weaned to room air entirely.",0
CARDIOVASCULAR: The patient throughout the admission had a normal blood pressure.,0
The murmur that was initially heard after birth resolved.,0
"FLUIDS, ELECTROLYTES AND NUTRITION: Weight on , was 2360, up 25 grams from the day prior.",0
Discharge weight will be provided at the end of this dictation.,0
The patient was initially made NPO and started on intravenous fluids at 80 cc per kilo per day.,0
The total fluids were gradually increased after extubation and resolution of respiratory symptoms.,0
The patient was started on enteral feeds and was seen taking good p.o.,0
"He is currently on breast milk 20, of which he takes most of his feeds by bottle, but also breast feeds approximately three to four times per day.",0
"GASTROINTESTINAL: As above, the patient tolerated feeds well.",0
He did develop a physiologic hyperbilirubinemia that was somewhat exaggerated on day of life five.,0
The total bilirubin peaked at 20.4.,0
Both mother and baby had A positive blood type and was negative.,0
"Double phototherapy was initiated and phototherapy was discontinued on day of life eight with rebound bilirubin 12 hours later that was the same as the bilirubin level at which the phototherapy had been discontinued, namely 8.9.",0
"HEMATOLOGY: The patient's CBC on admission was a white blood cell count of 13.8, 40 polys, 4 bands, a hematocrit of 53.8 and platelets 329.",0
"INFECTIOUS DISEASE: Given his initial respiratory distress, a blood culture was sent and the patient was started on Ampicillin and Gentamicin.",1
"At 48 hours, the patient's respiratory symptoms had greatly improved and the blood cultures remained no growth to date.",0
"At that time, Ampicillin and Gentamicin were discontinued.",0
"On day of life nine, , when the patient was transitioned from an incubator to an open crib, he did have a brief episode of hypothermia down to 36??????C.",0
The physical examination was entirely within normal limits.,0
"However, a CBC was sent at that time in addition to a blood culture.",0
The CBC showed a normal white count and differential with a hematocrit 47.8% and platelets 561k.,0
NEUROLOGY: The patient had a normal neurologic examination and given his gestational age did not require cranial ultrasound screening.,0
SENSORY: screening was performed and results were normal for both ears.,0
"OPHTHALMOLOGY: The patient did not undego retinal examination, given his gestational age.",0
PSYCHOSOCIAL: Social Worker was involved with the family.,0
"NAME OR PRIMARY CARE PEDIATRICIAN: , M.D.",0
His practice is Pediatrics and the phone number there is .,0
Feeds at discharge: Breast milk plus breast feeding p.o.,0
Medications: Ferinsol 2 cc p.o.,0
Car Seat Positioning Screening was performed and normal.,0
State Newborn Screening Status is still pending.,0
Immunizations received was a Hepatitis B vaccine on .,0
"Follow-up appointments: The mother will contact Dr. office to have a follow-up appointment on Monday or Tuesday of next week, namely or 13.",0
"Respiratory distress, suspect mild respiratory distress syndrome versus transient tachypnea of the newborn.",1
Dictated By: MEDQUIST36 D: 16:40 T: 17:14 JOB#:,0
"WHITE, P. ORTHO FA11 10:10 AM CT L-SPINE W/O CONTRAST Clip # Reason: Eval hardware.",0
PLEASE INCLUDE T12 IN SCAN.,0
Admitting Diagnosis: L2 COMPRESSION FRACTURE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman s/p T12-L5 fusion REASON FOR THIS EXAMINATION: Eval hardware.,0
CONTRAINDICATIONS for IV CONTRAST: No needed for bone eval ______________________________________________________________________________ PFI REPORT Expected post-op changes.,0
HArdware position- grossly unremarkable except for mild lateral deviation of the pedicle screws- left at L1 and right at L3.,0
2.7x3.2 cm peripherally calcified lesion in the left upper quadrant in the region of the tail of pancreas and spelnic artery- dd- splenic artery aneurysm or pancreatic pseudocyst.,0
Further evalaution with CT Abdomen and comparison with any prior studies.,0
5:46 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: s/p mvc ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with above REASON FOR THIS EXAMINATION: s/p mvc ______________________________________________________________________________ FINAL REPORT HISTORY: MVA.,0
AP FILM OF CHEST ON TRAUMA BOARD.,0
Right and probably left pneumothoraces layering on supine position with hyperlucency in the lung bases.,0
"There was one and probably two right chest tubes, the position of which raised a question whether they lie within major fissure.",0
There is an associated small amount of subcutaneous emphysema on the right.,0
The superior mediastinum is slightly widened and there is a unusual contour of the NG tube (suggestive of mediastinal hemorrhage).,0
The tip of ET tube lies at the level of T3.,0
No fracture identified although the lateral left hemithorax not optimally visualized.,1
"AP FILM OF THE PELVIS, ON TRAUMA BOARD.",0
Suboptimal exam with the upper portion of the sacrum and iliac bones not imaged and SI joint inadequately assessed.,1
IMPRESSION: Probable bilateral pneumothoraces and mediastinal hemorrhage.,0
", S. MED 5:43 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: r/o stone, cirrhosis, hepatic injury, abscess Admitting Diagnosis: HYPERKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with multisystem organ failure, shock liver REASON FOR THIS EXAMINATION: r/o stone, cirrhosis, hepatic injury, abscess ______________________________________________________________________________ PFI REPORT PFI: Cholelithiasis without evidence of acute cholecystitis.",1
", TSICU 2:28 PM PORTABLE ABDOMEN Clip # Reason: Ileus vs. mechanical SBO Admitting Diagnosis: HANGING ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with increased TF residuals and no BM after tracheal injury.",1
REASON FOR THIS EXAMINATION: Ileus vs. mechanical SBO ______________________________________________________________________________ PFI REPORT No evidence of obstruction.,0
Likely coiled right-sided femoral catheter.,0
9:24 AM CT HEAD W/O CONTRAST Clip # Reason: please compare with prior CT Admitting Diagnosis: FALL/HEAD INJURY ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with contusions REASON FOR THIS EXAMINATION: please compare with prior CT No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: A 67-year-old male with intracranial hemorrhage after trauma.,0
TECHNIQUE: CT imaging of the brain without intravenous contrast.,0
Comparison is made to prior CT'S from and .,0
FINDINGS: Foci of intraparenchymal hemorrhage with adjacent edema within both temporal lobes appear unchanged.,0
Hypodensity within the right temporal/occipital/parietal lobes with distribution of the inferior division of the right middle cerebral artery is again seen that has an appearance consistent with evolving infarction.,1
Subdural hematomas in the left temporal fossa and right frontal region are stable.,0
The ventricles and sulci are not dilated.,0
No shift of normally midline structures is seen.,0
A fracture of the right temporal bone appears stable.,0
"IMPRESSION: Unchanged examination with stable bilateral temporal lobe intraparenchymal hemorrhage, subdural hematomas, and evolving infarction in the distribution of the inferior branch of the right middle cerebral artery.",1
A right frontal intracranial pressure monitor has been removed.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY OF PRESENT ILLNESS: The infant was admitted to NICU on , for mild to moderate respiratory distress.",1
Birth weight was 3235 grams.,0
Gestational age is 40 and 4/7 weeks.,0
"Maternal history: Infant born to a 36-year-old gravida 1, para 0, 1 mother.",0
"type O positive, antibody negative.",0
"Hepatitis B negative, RPR nonreactive and rubella immune.",0
"Normal fetal survey, denying prenatal course except for mild hypertension, no treatment required.",0
"The infant born by cesarean section on , at 4:53 a.m. due to non-reassuring fetal heart rate tracing.",1
"Meconium thick and the infant cried initially at 3 minutes of age, known to have acute cyanosis with respiratory distress requiring oxygen, Never received positive pressure ventilation.",1
Apgar of 8 at 1 minute of age and 8 at 5 minutes of age.,0
Brought to NICU for further evaluation.,0
Rupture of membranes x5 hours and no interpartum antibiotics were given.,0
"PHYSICAL EXAMINATION: Weight 3235 grams, 50th percentile; length 50.8 cm, 50th percentile; head circumference 35 cm, 75th percentile.",0
"Temperature was 99.1, heart rate 140, respiratory rate 60, pressure 74/28 with a mean of 43%.",0
"Mild to moderate respiratory distress with nasal flaring, mild to moderate intercostal subcostal retractions.",0
Normal heart rate without murmur but heart sounds were distant.,0
Normal male genitalia with testes descended bilaterally.,0
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The patient was admitted to NICU with mild to moderate respiratory distress with nasal flaring and mild to moderate intercostal subcostal retractions with muffled heart sounds.,1
Initial chest x-ray showed bilateral pneumothoraces.,0
The infant was able to wean to room air during the newborn day.,1
Follow up chest x-ray revealed pneumothoraces resolved.,0
"CARDIOVASCULAR: No murmur, heart rate 110 to 140, regular.",0
pressure 74/43 with a mean of 55.,0
"FLUIDS, ELECTROLYTES AND NUTRITION: The infant initially NPO.",0
IV fluids of D10W began during newborn day.,1
The infant initially with episodes of hypoglycemia requiring D10 boluses.,1
"Enteral feeds began with Similac 20 and breast milk on newborn day, changed to Similac 24 or breast milk on day of life 1.",0
The infant successfully weaned off IV fluids on day of life 2.,0
Current weight is 3285 grams.,0
GASTROINTESTINAL: The infant had a bilirubin of 4.7/0.3 on day of life 1 and did not require phototherapy.,0
HEMATOLOGY: Initial hematocrit was 57.5 with a platelet count of 142 on admission to NICU.,0
INFECTIOUS DISEASE: CBC with differential and culture screen on admission to NICU.,0
Antibiotics subsequently discontinued after 48 hours with a negative culture.,0
"Initial CBC with a white count of 13.1, 58 poly's and 0 bands.",0
NEUROLOGY: The infant does not meet criteria for head ultrasound.,0
AUDIOLOGY: Hearing screen would be performed per newborn nursery's criteria.,0
OPHTHALMOLOGY: The infant does not meet criteria.,0
PSYCHOSOCIAL: social worker involved with the family.,0
Pediatrician was contact prior to the infant going to the newborn nursery.,1
"Feedings, ad lib less than 24 breast milk or breast feeding.",0
Does not meet criteria for car seat positioning.,0
State newborn screening will be sent by newborn nursery per protocol.,0
Immunizations received: The infant has not received immunizations.,0
"Transient tachypnea of the newborn, resolved.",1
", MD Dictated By: MEDQUIST36 D: 22:51:24 T: 03:13:31 Job#:",0
Height: (in) 70 Weight (lb): 185 BSA (m2): 2.02 m2 BP (mm Hg): 116/44 HR (bpm): 60 Status: Inpatient Date/Time: at 11:53 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Saline Technical Quality: Adequate INTERPRETATION: Findings: The underlying rhythm appears to be atrial fibrilaltion with ventricular paced rhythm.,0
"No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest x 2.",0
No discrete vegetations are seen.,0
IMPRESSION: Mild symmetric left ventricuclar hypertrophy with normal cavity size and preserved regional/global biventricular systolic function.,0
7:29 AM CHEST (PORTABLE AP) Clip # Reason: CHF Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with acute pul edema s/p intubvatuion REASON FOR THIS EXAMINATION: CHF ______________________________________________________________________________ FINAL REPORT AP CHEST 9:41 A.M.: HISTORY: Acute pulmonary edema following intubation.,1
IMPRESSION: AP chest compared to and 22: The patient has been extubated.,0
Mild interstitial edema has recurred following resolution of the left pleural effusion.,0
Transvenous right atrial and ventricular pacer leads project over their expected courses.,0
Change in its position suggests that the left pectoral pacemaker is mobile in its pouch.,0
"2:19 PM MR HEAD W & W/O CONTRAST Clip # Reason: increased or change in lesions Admitting Diagnosis: HEADACHE Contrast: MAGNEVIST Amt: 23 ______________________________________________________________________________ MEDICAL CONDITION: 18 year old woman with demyelinating disease, question chanege in lesions after steroid course.",1
REASON FOR THIS EXAMINATION: increased or change in lesions No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 18-year-old female patient with demyelinating disease and question of change in lesions after steroid course.,1
Rule out increase or change in lesions.,0
"TECHNIQUE: MRI of the head was performed with and without IV contrast as per ""multiple sclerosis protocol.""",1
"FINDINGS: There has been interval decrease in size of the non-enhancing ovoid FLAIR hyperintensity within the left parietal subcortical white matter, which measures 1.3 cm, previously measuring 1.8 cm.",0
There is stable non-enhancing FLAIR signal hyperintensity involving the bilateral forceps major and splenium of the corpus callosum.,0
There is a new heterogeneous FLAIR hyperintensity involving the right cerebral peduncle.,0
There is stable subtle FLAIR hyperintensity in the periphery of the right basis pons/right cerebellar peduncle junction.,0
"There are multiple punctate foci of FLAIR hyperintensity involving the left superior frontal gyrus, subtly seen on the prior exam.",0
There has been interval resolution of the increased FLAIR hyperintensity within the sulci.,0
There is no abnormal enhancement or restricted diffusion demonstrated.,0
The ventricles are normal in size with no evidence of hydrocephalus.,0
The visualized major vascular flow voids are unremarkable.,0
There is no evidence for acute infarction or hemorrhage.,1
There is fluid within the right mastoid air cells and mucosal thickening of the left mastoid air cells.,0
Otherwise the paranasal sinuses are clear.,0
Interval development of a heterogeneous FLAIR hyperintensity within the right cerebral peduncle.,0
"Interval decrease in size of the left parietal subcortical white matter hyperintensity and stable bilateral forceps major, splenium, and right cerebellar peduncle/basis pons FLAIR hyperintensity.",0
This can be seen demyelinating processes such as multiple sclerosis or ADEM.,1
(Over) 2:19 PM MR HEAD W & W/O CONTRAST Clip # Reason: increased or change in lesions Admitting Diagnosis: HEADACHE Contrast: MAGNEVIST Amt: 23 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
Fluid within the right mastoid air cells.,0
"In the correct clinical history, this can reflect mastoiditis.",0
4:50 AM MR HEAD W/ CONTRAST Clip # Reason: pre-surgical mapping Contrast: GADAVIST Amt: 8 ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with left frontal meningioma REASON FOR THIS EXAMINATION: pre-surgical mapping No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: MRI of the head with contrast.,0
"CLINICAL INDICATION: History of left frontal meningioma, presurgical mapping, WAND protocol.",0
COMPARISON: Multiple prior MRI examinations of the head since through .,0
"TECHNIQUE: After the intravenous administration of gadolinium contrast material, axial MP-RAGE sequences were obtained, sagittal and coronal reformations were provided.",0
"FINDINGS: Post-surgical changes are redemonstrated in the right parietal convexity with persistent irregular enhancement in the surgical cavity and vasogenic edema, no significant shifting of the midline structures is identified.",0
The pattern of enhancement is irregular and apparently remains unchanged since the most recent study dated .,0
"At the left parietal convexity, again an oval-shaped enhancing lesion is redemonstrated, measuring approximately 12 x 10 mm in transverse dimension, likely consistent with a meningioma, there is persistent and unchanged pattern of enhancement in the adjacent sulcus (image #85, series #2).",0
Fiducial markers are in place.,0
"The patient is status post right parietal craniotomy, with persistent irregular area of enhancement in the right parietal lobe and vasogenic edema.",0
"Unchanged oval-shaped enhancing lesion in the left parietal convexity, likely consistent with a meningioma and unchanged area of uniform enhancement in the left parietal region as described above.",0
"6:56 AM CHEST (PORTABLE AP) Clip # Reason: r/o pneumonia or other etiology Admitting Diagnosis: THROMBOCYTOPENIA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with constant chest pain over the past 24 hours REASON FOR THIS EXAMINATION: r/o pneumonia or other etiology ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST FROM AT 7:15 CLINICAL INDICATION: 56-year-old with constant chest pain for 24 hours, rule out pneumonia.",0
"Comparison is made to the patient's prior study of at 5:21 as well as selected images of a chest, abdominal, and pelvic CT performed at 23:25.",0
Single AP upright chest from at 7:15 a.m. is submitted.,0
IMPRESSION: The left hemidiaphragm is slightly elevated.,0
Slight prominence of the hilum is felt to likely be prominent vessels when correlated with the recent CT of .,0
No evidence of pleural effusions or pneumothorax.,0
Linear scarring at the left apex is unchanged.,0
"Calcification of the aorta is again seen, consistent with atherosclerosis.",0
"Please note that report of the CT study from did report multiple sites of osseous metastatic disease as well as a pathologic T12 fracture, none of which are visible on this plain film study.",1
"10:56 AM CHEST (PORTABLE AP) Clip # Reason: Left Pleural effusion increasing in size Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with left sided pleural effusion, CHF and a.fib with recent pacer placement REASON FOR THIS EXAMINATION: Left Pleural effusion increasing in size ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 4:28 PM 1.",1
Increased small right pleural effusion with associated atelectasis.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Left effusion, CHF and AFib with recent pacer placement, evaluate effusion.",1
FINDINGS: The right pectoral pacemaker remains in place.,1
"Since , the small right pleural effusion is increased with associated atelectasis.",0
A moderate left effusion and atelectasis are stable.,0
Aortic knob calcifications are redemonstrated.,0
The cardiac silhouette is obscured by the left effusion.,1
Stable moderate left effusion and atelectasis.,0
"2:33 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: evaluate extent of aortic dissection, through iliacs please Admitting Diagnosis: TYPE A DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with s/p repair asc aortic dissection w/ AVR REASON FOR THIS EXAMINATION: evaluate extent of aortic dissection, through iliacs please No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb TUE 6:37 PM 1. aortic dissection from arch, extending into right external and internal iliac arteries and into left common iliac artery.",1
Celiac artery also with dissection.,1
"Left renal artery arises from false lumen, but no signs of infarct.",0
2. pleural effusion with atelectasis.,0
3. mediastinal collection ______________________________________________________________________________ FINAL REPORT HISTORY: 47-year-old male status post repair of ascending aortic dissection with aortic valve regurgitation.,1
Evaluate extent of aortic dissection through iliac space.,1
"TECHNIQUE: CT of the chest, abdomen and pelvis was performed before and after administration of intravenous contrast.",0
"Images were reconstructed in the axial, sagittal, coronal planes.",0
3D images were also obtained.,0
CT CHEST WITHOUT AND WITH CONTRAST S/p sternotomy.,0
"Presence of pleural effusion, more prominent on the left side, associated with dependent atelectasis on the bases.",0
Presence of band of atelectasis in the right lower lobe.,0
Coronary arteries arise from expected location and are unremarkable.,0
CT ABDOME WITHOUT AND WITH CONTRAST Presence of 30 x 24 mm left renal cyst.,0
"Liver, spleen, right kidney, adrenals, pancreas, bowel loops are unremarkable.",0
CT PELVIS WITHOUT AND WITH CONTRAST: Visualized portions of small bowel are unremarkable.,0
"Small amount of fluid collection in the pelvis (series 3, image 216).",0
CT ANGIOGRAM: Presence of replaced aortic valve.,1
"(Over) 2:33 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: evaluate extent of aortic dissection, through iliacs please Admitting Diagnosis: TYPE A DISSECTION ______________________________________________________________________________ FINAL REPORT (Cont) Thoracic aorta graft seems intact, without signs of leak.",1
Presence of aorta dissection that starts distal to the PDA origin of the descending aorta and extends into the left common iliac artery and on the right side extends through the right external iliac as well as right internal iliac artery.,1
Note is made that the left renal artery comes off from the false lumen.,0
"The SMA, right renal and origins are patent and come off from the true lumen of the aorta.",0
"Celiac trunk is twisted at its origin and a hypodense plane can be seen in the lumen, suggestive of dissection.",0
Patient is status post aortic valve replacement and ascending aorta graft placement.,1
Presence of aortic dissection starting distally to the PDA origin and extends into the right external and internal iliacs and into the left common iliac arteries.,1
Dissection can also be demonstrated at celiac artery.,1
Pleural effusion associated with atelectasis.,0
7:26 PM CT HEAD W/O CONTRAST Clip # Reason: eval trauma ______________________________________________________________________________ MEDICAL CONDITION: 30 year old man s/p MCC REASON FOR THIS EXAMINATION: eval trauma No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 30-year-old man status post motorcycle collision.,1
TECHNIQUE: MDCT data were acquired through the head without the use of intravenous contrast.,0
Images were reconstructed using bone and soft tissue algorithms and displayed in multiple planes.,0
"FINDINGS: No hemorrhage, large territorial infarction, edema, mass or shift of normally midline structures is present.",0
The ventricles and sulci have normal size and configuration.,0
Incidental note is made of a left maxillary sinus mucous retention cyst.,0
Findings were discussed with Dr. and the trauma team in person at 9 p.m. on .,0
5:31 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: PTX Admitting Diagnosis: CAD; ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p right CT insertion REASON FOR THIS EXAMINATION: PTX ______________________________________________________________________________ FINAL REPORT (REVISED) STUDY: AP chest .,0
HISTORY: 69-year-old man status post right chest tube insertion.,0
There is a right basilar chest tube.,0
There is subcutaneous emphysema within the right chest wall.,0
"There is a right apical pneumothorax, faintly visualized.",0
There is low lung volumes.,0
There are small pleural effusions bilaterally.,0
Median sternotomy wires are present.,0
"IMPRESSION: Right apical pneunothorax persistent, following chest tube placement.",0
"5:10 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with scapular fracture, poly trauma REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old man with scapular fracture polytrauma.",1
TECHNIQUE: Single AP view of the chest was performed.,0
"COMPARISON: Portable radiograph from and 6, .",0
CT of the torso from .,0
FINDINGS: There is a diffuse reticulonodular opacity involving most of the right lung without focal consolidation.,0
The cardiomediastinal silhouette and hila are normal.,0
Right-sided subclavian line terminates at the cavoatrial junction.,0
"A nasogastric tube passes beyond the GE junction, with the tip not seen.",0
The endotracheal tube ends 3.5 cm above the carina.,0
An oval shaped foreign body projecting over the thoracic spine is new compared to and likely extracorporal.,0
IMPRESSION: Diffuse reticulonodular opacity on the right is likely secondary to aspiration or atelectasis.,0
"4:10 PM PICC LINE PLACMENT SCH Clip # Reason: s/p failed bedside attempt for PICC placement, will need IR- Admitting Diagnosis: PNEUMONIA ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.",0
"ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with bacteremia, endocarditis.",1
"REASON FOR THIS EXAMINATION: s/p failed bedside attempt for PICC placement, will need IR-guided PICC placement on Monday ______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for antibiotics.",0
Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access are on file.,0
A peel-away sheath was then placed over a guidewire and a single lumen PICC line measuring 33 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the left brachial venous approach.,0
"Final internal length is 32 cm, with the tip positioned in SVC.",0
4:03 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: HEPATIC ENCEPHALOPATHY ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with alcoholic cirrhosis, variceal bleeding, frequent episodes of respiratory failure currently off mechanical ventilation.",1
interval change ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF COMPARISON: Radiograph of .,0
FINDINGS: Feeding tube and central venous catheter remain in place.,0
"Widespread bilateral alveolar and interstitial opacities have slightly worsened in the interval and may reflect asymmetric pulmonary edema, with or without superimposed process such as infection or aspiration.",0
12:25 PM CHEST (PORTABLE AP) Clip # Reason: ?PNEUMO Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with CAD s/p CABG S/P CHEST TUBE REMOVAL REASON FOR THIS EXAMINATION: ?PNEUMO ______________________________________________________________________________ FINAL REPORT AP PORTABLE CHEST INDICATION: CAD status post CABG and chest tube removal.,1
FINDINGS: The patient is status post left chest tube removal and extubation.,0
A Swan-Ganz catheter has also been removed.,0
A tiny left apical penumothorax is noted.,0
The patient is status post median sternotomy and CABG with cardiomegaly and bilaterally small pleural effusions and patchy atelectasis at the left base.,0
IMPRESSION: Tiny left apical pneumothorax status post left chest tube removal.,0
Small left effusion and left basilar atelectasis.,0
"5:33 AM CT HEAD W/O CONTRAST Clip # Reason: Assess for CVA/bleed Admitting Diagnosis: LEG PAIN ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with h/o Afib and metastastic bladder CA, p/w lethargy and acute change MS REASON FOR THIS EXAMINATION: Assess for CVA/bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT CONTRAST INDICATION: A 75-year-old man with history of atrial fibrillation, metastatic bladder carcinoma, presenting with lethargy and acute mental status change.",1
"FINDINGS: There is no acute intracranial hemorrhage, edema, shift of normally midline structures or hydrocephalus.",0
There is no evidence of major vascular territorial infarction.,0
Surrounding soft tissues and osseous structures are unremarkable.,0
Minimal mucosal thickening is noted in the right maxillary sinus.,0
The rest of the paranasal sinuses and mastoid air cells are well aerated.,0
"The ventricles, sulci and extra-axial spaces are prominent, consistent with age-related involutional change.",0
"There are periventricular white matter hypodensities, mild, consistent with chronic microvascular ischemic changes.",0
"No CT evidence of major vascular territorial infarction, but MRI remains most sensitive for evaluation of acute ischemia.",0
"4:47 PM C-SPINE, TRAUMA Clip # Reason: eval for , completion series (open mouth odontoid, AP, ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with thumb fracture left hand REASON FOR THIS EXAMINATION: eval for , completion series (open mouth odontoid, AP, lateral) ______________________________________________________________________________ FINAL REPORT INDICATION: Trauma.",0
TWO LATERAL VIEWS OF CERVICAL SPINE provide visualization through the C7 vertebral body.,0
There is no evidence of fracture or malialignment.,0
There is chronic discogenic disease at the C3/4 and C6/7 levels.,0
Small anterior osteophytes are present.,0
Prevertebral soft tissues appear normal.,0
Please correlate with CT of cervical spine on same day.,0
", S. SICU-A 4:42 AM CHEST (PORTABLE AP) Clip # Reason: eval for improvement Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with ARDS REASON FOR THIS EXAMINATION: eval for improvement ______________________________________________________________________________ PFI REPORT 1.",0
Persistent low lung volumes with left greater than right basilar subsegmental atelectasis and small effusion.,0
7:39 PM PORTABLE ABDOMEN Clip # Reason: Obstruction?,0
Admitting Diagnosis: N STEMI ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with severe CAD with acute onset of severe abdominal pain with diffuse TTP and guarding.,1
REASON FOR THIS EXAMINATION: Obstruction?,0
______________________________________________________________________________ WET READ: SUN 8:15 PM single frontal view of abdomen with stool and contrast in large bowel with nonobstructive bowel gas pattern.,0
AAA repair with Y-stent placement similar in appearance compared to scout of .,0
______________________________________________________________________________ FINAL REPORT INDICATION: Severe CAD and acute onset abdominal pain with diffuse tenderness to palpation and guarding.,1
Assess for obstruction or perforation.,0
TECHNIQUE: Single supine radiograph of the abdomen.,0
"COMPARISONS: CT abdomen and pelvis, .",0
FINDINGS: Non-obstructive bowel gas pattern is seen with air and stool seen throughout the colon.,0
Aortic and iliac stents are unchanged in appearance from the recent CT.,0
Multiple clips are seen in the bilateral inguinal regions.,0
IMPRESSION: No evidence of ileus or obstruction.,0
9:07 AM BABYGRAM (CHEST ONLY) PORT Clip # Reason: possible pneumonia Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: worsening respiratory distress REASON FOR THIS EXAMINATION: possible pneumonia ______________________________________________________________________________ FINAL REPORT PORTABLE EXAM ON AT 9:12 A.M.,1
Overall diffuse opacification is improved compared to the prior study and nearly normal today.,0
There is a feeding tube within the stomach.,0
The PICC line on the left terminates above the left clavicle.,0
"Previously curved laterally, now just extends straight downwards.",0
Height: (in) 65 Weight (lb): 130 BSA (m2): 1.65 m2 BP (mm Hg): 90/34 HR (bpm): 108 Status: Inpatient Date/Time: at 13:49 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: Definity Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
"Compared with the findings of the prior study (tape reviewed) of , mitral regurgitation is now similar to slightly less prominent.",0
"9:56 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate for progression of volume overload Admitting Diagnosis: SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with dyspnea, tachycardia, crackles on exam REASON FOR THIS EXAMINATION: please evaluate for progression of volume overload ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:12 P.M., .",0
"There has been substantial improvement in pulmonary edema, particularly in the right lung.",0
Left perihilar consolidation is the most significant region of abnormality followed by the right lung base and these areas have not cleared.,0
Small bilateral pleural effusion has increased slightly on the left and decreased on the right.,0
Mediastinal vascular engorgement is unchanged.,0
Left-sided skinfold and overlying tubing should not be mistaken for pneumothorax.,0
1:52 PM CHEST (PORTABLE AP) Clip # Reason: eval for interval changes of bilat infiltrates.,0
"coord w/ tu Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 52 yo man with falling SpO2 s/p esophagogastrectomy, intubated.",0
REASON FOR THIS EXAMINATION: eval for interval changes of bilat infiltrates.,0
"coord w/ tube study ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: INDICATION: Status post esophagogastrectomy.",0
"An endotracheal tube remains in place, currently terminating approximately 6.5 cm above the carina.",0
"A right subclavian vascular catheter terminates in the right atrium, and a right internal jugular vascular catheter terminates within the superior vena cava.",0
"The patient is status post esophagogastrectomy, and there is a persistent barium collection in the lower right mediastinum, presumably within the pullthrough.",0
"Again demonstrated is a bilateral alveolar pattern, most prominent centrally in the perihilar and basilar regions, with slight interval worsening in the interval since the recent study.",0
Moderate-sized left pleural effusion and small right pleural effusion are without significant change allowing for incomplete imaging of the right lung laterally.,0
"Slightly proximal location of endotracheal tube, which could be advanced for more optimal placement.",0
New right subclavian vascular catheter terminates in the right atrium and could be withdrawn for more optimal placement.,0
These findings have been communicated with the clinical service caring for the patient on the date of the study.,0
"Slight worsening of bilateral alveolar pattern, most likely due to worsening pulmonary edema.",0
", D. MED MICU-7 10:54 AM PORTABLE ABDOMEN Clip # Reason: please assess for free air, other acute change Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with sepsis, s/p trach, with mesenteric ischemia REASON FOR THIS EXAMINATION: please assess for free air, other acute change ______________________________________________________________________________ PFI REPORT Continued distention of the small bowel loops.",1
"3:08 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: 81 year old man with NSCLCA with SOB and DOE eval for PE Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with NSCLCA with SOB and DOE eval for PECr 7d prior 0.5 REASON FOR THIS EXAMINATION: 81 year old man with NSCLCA with SOB and DOE eval for PE No contraindications for IV contrast ______________________________________________________________________________ WET READ: DCsc WED 3:45 PM NO PE R HILAR MASS SOME POT OPBSTRUCTIVE COLLAPSE IN ANT SED RUL, CANNNOT EXCLUFE INFECTION IN THIS REGION WET READ VERSION #1 DCsc WED 3:39 PM NO PE ______________________________________________________________________________ FINAL REPORT INDICATION: Shortness of breath and non-small cell lung cancer.",0
TECHNIQUE: Pre and post contrast images were obtained through the pulmonary vasculature.,0
100 cc of Optiray were administered without complication.,0
Nonionic contrast is provided the rapid bolus required for the angiogram images.,0
CT ANGIOGRAM CHEST BEFORE AND AFTER IV CONTRAST: There are no enlarged axillary lymph nodes.,0
There are coarse coronary artery calcifications.,0
There is excellent opacification of the pulmonary arterial vasculature and there is no evidence of embolus or thrombus.,0
There is a spiculated right upper lobe mass adjacent to the right hilum which encases the upper lobe pulmonary artery.,0
"The artery may be slightly narrowed, but there is no obstruction and there is good flow distally.",0
There is narrowing of the anterior segment airway resulting in post- obstructive collapse with air bronchograms.,0
Infection in this region is not excluded.,0
This region does not have a linear contour suggestive of post XRT fibrosis.,0
"There are small scattered opacities seen throughout the left lung, which are nonspecific.",0
There are no cavitating masses.,0
Limited views of the extreme upper abdomen show no definite abnormalities.,0
The patient has severe kyphosis.,0
There is calcification of the anterior longitudinal ligament and complete collapse of a mid thoracic vertebral body.,0
"Given the severity of the kyphosis, it is difficult to say exactly which level this is.",0
Sagittal and coronal reformats were useful in evaluating the spine and lungs.,0
(Over) 3:08 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: 81 year old man with NSCLCA with SOB and DOE eval for PE Contrast: OPTIRAY Amt: 100CC ______________________________________________________________________________ FINAL REPORT (Cont) Right upper lobe mass with partial post obstructive collapse and probable post obstructive pneumonia.,1
This region does not have the appearance of post XRT fibrosis.,0
Scattered small opacities in the left lung are nonspecific.,0
Severe kyphosis with compression deformities.,0
", M. NSURG SICU-B 1:20 PM MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Reason: Pls do fiesta sequence Admitting Diagnosis: ANEURYSM Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with R temporal headaches, no SAH, ACOMM aneurysm REASON FOR THIS EXAMINATION: Pls do fiesta sequence No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",1
"No evidence of subarachnoid or other intracranial hemorrhage, or other acute intracranial process.",0
Markedly abnormal appearance to the anterior communicating artery complex with a large 4.5 mm bilobed saccular aneurysm with relatively long and broad neck.,0
This originates from the junction of the right ACA and the ACom vessel and is directed inferiorly.,0
"Likely very small, less than 2-mm aneurysm originating at the junction of the left ACA and the ACom vessel, directed anterolaterally.",0
Unremarkable cervical MRA with no evidence of vertebral or carotid dissection.,0
9:15 AM CT HEAD W/O CONTRAST Clip # Reason: assess hydrocephlus please due around 0800 on Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 71 y/o with intraventricular and right frontal IPH resection with EVD clamped REASON FOR THIS EXAMINATION: assess hydrocephlus please due around 0800 on No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT ROUTINE UNENHANCED CT HEAD PERFORMED .,1
HISTORY: Intracranial hemorrhage with clamping of the ventricular drain.,1
Comparison is made with study from .,0
FINDINGS: There is a left frontal ventricular catheter with its tip in the left ventricular body.,0
Again seen is extensive intraventricular hemorrhage with approximately 9.5 mm midline shift.,0
"There is a right frontal burr hole with a residual right extra-axial mixed-density fluid collection, which has decreased in size since the prior study.",0
There is hypodensity in the right frontal lobe related to residual hematoma and gliosis.,0
The size of the residual right frontal hematoma has not increased.,0
"There is a right frontal subgaleal hematoma, which is unchanged.",0
Mild subarachnoid hemorrhage is unchanged.,0
IMPRESSION: Postoperative sequelae with residual intracranial hemorrhage as above.,1
Ventricles have not significantly changed in size status post clamping of the EVD.,0
"3:34 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: ETT placement, bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Reintubated, abd distention REASON FOR THIS EXAMINATION: ETT placement, bowel gas pattern ______________________________________________________________________________ FINAL REPORT EXAMINATION: Portable Babygram.",0
DATE OF EXAMINATION: TIME: 15:31.,0
CLINICAL HISTORY: The patient is seven week old with history of intubation and here for evaluation of bowel gas pattern.,0
COMPARISON: Comparison is made to prior examination dated .,0
"FINDINGS: In the interim, slight interval increase in coarse interstitial bilateral opacities associated with subsegmental atelectasis is noted.",0
"No focal consolidation, pleural effusion or pneumothorax is noted.",0
Endotracheal tube with its tip located approximately 1 cm above carina is seen.,0
There is a nasogastric tube with its tip projecting over the stomach.,0
"Mildly prominent several bowel loops are noted in the abdomen without evidence of pneumatosis, abnormal calcification, or abnormal mass.",0
Interval increase in diffuse coarse interstitial opacities associated with subsegmental atelectasis.,0
Mildly prominent several loops of bowel in the abdomen without evidence of pneumatosis.,0
"(Over) 3:34 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: ETT placement, bowel gas pattern Admitting Diagnosis: NEWBORN ______________________________________________________________________________ FINAL REPORT (Cont)",0
5:44 PM CHEST (PORTABLE AP) Clip # Reason: Please assess for infiltrates/edema.,0
"______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with inferior wall MI, has been febrile.",0
REASON FOR THIS EXAMINATION: Please assess for infiltrates/edema.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Fever.,0
"CHEST, AP PORTABLE: No comparisons.",0
There is opacification of the left hemithorax and shift of the mediastinum to the left consistent with h/o left pneumonectomy.,0
"A right IJ central venous catheter terminates probably in the mid-SVC, although exact location is difficult to assess with the mediastinal shift.",0
There is an ill-defined alveolar opacity within the right middle lobe with air bronchograms consistent with pneumonia or aspiration.,0
7:39 PM CHEST (PORTABLE AP) Clip # Reason: pneumonia?,0
"______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with SAH, thalamic infarct REASON FOR THIS EXAMINATION: pneumonia?",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Subarachnoid hemorrhage, thalamic infarct.",0
"PORTABLE SUPINE AP CHEST, ONE VIEW: Comparison .",0
The right lateral CP angle is not included on the study.,0
The heart is mildly enlarged with an LV configuration.,0
"There is linear density in the left lower lobe, likely reflecting atelectasis rather than consolidation.",0
The remainder of the lungs are grossly clear.,0
IMPRESSION: Left lower lobe atelectasis.,0
No CHF allowing for supine technique.,0
9:34 AM CTA ABD W&W/O C & RECONS; CT PELVIS W&W/O C Clip # CT 150CC NONIONIC CONTRAST Reason: please do CTA-triphasic to reconstruct hepatic artery Admitting Diagnosis: LIVER TX Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with elevated alk phos s/p hepatic artery repair s/p liver transplant REASON FOR THIS EXAMINATION: please do CTA-triphasic to reconstruct hepatic artery No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Elevated alkaline phosphatase after hepatic artery repair.,1
TECHNIQUE: CT of the abdomen before and after the administration of 150 cc of Optiray nonionic contrast due to fast bolus technique.,0
"CT ANGIOGRAM OF THE ABDOMEN: There has been interval increase in size of the right pleural effusion, now moderate.",0
"Small left pleural effusion persists, as does bibasilar compressive atelectasis.",0
Pre-contrast images demonstrate a 1 mm stone at the midpole of the right kidney.,0
A percutaneous drainage catheter is present within the right upper quadrant.,0
"Post-contrast, arterial phase images and reconstructed images demonstrate a patent hepatic artery with a 2-2.5 cm segment of mild narrowing, in the expected location of the surgical reanastomosis.",0
The hepatic vasculature within the liver appears patent.,0
The portal vein is patient.,0
"There are multifocal areas of nonenhancing liver parenchyma, consistent with infarction.",0
"The spleen, pancreas, adrenal glands, and kidneys are within normal limits.",0
"Again noted is a large fluid collection anterior to the liver, containing some high density components suggesting hematoma, as well as some pockets of gas.",1
"Additionally, a linear fluid collection extends along the medial edge of the liver containing fluid and gas.",0
Some of this may relate to Surgicel packing material.,0
There is a small to moderate amount of free abdominal fluid.,0
There is no sign of bowel obstruction.,0
"PELVIS WITH CONTRAST: The bladder, distal ureters, and pelvic loops of bowel are within normal limits.",0
There is no inguinal or deep pelvic lymphadenopathy.,0
There is a moderate amount of free pelvic fluid.,0
Multiplanar reformatted images and workstation reformatted images were essential in assessing the arterial narrowing.,0
Liver volume was calculated at 2216 cubic cm.,0
(Over) 9:34 AM CTA ABD W&W/O C & RECONS; CT PELVIS W&W/O C Clip # CT 150CC NONIONIC CONTRAST Reason: please do CTA-triphasic to reconstruct hepatic artery Admitting Diagnosis: LIVER TX Contrast: OPTIRAY Amt: 200 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,1
A 2 cm long area of mild narrowing within the hepatic artery.,0
Multifocal areas of nonenhancing liver parenchyma consistent with infarction.,0
"Multiple collections of fluid within the anterior abdomen and along the medial aspect of the liver, containing some gas and high density material consistent with hematoma.",1
These could be sampled if indicated.,0
Findings reviewed with Dr. at 3:00 p.m. .,0
"10:54 AM CHEST (PA & LAT) Clip # Reason: 38 year old woman with fever, r/o consolidation Admitting Diagnosis: CHIARI MALFORMATION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with fever, r/o consolidation REASON FOR THIS EXAMINATION: 38 year old woman with fever, r/o consolidation ______________________________________________________________________________ FINAL REPORT CHEST TWO VIEWS ON HISTORY: Consolidation.",0
FINDINGS: There is right IJ line with tip in the distal SVC.,0
There is a small amount of opacity in the left lower lobe just above the diaphragm that could represent volume loss or early infiltrate.,0
"Compared to the study from , there is improved aeration bilaterally.",0
"1:05 AM CT HEAD W/O CONTRAST Clip # Reason: SDH, ?",0
"PROGRESSION ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with SDH REASON FOR THIS EXAMINATION: ?progression No contraindications for IV contrast ______________________________________________________________________________ WET READ: YGd TUE 1:48 AM 19 mm left hemispheric acute possibly on chronic SDH with compression of left hemisphere and 16 mm rightward shift, similar as compared to preceding exam from outside hospital, c/w subfalcine herniation.",1
"Partial effacement suprasellar and ambien cistern on the R, concerning for early transtent herniation.",0
"WET READ VERSION #1 YGd TUE 1:47 AM 19 mm left hemispheric acute possibly on chronic SDH with compression of left hemisphere and 16 mm rightward shift, similar as compared to preceding exam from outside hospital.",1
______________________________________________________________________________ FINAL REPORT INDICATION: 45-year-old male with subdural hemorrhage; for evaluation of progression.,1
"COMPARISON: Preceding ""FUH"" NECT, at 22:37H on .",0
"TECHNIQUE: Contiguous non-contrast axial MDCT images were acquired through the brain, with multiplanar reformations.",0
"FINDINGS: There is a large 19 mm left cerebral convexity subdural hematoma of mixed attenuation, more hypodense anteriorly, suggestive of acute-on-subacute-to-chronic duration.",1
This hematoma demonstrates a more globular configuration along the parietal lobe and extends into the middle cranial fossa.,0
"Overall, this exerts significant mass effect on the subjacent parenchyma, causing a 19-mm rightward subfalcine herniation, not significantly changed (allowing for differences in plane of scanning).",0
The left lateral ventricle is effaced and the right lateral ventricular atrium and temporal appear entrapped.,0
"There is also partial obliteration of the suprasellar cistern and effacement of the right ambient cistern, suggestive of early transtentorial and uncal herniation.",0
No obvious intra-axial hemorrhage at this time.,0
"Additional note is made of an 8 mm hypodensity in the right frontal lobe, likely a sequela of prior ischemia.",0
No skull fracture is seen.,0
"There is mucosal thickening involving the ethmoidal, sphenoid, and bilateral maxillary sinuses.",0
"Aerosolized secretions are seen in the nasopharynx, likely related to intubation.",0
Globes and soft tissues are unremarkable.,0
Large left hemispheric subdural hematoma exerting tremendous mass effect on the brain causing 19 mm rightward shift.,1
"Subfalcine herniation and early (Over) 1:05 AM CT HEAD W/O CONTRAST Clip # Reason: SDH, ?",0
PROGRESSION ______________________________________________________________________________ FINAL REPORT (Cont) transtentorial and uncal herniation.,0
Overall appearance of shift and size of hematoma stable as compared to preceding exam from outside hospital.,0
"Subcentimeter hypodensity in the right frontal lobe, likely sequela of chronic small vessel ischemic disease.",0
"NOTE ADDED IN ATTENDING REVIEW: This study, performed at 0120H on , is available for my review at 0900H on .",0
8:08 PM TRAUMA #3 (PORT CHEST ONLY); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: TRAUMA ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: .,0
"HISTORY: Status post accident, hit by boat.",0
FINDINGS: Single portable view of the chest.,0
The lungs are clear of focal consolidation or large effusion.,0
There is no pneumothorax based on the supine film.,0
IMPRESSION: Unremarkable portable chest x-ray.,0
10:42 AM CHEST (PORTABLE AP) Clip # Reason: eval for worsening PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with worsening sob.,0
hypoxic with 88% on 5L NC.,0
Pt has been on aspiration precautions.,0
REASON FOR THIS EXAMINATION: eval for worsening PNA ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumonia.,0
FINDINGS: The heart and medistinal contours are normal.,0
There has been interval clearing in the left mid zone and right basal opacification.,0
There is persistent right middle lobe infiltrate.,0
There is a small left basal effusion.,0
There is a left-sided central line with the tip in the distal SVC or proximal right atrium.,0
IMPRESSION: Persistent right mid zone infiltrates in keeping with known infection.,0
1:07 PM CT CHEST W/O CONTRAST Clip # Reason: RMLF aspiration vs collapse Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: year old woman with ?aspiration pna vs collapse REASON FOR THIS EXAMINATION: RMLF aspiration vs collapse No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc WED 4:19 PM 1.,0
Marked increase in consolidation in the inferior right and upper lobes c/w pneumonia or aspiration.,0
"Marked increase in right lower lobe collapse with complete obstruction of the right lower lobe bronchus, with material filling the bronchial tree in the right lower lobe.",0
Marked increase in left lower lobe near-total collapse with obstruction of leftlower lobe bronchi.,0
PFI VERSION #1 PFI VERSION #2 CXWc WED 4:11 PM 1.,0
Marked increase in consolidation in the inferior right upper lobe c/w pneumonia or aspiration.,0
Marked increase in left lower lobe near-total collapse with obstruction of right lower lobe bronchi.,0
______________________________________________________________________________ FINAL REPORT HISTORY: -year-old woman with question of aspiration pneumonia or collapse.,0
TECHNIQUE: Non-contrast MDCT-acquired axial images were obtained through the chest.,0
5-mm and 1.25-mm collimated axial images and coronal and sagittal reformatted images were generated.,0
"CT CHEST WITHOUT IV CONTRAST: Since the prior study two days earlier, there has been a marked increase in heterogeneous consolidation in the inferior portion of the right upper lobe, compatible with pneumonia or sequela of aspiration.",0
"Further, there has been interval complete collapse of the right lower lobe and near-complete collapse of the right middle lobe.",0
"The bronchus intermedius is completely obstructed, with material filling the bronchi supplying the right lower lobe.",0
"On the left, there has been an increase in heterogeneous consolidation in the inferior left upper lobe, compatible with infection or sequela of aspiration.",0
"Additionally, there has been a further increase in near-complete collapse of the left lower lobe, with obstruction of many of the bronchi supplying the left lower lobe.",0
There is a small amount of pleural fluid bilaterally.,0
The lung apices remain aerated.,0
(Over) 1:07 PM CT CHEST W/O CONTRAST Clip # Reason: RMLF aspiration vs collapse Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT (Cont) The heart is slightly enlarged.,0
"Dense atherosclerotic calcifications are present in the mitral annulus, coronary arteries, aortic arch and origin of the cervical vessels.",0
The great vessels are otherwise unremarkable in the absence of IV contrast.,0
There is no mediastinal lymphadenopathy by size criteria.,0
"While this exam is not optimized for assessment of the abdomen, there are no acute abnormalities in the upper abdomen.",0
OSSEOUS STRUCTURES: The patient is markedly kyphotic and bones demonstrate diffuse demineralization.,0
"Numerous healed, sclerotic rib fractures are present.",0
"A compression deformity of the T12 vertebral bodies unchanged from , but the acuity is otherwise unknown.",0
No worrisome bony lesions are identified.,0
"Interval development of consolidation in the inferior right and left upper lobes, compatible with new pneumonia or sequela of aspiration and near-complete collapse of the right middle lobe.",0
"Marked interval increase in now complete right lower lobe collapse and near complete left lower lobe collapse, with total obstruction of the right lower lobe bronchus and material filling the right lower lobe bronchial tree.",0
"Additionally, there is near-complete obstruction of the left lower lobe bronchi.",0
Small amount of pleural fluid.,0
"Compression deformity of T12 vertebral body, acuity unknown.",0
", P. FA9A 6:11 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please do po contrast through NG tube +IV contrast, please a Admitting Diagnosis: ABDOMINAL PAIN Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with UC, sp proctocolectomy, now admitted for high ostomy output REASON FOR THIS EXAMINATION: please do po contrast through NG tube +IV contrast, please assess bowel No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.",0
Markedly-dilated proximal small bowel loops and more distal collapsed small bowel loops.,0
Contrast is seen entering the ileostomy.,0
These findings are concerning for partial small bowel obstruction.,1
"Extensive mesenteric fat stranding, which is nonspecific.",0
"Extensive anterior abdominal wall subcutaneous soft tissue fat stranding, new when compared to prior exam.",0
Interval development of pelvic free fluid.,0
Right lower lobe nodular opacities measuring up to 3 mm.,0
"11:51 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: uvc placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 28 week twin rds REASON FOR THIS EXAMINATION: uvc placement ______________________________________________________________________________ FINAL REPORT BABYGRAM, 24:58: CLINICAL HISTORY: Newborn twin on Day of Life #1, who is the product of a 28- week gestation.",1
"FINDINGS: A single portable view of the chest and abdomen was obtained and is compared to the previous film dated , at 22:49.",0
The UV catheter has been advanced somewhat so that its tip is at the junction between the right atrium and intrahepatic IVC.,0
"There is a fairly dense, ground-glass opacification of the lungs, in keeping with the diagnosis of hyaline membrane disease.",0
"Again, there is more than the usual amount of air projecting over the neck and upper mediastinum.",0
This may be positioned within the proximal esophagus.,0
"There may be a pneumomediastinum, as an alternate explanation.",0
"The bowel gas pattern is normal, and there are no appreciated vertebral anomalies.",0
", M. TSICU 5:57 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: POLYTRAUMA S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man s/p 30ft fall, now with rib fxs, posterior medistinal hematoma s/p embolization of intercostal arteries REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ PFI REPORT 1.",0
New bilateral moderate-sized pleural effusions with associated compressive atelectasis.,0
"4:25 PM CT HEAD W/O CONTRAST Clip # Reason: 55 year old man s/p VPS placement, please evaluate for inter Admitting Diagnosis: INTRACRANIAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man s/p VPS placement, please evaluate for interval changes.",0
"REASON FOR THIS EXAMINATION: 55 year old man s/p VPS placement, please evaluate for interval changes.",0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DRT WED 5:51 PM 1.,0
"Apparently status post interval placement of new external ventricular drainage catheter, with ventriculostomy tip reaching the end of the right foramen of , and expected postprocedural pneumocephalus.",0
Ventricles overall not significantly changed in size and configuration since the study with further resorption of the intraventricular blood.,0
"Status post recent ACOM aneurysm coiling, with continued resorption of the associated subarachnoid and right frontal parenchymal hemorrhage, and no new hemorrhage seen.",1
"Further evolution of the subacute infarct involving the right occipital lobe, extending into that parietal lobe and likely involving the splenium of the corpus callosum in a right posterior cerebral arterial distribution.",0
"This finding should be closely correlated with relevant clinical data, i.e., as patient developed a corresponding abnormality of visual field.",0
"______________________________________________________________________________ FINAL REPORT CT HEAD WITHOUT CONTRAST, HISTORY: 55-year-old male, status post VPS placement; evaluate for interval changes.",0
TECHNIQUE: Contiguous 5-mm axial MDCT sections were obtained from the skull base to the vertex and viewed in brain and bone window on the workstation.,0
"FINDINGS: The study is compared with the most recent CTA (including NECT) dated , as well as preceding study of .",0
"As before, the patient is status post coiling of the large lobulated ACom aneurysm with which he presented on .",0
Extensive metallic star artifact from the coil limits the evaluation of the adjacent structures.,0
"The patient is also status post right frontal burr hole, with apparent interval manipulation, in that there is now more extensive gas and a small amount of hemorrhage and fluid in the scalp subcutaneous tissues at the catheter insertion site.",0
"There is now also a relatively small amount of right paramedian frontal pneumocephalus, as well as gas within the ventricular chain, related to the placement of the ventriculostomy catheter, which terminates in the region of the right foramen of .",0
There is no discrete hemorrhage along the catheter tract.,0
"Since the time of the patient's admission, there has been continued resorption (Over) 4:25 PM CT HEAD W/O CONTRAST Clip # Reason: 55 year old man s/p VPS placement, please evaluate for inter Admitting Diagnosis: INTRACRANIAL BLEED ______________________________________________________________________________ FINAL REPORT (Cont) of the right paramedian frontal parenchymal hematoma, with only scant residual subarachnoid hemorrhage in sulci at, particularly, the left frontoparietal vertex.",1
"However, there is now more well-defined and wedged-shaped low-attenuation involving both and white matter of virtually the entire right occipital lobe, extending into the posterior parietal lobe, without internal hemorrhage.",0
This represents evolving right occipital infarct.,0
"There is also low-attenuation traversing the splenium of the corpus callosum, also present on the earlier and the most recent study, which may, at least in part, relate to this process.",0
There is no finding to suggest acute infarction in any additional vascular territory.,0
"Apparently status post interval placement of new external ventricular drain, with ventriculostomy catheter tip reaching the region of the right foramen of , and expected post-procedural pneumocephalus.",0
Ventricles not significantly changed in overall size and configuration since the study with further resorption of the intraventricular blood.,0
"Status post recent ACom aneurysm coiling, with continued resorption of the associated subarachnoid and right frontal parenchymal hemorrhage, and no new hemorrhage seen.",1
"This finding should be closely correlated with relevant clinical data, i.e.",0
has the patient developed a corresponding visual field abnormality?,0
"PATIENT/TEST INFORMATION: Indication: Chronic myelogenous leukemia, hypoxia, coronary artery disease.",1
Recently found to have new regional wall motion abnormaility Height: (in) 71 Weight (lb): 280 BSA (m2): 2.44 m2 BP (mm Hg): 116/53 HR (bpm): 86 Status: Inpatient Date/Time: at 11:10 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anteroseptal - hypo; mid anteroseptal - hypo; septal apex - hypo; RIGHT VENTRICLE: RV not well seen.,0
No MS. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.,0
Dilated main PA. Dilated branch PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion.,0
The anterior septum appears hypokinetic.,0
There is moderate pulmonic valve stenosis.,0
The main pulmonary artery is dilated.,1
The branch pulmonary arteries are dilated.,0
"Compared with the findings of the prior study (images reviewed) of , no obvious change but the technically suboptimal nature of both studies precludes definitive comparison.",0
6:50 PM HUMERUS (AP & LAT) LEFT Clip # Reason: ?,0
fracture alignment s/p fracture brace application.,0
Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old woman with left humerus fracture.,1
______________________________________________________________________________ FINAL REPORT SINGLE PORTABLE VIEW OF THE LEFT HUMERUS AT 19:11 HOURS.,0
HISTORY: Fracture alignment post-brace application.,0
Technologist notes single view was obtained as patient is unable to move arm due to brace.,0
FINDINGS: There has been interval improvement in the alignment post-application of brace as the previously noted overlap and one shaft width medial displacement of distal fracture fragment has now been reduced.,1
The distal fracture fragment is approximately one-half shaft width medially displaced and the overlap has been eliminated.,1
A large butterfly fragment remains in place along the lateral aspect.,0
IMPRESSION: Improved alignment as above.,0
12:38 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ?,0
"Admitting Diagnosis: HYPERKALEMIA;ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with worsening abdominal pain, distension.",1
CONTRAINDICATIONS for IV CONTRAST: Acute renal failure ______________________________________________________________________________ WET READ: SHSf FRI 1:58 PM 1.,1
"Bibasilar pulmonary opacities, greater on the right, could reflect pneumonia or aspiration.",0
"Unchanged fecal loading without evidence of obstruction, perforation or colitis.",0
Slight progression of stool with slight progression of contents into the descending colon.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Worsening abdominal pain and distention, assess for obstruction or perforation.",0
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to pubic symphysis without oral or IV contrast.,0
IV contrast was not administered secondary to allergy and renal dysfunction.,0
Oral contrast was not administered due to refusal by the primary team.,0
COMPARISONS: CT abdomen and pelvis from and abdominal radiograph from .,0
"CT OF THE ABDOMEN WITHOUT CONTRAST: The imaged lung bases demonstrate right greater than left ground-glass opacification and bibasilar consolidation which likely reflects pneumonia or aspiration with superimposed atelectasis Please note, assessment of solid and visceral organs in the abdomen is limited in the absence of intravenous contrast.",0
"The liver is normal in attenuation without focal lesion, intra- or extra-hepatic biliary ductal dilatation.",0
The gallbladder appears to be surgically absent.,0
"The pancreas is atrophic, but unremarkable.",0
The spleen and right adrenal gland are unremarkable.,0
Stable thickening of the left adrenal gland is noted.,0
The kidneys do not demonstrate hydronephrosis.,0
Right extrarenal pelvis is noted.,0
Calcifications in the kidneys bilaterally could reflect nonobstructive stones and/or vascular calcifications.,1
Severe atherosclerotic disease is seen descending aorta and at the ostia of the major vessels in the abdomen with the right renal artery stent noted.,1
Unchanged focal ulceration and an outpouching of the distal thoracic aorta (2:4) is unchanged.,0
Nasogastric tube is seen terminating in the stomach.,0
Residual oral contrast (Over) 12:38 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ?,0
Admitting Diagnosis: HYPERKALEMIA;ACUTE RENAL FAILURE ______________________________________________________________________________ FINAL REPORT (Cont) from the previous examination is seen in the stomach.,1
"Additionally, the previously administered oral contrast is shown to have passed into the small and large bowel.",0
Severe fecal loading is again noted and minimally changed from the prior study.,0
It does appear that more stool has progressed into the descending and sigmoid colon.,0
Diverticular disease is seen in the sigmoid colon without active inflammatory process.,1
Small bowel is relatively decompressed.,0
No bowel wall thickening or free fluid is seen.,0
There is no pericolonic stranding to suggest colitis.,0
No evidence of obstruction is seen.,0
CT OF THE PELVIS WITHOUT CONTRAST: Foley catheter and air are seen in the bladder.,0
"OSSEOUS STRUCTURES: Degenerative changes are seen in the spine, as in the prior study without suspicious focal lytic or blastic lesions.",0
Similar degree of extensive fecal loading seen in the large bowel with increased transit of stool into the previously somewhat decompressed descending and sigmoid colon.,0
No evidence of colitis or perforation.,0
Unchanged focal ulceration in the descending aorta without significant intramural hematoma.,0
Unchanged thickening of the left adrenal gland.,0
Unchanged extensive atherosclerotic calcification with renal artery stent on the right.,0
Interval increase in degree of right greater than left bibasilar opacities likely reflective of pneumonia or aspiration.,0
4:02 PM CHEST (PA & LAT) Clip # Reason: increased wbc and left shift ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with REASON FOR THIS EXAMINATION: increased wbc and left shift ______________________________________________________________________________ FINAL REPORT HISTORY: Increased white blood cell count and left shift.,0
PA/LATERAL VIEWS OF CHEST: Comparison is made to a previous exam of .,0
There are decreased lung volumes which accentuate the heart size and vascular markings.,1
The lungs show no focal consolidations or pleural effusions.,0
Noted is a left sided central venous catheter which terminates within the SVC.,0
"Again noted are multiple calcific densities in the region of the right axilla, unchanged from exams dating back to .",0
No evidence of an acute cardiopulmonary process.,0
"1:29 PM CHEST (PORTABLE AP) Clip # Reason: assess for evolving pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with alcohol withdrawal, with fever spike and incresing WBC count.",1
REASON FOR THIS EXAMINATION: assess for evolving pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: 53 y/o man with fever spike and increasing white blood cell count.,0
2 frontal portable radiographs of the chest were obtained and compared to the next prior study dated .,0
There is an ETT in good position with its tip approximately 4 cm above the carina.,0
A right IJ line is unchanged in position.,0
There is an NG tube with tip in the mid stomach.,0
The overall lung volumes remain low and there is persistent discoid atelectasis in the left mid lung zone.,0
There has been interval clearing within the left lower lobe in the retrocardiac region.,0
No new areas of consolidation are identified and there are no pleural effusions.,0
The pulmonary vascularity is unremarkable.,0
"IMPRESSION: Interval improvement in left lower lobe opacity, most likely representing improving atelectasis.",0
"This could also represent improving pneumonia if the patient has received interval therapy, but rapidity of improvement favors atelectasis.",0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: position of Left IJ Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with resp failure s/p left IJ placement.,0
REASON FOR THIS EXAMINATION: position of Left IJ ______________________________________________________________________________ FINAL REPORT HISTORY: Left IJ placement.,0
"FINDINGS: Left IJ central line is malpositioned, coursing towards the left axilla.",0
"New left apical pleural capping could reflect the re-distribution of effusion since the patient was in the Trendelenburg position for the procedure, though the possibility of a hematoma complicating the line placement must be considered.",0
This information was discussed by the radiology resident with Dr. .,0
1:43 AM CHEST (PA & LAT) Clip # Reason: please eval for interval change Admitting Diagnosis: TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with LLL pneumonia and new O2 requirement.,0
REASON FOR THIS EXAMINATION: please eval for interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 1:44 A.M. ON HISTORY: Previous left lower lobe pneumonia.,0
IMPRESSION: AP chest compared to : Previous left lower lobe consolidation and a small left pleural effusion and a smaller consolidation in the right upper lung have all cleared.,0
"The heart is moderately enlarged, but there is no pulmonary edema or appreciable pleural effusion.",0
Pleural thickening around the displaced right rib fractures is relatively mild and unchanged.,0
Spinal stabilization hardware is present but not evaluated by this study.,0
10:06 AM CHEST (PORTABLE AP) Clip # Reason: CHECKING PLACEMENT OF NG TUBE.,0
"please also comment on infilt Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: year old woman with S/P recent stroke, course complicated by pneumonia.",1
REASON FOR THIS EXAMINATION: CHECKING PLACEMENT OF NG TUBE.,0
"please also comment on infiltrates, effusions, edema.",0
______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess NG tube.,0
Large left pleural effusion has increased in size.,0
Moderate right pleural effusion is unchanged.,0
Cardiac silhouette is obscured by the pleural parenchymal opacities.,0
Mild interstitial pulmonary edema is unchanged.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby girl is a 41-week gestation infant born to a 37-year-old gravida 2 and para 0 (now 1).,1
"Mother with type O positive, hepatitis B surface antigen negative, rapid plasma reagin nonreactive, antibody negative, and Rubella immune.",0
There a maternal history of herpes simplex virus but without current lesions; on Famvir.,0
Mother presented in spontaneous premature labor.,0
"During delivery, there was a shoulder dystasia.",1
"By report, she emerged apneic without spontaneous movements and with a heart rate of 60.",0
Neonatology was called and arrived at one minute of age while the infant was receiving positive pressure ventilation and beginning to have some respiratory effort and a heart rate above 80.,1
"She continued to receive positive pressure ventilation and then developed a good respiratory effort with pink upper body, but overall poor perfusion and decreased tone.",0
She was intubated at four minutes of age with some improvement in her color.,0
She had a umbilical vein catheter emergently placed and was given 80 cc of normal saline in the delivery room.,0
"Her Apgar scores were 4 at one minute, 5 at five minutes and 8 at 10 minutes.",0
"She was brought to the Neonatal Intensive Care Unit, intubated to receive further management of her perinatal depression.",0
"Of note, there had been a maternal temperature to 101.2 in this group B strep status negative mother.",0
She had rupture of membranes for one and one half days but had been treated with antibiotics four hours prior to delivery.,0
"On arrival to the Neonatal Intensive Care Unit, her overall perfusion was still felt to be poor so she received a third 10 cc per kilogram normal saline bolus.",0
"PHYSICAL EXAMINATION ON ADMISSION: Birth weight was 4145 grams, length was 52 cm, and head circumference was 34 cm.",0
"Heart rate was 158, with a respiratory rate in the 60s, and a mean arterial pressure of 37.",0
"She was on synchronized intermittent mandatory ventilation with pressures of 22/5, with a rate of 20, and 21 percent oxygen.",0
"On examination, she was noted to have an open and flat anterior fontanel and a large posterior left occipital cap.",0
Her right cheek had significant bruising.,0
"She was moving both arms symmetrically, but there was an irregularity to her left clavicle - question of fracture.",0
Her breath sounds were coarse but equal bilaterally.,0
Her heart was regular rate and rhythm and a II/VI systolic murmur heard at the left sternal border.,0
Her extremities were warm but pale with decreased perfusion.,0
"Her spine had no clefts, , or dimples.",0
"LABORATORY DATA ON ADMISSION: Cord gas had a pH of 7.28, with a pCO2 of 46, and a pO2 of 26 from the umbilical artery.",0
"The initial capillary gas had a pH of 7.3, with a pCO2 of 42.",0
"Complete count on admission had a white count of 31.8 (with 50 percent polys, 6 percent bands, and 38 percent lymphocytes), hematocrit was 40.4 percent, with platelets of 308,000.",0
SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1.,0
RESPIRATORY: Baby was initially ventilated on low settings on room air until she recovered from her perinatal depression.,0
She was extubated at about six hours of life and was stable on room air without desaturations thereafter.,0
"However, immediately after extubation impressive suprasternal retractions were noted on inspiration.",0
"On expiration, she had a ballooning of the skin over her suprasternal notch.",0
This was less present with quiet breathing but was quite marked with crying or agitation.,0
"A chest x-ray was repeated to evaluate the sternum and clavicles, with a lateral view.",0
This was read as normal ossification centers of the sternum with normal rib anatomy and no clavicular fractures.,0
Airway films were also obtained and did not show any abnormality.,0
"Their initial impression was a question of laryngocele, so plans were made for a direct bronchoscopy to evaluate her airway.",0
"She was transferred to to undergo a bronchoscopy on the morning of , and that bronchoscopy revealed no laryngocele - but rather sternal deformity with ballooning of the apices of the lungs that was being seen through the chest wall.",0
"Thus, she was transferred to the Neonatal Intensive Care Unit for further evaluation and management.",0
CARDIOVASCULAR: Baby girl remained hemodynamically stable throughout her hospitalization.,0
"After initial normal saline boluses, she maintained normal pressures with excellent perfusion.",0
"The murmur heard on her admission examination persisted, so Cardiology was consulted.",0
"She had an echocardiogram on which revealed a small patent ductus arteriosus but good biventricular function, and no other structural abnormalities.",1
"FLUIDS, ELECTROLYTES, AND NUTRITION: Baby girl was initially held nothing by mouth on D-10-W at 60 cc per kilogram per day.",0
"At about 24 hours of life, she was allowed to take oral intake ad lib and fed between 20 cc and 30 cc every four hours.",0
She was noted by nurses to be quite dyscoordinated during her feedings with a lot of formula running out of her mouth.,0
She did not choke or have desaturations during feedings.,0
"On , day of life two - with developing concern about the laryngocele and concern over her dyscoordinated feedings - she was made nothing by mouth and fed by nasogastric tube because of concern about possible aspiration.",0
She has been voiding and stooling appropriately.,0
"Electrolytes were checked at 24 hours of live and revealed a sodium of 144, potassium was 5.1, chloride was 105, bicarbonate was 22, urea nitrogen was 15, and creatinine was 1.1.",0
"Total bilirubin was 1.6 with a direct component of 0.3, alkaline phosphatase was 159, aspartate aminotransferase was 154, with an alanine-aminotransferase of 117.",0
"The slightly elevated urea nitrogen, and creatinine, and liver function tests were felt to be related to her perinatal depression and are expected to normalize.",0
"HEMATOLOGY: Initial hematocrit was 44 percent with normal platelets of 308,000.",0
Baby girl did not receive any transfusions.,0
NEUROLOGY: Baby girl has had a normal neurologic examination throughout her stay.,0
She moves all of her extremities equally.,0
She is alert and active.,0
She has failed to demonstrate any evidence of a prolonged hypoxic injury.,0
INFECTIOUS DISEASE: Baby girl was initially started on ampicillin and gentamicin pending cultures.,0
She also received 2 doses of oxacillin for manipulation of her umbilical vessels with the umbilical vein catheter placement in the delivery room.,0
"Her cultures were negative at 48 hours, so her antibiotics were discontinued.",0
"GENETICS: Genetics was consulted secondary to some soft dysmorphic features; including widely spaced nipples, slight micrognathia, the question of laryngocele, and the question of bruising versus hemangioma on her right cheek.",0
The mother had a normal amniocentesis during the pregnancy.,0
Genetics preliminarily did not recommend any further testing at this time but planned to see the baby in followup in one month.,0
"DISCHARGE DISPOSITION: Transferred to Neonatal Intensive Care Unit, level 3.",0
PRIMARY PEDIATRICIAN: Dr. (telephone number ).,0
"At the time of transfer, the infant was nothing by mouth for a bronchoscopy.",0
She had previously been feeding Similac 20 at 100 cc per kilogram per day through her nasogastric tube.,0
Car seat testing: Not done yet.,0
State newborn screen: Sent at 48 hours of life.,0
Immunizations: Baby girl has not yet received her hepatitis B vaccination and will need this prior to discharge.,0
Hearing screening: Baby girl has not yet received a hearing screen but should have one prior to discharge.,0
Rule out sepsis - resolved.,0
"Reviewed By: , Dictated By: MEDQUIST36 D: 15:50:29 T: 17:25:04 Job#:",0
11:51 AM CT HEAD W/O CONTRAST Clip # Reason: bleed Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with falcine subdural not responsive REASON FOR THIS EXAMINATION: bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) CT OF THE HEAD W/O CONTRAST: INDICATION: 66 year old woman with parafalcine subdural hematoma.,0
TECHNIQUE: Contiguous 5 mm axial images were obtained from the vertex to the base of the skull in bone and soft tissue windows.,0
Comparison was made to prior study dated .,0
FINDINGS: No significant change is seen since the prior exam.,0
For details please refer to the previous day report.,0
IMPRESSION: Unchanged appearance of large parafalcine and tentorial subdural hematoma and intraparenchymal hemorrhages.,1
"Small amount of subarchnoid hemorrhage, unchanged.",0
2:02 PM DUPLEX DOPP ABD/PEL; ABDOMEN U.S. (COMPLETE STUDY) Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: please eval with dopplers.,0
"pls check Admitting Diagnosis: VARICEAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with HepC cirrhosis, ILD, presents with variceal bleed REASON FOR THIS EXAMINATION: please eval with dopplers.",0
pls check with dopplers ______________________________________________________________________________ FINAL REPORT STUDY: Liver and gallbladder ultrasound: -scale and Doppler evaluation.,0
(Over) 2:02 PM DUPLEX DOPP ABD/PEL; ABDOMEN U.S. (COMPLETE STUDY) Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: please eval with dopplers.,0
pls check Admitting Diagnosis: VARICEAL BLEED ______________________________________________________________________________ FINAL REPORT (Cont),0
"7:54 AM CHEST (PORTABLE AP) Clip # Reason: s/p cabg Admitting Diagnosis: MITRAL VALVE INSUFFICIENTCY ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man, s/p MV repair REASON FOR THIS EXAMINATION: s/p cabg ______________________________________________________________________________ FINAL REPORT HISTORY: CABG.",1
SG catheter is in right pulmonary artery at right hilar level.,0
The interaortic balloon has been removed.,0
"There is persistent bilateral pulmonary opacity consistent with pulmonary edema and opacity at the left base obscuring the medial portion of the left hemidiaphragm, likely due to atelectasis in the left lower lobe.",0
"5:47 AM LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT; ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.Clip # Reason: FIXATION OF LEFT ANKLE IN O.R.",0
Admitting Diagnosis: ANKLE FRACTURE ______________________________________________________________________________ FINAL REPORT HISTORY: Left ankle fixation in OR.,0
Fluoroscopic assistance provided to the surgeon in the OR without the radiologist present.,0
Five spot views were obtained.,0
These demonstrate fixation of a medial malleolar and distal fibular fracture about the left ankle.,0
"Slight asymmetry of the mortise is noted, within the range of normal.",0
Assessment of fine bony detail is limited by RF technique.,0
3:08 AM CHEST (PORTABLE AP) Clip # Reason: S/P GUN SHOT ______________________________________________________________________________ FINAL REPORT INDICATION: Gut shot wound.,0
FINDINGS: The exam is limited by overlying trauma board.,0
A bullet is noted overlying the left lateral hemithorax.,0
"Allowing for this, the heart size is probably normal.",0
"Slight prominence of the mediastinal structures is noted, possibly positional.",0
"There is no pulmonary vascular congestion, pleural, focal infiltrate, or evident pneumothorax.",0
"Prominent mediastinal structures - if the bullet trajectory was near the mediastinum, a follow-up chest CT is recommended.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: GENERAL SURGERY ADDENDUM TO DISCHARGE SUMMARY OF : Over the past 24 hours, the patient has not had any events.",0
His mental status continues to be improving.,0
"He continues to be alert and oriented to time, place and person.",0
His clonus and tremor have resolved.,0
"His ambulation has improved, as well.",0
"Based on the patient's current status and his level of improvement, the patient will be discharged to a rehab facility today for further assistance with ambulation.",0
Lisinopril 10 mg po qd.,0
Lamotrigine 100 mg po qd.,0
Pantoprazole 40 mg po qd.,0
Seroquel 300 mg po q hs.,0
The patient is to continue on his Insulin regimen as prior to admission.,0
"The patient is to call his doctor for any changes in mental status, tremors, shortness of breath, or other worrisome symptoms.",0
"He is to make a follow-up appointment with a psychiatrist, Dr. , at ( after discharge from the rehab facility.",0
"His lithium to be held at present and is to be restarted on an outpatient level, as the patient's inability to ambulate improves.",0
His nadolol has been held for bradycardia.,0
"This is to be restarted as an outpatient, as well.",0
Dictated By: MEDQUIST36 D: 10:07 T: 10:10 JOB#:,0
"11:27 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for signs of heart failure or infection Admitting Diagnosis: ICD LEAN INFECTION;VEGITATION ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with infected ICD leads, heart failure REASON FOR THIS EXAMINATION: evaluate for signs of heart failure or infection ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Heart failure in a patient with infected ICD leads.",1
Portable AP chest radiograph was reviewed with no prior studies available for comparison.,0
Pacemaker leads terminate in right ventricle with the second lead not clearly seen on the current study.,0
The right internal jugular line tip is at the level of low SVC.,0
Cardiomediastinal silhouettes demonstrate prior sternotomy and mild cardiomegaly.,0
"The evaluation of the lung parenchyma demonstrates nodular opacities projecting over the right lung that might represent unusual appearance of pulmonary edema, but infectious process would be a consideration.",0
"Evaluation of the patient after diuresis is suggested and if findings persist, further evaluation with chest CT would be highly recommended.",0
"Small amount of bilateral pleural effusion cannot be excluded, in particular on the left given the relatively significant distance between the gastric bubble and the low cardiac border that might suggest subpulmonic effusion on the left.",1
2:16 PM CHEST (PORTABLE AP) Clip # Reason: cardiopulm pathology ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with dyspnea REASON FOR THIS EXAMINATION: cardiopulm pathology ______________________________________________________________________________ FINAL REPORT INDICATION: 50-year-old man with dyspnea.,0
"COMPARISON: Multiple priors, most recent of .",0
SINGLE FRONTAL PORTABLE VIEW OF THE CHEST: Lung volumes are low with bibasilar atelectasis.,0
There are no focal consolidations seen to suggest pneumonia.,0
Please note that the left costophrenic angle is excluded from view.,0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY OF PRESENT ILLNESS: This infant was admitted to the newborn intensive care unit with respiratory distress.,1
"The infant was born in the early a.m. on , via cesarean section secondary to repeat cesarean section at 37 and 2/7 weeks with Apgars of 7 and 7 requiring some blow-by oxygen and tactile stimulation in the delivery room.",1
"At approximately 4 hours of life, the infant was noted to be grunting, flaring and retracting with respiratory rate in the 60s in the newborn nursery.",1
He remained pink and well perfused and was transferred to the NICU for further care and management.,0
There was no meconium stained fluid at delivery.,0
"Maternal prenatal screens - blood type O positive, antibody negative, HBSAG negative, RPR nonreactive, rubella immune, GBS negative.",0
There were sepsis risk factors.,0
Rupture of membranes occurred at delivery.,0
"Mother is a 23-year-old G2, P1, now 2 woman.",0
Other notable history was for postpartum hemorrhage requiring multiple transfusions and uterine embolization.,0
"Admission examination showed a weight of 2670 grams, which is 25th to 50th percentile; length 18 inches which is 25th percentile; head circumference 33 cm, which si 50th percentile.",0
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The infant developed worsening respiratory distress and was placed on CPAP.,1
The infant continued to have worsening respiratory distress requiring intubation and surfactant administration.,1
The infant subsequently extubated approximately 12 hours after surfactant administration back to CPAP and weaned to nasal cannula on day of life 2 and into room air on day of life 3.,0
"He has remained on room air since that time although did develop some apneic episodes, not requiring methylxanthine therapy but did require a spell count.",0
The infant will be 5 days spell free at discharge with most recent spell being on .,0
CARDIOVASCULAR: The infant has maintained cardiovascular stability while in the NICU.,0
"FLUIDS, ELECTROLYTES AND NUTRITION: The patient was made NPO on admission to the NICU and IV fluids were initiated.",0
"Enteral feedings were started on day of life 1 and subsequently advanced to full enteral feedings by , day of life 7.",0
The infant is presently ad lib p.o.,0
feeding Enfamil 24 calorie per ounce and taking approximately 170 to 200 ml per kg per day.,0
The most recent weight is 2650 grams and the infant has been showing good steady weight gain.,0
The infant is voiding and stooling normally.,0
No recent electrolytes have been measured.,0
The electrolytes that were done on day of life 1 were within normal range.,0
"GASTROINTESTINAL: The infant developed hyperbilirubinemia with a peak bilirubin level of 12.6/0.4, but the infant did require no phototherapy.",0
The most recent bilirubin was 11.8/0.4 on day of life 6.,0
"HEMATOLOGY: Blood type on this infant is O positive, Coombs negative.",0
CBC and blood cultures were done on admission to the NICU due to respiratory distress.,1
"Hematocrit at that time was 50 with platelet count of 374,000.",0
No further hematocrits and platelets have been measured and the infant has required no blood product transfusions.,0
INFECTIOUS DISEASE: CBC and blood culture were screened on admission to the NICU due to respiratory distress.,1
The infant was started on ampicillin and gentamycin which were subsequently discontinued at 48 hours when the blood culture remained negative at that time and the clinical status improved.,0
"The infant also developed Monilial yeast infection in the diaper area and was treated with 5 days of miconazole powder for that, and that has subsequently resolved.",0
The infant at the present time just has a mild diaper rash and is getting Critic-Aid ointment to that.,0
There have been no further issues with infectious disease.,0
NEUROLOGY: The infant has maintained a normal neurologic examination.,0
SENSORY: Audiology: A hearing screen was performed with automated auditory brain stem responses and the infant passed the hearing screen PSYCHOSOCIAL: This is an intact family.,0
Parents speak very little English and required translator for communication.,0
The social worker has been in contact with the family.,0
There are no active issues at this time but if there are any concerns she could be reached at .,0
NAME OF PRIMARY PEDIATRICIAN: This child will be followed by Medical Center.,0
feeds of Enfamil 24 calories per ounce.,0
Medications: Diaper cream as needed.,0
All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as a multivitamin preparation daily until 12 months corrected age.,0
Car seat position screening was performed and the infant passed in an upright position for 90 minutes in the car seat.,0
"State newborn screen was sent on , and result is pending.",0
Immunizations received: The infant received a Hepatitis B vaccine on .,0
Synagis RSV prophylaxis should be considered from through for infants who meet any of the following four criteria.,0
Born between 32 and 35 weeks with two of the following: i. daycare during the RSV season.,0
"ii.a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings.",0
hemodynamically significant congenital heart defect.,0
This infant has not received the rotavirus vaccine.,0
Follow up appointment recommended with the Medical Center within 3 days of discharge.,0
Dictated By: MEDQUIST36 D: 21:21:24 T: 02:53:58 Job#:,0
"3:28 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # Reason: evaluate lung fields, and UVC placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress, born at 32wks REASON FOR THIS EXAMINATION: evaluate lung fields, and UVC placement ______________________________________________________________________________ FINAL REPORT BABYGRAM, at 15:36: FINDINGS: Endotracheal tube has been pulled back and is now at T1-2.",1
This is a well-centered film showing a normal-sized heart and persistent haziness of the lungs consistent with hyaline membrane disease.,0
Abdominal gas pattern remains unremarkable.,0
"Umbilical venous catheter tip has been pulled back, but it is still directed within the liver, now laterally positioned.",0
"5:29 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # CT RECONSTRUCTION Reason: r/o perforated ulcer Admitting Diagnosis: GASTROINTESTINAL BLEED;TELEMETRY Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: year old woman with melena, coffee ground emesis and epigastric abdominal pain REASON FOR THIS EXAMINATION: r/o perforated ulcer CONTRAINDICATIONS for IV CONTRAST: ARF ______________________________________________________________________________ WET READ: MMBn MON 8:00 PM 1) Normal appearing stomach wihtou free air.",0
Ulcer disease cannot be evaluated.,0
Not evaluted on non-contrast study.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: -year-old female with melena, coffee-ground emesis, and epigastric abdominal pain.",0
TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed without intravenous contrast.,0
No contrast was administered for the patient's elevated creatinine.,0
"CT ABDOMEN WITH ORAL, WITHOUT INTRAVENOUS CONTRAST: The lung bases are clear.",0
There is a moderate/large sliding hiatal hernia.,0
Mild coronary artery calcifications are seen within the base of the heart.,0
Imaging of the abdomen is limited by the lack of intravenous contrast.,0
"Allowing for this, there is mixed attenuation in the liver and underlying nodules or masses cannot be ruled out.",0
The gallbladder and pancreas are grossly unremarkable.,0
There is a punctate calcificaiotn in the hilum of the liver of uncertain etiology - ?,0
"A 2.9 x 2.5 cm low attenuation lesion is seen within the posterior aspect of the spleen, most likely representing a simple cyst.",0
There is a 15 x 10 mm left adrenal adenoma.,0
Both kidneys are grossly unremarkable.,0
There is a 1.5-cm fat- containing periumbilical hernia.,0
"CT PELVIS WITH ORAL, WITHOUT INTRAVENOUS CONTRAST: There is diffuse sigmoid diverticulosis without evidence of diverticulitis.",0
The bladder and rectum are unremarkable.,0
BONE WINDOWS: There is diffuse bony demineralization.,0
There are no (Over) 5:29 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # CT RECONSTRUCTION Reason: r/o perforated ulcer Admitting Diagnosis: GASTROINTESTINAL BLEED;TELEMETRY Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont) suspicious lytic or sclerotic osseous abnormalities.,0
Coronal and sagittal reformatted images confirm the axial findings.,0
"Although the stomach lining is unremarkable, CT is not sensitive in evaluating luminal irregularities or the presence/absence of ulcers.",0
There is no evidence of oral contrast extravasation into the mesentery.,0
Differential attenuation of the liver.,0
"Ultrasound, multiphasic CT or MRI is recommended for further evaluation.",0
2.8 x 2.5 cm splenic cyst.,0
1.5 cm fat-containing periumbilical hernia.,0
Sigmoid diverticulosis without evidence of acute diverticulitis.,0
"12:25 PM CHEST (PORTABLE AP) Clip # Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",0
"Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with AVR now s/p CT removal REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax.",1
"INDICATION: 74-year-old male patient status post aortic valve replacement, now status post chest tube removal.",1
Comparison is made with the next previous postoperative followup examination of .,0
The patient is now extubated.,0
Swan-Ganz catheter and sheath have been removed.,0
"The same holds for the single mediastinal tube, advance from below.",0
Previously noted air collection in subpulmonic position on the right base has now disappeared.,0
No pneumothorax is identified and no new pulmonary infiltrates are seen.,0
Comparison is also made with the frontal view of the preoperative chest examination of .,0
"At that time, observed and commented increased reticular pattern has clearly improved.",0
"Thus, it confirms that it represented moderate chronic congestion with interstitial edema now relieved by the successful valve replacement.",1
IMPRESSION: Satisfactory postoperative chest findings.,0
6:39 PM CT HEAD W/O CONTRAST Clip # Reason: Eval interval change Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with L occiptal IPH with intraventricular extension.,0
REASON FOR THIS EXAMINATION: Eval interval change No contraindications for IV contrast ______________________________________________________________________________ WET READ: LLTc WED 9:20 PM 1.,0
"No change in appearance of large left parietal and occipital intraparenchymal hematomas, blood layering along the tentorial leaflets, with an intraventricular extension.",0
There is no evidence of new hemorrhage or new large vascular territorial infarction.,0
Minimal transgaleal herniation in the posterior aspect of the craniectomy site.,0
Slight increase in rightward shift of midline structures.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Intraparenchymal hemorrhage.,0
FINDINGS: The patient is status post left frontoparietal craniectomy.,0
A moderate amount of soft tissue swelling at the surgical site is again seen.,0
There is minimal transgaleal herniation at the posterior aspect of the craniectomy site (2:18).,0
"Again seen are large left parietal and occipital intraparenchymal hematomas (2:18, 15), with subdural blood tracking along the tentorial leaflets bilaterally.",1
Intraventricular extension of blood is redemonstrated (2:17).,0
Mild rightward shift of midline structures (2:17) is slightly increased.,0
The quadrigeminal and suprasellar cisterns remain preserved.,0
No new focus of hemorrhage or new large vascular territorial infarction is seen.,0
Partial opacification of the left mastoid air cells is seen.,0
The middle ear cavities and paranasal sinuses remain clear.,0
(Over) 6:39 PM CT HEAD W/O CONTRAST Clip # Reason: Eval interval change Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont),0
PATIENT/TEST INFORMATION: Indication: Endocarditis Height: (in) 68 Weight (lb): 150 BSA (m2): 1.81 m2 BP (mm Hg): 100/72 HR (bpm): 128 Status: Inpatient Date/Time: at 12:19 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Good INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
RIGHT VENTRICLE: Normal RV free wall thickness.,0
Normal main PA. No Doppler evidence for PDA PERICARDIUM: Small pericardial effusion.,0
The right ventricular free wall thickness is normal.,0
IMPRESSION: no vegetations seen; tachycardia; otherwise essentially normal study,0
"3:51 PM PELVIS, NON-OBSTETRIC PORT Clip # Reason: ?abcess Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with indurrated, inflamed labia concern for abcess/fluid collection REASON FOR THIS EXAMINATION: ?abcess ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 7:01 PM PFI: 1.",0
3-cm Bartholin gland cyst on the right which may be infected.,1
Heterogeneous material within the cyst could be blood or debris.,0
"Inflamed erythematous labia, but no fluid collections in the labia.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Indurated and inflamed labia concerning for abscess or fluid collection.,0
"SUPERFICIAL TISSUE ULTRASOUND: COMPARISON: CT abdomen and pelvis , CT torso .",0
"FINDINGS: There is marked skin thickening of the right labia, which is indurated and erythematous, but no fluid collections are present in the labia.",0
In the right perineal region is a heterogeneously echoic 3 x 3 x 2.9-cm collection without internal vascularity.,0
"Its location, particularly when compared to the CT examination from , is suggestive of a Bartholin gland cyst which is likely infected.",1
No other collections are present.,0
3-cm Bartholin gland cyst on the right which is likely infected.,1
Findings were discussed by telephone with Dr. via telephone at 6:15 p.m. on .,0
8:14 AM CHEST (PORTABLE AP) Clip # Reason: r/o iinfiltrate Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with s/ tube placement REASON FOR THIS EXAMINATION: r/o iinfiltrate ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: tube placement.,0
The 7 cm inflated balloon of the tube overlies the gastric fundus.,0
ETT is 4 cm above carina.,0
Cordis catheter is in proximal SVC.,0
There are linear atelectases at the lung bases.,0
"9:35 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate lung Admitting Diagnosis: AR\ AORTIC AND MITRAL VALVE REPLACEMENT REDO ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with s/p AVR/MVR/TVR s/p evacuation of R hemothorax REASON FOR THIS EXAMINATION: evaluate lung ______________________________________________________________________________ FINAL REPORT HISTORY: 46-year-old woman status post valve repair, now with hemothorax.",1
"TECHNIQUE: AP chest was obtained and compared to , at 9:39 a.m.",0
FINDINGS: There has been interval intubation of the patient with endotracheal tube 3 cm above the carina.,0
There has been interval placement of a right basal pleural drain and change in position of the right apical drain.,0
"There has been associated decrease in size of right pleural effusion versus hemothorax, which is now small.",0
There is mild left basilar atelectasis.,0
"Heart size and cardiomediastinal contours are stable and sternal wires, valve prostheses, and surgical clips are again noted overlying the mediastinum.",1
There is residual barium within the colon.,0
IMPRESSION: Tubes and lines as described.,0
Interval decrease in size of right pleural effusion versus hemothorax.,0
", M. TSURG CSRU 7:25 AM CHEST (PORTABLE AP) Clip # Reason: f/u PNA, confirm position ETT Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with multiple medical problems, PNA REASON FOR THIS EXAMINATION: f/u PNA, confirm position ETT ______________________________________________________________________________ PFI REPORT Loculated left pleural effusion decreased.",1
Small right pleural effusion is minimal.,1
Multiple pulmonary opacities very slightly improved.,0
5:53 PM CT HEAD W/O CONTRAST Clip # Reason: eval for interval change Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with recent SDH.,0
Please eval for interval change.,0
REASON FOR THIS EXAMINATION: eval for interval change No contraindications for IV contrast ______________________________________________________________________________ WET READ: 7:43 PM no significant interval change since prior in left sdh.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 37-year-old man with recent subdural hemorrhage.,1
COMPARISON: CT head without contrast .,0
FINDINGS: Stable left frontal extra-axial hypodense collection consistent with chronic subdural hematoma with stable mild mass effect upon the adjacent sulci.,1
"There is minimal effacement of the left lateral ventricle, unchanged from .",0
There is no evidence of new foci of acute hemorrhage.,1
There is no evidence of large acute major vascular territory infarction.,0
Stable hypodensity in the left basal ganglia is unchanged from .,0
Normal variant cavum septum pellucidum et vergae is once again noted.,0
Visualized osseous structures are grossly unremarkable.,0
IMPRESSION: No significant interval change since with stable left frontal extra-axial hypodense fluid collection consistent with chronic subdural hematoma with stable mild mass effect on adjacent sulci and mild effacement of the left lateral ventricle.,1
"9:28 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: NGT placement Admitting Diagnosis: MI ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with new trach placement, placement of NGT REASON FOR THIS EXAMINATION: NGT placement ______________________________________________________________________________ FINAL REPORT RADIOGRAPHS OF CHEST CLINICAL INDICATION: 76-year-old woman with new trach placement and placement of nasogastric tube.",0
FINDINGS: There has been interval placement of a nasogastric tube with tip in the stomach.,0
There is stable positioning of tracheostomy tube in good position.,0
"In addition, there is stable positioning of a left-sided internal jugular line with tip projecting over the upper SVC.",0
"There is mild interval decrease in interstitial opacity bilaterally and vascular distention, in keeping with mild decrease in pulmonary edema.",1
9:20 AM PICC LINE PLACMENT SCH Clip # Reason: please place picc for antibiotics Admitting Diagnosis: BILE DUCT OBSTRUCTION Contrast: OPTIRAY Amt: 20 ********************************* CPT Codes ******************************** * PICC W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI * * CHALNAGIOGRAPHY VIA EXISTING C -58 SERVIC BY SAME MD DURING POST OP * * CHALNAGIOGRAPHY VIA EXISTING C -59 DISTINCT PROCEDURAL SERVICE * * -58 SERVIC BY SAME MD DURING POST OP FLUORO GUID PLCT/REPLCT/REMOVE * * -79 UNRELATED PROCEDURE/SERVICE DURI US GUID FOR VAS.,0
ACCESS * * -79 UNRELATED PROCEDURE/SERVICE DURI TUBE CHOLANGIOGRAM * * TUBE CHOLANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with cbd stricture with PTCs for wall stents .,0
receiving tigercycline/amikacin for pan-resistent Klebsiella/e.coli bacteriemia REASON FOR THIS EXAMINATION: please place picc for antibiotics ______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 79-year-old woman with CBD stricture and bilateral wall stents placement on .,0
Patient needs cholangiograms to check the wall stents and possible removal of Amplatz catheters.,0
Patient also needs placement of double-lumen PICC line for antibiotics.,0
A request was placed for the same.,0
ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl and Versed throughout the intra-service time during which the patient's hemodynamic parameters were continuously monitored.,0
Local anesthesia with 1% lidocaine.,0
PICC LINE PLACEMENT: INDICATION: IV access needed for antibiotics.,0
A peel-away sheath was then placed over a guidewire and a double-lumen PICC line measuring 31 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
Position of the catheter was confirmed by a (Over) 9:20 AM PICC LINE PLACMENT SCH Clip # Reason: please place picc for antibiotics Admitting Diagnosis: BILE DUCT OBSTRUCTION Contrast: OPTIRAY Amt: 20 ______________________________________________________________________________ FINAL REPORT (Cont) fluoroscopic spot film of the chest.,0
TUBE CHOLANGIOGRAMS AND REMOVAL OF AMPLATZ ANCHOR CATHETERS: After obtaining a verbal consent the patient was placed supine on the imaging table and the upper abdomen as well as the existing anchor catheters were prepped and draped in the usual sterile fashion.,0
Under fluoroscopic guidance contrast was gently hand-injected through both anchor catheters demonstrating patency of both stents with free passage of contrast into the duodenum.,0
Both the catheters were cut distal to the hub releasing the locking mechanism and pulled out easily.,0
A final fluoroscopic image obtained after removal of the catheters and saved digitally.,0
Sterile dressings were applied over both access sites.,0
The patient tolerated the procedures well with no immediate complications.,0
Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right brachial venous approach.,0
Final internal length is 31 cm with the tip positioned in the SVC.,0
Bilateral tube cholangiograms demonstrating patent and satisfactorily positioned bilateral CBD wall stents with rapid contrast emptying into the duodenum.,0
Both Amplatz anchor catheters were successfully removed.,0
5:14 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for changes 24 hours post tpa Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with acute left hemiparesis s/p tpa REASON FOR THIS EXAMINATION: evaluate for changes 24 hours post tpa No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKSd TUE 5:38 AM stable extent of acute infarcts with no evidence of hemorrhagic transformation.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 36-year-old woman with acute left hemiparesis status post TPA.,0
Evaluate for changes 24 hours status post TPA.,1
"COMPARISON: MR of the head of , and CTA head and neck of .",0
TECHNIQUE: MDCT-acquired images were obtained through the head without contrast.,0
FINDINGS: A portion of the study was repeated due to motion on the initial acquisition.,0
"There is well defined hypodensity in the posterior limb of the right internal capsule, right putamen, and right corona radiata, corresponding to the acute infarct seen on the precedint MRI, and stable in size.",0
"There is a small focus of low density in the left cerebral peduncle, also corresponding to the acute infarct seen on the precedint MRI, and also grossly stable in size.",0
There is no evidence of hemorrhagic transformation.,0
No new areas of hypodensity are seen to suggest new areas of infarct.,0
Ventricles and sulci remain stable in size and configuration.,0
Visualized paranasal sinuses and mastoid air cells remain clear.,0
IMPRESSION: Stable extent of acute infarcts as described above with no evidence of hemorrhagic conversion.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: Pt had a left sided picc line placed,53cm,and needs tip conf Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with worsening b/l consolidations & ?",0
R lung abscess who needs picc line for IV antibiotics.,0
"REASON FOR THIS EXAMINATION: Pt had a left sided picc line placed,53cm,and needs tip confirmation,please page at with wet read,thanks.",0
______________________________________________________________________________ FINAL REPORT INDICATION: PICC for IV antibiotics.,0
"CHEST, ONE VIEW: Comparison with examination of same day, 1.5 hours prior.",0
New left PICC with tip in the distal SVC.,0
3:22 PM CT HEAD W/O CONTRAST Clip # Reason: assess ventriulcar bleeding Admitting Diagnosis: HYDROCEPHALUS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with change in MS - on heparin for PE - MR shows small amount ventricular blood REASON FOR THIS EXAMINATION: assess ventriulcar bleeding CONTRAINDICATIONS for IV CONTRAST: looking for bleed ______________________________________________________________________________ FINAL REPORT INDICATION: Change in mental status.,1
TECHNIQUE: Axial images of the head were obtained from the occiput to the vertex without IV contrast.,0
"COMPARISON: , head CT. HEAD CT: There is no intra or extraaxial hemorrhage.",0
"The ventricles are moderately enlarged, but not significantly changed in the interval.",0
The -white matter differentiation and basal cisterns are unremarkable.,0
"The osseous structures, mastoid air cells and visualized paranasal sinuses are unremarkable.",0
11:53 AM CHEST (PORTABLE AP) Clip # Reason: ACUTE SOB.,0
?PE ?EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with s/p liver transplant w/ elevated WBC count REASON FOR THIS EXAMINATION: ACUTE SOB.,0
?PE ?EFFUSION ______________________________________________________________________________ FINAL REPORT HISTORY: 41 y/o female status post liver transplant with elevated white blood cell count.,0
COMPARISONS: PORTABLE CHEST: The tip of a right IJ catheter is seen in the right atrium.,0
There has been interval increase in the bilateral interstitial and alveolar opacities.,0
The alveolar opacities are more prominent in the right middle lobe and right lower lobe.,0
Skin staples are seen over the upper abdomen.,0
IMPRESSION: Interval increase in the interstitial and alveolar opacities which could represent pneumonia associated with interstitial edema.,0
Height: (in) 64 Weight (lb): 104 BSA (m2): 1.48 m2 BP (mm Hg): 100/50 HR (bpm): 104 Status: Inpatient Date/Time: at 10:01 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
IMPRESSION: Small LV cavity size with hyperdynamic LV systolic function.,0
There is a small anterior pericardial effusion which appears echo-dense.,0
There is no evidence of tamponade.,0
Bilateral pleural effusions and ascites are present.,1
"Compared with the prior study (images reviewed) of , the left ventricular cavity is smaller, systolic function is more dynamic and the patient is more tachycardic.",0
", R. MED CC7A 2:54 PM UNILAT UP EXT VEINS US Clip # Reason: LT ARM SWELLING PLEASE EVAL FOR THROMBUS Admitting Diagnosis: EPIDURAL ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with PICC line, swollen L arm REASON FOR THIS EXAMINATION: please evaluate for thrombus ______________________________________________________________________________ PFI REPORT Extensive thrombus involving the left basilic, axillary as well as the subclavian vein.",1
"Name: , S Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE/ ADDENDUM: This discharge summary addendum will cover , to .",0
Respiratory - The patient was transferred from the Medical Intensive Care Unit to the floor on .,0
The patient remained stable with oxygen saturation ranging 93 to 96% in room air.,0
He did not require any additional nebulizer treatments.,0
He was maintained on his inhaled regimen.,0
The patient's lung examination continued to be clear to auscultation bilaterally on the day of discharge.,0
The patient had no further episodes of hemoptysis.,0
The patient was instructed to follow-up with pulmonologist including repeat CT scan in one month's time.,0
Cardiovascular - hypertension - The patient maintained blood pressure in the 140 range while on Captopril three times a day in house.,0
The patient was converted to Lisinopril 10 mg p.o.,0
This should be followed up as an outpatient for optimized management of hypertension.,0
Infectious disease - The patient was treated for a ventilator associated pneumonia.,0
"The patient was originally started on intravenous antibiotics, received five days of Ceftaz and Vancomycin.",0
"The patient's sensitivities returned from his sputum cultures on , and the patient was switched to a p.o.",0
regimen which included Ciprofloxacin and Augmentin.The patient was instructed to continue these for a total of a fourteen day course of antibiotics giving him nine more days postadmission for antibiotics.,0
Chronic back pain - The patient continued on Oxycodone and discharged with a prescription for six days of further pain medication.,0
Gastrointestinal - The patient had no gastrointestinal complaints during his stay on the medical .,0
The patient should follow-up for thickened esophagus of uncertain clinical correlate as an outpatient.,0
"FOLLOW-UP: The patient was instructed to follow-up in Clinic on either Friday, , or Monday, .",0
The patient was instructed to get a close first available appointment regardless of the care provider in .,0
The patient should follow-up with a pulmonologist with repeat CT scan in one month's time.,0
He should also follow-up for his thickened esophagus.,0
twice a day for nine days.,0
Oxycodone for a total course of six days.,0
The patient was restarted on his Plavix once daily for history of cerebrovascular accident.,0
Continue inhaled treatments for chronic obstructive pulmonary disease while at home.,0
The patient should have close follow-up for his pneumonia and episodes of hemoptysis of unknown etiology in addition to his thickened esophagus.,0
CONDITION ON DISCHARGE: The patient was discharged in stable condition with a stable hematocrit and stable vital signs.,0
Dictated By: MEDQUIST36 D: 15:55 T: 19:55 JOB#:,0
7:30 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o IVH Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 26 now 23 days old follow up previous study REASON FOR THIS EXAMINATION: r/o IVH ______________________________________________________________________________ FINAL REPORT DATE: NEONATAL HEAD ULTRASOUND OBTAINED PORTABLY: CLINICAL HISTORY: This is a former 26 week and premature infant who is now 23 days old with a prior history of left and possibly right intraventricular hemorrhage.,1
The ultrasound today is requested for routine follow up.,0
Comparison is made with multiple prior examinations most recently from .,0
coronal and sagittal images of the brain were obtained via the anterior fontanelle with additional mastoid views performed.,0
The lateral ventricles are now symmetric in size and shape.,0
The choroid plexus within both lateral ventricles is quite prominent and large.,0
"This is, however, a stable finding.",0
No definite residual dependent hemorrhage is seen within the right lateral ventricle.,0
Within the left lateral ventricle there is a small amount of dependent debris presumably representing resolving hemorrhage.,0
The germinal matrix has a normal appearance bilaterally with no evidence for acute abnormality.,0
The ventricles themselves are stable in size when compared to multiple prior examinations.,0
The 3rd and 4th ventricles are normal in size and without evidence for intraventricular blood.,0
Pulsed Doppler interrogation of the anterior cerebral artery at the level of the genu reveals a resistive index of approximately 0.83.,0
"With depression of the anterior fontanelle, the flow decreases in velocity and there is absence of antegrade flow in end diastole for a resistive index of approximately 1.0.",0
This is a stable finding when compared to the most recent prior exam from .,0
IMPRESSION: Stable head ultrasound with no evidence for progressive hydrocephalus.,0
"Abnormal, but unchanged resisitive indices in the anterior cerebral artery.",0
"7:17 AM CHEST (PORTABLE AP) Clip # Reason: eval for pleural effusions Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p type A dissection repair REASON FOR THIS EXAMINATION: eval for pleural effusions ______________________________________________________________________________ FINAL REPORT HISTORY: 54-year-old male status post type A dissection repair, evaluate for pleural effusions.",0
"FINDINGS: Portable frontal chest radiograph demonstrates slight interval improvement in lung volumes, as well as in bibasilar atelectasis.",0
"Subsegmental and dense retrocardiac atelectasis remains, along with moderate bilateral pleural effusions which are not significantly changed.",1
The cardiac silhouette and mediastinal contours are unchanged.,0
Median sternotomy wires remain intact.,0
A right internal jugular approach sheath remains in place with its tip in the upper SVC.,0
"IMPRESSION: Slight interval improvement in bibasilar atelectasis, with similar moderate bilateral pleural effusions.",0
3:51 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with CAD s/p CABG REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG.,1
AP PORTABLE SUPINE VIEW OF THE CHEST: Median sternotomy wires are in place and apparently intact.,0
There is interval placement of an endotracheal tube in satisfactory position.,0
The NG tube terminates below the diaphragm with the side port near the GE junction.,0
There is a left-sided chest tube and mediastinal drain in satisfactory position.,0
There is an apparent pulmonary artery catheter that terminates in the region of the junction between the right atrium and right ventricle.,0
No evidence of pneumothorax is seen.,0
The patient is rotated to the right.,0
"The mediastinal contour is prominent compared to the prior study, likely largely due to technique.",0
"The heart size is likely unchanged, allowing for technique.",0
"The right costophrenic angle is not completely imaged, but there is no evidence of a right-sided pleural effusion.",0
"IMPRESSION: 1) Heart size is unchanged, allowing for technique.",0
2) NG tube with side port terminating near the GE junction.,0
This may be advanced to ensure placement completely within the stomach.,0
3) Pulmonary artery catheter terminating in the region of the junction between the right atrium and right ventricle.,0
"The above findings were communicated with , cardiac thoracic surgery PA, at the time of interpretation of the study.",0
"6:29 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: EVAL FOR ABSCESS, DIVERTICULITIS Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with fever, hypotension, altered mental status and abd tenderness.",0
s/p upper and lower endoscopy last week.,0
REASON FOR THIS EXAMINATION: r/o abcess/diverticular dz No contraindications for IV contrast ______________________________________________________________________________ WET READ: CCqc MON 7:15 PM exam limited by patient habitus -- increased LLL consolidation/atelectasis; diverticuli of the transverse colon with possible early dioverticulitis ______________________________________________________________________________ FINAL REPORT *ABNORMAL!,0
"CLINICAL HISTORY: An 83-year-old female with fever, hypotension, and abdominal tenderness.",0
TECHNIQUE: Contiguous axial images were obtained from the lung bases through the symphysis pubis following the administration of 150 cc of Optiray.,0
Multiplanar reformatted images were created.,0
FINDINGS: There is a small right pleural effusion with associated atelectasis.,0
"In the interval, there is increased collapse/consolidation of the left lower lobe.",0
"Allowing for the limitations imposed by the patient's body habitus, the liver, gallbladder, spleen, adrenal glands, and right kidney appear grossly normal.",0
The left kidney is small and atrophied.,0
"As before, there are two low-attenuation lesions within the left kidney, one within the mid-pole and the other within the lower pole.",1
These are difficult to evaluate due to extensive beam hardening artifact.,0
They appear unchanged since the most recent exam but were not present in .,0
The abdominal aorta is diffusely calcified.,0
The stomach and proximal loops of bowel appear normal.,0
"There is subtle stranding of the fat adjacent to the transverse colon, suggesting possible early transverse colon diverticulitis.",0
No free fluid or air are present.,0
CT OF THE PELVIS WITHOUT IV CONTRAST: There is a large fibroid uterus.,0
The urinary bladder is collapsed due to the presence of a Foley catheter.,0
Pelvic loops of bowel appear grossly normal.,0
BONE WINDOWS: Extensive degenerative changes are evident involving the thoracic and lumbosacral spine.,0
"CT RECONSTRUCTIONS: Multiplanar reformatted images were reviewed and confirm (Over) 6:29 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: EVAL FOR ABSCESS, DIVERTICULITIS Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
Possible early transverse colon diverticulitis.,0
Two uncharacterized low-attenuation foci within the left kidney which were not present in .,0
Renal cell carcinoma cannot be excluded.,0
"If clinically warranted, an MRI can be performed for further evaluation.",0
Right pleural effusion and associated atelectatic changes.,0
Increased collapse/consolidation of the left lower lobe.,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with 3-vessel CAD, pre-op for CABG s/p MV repair, CABG REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVR.",1
"PORTABLE SUPINE CHEST: Comparison with examination of the same day, 8:13 a.m.",0
"There has been interval placement of a right-sided Swan-Ganz catheter with the tip in the right pulmonary artery, proximal aspect.",0
"Bilateral chest tubes, two mediastinal tubes, and nasogastric tube are seen.",0
There are midline sternotomy wires and staples overlying the heart.,0
"The endotracheal tube is approximately 2 cm above the carina, and should be withdrawn slightly.",0
No definite pleural effusion or pneumothorax on the supine view.,0
Linear atelectasis in mid left lung zone.,0
Expected post-thoracotomy appearance of the chest.,0
10:46 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: Please evaluate all liver vessel patency - hepatic artery no Admitting Diagnosis: CORONARY ARTERY DISEASE\AORTIC VALVE REPLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with question of shock liver PD#3 s/p CABG REASON FOR THIS EXAMINATION: Please evaluate all liver vessel patency - hepatic artery not visualized last night and needs to be seen this AM ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb FRI 3:42 PM Patent main hepatic artery with appropriate systolic and diastolic flow.,1
Patent main portal vein with hepatopetal directionality.,0
"Remainder of the hepatic vasculature was appropriately assessed within the last 12 hours ( 38, , 22:11).",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 62-year-old man with question of shocked liver, postop day 3.",0
Evaluate for left liver patency including hepatic artery not visualized last night.,1
FINDINGS: Limited evaluation was performed as a complete Doppler assessment of hepatic vasculature had been performed one day prior with the exception of main hepatic artery.,0
The main hepatic artery is patent with appropriate systolic upstroke and diastolic flow.,0
Limited views of the main portal vein are also normal with wall-to-wall hepatopetal flow.,0
IMPRESSION: Patent main hepatic artery with normal waveform.,0
"Remainder of the hepatic vasculature was assessed within the last 12 hours (, 22:11).",0
Height: (in) 72 Weight (lb): 155 BSA (m2): 1.91 m2 BP (mm Hg): 140/71 HR (bpm): 70 Status: Inpatient Date/Time: at 15:03 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
"Compared with the prior report (images unavailable for review) of , the findings are similar.",0
5:54 PM CHEST (PORTABLE AP) Clip # Reason: post op hypoxic Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with CAD s/p CABG REASON FOR THIS EXAMINATION: post op hypoxic ______________________________________________________________________________ FINAL REPORT INDICATION: Postop CABG with hypoxia.,1
There is some improvement in the bibasilar opacities from with some residual densities at the lung bases.,0
"1:19 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 32 year old man s/p MVA, C-spine fractures and cord compression, s/p trach with fever episodes of bradycardia with coughing machine REASON FOR THIS EXAMINATION: r/o pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: Bradycardia and coughing.",0
SUPINE AP PORTABLE CHEST: A tracheostomy tube ends at the level of the clavicular heads.,0
A patchy infiltrate is present in the right lung base.,0
IMPRESSION: Patchy right basilar infiltrate concerning for early pneumonia.,0
5:53 AM CHEST (PORTABLE AP) Clip # Reason: 86 year old woman intubated w/ difficulty weaning; please ev Admitting Diagnosis: CHEST PAIN;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman intubated w/ difficulty weaning; please evaluate for interval change in effusions and infiltrates.,0
REASON FOR THIS EXAMINATION: 86 year old woman intubated w/ difficulty weaning; please evaluate for interval change in effusions and infiltrates.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Some difficulty weaning from intubation.,0
"FINDINGS: In comparison with the study of , there is obliquity of the patient towards the left.",0
Continued prominence of interstitial markings is consistent with some combination of elevated pulmonary venous pressure and chronic lung disease.,0
No acute focal pneumonia is appreciated.,0
", OMED 7F 7:29 PM CHEST (PORTABLE AP) Clip # Reason: eval line placement Admitting Diagnosis: MYELOFIBROSIS\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with pain at central line site.",0
REASON FOR THIS EXAMINATION: eval line placement ______________________________________________________________________________ PFI REPORT 1.,0
"Bilateral central venous access devices in satisfactory position, with no pneumothorax.",0
Stable rounded cardiomegaly without CHF.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p fall Major Surgical or Invasive Procedure: 1.,0
Irrigation and debridement left open calcaneus fracture.,1
Closed treatment right calcaneus fracture.,1
Open reduction and internal fixation of left distal radius fracture.,1
History of Present Illness: This is a 20 year-old female who was intoxicated (alcohol and cocaine) at the Rolling Stones concert and fell >30 feet after climbing onto the rafters.,1
LEFT FOREARM AP & LATERAL: The lateral image does not include elbow.,0
"Compared to prior examination of 2:09 a.m., re-identified is an impacted comminuted fracture of the distal radial metaphysis with medial and dorsal displacement of the distal radial fracture fragment, unchanged.",0
There is ulnar positive variance.,0
Ulnar styloid fracture is re- identified.,0
The forearm is in a fiberglass cast which limits fine bony detail.,0
CT LOW EXT W/O C BILAT 8:07 AM CT LOW EXT W/O C BILAT; CT RECONSTRUCTION Reason: assess for fx MEDICAL CONDITION: 20 year old woman with s/p fall w/ bilat calcaneus fx REASON FOR THIS EXAMINATION: assess for fx CONTRAINDICATIONS for IV CONTRAST: None.,0
INDICATION: 20-year-old woman with bilateral calcaneus fractures status post fall.,1
TECHNIQUE: Non-contrast MDCT of the bilateral ankles acquired in the axial plane and reconstructed in the sagittal and coronal planes.,0
COMPARISON: No prior CT. Ankle radiographs dated .,0
"CT BILATERAL FEET: On the right, a comminuted fracture of the distal fibula extends as far superiorly as approximately the tibiotalar joint.",0
There is mild displacement of the fracture fragments.,0
Markedly comminuted fracture of the calcaneus extends to the subtalar and calcaneocuboid joints.,1
The posterior subtalar joint is particularly widened and disrupted.,0
The sustentaculum tali is comminuted.,0
There is narrowing of the sinus tarsi.,0
Fragments also project to the tarsal tunnel.,0
There is a generalized flattening to the configuration of the calcaneal fragments.,0
The ankle mortise remains relatively congruent.,0
"On the left, a tiny osseous fragment projects posterolaterally from the distal fibula at the expected level of the superior peroneal retinaculum, likely representing an avulsion.",0
A comminuted fracture of the calcaneus extends to the subtalar and calcaneocuboid joints.,1
"There is widening of the posterior subtalar joint, less pronounced than on the contralateral side.",0
The sustentaculum tali is separated as primarily one fragment.,0
The sinus tarsi is not particularly narrowed.,0
The calcaneal fragments have a generalized flattened configuration.,0
Limited assessment of tendons crossing the ankle joints is grossly unremarkable.,0
Diffuse soft tissue edema is more pronounced on the right than the left.,0
Casts have been placed on both lower extremities.,0
CT RECONSTRUCTIONS: Coronal and sagittal reformatted images were useful in delineating the extent of the severely comminuted bilateral calcaneal fractures.,1
"Comminuted bilateral calcaneal fractures, with disrupted subtalar joints, as above.",1
Comminuted distal right fibula fracture.,0
Calcific adjacent to left distal fibula suggestive fo avulsion fracture at the insertion site of the superior peroneal retinaculum.,0
CT C-SPINE W/O CONTRAST 10:47 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: fracture?,0
MEDICAL CONDITION: 20 year old woman s/p 5 feet REASON FOR THIS EXAMINATION: fracture?,0
CONTRAINDICATIONS for IV CONTRAST: None.,0
HISTORY: Status post fall from 20 feet.,0
FINDINGS: There is no fracture or malalignment.,0
"At C5/6, there is a small disc protrusion with associated mild uncovertebral spurring, suggesting that this is degenerative in nature.",0
"However, a traumatic component cannot be excluded.",0
"Small disc protrusion at C5/6, which may be degenerative in nature, but a traumatic component cannot be excluded.",0
Brief Hospital Course: On arrival she was hemodynamically unstable and was admitted to the Trauma ICU.,0
"She was awake and complained of head, abdominal and extremity pain.",0
Orthopedics was consulted immediately for her extremity fractures.,1
She was taken to the operating room on for repair of her injuries.,0
Ophthalmology and Plastic Surgery were consulted for her right orbital floor and nasal fractures; no surgical intervention at this time for these injuries.,1
She will need to follow up with Ophthalmology and Plastic Surgery after discharge.,0
Orthopedic Spine service was consulted for the disc protrusion noted on CT imaging of her cervical spine; no fractures or ligamentous injuries identified.,1
Recommendations for soft cervical collar for comfort and flexion extension films if patients developed any neck discomfort.,0
Physical and Occupational therapy were consulted; patient is strict NWB bilat LE's and LUE at this time.,0
Social work was also consulted for patient's ETOH/Substance abuse issues.,0
Her pain is being managed with Oxycodone prn with fairly good response; she does experience intermittent anxiety and has required prn Ativan.,0
Her bowel regimen was increased because of constipation secondary to immobility and narcotics.,0
On HD #10 patient with fever spike 101.8; urine and blood cultures obtained and sent; CXR ordered.,0
CXR revealed no active lung processes; Sinus CT scan obtained because of patent's facial fractures; abscess was ruled out.,1
Her operative wounds were also assessed and showed no signs of infectious process at this time.,0
Results of both urine and blood cultures pending at time of this summary.,0
Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed).,0
Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous DAILY (Daily).,0
Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: not to exceed 12 in 24 hours.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: of Discharge Diagnosis: s/p Fall from ~30 ft Left inferior pubic ramus fracture Right maxillary fracture Right inferior orbit fracture Left iliac fracture extending to SI joint Bilateral calcaneus fractures Right fibula fracture Left distal radius/ulna fracture Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedics on date scheduled.,1
You will need to continue with your Lovenox injections until stopped by Dr. .,0
"Followup Instructions: 1.Provider: , MD Where: ORTHOPEDICS Phone: Date/Time: 1:20 2.",0
"Call , Plastic Surgery CLinic to schedule a follow up appointment in 1 week 3.",0
Call to schedule an appointment in the Eye Clinic in 2 weeks.,0
2:57 PM N-G TUBE PLACEMENT Clip # Reason: Patient needs post-pyloric tube.,0
"Admitting Diagnosis: ACUTE JAUNDICE, HEPATITIS Contrast: OPTIRAY Amt: 10 ********************************* CPT Codes ******************************** * INTRODUCTION LONG GI TUBE, S&I INTRODUCTION LONG GI TUBE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with cirrhosis, acute hepatitis.",1
REASON FOR THIS EXAMINATION: Patient needs post-pyloric tube.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 69-year-old with cirrhosis, please place post-pyloric tube.",0
PROCEDURE/FINDINGS: An 8 French nasointestinal tube was inserted via the right nostril following administration of lidocaine spray and lidocaine jelly for local anesthesia.,0
"Under fluoroscopic guidance, the tip of the tube was positioned in the second portion of the duodenum, with confirmation of post-pyloric position by injection of approximately 5 cc of water-soluble contrast.",0
"IMPRESSION: Uneventful placement of post-pyloric nasointestinal Dobhoff tube, with tip at the ligament of Treitz.",0
", G. SICU-A 2:18 PM ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # Reason: ?cholelithiasis/cholestasis Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: year old man with hyperbili s/p colectomy REASON FOR THIS EXAMINATION: ?cholelithiasis/cholestasis ______________________________________________________________________________ PFI REPORT PFI: 1.",0
No intra- or extra-hepatic biliary dilatation.,0
Cholelithiasis and sludge without secondary signs of cholecystitis.,0
"7:26 AM CHEST (PORTABLE AP) Clip # Reason: ?widened mediastinum, tamponade Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman s/p CABG with high filling pressures & low cardiac output REASON FOR THIS EXAMINATION: ?widened mediastinum, tamponade ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST OF .",1
INDICATION: Evaluate for widening of the mediastinum.,0
Endotracheal tube terminates 2.5 cm above the carina with the neck in a flexed position.,0
A Swan-Ganz catheter has been advanced into the truncus anterior/right upper lobe branch of the pulmonary artery.,0
"Left-sided chest tube, nasogastric tube, and mediastinal drains remain in place.",0
Cardiac and mediastinal contours are stable compared to the previous two postoperative radiographs allowing for differences in lung volumes.,0
There is mild vascular engorgement and perihilar haziness.,0
Bibasilar atelectatic changes are slightly worse in the interval.,0
"There are probable small bilateral pleural effusions, but there are no pneumothoraces.",1
Position of Swan-Ganz catheter was discussed by telephone with Dr. on .,0
"10:53 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: assess for portal hypertension and splenomeg ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with incidental splenomeg seen on MR of hip for lytic bone lesion REASON FOR THIS EXAMINATION: assess for portal hypertension and splenomeg ______________________________________________________________________________ FINAL REPORT INDICATIONS: Splenomegaly identified incidentally on prior exam, ?",0
ABDOMINAL ULTRASOUND: There is a pleural effusion.,0
"The liver demonstrates normal echotexture and size, without masses identified.",0
"There is dilation of the entire portal venous system, with normal hepatopetal flow.",0
The hepatic venous system is dilated as well.,0
No intra or extra-hepatic biliary ductal dilatation.,0
There is a 0.7 x 1.7 cm shadowing echogenic structure at the dependent portion of the gallbladder.,0
There is no pericholecystic fluid or gallbladder wall thickening.,0
"There is splenomegaly, measuring 15 cm.",0
There is normal forward flow in the splenic vein.,0
"The right kidney is atrophic, measuring 6.9 cm.",0
"The left kidney appears, measuring 11.8 cm.",0
No hydronephrosis or calcifications are identified.,0
Portal venous and hepatic venous dilation are consistent with portal hypertension.,0
"Height: (in) 72 Weight (lb): 195 BSA (m2): 2.11 m2 BP (mm Hg): 158/54 Status: Inpatient Date/Time: at 17:30 Test: Portable TTE(Focused views) Doppler: Focused pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%).",0
"Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%).",0
"Compared to the previous study of , no major change is evident.",0
"The posterior clear space abutting the aortic root and aortic bioprosthesis is unchanged, as is the trace aortic regurgitation; left ventricular function remains normal.",0
1:39 AM FEMUR (AP & LAT) BILAT; KNEE (2 VIEWS) BILAT Clip # ANKLE 1 VIEW BILAT Reason: displaced ankles ______________________________________________________________________________ MEDICAL CONDITION: 18 year old man s/p high speed motorcycle crash REASON FOR THIS EXAMINATION: displaced ankles ______________________________________________________________________________ FINAL REPORT INDICATION: High speed motorcycle crash.,0
TECH INFO: Unable to perform lateral hips views due to pelvic fractures.,0
"FINDINGS: Two views of the right lower femur, three views of the left femur, two views of the right tibia/fibula, two views of the left tibia/fibula, and a single view of the right ankle was reviewed.",0
FINDINGS: There is a right superior pubic ramus fracture at the acetabular junction.,0
This is more fully evaluated on CT. No other fractures are identified in the right femur.,0
No fractures or dislocation is identified in the left femur.,0
No fractures or dislocations is present in the right or left fibula and tibia.,0
"Evaluation of the right ankle is inadequate on a single image, and further imaging would be necessary to exclude injury if clinically indicated.",0
IMPRESSION: No fractures identified except right superior pubic ramus fractures that has been more fully evaluated by CT.,1
Inadequate evaluation of the right ankle and left knee.,0
8:31 PM CHEST (PORTABLE AP) Clip # Reason: SUDDEN ONSET CP ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with sudden onset cp REASON FOR THIS EXAMINATION: r/o ptx ______________________________________________________________________________ FINAL REPORT INDICATION: Sudden onset chest pain.,0
AP UPRIGHT OF THE CHEST: There is mild cardiomegaly.,0
There are slightly low lung volumes with no focal infiltrates or effusions.,0
IMPRESSION: No evidence of CHF or pneumonia.,0
Height: (in) 71 Weight (lb): 230 BSA (m2): 2.24 m2 BP (mm Hg): 72/38 HR (bpm): 125 Status: Inpatient Date/Time: at 16:12 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Mild (1+) MR. LV inflow uninterpretable due to tachycardia and/or fusion of spectral Doppler E and A waves TRICUSPID VALVE: Normal tricuspid valve leaflets.,0
There is mild regional left ventricular systolic dysfunction with basal to mid inferior hypokinesis.,0
"Compared with the prior study (images reviewed) of , left ventricular thickness has decreased.",0
"The cardiac output is very high with overall low normal left ventricular systolic function, consistent with septic shock.",1
", C. MED FA2 1:38 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?",0
"Retroperitoneal bleeding Admitting Diagnosis: PULMONARY EMBOLISM ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with PE s/p IVC filter with unexplained dropping HCT, concern for retroperitoneal bleed REASON FOR THIS EXAMINATION: ?",1
Retroperitoneal bleeding No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.,0
Large predominantly intramuscular right thigh hematoma likely accounts for the drop in hematocrit in this anticoagulated patient.,0
Cannot evaluate for active extravasation without the use of intravenous contrast.,0
No retroperitoneal hemorrhage is present.,0
A small right gluteal hematoma is also noted and right lower extremity/thigh is asymmetrically swollen in comparison to the left.,1
Punctate nonobstructive right renal calculi.,0
Slightly atrophic appearing left kidney.,0
"6:44 PM CHEST (PORTABLE AP) Clip # Reason: dobhoff in place ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with cirrhosis, lingual squamous cell cancer ', presenting with variceal bleeding.",1
Sudden stridorous breathing and NS changes.,0
"REASON FOR THIS EXAMINATION: dobhoff in place ______________________________________________________________________________ FINAL REPORT INDICATION: Cirrhosis, squamous cell carcinoma, status post endotracheal tube and nasogastric tube placement.",0
FINDINGS: Portable chest radiograph with comparison to 3 hours prior.,0
The nasogastric tube tip is located just proximal to the gastroesophageal junction.,0
Endotracheal tube is not visualized.,0
There is interstitial edema but no gross pulmonary edema.,0
Compared to the prior study the lung fields are not significantly changed.,0
There are several dilated loops of bowel.,0
IMPRESSION: 1) High Dobhoff tube.,0
This tube should be advanced.,0
2) Interstitial edema not significantly changed from prior study.,0
3) Non specific dilated loops of bowel within the abdomen as before.,0
10:58 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: check NGT placement Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with new dobhoff REASON FOR THIS EXAMINATION: check NGT placement ______________________________________________________________________________ FINAL REPORT CHEST ON HISTORY: Dobbhoff placement.,0
FINDINGS: There is a new feeding tube with the tip just below the gastroesophageal junction.,0
This should be advanced prior to being used for feeding.,0
"Again, seen is the scoliosis involving the upper thoracic spine.",0
"7:34 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for interval change Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 64 year-old female with decompensated heart failure, COPD exacerbation REASON FOR THIS EXAMINATION: Please evaluate for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Decompensated heart failure with COPD.",1
There is still enlargement of the cardiac silhouette with evidence of pulmonary vascular congestion.,0
"Admission Date: Discharge Date: Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: off pump cabg x5 (LIMA to LAD, SVG to OM1 sequentially to OM 2, SVG to DIAG, SVG to PDA) History of Present Illness: Mrs. is an 85 yo woman with lymphoma s/p rituximab/Zevelin ~6 weeks ago (in nadir now) and recent admission to with NSTEMI managed medically who presented to - on with chest pain.",1
"There, her CKs were flat, and her chest pain resolved.",0
She received a bag of platelets for thrombocytopenia and aspirin 81 mg was started.,0
She also apparently had volume overload in the setting of a blood transfusion.,0
She responded well to furosemide.,0
"An echocardiogram revealed globally depressed systolic function (LVEF 35-40%), which is worse than her echocardiogram during her last admission to .",0
"In addition, a Foley catheter was placed for urinary frequency, and a urine culture grew out >100,000 Enterococcus.",0
She is being transferred for further management.,0
She reports that she awoke from sleep with 2 episodes of chest pain.,0
She can not quantify the intensity.,0
Seh reports that they lasted on the order of minutes to half an hour and radiated to back.,0
"They were not associated with shortness of breath, nausea or diaphoresis.",0
She called 911 and was taken to .,0
"She currently denies chest pain or shortness of breath, and reports that she was chest pain-free at .",0
"On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",0
"Past Medical History: HTN High Grade B cell NHL -Diagnoses -s/p three cycles R-CHOP on , nadir 4-8 weeks -Now on rituximab or Zevalin (research protocol) Colon cancer in B12 deficiency .",0
"Cardiac Risk Factors: (-) Diabetes, (-) Dyslipidemia, (+) Hypertension .",0
Cardiac History: s/p recent NSTEMI with planned medical management Social History: She denies any tobacco or alcohol use.,0
She used to work as a factory worker in an elastic factory.,0
Currently lives next door to her son and daughter in law who provide most of her care.,0
Family History: Her brother died of leukemia.,1
Her sister was diagnosed with uterine cancer and recently died.,0
Her other brother is alive after having a nephrectomy for renal cancer.,0
She also has family history of coronary artery disease in many of her seven siblings.,1
"Physical Exam: VS - 94.2, 106/60, 64, 18 93% on RA Gen: Pleasant elderly woman lying in bed, NAD, appropriate HEENT: NCAT.",0
Conjunctiva had mild pallor Neck: Supple with JVP of 6 cm.,0
"Chest: Resp were unlabored, no accessory muscle use.",0
"Bibasilar crackles of the way up Abd: Soft, NT, ND.",0
Pulses: Right: Carotid 2+ PT 2+ Left: Carotid 2+ PT 2+ Pertinent Results: 07:40AM BLOOD WBC-1.6* RBC-3.51* Hgb-11.5* Hct-31.9* MCV-91 MCH-32.9* MCHC-36.2* RDW-17.1* Plt Ct-93*# 07:40AM BLOOD Gran Ct-710* 07:40AM BLOOD Glucose-178* UreaN-27* Creat-0.7 Na-138 K-3.5 Cl-97 HCO3-31 AnGap-14 07:40AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.9 Catheterization 1.,0
Selective coronary angiography of this right dominant system demonstrated multi-vessel coronary artery disease.,1
The LMCA has a 80% distal stenosis.,0
"The LAD has a 80% stenosis at the origin, 80% mid stenosis, and all diagonals diffusely diseased with 100% in the inferior branch of the 3rd diagonal.",0
The LCx has a 90% stenosis at the origin.,0
"The RCA has a 60% stenosis at the origin, a long 90% mid level stenosis, and a 80% distal stenosis with left to right collaterals.",0
Limited resting hemodynamic measurement demonstrated normal systemic arterial pressures.,0
Brief Hospital Course: Mrs. is an 85 yo woman with HTN and NHL s/p recent chemotherapy and a recent discharge from with after an NSTEMI treated medically.,0
She presented to with intermittent chest pain.,0
Given history of unstable angina and recent MI she was taken to for catheterization.,0
"She was pancytopenic from her recnet chemotherapy, however, and the procedure had to be delayed several days.",0
"Her counts did slowly recover and when her platelets returned to 100,000 it was agreed, in conjunction with her oncologist, that catheterization would be safe.",0
"On catheterization, she was found to have severe distal L main along with three vessel disease.",0
At first she and her son were unsure whether she wanted to have this procedure done.,0
"Eventually, they agreed to undergo surgery and was taken for bypass surgery on , Her hospital course is as follows: .",0
CAD: s/p recent NSTEMI managed medically.,0
Ruled out for acute MI with flat CKs at .,0
Was stable on transfer with cardiac enzymes trending down.,0
"EKG at OSH with concern for lateral ischemia, EKGs relatively unchanged here.",0
"We continued ASA, metoprolol, high dose statin.",0
We maintained her Hct near 30+ and her Plts >50.,0
She did have intermittent rest angina responsive to nitro.,0
"After seeing that her counts begna to stabilize, the decision was made to pursue cardiac cath for symptoms.",0
She went for cath on which revealed distal L main along with 3 vessel disease.,0
She was referred for CABG .,0
Pump: Echo at OSH with interval worsening of systolic dysfunction.,0
"Became symptomatically volume overloaded after receiving PRBCs and Plts at the OSH, which was respsonsive to Lasix 20mg IV.",0
"Was given further IV diuresis and then continued on Lasix 20mg PO, tolerating this well.",0
She would benefit from ACE-I if her BP tolerates (baseline in 90s systolic).,0
NHL: Underwent chemo 6 weeks prior to admission.,0
She was pancytopenic on admission with borderline neutropenia (ANC 710).,0
She was initially put on neutropenic precautions.,0
Heme/Onc was consulted who felt that her counts would begin to improve.,0
Over the course of admission her counts began to improve starting on .,0
The issue of anti-platelet therapy was addressed given her unstable angina.,0
It was believed the pt had a fair prognosis per the oncology team and that this prognosis should not imprede her getting CABG.,0
Pancytopenia/Anemia: Was thought likely due to marrow suppression from chemotherapy.,0
Her counts improved in house as expected.,0
Urinary frequency: She was diagnosed with a UTI at the OSH.,0
She grew >100K of enterococcus sensitive to Ampicillin and Vancomycin.,0
She was started on Ampicillin to complete a 7 day course.,0
Code: DNR/DNI now reverted to FULL Referred to Dr. and underwent off pump cabg x5 on .,0
Transferred to CVICU in stable condition.,0
Continued to be followed by the heme/oncology team.,0
Extubated the next day and transferred to the floor on POD #2 to begin increasing her activity level.,0
"Mediastinal tubes and pacing wires removed, but left pleural tube remained for a pleural effusion.",0
Swallowing evaluation also done to assess risk of aspiration and ground solids and thin liquids were recommended.,0
Left chest tube was pulled without incident.,0
She was ready for discharge to rehab on POD #5.,0
"Medications on Admission: Metoprolol 100 mg tid Furosemide 20 mg daily Vitamin B12 100 mcg daily Simvastatin 80 mg daily MVI 1 daily Omeprazole 20 mg daily Aspirin 81 mg daily Discharge Disposition: Extended Care Facility: Healthcare - Discharge Diagnosis: CAD s/p OPCABG x5 lymphoma HTN MI B12 deficiency Discharge Condition: stable Discharge Instructions: SHOWER DAILY and pat incisions dry no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. in weeks see Dr. in weeks see Dr. in 4 weeks MD Completed by:",0
Height: (in) 60 Weight (lb): 220 BSA (m2): 1.95 m2 BP (mm Hg): 123/71 HR (bpm): 96 Status: Inpatient Date/Time: at 11:38 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT VENTRICLE: Mild regional LV systolic dysfunction.,0
Conclusions: There is mild regional left ventricular systolic dysfunction with inferolateral hypo- to akinesis.,0
The remaining visualized segments contract normally (LVEF probably around 45-50%).,0
There is normal right ventricular free wall contractility.,0
IMPRESSION: Small free-flowing pericardial effusion without signs of tamponade.,0
At least mild regional left ventricular systolic dysfunction.,0
"11:15 AM CHEST (PORTABLE AP) Clip # Reason: evaluate pulmonary edema ______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman s/p massive trama, difficulty ventilating REASON FOR THIS EXAMINATION: evaluate pulmonary edema ______________________________________________________________________________ FINAL REPORT INDICATION: S/P massive trauma with difficulty of ventilation.",0
TECHNIQUE: Single portable AP view of the chest is compared with 1 day prior.,0
"FINDINGS: Again seen is a tracheostomy tube as well as a right sided internal jugular catheter, terminating in the mid SVC.",0
"There has been interval placement of an NG tube, terminating in the stomach.",0
There is a stable appearance of the diffuse bilateral air space disease.,0
"There appears to be slightly more translucency of the left lung, and slight worsening of the right lung, which may be due to positional rotation.",0
"No pneumothorax, and a small right sided pleural effusion is noted.",0
"Again seen are sternotomy wires and abdominal and thoracic staples IMPRESSION: Placement of an NG tube, there has been no significant interval change.",0
"9:37 PM CHEST (PORTABLE AP) Clip # Reason: eval for acute pathology ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with hypoxia,lethargy, REASON FOR THIS EXAMINATION: eval for acute pathology ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia, lethargy.",1
Portable AP chest dated is compared to the prior from and .,0
"There is no definite pulmonary vascular congestion, however, there are bilateral lower lobe and right middle lobe patchy perihilar opacities consistent with pulmonary edema although superimposed consolidation cannot be excluded.",0
IMPRESSION: Cardiomegaly with patchy bilateral perihilar opacities likely representing pulmonary edema.,0
12:43 PM CHEST (PORTABLE AP) Clip # Reason: Left TLC pulled back.,0
"______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with a known seizure disorder now with increased frequency of seizures, low grade temps, cough, and leukocytosis.",0
Pt is at high risk for aspiration.,0
REASON FOR THIS EXAMINATION: Left TLC pulled back.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Seizures with fever, cough, and leukocytosis with intubation and line placements.",0
Endotracheal tube is 5 cm above carina.,0
NG tube extends below the diaphragm.,0
There is persistent airspace opacity at the right base consistent with pneumonia/aspiration.,0
"7:28 AM PICC LINE PLACMENT SCH Clip # Reason: place PICC Admitting Diagnosis: FEVER-FOOT WOUND ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with unsuccessful PICC placement at bedside who will need 3 more weeks of vancomycin.",0
REASON FOR THIS EXAMINATION: place PICC ______________________________________________________________________________ FINAL REPORT INDICATION: 59 year old female with MRSA bacteremia requiring antibiotics.,0
IV was not able to advance a PICC line.,0
PROCEDURE: This procedure was performed by Dr. and Dr. .,0
"Dr. , the attending radiologist, was present during the entire procedure.",0
The left upper arm was prepped and draped in the standard sterile fashion.,0
The left basilic vein was patent and compressible.,0
"After local anesthesia with approximately 4 cc of 1% Lidocaine, the basilic vein was entered under ultrasonographic guidance with a 21 gauge needle.",0
A 0.018 guidewire was then advanced under fluoroscopy into the superior vena cava.,0
Based on the markers on the guidewire it was determined that the length of 40 cm would be suitable.,0
The PICC line was then trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance in the superior vena cava.,0
The film demonstrates the tip of the catheter to be in the superior vena cava just above the right atrium.,0
A statlock was applied and the line was heplocked.,0
IMPRESSION: Successful placement of a 40 cm total length single lumen PICC line with the tip in the superior vena cava ready for use.,0
5:17 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
Interval change Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with likely fungal PNA.,0
"Interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Likely fungal pneumonia, to assess for change.",1
"FINDINGS: In comparison with the study of , the diffuse bilateral pulmonary opacification is essentially unchanged, presenting a pattern of multifocal pneumonia.",1
Some element of elevated pulmonary venous pressure may be present.,0
Extensive fixation devices about the cervical and upper thoracic spine are again seen.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: patient experienced low urinary output which did not respond to fluid bolus.",0
"Bladder scan showed 500cc , patatient than voided spontaneously with a post void residual of 60cc.",0
patient was began on flomax 0.4mgmHS a void trial was done today with success.,0
patient shoulkd folowup on an outpatient basis for urological and proatate evaluation to assess his urinary retention.,0
patient also had postoperative episode of PAF which converted to NSR.,0
Recommendations were to consider anticoagulation.,0
patient will be d/c on ASA.,0
He should followup with Dr. re anticoagulation for his PAF.,0
Discharge Disposition: Extended Care Facility: house MD Completed by:,0
1:49 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT CHEST W/CONTRAST Reason: evaluate for patency of mesenteric vessels Admitting Diagnosis: SMA CLOT Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with SMA thrombus s/p embolectomy REASON FOR THIS EXAMINATION: evaluate for patency of mesenteric vessels No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 9:00 PM 1.,0
"Status post SMA embolectomy, with patent mesenteric vessels.",0
"Pre-SMA mesenteric induration with trace intermediate density fluid and tiny foci of free gas, likely expected post-surgical change.",0
Two subcutaneous hematomas deep to midline incision.,0
Decreased clot burden of right main pulmonary arterial emboli and nonocclusive thrombus in the aortic arch.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old female with SMA thrombosis status post embolectomy, here for evaluation of patency of mesenteric vessels.",0
COMPARISON: Multiple prior CT's including and .,0
TECHNIQUE: MDCT images were acquired from thoracic inlet through the pubic symphysis prior to and following administration of intravenous and oral contrast.,1
CT CHEST: The heart is normal in size without pericardial effusion.,0
Moderate atheromatous changes with calcifications involve the aortic arch and proximal innominate artery.,0
"Small scattered anterior mediastinal lymph nodes do not meet CT size criteria for pathologic enlargement, with most prominent nodes in the prevascular and pretracheal stations.",0
"Eccentric thrombus adherent to the wall of right main pulmonary artery (6, 39) demonstrates decreased clot burden as compared to .",0
There is no longer thrombus extension into the subsegmental right pulmonary arteries.,0
"Previously noted intra-aortic thrombus involving the arch (6, 28) is also decreased as compared to .",0
Bibasilar consolidations are much less confluent as compared to .,0
CT ABDOMEN: The liver enhances homogeneously without focal lesion.,0
The (Over) 1:49 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT CHEST W/CONTRAST Reason: evaluate for patency of mesenteric vessels Admitting Diagnosis: SMA CLOT Contrast: OPTIRAY Amt: 110 ______________________________________________________________________________ FINAL REPORT (Cont) gallbladder may contain sludge.,0
"The spleen, pancreas, adrenal glands, and kidneys are unremarkable.",0
Small and large bowel loops are within normal caliber.,0
Patient is status post recent SMA embolectomy with post-surgical changes.,1
Just deep of the incision is a subcutaneous 4.2 x 3.7 cm hematoma.,0
"More inferiorly a second hematoma is present, measuring 4.6 x 3.8 cm (6, 184).",0
"Superficial to the level of SMA, is an estimated 6 x 4 cm area of mesenteric induration with trace intermediate density fluid (possible with a hemorrhagic component) and stranding, which contains small foci of free gas, likley postoperative change given recent intervention just two days ago.",0
There is no evidence of focal collection.,0
"Within limitation of a non-CTA study, the aorta, proximal celiac axis, SMA, renal arteries, and are patent and normal in caliber.",0
"CT PELVIS: The bladder is collapsed, with a Foley catheter in place.",0
"The uterus, rectum, and distal colon appear within normal limits.",0
BONE WINDOW: Severe thoracolumbar spondylosis is most pronounced at L5-S1.,0
There is anterior fusion of L2-3 vertebral bodies.,0
Multilevel lumbar posterior apophysitis is also present.,0
"Status post SMA embolectomy, with patent proximal mesenteric vessels.",0
pre-AVR/CABG Height: (in) 61 Weight (lb): 145 BSA (m2): 1.65 m2 BP (mm Hg): 160/70 HR (bpm): 64 Status: Inpatient Date/Time: at 10:31 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA.,0
Moderate AS (area 1.0-1.2cm2) Trace AR.,0
The aortic valve leaflets are moderately to severely thickened and calcified.,1
The mitral valve leaflets are moderately thickened/calcified.,0
4:27 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: S/P ARREST;CERVICAL FX ______________________________________________________________________________ MEDICAL CONDITION: 23 year old man with cervical spine injury REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Cervical spine injury.,1
FINDINGS: Comparison to serial radiographs dating back to indicates gradual improvement of the right middle and lower lobe atelectasis with residual right lower lobe atelectasis.,0
Left lower lobe linear atelectasis is also stable.,0
The cardiac and mediastinal structures appear normal.,0
The tracheostomy tube is in satisfactory position.,0
The metallic density projected over the left upper quadrant is unchanged in position and correlates with a metallic foreign body adjacent to the left twelfth rib on a CT dated .,0
IMPRESSION: Slowly resolving right lower lobe atelectasis and linear left lower lobar atelectasis.,0
"4:44 PM CHEST (PORTABLE AP) Clip # Reason: please assess for ET tube placement ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with syncope, intubated REASON FOR THIS EXAMINATION: please assess for ET tube placement ______________________________________________________________________________ WET READ: JJMl MON 5:21 PM ETT entering right mainstem bronchus.",0
"INDICATION: Status post intubation, with syncope.",0
AP PORTABLE SUPINE VIEW OF THE CHEST: The ET tube is entering the right main stem bronchus.,0
The NG tube terminates in the stomach.,0
"There are vague perihilar opacities, left greater than right.",0
The heart size is borderline.,0
IMPRESSION: 1) Low positioned ET tube entering the right main stem bronchus.,0
Recommend retraction by 3-4 cm to ensure more optimal placement within the trachea.,0
12:57 AM CHEST (PORTABLE AP) Clip # Reason: ETT placement (revised) Admitting Diagnosis: BACTERIAL MENINGITIS ______________________________________________________________________________ MEDICAL CONDITION: 40 year old woman with MENINGITIS and possible lll infiltrate REASON FOR THIS EXAMINATION: ETT placement (revised) ______________________________________________________________________________ FINAL REPORT INDICATION: Possible left lower lobe infiltrate status post revised endotracheal tube placement.,0
TECHNIQUE: Single AP portable semi-upright chest.,0
FINDINGS: The heart size and mediastinal contours are within normal limits.,0
An endotracheal tube is in place with tip terminating 2.6 cm from the carina.,0
Right internal jugular venous access catheter with tip remaining in the right atrium.,0
Nasogastric tube coils within the stomach.,0
The tip is poorly visualized but likely terminates in the gastric body.,0
The low lung volumes are unchanged.,0
There is slight improvement in left retrocardiac opacity with obscuration of the medial portion of the left hemidiaphragm.,0
IMPRESSION: 1) Right internal jugular venous access catheter remains within the right atrium.,0
Nasogastric tube in unchanged position.,0
2) Slight improvement in left lower lobe consolidation vs. atelectasis.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: PAST MEDICAL HISTORY: 1.,0
Adenoid cystic carcinoma of the ethmoid sinuses.,0
Cervical injury C4 to 6 in the past.,0
"HISTORY OF PRESENT ILLNESS: This is a 49 year-old male with a history of adenoid cystic carcinoma of the ethmoid sinuses on the left diagnosed in status post multiple bouts of sinusitis treated with antibiotics as well as status post multiple facial surgeries including a left orbital exenteration, left rectus flap to the left premaxillary area who presents for an excision of the left rectus flap, biopsy as well as left orbital exenteration due to a new lesion found on PET scan on .",1
Activity on the PET scan primarily showed maxillary and sphenoid sinus involvement.,1
He also complained of significant pain on the left face V2 distribution and is on considerable amount of narcotics at baseline.,0
The patient underwent the operation on .,0
During the Operating Room frozen section it was found that there was tumor recurrence adenoid cystic carcinoma on the preliminary read.,0
The left rectus flap was excised and the incision was primarily closed.,0
The patient also received a split thickness skin graft on the anterior surface of the orbit and maxillary sinus.,1
These were held in place by bolsters.,0
Postoperatively the patient did well from a surgical standpoint except for complaints of severe pain requiring postoperative pain service consultation.,0
"The patient was begun on Methadone, Topiramate as well as Dilaudid prn to control his pain.",0
Although initially the patient was on a Dilaudid PCA over subsequent days the patient was able to wean from the Dilaudid PCA and began taking Dilaudid po prn.,0
"On the day of discharge the patient was taken po, ambulating, voiding and is on a po pain regimen.",0
The patient will follow up with Dr. in his office on for removal of the left orbital and maxillary sinus bolsters.,1
The patient is being discharged in stable condition.,0
Dictated By: MEDQUIST36 D: 10:28 T: 10:10 JOB#:,0
12:08 PM CHEST (PORTABLE AP) Clip # Reason: Monitor for interval change Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: year old woman with altered mental status and increasing oxygen requirement.,1
REASON FOR THIS EXAMINATION: Monitor for interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Altered mental status with increased O2 requirement.,0
"AP SEMI-UPRIGHT CHEST: Compared to 12 hours prior, there is little change.",0
Moderate bilateral pleural effusions and bibasilar atelectasis is unchanged.,0
"An endogastric tube courses below the diaphragm, tip out of view.",0
A right subclavian central venous catheter is unchanged in position.,0
A single lead ventricular pacemaker lead is also unchanged.,0
IMPRESSION: No significant change in moderate bilateral pleural effusions and associated atelectasis.,0
2:06 PM CT HEAD W/O CONTRAST Clip # Reason: r/o mass or bleed Admitting Diagnosis: AKTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with AMS REASON FOR THIS EXAMINATION: r/o mass or bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: JXRl SAT 3:24 PM no intracranial hemorrhage ______________________________________________________________________________ FINAL REPORT HISTORY: 72-year-old woman with altered mental status.,0
"FINDINGS: There is no intracranial hemorrhage, mass effect, edema or shift of normally midline structures.",0
"An air-fluid level is noted within the right maxillary sinus, also seen on .",0
The left maxillary sinus is now well aerated.,0
No evidence of acute intracranial abnormalities.,0
"Fluid in the right maxillary sinus, which may indicate acute sinusitis.",0
"12:10 PM CHEST (PORTABLE AP) Clip # Reason: eval for pneumothorax s/p chest tube removal Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: .",0
"FINDINGS: Following removal of mediastinal drains and chest tube, there is no visible pneumothorax.",0
"Swan-Ganz catheter remains in place, and has been advanced in the interval.",0
It makes an abrupt downward turn at the level of the main pulmonary artery and could be repositioned for standard placement.,0
"The exam is otherwise similar in appearance to the recent study except for a new area of linear atelectasis in the right mid lung with adjacent small amount of fluid in the minor fissure, and improving left basilar atelectasis.",0
12:42 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate integral change Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with L basal ganglia bleed REASON FOR THIS EXAMINATION: evaluate integral change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Followup basal ganglia hemorrhage.,0
TECHNIQUE: Non-contrast axial images of the head are obtained with 5-mm section thickness.,0
"NON-CONTRAST CT HEAD: There is persistence of a large hemorrhage situated within the left lentiform nucleus, left internal capsule, and thalamus with intraventricular spread layering in the occipital horns bilaterally.",0
Overall there is likely more edema compared to and approximately 7-mm of rightward subfalcine herniation slightly also larger compared to prior.,0
No new intracranial hemorrhage is identified and no new abnormal extra-axial fluid collection is seen.,0
Surrounding osseous structures are unremarkable.,0
Mild ethmoid and maxillary sinus mucosal thickening with more extensive sphenoid sinus thickening is noted.,0
There is persistent near complete opacification of the mastoid air cells bilaterally.,0
The findings are likely inflammatory in origin.,0
IMPRESSION: Persistent left basal ganglia/thalamic hemorrhage with slightly increased edema and rightward subfalcine herniation.,0
evaluate for intracardiac thrombus and PFO.,0
"Height: (in) 65 Weight (lb): 139 BSA (m2): 1.70 m2 BP (mm Hg): 115/65 HR (bpm): 72 Status: Inpatient Date/Time: at 15:43 Test: TTE (Congenital, complete) Doppler: Full Doppler and color Doppler Contrast: Saline Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.",0
"GENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver.",0
No atrial septal defect is seen by 2D or color Doppler but a single premature bubble is seen after intravenous injection post-Valsalva (indeterminate for PFO).,1
IMPRESSION: Possible patent foramen ovale.No other structural heart disease or pathologic flow identified.,0
"If clinically indicated, a TEE with saline contrast/maneurvers is suggested to better define the interatrial septum.",0
"6:04 PM CHEST (PORTABLE AP) Clip # Reason: s/p L subclavian placement ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with malignant right pleural effusion, s/p chest tube placement , pleurodesis and after rigid bronchoscopy.",0
REASON FOR THIS EXAMINATION: s/p L subclavian placement ______________________________________________________________________________ FINAL REPORT INDICATION: Status post left subclavian.,0
Comparison was made to the prior film obtained on .,0
Again noted is slightly enlarged heart.,0
"There is placement of left subclavian central line, with the tip in the proximal SVC, in good position.",0
"Again noted is hazy appearance to the right hemithorax, consistent with the patient's history of pleurodesis.",0
The previously-noted opacity in the right costophrenic angle appears to have resolved to some extent.,0
Left base granuloma again noted.,0
"IMPRESSION: Interval placement of a left subclavian line, with the tip in the proximal SVC.",0
", J. FA10 11:39 PM PORTABLE ABDOMEN Clip # Reason: please evaluate dobhoff position - ?still postpyloric Admitting Diagnosis: HYDROTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man s/p liver transplant with manipulated dobhoff REASON FOR THIS EXAMINATION: please evaluate dobhoff position - ?still postpyloric ______________________________________________________________________________ PFI REPORT Dobbhoff tube remains in post-pyloric position",1
4:21 PM ABDOMEN (SUPINE ONLY) Clip # Reason: Please confirm placement of feeding tube Admitting Diagnosis: PANCREATIC CYST ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with feeding tube REASON FOR THIS EXAMINATION: Please confirm placement of feeding tube ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb MON 6:24 PM PFI: Feeding tube located in the third portion of the duodenum.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 56-year-old man with feeding tube.,0
Please confirm placement of feeding tube.,0
"COMPARISON: Fluoroscopic placement of post-pyloric feeding tube, dated .",0
FINDINGS: A single supine AP view of the abdomen shows a nasointestinal feeding tube located in the third portion of the duodenum.,0
The location is grossly unchanged from the prior image from .,0
There is a nonspecific pattern of bowel gas.,0
IMPRESSION: Feeding tube located in the third portion of the duodenum.,0
Height: (in) 60 Weight (lb): 155 BSA (m2): 1.68 m2 BP (mm Hg): 105/60 HR (bpm): 65 Status: Inpatient Date/Time: at 11:58 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls.,0
Mobile components are suggested (?vegetations - see clip ).,0
Severe aortic valve deformation and stenosis with possible vegetation on the aortic valve.,1
Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD.,0
"If clinically indicated, a TEE would be better able to define the aortic valve.",1
4:20 PM WRIST(3 + VIEWS) RIGHT PORT Clip # Reason: s/p ORIF ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with fall REASON FOR THIS EXAMINATION: s/p ORIF ______________________________________________________________________________ FINAL REPORT HISTORY: Follow up fracture.,0
"The patient is status post comminuted distal right radial fracture transfixed by two reconstruction plates, screws and pins.",0
Overall alignment is anatomic on these views.,0
A true lateral view was not obtained.,0
(The technologist reports difficulty in positioning due to patient's limited range of motion and overlying hardware).,0
Fracture lines remain partially visible.,0
"An ununited ulnar styloid fracture fragment, with a more punctate calcification adjacent to it, is noted.",0
"Compared with , the cast has been removed and hardware has been placed.",0
IMPRESSION: Status post ORIF distal right radial fracture in overall anatomic alignment.,0
2:39 PM CT HEAD W/O CONTRAST Clip # Reason: ?,0
bleed or injury ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with ams REASON FOR THIS EXAMINATION: ?,0
bleed or injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: 4:21 PM No acute intracranial hemorrhage or fracture.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: 44-year-old woman, with acute change in mental status, assess for bleed or injury.",0
TECHNIQUE: Contiguous helical MDCT images were acquired through the head without IV contrast.,0
COMPARISON: No prior comparison available.,0
"FINDINGS: There is no acute intracranial hemorrhage, mass effect, edema, large territorial infarct.",0
The ventricles and sulci are normal in size and appearance.,0
"There is partial opacification of the ethmoid air cells, but other paranasal sinuses are otherwise clear.",0
The mastoid air cells are clear bilaterally.,0
Mild soft tissue swelling is seen overlying the left frontal bone.,0
IMPRESSION: No acute intracranial hemorrhage or major vascular territorial infarct.,0
"Ethmoid sinus disease, likely inflammatory in etiology.",0
10:28 AM CHEST (PA & LAT) Clip # Reason: eval for pleural effusions s/p CABG Admitting Diagnosis: STEMI ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions s/p CABG ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient after CABG.,0
PA and lateral upright chest radiograph was reviewed in comparison to .,0
The post-sternotomy sutures appear to be unremarkable.,0
"The lungs are significantly better aerated, in particular the lung bases.",0
"Small left more than right pleural effusions are present, and there is no evidence of pneumothorax.",0
7:08 PM PORTABLE ABDOMEN Clip # Reason: eval for ileus Admitting Diagnosis: MITRAL REGURGITATION;CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man s/p MV ring s/p ex lap REASON FOR THIS EXAMINATION: eval for ileus ______________________________________________________________________________ WET READ: AJy MON 8:41 PM retained oral contrast and air in colon extend to pelvis.,1
no dilated small bowel loops.,0
no supine evidence of free air.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old male post-CABG and mitral valve repair, exploratory laparoscopy on for right upper quadrant pain.",0
COMPARISON: Radiograph and ultrasound from .,0
"ABDOMEN, ONE VIEW: Retained barium is noted in the colon and rectum.",0
"The bowel gas pattern is unremarkable, without evidence of dilation to suggest obstruction.",0
The presence of free air cannot be evaluated due to portable supine technique.,0
"The liver shadow appears slightly enlarged, consistent with known cirrhosis.",0
Changes of CABG and mitral valve annuloplasty are present.,0
There is a small right pleural effusion and some bibasilar atelectasis.,0
The left costophrenic angle is excluded from the film.,0
Please refer to subsequent chest radiograph for further evaluation.,0
7:32 AM CHEST (PORTABLE AP) Clip # Reason: s/p AVR w/worsening oxygenation r/o effusion Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with as above REASON FOR THIS EXAMINATION: s/p AVR w/worsening oxygenation r/o effusion ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .,1
FINDINGS: Indwelling devices are in standard position.,0
"Interval decrease in focal curvilinear gas collection adjacent to left ventricular apex, likely due to resolving pneumopericardium.",0
Decrease in width of cardiomediastinal contours and resolution of mild edema.,0
Persistent bibasilar retrocardiac atelectasis and small effusions.,0
2:55 AM CHEST (PORTABLE AP) Clip # Reason: eval for tube placement ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man intubated for hypoxia and pulm edema REASON FOR THIS EXAMINATION: eval for tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 67-year-old male.,0
Evaluate for endotracheal tube placement.,0
COMPARISONS: Comparison to radiographs performed approximately four hours prior on .,0
"FINDINGS: Since recent interval examination, there has been development of interstitial pulmonary edema with prominence of the bilateral hila and the interstitial markings.",0
There has been interval placement of an endotracheal tube with tip 3.7 cm above the level of the carina.,0
The patient is status post median sternotomy with valve replacement and CABG.,1
A nasogastric tube is seen coursing below the diaphragm.,0
IMPRESSION: Interval development of mild interstitial pulmonary edema.,0
Interval endotracheal tube and nasogastric tube placements in standard position.,0
Height: (in) 62 Weight (lb): 138 BSA (m2): 1.63 m2 BP (mm Hg): 110/71 HR (bpm): 64 Status: Inpatient Date/Time: at 09:49 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with 35-50% decrease during respiration (estimated RA pressure (10-15mmHg).,0
LV WALL MOTION: Regional LV wall motion abnormalities include: inferior apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
The estimated right atrial pressure is 10-15mmHg.,0
There is mild regional left ventricular systolic dysfunction with focal apical inferior hypokinesis.,0
IMPRESSION: Mild regional (apical inferior) hypokinesis with overall normal left ventricular systolic function.,0
8:34 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate fluid status Admitting Diagnosis: AMPULARY MASS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman s/p left subclavian line placement REASON FOR THIS EXAMINATION: Please evaluate fluid status ______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old female status post left subclavian line placement.,0
PORTABLE UPRIGHT CHEST RADIOGRAPH: There is a left subclavian central venous catheter with tip at the brachiocephalic-superior vena cava junction.,0
An endotracheal tube is present with tip 4 cm from the carina at the thoracic inlet.,0
The cardiomediastinal border is stable and low lung volumes are again noted.,0
"A focal opacity obscuring the left hemidiaphragm is again noted, representing either atelectasis or consolidation.",0
"IMPRESSION: Stable chest radiograph with central venous line tip position change, now at the superior vena cava-left brachiocephalic vein junction.",0
"6:18 PM CHEST (PORTABLE AP) Clip # Reason: 84 year old man with previous CXR with bibasilar opacities, Admitting Diagnosis: STROKE;TIA ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with previous CXR with bibasilar opacities, several episodes of desatats please evaluate for interveral change.",0
"REASON FOR THIS EXAMINATION: 84 year old man with previous CXR with bibasilar opacities, several episodes of desatats please evaluate for interveral change.",0
______________________________________________________________________________ WET READ: JMGw SAT 7:56 PM bilateral opacities appear stable since .,0
dobhoff was removed compared to most recent prior.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST AT 18:35 HOURS INDICATION: Desaturation.,0
"FINDINGS: Compared to the prior study, there are some more conspicuous interstitial and airspace markings but technical differences may be responsible.",0
Cardiac silhouette and mediastinal contours are stable.,0
"2:25 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate, evidence of aspiration Admitting Diagnosis: HYPOGLYCEMIC SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with h/o DM2 p/w hypoglycemia and seizure vs syncope.",0
"REASON FOR THIS EXAMINATION: Evaluate for infiltrate, evidence of aspiration ______________________________________________________________________________ FINAL REPORT AP CHEST, 2:43 A.M. ON HISTORY: 72-year-old man with diabetes and hypoglycemia.",0
Evaluate for evidence of aspiration.,0
IMPRESSION: AP chest compared to : Lung volumes are lower but there is no consolidation to suggest pneumonia.,0
Pleural effusion is small on the left if any.,0
"8:47 AM CHEST (PORTABLE AP) Clip # Reason: evaluate effusions, for PNA, ?",0
"pericardial effusion Admitting Diagnosis: CELIAC DISEASE;GASTROENTERITIS ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with celiac disease, presents with pneumonia, pleural effusion, s/p thoracocentesis last week.",1
Now subjectively more SOB with stable O2 sats.,0
"REASON FOR THIS EXAMINATION: evaluate effusions, for PNA, ?",0
"pericardial effusion ______________________________________________________________________________ FINAL REPORT INDICATION: 60-year-old female with celiac disease presenting with pneumonia, pleural effusion, status post thoracentesis, now subjectively with increased shortness of breath.",1
Upright chest radiograph of is compared to the previous chest radiograph of .,0
The study is technically limited secondary to patient rotation.,0
Questionable enlargement of the cardiac silhouette.,0
A small right pleural effusion is again unchanged.,1
A moderate/large sized left pleural effusion has increased in the interval.,1
Atelectasis at the left base.,0
Left upper lobe nodules are partially obscured.,0
There is displacement of the gastric fundus medially likely secondary to splenomegaly.,0
Possible interval enlargement of the heart better evaluated by PA and lateral chest radiographs.,0
Increasing moderate left pleural effusion accounts for worsening basal atelectasis.,1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending: Chief Complaint: transfer from for care of this patient who was stabbed above the sternal notch Major Surgical or Invasive Procedure: Wound exploration, median sternotomy, repair of right subclavian artery.",0
History of Present Illness: Patient is a 22 year old male with an unknown past medial history who was transferred to the ACS Surgery Service from the for management of the stab wound.,0
The stab wound was located above the sternal notch.,0
"Per report, patient presented to the OSH still alert and oriented, talking.",0
He was found to have bleeding into his chest from the stab injury.,0
Bilateral chest tubes were placed.,0
Patient became suddenly hypotensive and eventually lost blood pressure.,0
He was immediately transferred via to .,0
During transport he arrested two times and did not have any identifiable blood pressure.,1
Upon the arrival to he was taken from the flight deck immediately to the operating room.,0
"Past Medical History: PMH: unknown PSH: unknown Social History: cocaine user, otherwise unknown Family History: Unknown Physical Exam: PE: Patient was intubated and sedated on arrival.",0
"He was taken straight to OR where he had no measurable blood pressure, the pulse was intermittently appreciated.",0
"He had two chest tube, one on the right, one on the left side, both were draining blood.",0
There was a stab wound just superior of the sternal notch draining blood.,1
Patient was declared dead (time of death noted in Death Report.,0
Patient was unresponsive to verbal or tactile stimulation.,0
No evidence of heart sounds or carotic pulse.,0
No evidence of spontaneous respirations.,0
"Pupils unreactive, absence of pupillary light reflex.",0
No evidence of response to noxious stimuli.,0
Pertinent Results: 04:59AM TYPE-ART PO2-307* PCO2-49* PH-7.17* TOTAL CO2-19* BASE XS--10 04:12AM LACTATE-13.8* 03:50AM WBC-7.8 RBC-2.87* HGB-8.5* HCT-25.1* MCV-87 MCH-29.6 MCHC-33.9 RDW-15.0 03:50AM PLT COUNT-63* 03:17AM GLUCOSE-120* UREA N-17 SODIUM-148* POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-18* ANION GAP-25* 03:17AM GLUCOSE-152* UREA N-20 CREAT-1.5* SODIUM-155* POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-15* ANION GAP-37* 03:17AM WBC-6.5# RBC-1.53*# HGB-4.8*# HCT-14.0*# MCV-91 MCH-31.2 MCHC-34.2 RDW-15.7* 03:17AM PLT COUNT-29*# 01:20AM WBC-4.1 RBC-3.43* HGB-10.3* HCT-30.3* MCV-88 MCH-30.0 MCHC-33.9 RDW-15.2 01:20AM PLT SMR-LOW PLT COUNT-112* 01:20AM PT-19.0* PTT-128.7* INR(PT)-1.7* Brief Hospital Course: Patient was intubated and sedated on arrival.,0
Medications on Admission: Unknown Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval line position Admitting Diagnosis: SUBARACHNOID HEMATOMA;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 24M s/p fall REASON FOR THIS EXAMINATION: eval line position ______________________________________________________________________________ FINAL REPORT INDICATION: Status post chest tube removal.,0
COMPARISON: Chest x-ray of 2 hours previous.,0
SUPINE AP CHEST: The endotracheal tube remains at the thoracic inlet.,0
The right chest tube is unchanged.,0
There has been interval removal of the left chest tube.,0
The right subclavian catheter is in unchanged position.,0
A pneumothorax is seen laterally at the left chest.,0
There is lucency around the left hemidiaphragm and left mediastinum suggesting additional pneumothorax at these locales.,0
Subcutaneous emphysema within the neck is unchanged.,0
IMPRESSION: Mild-to-moderate pneumothorax status post left chest tube removal.,0
The findings were discussed with Dr. at approximately 9:00 p.m. on .,0
3:17 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with hypoxemic respiratory failure REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Hypoxemic respiratory failure.,1
Portable AP chest radiograph was compared to two prior studies obtained at day earlier.,0
There is slight interval improvement of the widespread parenchymal opacities most likely consistent with interval improvement of pulmonary edema.,0
No new consolidations have been demonstrated.,0
IMPRESSION: Overall slight improvement in the widespread parenchymal consolidations.,0
", J. TSICU 4:33 PM CHEST PORT.",0
PTX Admitting Diagnosis: BOWEL ISCHEMIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with new CVL R IJ REASON FOR THIS EXAMINATION: ?,0
"PTX ______________________________________________________________________________ PFI REPORT ET tube, NG tube, right IJ inserted in expected positions without complication.",0
Persistent left lung disease could be asymmetric edema or pneumonia.,0
1:23 AM CT C-SPINE W/O CONTRAST Clip # Reason: S/P FALL.PAIN.R/O FX ______________________________________________________________________________ MEDICAL CONDITION: year old woman with s/p fall REASON FOR THIS EXAMINATION: evaluate for Cervical spine fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: DJD SAT 3:22 AM No fracture.,0
"Widening of the C3-4 and C4-5 disc spaces may be degenerative, if there is concern for ligamentous injury, MRI is recommended.",0
MD WET READ VERSION #1 BTCa SAT 2:40 AM No fracture.,0
______________________________________________________________________________ FINAL REPORT INDICATION: -year-old female status post fall.,0
COMPARISON: Non-contrast CT head performed concurrently and dictated separately.,0
TECHNIQUE: Non-contrast MDCT axial images of the cervical spine with sagittal and coronal reconstructions.,0
FINDINGS: Cervical spine was imaged from the level of the skull base to the inferior endplate of T2.,0
There is no evidence of fracture or malalignment of the component vertebrae.,0
The atlanto-occipital and atlanto-axial relationships are maintained.,0
"There is multilevel degenerative change with loss of disc space height, osteophytes, and facet hypertrophy, most prominent at C3-4 and C4-5.",0
Slight widening of the anterior C3-4 and C4-5 disc space is likely degenerative.,0
"Lobular soft tissue density in the posterior nasopharynx is incompletely characterized and may represent a nasal polyp, polypoid adenoid tissue, secretions or soft tissue mass.",0
There is no erosion of the adjacent bony structures.,0
There is a tiny right apical hydropneumothorax adjacent to a posterior second rib fracture.,1
High-density material along the visualized right tentorium is consistent with known subdural hematoma.,0
No evidence of fracture or malalignment within the cervical spine.,0
Soft tissue density within the posterior nasopharynx is of unclear etiology.,0
"Diagnostic considerations include polypoid adenoidal tissue, nasal polyp, retained secretions or soft tissue mass.",0
"Tiny right hydropneumothorax, better characterized on the CT torso from the same date.",0
(Over) 1:23 AM CT C-SPINE W/O CONTRAST Clip # Reason: S/P FALL.PAIN.R/O FX ______________________________________________________________________________ FINAL REPORT (Cont) 4.,0
"Findings were discussed with Dr. at 2 a.m. on , .",0
"9:56 AM CAROT/CEREB Clip # Reason: Evaluate for aneurysm Admitting Diagnosis: INTRAVENTRICULAR HEMORRHAGE Contrast: OPTIRAY Amt: 333 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER * * EXT CAROTID BILAT CAROTID/CERVICAL BILAT * * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM * * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * MOD SEDATION, FIRST 30 MIN.",0
"MOD SEDATION, EACH ADDL 15 MIN * * MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 32 year old woman with IVH REASON FOR THIS EXAMINATION: Evaluate for aneurysm ______________________________________________________________________________ FINAL REPORT (REVISED) MEDICAL HISTORY: 32-year-old woman with intraventricular hemorrhage.",0
REASON FOR EXAM: Evaluate for aneurysm.,0
"TASKS PERFORMED: Diagnostic cerebral angiogram with right internal carotid arteriogram, right common carotid arteriogram, right external carotid arteriogram, right vertebral artery arteriogram, left internal carotid arteriogram, left common carotid arteriogram, left external carotid arteriogram, and left vertebral arteriogram.",0
ANESTHESIA: The patient was under moderate sedation provided by administration of 75 mcg of fentanyl and 1 mg of Versed through the total intraservice time of 70 minutes.,0
"DETAILS OF THE PROCEDURE: Informed consent was obtained from the patient and her husband after explaining risks, indications, and alternative management.",0
The patient was brought to the neurointerventional suite and placed in supine position on the biplane table.,0
Both groins were prepped and draped in normal sterile fashion.,0
"Preprocedure time-out was performed documenting the nature of the procedure, the patient identity and relevant blood work up using two independent verifiers.",0
"After injection of local anesthetic into the right femoral area, the right common femoral artery was accessed using a micropuncture set.",0
A 4 Fr vascular sheath was successfully placed into the right common femoral artery using Seldinger technique.,0
"Through the sheath, a Berenstein catheter was inserted over the wire and advanced into the aortic arch.",0
The wire was removed and .038 angled glidewire was used.,0
"The abovementioned vessels were selectively catheterized and arteriograms were performed from these locations and AP, lateral, oblique and three dimensional acquisitions were done where appropriate.",0
"After reviewing of films, the (Over) 9:56 AM CAROT/CEREB Clip # Reason: Evaluate for aneurysm Admitting Diagnosis: INTRAVENTRICULAR HEMORRHAGE Contrast: OPTIRAY Amt: 333 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) catheter and wire were withdrawn, the sheath was removed and pressure was held to the right groin for a total of 20 minutes until hemostasis was obtained.",0
The procedure was uneventful and the patient was examined and appeared neurologically unchanged.,0
The patient was sent to the trauma ICU with post procedure orders.,0
FINDINGS: Right common carotid arteriogram showed normal carotid bifurcation with brisk filling of both internal and external carotid arteries with no stenosis.,0
"Right internal carotid arteriogram showed normal filling along the cervical, petrous, cavernous and supraclinoid portions of the internal carotid artery.",0
The vesseles appear to be slightly displaced laterally due to mass effect.,0
Otherwise normal middle cerebral artery and anterior cerebral arteries and their branches.,0
There was no AVM or aneurysm seen.,0
There were normal appearing venous sinuses.,0
Right external carotid arteriogram showed normal vessels and its branches and no dural AV fistula seen.,0
Right vertebral artery showed normal distal portions of the vertebral artery.,0
There is no clear side predominance.,0
Basilar appears normal in course and caliber.,0
"There was normal right PICA/AICA, superior cerebellar arteries.",0
Both posterior cerebral arteries were seen and appeared normal.,0
There was an abnormal tangle of vessels originating from P2 segment of the right posterior cerebral artery with prominent veins but no definite draining vessels or early draining vein noticed.,0
This could represents an AVM.,0
Left common carotid arteriogram showed normal carotid bifurcation and brisk filling of the internal and external carotid arteries.,0
"Left internal carotid arteriogram showed normal filling along cervical, petrous, cavernous, and supraclinoid portions.",0
Normal middle and anterior cerebral arteries.,0
There is cross filling through the ACOM.,0
There is no aneurysm or arteriovenous malformation.,0
Left external carotid arteriogram showed normal vessels and its branches.,0
There is no dural AV fistula.,0
Left vertebral artery arteriogram showed normal distal portion of the left vertebral arteries and appeared unremarkable.,0
The basilar again appears normal in course and caliber.,0
"AICA, superior cerebellar arteries and PCAs were seen.",0
This study was limited because of the motion artifacts and was (Over) 9:56 AM CAROT/CEREB Clip # Reason: Evaluate for aneurysm Admitting Diagnosis: INTRAVENTRICULAR HEMORRHAGE Contrast: OPTIRAY Amt: 333 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) done by hand injection.,0
IMPRESSION: Diagnostic cerebral arteriogram was done which showed abnormal tangles of vessels arising from P2 segments of the right PCA which could represent arteriovenous malformation AVM .,0
We recommend follow up angiogram in one week with selective catheterization of the right posterior cerebral artery.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM: This is an Addendum to the original Discharge Summary dictation.",0
"CONCISE SUMMARY OF HOSPITAL COURSE (CONTINUED): On , the patient had improving urine output, a decrease in creatinine, and improving body rash.",0
The patient was on a dopamine infusion as well as Natrecor which was transitioned to hydralazine.,0
"By , the patient was felt to be hemodynamically optimized.",0
"The rash was sufficiently resolved, and the patient was to the operating room with Dr. for a redo mitral valve replacement with #27 mosaic valve via a right thoracotomy.",1
"The patient was transferred to the Intensive Care Unit in critical condition on a dobutamine, milrinone, Levophed, and propofol infusions.",0
"On arrival to the Intensive Care Unit, the patient was started inhaled nitric oxide for his consistently evaluated pulmonary artery pressures.",1
The patient had an adequate cardiac output.,0
He good oxygen saturation on mechanical ventilation.,0
The patient's ejection fraction in the operating room had been noted to 45% to 50%.,0
A Cardiology and Electrophysiology consultation was obtained to reprogram the patient's permanent pacemaker and chest for function.,0
The patient was found to be atrial flutter.,1
The atrial flutter was paced terminated.,0
"The patient was started on amiodarone, and the pacemaker was found to be in good working condition.",0
The patient continued to have adequate cardiac output.,0
The inhaled nitric oxide was weaned to 35 parts per million.,0
"By postoperative day three, the patient had weaned to 2.5 mg of dobutamine, milrinone at 0.5, inhaled nitric oxide at 30 parts per million, and intra-aortic balloon pump at 1:1.",0
The patient continued to have adequate cardiac indices.,0
The patient was started on a Lasix infusion for diuresis.,0
"On postoperative day four, the dobutamine was discontinued.",0
The milrinone was weaned down.,0
The patient continued to be diuresed.,0
The patient remained intubated on mechanical ventilation.,1
The patient was started on tube feeds.,0
"By postoperative day four, the nitric oxide was attempted to be weaned to off; however, the patient had significant rebound pulmonary hypertension and it was restarted.",1
"On the afternoon on postoperative day four, the patient's intra-aortic balloon pump was removed.",0
It was noted after removal that there was a loss of pulse in the right lower extremity.,0
By the time the Vascular Surgery team saw the patient the perfusion to the limb was improved.,0
It was felt that the limb was not threatened.,0
Recommended a low-dose heparin drip.,0
A femoral ultrasound was obtained which showed no evidence of pseudoaneurysm or arteriovenous fistula in the right groin.,0
The patient continued to be dependent on nitric oxide and milrinone.,0
The Vascular team thought that the examination of the right lower extremity was much improved.,0
"On postoperative day five, the inhaled nitric oxide was again attempted to be weaned off; however, the patient had significant rebound pulmonary hypertension.",1
It was recommended that the patient be started on nitroprusside for afterload reduction as well as reduction in the pulmonary vascular resistance to facilitate weaning of the nitric oxide.,1
The patient's was continued on a Lasix drip.,0
The milrinone infusion was increased.,0
"By postoperative day seven, the inhaled nitric oxide was weaned to off.",0
Pulmonary Medicine was consulted again to facilitate the weaning the anatropes and the management of the pulmonary hypertension.,0
"They recommended aggressive diuresis, aggressive afterload reduction, and gentle weaning of the anatropic support.",0
"On postoperative day eight, the patient was again found to be in atrial fibrillation.",1
The Electrophysiology Service recommended direct current cardioversion.,0
The patient was cardioverted with 200 joules times one to a sinus rhythm.,0
The patient was continued on a heparin infusion as well as a Lasix drip for diuresis.,0
The patient's ventilator was weaned to continuous positive airway pressure with pressure support which he tolerated well with adequate oxygenation.,0
"The milrinone was weaned down to 1.25, and the patient was weaned and extubated on postoperative day 11.",0
"However, after extubation the patient had an increase in his pulmonary artery pressures.",1
The patient's milrinone drip was increased.,0
"The patient was started on Natrecor, and the Lasix drip was increased to increase his diuresis.",0
"However, three hours of extubation the patient required reintubation for respiratory distress and hypoxia.",0
Reintubation was without significant event.,0
The patient's milrinone infusion continued at 0.37.,0
The patient was noted to have rising white blood cell count up to 15.,0
The patient's lines were re-sited.,0
"By postoperative day 13, it was thought that the patient was euvolemic and the Lasix and Natrecor infusions were stopped.",0
The patient had been started on vancomycin for increasing white blood cell counts.,0
"The line and blood cultures from the DR. , 02-351 Dictated By: MEDQUIST36 D: 16:44 T: 19:27 JOB#:",0
", R. SICU-B 3:40 AM CHEST (PORTABLE AP) Clip # Reason: eval change in CHF Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with CHF and pneumonia REASON FOR THIS EXAMINATION: eval change in CHF ______________________________________________________________________________ PFI REPORT Multifocal opacity slightly improved, likely due to improved multifocal pneumonia.",0
"_____ edema cannot be ruled out, would be improved.",0
Heart size is still top normal.,0
Small bilateral pleural effusions are stable.,0
"5:46 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: acute changes in respiratory status Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;SHORTNESS OF BREATH ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with CLL, s/p trach/peg now with acute hypoxia.",1
REASON FOR THIS EXAMINATION: acute changes in respiratory status ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Acute changes in respiratory status.,1
PORTABLE AP CHEST RADIOGRAPH: Radiograph acquired on at 5:45 a.m. and presented to the radiologist on at 11:11 a.m.,0
"Compared to prior radiograph from , the areas of multifocal pneumonia in the right lower lobe and left retrocardiac area appear unchanged.",0
"No pleural effusion is evident in the right lateral costophrenic sulci; however, there may be a small left-sided pleural effusion.",0
The heart size is normal with no pulmonary vascular congestion.,0
The tracheostomy tube is seen in unchanged position.,0
The tip of the left subclavian central venous catheter overlies the expected region of the brachiocephalic vein.,0
"IMPRESSION: Persistent multifocal pneumonia, not significantly changed from prior radiograph.",0
"7:18 AM NEONATAL HEAD PORTABLE Clip # Reason: PREMATURE INFANT, R/O IVH ______________________________________________________________________________ MEDICAL CONDITION: 7 day old 31 weeker REASON FOR THIS EXAMINATION: r/o IVH ______________________________________________________________________________ FINAL REPORT INDICATION: 7 day old 31 weeker baby.",1
There is no evidence of blood.,0
"The ventricles, sulci, and cisterns are normal.",0
There is no intra or extra-axial fluid collections or masses.,0
"9:54 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval PTX Admitting Diagnosis: R PTX ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with hx R PTX, CT on suction now REASON FOR THIS EXAMINATION: eval PTX ______________________________________________________________________________ FINAL REPORT INDICATION: 80-year-old woman with history of right pneumothorax COMPARISONS: None available.",1
SINGLE FRONTAL CHEST RADIOGRAPH: A right chest tube terminates in the right hilus.,0
Tiny right apical pneumothorax with right subcutaneous air collections are present.,1
Hiatal hernia is noted in the retrocardiac region.,0
The left lung is well expanded and clear.,0
"The mediastinal silhouette, hilar contours, and pleural surfaces are normal.",0
IMPRESSION: Small right apical pneumothorax with adjacent subcutaneous air collections.,1
"7:14 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for progression/change of small L hemopneumothro Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p MVC REASON FOR THIS EXAMINATION: Please eval for progression/change of small L hemopneumothroax ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after motor vehicle collision, for evaluation of the progression of pneumothorax.",1
Portable AP radiograph was compared to multiple prior studies obtained the date earlier.,0
The ET tube tip is currently 7.2 cm above the carina.,0
The left chest tube is in place with no appreciable pneumothorax currently seen.,1
"Multiple rib fractures are redemonstrated, both left and right.",0
The known fracture of the right scapula can be partially assessed on the current radiograph.,1
The increased opacity of the right lung is demonstrated and might suggest interval development of layering pleural effusion in the presence of multiple rib fractures.,0
"There is also small loculated lucency projecting over the mid-lower portion of the right lung and might reflect loculated pneumothorax in this location, not clearly seen on the original radiographs but corresponding to the small amount of pneumothorax seen on the prior CT torso and might potentially reflect its increase in size.",0
8:39 AM CHEST (PA & LAT) Clip # Reason: assess -V pacemaker leads Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with revision of -V PM REASON FOR THIS EXAMINATION: assess -V pacemaker leads ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after revision of biventricular pacemaker placement.,1
PA and lateral upright chest radiographs were reviewed in comparison to .,0
"The current study demonstrates biventricular pacing devices with the leads most likely located in the right atrium, right ventricle and the left epicardial vein in expected location.",1
Small amount of pleural effusion is noted most likely on the right.,0
"3:06 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax s/p ij central line placement ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman s/p acute mi and fem- bypass REASON FOR THIS EXAMINATION: r/o pneumothorax s/p ij central line placement ______________________________________________________________________________ FINAL REPORT INDICATION: 51 year old woman status post acute MI, central line placement.",0
Comparison to prior study from at 9:16 AM.,0
PORTABLE CHEST: A right IJ central line has been placed terminating in the SVC.,0
The endotracheal tube is in satisfactory position approximately 6 cm above the carina.,0
The pulmonary artery catheter terminates in the right main pulmonary artery.,0
The nasogastric tube terminates near the antrum.,0
Again seen are diffuse bilateral air space opacities.,0
Satisfactory position of right IJ line with no pneumothorax.,0
Persistent diffuse bilateral air space opacities likely representing CHF.,0
"Name: , H Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Addendum: During this admission, the patient was also treated for klebsiella pneumonia with meropenem.",1
"He also suffered renal failure, requiring CVVH.",1
Discharge Disposition: Expired MD Completed by:,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Keflex Attending: Chief Complaint: AAA Major Surgical or Invasive Procedure: AAA open resection-(ABI) cardiac catheterzation with PCI of LAD Bronchoscopy , Rt.",1
"chest tube placement bronchcoscopy, thearputic aspiration bronchcoscopy with LLL BAL trach with PEG throcentesis right Pussey-Murer Valve trach History of Present Illness: Admitted for elective open AAA repair Past Medical History: histroy of hyperlipdemia history of lumbar disc disease s/p laminectomy of L4-5 histroy of glall bladder disease s/p ccy histroy of MVA,s/p splenectomy histroy of current tobacco use Social History: married, lives with spouse retired : current smoker 1 ppd ETOH: denies Family History: un known Physical Exam: general: no acute distress HEENT: diminished ROM, no carotid bruits, no JVD Lungs: clear to auscultation Heart:RRR no mumur,gallop ,rub ABD: soft, nontender, nondistended + abdominal pulsation Ext: bilateral femoral pulses dopperable,dopperable DP pulses, PT pulses?",1
"moderate diffuse disease, rca totallly occluded , collatralized Left to right.",0
Epi dural d/c' RE intubated for hypoxia and respiratory acidosis.,0
"There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the basal inferolateral segment and mild hypokinesis of the mid to distal anterior wall, anterior septum and apex.",1
IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction consistent with multi-vessel coronary artery disease.,1
"Compared with the prior study (images reviewed) of , wall motion abnormalities are better appreciated on the current study (as above).",0
There is now a wire/catheter in the RA/RV.,0
nutritional consult for TF continued diuresis TPN began.,0
"CXR with infiltrate antibiotics brodened to VAnoc,Cipro,Meropeneum.",0
"CT chest: RLL,RML consolidation with RML abcess and moderate pleural effusion remains on vent support .",0
"Chest Tube placement.c/s sputum MRSA, c/s BAL klebsella and beta strep.Linezolid added to antibiotic regment but d/c 24hrs later.",0
Patient in septic shock requiring vassopressor support.,0
Thoracic surgery consulted for lung abcess.,0
"Recommendations no ct needle aspiration of abcess ,continue with chest tube drainage.Bronchoscopy with theareupedic aspiration.ID consulted; legonella c/s negative.",0
"no intraabdominal source for infection, RLL effusion.",1
"Bronch with BAL of LLL Trach, PEg Neruo surgery cx for C spine canal stenosis.",0
sacral wound care began for stage 2 sacral decubitus awaiting timing of C spine stablization by neuro surgery.,0
continued elevated WBC and temp.right thorocentesis>500cc.,0
continue with Tf no po's.,0
"transfused for anemia off vent, Trach mask, PMV placed.",0
transfered to VICU aphasia and dysphagia very pronounced with increasing mental confusionn.,0
WBC 20. c/s urine negative no temp.,0
Antibiotics discontinued planned spine stabllization cancelled secondary to leukocytosis.,0
Neuro consulted for persistant confusion.,0
MRI of head pending.MRI could not be done because patient needed to be vnetelated and sedated.WBC monitered continued to moniter WBC 12.5 Cervical stablization by neuro done.,0
"patient stable.awaiting rehab bed repeat swallow study done,patient continues to aspirate will remain NPO.",0
treated for UTI with cipro.,0
Medications on Admission: simvistatin 20mgm daily atenolol ?,0
daily asa 81 mg daily diazapam prn trazadone prn vit c daily vit e daily pencilliln 500mgm Discharge Medications: 1.,0
Albuterol 90 mcg/Actuation Aerosol : Four (4) Puff Inhalation Q4H (every 4 hours) as needed.,0
Atorvastatin 40 mg Tablet : One (1) Tablet PO DAILY (Daily).,0
Ipratropium Bromide 17 mcg/Actuation Aerosol : Six (6) Puff Inhalation Q4H (every 4 hours) as needed.,0
"Nystatin 100,000 unit/mL Suspension : Five (5) ML PO QID (4 times a day).",0
Miconazole Nitrate 2 % Powder : One (1) Appl Topical TID (3 times a day) as needed.,0
Bisacodyl 10 mg Suppository : One (1) Suppository Rectal DAILY (Daily) as needed.,0
Metoprolol Tartrate 50 mg Tablet : Two (2) Tablet PO TID (3 times a day).,0
Codeine-Guaifenesin 10-100 mg/5 mL Syrup : 5-10 MLs PO Q6H (every 6 hours) as needed for cough.,0
Humalog 100 unit/mL Solution : as directed Subcutaneous four times a day: AC: glucoses <120 no insulin 121-140/2u 141-160/4u 161-180/6u 181-200/8u 201-220/10u 221-240/12u 241-260/14u 261-280/16u 281-300/18u 301-320/20u 321-340/22u 341-360/24u >360 Md u=units.,0
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization : One (1) Inhalation Q6H (every 6 hours) as needed.,0
Ipratropium Bromide 0.02 % Solution : One (1) Inhalation Q6H (every 6 hours) as needed.,0
Lorazepam 2 mg/mL Syringe : One (1) Injection Q6H (every 6 hours) as needed.,0
Hydralazine 20 mg/mL Solution : Ten (10) mg Injection Q6H (every 6 hours) as needed.,0
Oxycodone-Acetaminophen 5-325 mg/5 mL Solution : 5-10 MLs PO Q6H (every 6 hours) as needed.,0
Ondansetron HCl (PF) 4 mg/2 mL Solution : Four (4) mg Injection Q8H (every 8 hours) as needed for nausea/vomiting.,0
"Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: abdominal aortic aneurysem history of lumbar disc disease s/p laminectomy L4-5 history of gallbladder disease s/p ccy history of MVA s/p splenectomy history of hyperlipdemia history of lung nodules history of current tobacco use-1ppd postoperative acute myocardial infract-RCA occlusion postop pulmonary edema postoperative klebsella /MRSA PNa of RLL,RML with RML abcess postoperative septic shock-vasopressors,resolved postop respirtory failure-Trach postoperative failure to thrive-PEG placement postoperative blood loss anemia transfused postoperative sacral decubitus Stag -2 , treated, stable postoperative cervical canal stenosis postoperative dysarthria, aspiration postoperative encephalopathy postoop UTI-treated Discharge Condition: stable Discharge Instructions: call if any questions.",1
"Followup Instructions: Dr.. call for appointment , post d/c from rehab Dr. of neuro surgery in 6 weeks Dr. ( interventional cardology ) please acll for an appoointment 6 Completed by:",0
8:59 PM CHEST (PORTABLE AP) Clip # Reason: ro ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man s/p CABG REASON FOR THIS EXAMINATION: ro ptx ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM: HISTORY: CABG.,1
ETT is ____ cm above carina.,0
Tip of Swan-Ganz catheter overlies proximal portion of right pulmonary artery.,1
Mediastinal and chest tubes in sity.. No pneumothorax.,0
"There is a large rounded mass in the left mid zone as previously demonstrated and atelectasis in the left lower lobe with poor definition of the left hemidiaphragm, essentially unchanged since the prior film of .",0
No change in the left mid zone mass.,0
Atelectasis in left lower lobe.,0
"7:42 AM CHEST (PORTABLE AP) Clip # Reason: eval for pneumothorax Admitting Diagnosis: S/P V-FIB ARREST ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Status post CABG, evaluate for pneumothorax.",1
CHEST Cardiac size is enlarged.,0
There is collapse consolidation in the left lower lobe with loss of the left hemidiaphragm.,0
No evidence of a pneumothorax is seen.,0
"IMPRESSION: No pneumothorax, left lower lobe collapse consolidation",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: UROLOGY Allergies: Celexa / Erythromycin Attending: Chief Complaint: Renal tumor Major Surgical or Invasive Procedure: Laparosopic right radical nephrectomy History of Present Illness: is a very pleasant and well informed a 61-year-old woman who back in had what appeared to be a pneumonia.,0
The lung CT unfortunately revealed a right renal tumor and left adrenal mass.,0
"She denies gross hematuria, urinary tract infections, or other urinary symptoms such as urgency.",0
She does state that she has been very thirsty with urinary frequency over the past couple of weeks.,0
She has not checked her blood sugar in many weeks she says.,0
"She states also admits to fatigue and crampy bilateral lower abdominal pain, which is not associated with nausea, vomiting, fever, or chills.",0
"It does not seem to be associated with food intake, urinary, or bowel habits.",0
"She has had a weight loss of 27 pounds over the past five months, denies night sweats.",0
"Past Medical History: Past medical history of coronary artery disease (CABG in , afib, hypertension), type 2 diabetes, obesity, cataracts, diverticulitis, COPD, arthritis, borderline personality/obsessive compulsive disorder/PTSD, carpal tunnel.",1
"Past Surgical History: Tonsils and adenoids , D&C /76, hysterectomy , lumpectomy CABG .",0
"Medications: Glipizide, Procardia, metoprolol, fluoxetine, guaifenesin, valsartan, ranitidine, stress tablets, vitamin C, nitroglycerin p.r.n., albuterol p.r.n., syllium powder, eyedrops, Vicodin, lorazepam, aspirin.",0
"Physical Exam: General: comfortable Abd: soft, non tender, non distended Incisions: clean, dry, intact; no signs of infection Brief Hospital Course: Patient was admitted to Urology after undergoing laparoscopic right radical nephrectomy.",0
The patient received perioperative antibiotic prophylaxis.,0
The patient was transferred to the floor from the PACU in stable condition.,0
"On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and ambulated once.",0
"On POD1, the patient was restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet.",0
"On POD2, urethral catheter (foley) removed without difficulty and diet was advanced as tolerated.",0
"Pulmonary edema and atelectasis noted on CXR, she was weaned off ocysgen with diuretics.",0
The remainder of the hospital course was relatively unremarkable.,0
"On POD4, the patient had chest pain but serial cardiac enzymes and EKG were negative x3 and the chest pain spontaneously resolved.",0
"The patient was discharged in stable condition, eating well, ambulating independently with oxygenation >91% on room air, voiding without difficulty, and with pain control on oral analgesics.",0
"On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection.",0
The patient was given explicit instructions to follow-up in clinic with Dr. in 3 weeks.,0
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 1 weeks: No alcohol or driving on this medication.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 weeks: Take while you are on narcotics.,0
Stop when you are having regular bowel movements.,0
Glipizide 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
"Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual q5min as needed for angina.",0
Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).,0
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).,0
"Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety, insomnia.",0
"Disp:*0 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Renal tumor Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision.",0
"-Do not eat constipating foods for 2-4 weeks, drink plenty of fluids.",0
-Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by Dr. in follow-up.,0
-Do not drive or drink alcohol while taking narcotics.,0
-Resume all of your home medications.,0
-Call Dr. office to schedule a follow-up appointment in 3 weeks AND if you have any questions.,0
"-If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER.",0
Followup Instructions: Call Dr. office to schedule a follow-up appointment in 3 weeks AND if you have any questions.,0
"Dr. , 2PM, , ,",0
Height: (in) 58 Weight (lb): 110 BSA (m2): 1.41 m2 BP (mm Hg): 128/70 HR (bpm): 97 Status: Inpatient Date/Time: at 11:41 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.,0
Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) with inferior hypokinesis suggested (poor quality cines).,0
with moderate global free wall hypokinesis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Percocet / Iodine; Iodine Containing Attending: Chief Complaint: Left hand pain and numbness Major Surgical or Invasive Procedure: None History of Present Illness: 57-year-old man w/ history of an MI in with clean coronaries and felt to be emboli, mitral valve repair in , a St.",0
"Identity pacemaker placed on the right side for complete heart block in , and a recent BiV pacer replacement in for dilated cardiomyopathy.",1
"For this recent pacer change, he was off coumadin from through .",0
INR yesterday 1.8 at Quest labs.,0
"On Monday, he began to notice left hand discomfort and swelling.",0
"He was to see his PCP until Wednesday, who noted swelling and referred him to Dr. .",0
"On the morning of admission, he saw Dr. , who noted, no pulses in left radial and sent him for CT scan, which revealed large clot in left atria, left ventricle, and embolus to left brachial artery.",0
"In the ED,T98.0 BP 134/86; HR 82 O2Sat 99%RA.",0
"Dr. asked Dr. to evaluate patient, and it was decided that medical management with no embolectomy at this time.",0
"He received heparin 5000 bolus, then 100/hour, no lysis.",0
"Coagulopathy w/up (ACL Ab, V leiden) initiated.",0
Non-contrast abd CT to r/o thrombus showed no other emboli/infarcts.,0
Patient was admitted to CCU for closer monitoring.,0
"Upon arrival to CCU, he is without complaints and feels at baseline except for a very mild achiness in left chest, nonradiating, not associated with any movements, and different from previous MI pain.",0
"Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.",0
"Otherwise, on review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools.",1
"Past Medical History: # Hyperlipidemia # s/p embolic MI with no CAD noted on cath # Severe dilated cardiomyopathy # : Concerto BiVentricular ICD: DDD mode, lower rate 50 beats per minute; treat rates greater than 188 beats per minute.",0
"# Congenital heart block, s/p right sided pacemaker placed in # Heart failure # Mitral regurgitation: s/p mitral valve repair at and Women?????",1
?s # Hemorrhoids # Hernia repair Social History: Pt works as a software writer and also plays piano.,0
"Family History: brother: same congenital heart block and MV, died stroke age 34 Mother: stoke in 80's Father: AAA, currently still alive 2 Sisters: no known hx of miscarriages Physical Exam: VS: T 98.6 , BP 125/68 , HR 89, RR 18, 96%RA Gen: WDWN middle aged male in NAD, resp or otherwise.",1
"Neck: no LAD, thyromegaly CV: RR, normal S1, S2.",0
"No S4, no S3; I/VI systolic murmur at RUSB Chest: No chest wall deformities, scoliosis or kyphosis.",0
"Ext: nailbed reperfusion <1sec, warm well perfused, no cyanosis Skin: No stasis dermatitis, ulcers, scars, or xanthomas.",0
"Pulses: Right: Carotid 2+ without bruit; 2+ DP; 2+ PT; 2+ radial Left: Carotid 2+ without bruit; 2+ DP; dopplerable PT; dopplerable radial Pertinent Results: 140 105 20 --------------< 98 4.7 24 1.2 Ca: 9.7 Mg: 2.2 P: 3.1 CK: 182 MB: 6 Trop-T: <0.01 94 10.4 > 15.5 < 242 45.1 N:72.0 L:21.1 M:4.7 E:1.8 Bas:0.4 PT: 24.0 PTT: 33.5 INR: 2.3 # CTA : LEFT UPPER EXTREMITY: An 8.3 cm segment of the left brachial artery, which is occluded by embolus, with distal reconstitution of both the radial and ulnar arteries.",1
This segment extends from the supracondylar humerus through the proximal radius just beyond the radial head level.,0
There is no contrast within this segment of the vessel and the vessel itself is mildly expanded.,0
CHEST: A focus of compressed enhancing lung parenchyma in the left lower lobe is most compatible with atelectasis.,0
"Homogeneous smooth filling defects in the left atrial appendage, left atrial chamber and left ventricle c/w thrombus.",0
AICD leads extend from a left-sided power pack.,0
There are post- surgical changes at the mitral valve.,0
There is ectasia of the ascending thoracic aorta which measures up to 4.3 cm at the level of the main pulmonary artery.,0
ABDOMEN: A 17 mm left upper renal cortical cyst is simple in appearance.,0
"Additional subcentimeter right renal cortical lesions are too small to characterize, but statistically, most likely represent additional cysts.",0
"There are multiple areas of cortical thinning in both kidneys, compatible with scar.",0
The spleen appears lobulated but otherwise unremarkable.,0
The pancreas and adrenal glands also appear also appear grossly unremarkable.,0
"There are multiple low-attenuation lesions throughout the liver, measuring up to 12 mm in diameter, the largest of which is suggestive of a cyst, the remainder of which are too small to characterize.",0
"PELVIS: The rectum, sigmoid colon, prostate gland, seminal vesicles, and bladder appear grossly unremarkable, as seen.",0
A fat-containing left inguinal hernia is noted.,0
There are no suspicious lytic or blastic lesions within the imaged bones.,0
"Left brachial artery embolus with reconstitution of the radial and ulnar arteries, thrombus apparently originating from the left heart, as detailed above.",0
"Low attenuations in the liver and left kidney, some of which are compatible with cysts and others of which are too small to characterize.",0
Ectasia of the ascending thoracic aorta measuring up to 4.4 cm at the level of the main pulmonary artery.,0
# ECHO TEE: The left atrium is dilated.,0
Moderate to severe spontaneous echo contrast is seen in the body of the left atrium.,0
A definite thrombus is seen in the left atrial appendage.,0
# ECHO : The left atrium is markedly dilated.,0
There is severe regional left ventricular systolic dysfunction with basal and mid-inferior akinesis.,0
There is moderate hypokinesis of the remaining segments (LVEF = 20-25%).,0
The aortic root at the sinus level and the ascending aorta are moderately dilated.,0
Estimated pulmonary pressure is normal.,0
IMPRESSION: No left ventricular thrombus seen.,0
Severe regional and global left ventricular systolic dysfunction.,0
# ECG : Atrial sensing with ventricular pacing.,0
Compared to the prior tracing there is no significant change Brief Hospital Course: 57 year old man with presumed embolic MI in and pacemaker for complete right heart block in presented with left arm pain and found to have clots in LA/LV and L brachial artery.,1
# LA/LV thrombus and brachial emboli: Initially presented with left arm pain and numbness.,0
Initially seem on CTA and futher characterized on and TEE.,0
He was monitored briefly in the CCU and was then transferred to the Cardiology Service for subsequent care.,0
"They agree with medical managment which including started heparin gtt, titrating to goal PTT of 70-90.",0
His coumadin was restarted and INR goal was set to be 2.5 and 3.5.,0
He was at goal for 72 hours before heparin gtt was stopped and he was discharged.,0
"Over the hospital course, his arm pain resolved and his claudication gradually improved.",0
"At discharge, he only has mild claudication but his hand was well perfused: warm with good capillary refill, although his left radial pulse was dimished compared to right.",0
He will follow up with Dr. at Cardiology Clinic on .,0
It is unclear why he is so thrombophilic.,0
He had an MI in with wall motion comprimise but cath did not show obstruction.,0
This was presumed to be en embolic event.,0
"Labs were sent including Factor V Leiden, lupus anticoagulant, antiphospholipid, prothrombin gene mutation and homocysteine level.",0
Apparently he had elevated homocysteine levels in the past for unclear reasons.,0
"On discharge, he will start Vitamin B12, Vitamin B6 and folate.",0
He will follow up with Dr. at clinic.,0
# Pump: Echo revealed severe regional left ventricular systolic dysfunction with basal and mid-inferior akinesis.,0
He remained euvolemic during this admission.,0
"He will continue Digoxin 0.125mg daily, lisinopril 5mg and Toprol XL 12.5mg daily # Rhythm: AV paced.",0
# Hyperlipidemia: continue Simvastatin 80mg daily and Zetia 10mg daily.,0
# Valves: s/p MV repair at .,0
2+ MR with normal MVR gradient.,0
"Medications on Admission: Coumadin 5mg MWF, 4mg Tu/Th/Sat/Sun last dose Simvastatin 80mg daily Digoxin 0.125mg daily Captopril 6.25mg TID Metoprolol 12.5mg daily Zetia 10mg daily Coenzyme Q 10 100mg daily Nitrostat as needed 60mg daily Celexa 10mg ( of 20mg tab) Discharge Medications: 1.",0
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).,0
Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO daily ().,0
Warfarin 5 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday).,0
Warfarin 2 mg Tablet Sig: Two (2) Tablet PO TUTHSATSUN ().,0
Pyridoxine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).,0
Cyanocobalamin 250 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily).,0
Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Left atrial thrombus and brachial artery emboli.,0
"SECONDARY: # Hyperlipidemia # Severe dilated cardiomyopathy # Congenital heart block, s/p right sided pacemaker placed in # Heart failure # Mitral regurgitation: s/p mitral valve repair # Hemorrhoids Discharge Condition: Hemodynamically stable; afebrile; ambulating Discharge Instructions: You were admitted for pain and swelling of your left hand and fingers.",1
You were found to have clost in the of your heart and in one of the arteries in your left arm.,0
You were treated with a blood thinner called heparin and coumadin with improvement of your pain and blood flow.,0
You will need to continue to coumadin and it is important not to stop this medication.,0
Please follow up with Dr. in Cardiology and Dr. in Hematology as outlined below.,0
Please take all medication as prescribed.,0
"Of note, you will take Coumadin 5mg on Monday Wed and Fri. On other days you will take 4mg.",0
There are some other changes and additions in your medication list; please review in detail.,0
"If you have any further numbness, tingling, weakness, blurry vision, headaches, weakness, chest pain, shortness of breath, or any other concerning symptoms, please call your PCP or return to the ER.",0
Please let your doctor know if the pain in your left hand does not improve or worsens.,0
Followup Instructions: Please follow up with Dr. ; appointment has been set for you on .,0
Please follow up with Dr. at clinic within two weeks.,0
Please call as soon as possible to make an appointment.,0
"OTHER APPOINTMENTS Provider: , MD Date/Time: 11:40 Provider: CLINIC Phone: Date/Time: 3:00 Provider: , MD Phone: Date/Time: 3:40 Completed by:",0
Height: (in) 73 Weight (lb): 180 BSA (m2): 2.06 m2 BP (mm Hg): 142/90 HR (bpm): 79 Status: Inpatient Date/Time: at 23:36 Test: TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
RIGHT VENTRICLE: Small RV cavity.,0
"Sustained RA diastolic collapse, c/w low filling pressures or early tamponade.",0
Right ventricular chamber size is relatively small with preserved free wall motion.,0
"There is a large circumferential pericardial effusion with sustained right atrial and right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology.",0
IMPRESSION: Large circumferential pericardial effusion with evidence for increased pericardial pressure/tamponade physiology.,0
"9:38 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for pulm edema or consolidation Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with incr WOB and tachycardia REASON FOR THIS EXAMINATION: eval for pulm edema or consolidation ______________________________________________________________________________ FINAL REPORT INDICATION: A 65-year-old man with increased work of breathing and tachycardia, evaluate for pulmonary edema or consolidation.",0
"COMPARISON: Multiple chest radiographs, the latest from .",0
ONE VIEW OF THE CHEST: The lungs are low in volume and evaluation is limited due to respiratory motion.,0
"Within these limitations, multifocal areas of opacities are unchanged compared to the prior examination with a more confluent left lower lobe opacity, unchanged as well.",0
"A left IJ catheter terminates in the brachiocephalic vein, a right subclavian catheter terminating in the mid SVC, and an NG tube passing out of view below the diaphragm.",0
"IMPRESSION: Limited examination due to respiratory motion, but no change in mild pulmonary edema and left lower lobe atelectasis.",0
2:38 PM CT HEAD W/O CONTRAST Clip # Reason: incracranial bleed Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with cardian arrest on the floor REASON FOR THIS EXAMINATION: incracranial bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: MXAk WED 3:58 PM Fractures of the anterior and posterior arches of C1 along with a type 2 dens fracture with canal narrowing.,1
No significant cord injury but prominence posterior to the level of the fractures may represent a small hematoma vs soft tissue prominence due to DJD.,1
Multiple subgaleal hematomas with no acute hemorrhage or edema in the brain.,1
Findings were discussed by Dr. with Dr. at 3:35pm on .,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluation of patient with cardiac arrest and fall.,1
TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast.,0
FINDINGS: Multiple frontal subgaleal hematomas are visualized with no evidence of a frontal bone fracture.,0
"There is, however, fractures through the anterior and posterior arches of C1 as well as a type 2 dens fracture with posterior angulation.",0
There is soft tissue prominence posterior to these fractures may represent a small hematoma versus prominence of soft tissues due to chronic degenerative changes.,1
"Otherwise, there is no evidence of intracranial edema, hemorrhage, masses, mass effect, or large vessel territorial infarction.",1
Fluid levels are visualized throughout the ethmoidal and sphenoidal sinuses.,0
Fractures through the anterior and posterior arches of C1 as well as a type 2 C2 fracture with posterior angulation.,0
There is mild narrowing of the spinal canal but no significant impingement of the cord.,0
Soft tissue prominence posterior to these fractures may represent small hematoma versus chronic changes.,1
Multiple frontal subgaleal hematomas with no evidence of frontal bone fractures.,0
"No evidence of intracranial hemorrhage, edema, or mass effect.",1
"These findings were discussed by Dr. with Dr. at 3:35 p.m. on (Over) 2:38 PM CT HEAD W/O CONTRAST Clip # Reason: incracranial bleed Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT (Cont) 6, .",0
"3:26 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 85F w/ h/o ex-lap, R colectomy & end ileostomy for LGIB now w/ mesenteric fat herniation near ostomy REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT STUDY: Portable AP chest radiograph.",0
COMPARISON EXAM: Portable AP chest radiograph .,0
"INDICATION: 85-year-old with history of abdominal surgery, evaluate interval change.",1
FINDINGS: The patient has been extubated.,0
There remains an upper alimentary tube coursing below the diaphragm with tip off the film as well as a right PICC line with tip terminating in the mid SVC.,0
There is stable moderate cardiomegaly.,0
Mediastinal and hilar contours are stable.,0
"There has been worsening of the right pleural effusion, and the left pleural effusion is stable.",0
Increased opacification of the right lung likely positional and due to layering of the right pleural effusion.,0
There are no new lung opacities.,0
IMPRESSION: Worsening right pleural effusion.,0
11:54 AM PORTABLE ABDOMEN Clip # Reason: Please evaluate for perforation Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with metastatic cancer (u/k primary) with abdominal tenderness.,0
REASON FOR THIS EXAMINATION: Please evaluate for perforation ______________________________________________________________________________ FINAL REPORT INDICATION: Abdominal tenderness.,0
FINDINGS: Clips after gallbladder removal.,0
"No evidence of free abdominal air, no pathologic calcifications.",0
Sparse phleboliths in the pelvis.,0
No distended bowel loops and no air-fluid levels are seen.,0
Remnants of contrast material in the colon show extensive colonic and sigmoidal diverticula.,0
"7:09 AM US INTR-OP 60 MINS Clip # Reason: Exploratory lap, right hepatic resection , cholecystectomy ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with REASON FOR THIS EXAMINATION: Exploratory lap, right hepatic resection , cholecystectomy ______________________________________________________________________________ FINAL REPORT INDICATION: Right lobectomy, patient with liver metastases.",0
Intraoperative guidance was provided to Dr. to facilitate localization of two lesions in the right lobe of the liver.,0
The lesions are peripheral and consistent with metastatic disease.,0
No additional lesions are identified in the left lobe of the liver.,0
All hepatic veins and portal veins are widely patent.,0
IMPRESSION: Intraoperative guidance provided to Dr. to document location of intrahepatic metastases.,0
No additional lesions are identified.,0
"5:18 AM CHEST (PORTABLE AP) Clip # Reason: Assess for interval change Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 50M s/p MVC rollover/ejection w/ polytrauma, neurogenic shock secondary to T3 spinal cord injury, now s/p non-instrumented fusion C5-T6, IVC filter placement, trach/PEG.",1
"REASON FOR THIS EXAMINATION: Assess for interval change ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post polytrauma, assessment for interval change.",1
The monitoring and support devices are in constant position.,0
Unchanged small bilateral pleural effusions with subsequent atelectasis.,0
No newly appeared parenchymal opacities.,0
9:57 PM CT HEAD W/ CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: soure of intraventricular hemorrhage?need ct angiogram Field of view: 27 Contrast: VISAPAQUE Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 86 year old man with intraventricular hemorrhage REASON FOR THIS EXAMINATION: soure of intraventricular hemorrhage?need ct angiogram No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: History of intraventricular hemorrhage.,0
CT angiogram of the circle of was performed.,0
FINDINGS: There is good flow noted in the anterior and posterior circulation.,0
The intracranial vessels are extremely tortuous which limits the evaluation.,0
There is questionable rounded density noted at the right posterior communicating artery region and also at the basilar tip region.,0
A small aneurysm cannot be totally excluded.,0
IMPRESSION: Study limited secondary to extremely tortuous vessels.,0
There is evidence of questionable aneurysm at the right posterior communicating artery or basilar tip.,0
A conventional angiogram is recommended for further evaluation.,0
"8:52 PM CHEST (PORTABLE AP) Clip # Reason: cxr r/o cardiopulmonary process Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 34F w/ severe intraop hypotension, now in PACU, intubated, hypoxic, requiring vasopressors REASON FOR THIS EXAMINATION: cxr r/o cardiopulmonary process ______________________________________________________________________________ FINAL REPORT Portable chest of , compared to previous study of earlier the same date.",0
Vascular stents remain in place.,0
"A catheter located to the right of the lumbar spine is also again demonstrated with the tip projecting in the region of the inferior aspect of the right atrium, unchanged.",0
There is stable widening of the cardiac and mediastinal contours.,0
There has been development of hazy increased opacity in the right hemithorax with loss of sharp definition of the right hemidiaphragm.,0
There is also new patchy opacity in the left retrocardiac region.,0
"IMPRESSION: 1) New hazy opacity in right hemithorax, most likely due to a layering pleural effusion.",0
"2) New patchy left retrocardiac opacity, which may relate to atelectasis or aspiration.",0
"8:08 AM CHEST (PORTABLE AP) Clip # Reason: change from prior Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 33 year old woman with asthma exacerbation, RUL collapse REASON FOR THIS EXAMINATION: change from prior ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Asthma exacerbation, evaluation for interval change.",1
"FINDINGS: As compared to the previous radiograph, the extent of the pre-existing right upper lobe atelectasis is unchanged.",0
8:58 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval RIJ line placement ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with hx likely cholangitis REASON FOR THIS EXAMINATION: eval RIJ line placement ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP.,0
"HISTORY: Cholangitis, evaluate right IJ placement.",0
"FINDINGS: A right-sided central line is seen terminating at the distal SVC, although tip is not well seen.",0
Slight increased interstitial lung markings may represent mild edema.,0
Diffuse haziness of the right lung is likely artifactual.,0
"The right lung apex is underpenetrated, although there is no large pneumothorax.",0
IMPRESSION: Right IJ line terminating in the lower SVC.,0
"4:50 PM MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # Reason: R/O CAROTID DISSECTION, ______________________________________________________________________________ MEDICAL CONDITION: 39 year old man with MVA REASON FOR THIS EXAMINATION: R/O CAROTID DISSECTION, ______________________________________________________________________________ FINAL REPORT INDICATIONS: Patient with MVA r/o carotid disection.",0
"MRI OF THE BRAIN: TECHNIQUE: T1 sagittal and axial, FLAIR, T2 and susceptibility axial images of the brain were obtained without gadolinium.",0
Diffusion axial images were also acquired.,0
3D time of flight MRA of the Circle of was obtained.,0
FINDINGS: The diffusion weighted images demonstrate no evidence of restricted diffusion to indicate acute infarct.,0
"No midline shift, mass effect or hydrocephalus is seen.",0
"On the susceptibity weighted images, subtle linear areas of low signal are identified at the convexity along the left cerebral hemisphere which could be related to small amount of post traumatic subarachnoid hemorrhage.",0
No other areas of low signal are identified within the brain on the susceptibility weighted images.,0
No evidence of territorial infarct is seen.,0
Soft tissue changes are identified within the nasal pharynx which could be related to intubation.,0
IMPRESSION: Subtle areas of linear low signal along the parasagittal left frontal parietal region could be due to small amount of post traumatic subararchnoid hemorrhage.,0
"No mass effect, midline shift or hydrocephalus.",0
MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and and posterior circulation.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Tetracycline Attending: Chief Complaint: Pulmonary Vein Isolation - Paroxysmal Atrial Fibrillation Bradycardia Major Surgical or Invasive Procedure: Pulmonary Vein Isolation Cardiac Catheterization History of Present Illness: The pt.,1
"is 57 y/o female with h/o carotid stenosis, scleroderma admitted for elective Afib ablation of pulmonary vein focus for symptomatic paroxysmal atrial fibrillation.",1
Post procedure her RN noted that she was bradycardic with HR in 30's to 40's and SBP in 70's.,0
When she went to her room the patient was sleeping.,0
She was woken up and her HR remained in the 40's with SBP 70's.,0
She reported substernal chest pressure after she was awoken.,0
"In addition, she felt nauseas.",0
"She was sleepy but never lost consciousness, awakening easily to voice, oriented.",0
"She was given atropine 1mg x2 with transient increase in HR, which then returned to the 40's.",0
EKG was taken showing sinus pause with junctional escape.,0
Bedside echocardiogram did not show any evidence of heart failure or pericardial fluid.,0
She was given 3L NS bolus.,0
She was started on dopamine gtt at 5mcg/kg/min with increase in blood pressure to 84/55.,0
By the time she arrived in the CCU her BP was up to 130's/100's.,0
Dopamine gtt was titrated to off over the next half hour with BP 120's/70's HR 70-80's.,0
She continued to complain of substernal chest pressure and also developed sharp left shoulder pain radiating down her arm within one hour of arrival to CCU.,0
The chest pain was similar to a pain that she has when in Afib.,0
No EKG changes concerning for active ischemia.,0
Past Medical History: Carotid artery disease s/p L CEA Scleroderma - CREST syndrome GERD Paroxysmal Afib Bipolar disorder GERD Irritable Bowel Syndrome Osteoarthritis .,1
PSH Surgeries: s/p Nissen Fundoplication Hysterectomay for endometriosis partial bowel resection for diverticulitis Social History: Social history is significant for the absence of tobacco use.,0
"Divorced, lives with roomate, no children.",0
Family History: Father died suddenly of heart failure.,0
"Physical Exam: VS: 120/66 HR 84 RR 24 O2 94% Gen: appears tired but awakens easily and answers questions appropriately HEENT: JVP to angle of jaw, +HJR CV: 1/6 systolic murmur at upper sternal border, no radiation, RRR Lungs: bilateral rales, no wheezing Abd: distended, BS +, soft, nontender Extrem: no pedal edema, DP's trace B, PT's 2+ B, tender at R groin at site of cath.",0
"Faint bilateral femoral bruits, no pulsatile mass or hematoma.",0
"Pertinent Results: 10:04AM BLOOD WBC-10.6 RBC-4.30 Hgb-10.3* Hct-31.8* MCV-74* MCH-23.9* MCHC-32.2 RDW-16.4* Plt Ct-250 07:15AM BLOOD WBC-6.4 RBC-5.31 Hgb-12.3 Hct-39.4 MCV-74* MCH-23.1* MCHC-31.2 RDW-16.8* Plt Ct-310 07:15AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-140 K-4.1 Cl-101 HCO3-28 AnGap-15 11:23PM BLOOD CK-MB-18* cTropnT-1.71* 10:04AM BLOOD CK-MB-14* MB Indx-10.2* cTropnT-1.29* 11:23PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.7 ECHO: LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded.",0
IMPRESSION: No significant pericardial effusion.,0
Brief Hospital Course: 57 y/o female s/p elective Afib ablation of pulmonary vein focus for symptomatic paroxysmal atrial fibrillation with bradycardia and hypotension post procedure.,1
# Paroxysmal A.Fib s/p PVI - Pt.,0
admitted for scheduled ablation of pulmonary vein focus for symptomatic paroxysmal atrial fibrillation.,1
Episode was most consistent with increased vagal stimulus following ablation.,0
Upon transfer to CCU her BP was up to 130's/100's.,0
Per pain was most consistent with pericardial irritation post procedure.,0
She became volume overloaded following the 3LNS bolus for hypotension but responded rapidly to 40mg IV lasix.,0
She continue to autodiurese appropriately.,0
The morning after procedure the patient was stable for transfer to floor.,0
Her home dose of flecanide was restarted prior to transfer.,0
She had no further episodes of bradycardia.,0
"On morning of discharge her SBP was 150s-170s and her HR 80s and she was restarted on her home dose of diltiazem CR, also used to treat her Raynaud's.",0
"She was also restarted on her coumadin prior to DC, with scheduled INR check on .",0
She was clinically improved and discharged home with a of Hearts Monitor to use for 3weeks.,0
She will also have a cardiac MR in 1 month and cardionet.,0
She will follow up in clinic in weeks.,0
"#CAD - recent cath with no significant CAD, however with history of carotid stenosis s/p CEA.",1
She was continued on aspirin and her home dose statin throughout her hospitalization.,0
followed by rheumatology as outpatient.,0
Her diltiazem used for Raynaud's was held briefly given her bradycardia but was restarted at home dose prior to discharge.,0
On day of discharge the patient was clinically improved and discharged home in good condition to follow up in cardiology clinic in week.,0
"Medications on Admission: Lamictal 200mg qHS Protonix 40mg qAM Cardizem CD 360mg qAM ASA 81mg daily Flecanide 150mg Zocor 20mg qPM Trazodone 50mg qHS prn Coumadin 8mg daily Glucosamine/chondroitin Benefiber 2 tabs qAM, 1 QPM MTV daily Discharge Medications: 1.",0
Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
"Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain.",0
Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours).,0
"Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily).",0
Flecainide 50 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours).,0
Warfarin 2 mg Tablet Sig: Four (4) Tablet PO DAILY16 (Once Daily at 16): Please take 8mg warfarin until Monday.,0
Have your INR checked on Monday .,0
Outpatient Lab Work Please check INR on Discharge Disposition: Home Discharge Diagnosis: Primary: 1.,0
Atrial Fibrillation s/p pulmonary vein isolation 2.,1
Carotid Artey Disease s/p Left carotidendarterectomy 3.,1
"Gastroesophageal Reflux Disease Discharge Condition: Good, Discharged Home Discharge Instructions: You were admitted for an ablation of a pulmonary vein focus for symptomatic paroxysmal atrial fibrillation.",1
After the procedure you had a slow heart rate for a brief period of time which has now resolved.,0
You will wear a holter monitor for the next three weeks.,0
Please use this monitor as you were directed.,0
You should also follow up with Dr. in clinic in weeks.,0
You will also have further cardiac imagining and monitoring in 1 month as listed below.,0
You will continue to take the medication coumadin.,0
You should take 8mg tonight and tomorrow.,0
Please have your INR check on Monday for further management of your coumadin dosing.,0
Please call Dr. at to schedule an appointment within 2 weeks.,0
"Please return if you expierence chest pain, shortness of breath, lightheadedness or palpitations.",0
Followup Instructions: Please follow up with Dr. in one month.,0
You should call to schedule and appointment.,0
Please wear your holter monitor for the next three weeks.,0
You should wear it three times a day or if you have symptoms.,0
You should have a cardiac MRI in 1 month.,0
You will be called to schedule an appointment.,0
You can also call with questions about scheduling.,0
You will also need to have a cardionet monitor in 1 month.,0
Please contact Dr. office if you have any questions at,0
11:47 PM CHEST (PA & LAT) Clip # Reason: pneumonia?,0
Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with stroke REASON FOR THIS EXAMINATION: pneumonia?,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Stroke, question pneumonia, CHF.",0
"Heart size is at the upper limits of normal or slightly enlarged, with prominence of the right heart border.",0
"There is prominence of the right perihilar interstitial markings, of uncertain significance.",0
"No CHF, focal consolidation, or gross effusion is identified.",0
"However, there is focal pleural thickening or loculated pleural fluid at the left lung base laterally.",0
IMPRESSION: 1) Prominence of interstitial markings about the right hilar region of indeterminate significance.,0
This could represent early asymmetric fluid overload or an early infectious infiltrate.,0
"In the appropriate clinical setting, impaired drainage through the right hilum due to a hilar mass would also be considered.",0
"Of note, there is no upper zone redistribution to confirm the presence of CHF.",0
2) Small focus of pleural thickening left base.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: DOE x several months Major Surgical or Invasive Procedure: redo MVR History of Present Illness: This is a 61 yo female s/p CABG x 3 adn MVR on with nes complaints od dyspnea on exertion.,0
"Finding of new murmur by PCP and echo finding 4+ MR. Past Medical History: MI CAD/MR ischemia and valvular cardiomyopathy LV systolic dysfunction ^ lipids HTN S/P CABG x 3 and MV repair in Social History: Lives alone in , MA.",0
+ 80 pk year tob hx -- quit 1.5 years ago.,0
"Family History: No known CAD Physical Exam: On presentation: VS HR 84 regular, BP 124/66.",0
"Ht 5'8"" Wt 200# General: Appears stated age in NAD -- anxious.",0
"Skin: Warm, dry, + rash on left knee.",0
"Neck: supple, no JVD, no lymphadenopathy.",0
S1S2 with II/VI murmur in apex.,0
Pertinent Results: 11:05PM WBC-15.3*# RBC-3.51* HGB-10.0*# HCT-30.2* MCV-86 MCH-28.6 MCHC-33.3 RDW-14.0 11:05PM PLT COUNT-299 11:05PM PT-14.1* PTT-32.4 INR(PT)-1.2 06:20PM UREA N-15 CREAT-0.7 CHLORIDE-111* TOTAL CO2-23 09:30AM BLOOD WBC-11.2* RBC-3.58* Hgb-10.6* Hct-31.9* MCV-89 MCH-29.5 MCHC-33.1 RDW-14.8 Plt Ct-676*# 09:30AM BLOOD Plt Ct-676*# 09:30AM BLOOD Glucose-204* UreaN-13 Creat-0.7 Na-137 K-4.8 Cl-100 HCO3-28 AnGap-14 Brief Hospital Course: Mr was admitted on .,0
He proceeded to the OR and underwent a redo MVR with a 29mm mosiac porcine heart valve via right thoracotomy.,1
Total cardio-pulmonary bypass time was 85 minutes.,0
There was no cross clamp time as this operation was done with a bleeding heart approach.,0
"He was tranferred to the ICU in NSR rate 98, MAP 62, CVP 8, on neosynephrine, milrinone, insulin, and propofol drips.",0
He was extubated on the evening of his operative day without any complications.,0
His IV medications were weaned and both the milrinone and the neosynephrine being discontinued on the AM of POD 2.,0
He had some post-op tachycardia for which is lopressor dose was increased and ace inhibitor adjusted.,0
He was also followed by the cradiology team and their recommendations were followed.,0
His chest tubes remained in longer than is typical because of ongoing drainage.,0
On POD 3 he was noted to have crepitus in his right check and upper chest.,0
His chest tubes x 3 remained on suction with an air leak.,0
On (POD 7) the chest tubes were put to water seal with a subsequent CXR showing a small pneumthorax and they were again put to suction.,0
A persistent pneumothorax remined and on (POD 9) a thoracic consult was obtained with rcommendations for doxycycline sclerosis.,0
The chest tube was eft to water seal with an ongoing leak but minimal drainage.,0
The chest tube was clamped for a 24-hour period without any respiratory distress and was eventually discontinued on (POD 15) per the recommendations of the thoracic surgery team.,0
Mr. was followed by the physical therapy team throughout his hospital stay with initial evaluation on POD 2 and on POD 7 he was found to be for for home.,0
On POD he was found to be safe for discharge home.,0
Medications on Admission: lopressor 50 lipitor 80 daily aspirin 325 daily plavix 75 daily zestril 2.5 daily Discharge Medications: 1.,0
Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD ().,0
Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD ().,0
Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours: Take with food.,0
Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD ().,0
Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain.,0
"Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Hospice and VNA Discharge Diagnosis: s/p redo MVR (#29 Mosaic porcine) vis right thoracotomy HTN, ^ chol, cardiomyopathy, s/p MVR/CABG ' persistent right pneumothorax Discharge Condition: good Discharge Instructions: keep wounds clean and dry.",0
"Take all medications as prescribed call for any fever, redness or drainage from wound Followup Instructions: Dr in wks Dr in wks Dr in 4 wks Completed by:",0
", GYN 12R 11:38 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: unxplained tachycardia POD#2, please rule out post-op PE.",0
th Admitting Diagnosis: FIBROIDS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman POD#2 s/p total laparosocpic hysterectomy w/ persistent unexplained tachycardia.,0
"REASON FOR THIS EXAMINATION: unxplained tachycardia POD#2, please rule out post-op PE.",0
thank you No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT 1.,0
"Greater than expected amount of pneumoperitoneum and ascites, findings are somewhat concerning, given complicated course of the procedure, further evaluation with CT abdomen and pelvis and oral Gastrografin preparation recommended.",1
"Trace left pneumothorax and moderate pneumomediastinum are not likely of clinical significance, and can be seen in the setting of prolonged intubation.",0
Bilateral small pleural effusions with atelectasis.,0
"3:54 PM CHEST (PA & LAT) Clip # Reason: s/p removal of apical tube, please assess and take Admitting Diagnosis: LEFT LOWER LOBE NODULE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with Left Lower lobectomy REASON FOR THIS EXAMINATION: s/p removal of apical tube, please assess and take film at 4:15pm ______________________________________________________________________________ FINAL REPORT HISTORY: Left lobectomy.",0
"PA and lateral radiographs of the chest demonstrate left-sided effusion, similar to that seen on chest radiograph obtained earlier the same day.",0
One of the two left-sided chest tubes has been removed.,0
The left basilar chest tube remains.,0
Increased bibasilar airspace opacities persist.,0
IMPRESSION: Interval removal of left apical chest tube.,0
7:53 PM CT L-SPINE W/O CONTRAST Clip # Reason: eval for frax ______________________________________________________________________________ MEDICAL CONDITION: 30 year old man s/p MVC +LOC REASON FOR THIS EXAMINATION: eval for frax No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT SCAN OF THE LUMBAR SPINE.,0
INDICATION: 30-year-old man status post MVC with loss of consciousness.,0
TECHNIQUE: CT scan of the lumbar spine was performed following intravenous administration of contrast.,0
Images were acquired in the axial plane.,0
Coronal and sagittal reformats were created and reviewed.,0
FINDINGS: Maintenance of the normal lumbar spine lordosis without listhesis.,0
Five lumbar-type vertebral bodies are seen.,0
Vertebral body heights are maintained.,0
No vertebral body fracture is noted.,1
Intervertebral disc spaces are preserved.,0
No abnormal density is identified within the central canal.,0
Prevertebral soft tissues are unremarkable.,0
IMPRESSION: No evidence of lumbar spine fracture.,0
10:01 AM CTA HEAD W&W/O C & RECONS Clip # Reason: eval for aneurysm/source of bleed Admitting Diagnosis: HEAD BLEED Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with moderate sized SAH REASON FOR THIS EXAMINATION: eval for aneurysm/source of bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: NPw SAT 2:03 PM WET READ BY ATTENDING: A small-moderate sized new hypodense area in the left occipital lobe involving the cortex and adj.,0
white matter representing an infarct-acute-subacute- correlate with MRI if not CI.,0
"( se 2, im 15) 2.",0
"Some degree of vasospasm- distal basilar, M1 , A1 and A2 segments bil.",0
Tiny outpouching from the lateral aspect of left cavernous carotid segment- ?,0
pending D/ by dr. on at 2pm.,0
WET READ VERSION #1 LLTc SAT 11:01 AM NCCT: S/P basilar tip anerusym coil placement since the CTA study.,0
A moderate amount of subararchnoid blood products is less conspicuous on today's examination.,0
No evidence of new hemorrhage or large vascular territorial infarct.,0
CTA: New aneursym coil at the basilar tip.,0
No dissection or flow limiting stenosis detected.,0
WET READ VERSION #2 NPw SAT 2:02 PM WET READ BY ATTENDING: A small-moderate sized new hypodense area in the left occipital lobe involving the cortex and adj.,0
D/ by dr. on at 2pm.,0
NCCT: S/P basilar tip anerusym coil placement since the CTA study.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Moderate size subarachnoid hemorrhage, with basilar tip aneurysm (Over) 10:01 AM CTA HEAD W&W/O C & RECONS Clip # Reason: eval for aneurysm/source of bleed Admitting Diagnosis: HEAD BLEED Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) status post coiling, to evaluate for changes.",1
COMPARISON: CTA done on .,0
TECHNIQUE: Non-contrast CT head and CTA of the head; 2D reformations.,0
PRELIMINARY REPORT: Status post basilar tip aneurysm coil placement since the CTA study.,0
A moderate amount of subarachnoid blood products is less conspicuous on today's examination.,0
No evidence for new hemorrhage or large vascular territorial infarct.,0
CTA: New aneurysm coiled at the basilar tip.,0
No dissection or flow-limiting stenosis is detected.,0
"FINDINGS: NON-CONTRAST CT HEAD: There is scattered amount of subarachnoid hemorrhage noted, slightly decreased compared to the prior study.",1
"Small amount of hemorrhage is noted in the occipital horns on both sides, decreased since the prior study.",0
Aneurysm coils are noted at the basilar tip.,0
"There is a focus of hypodense attenuation, in the left occipital lobe which is new since the prior study.",0
"This involves the cortex and adjacent white matter and is concerning for an evolving infarct (series 2, image 15).",0
The ventricles and extra-axial CSF spaces are unremarkable.,0
No suspicious osseous lesions are noted.,0
The soft tissues of the scalp are unremarkable.,0
CT ANGIOGRAM OF THE HEAD: There is mild narrowing of the distal basilar artery compared to the prior study.,0
"In addition, there is also mild narrowing of the middle cerebral-M1 segments and the A1 and A2 segments on both sides compared to the prior CT angiogram study, relating to a component of vasospasm.",0
A tiny oupouching from the lateral aspect of the left cavernous carotid segment is unchanged-?,0
"( se 3, im 57) Otherwise, the major intracranial arteries are patent, without focal flow-limiting stenosis, occlusion, or new aneurysm.",0
Assessment of the coiled aneurysm is limited due to artifacts.,0
"New hypodense area in the left occipital lobe involving the cortex and the adjacent white matter, representing an area of infarction.",0
MR can be considered if necessary for detailed assessment of the brain parenchyma if not CI.,0
(Over) 10:01 AM CTA HEAD W&W/O C & RECONS Clip # Reason: eval for aneurysm/source of bleed Admitting Diagnosis: HEAD BLEED Contrast: OMNIPAQUE Amt: 70 ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
"Mild narrowing of the distal basilar, the M1 and the A1 and A2 segments on both sides, likely related to a component of vasospasm- better seen on source images.",0
Decrease in the previously noted subarachnoid hemorrhage and intraventricular hemorrhage.,1
"A tiny outpouching from the left cavernous carotid segment, unchanged.",0
Patent major intracranial arteries otherwise without focal flow-limiting stenosis or occlusion or new aneurysm.,0
Assessment of the coiled aneurysm is limited on the present study.,0
Discussed with by Dr. on at 2pm.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Bactrim Attending: Chief Complaint: Fevers, Tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 50 yo M w/ Afib and pontine strokes w/ central fevers p/w afib and fever.",0
is s/p long admission w/ exhaustive workup for fevers which resulted in removal of several teeth and eventual resolution of his fevers for several days.,0
He was discharged yesterday to and spiked to 104.8F.,0
"In the ED, initial VS: 50 yo M w/ Hx of CVA and central fevers discharged from yesterday presenting w/ decreased UOP and fevers.",1
"Febrile, tachycardic not making much urine, had RVR in the 140s going as high as 170s.",0
"CT chest no PE, ?",0
Ucx and Blood cultures pending.,0
Bcx were drawn before Abx.,0
Initially was not making urine then got 3L of urine and now has made 225cc/6hrs and his HR has come down.,0
noted to be up to 1.1 from baseline of 0.7.,0
"Past Medical History: -Multiple Pontine and Cerebellar infarcts -Atrial fibrillation -CAD s/p stent placement x6 -HTN -CHF with diastolic dysfunction -morbid obesity -alcoholism with ?enlarged liver -DM (borderline - not on medications) -sleep apnea -R eye blindness since childhood -s/p stent placement (at ) -R CEA (at ) Social History: Long-standing alcoholic and smoker, daughter unable to quantify.",1
"Family History: -Multiple Pontine and Cerebellar infarcts -Atrial fibrillation -CAD s/p stent placement x6 -HTN -CHF with diastolic dysfunction -morbid obesity -alcoholism with ?enlarged liver -DM (borderline - not on medications) -sleep apnea -R eye blindness since childhood -s/p stent placement (at ) -R CEA (at ) Physical Exam: (Per Admitting Resident) GENERAL: Alert, Trach mask on, Able to nod yes/no (does not seem to answer appropriately all the time), Non-vocal, NAD HEENT: Normocephalic, atraumatic.",1
L eye with scleral injection.,0
LUNGS: Lungs diminished but clear anteriorly.,0
EXTREMITIES: Some slight pitting edema noted in the lower extremities.,0
Unable to palpate pedal pulses.,0
Pneumoboots present on lower extremities.,0
"NEURO: Alert; nods yes/no (however, unclear if pt always answers questions appropriately); Pt is able to follow commands (move eyes as instructed).",0
Pt moves left hand (but not right hand or either foot) on command.,0
Pertinent Results: Admission Labs: 06:25AM BLOOD WBC-11.8* RBC-3.37* Hgb-10.8* Hct-31.7* MCV-94 MCH-32.1* MCHC-34.1 RDW-15.9* Plt Ct-448* 01:10PM BLOOD Neuts-84.3* Lymphs-12.3* Monos-2.6 Eos-0.5 Baso-0.4 06:25AM BLOOD PT-17.9* PTT-33.5 INR(PT)-1.6* 06:25AM BLOOD Glucose-105 UreaN-19 Creat-0.7 Na-131* K-5.2* Cl-93* HCO3-25 AnGap-18 01:10PM BLOOD ALT-44* AST-28 TotBili-2.0* 08:27PM BLOOD LD(LDH)-268* 01:10PM BLOOD Lipase-60 01:10PM BLOOD proBNP-2428* 06:25AM BLOOD Calcium-9.0 Phos-5.2* Mg-2.1 01:20PM BLOOD Lactate-2.0 .,0
Additional Studies: 05:05PM BLOOD ACTH - FROZEN-Test - 15 (normal) 08:45AM BLOOD DEXAMETHASONE - pending 09:31PM URINE CATECHOLAMINES-Test - normal 09:31PM URINE METANEPHRINES-Test - normal 05:48AM URINE CATECHOLAMINES - pending 05:48AM URINE CORTISOL - pending 05:48AM URINE METANEPHRINES - normal .,0
Discharge Labs: 06:28AM BLOOD WBC-5.9 RBC-3.04* Hgb-9.7* Hct-31.1* MCV-102* MCH-31.9 MCHC-31.2 RDW-18.5* Plt Ct-545* 06:28AM BLOOD PT-22.0* PTT-48.5* INR(PT)-2.1* 06:28AM BLOOD Glucose-111* UreaN-6 Creat-0.4* Na-136 K-3.7 Cl-96 HCO3-33* AnGap-11 06:20AM BLOOD ALT-139* AST-73* LD(LDH)-187 AlkPhos-56 TotBili-0.3 06:22AM BLOOD Lipase-19 06:28AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.3 .,0
"Microbiology: Blood cultures from , , no growth (final); no growth to date Urine cultures from , , , , no growth Influenza A and B negative and C. Difficile toxin A and B negative .",0
Studies: AP CXR - IMPRESSION: Unchanged cardiomegaly.,0
Multiple areas of hypodensity as described above compatible with prior infarcts.,0
"If there is continued clinical concern for acute infarction, an MRI should be obtained.",0
CT Chest/Abdomen/Pelvis : IMPRESSION: 1.,0
No acute intrathoracic or intra-abdominal pathology.,0
Please correlate clinically for pulmonary hypertension.,0
"1.4 cm right adrenal nodule, stable since though of indeterminate etiology.",0
Consider MRI to further characterize.,0
"AP CXR - FINDINGS: As compared to the previous radiograph, the transparency of the lung parenchyma at the right lung base has increased, suggesting improved ventilation.",0
Unchanged is the moderate retrocardiac opacity and the moderate cardiomegaly.,0
No evidence of interval occurrence of new parenchymal opacities.,0
Unremarkable right upper quadrant ultrasound.,0
CXR: There is unchanged cardiomegaly.,0
There is a tracheostomy with the distal lead tip at the level of the clavicles.,0
There is a left retrocardiac opacity and left-sided pleural effusion.,0
"There is also pulmonary edema, which has worsened since the previous study.",0
KUB: GJ tube appears in the appropriate position.,0
"CXR: FINDINGS: In comparison to the study of , there is little overall change.",0
Opacification at the left base behind the heart persists with blunting of the costophrenic angle.,0
"Again, this is consistent with atelectasis or consolidation with associated pleural effusion.",0
The degree of pulmonary vascular prominence is less on the previous study.,0
"Brief Hospital Course: Mr. is a 50 year old male with PMHx significant for atrial fibrillation, CAD, HTN, CHF, DM, obesity, and recent pontine and cerebellar infarcts recently discharged after a prolonged hospitalization complicated by fevers who presented with fevers and tachycardia and was initially admitted to the MICU.",1
# Fevers - The patient had almost daily fevers (typically in the early evening) that were felt to likely have a central component to them.,0
"Initially, he was started on vancomycin and cefepime, which were stopped after cultures were negative.",0
"He was also started on Flagyl, which was stopped after he was negative for C.diff.",0
CT torso did not reveal any acute pathology.,0
"Of note, the patient was noted to have stenotrophomonas in his sputum during his previous hospitalization.",0
"He was treated with a 14-day course of bactrim, which ended on .",0
The patient continued to have episodes of fevers (typically 101-103) with temperatures that returned to 98-99 in between fevers with negative cultures.,0
He was treated with cooling blankets and around the clock tylenol.,0
He occassionally required IV fluid boluses for dehydration/hypotension.,1
# Atrial Fibrillation - He was also noted to be in atrial fibrillation with RVR on presentation and was admitted to the MICU.,1
"While in the MICU, his metoprolol was decreased to 12.5 mg TID secondary to hypotension.",1
"On the floor, however, he was noted to have episodes of tachycardia.",0
His metoprolol was increased to 50mg TID.,0
The patient was loaded and placed on Digoxin.,0
"The patient's coumadin was briefly held in the setting of a suspected GIB, however, this was restarted with a goal INR of .",0
"As his INR remained subtherpeutic, he was started on lovenox.",0
He remained rate controlled for at least a week prior to discharge and his metoprolol was decreased to 12.5 mg because he continued to have transient hypotension.,0
# Hypotension: The patient had several episodes of hypotension while on the floor.,0
Some were in the setting of fever spikes and AF with RVR to the 140s but others occured as isolated events.,0
There was improvement with IV hydration and also increased free water flushes via his G-tube to account for the free water losses from his body surface area especially with fevers.,0
His urine output increased and became much less concentrated.,0
He continued to have occasional hypotension to 75-80/D.,0
He remained alert through these episodes and did not show any evidence of hypoperfusion.,0
His blood pressure normalized at his baseline (around 100 systolic) usually within 15 minutes without any intervention.,0
This further supported a central process.,0
His metoprolol dose was lowered from 50 mg TID to 12.5 mg .,0
"If he develops additional episodes of afib with RVR, his beta-blocker dose will need to be increased again.",0
"# Anemia, Hematrocrit Drop - Initial labs revealed a decreased Hct (thought to be dilutional as pt received 7 liters of IVF's initially) and mildly guaiac positive stool (with no evidence of active bleeding).",0
"In the MICU, he was transfused with 1 unit of PRBC's.",0
His hematocrit remained stable but remained below baseline.,0
"On the floor, the patient received an additional 2 units of PRBC's.",0
"As there was no evidence of acute GI bleeding, they felt that urgent colonoscopy was not indicated.",0
They did recommend an outpatient screening colonoscopy when his condition is improved.,0
"Of note, a haptoglobin was checked and found to be <5 (however after 2 units of pRBC) and the patient had an elevated LDH.",0
"However there were no schiztocytes seen on peripheral smear, nor an increase in the total bilirubin, thus hemolysis was not suspected.",0
His hematocrit remained stable subsequently.,0
"# Left Eye Conjunctivitis - The patient was seen by ophtho, who felt that this was consistent with exposure keratitis.",0
He was given erythromycin eye drops and lacrilube and is being discharged with lacrilube.,0
"# Right Adrenal Nodule - The patient's CT scan revealed a right adrenal nodule, which was stable since scans from .",0
The patient had a 1 mg dexamethasone supression test that was abnormal.,0
"Serum ACTH and cortisol, as well as 24 hour urine cortisol, metanephrines, and catecholamines were sent.",0
"ACTH, metanephrines, and urine catecholamines were normal.",0
Urine cortisol was on the high range of normal but likely appropriate in the context of his severe illness.,0
# Diabetes Mellitus Type II - Patient was initially continued on his prior insulin regimen.,1
As his blood sugars remained above 150 most of the time his NPH was increased to 32 units and his sliding scale adjusted with finger sticks between 100 and 150.,0
# Skin Lesion on Forehead - The MICU team felt that this may represent a BCC.,0
He should see a dermatologist at some point.,0
This is non-urgent as long as the lesion is stable.,0
# Eczematous dermatitis of face - patient has a history of eczema per family.,0
This was treated with hydrocortinsone 1%.,0
# Abdominal pain - The patient intermittantly endorsed abdominal pain during his hospital stay.,0
"At times his responses to questions were inconsistent, making this difficult to assess.",0
He did have mildly elevated LFTs that improved or remained stable during his course.,0
RUQ ultrasound was without evidence of cholecystitis.,0
CT torso showed no evidence of intra-abdominal pathology.,0
"Due to concern of movement of the GJ tube, placement was confirmed with abdominal x-ray.",0
# Anticoagulation - The patient was kept anticoagulated given his atrial fibrillation and recent strokes.,1
His coumadin was briefly held in the setting of concern for GIB.,0
"It was restarted, but remained subtherapeutic.",0
Lovenox was started to bridge the patient until warfarin was therapeutic (goal INR 2.0-3.0).,0
His INR reached 2.1 on the morning of discharge.,0
He can be continued on lovenox for an additional day and then it can be stopped if INR remains in goal range.,0
# Recent Pontine and Cerebellar Strokes - No acute issues.,0
He opens his eyes to verbal stimuli and can follow simple commands such as moving his left hand and L toes.,0
He cannot move his right hand or foot to command.,0
He seems to cognitively understand most of what is going on around him.,0
He was evaluated by both PT and OT.,0
"He was also evaluated by speech and swallow and tolerated a passy-muir valve well and was able to vocalize ""yes"" and ""ah"".",0
"It appears the patient is clinically ""locked-in"" but susequent speech and swallow evaluation suggests improvement.",0
He would benefit greatly from aggressive rehab.,0
"# Thrombocytopenia: The patient's platelets dropped to the 90s, without signs of bleeding, toward the end of his 2-week bactrim course.",0
"Upon discontinuation of the Bactrim, his counts recovered.",0
"# Coronary artery disease, s/p stenting - no acute issues.",1
"Continued metoprolol, aspirin, and simvastatin.",0
"FEN: Tube feeds PPX: -DVT ppx: pneumoboots, coumadin/lovenox -Bowel regimen: lactulose CODE STATUS: Full, confirmed at recent family meeting EMERGENCY CONTACT: (daughter); (sister) Medications on Admission: 1.",0
Chlorhexidine Gluconate 0.12 % Mouthwash : One (1) ML Mucous membrane (2 times a day).,0
Bisacodyl 10 mg Suppository : One (1) suppository Rectal once a day as needed for constipation.,0
Acetaminophen 500 mg Tablet : 1-2 Tablets PO three times a day as needed for fever or pain: Do not exceed 4 grams in a 24-hour period.,0
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette : Drops Ophthalmic PRN (as needed) as needed for dry eyes.,0
"Aspirin 81 mg Tablet, Chewable : One (1) Tablet, Chewable PO DAILY (Daily).",0
Miconazole Nitrate 2 % Cream : One (1) application Topical twice a day.,0
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 8.,0
Glucagon (Human Recombinant) 1 mg Recon Soln : One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol.,0
Ibuprofen 400 mg Tablet : One (1) Tablet PO Q8H (every 8 hours) as needed for pain/fever: Do not excees 3200 mg per day.,0
Metoprolol Tartrate 25 mg Tablet : One (1) Tablet PO TID (3 times a day): Hold for SBP<100 or HR<60.,0
Prochlorperazine 10 mg IV Q6H:PRN nausea 12.,0
Simvastatin 40 mg Tablet : Two (2) Tablet PO DAILY (Daily).,0
"Trimethoprim-Sulfamethoxazole 160-800 mg Tablet : Five (5) Tablet PO TID (3 times a day): To complete a 14-day course, ending on .",0
NPH Insulin Human Recomb 100 unit/mL Suspension : Thirty (30) units Subcutaneous twice a day: Please administer 30 units of NPH at breakfast and at dinner.,0
Humalog 100 unit/mL Solution : As Directed Subcutaneous qACHS: Please follow humalog sliding scale.,0
Therapeutic Multivitamin Liquid : Five (5) ML PO DAILY (Daily).,0
Warfarin 1 mg Tablet : Three (3) Tablet PO Once Daily at 4 PM.,0
Miconazole Nitrate 2 % Powder : One (1) Appl Topical PRN (as needed) as needed for rash.,0
Multivitamin Tablet : One (1) Tablet PO DAILY (Daily).,0
Acetaminophen 160 mg/5 mL Solution : Six y (650) mg PO Q6H (every 6 hours).,0
Digoxin 125 mcg Tablet : One (1) Tablet PO DAILY (Daily).,0
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 10.,0
Enoxaparin 150 mg/mL Syringe : One (1) Subcutaneous (2 times a day): until INR is therapeutic.,0
White Petrolatum-Mineral Oil Ointment : One (1) application OU Ophthalmic once a day as needed for dry eye.,0
NPH Insulin Human Recomb 100 unit/mL Suspension : Thirty Two (32) units Subcutaneous twice a day.,0
Insulin Regular Human 100 unit/mL Solution : per sliding scale Injection every six (6) hours.,0
Lactulose 10 gram/15 mL Syrup : Thirty (30) ML PO TID (3 times a day): hold for high frequency stools.,0
Cortisone 1 % Cream : One (1) Appl Topical QID (4 times a day).,0
"Metoprolol Tartrate 25 mg Tablet : 0.5 Tablet PO BID (2 times a day): hold for SBP<100, HR<60.",0
Warfarin 5 mg Tablet : Two (2) Tablet PO Once Daily at 4 PM.,0
"Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Primary Central Fevers Strokes Stenotrophomonas infection Anemia Conjunctivitis Thrombocytopenia secondary to bactrim Secondary Atrial Fibrillation Coronary artery disease, s/p stenting Hypertension Congestive Heart Failure Morbid obesity Diabetes mellitus Discharge Condition: Mental Status:Usually clear, but sometimes appears confused Level of Consciousness:Alert and interactive Activity Status:Bedbound Discharge Instructions: You were brought to the hospital after a recent long hospitalization because you were continuing to have fevers.",1
It seems that your fevers likely have to do with your recent strokes and not an infection or other cause.,0
"While you were in the hospital, you completed a course of antibiotics for bacteria that was found in your lungs.",0
You also were treated for an irritation in your eye.,0
You were treated for a fast heart rate as well.,0
You had a CT scan that incidentally showed an adrenal adenoma.,0
This is unchanged in size since and your levels of enzymes produced by this gland are normal.,0
You are being transfered to a facility to work on rehabilitation after your strokes.,0
CHANGES TO YOUR MEDICATIONS: 1.,0
You were started on digoxin 2.,0
You were started on around the clock tylenol to control your fevers 3.,0
Ibuprofen was stopped to reduce damage to your stoamch 4.,0
"Metoprolol dose was decreased to 12.5mg twice a day Followup Instructions: Provider: ,ONE Phone: Date/Time: 7:00 Provider: WEST OUTPATIENT RADIOLOGY Phone: Date/Time: 8:30",0
", C. MED CC7A 7:10 AM CHEST (PORTABLE AP) Clip # Reason: r/o acute cardiopulmonary process Admitting Diagnosis: RIGHT FEMUR FX;ACUTE ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with PE now with SOB and R chest pain REASON FOR THIS EXAMINATION: r/o acute cardiopulmonary process ______________________________________________________________________________ PFI REPORT Since , small right pleural effusion is new.",1
11:19 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
pneumo Admitting Diagnosis: R/O PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p cabg x3; pt.,0
to be in CSRU approx.,0
1PM s/p chest tube removal REASON FOR THIS EXAMINATION: ?,0
pneumo ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: 76 y/o man status post CABG.,0
TECHNIQUE: Single AP view of the chest is provided.,0
FINDINGS: There is no evidence for pneumothorax.,0
There is a moderate left pleural effusion associated with atelectasis of the left lower lobe.,0
Underlying infiltrate cannot be excluded.,0
Swan-Ganz catheter has been removed as well as chest tube in the left hemithorax.,0
Right IJ introducer is still present with the tip at the level of the right cephalic vein.,0
ET tube has been removed.,0
"IMPRESSION: 1) Status post removal of ET tube, Swan-Ganz catheter, and left chest tube.",0
2) New left pleural effusion and increased atelectasis of the left lower lobe.,0
Underlying infiltrate cannot be entirely excluded.,0
3) No evidence for pneumothorax.,0
Height: (in) 67 Weight (lb): 158 BSA (m2): 1.83 m2 BP (mm Hg): 142/57 Status: Inpatient Date/Time: at 15:30 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - hypo; basal inferolateral - hypo; RIGHT VENTRICLE: Normal RV wall thickness.,1
2.Left ventricular wall thicknesses are normal.,0
Resting regional wall motion abnormalities include possible basal inferior and inferolateral hypokinesis.,1
6.Moderate [2+] tricuspid regurgitation is seen.,0
"Compared with the findings of the prior report (tape unavailable for review) of , probably no change.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Alcohol intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Mr is a 32 yo male with hx of ETOH abuse, tachycardia, brought in by EMS for AMS.",1
He was found with multiple bottles of hard liquor around him and reportedly said that he wanted to drink himself to death.,0
He was drinking about one liter of vodka per day for the past five weeks.,0
He has a history of heavy drinking.,0
"He claims he had been sober for 3-4 years, although he was seen in in the ED for EtOH related trauma.",0
"No clear h/o DT, but reports on seizure.",0
He was then brought to the ED for further workup.,0
"In the ED, initial VS were 97.2 131 151/87 16 98% RA.",0
"He was somnolent, and had no evidence of trauma.",0
He had no stigmata of chronic liver disease.,0
He was AOx1 and moving all extremities.,0
There was no seizure activity or focal deficits.,0
"He was given a banana bag, 2L IVF, and 20mg IV valium.",0
He was noted to have a serum etoh level of 574 and and osmolal gap of 16 when corrected for EtOH.,0
"He had an elevated lipase of 130, an ALT of 184, and an AST of 255.",0
The rest of his serum and urine tox is negative.,0
He had a lactate of 4.2 and a normal gas.,0
"Before transfer to the floor, vitals: HR 122, BP 137/80 RR15 99% RA .",0
"Upon arrival to the ICU, he was awake and alert, though somewhat sluggish.",0
"He reports shakiness, anxiety, nausea, HA, and ""hallucinations"" which he cannot characterize.",0
"He denied f/c, CP, SOB, abd pain, focal neurologic defects.",0
He reports that he has had seizures from withdrawal before when he tried to detox on his own.,0
"He denies ingestion of other substances such as ethylene glycol, methanol, isopropanol.",0
Past Medical History: Lonstanding alcohol abuse Tachycardia - treated with atenolol for the past 10 years.,1
Social History: Reports about 1L of hard alcohol daily.,0
"Family History: EtOH abuse Physical Exam: vitals: 98.6 128 136/82 21 98%RA gen: dissheveled, diaphoretic, shaky, appears intoxicated heent: ncat, nontraumatic, pupils large and equal, sluggish pulm: bibasilar rales which clear with deep inspiration.",0
"o/w ctab cv: tachy, 2/6 sem at base abd: s/nt/nd/nabs, no hsm extr: no c/c/e neuro: strength 5/5 and sensation to light touch intact throughout.",0
LIVER ULTRASOUND: Echogenic liver consistent with fatty infiltration.,0
CHEST X-RAY: No acute cardiopulmonary process.,0
Brief Hospital Course: 32 yo male with history of EtOH abuse and comorbid psychiatric problems presents with acute intoxication and withdrawal.,1
MICU COURSE: He was seen by psychiatry and social work.,0
He was placed on a standing taper as CIWA scales had been unreliable given baseline tachycardia.,0
His osmolality gap went from 145 to 60.,0
Heart rate improved from 130s to 70s.,0
"EtOH WITHDRAWAL: Patient admitted with elevated blood alcohol level, so likely was not in withdrawal.",1
CIWA scales consistantly < 10.,0
He was started on a benzodiazepine taper per psychiatry recommendations.,0
"He was given thiamine, folate, and MVI.",0
Patient had tachycardia to the 120s on admission.,0
This trended down to 60-80s in the ICU with IVF.,0
"His tacycardia was atributed to agitaion vs. withdawel, but he has a history of tachycardia, unclear etiology.",0
"As he was not tachycardic on discharge, he probably does not need this medication except prn anxiety.",0
LFT abnormalities: likely related to EtOH ingestion with AST > ALT (although not the classic 2:1).,0
Liver ultrasound showed fatty liver.,0
- Patient should have these rechecked as an outpatient.,0
LEUKOPENIA and THROMBOCYTOPENIA: There were thought to be most likely direct EtOH toxicity.,0
He has been trending up as an inpatient.,0
No splenomegaly on ultrasound - further outpatient w/u if not resolved .,0
"DEPRESSION and ANXIETY: Per report, he had reported SI to EMS.",0
"Since admission, he denyied SI/HI.",0
He has history of depression and anxiety.,0
"He was seen by psych and felt to be not suicidal, not a danger to self or others, and not in need of inpatient admission.",0
He was continued on citalopram.,0
"ELEVATED LIPASE: Asymptomatic, possibly subclinical pancreatitis from etoh.",0
- continue to trend .,0
"CONTACT: , (c) (h) Medications on Admission: atenolol 25 klonipin 4 citalopram 20 Discharge Medications: 1.",0
Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.,0
Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia.,0
"Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day.",0
Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.,0
Discharge Disposition: Home Discharge Diagnosis: ALCOHOL WITHDRAWAL TACHYCARDIA LIVER FUNCTION TEST abnormalities LEUKOPENIA and THROMBOCYTOPENIA DEPRESSION ANXIETY ELEVATED LIPASE Discharge Condition: Stable.,1
CIWA 4 Discharge Instructions: You were admitted with alcohol intoxication.,1
You were monitored in the ICU for signs of withdrawal.,0
"Although you did not have signs of withdrawal, you blood tests did show signs of damage from chronic alcohol use.",1
You should follow up with your PCP for follow up testing and to consider further evaluation.,0
You should avoid alcohol use entirely as this is particularly dangerous for you.,0
We encourage you in seeking assistance to help stay sober.,0
"If you have fevers, sweats, shaking, agitation, confusion, or feling of alcohol withdrawal, please seek medical attention.",1
"Followup Instructions: Mon , with Dr. , 9:10 AM in (.",0
Please bring this paperwork with you.,0
9:48 AM CT HEAD W/O CONTRAST Clip # Reason: eval interval change Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p dural AVM coiling c/b IPH and basilar artery embolus REASON FOR THIS EXAMINATION: eval interval change No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT SCAN OF THE HEAD WITHOUT CONTRAST HISTORY: Status post dural arteriovenous malformation coiling with intraparenchymal hemorrhage and basilar artery embolus.,1
COMPARISON STUDY ON PACS ARCHIVE: Noncontrast head CT scan from the previous day.,0
FINDINGS: Comparison with the prior day's study shows no change in the extent of the right parietal-occipital hemorrhage.,0
"There is somewhat less dense hemorrhage within the right lateral ventricle at this time, but there is a persistent small quantity of blood layering within the left occipital .",1
There has been no change in ventricular size or mass effect associated with the parenchymal hemorrhage.,0
No new osseous or extracranial soft tissue abnormality is seen.,0
"CONCLUSION: Stable appearance of abnormalities, as noted above.",0
/DOE/ Rapid Heartbeat Height: (in) 60 Weight (lb): 112 BSA (m2): 1.46 m2 BP (mm Hg): 160/80 HR (bpm): 110 Status: Outpatient Date/Time: at 10:00 Test: TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
PERICARDIUM: There is a moderate sized pericardial effusion.,1
"There is right ventricular and right atrial diastolic collapse, consistent with impaired fillling/tamponade physiology.",1
"There is probably significant, accentuated respiratory variation in mitral valve inflow, consistent with impaired ventricular filling.",0
"Compared with the findings of the prior study (tape reviewed) of , the pericardial effusion is now larger.",0
", G. MED 11:15 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: PLEASE EVALUATE OG AND ET TUBE PLACEMENT Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 37 year old man with severe pancreatitis ?",0
Contrast leak REASON FOR THIS EXAMINATION: please evaluate OG tube placement ______________________________________________________________________________ PFI REPORT Orogastric tube advanced to gastric antrum.,0
7:32 AM NEONATAL HEAD PORTABLE Clip # Reason: Screening HUS for 29 week premature.,0
______________________________________________________________________________ MEDICAL CONDITION: Infant with at 29 weeks.,0
Screening HUS REASON FOR THIS EXAMINATION: Screening HUS for 29 week premature.,0
______________________________________________________________________________ FINAL REPORT ULTRASOUND: This is our initial ultrasound on this boy born prematurely.,0
Today's exam through the anterior fontanelle with limited views through the mastoid foramen did not demonstrate any abnormalities.,0
12:53 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: please eval for abscess or other infectious process Admitting Diagnosis: ALTERED MENTAL STATUS Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with complicated past medical history who presents with altered mental status and seizures (may have hardware in her back) REASON FOR THIS EXAMINATION: please eval for abscess or other infectious process No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAMINATION: CT torso.,1
INDICATION: Complicated past medical history.,0
Altered mental status and seizures.,0
COMPARISON: Comparison is made with the previous study from .,0
"TECHNIQUE: A CT of chest, abdomen, and pelvis was performed with axial images taken from the lung apices to the symphysis pubis.",0
Reconstructions were performed in the coronal and sagittal planes.,0
CT CHEST FINDINGS: An NG tube is in situ.,0
"On the lung windows, there are multiple small subcentimeter nodules scattered throughout the lungs, there are also some more hazy appearing nodular infiltrates scattered throughout the lungs, these may represent infection.",0
Appropriate treatment and followup is advised.,0
Some atelectasis is noted bibasally.,0
CT ABDOMEN FINDINGS: The liver and spleen are normal.,0
A simple cyst is also identified inferiorly measuring 6.7 cm x 4.9 cm.,0
The CBD measures 11 mm.,0
Some artifact is projected due to the patient's left arm over the abdomen.,0
The stomach is distended with an NG tube in situ.,0
The adrenals and kidneys are normal.,0
Note is made of a left renal artery aneurysm which was also identified on the previous CT. A Dewisse filter is seen in relation to the IVC.,0
The pancreas is visualized and is normal.,0
No free air and no free fluid identified.,0
Some subcutaneous nodules are seen in the subcutaneous fat as well as some calcific densities.,0
This may be secondary to previous injections.,0
"Plate-like calcification is noted in the subcutaneous tissue of the buttocks, which may represent myositis ossificans.",0
CT PELVIS FINDINGS: The bladder is catheterized.,0
"Some sub cm inguinal lymph nodes are noted, which are not pathological.",0
No free fluid and no free air.,0
BONY WINDOWS: Some metal is identified in the spinal canal posteriorly in the upper thoracic vertebrae.,0
Degenerative changes noted in the spine.,0
(Over) 12:53 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: please eval for abscess or other infectious process Admitting Diagnosis: ALTERED MENTAL STATUS Field of view: 40 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) Multiplanar reconstructions were essential in depicting the anatomy and identifying the pathology.,1
No definite abscess or collection identified.,0
"Multiple tiny lung nodules, some of which are more infiltrates and may represent infection.",0
Subcutaneous skin nodules and calcification as well as myositis ossificans.,0
Cyst in the inferior portion of the spleen.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY: Baby girl was the gram product of a 37 and 2/7 weeks gestation born to a 31-year-old G1, P0 mother.",0
"Prenatal screens - O positive, antibody negative, hepatitis surface antigen negative, rubella immune, RPR nonreactive, GBS negative.",0
This pregnancy was notable for intrauterine growth restriction and spontaneous onset of labor.,0
The infant delivered vaginally with Apgars of 8 and 9.,0
She was noted to have dysmorphic features and developed stridor soon after birth.,0
"On arrival to the newborn intensive care unit, the infant with audible stridor and moderate subcostal retractions.",0
"PHYSICAL EXAMINATION: Weight grams, less than 10th percentile; length 42 cm, less than 10th percentile; head circumference 28 cm, less than 10th percentile.",0
"IUGR infant with obvious dysmorphic features, large long filtrum, depressed nasal bridge, small chin, short stubby hands and feet, bilateral single palmar crease and two phalanx each finger.",0
"Anterior fontanel at level, sutures normal, intact palate, neck supple.",0
Eyes with bilateral red reflex present.,0
"Continues audible stridor even at rest, bilateral moderate subcostal retractions with conducted sounds.",0
"CARDIOVASCULAR: Pink, well perfused, S1, S2 normal.",0
Anus patent but anteriorly displaced.,0
"SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The baby was admitted to the newborn intensive care unit for observation, and management of her IUGR status and her respiratory stridor.",1
She has remained stable in room air throughout her hospital course and has not required any methylxanthine therapy for apnea bradycardia.,0
ORL evaluated the infant and discovered severe laryngomalacia.,0
Plan is to have surgery to correct this issue at on .,0
CARDIOVASCULAR: The infant has an audible murmur.,0
"An echocardiogram was obtained revealing patent foramen ovale, small anterior muscular ventricular septal defect, small patent ductus arteriosus.",1
Cardiology was consulted and recommended continued care.,0
"FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was grams.",0
She was initially started on 80 cc per kg per day of D10W.,0
Enteral feedings were initiated on day of life 1.,0
"The infant is on full enteral feedings, requiring PG feeding.",0
She was evaluated by the feeding team at this week and it was recommended to continue offering PO feeds every other feed knowing that the infant is at high risk for aspiration at this time.,0
Plan is to reevaluate the infant following her surgery on Thursday.,0
She is currently receiving 150 cc per kg per day of breast milk 28 calorie with Beneprotein again an average 10 to 30 grams per day.,0
GASTROINTESTINAL: Peak bilirubin was on day of life 3 of 9.1/0.4.,0
HEMATOLOGY: Hematocrit on admission was 42.6.,0
CBC was benign and blood cultures remained negative at 48 hours at which time ampicillin and gentamycin were discontinued.,0
NEUROLOGIC: The infant has been appropriate for gestational age.,0
GENETICS: Genetics was consulted to evaluate this infant for dysmorphism.,0
A chromosome analysis was performed revealing normal 46 XX.,0
FISH was performed for chromosome 22 and chromosome 18 and those were normal.,0
Genetics has seen the infant most recently on recommending a signature CHIP being sent off which has not yet been done.,0
AUDIOLOGY: Hearing screen has not yet been performed but should be done prior to discharge.,0
OPHTHALMOLOGY: The infant was seen by ophthalmology to rule out ophthalmologic malformations.,0
"She was seen by Dr. on to reveal no colobomas, normal optic nerves and retina.",0
PSYCHOSOCIAL: The family lives on and are experiencing some financial strains due to housing in area.,0
They are interested and involved and loved their daughter.,0
"Feeds at discharge: She will be NPO at the time of transfer to , 130 cc per kg per day of D10W with 2 of sodium chloride and 1 mEq of potassium chloride.",0
Medications: Not applicable at the time of transfer but prior to transfer she was on no medications.,0
State newborn screens have been sent per protocol and have been within normal limits.,0
Immunizations received: The infant has not received any immunizations to date.,0
"A 37 week infant, small for gestational age.",0
", Dictated By: MEDQUIST36 D: 21:43:57 T: 22:48:45 Job#:",0
"3:44 AM CT C-SPINE W/O CONTRAST Clip # Reason: eval fx, subluxtn ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman s/p fall c traumatic SAH from OSH REASON FOR THIS EXAMINATION: eval fx, subluxtn No contraindications for IV contrast ______________________________________________________________________________ WET READ: DJD WED 4:28 AM No fracture or subluxation.",0
Overread: Agree MD WET READ VERSION #1 MAlb WED 4:10 AM No fracture or subluxation.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old woman status post fall with traumatic subarachnoid hemorrhage; evaluate for fracture or subluxation.,1
TECHNIQUE: Axial images of the cervical spine were obtained with coronal and sagittal reformatted images.,0
CT CERVICAL SPINE: No fracture or subluxation is identified.,0
"Minimal degenerative changes and marginal anterior and posterior osteophyte formation is seen, predominantly at the C5-6 and C6-7 levels.",0
"Limited evaluation of intrathecal contents on CT; however, the outline of the thecal sac is within normal limits.",0
"Posterior osteophytes at the C4-5 and C5-C6 levels result in some mild central canal narrowing, and abut the anterior aspect of the thecal sac.",0
Uncovertebral spurring causes moderate left C6-C7 neural foraminal narrowing.,0
"In the visualized portion of the lung apices, no pneumothorax or pleural effusion is seen.",0
IMPRESSION: No fracture or subluxation is identified.,0
"7:15 AM CHEST (PORTABLE AP) Clip # Reason: ?consolidation Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman s/p stroke REASON FOR THIS EXAMINATION: ?consolidation ______________________________________________________________________________ FINAL REPORT HISTORY: Stroke, to assess for consolidation.",1
"FINDINGS: In comparison with the study of , the tip of the endotracheal tube is now about 6 cm above the carina.",0
There is some increasing opacification at the bases medially.,0
"Although this could merely reflect atelectasis, the possibility of supervening pneumonia can certainly not be excluded.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Biaxin / Erythromycin Base / Amiodarone Attending: Chief Complaint: lethargy Major Surgical or Invasive Procedure: s/p R heart cardiac catheterization for trial of dobutamine.,1
"History of Present Illness: 59 y/o female with PMH significant for severe ischemic cardiomyopathy with a LVEF of 15%, CAD, and pulmonary hypertension admitted through the ED with lethargy and severe laboratory abnormalities.",1
Pt is really unable to give any history.,0
She simply reports that her girlfriend made her come in.,0
She reports that she has been feeling fine and denies any pain.,0
"available notes, the pt's neightbor had called Dr. and reported that the pt had been more lethargic over the last day or so.",0
The neighbor called EMS to bring the pt to the ED for further evaluation.,0
"In the ED, the pt's initial VS were 96.5 127/50 80 18 100% 0.5L.",0
Her finger stick was 42 and the pt received 1 mg IM glucagon.,0
"The pt was found to have multiple laboratory abnormalities including: bicarb of 7, creatinine of 1.9 (baseline 0.7 to 1.1), lactate of 15.7, and a INR of 13.8.",0
"She received levaquin, vancomycin, vitamin K 10 mg PO x1, and vitamin K 5 mg IV x1.",0
A cardiology consult was obtained.,0
Advanced CHF with a LVEF of 15 to 20% secondary to ischemic cardiomyopathy 2.,0
Severe 4+ MR on 3.,0
Mild to moderate + TR by on 4.,0
CAD s/p MI in and CABG in 6.,0
PFTs from with a mild restrictive ventilatory defect 7.,0
Hypothyroidism secondary to amiodarone toxicity 8.,0
History of paroxysmal atrial fibrillation- Pt is anticoagulated on coumadin and her INR from was 3.8.,1
S/P TIA x3 with slurred speech- This was transient and is currently resolved.,0
"Social History: Smoked for 7 years, currently, not smoking.",0
The patient lives alone and is retired.,0
Family History: Mother - non-alcoholic liver cirrhosis.,0
Father deceased of MI at 50.,0
Physical Exam: 97.8 116/74 80 18 98 RA Gen- Alert and oriented x2 ( and self).,0
Very lethargic and not really able to given a history/answer extensive questions.,0
III/VI SEM loudest at the left lower sternal border.,0
Extremities- Trace bilateral pedal edema.,0
Pertinent Results: CXR- Stable appearance of heart and lungs.,0
Head CT (WET READ)- No intracranial hemorrhage or mass effect.,0
Liver US- No change from previous studies.,0
No focal abnormalities of the liver.,0
CBD same size at approximately 10 mm.,0
ECG- Paced at 80 beats per minute.,0
05:57PM WBC-10.0 RBC-3.85* HGB-12.1 HCT-41.1# MCV-107*# MCH-31.6 MCHC-29.6* RDW-17.7* 05:57PM PLT COUNT-199# 05:57PM NEUTS-84.8* LYMPHS-11.6* MONOS-3.4 EOS-0.2 BASOS-0 05:57PM HYPOCHROM-3+ ANISOCYT-1+ MACROCYT-3+ 05:57PM GLUCOSE-162* UREA N-31* CREAT-1.9*# SODIUM-133 POTASSIUM-5.9* CHLORIDE-94* TOTAL CO2-7* ANION GAP-38* 05:57PM ALT(SGPT)-41* AST(SGOT)-119* LD(LDH)-604* CK(CPK)-77 ALK PHOS-189* AMYLASE-64 TOT BILI-2.0* 06:35PM LACTATE-15.7* 05:57PM LIPASE-22 05:57PM ALBUMIN-3.8 05:57PM TSH-6.4* 06:35PM LACTATE-15.7* 05:57PM DIGOXIN-2.8* 05:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.8 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 05:57PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-NEG amphetmn-POS mthdone-NEG 07:31PM TYPE-ART PO2-152* PCO2-20* PH-7.22* TOTAL CO2-9* BASE XS--17 07:31PM GLUCOSE-142* LACTATE-15.1* K+-4.9 07:31PM freeCa-1.16 .,0
"Cardiology Report C.CATH Study Date of *** Not Signed Out *** BRIEF HISTORY: The patient is a 59 year old woman with an ischemic cardiomyopathy (EF 15%) and severe mitral regurgitation s/p BiV-ICD placement with PAF, severe pulmonary hypertension, and hypothyroidism who is referred to the catheterization lab for evaluation of hemodynamic measurements with infusion of dopamine and dobutamine.",1
"INDICATIONS FOR CATHETERIZATION: Class IV heart failure, pre-cardiac transplant evaluation.",1
"PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through a 8 French introducing sheath.",1
A 5 French arterial sheath was placed for measurement of arterial pressure and for arterial blood draws.,0
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.87 m2 HEMOGLOBIN: 10.4 gms % ENTRY DOPAMINE 5 DOBUTAMINE 10 **PRESSURES RIGHT ATRIUM {a/v/m} -/13/11 -/19/18 RIGHT VENTRICLE {s/ed} 73/19 65/14 PULMONARY ARTERY {s/d/m} 73/32/47 80/40/55 65/24/38 PULMONARY WEDGE {a/v/m} -/32/32 -/52/40 -/19/18 AORTA {s/d/m} 124/70/82 131/74/93 120/52/73 **CARDIAC OUTPUT HEART RATE {beats/min} 80 88 80 RHYTHM AF AF AF O2 CONS.,1
IND {ml/min/m2} 125 125 125 A-V O2 DIFFERENCE {ml/ltr} 57 52 31 CARD.,0
OP/IND FICK {l/mn/m2} 4.1/2.2 4.5/2.4 7.5/4.0 **RESISTANCES SYSTEMIC VASC.,0
RESISTANCE 1385 587 PULMONARY VASC.,0
"RESISTANCE 293 267 213 **% SATURATION DATA (NL) PA MAIN .56, .57, .52, .75, .75 AO .96, .92, .89, .97 **ARTERIAL BLOOD GAS INSPIRED O2 CONCENTR'N .24 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.",0
TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 24 minutes.,0
Arterial time = 1 hour 24 minutes.,0
Fluoro time = 7.4 minutes.,0
Contrast: Premedications: ASA 81 mg P.O.,0
Fentanyl 25 mcg IV Midazolam 0.5 mg IV Anesthesia: 1% Lidocaine subq.,0
"Anticoagulation: Other medication: Dobutamine 1-10 mcg/kg/min IV Dopamine 2.5-5 mcg/kg/min IV Cardiac Cath Supplies Used: 300 CM MALLINCRODT, OPTIRAY 100CC COMMENTS: Resting hemodynamics upon entry revealed moderately elevated right and severely elevated left sided filling pressures, with a mean RA of 11, RVEDP of 19, mean PCWP of 32 mm Hg.",0
"Severe pulmonary artery systolic hypertension was present, at 73/32 (mean 47 mm Hg).",1
Central systemic arterial pressures were normal (124/70 mean 82 mm Hg).,0
"The cardiac index as calculated from the Fick equation was depressed, at 2.2 L/min/m2.",0
The SVR was elevated at 1385 dynes/sec/cm5.,0
"With infusion of dopamine (5 mcg/kg/min), there was no significant change in the pulmonary artery pressure (80/40/55 mm Hg).",0
The cardiac index was minimally higher (2.4 L/min/m2).,0
The systemic arterial pressure was likewise unchanged (131/74/93 mm Hg).,0
"After stopping dopamine infusion, initiating dobutamine, and titrating the dosage upwards to 10 mcg/kg/min, the patient's pulmonary arterial pressures decreased slightly to 65/24 with a mean of 38 mm Hg.",0
"Her mean PCWP decreased significantly to 18 mm Hg (from baseline of 32 mm Hg), and her systemic arterial pressure remained essentially unchanged (120/52/73 mm Hg).",0
"Her cardiac index also significantly improved, from a baseline of 2.2 to 4.0 L/min/m2 with dobutamine infusion.",0
Her SVR also significantly decreased from baseline of 1385 to 587 dynes/s/cm2 with dobutamine infusion.,0
"The PA saturation at baseline was 56%, which increased to 75% after dobutamine infusion.",0
Severe systolic and diastolic ventricular dysfunction.,1
Severe pulmonary artery sytolic hypertension.,0
Marked improvement in hemodynamic measurements with dobutamine infusion.,0
"CARDIOLOGY FELLOW: , S. ATTENDING STAFF: , J.",0
"Brief Hospital Course: A/P: 59 y/o female with PMH significant for severe ischemic cardiomyopathy with a LVEF of 15%, CAD, and pulmonary hypertension admitted through the ED with lethargy and severe laboratory abnormalities.",1
CHF with LVEF of 15 to 20%: Pt does not appear to be in decompensated failure at this time.,0
"-Had Swan Ganz with dobutamine titration, showing that the patient had decreased SVR and inceased cardiac output with dobutamine.",0
"Started dobutamine 5mcg/kg/min after PICC placed but titration up to 10 mcg/kg/min was limited by frequent PVC's 1 every 10 beats, so the patient was decreased to 5 mcg/kg/min.",0
She will likely receive dobutamine 5mcg/kg/min at home when she is stable for discharge.,0
Quadruple concentrated dobutamine (1g/250cc D5W) because of hyponatremia.,0
Titrating up ACEi and transitioning to daily lisinopril.,0
Hyponatremia: Pt presented with severely decreased oral intake over 1-2weeks.,0
"She then was volume repleted partially with saline, but also to a great degree with oral free water.",0
"Her sodium worsened further on initiation of dobutamine gtt, which is suspended in free water.",0
-Dobutamine has since been concentrated 4x.,0
"-Free water restriction, 1L orally.",0
-Continue 2g/day sodium restriction given severe CHF.,0
-Encourage oral intake up to 1L/day as above.,0
"Thrombocytopenia: Plt 522, upon last check before this admission.",0
"Admitted with Plt 199 on , trending down to 94 on but up at 115 on .",0
Heparin flushes d/c'd although HIT Ab negative.,0
DIC labs negative as well.,0
LE and WBC in urine with no epithelial cells and + bacteria.,0
Past micro data shows multiple pan-sensitive E.Coli infections.,0
Will treat with levofloxacin x 10 days.,0
"Since foley removed, due to void at 6pm.",0
"If no void by then and bladder scan >200cc, straight cath x 1 for residual.",0
Lactic acidosis: Lactic acidosis- Unclear etiology of pt's lactic acidosis.,0
"Does not appear to be septic in nature as afebrile, not tachycardic, not tachypnic.",0
Pt denied taking any new medications or any that don't belong to her.,0
"As her lactic acid has quickly improved in the few hours since arrival, could be due to a seizure as this would improve relatively quickly, or to severe dehydration with diarrhea and poor nutrition over 1.5 weeks (""I stopped eating for 12 days"") as she received rapid volume resuscitation.",0
"- Improved with gentle volume resuscitation, starting with 250 cc NS bolus and gentle maitnance fluids at 75 cc/hr, monitoring carefully given severely depressed LVEF.",0
- Also improved with dobutamine but limited by ectopy on higher doses as below.,0
Psych: Pt's toxin screen widely positive and there is concern for the patient being suicidal.,0
Psychiatry consult pending to assess for suicidality.,0
"Patient's prior history of refusing transplant, her current history of ingestion, and her management as bridge to future transplant make determining her suicidality important.",1
"However, pt had hx of taking fioricet (has barbituates); also known to be on benzodiazepines chronically at home.",0
"On further history, pt refused transplant due to no social support at home.",0
Psychiatry felt that her changing mental status was delirium.,0
Mental status has since stabilized and no acute concern for SI.,0
Atrial fibrillation: Pt with a elevated INR on admission.,1
"Initially, was concerned about severe hepatic failure/dysfunction causing synthetic dysfunction and other abnormalities.",1
"However, does not appear that her liver is dysfunctional, but this may be due to volume resuscitation in the setting of dehydration.",0
Pt denied taking large doses of her coumadin.,0
Got vitamin K in the ED and continued to monitor INR.,0
Started enoxaparin and prior dose of warfarin (2mg0 qhs) on as transition back to home regimen.,0
Diarrhea: Possibly secondary to refeeding.,0
"Pt was taking oral neutraphos and was not eating for days, which both may have resulted in diarrhea on refeeding.",0
"Dehydration: Pt was extremely dry, now close to euvolemic.",0
"Unclear if she became dehydrated for some reason and this led to her current state or she developed the acidosis, etc then became dehydrated.",1
Will rehydrate very gently given severely depressed LVEF.,0
Urine output continues to be low at 20cc/hr.,0
"Given 250cc bolus without much response and over a period of days, she received multiple small boluses and returned to euvolemic status with improved urine output.",0
"From R heart cardiac cath, her RA pressure was depending on dobutamine dose, but it may be possible that pt may need relatively high RA filling pressures if RHF severe.",1
10.FEN- Initially NPO until the pt became more alert.,0
Had self-limited episodes of lightheadedness and nausea despite stable vitals and BPs in 120s.,0
Possibly secondary to refeeding or dehydration.,0
"Checked albumin, most recently 3.3 from 3.8 on admission; prealbumin pending.",0
Started supplements tid c/w nutrition consultation recommendations.,0
11.Proph: Anticoagulated on lovenox-->warfarin; pneumoboots; H2 blocker.,0
"13.Dispo: The patient was discharged in stable condition on dobutamine, lisinopril, amiodarone, aspirin, and her home coumadin dose for atrial fibrillation as her cardiac regimen.",1
She was also discharged on 10 days of ciprofloxacin for UTI and history of pan-sensitive E.coli urinary tract infections.,1
Patient was set up for home dobutamine infusions and was cleared by PT after a number of physical therapy sessions resulted in the patient returning to her baseline functional ability.,0
14.Follow-up: The patient will receive VNA at home for nursing needs and to follow her INR until it reaches 2.0.,0
"Additionally, she will take daily weights and call her cardiologist for a weight change of 3 lbs.",0
She has a follow-up appointment with Dr. scheduled for .,0
Medications on Admission: Allergies: 1.,0
"Medications (As pt not able to give, these are from most recent DC summary): 1.",0
ASA 81 mg daily 2.,0
Levothyroxine 137 mcg daily 3.,0
Famotidine 40 mg daily 4.,0
Clonazepam 0.5 mg TID 5.,0
Digoxin 125 mcg daily 6.,0
Spironolactone 25 mg daily 7.,0
Mg oxide 400 mg 8.,0
Lorazepam 1 mg TID 9.,0
Sertraline 100 mg QHS 10.,0
Tylenol 325 mg tab Q4-6H 11.,0
Amiodarone 400 mg daily 12.,0
Warfarin 2 mg daily- Was supposed to hold dose today.,0
Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
"Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): Call your doctor if you have more than 10 minutes of chest pain.",0
"Disp:*75 Tablet, Sublingual(s)* Refills:*2* 6.",0
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed.,0
Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
"Dobutamine in D5W 4,000 mcg/mL Parenteral Solution Sig: Five (5) mcg/kg/minute Intravenous continuous infusion: Via portable infusion pump.",0
"Hold for chest pain, lightheadedness or arrhythmia.",0
Disp:*qs x 6 months qs x 6 months* Refills:*5* 9.,0
Heparin Sodium Lock Flush 100 unit/mL Solution Sig: Three (3) ml Intravenous once a day: to unsused PICC lumen.,0
Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.,0
Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).,0
Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days.,0
Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Physician Discharge Diagnosis: Congestive heart failure Discharge Condition: Stable and improved.,1
"Discharge Instructions: Weigh yourself every morning, MD if weight > 3 lbs.",0
"Adhere to 2 gm sodium diet strictly, but be sure to eat regularly.",0
"Fluid Restriction: 1 liter of combined juice, water, soda per day.",0
Please follow up with Dr. at your appointment noted below.,0
"Please call your doctor or return to the emergency department with difficulty breathing, shortness of breath, lightheadedness, increased leg swelling, weight change of 3 pounds, or other concern.",0
Where: CARDIAC SERVICES Phone: Date/Time: 3:00 Provider: CLINIC Where: CARDIAC SERVICES Phone: Date/Time: 1:00,0
"LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: line placement Admitting Diagnosis: RIGHT PLEURAL EFFUSION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with right decortication REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH: INDICATION: Status post right decortication, chest tube placement.",1
FINDINGS: As compared to the previous radiograph from 11:18 a.m. the extensive right pneumothorax has further increased in extent.,0
The three right-sided chest tubes are in unchanged position.,0
Also unchanged is the extensive gas collection in the right lateral soft tissues that extends into the cervical soft tissues.,0
There is right diaphragmatic depression indicating tension.,0
The contralateral left lung is unchanged.,0
"Unchanged position of the right subclavian access line, and the endotracheal tube.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Percocet / Codeine Attending: Chief Complaint: 1.,0
"Poor PO intake Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 56 y/o M s/p Whipple resection + SMV reconstruction for pancreatic ca with SMV thrombosis ( and ), with post-operative course marked by delayed gastric emptying, requiring NGT reinsertion on POD 7 until POD 11.",1
The remainder of his post-op course was notable for small wound infection treated by opening up each corner of the incision and packing with WTD dressings.,0
He was discharged home on .,0
"Yesterday he developed some nausea, limiting his PO intake, which progressed to emesis this morning of thin yellow-green fluid.",0
"Reports mild abdominal pain, described as a tightness across his upper abdomen in the region of the incision.",0
+ flatus yesterday but not today.,0
"Past Medical History: PMHx: Diet-controlled DM, HTN.",0
"PSHx: ERCP with sphincterotomy and stent placement, EUS.",0
Social History: Works at Shaws as produce manager.,0
Married with children and grandchildren.,0
"No tobacco use history, 1 drink EtOH/month, no recreational drugs.",0
He is only sexually active with his wife.,0
"Family History: Father had IDDM and HTN, brother with DM, HTN Physical Exam: On Admission: 97.9 102 145/89 22 96 on RA A&Ox3, active and continuous emesis of thin yellow-fluid without wretching, fatigued appearing CTAB with diminished breath sounds BL bases RRR soft, minimally tender without rebound or guarding, min distended.",1
"incision c/d/i with each corner showing clean granulation bed without surrounding erythema, re-packed with WTD gauze.",0
"WWP, wearing stockings BL (precludes examination for edema) NGT placed uneventually at bedside via R nare, no resistance encountered, no coughing or aspiration, volumous output of __cc of thin yellow-green fluid.",0
"On Discharge: VS: 98.2, 66, 121/79, 18, 99% 2L n/c Gen: Fatigued appearing, comfortably sitting on bed in NAD CV: RRR Lungs: diminished bilateraly on bases L > R Abd: Soft, normal tenderness around incision.",0
"Incision open on both corners and packed with moist-to-dry gauze dressing, middle portion with steri strips and c/d/i.",0
Ext: LUE PICC Pertinent Results: 11:00AM WBC-13.9* RBC-3.70* HGB-10.8* HCT-32.5* MCV-88 MCH-29.2 MCHC-33.3 RDW-15.1 11:00AM NEUTS-90.3* LYMPHS-4.1* MONOS-5.3 EOS-0.1 BASOS-0.2 11:00AM PLT COUNT-651* 11:00AM GLUCOSE-154* UREA N-15 CREAT-0.8 SODIUM-139 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14 11:00AM ALT(SGPT)-21 AST(SGOT)-17 CK(CPK)-20* ALK PHOS-126 AMYLASE-19 TOT BILI-1.0 11:00AM LIPASE-17 05:18PM TYPE-ART PO2-62* PCO2-39 PH-7.47* TOTAL CO2-29 BASE XS-4 INTUBATED-NOT INTUBA COMMENTS-15L NRB 05:01PM TYPE- PO2-97 PCO2-44 PH-7.37 TOTAL CO2-26 BASE XS-0 COMMENTS-GREEN TOP RADIOLOGY: ECG: Sinus tachycardia.,0
Possible anteroseptal myocardial infarction of indeterminate age.,0
Possible inferior myocardial infarction of indeterminate age.,0
Non-specific lateral repolarization changes consistent with myocardial ischemia.,0
Compared to the previous tracing of normal sinus rhythm has given way to sinus tachycardia and lateral repolarization changes consistent with myocardial ischemia are new.,0
Bilateral lower lobe opacities most compatible with aspiration pneumonia.,0
"Post-Whipple changes, with stable narrowing of the SMV just proximal to the splenic vein insertion into the portal vein.",0
Stable partial thrombosis of the right anterior portal vein.,0
"Small locules of free air inferior to the gallbladder fossa, may reflect residual postoperative air.",0
There is no associated fluid or collection.,0
Essentially resolved fluid collections previously seen adjacent to the Roux jejunal loop as well as inferior to the liver.,0
"Moderate gastric distention, though contrast passes freely through the small and large bowel without evidence for obstruction.",0
Moderate free fluid in the pelvis.,0
"Massive bilateral lower lobe consolidations, concerning for aspiration CHEST PA: IMPRESSION: 1.",0
Left PICC ends in the lower SVC.,0
Bibasal consolidations and bilateral small pleural effusions are unchanged since the previous study.,0
CHEST PA/LAT: Mild cardiomegaly is stable.,0
Bibasilar consolidations larger on the left side are consistent with pneumonia.,0
"Pulmonary edema has markedly improved, now mild.",0
LUE US: IMPRESSION: No thrombus is identified in the deep veins of the left upper limb.,0
"MICRO: 6:50 pm BLOOD CULTURE **FINAL REPORT ** Blood Culture, Routine (Final ): NO GROWTH.",0
5:15 pm SPUTUM Source: Expectorated.,0
4:01 pm URINE Source: CVS.,0
On patient was readmitted to the General Surgical Service with c/o nausea/vomiting and decreased PO intake.,0
"On admission in ED, patient continue to have active and continuous emesis of thin yellow-fluid.",0
"Patient was tachycardic with HRmax 130s, chest xray revealed aspiration pneumonia.",0
Patient was intubated for airway protection and transferred in ICU for observation and treatment.,0
Neuro: The patient received propofol and fentanyl for sedation while intubated.,0
"After extubation, patient's pain was controlled with IV Dilaudid with good effect and adequate pain control.",0
Currently patient taking Tylenol for pain control.,0
"CV: On admission patient was tachycardic, after he was hydrated patient HR returned to sinus rhythm.",0
Patient heart rate was monitored with telemetry during hospitalization.,0
The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored.,0
"Pulmonary: On admission patient had active emeses, and chest xr revealed aspiration pneumonia.",0
Patient was intubated and transferred in ICU.,0
"On patient was extubated, he was required 3-4 L of O2 via n/c for O2 Sats > 92%.",0
"Patient was transferred on the floor, where he continue to be monitored for O2 Sats.",0
"He continue require 2L O2, his O2 Sats 95-97%.",0
Last chest pa/lat demonstrated that pulmonary edema has markedly improved and now mild; bibasilar consolidations larger on the left side and consistent with pneumonia; there is no pneumothorax.,0
"Patient was started on Vancomycin and Zosyn on admission, late Erythromycin was added to his treatment.",0
"Patient currently stable from pulmonary standpoint, he will continue ABX treatment after discharge.",0
GI/GU/FEN: Patient was made NPO on admission and started on TPN.,0
His diet was advanced to clears on HD # 8.,0
Patient will continue TPN on discharge.,0
"His diet will be advanced slowly within 2 weeks to fulls, with no solid food allowed until follow up with Dr. (Surgery).",0
"Electrolytes were routinely followed, and repleted when necessary.",0
"On admission patient's WBC was elevated, but currently WNL.",0
Patient remained afebrile during hospitalization.,0
"Blood, urine and sputum cultures were negative.",0
Endocrine: Patient has a history of diet controlled diabetes.,1
"After TPN was started, patient's BS was continue to increase and required increased TPN insulin, standing insulin order and high sliding scale for BS control.",0
Currently patient's FS between 90s-200s.,0
Patient will require close blood sugar monitor when his TPN will started to wean off.,0
"Hematology: The patient's complete blood count was examined routinely, his Hct was stable low (23.1-24.6).",0
"On patient received one unit of RBC, after transfusion Hct was 24.6.",0
"On patient received one more unit of RBC, his Hct was 29.2 after second transfusion.",0
"After blood transfusions, patient reported increase of energy and patient's O2 requirements decreased from 5L to 3L.",0
"There was concern for a LUE DVT during his stay b/c of some swelling at and around the PICC site, but an ultrasound was performed that showed no clot and the swelling improved with elevation.",0
"The patient was tolerating a clear fluid diet and TPN, ambulating with stand by assist, voiding without assistance, and pain was well controlled.",0
"Medications on Admission: ASA 325', norvasc 10', losartan 25', indapamide 2.5', lipitor 10', protonix 40', reglan 10''', colace 100''prn, senna 8.6''prn, dilaudid 2-4q4:prn, tylenol prn Discharge Medications: 1.",0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q4H (every 4 hours).,0
Insulin Regular Human 100 unit/mL Solution Sig: 4-32 units Injection as directed.,0
Erythromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours).,0
Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Reglan 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours.,0
Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous twice a day for 4 days.,1
Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 4 days.,1
Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain.,0
Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: 1.,0
Pancreatic adenocarcinoma with SMV thrombosis 2.,0
Aspiration PNA Discharge Condition: Mental Status: Clear and coherent.,0
"PICC line care: *Please monitor the site regularly, and your MD, nurse practitioner, or Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site.",0
Followup Instructions: Please follow up with Dr. (PCP) in weeks after discharge .,0
"Provider: , MD Phone: Date/Time: 11:30 3, Completed by:",0
"4:46 AM CHEST (PORTABLE AP) Clip # Reason: acute process Admitting Diagnosis: ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with duodenal perf, intubated REASON FOR THIS EXAMINATION: acute process ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Duodenal perforation, intubated patient.",1
Cardiomediastinal contours are normal and unchanged.,0
Bibasilar opacities are stable allowing the difference in positioning of the patient and are a combination of atelectasis and pleural effusion.,0
Lines and tubes are in unchanged standard position.,0
Again noted enlargement of the main pulmonary arteries.,0
There is a stable mild vascular congestion.,0
There is a calcified granuloma in the right mid lung.,0
"10:34 AM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # Reason: -AP, Lat, axillary- Patient fell while getting US for DVT se Admitting Diagnosis: DELIRIUM TREMENS ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: This addendum completes the report from , 10:52.",0
"On two projections, cranially and medially to the humeral head, bony fragments are seen.",0
"These fragments were not present on the intraoperative fluoroscopic examination from , 3:47 p.m. On this basis, re-fracture of the bone is likely.",0
"This finding has been communicated to the section chief of MSK, Dr. , to the departmental QA chief, Dr. , and has been entered into the Radiology departmental QA system.",0
"10:34 AM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # Reason: -AP, Lat, axillary- Patient fell while getting US for DVT se Admitting Diagnosis: DELIRIUM TREMENS ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with POD # 4() s/p Left proximal humerus ORIF/K-Rod REASON FOR THIS EXAMINATION: -AP, Lat, axillary- Patient fell while getting US for DVT secondary to dizziness on right shoulder- Rule out disruption of joint s/p fracture or soft tissue issue ______________________________________________________________________________ FINAL REPORT Status post fracture of the the lefthumerus.",1
FINDINGS: Current radiograph documents fixation of the humeral head after displaced fracture of the left proximal humerus.,1
The position of the constituents is comparable to the fluoroscopic control of .,0
Post-surgical soft tissue clips in situ.,0
"2:50 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?obstruction ______________________________________________________________________________ MEDICAL CONDITION: LLQ ppain and vomiting for 1 day, with hxhx of obstruction due to Meckels and fecolith in REASON FOR THIS EXAMINATION: ?obstruction CONTRAINDICATIONS for IV CONTRAST: ALLERGY ______________________________________________________________________________ WET READ: 5:53 PM Small bowel obstruction; relative transition in left lower quadrant though eval for exact site of transition slightly limited.",0
"Resulting mesenteric edema/inflammation, concerning for developing ischemia though currently no advanced signs.",0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT HISTORY: 66-year-old male with left lower quadrant pain and vomiting for a day.,0
History of obstruction due to Meckel's and fecolith in .,0
TECHNIQUE: MDCT helical acquisition was performed from the diaphragm to the pubic symphysis without IV or oral contrast.,0
"CT ABDOMEN WITHOUT IV CONTRAST: The lung bases demonstrate no nodule, opacity, or pleural effusion.",0
There is mild subsegmental atelectasis.,0
There is fatty infiltration of liver.,0
The spleen is somewhat small.,0
The kidneys are somewhat atrophic and demonstrate mild perinephric stranding.,0
"Scattered calcification within the abdominal aorta is present, but the aorta is normal in caliber.",0
"There is a small-bowel obstruction, with a caliber change identified in the left lower quadrant (300a:14).",0
There is fecalization of a small bowel loop of approximately 10 cm (2:61) just proximal to the transition site.,0
The distal small bowel loops are collapsed.,0
There is moderate mesenteric edema and stranding.,0
No abscess or evidence of perforation.,0
The bowel wall is not thickened.,0
"CT PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon, and bladder are unremarkable.",0
Osseous structures demonstrate mild degenerative changes.,0
The aorta and its branches are somewhat calcified.,0
IMPRESSION: Small-bowel obstruction with transition point in the left lower quadrant with mesenteric edema and stranding.,0
(Over) 2:50 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?obstruction ______________________________________________________________________________ FINAL REPORT (Cont),0
"9:21 PM MR HEAD W & W/O CONTRAST Clip # Reason: eval for acute infarct Admitting Diagnosis: SUBDURAL HEMATOMA/SDA Contrast: GADAVIST Amt: 8 ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man s/p left crani, now with recurrent acute left SDH, new right hemiparesis/dysarthria, ?",1
seizure REASON FOR THIS EXAMINATION: eval for acute infarct No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old man status post left craniotomy with new recurrent left subdural hematoma.,1
COMPARISON: CT from and multiple priors.,0
"TECHNIQUE: Multiplanar, multisequence images of the head were performed with and without contrast.",0
FINDINGS: There is no evidence of acute infarct.,0
Again noted are post-surgical changes status post left craniotomy.,0
There is a left frontoparietal subdural collection measuring up to 1.5 cm containing blood products and causing mass effect over the left cerebral hemisphere and left lateral ventricle with a 5.5 mm midline shift to the left.,0
Again noted there is pneumocephalus in the left frontal subdural collection.,0
"Again noted there is left subarachnoid hemorrhage involving the frontal and parietal lobes, as well as the temporal lobes.",0
There are bilateral subcortical and periventricular T2 FLAIR hyperintensities which may represent microangiopathic chronic ischemic changes.,0
There is some dominant T2 FLAIR hyperintensity just lateral to the left caudate.,0
"There is left frontoparietal pachymeningeal enhancement, related to the surgery.",0
No other suspicious enhancement is noted.,0
The major intracranial flow voids are preserved.,0
There is fluid in the left mastoid air cells and mucosal thickening of the bilateral maxillary sinuses and ethmoid air cells.,0
The orbits are otherwise unremarkable.,0
Stable left frontoparietal subdural hematoma with stable mass effect and minimal midline shift.,0
"Stable subarachnoid hemorrhage involving the left frontal, temporal and parietal lobes.",0
"7:18 PM ABDOMEN (SUPINE ONLY) Clip # Reason: r/o SBO Admitting Diagnosis: HYDRONEPHROSIS ______________________________________________________________________________ MEDICAL CONDITION: 67 year old woman s/p sigmoid resection POD 3 now with nausea REASON FOR THIS EXAMINATION: r/o SBO ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 67-year-old female status post sigmoid resection post-op day #3, now with nausea.",1
FINDINGS: Two views of the abdomen demonstrate scattered air within the colon ane rectum with a general paucity of gas over the left lower abdomen.,0
The stomach is mildly distended.,0
An ostomy is seen in the right lower quadrant.,0
No intra- abdominal free air is detected.,0
IMPRESSION: No definite evidence of obstruction.,0
7:07 AM CHEST (PORTABLE AP) Clip # Reason: assess for changes ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman s/p IMI; on vent with ?PNA and CHF REASON FOR THIS EXAMINATION: assess for changes ______________________________________________________________________________ FINAL REPORT INDICATION: S/P inferior myocardial infarction.,1
PORTABLE CHEST: Comparison is made to .,0
The endotracheal and nasogastric tubes appear in good position.,0
There is persistent cardiomegaly and increased mild CHF.,0
There is a small left effusion and left lower lobe atelectasis vs. pneumonia.,0
"IMPRESSION: 1) Increased, mild CHF.",0
2) Left lower lobe atelectasis vs. pneumonia.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: clindamycin / Cipro Attending: Chief Complaint: Acute abdominal pain Difficulty with speach Decreased mental status Shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: History of Present Illness (on admission per Dr. : This 59-year old woman with history of hypertension, hyperlipidemia, diabetes, morbid obesity last well at either 8pm or 10pm last night presents with possible paraphasic errors and abdominal pain as transfer from .",1
Patient was reportedly hospitalized for much of and with cellulitis after a fall.,0
"Apparently during that time she had intermittent cognitive errors, for example thinking she was at Papa when she was at the hospital.",0
She did not seem to have a specific language impairment.,0
Since she has been at home husband thinks she's been cognitively normal.,0
"Last night around pm the patient's daughter saw her appear normal, and the patient went to bed.",0
At 1am the husband heard her yelling.,0
"He went upstairs to find her sitting on the side of her bed, possibly having vomiting.",0
"She appeared to be in substantial pain clutching her abdomen and saying ""my stomach is not stomaching.""",0
He recalled that she may have made some other unusual word choices but cannot recall them.,0
Her speech was slightly more difficult to understand than usual.,0
There was no focal weakness or facial droop appreciated.,0
"Her face appeared ""drawn"" though.",0
"She tried to stand up but had to sit back down due to pain, and apparently kept just repeating herself saying ""my stomach is stomaching.""",0
She may also have complained of a headache.,0
"EMS arrived and per their report she was making ""dysphasic errors"" and complained of a headache.",0
"She was brought to where she had initial vitals T 97.9, BP 173/76, HR 73, RR 20, exam showed ""expressive aphasic,"" and she was seen to have possible small left temporo-occipital infarct on head CT of undetermined age, and then she was intubated for concerns that she was not able to protect her airway while with nausea/vomiting.",0
Otherwise she had no signs of illness prior to her event in the middle of the night.,0
"She was not having fevers, belly pain, vomiting, or diarrhea.",0
She was not complaining of chest pain or shortness of breath.,0
"She did not have any weaknes, numbness, discoordination, speech, or language problems prior to night of presentation.",0
"70s RR 20 94% 3LNC I/O (8H) -550 (24H) 1080/400+ BMx2 PE: General: Alert, oriented, no acute distress Neck: JVP just below mandible at 30 degrees CV: Regular rate and rhythm, normal S1 + S2, G2 systolic murmur at RUSB.",0
"Lungs: No increased work of breathing, CTAB, good movement of air Abdomen: Protuberant, +BS, soft, non-tender, non-distended Ext: Erythematous, edematous, warm, well perfused, 2+ DP pulses b/l, no clubbing/cyanosis.",0
Skin: Diffuse morbilliform erythema of whole-body with significant peeling skin/excoriation of skin of LE bilaterally.,0
Improving with large clear patches.,0
Pertinent Results: : MRI IMPRESSION: Subacute infarct in the left posterior parietal lobe on a background of moderate microangiopathic small vessel disease.,1
Other possibilities include focal cerebritis and vasculitis.,0
: Echo The left atrium is moderately dilated.,0
No atrial septal defect is seen by 2D or color Doppler or bubble study x 3.,0
There is mild functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification.,0
"IMPRESSION: no intracardiac shunt (but suboptimal study); hypertrophic, hyperdynamic, stiff left ventricle with mild mitral stenosis and significant diastolic filling impairment, severe pulmonary hypertension, moderate tricuspid regurgitation ROTEUS MIRABILIS.",1
"SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Labs on discharge: 06:55AM BLOOD WBC-9.2 RBC-3.92* Hgb-12.1 Hct-36.8 MCV-94 MCH-30.8 MCHC-32.7 RDW-14.5 Plt Ct-276 06:55AM BLOOD Glucose-144* UreaN-11 Creat-0.5 Na-143 K-3.6 Cl-100 HCO3-36* AnGap-11 06:35AM BLOOD proBNP-2941* Brief Hospital Course: # 59 yo F with mild AS (valve area 1.2-1.9cm2), diastolic dysfunction, h/o CVA, hypertension, hyperlipidemia, diabetes Patient initially presented to OSH with garbled speech and confusion.",1
"CT at OSH was concerning for CVA, so was transferred to the neurology service at .",0
Due to her mental status she was intubated on arrival and transferred to the neuro ICU.,0
Work up for acute CVA was negative.,0
Incidently found an old tempero-parietal CVA and continued on Aspirin 325.,0
She was ultimately extubated and transferred to the floor.,0
She continued to have an increasing oxygen requirement.,0
She was found to be volume overloaded and transferred to the medicine service.,0
Her volume overload was secondary to a CHF exacerbation felt secondary to IVFs received in the ICU.,0
She was diuresed with IV lasix boluses.,0
Her oxygen requirement returned to her baseline of 3 liters.,0
Ultimately her lasix regimen was increased to 40 mg QAM and 20 mg QPM.,0
Her dry weight prior to discharge was 97.5 kg.,0
"If her weight continued to decrease or her Cr increases, decreasing her lasix regimen back to her home dose should be considered.",0
Initial culture from ED grew Proteus.,0
She was initially started on cipro but developed a desquamating rash.,0
Switched to ceftriaxone to complete full 10 day course for complicated UTI.,0
Decreased glargine to 8 units QAM and continued humulog insulin sliding scale.,0
"# Pulmonary hypertension: severe, requiring home O2.",1
Continued home metoprolol # Hyperlipidemia.,0
Continue home simvastatin # Mild Aortic stenosis.,0
Continued citalopram # Presumed GERD.,0
"# Code: DNR confirmed with patient though has never signed paperwork, OK to intubate Medications on Admission: Citalopram 40 mg daily Lasix 40 mg daily Insulin glargine (lantus) 15 units SQ QAM Omeprazole 20 mg daily SImvastatin 20 mg at bedtime Tramadol 50 mg oxycodone 5-10 mg q4h PRN Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).",0
"2. omeprazole 20 mg Tablet, Delayed Release (E.C.)",0
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
4. insulin glargine 100 unit/mL Solution Sig: One (1) 15 units Subcutaneous QAM.,0
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Tablet(s) 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.,0
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain.,0
8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for constipation.,0
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation.,0
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical (2 times a day) as needed for Yeast.,0
11. petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for Rash.,0
12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
Humulog Insulin Please use according to sliding scale attached 14.,0
Lantus 100 unit/mL Solution Sig: Eight (8) Units Subcutaneous QAM.,0
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)).,0
16. furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)).,0
17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.,0
Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: Primary Diagnosis: Heart Failure with preserved ejection fraction Urinary Tract Infection Drug Rash secondary to Cipro Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Dear Ms. , You were admitted after you developed difficulty for problems with speech and abdominal pain.",0
We completed a CT scan and an MRI during your hospital visit to rule out a stroke due to changes in your speech.,0
These studies revealed an old stroke.,0
"During your hospitalization, we found that you had a urinary tract infection and we started you first on ciprofloxacin shortly after you developed a rash and changed antibiotics to ceftriaxone which you tolerated fine.",1
You also had increasing oxygen requirements that was due to fluid in your lungs.,0
The fluid build up was from a congestive heart failure exacerbation.,1
We increased your lasix medicine and you got rid of the extra fluid.,0
You felt better after this.,0
We are discharging you to rehabilitation prior to returning home.,0
You should continue your medications prior to this hospital admission with the following important changes: 1.,0
INCREASE Lasix to 40 mg in the morning and 20 mg in the evening 2.,0
DECREASE Lantus to 8 mg in the morning 3.,0
START Aspirin 325 given your history of a stroke Followup Instructions: Please follow-up with Dr. as an outpatient in 6 weeks following discharge from rehabilitation.,0
His office phone number is (.,0
"2:12 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: Please evaluate pericardium., Please evaluate for mass or ot Field of view: 45 Contrast: OPTIRAY Amt: 150CC ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: Additional information has been obtained from CareWeb Clinical Lookup since the approval of the original report.",0
Reason for exam should also state chronic abdominal pain.,0
"2:12 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: Please evaluate pericardium., Please evaluate for mass or ot Field of view: 45 Contrast: OPTIRAY Amt: 150CC ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with DM, CAD, CRI, recent pericarditis/tamponade during this admission of unclear etiology.",0
REASON FOR THIS EXAMINATION: Please evaluate pericardium.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Patient with recent pericarditis, tamponade of unclear etiology.",0
"TECHNIQUE: A CT of the chest, abdomen and pelvis was performed following administration of IV and oral contrast.",0
CT CHEST WITH CONTRAST: A small amount of pericardial fluid is seen anteriorly and posteriorly with no evidence of loculation.,0
"The pericardium enhances, but is not particularly thickened measuring approximately 2 mm.",0
These findings are in keeping with the history of pericarditis.,1
"There is no axillary, mediastinal or hilar adenopathy.",0
Small bilateral pleural effusions are seen with adjacent compressive atelectasis.,0
There are no intravascular filling defects with pulmonary arterial branches to suggest PE.,0
"A non- specific density is visualized within the main pulmonary artery, of unclear etiology.",0
CT ABDOMEN WITH CONTRAST: The patient is S/P cholecystectomy.,0
"The common duct is dilated to 12 mm, possibly due to ampullary stenosis; however, a retained stone cannot definitively be excluded.",0
Pneumobilia is likely related to a previous sphincterotomy.,0
"The liver, spleen, adrenals and pancreas are normal in appearance.",0
The kidneys enhance promptly and symmetrically with sub-cm bilateral low attenuation lesions which are too small to characterize.,0
Small retroperitoneal lymph nodes are seen.,0
CT PELVIS WITH CONTRAST: A Foley catheter is in place.,0
Evaluation of the pelvis is limited secondary to streak artifact from a right hip prosthesis.,0
A left common iliac artery stent is in place.,0
The patient has had previous bypass surgery in the left groin region with post-operative changes.,0
Evaluation of the osseous structures demonstrates degenerative changes.,0
"IMPRESSION: Enhancing, non-thickened pericardium with small, non-loculated pockets of fluid in keeping with the patient's known history of pericarditis.",1
"(Over) 2:12 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: Please evaluate pericardium., Please evaluate for mass or ot Field of view: 45 Contrast: OPTIRAY Amt: 150CC ______________________________________________________________________________ FINAL REPORT (Cont)",0
", S. MED 10:42 AM PORTABLE ABDOMEN Clip # Reason: eval for perforation, toxic megacolon, obstruction Admitting Diagnosis: PLEURAL FLUID ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with septic shock, h/o C Diff, GPCs in blood, recent abdominal infections REASON FOR THIS EXAMINATION: eval for perforation, toxic megacolon, obstruction ______________________________________________________________________________ PFI REPORT Dilated small bowel loops filled with gas but not definitive evidence of obstruction.",1
"9:18 AM CHEST (PORTABLE AP) Clip # Reason: please check placement of left basilic PICC previous PICC a Admitting Diagnosis: ULCERATIVE COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with ulcerative colitis REASON FOR THIS EXAMINATION: please check placement of left basilic PICC previous PICC accidentaly pulled out during night please page IV nurse # thanks pt to resume TPN once placement confirmed ______________________________________________________________________________ FINAL REPORT INDICATION: History of UC, check PICC line.",0
AP UPRIGHT CHEST: Comparison to AP upright chest of .,0
"Left-sided PICC line identified, with its tip in the distal SVC.",0
Heart size within normal limits.,0
Lungs are clear without evidence of infiltrate or effusion.,0
Mediastinal and hilar contours are unremarkable.,0
IMPRESSION: Left-sided PICC line with tip in SVC.,0
"5:48 AM BABYGRAM AP ABD ONLY PORT Clip # Reason: evaluate bowel gas pattern, r/o NEC, Please do xray at 6:00 Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with bloody stool REASON FOR THIS EXAMINATION: evaluate bowel gas pattern, r/o NEC Please do xray at 6:00 AM ______________________________________________________________________________ FINAL REPORT EXAMINATION: Portable abdomen, 6:15 AM, .",1
HISTORY: Infant with bloody stools.,0
"FINDINGS: Since the study obtained 12 hours earlier, a nasogastric tube has been placed.",0
"There has been some interval redistribution and evacuation of bowel gas, however the region of the sigmoid and rectum shows more bowel distention.",0
"Although the findings are nonspecific, in the setting of bloody stools, consideration must be given to necrotizing enterocolitis and a follow- up film is necessary to ensure continued normal redistribution of the bowel gas.",0
The lung bases are clear.,0
No pneumatosis and no portal venous gas is evident.,0
IMPRESSION: Some interval gaseous distention of the bowel with nonspecific features.,0
Nonetheless given the history follow-up is necessary.,0
This was discussed with the clinical team.,0
"2:59 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate/effusion Admitting Diagnosis: RIGHT SIDED FACAIL WEAKNESS, DYSPHAGIA, DIPLOPIA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man intubated REASON FOR THIS EXAMINATION: eval for infiltrate/effusion ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male intubated.",0
Single AP chest radiograph compared to shows increased opacity in the right lung base which may be due to aspiration or pneumonia.,0
Left retrocardiac opacity is slightly increased.,0
There is probable small left pleural effusion.,0
The right lateral CP angle has been excluded.,0
ET tube terminates 2.1 cm above the carina and the balloon is overexpanded beyond the confines of the trachea.,0
NG tube tip not well evaluated.,0
IMPRESSION: Increased right basilar opacity which may be due to aspiration or pneumonia.,0
2:14 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
effusion Admitting Diagnosis: AORTIC DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with s/p asc aorta replacement REASON FOR THIS EXAMINATION: ?,1
effusion ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .,0
INDICATION: Status post aortic surgery.,0
Interval extubation and removal of nasogastric tube.,0
Slight decrease in degree of post-operative mediastinal widening.,0
"Left perihilar and right retrocardiac atelectasis unchanged, but some degree of improvement in the left lower lobe atelectasis.",0
Small bilateral pleural effusions but no evidence of pneumothorax.,0
"3:53 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with pneumonia, intubated, ?fluid overload REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia, intubated, question fluid overload interval change.",1
"CHEST, SINGLE AP VIEW Despite provided history, no ET tube is identified.",0
There is considerable respiratory motion blurring detail.,0
"Allowing for this, the right lung appearance is grossly unchanged compared with 5/1 and .",0
"However, even allowing for differences in technique, the degree of opacity along the lateral aspect of the left chest appears more pronounced and confluent, particularly at the left lung base.",0
The appearance is more suggestive of parenchymal consolidation than of layering fluid and the opacity does not extendto directly abut the chest wall.,0
"Although much of the abnormal appearance could relate to the patient's background COPD, the possibility of an acute superimposed pneumonic infiltrate must be considered.",1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: ICH Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Mr is a 51-year-old man with previous stroke on Coumadin who was transfer from OSH after LOC and found to have extensive intracranial bleeding.,0
His wife reported that he suddenly became confused while sitting at the table.,0
"He became unresponsive, turned his head to the right side, and had whole body stiffness.",0
This event happened around noontime.,0
The wife called the who arrived to find the patient unresponsive with decorticate posturing of the left arm.,0
Patient had vomiting which complicated to intubate and the EMS team brought him to the emergency department where a rapid sequence intubation was done with etomidate and succinylcholine.,0
A CT scan showed a large intracranial hemorrhage with blood in the ventricle and shift and herniation.,0
Patient was loaded with 1 g of fosphenytoin as well as 80 g of mannitol as well as fentanyl and propofol.,0
The patient also received 10 mg of vitamin K and then transferred here from .,0
"En route in the helicopter, the patient received propofol.",0
ROS: Patient was in his usual state of health and no other symptoms were mentioned by the family members.,0
was not compliant with his home medications.,0
"Past Medical History: PMH: Details were not given, but patient had a large left MCA stroke resulting in right sided hemiparesis and aphasia.",0
"Social History: Social Hx: Married, with good family support.",0
"-EtOh: unknown -tobacco: 1 or 2 cig/day -drugs: no Family History: unknown Physical Exam: Limitted patient in propofol, intubated Vitals: Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl.",0
Neuro exam: small reactive pupils.,0
4 (again limitted due to the medication).,0
Decerebration reaction to pain stim.,0
Pertinent Results: 03:30PM PT-12.2 PTT-22.2 INR(PT)-1.0 03:30PM WBC-18.9* RBC-5.32 HGB-15.3 HCT-46.0 MCV-86 MCH-28.8 MCHC-33.3 RDW-13.2 03:30PM WBC-18.9* RBC-5.32 HGB-15.3 HCT-46.0 MCV-86 MCH-28.8 MCHC-33.3 RDW-13.2 03:30PM LIPASE-22 03:30PM UREA N-14 CREAT-0.9 03:40PM HGB-16.7 calcHCT-50 03:40PM GLUCOSE-154* LACTATE-3.0* NA+-138 K+-4.9 CL--98* TCO2-25 04:45PM TYPE-ART RATES-/14 TIDAL VOL-500 PEEP-5 O2-100 PO2-229* PCO2-48* PH-7.38 TOTAL CO2-29 BASE XS-2 AADO2-439 REQ O2-75 -ASSIST/CON INTUBATED-INTUBATED CT head IMPRESSIONS: 1.,0
"Large right intraparenchymal hemorrhage centered in the right basal ganglia, unchanged in size from the prior study, with new intraventricular extension.",0
Stable 2 cm of subfalcine leftward herniation and mild uncal herniation.,0
Configuration favors hypertension as likely etiology.,0
Extensive edema and sulcal effacement of the entire right hemisphere.,0
"Marked encephalomalacia of the entire left cerebral hemisphere CT head IMPRESSION: Overall increase in size of the large right parenchymal hemorrhage, now 7 x 5.9 cm, with increased leftward shift of midline structures, now 2.8 cm, and worsening uncal herniation with new compression and leftward deviation of the midbrain.",1
"Increased size of the occipital and atrium of the left lateral ventricle concerning for ""trapping"" of this ventricle.",0
New left hemispheric subarachnoid and unchanged intraventricular hemorrhage.,0
"Brief Hospital Course: Mr. is a 51 year old man with history of AF, HTN, hyperlipidemia, and s/p an old left MCA infarct with residual aphasia and mild right sided weakness.",0
"He was found confused, then suddenly collapsed per his wife earlier today.",0
"He was taken to , where head CT showed an ICH.",0
"He was intubated, loaded with phosphenytoin & treated with vitamin K for presumed coagulopathy; then transferred to for surgical management of his ICH.",0
"Upon transfer from the outside hospital, the patient was initially evaluated by the neurosurgery service in regards to a possible right temporoparietal craniotomy.",0
"In lengthy discussion with the neurosurgery service and neurology service, the family decided against surgical intervention as they did not want the patient to suffer.",0
The neurology service was asked to see him urgently by Neurosurgery to assist with ICH management and to render our opinion regarding the futility of surgical intervention.,0
"At time of examination, the patient had no spontaneous movement and did not respond to voice.",0
He had a mild gag reflex.,0
Pupils were small ~ 1 to 1.5 mm but reactive.,0
Doll's eye was not elicited.,0
He moved the right side to pain & nasal stimulation.,0
He postures on the left in response to pain.,0
"Overall, his GCS was 4.",0
"Head CT showed a large right parenchymal ICH with IVH and extension into the brainstem, midline shift of ~ 22mm, and ventricular dilatation in addition to an old left temporo-parietal infarct.",0
"Overall, the cause of his ICH was difficult to ascertain.",0
"It is likely hypertensive, but one cannot entirely rule out a secondary cause.",0
"Regardless, his prognosis appeared grim.",0
"His ICH score was 4, indicating a 30-day mortality of ~ 97%.",0
"Multiple members of the neurology and neurosurgery service had lengthy discussions with multiple family members regarding his condition, expected prognosis, and treatment options.",0
"His chances for any meaningful recovery, if he survives, are minimal.",0
"While surgery could be life-saving, it is unlikely to improve his functional outcome.",0
"They decided on a DNR status, but wanted to discuss the surgical option with Dr. further.",0
"They were initially inclined to proceed with surgery, but later reversed their decision.",0
The patient was admitted to the NSICU for medical management.,0
A repeat CT head several hours after arrival revealed worsening hemorrhage with midline shift and uncal herniation.,0
"Social work consult was requested to help the family cope with the difficult situation and after further discussions, the patient was ultimately made CMO.",0
He was pronoucned dead at at 6:20 AM.,0
"Medications on Admission: coumadin, lisinopril & simvastatin.",0
Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: intraparenchymal hemorrhage Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired,0
4:04 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: perform at 4 p.m. .,0
"Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man with lung cancer, PTX on CT, tube now on waterseal.",0
REASON FOR THIS EXAMINATION: perform at 4 p.m. .,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: Previous study of earlier the same date.,0
INDICATION: Chest tube placed on water seal.,0
Right-sided pigtail pleural catheter remains in place.,0
Small right apical pneumothorax is identified at level of the right third posterior rib and in retrospect is unchanged from the recent study.,0
"Slight worsening of lung opacification is noted in the right mid and lower lung region, and could potentially represent an evolving infection in the appropriate clinical setting.",0
Othe abnormalities including massive right hilar and mediastinal lymphadenopathy related to known lung cancer with associated post- obstructive changes in the right lower lobe appear unchanged since the recent study.,0
Small left pleural effusion appears slightly less apparent.,1
"10:51 AM CHEST (PORTABLE AP) Clip # Reason: eval for itnerval changes Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 82 year old woman with lethary and desats, s/p chest tubes to water seal REASON FOR THIS EXAMINATION: eval for itnerval changes ______________________________________________________________________________ FINAL REPORT COMPARISON: .",0
INDICATION: Chest tube placed to water seal.,0
An endotracheal tube has been withdrawn slightly in the interval and now terminates about 7 cm above the carina.,0
"A right internal jugular vascular catheter, left PICC line, and bilateral chest tubes remain in place.",0
A PICC line has been slightly repositioned in the interval with the tip now abutting the expected lateral wall of the superior vena cava.,0
"There has been interval marked increase in size of a right pleural effusion, now moderate in size and tracking to the right apex.",0
There is also development of collapse of the right upper lobe as well as some degree of atelectasis in the right middle lobe.,0
There are worsening perihilar haziness as well as increasing more confluent areas of opacity in the retrocardiac regions.,0
There is also a component of interstitial opacification in the lung periphery.,0
"IMPRESSION: 1) Enlarging right pleural effusion, now moderate in size with adjacent collapse of the right upper lobe.",0
"2) Worsening perihilar and basilar opacities, most likely due to pulmonary edema.",0
Underlying infection is not excluded.,0
3) Proximal location of endotracheal tube.,0
Tip of PICC line abuts expected lateral wall of superior vena cava.,0
"11:29 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: interval assessment of microperf, evaluate for fluid collect Admitting Diagnosis: PERFORATED CHRON'S COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with crohn's, presented to OSH with diarrhea and chills, found to have microperforation of bowel, clinically remains stable however patient's immunosuppression and pain regimen make physical exam less dependable.",1
"REASON FOR THIS EXAMINATION: interval assessment of microperf, evaluate for fluid collection requiring drainage or surgical intervention.",0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKgc 2:19 PM 1.,0
"In this patient with history of Crohn's disease, and recent microperforation, there is no sognificant interval change in the amount of free intraperitoneal air.",1
No intra-abdominal abscesses or fluid collections are seen.,0
"Interval improvement in the bibasilar tree-in- opacities, likely related to infection or aspiration.",0
"Cholelithiasis, without evidence of acute cholecystitis.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old man with Crohn's disease, with microperforation of bowel, the patient clinically remains stable; however, patient's immunosuppression and pain regimen make physical exam less dependable.",1
To assess for intra-abdominal abscess.,0
COMPARISON: CT of the abdomen and pelvis .,0
TECHNIQUE: MDCT helical images were acquired through the abdomen and pelvis without oral or intravenous contrast.,1
Intravenous contrast was not administered as the patient's creatinine was elevated at 1.6.,1
"FINDINGS: CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Trace bilateral pleural effusions, are new since the prior study.",1
The previously seen centrilobular nodules in the lung bases have partially resolved.,0
The imaged portion of the heart and pericardium are unremarkable.,0
"Within the limitations of a non-contrast study, the liver, gallbladder, adrenal glands, and pancreas are normal.",0
"Both kidneys demonstrate mild cortical atrophy, without evidence of nephrolithiasis or hydronephrosis.",0
"There is a large amount of layering hyperdense gallstones, similar to the prior study.",0
"The stomach and small bowel loops are not well evaluated due to (Over) 11:29 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: interval assessment of microperf, evaluate for fluid collect Admitting Diagnosis: PERFORATED CHRON'S COLITIS ______________________________________________________________________________ FINAL REPORT (Cont) the lack of distention and oral contrast in the current study.",0
Previously described areas of small bowel strictures or luminal stenosis are not appreciated in the current study.,0
"The patient is status post ileocecectomy, and multiple small bowel resections.",1
The neoterminal ileum is decompressed.,0
The remainder of the colon is unremarkable.,0
"Again seen are small foci of free intraperitoneal air adjacent to the ileocolonic anastomosis (2A:33), and along the anterior abdominal wall, similar to the prior study.",0
No new intra-abdominal fluid collections or abscess is detected.,0
No significant retroperitoneal lymphadenopathy is detected.,0
"Multiple prominent mesenteric lymph nodes, particularly in the right lower quadrant, are similar to the prior study.",0
"Minimal aortic calcifications are seen, without aneurysmal dilation.",0
"CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The urinary bladder, prostate, are unremarkable.",0
"The rectum is distended with fluid, secondary to the presence of a rectal tube.",0
The sigmoid colon is unremarkable.,0
No pelvic lymphadenopathy or free fluid is detected.,0
"Again seen are chronic changes of avascular necrosis in both femoral heads, with collapse of the femoral heads with multiple subchondral cysts.",1
A bone island is seen in the left acetabulum.,0
Small foci of subcutaneous air along the anterior abdominal wall relate to recent injections.,0
"In this patient with history of Crohn's disease, and recent microperforation, there is no significant interval change in the amount of free intraperitoneal air.",1
AVN of bilateral femoral head.,0
"(Over) 11:29 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: interval assessment of microperf, evaluate for fluid collect Admitting Diagnosis: PERFORATED CHRON'S COLITIS ______________________________________________________________________________ FINAL REPORT (Cont)",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentals, Beans Attending: Chief Complaint: Weakness, dyspnea Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 60 yo F w/ h/o renal and pancreatic transplants, DM type 1, diastolic CHF, and CAD who presents with weakness and dyspnea.",1
"Of note, patient was discharged from yesterday after 3 day admission for SOB, chest pain, which was attributed to CHF exacerbation.",0
She was diuresed three liters and discharged home on fluid restriction and dietary modification as well as home dose of lasix.,0
"At home, patient reported feeling weak and tired- sleeping a lot.",1
Was febrile to over 101 and started shaking at home.,0
Also noticed dysuria and malodorous urine.,0
Developed some SOB w/ fevers.,0
Called friend who on seeing her suggested visit.,0
"In the ED, initial vs were: T102.4 P84 BP136/66 R14 O2 sat 95% RA.",0
"Patient was given 1 g tylenol, 1 g meropenam, and 300 cc fluid bolus as she appeared clinically dry; IVF were stopped at that point as she complained of worsened dyspnea.",0
"She maintained sats in the high 90s on room air, but given tachypnea was admitted to the ICU for monitoring.",0
VS on transfer were HR110 120/70 RR25 O2 sat 97 3L.,0
"In the ICU, patient reported mild nausea, fever, and mild dyspnea.",0
"Denied CP, cough, vomiting, hematemesis, abdominal pain, flank pain, diarrhea, melena, or BRBPR.",0
"No headaches, myalgias or arthralgias.",0
"Denies chest pain, chest pressure, palpitations.",0
"Denies vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits.",0
Denies urinary frequency or urgency.,0
"Denies alcohol, tobacco, or illicit drug use.",0
"Family History: Father with MI at 57 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.",0
"Physical Exam: Physical Exam on Admission: Vitals: T: BP: P: RR: SpO2: General: Alert, oriented, fatigued but interactive, shivering HEENT: exopthalmos, sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles, R>L, no wheezes, ronchi CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; well healed midline incision Back: no flank tenderness GU: no foley : warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema .",0
"Chest: IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions, similar compared to the prior study.",0
Bibasilar air space opacities likely reflect atelectasis.,0
8/ RENAL ULTRASOUND: The transplanted kidney measures 11.3 cm.,1
No evidence of hydronephrosis or perinephric fluid collection.,0
The main renal artery and vein are patent with normal waveforms.,0
"Resistive indices in the upper, mid and lower poles of the transplant kidney are 0.75, 0.74 and 0.72 respectively, previously ranging from 0.78 to 0.81.",1
The bladder is collapsed about the Foley and could not be well evaluated in this study.,0
No perinephric fluid or hydronephrosis.,0
"Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78.",1
9:00 pm URINE Site: CLEAN CATCH **FINAL REPORT ** URINE CULTURE (Final ): ESCHERICHIA COLI.,0
TETRACYCLINE SENSITIVITY REQUESTED BY DR. .,0
TETRACYCLINE sensitivity testing performed by .,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- 8 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S .,0
9:00 pm BLOOD CULTURE #2.,0
"**FINAL REPORT ** Blood Culture, Routine (Final ): ESCHERICHIA COLI.",0
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 328-1435P .,0
Anaerobic Bottle Gram Stain (Final ): GRAM NEGATIVE ROD(S).,0
"Brief Hospital Course: Primary Reason for Hospitalization: 60F with PMH pancreatic and renal transplants, DM type II, diastolic CHF, HTN, and hypothyroidism, recently admitted for CHF exacerbation who presents with weakness, fevers, and hypotension suggestive of urosepsis.",1
"Active Diagnoses: # Urosepsis: Patient presented with weakness, fevers, hypotension in setting of dirty UA.",1
"She has history of urosepsis as recently as , when was treated for cephalosporin sensitive E. coli with meropenem for 14 days.",0
"Given immunosuppression and altered anatomy, patient at higher risk for these infections.",1
She was treated again with meropenam (renally-dosed) and vancomycin for empiric coverage.,0
Urine and blood cultures were sent.,0
"For the first few days of hospitalization, she was bolused with IVF for hypotension and her anti-hypertensives were held.",0
"Her blood cx grew out E. coli, and she was continued on meropenem for total 14 days (complicated UTI).",0
The plan is to switch to ertepenem when discharged home (once daily IV).,0
"An urology consult was obtained for recurrent urosepsis, and outpatient follow-up was deemed ok.",1
"Since pancreas is draining through bladder, she may have a stone in the bladder not visualized on renal u/s.",0
Cystoscopy might show something that can be removed.,0
"On floor, pt was stable, her mental status was at baseline and did not have any fevers.",0
She was continued on iv antibiotics and renal function improved to baseline.,0
She was discharged on an additional 6 days of ertepenam and will start fosfomycin for ppx.,0
"# SOB/Tachypnea: On admission, the patient experienced a subjective feeling of dyspnea not associated with hypoxia.",0
"She was satting in high 90s on 1-2L oxygen, which appears to baseline for her, as she uses oxygen at home.",0
"Differential diagnosis included ischemic cardiac etiologies, pneumonia (no cough), CHF (CXR similar to prior admission CXR), and anxiety.",0
"She was noted to have crackles on lung exam and to have slight pulmonary edema, but likely not much worse than baseline.",0
Her cardiac enzymes were checked and returned elevated (see below).,0
"She was continued on supplemental oxygen, and diuresis was initially held given her hypotension and possible sepsis.",1
"As her blood pressure improved, she was diuresed.",0
On the floor pt was euvolemic and O2 saturations were normal on room air.,0
"At time of discharge, she was taking all home antihypertensives and diuretics.",0
"#NSTEMI: On admission, her troponin returned positive at 0.36 (she was discharged the day prior with troponin <0.01), CK 15, MB 10.6.",0
"She was noted on her last admission to have a LBBB, she is defined as having a NSTEMI (EKG changes masked), most likely secondary to demand instead of ACS.",0
"She was started on a heparin gtt, ASA, statin.",0
"Her troponin was trended q8h and stabilized to 1.11 by HD3, so her heparin drip was turned off.",0
On the floor she was stable without chest pain and her tele did not have any events.,0
"She was discharged on lisinopril, asa and carvedilol.",0
She will follow up with Cardiologist within next month.,0
"#Diastolic CHF: Patient has dilated LV with preserved EF, as well as crackles on lung exam and CXR showing b/l pleural effusions and pulmonary edema similar to prior admission.",1
"Her lasix, lisinopril and carvedilol were initially held for hypotension, but when her blood pressure improved by HD3, a lasix drip was started.",0
"On HD4, the lasix gtt was discontinued, and she was started on Lasix 60mg IV BID with a goal UOP of 1L/day.",0
"ETT was obtained, showing a likely distal LAD lesion, not cardiomyopathy, distal septal akinesis, 3+ MR which may have been associated with volume.",0
"Her carvedilol dose was slowly increased back to her home dose as tolerated, and her doxasozin continued to be held.",0
On the floor her pressures and kindney function improved and she was restarted on all home medications.,0
"She had an episode of orthostasis, but pressures continued to improve.",0
"# : Patient presented with acute kidney injury, stable from discharge the day prior at 2.0.",1
Baseline creatinine appears to be around 1.6.,0
Her lisinopril was initially held.,0
A renal ultrasound showed no perinephric fluid or hydronephrosis.,0
"AT the time of ICU call out, Cr stable at 1.9.",0
At time of discharge her cr was 1.6.,0
She will follow up with Dr .,0
"# HTN: On admission, was hypotensive from urosepsis, so carvedilol, doxazosin and lisinopril were held.",0
"As her bp improved, she was restarted on carvedilol, first at a lower than home dose and titrate up slowly to home dose of 12.5mg .",0
"At the time of ICU call out, lisinopril was still held.",0
On the floor her pressures improved and she was discharged on all home medications.,0
"# S/p Renal and pancreas transplant: Was seen by renal transplant and her sirolimus, tacrolimus, and prednisone were adjusted.",0
"Her sacrolimus was discontinued, tacrolimus dose decreased to 1.5 , and started on hydrocortisone 100mg q8h.",0
The hydrocortisone was tapered and she was eventually restarted on prednisone at 5mg daily.,0
"On HD3, she was restarted on rapamune 2mg daily and her tacrolimus 1.5 mg was retimed to 0600 and 1800 dosing.",0
Her tacro and levels were checked daily at 0530 (do NOT order with AM labs).,0
The goal levels for both rapamune and tacrolimus are and need to be checked daily.,0
She was also given pancreatic enzyme replacement per home regimen.,0
She was discharged on home tacro and doses.,0
"#History of C. Diff: Per ID, she was started on empiric PO vancomycin 125 Q6H for 1 week following end of meropenem therapy.",0
At time of discharge surveillance cdiff was negative and diarrhea had improved.,0
She will continue PO vanco until Chronic Diagnoses: # Hypothyroidism: TSH was in normal range during last hospitalization (0.7 on ).,1
She was continued on levothyroxine at alternate qOD dosing of 112mcg and 100 mcg.,0
# Glaucoma: She was continued on eye drops and methazolamide per home regimen.,0
"Transitional Issues: - pt will need weekly labs on Tuesdays: CBC, chem 10, tacro level, level - will need aranesp after d/c - needs podiatry for ingrowns - needs PT, prosthesis refit, OT, cards rehab Code Status: Full code Medications on Admission: acyclovir 400 mg PO Q12H doxazosin 2 mg PO QAM doxepin 10 mg PO HS levothyroxine 112 mcg qOD levothyroxine 100 mcg qOD lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, PO TID w/ meals methazolamide 50 mg PO BID prednisone 5 mg PO DAILY simvastatin 20 mg PO DAILY folic acid 1 mg PO DAILY omega-3 fatty acids 1 Capsule PO BID ipratropium bromide 0.02 % Solution 1 INH Q6H PRN Forteo 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig: One (1) ML Subcutaneous daily.",0
brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS aspirin 81 mg PO DAILY Calcium-Vitamin D Cyclosporine 0.05% dropperette albuterol sulfate 2.5 mg /3 mL (0.083 %) NEB One INH q6hr PRN Lasix 20 mg PO once a day sirolimus 2 mg PO DAILY carvedilol 12.5 mg PO BID tacrolimus 2 mg PO Q12H Home oxygen 1-2L as needed Discharge Medications: 1. fosfomycin tromethamine 3 gram Packet Sig: One (1) packet PO once a week: dissolve in ounces of water.,0
Can be taken with or without food.,0
Initiate after completion of Ertapenem course.,0
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours).,0
3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
4. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day).,0
"7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
8. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
10. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
15. ipratropium bromide 0.02 % Solution Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing.,0
16. teriparatide 20 mcg/dose (750 mcg/3 mL) Pen Injector Sig: One (1) ML Subcutaneous daily ().,0
17. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): administered at 6am.,0
18. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
19. tacrolimus 0.5 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours).,0
20. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100.,0
21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation.,0
"22. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain.",0
23. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).,0
24. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime).,0
25. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).,0
26. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic daily ().,0
27. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours).,0
28. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime).,0
"29. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.)",0
30. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic (2 times a day).,0
31. oxygen 1-2L PRN SOB or sats <91% 32.,0
"Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day.",0
Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) mL Injection once a month: please give monthly dose day pt arrives at rehab.,0
34. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 12 days: please continue until .,0
"Outpatient Lab Work Weekly labs (Tuesdays): Sirolimus (rapamycin) level, tacrolimus level, CBC, Chem 7 .",0
Fax to please fax to Dr. at transplant center: 36. pentamidine 300 mg Recon Soln Sig: One (1) INH Injection once a month.,0
Ertapenem 1g IV daily until .,0
Fax to please fax to Dr. at transplant center: Discharge Disposition: Extended Care Facility: Hospital for Continuing medical Care Discharge Diagnosis: Urosepsis NSTEMI CHF Discharge Condition: Mental Status: Clear and coherent.,1
"Discharge Instructions: Dear Dr. , It was a pleasure taking care of you.",0
You were admitted to the hospital for a complicated urinary tract infection that extended into your bloodstream (urosepsis).,1
You had a change in mental status secondary to the infection and needed to be transferred to the ICU.,0
You also had a heart attack.,0
You were treated with heparin for the heart attack.,0
No other new interventions for the heart attack are necessary at this time.,0
"Please continue all of your home medications with the following changes: Start Ertapenem for an additional 6 days (last day ) Start After you finish ertapenem, start Fosfamycin 3gm in 4 Oz of water weekly for UTI prophylaxis.",0
START: vancomycin oral liquid 125mg by mouth every six hours until .,0
START: Atorvastatin 80 mg by mouth daily and STOP simvastatin 20 mg by mouth daily CHANGE: Lasix 20mg tab one tablet by mouth daily to lasix 20mg tab one tablet by mouth twice daily .,0
"Followup Instructions: Department: PODIATRY When: FRIDAY at 1:50 PM With: , DPM Building: Ba ( Complex) Campus: WEST Best Parking: Garage Department: RADIOLOGY When: FRIDAY at 12:45 PM With: RADIOLOGY Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: CARDIAC SERVICES When: FRIDAY at 1 PM With: , NP Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: INFECTIOUS DISEASE When: TUESDAY at 9:30 AM With: , MD Building: LM Campus: WEST Best Parking: Garage **You will also be seeing Dr. your Transplant Nephrologist at this visit as well.",0
"Department: UROLOGY When: MONDAY at 10:30 AM With: , MD Building: Campus: EAST Best Parking: Garage MD",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: gross hematuria Major Surgical or Invasive Procedure: s/p radical cystoprostastectomy, obturator and iliac LND, ileal loop History of Present Illness: The patient is a 75-year-old male who presented initially with gross hematuria, was found to have bladder cancer which was found to be T1 high grade with CIS.",0
He was restaged which showed invasion to the lamina propria but also extensive glandular involvement of the prostate with no stromal invasion.,0
"Due to his history, he presented for surgical management.",0
He has been followed by pulmonary for pulmonary fibrosis which previously had shown BOOP in the past on biopsy.,1
Past Medical History: HTN BPH DM Social History: Has a 40 pack year h/o tobacco and quit at the age of 37.,0
He works as a caretaker for women and currently lives with his family.,0
He denies IVDU and drinks socially.,0
"Family History: Noncontributory Physical Exam: NAD EOM full, PERRLA Chest coarse throughout with bibasilar crackles RRR, no MRG Abdomen soft, appropriately tender, incision clean and dry LE warm, well-perfused Pertinent Results: CHEST PORT.",0
LINE PLACEMENT 5:23 PM CHEST PORT.,0
"LINE PLACEMENT Reason: r/o pulmonary edema MEDICAL CONDITION: 75 year old man with h/o BOOP, s/p radical cystoprostatectomy REASON FOR THIS EXAMINATION: r/o pulmonary edema AP CHEST HISTORY: BOOP.",1
"IMPRESSION: AP chest compared to and : Chronic interstitial pulmonary disease accounts for the bulk of pulmonary abnormalities, but there is slight increase in opacification in the left lower lobe, which could represent pneumonia or aspiration and an increase in the background density of the lungs, which may be a function of differing radiologic technique or mild pulmonary edema.",1
"Nevertheless, there is no mediastinal vascular engorgement, appreciable increase in heart size or indication of substantial pleural effusion to suggest congestive heart failure.",0
************ CHEST (PA & LAT) 4:34 PM CHEST (PA & LAT) Reason: pulmonary edema?,0
"***pt will be on in the afterno MEDICAL CONDITION: 75M IPF, s/p radical cystoprostatectomy, ileal loop, POD1 REASON FOR THIS EXAMINATION: pulmonary edema?",1
***pt will be on in the afternoon*** HISTORY: Postoperative with shortness of breath suggesting pulmonary edema.,0
"FINDINGS: In comparison with the study of , the patient has taken a much poorer inspiration.",0
There is again diffuse prominence of interstitial markings consistent with chronic pulmonary disease.,0
Some increasing opacification at the left base may reflect some atelectasis or pneumonia or be a manifestation of bronchiectatic changes from previous inflammatory disease.,0
The right IJ catheter again lies in the upper superior vena cava.,0
"The nasogastric tube extends at least to the upper stomach, though it is difficult to follow beyond this point.",0
Brief Hospital Course: GU: Pt admitted postoperatively after prostacystectomy with ileal loop and ileostomy creation.,0
"The night of admission, the pt's pain was well controlled with an epidural, and he was monitored in the PACU without any complications.",0
"On POD1, the pt was transferred to the floor, where he remained hemodynamically stable with good urine output from the ileostomy, which appeared well vascularized and pink in color.",0
"POD1, the pt was bolused on a few occasions for marginal urine output, but by POD2, the pt was making adequate urine without any additional fluids.",0
"Pulm: Preop diagnosis of pulmonary fibrosis, so pulmonology was intimately involved in the pt's postoperative plan.",1
"POD1, IV fluids were held to keep the pt dry and breathing comfortably.",0
CXRs demonstrated no evidence of CHF or worsening pulmonary processes.,0
"By POD1, the pt was weaned to room air while maintaining a saturation of 96%.",0
"Intraoperatively, the pt received stress dose steroids, which were weaned over the course of his 6 day hospitalization, on discharge, the pt was transitioned to prednisone 15 mg qd.",0
CV: The pt remained cardiovascularly stable throughout his hospitalization.,0
He received IV lopressor periop and was transitioned to his home dose of atenolol prior to discharge.,0
"No episodes of chest pain, palpitations or other cardiac events.",0
GI: Postop the pt was NPO with an NGT in place.,0
"Outputs remained low on POD1-2, after which time the tube was pulled.",0
"The pt remained NPO, and on POD3, after frequent flatus, the pt was advanced to sips, then clears and finally regular diet on POD4, which he tolerated well.",0
H: Postoperatively the pt received a dose of coumadin for PE prophylaxis.,0
His INR rose from 1.4 to 1.7 on POD2 then down to 1.4 again on POD5.,0
"After the INR dropped sufficiently, the epidural was pulled without complication, and the pt was discharged home on POD5.",0
Codeine-Guaifenesin 10-100 mg/5 mL Liquid Oral 4.,0
Glyburide 5 mg Tablet Sig: One (1) Tablet PO three times a day.,0
Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.,0
"Prednisone 5 mg Tablets, Dose Pack Sig: Three (3) Tablets, Dose Pack PO once a day for 2 months.",0
"Disp:*180 Tablets, Dose Pack(s)* Refills:*0* 8.",0
N-Acetyl-L-Cysteine Powder Sig: One (1) 600mg Miscellaneous three times a day.,0
"Disp:*1 Month* Refills:*2* Discharge Disposition: Home With Service Facility: Nursing Association Discharge Diagnosis: transitional cell bladder cancer Discharge Condition: good Discharge Instructions: -You may shower, but do not bathe, swim or otherwise immerse your incision.",0
-Do not lift anything heavier than a phone book.,0
-Do not drive or drink alcohol while taking narcotic pain medication.,0
"-If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room.",0
"Followup Instructions: Call your Urologist's office ( to schedule a follow-up appointment in 1 week, or if you have any questions.",0
You should arrange to see your primary care physician 2 weeks after discharge.,0
"8:32 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for obstruction, infection, pancreatitis PLEASE WAIT FO Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with h/o UC, pancreatitis, nephrolithiasis, DM with bilious vomiting and abdominal pain REASON FOR THIS EXAMINATION: eval for obstruction, infection, pancreatitis PLEASE WAIT FOR CREATININE THANK YOU No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKgc SUN 11:08 AM 1.",0
No acute intra-abdominal pathology detected.,0
Diffuse large bowel wall fatty infiltration relates to chronic IBD.,0
Stable L1 compression fracture and multiple healed rib fractures.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old man with history of UC, pancreatitis, nephrolithiasis and diabetes mellitus with bilious vomiting and abdominal pain.",1
"COMPARISON: CT abdomen and pelvis with contrast, .",0
TECHNIQUE: MDCT images were acquired through the abdomen and pelvis after administration of oral and 130 cc of Optiray intravenous contrast.,0
CT OF THE ABDOMEN WITH ORAL AND INTRAVENOUS CONTRAST: Visualized lung bases are unremarkable without suspicious pulmonary nodules or pleural effusions.,0
The visualized portion of the heart demonstrates calcification of the mitral annulus and moderate atherosclerotic coronary arterial calcification.,0
Incidental note of a small hiatal hernia is made.,0
Both adrenal glands are normal.,0
"Both kidneys show symmetric opacification and excretion of contrast without evidence of subcentimeter hypodense lesions within the lower pole of the right kidney, too small to characterize but statistically represent simple cysts.",0
Note that small calculus can be missed in this single-phase contrast-enhanced CT study.,0
Ureters appear mildly dilated bilaterally.,0
"The pancreas is atrophic, or there may be congenital absence of the tail, but no evidence of acute pancreatitis is present.",0
Prominent collateral vasculature is seen about the spleen.,0
The splenic vein is not clearly identified.,0
The stomach and small bowel loops appear unremarkable without evidence of bowel wall thickening or obstruction.,0
No significant retroperitoneal or mesenteric lymphadenopathy is detected.,0
"There is diffuse fatty infiltration (Over) 8:32 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for obstruction, infection, pancreatitis PLEASE WAIT FO Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) of the wall of the entire colon, more pronounced in the sigmoid colon and rectum, consistent with chronic inflammatory bowel disease.",0
"There is no evidence of fat stranding, inflammation.",0
"There is diffuse severe atherosclerotic calcification of the abdominal aorta and the iliac arteries, without aneurysmal dilation.",0
CT OF THE PELVIS WITH CONTRAST: The urinary bladder and the distal ureters appear unremarkable.,0
"Bladder is quite distended, to the umbilicus.",0
The prostate gland shows enlarged central gland.,0
The seminal vesicles are unremarkable.,0
There is no significant pelvic lymphadenopathy or free fluid.,0
The rectum and sigmoid colon have been described above.,0
Bilateral small fat-containing inguinal hernias are present.,0
"OSSEOUS STRUCTURES AND SOFT TISSUES: Multiple old healed rib fractures involving the right posterior eleventh, left posterior tenth and eleventh ribs are again noted.",0
No new fractures are identified.,0
Stable anterior wedge compression of L1 vertebral body is noted.,0
"Multilevel degenerative changes of the lumbosacral spine, with disc height reduction and anterior osteophyte formation are again noted without significant change since the recent prior study.",0
No acute intra-abdominal pathology identified to explain the patient's symptoms.,0
"Atrophic pancreas or congenital absence of the tail, without evidence of acute pancreatitis.",0
"Diffuse fatty infiltration of the colonic wall, secondary to chronic inflammatory bowel disease without evidence of active inflammation.",0
"Multiple rib fractures and old compression fracture of L1 vertebrae, stable.",0
Distended bladder to the umbilicus.,0
Slight ureteral dilation may be related.,0
Collateral vasculature from the spleen likely from absent of strictured splenic vein.,0
"Mild bilateral perinephric edema is present, of uncertain significance.",0
4:39 AM CHEST (PORTABLE AP) Clip # Reason: Please assess effusions.,0
"Thanks Admitting Diagnosis: CONGESTIVE HEART FAILURE,RENAL FAILURE,ACIDOSIS ______________________________________________________________________________ MEDICAL CONDITION: 53 yo female COPD, on home O2, on dialysis.",1
Now hypoxic REASON FOR THIS EXAMINATION: Please assess effusions.,0
Thanks ______________________________________________________________________________ FINAL REPORT AP CHEST 5:31 HISTORY: COPD.,0
On home oxygen and dialysis.,0
IMPRESSION: AP chest compared to through 28: Moderately severe pulmonary edema and small-to-moderate bilateral pleural effusions continued to increase.,0
Large cardiac silhouette may have also expanded.,0
Dual-channel left-sided central venous catheter and a right PIC line both end in the SVC.,0
8:39 PM SINUSES VIEWS Clip # Reason: Assess for source of infection/sinusitis.,1
Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with REASON FOR THIS EXAMINATION: Assess for source of infection/sinusitis.,1
______________________________________________________________________________ FINAL REPORT STUDY: Sinus series three views .,0
"HISTORY: 64-year-old woman with sinusitis, evaluate for source of infection.",1
FINDINGS: Comparison is made to the CT scan from .,0
No air-fluid levels are seen in the paranasal sinuses.,0
The endotracheal tube has been removed.,0
There is no focal fracture identified.,0
The patient has poor dentition.,0
10:11 AM UGI SGL CONTRAST W/ KUB Clip # Reason: Assess anatomy for leak at anastamosis site.,0
Please use Thi Admitting Diagnosis: ESOPHAGIAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p lap esophagectomy on REASON FOR THIS EXAMINATION: Assess anatomy for leak at anastamosis site.,0
Please use Thin Barium during exam.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Laparoscopic esophagectomy.,0
Assess for leak at cervical anastomosis.,0
The scout view demonstrates a surgical drain in the mediastinum.,0
There are overlying staples in the skin.,0
There is a right subclavian line.,0
There is an NG tube in place.,0
Barium passes freely through the area of the anastomosis.,0
There is no evidence of leak.,0
Contrast has not entered into the duodenum by the end of the study.,0
IMPRESSION: No evidence of leak at the cervical esophagectomy anastomosis.,0
"Surgical staples, drain, subclavian line and NG tube in appropriate position.",0
4:17 PM BABYGRAM (CHEST & ABDOMEN) PORT Clip # Reason: line adjustment ______________________________________________________________________________ MEDICAL CONDITION: Infant with adjusted lines REASON FOR THIS EXAMINATION: line adjustment ______________________________________________________________________________ FINAL REPORT BABYGRAM: The cardiac silhouette is enlarged.,0
Again seen is the hazy opacity throughout both lungs and a more focal area with air bronchograms in the left base that could represent atelectasis or superimposed neonatal pneumonia.The umbilical artery line is at the level of T6.,1
The umiblical venous line seems to be in the right atrium and crossing into the left atrium probably through a patent foramen ovale.,0
2:19 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: ?,0
"kidney lesions and 1.5cm Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with RLL PNA and paraneumonic effusion, presents w/ abdominal pain REASON FOR THIS EXAMINATION: ?",1
kidney lesions and 1.5cm liver lesion as identified on abd CT ______________________________________________________________________________ FINAL REPORT HISTORY: 82-year-old man with pneumonia and abdominal pain.,0
"FINDINGS: Stones are noted within a small nondistended gallbladder, without evidence of gallbladder wall thickening, or pericholecystic fluid.",0
A son sign was not elicited.,0
The common duct is within normal limits with maximal diameter measuring 7 mm.,0
There is a 1.6 x 1.9 cm hyperechoic focus within segment 7 of the right hepatic lobe consistent with a hemangioma.,0
"In segment 5 of the liver, there is a 1.8 x 1.1 cm hypoechoic cyst.",0
The liver echogenicity is within normal limits.,0
There is trace ascites surrounding the liver.,0
There is normal Doppler flow within the portal and hepatic veins.,0
The right kidney measures 10.6 cm.,0
The left kidney measures 10.2 cm.,0
The right kidney demonstrates a tiny nonobstructing upper pole calculus as well as a 7-mm nonobstructing mid pole calculus.,0
There is an 8 mm nonobstructing left renal calculus at the mid pole.,0
There are multiple bilateral renal cysts.,1
Right hepatic hemangioma and left hepatic cyst.,0
4:29 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: R/o abscess or mass.,0
Pls give PO and IV contrast.,0
"Admitting Diagnosis: STATUS EPILEPTICUS Field of view: 50 ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with Status epilepticus, increasing WBC of unknown origin REASON FOR THIS EXAMINATION: R/o abscess or mass.",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status epilepticus with increasing white count of unknown origin.,0
Evaluate for abscess or mass.,0
TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the pubic symphysis were acquired following the administration of oral and 130 cc of IV Optiray.,0
Non-ionic contrast was administered secondary to protocol.,0
"CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Again demonstrated are moderate- sized bilateral pleural effusions with bibasilar compressive atelectasis, not significantly changed in the interval.",0
A sliver of perihepatic ascites has developed in the interval.,0
"The liver, gallbladder, pancreas, spleen, adrenal glands, and small bowel are unremarkable.",0
A nasogastric tube is seen with the tip terminating in the antrum of the stomach.,0
"Again demonstrated are multiple hypodensities within both kidneys, unchanged from the prior exam.",0
"Additionally, a 2.6 cm exophytic hypodense lesion is seen originating off the lower pole of left kidney, an indeterminate lesion on this examination.",0
There is no hydronephrosis or new renal lesions demonstrated.,0
"Prominent mesenteric lymph nodes up to 10 mm wide are demonstrated predominantly within the region of the celiac axis, unchanged.",0
No retroperitoneal lymphadenopathy is present.,0
There is diffuse calcified atherosclerotic disease involving the abdominal aorta which is markedly ectatic.,0
There is no interval change in the appearance of the mild fusiform infrarenal aortic aneurysm measuring up to 3.1 cm.,0
"CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Again demonstrated within the left lateral pelvis is a heterogeneous fluid collection extending into the left psoas muscle consistent with a hematoma, which is minimally decreased in size from the prior exam.",0
"In greatest transverse dimensions, the pelvic hematoma measures 7.9 x 2.6 cm, previously 7.6 x 3.8 cm.",0
No new areas of hemorrhage are otherwise identified.,0
(Over) 4:29 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: R/o abscess or mass.,0
Admitting Diagnosis: STATUS EPILEPTICUS Field of view: 50 ______________________________________________________________________________ FINAL REPORT (Cont) There is new dilatation of the transverse and ascending colon to a maximal diameter of 8.8 cm with an apparent transition point in the splenic flexure.,0
"Distal to this transition point, the descending colon is decompressed throughout its course.",0
No mass lesion or bowel wall thickening is identified.,0
This could be secondary to an external adhesion causing stricturing of the sigmoid colon.,0
Foley catheter is demonstrated within a decompressed bladder.,0
No pelvic or inguinal lymphadenopathy is demonstrated.,0
"There is continued fat stranding and fluid demonstrated about the soft tissues of the right thight and hip, unchanged.",0
"Additionally, diffuse anasarca is present.",0
"There are degenerative changes noted in the lumbar spine with L2 on L3 and L3 on L4 anterolisthesis, unchanged.",0
No evidence of an intra-abdominal or pelvic abscess.,0
New dilatation of the ascending and transverse colon with transition point noted at the splenic flexure.,0
There is no associated mass lesion or bowel wall thickening present.,0
These findings may be suggestive of an adhesion causing stricturing and compression of the bowel at this region.,0
Clinical correlation with a colonoscopy is recommended.,0
Left pelvic hematoma extending into the left psoas muscle is minimally decreased in size since the prior exam.,0
"Diffuse anasarca with soft tissue stranding and fluid about the right hip and proximal thigh, unchanged.",0
Persistent moderate-sized bilateral pleural effusions and bibasilar atelectasis.,0
"12:02 PM CHEST (PORTABLE AP) Clip # Reason: patient with sob, hematemesis, evaluate for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: year old woman with REASON FOR THIS EXAMINATION: patient with sob, hematemesis, evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: y/o woman with shortness of breath and hematemesis.",0
COMPARISONS: AP UPRIGHT CHEST: The patient is slightly rotated.,0
"The heart size is within normal limits given technique, with a left ventricular configuration.",0
There are calcifications present in the aorta.,0
There is scoliosis convex to the right.,0
No pleural effusions or consolidations are identified.,0
Minimal linear atelectasis at the right lung base.,0
Pulmonary vascularity is normal in appearance.,0
"IMPRESSION: No pneumothorax, congestive heart failure, or radiographic evidence for pneumonia.",0
12:17 AM CHEST (PA & LAT) Clip # Reason: pre op CABG ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with 3VD awaiting CABG.,0
Hx lung nodules REASON FOR THIS EXAMINATION: pre op CABG ______________________________________________________________________________ FINAL REPORT HISTORY: 74 year old man with history of coronary artery disease.,1
This is a preop film for a CABG.,0
The patient also has a history of lung nodules.,0
PA AND LATERAL CHEST RADIOGRAPH: There are multifocal bibasilar lung nodules.,0
"Prior old studies, or a CT evaluation of these nodules should be considered.",0
The heart size is enlarged with LV predominance.,0
The pulmonary vascularity appears normal with no evidence of cardiac failure.,0
"No radiographic evidence of infiltrates, however, the multifocal bibasilar lung nodules are seen, whose etiology is unclear.",0
IMPRESSION: 1) No evidence of cardiac failure.,0
"2) Bibasilar lung nodules, etiology unclear at this point.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Ambien Attending: Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p redo sternotomy OPCABGx1 (SVG to PDA) on , MVR (#29 Medtroinc Mosaic), TV repair (#32 CE ring) via right thoracotomy History of Present Illness: Mr. is a 67 year old gentleman who has had multiple recent hospital admissions for congestive heart failure.",1
"A subsequent work-up revealed severe mitral regurgitation, severe tricuspid regurgitation, and 90% occlusion of left main.",1
He was therefore recommended for surgical correction of his cardiac pathologies.,1
"Past Medical History: - CHF, EF 20% - Hyperlipidemia - Hypertension - Severe Mitral valve disease.",1
- Severe Tricuspid valve disease.,1
- Idiopathic thrombocytopenic purpura (ITP).,1
- Pancreatic cysts s/p biopsy.,0
- Bilateral EEA approximately .,0
- Coronary artery bypass graft (CABG) x 5.,1
- Left inguinal hernia repair in .,0
"Social History: He used to drink alcohol excessively, but had his last drink several months ago.",0
He smoked a half pack to one pack per day for 15 years until he quit in .,0
Family History: His mother died of a heart attack.,0
His brother died of a heart attack at age 33.,0
His father died with disease.,0
Pt's maternal side of the family has marked hyperlipidemia.,0
He has no known family history of cancer.,0
"Physical Exam: On physical exam Mr. was found to be awake, alert, and oriented.",0
"On auscultation of his lungs, he was found to have scattered rales.",0
"His sternum was stable and his incision was clean, dry, and intact with no erythema or drainage.",0
His extremities were warm with no edema.,0
His lower extremity harvest site was clean and dry.,0
Pertinent Results: 07:40AM BLOOD WBC-8.3# RBC-3.82* Hgb-11.4* Hct-36.5*# MCV-96 MCH-29.9 MCHC-31.3 RDW-17.9* Plt Ct-195# 07:40AM BLOOD Plt Ct-195# 07:40AM BLOOD Glucose-76 UreaN-48* Creat-1.8* Na-147* K-4.1 Cl-109* HCO3-28 AnGap-14 Brief Hospital Course: is a 67 year old gentleman who has had multiple recent hospital admissions for congestive heart failure.,1
He was taken to the operating room on with for a redo sternotomy and off pump CABGx1.,0
He tolerated the procedure well and transferred to the surgical intensive care unit in critical but stable condition.,0
"On the following day on he underwent the second stage of his intervention, a mirtal valvereplacement with a #29 mosaic valve and a tricuspid valve repair with a 32 CE ring via a right thoracotomy.",1
He tolerated this procedure well and was transferred in critcal but stable condition to the surgical intensive care unit.,0
He was extubated on post-operative day 7 after multiple failed attempts.,0
"He was weaned from his pressors, his chest tubes were removed.",0
"His LFTs were found to be elevated early in his post-operative course, but these lab values were trending toward normal by the end of his stay.",0
By post-operative day 9 he was transferred to the step down floor.,0
Mr. was ready for discharge to a rehab by post-operative day 10.,0
Medications on Admission: protonix 40 toprol XL 25 lisinopril 2.5 lasix 80 TID digoxin 0.125 Discharge Medications: 1.,0
Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours).,0
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed.,0
"Disp:*qs ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Healthcare Center - Discharge Diagnosis: CAD, severe mitral regurgitation, severe tricuspid regurgitation s/p redo sternotomy OPCABGx1, MVR, TV repair congestive heart failure hypercholesterol hypertension chronic renal failure ITP pancreatic cysts renal artery stenosis s/p CEA s/p CABG1984 pulmonary hypertension Discharge Condition: good Discharge Instructions: Follow medications on discharge instructions.",1
Followup Instructions: Please see your primary care physician and your cardiologist in weeks.,0
Please see Dr. in weeks.,0
"Provider: , MD Phone: Date/Time: 3:00 Provider: MRI Phone: Date/Time: 10:20 Completed by:",0
"1:52 PM CHEST (PORTABLE AP) Clip # Reason: eval mediastinum, ?",0
"pneumothorax, check lines/tubes Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval mediastinum, ?",1
"pneumothorax, check lines/tubes ______________________________________________________________________________ FINAL REPORT HISTORY: AVR.",0
Endotracheal tube is 4 cm above carina.,0
Tip of Swan-Ganz catheter overlies proximal right main pulmonary artery.,0
NG tube is in antrum of stomach.,0
There is a minimal blunting left costophrenic sulcus and atelectasis at the left lung base.,0
", 8:09 AM CAROTID SERIES COMPLETE Clip # Reason: ?",0
carotid stenosis Admitting Diagnosis: AORTIC STENOSIS\AVR; MVR?,0
"______________________________________________________________________________ MEDICAL CONDITION: 89 year old man with AS< MR, TR, AI here for AVR REASON FOR THIS EXAMINATION: ?",0
"carotid stenosis ______________________________________________________________________________ PFI REPORT PFI: Less than 40% stenosis in the right internal carotid artery, 0% stenosis in the right internal carotid artery.",0
Height: (in) 66 Weight (lb): 186 BSA (m2): 1.94 m2 BP (mm Hg): 129/88 HR (bpm): 82 Status: Outpatient Date/Time: at 11:26 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
The ascending aorta and arch are mildly dilated.,0
"There is a moderate sized (1.6cm around the right atrium, 1.0cm inferolateral and lateral to the left ventricle, 0.5cm anterior to the right ventricle) circumferential pericardial effusion, with relatively little effusion anterior to the right ventricle.",0
"Intermittent, mild right ventricular diastolic collapse is suggested c/w increased pericardial pressures.",0
IMPRESSION: Moderate circumferential pericardial effusion with echocardiographic evidence for increased pericardial pressures c/w early tamponade physiology.,0
Clinical correlation and serial evaluation is suggested.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Lipitor / Amiodarone Attending: Chief Complaint: cc: weakness on left side, double vision Major Surgical or Invasive Procedure: Pulmonary vein isolation History of Present Illness: HPI: 54 yo M with hx of DM, CAD s/p CABG in , AF, HL s/p elective ablation for AF p/w chest pain, L-sided weakness and double vision.",0
"With his AF, he describes symptoms of fatigue, SOB, chest tightness and anxiety, and has symptoms almost every other day with rates > 100.",0
"He has had multiple admissions with lopressor treatment, and undergone catheterization 8-10 times for his chest tightness, most recently in at MWH, which were reportedly clear.",0
"He received a cardiac MR on in preparation for pulmonary vein isolation, which showed a normal EF and mild biatrial enlargement.",0
He subsequently was admitted on for elective pulmonary vein isolation under general anesthesia and was doing well post-operatively when he suddenly stopped responding to questions at ~3:30 PM.,0
He reported burning chest pain with R shoulder soreness.,0
Repeat EKGs showed no acute ST changes.,0
Received SL NTG x1 without improvement.,0
"He received a dose of morphine 4mg for this and during the infusion became sleepy, difficult to arouse and not moving his extemities at all.",0
He was given 0.4 mg Narcan and was noted to be weak in his L arm and leg with double vision in his L eye by the neurology stroke team.,0
He was taken for emergent CTA which showed no evidence of arterial occlusion.,0
A subsequent MRI showed no evidence of acute stroke.,0
Neurology felt that this could medication effect vs seizure.,0
He was transferred to the CCU for further monitoring.,0
"ROS: (-) TIA (-) CVA (-) melana/GIB Past Medical History: Afib high cholesterol DM CABG (LIMA-LAD, SVG-RCA, SVG-OM) cardiac catheterization - occluded LAD, OM and RCA.",0
bilateral shoulder surgeries bilateral knee surgeries appy .,0
Social History: Social History: Married for 4 years with one child.,0
His wife will drive him to and from the procedure.,0
Family History: Family History: (+) CAD Uncle died of MI at 54 yo.,0
Paternal grandparents died in early 60's from heart failure.,1
"Physical Exam: Tm 98.9 Tc 98.6 HR 84 BP 126/65 RR 23 99% on 4 L NC Gen: mildly obese man lying in bed with audible upper respiratory breath sounds responding slowly to questions HEENT: PERRL, does not track finger with eye movements - able to move eyes to R, not to L, does not open mouth very widely, able to stick out tongue, no gag reflex, Neck: JVP flat CV: RRR, nl s1, s2, no m/g/r Lungs: coarse breath shouds from chest Abd: BS+, soft, NT, ND Ext: chronic venous stasis changes, 1+ BL LE edema Neuro: CN 2, (3,4,6 on R eye), (3 on L eye), 7, 8, 9,10 (able to swallow, but no gag), 11 (SCM), 12 intact.",0
"2+ biceps and brachioradialis BL, + L patellar, + R patellar, downgoing toes on L, upgoing on R. fair squeeze on L, 1/5 strength on L biceps, biceps on R, 1/5 strength in L IP on L, IP on R. Pertinent Results: Studies: Cardiac MR 1.",0
Mild concentric left ventricular hypertrophy with normal cavity size and systolic function.,0
The LVEF was normal at 66%.,0
The RVEF was normal at 55%.,0
The diameters of the ascending aorta and arch were normal.,0
The diameter of the descending thoracic aorta was mildly increased.,0
The main pulmonary artery diameter was also mildly increased.,0
"(L atrium - 48 mm parasternal long axis, R atrium - 52 mm) 5.",0
Normal size and orientation of the pulmonary veins without CMR evidence of anomalous pulmonary venous return or pulmonary vein stenosis.,0
Normal coronary artery origins with no evidence of anomalous coronary arteries.,0
MR HEAD W/O CONTRAST 5:30 PM MR HEAD W/O CONTRAST Reason: Evaluate for CVA MEDICAL CONDITION: 54 year old man with h/o AF s/p Ablation p/w new neuro deficits.,0
"REASON FOR THIS EXAMINATION: Evaluate for CVA MRI EXAM OF THE BRAIN CLINICAL INDICATION: Neurologic deficit, evaluate for CVA.",0
Patient has undergone ablation for atrial fibrillation.,1
Multiplanar T1- and T2-weighted images of the brain was obtained.,0
The study is significantly degraded by motion artifact.,0
No prior exams were available for comparison.,0
There is minimally increased signal seen on diffusion images involving the lower aspect of the medulla.,0
This could be artifactual in nature or related to possible small infarction.,0
FLAIR images were significantly degraded by motion artifact and could not confirm the suspicion of this finding.,0
The ventricular system is symmetrical without hydrocephalus.,0
Signal flow voids are noted along the intracranial portions of the carotid arteries.,0
IMPRESSION: Significantly limited exam by motion artifact.,0
No cerebral infarcts were seen.,0
There was however suspicion for a tiny area of restricted diffusion involving the left aspect of the lower medulla.,0
This might be artifactual in nature or related to a small subacute infarct.,0
Further followup is suggested by obtaining repeat diffusion images and conventional images of the brain preferably after sedation if possible.,0
"CTA HEAD W&W/O C & RECONS 3:55 PM CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: change in mental status, r/o new CVA, or hemorrhage Contrast: OPTIRAY MEDICAL CONDITION: 54 year old man with question of acute bleed or stroke REASON FOR THIS EXAMINATION: change in mental status, r/o new CVA, or hemorrhage CONTRAINDICATIONS for IV CONTRAST: None.",0
CT CEREBRAL ANGIOGRAM: CLINICAL INFORMATION: ?,0
TECHNIQUE: Pre- and post-contrast multislice CT from skull base to vertex during arterial phase of contrast enhancement with multiplanar MIP and 3D reformats.,0
"FINDINGS: There is moderate arterial wall calcification at the cavernous portions of the internal carotid arteries bilaterally, without significant luminal narrowing.",0
The circle of and its principal tributaries otherwise demonstrate normal caliber and tapering.,0
"No critical stenosis, aneurysm, or vascular malformation can be seen within the scanned volume.",0
"There is minor opacification involving the ethmoidal air cells, sphenoid, and left maxillary sinus, likely to be infective/inflammatory in origin.",0
"CONCLUSION: Minor arterial wall calcification at the cavernous portions of the internal carotid arteries bilaterally, without significant luminal narrowing.",0
"MR HEAD W/O CONTRAST 1:33 PM MR HEAD W/O CONTRAST Reason: Per neurology, PLEASE DO DWI ONLY, do NOT need to do MRA.",0
"T MEDICAL CONDITION: 54 year old man with L sided weakness after EP procedure REASON FOR THIS EXAMINATION: Per neurology, PLEASE DO DWI ONLY, do NOT need to do MRA.",0
INDICATION: Left-sided weakness after EP procedure.,0
COMPARISON: Motion limited MR of the head of .,0
"TECHNIQUE: Sagittal T1, axial T2, FLAIR and susceptibility images were obtained, in addition to diffusion-weighted images of the brain.",0
FINDINGS: There are no areas of restricted diffusion on today's exam to suggest acute infarction.,0
There is a small focus of susceptibility within the left occipital lobe.,0
"As there is no hyperdense region in this locale on recent CT scan of , the finding likely represents an old hemorrhagic residue.",0
"Otherwise, the signal of the brain parenchyma is normal.",0
Normal flow voids are seen within major circle of tributaries.,0
"A lipoma is noted within the left parotid gland, and is partially imaged.",0
IMPRESSION: No definite areas of restricted diffusion on today's exam to suggest acute infarction.,0
CHEST (PA & LAT) 3:54 PM CHEST (PA & LAT) Reason: Evaluate for pneumonia vs. atelectasis.,0
MEDICAL CONDITION: 54 year old man with recent NG tube and aspiration vs. pna seen on previous chest x-ray.,0
REASON FOR THIS EXAMINATION: Evaluate for pneumonia vs. atelectasis.,0
The patient is status post median sternotomy and coronary artery bypass surgery.,1
There has been interval clearing of a previously reported bibasilar opacities.,0
Skeletal structures reveal evidence of prior sternotomy.,0
IMPRESSION: Interval resolution of bibasilar opacities.,0
"Brief Hospital Course: 54 yo M with hx of DM, CAD s/p CABG in , AF, HL s/p elective ablation for AF p/w chest pain, L-sided weakness and double vision without clear neurological cause.",0
"Altered mental status, Left sided weakness - Following transfer of the patient from the cath lab to the PACU, he became acutely confused with left sided weakness and double vision in his left eye.",0
"A CTA and MRI were negative by neurology's read for acute change, without evidence of arterial occlusion, bleed or CVA.",0
The patient was initially admitted to the CCU and his blood pressures were kept at 140-160 and he was started on heparin in case a CVA was missed and ASA was administered rectally as he had loss of his gag reflex.,0
"A final read of the MRI showed ""suspicion of a tiny area of restricted diffusion involving the left aspect of the lower medulla.",0
"This might be artifactual in nature or related to a small subacute infarct.""",0
"Neurology felt that the site of the restricted diffusion would not correlate with his deficits, and recommended a repeat diffusion weighted MRI.",0
A repeat scan showed no evidence of CVA.,0
"An NG tube was placed so that the patient could receive oral medications, and his blood pressure was normalized with a beta-blocker and ACE-I.",0
Patient reported h/o of Left sided deficits similar to those on admission after severe assault in .,0
This is most likely a reappearance of his old deficits following anesthesia and his procedure.,0
"Neuro was felt that his exam was inconsistent and that this was most likely a medication effect versus conversion disorder, as his MRI showed no evidence of anatomic pathology.",0
All opiates and benzodiazepines were withheld from the patient.,0
"Over the course of his hospitalization, his strength greatly improved (5-/5 in upper extremities and 4+/5 in lower extremities) as he worked with physical therapy and his vision gradually improved.",0
Physical therapy felt that he was safe for discharge home after in-house treatment sessions.,0
"He was evaluated by speech pathology when his gag reflex returned, and he was cleared for a regular diet.",0
Chest pain - The patient developed chest pain following his pulmonary vein isolation.,0
Repeated EKGs showed diffuse ST changes unchanged from prior to procedure.,0
EP felt that this was a result of the induced myocardial damage from the procedure vs. pericarditis.,0
"After a brief period of atrial fibrillation in the PACU, his heart remained in sinus rhythm.",1
"His pain waxed and waned, and he was started on ketorolac for his pain.",0
Cardiac enzymes were trended with a troponin leak peak of 1.79 (normal 0-0.01) and peak CK of 336 on morning following procedure.,0
"His chest pain resolved on POD3, and he remained without chest pain for the remainder of his hospital course.",0
Coronary Artery Disease - patient with long history of CAD s/p CABG with all grafts reportedly patent from last cath in .,1
His cardiac enzymes were trended with a troponin leak of 1.79 and peak CK of 336 (expected post procedure).,0
"His lipid panel was found to be LDL 113, Trig 207, HDL 51.",0
"He was started on crestor, which is associated with less myalgias than the other statins, without elevation in his LFTs or new muscle pains.",0
"He was continued on aspirin, metoprolol and lisinopril.",0
"Pump: A TTE showed a normal EF, mild MR .",0
"On admission, he appeared dehydrated, and he was started on 120 cc/hr NS.",0
"However, he became hypervolemic and required diuresis.",0
At time of discharge he was felt to be euvolemic.,0
He was continued on metoprolol and lisinopril.,0
Atrial Fibrillation - The patient remained in NSR on transfer.,1
He was started a heparin drip initially for question of stroke and then as a bridge to reaching a therapeutic INR.,0
Medications on Admission: metoprolol 50mg niaspan 500mg metformin 1000mg (last dose am) coumadin last dose 2/28 Discharge Medications: 1.,0
Metoprolol Succinate 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).,0
Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale Injection ASDIR (AS DIRECTED).,0
Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Lovenox 100 mg/mL Syringe Sig: One (1) injection Subcutaneous twice a day: Will be instructed when to discontinue by Dr. once your INR level is therapeutic with your coumadin dose.,0
Disp:*50 injections* Refills:*2* Discharge Disposition: Home With Service Facility: Hospice and VNA Discharge Diagnosis: Primary: Atrial Fibrillation Neurological deficits of uncertain cause Secondary: Coronary Artery Disease Hyperlipidemia Discharge Condition: Stable.,1
Patient walking and eating without difficulty.,0
Is being sent home with services for medication teaching with lovenox injections.,0
Please keep all follow-up appointments.,0
"Please seek medical attention if you develop fevers, chills, shortness of breath, chest pain or have any other concerning symptoms.",0
No heavy lifting for within the next 2-4 weeks.,0
No driving for the next 1-2 weeks or until you have consulted with your primary care doctor.,0
Please follow up in 1 month with Dr. at .,0
"Please make a follow up appointment with your cardiologist, Dr. at , for within the next 2-4 weeks.",0
"Please follow up with your primary care doctor, Dr. at , within the next 1-2 weeks.",0
"***You will need to get your blood drawn at Dr. office on Monday morning () for a 'PT, PTT and INR' to adjust your coumadin dose*** Completed by:",0
4:57 AM CT HEAD W/O CONTRAST Clip # Reason: ?,0
progression ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with SDH REASON FOR THIS EXAMINATION: ?,0
"progression No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 71-year-old woman with subdural hematoma, status post evacuation.",0
"COMPARISON: CT of the head, , 1:45 a.m.",0
TECHNIQUE: CT of the head without IV contrast.,0
"FINDINGS: There has been interval craniotomy on the right, with evacuation of the previously seen large right subdural hematoma.",0
There is a residual amount of blood in the middle cranial fossa along the right temporal lobe cerebral convexity.,0
"Pneumocephalus is seen along the right cerebral convexity, in the middle cranial fossa, along the right frontal lobe and along the right frontal lobe and deep to the craniotomy defect.",0
"The subdural hematoma identified on the left is still present, measuring approximately 1 cm in greatest axial diameter.",0
Blood is also seen along the tentorium on the right.,0
Interval development of intraparenchymal hemorrhages is seen in the mid brain and pons.,1
No major vascular acute territorial infarcts are identified.,0
Soft tissues are remarkable for gas in the subcutaneous tissues and staple line overlying the craniotomy defect.,0
There is scattered opacification of ethmoid air cells.,0
"IMPRESSION: Successful evacuation of right-sided subdural hematoma, as described above.",0
"Persistent left subdural hematoma, without significant shift.",0
Interval development of intraparenchymal hemorrhages in the mid brain and pons.,1
PATIENT/TEST INFORMATION: Indication: S/P COREVALV 24hr post Height: (in) 68 Weight (lb): 184 BSA (m2): 1.97 m2 BP (mm Hg): 126/46 HR (bpm): 74 Status: Inpatient Date/Time: at 14:04 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: This study was compared to the prior study of .,1
RIGHT VENTRICLE: Abnormal septal motion/position.,0
MITRAL VALVE: Trivial MR. PERICARDIUM: No pericardial effusion.,0
IMPRESSION: Well-positioned aortic valve bioprosthesis with trace posterior regurgitation.,1
"Compared with the prior study (images reviewed) of , severely stenotic aortic valve has been replaced with a bioprosthesis.",1
"2:42 AM CHEST (PORTABLE AP) Clip # Reason: infil Admitting Diagnosis: LEFT SIDED WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 71M with a history of CAD, s/p CABG which was complicated by post-op a.fib now on Coumadin, diabetes mellitus, HTN, h/o of GI bleedsecondary to a duodenal ulcer who is being transferred Medical Center for a R sided basal ganglia hemorrhageand is s/p reversal of anticoagulation and subsequent developmentof multiple ischemic strokes.",1
REASON FOR THIS EXAMINATION: infil ______________________________________________________________________________ FINAL REPORT HISTORY: CABG with right basal ganglia bleed.,0
FINDINGS: The left costophrenic angle has been excluded from the image.,0
The left basilar region has substantially cleared.,0
Mild atelectatic changes persist at the right base above the elevated hemidiaphragm.,0
The tracheostomy tube and PEG device remain in place.,0
"Substantial pneumoperitoneum persists, and there is continued marked dilatation of the gas-filled stomach.",0
Cardiac silhouette is essentially within normal limits at this time and the dual-channel pacemaker devices are in expected position.,1
Height: (in) 62 Weight (lb): 136 BSA (m2): 1.62 m2 BP (mm Hg): 126/62 HR (bpm): 95 Status: Inpatient Date/Time: at 12:20 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
The increased transaortic velocity irelated to high cardiac output.,0
No of mitral valve leaflets.,0
There is a mild (12mmHg) resting left ventricular outflow tract obstruction that increases to 24mmHg with Valsalva manuever.,0
There is no mitral valve prolapse or systolic anterior motion ().,0
IMPRESSION: Normal left ventricular cavity size with hyperdynamic systolic function.,0
Mild resting LVOT gradient that slightly increases with Valsalva.,0
"Is there a history to suggest high output syndrome (anemia, thyrotoxicosis, sepsis, fever, thiamine deficiency, Paget's disease, etc.)",1
8:54 AM CHEST (PORTABLE AP) Clip # Reason: s/p ct removal Admitting Diagnosis: CORONARY ARTERY DISEASE\OFF PUMP CORONARY ARTERY BYPASS ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with s/p cabg REASON FOR THIS EXAMINATION: s/p ct removal ______________________________________________________________________________ FINAL REPORT INDICATION: Coronary artery bypass grafting.,1
FINDINGS: Comparison is made with a radiograph dated .,0
"The left-sided chest tube has been removed, there is no evidence of pneumothorax.",0
The nasogastric tube and right internal jugular central venous catheter are in satisfactory positions.,0
The tip of the right internal jugular line is projected 1 cm below the cavoatrial junction.,0
Left lower lobe collapse consolidation and a moderately large left pleural effusion are stable.,0
IMPRESSION: No evidence of pneumothorax after chest tube removal.,0
Stable left lower lobe collapse/consolidation and moderately large left pleural effusion.,0
"Status: Inpatient Date/Time: at 13:00 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
"4:25 AM CHEST (PORTABLE AP) Clip # Reason: eval for pna Admitting Diagnosis: STROKE /TIA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old woman with intubated after sz REASON FOR THIS EXAMINATION: eval for pna ______________________________________________________________________________ FINAL REPORT AP CHEST, 4:40 A.M., HISTORY: 72-year-old woman, intubated after a seizure.",0
IMPRESSION: AP chest compared to : Lung volumes are appreciably lower.,0
"The endotracheal tube ends above the upper margin of the clavicles, no less than 7 cm from the carina and it should be advanced 2-3 cm for more secured seating.",0
"Dr. and I discussed these findings by telephone at 11:02 a.m., one minute following the recognition of the radiologic findings.",0
"Resolution of uncal herniation with decreased leftward shift of normally midline structures, effacement of the right lateral ventricle is persistent but improved.",0
New right frontal parenchymal contusion.,0
Right craniectomy changes with massive pneumocephalus.,0
Bilateral frontal subarachnoid hemorrhage and aqueductal and fourth intraventricular hemorrhage.,1
Occipital fracture extending into the right C1 transverse foramen and right portion of the foramen magnum.,0
"When patient is stable enough, CTA is recommended to evaluate the right vertebral artery.",0
Persistent downward transtentorial herniation evidenced by effacement of the basal cisterns.,0
"Left frontal approach hardware terminates in the left frontal parenchyma; if this is in tended to terminate in the ventricle, then advancing or replacing this hardware is recommended.",0
"Page: 4 , M 66 () , R. TSICU 3:49 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: 55 year old man s/p fall resulting in acute SDH.",0
Eval s/p cr Admitting Diagnosis: SUBDURAL HEMORRHAGE;SKULL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man s/p fall resulting in acute SDH.,1
Eval s/p crani & evac.,0
REASON FOR THIS EXAMINATION: 55 year old man s/p fall resulting in acute SDH.,0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.,0
Resolution of right uncal herniation with decreased leftward shift of normally midline structures; effacement of the right lateral ventricle is persistent but improved.,0
"New right frontal parenchymal contusions, most likely hemorrhagic contusions, less likely hemorrhagic infarct secondary to occlusion of right anterior cerebral artery by previously massive subfalcine herniation.",1
Bilateral frontal subarachnoid hemorrhage and Duret hemorrhages; small subdural hemorrhage still seen layering along tentorium and falx.,1
Occipital fracture extending into the right jugular foramen and right portion of the foramen magnum.,0
Left frontal approach hardware terminates in the left frontal parenchyma.,0
"Height: (in) 71 Weight (lb): 198 BSA (m2): 2.10 m2 BP (mm Hg): 101/58 HR (bpm): 63 Status: Inpatient Date/Time: at 10:05 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Patient is a y/o male admitted to the SICU for persistent UGI bleed and hypotension, currently on dopamine 10mcg/kg/min.",0
The IVC is dilated (>2.5cm) LEFT VENTRICLE: Symmetric LVH.,0
Estimated cardiac index is depressed (<2.0L/min/m2).,0
Transmitral Doppler and TVI c/w normal LV diastolic function.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
Overall left ventricular systolic function is moderately depressed (LVEF=35-40%).,0
"Compared with the findings of the prior study (images reviewed) of , the degree of antero-septal and septal hypokinesis and left-ventricular systolic funcdion is slightly worst now.",0
"IMPRESSION: Moderate left-ventricular systolic dysfunction, moderate mitral regurgitation, moderate tricuspid regurgitation, mild pulmonary hypertension.",0
9:02 AM CHEST (PORTABLE AP) Clip # Reason: acute change?,0
Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with cardiac arrest s/p extubation REASON FOR THIS EXAMINATION: acute change?,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Cardiac arrest status post extubation.,0
Comparison is made to prior study performed a day earlier.,0
There is no pneumothorax or enlarging pleural effusions.,0
The lateral aspect of the left hemithorax was not included on the film.,0
Bilateral perihilar opacities right greater than left have markedly improved consistent with improving pulmonary edema now only mild.,0
"1:13 PM CHEST (PORTABLE AP) Clip # Reason: eval for new infiltrate/effusion Admitting Diagnosis: RIGHT SIDED FACAIL WEAKNESS, DYSPHAGIA, DIPLOPIA ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with trach REASON FOR THIS EXAMINATION: eval for new infiltrate/effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj WED 5:24 PM PFI: Evolving infectious process at the right lung base.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 65-year-old male with trach.,0
A portable upright chest radiograph demonstrates increasing patchy opacities at the right lung base concerning for an evolving infectious process rather than reexpansion of collapsed lung as discussed on the examination from one day prior.,0
The right upper lobe is clear.,0
A few areas of linear left lower lobe atelectasis are evident.,0
"Otherwise, the left lung is clear.",0
Tracheostomy tube appears similar in position.,0
IMPRESSION: Probable evolving infection at the right lung base.,0
Aspiration is a diagnostic consideration.,0
Findings were discussed with Dr. on the afternoon of by Dr. .,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Back abscess; DKA Major Surgical or Invasive Procedure: None; incision and drainage of abscess History of Present Illness: 26yo woman with h/o gestational DM and hypothyroidism transferred from OSH w/ DKA.,1
Pat was having some /upper back pain over the past week and presented earlier today to OSH ED.,0
She was found to have a neck abscess and underwent I+D for that.,0
On routine lab work she was found to be in severe DKA with elevated glucose and metabolic acidosis.,0
She was tachy in 150s and respiring at 40s/50s.,0
"She was intubated, given 2L IVF,insulin, 1 dose Unasyn and transferred to ED.",0
"Here, initial ABG: 6.96 / 39 / 94 and UA positive for glucose and ketones.",0
"GAP 21, bicarb 8, glucose 467. urine beta hcg negative.",0
She was put on insulin drip; given a total of 5L of LR with 2 amps of bicarb.,0
Right subclavian line placed in ED for access.,0
"ROS: intubated, unable to obtain.",0
"per records + chills, nausea, vomiting.",0
"Past Medical History: - h/o gestational DM - hypothyroidism - hypercholesterolemia - HTN Allergies: NKDA Social History: +smoker Family History: ovarian cancer Physical Exam: Not responding to verbal or physical stimuli; sedated Right subclavian and Right art-line in place; no evidence of infection MMM, intubated; Pupils equal S1, S2, tachycardic, no murmur Lungs clear b/l Abdomen obese, soft, not tender Ext without edema; DP +2 b/l Pertinent Results: Labs: 19.3>41.2<321 N:69 Band:17 L:6 M:5 E:0 Bas:0 Metas: 3 PT: 13.5 PTT: 27.8 INR: 1.2 Chem7: 140 111 12 467 4.4 8 1.0 Ca: 9.4 Mg: 2.1 P: 3.7 ALT: 32 AP: 199 Tbili: 0.3 Alb: 3.3 AST: 66 LDH: 334 Dbili: TProt: : 101 Lip: 239 Acetone:Large Osms:328 .",1
ABGs 6.96/39/94 -> 7.07/25/293 .,0
EKG: Sinus tachy w/o acute ischemic changes .,0
"Imaging: CXR FINDINGS: Single bedside AP examination labeled ""supine"" with no comparisons.",0
"The ET tube terminates roughly 4.4 cm proximal to the carina, while an endogastric tube extends to the left hemidiaphragm, at the inferior margin of the study, with its tip and side-hole not seen.",0
"A right subclavian central venous catheter reaches the cavo-atrial junction, with no supine evidence of pneumothorax.",0
"The lung volumes are low with moderate minimal basilar atelectasis; however, no focal airspace process is seen.",0
"The cardiomediastinal silhouette and pulmonary vessels are within normal limits, but no significant pleural effusion.",0
"ET tube and right subclavian central venous catheter in satisfactory position, with tip of the endogastric tube not identified.",0
Low lung volumes with no focal airspace process.,0
CT CHEST W/O CONTRAST 11:22 AM FINDINGS: Lack of intravenous contrast limits diagnostic yield for vascular structures and solid organs.,0
An endotracheal tube is noted with its tip approximately 2 cm above the carina.,0
A right-sided internal jugular line with its tip in the cavoatrial junction is noted.,0
There are multifocal areas of consolidation involving the upper and lower lung fields of both lungs posteriorly.,0
"Outside these areas of consolidation, there are a few sub-6-mm foci of attenuation that are well-circumscribed and might represent additional infectious foci at the right apex.",0
"I Although this exam was not performed for subdiaphragmatic diagnosis, the liver, spleen, kidneys, and adrenal glands are grossly unremarkable.",0
The pancreas is unremarkable without evidence of calcifications.,0
"In the subcutaneous tissues of the midline right upper back, there is an 2.8 x 2 x 2.3 cm defect with packing material noted inside.",0
"There is no evidence of subcutaneous air tracking away from this region to suggest necrotizing fasciitis, though there is a mild amount of soft tissue stranding surrounding this area.",0
6 mm subcutaneous nodule (3:21) in the left upper back probably represents a lymph node.,0
"Given the dependent distribution of consolidation, aspiration should be considered.",0
No CT findings to suggest necrotizing fasciitis near the 2.5-cm defect in the subcutaneous tissues of the upper right back.,0
Other Labs: 05:40AM BLOOD WBC-6.1 RBC-3.97* Hgb-10.8* Hct-32.1* MCV-81* MCH-27.1 MCHC-33.6 RDW-13.4 Plt Ct-265 05:45AM BLOOD Glucose-166* UreaN-7 Creat-0.7 Na-141 K-3.8 Cl-102 HCO3-32 AnGap-11 04:46AM BLOOD ALT-18 AST-21 LD(LDH)-170 Amylase-21 TotBili-0.2 02:28PM BLOOD %HbA1c-13.8* 06:15PM BLOOD Acetone-LARGE Osmolal-328* 08:58AM BLOOD TSH-1.0 01:08AM BLOOD Lactate-1.3 4:31 am SWAB Site: NECK Source: back/neck.,0
WOUND CULTURE (Final ): STAPH AUREUS COAG +.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 1 S PENICILLIN------------ =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: 26yo woman with neck abscess and DKA.,1
"# DKA, DM2, uncontrolled, with complication, possibly representing ""Flatbush"" diabetes: Most likely etiology of DKA is infection (neck abscess) with resultant severe insulin resistance and or failure of pancreas to continue to produce insulin(Flatbush Diabetes).",1
Gap closed with insulin gtt.,0
"Ultimately, consult recs, better glycemic control achieved, and pt.",0
started on subcutaneous insulin regimen with Metformin.,0
#) respiratory failure: intubated at OSH for tachypnea in setting of severe metabolic acidosis due to DKA; extubated after gap closed and acidosis improved.,1
# Neck Abscess: s/p I+D at OSH.,0
Given Unasyn then switched to dicloxacillin when cx.,0
"Blood cultures remained negative, and called OSH on , and cx.",0
there had been neg for 72 hours.,0
"Surgery consulted and felt that no further debridement required, just wet to dry dressing changes.",0
instructed in how to do this and follow up with her PCP and with Surgery here arranged.,0
# Hypothyroidism: TSH checked and WNL.,0
"Pt was not on Levoxyl during hospitalization, however this is being restarted on discharge.",0
Medications on Admission: Levoxyl 125mcg Discharge Medications: 1.,0
Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days.,0
Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.,0
"Insulin Glargine 100 unit/mL Solution Sig: 24 Units Q AM and 12 Units Q PM Units, insulin Subcutaneous insulin.",0
"Insulin Lispro 100 unit/mL Solution Sig: 10 Units before each meal Units, insulin Subcutaneous Q AC.",0
"Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale, attached Units, insulin Subcutaneous QACHS.",0
"Syringe (Disposable) 1 mL Syringe Sig: One (1) syringe, for insulin injection, as directed Miscellaneous Q insulin injection.",0
Disp:*100 syringes for insulin injection* Refills:*2* 8.,0
Levoxyl 125 mcg Tablet Sig: One (1) Tablet PO once a day.,0
"Triple Antibiotic 3.5-400-10,000 mg-unit-unit/g Ointment Sig: small amount Ophthalmic twice a day: To wound near abscess on R back and to chest.",0
Disp:*1 tube* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Type II Diabetes Mellitus with DKA Upper back abscess (MSSA) s/p incision and drainage Hypothyroidism Discharge Condition: Stable.,1
"Eating and drinking, voiding without difficulty.",0
Discharge Instructions: Take all medications as prescribed.,0
Call your doctor or report to the nearest Emergency Department or the Emergency Department for: Fever.,0
"Worsening redness, pain, or drainage of pus from the wound in your back.",0
Change dressing to back wound including packing as instructed twice daily.,0
Do not get wound wet until seen by the surgery clinic or your primary care doctor.,0
Followup Instructions: The Diabetes Center will call you at home to arrange your appointment to see Dr. in follow up.,0
"If you do not hear from them next week, call: PCP: , .",0
"Provider (Surgery): , MD Phone: Date/Time: 10:30",0
"4:17 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PNEUMONIA;HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 25 year old woman with ARDS, intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: 25-year-old female with ARDS.",0
PORTABLE SUPINE AP CHEST RADIOGRAPH: An endotracheal tube terminates 4.6 cm above the level of the carina.,0
"A nasogastric tube courses below the diaphragm and is at least within the stomach, though not fully imaged.",0
Interval removal of a right-sided central venous catheter is noted.,0
"Diffuse bilateral opacities appear slightly increased in the lung apices compared to prior examination, likely secondary to differences in patient position.",0
The positional change in the opacities suggests some overlying layering pleural effusions.,1
Unchanged diffuse lung opacities consistent with ARDS.,0
Standard position of support devices.,0
Interval removal of right central line.,0
Stable probable moderate layering bilateral pleural effusions.,1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization, status post placement of drug-eluting stents.",0
History of Present Illness: 52 y.o.,0
"pt of Dr. , with h/o silent MI in , DM, HTN, with known 2 vessel disease by OSH cath report transferred to for a possible intervention.",0
The patient was admitted to the OSH on with a one-week history of nausea and non-bilious non-bloody vomiting.,0
The patient also describes symtpoms of fatigue and malaise over the last week.,0
For 2-3 days prior to admission she had had atypical angina.,0
She describes episodes of intermittent shortness of breath with associated left sided chest pain that would frequently happen at rest.,0
"She describes left sided chest pain as sharp, lasting ""minutes"", localized over left shoulder and radiating to left upper arm, pain would change with change in arm position.",0
Patient was admitted to hospital and treated with supportive therapy/antiemetrics.,0
She was given SL NTG with resolution of her symptoms.,0
She ruled out MI with three sets of enzymes.,0
On she underwent p-MIBI which showed inferior ischemia/no infarct.,0
"The patient was then cathed at the OSH and cath revealed 2 vessel disease: 85-90% proximal LAD and 70% RCA stenosis, dampening LMA; normal left heart hemodynamics.",0
"Per Dr., it was decided to tx the patient here for further treatment.",0
Patient had stents to LAD placed on .,0
"During the procedure she developed CP/nausea with 2mm ST elevations in inferior leads, became bradycardic and was given atropine and dopamine.",0
Flow in LAD/LCX normal/no dissection.,0
"RCA was stented with 2.5x18mm Cypher stent with no residual, TIMI 3 flow.",0
Following the procedure she ruled in for myocardial infarction by enzymes but was symptomatically stable until early morning when she developed acute chest pain with EKG changes.,1
In stent thrombosis was suspected and she was brought emergently to the cath lab.,0
"In the cath lab, she was found to have thrombus in her LAD.Export catheter was used to remove the clot when she started having EMD.",0
Code was called and she was defibrllated and pressor were started.,0
Stent was successfully deployed in the LAD.,0
She went into VF and was again shocked.,0
It was then decided that she might have had coronary spasm and showering of emboli.,0
All pressors were stopped and 2000mcg diltiazem were given intracoronary and she return to NSR.,0
Echocardiogram was done and ruled out pericardial tamponade but anterior wall AK.,0
SHe recieved 6 unit of blood transfusion during the procedure.,0
CT surgery evaluated patient in the catheterization lab but surgery was not deemed to be indicated at that time.,0
Patient was transferred to the CCU.,0
"Past Medical History: MI, silent in depression, followed by a psychiatrist diabetes x 5 years renal stones chronic back pain HTN COPD endometriosis s/p bilateral ooporectomy, on premarin spinal fusion L5-S1 for vertebral fractures ear surgery in s/p 4 c/section Social History: Lives with her daughter.",1
On disability because of back pain.,0
"Physical Exam: Vitals: AF, 107/70 80's 16 99% RA Gen: pale woman, awake, alert and oriented, in no apparent distress.",0
Anxious and tearful when talking about going for the procedure.,0
"Neck: supple, no elevation of JVP Lungs: CTA bilaterally.",0
"CV: regular, nl S1S2, no m/g/r Abd: soft, nontender, nondistended, with normoactive bowel sounds.",0
"R groin: with no ecchymosis, hematoma, no bruit Back: well healed vertical scar c/w prior back surgery Ext: warm, no LE edema Pertinent Results: *******Cath 2 vessel disease.",0
"Ao 142/82/108 RCA mid 80%; LMCA duffuse 40% (FFR 0.95 suggestivng non-flow limiting stenosis); LAD diffuse 40%; LAD prox 90%, mid 80-90%.",0
Prox LAD lesion could not be crossed with Cyphher stents and two 2.5x12mm overlapping Taxus stensts were placed.,0
This revealec mid LAD lesion that was underappreciated.,0
"Pt had CP/nausea, 2mm ST elevations in inferior leads, became bradycardic and was given atropine and dopamine.",0
"RCA was stented with 2.5x18mm Cypher stent - no residual, TIMI 3.",0
Mid LAD 2.5x8 cm Cypher stent with no residuaa and TIMI 3.,0
"EKG (post-cath at OSH): rate 80, sinus, nl axis, nl intervals, no ischemic ST or TW changes, Q in III, aVF.",0
"Labs at OSH: wbc 5.8, h/h 34.4/11.6, plt 181, inr 1.2, na 137, k 4.4, bun/creat 16/.8, trig 236, chol 239, HDL 40, LDL 113; FS=123 this AM .",0
"Echo : EF 60-65%; mild concentric LVH, trace MR. .",0
"P-MIBI : HR 76->96; SBP 126/70-> 100/62, no chest pain or ST changes.",0
Mild exercise induced LV dilation and failure.,0
Small to mod anterior wall ischemia.,0
Inferior infarct No evidence of infarct.,0
CT : no retroperitoneal bleed .,0
"Brief Hospital Course: A/P: 52 yo patient of Dr. , with history of silent MI in , diabetes mellitus, Hypertension, known 2 vessel transferred from the OSH which was intervened.",1
Patient has 2 vessel CAD s/p three stents to LAD and a stent to RCA complicated by MI.,0
Patient was found to have in stent thrombosis of LAD stent which was intervened upon after resuscitation in the cath lab.,0
She had polymorphic VT while in cath lab.,0
She was subsequently transferred to the CCU with intraaortic balloon pump support and was on bivalirudin due to question of heparin induced thrombocytopenia.,0
She was eventually stable enough to be weaned off balloon pump and dobutamine.,0
"She was continued on aspirin, lipitor.",0
Her plavix was switched to ticlopidine since she developed in stent thrombosis while on plavix.,0
Captopril was eventually started as her blood pressure tolerated it.,0
Beta blocker was held as she has severe bronchospasm.,0
She remained in normal sinus rhythm throughout CCU stay.,0
"On the day of her death, she developed respiratory distress and ventricular fibrillation.",1
Resuscitation effort was attempted without success.,0
Medications on Admission: Singulair 10 daily Premarin 0.3mg daily Lorazepam 1mg Celexa 40 mg qd (was resently changed to another antidepressant) Metoprolol XL 25 mg qd Glyburide 5 mg po qd Enalapril 10 mg po qd Morphine SR 30 mg tid Gemfibrozil 600 mg Advair 250 Albuterol qid Percocet 5/325 mg qid Ipratropium qid Lipitor 40 mg po qd Fosamax 70 mg q Monday Detrol Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1.,0
Myocardial infarction Secondary diagnoses: 1.,1
Hypercholesterolemia Discharge Condition: expired Completed by:,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: TlC placement ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with TLC placement in right IJ REASON FOR THIS EXAMINATION: TlC placement ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH HISTORY: Central line placement.,0
COMPARISONS: Earlier on the same evening.,0
"TECHNIQUE: Chest, portable AP semi-upright.",0
FINDINGS: A right internal jugular central venous catheter has been retracted somewhat and terminates at the cavoatrial junction.,0
"The cardiac, mediastinal and hilar contours appear unchanged.",0
There is a mild interstitial prominence suggesting a slight congestion.,0
Blunting of the costophrenic sulcus suggests a small pleural effusion potentially although less striking than on the recent prior examinations.,0
IMPRESSION: Central venous catheter terminating at the cavoatrial junction.,0
Findings suggesting mild pulmonary vascular congestion.,0
11:47 AM CHEST (PORTABLE AP) Clip # Reason: pna?,0
"______________________________________________________________________________ MEDICAL CONDITION: year old man with recent hospital stay now hypoxic and coughing, congested.",0
______________________________________________________________________________ FINAL REPORT INDICATION: -year-old male with cough and hypoxia.,0
"FINDINGS: Single AP radiograph of the chest again demonstrates bilateral calcified pleural plaques due to asbestos exposure, which partially obscure visualization of the underlying lung parenchyma.",1
The lungs are grossly clear without focal consolidation.,0
Again seen is a right-sided chest wall pacemaker with single lead overlying the right ventricle.,0
9:04 PM TIB/FIB (AP & LAT) RIGHT Clip # Reason: r/o fx ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with deform and abrasion of right LE REASON FOR THIS EXAMINATION: r/o fx ______________________________________________________________________________ FINAL REPORT HISTORY: Deformity and abrasion of the right lower extremity.,0
"FINDINGS: Four views of the right tibia, fibula and ankle demonstrate no evidence of acute fracture or dislocation.",0
Irregularity of the distal fibula and lateral aspect of the distal tibia is seen and likely represent the sequela of prior trauma.,0
The ankle mortise is congruent and the talar dome is intact.,0
Prominence of the soft tissue overlying the right ankle joint is noted.,0
IMPRESSION: No evidence of acute fracture or dislocation.,0
", F. MED MICU 10:56 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: pls re-eval OG tube placement Admitting Diagnosis: GANGRENE LEFT TOES ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with Mental status changes s/p intubation, now with OG tube advanced REASON FOR THIS EXAMINATION: pls re-eval OG tube placement ______________________________________________________________________________ PFI REPORT Satisfactory position of orogastric tube.",0
"11:52 AM CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # Reason: ?STATUS Admitting Diagnosis: PNA, ACUTE RENAL FAILURE ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for followup.",1
"FINDINGS: As compared to the previous examination, there is no unchanged position of monitoring and support devices, unchanged parenchymal opacities suggesting mild to moderate pulmonary edema.",0
"Suspicion of a small left-sided pleural effusion, retrocardiac atelectasis.",0
No newly appeared focal parenchymal opacities suggesting pneumonia.,0
"Clip # Reason: please use dopplers to assess for renal artery stenosis Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman with CHF, renal failure, concern based on urine microscopy for renal artery stenosis REASON FOR THIS EXAMINATION: please use dopplers to assess for renal artery stenosis ______________________________________________________________________________ FINAL REPORT INDICATION: 60-year-old female with CHF, renal failure, evaluate for renal artery stenosis.",1
FINDINGS: Note is made that this is an extremely limited ultrasound due to the patient's body habitus.,0
The right kidney is identified and measures 12.0 cm in length.,0
No hydronephrosis is seen in the right kidney.,0
A small shadowing non-obstructing stone is seen within the right renal collecting system measuring 5 mm.,0
"Despite diligent effort, the left kidney could not be identified in the left flank or in the pelvis.",0
Ascites is seen in the pelvis.,0
DOPPLER EXAMINATION: The Doppler examination is entirely non-diagnostic.,0
Flow cannot be detected in the right kidney due to the technical limitations.,0
The left kidney cannot be visualized.,0
No hydronephrosis in the right kidney.,0
Small non-obstructing right renal stone.,0
No Doppler examination could be performed as the visualization is extremely limited due to the patient's body habitus.,0
"Despite diligent effort, the left kidney could not be identified.",0
Small amount of ascites seen in the pelvis.,0
10:42 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
"R pneumothorax s/p chest tube removal ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p cabg with interstitial lung process, intubated following hypoxic respiratory failure, s/p R open lung biopsy, with cryptococcal and pseudomonas pneumonia and amio toxicity.",1
s/p trach placement today with increased RR and hypoxia and hypotension REASON FOR THIS EXAMINATION: ?,0
"R pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT HISTORY: Chest tube removal, question pneumothorax.",0
The small basilar pneumothorax noted on prior studies is somewhat difficult to identify but is still present.,0
"The extensive pulmonary parenchymal abnormalities are again noted and position of the tracheostomy, right IJ line, and feeding tube remain unchanged since .",0
IMPRESSION: No change in the chest with a small residual basilar pneumothorax.,0
"12:06 PM CHEST (PORTABLE AP) Clip # Reason: eval for edema Admitting Diagnosis: ACUTE APPENDICITIS ______________________________________________________________________________ MEDICAL CONDITION: 76M s/p lap appy, intubated.",1
REASON FOR THIS EXAMINATION: eval for edema ______________________________________________________________________________ FINAL REPORT AP CHEST.,0
"INDICATION: Status post appendectomy, intubated, evaluate for edema.",0
Comparison is made with the prior chest x-ray obtained six hours prior.,0
"AP UPRIGHT OF THE CHEST: There has been an endotracheal tube, right-sided subclavian central venous catheter and nasogastric tube present, in satisfactory position.",0
There are bilateral pleural effusions greater on the right side which are unchanged given differences in technique.,0
There is bibasilar atelectasis appearing slightly worse in the left mid lung area.,0
IMPRESSION: 1) Satisfactory positioning of lines and tubes.,0
2) Bilateral pleural effusions which are unchanged.,0
"3) Bibasilar atelectasis, slightly greater on the left.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Coronary artery bypass x1(Left internal mammary artery grafted to left anterior descending artery)/Mitral Valve repair (#28mm CG annuloplasty ring)- History of Present Illness: 82 year old female with known mitral regurgitation who has been experiencing worsening shortness of breath and orthopnea.,1
She is followed closely by Dr. who has been adjusting her diuretic therapy.,0
"Despite medical therapy, she continues to experience heart failure symptoms.",1
She was seen in clinic by Dr. on and now presents for preadmission testing in preparation for surgery.,0
There was severe mitral regurgitation with myxomatous degeneration of both leaflets and partail flail.,0
The vena contracta was > 7 mm.,0
Multiplanar reconstructions were generated and confirmed on an independent workstation.,0
AORTIC VALVE: Mildly thickened aortic valve leaflets (?#).,0
MITRAL VALVE: Myxomatous mitral valve leaflets.,1
MR vena contracta is >=0.7cm Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.,0
post-CPB: patient was weaned from bypass with 1 mcg/kg/min of phenylehrine.,0
There was no evidence of new regional wall motion abnormalities and EF was > 55%.,0
A well seated mitral annuloplasty ring was seen with interrogation via Doppler revealing minimal residual regurgitation in the settinag of a mean gradient of 4 mm Hg.,0
Conclusions The left atrium is dilated.,0
The mitral valve leaflets are myxomatous.,1
"Electronically signed by , MD, Interpreting physician 12:32 ?",0
Brief Hospital Course: Ms. was taken to the operating room and underwent coronary artery bypass grafting x1(left internal mammary artery grafted to the left anterior descending artery)/Mitral Valve repair (#28mm CG annuloplasty ring).,1
Cross clamp time = 56 minutes.,0
Cardiopulmonary Bypass time= 74 minutes.,0
She was transferred in critical but stable condition to the CVICU.,0
She awoke neurologically intact and was extubated without difficulty.,0
Beta-blocker and diuretic was initiated.,0
She continued to progress and was transferred to the step down unit on POD#1 for further monitoring.,0
Physical therapy was consulted and evaluated the patient.,0
Ms. postoperative course was essentially uneventful.,0
She continued to progress and was cleared by Dr. for discharge to rehab on POD #5.,0
Medications on Admission: Lasix 40 qd Levothyroxine 25 qd Lisinopril 10 qd Metoprolol Succ 25 qd Pepcid Discharge Medications: 1.,0
Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing.,0
Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Particle/Crystal PO twice a day.,0
"Particle/Crystal(s) Discharge Disposition: Extended Care Facility: Raphaels TCU - Discharge Diagnosis: Coronary artery disease/Mitral Regurgitation Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr in 4 weeks () please call for appointment Dr , H. in 1 week, please call for appointment Wound check appointment 6 as instructed by nurse () Completed by:",1
"8:14 AM CT HEAD W/O CONTRAST Clip # Reason: eval SAH Admitting Diagnosis: CHRONIC MYELOGENOUS LEUKEMIA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 31 year old man with CML s/p allo transplant, now with low plt counts, fall, and active bleeding and frontal SAH on AM CT REASON FOR THIS EXAMINATION: eval SAH No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NONCONTRAST HEAD CT SCAN: HISTORY: Chronic myelogenous leukemia s/p transplant.",1
FINDINGS: Comparison with the prior study of reveals apparent interval resorption of the very small quantity of subarachnoid blood that had been detected in the region of the inferior aspect of the right frontal lobe.,0
"Both studies show a small amount of mucosal thickening, likely with frothy secretions layering in the posterior aspect of the left sphenoid air cell.",0
CONCLUSION: No new intracranial hemorrhage.,1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old male who was brought to the Emergency Department following a motor vehicle accident when his car hit a pole.,1
The patient got out of the car after the initial event and was then struck by another car.,0
"On arrival, there was a questionable seat belt sign versus dark ecchymosis.",0
The patient was apparently combative and required intubation in order to control him.,0
The patient was then transferred to the Trauma Surgical Intensive Care Unit after initial stabilization.,0
VITALS ON ARRIVAL: Blood pressure 120/palp.,0
"Physical examination: Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light.",0
"Chest: Bilateral breath sounds, clear to auscultation.",0
"Abdomen: Soft, nontender, nondistended abdomen.",0
"Rectal: Normal tone, guaiac negative.",0
Back/spine: No deformities or step-offs.,0
GCS initial time was 14.,0
RADIOGRAPHIC RESULTS: Initial assessment: Chest x-ray was negative.,0
CT of the head negative.,0
CT abdomen and pelvis negative.,0
Initial CBC: White blood cell count was 4.8 and hematocrit was 35.,0
The patient had a positive blood alcohol level of 270 as well.,0
"Also, the patient had a laceration of the scalp which was stapled.",0
"CONCISE SUMMARY OF HOSPITAL COURSE: After the patient spent the initial evening in the Intensive Care Unit secondary to intubation, the patient was extubated the following morning and transferred to the floor for further evaluation.",0
The patient's stay on the floor was completely uneventful.,0
The patient was evaluated with Physical Therapy who felt he was safe to go home.,0
The patient ultimately left with instructions for follow-up in the Trauma Clinic for removal of staples and re-evaluation of his condition.,0
Status post motor vehicle accident.,1
Ibuprofen 800 mg three times a day for pain.,0
Percocet 1-2 tablets every 4-6 hours for pain.,0
FOLLOW-UP PLANS: The patient has been instructed to make an appointment for follow-up in the Trauma Clinic.,0
Dictated By: MEDQUIST36 D: 11:23 T: 11:32 JOB#:,0
"LINE PLACEMENT Clip # Reason: rt picc 41 cm Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with newly placed rt picc line REASON FOR THIS EXAMINATION: rt picc 41 cm ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : COMPARISON: .",0
"FINDINGS: Right PICC is malpositioned, coursing cephalad within the right internal jugular vein, extending high within the visualized portion of the neck, with distal tip not visualized on the radiograph.",0
This has been communicated by telephone to the nurse caring for the patient.,0
Apparent worsening aeration within the right lung is difficult to evaluate due to positional differences between the two studies.,0
Attention to positioning on the follow up radiograph after repositioning of the PICC would be helpful in this regard.,0
"At that time, an apparently new opacity in the left retrocardiac area can also be re- evaluated.",0
", M. NSURG MICU-7 8:00 AM CT HEAD W/O CONTRAST Clip # Reason: 60 year old man with knwon SDH - SAH - eval for interval cha Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with knwon SDH - SAH - eval for interval change REASON FOR THIS EXAMINATION: 60 year old man with knwon SDH - SAH - eval for interval change No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",1
Stable diffuse subarachnoid and left subdural hemorrhage.,1
9:21 AM CHEST (PORTABLE AP) Clip # Reason: check placement/ eval for ptx Admitting Diagnosis: AORTIC STENOSIS\Transcatheter Aortic Valve Implant (TAVI) with Pump Stand-by (CoreValve) ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman s/p tranvenous pacer wire REASON FOR THIS EXAMINATION: check placement/ eval for ptx ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Check placement of transvenous pacemaker wire.,1
"Patchy bilateral pulmonary opacities, consistent with known interstitial fibrosis and superimposed edema, persist.",1
"There is hazy increased density at the lung bases, more pronounced on the left, consistent with pleural fluid.",0
The cardiac silhouette is partially obscured.,0
"An endotracheal tube, nasogastric tube, CoreValve, and right subclavian catheter remain in place.",0
A small bore catheter has been inserted on the right and can be followed to the right axilla.,0
Two leads are now projected over the heart.,0
There is no other definite change.,0
IMPRESSION: Small bore catheter inserted into the right brachium terminates at the level of the axilla.,0
11:04 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: evaluate post tpa and intubation for bradycardia and loss of ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman with code stroke REASON FOR THIS EXAMINATION: evaluate post tpa and intubation for bradycardia and loss of gag No contraindications for IV contrast ______________________________________________________________________________ WET READ: MPtb SUN 11:16 PM Compared to prior study at 20:44 there is new right frontal subarachnoid hemorrhage.,0
"______________________________________________________________________________ FINAL REPORT 79-year-old female status post TPA infusion, now with bradycardia and loss of gag response with concern for intracranial hemorrhage.",0
"COMPARISON: Head CT, at 20:44.",0
"FINDINGS: Compared to prior study two hours earlier, there is now new right frontal subarachnoid hemorrhage.",0
There is no significant associated mass effect or shift of normally midline structures.,0
The ventricular system is stable in appearance.,0
"Otherwise, there has been no significant short interval change.",0
IMPRESSION: New right frontal subarachnoid hemorrhage.,0
ER dashboard wet read placed at 11:15 p.m. on .,0
"NOTE ADDED AT ATTENDING REVIEW: There appears to be of /white differentiation in the left MCA territory, suggesting early infarction.",0
"4:44 AM CT HEAD W/O CONTRAST Clip # Reason: eval mass effect, bleed ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with met lung ca, fever, MS changes REASON FOR THIS EXAMINATION: eval mass effect, bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: AEBc TUE 6:18 AM no acute intracranial process; stranding in tissues of upper rt neck near skull base ______________________________________________________________________________ FINAL REPORT INDICATIONS: 66-year-old man with metastatic lung cancer, fever and mental status change.",0
FINDINGS: There is no evidence of intra- or extra-axial hemorrhage.,0
"The ventricles, cisterns, and sulci are unremarkable without effacement.",0
"There is no mass effect, hydrocephalus, or shift of the normally midline structures.",0
"There are secretions in the nasal cavity and nasal pharynx, but the visualized paranasal sinuses appear clear.",0
"The mastoid air cells are clear, and the osseous structures are unremarkable.",0
There is some stranding in the subcutaneous tissues overlying the right upper neck.,0
Please note that metastatic disease cannot be excluded by this non-contrast study.,0
"Stranding in the fat overlying the right upper neck, near the skull base.",0
Correlation with physical examination is recommended.,0
Note added at attending review: I think the soft tissue stranding is on the left.,0
10:44 AM UGI SGL CONTRAST W/ KUB Clip # Reason: Pt has NG tube in place.,0
Please assess stomach for leak.,0
Admitting Diagnosis: WOUND INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with ?,1
"gastrocutaneous fistula s/p repair of gastrocutaneous fistula 6 days ago, still with some drainage of through wound and JP drains.",1
REASON FOR THIS EXAMINATION: Pt has NG tube in place.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Status post repair of gastrocutaneous fistula with question of persistent fistula.,0
"COMPARISON: Multiple priors, the most recent CT abdomen dated .",0
FINDINGS: Initial scout image demonstrates retained oral contrast in the colon.,0
Surgical clips and drains project over the mid and left upper abdomen.,0
Oral Conray and thin barium were administered under fluoroscopic surveillance.,0
Prompt filling of the stomach and proximal small bowel is demonstrated.,0
"Near the mid point of the greater curvature of the stomach, there is a focus of contrast opacification which extends approximately 12 mm beyond the expected confines of the stomach contour.",0
"At no point does it extend further than this and it is therefore felt unlikely to represent an enterocutaneous fistula, perhaps instead representing a small contained leak.",0
No other foci of leak are observed.,0
There is no evidence of obstruction of the stomach or proximal small bowel.,1
"IMPRESSION: While there is no definitive evidence of enterocutaneous fistula, question of a small contained leakage is raised near the mid portion of the greater curvature of the stomach.",1
3:14 PM CHEST (PORTABLE AP) Clip # Reason: pneumothorax?,0
"______________________________________________________________________________ MEDICAL CONDITION: 82 year old man s/p AVR MVR, now w/ clinical picture of ARDS, desaturating.",0
Now changed right subclavian over wire REASON FOR THIS EXAMINATION: pneumothorax?,0
______________________________________________________________________________ FINAL REPORT INDICATION: Subclavian exchange through wire.,0
SINGLE VIEW CHEST: Comparison is made of recent prior exam two hours prior.,0
There has been interval exchange of a subclavian catheter through a wire with tip seen to terminate in the upper SVC.,0
"Otherwise, there has been no change in patient's chest examination.",0
IMPRESSION: Exchange of central venous line catheter with tip seen at the upper SVC.,0
", D. MED MICU-7 12:12 PM CHEST (PORTABLE AP) Clip # Reason: ptx Admitting Diagnosis: HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 48 year old man with LUL obstruction to clot from recent hemoptysis.",0
s/p rigid bronch with clot extraction REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ PFI REPORT PFI: Segmental atelectasis.,0
Subtotal atelectasis of the left lower lobe persists.,0
4:16 PM WRIST(3 + VIEWS) IN O.R.,0
PORT LEFT; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.,0
PORT LEFTClip # Reason: REDUX DISTAL RADIAL FX LEFT Admitting Diagnosis: MULTIPLE TRAUMA ______________________________________________________________________________ FINAL REPORT HISTORY: Reduction of distal radial fracture.,0
Fluoroscopic assistance provided to surgeon in the OR without the radiologist present.,0
Views demonstrate left distal radius with hardware.,0
Fluoro time recorded as 0.5 seconds on the electronic requisition.,0
Correlation with real-time findings and when appropriate conventional radiographs recommended for full assessment.,0
"LINE PLACEMENT Clip # Reason: Pt had a left sided picc line placed,59cm and needs tip conf Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with PICC who needs it for IV antibiotics.",0
"REASON FOR THIS EXAMINATION: Pt had a left sided picc line placed,59cm and needs tip confirmation please page at .",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Status post PICC line for IV antibiotics, needs tip confirmation.",0
COMPARISON: Prior chest radiograph .,0
Chest Radiograph portable view only: The PICC line is seen with the tip terminating in the lower SVC.,0
"Interval increase of right lower lung opacity is noted, obscuring the right hemidiaphragm line.",0
"In addition, there is a possible retrocardiac opacity in the left lower lung.",0
"Cardiac, mediastinal and hilar contours are normal.",0
PICC line with the tip terminating in the lower SVC.,0
Interval increase of right lower lung opacity with possible left retrocardiac opacity in the left lower lung.,0
"2:59 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for intraabdominal infection Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with worsening abdominal apin REASON FOR THIS EXAMINATION: eval for intraabdominal infection No contraindications for IV contrast ______________________________________________________________________________ WET READ: CXWc WED 3:40 PM Interval improvement in colitis, now w/moderate fecal loading.",0
Cirrhotic liver with trace ascites.,0
No focal collection or abscess.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old woman with worsening abdominal pain, history of recent C. diff colitis.",0
TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and pelvis following the administration of intravenous contrast material.,0
"CT ABDOMEN WITH IV CONTRAST: The lung bases demonstrate mild dependent atelectasis, without consolidation or pleural effusion.",0
"The heart is normal in size, without pericardial effusion.",0
"In the abdomen, the liver again demonstrates a nodular contour consistent with cirrhosis.",1
"A small amount of pneumobilia is seen centrally, which is new since prior exams.",0
No worrisome focal liver lesions are identified.,0
"The main portal vein and its branches are patent, demonstrating normal opacification.",0
The gallbladder is collapsed without evidence of stones or acute cholecystitis.,0
"The pancreas, adrenal glands, stomach, and duodenum are unremarkable.",0
"The kidneys enhance and excrete contrast symmetrically without hydronephrosis, stones, or renal masses.",0
A large simple cyst at the upper pole of the right kidney is unchanged.,0
"The abdominal aorta and its major branches are stable, demonstrating mild atherosclerotic calcification, but no dilatation.",0
There is no mesenteric or retroperitoneal lymphadenopathy by size criteria.,0
"CT PELVIS WITH IV CONTRAST: Since the preceding study, there has been a marked interval improvement in bowel wall thickening throughout the colon.",0
"The colon is now thin-walled with normal mucosal enhancement, and moderate fecal loading.",0
A small amount of simple fluid tracks through the mesentery and collects in the dependent pelvis.,0
Loops of small bowel are unremarkable.,0
Relatively collapsed urinary bladder and distal ureters are unremarkable.,0
There is no pelvic or inguinal lymphadenopathy by size criteria.,0
(Over) 2:59 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for intraabdominal infection Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ FINAL REPORT (Cont) OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesions.,0
Degenerative changes are again noted in the lumbar spine.,0
Moderate fecal loading of the colon.,0
Small amount of air in the biliary tree new since prior exams; correlate with recent ERCP/sphincterotomy.,0
If no recent procedure this could reflect biliary-enteric fistula.,0
Cirrhotic liver and splenomegaly with a small amount of ascites adjacent to the liver and in the pelvis.,0
No evidence of drainable fluid collection or abscess.,0
Height: (in) 62 Weight (lb): 126 BSA (m2): 1.57 m2 BP (mm Hg): 145/52 HR (bpm): 80 Status: Inpatient Date/Time: at 09:38 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of .,0
"Compared with the report of the prior study (images unavailable for review) of , there is minimal aortic stenosis.",0
Borderline elevated pulmonary artery pressures are slightly higher.,0
"6:19 AM CHEST (PORTABLE AP) Clip # Reason: proper ICD placement Admitting Diagnosis: V TACH ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with CAD s/p CABG, multiple PCI's, s/p ICD placement here with intermittent VT REASON FOR THIS EXAMINATION: proper ICD placement ______________________________________________________________________________ FINAL REPORT AP CHEST, 6:33 A.M. ON HISTORY: Coronary artery disease, CABG.",0
"IMPRESSION: AP chest compared to : Transvenous right ventricular pacer defibrillator lead follows the expected course, left axillary pacemaker.",1
"Heart is mildly enlarged, exaggerated by large mediastinal paracardiac fat collection.",1
Lungs are fully expanded and not hyperinflated and clear.,0
Recent pericardial tap of 400 cc fluid.,0
18- hr f/u Height: (in) 70 Weight (lb): 190 BSA (m2): 2.04 m2 BP (mm Hg): 126/86 HR (bpm): 112 Status: Inpatient Date/Time: at 09:30 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Low normal LVEF.,0
Conclusions: Overall left ventricular systolic function is low normal (LVEF 50%).,0
"There is a large pericardial effusion, primarily anterior and apical in location.",0
"The effusion is echo dense, consistent with blood, inflammation or other cellular elements, with consolidation.",0
Reduced lateral displacement of the epicardial surface of the heart (visceral pericardium) relative to the parietal pericardium suggests early adhesion formation and the possibility of effusive-constrictive physiology.,1
"No signs of cardiac tamponade seen Compared with the findings of the prior study (images reviewed) of , the endocardial border of the left ventricle is much better visualized, demonstrating preserved contractile function and no septal or free wall rupture.",1
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion Admitting Diagnosis: AORTIC VALVE INSUFFIENCY\AVR STANDARD /SDA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with AS s/p AVR.,1
REASON FOR THIS EXAMINATION: r/o PTX/Effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PSS TUE 9:36 PM The lung volumes and very mild perihilar edema are a common postoperative findings.,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 11:46 A.M. HISTORY: AVR.",0
IMPRESSION: AP chest compared to preoperative study on : Cardiomediastinal silhouette has a normal postoperative appearance.,0
Lung volumes are somewhat low and a very mild degree of edema is present in the perihilar upper lungs.,0
There is no pleural effusion or appreciable pneumothorax.,0
8:18 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: fx ______________________________________________________________________________ MEDICAL CONDITION: 20 year old woman s/p mvc w/ multiple head injuries REASON FOR THIS EXAMINATION: fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: AEBc SAT 9:33 PM No evidence of cervical spine fracture.,0
Soft tissue swelling cannot be assessed with intubation.,0
"______________________________________________________________________________ FINAL REPORT (REVISED) INDICATIONS: 20-year-old woman, status post motor vehicle collision with multiple head injuries.",1
FINDINGS: The patient is intubated.,0
The head is rotated towards the left side.,0
There is no evidence of a fracture of the cervical spine.,0
Serpiginous lucency in C6 most likely represents a nutrient foramen.,0
"Soft tissue swelling cannot early be well assessed due to intubation, and the presence of orbital and nasal fractures, with resultant hemorrhagic products within the oro- and nasopharynx.",1
The complex facial and orbital fractures are described on the accompanying study.,1
IMPRESSION: No evidence of cervical spine fracture.,0
"Head rotated toward the left, which may be positional, although rotatory subluxation is accordingly difficult to exclude by imaging.",0
"A linear lucenccy is the C6 vertebral body, most probably a nutrient foramen.",0
If clinically warranted an MRI with STIR images may be performed to exclude a subtle abnormality.,0
8:54 AM ART DUP EXT LO UNI;F/U Clip # Reason: graft flow Admitting Diagnosis: HIP PAIN ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with rt fem -dp bpg REASON FOR THIS EXAMINATION: graft flow ______________________________________________________________________________ FINAL REPORT HISTORY: 85-year-old man with right femoral to dorsalis bypass graft.,1
TECHNIQUE: Evaluation of the bypass graft was performed with color and spectral Doppler ultrasound.,1
FINDINGS: Peak systolic velocities of 208 cm/sec were seen in the right common femoral artery.,0
At the proximal artery-to-graft anastomosis the peak systolic velocity is 218 cm/sec.,1
"In the proximal portion of the graft a very significant increase is seen in the peak systolic velocity, which is 754 cm/sec.",0
Throughout the remainder of the bypass graft peak systolic velocities range between 24 and 43 cm/sec.,1
"COMPARISON: Proximal in-graft stenosis appears to have worsened as compared to the previous Doppler scan performed on , based on the significantly increased velocities.",0
IMPRESSION: Tight stenosis in the proximal right femoral to dorsalis pedis bypass graft.,1
The degree of stenosis appears to be worse as compared to the Doppler scan obtained a year ago.,0
3:26 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: s/p fall Field of view: 50 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with intracranial bleed REASON FOR THIS EXAMINATION: s/p fall No contraindications for IV contrast ______________________________________________________________________________ WET READ: 4:25 PM no acute traumatic injury.,1
no fractures ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall with intracranial hemorrhage.,1
TECHNIQUE: Helically-acquired contiguous axial images were obtained from were obtained from the lung bases through the symphysis pubis following the administration of 150 cc of IV Optiray.,0
Nonionic contrast was administered secondary to patient's history of trauma.,0
CT OF THE ABDOMEN WITH IV CONTRAST: Bibasilar opacities are present representing atelectasis versus aspiration.,0
No pleural effusions or pulmonary nodules are present.,0
"The liver, pancreas, spleen, adrenal glands, stomach, loops of large and small bowel are all within normal limits.",0
A nasogastric tube is seen with the tip in the antrum of the stomach.,0
"Within both kidneys, there are small, well-defined, approximately 1.0 cm to 1.5 cm hypodensities present, most likely consistent with simple bilateral renal cysts.",0
Both kidneys enhance symetrically and excrete normally.,0
The proximal ureters are within normal limits.,0
The abdominal aora is unremarkable without evidence of dissection or aneurysmal dilatation.,0
"CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, distal ureters, and prostate are unremarkable.",0
"A foley catheter is seen within an unremarkable, collapsed bladder.",0
"No free fluid, and no pelvic or inguinal lymphadenopathy is present.",0
IMPRESSION: 1) No acute traumatic injury seen within the abdomen or pelvis.,0
2) Simple bilateral renal cysts.,0
3) Bibasilar opacities in the lungs which may be atelectasis or aspiration.,0
(Over) 3:26 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: s/p fall Field of view: 50 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont),0
"7:17 AM CHEST (PORTABLE AP) Clip # Reason: followup Admitting Diagnosis: LUNG CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man s/p esophagogastrectomy REASON FOR THIS EXAMINATION: followup ______________________________________________________________________________ FINAL REPORT INDICATIONS: Status post esophagogastrectomy, followup study.",0
PORTABLE AP CHEST: Single AP portable view of the chest is compared with study from one day ago.,0
"FINDINGS: Again seen are sternotomy wires, right sided Swan-Ganz catheter, NG tube, right sided chest tube, and left sided subclavian catheter, all in unchanged and appropriate position.",0
"NG tube is in appropriate position, considering esophagogastrectomy.",0
"Cardiac silhouette remains enlarged, with a dense retrocardiac opacity.",1
There is improvement of vascular engorgement.,0
There is increased resorption of free intraperitoneal air.,0
"No pneumothorax, but likely bilateral pleural effusions.",0
"IMPRESSION: Improvement of CHF, with persistence of bilateral pleural effusions, cardiomegaly and retrocardiac collapse/consolidation.",1
8:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?,0
location/ anatomy for IVC filter Admitting Diagnosis: GUN SHOT WOUND ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with IVC to be placed REASON FOR THIS EXAMINATION: ?,0
location/ anatomy for IVC filter No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 10:24 AM PFI: The IVC is right-sided and has expected configuration.,0
"However, absence of intravenous contrast limits full assessment of the IVC including patency.",0
Bibasilar atelectasis/consolidation is concerning for a bibasilar pneumonia.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 26-year-old man with IVC to be placed.,0
TECHNIQUE: Contiguous axial imaging was performed from the lung bases through the pubic symphysis without administration of intravenous or oral contrast.,0
Sagittal and coronal reformats were obtained.,0
CT ABDOMEN WITH CONTRAST: The partially visualized lung bases demonstrate marked bibasilar atelectasis/consolidation which is concerning for a bibasilar pneumonia which may be due to aspiration in this patient.,1
The partially visualized heart appears normal.,0
The absence of intravenous or oral contrast and streak artifact limits full evaluation of the intra-abdominal contents.,0
"However, given the limitations the spleen, adrenals, pancreas, gallbladder, and liver appear normal.",0
In the lower pole of the left kidney is a 2-mm (2:40) and the lower pole of the right kidney (2:43) are non- obstructive renal calculi.,0
The stomach and abdominal loops of small bowel appear grossly normal.,0
There is a percutaneous gastrostomy tube with the bulb positioned within the stomach.,0
No free air or free fluid is seen.,0
"There are scattered, non- pathologically enlarged mesenteric nodes.",0
"Lack of intravenous contrast limits full evaluation of the IVC; however, it is in its expected configuration on the right side adjacent to the abdominal aorta.",0
The renal veins drain into the IVC at approximatly the L1 vertebral body level.,0
CT PELVIS WITHOUT CONTRAST: There is a Foley catheter in a partially decompressed bladder.,0
Pelvic loops of small and large bowel appear grossly normal.,0
"No free air, no free fluid is seen.",0
No significant pelvic or inguinal adenopathy is present.,0
"Again the lack of intravenous contrast limits full evaluation of the vascular system; however, the common femoral veins appear to coalesce into a right-sided IVC extending superiorly.",0
There is a midline lower pelvic ventral scar (2:61).,0
(Over) 8:08 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?,0
location/ anatomy for IVC filter Admitting Diagnosis: GUN SHOT WOUND ______________________________________________________________________________ FINAL REPORT (Cont) BONE AND SOFT TISSUE WINDOWS: No suspicious sclerotic or lytic lesions are seen.,0
There is a lumbar spinal catheter entering posteriorly at approximately the L1/L2 intervertebral level.,0
Normal IVC configuration on the right side.,0
Renal veins enter the IVC at approximatly the L1 level .,0
"Lack of intravenous contrast, however limits full evaluation including assessment of patency.",0
Bibasilar atelectasis/consolidation which is concerning for aspiration pneumonia.,0
"Foley catheter, a spinal catheter and a percutaneous gastrostomy tube as described.",0
"8:13 AM BILAT UP EXT VEINS US Clip # Reason: SWELLING, EVAL FOR DVT Admitting Diagnosis: DISSECTION ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with upper extremity swelling REASON FOR THIS EXAMINATION: eval for DVT ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TUE 12:49 PM PFI: 1.",1
"Partially occlusive thrombus in the left internal jugular, left subclavian, left axillary and left brachial veins.",0
Partially occlusive thrombus within the right internal jugular and right basilic and cephalic vein.,0
"Findings were discussed with nurse in the OR, Jaimol, who conveyed the message to nurse practitioner, at 10:46 a.m. on via telephone.",0
Findings were discussed with Dr. at 10:56 a.m. on via telephone.,0
PFI VERSION #1 TUE 11:16 AM PFI: 1.,0
"Findings were discussed with _____ nurse practitioner, at 7:46 a.m. on via telephone.",0
Findings were discussed with Dr. at 10:46 a.m. on via telephone.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 64-year-old man with upper extremity swelling.,1
"BILATERAL UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of the bilateral internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins were performed.",1
Partially occlusive thrombus is noted within the right internal jugular vein as well as within the right basilic and cephalic veins.,0
The right subclavian and axillary veins as well as both right brachial veins were noted to be patent with adequate compressibility and flow.,0
"The left internal jugular, left subclavian and left axillary vein showed a partially occlusive thrombus.",0
"Only one left brachial vein was visualized, which showed a partially occlusive thrombus.",0
The left basilic vein shows near total occlusion with thrombus.,0
The left cephalic vein showed partially occlusive thrombus.,0
Partially occlusive thrombus within the right internal jugular vein.,0
Near total occlusion of the left basilic vein.,0
Partially occlusive thrombus in the right basilic and cephalic veins.,0
"Findings were discussed with nurse, Jaimol, in the OR who conveyed the message (Over) 8:13 AM BILAT UP EXT VEINS US Clip # Reason: SWELLING, EVAL FOR DVT Admitting Diagnosis: DISSECTION ______________________________________________________________________________ FINAL REPORT (Cont) to nurse practitioner, , at 10:46 a.m. on via telephone.",1
"Findings were also discussed with nurse practitioner, , at 10:56 a.m. on via telephone.",0
10:45 AM CHEST (PRE-OP PA & LAT) Clip # Reason: CHEST PAIN;DYSPNEA ON EXERTION;CORONARY ARTERY DISEASE\CARDIAC CATH Admitting Diagnosis: CHEST PAIN;DYSPNEA ON EXERTION;CORONARY ARTERY DISEASE\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with 3 vessel CAD going for CABG REASON FOR THIS EXAMINATION: Pre-op for CABG ______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST HISTORY: Coronary artery disease for CABG.,1
"IMPRESSION: PA and lateral chest reviewed in the absence of prior chest radiographs: Moderate cardiomegaly, is predominantly left ventricular.",0
Mediastinal and pulmonary vasculature not engorged.,0
No edema or pleural effusion.,0
4 mm wide nodule projecting over the anterior right third rib is not corroborated by the lateral view.,0
"CT scanning would be the most efficient in characterizing this possible nodule, but any prior chest radiographs should be obtained to see if it is a new finding at all, warranting further investigation.",0
Findings were posted into the online record of critical findings for direct notification of the referring physician.,0
Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB PATIENT ID: This infant's post discharge name is .,0
"HISTORY OF PRESENT ILLNESS: This is a former 35 and week gestation baby, admitted for prematurity.",0
"Birth weight 3.195 kg, 90th percentile.",0
"Length 50 cm, 90th percentile.",0
"Head circumference 33.5 cm, 75 to 90th percentile.",0
"This is the former 3.195 kg product of a 35 and week gestation pregnancy, born to a 33 year-old, G3, P2 now 3 mother.",1
"Prenatal screens: Blood type 0 positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis b surface antigen negative.",0
Group beta strep status positive.,0
The pregnancy was complicated by insulin dependent diabetes mellitus.,0
"The mother received her primary care at in , MA.",0
She presented with spontaneous rupture of membranes.,0
She was transferred to due to lack of special care nursery beds at .,0
She was treated with intrapartum antibiotics which were initiated 5 hours prior to delivery.,0
She was taken to repeat Cesarean section under combined spinal and epidural anesthesia.,0
There was no maternal fever or fetal tachycardia or other concerns for chorioamnionitis.,0
"At the time of delivery, a nuchal cord times one was noted.",0
It was reduced prior to delivery of the infant's head.,1
"PHYSICAL EXAM AT DISCHARGE: Weight 3.345 kg, 75 to 90th percentile.",0
"Length 50 cm, 75 to 90th percentile.",0
"Head circumference 35 cm, 90th percentile.",0
"GENERAL: Alert, non dysmorphic, non distressed infant in room air.",0
Chest: Breath sounds clear and equal.,0
Spine straight with normal sacrum.,0
Neuro: Alert with symmetric tone and reflexes.,0
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: This infant has been in room air for his entire Neonatal Intensive Care Unit admission.,1
He did not have central apnea of prematurity.,0
He did have some feeding discoordination with oxygen desaturations and bradycardias.,0
These improved after the introduction of a Nuk nipple.,0
He has not had any episodes of oxygen desaturations or bradycardias while feeding for the 72 hours prior to discharge.,0
"At the time of discharge, he is breathing comfortably in room air with a respiratory rate of 30 to 60 breaths per minute.",0
Cardiovascular: This infant has maintained normal heart rates and blood pressures.,0
A soft intermittent murmur was noted early in the admission but has since resolved.,0
A murmur was not audible at the time of discharge.,0
Baseline heart rate is 130 to 160 beats per minute with a recent blood pressure of 76 over 42; mean arterial pressure is 51.,0
"Fluids, electrolytes and nutrition: The infant required IV Dextrose for low blood glucoses.",0
Enteral feedings were started on the day of birth.,0
The IV fluids were discontinued on day of life 4.,0
"At the time of discharge, he is ad lib breast feeding or taking Enfamil 20 calories per ounce formula.",0
"feeds, he uses a Nuk nipple.",0
Weight on the day of discharge is 3.345 kg.,0
"Infectious disease: Due to the group B strep positive status of the mother and his prematurity, this infant was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit.",1
A white blood cell count and differential were within normal limits.,0
A blood culture was obtained.,0
The infant was not treated with antibiotics.,0
The blood culture was no growth at 48 hours.,0
Hematologic: This infant is blood type A positive and direct antibody test negative.,0
Hematocrit at birth was 56.2%.,0
Gastrointestinal: This infant required treatment for unconjugated hyperbilirubinemia with phototherapy.,0
Peak serum bilirubin occurred on day of life 7 at 15 mg/dl.,0
His most recent rebound bilirubin was 11.0 on .,0
Neurology: This infant has maintained a normal neurologic examination during admission.,0
There were no neurologic concerns at the time of discharge.,0
Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses.,0
This infant passed in both ears on .,0
Psychosocial: This is a Spanish speaking family.,0
There are 2 siblings at home.,0
"PRIMARY PEDIATRICIAN: Dr. , , , , .",0
Feeding ad lib breast feeding or p.o.,0
feeding Enfamil 20 calorie per ounce formula.,0
Fer-in- 0.3 mL PO daily; (b.,0
)Tri-vi- 1mL PO daily 3.,0
Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age.,1
All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u.,1
(may be provided as a multi- vitamin preparation) daily until 12 months corrected age.,0
Car seat position screening was performed.,0
This infant was observed in his car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia.,0
State newborn screen was sent on and with no notification of abnormal results to date.,0
Immunizations: Hepatitis B vaccine was administered on .,0
"Immunizations recommended: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease.",1
"Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers.",0
This infant has not received ROTA virus vaccine.,0
The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age.,1
Follow-up appointments: Appointment with Dr. within 3 days of discharge.,0
Infant of an insulin dependent diabetic mother.,1
", Dictated By: MEDQUIST36 D: 01:26:19 T: 05:14:07 Job#:",0
12:04 PM FOOT 2 VIEWS RIGHT Clip # Reason: eval for interval change please Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 79 year old woman s/p repair metatarsal fx/ dislocation REASON FOR THIS EXAMINATION: eval for interval change please ______________________________________________________________________________ FINAL REPORT HISTORY: Fracture.,1
Two radiographs of the right foot demonstrate the patient to be status post arthrodesis of the first tarsal-metatarsal joint.,1
Assessment is limited by overlying dressing material.,0
No hardware loosening is seen.,0
There is evidence of an ossified fragment along the inferomedial base of the first metatarsal which represents a minimally displaced fracture.,1
The first tarsal-metatarsal joint dislocation seen on has been reduced.,0
There is a small plantar calcaneal spur.,0
IMPRESSION: Interval reduction of first tarsal-metatarsal joint dislocation.,0
Minimally displaced fracture involving the base of the first metatarsal.,1
Assessment limited by overlying dressing material.,0
"9:08 AM PORTABLE ABDOMEN Clip # Reason: r/o obstruction Admitting Diagnosis: NON-Q-WAVE MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with inferior stemi, NG tube with gastric/bloody drainage.",1
No BM in several days REASON FOR THIS EXAMINATION: r/o obstruction ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old female with status post myocardial infarction.,1
No bowel movement for several days.,0
TECHNIQUE: Portable supine view of the abdomen.,0
FINDINGS: There is normal bowel gas pattern without evidence of small bowel obstruction.,0
Contrast from prior CT scan intermixed with stool is visualized in the ascending and descending colon and the sigmoid and rectum.,0
An NG tube is visualized terminating in the stomach.,0
IMPRESSION: There is no evidence of small bowel obstruction.,0
Height: (in) 66 Weight (lb): 156 BSA (m2): 1.80 m2 BP (mm Hg): 108/65 HR (bpm): 108 Status: Inpatient Date/Time: at 10:54 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
"Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg).",0
IMPRESSION: No evidence of endocarditis or clinically-significant regurgitant valvular disease.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: Intramedullary nail, left tibia.",0
"Right Chest Tube History of Present Illness: 46 yo F s/p motor vehicle crash; T-boned with + airbag deployment +LOC, intubated in the field for decreased oxygen saturation.",1
Transferred from referring hospital to for continued trauma care.,0
EMERGENCY LUMBAR SPINE CT HISTORY: Motor vehicle accident.,1
TECHNIQUE: Axial post-intravenously enhanced images of the lumbar spine were obtained.,0
Images were only submitted at this time using a bone algorithm.,0
"FINDINGS: Within these limitations, there is no definite evidence of a fracture or abnormal alignment of the component vertebrae.",0
The absence of soft tissue algorithm precludes optimum demonstration of the intervertebral discs and ligamentous structures.,0
"There is no definite paraspinal pathology seen, although more comprehensive analysis of the abdomen was obtained by the pre- existent torso CT scan.",0
CT RECONSTRUCTION 3:32 PM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: 46 year old woman s/p MVA MEDICAL CONDITION: 46 year old woman s/p MVA REASON FOR THIS EXAMINATION: 46 year old woman s/p MVA CONTRAINDICATIONS for IV CONTRAST: None.,0
EMERGENCY CT SCAN OF THE THORACIC SPINE HISTORY: Motor vehicle accident.,1
TECHNIQUE: Axial non-contrast images of the thoracic spine.,0
These were acquired only with bone window settings with corresponding coronal and sagittal reconstructions.,0
FINDINGS: There is no definite spine fracture seen.,0
There is a depression of the superior endplate of L1 with small anterior bridging osteophytes.,0
"The depression, when viewed axially, appears consistent with a Schmorl's node.",0
"There is imaging of the right pneumothorax, consolidation within the superior segment of the right lower lobe and apparent collapse or consolidation of the left lower lobe.",1
CONCLUSION: No definite spine fractures.,0
Please note that the absence of soft tissue algorithms for reconstruction of the images precludes optimum depiction of the intervertebral discs and ligamentous structures.,0
"BILAT LOWER EXT VEINS PORT 8:49 AM BILAT LOWER EXT VEINS PORT Reason: please eval for DVT MEDICAL CONDITION: 46 year old woman with BL LE edema, immobilization REASON FOR THIS EXAMINATION: please eval for DVT INDICATION: 46-year-old female with bilateral leg edema and immobilization.",0
FINDINGS: Grayscale and Doppler son of the bilateral lower extremity veins was performed.,0
"Bilateral common femoral, superficial femoral, and popliteal veins exhibit normal flow, waveforms, augmentation, and compressibility.",0
IMPRESSION: No evidence of deep venous thrombosis in either extremity.,0
CHEST (PORTABLE AP) 12:52 PM CHEST (PORTABLE AP) Reason: S/P CT PULL AP CHEST 12:55 P.M .,0
Rule out effusion or pneumothorax.,1
IMPRESSION: AP chest compared to and 9: Study performed at 11:25 this morning excluding the apex of the right chest showed a right pneumothorax and right lower lobe collapse both increased substantially since .,1
Current film shows little if any change.,0
Left lower lobe atelectasis is present as well and small left pleural effusion are stable.,0
The heart is normal in size and midline.,0
Poor definition of the left bronchial tree suggests significant retention of secretions.,0
"CTA CHEST W&W/O C &RECONS 7:30 PM CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Reason: r/o PE Field of view: 36 Contrast: OPTIRAY MEDICAL CONDITION: 46 year old woman with tachypnea, difficulty maintaining sats REASON FOR THIS EXAMINATION: r/o PE CONTRAINDICATIONS for IV CONTRAST: None.",0
"INDICATION: History of tachypnea and difficulty maintaining sats, evaluate for pulmonary embolism.",0
TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung bases to the thoracic inlet.,0
CONTRAST: 100 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study.,0
CTA OF THE CHEST: No filling defects or pulmonary emboli identified within the pulmonary arteries to the level of the segmental branches.,0
The aorta demonstrates normal caliber and contour.,0
CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images demonstrate no mediastinal fluid or pathologically enlarged mediastinal lymphadenopathy.,0
Lung window images demonstrate prominent bibasilar atelectasis.,0
"Additionally, within the right lower lung zone, there is a focal opacity which corresponds to the area of contusion seen previously.",0
"There is now increased area of opacity adjacent to this, which may represent atelectasis.",0
"Additionally, within the left middle lung zone, there are two areas of faint opacities which may represent areas of atelectasis or aspiration.",0
"There is a right pneumothorax, which is small, but appears to have increased slightly in comparison to prior study.",1
"Additionally, there is a small amount of pneumomediastinum which is similar in comparison to the prior exam.",0
Limited images of the superior portion of the abdomen are unremarkale.,0
"BONE WINDOWS: Again seen are fractures within the sternum, and within the first, second and third left ribs, and within the right first rib.",0
"Prominent atelectasis at the lung bases bilaterally, which was not seen previously.",0
Opacity within the right mid lung zone corresponds to the area of contusion seen previously and new adjacent atelectasis.,0
New opacities within the left mid lung zone may represent focal atelectasis or aspiration.,0
"Right pneumothorax is again seen, and appears slightly increased in comparison to prior study.",1
"Multiple rib fractures again seen, and a sternal fracture.",1
Results were discussed with Dr. at 10:45 p.m. on .,0
"Orthopedic surgery was consulted, patient taken to the operating room on for IM nail left tibia fracture.",1
She is currently in a hinged brace and is on subcutaneous Lovenox.,0
Her staples were discontinued on day of discharge.,0
She is touch down weight bearing on her LLE and will follow up with Orthopedics in 1 week.,0
Plastic surgery was consulted because of her nasal bone fracture; this injury was treated with splinting for 1 week.,1
She will need to follow up in clinic on .,0
Psychiatry was consulted because of her history with mental health problems; it was noted that patient was delirious during their evaluation.,0
It was recommended that Risperidone and Klonopin to be initiated.,0
She should have Psychiatry consult while in rehab for ongoing assessment of her issues.,0
Social work was consulted for assessment of home situation and patient's initial reports of abusive relationship with boyfriend which she ultimately denied when social work investigated this allegation.,0
Physical therapy consulted and evaluation revealed need for short term rehab stay.,0
Patient has been accepted at a facility in .,0
Medications on Admission: Percocet Paxil Valium Risperidol Zonisamide Discharge Medications: 1.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day.,0
Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)).,0
Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous Q 24H (Every 24 Hours): Continue for 3 weeks.,0
Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain.,0
Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain.,0
Discharge Disposition: Extended Care Facility: Southeastern Nursing and Rehab Discharge Diagnosis: s/p MVC Nasal Septum Fracture Right Pneumothorax Pneumomediastinum Left Tibia/Fibula Fracture Discharge Condition: Stable Discharge Instructions: Follow up in Clinic in 1 week.,1
Follow up in Clinic on .,0
Follow up in Trauma Clinic in weeks.,0
Followup Instructions: Call for an appointment in Clinic in 1 week.,0
Call for an appointment in clinic for next Tuesday .,0
Call for an appointment in Trauma Clinic.,0
"12:32 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: Eval for PE, Right pneumothorax Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with bradycardia, hypotension REASON FOR THIS EXAMINATION: Eval for PE, Right pneumothorax No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: Bradycardia and hypotension.",0
Clinical concern for pulmonary embolism.,1
TECHNIQUE: Multidetector CT images of the chest before and after administration of IV contrast.,0
"Coronal, sagittal and oblique reformats were submitted for interpretation.",0
"FINDINGS: Filling defects in a subsegmental branch of the right upper lobe pulmonary artery (3:40) and lingular pulmonary artery (3:56, 57) are compatible with acute pulmonary embolism.",1
There is no intramural hematoma on non-contrast images and no evidence of aortic dissection on post-contrst images.,0
There is minimal amount of fluid in the pericardial recess.,0
A few subcentimeter mediastinal lymph nodes with the largest measuring just under a centimeter at the subcarinal station (3:49) are of uncertain clinical significance.,0
Atherosclerotic calcifications of the coronary artery are mild.,0
Minimal atherosclerotic calcifications of the aorta and aortic valve are noted.,0
"There is no pneumothorax, pleural effusion or focal pulmonary consolidation.",0
Multiple calcified pleural plaques along bilateral medial and lateral pleural surfaces are compatible with prior asbestos exposure.,0
Mild reticular opacities bilateral lung bases are noted.,0
Airways are patent to the level of subsegmental branches.,0
Partially imaged upper abdominal organs demonstrate an enlarged spleen measuring up to 16.5 cm.,0
Questionable ill-defined small area of hypodensity in the inferior aspect of the right lobe of the liver (2:68) only seen on non-contrst images is incompletely evaluated.,0
No suspicious bony lesions to suggest malignancy or infection is identified.,0
Right upper lobe and lingular subsegmental filling defects compatible with acute pulmonary emboli.,0
Discussed with ED and medicine team house-staff at 4:25 pm .,0
Pleural calcified plaques compatible with prior asbestos exposure.,0
"While mild reticular and ground glass opacities at bilateral posterior lung bases (Over) 12:32 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: Eval for PE, Right pneumothorax Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ FINAL REPORT (Cont) most likely represent dependent atelectasis, it can also be seen in early asbestosis.",0
"In case of clinical concern for asbestosis, an HRCT with prone imaging can be obtained on a non-emergent basis as an outpatient following treatment for the acute PE.",0
Borderline mediastinal lymphadenopathy of uncertain clinical significance.,0
Questionable hypodense lesion in the inferior aspect of the right lobe of the liver is incompletely characterized.,0
An ultrasound can be obtained for further evaluation if clinically warranted.,0
8:17 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ptx Admitting Diagnosis: CHEST TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man s/p RUL repair-foreign body removal REASON FOR THIS EXAMINATION: ptx ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 10:35 AM Slight improved atelectasis left lower lobe with otherwise no change.,0
"______________________________________________________________________________ FINAL REPORT Portable chest x-ray, , at 8:37 a.m., with comparison to previous study of earlier the same date.",0
"With the exception of slight improved aeration in the left lower lobe, there has not been a substantial change in the appearance of the chest since the recent study from earlier the same date.",0
1:15 PM MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # Reason: acute vs. chronic compression fractures Admitting Diagnosis: CHRONIC PULM DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with back pain REASON FOR THIS EXAMINATION: acute vs. chronic compression fractures No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: MRI OF THORACIC AND LUMBAR SPINE.,1
CLINICAL INFORMATION: Back pain and question of compression fracture.,0
"THORACIC SPINE: TECHNIQUE: T1, T2 and inversion-recovery sagittal and T2 axial images of the thoracic spine were acquired.",0
FINDINGS: There is marked scoliosis of lumbar spine convex to the right in the mid thoracic region.,0
"There are chronic-appearing compressions of T6, T8 and T11 vertebral bodies as seen on the recent CT.",0
"There is retropulsion of the T8 vertebral body, which indents the thecal sac, but no evidence of cord compression identified.",0
"The T11 vertebra demonstrates well-defined increased signal at the superior margin, which could be due to subacute-to-chronic compression.",1
"There is increased signal at the superior endplate of T12, which indicates mild acute compression.",0
"There is no retropulsion seen, however.",0
There are bilateral loculated pleural effusions seen.,0
"The esophagus appears dilated, which could be secondary to gastroesophageal reflux.",0
IMPRESSION: Chronic-appearing compressions of T6 and T8.,0
Subacute-to-chronic compression of T11 vertebra.,1
"Mild retropulsion at T8 and T11, without compression of the spinal cord.",0
Acute mild compression of the superior endplate of T12.,0
"LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion-recovery sagittal and T2 axial images of the lumbar spine were acquired.",0
FINDINGS: There is increased signal seen at the inferior endplate of L2 vertebral body indicative of mild acute compression.,0
There is a Schmorl's node at the superior endplate of L2.,0
The remaining lumbar vertebral bodies demonstrate no evidence of acute compression fracture.,1
There is no evidence of spinal stenosis or focal disc herniation seen.,0
Mild degenerative changes are identified.,0
"(Over) 1:15 PM MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # Reason: acute vs. chronic compression fractures Admitting Diagnosis: CHRONIC PULM DISEASE ______________________________________________________________________________ FINAL REPORT (Cont) In the visualized posterior soft tissues, mild increased signal is identified, which could be due to soft tissue edema.",1
No focal collection is seen.,0
IMPRESSION: Mild acute compression of the inferior endplate of L2.,0
No spinal stenosis or high-grade thecal sac compression.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDTHORAC CHIEF COMPLAINT: Shortness of breath times two days.,0
"HISTORY OF PRESENT ILLNESS: A 75-year-old man with a history of coronary artery disease status post a myocardial infarction in as well as hypertension, hypercholesterolemia, diabetes mellitus with shortness of breath times two days.",1
The patient reports he has had chest pains four to five times a year.,0
Can only walk about a half a block at a time before he gets short of breath.,0
Has two pillow orthopnea and a history of lower extremity edema in the past.,0
He also reports fever and chills with cough although it is nonproductive.,0
"Two days prior to admission at the outside hospital, patient ruled in for a myocardial infarction with a peak CK of 520 and troponin-I of 15.4.",0
"He was started on aspirin, beta blocker, heparin and a statin.",0
Treated for pneumonia with Levaquin and ceftriaxone.,0
Patient transferred to for cardiac catheterization with an EKG that showed lateral ST depressions.,0
Catheterization revealed severe three vessel disease.,0
Following cardiac catheterization the patient was to be evaluated for coronary artery bypass grafting by Cardiothoracic Surgery.,1
Coronary artery disease status post myocardial infarction in .,1
MEDICATIONS ON ADMISSION: Include: 1.,0
NPH 35 q. a.m. and 15 q. p.m. 3.,0
Prednisone 40 q. day which was started the day prior to admission.,0
SOCIAL HISTORY: The patient lives with his wife.,0
Prior to that he had a 150 pack years.,0
FAMILY HISTORY: Mother died at 75 of heart disease.,0
Father died at 66 also of heart disease as well as emphysema.,0
"PHYSICAL EXAMINATION: Temperature 97.9, heart rate 80, blood pressure 110/47, respiratory rate 20, oxygen saturation 95% on three liters.",0
"General: No acute distress, alert and oriented times three.",0
HEENT: Mucus membranes are moist.,0
Jugular venous distention is at 12.,0
"Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops.",0
"Abdomen is soft, non-tender, non-distended with positive bowel sounds.",0
One plus pulses bilaterally and no bruits.,0
"LABORATORY DATA: White count 17.9, hematocrit 32, platelet count 309,000.",0
"Sodium 129, potassium 4.3, chloride 98, CO2 23, BUN 27, creatinine 1.3, glucose 195.",0
RADIOLOGY: Chest x-ray was consistent with mild congestive heart failure.,0
"CATHETERIZATION: His catheterization showed a wedge of 21, cardiac output of 6, left main 60% ostial stenosis, 80% distal stenosis, left anterior descending artery with proximal occlusion, circumflex large OM1 with 50% proximal disease, right coronary artery with 90% mid disease and a small vessel.",1
No ventriculogram was done due to severe pulmonary hypertension.,1
ECHOCARDIOGRAM: the day following transfer to he underwent an echocardiogram which showed an ejection fraction of 30% with mild to moderate mitral regurgitation and moderate tricuspid regurgitation as well as moderate pulmonary hypertension.,1
"CAROTID ULTRASOUND: Additionally, patient had carotid ultrasound which showed no significant lesions in right or left carotids.",0
HOSPITAL COURSE: The patient was seen by Cardiac Surgery and accepted for surgery once his potential Infectious Disease issues were fully sorted out.,0
The patient was followed by the Medical Service while these issues were resolved and on he was brought to the Operating Room where he underwent coronary artery bypass grafting.,1
"In summary, the patient had coronary artery bypass grafting times two with the left internal mammary artery to the left anterior descending artery and a saphenous vein graft to the obtuse marginal.",1
His bypass time was 59 minutes with a crossclamp time of 39 minutes.,0
He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit.,0
At the time of transfer the patient was AV paced at a rate of 87 beats per minute.,0
His mean arterial pressure was 69 and CVP was 11.,0
"He had epinephrine at 0.2 mcg/kg/min, nitroglycerin at 0.3 mcg/kg/min and propofol at 10 mcg/kg/min.",0
He was weaned from the ventilator and successfully extubated over the course of postoperative day.,0
"His propofol, epinephrine and nitroglycerin were all weaned to off.",0
"He was, however, started on a Neo-Synephrine drip to maintain an adequate blood pressure.",0
"On postoperative day one the patient remained hemodynamically stable, however, he was noted to have some heart block with occasional episodes of Wenckebach, therefore, he remained in the Intensive Care Unit.",0
"Additionally, the patient continued to require low dose Neo-Synephrine to maintain an adequate blood pressure.",0
On postoperative day two the patient continued to be hemodynamically stable.,0
His heart rhythm was a first degree AV block.,0
His chest tubes were discontinued.,0
He was weaned from his Neo-Synephrine drip and diuresis was begun.,0
On postoperative day three the patient continued to be hemodynamically stable.,0
He was noted to have episodes of atrial fibrillation that were rate controlled with a ventricular response in the 90-100 range.,1
"He was begun on beta blockers, did not convert to a sinus rhythm until after receiving amiodarone.",0
"Following conversion to sinus rhythm, the patient's amiodarone was discontinued given his history of heart block.",0
On postoperative day four the patient continued to progress slowly.,0
He remained hemodynamically stable and he was transferred to Two for continuing postoperative care and cardiac rehabilitation.,0
Over the next several days the hospital course was uneventful.,0
He remained on Two where he worked with the nursing staff and Physical Therapy to increase his level of activity.,0
"His Foley catheter was discontinued on postoperative day four and he failed to void and, therefore, his Foley catheter was reinserted.",0
A review of the patient's past history indicated that he had had bladder surgery in and had been straight cathing himself daily since that time.,0
On postoperative day seven it was decided that the patient would most likely be stable and ready to be transferred to rehabilitation on the following day.,0
"PHYSICAL EXAMINATION AT DISCHARGE: Vital signs: Temperature 98.1, heart rate 79 sinus rhythm, blood pressure 126/40, respiratory rate 20, oxygen saturation 100% on room air.",0
"Weight preoperatively 81.6 kilos, at discharge 78 kilos.",0
"LABORATORY DATA: Hematocrit 30.2, sodium 137, potassium 3.9, chloride 102, CO2 24, BUN 16, creatinine 1.0, glucose 110.",0
"Cardiac: Regular rate and rhythm, S1, S2, sternum is stable.",0
"Incision with Steri-Strips open to air, clean and dry.",0
Extremities are warm and well-perfused.,0
"Right saphenous vein graft site with Steri-Strips open to air, clean and dry.",0
Lasix 20 mg q. day times ten days.,0
Potassium chloride 20 mEq q. day times ten days.,0
Plavix 75 mg q. day.,0
Atorvastatin 40 mg q. day.,0
_____________ 0.4 mg q. hs.,0
"Insulin NPH 20 units q. a.m., 8 units q. p.m. 11.",0
"Blood sugar 120 to 140, 3 units; 141 to 160, 4 units; 161 to 180, 5 units; 181 to 200, 6 units; 201 to 220, 7 units; 221 to 240, 8 units.",0
Coronary artery disease status post coronary artery bypass grafting times two with the left internal mammary artery to the left anterior descending artery and a saphenous vein graft to obtuse marginal.,1
Bladder cancer status post bladder surgery .,0
DISPOSITION: The patient is to be discharged to rehabilitation.,0
FOLLOW UP: He is to have follow up with his primary care physician three to four weeks following his discharge from rehabilitation.,0
Follow up with Dr. in three to four weeks.,0
Follow up with Dr. in six weeks.,0
Dictated By: MEDQUIST36 D: 15:55 T: 16:48 JOB#:,0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: new picc Admitting Diagnosis: URINARY TRACT INFECTION,PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with new R IJ (cordis removed, Quad LC placed) REASON FOR THIS EXAMINATION: new picc ______________________________________________________________________________ FINAL REPORT CHEST COMPARISON: Study performed at 16:48 the same day.",1
Single spot film of the chest is submitted.,0
"Compared to the prior study, the left-sided PICC line has been advanced such that the tip of the PICC line is in the proximal most aspect of the SVC.",0
6:11 AM PORTABLE ABDOMEN Clip # Reason: S/P CABG/LLE BKA W/INCREASED ABD.,0
DISTENSION-R/O ILEUS ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with S/P CABG REASON FOR THIS EXAMINATION: S/P CABG/LLE BKA W/INCREASED ABD.,0
DISTENSION-R/O ILEUS ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE FILM: HISTORY: CABG with increasing abdominal distention.,0
Distribution of bowel gas is unremarkable with gas present throughout the colon and gas filled non-dilated loops of small bowel.,0
No evidence for intestinal obstruction or ileus.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Oxaliplatin Attending: Chief Complaint: CC: Major Surgical or Invasive Procedure: EGD History of Present Illness: 76F with Stage IIB pancreatic cancer s/p whipple , DM II, aortic stenosis currently C4 Day 14 of oxaliplatin given and capecitabine (antimetabolite) who felt lightheaded and dizzy yesterday morning, with some abdominal cramping.",0
"Of note she has had chronic diarrhea since her Whipple procedure, her usual diarrhea is brown but for the last month she has had ""black tarry stools"".",0
Patient was seen in clinic on with HCT 24.2 and transfused 2 units of blood.,0
"Of note she did have guiac + stool and Dr. was to arrange for GI evaluation at that time, last colonoscopy was 5 yrs ago and showed polyp per patient, has never had EGD.",0
"Of note recently admitted for allergic response to oxaliplatin but noted to have a decreasing hct, and coumadin for her hx of PE was held.",0
"Received oxaliplatin and was taking capecitabine from both of which cause anemia, thrombocytopenia.",0
"ED Course: CT ABD/PELVIS IMPRESSION: Interval development of a moderate amount of ascites, without a clear identifiable cause.",0
No abnormal soft tissue density within the surgical resection bed in the pancreas is identified.,0
"Got 2 units RBC and admit to ICU for concern for decompensation, pt.",0
Received 5mg oral vitamin K. GI was made aware of patient.,0
"ROS: + melena, abd pain improved since ER Denies NSAIDS, ETOH Past Medical History: Oncologic History: Stage IIB pancreatic cancer, status post Whipple surgery on .",0
The patient is status post two and a half cycles of adjuvant gemcitabine followed by CyberKnife therapy.,0
"She then completed five weeks of external beam radiation therapy overlapping with Xeloda 500 mg twice daily as a radiosensitizer, which was completed on .",0
Her dose was eventually titrated up to 1000 mg twice a day during the remaining half of her radiation treatment.,0
She completed radiation on .,0
The decision was made to initiate adjuvant chemotherapy following radiation therapy for an additional two to three cycles.,0
"In total, she completed five cycles of gemcitabine on , complicated by the development of febrile illnesses including hypotension requiring ICU hospitalization.",0
"Her fifth cycle of chemotherapy was reduced to 800 mg/m2; however, two days following treatment, she required readmission to the hospital in the setting of hypotension, tachycardia.",0
She was discharged on .,0
"During that evaluation, CT of the abdomen and pelvis revealed likely disease progression involving the porta hepatis in the site of her pancreatic resection.",0
There was no overt evidence of hepatic metastases.,0
"Since that time-frame, we have initiated capecitabine combined with oxaliplatin.",0
She received her first dose on .,0
Aortic Stenosis (no echo on file) 2.,0
"Glaucoma 5. h/o uterine mixed carcinoma endometrioid and clear cell: stage Ib, grade III, s/p TAH-BSO 6. history of PE at time of pancreatic cancer diagnosis, formerly on Coumadin which was stopped secondary to port hematoma.",0
She was treated with Coumadin for 10 months.,0
"B12 deficiency, on oral B12.",0
"Social History: Lives alone in home in , but son or daughter stays with her at night or checking in on her while she is taking chemotherapy.",0
She used to work as a teacher's aid for special education.,0
She has never smoked and drinks occasional alcohol.,0
Stomach: Other There was a small amount of red blood in the stomach but no obvious abnormalities seen.,0
Other findings: The patient is s/p pylorus preserving whipple procedure.,0
The Afferent limb was normal without any blood.,0
"At the initial portion of the efferent limb was blood and a 2.5 cm linear ulcer in the setting of irregular, heaped up mucosa.",0
This occupied an approximately 6 cm area.,0
The 10 cm of efferent limb distal to this was normal.,0
Cold forceps biopsies were performed for histology at the Efferent Limb.,0
Impression: There was a small amount of red blood in the stomach but no obvious abnormalities seen.,0
The patient is s/p pylorus preserving whipple procedure.,0
(biopsy) Otherwise normal EGD to approximately 10 cm into the afferent and efferent limbs Recommendations: Will rush the pathology results.,0
Most consistent with recurrence of her pancreatic adenocarcinoma.,0
Less likely a benign anastomotic ulcer.,0
Will initiate carafate qid while awaiting pathology results ---------------- CT CT OF THE PELVIS WITH IV CONTRAST: Multiple surgical clips are seen within the pelvis.,0
There is a tiny amount of air within the bladder.,0
Recommend correlation with history of instrumentation/catheterization.,0
There is a moderate amount of fluid within the pelvis.,0
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion identified.,0
Moderate degenerative changes of the lower lumbar spine are identified.,0
General anasarca of the soft tissue structures is seen.,0
"IMPRESSION: Interval development of a moderate amount of ascites, without a clear identifiable cause.",0
"-------------- Ultrasound:FINDINGS: There are innumerable anechoic and hypoechoic lesions within the hepatic parenchyma, better evaluated on the recent CT, largerst consistent with simple cysts.",0
"The largest anechoic cyst is in the right liver lobe, measuring 10.2 x 9.0 x 8.5 cm.",0
"Normal waveforms and appropriate directionality of flow and appropriate waveforms are demonstrated in the main portal, right anterior and posterior as well as left portal veins.",0
"The IVC, right mid and left hepatic veins were evaluated and demonstrate normal directionality of flow as well as waveforms.",0
"The evaluation of the hepatic arteries is suboptimal; however, normal flow and waveforms are demonstrated in the left hepatic artery and main hepatic artery.",0
No evidence of portal vein thrombosis.,0
Unremarkable evaluation of liver vasculature.,0
"Numerous hypo- and anechoic lesions within the hepatic parenchyma, largest consistent with symple cysts, some are suboptimally evaluated on this study.",0
"Micro Urine culture: + Ecoli, pan-sensitive .",0
9:15 pm BLOOD CULTURE Source: Line-poc.,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S .,0
Chem 7 04:30PM BLOOD Glucose-175* UreaN-20 Creat-1.0 Na-137 K-3.5 Cl-106 HCO3-20* AnGap-15 03:26AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-136 K-3.1* Cl-107 HCO3-21* AnGap-11 05:00AM BLOOD Glucose-129* UreaN-19 Creat-0.9 Na-134 K-3.8 Cl-106 HCO3-18* AnGap-14 12:00AM BLOOD Glucose-67* UreaN-18 Creat-0.9 Na-135 K-3.6 Cl-108 HCO3-19* AnGap-12 12:00AM BLOOD Glucose-104 UreaN-18 Creat-0.8 Na-134 K-3.8 Cl-111* HCO3-19* AnGap-8 12:01AM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-133 K-3.7 Cl-109* HCO3-20* AnGap-8 12:00AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-133 K-3.7 Cl-107 HCO3-20* AnGap-10 12:00AM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-133 K-3.7 Cl-108 HCO3-20* AnGap-9 12:01AM BLOOD Glucose-102 UreaN-11 Creat-0.7 Na-134 K-3.8 Cl-107 HCO3-21* AnGap-10 .,0
"Misc 04:30PM BLOOD ALT-13 AST-31 AlkPhos-103 TotBili-0.8 12:00AM BLOOD ALT-11 AST-33 AlkPhos-92 Amylase-10 TotBili-1.3 12:01AM BLOOD Calcium-7.9* Phos-2.0* Mg-1.7 12:00AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.9 12:00AM BLOOD Albumin-2.2* Calcium-8.1* Phos-2.6* Mg-1.7 12:01AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.9 Brief Hospital Course: 76-year-old female with stage II pancreatic adenocarcinoma, s/p Whipple presented with melena in setting recent chemotherapy.",0
# Melena: The patient was initially admitted to the ICU for observation.,0
"The patient underwent an EGD that revealed a 2.5-cm ulcer at site of Whipple anastamosis, with no active bleeding, concerning for pancreatic cancer recurrence.",0
There was no other intervention performed.,0
Patient received a total of 4 units of PRBC and 1 bag plateletes during her ICU stay.,0
Patient was continued on IV protonix and was started on caragate.,0
"Her HCT stabalized, and she was transfered to the floor.",0
"On the floor, she continued to have melena with slowly down-trending HCT.",0
She was transfused several times.,0
"Surgery, GI and Radiation-Oncology were consulted, but all services recomended against intervention.",0
The GI team reported that due to the size and shape of the ulcer and the lack of obvious vessels that endoscopic cauterization would only damage more tissue.,0
She continued to have small amounts of melena which were thought to be residual blood moving through the GI tract rather than new bleeding.,0
Her HCT was stable at 31-33 for 5 days prior to discharge.,0
# Ecoli Bacteremia: The patient was found to have an Ecoli bacteremia on senstive to Cipro and ceftriaxone.,0
She was started intially started on Flagyl and Cefepime prior to speciation/sensitivities with the thought that she had a GI source.,0
She was also noted to to have an Ecoli UTI which could also have been a source.,0
She was then switched to Cipro for a 14 day course to end on .,0
"On day 9 of 14 day course, she was found to have SBP and was switched from Cipro to Ceftriaxone.",0
She will finished Ceftriaxone on - which will be a complete course of antibiotics for E.coli bacteremia/UTI and SBP.,0
# Ascites: CT abdomen revealed a moderate amount of ascites that was not new.,0
On the patient developed a rapidly enlarging abdomen over one day.,0
"An U/S was performed showing ascites, no portal vein thrombosis.",0
"WBC 1172, segs 50% c/w SBP.",0
The patient was switched from Cipro to Ceftriaxone to complete a 5 day course.,0
The patient never developed fevers or chills.,0
# Pancreatic CA: The patient was followed by the inpatient oncology service in conjunction with her outpatient team Dr and Dr. .,0
Chemotherapy including capecitabine was held.,0
She is to have no further chemotherapy for the time being.,0
"Medications on Admission: Atenolol 50 mg Daily (never took) Enalapril Maleate 10 mg Daily (never took) Glyburide 2.5mg daily, sugars<200 Lorazepam 0.5 mg Tablet Sig: Q4HR PRN Cyanocobalamin 50 mcg Daily Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Prochlorperazine Maleate 10 mg Q6H PRN Loperamide 2 mg Capsule QID PRN Xeloda Discharge Disposition: Extended Care Facility: House Discharge Diagnosis: Pancreatic Cancer Ulcer at Whipple site with upper gastrointestinal bleeding Ecoli Bacteremia UTI Ascites Spontaneous Bacterial Peritonitis Discharge Condition: improved Discharge Instructions: You were admitted for melena and were found to have a bleeding stomach ulcer.",1
You were started on high dose antacids and sucrulfate to help heal the ulcer.,0
You will need to have -weekly lab draws to monitor your hematocrit and bleeding.,0
You were also found to have a urinary tract infection and blood infection.,1
You were treated with antibiotics.,0
You also had spontaneous bacterial peritonitis - an infection in you abdomen related to the swelling (ascites).,1
You were also on antibiotics for this infection.,0
"If you have any bleeding, worsening melena, dizziness, low blood pressure, fevers or chills, you should go to the emergency room MD,",0
"12:03 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p fall, ?syncope.",0
"REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Fall, cervical locked facet.",0
Evaluate after question of syncope.,0
TECHNIQUE: Single portable AP view of the chest was obtained with the patient on a trauma board.,0
FINDINGS: Images are limited by the metallic rods on the trauma board.,0
"Allowing for the rotation, no significant abnormalities are seen of the cardiomediastinal silhouette.",0
There is a pulmonary opacity at the left lower lobe measuring 6 mm in size.,0
No pleural effusions or evidence of pneumothorax are evident.,0
"Discrete density over the left lower lung field probably represents a pulmonary nodule, and its density is suggestive of granuloma.",0
"When the patient is able, a dedicated PA/lateral view of the chest may be obtained for further localization; correlation with prior chest imaging, or continued followup would be required to assess for stability.",0
"Status: Inpatient Date/Time: at 16:34 Test: Portable TTE(Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
", H. NMED SICU-A 11:26 AM CHEST PORT.",0
LINE PLACEMENT Clip # Reason: Confirm placement of L subclavian CVL Admitting Diagnosis: SUBDURAL HEMATOMA;MIDBRAIN BLEED ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man s/p placement of L subclavian CVL REASON FOR THIS EXAMINATION: Confirm placement of L subclavian CVL ______________________________________________________________________________ PFI REPORT Left subclavian line tip projects over the expected region of the upper/mid SVC.,0
10:42 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man s/p MIE and J-tube placement REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Status post MIE and J-tube placement.,0
"Left lower lobe opacity has worsened, could be due to worsening atelectasis.",0
Right chest tube remains in unchanged position.,0
Multiple healed right rib fractures are again noted.,0
There is a questionable tiny right apical pneumothorax.,0
1:34 PM CHEST (PORTABLE AP) Clip # Reason: evaluate infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 41 year old woman with Sz.,0
"d/o, in non-convulsive status REASON FOR THIS EXAMINATION: evaluate infiltrate ______________________________________________________________________________ FINAL REPORT INDICATION: Seizure disorder in non-convulsive status.",0
The ET tube is in proper position.,0
The right subclavian central venous catheter is in the lower SVC.,0
The NG tube extends below the diaphragm.,0
The previously demonstrated linear opacities within the left lung base are slightly improved.,0
IMPRESSION: 1) Lines and tubes in proper position.,0
2) Mild residual left basilar atelectasis.,0
"4:52 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: BACK PAIN, ABD PAIN Field of view: 36 Contrast: OPTIRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with REASON FOR THIS EXAMINATION: back pain, abd pain, rule out aortic pathology No contraindications for IV contrast ______________________________________________________________________________ WET READ: EEZ WED 5:49 PM no aortic dissection.",0
Findings consistent with mechanical small bowel obstruction.,0
INDICATION: Back pain and abdominal pain.,0
TECHNIQUE: Axial images of the chest abdomen and pelvis were acquired helically from the lung apices through the pubic symphysis before and after administration of 150 cc of Optiray contrast.,0
Non-ionic contrast was used secondary to the rapid bolus injection rate required for CT angiography of the aorta.,0
There were no adverse reactions to contrast administration.,0
FINDINGS: CT OF THE CHEST WITH IV CONTRAST: The ascending aorta and descending aorta are normal in course and caliber.,0
There are two small areas of likely asymmetric mural plaque in the aortic isthmus.,0
"There is no extravasation, peri- aortic hematoma, dissection, or evidence of active extravasation.",0
"No pathologically enlarged axillary, hilar, or mediastinal lymph nodes are seen.",0
Atelectasis/scarring is seen in both lung bases.,0
There is mild esophageal dilatation with an air fluid level.,0
"There is a large hiatal hernia, which is slightly larger than on the prior study.",0
CT OF THE ABDOMEN WITH IV CONTRAST: The descending aorta is of normal course and caliber.,0
There are areas of mural plaquing and aortic calcification.,0
"Some of the plaque is eccentric, but there is no evidence of aortic dissection.",0
"The origins of the celiac axis, superior mesenteric artery, renal arteries, and inferior mesenteric artery are all patent.",0
There is small bowel dilatation proximally extending from the stomach through the proximal jejunum.,0
"There is an abrupt transition point in the mid-jejunum, distal to which the small bowel loops are collapsed.",0
"There is a small amount of stool seen in the cecum, but the colon is predominantly collapsed.",0
"No focal liver lesions are identified, but evaluation is somewhat limited with only one phase of contrast.",0
"The gallbladder is mildly distended and contains a stone in the fundus, but there is no evidence of acute cholecystitis.",0
The kidneys enhance symmetrically without evidence of obstruction.,0
Likely bilateral renal cysts are present.,0
"There is no ascites or pathological (Over) 4:52 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: BACK PAIN, ABD PAIN Field of view: 36 Contrast: OPTIRAY Amt: ______________________________________________________________________________ FINAL REPORT *ABNORMAL!",0
(Cont) mesenteric or retroperitoneal lymphadenopathy.,0
"CT OF THE PELVIS WITH IV CONTRAST: Distal ureters, bladder, and female reproductive structures are unremarkable.",0
"There are numerous colonic diverticula, but no evidence of acute diverticulitis.",0
There is no free fluid in the pelvis or pathological inguinal or pelvic lymphadenopathy.,0
Degenerative changes are seen throughout the spine.,0
No suspicious lytic or sclerotic lesions are present.,0
CT RECONSTRUCTIONS: Multiplanar reformatations demonstrate a mechanical small bowel obstruction and a normal aorta.,0
IMPRESSION: No evidence of aortic dissection.,0
"Findings consistent with mechanical small bowel obstruction, likely adhesion related.",0
Transition point seen in the left mid- abdomen.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY OF PRESENT ILLNESS: , twin #2, is a 33 and -week infant twin with a birth weight of 1570 grams who was admitted to the NICU for prematurity.",1
"MATERNAL HISTORY: She delivered at 33 and 3/7 weeks to a 38- year-old G2/P1 (now 3) mother with prenatal labs of maternal blood type A+, antibody negative, rubella immune, RPR nonreactive, hep B surface antigen negative, GBS status unknown.",1
"Pregnancy was remarkable for twins, dichorionic- diamniotic.",0
DELIVERY COURSE: This infant was delivered via C-section because of worsening maternal pregnancy-induced hypertension.,1
was crying and vigorous at delivery with Apgar's 8 and 9.,0
"PHYSICAL EXAMINATION: Upon admission to the NICU her weight was 1570 grams (25th percentile), length 44 cm (50th percentile), head circumference 29 cm (25th to 50th percentile).",0
Her oxygen saturations were 98% on room air.,0
Blood pressure was stable at 72/23 with a mean of 42.,0
"She was a nondysmorphic, well-appearing, twin, premature, female infant in no acute distress.",0
She did have episodes of apnea and bradycardia with feeds primarily.,0
She finished a 5-day countdown prior to discharge on .,0
"FLUIDS, ELECTROLYTES, NUTRITION/GASTROINTESTINAL: She attained full enteral feeds by day of life #4.",0
Her maximum bilirubin was 7.1.,0
She received phototherapy for 3 days early on in life.,0
HEMATOLOGY: Her hematocrit was 52.3% on day of birth.,0
"She never received a transfusion, and she is on iron therapy.",0
She has not received a second subsequent CBC.,0
INFECTIOUS DISEASE: She never received any antibiotics.,0
Blood cultures were no growth to date.,0
NEUROLOGY: Neurologic exam has been within normal limits.,0
AUDIOLOGY: Hearing screen was performed on with automated auditory brain stem responses; results were a pass in both ears.,0
OPHTHALMOLOGY: The patient's eyes were not examined given gestational age of 33 weeks.,1
PRIMARY PEDIATRICIAN: Dr. at ; phone number is (.,0
PMD was updated prior to discharge.,0
Feeds at discharge will be breast milk 24-kilocalories per ounce supplemented with Enfamil Powder or Enfamil 24.,0
Car seat position screening was performed and passed prior to discharge.,0
State newborn screening was sent on with results pending.,0
She received hepatitis B vaccine on .,0
"Synagis RSV prophylaxis should be considered from through for infants who meet any of the following 3 criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease.",1
Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers.,0
"FOLLOW-UP APPOINTMENTS: Include with the primary pediatrician, Dr. .",0
A VNA appointment will be set up for the home prior to discharge.,0
", Dictated By: MEDQUIST36 D: 16:29:06 T: 11:54:37 Job#:",0
"1:36 PM CHEST (PORTABLE AP) Clip # Reason: Pt s/p intubation for resp distress, finding of CHF.",0
"Please ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with DM, CAD, gout, admitted with cellulitis REASON FOR THIS EXAMINATION: Pt s/p intubation for resp distress, finding of CHF.",0
"Please evaluate for improvement ______________________________________________________________________________ FINAL REPORT INDICATION: S/p , CHF.",0
SINGLE-VIEW CHEST: There is moderate LV enlargement.,0
Upper zone redistribution is present.,0
There is blurring of the vascular detail at both lung bases.,0
There is a small amount of collapse/consolidation of the left lower lobe.,0
The ET tube is was in appropriate position.,0
A left-sided CVC terminates within the mid SVC.,0
IMPRESSION: Findings consistent with worsening CHF.,0
Lines and tubes in appropriate position.,0
12:58 PM OR VASCULAR A-GRAM Clip # Reason: place PEG Admitting Diagnosis: PULMONARY EDEMA ********************************* CPT Codes ******************************** * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 84 year old man with CT guided PEG placement REASON FOR THIS EXAMINATION: place PEG ______________________________________________________________________________ FINAL REPORT INDICATIONS: Please place percutaneous gastrostomy tube.,0
"NON-CONTRAST ABDOMINAL CT SCAN: After explaining the risks and benefits of percutaneous gastrostomy tube placement, consent was obtained from the patient's family.",0
"A preprocedure timeout was performed verifying patient identity, site of procedure, and the proposed procedure, using two patient identifiers.",1
The patient was placed supine on the CT table.,0
"Limited non- contrast scanning showed small bilateral pleural effusions, a moderate amount of ascites throughout the upper abdomen, and NG tube within the fundus, and a Dobhoff tube with the tip past the level of the ligament of Treitz.",0
CT-GUIDED NEEDLE INSERTION: CT fluoroscopy was used to select an appropriate spot for percutaneous gastrostomy tube placement.,0
The area was marked and prepped and draped in sterile fashion.,0
"CT-GUIDED NEEDLE INSERTION: Using CT fluoroscopic guidance, after insufflating the stomach with air via the NG tube, four metallic T- fasteners were placed anchoring the stomach to the anterior abdominal wall.",0
"Using the same introducer needle, the stomach was accessed using intermittent fluoroscopic guidance.",0
"With appropriate positioning confirmed within the stomach using CT fluoroscopy, a 0.035 Amplatz wire was advanced into and coiled within the stomach.",0
"CT-GUIDED CATHETER PLACEMENT: With appropriate positioning within the stomach verified by CT-fluoroscopy, the tract was serially dilated to accommodate the 12 French - gastrostomy tube, which was advanced into the stomach without difficulty.",0
"With appropriate positioning documented within the stomach by CT fluoroscopy, the pigtail was deployed, securing the catheter.",0
The catheter was attached to the skin using a StatLock.,0
Approximately 60 cc of dilute water- soluble contrast material was then injected.,0
Repeat non- contrast scanning showed the contrast contained within the stomach lumen.,0
There is no evidence of leak or free intraperitoneal air in areas covered by imaging.,0
Note was made that the existing NG tube was no longer in the stomach.,0
"The patient tolerated the procedure well without immediate complication, and left the department in stable condition.",1
(Over) 12:58 PM OR VASCULAR A-GRAM Clip # Reason: place PEG Admitting Diagnosis: PULMONARY EDEMA ______________________________________________________________________________ FINAL REPORT (Cont) Sedation was provided by ICU nursing staff.,0
IMPRESSION: 1) Successful CT-guided gastrostomy tube placement.,0
The catheter is in good position for conversion to gastrojejunostomy should this prove necessary.,0
Instructions for use given to ICU staff via POE.,0
2) Existing NG tube no longer in stomach at end of procedure.,0
"Should either be removed if no longer needed, or advanced if neccessary.",0
Results were discussed with Dr. at 4:12 PM on .,0
"Status: Inpatient Date/Time: at 11:19 Test: Portable TTE(Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: Mr. is a 43-year-old male with a past medical history of chronic hepatitis B and metastatic hepatocellular carcinoma who presented to the Emergency Room on after four episodes of hematemesis.,1
"He described the vomitus as bright red blood with some clots, possibly also with some coffee ground.",0
"He state through a translator that he had had one episode of hematemesis one year ago, was admitted briefly to an outside hospital, and then was discharged on some unknown medicines.",0
He has never had an upper endoscopy.,0
He denied any chest pain or pressure.,0
He had some shortness of breath associated with the vomiting.,0
He also had some lightheadedness.,0
He denied bright red blood per rectum or melena.,0
"PAST MEDICAL HISTORY: Chronic hepatitis B, poorly differentiated hepatoma by liver biopsy with metastases to the right adrenal gland, extensive metastases to the lung, and direct invasion of the superior vena cava.",1
"MEDICATIONS: On admission, Vicodin 1-2 tablets q 4-6 hours prn pain and Chinese herbal medicine.",0
FAMILY HISTORY: Strong family history of hepatoma (both parents and two brothers deceased of hepatoma).,0
SOCIAL HISTORY: The patient lives with his wife and 10-year-old son.,0
PHYSICAL EXAMINATION: A fatigued appearing male.,0
"Blood pressure 110/60, pulse 110 to 120, sat 97-99% on room air.",0
"HEENT: Pupils are equal, round, and reactive to light, mild scleral icterus.",0
Oropharynx with dry blood in the oropharynx.,0
"Cardiac, sinus tachycardia, grade 2/6 systolic murmur at the left sternal border, no increase in JVP.",0
Lungs clear to auscultation with decreased breath sounds at the bases bilaterally.,0
"Abdomen, distended with bowel sounds present, nontender.",0
"Extremities, 2+ pulses, dorsalis pedis bilaterally without edema.",0
"Neurologic, alert and oriented times three, moving all extremities spontaneously.",0
"LABORATORY DATA: On admission, white blood cell count 6.8, hematocrit 31.3, platelet count 92,000, PT 14.1, PTT 31.6, INR 1.4, sodium 137, potassium 5.6 (hemolyzed), chloride 106, CO2 26, BUN 12, creatinine 0.6, glucose 117.",0
"Labs from , LDH 734, alkaline phosphatase 282, total bilirubin 1.7, alpha fetoprotein 67.2 (29.3 on ).",0
"MRI of the abdomen from , 11 by 9 by 8 cm lesion in the liver, non occlusive thrombus in the right portal vein, tumor throughout right adrenal gland with invasion to the inferior vena cava, multiple pulmonary nodules.",1
"Pathology, biopsy of liver mass showed poorly differentiated malignant tumor with marked fibrosis and focal nodules suggesting likely cirrhosis.",1
"EGD from , grade 2 varices in the mid and distal esophagus.",0
"GI: The patient was admitted to the Intensive Care Unit at on and underwent urgent upper endoscopy which showed varices of the upper, middle and lower thirds of the esophagus as well as blood in the stomach.",0
Six bands were successfully placed during the procedure.,0
The patient was then started on Protonix 40 mg po bid and Octreotide drip over the next several days per the GI service.,0
He had no further episodes of hematemesis and his hematocrit remained stable.,0
On the patient underwent a repeat upper endoscopy which showed no active bleeding from the esophageal varices.,1
The patient was transferred from the Intensive Care Unit to the floor on .,0
"In terms of the patient's hepatocellular carcinoma, the oncology staff unfortunately was not able to offer any further chemotherapeutic options for Mr. cancer as it was widely metastatic.",0
Dictated By: MEDQUIST36 D: 13:21 T: 21:46 JOB#:,0
"6:01 PM UNILAT UP EXT VEINS US Clip # Reason: rule out left upper extremity dvt/septic embolus Admitting Diagnosis: ACUTE LUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with h/o AML s/p induction chemo, course complicated by febrile neutropenia, with new left upper extremity edema and erythema concerning for clot.",0
"REASON FOR THIS EXAMINATION: rule out left upper extremity dvt/septic embolus ______________________________________________________________________________ FINAL REPORT INDICATION: Left upper extremity swelling, history of AML and febrile neutropenia.",0
"Left upper extremity ultrasound grayscale and Doppler son of the left internal jugular, subclavian, axillary, brachial and basilic veins was performed.",0
"Normal flow, compressibility, augmentation and wave forms were demonstrated.",0
"5:41 AM CTA HEAD W&W/O C & RECONS Clip # Reason: HA, TUBES CSF WITH 4000 RBCS.",0
Contrast: OPTIRAY Amt: 80 ______________________________________________________________________________ MEDICAL CONDITION: 36 year old woman with 10/10 HA and tubes CSF with RBC's.,0
"Pt cannot tolerate MRI/A REASON FOR THIS EXAMINATION: ?Evidence aneurism, SAH?",0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 36-year-old woman with severe headache and lumbar puncture positive for red blood cells in four of four tubes.,0
Query aneurysm or subarachnoid hemorrhage.,0
Comparison: Images from a limited MRI brain examination of .,0
"Subsequently, rapid axial imaging was performed from the base of the skull through the brain during infusion of 80 cc of Omnipaque intravenous contrast material.",0
"Images were processed on a separate workstation with display of curved reformat, volume-rendered images, and maximum intensity projection images.",0
"FINDINGS: HEAD CT: There is no evidence of hemorrhage, edema, masses, mass effect or infarction.",0
HEAD AND NECK CTA: There is no evidence of aneurysm formation or other vascular abnormality.,0
The carotid and vertebral arteries and their major branches are with no evidence of stenosis.,0
The distal cervical internal carotid arteries measure 6 mm in diameter bilaterally.,0
"6:34 AM CHEST (PORTABLE AP) Clip # Reason: CXR s/p extubation Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME ______________________________________________________________________________ MEDICAL CONDITION: 42 y/o F w/ARDS, unclr etiology, ?",1
PNA now s/p extubation REASON FOR THIS EXAMINATION: CXR s/p extubation ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate status post extubation.,0
PORTABLE AP CHEST RADIOGRAPH: There has been interval removal of an ET tube and NG tube.,0
"Diffuse bilateral multifocal opacities are again seen, and there appears to be some slight improvement of this within the left lung.",0
"The heart size, mediastinal contours are stable in appearance.",0
IMPRESSION: Interval extubation and removal of an NG tube.,0
"Diffuse multifocal bilateral opacities are again seen, with slight interval improvement within the left lung.",0
3:28 PM PLEURAL ASP BY RADIOLOGIST LEFT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # CHEST U.S. Reason: ULTRASOUND GUIDED TAP OF LEFT PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with LEFT PLEURAL EFFUSION AND DIFFICULT TO WEAN REASON FOR THIS EXAMINATION: ultrasound guided tap of left pleural effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Left pleural effusion.,0
ULTRASOUND-GUIDED THORACENTESIS: A targeted left chest ultrasound was obtained to localize a pocket of fluid.,0
Informed consent was obtained through the patient's husband.,0
"The skin entry site was cleaned with Betadine, and 1% lidocaine was used for local anesthesia.",0
"An 18-gauge catheter was advanced into the fluid collection, and approximately 200 cc of serosanguineous fluid was withdrawn and sent for culture.",0
Dr. was present throughout the procedure.,0
IMPRESSION: Successful ultrasound-guided thoracentesis of the left pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ibuprofen Attending: Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: Ms. is an 83 year-old woman with history of recent hospitalization with upper GI bleed found to have gastric AVMs, atrial fibrillation, thyroid cancer s/p thyroidectomy, hypertension, hyperlipidemia, osteoarthritis, and CAD s/p MI presenting with bright red blood per rectum starting this morning.",1
She awoke from sleep at 1:30 AM to have bowel movement and had bright red blood mixed with dark stool.,0
Patient had four episodes of BRBPR at home and came to ED.,0
Pt also noted intermittent epigastric cramping.,0
"Patient was discharged from , yesterday following hospitalization for BRBPR and melena secondary to upper GI bleed while on dabigatran for atrial fibrillation.",1
Patient was admitted to MICU and received a total of 3 units PRBC for a transfusion goal of 30.,0
She received vitamin K 10 mg PO for elevated INR and was started on PPI.,0
An EGD showed multiple AVMs and gastritis and the AVMs were ablated.,0
The ppi gtt was continued and plans were made for colonoscopy.,0
She underwent colonoscopy which demonstrated no acute source for her bleeding.,0
"At discharge, anticoagulation was held.",0
Patient's hospitalization course was complicated by atrial fibrillation with tachycardia in 110s.,1
She received metoprolol IV and diltiazem IV and her home oral medications were restarted.,0
Patient was rate controlled prior to discharge.,0
Patient's anticoagulation was held during admission and at discharge given GI bleed.,0
"In the ED, initial vs were: P 100, BP 100/60 R 16 O2 98% on RA.",0
"Patient underwent NG lavage, which initally returned 10 - 15 cc of bright red blood (no coffee grounds) and then ran clear.",0
"Pt was noted to have 50 - 100 cc of bright red blood from rectum, no melena.",0
Exam was notable for epigastric tenderness.,0
Patient received 1 L NS and Type & Cross.,0
She underwent non-contrast CT of abdomen to assess for perforation given recent colonsocopy.,0
Labs were notable for a HCT of 37 (increased from 30 on discharge yesterday).,0
"On transfer HR 77, BP 97/62.",0
"On the floor, patient is complaining of intermittent crampy abdominal pain, but has not has any further episodes of BRBPR since the ED.",0
Edematous wall of a loop of distal small bowel and hazy mesentery is worrisome for ischemic bowel.,0
Right adnexal cystic lesion with layering hyperdense free fluid in the pelvis.,0
This suggests blood in the pouch of and surrounding the cystic lesion; significance is uncertain in this postmenopausal patient.,0
Suggest pelvic ultrasound or MRI for further evaluation.,0
"Large hiatal hernia with nasogastric tube in the stomach, above the level of the diaphragm.",0
"Multiple cystic lesions in the kidneys bilaterally, some of which are not simple on this noncontrast examination.",0
Recommend ultrasound on non-emergent basis for further evaluation if clinically indicated.,0
"Brief Hospital Course: 83 year-old woman with history of recent hospitalization for UGIB gastric AVM, atrial fibrillation not on anticoagulation, hypertension, and CAD s/p MI presenting with BRBPR x 1 day.",1
Mesenteric ischemia: Patient initally presented with small amounts of bright red blood per rectum and epigastric pain.,0
Hcts stable 30-37 during ICU course.,0
Patient had no further episodes of BRPPR after admission.,0
CT scan showed ischemic colitis.,0
Patient likely either had a watershed infarct from self-limited upper GIB or embolic mesenteric infarct from atrial fibrillation and discontinuation of anticoagulation.,1
The GI service wasd consulted and felt that she did not need an emergent endoscopic procedure.,0
Surgery was not consulted as it was not consistent with patient's goals of care.,0
She did not want to have surgical intervention.,0
She was treated supportively with IVF and antibiotics and diet advanced prior to discharge.,0
Patient will complete 10 day course of IV flagyl and IV cipro to be complete .,0
Acute renal failure: Patient's Cr increased to 2.3 from baseline .7.,1
Began to decrease and was 1.9 on transfer to the floor.,0
Most likely etiology ATN in the setting of acute volume loss.,0
"Patient was oliguric on admission, but urine output gradually picked up throughout hospitalization.",0
"# Atrial fibrillation: Prior to recent upper GI bleed patient had been on dabigatran and aspirin, which were stopped during last hospitalization.",1
"Patient takes atenolol and nifedipine at home, anticoagulation stopped (dabigatran) on last admission.",0
Patient in slow AFib currently with rates at 80.,0
"When patient stabilized, started metoprolol tartrate 12.5 .",0
Atenolol was held because of poor renal function.,0
Patient will follow-up with her cardiologist regarding re-starting anticoagulation in the future.,0
# Coronary artery disease: Patient with remote history of MI.,1
Pt with non-specific inferolateral ST changes.,0
Continued simvastatin 20 mg daily and started metoprolol 12.5 mg .,0
# Hypertension: Pt was hypotensive on admission to the ICU.,0
All home anti-hypertensive medications were held.,0
Patient was normotensive on transfer from ICU.,0
Started metoprolol tartrate 12.5 mg .,0
Consider restarting lisinopril 10 mg daily if patietn's blood pressure tolerates.,0
Titrate blood pressure medications as necesary.,0
# Hyperlipidemia: Continued Simvastatin 20. .,0
"# Thyroid cancer: Inactive, s/p thyroidectomy and reported in remission for years.",0
"# Code: DNR/DNI (confirmed with patient and health care proxy) Medications on Admission: - Simvastatin 20 mg dialy - nitroglycerin 0.3 SL tab PRN - nitroglycerin 0.1 mg patch Q24H - atenolol 50 mg daily - lasix 60 mg qAM, 20 mg qPM - zolpidem 5 mg qHS PRN insomnia - pantoprazole 40 mg Q12H - nifedipine 120 mg Tablet ER daily - lisinopril 80 mg daily - clonidine 0.3 mg PO BID - Tylenol-Codeine #3 300-30 mg 1-2 Tablets PO Q6 PRN pain Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).",0
"Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: PRIMARY: Mesenteric ischemia, bright red blood per rectum, hypotension, acute renal failure SECONDARY: Atrial fibrillation, coronary artery disease Discharge Condition: Mental Status: Clear and coherent.",1
Discharge Instructions: It was a pleasure to participate in your care Ms. .,0
You were admitted to the hospital with abdominal pain and rectal bleeding.,0
We found that you had inflammation in your colon that was likely because you did not get enough blood to your colon.,0
We treated you with IV fluids and antibiotics and your symptoms improved.,0
"We also found that your kidneys were not working well, either because you were dehydrated or your blood pressure was too low.",0
Your kidney function improved during your hospitalization.,0
Please make the following changes to your medications: 1.,0
Add cipro 400 mg IV BID - course will be complete 2.,0
Add flagyl 500 mg IV Q8H - course will be complete 3.,0
Start metoprolol tartrate 12.5 mg 4.,0
HOLD lisinopril 80 mg daily for now - you will restart this medication as needed to control your blood pressure 5.,0
HOLD nitroglycerin 0.1 mg patch Q24H - you will restart this medication as needed to control your blood pressure 6.,0
HOLD atenolol 50 mg daily - you will restart this medication to control your heart rate when your kidney function improves (you are on metoprolol instead of atenolol at this time) 7.,0
"HOLD lasix 60 mg qAM, 20 mg qPM - you will restart this medication at rehab when your kidney function improves 8.",0
HOLD nifedipine 120 mg Tablet ER daily - you will restart this medication as neede for hypertension 9.,0
HOLD clonidine 0.3 mg PO BID - you will restart this medication as neede for hypertension Followup Instructions: You will follow-up with the physicians at the extended care facilities.,0
"Department: CARDIAC SERVICES When: TUESDAY at 12:40 PM With: , M.D.",0
Building: SC Clinical Ctr Campus: EAST Best Parking: Garage MD,0
Admission Date: Discharge Date: Service: GEN HISTORY OF PRESENT ILLNESS: This is a -year-old female in fairly consistent health who was seen in the Emergency Room by the General Surgery service on .,0
"On physical exam at that time this patient had been complaining of nausea, vomiting, and abdominal distention and pain.",0
She had not moved her bowels in a number of days.,0
CT scan was obtained in the Emergency Room.,0
This revealed a small bowel obstruction with the transition point in the right lower quadrant.,0
There is a small amount of free fluid within the pelvis and along the inferior pole of the liver.,0
There was no evidence of bowel ischemia at that time.,0
The patient was then consented for exploratory laparotomy.,0
This was discussed with her primary care physician and with her family extensively before the surgery was undertaken.,0
Consent was taken from all necessary parties.,0
"PAST MEDICAL HISTORY: Significant for aortic stenosis, hypertension, atrial fibrillation, constipation, gastroesophageal reflux disease.",1
PAST SURGICAL HISTORY: Significant for an appendectomy at a young age.,0
Dictated By: MEDQUIST36 D: 13:07 T: 14:45 JOB#:,0
"11:56 AM CHEST (PA & LAT) Clip # Reason: eval LLL infiltrate, pna, effusion, edema Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE,SYNCOPE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with COPD and hypoxia, syncope a and h/o chf REASON FOR THIS EXAMINATION: eval LLL infiltrate, pna, effusion, edema ______________________________________________________________________________ FINAL REPORT STUDY CODED IS PA AND LATERAL BUT PERFORMED AS AN UPRIGHT FRONTAL AP CHEST AT 11:52 A.M. ON .",1
Evaluate left lower lobe consolidation.,0
"IMPRESSION: AP chest compared to chest radiographs since : Severe bullous emphysema is present most pronounced in the right upper lobe, accounting for vascular crowding in the right lower lobe, asymmetric distribution of edema and leftward mediastinal shift.",0
There is no good evidence for pneumonia.,0
Left apical pleural thickening could be evaluated by comparison to prior films to see if this has been a progressive finding.,0
Atrial and ventricular pacer leads project over their expected courses to the right atrium and right ventricle respectively.,0
Clip # Reason: pls eval for hydronephrosis Admitting Diagnosis: ACUTE LEUKEMIA;NEUTROPENIA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old woman with AML with acute renal failure REASON FOR THIS EXAMINATION: pls eval for hydronephrosis ______________________________________________________________________________ FINAL REPORT HISTORY: Leukemia and acute renal failure.,1
"FINDINGS: The right kidney measures 10.2 cm, and the left kidney measures 11.3 cm.",0
"While the kidneys are not small, they appear echogenic, which is suggestive of medical renal disease.",0
There are no renal stones or masses.,0
There are no perirenal fluid collections.,0
"IMPRESSION: The kidneys are normal in size but echogenic, which is suggestive of medical renal disease.",0
"7:01 AM CHEST (PORTABLE AP) Clip # Reason: Intubated pt, please assess tube position and also any new l Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man intubated from OSH, with likely PNA REASON FOR THIS EXAMINATION: Intubated pt, please assess tube position and also any new lung findings ______________________________________________________________________________ FINAL REPORT AP CHEST, 7:31 A.M., .",0
HISTORY: Intubated at an outside hospital.,0
"IMPRESSION: AP chest compared to and 8: Endotracheal tube tip is at the level of the sternal notch, approximately 4.5 cm from the carina, with the chin slightly flexed.",0
Advancing the tube by 2 cm would probably yield optimal positioning.,0
There has been clearing of what was probably pulmonary edema earlier on .,0
"Consolidation in the left lower lobe, which worsened from to has not cleared.",0
This could be pneumonia or pulmonary edema.,1
"Heart is top normal in size, and there is mild-to-moderate engorgement of mediastinal veins.",0
2:17 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: Eval for abscess.,0
Please use po and IV contrast.,0
Admitting Diagnosis: SEIZURES Field of view: 38 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 74 year old woman with seizure disorder s/p ileocolectomy for LBO.,0
REASON FOR THIS EXAMINATION: Eval for abscess.,0
No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 74 year old woman status post ileocolectomy for large bowel obstruction now with fevers.,0
TECHNIQUE: Multiple axial images from the lung bases to the pubic symphysis were obtained following the administration of oral contrast and 150 cc of Optiray.,0
"CT OF THE ABDOMEN WITH IV CONTRAST: There are small to moderate bilateral pleural effusions, with subsegmental consolidation/collapse bilaterally.",0
"The liver, spleen, pancreas, adrenal glands are normal in appearance.",0
"The kidneys are unremarkable with the exception of low attenuation foci in both kidneys, the largest on the right is approximately 1.6 and is a simple cyst.",0
Oral contrast is seen in the stomach and small bowel loops.,0
The small bowel loops are dilated throughout to the region of neo-ileal colic junction.,0
There is fluid seen in the transverse and sigmoid colon.,0
There is some free fluid in the right paracolic gutter.,0
CT OF THE PELVIS WITH IV CONTRAST: There is a foley catheter in the bladder.,0
No pathologically enlarged inguinal or pelvic lymph nodes.,0
Findings communicated by telephone to Dr on .,0
Dilated loops of small bowel throughout to the region of neo-ileal colic anastomosis.,0
This is worrisome for small bowel obstruction.,0
ADDENDUM; No abscess are seen.,0
The findings of small bowel obstruction were (Over) 2:17 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: Eval for abscess.,0
Admitting Diagnosis: SEIZURES Field of view: 38 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) comminucated via telephone to Dr. on .,0
"5:22 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields, heart size ______________________________________________________________________________ MEDICAL CONDITION: term infant with frequent desaturations REASON FOR THIS EXAMINATION: evaluate lung fields, heart size ______________________________________________________________________________ FINAL REPORT BABYGRAM CHEST: HISTORY: Term infant with frequent desaturations.",0
Evaluate lung field and heart size.,0
FINDINGS: The lung volumes are moderate.,0
There are streaky atelectatic opacities seen in the bilateral upper lobes and lower lobes medially.,0
These opacities are very mild.,0
The cardiomediastinal contour shows a heart size which is upper limits of normal.,0
There is no focal air space opacity seen.,0
9:21 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with ESRD and hypertensive urgency REASON FOR THIS EXAMINATION: r/o bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: EEZ FRI 9:44 PM no intracranial hemorrhage ______________________________________________________________________________ FINAL REPORT INDICATIONS: End-stage renal disease.,1
NON-CONTRAST HEAD CT: Portions of the study are limited by motion.,0
"There is no evidence of acute intracranial hemorrhage, hydrocephalus, shift of normally midline structures, or major vascular territorial infarction.",0
"Again are noticed focal areas of decreased attenuation in the periventricular white matter adjacent to the atria and occipital horns of the lateral ventricles bilaterally, which are consistent with chronic microvascular infarction, and are unchanged in appearance.",1
"A focal area of lacunar infarction is seen in the right thalamus, and another in the right basal ganglia.",0
Both of these are unchanged since the prior study.,0
Osseous and extracranial soft-tissue structures are unchanged in appearance.,0
LINE PLACEMENT Clip # Reason: 49cm SL R basilic PICC placed ?,0
tip Admitting Diagnosis: JOINT EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with septic knee REASON FOR THIS EXAMINATION: 49cm SL R basilic PICC placed ?,0
tip ______________________________________________________________________________ FINAL REPORT INDICATION: Right line placement evaluation.,0
SINGLE AP UPRIGHT CHEST RADIOGRAPH: Right PICC line guidewire tip is in the low SVC at the superior cavoatrial junction.,0
Left PICC line terminates in the upper SVC.,0
New linear atelectasis is seen in the right mid lung.,0
The left lung is well expanded and appears clear.,0
IMPRESSION: Right PICC line tip in the superior cavoatrial junction.,0
8:05 AM CHEST (PORTABLE AP) Clip # Reason: pls assess interval change.,0
"Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with severe AS, CHF exacerbation, ESRD.",1
REASON FOR THIS EXAMINATION: pls assess interval change.,0
______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 12:25 PM Marked improvement in still mild severe pulmonary edema.,0
Persistent moderate left pleural effusion with adjacent atelectasis and small-to-moderate right pleural effusion.,0
"______________________________________________________________________________ FINAL REPORT REASON FOR EXAM: CHF, ESRD, and severe AS.",0
Comparison is made with prior study performed the day earlier.,0
There has been marked improvement in still mild-to-moderate pulmonary edema.,0
Moderate left pleural effusion with adjacent atelectasis is unchanged.,0
The right pleural effusion with adjacent atelectasis has improved.,0
Cardiomegaly is partially obscured by the pleuroparenchymal abnormalities.,0
Right supraclavicular catheter remains in place as is right PICC.,0
1:23 PM CHEST (PORTABLE AP) Clip # Reason: eval for NG tube placement Admitting Diagnosis: LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with decompensated cirrhosis s/p NG tube placement REASON FOR THIS EXAMINATION: eval for NG tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: NG tube placement.,1
"In comparison with study of , there has been placement of a nasogastric tube that extends well into the left mainstem bronchus.",0
This information was telephoned to the nurse taking care of the patient in the unit at 1:37 p.m. on .,0
Discovery of this finding was made at 1:36 p.m.,0
11:28 AM CHEST (PORTABLE AP) Clip # Reason: eval s/p ct removal Admitting Diagnosis: THORACIC AORTIC ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with Asc.,0
Please with abnormalities at .,0
ETA to CSRU 45 minutes.,0
"REASON FOR THIS EXAMINATION: eval s/p ct removal ______________________________________________________________________________ FINAL REPORT INDICATION: 87-year-old female status post ascending aortic dissection, ascending aorta and hemiarch replacement.",1
PORTABLE CHEST X-RAY: The patient is status post median sternotomy.,0
Cardiomediastinal contour is consistent with patient's ascending aorta replacement.,0
"Right internal jugular Swan-Ganz catheter has been removed in the interval, with the sheath left in place.",0
"A right apical pneumothorax is minimally increased from one day earlier, but remains small in size.",0
"A right chest tube has been removed, and there is increased atelectasis at the right lung base.",0
"A left chest tube is in place, in unchanged position.",0
Mild/moderate linear atelectasis at the left lung base is expected post-surgery.,0
The left lung is otherwise clear.,0
Status post removal of right chest tube with minimal interval increase in size of small right apical pneumothorax.,0
New right lower lung atelectasis.,0
Status post removal of Swan-Ganz catheter with the sheath left in place.,0
These findings were discussed with Dr. at 2 p.m. on .,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending: Chief Complaint: syncope Major Surgical or Invasive Procedure: Replacment of Ascending Aorta and hemiarch (32mm Gelweave)/Aortic valve replacement (21mm CE pericardial)/Coronary artery bypass grafts x 4(LIMA-LAD,SVG-Dg,SVG-OM,SVG-PDA) History of Present Illness: This 80 year old female had a syncopal epsiode while driving and was involved in an accident.",1
Her work-up was remarkable for paroxysmal supraventricular tachycardia and the finding of a large thoracic aortic aneurysm.,1
"She was referred to Dr. who peformed an echocardiogram which showed the aorta to measure 6.9cm at the root, 6.3cm at the arch to 4.1cm in the descending thoracic aorta.",0
There was + aortic insufficiency without mention of the leaflet anatomy.,1
"Given the size of her thoracic aortic aneurysm, she is referred for surgical evaluation.",1
Subsequently cardiac catheterization was done to reveal triple vessel disease.,0
She was admitted for operation.,0
"HISTORY: Ascending aortic repair, AVR and CABG.",1
"IMPRESSION: PA and lateral chest compared to : Moderate left pleural effusion has increased slightly, small right pleural effusion is new or increased.",0
Mild postoperative enlargement of the cardiac silhouette is stable.,0
Upper mediastinal contour has normal postoperative appearance with no indication of recurrent localized bleeding.,0
"Bibasilar atelectasis is substantial, possibly worsened since .",0
Right jugular line tip projects over the superior cavoatrial junction.,0
"DR. Approved: MON 5:54 PM ECHOCARDIOGRAPHY REPORT , (Complete) Done at 12:10:01 PM PRELIMINARY Referring Physician Information , C. , Status: Inpatient DOB: Age (years): 80 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease.",1
"ICD-9 Codes: 440.0, V43.3, 424.1, 424.0 Test Information Date/Time: at 12:10 Interpret MD: , MD Test Type: TEE (Complete) 3D imaging.",0
"Son: , MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: 5% to 55% >= 55% Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: *6.5 cm <= 3.4 cm Aortic Valve - LVOT diam: 1.8 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation.",1
"REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated.",0
The ascending aorta is markedly dilated There are simple atheroma in the ascending aorta.,0
"Interpretation assigned to , MD, Interpreting physician Brief Hospital Course: Following same day admission she was taken to the Operating Room where her operation was performed as noted.",0
See the operative note for details.,0
"She tolerated the procedure, weaning fom bypass on Epinephrine and neosynephrine.",0
They were quickly able to be weaned off and she was extubated the following morning.,0
"CTs were removed on the first surgical day, beta blockers and ACE inhibitors were resumed for control of her hypertension.",0
She continued to progress and was ready for floor transfer on POD 2.,0
"Physical therapy worked with her for strength and mobility, diuresis towards her preoperative weight was continued.",0
Beta blockade and ACE inhibitors were adjusted to provide adequate blood pressure control.,0
She was evaluated for a rehabilitation facility to allow further recovery prior to eventual return home.,0
Pacing wires were removed on POD 3.,0
She was ready for discharge to rehab on postoperative day four with continued diuresis and zarolxyn for seven days.,0
Medications on Admission: Lipitor 10mg daily Atenolol 25mg daily Quinapril 10mg daily Discharge Medications: 1.,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever.,0
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.,0
Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: please give 30 minutes prior to lasix .,0
() after discharge from rehab Dr. after discharge from rehab Completed by:,0
"8:00 PM CHEST (PA & LAT) Clip # Reason: evaluate for interval change, pt with L sided pleuritic CP ( Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 57 year old woman with asthma, pneumonia, worsening wheeze and chest pain REASON FOR THIS EXAMINATION: evaluate for interval change, pt with L sided pleuritic CP (effusion?)",1
"and diffuse wheezing ______________________________________________________________________________ WET READ: EHAb FRI 8:19 PM Compared to , right perihilar and left mid and lower lung opacities persist but are greatly improved.",0
"There is a small left pleural effusion, which was present on CT dated but not seen on radiograph dated .",0
"Enlarged pulmonary arteries suggest pulmonary arterial hypertension, as seen on recent chest CTA.",0
Interval removal of right internal jugular catheter.,0
"Lung hyperinflation appears increased, with increased peribronchial cuffing, suggestive of small airways disease with obstructive physiology.",0
Discussed with Dr. by phone at 8:15 p.m. on at time of initial review of the study.,0
"______________________________________________________________________________ FINAL REPORT PA AND LATERAL CHEST FILM, AT 20:05.",0
"CLINICAL INDICATION: 57-year-old with asthma, pneumonia, worsening wheezing and chest pain, evaluate for interval change.",1
Comparison is made to the patient's prior study of at 3:17.,0
"PA and lateral views of the chest, at 20:05, are submitted.",0
IMPRESSION: Interval improvement in airspace opacities within the right perihilar/upper and middle lobe and left mid and lower lobe suggestive of an improving pneumonia.,0
Bilateral large pulmonary arteries consistent with known pulmonary arterial hypertension.,0
Coarsening of the interstitium bilaterally which likely reflects underlying small airways disease.,0
Interval removal of the right internal jugular central line.,0
No acute bony abnormality appreciated.,0
Height: (in) 74 Weight (lb): 290 BSA (m2): 2.55 m2 BP (mm Hg): 124/80 HR (bpm): 109 Status: Inpatient Date/Time: at 15:18 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated.,0
LEFT VENTRICLE: The left ventricular cavity is moderately dilated.,0
TRICUSPID VALVE: Mild to moderate [+] tricuspid regurgitation is seen.,0
12:02 AM MR CERVICAL SPINE Clip # Reason: c-spine injury?,0
Admitting Diagnosis: FALL;FACIAL FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p fall down stairs w/ closed head injury.,1
REASON FOR THIS EXAMINATION: c-spine injury?,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall, evaluate for cervical spine injury.",0
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the cervical spine was reviewed.,0
Skull base through T4 was visualized.,0
"There is a thin crescent of abnormal high STIR signal along the anterior prevertebral soft tissues beneath the anterior longitudinal ligament at C3-C5, though the ligament itself appears normal.",0
"Vertebral body alignment is anatomic, though there is note of mild thoracic kyphosis and cervical lordosis.",0
There is a mild loss of intervertebral disc height at C5- C6 and C6- C7.,0
There is a very mild broad- based posterior disc bulge at C5- C6 and right- based mild disc protrusion at C6-C7 causing moderate foraminal narrowing at this level.,0
There is no evidence for spinal canal stenosis or cord compression.,0
There is no abnormal signal within the cord.,0
IMPRESSION: Nonspecific prevertebral fluid at C3-5 that can belie ligamentous injury though the anterior longitudinal ligament itself appears normal.,0
Note that MR cervical spine is not as sensitive for detecting fracture as CT which is the preferred modality for evaluating for acute osseous injury.,0
"Dr. and I discussed these findings via telephone, 2pm, .",0
"2:14 PM CHEST (PORTABLE AP) Clip # Reason: eval for ptx Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p ct removal REASON FOR THIS EXAMINATION: eval for ptx ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST ON AT 14:17 CLINICAL INDICATION: 78-year-old with chest tube removal, evaluate for pneumothorax.",1
Comparison is made to the patient's previous study dated at13:53.,0
Portable semi-erect chest film at 14:17 is submitted.,0
Interval removal of the left basilar chest tube with no evidence of a pneumothorax.,0
Interval removal of the endotracheal tube and right internal jugular Swan-Ganz catheter as well as the mediastinal drains.,0
Status post median sternotomy for CABG.,0
Residual linear opacity in the left mid upper lung and at the left lung base likely reflect areas of subsegmental atelectasis.,0
No large effusions or pulmonary edema is evident.,0
"Overall, cardiac and mediastinal postoperative contours are stable.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: UROLOGY Allergies: Latex Attending: Chief Complaint: large right renal mass tumoral thrombus extending into the right renal vein, hepatic vein, and inferior vena cava Major Surgical or Invasive Procedure: Dr.",0
Retroperitoneal lymph node dissection 3.,0
Inferior vena cava removal (dictated by and performed by Dr. .,0
"Dr. PROCEDURE PERFORMED: Mobilization the liver and takedown of the caudate lobe off the inferior vena cava, resection of the infrahepatic inferior vena cava down to the bifurcation of the common iliac veins.",0
"History of Present Illness: 59F with recently diagnosed large right renal mass with tumoral replacement of the right kidney and tumoral thrombus extending into the right renal vein, hepatic vein, and inferior vena cava now s/p right radical nephrectomy with resection of IVC and RPLND.",1
She intially presented to her PCP back in with vague symptoms of fatigue and back pain.,0
In the month following she reported some abd discomfort and bloating and peripheral edema.,0
She was sent for CT abd/pelvis which then revealed the renal mass which was highly suspicious for renal cell carcinoma.,0
In the setting of IVC involvement the decision was made to proceed with tumor debulking as opposed to tissue biopsy.,0
Prior to surgery she was sent for staging with CT chest and bone scan which did not show evidence of metastasis.,0
"Past Medical History: PMHx: -HLD -osteopenia -basal cell carcinoma of forehead s/p excision -superficial melanoma s/p excision -cervical cancer -h/o PUD and h.pylori PSHx: -s/p hysterectomy and appendectomy Social History: SocHx: -30 py smoker - quit -occasional etoh -no IVDA Family History: FamHx: -sister - breast cancer Physical Exam: WdWn pleasant female, NAD, AVSS Abdomen soft, nt/nd appropriate tenderness along large incision line with staples/surgical skin clips.",1
Localized erythema c/w with skin clips.,0
"extremities soft w/out pitting, calf pain.",0
Bilateral lower extremities w/out pitting to palpation to proximal tibia areas.,0
Ms. was recoved in the TSICU afte surgery and kept intubated until POD1 where she was successfully weened and extubated.,0
She was transferred to the general surgical floor from the TSICU in stable condition on POD2.,0
"Pain was well controlled with an epidural managed by the Acute Pain service and she was hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and kept on subcutaneous heparin.",0
On POD2 she was out of bed to chair and by POD3 she was ambulating.,0
On POD2 her nasogastric tube was clamped and on POD3 it was discontinued alltogether.,0
"With the gradual passage of flatus her diet was slowly advanced, epidural discontinued and she was transitioned to oral pain medications.",0
Her labs were monitored daily and she did not require any blood transfusions.,0
Urethral Foley catheter was removed without difficulty and the remainder of the hospital course was relatively unremarkable.,0
"The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics.",0
"The patient was given explicit instructions to follow-up with Dr. , Dr. and her PCP.",0
Medications on Admission: Allergies: -latex Home medications: -cyclobenzaprine -diclofenac -vicodin 2.5mg / 500 -raloxifene -simvastatin Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain.,0
Disp:*40 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
Disp:*60 Capsule(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).,0
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
"Disp:*50 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP < 100, HR < 55 .",0
Disp:*45 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Renal cell carcinoma with a caval thrombus and extension of tumor.,0
POSTOPERATIVE DIAGNOSIS: Renal cell carcinoma with a caval thrombus and extension of tumor.,0
"Discharge Instructions: -Please also refer to the provided written instructions on post-operative care, instructions and expectations made available from Dr.",0
-Resume your pre-admission/home medications except as noted.,0
"ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -To help manage your Blood pressure (control hypertension) we have started you on a NEW medication called METOPROLOL listed here.",0
"metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP < 100, HR < 55 .",0
"A prescription ""script"" has been provided.",0
-Please keep a blood pressure log and review this medication and log with your surgeons and PCP.,0
Disp:*45 Tablet(s)* Refills:*2* -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Resume all of your pre-admission/home medications except as noted.,0
"Do not take Aspirin or Non-steroidal anti-inflammatories (ibuprofen, etc.)",0
unless advised to do so.,0
-Call your Urologist's and Vascular Surgeon's office to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions.,0
"-Do not eat constipating foods for 2-4 weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4.",0
Replace Tylenol with narcotic pain medication.,0
"-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -If you have been prescribed IBUPROFEN (the ingredient of Advil, Motrin, etc.)",0
", you may take this and Tylenol together (alternating) for additional pain control---please try TYLENOL FIRST and take the narcotic pain medication as prescribed if additional pain relief is needed.",0
-Ibuprofen should always be taken with food.,0
Please discontinue taking and notify your doctor should you develop blood in your stool (dark tarry stools) -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication.,0
Discontinue if loose stool or diarrhea develops.,0
"Colace is a stool-softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room.ks time.",0
Followup Instructions: -Call Dr. office at ( for follow-up AND if you have any urological questions.,0
?s Nurse Practitioner may be reached at the same number.,0
-You will follow-up in days for post-operative evaluation and Surgical skin clip (staple) removal Please call and arrange follow up with Dr.,0
"Please call your PCP for an appointment as well: Dr. , Completed by:",0
9:30 AM CHEST (PA & LAT) Clip # Reason: eval for effusion Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with s/p cabg REASON FOR THIS EXAMINATION: eval for effusion ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf FRI 1:31 PM Small left greater than right pleural effusions with associated atelectasis.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG, evaluate for effusion.",0
TECHNIQUE: PA and lateral radiographs of the chest.,0
FINDINGS: Small left greater than right pleural effusions with associated atelectasis are again seen.,0
Cardiomediastinal widening has decreased from the prior study.,0
Sternotomy wires and surgical sutures in place.,0
IMPRESSION: Small left greater than right pleural effusions with associated atelectasis.,0
9:09 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with new dobhoff REASON FOR THIS EXAMINATION: eval for placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST.,1
"Feeding tube has either been repositioned or replaced, with radiodense tip now terminating within the stomach.",0
9:44 PM CHEST (PORTABLE AP) Clip # Reason: Pt with decreased O2 sats.,0
"Please eval for pneumonia, CHF.",0
"Admitting Diagnosis: RENAL CELL CARCINOMA;FEVER,HYPOKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with metastatic renal cell CA, intubated, ?",0
R main stem obstruction REASON FOR THIS EXAMINATION: Pt with decreased O2 sats.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Metastatic renal CA.,0
"Single portable upright chest radiograph demonstrates marked bilateral mediastinal adenopathy, unchanged from .",0
Again noted is a right sided PICC line with its tip in the SVC.,0
There is a nasogastric tube with its tip in the body of the stomach.,0
"Multiple round pulmonary opacities are again seen in a background of prominent pulmonary vasculature, unchanged.",0
"The left costophrenic angle is not included on this examination, but the right sided pleural effusion is unchanged.",0
The patient's endotracheal tube has been removed and a tracheostomy is now in place.,0
Endobroncheal stents in the main stem bronchi are also new.,0
IMPRESSION: Interval removal of endotracheal tube and placement of tracheostomy.,0
"Placement of endobronchial stents in the main stem bronchi, bilaterally.",0
"Marked mediastinal nodal disease with pulmonary metastasis and prominent pulmonary vasculature, all unchanged.",0
"4:46 PM CHEST (PORTABLE AP) Clip # Reason: eval for PNA Admitting Diagnosis: VENTRICULAR FIBRILLATION ARREST ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with s/p revision R AKA, febrile REASON FOR THIS EXAMINATION: eval for PNA ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW ON HISTORY: Status post right AKA, afebrile, question pneumonia.",1
FINDINGS: Tracheostomy tube is present.,0
There is some patchy volume loss in the retrocardiac region and right lower lobe.,1
Appearance is similar compared to the prior study from three days ago.,0
"10:57 PM CHEST (PORTABLE AP) Clip # Reason: eval for ptx, infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with RUQ pain s/p liver bx REASON FOR THIS EXAMINATION: eval for ptx, infiltrate ______________________________________________________________________________ FINAL REPORT STUDY: Single portable AP chest radiograph.",0
INDICATION: Right upper quadrant pain after liver biopsy.,0
COMPARISON: CT chest from the same date.,0
FINDINGS: Cardiac silhouette is at the upper limits of normal.,0
No focal consolidation is identified to suggest pneumonia.,0
Median sternotomy wires appear intact.,0
No effusion or pneumothorax identified.,0
No displaced rib fractures are identified.,0
IMPRESSION: No evidence of acute cardiopulmonary process detected.,0
No evidence of free intra-abdominal air.,0
"9:17 AM CT HEAD W/O CONTRAST Clip # Reason: Please assess for re-accumulation of chronic subdurals Admitting Diagnosis: ACUTE RENAL FAILURE,HEMATURIA ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with SDH, r craniotomy REASON FOR THIS EXAMINATION: Please assess for re-accumulation of chronic subdurals No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT (REVISED) CLINICAL INDICATION: 78-year-old man with subdural hematoma status post right craniotomy, assess for reaccumulation of subdural hemorrhages.",1
TECHNIQUE: Axial 5-mm sections of the brain were obtained and compared to the most recent prior noncontrast head CT dated .,0
FINDINGS: There is no significant interval change in the subdural collections when compared to the prior study.,0
The drainage catheter has been removed from the left subdural collection.,0
There remains a small amount of pneumocephalus.,0
There are bilateral subdural low-attenuating collections consistent with chronic subdural hematomas.,1
There is no shift of the normal midline structures.,0
The -white matter differentiation is within normal limits.,0
There is no evidence of an intra-axial mass or hemorrhage.,0
IMPRESSION: No significant interval change in low-attenuating subdural collections consistent with chronic subdural hematomas.,1
"4:24 AM CHEST (PORTABLE AP) Clip # Reason: please eval for worsening pulm status Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with LUL PE and poss PNA, please eval for worsening REASON FOR THIS EXAMINATION: please eval for worsening pulm status ______________________________________________________________________________ FINAL REPORT INDICATION: Respiratory failure.",1
COMPARISONS: Chest x-rays from .,0
"FINDINGS: Small bilateral pleural effusions, right greater than left, are unchanged.",1
"Bilateral heterogeneous patchy opacities, are unchanged.",0
"Mediastinal, hilar, and cardiac silhouettes are stable.",0
Left subclavian line tip projects over mid SVC.,0
"NG tube is in nondistended stomach, its tip out of view.",0
"Small bilateral pleural effusions, right greater than left, stable in appearance.",1
"Bilateral patchy heterogeneous opacities, unchanged, may represent atelectasis or superimposed infection.",0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Aspirin / Penicillins Attending: Addendum: On , prior to EGD, the patient underwent a GI bleeding study which yielded delayed blood pool images showing abnormal activity within the region of the distal stomach and duodenum, which moved to the left upper quadrant.",0
The findings were consistent with active bleeding within the distal stomach or duodenum.,0
"In addition to the EGD, pt also underwent a colonoscopy on which yielded diveriticulosis, internal hemmorhoids and blood in the colon of unknown source.",1
GI recommended follow up bleeding study and angiography but patient refused these follow up diagnostic tests.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: This patient had lower extremity swelling for two months prior to coming in for preadmission testing.,0
Lower extremity edema times two months.,0
Status post left axillary lymph node removal in .,0
"Status post right lymphoma excision, right arm, .",0
High porphyrin level for which patient undergoes phlebotomy every six months; is the Hematologist.,0
MEDICATIONS PRIOR TO ADMISSION: 1.,0
Levoxyl 88 micrograms q. day.,0
Folic acid 1 mg p.o.,0
Climara 0.05 patch q. week.,0
ALLERGIES: She had no known drug allergies.,0
"PHYSICAL EXAMINATION: On her examination a couple of weeks prior to admission, she was alert and oriented.",0
Her pupils are equally responsive and reactive to light and accommodation.,0
Her neck was supple; she had no jugular venous distention.,0
No lymphadenopathy or thyromegaly and no carotid bruits.,0
"She had decreased breath sounds slightly on the right side, but her lungs were clear bilaterally and without any wheezing.",0
"Heart was a regular rate and rhythm; she has an S1, S2, and she had a Grade III/IV systolic murmur heard best at the right sternal border and left sternal border which radiated to the second ICS.",0
Her abdominal examination was benign.,0
Her neurologic examination was grossly intact with normal motor and sensory function.,0
"LABORATORY: Prior to admission, her catheterization showed normal coronaries with two plus mitral regurgitation and an ejection fraction of 60% as well as ascending aortic aneurysm, which had been found incidentally, preoperatively, on TTE.",1
"Preoperative labs were sodium 139, potassium 3.7, chloride 99, CO2 22, BUN 21, creatinine 0.8, hematocrit 40.3, platelet count 244,000, and a white count of 8.4.",0
"Additional laboratory work showed a blood sugar of 156, ALT of 13 and LDH of 243.",0
"PT 12.1, PTT 29.3 and INR of 1.0.",0
Preoperative chest x-ray showed no evidence of a pneumonia or heart failure.,0
"HO COURSE: On , the patient underwent a Bentall procedure with aortic homograft as well as aortic Dacron graft and a coronary artery bypass grafting times one with a vein graft to the right coronary artery by Dr. .",0
The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition.,0
"On postoperative day one, the patient did have an episode of ventricular tachycardia in the Operating Room the prior evening.",0
"The patient was on Cefazolin, Amiodarone at 1.0, Dobutamine at 3, Lidocaine at 2, Propofol at 30, Aprotinin drip as well as Sucralfate and Zantac.",0
"Postoperative hematocrit was 33, potassium 4.8, BUN 16, creatinine 0.7, with a blood sugar of 239, lactate 2.7, calcium 1.11, alkaline phosphatase 24, ALT 24, AST 103, and a total bilirubin of 0.6.",0
The patient remained intubated at that time with plans to wean to extubate and have the Propofol turned down as the patient was being sedated.,0
Amylase was ordered to be checked and the patient continued on perioperative antibiotics.,0
The patient was seen by Physical Therapy and Case Management reviewed the chart.,0
"On postoperative day two, the patient was off pressors and remained on Lidocaine at 1 and continued perioperative antibiotics.",0
The patient had some wheezes.,0
Heart was regular in rate and rhythm; it was in the 70s in sinus rhythm with a good blood pressure of 111/52.,0
"White count 9.0, hematocrit 27.8, platelet count 114,000, sodium 137, potassium 5.5, chloride 104, CO2 26, BUN 20, creatinine 0.8; a CK of 961.",0
Calcium was low and this to be repleted.,0
"The patient was receiving Lidocaine which was discontinued so that the patient could start Lasix diuresis and have Lopressor and aspirin, and the Swan was to be discontinued as well as restarting the thyroid medications.",0
The patient was followed by Physical Therapy and was transferred out to the Floor.,0
"On postoperative day three, the patient had some complaints of shortness of breath in the sub-xiphoid area, had a temperature maximum of 99.2 F., was maintaining good blood pressure and saturating 94% on four liters.",0
Chest tubes remained in place for an increased output since midnight the day prior.,0
The patient had bibasilar crackles with some poor respiratory excursion.,0
"Heart was regular in rate and rhythm; no murmur, no jugular venous distention.",0
"Chest x-ray showed no congestive heart failure, but had stable effusions bilaterally.",0
EKG showed normal sinus rhythm with no ST or T wave changes or ischemia.,0
"The patient continued with aggressive pulmonary toilet, was out of bed.",0
"Chest tubes were discontinued, labs were rechecked and discharge planning was begun.",0
"On postoperative day four, the patient still had occasional shortness of breath and received some nebulizers.",0
"The patient was ambulatory, was hemodynamically stable, saturating 97% on three liters with a blood pressure of 107/65 in sinus rhythm.",0
"There were decreased breath sounds bilaterally with occasional crackles, and no edema peripherally.",0
"The patient continued with ambulation and pulmonary toilet, and was seen again by Respiratory Care as well as Case Management.",0
"On postoperative day five, the patient was feeling improved with decreased shortness of breath and pain under control.",0
Still had bilaterally occasional crackles but the sternum was stable.,0
The patient continued with ambulation and chest Physical Therapy with plans for discharge the day after if possible.,0
"On the night of the 9th, the patient was found on the floor of the bathroom at approximately midnight in a kneeling position.",0
She slipped on some urine in the bathroom.,0
She denied hitting her head or pain or discomfort from her fall.,0
"At the time, her vital signs were 114/62; heart rate of 93; respiratory rate of 18; a temperature maximum of 98.9 F.; she was saturating 95% on two liters.",0
She was assisted back to bed.,0
The covering physician was made aware.,0
"On postoperative day seven, the patient had no complaints; her shortness of breath was improved.",0
Heart rate in sinus in the 80s.,0
The patient had some new inferior wound erythema at the staples on the sternal incision with no drainage.,0
Heart was regular rate and rhythm.,0
"Extremities had no cyanosis, clubbing or edema.",0
The patient continued to improve and was ambulating and having pulmonary toilet.,0
The patient continued also to receive nebulizer for part of that pulmonary regimen.,0
Th complained of some vision changes on the 10th.,0
"She had some complaints to nursing about the way ""her eyes were working"".",0
A routine EEG was performed and Neurology consultation was obtained on the 10th.,0
"The patient was complaining of blurry vision which had been getting a little bit worse and Neurology made some recommendations, and an MRI study was ordered.",0
"The attending Neurologist noted that this was possibly an old lesion in mid-brain or thalamus and it may be related to stroke, but was too small to be seen on MRI.",0
The MRI report is on record.,0
Please note the final report.,0
"They did tell the patient that she had a good prognosis with excellent recovery to be expected, but the final report of the MRI was not available at that moment for the neurologist.",0
Dr. signed off to make sure that everyone understood that it was okay for the patient to have an MRI.,0
The patient did have occasional tachy dysrhythmias over 36 hours with scant drainage from the inferior margin of her sternum with mild erythema around her staples but her sternum was stable.,0
"Her white count was 10, hematocrit 32.",0
The patient did have an episode of atrial fibrillation.,0
"Otherwise, the patient felt okay.",0
She felt that her vision is somewhat improved.,0
"Sodium was 136, potassium 4.1, hematocrit 32, platelet count 383,000.",0
"Chloride 98, CO2 28, BUN 14, creatinine 0.9 with a blood sugar of 120.",0
Her lungs were clear bilaterally.,0
At this point there was a question whether or not this was a posterior circulation cerebrovascular accident.,0
"Labs were reasonable and the plan was to let the patient discharge to home soon, as soon as Physical Therapy felt the patient was safe to ambulate at home.",0
Final report of the MRI was being awaited.,0
"The patient, on the 14th, said that she would like to see the Neuro-ophthalmologist.",0
Inferior aspect had some erythema with very scant yellow exudate.,0
Right thigh incision was okay.,0
Left groin incision had some mild erythema with no exudate.,0
Sternum was stable with staples in place.,0
"Again, the patient did continue to have a postoperative supra-nuclear upward gaze, question of a palsy, but this was not seen definitively on the MRI/MRA.",0
"The patient was seen by Neuro-Ophthalmology on the 14th prior to discharge, who noted that this palsy was most likely reflective of a pontine hypoperfusion injury secondary to this difficult surgical procedure that she had.",0
"Please refer to the final report of the MRI, and Dr. , Neuro-Ophthalmology, recommended that the patient be seen in the Eye Clinic for more detailed evaluation the following week, and the patient was discharged to home on , with services provided by the .",0
The patient had instructions to see Dr. within 30 days.,0
"To see the Neuro-Ophthalmologist, Dr. at in one week.",0
"As well, follow-up with her primary care physician.",0
Status post Bentall procedure with homograft with coronary artery bypass grafting times one.,0
Status post mitral valve prolapse.,1
Porphyria with q. six months phlebotomy.,0
Status post abnormal ocular gaze with a question of pontine injury; final results on MRI.,0
Dilaudid 2 mg q. four hours p.r.n.,0
Combivent Multi-Dose Inhaler two puffs p.r.n.,0
q. day times seven days.,0
Climara Patch 0.05 mg q. Wednesdays.,0
four times a day times two weeks.,0
three times a day times one week.,0
twice a day times the following week.,0
"q. day times the final two weeks, and then discontinue Amiodarone.",0
q. day; please note that this is 88 micrograms.,0
"The patient was also given instructions to leave the staples intact and to return to Clinic in one week, on F-6 as well as the other postoperative proscribed visits recommended in the prior paragraph.",0
DISPOSITION: The patient was discharged to home on .,0
Dictated By: MEDQUIST36 D: 11:01 T: 14:06 JOB#:,0
"11:48 AM CHEST (PORTABLE AP) Clip # Reason: eval effusions, CT placement Admitting Diagnosis: PNEUMONIA, ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with with increasing shortness of breath, RLL PNA, now in MICU, intubated c hypoxia resp failure REASON FOR THIS EXAMINATION: eval effusions, CT placement ______________________________________________________________________________ FINAL REPORT INDICATION: Increasing shortness of breath, right lower lobe pneumonia, hypoxia.",1
VIEWS: AP view compared with upright AP view from .,0
"FINDINGS: The endotracheal tube, left subclavian central venous line, right chest tube, and nasogastric tube remain in stable and satisfactory positions.",0
There is continued right lower lobe consolidation and a small right pleural effusion.,1
"Small right pneumothorax is likely present at the right costophrenic angle, not significantly changed from the prior study.",0
The left lung remains grossly clear.,0
There is extensive subcutaneous emphysema within the right chest wall.,0
IMPRESSION: 1) Continued right lower lobe collapse/consolidation with small right pleural effusion.,1
2) Stable appearance of small right pneumothorax at the right costophrenic angle.,0
"3) Extensive subcutaneous emphysema in the right chest wall, increased from the prior study.",0
1:12 PM US EXTREMITY NONVASCULAR Clip # Reason: *** BILATERAL please!,0
"please evaluate for any fluid collecti Admitting Diagnosis: ACUTE RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with HIV, Staph aureus bacteremia, with b/l hip prosthesis who is still spiking temps on Vanc REASON FOR THIS EXAMINATION: *** BILATERAL please!",1
"please evaluate for any fluid collections in b/l hips, thanks ______________________________________________________________________________ FINAL REPORT INDICATION: 55-year-old man with HIV, bacteriemia, evaluate for fluid collection in bilateral hips.",0
COMPARISON: No previous ultrasound for comparison.,0
FINDINGS: Transverse and sagittal images were obtained of the region of the hip bilaterally.,0
No fluid collection is identified.,0
IMPRESSION: No fluid identified in either hip.,0
Status: Inpatient Date/Time: at 10:49 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Billing error corrected.,0
No changes made in findings.,0
WJM LEFT ATRIUM: Moderate LA enlargement.,0
Conclusions: Pre Bypass: The left atrium is moderately dilated.,0
The anterior mitral leaflet is tethered and myomatous.,0
The posterior leaflet is severely degenerated.,0
Dr. was notified in person of the results at the time of study.,0
Post Bypass: The pateint is s/p mitral valve repair.,1
There is minimal residual mitral regurgition.,0
"The valve is functioning appropriately, and has a maximal gradient of 8 mmHg.",0
Left and right ventricular function is preserved.,0
"7:05 AM NEONATAL HEAD PORTABLE Clip # Reason: evaluate bilateral gr 3 IVH Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant BORN AT 25 WEEKS GESTATION, DONOR TWIN OF TWIN/TWIN TRANSFUSION SYNDROME, unstable REASON FOR THIS EXAMINATION: evaluate bilateral gr 3 IVH ______________________________________________________________________________ FINAL REPORT PORTABLE NEONATAL HEAD ULTRASOUND HISTORY: Six-day-old girl who is a triplet and was born prematurely at about 25 weeks EGA.",1
History of bilateral grade III germinal matrix hemorrhage.,1
COMPARISON STUDIES: Portable neonatal head ultrasound .,0
FINDINGS: son of the neonatal head was performed portably in the NICU.,0
Continued evolution of bilateral germinal matrix hemorrhage with intraventricular extension.,1
"There are new foci of ovoid increased echogenicity scattered throughout the ventricles that are consistent with evolving, adherent clot.",0
Many of these foci are in a nondependent location.,0
There is no convincing evidence for new intraventricular hemorrhage.,1
Interval increase in ventriculomegaly that is now moderate to marked in both lateral ventricles.,0
The third ventricle is moderately dilated and contains heterogeneous echogenic material consistent with blood clot.,0
"The fourth ventricle is poorly visualized, likely indicating that it contains a blood clot.",0
"Newly appreciated are areas of increased echogenicity in both cerebellar hemispheres, right greater than left.",0
Remainder of the brain parenchyma appears normal.,0
No abnormal extra-axial fluid collections.,0
The resistive index in the anterior cerebral artery measures 0.91 without compression and shows reversal of diastolic flow with compression.,0
Increased lateral ventriculomegaly that is now moderate to marked.,0
Reversal of diastolic flow in the anterior cerebral artery with compression suggests that the hydrocephalus is hemodynamically significant.,0
Blood clot within the third and fourth ventricles.,0
Abnormal areas of increased echogenicity in both cerebellar hemispheres that suggest either hemorrhage or ischemia.,0
NOTE: Discussed in person with members of the patient's NICU treatment team at about 9:45 a.m. on .,0
(Over) 7:05 AM NEONATAL HEAD PORTABLE Clip # Reason: evaluate bilateral gr 3 IVH Admitting Diagnosis: NEWBORN ______________________________________________________________________________ FINAL REPORT (Cont),1
"3:27 AM CHEST (PORTABLE AP) Clip # Reason: R/o PNA vs CHF Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with head bleed, PNA with worsening oxygenation REASON FOR THIS EXAMINATION: R/o PNA vs CHF ______________________________________________________________________________ FINAL REPORT INDICATION: Cerebral hemorrhage, pneumonia with worsening oxygenation, and followup examination.",1
FINDINGS: The AP single view obtained with the patient in semierect position was analyzed in direct comparison with a similar study obtained on .,0
The tracheostomy tube remains in place.,0
Status post previous bypass surgery and moderate cardiac enlargement is unchanged.,1
"No new parenchymal infiltrates are present, but the diffuse obturation of the left diaphragmatic contour and that of the descending thoracic aorta remains indicative of a left lower lobe posterior segment atelectasis.",0
"Comparison does not demonstrate new infiltrates, but rather suggests that some perivascular haze which existed previously has been improved.",0
"IMPRESSION: No new infiltrates, possibly just vascular haze and persistent left lower lobe atelectasis.",0
"11:30 AM CHEST (PA & LAT) Clip # Reason: assess for interval change Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with right asp pna and parapneumonic effusion with chest tube REASON FOR THIS EXAMINATION: assess for interval change ______________________________________________________________________________ FINAL REPORT CHEST TWO VIEWS, CLINICAL INFORMATION: Aspiration pneumonia.",1
FINDINGS: There is little appreciable change in the appearance of the chest.,0
There is a moderate right-sided pleural effusion with patchy consolidation of the right middle and lower lobes.,1
"In addition, there are patchy foci of airspace opacity in the left lower lobe.",0
PORT; DUPLEX DOPP ABD/PEL Clip # Reason: post op renal failure.,0
to assess need for dialysis Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 49 year old M s/p AVR/ASc Ao repair currently on CVVHD REASON FOR THIS EXAMINATION: post op renal failure.,0
to assess need for dialysis ______________________________________________________________________________ FINAL REPORT PORTABLE RENAL ULTRASOUND INDICATION: Patient with renal failure postoperatively.,1
To assess for renal size.,0
TECHNIQUE: Portable scale and Doppler son of both kidneys was performed.,0
The right kidney measures 12.8 cm.,0
The left kidney measures 10.9 cm.,0
"Both kidneys are slightly echogenic, with mildly reduced corticomedullary differentiation.",0
The appearances are consistent with intrinsic medical renal disease.,0
"Arterial Doppler traces can be returned from the upper and interpolar region of the right kidney and also from the interpolar region of the left kidney, suggesting at least perfusion to both kidneys.",0
"Examination was somewhat limited by the patient debility, however.",0
CONCLUSION: Normal size but echogenic kidneys.,0
Appearances are more suggestive of a subacute or chronic process rather than an acute process and suggest the possibility of preexisting renal disease prior to recent operation.,1
"1:19 PM MR CARDIAC W/FLOW/ CONTRAST Clip # Reason: DEPRESSED LV FUNCTION, VT Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ FINAL REPORT Patient Name: MR#: Status: Outpatient Study Date: Indication: 40-year-old man with history of Ebstein's anomaly and LV non- compaction, S/P tricuspid annuloplasty, andASD repair referred for assessment of -ventricular function.",1
"1) Structure: Axial dual-inversion T1-weighted images of the myocardium were obtained 2) Function: Non breath-hold cine SSFP images were acquired in the left ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8- mm slices with 2-mm gaps), sagittal and coronal orientations of the left ventricular outflow tract, sagittal orientation of the right ventricular outflow tract, and aortic valve short axis orientations.",1
"Breath-hold real time SSFP images were acquired in the left ventricular 2-chamber, 4-chamber, and mid-papillary short axis slices.",0
3) Flow: Phase-contrast cine images were obtained transverse to the aorta (axial plane) and main pulmonary artery (oblique plane).,0
Findings: Structure and Function There was prominent epicardial and mediastinal fat.,0
The myocardium appeared to have homogenous signal intensity.,0
The pericardial thickness was normal.,0
There were no pericardial or pleural effusions.,0
The main pulmonary artery diameter index was normal.,0
The right and left atrial lengths in the 4-chamber view were moderately increased.,0
The inferior vena cava and hepatic veins were markedly dilated.,0
The left ventricular end-diastolic dimension index was normal.,0
The end- diastolic volume index was normal.,0
"The calculated left ventricular ejection (Over) 1:19 PM MR CARDIAC W/FLOW/ CONTRAST Clip # Reason: DEPRESSED LV FUNCTION, VT Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ FINAL REPORT (Cont) fraction was mildly decreased at 42%.",1
The anteroseptal and inferolateral wall thicknesses were normal.,0
There were prominent trabeculations from the mid to apical segments of the left ventricle with maximum ratio of non-compacted myocardium to compacted myocardium during diastole of 3.5 in the mid inferolateral wall.,0
This is consistent with diagnosis of LV non-compaction.,0
The left ventricular mass index was normal (excluding volume of non compacted ventricle).,0
The inter-ventricular septum was flattened (D-shape) in diastole consistent with RV volume overload.,0
The functional right ventricular end-diastolic volume index was mildly increased.,0
The calculated right ventricular ejection fraction of the functional RV was severely decreased at 29%.,0
The right ventricular end- diastolic volume index of the structural RV (including atrialized RV) was severely increased.,0
The calculated right ventricular ejection fraction of the structural RV was severely decreased at 35% The aortic valve was tri-leaflet with normal valve area.,1
"The tricuspid valve had abnormalities consistent with Ebstein's anomaly with mobile leaflets, a mobile posterior that was markedly displaced apically.",1
A well seated tricuspid annuloplasty ring was present.,0
A signal void was seen in the anatomic right atrium during systole consistent with tricuspid regurgitation.,0
Aortic flow demonstrated mild aortic regurgitation.,0
The calculated mitral valve regurgitant fraction was consistent with no mitral regurgitation.,1
The resultant effective forward LVEF was mildly decreased at 41%.,0
The right ventricular stroke volume and pulmonic flow demonstrated no significant pulmonic regurgitation.,0
"Using volumetric data from the functional RV, there was moderate tricuspid regurgitation.",0
"Using volumetric data from the structural RV, there was severe tricuspid regurgitation through the tricuspid annulus.",0
Non-Cardiac Findings The patient is s/p sternotomy.,0
"Also noted are slight anterior wedge compression fractures in the lower thoracic spine, with narrowing of intervening disc space, similar to previous CMR findings on .",0
Normal left ventricular cavity size with mild global left ventricular hypokinesis.,0
The LVEF was mildly decreased at 42%.,0
The effective forward LVEF was mildly decreased at 41%.,0
Prominent non-compacted left ventricular myocardium that meet CMR criteria for non-compaction.,0
Mild functional right ventricular enlargement with evidence of RV volume overload.,0
Severe right ventricular systolic dysfunction with RVEF at 29%.,1
Severely decreased structural RV systolic function with RVEF at 35%.,0
"Markedly dilated inferior vena cava and hepatic veins consistent with (Over) 1:19 PM MR CARDIAC W/FLOW/ CONTRAST Clip # Reason: DEPRESSED LV FUNCTION, VT Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ FINAL REPORT (Cont) elevated right atrial pressure.",1
Abnormal and apically displaced tricuspid valve consistent with Ebstein's anomaly.,1
Moderate tricuspid regurgitation through tricuspid leaflets of functional right ventricle.,0
Severe tricuspid regurgitation through tricuspid annulus of structural right ventricle.,0
No CMR evidence of residual intra-cardiac shunt.,0
(post ASD patch repair) 9.,0
A note is made of previously noted compression fractures in the lower thoracic spine compared with prior CMR study of .,0
", , , , , and .",0
1:18 AM PORTABLE ABDOMEN Clip # Reason: 68 year old man with large ventral hernia; new NG tube for p Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with large ventral hernia; new NG tube for possible SBO.,1
Please evaluate for NG tube placement.,0
REASON FOR THIS EXAMINATION: 68 year old man with large ventral hernia; new NG tube for possible SBO.,1
______________________________________________________________________________ FINAL REPORT STUDY: Portable abdomen HISTORY: Patient with large ventral hernia.,1
Patient with possible small-bowel obstruction.,0
"FINDINGS: There has been placement of the nasogastric tube; however, this is poorly seen on this image which is limited by patient motion and technical artifact.",0
"There is suggestion of the tip of the catheter is in the body and fundus of the stomach; however, repeat images would be more helpful to establish the exact location given the technical limitations.",0
There is again seen several dilated loops of bowel which may be small bowel within the upper and lower abdomen.,0
"5:29 AM CHEST (PORTABLE AP) Clip # Reason: interval change, lobar collapse Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with underlying bronchiolitis related to GVHD, likely multiple lobar collapse REASON FOR THIS EXAMINATION: interval change, lobar collapse ______________________________________________________________________________ FINAL REPORT AP CHEST 6:23 A.M : HISTORY: Bronchiolitis related to graft vs. host disease.",1
IMPRESSION: AP chest compared to through 30: Greater opacification at the base of the right lung is probably worsening atelectasis.,0
Severe atelectasis in the left lower lobe and small bilateral pleural effusions are stable.,1
Lungs elsewhere are grossly clear though pulmonary and mediastinal vascular congestion suggests volume overload.,0
"Of note, recent chest CT scan showed abundant bronchial secretions which may be playing a role in the persistent atelectasis.",0
7:33 PM BABYGRAM (CHEST & ABDOMEN) Clip # Reason: tube placement ______________________________________________________________________________ MEDICAL CONDITION: Infant with rds REASON FOR THIS EXAMINATION: tube placement ______________________________________________________________________________ FINAL REPORT CHEST AND ABDOMINAL FILM TAKEN AT 8:20PM FINDINGS: Endotracheal tube is at T1-2.,0
Umbilical artery tip is at the body of T8.,0
Umbilical venous catheter tip is at the T6-7 interspace.,0
The lungs are mildly and diffusely hazy consistent with hyaline membrane disease.,0
The abdominal gas pattern shows air only on the left side of the abdomen which is most likely normal.,0
No abnormalities are noted in the bones or soft tissues.,0
"9:03 AM CHEST (PORTABLE AP) Clip # Reason: eval infiltrates Admitting Diagnosis: PELVIC MASS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with pelvic abscess pod#0 s/p sch/bso/ sigmoid colectomy with reanastomosis REASON FOR THIS EXAMINATION: eval infiltrates ______________________________________________________________________________ FINAL REPORT INDICATION: Pelvic abscess, sigmoid colectomy, evaluate for infiltrates.",0
FINDINGS: The Swan-Ganz catheter has been pulled back with the tip now lying in the right pulmonary artery.,0
"The right internal jugular, endotracheal tube, and nasogastric tube all remain in stable and satisfactory positions.",0
"Allowing for the underpenetration of the film, there has been no significant interval change in the appearance of the chest.",0
There is a persistent right lower lobe patchy opacity.,0
"There is left lower lobe collapse/consolidation, not changed from the prior exam.",0
"The cardiac, mediastinal, and hilar contours remain stable.",0
"It is difficult to comment on pulmonary vascularity, given the underpenetration of this film.",0
IMPRESSION: 1) Satisfactory placement of Swan-Ganz catheter.,0
2) No interval change in the appearance of the chest.,0
Persistent right lower lobe patchy opacity and left lower lobe collapse/consolidation.,0
"7:08 AM ABDOMEN U.S. (COMPLETE STUDY) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOP ABD/PEL LIMITED PORT Reason: evaluate aorta and renal veins for thrombosus Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: infant born at 27 wks now 3 days old , had UAC, and hematuria REASON FOR THIS EXAMINATION: evaluate aorta and renal veins for thrombosus ______________________________________________________________________________ FINAL REPORT ABDOMINAL ULTRASOUND ON HISTORY: Hematuria.",0
Question renal vein or arterial thrombosis.,0
The right kidney measures 3.4 cm.,0
The left kidney measures 3.5 cm.,0
Color and pulse wave Doppler analysis of renal blood flow demonstrates normal arterial and venous waveforms bilaterally.,0
There is no evidence for renal vein or arterial thrombosis on either side.,0
The liver and the spleen appear normal.,0
The pancreas was not demonstrated.,0
The common bile duct measures 1 mm.,0
There is no evidence for thrombosis within the aorta.,0
IMPRESSION: No evidence for renal arterial or venous thrombosis.,0
"8:44 AM BILIARY CATH CHECK Clip # Reason: eval drain Admitting Diagnosis: SEPSIS Contrast: OPTIRAY Amt: 30 ********************************* CPT Codes ******************************** * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER * * TUBE CHOLANGIOGRAM * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 72M s/p duodenectomy (4th portion) for adenocarcinoid tumor (duodenal primary w Lung Mets) and CCY , now w/recurrence in mediastinal nodes , and biliary obstruction; s/p ptc drain, EGD with failed duodenal stent placement ; s/p internalization of ptc , s/p 2 duodenal stents/GI , s/p failed GI metallic stents .",1
"Now with N/V x2, hypotension, WBC 17.5 REASON FOR THIS EXAMINATION: eval drain ______________________________________________________________________________ FINAL REPORT INDICATION: 72-year-old status post duodenectomy for adenocarcinoid tumor, now with recurrence and biliary and duodenal obstruction.",0
Status post placement of internal-external biliary drain as well as duodenal stent.,0
"Now representing with nausea, vomiting, leukocytosis and hypotension.",0
"and , the Attending Radiologist who was present and supervising throughout, performed the procedure.",0
PROCEDURE/FINDINGS: Initial scout film of the abdomen demonstrates the tube to be in unchanged position in the right upper quadrant as well as a duodenal stent overlying the mid abdomen.,0
There is also an aortic stent seen in the mid lower abdomen.,0
"Injection of 20 cc of IV Optiray via the percutaneous biliary stent demonstrates opacification of a moderately dilated biliary tree, slightly decreased compared to the prior exam, as well as opacification of the cystic duct remnant.",0
There was no evidence of obstruction or extravasation.,0
Contrast is also seen opacifying the proximal jejunum via the distal pigtail.,0
"Contrast also tracks along the course of the intrahepatic portion of the biliary catheter with a small amount of contrast extravasating external to the patient's skin, likely due to a patulous tract.",0
The catheter was advanced slightly internally (2 cm) and resutured.,0
Bacitracin was applied to the catheter entry site and a DuoDERM dressing was placed to minimize skin irritation secondary to the dressing tape.,0
IMPRESSION: Cholangiogram demonstrating internal/external drain in place with no evidence of obstruction or extravasation.,0
Contrast passes through the catheter into the jejunum.,0
The catheter was advanced slightly (2 cm) internally.,0
(Over) 8:44 AM BILIARY CATH CHECK Clip # Reason: eval drain Admitting Diagnosis: SEPSIS Contrast: OPTIRAY Amt: 30 ______________________________________________________________________________ FINAL REPORT (Cont),0
"LINE PLACEMENT Clip # Reason: line placement and evaluation of lungs Admitting Diagnosis: POLYP ADENOMATOUS/SDA ______________________________________________________________________________ MEDICAL CONDITION: 52M s/p colectomy, with shortness of breath.",0
"s/p L subclavian CVL placement REASON FOR THIS EXAMINATION: line placement and evaluation of lungs ______________________________________________________________________________ FINAL REPORT AP CHEST, AT 10:58 A.M. HISTORY: Shortness of breath.",0
Left subclavian central venous line placement.,0
"IMPRESSION: AP chest compared to at 15:47 hours: Lung volumes remain quite low with severe bibasilar atelectasis, possibly due to severe gaseous distention of the stomach.",0
New left subclavian line projects over the course of the left brachiocephalic vein.,0
", A. MED MICU-7 4:37 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman s/p extubation after intubation for airway protection.",0
"REASON FOR THIS EXAMINATION: r/o infiltrate ______________________________________________________________________________ PFI REPORT PFI: Status post extubation with no lobar consolidation, just low lung volumes.",0
"12:52 AM CHEST (PORTABLE AP) Clip # Reason: eval for PNA, CHF ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with ?PNA, intubated REASON FOR THIS EXAMINATION: eval for PNA, CHF ______________________________________________________________________________ FINAL REPORT HISTORY: 76-year-old female with question of pneumonia, now intubated.",1
PORTABLE SUPINE CHEST RADIOGRAPH: An ET tube terminates 2.4 cm above the carina.,0
Moderate cardiomegaly is not changed.,0
There is no mediastinal widening.,0
A small amount of pleural effusion is seen within the right fissure.,0
No supine evidence of pneumothorax is seen.,0
"There is diffuse airspace opacity in the right mid and lower lungs, which does not obscure either the right heart border or the diaphragm.",0
Streaky opacities are also noted in the left retrocardiac region.,0
Right perihilar pneumonia or hemorrhage.,0
Left retrocardiac atelectasis or aspiration.,0
"Moderate cardiomegaly, without pulmonary edema.",0
9:04 AM CT HEAD W/O CONTRAST Clip # Reason: eval for trauma ______________________________________________________________________________ MEDICAL CONDITION: 59 year old woman with s/p trauma REASON FOR THIS EXAMINATION: eval for trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKPe SAT 9:21 AM no traumatic injury ______________________________________________________________________________ FINAL REPORT HISTORY: Trauma.,0
"NON-CONTRAST HEAD CT: There is no evidence of intracranial hemorrhage, mass effect, shift of midline structures, hydrocephalus, or acute major vascular territorial infarct.",0
No discrete soft tissue hematoma is noted with mild swelling probably noted in the region of the forehead.,0
The globes are intact with no extra- or intra-conal injury noted.,0
"Mild pooling of secretions within the oropharynx, likely corresponds to the patient's intubated status with mild mucosal thickening noted within the ethmoid air cells bilaterally.",0
The remaining paranasal sinuses and mastoid air cells are well aerated.,0
No calvarial fractures are present.,0
IMPRESSION: No acute traumatic injury.,0
"6:03 PM CHEST (PORTABLE AP) Clip # Reason: interval changes Admitting Diagnosis: PERICARDIAL EFFUSION, TOMPONADE ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: Re-evaluation of the study demonstrates small left apical pneumothorax that was demonstrated to be unchanged or slightly smaller on the subsequent study obtained at 3:45 p.m. on .",0
"6:03 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: interval changes Admitting Diagnosis: PERICARDIAL EFFUSION, TOMPONADE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman s/p pericardial tamponade with pericardial window; now with gradual desaturation and fever REASON FOR THIS EXAMINATION: interval changes ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient after pericardial tamponade with pericardial window and gradual desaturation and fever.",1
"Portable AP chest radiograph was compared to , obtained at 04:21.",0
The lower of the two of the left chest tubes has been pulled back and currently it is unclear if contributing to draining.,0
The cardiomediastinal silhouette is unchanged and there is no evidence of interval development of pleural effusions.,1
The complex appearance of the mediastinum is redemonstrated but with no significant change compared to the prior study.,0
"5:24 AM CHEST (PORTABLE AP) Clip # Reason: tube and line placement, fluid status Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with septic shock, intubated.",0
"REASON FOR THIS EXAMINATION: tube and line placement, fluid status ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of tubes and line placement.",0
The right internal jugular line tip terminates at the level of cavoatrial junction.,0
"The NG tube tip passes below the diaphragm, most likely terminating in the stomach, but with its tip below the inferior field of view.",0
"The lung volumes have decreased compared to the previous study and this might partially contribute to the increased crowdness of the vessels, although mild pulmonary edema cannot be excluded.",0
The _____worsening of left retrocardiac consolidation which also may be at least partially explained by decreased lung volumes.,0
The left pleural effusion is small to moderate.,0
No sizable right pleural effusion is demonstrated.,0
11:58 AM PORTABLE ABDOMEN Clip # Reason: evaluate for acute process Admitting Diagnosis: CROHN'S DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman s/p colectomy with likely ileus with n/v REASON FOR THIS EXAMINATION: evaluate for acute process ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 2:44 PM PFI: Non-obstructive bowel gas pattern.,1
______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old woman status post colectomy with nausea and vomiting.,0
COMPARISON: Supine and erect abdominal radiograph .,0
FINDINGS: Suboptimal radiographs due to patient body habitus.,0
"Within this limitation, nonspecific bowel gas pattern is noted.",0
Air is seen within the rectum.,0
IMPRESSION: Non-obstructive bowel gas pattern.,0
12:58 PM BILAT LOWER EXT VEINS Clip # Reason: please evaluate extent of clot; rule out clot in right Admitting Diagnosis: CROHN'S COLITIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with recent CT of the pelvis showing clot in left femoral vein; please evaluate for extent of clot REASON FOR THIS EXAMINATION: please evaluate extent of clot; rule out clot in right ______________________________________________________________________________ FINAL REPORT STUDY: Bilateral lower extremity ultrasound.,1
CLINICAL HISTORY: 64-year-old woman with recent pelvic CT showing left femoral vein clot.,0
Please evaluate for extent of clot.,0
FINDINGS: Bilateral lower extremity venous Doppler ultrasound was performed on .,1
Comparison made to CT of the abdomen and pelvis dated .,0
"The left common femoral vein demonstrates intraluminal thrombus and is not completely compressible, although it is patent.",0
"This finding is consistent with short-segment, nonocclusive thrombus of the proximal left common femoral vein that does not extend into the superficial femoral vein.",0
"The remaining lower extremity deep veins, namely the superficial femoral and popliteal, are patent and compressible.",1
Left calf veins are also patent.,0
"The right common femoral, superficial femoral, and popliteal veins are widely patent, compressible and demonstrate normal venous flow and augmentation.",0
IMPRESSION: Nonocclusive thrombus of proximal left common femoral vein.,0
"9:59 AM CHEST (PORTABLE AP) Clip # Reason: PTX ***Please do at 1030-placed on waterseal Admitting Diagnosis: CHEST PAIN;DYSPNEA\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man s/p CABG REASON FOR THIS EXAMINATION: PTX ***Please do at 1030-placed on waterseal ______________________________________________________________________________ FINAL REPORT AP CHEST, 10:18 A.M., ON .",0
HISTORY: Chest tubes to waterseal.,0
"IMPRESSION: AP chest compared to : Much smaller lung volumes may account for apparent increase in cardiac diameter, mildly enlarged.",0
The patient has been extubated in the interim explaining new left lower lobe collapse.,0
"Tiny right apical pneumothorax is new and newly apparent, with a right apical pleural tube still in place.",0
"10:44 AM US ABD LIMIT, SINGLE ORGAN PORT Clip # Reason: Eval for infected pseudocyst, evidence of intraabdominal inf Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with recent h/o ETOH pancreatitis a/w high fever, leukocytosis of unknown origin REASON FOR THIS EXAMINATION: Eval for infected pseudocyst, evidence of intraabdominal infection ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc TUE 4:25 PM No pseudocyst identified.",1
"______________________________________________________________________________ FINAL REPORT HISTORY: 63-year-old female with recent history of alcoholic pancreatitis, admitted with high fever, and leukocytosis of unknown origin.",1
"FINDINGS: The liver demonstrates normal echogenicity, without a focal lesion.",0
"Gallbladder is within normal limits, without evidence of gallstones or cholecystitis.",0
"There is no intra- or extra-hepatic biliary ductal dilatation, with the CBD measuring approximately 3 mm.",0
Views of the pancreas reveal no evidence for pseudocyst formation.,1
IMPRESSION: No evidence of a pseudocyst adjacent to the pancreas.,1
"8:54 AM MRA CHEST W&W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: *** NEED EVALUATIO OF THORACIC AND ABDOMINAL AORTA ***please Admitting Diagnosis: AORTIC DISSECTION Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ MEDICAL CONDITION: 78 year old man with htn presents with back pain to OSH and found to have descending thoracic aneurym on OSH CT, qith questionable dissection REASON FOR THIS EXAMINATION: *** NEED EVALUATIO OF THORACIC AND ABDOMINAL AORTA ***please evaluate for dissection ______________________________________________________________________________ FINAL REPORT INDICATION: Hypertension and back pain, with descending thoracic aneurysm on outside hospital CT and questionable dissection, please evaluate for aortic dissection.",1
"TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the chest and abdomen, including dark blood, SSFSE and gated FIESTA images, and dynamic images obtained prior to, during, and after the eventful intravenous administration of 0.1 millimoles per kilogram gadolinium BOPTA.",0
Multiplanar reformations and subtraction images were generated and reviewed on a separate workstation.,0
"FINDINGS: There is mild aneurysmal dilation of the proximal aspect of the descending aorta, which measures up to 3.8 cm in diameter.",0
"The caliber of the remainder of the descending aorta, as well as the ascending aorta, are within normal limits.",0
Crescentic mural thickening and irregularity is seen extending from the distal aspect of the left subclavian artery ostium to the level of the renal arteries.,0
"On dark blood T1- weighted images, there is intramural hyperintensity in the thickened area, with a lesser degree of hyperintensity seen on the BB SSFSE images.",0
"The mural irregularity extends in a contiguous fashion along the dorsal aspect of the arch, to the posteromedial descending aorta, and continues to involve the medial and posterior aspect of the proximal abdominal aorta.",0
"The arch branch vessels, celiac artery, superior mesenteric artery, and both renal arteries are uninvolved.",0
"Note is made of common origin of the brachiocephalic and left common carotid arteries, a normal variant.",0
"The imaged portion of the liver, spleen, adrenal glands, pancreas, and gallbladder appear normal.",0
There is a 1.9 cm cyst in the upper pole of the left kidney.,0
The imaged marrow signal appears within normal limits.,0
Multiplanar reformations were essential in delineating the features of the aortic mural abnormality.,0
IMPRESSION: (Over) 8:54 AM MRA CHEST W&W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: *** NEED EVALUATIO OF THORACIC AND ABDOMINAL AORTA ***please Admitting Diagnosis: AORTIC DISSECTION Contrast: MAGNEVIST Amt: 15 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
Crescentic mural irregularity and signal abnormality involving the descending aorta from the level of the left subclavian artery to the renal arteries.,0
The imaging features are most consistent with thrombosed aortic dissection.,0
Intramural hematoma and atherosclerotic disease are considered less likely.,0
Results were discussed with Dr. at 4:00 p.m. on .,0
"8:25 AM CAROT/CEREB Clip # Reason: evaluate for aneurysm Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: OPTIRAY Amt: 110ML OPTI240; 71ML OPTI320 ********************************* CPT Codes ******************************** * SEL CATH 2ND ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT * * CAROTID/CEREBRAL BILAT EXT CAROTID UNILAT * * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM * * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, FIRST 30 MIN.",1
"* * MOD SEDATION, EACH ADDL 15 MIN * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with R frontal and IV hemorrhage REASON FOR THIS EXAMINATION: evaluate for aneurysm ______________________________________________________________________________ FINAL REPORT DATE OF SERVICE: DIAGNOSIS: 54-year-old female with right frontal hemorrhage and intraventricular hemorrhage.",0
INDICATION: Assess for aneurysm and other vascular abnormalities.,0
"ANESTHESIA: Moderate sedation was provided by administering divided doses of 50 mcg of fentanyl and 1 mg of Versed throughout the total intraservice time of 45 minutes, during which the patient's parameters were continuously monitored.",0
"PROCEDURE PERFORMED: Right subclavian artery arteriogram, right common carotid artery arteriogram, left common carotid artery arteriogram, left external carotid artery arteriogram, left vertebral artery arteriogram and right common femoral artery arteriogram.",0
We now prepped and draped both groins in a sterile fashion.,0
Access was gained to the right common femoral artery using a Seldinger technique and a 5 French vascular sheath was placed in the right common femoral artery.,0
This was connected to a continuous saline flush.,0
The above-mentioned vessels were catheterized and AP lateral filming done.,0
This revealed that there was an occlusion of the left internal carotid artery at the origin and extensive pial collateralization to the left external carotid artery.,1
There was significant stenosis in the right vertebral artery origin.,0
The left internal carotid artery origin and the left vertebral artery origin was also seen to be stenotic.,0
(Over) 8:25 AM CAROT/CEREB Clip # Reason: evaluate for aneurysm Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: OPTIRAY Amt: 110ML OPTI240; 71ML OPTI320 ______________________________________________________________________________ FINAL REPORT (Cont) The patient tolerated the procedure well.,0
The right common femoral artery was seen to be stenotic higher up in the common iliac region.,0
"Therefore, we did not Angio-Seal the patient.",0
The patient's sheath was taken out and manual compression applied for hemostasis.,0
FINDINGS: Right subclavian artery arteriogram shows that the right vertebral artery is very stenotic at the origin with about 80-90% stenosis and a post-stenotic dilatation.,0
The right vertebral artery fills well into the basilar and there is an extensive pial collateralization of the left hemisphere through the left posterior cerebral artery.,1
Left common carotid artery arteriogram shows that the left internal carotid artery is occluded at the origin.,0
Left external carotid artery arteriogram shows filling of the left external carotid artery and its branches.,0
"There are extensive pial collaterals from the left middle meningeal artery, especially in the inferior frontal and temporal region.",0
There are also additional collaterals in the parietal area.,0
One of the collaterals is seen to be draining into a large vascular structure which is most likely a vein.,0
Subclavian artery arteriogram shows a rather tortuous origin of the left vertebral artery with mild-to-moderate stenosis at the origin.,0
Left vertebral artery arteriogram shows normal filling of the left vertebral artery with the basilar and both posterior cerebral arteries filling well.,1
There is extensive pial collateralization of the left hemisphere.,0
There is also a posterior communicating artery which is filling the left internal carotid artery which is seen to be stenotic.,0
There are multiple perforators arising from the posterior communicating artery and the distal supraclinoid left carotid artery consistent with moyamoya configuration of vessels.,0
Right common carotid artery arteriogram shows about 50% stenosis of the right internal carotid artery at the origin with an ulcerated plaque.,0
"The right internal carotid artery fills well along the cervical, petrous, cavernous and supraclinoid portion.",0
The right middle and anterior cerebral arteries are seen normally.,0
There is very little cross-fill into the left hemisphere.,0
"The right common femoral artery arteriogram shows normal filling of the right common femoral artery, however, there is significant stenosis.",0
There is significant stenosis in the proximal area especially in the common iliac area.,0
"However, this could be an artifact from the large 6-French catheter.",0
"IMPRESSION: (Over) 8:25 AM CAROT/CEREB Clip # Reason: evaluate for aneurysm Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: OPTIRAY Amt: 110ML OPTI240; 71ML OPTI320 ______________________________________________________________________________ FINAL REPORT (Cont) underwent cerebral angiography which revealed high-grade stenosis of the right vertebral artery at it's origin, 50% stenosis of the right internal carotid artery at its origin, occlusion of the left internal carotid artery at its origin and extensive pial collateralization of the left hemisphere through the left external carotid artery and the left posterior cerebral artery.",1
1:19 PM CHEST (PORTABLE AP) Clip # Reason: eval for pna ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with hypoxia REASON FOR THIS EXAMINATION: eval for pna ______________________________________________________________________________ FINAL REPORT INDICATION: 85-year-old man with hypoxia.,0
SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 13:30 HOURS: A dual-lead pacemaker overlies the left hemithorax with intact leads terminating in the right atrium and right ventricle.,0
A dual-lumen hemodialysis catheter terminates in the right atrium.,0
"Again seen are layering bilateral pleural effusions, slightly increased since .",0
These are associated with compressive atelectasis.,0
Superimposed consolidation due to pneumonia cannot be ruled out at the lung bases.,0
"However, the upper lungs remain well aerated, with some cephalization of vessels.",0
The mediastinal silhouette is largely unchanged.,0
Again visualized is a hiatal hernia.,0
Soft tissue and bony structures demonstrate mild convex rightward curvature of the spine.,0
"IMPRESSION: Large bilateral pleural effusions, increased since , with vascular congestion consistent with failure or fluid overload.",1
Superimposed pneumonia at the lung bases cannot be excluded.,0
12:09 AM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: 47 year old man with acute cerebral hemorrage that is concer Field of view: 38 ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with acute cerebral hemorrage that is concerning for underlying lesion.,1
Evaluate for malignancy in setting of long term tobacco use.,0
REASON FOR THIS EXAMINATION: 47 year old man with acute cerebral hemorrage that is concerning for underlying lesion.,1
No contraindications for IV contrast ______________________________________________________________________________ WET READ: 12:57 AM No thoracic or abdominal malignancy.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old man with acute cerebral hemorrhage, with concern for underlying lesion.",1
"TECHNIQUE: MDCT helical images were acquired through the chest, abdomen, and pelvis after the administration of 130 cc of Omnipaque intravenous contrast.",0
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The major airways are patent to subsegmental levels bilaterally.,0
"The lungs are clear, without consolidation or pulmonary nodules.",0
"No significant mediastinal, hilar or axillary adenopathy is seen.",0
"CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver enhances homogeneously, without focal lesions.",0
There is no intra- or extra-hepatic biliary dilation.,0
"The adrenal glands, spleen and the pancreas are normal.",0
"Both kidneys enhance and excrete contrast symmetrically, without evidence of hydroureteronephrosis.",0
"The stomach, small and large bowel loops including the appendix are normal without evidence of bowel wall thickening or mass lesions.",0
No significant retroperitoneal or mesenteric lymphadenopathy is seen.,0
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is nearly empty with a Foley catheter in place.,0
"The prostate gland, rectum, and sigmoid colon are normal.",0
No pelvic lymphadenopathy or free fluid is noted.,0
BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected.,0
IMPRESSION: No evidence of intrathoracic or abdominal malignancy.,0
(Over) 12:09 AM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: 47 year old man with acute cerebral hemorrage that is concer Field of view: 38 ______________________________________________________________________________ FINAL REPORT (Cont),1
"1:26 PM HUMERUS (AP & LAT) LEFT; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # Reason: ORIF LEFT HUMERUS FX Admitting Diagnosis: S/P FALL ______________________________________________________________________________ FINAL REPORT STUDY: Left humerus two views, .",1
HISTORY: ORIF left humerus fracture.,1
FINDINGS: Seven fluoroscopic images from the operating room demonstrates interval placement of a large fracture plate and multiple associated cortical screws within the proximal humerus.,1
There is a bony defect at the superolateral aspect of the humerus.,0
There are no signs of hardware-related complications.,0
Please refer to the operative note for additional details.,0
LINE PLACEMENT Clip # Reason: r/o PTX/Effusion Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man s/p AVR/MVR.,0
REASON FOR THIS EXAMINATION: r/o PTX/Effusion ______________________________________________________________________________ FINAL REPORT HISTORY: Status post AVR/MVR.,1
"FINDINGS: In comparison with the study of , there are now midline sternal sutures in place.",0
Endotracheal tube tip lies 5.3 cm above the carina.,0
Right IJ Swan-Ganz catheter extends to the right pulmonary artery.,1
Nasogastric tube extends well into the stomach.,0
Atelectatic changes are seen at both bases.,0
5:36 PM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: r/o injury ______________________________________________________________________________ MEDICAL CONDITION: s/p MVA REASON FOR THIS EXAMINATION: r/o injury No contraindications for IV contrast ______________________________________________________________________________ WET READ: JXKc FRI 7:59 PM Multiple right sided rib fx with small hemothorax.,1
Right transverse fx involving L3 and L4.,0
Coracoid fx on the left with extension to the glenoid.,1
Extensive soft tissue swelling and hematoma in the region of the left deltoid.,0
"Mild compression deformity of the T5 and T7 vertebral bodies, may be acute.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 85-year-old status post MVA, rule out injury.",0
TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis with the administration of IV contrast.,0
Delayed images through the liver were also obtained.,0
Coronal and sagittal reformatted images were viewed in conjunction with the axial.,0
CT OF THE CHEST WITH IV CONTRAST: Mild atherosclerotic calcifications of the coronary arteries and aortic arch are seen.,0
"Otherwise, the heart, pericardium, and great vessels are unremarkable, without evidence of an acute injury.",0
"There are no pathologically enlarged mediastinal, hilar, or axillary lymphadenopathy.",0
The lungs are clear without evidence of a focal contusion.,0
"There is a small amount of fluid within the right posterior pleural space in the region of multiple rib fractures, consistent with a small hemothorax.",1
"Within this hemothorax, there is a sliver of bone from an adjacent rib fracture.",1
"CT OF THE ABDOMEN WITH IV CONTRAST: Within the right lobe of the liver, there is a large heterogeneous 5 cm predominantly hypodense lesion, and a smaller one measuring approximately 1.6 cm slightly cephalad.",0
"On delayed images, these subsequently demonstrate centripetal enhancement, suggestive of hemangiomas.",0
"Linear hypodense structures coursing adjacent to the largest lesion, may reflect a minimally dilated intrahepatic duct.",0
There is no evidence of an acute injury in the liver.,0
"The kidneys, gallbladder, spleen, adrenal glands, and pancreas are unremarkable.",0
Stomach and bowel are within normal limits.,0
"There is no free air, free fluid, or adenopathy.",0
"There are atherosclerotic calcifications of the abdominal aorta, with atheromatous plaque seen.",0
There is no evidence of an acute aortic injury.,0
(Over) 5:36 PM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: r/o injury ______________________________________________________________________________ FINAL REPORT (Cont) Prostate and rectum are unremarkable.,0
There is no free fluid or adenopathy.,0
OSSEOUS STRUCTURES: There are multiple minimally displaced right-sided rib fractures.,0
"Specifically, there is a fracture involving the posterior right fifth, sixth, seventh, and eighth ribs; the lateral right ninth, tenth, and eleventh ribs; and the posterior right twelfth rib.",1
There are minimally displaced fractures of the right transverse process at L3 and L4.,1
"There is a displaced fracture of the left coracoid process, and a bone fragment in the joint space, possibly from the glenoid.",1
There is associated extensive soft tissue swelling and hematoma in the left upper extremity and around the deltoid.,0
"Within the soft tissues in the right posterior pelvis, subcutaneous stranding may also possibly represent an area of contusion.",0
Mild anterior wedging of the T5 and T7 vertebral bodies.,0
"Although there is no associated hematoma or retropulsion of fragments into the central canal, these may represent acute compression fractures.",0
"There is also slight irregularity of the inferior endplate of the T6 vertebral body, which likely represents a degenerative/Schmorl's node.",0
"Multiple right-sided rib fractures, with an associated small right hemothorax.",1
"Left coracoid fracture, with possible involvement of the glenoid, and associated extensive soft tissue swelling and hematoma.",1
Minimally displaced right transverse process fractures at L3 and L4.,1
"Slight anterior wedging of T5 and T7 vertebral bodies, without associated hematoma or retropulsion.",0
These may represent an acute compression fracture.,0
"If clinically warranted, an MR may be obtained for confirmation.",0
"Two rounded hypodense lesions within the liver, likely representing hemangiomas.",0
Findings posted to the ED dashboard at the time of interpretation.,0
"7:27 PM CHEST (PRE-OP PA & LAT) Clip # Reason: PALPITATIONS, SOB, ATRIAL MYXOMA Admitting Diagnosis: PALPITATIONS, SOB, ATRIAL MYXOMA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old woman with large atrial mixoma to undergo c- friday REASON FOR THIS EXAMINATION: pre-op ______________________________________________________________________________ FINAL REPORT STUDY: PA and lateral views of the chest.",0
INDICATION: 50-year-old female with large atrial myxoma for cardiac surgery on Friday.,1
FINDINGS: The cardiomediastinal contours are unchanged.,0
The lungs are clear and there is no pleural effusion.,0
The visualized soft tissues and osseous structures are intact.,0
"11:49 AM PELVIS (AP ONLY) PORT Clip # Reason: eval bony pelvis s/p hip disarticulation Admitting Diagnosis: HIP PAIN ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with s/p hip disarticulation REASON FOR THIS EXAMINATION: eval bony pelvis s/p hip disarticulation ______________________________________________________________________________ FINAL REPORT AP PELVIS, , AT 11:59 A.M. HISTORY: Status post hip disarticulation.",0
"COMPARISON: Multiple priors, the most recent is the CT scan dated .",0
"FINDINGS: Consistent with the given history, the patient has undergone left lower extremity amputation.",0
"The large soft tissue defect of the stump remains in place with significant edema and internal air, likely postop in nature.",0
Surgical sutures are noted throughout the site.,0
There are small bony fragments scattered throughout the operative region as well.,0
There is again relative irregularity along the acetabular margin which had been involved with chronic osteomyelitis.,1
An indwelling bipolar right total hip arthroplasty is in place.,0
IMPRESSION: Status post amputation as above.,0
10:48 AM TIB/FIB (AP & LAT) IN O.R.,0
RIGHT Clip # Reason: RESECTION LEIOMYOSARCOMA ______________________________________________________________________________ FINAL REPORT HISTORY: Intraoperative film for resection of leiomyosarcoma.,0
"TIBIA, SIDE NOT INDICATED, TWO VIEWS.",0
The proximal and distal-most portions of the tibia and fibula are not included on these views.,0
"Allowing for this, there is a sideplate and multiple screws extending along the medial aspect of the mid diaphysis of the tibia, flush with the bone.",0
"Bony detail is limited due to technique, but overall alignment is anatomic.",0
", S. MED 5:35 AM CHEST PORT.",0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement Admitting Diagnosis: URO-SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with central line placement REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ PFI REPORT No PTX.,0
Right IJ line with tip terminating in right atrium.,0
10:47 AM CHEST (PORTABLE AP) Clip # Reason: effusion?,0
"Admitting Diagnosis: NAUSEA, DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with CHF and SOB & bilat crackles REASON FOR THIS EXAMINATION: effusion?",0
"______________________________________________________________________________ FINAL REPORT HISTORY: CHF and shortness of breath, to evaluate for pulmonary edema.",0
"FINDINGS: In comparison with the study of , the Swan-Ganz catheter has been removed.",0
The other catheters remain in place.,0
Continued enlargement of the cardiac silhouette without evidence of vascular congestion.,0
"Mild bibasilar atelectatic changes, with blunting of the left costophrenic angle that could relate to a small amount of pleural fluid.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Bacitracin Attending: Chief Complaint: transferred for management of hypotension, dyspnea Major Surgical or Invasive Procedure: Left arterial line placement Right internal jugular central venous line placement.",1
"History of Present Illness: This is a 79 yo man w/h/o PEs, , COPD on 2-3LNC outpt, who p/w 4-5days of SOB and nonproductive cough.",0
Most of hx is given by pt's son who notes that the SOB began ~2 weeks ago.,0
"At that time, he was febrile w/productive cough.",0
"He was treated w/2 weeks of levofloxacin and a ZPak, course complete last Fri.",0
"Since then, pt notes that his breathing was slightly better, but upon following up with his PCP this past , she noted that he was fluid overloaded.",0
"They had been increasing the outpt dose of lasix, but both son and pt are unable to recall what the most recent dose was.",0
"Pt's dry weight is ~210lbs, and most recently he weighed 215lbs outpt.",0
Pts son notes that has been checking vitals daily and day PTA his father's O2 sat dropped to mid 70's on 5L O2 which improved w/son's CPAP to 93%.,0
He has otherwise been afebrile.,0
"Denied recent CP/palpitations, notes + orthopnea, PND, DOE.",0
They presented to where he received Ceftriaxone and Levofloxacin and was started on pressors for SBP 70s/50s.,0
"In the ED, right IJ was placed to continue levophed.",0
Vitals were T 100.6 BP 96/56 HR 96 RR 28 sat 99% on NRB.,0
"ROS: The patient denies any nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes.",1
"Past Medical History: # Dyslipidemia # Hypertension # Systolic heart failure- EF 35% # Aortic stenosis- moderate to severe # PE: junction right upper and right middle lob artery; also PE of RML, RLL, LLL distal vessels # Extensive mural thrombus of aortic arch and descending abdominal aorta # RLE DVT # Prostate CA s/p radiation # Hypercholesterolemia # COPD # Hx of ETOH abuse Social History: Positive for alcohol and tobacco use: 6beers and 2 shots/day, 60pack year hx.",1
"Family History: FAMILY HISTORY: No family history of early MI, otherwise non-contributory.",0
Physical Exam: Tmax: 37.1 ?,0
There is severe global left ventricular hypokinesis (LVEF = XX %).,0
There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2).,1
IMPRESSION: Severe global LV hypokinesis with moderate LV dilatation.,0
Moderate to severe aortic stenosis.,0
Mild to moderate aortic and mitral regurgitation.,1
"Compared with the prior study (images reviewed) of , the left ventricle is now dilated.",0
"The inferior and inferolateral segments, which previously had relatively preserved function are now hypokinetic.",0
The valvular pathologies are similar.,0
The degree of pulmonary artery systolic hypertension is slightly lower.,0
"Brief Hospital Course: Mr. is a 79 year old gentleman with a PMH significant for COPD on 2-3L home O2, recent PE on coumadin s/p IVF filter placement, and recent medically managed admitted for days of SOB, nonproductive cough, and hypotension.",0
"The patient was found to have decompensated heart failure and started on dobutamine, dopamine, and lasix gtt.",1
The patient's condition continued to deteriorate and the decision was made in conjunction with his entire family to make the patient Comfort Measures Only and died shortly thereafter.,1
Hypotension: This most likely represents decompensated heart failure/cardiogenic shock and less likely sepsis.,1
Pt ECHO shows reduced EF (20-25%) and severe global hypokinesis.,0
Cardiology was consulted and recommended diuresis and attempting to wean pressors.,0
Potential infectious sources include urosepsis versus pneumonia.,0
"The patient had worsening CXR showing possible retrocardiac opacity concerning for effusion versus pneumonia, although patient with recently treated CAP as outpatient with azithromycin.",1
The patient was continued on dobutaime and dopamine.,0
"He was diuresised on a lasix drip, but his output was limited by his hypotension.",0
"The patient was also started on broad spectrum antibiotics for pneumonia, vancomycin, zosyn and levofloxacin.",1
On in the morning the patient was found to be more lethargic and confused.,0
A blood gas showed that he had hypercapneic respiratory failure and was placed on BiPAP.,1
He did not improve on BiPAP and given his clinical deterioration the patient and family decided to pursue comfort measures only.,0
All additional interventions and treatments were suspended and the patient was only given morphine and placed on a NRB.,0
"Dyspnea: Likely multifactorial including fluid overload due to decompensated systolic heart failure (BNP >36,000), possibly secondary to ARF (Cr trending down from 2.1, baseline 1.0) and baseline COPD although without signs of exacerbation including wheezes.",1
CAD: Recent that was medically managed.,0
ECG without evidence of acute ischemia and patient without chest pain.,1
"ARF: FeUrea 21.3%, suggesting that acute renal failure is due to pre-renal azotemia consistent with decreased renal perfusion/forward flow from decompensated heart failure.",1
UTI: Treated with ceftriaxone until patient made CMO.,0
"Anemia: Baseline hct of 30-40, now with hct of 27.9 after 1U pRBC with unknown etiology to acute decrease.",0
Pt haptoglobin (230) and TBili mildly elevated.,0
Pulmonary embolism: Patient with multiple PE in currently on coumadin with mildly supratherapeutic INR.,0
Continued on coumadin during admission.,0
EtOH abuse: Past history of EtOH use.,1
Continued on thiamine and folate.,0
"Code status: As above, patient made CMO after discussion with family.",0
Medications on Admission: Coumadin as directed metoprolol 12.5 mg twice a day Plavix 75 mg daily aspirin 81 mg daily lisinopril 5 mg daily Zocor 80 mg daily folic acid thiamine protonix 40mg Discharge Medications: Patiend died.,0
Discharge Disposition: Expired Discharge Diagnosis: Patiend died.,0
1:17 AM MR HEAD W & W/O CONTRAST Clip # Reason: evaluate 3 hypodensities in left parieto-occipital region se Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ MEDICAL CONDITION: 44 year old man with large left BG intraparenchymal hemorrhage.,1
REASON FOR THIS EXAMINATION: evaluate 3 hypodensities in left parieto-occipital region seen on most recent CT - infarct?,0
Also eval for mass underlying bleed No contraindications for IV contrast ______________________________________________________________________________ WET READ: KN WED 3:13 AM large left BG bleed (6.8x2.6cm) .,0
8mm of left to right subfalcine herniation.,0
"no evidence of underlying mass, BUT THERE ARE MULTIPLE BILATERAL ACUTE LACUNAR CEREBRAL HEMISPHERE AND PONTINE CVA'S, CONSISTENT WITH AN EMBOLIC PHENOMENA.",1
______________________________________________________________________________ FINAL REPORT MRI HEAD HISTORY: 44-year-old man with large left basal ganglia hemorrhage with three hypodensities in the left parieto-occipital region seen on most recent head CT.,0
"TECHNIQUE: Multiplanar multisequence MR images of the head were obtained before and after the administration of IV gadolinium, including sagittal post- gadolinium MP-RAGE with coronal and axial reformats.",0
FINDINGS: Comparison is made to a head CTA from as well as a head CT from .,0
Again seen is a large intraparenchymal hemorrhage centered within the left basal ganglia which measures approximately 7.2 x 3.6 cm in its greatest transverse dimensions.,0
There is surrounding vasogenic edema and there is left to right subfalcine herniation and effacement of the left ambient cistern as before.,0
"There are multiple scattered areas of slow diffusion involving both centrum semiovale as well as the corpus collosum, the left globus pallidus, the white matter and matter of the occipital lobes and right frontal lobe as well as the pons consistent with embolic infarcts.",0
Seen on the post-gadolinium MP-RAGE images are two small foci of apparent enhancement involving either the cortex or the subarachnoid space of the left frontal and parietal lobes near the site of hemorrhage.,0
This is of uncertain etiology and may represent dilated veins or enhancement related to the embolic infarcts.,0
The visualized orbits and major flow voids appear normal.,0
"There is mucosal thickening within the right mastoid air cells as well as the sphenoid, ethmoid, and maxillary sinuses.",0
(Over) 1:17 AM MR HEAD W & W/O CONTRAST Clip # Reason: evaluate 3 hypodensities in left parieto-occipital region se Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1.,0
Large left basal ganglia intraparenchymal hemorrhage with surrounding vasogenic edema causing subfalcine herniation and compression of the ambient cistern on the left.,1
"Multiple embolic infarcts as described above, both supra and infratentorially.",0
Two small foci of either cortical or subarachnoid enhancement adjacent to the hemorrhage which may represent dilated veins related to the hemorrhage or infarct-related enhancement.,1
COMMENT: The above findings were discussed with Dr. on at approximately 1 30 p.m.,0
"11:53 AM CT C-SPINE W/O CONTRAST Clip # Reason: MCC TRAUMA, ?",0
"FX, SUBLUXATION ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man s/p MCC REASON FOR THIS EXAMINATION: fx?",0
No contraindications for IV contrast ______________________________________________________________________________ WET READ: KMcd SAT 12:36 PM no fractures or dislocations ______________________________________________________________________________ FINAL REPORT INDICATION: Status post MCC.,0
There is anatomic vertebral alignment.,0
No fractures or dislocations are seen.,0
Vertebral heights and intervertebral disc spaces are preserved.,0
CT is unable to provide intrathecal detail comparable to MRI.,0
IMPRESSION: No evidence of fractures or dislocations.,0
"9:47 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: interval change Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with pancreatitis, HAP s/p self-extubation, re-intubation REASON FOR THIS EXAMINATION: ETT placement ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Evaluation of ET tube placement.",0
Portable AP chest radiograph compared to previous film obtained the same day earlier at 0521.,0
The ET tube tip is 6.7 cm above the carina.,0
The right subclavian line tip is in the distal SVC.,0
"The NG tube was exchanged by a Dobbhoff tube, which passing below the diaphragm with its tip terminating distal to the proximal stomach, not included in the field of view.",0
The interstitial edema is grossly unchanged since the previous study and might be either cardiogenic or non-cardiogenic in etiology.,0
Bibasilar retrocardiac atelectasis unchanged as well as small pleural effusion.,1
"10:39 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for pulm edema, infiltrate, trach placement.",0
Admitting Diagnosis: INFECTED ULCER ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman with respiratory failure s/p intubationx6 now with trach and increasing O2 requirement.,1
"REASON FOR THIS EXAMINATION: evaluate for pulm edema, infiltrate, trach placement.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 53-year-old woman with respiratory failure and increasing oxygen requirement to rule out pulmonary edema.,1
"Chest x-ray, portable AP view.",0
FINDINGS: There has been interval removal of the ET tube.,0
A new tracheostomy tube is seen in good position at the thoracic inlet.,0
The tip of the right IJ catheter overlies the cavoatrial junction.,0
There are bilateral moderate pleural effusions.,0
There is slight improvement in pulmonary edema.,0
Improving pulmonary edema with bilateral moderate effusions and moderate cardiomegaly.,0
Tracheostomy tube in good position.,0
", TSURG CSRU 4:16 PM CHEST PORT.",0
"LINE PLACEMENT Clip # Reason: assess line placement- r/o ptx Admitting Diagnosis: BACK PAIN ______________________________________________________________________________ MEDICAL CONDITION: year old man s/p asc ao replaceemnt and new sc tlc placement REASON FOR THIS EXAMINATION: assess line placement- r/o ptx ______________________________________________________________________________ PFI REPORT Since , new left subclavian catheter curves in the left internal jugular with the tip upper in the neck, not imaged on this study.",0
"Right internal jugular catheter ends in lower right atrium, could be pulled back 9.5 cm for optimal placement.",0
Left internal jugular catheter ends in mid SVC.,0
ETT tip is 6 cm above the carina.,0
Tiny blunting of costodiaphragmatic angles is unchanged.,0
The stomach remains distended despite nasogastric tube.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: AAA Major Surgical or Invasive Procedure: Resection and repair of abdominal aortic aneurysm with 18-mm Dacron tube graft.,1
History of Present Illness: This 83-year-old lady has an enlarging abdominal aortic aneurysm.,1
It is tender to the touch.,0
Maximum diameter is about 7 cm.,0
"It extends up to the renal arteries and is not suitable for endovascular repair Past Medical History: PMH: COPD, AAA, HTN, carotid stenosis, bladder incontinence PSH: cysto, bladder suspension, right ear drum repair Social History: She has a long cigarette smoking history of two packs a day for most of her adult life Family History: n/c Physical Exam: On physical examination, she is a thin spry-appearing elderly lady in no acute distress.",1
She has no cervical bruits.,0
Heart is in regular rhythm.,0
"Abdomen is soft, with pos bs.",0
It starts at the level of the left upper quadrant and extends below the umbilicus.,0
Femoral and popliteal pulses are strongly palpable without evident peripheral aneurysm.,0
Her foot pulses are nonpalpable.,0
Pertinent Results: 06:20AM BLOOD WBC-6.8 RBC-3.80* Hgb-11.8* Hct-34.7* MCV-91 MCH-31.1 MCHC-34.0 RDW-14.0 Plt Ct-240# 06:20AM BLOOD Glucose-88 UreaN-9 Creat-0.5 Na-137 K-3.6 Cl-103 HCO3-28 AnGap-10 06:20AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.9 12:09PM BLOOD Hgb-13.7 calcHCT-41 CXR: IMPRESSION: Clear lungs.,0
Normal tube and line placement.,0
"Brief Hospital Course: Mrs. , was admitted on with AAA.",0
She agreed to have an elective surgery.,0
"A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made.",0
It was decided that she would undergo a Resection and repair of abdominal aortic aneurysm with 18-mm Dacron tube graft.,1
"She was prepped, and brought down to the operating room for surgery.",0
She tolerated the procedure well without any difficulty or complication.,0
"Post-operatively, she was extubated and transferred to the for further stabilization and monitoring.",0
"While in the , pt had respiratory distress.",0
She had to be re intubated.,0
She was then transferred to the CVICU intubated.,0
"She was eventually weaned from her vent, She was then transferred to the VICU in stable condition.",0
While in the VICU she received monitored care.,0
When stable she was delined.,0
A PT consult was obtained.,0
"When she was stabilized from the acute setting of post operative care, she was transferred to floor status On the floor, she remained hemodynamically stable with his pain controlled.",0
She progressed with physical therapy to improve her strength and mobility.,0
She continues to make steady progress without any incidents.,0
She was discharged to a rehabilitation facility in stable condition.,0
"Medications on Admission: advair, albuterol, norvasc 5, ASA 81, atenolol 50, calcium, lisinopril 10 Discharge Medications: 1.",0
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.,0
Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): (new med).,0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain.,0
Discharge Disposition: Extended Care Facility: Life Care Center of Discharge Diagnosis: abdominal aortic aneurysm Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?,1
Do not stop Aspirin unless your Vascular Surgeon instructs you to do so.,0
You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?,0
Elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?,0
"Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?",0
Drink plenty of fluids and eat small frequent meals ?,0
"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 ?",0
To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?,0
No driving until you are no longer taking pain medications ?,0
Call and schedule an appointment to be seen in weeks for post procedure check and CTA What to report to office: ?,0
"Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?",0
"Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes.",0
"If bleeding stops, call vascular office.",0
"If bleeding does not stop, call 911 for transfer to closest Emergency Room.",0
"Followup Instructions: Provider: , MD Phone: Date/Time: 12:50 Completed by:",0
MVR with bioprosthetic valve - unknown size and type.,0
Height: (in) 64 Weight (lb): 108 BSA (m2): 1.51 m2 BP (mm Hg): 115/66 HR (bpm): 106 Status: Inpatient Date/Time: at 09:15 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.,0
IMPRESSION: Mitral prosthesis with high-normal gradients and trivial mitral regurgitation.,0
Mildly dilated and hypokinetic right ventricle.,0
", P. MED 11R 3:02 PM CHEST (PA & LAT) Clip # Reason: eval for e/o CHF Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with SOB, unclear cause REASON FOR THIS EXAMINATION: eval for e/o CHF ______________________________________________________________________________ PFI REPORT Possible early developing bibasilar infiltrate.",0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: STEMI Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 66 yo male with h/o AAA, HTN, and remote Tobacco use (quit in ') who presented to the ED with chest pain, transferred to CCU after cardiac catheterization for STEMI.",1
"He reported substernal chest pressure that radiated to his back, between shoulder blades, and bilateral arms.",0
"He denies nausea, vomiting, diaphoresis.",0
"He described the pain as a burning mid chest pain that started over a week ago, which he thought was heartburn.",0
"Prior to admission, the pain had worsened and he took two ASA at home.",0
"In the ED, the patient was found to have BP 150s and HR in 120s.",0
"ECG showed 4-5 mm STE in II/III/AVF, depressions in V2-V6.",0
"He received an integrilin and heparin boluses, clopidogrel load, and a nitro GTT.",0
Cardiac cath showed severe 3vd.,0
"There was a 90% LAD stenosis at the D1 bifurcation with distal occlusion in the RCA, but with collaterals from the LAD.",0
"Cardiac surgery was consulted for emergent CABG, but deferred due to anticoagulation load.",0
"He was transferred to the CCU, clincally stable with BPs around 100. .",0
"On review of symptoms, he denies any prior history of stroke, TIA, cough, hemoptysis, black stools, or red stools.",0
Cardiac review of systems is notable for chest pain as described above.,0
"He denied dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.",0
"Past Medical History: seizure disorder HTN AAA - being monitored currently, dx 2 years ago Social History: Social history is significant for the absence of current tobacco use- used to smoke but quit in .",0
"Physical Exam: VS: T 98 , BP 112/50, HR 66, RR 15 , O2 100% on 2LNC Gen: WDWN middle aged male in NAD, resp or otherwise.",0
Neck: Supple; difficult to determine JVP given pt was supine.,0
"CV: RR, normal S1, S2.",0
"No S4, no S3- but distant heart sounds and difficult to auscultate Chest: No chest wall deformities.",0
Pulses: Right: Carotid 2+; Femoral 2+ without bruit; 2+ DP/PT : Carotid 2+; Femoral 2+ without bruit; 2+ DP/PT Pertinent Results: 09:59PM WBC-9.3 RBC-4.30* HGB-14.8 HCT-42.4 MCV-99* MCH-34.3* MCHC-34.8 RDW-13.4 09:59PM PT-11.8 PTT-24.5 INR(PT)-1.0 09:59PM PLT COUNT-282 09:59PM TRIGLYCER-122 HDL CHOL-67 CHOL/HDL-3.2 LDL(CALC)-121 LDL()-135* 09:59PM %HbA1c-5.4 09:59PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.3 CHOLEST-212* 09:59PM cTropnT-0.27* 09:59PM CK-MB-37* MB INDX-11.7* cTropnT-0.24* 09:59PM ALT(SGPT)-21 AST(SGOT)-46* CK(CPK)-317* 09:59PM GLUCOSE-158* UREA N-18 CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-29 ANION GAP-12 04:58AM CK(CPK)-1145* 04:58AM CK-MB-142* MB INDX-12.4* cTropnT-2.16* 03:23PM CK(CPK)-1521* 03:23PM CK-MB-186* MB INDX-12.2* cTropnT-2.48* 03:38PM URINE COLOR-Yellow APPEAR-Hazy SP -1.033 03:38PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 03:38PM URINE RBC-84* WBC-5 BACTERIA-RARE YEAST-NONE EPI-0 Cardiac Cath - 1.,0
Selective coronary angiography of this right dominant system revealed severe 3 vessel coronary artery disease.,1
The LMCA had mild diffuse disease with a 20% stenosis throughout.,0
The LAD had a 90% stenosis at the D1 bifurcation.,0
The LCx had an 80% proximal lesion.,0
The RCA was markedly tortuous with large thrombus burden and distal occlusion.,0
Collaterals were present from the LMCA.,0
Limited resting hemodynamics revealed normal systemic pressures.,0
Unsuccessful PTCA/PCI of the thrombotic and tortuous RCA.,0
Plan for CABG this admission.,0
"Acute inferior myocardial infarction, with unsuccessful PCI of occluded RCA managed by medical therapy.",1
CT surgery consult for non-emergent coronary artery bypass grafting.,1
TTE - The left atrium is mildly dilated.,0
LV systolic function appears mildly-to-moderately depressed (ejection fraction 40 percent) secondary to severe hypokinesis of the inferior free wall and moderate hypokinesis of the posterior wall.,0
There is no pericardial effusion TTE - The left atrium is normal in size.,0
"There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior wall, distal septum and apex.",0
"Compared with the prior study (images reviewed) of , mild mitral regurgitation is now identified with normal valve mophology suggestive of papillary muscle dysfunction.",0
Regional left ventricular systolic function of the inferolateral wall is improved.,1
"Port CXR - In comparison with the study of , the patient has taken a somewhat better inspiration.",0
Blunting of the costophrenic angles persists though there is no evidence of acute pneumonia.,0
The cardiac borders and hemidiaphragms are well seen on this study.,0
TEE - TEE placed in the OR to evaluate etiology of cardiopulmonary arrest.,0
There is noted hemopericardium along the posterior aspect of the heart measuring at greatest diameter 5.1 cm (This measurement was taken after patient expired).,1
There is no apparent aortic dissection.,0
"Brief Hospital Course: 66 yo male with a history of AAA, HTN, and remote Tobacco use (quit in ') who presented to the ED with chest pain, transferred to CCU after cardiac catheterization for inferior STEMI.",1
"1) Cardiac Ischemia: The patient presented with a inferolateral STEMI and underwent emergenct cardiac catheterization that revealed severe 3-vessel disease as per the cath report with failed PCI of the tortuous, thrombus filled RCA.",1
"Cardiac surgery was immediately consulted for a CABG and felt that the risks of bleeding, as the patient had received a plavix load, was greater than the benefits of immediately proceeding to CABG.",1
"As the cath was complicated by a small groin hematoma, heparin and integrillin drips were stopped.",0
"However, when cardiac surgery scheduled the patient for a CABG on hospital day three, both heparin and integrillin were restarted as he was thought to be a high risk for rethrombosis.",1
His groin hematoma remained stable and Hct did not drop significantly.,0
Plavix was held in anticipation of CABG.,0
His cardiac enzymes were cycled with a peak CK of 1521 and peak troponin of 2.74.,0
A HgbA1c was not significantly elevated and fasting lipids were checked.,0
"The patient was maintained on aspirin, high-dose statin, beta-blocker, and was started on an ACE-I.",1
"Unfortunately, on hospital day 3, the patient had a fever to 101.5 and his CABG was further postponed.",0
Blood and urine cultures were checked and were negative.,0
His temperature was thought to be secondary to post-infarct epicardial inflammatory changes and atelectasis.,0
"The patient also continued to complain of chest pain, that was at times as severe as a .",0
Serial EKGs were not significant for evolving ischemic changes.,0
He responded to IV morphine and was also started on toradol after clearing the use of a NSAID with c-surgery.,0
The patient was taken for a CABG on hospital day 5.,0
"In the surgical holding area while getting prepped for CABG, the patient suddenly complained of lightheadedness, then clutched his chest, and became unsreponsive.",0
A code blue was called and he was determined to be in PEA arrest.,0
"After intubation and several rounds of CPR and epinephrine and atropine, the patient was rushed emergently to the OR where he was found to have a perforated wall of his ventricular cavity.",0
The patient expired and an autospy was requested and accepted.,0
Pump: The patient remained euvolemic on exam during the hospital course.,0
"On the first hospital day, he required a total of 3 L of IVF boluses to maintain his SBPs > 90.",0
"A TTE was significant for a LVEF 40% with hypokinesis of inferior free wall and posterior wall, triv MR, and LVH.",0
"On hospital day 3, a rub vs. a MR murmur was heard on exam.",0
A repeat TTE was significant for new onset mild mitral regurgitaiton that was consistent with papillary muscle dysfunction.,0
A trivial pericardial effusion was also noted.,0
"A beta-blocker was started on admission and titrated up, but was eventually held due to Wenkebach (see below).",0
An ACE-I was also started for afterload reduction.,0
Rhythm: The patient was monitored on telemetry and remained in NSR with occasional ectopy.,0
"On hospital day 3, telemetry was significant for Wenkebach and the patient's beta-blocker was held.",1
He remained in Wenkebach until he was taken for CAB on hospital day 5.,0
2) Fever: Spiked to 101.5 on night of .,0
This subsequently delayed surgery as above.,0
"His UA was negative X 2, and all blood and urine cultures were no growth.",0
There were no signs of focal consolidation on CXR.,0
His fever was thought to be due to a combination of atelectasis and post-infarction epicardial inflammation as above.,0
3) h/o AAA: Undergoing surveillance as an outpatient.,0
Equal BPs in both arms during hospital course.,0
4) Seizure Disorder: Continued dilantin.,0
Medications on Admission: Quinapril 40 mg QAM and 20 mg QPM Dilantin- 400 mg daily ASA 81 mg daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Arrest Inferior STEMI HTN Discharge Condition: Expired.,0
Discharge Instructions: n/a Followup Instructions: n/a Completed by:,0
"9:57 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: chest tube clamped eval for rt ptx Admitting Diagnosis: AORTIC ARCH ANEURYSM ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with s/p asc aorta replacement REASON FOR THIS EXAMINATION: chest tube clamped eval for rt ptx ______________________________________________________________________________ FINAL REPORT PORTABLE AP CHEST FILM, AT 9:55 CLINICAL INDICATION: 70-year-old status post ascending aorta replacement, clamping of chest tube, evaluate right pneumothorax.",1
Comparison is made to the patient's prior study of at 7:22 and at 19:47.,0
Single portable AP upright chest film at 9:55 is submitted.,0
Single-lead right-sided pacemaker is unchanged in position.,0
"Right internal jugular introducer catheter and feeding tube are also likely unchanged, although the tip of the feeding tube cannot be definitively identified.",0
No definite chest tube is seen.,0
"However, the right apical pneumothorax does not appear to be changed.",0
"Persistent bibasilar patchy opacities with more focal consolidation in the retrocardiac area and associated pleural effusions are also stable and likely reflect compressive atelectasis, although pneumonia cannot be excluded.",0
"Overall, stable post-operative cardiac and mediastinal contours status post median sternotomy.",0
"10:30 AM BILAT LOWER EXT VEINS Clip # Reason: LE SWELLING ,EVAL FOR DVT Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with asymetric LE swelling.",0
"REASON FOR THIS EXAMINATION: R/O DVT ______________________________________________________________________________ FINAL REPORT INDICATION: 58-year-old man with asymmetric lower extremity swelling, evaluate for DVT.",1
"FINDINGS: -scale, color and Doppler son of bilateral common femoral, superficial femoral, popliteal and tibial veins were performed.",0
There is non-occlusive thrombus material seen within the left common femoral vein.,0
"At this location, the vein does not compress.",0
"However, vascular flow is seen on color Doppler and pulse wave Doppler imaging.",0
"There is normal flow, compression, and augmentation seen in the remainder of the veins of both legs.",0
cyst is seen in the right popliteal fossa measuring 3.7 x 2.2 x 1.1 cm.,0
Non-occlusive thrombus in the left common femoral vein.,0
3.7-cm cyst in the right popliteal fossa.,0
"Findings of non-occlusive thrombus were conveyed to /, NP at 4 p.m. on .",0
7:29 AM CHEST (PORTABLE AP) Clip # Reason: eval effusions Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man REASON FOR THIS EXAMINATION: eval effusions ______________________________________________________________________________ FINAL REPORT HISTORY: To assess effusions.,1
"FINDINGS: In comparison with study of , there are somewhat improved lung volumes.",0
The degree of vascular congestion is less pronounced.,0
"Right upper lobe opacity is again seen, consistent with history of esophagectomy and radiation therapy.",0
"The degree of pleural effusions appears to be less, though this could represent merely mild differences in patient position.",0
12:23 AM CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # Reason: please eval Lower T and the L spine for abcess Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with T9-L2 fusion and purulent drainage at wound REASON FOR THIS EXAMINATION: please eval Lower T and the L spine for abcess No contraindications for IV contrast ______________________________________________________________________________ WET READ: KKgc SAT 2:14 AM 1.,0
S/P T9-L2 posterior spinal fusion.,0
"R paraspinal fluid collections with rim enhancement and increasing amount of air within , concerning for paraspinal abscess.",1
"Two components of the collection- the collection apposed to the spine and the thecal sac measures approx 5.9 x 2.5 x 3.5 cm , extends from T11-T12 level.",0
The second collection more lateral in the paraspinal soft tissues measures 8.0 x 5.2 x 1.7 cm.,1
There is enhancement of the thecal sace.,0
"No definite cord compression is seen, but this study is limited given the streak artifatcs.",0
"Significant distention of the gall bladder, correlate clinically for signs of acute cholecystitis.",0
"Known metastatic disease ______________________________________________________________________________ FINAL REPORT INDICATION: 47-year-old man status post T9-L2 fusion, now presenting with purulent discharge at the wound, to evaluate for abscess.",1
"COMPARISON: CT of the lumbar spine with contrast, and CT of the torso with contrast .",0
TECHNIQUE: MDCT helical images were obtained through the thoracic and lumbar spine after administration of intravenous contrast.,0
"FINDINGS: The patient is status post posterior spinal fusion from T9-L2 levels, with paired rods and pedicle screws at T9, T10, L1 and L2.",1
"The fixation hardware is in stable position, without evidence of hardware-related complications.",0
The patient is status post laminectomy from T10-L1.,1
The alignment of the thoracic and lumbar spine is within normal limits.,0
"There is an enhancing, predominantly hypodense fluid collection in the paraspinal region adjacent to T11 and T12 vertebral bodies, measuring approximately 5.9 x 2.5 x 3.5 cm (SI x AP x TR).",0
"An additional fluid collection tracks along the lateral aspect of the right paraspinal region extending down to the level of L1-L3 vertebral body, and measures approximately 8 x 5.2 x 1.7 cm.",1
There is communication between the collections.,0
"There is a large amount of air within the fluid collections, significantly increased since the earlier postoperative study.",1
These findings are highly concerning for a paraspinal abscess.,1
There is mild enhancement of the dura.,0
Extensive streak artifact limits evaluation for cord compression.,0
"Within this limitation, no definite cord compression is identified.",0
"If there is concern, an MRI may be performed for further evaluation.",0
"(Over) 12:23 AM CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # Reason: please eval Lower T and the L spine for abcess Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) In the imaged portion of the upper abdomen, there is significant distention of the gallbladder, if there is concern for acute cholecystitis, an ultrasound can be performed.",0
"Again seen are multiple pulmonary nodules, which are partially necrotic throughout both lungs, consistent with the patient's known metastatic disease.",1
Assessment for progression is limited due to the limited field of view.,0
"Large bilobed right paraspinal fluid collection with rim enhancement and internal foci of air, concerning for paraspinal abscess.",1
This collection extends from the level of T11 to L2 vertebra.,0
The posterior spinal fixation hardware from T9-L2 is intact.,0
"Significant distention of the gallbladder, correlate clinically for signs of acute cholecystitis.",0
Known metastatic pulmonary nodules redemonstrated.,0
12:17 PM TEMP DIALYSIS LINE PLCT Clip # Reason: please exchange temp triple lumen access line with temporary Admitting Diagnosis: MYELODYSPLASTIC SYNDROME\BONE MARROW TRANSPLANT ********************************* CPT Codes ******************************** * EXCH CENTRAL NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman post SCT for MDS/MPD and on multiple antimicrobials.,1
Sustained small trauamatic SAH from fall.,0
Needs dialysis today as per renal.,0
Current dialysis line not working.,0
REASON FOR THIS EXAMINATION: please exchange temp triple lumen access line with temporary dialysis line with VIP port.,0
______________________________________________________________________________ FINAL REPORT MEDICAL HISTORY: 52-year-old woman status post stem cell transplant for myelodysplastic syndrome and on multiple antimicrobials.,1
The patient is being dialyzed via a right femoral temporary dialysis catheter which has been malfunctioning.,0
The patient also has a right internal jugular tunneled central line and left internal jugular non-tunneled central line.,0
A request was placed to exchange the left internal jugular temporary central venous catheter for a temporary hemodialysis catheter with a VIP port.,0
"Dr. , the attending radiologist was present and supervising throughout.",0
ANESTHESIA: Local anesthesia with 1% lidocaine.,0
"PROCEDURE AND FINDINGS: An informed consent was obtained from patient's husband who is her healthcare proxy after explaining the procedure, benefits, alternatives and risks involved.",1
The left side of the neck including the existing temporary central venous catheter were prepped and draped in the usual sterile fashion.,0
An initial scout image of the chest was obtained demonstrating right and left central venous catheters in the expected position.,0
Left central venous catheter ports were aspirated to clear the heparin and flushed with normal saline.,0
A 0.035 wire was placed through one of the ports and advanced into IVC after taking appropriate measurements.,0
The catheter was then removed over the guidewire.,0
Soft tissue tract dilated over the wire and a 12-French x 16 cm long temporary HD catheter with a VIP port was placed over the guidewire and the tip advanced into proximal right atrium.,0
All three ports of the catheter were easily aspirated and flushed.,0
Catheter secured in place with 0 silk sutures and sterile dressings applied.,0
A fluoroscopic spot chest film was obtained and stored digitally.,0
The right groin was prepped and draped and the temporary HD catheter was removed.,0
Hemostasis was achieved with digital compression for 10 minutes.,0
(Over) 12:17 PM TEMP DIALYSIS LINE PLCT Clip # Reason: please exchange temp triple lumen access line with temporary Admitting Diagnosis: MYELODYSPLASTIC SYNDROME\BONE MARROW TRANSPLANT ______________________________________________________________________________ FINAL REPORT (Cont) The patient tolerated both the above procedures well and there were no immediate complications.,1
Successful exchange of left internal jugular temporary central venous catheter for a 12 French x 16 cm long temporary HD catheter with a VIP port.,0
The tip of the catheter is in the proximal right atrium and the line is ready for use.,0
Uncomplicated removal of right femoral temporary HD catheter which has been malfunctioning.,0
", E. TSICU 11:30 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please use PO / IV contrast ?fever source in patient s/p fal Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with abd distention REASON FOR THIS EXAMINATION: please use PO / IV contrast ?fever source in patient s/p fall w/mult cervical fractures, abd distention, fever No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT New small bilateral pleural effusions, small amount of ascites and mild periportal edema.",1
No other acute abnormalities in abdomen or pelvis.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass grafts x3(LIMA-LAD, SVG-diag,svg-OM),repair diapragmatic hernia with core matrix patch History of Present Illness: This 78 year old white male with a history of hypertension is status post permanent pacemaker for symptomatic bradycardia 1-1/2 years ago.",1
"On he developed retrosternal chest pain, which was waxing and and finally crescendoed 2 days later.",0
He was admitted to an outside hospital with a STEMI and underwent further cardiac cath.,0
A 600 mg Plavix bolus was given.,0
"Catheterization revealed 100% RCA occlusion, 60-70% LM, 90% LAD lesion, and 90% Circumflex with LVEF 45%.",0
Stenting was performed and 2 bare metal stents were placed in the RCA.,0
Mr. was transferred to for evaluation for coronary revascularization.,0
"Past Medical History: hypertension s/p permanent pacemaker anxiety/depression s/p prostatectomy Social History: Race: Last Dental Exam:*full upper dentures/partial lower Lives with:his wife Occupation:retired Tobacco: one pack per week for 20 years, quit age 40 ETOH:occasional Family History: noncontributory Physical Exam: Admission: Pulse: 72 Resp: 20 O2 sat: 95%RA B/P Right: 126/72 Left: Height:5'7"" Weight:90 Kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft x[] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: (R)LE medial nodule-NT.",1
"ICD-9 Codes: 786.51, 424.1, 424.0, 424.2 Test Information Date/Time: at 11:03 Interpret MD: , MD Test Type: TEE (Complete) Son: , MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 35% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV.",1
LEFT VENTRICLE: Moderate regional LV systolic dysfunction.,0
"REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler.",1
"There is moderate regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and midportions of the anterior septum and inferior wall..",1
Dr. was notified in person of the results on at 1045am.,0
Post bypass Patient is receiving epinephrine and phenylephrine infusions.,1
"Electronically signed by , MD, Interpreting physician 17:16 ?",0
Brief Hospital Course: Following admission the usual preoperative workup was undertaken.,0
On he was taken to the Operating Room where coronary revascularization was performed.,0
A diaphragmatic hernia was found at surgery with dense adhesions to the left ventricle.,1
"After dissection of the adhesions and control of surface bleeding, the defect was closed using core matrix patch.",0
See operative note for details.,0
"He weaned from bypas on Propofol, Epinephrine and Neo Synephrine infusions.",0
Amiodarone was given for perioperative ventricular ectopy.,0
He tolerated the procedure well and transferred intubated and sedated in critical but stable condition to the CVICU.,0
EP was consulted for PPM interrogation and perioperative ectopy/arrythmias.,0
Mr. e neurologically intact and on POD# 1 he was extubated without difficulty.,0
Anticoagulation was intitiated for postoperative atrial fibrillation.,1
Beta blockade and diuresis was initiated.,0
EP reprogrammed the pacemaker to a slower rate as well as decreased the pacing output on his PPM.,1
The temporary pacing wires were then removed.,0
POD#2 he was transferred to the step down unit for further monitoring.,0
Physical therapy was consulted for evaluation of strength and mobility.,0
Post-pull chest tube CXRs showed persistent right pneumothorax without signs or symptoms of respiratory comprimise.,0
On POD# 5 Dr. cleared Mr. for discharge to rehab.,0
Medications on Admission: Amlodipine 10mg daily Trazodone 100mg HS prn sleep Paroxetine 20mg daily Discharge Medications: 1.,0
"Aspirin 81 mg , Delayed Release (E.C.)",0
"Sig: One (1) , Delayed Release (E.C.)",0
Acetaminophen 325 mg Sig: Two (2) PO Q4H (every 4 hours) as needed for pain.,0
Atorvastatin 80 mg Sig: One (1) PO DAILY (Daily).,0
Metformin 500 mg Sig: One (1) PO BID (2 times a day).,0
Tramadol 50 mg Sig: One (1) PO Q4H (every 4 hours) as needed for pain for 4 weeks.,0
Clopidogrel 75 mg Sig: One (1) PO DAILY (Daily).,0
Paroxetine HCl 20 mg Sig: One (1) PO DAILY (Daily).,0
Trazodone 50 mg Sig: Two (2) PO HS (at bedtime) as needed for sleep.,0
Metoprolol Tartrate 100 mg Sig: One (1) PO twice a day.,0
Amlodipine 5 mg Sig: Two (2) PO DAILY (Daily).,0
Warfarin 1 mg Sig: MD Once Daily at 4 PM: INR goal >2.0 FOR Atrial Fibrillation.,1
Warfarin 5 mg Sig: One (1) PO ONCE (Once) for 1 doses.,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing.,0
Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts permanent pacemeker depression/anxiety s/p coronary stents diapragmatic hernia hypertension noninsulin dependent diabetes Discharge Condition: Mental Status: Clear and coherent.,1
"pain well controlled on Ultram 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Please call to schedule appointments Surgeon: Dr. on at 1PM () Primary Care: Dr. () in weeks Cardiologist: Dr. in weeks Completed by:",0
", D. MED 5:33 AM CHEST (PORTABLE AP) Clip # Reason: Please assess interval change Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man in FOR THIS EXAMINATION: Please assess interval change ______________________________________________________________________________ PFI REPORT Compared to , there is no significant change in large right pleural effusion and small left pleural effusion.",0
The degree of CHF is decreased compared to prior exam.,0
Admission Date: Date: Service: SURGERY Allergies: Penicillins / Optiray 350 Attending: Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: Paravertebral cathether placement History of Present Illness: 89 yo male s/p trip and fall at home in bathroom falling onto toilet striking his left chest.,0
He was transported to for further care.,0
"Past Medical History: Parkinson's disease DM2 c/b neuropathy on neurontin diplopia x one year, horizontal, no clear etiology per patient, followed by ophtho HTN Migraines s/p MI yrs ago s/p cataract bilat s/p laminectomy in Social History: Recent move to from NY 10 days ago.",0
"lives with wife in senior citizen home, + tob 30yrs x 1ppd, quit 30 yrs ago, no etoh, no drugs, has 2 sons Family History: Father with strokes, no seizures, no parkinsons, sons are healthy Pertinent Results: 02:30PM GLUCOSE-125* UREA N-57* CREAT-2.1* SODIUM-141 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-19 02:30PM CALCIUM-9.3 PHOSPHATE-4.4# MAGNESIUM-2.0 02:30PM WBC-11.3* RBC-4.69 HGB-12.1* HCT-37.9* MCV-81* MCH-25.8* MCHC-31.9 RDW-17.0* 02:30PM NEUTS-73.1* LYMPHS-21.5 MONOS-3.8 EOS-1.2 BASOS-0.4 02:30PM PLT COUNT-236 CT Head IMPRESSION: 1.",0
No acute intracranial hemorrhage or mass effect.,0
Air-fluid level within the left maxillary sinus without definitive fracture detected.,0
No evidence of acute fracture or traumatic malalignment.,1
Multilevel cervical stenosis secondary to degenerative change.,0
"If there is clinical concern for myelopathy, MRI of the cervical spine is recommended for further evaluation to evaluate for cord edema/injury.",0
Tiny left apical pneumothorax with subcutaneous emphysema.,0
"Soft tissue opacity within the right lung apex is non-specific, possibly reflecting scar and is little changed since .",0
Numerous left-sided acute rib fractures causing small left hemopneumothorax and atelectasis.,1
Moderate-to-severe coronary artery calcifications and moderate calcification of the aortic valve of unknown hemodynamic significance.,0
Possible mild reaction to IV contrast material as detailed in technique portion of the report.,0
"Chest xray FINDINGS: Multiple left rib fractures are again noted, and there is evidence of left pleural fluid and atelectasis.",0
Retrocardiac density is not significantly different.,0
Brief Hospital Course: He was admitted to the Trauma service and transferred to the Trauma ICU for close monitoring of his respiratory status because of his injuries.,1
The Pain Service was consulted for epidural analgesia; it was decided to place a paravertebral catheter which remained in place for several days.,0
He was also started on PCA Dilaudid initially and was then changed oral narcotics but became disoriented with the narcotics.,0
A short trial of Ultram was started and then discontinued as his disorientation did not improve initially.,0
Once off of all narcotics and the Ultram his mental status improved significantly.,0
Geriatrics was also consulted and made several recommendations regarding his pain medications.,0
His current pain regimen includes Tylenol 1 gram around the clock and Lidocaine 5% patch.,0
He still requires supplemental nasal oxygen as he does desaturate on room air to low 90's high 80's.,0
"Most recent chest xray does show some pleural fluid and atelectasis, bu no pneumothorax.",0
He is able to illicit a fairly strong productive cough with encouragement.,0
On hospital day 5 he self discontinued his Foley catheter with the balloon inflated and was noted to have hematuria following this.,0
A 3 way catheter was attempted without success and so a one way Foley was replaced.,0
He is ordered for q shift catheter flushes with sterile water.,0
The hematuria has decreased significantly; the catheter can be removed in the next day or so as long as the hematuria has resolved.,0
Physical and Occupational therapy were consulted and have recommended acute level rehab after his hospital stay.,0
"Medications on Admission: Allopurinol 100, Amitriptyline 25, Atenolol 100, Carbidopa-Levodopa 25-100"""", Enalapril Maleate 10, GlipiZIDE 5"", Gabapentin 300 Medications: 1.",0
Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours).,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours).,0
"Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day).",0
Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day).,0
Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation.,0
Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours).,0
"Disposition: Extended Care Facility: for the Aged - MACU Diagnosis: s/p Fall Left hemothorax Left rib fractures Traumatic hematuria Condition: Hemodynamically stable, tolerating a regular diet, pain fairly well controlled.",1
"Followup Instructions: Follow up in 2 weeks with Dr. , Trauma Surgery.",0
Follow up with your primary care doctor from rehab; you or your family will need to call for an appointment.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: NB HISTORY OF PRESENT ILLNESS: is the former 905-gram product of a twin gestation pregnancy born at 33 weeks gestation to a 33-year-old G1, P0 woman.",1
"Prenatal screens: Blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B Strep status unknown.",0
The pregnancy was complicated by cervical shortening status post a cerclage placement at 22 weeks gestation.,1
This was a diamniotic- dichorionic twin conception.,0
Growth restriction was noted in this twin number two initially with normal amniotic fluid and intermittently reverse diastolic flow.,0
Mild preterm labor was noted at 28-weeks gestation.,1
The mother was beta complete on .,0
The decision was made to proceed to delivery due to lack of growth in this twin over the prior two weeks with growth parameters of less than the 2nd percentile.,1
There was also worsening oligohydramnios with no amniotic fluid noted on this twin by ultrasound on the day of delivery.,0
The infants were delivered by cesarean section.,1
"This twin number two emerged active with good respiratory effort, received blow-by oxygen for central cyanosis.",0
Apgar scores were 8 at one minute and 8 at five minutes.,0
She was admitted to the Neonatal Intensive Care Unit for further care.,0
"PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 905 grams, head circumference 26.5 cm, length 34.5 cm, all well below the 10th percentile.",1
General: Small for gestational age infant in mild respiratory distress.,1
"Head, eyes, ears, nose, and throat: Anterior fontanel is open and flat.",0
Breaths sound slightly decreased bilaterally.,0
"Abdomen is soft, nontender, nondistended.",0
"Extremities: Well perfused, moving all.",0
Neurologic: Tone appropriate for gestational age with intact reflexes.,0
"Musculoskeletal: Spine straight, normal sacrum, hips stable.",0
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: required treatment for her respiratory distress with continuous positive airway pressure.,1
Her maximum oxygen requirement was 25 percent.,0
She weaned to room air by day of life number one.,0
The continuous positive airway pressure was discontinued on day of life number three.,0
remained on room air for the rest of her Neonatal Intensive Care Unit admission.,0
She has had rare episodes of apnea and bradycardia.,0
Most recent episode was a bradycardia episode with feeding on .,0
"At the time of discharge, she is breathing comfortably with respiratory rate of 30-40 respirations/minute.",0
Cardiovascular: has maintained normal heart rates and blood pressures.,0
"Fluid, electrolytes, and nutrition: was initially nothing by mouth and treated with intravenous fluids.",0
Enteral feeds were started on day of life number six and gradually advanced to full volume.,0
"At the time of discharge, she is taking breast milk fortified to 26 calories per ounce with 6 calories of NeoSure powder or NeoSure formula fortified to 26 calories per ounce.",0
Her weight on the day of discharge is 1.545 kg with a recent head circumference of 29.5 cm and a length of 39 cm.,0
Serum electrolytes were checked in the first week of life and were within normal limits.,0
"Infectious disease: Due to her prematurity, was evaluated for sepsis at the time of admission to the Neonatal Intensive Care Unit.",0
An initial complete blood count was within normal limits.,0
A blood culture was attained prior to starting intravenous ampicillin and gentamicin.,0
A blood culture was no growth at 48 hours and the antibiotics were discontinued.,0
"Due to some abdominal distention and her history of thrombocytopenia, the antibiotics were continued to complete a one week course.",0
"Due to her growth restriction, was evaluated for possible congenital cytomegaloviral infection.",0
A urine for CMV was sent on .,0
The rapid antigen was negative and the culture was negative at 28 days.,0
"Hematological: is blood type A positive, Coombs negative.",0
"As previously noted, her platelet count at birth was 86,000.",0
"This was repeated on day of life number one and had fallen to 45,000.",0
She was electively transfused with platelets.,0
"Her subsequent platelet counts remained over 100,000.",0
"Her most recent platelet count was on , day of life number 10, and was 252,000.",0
Her most recent hematocrit was on and was 25 percent with a reticulocyte count of 6.1 percent.,0
She received only the platelet transfusion during the admission.,0
A repeat HCt is suggested for one to two weeks.,0
Gastrointestinal: required treatment for unconjugated hyperbilirubinemia with phototherapy.,0
Peak serum bilirubin occurred on day of life number one with a total of 6.3/0.5 mg/dl direct.,0
She received phototherapy for approximately five days.,0
Her rebound bilirubin on day of life five was a total of 2.3/0.4 mg/dl direct.,0
She was also evaluated for abdominal distention on day of life numbers three to four.,0
Several abdominal x-rays were obtained and were within normal limits.,0
The abdominal distention was thought to be secondary to the continuous positive airway pressure.,0
Theer were no further GI issues.,0
Neurological: has maintained a normal neurological examination during admission and there are no neurological concerns at the time of discharge.,0
"She had head ultrasounds on and , both of which were within normal limits.",0
Ophthalmology: eyes were most recently examined on showing immature retinas to zone III bilaterally.,0
Recommended followup within three weeks which will be due the week of .,0
"was examined by Dr. , Pediatric Radiology from .",0
"Her recommended followup can be with Dr. at or at the at Clinic 6 One , , MA with a phone number of .",0
The ophthalmologist there is Dr. and her office number is .,0
"PRIMARY PEDIATRICIAN: Dr. , at , , , phone number .",0
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: Oral adlib feeding breast milk 26 calories with NeoSure powder or NeoSure formula 26 calories per ounce.,0
The NeoSure is recommended until 6-9 months corrected age.,0
Follow up with Opthamology as sugegsted above.,0
Repeat Hematocrit in weeks or sooner as needed.,0
MEDICATIONS: Ferrous sulfate 25 mg/mL dilution 0.15 mL orally once daily.,0
Vi-Daylin 1 mL by mouth once daily.,0
CAR SEAT POSITION SCREENING: Car seat position screening was performed.,0
was observed in her car seat for 90 minutes.,0
"STATE NEWBORN SCREEN: State newborn screenings were sent on and , all results are within normal limits.",0
"A repeat screen was sent on , and the results remain pending at the time of his dictation.",0
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was administered on .,0
"Born between 32 and 35 weeks with two of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or 3.",0
"FOLLOW-UP APPOINTMENTS SCHEDULED/RECOMMENDED: Appointment with Dr. , primary pediatrician within three days of discharge.",0
"Pediatric Ophthalmology, either Dr. or Dr. at either in or the at .",0
Phone number for at is .,0
The phone number for Dr. at is .,0
DISCHARGE DIAGNOSES: Prematurity at 33-weeks gestation.,1
Twin number two of twin gestation.,0
Small for gestational age secondary to intrauterine growth restriction.,0
Congenital cytomegalovirus infection ruled out.,0
", Dictated By: MEDQUIST36 D: 01:29:16 T: 04:35:58 Job#:",0
3:38 PM DUPLEX DOPP ABD/PEL; -53 INCOMPLETE/UNSCUCCESSFUL Clip # Reason: ?,0
visible residual liver pathology Admitting Diagnosis: HEPATIC FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 52 year old woman with h/o recent fulminant hepatic failure ?,1
"bactrim, tylenol with recent incr in LFTs REASON FOR THIS EXAMINATION: ?",0
visible residual liver pathology- please do dopplers as pt has plt of 999 ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): TUE 4:54 PM Doppler examination not completed.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 52-year-old female with recent fulminant hepatic failure and increasing LFTs.,1
Evaluate for liver pathology and evaluate Doppler exam.,0
FINDINGS: Transverse and sagittal images of the liver demonstrate no focal abnormality and there is no textural abnormality identified.,1
This examination was prematurely terminated as the patient refused to complete the exam.,0
No Doppler imaging was performed.,0
IMPRESSION: No liver abnormality identified.,1
Exam prematurely terminated as patient refused to complete the exam.,0
10:36 AM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: r/o ligamentous injury Admitting Diagnosis: TSAH ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with accident of unknown mechanism leading to SDH and intubated with GCS 7 REASON FOR THIS EXAMINATION: r/o ligamentous injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CERVICAL SPINE MRI SCAN HISTORY: 21-year-old man with accident of unknown mechanism leading to subdural hematoma- intubated with coma score of 7.,1
"TECHNIQUE: Sagittal T1- and T2-weighted as well as STIR images of the cervical spine were obtained, with axial gradient echo scans as well as T2- weighted images.",0
COMPARISON STUDIES ON PACS ARCHIVE: Cervical spine CT scan from .,0
FINDINGS: There is moderate prevertebral soft tissue swelling extending from the apical ligament as far distally as the C5 vertebral body.,0
The maximal width of the prevertebral soft tissue swelling is 6 mm.,0
"There is also extensive fluid accumulating within the posterior nasopharynx, as well as overlying the supraglottic portion of the larynx.",0
The latter finding presumably correlates with the intubated status of the patient.,0
"There is very slight T2 hyperintensity of the C6-7 disc, but without other morphological findings to suggest traumatic disc disruption.",0
There is no other cervical disc or vertebral abnormality.,0
"The spinal cord outline and signal pattern, foramen magnum and its contents are otherwise within normal limits, aside from the presence of a nasogastric tube.",0
"CONCLUSION: Moderate upper cervical prevertebral soft tissue swelling, certainly could be posttraumatic in etiology.",0
No sign of cervical cord injury.,0
"Possible minimal traumatic disc injury at C6/7, as noted above.",0
I discussed all findings with Dr. and Dr. immediately after review of this study.,0
", H. NMED SICU-A 11:22 AM CT HEAD W/O CONTRAST Clip # Reason: eval progression of midbrain IPH to r/o evolution/structural Admitting Diagnosis: SUBDURAL HEMATOMA;MIDBRAIN BLEED ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with midbrain IPH (left-central/paramedian), recovering on vent/CPAP, stable medically and with stably improved Neurologic exam - NOW now 1d s/p trach/PEG with unresponsiveness at 11am REASON FOR THIS EXAMINATION: eval progression of midbrain IPH to r/o evolution/structural cause of new unresponsiveness No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: 1.",0
"No significant interval change in the overall appearance of the hematoma involving the left dorsolateral aspect of the brainstem, at the level of the pontomesencephalic junction, with adjacent edema, but no further mass effect.",1
"Continued interval resorption of intracranial hemorrhage in other compartments, with no new hemorrhage.",0
"Acute-on-chronic inflammatory changes in the paranasal sinuses, as before.",0
"7:48 PM MR SHOULDER W&W/O CONTRAST RIGHT Clip # Reason: pls evaluate for progression and abscess Admitting Diagnosis: PNEUMONIA;SHOULDER PAIN Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with MSSA bacteremia, p/w erythematous shoulder, question of AC joint infection, MRI concerning for fasciitis v myositis with persistent erythema/pain and new leukocytosis w/ left shift infection, concerned about soft tissue infection REASON FOR THIS EXAMINATION: REASON FOR THIS EXAMINATION: pls evaluate for progression and abscess No contraindications for IV contrast ______________________________________________________________________________ WET READ: DSsd SUN 6:22 PM No significant change in appearance of fasciitis and myositis about the right shoulder.",1
No MR evidence of gas to suggest necrotizing fasciitis.,0
"Bone marrow edema little changed, remains nospecific, but osteomyelitis is not excluded.",0
"______________________________________________________________________________ FINAL REPORT MRI OF THE SHOULDER, CLINICAL HISTORY: bacteremia, erythematous shoulder, question of AC joint infection.",0
TECHNIQUE: Multiplanar T1- and T2-weighted images of the right shoulder were acquired on a 1.5 Tesla magnet before and after uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA.,0
"FINDINGS: Overall, there has been little interval change in appearance of edema throughout the rotator cuff muscles and deltoid, with edema and enhancement in the fascial planes and muscle, particularly the infraspinatus.",0
Diffuse subcutaneous edema and inflammatory change is also not significantly changed.,0
"This study was not specifically tailored for evaluation of the rotator cuff tendon attachments, but overall appearance is grossly unchanged from prior study.",0
There is no MR evidence of gas to suggest necrotizing fasciitis.,0
"There is no rim enhancement, focal fluid collection, or other evidence of abscess.",0
"Abnormality about the acromioclavicular joint, with bony irregularity, proliferative change, and diffuse edema and enhancement in the acromion and distal clavicle is little changed in appearance.",0
Small amount of fluid within the acromioclavicular joint is unchanged.,0
Bone marrow signal is otherwise within normal limits.,0
IMPRESSION: (Over) 7:48 PM MR SHOULDER W&W/O CONTRAST RIGHT Clip # Reason: pls evaluate for progression and abscess Admitting Diagnosis: PNEUMONIA;SHOULDER PAIN Contrast: MAGNEVIST Amt: 17 ______________________________________________________________________________ FINAL REPORT (Cont) 1.,1
No significant change in appearance of nonspecific myositis about the right shoulder.,1
Bone marrow edema and enhancement in the acromion and distal clavicle is little changed in distribution over short interval.,0
10:44 AM CHEST (PORTABLE AP) Clip # Reason: INterval Change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 87 year old woman with worsening respiratory status REASON FOR THIS EXAMINATION: INterval Change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Worsening respiratory status.,1
AP radiograph of the chest was reviewed in comparison to and several prior radiographs dating back to .,0
"There is gradual progression of widespread consolidation, now involving entire lungs, but with no substantial change as compared to the recent radiograph from .",0
There is most likely present small amount of pleural effusion.,0
Findings might be consistent with infectious multifocal process or ARDS.,0
2:18 PM CHEST (PORTABLE AP) Clip # Reason: F/u bilat PTX with CT Admitting Diagnosis: MULTIPLE STAB WOUNDS ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with multiple stab wounds and bilat PTX REASON FOR THIS EXAMINATION: F/u bilat PTX with CT ______________________________________________________________________________ FINAL REPORT HISTORY: Multiple stab wounds with bilateral pneumothoraces.,0
"FINDINGS: In comparison with the study of , there has been the development of some patchy opacification at the left base.",0
This could represent pulmonary contusion or possible pneumonia.,0
Bilateral chest tubes remain in place and there is no evidence of pneumothorax.,1
Endotracheal and nasogastric tubes have been removed.,0
8:21 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: r/o CVA/mets Admitting Diagnosis: RENAL FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with renal cancer and treansient rt UE weakness.,0
"Non-contrast CT head neg for acute events, radiologist recommended MRI REASON FOR THIS EXAMINATION: r/o CVA/mets ______________________________________________________________________________ FINAL REPORT INDICATION: 75-year-old male with renal cancer and transient right upper extremity weakness.",0
COMPARISON: Non-contrast head CT from one day prior.,0
"TECHNIQUE: Sagittal T1, axial T2, FLAIR, gradient-echo, and diffusion- weighted images of the brain were performed.",0
"In addition, 3D MRA of the circle of was obtained using time-of-flight technique.",0
MRI OF THE BRAIN: There is no evidence of acute brain ischemia.,0
"There is mild brain atrophy, resulting in slight sulcal and ventricular prominence.",0
There is no abnormal signal within the brain parenchyma.,0
The craniocervical junction appears unremarkable.,0
There is high T2/FLAIR signal within one of the right frontal air cells.,0
"Magnetic susceptibility artifact is seen in the area of the medial right maxillary sinus anteriorly, which may relate to some sort of metal in this localization.",0
"MRA OF THE BRAIN: There is no area of hemodynamically significant stenosis, or aneurysmal dilation within the circle of or its major branches.",0
There is no evidence of arteriovenous malformation.,0
"The right vertebral artery is not visualized, which is likely a developmental/congenital finding.",0
No evidence of acute brain ischemia.,0
Chronic paranasal sinus disease as described above.,0
Metallic artifacts in the right nose/right maxillary sinus.,0
No evidence of aneurysm or significant stenosis within the circle of .,0
7:53 AM CHEST (PORTABLE AP) Clip # Reason: INTERVAL CHANGE Admitting Diagnosis: MITRAL VALVE REGURGITATION;VENTRICULAR TACHYCARDIA ______________________________________________________________________________ FINAL REPORT INDICATION: Interval change.,1
"COMMENT: Portable supine AP radiograph of the chest is reviewed, and compared with the study of .",0
The previously identified moderate to severe congestive heart failure has been improving.,1
There is continued cardiomegaly with small bilateral pleural effusion.,0
"The tracheostomy tube, right subclavian IV catheter, and pacemaker leads remain in place.",0
IMPRESSION: Improving congestive heart failure with continued cardiomegaly and small bilateral pleural effusion.,1
Admission Date: Discharge Date: Date of Birth: Sex: F Service: Gynecology/Oncology HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old gravida 2 para 2 with a history of stage IIIB cervical cancer who presented for a total pelvic exenteration secondary to cancer recurrence on bladder biopsy which was performed on .,1
The patient had initially presented in with heavy irregular vaginal bleeding.,0
A cervical biopsy in showed invasive squamous cell carcinoma.,0
At this time she was stage IIIB.,0
The patient began cisplatin and radiation therapy in .,0
At that time she was also noted to have left-sided hydronephrosis secondary to cancer obstruction and a double-J ureteral stent was placed on the left side.,0
In the patient had completed five cycles of cisplatin and concomitant radiation therapy.,0
"In , the patient had brachytherapy (50 hours), On , a CT scan showed no metastases.",0
"On , the patient had a cystoscopy to replace a double-J stent in her left ureter.",0
At that time a bladder mass was found which was biopsied.,0
Pathology showed that it was recurrent cervical carcinoma in the bladder.,0
"On , a CT scan showed no metastases; therefore, it appeared that the patient had an isolated central pelvic recurrence.",0
"At that point, the treatment options were discussed with the patient and that total pelvic exenteration would be the curative option at this point.",0
"Once the procedure was discussed with the patient, including the risks and benefits of the procedure, and all questions were answered, she was consented for a total pelvic exenteration.",0
Only complaint on admission was urinary frequency and occasional hematuria.,0
PAST GYNECOLOGICAL HISTORY: Please see History of Present Illness for details of stage IIIB cervical cancer.,0
"No history of abnormal PAP smears; although, her last PAP smear was nine years prior to diagnosis of cancer.",0
The patient denies a history of sexually transmitted diseases or endometriosis.,0
PAST OBSTETRICAL HISTORY: Status post spontaneous vaginal delivery times one and cesarean section times one.,0
No complications with either procedure.,0
"PAST MEDICAL HISTORY: In the patient was diagnosed with melanoma of her right posterior calf, stage level 4.",0
A surgical excision was performed without complications.,0
There was no evidence of recurrence.,0
PAST SURGICAL HISTORY: Cesarean section times one.,0
MEDICATIONS ON ADMISSION: Valium 5 mg p.o.,0
ALLERGIES: IV CONTRAST and BACTRIM.,0
SOCIAL HISTORY: The patient is a cardiac nurse.,0
She denies tobacco or alcohol use.,0
FAMILY HISTORY: Father died of bladder cancer in with liver and bone metastases.,0
Her mother died at the age of 72 of a abdominal aortic aneurysm.,0
Her mother also had hypertension.,0
"REVIEW OF SYSTEMS: Review of systems revealed urinary frequency, hematuria.",0
PHYSICAL EXAMINATION ON ADMISSION: Physical examination on admission was significant for a nontender and nondistended abdomen with positive bowel sounds.,0
There was a vertical cesarean section scar.,0
There was a question whether the uterus was palpable just below the umbilicus.,0
"On pelvic examination, the vulva and vagina had extensive radiation affect.",0
The vaginal canal was foreshortened.,0
The cervix was not identifiable.,0
"There was no obvious tumor on bimanual, and rectovaginal examination revealed smooth vaginal walls and smooth rectal mucosa.",0
"There was no nodularity, but there was extensive radiation affect.",0
LABORATORY ON ADMISSION: Crossed and typed for 4 units.,0
Complete blood count and Chem-10 were sent.,0
The patient's preoperative hematocrit was 31.5.,0
"Her creatinine was 1.2; however, her baseline creatinine was 1.1 to 1.4.",0
The rest of the preoperative laboratories were within normal limits.,0
"HOSPITAL COURSE: In summary, the patient is a 54-year-old gravida 2 para 2 with stage IIIB cervical cancer, status post chemotherapy radiation and brachy therapy, who presented with localized recurrence in the bladder.",0
She was admitted on the day prior to her total pelvic exenteration for preoperative bowel preparation with Fleets soda.,0
"The patient underwent a total pelvic exenteration, pouch, and colostomy on .",0
Please see the Operative Note for details of the procedure.,0
"Intraoperative the patient received 15 liters of intravenous fluids, 12 units of packed red blood cells, 7 units fresh frozen plasma, 6 packs of platelets, 100 cc albumin, 1000 cc of hespan.",0
Estimated blood loss was 5.5 liters.,0
"Intraoperatively, the patient's hematocrit decreased to a low of 14.1.",0
"Her platelets decreased to a low of 61, and her INR at maximum was 5.",0
"Postoperatively, the patient was admitted to the Surgical Intensive Care Unit.",0
She was transferred to the floor on postoperative day three.,0
CARDIOVASCULAR: The patient was in normal sinus rhythm throughout her hospital course.,0
"In the Surgical Intensive Care Unit, her blood pressure was kept greater than 100 systolic and greater than 60 diastolic.",0
She was repleted with crystalloid as well as with blood products to keep her hematocrit greater than 25.,0
She did not require pressors.,0
There were no active cardiac issues both in the Medical Intensive Care Unit and on the floor.,0
"HEMATOLOGY: In the operating room, the patient appeared to have a mild coagulopathy.",0
Her blood products including fresh frozen plasma and platelets were repleted as needed.,0
Coagulation panel was checked in the Medical Intensive Care Unit.,0
The patient did not have any further coagulopathy postoperatively.,0
The patient was transfused as needed to keep her hematocrit greater than 25.,0
She received a total of 14 units of packed red blood cells between the operating room and the Surgical Intensive Care Unit.,0
She did not require further packed red blood cells on the floor.,0
The patient was Rh negative.,0
"Given that, she received Rh positive platelets.",0
She was given RhoGAM times one.,0
PULMONARY: The patient was intubated in the operating room and was taken to the Surgical Intensive Care Unit intubated.,0
"Chest x-ray revealed proper placement of the endotracheal tube, and there was no evidence of infiltrate.",0
The patient was sedated on propofol.,0
"Attempts were made to wean the patient off of the respirator, and eventually, on postoperative day two, the patient was extubated.",0
"Once the patient was extubated, throughout the hospital course there were no further respiratory issues.",0
She was given incentive spirometry for the prevention of atelectasis.,0
"INFECTIOUS DISEASE: Given that the patient underwent a major intra-abdominal surgery, she was started on Kefzol and Flagyl postoperatively.",1
She was afebrile on Kefzol and Flagyl.,0
"On postoperative day three, she had a temperature to 100.6 which was likely secondary to atelectasis.",0
"On postoperative day three, there was some erythema noted at the wound side.",0
"Therefore, her antibiotics were changed to ampicillin, ceftriaxone, and Flagyl.",0
She completed a 7-day course of the triple antibiotics and was then started on a oxacillin for skin coverage.,0
On postoperative day 14 (day five of the oxacillin) the patient was changed to dicloxacillin.,0
She was sent home with a 7-day course total of the dicloxacillin (including the day she had spent on the oxacillin).,0
GENITOURINARY: The patient had a pouch created.,0
"Postoperatively, there were issues with low urine output.",0
Her - output was high in the Surgical Intensive Care Unit.,0
Her urine output did improve after receiving blood.,0
"By postoperative day two, the patient was draining urine from the pouch.",0
"On postoperative day two, the pouch started to be irrigated every three hours with 60 cc of normal saline.",0
"Throughout the rest of her hospital course, the patient maintained adequate urine output.",0
Her creatinine throughout her hospital course was within her baseline range of 1.1 to 1.4.,0
On the day prior to discharge there was some drainage of urine surrounding the Foley catheter that was in the pouch.,0
This was thought to be secondary to mucous plugging the urostomy.,0
This resolved with irrigation and flushing of the pouch with normal saline.,0
"Throughout her hospital course, the urostomy was violaceous and appeared to have no breakdown.",0
GASTROINTESTINAL: The patient had a colostomy at the time of the operation.,0
The patient was made n.p.o.,0
"She was started on intravenous fluid hydration in the Surgical Intensive Care Unit, and her electrolytes were followed and repleted as needed.",0
She was placed on Protonix for gastrointestinal prophylaxis.,0
The patient was started on total parenteral nutrition on postoperative day three.,0
The patient had a right internal jugular to receive the total parenteral nutrition.,0
This was changed to a left PICC line on postoperative day four.,0
The patient also had an nasogastric tube that was placed intraoperatively.,0
This was maintained on low wall suction and was discontinued on postoperative day five.,0
"On postoperative day six, the patient's diet was advanced to clears, and her diet was advanced as tolerated.",0
"The total parenteral nutrition was weaned, and on postoperative day 13 the patient's total parenteral nutrition was discontinued.",0
She was started on a multivitamin and was receiving Boost supplements.,0
"Nutrition laboratories were checked while the patient was on total parenteral nutrition, and there were no abnormalities.",0
"NEUROLOGY: While in the Surgical Intensive Care Unit, the patient was on propofol while intubated and was also receiving intravenous morphine and Versed as needed for pain control.",0
"When the patient was transferred to the floor, she was receiving morphine as needed for pain control as well until she was tolerating adequate p.o.",0
At that time she was changed to Percocet which provided good pain relief.,0
PROPHYLAXIS: The patient was placed on Pneumo boots until she was ambulating and received Protonix as gastrointestinal prophylaxis.,0
POSTOPERATIVE CARE: The patient had staples to close her skin incision.,0
These should remain for approximately one month postoperatively.,0
"CODE STATUS: Throughout her hospital course, the patient remained full code.",0
CONDITION AT DISCHARGE: Condition at the time of discharge was stable.,0
Stage IIIB cervical cancer with local recurrence to the bladder.,0
"Status post total pelvic exenteration, pouch, and colostomy.",0
times six days for a total 10-day course of dicloxacillin and oxacillin.,0
8. pouch flush 60 cc of 0.25% acetic acid and normal saline via the Foley catheter q.3h.,0
Change ostomy bag as instructed.,0
DISCHARGE FOLLOWUP: The patient was to follow up with Dr. nine days after discharge.,0
Dictated By: MEDQUIST36 D: 12:21 T: 08:03 JOB#:,0
"10:17 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: please perform RUQ ultrasound to assess for cholecystitis, e ______________________________________________________________________________ MEDICAL CONDITION: 74M heavy drinker comes in with 1day of abdominal pain, diarrhea, chills/sweats.",1
"+RUQ tenderness on exam REASON FOR THIS EXAMINATION: please perform RUQ ultrasound to assess for cholecystitis, evidence of biliary obstruction, abscess ______________________________________________________________________________ WET READ: AKSb TUE 11:52 PM Gallstones without definite evidence of cholecystitis.",1
"Patient was guarding in RUQ, but son not elicited (though the patient also has received pain medication).",0
CBD prominent (1.1 cm) but can be traced to pancreatic head with no stones visualized.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old drinker with one day of abdominal pain and right upper quadrant tenderness.,0
Evaluate for cholecystitis or biliary obstruction.,1
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture with minimal if any prominence of the intrahepatic biliary ducts.,1
"The common bile duct is prominent, measuring up to 1.1 cm.",0
The common bile duct can be traced nearly in its entirety to the pancreatic head with no evidence of CBD stone.,0
The proximal pancreatic duct is dilated up to approximately 5 mm.,0
"There are multiple shadowing gallstones within the gallbladder, however, the gallbladder is not distended.",0
The gallbladder wall measures approximately 3 mm with no evidence of edema.,0
There is no pericholecystic fluid.,0
"Son sign was not elicited, though the patient has recently received pain medications.",0
"The patient was guarding when the right upper quadrant was palpated, however, this was diffuse, both over the gallbladder and the liver.",1
"The kidney is mildly echogenic, suggesting medical renal disease.",0
There is no evidence of right- sided hydronephrosis.,0
"Son sign was not able to be elicited, though the patient had just received pain medication.",0
"Dilated common bile duct and pancreatic duct; however, the CBD can be traced quite distally to the region of the pancreatic head, with no evidence of CBD calculus.",0
"(Over) 10:17 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: please perform RUQ ultrasound to assess for cholecystitis, e ______________________________________________________________________________ FINAL REPORT (Cont)",1
Admission Date: Discharge Date: Service: ADMITTING DIAGNOSIS: 1.,0
"CHIEF COMPLAINT: The patient was an 81-year-old woman admitted to the CCU service with a chief complaint of ischemia, transient left bundle branch block, status post cardiac catheterization.",0
"HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman with a past medical history significant for dementia, depression, coronary artery disease of three vessels, status post non Q wave MI in .",0
The patient refused further work-up at that time.,0
The patient was transferred from the morning of admission for the evaluation of respiratory distress.,0
On at 10 p.m. the patient started to complain of chest pain.,0
"At that time she had vital signs done which were significant for temperature of 100.4, heart rate 88, respiratory rate 28 and blood pressure 160/80, no oxygen saturation was recorded.",1
"She received Nitroglycerin .4 mg sublingual, Ativan 0.5 mg and Lasix 40 mg po.",0
She was started on oxygen at that time.,0
She felt better after these interventions.,0
At 3:30 a.m. the day of admission she again experienced chest pain and was given Nitroglycerin sublingual times two.,0
At 7:30 a.m. she was noted to be hypoxic with an oxygen saturation of 70% on three liters and she complained of chest pain again.,0
Initially she refused to go to the hospital and then she acquiesced and she was transferred to for further care.,0
"On her way, the paramedics gave her Lasix 80 mg IV times one and three Nitroglycerin sublingual.",0
"In the Emergency Room she had a systolic blood pressure in the 100's, she was tachycardic to 110 and tachypneic to respiratory rate of 34.",0
"She had an EKG that showed a heart rate of 120 with a new left bundle branch block, increased left axis deviation and ST depression in V4 through V6 on the initial EKG.",1
"Subsequent EKGs showed progressive diffuse ST depression and 3-4 mm depressions in V3 through V6, 2-3 mm in V2, V3 and AVF and depression in 1, and elevation in AVL.",0
Oxygen saturation was in the 60's in the Emergency Room.,0
She was intubated nasally for hypoxia.,0
"Her O2 sat increased to 80% and the ABG following intubation was 7.32, PCO2 50, PO2 74.",0
"Following intubation and sedation, she dropped her blood pressure to 50/30 and was started on Dopamine drip or hypertension.",0
The patient then progressed to emergent cardiac catheterization with a new left bundle branch block and these ischemic changes with the presumption of cardiogenic shock.,1
"When she arrived in the cath lab, she had a borderline systolic blood pressure in the low 100's on 20 mcg per minute of Dopamine and she had an intra-aortic balloon pump placed.",0
She was started on Heparin and Integrilin.,0
The RCA was noted to be diffusely diseased as was the LAD and the circumflex.,0
The OM1 had a lesion that looked acutely ruptured and occluding.,0
"It was a small vessel, it was intervened on by PTCA but it was not stented.",0
"During the cath, they noted her filling pressures to be quite low.",0
She was given bolus of normal saline and the cath lab team was able to wean off the Dopamine and the balloon pump was also removed post catheterization as her pressure came up with aggressive fluid resuscitation.,0
She was then transferred to the CCU for further care.,0
Upon arrival in the CCU the Heparin and Integrilin had also been discontinued.,0
"Prior to transfer to the CCU, a transthoracic echocardiogram was done to evaluate for wide open mitral regurgitation.",0
"It showed ejection fraction 35-40% on the intra-aortic balloon pump, 2+ TR, moderate regional LV dysfunction and hypokinesis of the anterior septal and apical wall, 1+ MR and mild pulmonary artery hypertension.",0
"PAST MEDICAL HISTORY: 1) Dementia, Alzheimer's vs multi infarct dementia and head CT has shown periventricular small vessel ischemic changes.",0
2) Failure to thrive at home with placement in a nursing home in the past year.,0
4) Anxiety disorder presenting as stridor.,0
"7) History of CAD, status post non Q wave MI in .",0
She refused further work-up and left AMA.,0
"MEDICATIONS: Aspirin 81 mg po q d, Risperdal .25 mg po q a.m., 25 mg po q h.s., Buspirone 5 mg po bid, Depakote 125 mg po bid, Colace 100 mg po bid, Ultram 50 mg po bid, Vasocidin 1 drop tid, Atenolol 25 mg po q d, Celexa 40 mg po q d, Lasix 40 mg po q d, Levoxyl 112 mcg po q d, Multivitamin one tablet po q d, KCL 20 mEq po q d, Prevacid 15 mg po q d, Prinivil 10 mg po q d, Dulcolax as needed and Milk of Magnesia as needed, Tylenol as needed and Trazodone 25 mg po q h.s.",0
prn for sleep as needed.,0
SOCIAL HISTORY: The patient lives at with a baseline dementia.,0
She does not use tobacco or alcohol.,0
"Her son, , is the next of .",0
"PHYSICAL EXAMINATION: On arrival in the CCU, physical exam revealed the patient was awake, she opened her eyes to voice, she was nasotracheally intubated.",0
"Heart rate 88, blood pressure 111/43, respiratory rate 24.",1
"Ventilation settings were IMV 500 total volume, respiratory rate set at 10, PEEP 5, pressure support of 5, FIO2 70%.",0
This was changed to C-Pap pressure support 10 and 5 with FIO2 of 50%.,0
"ABG was 7.38, 45, 95.",0
HEENT: She was nasotracheally intubated through the right nare.,0
"Neck exam, patient had no JVD.",0
"Heart sounds, regular rate and rhythm, S1 and S2 were normal, no murmurs, gallops or rubs.",0
"Abdominal exam was soft, nontender, non distended, positive bowel sounds.",0
Extremities were cool with palpable pulses in all four extremities.,0
"Neuro, she moved all four extremities spontaneously.",0
"LABORATORY DATA: White count 13.9, hemoglobin 13.8, hematocrit 39.2, platelet count 231,000.",0
"Differential on the white count, 83 neutrophils, 3 bands, 10 lymphs, 4 monos.",0
"PT 12.7, PTT 36.0, INR 1.1.",0
"SMA 7 was 142, 4.1, 99, 29, 22, 1.0 and glucose 151.",0
"CK #1 in the Emergency Room was 129 with MB of 3, CK #2 drawn on arrival at the CCU was 285, MB 32, MB index 11.2.",0
"Chest x-ray showed slightly hyperinflated lungs with pulmonary infiltrates consistent with pulmonary edema, right greater than left without any obvious infiltrates.",0
"EKG #1 done in the Emergency Room as above, normal sinus rhythm at 120, left bundle branch block, left axis deviation, ST depression 3-4 mm in V4 through V6, ST depression 1 mm in 2.",0
"Compared with prior EKG from , left bundle branch block is new.",0
"EKG #2, normal sinus rhythm at 100, 3- depressions in V3 through V6, 2- depressions in 2, 3, and F. ASSESSMENT: This is an 81-year-old woman with past medical history of coronary artery disease of three vessels, status post non Q MI in , hypothyroidism, depression, dementia, admitted following an episode of acute pulmonary edema but still unclear etiology.",1
"Several scenarios are still possible at the time of admission including: 1) Respiratory distress from some other etiology, possibly pneumonia leading to overdiuresis and ischemia.",0
"2) Diastolic dysfunction, it is unknown why the patient would have become ischemic but is it possible she became ischemic which then led to pulmonary edema.",0
The patient also seems to be ruling in for non Q wave MI.,0
This certainly could be the primary lesion.,0
Patient became ischemic and went into pulmonary edema.,0
Cardiac: CKs will be cycled until trending down.,0
"The patient will be placed on Aspirin, Lipitor and a beta blocker as the blood pressure tolerates.",0
The patient will also be started on an ACE inhibitor as the blood pressure tolerates.,0
She will be given IV fluids and Lasix as needed to balance her volume status.,0
Pulmonary: From a pulmonary perspective the patient has a possible pneumonia.,0
She will be started on Levaquin 500 mg per day.,0
We will try to aggressively wean off the patient's sedation and extubate her as quickly as possible.,0
Infectious Disease: Blood cultures were sent from the Emergency Room and from the cath lab.,0
These will be followed up.,0
We will also check a urinalysis and urine culture and send sputum if the patient is producing it.,0
HOSPITAL COURSE: The day of admission the patient was quickly weaned off her sedation and was placed on vent settings of 10 and 5.,0
A pressure support wean was initiated.,0
The patient was placed on pressure support and did well.,0
She was then extubated later that evening around 6 p.m. Post extubation the patient did well for a few hours.,0
"She had no issues with hypoxia or hypercarbia, however, she had copious secretions and the patient could not clear her own secretions.",0
"The secretions could be cleared by suctioning, however, suctioning provided such stimulus to the patient that her heart rate increased into the 120's and she became hypertensive to the 180's/100's.",0
"Given the patient's recent non Q wave MI, these values were unacceptable and the patient was electively reintubated for inability to protect her airway.",0
This allowed us to suction her secretions without causing tachycardia and hypertension as the patient was sedated.,0
CKs were cycled and peaked at 842 at midnight the day of admission.,0
EKGs were checked and revealed that the left bundle branch block was either rate related or ischemia related as it resolved.,0
The patient's heart rate and blood pressure were controlled with beta blocker and ACE inhibitors.,0
For the next two days the patient became hypotensive while she was intubated and on sedation.,0
She required aggressive fluid resuscitation and transiently required Dopamine as a pressor on and off with maximum dose being approximately 10 mcg per minute.,0
Further chest x-rays were obtained that revealed the patient had a pneumonia.,0
"She had worsening bilateral pulmonary infiltrates consistent with either ARDS or cardiogenic pulmonary edema, however, as the hospital course progressed and the patient was maintained on antibiotics, her bilateral pulmonary infiltrates slowly resolved.",0
"The patient's secretions which were copious and purulent at first, also decreased.",0
"On a family meeting was held with the son, the daughter-in-law, the attending, social worker and the house staff.",0
We all discussed the patient's course and prognosis and wishes.,0
Her son expressed that she would not want to be kept alive on a respirator.,0
The team expressed their opinion that the patient was close to extubation.,0
The son thought that once patient was extubated she would not want to be reintubated.,0
The team thought this was a reasonable course of action as if the patient could not be extubated in the next 48 hours it would entail a long recovery; likely including a tracheostomy and month long vent weaning process that the patient would not want.,0
The course of action was then decided to extubate the patient in the next 24-48 hours as medically indicated and when she was extubated to now reintubate the patient.,0
"She was made DNR on the 11th, after that family discussion.",0
On the patient's secretions had decreased.,0
She was placed on a spontaneous C-pap trial of pressure support 5 and 5.,0
The patient did well with a rapid trial of breathing index in the 70's to 80's.,0
Her sedation had been turned off the night before and she was alert and able to follow commands.,0
The team thought it was medically indicated to attempt to extubate the patient on the 12th.,0
The patient did well for approximately 4-5 hours.,0
"After that time, however, the patient slowly began to tire.",0
Her initial respiratory rate was at 26 and she declined to breathing around 15-20 after the first hour.,1
Her blood pressure was controlled with Labetalol drip during this time.,0
"As the hours progressed, the patient's respiratory rate slowed.",0
"An ABG was checked that showed a PH of 7.17, PCO2 77 and PO2 of 143.",0
"The patient was becoming more somnolent, the team believed this was due to the hypercarbia.",0
The son was and at that point he said the patient should be kept comfortable above all.,0
The team shifted their goals to meet this requirement as well as to give the patient the best chance to recover.,0
"Over the course of the night her respirations maintained in the low teens, between .",0
The patient was kept comfortable during this time with Morphine.,0
On the patient slowly became less and less responsive and more and more somnolent as her respiratory rate declined and at 6:30 p.m. on the evening of the patient's respirations and heart rate stopped and she was pronounced dead at that time.,1
The son was with her when she passed.,0
The patient died of cardiopulmonary arrest that was due to a pneumonia and a non Q wave MI on this admission.,0
Dictated By: MEDQUIST36 D: 11:07 T: 16:18 JOB#:,0
12:42 PM CTA NECK W&W/OC & RECONS Clip # Reason: r/o vascular injury in trauma Admitting Diagnosis: POLYTRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man with REASON FOR THIS EXAMINATION: r/o vascular injury in trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKPe WED 10:47 PM Limited study secondary to poor bolus.,0
No evidence of vascular injury.,0
No cervical spine injury identified.,0
Facial fractures and sinus fluid as previosuly described.,1
TECHNIQUE: Contrast-enhanced axial CT images of the neck were obtained according to the CTA protocol.,0
Multiplanar reformatted images were also submitted for review.,0
70 cc of IV Optiray contrast was administered.,0
"CTA NECK: Evaluation of arterial vessel is very limited secondary to poor bolus timing, though no obvious vascular injury is appreciated.",0
"Additionally, no secondary signs of vascular injury, i.e.",0
"Also, there is no evidence of a cervical spine fracture or basilar skull fracture which would predispose to vascular injury.",1
"Previously noted nasal, maxillary sinus, and orbital fractures are partially imaged and better evaluated on recent dedicated facial CT. Extensive facial soft tissue swelling, sinus fluid and mucosal thickening, and subcutaneous emphysema also partially imaged.",1
An endotracheal and nasogastric tube are in place.,0
The lung apices appear unremarkable.,0
Limited CTA of the neck as described with no evidence or secondary signs of a vascular injury.,0
"Extensive facial fractures, partially imaged and better evaluated on recent dedicated CT study.",1
1:17 PM L-SPINE (AP & LAT) IN O.R.,0
; SPINAL FLUORO WITHOUT RADIOLOGIST Clip # Reason: T1-L3 CORPECTOMY Admitting Diagnosis: CHEST PAIN ______________________________________________________________________________ FINAL REPORT 27 INTRAOPERATIVE RADIOGRAPHS INDICATION: T1 to L3 corpectomy.,0
FINDINGS: 27 intraoperative radiographs were obtained in the operating room without a radiologist present.,0
These were obtained for operative assistance.,0
The radiographs demonstrate multiple sites of instrumentation at the thoracic and lumbar spine.,0
"For full details of the surgical procedure, please consult the operative report.",0
"7:47 PM MR HEAD W & W/O CONTRAST Clip # Reason: seizure protocol Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 14 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with unknown PMH presenting with seizures REASON FOR THIS EXAMINATION: seizure protocol No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old woman with unknown past medical history, presenting with altered mental status and seizures.",0
"TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, susceptibility and diffusion-weighted sequences were performed.",0
"Post-IV administration of gadolinium, axial T1 and sag MP-RAGE sequences were performed.",0
Axial and coronal MPR images were reconstructed and reviewed.,0
FINDINGS: There is an area of focal encephalomalacia in the right inferior frontal region with post craniotomy changes in the frontal bone.,0
"No hemorrhage, mass, edema or infarction are seen.",0
There is no area of abnormal enhancement in the brain parenchyma.,0
There are no areas of susceptibility to suggest chronic microhemorrhages.,0
There is no area of restricted diffusion.,0
Ventricles and sulci are normal in caliber and configuration.,0
The right globe appears small and atrophic.,0
"On correlation with the CT scan, multiple calcifications are seen in the right globe, suggesting phthisis bulbi.",0
"There is mild mucosal thickening and fluid seen in bilateral maxillary sinuses, right more than left, suggestive of mild sinusitis.",0
Mild fluid is also seen in bilateral mastoid air cells.,0
Intracranial flow voids appear normal.,0
IMPRESSION: Post-craniotomy changes in the frontal bone with focal encephalomalacia and right inferior frontal region.,0
"7:44 PM CHEST (PA & LAT) Clip # Reason: eval for pneumonia ______________________________________________________________________________ MEDICAL CONDITION: History: 34F with chest pain, shortness of breath, DKA REASON FOR THIS EXAMINATION: eval for pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Chest pain, shortness of breath, diabetic ketoacidosis.",0
TECHNIQUE: PA and lateral views of the chest.,0
FINDINGS: The heart size is normal.,0
Lungs are clear and the pulmonary vascularity is normal.,0
No acute osseous abnormalities are detected.,0
12:51 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval changes Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with chronic respo failure now with PNA REASON FOR THIS EXAMINATION: ?,1
"interval changes ______________________________________________________________________________ FINAL REPORT AP CHEST, 12:49 P.M. .",0
HISTORY: Chronic respiratory failure and pneumonia.,1
"IMPRESSION: AP chest compared to : Bibasilar consolidation has improved, probably more so on the left, consistent with resolving pneumonia.",0
Mediastinal vascular engorgement suggests volume overload but there is no pulmonary edema.,0
There may be a small right pleural effusion.,0
", V. 2:03 PM TEMP DIALYSIS LINE PLCT Clip # Reason: please place temp dialysis line for HD Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY STENTING ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with CAD s/p cath now w/ ARF, volume overloaded, and short of breath REASON FOR THIS EXAMINATION: please place temp dialysis line for HD ______________________________________________________________________________ PFI REPORT Uncomplicated placement of temporary right IJ hemodialysis catheter with the tip terminating in the right atrium.",1
"9:44 AM CHEST (PORTABLE AP) Clip # Reason: assess chf/effusions Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p endovascular ao stent post-op pulm edema REASON FOR THIS EXAMINATION: assess chf/effusions ______________________________________________________________________________ FINAL REPORT INDICATION: 70-year-old man, postoperative evaluation following endovascular stent.",1
"SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 10:10 A.M.: An endotracheal tube terminates approximately 9 cm from the carina, and advancement of approximately 4 cm is recommended for standard positioning.",0
"The right internal jugular catheter terminates in the proximal SVC, and a nasogastric tube extends below the diaphragm.",0
"There has been a substantial interval improvement in pulmonary edema, with minimal remaining pulmonary vascular congestion.",0
"There is no pleural effusion, and no new foci of air space consolidation.",0
Bibasilar atelectasis has also undergone interval improvement.,0
"Mild cardiomegaly is unchanged, and there is no hilar or mediastinal enlargement.",0
IMPRESSION: Improved pulmonary edema and bibasilar atelectasis.,0
Persistent cardiomegaly with vascular congestion.,0
12:25 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: NG tube placement Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 63 yo with chest wall hernia REASON FOR THIS EXAMINATION: NG tube placement ______________________________________________________________________________ FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess NG tube.,0
"NG tube tip is not clearly visualized but appears to be at the GE junction and should be advanced for standard position, repeat radiograph is recommended.",0
10:52 AM CHEST (PORTABLE AP) Clip # Reason: ETT ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with REASON FOR THIS EXAMINATION: ETT ______________________________________________________________________________ FINAL REPORT HISTORY: 48-year-old woman transferred from outside hospital with intracranial bleed.,0
SINGLE PORTABLE SUPINE CHEST RADIOGRAPH Tip of the endotracheal tube is approximately 1.2 cm from the carina and appears to be overdistention of the balloon cuff.,0
Nasogastric tube tip is located within the gastric antrum.,0
"Cardiac, mediastinal silhouette, hilar contours, and pleural surfaces are normal.",0
There are old right-sided posterior sixth through eighth rib fractures.,0
Malpositioned endotracheal tube with overdistention of balloon cuff.,0
"These findings were discussed with caring physician, .",0
on date of exam at approximately 11:20 a.m.,0
12:31 AM FEMORAL VASCULAR US RIGHT PORT Clip # Reason: hematoma/ pseudoaneurysm of right groin s/p cath Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: year old man with PVD s/p right groin cath with post cath hematoma - please eval for pseudoaneurysm REASON FOR THIS EXAMINATION: hematoma/ pseudoaneurysm of right groin s/p cath ______________________________________________________________________________ FINAL REPORT Ultrasound of the right groin from .,1
"INDICATION: Right groin catheterization with hematoma, please assess for pseudoaneurysm.",0
"FINDINGS: Right common femoral artery and common femoral vein are widely patent, without pseudoaneurysm or AV fistula.",0
No large hematoma is identified within the soft tissues of the right groin.,0
"IMPRESSION: No evidence of pseudoaneurysm, AV fistula or hematoma within the right groin.",0
"9:04 PM BILAT LOWER EXT VEINS Clip # Reason: Please eval for DVT Admitting Diagnosis: ST ELEVATION\CORONARY ANGIOGRAM ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p PEA arrest, intubated, concern for PE.",0
REASON FOR THIS EXAMINATION: Please eval for DVT ______________________________________________________________________________ WET READ: 10:34 PM No DVT.,0
"WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 74-year-old with PE arrest, intubated, concern for PE.",0
"TECHNIQUE: Bilateral lower extremity Grayscale, color Doppler ultrasound images.",0
"FINDINGS: There is normal compressibility, flow and augmentation of bilateral common femoral, superficial femoral, popliteal and calf veins.",0
PATIENT/TEST INFORMATION: Indication: Left ventricular function Height: (in) 73 Weight (lb): 250 BSA (m2): 2.37 m2 BP (mm Hg): 124/68 HR (bpm): 80 Status: Inpatient Date/Time: at 11:34 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; RIGHT VENTRICLE: RV not well seen.,0
"Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %) secondary to hypokinesis of the inferior septum, inferior free wall, and posterior wall.",0
"Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is increased.",0
BP (mm Hg): 120/70 HR (bpm): 108 Status: Inpatient Date/Time: at 15:35 Test: TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion.,0
MITRAL VALVE: No MR. TRICUSPID VALVE: Tricuspid valve not well visualized.,0
Conclusions: The left atrium is mildly elongated.,0
"There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the anterior septum and anterior walls, distal septum.",0
The remaining segments are hyperdynamic (LVEF = 50%).,0
No mitral regurgitation is seen (focused views).,0
Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (mid-LAD distribution).,0
"Compared with the prior study (images reviewed) of , the wall motion abnormality is new and c/w interim ischemia.",0
The pericardial effusion is no longer seen.,0
2:33 PM BILAT LOWER EXT VEINS Clip # Reason: 61 yr old male s/p fall with closed head injury and csf leak Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with REASON FOR THIS EXAMINATION: 61 yr old male s/p fall with closed head injury and csf leak with lumbar drain in place on bedrest for one week please assess for bilat lower extremity DVT's ______________________________________________________________________________ FINAL REPORT DOPPLER ULTRASOUND OF BOTH LEGS.,1
"TECHNIQUE: Color flow, pulsed-wave Doppler and -scale imaging of the deep veins of both limbs was performed.",0
There is a relatively short segment of chronic thrombosis within the proximal right superficial femoral vein.,0
This is evidenced by some luminal narrowing with eccentric thrombus and calcification.,0
"In the remainder of the vein there is evidence of normal compressibility, augmentation and respiratory variation.",0
"There is normal compressibility, augmentation, and respiratory variation in the deep veins of the left side.",0
There is no evidence of left- sided DVT.,0
CONCLUSION: Chronic non-occlusive thrombus of the right side.,0
No abnormality on the left side.,0
"11:48 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman with fever, cough REASON FOR THIS EXAMINATION: assess for infiltrate ______________________________________________________________________________ WET READ: EAGg WED 12:17 PM No acute abnormality.",1
______________________________________________________________________________ FINAL REPORT INDICATION: A 63-year-old female with fever and cough.,0
UPRIGHT AP VIEW OF THE CHEST: The lungs are clear.,0
Mild cardiomegaly and elevation of the right hemidiaphragm are unchanged from .,0
"The mediastinal silhouette, hilar contours and pulmonary vasculature are unremarkable.",0
"2:53 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX Admitting Diagnosis: BLAST CRISIS ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man s/p fall with pulmonary edema after fluids overload, s/p R thoracentesis.",0
REASON FOR THIS EXAMINATION: r/o PTX ______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall and pulmonary edema.,0
PORTABLE AP CHEST RADIOGRAPH: There has been interval decrease in the right- sided pleural effusion.,1
"Bibasilar opacities are seen, which may represent atelectasis, aspiration, or pneumonia.",0
The soft tissue and osseous structures are stable.,0
IMPRESSION: Interval decrease in the right-sided pleural effusion.,1
"Bibasilar opacities are identified, which may represent atelectasis, aspiration, or pneumonia.",0
"8:03 AM CHEST (PORTABLE AP) Clip # Reason: flu ards ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with MVA, descending thoracic aortic injury and intraparenchymal liver injury b/l pulm contusion ct to water seal REASON FOR THIS EXAMINATION: flu ards ______________________________________________________________________________ FINAL REPORT HISTORY: Pulmonary contusion following injury.",1
This is a limited examination.,0
The lower left hemithorax has been excluded from the film.,0
"There are bilateral chest tubes, an NGT, an ETT, and a right subclavian catheter, and there is considerable opacity in the right mid and lower lung zone.",0
The overall appearance of the chest is similar to the last chest xray at 10:52 AM on .,0
8:38 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: eval for causes of low o2 sats Admitting Diagnosis: BOWEL OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 71 year old man with psbo and sagging o2 sats REASON FOR THIS EXAMINATION: eval for causes of low o2 sats ______________________________________________________________________________ FINAL REPORT HISTORY: Decreasing oxygen saturation.,0
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Hyperinflation and vascular deficiency in the lungs indicate significant emphysema.,0
Multifocal opacification has a generally perihilar distribution except for the most severe consolidation at the base of the left lung.,0
This is probably widespread pneumonia.,0
There is no pleural effusion or pneumothorax but the pneumomediastinum may be present.,0
"The esophagus is generally dilated could be due to a distal stricture or achalasia, traversed by a nasogastric tube ending in moderately dilated stomach.",0
Other loops of bowel seen in the upper abdomen are also dilated.,0
", R. SICU-B 4:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: NG tube placement Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with hepatic sarcoidosis REASON FOR THIS EXAMINATION: NG tube placement ______________________________________________________________________________ PFI REPORT Successfully placed NG tube.",1
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Otolaryngology DISCHARGE DATE: Unknown exactly at this time.,0
HISTORY OF PRESENT ILLNESS: A 59-year-old man with a history of glottic cancer status post radiation completed in presented with a forced whisper to clinic.,0
"Workup including a direct laryngoscopy and biopsy on of confirmed recurrence of a left vocal cord and glottic cancer, which was T4 N0 M0.",0
Preoperative airway compromise required steroids for improvement.,0
PAST MEDICAL HISTORY: Glottic cancer as above.,0
PAST SURGICAL HISTORY: Status post surgical removal of a laryngeal papilloma in .,0
SOCIAL HISTORY: A 25 pack year smoker and one beverage of alcohol per week.,0
He is an electrician and married with children.,0
"PHYSICAL EXAM ON ADMISSION: He is afebrile with vital signs that are stable, a pleasant, cachectic gentleman in no acute distress.",0
"His voice is aphonic, inspiratory stridor is noticed.",0
"Heart is regular, rate, and rhythm.",0
Extremities are warm and well perfused with no edema.,0
"HOSPITAL COURSE: On , he was taken to the operating room for a left selective neck dissection, levels , and the spinal accessory nerve was not stimulated, and a left selective neck dissection levels 2 through 4.",0
He also underwent a left hemithyroidectomy and a total laryngectomy.,0
Estimated blood loss was 250 and total in was 5.7 liters.,0
"He was taken immediately postoperative to the Intensive Care Unit, where he stayed for two days.",0
"Postoperative day one, calcium was noted to be low, ionized calcium was 0.88 and he was repleted with 4 amps of calcium gluconate.",0
"He received perioperative clindamycin and was extubated postoperative day one, moved easily to the chair.",0
"Postoperative day two, tube feeds began slowly, and he was transferred to the floor.",0
He began electrolarynx training with Speech Therapy.,0
"On postoperative day three, his hematocrit was noted to be 27.1 down from 29.",0
It was probably from fluid overloading.,0
"By postoperative day three, he was still 5 liters positive from the operation; at this point, he was started on iron and Colace, however.",0
Postoperative day four he was cleared by Physical Therapy for discharge to home.,0
"Postoperative day five, neck tenderness was noted on the right sternocleidomastoid and erythema and tenderness of the stoma especially at the inferior edge was noted.",0
Radiation Oncology was consulted and a follow-up appointment with Dr. was setup.,0
"Postoperative day six, a culture of the stoma revealed yeast and gram-negative rods, so ciprofloxacin was started empirically.",0
An Enterostomal Therapy consult told us to not treat the yeast and continue care of the stoma.,0
Tube feeds were held secondary to patient feeling fullness and some nausea.,0
His tube feeds were then started with bolusing.,0
"On postoperative day seven, he had a fever of 103 and heart rate was 146.",0
The workup found chest x-ray to be negative for pneumonia.,0
EKG showed sinus tachycardia without ischemia.,0
"A urinalysis was negative, and a complete blood count was drawn.",0
"At this point, his tube feeds were decreased to 250 cc at seven times a day.",0
"Prior to his fever, he took two sips of Gingerale about 1-2 hours prior to his fever spike.",0
"On postoperative day nine, a leak was suspected, so an esophagram done confirmed a small esophageal leak at the level of C3.",0
"At this point, the patient was instructed to continue with a strict NPO diet and careful slow tube feeds.",0
"Postoperative day ten, he remained afebrile and NPO.",0
His tube feeds were slowly advanced to goal.,0
He again was ambulatory and comfortable.,0
His stoma looked clear with decreased tenderness and erythema.,0
He will be following up with Dr. and Dr. of Radiation Oncology.,0
"On postoperative day ten, ciprofloxacin was changed to levofloxacin based on culture data showing Proteus mirabilis which was most sensitive to levofloxacin.",0
An addendum dictation will be added once the final details of his discharge are planned.,0
"His most recent complete blood count was notable for a white count of 8.6, hematocrit of 29.4, and platelets of 359. , M.D.",0
Dictated By: MEDQUIST36 D: 22:57 T: 09:46 JOB#:,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Lipitor / Zocor Attending: Chief Complaint: Lower gastrointestinal bleed Major Surgical or Invasive Procedure: PICC line placement Colonoscopy History of Present Illness: Ms is a 68 year old woman with multiple medical problems, including CAD s/p CABG in 85' and LAD DES in 03', recent diagnosis of lung cancer s/p partial lobectomy, newly diagnosed atrial fibrillation, presenting to the hospital with hematochezia.",1
"Patient was given 2U PRBC and was closely monitored on the wards, when she was noted to have a large bloody bowel movement accompanied by onset of Afib with RVR and hypotension.",1
Patient was bolused with 500ml of NS and transfered to the MICU for further management.,0
"Last colonoscopy in with severe diverticulosis, patient has had two prior episodes of GIB which required several transfusions.",1
"In the floor prior to transfer, Temp 97.4 BP 74/57, HR 77, RR 20 O2 sat 98% Currently, she denies any lightheadedness, dizziness, chest pain, palpitations, shortness of breath, nausea or vomiting, but does report some ""chest pressure"" which is rated and is different from her angina.",0
"Coronary artery disease -- MI x3 with her first MI at age 34 -- 3V CABG in (LIMA to LAD and SVGs to OM, RCA and D1.)",1
-- All vein grafts 100% occluded -- Mid LAD drug-eluting stent in .,0
Peripheral disease -- s/p angioplasty of the right leg - -- PTA and stenting to distal aorta and ostial iliac arteries 3.,1
Chronic kidney disease: Baseline Cr 1.2-1.4 4.,1
Renal artery stenosis status post right renal artery stent- 5.,0
Carotid stenosis status post left internal carotid stent- 08/.,0
Endometrial polyps- The patient has been followed by Dr. .,0
GI bleed secondary to diverticulosis 13.,1
Squamous cell carcinoma of lung- synchronous right and left lower lobe nodules found in now s/p left lobectomy.,0
Has not had XRT or chemo yet.,0
"Smoked in the past but quit 25 years ago, denies alcohol or illicit drug use.",0
Family History: The patient's father died of CAD as did her mother.,0
A sister has had multiple TIAs.,0
"Physical Exam: vitals: T 97.8, BP 117/54, HR 71, RR 19, O2sat 100% RA Gen: NAD, lying in bed, pale HEENT: PERRL, EOMI, pale conjuctiva CV: Regular rate, no murmurs, rubs or gallops.",0
"Resp: CTAB no w/r/r, slightly diminished BS on left base.",0
"Abd: NTND, hyperactive bowel sounds Ext: no edema, DP pulses palpable symmetrically.",0
well healed scar from grafts.,0
Brief Hospital Course: Ms. is a 68yo female with CAD and PVD with multiple coronary and peripheral artery stents and recent left lobectomy for lung cancer complicated by atrial fibrillation on Coumadin now presenting with LGIB.,1
"# LGIB: Upon admission, patient was given 2U PRBC and was closely monitored on the wards, when she was noted to have a large bloody bowel movement accompanied by onset of Afib with RVR and hypotension.",1
"In the MICU, patient continued to pass BRBPR and received an additional 10 units of PRBC.",0
INR was measured at 2.2.,0
"ASA and coumadin were discontinued, while plavix was continued.",0
"Colonoscopy was performed on , showing old and new blood throughout the colon, with more active bleeding present in the descending colon when compared to ascending colon.",1
Moderate to severe diverticulosis was also noted.,0
"Per GI recs, tagged red blood cell scan was performed on and showed no evidence of GI bleed.",0
"By , the patient had received a total of 10 units of blood and was no longer passing BRBPR, though she continued to pass clots.",0
Hct stabilized in the upper 20s and INR was 1.1.,0
"After transfer to the general medical service on , patient continued to pass clots, but her hct remained stable in the 28-30 range.",0
"Towards the end of her stay (), plavix was discontinued and she was started on ASA 81mg.",0
"Given history of diverticular disease () and severe diverticulosis observed on colonoscopy, this episode of LGIB is most consistent with diverticular bleeding.",1
She will follow up with her cardiologist next week to discuss reinitiation of plavix and coumadin.,0
"# Atrial fibrillation: Patient had an episode of atrial fibrillation on initial presentation associated with hypotension, resulting in MICU transfer.",1
She converted to sinus and remained there while in the MICU.,0
"Patient was transferred to the general medical service where she was monitored on telemetry and had a recurrence of atrial fibrillation with RVR to the 140s, though mostly resting in the low 100s.",1
She remained hemodynamically stable with palpitations as her only symptom.,0
She spontaneously converted to sinus with a rate in the 60s the following morning.,0
She remained in sinus rhythm for the rest of her hospital stay.,0
"Per recommendations of her outpatient cardiologist Dr. , she was continued on her home dose of amiodarone.",0
Her coumadin was discontinued in the setting of her GI bleed.,0
Oral metoprolol was restarted at increased dose of 25mg tid.,0
# CAD: Patient remained chest pain free during her hospitalization.,0
Cardiology was contact on admission to discuss risks of being on ASA and Plavix.,0
"Given significant cardiac history, they recommneded that she be continued on both.",0
Nitrate and beta-blocker were initially held in the setting of GI bleed.,0
"In the latter part of her hospitalization given that she was still having small amount of bleeding even on plavix alone, Dr. was contact and he recommended discontinuing the plavix given that her last bare metal stent was placed in (renal artery stent), and her last drug-eluting stent was placed in .",0
She was instead put on ASA 81mg daily.,0
"As above, her metoprolol was restarted at a higher dose given her a. fib with RVR.",0
"She was, however, normotensive at time of discharge so her imdur was held pending follow up and repeat blood pressure check this upcoming week.",0
# PVD: Patient has several stents to renal and carotid arteries.,0
"As above, her plavix was ultimately held and ASA was continued at 81mg daily.",0
This will be addressed further upon outpatient follow up with her PCP and cardiologist.,0
# CRI: Creatinine remained within her baseline throughout this admission.,0
# Lung cancer: s/p lobectomy.,0
Her respiratory status remained stable during her hospital stay.,0
She has outpatient follow up appointments scheduled with her oncologists next week.,0
# PMR: Patient on Prednisone 10mg as outpatient; she was continued on this dose during her hospitalization.,0
"# ACCESS: due to poor peripheral access, PICC line was placed prior to transfer to the floor.",0
This was removed prior to discharge.,0
"Medications on Admission: Atacand HCT 16-12.5mg PO daily Clopidogrel 75mg PO daily Imdur 15mg PO daily Prednisone 10mg PO daily Oxycodone-Acetaminophen 5-325mg PO Q4-6H PRN Docusate Sodium 100mg PO TID Metoprolol Tartrate 12.5mg PO BID Allopurinol 100mg PO daily Amiodarone 200mg Po daily Aspirin 81 mg Tablet, Delayed Release (E.C.)",0
Coumadin 1 mg Tablet Sig: One (1) Tablet PO Discharge Medications: 1.,0
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day: take in the evening.,0
"CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO three times a day.",0
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: 1) Do not Drive while on the medication 2) Do not exceed 12 tablets in any 24 hour period .,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours as needed for constipation: Take as long as taking Narcotics Stop if stools become loose .,0
"Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes as needed for pain: one under the tongue every 5 minutes as needed for pain.",0
Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
"Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed, probable diverticular bleed Atrial fibrillation Squamous cell lung cancer Discharge Condition: Stable, in normal sinus rhythm with stable hematocrit.",1
"Discharge Instructions: You were admitted to the hospital for lower gastrointestinal bleeding, that is most likely due to diverticulosis.",0
"While you were in the hospital, you went into atrial fibrillation and your blood pressure decreased.",1
You were sent to the intensive care unit to manage your blood pressure and were transfused with 10 units of blood.,0
"Your home medications, aspirin and coumadin, were stopped while you were in the hospital in order to help control the bleeding.",0
You underwent a colonoscopy which showed blood and diverticula in your colon.,1
"A tagged red blood cell scan to localize the source of bleeding was then done, and did not show any active bleeding.",0
"After leaving the ICU, you were transfered to the general medical floor where your heart rate, rhythm, and blood pressure were monitored.",0
You experienced another episode of atrial fibrillation which resolved on its own overnight.,1
You were discharged when these became stable and you were no longer bleeding.,0
"While you were in the hospital we stopped your plavix and coumadin, and changed your dose of aspirin from 325mg to 81mg.",0
When you go home please continue the aspirin 81mg but do NOT restart the plavix or coumadin until following up with Dr. .,0
We also increased your dose of metoprolol from 25 mg twice a day to 25 mg three times a day.,0
Please continue taking the metoprolol 25 mg THREE TIMES per day when you go home.,0
We stopped your imdur while you were in the hospital and suggest that you do not take anymore until you see Dr. and he re-evaluates you.,0
Please follow up with your primary care physician .,0
", your cardiologist Dr. , and your oncologist Dr. as detailed below.",0
"Please call your doctor or return to the emergency room if you develop shortness of breath, lightheadedness, dizziness, chest pain, blood in your stools or any other symptoms that concern you.",0
"Followup Instructions: Provider: , MD (Heme/Onc) Phone: Date/Time: 2:30 Provider: , MD (Thoracic surgery) Phone: Date/Time: 2:30 Provider: , MD Phone: Date/Time: 11:30 Provider: .",0
"Phone: Date/Time: at 10:30am Provider: , MD Phone: Date/Time: 9:00AM",0
", D. MED MICU 12:53 AM CT HEAD W/O CONTRAST Clip # Reason: cerebral edema?",0
"Admitting Diagnosis: RESPIRATORY FAILURE, SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with altered MS, nonreactive mydriatic pupils, nonfocal neuro exam REASON FOR THIS EXAMINATION: cerebral edema?",1
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: No acute intracranial abnormality or evidence of cerebral edema.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old male with a history of chronic obstructive pulmonary disease, mitral valve replacement and atrial valve replacement with mechanical valves, hypertension, atrial fibrillation who was admitted to the Medical Intensive Care Unit on for right lateral lower lobe pneumonia complicated by hypotension.",1
"He complained of cough with green sputum times three weeks and received amoxicillin from to , prescribed by his primary care physician without improvement, but did complain of occasional chest discomfort, loose bowel movements, and occasional shortness of breath.",0
"On he noted hemoptysis, fevers, chills, and rigors.",0
"At the Emergency Room of he was found to have bilateral lower lobe pneumonia, was tachypneic with rates of 22 to 26 respirations per minute, and required supplemental oxygen via nasal cannula.",0
He suffered from systolic hypotension in the 90s and was fluid resuscitated with 3 liters of normal saline and required dopamine.,0
Dopamine was discontinued because of resulting tachycardia and he was changed to Neo-Synephrine via peripheral IV.,0
Pneumonia was treated with levofloxacin in the Emergency Room and changed to ceftriaxone plus azithromycin.,0
"A femoral line was placed due to increased INR, and 2 units of fresh frozen plasma were administered.",0
He showed some evidence of mild prerenal azotemia which was treated with volume resuscitation.,0
The patient then became normotensive and again was noted to be in atrial fibrillation.,1
"At this point, on , the patient was transferred to the General Medicine Service.",0
"There, he was noted to feel improved but still suffered from cough and mild hemoptysis.",0
He also noted chest discomfort while coughing along with mild shortness of breath.,0
He showed no peripheral edema.,0
No resting chest pain was noted.,0
Prior to transfer to the General Medicine Service his right femoral central line was pulled without complications.,0
Atrial valve and mitral replacements with mechanical valves.,1
"Atrial fibrillation, status post conversion, on amiodarone.",1
Status post cholecystectomy with appendectomy.,0
Status post bilateral total knee replacement.,0
History of pneumonia five years ago.,0
MEDICATIONS ON ADMISSION: Medications on admission include Lasix 40 mg p.o.,0
"b.i.d., enalapril 20 mg p.o.",0
"b.i.d., Coumadin 7.5 mg p.o.",0
"q.p.m., Prilosec 40 mg p.o.",0
"q.d., beclomethasone nasal spray, Atrovent 2 puffs q.i.d., Flovent 110 2 puffs b.i.d., 60 mg p.o.",0
"b.i.d., amiodarone 200 mg p.o.",0
SOCIAL HISTORY: The patient lives in .,0
He is married and has seven children.,0
He is a former construction worker.,0
He smoked one pack of cigarettes per day for 15 years but quit in the middle .,0
He reports that he does not drink but has drank in the past.,0
"PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on the General Medicine Service revealed temperature maximum and temperature current 99.1, pulse 86 irregular (running from the 60s to the 80s), blood pressure 123/49 (running from 103 to 120 systolic over 39 to 72 diastolic), respiratory rate at 21.",0
"He was satting 98% on 2 liters; in 5961, out 3290.",0
"In general, the patient was an obese older male in mild distress who was diaphoretic, spoke in full sentences, and no visible rashes.",0
"Head, ears, nose, eyes and throat revealed the patient's pupils were equal, round, and reactive to light.",0
There was no sinus tenderness.,0
Cardiovascular revealed his heart rate was irregularly irregular.,0
First heart sound and second heart sound were punctuated by a mechanical click.,0
"Lungs were notable for wheezes throughout, bibasilar rales reaching one-quarter up the lung fields, left greater than right.",0
"Abdomen examination revealed the patient was obese, nontender, nondistended, positive bowel sounds with noted scars.",0
Extremities were warm with 2+ peripheral edema bilaterally.,0
Right groin was without hematoma.,0
Neurologic examination was grossly intact.,0
"LABORATORY DATA ON PRESENTATION: Laboratories on admission to the General Medicine Service included a white blood cell count of 23.8, hematocrit of 27.3, mean cell volume of 80, platelet count of 194.",0
"The white blood cell differential was 92% polys, 0 bands, 5% lymphocytes, 1.6% monocytes, 0.5% eosinophils, 0.2% basophils.",0
"Chemistries included a sodium of 139, potassium of 4.7, chloride of 106, bicarbonate of 25, blood urea nitrogen of 33, creatinine of 1.4, glucose of 89.",0
"ALT of 40, AST of 29, albumin of 3.1, alkaline phosphatase 115, amylase 61, total bilirubin of 0.7, magnesium of 2.3.",0
Urinary Legionella antigen was negative.,0
Sputum culture was colonized with oropharyngeal flora.,0
Blood cultures had no growth.,0
"Arterial blood gas was notable for a pH of 7.38, a PCO2 of 39, PAO2 of 48, bicarbonate of 24, and a base excess of -1.",0
"RADIOLOGY/IMAGING: Chest x-ray showed bilateral bibasilar consolidations, left greater than right, with evidence of small pleural effusions.",0
No change between the chest x-ray of and ; consistent with congestive heart failure with dependent pulmonary edema versus aspiration pneumonia.,1
"ASSESSMENT: This is a 65-year-old male with a history of chronic obstructive pulmonary disease, hypertension, atrial valve and mitral replacements, presenting with hypotension and bibasilar pneumonia, as well as evidence of mild congestive heart failure.",1
HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and after initial improvement was transferred to the Medicine Service.,0
His course by problem includes: 1.,0
PNEUMONIA: The patient presented with bibasilar consolidations consistent with bibasilar pneumonia.,0
"The patient initially presented with an elevated white blood cell count, but by the patient's white blood cell count had dropped to 11,000.",0
He reported symptomatic improvement over the course of his stay and was able to walk freely on the medical floor without shortness of breath or desaturation by the day of discharge.,0
"The patient's fevers improved over the course of his admission, and the patient was running low-grade fevers by the day of discharge including a temperature of 99.9 on the day prior to discharge.",0
Repeat chest x-rays revealed improving consolidations over the course of the patient's admission.,0
"Upon admission to the Medicine Service the patient was treated on levofloxacin 500 mg q.d., and ceftriaxone and azithromycin were discontinued.",0
The patient responded well to aggressive daily chest physical therapy as well.,0
The patient was to proceed with a 14-day course of levofloxacin 500 mg p.o.,0
"and was to follow up with his primary care physician on , .",0
ATRIAL FIBRILLATION: After admission to the general Medicine Service the patient was hemodynamically stable throughout his stay.,1
He was maintained on a reduced dose of Lopressor at 12.5 mg p.o.,0
and a full dose of amiodarone 200 mg p.o.,0
He was in atrial fibrillation throughout his stay.,1
The patient was maintained on a regimen of Coumadin 7.5 mg p.o.,0
"during his stay, and his INR remained therapeutic.",0
"On discharge, the patient's INR was 2.5.",0
ANEMIA: The patient appeared to have a longstanding borderline microcytic anemia.,0
His last normal hematocrit was on .,0
The anemia shows a borderline increased RDW.,0
"Evaluation was begun during this admission including a workup for iron deficiency anemia with total iron binding capacity, iron, and reticulocyte counts pending, as well as an evaluation of potential dietary deficiency including B12 and folate levels.",0
"All the patient's stools were guaiaced, and during his stay on the medicine floor he was guaiac-negative.",0
"Additionally, a haptoglobin was sent and was pending at the time of discharge for some concern of hemolysis given the patient's mechanical heart valves.",1
These values and the further workup of the patient's anemia should be pursued in the context of his outpatient care.,0
"It should be noted that the patient's hematocrit did fluctuate during his stay, reaching as low as 25.7 before stabilizing and rising modestly to 26.5.",0
This was likely in the context of delusional influence on the patient's hematocrit values.,0
AZOTEMIA: The patient showed evidence of a prerenal azotemia throughout his stay which improved with fluid resuscitation.,0
"On discharge, the patient's blood urea nitrogen was 15, and creatinine was 0.9.",0
HYPOTENSION: The patient's considerable hypotension resolved.,0
The patient was begun on a modest regimen of antihypertensives including a reduced dose of Lopressor 12.5 mg p.o.,0
"b.i.d., and his baseline dose of amiodarone 200 mg p.o.",0
The patient's home dose of enalapril was also reduced to 10 mg p.o.,0
Modifications in the patient's regimen for hypertension should be considered when the patient presents in two weeks to his primary care physician.,0
Status post atrial valve and mitral valve replacements.,1
Status post cholecystectomy and appendectomy.,0
Status post total knee replacement.,0
Dictated By: MEDQUIST36 D: 16:01 T: 12:48 JOB#:,0
2:57 PM CHEST (PA & LAT) Clip # Reason: markedly worsened lung exam w/ diffuse crackles.,0
"please ______________________________________________________________________________ MEDICAL CONDITION: year old woman with cough, atrial tachycardia w/ block (started amiodarone yesterday), CHF, recent lower GI bleed.",0
REASON FOR THIS EXAMINATION: markedly worsened lung exam w/ diffuse crackles.,0
______________________________________________________________________________ FINAL REPORT HISTORY: y/o woman with cough.,0
"CHEST, TWO VIEWS: Comparison study dated .",0
No upper zone vascular redistribution is noted.,0
There is atelectasis at the lung bases bilaterally and small bilateral pleural effusions are noted.,0
IMPRESSION: 1) Cardiomegaly without evidence of CHF.,0
3) Atelectasis at lung bases bilaterally.,0
", M. OMED 7F 3:56 PM UNILAT UP EXT VEINS US LEFT PORT Clip # Reason: r/o DVT, assess for hematoma Admitting Diagnosis: LEUKEMIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with AML and thrombocytopenia with prolonged hospitalization and new swelling on L arm near picc site REASON FOR THIS EXAMINATION: r/o DVT, assess for hematoma ______________________________________________________________________________ PFI REPORT PFI: 1.",1
Thrombus within the basilic vein in the region of the antecubital fossa at the PICC site insertion consistent with superficial thrombophlebitis.,1
Incidentally noted 2.5 cm hypoechoic left thyroid nodule which is incompletely characterized.,0
A formal ultrasound may be obtained for further characterization.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: Cardiothoracic Surgery Service HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with a known heart murmur times five years.,0
"The patient has been followed by serial echocardiograms; most recently, on .",0
"This latest study revealed significantly dilated aortic root of 6.1 cm, with an ascending aorta 4.5 cm, and an aortic arch of 3.8 cm.",0
"The patient presented for cardiac catheterization on which revealed normal coronary arteries, and an ejection fraction of 65%, and moderate aortic insufficiency.",0
Status post multiple hernia repairs.,0
Questionable history of tachycardic arrhythmia.,0
PAST SURGICAL HISTORY: Significant for hernia repairs.,0
Atenolol 25 mg by mouth once per day.,0
Aspirin 81 mg by mouth once per day.,0
"SOCIAL HISTORY: Significant for an alcohol history of one drink per week, and no tobacco history.",0
FAMILY HISTORY: Family history was noncontributory.,0
"PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient was in no apparent distress.",0
He was alert and oriented times three.,0
Head was normocephalic and atraumatic.,0
No scleral icterus was noted.,0
The neck was supple and soft.,0
Heart was regular in rate and rhythm with first heart sounds and second heart sounds.,0
A grade 3/6 systolic ejection murmur.,0
The chest was clear to auscultation bilaterally.,0
There were positive bowel sounds.,0
"Extremities were without clubbing, cyanosis, or edema.",0
PERTINENT RADIOLOGY/IMAGING: As stated in the History of Present Illness with cardiac catheterization results and echocardiogram results.,0
"BRIEF SUMMARY OF HOSPITAL COURSE: The patient is a 57-year-old male with severely dilated aortic root and aortic insufficiency who presented to the Cardiothoracic Surgery Service for a Bentall procedure as a same day admission on , M.D.",1
Dictated By: MEDQUIST36 D: 10:05 T: 10:11 JOB#:,0
"1:52 PM US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # Reason: PT WITH JAUNDICE, EVALUATE CBD FOR STONES OR OBSRUCTION Admitting Diagnosis: CIRRHOSIS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with h/o EtOH abuse, p/w hct 11%, INR 3.1 and L flank ecchymosis with increasing jaundice REASON FOR THIS EXAMINATION: evaluate CBD/B for stones/obstruction ______________________________________________________________________________ FINAL REPORT HISTORY: This is a 51 year old male with increasing jaundice.",0
COMPARISON: Previous ultrasound study from is available.,0
FINDINGS: The liver shows coarsened echotexture without focal lesion or intrahepatic ductal dilatation.,1
There is hepatofugal flow in the portal vein.,0
There is a small right pleural effusion seen as well as a small amount of free fluid adjacent to the liver.,0
The gallbladder contains sludge and small stones however there is no gallbladder wall edema.,0
The common bile duct measures less than 3 mm in maximum dimension.,0
IMPRESSION: Gallbladder sludge and small stones without evidence of cholecystitis.,0
No dilatation of the common bile duct or intrahepatic ducts.,0
Portal flow abnormalities in the liver consistent with cirrhosis.,1
"4:54 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with CP, peritonitis and ascites, and Hepatitis B, intubated and sedated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 4:57 A.M. HISTORY: 35-year-old man with peritonitis and ascites.",1
IMPRESSION: AP chest compared to : Small bilateral pleural effusions have increased.,1
"Heart is normal in size but mediastinal vasculature is more engorged, suggesting elevated central venous pressure or volume, reflected in mild vascular engorgement of the pulmonary vessels.",0
Infrahilar atelectasis in both lower lobes has worsened appreciably since following tracheal extubation.,0
Left subclavian line ends at the superior cavoatrial junction and a nasogastric tube in the stomach.,0
"3:00 PM PICC LINE PLACMENT SCH Clip # Reason: place PICC, IV team unable to place at bedside.",0
Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
ACCESS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 88 year old woman with urosepsis.,0
"REASON FOR THIS EXAMINATION: place PICC, IV team unable to place at bedside.",0
______________________________________________________________________________ FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for infusion therapy.,0
A peel-away sheath was then placed over a guidewire and a 5 French double-lumen PICC line measuring 43 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance.,0
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right basilic venous approach.,0
2:32 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for effusion or lobar collapse Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man s/p open cholecystectomy with likely pneumonia now with oxygen desaturations.,0
REASON FOR THIS EXAMINATION: evaluate for effusion or lobar collapse ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST AT 02:31.,0
FINDINGS: Tip of the ETT remains in place.,0
"Right effusion is again noted, and there is some patchiness at the right lower lobe that is more conspicuous compared to prior.",0
Retrocardiac opacity remains and is not significantly different.,0
I do not see evolving CHF features.,0
An NGT has been placed with the tip overlying the gastric air bubble.,0
IMPRESSION: Increased airspace density at the right lower lobe and new placement of NGT; no other changes noted.,0
9:29 AM MR HEAD W/O CONTRAST Clip # Reason: S/P subdural evacuation.Prolonged altered mental stattus.,0
______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with subdural hgh.,0
s/p craniotomy for evacuation SHD.,0
Prolonged altered mental status.Evaluate for Mid brain edema.,0
REASON FOR THIS EXAMINATION: S/P subdural evacuation.Prolonged altered mental stattus.Evaluate for midbrain edema.,0
______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: Subdural hematoma.,0
TECHNIQUE: Multiplanar T1 and T2W images of the brain were obtained.,0
Diffusion weighted imaging was also performed.,0
BRAIN MRI: Again seen are a moderate right and large left subdural hematomas.,0
"There is now evidence of T1 hyperintensity within the extra-axial collections, making them appear more discernable on the current exam.",0
"This may reflect evolution of pre-existent hemorrhage, rather than rehemorrhage.",0
"If detection of rehemorrhage is of clinical importance, follow-up CT scan would be useful.",0
This appearance is consistent with subacute hemorrhage.,0
There is continued shift of normally midline structures to the right consistent with subfalcine herniation.,0
"In addition, there is continued compression and telescoping of the mid brain, consistent with transtentorial herniation.",0
The degree of transtentorial herniation is not significantly changed since the previous exam.,0
No areas of abnormal signal are seen to suggest the presence of an acute infarct.,0
"There are a few foci of T2 hyperintensity within the corona radiata, in the frontal regions bilaterally, consistent with chronic microvascular infarcts.",0
"IMPRESSION: No significant change in size of the bilateral subdural hematomas, left greater than right.",0
There is now evidence of subacute hemorrhage within these extra-axial collections.,0
The degree of subfalcine and transtentorial herniation is unchanged.,0
"8:18 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: assess effusions Admitting Diagnosis: CORONARY ARTERY DISEASE\OFF PUMP CORONARY ARTERY BYPASS /SDA ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man s/p opcabg REASON FOR THIS EXAMINATION: assess effusions ______________________________________________________________________________ FINAL REPORT HISTORY: CABG, to assess for effusions.",1
"FINDINGS: In comparison with the study of earlier in this date, there is little change except for slightly lower lung volumes and apparent removal of the right chest tube.",0
"PATIENT/TEST INFORMATION: Indication: coronary artery bypass graft off pump, monitor function Height: (in) 71 Weight (lb): 183 BSA (m2): 2.03 m2 BP (mm Hg): 111/57 HR (bpm): 60 Status: Inpatient Date/Time: at 09:49 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA.",1
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - normal; mid anterior - hypo; basal anteroseptal - normal; mid anteroseptal - hypo; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Mildly dilated RV cavity.,0
Conclusions: Pre Bypass Graft The left atrium is dilated.,0
There is moderate regional left ventricular systolic dysfunction with a global mild hypokinesis of LV and focalities in apical regions with mid anteroseptal and anterior regions..,0
Overall left ventricular systolic function is moderately depressed (LVEF= 30 to 35 %).,0
Post grafting: Normal RV systolic function.,0
The wall motion abnormalities are similar to pre grafting.,0
Dr. was notified in person of the results on Mr. at 9AM..,0
Admission Date: Discharge Date: Service: TRAUMA HISTORY OF PRESENT ILLNESS: This is a 79 year old female who was a pedestrian struck by a car with loss of consciousness.,1
She recovered consciousness once the medics arrived.,0
She complained of lower extremity and head pain.,0
"PHYSICAL EXAMINATION: On admission, temperature is 96.7, blood pressure 164/palpable, heart rate 72, respiratory rate 20, oxygen saturation 98% in room air.",0
"Head, eyes, ears, nose and throat examination showed a stellate laceration over the right frontal parietal area.",0
Neck - cervical collar was in place.,0
"Cardiovascular - regular rate and rhythm, no murmurs, rubs or gallops.",0
The lungs are clear to auscultation bilaterally.,0
Back - There was no step-off but there was scoliosis and there was tenderness over the thoracic spine.,0
Rectal was guaiac negative with normal tone.,0
"Extremities - bilateral lower extremity swelling and deformities at the level of the proximal tibial region, 1+ radial, femoral, popliteal pulses, dorsalis pedis and posterior tibial pulses.",1
"Neurologically, she was alert and oriented times three and following commands.",0
"LABORATORY DATA: White blood cell count 9.0, hematocrit 23.0, platelet count 205,000.",0
"INR 1.1, prothrombin time 12.5, partial thromboplastin time 23.8.",0
"Sodium 134, potassium 4.0, chloride 103, blood urea nitrogen 29, creatinine 0.9, glucose 116.",0
Arterial blood gases was 7.42/37/66/25/0.,0
Chest x-ray showed no pneumothorax or widened mediastinum.,0
Pelvis showed no gross deformity.,0
Head CT was negative for bleed.,0
CT cervical spine showed a C2 fracture involving the vertebral artery foramen.,1
"Abdominal and pelvic CT showed a right sacral fracture, symphysis pubic fracture and inferior pubic rami fracture.",0
Lower extremity x-rays showed right lateral tibial plateau split fracture with metaphyseal segmental fracture.,1
"On the left lower extremity, there was a tibial plateau fracture.",1
HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit for further management.,0
"The patient developed bilateral compartment syndrome and was taken to the operating room on , for bilateral fasciotomies and external fixation of her bilateral tibial plateau fractures.",1
The patient remained in the Intensive Care Unit until .,0
She was appropriately weaned off pressors and drips.,0
"On , the patient was transferred to the floor.",0
"For her C2 fracture involving the vertebral artery foramen, orthopedic spine was consulted and recommended a hard collar to stay in place for two to three months.",1
"On , the patient returned to the operating room for open reduction and internal fixation of her bilateral tibial fibular fractures.",1
"Postoperatively, the patient remained in the Post Anesthesia Care Unit for two days and was appropriately weaned off pressors.",0
Her wound culture grew pseudomonas which was sensitive to Ciprofloxacin.,0
The patient was initially started on Zosyn and then changed to Ciprofloxacin.,0
"While in the hospital, the patient was started on TPN and tolerated tube feeds and p.o.",0
calorie counts were done and were adequate.,0
"Towards the end of her hospital course, the patient developed some edema and required diuresis with Lasix.",0
DISCHARGE STATUS: The patient is discharged to rehabilitation.,0
"Status post pedestrian struck by motor vehicle with a right sacral fracture with pubic rami fracture, C2 fracture of the vertebral artery foramen, bilateral tibial fibular fractures, status post open reduction and internal fixation.",1
Lovenox 30 mg subcutaneous twice a day.,0
twice a day to be administered for two weeks starting from .,0
Morphine Sulfate 2 to 4 mg intravenously q2hours p.r.n.,0
"Percocet Elixir 5/325, 5 to 10 ccs q4-6hours p.r.n.",0
Dulcolax 10 mg PR p.r.n.,0
Bacitracin Ointment to the right forehead three times a day.,0
The patient is to remain in her cervical collar for approximately six to eight weeks.,0
"She is to have a follow-up appointment with orthopedic spine, Dr. , in three weeks.",0
The patient is nonweight-bearing bilateral lower extremities for six to eight weeks and is to follow-up with orthopedics in one to two weeks.,0
The patient is to have CPM of the right lower extremity and her dressing changed once daily.,0
The patient is to follow-up with orthopedic spine in three weeks and with orthopedics in one to two weeks.,0
Dictated By: MEDQUIST36 D: 10:43 T: 11:19 JOB#:,0
"10:08 AM ABDOMEN U.S. (PORTABLE) Clip # Reason: please evaluate for abd aortic aneurysm Admitting Diagnosis: ST ELEVATION MI ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with STEMI, s/p PTCA, with epigastric/mid-abd pain REASON FOR THIS EXAMINATION: please evaluate for abd aortic aneurysm ______________________________________________________________________________ FINAL REPORT INDICATION: The patient with ST elevation myocardial infarction status post PTCA.",1
Epigastric to mid abdominal pain.,0
Please evaluate for abdominal aortic aneurysm.,0
ABDOMEN ULTRASOUND: The liver echotexture is normal.,0
"There is an oval anechoic lesion at the liver dome of the right lobe, which may represent a hepatic cyst.",0
There is no flow within this structure.,0
There are no solid liver lesions identified.,0
The main portal vein is patent with the appropriate direction of flow.,0
"The gallbladder contains a few tiny rounded foci, some of which are nondependent and all of which are non-shadowing.",0
"Most of these likely represent tiny polyps (measuring 2-3 mm), but a couple may represent tiny stones.",0
"There is no gallbladder wall edema, thickening or pericholecystic fluid.",0
The common duct measures 7 mm at the porta.,0
The right kidney measures 10.1 cm.,0
The left kidney measures 11.4 cm.,0
"There is no hydronephrosis, stone or solid renal mass.",0
There is a simple cyst within the mid portion of the left kidney measuring 1.2 cm in diameter.,0
A single view of the spleen is unremarkable.,0
The pancreas is not visualized.,0
The aorta is of normal caliber throughout.,0
"The gallbladder contains tiny echogenic foci, some of which likely represent polyps, but a few of which may represent tiny stones.",0
The gallbladder is otherwise unremarkable.,0
Probable cyst at the liver dome.,0
Simple cyst of the left kidney.,0
RVF Height: (in) 65 Weight (lb): 160 BSA (m2): 1.80 m2 BP (mm Hg): 130/80 Status: Inpatient Date/Time: at 09:11 Test: TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
PERICARDIUM: There is a moderate to large sized pericardial effusion.,0
There is brief right atrial collapse.,0
The physician caring for the patient was notified of the echocardiographic results by e-mail.,0
"Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%).",0
There is brief right atrial collapse as well as mild diastolic invagination (but not collapse) of the right ventricular free wall.,0
"However, there does not appear to be any major respirophasic variation of mitral or tricuspid inflow; therefore, frank tamponade is not present.",0
"Impression: moderate-to-large circumferential pericardial effusion with right ventricular free wall invagination but not collapse; frank tamponade is not present, but close serial clinical and echocardiographic monitoring is recommended",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Lethargy.,0
"Major Surgical or Invasive Procedure: None History of Present Illness: 59 yo F with PMH left upper lobe NSCLC stage IV adenocarcinoma with brain mets s/p met resection, cyberknife, and whole brain radiation completed on not currently undergoing chemo (planned to start this on ) who reports being too weak to get out of bed for past four days with very poor po intake.",1
"Also notes constipation which improved with senna, abdominal pain which she felt was related to constipation and has improved since moving her bowels, nausea, vomiting.",0
"In the ED, initial vitals were 98.4 124 73/23 18 90%.",0
CXR showed PTX on left with no shift or tension.,0
"CTA C/A/P was obtained which showed consistent findings with PTX, bilateral pulmonary emboli, DVT in left common iliac left superficial femoral veins, and extensive metastatic progression with innumerable mets to the liver and bones.",1
Also obtained head CT which shows edema at sites of known brain mets.,1
Started heparin drip without bolus in ED per onc recs in effort to treat PE but reduce risk of hemorrhage into brain mets.,0
Got 6L fluid and SBP improved.,0
Pt appeared more alert after fluid rescuscitation.,0
Lactate was 7.2 with increase to 12.1 after a few hours.,0
IP felt chest tube was appropriate if patient was not CMO however patient wanted to think about this more.,0
Oncologist saw pt in ED and discussed GOC - explained that she had only a few weeks to live at best.,0
Pt agreed to be DNR/DNI but refused CMO and wished to continue treatment.,0
"Vitals on transfer were 107/71, 80, 18, 98% RA .",0
"On the floor, patient is comfortable and denies pain.",0
Notes she would like some coffee.,0
Past Medical History: Past Oncologic History: (Per Dr.,0
"Note ) NSCLC stage IV adenocarcinoma EGFR/ALK/KRAS w/t - Developed progressive DOE and weight loss - Presented to her PCP with DOE, referred to the ED where she was found to have a LUL mass on CXR.",0
"CT chest showed mass in the left upper lobe measuring up to 4.6 cm, causing complete collapse of the left upper lobe.",0
This tumor is centrally located and extends into the mediastinal fat.,0
Outpatient work up arranged - 08/12-13/11 Presented with L sided numbness c/w a complex partial seizure.,0
Heat CT revealed new brain mets.,0
"- Brain CT showed right parietal lobe mass at the -white junction, with extensive surrounding vasogenic edema and 5-mm left shift.",1
- Brain MRI showed right posterior frontal and anterior parietal mass measuring approximately 3 cm.,0
"- Resection of brain met, consistent with NSCLC adenocarcinoma of lung primary - CyberKnive to brain lesion - PET CT showed intensely avid paraortic lymph node demonstrated adjacent to the primary left upper lobe mass measuring 21 x 17mm.",1
"Known FDG-avid left upper lobe mass as detailed above, most compatible with the primary carcinoma.",0
Several other scattered pulmonary nodules in the left hemithorax as detailed above.,0
"Increased bilateral adrenal FDG-avidity to SUVmax of 4.6 most compatible with metastatic involvement, left greater than right with an associated soft tissue lesion on the left.",0
Known right cerebellar metastasis is better appreciated on the prior MRI from .,0
Post-surgical changes from prior right parietal craniotomy.,0
"- MRI of the brain showed multiple new mets - Start WBRT, planned to complete on .",0
Past Medical History: None Social History: She lives alone in .,0
"She was never married, but has a boyfriend that lives in .",0
She works as a genealogist and with the Ford forum.,0
"She previously smoked 10 cigarettes/day for 20 years, but quit one year ago.",0
She has an occasional drink with dinner.,0
"Family History: Father with EtOH abuse and peripheral neuropathy, died at 80.",0
"Mother with HL, died at 88.",0
Denies any family history of cancer.,0
"Physical Exam: ADMISSION EXAM: Vitals: T:98.8 BP:109/78 P: 88 R: 18 O2: 96% General: Alert, oriented, no acute distress, Cachectic HEENT: Sclera anicteric, Dry Mucous Membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Course expiratory wheeze heard bilaterally, bilateral breath sounds, no rales.",0
No signs of tension at this time.,0
Results were relayed over the phone initially to Dr. at approximately 12:05 p.m. on the day of study and then reviewed in person at approximately 12:10 p.m. CTA C/A/P:1.,0
Large left pneumothorax without evidence of tension.,0
Right upper lobe pulmonary embolus in the apical segmental artery.,1
Right lower lobe pulmonary emboli in the lateral basal and posterior basal segmental arteries.,1
No evidence of right heart strain or definite pulmonary infarction.,1
Large DVT in the left common femoral and right superficial femoral veins likely source of pulmonary emboli.,1
Enlarged left upper lobe mass with areas of hypoattenuation suggesting necrosis or pulmonary infarction.,1
"Continued encasement of the left pulmonary artery, which is narrowed to a diameter of 3 mm, also seen on prior study.",0
Obliteration of the left upper lobe pulmonary artery and left upper lobe bronchus.,1
"Complete occlusion of the left superior pulmonary vein with eccentric filling, which may represent thrombus or tumor invasion.",0
"Extensive progression of metastatic disease in the chest, abdomen and pelvis.",0
Progression of mediastinal lymphadenopathy with new epicardial lymph node.,0
New right lower lobe spiculated lung nodule.,0
"Multiple new intra-abdominal metastases including lesions too numerous to count within the liver, bilateral adrenal and bilateral renal metastases.",0
Encephalomalacic post-surgical changes in the right frontoparietal region.,0
"Brief Hospital Course: 59 yo P with PMH NSCLC stage IV adenocarcinoma with brain mets s/p met resection, cyberknife, whole brain radiation completed on not currently undergoing chemo (planned to start this on ) who presented with lethargy and hypotension, found to have PTX and bilateral PE in the setting of cancer progression on imaging.",1
"She was made CMO on , and passed away on the morning of .",0
# Hypotension: SBP to 70s on admission.,0
Likely secondary to poor po intake as pt reports being bedbound for several days.,0
Lactate was 12 on transfer for .,0
SBP improved to 100s s/p 6L IVF in ED.,0
"While she has a PTX and PE, these are not likely to have contributed to hypotension as PE were subsegmental and PTX was not tension and had no shift.",0
Obtained blood and urine cultures to rule out infection/sepsis as cause of hypotension.,0
Stable overnight so called out to floor after less than 24 hours in .,0
"While on the floor, BP remained stable in the 100-110/60-70 range.",0
Pt did require 1L fluid bolus while on the floor for drop in BP to 80/40 with standing.,0
This episode of hypotension was asymptomatic.,0
Ms. was subsequently maintained on IV maintenance fluids for SBPs in the 80s-90's from .,0
"She then decided to become comfort measures only on , and vital signs were discontinued.",0
Ms. passed away on .,0
Right upper/lower PEs/DVT: Evidence of large left common and right superficial femoral vein DVTs.,1
Comfortable on 2 Liters nasal cannula on admission.,0
Gave heparin drip without bolus to reduce bleeding risk and then switched to lovenox on hospital day 2.,0
This was discontinued on as Ms. was made comfort measures only.,0
# Pneumothorax: No evidence of tension pneumo.,0
IP was consulted but pt refused placement of any device to manage PTX.,0
Given patients prognosis and desire to avoid chest tube IP agreed that if pt was comfortable they could follow and intervene later if necessary.,0
"This issue was readdressed on the third day of admission, and the patient decided that she was comfortable w/o a chest tube.",0
"# NSCLC stage IV adenocarcinoma with brain/liver/abdominal mets: Per primary oncologist, no current indication for chemotherapy given her very poor prognosis and performance status.",1
Pt has agreed to DNR/DNI and agreed to go home with hospice.,0
Continued Levetiracetam for seizure prophylaxis in setting of brain mets.,0
This was continued until Ms. passed away on .,0
"# Leukocytosis: Given PNA on chest CT, leukocytosis may be secondary to infection.",1
Unfortunately leukocytosis progressed despite treatment of PEs as well as PNA and may represent inflammatory state incurred by advanced malignancy.,0
Laboratory tests were discontinued on when Ms. decided to become CMO.,0
"Medications on Admission: LEVETIRACETAM - (Prescribed by Other Provider) - 250 mg Tablet - 3 Tablet(s) by mouth twice a day Discharge Medications: None, the patient passed away Discharge Disposition: Expired Discharge Diagnosis: Metastatic Lung Cancer Deep Vein Thrombosis Pulmonary Embolism Spontaneous Pneumothorax Epilepsy secondary to metastastatic brain lesions Discharge Condition: Patient passed away on Discharge Instructions: None needed, patient passed away on Followup Instructions: None needed, patient passed away on",1
10:37 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: Please assess for injury.,0
"Admitting Diagnosis: SEPTIC SHOCK ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with possible trauma/head injury, hypotensive.",1
"No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 56-year-old post fall, unknown history.",0
CT of the cervical spine without IV contrast.,0
"In the sagittal view, the C1 through T2 vertebral bodies are visualized.",0
There is normal vertebral body height and alignment.,0
Degenerative changes are seen with disc space narrowing at C5-6.,0
Mild osteophyte formation is also seen at this level.,0
There is also minimal narrowing of the spinal canal at this level.,0
An NG tube and endotracheal tube are present.,0
IMPRESSION: Mild degenerative changes in the mid cervical spine without evidence of fracture.,0
5:21 AM PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # Reason: follow up of pneumatosis Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with pneumaotsis REASON FOR THIS EXAMINATION: follow up of pneumatosis ______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN RADIOGRAPH CLINICAL HISTORY: Pneumatosis.,1
"Since last examination dated earlier in the day, any residual pneumatosis has resolved.",0
There is no evidence of free peritoneal air or bowel dilatation identified.,0
Bowel gas pattern is normal throughout.,0
Nasogastric tube is present with its tip in the fundus of the stomach.,0
IMPRESSION: Normal bowel gas pattern.,0
2:08 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: dobhoff placement Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with retroperitoneal bleed s/p evacuation REASON FOR THIS EXAMINATION: dobhoff placement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 3:20 PM Dobbhoff tube terminates within the stomach in good position.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male with retroperitoneal bleed status post evacuation.,0
Supine portable AP chest is compared examination performed at 11:20 a.m. same day.,0
A newly placed Dobbhoff feeding tube terminates well within the stomach in good position.,0
No other substantial changes from examination performed earlier the same day are evident.,0
7:47 AM CHEST (PORTABLE AP) Clip # Reason: altelectasis v. consolidation Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with h/o t spine trauma and epidural hematoma p/w PE REASON FOR THIS EXAMINATION: altelectasis v. consolidation ______________________________________________________________________________ FINAL REPORT STUDY: AP chest .,0
CLINICAL HISTORY: 50-year-old man with history of thoracic spine trauma and epidural hematoma.,1
There is again seen a left retrocardiac opacity.,0
There is atelectasis at the right lung base.,0
There are no signs for pulmonary consolidation or pulmonary edema.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Codeine / Iodine; Iodine Containing / Soybean / Lecithin Attending: Chief Complaint: CC: Major Surgical or Invasive Procedure: Radial Artery Cannulation Intubation for respiratory failure PICC line placement and removale Chest tube placement and removal History of Present Illness: HPI: 50F w/ HIV (last CD4 408 ), Hep C, COPD, asthma, prior aspiration PNA presents from Rehab after recent ICU admission to for COPD flare.",1
"Was being treated for COPD flare c steroids, abx, nebs at rehab until yesterday when patient noted to have some dyspnea night prior to presentation; otherwise ROS negative from rehab.",0
found unconscious in bathtub with O2 sat 55% RA.,0
Placed on O2 6L NC c O2 sat 88%.,0
"Then started BiPap 6L, c O2 sat 96%, BP 125/66, 115.",0
ABG done at Rehab showing 7.30/85/71.,0
"In ED, vitals: 75% NRB, 10, 98.0, 101/68, 96.",0
"Intubated for GCS 5, hypoxic respiratory failure.",1
Head and C-spine CT done to look for fracture/bleed - negative.,0
CXR done showing diffuse L lung opacity.,0
Given ceftriaxone / flagyl / vancomycin for aspiration PNA and nosocomial PNA.,0
"Sputum sent, including samples for PCP.",0
"intubated, sedated and no history available.",0
COPD/asthma - recent admission for COPD flare.,0
"Was taking levofloxacin, nebs, theophylline, advair and solumedrol 80 q8 hrs.",0
Aspiration PNA - recurrent but unknown # hosp.,0
"DMII - on NPH 52 qAM, 30 qPM + sliding scale 4.",0
R Breast CA s/p lumpectomy/radiation therapy in .,0
"HIV - CD4 408, 7.",0
"Psoriasis Social History: SH: Lives in group home, continues to smoke ppd > 25 yrs, drinks socially.",0
Family History: FH: Mother with emphysema.,0
"Physical Exam: VS - 97.3, 136/76, 87 - On vent A/C FiO2 0.5, PEEP 5, Vt 500, RR 20 HEENT - MMM, ETT in place, EOMI LUNGS - coarse rhonchi b/l at apices/axillae HEART - RRR, S1, S2, no rmg ABD - soft, NT, ND, BS+ EXT - wwp, no peripheral edema, 2+ DP pulse, denuded, chronic venous stasis changes over legs b/l NEURO - intubated, sedated.",1
"Upgoing toe R, no response L Babinski Pertinent Results: labs - see below; notable for LDH 480, WBC 18.7 imaging - CXR: diffuse, interstitial pattern over L lung field.",0
"diffuse pattern over R middle lobe CT head: There is no evidence of intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major vascular territorial infarction, or fracture.",0
The ventricles and sulci are symmetric.,0
There is preservation of the normal /white matter differentiation.,0
The paranasal sinuses are clear and the orbits are unremarkable.,0
Regional soft tissues demonstrate no significant abnormality.,0
CT C-spine: No acute fracture.,0
Minimal grade 1 anterolisthesis of T1 over T2.,0
Large left upper lobe consolidation concerning for aspiration or pneumonia.,0
"If there is clinical concern for diaphragmatic paralysis, fluoroscopic assessment may be helpful.",0
No mass is identified in the expected course of the phrenic nerve.,0
"Centrilobular opacities in right lower lobe, which may be due to infectious small airways disease or aspiration.",0
No evidence of subpulmonic pleural effusion.,0
"Small low-attenuation lesion in upper pole portion of left kidney and low attenuation lesion in the thyroid gland left lobe, both incompletely evaluated on this study.",0
"If warranted clinically, dedicated ultrasound could be considered to evaluate these areas.",0
CHEST FLUOROSCOPY: There is normal motion of the right hemidiaphragm.,0
The motion of the left hemidiaphragm is sluggish.,0
There is no evidence of paradoxical motion.,0
IMPRESSION: Sluggish left hemidiaphragm but no evidence for diaphragmatic paralysis.,0
ECHO : The left atrium is mildly dilated.,0
IMPRESSION: Dilated RV cavity with moderate pulmonary hypertension (?,0
SPUTUM GRAM STAIN (Final ): PMNs and <10 epithelial cells/100X field.,0
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).,0
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).,0
SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII | CEFEPIME-------------- 32 R CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 1.,0
Failure - Differential included PNA (CAP vs. nosocomial vs. PCP .,0
"aspiration), likely concurrent with or exacerbating a COPD flare.",0
Less likely possibilities included PE and CHF.,0
A CXR in the ED showed diffuse L lung opacity.,0
"Patient was started on Ceftriaxone, Flagyl, Vancomycin, Bactrim, and prednisone.",0
Blood and sputum was sent for culture and patient was transferred to the for further management.,0
"In the , patient was underwent a bronchoscopy which showed: no inflammation, minimal secretions, and a partially obstructing lesion, likely a foreign body, which looked exactly like a piece of , report.",0
"Of note, patient was admitted to hospital ~ 3 months prior to this admission after aspirating .",0
Urine was sent to check for legionella antigen and was negative.,0
Sputum was sent to assess for PCP and was negative.,0
Patient was ruled out for ACS with negative cardiac enzymes x 3.,0
An arterial line was placed.,0
A BAL was performed and the initial read showed gram-positive cocci and gram-negative rods.,0
"Patient was maintained on theophylline, albuterol/atrovent INH, fluticasone, montelukast, and prednisone.",0
Sputum culture returned positive for acinitobacter baumanni which was sensitive to bactrim and imipenum.,0
A repeat bronchoscopy was performed on which showed continuing obstruction.,0
"A central line was attempted, with resulting R pneumothorax.",0
CT surgery was consulted and a chest tube was placed with good resolution of pneumothorax.,0
"A femoral line was placed, then removed once patient had a L PICC line placed.",0
The bronchopscopy was repeated on with removed.,0
A repeat bronchoscopy performed on - no findings were documented.,0
Patient was extubated on without difficulty.,0
The chest tube was also removed on .,0
"Shortly after extubation, the patient became somewhat agitated, crying out and moving around restlessly in bed.",0
She was treated with haldol and zyprexa with good effect and her agitation had entirely resolved by the next day.,0
Speech and swallow evaluation was ordered and is discussed below in FEN in more detail.,0
Imipenum was discontinued on and the a-line was discontinued secondary to concerns of infection.,0
"Patient appeared somewhat tremulous on and although she says that she is normally shaky at baseline, Albuterol was changed to PRN and patient was started on serovent.",0
"Seroquel was restarted with aplan to uptitrate to home dose as tolerated, which was done.",0
Imipenim was restarted and Bactrim and imipenem were continued for a 14 day course and prednisone was started for possible COPD exacerbation and tapered.,0
"#Altered MS - Differential diagnosis included hypoxia insetting fo respiratory distress, infection (given HIV status, unknown CD4 count, not on HAART or prophylaxis), seizure (possibly secondary to infection), toxic/metabolic, and less likely, CVA.",1
A CT scan was obtained in the ED which was negative for masses or bleeding with preserved grey-white matter differentiation.,0
Seroquel was discontinued for it's sedating effects and possible contribution to her mental status.,0
There was some concern that depakote may also be contributing so that was discontinued on .,0
Mental status improved as patient stabilized and she is now back to her baseline.,0
"#Neck pain: Patient had plain films of the cervical spine to rule-out possible fracture, but while in the complained of diffuse posterior cervical neck pain on palpation.",0
"Patient was placed back into a rigid neck collar, which she tolerated very poorly.",0
The neck collar was removed and patient denied any further neck pain.,0
"Given her somewhat questionable mental status, repeat flexion and extension films were obtained and showed some minimal instability at at C2/3 and C3/4, of indeterminate acuity.",0
A formal spine/ortho consult was obtained and patient was cleared of possible cervical spinal trauma.,0
#Cardiac - Patient had some chest pain on .,0
"Pain was not relieved with nitroglycerin SL, but did entirely resolve with 2 mg IV morphine.",0
Patient had been ruled out for ACS with three sets of negative cardiac enzymes on admission.,0
Another set was set and again was negative.,0
Her chest pain was attributed to anxiety.,0
Patient also became somewhat intermittently tachycardiac during her stay in the ICU.,0
"There was no obvious etiology and patient was comfortable, making good urine so not further action was taken.",0
#DM II - Patient was initially maintained on an insulin gtt per protocol.,0
Currently she is being covered with an insulin sliding scale and glargine.,1
"She was started on NPH in the a.m. and dose increased to help with high afternoon sugars, and we continue to adjust this regimen.",0
#HTN - Nifedipine was held in the acute setting of infection.,1
"Once patient was more stable, it was restarted at her usual outpatient dose.",0
Patient remained hypertensive with SBP in the 160-170's.,0
"Nifedipine was changed to diltiazem, which was uptitrated, and Captopril was added with good control.",0
#HIV - Patient is not on HAART or any prophylaxis.,0
Her most recent CD4 count on was 296. .,0
#Hyperlipidemia - Atorvastatin was continued at outpatient dose.,0
#Schizoaffective D/O - Depakote Sprinkles and seroquel were both discontinued secondary to concerns they may be contributing to patient altered mental status.,1
"After patient's mental status improved, her seroquel was restarted and is being tapered up to her previous dose.",0
"FEN - Maintained on tube feeds without problem while intubated, then transitioned over to a diabetic diet.",0
"A Speech and swallow evaluation was ordered and after bedside eval, a videoswallow study was ordered.",0
Patient was cleared for a ground solid diet with nectar-thick liquids.,0
Meds should be crushed and given with purees.,0
Lytes were repleted as necessary.,0
On the day of discharge she was tolerating a regular diabetic diet without any signs or symptoms of aspiration.,0
"Ppx - PPI, SC hep, Pneumoboots .",0
Access - PIV and PICC .,0
Code - Full; confirmed verbally with patient on .,0
report patient has HCP: Aunt who has not been able to be contact for the duration of this admission.,0
Patient verbalized that she would like to speak for her if she is unable to speak for herself.,0
"She works at house, phone number , a group housing facility which the patient has lived at for more than 5 years.",0
"Need to clarify if or another Ruah House employee (Nurit Adem) will be the new HCP or if this is a temporary arrangement until the aunt can be contact; PCP is at Clinic at Hospital, phone # I, , attending of record, assumed care on the day of discharge.",0
I spoke directly with patient's nurse practioner about the kidney lesion and thyroid lesion and recommended follow up with urology and endocrine for further evaluation.,0
She understood and will discuss follow up with patient's PCP This d/c summary was faxed to the NP.,0
"Medications on Admission: Meds: NPH 52 AM, 30 PM Protonix 40 Theophylline 200 qd Albuterol nebs Solumedrol 80 IV q8 Diamox 250 PO bid Moxifloxacin 400 IV qd Singulair 10 qd Advair 500/50 1 puff Spiriva 1 puff QD Nifedipine XL 60 PO qd ECASA 81 qd Atorvastatin 40 qd Quetiapine 75 tid Depakote 750 Celexa 20 qd Nicotine patch Tylenol 650 q8 Arimidex 1 mg daily Potassium chlride 40 meq PO daily prn K<4.0 Discharge Medications: 1.",0
Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day).,0
"Divalproex 250 mg Tablet, Delayed Release (E.C.)",0
Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily).,0
Disp:*30 Patch 24HR(s)* Refills:*2* 7.,0
Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain.,0
Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().,0
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing.,0
Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed.,0
Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 1 days.,0
Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty Five (35) units Subcutaneous QAM.,1
Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty (20) units SC Subcutaneous at bedtime.,1
Regular Insulin Sliding Scale Please use a regular insulin sliding scale four times a day - before meals and QHS.,0
Home Oxygen Home oxygen at 3L/min via nasal cannula to keep oxygen sats >92%.,0
Discharge Disposition: Home With Service Facility: Homecare Discharge Diagnosis: Aspiration pneumonia Chronic Obstructive Pulmonary Disease Asthma H/o breast cancer Type II Diabetes Mellitus Hypertension Hepatitis C Obstructive Sleep Apnea Schizoaffective Disorder Psoriasis HIV Discharge Condition: Stable.,1
"Patient oxygenating at 97% on 3L, which is her baseline.",0
"Discharge Instructions: # Please take all of your medications as prescribed # Please call your PCP or return to the ED if you have difficutly breathing, chest pain, worsening cough, fevers, chills, nausea, vomiting, or any other symptom that is of concern to you.",0
# Please follow-up with your primary care doctor a thyroid ultrasound to evaluate a thyroid lesion that was seen on CT scan.,0
This may need to be biopsied.,0
# Please follow-up with a urologist regarding a small kidney cyst on your CT scan.,0
"Followup Instructions: # Please follow up with your NP, (attending physician is .",0
", at , on Friday at 9:30 a.m.",0
"Her pager is pager , fax .",0
Please follow-up with your primary care doctor a thyroid ultrasound to evaluate a thyroid lesion that was seen on CT scan.,0
# Please follow up with Dr. on at 3:00 to have your stitches removed.,0
"Provider: , MD Phone: Date/Time: 3:00 # Please follow-up with a urologist (kidney doctor) regarding a small kidney cyst on your CT scan.",0
"10:59 AM CT TRACHEA W/O C W/RECONS Clip # Reason: EVLUATE EXTRINIC CSIC COMPRESSION OF THE LMS BRONCHUS SEEN O ______________________________________________________________________________ CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED: EVLUATE EXTRINIC CSIC COMPRESSION OF THE LMS BRONCHUS SEEN ON BRONCHOSCOPY, S/P S/P LMS STENT PLACEMENT No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Extrinsic compression of main stem bronchus.",0
CT of the airway was performed at end-inspiration.,0
No intravenous or oral contrast was administered.,0
Images were obtained from the level of the lower cervical region just above the level of the tracheostomy tube insertion site to approximately the level of the inferior pulmonary veins.,0
The entirety of the chest was not imaged as this was ordered as a dedicated airway study.,0
"From the original axial CT data set, a series of three-dimensional reconstructions were performed using internal rendering technique.",0
"Additionally, 2D multiplanar reformatted images were obtained in the coronal and sagittal projections.",0
"The cuff of the tube appears over-distended, resulting in widening of the tracheal lumen at the level of the cuff.",0
"The trachea appears enlarged even below this level, with maximal transverse dimension above the aortic arch of approximately 26 mm.",0
There is also enlargement of the right main stem bronchus.,0
The origin of the left mainstem bronchus appears narrowed but there is no intrinsic or extrinsic mass identified.,0
"Note is made of a narrowed AP diameter of the thorax at the level where the left main stem bronchus crosses the midline, and it is possible that the bronchus may be compressed by the combination of a narrow AP diameter with compression between the thoracic spine posteriorly and the ascending aorta anteriorly.",0
A stent is identified within the left main stem bronchus but begins distal to the origin of the narrowing.,0
No significantly enlarged mediastinal or hilar lymph nodes are identified using short axis criteria of 1 cm as upper limits of normal.,0
Note is made of distention of the thoracic esophagus which contains and air-fluid level.,0
The esophagus is dilated in the cervical and upper thoracic region.,0
It also appears to be compressed by a narrow AP diameter and compression between the spine and aortic arch could also account for this finding.,0
There is a small pericardial effusion which is incompletely imaged as the entirety of the heart is not included on this study.,0
No significant pleural effusion is identified.,0
Assessment of the lungs reveals traction bronchiectasis and conglomerate area of fibrosis with volume loss in the right lung apex.,0
There are also nonspecific patchy areas of ground glass opacity in the superior segments of both lower lobes extending into the posterior basilar segments as well.,0
Scattered reticular changes are seen in the right apex.,0
Skeletal structures of the thorax reveal marked narrowing of the AP dimension (Over) 10:59 AM CT TRACHEA W/O C W/RECONS Clip # Reason: EVLUATE EXTRINIC CSIC COMPRESSION OF THE LMS BRONCHUS SEEN O ______________________________________________________________________________ FINAL REPORT (Cont) of the thorax.,0
Two-dimensional coronal and sagittal reformatted images confirm the presence of overdistention of the tracheostomy tube cuff and narrowing of the proximal main stem bronchus.,0
Three-dimensional internal rendering also confirms narrowing of the left main stem bronchus.,0
"Narrowing of the left main stem bronchus, without evidence of intrinsic lesion or extrinsic mass.",0
"There is a markedly decreased AP diameter of the thorax, and it appears that the left main stem bronchus is narrowed by compression between the spine posteriorly and the ascending aorta and aortic arch anteriorly.",0
"Similarly, the esophagus is compressed by the same mechanism resulting in marked proximal esophageal distension.",0
"Fibrosis in the right upper lobe, which may be related to prior radiation therapy or prior granulomatous infection.",0
"Patchy foci of ground glass opacity in dependent portions of both lower lobes, most likely due to aspiration.",0
Overdistention of tracheostomy tube cuff.,0
8:14 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W/CONTRAST Reason: eval for vascular injury Admitting Diagnosis: S/P FALL;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 46 year old man with known fx at C4-6 w/possible vertebral artery injury REASON FOR THIS EXAMINATION: eval for vascular injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: MRI of the brain and MRA of the head and neck.,1
CLINICAL INFORMATION: Patient with known fracture at C4-C6 level with possible vertebral artery injury.,1
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired.,0
2D and 3D time-of-flight MRA of the neck vessels and 3D time-of-flight MRA of the circle of obtained.,0
The neck MRA is limited by motion.,0
FINDINGS: BRAIN MRI: There is no evidence of acute infarct identified.,0
There is a chronic infarct seen in the right periventricular region.,1
Mild changes of small vessel disease are identified.,0
There is no midline shift or hydrocephalus.,0
Soft tissue swelling is seen in the posterior scalp region.,0
Soft tissue changes are also noted in the right maxillary sinus and sphenoid sinus as well as in the right frontal sinus.,0
IMPRESSION: No evidence of acute infarct.,0
Small vessel disease and chronic right-sided lacunar infarct.,1
"Soft tissue changes right-sided maxillary, frontal, and ethmoid sinuses.",0
MRA OF THE NECK: The neck MRA is limited by motion.,0
Both carotid right and left vertebral arteries are normal in appearance.,0
The right vertebral artery is small in size and extends to the level of C2 and is not visualized distally.,0
There is slight motion limiting evaluation of both vertebral arteries at the level of C4-5.,0
"On fat-suppressed axial images, there is increased signal seen throughout the right vertebral artery which could be secondary to slow flow.",0
The appearance could be due to congenitally small vertebral artery or chronic disease within the vertebral artery distally in the distal cervical and intracranial region.,1
"However, the evaluation has remained limited secondary to motion and a repeat MRA or if the patient is on hemodialysis, then CT angiography would help for further assessment.",0
"IMPRESSION: As described above, the right vertebral artery is small in size which could be congenital variation as the vertebral artery is not occluded or affected at the site of abnormality seen at C4-5 level.",1
"However, the MRA is (Over) 8:14 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MRA NECK W/CONTRAST Reason: eval for vascular injury Admitting Diagnosis: S/P FALL;TELEMETRY ______________________________________________________________________________ FINAL REPORT (Cont) limited by motion and for better evaluation repeat MRA or CT angiography are recommended.",0
MRA OF THE HEAD: The head MRA demonstrates a dominant left intracranial vertebral artery.,0
The right vertebral artery is not visualized in the intracranial region.,1
The basilar artery demonstrates normal appearance.,0
In the anterior circulation the arteries demonstrate normal appearance.,0
"IMPRESSION: Except for nonvisualization of distal right vertebral artery, no other abnormalities are seen.",1
"2:17 AM CHEST (PORTABLE AP) Clip # Reason: interval progression Admitting Diagnosis: HIP FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with pulmonary vascular congestion, hypoTN REASON FOR THIS EXAMINATION: interval progression ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Hypotension and vascular congestion.",1
"Comparison is made to prior study, .",0
Left Port-A-Cath tip is in the right atrium.,0
Mild-to-moderate pulmonary edema is stable.,0
"LINE PLACEMENT Clip # Reason: line placement Admitting Diagnosis: SUBDURAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man s/p MVC c head bleed, now R CVL changed over wire REASON FOR THIS EXAMINATION: line placement ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE VIEW, ON HISTORY: Motor vehicle accident, check central line.",1
FINDINGS: The endotracheal tube is unchanged.,0
There is a right subclavian line with tip in the SVC.,0
There is dense opacification of the right lower lung consistent with an effusion.,0
An underlying infiltrate or atelectasis cannot be excluded.,0
"Compared to the prior study from a day ago, the opacity in the right lower lung has increased.",0
The left lung is relatively clear.,0
The cardiac and mediastinal silhouettes are unchanged.,0
"7:19 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # -77 BY DIFFERENT PHYSICIAN : please assess NGT and ETT locations Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with s/p liver transplant REASON FOR THIS EXAMINATION: please assess NGT and ETT locations ______________________________________________________________________________ FINAL REPORT 60-year-old male status post liver transplant, referred for evaluation of nasogastric and endotracheal tube placements.",0
AP SUPINE PORTABLE CHEST: The endotracheal tube tip is in a high position approximately 6 cm above the carina.,0
There is a right internal jugular Swan- Ganz catheter terminating in the main pulmonary artery.,0
There are bibasal pleural drains.,0
Considering the low inspiratory volumes the lungs are grossly clear.,0
Endotracheal tube in high position and advancement 2-3 cm is suggested.,0
This was discussed with Dr. at 9:15 p.m. on .,0
"LINE PLACEMENT Clip # Reason: r/o PTX/Effuison/Tamponade Admitting Diagnosis: CORONARY ARTERY BYPASS GRAFT ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with CAD s/p CABG REASON FOR THIS EXAMINATION: r/o PTX/Effuison/Tamponade ______________________________________________________________________________ FINAL REPORT CHEST, ONE VIEW, PORTABLE.",1
"INDICATION: 73-year-old man with CAD, status post CABG.",0
"COMMENTS: Portable supine AP radiograph of the chest is reviewed, and compared with the previous study of .",0
A nasogastric tube terminates in the gastric fundus.,0
There is a left chest tube and mediastinal drain in place.,0
The right jugular Swan-Ganz catheter terminates in the right main PA.,0
The right subclavian pacemaker leads remain in place.,0
There is small left pleural effusion and atelectasis in the left lower lobe.,0
"7:36 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o IVH, PVL Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity@ 32wks REASON FOR THIS EXAMINATION: r/o IVH, PVL ______________________________________________________________________________ FINAL REPORT HISTORY: Nearly 1-month-old girl who was born prematurely at 32 weeks EGA.",1
Evaluate for intraventricular hemorrhage and PVL.,1
"A somewhat geographic focus of abnormal echogenicity in the deep left frontoparietal region, located just superior to the temporal lobe.",0
It does not appear to be wedge shaped or extend to involve the peripheral cortex.,0
"It is largely hyperechoic, with scattered, rounded, low echogenicity areas centrally that have a cystic appearance.",0
Some images appear to demonstrate blood flow within the lesion.,0
A rim of increased blood flow is not appreciated.,0
The lesion appears to have some mass effect on the adjacent basal ganglia.,0
Remainder of the brain parenchyma has normal echogenicity.,0
Globular increased echogenicity with an ovoid hypoechoic area centrally in the left caudo-thalamic groove.,0
No evidence for left intraventricular hemorrhage.,1
No right germinal matrix hemorrhage.,0
The ventricles have normal size without evidence for ventriculomegaly.,0
"IMPRESSION: 1) Heterogeneous lesion in the left frontoparietal region, just superior to the temporal lobe.",0
This has some degree of mass effect.,0
"It raises the question of cerebritis or intracranial abscess, given the patient's staph aureus bacteremia.",0
2) Evolving left grade I germinal matrix hemorrhage.,1
RECOMMENDATION: Further evaluation with brain MRI.,0
Note: Discussed in person with members of the patient's treatment team at about noon on .,0
"(Over) 7:36 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o IVH, PVL Admitting Diagnosis: NEWBORN ______________________________________________________________________________ FINAL REPORT (Cont)",1
"11:34 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrates, effusions ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man s/p cabg with rising wbc REASON FOR THIS EXAMINATION: r/o infiltrates, effusions ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: Elevated white blood cell count in patient status post coronary artery bypass surgery.",1
Comparison is made to previous study of .,0
"A Swan-Ganz catheter is present, with the distal tip projecting within a segmental branch of the right pulmonary artery, projecting lateral to the right hilum.",0
"An endotracheal tube and nasogastric tube are in satisfactory position, and a single left chest tube remains in place.",0
There are improving left retrocardiac opacities.,0
No new or progressive abnormalities are identied but the right costophrenic angle area has been excluded from the study and cannot be assessed.,0
"IMPRESSION: 1) Distal location of Swan-Ganz catheter, terminating within a segmental branch of the right pulmonary artery.",0
"2) Improving left lower lobe opacity, likely due to ateletasis in this recently postoperative patient.",0
These findings were communicated with the clinical service caring for the patient on the date of the examination.,0
"7:58 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change in pneumothorax Admitting Diagnosis: MULTIPLE TRAUMA,PLANE CRASH ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman s/p L-CVL c/b PTX, now s/p L CT removal w/?",0
"increase in PTX; respiratory function non-compromised REASON FOR THIS EXAMINATION: please eval for interval change in pneumothorax ______________________________________________________________________________ FINAL REPORT AP CHEST 7:53 A.M. HISTORY: Chest tube removal, rule out pneumothorax.",0
"IMPRESSION: AP chest compared to through 10: Tiny left apical pneumothorax has decreased in size since , and small left pleural effusion is slightly larger.",0
Small right pleural effusion unchanged.,0
Mild left basal atelectasis is stable.,0
"Heart size top normal, but leftward shift has increased.",0
"ET tube at the upper margin of the clavicles is nearly 6 cm from the carina, approximately 2 cm above optimal placement.",0
"Nasogastric tube passes into the stomach and out of view, tip of the left subclavian line projects over the junction of the brachiocephalic veins.",0
"2:08 PM CHEST (PORTABLE AP) Clip # Reason: please assess for pneumonia Admitting Diagnosis: BILATERAL ANKLE FX; NEW AFLUTTER ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with history of aspiration pna, worsening delirium REASON FOR THIS EXAMINATION: please assess for pneumonia ______________________________________________________________________________ FINAL REPORT INDICATION: History of aspiration pneumonia, worsening delirium.",1
"TECHNIQUE: A single portal AP upright view of the chest was performed at 14:30, with comparison made to examination of .",0
FINDINGS: Cardiac and mediastinal contours appear unchanged when compared to the prior examination.,0
"There are no new focal pulmonary opacities, pleural effusions, or evidence of pneumothorax.",0
There is improvement in appearance of atelectasis seen on the prior examination.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Ranitidine Attending: Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. is a 55 year-old female with a history of congestive heart failure who presents with shortness of breath.,1
Reports that she was in her usual state of health two days prior to admission.,0
She slept well without CPAP on the evening of .,0
"On , she felt ""tired"" all day and slept quite a bit of the day.",0
That evening she was not tired and did not sleep overnight.,0
At 6am on the day of admission she got up to see her grand-daughter and felt very short of breath and could not walk more than a few steps (at baseline she can walk one block without feeling short of breath).,0
"She put on 2 liters of O2 nnd shortly thereafter felt more short of breath, shaking and sweaty.",0
She called her daughter who called EMS.,0
Has gained ~7 pounds over last week.,0
"Ate Chinese food on day prior to admission, but otherwise uses low salt diet.",0
"In the ED, was afebrile with a heart rate in the 70s.",0
Her blood pressure was markedly elevated at 226/87.,0
"Was given aspirin 325, flagyl, 80mg IV lasix and started on a nitro gtt.",0
Congestive heart failure: - Non-obstructive hypertrophic cardiomyopathy - Echo () with normal EF and likely diastolic failure 2.,1
"Atrial Fibrillation: - , hospitalised in for palpitations and paresthesias 4.",1
"Chronic, intermittent pain: Hospital admission in for left upper back pain, left hip pain, and left headache ED visit in for total body discomfort; also with neck pain.",0
"Asthma: - PFTs () with suggestion of marked obstructive ventilatory defect with gas trapping; FVC 35%, FEV1 36% and the Dsb decreased 5.8 ml 46%.",0
Thalamic Stroke ( - lacunae involving her right thalamus causing numbness on the left side of her body) 9.,0
Positive PPD Social History: Originally from Barbados.,0
"Lives with daughter and granddaughter, reports good relationship with family members, no specific social stressors.",0
"Family History: Sister: HTN Family history of diabetes Physical Exam: vitals - T 98.6, BP 157/63, HR 67, 100% on CPAP 10/5, weight 120kg gen - Obese, breathing comfortably.",0
heent - JVP to ear.,0
II/VI systolic murmur best heart at aortic site.,0
abd - Soft and obese.,0
ext - Warm with trace edema.,0
No large effusions or definite airspace opacity to indicate pneumonia.,0
"IMPRESSION: Massive cardiomegaly associated with increasing pulmonary edema <br> ECG (): Sinus bradycardia @58 Premature atrial contractions with aberration Long QTc interval Anterolateral ST-T changes Since previous tracing of , atrial premature complex new Brief Hospital Course: 1.",0
Shortness of breath/diastolic CHF/Obesity/hypoventilation be multifactorial with component of acute diastolic heart failure (in setting of dietary indiscretion) and obesity/hypoventilation syndrome.,1
"Was placed on IV diuretics, subsequently changed to PO with improvement in respiratory status.",0
Was maintained on BiPAP at night.,0
"Was continued on aldactone, lisinopril, Toprol XL.",0
Chest pressure episode: Resolved with nitro.,0
Cardiac enzymes negative x 3.,0
Continued on meds as above.,0
Started on ASA 81mg daily.,0
Atrial fibrillation: Intermittently in this vs. NSR.,1
Maintained on B-blocker and coumadin.,0
Hypertension: Extremely hypertensive in the ED.,0
Started on nitro gtt in ED.,0
Hypertensive again when transferred from to the floor.,0
"Diabetes Mellitus, Type II Continued on lantus and SSI.",1
Elevated ferritin; likely some degree of chronic inflammation.,0
Pain/neuropathy: Continued gabapentin renally dosed .,0
Amiodarone 200 mg Daily 2.,0
Lisinopril 40 mg Daily 3.,0
Toprol XL 100 mg Daily 4.,0
Spironolactone 25 mg Daily 5.,0
Simvastatin 20 mg Daily 7.,0
Warfarin 2 mg Tablet Daily 8.,0
Insulin Glargine (24) units Subcutaneous at bedtime.,0
Insulin Lispro 100 Sliding Scale 10.,0
Clobetasol 0.05 % Cream 11.,0
Fluticasone 110 mcg/Actuation 2 PUFFS 12.,0
Pantoprazole 40 mg Tablet Daily 14.,0
Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS 15.,0
Sertraline 50 mg Daily Discharge Medications: 1.,0
Clobetasol 0.05 % Cream Sig: One (1) Appl Topical (2 times a day).,0
Gabapentin 300 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours).,0
Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) Units Subcutaneous at bedtime.,0
Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous as directed: Sliding scale as directed.,0
Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)).,0
"Disp:*30 Tablet, Chewable(s)* Refills:*2* 15.",0
Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).,0
Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: Acute on Chronic Diastolic CHF Exacerbation Secondary: Atrial Fibrillation Hypertension, benign Diabetes Type II Anemia, Chronic Depression Obesity Hypoventilation Syndrome Discharge Condition: Afebrile, vital signs stable.",1
Discharge Instructions: You were admitted due to a worsening of your heart failure.,1
This was likely due to too much salt in your diet.,0
"It is important that you follow the recommended guidelines for people with heart failure: -Weigh yourself every morning, MD if weight > 3 lbs.",1
-follow a 2 gm sodium diet -take your prescribed medications every day .,0
Please return to the emergency room or call your doctor if you have increased shortness of breath or chest pain.,0
You will need to follow up with Dr. regarding your heart failure and to have your INR (coumadin level) checked.,1
"Until your level is checked, you should continue to take the lower dose of coumadin (1mg daily instead of 2mg daily) Followup Instructions: Provider: ,TEACHING CLINIC-CC2 (SB) Phone: Date/Time: 8:30 Cardiology: , M.D.",0
"Phone: Date/Time: 9:40 Primary Care: , M.D.",0
"Date/Time: 11:00 Primary Care: , RNC Date/Time: 11:00",0
"LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: Pt had a left sided picc line placed,53cm and needs tip conf Admitting Diagnosis: CARDIAC ARREST ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with PICC.",1
"REASON FOR THIS EXAMINATION: Pt had a left sided picc line placed,53cm and needs tip confirmation please page at with wet read,thanks.",0
______________________________________________________________________________ FINAL REPORT INDICATION: To assess PICC line placement.,0
PORTABLE AP UPRIGHT CHEST RADIOGRAPH: A left upper extremity PICC terminates at the level of the cavoatrial junction.,0
"Small right apical pneumothorax, is slightly larger since the recent prior study.",1
Right chest tube is unchanged in position.,0
Scattered opacities in both lungs suggests mild-to-moderate pulmonary edema.,0
An endotracheal tube is 8 cm above the carina.,0
A nasogastric tube courses through the stomach and out of view.,0
Left upper extremity PICC terminates in the cavoatrial junction.,0
"Small right apical pneumothorax, slightly larger since the recent study of .",1
", MED MICU 3:38 AM CHEST (PORTABLE AP) Clip # Reason: cardiopulm change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old man with respiratory failure REASON FOR THIS EXAMINATION: cardiopulm change ______________________________________________________________________________ PFI REPORT Interval worsening of left basilar airspace disease and stable left upper lobe airspace disease concerning for infection.",1
Interval placement of tracheostomy tube terminating 4.7 cm above the carina.,0
", R. MED MICU 4:20 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: Elevated Cr and no definite plans for dialysis.",0
"Likely can't Admitting Diagnosis: END STAGE RENAL DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 80-year-old female with systolic heart failure, atrial fibrillation previously on coumadin, diabetes mellitus type II, primary biliary cirrhosis-autoimmune hepatitis overlap syndrome p/w acute on chronic renal failure, altered mental status, hypothermia REASON FOR THIS EXAMINATION: Elevated Cr and no definite plans for dialysis.",1
"Likely can't have IV contrast.r/o intra-abdominal catastrophe- perforation, large abscess.",0
CONTRAINDICATIONS for IV CONTRAST: elev cr;incr cr ______________________________________________________________________________ PFI REPORT PFI: 1.,0
"Bilateral pleural effusions, right greater than left with atelectasis.",0
Tree-in- opacities in the right upper lobe may reflect infection.,0
Large volume of abdominal pelvic ascites.,0
Minimally prominent loops of small bowel may reflect ileus but no bowel obstruction.,0
"Sigmoid diverticulosis, but no diverticulitis.",0
"8:14 PM FOOT AP,LAT & OBL RIGHT; FOOT AP,LAT & OBL LEFT Clip # Reason: eval for sc gas ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with lateral R foot wound bleeding ""bubbling"" per call in, clearly infected REASON FOR THIS EXAMINATION: eval for sc gas ______________________________________________________________________________ FINAL REPORT INDICATION: Lateral right foot wound bleeding which appears clearly infected.",0
TWO VIEWS OF EACH FOOT: Post-surgical changes appear to be present within the right fifth digit which appears to have undergone fifth metatarsal osteotomy and resection of the proximal phalanx.,0
No acute fracture or dislocation is identified.,0
"Degenerative changes are seen involving the first MTP and IP joint, as well as within the mid foot.",0
No cortical destruction is seen to suggest the presence of osteomyelitis in the right foot.,0
No subcutaneous gas is identified.,0
"Within the left foot, post-surgical changes are seen involving the fifth digit with evidence of left fifth metatarsal osteotomy and likely resection of the proximal phalanx.",0
"The lateral cortex of the left fifth metatarsal is not clearly delineated, and osteomyelitis within this region is not excluded.",0
No subcutaneous gas is noted.,0
Degenerative changes are seen involving the first MTP joint with joint space narrowing and subchondral sclerosis.,0
Small calcaneal plantar enthesiophyte is noted.,0
There is diffuse soft tissue swelling involving both feet.,0
No evidence of subcutaneous gas identified.,0
Diffuse soft tissue swelling is seen in both feet.,0
"Irregularity of the lateral cortical margin of the left fifth metatarsal, and osteomyelitis within this region is not excluded.",0
Post-surgical changes involving both fifth digits.,0
"3:12 AM CHEST (PORTABLE AP) Clip # Reason: Re-assess pna Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with multilobar pna, hypoxia REASON FOR THIS EXAMINATION: Re-assess pna ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Hypoxia in a patient with multifocal pneumonia.",0
"COMPARISON: Two chest radiographs from , dating 12:52 and 5:47 p.m. A rapid progression in the right lung consolidation is demonstrated with currently widespread right lower lobe and anterior segment of right upper lobe consolidations demonstrated.",0
"The left lower lobe consolidation has also progressed in the interim, although less compared to the right lung.",0
"There is no appreciable pleural effusion, although small amount of right pleural fluid cannot be excluded.",0
The upper lungs are unremarkable.,0
IMPRESSION: Rapidly progressing right lung and slower but also progressing left lower lobe consolidations.,0
Differential diagnosis in an appropriate clinical setting would include rapidly progressing pneumonia.,0
"Aspiration or acute drug toxicity associated with recreational drug use should be considered, although less likely.",0
Findings discussed with Dr at the time of dictation over a phone bbu dr DL DR.,0
2:48 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: PLEASE DO AT 1400; eval for pneumo s/p chest tube removal Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 48F with h/o recently diagnosed metastatic thyroid carcinoma to the lung and T spine.,0
"Now w/ bilateral PE and droppping hematocrit REASON FOR THIS EXAMINATION: eval for pneumo s/p chest tube removal ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of chest tube removal in patient with metastatic thyroid cancer and pulmonary embolism.",1
Status post removal of left-sided chest tube.,0
Status post median sternotomy and lower cervical spine fusion.,0
Right jugular CV line is in distal SVC.,0
"There is slight elevation of the left hemidiaphragm with associated atelectasis at the left lung base, are unchanged.",0
IVC filter overlies region of LV tube.,0
11:07 AM CHEST (PORTABLE AP) Clip # Reason: NGT placed.,0
"Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 47 year old woman with diabetes, ESRD, left small toe infection, who p/w sepsis, now with increased CVP and BP REASON FOR THIS EXAMINATION: NGT placed.",1
______________________________________________________________________________ FINAL REPORT PORTABLE SEMI-UPRIGHT CHEST OF INDICATION: Nasogastric tube placement.,0
"A nasogastric tube has been placed, terminating below the diaphragm at least in the distal portion of the stomach.",0
"The tip of the tube is not included on the radiograph, however.",0
A left internal jugular vascular catheter continues to terminate deep within the right atrium.,0
A right internal jugular catheter has been removed with no evidence of pneumothorax.,0
There has been slight improvement in degree of pulmonary edema.,0
Residual asymmetrical opacity in the right lung is likely due to asymmetrical edema although superimposed infectious process is not excluded.,0
Moderate-to-large right pleural effusion is without change.,1
Nasogastric tube courses below the diaphragm.,0
Low position of left internal jugular catheter without change.,0
Height: (in) 69 Weight (lb): 240 BSA (m2): 2.23 m2 BP (mm Hg): 128/80 HR (bpm): 130 Status: Inpatient Date/Time: at 17:39 Test: Portable TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
AORTIC VALVE: Normal aortic valve leaflets.,0
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. PERICARDIUM: Moderate to large pericardial effusion.,0
There is a moderate to large sized pericardial effusion primarily anterior to the right atrium and right ventricle (2.1cm) and inferolateral left ventricle (1.2cm) with relatively less (<1cm) around the left ventricular apex and inferior wall.,0
IMPRESSION: Moderate to large partially loculated pericardial effusion with evidence of hemodynamic compromise/tamponade physiology.,0
"2:03 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: r/o stones and obstruciton from pancreatic mass Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with likley metastatic pancreatic cancer presents for evaluation and treatment, with HCT drop and fatigue, elevated LDH and T bili.",0
REASON FOR THIS EXAMINATION: r/o stones and obstruciton from pancreatic mass.,0
Please perform dopplers to look portal and splenic vein thrombosis.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic pancreatic cancer with elevated bilirubin.,0
Rule out stones or obstruction.,0
Also evaluate for portal or splenic vein thrombosis.,0
ABDOMINAL ULTRASOUND: There is a moderate amount of ascites within the abdomen.,0
The liver is heterogeneous with multiple hypoechoic lesions in both the right and left lobe.,0
"The largest lesion is in the left lobe measures 2.1 x 1.9 x 1.9 cm, without significant vascularity.",0
The gallbladder has no gallstones.,0
Mild gallbladder wall edema is likely due to hypoalbuminemia.,0
The portal and splenic veins are patent with antegrade flow.,0
The pancreas shows no focal masses.,0
No pancreatic ductal or intrahepatic biliary dilatation is noted.,0
"The right kidney measures 11 cm and left kidney measures 11.8 cm with no hydronephrosis, masses, or stones.",0
The spleen is enlarged measuring 15 cm.,0
Adjacent to the spleen is a hypoechoic soft tissue structure measuring 3.2 x 2.7 cm.,0
"This mass has a heterogeneous echotexture that is different than the spleen, and may represent a lymph node, metastatic lesion, or mass in the tail of the pancreas.",1
Multiple hypoechoic liver masses are consistent with metastatic disease.,0
"No intrahepatic biliary dilatation, pancreatic ductal dilatation, or portal/ splenic vein thrombosis.",0
Soft tissue lesion adjacent to the spleen is likely a metastases or pancreatic tail lesion.,0
Height: (in) 60 Weight (lb): 190 BSA (m2): 1.83 m2 BP (mm Hg): 148/76 HR (bpm): 87 Status: Inpatient Date/Time: at 10:04 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Optison Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.,0
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<=2.1cm) with <50% decrease with sniff (estimated RA pressure (5-10 mmHg).,0
"8:41 PM CHEST (PORTABLE AP) Clip # Reason: EVAL L SUBCLAV PLACEMENT Admitting Diagnosis: CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with aortic stenosis and chf, with hypercarbic respiratory failure and possible aspiration pna REASON FOR THIS EXAMINATION: EVAL L SUBCLAV PLACEMENT ______________________________________________________________________________ FINAL REPORT INDICATION: 71 y/o woman with aortic stenosis and congestive heart failure with hypercarbic respiratory failure and possible aspiration pneumonia.",1
COMPARISON: Supine AP portable chest x ray of .,0
TECHNIQUE: Supine AP portable chest x ray.,0
FINDINGS: There has been interval retraction of the left subclavian venous catheter.,0
Now the tip is located near the junction of the left axillary and brachiocephalic veins.,0
The ET and NG tubes remain in satisfactory positions.,0
There has been no significant interval change in the evidence of congestive heart failure.,1
IMPRESSION: 1) Interval retraction of the left subclavian venous catheter with the tip lying at the junction of the left axillary and brachiocephalic veins.,0
2) Stable evidence of congestive heart failure.,1
"7:59 AM CHEST (PORTABLE AP) Clip # Reason: eval for pulm edema Admitting Diagnosis: MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with VT and pea arrest, now s/p MI REASON FOR THIS EXAMINATION: eval for pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 55 y/o man status post MI and VT arrest.",1
PORTABLE SUPINE FRONTAL RADIOGRAPH: There are no prior studies for comparison.,0
FINDINGS: The patient is intubated with the ET tube in satisfactory position.,0
A femoral approach swan ganz catheter terminates in the left pulmonary artery.,0
An NG tube is seen coursing below the diaphragm.,0
An intra aortic balloon pump is in place with its tip terminating 1 cm from the roof of the aortic knob.,0
There is marked perhilar haziness as well as increased pulmonary vascular markings consistent with CHF.,0
The extreme bilateral costophrenic angles are excluded from this study.,0
There is patchy atelectasis at bilateral bases.,0
IMPRESSION: 1) Congestive heart failure.,0
Intra aortic balloon pump tip 1 cm from the roof of the aortic knob.,0
Findings were discussed with the house staff caring for the patient.,0
OR THERAPEUTIC; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # GUIDANCE FOR /ABD/PARA CENTESIS US Reason: please perform diagnostic paracentesis with culture Admitting Diagnosis: BOWEL RESECTION;CDIFFCOLITIS;LIVE TRANSPLANT LIST ********************************* CPT Codes ******************************** * PARACENTESIS DIAG.,1
"OR THERAPEUTIC -79 UNRELATED PROCEDURE/SERVICE DURI * * GUIDANCE FOR /ABD/PARA CENTESIS * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 48 year old woman with PSC, persistent fevers, and SBP with unknown organism.",1
"REASON FOR THIS EXAMINATION: please perform diagnostic paracentesis with culture ______________________________________________________________________________ FINAL REPORT ULTRASOUND-GUIDED PARACENTESIS DATED INDICATION: 48-year-old woman with PSC, persistent fevers and SBP with unknown organism.",0
Please perform diagnostic paracentesis for culture.,0
COMPARISON: Comparison is made to previous ultrasounds dated .,0
PHYSICIANS: Dr. and Dr. performed the procedure.,0
"Dr. , the attending radiologist, was present throughout the procedure.",0
"PROCEDURE: Following a detailed discussion of the risks, benefits and alternatives to the procedure with the patient's daughter, informed consent was obtained by phone.",1
A limited preprocedure ultrasound demonstrated a large pocket of fluid within the right lower quadrant.,0
A preprocedure timeout was performed using three unique patient identifiers upper protocol.,1
The skin overlying the right lower quadrant was prepped and draped in usual sterile fashion.,0
6 mL of 1% lidocaine was instilled into the subcutaneous tissues into the peritoneum for local anesthesia.,0
A 22-gauge needle was inserted into the abdominal cavity and 20 mL of dark straw-colored fluid was aspirated.,0
"Samples were sent for biochemistry, cell count and microbiology as requested.",0
The patient was transferred back to the floor in satisfactory condition.,1
IMPRESSION: Technically successful ultrasound-guided diagnostic paracentesis.,0
2:02 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for PNA ______________________________________________________________________________ MEDICAL CONDITION: 29 year old man with h/o PNA and recent ARDS REASON FOR THIS EXAMINATION: Please evaluate for PNA ______________________________________________________________________________ FINAL REPORT INDICATION: 29-year-old with history of pneumonia.,0
SEMI-UPRIGHT CHEST RADIOGRAPH: Cardiomediastinal silhouette is stable.,0
Faint bilateral lower lobe opacities have resolved.,0
Height: (in) 60 BP (mm Hg): 69/47 HR (bpm): 140 Status: Inpatient Date/Time: at 15:22 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is markedly dilated.,0
AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not stenotic.,0
MITRAL VALVE: A single tilting disk mitral valve prosthesis is present.,0
TRICUSPID VALVE: Severe [4+] tricuspid regurgitation is seen.,0
There is severe global left ventricular hypokinesis to akinesis.,0
A single tilting disk mitral valve prosthesis is present.,0
"Acute valve thrombosis is present with no leaflet motion, multiple, large (3x6 cm), atrial thrombi, pannus formation, and thrombi on the ventricular side of the mitral valve.",1
"In comparison to the previous study of , the acute valve thrombosis is new.",0
4:12 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
interval evolution of pulm process Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with altered mental status with a ?,0
worsening pna REASON FOR THIS EXAMINATION: ?,0
interval evolution of pulm process ______________________________________________________________________________ FINAL REPORT INDICATIONS: Altered mental status.,0
PORTABLE AP CHEST AT 5:29: Comparison is made to .,0
Pacemaker leads and Dobhoff tube are unchanged.,0
Assessment of the left lower lobe is limited by the pacemaker control box.,0
"There is slight worsening opacity in the right lower lobe, which could be due to aspiration, pneumonia, or asymmetrical pulmonary edema.",0
"9:50 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: interval change Admitting Diagnosis: HYPOXIA ______________________________________________________________________________ MEDICAL CONDITION: 52 year old man with obesity, hypoxia and tachypnea intubated after resp distress REASON FOR THIS EXAMINATION: central line placement ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
HISTORY: 52-year-old man with obesity and hypoxia.,0
Patient is status post intubation.,0
FINDINGS: Comparison is made to the prior study performed seven hours earlier.,0
The tip of the endotracheal tube is 5 cm above the carina.,0
There again appears to be slight overinflation of the cuff.,0
Nasogastric tube distal tip is not well visualized.,0
The study is limited due to the patient's large body habitus.,0
There is a right IJ central venous line with the distal tip in the mid SVC.,0
"There is again seen prominence of the pulmonary vascular markings, however, they have decreased suggesting improvement of the pulmonary edema.",0
"3:02 PM CT HEAD W/O CONTRAST Clip # Reason: MS CHANGES.INTUBATED.ASSESS FOR ICH ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with acute MS change, apnea.",0
REASON FOR THIS EXAMINATION: r/o ICH No contraindications for IV contrast ______________________________________________________________________________ WET READ: 4:51 PM negative ______________________________________________________________________________ FINAL REPORT CT HEAD W/O CONTRAST: HISTORY: Acute mental status change with apnea.,0
Contiguous axial images were performed through the brain.,0
No prior brain imaging studies are available for comparison.,0
FINDINGS: The study is normal.,0
"There is no evidence of hemorrhage, edema, masses, mass effect or infarction.",0
"Incidentally noted is a slightly low position of the cerebellar tonsils, a normal variant.",0
CONCLUSION: The cerebellar tonsils are slightly low.,0
Height: (in) 65 Weight (lb): 140 BSA (m2): 1.70 m2 BP (mm Hg): 178/50 HR (bpm): 66 Status: Inpatient Date/Time: at 10:07 Test: Portable TTE(Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is markedly dilated.,0
LV WALL MOTION: The following resting regional left ventricular wall motion abnormalities are seen: basal inferior - hypokinetic; mid inferior - hypokinetic; basal inferolateral - hypokinetic; mid inferolateral - hypokinetic; basal anterolateral - hypokinetic; inferior apex - hypokinetic; RIGHT VENTRICLE: The right ventricular wall thickness is normal.,0
Resting regional wall motion abnormalities include severe inferior and inferolateral hypokinesis along with basal lateral hypokinesis.,0
Moderate to severe (+) mitral regurgitation is seen.,0
"2:21 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with GIB, now intubated REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST, 2:29 A.M., HISTORY: 50-year-old man with GI bleed.",0
"IMPRESSION: AP chest compared to , 8:30 p.m.: Lung volumes have improved, though still quite low, and mild pulmonary edema has improved as well.",0
"Bibasilar atelectasis is moderately severe on the left, milder on the right.",0
Pleural effusion is not evident.,0
"ET tube and right jugular line are in standard placements respectively and the fundic balloon of the tube is inflated in the upper stomach, as before.",0
Height: (in) 71 Weight (lb): 240 BSA (m2): 2.28 m2 BP (mm Hg): 106/58 HR (bpm): 70 Status: Inpatient Date/Time: at 12:05 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
There is abnormal septal motion/position suggestive of possible effusive/constrictive pericarditis.,0
There is a small pericardial effusion particularly prominent apically and anteriorly (may be loculated).,0
There is significant organization of the effusion (solid appearing elements within it).,0
"Compared with the prior study (tape reviewed) of , the pericardial effusion is probably similar although views in the prior study are technically suboptimal for comparison.",0
"3:27 PM CT HEAD W/O CONTRAST Clip # Reason: SLURRED SPEECH, ?",0
SDH Admitting Diagnosis: ETOH WITHDRAWAL;FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: 62 year old woman with slurred speech and chronic EtOH use REASON FOR THIS EXAMINATION: evaluate for subdural hematoma No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: History of chronic alcohol use and slurred speech.,0
FINDINGS: The patient's head is cued within the CT scanner producing obliquity of the obtained axial slices.,0
There is periventricular white matter hypodensity consistent with chronic microvascular small vessel disease.,1
There is prominence of the ventricles and sulci consistent with atrophic change.,0
There are two rounded hypodense foci in the left basal ganglia consistent with chronic lacunar infarcts.,0
No evidence of acute intra- or extra-axial hemorrhage.,1
There is partial opacification of the sphenoid sinuses.,0
Prominence of ventricles and sulci consistent with atrophic change.,0
Chronic small vessel ischemic disease.,1
"7:24 AM TUNNEDLED DIALYSIS CATH PLACE Clip # Reason: can be on either side Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * TUNNELED W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN * * FLUOR GUID PLCT/REPLCT/REMOVE C1750 CATH,HEMO/PERTI DIALYSIS LONG * * C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with ESRD who has no access needs tunneled line placement for HD.",1
Blood Cx neg since REASON FOR THIS EXAMINATION: can be on either side ______________________________________________________________________________ FINAL REPORT INDICATION: Renal failure.,0
"Recently admitted for line sepsis, but cultures have been negative for 6 days.",0
The patient currently has a temporary right femoral dialysis catheter.,1
"and , the Attending Radiologist, present and supervising the entire procedure.",0
Written informed consent was obtained from the patient after the patient's questions were answered.,0
A preprocedure timeout checklist including patient identity and nature of the procedure was completed.,1
The patient's existing left subclavian triple lumen site was prepped and draped in the usual sterile fashion.,0
Initial scout image demonstrated the subclavian line tip to be within the SVC.,0
wire was advanced under fluoroscopic guidance into the SVC and then into the IVC.,0
Attention was then directed towards the creation of a tunnel.,0
15 cc of 1% lidocaine was instilled into the subcutaneous tissues of the left upper chest.,0
"Using blunt dissection, a tract was created.",0
"Following this, the subclavian access site was sequentially dilated, and a 14-French dual lumen dialysis catheter was advanced through the tract and into the subclavien vein through a peel-away sheath.",0
Final fluoroscopic image demonstrates the tip to be within the right atrium.,0
Both ports aspirated and flushed easily.,0
"The line was sutured in place, and dressed sterilely.",0
"Throughout the procedure, the patient was in extensive pain, most notably in his lower back region, despite being administered conscious sedation under continuous cardiac monitoring by the radiology nurse.",1
"At the end of the dialysis catheter placement, the patient could not tolerate lying on his back any longer, and thus was moved to a stretcher, where one of the radiology nurses placed a peripheral IV.",1
"If desired, the patient can return at a later date for PICC.",1
The patient could not tolerate positioning for PICC placement at the time of the dialysis line placement.,1
The right groin temporary dialysis catheter was removed and hemostasis obtained.,0
(Over) 7:24 AM TUNNEDLED DIALYSIS CATH PLACE Clip # Reason: can be on either side Admitting Diagnosis: SEPSIS ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION: 1) Successful conversion of left subclavian triple lumen to dialysis tunneled line.,1
2) Removal of temporary right femoral dialysis catheter.,0
"3) Due to patient discomfort lying supine on the fluoroscopy table, a PICC could not be placed.",0
"However, a peripheral access was established by the radiology nurse.",0
"If desired, the patient may return at a later date for PICC.",1
7:52 PM CHEST (PORTABLE AP) Clip # Reason: ?,0
ASPIRATION Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with fall REASON FOR THIS EXAMINATION: ?,0
ASPIRATION ______________________________________________________________________________ FINAL REPORT INDICATIONS: Fall.,0
"PORTABLE AP CHEST: Comparison is made to previous films from one day prior, shows persistent left basilar atelectasis.",0
"No definite infiltrates, effusions, vascular congestions or pneumothorax.",0
3:57 PM CHEST (PORTABLE AP) Clip # Reason: NG tube placement Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with new NG tube REASON FOR THIS EXAMINATION: NG tube placement ______________________________________________________________________________ FINAL REPORT INDICATION: 66-year-old woman with new NG tube placement.,0
FINDINGS: The lungs are well expanded.,0
Aeration of the lungs has dramatically improved since with near complete resolution of the bibasilar pulmonary opacities.,0
"No consolidation, effusion or pneumothorax.",0
A nasogastric tube is in the appropriate position in the stomach.,0
There are no abnormal cardiac and mediastinal contours.,0
IMPRESSION: NG tube in the stomach.,0
Resolution of prior bibasilar pulmonary opacities.,0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Gunshot wound to head Major Surgical or Invasive Procedure: none History of Present Illness: 72 yo woman with ho of depression with self-inflicted gunshot wound today.,1
Patient was found by son on floor this evening and EMS called immediately.,0
Patient was brought to with GCS of 6 and intubated for respiratory management.,0
"By ED report, patient had eyes open and was moving the right side of body, no vocalization, agitated prior to intubation.",0
Neurosurgery called for further surgical management.,0
Past Medical History: Depression Social History: non contributory Family History: non-contributory Physical Exam: PHYSICAL EXAM: O: T: 97.3 BP: 219 / 126 HR: 100 R 20 O2Sats 100% on AC Gen: Patient intubated and sedated with propofol.,0
HEENT: Pupils: 3mm and min.,0
Has bone fragments of Lungs: CTA bilaterally.,0
Neuro: Mental status: Intubated and sedated.,0
"III, IV, VI: Extraocular movements not tested with inubation and c-collar V, VII: Slight nasal grimace to nasal tickle bilat.",0
"VIII: deferred IX, X: deferred : deferred XII: deferred Motor: minimal flexion at right wrist with deep pain, no respoonse to deep pain in all other extrem Reflexes: B T Br Pa Ac Right 1 1 1 1 1 Left 1 1 1 1 1 Pertinent Results: 07:10PM PO2-81* PCO2-55* PH-7.22* TOTAL CO2-24 BASE XS--5 07:10PM LACTATE-3.9* 07:10PM HGB-10.1* calcHCT-30 06:58PM UREA N-23* CREAT-1.0 06:58PM estGFR-Using this 06:58PM AMYLASE-114* 06:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG 06:58PM WBC-14.3* RBC-2.92* HGB-9.7* HCT-29.5* MCV-101* MCH-33.2* MCHC-32.8 RDW-13.7 06:58PM PLT COUNT-290 06:58PM PT-13.0 PTT-26.0 INR(PT)-1.1 06:58PM FIBRINOGE-157 Brief Hospital Course: 71 yo woman with ho depression who comes to ED with gunshot wound with intraparenchymal damage to the right hemisphere.",0
Pt was intubated in the field and taken to where she was assessed as a STAT trauma.,0
"After evaluation and radiography, No surgical management was recommeded given patient's age, intraparenchymal damage and poor GCS score on admission.",0
"This recommendation was made in discussion with Dr. , Trauma attending and Dr. , Neurosurgery attending.",0
The patient was made CMO on and expired on .,0
Medications on Admission: unknown Discharge Medications: deceased Discharge Disposition: Expired Facility: No Facility - Deceased Discharge Diagnosis: deceased from gunshot wound to head Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased,0
"9:13 AM CT HEAD W/O CONTRAST Clip # Reason: assess bleed Admitting Diagnosis: R/O PULMONARY EMBOLUS ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with old subdural now worsening on anticoag for PE REASON FOR THIS EXAMINATION: assess bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 57-year-old man with subdural now worsening, on anticoagulation for PE.",1
FINDINGS: Today's examination is compared with the prior from .,0
There has been continued evolution of the subdural hematoma at the right frontal convexity.,0
The overall volume of the hematoma appears to have slightly increased when measured from the inner table.,0
"On today's examination, this measures 1.2 cm from the inner table whereas previously it had only measured 1 cm.",0
"However, there is no evidence of midline shift.",0
There is mild mass effect upon the underlying frontal lobe and upon the ipsilateral frontal of the lateral ventricle.,0
"As before, there is hypodensity within the right inferior frontal lobe consistent with contusion.",0
There is no evidence of a new hemorrhage.,0
IMPRESSION: Slight increase in the size of the right frontal convexity subdural hematoma.,0
Continued evolution of the contained blood products.,0
2:00 AM CHEST (PORTABLE AP) Clip # Reason: eval for mediastinal widening ______________________________________________________________________________ MEDICAL CONDITION: History: 64M with CP and ?STEMI on EKG REASON FOR THIS EXAMINATION: eval for mediastinal widening No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Chest pain.,0
FRONTAL CHEST RADIOGRAPH: The heart size is normal.,0
"There is no pneumothorax, focal consolidation, or pleural effusion.",0
PATIENT/TEST INFORMATION: Indication: Thrombus in RA???,0
Foucused f/u ss/p line pull Height: (in) 67 Weight (lb): 183 BSA (m2): 1.95 m2 BP (mm Hg): 165/67 HR (bpm): 57 Status: Inpatient Date/Time: at 12:26 Test: Portable TTE (Focused views) Doppler: Color Doppler only Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral - akinetic; mid anterolateral - akinetic; lateral apex - akinetic; TRICUSPID VALVE: Moderate vegetation on tricuspid valve.,0
A small PFO is present.,0
A mass is seen in the right atrium.,0
This mass is round at the end(1.6 x 1.0 cm) and is attached to the wall of the right atrium by way of a thick stump.,0
A filamentous mass is attached to the round mass and extends 2.7 cm.,0
3.There is mild symmetric left ventricular hypertrophy.,0
"While the vies are limited, it appears that the overall left ventricular systolic function is moderately depressed (LVEF 35-40%).",0
Resting regional wall motion abnormalities include inferolateral and anterolateral akinesis.,0
There is moderately severe (3+) tricuspid regurgitation.,0
"Compared with the findings of the prior study (images reviewed) of , there is no change with regards to LV function or size of mass.",0
Suspect that this mass is a very prominent Eustachian valve with an attached Chiari network (normal variant).,0
This mass could also be a right atrial thrombus but tht possibility is much less likely.,0
"10:14 AM MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # MR RECONSTRUCTION IMAGING Reason: to rule out intracranial mass Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with mental status changes, negative CT head and repeated bloody spinal tap REASON FOR THIS EXAMINATION: to rule out intracranial mass ______________________________________________________________________________ FINAL REPORT (REVISED) INDICATION: 66 YEAR OLD MAN WITH MENTAL STATUS CHANGES.",0
COMPARISON: Head CT from with CTA.,0
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the brain pre and post administration of gadolinium.,0
FINDINGS: There are scattered small T2 hyperintensities in the white matter in the corona radiata and in the periventricular white matter compatible with chronic microvascular infarction.,0
"In several left suprasylvian fissures on FLAIR imaging, there are two adjacent regions of high signal following the sulci or along the cortical surface which may represent flow related enhancement in vessels within the sulcus or may represent a small amount of subacute subarachnoid hemorrhage.",0
"There is no susceptibility abnormality in that region to support the latter, but subacute hemorrhage may not have susceptibility changes.",0
"The ventricles, cisterns, and sulci are within normal limits.",0
There is prominent soft tissue in the ethmoid sinuses as well as in the left maxillary sinus.,0
"Abnormal FLAIR signal in left suprasylvian fissures, which may be flow related signal in vessels.",0
"Alternatively, high FLAIR signal may represent subacute subarachnoid hemorrhage in this location.",0
"Frontal, maxillary, and ethmoid sinus disease, likely inflammatory in origin.",0
"MRA OF CIRCLE OF TECHNNIQUE: 3D time of flight MR angiographic images of the circle of and its tributaries, with multiplanar reconstructions.",0
COMPARISON: CT angiogram from earlier the same day.,0
FINDINGS: No vascular malformations are identified.,0
There are no areas of aneurysmal dilatation.,0
There is apparent stenosis near the bifurcation of the right middle cerebral artery.,0
"However, this does not correlate with the (Over) 10:14 AM MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # MR RECONSTRUCTION IMAGING Reason: to rule out intracranial mass Contrast: MAGNEVIST Amt: 10 ______________________________________________________________________________ FINAL REPORT (REVISED) (Cont) normal findings in that region on the recent CT angiogram.",0
This is likely artifact related to the course of this vessel in proximity to the bone.,0
The right A1 segment of the anterior cerebral artery is dominant.,0
IMPRESSION: MRA without evidence of aneurysm.,0
7:53 PM CHEST (PA & LAT) Clip # Reason: preop for cabg ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with REASON FOR THIS EXAMINATION: preop for cabg ______________________________________________________________________________ FINAL REPORT INDICATION: Preop for CABG surgery.,0
FINDINGS: Standard PA and left lateral views.,0
"The heart shows moderate enlargement, probably polychamber involvement.",0
The pulmonary vessels show minimal if any upper zone redistribution.,0
No significant pulmonary infiltrates or pleural effusions are identified.,0
There is a moderate thoracic kyphosis associated with slight wedging of a few mid thoracic vertebral bodies.,0
IMPRESSION: Polychamber cardiomegaly of moderate severity.,0
Slight LV failure cannot be excluded.,0
Fairly marked thoracic kyphosis noted.,0
"7:13 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval empyema, effusions, PTX, PNA Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 35 year old man with Right empyema s/p decortication, bilater Chest tubes w/ desaturation REASON FOR THIS EXAMINATION: eval empyema, effusions, PTX, PNA ______________________________________________________________________________ WET READ: 7:30 PM multiple lines/tubes unchanged.",1
- ______________________________________________________________________________ FINAL REPORT HISTORY: Empyema status post decortication with bilateral chest tubes.,0
"FINDINGS: Comparison with the earlier study of this date, there are again two chest tubes on the right and one on the left.",0
No change in the appearance of the heart and lungs.,0
"The endotracheal tube is now somewhat closer to the carina, only about 3 cm away.",0
The Dobbhoff tube extends well into the stomach and the left subclavian catheter extends to the mid portion of the SVC.,0
11:29 AM CTA HEAD W&W/O C & RECONS Clip # Reason: eval vessels Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 75 year old woman with h/o temporal arteritis presents w/ left ant temporal and R parietoocciptital hemorrhage REASON FOR THIS EXAMINATION: eval vessels No contraindications for IV contrast ______________________________________________________________________________ WET READ: MNIa SUN 12:31 PM Oveall unchanged left frontal and right parietal hemorrhages and surrounding edema and mass effect.,0
"However, subarachnoid component has increased since and now seen in bilateral frontal lobes.",0
Official read awaits for 3D reformats.,0
D/w Dr. at 12:30PM .,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Bilateral intraparenchymal hemorrhages, history of temporal arteritis.",0
Query vascular source of hemorrhages.,0
"TECHNIQUE: Noncontrast head CT followed by uneventful administration of 70 mL of Optiray IV contrast, and CT angiogram technique images through the brain.",0
Multiplanar and volume rendering images also obtained.,0
"Comparison with MRI, , and CT head, .",0
"FINDINGS: Intraparenchymal hemorrhages, one in the left frontal lobe, the other in the right parietooccipital region, are unchanged in size; the left frontal lobe lesion exerts mild mass effect on the left frontal ; the right hemorrhage exerts mass effect on the right occipital .",0
No intraventricular extension of hemorrhage is seen.,0
There is no significant change in the size or appearance of the hemorrhages; no new hemorrhages are seen.,0
Angiographic images are notable for slight prominence of the anterior cerebral artery at the junction of the A1 and A2 segments on the right.,0
"This may be due to superimposition of the horizontal segment of the artery, a slight fusiform dilatation, or a fenestration of the artery at this level.",0
"In any case, this focal abnormality is not near the intraparenchymal hemorrhages, and is highly unlikely to be related to the current clinical scenario.",0
"Otherwise, the circle of and its major branches are patent.",0
No filling defects are seen within the dural venous sinuses.,0
"IMPRESSION: Tiny focal irregularity at right A1-A2 junction of the anterior cerebral artery, likely representing artifact versus fenestration versus tiny fusiform dilatation, and unrelated to current intraparenchymal hemorrhages.",0
No vascular source of hemorrhage is identified.,0
(Over) 11:29 AM CTA HEAD W&W/O C & RECONS Clip # Reason: eval vessels Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ FINAL REPORT (Cont),0
"3:11 AM CHEST (PORTABLE AP) Clip # Reason: pls evaluate chest tube placement on L and pulm edema vs. in Admitting Diagnosis: PLEURAL EFFUSION ______________________________________________________________________________ MEDICAL CONDITION: 60 year old woman s/p L VATS with chest tube in place, ARF now oliguric REASON FOR THIS EXAMINATION: pls evaluate chest tube placement on L and pulm edema vs. infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Left chest tube placement and pulmonary edema vs. infiltrate.",1
SUPINE PORTABLE CHEST RADIOGRAPH Comparison is made to prior films dated and .,0
"Other than slightly increased right basilar atelectasis, the appearance of this radiograph has not significantly changed given differences in technique.",0
Evaluation for the left chest wall subcutaneous emphysema is limited due to the field of view on current examination.,0
"5:06 PM CT HEAD W/O CONTRAST Clip # Reason: rule out bleed, cerebral edema Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ FINAL ADDENDUM ADDENDUM: Additional information has been obtained from CareWeb Clinical Lookup since the approval of the original report.",0
Reason for exam should also state lethargy.,0
"5:06 PM CT HEAD W/O CONTRAST Clip # Reason: rule out bleed, cerebral edema Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman with respiratory distress, tylenol toxicity, with coagulopathy REASON FOR THIS EXAMINATION: rule out bleed, cerebral edema No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT STUDY: CT of the head without contrast.",1
"INDICATION: 51-year-old female with respiratory distress, Tylenol toxicity, coagulopathy.",1
"Assess for intracranial hemorrhage, cerebral edema.",0
"FINDINGS: There is no evidence of infarction, hemorrhage, shift of normally midline structures, or hydrocephalus.",0
The density values of the brain parenchyma are maintained.,0
"The soft tissues, osseous structures, and the visualized portions of the paranasal sinuses and mastoid air cells are within normal limits.",0
1:15 PM CHEST (PORTABLE AP) Clip # Reason: s/p CABG w/hypoxia and air leak from chest tube-R/O PTX ______________________________________________________________________________ MEDICAL CONDITION: 83 year old man with s/p CABG REASON FOR THIS EXAMINATION: s/p CABG w/hypoxia and air leak from chest tube-R/O PTX ______________________________________________________________________________ FINAL REPORT CLINICAL INDICATION: S/P CABG with decreased 02 sats and air leak from chest tube.,0
A single frontal view of the chest dated is compared with prior study dated .,0
"The patient is status post CABG in the interval, with sternal wires, mediastinal clips, mediastinal drains, and skin staples noted.",0
There is also subcutaneous air.,0
There is a chest tube in the left hemithorax with its tip pointing toward the apex.,0
The patient is intubated with the tip of the endotracheal tube in satisfactory position.,0
There is an orogastric tube with its side-port located well above the diaphragm and its tip located above the diaphragm as well.,0
There is a right internal jugular swan-ganz catheter with its tip in the right pulmonary artery.,0
"Allowing for post surgical change, the mediastinal and hilar contours appear stable.",0
"There is thin lucency seen on both sides of the heart, however no definite pericardial membrane is visualized.",0
There is no discernible effusions.,0
2) Apparent hyperlucency adjacent to heart borders likely artifactual.,0
"Followup radiograph suggested to exclude pneumopericardium, which is considered unlikely.",0
"7:39 AM CHEST (PORTABLE AP) Clip # Reason: assess swan Admitting Diagnosis: ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with CHF, liver and new ARF.",0
"sp swan REASON FOR THIS EXAMINATION: assess swan ______________________________________________________________________________ FINAL REPORT INDICATION: A 62-year-old man with CHF, liver failure and renal failure.",1
AP upright single view of the chest is compared to a similar view from the same six hours earlier.,0
"FINDINGS: ET tube, right IJ Swan-Ganz catheter, pacemaker and its leads, Dobhoff tube are unchanged in position.",0
There is slight worsening of the bilateral basilar atelectasis or consolidations.,0
"The cardiac, mediastinal and hilar contours are unchanged.",0
Slight worsening of the bibasilar atelectasis or consolidations.,0
"7:20 AM CHEST (PORTABLE AP) Clip # Reason: assess progression Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: year old woman with SOB, h/o CHF REASON FOR THIS EXAMINATION: assess progression ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST 7:30 a.m.: INDICATION: Shortness of breath.",1
Comparison to the patient's prior chest x-ray at 6:00 a.m. on shows no overall change in appearance of the chest given positional changes in the film this morning and the prior study.,0
IMPRESSION: Persistent failure with more pleural fluid in the left than in the right chest.,0
"Clip # Reason: GROIN, PAIN, EVAL FOR HYDROCELE, HERNIA Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with pancolitis and neutropenia REASON FOR THIS EXAMINATION: eval for hydrocele, hernia ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old man with pancolitis and neutropenia.",1
Evaluate for hydrocele or hernia.,0
COMPARISON: CT of the abdomen and pelvis of .,0
FINDINGS: The right testis measures 3.5 x 2.1 x 1.7 cm and is normal.,0
The left testis measures 3.3 x 2 x 1.5 cm and is also normal.,0
There is a small left epididymal cyst measuring 3 mm.,0
No evidence of hydrocele or varicocele is noted.,0
There is mild thickening of the scrotal skin.,0
"10:23 PM PORTABLE ABDOMEN Clip # Reason: 11 pm Dobhoff tube placement check, pushed 15 cms aft Admitting Diagnosis: GALLBLADDER MASS ______________________________________________________________________________ MEDICAL CONDITION: 11 pm 86M w/ perf gallbladder ca s/p subtotal ccy, intraop path showing invasive gb ca REASON FOR THIS EXAMINATION: 11 pm Dobhoff tube placement check, pushed 15 cms after the last film showing in the stomach.",0
"______________________________________________________________________________ WET READ: IPf FRI 2:33 AM Dobhoff curling in the stomach, with tip in the stomach.",0
"______________________________________________________________________________ FINAL REPORT PORTABLE ABDOMEN, SINGLE VIEW COMPARISON: .",0
HISTORY: Post-pyloric NG tube placement.,0
FINDINGS: A Dobbhoff tube is identified coiled in the stomach.,0
Overlying skin staples are seen in the right upper quadrant.,0
A drain is also identified in the right upper quadrant.,0
IMPRESSION: Coiled NG tube within the stomach.,0
"3:07 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: r/o heme ****PLEASE DO STUDY AT 3PM TODAY****** Admitting Diagnosis: STROKE,TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with s/p d/c REASON FOR THIS EXAMINATION: r/o heme ****PLEASE DO STUDY AT 3PM TODAY****** No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old woman with left vertebral artery dissection and left PICA territory infarction, now status post removal of ventricular catheter.",1
COMPARISON: Comparison is made to a CT of the head from the same day at 6:11 a.m.,0
FINDINGS: There has been interval removal of a right frontal intraventricular catheter.,0
Along the catheter tract is an area of linear hyperdensity extending from the inner table to the frontal of the lateral ventricle consistent with hemorrhage.,0
There is surrounding hypodensity consistent with midl edema.,0
Ventricles are normal in size and symmetric.,0
The basal cisterns are well visualized.,0
The previously seen hypodensity in the left cerebellum has become increasingly isodense to brain parenchyma and is faintly discernable on this study.,0
No new areas of parenchymal abnormality are identified.,0
The remaining -white matter differentiation is well preserved.,0
The osseous structures demonstrate a defect in the area of the recent ventricular catheter.,0
There is stable near total opacification of the left maxillary sinus.,0
Intraparenchymal hemorrhage along the back of the previous ventriculostomy catheter with mild surrounding edema.,0
Subacute left PICA territory infarction.,0
Near-total opacification of the left maxillary sinus.,0
Findings were paged to Dr. at 4pm on .,0
"2:01 PM CHEST (PORTABLE AP) Clip # Reason: Please evaluate degree of edema and correlate infiltrate wit Admitting Diagnosis: ENDOCARDITIS\TRANSESOPHAGEAL ECHOCARDIOGRAM ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with CAD, likely endocarditis and now pneumonia, increasing respiratory distress.",1
REASON FOR THIS EXAMINATION: Please evaluate degree of edema and correlate infiltrate with CT chest.,0
"______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: CAD, likely endocarditis, increasing respiratory distress.",0
"As compared to the previous radiograph, there is an increase in interstitial markings at the lung bases, notably at the periphery.",0
Some of these markings assume the morphology of Kerley B lines.,0
"In addition, there is an increasing diameter of the pulmonary vasculature.",0
In combination with minimal thickening of the peribronchovascular interstitium the findings are indicative of moderate interstitial lung edema.,0
The size of the cardiac silhouette is unchanged and at the upper range of normal.,0
No evidence of focal parenchymal opacities suggesting pneumonia.,0
"4:04 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: patient with HCT drop, ongoing abdomen and back pain Admitting Diagnosis: GASTROINTESTINAL BLEED Field of view: 40 ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man with CAD, s/p cabg x 5, s/p electrocaudery of duodenal ulcer REASON FOR THIS EXAMINATION: patient with HCT drop, ongoing abdomen and back pain No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: 81 year old man with CAD, status post CABG x 5, status post electrocautery of duodenal ulcer with hematocrit drop and ongoing abdominal and neck pain.",1
CT OF THE ABDOMEN AND PELVIS WITHOUT IV CONTRAST TECHNIQUE: Helical scanning was performed from the diaphragm through the symphysis without intravenous or oral contrast.,0
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is minimal atelectasis at the right lung base.,0
A pacemaker is visualized and multiple surgical clips from cardiac bypass surgery.,1
No liver lesions are noted.,0
"The spleen, pancreas, both adrenal glands and both kidneys are unremarkable.",0
No retroperitoneal lymphadenopathy is noted.,0
Small and large bowel loops appear unremarkable.,0
CT OF THE PELVIS WITHOUT IV CONTRAST: Normal appearance of the small and large bowel.,0
The prostate gland is somewhat enlarged and there is a sub-central hypodense area consistent with a TURP defect.,0
There is no lymphadenopathy or free fluid in the pelvis.,0
Small and large bowel appear unremarkable.,0
Calcified injection granulomas are seen in the subcutaneous soft tissues of the buttock.,0
"On bone windows, there are extensive degenerative changes.",0
Several bone islands are noted.,0
No destructive osteolytic or osteosclerotic lesions are noted.,0
IMPRESSION: 1) No evidence of retroperitoneal hematoma.,0
2) Incidental findings as described above.,0
"11:33 PM CHEST (PORTABLE AP) Clip # Reason: eval for PTX s/p attempt at R SCL (unsuccessful) ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman w h/o CVA, w asp PNA, spiking fevers, increased sputum production REASON FOR THIS EXAMINATION: eval for PTX s/p attempt at R SCL (unsuccessful) ______________________________________________________________________________ FINAL REPORT INDICATION: 31-year-old with history of CVA, presenting with spiking fevers status post attempt at right cental venous catheter.",1
COMPARISON: Prior study from earlier the same date at 21:58 hours.,0
AP SUPINE CHEST: The tracheostomy tube remains in a standard position.,0
"Otherwise, there is no change from the study performed two hours prior.",0
"8:47 AM CHEST (PORTABLE AP) Clip # Reason: eval change air space disease ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with severe CHF from ischemic cardiomyopathy, intubated for hypoxemia from pulm edema.",1
pressor dependent REASON FOR THIS EXAMINATION: eval change air space disease ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxemia and pulmonary edema.,0
"PORTABLE AP CHEST RADIOGRAPH: Comparison is made to studies from , 20 and 21.",0
An ETT is seen 7 cm above the carina.,0
An NG tube courses beneath the diaphragms and off the bottom of the film.,0
A right IJ central venous catheter terminates in the upper SVC.,0
There is continued blurring of the pulmonary vasculature.,0
Ill defined patchy pulmonary infiltrates are improved from the previous studies.,0
There are no new areas of consolidation.,0
IMPRESSION: 1) Findings consistent with left heart failure and pulmonary edema.,1
Slight interval improvement from .,0
3:27 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?,0
"splenic ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with left sided abd pain, wbc count and dizzyness REASON FOR THIS EXAMINATION: ?",0
splenic No contraindications for IV contrast ______________________________________________________________________________ WET READ: JKPe TUE 4:45 PM moderate sized new left sided RP bleed with new mild left sided hydronephrosis.,0
"______________________________________________________________________________ FINAL REPORT HISTORY: Left-sided abdominal pain, hematuria, leukocytosis, and dizziness with markedly elevated INR (approximately 22).",0
Comparison is made to and CT examinations.,0
Intravenous contrast was withheld due to rising creatinine over the last two days.,0
CT OF THE ABDOMEN AND PELVIS WITH ORAL CONTRAST ONLY: Limited evaluation of lung bases displays no pleural or pericardial effusion and a stable peripheral calcified granuloma in the right lower lobe.,0
"Non-contrast evaluation of the liver, spleen, pancreas, stomach, small bowel, and adrenal glands is unremarkable as is the left kidney.",0
Mild peripheral calcifications are unchanged involving the gallbladder wall.,0
"There has been interval development of a moderate-sized retroperitoneal hematoma within the perinephric space and posterior pararenal space, tracking inferiorly along the psoas, iliopsoas, and retroperitoneal pelvic cavity.",0
"Additionally, there has been interval development of mild-to- moderate left- sided hydronephrosis with regions of hyperdensity noted within and surrounding the proximal left ureter which is dilated (3:41).",0
The mid and distal ureter are normal in caliber.,0
No significant right- sided hydronephrosis is identified.,0
Scattered mesenteric and retroperitoneal lymphadenopathy is not significantly changed.,0
Anteromedial displacement of the descending colon related to the retroperitoneal hemorrhage.,0
"Pelvic loops of bowel, bladder, and prostate are unremarkable.",0
"Interval development of moderate-sized retroperitoneal hematoma, likely due to the patient's coagulopathy.",0
(Over) 3:27 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?,0
splenic ______________________________________________________________________________ FINAL REPORT (Cont) 2.,0
"Interval development of mild-to-moderate left-sided hydronephrosis, which may be due to hemorrhage within the proximal ureter, or related to inflammation/stranding within the retroperitoneum from underlying hemorrhage.",0
"An underlying proximal ureteral stricture cannot be completely excluded, as no IV contrast was administered.",0
A followup CT or MRI examination is recommended after resolution of the hematoma to exclude an underlying lesion.,0
"Unchanged mesenteric and retroperitoneal lymphadenopathy dating back to , of unclear etiology.",0
Stable mild calcification involving the gallbladder wall.,0
Preliminary findings were entered into the ED dashboard shortly after exam acquisition and flagged as urgent.,0
7:56 AM CHEST (PORTABLE AP) Clip # Reason: assess for interval change.,0
"Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with CHF, intubation and fevers REASON FOR THIS EXAMINATION: assess for interval change.",1
______________________________________________________________________________ PFI REPORT No significant interval change.,0
"8:44 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: DEHISENCE OF WOUND ______________________________________________________________________________ MEDICAL CONDITION: 34 year old woman with resp failure, req.",0
"reintubation, high A-a gradient REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT AP CHEST 8:55 A.M. ON .",0
HISTORY: Respiratory failure following re-intubation.,1
IMPRESSION: AP chest compared to and 31: Mild-to-moderate pulmonary edema unchanged since .,0
-basilar opacification likely a combination of dependent edema and atelectasis.,0
"Tip of endotracheal tube, with the chin down is at the thoracic inlet, approximately 5.5 cm from the carina, 3 cm above optimal placement.",0
"Dr. was paged to discuss these findings, at the time of dictation.",0
5:16 AM CHEST (PORTABLE AP) Clip # Reason: interval changes Admitting Diagnosis: STROKE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 75M s/p intubation with recent repositioning of ET tube REASON FOR THIS EXAMINATION: interval changes ______________________________________________________________________________ FINAL REPORT HISTORY: Recent repositioning of the ET tube.,0
AP SUPINE PORTABLE CHEST: The endotracheal tube tip is 4 cm above the carina.,0
"An NG tube is noted, coursing below the level of the hemidiaphragm into the left upper quadrant, though its tip is not visualized.",0
A left subclavian central venous catheter is unchanged with its tip in the proximal SVC.,0
The appearance of the lungs is unchanged with diffuse bilateral alveolar and granular opacities without focality.,0
IMPRESSION: Satisfactory endotracheal tube position.,0
"Persistent bilateral alveolar opacities consistent with pulmonary edema, possibly from ARDS.",0
"5:22 PM CHEST (PORTABLE AP) Clip # Reason: placement of OG tube Admitting Diagnosis: UPPER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 51 year old woman w/known etoh cirrhosis found down, intubated.",0
"REASON FOR THIS EXAMINATION: placement of OG tube ______________________________________________________________________________ WET READ: GWp MON 6:55 PM OGT tip pojects over gastric antrum, ETT & R IJ cath unchanged, low lung volumes with bibasal atelectasis increased on right with possible consolidation ?",0
"pna GWlms ______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Cirrhosis, intubated orogastric tube.",0
Bibasilar atelectasis and/or consolidation and elevation of the right hemidiaphragm are again demonstrated.,0
"In addition, there is now hazy density at the lung bases probably representing pleural fluid and the retrocardiac area is less well penetrated.",0
Right internal jugular line is unchanged in position.,0
An orogastric tube has been replaced or advanced and now terminates in the region of the gastric fundus or duodenal bulb.,0
IMPRESSION: Bibasilar atelectasis or consolidation with increasing density at the left base.,0
Evidence for small bilateral pleural effusions.,0
Tube and line placement as described.,0
"9:58 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: pt has not had bowel movement since admit 11 days ago, KUB s Admitting Diagnosis: CHRONIC PULM DISEASE;HEMOPTYSIS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with respiratory distress, intubated REASON FOR THIS EXAMINATION: pt has not had bowel movement since admit 11 days ago, KUB shows stool backed up into the R colon, please evaluate for intraabdominal pathology - please administer oral contrast and then image 3 hours later (per GI) No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT ABDOMEN AND PELVIS.",0
HISTORY: 51-year-old male with respiratory distress and intubated with no bowel movement for 11 days.,1
"FINDINGS: The lung bases demonstrate severe emphysematous changes and large bullae formation with patchy areas of consolidation, worse when compared to prior exam.",1
The kidneys excrete contrast symmetrically.,0
Small amount of sludge within the gallbladder is identified.,0
Extensive stool is seen throughout the entire colon.,0
There is no evidence of bowel wall thickening or pneumatosis.,0
There is extensive anterior abdominal wall subcutaneous emphysema which is new when compared to prior exam.,0
"CT OF THE PELVIS: The rectum, sigmoid colon, and bladder are unremarkable.",0
Foley catheter is identified within the bladder.,0
Stool is seen throughout the colon.,0
Extensive degenerative changes throughout the spine are noted.,0
"Severe emphysematous changes and patchy consolidations in the lung bases, worse when compared to prior exam.",1
New extensive anterior abdominal wall subcutaneous emphysema.,0
"(Over) 9:58 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: pt has not had bowel movement since admit 11 days ago, KUB s Admitting Diagnosis: CHRONIC PULM DISEASE;HEMOPTYSIS ______________________________________________________________________________ FINAL REPORT (Cont) 3.",0
Extensive amount of stool throughout the colon.,0
No evidence of obstruction or intra-abdominal pathology.,0
11:35 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # Reason: ETT placement and UVC placement Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with 30 week gestation REASON FOR THIS EXAMINATION: ETT placement and UVC placement ______________________________________________________________________________ FINAL REPORT EXAMINATION: Portable babygram.,1
CLINICAL HISTORY: Premature baby who is here for evaluation of ET tube placement.,0
"FINDINGS: Mild ground-glass opacity is noted in both lungs without focal consolidation, pleural effusion, or pneumothorax.",0
There is an endotracheal tube with its tip located at the level of carina.,0
"Bowel gas pattern is normal without evidence of dilated small bowel loops, pneumatosis, portal venous gas, or abnormal calcification.",0
Umbilical vein catheter with its tip located within the inferior vena cava at the junction with right atrium is seen.,0
"Mild ground-glass opacities in both lungs, possibly due to surfactant deficiency syndrome in this patient with known history of prematurity.",0
Endotracheal tube with its tip located at the level of carina.,0
"Status: Inpatient Date/Time: at 11:00 Test: Portable TTE (Congenital, complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Conclusions: Pediatric study.",0
8:30 AM UNILAT LOWER EXT VEINS LEFT PORT Clip # Reason: ?,0
"DVT Admitting Diagnosis: ?OBSTRUCTION ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with Left leg swelling, concern for DVT REASON FOR THIS EXAMINATION: ?",0
DVT ______________________________________________________________________________ FINAL REPORT INDICATION: 51-year-old man with left leg swelling and concern for DVT.,0
"FINDINGS: Grayscale, color, and spectral Doppler evaluation was performed of the left lower extremity veins.",0
There is normal phasicity of the common femoral veins bilaterally.,0
"There is normal compression and augmentation of the left common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial, and peroneal veins.",0
IMPRESSION: No evidence of DVT in the left lower extremity.,0
"2:09 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval changes Admitting Diagnosis: GASTROINTESTINAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man w esophageal variceal bleed, intubated REASON FOR THIS EXAMINATION: eval for interval changes ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup.",0
"FINDINGS: As compared to the previous radiograph, there is a further decrease in lung volumes.",0
"As a consequence, the areas of basal atelectasis has increased bilaterally, left more than right.",0
"On the left, a small pleural effusion cannot be excluded.",0
"Unchanged moderate cardiomegaly, no newly appeared focal parenchymal opacities.",0
Unchanged position of the endotracheal tube and the right insertion sheath.,0
"The previously malpositioned left double-lumen catheter is now in correct position, with its tip pointing slightly downwards.",0
9:16 PM PELVIS (AP ONLY) PORT Clip # Reason: ?,0
placement of cordic in right groin Admitting Diagnosis: LOWER GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 67 year old man with MM - confirm placement of cordis line (concern misplaced) REASON FOR THIS EXAMINATION: ?,0
"placement of cordic in right groin ______________________________________________________________________________ WET READ: AJy MON 9:33 PM the right cordis catheter tip projects just inferior to the superior margin of the medial femoral head, implying that the catheter enters the femoral vessel at or below the level of the femoral head, and not higher as suspected clinically.",0
lytic lesion in right iliac bone c/w known myeloma.,0
"______________________________________________________________________________ FINAL REPORT STUDY: AP pelvis, .",0
HISTORY: 67-year-old man with multiple myeloma.,1
Confirm placement of central line.,0
There is a catheter projecting over the left hip with the distal tip projecting over the medial aspect of the femoral head.,0
There is again seen a lytic lesion involving the right iliac which is consistent with a known lesion consistent with multiple myeloma.,1
These findings have been discussed by Dr. with Dr. at the time of the examination.,0
"7:57 PM CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # Reason: please assess for aneurysmal bleed Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with fall two days ago, now with L SAH.",0
REASON FOR THIS EXAMINATION: please assess for aneurysmal bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 59 y/o man status post fall with left subarachnoid hemorrhage.,1
TECHNIQUE: Helically acquired contiguous axial images were obtained from the skull base through the cranial vertex following the administration of 145 cc of optiray contrast IV.,0
This is performed without the 3D images.,0
COMPARISON: Head CT from 4 hours earlier.,0
FINDINGS: Assessment of the brain again reveals the presence of an intraparenchymal hemorrhage in the left basal ganglia which extends into the left sylvian fissure and into the subarachnoid space.,1
The hemorrhage is unchanged in size in comparison with the previous study.,0
There is no shift of the normally midline structures and the ventricles are also stable.,0
Note is again made of chronic right frontal lobe infarctions with a large area of encephalomalacia anteriorly.,0
There are no abnormal vessels identified in the region of the hemorrhage.,0
"The anterior cerebral, anterior communicating, middle cerebral and posterior cerebral arteries all are normal in appearance.",0
The superior portions of the internal carotid arteries and basilar artery are also normal.,0
There are sylvian vessels extending towards the region of hemorrhage which are normal in appearance.,0
The superior cerebellar arteries are also normal.,0
IMPRESSION: 1) Stable appearance of left basal ganglion hemorrhage.,0
2) Normal CT angiogram with no evidence of abnormal vasculature in the region of the hemorrhage.,0
"9:08 AM CT HEAD W/O CONTRAST Clip # Reason: eval for head bleed Admitting Diagnosis: END STAGE LIVER DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 46 year old woman with coagulopathy, fall, and mental status changes REASON FOR THIS EXAMINATION: eval for head bleed No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 46-year-old with coagulopathy, fall and mental status changes, evaluate for head bleed.",1
"FINDINGS: There is a 10 x 9 mm hyperdense structure (Hounsfield units average 51) intimately associated with the falx on the left (series 2, image 21).",0
This most likely represents a meningioma although a hemorrhage in this clinical context cannot be excluded.,0
There are prominent bifrontal extra-axial fluid collections.,0
No other focus of hyperattenuation to suggest intracranial hemorrhage is seen.,1
"There is no loss of -white matter junction differentiation, mass, mass effect or edema.",0
There is no abnormality of the extracranial soft tissues.,0
No depressed skull fracture is seen.,0
Visualized paranasal sinuses are unremarkable.,0
"A 10 x 9 mm hyperdensity apparently attached to the falx on the left, although a meningioma is in consideration given clinical history this could represent subdural blood along falx.",0
Consider followup CT for further characterization.,0
Prominent extra-axial spaces bifrontally likely represent subdural hygromas versus atrophy.,0
COMMENT: These results were discussed with the floor team at 10:30 a.m.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: 38cm right picc.,0
Admitting Diagnosis: EPIDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: year old man with new picc REASON FOR THIS EXAMINATION: 38cm right picc.,0
"FINDINGS: As compared to the previous radiograph, a right-sided PICC line has been placed.",0
The tip of the line projects above the mid SVC.,0
"Normal course, no evidence of complications.",0
Unchanged position of left-sided central venous access line.,0
The IV nurse by telephone at the time of dictation.,0
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: F Service: CARDIOTHORACIC Allergies: morphine / Percocet Attending: Addendum: Corrected discharge diagnosis: Mitral Regurgitation.",0
7:17 AM CT HEAD W/O CONTRAST Clip # Reason: Eval for head trauma ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p mvc REASON FOR THIS EXAMINATION: Eval for head trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: MRSg WED 10:48 AM No acute intracranial hemorrhage or mass effect.,0
Incidental note of small lucencies in C1 vertebra of uncertain significance.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: Status post MVC, evaluate for head trauma.",0
TECHNIQUE: Noncontrast head CT. CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: No acute intracranial hemorrhage is identified.,0
The lateral ventricles are symmetric and nondilated.,0
Bone windows demonstrate no evidence of fracture within the surrounding osseous structures.,0
"There are multiple rounded, well-circumscribed lucencies noted within the lateral masses of C1 without evidence of cortical destruction.",0
IMPRESSION: 1) No acute intracranial hemorrhage or mass effect.,0
"2) Well-circumscribed lucencies within C1 without evidence of cortical destruction, a finding that is of uncertain significance.",0
"5:37 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; OUTSIDE FILMS READ ONLYClip # Reason: pls provide second read for facial CT ______________________________________________________________________________ MEDICAL CONDITION: 22 year old woman jumped out of moving car REASON FOR THIS EXAMINATION: pls provide second read for facial CT No contraindications for IV contrast ______________________________________________________________________________ WET READ: IPf SAT 9:27 AM Fracture through the right occipital and left temporal bone Foci of air in the right extraconal fat, no defnite fracture seen; however cannot exclude one.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 22-year-old woman, jumped from moving car.",0
TECHNIQUE: CT sinus and mandible were uploaded in PACS for a second opinion.,0
CT was done at outside hospital.,0
FINDINGS: There is a fracture through the squamous portion of the right temporal bone.,0
There is minimal amount of fluid in the right mastoid air cells.,0
The extension of the fracture through the temporal bone could be extending through the petrous bone and it is incompletely characterized on current CT.,0
"There is a small amount of hemorrhage and a few foci of air in the right orbit and in the extraconal fat, along the medial wall of the right orbit, 6:52, and although we do not see a clear fracture, we cannot exclude a fracture due to presence of air emboli.",1
"There are bilateral frontal lobe contusions with bilateral focal subarachnoid hemorrhage, characterized on concurrent CT head.",1
"Fracture through the squamous portion of the right temporal bone, and concern for questionable fracture extending through the petrous bone, although incompletely characterized.",0
CT temporal bone is recommended to evaluate further.,0
"Small amount of hematoma, and focus of air along the medial superior wall of the right orbit, and although no gross fracture is seen, we cannot exclude a fracture.",0
"Bilateral foci of contusion in the frontal lobes, and subarachnoid hemorrhage better characterized on concurrent CT head.",1
(Over) 5:37 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; OUTSIDE FILMS READ ONLYClip # Reason: pls provide second read for facial CT ______________________________________________________________________________ FINAL REPORT (Cont),0
Height: (in) 66 Weight (lb): 136 BSA (m2): 1.70 m2 BP (mm Hg): 92/53 HR (bpm): 92 Status: Inpatient Date/Time: at 10:59 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement.,0
LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - akinetic; mid anterior - akinetic; basal anteroseptal - akinetic; mid anteroseptal - akinetic; mid inferolateral - akinetic; anterior apex - akinetic; septal apex- akinetic; lateral apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Normal RV wall thickness.,0
Moderate (2+) MR. TRICUSPID VALVE: Moderate to severe [3+] TR.,0
"Resting regional wall motion abnormalities include anterior, septal, apical and apical and mid inferolateral akinesis.",0
6.Moderate to severe [3+] tricuspid regurgitation is seen.,0
7.There is moderate pulmonary artery systolic hypertension.,0
8.There is no pericardial effusion.,0
LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement assessment.,0
"Admitting Diagnosis: AIRWAY MONITORING; RIGID BRONCHOSCOPY ______________________________________________________________________________ MEDICAL CONDITION: 40 year old man, resp failure, renal transplant, tracheal stent, intubated.",1
REASON FOR THIS EXAMINATION: line placement assessment.,0
______________________________________________________________________________ FINAL REPORT HISTORY: New line placement.,0
"FINDINGS: In comparison with the earlier study of this date, the aberrant left subclavian line has been removed and replaced with a left IJ catheter, which extends to approximately the junction of the brachiocephalic vein and the superior vena cava.",0
"There is some increasing opacification in the retrocardiac region, consistent with atelectasis or possible aspiration in the left lower lobe.",0
"PATIENT/TEST INFORMATION: Indication: Intraop sternal debridement, ex lap Height: (in) 63 Weight (lb): 135 BSA (m2): 1.64 m2 Status: Inpatient Date/Time: at 15:06 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA and RA cavity sizes.",0
"Conclusions: Patient was on vasopressin, norepinepherine, and epinepherine infusions.",0
Overall left ventricular systolic function is mildly depressed (LVEF= 35-40%).,0
"Septal motion is paradoxical, c/w post CABG.",0
"Inferior wall is mild-moderately hypokinetic, remaining segments are mildly hypokinetic.",0
Mean gradients are 3-5 mm Hg.,0
"Complete exams were conducted pre and post procedure, and TEE was used to guide volume status throughout.",1
No changes were noted during procedure.,0
All findings were discussed with surgeons at the time of the exam.,0
"12:42 PM FISTULOGRAM/SINOGRAM Clip # Reason: please inject contrast thru L flank drain (chest tube) to lo Admitting Diagnosis: PANCREATITIS Contrast: CONRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with pancreatitis, L flank abscess with fistula to GI tract REASON FOR THIS EXAMINATION: please inject contrast thru L flank drain (chest tube) to localize fistula *** Dr or Dr please *** ______________________________________________________________________________ FINAL REPORT STUDY: Fistulogram study.",1
"INDICATION: Patient with a complex history of pancreatitis, status post multiple tube exchanges for evaluation.",0
TECHNIQUE: The patient's chest tube in the right flank was cannulated.,0
The angled 5 French diameter Klumpke was placed through this.,0
"Using this Kumpe catheter and using a combination of glide wires, attempts were made to opacify the patient's small bowel.",0
"During real-time, no filling of bowel was noted.",0
"However, in the view of the final images, there does appear to be opacification of both the fundus and the bulb of the duodenum.",0
The exact size of any fistula to this regiona is not apparent however and was not noticed real time.,0
A more distal communication is not seen.,0
CONCLUSION: Suggestion of more proximal (between fundus of stomach and duodenum sweep communication).,0
No filling of bowel distal to this.The exact site of filling was not observed.,0
8:49 AM CHEST (PORTABLE AP) Clip # Reason: eval for pleural effusions Admitting Diagnosis: TRICUSPID VALVE DISORDER\REDO STERNOTOMY TVR ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman s/p redo /TVR REASON FOR THIS EXAMINATION: eval for pleural effusions ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Patient with multiple catheters and pleural effusions.,1
STUDY: Portable AP upright chest x-ray.,0
"FINDINGS: Compared to , the endotracheal tube has been removed and there is slightly increased bibasilar atelectasis.",0
Small right pleural effusion and likely small left pleural effusion are noted.,0
Four mediastinal and chest tubes are again present with no definite pneumothorax.,0
"Right PICC has its tip in the mid SVC, unchanged.",0
IMPRESSION: Status post extubation with slightly increased left basilar atelectasis and small bilateral pleural effusions.,0
Multiple chest tubes with no definite pneumothorax.,0
"3:54 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: MENINGIOMA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 83 year old woman with SAH, prolonged intubation REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT INDICATION: SAH, intubation, evaluation for interval change.",0
Borderline size of the cardiac silhouette with retrocardiac atelectasis.,0
"Minimal enlargement of the pulmonary vessels, making minimal overhydration likely.",0
4:49 PM CHEST (PORTABLE AP) Clip # Reason: please assess ett and lung fields ______________________________________________________________________________ MEDICAL CONDITION: 33 year old man with cough and SOB Hx of sarcoid and CHF with EF <20% p/w Pt intubated in setting of hypoxia after AICD placement please R/O worsening CHF and eval ett tube along with ICD lead placement.,0
"REASON FOR THIS EXAMINATION: please assess ett and lung fields ______________________________________________________________________________ FINAL REPORT INDICATION: 33-year-old man with history of cough, shortness of breath, and sarcoidosis.",0
Congestive heart failure with reduced ejection fraction.,1
Intubated in the setting of hypoxia following AOCD placement with worsening CHF.,0
Evaluation of ET tube and lead placements requested.,0
COMPARISONS: PA and lateral chest x-ray of .,0
a TECHNIQUE: Supine AP portable chest x-ray.,0
FINDINGS: There has been interval placement of an AICD.,0
One of the electrodes is located in satisfactory position in the right ventricle.,0
"The other electrode lies low in the right atrium in a somewhat unusual position, however.",0
The ET tube lies in satisfactory position.,0
There is also stable increased paratracheal density corresponding with the adenopathy noted on recent CT.,0
"There is somewhat increased bilateral upper zone redistribution of the pulmonary vascularity, although this appearance may relate to position.",0
There is also possible increased retrocardiac opacity in the left lower lobe.,0
There is no definite evidence of a pleural effusion and no pneumothorax.,0
The surrounding osseous structures and soft tissues are unremarkable to the limited extent visualized.,0
Interval placement of an AICD with one electrode in the right ventricle and the other in a somewhat unusual position in the right atrium.,0
Status post intubation with satisfactory ET tube placement.,0
Evidence of increased pulmonary edema and left lower lobe opacity.,0
"PORT Clip # Reason: worsening renal function post-abd surgery, eval ureters Admitting Diagnosis: ASCITES ______________________________________________________________________________ MEDICAL CONDITION: 55 yo F w/ ovarian ca s/p OR intubated for ARDS REASON FOR THIS EXAMINATION: worsening renal function post-abd surgery, eval ureters ______________________________________________________________________________ WET READ: JXRl SAT 12:55 PM mild left hydronephrosis.",1
urinary bladder not evaulated due to prone position of patient.,1
______________________________________________________________________________ FINAL REPORT HISTORY: 55-year-old woman with ovarian cancer after surgery with worsening renal function.,0
RENAL ULTRASOUND: The patient was examined in the prone position.,0
The right kidney measures 10.1 cm in length.,0
There is no right hydronephrosis.,0
The left kidney measures 10.8 cm in length.,0
The urinary bladder was not examined due to the patient's prone position.,1
"1:33 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity, on HFOV, PIE REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT HISTORY: Infant with prematurity on HOV, PIE.",0
There has been no significant interval change since the earlier study at 9:05 AM.,0
PATIENT/TEST INFORMATION: Indication: clot Weight (lb): 187 BP (mm Hg): 121/62 Status: Inpatient Date/Time: at 15:09 Test: Portable TTE (Complete) Doppler: Complete pulse and color flow Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is normal in size.,0
Noobvious masses or thrombi are seen in the left ventricle.,0
"7:18 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: eval chest tube position and PNA Admitting Diagnosis: ESOPHAGEAL CANCER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with chest tube, PNA REASON FOR THIS EXAMINATION: eval chest tube position and PNA ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of the patient with chest tube and suspected pneumonia.",0
Portable AP chest radiograph was compared to obtained at 00:31 a.m.,0
There is no change in the cardiomediastinal silhouette including cardiomegaly.,0
The mediastinal contours are stable.,0
There is right pleural effusion that is currently at least moderate and it is most likely unchanged in size compared to the prior study.,0
"Slightly increased left pleural effusion is noted, although it may be due to the different distribution of the pleural fluid.",0
Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Tetanus Toxoid Attending: Chief Complaint: Motor Vehicle Accident Major Surgical or Invasive Procedure: None.,1
"History of Present Illness: 61yo restrained female passenger in car T-boned on passenger's side by police cruiser at approx 30mph, then car hit tree.",0
Prolonged extracation per EMS report.,0
Patient transported from outside hospital with films of head/neck/chest/abd/pelvis showing a grade II liver laceration.,1
Patient hemodynamically stable upon arrival to ED.,0
"Patient reports +LOC, complaining of mild epigastric discomfort.",0
"Past Medical History: Cholycystectomy C4-5 Herniation Excision of Neuroma on left leg Social History: Married, lives with husband.",0
as a nurse in a rehab facility.,0
- Repeat CXR shows small pneumo unchanged/resolving.,0
"Tolerating food, urinating well w/o foley, ambulating.",0
PT eval cleared for d/c home.,0
Patient d/c home w/instructions for no lifting x6 weeks and close f/u.,0
Medications on Admission: Ibuprofen prn for pain.,0
Neurontin Multivitamins Discharge Medications: 1.,0
Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for pain: For pain unrelieved with over the counter medications.,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days: Take for prevention of constipation with narcotic pain killers.,0
Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Grade 2 Liver Laceration s/p MVC - clinically stable.,1
Discharge Condition: Stable / Good.,0
Discharge Instructions: No lifting > 10 lbs x 6 weeks.,0
"No work x 1 week, conditional return to work as dictated by toleration of activity.",0
"If you notice any of the following seek medical attention immediately: fever > 101.5F, shortness of breath, chest pain, increasing right upper quadrant abdomen pain, change in skin color, dizziness, heart palpitations, or any other concerning symptoms.",0
Followup Instructions: Follow up with primary care physician within the next 5-7 days.,0
Call to schedule a follow up appointment with the trauma service within the next 10-14 days.,0
3:07 PM BILAT LOWER EXT VEINS Clip # Reason: HYPOXIA ASSYMMETRIC LOWER EVT RULE OUT DVT Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with altered mental status and asymmetric distal FOR THIS EXAMINATION: Rule out DVT ______________________________________________________________________________ FINAL REPORT HISTORY: 62-year-old male with altered mental status and asymmetric lower extremity edema.,1
COMPARISON: Bilateral lower extremity ultrasound from .,0
"BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the bilateral common femoral, superficial femoral, popliteal, and posterior tibial veins were obtained.",1
"The left peroneal veins were also imaged, however, the right peroneal veins could not be identified.",0
"There is normal flow, compressibility and augmentation in the above examined veins.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending: Chief Complaint: lightheadedness and throat pressure Major Surgical or Invasive Procedure: coronary artery bypass grafting History of Present Illness: The patient is a 68 year old white male with history as listed below who presented to an outside hospital after an episode of lightheadedness and throat discomfort.,1
He was brought in by ambulance to the emergency department where he ruled in for non-ST elevation myocardial infarction.,0
Cardiac catheterization revealed significant coronary artery disease.,1
He was referred to for surgical intervention.,0
"Past Medical History: coronary artery disease myocardial infarction (non-ST elevation) hypertension hypercholesterolemia abdominal aortic aneurysm (4.6cm) gastroesophageal reflux disease benign prostatic hyperplasia Social History: retired auto mechanic tobacco: very remote alcohol: 1-2 beers per month lives with wife Family History: mom died 81 (h/o AAA s/p repair, CAD s/p CABG in her 70s) dad died 87 ?",1
"cancer Physical Exam: VS 98.8 106/65 79 20 No acute distress Heart of regular rate and rhythm Lungs clear to auscultation bilaterally Abdomen soft, non-tender, non-distended Extremities with trace to 1+ edema Mediastinal incision clean, dry, and intact Sternum stable Vein harvest sites clean, dry, and intact Pertinent Results: ECHOCARDIOGRAPHY REPORT , (Complete) Done at 12:46:02 PM FINAL Referring Physician Information , R. , Division of Cardiothorac , Status: Inpatient DOB: Age (years): 68 M Hgt (in): 70 BP (mm Hg): 145/67 Wgt (lb): 180 HR (bpm): 55 BSA (m2): 2.00 m2 Indication: Intraoperative TEE for CABG procedure.",0
Dr. was notified in person of the results on at 1230 pm.. POST CPB: Pt is being A-paced on an infusion of phenylephrine.,0
Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations.,0
"Electronically signed by , MD, MD, Interpreting physician 16:27 ?",0
ECG Study Date of 7:52:58 AM Sinus rhythm.,0
Intraventricular conduction delay of the right bundle-branch block type.,1
"Read by: , A. Intervals Axes Rate PR QRS QT/QTc P QRS T 51 / -4 Brief Hospital Course: The patient was admitted to on for surgical management of his coronary artery disease.",1
He underwent the usual pre-operative work-up and was started on a heparin drip in light of his recent MI.,0
The patient did receive Plavix on the morning of .,0
"On he underwent coronary artery bypass grafting times 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) on .",1
Post-operatively he was transferred to the cardiac surgical ICU for invasive hemodynamic monitoring.,0
He was extubated the following morning without incident and weaned from his pressors.,0
On post-op day two he was transferred to the surgical step down floor.,0
His chest tubes and wires were removed.,0
"His platelets dropped initially and he was found to be heparin antibody positive, but his platelets quickly recovered.",1
He was not placed on argatroban per Dr. .,0
On the evening of post-operative day three he had atrial fibrillation and converted with lopressor and amiodarone.,1
Physical therapy was consulted to work on strength and balance.,0
He was gently diuresed towards his pre-operative weight.,0
By post-operative day 5 he was ready for discharge to home.,0
Medications on Admission: heparin norvasc 10mg qd aspirin 325 qd lisinopril 40qd lopressor 25 calcium/vitamin d 500 qd plavix 75 qd lasix 40 qd flomax 0.4 q72h zetia 10 qd zocor 40 qd omeprazole 20 qd flonase sprays daily prn Discharge Medications: 1.,0
"Disp:*30 Tablet, Chewable(s)* Refills:*0* 3.",0
Release 24 hr(s)* Refills:*0* 4.,0
"Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): take 400mg (2 tablets) two times for day for 1 week, then decrease to 400mg (2 tablets) daily for one week, then decrease to 200mg (1 tablet) daily.",0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days.,0
Particle/Crystal PO once a day for 7 days.,0
Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at bedtime.,0
Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 7 days.,0
4:43 PM CHEST (PA & LAT) Clip # Reason: infiltrate?,0
"______________________________________________________________________________ MEDICAL CONDITION: 65 year old man with cough, chills, n/v X 3 days REASON FOR THIS EXAMINATION: infiltrate?",0
"______________________________________________________________________________ FINAL REPORT HISTORY: 65-year-old male with cough, chills, nausea, and vomiting.",1
"CHEST, TWO VIEWS: The lungs are clear and well expanded.",0
"There is no airspace consolidation, effusion or evidence of pulmonary edema.",0
"Cardiac size, pulmonary vasculature and hila are within normal limits.",0
"12:46 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: COLON CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 88 year old man with new rapid AF c RVR REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM History of new rapid atrial fibrillation, NG tube is in distal antrum of stomach.",1
Allowing for technique heart size is within normal limits.,0
There is tortuosity of the thoracic aorta.,0
The right costophrenic angle is not included on the film.,0
A curvilinear density in the right upper zone is believed to be a skin fold.,0
12:44 PM CT HEAD W/O CONTRAST Clip # Reason: r/o trauma ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man s/p fall REASON FOR THIS EXAMINATION: r/o trauma No contraindications for IV contrast ______________________________________________________________________________ WET READ: LLTc SUN 1:21 PM No acute intracranial process.,0
______________________________________________________________________________ FINAL REPORT INDICATION: Status post fall.,0
CT C- Spine from an outside institution dated .,0
"The ventricles and sulci are mildly prominent, compatible with mild diffuse cortical atrophy.",0
Moderate mucosal thickening and retention cysts are present at the bilateral maxillary and ethmoid sinuses.,0
Mild mucosal thickening is present in the sphenoid sinus.,0
Included views of the mastoid air cells and middle ear cavities are clear.,0
"Extensive left grater-than-right soft tissue emphysema, extending to the prevertebral space, as described on the prior CT of the cervical spine.",1
Extensive left grater-than-right cervical soft tissue emphysema.,0
9:03 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
"interval change Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 64 year old woman with sepsis and COPD, worsening wheezes REASON FOR THIS EXAMINATION: ?",0
"interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Sepsis and COPD, worsening wheezes, question interval change.",0
"COMPARISON: Chest radiograph from , , and .",0
FINDINGS: One AP portable upright view of the chest.,0
The left internal jugular line ends in the left brachiocephalic vein.,0
The ETT and nasogastric tube have been removed.,0
The mild pulmonary edema and bibasilar atelectasis is unchanged.,0
Small left pleural effusion and no right pleural effusion.,0
"The cardiac, mediastinal, and hilar contours are normal.",0
1:52 PM CHEST (PORTABLE AP) Clip # Reason: ?PNA Admitting Diagnosis: BACK PAIN ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man with ?,0
PNA REASON FOR THIS EXAMINATION: ?PNA ______________________________________________________________________________ FINAL REPORT HISTORY: Possible pneumonia.,1
"FINDINGS: In comparison with the study of , the coiling of the nasogastric tube in the larynx and upper esophagus appears to have cleared.",0
The opacification at the left base silhouetting the hemidiaphragm has increased.,0
This is consistent with further volume loss in the left lower lobe and possible effusion.,0
"There is poor definition of the right hemidiaphragm, consistent with volume loss and possible fluid at the right base as well.",0
"3:40 PM CHEST (PA & LAT) Clip # Reason: r/o PNA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman with fever, cough, HIV+ REASON FOR THIS EXAMINATION: r/o PNA ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Fever, cough, HIV.",1
Comparison is made with the prior chest x-ray of .,0
There has been no significant change since this time.,0
LINE PLACEMENT Clip # Reason: s/p Right 52cm Picc Placement Admitting Diagnosis: HYPONATREMIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with REASON FOR THIS EXAMINATION: s/p Right 52cm Picc Placement ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 11:11 AM Picc line terminating in mid SVC.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 79-year-old male with right 52 mm PICC line placement.,0
PORTABLE AP CHEST RADIOGRAPH: Right-sided PICC line with tip terminating in mid to lower SVC.,0
8:08 AM CHEST (PORTABLE AP) Clip # Reason: please assess for interval change in CHF.,0
"______________________________________________________________________________ MEDICAL CONDITION: 85 yo female with NIDDM, HTN, CAD, PVD now with NSTEMI, CHF, and ARF.",0
REASON FOR THIS EXAMINATION: please assess for interval change in CHF.,0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST: 8:42 INDICATION: Congestive heart failure.,1
COMPARISON: - 9:47 FINDINGS: Compared to previous examination increased interstitial markings are seen in the paracentral region especially on the left consistent with worsening fluid status.,0
There is also accumulation of left pleural fluid and likely an element of subsegmental atelectasis in this location.,0
Since the left hemidiaphragm is not well seen the possibility of pneumonia cannot be excluded.,0
Pulmonary vascular markings remain prominent and not substantially different.,0
"ptx after CT removal Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEVERE MITRAL REGURGITATION;COPD\CATH ______________________________________________________________________________ MEDICAL CONDITION: 76 year old woman with MVrepair, CABG REASON FOR THIS EXAMINATION: ?",1
ptx after CT removal ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 3:21 PM PFI: New small-to-moderate right pleural effusion after removal of the chest tube.,1
"Pulmonary edema improved, now mild.",0
Left retrocardiac opacity with pleural effusion increased.,1
"______________________________________________________________________________ FINAL REPORT CHEST PORTABLE REASON FOR EXAM: 76-year-old woman with MV repair, CABG, rule out pneumothorax after chest tube removal.",0
"Since yesterday, the patient was extubated and the nasogastric tube was removed.",1
Right chest tube was removed and a small-to-moderate right pneumothorax is now present.,0
The Swan- Ganz catheter is still ending in the right pulmonary artery in this patient post-recent sternotomy for MVR and CABG.,1
"Left retrocardiac opacity with pleural effusion increased, likely atelectasis.",1
"Incidentally, clips of cholecystectomy are present.",0
Results were discussed with at the time of dictation.,0
5:13 AM CHEST (PORTABLE AP) Clip # Reason: polytrauma Admitting Diagnosis: S/P FALL ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man with polytrauma REASON FOR THIS EXAMINATION: polytrauma ______________________________________________________________________________ FINAL REPORT INDICATION: Polytrauma after fall.,1
FINDINGS: Bilateral chest tubes are unchanged in position.,0
An endotracheal tube is seen 2.7 cm from the carina.,0
The right central line ends at the atriocaval junction.,0
A feeding tube is in place with the tip out of the field of view.,0
"In comparison to the prior radiograph, there are lower lung volumes which is likely due to acquisition of the image in a different phase of the respiratory cycle or decrease in PEEP.",0
"As a consequence, the right and left lower lobe opacities appear slightly larger, but are likely unchanged in size.",0
The previously seen deep sulcus sign is not present.,0
Again noted are rib fractures of the seventh and eighth right ribs.,0
IMPRESSION: Decreased lung volumes with no significant change in the right and left lower lobe opacities.,0
"7:50 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for interval change after diuresis Admitting Diagnosis: CONGESTIVE HEART FAILURE;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with CHF exacerbation, shortness of breath, and chest pain.",1
REASON FOR THIS EXAMINATION: please evaluate for interval change after diuresis ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath in a patient with congestive heart failure exacerbation.,1
"Portable AP chest radiograph was compared to , 4th, and 14th of .",0
There is fluctuating appearance of the parenchymal opacities consistent with recurrent pulmonary edema.,0
"Compared to the most recent chest radiograph from , there is interval progression of parenchymal opacities involving the entire lungs that is worrisome for interval worsening of pulmonary edema.",0
"No appreciable pleural effusions have been seen, although small amount of pleural fluid cannot be excluded.",0
No changes in the sternotomy wires position as well as in the cardiomediastinal contour have been demonstrated.,0
"The fluctuating character of the parenchymal opacities is more consistent with pulmonary edema than infection, although underlying foci of infection or ARDS cannot be completely excluded.",0
"11:58 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate/effusion/CHF Admitting Diagnosis: LYMPHOMA ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with Hodgkin's disease and chest, now with worsening sob REASON FOR THIS EXAMINATION: eval for infiltrate/effusion/CHF ______________________________________________________________________________ FINAL REPORT HISTORY: Hodgkin lymphoma and worsening shortness of breath.",1
"There is mild interval improvement in the left upper lung field aeration, which may represent improvement in lung collapse or decreased pleural fluid.",0
Small right pleural effusion is minimally decreased in size.,0
Previously noted mild pulmonary edema in the right lung has resolved.,0
"Bilateral central venous catheters remain in unchanged, satisfactory positions.",0
IMPRESSION: Mild improvement in left upper lung aeration.,0
4:49 AM CHEST (PORTABLE AP) Clip # Reason: eval for int change Admitting Diagnosis: HYDROTHORAX ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with liver failure REASON FOR THIS EXAMINATION: eval for int change ______________________________________________________________________________ FINAL REPORT HISTORY: Liver failure.,1
"FINDINGS: In comparison with study of , the monitoring and support devices remain in place.",0
"Diffuse bilateral pulmonary opacifications are again seen, consistent with multifocal pneumonia, elevated pulmonary venous pressure and volume loss in the left lower lobe.",1
PATIENT/TEST INFORMATION: Indication: source of embolism Height: (in) 74 Weight (lb): 200 BSA (m2): 2.18 m2 BP (mm Hg): 150/96 HR (bpm): 56 Status: Inpatient Date/Time: at 10:46 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: Saline Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.,0
"Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver.",0
IMPRESSION: No cardiac source of embolism seen.,0
6:43 PM CHEST (PORTABLE AP) Clip # Reason: ett placement.,0
______________________________________________________________________________ MEDICAL CONDITION: 73 year old woman with intubated for head bleed.,0
REASON FOR THIS EXAMINATION: ett placement.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 73-year-old woman, intubated for head bleed.",0
SINGLE SUPINE VIEW OF THE CHEST AT 1835 HOURS: The endotracheal tube terminates approximately 2 cm from the carina.,0
"The lung volumes are low, resulting in vascular crowding.",0
"An enteric tube terminates in the stomach, with the sideport at the GE junction.",0
There is likely no pleural effusion.,0
"There is mild hilar fullness, with mild vascular congestion bilaterally.",0
The aortic arch demonstrates calcification.,0
Endotracheal tube terminates 2 cm from the carina.,0
"Orogastric tube sideport situated at GE junction, could be advanced for standard positioning.",0
Hilar fullness and mild vascular congestion consistent with mild fluid overload.,0
"3:39 PM DUP EXTEXT BIL (MAP/DVT) Clip # Reason: please evaluate for DVT Admitting Diagnosis: ANEMIA ______________________________________________________________________________ MEDICAL CONDITION: 71 year old woman with new dilated, hypokinetic RV on echo.",0
"Concern for new PE, but unable to perform CTA due to renal failure REASON FOR THIS EXAMINATION: please evaluate for DVT ______________________________________________________________________________ FINAL REPORT PROCEDURE: Bilateral lower extremity venous duplex.",0
INDICATION: 71-year-old female patient with new dilated hypokinetic right ventricle.,0
Study requested due to concern for new pulmonary embolism and inability to perform CTA due to renal failure.,0
"TECHNIQUE: Son -scale, duplex, and Doppler images were obtained for both lower extremities.",0
FINDINGS: Duplex evaluation was performed on the bilateral lower extremity veins.,0
"There is normal compression and augmentation of the common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal veins.",0
IMPRESSION: No evidence of deep vein thrombosis either right or left extremity.,0
"8:42 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: pulmonary edema improvement, pleural effusions Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with vfib, and potential sepsis REASON FOR THIS EXAMINATION: pulmonary edema improvement, pleural effusions ______________________________________________________________________________ FINAL REPORT AP CHEST, 8:58 A.M. ON HISTORY: Ventricular fibrillation.",1
"IMPRESSION: AP chest compared to through , 4:31 a.m.: Substantial improvement in the appearance of the right lower lung, in the face of mild pulmonary edema elsewhere suggests this is asymmetric edema and of course, a small region of pneumonia is not excluded, and should continue to be followed.",0
"Pleural effusion, if any, is small.",0
"ET tube is in standard placement, right internal jugular line ends in the low SVC, nasogastric tube passes into the stomach and out of view.",0
Transvenous pacer defibrillator lead tip projects over the anticipated location of the right ventricular apex.,0
12:57 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: Need to evaluate aorta from aortic arch to femoral arteries Admitting Diagnosis: ISCHEMIA Field of view: 36\ Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 81 year old woman with necrotic bowel s/p ex-lap.,0
REASON FOR THIS EXAMINATION: Need to evaluate aorta from aortic arch to femoral arteries No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT PROCEDURE: CT torso.,1
HISTORY: 81-year-old woman with necrotic bowel S/P exploratory laparotomy.,0
"TECHNIQUE: Multidetector CT images of the thorax without contrast were first obtained, followed by continuous axial images with IV contrast of the chest, abdomen, and pelvis.",0
FINDINGS: CHEST CT WITH AND WITHOUT CONTRAST: There has been mild interval increase in the bilateral pleural effusions.,0
There is associated adjacent bibasal atelectasis.,0
Bronchiectasis are seen in both upper lungs.,0
"The airways are patent, endotracheal tube is seen in adequate position.",0
There are no mediastinal or axillary pathologically enlarged lymph nodes.,0
"The aorta is normal in caliber, the main branches are widely patent.",0
Small hypodense areas are seen in both lobes of the thyroid gland.,0
"ABDOMEN CT WITH IV CONTRAST: Given the single early arterial phase, the liver, pancreas, and adrenals are unremarkable.",0
Multiple peripheral wedge- shaped areas are seen in the spleen and in the cortical regions of both kidneys consistent with areas of infarcts.,0
Tiny multiple stones are seen within the gallbladder lumen.,0
The G-tube appears in satisfactory position.,0
"The main branches (celiac axis, SMA, , and renal arteries) are widely patent.",0
The small bowel loops are unremarkable.,0
PELVIC CT: There is moderate quantity of free fluid.,0
The bowel loops are unremarkable.,0
The bladder has a Foley catheter in its lumen.,0
(Over) 12:57 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: Need to evaluate aorta from aortic arch to femoral arteries Admitting Diagnosis: ISCHEMIA Field of view: 36\ Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) BONE WINDOWS: There are no concerning bone lesions.,0
"Compression fractures are seen in the vertebral bodies of T12, L1, L2, and L3.",0
CT reconstructions confirm the findings in the axial images.,0
A slight interval increase in size in the bilateral pleural effusions and adjacent consolidation/atelectasis.,0
"The aorta is normal in caliber, all its main branches are widely patent.",0
Hypodense areas in both lobe of the thyroid gland.,0
Splenic and cortical renal infarcts.,0
Admission Date: Discharge Date: Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: 80 F fall from wheelchair.,0
"PMH of Multiple sclerosis, GCS 3T on arrival in ED Major Surgical or Invasive Procedure: none History of Present Illness: 87 y/o F with long history of MS was being pushed in her wheelchair today, seatbelt off and wheels accidently over top of stairs.",1
fell from wheelchair and tumbled about 2 steps onto her head.,0
with confusion at scene but no LOC.,0
"intubated in route by EMS without sedation, she was unresponsive/minimally responsive at scene.",0
"initially evaluated w/GCS of 3 however, once in the CT scanner and after getting IVF the pt.",0
opened eyes spontaneously and would localize to voice.,0
Past Medical History: Patient has MS. reports that at baseline she does not move below the neck and when in a particularly good mood will speak in full sentences.,0
"Social History: Husband and two sons at side Family History: unknown, NC Physical Exam: T: BP: 118/62 HR: 52 R: 18 O2Sats: 100 on vent Gen: WD/WN, thin, NAD HEENT: Pupils: ERRL EOMs intact Neck: in c-collar Lungs: CTA bilaterally.",0
"Abd: Soft, NT, BS+, ND Extrem: Warm and well-perfused.",0
"Neuro: Mental status: Awake and alert, not cooperative w/exam Motor: Pt.",0
cannot move below the neck at baseline Sensation: pt.,0
"no responsive at time Reflexes: B T Br Pa Ac Right difficult to assess, pt does not relax Left Toes downgoing bilaterally Rectal exam: sphincter tone wnl Pertinent Results: 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG 04:53PM GLUCOSE-165* LACTATE-2.4* NA+-137 K+-3.7 CL--107 TCO2-21 04:50PM CK(CPK)-30 AMYLASE-61 04:50PM UREA N-19 CREAT-0.7 04:50PM CK-MB-NotDone cTropnT-<0.01 04:50PM WBC-4.8 RBC-3.25* HGB-10.7* HCT-29.2* MCV-90 MCH-32.8* MCHC-36.5* RDW-13.2 Brief Hospital Course: In the ED, CT scans of the cervical spine showed rotary subluxation of C1 and C2.",0
Pt was admitted to the hospital DNR/DNI and Neurology was consulted.,0
Pt was admitted intubated with a C-collar in place.,0
Once in house patient was extubated and never regained her baseline mental status.,0
Pt did not receive code level care per the family's wishes.,0
On HD#6 she expired and was pronounced Medications on Admission: ASA Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:,0
"1:09 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for ptx/ effusion Admitting Diagnosis: OSTEOMYLITIS AND CELLULITIS OF LEFT FOOT ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p fem bypass with acute SOB REASON FOR THIS EXAMINATION: eval for ptx/ effusion ______________________________________________________________________________ FINAL REPORT INDICATION: Status post femoral bypass, followup.",1
"FINDINGS: As compared to the previous examination, unchanged cardiomegaly and evidence of moderate pulmonary edema.",0
The edema is minimally progressive.,0
"In the interval, the nasogastric tube has been removed and the right IJ line is in unchanged position.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Ileostomy following J-pouch.,1
Major Surgical or Invasive Procedure: Dilatation of ileoanal anastomosis and closure of ileostomy.,1
"History of Present Illness: Mr. is a 53 year old man with HTN, HCV, Ulcerative colitis refractory to medical managment s/p proctocolectomy, ileostomy in who in underwent creation of ileoanal pouch with lysis of adhesions, resection of area of fat necrosis in small bowel, and creation of new diverting ileostomy for surgical management of chronic ulcerative colitis and persistent leakage at the old ostomy site after intentional 100 pound weight loss.",1
"Past Medical History: Ulcerative colitis diagnosed in s/p proctocolectomy/ileostomy , ileoanal pouch and new diverting ileostomy(), s/p ileostomy closure Partial SBO HTN HCV post interferon and ribaviron treatments Social History: Lives in with wife, .",1
No longer drinks (+ EtOH use in past).,0
"Quit smoking 10 years ago, had 30 pack-yr history.",0
"Continues to smoke cigars, but says he does not inhale.",0
Has used IV drugs in past 1-2x.,0
"Says he's ""tried everything"", but sober for many years.",0
"Family History: Adopted, unknown history of biological mother.",0
"Father dies of stroke and may have had DM but other history unknown Physical Exam: Vitals: 98.6,69, 128/90,16, 100% RA.",0
Available for comparison is the next preceding chest examination of .,0
The on previous examination identified right-sided PICC line has been removed.,0
Appearance of chest is grossly unaltered with heart size within normal limits and no acute pulmonary abnormalities.,1
"Although the cardiac area is somewhat underpenetrated, one can identify an NG tube in the upper portion of the esophagus and reappearance just below the diaphragm indicating that the tube has reached well into the stomach where it is curled up.",0
This includes also the side port.,0
No other significant findings on this single chest view examination.,0
CXR PORTABLE SHALLOW OBLIQUE CHEST RADIOGRAPH: Right upper extremity PICC terminates in the mid to lower SVC.,0
"Again seen are bibasilar atelectasis, with mild worsening of the right basal atelectasis.",0
"The cardiomediastinal and hilar contours are stable, with a mildly tortuous thoracic aorta.",0
"IMPRESSION: Right PICC terminates in the mid to lower SVC Brief Hospital Course: 53 yo male with ulcerative colitis s/p ileoanal pouch and diverting ileostomy in , presents with GI bleed and hypotension after ileostomy closure.On , patient underwent takedown of ileostomy and is admitted to from the PACU with GIB and hypotension.",1
The patient's ileostomy takedown procedure went well;refer to operative note for further details of surgery.,1
"While in the PACU though, pt had a BM with 100 cc of frank blood, then subsequently had another BM with 300 cc of frank blood.",0
"The pt became hypotensive to 60-70s, hr 70s and felt dizzy and nauseous.",0
"He was given 4L of fluid, given a 100mcg of phenylephrine and his BP improved.",0
"A foley was placed in the patients rectum, and irrigated with clot.",0
The patient is currently receiving 2 units pRBCs.,0
"On arrival to the , patient's vs. were BP 133/51 HR 89 RR 17 100% on RA.",0
"He reports feeling tired, with abdominal pain over ostomy removal site that he states is more superficial than deep and rates a with improvement with pain medication.",0
"He states mild lightheadedness that was worse in the afternoon, and nausea upon receipt of pain medications.",0
"Denies chest pain, shortness of breath, cough, constitutional symptoms, dysuria, recent illness.",0
"# GI Bleed: Occurred s/p ileostomy takedown and completion of the anastomosis, this is likely bleeding from the staple line, which is usually self limited.",1
Patient's HCT was initially 31.9 this trending downward to a nadir of 22.,0
A rectal tube was placed and bleeding continued.,0
The patient additional was noted to have one episode of hematemesis.,0
A NGT was placed and lavage returned dark blood.,0
Hematemesis was attributed to backflow from his anastomotic site bleed.,0
He was given transfusions with a goal HCT of 28.,0
He required transfusion of a total of 13 units of PRBCs and 2 units of FFP.,0
Bleeding subsided and pressures stabilized and patient HCT remained stable.,0
-# Bradycardia: Patient was initially noted to have a HR into 30s-40s while hypotensive.,0
Inappropriate response to blood pressure.,0
"Most likely to vagal event from bleeding, rectal tube, pain, and may be exacerbated by reflex bradycardia from phenylephrine.",0
# Pain control: Pain was controlled with a morphine PCA.,0
STABLE ISSUES # Ulcerative colitis: S/p proctocolectomy.,0
No evidence of PSC clinically.,0
# Hypertension: The patient's home amlodipine was held in the setting of GIB.,1
"# Hypotension: Most likely to bleeding and vagal response given HR, presence of tube in rectum, as well as pain which per nurse, often correlates with descent in HR.",0
He was given fluid boluses with LR and transfused as above.,0
He initially required phenylephrine however he was quickly weaned from pressor support.,0
The patient was without signs or symptoms of infection.,0
"POD 3,patient was transferred to the floor.",0
Patient remained NPO with intravenous fluids and NGT in place.,0
Patient NGT output was monitored closely and was having large bilious output.,1
A PICC line was placed for intravenous fluids.,0
"POD 4,patient continued to be diuresed with acetazolamide.",0
The foley catheter was discontinued and patient voided without difficulty.,0
POD 5 the nasogastric tube was discontinued and the diet was advanced from clears to regular which was tolerated well.,0
Patient was noted to have copious amounts of stool output greater than 2 liters per day and was started on psyllium wafers.,0
Patient intake and output were monitored closely.,0
POD 6 patient continued to have high stool output and was started on loperamide.,0
However continued to report having multiple explosive non bloody stool output.,0
Patient's loperamide and psyllium wafers were titrated up as needed.,0
Patient was started on a regular diet and encouraged to increase fiber intake to bulk up the stool.,0
POD 7 patient reported no significant change in bowel frequency and urgency.,0
In addition to his current bowel regimen he was started on Librium.,0
Patient mobility was limited due to increase frequency and urgency of bowel movements.,0
Thus patient was started on Heparin subcutaneously for DVT prophylaxis.,0
Patient was encouraged to ambulate several times a day.,0
Patient hematocrit was monitored closely and was stable.,0
By POD 8 patient had satisfactory stool output on current bowel regimen and was deemed ready for discharge to home.,0
"Patient was instructed to monitor his stool output closely and to titrate his bowel regimen (Loperamide, psyllium wafers and Librax) as instructed by Dr. .",0
Patient was also instructed to monitor for dehydration and to keep with oral fluids.,0
Patient PICC line was discontinued prior to discharge.,0
He will have his staples removed at his PCP .,0
Patient was discharged home in good condition and will follow-up with Dr. in clinic in months.,0
Medications on Admission: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain.,0
Disp:*30 Tablet(s)* Refills:*2* 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain.,0
Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Ileostomy following J-pouch.,0
"Discharge Instructions: Mr. ,you have recovered well from your surgery and may return home.",0
"You are tolerating a regular diet, passing gas and your stool output has slowed down.",0
Please continue to monitor your stool and urine output to avoid becoming dehydrated.,0
"If you notice your stool output increasing, take in more electrolyte drink such as gatorade.Please monitor yourself for signs and symptoms of dehydration including: dizziness(especially upon standing),weakness, dry mouth, headache, or fatigue.",0
If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe.,0
"Please titrate your bowel medications loperamide,psyllium wafers and librax as instructed by Dr. .",0
You may also bulk up your stool to achieve desired stool output with fiber such as bran muffins.If you have any questions or concerns call the office for further advice.,0
You have an incision to your lower right abdomen that is closed with staples.,0
This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing.,0
Please have your staples removed in 7- 10 days.,0
This can be done at your primary care provider office visit.,0
"Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow foul smelling drainage, or if you develop a fever.",0
Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe.,0
"You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub.",0
No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgeon.,0
You may gradually increase your activity as tolerated but clear heavy excercise with your surgeon.Please continue to walk several times a day to prevent developing a blood clot in your legs.,0
You will be prescribed a small amount of the pain medication;please take this medication exactly as prescribed.,0
You may take Tylenol as recommended for pain.,0
Please do not take more than 4000 mg of Tylenol daily.,0
Do not drink alcohol while taking narcotic pain medication or Tylenol.,0
Please do not drive a car while taking narcotic pain medication.,0
Thank you for allowing us to participate in your care!,0
Our hope is that you will have a quick return to your life and usual activities.,0
Followup Instructions: Follow-up with your PCP/Gastroenterologist in weeks Call and schedule follow-up appointment with Dr. in months .,0
LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval for placement of new right sided picc Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 79M w/ multifocal pna now s/p right picc line placement - please confirm placement REASON FOR THIS EXAMINATION: eval for placement of new right sided picc ______________________________________________________________________________ FINAL REPORT INDICATION: Pneumonia status post right PICC.,1
"FINDINGS: New right PICC tip projects over the right atrium, withdrawal of the tip at the cavoatrial junction.",0
Study is otherwise unchanged with multifocal opacities and pulmonary edema.,0
IMPRESSION: Right PICC in right atrium.,0
These findings were discussed over the telephone with the PICC nursing team at 3 p.m. on .,0
10:03 AM CAROTID SERIES COMPLETE Clip # Reason: bilateral carotid duplex Admitting Diagnosis: CLAUDICATION/SDA ______________________________________________________________________________ MEDICAL CONDITION: year old woman mental status changes sensitive to changes in blood pressure REASON FOR THIS EXAMINATION: bilateral carotid duplex ______________________________________________________________________________ FINAL REPORT Standard Report Carotid US Study: Carotid Series Complete Reason: year old with mental status changes Findings: Duplex evaluation was performed of bilateral carotid arteries.,1
On the right there is mild heterogeneous plaque in the ICA.,0
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 75/15, 93/20, 93/20 cm/sec.",0
CCA peak systolic velocity is 90 cm/sec.,0
ECA peak systolic velocity is 146 cm/sec.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 110/19, 109/20, 97/17 cm/sec.",0
ECA peak systolic velocity is 151 cm/sec.,0
"10:39 AM CHEST (PORTABLE AP) Clip # Reason: r/o pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 66 year old man with REASON FOR THIS EXAMINATION: r/o pneumonia ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, : INDICATION: Post-CABG film.",0
FINDINGS: A right central venous catheter is seen with the tip in the SVC and no pneumothorax.,0
A shallow level of inspiration limits this assessment and the vascular markings appear crowded.,0
Distinction between fluid overload and artifact from shallow inspiration cannot be made.,0
Left hemidiaphragm is not well seen and therefore the possibility of a left lower lobe infiltrate exists but no definite air bronchograms are seen.,0
Some pleural fluid layers on the left.,0
IMPRESSION: Limited film with markedly shallow inspiration.,0
Left effusion; left lower lobe consolidation cannot be excluded.,0
1:40 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: pneumothorax?,0
"Admitting Diagnosis: CLAUDICATION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 77yr old female with SOB requiring continuos O2, now s/p thoracentesis REASON FOR THIS EXAMINATION: pneumothorax?",0
______________________________________________________________________________ FINAL REPORT PORTABLE CHEST at 13:44: COMPARISON: @ 9:59.,0
"Following left thoracentesis, a left pleural effusion has nearly resolved.",1
"No pneumothorax is identified, and there is otherwise no substantial change since the recent radiograph performed earlier the same date.",0
BP (mm Hg): 130/80 HR (bpm): 114 Status: Inpatient Date/Time: at 23:51 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: PERICARDIUM: Small pericardial effusion.,0
Conclusions: There is a small pericardial effusion.,0
"Compared with the findings of the prior study (images reviewed) of , ther pericardial effusion appears smaller in limited imaging windows.",0
"6:01 AM MR HEAD W/CNTRST&TUMOR VOLUMETRIC; CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Pre surgery wand protocol for marking place for intraoperati Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ MEDICAL CONDITION: 46 year old male patient with left occipital tumor REASON FOR THIS EXAMINATION: Pre surgery wand protocol for marking place for intraoperative navigation No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 46-year-old male patient, with cutaneous melanoma, two brain lesions, for pre-operative planning.",1
COMPARISON: MR of the head done on .,0
"TECHNIQUE: MR of the head with IV contrast was performed including axial MP- RAGE post-contrast images and sagittal and coronal reformations, per WAND protocol.",0
FINDINGS: @ lesions - in the right frontal and left occipital lobe demonstrated for surgical planning.,0
Please see the detailed report done on .,0
TUMOR VOLUMETRY: Volume of the right frontal lesion 10.47 cc; volume of the left occipital lobe lesion 10.47 cc; volume of the right frontal lobe lesion 2.36 cc.,0
IMPRESSION: 2 enhancing lesions in the brain as above for surgical planning.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: - Coronary artery bypass grafting to three vessels.,1
"(Left internal mammary artery->left anterior descending artery, saphenous vein graft(SVG)->Obtuse marginal artery, SVG->Right coronary artery).",1
- Cardiac catheterization History of Present Illness: The patient is a 51-year-old who presented to with 2 days of chest pain.,0
The patient had cardiac catheterization and he was found to have three-vessel coronary artery disease.,1
Past Medical History: Depression Possible transient ischemic attack in past Myocardial infarction Social History: Employed as a machinist.,0
Active 2 pack per day smoker with a 60+ pack year history.,0
Family History: Significant for coronary artery disease and diabetes.,1
Physical Exam: PHYSICAL EXAMINATION: VS: 97.8 67 128/85 14 98% RA GENERAL: male in no acute distress.,0
NECK: Supple with JVP of flat.,0
"CARDIAC: Point of maximal impulse located in 5th intercostal space, midclavicular line.",0
"Regular rate, normal S1, S2.",0
"clear, no crackles, wheezes or rhonchi.",0
PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Cardiac Catheterization 1.,0
Selective coronary angiography of this right-dominant system revealed three-vessel coronary artery disease.,1
The LMCA had a 40% distal stenosis.,0
The LAD had a long 90% mid-vessel stenosis.,0
The LCX had a 90% proximal stenosis.,0
The RCA had a 90% mid-vessel stenosis.,0
Limited resting hemodyamics demonstrated normal central aortic pressures.,0
Dr. was notified in person of the results on at 0930am.,0
Post Bypass: Patient is in sinus rhythm and receiving an infusion of phenylephrine.,0
"07:10AM BLOOD WBC-11.4* RBC-2.94* Hgb-9.3* Hct-25.7* MCV-88 MCH-31.6 MCHC-36.0* RDW-13.4 Plt Ct-290 01:25PM BLOOD PT-16.1* PTT-44.2* INR(PT)-1.4* 07:10AM BLOOD Glucose-95 UreaN-21* Creat-0.7 Na-132* K-3.9 Cl-93* HCO3-31 AnGap-12 12:45PM BLOOD ALT-31 AST-36 CK(CPK)-169 AlkPhos-87 TotBili-0.4 DirBili-0.1 IndBili-0.3 Radiology Report CHEST (PA & LAT) Study Date of 1:41 PM , FA6A 1:41 PM CHEST (PA & LAT) Clip # Reason: eval for pneumothoraces s/p chest tube removal MEDICAL CONDITION: 51 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothoraces s/p chest tube removal Provisional Findings Impression: LCpc FRI 3:29 PM PFI: All tubes and catheters were removed.",0
Final Report CHEST PA AND LATERAL REASON FOR EXAM: 51-year-old man status post CABG.,0
Evaluate for pneumothorax status post chest tube removal.,0
"Since yesterday, all tubes and catheters were removed.",0
Cardiomegaly and sternotomy are unchanged.,0
"Interstitial edema increased, now moderate.",0
"Minimal left pneumothorax decreased, almost completely cleared.",0
Lung volumes improved with improvement in bibasilar atelectasis.,0
DR. DR. Approved: FRI 4:37 PM Brief Hospital Course: Mr. was admitted to the on for further management of his myocardial infarction.,0
He continued on heparin and remained chest pain free.,0
A cardiac cathetheterization was performed which showed severe three vessel disease.,0
"Given these findings, the cardiac surgical service was consulted for surgical revascularization.",0
Plavix was held in anticipation of surgery.,0
He was worked-up in the usual preoperative manner and found suitable for surgery.,0
"After a sufficient plavix washout, Mr. was taken to the operating room on where he underwent coronary artery bypass grafting to three vessels.",1
Postoperatively he was taken to the surgical intensive care unit for monitoring.,0
"Over the next several hours, he awoke neurologically intact and was extubated.",0
"After pressors were weaned, beta blockade, aspirin and a statin were resumed.",0
"On postoperative day one, he was transferred to the step down for further recovery.",0
A fluid restriction was applied for hyponatremia.,0
He continued to make steady progress and was discharged home on postoperative day 4 in stable condition.,0
He will follow-up with Dr. and Dr. as an outpatient.,0
Medications on Admission: Omeprazole 20 mg daily Paroxetine 20 mg daily Vicodin PRN Flexeril 10 mg PRN Discharge Medications: 1.,0
Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed.,0
Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks: Take with food.,0
Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass.,0
Discharge Diagnosis: CAD s/p CABGx3 TIA Myocardial infarction Depression GERD Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection.,1
Followup Instructions: Please follow-up with Dr. in 4 weeks ( Please follow-up with in 2 weeks Please call all providers for appointments.,0
3:55 PM CHEST (PORTABLE AP) Clip # Reason: Please do chest xray and evaluate lung status.,0
Admitting Diagnosis: POST TRAUMATIC ARTHRITIS INFECTION LEFT KNEE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man s/p left leg surgery on Monday now with fever.,0
He is in knee immobilizer and on bedrest so need portable.,0
REASON FOR THIS EXAMINATION: Please do chest xray and evaluate lung status.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Post-surgical fever.,0
FINDINGS: The heart is within normal limits in size and the lungs are clear without evidence of vascular congestion or pleural effusion.,0
"7:58 AM CHEST (PORTABLE AP) Clip # Reason: eval for widened mediastinum Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 44 year old woman post cardiac surgery w/ decreased HCT REASON FOR THIS EXAMINATION: eval for widened mediastinum ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",1
"HISTORY: 44-year-old woman, status post cardiac surgery with decreased hematocrit.",1
There is a right-sided IJ central venous catheter with the distal tip in the proximal SVC.,0
There are again noted bilateral subsegmental linear atelectases with a left retrocardiac opacity which is stable.,0
"Consolidation at the left base is not entirely excluded; however, this is felt more likely to be due to atelectasis.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Known severe arotic stenosis with increasing shortness of breath.,0
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old gentleman with a known history of aortic stenosis followed up by serial echocardiogram.,1
He underwent a successful right coronary artery stent on .,1
He was admitted for elective aortica valve surgery.,1
"PAST MEDICAL HISTORY: Aortic stenosis, diverticulosis, gastrointestinal bleed with colon AVM status post laser treatment, cerebrovascular accident, hypertension.",1
"MEDICATIONS ON ADMISSION: FES04 b.i.d., Prilosec 20 q.d., Lopressor 25 mg b.i.d., Procardia 30 mg b.i.d., Flomax .4 mg q.d.",0
HOSPITAL COURSE: The patient underwent a minimally invasive aortic valve replacement with a pericardial #21 valve.,1
"Postoperatively, he was extubated on postoperative day one in the CSRU.",0
He was transferred to the floor in stable condition on postoperative day one.,0
He made good progress over the next couple of days.,0
His chest tube was discontinued on postoperative day two as well as his Foley.,0
On postoperative day two he went into atrial fibrillation.,1
For a brief period of time he went back into sinus rhythm and then he reverted into atrial fibrillation.,1
He was treated with an amiodarone load and started on Amiodarone po.,0
He also had an increase in his creatinine on postoperative day two.,0
He was hydrated for this.,0
"His atrial fibrillation was treated with Coumadin with an aim of an INR of 1.8 to 2, because of previous history of gastrointestinal bleed.",1
After three days of Coumadin his INR rose abruptly to a level of 2.9.,0
At this point the Coumadin was held while we awaited a return to a safe level of his INR.,0
"On postoperative day eight, he reverted back to a sinus rhythm.",0
His INR continued to be in the high range.,0
"During this period he was otherwise completely stable, ambulating, tolerating a regular diet with pain under control with the analgesia.",0
On postoperative day nine his INR had come down to a level of 2.5.,0
His creatinine had marginally risen to 1.6.,0
He was deemed ready for discharge on postoperative day ten with an INR of 2.5.,0
He was started on iron for a hematocrit of 28.5.,0
His hematocrit at the time of discharge was 31.4.,0
His creatinine was stable at 1.6.,0
"MEDICATIONS ON DISCHARGE: Lopressor 75 mg b.i.d., Amiodarone 400 mg q.d.",0
"for one month, Colace 100 mg b.i.d., enteric coated aspirin 325 mg po q.d., Protonix 40 mg q.d., iron sulfate 325 mg b.i.d., Tylenol 600 mg q 4 to 6 hours prn, Percocet one to two tablets q 4 to 6 hours prn.",0
Follow up with primary care physician .,0
"He needs a laboratory check prior to that on Monday for a chem 7, coags, hematocrit.",0
He will also follow up with Dr. in four weeks.,0
Dictated By: MEDQUIST36 D: 22:49 T: 06:11 JOB#:,0
9:12 AM CHEST (PORTABLE AP) Clip # Reason: assess infiltrates/effusions Admitting Diagnosis: AORTIC STENOSIS\ AORTIC AND MITRAL VALVE REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with AS/MS s/p AVR/MVR.,1
lower o2 sats REASON FOR THIS EXAMINATION: assess infiltrates/effusions ______________________________________________________________________________ FINAL REPORT INDICATION: Low oxygen saturation.,0
"CHEST, AP: The patient is s/p AVR/MVR.",0
Marked cardiomegaly and bilateral pleural effusions with atelectasis in both lower zones are again visualized.,0
"12:39 PM CHEST (PORTABLE AP) Clip # Reason: Intubated, acute cardiopulm process Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 58 yo M s/p esophageal stent for perforation/fistula and new esophageal cancer diagnosis REASON FOR THIS EXAMINATION: Intubated, acute cardiopulm process ______________________________________________________________________________ FINAL REPORT COMPARISON: Radiograph and CT of .",1
"FINDINGS: Homogeneous opacity extends from the minor fissure to a partially obscured right hemidiaphragm, with associated signs of volume loss.",0
"Observed findings likely represent collapse of the right middle lobe and partial atelectasis of the right lower lobe, the latter coexisting with known complex fluid collection and consolidation based on review of recent CT.",0
Moderate right pleural effusion has increased in size in the interval.,1
New bilateral asymmetrical perihilar opacities worse on the left than the right could reflect pulmonary edema or new sites of aspiration or infection.,1
Dense left retrocardiac opacity and a small left pleural effusion are also new.,1
"Since the prior study, esophageal stent has been placed, and the patient has been intubated, with tip of endotracheal tube terminating at the level of the medial clavicles, about 7.7 cm above the carina.",0
This could be advanced a few centimeters for standard positioning.,0
Dr. has been telephoned with these results at 4:15 on .,0
"7:32 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement, interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE;COMPLETE HEART BLOCK;ATRIAL FIBRILLATION\BIVENTRICULAR PACEMAKERIMPLANT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 85 yo M with hx of AF & CHB s/p PPM (), CAD s/p CABG () & multiple coronary/renal/peripheral stents, ischemic CM (EF 35%) who presented for resynchronization with upgrade to biventricular pacer, and whose procedure was complicated by likely cardiogenic shock and PEA arrest.",1
"REASON FOR THIS EXAMINATION: ET tube placement, interval change ______________________________________________________________________________ FINAL REPORT INDICATION: Biventricular pacemaker placement complicated by cardiogenic shock.",1
"FINDINGS: Peripheral left lower lobe and right lower lobe consolidations are consistent with pneumonia, or given the appropriate clinical history, contusion from chest compressions.",1
Pulmonary edema is worse on the present study compared to one day previous.,0
Biventricular pacing leads are in the appropriate locations.,0
The left-sided PICC line terminates at the upper SVC.,0
"IMPRESSION: Persistent bilateral pneumonia, or resuscitation-related lung contusion.",1
6:44 PM CHEST SGL VIEW/LINE PLACEMENT PORT; -77 BY DIFFERENT PHYSICIAN # Reason: r/o pneumo and cvl tip position ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with s/p cvl placement REASON FOR THIS EXAMINATION: r/o pneumo and cvl tip position ______________________________________________________________________________ FINAL REPORT HISTORY: 73-year-old man status post central line placement.,0
Please assess for pneumothorax and tip position.,0
TECHNIQUE: A single upright portable AP chest radiograph was obtained.,0
COMPARISON: Comparison is made to upright AP portable chest radiograph from earlier the same day.,0
FINDINGS: There has been interval placement of a right IJ central venous catheter with tip just below the junction of the SVC and right atrium.,0
"The patient is rotated, but given this, the cardiac and mediastinal contours are unremarkable.",0
The heart size is at the upper limits of normal.,0
"Since the prior study 8 hours earlier, there has been interval development of patchy retrocardiac opacity at the left base.",0
Given the time course of this finding likely represents focal atelectasis or aspiration and clinical correlation is suggested.,0
There is stable dextroscoliosis of the thoracic spine.,0
IMPRESSION: Right IJ central line tip just below SVC-RA junction.,0
"New patchy left retrocardiac opacity, which given the time course likely represents focal atelectasis or aspiration.",0
"8:16 PM CHEST (PORTABLE AP) Clip # Reason: eval for acute process, ET tube placement Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 42yo F newly intubated after tachypnea and oxygen desaturation REASON FOR THIS EXAMINATION: eval for acute process, ET tube placement ______________________________________________________________________________ FINAL REPORT HISTORY: ET tube placement.",0
"FINDINGS: In comparison with study of , there is now an endotracheal tube in place with its tip approximately 5 cm above the carina.",0
Extremely low lung volumes with enlargement of the cardiac silhouette and pulmonary edema.,0
Extensive opacification is seen in the retrocardiac region consistent with substantial volume loss in the left lower lobe with possible effusion.,0
Obliquity of the patient makes it difficult to determine whether there has been any true mediastinal shift.,0
"5:58 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: please eval for ?fluid collection or other source of infecti Admitting Diagnosis: HYPERCARBIC RESPIRATORY FAILURE Field of view: 34 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with trach & peg and new fevers/leukocytosis; s/p long procedure to remove excess tube feeds from esophagous REASON FOR THIS EXAMINATION: please eval for ?fluid collection or other source of infection, esp near G-tube and esophagous; CT chest and abd only through level of G-tube No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Status post G-tube manipulation.",1
Please evaluate for fluid collection.,0
TECHNIQUE: Multidetector CT images were obtained from the thoracic inlet to the pubic symphysis with oral and intravenous contrast.,0
CT OF THE CHEST WITH CONTRAST: The lung fields show bilateral apical scarring.,0
"There are emphysematous changes, more prominently in the apices.",0
There is a unchanged 3-cm mass in the left lingula.,0
"There are multiple 2-3 mm noncalcified pulmonary nodules, which are stable in size.",0
The previously identified left lower lung lobe nodule has resolved.,0
The esophagus again shows diffuse wall thickening.,0
The previously identified air within the esophageal wall is no longer present.,0
"There is no pathologically enlarged axillary or hilar lymphadenopathy; however, there is an 8-mm right paratracheal lymph node, which is unchanged.",0
There are atherosclerotic calcifications throughout the aorta.,0
"CT OF THE ABDOMEN WITH CONTRAST: There are tiny low-density foci within the right lobe of the liver, which are too small to characterize, but are unchanged.",0
"The gallbladder, pancreas, and adrenal glands are unremarkable.",0
"The spleen contains multiple tiny low-density lesions, which are too small to characterize.",0
"Multiple 5-mm rounded hypodensities are seen within the left kidney as well as smaller hypodensities, which are too small to characterize.",0
The right kidney contains one 7-mm rounded hypodensity.,0
These foci most likely represent simple renal cysts.,0
There is no evidence for hydronephrosis or hydroureter.,0
The stomach contains a G-tube.,0
The intraabdominal loops of small and large bowel are unremarkable.,0
"Just medial to the insertion site of the G-tube, primarily within the subcutaneous tissues is a 3.5 x 3.3 cm region of inflammatory fat stranding, most consistent with a phlegmon.",0
This focus of inflammation crosses the abdominal wall and appears to extend into the peritoneum.,0
"(Over) 5:58 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: please eval for ?fluid collection or other source of infecti Admitting Diagnosis: HYPERCARBIC RESPIRATORY FAILURE Field of view: 34 Contrast: OPTIRAY Amt: 150 ______________________________________________________________________________ FINAL REPORT (Cont) CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, intrapelvic loops of small and large bowel, uterus and adnexa, and distal ureters are unremarkable.",1
There is no pathologically enlarged pelvic or inguinal lymphadenopathy.,0
Degenerative changes are seen throughout the thoracolumbar spine.,0
"3.5 x 3.3 cm region of inflammatory fat stranding in the subcutaneous tissues of the midline abdomen, just medial to the G-tube insertion site, most consistent with a phlegmon.",0
This region of inflammation extends from the subcutaneous tissues into the peritoneum.,0
Stable mass within the left lingula.,0
"Interval resolution of the left lung base nodule, which suggests infectious etiology of the nodule seen on the prior scan.",0
"Emphysematous changes throughout the lungs, unchanged.",0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: SURGERY Allergies: Morphine / Iodine Containing Agents Classifier Attending: Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1.,0
Exploration of abdomen and anterior mediastinum.,0
Repair of thoracoabdominal defect with polypropylene mesh interposition 20x25 cm.,0
History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 68 year old male who complains of ABD PAIN.,0
The patient is a 68-year-old gentleman with a long-standing ventral hernia who developed pain at the hernia site today.,0
Timing: Sudden Onset Quality: Dull Severity: Moderate Duration: Hours Past Medical History: 1.,0
"CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2.",0
"CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: five caths since CABG, ATRIUS records attached.",0
"He was put on telemetry, NPO on IVF He was started on his home medications and put on an insulin sliding scale with dilaudid for pain control.",0
"After a preoperative workup, he was transferred to the OR for a ventral hernia repair.",0
Please see the operative note for full details.,0
Post operatively he was transferred to the ICU for recovery.,0
"He had drains in place, had an NGT, was on IV antibiotics perioperatively, he was intubated, had a foley for urine output monitoring, as well as heparin SQ and pneumatic boots for prophylaxis.",0
On he was transfused two units of pRBC.,0
"His CHF was managed with close fluid status monitoring, cardiology consultation, and beta blockers.",0
"On he was transferred to the floor with PPI and HSQ for prophylaxis, NPO on IVF, on telemetry.",0
He had a foley for urine output monitoring.,0
He had an NGT as well as two JP drains.,0
He was started on a subset of his home medicaitons through his NGT.,0
"On , he was transferred back to the ICU for closer monitoring.",0
He was started on his plavix and aspirin.,0
His cardiac status was monitored with EKGs and cardiac enzyme tests.,0
"On , his IV PPI was switched to PO famotidine.",0
He was transferred back to the floor on on his home medications.,0
his NGT was d/ced and he was started on sips of clear liquids.,0
His foley was d/ced and he voided.,0
Later that day he was advanced to full liquids.,0
At this point more aggressive diuresis was necessary and he was started on lasix 20 mg .,0
On he was advanced to a regular diet and restarted on his bumetanide after contacting his cardiologist.,0
"On , a physical therapy consult was initiated.",0
He was given a bowel regimen to help facilitate a bowel movement.,0
"On , his bumetanide dose was increased to 4 mg PO TID.",0
"He was discharged home with services on with close follow up with his surgeon, and VNA for drain care.",0
Medications on Admission: emazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia.,0
2. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).,0
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QSUN (every Sunday).,0
"5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina.",0
"6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).,0
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for stress ulcer ppx.,0
9. bumetanide 2 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day).,0
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
11. ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO q 6 hours () as needed for anti-anginal.,0
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours).,0
13. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours) as needed for angina.,0
14. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
16. potassium chloride 20 mEq Tab Sust.Rel.,0
Particle/Crystal Sig: Three (3) Tab Sust.Rel.,0
Particle/Crystal PO QID (4 times a day).,0
Import Discharge Medications Discharge Medications: Discharge Medications: 1. temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia.,0
9. bumetanide 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day).,0
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours).,0
Disp:*50 Tablet(s)* Refills:*0* 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours).,0
14. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours) as needed for angina.,0
15. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day).,0
16. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
17. potassium chloride 20 mEq Tab Sust.Rel.,0
Discharge Disposition: Home With Service Facility: Health VNA Discharge Diagnosis: Incarcerated strangulated hernia with necrotic small bowel in anterior mediastinum.,0
"Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness.",0
Followup Instructions: Please follow up with Acute care surgery in one to weeks to have your sutures removed and for a check up.,0
"11:11 AM CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # Reason: RO ______________________________________________________________________________ FINAL REPORT INDICATION: Evaluate for interval change in effusions and airspace disease.",0
FINDINGS: The initial chest radiograph was obtained at 6:42AM.,0
"This was repeated at 11:29AM due to the poor technical quality of the first, and these studies are being reported together.",0
There is a tiny right apical pneumothorax.,0
The tracheostomy tube is in appropriate position.,0
The dual chamber pacing leads also are appropriately positioned.,0
"From , there has been interval improvement in the appearance of the left pleural effusion and left retrocardiac opacity.",0
"However, there is now evidence for congestive heart failure with perihilar haziness and indistinctness of the pulmonary vessels.",1
This appearance appears slightly worse on the chest radiograph from 11:29AM than on the chest radiograph from 6:42AM.,0
Interval improvement in the appearance of the left pleural effusion and left retrocardiac opacity.,0
4:49 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
PTX ***PLEASE PERFORM @ 0500 AM**** Admitting Diagnosis: FLAIL CHEST ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with small residual PTX s/p CT pull REASON FOR THIS EXAMINATION: ?,1
"PTX ***PLEASE PERFORM @ 0500 AM**** ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Small residual pneumothorax, evaluation.",1
"FINDINGS: As compared to the previous radiograph, there is an unchanged approximately 1 cm right pneumothorax.",0
No changes in appearance of the right lung.,0
The internal jugular vein catheter has been removed in the interval.,0
Height: (in) 64 Weight (lb): 205 BSA (m2): 1.98 m2 BP (mm Hg): 173/88 HR (bpm): 110 Status: Inpatient Date/Time: at 12:28 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: Dr. was notified by telephone on at 12:45 pm.,0
AORTA: No atheroma in descending aorta.,0
IMPRESSION: Mild to moderate mitral regurgitation with normal valve morphology.,0
No echocardiographic evidence of endocarditis.,0
"10:26 AM CHEST (PORTABLE AP) Clip # Reason: Evaluation of volume overload and effusions Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA\BONE MARROW TRANSPLANT ______________________________________________________________________________ MEDICAL CONDITION: 40F with AML, s/p alloSCT, pulling at central line REASON FOR THIS EXAMINATION: Evaluation of volume overload and effusions ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: AML, check for fluid overload.",1
CHEST: The position of the two central lines is unchanged.,0
Bilateral effusions are present and interstitial alveolar infiltrates are present in both lungs consistent with failure.,0
Size of the effusions has increased.,0
Bilateral alveolar interstitial opacities consistent with failure.,0
"12:07 AM CT C-SPINE W/O CONTRAST Clip # Reason: FOUND DOWN, DELTA MS. ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with delta ms found down REASON FOR THIS EXAMINATION: fracture No contraindications for IV contrast ______________________________________________________________________________ WET READ: DJD WED 3:04 AM Preliminary Results: Agree.",0
"No fracture or malalignment Interpreted by: , MD WET READ VERSION #1 JCT WED 2:02 AM no c-spine fx ______________________________________________________________________________ FINAL REPORT HISTORY: 57-year-old man with mental status changes, found down.",0
TECHNIQUE: Multidetector axial images of the cervical spine were obtained without contrast.,0
FINDINGS: There is no evidence of cervical spine fracture or abnormal alignment of the component vertebrae.,0
Degenerative changes of the lower cervical spine are noted with disc space narrowing and osteophyte formation.,0
Endotracheal and orogastric tubes are noted.,0
"5:43 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please eval lung parenchyma s/p chest tube removal Admitting Diagnosis: CIRRHOSIS;ASCITES;CHEST PAIN;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman hx sarcoid, cirrhosis, with cough, with pleural and pericardial effusions.",0
"S/P pleural biopsy and chest tube placement, now s/p removal REASON FOR THIS EXAMINATION: please eval lung parenchyma s/p chest tube removal ______________________________________________________________________________ FINAL REPORT HISTORY: 58-year-old female, status post chest tube removal.",0
FINDINGS: A single semi-erect AP portable chest radiograph was obtained.,0
There has been interval removal of the left basal pleural drain.,0
There remains a small left pleural effusion.,0
The previously identified tiny left apical pneumothorax is no longer seen.,0
"Otherwise, there has been no significant interval change in appearance of the chest compared to 9:10 a.m. this morning.",0
"4:31 PM CHEST (PRE-OP PA & LAT) Clip # Reason: CONGESTIVE HEART FAILURE;TELEMETRY\TRANSCATHETER AORTIC VALVE IMPLANT (TAVI) W/ DIRECT AORTIC APPROACH Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\TRANSCATHETER AORTIC VALVE IMPLANT (TAVI) W/ DIRECT AORTIC APPROACH ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with severe aortic stenosis REASON FOR THIS EXAMINATION: preop ______________________________________________________________________________ FINAL REPORT INDICATION: 86-year-old woman with severe aortic stenosis, preop.",1
FINDINGS: The lungs are well inflated and clear.,0
"No consolidation, effusion, or pneumothorax is present.",0
There is moderate to severe aortic valve and arch calcification.,1
There is moderate kyphosis of the thoracic spine with multilevel degenerative disease.,0
Surgical clips are seen in the right side of the neck.,0
Admission Date: Discharge Date: Date of Birth: Sex: M Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male brought to the Trauma Resuscitation Bay following a motor vehicle crash involving his vehicle crashing into a house.,1
"Immediately following the impact, the patient noted immediate loss of motor and sensory function in his bilateral lower extremities.",0
PAST MEDICAL HISTORY: The patient's only known past medical history is that of type 2 diabetes mellitus.,0
ALLERGIES: NO KNOWN DRUG ALLERGIES.,0
MEDICATIONS: The patient takes no medications at home.,0
"PHYSICAL EXAMINATION: General: In the trauma bay upon evaluation, the patient was found to be somnolent with a degree of combativeness for which he was immediately intubated.",0
He was afebrile and hemodynamically stable.,0
"HEENT: Pupils equal, round and reactive to light and accommodation with no evidence of obvious head trauma.",0
"Cervical block, collar, and chest were clear.",0
Rectal: He was noted to have no rectal tone.,0
"HOSPITAL COURSE: On trauma series the patient was noted to have C4 burst fracture, and C5, C6, and C7 fractures.",0
He was noted to have no movement or sensation in his bilateral lower extremities.,0
The patient was also noticed to have no sensation in his abdomen.,0
"For these injuries, the patient was started immediately on Solu-Medrol infusion per spinal injury protocol.",1
The patient was immediately taken for CT scan of his head which revealed no acute injury and no bleed.,1
"CT of his cervical spine revealed fractures at C4, C6, T2, and T12, and also most significantly was his C7 fracture which appeared to be the worst which showed the vertebral body had been burst into many pieces.",0
CT of the abdomen and pelvis was negative.,0
Neurosurgical consult was immediately obtained.,0
The patient was kept on strict C-spine logroll precautions and required pressor support to keep his systolics greater than 100.,0
MRI of the cervical spine showed findings consistent with that of his CT scan along with significant cord damage in that area.,0
"Over the next few days, the patient's steroid drip was weaned off, and plans were made for neurosurgical open reduction and internal fixation stabilization of his cervical and thoracic spine.",0
"On , the patient was hemodynamically stable and taken to the Operating Room by the Neurosurgical Service where a C7 vertebrectomy was performed, a C6-T1 anterior arthrodesis infusion was performed along with ............... interbody titanium surgical .............. cage was placed which was packed with vertebral autograft.",0
The patient also received anterior screw with plate fixation.,0
"The patient tolerated the procedure well, and there were no complications.",0
The patient was transferred back to the Trauma Surgical Intensive Care Unit where he remained intubated and was hemodynamically stable.,0
The Orthopedic surgeons had addressed his orthopedic fractures which included a left wrist fracture and right ankle fracture which were splinted.,1
The patient was also found to have a right lower lobe pneumonia with spiking fevers for which antibiotics were started.,0
"Although initially in the Trauma Bay the patient was noted to have no sensation in his bilateral lower extremities and decreased movement of his upper extremities, over the following few days in the Intensive Care Unit, he began to move his upper extremities significantly more and began to become sensate; however, no function appeared to return to his lower extremities.",0
His Intensive Care Unit course at this time remained complicated by several episodes of ventilator associated pneumonia intermittently requiring pressors.,0
The patient underwent several bronchoscopic exams for removal of secretions and plugs.,0
Several attempts were made to wean to extubate which were unsuccessful.,0
"A nasoenteric feeding tube was placed, and tube feeds were started with success.",0
The patient's Intensive Care Unit course continued to be complicated by multiple episodes of ventilator associated pneumonia and central line sepsis.,0
"On , the patient was taken to the Interventional Radiology Suite where a percutaneous gastrojejunostomy feeding tube was placed.",0
"Because of the multiple episodes of line sepsis and problems with central access for this patient, a PICC line was placed; however, the patient also had spiking fevers following this, and this PICC line was removed.",0
"Following several attempts at weaning and failures requiring increased pressure support, on , the patient underwent bedside percutaneous tracheostomy and bronchoscopy to verify placement.",0
He tolerated this procedure well without complication.,0
"Following this, the patient's tube feeds were advanced by his percutaneous gastrojejunostomy tube which he tolerated well.",0
"He slowly became more awake, and his pressure support wean continued slowly which he was tolerating well.",0
The patient underwent speech and swallow study which revealed that his swallowing mechanism was intact.,0
"Due to continued spiking temperatures, the patient underwent a cardiac echocardiogram which revealed no evidence of valve vegetation.",0
"Following this, all intravenous and intra-arterial catheters were discontinued in this patient, and all antibiotics were stopped.",0
He continued on tube feeds with a slow ventilator wean.,0
The patient was pancultured several times following this which revealed sterile cavities.,0
"The patient also grew one blood culture of methicillin resistant Staphylococcus epidermidis; however, this presumably was the only source of infection, so a course of Vancomycin was started and completed.",0
"Although the patient had passed speech and swallow study, he still had copious secretions and was deemed unsafe to begin p.o.",0
"For this reason, he underwent an additional bronchoscopy which revealed secretions but non-occluded airway.",0
"At this point, his ventilatory support decreased.",0
He began to slowly wean from the standpoint of his requirement for pressure support.,0
He was screened for placement and vent rehabilitation.,0
"Following this course of Vancomycin, the patient for the first time in weeks, had become afebrile.",0
He began to take small sips of clears and advanced to soft solids and eventually was taking a regular diet.,0
"After 48 hours or regular diet, the patient was seen to have coughed and not tolerated some of this, so his p.o.",0
"feeds were discontinued, and his tube feeds were resumed by his PEJ tube.",0
"On , the patient remained afebrile with stable vitals signs.",0
"His vent support was at pressure support of 10, PEEP of 7.5, FIO2 50%.",0
"He was taking tidal volumes of 650, breathing 22 times a minute.",0
"On exam he was awake, alert, and oriented times three, and was in no distress.",0
He was in a cervical collar without spinal tenderness.,0
"Pulmonary exam showed coarse breath sounds bilaterally but was oxygenating well, and he was in no distress.",0
"His PEJ tube site was clean, dry, and intact.",0
Extremities were edematous but warm and dry with triphasic Doppler signals and bilateral dorsalis pedis posterior tibial pulses.,0
He has no invasive central venous monitoring and no arterial monitoring.,0
He is maintained on a peripheral IV only.,0
The patient was doing well.,0
He was screened for discharge and will be discharged to a ventilatory rehabilitation facility.,0
"DISCHARGE MEDICATIONS: Zoloft 50 mg per PEJ tube q.d., Lovenox 40 mg subcue b.i.d., regular Insulin sliding scale, Zantac 150 mg per PEJ tube b.i.d., Nystatin swish and swallow 5 cc p.o.",0
"q.i.d., NPH Insulin 27 U subcue b.i.d., Tylenol 650 mg per PEJ tube q.4-6 hours p.r.n., Albuterol and Atrovent MDIs 4-6 puffs q.4 hours p.r.n., Lacrilube drops O.U.",0
"p.r.n., Imodium per PEG tube p.r.n., the patient is receiving tube feeds Impact with fiber at 80 cc/hr at goal through his PEJ tube.",0
It should be noted that the anatomy of the patient's feeding tube is a percutaneous gastroduodenal jejunostomy tube.,0
", MD Dictated By: MEDQUIST36 D: 09:34 T: 10:06 JOB#:",0
8:57 AM CHEST (PORTABLE AP) Clip # Reason: Intubation for resp.,0
"______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with CHF, CAD, s/p PA Cath placment.",0
"hypercarbic, acidotic REASON FOR THIS EXAMINATION: Intubation for resp.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: CHF, CAD, status post PA cath placement.",0
"CHEST, SINGLE AP PORTABLE VIEW: Compared with 2 days earlier, an ET tube has been placed, tip in satisfactory position 5 cm above the carina.",0
"A left subclavian Swan-Ganz catheter is present, with tip over right pulmonary artery.",0
"There is cardiomegaly, diffuse vascular blurring and increased retrocardiac density.",0
Dense carotid artery calcification noted.,0
"Status post sternotomy, with mediastinal clips.",0
"IMPRESSION: 1) Interval placement of ET tube, in satisfactory position.",0
3) Left lower lobe collapse and/or consolidation.,0
"LINE PLACEMENT Clip # Reason: ptx, effusion - icu provider is , please page h Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\LEFT HEART CATH ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with s/p AVR/CABG - cardiac surgery patient, icu provider is , please page him if there is concern with findings REASON FOR THIS EXAMINATION: ptx, effusion - icu provider is , please page him if there is concern with findings ______________________________________________________________________________ WET READ: AJy TUE 11:22 PM ett 8 cm above carina.",1
"ng extends to stomach, tip not well seen.",0
lucencies along the right heart border are c/w postoperative pneumomediastinum.,0
there is basilar atelectasis and likely small effusions.,0
mediastinal widening is likely post-operative and exagerraetd by rotation.,0
"______________________________________________________________________________ FINAL REPORT PORTABLE CHEST RADIOGRAPH, 6:03 P.M. ON HISTORY: Immediate post-cardiac surgery.",1
"IMPRESSION: AP chest compared to preoperative chest radiograph on : Tip of the ET tube is less than 8 cm from the carina, with the chin mildly elevated, 3 cm above optimal placement.",0
"Bibasilar atelectasis is substantial, greater than generally seen initially after heart surgery.",0
Pneumomediastinum is generally of no clinical import.,0
Left pleural effusion is small.,0
The caliber of the postoperative cardiomediastinal silhouette is not unexpected given the preoperative appearance.,0
"Right internal jugular Swan-Ganz catheter passes into the right atrium, but the tip is indistinct.",0
Midline and left pleural drains in place.,0
was paged at the time of dictation.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: Chief Complaint: RUQ pain Reason for MICU transfer: Post-ERCP monitoring, intubated Major Surgical or Invasive Procedure: ERCP with sphincterotomy and stone removal History of Present Illness: 41 year old female with h/o intracranial hemorrhage s/p craniotomy with seizures and L hemiparesis, obesity who initially presented to with RUQ discomfort.",0
"The patient described the RUQ discomfort as acute in onset, constant and associated with nausea and back pain.",0
"No vomiting, fevers, CP, or SOB.",0
"Notably, the patient presented to Hospital on with abdominal pain and underwent CT abd that showed peri-GB fat stranding.",0
She was not admitted on that occassion.,0
"At , the patient was noted to have a low-grade fever to 100.1, HR of 92 and a (+) murphys sign.",0
"Initially laboratory values showed AST OF 374, ALT of 425, Tbili of 1.5 (Dbili 1.2), elevated Alk Phos and normal amylase/lipase.",0
A RUQ US was performed showing numerous gallstones but no evidence of acute cholecystitis.,1
"On HOD #1, the patient's Tbili climbed to 2.5 and her LFTs continued to rise.",0
Per report temp was 102.3 (10pm ).,0
Was transferred to for ERCP.,0
Oxygen sats prior to transfer were low 90s and the patient was placed on a facemask.,0
"On arrival to , the patient was hypoxic to the high 90%s on face mask, low 80s on RA.",0
Intubated and underwent ERCP with general anestesia.,0
2 stones were removed from the CBD and a sphincterotomy was performed.,0
"Following the procedure, the patient was not able to be extubated and was transferred to the for further mgmt.",0
"Of note, the patient intermittently requires O2 at nursing facility (for desats to mid 80s).",0
"In the , the patient was initially hypotensive to the 80s systolic.",0
Propofol was reduced and the patient's PEEP was turned down with good response.,0
"Past Medical History: -Right craniotomy, left VP shunt following ICH -GERD -HTN -HL - Seizure d/o - Asthma - Hypothyroidism Social History: Lives at Healthcare Center nursing facility.",1
17 pack year smoking history although does not smoke presently.,0
Family History: Mother with a history of alcoholism.,0
"Physical Exam: On Admission: Vitals - 99.4 107/70 71 Intubated General- Patient is obese, intubated.",0
"Cardiac- RRR, S1 and S2, no m/r/g Lung- Lung sounds decreased on the left.",0
Good air entry on the right.,0
Limited exam given patient positioning.,0
Could not assess tenderness as patient sedated.,0
Extremeties- No gross deformity or edema Neuro- Intubated and sedated.,0
"On Discharge: Vitals: 98.8 120/68 102 22 93%RA GEN: Obese female, no acute distress.",0
"HEENT: Mucous membranes moist, no lesions noted.",0
NECK: Unable to assess JVP.,0
"CV: Regular rate and rhythm, no murmurs, rubs or .",0
PULM: Shallow breaths but clear.,0
"ABD: Soft, reports diffuse tenderness across abdomen, worst in right upper, non distended, bowel sounds present.",0
"No hepatosplenomegaly EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally.",0
Dense hemiparesis of left upper and lower extremities SKIN: No ulcerations or rashes noted.,0
Pertinent Results: ADMISSION LABS: 12:13PM BLOOD WBC-7.7 RBC-4.06* Hgb-11.7* Hct-36.9 MCV-91 MCH-28.9 MCHC-31.8 RDW-15.1 Plt Ct-189 12:13PM BLOOD Glucose-96 UreaN-23* Creat-1.0 Na-139 K-6.5* Cl-105 HCO3-27 AnGap-14 01:45PM BLOOD ALT-466* AST-182* LD(LDH)-171 AlkPhos-385* TotBili-0.8 12:13PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9 DISCHARGE LABS: 01:10PM BLOOD WBC-8.9 RBC-4.50 Hgb-13.0 Hct-39.1 MCV-87 MCH-28.9 MCHC-33.3 RDW-14.8 Plt Ct-216 01:10PM BLOOD Glucose-93 UreaN-35* Creat-0.9 Na-142 K-3.7 Cl-100 HCO3-31 AnGap-15 06:50AM BLOOD ALT-13 AST-13 AlkPhos-83 TotBili-0.4 Micro: 1:50 pm URINE Source: Catheter.,0
"10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S 1:06 am Blood Culture, Routine (Final ): NO GROWTH.",0
6:38 pm URINE CULTURE (Final ): NO GROWTH.,0
Catheter Tip: WOUND CULTURE (Final ): No significant growth.,0
5:29 pm PLEURAL FLUID **FINAL REPORT ** GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
5:37 pm PERITONEAL FLUID **FINAL REPORT ** GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.,0
12:08 pm SPUTUM Source: Endotracheal.,0
7:36 pm SPUTUM Source: Endotracheal.,0
**FINAL REPORT ** GRAM STAIN (Final ): PMNs and >10 epithelial cells/100X field.,0
Studies: ERCP: Successful cannulation of the bile duct (cannulation) Two stones at the biliary tree A sphincterotomy was performed.,0
"2 stones were extracted successfully using a balloon catheter(sphincterotomy, stone extraction) Otherwise normal ercp to third part of the duodenum CT Chest () - 1.",0
The endotracheal tube has its tip approximately 1.5 cm above the carina.,0
It should be repositioned by pulling back at least 2-3 cm.,0
"The patient's nurse, , was notified of the need for repositioning at 2:30 p.m. on and informed me that the tube has already been repositioned and a followup chest film has been ordered.",0
Consolidative process within the left lung with some residual aerated lung at the left base and in the region of the lingula.,0
"Although this may represent atelectasis, other processes such as aspiration, pulmonary hemorrhage or pneumonia should be considered.",0
The right lung is low in volume but grossly clear.,0
Cardiac and mediastinal contours are difficult to assess due to marked patient rotation on the current examination.,0
CT Head () - IMPRESSION: 1.,0
Left frontal approach ventriculostomy shunt catheter terminating in the region of the septum pellucidum.,0
Evidence of prior right-sided hemorrhagic infarct with postsurgical changes from right frontoparietal craniotomy.,0
"Following drainage, the loculated left upper lung collection has completely resolved with residual opacity which is likely a combination of atelectasis and chronic pleural thickening.",1
"Since , lower lung atelectasis has progressed to complete collapse of the right lower lobe and partial collapse of right upper lobe.",0
Mild-to-moderate opacities in the middle lobe is likely atelectasis or secondary to aspiration.,0
Left lower lung atelectasis is fairly unchanged.,0
The ventriculoperitoneal shunt catheter ends in the peritoneal cavity of upper abdomen and there is no associated fluid collection.,0
ECHO: The left atrium is elongated.,0
No definite intracardiac shunt is identified on intravenous saline injection.,0
No intracardiac shunt identified (images are suboptimal and cannot exclude a small PFO).,0
"CTA: FINDINGS: There is no main, branch, lobar, or segmental pulmonary embolus.",0
The main pulmonary artery is dilated to 3.8 cm.,0
"Branch arteries are also prominent, with peripheral pruning, compatible with pulmonary arterial hypertension.",1
"Thoracic aorta is normal in caliber throughout, without aneurysm or dissection.",0
Calcifications involve the thoracic aorta and coronary arteries.,0
"The heart is normal in size, without pericardial effusion or right heart strain.",0
"Moderate left pleural thickening and simple effusion persist, with prominent loculations along the left mediastinum and left cardiophrenic angle (3:57, 40B:38).",1
"Prior foci of air have resolved, and faint linear rim enhancement remains following instrumentation.",0
"Pulmonary aeration appears minimally improved at the lung bases, with persistent bilateral areas of discoid atelectasis.",0
"Mild central irregular bronchial wall thickening is present, which may be compatible with small airways disease.",0
"Again noted are multiple prominent paraaortic nodes measuring up to 8-9 mm, likely reactive.",0
There is a small sliding hiatal hernia.,0
Left ventriculoperitoneal shunt is noted in the left anterior chest wall.,0
Note is made of a sternal foramen.,0
Examination is not tailored for subdiaphragmatic evaluation.,0
"Extubation, with continued areas of diffuse subsegmental atelectasis.",0
"Moderate left effusion and pleural thickening, with small medial loculations.",1
Portable CXR: FINDINGS: No relevant changes in the lungs since .,0
Low lung volumes with mild bibasal atelectasis are unchanged.,0
Mild widening of the mediastinum to the left side extending to the apex which is a persisting postoperative feature has been stable since .,0
No new lung opacities of concern.,0
"Mild to moderately enlarged heart, mediastinal and hilar contours are stable.",0
Brief Hospital Course: Ms. is a 42 year-old female with neurological deficits who presented with cholangitis.,1
Intubated for ERCP due to hypoxia on presentation.,0
Found to have VP shunt and fluid collection in pleural space.,0
"Cholangitis - The patient initially presented to with fever, RUQ pain and elevated Tbili.",0
A RUQ US there showed numerous gallstones but no evidence of acute cholecystitis.,1
"Per report, temp was 102.3 (10pm ).",0
At the patient underwent ERCP with 2 stones removed from the CBD and a sphinterotomy was performed.,0
The patient finished a 10 day course of Zosyn.,0
She was scheduled to see surgery as outpatient for discussion of cholecystectomy.,0
Respiratory failure - The patient was hypoxic to the 77% saturation on arrival to .,1
Unclear what patient's baseline level of oxygenation is although per nursing facility she does intermittently require O2 supplementation for sats in the mid-80s.,0
She was intubated for her ERCP with plans to transfer the patient intubated to the ICU after.,0
"In the ICU, the patient had been requiring high levels of oxygenation, likely multifactorial, related to sedation, probable restrictive disease from habitus, atelectasis, OSA or obesity hypoventilation syndrome, and pulmonary edema.",1
"After VP shunt revision (see below), patient was diuresed and weaned off sedation.",0
She was extubated successfully on .,0
"She continued to be hypoxic on the floor, and we attempted CPAP at night due to suspected OSA, although the patient had great difficulty with compliance.",0
"Further diuresis was attempted on the floor, resulting in improvement in oxygenation.",0
CTA was performed that did not show pulmonary embolus.,0
CXR showed atelectasis and low lung volumes.,0
She was scheduled to follow up with pulmonary as outpatient.,0
She should get formal PFT testing as well as a sleep study as we suspect she may have a diagnosis of OSA or obesity hypoventilation syndrome.,1
VP shunt - The patient has a VP shunt placed at in .,0
"Per records, the VP shunt was initially left draining into the pleural space.",0
"On presentation here, CXR showed opacification of the LUL.",0
A CT revealed a large fluid collection in the pleural space believed to be CSF.,0
Neurosurgery was consulted and took the patient for a VP shunt revision.,0
Shunt was placed in the peritoneal space.,0
Pleural effusion was drained; pleural fluid cultures did not grow organisms.,1
"Menstrual bleeding: Patient with heavy period of 1 week duration, then recurred 2 days later.",0
be related to dermoid cyst seen on OSH imaging.,0
Patient can follow-up as an outpatient for further work-up.,0
L leg pain: Pt reported chronic left foot pain.,0
Continued Tylenol and Oxycodone #.,0
"Seizure D/o - Continued home depakote, diazepam, and risperidone.",0
She showed occasional agitation and noncompliance with medical care.,0
She was given quetiapine 25mg prn for agitation.,0
HTN - Held all anti-hypertesnives in the setting of acute illness.,0
She had been on lisinopril 5mg daily at rehab.,0
This may be restarted at rehab if BP is elevated and electrolytes/kidney function are stable.,0
HL - Continued simvastatin #.,0
Hypothyroidism - Continued levothyroxine #.,0
Asthma - Continued albuterol once extubated.,0
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).,0
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical (2 times a day).,0
4. risperidone 1 mg/mL Solution Sig: 0.25 PO HS (at bedtime).,0
"5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily).",0
"6. divalproex 500 mg Tablet, Delayed Release (E.C.)",0
"7. divalproex 125 mg Tablet, Delayed Release (E.C.)",0
PO QHS (once a day (at bedtime)).,0
PO DAILY (Daily) as needed for Constipation.,0
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation.,0
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day).,0
"11. ergocalciferol (vitamin D2) 8,000 unit/mL Drops Sig: One (1) 50000U PO 1X/WEEK ().",0
12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
"13. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical (2 times a day).",0
14. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation.,0
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain.,0
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
"18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain, fever.",0
19. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain.,0
20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze.,0
"Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day.",0
Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation.,0
23. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO every eight (8) hours as needed for constipation.,0
"Discharge Disposition: Extended Care Facility: Health Care Center - Discharge Diagnosis: Cholangitis Pleural effusion VP shunt Discharge Condition: Mental Status: Answers to questions appropriately but often non-compliant with care, has cognitive dysfunction Level of Consciousness: Alert and interactive.",1
Discharge Instructions: Dear Ms. You were admitted to the hospital because you had a severe infection of your biliary tract.,1
You underwent a procedure called ERCP that removed two infected gallstones from your bile duct.,0
You were scheduled to see a surgeon in the next few weeks to discuss removal of your gallbladder You had to stay in the ICU for a while because your oxygen levels were low and needed a breathing tube.,0
Your oxygen saturation improved but were on the lower end of normal.,0
You were scheduled to see a pulmonary doctor for further evaluation as outpatient (see appointments below).,0
"Finally, you have a shunt going from your brain to your abdomen that had to be fixed.",0
"This was done by our neurosurgeons The following changes were made to your medications: -miconazole and nystatin powders were started for rash -lisinopril 5mg daily was HELD; if your blood pressure starts to rise, you may be restarted on this medication Followup Instructions: Name: DO,HUNG T Specialty:INTERNAL MEDICINE Address: 16 BRANCH , , Phone: **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge.",0
"** Department: PULMONARY FUNCTION LAB When: MONDAY at 9:10 AM With: PULMONARY FUNCTION LAB Building: Campus: EAST Best Parking: Garage Department: MEDICAL SPECIALTIES When: MONDAY at 9:30 AM With: , M.D.",0
Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: PFT When: MONDAY at 9:30 AM Department: GENERAL SURGERY/ When: THURSDAY at 3:00 PM With: ACUTE CARE CLINIC Building: LM Bldg () Campus: WEST Best Parking: Garage MD Completed by:,0
"1:28 PM HAND (AP, LAT & OBLIQUE) RIGHT PORT; ELBOW (AP, LAT & OBLIQUE) RIGHT PORTClip # Reason: fractures Admitting Diagnosis: BLUNT TRAUMA ______________________________________________________________________________ MEDICAL CONDITION: 30M s/p polytrauma with overlying laceration/ecchymoses REASON FOR THIS EXAMINATION: fractures ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Polytrauma.",0
Portable radiographs obtained at the bedside of the patient in ICU were brought to our review and focusing on elbow and wrist.,0
As compared to the prior radiograph the displaced fracture of the mid shaft of the ulna is noted as well as second fracture through the distal ulna.,1
The findings are concerning for Monteggia fracture.,1
The imaging of the wrist is limited but dislocation of the ulna cannot be entirely excluded.,0
"4:15 PM BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # Reason: EVALUATE LUNGS AND STATUS LEFT PNEUMOTHORAX, , ****PLEASE D Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with LEFT PNEUMOTHORAX, CHEST TUBE REPLACED REASON FOR THIS EXAMINATION: EVALUATE LUNGS AND STATUS LEFT PNEUMOTHORAX ****PLEASE DO X-TABLE LATERAL IN ADDITION TO AP VIEW**** ______________________________________________________________________________ FINAL REPORT A chest x-ray taken on at 1627 hours and compared to at 1423 hours.",0
FINDINGS: Endotracheal tube remains at the carina.,0
No change in chest tube or central lines.,0
"Small left medial pneumothorax noted, which is slightly larger than on the comparison film.",0
"3:38 PM ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # Reason: eval ruq for potential cirrhosis in 47 male w/ hcv and mild Admitting Diagnosis: UNRESPONSIVE ______________________________________________________________________________ MEDICAL CONDITION: 47 year old man with hcv, etoh abuse admitted w/ mental status changes and now w/ mild abdominal pain, labs c/w mild pancreatitis REASON FOR THIS EXAMINATION: eval ruq for potential cirrhosis in 47 male w/ hcv and mild pancreatitis and transaminitis - would like to r/o biliary path and and eval pancreas ______________________________________________________________________________ FINAL REPORT ABDOMINAL ULTRASOUND PORTABLE STUDY: INDICATION: Abdominal pain, ethenol abuse, hepatitis C, abnormal liver function studies.",1
The liver is heterogeneous in echotexture with no focal mass lession.,0
No intra or extrahepatic bile duct dilatation is noted.,0
The gallbladder is not distended and has no wall thickening or stones.,0
No ascites or adenopathy is noted.,0
The common duct measures 5 mm in maximal diameter.,0
"The right kidney measures 12 cm in length with no mass lesions, stones or hydronephrosis.",0
"The left kidney measures 11.5 cm in length with no mass lesions, stones or hydronephrosis.",0
IMPRESSION: Mildly heterogeneous liver echotexture with no focal mass lesions.,0
Height: (in) 62 Weight (lb): 100 BSA (m2): 1.43 m2 BP (mm Hg): 136/68 HR (bpm): 73 Status: Inpatient Date/Time: at 14:19 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%).,0
RIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiac surgery.,0
Mild (1+) MR. Eccentric MR jet.,0
A paravalvular mitral prosthesis leak is probably present.,0
IMPRESSION: Thickened mitral prosthesis with higher than normal gradients.,0
"If clinically indicated, a TEE would better evaluate the the function of the mitral prosthesis.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: Chief Complaint: syncope Major Surgical or Invasive Procedure: Pacemaker Implantation History of Present Illness: 78 year old woman with history of atrial fibrillation on coumadin and h/o CVA (residual mild right hemiparesis), presented initially to OSH with syncope and bradycardia.",1
She was found sitting on the floor without recollection of the events preceeding.,0
"Denied preceeding chest pain, lightheadedness or diaphoresis.",0
"Upon waking, had new right shoulder and right hip pain as well as a new ecchymosis on right forehead.",0
"At the OSH ( Hosp), she was found to have a small right frontal parietal subcutaneous hematoma, CT head was without acute intracranial pathology.",0
ECG showed afib with inferolateral scooping ST depressions.,0
INR was therapeutic at 2.4.,0
She was hemodynamically stable despite brief epsisodes of bradycardia into the high 30s.,0
Her neurological exam was at baseline.,0
Xrays of right hip and right shoulder were negative.,0
ASA 325mg and nitropaste were administered and she was transferred to BIMDC for further workup.,0
She received nitropast and aspirin prior to admission.,0
Her daughter left the hospital prior to patient arriving on the floor thus the history is somewhat abreviated.,0
"Per report from the caridology fellow who saw her in the ED, she was recently confused and was aggressive towards her daughter which is unusual.",0
"In the ED, initial VS: 99.8 67 148/57 18 97% 2l.",0
"Labs notable for trop 0.07, Creatinine 1.4, BUN 33, Digoxin 2.2, WBC 10.9, HCT 29.9 with MCV 93, INR 2.5, K 3.6.",0
"ECG showed depressed scooped ST segments in I, II, avF and V3-V6.",0
Most recent set of vitals: 97.6 63 (in & out of afib with episodes of bradycardia to the 30's not causing hemodynamic or subjective compromise) 141/57 22 98% RA.,0
"Upon arrival to the floor, HR ranged from 33-70s without symptoms or evidence of AV block.",0
"She denies chest pain, SOB, palpitations, lightheadedness or dizziness.",0
No vision changes or color changes in field of vision.,0
She does not recall todays morning events (cannot remember waking up or eating breakfast).,0
No paresthesias or weakness above her baseline.,0
"She has intermittent diarrhea, last occured 1 week prior to admission.",0
"Past Medical History: atrial fibrillation on coumadin CVA with mild residual right sided hemiparesis DM2 HLD HTN Social History: Lives with her daughter, she is widowed.",1
"No tob, ETOH or IVDA.",0
Walks independently without walker or cane.,0
"Family History: brother with throat cancer, no CAD/DM2 or malignancy Physical Exam: ADMISSION EXAM VS - 98 175/77 63 sinus 20 97% RA GENERAL - NAD, comfortable, appropriate, subtle poor short term memory HEENT - NC/AT, PERRLA, EOMI intact during interviwe, but upon testing EOM she does not follow well on right indicating possible visual field deficit, sclerae anicteric, MM dry, OP clear NECK - supple, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength throughout, sensation grossly intact throughout .",0
"DISCHARGE EXAM VS: 98.1, BP 120-140/50-70, HR 80, RR 18, O2 sat 97% on RA GEN: NAD, A & O X2 (person and place) NECK: supple, JVD flat, HEART: Irregularly irregular, good S1, S2, no m/r/g LUNG: CTA BL, no w/r/rh ABD: soft, NT/ND, no HSM EXT: no pitting edema, 2+ DP/PT bilaterally Pertinent Results: ADMISSION LABS 07:55PM BLOOD WBC-10.9 RBC-3.21* Hgb-9.8* Hct-29.9* MCV-93 MCH-30.5 MCHC-32.7 RDW-16.1* Plt Ct-242 07:55PM BLOOD Neuts-81.1* Lymphs-15.0* Monos-3.4 Eos-0.1 Baso-0.3 07:55PM BLOOD PT-26.4* PTT-35.0 INR(PT)-2.5* 07:55PM BLOOD Glucose-206* UreaN-33* Creat-1.4* Na-137 K-3.6 Cl-97 HCO3-27 AnGap-17 07:55PM BLOOD TotProt-6.9 Calcium-9.6 Phos-2.4* Mg-1.2* .",0
DISCHARGE LABS 06:00AM BLOOD WBC-9.6 RBC-2.90* Hgb-9.1* Hct-27.4* MCV-94 MCH-31.3 MCHC-33.2 RDW-16.3* Plt Ct-206 06:00AM BLOOD PT-25.8* PTT-31.3 INR(PT)-2.5* 06:00AM BLOOD Glucose-183* UreaN-37* Creat-1.4* Na-135 K-4.2 Cl-97 HCO3-27 AnGap-15 06:00AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.3 .,0
CARDIAC ENZYMES 07:55PM BLOOD CK-MB-6 07:55PM BLOOD cTropnT-0.07* 08:09AM BLOOD CK-MB-4 cTropnT-0.08* 04:17AM BLOOD CK-MB-3 cTropnT-0.05* .,0
PERTINENT STUDIES 06:45AM BLOOD ALT-17 AST-46* AlkPhos-57 TotBili-0.5 06:45AM BLOOD TSH-1.8 07:55PM BLOOD Free T4-1.7 09:13AM BLOOD Lactate-1.8 07:55PM BLOOD Digoxin-2.2* 06:00AM BLOOD Digoxin-1.5 .,0
PERTINENT STUDIES # CXR There is moderate cardiomegaly.,0
Bibasilar atelectasis are larger on the right side.,0
There is no evident pneumothorax or pleural effusion.,0
# CT noncontrast FINDINGS: There is no evidence of hemorrhage or recent infarction.,0
"Regions of hypodensity in the left frontal, parietal, and occipital lobes as well as in the right parietal love (2; 23) represent sequelae of prior infarction; these appear similar to prior exam.",0
There is no edema or mass effect.,0
Prominence of the ventricles reflects age-related atrophic change.,0
Subtle periventricular hypodensities represent chronic small vessel ischemic changes.,0
The visualized paranasal sinuses demonstrate mild mucosal thickening of the sphenoid sinuses.,0
IMPRESSION: Sequelae of old infarction but no evidence of hemorrhage or recent infarction.,0
# ECHO (TTE) Conclusions The left atrium is elongated.,0
There is mild to moderate regional left ventricular systolic dysfunction with apical aneurysm/dyskinesis and near akinesis of the anterior wall and distal septum.,1
IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction (mid-LAD distribution) and apical aneurysm.,1
"# Carotid series IMPRESSION: On the right, minimal plaque with less than 40% carotid stenosis.",0
"On the left, possible ICA occlusion; however, no confirmatory study.",0
# CXR PA/LAT The left-sided pacemaker has been placed with its tip terminating in the expected location of the right ventricle.,0
There is no substantial change in the cardiomegaly.,0
There is substantial interval improvement up to complete resolution of pulmonary edema.,0
Still present small bilateral pleural effusions are noted.,0
"There is no definite pneumothorax seen, but minimal amount of apical pleural air cannot be excluded.",0
"Brief Hospital Course: 78 y/o woman with atrial fibrillation on coumadin and h/o CVA, who was transferred from OSH s/p syncope and was found bradycardic.",1
"ACTIVE ISSUES: # Digixin toxicity: Pt presented with bradycardia in 40-50s, with occasional drop to 30s.",0
"Although the cause of bradycardia is likely multifactorial, digoxin toxicity was high on the differential given her subacute worsening of diarrhea and personality changes in the past several weeks.",0
"Her digoxin level on admission was 2.2, however, the digoxin level does not correlate with toxicity, especially in elderly.",0
"Pt had a ~6 sec pause on the night of admission, and subsequently responded after one round of CPR.",0
Two vials of digoxin binder was given in this setting.,0
Her repeat digoxin level was 1.5. .,0
# Bradycardia: Pt presented with hemodynamically stable bradycardia on admission.,0
"The causes of her bradycardia include digoxin toxicity, tachy-brady syndrome, and iatrogenic effect from nodal agents.",0
"Her medication were held on admission, and digoxin binder was provided in the setting of asystole.",0
A single lead ventricular pacemaker was placed.,0
Pt tolerated the procedure well with native atrial fibrillation rhythm in 70-80 bpm at the time of discharge.,1
"# Syncope: Pt underwent unwitnessed fall at home, which she did not have recollection of, likely representing a syncopal episode.",0
"At OSH, workup was notable for right frontal/parietal hematoma, but no evidence of subdural hematoma or fractures.",0
Her INR was therapeutic at 2.4.,0
"A repeat CT-head noncontrast was performed after the transfer, which again did not reveal intracranial bleed.",0
"The cause of her syncope was unclear, but could be explained by the bradycardia.",0
"# Altered mental status: Pt presented with borderline mental status, was significantly worse than her baseline per family.",0
"There was a subacute process, notable for more aggressive behavior in the past 2-3 weeks prior to admission.",0
There was also a more acute change to wax- confusion and somnolence.,0
The etiology is felt multifactorial.,0
Digoxin toxicity could be responsible for the subacute changes.,0
"However, the more acute changes likely represents a delirious process.",0
"Pt was found to have developed UTI during this admission, which was treated with iv antibiotics.",0
"Workup was notable for normal TSH, liver function.",0
"Pt received monthly B12 infusion, thus unlikely the culprit.",0
Delirium in elderly going through acute stress of hospitalization is most likely explanation.,1
"However, acute on chronic vascular dementia secondary to a recent CVA cannot be completely ruled out.",1
# UTI: Pt was found to have developed positive UA during this admission.,0
She had no urinary symptoms.,0
We decided to treat given her altered mental status.,0
We avoided Cipro and Bactrim given she was on coumadin and treated her with iv ceftriaxone.,0
# systolic CHF: Pt was found to have worsened systolic function to 40% from 55-60% last year.,0
"ECHO also revealed LVH with regional systolic dysfunction (mid-LAD distribution), apical aneurysm as well as mild pulmonary artery systolic hypertension.",1
Pt represented with mildly elevated troponin with no CKMB elevation.,0
"Pt was otherwise asymptomatic, with no EKG changes.",0
The elevated troponin most likely came from bradycardia in the setting of worsening kidney function.,0
"However, a subacute ischemic event could not be completely ruled out, especially given the new ECHO findings.",0
Pt may need repeat ECHO.,0
# Hypoxia: Pt developed pulmonary edema in the setting of iv fluid on the presumption of hypovolemia on admission.,0
She was treated with iv lasix which she responded well.,0
CHRONIC ISSUES # Atrial fibrillation: Pt has paroxysmal atrial fibrillation with CHADS score .,1
"We continued her warfarin at home dose, and adjusted her rate control with metoprolol 50 mg daily.",0
"# Renal insufficiency: Pt's Cr during this admission is 1.2-1.4, which were close to her recent value of 1.4-1.5. .",0
Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.,0
2. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.,0
3. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day.,0
"4. warfarin 2 mg Tablet Sig: One (1) Tablet PO 16 PM ON TUE, WED, FRI, SAT, SUN ().",0
"5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q16PM ON MON, ().",0
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day.,0
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).,0
10. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.,0
11. valsartan 40 mg Tablet Sig: One (1) Tablet PO twice a day.,0
12. ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a day for 1 days: Please give on .,0
Discharge Disposition: Extended Care Facility: HealthCare Center at Discharge Diagnosis: Primary diagnosis - digoxin toxicity - Tachy-brady syndrome Secondary diagnosis - atrial fibrillation - bradycardia - diabetes mellitus type 2 - hypertension Discharge Condition: Mental Status: Alert and confused (oriented x place and person) at times Level of Consciousness: Alert and interactive.,1
"Discharge Instructions: Dear Ms. , .",0
You came to our hospital after having a fall and striking your head.,0
You were found to have low heart rate as well.,0
You were found to have elevated levels of digoxin which were likely contributing to your symptoms.,0
Your digoxin was stopped and you were also given a medication to decrease the level of medicaiton.,0
You had a pacemaker placed for your low heart rate.,0
You also repeated an Cat scan of your head and this was reasurring that there was no bleeding or other acute changes.,0
You were then discharge to a rehabilitation facility.,0
"We have made the following changes to your medications: - Please STOP digoxin - Please STOP diltiazem - Please INCREASE metoprolol succinate to 50 mg tablet by mouth daily - Please START ceftriaxone 1 g iv for one additional dose on for urinary tract infection - Please START valsartan 40 mg by mouth twice a day - Please START aspirin 81 mg by mouth daily - Pleaes DECREASE allopurinol to 100 mg tablet by mouth daily - Please continue to take the rest of your medication We also recommend that you discuss with your PCP the change of your anti-diabetic medications given your age, creatine clearance and CHF.",1
Please continue your routine followup at clinic at after leaving the rehab.,0
It has been a pleasure taking care of you here at .,0
We wish you a speedy recovery.,0
Followup Instructions: When: FRIDAY at 11:10 AM With: Dr.,0
4:19 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ngt positioning Admitting Diagnosis: ACUTE APPENDICITIS ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with chf REASON FOR THIS EXAMINATION: ngt positioning ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Nasogastric tube positioning.,1
"FINDINGS: As compared to the previous radiograph, the nasogastric tube is now visible.",0
It is coiled in the stomach but the tip is located in the middle parts of the stomach.,0
"No evidence of complications, notably no pneumothorax.",0
9:55 AM CHEST (PA & LAT) Clip # Reason: eval.,0
"for gastric dilation Admitting Diagnosis: ESOPHAGEAL CA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 33 year old woman s/p esophagectomy, right chest tube removed REASON FOR THIS EXAMINATION: eval.",0
for gastric dilation ______________________________________________________________________________ FINAL REPORT CHEST 2 VIEWS: INDICATION: 33 y/o woman s/p esophagectomy.,0
"COMMENT: PA & lateral radiographs of the chest are reviewed, and compared with the previous study of .",0
The patient is s/p esophagectomy.,0
The right chest tube has been removed.,0
There is a small right apical pneumothorax (10%).,0
There is continued small right pleural effusion and patchy atelectasis in the right lung base.,0
There is probably a small left pleural effusion as well.,0
IMPRESSION: 1) Small right apical pneumothorax (10%).,0
Continued small right pleural effusion and patchy atelectasis in the right lower lobe.,0
12:31 AM ERCP S&I () Clip # Reason: 58 yo female with suspected ascending cholangitis 2 to pancr Admitting Diagnosis: PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 58 year old woman with REASON FOR THIS EXAMINATION: 58 yo female with suspected ascending cholangitis 2 to pancreatic mass obstruction ______________________________________________________________________________ FINAL REPORT HISTORY: 58 year-old woman with suspected ascending cholangitis secondary to pancreatic mass obstruction.,1
FINDINGS: Thirteen fluoroscopic spot images from an ERCP procedure performed by the gastroenterology department are provided for review.,0
The scout view demonstrates a plastic biliary stent present in the common bile duct.,0
Subsequent images showed removal of the stent.,0
There is a stricture of the distal common bile duct with marked dilatation and irregularity of the proximal common bile duct.,0
The differential for this includes tumor infiltration.,0
Subsequent images demonstrate balloon dilatation of the strictured region and subsequent placement of two double pigtail catheters in the distal common bile duct.,0
IMPRESSION: Marked dilatation of the proximal common bile duct secondary to an irregular stricture appearance of the distal common bile duct secondary to tumor.,0
2:35 PM ART DUP EXT LO UNI;F/U Clip # Reason: graft survillance on LEFT ONLY.,0
Right is too painful to do a Admitting Diagnosis: ISCHEMIC LEGS ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man s/p Left common femoral artery to above-knee popliteal artery bypass graft with 8-mm ringed PTFE ' who had graft occlusion s/p thrombecctomy REASON FOR THIS EXAMINATION: graft survillance on LEFT ONLY.,1
"Right is too painful to do an ultrasound on ______________________________________________________________________________ FINAL REPORT ARTERIAL STUDY DATED 27 HISTORY: Left common femoral to above-knee popliteal bypass graft with PTFE in , status post thrombectomy, assess for patency.",1
"FINDINGS: The peak systolic velocity within the left common femoral artery is 238 cm/sec and that at the proximal graft anastomosis with this vessel, 154 cm/sec.",1
"Graft velocities range from a minimum of 45 cm/sec to a maximum of 76 cm/sec, the former occurring at the distal graft anastomosis with the native vessel.",1
Peak systolic velocity within the native popliteal artery is 47 cm/sec.,0
"All waveforms of note, are monophasic.",0
IMPRESSION: Widely patent left common femoral to popliteal bypass graft.,1
Monophasic waveforms indicate presence of some baseline underlying ischemia of the left lower extremity distal to the popliteal artery.,1
"8:53 AM CHEST (PORTABLE AP) Clip # Reason: evaluate left lower lobe Admitting Diagnosis: CHEST PAIN,HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 69 year old man s/p CABG REASON FOR THIS EXAMINATION: evaluate left lower lobe ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST COMPARISON: .",0
"Left internal jugular vascular catheter has been placed, terminating in the proximal to mid superior vena cava with no pneumothorax.",0
"Nasogastric tube is in place, and quells within the proximal stomach.",0
Left hemidiaphragm is moderately elevated.,0
Homogenous opacity in left retrocardiac region persists and probably reflects a combination of atelectasis and effusion.,0
"Asymmetrical pulmonary edema is present, affecting the right lung to a greater degree than the left.",0
Superimposed secondary processes such as aspiration in the right lung is also possible in the appropriate clinical setting.,0
5:20 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC--bedside unable to evaluate.,0
Admitting Diagnosis: BILATERAL FEMORAL FX ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS.,0
"ACCESS C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** ______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with COPD REASON FOR THIS EXAMINATION: Please place PICC--bedside unable to evaluate.",0
______________________________________________________________________________ FINAL REPORT HISTORY: 66 year-old-female with COPD and need for intravenous medications.,0
Please place single lumen PICC line.,0
"PHYSICIANS: The procedure was performed by Dr. , Dr. , and Dr. .",0
"Dr. , the staff radiologist was present and supervising throughout the entire procedure.",0
PROCEDURE: The patient was placed supine on the angiography table.,0
Her left upper extremity was prepped and draped in the standard sterile fashion.,0
The skin was anesthetized with 3 cc of 1% Lidocaine.,0
"Under ultrasonographic guidance, the left basilic vein was accessed using a 21-gauge micropuncture needle.",0
A 0.018 guidewire was advanced through the access needle into the superior vena cava under fluoroscopic guidance.,0
The access needle was exchanged for a 4- French micropunture sheath with inner dilator.,0
"Based on the markers on the guidewire, it was determined that a length of 31 cm would be appropriate.",0
The PICC line was then trimmed to length and advanced over the guidewire through the peel-away sheath into the superior vena cava.,0
It was secured to the skin using a Stat-Lock device.,0
"FINDINGS: A final AP chest x-ray was obtained, demonstrating the tip of the catheter to be present in the superior vena cava just above the right atrium.",0
"IMPRESSION: Successful placement of a 31 c long, 4-French single lumen PICC line via the left basilic vein.",0
"4:28 AM UNILAT LOWER EXT VEINS LEFT Clip # Reason: please eval for DVT Admitting Diagnosis: ALCOHOLIC HEPATITIS ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with HRS, liver failure, now with new LLE swelling, erythema, pain REASON FOR THIS EXAMINATION: please eval for DVT ______________________________________________________________________________ WET READ: KYg TUE 5:34 AM no dvt ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: 59-year-old fell with pain.",1
"LEFT UNILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: -scale and Doppler son of the left common femoral, superficial femoral, and popliteal veins were performed.",0
"Normal waveform, flow, compressibility, and augmentation is demonstrated.",0
"3:14 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: DYSPNEA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with myasthenia , shortness of breath.",0
REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:09 AM Low lung volumes.,0
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Shortness of breath in a patient with myasthenia .,0
Portable AP chest radiograph was compared to obtained at 4:21 a.m.,0
The bibasilar linear opacities are demonstrated that might be attributable to suboptimal inspiration effort.,0
Small bilateral pleural effusion cannot be excluded.,0
"12:37 PM UGI AIR Clip # Reason: Please schedule after stress test., , 44 DM in DKA c/o dysp ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with DM, dysphagia.",0
REASON FOR THIS EXAMINATION: Please schedule after stress test.,0
44 DM in DKA c/o dysphagia.,0
History of etoh and tobacco.,0
Eval for strictures or masses.,0
______________________________________________________________________________ FINAL REPORT INDICATION: History of dysphagia.,0
Complains of intermittent sensation of food sticking but not becoming stuck in the lower esophagus.,0
Comparison is made to study of .,0
DOUBLE CONTRAST UPPER GI EXAMINATION: Thick barium passed freely through the esophagus and into the stomach.,0
There is a normal primary stripping wave within the esophagus.,0
No mucosal abnormalities are identified.,0
No hiatal hernia or GE reflux is demonstrated on the examination.,0
Stomach distends and empties in a normal fashion.,0
No mucosal abnormalities or filling defects are seen within the stomach.,0
The duodenal bulb distends normally and has a normal mucosal pattern.,0
The duodenal sweep is normal in appearance.,0
IMPRESSION: 1) Normal double-contrast upper GI examination.,0
No hiatal hernia or reflux demonstrated on the examination.,0
"Clip # Reason: Thickening at UP junction on right, R hydroureter.",0
"Recent c Admitting Diagnosis: NON ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with NSTEMI, cath showed 3VD.",0
"REASON FOR THIS EXAMINATION: Thickening at UP junction on right, R hydroureter.",0
"Recent cath, excreted contrast present in ureter.",0
______________________________________________________________________________ FINAL REPORT INDICATION: Hematuria.,0
Followup from previous day's CT study.,0
TECHNIQUE: Grayscale imaging of the kidneys and bladder was performed.,0
COMPARISON: Previous day's CT. REPORT: The right kidney measures 13.5 cm.,0
There is evidence of mild-to- moderate hydronephrosis.,0
No focal renal mass identified.,0
"Proximal hydroureter is identified, but the midureter cannot be seen.",0
"In the right UvJ, there is evidence of a 9 mm hyperechoic lesion.",0
This is consistent with an impacted stone.,0
"There also is, however, some circumferential thickening involving the right hemitrigone.",0
This is atypical for a calculus and is suggestive of tumor in this region.,0
The calculus is not mobile on moving the patient around.,0
"The bladder is somewhat suboptimally distended, lessening the value of this examination.",0
The left kidney measures 12.1 cm.,0
"Appears normal in size, shape, and echotexture.",0
A few non-obstructing hyperechoic crystals are identified within the left renal sinus.,0
Assymetric bladder wall thickening at the right vesicoureteric junction.,0
"Although an echogenic lesion here likely reflects calculus, the degree of thickening is thought to be atypical for a calculus, even an impacted one, and cystoscopic evaluation is recommended to rule out tumor.",0
Findings were telephoned to Dr. at the time of reporting.,0
(Over) 10:11 AM RENAL U.S.,0
Recent c Admitting Diagnosis: NON ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ______________________________________________________________________________ FINAL REPORT (Cont),0
"3:03 PM CHEST (PA & LAT) Clip # Reason: fever of 101.1 r/o pneumonia ______________________________________________________________________________ MEDICAL CONDITION: 53 year old woman s/p L9-T3 fusion, prolonged intubation, pneumonia/wound infection/bacteremia, improving on IV oxicillin, now with new fever REASON FOR THIS EXAMINATION: fever of 101.1 r/o pneumonia ______________________________________________________________________________ FINAL REPORT HISTORY: Postoperative fever.",1
Two views of the chest are compared to a previous study dated .,0
The left-sided PICC line is in the appropriate position.,0
There is blunting of the left costophrenic angle consistent with a pleural effusion and probably associated atelectatic changes.,0
The remaining lungs are clear.,0
There are no new infiltrates.,0
Orthopedic hardware is seen within the posterior spine.,0
IMPRESSION: Persistent left basilar opacity representing pleural effusion and associated atelectatic changes.,0
"Although infection is less likely, it cannot be entirely excluded.",0
"8:37 AM CHEST (PORTABLE AP) Clip # Reason: mrsa pneumonia, ?chf ______________________________________________________________________________ MEDICAL CONDITION: 75 year old man with stroke, respiratory distress REASON FOR THIS EXAMINATION: mrsa pneumonia, ?chf ______________________________________________________________________________ FINAL REPORT INDICATIONS: Stroke and respiratory distress, now with MRSA pneumonia.",1
PORTABLE AP CHEST: ET tube is noted several cm above the carina.,0
The NG tube tip is within the stomach.,0
"The heart appears enlarged, which may be partially positional as the patient is rotated on today's exam.",0
"There is no pulmonary vascular congestion, pleural effusions, or pneumothorax.",0
There is atelectasis at the left base with associated elevation of the left hemidiaphragm.,0
IMPRESSION: Left base atelectasis with associated elevation of the left hemidiaphragm.,0
", C. MED MICU 3:31 AM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: HYPOTENSION ______________________________________________________________________________ MEDICAL CONDITION: 55 year old woman with ESRD admitted with hypotension.",0
REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ PFI REPORT Interval improvement in the right lower lobe linear opacity consistent with resolution of atelectasis.,0
"Resolution of left lower lobe atelectasis, almost complete.",0
11:19 AM UNILAT UP EXT VEINS US RIGHT Clip # Reason: SWELLING Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman with RUE edema REASON FOR THIS EXAMINATION: eval for dvt ______________________________________________________________________________ FINAL REPORT RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: INDICATION: Right upper extremity edema.,1
"FINDINGS: -scale and color Doppler images of the right internal jugular, subclavian, axillary and brachial veins were obtained.",0
"These demonstrate normal flow, compressibility, augmentation and respiratory variation where applicable.",0
Right cephalic vein is not seen.,0
IMPRESSION: No evidence of right upper extremity deep venous thrombosis.,0
"10:07 AM CHEST (PORTABLE AP) Clip # Reason: respiratory distress, eval for consolidations, collapse Admitting Diagnosis: ACUTE PANCREATITIS ______________________________________________________________________________ MEDICAL CONDITION: 76 year old man with idiopathic pancreatitis REASON FOR THIS EXAMINATION: respiratory distress, eval for consolidations, collapse ______________________________________________________________________________ FINAL REPORT CHEST RADIOGRAPH INDICATION: Follow up.",1
"As compared to the previous examination, the tracheostomy tube has been exchanged.",0
The position of the current tube is 1.6 cm above the carina.,0
There is unchanged cardiomegaly with retrocardiac atelectasis and mild signs of overhydration.,0
Moderate bilateral pleural effusions are also unchanged.,1
No newly occurred parenchymal opacities suggestive of pneumonia.,0
"11:10 PM CHEST (PRE-OP AP ONLY) PORT Clip # Reason: preop Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 55 year old man with CAD with IABP, awaiting CABG REASON FOR THIS EXAMINATION: preop ______________________________________________________________________________ FINAL REPORT CHEST ONE VIEW.",0
INDICATION: 55 year old man with CAD and IABP.,0
COMMENT: A single frontal radiograph of the chest is reviewed.,0
No previous study is available for comparison.,0
There is mild congestive heart failure with cardiomegaly.,0
The left costophrenic angle is not included in the radiograph.,0
The IABP marker is identified 18 mm from the roof of the aortic arch.,0
IMPRESSION: Mild congestive heart failure with cardiomegaly.,0
"7:04 AM NEONATAL HEAD PORTABLE Clip # Reason: r/o ivh Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant born at 27 5/7 weeks gestation, now 4 days olddol 7 REASON FOR THIS EXAMINATION: r/o ivh ______________________________________________________________________________ FINAL REPORT INDICATION: Premature infant with concern for intraventricular hemorrhage.",1
CRANIAL ULTRASOUND: The brain parenchyma is normal in echogenicity and morphology.,0
The sulci and gyri have an appearance consistent with the patient's prematurity.,0
The ventricles are normal in size and there is no evidence of intraventricular or intraparenchymal hemorrhage.,0
Extra-axial fluid spaces are normal.,0
"11:54 AM CHEST (PA & LAT) Clip # Reason: eval for infiltrate Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 80M s/p CABG, with high WBC REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Status post CABG with elevated white count, question infiltrate.",1
"FINDINGS: PA and lateral views of the chest demonstrate some blunting of the left CP angle, suggesting a small left effusion.",0
There is a small patchy area of increased opacity in the retrocardiac region that could represent a small infiltrate.,0
"Compared to the film from , there has been interval removal of the ET tube, Swan-Ganz catheter, NG tube.",0
10:32 AM CHEST (PORTABLE AP) Clip # Reason: please eval r/o intrathoracic process ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with hypoxia REASON FOR THIS EXAMINATION: please eval r/o intrathoracic process ______________________________________________________________________________ WET READ: JEKh MON 11:01 AM 1.,0
L lung opacities concerning for multifocal PNA 2. s/p RLLobectomy w/ persisting pleural air locule - no evidence of tension ______________________________________________________________________________ FINAL REPORT HISTORY: 70-year-old male with history of right lower lobectomy at an outside institution complicated by a bronchopleural fistula and empyema.,1
"He has been treated with antibiotics, with persistent empyema cavity in the inferior hemithorax, now with tachycardia and hypoxia.",0
STUDY: AP portable upright chest radiograph.,0
COMPARISON: Chest radiographs from to as well as reference CTs uploaded .,0
FINDINGS: There is new airspace consolidation in the left lung (primarily upper lobe) with air-bronchograms compatible with pneumonia.,0
There is a loculated pleural gas collection at the lateral aspect of the right lung base likely representing the empyema cavity.,0
The heart and mediastinal contours appear unchanged from prior study.,0
Again noted is rightward deviation of the trachea.,0
Degenerative changes in the thoracic spine noted.,0
"Pneumonia in the left lung, most notable in the LUL.",0
Gas- filled presumed empyema cavity at the right lung base laterally.,0
These findings were posted emergently to the ED dashboard at the time of dictation.,0
3:10 AM CT C-SPINE W/O CONTRAST Clip # Reason: FOUND DOWN; EVAL FOR FX ______________________________________________________________________________ MEDICAL CONDITION: 34 year old man found down REASON FOR THIS EXAMINATION: eval for fx No contraindications for IV contrast ______________________________________________________________________________ WET READ: DJD WED 5:48 AM No fracture.,0
Loss of normal cervical lordosis likely related to collar.,0
Paraseptal emphysema at bilateral lung apices.,0
OVERREAD: Agree MD WET READ VERSION #1 MMBn WED 5:08 AM No fracture.,0
______________________________________________________________________________ FINAL REPORT INDICATION: 34-year-old man found down.,0
TECHNIQUE: MDCT imaging of the cervical spine was performed without intravenous contrast.,0
FINDINGS: There is no fracture within the cervical spine.,0
Loss of the normal cervical spinal lordosis is likely related to collar position.,0
The vertebral body and intervertebral disc space heights are preserved.,0
CT is not as sensitive as MRI in defining intrathecal detail.,0
The lung apices demonstrate bilateral paraseptal emphysema.,0
No evidence of acute fracture within the cervical spine.,0
Paraseptal thickening in bilateral lung apices.,0
"11:05 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: S/p thoracentesis Admitting Diagnosis: PARAESOPHAGEAL HERNIA/SDA ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with COPD and resp failure s/p esoph hernia repair REASON FOR THIS EXAMINATION: S/p thoracentesis ______________________________________________________________________________ FINAL REPORT HISTORY: COPD with respiratory failure, status post thoracentesis.",1
"FINDINGS: In comparison with earlier study of this date, there has been some decrease in pleural fluid.",0
"Specifically, no evidence of pneumothorax.",0
3:37 PM CHEST (PORTABLE AP) Clip # Reason: pre-op.,0
Evaluate for infiltrate Admitting Diagnosis: BRAIN MASS ______________________________________________________________________________ MEDICAL CONDITION: 85 year old woman with brain mass.,0
Evaluate for infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Preoperative.,0
"FINDINGS: In comparison with study of , the vague opacification in the left upper zone is much less well appreciated.",0
It is unclear whether this could have represented some post-obstructive atelectasis secondary to what appears to be a left upper lobe mass in the perihilar region on CT.,0
"9:16 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate, consolidation or any other infectious process Admitting Diagnosis: SUBDURAL HEMATOMA ______________________________________________________________________________ MEDICAL CONDITION: 86 year old woman with new leukocytosis, wheezing on lung exam REASON FOR THIS EXAMINATION: infiltrate, consolidation or any other infectious process ______________________________________________________________________________ FINAL REPORT HISTORY: New leukocytosis and wheezing, to evaluate for pneumonia.",0
Retrocardiac opacification is again seen with poor definition of the hemidiaphragm.,0
"Although this could merely represent atelectasis, in view of the clinical history of elevated white count, the possibility of supervening pneumonia must be seriously considered.",0
"2:02 PM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: Please evaluate liver and kidneys with doppler; r/o renal v Admitting Diagnosis: PERIPHERAL EDEMA ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with ESLD and ESRD, starting CVVHD REASON FOR THIS EXAMINATION: Please evaluate liver and kidneys with doppler; r/o renal v thrombus ______________________________________________________________________________ FINAL REPORT ABDOMINAL ULTRASOUND INDICATION: 61-year-old woman with end-stage liver disease and end-stage renal disease, and CVVHD.",1
Please evaluate liver and kidneys with Doppler.,1
"FINDINGS: The liver is coarse in echotexture, consistent with known cirrhosis.",1
No focal lesions are identified.,0
There is no evidence of intra- or extra-hepatic biliary ductal dilatation.,0
The hepatic veins are widely patent and demonstrate normal flow.,0
"The main, right, and left hepatic arteries are patent and demonstrate normal arterial waveforms.",0
"The main, right, and left portal veins are also widely patent.",0
"The right kidney is normal in echogenicity, measuring 10.7 cm.",0
"The study is limited due to technical difficulties or Doppler evaluation, however, the right renal artery and vein appears patent.",0
Small amount of pleural effusions and ascites.,1
IMPRESSION: Cirrhotic liver with patent hepatic vessels.,1
"Limited evaluation of the renal flow, however, the vessels appear to be patent.",0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: 34-year-old female with type 1 diabetes, gastroparesis, chronic renal insufficiency, neuropathy, history of multiple admissions for diabetic ketoacidosis most recently in INCOMPLETE REPORT...DICTATOR HUNG UP.",1
Dictated By: MEDQUIST36 D: 00:49 T: 15:38 JOB#:,0
8:18 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate Admitting Diagnosis: THORACO-ABDOMINAL ANEURYSM \ THORACO-ABDOMINAL ANEURYSM/SDA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p descending Ao Aneurysm repair now febrile REASON FOR THIS EXAMINATION: assess for infiltrate ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: S/P descending aortic aneurysm repair.,0
FINDINGS: 2 AP supine chest images are provided.,0
The ETT and the NG line appear in satisfactory positions though the NG line could be advanced further into the stomach.,0
"Surgical clips are again noted in the superior mediastinum, projecting medial to the aortic knob.",0
There has been partial re-expansion of the previously collapsed left lower lobe behind the heart.,0
No new pulmonary infiltrates are identified.,0
Some minor atelectasis is again noted in the left upper lobe laterally.,0
The costophrenic angles are clear and no significant pleural effusion is demonstrated.,0
"IMPRESSION: Since the examination of 1 day earlier, there has been some improved lung inflation with partial re-expansion of the previously collapsed left lower lobe.",0
There is evidence of the surgery of the descending thoracic aorta with some residual irregularity of the aortic profile.,0
"3:37 PM CHEST (PA & LAT) Clip # Reason: eval interval change Admitting Diagnosis: RESPIRATORY FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with PNA, SOB REASON FOR THIS EXAMINATION: eval interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc MON 7:36 PM PFI: Left pleural effusion improved.",1
"______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 77-year-old male with pneumonia, shortness of breath.",0
EXAMINATION: PA and lateral chest radiographs.,0
COMPARISONS: Comparison to portable radiographs from .,0
FINDINGS: There is interval improvement of the left retrocardiac opacity consistent with improved atelectatic changes.,0
The lungs are otherwise clear with no signs of superimposed pneumonia or congestive heart failure.,1
The cardiac and mediastinal contours are stable in configuration.,0
There is a right-sided PICC line with tip in stable position projecting over the low SVC/cavoatrial junction.,0
IMPRESSION: Stable left pleural effusion.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: Baby is a 32-1/7-week gestational age baby born to a 34-year-old, G-3, P-1 now 2 mom, with type B positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella immune, GBS unknown.",1
"Mom had spontaneous pre-term prolonged rupture of membranes on , which is approximately 3 weeks prior to delivery.",1
She was treated with ampicillin and erythromycin.,0
She had betamethasone which was complete on .,0
Her past OB history is significant for an 18- week pregnancy loss and a spontaneous vaginal delivery in of a 39-week boy who is now 2 years old.,0
Maternal past medical history and family history are noncontributory to the clinical status of this newborn son.,0
"On approximately , mom developed signs and symptoms consistent with chorioamnionitis, including uterine tenderness and foul-smelling vaginal discharge.",0
The OB delivered the infant by C-section that night due to chorioamnionitis concerns and breech presentation of the infant.,1
"At delivery the infant had a spontaneous cry with vigorous tone, was within normal limits, and he pinked within the first 5 minutes, with distant blow- by oxygen.",0
Perfusion was within normal limits.,0
The infant's pink appearance on room air appeared within normal limits.,0
Apgars at one and five minutes were 8 and 9.,0
In the NICU the infant continued with vigorous activity.,0
"PHYSICAL EXAMINATION: On physical examination on admission, vital signs: Temperature 97.4, pulse 166, respiratory rate 61, pressure 60/33 (43), O2 saturation 95%-100% on room air.",0
Anterior fontanelle is flat and soft.,0
"Eyes, ears, and nose appear within normal limits by external exam.",0
Peripheral pulses within normal limits.,0
Back appears within normal limits.,0
"Extremities: Flexed position of the hip, which is consistent with breech presentation.",0
Movements appear within normal limits.,0
"Physical measurements at discharge: Weight grams, head circumference 31cm, length 44 cm.",0
Respiratory: The baby was in room air since admission.,0
He had some apnea of prematurity.,0
He has been 5 days without apnea.,0
Cardiovascular: The baby had normal pressure and heart rate on admission.,0
Never required boluses or pressors.,0
"Fluid, electrolytes, nutrition: The baby was started n.p.o.",0
"on IV fluids and started on feeds on day of life 2, which were advanced as tolerated.",0
He is currently on ad lib.,0
feeds of breast milk 24 or EnfaCare 24.,0
GI: The baby was found to have hyperbilirubinemia on day of life 3 with a peak of 9/0.3 on that day.,0
He was started on phototherapy for 2 days.,0
"He had a rebound bilirubin that was lower than previously, 4.4/0.3.",0
"Hematology: On admission the baby had a CBC which revealed a hematocrit of 57.1, and platelets of 196.",0
"He was started on iron supplementation on day of life 8, which he continues.",0
"Infectious disease: Secondary to mom's question of chorioamnionitis, he was given a full sepsis workup.",0
His white count was 15.8 with 19 polys and 1 band.,0
"He had a culture which is no-growth, and had amp and gent for 7 days.",0
He had had no further issues.,0
Neurology: The baby had a normal neurological exam on admission and continues to have a normal neurologic exam.,0
"He was started in an isolette, which was weaned to a crib on day of life 13.",0
He has had stable temperatures since then.,0
"Sensory: a. Audiology: Hearing screen was performed with automated auditory brainstem responses, which was passed on .",0
b. Ophthalmology: The baby never had an ophthalmology exam secondary to gestational age greater than 32 weeks.,1
NAME OF PRIMARY CARE PEDIATRICIAN: Pediatrics.,0
Please continue breast milk 24 K-cals with EnfaCare or EnfaCare 24.,0
Medications: Please continue iron supplementation of 2 mg per kg per day p.o.,0
Iron supplementation is recommended for pre-term and low birth weight infants until 12-months corrected age.,0
All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as multivitamin preparation) daily until 12-months corrected age.,0
"Car seat position screening: The baby had her car seat position screening on , which was passed.",0
State newborn screening: The baby had 2 state newborn screenings which were both normal.,0
Immunizations received: The baby received hepatitis B immunization prior to discharge.,0
Immunizations recommended: a. Synagis RSV prophylaxis should be considered from through for infants who meet any of the following 4 criteria: 8.,0
"Born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school- age siblings.",0
11.Hemodynamically significant congenital heart disease.,0
"Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contact and out-of-home caregivers.",0
"The American Academy of Pediatrics recommends initial vaccination of pre-term infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age.",1
"12.Follow up appointment scheduled/recommended: The baby has a followup appointment with Pediatrics on , .",0
"Reviewed By: , Dictated By: MEDQUIST36 D: 09:20:07 T: 10:14:13 Job#:",0
7:18 AM CHEST (PORTABLE AP) Clip # Reason: r/o mediastinal fluid collection Admitting Diagnosis: CORONARY ARTERY DISEASE; AF ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p AVR with labile blood pressure REASON FOR THIS EXAMINATION: r/o mediastinal fluid collection ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST FILM AT 7:28.,1
"CLINICAL INDICATION: 70-year-old with AVR, labile blood pressure, rule out mediastinal fluid collection.",0
Comparison to prior study at 7:55.,0
Single semi-erect chest film 6/30/ at 7:28 is submitted.,0
Status post median sternotomy with aortic valve replacement and CABG with stable postoperative contours to the mediastinum and heart.,1
"If a mediastinal fluid collection remains of concern, CT would be more sensitive.",0
Right internal jugular central line continues to have its tip in the distal SVC.,0
"The visualized and aerated left upper mid lung and the right lung continue to have some scattered nodular opacities, likely represent vessels on end in the setting of low lung volumes, given their absence on a study from .",0
Evaluation of the left lower lobe is not possible due to patient rotation.,0
"9:47 AM CHEST (PA & LAT) Clip # Reason: Evaluate for infiltrate, pleural effusions.",0
"______________________________________________________________________________ MEDICAL CONDITION: 66 year old woman with hx CHF, CAD presents with incr WBC, UTI, ileus, crackles heard on exam.",0
"REASON FOR THIS EXAMINATION: Evaluate for infiltrate, pleural effusions.",0
"______________________________________________________________________________ FINAL REPORT INDICATION: Increasing white count, ileus, crackles on exam, evaluate for pleural effusion.",0
"CHEST, PA AND LATERAL: Cardiomediastinal silhouette is stable in appearance.",0
"There is biapical pleural thickening, left greater than right, which is unchanged.",0
IMPRESSION: No pneumonia or failure.,0
No change from previous exam.,0
"2:07 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrates Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 21 year old man w/trach who recently finished long term abx for PNA, with increased secrettion.",0
REASON FOR THIS EXAMINATION: eval for infiltrates ______________________________________________________________________________ FINAL REPORT History of tracheostomy and pneumonia with increased secretions.,0
The tracheostomy is 4 cm above the carina with the neck flexed.,0
"There is persistent partial collapse of the right middle and lower lobes, unchanged from the prior exam of .",0
"In addition, there is retrocardiac density with obscuration of the medial portion of the left hemidiaphragm consistent with atelectasis/consolidation in the left lower lobe, also unchanged.",0
IMPRESSION: No significant change in the collapse/consolidation of the lower lobes bilaterally.,0
"6:30 AM CT HEAD W/O CONTRAST Clip # Reason: new onset bleed or changes Change in pupil size R 4mm, L2mm Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 60 year old man with 60M with metastatic lung ca to brain s/p resection 1yr ago found down, CT shows SDH and SAH in setting of coumadin therapy new neurological deficits.",1
"REASON FOR THIS EXAMINATION: new onset bleed or changes Change in pupil size R 4mm, L2mm No contraindications for IV contrast ______________________________________________________________________________ WET READ: SPfc MON 7:05 AM Overall, minimal change.",0
Redemonstration of left subarachnoid and subdural blood as well as minimal intraventricular blood.,0
"Small parenchymal foci of hemorrhage are also redemonstrated, though a small focus near the vertex in the right parietal lobe was not definitely seen previously and may be new.",0
"______________________________________________________________________________ FINAL REPORT HISTORY: Metastatic colon cancer to brain, status post resection one year ago with more recent CT scan showing intracranial hemorrhage in the setting of Coumadin anticoagulation.",1
COMPARISON: Comparison is made to a CT of the head from as well as .,0
TECHNIQUE: Axial CT images were acquired through the head contiguous fashion in the absence of intravenous contrast.,0
"FINDINGS: Numerous hyperdense foci in the right parietal lobe are redemonstrated, predominantly unchanged.",0
"A small focus (2:25) near the vertex in the parietal lobe was not definitively seen on previous studies, and may be new.",0
An additional focus in the left parietal lobe is stable.,0
A small dependent subdural hematoma layers over the left occipital and parietal lobes.,0
"There is now a tiny subdural hematoma along the falx, best seen on images 23 and 24 of series 2.",0
"In addition, hyperdensity in the subarachnoid space is present in the sulci over the left frontal lobe.",0
Hypodensity in the subjacent gyri involves and white matter and is stable.,0
A small amount of intraventricular blood settles in the occipital horns of the lateral ventricles.,0
The ventricles and sulci are normal in size and in configuration.,0
Extracranial soft tissue structures are unremarkable.,0
The patient is status post right parietal craniotomy.,0
The mastoid air cells are clear and note is made of a mild amount of mucosal thickening in the left anterior ethmoidal air cells.,0
"IMPRESSION: Overall, similar appearance with redemonstration of subdural, subarachnoid, intraventricular and parenchymal hemorrhage as above.",1
A single small focus in the right parietal lobe is not definitively seen on previous studies and may be new.,0
There is a small amount of new subdural hemorrhage along the falx.,0
The large left frontal contusion appears stable.,0
"(Over) 6:30 AM CT HEAD W/O CONTRAST Clip # Reason: new onset bleed or changes Change in pupil size R 4mm, L2mm Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ FINAL REPORT (Cont)",1
"5:48 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 78 year old woman with fever and crackles on left on exam REASON FOR THIS EXAMINATION: Please eval for interval change ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM History of fever and left-sided crackles.",0
There is persistent opacity in the left lower zone consistent with atelectasis/consolidation in the left lower lobe and an associated small left pleural effusion cannot be ruled out.,0
A small ill-defined area of opacity in the left upper lobe is noted which may be new since the prior study of .,0
"4:27 PM CHEST (PORTABLE AP) Clip # Reason: assess degree of pulm edema Admitting Diagnosis: BLEEDING,S/P TOTAL HIP REPLACEMENT ______________________________________________________________________________ MEDICAL CONDITION: 77 year old woman with infected R hip, difficult to wean REASON FOR THIS EXAMINATION: assess degree of pulm edema ______________________________________________________________________________ FINAL REPORT INDICATION: 77-year-old woman with infected right hip and difficult to extubate.",0
Portable AP view of the chest dated is compared to the prior from at 13:05.,0
The endotracheal tube is positioned appropriately 3.5 cm above the carina.,0
Nasogastric tube is coiled above the diaphragm presumably within the patient's hiatal hernia.,0
The right internal jugular central venous catheter terminates in the right atrium.,0
An IVC filter is seen overlying the mid abdomen.,0
"The heart is enlarged, and there has been interval worsening of pulmonary vascular congestion and interval increase in the size of the bilateral pleural effusions.",0
Retrocardiac opacity is most likely the patient's known hiatal hernia.,0
Right internal jugular line terminating in the right atrium.,0
Nasogastric tube in a large retrocardiac hiatal hernia.,0
"11:00 AM US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # Reason: POST TIPS PLACEMENT Admitting Diagnosis: VARICEAL BLEED ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with liver cirrhosis (NASH and alcoholic) who was admitted for UGI Bleed, s/p TIPS on Wednesday.",1
REASON FOR THIS EXAMINATION: Please evaluate for proper TIPS positon.,0
______________________________________________________________________________ FINAL REPORT HISTORY: 70-year-old man with cirrhosis post-TIPS placement.,0
FINDINGS: Interval TIPS is seen with wall-to-wall flow.,0
The velocity at the portal vein and ranges from 39-47 cm per second.,0
"In the mid portion, these velocities range from 75-86 cm per second, and at the hepatic venous end is approximately 137 cm per second.",0
The anterior right portal vein is patent.,0
The main hepatic artery is patent with a resistive index of 0.65.,0
The left hepatic artery is patent.,0
The left portal vein is not visualized secondary to technical difficulties.,0
"PORT Clip # Reason: cont to be hypertensive, r/o renal artery stenosis Admitting Diagnosis: HYPERTENSIVE EMERGENCY ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with s/p cabg REASON FOR THIS EXAMINATION: cont to be hypertensive, r/o renal artery stenosis ______________________________________________________________________________ WET READ: MMBn FRI 7:52 PM No hydronephrosis or stones.",0
"Unable to assess flow, as pt unable to cooperate.",0
______________________________________________________________________________ FINAL REPORT INDICATION: 45-year-old male status post CABG with hypertension.,0
Rule out renal artery stenosis.,0
RENAL ULTRASOUND: The right kidney measures 12.5 cm.,0
The left kidney measures 11.9 cm.,0
Unfortunately doppler study could not be performed due to patient's inability to cooperate.,0
IMPRESSION: Normal son grayscale appeareance of the kidneys.,0
"9:44 PM CT HEAD W/O CONTRAST Clip # Reason: AMS ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man with AMS, hyperglycemia REASON FOR THIS EXAMINATION: eval for acute process No contraindications for IV contrast ______________________________________________________________________________ WET READ: 12:55 AM No acute intracranial process.",1
______________________________________________________________________________ FINAL REPORT INDICATION: Altered mental status and hyperglycemia.,0
TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast material.,0
"FINDINGS: There is no evidence of hemorrhage, edema, shift of normally midline structures, hydrocephalus, or infarction.",0
Mild prominence of the ventricles and sulci are consistent with age-related involutional change.,0
Bilateral cavernous carotid artery calcifications are seen.,0
The orbits are grossly unremarkable.,0
The imaged osseous structures are intact.,0
IMPRESSION: Carotid arterial atherosclerotic calcifications.,0
12:30 AM CHEST (PORTABLE AP) Clip # Reason: ?,0
pneumothorax or change Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with respiratory failure REASON FOR THIS EXAMINATION: ?,1
pneumothorax or change ______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Respiratory failure.,1
FINDINGS: Supine portable chest x-ray is compared with .,0
"The endotracheal tube has been pulled back, and terminates 4 cm from the carina.",0
There is improved aeration of the right upper lobe.,1
"There are more confluent bilateral airspace opacification, consistent with pulmonary edema.",0
There is mild unchanged cardiomegaly.,0
The orogastric tube terminates below the diaphragm.,0
2:44 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Please eval aeration s/p bronch.,0
"Admitting Diagnosis: WEAKNESS ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with epidural abcess, s/p bronchoscopy with extensive mucus removal REASON FOR THIS EXAMINATION: Please eval aeration s/p bronch.",0
______________________________________________________________________________ FINAL REPORT CHEST HISTORY: Status post bronchoscopy.,0
"Compared to the prior study, tip of the endotracheal tube remains in good position 4.4 cm above the carina.",0
"Compared to the prior study, there has been significant improvement in the aeration of the left lung.",0
"There is, however, persistent left basal opacity most consistent with residual atelectasis.",0
IMPRESSION: Partial re-expansion of the left lung with residual left basal atelectasis.,0
Please note this study was performed at 14:55 on .,0
"6:36 PM TIB/FIB (AP & LAT) RIGHT; -77 BY DIFFERENT PHYSICIAN # Reason: post-splint reduction Admitting Diagnosis: DISTAL TIBIA FIBULA FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 84 year old woman with R tib/fib fx REASON FOR THIS EXAMINATION: post-splint reduction ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Post-reduction of fractured right tibia and fibula, check position.",1
"RIGHT TIBIA AND FIBULA, AP AND LATERAL Some angulation is present following reduction, but the position is markedly improved since the pre-reduction position.",1
Height: (in) 63 Weight (lb): 230 BSA (m2): 2.05 m2 BP (mm Hg): 110/44 HR (bpm): 98 Status: Inpatient Date/Time: at 10:53 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
Normal IVC diameter (<=2.1cm) with <50% decrease with sniff (estimated RA pressure (5-10 mmHg).,0
Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized.,0
"The right ventricular cavity is mildly dilated The diameters of aorta at the sinus, ascending and arch levels are normal.",0
IMPRESSION: Normal left ventricular wall thickness and cavity size with preserved global left ventricular systolic function.,0
Dilated right ventricle with mildly depressed function.,0
"Compared to the previous study of , the severity of pulmonary artery systolic hypertension has increased and is now severe.",1
"The right ventricle was not previously well-visualized, but is now mildly dilated and hypokinetic.",0
Dr. notified of the results by phone.,0
"5:12 AM CHEST (PORTABLE AP) Clip # Reason: Interval change Admitting Diagnosis: CROHN'S DISEASE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 26 year old man with new hypoxia, respiratory distress, fluid overload s/p diuresis.",0
"REASON FOR THIS EXAMINATION: Interval change ______________________________________________________________________________ FINAL REPORT STUDY: AP chest, .",0
HISTORY: A 26-year-old man with new hypoxia and respiratory distress.,0
"There is a consolidation at the right base, which has worsened since the previous study.",0
This may represent aspiration or developing pneumonia.,0
The cardiac silhouette and mediastinum is normal.,0
There is some atelectasis at the left base.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: intubation, mechanical ventilation History of Present Illness: 54 yo male with Hepatitis C cirrhosis and mult admissions for encephalopathy now with admission s/p increasing confusion, ?fall, AMS and intubation for desaturations in the field.",1
"Pt found down by sister in home holding onto a door in basement with bruise on head, likely s/p fall.",0
Sister had noticed he had been increasingly confused over the previous few days after having been doing quite well since discharge from (?),0
s/p hepatic encephalopathy; currently compliant on home meds regimen.,1
"Pt transfered to OSH, during transfer pt with acute desaturations and was intubated in the field, requiring ativan and pancuronium.",0
"Head CT, neck CT neg for acute pathology.",0
Transfered to for further management.,0
"On admission to MICU, pt hemodynamically stable on ventilator and responsive to verbal and physical stimuli with ativan on board from OSH.",0
HCV cirrhosis (hx portal htn/ ascites/ arices/ encephalopathy/ sbp) 2.,1
Chronic Renal Insufficiency (baseline Cr = 1.6) 3.,0
Pancytopenia likely d/t hypersplenism 5. chronic hyperkalemia 6.,1
Persistent small amount of ascites.,0
---- LLE doppler:There is no evidence of DVT.,0
---- p-MIBI:1) Normal myocardial perfusion.,0
2) Normal left ventricular cavity size and systolic function.,0
---- Chemical cardiac stress: No angina with no ischemic ECG changes.,0
Nuclear report will be sent separately.,0
He was intially in the ICU and then extubated and transferred to the floor.,0
Mental status changes/encephalopathy: This was again likely hepatic encephalopathy from worsening liver fxn.,1
"The reason he continues to have these episodes in unclear, although infectious cause must be ruled out.",0
He is afebrile and has no evidence of infection.,0
Abd U/S showed again only a small amt of untappable ascites.,0
Not changed from previous admit.,0
"A CT of his head was neg, and despite a low Hct, his levels were stable and stol guaiac was negative.",0
This suggests he is not having a GI bleed.,0
Cultures were drawn from blood and urine and were negative for growth.,0
"He was continued on a high dose of lactulose with a goal of 5 BMs/day, but was initially having closer to 10.",0
"His dose was dropped to get him to an appropriate range, andhe was sent out on this dose.",0
"Again, his methaodne was considered to be a possible factor in his mental status alterations.",0
"It was initially held in the ICU, but restarted on the floor, and eventually, the team and the patient agreed on a dose of 15 .",0
The patient was to eventually get off of it all together and can hopefully do this as an outpt.,0
His Cipro and Flagyl were continued as well.,0
Hypoxic respiratory failure: Initially had hypoxia in the field and was intubated.,0
"Question of whether this was true hypoxia, or intubation was more for airway protection.",0
It resolved in the ICU and he was extubated.,0
"He may have been sedated due to his encephalopathy, causing him respiratory problems.",0
"For the remainder of his stay, he had no hypoxia or DOE or other pulmonary issues.",0
Cirrhosis: We continued his propranolol and cipro/flagyl as above.,0
"He was sent out on dosing of propranolol after his last admit, but was apparently coming back in on tid dosing.",0
"This was continued here, and his PCP can hopefully work to decrease this as an outpt if his BP will not becoem too elevated.",0
This medicine will prevent some portal flow and impair his liver even further if not managed appropriately.,0
His lactulose was given with a goal of 5 BMs/day.,0
"He was achieving this, so he was sent out on the hospital dose.",0
"Again, no tappable ascites or reason to worry about SBP.",0
"Also, no hemoptysis or Hct drop that would suggest varices.",0
"4.Methadone: Initially continued 20 , and after much resistance, pt agreed to 15 .",0
"Would like to eventually get him off of this all together, but his psychological dependence is strong.",0
Can work on this as an outpt.,0
HTN: Continued his propranolol at outpt tid dose.,0
"Adequate control, but could probably go down to .",0
DM2: His outpt regimen is unclear as some records indicate he takes glargine while other say glipizide.,0
He was covered here with SSI alone and maintained blood glucoses in the high 100s(covered with insulin for these).,0
"Although glipizide not that good a drug for people in liver failure, pt and his sister both state he does not take insulin shots now, but does take glipizide every day.",0
This could not be confirmed with his PCP.,0
was sent out on a low dose of glipizide for the short term to help control his blood glucose and asked to see his PCP 1 week to get on a better regimen long term.,0
Unfortunately insulin amnagement may be too difficult for him due to his mental capacity.,0
"EKG changes: He had questionable changes at an OSH, and an ECG read here was also showing possible ischemia.",0
"His cardiac enzymes were cycled and he did have a troponin bump, but flat CKs/CK-MBs.",0
This was likely demand ischemia and not an MI.,0
"He had a stress in but it wasn't an adequate study, so we performed a p-MIBI here.",0
"It was normal, with no evidence of ischemia or perfusion defects.",0
"8.LLE swelling: Thought to be chronic, but got LLE doppler that was neg for DVT.",0
9.Foley removal:Pt at one point pulled out his own foley with the bulb inflated.,0
He had bleeding from his penis afterwards that was controlled by pressure.,0
He was monitored closely for clots/bladder outlet obstruction.,0
"He had one additional episode of gross hematuria, but then reported no blood in his urine.",0
He also reported no additional dysuria/pain.,0
He was urinating noramlly and without blood on discharge.,0
No Hct drop as a result.,0
"10.Pancytopenia:His blood counts were all low, but monitored daily.",0
"Also, his Hct was low, but asymptomatic and stable.",0
"His platelets also stayed low, but stable and no dangerous bleeding was observed.",0
He did not require platelets to stop his penile bleeding episode after the folwy removal.,0
"He was discharged with close follow-up by his PCP to put him on a good insulin/diabetes regimen, and with Dr .",0
"Medications on Admission: methadone 30 , protonix 40 mg, aspranolol 20 tid, cipro 250 qd, flagyl 250 tid, lactulose 45cc tid, lasix 40 qd, nicotine patch, procrit 40K QW, kayexalate 30cc QW, glargine 20u Qpm Discharge Medications: 1.",0
Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours).,0
Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day).,0
Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO TID (3 times a day).,0
Methadone HCl 10 mg Tablet Sig: 1.5 Tablets PO twice a day.,0
Glipizide 5 mg Tablet Sig: One (1) Tablet PO qam.,0
Discharge Disposition: Home With Service Facility: Gentiva/ Discharge Diagnosis: Hepatic encephalopathy HCV cirrhosis CRI Type II diabetes Pancytopenia HTN Discharge Condition: Good.,1
He was at his baseline per pt.,0
"Discharge Instructions: Please call your PCP or return to the hospital if you have more confusion, trouble with your thinking, falls, or you are overly sleepy.",0
"Also call if you have any other symptoms that concern you, such as fever or chills.",0
We changed your methadone dose to 15 mg twice a day.,0
"Followup Instructions: Provider: , MD Where: LM Phone: Date/Time: 11:00 Provider: TRANSPLANT,ORIENTATION TRANSPLANT CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE Date/Time: 3:00 Provider: , TRANSPLANT CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE Date/Time: 2:00 Please call your PCP and make an appointment to follow-up within 1 week to discuss your diabetes management and to follow-up after your hospital stay",0
7:25 PM SHOULDER VIEWS NON TRAUMA RIGHT IN O.R.,0
PORT; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.,0
PORT RIGHTClip # Reason: ORIF SHOULDER R IN OR Admitting Diagnosis: DHOULDER DISLOCATION ______________________________________________________________________________ FINAL REPORT RIGHT SHOULDER RADIOGRAPH DATED CLINICAL INDICATION: 75-year-old for ORIF.,0
FINDINGS: Three total fluoroscopic spot radiographs for a total fluoroscopic time of 49.1 seconds demonstrates interval changes of shoulder hemiarthroplasty with expected operative appearance.,0
IMPRESSION: ORIF of right shoulder with shoulder hemi-arthroplasty with expected operative appearance.,0
Please refer to operative report for further details.,0
PATIENT/TEST INFORMATION: Indication: Intra-op TEE for MVR Height: (in) 69 Weight (lb): 175 BSA (m2): 1.95 m2 BP (mm Hg): 124/74 HR (bpm): 84 Status: Inpatient Date/Time: at 13:42 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement.,0
MITRAL VALVE: Partial mitral leaflet flail.,1
MR vena contracta is >=0.7cm Severe (4+) MR. TRICUSPID VALVE: Mild [1+] TR.,0
There is partial mitral leaflet flail of P2 scallop.,0
Torn mitral chordae are present.,0
"An eccentric, anterior directed jet of The effective regurgitant orifice is >=0.40cm2 The mitral regurgitation vena contracta is >=0.7cm.",0
Pt was in sinus/ junctional tachycardia 1.,0
Biventricular function is preserved 2.,0
A mitral annuloplasty ring is seen well seated.,0
Some is noted that significantly improved with Beta Blockade and volume infusion.,0
Due to poor echo windows an LVOT gradient was not obtained.,0
Other findings are unchanged 4.,0
8:00 AM CT HEAD W/O CONTRAST Clip # Reason: Please re-evaluate for changes in epidural fluid collection Admitting Diagnosis: ALTERED MENTAL STATUS ______________________________________________________________________________ MEDICAL CONDITION: 51 year old man with epidural fluid collection REASON FOR THIS EXAMINATION: Please re-evaluate for changes in epidural fluid collection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT NONCONTRAST HEAD CT SCAN HISTORY: Evaluate for changes in epidural fluid collection.,0
"COMPARISON STUDY: , MR examination of the brain.",0
FINDINGS: Comparison with the prior study of reveals no significant interval change in either the extent of the previously noted epidural fluid collection subjacent to and marginated by the craniotomy flap nor the low density areas seen within the right frontal and left occipital- temporal portions of the brain.,0
"There are no new areas of intracranial hemorrhage, mass effect or shift of normally midline structures.",0
"The surrounding osseous and soft tissue structures, as well, are unaltered in appearance.",0
"CONCLUSION: Stable, abnormal study as noted above.",0
11:01 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: ?,0
aspiration risk Admitting Diagnosis: ICH ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with intraparenchymal hemorrhage REASON FOR THIS EXAMINATION: ?,0
"aspiration risk ______________________________________________________________________________ FINAL REPORT INDICATION: Intraparenchymal hemorrhage, abnormal chest x-ray, assess aspiration risk.",0
VIDEO OROPHARYNGEAL SWALLOW: The study was conducted in conjunction with speech pathology.,0
Various consistencies of barium was administered by mouth.,0
There is moderate premature spill into the pyriform sinuses.,0
There is moderate to severe impairment of the oral phase.,0
There is mild retention in the valleculae with nectar consistency barium.,0
Trace residuals are noted in the pyriform sinuses.,0
There is full/severe retention in the valleculae with puree consistency.,0
The patient is unable to clear his residuals.,0
There is no penetration or aspiration identified during the study.,0
IMPRESSION: Moderate-to-severe retention in the valleculae.,0
Moderate to severe impairment of the oral phase of swallow.,0
No penetration or aspiration identified.,0
Please refer to Speech Pathologist note in Careweb for the full report and dietary recommendations.,0
"6:44 PM PORTABLE ABDOMEN Clip # Reason: please assess for obstructionSTAT PLEASE Admitting Diagnosis: COPD EXACERBATION ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with tachypnea, s/p rapid afib, pneumonia now with severe abdominal pain REASON FOR THIS EXAMINATION: please assess for obstructionSTAT PLEASE ______________________________________________________________________________ FINAL REPORT ABDOMEN SINGLE FILM: HISTORY: Abdominal pain.",1
The left flank and pelvic cavity are not included on the film.,0
Distribution of bowel gas is unremarkable and no diagnostic abnormalities are noted on this limited film.,0
12:31 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: PTX?,0
s/p 2 chest tubes removed.,0
Admitting Diagnosis: UPPER LOBE LESION/SDA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p RUL sleeve resection now s/p removal of CT REASON FOR THIS EXAMINATION: PTX?,0
______________________________________________________________________________ FINAL REPORT AP CHEST 12:51 P.M. .,0
HISTORY: Right upper lobectomy and sleeve resection.,0
"IMPRESSION: AP chest compared to and earlier on at 8:40 a.m. Small right pneumothorax previously just basal has increased in volume since removal of the two right apical tubes, now with the apical pleural margin at the level of the second posterior rib with separation from the costal surface extending to the fifth posterior rib.",1
Dr. was paged report these findings.,0
Postoperative right lung shows mild increase in congestion.,0
"8:01 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: Admitting Diagnosis: LIVER LACERATION ______________________________________________________________________________ MEDICAL CONDITION: 42 year old man with s/p bike accident, multi-trauma REASON FOR THIS EXAMINATION: cord injury No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT EXAM: MRI of the cervical spine.",1
CLINICAL INFORMATION: Patient with status post bike accident.,0
"TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient echo axial images of cervical spine were acquired.",0
Correlation was made with the cervical spine CT of .,0
FINDINGS: Extensive soft tissue changes with increased signal on inversion recovery images identified in the posterior soft tissues involving the posterior interspinous regions at C1-C2 to T1-T2 level involving the interspinous region in the posterior soft tissues.,0
There is no sign of disruption of the ligamentum flavum seen.,0
There is no disruption of the posterior longitudinal ligament identified.,0
There is no evidence of intraspinal hematoma seen or evidence of spinal cord compression or abnormal signal seen within the spinal cord.,0
"There are fractures of C6 and C7 spinous processes are visualized, but better appreciated on the accompanying CT of .",0
There is increased soft tissue increased signal seen in the nasopharynx and extending to C4 level.,0
"This could be due to mild prevertebral edema, but most likely the majority of the changes are due to fluid within the nasopharynx.",0
"The axial images demonstrate extensive soft tissue changes within the posterior soft tissues as well as the right side of the neck, which is better evaluated on the cervical spine CT. Disc bulging is identified at C3-C4 level.",0
There is no herniation or spinal stenosis.,0
No abnormal signal seen within the vertebral bodies.,0
Both vertebral artery flow voids are maintained.,0
IMPRESSION: Extensive interspinous ligament signal changes are seen in the cervical region with fractures of spinous processes of C6 and C7.,1
No evidence of facet joint malalignment or vertebral malalignment seen.,0
No evidence of intraspinal hematoma or evidence of spinal cord edema or contusion identified.,0
(Over) 8:01 PM MR CERVICAL SPINE W/O CONTRAST Clip # Reason: Admitting Diagnosis: LIVER LACERATION ______________________________________________________________________________ FINAL REPORT (Cont),1
9:34 AM CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.,0
Clip # Reason: PORTA CATH INSERTION Admitting Diagnosis: HYPERTENSION ______________________________________________________________________________ FINAL REPORT Chest fluoroscopy was provided without the presence of a radiologist.,0
There were 30 seconds of fluoro time used.,0
There are no films submitted.,0
12:14 PM CHEST (PORTABLE AP) Clip # Reason: eval for effusion/atelectasis/ARDS Admitting Diagnosis: LT FOOT GANGRENE ______________________________________________________________________________ MEDICAL CONDITION: 73 year old man with recetn aortobifem/L-fem- bypass REASON FOR THIS EXAMINATION: eval for effusion/atelectasis/ARDS ______________________________________________________________________________ FINAL REPORT INDICATION: Status post peripheral vascular surgery.,1
AP supine view of the chest dated at 12:04 pm is compared to AP upright view dated at 12:42 am.,0
Bilateral pleural effusions and associated areas of bibasilar atelectasis are once again noted.,0
"The heart size is normal, and there is no congestive heart failure.",0
"The endotracheal tube, the right IJ Swan-Ganz catheter, and the NG tube remain in good positions.",0
IMPRESSION: Persistent bilateral pleural effusions with associated areas of bibasilar atelectasis.,0
"5:04 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx, r/o infil ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with severe L pleuritic cp and sob REASON FOR THIS EXAMINATION: r/o ptx, r/o infil ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old man with severe left pleuritic chest pain and shortness of breath.",0
"Rule out pneumothorax, rule out pneumonia.",0
"PORTABLE UPRIGHT CHEST: When compared to , there is a new hazy opacity at the left lung base and less prominent also at the right lung base, probably representing pneumonic consolidations.",0
A lateral chest x-ray is recommended for better assessment.,0
"The cardiac silhouette appears enlarged, although difficult to assess on this AP technique film.",0
IMPRESSION: New bibasilar airspace opacitites consistent with pneumonia.,0
Height: (in) 66 Weight (lb): 200 BSA (m2): 2.00 m2 BP (mm Hg): 104/37 HR (bpm): 62 Status: Inpatient Date/Time: at 11:46 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Suboptimal INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
GENERAL COMMENTS: Resting bradycardia (HR<60bpm).,0
"6:32 PM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: please evaluate for infiltrate, effusion Admitting Diagnosis: HYPONATREMIA;HYPERKALEMIA;WEAKNESS;BREAST CANCER ______________________________________________________________________________ MEDICAL CONDITION: 62F w/ hyponatremia s/p left subclavian line placement now with hypoxia, hematemesis REASON FOR THIS EXAMINATION: please evaluate for infiltrate, effusion ______________________________________________________________________________ FINAL REPORT INDICATION: History of hyponatremia and hypoxia with hematemesis.",1
AP PORTABLE UPRIGHT VIEW OF THE CHEST: The left subclavian line is unchanged.,0
There are persistent bilateral pleural effusions that appear to have increased in size compared to the prior study.,0
There are bibasilar opacities consistent with collapse/consolidation.,0
There is an NG tube terminating in the stomach.,0
The cardiac contour is obscured by the effusions and bibasilar opacities.,0
IMPRESSION: Apparent interval increase in the previously demonstrated bilateral pleural effusions with bibasilar opacities consistent with collapse/consolidation.,0
"12:31 PM CHEST (PORTABLE AP) Clip # Reason: s/p line placement Admitting Diagnosis: ASTHMA; PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 49 year old woman with COPD, difficult intubation, s/p transfer from OSH REASON FOR THIS EXAMINATION: s/p line placement ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: S/P line placement.",0
ICD's are present with the tips in the right atrium and the right ventricle in satisfactory position.,0
Some scarring at the left base is present consistent with prior surgery.,0
Small bilateral effusions are identified.,0
IMPRESSION: Successful placement of ICD.,0
3:55 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate lower lung fields and upper abdomen for plac ______________________________________________________________________________ MEDICAL CONDITION: 50 year old man with morbid obesity s/p tracheostomy.,1
"Pt had self-removed NG tube, which has now been replaced.",0
REASON FOR THIS EXAMINATION: please evaluate lower lung fields and upper abdomen for placement of Dopoff tube ______________________________________________________________________________ FINAL REPORT INDICATION: Check position of dobbhoff tube.,0
Single AP upright portable chest radiograph is compared with the prior study dated .,0
The dobbhoff tube passes below the left hemidiaphragm and is at least in the mid stomach.,0
There has been no significant interval change in layering right pleural effusion with chronic left pleural thickening and volume loss in the left lung.,0
Tip of dobbhoff tube in the left upper abdomen.,0
"If exact location of the tip is needed, an abdominal film would be helpful.",0
Clip # Reason: please assess for bleed; blood collection Admitting Diagnosis: DYSPHAGIA ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with drop in hct.,0
"REASON FOR THIS EXAMINATION: please assess for bleed; blood collection ______________________________________________________________________________ FINAL REPORT INDICATION: Dropping hematocrit, evaluate for bleed.",0
Ultrasound is compared with a CT scan performed 1 day previously.,0
"Again, shown is bilateral hydronephrosis with atrophic kidneys with marked cortical atrophy.",1
No perirenal fluid is identified.,0
The retroperitoneal hematoma surrounding the left kidney is not seen.,1
Please note that ultrasound is not a reliable imaging technique for excluding the presence of retroperitoneal blood or for ongoing active bleeding.,0
"5:58 PM CHEST (PORTABLE AP) Clip # Reason: SWAN PLACEMENT Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\CARDIAC CATH ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man s/p CABG, s/p ex-lap, cholecystetomy.",1
"REASON FOR THIS EXAMINATION: SWAN PLACEMENT ______________________________________________________________________________ FINAL REPORT INDICATION: Status post CABG, status post exploratory laparotomy, cholecystectomy.",0
Now status post Swan-Ganz catheter placement.,0
SINGLE VIEW OF THE CHEST: The right-sided Swan-Ganz catheter has been removed in the interval.,0
There is now a left-sided Swan-Ganz catheter with the tip overlying the right interlobar artery.,0
There is now a sheath in the right internal jugular vein.,0
The left IJ catheter and right-sided chest tube are unchanged in position.,0
The NG tube is also unchanged.,0
The endotracheal tube is just above the thoracic inlet and could be advanced by 1-2 cm.,0
"There is mild atelectasis at the left lung base, which may be slightly increased in extent from the prior study.",0
The two left-sided chest tubes are also unchanged in position.,0
Satisfactory placement of the Swan-Ganz catheter.,0
Patchy atelectasis at the left lung base.,0
"4:57 AM CHEST (PORTABLE AP) Clip # Reason: eval of chest tubes/pneumothorax Admitting Diagnosis: LEFT UPPER LOBE NODULE/SDA ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p LUL lobectomy, dropping sats, multiple chest tubes.",1
REASON FOR THIS EXAMINATION: eval of chest tubes/pneumothorax ______________________________________________________________________________ FINAL REPORT AP CHEST AT 5:25 A.M. HISTORY: Left upper lobectomy.,1
"IMPRESSION: AP chest compared to and : Heterogeneous opacification in the right mid and lower lung zones has worsened slightly since , consistent with worsening pulmonary edema, though pneumonia in the setting of severe emphysema could have a similar appearance.",1
The small moderate right hydropneumothorax is smaller generally than it was on .,0
A right pleural tube still courses obliquely inferomedially from the lateral chest wall.,0
Postoperative left hemithorax shows increasing consolidation in the lung as well as increasing fluid collected in multiloculated pneumothorax and probably in large bullae in the lung.,0
Leftward mediastinal shift indicates a component of atelectasis at the base of the left lung.,0
Two left apical basal pleural drains are unchanged in their positions.,0
Tracheostomy tube is mildly canted projecting over the mid trachea.,0
"12:42 PM CHEST (PA & LAT) Clip # Reason: r/o effusion/PTX Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man s/p CABG REASON FOR THIS EXAMINATION: r/o effusion/PTX ______________________________________________________________________________ FINAL REPORT CHEST, TWO VIEWS, PA AND LATERAL: HISTORY: CABG.",1
Discoid atelectasis is present in the left mid and lower zones and there is a small left pleural effusion.,0
"Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY: The patient is a 2515 gram product, 37 week gestation age born to a 41-year-old G2, para 1 woman whose pregnancy was notable for increased blood pressure and proteinuria.",0
"Mom is 41-year-old G2, para 2 prenatal screens included blood type B positive, antibody negative, rubella immune, RPR nonreactive.",0
The GBS status was unknown and there was no other sepsis risk factors.,0
Delivery was precipitous by spontaneous vaginal delivery.,0
The Apgar scores were 8 and 8 for 1 and 5 minutes respectively.,0
NICU team was called to see the patient for persistent grunting.,0
"The patient was transferred at one hour of age to the NICU for further evaluation of this grunting, flaring and retraction.",0
"The birthweight was 2151 grams which fell in the 10th to 25th percentile, length 46 cm at 25th to 30th percentile and head circumference 32.5 cm at the 25th to 50th percentile.",0
"On examination baby boy appeared pink, non-dysmorphic, well saturated and perfused in room air.",0
The lungs were clear and equal.,0
Head: Normocephalic with anterior fontanel open and flat.,0
Mild grunting was noted with some intercostal and subcostal retraction.,0
The heart sounds: S1 and S2 were normal with no audible murmur.,0
"The abdomen was soft, nondistended and sluggish bowel sounds.",0
"The patient had normal male genitalia, with anus patent.",0
Neurologically the patient appeared nonfocal.,0
Moving all extremities well and equal and tone was age appropriate.,0
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: A.,0
Respiratory: The patient was initially put on CPAP with pressures of 5 cm and FIO2 requirement of 25-30.,0
A chest x-ray was obtained which showed normal to upper limits of the heart size.,0
There were granular opacities and air bronchograms which was consistent with mild to moderate RDS.,0
The patient remained on C-PAP of 5 on day one of life with O2 requirement persisting between 22 to 28 percent.,0
"On day two, he developed a spontaneous right sided pneumothorax.",0
Initial attempts to evacuate the air with needle thoracocentesis failed.,0
A chest tube was inserted in the right intercostal space.,0
His blood gas prior to his chest tube showed hypercapnia.,0
The capillary blood gas had values of 7.22/72.,0
His blood pressures were normal and his capillary perfusion was less than 3 seconds.,0
Post placement of the chest tube the patient remained on CPAP.,0
For the chest tube an incision was made at the level of the fifth intercostal space and the pleura entered at the fourth intercostal space with a 10 French chest tube.,0
Follow-up chest x-ray showed a confirmed placement of this chest tube.,0
After a few minutes on CPAP the patient experienced an apneic episode with cyanosis and bradycardia.,0
Bag and mask ventilation was provided with rapid resolution of this apneic episode.,0
At this time the patient was sedated and intubated with a 3-U endotracheal tube.,0
The patient remained intubated from day 2 to day 3 of life.,0
He was progressively weaned on good blood gases and extubated on day three of life to nasal cannula.,0
He was started on a nasal cannula at 200 cc's of 100% FIO2 and was gradually weaned on day five to six of life to room air.,0
The chest tube was put to water seal on day six of life and removed on day seven of life with follow-up x-ray showing no evidence of residual pneumothorax.,0
The patient was hemodynamically stable during stay in the NICU.,0
He did not require any vascular support medication.,0
A soft murmur was heard on day two of life.,0
We followed this murmur clinically and this murmur disappeared from day three onwards.,0
His blood pressures remained stable and his peripheral perfusion was brisk during this period.,0
"C. Fluid, electrolytes, nutrition: The patient was initially kept NPO and was started on D10 intravenous fluid at 60 cc's per kg per day.",0
He was weaned very gradually to 80 cc's per kg per day on day three.,0
The patient was started on p.o.,0
feeds on day five of life and was gradually advanced ad lib with a minimum of 100 cc's per kg per day.,0
His electrolytes remained stable during his stay in the NICU.,0
"Currently the patient is taking a minimum of 120 cc's kg per day breast milk, Special Care 20 ad lib.",0
His recent weight is 2.458 kg which lies between 10 to 25th percentile.,0
D. Gastrointestinal: The patient had a peak bilirubin of total of 12.7 and a direct component of 0.5 on day five of life.,0
He did not receive any phototherapy.,0
Follow-up bilirubin on day eight showed a level of 10.4 and a direct of 0.4.,0
"E. Hematology: The initial CBC at the time of admission showed a hematocrit of 65.5, a follow-up crit on day two of life showed a crit of 16.1.",0
Platelet counts were stable with an initial level of 251.,0
"F. Infectious Disease: The patient initial CBC showed a white count of 20.4, with 53 polymorphs and 5 bands.",0
He was started on Ampicillin and Gentamicin.,0
He was continued on ampicillin and gentamicin for a period of five days and then discontinued.,0
His blood cultures remained now growth to date.,0
The gentamicin levels during this period showed a peak of 7.8 and trough of 0.6.,0
G. Neurology: The patient was started on Fentanyl p.r.n.,0
for his pain during the period when he had his chest tube.,0
Prior to and during the procedures he received one or two doses of morphine sulfate for pain and agitation.,0
No ultrasound was performed on him during his stay in the NICU.,0
H. Sensory: Hearing screen was passed on the left but referred on the right.,0
She will be seen again by audiology prior to discharge.,0
A. Ophthalmology: The eyes were not examined during this period.,0
J. Psychosocial: social worker involved with the family.,0
Name of primary pediatrician: Dr. at .,0
CARE/RECOMMENDATIONS: A. Feeds at discharge: Breast milk or Special Care 20 ad lib as tolerated.,0
C. Car seat position screening: She passed the car seat test prior to transfer.,0
D. State newborn screening status: The State newborn screening was sent on and the results are pending at the time of this dictation.,0
E. Immunizations: The patient received his first dose of Hepatitis B vaccine on .,0
F: Immunizations recommended: Influenza immunization is recommended ad lib in the Fall for all infants once they reach six months of age.,0
"Before this age (and for the first 24 months of the childs life), immunization again influenza is recommended for household contacts and out of home caregivers.",0
follow-up appointments have been scheduled at the time of this dictation.,0
Right sided pneumothorax status post chest tube placement.,0
Dictated By: MEDQUIST36 D: 14:38:33 T: 15:48:58 Job#:,0
"11:22 AM UNILAT LOWER EXT VEINS RIGHT PORT Clip # Reason: RESPIRATORY FAILURE, RIGHT LOWER EXTREMITY GREATER THAN THE LEFT, R/O DVT Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with respiratory failure and now right greater than left lower extremity edema REASON FOR THIS EXAMINATION: eval for dvt ______________________________________________________________________________ WET READ: JCT SAT 12:24 PM DVT extending from mid right superficial femoral vein to popliteal vein.",1
______________________________________________________________________________ FINAL REPORT HISTORY: 74-year-old man with respiratory failure and right greater than left lower extremity edema.,1
"FINDINGS: Grayscale and Doppler son of the right common femoral, superficial femoral, and popliteal veins were performed.",0
Intraluminal thrombus is identified from the mid superficial femoral vein extending down to the popliteal vein.,0
The thrombus is occlusive and no flow or compressibility of the vein is demonstrated.,0
"The common femoral vein is patent with normal flow, augmentation, compressibility, and waveforms.",0
IMPRESSION: Deep venous thrombosis extending from the mid right superficial femoral vein to the popliteal vein.,1
3:53 PM CHEST (PORTABLE AP) Clip # Reason: ro ptx line placement Admitting Diagnosis: RUPTURED AAA ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man s/p aortic aneurysm repair hypoxemia REASON FOR THIS EXAMINATION: ro ptx line placement ______________________________________________________________________________ FINAL REPORT INDICATION: Hypoxia and line placement.,0
FINDINGS: Tip of the ET tube is above the carina.,0
A right introducer sheath is seen with the tip of the catheter appropiately located and no pneumothorax.,0
"Chest tubes remain in place, and the medistinal widening appears the same perhaps contributed to by the shallow level of inspiration.",0
"Pulmonary vessels appear crowded, but the shallow level of inspiration could contribute to that.",0
No new infiltrates are seen.,0
IMPRESSION: No PTX following line placement.,0
No significant interval change vs. prior.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Patient is the 3.345-kilogram product of a 36-week gestation born to a 38-year-old gravida 2, para 0 mother.",0
The pregnancy was complicated by notation on ultrasound of fetal Ebstein anomaly.,1
The patient has been followed closely by the Advanced Care Center including the cardiology team with frequent echocardiograms.,0
"Echocardiogram shows severe right atrial dilatation with severe tricuspid regurgitation, cardiomegaly, and initially mild pulmonary regurgitation.",0
Subsequent ultrasounds have shown absence of pulmonary flow.,0
Recent echocardiograms had showed the presence of fetal atrial premature beats for which the mother was started on digoxin.,0
"Also on echocardiogram today at , a small pericardial effusion was noted.",0
There was no other evidence of fetal hydrops.,0
"The initial plan was for planned C-section at on Thursday, .",0
"However, after fetal imaging this afternoon, the patient was seen in obstetric triage and was noted to have an abnormal fetal heart rate tracing.",0
"After discussion with the cardiology team, it was decided that the best way to proceed was with delivery this evening.",0
Arrangements were made for the presence of cardiology team and transport team and delivery here at .,0
"Mother's prenatal screens include an A-positive blood type, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS unknown status.",0
There were no sepsis risk factors noted.,0
The mother had received a course of betamethasone previously in the pregnancy.,0
"HOSPITAL COURSE BY SYSTEMS: At delivery, the patient emerged vigorous and blue.",0
"Initially with blow-by O2, he remained cyanotic.",0
Patient was subsequently given bag and mask ventilation with no change on O2 saturations which remained in the 40%-55% range.,0
The patient was intubated with a 3.5 oral endotracheal tube.,0
"Subsequent to this and with mechanical ventilation, the patient's saturations slowly improved to the 70%-88% range.",0
A low UV line was placed.,0
Correct positioning of the UV line was confirmed with the receipt return of blood with a catheter replaced at approximately 4 cm.,0
Endotracheal tube position was confirmed with CO2 detection and auscultation.,0
It was decided in conjunction with the transport and cardiology teams to transport the patient directly from the delivery room here at to the cardiac ICU.,0
This was accomplished after a PKU specimen was obtained and vitamin K as well as Ilotycin ophthalmic ointment were administered.,0
Mother and father were able to visit for a short period of time with the child prior to transfer.,0
Respiratory failure requiring mechanical ventilation.,1
Patient transferred to the cardiac ICU via the transport team.,0
The team will obtain x-rays to confirm placement of the endotracheal tube and UV line following placement.,0
"Although placed under sterile conditions, it was suggested that at least several doses of antibiotic coverage be provided given the umbilical venous line placement.",0
An umbilical sample for blood bank was sent with the cardiology team.,0
Patient has not identified a pediatrician for the patient.,0
", Dictated By: MEDQUIST36 D: 21:30:24 T: 05:34:12 Job#:",0
10:49 PM CT HEAD W/O CONTRAST Clip # Reason: ?,0
"Needs followup CT performed between 9 pm Admitting Diagnosis: SUBDURAL HEMORRHAGE;IPH ______________________________________________________________________________ MEDICAL CONDITION: 19 year old man with IPH, SDH, 7 mm midline shift.",1
Needs followup CT performed between 9 pm and 12 am tonight - .,0
No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): 12:18 AM 1.,0
Stable appearance of multicompartmental hemorrhage since examination from 1:30 p.m.,0
"This includes hemorrhagic contusions involving the inferior frontal lobes, subdural hemorrhage tracking along the right cerebral complexity and falx, and trace subarachnoid hemorrhage in the interpeduncular cistern.",1
______________________________________________________________________________ FINAL REPORT INDICATION: Patient is a 19-year-old male with intraparenchymal hemorrhage and subdural hemorrhage status post trauma.,1
COMPARISONS: Comparison is made to CT examinations from .,0
"FINDINGS: Overall, there is no significant interval change since examination from performed at 1:30 p.m.",0
There are stable areas of multicompartmental hemorrhage.,0
"For example, there is subdural hemorrhage layering along the right cerebral convexity measuring up to 4 mm in transverse diameter, and also seen layering along the falx.",1
"In addition, there are multiple foci of inferior bifrontal intraparenchymal hemorrhage, the largest contusion of which measures 3.1 x 0.9 cm in AP x TRV dimensions.",0
There is mild surrounding vasogenic edema involving these contusions.,0
"Overall, the size and distribution of these contusions is little changed since the prior examination.",0
"In addition, there is an area of contusion within the region of the right temporal lobe (2:9) that is again little changed since prior examination.",0
There is a small amount of subarachnoid hemorrhage (2:5) layering within the interpeduncular cisterns.,1
"Overall, the size and configuration of the ventricles are stable with mild effacement of the frontal horns.",0
There is unchanged appaearance of cerebral edema involving the right cerebral hemisphere.,1
There is persistent approximately 6 mm leftward midline shift.,0
There is no evidence of new uncal or transtentorial herniation.,0
Partially imaged is a minimally displaced fracture of the right occipital bone which extends to involve the occipital condyle as better appreciated on prior (Over) 10:49 PM CT HEAD W/O CONTRAST Clip # Reason: ?,0
Needs followup CT performed between 9 pm Admitting Diagnosis: SUBDURAL HEMORRHAGE;IPH ______________________________________________________________________________ FINAL REPORT (Cont) CT of the cervical spine.,1
Stable right sided cerebral edema.,1
"7:05 AM CHEST (PORTABLE AP) Clip # Reason: r/o aspiration Admitting Diagnosis: ACUTE RENAL FAILURE;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 56 year old woman with tachycardia, sob, aspiration risk REASON FOR THIS EXAMINATION: r/o aspiration ______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP REASON FOR EXAM: 56-year-old woman with tachycardia, exclude aspiration.",1
"FINDINGS: The patient has been intubated since the previous study, he tip of the ET tube resides 2-3 cm above the carina.",0
The tip of the left- sided PICC line lies in the SVC.,0
There are multiple new septal lines with a small right-sided pleural effusion.,0
Heart size remains unchanged and is normal.,0
There are new areas of consolidation in the leftand right lower lobes.,0
"metallic biliary stent, gallbladder clips and IVC filter are again noted.",0
IMPRESSION: Extensive new bilateral septal lines with a focal area of consolidation in the right lower lobe and the right pleural effusions are most likely due to a combination of fluid overload and possible aspiration.,0
A repeat chest x-ray is recommended following treatment to ensure resolution.,0
5:54 AM CHEST (PORTABLE AP) Clip # Reason: development of infiltrate?,0
Admitting Diagnosis: RESPIRATORY DISTRESS ______________________________________________________________________________ MEDICAL CONDITION: 28 year old woman with cerebral palsy chronically vented who spiked fever.,1
REASON FOR THIS EXAMINATION: development of infiltrate?,0
"______________________________________________________________________________ FINAL REPORT AP CHEST, 6:44 A.M. HISTORY: Cerebral palsy.",0
IMPRESSION: AP chest compared to and 21: The only change since preceding two films is at the medial aspect of the left diaphragmatic pleural interface which is less distinct.,0
This could be a function of lower lung volumes or slight difference in patient positioning but could also be an indication of new consolidation in the left lower lobe.,0
The upper lungs best as I can evaluate given severe scoliotic chest deformity are clear and the heart is normal size.,0
Small bilateral pleural effusions could be present but there is no appreciable pleural collection and no indication of pneumothorax.,0
Tracheostomy tube is unchanged in position ending at the thoracic inlet and tip of the left subclavian line projects over the junction of the brachiocephalic veins.,0
11:39 AM CT GUIDANCE DRAINAGE; CT FINE NEEDLE ASP Clip # CT GUIDED NEEDLE PLACTMENT; CT ABDOMEN W/O CONTRAST CT PELVIS W/O CONTRAST Reason: please drain right retroperitoneum fluid collection Admitting Diagnosis: GI BLEED ______________________________________________________________________________ MEDICAL CONDITION: 56 year old man s/p gastro-jejunostomy s/p repair of duodenal ulcer/perforation REASON FOR THIS EXAMINATION: please drain right retroperitoneum fluid collection No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT CT-GUIDED DRAINAGE.,1
INDICATION: Patient with history of collection post-biliary leak.,0
"The patient's drain is in situ, but recent CT suggests a persistent fluid.",0
TECHNIQUE: Informed consent was obtained from the patient.,0
Pre-procedure timeout was performed to confirm patient identity and indication for examination.,0
The patient was consented for a possible exchange or insertion of a new catheter.,0
REPORT: A pre-procedure CT showed that the original catheter was within the collection but located marginally.,0
"Although this could be aspirated, repositioning of this catheter with the aid of a wire was not possible.",0
"Hence, a decision was taken to insert a new catheter.",0
A new spot was marked and an 8-French catheter was inserted using a trocar technique.,0
The catheter was secured into position.,0
Approximately 100 mL of purulent fluid was aspirated.,0
"The attending, Dr. , was present and assisted throughout.",0
"3:02 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: OVERDOSE;ARDS ______________________________________________________________________________ MEDICAL CONDITION: 40M aspiration PNA cocaine & heroin OD, continued O2 requirement REASON FOR THIS EXAMINATION: interval change ______________________________________________________________________________ FINAL REPORT HISTORY: Aspiration pneumonia, assess for change.",0
Bilateral pulmonary infiltrates and subsegmental atelectasis in the left mid lung persist.,0
A feeding tube and right internal jugular catheter have been removed.,0
IMPRESSION: No significant change in bilateral pulmonary infiltrates.,0
"6:54 AM CHEST (PORTABLE AP) Clip # Reason: eval for chf, infiltrate Admitting Diagnosis: SEPSIS ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man with tachypnea REASON FOR THIS EXAMINATION: eval for chf, infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: 80-year-old man with tachypnea evaluate for CHF or infiltrate.",0
Comparison is made to prior radiographs dated and prior CTA dated .,0
"SUPINE PORTABLE CHEST RADIOGRAPH FINDINGS: Low lung volumes persist with mild interstitial edema appearing slightly improved, which may be partially related to technique.",0
No new focal consolidations are identified with persistent patchy opacities noted within the right upper and infrahilar regions and retrocardiac/left lower lobe.,1
No new opacities or pneumothorax is identified.,0
Small bilateral pleural effusions have improved.,0
This is mild amount of lower lobe atelectasis.,0
Surgical changes and pacemaker leads are unchanged.,1
Mildly improved interstitial pulmonary edema with unchanged multifocal patchy opacities.,0
Right upper lobe peripheral opacity is nonspecific but could be due to an infarct given history of prior PE and femoral clots.,0
Interval decrease in small bilateral pleural effusions.,0
Right heart strain Weight (lb): 172 BP (mm Hg): 87/54 HR (bpm): 52 Status: Inpatient Date/Time: at 14:18 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size.,0
RIGHT VENTRICLE: Indeterminate RV wall thickness.,0
"3:38 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: please evaluate for evidence source of sepsis; please admini Admitting Diagnosis: MORBID OBESITY/SDA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p ex-lap, gastrectomy, elevating pressor requirements, leukocytosis REASON FOR THIS EXAMINATION: please evaluate for evidence source of sepsis; please administer gastrograffin via NGT, as well as IV contrast No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT HISTORY: Status post ex lap and partial gastrectomy with elevating pressor requirements and elevated white count.",1
TECHNIQUE: CT of the torso was performed after administration of IV contrast and oral Gastrografin through the NG tube.,0
FINDINGS: The study is markedly limited due to patient's body habitus.,0
CHEST: There is a moderate left pleural effusion.,0
There is near-complete collapse of the left lower lobe with minimal aeration seen in the left upper lobe still.,0
The collapsed lung does enhance homogeneously.,0
The right lung demonstrates more minimal atelectasis at the base.,0
No mediastinal lymphadenopathy is seen.,0
Tracheal tube and IJ are in appropriate position.,0
The NG tube is within the stomach.,0
ABDOMEN: There is an open anterior abdominal wound.,0
The liver has a normal appearance.,0
"There is a stable amount of fluid surrounding the liver, tracking down the right paracolic gutter.",0
"However, now this does demonstrate an enhancing rim consistent with enhancing peritoneum.",0
The gallbladder is normal with exception of vicarious excretion of contrast within it.,0
Pancreas is difficult to visualize but is grossly unremarkable.,0
The adrenal glands are grossly unremarkable.,0
"The kidneys enhance normally bilaterally, but do not demonstrate excretion of contrast, which is suggestive of renal failure.",1
The patient has had a partial gastrectomy.,0
There is a large amount of mesenteric fluid throughout the abdomen and pelvis.,0
"Prominent retroperitoneal lymph nodes are noted, including a 1.7-cm lymph node anterior to the IVC.",0
"These were prominent, all the way back to , however.",0
(Over) 3:38 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: please evaluate for evidence source of sepsis; please admini Admitting Diagnosis: MORBID OBESITY/SDA Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) PELVIS: The pelvic bowel loops are unremarkable except for a few diverticula in the sigmoid.,1
"There is again mesenteric stranding and fluid in the pelvis, but no discrete fluid collection seen.",0
There is anasarca with diffuse subcutaneous edema seen.,0
There is degenerative disc disease of the spine.,0
Note is made of a bony bridge between the right posterior sixth and seventh ribs.,0
Near complete collapse of the left lower lobe.,0
Diffuse mesenteric stranding/fluid as well as diffuse subcutaneous edema consistent with anasarca.,0
The fluid surrounding the liver and tracking in the right paracolic gutter now has enhancing peritoneum surrounding it.,0
Infection can not be excluded.,0
"Lack of excretion of IV contrast by the kidneys is suggestive of renal dysfunction, degree uncertain.",0
"Prominent retroperitoneal lymph nodes, which appear stable from prior studies.",0
7:46 PM MR HEAD W & W/O CONTRAST Clip # Reason: rule out brain stem lesion that could have caused central ap Admitting Diagnosis: RESPIRATORY FAILURE Contrast: MAGNEVIST Amt: 14 ______________________________________________________________________________ MEDICAL CONDITION: 77 year old man with episode of unresponsiveness REASON FOR THIS EXAMINATION: rule out brain stem lesion that could have caused central apnea No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): KCLd WED 6:22 PM PFI: INDICATION: No evidence of acute intracranial process.,1
"______________________________________________________________________________ FINAL REPORT INDICATION: Episode of unresponsiveness, rule out lesion that would cause central apnea.",0
TECHNIQUE: Multiplanar T1- and T2-weighted of the brain were obtained prior to administration of contrast.,0
"FINDINGS: There is no evidence of hemorrhage, edema, mass, or infarction.",0
No diffusion abnormality is identified.,0
Confluent T2-hyperintensity is seen within the periventricular and subcortical white matter of both cerebral hemispheres consistent with chronic microvascular infarction.,0
No abnormal enhancement identified on post-contrast images.,0
"8:19 AM CAROTID SERIES COMPLETE Clip # Reason: pre-op cardiac surgery Admitting Diagnosis: ENDOCARDITIS ______________________________________________________________________________ MEDICAL CONDITION: 31 year old woman with endocarditis, may need new valves REASON FOR THIS EXAMINATION: pre-op cardiac surgery ______________________________________________________________________________ FINAL REPORT Study: Carotid Series Complete Reason: .31 year old woman with endocarditis.",1
"On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 107/14, 72/12, 70/18, cm/sec.",0
CCA peak systolic velocity is 113 cm/sec.,0
ECA peak systolic velocity is 88 cm/sec.,0
"On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 74/26, 84/25, 73/19, cm/sec.",0
CCA peak systolic velocity is 123 cm/sec.,0
The ICA/CCA ratio is .68.,0
"2:03 AM BABYGRAM (CHEST & ABDOMEN) Clip # Reason: check ett placement, assess for bowel distention Admitting Diagnosis: PREMATURITY ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity REASON FOR THIS EXAMINATION: check ett placement assess for bowel distention ______________________________________________________________________________ FINAL REPORT BABYGRAM CHEST AND ABDOMEN: HISTORY: Infant with prematurity.",0
"FINDINGS: Since the examination of one day prior, the bowel gas pattern shows less gaseous distention and is non-obstructive.",0
The endotracheal tube has been pulled back and is now just past the thoracic inlet.,0
The lung volumes are normal.,0
Very mild hyaline membrane disease persists and appears improved.,0
Streaky left medial basilar atelectasis is seen and tiny amount of atelectasis has a streaky configuration in both the right upper lobe and right lower lobe.,0
The heart and mediastinal contours appear unchanged.,0
"7:02 PM MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # MR L SPINE W/O CONTRAST Reason: eval for central cord syndrome ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with fall from standing and now with myoclonus of BLE,unable to pee now REASON FOR THIS EXAMINATION: eval for central cord syndrome No contraindications for IV contrast ______________________________________________________________________________ WET READ: 12:43 AM MR CERVICAL: Small multilevel disk protrusions: C2-3, C3-4, C4-5, C5-6, C6-7.",0
"Otherwise, normal: No major canal stenosis.",0
"Grossly negative for cord, canal abnormalities MD MRI THORACIC: Small disk protrusions T6-7, T7-8, T10-11, otherwise normal T- Spine MD MRI LUMBAR: Minimal multilevel disk bulges.",0
"Small far lateral herniated components at L3-4, L4-5.",0
"Rest of L spine is normal MD ______________________________________________________________________________ FINAL REPORT HISTORY: Fall from standing, now with bilateral lower extremity weakness and urinary retention.",0
COMPARISON: Comparison is made to CT of the cervical spine as well as radiograph of the lumbar spine.,0
"TECHNIQUE: Sagittal T1, T2, and STIR sequences were acquired in the absence of intravenous contrast throughout the cervical, thoracic, and lumbar spine.",0
"Axial T2-weighted images were also acquired through most of the cervical, thoracic, and lumbar spine.",0
"FINDINGS: In the cervical spine, there is no evidence of fracture or malalignment.",0
There is no paravertebral soft tissue signal abnormality.,0
There is no narrowing of the spinal canal or spinal cord signal abnormality.,0
"In the thoracic spine, vertebral body alignment is normal, and there is no vertebral body loss of height.",0
"Spinal cord signal is normal, and there is no evidence of thecal sac deformity.",0
"A small right disc bulge is noted at T10-11, with no evidence of nerve root impingement.",0
"In the lumbar spine, vertebral body alignment is normal with the exception of a small grade 1 retrolisthesis of L5 on S1.",0
Vertebral body height is normal.,0
"Note is made incidentally of small focal fat at the L1 vertebral body; otherwise, the signal characteristics of the vertebral bodies are unremarkable.",0
"The spinal cord terminates appropriately at the level of L1, and there is no signal abnormality seen in the spinal cord or at the nerve roots through the lumbar levels.",0
There is a small central disc bulge at L5-S1 as well as broad-based disc bulges at L3-L4 and L4-L5.,0
The bulge at L4-L5 also extends laterally to the right with no definite nerve root involvement.,0
"(Over) 7:02 PM MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # MR L SPINE W/O CONTRAST Reason: eval for central cord syndrome ______________________________________________________________________________ FINAL REPORT (Cont) IMPRESSION No evidence of cord compression throughout the cervical, thoracic, and lumbar spine.",0
Scattered degenerative changes as detailed above.,0
"10:08 AM BABYGRAM (CHEST & ABDOMEN) Clip # Reason: Heme positive stool, check lung expansion Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with prematurity REASON FOR THIS EXAMINATION: Heme positive stool, check lung expansion ______________________________________________________________________________ FINAL REPORT Submitted for interpretation on .",0
There is no change in the diffuse opacity of the lungs consistent with hyaline membrane disease.,0
The ETT is above the thoracic inlet.,0
The feeding tube extends into distal esophagus.,0
Bowel gas pattern appears normal.,0
"There is no evidence of pneumatosis, free air or portal venous gas.",0
9:58 AM CHEST (PORTABLE AP) Clip # Reason: eval ptx s/p ct d/c Admitting Diagnosis: AORTIC STENOSIS\ AVR ASCENDING AORTIC REPAIR/SDA ______________________________________________________________________________ MEDICAL CONDITION: 54 year old woman with Asc.,0
"Aorta Replacement REASON FOR THIS EXAMINATION: eval ptx s/p ct d/c ______________________________________________________________________________ FINAL REPORT AP CHEST, 11 A.M., HISTORY: Ascending aortic aneurysm.",0
IMPRESSION: AP chest compared to and an earlier postoperative film on : Borderline interstitial edema and small right pleural effusion are new following extubation.,0
Mild degree of postoperative widening of the mediastinum is stable.,0
7:24 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: pt with very complicated surgical history s/p total colectom ______________________________________________________________________________ MEDICAL CONDITION: History: 61M with above REASON FOR THIS EXAMINATION: pt with very complicated surgical history s/p total colectomy now with ileorectal anastomosis now with pill fragments coming out of wound ?,1
fistula No contraindications for IV contrast ______________________________________________________________________________ WET READ: SHSf WED 9:16 PM Limited study due to artifact from patient body habitus.,1
Presumed (but not fully characterized) enterocutaneous fistula extends from the lower aspect of the anterior abdominal wall likely communicating with the anastamosis (which is likely discontinuous) with air and possibly contrast material within the tract.,0
"Air and fluid in the right ant abdominal wall extends into right inguinal canal and scrotum as before, cannot exclude superinfection.",0
Air in bladder lumen- correlate with recent catheterization.,0
WET READ VERSION #1 ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old man with recent total colectomy with take back for anastomotic leak presents with concern for enterocutaneous fistula with feculent material and pills draining from the anterior abdominal wound VAC.,1
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to the pubic symphysis after the uneventful administration of Gastrografin oral and 150 cc of Omnipaque intravenous contrast medium.,0
"COMPARISONS: Multiple previous examinations, most recently .",0
CT ABDOMEN WITH CONTRAST: This study is markedly limited due to patient body habitus resulting in marked beam hardening.,0
Imaged lung bases are clear without pleural or pericardial effusion.,0
The portal and hepatic veins appear patent.,0
"The gallbladder, pancreas, spleen and bilateral adrenal glands are unremarkable.",0
The kidneys enhance and excrete contrast symmetrically with a 15 mm exophytic simple cyst in the left kidney.,0
Other hypodensities in the kidneys bilaterally are too small to be accurately characterized on CT.,1
The patient is status post total colectomy with ileorectal anastomosis.,1
"In the left lower quadrant at the presumed site of anastomosis, there is (Over) 7:24 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: pt with very complicated surgical history s/p total colectom ______________________________________________________________________________ FINAL REPORT (Cont) extensive fat stranding with multiple scattered gas locules which are presumed to be extraluminal potentially within a fistulous tract as they are directed towards the inferior aspect of the anterior abdominal wound where there is extensive enhancement and thickening of the anterior abdominal wall fascia.",1
The bowel in the vicinity of the ileorectal anastamosis is irregular and not well followed.,0
Irregular hyperdense material (2:77) in this region is compatible with discontinuous suture material.,0
Other linear areas of hyperdensity best seen on the coronal images (300B:33) could reflect extraluminal Gastrografin.,0
"The fistulous tract is not clearly delineated, but most likely region extends from the ileorectal anastomosis towards the inferior aspect of the anterior abdominal wound (2:75).",0
"Extensive fat stranding, gas locules and anterior abdominal wall fascial thickening in this area are compatible with phlegmonous change without discrete drainable collection.",0
The remainder of the rectum is unremarkable.,0
The aorta and major branches appear patent with moderate atherosclerotic calcification as before.,0
CT OF THE PELVIS WITH CONTRAST: The bladder is tented towards the right lower quadrant likely relating to changes from herniorrhaphy.,0
The gas collecting in the anterior lumen of the bladder could relate to recent Foley catheterization and correlation with history is recommended.,0
"Air and fluid collection extending from the anterior abdominal wall into the inguinal canal and scrotum is similar in appearance to the previous study, perhaps slightly improved, but not discretely measurable.",0
Superinfection would be difficult to exclude in this area.,0
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion concerning for osseous malignant process with sacroiliac and lumbosacral degenerative changes.,0
Scattered injection granulomata are seen in the gluteal soft tissues.,0
"Probable enterocutaneous fistula extending from the lower aspect of the anterior abdominal wound through thickened anterior abdominal wall fascia, probably connecting at the site of the ileocolic anastomosis with disrupted appearance of the suture material in this area.",1
No drainable collection with phlegmonous change in the left lower quadrant anteriorly.,0
"Air and fluid traversing the right lower anterior abdominal wall into the right inguinal canal and scrotum is slightly improved from the previous study, though superinfection would be difficult to exclude.",0
The anterior bladder is tented towards the right lower quadrant with air collecting anteriorly.,0
"This is likely just post-surgical change with air from recent Foley catheterization, but correlation with history of instrumentation is recommended.",1
(Over) 7:24 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: pt with very complicated surgical history s/p total colectom ______________________________________________________________________________ FINAL REPORT (Cont),1
"7:17 AM CHEST (PORTABLE AP) Clip # Reason: assess for collapse Admitting Diagnosis: AORTIC ANEURYSM\ BENTAL PROCEDURE VS VALVE SPARING AORTIC ROOT REPLACEMENT/SDA ______________________________________________________________________________ MEDICAL CONDITION: 58 year old man sp CABG/aortic aneurysm repair, WORSENING HYPOXIA REASON FOR THIS EXAMINATION: assess for collapse ______________________________________________________________________________ FINAL REPORT CHEST, SINGLE AP FILM: History of CABG and aortic aneurysm.",0
The Swan Ganz catheter overlies proximal right pulmonary artery.,1
LINE PLACEMENT Clip # Reason: picc placed Admitting Diagnosis: BRAIN ABSCESS ______________________________________________________________________________ MEDICAL CONDITION: 42 year old woman with right brain abscess REASON FOR THIS EXAMINATION: picc placed ______________________________________________________________________________ FINAL REPORT CHEST SINGLE AP FILM.,0
History of PICC line placement.,0
The PICC line is in distal SVC.,0
Jugular CV line is in mid SVC.,0
Minimal atelectasis left lung base.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 73 year old male with moderate severe aortic stenosis and severe chronic obstructive pulmonary disease admitted three times in the past six months for chronic obstructive pulmonary disease exacerbation, most recently last week.",1
The patient had arranged a visiting nurse.,0
The patient met compliance to assure he is on his proper medications at home.,0
"Per the daughter, the patient is unable to keep his medications straight and he sometimes misses doses.",0
The patient is here with similar symptoms to prior admissions and states he feels better off his medications.,0
"The patient was administered intravenous steroids and oxygen by face mask in the Emergency Department, and he was transferred to the floor where he became more short of breath.",0
"He has had some fevers at home reportedly and intermittent atypical chest pain episode on the day prior to the day of admission, left-sided pleuritic pain and general discomfort with dyspnea.",0
"REVIEW OF SYSTEMS: Review of systems was negative for headache, vision changes, change in appetite and positive for chest pain with shortness of breath, negative for orthopnea, paroxysmal nocturnal dyspnea, edema, diaphoresis.",0
"Occasional constipation, no bright red blood per rectum.",0
"HOME MEDICATIONS: Albuterol 2 puffs q.i.d., Afrin 81 q.d., Atrovent 4 puffs b.i.d., calcium carbonate 500 t.i.d., Flovent 2 puffs b.i.d., Lac-Hydrin prn, Levofloxacin finished this course on , Prednisone taper ended on , Protonix 40, Serevent discus, Vitamin D. PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease with an FEV1 of 0.98, aortic stenosis, critical valve area of 0.8 cm on an echocardiogram in .",1
Dyspepsia status post treatment for Helicobacter pylori in .,0
Degenerative joint disease and cervical spondylitis.,0
"SOCIAL HISTORY: The patient is Somalian, a retired engineer, lives with his wife and three children.",0
"He quit tobacco six years ago, no alcohol, no other medications or illegal drugs.",0
"PHYSICAL EXAMINATION: Temperature 95.2 axillary, heartrate 107, blood pressure 148/76, respiratory rate 29, 100% on facemask.",1
The patient is an elderly Somalian male lying in bed in moderate severe respiratory distress.,0
"Head, eyes, ears, nose and throat: Nasal flaring, pupils equally round, and reactive to light, extraocular movements intact, dentures are in place.",0
"Neck supple, notable for accessory muscle use.",0
"Cardiovascular, tachycardiac, distant S1 and S2.",0
"Pulmonary, poor air movement, tachypnea, diffuse wheezes.",0
"Abdominal examination: Normal bowel sounds, soft, mild left lower quadrant tenderness.",0
Per family moves all extremities grossly intact.,0
"LABORATORY DATA: Laboratory data on admission notable for lactate of 4.4 and blood gases which initially were 7.34, 47, 228 and progressed to 7.21, 60, 159.",0
"White count 11.4, hematocrit 34.2, creatinine 1.1.",0
"HOSPITAL COURSE: This 73 year old male with chronic obstructive pulmonary disease exacerbation with multiple recent admissions, readmitted for shortness of breath, stabilized in the Emergency transferred to the floor and developed worsening respiratory failure.",1
Respiratory failure - The patient was transferred to the Intensive Care Unit where he was placed on BiPAP in light of his respiratory fatigue and increased secretions with worsening hypoxia.,1
He was started on Azithromycin 500 mg times one and then 250 mg times four days.,0
The patient was weaned off of biPAP and had improving respiratory status.,0
Chest x-ray showed heart and mediastinal contours stable.,0
"Aorta, slightly avulsed, lungs clear without effusion, consolidations or pneumothorax.",0
Shortness of breath improved and the patient was transferred back to the floor on and was continued on steroids and was changed to p.o.,0
Prednisone 60 to begin a long taper.,0
"Continued on nebulizers, chest physical therapy, Azithromycin, incentive spirometry.",0
The patient improved on this course.,0
At the time of discharge it was thought the patient would be a good candidate for outpatient pulmonary rehabilitation.,0
Congestive heart failure/volume overload - In the Emergency Department the patient had good diuresis with Lasix 20 mg intravenously.,1
Continued diuresis while in the Emergency Room noted creatinine up to 1.3.,0
"In the Medicine Intensive Care Unit the patient continued his diuresis, BUN and creatinine were heavily followed.",0
"The patient had an echocardiogram to assess cardiac function which revealed an ejection fraction of 50% with mild symmetric left ventricular hypertrophy, 1+ aortic regurgitation, aortic valves are severely thickened and deformed.",1
"Mitral valve with 1 to 2+ mitral regurgitation, moderate 2+ tricuspid regurgitation when compared with prior studies.",0
"In , the left ventricle was less hyperdynamic and the aortic valve orifice area is now further reduced to 0.7 cm squared.",1
"The patient's cardiologist, Dr. was consulted who felt that this could be managed as an outpatient and cardiac function was not the cause of his admission or repeated admissions which are likely due to chronic obstructive pulmonary disease.",1
He recommended further outpatient treatment for his cardiac problems.,0
"Chest/epigastric pain - Per primary care notes, this is a chronic non-cardiac pain.",0
"The patient had ruled out and did have a small increase in troponins, maximum of 0.02 probably due to demand in the setting of tachycardia and tachypnea.",0
The patient's pain appeared worse postprandially while the patient is on Protonix.,0
He has had a history of gastritis in the past.,0
"Gastrointestinal was consulted as he has had Helicobacter pylori in the past, they recommend an outpatient workup of the questionable gastritis.",0
They recommend a ten day period off Protonix prior to a Helicobacter pylori breast test.,0
This will be followed up with his outpatient provider.,0
Acute renal failure - The patient's increase in BUN and creatinine in the setting of diuresis returned to baseline prior to his discharge.,1
Elevated blood glucose levels - Most likely secondary to steroid use.,0
The patient was covered with an insulin drip in the Intensive Care Unit and then transitioned to an insulin sliding scale and q.i.d.,0
Hemoglobin A1c was measured and found to be 6.9.,0
The patient's lowest blood glucose even on the sliding scale were in the 150 range.,0
Diabetes was consulted and recommended starting Glucotrol XL 5 p.o.,0
as well as increasing the patient's Humalog sliding scale.,0
They recommend a trial of Metformin 500 mg q.d.,0
as the patient's creatinine returned to a baseline of 1.0 and we were no longer concerned about congestive heart failure as this medication may precipitate congestive heart failure.,1
The patient had a nutrition evaluation and teaching on diabetic diet and follow up was arranged at Clinic.,0
The patient was assessed by physical therapy and occupational therapy.,0
Chronic obstructive pulmonary disease exacerbation 2.,1
Moderate to severe aortic stenosis 3.,0
"Dyspepsia, status post Helicobacter pylori treatment in 8.",0
History of herpes zoster 12.,0
Cervical spondylosis FOLLOW UP: The patient has follow up scheduled for rehabilitation services on .,0
Pulmonary function tests on .,0
Follow up with Dr. .................. .,0
"Follow up with his primary care physician, .",0
", as well as Clinic, .",0
"DISCHARGE CONDITION: The patient is requiring nebulizers, chest physical therapy, does not desaturate with walking although has dyspnea with mild exertion.",0
"Prednisone 60 mg for a total of 5 doses, Prednisone 50 mg for another total of 5 doses followed by Prednisone 40 mg for a total of 5 doses followed by Prednisone 30 mg for another total of 5 doses followed by Prednisone 20 mg for another total of 5 doses followed by Prednisone 10 mg for another total of 5 doses followed by Prednisone 5 mg for another total of 5 doses, each as q.d.",0
Azithromycin 250 mg for a total of a four day course.,0
Glipizide 5 mg tablets q.d.,0
Humalog sliding scale prn .................. 11.,0
"Nebulizers prn as well as his home pulmonary medications DR., 12-735 Dictated By: MEDQUIST36 D: 15:00 T: 16:37 JOB#:",0
4:51 PM CHEST (PORTABLE AP) Clip # Reason: s/p thoracotomy.,0
chest tube placed ______________________________________________________________________________ MEDICAL CONDITION: 65 year old woman with patrial pericardiectomy REASON FOR THIS EXAMINATION: s/p thoracotomy.,0
chest tube placed ______________________________________________________________________________ FINAL REPORT INDICATION: S/P thoracotomy with pericardiectomy and chest tube placement.,0
"COMPARISON: Chest radiograph dated and scout radiograph from chest CT dated CHEST, PORTABLE: There is a new left sided chest tube.",0
"Heart size appears smaller, likely reflecting s/p partial surgical pericardiectomy.",0
There is interval resolution of small left sided pleural effusion.,0
Right sided pleural effusion shows significant interval enlargement.,0
The patient is s/p esophagectomy and pull-through of neoesophagus is apparent.,0
Interval decrease in heart size likely from recent surgery.,0
New left sided chest tube with resolution of left pleural effusion.,0
Enlargement of right sided pleural effusion.,0
"7:43 PM CT HEAD W/O CONTRAST Clip # Reason: S/P RT ICA STENTING , NOW WITH LT ARM WEAKNESS.",0
Admitting Diagnosis: CAROTID STENOSIS\CAROTID ANGIOPLASTY/SDA ______________________________________________________________________________ MEDICAL CONDITION: 72 year old man s/p R.ICA stenting today.,1
Now with L.arm heaviness/weakness REASON FOR THIS EXAMINATION: pls eval for evidence of stroke/bleed/embolism or other IC event.,0
No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT PFI: No acute intracranial hemorrhage or major vascular territorial infarction.,1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Tetracyclines Attending: Chief Complaint: SOB, wheezing Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. is a 60 y/o woman with severe COPD, with frequent flares but no prior intubation for COPD flare.",0
"Presented with approximately one week dyspnea, wheezing, productive cough of green sputum.",0
"Saw her PCP 1 wk ago and treated with bactrim, as past data had shown respiratory pathogen Moraxella.",0
Pt took her antibiotics but presented with unresolved symptoms of severe dyspnea and wheezing.,0
+ chills but with no fever.,0
"ROS: cough, congestion, chills, x 3 weeks worse over one day.",0
Abdominal pain given chronic constipation.,0
"COPD, last PFTs with FVC 2.03 and FEV1 0.94 (62 and 39% predicted respectively) 2.",0
"IgA deficiency, on IV gamma globulin with Dr. but apparently no longer receiving; per PCP IV gamma globulin did not seem to make measurable impact on her frequency of COPD flares 3.",0
"CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pain with left arm discomfort).",0
Cath in with single vessel CAD s/p PTCA/stent to LCx.,0
Cath in with stent placement to RCA and LCx.,0
"Osteoporosis, with history of multiple compression and rib fractures from coughing 8.",0
"History of thrush/ esophagitis steroid therapy, on Diflucan prn 9.",0
"Tremor Social History: She lives with her daughter, son-in-law and 3 grand-children.",0
"She is an ex-smoker, with about a 30-pack-year smoking history, quit in (had previously stopped, then restarted, then stopped again).",0
"Family History: Mother with DM, father with pancreatic cancer.",0
"Physical Exam: T 97.8, HR 94, BP 152/91, RR 20.",0
"Sat97% on 6L GENERAL: flushed appearing female using accessory muscles for breathing with mask on face HEENT: OP clear, non elevated JVP.",0
LUNGS: decreased breath sounds bilaterally.,0
EXTREMETIES: trace pre-tibial edema SKIN: Warm well perfused.,0
Pertinent Results: pH 7.40 pCO2 49 PCO2 78 PO2 .,0
09:00PM GLUCOSE-114* UREA N-12 CREAT-0.8 SODIUM-134 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-32 ANION GAP-13 09:00PM WBC-12.3* RBC-4.81 HGB-13.8 HCT-41.0 MCV-85 MCH-28.7 MCHC-33.7 RDW-14.6 Lactate:1.5 Trop-T: <0.01 .,0
PT: 10.4 PTT: 22.6 INR: 0.9 .,0
"CXR: no pleural effusions, no consolidation .",0
No pulmonary embolism or aortic dissection.,0
"Atherosclerosis is present in the coronary arteries, abdominal aorta and the proximal renal arteries.",1
Consolidation/atelectasis is present at the right lower lobe.,0
Multiple bilateral rib fractures and compression collapse of multiple vertebral bodies in the thoracic spine as described above.,0
"Brief Hospital Course: A/P: 60 y/o woman with severe COPD presenting with SOB, cough likely COPD exacerbation, requiring intubation for respiratory muscle fatigue.",1
"1) COPD, acute exacerbation In ED T 97.8, HR 94, BP 152/91, RR 20.",1
Lung exam diffuse expiratory wheeze and crackles.,0
Solumedrol 125 IV x 1.,0
Mag 2 gram IV x 1.,0
EKG with NSR no acute changes.,0
CTA with no evidence of PE.,0
"She was subsequently admitted to given need for continuous nebs, continuous wheezing with need for face mask at 100%.",0
"By the patient's history, she has had multiple COPD flares in the past but none requiring intubation.",0
"She initially tolerated BiPAP, however, experienced worsening distress and required intubation , extubated but then developed acute onset of worsening respiratory distress.",1
"She was also hypertensive to SBPs 190s-200s, possible flash pulmonary edema She was given lasix with good diuresis, and started on labetolol & nitro drips for BP control.",0
At that point she underwent a trial of BiPAP which after a short time she asked to discontinue the BiPAP and made clear at that point that she did not want to go through another intubation.,0
"Her family was contact and were in agreement with patient's wishes not to pursue either noninvasive or intubation and the decision was made to optimize medical therapy including steroids, nebulizer treatments, and provide morphine and ativan for symptomatic control of respiratory distress.",0
She was on fentanyl patch as for chronic ?rib pain and this was titrated to 50 mcg/hr patch to help dyspnea as well.,0
She and her daughters met with the palliative care NP when she was tenuous in the ICU and they discussed various options including hospice.,0
"The pt has made it clear that being at home is a priority, though at this time her daughters have work obligations that make it difficult for someone to be home with her.",0
"Fortunately, the pt's respiratory status has improved significantly and she is to go to rehab.",0
She has completed a 7 day course of Cefepime and Vancomycin () for empiric coverage of pneumonia.,0
Her chest X-ray showed no evidence of no new infiltrate on CXR or evidence of pneumonia.,0
At this time she is stable on liters NC and breathing quite comfortably.,0
"She is to continue her nebs, inhalers, and will complete a steroid taper.",0
2) Leukocytosis: believed probably secondary to steroids.,0
Culture data shows no active infection.,0
One sputum showed sparse aspergillus but she has improved clinically without antifungal treatment and thus this was believed to be a colonizer rather than pathogen.,0
3) CAD: no active symptoms.,0
"SHe is to continue ASA, Plavix, b-blocker statin, ACEi 4) HTN: episode elevated BP but now stable on the floor.",0
"She is on metoprolol, lisinopril.",0
5) Osteoporosis: - Continue bisphosphonate.,0
"Her calcium has been temporarily held due to a few low phosphorous readings, but if this resolved in future she can resume Ca supplements .",0
6) Depression: continue Nortriptyline 7) Urinary retention: pt experienced several episodes of urinary retention on the floor after her ICU foley was removed.,0
Possibly secondary to having recent foley vs. opioid.,0
She was straight cathed intermittently but was able to urinate the day of discharge.,0
We would like to avoid foley if necessary.,0
UOP should be followed carefully at rehab.,0
"8) Prophylaxis: she was initially on Hep SQ but this was discontinued due to her tendency to have prolonged ooze/bleed from injection sites (pt on ASA, Plavix).",0
She was changed to sequential compression devices She was given influenza vaccine this admission.,0
She reports she received the pneumovax within the last 1-2 years.,0
"Code status: Do not resuscitate (DNR/DNI), discussed with Ms. and daughters, decided on .",0
Confirmed again when transferred to the floor.,0
# Communication: Daughter Phone number: Medications on Admission: Albuterol nebs/INH Simvastatin 20mg po qam Clopidogrel 75 mg po daily Omeprazole 20 mg po daily Alendronate 70 mg PO QSUN Fentanyl 25 mcg/hr Patch 72HR Oxycodone-Acetaminophen 5-325 mg 1-2 Tabs po Q4-6H Nortriptyline 25 mg po qhs Fluticasone-Salmeterol 500-50 mcg Atenolol 25 mg po daily Calcium 500 mg po daily Senna 8.6 mg po bid prn Docusate Sodium 100 mg po bid prn Prednisone 10 mg daily Insulin Lispro (Human): per SSI U subQ four times a day.,0
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stools.,0
Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime).,0
"Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 2X/WEEK (,WE).",0
Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for Constipation.,0
Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 3 days: start .,0
Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: start .,0
Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: start and take last dose on .,0
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools.,0
Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours).,0
Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for agitation or dyspnea.,0
"Morphine 10 mg/5 mL Solution Sig: 5-15 mg PO Q3H (every 3 hours) as needed for dyspnea, pain.",0
Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day.,0
Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing.,0
Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation every four (4) hours as needed for wheezing/shortness of breath.,0
"Discharge Disposition: Extended Care Facility: Hospital - Discharge Diagnosis: Primary: Chronic Obstructive Pulmonary Disease, Acute exacerbation Secondary: Coronary artery disease Hypertension Hyperlipidemia Hx gastritis Osteoporosis Depression Discharge Condition: stable Discharge Instructions: Please call your PCP with any worsening symptoms of shortness of breath, fever, chills, new cough.",1
During this hospital stay you have expressed your desire not to be reintubated and not be on ventilator support in the future.,0
Please continue to communicate with your family and physicians regarding your medical wishes.,0
"Phone: Date/Time: 10:20 Provider: BREATHING TESTS Phone: Date/Time: 10:40 Provider: , M.D.",0
Phone: Date/Time: 11:00 MD Completed by:,0
", NMED TSICU 5:47 PM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT PORT Clip # Reason: eval for acute process Admitting Diagnosis: NEW MASS ______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with ?",0
shoulder injury REASON FOR THIS EXAMINATION: eval for acute process ______________________________________________________________________________ PFI REPORT PFI: No fracture or dislocation detected.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: MEDICINE Allergies: Latex Attending: Chief Complaint: Dyspnea and chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 58 y/o M cirrhosis secondary to hepatitis C, CAD s/p CABG presented to for chest pain.",1
Over the past several months patient has been experiencing intermittent chest pain which lasts for 1 hour and resolves without intervention.,0
"At first patient states the chest pain started the past several weeks, but then stated he experienced it prior to his cardiac cath .",0
"The pain is described as pressure, burning and sharp at times - but predimonetely pressure.",0
The pain occurs at rest and with exertion.,0
He feels stress worsens the pain and nothing makes it better including nitro.,0
"He also describes nocturnal cough, bad taste but no sensation of reflex.",0
Patient additionally describes shortness of breath worsening over the past several months - worse with exertion.,0
Patient describes mild improvement lying flat.,0
During his stay at work-up involved negative cardiac enzymes.,0
Cardiology was consulted who felt pain was not cardiac in nature.,0
Per discharge summary this is in light of a recent cath at - however the most recent is .,0
Patient's work-up also included a negative chest CTA.,0
Patient was evaluated by pulmonary who recommended treatment for COPD exacerbation.,0
Over the course of the admission patient became progressively hypoxic decreasing to the low 90s on RA and 80s upon standing - bringing up the possibility of hepatopulmonary syndrome.,0
Patient transferred to for further work-up.,0
Review of systems: (+) Per HPI.,0
"(-) Denies fever, night sweats, recent weight loss or gain.",0
"Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits.",0
Past Medical History: CAD s/p NSTEMI and CABG Hepatitis C liver cirrhosis Diabetes type II HTN Hyperlipidemia Hepatic enchaplopathy EGD: 3 cords of grade I varices Osteoarthritis of knees Ulcer on base of nostril- being eval?????,1
?d by ENT Emphysema/COPD Colon polyps Chronic back pain secondary to spinal stenosis Depression/Anxiety Peripheral vascular disease Social History: Lives with his brother.,1
2 adult children but does not have an ongoing relationship with them.,0
Occupation: Not currently employed; medical disability ETOH: none since Tobacco: 2 pack day 30 years - quit .,0
"Illicits: Prior heroin use-quit Family History: Mother died of an aneurysm, father died of gastric cancer.",0
"Physical Exam: On transfer to MICU from OSH: General: Alert, oriented, no acute distress HEENT: Normocephalic and atraumatic.",0
CHEST: Clear to auscultation biltaral - no wheezes or crackles.,0
"HEART: Regular rhythm with normal S1, physiologically split S2, no S3, and no S4.",0
There is a soft apical holosystolic murmur that radiates to the left axilla.,0
There is no click or rub.,0
The left ventricular impulse is nondisplaced.,0
Tenderness to palpation over left breat.,0
Moderate tenderness lower middle region.,0
The bowel sounds are normal.,0
"EXTREMITIES: No cyanosis, clubbing, or edema.",0
Pertinent Results: Chem 10 135 107 24 182 AGap=11 4.5 22 1.3 Ca: 8.0 Mg: 2.0 P: 3.6 .,0
CK: 215 MB: 7 Trop-T: <0.01 .,0
LFT ALT: 50 AP: 178 Tbili: 2.7 AST: 63 .,0
"Serum ASA, EtOH, Acetmnphn, , , Tricyc Negative Urine ASA, EtOH, , , Tricyclic negative; AMPHETAMINE POS .",0
CBC 12.7 > 12.6 < 85 37.3 N:83.6 L:10.9 M:5.4 E:0 Bas:0 .,0
PT: 16.5 PTT: 45.9 INR: 1.5 .,0
Abdominal ultrasound with Doppler: Nodular liver countour is consistent with cirrhosis.,1
The main portal vein and artery are patent and demonstrate normal flow.,0
** OLD IMAGING ** From OSH : CTA: No PE.,0
Mild emphysematous changes in upper lobe.,0
ECHO : Dilated LV with normal systolic function.,0
Moderate MR. shunt bubble study performed with opacification of the LV after the fourth or fifth beat.,0
Recent ECHO : Bubble study revealed late contrast in the left atrium c/w pulmonary arterial venous malformation (and bubbles appeared to eminate from the pulmonary vein into the left atrium (clip )).,0
Extensive complex (>4mm) nonmobile atheroma in the descending thoracic aorta to 37 cm from the incisors.,0
A very small (~4mm) mobile echodense structure is noted on the left ventricular outflow side of the non-coronary cusp of the aortic valve consistent with probable Lambl's excresence (clip #) although a vegetation cannot be definitively excluded (clinical correlation recommended).,0
IMPRESSION: Agitated saline contrast study revealed late contrast in the left atrium consistent with pulmonary arterial venous malformation.,0
Extensive nonmobile complex atheroma in the thoracic aorta.,0
Native LMCA and three vessel coronary artery disease.,1
Patent LIMA-LAD and SVG-PDA grafts.,0
Moderate left ventricular diastolic heart failure.,1
EKG: At : Normal axis.,0
No ST elevation or depression.,0
"No ST elevation, depression, TWI.",0
"Brief Hospital Course: 58 M h/o cirrhosis secondary to hepatitis C, CAD s/p CABG presented to with chest pain and shortness of breath.",1
Transferred to for further evaluation.,0
# Hepatopulmonary Syndrome: Patient with a clinical history supportive of orthodeoxia and platypnea.,0
and consistent with hepatopulmonary syndrome.,0
"A TTE with bubble study at an OSH bubble showed opacification of LV after 4th or 5th beat, consistent with HPS.",0
He also had an ECHO with bubble study done at in that showed likely pulmonary arterial malformation possibly consistent with hepatopulmonary syndrome.,0
"Additional work-up was negative for PE, pneumonia, or evidence of heart failure.",1
The patient was placed on 2-4L of supplemental oxygen to treat his shortness of breath with good effect.,0
Hepatology saw the patient in the MICU and recommended abdominal ultrasound and right heart catheterization for Liver Transplantation workup that were completed and detailed below.,1
He is scheduled to follow-up next week with Dr. .,0
# CAD: Patient is s/p NSTEMI and CABG in with a recent clean cardiac catheterization in .,0
"Despite his presentation of chest pain on , CE's were negative and EKG's were without evidence of ischemia/pericarditis.",0
"After transfer from the OSH, he became chest pain free and repeat cardiac enzymes performed on transfer to the were also negative.",0
CTA ruled out PE or pneumonia.,0
"His description of burning and nighttime cough were thought to be more consistent with GERD, but they did not recur as an inpatient.",0
"He was continued on his home Nadolol and ASA, but his statin was held due to his liver disease.",0
# Respiratory Alkalosis: Evaluated by ABG on & .,0
"It was thought to be multifactorial due to pain, liver disease, anxiety +/- toxin ingestions.",0
"Serum tox screen was negative, but a urine tox was positive for amphetamines.",0
"In discussions with Pharmacy, it was felt that none of patient's home/OSH transfer medications (including Doxepin) could result in a false positive for amphetamines.",0
Patient continued to deny recent amphetamine use and could not recall taking any dextromethorphan recently that could cause a positive amphetamine tox screen.,0
Social work met with the patient and felt that this would not prevent liver transplant.,0
"# Acute renal failure: Baseline 0.7-1.1, was found to have a Creatinine of 1.3 on admission.",1
He received IVF's & an albumin challenge and the patient's creatinine normalized to his baseline.,0
# Cirrhosis from Hepatitis C: Patient's cirrhosis is complicated by hepatic enchaplopathy & grade I varices.,1
His MELD score remained 17 throughout his stay.,0
Patient's LFT's were at his baseline during this hospitalization and abdominal ultrasound demonstrated patent portal vein and artery with normal flow and no evidence of ascites.,0
Hepatology social work met with the patient in-house and cleared him to proceed with work-up for transplant.,0
As a result he underwent a right heart catheterization that demonstrated no evidence of pulmonary hypertension.,1
He was continued on Lactulose and Xifaxin although he did refuse the former while in the MICU.,0
Patient only had one bowel movement daily during his MICU stay and was found to be lethargic and occasionally confused but orientable.,0
His lactulose dose was increased to 45mL four times daily to titrate to 3 bowel movements and the need for medication compliance was impressed upon the patient.,0
He was continued on his home Lasix & Spirinolactone.,0
# HTN: Patient continued on Clonidine 0.2 mg nightly & Nadolol 40mg PO daily per home regimen as well as home Lasix 40mg PO daily and Spirinolactone 100mg PO daily.,0
"# Thrombocytopenia: Patient with PLT of 85 on admission, nadir'ed to 53.",0
"This was thought to be sequelae from his liver disease, so SC Heparin was held in lieu of pneumatic boots for prophylaxis.",0
"# Macrocytic Anemia: Patient with baseline Hct in the low 40's, but admitted with Hct in the upper 30's.",0
Iron/Folate/B12 studies c/w anemia of chronic disease.,1
An OSH guaiac was negative and his Hct remained stable throughout his hospitalization.,0
# Hyperlipidemia: Zetia was held given known liver disease.,1
# Diabetes: HgbA1c 6.5% on 2/.,0
Patient was maintained on insulin sliding scale while in-house.,0
# COPD: Continued on Albuterol nebulizers & supplemental O2 with improved shortness of breath and oxygen saturation >95%.,0
# Peripheral vascular disease: Not an active issue on this hospitalization.,0
Continued on home ASA 81mg PO daily.,0
# Psych: Continued on home Doxepin and Sertraline.,0
# Code: Full To do: F/U blood cultures from & that were still pending at the time of discharge Medications on Admission: On transfer: Advair Aldactone 50 mg qd ASA 81 mg Avelox 400 mg IV Cephulac 30 mg TID Corgard 20 mg qd Duoneb 3mg Folic Acid Heparin SC TID Maalox QID Multivitamin Nitrostat 0.4 mg Xifaxan 200 mg Prilosec 20 mg Regular sliding scale Solumedrol 40 mg q6hr Spiriva Vitamin B1 Zoloft 105 mg qd .,0
At home: Clonidine 0.1 mg 2 tablets at night Doxepin 10 mg 2 capsules qd (tricylic) Enulose 10gram/15ml oral solution daily Lasix 40 mg qd Glipizide 2.5 mg MV tablet Metoclopramide 5 mg prn Nadolol 40 mg tab qd Albuterol inhaler Spironolactone 50 mg tab 2 tabs qd Sertraline 100mg qd Xifaxan 200mg 3 tablets (Rifaximin) Zetia 10 mg qd ASA 81 mg qd .,0
"Allergies: Latex Discharge Disposition: Extended Care Facility: radius Discharge Diagnosis: Primary: Hepaopulmonary syndrome Secondary: Cirrhosis Diabetes Mellitus, Type II Depression Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to the hospital for shortness of breath and chest pain.",1
"In the hospital, it was determined that you were not having a heart attack, but you were found to have a complication from your liver disease called hepatopulmonary syndrome.",1
The treatment for this syndrome is to use oxygen to help your breathing.,0
Zetia: This medication was STOPPED due to your impaired liver function.,0
Oxygen: This was started to help with your breathing.,0
Please use oxygen at all times.,0
Followup Instructions: Please follow-up with Dr. .,0
", the transplant coordinator, will contact you about scheduling an appointment.",0
"If you have any questions for her, please call: .",0
Dr. offices are located at in .,0
"To schedule an appointment or speak with a representative in his office, please call: (.",0
"2:11 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: mildly distended abdomen, need KUB Admitting Diagnosis: ASPIRATION; FAILURE TO THRIVE ______________________________________________________________________________ MEDICAL CONDITION: 80 year old man s/p partial esophagogastrectomy for gastric CA.",0
"need KUB REASON FOR THIS EXAMINATION: mildly distended abdomen, need KUB ______________________________________________________________________________ FINAL REPORT TYPE OF THE STUDY: Portable abdominal radiograph.",0
"INDICATION: 80-year-old man status post partial esophagogastrectomy for gastric cancer, presented with abdomen mildly distended.",0
FINDINGS: Normal gas pattern is observed in the bowel loops.,0
No evidence of air-fluid levels.,0
There is left-sided total arthroplasty.,0
IMPRESSION: No evidence of acute obstruction.,1
", C. NSURG SICU-B 5:41 PM CT HEAD W/O CONTRAST Clip # Reason: Interval change Admitting Diagnosis: HEAD BLEED ______________________________________________________________________________ MEDICAL CONDITION: 68 year old man with metastatic CA to cerebellum, s/p resection REASON FOR THIS EXAMINATION: Interval change No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Status post left occipital craniotomy with fluid in postoperative bed and expected decrease in amount of pneumocephalus.",1
Continued edema in the left cerebellar hemisphere with similar degree of mass effect on the fourth ventricle.,0
Slight increased size of the lateral ventricles.,0
Unchanged trace intraventricular hemorrhage layering in the occipital .,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Shortness of breath, Fractures Major Surgical or Invasive Procedure: Endotracheal Intubation PEG Tube placement, Interventional Radiology, Casting of left wrist PICC placement.",1
"History of Present Illness: This is an 89 year old male with a history of COPD, hypertension, chronic kidney disease, hypertension and end stage congestive heart failure who was found down in his living days prior to admission.",1
He hit his head but denied history of loss of consciousness.,0
He initially was taken to where CT neck revealed a C2 fracture.,0
He was tranferred to this hospital for further management.,0
"In the ED, initial vs were: T: 97.3 P: 130 BP: 124/78 R: 28 O2 sat 100% on NRB.",0
"Patient was given two liters of normal saline, morhine 2 mg IV x 1, zofran 4 mg IV x 1 and metoprolol 5 mg IV x 1.",0
He was admitted to the TSICU for further management.,0
Since arrival to the TSICU he has had an MRI which shows a type II odontoind fracture.,0
He also has had a right forearm xray which revealed distal radial and ulnar styloid fractures which have been casted.,0
He has been in a c-collar throughout.,0
While in the TSICU he has been noted to be inattentive and inconsistent answering questions with periods of frank agitation where he has been combative and refusing care.,0
He has required haldol and zyprexa PRN for these symptoms.,0
"Per discussion with the patient's son, at baseline his speech is interpretable 50% of the time and that he often talks about the past.",0
He was briefly transferred to the floor on .,0
"There he was receiving gentle hydration as well as PRN zyprexa, haldol and morphine.",0
He was noted to be tachycardic and received significant doses of PRN metoprolol although telemetry strips appear to show sinus tachycardiac versus MAT.,0
He was initially requiring 35% facemask but this required titration during the day.,0
He was also noted to be increasingly somnolent.,0
Of note his lasix has been held since admission and on the day of intubation he received lasix 40 mg IV x 2 without significant increase in his urine output.,0
He was ultimately intubated for hypoxic and hypercarbic respiratory failure.,1
ABG at the time of intubation was 7.29/65/85 on a non-rebreather.,0
Peri-intubation he was transiently hypotensive and required neosynephrine.,0
He had a non-contrast CT of the test which showed a possible pneumonia versus atelectasis.,0
"He was started on vancomycin, cefepime and ciprofloxacin for presumed hospital acquired pneumonia given an isolated fever to 102 degrees.",0
Subclavian line was attempted but was unsuccessful and a femoral line was placed for access.,0
He also had an arterial line placed and an NGT to allow for tube feeds.,0
He is now being transferrd to the MICU for management of respiratory failure.,1
"Past Medical History: COPD - has been on inhalers in the past but is not on currently Hypertension Stage III Chronic Kidney Disease (baseline creatinine 1.4-1.6) Polyarticular Gout - on prednisone 2.5 mg daily Congestive Heart Failure (preserved EF, severe aortic regurgitation, moderate mitral regurgitation) Benign Prostatic Hypertrophy Home oxygen requirement (2L) for unclear reasons.",1
notes attributed both to emphysema and congestive heart failure Social History: Patient currently lives with his wife and his eldest son.,1
uses a walker and/or cane to get around.,0
"He occasionally dresses himself, is able to toliet on his own.",0
He quit smoking 20 years ago but has a 50 pack year history.,0
notes his diet consists of nectar thickened liquids and ground solids.,0
"Family History: Coronary artery disease, hypertension.",1
Mild atelectasis at the left lung base.,0
Stable ascending aortic aneurysm measuring up to 5.8 cm.,0
MRI C-spine w/o contrast : 1.,0
"Ill-defined area of heterogeneous signal identified at the odontoid process, the possibility of chronic degenerative changes and an old unhealed fracture are considerations, however, correlation with a dedicated MRI of the cervical spine with contrast is recommended for further characterization.",1
Multilevel disc degenerative changes throughout the cervical spine as described in detail above.,1
There is no evidence of focal or diffuse abnormalities within the cervical spinal cord.,1
Right Forearm XRAY : Study is limited due to the overlying cast material.,0
Evaluation for subtle fractures cannot be made on these images.,0
"However, there is gross alignment of the elbow joint as well as of the distal radioulnar joint.",0
There is again seen innumerable erosions within the carpal bones which appear similar to the prior study of .,0
No fractures of the distal humeral shaft or of the ulnar and radial shafts are identified.,0
"If there is high clinical concern for subtle fractures, imaging without the cast may be more helpful.",0
Pelvis XRAY : No evidence of trauma.,0
Subtle atelectasis at the left lung base.,0
"EKG: sinus tachycardia with frequent PACs, first degree AV block, no acute ST segment changes, no change from prior dated .",0
MRI Head (): No evidence of acute infarct.,0
Moderate-to-severe changes of small vessel disease and moderate brain atrophy.,1
Small amount of fluid in both mastoid air cells.,0
"Right Hand (): There are innumerable erosions consistent with the history of gouty arthritis, little changed from .",0
"Left Wrist (): The left distal radial fracture line is still visible, though there is some small amount of adjacent callus formation.",0
"Overall, the degree of angulation of the fracture fragments is near anatomic, though small impaction persists.",0
A non-united ulnar styloid fragment is also unchanged.,0
There is no new fracture or dislocation.,0
Extensive cystic changes and erosions of multiple carpal bones with is also unchanged.,0
ABD Xray (): No signs of perforation or obstruction.,0
Pt to follow up with Orthopaedics re: J Collar (needed for wks) and wrist fracture 2.,0
At this time decision was made with family to hold Coumadin at this given the patients fall risk.,0
Given patients history of atrial fibrillation.,1
The decision to restart Coumadin should occur after patient is stabilized and not a fall risk.,0
Speech/Swallow should reevaluate patient's ability to swallow safely without aspiration in the next one - two months.,0
Pt showed improvement while hospitalized.,0
Colchicine/Prednisone which patient took for gout was stopped while hospitalized given patient was between flairs.,0
These should be restarted as needed.,0
Medication for benign prostatic hypertrophy should be restarted after patient's delirium resolves.,1
Patient previously on Proscar daily and Flomax 0.4 qhs.,0
"_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ 89M h/o severe COPD, hypertension, chronic kidney disease, hypertension and end stage CHF, originally found down in his living room two days prior to admission, found to have multiple fractires, admitted to MICU with hypoxic and hypercarbic respiratory failure, now s/p intubation, intermittent desaturations often relieved with sunctioning.",1
"Mental status waxing and , continues to improve and is better when family is available to speek in cantonese to patient, patient somewhat conversational in English.",0
"Waxing and mental status but consistently below baseline, with ongoing altered level of sensorium and unclear level of orientation.",0
"Language barriers contributing to difficulty in assessing, but clear some level of change from baseline.",0
"Unclear etiology but top of differential includes post-intubation status, intubation meds, infection, other medications, metabolic abnormalities.",0
"Patient without signs of infection, blood cultures, urine cultures have been negative.",0
Chest xray without clear pneumonia.,0
Patient at discharge continued to be afebrile.,0
During the hospitalization patient was provided olanzapine for agitation followed by soft restraints and mittens.,0
Geriatrics was also consulted and provided recommendations for improving patient's delirium.,0
Foley was removed and we attempted to normalize sleep/wake cycle.,0
"# ANEMIA: Anemia of Chronic Inflammation and Iron Deficiency (low iron, low TIBC, ferritin normal).",1
"Occult positive stool on , BRBPR (thought to be related to supratherapeutic INR).",0
"B12, folate, hemolysis labs normal.",0
"Trending down since, now ~21.",0
No previous signs of active blood loss.,0
During his stay an active type and screen was maintained and transfusion goal was set at 21.,0
When PEG tube was placed iron was restarted.,0
"Baseline: - HCT ~41 Since Admission: - HCT ~ 26-32 - HCT ~ 22-26 ~ 21, INR ~ 4, given 2 units PRBC + Vit K ~ 27.9, INR = 1.2 - 26.8, INR=1.2 ASPIRATION: Very high-risk.",0
Swallowing pattern correlates to a Functional Oral Intake Scale (FOIS) rating of 1 out of 7.,0
Speech/Swallow re-evaluated after pt pulled out NGT but patient still failed.,0
Speech/swallow evaluated again per families reguest to determine the effect the neck collar had on swallowing.,0
Based on their evaluation the neck collar was not contributing to dysphagia.,0
On video swallow patient did show some improvement however not enough to change from NPO.,0
Given the chronic nature of this problem PEG tube was placed and tube feeds were started.,0
Speech/swallow should re evaluate in the future when patient gets closer to his baseline with the hopes of continued improvement and the possibility of removing the PEG tube.,0
Further during the hospitalization moist spongettes or humidified shovel mask for comfort and Q4 oral care was provided.,0
# Hyperkalemia: Prior to DC to rehab facility patient developed hyperkalemia.,0
Thought to be nutrional as it developed after tube feeds were initiated.,0
Banana Flakes were dc'd from tube feed regimen.,0
"Potassium 5.5, no EKG changes.",0
Pt given Kayexalate and potassium eventually resolved.,0
Pt continued on ACE I at this time given benefit.,0
# RESPIRATORY FAILURE: Patient required intubation in MICU for hypoxic and hypercarbic respiratory failure.,1
"Multifactorial etiology including underlying COPD and CO2 retention, possible CAP, +/- fluid overload from IVF and cessation of CHF medications on admission (including lasix and lisinopril).",0
"ABG intially showed well-compensated respiratory acidosis, later with acute decompensation.",1
Patient now stable on RA - 2L with sats in mid to upper 90s.,0
Patient benefits from frequent suctioning.,0
"COPD: Baseline 2L O2 at home but w/unknown sats, h/o CO2 retention.",0
He does not take inhalers at home but has been prescribed them in the past.,0
Prescribed inhalers in past but not using prior to admission.,0
Restarted albuterol and ipratropium nebulizers on admission.,0
"PNA: History of aspiration, some evidence of small infiltrates versus atelectasis on his CT chest.",0
Patient treated with eight day course of Vanc/Zosyn (start date ) for hosptial acquired pneumonia.,1
"After completion of course patient has been afebrile, with white blood cell count that continues to trend down.",0
On chest xray concern for aspiration pneumonitis.,0
Since that time CXR has been stable with segmental atelectasis.,0
CHF: End-stage diastolic CHF complicated by severe AR and moderate MR. likely fluid resuscitation as well as withholding of CHF meds.,1
"Lasix held (last dose ) due to rising creatinine, dry exam.",0
"During hospitalization creatinine significantly improved and BNP began to increase to 10,000 from 2,000 on admission.",0
Lasix was restarted at half home dose and captopril was restarted when patient's peg tube was placed.,0
Metoprolol was continued throughout the hospitalization.,0
Daily weights and I/0s were followed daily.,0
"# CKD: Baseline since ~1.5, 1.8 on admission.",0
Has fluctuated while hospitalized however has remained stable at 0.9 prior to discharge.,0
While renal function was fluctuating renal toxic medications were held.,0
On improvement of renal function meds were reinitiated.,0
Fluctuation in renal function was thought to be secondary to fluctuations in volume status.,0
# THROMBOCYTOSIS: platelet count rose to ~750 and is now trending down.,0
"Likely just reactive, also could be iron deficiency.",0
# AF w/RVR: rate and rythm controlled on beta-blockade.,0
"HR 90-120s in ICU, now rate controlled on metoprolol.",0
Per discussion with family/attending decision was made to hold coumadin at this time given the fall risk.,0
"# HTN: Controlled on Metoprolol, Captopril.",0
# Right wrist fracture: s/p reduction and splinting.,0
No plan for operative intervention.,0
Will follow up with Orthopaedics.,0
# Dens Fracture: Type II dens fracture.,0
"Per discussions with spine service this fracture is new, and accordingly he should continue to wear the collar for the next 8 weeks.",0
Patient should follow up with Orthopaedics for further evaluation.,0
# Gout: At discharge prednisone/colchicine held given patient does not appear to have a current gout flair.,1
# Benign Prostatic Hypertrophy: Held while inpatient.,1
Medications should be restarted after patients mental status improves.,0
# GOALS OF CARE: Family meeting : -- At this time patient is FULL CODE.,0
Pt is the elder of the family and when the patient is clear has told family that he would like everything done.,0
Discussion of code status has continued.,0
Medications on Admission: Lopressor 25 Lisinopril 5 daily Lasix 60 Prednisone 2.5 mg daily Allopurinol 300 Iron 65 Proscar daily Flomax 0.4 qhs Discharge Medications: 1.,0
"Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation: Please monitor QTc daily when using medication.",0
Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).,0
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day).,0
Allopurinol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).,0
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours).,0
Pantoprazole 40 mg IV Q24H 14.,0
"Heparin 5,000 Units Sub Cutaneous Three Times Daily, For DVT Prophylaxis 15.",0
Captopril 12.5 mg Tablet Sig: One (1) Tablet PO three times a day.,0
Insulin Sliding Scale Please refer to provided scale.,0
Discharge Disposition: Extended Care Facility: at Medical Center Discharge Diagnosis: PRIMARY: 1.,0
Type II dens fracture and non-displaced right wrist lunate and distal radius fracture 4.,1
Acute on Chronic Renal Failure 6.,1
"Delirium: Multifactorial Discharge Condition: Hemodynamically stable, Afebrile, Mental Status waxing/ Discharge Instructions: Dear Mr. , It was a pleasure participating in your care during your admission to .",0
You were originally admitted for fractures after falling down at home.,0
You then developed respiratory failure which required intubation.,1
When your respiratory status improved you were transfered out of the ICU and were continued to be medically stabilized and treated for a hospital acquired pneumonia.,1
Because you had difficulty swallowing with high risk of aspiration a PEG tube was placed so you could receive tube feeds.,0
After intubation you also developed a delirium that has waxed and waned.,0
We have changed several of your medications.,0
Please take all of your medications exactly as prescribed.,0
Please see list provided for these changes.,0
"Please call your physician or come to the hospital if you experience any of the following new pains that are not controlled with your usual pain regimen, chest pain, shortness of breath, fevers, chills, changes in your vision, weakness or numbess in your extremities, or slurring of your speech.",0
Please follow up with your primary care physician in the next 2-4 weeks.,0
"Specialty: Orthopedics Date and time: , at 11:00am Location: , Bldg , , MA Phone number: Special instructions if applicable: Please arrive at 11:00am for X-Rays and then you will see Dr. at 11:20am.",0
"Rheumatology: , MD Phone: Date/Time: 10:30 MD,",0
"4:54 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: TACHY W/ O2 REQUIREMENT, ABD PAIN.",0
"Admitting Diagnosis: ABDOMINAL PAIN;PORTAL VEIN THROMBOSIS Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with venous thrombosis of hepatic, splenic, hepatic veins.",1
"Also tachynpeic,tachycardic and w/ 02 requirement REASON FOR THIS EXAMINATION: r/o pe No contraindications for IV contrast ______________________________________________________________________________ WET READ: JRCi WED 6:15 AM Partial thrombus within the splenic and smv with likely complete thrombosis in the distal mesenteric veins leading to several loops of ischemic appearing bowel in the right lower quadrant with wall thickening and interloop fluid.",0
Recommend non-delayed interventional radiology consult.,0
"______________________________________________________________________________ FINAL REPORT INDICATION: 54-year-old man with abdominal pain, tachypnea, and hypoxia, reproduce history of abdominal venous thrombosis.",1
"TECHNIQUE: MDCT-acquired axial images were obtained through the chest, abdomen, and pelvis following administration of oral and intravenous contrast material.",0
"CT CHEST: The pulmonary arterial tree is minimally opacified with contrast, due to technical factors with timing of the contrast bolus.",0
"However, there is no central or first-order arterial branch pulmonary embolus.",0
"Subsegmental thrombus is unlikely, but filling in the distal branches is less optimal.",0
There is no acute aortic abnormality.,0
"Extensive atherosclerotic calcification is noted within the coronary arteries, particularly within the LAD.",0
The great vessels are unremarkable.,0
No mediastinal or hilar lymph nodes meet CT criteria for pathologic enlargement.,0
The tracheobronchial tree is patent to subsegmental levels.,0
"In the dependent portion of the lungs, there is mild-to-moderate atelectasis, but no focal consolidation or pleural effusion.",0
CT ABDOMEN: The stomach is distended with ingested material mixed with oral contrast.,0
The liver demonstrates a nodular contour consistent with cirrhosis.,1
"A small amount of ascites is present around the liver, and tracks along the pericolic gutter into the pelvis.",0
There is a large filling defect at the confluence of the splenic vein and superior mesenteric vein.,0
Thrombus extends into the superior mesenteric vein and into many of its tributaries more distally.,0
"The main portal vein appears free of thrombus, but additional filling defect is noted at the origin of the (Over) 4:54 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: TACHY W/ O2 REQUIREMENT, ABD PAIN.",0
"Admitting Diagnosis: ABDOMINAL PAIN;PORTAL VEIN THROMBOSIS Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) left portal vein, extending slightly into the left portal vein, and into the right anterior portal vein.",1
The right posterior portal vein appears free of thrombus.,0
"Multiple loops of small bowel are dilated, maximally 3.8 cm.",0
"In the territory supplied by the thrombosed mesenteric vein, there is a loop of small bowel with marked mucosal thickening, with surrounding inflammatory changes, vascular congestion within the mesentery, and small pockets of adjacent free fluid.",0
This is highly concerning for a venous infarct.,0
"The gallbladder, spleen, pancreas, adrenal glands, and intra-abdominal loops of large bowel are unremarkable.",0
"The abdominal aorta demonstrates mild atherosclerotic calcification, without aneurysmal dilatation or evidence of arterial thrombus.",0
CT PELVIS: Small pockets of intraperitoneal fluid are present in the pelvis.,0
"The rectum, sigmoid colon, and prostate gland are unremarkable.",0
The urinary bladder contains a Foley catheter and is largely collapsed.,0
No pelvic or mesenteric lymph nodes meet CT criteria for pathologic enlargement.,0
"OSSEOUS STRUCTURES: Degenerative changes are present throughout the thoracic and lumbar spine, with marked loss of intervertebral disc space at L1-2.",0
No lytic or sclerotic bony lesions or fractures are identified.,0
"Thrombus at the confluence of the splenic and superior mesenteric veins, extending into the SMV and many of its tributaries.",0
"Findings concerning for ischemia of several loops of small bowel in the left lower quadrant, likely secondary to venous infarct.",0
"Thrombus at the origin of the left portal vein, extending into both left portal vein and right anterior portal vein.",0
Hepatic veins are not evaluated on this examination.,0
Hepatic Doppler ultrasound can be obtained for further evaluation.,0
No central or segmental pulmonary embolus.,0
"Subsegmental pulmonary embolus unlikely, but evaluation somewhat limited.",0
"(Over) 4:54 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: TACHY W/ O2 REQUIREMENT, ABD PAIN.",0
Admitting Diagnosis: ABDOMINAL PAIN;PORTAL VEIN THROMBOSIS Field of view: 50 Contrast: OPTIRAY Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) 5.,1
"Distended stomach, with ingested material and oral contrast.",0
Nasogastric tube may be helpful.,0
Atherosclerotic calcification of the coronary arteries.,0
LINE PLACEMENT Clip # Reason: -contact NP # if abnormal-will be in CVIC Admitting Diagnosis: AORTIC VALVE DISORDER\AORTIC VALVE REPLACEMENT /SDA ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man s/p AVR REASON FOR THIS EXAMINATION: -contact NP # if abnormal-will be in CVICU approx.11:30 AM-please call first ______________________________________________________________________________ FINAL REPORT INDICATION: 59-year-old status post AVR.,1
AP SUPINE PORTABLE CHEST: Compared to .,0
Endotracheal tube terminates 4.7 cm above the carina.,0
Swan-Ganz catheter tip in good position.,0
Bilateral chest and mediastinal tubes appear well positioned without evidence of pneumothorax.,0
There is no evidence of pulmonary edema with only trace expected postoperative bibasilar atelectasis and tiny pleural effusions.,0
NG tube tip coiled in fundus of the stomach.,0
IMPRESSION: Satisfactory positioning of lines and tubes.,0
10:38 PM PORTABLE ABDOMEN Clip # Reason: Please do an upright (KUB).,0
"Admitting Diagnosis: LINE INFECTION ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with EC fistulae, worsening distension and abdominal pain REASON FOR THIS EXAMINATION: Please do an upright (KUB).",1
"______________________________________________________________________________ FINAL REPORT INDICATION: 41-year-old male with enterocutaneous fistula, worsening distention and abdominal pain.",0
AP UPRIGHT ABDOMEN: The study is technically limited and does not include the four abdominal quadrants.,0
No definite free air is seen beneath the hemidiaphragms.,0
Air is seen in a loop of transverse colon.,0
There is no definite evidence of obstruction.,0
No definite free air or evidence of obstruction.,0
"9:47 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: evaluate extent of ileus and compare to prior exams for any Admitting Diagnosis: UNRESPONSIVE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old man with ileus - ongoing, please evaluate.",0
REASON FOR THIS EXAMINATION: evaluate extent of ileus and compare to prior exams for any improvement-thanks.,0
______________________________________________________________________________ FINAL REPORT History of persistent ileus.,0
There has been no significant change since the previous study.,0
There are some dilated loops of small bowel with air-fluid levels with gas present throughout the colon and in the rectum and without undue dilatation of the cecum.,0
IMPRESSION: No significant change since prior studies with persistent changes consistent with ileus (pseudo-obstruction).,0
"Admission Date: Discharge Date: Service: MEDICINE Allergies: Aspirin Attending: Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Intubation History of Present Illness: y ear old female with advanced Alzheimer's Disease, asthma, and recent Right distal femur fracture s/p ORIF on presents from nursing home with hypoxia.",1
"There, she was found to be tachypneic with RR in 30s, O2 sat 87% RA, 90% on 2L.",0
"EMS was called, and she was given SL NTG and IV lasix.",0
"Per her daughter, over the past 2 days, she has been more somnolent than usual.",0
She had no complaints except leg pain and involuntary movements of her right arm.,0
"She denied cough, shortness of breath, chest pain, urinary symptoms, diarrhea.",0
Her daughter also noted that her left arm was swollen but does not know for how long.,0
"In the ED, the patient was febrile to 104.8.",0
Her respiratory rate was in the 30s.,0
"Her O2 sats were 85-90% RA, and she was placed on NRB.",0
"Due to continued respiratory distress, she was intubated.",0
"Following intubation, she was noted to have coffee grounds in her ET tube, which cleared with lavage.",0
"She was given IV protonix, in addition to IVF, levofloxacin, vancomycin, metronidazole, combivent, and Decadron prior to admission to the medical ICU.",0
"On arrival to the , she was sedated from propofol.",0
She was shivering and diaphoretic.,0
"Past Medical History: 1) Right Distal Femur Fracture - 1 week ago after falling out of her wheelchair--venodynes for anticoagulation 2) Alzheimer's Disease 3) Asthma 4) HTN 5) Anemia - iron deficiency - baseline HCT 25.8 6) H/O TIAs 7) Osteoporosis 8) CRI - baseline 1.4, up to 2.2 during hospital course at on 9) H/O Pubic ramus Fx 10) H/O Diverticulitis Social History: She is currently living at after right ORIF on .",1
She lived with her daughter prior to the femur fx.,0
She was an for actors on .,0
(+)tobacco history - ppd x 35 years.,0
No history of alcohol use.,0
"ST segment elevation in leads II, III, aVF and V2-V3 raising the question of active ischemia.",0
Followup and clinical correlation are suggested.,0
Right Tib/fib: Diagnostic quality is limited by overlying casting material and probable diffuse osteopenia.,0
There is an angulated and impacted comminuted fracture involving the distal right femoral metadiaphysis.,0
"No leg or ankle fracture is evident, although assessment is again limited by casting material and osteopenia.",0
Talar dome contour is smooth.,0
"A right-sided dynamic hip screw is seen in the right femur, but is incompletely assessed as it extends off the superior aspect of the imaged field of view.",0
No Previous studies are available for comparison.,0
Abdominal ultrasound: COMPLETE ABDOMEN ULTRASOUND: The right kidney measures 7.1 cm in length.,0
The left kidney measures 7.1 cm in length.,0
There is no hydronephrosis or nephrolithiasis.,0
No perirenal fluid collections or masses are seen.,0
The liver appears unremarkable without focal or textural abnormalities.,0
There is no intra- or extrahepatic biliary dilatation.,0
The common bile duct measures 4 mm.,0
Hepatic veins are patent but appear prominent and note is made of reflux indicating probable right heart insufficiency.,0
The gallbladder is distended measuring 5.5 x 6.7 cm in size.,0
"The gallbladder contains sludge, no stones are seen.",0
The gallbladder wall is within normal limits and no pericholecystic fluid is seen.,0
The main portal vein is patent with appropriate flow directionality.,0
The aorta is normal in caliber throughout its visualized portion.,0
Aorta and IVC are patent with appropriate waveforms.,0
The visualized portions of the pancreas appear unremarkable.,0
Pancreatic tail is not well seen due to overlying bowel gas.,0
The spleen measures 7.7 cm and appears normal.,0
"left upper extremity ultrasound: Left internal jugular, subclavian, axillary and brachial veins was performed with ormal compressibility, waveforms, augmentation and Doppler flow demonstrated.",0
There is no evidence of intraluminal clot.,0
CT abdomen/chest/pelvis: CT OF THE CHEST: Small mediastinal lymph nodes are seen which do not meet criteria for pathologic enlargement.,0
The caliber of the thoracic aorta is normal.,0
Extensive coronary artery calcifications are seen.,0
The lungs do not demonstrate any regions of consolidation.,0
"There are small bilateral pleural effusions, right greater than left, and associated minimal lower lobe atelectasis.",0
"Narrowing of the main stem bronchi, particularly on the left is consistent with bronchomalacia.",0
The non-contrast study limits assessment of abdominal organs.,0
"The liver, spleen, pancreas, and adrenal glands appear unremarkable.",0
"The gallbladder is distended measuring up to 0.9 cm, as was seen on the ultrasound.",0
Contrast reaches the proximal colon.,0
No dilated loops of bowel are seen.,0
There is no free intraperitoneal air or ascites.,0
There is hydronephrosis or nephrolithiasis.,0
The abdominal aorta demonstrates extensive atherosclerotic calcifications but is of normal caliber.,0
Artifact from a right femoral screw limits assessment.,0
A Foley catheter is within the bladder lumen.,0
There is diffuse body wall edema consistent with anasarca.,0
Small foci of subcutaneous air in the anterior abdominal wall are consistent with injection sites TTE: The left atrium is normal in size.,0
"There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the septum and anterior walls, and distal inferior wall.",0
The apex is akinetic and mildly aneurysmal.,0
Right ventricular chamber size is normal with focal hypokinesis of the apical free wall (clip #).,0
There is a small circumferential pericardial effusion without evidence of hemodynamic compromise.,0
CXR: Endotracheal tube again seen with tip approximately 3.5 cm above the carina right-sided subclavian line seen with tip in the region of the cavoatrial junction.,0
Nasogastric tube is again seen coiled within the stomach.,0
Again seen are bilateral pleural effusions and retrocardiac opacity unchanged from prior allowing for technical differences and low lung volumes.,0
"Brief Hospital Course: year old female with advanced Alzheimer's Disease, HTN, and right femur fx repaird on presents with hypoxia, fevers, and coffee ground emesis.",1
"As mentioned above, she was intubated and empirically covered with broad-spectrum antibiotics for presumed pneumonia, although CXR/Chest CT did not show a clear infiltrate.",0
"ICU course was notable for NSTEMI (peak TnT 1.13), with an echocardiogram showing regional dysfunction consistent with mid-LAD distribution, in addition to acute renal failure and metabolic acidosis.",1
Multiple attempts in the ICU was unsuccessful in weaning her from the ventilator.,0
"After extensive discusions with her health care proxy/family, given her poor prognosis, it was decided to focus on comfort oriented care.",0
She was extubated and made DNR/DNI (comfort measures only).,0
She was started on an IV morphine drip and transferred to the general floor on .,0
She passed away on at 8:25 p.m.,0
"Her daughter was notified, who declined an autopsy.",0
The coverage for her PCP .,0
"Medications on Admission: Tylenol 650 mg Colace 2 tabs daily Senna 1 tab qod MOM MVI Celexa 20 mg daily Seroquel 12.5 mg 2pm and 8pm Flexeril 10 mg qhs Lidoderm patch to right thigh Detrol LA 4 mg daily Fosamax 70 mg daily TUMS tid Niferex 150 mg daily Duonebs HCTZ 25 mg daily Atenolol 12.5 mg daily Oxycodone 5 mg q4hrs Fleet prn Discharge Disposition: Expired Discharge Diagnosis: Primary: respiratory failure Secondary: non ST-elevation MI, transaminitis, acute renal failure Discharge Condition: Deceased MD Completed by:",1
"7:26 AM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate, chf ______________________________________________________________________________ MEDICAL CONDITION: History: 75F with dyspnea REASON FOR THIS EXAMINATION: r/o infiltrate, chf No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: Dyspnea.",0
Assess for infiltrate or congestive heart failure.,1
FINDINGS: A single portable frontal radiograph of the chest was acquired.,0
"There is redemonstration of intact sternotomy wires as well as surgical clips scattered throughout the lower thorax, unchanged.",0
The previously seen vascular stent projecting over the mid abdomen is only partially imaged on today's study.,0
Moderate enlargement of the cardiac silhouette is increased compared to the prior study.,0
"There is a dense retrocardiac opacification, increased, possibly secondary to atelectasis, although infection and/or aspiration could have an identical appearance.",0
Small bilateral pleural effusions are not significantly changed.,0
There is persistent pulmonary vascular congestion without frank interstitial edema.,0
The mediastinal contours are unchanged.,0
"Increased bibasilar retrocardiac dense opacification, possibly secondary to atelectasis, although an infectious process could appear similar.",0
Unchanged small bilateral pleural effusions.,0
"8:57 AM FINGER(S),2+VIEWS RIGHT Clip # Reason: please eval for fracture ______________________________________________________________________________ MEDICAL CONDITION: 41 year old man with swelling and deformity of Right 4th digit REASON FOR THIS EXAMINATION: please eval for fracture ______________________________________________________________________________ FINAL REPORT INDICATION: Swelling and deformity.",0
"FINDINGS: Three views of the right fourth digit show an oblique, comminuted fracture of the middle phalanx with suspected extension into the distal interphalangeal joint.",1
The proximal and distal phalanges appear normal.,1
No foreign body or soft tissue gas is identified.,0
IMPRESSION: Comminuted intra-articular fracture of the middle phalanx with suspected extension into distal interphalangeal joint.,1
"6:18 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: consolidation or pneumonitis in lungsfluid collection or sig Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 130 ______________________________________________________________________________ MEDICAL CONDITION: 66F with morbid obesity, COPD on 2-3L at baseline, OSA, obesity hypoventialtion, recurrent aspiration PNA initially presented to with SOB and s/p fall and now transferred here in shock, intubated for hypoxic respiratory failure, with A flutter with RVR.",1
REASON FOR THIS EXAMINATION: consolidation or pneumonitis in lungsfluid collection or sign of infection in abdomenany reason to explain persistent feverpls check any progression of subcutaneous edema No contraindications for IV contrast ______________________________________________________________________________ WET READ: MXAk SUN 7:07 PM 1.,1
There are bilateral groundglass opacities with mild interlobular septal thickening likely representative of mild to moderate pulmonary edema.,0
"However, pneumonitis must be excluded in the proper clinical setting.",0
Bilateral pleural effusions have resolved.,0
Bibasilar nodular atelectasis persists but is decreased.,0
Pneumonia must be excluded in the proper clinical setting.,0
Left abdominal wall edema has decreased.,0
"No evidence of other new processes in chest, abdomen, or pelvis.",0
"______________________________________________________________________________ FINAL REPORT REASON FOR THE EXAMINATION: 66-year-old patient with morbid obesity, COPD with recurrent aspiration pneumonia initially presented with SOB, transferred to in shock, intubated for hypoxic respiratory failure.",1
The patient has spiking fever.,0
The request is to evaluate for source for fever.,0
COMPARISON: Prior CT examination from .,0
"TECHNIQUE: CT of the chest, abdomen and pelvis with IV and oral contrast.",0
Coronal and sagittal reformations were made.,0
TOTAL EXAM DLP: 1212.3 mGy-cm.,0
FINDINGS: CHEST: Normal appearance of the thyroid gland.,0
Well positioned endotracheal tube is seen.,0
The heart is within normal limits regarding size and configuration.,0
The mild pericardial effusion that was seen on prior examination is barely seen on current examination.,0
Unchanged prominent pre-vascular lymph nodes (2:17).,0
No other lymphadenopathy is seen in the mediastinum.,0
"Mild enlarged right hilar lymph node (2, 24) is seen.",0
The lesion measures on current examination 14 mm on its short axis in comparison to 15 mm on prior examination.,0
No other lymph nodes are seen in the hila.,0
(Over) 6:18 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: consolidation or pneumonitis in lungsfluid collection or sig Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) No evidence of enlarged lymph nodes in the axilla.,1
"Diffuse interlobular septal thickening is seen, might represent mild pulmonary congestion.",0
"Small ground-glass opacities are seen in the apical segment of the right lower lobe (2, 31) which is more prominent in comparison to prior examination.",0
"Re-identified is subsegmental atelectasis in the apical segment of the left lower lobe (2, 21) infection cannot be definitively ruled out.",0
Bilateral small subsegmental atelectasis is seen in the lung bases.,0
The pleural fluid that was seen on prior examination is not seen on current examination.,0
The pulmonary arteries are within normal limits.,0
ABDOMEN: The liver is within normal limits.,0
"Sludge is seen in the gallbladder (2, 70).",0
There is no intra- or extra-hepatic biliary duct dilation.,0
"The spleen, pancreas and both adrenals are unremarkable.",0
Both kidneys enhance and excrete symmetrically.,0
"Note is made to few irregularities in the right kidney contour (2, 74 and 2, 76).",0
This might represent prior infection in this kidney.,1
"Unchanged prominent lymph nodes in the porta hepatis (2, 63) and in the periportal region (2, 64).",0
No other mesenteric or retroperitoneal lymph nodes are identified.,0
"Nasogastric tube is seen, its tip is located in the stomach.",0
Normal appearance of the small bowel.,0
"Mild thickening of the ascending colon and hepatic flexure (2, 76).",0
This is most probably related to under-filling of the colon.,0
"Mild thickening of the rectum wall is seen (2, 100) most probably represents under-filling of the colon.",0
PELVIS: Normal appearance of the uterus.,0
A Foley catheter is seen within the urinary bladder.,0
There is no lymphadenopathy or fluid within the pelvis.,0
Mild atherosclerosis of the aorta and its branches that are otherwise patent and are of normal caliber.,0
(Over) 6:18 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: consolidation or pneumonitis in lungsfluid collection or sig Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 130 ______________________________________________________________________________ FINAL REPORT (Cont) The portal vein and its branches are of normal caliber and patent.,1
The splenic vein and the SMV are normal.,0
The vena cava appears normal.,0
"Multiple soft tissue densities are seen in the abdominal wall, most probably represent injection sites, mostly unchanged from prior examination.",0
The subcutaneous edema that was seen in the left lateral abdominal wall is not well visualized on current examination.,0
OSSEOUS STRUCTURES: No concerning lytic or osteoblastic lesions are seen in the bones.,0
Note is made to superior end plate depression of T11 vertebra.,0
"Mild interseptal thickening, might represent pulmonary congestion.",0
No pericardial or pleural effusion is seen on current examination.,0
"Subsegmental atelectasis in the apical segment of the left lower lobe and in both lung bases, infection cannot be definitely ruled out.",0
Small and large bowels are within normal limits.,0
No intra-abdominal source for fevers is identified.,0
", ORTHO FA9A 11:57 AM CT LOW EXT W/O C RIGHT Clip # Reason: CT R foot to assess for fx Admitting Diagnosis: OPEN TIB/FIB FRACTURE ______________________________________________________________________________ MEDICAL CONDITION: 45 year old man with MCA REASON FOR THIS EXAMINATION: CT R foot to assess for fx CONTRAINDICATIONS for IV CONTRAST: no need ______________________________________________________________________________ PFI REPORT PFI: Complex fractures of the distal tibial and fibular diaphyses, fractures of the medial malleolus, anterior malleolus, as well as tarsal and metatarsal fractures.",1
", F. TSICU 9:48 AM CT CHEST W/O CONTRAST Clip # Reason: eval for interval change in pleural effusions, non con chest Admitting Diagnosis: MOTOR VEHICLE ACCIDENT ______________________________________________________________________________ MEDICAL CONDITION: 79 year old man with pleural effusions, ?",1
"hemothoraces REASON FOR THIS EXAMINATION: eval for interval change in pleural effusions, non con chest CT please No contraindications for IV contrast ______________________________________________________________________________ PFI REPORT Slight interval increase in the size of the bilateral pleural effusion since the prior exam.",1
"There has been an interval decrease in the attenuation of the bilateral pleural effusions, consistent with evolving bilateral hemothoraces.",1
Interval decrease in the amount of mediastinal hematoma.,0
"New pneumoperitoneum, which is presumably secondary to the interval G-tube placement, however, clinical correlation is recommended.",0
"The comminuted sternomanubrial fracture, bilateral rib fractures, nondisplaced left proximal clavicular fracture, and T4 through 6 thoracic vertebral body fractures are unchanged.",1
"Name: , Unit No: Admission Date: Discharge Date: Date of Birth: Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Addendum: Prior to discharge, patient found to have guiuac postive stool from rectal tube.",0
"Patient will f/u in 4 weeks to General Surgery for outpatient work-up, will also have Hct checked regularly at rehab.",0
Discharge Disposition: Extended Care Facility: Medical Center - MD Completed by:,0
", MED SICU-B 6:02 PM MESSENERTIC Clip # Reason: possible embolization Admitting Diagnosis: LOWER GI BLEED Contrast: VISAPAQUE Amt: 86 ______________________________________________________________________________ MEDICAL CONDITION: 82 year old man with lower GI bleed REASON FOR THIS EXAMINATION: possible embolization ______________________________________________________________________________ PFI REPORT Selective arteriograms obtained in multiple projections of the SMA and failed to demonstrate evidence of active bleeding.",0
"3:48 AM CHEST (PORTABLE AP) Clip # Reason: please eval tubes/lines Admitting Diagnosis: CLOTTED DIALYSIS FISTULA;GASTROINTESTINAL BLEED;LIVER FAILURE ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man s/p intubation, transferred for OSH REASON FOR THIS EXAMINATION: please eval tubes/lines ______________________________________________________________________________ FINAL REPORT HISTORY: Transferred for OSH.",1
FINDINGS: An AP supine portable chest radiograph shows an endotracheal tube in place with the tip ending 4.5 cm above the carina.,0
Catheter projected over the right internal jugular vein seen with the tip projecting at the level of the mid to distal SVC.,0
"Central venous catheter on the left and at the distal brachiocephalic veins, not reaching the SVC.",0
No pneumothorax seen on this side.,0
"A nasogastric tube is seen with the tip and side hole both well below the left hemidiaphragm, with the tip off the view of the film.",0
"Lung volumes are small, crowding the central pulmonary vasculature which is probably not congested.",0
"Bilateral pleural effusions, however present and probably some subsegmental atelectasis at the left lung base.",0
CONCLUSION: Supporting tubes and lines positioned as described.,0
Bilateral pleural effusions and small lung volumes.,0
"5:50 PM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: evaluate lungs fields, Et-Tube and UAC/UVC placements Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with respiratory distress born at 27wks gestation REASON FOR THIS EXAMINATION: evaluate lungs fields, Et-Tube and UAC/UVC placements ______________________________________________________________________________ FINAL REPORT Infant with respiratory distress, born at 27 weeks.",1
Examination on this newborn demonstrating the endotracheal tube below the thoracic inlet.,0
The umbilical arterial catheter reaches the level of T6.,0
The umbilical venous catheter reaches the right atrium.,0
Heart size is upper limits of normal.,0
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: SURGERY Allergies: Celexa / Aspirin / Codeine Attending: Chief Complaint: Jaundice, abdomenal pain Major Surgical or Invasive Procedure: 1.",0
Re-exploration of a recent laparotomy.,0
History of Present Illness: This 75-year-old lady has a history of well-differentiated node-positive gastric cancer with a distal gastrectomy performed about 2 years ago.,1
This reconstruction was performed with a Roux-en-Y conduit.,0
"She has a history of gastrojejunal ulcer disease as well, with a significant ulcer this summer that apparently had cleared on endoscopy.",1
"She currently comes back with biliary obstruction and at the request of Dr. , Dr. was asked to get involved with her care when, after an endoscopy 2 days prior to this procedure, she developed evidence of free air on a CAT scan.",1
"During that endoscopy, Dr. was attempting to find the ampulla to relieve the biliary obstruction endoscopically.",0
"He encountered a necrotic cavity in the stomach area and took a biopsy and then proceeded through an obstructed area into a drainage limb, but was unable to ultimately identify the ampulla of Vater.",0
Therefore the biliary obstruction remained and a follow-up CAT scan was performed for some abdominal pain and this revealed isolated free air in the area of the left upper quadrant with a mass effect in around the stomach on an noncontrast CT.,1
There was no evidence of any large masses or distant metastasis.,0
There was central bile duct obstruction and gallbladder distension but no evidence of intrahepatic distention of her bile duct.,0
"Past Medical History: hypertension, depression, GERD Social History: lives alone, denies alcohol and tobacco Pertinent Results: 01:45PM BLOOD ALT-48* AST-40 AlkPhos-471* Amylase-60 TotBili-12.1* 01:45PM BLOOD Lipase-29 06:40AM BLOOD calTIBC-163* TRF-125* 06:40AM BLOOD Triglyc-559* Brief Hospital Course: Upon presentation, the pt was admitted to the Gold Surgical Service and surgery was performed the next day [see operative note for details].",1
She tolerated the procedure and was admitted to the intensive care unit for close monitoring while intubated.,0
She was extubated POD 3 and subsequently transferred to the floor the following day.,0
She did well until about a week post-op.,0
A CT was obtained on day 9 which showed high-grade obstruction.,0
The pt was taken back to the OR [see 2nd op note] for lysis of adhesion.,0
She tolerated the second procedure well.,0
"She was slow to regain bowel function, but did come around and is now tolerating a regular diet.",0
She has been working with the physical therapy team to regain her strength.,0
"On day of discharge, she has been afebrile with normal vitals, ambulating with help, while producing good urine output.",0
She will be discharged to a rehab center to continue her therapy.,0
Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): see scale.,0
"Discharge Disposition: Extended Care Facility: - , NH Discharge Diagnosis: 1.",0
Gastric perforation from presumed gastrojejunal ulcer.,1
Small bowel obstruction secondary to adhesions Discharge Condition: Good Discharge Instructions: return to taking outpatient medications.,1
Please follow directions as discussed previously with Dr. .,0
Please take medications as prescribed and read warning labels carefully.,0
"If signs of infections such as purulent discharge from wound, increased pain and redness around wound, please call or go to the emergency room.",0
Remember to call for a follow up appointment (bellow).,0
Light activities until seen in clinic.,0
take quick showers but no baths.,0
Followup Instructions: Please call Dr. office for an appointment to be seen in 2 weeks ( Completed by:,0
PATIENT/TEST INFORMATION: Indication: Intraoperative TEE during liver transpalnt Status: Inpatient Date/Time: at 22:17 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement.,1
"No masses or vegetations on pulmonic valve, but cannot be fully excluded due to suboptimal image quality.",0
A small secundum atrial septal defect is present withleft to right flow evident.,0
The right ventricle displays mild global free wall hypokinesis.,0
"No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality.",0
3:33 PM CT STEREOTAXIS W/ CONTRAST Clip # Reason: Preop film prior to left ventricular drain placement Admitting Diagnosis: HEAD BLEED Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 61 year old woman with SAH.,0
"REASON FOR THIS EXAMINATION: Preop film prior to left ventricular drain placement No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 61-year-old woman with intracranial hemorrhage, preoperative evaluation prior to left ventricular drain placement.",0
"TECHNIQUE: Limited axial CT imaging was performed and 18 images were acquired from the vertex to the level of the body of the lateral ventricles, without intravenous contrast.",0
The examination was performed with a stereotactic frame for surgical planning purposes.,0
COMPARISON: CT of the head done earlier today at 8:19 a.m.,0
FINDINGS: The previously seen left frontal approach shunt catheter has been removed.,0
Hemorrhage along the left frontal shunt catheter track is unchanged.,0
The surrounding edema is similar in appearance to the prior study.,0
Minimal pneumocephalus along the shunt tube track is new since the prior study.,0
The visualized portion of the lateral ventricles are dilated and unchanged .,0
The study is limited due to the exclusion of the remainder of the brain and hence the right intraparenchymal bleed cannot be assessed in this current study.,0
"IMPRESSION: Limited intraoperative assessment before surgical planning re-demonstrating a left frontal intraparenchymal hemorrhage along the shunt tube track, unchanged.",1
"9:21 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: evaluate for pneumothorax s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT WITH MVR /SDA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman s/p MVR/cabg x3 REASON FOR THIS EXAMINATION: evaluate for pneumothorax s/p chest tube removal ______________________________________________________________________________ FINAL REPORT AP CHEST, 9:21 A.M., HISTORY: Status post CABG and MVR.",1
IMPRESSION: AP chest compared to and 23: Moderate right pleural effusion is new and mild interstitial edema has recurred.,0
Large postoperative cardiomediastinal silhouette is stable.,0
A very small left pleural effusion has reaccumulated.,0
Swan-Ganz catheter ends in the right pulmonary artery.,0
"Dr. was paged to report these findings, at the time of dictation.",0
7:19 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG w/hypoxia-r/o effusion Admitting Diagnosis: CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 81 year old man s/p left thyroidectomy/AVR/cabg REASON FOR THIS EXAMINATION: s/p CABG w/hypoxia-r/o effusion ______________________________________________________________________________ FINAL REPORT Compared to 1 day earlier.,1
The patient is s/p median sternotomy and aortic valve replacement.,1
"ETT, Swan- Ganz catheter, NG tube and mediastinal drains are in satisfactory position.",0
Again demonstrated are bibasilar opacities most prominent in the retrocardiac region.,0
"Overall, there has been slight interval improved aeration at the right lung base with improved visualization of the right hemidiaphragm.",0
IMPRESSION: Bibasilar atelectasis with slight improvement in the right lung base.,0
"3:21 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: RENAL CELL CARCINOMA;FEVER,HYPOKALEMIA ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with metastatic renal cell CA, intubated, ?",0
"R main stem obstruction, new hypoxia REASON FOR THIS EXAMINATION: eval for interval change ______________________________________________________________________________ FINAL REPORT CHEST: INDICATION: Metastatic renal cell CA.",0
Check for right main stem obstruction.,0
FINDINGS: The single AP supine image.,0
Comparison study dated taken semi-upright.,0
Multiple nodular lesions are again noted in the right mid and lower zones.,0
Illdefined infiltrate/atelectasis is also again noted in the left lower lobe behind the heart.,0
The stent is again visible in the left main bronchus.,0
Some patchy infiltrate is present in the left upper lobe and lingula.,0
There is again evidence of a small pleural effusion on the right side but the left CP angle area is not demonstrated.,0
The right subclavian PICC line extends into the upper SVC.,0
"IMPRESSION: Allowing for technical and postural differences, the appearances of the metastases, the pulmonary infiltrates and the left lower lobe atelectasis are not significantly changed.",0
The right pleural effusion is also unchanged.,0
Height: (in) 72 Weight (lb): 216 BSA (m2): 2.20 m2 BP (mm Hg): 114/51 HR (bpm): 96 Status: Inpatient Date/Time: at 10:41 Test: TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Technical Quality: Adequate INTERPRETATION: Findings: This study was compared to the prior study of .,0
LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - akinetic; mid anteroseptal - akinetic; anterior apex - akinetic; lateral apex - akinetic; apex - akinetic; RIGHT VENTRICLE: RV not well seen.,0
"There is moderate regional left ventricular systolic dysfunction with anteroseptal, anterior and apical akinesis.",0
Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %).,0
IMPRESSION: Regional LV systolic dysfunction consistent with prior LAD infarction.,1
The right ventricle is not well seen but its function is probably normal.,0
The degree of mitral regurgitation is less.,0
LINE PLACEMENT Clip # Reason: swan placement Admitting Diagnosis: ADENAL CARCINOMA OF LIVER/SDA ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with metastatic colon CA to the liver s/p R-trisegmentectomy REASON FOR THIS EXAMINATION: swan placement ______________________________________________________________________________ FINAL REPORT INDICATION: Metastatic colon cancer to the liver.,1
Status post right trisegmentectomy and Swan placement.,0
"Single portable supine view of the chest was performed at 12:20 a.m., with comparison to examination of the previous day at 19:35.",0
The tip of the endotracheal tube is approximately 5.5 cm above the carina.,0
"NG tube extends into the stomach, and beyond the inferior confines of this film.",0
"Left-sided IJ Swan-Ganz catheter is again seen, with the tip in the right pulmonary artery trunk.",0
"Cardiac and mediastinal silhouettes are unchanged, allowing for slight rotation.",0
"There are no focal pulmonary opacities, pleural effusions, or evidence of pneumothorax.",1
"Two linear radiopacities are seen overlying the hepatic silhouette, likely representing surgical drains.",1
IMPRESSION: Tip of Swan-Ganz catheter in the right pulmonary artery trunk.,0
LINE PLACEMENT Clip # Reason: assess line placement.,0
"Admitting Diagnosis: SEPSIS;TELEMETRY ______________________________________________________________________________ MEDICAL CONDITION: 59 year old man with ascending cholangitis, sepsis, intubated now s/p replacement of right IJ central line.",1
REASON FOR THIS EXAMINATION: assess line placement.,0
______________________________________________________________________________ FINAL REPORT HISTORY: Right IJ line placement.,0
"FINDINGS: In comparison with earlier study of this date, there is little change in the appearance of the heart and lungs.",0
Right IJ catheter extends to the mid portion of the SVC at the level of the carina.,0
"1:37 PM CAROTID SERIES COMPLETE PORT Clip # Reason: RIGHT HEMIPARESIS, LEFT MCA STROKE Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK ______________________________________________________________________________ MEDICAL CONDITION: 74 year old man with right hemiparesis likely L MCA stroke.",0
stenosis or unstable plaque ______________________________________________________________________________ FINAL REPORT CAROTID DUPLEX REASON: 74-year-old man with right hemiparesis and likely left MCA stroke.,0
FINDINGS: Duplex evaluation was performed on the carotid arteries.,0
"On B-mode imaging, there is minimal heterogeneous plaque in the proximal right ICA.",0
"On the right, the peak systolic velocities are 76/27 in the proximal ICA, 63/18 in the mid ICA, 77/27 in the distal ICA.",0
There is a velocity of 52/13 in the CCA and 96 in the ECA.,0
The ICA/CCA ratio is 1.48 and this is consistent with a less than 40% right ICA stenosis.,0
"On the left, the peak systolic velocities are 51/9 in the proximal ICA, 31/1 in the mid ICA, and 41/5 in the distal ICA.",0
There is a velocity of 41/8 in the CCA and 51 in the ECA.,0
The ICA/CCA ratio is 1.24.,0
This is consistent with a less than 40% left ICA stenosis.,0
The right vertebral artery is unable to be visualized and there is antegrade flow in the left vertebral artery.,0
IMPRESSION: There is a less than 40% right ICA stenosis and less than 40% left ICA stenosis with nonvisualized right vertebral artery and antegrade flow in the left vertebral artery.,0
6:17 AM CHEST (PORTABLE AP) Clip # Reason: Assess for interval change Admitting Diagnosis: FEVER ______________________________________________________________________________ MEDICAL CONDITION: 38 year old woman with respiratory failure REASON FOR THIS EXAMINATION: Assess for interval change ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 11:02 AM No significant interval change compared to the radiograph from a day before.,1
______________________________________________________________________________ FINAL REPORT REASON FOR EXAMINATION: Followup of a patient with respiratory failure.,1
"Portable AP chest radiograph was compared to prior study obtained on , at 05:20.",0
The position of the supporting devices is unchanged.,0
There is no change in the cardiomediastinal contour and diffuse parenchymal opacities.,0
Bilateral pleural effusion is most likely present.,0
"9:39 AM BILAT LOWER EXT VEINS Clip # Reason: PT WITH LARGE PE, ?DVT Admitting Diagnosis: PULMONARY EMBOLIS ______________________________________________________________________________ MEDICAL CONDITION: 34 year old woman 24 weeks pregnant who presents with large PE REASON FOR THIS EXAMINATION: ?DVT ______________________________________________________________________________ WET READ: YGd SAT 11:48 AM Occlusive thrombus L CFV and L .",1
Nonocclusive thrombus in predominantly proximal R SFV w mild extension into R CFV.,0
"- x ______________________________________________________________________________ FINAL REPORT INDICATION: 34-year-old, 24-week pregnant patient presents with bilateral large PE, here for evaluation of lower extremity DVT in anticipation of possible IVC filter placement.",1
COMPARISON: Reference CT dated .,0
FINDINGS: Grayscale and color Doppler son were performed for bilateral lower extremities.,0
"There is expansion and non-compressibility of the left common femoral vein with intraluminal echogenic material, compatible with thrombosis.",0
This extends distally into the proximal superficial femoral vein and origin of greater saphenous vein.,0
"More distally, there is normal compressibility in the mid-to-distal superficial femoral vein.",0
"However, no color flow is demonstrated in a non-compressible left popliteal vein, suggestive of thrombus.",0
"In the right lower extremity, there is non-occlusive residual adherent clot in the right common femoral vein, with moderate non-occlusive thrombus extending to the proximal superficial femoral vein.",1
The mid and distal right superficial femoral vein compresses normally.,0
The popliteal vein demonstrates normal compression and color flow.,0
IMPRESSION: Occlusive thrombus within the left common femoral vein and left popliteal vein.,0
Non-occlusive residual thrombus occupying predominantly the proximal right superficial femoral vein with extension into right common femoral vein.,0
Findings reported to Dr. at pager number by phone at 11:30 a.m. on .,0
11:27 PM CHEST (PORTABLE AP) Clip # Reason: {See Clinical Indication Field} Admitting Diagnosis: ABSCESS CELLULITIS ______________________________________________________________________________ MEDICAL CONDITION: 69F has trach and PICC.,1
REASON FOR THIS EXAMINATION: {See Clinical Indication Field} No contraindications for IV contrast ______________________________________________________________________________ FINAL REPORT INDICATION: 69-year-old female with tracheostomy and recently placed PICC.,0
COMPARISON: Multiple chest radiographs dating back to and most recent .,0
TECHNIQUE: Portable upright AP chest radiograph.,0
FINDINGS: Right-sided PICC catheter is seen in unchanged position terminating within the right atrium.,0
Tracheostomy tube is seen in unchanged position with no obvious signs of cuff hyperinflation.,0
There has been increase in right pleural effusion with likely superimposed right-sided edema.,0
There has been decrease in the observed left-sided effusion.,0
Apparent shift in pleural effusion is most likely related to patient positioning.,0
"Sternotomy wires are seen in unchanged position, aligned along the midline with no evidence of failure.",0
Aortic valve prosthesis is seen unchanged in position within the heart.,1
IMPRESSION: 1) Right-sided PICC catheter still terminates within the right atrium.,0
2) Heart is stably enlarged with interval increase in right-sided pleural effusion and decrease in left-sided effusion.,0
9:47 AM PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # -77 BY DIFFERENT PHYSICIAN : s/p advancement of feeding tube: confirm post pyloric placem Admitting Diagnosis: CHEST PAIN;CORONARY ARTERY DISEASE ______________________________________________________________________________ MEDICAL CONDITION: 65 year old man s/p CABG to start tube feeding REASON FOR THIS EXAMINATION: s/p advancement of feeding tube: confirm post pyloric placement ______________________________________________________________________________ FINAL REPORT INDICATION: 65-year-old male status post CABG.,1
Evaluate for feeding tube placement.,0
-INTESTINAL TUBE PLACEMENT: A feeding tube is seen extending into the mid stomach.,0
There is air filled overlying transverse colon.,0
Osseous structures are otherwise unremarkable.,0
"4:38 PM BABYGRAM (CHEST ONLY) Clip # Reason: evaluate lung fields Admitting Diagnosis: NEWBORN ______________________________________________________________________________ MEDICAL CONDITION: Infant with CLD, increasing fio2 REASON FOR THIS EXAMINATION: evaluate lung fields ______________________________________________________________________________ FINAL REPORT STUDY DONE: Chest x-ray.",0
CLINICAL HISTORY: This is a 1-month-old preterm infant with chronic lung disease.,1
"FINDINGS: A single, portable view of the chest was obtained and is compared to the previous film dated at 12:33.",0
The ET tube tip is just beyond the thoracic inlet.,0
The NG tube tip is in the left-sided stomach.,0
"There is a patchy, bilateral opacification of the lungs with a more focal region of atelectasis involving the right upper lobe.",0
There is no evidence for PIE or pneumothorax.,0
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x 5 (Lima to LAD, SVG to OM1, SVG to OM2, SVG to RCA with Y-graft to PLB) on History of Present Illness: 49 y/o male with 1 month hx of chest pain.",1
"Underwent cardiac cath at which showed severe three vessel disease (LAD 40%-90%, Lcx 70-90%, RCA 50-70%).",0
Mr. was then transferred to for surgical intervention.,0
"Past Medical History: Diabetes Type II, Hypertension, Hypercholesterolemia, Obesity, Sleep Apnea, Varicose veins, s/p Tonsillectomy Social History: Denies Tobacco or ETOH use Family History: Non-contributory Physical Exam: VS: Afebrile, 80 120/63 General: Alert, NAD HEENT: EOMI, PERRL, sclera non-icteric Neck: Supple, -JVD, -carotid bruits Lungs: CTAB -w/r/r Heart: RRR +S1S2 -c/r/m/g Abd: Obese, Soft, NT/ND, +BS, -organomegaly Ext: Warm, -edema, right groing with cordis, BLE varicosities L>R Neuro: Non-focal Pertinent Results: Echo : PRE-CPB: There are three aortic valve leaflets.",1
The prosthetic aortic leaflets appear normal.,0
POST-CPB: Improved biventricular systolic function post cpb.,0
CXR : There has been interval extubation.,0
"Mediastinal drains, left-sided chest tube and Swan-Ganz catheter remain in place.",0
The tip of the Swan-Ganz catheter is not well visualized on the current study.,0
Bibasilar atelectatic changes and a small left pleural effusion are again demonstrated.,0
A previously identified area of lucency adjacent to the left heart border has resolved in the interval.,0
11:27PM BLOOD WBC-8.7 RBC-4.49* Hgb-13.8* Hct-38.8* MCV-86 MCH-30.6 MCHC-35.4* RDW-13.0 Plt Ct-275 07:00AM BLOOD WBC-9.2 RBC-3.45* Hgb-10.6* Hct-30.7* MCV-89 MCH-30.7 MCHC-34.5 RDW-13.0 Plt Ct-305 04:35AM BLOOD Hct-28.0* 11:27PM BLOOD PT-12.5 PTT-26.7 INR(PT)-1.1 03:01PM BLOOD PT-14.5* PTT-25.6 INR(PT)-1.3* 11:27PM BLOOD Glucose-128* UreaN-13 Creat-1.0 Na-140 K-3.9 Cl-104 HCO3-25 AnGap-15 07:00AM BLOOD Glucose-128* UreaN-18 Creat-0.9 Na-139 K-4.0 Cl-97 HCO3-29 AnGap-17 04:35AM BLOOD UreaN-24* Creat-1.0 K-4.0 11:27PM BLOOD %HbA1c-6.4* [Hgb]-DONE [A1c]-DONE 11:27PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG 11:27PM URINE Color-Yellow Appear-Clear Sp -1.024 Brief Hospital Course: Mr. was admitted and underwent usual per-operative work-up.,0
He was brought to the operating room on hospital day two and underwent a coronary artery bypass graft x 5.,1
He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition.,0
He remained intubated until post-op day one when sedation was weaned and he was extubated after awaking neurologically intact.,0
Chest tubes were removed and beta blockers and diuretics were initiated.,0
He was gently diuresed throughout hospital course towards his pre-op weight.,0
He remained in the ICU for one more night and was transferred to the cardiac surgery step down floor on post-op day two.,0
Epicardial pacing wires were removed.,0
"He remained stable, improving well over the next several days with beta blockers titrated for maximum BP and HR control.",0
Physical therapy followed patient during entire post-op course for strength and mobility.,0
"On post-op day five he appeared well, physical exam and labs were stable, and he was discharged home with VNA services and the appropriate follow-up appointments.",0
"Medications on Admission: NTG gtt, Heparin gtt, Toprol XL 25mg qd, Lipitor 80mg qd, Aspirin 325mg qd Discharge Medications: 1.",0
"Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days.",0
"Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2.",0
Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.,0
"Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Diabetes Type II, Hypertension, Hypercholesterolemia, Obesity, Sleep Apnea, Varicose veins, s/p Tonsillectomy Discharge Condition: good Discharge Instructions: no lifting > 10# for 10 weeks may shower, no bathing or swimming for 1 month no driving for 1 month Followup Instructions: with Dr. in weeks with Dr. in weeks with Dr. in 4 weeks Completed by:",1
"Admission Date: Discharge Date: Date of Birth: Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: Cardiac catherization Urgent coronary artery bypass grafting x2: Left internal mammary artery graft to the left anterior descending, reverse saphenous vein graft to the marginal branch.",1
History of Present Illness: 63 year old man with chest discomfort symptoms and a recent positive stress test.,0
Prominent moderator band/trabeculations are noted in the RV apex.,0
Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler.,0
There is mild regional left ventricular systolic dysfunction (EF 40%) with apical hypokinesis.,0
A PA catheter is seen.,0
POSTBYPASS Left ventricular systolic function is improved and now normal (EF > 55%) without focal wall motion abnormalities.,0
Mild-moderate tricuspid regurgitation is seen and is slightly increased.,0
PRELIMINARY REPORT developed by a Cardiology Fellow.,0
Not reviewed/approved by the Attending Echo Physician.,0
"assigned to , MD, MD, Interpreting physician Cardiology Report ECG Study Date of 2:13:58 PM Artifact is present.",0
There is a late transition with tiny R waves in the anterior leads consistent with possible prior anterior myocardial infarction.,1
Low voltage in the precordial leads.,0
Compared to the previous tracing low voltage is new.,0
"Read by: , H. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 172 92 420/435 34 -27 -18 Brief Hospital Course: Transferred from outside hospital after cardiac catherization for surgical evaluation.",0
He underwent preoperative work up and on was brought to the operating room and underwent coronary artery bypass graft surgery.,1
See operative report for details.,0
"In operating room there was difficult with intubation, see anesthesia report for details.",0
He received vancomycin for perioperative antibiotics as he was in the hospital preoperatively.,0
He was transferred to the intensive care unit for hemodynamic management.,0
"In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated.",0
"After extubation, his voice was hoarse and ENT was consulted.",0
"His vocal cords were mobile bilaterally but there was some swelling of L and R false cord, which would be consistent with difficult intubation, and recent extubation, no evidence of hematoma.",0
He remained in the intensive care unit for airway monitoring and placed on humidified oxygen and proton pump inhibitor twice a day.,0
Additionally he was started on beta blockers and diuretics.,0
On post operative day two he was transferred to the floor for the remainder of his care.,0
Physical therapy worked with him on strength and mobility.,0
He continued to progress and voice improved.,0
Speech and swallow evaluated him for swallowing and cleared him for a soft diet with thin liquids.,0
He was instructed to follow up with ENT and/or the swallow team if he experienced any further difficulty with his voice or swallowing.,0
He was ready for discharge home with services on post operative day four.,0
Medications on Admission: -HCTZ 25 mg daily -Lisinopril 10 mg daily -Atenolol 50 mg daily -Aspirin 81 mg daily -Lipitor 80 mg daily -Bupropion XL 300 mg daily -Diazepam 5-10 mg prn sleep Discharge Medications: 1.,0
Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours.,0
Wellbutrin XL 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day.,0
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 6.,0
PO Q12H (every 12 hours) for 1 weeks.,0
"Disp:*14 Tablet, Delayed Release (E.C.",0
Particle/Crystal PO BID (2 times a day) for 7 days.,0
4:49 PM CHEST (PORTABLE AP) Clip # Reason: Pneumonia/infiltrate?,0
"Admitting Diagnosis: VFIB ARREST ______________________________________________________________________________ MEDICAL CONDITION: 61 year old man with leukocytosis, cough.",0
REASON FOR THIS EXAMINATION: Pneumonia/infiltrate?,0
______________________________________________________________________________ WET READ: PXDb TUE 6:48 PM No acute cardiopulmonary process.,0
( ) ______________________________________________________________________________ FINAL REPORT STUDY: PORTABLE CHEST RADIOGRAPH.,0
HISTORY: 61-year-old man with cough and leukocytosis.,0
COMPARISON: Comparison is made to chest radiograph from .,0
"FINDINGS: Overall, there is no significant change when compared to the previous examination.",0
There is no pulmonary consolidation or pleural effusion.,0
"The cardiac silhouette is slightly enlarged, stable from previous examination.",0
There is no suspicious osseous lesion.,0
The visualized soft tissue structures are normal.,0
"Overall, no significant change when compared to the study of .",0
There is no acute cardio-pulmonary.,0
"1:18 PM VIDEO OROPHARYNGEAL SWALLOW PORT Clip # Reason: r/o aspiration Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS ______________________________________________________________________________ MEDICAL CONDITION: 54 year old man with quadreplegia MVA (), R BKA, recently extubated, ?",0
REASON FOR THIS EXAMINATION: r/o aspiration ______________________________________________________________________________ FINAL REPORT INDICATION: Change in mental status.,0
FINDINGS: Video oropharyngeal swallow was performed in conjunction with the speech and swallow division.,0
The oral phase demonstrated premature spillage into the pharynx on thin liquids only.,0
The pharyngeal phase demonstrated incomplete epiglottic deflection and reduced bolus propulsion with moderate vallecular residue on solid more than pureed barium consistencies.,0
There were episode of trace penetration that occurred before and during the swallow with incomplete epiglottic deflection.,0
IMPRESSION: Intermittent trace penetration without evidence of aspiration.,0
12:37 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX Admitting Diagnosis: BRADYCARDIA ______________________________________________________________________________ MEDICAL CONDITION: 80 year old woman s/p PM via left subclavian REASON FOR THIS EXAMINATION: r/o PTX ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 4:44 PM Since yesterday dual-chamber left pacemaker was installed.,0
The first wire is in right atrium and the second wire could be in right ventricle or coronary sinus.,0
Standard PA and lateral chest x-ray is recommended for further characterization.,0
Right internal jugular sheath is unchanged.,0
Left retrocardiac atelectasis is small.,0
Probable right small pleural effusion is unchanged.,1
"______________________________________________________________________________ FINAL REPORT CHEST PORTABLE AP COMMENTS: 80-year-old woman status post PM via left subclavian, rule out pneumothorax.",0
"Since yesterday, dual-chamber pacemaker was installed.",0
The first wire is in right atrium and the second wire could be either in right ventricle or coronary sinus.,0
PA and lateral chest x-ray is recommended for further characterization.,0
Right internal jugular sheath is in unchanged position.,0
Probable tiny right pleural effusion is unchanged.,1
"2:32 PM -INTESTINAL TUBE PLACEMENT (W/FLUORO); -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # Reason: please place NasoJejunal tube Admitting Diagnosis: UPPER GI BLEED Contrast: CONRAY Amt: ______________________________________________________________________________ MEDICAL CONDITION: 62 year old man with melena, in TICU workup GI bleed.",1
REASON FOR THIS EXAMINATION: please place NasoJejunal tube ______________________________________________________________________________ FINAL REPORT INDICATION: Previous feeding tube displaced.,0
FINDINGS: The left naris was anesthetized with lidocaine jelly.,0
"Under fluoroscopic guidance, an 8 French - feeding tube was advanced until the tip extended past the Roux-en-Y anastomosis.",0
Tube position was confirmed with the injection of contrast.,0
The tube was secured in place using a bridle device.,0
IMPRESSION: Successful post-anastomotic feeding tube placement.,0
4:47 PM CT HEAD W/O CONTRAST Clip # Reason: re-evaluate.,0
______________________________________________________________________________ MEDICAL CONDITION: 63 year old man with SDH REASON FOR THIS EXAMINATION: re-evaluate.,0
"No contraindications for IV contrast ______________________________________________________________________________ WET READ: WWM SUN 6:41 PM grossly stable acute on chronic R hemispheric SDH and scattered R SAH; R cerebral sulcal effacement and ~6mm R-to-L MLS (was 5mm) with no herniation noted ______________________________________________________________________________ FINAL REPORT HEAD CT WITHOUT CONTRAST, AT 1647 HOURS.",1
TECHNIQUE: Serial transverse images were acquired sequentially through the brain and reconstructed at 2.5 mm increments in bone windows and 5-mm increments in soft tissue windows.,0
Coronal and sagittal reformatted images were generated.,0
COMPARISON: Head CT acquired at outside hospital earlier same day.,0
"FINDINGS: Consistent with the prior exam, hemispheric right subdural hematoma of mixed attenuation is again noted and grossly stable in size.",0
There is resultant again hemispheric sulcal effacement of the right cerebral hemisphere and approximately 6 mm of midline shift measured at the septum pellucidum.,0
Previously this was approximately 5 mm of midline shift.,0
There are scattered foci of subarachnoid hemorrhage again similar to the prior exam.,1
There is effacement of majority of the right lateral ventricle.,0
No underlying skull fracture is identified.,0
The globes are intact with lenses in place.,0
The included paranasal sinuses and mastoid air cells are clear.,0
No CT evidence of acute cortical stroke identified.,0
IMPRESSION: Grossly stable hemispheric right subdural hematoma with acute on chronic components.,1
Midline shift has minimally increased since the prior study.,0
"However, there are no overt signs of herniation at this time.",0
Scattered subarachnoid hemorrhage also noted.,1
"3:07 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: please eval for aortic dissection, for right lung pathology Admitting Diagnosis: PLEURAL EFFUSION Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ MEDICAL CONDITION: 57 year old man with large R pleural effusion, minimal lung reexpansion, with widened mediastinum on portable CXR and hypotension REASON FOR THIS EXAMINATION: please eval for aortic dissection, for right lung pathology given pneumothorax and question of trapped lung, and chest tube position CONTRAINDICATIONS for IV CONTRAST: Renal Failure/ Diabetes - ok'd by renal ______________________________________________________________________________ FINAL REPORT INDICATION: Widened mediastinum on portable chest x-ray and hypotension.",1
"Evaluate for aortic dissection, right lung pathology given pneumothorax and question of trapped lung.",0
COMPARISON: Chest radiographs of the previous day.,0
TECHNIQUE: Contiguous axial images through the chest were obtained without contrast.,0
"Subsequently, following the administration of 100 cc of Optiray, contiguous axial images through the chest were obtained during opacification of the aorta and pulmonary artery.",0
"Coronal, sagittal, and oblique reconstructions were obtained.",0
CTA OF THE CHEST: The aorta is of normal caliber.,0
There is no evidence of thoracic aortic dissection.,0
There is no evidence of pulmonary embolus.,0
CT OF THE CHEST WITHOUT AND WITH CONTRAST: There is a right-sided chest tube in place.,0
"This chest tube enters the chest at the lateral chest wall, and is oriented posterior to the lung in the mid chest.",0
"The tip of the chest tube approximates the medial most portion of the right pleura, adjacent to the spine.",0
There is a small anterior pneumothorax present.,0
"Right upper and anterior lung appears fairly well aerated, and there is some atelectasis of the right lower lobe.",0
"There is opacity of a fair amount of this right lung parenchyma, which may represent atelectasis with or without superimposed edema or infiltrate.",0
"There is ground-glass and patchy opacity within the right lung as well, suggesting edema and/or infiltrate.",0
There are coronary artery calcifications.,1
There are calcifications of the aorta.,0
The central airways are patent to the level of the segmental bronchi bilaterally.,0
There are small prevascular lymph nodes within the mediastinum measuring about 9 mm in short axis dimension.,0
"There are couple of pretracheal lymph nodes as well, measuring roughly the same.",0
These are borderline in terms of criteria for pathologic enlargement.,0
The mediastinum likely appears widened on chest x-ray due to mediastinal lipomatosis.,0
No pathologically enlarged axillary lymph nodes.,0
Subcutaneous air is noted adjacent to the chest tube entry site on the right.,0
"Within the imaged portion of the upper abdomen, reflux of contrast is noted within the IVC and hepatic veins.",0
"Visualized portions of the liver and spleen (Over) 3:07 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: please eval for aortic dissection, for right lung pathology Admitting Diagnosis: PLEURAL EFFUSION Field of view: 40 Contrast: OPTIRAY Amt: 100 ______________________________________________________________________________ FINAL REPORT (Cont) are unremarkable.",0
Multiplanar reformatted images were essential in delineating the anatomy and pathology in this case (grade 1).,0
No evidence of thoracic aortic dissection.,0
The mediastinum likely appears widened on chest radiograph due to mediastinal lipomatosis.,0
"Small anterior right pneumothorax, with right chest tube in place posteriorly as described.",0
"Ground-glass within both lungs, which may be related to atelectasis plus or minus superimposed edema or infiltrate.",0
5:16 PM CT TRACHEA W/O C W/3D REND Clip # Reason: PAROXYSMAL HYPOXIA AND POSSIBLE TRANSIENT UPPER AIRWAY OBSTRUCTION Admitting Diagnosis: SEIZURE ______________________________________________________________________________ MEDICAL CONDITION: 70 year old woman with paroxysmal hypoxia and seemingly possible transient upper airway obstruction REASON FOR THIS EXAMINATION: please eval during inspiration and expiration for possible tracheomalacia.,1
PLEASE ALSO INCLUDE KIDNEYS TO EVALUATE SIZE.,0
CONTRAINDICATIONS for IV CONTRAST: Creat 3.9 (acute worsening) ______________________________________________________________________________ FINAL REPORT INDICATION: Paroxysmal hypoxia and transient upper airway obstruction.,1
CT CHEST AND TRACHEA WITHOUT CONTRAST.,0
TECHNIQUE: MDCT of the chest was performed from the thoracic inlet through the adrenals.,0
"Images were obtained during inspiration, dynamic breathing and cough.",0
Multiplanar high resolution reconstructions and multiplanar reformations were also obtained.,0
FINDINGS: There are bilateral moderate effusions and severe lower lobe consolidation.,0
"Ground glass opacities with bronchial wall thickening and interlobular septal thickening in the right middle lobe, lateral segment of the lingula and apicoposterior segment of the left upper lobe are probably pneumonia.",0
The right lower lobe bronchi are plugged with secretions.,0
Soft tissue material in the left main bronchus is also likely secretions.,0
There is diffuse moderate emphysema.,0
"There is severe atherosclerosis of the aorta in the chest, virtually obliterating the lumen in the abdomen, and in the left subclavian, innominate and superior mesenteric arteries.",0
Severe atherosclerotic coronary calcifications are also noted.,0
Subcentimeter mediastinal nodes do not meet the CT size criteria for lymphadenopathy.,0
"The trachea is patent, but there is abnormal bowing of the posterior membranous portion on coughing and similar narrowing of the bronchus intermedius and right lower lobe bronchus on dynamic breathing.",0
"In the imaged upper abdomen, there are multiple calcified granulomas in the liver.",0
The left kidney is small with a 2.2-cm hypodense lesion probably a cyst in the upper pole.,0
There are no osteolytic or osteoblastic lesions.,0
Bilateral moderate pleural effusions and bilateral lower lobe atelectasis and/or pneumonia.,0
"Multifocal pneumonia--right middle lobe, lingula and apicoposterior (Over) 5:16 PM CT TRACHEA W/O C W/3D REND Clip # Reason: PAROXYSMAL HYPOXIA AND POSSIBLE TRANSIENT UPPER AIRWAY OBSTRUCTION Admitting Diagnosis: SEIZURE ______________________________________________________________________________ FINAL REPORT (Cont) segment of right upper lobe.",1
Secretions in the right lower lobe and segmental bronchi and in the left main bronchus.,0
"Given the amount of secretions, a small endobronchial lesion cannot be excluded.",0
"Moderate tracheobronchomalacia, at the level of the carina, right bronchus intermedius and right lower lobe bronchus.",0
"Severe atherosclerotic calcification of the entire aorta, coronary, superior mesenteric, left subclavian and innominate arteries.",0
Atrophic left kidney with a 2.2-cm cyst.,0
"5:54 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: check for pneumothorax Admitting Diagnosis: PNEUMOTHORAX;FRACTURES ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with small pneumothorax, now s/p positive pressure ventilation.",1
REASON FOR THIS EXAMINATION: check for pneumothorax ______________________________________________________________________________ WET READ: RSRc TUE 9:03 PM No PTX.,1
"No change since earlier in day, with left rib/scapula fractures, left basilar opacification consistent with atelectasis, effusion, pna, or hemorrhage.",1
______________________________________________________________________________ FINAL REPORT PROCEDURE: Chest portable AP on .,0
"HISTORY: 35-year-old woman with small pneumothorax, status post pressure ventilation.",1
Patient had a history of an acute trauma.,0
"FINDINGS: Where as the most recent examination showed a gradual decrease of the airspace disease described as contusion in the left lung, on today's examination there is worsening airspace disease in both right and left lung left more than right, which is more in favor of volume overload from excessive hydration.",0
"A persistent left lower lobe atelectasis is again seen, with minimal left-sided pleural effusion.",0
Ipsilateral four left rib fractures are seen along with the left scapular fracture.,1
The right costophrenic angle is sharp.,0
"IMPRESSION: Worsening bilateral airspace disease, left more than right, with small left pleural effusion and multiple rib fractures indicative of overhydration from volume overload.",0
9:43 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: r/o SBO or ileus ______________________________________________________________________________ MEDICAL CONDITION: 69 year old woman with s/p AAA repair with vomiting REASON FOR THIS EXAMINATION: r/o SBO or ileus ______________________________________________________________________________ FINAL REPORT ABDOMEN 2 VIEWS: HISTORY: Persistent vomiting following AAA repair.,0
Gas is present throughout the colon and there is no evidence for intestinal obstruction.,0
No specific signs to suggest mesenteric ischemia.,0
Surgical clips are present in the left abdomen.,0
IMPRESSION: No evidence for intestinal obstruction or ileus.,0
"2:38 PM MR FUNCTIONAL BRAIN BY PHYS/PSYCH; MR HEAD W & W/O CONTRAST Clip # Reason: 43 year old man with L frontal mass, please do WAND and func Admitting Diagnosis: FRONTAL MASS Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ MEDICAL CONDITION: 43 year old man with L frontal mass, please do WAND and functional MRI at same time REASON FOR THIS EXAMINATION: 43 year old man with L frontal mass, please do WAND and functional MRI at same time No contraindications for IV contrast ______________________________________________________________________________ PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa MON 7:31 PM PFI: A large necrotic left frontal lobe mass lesion is redemonstrated and unchanged since the prior study dated .",0
Persistent vasogenic edema and mild mass effect on the left frontal lobe is again seen.,1
This lesion apparently is crossing the midline towards the right and may represent a primary brain neoplasm such as a glioblastoma multiforme.,0
The functional MRI demonstrates the expected activation areas during the movement of the hands and feet.,0
"The language paradigm demonstrates the major activation areas on the left opercular region, possibly related with language dominance and areas of activation adjacent to the posterior aspect of the mass lesion.",0
"There are areas of activation in the mass lesion, likely consistent with venous contamination.",0
______________________________________________________________________________ FINAL REPORT STUDY: MRI of the brain with WAND protocol and also functional MRI of the brain for pre-surgical mapping.,0
COMPARISON: Prior MRI of the brain dated .,0
"TECHNIQUE: Post-contrast sequences were obtained on a 3 Tesla magnet as per departmental WAND protocol including axial, sagittal and T1-weighted FLAIR sequences, axial ASL sequence, axial MP-RAGE with multiplanar reconstructions.",0
"Functional MRI of the brain echo-planar technique with block sequences of activation and rest using BOLD technique, during the alternating movements of the hands and feet.",0
Language paradigms during the alternating movement of the tongue and non-verbalizing task activation paradigm during the mental process of generating words with different letters.,0
"FINDINGS: The previously demonstrated left fronal lobe necrotic mass lesion appears unchanged, with similar pattern of vasogenic edema, mass effect and necrotic areas, consistent with an intra-axial neoplastic mass.",0
No significant changes are identified on the ASL sequence or diffusion abnormalities to indicate acute/subacute ischemic changes.,0
"The functional MRI demonstrates the expected activation areas during the movement of the hand and feet and the language paradigm demonstrates the major BOLD signal on the left opercular region, likely related with the language (Over) 2:38 PM MR FUNCTIONAL BRAIN BY PHYS/PSYCH; MR HEAD W & W/O CONTRAST Clip # Reason: 43 year old man with L frontal mass, please do WAND and func Admitting Diagnosis: FRONTAL MASS Contrast: MAGNEVIST Amt: 19 ______________________________________________________________________________ FINAL REPORT (Cont) dominance.",0
Areas of activation during the language paradigm are demonstrated adjacent to the mass lesion and in the areas of enhancement.,0
The posterior areas of activation apparently are located in the operculum and also in the Broca's area.,0
The areas of activation within the mass lesion may represent venous contamination.,0
"During the movement of the tongue, BOLD signal is demonstrated adjacent to the mass lesion on the left insular region, however the majority of the signal activation is located on the right cerebral hemisphere.",0
"IMPRESSION: Left frontal lobe necrotic mass lesion, which appears stable since the prior study dated .",0
"The functional MRI demonstrates areas of BOLD activation during the language paradigm on the left operculum, Broca's area and also within the mass lesion.",0
The areas of activation surrounding the mass lesion anteriorly possibly represent venous contamination.,0
The dominance of the language apparently is located on the left opercular region.,0
These findings were communicated to Dr. on at 1754.,0
"9:12 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: PNEUMONIA ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with COPD, worsening wheezes REASON FOR THIS EXAMINATION: eval for infiltrate ______________________________________________________________________________ FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Patient with COPD and worsening wheeze.",0
The lungs are hyperinflated consistent with COPD.,0
Left mid lung opacity has improved.,0
"There are no new lung opacities, pneumothorax or pleural effusion.",0
"12:53 PM SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # Reason: please evlaute for fracture Admitting Diagnosis: INTRACRANIAL HEMORRHAGE ______________________________________________________________________________ MEDICAL CONDITION: 53 year old man with s/p fall REASON FOR THIS EXAMINATION: please evlaute for fracture ______________________________________________________________________________ FINAL REPORT STUDY: Right shoulder three views .",0
"HISTORY: 53-year-old man status post fall, evaluate for fracture.",0
FINDINGS: There is an old healed fracture involving the mid shaft of the right clavicle.,0
Degenerative changes of the AC joint is visualized.,0
There are no signs for acute fractures or dislocations.,0
The patient has a PICC line with the distal tip in the mid SVC.,0
The visualized right lung apex is clear.,0
IMPRESSION: No signs for acute bony injury.,0
"LINE PLACEMENT Clip # Reason: s/p CL change Admitting Diagnosis: ASCENDIBG AORTIC ANEURYSM\BENTAL PROCEDURE /SDA ______________________________________________________________________________ MEDICAL CONDITION: 63 year old woman REASON FOR THIS EXAMINATION: s/p CL change ______________________________________________________________________________ FINAL REPORT CLINICAL HISTORY: Central line placed, check for change in position.",1
The tip of the central line has been pulled back and now lies within the upper portion of the right atrium.,0
"Bilateral pleural effusions are present, larger on the right side, some atelectasis is also seen.",0
The lung fields are otherwise clear.,0
"LINE PLACEMENT Clip # Reason: central line placement Admitting Diagnosis: ABDOMINAL PAIN ______________________________________________________________________________ MEDICAL CONDITION: 64 year old man with EtOH cirrhosis REASON FOR THIS EXAMINATION: central line placement ______________________________________________________________________________ FINAL REPORT PORTABLE CHEST, COMPARISON: .",0
FINDINGS: Endotracheal tube tip terminates 5.3 cm above the carina.,0
"Cardiac silhouette is mildly enlarged, even accounting for portable supine technique.",0
This is accompanied by mild vascular engorgement but no interstitial or alveolar edema.,0
Minor atelectasis has developed at left lung base.,0
"2:16 AM CHEST (PORTABLE AP) Clip # Reason: eval progress of abscess, edema, infiltrate Admitting Diagnosis: PLEURAL CUT FISTULA PE ______________________________________________________________________________ MEDICAL CONDITION: 35 year old woman with PE, abscess, pneumonia, bronchopleural fistula REASON FOR THIS EXAMINATION: eval progress of abscess, edema, infiltrate ______________________________________________________________________________ FINAL REPORT HISTORY: Pneumonia and edema.",1
"FINDINGS: In comparison with the study of , there is little overall change in the diffuse bilateral pulmonary opacifications.",1
Cardiac silhouette is essentially within normal limits.,0
"Diagnostic possibilities would include widespread pulmonary edema, diffuse pneumonia, or even ARDS.",1
"Admission Date: Discharge Date: Date of Birth: Sex: F Service: MEDICINE Allergies: Adhesive Pads Attending: Chief Complaint: palpitations, anxiety Major Surgical or Invasive Procedure: none History of Present Illness: Ms. is 28 year old female with PMH of HCV who presented to the ED with a chief complaint of anxiety, palpitations, and abdominal pain.",0
"Per patient, she has been using GHB every hours for the past 1.5 weeks until Tuesday at 5pm, when she ran out.",0
"She subsequently presented to a few hours later with symptoms of anxiety, mild SOB, palpitations that she attributed to GHB withdrawal, which had not abated at home with Phenibut.",0
"Per her, she was admitted to the ICU at for 3 days.",0
"She is unclear on the management and states she does not remember the first two; however, she received infrequent medication, is unclear on the treatment, and was sent home without medical management or follow-up.",0
She states she was discharged earlier today.,0
"After discharge, she found two 0.5mg of ativan in her car, which she took because of anxiety.",0
"She states she infrequently takes ativan, and none in the last two weeks before day of admission.",0
"She continued to have worsening anxiety and palpitations at home, as well as epigastric sharp abdominal pain, muscle ""clenching"", and panic-like symptoms.",1
"Therefore, she presented to the ED.",0
"In the emergency department, initial vitals: 97.6 145 149/95 12 99.",0
She was given 10mg of IV valium with resultant drop in her HR to 105.,0
Her abdominal pain subsided with benzo administration.,0
"She continued to be anxious, so phenobarbital was started.",0
"A total of 150mg was given, but then it was stopped because increased anxiety and muscle tremors.",0
"At the time of signout, she was sleeping.",0
Neurological exam was described as nonfocal.,0
"Labs were notable for a normal chem 7, WBC of 13.9 (N 79, L 15.6, M 4.5, E 0.8, Bas 0.2) but otherwise normal CBC, HCG negative, and tox screen negative for asa, etoh, acetaminophen, benzos, barbiturates, and tricyclics.",0
Toxicology was called and plan to see her in the AM.,0
Phone recs included benzos and then phenobarbital if needed.,0
Indication for ICU admission was risk of respiratory depression from receiving phenobarbital.,0
"Prior to transport, vitals were: 98.9 120 117/84 18 99%RA .",0
"REVIEW OF SYSTEMS: (+)ve: as per HPI (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: 1.",0
"Hepatitis C, genotype 3a, not currently treated.",0
Social History: She is with a steady monogamous relationship for the past 2 years.,0
She works as a waitress at Stephanie's .,0
She smokes 10 cigarettes a day.,0
She drinks alcohol about 1x per month.,0
She does recreational intranasal cocaine about twice monthly.,0
She reports IVDU twice in the past about 2 yrs ago.,0
She reports she feels safe at home and denies physical/emotional abuse.,0
Family History: Her mother has a brain tumor.,0
No history of substance abuse.,0
Physical Exam: Admission: 98.6 105 121/81 13 96%RA .,0
"PHYSICAL EXAM GENERAL: Pleasant, well appearing, in NAD though slightly anxious HEENT: Normocephalic, atraumatic.",0
"No JVD LUNGS: CTAB, good air movement biaterally.",0
"Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: 08:40PM PLT COUNT-308 08:40PM NEUTS-79.0* LYMPHS-15.6* MONOS-4.5 EOS-0.8 BASOS-0.2 08:40PM WBC-13.9* RBC-5.18 HGB-15.3 HCT-44.2 MCV-85 MCH-29.6 MCHC-34.7 RDW-13.1 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 08:40PM HCG-<5 08:40PM estGFR-Using this 08:40PM GLUCOSE-109* UREA N-22* CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 Chest film IMPRESSION: No acute cardiopulmonary abnormality 06:25AM BLOOD WBC-6.5 RBC-5.02 Hgb-14.6 Hct-42.9 MCV-85 MCH-29.1 MCHC-34.1 RDW-12.8 Plt Ct-272 06:25AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-138 K-4.7 Cl-102 HCO3-29 AnGap-12 04:46AM BLOOD ALT-30 AST-26 CK(CPK)-73 AlkPhos-59 TotBili-0.8 04:46AM BLOOD TSH-0.80 08:40PM BLOOD HCG-<5 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 04:46AM URINE opiates-NEG cocaine-NEG amphetm-NEG EKG: Baseline artifact is present.",0
Compared to the previous tracing the rate is slower and the ST-T wave changes are less apparent.,0
"Brief Hospital Course: 28 year old female presenting with agitation and tachycardia with known GBL use, presemted with GBL withdrawl.",0
"Tachycardia/agitation: Patient was initially managed in the ICU for airway monitoring/precautions, and was placed on a CIWA scale, on which she scored infrequently.",0
Cocaine and opiates were negative on urine tox screen.,0
"Thiamine, magnesium, and folate were given.",0
Pt's severe anxiety and significant tachycardia were likely due to significant GBL withdrawl.,0
"She was managed with a CIWA scale, however this did not seem to adequately capture her symptoms of withdrawl, which included anxiety and tachycardia primarily, but also included sweats and occas palpitations.",0
"As pt seems to have significant anxiety at baseline, and pt claimed to be self-medicating for anxiety, Psychiatry was consulted for assistance.",0
Pt was started on scheduled Valium which was gradually tapered.,0
"Pt had significant improvement in symptoms with scheduled valium, and her withdrawl symptoms gradually decreased.",0
"Her tachycardia appeared to be the most consistent sign of her withdrawl, and at the time of discharge, her tachycardia had resolved.",0
She was monitored on telemetry throughout the hospitalization.,0
"Social work was consulted as well, and between Social Work and Psychiatry, pt was provided extensive resources for Psychiatry and Social Work follow up as an outpatient.",0
Pt was discharged with 2 additional days of Valium taper.,0
"HCV: diagnosed in , followed by Dr. at .",0
Likely too early in disease to have developed fibrosis.,0
No stigmata of chronic liver disease.,0
"Liver function tests, albumin, and coag studies were normal.",0
She will follow up with Dr. as an outpt.,0
CODE STATUS: full Medications on Admission: seroquel 100mg qhs Ativan 0.5mg 1-2 tabs prn Discharge Medications: 1.,0
Diazepam 5 mg Tablet Sig: One (1) Tablet PO as directed for 2 days: Take 1 tab every 6 hours on ; then 1 tab every 8 hours on ; then discontinue.,0
Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): you may purchase over the counter.,0
Multivitamin Tablet Sig: One (1) Tablet PO once a day: you may purchase over the counter.,0
"Discharge Disposition: Home Discharge Diagnosis: # GBL withdrawl # Anxiety Secondary Hepatitis C Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted for GBL withdrawl, and you were treated with a valium taper with improvement in your symptoms.",0
"You were followed by Psychiatry and Social Work, who have helped you obtain outpatient follow up.",0
"It is extremely important that you remain off of all drugs and alcohol, and follow up with your outpatient providers.",0
Please finish the Valium taper as prescribed.,0
"Followup Instructions: Please schedule a follow up appointment with your primary care provider, keep the appointments that you scheduled with Psychiatry and social work.",0